hospital_name last_updated_on version hospital_location hospital_address license_number | IN "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." JOHNSON MEMORIAL HOSPITAL FRANKLIN 3/2/24 2.0.0 JOHNSON MEMORIAL HOSPITAL FRANKLIN 1125 WEST JEFFERSON STREET FRANKLIN IN 46131 IN TRUE description code|1 code|1|type code|2 code|2|type code|3 code|3|type code|4 code|4|type setting drug_unit_of_measurement drug_type_of_measurement standard_charge|gross standard_charge|discounted_cash payer_name plan_name modifiers standard_charge|negotiated_dollar standard_charge|negotiated_percentage standard_charge|negotiated_algorithm estimated_amount standard_charge|min standard_charge|max standard_charge|methodology additional_generic_notes Application of blood vessel compression device 10111749_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 10111749_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 10111749_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 10111749_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 10111749_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 10111749_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 10111749_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 10111749_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 10111749_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 Application of blood vessel compression device 10111749_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 Application of blood vessel compression device 10111749_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 Application of blood vessel compression device 10111749_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 Application of blood vessel compression device 10111749_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 10111749_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 Hepatitis B core antibody measurement 1013359_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 1013359_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 1013359_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 1013359_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 1013359_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 1013359_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 1013359_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 1013359_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 1013359_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 Hepatitis B core antibody measurement 1013359_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 Hepatitis B core antibody measurement 1013359_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 Hepatitis B core antibody measurement 1013359_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 Hepatitis B core antibody measurement 1013359_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 1013359_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 Measurement of Hepatitis A antibody (IgM) 10234947_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 10234947_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 10234947_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 10234947_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 10234947_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 10234947_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 10234947_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 10234947_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 10234947_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 Measurement of Hepatitis A antibody (IgM) 10234947_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 Measurement of Hepatitis A antibody (IgM) 10234947_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 Measurement of Hepatitis A antibody (IgM) 10234947_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 Measurement of Hepatitis A antibody (IgM) 10234947_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 10234947_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 "Blood test, clotting time" 1048599_1 CDM 0305 RC 85610 HCPCS inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges "Blood test, clotting time" 1048599_1 CDM 0305 RC 85610 HCPCS inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges "Blood test, clotting time" 1048599_1 CDM 0305 RC 85610 HCPCS inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges "Blood test, clotting time" 1048599_1 CDM 0305 RC 85610 HCPCS inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges "Blood test, clotting time" 1048599_1 CDM 0305 RC 85610 HCPCS inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges "Blood test, clotting time" 1048599_1 CDM 0305 RC 85610 HCPCS inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges "Blood test, clotting time" 1048599_1 CDM 0305 RC 85610 HCPCS inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges "Blood test, clotting time" 1048599_1 CDM 0305 RC 85610 HCPCS inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges "Blood test, clotting time" 1048599_1 CDM 0305 RC 85610 HCPCS inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 "Blood test, clotting time" 1048599_1 CDM 0305 RC 85610 HCPCS inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 "Blood test, clotting time" 1048599_1 CDM 0305 RC 85610 HCPCS inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 "Blood test, clotting time" 1048599_1 CDM 0305 RC 85610 HCPCS inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 "Blood test, clotting time" 1048599_1 CDM 0305 RC 85610 HCPCS inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges "Blood test, clotting time" 1048599_1 CDM 0305 RC 85610 HCPCS inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 "Evaluation for work hardening or conditioning, initial 2 hours" 1066686_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 AETNA AETNA 464.52 79 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 1066686_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 382.2 65 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 1066686_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 570.36 97 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 1066686_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 405.72 69 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 1066686_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 458.64 78 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 1066686_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 UMR - ALL PLANS UMR - ALL PLANS 411.6 70 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 1066686_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 SIHO - ALL PLANS SIHO - ALL PLANS 529.2 90 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 1066686_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 356.03 60.55 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 1066686_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 1066686_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 1066686_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 1066686_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 ANTHEM HMO ANTHEM HMO 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 1066686_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 397.49 67.6 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 1066686_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, each additional hour" 1066687_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 AETNA AETNA 237.79 79 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 1066687_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 195.65 65 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 1066687_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291.97 97 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 1066687_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 207.69 69 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 1066687_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 234.78 78 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 1066687_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 UMR - ALL PLANS UMR - ALL PLANS 210.7 70 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 1066687_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 SIHO - ALL PLANS SIHO - ALL PLANS 270.9 90 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 1066687_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.26 60.55 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 1066687_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 1066687_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 1066687_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 1066687_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 ANTHEM HMO ANTHEM HMO 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 1066687_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 203.48 67.6 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 1066687_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.26 291.97 "X-ray of knee, 3 views" 1066969_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 AETNA AETNA 386.31 79 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 1066969_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 317.85 65 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 1066969_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 474.33 97 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 1066969_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 337.41 69 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 1066969_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 381.42 78 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 1066969_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 UMR - ALL PLANS UMR - ALL PLANS 342.3 70 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 1066969_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 SIHO - ALL PLANS SIHO - ALL PLANS 440.1 90 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 1066969_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 296.09 60.55 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 1066969_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 296.09 474.33 "X-ray of knee, 3 views" 1066969_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 296.09 474.33 "X-ray of knee, 3 views" 1066969_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 296.09 474.33 "X-ray of knee, 3 views" 1066969_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ANTHEM HMO ANTHEM HMO 999999999 296.09 474.33 "X-ray of knee, 3 views" 1066969_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 330.56 67.6 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 1066969_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 296.09 474.33 "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 1074599_1 CDM 0510 RC J3301 HCPCS inpatient 12.5 8.13 AETNA AETNA 9.88 79 999999999 7.57 12.13 percent of total billed charges "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 1074599_1 CDM 0510 RC J3301 HCPCS inpatient 12.5 8.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.13 65 999999999 7.57 12.13 percent of total billed charges "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 1074599_1 CDM 0510 RC J3301 HCPCS inpatient 12.5 8.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.13 97 999999999 7.57 12.13 percent of total billed charges "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 1074599_1 CDM 0510 RC J3301 HCPCS inpatient 12.5 8.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.63 69 999999999 7.57 12.13 percent of total billed charges "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 1074599_1 CDM 0510 RC J3301 HCPCS inpatient 12.5 8.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.75 78 999999999 7.57 12.13 percent of total billed charges "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 1074599_1 CDM 0510 RC J3301 HCPCS inpatient 12.5 8.13 UMR - ALL PLANS UMR - ALL PLANS 8.75 70 999999999 7.57 12.13 percent of total billed charges "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 1074599_1 CDM 0510 RC J3301 HCPCS inpatient 12.5 8.13 SIHO - ALL PLANS SIHO - ALL PLANS 11.25 90 999999999 7.57 12.13 percent of total billed charges "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 1074599_1 CDM 0510 RC J3301 HCPCS inpatient 12.5 8.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.57 60.55 999999999 7.57 12.13 percent of total billed charges "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 1074599_1 CDM 0510 RC J3301 HCPCS inpatient 12.5 8.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.57 12.13 "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 1074599_1 CDM 0510 RC J3301 HCPCS inpatient 12.5 8.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.57 12.13 "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 1074599_1 CDM 0510 RC J3301 HCPCS inpatient 12.5 8.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.57 12.13 "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 1074599_1 CDM 0510 RC J3301 HCPCS inpatient 12.5 8.13 ANTHEM HMO ANTHEM HMO 999999999 7.57 12.13 "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 1074599_1 CDM 0510 RC J3301 HCPCS inpatient 12.5 8.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.45 67.6 999999999 7.57 12.13 percent of total billed charges "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 1074599_1 CDM 0510 RC J3301 HCPCS inpatient 12.5 8.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.57 12.13 Application of mechanical traction 10802053_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 AETNA AETNA 168.27 79 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 10802053_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 138.45 65 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 10802053_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 206.61 97 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 10802053_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 146.97 69 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 10802053_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 166.14 78 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 10802053_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 UMR - ALL PLANS UMR - ALL PLANS 149.1 70 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 10802053_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 SIHO - ALL PLANS SIHO - ALL PLANS 191.7 90 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 10802053_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 128.97 60.55 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 10802053_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 128.97 206.61 Application of mechanical traction 10802053_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 128.97 206.61 Application of mechanical traction 10802053_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 128.97 206.61 Application of mechanical traction 10802053_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 ANTHEM HMO ANTHEM HMO 999999999 128.97 206.61 Application of mechanical traction 10802053_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 128.97 206.61 Application of mechanical traction 10802053_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 143.99 67.6 999999999 128.97 206.61 percent of total billed charges Therapy procedure in a group setting 10815062_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 10815062_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 10815062_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 10815062_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 10815062_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 10815062_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 10815062_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 10815062_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 10815062_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 Therapy procedure in a group setting 10815062_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 Therapy procedure in a group setting 10815062_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 Therapy procedure in a group setting 10815062_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 Therapy procedure in a group setting 10815062_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 Therapy procedure in a group setting 10815062_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 10826863_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 AETNA AETNA 304.94 79 999999999 233.72 374.42 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 10826863_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 250.9 65 999999999 233.72 374.42 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 10826863_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 374.42 97 999999999 233.72 374.42 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 10826863_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 266.34 69 999999999 233.72 374.42 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 10826863_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.08 78 999999999 233.72 374.42 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 10826863_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 UMR - ALL PLANS UMR - ALL PLANS 270.2 70 999999999 233.72 374.42 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 10826863_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 SIHO - ALL PLANS SIHO - ALL PLANS 347.4 90 999999999 233.72 374.42 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 10826863_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 233.72 60.55 999999999 233.72 374.42 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 10826863_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 233.72 374.42 Fluoroscopic guidance for insertion or removal of central vein access device 10826863_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 233.72 374.42 Fluoroscopic guidance for insertion or removal of central vein access device 10826863_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 233.72 374.42 Fluoroscopic guidance for insertion or removal of central vein access device 10826863_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 ANTHEM HMO ANTHEM HMO 999999999 233.72 374.42 Fluoroscopic guidance for insertion or removal of central vein access device 10826863_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 233.72 374.42 Fluoroscopic guidance for insertion or removal of central vein access device 10826863_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 260.94 67.6 999999999 233.72 374.42 percent of total billed charges Blood typing for red blood cell antigens 10958951_1 CDM 0300 RC 86905 HCPCS inpatient 319 207.35 AETNA AETNA 252.01 79 999999999 193.15 309.43 percent of total billed charges Blood typing for red blood cell antigens 10958951_1 CDM 0300 RC 86905 HCPCS inpatient 319 207.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 207.35 65 999999999 193.15 309.43 percent of total billed charges Blood typing for red blood cell antigens 10958951_1 CDM 0300 RC 86905 HCPCS inpatient 319 207.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 309.43 97 999999999 193.15 309.43 percent of total billed charges Blood typing for red blood cell antigens 10958951_1 CDM 0300 RC 86905 HCPCS inpatient 319 207.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 220.11 69 999999999 193.15 309.43 percent of total billed charges Blood typing for red blood cell antigens 10958951_1 CDM 0300 RC 86905 HCPCS inpatient 319 207.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 248.82 78 999999999 193.15 309.43 percent of total billed charges Blood typing for red blood cell antigens 10958951_1 CDM 0300 RC 86905 HCPCS inpatient 319 207.35 UMR - ALL PLANS UMR - ALL PLANS 223.3 70 999999999 193.15 309.43 percent of total billed charges Blood typing for red blood cell antigens 10958951_1 CDM 0300 RC 86905 HCPCS inpatient 319 207.35 SIHO - ALL PLANS SIHO - ALL PLANS 287.1 90 999999999 193.15 309.43 percent of total billed charges Blood typing for red blood cell antigens 10958951_1 CDM 0300 RC 86905 HCPCS inpatient 319 207.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 193.15 60.55 999999999 193.15 309.43 percent of total billed charges Blood typing for red blood cell antigens 10958951_1 CDM 0300 RC 86905 HCPCS inpatient 319 207.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 193.15 309.43 Blood typing for red blood cell antigens 10958951_1 CDM 0300 RC 86905 HCPCS inpatient 319 207.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 193.15 309.43 Blood typing for red blood cell antigens 10958951_1 CDM 0300 RC 86905 HCPCS inpatient 319 207.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 193.15 309.43 Blood typing for red blood cell antigens 10958951_1 CDM 0300 RC 86905 HCPCS inpatient 319 207.35 ANTHEM HMO ANTHEM HMO 999999999 193.15 309.43 Blood typing for red blood cell antigens 10958951_1 CDM 0300 RC 86905 HCPCS inpatient 319 207.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 193.15 309.43 Blood typing for red blood cell antigens 10958951_1 CDM 0300 RC 86905 HCPCS inpatient 319 207.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 215.64 67.6 999999999 193.15 309.43 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 10989063_1 CDM 0320 RC 76000 HCPCS inpatient 1172 761.8 AETNA AETNA 925.88 79 999999999 709.65 1136.84 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 10989063_1 CDM 0320 RC 76000 HCPCS inpatient 1172 761.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 761.8 65 999999999 709.65 1136.84 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 10989063_1 CDM 0320 RC 76000 HCPCS inpatient 1172 761.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1136.84 97 999999999 709.65 1136.84 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 10989063_1 CDM 0320 RC 76000 HCPCS inpatient 1172 761.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 808.68 69 999999999 709.65 1136.84 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 10989063_1 CDM 0320 RC 76000 HCPCS inpatient 1172 761.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 914.16 78 999999999 709.65 1136.84 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 10989063_1 CDM 0320 RC 76000 HCPCS inpatient 1172 761.8 UMR - ALL PLANS UMR - ALL PLANS 820.4 70 999999999 709.65 1136.84 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 10989063_1 CDM 0320 RC 76000 HCPCS inpatient 1172 761.8 SIHO - ALL PLANS SIHO - ALL PLANS 1054.8 90 999999999 709.65 1136.84 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 10989063_1 CDM 0320 RC 76000 HCPCS inpatient 1172 761.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 709.65 60.55 999999999 709.65 1136.84 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 10989063_1 CDM 0320 RC 76000 HCPCS inpatient 1172 761.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 709.65 1136.84 "Imaging guidance for procedure, 60 minutes or less" 10989063_1 CDM 0320 RC 76000 HCPCS inpatient 1172 761.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 709.65 1136.84 "Imaging guidance for procedure, 60 minutes or less" 10989063_1 CDM 0320 RC 76000 HCPCS inpatient 1172 761.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 709.65 1136.84 "Imaging guidance for procedure, 60 minutes or less" 10989063_1 CDM 0320 RC 76000 HCPCS inpatient 1172 761.8 ANTHEM HMO ANTHEM HMO 999999999 709.65 1136.84 "Imaging guidance for procedure, 60 minutes or less" 10989063_1 CDM 0320 RC 76000 HCPCS inpatient 1172 761.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 709.65 1136.84 "Imaging guidance for procedure, 60 minutes or less" 10989063_1 CDM 0320 RC 76000 HCPCS inpatient 1172 761.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 792.27 67.6 999999999 709.65 1136.84 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 10989305_1 CDM 0402 RC 76830 HCPCS inpatient 550 357.5 AETNA AETNA 434.5 79 999999999 333.03 533.5 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 10989305_1 CDM 0402 RC 76830 HCPCS inpatient 550 357.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 357.5 65 999999999 333.03 533.5 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 10989305_1 CDM 0402 RC 76830 HCPCS inpatient 550 357.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 533.5 97 999999999 333.03 533.5 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 10989305_1 CDM 0402 RC 76830 HCPCS inpatient 550 357.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 379.5 69 999999999 333.03 533.5 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 10989305_1 CDM 0402 RC 76830 HCPCS inpatient 550 357.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 429 78 999999999 333.03 533.5 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 10989305_1 CDM 0402 RC 76830 HCPCS inpatient 550 357.5 UMR - ALL PLANS UMR - ALL PLANS 385 70 999999999 333.03 533.5 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 10989305_1 CDM 0402 RC 76830 HCPCS inpatient 550 357.5 SIHO - ALL PLANS SIHO - ALL PLANS 495 90 999999999 333.03 533.5 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 10989305_1 CDM 0402 RC 76830 HCPCS inpatient 550 357.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 333.03 60.55 999999999 333.03 533.5 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 10989305_1 CDM 0402 RC 76830 HCPCS inpatient 550 357.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 333.03 533.5 "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 10989305_1 CDM 0402 RC 76830 HCPCS inpatient 550 357.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 333.03 533.5 "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 10989305_1 CDM 0402 RC 76830 HCPCS inpatient 550 357.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 333.03 533.5 "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 10989305_1 CDM 0402 RC 76830 HCPCS inpatient 550 357.5 ANTHEM HMO ANTHEM HMO 999999999 333.03 533.5 "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 10989305_1 CDM 0402 RC 76830 HCPCS inpatient 550 357.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 333.03 533.5 "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 10989305_1 CDM 0402 RC 76830 HCPCS inpatient 550 357.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 371.8 67.6 999999999 333.03 533.5 percent of total billed charges Nuclear medicine study of liver and bile duct system with use of drugs 10989351_1 CDM 0341 RC 78227 HCPCS inpatient 2534 1647.1 AETNA AETNA 2001.86 79 999999999 1534.34 2457.98 percent of total billed charges Nuclear medicine study of liver and bile duct system with use of drugs 10989351_1 CDM 0341 RC 78227 HCPCS inpatient 2534 1647.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1647.1 65 999999999 1534.34 2457.98 percent of total billed charges Nuclear medicine study of liver and bile duct system with use of drugs 10989351_1 CDM 0341 RC 78227 HCPCS inpatient 2534 1647.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2457.98 97 999999999 1534.34 2457.98 percent of total billed charges Nuclear medicine study of liver and bile duct system with use of drugs 10989351_1 CDM 0341 RC 78227 HCPCS inpatient 2534 1647.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 1748.46 69 999999999 1534.34 2457.98 percent of total billed charges Nuclear medicine study of liver and bile duct system with use of drugs 10989351_1 CDM 0341 RC 78227 HCPCS inpatient 2534 1647.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1976.52 78 999999999 1534.34 2457.98 percent of total billed charges Nuclear medicine study of liver and bile duct system with use of drugs 10989351_1 CDM 0341 RC 78227 HCPCS inpatient 2534 1647.1 UMR - ALL PLANS UMR - ALL PLANS 1773.8 70 999999999 1534.34 2457.98 percent of total billed charges Nuclear medicine study of liver and bile duct system with use of drugs 10989351_1 CDM 0341 RC 78227 HCPCS inpatient 2534 1647.1 SIHO - ALL PLANS SIHO - ALL PLANS 2280.6 90 999999999 1534.34 2457.98 percent of total billed charges Nuclear medicine study of liver and bile duct system with use of drugs 10989351_1 CDM 0341 RC 78227 HCPCS inpatient 2534 1647.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1534.34 60.55 999999999 1534.34 2457.98 percent of total billed charges Nuclear medicine study of liver and bile duct system with use of drugs 10989351_1 CDM 0341 RC 78227 HCPCS inpatient 2534 1647.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1534.34 2457.98 Nuclear medicine study of liver and bile duct system with use of drugs 10989351_1 CDM 0341 RC 78227 HCPCS inpatient 2534 1647.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1534.34 2457.98 Nuclear medicine study of liver and bile duct system with use of drugs 10989351_1 CDM 0341 RC 78227 HCPCS inpatient 2534 1647.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1534.34 2457.98 Nuclear medicine study of liver and bile duct system with use of drugs 10989351_1 CDM 0341 RC 78227 HCPCS inpatient 2534 1647.1 ANTHEM HMO ANTHEM HMO 999999999 1534.34 2457.98 Nuclear medicine study of liver and bile duct system with use of drugs 10989351_1 CDM 0341 RC 78227 HCPCS inpatient 2534 1647.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1534.34 2457.98 Nuclear medicine study of liver and bile duct system with use of drugs 10989351_1 CDM 0341 RC 78227 HCPCS inpatient 2534 1647.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1712.98 67.6 999999999 1534.34 2457.98 percent of total billed charges Ultrasonic guidance for needle placement 10989387_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 10989387_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 10989387_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 10989387_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 10989387_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 10989387_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 10989387_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 10989387_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 10989387_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 10989387_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 10989387_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 10989387_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Ultrasonic guidance for needle placement 10989387_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 10989387_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges CT scan of chest before and after contrast 1102623_1 CDM 0352 RC 71270 HCPCS inpatient 489 317.85 AETNA AETNA 386.31 79 999999999 296.09 474.33 percent of total billed charges CT scan of chest before and after contrast 1102623_1 CDM 0352 RC 71270 HCPCS inpatient 489 317.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 317.85 65 999999999 296.09 474.33 percent of total billed charges CT scan of chest before and after contrast 1102623_1 CDM 0352 RC 71270 HCPCS inpatient 489 317.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 474.33 97 999999999 296.09 474.33 percent of total billed charges CT scan of chest before and after contrast 1102623_1 CDM 0352 RC 71270 HCPCS inpatient 489 317.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 337.41 69 999999999 296.09 474.33 percent of total billed charges CT scan of chest before and after contrast 1102623_1 CDM 0352 RC 71270 HCPCS inpatient 489 317.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 381.42 78 999999999 296.09 474.33 percent of total billed charges CT scan of chest before and after contrast 1102623_1 CDM 0352 RC 71270 HCPCS inpatient 489 317.85 UMR - ALL PLANS UMR - ALL PLANS 342.3 70 999999999 296.09 474.33 percent of total billed charges CT scan of chest before and after contrast 1102623_1 CDM 0352 RC 71270 HCPCS inpatient 489 317.85 SIHO - ALL PLANS SIHO - ALL PLANS 440.1 90 999999999 296.09 474.33 percent of total billed charges CT scan of chest before and after contrast 1102623_1 CDM 0352 RC 71270 HCPCS inpatient 489 317.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 296.09 60.55 999999999 296.09 474.33 percent of total billed charges CT scan of chest before and after contrast 1102623_1 CDM 0352 RC 71270 HCPCS inpatient 489 317.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 296.09 474.33 CT scan of chest before and after contrast 1102623_1 CDM 0352 RC 71270 HCPCS inpatient 489 317.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 296.09 474.33 CT scan of chest before and after contrast 1102623_1 CDM 0352 RC 71270 HCPCS inpatient 489 317.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 296.09 474.33 CT scan of chest before and after contrast 1102623_1 CDM 0352 RC 71270 HCPCS inpatient 489 317.85 ANTHEM HMO ANTHEM HMO 999999999 296.09 474.33 CT scan of chest before and after contrast 1102623_1 CDM 0352 RC 71270 HCPCS inpatient 489 317.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 296.09 474.33 CT scan of chest before and after contrast 1102623_1 CDM 0352 RC 71270 HCPCS inpatient 489 317.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 330.56 67.6 999999999 296.09 474.33 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - OBSTETRICS (OB) 11040767_1 CDM 0112 RC inpatient 1618 1051.7 AETNA AETNA 1278.22 79 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - OBSTETRICS (OB) 11040767_1 CDM 0112 RC inpatient 1618 1051.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1051.7 65 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - OBSTETRICS (OB) 11040767_1 CDM 0112 RC inpatient 1618 1051.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1569.46 97 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - OBSTETRICS (OB) 11040767_1 CDM 0112 RC inpatient 1618 1051.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1116.42 69 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - OBSTETRICS (OB) 11040767_1 CDM 0112 RC inpatient 1618 1051.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1262.04 78 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - OBSTETRICS (OB) 11040767_1 CDM 0112 RC inpatient 1618 1051.7 UMR - ALL PLANS UMR - ALL PLANS 1132.6 70 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - OBSTETRICS (OB) 11040767_1 CDM 0112 RC inpatient 1618 1051.7 SIHO - ALL PLANS SIHO - ALL PLANS 1456.2 90 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - OBSTETRICS (OB) 11040767_1 CDM 0112 RC inpatient 1618 1051.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 979.7 60.55 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - OBSTETRICS (OB) 11040767_1 CDM 0112 RC inpatient 1618 1051.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 979.7 1569.46 ROOM & BOARD - PRIVATE (ONE BED) - OBSTETRICS (OB) 11040767_1 CDM 0112 RC inpatient 1618 1051.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 979.7 1569.46 ROOM & BOARD - PRIVATE (ONE BED) - OBSTETRICS (OB) 11040767_1 CDM 0112 RC inpatient 1618 1051.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 979.7 1569.46 ROOM & BOARD - PRIVATE (ONE BED) - OBSTETRICS (OB) 11040767_1 CDM 0112 RC inpatient 1618 1051.7 ANTHEM HMO ANTHEM HMO 999999999 979.7 1569.46 ROOM & BOARD - PRIVATE (ONE BED) - OBSTETRICS (OB) 11040767_1 CDM 0112 RC inpatient 1618 1051.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 979.7 1569.46 ROOM & BOARD - PRIVATE (ONE BED) - OBSTETRICS (OB) 11040767_1 CDM 0112 RC inpatient 1618 1051.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1093.77 67.6 999999999 979.7 1569.46 percent of total billed charges "Red blood count automated, with additional calculations" 11040896_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges "Red blood count automated, with additional calculations" 11040896_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges "Red blood count automated, with additional calculations" 11040896_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges "Red blood count automated, with additional calculations" 11040896_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges "Red blood count automated, with additional calculations" 11040896_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges "Red blood count automated, with additional calculations" 11040896_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges "Red blood count automated, with additional calculations" 11040896_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges "Red blood count automated, with additional calculations" 11040896_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges "Red blood count automated, with additional calculations" 11040896_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 "Red blood count automated, with additional calculations" 11040896_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 "Red blood count automated, with additional calculations" 11040896_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 "Red blood count automated, with additional calculations" 11040896_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 "Red blood count automated, with additional calculations" 11040896_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 "Red blood count automated, with additional calculations" 11040896_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges Application of lower and upper arm splint 11109095_1 CDM 0430 RC 29105 HCPCS inpatient 490 318.5 AETNA AETNA 387.1 79 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 11109095_1 CDM 0430 RC 29105 HCPCS inpatient 490 318.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 318.5 65 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 11109095_1 CDM 0430 RC 29105 HCPCS inpatient 490 318.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 475.3 97 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 11109095_1 CDM 0430 RC 29105 HCPCS inpatient 490 318.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 338.1 69 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 11109095_1 CDM 0430 RC 29105 HCPCS inpatient 490 318.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 382.2 78 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 11109095_1 CDM 0430 RC 29105 HCPCS inpatient 490 318.5 UMR - ALL PLANS UMR - ALL PLANS 343 70 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 11109095_1 CDM 0430 RC 29105 HCPCS inpatient 490 318.5 SIHO - ALL PLANS SIHO - ALL PLANS 441 90 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 11109095_1 CDM 0430 RC 29105 HCPCS inpatient 490 318.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 296.7 60.55 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 11109095_1 CDM 0430 RC 29105 HCPCS inpatient 490 318.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 296.7 475.3 Application of lower and upper arm splint 11109095_1 CDM 0430 RC 29105 HCPCS inpatient 490 318.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 296.7 475.3 Application of lower and upper arm splint 11109095_1 CDM 0430 RC 29105 HCPCS inpatient 490 318.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 296.7 475.3 Application of lower and upper arm splint 11109095_1 CDM 0430 RC 29105 HCPCS inpatient 490 318.5 ANTHEM HMO ANTHEM HMO 999999999 296.7 475.3 Application of lower and upper arm splint 11109095_1 CDM 0430 RC 29105 HCPCS inpatient 490 318.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 296.7 475.3 Application of lower and upper arm splint 11109095_1 CDM 0430 RC 29105 HCPCS inpatient 490 318.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 331.24 67.6 999999999 296.7 475.3 percent of total billed charges Application of nonmoveable finger splint 11109098_1 CDM 0430 RC 29130 HCPCS inpatient 404 262.6 AETNA AETNA 319.16 79 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 11109098_1 CDM 0430 RC 29130 HCPCS inpatient 404 262.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 262.6 65 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 11109098_1 CDM 0430 RC 29130 HCPCS inpatient 404 262.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 391.88 97 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 11109098_1 CDM 0430 RC 29130 HCPCS inpatient 404 262.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 278.76 69 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 11109098_1 CDM 0430 RC 29130 HCPCS inpatient 404 262.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 315.12 78 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 11109098_1 CDM 0430 RC 29130 HCPCS inpatient 404 262.6 UMR - ALL PLANS UMR - ALL PLANS 282.8 70 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 11109098_1 CDM 0430 RC 29130 HCPCS inpatient 404 262.6 SIHO - ALL PLANS SIHO - ALL PLANS 363.6 90 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 11109098_1 CDM 0430 RC 29130 HCPCS inpatient 404 262.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 244.62 60.55 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 11109098_1 CDM 0430 RC 29130 HCPCS inpatient 404 262.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 244.62 391.88 Application of nonmoveable finger splint 11109098_1 CDM 0430 RC 29130 HCPCS inpatient 404 262.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 244.62 391.88 Application of nonmoveable finger splint 11109098_1 CDM 0430 RC 29130 HCPCS inpatient 404 262.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 244.62 391.88 Application of nonmoveable finger splint 11109098_1 CDM 0430 RC 29130 HCPCS inpatient 404 262.6 ANTHEM HMO ANTHEM HMO 999999999 244.62 391.88 Application of nonmoveable finger splint 11109098_1 CDM 0430 RC 29130 HCPCS inpatient 404 262.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 244.62 391.88 Application of nonmoveable finger splint 11109098_1 CDM 0430 RC 29130 HCPCS inpatient 404 262.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 273.1 67.6 999999999 244.62 391.88 percent of total billed charges Evaluation of swallowing function image 11109125_1 CDM 0444 RC 92611 HCPCS inpatient 673 437.45 AETNA AETNA 531.67 79 999999999 407.5 652.81 percent of total billed charges Evaluation of swallowing function image 11109125_1 CDM 0444 RC 92611 HCPCS inpatient 673 437.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 437.45 65 999999999 407.5 652.81 percent of total billed charges Evaluation of swallowing function image 11109125_1 CDM 0444 RC 92611 HCPCS inpatient 673 437.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 652.81 97 999999999 407.5 652.81 percent of total billed charges Evaluation of swallowing function image 11109125_1 CDM 0444 RC 92611 HCPCS inpatient 673 437.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 464.37 69 999999999 407.5 652.81 percent of total billed charges Evaluation of swallowing function image 11109125_1 CDM 0444 RC 92611 HCPCS inpatient 673 437.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 524.94 78 999999999 407.5 652.81 percent of total billed charges Evaluation of swallowing function image 11109125_1 CDM 0444 RC 92611 HCPCS inpatient 673 437.45 UMR - ALL PLANS UMR - ALL PLANS 471.1 70 999999999 407.5 652.81 percent of total billed charges Evaluation of swallowing function image 11109125_1 CDM 0444 RC 92611 HCPCS inpatient 673 437.45 SIHO - ALL PLANS SIHO - ALL PLANS 605.7 90 999999999 407.5 652.81 percent of total billed charges Evaluation of swallowing function image 11109125_1 CDM 0444 RC 92611 HCPCS inpatient 673 437.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 407.5 60.55 999999999 407.5 652.81 percent of total billed charges Evaluation of swallowing function image 11109125_1 CDM 0444 RC 92611 HCPCS inpatient 673 437.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 407.5 652.81 Evaluation of swallowing function image 11109125_1 CDM 0444 RC 92611 HCPCS inpatient 673 437.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 407.5 652.81 Evaluation of swallowing function image 11109125_1 CDM 0444 RC 92611 HCPCS inpatient 673 437.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 407.5 652.81 Evaluation of swallowing function image 11109125_1 CDM 0444 RC 92611 HCPCS inpatient 673 437.45 ANTHEM HMO ANTHEM HMO 999999999 407.5 652.81 Evaluation of swallowing function image 11109125_1 CDM 0444 RC 92611 HCPCS inpatient 673 437.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 407.5 652.81 Evaluation of swallowing function image 11109125_1 CDM 0444 RC 92611 HCPCS inpatient 673 437.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 454.95 67.6 999999999 407.5 652.81 percent of total billed charges Evaluation of use of breathing device 11201889_1 CDM 0460 RC 94664 HCPCS inpatient 175 113.75 AETNA AETNA 138.25 79 999999999 105.96 169.75 percent of total billed charges Evaluation of use of breathing device 11201889_1 CDM 0460 RC 94664 HCPCS inpatient 175 113.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 113.75 65 999999999 105.96 169.75 percent of total billed charges Evaluation of use of breathing device 11201889_1 CDM 0460 RC 94664 HCPCS inpatient 175 113.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 169.75 97 999999999 105.96 169.75 percent of total billed charges Evaluation of use of breathing device 11201889_1 CDM 0460 RC 94664 HCPCS inpatient 175 113.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 120.75 69 999999999 105.96 169.75 percent of total billed charges Evaluation of use of breathing device 11201889_1 CDM 0460 RC 94664 HCPCS inpatient 175 113.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 136.5 78 999999999 105.96 169.75 percent of total billed charges Evaluation of use of breathing device 11201889_1 CDM 0460 RC 94664 HCPCS inpatient 175 113.75 UMR - ALL PLANS UMR - ALL PLANS 122.5 70 999999999 105.96 169.75 percent of total billed charges Evaluation of use of breathing device 11201889_1 CDM 0460 RC 94664 HCPCS inpatient 175 113.75 SIHO - ALL PLANS SIHO - ALL PLANS 157.5 90 999999999 105.96 169.75 percent of total billed charges Evaluation of use of breathing device 11201889_1 CDM 0460 RC 94664 HCPCS inpatient 175 113.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 105.96 60.55 999999999 105.96 169.75 percent of total billed charges Evaluation of use of breathing device 11201889_1 CDM 0460 RC 94664 HCPCS inpatient 175 113.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 105.96 169.75 Evaluation of use of breathing device 11201889_1 CDM 0460 RC 94664 HCPCS inpatient 175 113.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 105.96 169.75 Evaluation of use of breathing device 11201889_1 CDM 0460 RC 94664 HCPCS inpatient 175 113.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 105.96 169.75 Evaluation of use of breathing device 11201889_1 CDM 0460 RC 94664 HCPCS inpatient 175 113.75 ANTHEM HMO ANTHEM HMO 999999999 105.96 169.75 Evaluation of use of breathing device 11201889_1 CDM 0460 RC 94664 HCPCS inpatient 175 113.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 105.96 169.75 Evaluation of use of breathing device 11201889_1 CDM 0460 RC 94664 HCPCS inpatient 175 113.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.3 67.6 999999999 105.96 169.75 percent of total billed charges RT Continuous Neb Subsequent Charge 11201890_1 CDM 0460 RC inpatient 266 172.9 AETNA AETNA 210.14 79 999999999 161.06 258.02 percent of total billed charges RT Continuous Neb Subsequent Charge 11201890_1 CDM 0460 RC inpatient 266 172.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 172.9 65 999999999 161.06 258.02 percent of total billed charges RT Continuous Neb Subsequent Charge 11201890_1 CDM 0460 RC inpatient 266 172.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 258.02 97 999999999 161.06 258.02 percent of total billed charges RT Continuous Neb Subsequent Charge 11201890_1 CDM 0460 RC inpatient 266 172.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 183.54 69 999999999 161.06 258.02 percent of total billed charges RT Continuous Neb Subsequent Charge 11201890_1 CDM 0460 RC inpatient 266 172.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 207.48 78 999999999 161.06 258.02 percent of total billed charges RT Continuous Neb Subsequent Charge 11201890_1 CDM 0460 RC inpatient 266 172.9 UMR - ALL PLANS UMR - ALL PLANS 186.2 70 999999999 161.06 258.02 percent of total billed charges RT Continuous Neb Subsequent Charge 11201890_1 CDM 0460 RC inpatient 266 172.9 SIHO - ALL PLANS SIHO - ALL PLANS 239.4 90 999999999 161.06 258.02 percent of total billed charges RT Continuous Neb Subsequent Charge 11201890_1 CDM 0460 RC inpatient 266 172.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 161.06 60.55 999999999 161.06 258.02 percent of total billed charges RT Continuous Neb Subsequent Charge 11201890_1 CDM 0460 RC inpatient 266 172.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 161.06 258.02 RT Continuous Neb Subsequent Charge 11201890_1 CDM 0460 RC inpatient 266 172.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 161.06 258.02 RT Continuous Neb Subsequent Charge 11201890_1 CDM 0460 RC inpatient 266 172.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 161.06 258.02 RT Continuous Neb Subsequent Charge 11201890_1 CDM 0460 RC inpatient 266 172.9 ANTHEM HMO ANTHEM HMO 999999999 161.06 258.02 RT Continuous Neb Subsequent Charge 11201890_1 CDM 0460 RC inpatient 266 172.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 161.06 258.02 RT Continuous Neb Subsequent Charge 11201890_1 CDM 0460 RC inpatient 266 172.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 179.82 67.6 999999999 161.06 258.02 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 11201894_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 AETNA AETNA 348.39 79 999999999 267.03 427.77 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 11201894_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 286.65 65 999999999 267.03 427.77 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 11201894_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 427.77 97 999999999 267.03 427.77 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 11201894_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 304.29 69 999999999 267.03 427.77 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 11201894_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 343.98 78 999999999 267.03 427.77 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 11201894_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 UMR - ALL PLANS UMR - ALL PLANS 308.7 70 999999999 267.03 427.77 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 11201894_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 SIHO - ALL PLANS SIHO - ALL PLANS 396.9 90 999999999 267.03 427.77 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 11201894_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 267.03 60.55 999999999 267.03 427.77 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 11201894_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 267.03 427.77 Test to measure expiratory airflow and volume changes before and after medication administration 11201894_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 267.03 427.77 Test to measure expiratory airflow and volume changes before and after medication administration 11201894_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 267.03 427.77 Test to measure expiratory airflow and volume changes before and after medication administration 11201894_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 ANTHEM HMO ANTHEM HMO 999999999 267.03 427.77 Test to measure expiratory airflow and volume changes before and after medication administration 11201894_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 267.03 427.77 Test to measure expiratory airflow and volume changes before and after medication administration 11201894_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 298.12 67.6 999999999 267.03 427.77 percent of total billed charges "X-ray of elbow, minimum of 3 views" 11287199_1 CDM 0320 RC 73080 HCPCS inpatient 430 279.5 AETNA AETNA 339.7 79 999999999 260.37 417.1 percent of total billed charges "X-ray of elbow, minimum of 3 views" 11287199_1 CDM 0320 RC 73080 HCPCS inpatient 430 279.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 279.5 65 999999999 260.37 417.1 percent of total billed charges "X-ray of elbow, minimum of 3 views" 11287199_1 CDM 0320 RC 73080 HCPCS inpatient 430 279.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 417.1 97 999999999 260.37 417.1 percent of total billed charges "X-ray of elbow, minimum of 3 views" 11287199_1 CDM 0320 RC 73080 HCPCS inpatient 430 279.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 296.7 69 999999999 260.37 417.1 percent of total billed charges "X-ray of elbow, minimum of 3 views" 11287199_1 CDM 0320 RC 73080 HCPCS inpatient 430 279.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 335.4 78 999999999 260.37 417.1 percent of total billed charges "X-ray of elbow, minimum of 3 views" 11287199_1 CDM 0320 RC 73080 HCPCS inpatient 430 279.5 UMR - ALL PLANS UMR - ALL PLANS 301 70 999999999 260.37 417.1 percent of total billed charges "X-ray of elbow, minimum of 3 views" 11287199_1 CDM 0320 RC 73080 HCPCS inpatient 430 279.5 SIHO - ALL PLANS SIHO - ALL PLANS 387 90 999999999 260.37 417.1 percent of total billed charges "X-ray of elbow, minimum of 3 views" 11287199_1 CDM 0320 RC 73080 HCPCS inpatient 430 279.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 260.37 60.55 999999999 260.37 417.1 percent of total billed charges "X-ray of elbow, minimum of 3 views" 11287199_1 CDM 0320 RC 73080 HCPCS inpatient 430 279.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 260.37 417.1 "X-ray of elbow, minimum of 3 views" 11287199_1 CDM 0320 RC 73080 HCPCS inpatient 430 279.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 260.37 417.1 "X-ray of elbow, minimum of 3 views" 11287199_1 CDM 0320 RC 73080 HCPCS inpatient 430 279.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 260.37 417.1 "X-ray of elbow, minimum of 3 views" 11287199_1 CDM 0320 RC 73080 HCPCS inpatient 430 279.5 ANTHEM HMO ANTHEM HMO 999999999 260.37 417.1 "X-ray of elbow, minimum of 3 views" 11287199_1 CDM 0320 RC 73080 HCPCS inpatient 430 279.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 260.37 417.1 "X-ray of elbow, minimum of 3 views" 11287199_1 CDM 0320 RC 73080 HCPCS inpatient 430 279.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 290.68 67.6 999999999 260.37 417.1 percent of total billed charges "X-ray of elbow, minimum of 3 views" 11287202_1 CDM 0320 RC 73080 HCPCS inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges "X-ray of elbow, minimum of 3 views" 11287202_1 CDM 0320 RC 73080 HCPCS inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges "X-ray of elbow, minimum of 3 views" 11287202_1 CDM 0320 RC 73080 HCPCS inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges "X-ray of elbow, minimum of 3 views" 11287202_1 CDM 0320 RC 73080 HCPCS inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges "X-ray of elbow, minimum of 3 views" 11287202_1 CDM 0320 RC 73080 HCPCS inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges "X-ray of elbow, minimum of 3 views" 11287202_1 CDM 0320 RC 73080 HCPCS inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges "X-ray of elbow, minimum of 3 views" 11287202_1 CDM 0320 RC 73080 HCPCS inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges "X-ray of elbow, minimum of 3 views" 11287202_1 CDM 0320 RC 73080 HCPCS inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges "X-ray of elbow, minimum of 3 views" 11287202_1 CDM 0320 RC 73080 HCPCS inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 "X-ray of elbow, minimum of 3 views" 11287202_1 CDM 0320 RC 73080 HCPCS inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 "X-ray of elbow, minimum of 3 views" 11287202_1 CDM 0320 RC 73080 HCPCS inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 "X-ray of elbow, minimum of 3 views" 11287202_1 CDM 0320 RC 73080 HCPCS inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 "X-ray of elbow, minimum of 3 views" 11287202_1 CDM 0320 RC 73080 HCPCS inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 "X-ray of elbow, minimum of 3 views" 11287202_1 CDM 0320 RC 73080 HCPCS inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 11397016_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 11397016_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 11397016_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 11397016_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 11397016_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 11397016_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 11397016_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 11397016_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 11397016_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 11397016_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 11397016_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 11397016_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 11397016_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 11397016_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges Radioactive drug therapy by mouth 11408816_1 CDM 0342 RC 79005 HCPCS inpatient 2243 1457.95 AETNA AETNA 1771.97 79 999999999 1358.14 2175.71 percent of total billed charges Radioactive drug therapy by mouth 11408816_1 CDM 0342 RC 79005 HCPCS inpatient 2243 1457.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1457.95 65 999999999 1358.14 2175.71 percent of total billed charges Radioactive drug therapy by mouth 11408816_1 CDM 0342 RC 79005 HCPCS inpatient 2243 1457.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2175.71 97 999999999 1358.14 2175.71 percent of total billed charges Radioactive drug therapy by mouth 11408816_1 CDM 0342 RC 79005 HCPCS inpatient 2243 1457.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1547.67 69 999999999 1358.14 2175.71 percent of total billed charges Radioactive drug therapy by mouth 11408816_1 CDM 0342 RC 79005 HCPCS inpatient 2243 1457.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1749.54 78 999999999 1358.14 2175.71 percent of total billed charges Radioactive drug therapy by mouth 11408816_1 CDM 0342 RC 79005 HCPCS inpatient 2243 1457.95 UMR - ALL PLANS UMR - ALL PLANS 1570.1 70 999999999 1358.14 2175.71 percent of total billed charges Radioactive drug therapy by mouth 11408816_1 CDM 0342 RC 79005 HCPCS inpatient 2243 1457.95 SIHO - ALL PLANS SIHO - ALL PLANS 2018.7 90 999999999 1358.14 2175.71 percent of total billed charges Radioactive drug therapy by mouth 11408816_1 CDM 0342 RC 79005 HCPCS inpatient 2243 1457.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1358.14 60.55 999999999 1358.14 2175.71 percent of total billed charges Radioactive drug therapy by mouth 11408816_1 CDM 0342 RC 79005 HCPCS inpatient 2243 1457.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1358.14 2175.71 Radioactive drug therapy by mouth 11408816_1 CDM 0342 RC 79005 HCPCS inpatient 2243 1457.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1358.14 2175.71 Radioactive drug therapy by mouth 11408816_1 CDM 0342 RC 79005 HCPCS inpatient 2243 1457.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1358.14 2175.71 Radioactive drug therapy by mouth 11408816_1 CDM 0342 RC 79005 HCPCS inpatient 2243 1457.95 ANTHEM HMO ANTHEM HMO 999999999 1358.14 2175.71 Radioactive drug therapy by mouth 11408816_1 CDM 0342 RC 79005 HCPCS inpatient 2243 1457.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1358.14 2175.71 Radioactive drug therapy by mouth 11408816_1 CDM 0342 RC 79005 HCPCS inpatient 2243 1457.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1516.27 67.6 999999999 1358.14 2175.71 percent of total billed charges "Calcium level, total" 11444643_1 CDM 0300 RC 82310 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges "Calcium level, total" 11444643_1 CDM 0300 RC 82310 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges "Calcium level, total" 11444643_1 CDM 0300 RC 82310 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges "Calcium level, total" 11444643_1 CDM 0300 RC 82310 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges "Calcium level, total" 11444643_1 CDM 0300 RC 82310 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges "Calcium level, total" 11444643_1 CDM 0300 RC 82310 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges "Calcium level, total" 11444643_1 CDM 0300 RC 82310 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges "Calcium level, total" 11444643_1 CDM 0300 RC 82310 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges "Calcium level, total" 11444643_1 CDM 0300 RC 82310 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 "Calcium level, total" 11444643_1 CDM 0300 RC 82310 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 "Calcium level, total" 11444643_1 CDM 0300 RC 82310 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 "Calcium level, total" 11444643_1 CDM 0300 RC 82310 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 "Calcium level, total" 11444643_1 CDM 0300 RC 82310 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 "Calcium level, total" 11444643_1 CDM 0300 RC 82310 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 11473584_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 11473584_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 11473584_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 11473584_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 11473584_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 11473584_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 11473584_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 11473584_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 11473584_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 "Creatine kinase (cardiac enzyme) level, total" 11473584_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 "Creatine kinase (cardiac enzyme) level, total" 11473584_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 "Creatine kinase (cardiac enzyme) level, total" 11473584_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 "Creatine kinase (cardiac enzyme) level, total" 11473584_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 "Creatine kinase (cardiac enzyme) level, total" 11473584_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges Hepatitis B core antibody measurement 11542345_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 11542345_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 11542345_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 11542345_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 11542345_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 11542345_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 11542345_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 11542345_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 11542345_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 Hepatitis B core antibody measurement 11542345_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 Hepatitis B core antibody measurement 11542345_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 Hepatitis B core antibody measurement 11542345_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 Hepatitis B core antibody measurement 11542345_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 Hepatitis B core antibody measurement 11542345_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges Application of nonmoveable forearm to hand splint 12061393_1 CDM 0430 RC 29125 HCPCS inpatient 404 262.6 AETNA AETNA 319.16 79 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable forearm to hand splint 12061393_1 CDM 0430 RC 29125 HCPCS inpatient 404 262.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 262.6 65 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable forearm to hand splint 12061393_1 CDM 0430 RC 29125 HCPCS inpatient 404 262.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 391.88 97 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable forearm to hand splint 12061393_1 CDM 0430 RC 29125 HCPCS inpatient 404 262.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 278.76 69 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable forearm to hand splint 12061393_1 CDM 0430 RC 29125 HCPCS inpatient 404 262.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 315.12 78 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable forearm to hand splint 12061393_1 CDM 0430 RC 29125 HCPCS inpatient 404 262.6 UMR - ALL PLANS UMR - ALL PLANS 282.8 70 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable forearm to hand splint 12061393_1 CDM 0430 RC 29125 HCPCS inpatient 404 262.6 SIHO - ALL PLANS SIHO - ALL PLANS 363.6 90 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable forearm to hand splint 12061393_1 CDM 0430 RC 29125 HCPCS inpatient 404 262.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 244.62 60.55 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable forearm to hand splint 12061393_1 CDM 0430 RC 29125 HCPCS inpatient 404 262.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 244.62 391.88 Application of nonmoveable forearm to hand splint 12061393_1 CDM 0430 RC 29125 HCPCS inpatient 404 262.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 244.62 391.88 Application of nonmoveable forearm to hand splint 12061393_1 CDM 0430 RC 29125 HCPCS inpatient 404 262.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 244.62 391.88 Application of nonmoveable forearm to hand splint 12061393_1 CDM 0430 RC 29125 HCPCS inpatient 404 262.6 ANTHEM HMO ANTHEM HMO 999999999 244.62 391.88 Application of nonmoveable forearm to hand splint 12061393_1 CDM 0430 RC 29125 HCPCS inpatient 404 262.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 244.62 391.88 Application of nonmoveable forearm to hand splint 12061393_1 CDM 0430 RC 29125 HCPCS inpatient 404 262.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 273.1 67.6 999999999 244.62 391.88 percent of total billed charges Application of moveable or hinged forearm to hand splint 12061394_1 CDM 0430 RC 29126 HCPCS inpatient 336 218.4 AETNA AETNA 265.44 79 999999999 203.45 325.92 percent of total billed charges Application of moveable or hinged forearm to hand splint 12061394_1 CDM 0430 RC 29126 HCPCS inpatient 336 218.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 218.4 65 999999999 203.45 325.92 percent of total billed charges Application of moveable or hinged forearm to hand splint 12061394_1 CDM 0430 RC 29126 HCPCS inpatient 336 218.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 325.92 97 999999999 203.45 325.92 percent of total billed charges Application of moveable or hinged forearm to hand splint 12061394_1 CDM 0430 RC 29126 HCPCS inpatient 336 218.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 231.84 69 999999999 203.45 325.92 percent of total billed charges Application of moveable or hinged forearm to hand splint 12061394_1 CDM 0430 RC 29126 HCPCS inpatient 336 218.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 262.08 78 999999999 203.45 325.92 percent of total billed charges Application of moveable or hinged forearm to hand splint 12061394_1 CDM 0430 RC 29126 HCPCS inpatient 336 218.4 UMR - ALL PLANS UMR - ALL PLANS 235.2 70 999999999 203.45 325.92 percent of total billed charges Application of moveable or hinged forearm to hand splint 12061394_1 CDM 0430 RC 29126 HCPCS inpatient 336 218.4 SIHO - ALL PLANS SIHO - ALL PLANS 302.4 90 999999999 203.45 325.92 percent of total billed charges Application of moveable or hinged forearm to hand splint 12061394_1 CDM 0430 RC 29126 HCPCS inpatient 336 218.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 203.45 60.55 999999999 203.45 325.92 percent of total billed charges Application of moveable or hinged forearm to hand splint 12061394_1 CDM 0430 RC 29126 HCPCS inpatient 336 218.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 203.45 325.92 Application of moveable or hinged forearm to hand splint 12061394_1 CDM 0430 RC 29126 HCPCS inpatient 336 218.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 203.45 325.92 Application of moveable or hinged forearm to hand splint 12061394_1 CDM 0430 RC 29126 HCPCS inpatient 336 218.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 203.45 325.92 Application of moveable or hinged forearm to hand splint 12061394_1 CDM 0430 RC 29126 HCPCS inpatient 336 218.4 ANTHEM HMO ANTHEM HMO 999999999 203.45 325.92 Application of moveable or hinged forearm to hand splint 12061394_1 CDM 0430 RC 29126 HCPCS inpatient 336 218.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 203.45 325.92 Application of moveable or hinged forearm to hand splint 12061394_1 CDM 0430 RC 29126 HCPCS inpatient 336 218.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 227.14 67.6 999999999 203.45 325.92 percent of total billed charges Creatinine level to test for kidney function or muscle injury 12166925_1 CDM 0301 RC 82570 HCPCS inpatient 195 126.75 AETNA AETNA 154.05 79 999999999 118.07 189.15 percent of total billed charges Creatinine level to test for kidney function or muscle injury 12166925_1 CDM 0301 RC 82570 HCPCS inpatient 195 126.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 126.75 65 999999999 118.07 189.15 percent of total billed charges Creatinine level to test for kidney function or muscle injury 12166925_1 CDM 0301 RC 82570 HCPCS inpatient 195 126.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 189.15 97 999999999 118.07 189.15 percent of total billed charges Creatinine level to test for kidney function or muscle injury 12166925_1 CDM 0301 RC 82570 HCPCS inpatient 195 126.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 134.55 69 999999999 118.07 189.15 percent of total billed charges Creatinine level to test for kidney function or muscle injury 12166925_1 CDM 0301 RC 82570 HCPCS inpatient 195 126.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 152.1 78 999999999 118.07 189.15 percent of total billed charges Creatinine level to test for kidney function or muscle injury 12166925_1 CDM 0301 RC 82570 HCPCS inpatient 195 126.75 UMR - ALL PLANS UMR - ALL PLANS 136.5 70 999999999 118.07 189.15 percent of total billed charges Creatinine level to test for kidney function or muscle injury 12166925_1 CDM 0301 RC 82570 HCPCS inpatient 195 126.75 SIHO - ALL PLANS SIHO - ALL PLANS 175.5 90 999999999 118.07 189.15 percent of total billed charges Creatinine level to test for kidney function or muscle injury 12166925_1 CDM 0301 RC 82570 HCPCS inpatient 195 126.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 118.07 60.55 999999999 118.07 189.15 percent of total billed charges Creatinine level to test for kidney function or muscle injury 12166925_1 CDM 0301 RC 82570 HCPCS inpatient 195 126.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 118.07 189.15 Creatinine level to test for kidney function or muscle injury 12166925_1 CDM 0301 RC 82570 HCPCS inpatient 195 126.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 118.07 189.15 Creatinine level to test for kidney function or muscle injury 12166925_1 CDM 0301 RC 82570 HCPCS inpatient 195 126.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 118.07 189.15 Creatinine level to test for kidney function or muscle injury 12166925_1 CDM 0301 RC 82570 HCPCS inpatient 195 126.75 ANTHEM HMO ANTHEM HMO 999999999 118.07 189.15 Creatinine level to test for kidney function or muscle injury 12166925_1 CDM 0301 RC 82570 HCPCS inpatient 195 126.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 118.07 189.15 Creatinine level to test for kidney function or muscle injury 12166925_1 CDM 0301 RC 82570 HCPCS inpatient 195 126.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 131.82 67.6 999999999 118.07 189.15 percent of total billed charges Urine microalbumin (protein) level 12182921_1 CDM 0301 RC 82043 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges Urine microalbumin (protein) level 12182921_1 CDM 0301 RC 82043 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges Urine microalbumin (protein) level 12182921_1 CDM 0301 RC 82043 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges Urine microalbumin (protein) level 12182921_1 CDM 0301 RC 82043 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges Urine microalbumin (protein) level 12182921_1 CDM 0301 RC 82043 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges Urine microalbumin (protein) level 12182921_1 CDM 0301 RC 82043 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges Urine microalbumin (protein) level 12182921_1 CDM 0301 RC 82043 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges Urine microalbumin (protein) level 12182921_1 CDM 0301 RC 82043 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges Urine microalbumin (protein) level 12182921_1 CDM 0301 RC 82043 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 Urine microalbumin (protein) level 12182921_1 CDM 0301 RC 82043 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 Urine microalbumin (protein) level 12182921_1 CDM 0301 RC 82043 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 Urine microalbumin (protein) level 12182921_1 CDM 0301 RC 82043 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 Urine microalbumin (protein) level 12182921_1 CDM 0301 RC 82043 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 Urine microalbumin (protein) level 12182921_1 CDM 0301 RC 82043 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges Evaluation of use of breathing device 12436883_1 CDM 0410 RC 94664 HCPCS inpatient 239 155.35 AETNA AETNA 188.81 79 999999999 144.71 231.83 percent of total billed charges Evaluation of use of breathing device 12436883_1 CDM 0410 RC 94664 HCPCS inpatient 239 155.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 155.35 65 999999999 144.71 231.83 percent of total billed charges Evaluation of use of breathing device 12436883_1 CDM 0410 RC 94664 HCPCS inpatient 239 155.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 231.83 97 999999999 144.71 231.83 percent of total billed charges Evaluation of use of breathing device 12436883_1 CDM 0410 RC 94664 HCPCS inpatient 239 155.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.91 69 999999999 144.71 231.83 percent of total billed charges Evaluation of use of breathing device 12436883_1 CDM 0410 RC 94664 HCPCS inpatient 239 155.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 186.42 78 999999999 144.71 231.83 percent of total billed charges Evaluation of use of breathing device 12436883_1 CDM 0410 RC 94664 HCPCS inpatient 239 155.35 UMR - ALL PLANS UMR - ALL PLANS 167.3 70 999999999 144.71 231.83 percent of total billed charges Evaluation of use of breathing device 12436883_1 CDM 0410 RC 94664 HCPCS inpatient 239 155.35 SIHO - ALL PLANS SIHO - ALL PLANS 215.1 90 999999999 144.71 231.83 percent of total billed charges Evaluation of use of breathing device 12436883_1 CDM 0410 RC 94664 HCPCS inpatient 239 155.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.71 60.55 999999999 144.71 231.83 percent of total billed charges Evaluation of use of breathing device 12436883_1 CDM 0410 RC 94664 HCPCS inpatient 239 155.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.71 231.83 Evaluation of use of breathing device 12436883_1 CDM 0410 RC 94664 HCPCS inpatient 239 155.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.71 231.83 Evaluation of use of breathing device 12436883_1 CDM 0410 RC 94664 HCPCS inpatient 239 155.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.71 231.83 Evaluation of use of breathing device 12436883_1 CDM 0410 RC 94664 HCPCS inpatient 239 155.35 ANTHEM HMO ANTHEM HMO 999999999 144.71 231.83 Evaluation of use of breathing device 12436883_1 CDM 0410 RC 94664 HCPCS inpatient 239 155.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.71 231.83 Evaluation of use of breathing device 12436883_1 CDM 0410 RC 94664 HCPCS inpatient 239 155.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 161.56 67.6 999999999 144.71 231.83 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436884_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 AETNA AETNA 182.49 79 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436884_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 150.15 65 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436884_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 224.07 97 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436884_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 159.39 69 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436884_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 180.18 78 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436884_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 UMR - ALL PLANS UMR - ALL PLANS 161.7 70 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436884_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 SIHO - ALL PLANS SIHO - ALL PLANS 207.9 90 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436884_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 139.87 60.55 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436884_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 12436884_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 12436884_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 12436884_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM HMO ANTHEM HMO 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 12436884_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 12436884_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 156.16 67.6 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436889_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 AETNA AETNA 182.49 79 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436889_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 150.15 65 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436889_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 224.07 97 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436889_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 159.39 69 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436889_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 180.18 78 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436889_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 UMR - ALL PLANS UMR - ALL PLANS 161.7 70 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436889_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 SIHO - ALL PLANS SIHO - ALL PLANS 207.9 90 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436889_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 139.87 60.55 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436889_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 12436889_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 12436889_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 12436889_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM HMO ANTHEM HMO 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 12436889_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 12436889_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 156.16 67.6 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436890_1 CDM 0410 RC 94640 HCPCS inpatient 188 122.2 AETNA AETNA 148.52 79 999999999 113.83 182.36 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436890_1 CDM 0410 RC 94640 HCPCS inpatient 188 122.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.2 65 999999999 113.83 182.36 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436890_1 CDM 0410 RC 94640 HCPCS inpatient 188 122.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 182.36 97 999999999 113.83 182.36 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436890_1 CDM 0410 RC 94640 HCPCS inpatient 188 122.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.72 69 999999999 113.83 182.36 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436890_1 CDM 0410 RC 94640 HCPCS inpatient 188 122.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 146.64 78 999999999 113.83 182.36 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436890_1 CDM 0410 RC 94640 HCPCS inpatient 188 122.2 UMR - ALL PLANS UMR - ALL PLANS 131.6 70 999999999 113.83 182.36 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436890_1 CDM 0410 RC 94640 HCPCS inpatient 188 122.2 SIHO - ALL PLANS SIHO - ALL PLANS 169.2 90 999999999 113.83 182.36 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436890_1 CDM 0410 RC 94640 HCPCS inpatient 188 122.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.83 60.55 999999999 113.83 182.36 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 12436890_1 CDM 0410 RC 94640 HCPCS inpatient 188 122.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.83 182.36 Inhalation treatment for airway obstruction or sputum production 12436890_1 CDM 0410 RC 94640 HCPCS inpatient 188 122.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.83 182.36 Inhalation treatment for airway obstruction or sputum production 12436890_1 CDM 0410 RC 94640 HCPCS inpatient 188 122.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.83 182.36 Inhalation treatment for airway obstruction or sputum production 12436890_1 CDM 0410 RC 94640 HCPCS inpatient 188 122.2 ANTHEM HMO ANTHEM HMO 999999999 113.83 182.36 Inhalation treatment for airway obstruction or sputum production 12436890_1 CDM 0410 RC 94640 HCPCS inpatient 188 122.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.83 182.36 Inhalation treatment for airway obstruction or sputum production 12436890_1 CDM 0410 RC 94640 HCPCS inpatient 188 122.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.09 67.6 999999999 113.83 182.36 percent of total billed charges Application of mechanical traction 12820907_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 AETNA AETNA 168.27 79 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 12820907_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 138.45 65 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 12820907_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 206.61 97 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 12820907_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 146.97 69 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 12820907_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 166.14 78 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 12820907_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 UMR - ALL PLANS UMR - ALL PLANS 149.1 70 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 12820907_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 SIHO - ALL PLANS SIHO - ALL PLANS 191.7 90 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 12820907_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 128.97 60.55 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 12820907_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 128.97 206.61 Application of mechanical traction 12820907_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 128.97 206.61 Application of mechanical traction 12820907_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 128.97 206.61 Application of mechanical traction 12820907_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 ANTHEM HMO ANTHEM HMO 999999999 128.97 206.61 Application of mechanical traction 12820907_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 128.97 206.61 Application of mechanical traction 12820907_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 143.99 67.6 999999999 128.97 206.61 percent of total billed charges Test to measure the total volume of air that can be exhaled after inhaling 12969358_1 CDM 0410 RC 94150 HCPCS inpatient 280 182 AETNA AETNA 221.2 79 999999999 169.54 271.6 percent of total billed charges Test to measure the total volume of air that can be exhaled after inhaling 12969358_1 CDM 0410 RC 94150 HCPCS inpatient 280 182 SELF PAY DISCOUNT SELF PAY DISCOUNT 182 65 999999999 169.54 271.6 percent of total billed charges Test to measure the total volume of air that can be exhaled after inhaling 12969358_1 CDM 0410 RC 94150 HCPCS inpatient 280 182 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 271.6 97 999999999 169.54 271.6 percent of total billed charges Test to measure the total volume of air that can be exhaled after inhaling 12969358_1 CDM 0410 RC 94150 HCPCS inpatient 280 182 ENCORE - ALL PLANS ENCORE - ALL PLANS 193.2 69 999999999 169.54 271.6 percent of total billed charges Test to measure the total volume of air that can be exhaled after inhaling 12969358_1 CDM 0410 RC 94150 HCPCS inpatient 280 182 HUMANA - ALL PLANS HUMANA - ALL PLANS 218.4 78 999999999 169.54 271.6 percent of total billed charges Test to measure the total volume of air that can be exhaled after inhaling 12969358_1 CDM 0410 RC 94150 HCPCS inpatient 280 182 UMR - ALL PLANS UMR - ALL PLANS 196 70 999999999 169.54 271.6 percent of total billed charges Test to measure the total volume of air that can be exhaled after inhaling 12969358_1 CDM 0410 RC 94150 HCPCS inpatient 280 182 SIHO - ALL PLANS SIHO - ALL PLANS 252 90 999999999 169.54 271.6 percent of total billed charges Test to measure the total volume of air that can be exhaled after inhaling 12969358_1 CDM 0410 RC 94150 HCPCS inpatient 280 182 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 169.54 60.55 999999999 169.54 271.6 percent of total billed charges Test to measure the total volume of air that can be exhaled after inhaling 12969358_1 CDM 0410 RC 94150 HCPCS inpatient 280 182 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 169.54 271.6 Test to measure the total volume of air that can be exhaled after inhaling 12969358_1 CDM 0410 RC 94150 HCPCS inpatient 280 182 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 169.54 271.6 Test to measure the total volume of air that can be exhaled after inhaling 12969358_1 CDM 0410 RC 94150 HCPCS inpatient 280 182 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 169.54 271.6 Test to measure the total volume of air that can be exhaled after inhaling 12969358_1 CDM 0410 RC 94150 HCPCS inpatient 280 182 ANTHEM HMO ANTHEM HMO 999999999 169.54 271.6 Test to measure the total volume of air that can be exhaled after inhaling 12969358_1 CDM 0410 RC 94150 HCPCS inpatient 280 182 UHC - ALL PLANS UHC - ALL PLANS 999999999 169.54 271.6 Test to measure the total volume of air that can be exhaled after inhaling 12969358_1 CDM 0410 RC 94150 HCPCS inpatient 280 182 CIGNA - ALL PLANS CIGNA - ALL PLANS 189.28 67.6 999999999 169.54 271.6 percent of total billed charges Insertion of needle into vein for collection of blood sample 12994894_1 CDM 0300 RC 36415 HCPCS inpatient 47 30.55 AETNA AETNA 37.13 79 999999999 28.46 45.59 percent of total billed charges Insertion of needle into vein for collection of blood sample 12994894_1 CDM 0300 RC 36415 HCPCS inpatient 47 30.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 30.55 65 999999999 28.46 45.59 percent of total billed charges Insertion of needle into vein for collection of blood sample 12994894_1 CDM 0300 RC 36415 HCPCS inpatient 47 30.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 45.59 97 999999999 28.46 45.59 percent of total billed charges Insertion of needle into vein for collection of blood sample 12994894_1 CDM 0300 RC 36415 HCPCS inpatient 47 30.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 32.43 69 999999999 28.46 45.59 percent of total billed charges Insertion of needle into vein for collection of blood sample 12994894_1 CDM 0300 RC 36415 HCPCS inpatient 47 30.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 36.66 78 999999999 28.46 45.59 percent of total billed charges Insertion of needle into vein for collection of blood sample 12994894_1 CDM 0300 RC 36415 HCPCS inpatient 47 30.55 UMR - ALL PLANS UMR - ALL PLANS 32.9 70 999999999 28.46 45.59 percent of total billed charges Insertion of needle into vein for collection of blood sample 12994894_1 CDM 0300 RC 36415 HCPCS inpatient 47 30.55 SIHO - ALL PLANS SIHO - ALL PLANS 42.3 90 999999999 28.46 45.59 percent of total billed charges Insertion of needle into vein for collection of blood sample 12994894_1 CDM 0300 RC 36415 HCPCS inpatient 47 30.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 28.46 60.55 999999999 28.46 45.59 percent of total billed charges Insertion of needle into vein for collection of blood sample 12994894_1 CDM 0300 RC 36415 HCPCS inpatient 47 30.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 28.46 45.59 Insertion of needle into vein for collection of blood sample 12994894_1 CDM 0300 RC 36415 HCPCS inpatient 47 30.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 28.46 45.59 Insertion of needle into vein for collection of blood sample 12994894_1 CDM 0300 RC 36415 HCPCS inpatient 47 30.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 28.46 45.59 Insertion of needle into vein for collection of blood sample 12994894_1 CDM 0300 RC 36415 HCPCS inpatient 47 30.55 ANTHEM HMO ANTHEM HMO 999999999 28.46 45.59 Insertion of needle into vein for collection of blood sample 12994894_1 CDM 0300 RC 36415 HCPCS inpatient 47 30.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 28.46 45.59 Insertion of needle into vein for collection of blood sample 12994894_1 CDM 0300 RC 36415 HCPCS inpatient 47 30.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 31.77 67.6 999999999 28.46 45.59 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 12994896_1 CDM 0302 RC 85460 HCPCS inpatient 192 124.8 AETNA AETNA 151.68 79 999999999 116.26 186.24 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 12994896_1 CDM 0302 RC 85460 HCPCS inpatient 192 124.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 124.8 65 999999999 116.26 186.24 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 12994896_1 CDM 0302 RC 85460 HCPCS inpatient 192 124.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 186.24 97 999999999 116.26 186.24 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 12994896_1 CDM 0302 RC 85460 HCPCS inpatient 192 124.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 132.48 69 999999999 116.26 186.24 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 12994896_1 CDM 0302 RC 85460 HCPCS inpatient 192 124.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 149.76 78 999999999 116.26 186.24 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 12994896_1 CDM 0302 RC 85460 HCPCS inpatient 192 124.8 UMR - ALL PLANS UMR - ALL PLANS 134.4 70 999999999 116.26 186.24 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 12994896_1 CDM 0302 RC 85460 HCPCS inpatient 192 124.8 SIHO - ALL PLANS SIHO - ALL PLANS 172.8 90 999999999 116.26 186.24 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 12994896_1 CDM 0302 RC 85460 HCPCS inpatient 192 124.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.26 60.55 999999999 116.26 186.24 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 12994896_1 CDM 0302 RC 85460 HCPCS inpatient 192 124.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.26 186.24 "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 12994896_1 CDM 0302 RC 85460 HCPCS inpatient 192 124.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.26 186.24 "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 12994896_1 CDM 0302 RC 85460 HCPCS inpatient 192 124.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.26 186.24 "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 12994896_1 CDM 0302 RC 85460 HCPCS inpatient 192 124.8 ANTHEM HMO ANTHEM HMO 999999999 116.26 186.24 "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 12994896_1 CDM 0302 RC 85460 HCPCS inpatient 192 124.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.26 186.24 "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 12994896_1 CDM 0302 RC 85460 HCPCS inpatient 192 124.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 129.79 67.6 999999999 116.26 186.24 percent of total billed charges CT scan of blood vessels of chest with contrast 1339986_1 CDM 0352 RC 71275 HCPCS inpatient 3248 2111.2 AETNA AETNA 2565.92 79 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of chest with contrast 1339986_1 CDM 0352 RC 71275 HCPCS inpatient 3248 2111.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 2111.2 65 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of chest with contrast 1339986_1 CDM 0352 RC 71275 HCPCS inpatient 3248 2111.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3150.56 97 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of chest with contrast 1339986_1 CDM 0352 RC 71275 HCPCS inpatient 3248 2111.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 2241.12 69 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of chest with contrast 1339986_1 CDM 0352 RC 71275 HCPCS inpatient 3248 2111.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 2533.44 78 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of chest with contrast 1339986_1 CDM 0352 RC 71275 HCPCS inpatient 3248 2111.2 UMR - ALL PLANS UMR - ALL PLANS 2273.6 70 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of chest with contrast 1339986_1 CDM 0352 RC 71275 HCPCS inpatient 3248 2111.2 SIHO - ALL PLANS SIHO - ALL PLANS 2923.2 90 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of chest with contrast 1339986_1 CDM 0352 RC 71275 HCPCS inpatient 3248 2111.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1966.66 60.55 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of chest with contrast 1339986_1 CDM 0352 RC 71275 HCPCS inpatient 3248 2111.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1966.66 3150.56 CT scan of blood vessels of chest with contrast 1339986_1 CDM 0352 RC 71275 HCPCS inpatient 3248 2111.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1966.66 3150.56 CT scan of blood vessels of chest with contrast 1339986_1 CDM 0352 RC 71275 HCPCS inpatient 3248 2111.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1966.66 3150.56 CT scan of blood vessels of chest with contrast 1339986_1 CDM 0352 RC 71275 HCPCS inpatient 3248 2111.2 ANTHEM HMO ANTHEM HMO 999999999 1966.66 3150.56 CT scan of blood vessels of chest with contrast 1339986_1 CDM 0352 RC 71275 HCPCS inpatient 3248 2111.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1966.66 3150.56 CT scan of blood vessels of chest with contrast 1339986_1 CDM 0352 RC 71275 HCPCS inpatient 3248 2111.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 2195.65 67.6 999999999 1966.66 3150.56 percent of total billed charges Review by radiologist of CT guidance for needle placement 1339998_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 AETNA AETNA 1467.82 79 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1339998_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1207.7 65 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1339998_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1802.26 97 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1339998_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1282.02 69 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1339998_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1449.24 78 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1339998_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 UMR - ALL PLANS UMR - ALL PLANS 1300.6 70 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1339998_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 SIHO - ALL PLANS SIHO - ALL PLANS 1672.2 90 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1339998_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1125.02 60.55 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1339998_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 1339998_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 1339998_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 1339998_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 ANTHEM HMO ANTHEM HMO 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 1339998_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 1339998_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1256.01 67.6 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340001_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 AETNA AETNA 1334.31 79 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340001_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.85 65 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340001_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1638.33 97 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340001_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1165.41 69 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340001_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1317.42 78 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340001_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UMR - ALL PLANS UMR - ALL PLANS 1182.3 70 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340001_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SIHO - ALL PLANS SIHO - ALL PLANS 1520.1 90 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340001_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.69 60.55 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340001_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340001_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340001_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM HMO ANTHEM HMO 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340001_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340001_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340001_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.76 67.6 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340004_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 AETNA AETNA 1334.31 79 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340004_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.85 65 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340004_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1638.33 97 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340004_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1165.41 69 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340004_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1317.42 78 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340004_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UMR - ALL PLANS UMR - ALL PLANS 1182.3 70 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340004_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SIHO - ALL PLANS SIHO - ALL PLANS 1520.1 90 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340004_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.69 60.55 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340004_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340004_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340004_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM HMO ANTHEM HMO 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340004_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340004_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340004_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.76 67.6 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340007_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 AETNA AETNA 1334.31 79 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340007_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.85 65 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340007_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1638.33 97 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340007_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1165.41 69 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340007_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1317.42 78 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340007_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UMR - ALL PLANS UMR - ALL PLANS 1182.3 70 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340007_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SIHO - ALL PLANS SIHO - ALL PLANS 1520.1 90 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340007_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.69 60.55 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340007_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340007_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340007_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM HMO ANTHEM HMO 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340007_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340007_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340007_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.76 67.6 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340010_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 AETNA AETNA 1333.52 79 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340010_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.2 65 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340010_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1637.36 97 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340010_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1164.72 69 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340010_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1316.64 78 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340010_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 UMR - ALL PLANS UMR - ALL PLANS 1181.6 70 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340010_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 SIHO - ALL PLANS SIHO - ALL PLANS 1519.2 90 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340010_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.08 60.55 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340010_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 1340010_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 1340010_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 ANTHEM HMO ANTHEM HMO 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 1340010_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 1340010_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 1340010_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.09 67.6 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340013_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 AETNA AETNA 1334.31 79 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340013_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.85 65 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340013_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1638.33 97 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340013_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1165.41 69 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340013_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1317.42 78 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340013_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UMR - ALL PLANS UMR - ALL PLANS 1182.3 70 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340013_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SIHO - ALL PLANS SIHO - ALL PLANS 1520.1 90 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340013_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.69 60.55 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340013_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340013_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340013_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM HMO ANTHEM HMO 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340013_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340013_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340013_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.76 67.6 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340015_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 AETNA AETNA 1334.31 79 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340015_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.85 65 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340015_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1638.33 97 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340015_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1165.41 69 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340015_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1317.42 78 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340015_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UMR - ALL PLANS UMR - ALL PLANS 1182.3 70 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340015_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SIHO - ALL PLANS SIHO - ALL PLANS 1520.1 90 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340015_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.69 60.55 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340015_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340015_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340015_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM HMO ANTHEM HMO 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340015_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340015_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340015_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.76 67.6 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340017_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 AETNA AETNA 1334.31 79 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340017_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.85 65 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340017_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1638.33 97 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340017_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1165.41 69 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340017_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1317.42 78 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340017_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UMR - ALL PLANS UMR - ALL PLANS 1182.3 70 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340017_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SIHO - ALL PLANS SIHO - ALL PLANS 1520.1 90 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340017_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.69 60.55 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340017_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340017_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340017_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM HMO ANTHEM HMO 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340017_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340017_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340017_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.76 67.6 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340019_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 AETNA AETNA 1334.31 79 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340019_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.85 65 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340019_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1638.33 97 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340019_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1165.41 69 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340019_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1317.42 78 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340019_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UMR - ALL PLANS UMR - ALL PLANS 1182.3 70 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340019_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SIHO - ALL PLANS SIHO - ALL PLANS 1520.1 90 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340019_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.69 60.55 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340019_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340019_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340019_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM HMO ANTHEM HMO 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340019_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340019_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340019_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.76 67.6 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340027_1 CDM 0350 RC 77012 HCPCS inpatient 1858 1207.7 AETNA AETNA 1467.82 79 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340027_1 CDM 0350 RC 77012 HCPCS inpatient 1858 1207.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1207.7 65 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340027_1 CDM 0350 RC 77012 HCPCS inpatient 1858 1207.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1802.26 97 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340027_1 CDM 0350 RC 77012 HCPCS inpatient 1858 1207.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1282.02 69 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340027_1 CDM 0350 RC 77012 HCPCS inpatient 1858 1207.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1449.24 78 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340027_1 CDM 0350 RC 77012 HCPCS inpatient 1858 1207.7 UMR - ALL PLANS UMR - ALL PLANS 1300.6 70 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340027_1 CDM 0350 RC 77012 HCPCS inpatient 1858 1207.7 SIHO - ALL PLANS SIHO - ALL PLANS 1672.2 90 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340027_1 CDM 0350 RC 77012 HCPCS inpatient 1858 1207.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1125.02 60.55 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340027_1 CDM 0350 RC 77012 HCPCS inpatient 1858 1207.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 1340027_1 CDM 0350 RC 77012 HCPCS inpatient 1858 1207.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 1340027_1 CDM 0350 RC 77012 HCPCS inpatient 1858 1207.7 ANTHEM HMO ANTHEM HMO 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 1340027_1 CDM 0350 RC 77012 HCPCS inpatient 1858 1207.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 1340027_1 CDM 0350 RC 77012 HCPCS inpatient 1858 1207.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 1340027_1 CDM 0350 RC 77012 HCPCS inpatient 1858 1207.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1256.01 67.6 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340029_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 AETNA AETNA 1467.82 79 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340029_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1207.7 65 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340029_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1802.26 97 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340029_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1282.02 69 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340029_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1449.24 78 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340029_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 UMR - ALL PLANS UMR - ALL PLANS 1300.6 70 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340029_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 SIHO - ALL PLANS SIHO - ALL PLANS 1672.2 90 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340029_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1125.02 60.55 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340029_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 1340029_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 1340029_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 ANTHEM HMO ANTHEM HMO 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 1340029_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 1340029_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 1340029_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1256.01 67.6 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340031_1 CDM 0320 RC 77012 HCPCS inpatient 1688 1097.2 AETNA AETNA 1333.52 79 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340031_1 CDM 0320 RC 77012 HCPCS inpatient 1688 1097.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.2 65 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340031_1 CDM 0320 RC 77012 HCPCS inpatient 1688 1097.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1637.36 97 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340031_1 CDM 0320 RC 77012 HCPCS inpatient 1688 1097.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1164.72 69 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340031_1 CDM 0320 RC 77012 HCPCS inpatient 1688 1097.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1316.64 78 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340031_1 CDM 0320 RC 77012 HCPCS inpatient 1688 1097.2 UMR - ALL PLANS UMR - ALL PLANS 1181.6 70 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340031_1 CDM 0320 RC 77012 HCPCS inpatient 1688 1097.2 SIHO - ALL PLANS SIHO - ALL PLANS 1519.2 90 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340031_1 CDM 0320 RC 77012 HCPCS inpatient 1688 1097.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.08 60.55 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340031_1 CDM 0320 RC 77012 HCPCS inpatient 1688 1097.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 1340031_1 CDM 0320 RC 77012 HCPCS inpatient 1688 1097.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 1340031_1 CDM 0320 RC 77012 HCPCS inpatient 1688 1097.2 ANTHEM HMO ANTHEM HMO 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 1340031_1 CDM 0320 RC 77012 HCPCS inpatient 1688 1097.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 1340031_1 CDM 0320 RC 77012 HCPCS inpatient 1688 1097.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 1340031_1 CDM 0320 RC 77012 HCPCS inpatient 1688 1097.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.09 67.6 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340036_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 AETNA AETNA 1334.31 79 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340036_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.85 65 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340036_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1638.33 97 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340036_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1165.41 69 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340036_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1317.42 78 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340036_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UMR - ALL PLANS UMR - ALL PLANS 1182.3 70 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340036_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SIHO - ALL PLANS SIHO - ALL PLANS 1520.1 90 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340036_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.69 60.55 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340036_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340036_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340036_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM HMO ANTHEM HMO 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340036_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340036_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340036_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.76 67.6 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340038_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 AETNA AETNA 1334.31 79 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340038_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.85 65 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340038_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1638.33 97 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340038_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1165.41 69 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340038_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1317.42 78 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340038_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UMR - ALL PLANS UMR - ALL PLANS 1182.3 70 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340038_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SIHO - ALL PLANS SIHO - ALL PLANS 1520.1 90 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340038_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.69 60.55 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1340038_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340038_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340038_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM HMO ANTHEM HMO 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340038_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340038_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1340038_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.76 67.6 999999999 1022.69 1638.33 percent of total billed charges CT scan of heart with evaluation of blood vessel calcium 1340055_1 CDM 0350 RC 75571 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges CT scan of heart with evaluation of blood vessel calcium 1340055_1 CDM 0350 RC 75571 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges CT scan of heart with evaluation of blood vessel calcium 1340055_1 CDM 0350 RC 75571 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges CT scan of heart with evaluation of blood vessel calcium 1340055_1 CDM 0350 RC 75571 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges CT scan of heart with evaluation of blood vessel calcium 1340055_1 CDM 0350 RC 75571 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges CT scan of heart with evaluation of blood vessel calcium 1340055_1 CDM 0350 RC 75571 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges CT scan of heart with evaluation of blood vessel calcium 1340055_1 CDM 0350 RC 75571 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges CT scan of heart with evaluation of blood vessel calcium 1340055_1 CDM 0350 RC 75571 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges CT scan of heart with evaluation of blood vessel calcium 1340055_1 CDM 0350 RC 75571 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 CT scan of heart with evaluation of blood vessel calcium 1340055_1 CDM 0350 RC 75571 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 CT scan of heart with evaluation of blood vessel calcium 1340055_1 CDM 0350 RC 75571 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 CT scan of heart with evaluation of blood vessel calcium 1340055_1 CDM 0350 RC 75571 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 CT scan of heart with evaluation of blood vessel calcium 1340055_1 CDM 0350 RC 75571 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 CT scan of heart with evaluation of blood vessel calcium 1340055_1 CDM 0350 RC 75571 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges "Placement of locating device in breast using imaging guidance, first growth" 1340093_1 CDM 0361 RC 19281 HCPCS inpatient 695 451.75 AETNA AETNA 549.05 79 999999999 420.82 674.15 percent of total billed charges "Placement of locating device in breast using imaging guidance, first growth" 1340093_1 CDM 0361 RC 19281 HCPCS inpatient 695 451.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 451.75 65 999999999 420.82 674.15 percent of total billed charges "Placement of locating device in breast using imaging guidance, first growth" 1340093_1 CDM 0361 RC 19281 HCPCS inpatient 695 451.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 674.15 97 999999999 420.82 674.15 percent of total billed charges "Placement of locating device in breast using imaging guidance, first growth" 1340093_1 CDM 0361 RC 19281 HCPCS inpatient 695 451.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 479.55 69 999999999 420.82 674.15 percent of total billed charges "Placement of locating device in breast using imaging guidance, first growth" 1340093_1 CDM 0361 RC 19281 HCPCS inpatient 695 451.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 542.1 78 999999999 420.82 674.15 percent of total billed charges "Placement of locating device in breast using imaging guidance, first growth" 1340093_1 CDM 0361 RC 19281 HCPCS inpatient 695 451.75 UMR - ALL PLANS UMR - ALL PLANS 486.5 70 999999999 420.82 674.15 percent of total billed charges "Placement of locating device in breast using imaging guidance, first growth" 1340093_1 CDM 0361 RC 19281 HCPCS inpatient 695 451.75 SIHO - ALL PLANS SIHO - ALL PLANS 625.5 90 999999999 420.82 674.15 percent of total billed charges "Placement of locating device in breast using imaging guidance, first growth" 1340093_1 CDM 0361 RC 19281 HCPCS inpatient 695 451.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 420.82 60.55 999999999 420.82 674.15 percent of total billed charges "Placement of locating device in breast using imaging guidance, first growth" 1340093_1 CDM 0361 RC 19281 HCPCS inpatient 695 451.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 420.82 674.15 "Placement of locating device in breast using imaging guidance, first growth" 1340093_1 CDM 0361 RC 19281 HCPCS inpatient 695 451.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 420.82 674.15 "Placement of locating device in breast using imaging guidance, first growth" 1340093_1 CDM 0361 RC 19281 HCPCS inpatient 695 451.75 ANTHEM HMO ANTHEM HMO 999999999 420.82 674.15 "Placement of locating device in breast using imaging guidance, first growth" 1340093_1 CDM 0361 RC 19281 HCPCS inpatient 695 451.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 420.82 674.15 "Placement of locating device in breast using imaging guidance, first growth" 1340093_1 CDM 0361 RC 19281 HCPCS inpatient 695 451.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 420.82 674.15 "Placement of locating device in breast using imaging guidance, first growth" 1340093_1 CDM 0361 RC 19281 HCPCS inpatient 695 451.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 469.82 67.6 999999999 420.82 674.15 percent of total billed charges "Placement of locating device in breast using imaging guidance, first growth" 1340095_1 CDM 0361 RC 19281 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges "Placement of locating device in breast using imaging guidance, first growth" 1340095_1 CDM 0361 RC 19281 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges "Placement of locating device in breast using imaging guidance, first growth" 1340095_1 CDM 0361 RC 19281 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges "Placement of locating device in breast using imaging guidance, first growth" 1340095_1 CDM 0361 RC 19281 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges "Placement of locating device in breast using imaging guidance, first growth" 1340095_1 CDM 0361 RC 19281 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges "Placement of locating device in breast using imaging guidance, first growth" 1340095_1 CDM 0361 RC 19281 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges "Placement of locating device in breast using imaging guidance, first growth" 1340095_1 CDM 0361 RC 19281 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges "Placement of locating device in breast using imaging guidance, first growth" 1340095_1 CDM 0361 RC 19281 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges "Placement of locating device in breast using imaging guidance, first growth" 1340095_1 CDM 0361 RC 19281 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 "Placement of locating device in breast using imaging guidance, first growth" 1340095_1 CDM 0361 RC 19281 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 "Placement of locating device in breast using imaging guidance, first growth" 1340095_1 CDM 0361 RC 19281 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 "Placement of locating device in breast using imaging guidance, first growth" 1340095_1 CDM 0361 RC 19281 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 "Placement of locating device in breast using imaging guidance, first growth" 1340095_1 CDM 0361 RC 19281 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 "Placement of locating device in breast using imaging guidance, first growth" 1340095_1 CDM 0361 RC 19281 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges MRI scan of blood vessels of abdomen 1340121_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 AETNA AETNA 2370.79 79 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1340121_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1950.65 65 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1340121_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2910.97 97 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1340121_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2070.69 69 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1340121_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2340.78 78 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1340121_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 UMR - ALL PLANS UMR - ALL PLANS 2100.7 70 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1340121_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 SIHO - ALL PLANS SIHO - ALL PLANS 2700.9 90 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1340121_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1817.11 60.55 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1340121_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1817.11 2910.97 MRI scan of blood vessels of abdomen 1340121_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1817.11 2910.97 MRI scan of blood vessels of abdomen 1340121_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 ANTHEM HMO ANTHEM HMO 999999999 1817.11 2910.97 MRI scan of blood vessels of abdomen 1340121_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1817.11 2910.97 MRI scan of blood vessels of abdomen 1340121_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1817.11 2910.97 MRI scan of blood vessels of abdomen 1340121_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2028.68 67.6 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1340123_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 AETNA AETNA 2370.79 79 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1340123_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1950.65 65 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1340123_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2910.97 97 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1340123_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2070.69 69 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1340123_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2340.78 78 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1340123_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 UMR - ALL PLANS UMR - ALL PLANS 2100.7 70 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1340123_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 SIHO - ALL PLANS SIHO - ALL PLANS 2700.9 90 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1340123_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1817.11 60.55 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1340123_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1817.11 2910.97 MRI scan of blood vessels of abdomen 1340123_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1817.11 2910.97 MRI scan of blood vessels of abdomen 1340123_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 ANTHEM HMO ANTHEM HMO 999999999 1817.11 2910.97 MRI scan of blood vessels of abdomen 1340123_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1817.11 2910.97 MRI scan of blood vessels of abdomen 1340123_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1817.11 2910.97 MRI scan of blood vessels of abdomen 1340123_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2028.68 67.6 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 1340125_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 AETNA AETNA 2370.79 79 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 1340125_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1950.65 65 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 1340125_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2910.97 97 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 1340125_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2070.69 69 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 1340125_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2340.78 78 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 1340125_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 UMR - ALL PLANS UMR - ALL PLANS 2100.7 70 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 1340125_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 SIHO - ALL PLANS SIHO - ALL PLANS 2700.9 90 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 1340125_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1817.11 60.55 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 1340125_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1817.11 2910.97 MRI scan of blood vessels of chest 1340125_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1817.11 2910.97 MRI scan of blood vessels of chest 1340125_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 ANTHEM HMO ANTHEM HMO 999999999 1817.11 2910.97 MRI scan of blood vessels of chest 1340125_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1817.11 2910.97 MRI scan of blood vessels of chest 1340125_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1817.11 2910.97 MRI scan of blood vessels of chest 1340125_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2028.68 67.6 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of leg 1340127_1 CDM 0610 RC 73725 HCPCS inpatient 5972 3881.8 AETNA AETNA 4717.88 79 999999999 3616.05 5792.84 percent of total billed charges MRI scan of blood vessels of leg 1340127_1 CDM 0610 RC 73725 HCPCS inpatient 5972 3881.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 3881.8 65 999999999 3616.05 5792.84 percent of total billed charges MRI scan of blood vessels of leg 1340127_1 CDM 0610 RC 73725 HCPCS inpatient 5972 3881.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5792.84 97 999999999 3616.05 5792.84 percent of total billed charges MRI scan of blood vessels of leg 1340127_1 CDM 0610 RC 73725 HCPCS inpatient 5972 3881.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 4120.68 69 999999999 3616.05 5792.84 percent of total billed charges MRI scan of blood vessels of leg 1340127_1 CDM 0610 RC 73725 HCPCS inpatient 5972 3881.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 4658.16 78 999999999 3616.05 5792.84 percent of total billed charges MRI scan of blood vessels of leg 1340127_1 CDM 0610 RC 73725 HCPCS inpatient 5972 3881.8 UMR - ALL PLANS UMR - ALL PLANS 4180.4 70 999999999 3616.05 5792.84 percent of total billed charges MRI scan of blood vessels of leg 1340127_1 CDM 0610 RC 73725 HCPCS inpatient 5972 3881.8 SIHO - ALL PLANS SIHO - ALL PLANS 5374.8 90 999999999 3616.05 5792.84 percent of total billed charges MRI scan of blood vessels of leg 1340127_1 CDM 0610 RC 73725 HCPCS inpatient 5972 3881.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3616.05 60.55 999999999 3616.05 5792.84 percent of total billed charges MRI scan of blood vessels of leg 1340127_1 CDM 0610 RC 73725 HCPCS inpatient 5972 3881.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3616.05 5792.84 MRI scan of blood vessels of leg 1340127_1 CDM 0610 RC 73725 HCPCS inpatient 5972 3881.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3616.05 5792.84 MRI scan of blood vessels of leg 1340127_1 CDM 0610 RC 73725 HCPCS inpatient 5972 3881.8 ANTHEM HMO ANTHEM HMO 999999999 3616.05 5792.84 MRI scan of blood vessels of leg 1340127_1 CDM 0610 RC 73725 HCPCS inpatient 5972 3881.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3616.05 5792.84 MRI scan of blood vessels of leg 1340127_1 CDM 0610 RC 73725 HCPCS inpatient 5972 3881.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 3616.05 5792.84 MRI scan of blood vessels of leg 1340127_1 CDM 0610 RC 73725 HCPCS inpatient 5972 3881.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 4037.07 67.6 999999999 3616.05 5792.84 percent of total billed charges MRI scan of blood vessels of pelvis 1340131_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 AETNA AETNA 2370.79 79 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1340131_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1950.65 65 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1340131_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2910.97 97 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1340131_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2070.69 69 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1340131_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2340.78 78 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1340131_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 UMR - ALL PLANS UMR - ALL PLANS 2100.7 70 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1340131_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 SIHO - ALL PLANS SIHO - ALL PLANS 2700.9 90 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1340131_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1817.11 60.55 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1340131_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1817.11 2910.97 MRI scan of blood vessels of pelvis 1340131_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1817.11 2910.97 MRI scan of blood vessels of pelvis 1340131_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 ANTHEM HMO ANTHEM HMO 999999999 1817.11 2910.97 MRI scan of blood vessels of pelvis 1340131_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1817.11 2910.97 MRI scan of blood vessels of pelvis 1340131_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1817.11 2910.97 MRI scan of blood vessels of pelvis 1340131_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2028.68 67.6 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of arm 1340136_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 AETNA AETNA 2193.83 79 999999999 1681.47 2693.69 percent of total billed charges MRI scan of blood vessels of arm 1340136_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1805.05 65 999999999 1681.47 2693.69 percent of total billed charges MRI scan of blood vessels of arm 1340136_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2693.69 97 999999999 1681.47 2693.69 percent of total billed charges MRI scan of blood vessels of arm 1340136_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1916.13 69 999999999 1681.47 2693.69 percent of total billed charges MRI scan of blood vessels of arm 1340136_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 2166.06 78 999999999 1681.47 2693.69 percent of total billed charges MRI scan of blood vessels of arm 1340136_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 UMR - ALL PLANS UMR - ALL PLANS 1943.9 70 999999999 1681.47 2693.69 percent of total billed charges MRI scan of blood vessels of arm 1340136_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 SIHO - ALL PLANS SIHO - ALL PLANS 2499.3 90 999999999 1681.47 2693.69 percent of total billed charges MRI scan of blood vessels of arm 1340136_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1681.47 60.55 999999999 1681.47 2693.69 percent of total billed charges MRI scan of blood vessels of arm 1340136_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1681.47 2693.69 MRI scan of blood vessels of arm 1340136_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1681.47 2693.69 MRI scan of blood vessels of arm 1340136_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 ANTHEM HMO ANTHEM HMO 999999999 1681.47 2693.69 MRI scan of blood vessels of arm 1340136_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1681.47 2693.69 MRI scan of blood vessels of arm 1340136_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1681.47 2693.69 MRI scan of blood vessels of arm 1340136_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1877.25 67.6 999999999 1681.47 2693.69 percent of total billed charges MRI scan of blood vessels of arm 1340139_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 AETNA AETNA 2193.83 79 999999999 1681.47 2693.69 percent of total billed charges MRI scan of blood vessels of arm 1340139_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1805.05 65 999999999 1681.47 2693.69 percent of total billed charges MRI scan of blood vessels of arm 1340139_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2693.69 97 999999999 1681.47 2693.69 percent of total billed charges MRI scan of blood vessels of arm 1340139_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1916.13 69 999999999 1681.47 2693.69 percent of total billed charges MRI scan of blood vessels of arm 1340139_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 2166.06 78 999999999 1681.47 2693.69 percent of total billed charges MRI scan of blood vessels of arm 1340139_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 UMR - ALL PLANS UMR - ALL PLANS 1943.9 70 999999999 1681.47 2693.69 percent of total billed charges MRI scan of blood vessels of arm 1340139_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 SIHO - ALL PLANS SIHO - ALL PLANS 2499.3 90 999999999 1681.47 2693.69 percent of total billed charges MRI scan of blood vessels of arm 1340139_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1681.47 60.55 999999999 1681.47 2693.69 percent of total billed charges MRI scan of blood vessels of arm 1340139_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1681.47 2693.69 MRI scan of blood vessels of arm 1340139_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1681.47 2693.69 MRI scan of blood vessels of arm 1340139_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 ANTHEM HMO ANTHEM HMO 999999999 1681.47 2693.69 MRI scan of blood vessels of arm 1340139_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1681.47 2693.69 MRI scan of blood vessels of arm 1340139_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1681.47 2693.69 MRI scan of blood vessels of arm 1340139_1 CDM 0618 RC 73225 HCPCS inpatient 2777 1805.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1877.25 67.6 999999999 1681.47 2693.69 percent of total billed charges MRI scan of brain before and after contrast 1340202_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 AETNA AETNA 3607.93 79 999999999 2765.32 4429.99 percent of total billed charges MRI scan of brain before and after contrast 1340202_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 2968.55 65 999999999 2765.32 4429.99 percent of total billed charges MRI scan of brain before and after contrast 1340202_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4429.99 97 999999999 2765.32 4429.99 percent of total billed charges MRI scan of brain before and after contrast 1340202_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 3151.23 69 999999999 2765.32 4429.99 percent of total billed charges MRI scan of brain before and after contrast 1340202_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 3562.26 78 999999999 2765.32 4429.99 percent of total billed charges MRI scan of brain before and after contrast 1340202_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 UMR - ALL PLANS UMR - ALL PLANS 3196.9 70 999999999 2765.32 4429.99 percent of total billed charges MRI scan of brain before and after contrast 1340202_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 SIHO - ALL PLANS SIHO - ALL PLANS 4110.3 90 999999999 2765.32 4429.99 percent of total billed charges MRI scan of brain before and after contrast 1340202_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2765.32 4429.99 MRI scan of brain before and after contrast 1340202_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2765.32 60.55 999999999 2765.32 4429.99 percent of total billed charges MRI scan of brain before and after contrast 1340202_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2765.32 4429.99 MRI scan of brain before and after contrast 1340202_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 ANTHEM HMO ANTHEM HMO 999999999 2765.32 4429.99 MRI scan of brain before and after contrast 1340202_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2765.32 4429.99 MRI scan of brain before and after contrast 1340202_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 2765.32 4429.99 MRI scan of brain before and after contrast 1340202_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 3087.29 67.6 999999999 2765.32 4429.99 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck without contrast" 1340208_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 AETNA AETNA 3776.99 79 999999999 2894.9 4637.57 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck without contrast" 1340208_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 3107.65 65 999999999 2894.9 4637.57 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck without contrast" 1340208_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4637.57 97 999999999 2894.9 4637.57 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck without contrast" 1340208_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 3298.89 69 999999999 2894.9 4637.57 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck without contrast" 1340208_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 3729.18 78 999999999 2894.9 4637.57 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck without contrast" 1340208_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 UMR - ALL PLANS UMR - ALL PLANS 3346.7 70 999999999 2894.9 4637.57 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck without contrast" 1340208_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 SIHO - ALL PLANS SIHO - ALL PLANS 4302.9 90 999999999 2894.9 4637.57 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck without contrast" 1340208_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2894.9 4637.57 "MRI scan of bone of eye socket, face, and/or neck without contrast" 1340208_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2894.9 60.55 999999999 2894.9 4637.57 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck without contrast" 1340208_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2894.9 4637.57 "MRI scan of bone of eye socket, face, and/or neck without contrast" 1340208_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 ANTHEM HMO ANTHEM HMO 999999999 2894.9 4637.57 "MRI scan of bone of eye socket, face, and/or neck without contrast" 1340208_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2894.9 4637.57 "MRI scan of bone of eye socket, face, and/or neck without contrast" 1340208_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 2894.9 4637.57 "MRI scan of bone of eye socket, face, and/or neck without contrast" 1340208_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 3231.96 67.6 999999999 2894.9 4637.57 percent of total billed charges RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340223_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 AETNA AETNA 3212.93 79 999999999 2462.57 3944.99 percent of total billed charges RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340223_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 2643.55 65 999999999 2462.57 3944.99 percent of total billed charges RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340223_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3944.99 97 999999999 2462.57 3944.99 percent of total billed charges RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340223_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 2806.23 69 999999999 2462.57 3944.99 percent of total billed charges RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340223_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 3172.26 78 999999999 2462.57 3944.99 percent of total billed charges RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340223_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 UMR - ALL PLANS UMR - ALL PLANS 2846.9 70 999999999 2462.57 3944.99 percent of total billed charges RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340223_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 SIHO - ALL PLANS SIHO - ALL PLANS 3660.3 90 999999999 2462.57 3944.99 percent of total billed charges RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340223_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2462.57 3944.99 RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340223_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2462.57 60.55 999999999 2462.57 3944.99 percent of total billed charges RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340223_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2462.57 3944.99 RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340223_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 ANTHEM HMO ANTHEM HMO 999999999 2462.57 3944.99 RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340223_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2462.57 3944.99 RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340223_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 2462.57 3944.99 RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340223_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 2749.29 67.6 999999999 2462.57 3944.99 percent of total billed charges RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340226_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 AETNA AETNA 3212.93 79 999999999 2462.57 3944.99 percent of total billed charges RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340226_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 2643.55 65 999999999 2462.57 3944.99 percent of total billed charges RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340226_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3944.99 97 999999999 2462.57 3944.99 percent of total billed charges RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340226_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 2806.23 69 999999999 2462.57 3944.99 percent of total billed charges RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340226_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 3172.26 78 999999999 2462.57 3944.99 percent of total billed charges RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340226_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 UMR - ALL PLANS UMR - ALL PLANS 2846.9 70 999999999 2462.57 3944.99 percent of total billed charges RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340226_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 SIHO - ALL PLANS SIHO - ALL PLANS 3660.3 90 999999999 2462.57 3944.99 percent of total billed charges RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340226_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2462.57 3944.99 RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340226_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2462.57 60.55 999999999 2462.57 3944.99 percent of total billed charges RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340226_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2462.57 3944.99 RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340226_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 ANTHEM HMO ANTHEM HMO 999999999 2462.57 3944.99 RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340226_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2462.57 3944.99 RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340226_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 2462.57 3944.99 RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; WHOLE BODY 1340226_1 CDM 0341 RC 78806 HCPCS inpatient 4067 2643.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 2749.29 67.6 999999999 2462.57 3944.99 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 1340235_1 CDM 0341 RC 78803 HCPCS inpatient 1971 1281.15 AETNA AETNA 1557.09 79 999999999 1193.44 1911.87 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 1340235_1 CDM 0341 RC 78803 HCPCS inpatient 1971 1281.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1281.15 65 999999999 1193.44 1911.87 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 1340235_1 CDM 0341 RC 78803 HCPCS inpatient 1971 1281.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1911.87 97 999999999 1193.44 1911.87 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 1340235_1 CDM 0341 RC 78803 HCPCS inpatient 1971 1281.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1359.99 69 999999999 1193.44 1911.87 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 1340235_1 CDM 0341 RC 78803 HCPCS inpatient 1971 1281.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1537.38 78 999999999 1193.44 1911.87 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 1340235_1 CDM 0341 RC 78803 HCPCS inpatient 1971 1281.15 UMR - ALL PLANS UMR - ALL PLANS 1379.7 70 999999999 1193.44 1911.87 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 1340235_1 CDM 0341 RC 78803 HCPCS inpatient 1971 1281.15 SIHO - ALL PLANS SIHO - ALL PLANS 1773.9 90 999999999 1193.44 1911.87 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 1340235_1 CDM 0341 RC 78803 HCPCS inpatient 1971 1281.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1193.44 1911.87 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 1340235_1 CDM 0341 RC 78803 HCPCS inpatient 1971 1281.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1193.44 60.55 999999999 1193.44 1911.87 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 1340235_1 CDM 0341 RC 78803 HCPCS inpatient 1971 1281.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1193.44 1911.87 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 1340235_1 CDM 0341 RC 78803 HCPCS inpatient 1971 1281.15 ANTHEM HMO ANTHEM HMO 999999999 1193.44 1911.87 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 1340235_1 CDM 0341 RC 78803 HCPCS inpatient 1971 1281.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1193.44 1911.87 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 1340235_1 CDM 0341 RC 78803 HCPCS inpatient 1971 1281.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1193.44 1911.87 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 1340235_1 CDM 0341 RC 78803 HCPCS inpatient 1971 1281.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1332.4 67.6 999999999 1193.44 1911.87 percent of total billed charges Nuclear medicine study of bone taken at different times 1340238_1 CDM 0341 RC 78315 HCPCS inpatient 4312 2802.8 AETNA AETNA 3406.48 79 999999999 2610.92 4182.64 percent of total billed charges Nuclear medicine study of bone taken at different times 1340238_1 CDM 0341 RC 78315 HCPCS inpatient 4312 2802.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 2802.8 65 999999999 2610.92 4182.64 percent of total billed charges Nuclear medicine study of bone taken at different times 1340238_1 CDM 0341 RC 78315 HCPCS inpatient 4312 2802.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4182.64 97 999999999 2610.92 4182.64 percent of total billed charges Nuclear medicine study of bone taken at different times 1340238_1 CDM 0341 RC 78315 HCPCS inpatient 4312 2802.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 2975.28 69 999999999 2610.92 4182.64 percent of total billed charges Nuclear medicine study of bone taken at different times 1340238_1 CDM 0341 RC 78315 HCPCS inpatient 4312 2802.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 3363.36 78 999999999 2610.92 4182.64 percent of total billed charges Nuclear medicine study of bone taken at different times 1340238_1 CDM 0341 RC 78315 HCPCS inpatient 4312 2802.8 UMR - ALL PLANS UMR - ALL PLANS 3018.4 70 999999999 2610.92 4182.64 percent of total billed charges Nuclear medicine study of bone taken at different times 1340238_1 CDM 0341 RC 78315 HCPCS inpatient 4312 2802.8 SIHO - ALL PLANS SIHO - ALL PLANS 3880.8 90 999999999 2610.92 4182.64 percent of total billed charges Nuclear medicine study of bone taken at different times 1340238_1 CDM 0341 RC 78315 HCPCS inpatient 4312 2802.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2610.92 4182.64 Nuclear medicine study of bone taken at different times 1340238_1 CDM 0341 RC 78315 HCPCS inpatient 4312 2802.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2610.92 60.55 999999999 2610.92 4182.64 percent of total billed charges Nuclear medicine study of bone taken at different times 1340238_1 CDM 0341 RC 78315 HCPCS inpatient 4312 2802.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2610.92 4182.64 Nuclear medicine study of bone taken at different times 1340238_1 CDM 0341 RC 78315 HCPCS inpatient 4312 2802.8 ANTHEM HMO ANTHEM HMO 999999999 2610.92 4182.64 Nuclear medicine study of bone taken at different times 1340238_1 CDM 0341 RC 78315 HCPCS inpatient 4312 2802.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2610.92 4182.64 Nuclear medicine study of bone taken at different times 1340238_1 CDM 0341 RC 78315 HCPCS inpatient 4312 2802.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 2610.92 4182.64 Nuclear medicine study of bone taken at different times 1340238_1 CDM 0341 RC 78315 HCPCS inpatient 4312 2802.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 2914.91 67.6 999999999 2610.92 4182.64 percent of total billed charges Nuclear medicine study of heart muscle following heart attack 1340250_1 CDM 0340 RC 78466 HCPCS inpatient 2417 1571.05 AETNA AETNA 1909.43 79 999999999 1463.49 2344.49 percent of total billed charges Nuclear medicine study of heart muscle following heart attack 1340250_1 CDM 0340 RC 78466 HCPCS inpatient 2417 1571.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1571.05 65 999999999 1463.49 2344.49 percent of total billed charges Nuclear medicine study of heart muscle following heart attack 1340250_1 CDM 0340 RC 78466 HCPCS inpatient 2417 1571.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2344.49 97 999999999 1463.49 2344.49 percent of total billed charges Nuclear medicine study of heart muscle following heart attack 1340250_1 CDM 0340 RC 78466 HCPCS inpatient 2417 1571.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1667.73 69 999999999 1463.49 2344.49 percent of total billed charges Nuclear medicine study of heart muscle following heart attack 1340250_1 CDM 0340 RC 78466 HCPCS inpatient 2417 1571.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1885.26 78 999999999 1463.49 2344.49 percent of total billed charges Nuclear medicine study of heart muscle following heart attack 1340250_1 CDM 0340 RC 78466 HCPCS inpatient 2417 1571.05 UMR - ALL PLANS UMR - ALL PLANS 1691.9 70 999999999 1463.49 2344.49 percent of total billed charges Nuclear medicine study of heart muscle following heart attack 1340250_1 CDM 0340 RC 78466 HCPCS inpatient 2417 1571.05 SIHO - ALL PLANS SIHO - ALL PLANS 2175.3 90 999999999 1463.49 2344.49 percent of total billed charges Nuclear medicine study of heart muscle following heart attack 1340250_1 CDM 0340 RC 78466 HCPCS inpatient 2417 1571.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1463.49 2344.49 Nuclear medicine study of heart muscle following heart attack 1340250_1 CDM 0340 RC 78466 HCPCS inpatient 2417 1571.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1463.49 60.55 999999999 1463.49 2344.49 percent of total billed charges Nuclear medicine study of heart muscle following heart attack 1340250_1 CDM 0340 RC 78466 HCPCS inpatient 2417 1571.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1463.49 2344.49 Nuclear medicine study of heart muscle following heart attack 1340250_1 CDM 0340 RC 78466 HCPCS inpatient 2417 1571.05 ANTHEM HMO ANTHEM HMO 999999999 1463.49 2344.49 Nuclear medicine study of heart muscle following heart attack 1340250_1 CDM 0340 RC 78466 HCPCS inpatient 2417 1571.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1463.49 2344.49 Nuclear medicine study of heart muscle following heart attack 1340250_1 CDM 0340 RC 78466 HCPCS inpatient 2417 1571.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1463.49 2344.49 Nuclear medicine study of heart muscle following heart attack 1340250_1 CDM 0340 RC 78466 HCPCS inpatient 2417 1571.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1633.89 67.6 999999999 1463.49 2344.49 percent of total billed charges NM Myocardial Spect Multi Rest/Stress 1340265_1 CDM 0341 RC 78465 HCPCS inpatient 4617 3001.05 AETNA AETNA 3647.43 79 999999999 2795.59 4478.49 percent of total billed charges NM Myocardial Spect Multi Rest/Stress 1340265_1 CDM 0341 RC 78465 HCPCS inpatient 4617 3001.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 3001.05 65 999999999 2795.59 4478.49 percent of total billed charges NM Myocardial Spect Multi Rest/Stress 1340265_1 CDM 0341 RC 78465 HCPCS inpatient 4617 3001.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4478.49 97 999999999 2795.59 4478.49 percent of total billed charges NM Myocardial Spect Multi Rest/Stress 1340265_1 CDM 0341 RC 78465 HCPCS inpatient 4617 3001.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 3185.73 69 999999999 2795.59 4478.49 percent of total billed charges NM Myocardial Spect Multi Rest/Stress 1340265_1 CDM 0341 RC 78465 HCPCS inpatient 4617 3001.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 3601.26 78 999999999 2795.59 4478.49 percent of total billed charges NM Myocardial Spect Multi Rest/Stress 1340265_1 CDM 0341 RC 78465 HCPCS inpatient 4617 3001.05 UMR - ALL PLANS UMR - ALL PLANS 3231.9 70 999999999 2795.59 4478.49 percent of total billed charges NM Myocardial Spect Multi Rest/Stress 1340265_1 CDM 0341 RC 78465 HCPCS inpatient 4617 3001.05 SIHO - ALL PLANS SIHO - ALL PLANS 4155.3 90 999999999 2795.59 4478.49 percent of total billed charges NM Myocardial Spect Multi Rest/Stress 1340265_1 CDM 0341 RC 78465 HCPCS inpatient 4617 3001.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2795.59 4478.49 NM Myocardial Spect Multi Rest/Stress 1340265_1 CDM 0341 RC 78465 HCPCS inpatient 4617 3001.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2795.59 60.55 999999999 2795.59 4478.49 percent of total billed charges NM Myocardial Spect Multi Rest/Stress 1340265_1 CDM 0341 RC 78465 HCPCS inpatient 4617 3001.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2795.59 4478.49 NM Myocardial Spect Multi Rest/Stress 1340265_1 CDM 0341 RC 78465 HCPCS inpatient 4617 3001.05 ANTHEM HMO ANTHEM HMO 999999999 2795.59 4478.49 NM Myocardial Spect Multi Rest/Stress 1340265_1 CDM 0341 RC 78465 HCPCS inpatient 4617 3001.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2795.59 4478.49 NM Myocardial Spect Multi Rest/Stress 1340265_1 CDM 0341 RC 78465 HCPCS inpatient 4617 3001.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 2795.59 4478.49 NM Myocardial Spect Multi Rest/Stress 1340265_1 CDM 0341 RC 78465 HCPCS inpatient 4617 3001.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 3121.09 67.6 999999999 2795.59 4478.49 percent of total billed charges Injection of radioactive material for X-ray identification of lymph node 1340280_1 CDM 0341 RC 38792 HCPCS inpatient 766 497.9 AETNA AETNA 605.14 79 999999999 463.81 743.02 percent of total billed charges Injection of radioactive material for X-ray identification of lymph node 1340280_1 CDM 0341 RC 38792 HCPCS inpatient 766 497.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 497.9 65 999999999 463.81 743.02 percent of total billed charges Injection of radioactive material for X-ray identification of lymph node 1340280_1 CDM 0341 RC 38792 HCPCS inpatient 766 497.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 743.02 97 999999999 463.81 743.02 percent of total billed charges Injection of radioactive material for X-ray identification of lymph node 1340280_1 CDM 0341 RC 38792 HCPCS inpatient 766 497.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 528.54 69 999999999 463.81 743.02 percent of total billed charges Injection of radioactive material for X-ray identification of lymph node 1340280_1 CDM 0341 RC 38792 HCPCS inpatient 766 497.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 597.48 78 999999999 463.81 743.02 percent of total billed charges Injection of radioactive material for X-ray identification of lymph node 1340280_1 CDM 0341 RC 38792 HCPCS inpatient 766 497.9 UMR - ALL PLANS UMR - ALL PLANS 536.2 70 999999999 463.81 743.02 percent of total billed charges Injection of radioactive material for X-ray identification of lymph node 1340280_1 CDM 0341 RC 38792 HCPCS inpatient 766 497.9 SIHO - ALL PLANS SIHO - ALL PLANS 689.4 90 999999999 463.81 743.02 percent of total billed charges Injection of radioactive material for X-ray identification of lymph node 1340280_1 CDM 0341 RC 38792 HCPCS inpatient 766 497.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 463.81 743.02 Injection of radioactive material for X-ray identification of lymph node 1340280_1 CDM 0341 RC 38792 HCPCS inpatient 766 497.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 463.81 60.55 999999999 463.81 743.02 percent of total billed charges Injection of radioactive material for X-ray identification of lymph node 1340280_1 CDM 0341 RC 38792 HCPCS inpatient 766 497.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 463.81 743.02 Injection of radioactive material for X-ray identification of lymph node 1340280_1 CDM 0341 RC 38792 HCPCS inpatient 766 497.9 ANTHEM HMO ANTHEM HMO 999999999 463.81 743.02 Injection of radioactive material for X-ray identification of lymph node 1340280_1 CDM 0341 RC 38792 HCPCS inpatient 766 497.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 463.81 743.02 Injection of radioactive material for X-ray identification of lymph node 1340280_1 CDM 0341 RC 38792 HCPCS inpatient 766 497.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 463.81 743.02 Injection of radioactive material for X-ray identification of lymph node 1340280_1 CDM 0341 RC 38792 HCPCS inpatient 766 497.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 517.82 67.6 999999999 463.81 743.02 percent of total billed charges Ultrasonic guidance for needle placement 1340290_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1340290_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1340290_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1340290_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1340290_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1340290_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1340290_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1340290_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 1340290_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1340290_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 1340290_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Ultrasonic guidance for needle placement 1340290_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 1340290_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 1340290_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1340292_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1340292_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1340292_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1340292_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1340292_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1340292_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1340292_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1340292_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 1340292_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1340292_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 1340292_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Ultrasonic guidance for needle placement 1340292_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 1340292_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 1340292_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges Complete ultrasound scan of 1 breast 1340297_1 CDM 0402 RC 76641 HCPCS inpatient 1484 964.6 AETNA AETNA 1172.36 79 999999999 898.56 1439.48 percent of total billed charges Complete ultrasound scan of 1 breast 1340297_1 CDM 0402 RC 76641 HCPCS inpatient 1484 964.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 964.6 65 999999999 898.56 1439.48 percent of total billed charges Complete ultrasound scan of 1 breast 1340297_1 CDM 0402 RC 76641 HCPCS inpatient 1484 964.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1439.48 97 999999999 898.56 1439.48 percent of total billed charges Complete ultrasound scan of 1 breast 1340297_1 CDM 0402 RC 76641 HCPCS inpatient 1484 964.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1023.96 69 999999999 898.56 1439.48 percent of total billed charges Complete ultrasound scan of 1 breast 1340297_1 CDM 0402 RC 76641 HCPCS inpatient 1484 964.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1157.52 78 999999999 898.56 1439.48 percent of total billed charges Complete ultrasound scan of 1 breast 1340297_1 CDM 0402 RC 76641 HCPCS inpatient 1484 964.6 UMR - ALL PLANS UMR - ALL PLANS 1038.8 70 999999999 898.56 1439.48 percent of total billed charges Complete ultrasound scan of 1 breast 1340297_1 CDM 0402 RC 76641 HCPCS inpatient 1484 964.6 SIHO - ALL PLANS SIHO - ALL PLANS 1335.6 90 999999999 898.56 1439.48 percent of total billed charges Complete ultrasound scan of 1 breast 1340297_1 CDM 0402 RC 76641 HCPCS inpatient 1484 964.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 898.56 1439.48 Complete ultrasound scan of 1 breast 1340297_1 CDM 0402 RC 76641 HCPCS inpatient 1484 964.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 898.56 60.55 999999999 898.56 1439.48 percent of total billed charges Complete ultrasound scan of 1 breast 1340297_1 CDM 0402 RC 76641 HCPCS inpatient 1484 964.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 898.56 1439.48 Complete ultrasound scan of 1 breast 1340297_1 CDM 0402 RC 76641 HCPCS inpatient 1484 964.6 ANTHEM HMO ANTHEM HMO 999999999 898.56 1439.48 Complete ultrasound scan of 1 breast 1340297_1 CDM 0402 RC 76641 HCPCS inpatient 1484 964.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 898.56 1439.48 Complete ultrasound scan of 1 breast 1340297_1 CDM 0402 RC 76641 HCPCS inpatient 1484 964.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 898.56 1439.48 Complete ultrasound scan of 1 breast 1340297_1 CDM 0402 RC 76641 HCPCS inpatient 1484 964.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1003.18 67.6 999999999 898.56 1439.48 percent of total billed charges Complete ultrasound scan of 1 breast 1340300_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 AETNA AETNA 601.19 79 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 1340300_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 494.65 65 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 1340300_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 738.17 97 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 1340300_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 525.09 69 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 1340300_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 593.58 78 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 1340300_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 UMR - ALL PLANS UMR - ALL PLANS 532.7 70 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 1340300_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 SIHO - ALL PLANS SIHO - ALL PLANS 684.9 90 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 1340300_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 1340300_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 460.79 60.55 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 1340300_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 1340300_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ANTHEM HMO ANTHEM HMO 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 1340300_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 1340300_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 1340300_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 514.44 67.6 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 1340309_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 AETNA AETNA 601.19 79 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 1340309_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 494.65 65 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 1340309_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 738.17 97 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 1340309_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 525.09 69 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 1340309_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 593.58 78 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 1340309_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 UMR - ALL PLANS UMR - ALL PLANS 532.7 70 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 1340309_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 SIHO - ALL PLANS SIHO - ALL PLANS 684.9 90 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 1340309_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 1340309_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 460.79 60.55 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 1340309_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 1340309_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ANTHEM HMO ANTHEM HMO 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 1340309_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 1340309_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 1340309_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 514.44 67.6 999999999 460.79 738.17 percent of total billed charges Limited ultrasound scan of abdomen 1340339_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 AETNA AETNA 854.78 79 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 1340339_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 703.3 65 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 1340339_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1049.54 97 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 1340339_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 746.58 69 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 1340339_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 843.96 78 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 1340339_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UMR - ALL PLANS UMR - ALL PLANS 757.4 70 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 1340339_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 SIHO - ALL PLANS SIHO - ALL PLANS 973.8 90 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 1340339_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 1340339_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 655.15 60.55 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 1340339_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 1340339_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM HMO ANTHEM HMO 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 1340339_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 1340339_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 1340339_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 731.43 67.6 999999999 655.15 1049.54 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 1340348_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 AETNA AETNA 429.76 79 999999999 329.39 527.68 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 1340348_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 353.6 65 999999999 329.39 527.68 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 1340348_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 527.68 97 999999999 329.39 527.68 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 1340348_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 375.36 69 999999999 329.39 527.68 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 1340348_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 424.32 78 999999999 329.39 527.68 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 1340348_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 UMR - ALL PLANS UMR - ALL PLANS 380.8 70 999999999 329.39 527.68 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 1340348_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 SIHO - ALL PLANS SIHO - ALL PLANS 489.6 90 999999999 329.39 527.68 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 1340348_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 329.39 527.68 "X-ray of abdomen, minimum of 3 views" 1340348_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 329.39 60.55 999999999 329.39 527.68 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 1340348_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 329.39 527.68 "X-ray of abdomen, minimum of 3 views" 1340348_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 ANTHEM HMO ANTHEM HMO 999999999 329.39 527.68 "X-ray of abdomen, minimum of 3 views" 1340348_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 329.39 527.68 "X-ray of abdomen, minimum of 3 views" 1340348_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 329.39 527.68 "X-ray of abdomen, minimum of 3 views" 1340348_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 367.74 67.6 999999999 329.39 527.68 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 1340351_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 AETNA AETNA 429.76 79 999999999 329.39 527.68 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 1340351_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 353.6 65 999999999 329.39 527.68 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 1340351_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 527.68 97 999999999 329.39 527.68 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 1340351_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 375.36 69 999999999 329.39 527.68 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 1340351_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 424.32 78 999999999 329.39 527.68 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 1340351_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 UMR - ALL PLANS UMR - ALL PLANS 380.8 70 999999999 329.39 527.68 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 1340351_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 SIHO - ALL PLANS SIHO - ALL PLANS 489.6 90 999999999 329.39 527.68 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 1340351_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 329.39 527.68 "X-ray of abdomen, minimum of 3 views" 1340351_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 329.39 60.55 999999999 329.39 527.68 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 1340351_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 329.39 527.68 "X-ray of abdomen, minimum of 3 views" 1340351_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 ANTHEM HMO ANTHEM HMO 999999999 329.39 527.68 "X-ray of abdomen, minimum of 3 views" 1340351_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 329.39 527.68 "X-ray of abdomen, minimum of 3 views" 1340351_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 329.39 527.68 "X-ray of abdomen, minimum of 3 views" 1340351_1 CDM 0320 RC 74021 HCPCS inpatient 544 353.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 367.74 67.6 999999999 329.39 527.68 percent of total billed charges Single contrast X-ray of esophagus 1340354_1 CDM 0320 RC 74220 HCPCS inpatient 872 566.8 AETNA AETNA 688.88 79 999999999 528 845.84 percent of total billed charges Single contrast X-ray of esophagus 1340354_1 CDM 0320 RC 74220 HCPCS inpatient 872 566.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 566.8 65 999999999 528 845.84 percent of total billed charges Single contrast X-ray of esophagus 1340354_1 CDM 0320 RC 74220 HCPCS inpatient 872 566.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 845.84 97 999999999 528 845.84 percent of total billed charges Single contrast X-ray of esophagus 1340354_1 CDM 0320 RC 74220 HCPCS inpatient 872 566.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 601.68 69 999999999 528 845.84 percent of total billed charges Single contrast X-ray of esophagus 1340354_1 CDM 0320 RC 74220 HCPCS inpatient 872 566.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 680.16 78 999999999 528 845.84 percent of total billed charges Single contrast X-ray of esophagus 1340354_1 CDM 0320 RC 74220 HCPCS inpatient 872 566.8 UMR - ALL PLANS UMR - ALL PLANS 610.4 70 999999999 528 845.84 percent of total billed charges Single contrast X-ray of esophagus 1340354_1 CDM 0320 RC 74220 HCPCS inpatient 872 566.8 SIHO - ALL PLANS SIHO - ALL PLANS 784.8 90 999999999 528 845.84 percent of total billed charges Single contrast X-ray of esophagus 1340354_1 CDM 0320 RC 74220 HCPCS inpatient 872 566.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 528 845.84 Single contrast X-ray of esophagus 1340354_1 CDM 0320 RC 74220 HCPCS inpatient 872 566.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 528 60.55 999999999 528 845.84 percent of total billed charges Single contrast X-ray of esophagus 1340354_1 CDM 0320 RC 74220 HCPCS inpatient 872 566.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 528 845.84 Single contrast X-ray of esophagus 1340354_1 CDM 0320 RC 74220 HCPCS inpatient 872 566.8 ANTHEM HMO ANTHEM HMO 999999999 528 845.84 Single contrast X-ray of esophagus 1340354_1 CDM 0320 RC 74220 HCPCS inpatient 872 566.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 528 845.84 Single contrast X-ray of esophagus 1340354_1 CDM 0320 RC 74220 HCPCS inpatient 872 566.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 528 845.84 Single contrast X-ray of esophagus 1340354_1 CDM 0320 RC 74220 HCPCS inpatient 872 566.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 589.47 67.6 999999999 528 845.84 percent of total billed charges Review by radiologist of previous placed shunt image 1340411_1 CDM 0320 RC 75809 HCPCS inpatient 529 343.85 AETNA AETNA 417.91 79 999999999 320.31 513.13 percent of total billed charges Review by radiologist of previous placed shunt image 1340411_1 CDM 0320 RC 75809 HCPCS inpatient 529 343.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 343.85 65 999999999 320.31 513.13 percent of total billed charges Review by radiologist of previous placed shunt image 1340411_1 CDM 0320 RC 75809 HCPCS inpatient 529 343.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 513.13 97 999999999 320.31 513.13 percent of total billed charges Review by radiologist of previous placed shunt image 1340411_1 CDM 0320 RC 75809 HCPCS inpatient 529 343.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 365.01 69 999999999 320.31 513.13 percent of total billed charges Review by radiologist of previous placed shunt image 1340411_1 CDM 0320 RC 75809 HCPCS inpatient 529 343.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 412.62 78 999999999 320.31 513.13 percent of total billed charges Review by radiologist of previous placed shunt image 1340411_1 CDM 0320 RC 75809 HCPCS inpatient 529 343.85 UMR - ALL PLANS UMR - ALL PLANS 370.3 70 999999999 320.31 513.13 percent of total billed charges Review by radiologist of previous placed shunt image 1340411_1 CDM 0320 RC 75809 HCPCS inpatient 529 343.85 SIHO - ALL PLANS SIHO - ALL PLANS 476.1 90 999999999 320.31 513.13 percent of total billed charges Review by radiologist of previous placed shunt image 1340411_1 CDM 0320 RC 75809 HCPCS inpatient 529 343.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 320.31 513.13 Review by radiologist of previous placed shunt image 1340411_1 CDM 0320 RC 75809 HCPCS inpatient 529 343.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 320.31 60.55 999999999 320.31 513.13 percent of total billed charges Review by radiologist of previous placed shunt image 1340411_1 CDM 0320 RC 75809 HCPCS inpatient 529 343.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 320.31 513.13 Review by radiologist of previous placed shunt image 1340411_1 CDM 0320 RC 75809 HCPCS inpatient 529 343.85 ANTHEM HMO ANTHEM HMO 999999999 320.31 513.13 Review by radiologist of previous placed shunt image 1340411_1 CDM 0320 RC 75809 HCPCS inpatient 529 343.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 320.31 513.13 Review by radiologist of previous placed shunt image 1340411_1 CDM 0320 RC 75809 HCPCS inpatient 529 343.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 320.31 513.13 Review by radiologist of previous placed shunt image 1340411_1 CDM 0320 RC 75809 HCPCS inpatient 529 343.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 357.6 67.6 999999999 320.31 513.13 percent of total billed charges Injection into tendon or ligament 1353686_1 CDM 0360 RC 20550 HCPCS inpatient 675 438.75 AETNA AETNA 533.25 79 999999999 408.71 654.75 percent of total billed charges Injection into tendon or ligament 1353686_1 CDM 0360 RC 20550 HCPCS inpatient 675 438.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 438.75 65 999999999 408.71 654.75 percent of total billed charges Injection into tendon or ligament 1353686_1 CDM 0360 RC 20550 HCPCS inpatient 675 438.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 654.75 97 999999999 408.71 654.75 percent of total billed charges Injection into tendon or ligament 1353686_1 CDM 0360 RC 20550 HCPCS inpatient 675 438.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 465.75 69 999999999 408.71 654.75 percent of total billed charges Injection into tendon or ligament 1353686_1 CDM 0360 RC 20550 HCPCS inpatient 675 438.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 526.5 78 999999999 408.71 654.75 percent of total billed charges Injection into tendon or ligament 1353686_1 CDM 0360 RC 20550 HCPCS inpatient 675 438.75 UMR - ALL PLANS UMR - ALL PLANS 472.5 70 999999999 408.71 654.75 percent of total billed charges Injection into tendon or ligament 1353686_1 CDM 0360 RC 20550 HCPCS inpatient 675 438.75 SIHO - ALL PLANS SIHO - ALL PLANS 607.5 90 999999999 408.71 654.75 percent of total billed charges Injection into tendon or ligament 1353686_1 CDM 0360 RC 20550 HCPCS inpatient 675 438.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 408.71 654.75 Injection into tendon or ligament 1353686_1 CDM 0360 RC 20550 HCPCS inpatient 675 438.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 408.71 60.55 999999999 408.71 654.75 percent of total billed charges Injection into tendon or ligament 1353686_1 CDM 0360 RC 20550 HCPCS inpatient 675 438.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 408.71 654.75 Injection into tendon or ligament 1353686_1 CDM 0360 RC 20550 HCPCS inpatient 675 438.75 ANTHEM HMO ANTHEM HMO 999999999 408.71 654.75 Injection into tendon or ligament 1353686_1 CDM 0360 RC 20550 HCPCS inpatient 675 438.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 408.71 654.75 Injection into tendon or ligament 1353686_1 CDM 0360 RC 20550 HCPCS inpatient 675 438.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 408.71 654.75 Injection into tendon or ligament 1353686_1 CDM 0360 RC 20550 HCPCS inpatient 675 438.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 456.3 67.6 999999999 408.71 654.75 percent of total billed charges "Injection of trigger points, 1-2 muscles" 1359598_1 CDM 0360 RC 20552 HCPCS inpatient 732 475.8 AETNA AETNA 578.28 79 999999999 443.23 710.04 percent of total billed charges "Injection of trigger points, 1-2 muscles" 1359598_1 CDM 0360 RC 20552 HCPCS inpatient 732 475.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 475.8 65 999999999 443.23 710.04 percent of total billed charges "Injection of trigger points, 1-2 muscles" 1359598_1 CDM 0360 RC 20552 HCPCS inpatient 732 475.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 710.04 97 999999999 443.23 710.04 percent of total billed charges "Injection of trigger points, 1-2 muscles" 1359598_1 CDM 0360 RC 20552 HCPCS inpatient 732 475.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 505.08 69 999999999 443.23 710.04 percent of total billed charges "Injection of trigger points, 1-2 muscles" 1359598_1 CDM 0360 RC 20552 HCPCS inpatient 732 475.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 570.96 78 999999999 443.23 710.04 percent of total billed charges "Injection of trigger points, 1-2 muscles" 1359598_1 CDM 0360 RC 20552 HCPCS inpatient 732 475.8 UMR - ALL PLANS UMR - ALL PLANS 512.4 70 999999999 443.23 710.04 percent of total billed charges "Injection of trigger points, 1-2 muscles" 1359598_1 CDM 0360 RC 20552 HCPCS inpatient 732 475.8 SIHO - ALL PLANS SIHO - ALL PLANS 658.8 90 999999999 443.23 710.04 percent of total billed charges "Injection of trigger points, 1-2 muscles" 1359598_1 CDM 0360 RC 20552 HCPCS inpatient 732 475.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 443.23 710.04 "Injection of trigger points, 1-2 muscles" 1359598_1 CDM 0360 RC 20552 HCPCS inpatient 732 475.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 443.23 60.55 999999999 443.23 710.04 percent of total billed charges "Injection of trigger points, 1-2 muscles" 1359598_1 CDM 0360 RC 20552 HCPCS inpatient 732 475.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 443.23 710.04 "Injection of trigger points, 1-2 muscles" 1359598_1 CDM 0360 RC 20552 HCPCS inpatient 732 475.8 ANTHEM HMO ANTHEM HMO 999999999 443.23 710.04 "Injection of trigger points, 1-2 muscles" 1359598_1 CDM 0360 RC 20552 HCPCS inpatient 732 475.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 443.23 710.04 "Injection of trigger points, 1-2 muscles" 1359598_1 CDM 0360 RC 20552 HCPCS inpatient 732 475.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 494.83 67.6 999999999 443.23 710.04 percent of total billed charges "Injection of trigger points, 1-2 muscles" 1359598_1 CDM 0360 RC 20552 HCPCS inpatient 732 475.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 443.23 710.04 MRI scan of blood vessels of abdomen 1403599_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 AETNA AETNA 2370.79 79 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1403599_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1950.65 65 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1403599_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2910.97 97 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1403599_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2070.69 69 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1403599_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2340.78 78 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1403599_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 UMR - ALL PLANS UMR - ALL PLANS 2100.7 70 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1403599_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 SIHO - ALL PLANS SIHO - ALL PLANS 2700.9 90 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1403599_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1817.11 2910.97 MRI scan of blood vessels of abdomen 1403599_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1817.11 60.55 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1403599_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1817.11 2910.97 MRI scan of blood vessels of abdomen 1403599_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 ANTHEM HMO ANTHEM HMO 999999999 1817.11 2910.97 MRI scan of blood vessels of abdomen 1403599_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1817.11 2910.97 MRI scan of blood vessels of abdomen 1403599_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2028.68 67.6 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of abdomen 1403599_1 CDM 0618 RC 74185 HCPCS inpatient 3001 1950.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1817.11 2910.97 "DXA bone density measurement of forearm, finger, hand, or foot" 1405655_1 CDM 0320 RC 77081 HCPCS inpatient 203 131.95 AETNA AETNA 160.37 79 999999999 122.92 196.91 percent of total billed charges "DXA bone density measurement of forearm, finger, hand, or foot" 1405655_1 CDM 0320 RC 77081 HCPCS inpatient 203 131.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 131.95 65 999999999 122.92 196.91 percent of total billed charges "DXA bone density measurement of forearm, finger, hand, or foot" 1405655_1 CDM 0320 RC 77081 HCPCS inpatient 203 131.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 196.91 97 999999999 122.92 196.91 percent of total billed charges "DXA bone density measurement of forearm, finger, hand, or foot" 1405655_1 CDM 0320 RC 77081 HCPCS inpatient 203 131.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.07 69 999999999 122.92 196.91 percent of total billed charges "DXA bone density measurement of forearm, finger, hand, or foot" 1405655_1 CDM 0320 RC 77081 HCPCS inpatient 203 131.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 158.34 78 999999999 122.92 196.91 percent of total billed charges "DXA bone density measurement of forearm, finger, hand, or foot" 1405655_1 CDM 0320 RC 77081 HCPCS inpatient 203 131.95 UMR - ALL PLANS UMR - ALL PLANS 142.1 70 999999999 122.92 196.91 percent of total billed charges "DXA bone density measurement of forearm, finger, hand, or foot" 1405655_1 CDM 0320 RC 77081 HCPCS inpatient 203 131.95 SIHO - ALL PLANS SIHO - ALL PLANS 182.7 90 999999999 122.92 196.91 percent of total billed charges "DXA bone density measurement of forearm, finger, hand, or foot" 1405655_1 CDM 0320 RC 77081 HCPCS inpatient 203 131.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 122.92 196.91 "DXA bone density measurement of forearm, finger, hand, or foot" 1405655_1 CDM 0320 RC 77081 HCPCS inpatient 203 131.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 122.92 60.55 999999999 122.92 196.91 percent of total billed charges "DXA bone density measurement of forearm, finger, hand, or foot" 1405655_1 CDM 0320 RC 77081 HCPCS inpatient 203 131.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 122.92 196.91 "DXA bone density measurement of forearm, finger, hand, or foot" 1405655_1 CDM 0320 RC 77081 HCPCS inpatient 203 131.95 ANTHEM HMO ANTHEM HMO 999999999 122.92 196.91 "DXA bone density measurement of forearm, finger, hand, or foot" 1405655_1 CDM 0320 RC 77081 HCPCS inpatient 203 131.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 122.92 196.91 "DXA bone density measurement of forearm, finger, hand, or foot" 1405655_1 CDM 0320 RC 77081 HCPCS inpatient 203 131.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.23 67.6 999999999 122.92 196.91 percent of total billed charges "DXA bone density measurement of forearm, finger, hand, or foot" 1405655_1 CDM 0320 RC 77081 HCPCS inpatient 203 131.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 122.92 196.91 Review by radiologist of CT guidance for needle placement 1405670_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 AETNA AETNA 1333.52 79 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1405670_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.2 65 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1405670_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1637.36 97 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1405670_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1164.72 69 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1405670_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1316.64 78 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1405670_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 UMR - ALL PLANS UMR - ALL PLANS 1181.6 70 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1405670_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 SIHO - ALL PLANS SIHO - ALL PLANS 1519.2 90 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1405670_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 1405670_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.08 60.55 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1405670_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 1405670_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 ANTHEM HMO ANTHEM HMO 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 1405670_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 1405670_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.09 67.6 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 1405670_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 1405715_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 AETNA AETNA 1334.31 79 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1405715_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.85 65 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1405715_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1638.33 97 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1405715_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1165.41 69 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1405715_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1317.42 78 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1405715_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UMR - ALL PLANS UMR - ALL PLANS 1182.3 70 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1405715_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SIHO - ALL PLANS SIHO - ALL PLANS 1520.1 90 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1405715_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1405715_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.69 60.55 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1405715_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1405715_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM HMO ANTHEM HMO 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1405715_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 1405715_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.76 67.6 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 1405715_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.69 1638.33 MRI scan of blood vessels of chest 1405751_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 AETNA AETNA 2370.79 79 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 1405751_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1950.65 65 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 1405751_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2910.97 97 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 1405751_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2070.69 69 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 1405751_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2340.78 78 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 1405751_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 UMR - ALL PLANS UMR - ALL PLANS 2100.7 70 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 1405751_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 SIHO - ALL PLANS SIHO - ALL PLANS 2700.9 90 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 1405751_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1817.11 2910.97 MRI scan of blood vessels of chest 1405751_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1817.11 60.55 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 1405751_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1817.11 2910.97 MRI scan of blood vessels of chest 1405751_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 ANTHEM HMO ANTHEM HMO 999999999 1817.11 2910.97 MRI scan of blood vessels of chest 1405751_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1817.11 2910.97 MRI scan of blood vessels of chest 1405751_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2028.68 67.6 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 1405751_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1817.11 2910.97 MRI scan of blood vessels of pelvis 1405766_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 AETNA AETNA 2370.79 79 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1405766_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1950.65 65 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1405766_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2910.97 97 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1405766_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2070.69 69 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1405766_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2340.78 78 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1405766_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 UMR - ALL PLANS UMR - ALL PLANS 2100.7 70 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1405766_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 SIHO - ALL PLANS SIHO - ALL PLANS 2700.9 90 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1405766_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1817.11 2910.97 MRI scan of blood vessels of pelvis 1405766_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1817.11 60.55 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1405766_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1817.11 2910.97 MRI scan of blood vessels of pelvis 1405766_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 ANTHEM HMO ANTHEM HMO 999999999 1817.11 2910.97 MRI scan of blood vessels of pelvis 1405766_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1817.11 2910.97 MRI scan of blood vessels of pelvis 1405766_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2028.68 67.6 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1405766_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1817.11 2910.97 MRI scan of blood vessels of pelvis 1405769_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 AETNA AETNA 2370.79 79 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1405769_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1950.65 65 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1405769_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2910.97 97 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1405769_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2070.69 69 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1405769_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2340.78 78 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1405769_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 UMR - ALL PLANS UMR - ALL PLANS 2100.7 70 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1405769_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 SIHO - ALL PLANS SIHO - ALL PLANS 2700.9 90 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1405769_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1817.11 2910.97 MRI scan of blood vessels of pelvis 1405769_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1817.11 60.55 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1405769_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1817.11 2910.97 MRI scan of blood vessels of pelvis 1405769_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 ANTHEM HMO ANTHEM HMO 999999999 1817.11 2910.97 MRI scan of blood vessels of pelvis 1405769_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1817.11 2910.97 MRI scan of blood vessels of pelvis 1405769_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2028.68 67.6 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of pelvis 1405769_1 CDM 0618 RC 72198 HCPCS inpatient 3001 1950.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1817.11 2910.97 MRI scan of blood vessels of arm 1405772_1 CDM 0618 RC 73225 HCPCS inpatient 5972 3881.8 AETNA AETNA 4717.88 79 999999999 3616.05 5792.84 percent of total billed charges MRI scan of blood vessels of arm 1405772_1 CDM 0618 RC 73225 HCPCS inpatient 5972 3881.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 3881.8 65 999999999 3616.05 5792.84 percent of total billed charges MRI scan of blood vessels of arm 1405772_1 CDM 0618 RC 73225 HCPCS inpatient 5972 3881.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5792.84 97 999999999 3616.05 5792.84 percent of total billed charges MRI scan of blood vessels of arm 1405772_1 CDM 0618 RC 73225 HCPCS inpatient 5972 3881.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 4120.68 69 999999999 3616.05 5792.84 percent of total billed charges MRI scan of blood vessels of arm 1405772_1 CDM 0618 RC 73225 HCPCS inpatient 5972 3881.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 4658.16 78 999999999 3616.05 5792.84 percent of total billed charges MRI scan of blood vessels of arm 1405772_1 CDM 0618 RC 73225 HCPCS inpatient 5972 3881.8 UMR - ALL PLANS UMR - ALL PLANS 4180.4 70 999999999 3616.05 5792.84 percent of total billed charges MRI scan of blood vessels of arm 1405772_1 CDM 0618 RC 73225 HCPCS inpatient 5972 3881.8 SIHO - ALL PLANS SIHO - ALL PLANS 5374.8 90 999999999 3616.05 5792.84 percent of total billed charges MRI scan of blood vessels of arm 1405772_1 CDM 0618 RC 73225 HCPCS inpatient 5972 3881.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3616.05 5792.84 MRI scan of blood vessels of arm 1405772_1 CDM 0618 RC 73225 HCPCS inpatient 5972 3881.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3616.05 60.55 999999999 3616.05 5792.84 percent of total billed charges MRI scan of blood vessels of arm 1405772_1 CDM 0618 RC 73225 HCPCS inpatient 5972 3881.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3616.05 5792.84 MRI scan of blood vessels of arm 1405772_1 CDM 0618 RC 73225 HCPCS inpatient 5972 3881.8 ANTHEM HMO ANTHEM HMO 999999999 3616.05 5792.84 MRI scan of blood vessels of arm 1405772_1 CDM 0618 RC 73225 HCPCS inpatient 5972 3881.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3616.05 5792.84 MRI scan of blood vessels of arm 1405772_1 CDM 0618 RC 73225 HCPCS inpatient 5972 3881.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 4037.07 67.6 999999999 3616.05 5792.84 percent of total billed charges MRI scan of blood vessels of arm 1405772_1 CDM 0618 RC 73225 HCPCS inpatient 5972 3881.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 3616.05 5792.84 X-ray for bone length assessment 1405792_1 CDM 0320 RC 77073 HCPCS inpatient 548 356.2 AETNA AETNA 432.92 79 999999999 331.81 531.56 percent of total billed charges X-ray for bone length assessment 1405792_1 CDM 0320 RC 77073 HCPCS inpatient 548 356.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 356.2 65 999999999 331.81 531.56 percent of total billed charges X-ray for bone length assessment 1405792_1 CDM 0320 RC 77073 HCPCS inpatient 548 356.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 531.56 97 999999999 331.81 531.56 percent of total billed charges X-ray for bone length assessment 1405792_1 CDM 0320 RC 77073 HCPCS inpatient 548 356.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 378.12 69 999999999 331.81 531.56 percent of total billed charges X-ray for bone length assessment 1405792_1 CDM 0320 RC 77073 HCPCS inpatient 548 356.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 427.44 78 999999999 331.81 531.56 percent of total billed charges X-ray for bone length assessment 1405792_1 CDM 0320 RC 77073 HCPCS inpatient 548 356.2 UMR - ALL PLANS UMR - ALL PLANS 383.6 70 999999999 331.81 531.56 percent of total billed charges X-ray for bone length assessment 1405792_1 CDM 0320 RC 77073 HCPCS inpatient 548 356.2 SIHO - ALL PLANS SIHO - ALL PLANS 493.2 90 999999999 331.81 531.56 percent of total billed charges X-ray for bone length assessment 1405792_1 CDM 0320 RC 77073 HCPCS inpatient 548 356.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 331.81 531.56 X-ray for bone length assessment 1405792_1 CDM 0320 RC 77073 HCPCS inpatient 548 356.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 331.81 60.55 999999999 331.81 531.56 percent of total billed charges X-ray for bone length assessment 1405792_1 CDM 0320 RC 77073 HCPCS inpatient 548 356.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 331.81 531.56 X-ray for bone length assessment 1405792_1 CDM 0320 RC 77073 HCPCS inpatient 548 356.2 ANTHEM HMO ANTHEM HMO 999999999 331.81 531.56 X-ray for bone length assessment 1405792_1 CDM 0320 RC 77073 HCPCS inpatient 548 356.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 331.81 531.56 X-ray for bone length assessment 1405792_1 CDM 0320 RC 77073 HCPCS inpatient 548 356.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 370.45 67.6 999999999 331.81 531.56 percent of total billed charges X-ray for bone length assessment 1405792_1 CDM 0320 RC 77073 HCPCS inpatient 548 356.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 331.81 531.56 "X-ray of chest, 2 views" 1405795_1 CDM 0324 RC 71046 HCPCS inpatient 696 452.4 AETNA AETNA 549.84 79 999999999 421.43 675.12 percent of total billed charges "X-ray of chest, 2 views" 1405795_1 CDM 0324 RC 71046 HCPCS inpatient 696 452.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 452.4 65 999999999 421.43 675.12 percent of total billed charges "X-ray of chest, 2 views" 1405795_1 CDM 0324 RC 71046 HCPCS inpatient 696 452.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 675.12 97 999999999 421.43 675.12 percent of total billed charges "X-ray of chest, 2 views" 1405795_1 CDM 0324 RC 71046 HCPCS inpatient 696 452.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 480.24 69 999999999 421.43 675.12 percent of total billed charges "X-ray of chest, 2 views" 1405795_1 CDM 0324 RC 71046 HCPCS inpatient 696 452.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 542.88 78 999999999 421.43 675.12 percent of total billed charges "X-ray of chest, 2 views" 1405795_1 CDM 0324 RC 71046 HCPCS inpatient 696 452.4 UMR - ALL PLANS UMR - ALL PLANS 487.2 70 999999999 421.43 675.12 percent of total billed charges "X-ray of chest, 2 views" 1405795_1 CDM 0324 RC 71046 HCPCS inpatient 696 452.4 SIHO - ALL PLANS SIHO - ALL PLANS 626.4 90 999999999 421.43 675.12 percent of total billed charges "X-ray of chest, 2 views" 1405795_1 CDM 0324 RC 71046 HCPCS inpatient 696 452.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 421.43 675.12 "X-ray of chest, 2 views" 1405795_1 CDM 0324 RC 71046 HCPCS inpatient 696 452.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 421.43 60.55 999999999 421.43 675.12 percent of total billed charges "X-ray of chest, 2 views" 1405795_1 CDM 0324 RC 71046 HCPCS inpatient 696 452.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 421.43 675.12 "X-ray of chest, 2 views" 1405795_1 CDM 0324 RC 71046 HCPCS inpatient 696 452.4 ANTHEM HMO ANTHEM HMO 999999999 421.43 675.12 "X-ray of chest, 2 views" 1405795_1 CDM 0324 RC 71046 HCPCS inpatient 696 452.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 421.43 675.12 "X-ray of chest, 2 views" 1405795_1 CDM 0324 RC 71046 HCPCS inpatient 696 452.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 470.5 67.6 999999999 421.43 675.12 percent of total billed charges "X-ray of chest, 2 views" 1405795_1 CDM 0324 RC 71046 HCPCS inpatient 696 452.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 421.43 675.12 "X-ray of joints, multiple" 1405801_1 CDM 0320 RC 77077 HCPCS inpatient 527 342.55 AETNA AETNA 416.33 79 999999999 319.1 511.19 percent of total billed charges "X-ray of joints, multiple" 1405801_1 CDM 0320 RC 77077 HCPCS inpatient 527 342.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 342.55 65 999999999 319.1 511.19 percent of total billed charges "X-ray of joints, multiple" 1405801_1 CDM 0320 RC 77077 HCPCS inpatient 527 342.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 511.19 97 999999999 319.1 511.19 percent of total billed charges "X-ray of joints, multiple" 1405801_1 CDM 0320 RC 77077 HCPCS inpatient 527 342.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 363.63 69 999999999 319.1 511.19 percent of total billed charges "X-ray of joints, multiple" 1405801_1 CDM 0320 RC 77077 HCPCS inpatient 527 342.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 411.06 78 999999999 319.1 511.19 percent of total billed charges "X-ray of joints, multiple" 1405801_1 CDM 0320 RC 77077 HCPCS inpatient 527 342.55 UMR - ALL PLANS UMR - ALL PLANS 368.9 70 999999999 319.1 511.19 percent of total billed charges "X-ray of joints, multiple" 1405801_1 CDM 0320 RC 77077 HCPCS inpatient 527 342.55 SIHO - ALL PLANS SIHO - ALL PLANS 474.3 90 999999999 319.1 511.19 percent of total billed charges "X-ray of joints, multiple" 1405801_1 CDM 0320 RC 77077 HCPCS inpatient 527 342.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 319.1 511.19 "X-ray of joints, multiple" 1405801_1 CDM 0320 RC 77077 HCPCS inpatient 527 342.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 319.1 60.55 999999999 319.1 511.19 percent of total billed charges "X-ray of joints, multiple" 1405801_1 CDM 0320 RC 77077 HCPCS inpatient 527 342.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 319.1 511.19 "X-ray of joints, multiple" 1405801_1 CDM 0320 RC 77077 HCPCS inpatient 527 342.55 ANTHEM HMO ANTHEM HMO 999999999 319.1 511.19 "X-ray of joints, multiple" 1405801_1 CDM 0320 RC 77077 HCPCS inpatient 527 342.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 319.1 511.19 "X-ray of joints, multiple" 1405801_1 CDM 0320 RC 77077 HCPCS inpatient 527 342.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 356.25 67.6 999999999 319.1 511.19 percent of total billed charges "X-ray of joints, multiple" 1405801_1 CDM 0320 RC 77077 HCPCS inpatient 527 342.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 319.1 511.19 "X-ray of ribs on both sides of body, 3 views" 1405804_1 CDM 0320 RC 71110 HCPCS inpatient 609 395.85 AETNA AETNA 481.11 79 999999999 368.75 590.73 percent of total billed charges "X-ray of ribs on both sides of body, 3 views" 1405804_1 CDM 0320 RC 71110 HCPCS inpatient 609 395.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 395.85 65 999999999 368.75 590.73 percent of total billed charges "X-ray of ribs on both sides of body, 3 views" 1405804_1 CDM 0320 RC 71110 HCPCS inpatient 609 395.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 590.73 97 999999999 368.75 590.73 percent of total billed charges "X-ray of ribs on both sides of body, 3 views" 1405804_1 CDM 0320 RC 71110 HCPCS inpatient 609 395.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 420.21 69 999999999 368.75 590.73 percent of total billed charges "X-ray of ribs on both sides of body, 3 views" 1405804_1 CDM 0320 RC 71110 HCPCS inpatient 609 395.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 475.02 78 999999999 368.75 590.73 percent of total billed charges "X-ray of ribs on both sides of body, 3 views" 1405804_1 CDM 0320 RC 71110 HCPCS inpatient 609 395.85 UMR - ALL PLANS UMR - ALL PLANS 426.3 70 999999999 368.75 590.73 percent of total billed charges "X-ray of ribs on both sides of body, 3 views" 1405804_1 CDM 0320 RC 71110 HCPCS inpatient 609 395.85 SIHO - ALL PLANS SIHO - ALL PLANS 548.1 90 999999999 368.75 590.73 percent of total billed charges "X-ray of ribs on both sides of body, 3 views" 1405804_1 CDM 0320 RC 71110 HCPCS inpatient 609 395.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 368.75 590.73 "X-ray of ribs on both sides of body, 3 views" 1405804_1 CDM 0320 RC 71110 HCPCS inpatient 609 395.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 368.75 60.55 999999999 368.75 590.73 percent of total billed charges "X-ray of ribs on both sides of body, 3 views" 1405804_1 CDM 0320 RC 71110 HCPCS inpatient 609 395.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 368.75 590.73 "X-ray of ribs on both sides of body, 3 views" 1405804_1 CDM 0320 RC 71110 HCPCS inpatient 609 395.85 ANTHEM HMO ANTHEM HMO 999999999 368.75 590.73 "X-ray of ribs on both sides of body, 3 views" 1405804_1 CDM 0320 RC 71110 HCPCS inpatient 609 395.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 368.75 590.73 "X-ray of ribs on both sides of body, 3 views" 1405804_1 CDM 0320 RC 71110 HCPCS inpatient 609 395.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 411.68 67.6 999999999 368.75 590.73 percent of total billed charges "X-ray of ribs on both sides of body, 3 views" 1405804_1 CDM 0320 RC 71110 HCPCS inpatient 609 395.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 368.75 590.73 "X-ray of skull, 1-3 views" 1405806_1 CDM 0320 RC 70250 HCPCS inpatient 586 380.9 AETNA AETNA 462.94 79 999999999 354.82 568.42 percent of total billed charges "X-ray of skull, 1-3 views" 1405806_1 CDM 0320 RC 70250 HCPCS inpatient 586 380.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 380.9 65 999999999 354.82 568.42 percent of total billed charges "X-ray of skull, 1-3 views" 1405806_1 CDM 0320 RC 70250 HCPCS inpatient 586 380.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 568.42 97 999999999 354.82 568.42 percent of total billed charges "X-ray of skull, 1-3 views" 1405806_1 CDM 0320 RC 70250 HCPCS inpatient 586 380.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 404.34 69 999999999 354.82 568.42 percent of total billed charges "X-ray of skull, 1-3 views" 1405806_1 CDM 0320 RC 70250 HCPCS inpatient 586 380.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 457.08 78 999999999 354.82 568.42 percent of total billed charges "X-ray of skull, 1-3 views" 1405806_1 CDM 0320 RC 70250 HCPCS inpatient 586 380.9 UMR - ALL PLANS UMR - ALL PLANS 410.2 70 999999999 354.82 568.42 percent of total billed charges "X-ray of skull, 1-3 views" 1405806_1 CDM 0320 RC 70250 HCPCS inpatient 586 380.9 SIHO - ALL PLANS SIHO - ALL PLANS 527.4 90 999999999 354.82 568.42 percent of total billed charges "X-ray of skull, 1-3 views" 1405806_1 CDM 0320 RC 70250 HCPCS inpatient 586 380.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 354.82 568.42 "X-ray of skull, 1-3 views" 1405806_1 CDM 0320 RC 70250 HCPCS inpatient 586 380.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 354.82 60.55 999999999 354.82 568.42 percent of total billed charges "X-ray of skull, 1-3 views" 1405806_1 CDM 0320 RC 70250 HCPCS inpatient 586 380.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 354.82 568.42 "X-ray of skull, 1-3 views" 1405806_1 CDM 0320 RC 70250 HCPCS inpatient 586 380.9 ANTHEM HMO ANTHEM HMO 999999999 354.82 568.42 "X-ray of skull, 1-3 views" 1405806_1 CDM 0320 RC 70250 HCPCS inpatient 586 380.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 354.82 568.42 "X-ray of skull, 1-3 views" 1405806_1 CDM 0320 RC 70250 HCPCS inpatient 586 380.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 396.14 67.6 999999999 354.82 568.42 percent of total billed charges "X-ray of skull, 1-3 views" 1405806_1 CDM 0320 RC 70250 HCPCS inpatient 586 380.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 354.82 568.42 "X-ray of middle and lower spine, 2 views" 1405815_1 CDM 0320 RC 72080 HCPCS inpatient 270 175.5 AETNA AETNA 213.3 79 999999999 163.49 261.9 percent of total billed charges "X-ray of middle and lower spine, 2 views" 1405815_1 CDM 0320 RC 72080 HCPCS inpatient 270 175.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 175.5 65 999999999 163.49 261.9 percent of total billed charges "X-ray of middle and lower spine, 2 views" 1405815_1 CDM 0320 RC 72080 HCPCS inpatient 270 175.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 261.9 97 999999999 163.49 261.9 percent of total billed charges "X-ray of middle and lower spine, 2 views" 1405815_1 CDM 0320 RC 72080 HCPCS inpatient 270 175.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 186.3 69 999999999 163.49 261.9 percent of total billed charges "X-ray of middle and lower spine, 2 views" 1405815_1 CDM 0320 RC 72080 HCPCS inpatient 270 175.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 210.6 78 999999999 163.49 261.9 percent of total billed charges "X-ray of middle and lower spine, 2 views" 1405815_1 CDM 0320 RC 72080 HCPCS inpatient 270 175.5 UMR - ALL PLANS UMR - ALL PLANS 189 70 999999999 163.49 261.9 percent of total billed charges "X-ray of middle and lower spine, 2 views" 1405815_1 CDM 0320 RC 72080 HCPCS inpatient 270 175.5 SIHO - ALL PLANS SIHO - ALL PLANS 243 90 999999999 163.49 261.9 percent of total billed charges "X-ray of middle and lower spine, 2 views" 1405815_1 CDM 0320 RC 72080 HCPCS inpatient 270 175.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 163.49 261.9 "X-ray of middle and lower spine, 2 views" 1405815_1 CDM 0320 RC 72080 HCPCS inpatient 270 175.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 163.49 60.55 999999999 163.49 261.9 percent of total billed charges "X-ray of middle and lower spine, 2 views" 1405815_1 CDM 0320 RC 72080 HCPCS inpatient 270 175.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 163.49 261.9 "X-ray of middle and lower spine, 2 views" 1405815_1 CDM 0320 RC 72080 HCPCS inpatient 270 175.5 ANTHEM HMO ANTHEM HMO 999999999 163.49 261.9 "X-ray of middle and lower spine, 2 views" 1405815_1 CDM 0320 RC 72080 HCPCS inpatient 270 175.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 163.49 261.9 "X-ray of middle and lower spine, 2 views" 1405815_1 CDM 0320 RC 72080 HCPCS inpatient 270 175.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 182.52 67.6 999999999 163.49 261.9 percent of total billed charges "X-ray of middle and lower spine, 2 views" 1405815_1 CDM 0320 RC 72080 HCPCS inpatient 270 175.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 163.49 261.9 Single contrast X-ray of upper digestive tract 1405821_1 CDM 0320 RC 74240 HCPCS inpatient 869 564.85 AETNA AETNA 686.51 79 999999999 526.18 842.93 percent of total billed charges Single contrast X-ray of upper digestive tract 1405821_1 CDM 0320 RC 74240 HCPCS inpatient 869 564.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 564.85 65 999999999 526.18 842.93 percent of total billed charges Single contrast X-ray of upper digestive tract 1405821_1 CDM 0320 RC 74240 HCPCS inpatient 869 564.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 842.93 97 999999999 526.18 842.93 percent of total billed charges Single contrast X-ray of upper digestive tract 1405821_1 CDM 0320 RC 74240 HCPCS inpatient 869 564.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 599.61 69 999999999 526.18 842.93 percent of total billed charges Single contrast X-ray of upper digestive tract 1405821_1 CDM 0320 RC 74240 HCPCS inpatient 869 564.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 677.82 78 999999999 526.18 842.93 percent of total billed charges Single contrast X-ray of upper digestive tract 1405821_1 CDM 0320 RC 74240 HCPCS inpatient 869 564.85 UMR - ALL PLANS UMR - ALL PLANS 608.3 70 999999999 526.18 842.93 percent of total billed charges Single contrast X-ray of upper digestive tract 1405821_1 CDM 0320 RC 74240 HCPCS inpatient 869 564.85 SIHO - ALL PLANS SIHO - ALL PLANS 782.1 90 999999999 526.18 842.93 percent of total billed charges Single contrast X-ray of upper digestive tract 1405821_1 CDM 0320 RC 74240 HCPCS inpatient 869 564.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 526.18 842.93 Single contrast X-ray of upper digestive tract 1405821_1 CDM 0320 RC 74240 HCPCS inpatient 869 564.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 526.18 60.55 999999999 526.18 842.93 percent of total billed charges Single contrast X-ray of upper digestive tract 1405821_1 CDM 0320 RC 74240 HCPCS inpatient 869 564.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 526.18 842.93 Single contrast X-ray of upper digestive tract 1405821_1 CDM 0320 RC 74240 HCPCS inpatient 869 564.85 ANTHEM HMO ANTHEM HMO 999999999 526.18 842.93 Single contrast X-ray of upper digestive tract 1405821_1 CDM 0320 RC 74240 HCPCS inpatient 869 564.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 587.44 67.6 999999999 526.18 842.93 percent of total billed charges Single contrast X-ray of upper digestive tract 1405821_1 CDM 0320 RC 74240 HCPCS inpatient 869 564.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 526.18 842.93 Single contrast X-ray of upper digestive tract 1405821_1 CDM 0320 RC 74240 HCPCS inpatient 869 564.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 526.18 842.93 "PSA (prostate specific antigen) measurement, free" 1413617_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 AETNA AETNA 210.93 79 999999999 161.67 258.99 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 1413617_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 173.55 65 999999999 161.67 258.99 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 1413617_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 258.99 97 999999999 161.67 258.99 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 1413617_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.23 69 999999999 161.67 258.99 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 1413617_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 208.26 78 999999999 161.67 258.99 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 1413617_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 UMR - ALL PLANS UMR - ALL PLANS 186.9 70 999999999 161.67 258.99 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 1413617_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 SIHO - ALL PLANS SIHO - ALL PLANS 240.3 90 999999999 161.67 258.99 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 1413617_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 161.67 258.99 "PSA (prostate specific antigen) measurement, free" 1413617_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 161.67 60.55 999999999 161.67 258.99 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 1413617_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 161.67 258.99 "PSA (prostate specific antigen) measurement, free" 1413617_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 ANTHEM HMO ANTHEM HMO 999999999 161.67 258.99 "PSA (prostate specific antigen) measurement, free" 1413617_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 180.49 67.6 999999999 161.67 258.99 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 1413617_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 161.67 258.99 "PSA (prostate specific antigen) measurement, free" 1413617_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 161.67 258.99 Hemoglobin A1C level 1413627_1 CDM 0301 RC 83036 HCPCS inpatient 196 127.4 AETNA AETNA 154.84 79 999999999 118.68 190.12 percent of total billed charges Hemoglobin A1C level 1413627_1 CDM 0301 RC 83036 HCPCS inpatient 196 127.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 127.4 65 999999999 118.68 190.12 percent of total billed charges Hemoglobin A1C level 1413627_1 CDM 0301 RC 83036 HCPCS inpatient 196 127.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 190.12 97 999999999 118.68 190.12 percent of total billed charges Hemoglobin A1C level 1413627_1 CDM 0301 RC 83036 HCPCS inpatient 196 127.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 135.24 69 999999999 118.68 190.12 percent of total billed charges Hemoglobin A1C level 1413627_1 CDM 0301 RC 83036 HCPCS inpatient 196 127.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 152.88 78 999999999 118.68 190.12 percent of total billed charges Hemoglobin A1C level 1413627_1 CDM 0301 RC 83036 HCPCS inpatient 196 127.4 UMR - ALL PLANS UMR - ALL PLANS 137.2 70 999999999 118.68 190.12 percent of total billed charges Hemoglobin A1C level 1413627_1 CDM 0301 RC 83036 HCPCS inpatient 196 127.4 SIHO - ALL PLANS SIHO - ALL PLANS 176.4 90 999999999 118.68 190.12 percent of total billed charges Hemoglobin A1C level 1413627_1 CDM 0301 RC 83036 HCPCS inpatient 196 127.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 118.68 190.12 Hemoglobin A1C level 1413627_1 CDM 0301 RC 83036 HCPCS inpatient 196 127.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 118.68 60.55 999999999 118.68 190.12 percent of total billed charges Hemoglobin A1C level 1413627_1 CDM 0301 RC 83036 HCPCS inpatient 196 127.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 118.68 190.12 Hemoglobin A1C level 1413627_1 CDM 0301 RC 83036 HCPCS inpatient 196 127.4 ANTHEM HMO ANTHEM HMO 999999999 118.68 190.12 Hemoglobin A1C level 1413627_1 CDM 0301 RC 83036 HCPCS inpatient 196 127.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 132.5 67.6 999999999 118.68 190.12 percent of total billed charges Hemoglobin A1C level 1413627_1 CDM 0301 RC 83036 HCPCS inpatient 196 127.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 118.68 190.12 Hemoglobin A1C level 1413627_1 CDM 0301 RC 83036 HCPCS inpatient 196 127.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 118.68 190.12 "Creatine kinase (cardiac enzyme) level, MB fraction only" 1417603_1 CDM 0301 RC 82553 HCPCS inpatient 244 158.6 AETNA AETNA 192.76 79 999999999 147.74 236.68 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 1417603_1 CDM 0301 RC 82553 HCPCS inpatient 244 158.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 158.6 65 999999999 147.74 236.68 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 1417603_1 CDM 0301 RC 82553 HCPCS inpatient 244 158.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 236.68 97 999999999 147.74 236.68 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 1417603_1 CDM 0301 RC 82553 HCPCS inpatient 244 158.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 168.36 69 999999999 147.74 236.68 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 1417603_1 CDM 0301 RC 82553 HCPCS inpatient 244 158.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 190.32 78 999999999 147.74 236.68 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 1417603_1 CDM 0301 RC 82553 HCPCS inpatient 244 158.6 UMR - ALL PLANS UMR - ALL PLANS 170.8 70 999999999 147.74 236.68 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 1417603_1 CDM 0301 RC 82553 HCPCS inpatient 244 158.6 SIHO - ALL PLANS SIHO - ALL PLANS 219.6 90 999999999 147.74 236.68 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 1417603_1 CDM 0301 RC 82553 HCPCS inpatient 244 158.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.74 236.68 "Creatine kinase (cardiac enzyme) level, MB fraction only" 1417603_1 CDM 0301 RC 82553 HCPCS inpatient 244 158.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.74 60.55 999999999 147.74 236.68 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 1417603_1 CDM 0301 RC 82553 HCPCS inpatient 244 158.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.74 236.68 "Creatine kinase (cardiac enzyme) level, MB fraction only" 1417603_1 CDM 0301 RC 82553 HCPCS inpatient 244 158.6 ANTHEM HMO ANTHEM HMO 999999999 147.74 236.68 "Creatine kinase (cardiac enzyme) level, MB fraction only" 1417603_1 CDM 0301 RC 82553 HCPCS inpatient 244 158.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.94 67.6 999999999 147.74 236.68 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 1417603_1 CDM 0301 RC 82553 HCPCS inpatient 244 158.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.74 236.68 "Creatine kinase (cardiac enzyme) level, MB fraction only" 1417603_1 CDM 0301 RC 82553 HCPCS inpatient 244 158.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.74 236.68 Nuclear medicine study of bone and/or joint whole body 1428649_1 CDM 0341 RC 78306 HCPCS inpatient 1978 1285.7 AETNA AETNA 1562.62 79 999999999 1197.68 1918.66 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 1428649_1 CDM 0341 RC 78306 HCPCS inpatient 1978 1285.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1285.7 65 999999999 1197.68 1918.66 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 1428649_1 CDM 0341 RC 78306 HCPCS inpatient 1978 1285.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1918.66 97 999999999 1197.68 1918.66 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 1428649_1 CDM 0341 RC 78306 HCPCS inpatient 1978 1285.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1364.82 69 999999999 1197.68 1918.66 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 1428649_1 CDM 0341 RC 78306 HCPCS inpatient 1978 1285.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1542.84 78 999999999 1197.68 1918.66 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 1428649_1 CDM 0341 RC 78306 HCPCS inpatient 1978 1285.7 UMR - ALL PLANS UMR - ALL PLANS 1384.6 70 999999999 1197.68 1918.66 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 1428649_1 CDM 0341 RC 78306 HCPCS inpatient 1978 1285.7 SIHO - ALL PLANS SIHO - ALL PLANS 1780.2 90 999999999 1197.68 1918.66 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 1428649_1 CDM 0341 RC 78306 HCPCS inpatient 1978 1285.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1197.68 1918.66 Nuclear medicine study of bone and/or joint whole body 1428649_1 CDM 0341 RC 78306 HCPCS inpatient 1978 1285.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1197.68 60.55 999999999 1197.68 1918.66 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 1428649_1 CDM 0341 RC 78306 HCPCS inpatient 1978 1285.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1197.68 1918.66 Nuclear medicine study of bone and/or joint whole body 1428649_1 CDM 0341 RC 78306 HCPCS inpatient 1978 1285.7 ANTHEM HMO ANTHEM HMO 999999999 1197.68 1918.66 Nuclear medicine study of bone and/or joint whole body 1428649_1 CDM 0341 RC 78306 HCPCS inpatient 1978 1285.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1337.13 67.6 999999999 1197.68 1918.66 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 1428649_1 CDM 0341 RC 78306 HCPCS inpatient 1978 1285.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1197.68 1918.66 Nuclear medicine study of bone and/or joint whole body 1428649_1 CDM 0341 RC 78306 HCPCS inpatient 1978 1285.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 1197.68 1918.66 "Nuclear medicine study, whole body" 1428661_1 CDM 0341 RC 78802 HCPCS inpatient 2004 1302.6 AETNA AETNA 1583.16 79 999999999 1213.42 1943.88 percent of total billed charges "Nuclear medicine study, whole body" 1428661_1 CDM 0341 RC 78802 HCPCS inpatient 2004 1302.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1302.6 65 999999999 1213.42 1943.88 percent of total billed charges "Nuclear medicine study, whole body" 1428661_1 CDM 0341 RC 78802 HCPCS inpatient 2004 1302.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1943.88 97 999999999 1213.42 1943.88 percent of total billed charges "Nuclear medicine study, whole body" 1428661_1 CDM 0341 RC 78802 HCPCS inpatient 2004 1302.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1382.76 69 999999999 1213.42 1943.88 percent of total billed charges "Nuclear medicine study, whole body" 1428661_1 CDM 0341 RC 78802 HCPCS inpatient 2004 1302.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1563.12 78 999999999 1213.42 1943.88 percent of total billed charges "Nuclear medicine study, whole body" 1428661_1 CDM 0341 RC 78802 HCPCS inpatient 2004 1302.6 UMR - ALL PLANS UMR - ALL PLANS 1402.8 70 999999999 1213.42 1943.88 percent of total billed charges "Nuclear medicine study, whole body" 1428661_1 CDM 0341 RC 78802 HCPCS inpatient 2004 1302.6 SIHO - ALL PLANS SIHO - ALL PLANS 1803.6 90 999999999 1213.42 1943.88 percent of total billed charges "Nuclear medicine study, whole body" 1428661_1 CDM 0341 RC 78802 HCPCS inpatient 2004 1302.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1213.42 1943.88 "Nuclear medicine study, whole body" 1428661_1 CDM 0341 RC 78802 HCPCS inpatient 2004 1302.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1213.42 60.55 999999999 1213.42 1943.88 percent of total billed charges "Nuclear medicine study, whole body" 1428661_1 CDM 0341 RC 78802 HCPCS inpatient 2004 1302.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1213.42 1943.88 "Nuclear medicine study, whole body" 1428661_1 CDM 0341 RC 78802 HCPCS inpatient 2004 1302.6 ANTHEM HMO ANTHEM HMO 999999999 1213.42 1943.88 "Nuclear medicine study, whole body" 1428661_1 CDM 0341 RC 78802 HCPCS inpatient 2004 1302.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1354.7 67.6 999999999 1213.42 1943.88 percent of total billed charges "Nuclear medicine study, whole body" 1428661_1 CDM 0341 RC 78802 HCPCS inpatient 2004 1302.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1213.42 1943.88 "Nuclear medicine study, whole body" 1428661_1 CDM 0341 RC 78802 HCPCS inpatient 2004 1302.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1213.42 1943.88 Blood group typing (ABO) 1433598_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 AETNA AETNA 135.09 79 999999999 103.54 165.87 percent of total billed charges Blood group typing (ABO) 1433598_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.15 65 999999999 103.54 165.87 percent of total billed charges Blood group typing (ABO) 1433598_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 165.87 97 999999999 103.54 165.87 percent of total billed charges Blood group typing (ABO) 1433598_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.99 69 999999999 103.54 165.87 percent of total billed charges Blood group typing (ABO) 1433598_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 133.38 78 999999999 103.54 165.87 percent of total billed charges Blood group typing (ABO) 1433598_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 UMR - ALL PLANS UMR - ALL PLANS 119.7 70 999999999 103.54 165.87 percent of total billed charges Blood group typing (ABO) 1433598_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 SIHO - ALL PLANS SIHO - ALL PLANS 153.9 90 999999999 103.54 165.87 percent of total billed charges Blood group typing (ABO) 1433598_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 103.54 165.87 Blood group typing (ABO) 1433598_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 103.54 60.55 999999999 103.54 165.87 percent of total billed charges Blood group typing (ABO) 1433598_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 103.54 165.87 Blood group typing (ABO) 1433598_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 ANTHEM HMO ANTHEM HMO 999999999 103.54 165.87 Blood group typing (ABO) 1433598_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 115.6 67.6 999999999 103.54 165.87 percent of total billed charges Blood group typing (ABO) 1433598_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 103.54 165.87 Blood group typing (ABO) 1433598_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 103.54 165.87 Screening test for red blood cell antibodies 1433599_1 CDM 0302 RC 86850 HCPCS inpatient 135 87.75 AETNA AETNA 106.65 79 999999999 81.74 130.95 percent of total billed charges Screening test for red blood cell antibodies 1433599_1 CDM 0302 RC 86850 HCPCS inpatient 135 87.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 87.75 65 999999999 81.74 130.95 percent of total billed charges Screening test for red blood cell antibodies 1433599_1 CDM 0302 RC 86850 HCPCS inpatient 135 87.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 130.95 97 999999999 81.74 130.95 percent of total billed charges Screening test for red blood cell antibodies 1433599_1 CDM 0302 RC 86850 HCPCS inpatient 135 87.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.15 69 999999999 81.74 130.95 percent of total billed charges Screening test for red blood cell antibodies 1433599_1 CDM 0302 RC 86850 HCPCS inpatient 135 87.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 105.3 78 999999999 81.74 130.95 percent of total billed charges Screening test for red blood cell antibodies 1433599_1 CDM 0302 RC 86850 HCPCS inpatient 135 87.75 UMR - ALL PLANS UMR - ALL PLANS 94.5 70 999999999 81.74 130.95 percent of total billed charges Screening test for red blood cell antibodies 1433599_1 CDM 0302 RC 86850 HCPCS inpatient 135 87.75 SIHO - ALL PLANS SIHO - ALL PLANS 121.5 90 999999999 81.74 130.95 percent of total billed charges Screening test for red blood cell antibodies 1433599_1 CDM 0302 RC 86850 HCPCS inpatient 135 87.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 81.74 130.95 Screening test for red blood cell antibodies 1433599_1 CDM 0302 RC 86850 HCPCS inpatient 135 87.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 81.74 60.55 999999999 81.74 130.95 percent of total billed charges Screening test for red blood cell antibodies 1433599_1 CDM 0302 RC 86850 HCPCS inpatient 135 87.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 81.74 130.95 Screening test for red blood cell antibodies 1433599_1 CDM 0302 RC 86850 HCPCS inpatient 135 87.75 ANTHEM HMO ANTHEM HMO 999999999 81.74 130.95 Screening test for red blood cell antibodies 1433599_1 CDM 0302 RC 86850 HCPCS inpatient 135 87.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.26 67.6 999999999 81.74 130.95 percent of total billed charges Screening test for red blood cell antibodies 1433599_1 CDM 0302 RC 86850 HCPCS inpatient 135 87.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 81.74 130.95 Screening test for red blood cell antibodies 1433599_1 CDM 0302 RC 86850 HCPCS inpatient 135 87.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 81.74 130.95 "Red blood cell antibody detection test, direct" 1433620_1 CDM 0300 RC 86880 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 1433620_1 CDM 0300 RC 86880 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 1433620_1 CDM 0300 RC 86880 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 1433620_1 CDM 0300 RC 86880 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 1433620_1 CDM 0300 RC 86880 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 1433620_1 CDM 0300 RC 86880 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 1433620_1 CDM 0300 RC 86880 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 1433620_1 CDM 0300 RC 86880 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Red blood cell antibody detection test, direct" 1433620_1 CDM 0300 RC 86880 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 1433620_1 CDM 0300 RC 86880 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Red blood cell antibody detection test, direct" 1433620_1 CDM 0300 RC 86880 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Red blood cell antibody detection test, direct" 1433620_1 CDM 0300 RC 86880 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 1433620_1 CDM 0300 RC 86880 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Red blood cell antibody detection test, direct" 1433620_1 CDM 0300 RC 86880 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 Removal of antibodies from surface of red blood cell 1433624_1 CDM 0302 RC 86860 HCPCS inpatient 499 324.35 AETNA AETNA 394.21 79 999999999 302.14 484.03 percent of total billed charges Removal of antibodies from surface of red blood cell 1433624_1 CDM 0302 RC 86860 HCPCS inpatient 499 324.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 324.35 65 999999999 302.14 484.03 percent of total billed charges Removal of antibodies from surface of red blood cell 1433624_1 CDM 0302 RC 86860 HCPCS inpatient 499 324.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 484.03 97 999999999 302.14 484.03 percent of total billed charges Removal of antibodies from surface of red blood cell 1433624_1 CDM 0302 RC 86860 HCPCS inpatient 499 324.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 344.31 69 999999999 302.14 484.03 percent of total billed charges Removal of antibodies from surface of red blood cell 1433624_1 CDM 0302 RC 86860 HCPCS inpatient 499 324.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 389.22 78 999999999 302.14 484.03 percent of total billed charges Removal of antibodies from surface of red blood cell 1433624_1 CDM 0302 RC 86860 HCPCS inpatient 499 324.35 UMR - ALL PLANS UMR - ALL PLANS 349.3 70 999999999 302.14 484.03 percent of total billed charges Removal of antibodies from surface of red blood cell 1433624_1 CDM 0302 RC 86860 HCPCS inpatient 499 324.35 SIHO - ALL PLANS SIHO - ALL PLANS 449.1 90 999999999 302.14 484.03 percent of total billed charges Removal of antibodies from surface of red blood cell 1433624_1 CDM 0302 RC 86860 HCPCS inpatient 499 324.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 302.14 484.03 Removal of antibodies from surface of red blood cell 1433624_1 CDM 0302 RC 86860 HCPCS inpatient 499 324.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 302.14 60.55 999999999 302.14 484.03 percent of total billed charges Removal of antibodies from surface of red blood cell 1433624_1 CDM 0302 RC 86860 HCPCS inpatient 499 324.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 302.14 484.03 Removal of antibodies from surface of red blood cell 1433624_1 CDM 0302 RC 86860 HCPCS inpatient 499 324.35 ANTHEM HMO ANTHEM HMO 999999999 302.14 484.03 Removal of antibodies from surface of red blood cell 1433624_1 CDM 0302 RC 86860 HCPCS inpatient 499 324.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 337.32 67.6 999999999 302.14 484.03 percent of total billed charges Removal of antibodies from surface of red blood cell 1433624_1 CDM 0302 RC 86860 HCPCS inpatient 499 324.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 302.14 484.03 Removal of antibodies from surface of red blood cell 1433624_1 CDM 0302 RC 86860 HCPCS inpatient 499 324.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 302.14 484.03 Microscopic examination for white blood cells 1452105_1 CDM 0305 RC 85008 HCPCS inpatient 348 226.2 AETNA AETNA 274.92 79 999999999 210.71 337.56 percent of total billed charges Microscopic examination for white blood cells 1452105_1 CDM 0305 RC 85008 HCPCS inpatient 348 226.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 226.2 65 999999999 210.71 337.56 percent of total billed charges Microscopic examination for white blood cells 1452105_1 CDM 0305 RC 85008 HCPCS inpatient 348 226.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 337.56 97 999999999 210.71 337.56 percent of total billed charges Microscopic examination for white blood cells 1452105_1 CDM 0305 RC 85008 HCPCS inpatient 348 226.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 240.12 69 999999999 210.71 337.56 percent of total billed charges Microscopic examination for white blood cells 1452105_1 CDM 0305 RC 85008 HCPCS inpatient 348 226.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 271.44 78 999999999 210.71 337.56 percent of total billed charges Microscopic examination for white blood cells 1452105_1 CDM 0305 RC 85008 HCPCS inpatient 348 226.2 UMR - ALL PLANS UMR - ALL PLANS 243.6 70 999999999 210.71 337.56 percent of total billed charges Microscopic examination for white blood cells 1452105_1 CDM 0305 RC 85008 HCPCS inpatient 348 226.2 SIHO - ALL PLANS SIHO - ALL PLANS 313.2 90 999999999 210.71 337.56 percent of total billed charges Microscopic examination for white blood cells 1452105_1 CDM 0305 RC 85008 HCPCS inpatient 348 226.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 210.71 337.56 Microscopic examination for white blood cells 1452105_1 CDM 0305 RC 85008 HCPCS inpatient 348 226.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 210.71 60.55 999999999 210.71 337.56 percent of total billed charges Microscopic examination for white blood cells 1452105_1 CDM 0305 RC 85008 HCPCS inpatient 348 226.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 210.71 337.56 Microscopic examination for white blood cells 1452105_1 CDM 0305 RC 85008 HCPCS inpatient 348 226.2 ANTHEM HMO ANTHEM HMO 999999999 210.71 337.56 Microscopic examination for white blood cells 1452105_1 CDM 0305 RC 85008 HCPCS inpatient 348 226.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 235.25 67.6 999999999 210.71 337.56 percent of total billed charges Microscopic examination for white blood cells 1452105_1 CDM 0305 RC 85008 HCPCS inpatient 348 226.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 210.71 337.56 Microscopic examination for white blood cells 1452105_1 CDM 0305 RC 85008 HCPCS inpatient 348 226.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 210.71 337.56 Ultrasonic guidance during surgery 1457744_1 CDM 0402 RC 76998 HCPCS inpatient 280 182 AETNA AETNA 221.2 79 999999999 169.54 271.6 percent of total billed charges Ultrasonic guidance during surgery 1457744_1 CDM 0402 RC 76998 HCPCS inpatient 280 182 SELF PAY DISCOUNT SELF PAY DISCOUNT 182 65 999999999 169.54 271.6 percent of total billed charges Ultrasonic guidance during surgery 1457744_1 CDM 0402 RC 76998 HCPCS inpatient 280 182 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 271.6 97 999999999 169.54 271.6 percent of total billed charges Ultrasonic guidance during surgery 1457744_1 CDM 0402 RC 76998 HCPCS inpatient 280 182 ENCORE - ALL PLANS ENCORE - ALL PLANS 193.2 69 999999999 169.54 271.6 percent of total billed charges Ultrasonic guidance during surgery 1457744_1 CDM 0402 RC 76998 HCPCS inpatient 280 182 HUMANA - ALL PLANS HUMANA - ALL PLANS 218.4 78 999999999 169.54 271.6 percent of total billed charges Ultrasonic guidance during surgery 1457744_1 CDM 0402 RC 76998 HCPCS inpatient 280 182 UMR - ALL PLANS UMR - ALL PLANS 196 70 999999999 169.54 271.6 percent of total billed charges Ultrasonic guidance during surgery 1457744_1 CDM 0402 RC 76998 HCPCS inpatient 280 182 SIHO - ALL PLANS SIHO - ALL PLANS 252 90 999999999 169.54 271.6 percent of total billed charges Ultrasonic guidance during surgery 1457744_1 CDM 0402 RC 76998 HCPCS inpatient 280 182 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 169.54 271.6 Ultrasonic guidance during surgery 1457744_1 CDM 0402 RC 76998 HCPCS inpatient 280 182 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 169.54 60.55 999999999 169.54 271.6 percent of total billed charges Ultrasonic guidance during surgery 1457744_1 CDM 0402 RC 76998 HCPCS inpatient 280 182 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 169.54 271.6 Ultrasonic guidance during surgery 1457744_1 CDM 0402 RC 76998 HCPCS inpatient 280 182 ANTHEM HMO ANTHEM HMO 999999999 169.54 271.6 Ultrasonic guidance during surgery 1457744_1 CDM 0402 RC 76998 HCPCS inpatient 280 182 CIGNA - ALL PLANS CIGNA - ALL PLANS 189.28 67.6 999999999 169.54 271.6 percent of total billed charges Ultrasonic guidance during surgery 1457744_1 CDM 0402 RC 76998 HCPCS inpatient 280 182 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 169.54 271.6 Ultrasonic guidance during surgery 1457744_1 CDM 0402 RC 76998 HCPCS inpatient 280 182 UHC - ALL PLANS UHC - ALL PLANS 999999999 169.54 271.6 "X-ray of chest, 2 views" 1457758_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 AETNA AETNA 526.14 79 999999999 403.26 646.02 percent of total billed charges "X-ray of chest, 2 views" 1457758_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 432.9 65 999999999 403.26 646.02 percent of total billed charges "X-ray of chest, 2 views" 1457758_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 646.02 97 999999999 403.26 646.02 percent of total billed charges "X-ray of chest, 2 views" 1457758_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 459.54 69 999999999 403.26 646.02 percent of total billed charges "X-ray of chest, 2 views" 1457758_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 519.48 78 999999999 403.26 646.02 percent of total billed charges "X-ray of chest, 2 views" 1457758_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 UMR - ALL PLANS UMR - ALL PLANS 466.2 70 999999999 403.26 646.02 percent of total billed charges "X-ray of chest, 2 views" 1457758_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 SIHO - ALL PLANS SIHO - ALL PLANS 599.4 90 999999999 403.26 646.02 percent of total billed charges "X-ray of chest, 2 views" 1457758_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 403.26 646.02 "X-ray of chest, 2 views" 1457758_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 403.26 60.55 999999999 403.26 646.02 percent of total billed charges "X-ray of chest, 2 views" 1457758_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 403.26 646.02 "X-ray of chest, 2 views" 1457758_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 ANTHEM HMO ANTHEM HMO 999999999 403.26 646.02 "X-ray of chest, 2 views" 1457758_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 450.22 67.6 999999999 403.26 646.02 percent of total billed charges "X-ray of chest, 2 views" 1457758_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 403.26 646.02 "X-ray of chest, 2 views" 1457758_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 403.26 646.02 Review by radiologist of image for drainage of fluid 1457762_1 CDM 0320 RC 75989 HCPCS inpatient 1689 1097.85 AETNA AETNA 1334.31 79 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of image for drainage of fluid 1457762_1 CDM 0320 RC 75989 HCPCS inpatient 1689 1097.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.85 65 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of image for drainage of fluid 1457762_1 CDM 0320 RC 75989 HCPCS inpatient 1689 1097.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1638.33 97 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of image for drainage of fluid 1457762_1 CDM 0320 RC 75989 HCPCS inpatient 1689 1097.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1165.41 69 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of image for drainage of fluid 1457762_1 CDM 0320 RC 75989 HCPCS inpatient 1689 1097.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1317.42 78 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of image for drainage of fluid 1457762_1 CDM 0320 RC 75989 HCPCS inpatient 1689 1097.85 UMR - ALL PLANS UMR - ALL PLANS 1182.3 70 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of image for drainage of fluid 1457762_1 CDM 0320 RC 75989 HCPCS inpatient 1689 1097.85 SIHO - ALL PLANS SIHO - ALL PLANS 1520.1 90 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of image for drainage of fluid 1457762_1 CDM 0320 RC 75989 HCPCS inpatient 1689 1097.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.69 1638.33 Review by radiologist of image for drainage of fluid 1457762_1 CDM 0320 RC 75989 HCPCS inpatient 1689 1097.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.69 60.55 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of image for drainage of fluid 1457762_1 CDM 0320 RC 75989 HCPCS inpatient 1689 1097.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of image for drainage of fluid 1457762_1 CDM 0320 RC 75989 HCPCS inpatient 1689 1097.85 ANTHEM HMO ANTHEM HMO 999999999 1022.69 1638.33 Review by radiologist of image for drainage of fluid 1457762_1 CDM 0320 RC 75989 HCPCS inpatient 1689 1097.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.76 67.6 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of image for drainage of fluid 1457762_1 CDM 0320 RC 75989 HCPCS inpatient 1689 1097.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of image for drainage of fluid 1457762_1 CDM 0320 RC 75989 HCPCS inpatient 1689 1097.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.69 1638.33 Review by radiologist of abscess or sinus cavity study 1457764_1 CDM 0320 RC 76080 HCPCS inpatient 612 397.8 AETNA AETNA 483.48 79 999999999 370.57 593.64 percent of total billed charges Review by radiologist of abscess or sinus cavity study 1457764_1 CDM 0320 RC 76080 HCPCS inpatient 612 397.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 397.8 65 999999999 370.57 593.64 percent of total billed charges Review by radiologist of abscess or sinus cavity study 1457764_1 CDM 0320 RC 76080 HCPCS inpatient 612 397.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 593.64 97 999999999 370.57 593.64 percent of total billed charges Review by radiologist of abscess or sinus cavity study 1457764_1 CDM 0320 RC 76080 HCPCS inpatient 612 397.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 422.28 69 999999999 370.57 593.64 percent of total billed charges Review by radiologist of abscess or sinus cavity study 1457764_1 CDM 0320 RC 76080 HCPCS inpatient 612 397.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 477.36 78 999999999 370.57 593.64 percent of total billed charges Review by radiologist of abscess or sinus cavity study 1457764_1 CDM 0320 RC 76080 HCPCS inpatient 612 397.8 UMR - ALL PLANS UMR - ALL PLANS 428.4 70 999999999 370.57 593.64 percent of total billed charges Review by radiologist of abscess or sinus cavity study 1457764_1 CDM 0320 RC 76080 HCPCS inpatient 612 397.8 SIHO - ALL PLANS SIHO - ALL PLANS 550.8 90 999999999 370.57 593.64 percent of total billed charges Review by radiologist of abscess or sinus cavity study 1457764_1 CDM 0320 RC 76080 HCPCS inpatient 612 397.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 370.57 593.64 Review by radiologist of abscess or sinus cavity study 1457764_1 CDM 0320 RC 76080 HCPCS inpatient 612 397.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 370.57 60.55 999999999 370.57 593.64 percent of total billed charges Review by radiologist of abscess or sinus cavity study 1457764_1 CDM 0320 RC 76080 HCPCS inpatient 612 397.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 370.57 593.64 Review by radiologist of abscess or sinus cavity study 1457764_1 CDM 0320 RC 76080 HCPCS inpatient 612 397.8 ANTHEM HMO ANTHEM HMO 999999999 370.57 593.64 Review by radiologist of abscess or sinus cavity study 1457764_1 CDM 0320 RC 76080 HCPCS inpatient 612 397.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 413.71 67.6 999999999 370.57 593.64 percent of total billed charges Review by radiologist of abscess or sinus cavity study 1457764_1 CDM 0320 RC 76080 HCPCS inpatient 612 397.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 370.57 593.64 Review by radiologist of abscess or sinus cavity study 1457764_1 CDM 0320 RC 76080 HCPCS inpatient 612 397.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 370.57 593.64 "X-ray of ribs on side of body, 2 views" 1457770_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 AETNA AETNA 378.41 79 999999999 290.03 464.63 percent of total billed charges "X-ray of ribs on side of body, 2 views" 1457770_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 311.35 65 999999999 290.03 464.63 percent of total billed charges "X-ray of ribs on side of body, 2 views" 1457770_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 464.63 97 999999999 290.03 464.63 percent of total billed charges "X-ray of ribs on side of body, 2 views" 1457770_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 330.51 69 999999999 290.03 464.63 percent of total billed charges "X-ray of ribs on side of body, 2 views" 1457770_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 373.62 78 999999999 290.03 464.63 percent of total billed charges "X-ray of ribs on side of body, 2 views" 1457770_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 UMR - ALL PLANS UMR - ALL PLANS 335.3 70 999999999 290.03 464.63 percent of total billed charges "X-ray of ribs on side of body, 2 views" 1457770_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 SIHO - ALL PLANS SIHO - ALL PLANS 431.1 90 999999999 290.03 464.63 percent of total billed charges "X-ray of ribs on side of body, 2 views" 1457770_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 290.03 464.63 "X-ray of ribs on side of body, 2 views" 1457770_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 290.03 60.55 999999999 290.03 464.63 percent of total billed charges "X-ray of ribs on side of body, 2 views" 1457770_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 290.03 464.63 "X-ray of ribs on side of body, 2 views" 1457770_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 ANTHEM HMO ANTHEM HMO 999999999 290.03 464.63 "X-ray of ribs on side of body, 2 views" 1457770_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 323.8 67.6 999999999 290.03 464.63 percent of total billed charges "X-ray of ribs on side of body, 2 views" 1457770_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 290.03 464.63 "X-ray of ribs on side of body, 2 views" 1457770_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 290.03 464.63 "X-ray of ribs on side of body, 2 views" 1457773_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 AETNA AETNA 378.41 79 999999999 290.03 464.63 percent of total billed charges "X-ray of ribs on side of body, 2 views" 1457773_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 311.35 65 999999999 290.03 464.63 percent of total billed charges "X-ray of ribs on side of body, 2 views" 1457773_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 464.63 97 999999999 290.03 464.63 percent of total billed charges "X-ray of ribs on side of body, 2 views" 1457773_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 330.51 69 999999999 290.03 464.63 percent of total billed charges "X-ray of ribs on side of body, 2 views" 1457773_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 373.62 78 999999999 290.03 464.63 percent of total billed charges "X-ray of ribs on side of body, 2 views" 1457773_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 UMR - ALL PLANS UMR - ALL PLANS 335.3 70 999999999 290.03 464.63 percent of total billed charges "X-ray of ribs on side of body, 2 views" 1457773_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 SIHO - ALL PLANS SIHO - ALL PLANS 431.1 90 999999999 290.03 464.63 percent of total billed charges "X-ray of ribs on side of body, 2 views" 1457773_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 290.03 464.63 "X-ray of ribs on side of body, 2 views" 1457773_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 290.03 60.55 999999999 290.03 464.63 percent of total billed charges "X-ray of ribs on side of body, 2 views" 1457773_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 290.03 464.63 "X-ray of ribs on side of body, 2 views" 1457773_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 ANTHEM HMO ANTHEM HMO 999999999 290.03 464.63 "X-ray of ribs on side of body, 2 views" 1457773_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 323.8 67.6 999999999 290.03 464.63 percent of total billed charges "X-ray of ribs on side of body, 2 views" 1457773_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 290.03 464.63 "X-ray of ribs on side of body, 2 views" 1457773_1 CDM 0320 RC 71100 HCPCS inpatient 479 311.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 290.03 464.63 Injection of drug or substance under skin or into muscle 1489779_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 AETNA AETNA 41.48 79 999999999 31.79 50.93 percent of total billed charges Injection of drug or substance under skin or into muscle 1489779_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.13 65 999999999 31.79 50.93 percent of total billed charges Injection of drug or substance under skin or into muscle 1489779_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 50.93 97 999999999 31.79 50.93 percent of total billed charges Injection of drug or substance under skin or into muscle 1489779_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.23 69 999999999 31.79 50.93 percent of total billed charges Injection of drug or substance under skin or into muscle 1489779_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 SIHO - ALL PLANS SIHO - ALL PLANS 47.25 90 999999999 31.79 50.93 percent of total billed charges Injection of drug or substance under skin or into muscle 1489779_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 40.95 78 999999999 31.79 50.93 percent of total billed charges Injection of drug or substance under skin or into muscle 1489779_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 UMR - ALL PLANS UMR - ALL PLANS 36.75 70 999999999 31.79 50.93 percent of total billed charges Injection of drug or substance under skin or into muscle 1489779_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 31.79 60.55 999999999 31.79 50.93 percent of total billed charges Injection of drug or substance under skin or into muscle 1489779_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 31.79 50.93 Injection of drug or substance under skin or into muscle 1489779_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 31.79 50.93 Injection of drug or substance under skin or into muscle 1489779_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 ANTHEM HMO ANTHEM HMO 999999999 31.79 50.93 Injection of drug or substance under skin or into muscle 1489779_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.49 67.6 999999999 31.79 50.93 percent of total billed charges Injection of drug or substance under skin or into muscle 1489779_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 31.79 50.93 Injection of drug or substance under skin or into muscle 1489779_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 31.79 50.93 "Bilirubin level, total" 15340860_1 CDM 0301 RC 82247 HCPCS inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges "Bilirubin level, total" 15340860_1 CDM 0301 RC 82247 HCPCS inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges "Bilirubin level, total" 15340860_1 CDM 0301 RC 82247 HCPCS inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges "Bilirubin level, total" 15340860_1 CDM 0301 RC 82247 HCPCS inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges "Bilirubin level, total" 15340860_1 CDM 0301 RC 82247 HCPCS inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges "Bilirubin level, total" 15340860_1 CDM 0301 RC 82247 HCPCS inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges "Bilirubin level, total" 15340860_1 CDM 0301 RC 82247 HCPCS inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges "Bilirubin level, total" 15340860_1 CDM 0301 RC 82247 HCPCS inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges "Bilirubin level, total" 15340860_1 CDM 0301 RC 82247 HCPCS inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 "Bilirubin level, total" 15340860_1 CDM 0301 RC 82247 HCPCS inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 "Bilirubin level, total" 15340860_1 CDM 0301 RC 82247 HCPCS inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 "Bilirubin level, total" 15340860_1 CDM 0301 RC 82247 HCPCS inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges "Bilirubin level, total" 15340860_1 CDM 0301 RC 82247 HCPCS inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 "Bilirubin level, total" 15340860_1 CDM 0301 RC 82247 HCPCS inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 "Bilirubin level, direct" 15340861_1 CDM 0301 RC 82248 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges "Bilirubin level, direct" 15340861_1 CDM 0301 RC 82248 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges "Bilirubin level, direct" 15340861_1 CDM 0301 RC 82248 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges "Bilirubin level, direct" 15340861_1 CDM 0301 RC 82248 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges "Bilirubin level, direct" 15340861_1 CDM 0301 RC 82248 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges "Bilirubin level, direct" 15340861_1 CDM 0301 RC 82248 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges "Bilirubin level, direct" 15340861_1 CDM 0301 RC 82248 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges "Bilirubin level, direct" 15340861_1 CDM 0301 RC 82248 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges "Bilirubin level, direct" 15340861_1 CDM 0301 RC 82248 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 "Bilirubin level, direct" 15340861_1 CDM 0301 RC 82248 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 "Bilirubin level, direct" 15340861_1 CDM 0301 RC 82248 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 "Bilirubin level, direct" 15340861_1 CDM 0301 RC 82248 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges "Bilirubin level, direct" 15340861_1 CDM 0301 RC 82248 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 "Bilirubin level, direct" 15340861_1 CDM 0301 RC 82248 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 "PSA (prostate specific antigen) measurement, total" 15768857_1 CDM 0300 RC 84153 HCPCS inpatient 307 199.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 199.55 65 999999999 185.89 297.79 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 15768857_1 CDM 0300 RC 84153 HCPCS inpatient 307 199.55 AETNA AETNA 242.53 79 999999999 185.89 297.79 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 15768857_1 CDM 0300 RC 84153 HCPCS inpatient 307 199.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 297.79 97 999999999 185.89 297.79 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 15768857_1 CDM 0300 RC 84153 HCPCS inpatient 307 199.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 211.83 69 999999999 185.89 297.79 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 15768857_1 CDM 0300 RC 84153 HCPCS inpatient 307 199.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 239.46 78 999999999 185.89 297.79 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 15768857_1 CDM 0300 RC 84153 HCPCS inpatient 307 199.55 UMR - ALL PLANS UMR - ALL PLANS 214.9 70 999999999 185.89 297.79 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 15768857_1 CDM 0300 RC 84153 HCPCS inpatient 307 199.55 SIHO - ALL PLANS SIHO - ALL PLANS 276.3 90 999999999 185.89 297.79 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 15768857_1 CDM 0300 RC 84153 HCPCS inpatient 307 199.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 185.89 60.55 999999999 185.89 297.79 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 15768857_1 CDM 0300 RC 84153 HCPCS inpatient 307 199.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 185.89 297.79 "PSA (prostate specific antigen) measurement, total" 15768857_1 CDM 0300 RC 84153 HCPCS inpatient 307 199.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 185.89 297.79 "PSA (prostate specific antigen) measurement, total" 15768857_1 CDM 0300 RC 84153 HCPCS inpatient 307 199.55 ANTHEM HMO ANTHEM HMO 999999999 185.89 297.79 "PSA (prostate specific antigen) measurement, total" 15768857_1 CDM 0300 RC 84153 HCPCS inpatient 307 199.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 207.53 67.6 999999999 185.89 297.79 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 15768857_1 CDM 0300 RC 84153 HCPCS inpatient 307 199.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 185.89 297.79 "PSA (prostate specific antigen) measurement, total" 15768857_1 CDM 0300 RC 84153 HCPCS inpatient 307 199.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 185.89 297.79 Iron binding capacity 16598872_1 CDM 0301 RC 83550 HCPCS inpatient 71 46.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.15 65 999999999 42.99 68.87 percent of total billed charges Iron binding capacity 16598872_1 CDM 0301 RC 83550 HCPCS inpatient 71 46.15 AETNA AETNA 56.09 79 999999999 42.99 68.87 percent of total billed charges Iron binding capacity 16598872_1 CDM 0301 RC 83550 HCPCS inpatient 71 46.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 68.87 97 999999999 42.99 68.87 percent of total billed charges Iron binding capacity 16598872_1 CDM 0301 RC 83550 HCPCS inpatient 71 46.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.99 69 999999999 42.99 68.87 percent of total billed charges Iron binding capacity 16598872_1 CDM 0301 RC 83550 HCPCS inpatient 71 46.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 55.38 78 999999999 42.99 68.87 percent of total billed charges Iron binding capacity 16598872_1 CDM 0301 RC 83550 HCPCS inpatient 71 46.15 UMR - ALL PLANS UMR - ALL PLANS 49.7 70 999999999 42.99 68.87 percent of total billed charges Iron binding capacity 16598872_1 CDM 0301 RC 83550 HCPCS inpatient 71 46.15 SIHO - ALL PLANS SIHO - ALL PLANS 63.9 90 999999999 42.99 68.87 percent of total billed charges Iron binding capacity 16598872_1 CDM 0301 RC 83550 HCPCS inpatient 71 46.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.99 60.55 999999999 42.99 68.87 percent of total billed charges Iron binding capacity 16598872_1 CDM 0301 RC 83550 HCPCS inpatient 71 46.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.99 68.87 Iron binding capacity 16598872_1 CDM 0301 RC 83550 HCPCS inpatient 71 46.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.99 68.87 Iron binding capacity 16598872_1 CDM 0301 RC 83550 HCPCS inpatient 71 46.15 ANTHEM HMO ANTHEM HMO 999999999 42.99 68.87 Iron binding capacity 16598872_1 CDM 0301 RC 83550 HCPCS inpatient 71 46.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 48 67.6 999999999 42.99 68.87 percent of total billed charges Iron binding capacity 16598872_1 CDM 0301 RC 83550 HCPCS inpatient 71 46.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.99 68.87 Iron binding capacity 16598872_1 CDM 0301 RC 83550 HCPCS inpatient 71 46.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.99 68.87 Urine phosphate level 16598874_1 CDM 0301 RC 84105 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges Urine phosphate level 16598874_1 CDM 0301 RC 84105 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges Urine phosphate level 16598874_1 CDM 0301 RC 84105 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges Urine phosphate level 16598874_1 CDM 0301 RC 84105 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges Urine phosphate level 16598874_1 CDM 0301 RC 84105 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges Urine phosphate level 16598874_1 CDM 0301 RC 84105 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges Urine phosphate level 16598874_1 CDM 0301 RC 84105 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges Urine phosphate level 16598874_1 CDM 0301 RC 84105 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges Urine phosphate level 16598874_1 CDM 0301 RC 84105 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 Urine phosphate level 16598874_1 CDM 0301 RC 84105 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 Urine phosphate level 16598874_1 CDM 0301 RC 84105 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 Urine phosphate level 16598874_1 CDM 0301 RC 84105 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges Urine phosphate level 16598874_1 CDM 0301 RC 84105 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 Urine phosphate level 16598874_1 CDM 0301 RC 84105 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Uric acid level 16600878_1 CDM 0301 RC 84560 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges Uric acid level 16600878_1 CDM 0301 RC 84560 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges Uric acid level 16600878_1 CDM 0301 RC 84560 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges Uric acid level 16600878_1 CDM 0301 RC 84560 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges Uric acid level 16600878_1 CDM 0301 RC 84560 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges Uric acid level 16600878_1 CDM 0301 RC 84560 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges Uric acid level 16600878_1 CDM 0301 RC 84560 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges Uric acid level 16600878_1 CDM 0301 RC 84560 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges Uric acid level 16600878_1 CDM 0301 RC 84560 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 Uric acid level 16600878_1 CDM 0301 RC 84560 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 Uric acid level 16600878_1 CDM 0301 RC 84560 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 Uric acid level 16600878_1 CDM 0301 RC 84560 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges Uric acid level 16600878_1 CDM 0301 RC 84560 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 Uric acid level 16600878_1 CDM 0301 RC 84560 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 "Blood unit compatibility test, immediate spin technique" 16802881_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 280.8 65 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 16802881_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 AETNA AETNA 341.28 79 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 16802881_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 419.04 97 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 16802881_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 298.08 69 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 16802881_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 336.96 78 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 16802881_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 UMR - ALL PLANS UMR - ALL PLANS 302.4 70 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 16802881_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 SIHO - ALL PLANS SIHO - ALL PLANS 388.8 90 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 16802881_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 261.58 60.55 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 16802881_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 261.58 419.04 "Blood unit compatibility test, immediate spin technique" 16802881_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 261.58 419.04 "Blood unit compatibility test, immediate spin technique" 16802881_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 ANTHEM HMO ANTHEM HMO 999999999 261.58 419.04 "Blood unit compatibility test, immediate spin technique" 16802881_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 292.03 67.6 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 16802881_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 261.58 419.04 "Blood unit compatibility test, immediate spin technique" 16802881_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 261.58 419.04 Imaging of urinary tract using infusion technique with kidney section filming 1712827_1 CDM 0320 RC 74415 HCPCS inpatient 1248 811.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 811.2 65 999999999 755.66 1210.56 percent of total billed charges Imaging of urinary tract using infusion technique with kidney section filming 1712827_1 CDM 0320 RC 74415 HCPCS inpatient 1248 811.2 AETNA AETNA 985.92 79 999999999 755.66 1210.56 percent of total billed charges Imaging of urinary tract using infusion technique with kidney section filming 1712827_1 CDM 0320 RC 74415 HCPCS inpatient 1248 811.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1210.56 97 999999999 755.66 1210.56 percent of total billed charges Imaging of urinary tract using infusion technique with kidney section filming 1712827_1 CDM 0320 RC 74415 HCPCS inpatient 1248 811.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 861.12 69 999999999 755.66 1210.56 percent of total billed charges Imaging of urinary tract using infusion technique with kidney section filming 1712827_1 CDM 0320 RC 74415 HCPCS inpatient 1248 811.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 973.44 78 999999999 755.66 1210.56 percent of total billed charges Imaging of urinary tract using infusion technique with kidney section filming 1712827_1 CDM 0320 RC 74415 HCPCS inpatient 1248 811.2 UMR - ALL PLANS UMR - ALL PLANS 873.6 70 999999999 755.66 1210.56 percent of total billed charges Imaging of urinary tract using infusion technique with kidney section filming 1712827_1 CDM 0320 RC 74415 HCPCS inpatient 1248 811.2 SIHO - ALL PLANS SIHO - ALL PLANS 1123.2 90 999999999 755.66 1210.56 percent of total billed charges Imaging of urinary tract using infusion technique with kidney section filming 1712827_1 CDM 0320 RC 74415 HCPCS inpatient 1248 811.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 755.66 60.55 999999999 755.66 1210.56 percent of total billed charges Imaging of urinary tract using infusion technique with kidney section filming 1712827_1 CDM 0320 RC 74415 HCPCS inpatient 1248 811.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 755.66 1210.56 Imaging of urinary tract using infusion technique with kidney section filming 1712827_1 CDM 0320 RC 74415 HCPCS inpatient 1248 811.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 755.66 1210.56 Imaging of urinary tract using infusion technique with kidney section filming 1712827_1 CDM 0320 RC 74415 HCPCS inpatient 1248 811.2 ANTHEM HMO ANTHEM HMO 999999999 755.66 1210.56 Imaging of urinary tract using infusion technique with kidney section filming 1712827_1 CDM 0320 RC 74415 HCPCS inpatient 1248 811.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 843.65 67.6 999999999 755.66 1210.56 percent of total billed charges Imaging of urinary tract using infusion technique with kidney section filming 1712827_1 CDM 0320 RC 74415 HCPCS inpatient 1248 811.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 755.66 1210.56 Imaging of urinary tract using infusion technique with kidney section filming 1712827_1 CDM 0320 RC 74415 HCPCS inpatient 1248 811.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 755.66 1210.56 CT scan of chest before and after contrast 1712896_1 CDM 0350 RC 71270 HCPCS inpatient 4113 2673.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 2673.45 65 999999999 2490.42 3989.61 percent of total billed charges CT scan of chest before and after contrast 1712896_1 CDM 0350 RC 71270 HCPCS inpatient 4113 2673.45 AETNA AETNA 3249.27 79 999999999 2490.42 3989.61 percent of total billed charges CT scan of chest before and after contrast 1712896_1 CDM 0350 RC 71270 HCPCS inpatient 4113 2673.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3989.61 97 999999999 2490.42 3989.61 percent of total billed charges CT scan of chest before and after contrast 1712896_1 CDM 0350 RC 71270 HCPCS inpatient 4113 2673.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 2837.97 69 999999999 2490.42 3989.61 percent of total billed charges CT scan of chest before and after contrast 1712896_1 CDM 0350 RC 71270 HCPCS inpatient 4113 2673.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 3208.14 78 999999999 2490.42 3989.61 percent of total billed charges CT scan of chest before and after contrast 1712896_1 CDM 0350 RC 71270 HCPCS inpatient 4113 2673.45 UMR - ALL PLANS UMR - ALL PLANS 2879.1 70 999999999 2490.42 3989.61 percent of total billed charges CT scan of chest before and after contrast 1712896_1 CDM 0350 RC 71270 HCPCS inpatient 4113 2673.45 SIHO - ALL PLANS SIHO - ALL PLANS 3701.7 90 999999999 2490.42 3989.61 percent of total billed charges CT scan of chest before and after contrast 1712896_1 CDM 0350 RC 71270 HCPCS inpatient 4113 2673.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2490.42 60.55 999999999 2490.42 3989.61 percent of total billed charges CT scan of chest before and after contrast 1712896_1 CDM 0350 RC 71270 HCPCS inpatient 4113 2673.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2490.42 3989.61 CT scan of chest before and after contrast 1712896_1 CDM 0350 RC 71270 HCPCS inpatient 4113 2673.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2490.42 3989.61 CT scan of chest before and after contrast 1712896_1 CDM 0350 RC 71270 HCPCS inpatient 4113 2673.45 ANTHEM HMO ANTHEM HMO 999999999 2490.42 3989.61 CT scan of chest before and after contrast 1712896_1 CDM 0350 RC 71270 HCPCS inpatient 4113 2673.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 2780.39 67.6 999999999 2490.42 3989.61 percent of total billed charges CT scan of chest before and after contrast 1712896_1 CDM 0350 RC 71270 HCPCS inpatient 4113 2673.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2490.42 3989.61 CT scan of chest before and after contrast 1712896_1 CDM 0350 RC 71270 HCPCS inpatient 4113 2673.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 2490.42 3989.61 Ultrasonic guidance for needle placement 1712920_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1712920_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1712920_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1712920_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1712920_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1712920_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1712920_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1712920_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1712920_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 1712920_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 1712920_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Ultrasonic guidance for needle placement 1712920_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 1712920_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 1712920_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 1712926_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 627.25 65 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 1712926_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 AETNA AETNA 762.35 79 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 1712926_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 936.05 97 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 1712926_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 665.85 69 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 1712926_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 752.7 78 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 1712926_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UMR - ALL PLANS UMR - ALL PLANS 675.5 70 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 1712926_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SIHO - ALL PLANS SIHO - ALL PLANS 868.5 90 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 1712926_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 584.31 60.55 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 1712926_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 1712926_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 1712926_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM HMO ANTHEM HMO 999999999 584.31 936.05 Ultrasonic guidance for needle placement 1712926_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 652.34 67.6 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 1712926_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 1712926_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 584.31 936.05 "X-ray of finger, minimum of 2 views" 1712953_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 245.7 65 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 1712953_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 AETNA AETNA 298.62 79 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 1712953_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 366.66 97 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 1712953_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 260.82 69 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 1712953_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 294.84 78 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 1712953_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UMR - ALL PLANS UMR - ALL PLANS 264.6 70 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 1712953_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SIHO - ALL PLANS SIHO - ALL PLANS 340.2 90 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 1712953_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 228.88 60.55 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 1712953_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 1712953_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 1712953_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM HMO ANTHEM HMO 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 1712953_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 255.53 67.6 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 1712953_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 1712953_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 1712956_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 245.7 65 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 1712956_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 AETNA AETNA 298.62 79 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 1712956_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 366.66 97 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 1712956_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 260.82 69 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 1712956_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 294.84 78 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 1712956_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UMR - ALL PLANS UMR - ALL PLANS 264.6 70 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 1712956_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SIHO - ALL PLANS SIHO - ALL PLANS 340.2 90 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 1712956_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 228.88 60.55 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 1712956_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 1712956_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 1712956_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM HMO ANTHEM HMO 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 1712956_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 255.53 67.6 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 1712956_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 1712956_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 228.88 366.66 "X-ray of upper spine, 4-5 views" 1713008_1 CDM 0320 RC 72050 HCPCS inpatient 573 372.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 372.45 65 999999999 346.95 555.81 percent of total billed charges "X-ray of upper spine, 4-5 views" 1713008_1 CDM 0320 RC 72050 HCPCS inpatient 573 372.45 AETNA AETNA 452.67 79 999999999 346.95 555.81 percent of total billed charges "X-ray of upper spine, 4-5 views" 1713008_1 CDM 0320 RC 72050 HCPCS inpatient 573 372.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 555.81 97 999999999 346.95 555.81 percent of total billed charges "X-ray of upper spine, 4-5 views" 1713008_1 CDM 0320 RC 72050 HCPCS inpatient 573 372.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 395.37 69 999999999 346.95 555.81 percent of total billed charges "X-ray of upper spine, 4-5 views" 1713008_1 CDM 0320 RC 72050 HCPCS inpatient 573 372.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 446.94 78 999999999 346.95 555.81 percent of total billed charges "X-ray of upper spine, 4-5 views" 1713008_1 CDM 0320 RC 72050 HCPCS inpatient 573 372.45 UMR - ALL PLANS UMR - ALL PLANS 401.1 70 999999999 346.95 555.81 percent of total billed charges "X-ray of upper spine, 4-5 views" 1713008_1 CDM 0320 RC 72050 HCPCS inpatient 573 372.45 SIHO - ALL PLANS SIHO - ALL PLANS 515.7 90 999999999 346.95 555.81 percent of total billed charges "X-ray of upper spine, 4-5 views" 1713008_1 CDM 0320 RC 72050 HCPCS inpatient 573 372.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 346.95 60.55 999999999 346.95 555.81 percent of total billed charges "X-ray of upper spine, 4-5 views" 1713008_1 CDM 0320 RC 72050 HCPCS inpatient 573 372.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 346.95 555.81 "X-ray of upper spine, 4-5 views" 1713008_1 CDM 0320 RC 72050 HCPCS inpatient 573 372.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 346.95 555.81 "X-ray of upper spine, 4-5 views" 1713008_1 CDM 0320 RC 72050 HCPCS inpatient 573 372.45 ANTHEM HMO ANTHEM HMO 999999999 346.95 555.81 "X-ray of upper spine, 4-5 views" 1713008_1 CDM 0320 RC 72050 HCPCS inpatient 573 372.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 387.35 67.6 999999999 346.95 555.81 percent of total billed charges "X-ray of upper spine, 4-5 views" 1713008_1 CDM 0320 RC 72050 HCPCS inpatient 573 372.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 346.95 555.81 "X-ray of upper spine, 4-5 views" 1713008_1 CDM 0320 RC 72050 HCPCS inpatient 573 372.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 346.95 555.81 "X-ray of middle spine, 3 views" 1713017_1 CDM 0320 RC 72072 HCPCS inpatient 583 378.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 378.95 65 999999999 353.01 565.51 percent of total billed charges "X-ray of middle spine, 3 views" 1713017_1 CDM 0320 RC 72072 HCPCS inpatient 583 378.95 AETNA AETNA 460.57 79 999999999 353.01 565.51 percent of total billed charges "X-ray of middle spine, 3 views" 1713017_1 CDM 0320 RC 72072 HCPCS inpatient 583 378.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 565.51 97 999999999 353.01 565.51 percent of total billed charges "X-ray of middle spine, 3 views" 1713017_1 CDM 0320 RC 72072 HCPCS inpatient 583 378.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 402.27 69 999999999 353.01 565.51 percent of total billed charges "X-ray of middle spine, 3 views" 1713017_1 CDM 0320 RC 72072 HCPCS inpatient 583 378.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 454.74 78 999999999 353.01 565.51 percent of total billed charges "X-ray of middle spine, 3 views" 1713017_1 CDM 0320 RC 72072 HCPCS inpatient 583 378.95 UMR - ALL PLANS UMR - ALL PLANS 408.1 70 999999999 353.01 565.51 percent of total billed charges "X-ray of middle spine, 3 views" 1713017_1 CDM 0320 RC 72072 HCPCS inpatient 583 378.95 SIHO - ALL PLANS SIHO - ALL PLANS 524.7 90 999999999 353.01 565.51 percent of total billed charges "X-ray of middle spine, 3 views" 1713017_1 CDM 0320 RC 72072 HCPCS inpatient 583 378.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 353.01 60.55 999999999 353.01 565.51 percent of total billed charges "X-ray of middle spine, 3 views" 1713017_1 CDM 0320 RC 72072 HCPCS inpatient 583 378.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 353.01 565.51 "X-ray of middle spine, 3 views" 1713017_1 CDM 0320 RC 72072 HCPCS inpatient 583 378.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 353.01 565.51 "X-ray of middle spine, 3 views" 1713017_1 CDM 0320 RC 72072 HCPCS inpatient 583 378.95 ANTHEM HMO ANTHEM HMO 999999999 353.01 565.51 "X-ray of middle spine, 3 views" 1713017_1 CDM 0320 RC 72072 HCPCS inpatient 583 378.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 394.11 67.6 999999999 353.01 565.51 percent of total billed charges "X-ray of middle spine, 3 views" 1713017_1 CDM 0320 RC 72072 HCPCS inpatient 583 378.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 353.01 565.51 "X-ray of middle spine, 3 views" 1713017_1 CDM 0320 RC 72072 HCPCS inpatient 583 378.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 353.01 565.51 "X-ray of toe, minimum of 2 views" 1713020_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 SELF PAY DISCOUNT SELF PAY DISCOUNT 221 65 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 1713020_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 AETNA AETNA 268.6 79 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 1713020_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 329.8 97 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 1713020_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ENCORE - ALL PLANS ENCORE - ALL PLANS 234.6 69 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 1713020_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 HUMANA - ALL PLANS HUMANA - ALL PLANS 265.2 78 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 1713020_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UMR - ALL PLANS UMR - ALL PLANS 238 70 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 1713020_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 SIHO - ALL PLANS SIHO - ALL PLANS 306 90 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 1713020_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.87 60.55 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 1713020_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 1713020_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 1713020_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM HMO ANTHEM HMO 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 1713020_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.84 67.6 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 1713020_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 1713020_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 1713023_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 SELF PAY DISCOUNT SELF PAY DISCOUNT 221 65 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 1713023_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 AETNA AETNA 268.6 79 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 1713023_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 329.8 97 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 1713023_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ENCORE - ALL PLANS ENCORE - ALL PLANS 234.6 69 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 1713023_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 HUMANA - ALL PLANS HUMANA - ALL PLANS 265.2 78 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 1713023_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UMR - ALL PLANS UMR - ALL PLANS 238 70 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 1713023_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 SIHO - ALL PLANS SIHO - ALL PLANS 306 90 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 1713023_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.87 60.55 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 1713023_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 1713023_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 1713023_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM HMO ANTHEM HMO 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 1713023_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.84 67.6 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 1713023_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 1713023_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.87 329.8 Insertion of tube into airway for aspiration of secretions 17680938_1 CDM 0410 RC 31720 HCPCS inpatient 258 167.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.7 65 999999999 156.22 250.26 percent of total billed charges Insertion of tube into airway for aspiration of secretions 17680938_1 CDM 0410 RC 31720 HCPCS inpatient 258 167.7 AETNA AETNA 203.82 79 999999999 156.22 250.26 percent of total billed charges Insertion of tube into airway for aspiration of secretions 17680938_1 CDM 0410 RC 31720 HCPCS inpatient 258 167.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 250.26 97 999999999 156.22 250.26 percent of total billed charges Insertion of tube into airway for aspiration of secretions 17680938_1 CDM 0410 RC 31720 HCPCS inpatient 258 167.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 178.02 69 999999999 156.22 250.26 percent of total billed charges Insertion of tube into airway for aspiration of secretions 17680938_1 CDM 0410 RC 31720 HCPCS inpatient 258 167.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 201.24 78 999999999 156.22 250.26 percent of total billed charges Insertion of tube into airway for aspiration of secretions 17680938_1 CDM 0410 RC 31720 HCPCS inpatient 258 167.7 UMR - ALL PLANS UMR - ALL PLANS 180.6 70 999999999 156.22 250.26 percent of total billed charges Insertion of tube into airway for aspiration of secretions 17680938_1 CDM 0410 RC 31720 HCPCS inpatient 258 167.7 SIHO - ALL PLANS SIHO - ALL PLANS 232.2 90 999999999 156.22 250.26 percent of total billed charges Insertion of tube into airway for aspiration of secretions 17680938_1 CDM 0410 RC 31720 HCPCS inpatient 258 167.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 156.22 60.55 999999999 156.22 250.26 percent of total billed charges Insertion of tube into airway for aspiration of secretions 17680938_1 CDM 0410 RC 31720 HCPCS inpatient 258 167.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 156.22 250.26 Insertion of tube into airway for aspiration of secretions 17680938_1 CDM 0410 RC 31720 HCPCS inpatient 258 167.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 156.22 250.26 Insertion of tube into airway for aspiration of secretions 17680938_1 CDM 0410 RC 31720 HCPCS inpatient 258 167.7 ANTHEM HMO ANTHEM HMO 999999999 156.22 250.26 Insertion of tube into airway for aspiration of secretions 17680938_1 CDM 0410 RC 31720 HCPCS inpatient 258 167.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 174.41 67.6 999999999 156.22 250.26 percent of total billed charges Insertion of tube into airway for aspiration of secretions 17680938_1 CDM 0410 RC 31720 HCPCS inpatient 258 167.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 156.22 250.26 Insertion of tube into airway for aspiration of secretions 17680938_1 CDM 0410 RC 31720 HCPCS inpatient 258 167.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 156.22 250.26 Fluoroscopic guidance for spine or back muscle injection 18692284_1 CDM 0320 RC 77003 HCPCS inpatient 1167 758.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 758.55 65 999999999 706.62 1131.99 percent of total billed charges Fluoroscopic guidance for spine or back muscle injection 18692284_1 CDM 0320 RC 77003 HCPCS inpatient 1167 758.55 AETNA AETNA 921.93 79 999999999 706.62 1131.99 percent of total billed charges Fluoroscopic guidance for spine or back muscle injection 18692284_1 CDM 0320 RC 77003 HCPCS inpatient 1167 758.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1131.99 97 999999999 706.62 1131.99 percent of total billed charges Fluoroscopic guidance for spine or back muscle injection 18692284_1 CDM 0320 RC 77003 HCPCS inpatient 1167 758.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 805.23 69 999999999 706.62 1131.99 percent of total billed charges Fluoroscopic guidance for spine or back muscle injection 18692284_1 CDM 0320 RC 77003 HCPCS inpatient 1167 758.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 910.26 78 999999999 706.62 1131.99 percent of total billed charges Fluoroscopic guidance for spine or back muscle injection 18692284_1 CDM 0320 RC 77003 HCPCS inpatient 1167 758.55 UMR - ALL PLANS UMR - ALL PLANS 816.9 70 999999999 706.62 1131.99 percent of total billed charges Fluoroscopic guidance for spine or back muscle injection 18692284_1 CDM 0320 RC 77003 HCPCS inpatient 1167 758.55 SIHO - ALL PLANS SIHO - ALL PLANS 1050.3 90 999999999 706.62 1131.99 percent of total billed charges Fluoroscopic guidance for spine or back muscle injection 18692284_1 CDM 0320 RC 77003 HCPCS inpatient 1167 758.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 706.62 60.55 999999999 706.62 1131.99 percent of total billed charges Fluoroscopic guidance for spine or back muscle injection 18692284_1 CDM 0320 RC 77003 HCPCS inpatient 1167 758.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 706.62 1131.99 Fluoroscopic guidance for spine or back muscle injection 18692284_1 CDM 0320 RC 77003 HCPCS inpatient 1167 758.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 706.62 1131.99 Fluoroscopic guidance for spine or back muscle injection 18692284_1 CDM 0320 RC 77003 HCPCS inpatient 1167 758.55 ANTHEM HMO ANTHEM HMO 999999999 706.62 1131.99 Fluoroscopic guidance for spine or back muscle injection 18692284_1 CDM 0320 RC 77003 HCPCS inpatient 1167 758.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 788.89 67.6 999999999 706.62 1131.99 percent of total billed charges Fluoroscopic guidance for spine or back muscle injection 18692284_1 CDM 0320 RC 77003 HCPCS inpatient 1167 758.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 706.62 1131.99 Fluoroscopic guidance for spine or back muscle injection 18692284_1 CDM 0320 RC 77003 HCPCS inpatient 1167 758.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 706.62 1131.99 HDL cholesterol level 1881473_1 CDM 0301 RC 83718 HCPCS inpatient 176 114.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 114.4 65 999999999 106.57 170.72 percent of total billed charges HDL cholesterol level 1881473_1 CDM 0301 RC 83718 HCPCS inpatient 176 114.4 AETNA AETNA 139.04 79 999999999 106.57 170.72 percent of total billed charges HDL cholesterol level 1881473_1 CDM 0301 RC 83718 HCPCS inpatient 176 114.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 170.72 97 999999999 106.57 170.72 percent of total billed charges HDL cholesterol level 1881473_1 CDM 0301 RC 83718 HCPCS inpatient 176 114.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 121.44 69 999999999 106.57 170.72 percent of total billed charges HDL cholesterol level 1881473_1 CDM 0301 RC 83718 HCPCS inpatient 176 114.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 137.28 78 999999999 106.57 170.72 percent of total billed charges HDL cholesterol level 1881473_1 CDM 0301 RC 83718 HCPCS inpatient 176 114.4 UMR - ALL PLANS UMR - ALL PLANS 123.2 70 999999999 106.57 170.72 percent of total billed charges HDL cholesterol level 1881473_1 CDM 0301 RC 83718 HCPCS inpatient 176 114.4 SIHO - ALL PLANS SIHO - ALL PLANS 158.4 90 999999999 106.57 170.72 percent of total billed charges HDL cholesterol level 1881473_1 CDM 0301 RC 83718 HCPCS inpatient 176 114.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 106.57 60.55 999999999 106.57 170.72 percent of total billed charges HDL cholesterol level 1881473_1 CDM 0301 RC 83718 HCPCS inpatient 176 114.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 106.57 170.72 HDL cholesterol level 1881473_1 CDM 0301 RC 83718 HCPCS inpatient 176 114.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 106.57 170.72 HDL cholesterol level 1881473_1 CDM 0301 RC 83718 HCPCS inpatient 176 114.4 ANTHEM HMO ANTHEM HMO 999999999 106.57 170.72 HDL cholesterol level 1881473_1 CDM 0301 RC 83718 HCPCS inpatient 176 114.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.98 67.6 999999999 106.57 170.72 percent of total billed charges HDL cholesterol level 1881473_1 CDM 0301 RC 83718 HCPCS inpatient 176 114.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 106.57 170.72 HDL cholesterol level 1881473_1 CDM 0301 RC 83718 HCPCS inpatient 176 114.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 106.57 170.72 "Red blood cell count, automated test" 1881511_1 CDM 0305 RC 85041 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges "Red blood cell count, automated test" 1881511_1 CDM 0305 RC 85041 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges "Red blood cell count, automated test" 1881511_1 CDM 0305 RC 85041 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges "Red blood cell count, automated test" 1881511_1 CDM 0305 RC 85041 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges "Red blood cell count, automated test" 1881511_1 CDM 0305 RC 85041 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges "Red blood cell count, automated test" 1881511_1 CDM 0305 RC 85041 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges "Red blood cell count, automated test" 1881511_1 CDM 0305 RC 85041 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges "Red blood cell count, automated test" 1881511_1 CDM 0305 RC 85041 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges "Red blood cell count, automated test" 1881511_1 CDM 0305 RC 85041 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 "Red blood cell count, automated test" 1881511_1 CDM 0305 RC 85041 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 "Red blood cell count, automated test" 1881511_1 CDM 0305 RC 85041 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 "Red blood cell count, automated test" 1881511_1 CDM 0305 RC 85041 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges "Red blood cell count, automated test" 1881511_1 CDM 0305 RC 85041 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 "Red blood cell count, automated test" 1881511_1 CDM 0305 RC 85041 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 CT scan of chest with contrast 1881678_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1801.8 65 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 1881678_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 AETNA AETNA 2189.88 79 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 1881678_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2688.84 97 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 1881678_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1912.68 69 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 1881678_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 2162.16 78 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 1881678_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 UMR - ALL PLANS UMR - ALL PLANS 1940.4 70 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 1881678_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 SIHO - ALL PLANS SIHO - ALL PLANS 2494.8 90 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 1881678_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1678.45 60.55 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 1881678_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1678.45 2688.84 CT scan of chest with contrast 1881678_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1678.45 2688.84 CT scan of chest with contrast 1881678_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 ANTHEM HMO ANTHEM HMO 999999999 1678.45 2688.84 CT scan of chest with contrast 1881678_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1873.87 67.6 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 1881678_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1678.45 2688.84 CT scan of chest with contrast 1881678_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1678.45 2688.84 Blood typing Rh phenotyping 1932605_1 CDM 0300 RC 86906 HCPCS inpatient 284 184.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 184.6 65 999999999 171.96 275.48 percent of total billed charges Blood typing Rh phenotyping 1932605_1 CDM 0300 RC 86906 HCPCS inpatient 284 184.6 AETNA AETNA 224.36 79 999999999 171.96 275.48 percent of total billed charges Blood typing Rh phenotyping 1932605_1 CDM 0300 RC 86906 HCPCS inpatient 284 184.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 275.48 97 999999999 171.96 275.48 percent of total billed charges Blood typing Rh phenotyping 1932605_1 CDM 0300 RC 86906 HCPCS inpatient 284 184.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 195.96 69 999999999 171.96 275.48 percent of total billed charges Blood typing Rh phenotyping 1932605_1 CDM 0300 RC 86906 HCPCS inpatient 284 184.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 221.52 78 999999999 171.96 275.48 percent of total billed charges Blood typing Rh phenotyping 1932605_1 CDM 0300 RC 86906 HCPCS inpatient 284 184.6 UMR - ALL PLANS UMR - ALL PLANS 198.8 70 999999999 171.96 275.48 percent of total billed charges Blood typing Rh phenotyping 1932605_1 CDM 0300 RC 86906 HCPCS inpatient 284 184.6 SIHO - ALL PLANS SIHO - ALL PLANS 255.6 90 999999999 171.96 275.48 percent of total billed charges Blood typing Rh phenotyping 1932605_1 CDM 0300 RC 86906 HCPCS inpatient 284 184.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 171.96 60.55 999999999 171.96 275.48 percent of total billed charges Blood typing Rh phenotyping 1932605_1 CDM 0300 RC 86906 HCPCS inpatient 284 184.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 171.96 275.48 Blood typing Rh phenotyping 1932605_1 CDM 0300 RC 86906 HCPCS inpatient 284 184.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 171.96 275.48 Blood typing Rh phenotyping 1932605_1 CDM 0300 RC 86906 HCPCS inpatient 284 184.6 ANTHEM HMO ANTHEM HMO 999999999 171.96 275.48 Blood typing Rh phenotyping 1932605_1 CDM 0300 RC 86906 HCPCS inpatient 284 184.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 191.98 67.6 999999999 171.96 275.48 percent of total billed charges Blood typing Rh phenotyping 1932605_1 CDM 0300 RC 86906 HCPCS inpatient 284 184.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 171.96 275.48 Blood typing Rh phenotyping 1932605_1 CDM 0300 RC 86906 HCPCS inpatient 284 184.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 171.96 275.48 Test to measure oxygen level in blood using ear or finger device 19952406_1 CDM 0410 RC 94760 HCPCS inpatient 209 135.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 135.85 65 999999999 126.55 202.73 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 19952406_1 CDM 0410 RC 94760 HCPCS inpatient 209 135.85 AETNA AETNA 165.11 79 999999999 126.55 202.73 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 19952406_1 CDM 0410 RC 94760 HCPCS inpatient 209 135.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 202.73 97 999999999 126.55 202.73 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 19952406_1 CDM 0410 RC 94760 HCPCS inpatient 209 135.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 144.21 69 999999999 126.55 202.73 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 19952406_1 CDM 0410 RC 94760 HCPCS inpatient 209 135.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 163.02 78 999999999 126.55 202.73 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 19952406_1 CDM 0410 RC 94760 HCPCS inpatient 209 135.85 UMR - ALL PLANS UMR - ALL PLANS 146.3 70 999999999 126.55 202.73 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 19952406_1 CDM 0410 RC 94760 HCPCS inpatient 209 135.85 SIHO - ALL PLANS SIHO - ALL PLANS 188.1 90 999999999 126.55 202.73 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 19952406_1 CDM 0410 RC 94760 HCPCS inpatient 209 135.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 126.55 60.55 999999999 126.55 202.73 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 19952406_1 CDM 0410 RC 94760 HCPCS inpatient 209 135.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 126.55 202.73 Test to measure oxygen level in blood using ear or finger device 19952406_1 CDM 0410 RC 94760 HCPCS inpatient 209 135.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 126.55 202.73 Test to measure oxygen level in blood using ear or finger device 19952406_1 CDM 0410 RC 94760 HCPCS inpatient 209 135.85 ANTHEM HMO ANTHEM HMO 999999999 126.55 202.73 Test to measure oxygen level in blood using ear or finger device 19952406_1 CDM 0410 RC 94760 HCPCS inpatient 209 135.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 141.28 67.6 999999999 126.55 202.73 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 19952406_1 CDM 0410 RC 94760 HCPCS inpatient 209 135.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 126.55 202.73 Test to measure oxygen level in blood using ear or finger device 19952406_1 CDM 0410 RC 94760 HCPCS inpatient 209 135.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 126.55 202.73 Vitamin D-3 level 20572257_1 CDM 0301 RC 82306 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges Vitamin D-3 level 20572257_1 CDM 0301 RC 82306 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges Vitamin D-3 level 20572257_1 CDM 0301 RC 82306 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges Vitamin D-3 level 20572257_1 CDM 0301 RC 82306 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges Vitamin D-3 level 20572257_1 CDM 0301 RC 82306 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges Vitamin D-3 level 20572257_1 CDM 0301 RC 82306 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges Vitamin D-3 level 20572257_1 CDM 0301 RC 82306 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges Vitamin D-3 level 20572257_1 CDM 0301 RC 82306 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges Vitamin D-3 level 20572257_1 CDM 0301 RC 82306 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 Vitamin D-3 level 20572257_1 CDM 0301 RC 82306 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 Vitamin D-3 level 20572257_1 CDM 0301 RC 82306 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 Vitamin D-3 level 20572257_1 CDM 0301 RC 82306 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges Vitamin D-3 level 20572257_1 CDM 0301 RC 82306 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 Vitamin D-3 level 20572257_1 CDM 0301 RC 82306 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 Blood group typing (ABO) 2200615_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.15 65 999999999 103.54 165.87 percent of total billed charges Blood group typing (ABO) 2200615_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 AETNA AETNA 135.09 79 999999999 103.54 165.87 percent of total billed charges Blood group typing (ABO) 2200615_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 165.87 97 999999999 103.54 165.87 percent of total billed charges Blood group typing (ABO) 2200615_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.99 69 999999999 103.54 165.87 percent of total billed charges Blood group typing (ABO) 2200615_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 133.38 78 999999999 103.54 165.87 percent of total billed charges Blood group typing (ABO) 2200615_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 UMR - ALL PLANS UMR - ALL PLANS 119.7 70 999999999 103.54 165.87 percent of total billed charges Blood group typing (ABO) 2200615_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 SIHO - ALL PLANS SIHO - ALL PLANS 153.9 90 999999999 103.54 165.87 percent of total billed charges Blood group typing (ABO) 2200615_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 103.54 60.55 999999999 103.54 165.87 percent of total billed charges Blood group typing (ABO) 2200615_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 103.54 165.87 Blood group typing (ABO) 2200615_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 103.54 165.87 Blood group typing (ABO) 2200615_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 ANTHEM HMO ANTHEM HMO 999999999 103.54 165.87 Blood group typing (ABO) 2200615_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 115.6 67.6 999999999 103.54 165.87 percent of total billed charges Blood group typing (ABO) 2200615_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 103.54 165.87 Blood group typing (ABO) 2200615_1 CDM 0302 RC 86900 HCPCS inpatient 171 111.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 103.54 165.87 Screening test for red blood cell antibodies 2200617_1 CDM 0302 RC 86850 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges Screening test for red blood cell antibodies 2200617_1 CDM 0302 RC 86850 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges Screening test for red blood cell antibodies 2200617_1 CDM 0302 RC 86850 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges Screening test for red blood cell antibodies 2200617_1 CDM 0302 RC 86850 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges Screening test for red blood cell antibodies 2200617_1 CDM 0302 RC 86850 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges Screening test for red blood cell antibodies 2200617_1 CDM 0302 RC 86850 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges Screening test for red blood cell antibodies 2200617_1 CDM 0302 RC 86850 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges Screening test for red blood cell antibodies 2200617_1 CDM 0302 RC 86850 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges Screening test for red blood cell antibodies 2200617_1 CDM 0302 RC 86850 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 Screening test for red blood cell antibodies 2200617_1 CDM 0302 RC 86850 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 Screening test for red blood cell antibodies 2200617_1 CDM 0302 RC 86850 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 Screening test for red blood cell antibodies 2200617_1 CDM 0302 RC 86850 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges Screening test for red blood cell antibodies 2200617_1 CDM 0302 RC 86850 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 Screening test for red blood cell antibodies 2200617_1 CDM 0302 RC 86850 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 Blood group typing (ABO) 2200619_1 CDM 0302 RC 86900 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges Blood group typing (ABO) 2200619_1 CDM 0302 RC 86900 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges Blood group typing (ABO) 2200619_1 CDM 0302 RC 86900 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges Blood group typing (ABO) 2200619_1 CDM 0302 RC 86900 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges Blood group typing (ABO) 2200619_1 CDM 0302 RC 86900 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges Blood group typing (ABO) 2200619_1 CDM 0302 RC 86900 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges Blood group typing (ABO) 2200619_1 CDM 0302 RC 86900 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges Blood group typing (ABO) 2200619_1 CDM 0302 RC 86900 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges Blood group typing (ABO) 2200619_1 CDM 0302 RC 86900 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 Blood group typing (ABO) 2200619_1 CDM 0302 RC 86900 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 Blood group typing (ABO) 2200619_1 CDM 0302 RC 86900 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 Blood group typing (ABO) 2200619_1 CDM 0302 RC 86900 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges Blood group typing (ABO) 2200619_1 CDM 0302 RC 86900 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 Blood group typing (ABO) 2200619_1 CDM 0302 RC 86900 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 "Blood unit compatibility test, immediate spin technique" 2216608_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 280.8 65 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 2216608_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 AETNA AETNA 341.28 79 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 2216608_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 419.04 97 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 2216608_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 298.08 69 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 2216608_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 336.96 78 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 2216608_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 UMR - ALL PLANS UMR - ALL PLANS 302.4 70 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 2216608_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 SIHO - ALL PLANS SIHO - ALL PLANS 388.8 90 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 2216608_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 261.58 60.55 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 2216608_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 261.58 419.04 "Blood unit compatibility test, immediate spin technique" 2216608_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 261.58 419.04 "Blood unit compatibility test, immediate spin technique" 2216608_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 ANTHEM HMO ANTHEM HMO 999999999 261.58 419.04 "Blood unit compatibility test, immediate spin technique" 2216608_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 292.03 67.6 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 2216608_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 261.58 419.04 "Blood unit compatibility test, immediate spin technique" 2216608_1 CDM 0300 RC 86920 HCPCS inpatient 432 280.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 261.58 419.04 "Application of hot and cold baths, each 15 minutes" 22736256_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 22736256_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 22736256_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 22736256_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 22736256_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 22736256_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 22736256_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 22736256_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 22736256_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 22736256_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 22736256_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 22736256_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 22736256_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 22736256_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 "Training for self-care or home management, each 15 minutes" 22736257_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 129.35 65 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 22736257_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 AETNA AETNA 157.21 79 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 22736257_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 193.03 97 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 22736257_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 137.31 69 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 22736257_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 155.22 78 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 22736257_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 UMR - ALL PLANS UMR - ALL PLANS 139.3 70 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 22736257_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 SIHO - ALL PLANS SIHO - ALL PLANS 179.1 90 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 22736257_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 120.49 60.55 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 22736257_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 120.49 193.03 "Training for self-care or home management, each 15 minutes" 22736257_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 120.49 193.03 "Training for self-care or home management, each 15 minutes" 22736257_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 ANTHEM HMO ANTHEM HMO 999999999 120.49 193.03 "Training for self-care or home management, each 15 minutes" 22736257_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 134.52 67.6 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 22736257_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 120.49 193.03 "Training for self-care or home management, each 15 minutes" 22736257_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 120.49 193.03 "Test or measurement for functional capacity, each 15 minutes" 22736352_1 CDM 0420 RC 97750 HCPCS inpatient 1008 655.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 655.2 65 999999999 610.34 977.76 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 22736352_1 CDM 0420 RC 97750 HCPCS inpatient 1008 655.2 AETNA AETNA 796.32 79 999999999 610.34 977.76 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 22736352_1 CDM 0420 RC 97750 HCPCS inpatient 1008 655.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 977.76 97 999999999 610.34 977.76 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 22736352_1 CDM 0420 RC 97750 HCPCS inpatient 1008 655.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 695.52 69 999999999 610.34 977.76 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 22736352_1 CDM 0420 RC 97750 HCPCS inpatient 1008 655.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 786.24 78 999999999 610.34 977.76 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 22736352_1 CDM 0420 RC 97750 HCPCS inpatient 1008 655.2 UMR - ALL PLANS UMR - ALL PLANS 705.6 70 999999999 610.34 977.76 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 22736352_1 CDM 0420 RC 97750 HCPCS inpatient 1008 655.2 SIHO - ALL PLANS SIHO - ALL PLANS 907.2 90 999999999 610.34 977.76 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 22736352_1 CDM 0420 RC 97750 HCPCS inpatient 1008 655.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 610.34 60.55 999999999 610.34 977.76 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 22736352_1 CDM 0420 RC 97750 HCPCS inpatient 1008 655.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 610.34 977.76 "Test or measurement for functional capacity, each 15 minutes" 22736352_1 CDM 0420 RC 97750 HCPCS inpatient 1008 655.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 610.34 977.76 "Test or measurement for functional capacity, each 15 minutes" 22736352_1 CDM 0420 RC 97750 HCPCS inpatient 1008 655.2 ANTHEM HMO ANTHEM HMO 999999999 610.34 977.76 "Test or measurement for functional capacity, each 15 minutes" 22736352_1 CDM 0420 RC 97750 HCPCS inpatient 1008 655.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 681.41 67.6 999999999 610.34 977.76 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 22736352_1 CDM 0420 RC 97750 HCPCS inpatient 1008 655.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 610.34 977.76 "Test or measurement for functional capacity, each 15 minutes" 22736352_1 CDM 0420 RC 97750 HCPCS inpatient 1008 655.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 610.34 977.76 "Application of hot and cold baths, each 15 minutes" 22780435_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 22780435_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 22780435_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 22780435_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 22780435_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 22780435_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 22780435_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 22780435_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 22780435_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 22780435_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 22780435_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 22780435_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 22780435_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 22780435_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 "Test or measurement for functional capacity, each 15 minutes" 22780438_1 CDM 0430 RC 97750 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 22780438_1 CDM 0430 RC 97750 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 22780438_1 CDM 0430 RC 97750 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 22780438_1 CDM 0430 RC 97750 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 22780438_1 CDM 0430 RC 97750 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 22780438_1 CDM 0430 RC 97750 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 22780438_1 CDM 0430 RC 97750 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 22780438_1 CDM 0430 RC 97750 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 22780438_1 CDM 0430 RC 97750 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 "Test or measurement for functional capacity, each 15 minutes" 22780438_1 CDM 0430 RC 97750 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 "Test or measurement for functional capacity, each 15 minutes" 22780438_1 CDM 0430 RC 97750 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 "Test or measurement for functional capacity, each 15 minutes" 22780438_1 CDM 0430 RC 97750 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 22780438_1 CDM 0430 RC 97750 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 "Test or measurement for functional capacity, each 15 minutes" 22780438_1 CDM 0430 RC 97750 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 CT scan of chest with contrast 2342693_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1801.8 65 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 2342693_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 AETNA AETNA 2189.88 79 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 2342693_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2688.84 97 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 2342693_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1912.68 69 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 2342693_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 2162.16 78 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 2342693_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 UMR - ALL PLANS UMR - ALL PLANS 1940.4 70 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 2342693_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 SIHO - ALL PLANS SIHO - ALL PLANS 2494.8 90 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 2342693_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1678.45 60.55 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 2342693_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1678.45 2688.84 CT scan of chest with contrast 2342693_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1678.45 2688.84 CT scan of chest with contrast 2342693_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 ANTHEM HMO ANTHEM HMO 999999999 1678.45 2688.84 CT scan of chest with contrast 2342693_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1873.87 67.6 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 2342693_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1678.45 2688.84 CT scan of chest with contrast 2342693_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1678.45 2688.84 CT scan of abdomen without contrast 2342699_1 CDM 0352 RC 74150 HCPCS inpatient 2684 1744.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1744.6 65 999999999 1625.16 2603.48 percent of total billed charges CT scan of abdomen without contrast 2342699_1 CDM 0352 RC 74150 HCPCS inpatient 2684 1744.6 AETNA AETNA 2120.36 79 999999999 1625.16 2603.48 percent of total billed charges CT scan of abdomen without contrast 2342699_1 CDM 0352 RC 74150 HCPCS inpatient 2684 1744.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2603.48 97 999999999 1625.16 2603.48 percent of total billed charges CT scan of abdomen without contrast 2342699_1 CDM 0352 RC 74150 HCPCS inpatient 2684 1744.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1851.96 69 999999999 1625.16 2603.48 percent of total billed charges CT scan of abdomen without contrast 2342699_1 CDM 0352 RC 74150 HCPCS inpatient 2684 1744.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 2093.52 78 999999999 1625.16 2603.48 percent of total billed charges CT scan of abdomen without contrast 2342699_1 CDM 0352 RC 74150 HCPCS inpatient 2684 1744.6 UMR - ALL PLANS UMR - ALL PLANS 1878.8 70 999999999 1625.16 2603.48 percent of total billed charges CT scan of abdomen without contrast 2342699_1 CDM 0352 RC 74150 HCPCS inpatient 2684 1744.6 SIHO - ALL PLANS SIHO - ALL PLANS 2415.6 90 999999999 1625.16 2603.48 percent of total billed charges CT scan of abdomen without contrast 2342699_1 CDM 0352 RC 74150 HCPCS inpatient 2684 1744.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1625.16 60.55 999999999 1625.16 2603.48 percent of total billed charges CT scan of abdomen without contrast 2342699_1 CDM 0352 RC 74150 HCPCS inpatient 2684 1744.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1625.16 2603.48 CT scan of abdomen without contrast 2342699_1 CDM 0352 RC 74150 HCPCS inpatient 2684 1744.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1625.16 2603.48 CT scan of abdomen without contrast 2342699_1 CDM 0352 RC 74150 HCPCS inpatient 2684 1744.6 ANTHEM HMO ANTHEM HMO 999999999 1625.16 2603.48 CT scan of abdomen without contrast 2342699_1 CDM 0352 RC 74150 HCPCS inpatient 2684 1744.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1814.38 67.6 999999999 1625.16 2603.48 percent of total billed charges CT scan of abdomen without contrast 2342699_1 CDM 0352 RC 74150 HCPCS inpatient 2684 1744.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1625.16 2603.48 CT scan of abdomen without contrast 2342699_1 CDM 0352 RC 74150 HCPCS inpatient 2684 1744.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1625.16 2603.48 "Computed tomography (CT) of brain blood flow, volume, and timing of flow analysis with contrast" 2342735_1 CDM 0352 RC 0042T HCPCS inpatient 2096 1362.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1362.4 65 999999999 1269.13 2033.12 percent of total billed charges "Computed tomography (CT) of brain blood flow, volume, and timing of flow analysis with contrast" 2342735_1 CDM 0352 RC 0042T HCPCS inpatient 2096 1362.4 AETNA AETNA 1655.84 79 999999999 1269.13 2033.12 percent of total billed charges "Computed tomography (CT) of brain blood flow, volume, and timing of flow analysis with contrast" 2342735_1 CDM 0352 RC 0042T HCPCS inpatient 2096 1362.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2033.12 97 999999999 1269.13 2033.12 percent of total billed charges "Computed tomography (CT) of brain blood flow, volume, and timing of flow analysis with contrast" 2342735_1 CDM 0352 RC 0042T HCPCS inpatient 2096 1362.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1446.24 69 999999999 1269.13 2033.12 percent of total billed charges "Computed tomography (CT) of brain blood flow, volume, and timing of flow analysis with contrast" 2342735_1 CDM 0352 RC 0042T HCPCS inpatient 2096 1362.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1634.88 78 999999999 1269.13 2033.12 percent of total billed charges "Computed tomography (CT) of brain blood flow, volume, and timing of flow analysis with contrast" 2342735_1 CDM 0352 RC 0042T HCPCS inpatient 2096 1362.4 UMR - ALL PLANS UMR - ALL PLANS 1467.2 70 999999999 1269.13 2033.12 percent of total billed charges "Computed tomography (CT) of brain blood flow, volume, and timing of flow analysis with contrast" 2342735_1 CDM 0352 RC 0042T HCPCS inpatient 2096 1362.4 SIHO - ALL PLANS SIHO - ALL PLANS 1886.4 90 999999999 1269.13 2033.12 percent of total billed charges "Computed tomography (CT) of brain blood flow, volume, and timing of flow analysis with contrast" 2342735_1 CDM 0352 RC 0042T HCPCS inpatient 2096 1362.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1269.13 60.55 999999999 1269.13 2033.12 percent of total billed charges "Computed tomography (CT) of brain blood flow, volume, and timing of flow analysis with contrast" 2342735_1 CDM 0352 RC 0042T HCPCS inpatient 2096 1362.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1269.13 2033.12 "Computed tomography (CT) of brain blood flow, volume, and timing of flow analysis with contrast" 2342735_1 CDM 0352 RC 0042T HCPCS inpatient 2096 1362.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1269.13 2033.12 "Computed tomography (CT) of brain blood flow, volume, and timing of flow analysis with contrast" 2342735_1 CDM 0352 RC 0042T HCPCS inpatient 2096 1362.4 ANTHEM HMO ANTHEM HMO 999999999 1269.13 2033.12 "Computed tomography (CT) of brain blood flow, volume, and timing of flow analysis with contrast" 2342735_1 CDM 0352 RC 0042T HCPCS inpatient 2096 1362.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1416.9 67.6 999999999 1269.13 2033.12 percent of total billed charges "Computed tomography (CT) of brain blood flow, volume, and timing of flow analysis with contrast" 2342735_1 CDM 0352 RC 0042T HCPCS inpatient 2096 1362.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1269.13 2033.12 "Computed tomography (CT) of brain blood flow, volume, and timing of flow analysis with contrast" 2342735_1 CDM 0352 RC 0042T HCPCS inpatient 2096 1362.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1269.13 2033.12 CT scan of blood vessels and grafts of heart with contrast 2342780_1 CDM 0350 RC 75574 HCPCS inpatient 2592 1684.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1684.8 65 999999999 1569.46 2514.24 percent of total billed charges CT scan of blood vessels and grafts of heart with contrast 2342780_1 CDM 0350 RC 75574 HCPCS inpatient 2592 1684.8 AETNA AETNA 2047.68 79 999999999 1569.46 2514.24 percent of total billed charges CT scan of blood vessels and grafts of heart with contrast 2342780_1 CDM 0350 RC 75574 HCPCS inpatient 2592 1684.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2514.24 97 999999999 1569.46 2514.24 percent of total billed charges CT scan of blood vessels and grafts of heart with contrast 2342780_1 CDM 0350 RC 75574 HCPCS inpatient 2592 1684.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1788.48 69 999999999 1569.46 2514.24 percent of total billed charges CT scan of blood vessels and grafts of heart with contrast 2342780_1 CDM 0350 RC 75574 HCPCS inpatient 2592 1684.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 2021.76 78 999999999 1569.46 2514.24 percent of total billed charges CT scan of blood vessels and grafts of heart with contrast 2342780_1 CDM 0350 RC 75574 HCPCS inpatient 2592 1684.8 UMR - ALL PLANS UMR - ALL PLANS 1814.4 70 999999999 1569.46 2514.24 percent of total billed charges CT scan of blood vessels and grafts of heart with contrast 2342780_1 CDM 0350 RC 75574 HCPCS inpatient 2592 1684.8 SIHO - ALL PLANS SIHO - ALL PLANS 2332.8 90 999999999 1569.46 2514.24 percent of total billed charges CT scan of blood vessels and grafts of heart with contrast 2342780_1 CDM 0350 RC 75574 HCPCS inpatient 2592 1684.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1569.46 60.55 999999999 1569.46 2514.24 percent of total billed charges CT scan of blood vessels and grafts of heart with contrast 2342780_1 CDM 0350 RC 75574 HCPCS inpatient 2592 1684.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1569.46 2514.24 CT scan of blood vessels and grafts of heart with contrast 2342780_1 CDM 0350 RC 75574 HCPCS inpatient 2592 1684.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1569.46 2514.24 CT scan of blood vessels and grafts of heart with contrast 2342780_1 CDM 0350 RC 75574 HCPCS inpatient 2592 1684.8 ANTHEM HMO ANTHEM HMO 999999999 1569.46 2514.24 CT scan of blood vessels and grafts of heart with contrast 2342780_1 CDM 0350 RC 75574 HCPCS inpatient 2592 1684.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1752.19 67.6 999999999 1569.46 2514.24 percent of total billed charges CT scan of blood vessels and grafts of heart with contrast 2342780_1 CDM 0350 RC 75574 HCPCS inpatient 2592 1684.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1569.46 2514.24 CT scan of blood vessels and grafts of heart with contrast 2342780_1 CDM 0350 RC 75574 HCPCS inpatient 2592 1684.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1569.46 2514.24 Ultrasound measurement of bladder capacity after voiding 2342828_1 CDM 0402 RC 51798 HCPCS inpatient 132 85.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.8 65 999999999 79.93 128.04 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 2342828_1 CDM 0402 RC 51798 HCPCS inpatient 132 85.8 AETNA AETNA 104.28 79 999999999 79.93 128.04 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 2342828_1 CDM 0402 RC 51798 HCPCS inpatient 132 85.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 128.04 97 999999999 79.93 128.04 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 2342828_1 CDM 0402 RC 51798 HCPCS inpatient 132 85.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.08 69 999999999 79.93 128.04 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 2342828_1 CDM 0402 RC 51798 HCPCS inpatient 132 85.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.96 78 999999999 79.93 128.04 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 2342828_1 CDM 0402 RC 51798 HCPCS inpatient 132 85.8 UMR - ALL PLANS UMR - ALL PLANS 92.4 70 999999999 79.93 128.04 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 2342828_1 CDM 0402 RC 51798 HCPCS inpatient 132 85.8 SIHO - ALL PLANS SIHO - ALL PLANS 118.8 90 999999999 79.93 128.04 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 2342828_1 CDM 0402 RC 51798 HCPCS inpatient 132 85.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.93 60.55 999999999 79.93 128.04 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 2342828_1 CDM 0402 RC 51798 HCPCS inpatient 132 85.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.93 128.04 Ultrasound measurement of bladder capacity after voiding 2342828_1 CDM 0402 RC 51798 HCPCS inpatient 132 85.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.93 128.04 Ultrasound measurement of bladder capacity after voiding 2342828_1 CDM 0402 RC 51798 HCPCS inpatient 132 85.8 ANTHEM HMO ANTHEM HMO 999999999 79.93 128.04 Ultrasound measurement of bladder capacity after voiding 2342828_1 CDM 0402 RC 51798 HCPCS inpatient 132 85.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.23 67.6 999999999 79.93 128.04 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 2342828_1 CDM 0402 RC 51798 HCPCS inpatient 132 85.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.93 128.04 Ultrasound measurement of bladder capacity after voiding 2342828_1 CDM 0402 RC 51798 HCPCS inpatient 132 85.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.93 128.04 Ultrasonic guidance for needle placement 2342834_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 2342834_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 2342834_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 2342834_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 2342834_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 2342834_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 2342834_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 2342834_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 2342834_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 2342834_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 2342834_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Ultrasonic guidance for needle placement 2342834_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 2342834_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 2342834_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 2342837_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 2342837_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 2342837_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 2342837_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 2342837_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 2342837_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 2342837_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 2342837_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 2342837_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 2342837_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 2342837_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Ultrasonic guidance for needle placement 2342837_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 2342837_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 2342837_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 2342840_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 627.25 65 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 2342840_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 AETNA AETNA 762.35 79 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 2342840_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 936.05 97 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 2342840_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 665.85 69 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 2342840_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 752.7 78 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 2342840_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UMR - ALL PLANS UMR - ALL PLANS 675.5 70 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 2342840_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SIHO - ALL PLANS SIHO - ALL PLANS 868.5 90 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 2342840_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 584.31 60.55 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 2342840_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 2342840_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 2342840_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM HMO ANTHEM HMO 999999999 584.31 936.05 Ultrasonic guidance for needle placement 2342840_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 652.34 67.6 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 2342840_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 2342840_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 584.31 936.05 "Ultrasound scan of pregnant uterus (14 weeks or more), each additional fetus" 2342885_1 CDM 0402 RC 76810 HCPCS inpatient 1179 766.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 766.35 65 999999999 713.88 1143.63 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), each additional fetus" 2342885_1 CDM 0402 RC 76810 HCPCS inpatient 1179 766.35 AETNA AETNA 931.41 79 999999999 713.88 1143.63 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), each additional fetus" 2342885_1 CDM 0402 RC 76810 HCPCS inpatient 1179 766.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1143.63 97 999999999 713.88 1143.63 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), each additional fetus" 2342885_1 CDM 0402 RC 76810 HCPCS inpatient 1179 766.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 813.51 69 999999999 713.88 1143.63 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), each additional fetus" 2342885_1 CDM 0402 RC 76810 HCPCS inpatient 1179 766.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 919.62 78 999999999 713.88 1143.63 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), each additional fetus" 2342885_1 CDM 0402 RC 76810 HCPCS inpatient 1179 766.35 UMR - ALL PLANS UMR - ALL PLANS 825.3 70 999999999 713.88 1143.63 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), each additional fetus" 2342885_1 CDM 0402 RC 76810 HCPCS inpatient 1179 766.35 SIHO - ALL PLANS SIHO - ALL PLANS 1061.1 90 999999999 713.88 1143.63 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), each additional fetus" 2342885_1 CDM 0402 RC 76810 HCPCS inpatient 1179 766.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 713.88 60.55 999999999 713.88 1143.63 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), each additional fetus" 2342885_1 CDM 0402 RC 76810 HCPCS inpatient 1179 766.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 713.88 1143.63 "Ultrasound scan of pregnant uterus (14 weeks or more), each additional fetus" 2342885_1 CDM 0402 RC 76810 HCPCS inpatient 1179 766.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 713.88 1143.63 "Ultrasound scan of pregnant uterus (14 weeks or more), each additional fetus" 2342885_1 CDM 0402 RC 76810 HCPCS inpatient 1179 766.35 ANTHEM HMO ANTHEM HMO 999999999 713.88 1143.63 "Ultrasound scan of pregnant uterus (14 weeks or more), each additional fetus" 2342885_1 CDM 0402 RC 76810 HCPCS inpatient 1179 766.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 797 67.6 999999999 713.88 1143.63 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), each additional fetus" 2342885_1 CDM 0402 RC 76810 HCPCS inpatient 1179 766.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 713.88 1143.63 "Ultrasound scan of pregnant uterus (14 weeks or more), each additional fetus" 2342885_1 CDM 0402 RC 76810 HCPCS inpatient 1179 766.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 713.88 1143.63 "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 2396609_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 527.15 65 999999999 491.06 786.67 percent of total billed charges "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 2396609_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 AETNA AETNA 640.69 79 999999999 491.06 786.67 percent of total billed charges "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 2396609_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 786.67 97 999999999 491.06 786.67 percent of total billed charges "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 2396609_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 559.59 69 999999999 491.06 786.67 percent of total billed charges "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 2396609_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 632.58 78 999999999 491.06 786.67 percent of total billed charges "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 2396609_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 UMR - ALL PLANS UMR - ALL PLANS 567.7 70 999999999 491.06 786.67 percent of total billed charges "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 2396609_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 SIHO - ALL PLANS SIHO - ALL PLANS 729.9 90 999999999 491.06 786.67 percent of total billed charges "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 2396609_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 491.06 60.55 999999999 491.06 786.67 percent of total billed charges "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 2396609_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 491.06 786.67 "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 2396609_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 491.06 786.67 "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 2396609_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 ANTHEM HMO ANTHEM HMO 999999999 491.06 786.67 "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 2396609_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 548.24 67.6 999999999 491.06 786.67 percent of total billed charges "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 2396609_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 491.06 786.67 "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 2396609_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 491.06 786.67 "Training for self-care or home management, each 15 minutes" 2573543_1 CDM 0430 RC 97535 HCPCS inpatient 186 120.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 120.9 65 999999999 112.62 180.42 percent of total billed charges "Training for self-care or home management, each 15 minutes" 2573543_1 CDM 0430 RC 97535 HCPCS inpatient 186 120.9 AETNA AETNA 146.94 79 999999999 112.62 180.42 percent of total billed charges "Training for self-care or home management, each 15 minutes" 2573543_1 CDM 0430 RC 97535 HCPCS inpatient 186 120.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 128.34 69 999999999 112.62 180.42 percent of total billed charges "Training for self-care or home management, each 15 minutes" 2573543_1 CDM 0430 RC 97535 HCPCS inpatient 186 120.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 180.42 97 999999999 112.62 180.42 percent of total billed charges "Training for self-care or home management, each 15 minutes" 2573543_1 CDM 0430 RC 97535 HCPCS inpatient 186 120.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 145.08 78 999999999 112.62 180.42 percent of total billed charges "Training for self-care or home management, each 15 minutes" 2573543_1 CDM 0430 RC 97535 HCPCS inpatient 186 120.9 UMR - ALL PLANS UMR - ALL PLANS 130.2 70 999999999 112.62 180.42 percent of total billed charges "Training for self-care or home management, each 15 minutes" 2573543_1 CDM 0430 RC 97535 HCPCS inpatient 186 120.9 SIHO - ALL PLANS SIHO - ALL PLANS 167.4 90 999999999 112.62 180.42 percent of total billed charges "Training for self-care or home management, each 15 minutes" 2573543_1 CDM 0430 RC 97535 HCPCS inpatient 186 120.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 112.62 60.55 999999999 112.62 180.42 percent of total billed charges "Training for self-care or home management, each 15 minutes" 2573543_1 CDM 0430 RC 97535 HCPCS inpatient 186 120.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 112.62 180.42 "Training for self-care or home management, each 15 minutes" 2573543_1 CDM 0430 RC 97535 HCPCS inpatient 186 120.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 112.62 180.42 "Training for self-care or home management, each 15 minutes" 2573543_1 CDM 0430 RC 97535 HCPCS inpatient 186 120.9 ANTHEM HMO ANTHEM HMO 999999999 112.62 180.42 "Training for self-care or home management, each 15 minutes" 2573543_1 CDM 0430 RC 97535 HCPCS inpatient 186 120.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 125.74 67.6 999999999 112.62 180.42 percent of total billed charges "Training for self-care or home management, each 15 minutes" 2573543_1 CDM 0430 RC 97535 HCPCS inpatient 186 120.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 112.62 180.42 "Training for self-care or home management, each 15 minutes" 2573543_1 CDM 0430 RC 97535 HCPCS inpatient 186 120.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 112.62 180.42 "Application of electrical stimulation with therapist present, each 15 minutes" 2573545_1 CDM 0430 RC 97032 HCPCS inpatient 188 122.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.2 65 999999999 113.83 182.36 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 2573545_1 CDM 0430 RC 97032 HCPCS inpatient 188 122.2 AETNA AETNA 148.52 79 999999999 113.83 182.36 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 2573545_1 CDM 0430 RC 97032 HCPCS inpatient 188 122.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.72 69 999999999 113.83 182.36 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 2573545_1 CDM 0430 RC 97032 HCPCS inpatient 188 122.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 182.36 97 999999999 113.83 182.36 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 2573545_1 CDM 0430 RC 97032 HCPCS inpatient 188 122.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 146.64 78 999999999 113.83 182.36 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 2573545_1 CDM 0430 RC 97032 HCPCS inpatient 188 122.2 UMR - ALL PLANS UMR - ALL PLANS 131.6 70 999999999 113.83 182.36 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 2573545_1 CDM 0430 RC 97032 HCPCS inpatient 188 122.2 SIHO - ALL PLANS SIHO - ALL PLANS 169.2 90 999999999 113.83 182.36 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 2573545_1 CDM 0430 RC 97032 HCPCS inpatient 188 122.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.83 60.55 999999999 113.83 182.36 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 2573545_1 CDM 0430 RC 97032 HCPCS inpatient 188 122.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.83 182.36 "Application of electrical stimulation with therapist present, each 15 minutes" 2573545_1 CDM 0430 RC 97032 HCPCS inpatient 188 122.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.83 182.36 "Application of electrical stimulation with therapist present, each 15 minutes" 2573545_1 CDM 0430 RC 97032 HCPCS inpatient 188 122.2 ANTHEM HMO ANTHEM HMO 999999999 113.83 182.36 "Application of electrical stimulation with therapist present, each 15 minutes" 2573545_1 CDM 0430 RC 97032 HCPCS inpatient 188 122.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.09 67.6 999999999 113.83 182.36 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 2573545_1 CDM 0430 RC 97032 HCPCS inpatient 188 122.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.83 182.36 "Application of electrical stimulation with therapist present, each 15 minutes" 2573545_1 CDM 0430 RC 97032 HCPCS inpatient 188 122.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.83 182.36 "Application of medication using electrical current, each 15 minutes" 2573546_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 140.4 65 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 2573546_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 AETNA AETNA 170.64 79 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 2573546_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 149.04 69 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 2573546_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 209.52 97 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 2573546_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 168.48 78 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 2573546_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 UMR - ALL PLANS UMR - ALL PLANS 151.2 70 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 2573546_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 SIHO - ALL PLANS SIHO - ALL PLANS 194.4 90 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 2573546_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 130.79 60.55 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 2573546_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 2573546_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 2573546_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 ANTHEM HMO ANTHEM HMO 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 2573546_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 146.02 67.6 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 2573546_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 2573546_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 130.79 209.52 "Therapy procedure using massage, each 15 minutes" 2573548_1 CDM 0430 RC 97124 HCPCS inpatient 196 127.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 127.4 65 999999999 118.68 190.12 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 2573548_1 CDM 0430 RC 97124 HCPCS inpatient 196 127.4 AETNA AETNA 154.84 79 999999999 118.68 190.12 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 2573548_1 CDM 0430 RC 97124 HCPCS inpatient 196 127.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 135.24 69 999999999 118.68 190.12 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 2573548_1 CDM 0430 RC 97124 HCPCS inpatient 196 127.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 190.12 97 999999999 118.68 190.12 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 2573548_1 CDM 0430 RC 97124 HCPCS inpatient 196 127.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 152.88 78 999999999 118.68 190.12 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 2573548_1 CDM 0430 RC 97124 HCPCS inpatient 196 127.4 UMR - ALL PLANS UMR - ALL PLANS 137.2 70 999999999 118.68 190.12 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 2573548_1 CDM 0430 RC 97124 HCPCS inpatient 196 127.4 SIHO - ALL PLANS SIHO - ALL PLANS 176.4 90 999999999 118.68 190.12 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 2573548_1 CDM 0430 RC 97124 HCPCS inpatient 196 127.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 118.68 60.55 999999999 118.68 190.12 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 2573548_1 CDM 0430 RC 97124 HCPCS inpatient 196 127.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 118.68 190.12 "Therapy procedure using massage, each 15 minutes" 2573548_1 CDM 0430 RC 97124 HCPCS inpatient 196 127.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 118.68 190.12 "Therapy procedure using massage, each 15 minutes" 2573548_1 CDM 0430 RC 97124 HCPCS inpatient 196 127.4 ANTHEM HMO ANTHEM HMO 999999999 118.68 190.12 "Therapy procedure using massage, each 15 minutes" 2573548_1 CDM 0430 RC 97124 HCPCS inpatient 196 127.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 132.5 67.6 999999999 118.68 190.12 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 2573548_1 CDM 0430 RC 97124 HCPCS inpatient 196 127.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 118.68 190.12 "Therapy procedure using massage, each 15 minutes" 2573548_1 CDM 0430 RC 97124 HCPCS inpatient 196 127.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 118.68 190.12 Application of hot wax bath 2573551_1 CDM 0430 RC 97018 HCPCS inpatient 201 130.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 130.65 65 999999999 121.71 194.97 percent of total billed charges Application of hot wax bath 2573551_1 CDM 0430 RC 97018 HCPCS inpatient 201 130.65 AETNA AETNA 158.79 79 999999999 121.71 194.97 percent of total billed charges Application of hot wax bath 2573551_1 CDM 0430 RC 97018 HCPCS inpatient 201 130.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 138.69 69 999999999 121.71 194.97 percent of total billed charges Application of hot wax bath 2573551_1 CDM 0430 RC 97018 HCPCS inpatient 201 130.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 194.97 97 999999999 121.71 194.97 percent of total billed charges Application of hot wax bath 2573551_1 CDM 0430 RC 97018 HCPCS inpatient 201 130.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 156.78 78 999999999 121.71 194.97 percent of total billed charges Application of hot wax bath 2573551_1 CDM 0430 RC 97018 HCPCS inpatient 201 130.65 UMR - ALL PLANS UMR - ALL PLANS 140.7 70 999999999 121.71 194.97 percent of total billed charges Application of hot wax bath 2573551_1 CDM 0430 RC 97018 HCPCS inpatient 201 130.65 SIHO - ALL PLANS SIHO - ALL PLANS 180.9 90 999999999 121.71 194.97 percent of total billed charges Application of hot wax bath 2573551_1 CDM 0430 RC 97018 HCPCS inpatient 201 130.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 121.71 60.55 999999999 121.71 194.97 percent of total billed charges Application of hot wax bath 2573551_1 CDM 0430 RC 97018 HCPCS inpatient 201 130.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 121.71 194.97 Application of hot wax bath 2573551_1 CDM 0430 RC 97018 HCPCS inpatient 201 130.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 121.71 194.97 Application of hot wax bath 2573551_1 CDM 0430 RC 97018 HCPCS inpatient 201 130.65 ANTHEM HMO ANTHEM HMO 999999999 121.71 194.97 Application of hot wax bath 2573551_1 CDM 0430 RC 97018 HCPCS inpatient 201 130.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 135.88 67.6 999999999 121.71 194.97 percent of total billed charges Application of hot wax bath 2573551_1 CDM 0430 RC 97018 HCPCS inpatient 201 130.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 121.71 194.97 Application of hot wax bath 2573551_1 CDM 0430 RC 97018 HCPCS inpatient 201 130.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 121.71 194.97 "Application of ultrasound, each 15 minutes" 2573552_1 CDM 0430 RC 97035 HCPCS inpatient 196 127.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 127.4 65 999999999 118.68 190.12 percent of total billed charges "Application of ultrasound, each 15 minutes" 2573552_1 CDM 0430 RC 97035 HCPCS inpatient 196 127.4 AETNA AETNA 154.84 79 999999999 118.68 190.12 percent of total billed charges "Application of ultrasound, each 15 minutes" 2573552_1 CDM 0430 RC 97035 HCPCS inpatient 196 127.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 135.24 69 999999999 118.68 190.12 percent of total billed charges "Application of ultrasound, each 15 minutes" 2573552_1 CDM 0430 RC 97035 HCPCS inpatient 196 127.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 190.12 97 999999999 118.68 190.12 percent of total billed charges "Application of ultrasound, each 15 minutes" 2573552_1 CDM 0430 RC 97035 HCPCS inpatient 196 127.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 152.88 78 999999999 118.68 190.12 percent of total billed charges "Application of ultrasound, each 15 minutes" 2573552_1 CDM 0430 RC 97035 HCPCS inpatient 196 127.4 UMR - ALL PLANS UMR - ALL PLANS 137.2 70 999999999 118.68 190.12 percent of total billed charges "Application of ultrasound, each 15 minutes" 2573552_1 CDM 0430 RC 97035 HCPCS inpatient 196 127.4 SIHO - ALL PLANS SIHO - ALL PLANS 176.4 90 999999999 118.68 190.12 percent of total billed charges "Application of ultrasound, each 15 minutes" 2573552_1 CDM 0430 RC 97035 HCPCS inpatient 196 127.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 118.68 60.55 999999999 118.68 190.12 percent of total billed charges "Application of ultrasound, each 15 minutes" 2573552_1 CDM 0430 RC 97035 HCPCS inpatient 196 127.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 118.68 190.12 "Application of ultrasound, each 15 minutes" 2573552_1 CDM 0430 RC 97035 HCPCS inpatient 196 127.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 118.68 190.12 "Application of ultrasound, each 15 minutes" 2573552_1 CDM 0430 RC 97035 HCPCS inpatient 196 127.4 ANTHEM HMO ANTHEM HMO 999999999 118.68 190.12 "Application of ultrasound, each 15 minutes" 2573552_1 CDM 0430 RC 97035 HCPCS inpatient 196 127.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 132.5 67.6 999999999 118.68 190.12 percent of total billed charges "Application of ultrasound, each 15 minutes" 2573552_1 CDM 0430 RC 97035 HCPCS inpatient 196 127.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 118.68 190.12 "Application of ultrasound, each 15 minutes" 2573552_1 CDM 0430 RC 97035 HCPCS inpatient 196 127.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 118.68 190.12 "Strapping, Unna boot" 2573952_1 CDM 0420 RC 29580 HCPCS inpatient 350 227.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 227.5 65 999999999 211.93 339.5 percent of total billed charges "Strapping, Unna boot" 2573952_1 CDM 0420 RC 29580 HCPCS inpatient 350 227.5 AETNA AETNA 276.5 79 999999999 211.93 339.5 percent of total billed charges "Strapping, Unna boot" 2573952_1 CDM 0420 RC 29580 HCPCS inpatient 350 227.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 241.5 69 999999999 211.93 339.5 percent of total billed charges "Strapping, Unna boot" 2573952_1 CDM 0420 RC 29580 HCPCS inpatient 350 227.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 339.5 97 999999999 211.93 339.5 percent of total billed charges "Strapping, Unna boot" 2573952_1 CDM 0420 RC 29580 HCPCS inpatient 350 227.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 273 78 999999999 211.93 339.5 percent of total billed charges "Strapping, Unna boot" 2573952_1 CDM 0420 RC 29580 HCPCS inpatient 350 227.5 UMR - ALL PLANS UMR - ALL PLANS 245 70 999999999 211.93 339.5 percent of total billed charges "Strapping, Unna boot" 2573952_1 CDM 0420 RC 29580 HCPCS inpatient 350 227.5 SIHO - ALL PLANS SIHO - ALL PLANS 315 90 999999999 211.93 339.5 percent of total billed charges "Strapping, Unna boot" 2573952_1 CDM 0420 RC 29580 HCPCS inpatient 350 227.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 211.93 60.55 999999999 211.93 339.5 percent of total billed charges "Strapping, Unna boot" 2573952_1 CDM 0420 RC 29580 HCPCS inpatient 350 227.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 211.93 339.5 "Strapping, Unna boot" 2573952_1 CDM 0420 RC 29580 HCPCS inpatient 350 227.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 211.93 339.5 "Strapping, Unna boot" 2573952_1 CDM 0420 RC 29580 HCPCS inpatient 350 227.5 ANTHEM HMO ANTHEM HMO 999999999 211.93 339.5 "Strapping, Unna boot" 2573952_1 CDM 0420 RC 29580 HCPCS inpatient 350 227.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 236.6 67.6 999999999 211.93 339.5 percent of total billed charges "Strapping, Unna boot" 2573952_1 CDM 0420 RC 29580 HCPCS inpatient 350 227.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 211.93 339.5 "Strapping, Unna boot" 2573952_1 CDM 0420 RC 29580 HCPCS inpatient 350 227.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 211.93 339.5 Application of whirlpool therapy 2573954_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 2573954_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 2573954_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 2573954_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 2573954_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 2573954_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 2573954_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 2573954_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 2573954_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 Application of whirlpool therapy 2573954_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 Application of whirlpool therapy 2573954_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 Application of whirlpool therapy 2573954_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 2573954_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 Application of whirlpool therapy 2573954_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574031_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574031_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574031_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574031_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574031_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574031_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574031_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574031_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574031_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574031_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574031_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574031_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574031_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574031_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574033_1 CDM 0430 RC 97760 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574033_1 CDM 0430 RC 97760 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574033_1 CDM 0430 RC 97760 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574033_1 CDM 0430 RC 97760 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574033_1 CDM 0430 RC 97760 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574033_1 CDM 0430 RC 97760 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574033_1 CDM 0430 RC 97760 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574033_1 CDM 0430 RC 97760 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574033_1 CDM 0430 RC 97760 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574033_1 CDM 0430 RC 97760 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574033_1 CDM 0430 RC 97760 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574033_1 CDM 0430 RC 97760 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574033_1 CDM 0430 RC 97760 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 2574033_1 CDM 0430 RC 97760 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 "Therapy procedure using massage, each 15 minutes" 2574137_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 2574137_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 2574137_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 2574137_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 2574137_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 2574137_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 2574137_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 2574137_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 2574137_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 2574137_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 2574137_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 2574137_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 2574137_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 2574137_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 Application of hot wax bath 2574141_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.95 65 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 2574141_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 AETNA AETNA 144.57 79 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 2574141_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.27 69 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 2574141_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.51 97 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 2574141_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 142.74 78 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 2574141_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 UMR - ALL PLANS UMR - ALL PLANS 128.1 70 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 2574141_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 SIHO - ALL PLANS SIHO - ALL PLANS 164.7 90 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 2574141_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.81 60.55 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 2574141_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.81 177.51 Application of hot wax bath 2574141_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.81 177.51 Application of hot wax bath 2574141_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 ANTHEM HMO ANTHEM HMO 999999999 110.81 177.51 Application of hot wax bath 2574141_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.71 67.6 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 2574141_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.81 177.51 Application of hot wax bath 2574141_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.81 177.51 Application of mechanical traction 2574174_1 CDM 0420 RC 97012 HCPCS inpatient 199 129.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 129.35 65 999999999 120.49 193.03 percent of total billed charges Application of mechanical traction 2574174_1 CDM 0420 RC 97012 HCPCS inpatient 199 129.35 AETNA AETNA 157.21 79 999999999 120.49 193.03 percent of total billed charges Application of mechanical traction 2574174_1 CDM 0420 RC 97012 HCPCS inpatient 199 129.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 137.31 69 999999999 120.49 193.03 percent of total billed charges Application of mechanical traction 2574174_1 CDM 0420 RC 97012 HCPCS inpatient 199 129.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 193.03 97 999999999 120.49 193.03 percent of total billed charges Application of mechanical traction 2574174_1 CDM 0420 RC 97012 HCPCS inpatient 199 129.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 155.22 78 999999999 120.49 193.03 percent of total billed charges Application of mechanical traction 2574174_1 CDM 0420 RC 97012 HCPCS inpatient 199 129.35 UMR - ALL PLANS UMR - ALL PLANS 139.3 70 999999999 120.49 193.03 percent of total billed charges Application of mechanical traction 2574174_1 CDM 0420 RC 97012 HCPCS inpatient 199 129.35 SIHO - ALL PLANS SIHO - ALL PLANS 179.1 90 999999999 120.49 193.03 percent of total billed charges Application of mechanical traction 2574174_1 CDM 0420 RC 97012 HCPCS inpatient 199 129.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 120.49 60.55 999999999 120.49 193.03 percent of total billed charges Application of mechanical traction 2574174_1 CDM 0420 RC 97012 HCPCS inpatient 199 129.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 120.49 193.03 Application of mechanical traction 2574174_1 CDM 0420 RC 97012 HCPCS inpatient 199 129.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 120.49 193.03 Application of mechanical traction 2574174_1 CDM 0420 RC 97012 HCPCS inpatient 199 129.35 ANTHEM HMO ANTHEM HMO 999999999 120.49 193.03 Application of mechanical traction 2574174_1 CDM 0420 RC 97012 HCPCS inpatient 199 129.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 134.52 67.6 999999999 120.49 193.03 percent of total billed charges Application of mechanical traction 2574174_1 CDM 0420 RC 97012 HCPCS inpatient 199 129.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 120.49 193.03 Application of mechanical traction 2574174_1 CDM 0420 RC 97012 HCPCS inpatient 199 129.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 120.49 193.03 "Therapy procedure for walking training, each 15 minutes" 2574888_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 2574888_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 2574888_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 2574888_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 2574888_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 2574888_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 2574888_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 2574888_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 2574888_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 "Therapy procedure for walking training, each 15 minutes" 2574888_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 "Therapy procedure for walking training, each 15 minutes" 2574888_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 "Therapy procedure for walking training, each 15 minutes" 2574888_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 2574888_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 "Therapy procedure for walking training, each 15 minutes" 2574888_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 Therapy procedure using functional activities 2574922_1 CDM 0430 RC 97530 HCPCS inpatient 169 109.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.85 65 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 2574922_1 CDM 0430 RC 97530 HCPCS inpatient 169 109.85 AETNA AETNA 133.51 79 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 2574922_1 CDM 0430 RC 97530 HCPCS inpatient 169 109.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 116.61 69 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 2574922_1 CDM 0430 RC 97530 HCPCS inpatient 169 109.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 163.93 97 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 2574922_1 CDM 0430 RC 97530 HCPCS inpatient 169 109.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.82 78 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 2574922_1 CDM 0430 RC 97530 HCPCS inpatient 169 109.85 UMR - ALL PLANS UMR - ALL PLANS 118.3 70 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 2574922_1 CDM 0430 RC 97530 HCPCS inpatient 169 109.85 SIHO - ALL PLANS SIHO - ALL PLANS 152.1 90 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 2574922_1 CDM 0430 RC 97530 HCPCS inpatient 169 109.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.33 60.55 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 2574922_1 CDM 0430 RC 97530 HCPCS inpatient 169 109.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.33 163.93 Therapy procedure using functional activities 2574922_1 CDM 0430 RC 97530 HCPCS inpatient 169 109.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.33 163.93 Therapy procedure using functional activities 2574922_1 CDM 0430 RC 97530 HCPCS inpatient 169 109.85 ANTHEM HMO ANTHEM HMO 999999999 102.33 163.93 Therapy procedure using functional activities 2574922_1 CDM 0430 RC 97530 HCPCS inpatient 169 109.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.24 67.6 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 2574922_1 CDM 0430 RC 97530 HCPCS inpatient 169 109.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.33 163.93 Therapy procedure using functional activities 2574922_1 CDM 0430 RC 97530 HCPCS inpatient 169 109.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.33 163.93 Application of blood vessel compression device 2575085_1 CDM 0420 RC 97016 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 2575085_1 CDM 0420 RC 97016 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 2575085_1 CDM 0420 RC 97016 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 2575085_1 CDM 0420 RC 97016 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 2575085_1 CDM 0420 RC 97016 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 2575085_1 CDM 0420 RC 97016 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 2575085_1 CDM 0420 RC 97016 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 2575085_1 CDM 0420 RC 97016 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 2575085_1 CDM 0420 RC 97016 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 Application of blood vessel compression device 2575085_1 CDM 0420 RC 97016 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 Application of blood vessel compression device 2575085_1 CDM 0420 RC 97016 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 Application of blood vessel compression device 2575085_1 CDM 0420 RC 97016 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 2575085_1 CDM 0420 RC 97016 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 Application of blood vessel compression device 2575085_1 CDM 0420 RC 97016 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 "Test to assess the loss of the ability to speak, write, and understand language" 2575143_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 251.55 65 999999999 234.33 375.39 percent of total billed charges "Test to assess the loss of the ability to speak, write, and understand language" 2575143_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 AETNA AETNA 305.73 79 999999999 234.33 375.39 percent of total billed charges "Test to assess the loss of the ability to speak, write, and understand language" 2575143_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.03 69 999999999 234.33 375.39 percent of total billed charges "Test to assess the loss of the ability to speak, write, and understand language" 2575143_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 375.39 97 999999999 234.33 375.39 percent of total billed charges "Test to assess the loss of the ability to speak, write, and understand language" 2575143_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.86 78 999999999 234.33 375.39 percent of total billed charges "Test to assess the loss of the ability to speak, write, and understand language" 2575143_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 UMR - ALL PLANS UMR - ALL PLANS 270.9 70 999999999 234.33 375.39 percent of total billed charges "Test to assess the loss of the ability to speak, write, and understand language" 2575143_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 SIHO - ALL PLANS SIHO - ALL PLANS 348.3 90 999999999 234.33 375.39 percent of total billed charges "Test to assess the loss of the ability to speak, write, and understand language" 2575143_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.33 60.55 999999999 234.33 375.39 percent of total billed charges "Test to assess the loss of the ability to speak, write, and understand language" 2575143_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.33 375.39 "Test to assess the loss of the ability to speak, write, and understand language" 2575143_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.33 375.39 "Test to assess the loss of the ability to speak, write, and understand language" 2575143_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 ANTHEM HMO ANTHEM HMO 999999999 234.33 375.39 "Test to assess the loss of the ability to speak, write, and understand language" 2575143_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 261.61 67.6 999999999 234.33 375.39 percent of total billed charges "Test to assess the loss of the ability to speak, write, and understand language" 2575143_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.33 375.39 "Test to assess the loss of the ability to speak, write, and understand language" 2575143_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.33 375.39 "Evaluation for wheelchair, each 15 minutes" 2575559_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 2575559_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 2575559_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 2575559_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 2575559_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 2575559_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 2575559_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 2575559_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 2575559_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 2575559_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 2575559_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 2575559_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 2575559_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 2575559_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 "Removal of tissue from wound, 20.0 sq cm or less" 2575658_1 CDM 0420 RC 97597 HCPCS inpatient 456 296.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 296.4 65 999999999 276.11 442.32 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 2575658_1 CDM 0420 RC 97597 HCPCS inpatient 456 296.4 AETNA AETNA 360.24 79 999999999 276.11 442.32 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 2575658_1 CDM 0420 RC 97597 HCPCS inpatient 456 296.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 314.64 69 999999999 276.11 442.32 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 2575658_1 CDM 0420 RC 97597 HCPCS inpatient 456 296.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 442.32 97 999999999 276.11 442.32 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 2575658_1 CDM 0420 RC 97597 HCPCS inpatient 456 296.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 355.68 78 999999999 276.11 442.32 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 2575658_1 CDM 0420 RC 97597 HCPCS inpatient 456 296.4 UMR - ALL PLANS UMR - ALL PLANS 319.2 70 999999999 276.11 442.32 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 2575658_1 CDM 0420 RC 97597 HCPCS inpatient 456 296.4 SIHO - ALL PLANS SIHO - ALL PLANS 410.4 90 999999999 276.11 442.32 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 2575658_1 CDM 0420 RC 97597 HCPCS inpatient 456 296.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 276.11 60.55 999999999 276.11 442.32 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 2575658_1 CDM 0420 RC 97597 HCPCS inpatient 456 296.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 276.11 442.32 "Removal of tissue from wound, 20.0 sq cm or less" 2575658_1 CDM 0420 RC 97597 HCPCS inpatient 456 296.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 276.11 442.32 "Removal of tissue from wound, 20.0 sq cm or less" 2575658_1 CDM 0420 RC 97597 HCPCS inpatient 456 296.4 ANTHEM HMO ANTHEM HMO 999999999 276.11 442.32 "Removal of tissue from wound, 20.0 sq cm or less" 2575658_1 CDM 0420 RC 97597 HCPCS inpatient 456 296.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 308.26 67.6 999999999 276.11 442.32 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 2575658_1 CDM 0420 RC 97597 HCPCS inpatient 456 296.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 276.11 442.32 "Removal of tissue from wound, 20.0 sq cm or less" 2575658_1 CDM 0420 RC 97597 HCPCS inpatient 456 296.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 276.11 442.32 "Evaluation of speech continuity, smoothness, rate, and effort" 25864904_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 218.4 65 999999999 203.45 325.92 percent of total billed charges "Evaluation of speech continuity, smoothness, rate, and effort" 25864904_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 AETNA AETNA 265.44 79 999999999 203.45 325.92 percent of total billed charges "Evaluation of speech continuity, smoothness, rate, and effort" 25864904_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 231.84 69 999999999 203.45 325.92 percent of total billed charges "Evaluation of speech continuity, smoothness, rate, and effort" 25864904_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 325.92 97 999999999 203.45 325.92 percent of total billed charges "Evaluation of speech continuity, smoothness, rate, and effort" 25864904_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 262.08 78 999999999 203.45 325.92 percent of total billed charges "Evaluation of speech continuity, smoothness, rate, and effort" 25864904_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 UMR - ALL PLANS UMR - ALL PLANS 235.2 70 999999999 203.45 325.92 percent of total billed charges "Evaluation of speech continuity, smoothness, rate, and effort" 25864904_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 SIHO - ALL PLANS SIHO - ALL PLANS 302.4 90 999999999 203.45 325.92 percent of total billed charges "Evaluation of speech continuity, smoothness, rate, and effort" 25864904_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 203.45 60.55 999999999 203.45 325.92 percent of total billed charges "Evaluation of speech continuity, smoothness, rate, and effort" 25864904_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 203.45 325.92 "Evaluation of speech continuity, smoothness, rate, and effort" 25864904_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 203.45 325.92 "Evaluation of speech continuity, smoothness, rate, and effort" 25864904_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 ANTHEM HMO ANTHEM HMO 999999999 203.45 325.92 "Evaluation of speech continuity, smoothness, rate, and effort" 25864904_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 227.14 67.6 999999999 203.45 325.92 percent of total billed charges "Evaluation of speech continuity, smoothness, rate, and effort" 25864904_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 203.45 325.92 "Evaluation of speech continuity, smoothness, rate, and effort" 25864904_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 203.45 325.92 Evaluation of speech sound production 25864906_1 CDM 0440 RC 92522 HCPCS inpatient 301 195.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 195.65 65 999999999 182.26 291.97 percent of total billed charges Evaluation of speech sound production 25864906_1 CDM 0440 RC 92522 HCPCS inpatient 301 195.65 AETNA AETNA 237.79 79 999999999 182.26 291.97 percent of total billed charges Evaluation of speech sound production 25864906_1 CDM 0440 RC 92522 HCPCS inpatient 301 195.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 207.69 69 999999999 182.26 291.97 percent of total billed charges Evaluation of speech sound production 25864906_1 CDM 0440 RC 92522 HCPCS inpatient 301 195.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291.97 97 999999999 182.26 291.97 percent of total billed charges Evaluation of speech sound production 25864906_1 CDM 0440 RC 92522 HCPCS inpatient 301 195.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 234.78 78 999999999 182.26 291.97 percent of total billed charges Evaluation of speech sound production 25864906_1 CDM 0440 RC 92522 HCPCS inpatient 301 195.65 UMR - ALL PLANS UMR - ALL PLANS 210.7 70 999999999 182.26 291.97 percent of total billed charges Evaluation of speech sound production 25864906_1 CDM 0440 RC 92522 HCPCS inpatient 301 195.65 SIHO - ALL PLANS SIHO - ALL PLANS 270.9 90 999999999 182.26 291.97 percent of total billed charges Evaluation of speech sound production 25864906_1 CDM 0440 RC 92522 HCPCS inpatient 301 195.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.26 60.55 999999999 182.26 291.97 percent of total billed charges Evaluation of speech sound production 25864906_1 CDM 0440 RC 92522 HCPCS inpatient 301 195.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.26 291.97 Evaluation of speech sound production 25864906_1 CDM 0440 RC 92522 HCPCS inpatient 301 195.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.26 291.97 Evaluation of speech sound production 25864906_1 CDM 0440 RC 92522 HCPCS inpatient 301 195.65 ANTHEM HMO ANTHEM HMO 999999999 182.26 291.97 Evaluation of speech sound production 25864906_1 CDM 0440 RC 92522 HCPCS inpatient 301 195.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 203.48 67.6 999999999 182.26 291.97 percent of total billed charges Evaluation of speech sound production 25864906_1 CDM 0440 RC 92522 HCPCS inpatient 301 195.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.26 291.97 Evaluation of speech sound production 25864906_1 CDM 0440 RC 92522 HCPCS inpatient 301 195.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.26 291.97 Evaluation of speech sound production with evaluation of language comprehension and expression 25864908_1 CDM 0440 RC 92523 HCPCS inpatient 529 343.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 343.85 65 999999999 320.31 513.13 percent of total billed charges Evaluation of speech sound production with evaluation of language comprehension and expression 25864908_1 CDM 0440 RC 92523 HCPCS inpatient 529 343.85 AETNA AETNA 417.91 79 999999999 320.31 513.13 percent of total billed charges Evaluation of speech sound production with evaluation of language comprehension and expression 25864908_1 CDM 0440 RC 92523 HCPCS inpatient 529 343.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 365.01 69 999999999 320.31 513.13 percent of total billed charges Evaluation of speech sound production with evaluation of language comprehension and expression 25864908_1 CDM 0440 RC 92523 HCPCS inpatient 529 343.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 513.13 97 999999999 320.31 513.13 percent of total billed charges Evaluation of speech sound production with evaluation of language comprehension and expression 25864908_1 CDM 0440 RC 92523 HCPCS inpatient 529 343.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 412.62 78 999999999 320.31 513.13 percent of total billed charges Evaluation of speech sound production with evaluation of language comprehension and expression 25864908_1 CDM 0440 RC 92523 HCPCS inpatient 529 343.85 UMR - ALL PLANS UMR - ALL PLANS 370.3 70 999999999 320.31 513.13 percent of total billed charges Evaluation of speech sound production with evaluation of language comprehension and expression 25864908_1 CDM 0440 RC 92523 HCPCS inpatient 529 343.85 SIHO - ALL PLANS SIHO - ALL PLANS 476.1 90 999999999 320.31 513.13 percent of total billed charges Evaluation of speech sound production with evaluation of language comprehension and expression 25864908_1 CDM 0440 RC 92523 HCPCS inpatient 529 343.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 320.31 60.55 999999999 320.31 513.13 percent of total billed charges Evaluation of speech sound production with evaluation of language comprehension and expression 25864908_1 CDM 0440 RC 92523 HCPCS inpatient 529 343.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 320.31 513.13 Evaluation of speech sound production with evaluation of language comprehension and expression 25864908_1 CDM 0440 RC 92523 HCPCS inpatient 529 343.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 320.31 513.13 Evaluation of speech sound production with evaluation of language comprehension and expression 25864908_1 CDM 0440 RC 92523 HCPCS inpatient 529 343.85 ANTHEM HMO ANTHEM HMO 999999999 320.31 513.13 Evaluation of speech sound production with evaluation of language comprehension and expression 25864908_1 CDM 0440 RC 92523 HCPCS inpatient 529 343.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 357.6 67.6 999999999 320.31 513.13 percent of total billed charges Evaluation of speech sound production with evaluation of language comprehension and expression 25864908_1 CDM 0440 RC 92523 HCPCS inpatient 529 343.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 320.31 513.13 Evaluation of speech sound production with evaluation of language comprehension and expression 25864908_1 CDM 0440 RC 92523 HCPCS inpatient 529 343.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 320.31 513.13 Analysis of voice and resonance production 25864911_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 184.6 65 999999999 171.96 275.48 percent of total billed charges Analysis of voice and resonance production 25864911_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 AETNA AETNA 224.36 79 999999999 171.96 275.48 percent of total billed charges Analysis of voice and resonance production 25864911_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 195.96 69 999999999 171.96 275.48 percent of total billed charges Analysis of voice and resonance production 25864911_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 275.48 97 999999999 171.96 275.48 percent of total billed charges Analysis of voice and resonance production 25864911_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 221.52 78 999999999 171.96 275.48 percent of total billed charges Analysis of voice and resonance production 25864911_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 UMR - ALL PLANS UMR - ALL PLANS 198.8 70 999999999 171.96 275.48 percent of total billed charges Analysis of voice and resonance production 25864911_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 SIHO - ALL PLANS SIHO - ALL PLANS 255.6 90 999999999 171.96 275.48 percent of total billed charges Analysis of voice and resonance production 25864911_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 171.96 60.55 999999999 171.96 275.48 percent of total billed charges Analysis of voice and resonance production 25864911_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 171.96 275.48 Analysis of voice and resonance production 25864911_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 171.96 275.48 Analysis of voice and resonance production 25864911_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 ANTHEM HMO ANTHEM HMO 999999999 171.96 275.48 Analysis of voice and resonance production 25864911_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 191.98 67.6 999999999 171.96 275.48 percent of total billed charges Analysis of voice and resonance production 25864911_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 171.96 275.48 Analysis of voice and resonance production 25864911_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 171.96 275.48 "Evaluation of speech continuity, smoothness, rate, and effort" 26222695_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 218.4 65 999999999 203.45 325.92 percent of total billed charges "Evaluation of speech continuity, smoothness, rate, and effort" 26222695_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 AETNA AETNA 265.44 79 999999999 203.45 325.92 percent of total billed charges "Evaluation of speech continuity, smoothness, rate, and effort" 26222695_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 231.84 69 999999999 203.45 325.92 percent of total billed charges "Evaluation of speech continuity, smoothness, rate, and effort" 26222695_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 325.92 97 999999999 203.45 325.92 percent of total billed charges "Evaluation of speech continuity, smoothness, rate, and effort" 26222695_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 262.08 78 999999999 203.45 325.92 percent of total billed charges "Evaluation of speech continuity, smoothness, rate, and effort" 26222695_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 UMR - ALL PLANS UMR - ALL PLANS 235.2 70 999999999 203.45 325.92 percent of total billed charges "Evaluation of speech continuity, smoothness, rate, and effort" 26222695_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 SIHO - ALL PLANS SIHO - ALL PLANS 302.4 90 999999999 203.45 325.92 percent of total billed charges "Evaluation of speech continuity, smoothness, rate, and effort" 26222695_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 203.45 60.55 999999999 203.45 325.92 percent of total billed charges "Evaluation of speech continuity, smoothness, rate, and effort" 26222695_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 203.45 325.92 "Evaluation of speech continuity, smoothness, rate, and effort" 26222695_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 203.45 325.92 "Evaluation of speech continuity, smoothness, rate, and effort" 26222695_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 ANTHEM HMO ANTHEM HMO 999999999 203.45 325.92 "Evaluation of speech continuity, smoothness, rate, and effort" 26222695_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 227.14 67.6 999999999 203.45 325.92 percent of total billed charges "Evaluation of speech continuity, smoothness, rate, and effort" 26222695_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 203.45 325.92 "Evaluation of speech continuity, smoothness, rate, and effort" 26222695_1 CDM 0440 RC 92521 HCPCS inpatient 336 218.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 203.45 325.92 Evaluation of speech sound production 26222697_1 CDM 0440 RC 92522 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges Evaluation of speech sound production 26222697_1 CDM 0440 RC 92522 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges Evaluation of speech sound production 26222697_1 CDM 0440 RC 92522 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges Evaluation of speech sound production 26222697_1 CDM 0440 RC 92522 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges Evaluation of speech sound production 26222697_1 CDM 0440 RC 92522 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges Evaluation of speech sound production 26222697_1 CDM 0440 RC 92522 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges Evaluation of speech sound production 26222697_1 CDM 0440 RC 92522 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges Evaluation of speech sound production 26222697_1 CDM 0440 RC 92522 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges Evaluation of speech sound production 26222697_1 CDM 0440 RC 92522 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 Evaluation of speech sound production 26222697_1 CDM 0440 RC 92522 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 Evaluation of speech sound production 26222697_1 CDM 0440 RC 92522 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 Evaluation of speech sound production 26222697_1 CDM 0440 RC 92522 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges Evaluation of speech sound production 26222697_1 CDM 0440 RC 92522 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 Evaluation of speech sound production 26222697_1 CDM 0440 RC 92522 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 Evaluation of speech sound production with evaluation of language comprehension and expression 26222699_1 CDM 0440 RC 92523 HCPCS inpatient 566 367.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 367.9 65 999999999 342.71 549.02 percent of total billed charges Evaluation of speech sound production with evaluation of language comprehension and expression 26222699_1 CDM 0440 RC 92523 HCPCS inpatient 566 367.9 AETNA AETNA 447.14 79 999999999 342.71 549.02 percent of total billed charges Evaluation of speech sound production with evaluation of language comprehension and expression 26222699_1 CDM 0440 RC 92523 HCPCS inpatient 566 367.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 390.54 69 999999999 342.71 549.02 percent of total billed charges Evaluation of speech sound production with evaluation of language comprehension and expression 26222699_1 CDM 0440 RC 92523 HCPCS inpatient 566 367.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 549.02 97 999999999 342.71 549.02 percent of total billed charges Evaluation of speech sound production with evaluation of language comprehension and expression 26222699_1 CDM 0440 RC 92523 HCPCS inpatient 566 367.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 441.48 78 999999999 342.71 549.02 percent of total billed charges Evaluation of speech sound production with evaluation of language comprehension and expression 26222699_1 CDM 0440 RC 92523 HCPCS inpatient 566 367.9 UMR - ALL PLANS UMR - ALL PLANS 396.2 70 999999999 342.71 549.02 percent of total billed charges Evaluation of speech sound production with evaluation of language comprehension and expression 26222699_1 CDM 0440 RC 92523 HCPCS inpatient 566 367.9 SIHO - ALL PLANS SIHO - ALL PLANS 509.4 90 999999999 342.71 549.02 percent of total billed charges Evaluation of speech sound production with evaluation of language comprehension and expression 26222699_1 CDM 0440 RC 92523 HCPCS inpatient 566 367.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 342.71 60.55 999999999 342.71 549.02 percent of total billed charges Evaluation of speech sound production with evaluation of language comprehension and expression 26222699_1 CDM 0440 RC 92523 HCPCS inpatient 566 367.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 342.71 549.02 Evaluation of speech sound production with evaluation of language comprehension and expression 26222699_1 CDM 0440 RC 92523 HCPCS inpatient 566 367.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 342.71 549.02 Evaluation of speech sound production with evaluation of language comprehension and expression 26222699_1 CDM 0440 RC 92523 HCPCS inpatient 566 367.9 ANTHEM HMO ANTHEM HMO 999999999 342.71 549.02 Evaluation of speech sound production with evaluation of language comprehension and expression 26222699_1 CDM 0440 RC 92523 HCPCS inpatient 566 367.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 382.62 67.6 999999999 342.71 549.02 percent of total billed charges Evaluation of speech sound production with evaluation of language comprehension and expression 26222699_1 CDM 0440 RC 92523 HCPCS inpatient 566 367.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 342.71 549.02 Evaluation of speech sound production with evaluation of language comprehension and expression 26222699_1 CDM 0440 RC 92523 HCPCS inpatient 566 367.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 342.71 549.02 Analysis of voice and resonance production 26222701_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 184.6 65 999999999 171.96 275.48 percent of total billed charges Analysis of voice and resonance production 26222701_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 AETNA AETNA 224.36 79 999999999 171.96 275.48 percent of total billed charges Analysis of voice and resonance production 26222701_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 195.96 69 999999999 171.96 275.48 percent of total billed charges Analysis of voice and resonance production 26222701_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 275.48 97 999999999 171.96 275.48 percent of total billed charges Analysis of voice and resonance production 26222701_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 221.52 78 999999999 171.96 275.48 percent of total billed charges Analysis of voice and resonance production 26222701_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 UMR - ALL PLANS UMR - ALL PLANS 198.8 70 999999999 171.96 275.48 percent of total billed charges Analysis of voice and resonance production 26222701_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 SIHO - ALL PLANS SIHO - ALL PLANS 255.6 90 999999999 171.96 275.48 percent of total billed charges Analysis of voice and resonance production 26222701_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 171.96 60.55 999999999 171.96 275.48 percent of total billed charges Analysis of voice and resonance production 26222701_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 171.96 275.48 Analysis of voice and resonance production 26222701_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 171.96 275.48 Analysis of voice and resonance production 26222701_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 ANTHEM HMO ANTHEM HMO 999999999 171.96 275.48 Analysis of voice and resonance production 26222701_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 191.98 67.6 999999999 171.96 275.48 percent of total billed charges Analysis of voice and resonance production 26222701_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 171.96 275.48 Analysis of voice and resonance production 26222701_1 CDM 0440 RC 92524 HCPCS inpatient 284 184.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 171.96 275.48 "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258645_1 CDM 0361 RC 19081 HCPCS inpatient 8895 5781.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 5781.75 65 999999999 5385.92 8628.15 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258645_1 CDM 0361 RC 19081 HCPCS inpatient 8895 5781.75 AETNA AETNA 7027.05 79 999999999 5385.92 8628.15 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258645_1 CDM 0361 RC 19081 HCPCS inpatient 8895 5781.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 6137.55 69 999999999 5385.92 8628.15 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258645_1 CDM 0361 RC 19081 HCPCS inpatient 8895 5781.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8628.15 97 999999999 5385.92 8628.15 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258645_1 CDM 0361 RC 19081 HCPCS inpatient 8895 5781.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 6938.1 78 999999999 5385.92 8628.15 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258645_1 CDM 0361 RC 19081 HCPCS inpatient 8895 5781.75 UMR - ALL PLANS UMR - ALL PLANS 6226.5 70 999999999 5385.92 8628.15 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258645_1 CDM 0361 RC 19081 HCPCS inpatient 8895 5781.75 SIHO - ALL PLANS SIHO - ALL PLANS 8005.5 90 999999999 5385.92 8628.15 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258645_1 CDM 0361 RC 19081 HCPCS inpatient 8895 5781.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5385.92 60.55 999999999 5385.92 8628.15 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258645_1 CDM 0361 RC 19081 HCPCS inpatient 8895 5781.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5385.92 8628.15 "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258645_1 CDM 0361 RC 19081 HCPCS inpatient 8895 5781.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5385.92 8628.15 "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258645_1 CDM 0361 RC 19081 HCPCS inpatient 8895 5781.75 ANTHEM HMO ANTHEM HMO 999999999 5385.92 8628.15 "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258645_1 CDM 0361 RC 19081 HCPCS inpatient 8895 5781.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 6013.02 67.6 999999999 5385.92 8628.15 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258645_1 CDM 0361 RC 19081 HCPCS inpatient 8895 5781.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5385.92 8628.15 "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258645_1 CDM 0361 RC 19081 HCPCS inpatient 8895 5781.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 5385.92 8628.15 "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258648_1 CDM 0361 RC 19081 HCPCS inpatient 8086 5255.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 5255.9 65 999999999 4896.07 7843.42 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258648_1 CDM 0361 RC 19081 HCPCS inpatient 8086 5255.9 AETNA AETNA 6387.94 79 999999999 4896.07 7843.42 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258648_1 CDM 0361 RC 19081 HCPCS inpatient 8086 5255.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 5579.34 69 999999999 4896.07 7843.42 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258648_1 CDM 0361 RC 19081 HCPCS inpatient 8086 5255.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7843.42 97 999999999 4896.07 7843.42 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258648_1 CDM 0361 RC 19081 HCPCS inpatient 8086 5255.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 6307.08 78 999999999 4896.07 7843.42 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258648_1 CDM 0361 RC 19081 HCPCS inpatient 8086 5255.9 UMR - ALL PLANS UMR - ALL PLANS 5660.2 70 999999999 4896.07 7843.42 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258648_1 CDM 0361 RC 19081 HCPCS inpatient 8086 5255.9 SIHO - ALL PLANS SIHO - ALL PLANS 7277.4 90 999999999 4896.07 7843.42 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258648_1 CDM 0361 RC 19081 HCPCS inpatient 8086 5255.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4896.07 60.55 999999999 4896.07 7843.42 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258648_1 CDM 0361 RC 19081 HCPCS inpatient 8086 5255.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4896.07 7843.42 "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258648_1 CDM 0361 RC 19081 HCPCS inpatient 8086 5255.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4896.07 7843.42 "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258648_1 CDM 0361 RC 19081 HCPCS inpatient 8086 5255.9 ANTHEM HMO ANTHEM HMO 999999999 4896.07 7843.42 "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258648_1 CDM 0361 RC 19081 HCPCS inpatient 8086 5255.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 5466.14 67.6 999999999 4896.07 7843.42 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258648_1 CDM 0361 RC 19081 HCPCS inpatient 8086 5255.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4896.07 7843.42 "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 26258648_1 CDM 0361 RC 19081 HCPCS inpatient 8086 5255.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 4896.07 7843.42 ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 2638605_1 CDM 0110 RC inpatient 1855 1205.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1205.75 65 999999999 1123.2 1799.35 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 2638605_1 CDM 0110 RC inpatient 1855 1205.75 AETNA AETNA 1465.45 79 999999999 1123.2 1799.35 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 2638605_1 CDM 0110 RC inpatient 1855 1205.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1279.95 69 999999999 1123.2 1799.35 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 2638605_1 CDM 0110 RC inpatient 1855 1205.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1799.35 97 999999999 1123.2 1799.35 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 2638605_1 CDM 0110 RC inpatient 1855 1205.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1446.9 78 999999999 1123.2 1799.35 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 2638605_1 CDM 0110 RC inpatient 1855 1205.75 UMR - ALL PLANS UMR - ALL PLANS 1298.5 70 999999999 1123.2 1799.35 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 2638605_1 CDM 0110 RC inpatient 1855 1205.75 SIHO - ALL PLANS SIHO - ALL PLANS 1669.5 90 999999999 1123.2 1799.35 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 2638605_1 CDM 0110 RC inpatient 1855 1205.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1123.2 60.55 999999999 1123.2 1799.35 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 2638605_1 CDM 0110 RC inpatient 1855 1205.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1123.2 1799.35 ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 2638605_1 CDM 0110 RC inpatient 1855 1205.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1123.2 1799.35 ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 2638605_1 CDM 0110 RC inpatient 1855 1205.75 ANTHEM HMO ANTHEM HMO 999999999 1123.2 1799.35 ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 2638605_1 CDM 0110 RC inpatient 1855 1205.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1253.98 67.6 999999999 1123.2 1799.35 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 2638605_1 CDM 0110 RC inpatient 1855 1205.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1123.2 1799.35 ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 2638605_1 CDM 0110 RC inpatient 1855 1205.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1123.2 1799.35 Manual attempt to restore blood circulation and breathing 2764616_1 CDM 0450 RC 92950 HCPCS inpatient 1056 686.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 686.4 65 999999999 639.41 1024.32 percent of total billed charges Manual attempt to restore blood circulation and breathing 2764616_1 CDM 0450 RC 92950 HCPCS inpatient 1056 686.4 AETNA AETNA 834.24 79 999999999 639.41 1024.32 percent of total billed charges Manual attempt to restore blood circulation and breathing 2764616_1 CDM 0450 RC 92950 HCPCS inpatient 1056 686.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 728.64 69 999999999 639.41 1024.32 percent of total billed charges Manual attempt to restore blood circulation and breathing 2764616_1 CDM 0450 RC 92950 HCPCS inpatient 1056 686.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1024.32 97 999999999 639.41 1024.32 percent of total billed charges Manual attempt to restore blood circulation and breathing 2764616_1 CDM 0450 RC 92950 HCPCS inpatient 1056 686.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 823.68 78 999999999 639.41 1024.32 percent of total billed charges Manual attempt to restore blood circulation and breathing 2764616_1 CDM 0450 RC 92950 HCPCS inpatient 1056 686.4 UMR - ALL PLANS UMR - ALL PLANS 739.2 70 999999999 639.41 1024.32 percent of total billed charges Manual attempt to restore blood circulation and breathing 2764616_1 CDM 0450 RC 92950 HCPCS inpatient 1056 686.4 SIHO - ALL PLANS SIHO - ALL PLANS 950.4 90 999999999 639.41 1024.32 percent of total billed charges Manual attempt to restore blood circulation and breathing 2764616_1 CDM 0450 RC 92950 HCPCS inpatient 1056 686.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 639.41 60.55 999999999 639.41 1024.32 percent of total billed charges Manual attempt to restore blood circulation and breathing 2764616_1 CDM 0450 RC 92950 HCPCS inpatient 1056 686.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 639.41 1024.32 Manual attempt to restore blood circulation and breathing 2764616_1 CDM 0450 RC 92950 HCPCS inpatient 1056 686.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 639.41 1024.32 Manual attempt to restore blood circulation and breathing 2764616_1 CDM 0450 RC 92950 HCPCS inpatient 1056 686.4 ANTHEM HMO ANTHEM HMO 999999999 639.41 1024.32 Manual attempt to restore blood circulation and breathing 2764616_1 CDM 0450 RC 92950 HCPCS inpatient 1056 686.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 713.86 67.6 999999999 639.41 1024.32 percent of total billed charges Manual attempt to restore blood circulation and breathing 2764616_1 CDM 0450 RC 92950 HCPCS inpatient 1056 686.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 639.41 1024.32 Manual attempt to restore blood circulation and breathing 2764616_1 CDM 0450 RC 92950 HCPCS inpatient 1056 686.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 639.41 1024.32 Ultrasound measurement of bladder capacity after voiding 2764622_1 CDM 0450 RC 51798 HCPCS inpatient 123 79.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.95 65 999999999 74.48 119.31 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 2764622_1 CDM 0450 RC 51798 HCPCS inpatient 123 79.95 AETNA AETNA 97.17 79 999999999 74.48 119.31 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 2764622_1 CDM 0450 RC 51798 HCPCS inpatient 123 79.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.87 69 999999999 74.48 119.31 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 2764622_1 CDM 0450 RC 51798 HCPCS inpatient 123 79.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 119.31 97 999999999 74.48 119.31 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 2764622_1 CDM 0450 RC 51798 HCPCS inpatient 123 79.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.94 78 999999999 74.48 119.31 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 2764622_1 CDM 0450 RC 51798 HCPCS inpatient 123 79.95 UMR - ALL PLANS UMR - ALL PLANS 86.1 70 999999999 74.48 119.31 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 2764622_1 CDM 0450 RC 51798 HCPCS inpatient 123 79.95 SIHO - ALL PLANS SIHO - ALL PLANS 110.7 90 999999999 74.48 119.31 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 2764622_1 CDM 0450 RC 51798 HCPCS inpatient 123 79.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 74.48 60.55 999999999 74.48 119.31 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 2764622_1 CDM 0450 RC 51798 HCPCS inpatient 123 79.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 74.48 119.31 Ultrasound measurement of bladder capacity after voiding 2764622_1 CDM 0450 RC 51798 HCPCS inpatient 123 79.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 74.48 119.31 Ultrasound measurement of bladder capacity after voiding 2764622_1 CDM 0450 RC 51798 HCPCS inpatient 123 79.95 ANTHEM HMO ANTHEM HMO 999999999 74.48 119.31 Ultrasound measurement of bladder capacity after voiding 2764622_1 CDM 0450 RC 51798 HCPCS inpatient 123 79.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.15 67.6 999999999 74.48 119.31 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 2764622_1 CDM 0450 RC 51798 HCPCS inpatient 123 79.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 74.48 119.31 Ultrasound measurement of bladder capacity after voiding 2764622_1 CDM 0450 RC 51798 HCPCS inpatient 123 79.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 74.48 119.31 External shock to heart to regulate heart beat 2764624_1 CDM 0450 RC 92960 HCPCS inpatient 1187 771.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 771.55 65 999999999 718.73 1151.39 percent of total billed charges External shock to heart to regulate heart beat 2764624_1 CDM 0450 RC 92960 HCPCS inpatient 1187 771.55 AETNA AETNA 937.73 79 999999999 718.73 1151.39 percent of total billed charges External shock to heart to regulate heart beat 2764624_1 CDM 0450 RC 92960 HCPCS inpatient 1187 771.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 819.03 69 999999999 718.73 1151.39 percent of total billed charges External shock to heart to regulate heart beat 2764624_1 CDM 0450 RC 92960 HCPCS inpatient 1187 771.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1151.39 97 999999999 718.73 1151.39 percent of total billed charges External shock to heart to regulate heart beat 2764624_1 CDM 0450 RC 92960 HCPCS inpatient 1187 771.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 925.86 78 999999999 718.73 1151.39 percent of total billed charges External shock to heart to regulate heart beat 2764624_1 CDM 0450 RC 92960 HCPCS inpatient 1187 771.55 UMR - ALL PLANS UMR - ALL PLANS 830.9 70 999999999 718.73 1151.39 percent of total billed charges External shock to heart to regulate heart beat 2764624_1 CDM 0450 RC 92960 HCPCS inpatient 1187 771.55 SIHO - ALL PLANS SIHO - ALL PLANS 1068.3 90 999999999 718.73 1151.39 percent of total billed charges External shock to heart to regulate heart beat 2764624_1 CDM 0450 RC 92960 HCPCS inpatient 1187 771.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 718.73 60.55 999999999 718.73 1151.39 percent of total billed charges External shock to heart to regulate heart beat 2764624_1 CDM 0450 RC 92960 HCPCS inpatient 1187 771.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 718.73 1151.39 External shock to heart to regulate heart beat 2764624_1 CDM 0450 RC 92960 HCPCS inpatient 1187 771.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 718.73 1151.39 External shock to heart to regulate heart beat 2764624_1 CDM 0450 RC 92960 HCPCS inpatient 1187 771.55 ANTHEM HMO ANTHEM HMO 999999999 718.73 1151.39 External shock to heart to regulate heart beat 2764624_1 CDM 0450 RC 92960 HCPCS inpatient 1187 771.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 802.41 67.6 999999999 718.73 1151.39 percent of total billed charges External shock to heart to regulate heart beat 2764624_1 CDM 0450 RC 92960 HCPCS inpatient 1187 771.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 718.73 1151.39 External shock to heart to regulate heart beat 2764624_1 CDM 0450 RC 92960 HCPCS inpatient 1187 771.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 718.73 1151.39 Simple change of bladder tube 2764625_1 CDM 0450 RC 51705 HCPCS inpatient 511 332.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 332.15 65 999999999 309.41 495.67 percent of total billed charges Simple change of bladder tube 2764625_1 CDM 0450 RC 51705 HCPCS inpatient 511 332.15 AETNA AETNA 403.69 79 999999999 309.41 495.67 percent of total billed charges Simple change of bladder tube 2764625_1 CDM 0450 RC 51705 HCPCS inpatient 511 332.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 352.59 69 999999999 309.41 495.67 percent of total billed charges Simple change of bladder tube 2764625_1 CDM 0450 RC 51705 HCPCS inpatient 511 332.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 495.67 97 999999999 309.41 495.67 percent of total billed charges Simple change of bladder tube 2764625_1 CDM 0450 RC 51705 HCPCS inpatient 511 332.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 398.58 78 999999999 309.41 495.67 percent of total billed charges Simple change of bladder tube 2764625_1 CDM 0450 RC 51705 HCPCS inpatient 511 332.15 UMR - ALL PLANS UMR - ALL PLANS 357.7 70 999999999 309.41 495.67 percent of total billed charges Simple change of bladder tube 2764625_1 CDM 0450 RC 51705 HCPCS inpatient 511 332.15 SIHO - ALL PLANS SIHO - ALL PLANS 459.9 90 999999999 309.41 495.67 percent of total billed charges Simple change of bladder tube 2764625_1 CDM 0450 RC 51705 HCPCS inpatient 511 332.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 309.41 60.55 999999999 309.41 495.67 percent of total billed charges Simple change of bladder tube 2764625_1 CDM 0450 RC 51705 HCPCS inpatient 511 332.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 309.41 495.67 Simple change of bladder tube 2764625_1 CDM 0450 RC 51705 HCPCS inpatient 511 332.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 309.41 495.67 Simple change of bladder tube 2764625_1 CDM 0450 RC 51705 HCPCS inpatient 511 332.15 ANTHEM HMO ANTHEM HMO 999999999 309.41 495.67 Simple change of bladder tube 2764625_1 CDM 0450 RC 51705 HCPCS inpatient 511 332.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 345.44 67.6 999999999 309.41 495.67 percent of total billed charges Simple change of bladder tube 2764625_1 CDM 0450 RC 51705 HCPCS inpatient 511 332.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 309.41 495.67 Simple change of bladder tube 2764625_1 CDM 0450 RC 51705 HCPCS inpatient 511 332.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 309.41 495.67 Collection of blood sample from implanted device 2764631_1 CDM 0450 RC 36591 HCPCS inpatient 171 111.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.15 65 999999999 103.54 165.87 percent of total billed charges Collection of blood sample from implanted device 2764631_1 CDM 0450 RC 36591 HCPCS inpatient 171 111.15 AETNA AETNA 135.09 79 999999999 103.54 165.87 percent of total billed charges Collection of blood sample from implanted device 2764631_1 CDM 0450 RC 36591 HCPCS inpatient 171 111.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.99 69 999999999 103.54 165.87 percent of total billed charges Collection of blood sample from implanted device 2764631_1 CDM 0450 RC 36591 HCPCS inpatient 171 111.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 165.87 97 999999999 103.54 165.87 percent of total billed charges Collection of blood sample from implanted device 2764631_1 CDM 0450 RC 36591 HCPCS inpatient 171 111.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 133.38 78 999999999 103.54 165.87 percent of total billed charges Collection of blood sample from implanted device 2764631_1 CDM 0450 RC 36591 HCPCS inpatient 171 111.15 UMR - ALL PLANS UMR - ALL PLANS 119.7 70 999999999 103.54 165.87 percent of total billed charges Collection of blood sample from implanted device 2764631_1 CDM 0450 RC 36591 HCPCS inpatient 171 111.15 SIHO - ALL PLANS SIHO - ALL PLANS 153.9 90 999999999 103.54 165.87 percent of total billed charges Collection of blood sample from implanted device 2764631_1 CDM 0450 RC 36591 HCPCS inpatient 171 111.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 103.54 60.55 999999999 103.54 165.87 percent of total billed charges Collection of blood sample from implanted device 2764631_1 CDM 0450 RC 36591 HCPCS inpatient 171 111.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 103.54 165.87 Collection of blood sample from implanted device 2764631_1 CDM 0450 RC 36591 HCPCS inpatient 171 111.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 103.54 165.87 Collection of blood sample from implanted device 2764631_1 CDM 0450 RC 36591 HCPCS inpatient 171 111.15 ANTHEM HMO ANTHEM HMO 999999999 103.54 165.87 Collection of blood sample from implanted device 2764631_1 CDM 0450 RC 36591 HCPCS inpatient 171 111.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 115.6 67.6 999999999 103.54 165.87 percent of total billed charges Collection of blood sample from implanted device 2764631_1 CDM 0450 RC 36591 HCPCS inpatient 171 111.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 103.54 165.87 Collection of blood sample from implanted device 2764631_1 CDM 0450 RC 36591 HCPCS inpatient 171 111.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 103.54 165.87 Simple drainage of abscess or blood accumulation of external ear 2764634_1 CDM 0450 RC 69000 HCPCS inpatient 471 306.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 306.15 65 999999999 285.19 456.87 percent of total billed charges Simple drainage of abscess or blood accumulation of external ear 2764634_1 CDM 0450 RC 69000 HCPCS inpatient 471 306.15 AETNA AETNA 372.09 79 999999999 285.19 456.87 percent of total billed charges Simple drainage of abscess or blood accumulation of external ear 2764634_1 CDM 0450 RC 69000 HCPCS inpatient 471 306.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 324.99 69 999999999 285.19 456.87 percent of total billed charges Simple drainage of abscess or blood accumulation of external ear 2764634_1 CDM 0450 RC 69000 HCPCS inpatient 471 306.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 456.87 97 999999999 285.19 456.87 percent of total billed charges Simple drainage of abscess or blood accumulation of external ear 2764634_1 CDM 0450 RC 69000 HCPCS inpatient 471 306.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 367.38 78 999999999 285.19 456.87 percent of total billed charges Simple drainage of abscess or blood accumulation of external ear 2764634_1 CDM 0450 RC 69000 HCPCS inpatient 471 306.15 UMR - ALL PLANS UMR - ALL PLANS 329.7 70 999999999 285.19 456.87 percent of total billed charges Simple drainage of abscess or blood accumulation of external ear 2764634_1 CDM 0450 RC 69000 HCPCS inpatient 471 306.15 SIHO - ALL PLANS SIHO - ALL PLANS 423.9 90 999999999 285.19 456.87 percent of total billed charges Simple drainage of abscess or blood accumulation of external ear 2764634_1 CDM 0450 RC 69000 HCPCS inpatient 471 306.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 285.19 60.55 999999999 285.19 456.87 percent of total billed charges Simple drainage of abscess or blood accumulation of external ear 2764634_1 CDM 0450 RC 69000 HCPCS inpatient 471 306.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 285.19 456.87 Simple drainage of abscess or blood accumulation of external ear 2764634_1 CDM 0450 RC 69000 HCPCS inpatient 471 306.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 285.19 456.87 Simple drainage of abscess or blood accumulation of external ear 2764634_1 CDM 0450 RC 69000 HCPCS inpatient 471 306.15 ANTHEM HMO ANTHEM HMO 999999999 285.19 456.87 Simple drainage of abscess or blood accumulation of external ear 2764634_1 CDM 0450 RC 69000 HCPCS inpatient 471 306.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 318.4 67.6 999999999 285.19 456.87 percent of total billed charges Simple drainage of abscess or blood accumulation of external ear 2764634_1 CDM 0450 RC 69000 HCPCS inpatient 471 306.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 285.19 456.87 Simple drainage of abscess or blood accumulation of external ear 2764634_1 CDM 0450 RC 69000 HCPCS inpatient 471 306.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 285.19 456.87 Aspiration and/or injection of fluid from medium joint 2764639_1 CDM 0450 RC 20605 HCPCS inpatient 796 517.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 517.4 65 999999999 481.98 772.12 percent of total billed charges Aspiration and/or injection of fluid from medium joint 2764639_1 CDM 0450 RC 20605 HCPCS inpatient 796 517.4 AETNA AETNA 628.84 79 999999999 481.98 772.12 percent of total billed charges Aspiration and/or injection of fluid from medium joint 2764639_1 CDM 0450 RC 20605 HCPCS inpatient 796 517.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 549.24 69 999999999 481.98 772.12 percent of total billed charges Aspiration and/or injection of fluid from medium joint 2764639_1 CDM 0450 RC 20605 HCPCS inpatient 796 517.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 772.12 97 999999999 481.98 772.12 percent of total billed charges Aspiration and/or injection of fluid from medium joint 2764639_1 CDM 0450 RC 20605 HCPCS inpatient 796 517.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 620.88 78 999999999 481.98 772.12 percent of total billed charges Aspiration and/or injection of fluid from medium joint 2764639_1 CDM 0450 RC 20605 HCPCS inpatient 796 517.4 UMR - ALL PLANS UMR - ALL PLANS 557.2 70 999999999 481.98 772.12 percent of total billed charges Aspiration and/or injection of fluid from medium joint 2764639_1 CDM 0450 RC 20605 HCPCS inpatient 796 517.4 SIHO - ALL PLANS SIHO - ALL PLANS 716.4 90 999999999 481.98 772.12 percent of total billed charges Aspiration and/or injection of fluid from medium joint 2764639_1 CDM 0450 RC 20605 HCPCS inpatient 796 517.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 481.98 60.55 999999999 481.98 772.12 percent of total billed charges Aspiration and/or injection of fluid from medium joint 2764639_1 CDM 0450 RC 20605 HCPCS inpatient 796 517.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 481.98 772.12 Aspiration and/or injection of fluid from medium joint 2764639_1 CDM 0450 RC 20605 HCPCS inpatient 796 517.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 481.98 772.12 Aspiration and/or injection of fluid from medium joint 2764639_1 CDM 0450 RC 20605 HCPCS inpatient 796 517.4 ANTHEM HMO ANTHEM HMO 999999999 481.98 772.12 Aspiration and/or injection of fluid from medium joint 2764639_1 CDM 0450 RC 20605 HCPCS inpatient 796 517.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 538.1 67.6 999999999 481.98 772.12 percent of total billed charges Aspiration and/or injection of fluid from medium joint 2764639_1 CDM 0450 RC 20605 HCPCS inpatient 796 517.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 481.98 772.12 Aspiration and/or injection of fluid from medium joint 2764639_1 CDM 0450 RC 20605 HCPCS inpatient 796 517.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 481.98 772.12 Aspiration and/or injection of fluid from large joint 2764641_1 CDM 0450 RC 20610 HCPCS inpatient 963 625.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 625.95 65 999999999 583.1 934.11 percent of total billed charges Aspiration and/or injection of fluid from large joint 2764641_1 CDM 0450 RC 20610 HCPCS inpatient 963 625.95 AETNA AETNA 760.77 79 999999999 583.1 934.11 percent of total billed charges Aspiration and/or injection of fluid from large joint 2764641_1 CDM 0450 RC 20610 HCPCS inpatient 963 625.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 664.47 69 999999999 583.1 934.11 percent of total billed charges Aspiration and/or injection of fluid from large joint 2764641_1 CDM 0450 RC 20610 HCPCS inpatient 963 625.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 934.11 97 999999999 583.1 934.11 percent of total billed charges Aspiration and/or injection of fluid from large joint 2764641_1 CDM 0450 RC 20610 HCPCS inpatient 963 625.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 751.14 78 999999999 583.1 934.11 percent of total billed charges Aspiration and/or injection of fluid from large joint 2764641_1 CDM 0450 RC 20610 HCPCS inpatient 963 625.95 UMR - ALL PLANS UMR - ALL PLANS 674.1 70 999999999 583.1 934.11 percent of total billed charges Aspiration and/or injection of fluid from large joint 2764641_1 CDM 0450 RC 20610 HCPCS inpatient 963 625.95 SIHO - ALL PLANS SIHO - ALL PLANS 866.7 90 999999999 583.1 934.11 percent of total billed charges Aspiration and/or injection of fluid from large joint 2764641_1 CDM 0450 RC 20610 HCPCS inpatient 963 625.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 583.1 60.55 999999999 583.1 934.11 percent of total billed charges Aspiration and/or injection of fluid from large joint 2764641_1 CDM 0450 RC 20610 HCPCS inpatient 963 625.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 583.1 934.11 Aspiration and/or injection of fluid from large joint 2764641_1 CDM 0450 RC 20610 HCPCS inpatient 963 625.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 583.1 934.11 Aspiration and/or injection of fluid from large joint 2764641_1 CDM 0450 RC 20610 HCPCS inpatient 963 625.95 ANTHEM HMO ANTHEM HMO 999999999 583.1 934.11 Aspiration and/or injection of fluid from large joint 2764641_1 CDM 0450 RC 20610 HCPCS inpatient 963 625.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 650.99 67.6 999999999 583.1 934.11 percent of total billed charges Aspiration and/or injection of fluid from large joint 2764641_1 CDM 0450 RC 20610 HCPCS inpatient 963 625.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 583.1 934.11 Aspiration and/or injection of fluid from large joint 2764641_1 CDM 0450 RC 20610 HCPCS inpatient 963 625.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 583.1 934.11 Complicated insertion of bladder tube 2764644_1 CDM 0450 RC 51703 HCPCS inpatient 503 326.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 326.95 65 999999999 304.57 487.91 percent of total billed charges Complicated insertion of bladder tube 2764644_1 CDM 0450 RC 51703 HCPCS inpatient 503 326.95 AETNA AETNA 397.37 79 999999999 304.57 487.91 percent of total billed charges Complicated insertion of bladder tube 2764644_1 CDM 0450 RC 51703 HCPCS inpatient 503 326.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 347.07 69 999999999 304.57 487.91 percent of total billed charges Complicated insertion of bladder tube 2764644_1 CDM 0450 RC 51703 HCPCS inpatient 503 326.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 487.91 97 999999999 304.57 487.91 percent of total billed charges Complicated insertion of bladder tube 2764644_1 CDM 0450 RC 51703 HCPCS inpatient 503 326.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 392.34 78 999999999 304.57 487.91 percent of total billed charges Complicated insertion of bladder tube 2764644_1 CDM 0450 RC 51703 HCPCS inpatient 503 326.95 UMR - ALL PLANS UMR - ALL PLANS 352.1 70 999999999 304.57 487.91 percent of total billed charges Complicated insertion of bladder tube 2764644_1 CDM 0450 RC 51703 HCPCS inpatient 503 326.95 SIHO - ALL PLANS SIHO - ALL PLANS 452.7 90 999999999 304.57 487.91 percent of total billed charges Complicated insertion of bladder tube 2764644_1 CDM 0450 RC 51703 HCPCS inpatient 503 326.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 304.57 60.55 999999999 304.57 487.91 percent of total billed charges Complicated insertion of bladder tube 2764644_1 CDM 0450 RC 51703 HCPCS inpatient 503 326.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 304.57 487.91 Complicated insertion of bladder tube 2764644_1 CDM 0450 RC 51703 HCPCS inpatient 503 326.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 304.57 487.91 Complicated insertion of bladder tube 2764644_1 CDM 0450 RC 51703 HCPCS inpatient 503 326.95 ANTHEM HMO ANTHEM HMO 999999999 304.57 487.91 Complicated insertion of bladder tube 2764644_1 CDM 0450 RC 51703 HCPCS inpatient 503 326.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 340.03 67.6 999999999 304.57 487.91 percent of total billed charges Complicated insertion of bladder tube 2764644_1 CDM 0450 RC 51703 HCPCS inpatient 503 326.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 304.57 487.91 Complicated insertion of bladder tube 2764644_1 CDM 0450 RC 51703 HCPCS inpatient 503 326.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 304.57 487.91 "Drainage of abscess, cyst, or blood accumulation of dental bone" 2764646_1 CDM 0450 RC 41800 HCPCS inpatient 422 274.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 274.3 65 999999999 255.52 409.34 percent of total billed charges "Drainage of abscess, cyst, or blood accumulation of dental bone" 2764646_1 CDM 0450 RC 41800 HCPCS inpatient 422 274.3 AETNA AETNA 333.38 79 999999999 255.52 409.34 percent of total billed charges "Drainage of abscess, cyst, or blood accumulation of dental bone" 2764646_1 CDM 0450 RC 41800 HCPCS inpatient 422 274.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 291.18 69 999999999 255.52 409.34 percent of total billed charges "Drainage of abscess, cyst, or blood accumulation of dental bone" 2764646_1 CDM 0450 RC 41800 HCPCS inpatient 422 274.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 409.34 97 999999999 255.52 409.34 percent of total billed charges "Drainage of abscess, cyst, or blood accumulation of dental bone" 2764646_1 CDM 0450 RC 41800 HCPCS inpatient 422 274.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 329.16 78 999999999 255.52 409.34 percent of total billed charges "Drainage of abscess, cyst, or blood accumulation of dental bone" 2764646_1 CDM 0450 RC 41800 HCPCS inpatient 422 274.3 UMR - ALL PLANS UMR - ALL PLANS 295.4 70 999999999 255.52 409.34 percent of total billed charges "Drainage of abscess, cyst, or blood accumulation of dental bone" 2764646_1 CDM 0450 RC 41800 HCPCS inpatient 422 274.3 SIHO - ALL PLANS SIHO - ALL PLANS 379.8 90 999999999 255.52 409.34 percent of total billed charges "Drainage of abscess, cyst, or blood accumulation of dental bone" 2764646_1 CDM 0450 RC 41800 HCPCS inpatient 422 274.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 255.52 60.55 999999999 255.52 409.34 percent of total billed charges "Drainage of abscess, cyst, or blood accumulation of dental bone" 2764646_1 CDM 0450 RC 41800 HCPCS inpatient 422 274.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 255.52 409.34 "Drainage of abscess, cyst, or blood accumulation of dental bone" 2764646_1 CDM 0450 RC 41800 HCPCS inpatient 422 274.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 255.52 409.34 "Drainage of abscess, cyst, or blood accumulation of dental bone" 2764646_1 CDM 0450 RC 41800 HCPCS inpatient 422 274.3 ANTHEM HMO ANTHEM HMO 999999999 255.52 409.34 "Drainage of abscess, cyst, or blood accumulation of dental bone" 2764646_1 CDM 0450 RC 41800 HCPCS inpatient 422 274.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 285.27 67.6 999999999 255.52 409.34 percent of total billed charges "Drainage of abscess, cyst, or blood accumulation of dental bone" 2764646_1 CDM 0450 RC 41800 HCPCS inpatient 422 274.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 255.52 409.34 "Drainage of abscess, cyst, or blood accumulation of dental bone" 2764646_1 CDM 0450 RC 41800 HCPCS inpatient 422 274.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 255.52 409.34 Incision and drainage of abscess of external female genitals 2764647_1 CDM 0450 RC 56405 HCPCS inpatient 601 390.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 390.65 65 999999999 363.91 582.97 percent of total billed charges Incision and drainage of abscess of external female genitals 2764647_1 CDM 0450 RC 56405 HCPCS inpatient 601 390.65 AETNA AETNA 474.79 79 999999999 363.91 582.97 percent of total billed charges Incision and drainage of abscess of external female genitals 2764647_1 CDM 0450 RC 56405 HCPCS inpatient 601 390.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 414.69 69 999999999 363.91 582.97 percent of total billed charges Incision and drainage of abscess of external female genitals 2764647_1 CDM 0450 RC 56405 HCPCS inpatient 601 390.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 582.97 97 999999999 363.91 582.97 percent of total billed charges Incision and drainage of abscess of external female genitals 2764647_1 CDM 0450 RC 56405 HCPCS inpatient 601 390.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 468.78 78 999999999 363.91 582.97 percent of total billed charges Incision and drainage of abscess of external female genitals 2764647_1 CDM 0450 RC 56405 HCPCS inpatient 601 390.65 UMR - ALL PLANS UMR - ALL PLANS 420.7 70 999999999 363.91 582.97 percent of total billed charges Incision and drainage of abscess of external female genitals 2764647_1 CDM 0450 RC 56405 HCPCS inpatient 601 390.65 SIHO - ALL PLANS SIHO - ALL PLANS 540.9 90 999999999 363.91 582.97 percent of total billed charges Incision and drainage of abscess of external female genitals 2764647_1 CDM 0450 RC 56405 HCPCS inpatient 601 390.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 363.91 60.55 999999999 363.91 582.97 percent of total billed charges Incision and drainage of abscess of external female genitals 2764647_1 CDM 0450 RC 56405 HCPCS inpatient 601 390.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 363.91 582.97 Incision and drainage of abscess of external female genitals 2764647_1 CDM 0450 RC 56405 HCPCS inpatient 601 390.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 363.91 582.97 Incision and drainage of abscess of external female genitals 2764647_1 CDM 0450 RC 56405 HCPCS inpatient 601 390.65 ANTHEM HMO ANTHEM HMO 999999999 363.91 582.97 Incision and drainage of abscess of external female genitals 2764647_1 CDM 0450 RC 56405 HCPCS inpatient 601 390.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 406.28 67.6 999999999 363.91 582.97 percent of total billed charges Incision and drainage of abscess of external female genitals 2764647_1 CDM 0450 RC 56405 HCPCS inpatient 601 390.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 363.91 582.97 Incision and drainage of abscess of external female genitals 2764647_1 CDM 0450 RC 56405 HCPCS inpatient 601 390.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 363.91 582.97 Injection of blood or blood clot into spinal canal 2764651_1 CDM 0450 RC 62273 HCPCS inpatient 1176 764.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 764.4 65 999999999 712.07 1140.72 percent of total billed charges Injection of blood or blood clot into spinal canal 2764651_1 CDM 0450 RC 62273 HCPCS inpatient 1176 764.4 AETNA AETNA 929.04 79 999999999 712.07 1140.72 percent of total billed charges Injection of blood or blood clot into spinal canal 2764651_1 CDM 0450 RC 62273 HCPCS inpatient 1176 764.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 811.44 69 999999999 712.07 1140.72 percent of total billed charges Injection of blood or blood clot into spinal canal 2764651_1 CDM 0450 RC 62273 HCPCS inpatient 1176 764.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1140.72 97 999999999 712.07 1140.72 percent of total billed charges Injection of blood or blood clot into spinal canal 2764651_1 CDM 0450 RC 62273 HCPCS inpatient 1176 764.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 917.28 78 999999999 712.07 1140.72 percent of total billed charges Injection of blood or blood clot into spinal canal 2764651_1 CDM 0450 RC 62273 HCPCS inpatient 1176 764.4 UMR - ALL PLANS UMR - ALL PLANS 823.2 70 999999999 712.07 1140.72 percent of total billed charges Injection of blood or blood clot into spinal canal 2764651_1 CDM 0450 RC 62273 HCPCS inpatient 1176 764.4 SIHO - ALL PLANS SIHO - ALL PLANS 1058.4 90 999999999 712.07 1140.72 percent of total billed charges Injection of blood or blood clot into spinal canal 2764651_1 CDM 0450 RC 62273 HCPCS inpatient 1176 764.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 712.07 60.55 999999999 712.07 1140.72 percent of total billed charges Injection of blood or blood clot into spinal canal 2764651_1 CDM 0450 RC 62273 HCPCS inpatient 1176 764.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 712.07 1140.72 Injection of blood or blood clot into spinal canal 2764651_1 CDM 0450 RC 62273 HCPCS inpatient 1176 764.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 712.07 1140.72 Injection of blood or blood clot into spinal canal 2764651_1 CDM 0450 RC 62273 HCPCS inpatient 1176 764.4 ANTHEM HMO ANTHEM HMO 999999999 712.07 1140.72 Injection of blood or blood clot into spinal canal 2764651_1 CDM 0450 RC 62273 HCPCS inpatient 1176 764.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 794.98 67.6 999999999 712.07 1140.72 percent of total billed charges Injection of blood or blood clot into spinal canal 2764651_1 CDM 0450 RC 62273 HCPCS inpatient 1176 764.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 712.07 1140.72 Injection of blood or blood clot into spinal canal 2764651_1 CDM 0450 RC 62273 HCPCS inpatient 1176 764.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 712.07 1140.72 Administration of vaccine 2764658_1 CDM 0450 RC 90471 HCPCS inpatient 209 135.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 135.85 65 999999999 126.55 202.73 percent of total billed charges Administration of vaccine 2764658_1 CDM 0450 RC 90471 HCPCS inpatient 209 135.85 AETNA AETNA 165.11 79 999999999 126.55 202.73 percent of total billed charges Administration of vaccine 2764658_1 CDM 0450 RC 90471 HCPCS inpatient 209 135.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 144.21 69 999999999 126.55 202.73 percent of total billed charges Administration of vaccine 2764658_1 CDM 0450 RC 90471 HCPCS inpatient 209 135.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 202.73 97 999999999 126.55 202.73 percent of total billed charges Administration of vaccine 2764658_1 CDM 0450 RC 90471 HCPCS inpatient 209 135.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 163.02 78 999999999 126.55 202.73 percent of total billed charges Administration of vaccine 2764658_1 CDM 0450 RC 90471 HCPCS inpatient 209 135.85 UMR - ALL PLANS UMR - ALL PLANS 146.3 70 999999999 126.55 202.73 percent of total billed charges Administration of vaccine 2764658_1 CDM 0450 RC 90471 HCPCS inpatient 209 135.85 SIHO - ALL PLANS SIHO - ALL PLANS 188.1 90 999999999 126.55 202.73 percent of total billed charges Administration of vaccine 2764658_1 CDM 0450 RC 90471 HCPCS inpatient 209 135.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 126.55 60.55 999999999 126.55 202.73 percent of total billed charges Administration of vaccine 2764658_1 CDM 0450 RC 90471 HCPCS inpatient 209 135.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 126.55 202.73 Administration of vaccine 2764658_1 CDM 0450 RC 90471 HCPCS inpatient 209 135.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 126.55 202.73 Administration of vaccine 2764658_1 CDM 0450 RC 90471 HCPCS inpatient 209 135.85 ANTHEM HMO ANTHEM HMO 999999999 126.55 202.73 Administration of vaccine 2764658_1 CDM 0450 RC 90471 HCPCS inpatient 209 135.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 141.28 67.6 999999999 126.55 202.73 percent of total billed charges Administration of vaccine 2764658_1 CDM 0450 RC 90471 HCPCS inpatient 209 135.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 126.55 202.73 Administration of vaccine 2764658_1 CDM 0450 RC 90471 HCPCS inpatient 209 135.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 126.55 202.73 "Incision and drainage of sperm reservoir, testis, and/or scrotal area" 2764665_1 CDM 0450 RC 54700 HCPCS inpatient 4445 2889.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 2889.25 65 999999999 2691.45 4311.65 percent of total billed charges "Incision and drainage of sperm reservoir, testis, and/or scrotal area" 2764665_1 CDM 0450 RC 54700 HCPCS inpatient 4445 2889.25 AETNA AETNA 3511.55 79 999999999 2691.45 4311.65 percent of total billed charges "Incision and drainage of sperm reservoir, testis, and/or scrotal area" 2764665_1 CDM 0450 RC 54700 HCPCS inpatient 4445 2889.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 3067.05 69 999999999 2691.45 4311.65 percent of total billed charges "Incision and drainage of sperm reservoir, testis, and/or scrotal area" 2764665_1 CDM 0450 RC 54700 HCPCS inpatient 4445 2889.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4311.65 97 999999999 2691.45 4311.65 percent of total billed charges "Incision and drainage of sperm reservoir, testis, and/or scrotal area" 2764665_1 CDM 0450 RC 54700 HCPCS inpatient 4445 2889.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 3467.1 78 999999999 2691.45 4311.65 percent of total billed charges "Incision and drainage of sperm reservoir, testis, and/or scrotal area" 2764665_1 CDM 0450 RC 54700 HCPCS inpatient 4445 2889.25 UMR - ALL PLANS UMR - ALL PLANS 3111.5 70 999999999 2691.45 4311.65 percent of total billed charges "Incision and drainage of sperm reservoir, testis, and/or scrotal area" 2764665_1 CDM 0450 RC 54700 HCPCS inpatient 4445 2889.25 SIHO - ALL PLANS SIHO - ALL PLANS 4000.5 90 999999999 2691.45 4311.65 percent of total billed charges "Incision and drainage of sperm reservoir, testis, and/or scrotal area" 2764665_1 CDM 0450 RC 54700 HCPCS inpatient 4445 2889.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2691.45 60.55 999999999 2691.45 4311.65 percent of total billed charges "Incision and drainage of sperm reservoir, testis, and/or scrotal area" 2764665_1 CDM 0450 RC 54700 HCPCS inpatient 4445 2889.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2691.45 4311.65 "Incision and drainage of sperm reservoir, testis, and/or scrotal area" 2764665_1 CDM 0450 RC 54700 HCPCS inpatient 4445 2889.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2691.45 4311.65 "Incision and drainage of sperm reservoir, testis, and/or scrotal area" 2764665_1 CDM 0450 RC 54700 HCPCS inpatient 4445 2889.25 ANTHEM HMO ANTHEM HMO 999999999 2691.45 4311.65 "Incision and drainage of sperm reservoir, testis, and/or scrotal area" 2764665_1 CDM 0450 RC 54700 HCPCS inpatient 4445 2889.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 3004.82 67.6 999999999 2691.45 4311.65 percent of total billed charges "Incision and drainage of sperm reservoir, testis, and/or scrotal area" 2764665_1 CDM 0450 RC 54700 HCPCS inpatient 4445 2889.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2691.45 4311.65 "Incision and drainage of sperm reservoir, testis, and/or scrotal area" 2764665_1 CDM 0450 RC 54700 HCPCS inpatient 4445 2889.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 2691.45 4311.65 Simple or single drainage of skin abscess 2764668_1 CDM 0450 RC 10060 HCPCS inpatient 549 356.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 356.85 65 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 2764668_1 CDM 0450 RC 10060 HCPCS inpatient 549 356.85 AETNA AETNA 433.71 79 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 2764668_1 CDM 0450 RC 10060 HCPCS inpatient 549 356.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 378.81 69 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 2764668_1 CDM 0450 RC 10060 HCPCS inpatient 549 356.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 532.53 97 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 2764668_1 CDM 0450 RC 10060 HCPCS inpatient 549 356.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 428.22 78 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 2764668_1 CDM 0450 RC 10060 HCPCS inpatient 549 356.85 UMR - ALL PLANS UMR - ALL PLANS 384.3 70 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 2764668_1 CDM 0450 RC 10060 HCPCS inpatient 549 356.85 SIHO - ALL PLANS SIHO - ALL PLANS 494.1 90 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 2764668_1 CDM 0450 RC 10060 HCPCS inpatient 549 356.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 332.42 60.55 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 2764668_1 CDM 0450 RC 10060 HCPCS inpatient 549 356.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 332.42 532.53 Simple or single drainage of skin abscess 2764668_1 CDM 0450 RC 10060 HCPCS inpatient 549 356.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 332.42 532.53 Simple or single drainage of skin abscess 2764668_1 CDM 0450 RC 10060 HCPCS inpatient 549 356.85 ANTHEM HMO ANTHEM HMO 999999999 332.42 532.53 Simple or single drainage of skin abscess 2764668_1 CDM 0450 RC 10060 HCPCS inpatient 549 356.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 371.12 67.6 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 2764668_1 CDM 0450 RC 10060 HCPCS inpatient 549 356.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 332.42 532.53 Simple or single drainage of skin abscess 2764668_1 CDM 0450 RC 10060 HCPCS inpatient 549 356.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 332.42 532.53 Incision and drainage of abscess of female genital gland 2764670_1 CDM 0450 RC 56420 HCPCS inpatient 592 384.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 384.8 65 999999999 358.46 574.24 percent of total billed charges Incision and drainage of abscess of female genital gland 2764670_1 CDM 0450 RC 56420 HCPCS inpatient 592 384.8 AETNA AETNA 467.68 79 999999999 358.46 574.24 percent of total billed charges Incision and drainage of abscess of female genital gland 2764670_1 CDM 0450 RC 56420 HCPCS inpatient 592 384.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 408.48 69 999999999 358.46 574.24 percent of total billed charges Incision and drainage of abscess of female genital gland 2764670_1 CDM 0450 RC 56420 HCPCS inpatient 592 384.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 574.24 97 999999999 358.46 574.24 percent of total billed charges Incision and drainage of abscess of female genital gland 2764670_1 CDM 0450 RC 56420 HCPCS inpatient 592 384.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 461.76 78 999999999 358.46 574.24 percent of total billed charges Incision and drainage of abscess of female genital gland 2764670_1 CDM 0450 RC 56420 HCPCS inpatient 592 384.8 UMR - ALL PLANS UMR - ALL PLANS 414.4 70 999999999 358.46 574.24 percent of total billed charges Incision and drainage of abscess of female genital gland 2764670_1 CDM 0450 RC 56420 HCPCS inpatient 592 384.8 SIHO - ALL PLANS SIHO - ALL PLANS 532.8 90 999999999 358.46 574.24 percent of total billed charges Incision and drainage of abscess of female genital gland 2764670_1 CDM 0450 RC 56420 HCPCS inpatient 592 384.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 358.46 60.55 999999999 358.46 574.24 percent of total billed charges Incision and drainage of abscess of female genital gland 2764670_1 CDM 0450 RC 56420 HCPCS inpatient 592 384.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 358.46 574.24 Incision and drainage of abscess of female genital gland 2764670_1 CDM 0450 RC 56420 HCPCS inpatient 592 384.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 358.46 574.24 Incision and drainage of abscess of female genital gland 2764670_1 CDM 0450 RC 56420 HCPCS inpatient 592 384.8 ANTHEM HMO ANTHEM HMO 999999999 358.46 574.24 Incision and drainage of abscess of female genital gland 2764670_1 CDM 0450 RC 56420 HCPCS inpatient 592 384.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 400.19 67.6 999999999 358.46 574.24 percent of total billed charges Incision and drainage of abscess of female genital gland 2764670_1 CDM 0450 RC 56420 HCPCS inpatient 592 384.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 358.46 574.24 Incision and drainage of abscess of female genital gland 2764670_1 CDM 0450 RC 56420 HCPCS inpatient 592 384.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 358.46 574.24 Removal of fluid from between lung and chest cavity 2764673_1 CDM 0450 RC 32551 HCPCS inpatient 1536 998.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 998.4 65 999999999 930.05 1489.92 percent of total billed charges Removal of fluid from between lung and chest cavity 2764673_1 CDM 0450 RC 32551 HCPCS inpatient 1536 998.4 AETNA AETNA 1213.44 79 999999999 930.05 1489.92 percent of total billed charges Removal of fluid from between lung and chest cavity 2764673_1 CDM 0450 RC 32551 HCPCS inpatient 1536 998.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1059.84 69 999999999 930.05 1489.92 percent of total billed charges Removal of fluid from between lung and chest cavity 2764673_1 CDM 0450 RC 32551 HCPCS inpatient 1536 998.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1489.92 97 999999999 930.05 1489.92 percent of total billed charges Removal of fluid from between lung and chest cavity 2764673_1 CDM 0450 RC 32551 HCPCS inpatient 1536 998.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1198.08 78 999999999 930.05 1489.92 percent of total billed charges Removal of fluid from between lung and chest cavity 2764673_1 CDM 0450 RC 32551 HCPCS inpatient 1536 998.4 UMR - ALL PLANS UMR - ALL PLANS 1075.2 70 999999999 930.05 1489.92 percent of total billed charges Removal of fluid from between lung and chest cavity 2764673_1 CDM 0450 RC 32551 HCPCS inpatient 1536 998.4 SIHO - ALL PLANS SIHO - ALL PLANS 1382.4 90 999999999 930.05 1489.92 percent of total billed charges Removal of fluid from between lung and chest cavity 2764673_1 CDM 0450 RC 32551 HCPCS inpatient 1536 998.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 930.05 60.55 999999999 930.05 1489.92 percent of total billed charges Removal of fluid from between lung and chest cavity 2764673_1 CDM 0450 RC 32551 HCPCS inpatient 1536 998.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 930.05 1489.92 Removal of fluid from between lung and chest cavity 2764673_1 CDM 0450 RC 32551 HCPCS inpatient 1536 998.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 930.05 1489.92 Removal of fluid from between lung and chest cavity 2764673_1 CDM 0450 RC 32551 HCPCS inpatient 1536 998.4 ANTHEM HMO ANTHEM HMO 999999999 930.05 1489.92 Removal of fluid from between lung and chest cavity 2764673_1 CDM 0450 RC 32551 HCPCS inpatient 1536 998.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1038.34 67.6 999999999 930.05 1489.92 percent of total billed charges Removal of fluid from between lung and chest cavity 2764673_1 CDM 0450 RC 32551 HCPCS inpatient 1536 998.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 930.05 1489.92 Removal of fluid from between lung and chest cavity 2764673_1 CDM 0450 RC 32551 HCPCS inpatient 1536 998.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 930.05 1489.92 Drainage of superficial rectal abscess surrounding anus 2764674_1 CDM 0450 RC 46050 HCPCS inpatient 750 487.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 487.5 65 999999999 454.13 727.5 percent of total billed charges Drainage of superficial rectal abscess surrounding anus 2764674_1 CDM 0450 RC 46050 HCPCS inpatient 750 487.5 AETNA AETNA 592.5 79 999999999 454.13 727.5 percent of total billed charges Drainage of superficial rectal abscess surrounding anus 2764674_1 CDM 0450 RC 46050 HCPCS inpatient 750 487.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 517.5 69 999999999 454.13 727.5 percent of total billed charges Drainage of superficial rectal abscess surrounding anus 2764674_1 CDM 0450 RC 46050 HCPCS inpatient 750 487.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 727.5 97 999999999 454.13 727.5 percent of total billed charges Drainage of superficial rectal abscess surrounding anus 2764674_1 CDM 0450 RC 46050 HCPCS inpatient 750 487.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 585 78 999999999 454.13 727.5 percent of total billed charges Drainage of superficial rectal abscess surrounding anus 2764674_1 CDM 0450 RC 46050 HCPCS inpatient 750 487.5 UMR - ALL PLANS UMR - ALL PLANS 525 70 999999999 454.13 727.5 percent of total billed charges Drainage of superficial rectal abscess surrounding anus 2764674_1 CDM 0450 RC 46050 HCPCS inpatient 750 487.5 SIHO - ALL PLANS SIHO - ALL PLANS 675 90 999999999 454.13 727.5 percent of total billed charges Drainage of superficial rectal abscess surrounding anus 2764674_1 CDM 0450 RC 46050 HCPCS inpatient 750 487.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 454.13 60.55 999999999 454.13 727.5 percent of total billed charges Drainage of superficial rectal abscess surrounding anus 2764674_1 CDM 0450 RC 46050 HCPCS inpatient 750 487.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 454.13 727.5 Drainage of superficial rectal abscess surrounding anus 2764674_1 CDM 0450 RC 46050 HCPCS inpatient 750 487.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 454.13 727.5 Drainage of superficial rectal abscess surrounding anus 2764674_1 CDM 0450 RC 46050 HCPCS inpatient 750 487.5 ANTHEM HMO ANTHEM HMO 999999999 454.13 727.5 Drainage of superficial rectal abscess surrounding anus 2764674_1 CDM 0450 RC 46050 HCPCS inpatient 750 487.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 507 67.6 999999999 454.13 727.5 percent of total billed charges Drainage of superficial rectal abscess surrounding anus 2764674_1 CDM 0450 RC 46050 HCPCS inpatient 750 487.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 454.13 727.5 Drainage of superficial rectal abscess surrounding anus 2764674_1 CDM 0450 RC 46050 HCPCS inpatient 750 487.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 454.13 727.5 Insertion of non-tunneled central venous tube for infusion (5 years or older) 2764675_1 CDM 0450 RC 36556 HCPCS inpatient 2929 1903.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1903.85 65 999999999 1773.51 2841.13 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 2764675_1 CDM 0450 RC 36556 HCPCS inpatient 2929 1903.85 AETNA AETNA 2313.91 79 999999999 1773.51 2841.13 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 2764675_1 CDM 0450 RC 36556 HCPCS inpatient 2929 1903.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 2021.01 69 999999999 1773.51 2841.13 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 2764675_1 CDM 0450 RC 36556 HCPCS inpatient 2929 1903.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2841.13 97 999999999 1773.51 2841.13 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 2764675_1 CDM 0450 RC 36556 HCPCS inpatient 2929 1903.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 2284.62 78 999999999 1773.51 2841.13 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 2764675_1 CDM 0450 RC 36556 HCPCS inpatient 2929 1903.85 UMR - ALL PLANS UMR - ALL PLANS 2050.3 70 999999999 1773.51 2841.13 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 2764675_1 CDM 0450 RC 36556 HCPCS inpatient 2929 1903.85 SIHO - ALL PLANS SIHO - ALL PLANS 2636.1 90 999999999 1773.51 2841.13 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 2764675_1 CDM 0450 RC 36556 HCPCS inpatient 2929 1903.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1773.51 60.55 999999999 1773.51 2841.13 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 2764675_1 CDM 0450 RC 36556 HCPCS inpatient 2929 1903.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1773.51 2841.13 Insertion of non-tunneled central venous tube for infusion (5 years or older) 2764675_1 CDM 0450 RC 36556 HCPCS inpatient 2929 1903.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1773.51 2841.13 Insertion of non-tunneled central venous tube for infusion (5 years or older) 2764675_1 CDM 0450 RC 36556 HCPCS inpatient 2929 1903.85 ANTHEM HMO ANTHEM HMO 999999999 1773.51 2841.13 Insertion of non-tunneled central venous tube for infusion (5 years or older) 2764675_1 CDM 0450 RC 36556 HCPCS inpatient 2929 1903.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1980 67.6 999999999 1773.51 2841.13 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 2764675_1 CDM 0450 RC 36556 HCPCS inpatient 2929 1903.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1773.51 2841.13 Insertion of non-tunneled central venous tube for infusion (5 years or older) 2764675_1 CDM 0450 RC 36556 HCPCS inpatient 2929 1903.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1773.51 2841.13 Drainage of deep abscess in rectum 2764676_1 CDM 0450 RC 46040 HCPCS inpatient 3221 2093.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 2093.65 65 999999999 1950.32 3124.37 percent of total billed charges Drainage of deep abscess in rectum 2764676_1 CDM 0450 RC 46040 HCPCS inpatient 3221 2093.65 AETNA AETNA 2544.59 79 999999999 1950.32 3124.37 percent of total billed charges Drainage of deep abscess in rectum 2764676_1 CDM 0450 RC 46040 HCPCS inpatient 3221 2093.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2222.49 69 999999999 1950.32 3124.37 percent of total billed charges Drainage of deep abscess in rectum 2764676_1 CDM 0450 RC 46040 HCPCS inpatient 3221 2093.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3124.37 97 999999999 1950.32 3124.37 percent of total billed charges Drainage of deep abscess in rectum 2764676_1 CDM 0450 RC 46040 HCPCS inpatient 3221 2093.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2512.38 78 999999999 1950.32 3124.37 percent of total billed charges Drainage of deep abscess in rectum 2764676_1 CDM 0450 RC 46040 HCPCS inpatient 3221 2093.65 UMR - ALL PLANS UMR - ALL PLANS 2254.7 70 999999999 1950.32 3124.37 percent of total billed charges Drainage of deep abscess in rectum 2764676_1 CDM 0450 RC 46040 HCPCS inpatient 3221 2093.65 SIHO - ALL PLANS SIHO - ALL PLANS 2898.9 90 999999999 1950.32 3124.37 percent of total billed charges Drainage of deep abscess in rectum 2764676_1 CDM 0450 RC 46040 HCPCS inpatient 3221 2093.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1950.32 60.55 999999999 1950.32 3124.37 percent of total billed charges Drainage of deep abscess in rectum 2764676_1 CDM 0450 RC 46040 HCPCS inpatient 3221 2093.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1950.32 3124.37 Drainage of deep abscess in rectum 2764676_1 CDM 0450 RC 46040 HCPCS inpatient 3221 2093.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1950.32 3124.37 Drainage of deep abscess in rectum 2764676_1 CDM 0450 RC 46040 HCPCS inpatient 3221 2093.65 ANTHEM HMO ANTHEM HMO 999999999 1950.32 3124.37 Drainage of deep abscess in rectum 2764676_1 CDM 0450 RC 46040 HCPCS inpatient 3221 2093.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2177.4 67.6 999999999 1950.32 3124.37 percent of total billed charges Drainage of deep abscess in rectum 2764676_1 CDM 0450 RC 46040 HCPCS inpatient 3221 2093.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1950.32 3124.37 Drainage of deep abscess in rectum 2764676_1 CDM 0450 RC 46040 HCPCS inpatient 3221 2093.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1950.32 3124.37 Simple insertion of temporary bladder tube 2764677_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 156.65 65 999999999 145.93 233.77 percent of total billed charges Simple insertion of temporary bladder tube 2764677_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 AETNA AETNA 190.39 79 999999999 145.93 233.77 percent of total billed charges Simple insertion of temporary bladder tube 2764677_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 166.29 69 999999999 145.93 233.77 percent of total billed charges Simple insertion of temporary bladder tube 2764677_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 233.77 97 999999999 145.93 233.77 percent of total billed charges Simple insertion of temporary bladder tube 2764677_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.98 78 999999999 145.93 233.77 percent of total billed charges Simple insertion of temporary bladder tube 2764677_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 UMR - ALL PLANS UMR - ALL PLANS 168.7 70 999999999 145.93 233.77 percent of total billed charges Simple insertion of temporary bladder tube 2764677_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 SIHO - ALL PLANS SIHO - ALL PLANS 216.9 90 999999999 145.93 233.77 percent of total billed charges Simple insertion of temporary bladder tube 2764677_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.93 60.55 999999999 145.93 233.77 percent of total billed charges Simple insertion of temporary bladder tube 2764677_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.93 233.77 Simple insertion of temporary bladder tube 2764677_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.93 233.77 Simple insertion of temporary bladder tube 2764677_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 ANTHEM HMO ANTHEM HMO 999999999 145.93 233.77 Simple insertion of temporary bladder tube 2764677_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.92 67.6 999999999 145.93 233.77 percent of total billed charges Simple insertion of temporary bladder tube 2764677_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.93 233.77 Simple insertion of temporary bladder tube 2764677_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.93 233.77 Incision of external hemorrhoid with blood clot 2764680_1 CDM 0450 RC 46083 HCPCS inpatient 618 401.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 401.7 65 999999999 374.2 599.46 percent of total billed charges Incision of external hemorrhoid with blood clot 2764680_1 CDM 0450 RC 46083 HCPCS inpatient 618 401.7 AETNA AETNA 488.22 79 999999999 374.2 599.46 percent of total billed charges Incision of external hemorrhoid with blood clot 2764680_1 CDM 0450 RC 46083 HCPCS inpatient 618 401.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 426.42 69 999999999 374.2 599.46 percent of total billed charges Incision of external hemorrhoid with blood clot 2764680_1 CDM 0450 RC 46083 HCPCS inpatient 618 401.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 599.46 97 999999999 374.2 599.46 percent of total billed charges Incision of external hemorrhoid with blood clot 2764680_1 CDM 0450 RC 46083 HCPCS inpatient 618 401.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 482.04 78 999999999 374.2 599.46 percent of total billed charges Incision of external hemorrhoid with blood clot 2764680_1 CDM 0450 RC 46083 HCPCS inpatient 618 401.7 UMR - ALL PLANS UMR - ALL PLANS 432.6 70 999999999 374.2 599.46 percent of total billed charges Incision of external hemorrhoid with blood clot 2764680_1 CDM 0450 RC 46083 HCPCS inpatient 618 401.7 SIHO - ALL PLANS SIHO - ALL PLANS 556.2 90 999999999 374.2 599.46 percent of total billed charges Incision of external hemorrhoid with blood clot 2764680_1 CDM 0450 RC 46083 HCPCS inpatient 618 401.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 374.2 60.55 999999999 374.2 599.46 percent of total billed charges Incision of external hemorrhoid with blood clot 2764680_1 CDM 0450 RC 46083 HCPCS inpatient 618 401.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 374.2 599.46 Incision of external hemorrhoid with blood clot 2764680_1 CDM 0450 RC 46083 HCPCS inpatient 618 401.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 374.2 599.46 Incision of external hemorrhoid with blood clot 2764680_1 CDM 0450 RC 46083 HCPCS inpatient 618 401.7 ANTHEM HMO ANTHEM HMO 999999999 374.2 599.46 Incision of external hemorrhoid with blood clot 2764680_1 CDM 0450 RC 46083 HCPCS inpatient 618 401.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 417.77 67.6 999999999 374.2 599.46 percent of total billed charges Incision of external hemorrhoid with blood clot 2764680_1 CDM 0450 RC 46083 HCPCS inpatient 618 401.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 374.2 599.46 Incision of external hemorrhoid with blood clot 2764680_1 CDM 0450 RC 46083 HCPCS inpatient 618 401.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 374.2 599.46 Insertion of temporary bladder tube 2764681_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 144.95 65 999999999 135.03 216.31 percent of total billed charges Insertion of temporary bladder tube 2764681_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 AETNA AETNA 176.17 79 999999999 135.03 216.31 percent of total billed charges Insertion of temporary bladder tube 2764681_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 153.87 69 999999999 135.03 216.31 percent of total billed charges Insertion of temporary bladder tube 2764681_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 216.31 97 999999999 135.03 216.31 percent of total billed charges Insertion of temporary bladder tube 2764681_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 173.94 78 999999999 135.03 216.31 percent of total billed charges Insertion of temporary bladder tube 2764681_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 UMR - ALL PLANS UMR - ALL PLANS 156.1 70 999999999 135.03 216.31 percent of total billed charges Insertion of temporary bladder tube 2764681_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 SIHO - ALL PLANS SIHO - ALL PLANS 200.7 90 999999999 135.03 216.31 percent of total billed charges Insertion of temporary bladder tube 2764681_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 135.03 60.55 999999999 135.03 216.31 percent of total billed charges Insertion of temporary bladder tube 2764681_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 135.03 216.31 Insertion of temporary bladder tube 2764681_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 135.03 216.31 Insertion of temporary bladder tube 2764681_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 ANTHEM HMO ANTHEM HMO 999999999 135.03 216.31 Insertion of temporary bladder tube 2764681_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 150.75 67.6 999999999 135.03 216.31 percent of total billed charges Insertion of temporary bladder tube 2764681_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 135.03 216.31 Insertion of temporary bladder tube 2764681_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 135.03 216.31 Emergent insertion of breathing tube into windpipe using an endoscope 2764685_1 CDM 0450 RC 31500 HCPCS inpatient 1184 769.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 769.6 65 999999999 716.91 1148.48 percent of total billed charges Emergent insertion of breathing tube into windpipe using an endoscope 2764685_1 CDM 0450 RC 31500 HCPCS inpatient 1184 769.6 AETNA AETNA 935.36 79 999999999 716.91 1148.48 percent of total billed charges Emergent insertion of breathing tube into windpipe using an endoscope 2764685_1 CDM 0450 RC 31500 HCPCS inpatient 1184 769.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 816.96 69 999999999 716.91 1148.48 percent of total billed charges Emergent insertion of breathing tube into windpipe using an endoscope 2764685_1 CDM 0450 RC 31500 HCPCS inpatient 1184 769.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1148.48 97 999999999 716.91 1148.48 percent of total billed charges Emergent insertion of breathing tube into windpipe using an endoscope 2764685_1 CDM 0450 RC 31500 HCPCS inpatient 1184 769.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 923.52 78 999999999 716.91 1148.48 percent of total billed charges Emergent insertion of breathing tube into windpipe using an endoscope 2764685_1 CDM 0450 RC 31500 HCPCS inpatient 1184 769.6 UMR - ALL PLANS UMR - ALL PLANS 828.8 70 999999999 716.91 1148.48 percent of total billed charges Emergent insertion of breathing tube into windpipe using an endoscope 2764685_1 CDM 0450 RC 31500 HCPCS inpatient 1184 769.6 SIHO - ALL PLANS SIHO - ALL PLANS 1065.6 90 999999999 716.91 1148.48 percent of total billed charges Emergent insertion of breathing tube into windpipe using an endoscope 2764685_1 CDM 0450 RC 31500 HCPCS inpatient 1184 769.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 716.91 60.55 999999999 716.91 1148.48 percent of total billed charges Emergent insertion of breathing tube into windpipe using an endoscope 2764685_1 CDM 0450 RC 31500 HCPCS inpatient 1184 769.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 716.91 1148.48 Emergent insertion of breathing tube into windpipe using an endoscope 2764685_1 CDM 0450 RC 31500 HCPCS inpatient 1184 769.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 716.91 1148.48 Emergent insertion of breathing tube into windpipe using an endoscope 2764685_1 CDM 0450 RC 31500 HCPCS inpatient 1184 769.6 ANTHEM HMO ANTHEM HMO 999999999 716.91 1148.48 Emergent insertion of breathing tube into windpipe using an endoscope 2764685_1 CDM 0450 RC 31500 HCPCS inpatient 1184 769.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 800.38 67.6 999999999 716.91 1148.48 percent of total billed charges Emergent insertion of breathing tube into windpipe using an endoscope 2764685_1 CDM 0450 RC 31500 HCPCS inpatient 1184 769.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 716.91 1148.48 Emergent insertion of breathing tube into windpipe using an endoscope 2764685_1 CDM 0450 RC 31500 HCPCS inpatient 1184 769.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 716.91 1148.48 Simple bladder irrigation and/or instillation 2764687_1 CDM 0450 RC 51700 HCPCS inpatient 556 361.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 361.4 65 999999999 336.66 539.32 percent of total billed charges Simple bladder irrigation and/or instillation 2764687_1 CDM 0450 RC 51700 HCPCS inpatient 556 361.4 AETNA AETNA 439.24 79 999999999 336.66 539.32 percent of total billed charges Simple bladder irrigation and/or instillation 2764687_1 CDM 0450 RC 51700 HCPCS inpatient 556 361.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 383.64 69 999999999 336.66 539.32 percent of total billed charges Simple bladder irrigation and/or instillation 2764687_1 CDM 0450 RC 51700 HCPCS inpatient 556 361.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 539.32 97 999999999 336.66 539.32 percent of total billed charges Simple bladder irrigation and/or instillation 2764687_1 CDM 0450 RC 51700 HCPCS inpatient 556 361.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 433.68 78 999999999 336.66 539.32 percent of total billed charges Simple bladder irrigation and/or instillation 2764687_1 CDM 0450 RC 51700 HCPCS inpatient 556 361.4 UMR - ALL PLANS UMR - ALL PLANS 389.2 70 999999999 336.66 539.32 percent of total billed charges Simple bladder irrigation and/or instillation 2764687_1 CDM 0450 RC 51700 HCPCS inpatient 556 361.4 SIHO - ALL PLANS SIHO - ALL PLANS 500.4 90 999999999 336.66 539.32 percent of total billed charges Simple bladder irrigation and/or instillation 2764687_1 CDM 0450 RC 51700 HCPCS inpatient 556 361.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 336.66 60.55 999999999 336.66 539.32 percent of total billed charges Simple bladder irrigation and/or instillation 2764687_1 CDM 0450 RC 51700 HCPCS inpatient 556 361.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 336.66 539.32 Simple bladder irrigation and/or instillation 2764687_1 CDM 0450 RC 51700 HCPCS inpatient 556 361.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 336.66 539.32 Simple bladder irrigation and/or instillation 2764687_1 CDM 0450 RC 51700 HCPCS inpatient 556 361.4 ANTHEM HMO ANTHEM HMO 999999999 336.66 539.32 Simple bladder irrigation and/or instillation 2764687_1 CDM 0450 RC 51700 HCPCS inpatient 556 361.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 375.86 67.6 999999999 336.66 539.32 percent of total billed charges Simple bladder irrigation and/or instillation 2764687_1 CDM 0450 RC 51700 HCPCS inpatient 556 361.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 336.66 539.32 Simple bladder irrigation and/or instillation 2764687_1 CDM 0450 RC 51700 HCPCS inpatient 556 361.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 336.66 539.32 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 2764689_1 CDM 0450 RC 62270 HCPCS inpatient 807 524.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 524.55 65 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 2764689_1 CDM 0450 RC 62270 HCPCS inpatient 807 524.55 AETNA AETNA 637.53 79 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 2764689_1 CDM 0450 RC 62270 HCPCS inpatient 807 524.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 556.83 69 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 2764689_1 CDM 0450 RC 62270 HCPCS inpatient 807 524.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 782.79 97 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 2764689_1 CDM 0450 RC 62270 HCPCS inpatient 807 524.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 629.46 78 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 2764689_1 CDM 0450 RC 62270 HCPCS inpatient 807 524.55 UMR - ALL PLANS UMR - ALL PLANS 564.9 70 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 2764689_1 CDM 0450 RC 62270 HCPCS inpatient 807 524.55 SIHO - ALL PLANS SIHO - ALL PLANS 726.3 90 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 2764689_1 CDM 0450 RC 62270 HCPCS inpatient 807 524.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 488.64 60.55 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 2764689_1 CDM 0450 RC 62270 HCPCS inpatient 807 524.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 488.64 782.79 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 2764689_1 CDM 0450 RC 62270 HCPCS inpatient 807 524.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 488.64 782.79 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 2764689_1 CDM 0450 RC 62270 HCPCS inpatient 807 524.55 ANTHEM HMO ANTHEM HMO 999999999 488.64 782.79 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 2764689_1 CDM 0450 RC 62270 HCPCS inpatient 807 524.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 545.53 67.6 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 2764689_1 CDM 0450 RC 62270 HCPCS inpatient 807 524.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 488.64 782.79 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 2764689_1 CDM 0450 RC 62270 HCPCS inpatient 807 524.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 488.64 782.79 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 2764692_1 CDM 0450 RC 96367 HCPCS inpatient 104 67.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 67.6 65 999999999 62.97 100.88 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 2764692_1 CDM 0450 RC 96367 HCPCS inpatient 104 67.6 AETNA AETNA 82.16 79 999999999 62.97 100.88 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 2764692_1 CDM 0450 RC 96367 HCPCS inpatient 104 67.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.76 69 999999999 62.97 100.88 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 2764692_1 CDM 0450 RC 96367 HCPCS inpatient 104 67.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 100.88 97 999999999 62.97 100.88 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 2764692_1 CDM 0450 RC 96367 HCPCS inpatient 104 67.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.12 78 999999999 62.97 100.88 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 2764692_1 CDM 0450 RC 96367 HCPCS inpatient 104 67.6 UMR - ALL PLANS UMR - ALL PLANS 72.8 70 999999999 62.97 100.88 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 2764692_1 CDM 0450 RC 96367 HCPCS inpatient 104 67.6 SIHO - ALL PLANS SIHO - ALL PLANS 93.6 90 999999999 62.97 100.88 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 2764692_1 CDM 0450 RC 96367 HCPCS inpatient 104 67.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.97 60.55 999999999 62.97 100.88 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 2764692_1 CDM 0450 RC 96367 HCPCS inpatient 104 67.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.97 100.88 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 2764692_1 CDM 0450 RC 96367 HCPCS inpatient 104 67.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.97 100.88 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 2764692_1 CDM 0450 RC 96367 HCPCS inpatient 104 67.6 ANTHEM HMO ANTHEM HMO 999999999 62.97 100.88 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 2764692_1 CDM 0450 RC 96367 HCPCS inpatient 104 67.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.3 67.6 999999999 62.97 100.88 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 2764692_1 CDM 0450 RC 96367 HCPCS inpatient 104 67.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.97 100.88 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 2764692_1 CDM 0450 RC 96367 HCPCS inpatient 104 67.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.97 100.88 Suture of nonobstetrical injury of vagina 2764696_1 CDM 0450 RC 57200 HCPCS inpatient 3651 2373.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 2373.15 65 999999999 2210.68 3541.47 percent of total billed charges Suture of nonobstetrical injury of vagina 2764696_1 CDM 0450 RC 57200 HCPCS inpatient 3651 2373.15 AETNA AETNA 2884.29 79 999999999 2210.68 3541.47 percent of total billed charges Suture of nonobstetrical injury of vagina 2764696_1 CDM 0450 RC 57200 HCPCS inpatient 3651 2373.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 2519.19 69 999999999 2210.68 3541.47 percent of total billed charges Suture of nonobstetrical injury of vagina 2764696_1 CDM 0450 RC 57200 HCPCS inpatient 3651 2373.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3541.47 97 999999999 2210.68 3541.47 percent of total billed charges Suture of nonobstetrical injury of vagina 2764696_1 CDM 0450 RC 57200 HCPCS inpatient 3651 2373.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 2847.78 78 999999999 2210.68 3541.47 percent of total billed charges Suture of nonobstetrical injury of vagina 2764696_1 CDM 0450 RC 57200 HCPCS inpatient 3651 2373.15 UMR - ALL PLANS UMR - ALL PLANS 2555.7 70 999999999 2210.68 3541.47 percent of total billed charges Suture of nonobstetrical injury of vagina 2764696_1 CDM 0450 RC 57200 HCPCS inpatient 3651 2373.15 SIHO - ALL PLANS SIHO - ALL PLANS 3285.9 90 999999999 2210.68 3541.47 percent of total billed charges Suture of nonobstetrical injury of vagina 2764696_1 CDM 0450 RC 57200 HCPCS inpatient 3651 2373.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2210.68 60.55 999999999 2210.68 3541.47 percent of total billed charges Suture of nonobstetrical injury of vagina 2764696_1 CDM 0450 RC 57200 HCPCS inpatient 3651 2373.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2210.68 3541.47 Suture of nonobstetrical injury of vagina 2764696_1 CDM 0450 RC 57200 HCPCS inpatient 3651 2373.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2210.68 3541.47 Suture of nonobstetrical injury of vagina 2764696_1 CDM 0450 RC 57200 HCPCS inpatient 3651 2373.15 ANTHEM HMO ANTHEM HMO 999999999 2210.68 3541.47 Suture of nonobstetrical injury of vagina 2764696_1 CDM 0450 RC 57200 HCPCS inpatient 3651 2373.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 2468.08 67.6 999999999 2210.68 3541.47 percent of total billed charges Suture of nonobstetrical injury of vagina 2764696_1 CDM 0450 RC 57200 HCPCS inpatient 3651 2373.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2210.68 3541.47 Suture of nonobstetrical injury of vagina 2764696_1 CDM 0450 RC 57200 HCPCS inpatient 3651 2373.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 2210.68 3541.47 Removal of foreign body in cornea using slit lamp 2764701_1 CDM 0450 RC 65222 HCPCS inpatient 567 368.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 368.55 65 999999999 343.32 549.99 percent of total billed charges Removal of foreign body in cornea using slit lamp 2764701_1 CDM 0450 RC 65222 HCPCS inpatient 567 368.55 AETNA AETNA 447.93 79 999999999 343.32 549.99 percent of total billed charges Removal of foreign body in cornea using slit lamp 2764701_1 CDM 0450 RC 65222 HCPCS inpatient 567 368.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 391.23 69 999999999 343.32 549.99 percent of total billed charges Removal of foreign body in cornea using slit lamp 2764701_1 CDM 0450 RC 65222 HCPCS inpatient 567 368.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 549.99 97 999999999 343.32 549.99 percent of total billed charges Removal of foreign body in cornea using slit lamp 2764701_1 CDM 0450 RC 65222 HCPCS inpatient 567 368.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 442.26 78 999999999 343.32 549.99 percent of total billed charges Removal of foreign body in cornea using slit lamp 2764701_1 CDM 0450 RC 65222 HCPCS inpatient 567 368.55 UMR - ALL PLANS UMR - ALL PLANS 396.9 70 999999999 343.32 549.99 percent of total billed charges Removal of foreign body in cornea using slit lamp 2764701_1 CDM 0450 RC 65222 HCPCS inpatient 567 368.55 SIHO - ALL PLANS SIHO - ALL PLANS 510.3 90 999999999 343.32 549.99 percent of total billed charges Removal of foreign body in cornea using slit lamp 2764701_1 CDM 0450 RC 65222 HCPCS inpatient 567 368.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 343.32 60.55 999999999 343.32 549.99 percent of total billed charges Removal of foreign body in cornea using slit lamp 2764701_1 CDM 0450 RC 65222 HCPCS inpatient 567 368.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 343.32 549.99 Removal of foreign body in cornea using slit lamp 2764701_1 CDM 0450 RC 65222 HCPCS inpatient 567 368.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 343.32 549.99 Removal of foreign body in cornea using slit lamp 2764701_1 CDM 0450 RC 65222 HCPCS inpatient 567 368.55 ANTHEM HMO ANTHEM HMO 999999999 343.32 549.99 Removal of foreign body in cornea using slit lamp 2764701_1 CDM 0450 RC 65222 HCPCS inpatient 567 368.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 383.29 67.6 999999999 343.32 549.99 percent of total billed charges Removal of foreign body in cornea using slit lamp 2764701_1 CDM 0450 RC 65222 HCPCS inpatient 567 368.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 343.32 549.99 Removal of foreign body in cornea using slit lamp 2764701_1 CDM 0450 RC 65222 HCPCS inpatient 567 368.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 343.32 549.99 Removal of foreign body in cornea 2764703_1 CDM 0450 RC 65220 HCPCS inpatient 502 326.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 326.3 65 999999999 303.96 486.94 percent of total billed charges Removal of foreign body in cornea 2764703_1 CDM 0450 RC 65220 HCPCS inpatient 502 326.3 AETNA AETNA 396.58 79 999999999 303.96 486.94 percent of total billed charges Removal of foreign body in cornea 2764703_1 CDM 0450 RC 65220 HCPCS inpatient 502 326.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 346.38 69 999999999 303.96 486.94 percent of total billed charges Removal of foreign body in cornea 2764703_1 CDM 0450 RC 65220 HCPCS inpatient 502 326.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 486.94 97 999999999 303.96 486.94 percent of total billed charges Removal of foreign body in cornea 2764703_1 CDM 0450 RC 65220 HCPCS inpatient 502 326.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 391.56 78 999999999 303.96 486.94 percent of total billed charges Removal of foreign body in cornea 2764703_1 CDM 0450 RC 65220 HCPCS inpatient 502 326.3 UMR - ALL PLANS UMR - ALL PLANS 351.4 70 999999999 303.96 486.94 percent of total billed charges Removal of foreign body in cornea 2764703_1 CDM 0450 RC 65220 HCPCS inpatient 502 326.3 SIHO - ALL PLANS SIHO - ALL PLANS 451.8 90 999999999 303.96 486.94 percent of total billed charges Removal of foreign body in cornea 2764703_1 CDM 0450 RC 65220 HCPCS inpatient 502 326.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 303.96 60.55 999999999 303.96 486.94 percent of total billed charges Removal of foreign body in cornea 2764703_1 CDM 0450 RC 65220 HCPCS inpatient 502 326.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 303.96 486.94 Removal of foreign body in cornea 2764703_1 CDM 0450 RC 65220 HCPCS inpatient 502 326.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 303.96 486.94 Removal of foreign body in cornea 2764703_1 CDM 0450 RC 65220 HCPCS inpatient 502 326.3 ANTHEM HMO ANTHEM HMO 999999999 303.96 486.94 Removal of foreign body in cornea 2764703_1 CDM 0450 RC 65220 HCPCS inpatient 502 326.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 339.35 67.6 999999999 303.96 486.94 percent of total billed charges Removal of foreign body in cornea 2764703_1 CDM 0450 RC 65220 HCPCS inpatient 502 326.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 303.96 486.94 Removal of foreign body in cornea 2764703_1 CDM 0450 RC 65220 HCPCS inpatient 502 326.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 303.96 486.94 Removal of foreign body in ear canal 2764704_1 CDM 0450 RC 69200 HCPCS inpatient 426 276.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 276.9 65 999999999 257.94 413.22 percent of total billed charges Removal of foreign body in ear canal 2764704_1 CDM 0450 RC 69200 HCPCS inpatient 426 276.9 AETNA AETNA 336.54 79 999999999 257.94 413.22 percent of total billed charges Removal of foreign body in ear canal 2764704_1 CDM 0450 RC 69200 HCPCS inpatient 426 276.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 293.94 69 999999999 257.94 413.22 percent of total billed charges Removal of foreign body in ear canal 2764704_1 CDM 0450 RC 69200 HCPCS inpatient 426 276.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 413.22 97 999999999 257.94 413.22 percent of total billed charges Removal of foreign body in ear canal 2764704_1 CDM 0450 RC 69200 HCPCS inpatient 426 276.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 332.28 78 999999999 257.94 413.22 percent of total billed charges Removal of foreign body in ear canal 2764704_1 CDM 0450 RC 69200 HCPCS inpatient 426 276.9 UMR - ALL PLANS UMR - ALL PLANS 298.2 70 999999999 257.94 413.22 percent of total billed charges Removal of foreign body in ear canal 2764704_1 CDM 0450 RC 69200 HCPCS inpatient 426 276.9 SIHO - ALL PLANS SIHO - ALL PLANS 383.4 90 999999999 257.94 413.22 percent of total billed charges Removal of foreign body in ear canal 2764704_1 CDM 0450 RC 69200 HCPCS inpatient 426 276.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 257.94 60.55 999999999 257.94 413.22 percent of total billed charges Removal of foreign body in ear canal 2764704_1 CDM 0450 RC 69200 HCPCS inpatient 426 276.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 257.94 413.22 Removal of foreign body in ear canal 2764704_1 CDM 0450 RC 69200 HCPCS inpatient 426 276.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 257.94 413.22 Removal of foreign body in ear canal 2764704_1 CDM 0450 RC 69200 HCPCS inpatient 426 276.9 ANTHEM HMO ANTHEM HMO 999999999 257.94 413.22 Removal of foreign body in ear canal 2764704_1 CDM 0450 RC 69200 HCPCS inpatient 426 276.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 287.98 67.6 999999999 257.94 413.22 percent of total billed charges Removal of foreign body in ear canal 2764704_1 CDM 0450 RC 69200 HCPCS inpatient 426 276.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 257.94 413.22 Removal of foreign body in ear canal 2764704_1 CDM 0450 RC 69200 HCPCS inpatient 426 276.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 257.94 413.22 Removal of foreign body from external eye (conjunctiva) 2764706_1 CDM 0450 RC 65205 HCPCS inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges Removal of foreign body from external eye (conjunctiva) 2764706_1 CDM 0450 RC 65205 HCPCS inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges Removal of foreign body from external eye (conjunctiva) 2764706_1 CDM 0450 RC 65205 HCPCS inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges Removal of foreign body from external eye (conjunctiva) 2764706_1 CDM 0450 RC 65205 HCPCS inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges Removal of foreign body from external eye (conjunctiva) 2764706_1 CDM 0450 RC 65205 HCPCS inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges Removal of foreign body from external eye (conjunctiva) 2764706_1 CDM 0450 RC 65205 HCPCS inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges Removal of foreign body from external eye (conjunctiva) 2764706_1 CDM 0450 RC 65205 HCPCS inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges Removal of foreign body from external eye (conjunctiva) 2764706_1 CDM 0450 RC 65205 HCPCS inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges Removal of foreign body from external eye (conjunctiva) 2764706_1 CDM 0450 RC 65205 HCPCS inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 Removal of foreign body from external eye (conjunctiva) 2764706_1 CDM 0450 RC 65205 HCPCS inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 Removal of foreign body from external eye (conjunctiva) 2764706_1 CDM 0450 RC 65205 HCPCS inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 Removal of foreign body from external eye (conjunctiva) 2764706_1 CDM 0450 RC 65205 HCPCS inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges Removal of foreign body from external eye (conjunctiva) 2764706_1 CDM 0450 RC 65205 HCPCS inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 Removal of foreign body from external eye (conjunctiva) 2764706_1 CDM 0450 RC 65205 HCPCS inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 Removal of foreign body in nose 2764711_1 CDM 0450 RC 30300 HCPCS inpatient 366 237.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 237.9 65 999999999 221.61 355.02 percent of total billed charges Removal of foreign body in nose 2764711_1 CDM 0450 RC 30300 HCPCS inpatient 366 237.9 AETNA AETNA 289.14 79 999999999 221.61 355.02 percent of total billed charges Removal of foreign body in nose 2764711_1 CDM 0450 RC 30300 HCPCS inpatient 366 237.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 252.54 69 999999999 221.61 355.02 percent of total billed charges Removal of foreign body in nose 2764711_1 CDM 0450 RC 30300 HCPCS inpatient 366 237.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.02 97 999999999 221.61 355.02 percent of total billed charges Removal of foreign body in nose 2764711_1 CDM 0450 RC 30300 HCPCS inpatient 366 237.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 285.48 78 999999999 221.61 355.02 percent of total billed charges Removal of foreign body in nose 2764711_1 CDM 0450 RC 30300 HCPCS inpatient 366 237.9 UMR - ALL PLANS UMR - ALL PLANS 256.2 70 999999999 221.61 355.02 percent of total billed charges Removal of foreign body in nose 2764711_1 CDM 0450 RC 30300 HCPCS inpatient 366 237.9 SIHO - ALL PLANS SIHO - ALL PLANS 329.4 90 999999999 221.61 355.02 percent of total billed charges Removal of foreign body in nose 2764711_1 CDM 0450 RC 30300 HCPCS inpatient 366 237.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 221.61 60.55 999999999 221.61 355.02 percent of total billed charges Removal of foreign body in nose 2764711_1 CDM 0450 RC 30300 HCPCS inpatient 366 237.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 221.61 355.02 Removal of foreign body in nose 2764711_1 CDM 0450 RC 30300 HCPCS inpatient 366 237.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 221.61 355.02 Removal of foreign body in nose 2764711_1 CDM 0450 RC 30300 HCPCS inpatient 366 237.9 ANTHEM HMO ANTHEM HMO 999999999 221.61 355.02 Removal of foreign body in nose 2764711_1 CDM 0450 RC 30300 HCPCS inpatient 366 237.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 247.42 67.6 999999999 221.61 355.02 percent of total billed charges Removal of foreign body in nose 2764711_1 CDM 0450 RC 30300 HCPCS inpatient 366 237.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 221.61 355.02 Removal of foreign body in nose 2764711_1 CDM 0450 RC 30300 HCPCS inpatient 366 237.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 221.61 355.02 Removal of IUD 2764714_1 CDM 0450 RC 58301 HCPCS inpatient 286 185.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.9 65 999999999 173.17 277.42 percent of total billed charges Removal of IUD 2764714_1 CDM 0450 RC 58301 HCPCS inpatient 286 185.9 AETNA AETNA 225.94 79 999999999 173.17 277.42 percent of total billed charges Removal of IUD 2764714_1 CDM 0450 RC 58301 HCPCS inpatient 286 185.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 197.34 69 999999999 173.17 277.42 percent of total billed charges Removal of IUD 2764714_1 CDM 0450 RC 58301 HCPCS inpatient 286 185.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 277.42 97 999999999 173.17 277.42 percent of total billed charges Removal of IUD 2764714_1 CDM 0450 RC 58301 HCPCS inpatient 286 185.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 223.08 78 999999999 173.17 277.42 percent of total billed charges Removal of IUD 2764714_1 CDM 0450 RC 58301 HCPCS inpatient 286 185.9 UMR - ALL PLANS UMR - ALL PLANS 200.2 70 999999999 173.17 277.42 percent of total billed charges Removal of IUD 2764714_1 CDM 0450 RC 58301 HCPCS inpatient 286 185.9 SIHO - ALL PLANS SIHO - ALL PLANS 257.4 90 999999999 173.17 277.42 percent of total billed charges Removal of IUD 2764714_1 CDM 0450 RC 58301 HCPCS inpatient 286 185.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 173.17 60.55 999999999 173.17 277.42 percent of total billed charges Removal of IUD 2764714_1 CDM 0450 RC 58301 HCPCS inpatient 286 185.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 173.17 277.42 Removal of IUD 2764714_1 CDM 0450 RC 58301 HCPCS inpatient 286 185.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 173.17 277.42 Removal of IUD 2764714_1 CDM 0450 RC 58301 HCPCS inpatient 286 185.9 ANTHEM HMO ANTHEM HMO 999999999 173.17 277.42 Removal of IUD 2764714_1 CDM 0450 RC 58301 HCPCS inpatient 286 185.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 193.34 67.6 999999999 173.17 277.42 percent of total billed charges Removal of IUD 2764714_1 CDM 0450 RC 58301 HCPCS inpatient 286 185.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 173.17 277.42 Removal of IUD 2764714_1 CDM 0450 RC 58301 HCPCS inpatient 286 185.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 173.17 277.42 Removal of impacted ear wax 2764717_1 CDM 0450 RC 69210 HCPCS inpatient 401 260.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 260.65 65 999999999 242.81 388.97 percent of total billed charges Removal of impacted ear wax 2764717_1 CDM 0450 RC 69210 HCPCS inpatient 401 260.65 AETNA AETNA 316.79 79 999999999 242.81 388.97 percent of total billed charges Removal of impacted ear wax 2764717_1 CDM 0450 RC 69210 HCPCS inpatient 401 260.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 276.69 69 999999999 242.81 388.97 percent of total billed charges Removal of impacted ear wax 2764717_1 CDM 0450 RC 69210 HCPCS inpatient 401 260.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 388.97 97 999999999 242.81 388.97 percent of total billed charges Removal of impacted ear wax 2764717_1 CDM 0450 RC 69210 HCPCS inpatient 401 260.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 312.78 78 999999999 242.81 388.97 percent of total billed charges Removal of impacted ear wax 2764717_1 CDM 0450 RC 69210 HCPCS inpatient 401 260.65 UMR - ALL PLANS UMR - ALL PLANS 280.7 70 999999999 242.81 388.97 percent of total billed charges Removal of impacted ear wax 2764717_1 CDM 0450 RC 69210 HCPCS inpatient 401 260.65 SIHO - ALL PLANS SIHO - ALL PLANS 360.9 90 999999999 242.81 388.97 percent of total billed charges Removal of impacted ear wax 2764717_1 CDM 0450 RC 69210 HCPCS inpatient 401 260.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 242.81 60.55 999999999 242.81 388.97 percent of total billed charges Removal of impacted ear wax 2764717_1 CDM 0450 RC 69210 HCPCS inpatient 401 260.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 242.81 388.97 Removal of impacted ear wax 2764717_1 CDM 0450 RC 69210 HCPCS inpatient 401 260.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 242.81 388.97 Removal of impacted ear wax 2764717_1 CDM 0450 RC 69210 HCPCS inpatient 401 260.65 ANTHEM HMO ANTHEM HMO 999999999 242.81 388.97 Removal of impacted ear wax 2764717_1 CDM 0450 RC 69210 HCPCS inpatient 401 260.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 271.08 67.6 999999999 242.81 388.97 percent of total billed charges Removal of impacted ear wax 2764717_1 CDM 0450 RC 69210 HCPCS inpatient 401 260.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 242.81 388.97 Removal of impacted ear wax 2764717_1 CDM 0450 RC 69210 HCPCS inpatient 401 260.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 242.81 388.97 "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, each additional 5.0 cm or less" 2764724_1 CDM 0450 RC 13133 HCPCS inpatient 894 581.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 581.1 65 999999999 541.32 867.18 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, each additional 5.0 cm or less" 2764724_1 CDM 0450 RC 13133 HCPCS inpatient 894 581.1 AETNA AETNA 706.26 79 999999999 541.32 867.18 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, each additional 5.0 cm or less" 2764724_1 CDM 0450 RC 13133 HCPCS inpatient 894 581.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 616.86 69 999999999 541.32 867.18 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, each additional 5.0 cm or less" 2764724_1 CDM 0450 RC 13133 HCPCS inpatient 894 581.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 867.18 97 999999999 541.32 867.18 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, each additional 5.0 cm or less" 2764724_1 CDM 0450 RC 13133 HCPCS inpatient 894 581.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 697.32 78 999999999 541.32 867.18 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, each additional 5.0 cm or less" 2764724_1 CDM 0450 RC 13133 HCPCS inpatient 894 581.1 UMR - ALL PLANS UMR - ALL PLANS 625.8 70 999999999 541.32 867.18 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, each additional 5.0 cm or less" 2764724_1 CDM 0450 RC 13133 HCPCS inpatient 894 581.1 SIHO - ALL PLANS SIHO - ALL PLANS 804.6 90 999999999 541.32 867.18 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, each additional 5.0 cm or less" 2764724_1 CDM 0450 RC 13133 HCPCS inpatient 894 581.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 541.32 60.55 999999999 541.32 867.18 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, each additional 5.0 cm or less" 2764724_1 CDM 0450 RC 13133 HCPCS inpatient 894 581.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 541.32 867.18 "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, each additional 5.0 cm or less" 2764724_1 CDM 0450 RC 13133 HCPCS inpatient 894 581.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 541.32 867.18 "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, each additional 5.0 cm or less" 2764724_1 CDM 0450 RC 13133 HCPCS inpatient 894 581.1 ANTHEM HMO ANTHEM HMO 999999999 541.32 867.18 "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, each additional 5.0 cm or less" 2764724_1 CDM 0450 RC 13133 HCPCS inpatient 894 581.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 604.34 67.6 999999999 541.32 867.18 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, each additional 5.0 cm or less" 2764724_1 CDM 0450 RC 13133 HCPCS inpatient 894 581.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 541.32 867.18 "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, each additional 5.0 cm or less" 2764724_1 CDM 0450 RC 13133 HCPCS inpatient 894 581.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 541.32 867.18 "Complicated repair of wound of eyelids, nose, ears, or lip, each additional 5.0 cm or less" 2764726_1 CDM 0450 RC 13153 HCPCS inpatient 868 564.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 564.2 65 999999999 525.57 841.96 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, each additional 5.0 cm or less" 2764726_1 CDM 0450 RC 13153 HCPCS inpatient 868 564.2 AETNA AETNA 685.72 79 999999999 525.57 841.96 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, each additional 5.0 cm or less" 2764726_1 CDM 0450 RC 13153 HCPCS inpatient 868 564.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 598.92 69 999999999 525.57 841.96 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, each additional 5.0 cm or less" 2764726_1 CDM 0450 RC 13153 HCPCS inpatient 868 564.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 841.96 97 999999999 525.57 841.96 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, each additional 5.0 cm or less" 2764726_1 CDM 0450 RC 13153 HCPCS inpatient 868 564.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 677.04 78 999999999 525.57 841.96 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, each additional 5.0 cm or less" 2764726_1 CDM 0450 RC 13153 HCPCS inpatient 868 564.2 UMR - ALL PLANS UMR - ALL PLANS 607.6 70 999999999 525.57 841.96 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, each additional 5.0 cm or less" 2764726_1 CDM 0450 RC 13153 HCPCS inpatient 868 564.2 SIHO - ALL PLANS SIHO - ALL PLANS 781.2 90 999999999 525.57 841.96 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, each additional 5.0 cm or less" 2764726_1 CDM 0450 RC 13153 HCPCS inpatient 868 564.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 525.57 60.55 999999999 525.57 841.96 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, each additional 5.0 cm or less" 2764726_1 CDM 0450 RC 13153 HCPCS inpatient 868 564.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 525.57 841.96 "Complicated repair of wound of eyelids, nose, ears, or lip, each additional 5.0 cm or less" 2764726_1 CDM 0450 RC 13153 HCPCS inpatient 868 564.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 525.57 841.96 "Complicated repair of wound of eyelids, nose, ears, or lip, each additional 5.0 cm or less" 2764726_1 CDM 0450 RC 13153 HCPCS inpatient 868 564.2 ANTHEM HMO ANTHEM HMO 999999999 525.57 841.96 "Complicated repair of wound of eyelids, nose, ears, or lip, each additional 5.0 cm or less" 2764726_1 CDM 0450 RC 13153 HCPCS inpatient 868 564.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 586.77 67.6 999999999 525.57 841.96 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, each additional 5.0 cm or less" 2764726_1 CDM 0450 RC 13153 HCPCS inpatient 868 564.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 525.57 841.96 "Complicated repair of wound of eyelids, nose, ears, or lip, each additional 5.0 cm or less" 2764726_1 CDM 0450 RC 13153 HCPCS inpatient 868 564.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 525.57 841.96 "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 1.1-2.5 cm" 2764731_1 CDM 0450 RC 13131 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 1.1-2.5 cm" 2764731_1 CDM 0450 RC 13131 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 1.1-2.5 cm" 2764731_1 CDM 0450 RC 13131 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 1.1-2.5 cm" 2764731_1 CDM 0450 RC 13131 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 1.1-2.5 cm" 2764731_1 CDM 0450 RC 13131 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 1.1-2.5 cm" 2764731_1 CDM 0450 RC 13131 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 1.1-2.5 cm" 2764731_1 CDM 0450 RC 13131 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 1.1-2.5 cm" 2764731_1 CDM 0450 RC 13131 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 1.1-2.5 cm" 2764731_1 CDM 0450 RC 13131 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 1.1-2.5 cm" 2764731_1 CDM 0450 RC 13131 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 1.1-2.5 cm" 2764731_1 CDM 0450 RC 13131 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 1.1-2.5 cm" 2764731_1 CDM 0450 RC 13131 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 1.1-2.5 cm" 2764731_1 CDM 0450 RC 13131 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 1.1-2.5 cm" 2764731_1 CDM 0450 RC 13131 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 "Complicated repair of wound of eyelids, nose, ears, or lip, 1.1-2.5 cm" 2764733_1 CDM 0450 RC 13151 HCPCS inpatient 855 555.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 555.75 65 999999999 517.7 829.35 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, 1.1-2.5 cm" 2764733_1 CDM 0450 RC 13151 HCPCS inpatient 855 555.75 AETNA AETNA 675.45 79 999999999 517.7 829.35 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, 1.1-2.5 cm" 2764733_1 CDM 0450 RC 13151 HCPCS inpatient 855 555.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 589.95 69 999999999 517.7 829.35 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, 1.1-2.5 cm" 2764733_1 CDM 0450 RC 13151 HCPCS inpatient 855 555.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 829.35 97 999999999 517.7 829.35 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, 1.1-2.5 cm" 2764733_1 CDM 0450 RC 13151 HCPCS inpatient 855 555.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 666.9 78 999999999 517.7 829.35 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, 1.1-2.5 cm" 2764733_1 CDM 0450 RC 13151 HCPCS inpatient 855 555.75 UMR - ALL PLANS UMR - ALL PLANS 598.5 70 999999999 517.7 829.35 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, 1.1-2.5 cm" 2764733_1 CDM 0450 RC 13151 HCPCS inpatient 855 555.75 SIHO - ALL PLANS SIHO - ALL PLANS 769.5 90 999999999 517.7 829.35 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, 1.1-2.5 cm" 2764733_1 CDM 0450 RC 13151 HCPCS inpatient 855 555.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 517.7 60.55 999999999 517.7 829.35 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, 1.1-2.5 cm" 2764733_1 CDM 0450 RC 13151 HCPCS inpatient 855 555.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 517.7 829.35 "Complicated repair of wound of eyelids, nose, ears, or lip, 1.1-2.5 cm" 2764733_1 CDM 0450 RC 13151 HCPCS inpatient 855 555.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 517.7 829.35 "Complicated repair of wound of eyelids, nose, ears, or lip, 1.1-2.5 cm" 2764733_1 CDM 0450 RC 13151 HCPCS inpatient 855 555.75 ANTHEM HMO ANTHEM HMO 999999999 517.7 829.35 "Complicated repair of wound of eyelids, nose, ears, or lip, 1.1-2.5 cm" 2764733_1 CDM 0450 RC 13151 HCPCS inpatient 855 555.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 577.98 67.6 999999999 517.7 829.35 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, 1.1-2.5 cm" 2764733_1 CDM 0450 RC 13151 HCPCS inpatient 855 555.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 517.7 829.35 "Complicated repair of wound of eyelids, nose, ears, or lip, 1.1-2.5 cm" 2764733_1 CDM 0450 RC 13151 HCPCS inpatient 855 555.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 517.7 829.35 "Complicated repair of wound of scalp, arms, or legs, 1.1-2.5 cm" 2764735_1 CDM 0450 RC 13120 HCPCS inpatient 861 559.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 559.65 65 999999999 521.34 835.17 percent of total billed charges "Complicated repair of wound of scalp, arms, or legs, 1.1-2.5 cm" 2764735_1 CDM 0450 RC 13120 HCPCS inpatient 861 559.65 AETNA AETNA 680.19 79 999999999 521.34 835.17 percent of total billed charges "Complicated repair of wound of scalp, arms, or legs, 1.1-2.5 cm" 2764735_1 CDM 0450 RC 13120 HCPCS inpatient 861 559.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 594.09 69 999999999 521.34 835.17 percent of total billed charges "Complicated repair of wound of scalp, arms, or legs, 1.1-2.5 cm" 2764735_1 CDM 0450 RC 13120 HCPCS inpatient 861 559.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 835.17 97 999999999 521.34 835.17 percent of total billed charges "Complicated repair of wound of scalp, arms, or legs, 1.1-2.5 cm" 2764735_1 CDM 0450 RC 13120 HCPCS inpatient 861 559.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 671.58 78 999999999 521.34 835.17 percent of total billed charges "Complicated repair of wound of scalp, arms, or legs, 1.1-2.5 cm" 2764735_1 CDM 0450 RC 13120 HCPCS inpatient 861 559.65 UMR - ALL PLANS UMR - ALL PLANS 602.7 70 999999999 521.34 835.17 percent of total billed charges "Complicated repair of wound of scalp, arms, or legs, 1.1-2.5 cm" 2764735_1 CDM 0450 RC 13120 HCPCS inpatient 861 559.65 SIHO - ALL PLANS SIHO - ALL PLANS 774.9 90 999999999 521.34 835.17 percent of total billed charges "Complicated repair of wound of scalp, arms, or legs, 1.1-2.5 cm" 2764735_1 CDM 0450 RC 13120 HCPCS inpatient 861 559.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 521.34 60.55 999999999 521.34 835.17 percent of total billed charges "Complicated repair of wound of scalp, arms, or legs, 1.1-2.5 cm" 2764735_1 CDM 0450 RC 13120 HCPCS inpatient 861 559.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 521.34 835.17 "Complicated repair of wound of scalp, arms, or legs, 1.1-2.5 cm" 2764735_1 CDM 0450 RC 13120 HCPCS inpatient 861 559.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 521.34 835.17 "Complicated repair of wound of scalp, arms, or legs, 1.1-2.5 cm" 2764735_1 CDM 0450 RC 13120 HCPCS inpatient 861 559.65 ANTHEM HMO ANTHEM HMO 999999999 521.34 835.17 "Complicated repair of wound of scalp, arms, or legs, 1.1-2.5 cm" 2764735_1 CDM 0450 RC 13120 HCPCS inpatient 861 559.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 582.04 67.6 999999999 521.34 835.17 percent of total billed charges "Complicated repair of wound of scalp, arms, or legs, 1.1-2.5 cm" 2764735_1 CDM 0450 RC 13120 HCPCS inpatient 861 559.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 521.34 835.17 "Complicated repair of wound of scalp, arms, or legs, 1.1-2.5 cm" 2764735_1 CDM 0450 RC 13120 HCPCS inpatient 861 559.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 521.34 835.17 "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 2.6-7.5 cm" 2764738_1 CDM 0450 RC 13132 HCPCS inpatient 881 572.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 572.65 65 999999999 533.45 854.57 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 2.6-7.5 cm" 2764738_1 CDM 0450 RC 13132 HCPCS inpatient 881 572.65 AETNA AETNA 695.99 79 999999999 533.45 854.57 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 2.6-7.5 cm" 2764738_1 CDM 0450 RC 13132 HCPCS inpatient 881 572.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 607.89 69 999999999 533.45 854.57 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 2.6-7.5 cm" 2764738_1 CDM 0450 RC 13132 HCPCS inpatient 881 572.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 854.57 97 999999999 533.45 854.57 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 2.6-7.5 cm" 2764738_1 CDM 0450 RC 13132 HCPCS inpatient 881 572.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 687.18 78 999999999 533.45 854.57 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 2.6-7.5 cm" 2764738_1 CDM 0450 RC 13132 HCPCS inpatient 881 572.65 UMR - ALL PLANS UMR - ALL PLANS 616.7 70 999999999 533.45 854.57 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 2.6-7.5 cm" 2764738_1 CDM 0450 RC 13132 HCPCS inpatient 881 572.65 SIHO - ALL PLANS SIHO - ALL PLANS 792.9 90 999999999 533.45 854.57 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 2.6-7.5 cm" 2764738_1 CDM 0450 RC 13132 HCPCS inpatient 881 572.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 533.45 60.55 999999999 533.45 854.57 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 2.6-7.5 cm" 2764738_1 CDM 0450 RC 13132 HCPCS inpatient 881 572.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 533.45 854.57 "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 2.6-7.5 cm" 2764738_1 CDM 0450 RC 13132 HCPCS inpatient 881 572.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 533.45 854.57 "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 2.6-7.5 cm" 2764738_1 CDM 0450 RC 13132 HCPCS inpatient 881 572.65 ANTHEM HMO ANTHEM HMO 999999999 533.45 854.57 "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 2.6-7.5 cm" 2764738_1 CDM 0450 RC 13132 HCPCS inpatient 881 572.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 595.56 67.6 999999999 533.45 854.57 percent of total billed charges "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 2.6-7.5 cm" 2764738_1 CDM 0450 RC 13132 HCPCS inpatient 881 572.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 533.45 854.57 "Complicated repair of wound of forehead, cheeks, chin, mouth, neck, underarms, genitals, hands, or feet, 2.6-7.5 cm" 2764738_1 CDM 0450 RC 13132 HCPCS inpatient 881 572.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 533.45 854.57 "Complicated repair of wound of eyelids, nose, ears, or lip, 2.6-7.5 cm" 2764740_1 CDM 0450 RC 13152 HCPCS inpatient 861 559.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 559.65 65 999999999 521.34 835.17 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, 2.6-7.5 cm" 2764740_1 CDM 0450 RC 13152 HCPCS inpatient 861 559.65 AETNA AETNA 680.19 79 999999999 521.34 835.17 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, 2.6-7.5 cm" 2764740_1 CDM 0450 RC 13152 HCPCS inpatient 861 559.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 594.09 69 999999999 521.34 835.17 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, 2.6-7.5 cm" 2764740_1 CDM 0450 RC 13152 HCPCS inpatient 861 559.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 835.17 97 999999999 521.34 835.17 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, 2.6-7.5 cm" 2764740_1 CDM 0450 RC 13152 HCPCS inpatient 861 559.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 671.58 78 999999999 521.34 835.17 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, 2.6-7.5 cm" 2764740_1 CDM 0450 RC 13152 HCPCS inpatient 861 559.65 UMR - ALL PLANS UMR - ALL PLANS 602.7 70 999999999 521.34 835.17 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, 2.6-7.5 cm" 2764740_1 CDM 0450 RC 13152 HCPCS inpatient 861 559.65 SIHO - ALL PLANS SIHO - ALL PLANS 774.9 90 999999999 521.34 835.17 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, 2.6-7.5 cm" 2764740_1 CDM 0450 RC 13152 HCPCS inpatient 861 559.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 521.34 60.55 999999999 521.34 835.17 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, 2.6-7.5 cm" 2764740_1 CDM 0450 RC 13152 HCPCS inpatient 861 559.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 521.34 835.17 "Complicated repair of wound of eyelids, nose, ears, or lip, 2.6-7.5 cm" 2764740_1 CDM 0450 RC 13152 HCPCS inpatient 861 559.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 521.34 835.17 "Complicated repair of wound of eyelids, nose, ears, or lip, 2.6-7.5 cm" 2764740_1 CDM 0450 RC 13152 HCPCS inpatient 861 559.65 ANTHEM HMO ANTHEM HMO 999999999 521.34 835.17 "Complicated repair of wound of eyelids, nose, ears, or lip, 2.6-7.5 cm" 2764740_1 CDM 0450 RC 13152 HCPCS inpatient 861 559.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 582.04 67.6 999999999 521.34 835.17 percent of total billed charges "Complicated repair of wound of eyelids, nose, ears, or lip, 2.6-7.5 cm" 2764740_1 CDM 0450 RC 13152 HCPCS inpatient 861 559.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 521.34 835.17 "Complicated repair of wound of eyelids, nose, ears, or lip, 2.6-7.5 cm" 2764740_1 CDM 0450 RC 13152 HCPCS inpatient 861 559.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 521.34 835.17 "Complicated repair of wound of scalp, arms, or legs, 2.6-7.5 cm" 2764742_1 CDM 0450 RC 13121 HCPCS inpatient 868 564.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 564.2 65 999999999 525.57 841.96 percent of total billed charges "Complicated repair of wound of scalp, arms, or legs, 2.6-7.5 cm" 2764742_1 CDM 0450 RC 13121 HCPCS inpatient 868 564.2 AETNA AETNA 685.72 79 999999999 525.57 841.96 percent of total billed charges "Complicated repair of wound of scalp, arms, or legs, 2.6-7.5 cm" 2764742_1 CDM 0450 RC 13121 HCPCS inpatient 868 564.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 598.92 69 999999999 525.57 841.96 percent of total billed charges "Complicated repair of wound of scalp, arms, or legs, 2.6-7.5 cm" 2764742_1 CDM 0450 RC 13121 HCPCS inpatient 868 564.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 841.96 97 999999999 525.57 841.96 percent of total billed charges "Complicated repair of wound of scalp, arms, or legs, 2.6-7.5 cm" 2764742_1 CDM 0450 RC 13121 HCPCS inpatient 868 564.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 677.04 78 999999999 525.57 841.96 percent of total billed charges "Complicated repair of wound of scalp, arms, or legs, 2.6-7.5 cm" 2764742_1 CDM 0450 RC 13121 HCPCS inpatient 868 564.2 UMR - ALL PLANS UMR - ALL PLANS 607.6 70 999999999 525.57 841.96 percent of total billed charges "Complicated repair of wound of scalp, arms, or legs, 2.6-7.5 cm" 2764742_1 CDM 0450 RC 13121 HCPCS inpatient 868 564.2 SIHO - ALL PLANS SIHO - ALL PLANS 781.2 90 999999999 525.57 841.96 percent of total billed charges "Complicated repair of wound of scalp, arms, or legs, 2.6-7.5 cm" 2764742_1 CDM 0450 RC 13121 HCPCS inpatient 868 564.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 525.57 60.55 999999999 525.57 841.96 percent of total billed charges "Complicated repair of wound of scalp, arms, or legs, 2.6-7.5 cm" 2764742_1 CDM 0450 RC 13121 HCPCS inpatient 868 564.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 525.57 841.96 "Complicated repair of wound of scalp, arms, or legs, 2.6-7.5 cm" 2764742_1 CDM 0450 RC 13121 HCPCS inpatient 868 564.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 525.57 841.96 "Complicated repair of wound of scalp, arms, or legs, 2.6-7.5 cm" 2764742_1 CDM 0450 RC 13121 HCPCS inpatient 868 564.2 ANTHEM HMO ANTHEM HMO 999999999 525.57 841.96 "Complicated repair of wound of scalp, arms, or legs, 2.6-7.5 cm" 2764742_1 CDM 0450 RC 13121 HCPCS inpatient 868 564.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 586.77 67.6 999999999 525.57 841.96 percent of total billed charges "Complicated repair of wound of scalp, arms, or legs, 2.6-7.5 cm" 2764742_1 CDM 0450 RC 13121 HCPCS inpatient 868 564.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 525.57 841.96 "Complicated repair of wound of scalp, arms, or legs, 2.6-7.5 cm" 2764742_1 CDM 0450 RC 13121 HCPCS inpatient 868 564.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 525.57 841.96 Application of nonmoveable finger splint 2764753_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 262.6 65 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 2764753_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 AETNA AETNA 319.16 79 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 2764753_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 278.76 69 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 2764753_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 391.88 97 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 2764753_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 315.12 78 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 2764753_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 UMR - ALL PLANS UMR - ALL PLANS 282.8 70 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 2764753_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 SIHO - ALL PLANS SIHO - ALL PLANS 363.6 90 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 2764753_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 244.62 60.55 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 2764753_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 244.62 391.88 Application of nonmoveable finger splint 2764753_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 244.62 391.88 Application of nonmoveable finger splint 2764753_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 ANTHEM HMO ANTHEM HMO 999999999 244.62 391.88 Application of nonmoveable finger splint 2764753_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 273.1 67.6 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 2764753_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 244.62 391.88 Application of nonmoveable finger splint 2764753_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 244.62 391.88 Application of lower and upper arm splint 2764757_1 CDM 0450 RC 29105 HCPCS inpatient 529 343.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 343.85 65 999999999 320.31 513.13 percent of total billed charges Application of lower and upper arm splint 2764757_1 CDM 0450 RC 29105 HCPCS inpatient 529 343.85 AETNA AETNA 417.91 79 999999999 320.31 513.13 percent of total billed charges Application of lower and upper arm splint 2764757_1 CDM 0450 RC 29105 HCPCS inpatient 529 343.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 365.01 69 999999999 320.31 513.13 percent of total billed charges Application of lower and upper arm splint 2764757_1 CDM 0450 RC 29105 HCPCS inpatient 529 343.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 513.13 97 999999999 320.31 513.13 percent of total billed charges Application of lower and upper arm splint 2764757_1 CDM 0450 RC 29105 HCPCS inpatient 529 343.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 412.62 78 999999999 320.31 513.13 percent of total billed charges Application of lower and upper arm splint 2764757_1 CDM 0450 RC 29105 HCPCS inpatient 529 343.85 UMR - ALL PLANS UMR - ALL PLANS 370.3 70 999999999 320.31 513.13 percent of total billed charges Application of lower and upper arm splint 2764757_1 CDM 0450 RC 29105 HCPCS inpatient 529 343.85 SIHO - ALL PLANS SIHO - ALL PLANS 476.1 90 999999999 320.31 513.13 percent of total billed charges Application of lower and upper arm splint 2764757_1 CDM 0450 RC 29105 HCPCS inpatient 529 343.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 320.31 60.55 999999999 320.31 513.13 percent of total billed charges Application of lower and upper arm splint 2764757_1 CDM 0450 RC 29105 HCPCS inpatient 529 343.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 320.31 513.13 Application of lower and upper arm splint 2764757_1 CDM 0450 RC 29105 HCPCS inpatient 529 343.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 320.31 513.13 Application of lower and upper arm splint 2764757_1 CDM 0450 RC 29105 HCPCS inpatient 529 343.85 ANTHEM HMO ANTHEM HMO 999999999 320.31 513.13 Application of lower and upper arm splint 2764757_1 CDM 0450 RC 29105 HCPCS inpatient 529 343.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 357.6 67.6 999999999 320.31 513.13 percent of total billed charges Application of lower and upper arm splint 2764757_1 CDM 0450 RC 29105 HCPCS inpatient 529 343.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 320.31 513.13 Application of lower and upper arm splint 2764757_1 CDM 0450 RC 29105 HCPCS inpatient 529 343.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 320.31 513.13 Application of long leg splint from thigh to ankle or toe 2764760_1 CDM 0450 RC 29505 HCPCS inpatient 244 158.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 158.6 65 999999999 147.74 236.68 percent of total billed charges Application of long leg splint from thigh to ankle or toe 2764760_1 CDM 0450 RC 29505 HCPCS inpatient 244 158.6 AETNA AETNA 192.76 79 999999999 147.74 236.68 percent of total billed charges Application of long leg splint from thigh to ankle or toe 2764760_1 CDM 0450 RC 29505 HCPCS inpatient 244 158.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 168.36 69 999999999 147.74 236.68 percent of total billed charges Application of long leg splint from thigh to ankle or toe 2764760_1 CDM 0450 RC 29505 HCPCS inpatient 244 158.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 236.68 97 999999999 147.74 236.68 percent of total billed charges Application of long leg splint from thigh to ankle or toe 2764760_1 CDM 0450 RC 29505 HCPCS inpatient 244 158.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 190.32 78 999999999 147.74 236.68 percent of total billed charges Application of long leg splint from thigh to ankle or toe 2764760_1 CDM 0450 RC 29505 HCPCS inpatient 244 158.6 UMR - ALL PLANS UMR - ALL PLANS 170.8 70 999999999 147.74 236.68 percent of total billed charges Application of long leg splint from thigh to ankle or toe 2764760_1 CDM 0450 RC 29505 HCPCS inpatient 244 158.6 SIHO - ALL PLANS SIHO - ALL PLANS 219.6 90 999999999 147.74 236.68 percent of total billed charges Application of long leg splint from thigh to ankle or toe 2764760_1 CDM 0450 RC 29505 HCPCS inpatient 244 158.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.74 60.55 999999999 147.74 236.68 percent of total billed charges Application of long leg splint from thigh to ankle or toe 2764760_1 CDM 0450 RC 29505 HCPCS inpatient 244 158.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.74 236.68 Application of long leg splint from thigh to ankle or toe 2764760_1 CDM 0450 RC 29505 HCPCS inpatient 244 158.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.74 236.68 Application of long leg splint from thigh to ankle or toe 2764760_1 CDM 0450 RC 29505 HCPCS inpatient 244 158.6 ANTHEM HMO ANTHEM HMO 999999999 147.74 236.68 Application of long leg splint from thigh to ankle or toe 2764760_1 CDM 0450 RC 29505 HCPCS inpatient 244 158.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.94 67.6 999999999 147.74 236.68 percent of total billed charges Application of long leg splint from thigh to ankle or toe 2764760_1 CDM 0450 RC 29505 HCPCS inpatient 244 158.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.74 236.68 Application of long leg splint from thigh to ankle or toe 2764760_1 CDM 0450 RC 29505 HCPCS inpatient 244 158.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.74 236.68 Application of nonmoveable forearm to hand splint 2764764_1 CDM 0450 RC 29125 HCPCS inpatient 438 284.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 284.7 65 999999999 265.21 424.86 percent of total billed charges Application of nonmoveable forearm to hand splint 2764764_1 CDM 0450 RC 29125 HCPCS inpatient 438 284.7 AETNA AETNA 346.02 79 999999999 265.21 424.86 percent of total billed charges Application of nonmoveable forearm to hand splint 2764764_1 CDM 0450 RC 29125 HCPCS inpatient 438 284.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 302.22 69 999999999 265.21 424.86 percent of total billed charges Application of nonmoveable forearm to hand splint 2764764_1 CDM 0450 RC 29125 HCPCS inpatient 438 284.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 424.86 97 999999999 265.21 424.86 percent of total billed charges Application of nonmoveable forearm to hand splint 2764764_1 CDM 0450 RC 29125 HCPCS inpatient 438 284.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 341.64 78 999999999 265.21 424.86 percent of total billed charges Application of nonmoveable forearm to hand splint 2764764_1 CDM 0450 RC 29125 HCPCS inpatient 438 284.7 UMR - ALL PLANS UMR - ALL PLANS 306.6 70 999999999 265.21 424.86 percent of total billed charges Application of nonmoveable forearm to hand splint 2764764_1 CDM 0450 RC 29125 HCPCS inpatient 438 284.7 SIHO - ALL PLANS SIHO - ALL PLANS 394.2 90 999999999 265.21 424.86 percent of total billed charges Application of nonmoveable forearm to hand splint 2764764_1 CDM 0450 RC 29125 HCPCS inpatient 438 284.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 265.21 60.55 999999999 265.21 424.86 percent of total billed charges Application of nonmoveable forearm to hand splint 2764764_1 CDM 0450 RC 29125 HCPCS inpatient 438 284.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 265.21 424.86 Application of nonmoveable forearm to hand splint 2764764_1 CDM 0450 RC 29125 HCPCS inpatient 438 284.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 265.21 424.86 Application of nonmoveable forearm to hand splint 2764764_1 CDM 0450 RC 29125 HCPCS inpatient 438 284.7 ANTHEM HMO ANTHEM HMO 999999999 265.21 424.86 Application of nonmoveable forearm to hand splint 2764764_1 CDM 0450 RC 29125 HCPCS inpatient 438 284.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 296.09 67.6 999999999 265.21 424.86 percent of total billed charges Application of nonmoveable forearm to hand splint 2764764_1 CDM 0450 RC 29125 HCPCS inpatient 438 284.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 265.21 424.86 Application of nonmoveable forearm to hand splint 2764764_1 CDM 0450 RC 29125 HCPCS inpatient 438 284.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 265.21 424.86 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 2764765_1 CDM 0450 RC 12035 HCPCS inpatient 690 448.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 448.5 65 999999999 417.8 669.3 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 2764765_1 CDM 0450 RC 12035 HCPCS inpatient 690 448.5 AETNA AETNA 545.1 79 999999999 417.8 669.3 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 2764765_1 CDM 0450 RC 12035 HCPCS inpatient 690 448.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 476.1 69 999999999 417.8 669.3 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 2764765_1 CDM 0450 RC 12035 HCPCS inpatient 690 448.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 669.3 97 999999999 417.8 669.3 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 2764765_1 CDM 0450 RC 12035 HCPCS inpatient 690 448.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 538.2 78 999999999 417.8 669.3 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 2764765_1 CDM 0450 RC 12035 HCPCS inpatient 690 448.5 UMR - ALL PLANS UMR - ALL PLANS 483 70 999999999 417.8 669.3 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 2764765_1 CDM 0450 RC 12035 HCPCS inpatient 690 448.5 SIHO - ALL PLANS SIHO - ALL PLANS 621 90 999999999 417.8 669.3 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 2764765_1 CDM 0450 RC 12035 HCPCS inpatient 690 448.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 417.8 60.55 999999999 417.8 669.3 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 2764765_1 CDM 0450 RC 12035 HCPCS inpatient 690 448.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 417.8 669.3 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 2764765_1 CDM 0450 RC 12035 HCPCS inpatient 690 448.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 417.8 669.3 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 2764765_1 CDM 0450 RC 12035 HCPCS inpatient 690 448.5 ANTHEM HMO ANTHEM HMO 999999999 417.8 669.3 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 2764765_1 CDM 0450 RC 12035 HCPCS inpatient 690 448.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 466.44 67.6 999999999 417.8 669.3 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 2764765_1 CDM 0450 RC 12035 HCPCS inpatient 690 448.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 417.8 669.3 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 2764765_1 CDM 0450 RC 12035 HCPCS inpatient 690 448.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 417.8 669.3 Application of short leg splint from calf to foot 2764768_1 CDM 0450 RC 29515 HCPCS inpatient 287 186.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 186.55 65 999999999 173.78 278.39 percent of total billed charges Application of short leg splint from calf to foot 2764768_1 CDM 0450 RC 29515 HCPCS inpatient 287 186.55 AETNA AETNA 226.73 79 999999999 173.78 278.39 percent of total billed charges Application of short leg splint from calf to foot 2764768_1 CDM 0450 RC 29515 HCPCS inpatient 287 186.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 198.03 69 999999999 173.78 278.39 percent of total billed charges Application of short leg splint from calf to foot 2764768_1 CDM 0450 RC 29515 HCPCS inpatient 287 186.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 278.39 97 999999999 173.78 278.39 percent of total billed charges Application of short leg splint from calf to foot 2764768_1 CDM 0450 RC 29515 HCPCS inpatient 287 186.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 223.86 78 999999999 173.78 278.39 percent of total billed charges Application of short leg splint from calf to foot 2764768_1 CDM 0450 RC 29515 HCPCS inpatient 287 186.55 UMR - ALL PLANS UMR - ALL PLANS 200.9 70 999999999 173.78 278.39 percent of total billed charges Application of short leg splint from calf to foot 2764768_1 CDM 0450 RC 29515 HCPCS inpatient 287 186.55 SIHO - ALL PLANS SIHO - ALL PLANS 258.3 90 999999999 173.78 278.39 percent of total billed charges Application of short leg splint from calf to foot 2764768_1 CDM 0450 RC 29515 HCPCS inpatient 287 186.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 173.78 60.55 999999999 173.78 278.39 percent of total billed charges Application of short leg splint from calf to foot 2764768_1 CDM 0450 RC 29515 HCPCS inpatient 287 186.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 173.78 278.39 Application of short leg splint from calf to foot 2764768_1 CDM 0450 RC 29515 HCPCS inpatient 287 186.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 173.78 278.39 Application of short leg splint from calf to foot 2764768_1 CDM 0450 RC 29515 HCPCS inpatient 287 186.55 ANTHEM HMO ANTHEM HMO 999999999 173.78 278.39 Application of short leg splint from calf to foot 2764768_1 CDM 0450 RC 29515 HCPCS inpatient 287 186.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 194.01 67.6 999999999 173.78 278.39 percent of total billed charges Application of short leg splint from calf to foot 2764768_1 CDM 0450 RC 29515 HCPCS inpatient 287 186.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 173.78 278.39 Application of short leg splint from calf to foot 2764768_1 CDM 0450 RC 29515 HCPCS inpatient 287 186.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 173.78 278.39 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 2764769_1 CDM 0450 RC 12055 HCPCS inpatient 651 423.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 423.15 65 999999999 394.18 631.47 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 2764769_1 CDM 0450 RC 12055 HCPCS inpatient 651 423.15 AETNA AETNA 514.29 79 999999999 394.18 631.47 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 2764769_1 CDM 0450 RC 12055 HCPCS inpatient 651 423.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 449.19 69 999999999 394.18 631.47 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 2764769_1 CDM 0450 RC 12055 HCPCS inpatient 651 423.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 631.47 97 999999999 394.18 631.47 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 2764769_1 CDM 0450 RC 12055 HCPCS inpatient 651 423.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 507.78 78 999999999 394.18 631.47 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 2764769_1 CDM 0450 RC 12055 HCPCS inpatient 651 423.15 UMR - ALL PLANS UMR - ALL PLANS 455.7 70 999999999 394.18 631.47 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 2764769_1 CDM 0450 RC 12055 HCPCS inpatient 651 423.15 SIHO - ALL PLANS SIHO - ALL PLANS 585.9 90 999999999 394.18 631.47 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 2764769_1 CDM 0450 RC 12055 HCPCS inpatient 651 423.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 394.18 60.55 999999999 394.18 631.47 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 2764769_1 CDM 0450 RC 12055 HCPCS inpatient 651 423.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 394.18 631.47 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 2764769_1 CDM 0450 RC 12055 HCPCS inpatient 651 423.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 394.18 631.47 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 2764769_1 CDM 0450 RC 12055 HCPCS inpatient 651 423.15 ANTHEM HMO ANTHEM HMO 999999999 394.18 631.47 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 2764769_1 CDM 0450 RC 12055 HCPCS inpatient 651 423.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 440.08 67.6 999999999 394.18 631.47 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 2764769_1 CDM 0450 RC 12055 HCPCS inpatient 651 423.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 394.18 631.47 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 2764769_1 CDM 0450 RC 12055 HCPCS inpatient 651 423.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 394.18 631.47 Aspiration and/or injection of fluid from small joint 2764771_1 CDM 0450 RC 20600 HCPCS inpatient 675 438.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 438.75 65 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 2764771_1 CDM 0450 RC 20600 HCPCS inpatient 675 438.75 AETNA AETNA 533.25 79 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 2764771_1 CDM 0450 RC 20600 HCPCS inpatient 675 438.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 465.75 69 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 2764771_1 CDM 0450 RC 20600 HCPCS inpatient 675 438.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 654.75 97 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 2764771_1 CDM 0450 RC 20600 HCPCS inpatient 675 438.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 526.5 78 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 2764771_1 CDM 0450 RC 20600 HCPCS inpatient 675 438.75 UMR - ALL PLANS UMR - ALL PLANS 472.5 70 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 2764771_1 CDM 0450 RC 20600 HCPCS inpatient 675 438.75 SIHO - ALL PLANS SIHO - ALL PLANS 607.5 90 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 2764771_1 CDM 0450 RC 20600 HCPCS inpatient 675 438.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 408.71 60.55 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 2764771_1 CDM 0450 RC 20600 HCPCS inpatient 675 438.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 408.71 654.75 Aspiration and/or injection of fluid from small joint 2764771_1 CDM 0450 RC 20600 HCPCS inpatient 675 438.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 408.71 654.75 Aspiration and/or injection of fluid from small joint 2764771_1 CDM 0450 RC 20600 HCPCS inpatient 675 438.75 ANTHEM HMO ANTHEM HMO 999999999 408.71 654.75 Aspiration and/or injection of fluid from small joint 2764771_1 CDM 0450 RC 20600 HCPCS inpatient 675 438.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 456.3 67.6 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 2764771_1 CDM 0450 RC 20600 HCPCS inpatient 675 438.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 408.71 654.75 Aspiration and/or injection of fluid from small joint 2764771_1 CDM 0450 RC 20600 HCPCS inpatient 675 438.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 408.71 654.75 "Intermediate repair of wound of neck, hands, feet, or genitals, 2.5 cm or less" 2764774_1 CDM 0450 RC 12041 HCPCS inpatient 561 364.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 364.65 65 999999999 339.69 544.17 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.5 cm or less" 2764774_1 CDM 0450 RC 12041 HCPCS inpatient 561 364.65 AETNA AETNA 443.19 79 999999999 339.69 544.17 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.5 cm or less" 2764774_1 CDM 0450 RC 12041 HCPCS inpatient 561 364.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 387.09 69 999999999 339.69 544.17 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.5 cm or less" 2764774_1 CDM 0450 RC 12041 HCPCS inpatient 561 364.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 544.17 97 999999999 339.69 544.17 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.5 cm or less" 2764774_1 CDM 0450 RC 12041 HCPCS inpatient 561 364.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 437.58 78 999999999 339.69 544.17 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.5 cm or less" 2764774_1 CDM 0450 RC 12041 HCPCS inpatient 561 364.65 UMR - ALL PLANS UMR - ALL PLANS 392.7 70 999999999 339.69 544.17 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.5 cm or less" 2764774_1 CDM 0450 RC 12041 HCPCS inpatient 561 364.65 SIHO - ALL PLANS SIHO - ALL PLANS 504.9 90 999999999 339.69 544.17 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.5 cm or less" 2764774_1 CDM 0450 RC 12041 HCPCS inpatient 561 364.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 339.69 60.55 999999999 339.69 544.17 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.5 cm or less" 2764774_1 CDM 0450 RC 12041 HCPCS inpatient 561 364.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 339.69 544.17 "Intermediate repair of wound of neck, hands, feet, or genitals, 2.5 cm or less" 2764774_1 CDM 0450 RC 12041 HCPCS inpatient 561 364.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 339.69 544.17 "Intermediate repair of wound of neck, hands, feet, or genitals, 2.5 cm or less" 2764774_1 CDM 0450 RC 12041 HCPCS inpatient 561 364.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 339.69 544.17 "Intermediate repair of wound of neck, hands, feet, or genitals, 2.5 cm or less" 2764774_1 CDM 0450 RC 12041 HCPCS inpatient 561 364.65 ANTHEM HMO ANTHEM HMO 999999999 339.69 544.17 "Intermediate repair of wound of neck, hands, feet, or genitals, 2.5 cm or less" 2764774_1 CDM 0450 RC 12041 HCPCS inpatient 561 364.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 379.24 67.6 999999999 339.69 544.17 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.5 cm or less" 2764774_1 CDM 0450 RC 12041 HCPCS inpatient 561 364.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 339.69 544.17 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 2764776_1 CDM 0450 RC 12051 HCPCS inpatient 571 371.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 371.15 65 999999999 345.74 553.87 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 2764776_1 CDM 0450 RC 12051 HCPCS inpatient 571 371.15 AETNA AETNA 451.09 79 999999999 345.74 553.87 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 2764776_1 CDM 0450 RC 12051 HCPCS inpatient 571 371.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 393.99 69 999999999 345.74 553.87 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 2764776_1 CDM 0450 RC 12051 HCPCS inpatient 571 371.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 553.87 97 999999999 345.74 553.87 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 2764776_1 CDM 0450 RC 12051 HCPCS inpatient 571 371.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 445.38 78 999999999 345.74 553.87 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 2764776_1 CDM 0450 RC 12051 HCPCS inpatient 571 371.15 UMR - ALL PLANS UMR - ALL PLANS 399.7 70 999999999 345.74 553.87 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 2764776_1 CDM 0450 RC 12051 HCPCS inpatient 571 371.15 SIHO - ALL PLANS SIHO - ALL PLANS 513.9 90 999999999 345.74 553.87 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 2764776_1 CDM 0450 RC 12051 HCPCS inpatient 571 371.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 345.74 60.55 999999999 345.74 553.87 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 2764776_1 CDM 0450 RC 12051 HCPCS inpatient 571 371.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 345.74 553.87 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 2764776_1 CDM 0450 RC 12051 HCPCS inpatient 571 371.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 345.74 553.87 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 2764776_1 CDM 0450 RC 12051 HCPCS inpatient 571 371.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 345.74 553.87 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 2764776_1 CDM 0450 RC 12051 HCPCS inpatient 571 371.15 ANTHEM HMO ANTHEM HMO 999999999 345.74 553.87 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 2764776_1 CDM 0450 RC 12051 HCPCS inpatient 571 371.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 386 67.6 999999999 345.74 553.87 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 2764776_1 CDM 0450 RC 12051 HCPCS inpatient 571 371.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 345.74 553.87 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 2764778_1 CDM 0450 RC 12052 HCPCS inpatient 586 380.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 380.9 65 999999999 354.82 568.42 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 2764778_1 CDM 0450 RC 12052 HCPCS inpatient 586 380.9 AETNA AETNA 462.94 79 999999999 354.82 568.42 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 2764778_1 CDM 0450 RC 12052 HCPCS inpatient 586 380.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 404.34 69 999999999 354.82 568.42 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 2764778_1 CDM 0450 RC 12052 HCPCS inpatient 586 380.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 568.42 97 999999999 354.82 568.42 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 2764778_1 CDM 0450 RC 12052 HCPCS inpatient 586 380.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 457.08 78 999999999 354.82 568.42 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 2764778_1 CDM 0450 RC 12052 HCPCS inpatient 586 380.9 UMR - ALL PLANS UMR - ALL PLANS 410.2 70 999999999 354.82 568.42 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 2764778_1 CDM 0450 RC 12052 HCPCS inpatient 586 380.9 SIHO - ALL PLANS SIHO - ALL PLANS 527.4 90 999999999 354.82 568.42 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 2764778_1 CDM 0450 RC 12052 HCPCS inpatient 586 380.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 354.82 60.55 999999999 354.82 568.42 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 2764778_1 CDM 0450 RC 12052 HCPCS inpatient 586 380.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 354.82 568.42 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 2764778_1 CDM 0450 RC 12052 HCPCS inpatient 586 380.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 354.82 568.42 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 2764778_1 CDM 0450 RC 12052 HCPCS inpatient 586 380.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 354.82 568.42 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 2764778_1 CDM 0450 RC 12052 HCPCS inpatient 586 380.9 ANTHEM HMO ANTHEM HMO 999999999 354.82 568.42 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 2764778_1 CDM 0450 RC 12052 HCPCS inpatient 586 380.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 396.14 67.6 999999999 354.82 568.42 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 2764778_1 CDM 0450 RC 12052 HCPCS inpatient 586 380.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 354.82 568.42 Replacement of stomach stoma tube 2764781_1 CDM 0450 RC 43762 HCPCS inpatient 600 390 SELF PAY DISCOUNT SELF PAY DISCOUNT 390 65 999999999 363.3 582 percent of total billed charges Replacement of stomach stoma tube 2764781_1 CDM 0450 RC 43762 HCPCS inpatient 600 390 AETNA AETNA 474 79 999999999 363.3 582 percent of total billed charges Replacement of stomach stoma tube 2764781_1 CDM 0450 RC 43762 HCPCS inpatient 600 390 ENCORE - ALL PLANS ENCORE - ALL PLANS 414 69 999999999 363.3 582 percent of total billed charges Replacement of stomach stoma tube 2764781_1 CDM 0450 RC 43762 HCPCS inpatient 600 390 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 582 97 999999999 363.3 582 percent of total billed charges Replacement of stomach stoma tube 2764781_1 CDM 0450 RC 43762 HCPCS inpatient 600 390 HUMANA - ALL PLANS HUMANA - ALL PLANS 468 78 999999999 363.3 582 percent of total billed charges Replacement of stomach stoma tube 2764781_1 CDM 0450 RC 43762 HCPCS inpatient 600 390 UMR - ALL PLANS UMR - ALL PLANS 420 70 999999999 363.3 582 percent of total billed charges Replacement of stomach stoma tube 2764781_1 CDM 0450 RC 43762 HCPCS inpatient 600 390 SIHO - ALL PLANS SIHO - ALL PLANS 540 90 999999999 363.3 582 percent of total billed charges Replacement of stomach stoma tube 2764781_1 CDM 0450 RC 43762 HCPCS inpatient 600 390 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 363.3 60.55 999999999 363.3 582 percent of total billed charges Replacement of stomach stoma tube 2764781_1 CDM 0450 RC 43762 HCPCS inpatient 600 390 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 363.3 582 Replacement of stomach stoma tube 2764781_1 CDM 0450 RC 43762 HCPCS inpatient 600 390 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 363.3 582 Replacement of stomach stoma tube 2764781_1 CDM 0450 RC 43762 HCPCS inpatient 600 390 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 363.3 582 Replacement of stomach stoma tube 2764781_1 CDM 0450 RC 43762 HCPCS inpatient 600 390 ANTHEM HMO ANTHEM HMO 999999999 363.3 582 Replacement of stomach stoma tube 2764781_1 CDM 0450 RC 43762 HCPCS inpatient 600 390 CIGNA - ALL PLANS CIGNA - ALL PLANS 405.6 67.6 999999999 363.3 582 percent of total billed charges Replacement of stomach stoma tube 2764781_1 CDM 0450 RC 43762 HCPCS inpatient 600 390 UHC - ALL PLANS UHC - ALL PLANS 999999999 363.3 582 "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 2764782_1 CDM 0450 RC 12042 HCPCS inpatient 571 371.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 371.15 65 999999999 345.74 553.87 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 2764782_1 CDM 0450 RC 12042 HCPCS inpatient 571 371.15 AETNA AETNA 451.09 79 999999999 345.74 553.87 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 2764782_1 CDM 0450 RC 12042 HCPCS inpatient 571 371.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 393.99 69 999999999 345.74 553.87 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 2764782_1 CDM 0450 RC 12042 HCPCS inpatient 571 371.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 553.87 97 999999999 345.74 553.87 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 2764782_1 CDM 0450 RC 12042 HCPCS inpatient 571 371.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 445.38 78 999999999 345.74 553.87 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 2764782_1 CDM 0450 RC 12042 HCPCS inpatient 571 371.15 SIHO - ALL PLANS SIHO - ALL PLANS 513.9 90 999999999 345.74 553.87 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 2764782_1 CDM 0450 RC 12042 HCPCS inpatient 571 371.15 UMR - ALL PLANS UMR - ALL PLANS 399.7 70 999999999 345.74 553.87 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 2764782_1 CDM 0450 RC 12042 HCPCS inpatient 571 371.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 345.74 60.55 999999999 345.74 553.87 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 2764782_1 CDM 0450 RC 12042 HCPCS inpatient 571 371.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 345.74 553.87 "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 2764782_1 CDM 0450 RC 12042 HCPCS inpatient 571 371.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 345.74 553.87 "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 2764782_1 CDM 0450 RC 12042 HCPCS inpatient 571 371.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 345.74 553.87 "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 2764782_1 CDM 0450 RC 12042 HCPCS inpatient 571 371.15 ANTHEM HMO ANTHEM HMO 999999999 345.74 553.87 "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 2764782_1 CDM 0450 RC 12042 HCPCS inpatient 571 371.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 386 67.6 999999999 345.74 553.87 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 2764782_1 CDM 0450 RC 12042 HCPCS inpatient 571 371.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 345.74 553.87 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 20.1-30.0 cm" 2764784_1 CDM 0450 RC 12036 HCPCS inpatient 632 410.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 410.8 65 999999999 382.68 613.04 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 20.1-30.0 cm" 2764784_1 CDM 0450 RC 12036 HCPCS inpatient 632 410.8 AETNA AETNA 499.28 79 999999999 382.68 613.04 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 20.1-30.0 cm" 2764784_1 CDM 0450 RC 12036 HCPCS inpatient 632 410.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 436.08 69 999999999 382.68 613.04 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 20.1-30.0 cm" 2764784_1 CDM 0450 RC 12036 HCPCS inpatient 632 410.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 613.04 97 999999999 382.68 613.04 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 20.1-30.0 cm" 2764784_1 CDM 0450 RC 12036 HCPCS inpatient 632 410.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 492.96 78 999999999 382.68 613.04 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 20.1-30.0 cm" 2764784_1 CDM 0450 RC 12036 HCPCS inpatient 632 410.8 SIHO - ALL PLANS SIHO - ALL PLANS 568.8 90 999999999 382.68 613.04 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 20.1-30.0 cm" 2764784_1 CDM 0450 RC 12036 HCPCS inpatient 632 410.8 UMR - ALL PLANS UMR - ALL PLANS 442.4 70 999999999 382.68 613.04 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 20.1-30.0 cm" 2764784_1 CDM 0450 RC 12036 HCPCS inpatient 632 410.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 382.68 60.55 999999999 382.68 613.04 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 20.1-30.0 cm" 2764784_1 CDM 0450 RC 12036 HCPCS inpatient 632 410.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 382.68 613.04 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 20.1-30.0 cm" 2764784_1 CDM 0450 RC 12036 HCPCS inpatient 632 410.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 382.68 613.04 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 20.1-30.0 cm" 2764784_1 CDM 0450 RC 12036 HCPCS inpatient 632 410.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 382.68 613.04 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 20.1-30.0 cm" 2764784_1 CDM 0450 RC 12036 HCPCS inpatient 632 410.8 ANTHEM HMO ANTHEM HMO 999999999 382.68 613.04 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 20.1-30.0 cm" 2764784_1 CDM 0450 RC 12036 HCPCS inpatient 632 410.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 427.23 67.6 999999999 382.68 613.04 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 20.1-30.0 cm" 2764784_1 CDM 0450 RC 12036 HCPCS inpatient 632 410.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 382.68 613.04 Closed treatment of dislocated shoulder and broken upper arm bone at shoulder joint with manipulation 2764787_1 CDM 0450 RC 23665 HCPCS inpatient 2116 1375.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1375.4 65 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of dislocated shoulder and broken upper arm bone at shoulder joint with manipulation 2764787_1 CDM 0450 RC 23665 HCPCS inpatient 2116 1375.4 AETNA AETNA 1671.64 79 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of dislocated shoulder and broken upper arm bone at shoulder joint with manipulation 2764787_1 CDM 0450 RC 23665 HCPCS inpatient 2116 1375.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1460.04 69 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of dislocated shoulder and broken upper arm bone at shoulder joint with manipulation 2764787_1 CDM 0450 RC 23665 HCPCS inpatient 2116 1375.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2052.52 97 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of dislocated shoulder and broken upper arm bone at shoulder joint with manipulation 2764787_1 CDM 0450 RC 23665 HCPCS inpatient 2116 1375.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1650.48 78 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of dislocated shoulder and broken upper arm bone at shoulder joint with manipulation 2764787_1 CDM 0450 RC 23665 HCPCS inpatient 2116 1375.4 SIHO - ALL PLANS SIHO - ALL PLANS 1904.4 90 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of dislocated shoulder and broken upper arm bone at shoulder joint with manipulation 2764787_1 CDM 0450 RC 23665 HCPCS inpatient 2116 1375.4 UMR - ALL PLANS UMR - ALL PLANS 1481.2 70 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of dislocated shoulder and broken upper arm bone at shoulder joint with manipulation 2764787_1 CDM 0450 RC 23665 HCPCS inpatient 2116 1375.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1281.24 60.55 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of dislocated shoulder and broken upper arm bone at shoulder joint with manipulation 2764787_1 CDM 0450 RC 23665 HCPCS inpatient 2116 1375.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1281.24 2052.52 Closed treatment of dislocated shoulder and broken upper arm bone at shoulder joint with manipulation 2764787_1 CDM 0450 RC 23665 HCPCS inpatient 2116 1375.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1281.24 2052.52 Closed treatment of dislocated shoulder and broken upper arm bone at shoulder joint with manipulation 2764787_1 CDM 0450 RC 23665 HCPCS inpatient 2116 1375.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1281.24 2052.52 Closed treatment of dislocated shoulder and broken upper arm bone at shoulder joint with manipulation 2764787_1 CDM 0450 RC 23665 HCPCS inpatient 2116 1375.4 ANTHEM HMO ANTHEM HMO 999999999 1281.24 2052.52 Closed treatment of dislocated shoulder and broken upper arm bone at shoulder joint with manipulation 2764787_1 CDM 0450 RC 23665 HCPCS inpatient 2116 1375.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1430.42 67.6 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of dislocated shoulder and broken upper arm bone at shoulder joint with manipulation 2764787_1 CDM 0450 RC 23665 HCPCS inpatient 2116 1375.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1281.24 2052.52 Closed treatment of 2 broken lower leg bones at ankle with manipulation 2764789_1 CDM 0450 RC 27810 HCPCS inpatient 503 326.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 326.95 65 999999999 304.57 487.91 percent of total billed charges Closed treatment of 2 broken lower leg bones at ankle with manipulation 2764789_1 CDM 0450 RC 27810 HCPCS inpatient 503 326.95 AETNA AETNA 397.37 79 999999999 304.57 487.91 percent of total billed charges Closed treatment of 2 broken lower leg bones at ankle with manipulation 2764789_1 CDM 0450 RC 27810 HCPCS inpatient 503 326.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 347.07 69 999999999 304.57 487.91 percent of total billed charges Closed treatment of 2 broken lower leg bones at ankle with manipulation 2764789_1 CDM 0450 RC 27810 HCPCS inpatient 503 326.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 487.91 97 999999999 304.57 487.91 percent of total billed charges Closed treatment of 2 broken lower leg bones at ankle with manipulation 2764789_1 CDM 0450 RC 27810 HCPCS inpatient 503 326.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 392.34 78 999999999 304.57 487.91 percent of total billed charges Closed treatment of 2 broken lower leg bones at ankle with manipulation 2764789_1 CDM 0450 RC 27810 HCPCS inpatient 503 326.95 SIHO - ALL PLANS SIHO - ALL PLANS 452.7 90 999999999 304.57 487.91 percent of total billed charges Closed treatment of 2 broken lower leg bones at ankle with manipulation 2764789_1 CDM 0450 RC 27810 HCPCS inpatient 503 326.95 UMR - ALL PLANS UMR - ALL PLANS 352.1 70 999999999 304.57 487.91 percent of total billed charges Closed treatment of 2 broken lower leg bones at ankle with manipulation 2764789_1 CDM 0450 RC 27810 HCPCS inpatient 503 326.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 304.57 60.55 999999999 304.57 487.91 percent of total billed charges Closed treatment of 2 broken lower leg bones at ankle with manipulation 2764789_1 CDM 0450 RC 27810 HCPCS inpatient 503 326.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 304.57 487.91 Closed treatment of 2 broken lower leg bones at ankle with manipulation 2764789_1 CDM 0450 RC 27810 HCPCS inpatient 503 326.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 304.57 487.91 Closed treatment of 2 broken lower leg bones at ankle with manipulation 2764789_1 CDM 0450 RC 27810 HCPCS inpatient 503 326.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 304.57 487.91 Closed treatment of 2 broken lower leg bones at ankle with manipulation 2764789_1 CDM 0450 RC 27810 HCPCS inpatient 503 326.95 ANTHEM HMO ANTHEM HMO 999999999 304.57 487.91 Closed treatment of 2 broken lower leg bones at ankle with manipulation 2764789_1 CDM 0450 RC 27810 HCPCS inpatient 503 326.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 340.03 67.6 999999999 304.57 487.91 percent of total billed charges Closed treatment of 2 broken lower leg bones at ankle with manipulation 2764789_1 CDM 0450 RC 27810 HCPCS inpatient 503 326.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 304.57 487.91 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 2764790_1 CDM 0450 RC 12053 HCPCS inpatient 632 410.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 410.8 65 999999999 382.68 613.04 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 2764790_1 CDM 0450 RC 12053 HCPCS inpatient 632 410.8 AETNA AETNA 499.28 79 999999999 382.68 613.04 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 2764790_1 CDM 0450 RC 12053 HCPCS inpatient 632 410.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 436.08 69 999999999 382.68 613.04 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 2764790_1 CDM 0450 RC 12053 HCPCS inpatient 632 410.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 613.04 97 999999999 382.68 613.04 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 2764790_1 CDM 0450 RC 12053 HCPCS inpatient 632 410.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 492.96 78 999999999 382.68 613.04 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 2764790_1 CDM 0450 RC 12053 HCPCS inpatient 632 410.8 SIHO - ALL PLANS SIHO - ALL PLANS 568.8 90 999999999 382.68 613.04 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 2764790_1 CDM 0450 RC 12053 HCPCS inpatient 632 410.8 UMR - ALL PLANS UMR - ALL PLANS 442.4 70 999999999 382.68 613.04 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 2764790_1 CDM 0450 RC 12053 HCPCS inpatient 632 410.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 382.68 60.55 999999999 382.68 613.04 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 2764790_1 CDM 0450 RC 12053 HCPCS inpatient 632 410.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 382.68 613.04 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 2764790_1 CDM 0450 RC 12053 HCPCS inpatient 632 410.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 382.68 613.04 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 2764790_1 CDM 0450 RC 12053 HCPCS inpatient 632 410.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 382.68 613.04 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 2764790_1 CDM 0450 RC 12053 HCPCS inpatient 632 410.8 ANTHEM HMO ANTHEM HMO 999999999 382.68 613.04 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 2764790_1 CDM 0450 RC 12053 HCPCS inpatient 632 410.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 427.23 67.6 999999999 382.68 613.04 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 2764790_1 CDM 0450 RC 12053 HCPCS inpatient 632 410.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 382.68 613.04 Closed treatment of dislocated finger joint with manipulation under anesthesia 2764791_1 CDM 0450 RC 26775 HCPCS inpatient 1390 903.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 903.5 65 999999999 841.65 1348.3 percent of total billed charges Closed treatment of dislocated finger joint with manipulation under anesthesia 2764791_1 CDM 0450 RC 26775 HCPCS inpatient 1390 903.5 AETNA AETNA 1098.1 79 999999999 841.65 1348.3 percent of total billed charges Closed treatment of dislocated finger joint with manipulation under anesthesia 2764791_1 CDM 0450 RC 26775 HCPCS inpatient 1390 903.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 959.1 69 999999999 841.65 1348.3 percent of total billed charges Closed treatment of dislocated finger joint with manipulation under anesthesia 2764791_1 CDM 0450 RC 26775 HCPCS inpatient 1390 903.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1348.3 97 999999999 841.65 1348.3 percent of total billed charges Closed treatment of dislocated finger joint with manipulation under anesthesia 2764791_1 CDM 0450 RC 26775 HCPCS inpatient 1390 903.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1084.2 78 999999999 841.65 1348.3 percent of total billed charges Closed treatment of dislocated finger joint with manipulation under anesthesia 2764791_1 CDM 0450 RC 26775 HCPCS inpatient 1390 903.5 SIHO - ALL PLANS SIHO - ALL PLANS 1251 90 999999999 841.65 1348.3 percent of total billed charges Closed treatment of dislocated finger joint with manipulation under anesthesia 2764791_1 CDM 0450 RC 26775 HCPCS inpatient 1390 903.5 UMR - ALL PLANS UMR - ALL PLANS 973 70 999999999 841.65 1348.3 percent of total billed charges Closed treatment of dislocated finger joint with manipulation under anesthesia 2764791_1 CDM 0450 RC 26775 HCPCS inpatient 1390 903.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 841.65 60.55 999999999 841.65 1348.3 percent of total billed charges Closed treatment of dislocated finger joint with manipulation under anesthesia 2764791_1 CDM 0450 RC 26775 HCPCS inpatient 1390 903.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 841.65 1348.3 Closed treatment of dislocated finger joint with manipulation under anesthesia 2764791_1 CDM 0450 RC 26775 HCPCS inpatient 1390 903.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 841.65 1348.3 Closed treatment of dislocated finger joint with manipulation under anesthesia 2764791_1 CDM 0450 RC 26775 HCPCS inpatient 1390 903.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 841.65 1348.3 Closed treatment of dislocated finger joint with manipulation under anesthesia 2764791_1 CDM 0450 RC 26775 HCPCS inpatient 1390 903.5 ANTHEM HMO ANTHEM HMO 999999999 841.65 1348.3 Closed treatment of dislocated finger joint with manipulation under anesthesia 2764791_1 CDM 0450 RC 26775 HCPCS inpatient 1390 903.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 939.64 67.6 999999999 841.65 1348.3 percent of total billed charges Closed treatment of dislocated finger joint with manipulation under anesthesia 2764791_1 CDM 0450 RC 26775 HCPCS inpatient 1390 903.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 841.65 1348.3 Closed treatment of broken end of finger or thumb with manipulation 2764793_1 CDM 0450 RC 26755 HCPCS inpatient 388 252.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 252.2 65 999999999 234.93 376.36 percent of total billed charges Closed treatment of broken end of finger or thumb with manipulation 2764793_1 CDM 0450 RC 26755 HCPCS inpatient 388 252.2 AETNA AETNA 306.52 79 999999999 234.93 376.36 percent of total billed charges Closed treatment of broken end of finger or thumb with manipulation 2764793_1 CDM 0450 RC 26755 HCPCS inpatient 388 252.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.72 69 999999999 234.93 376.36 percent of total billed charges Closed treatment of broken end of finger or thumb with manipulation 2764793_1 CDM 0450 RC 26755 HCPCS inpatient 388 252.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 376.36 97 999999999 234.93 376.36 percent of total billed charges Closed treatment of broken end of finger or thumb with manipulation 2764793_1 CDM 0450 RC 26755 HCPCS inpatient 388 252.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 302.64 78 999999999 234.93 376.36 percent of total billed charges Closed treatment of broken end of finger or thumb with manipulation 2764793_1 CDM 0450 RC 26755 HCPCS inpatient 388 252.2 SIHO - ALL PLANS SIHO - ALL PLANS 349.2 90 999999999 234.93 376.36 percent of total billed charges Closed treatment of broken end of finger or thumb with manipulation 2764793_1 CDM 0450 RC 26755 HCPCS inpatient 388 252.2 UMR - ALL PLANS UMR - ALL PLANS 271.6 70 999999999 234.93 376.36 percent of total billed charges Closed treatment of broken end of finger or thumb with manipulation 2764793_1 CDM 0450 RC 26755 HCPCS inpatient 388 252.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.93 60.55 999999999 234.93 376.36 percent of total billed charges Closed treatment of broken end of finger or thumb with manipulation 2764793_1 CDM 0450 RC 26755 HCPCS inpatient 388 252.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.93 376.36 Closed treatment of broken end of finger or thumb with manipulation 2764793_1 CDM 0450 RC 26755 HCPCS inpatient 388 252.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.93 376.36 Closed treatment of broken end of finger or thumb with manipulation 2764793_1 CDM 0450 RC 26755 HCPCS inpatient 388 252.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.93 376.36 Closed treatment of broken end of finger or thumb with manipulation 2764793_1 CDM 0450 RC 26755 HCPCS inpatient 388 252.2 ANTHEM HMO ANTHEM HMO 999999999 234.93 376.36 Closed treatment of broken end of finger or thumb with manipulation 2764793_1 CDM 0450 RC 26755 HCPCS inpatient 388 252.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 262.29 67.6 999999999 234.93 376.36 percent of total billed charges Closed treatment of broken end of finger or thumb with manipulation 2764793_1 CDM 0450 RC 26755 HCPCS inpatient 388 252.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.93 376.36 "Intermediate repair of wound of neck, hands, feet, or genitals, 7.6-12.5 cm" 2764794_1 CDM 0450 RC 12044 HCPCS inpatient 627 407.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 407.55 65 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 7.6-12.5 cm" 2764794_1 CDM 0450 RC 12044 HCPCS inpatient 627 407.55 AETNA AETNA 495.33 79 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 7.6-12.5 cm" 2764794_1 CDM 0450 RC 12044 HCPCS inpatient 627 407.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 432.63 69 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 7.6-12.5 cm" 2764794_1 CDM 0450 RC 12044 HCPCS inpatient 627 407.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 608.19 97 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 7.6-12.5 cm" 2764794_1 CDM 0450 RC 12044 HCPCS inpatient 627 407.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 489.06 78 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 7.6-12.5 cm" 2764794_1 CDM 0450 RC 12044 HCPCS inpatient 627 407.55 SIHO - ALL PLANS SIHO - ALL PLANS 564.3 90 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 7.6-12.5 cm" 2764794_1 CDM 0450 RC 12044 HCPCS inpatient 627 407.55 UMR - ALL PLANS UMR - ALL PLANS 438.9 70 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 7.6-12.5 cm" 2764794_1 CDM 0450 RC 12044 HCPCS inpatient 627 407.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 379.65 60.55 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 7.6-12.5 cm" 2764794_1 CDM 0450 RC 12044 HCPCS inpatient 627 407.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 379.65 608.19 "Intermediate repair of wound of neck, hands, feet, or genitals, 7.6-12.5 cm" 2764794_1 CDM 0450 RC 12044 HCPCS inpatient 627 407.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 379.65 608.19 "Intermediate repair of wound of neck, hands, feet, or genitals, 7.6-12.5 cm" 2764794_1 CDM 0450 RC 12044 HCPCS inpatient 627 407.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 379.65 608.19 "Intermediate repair of wound of neck, hands, feet, or genitals, 7.6-12.5 cm" 2764794_1 CDM 0450 RC 12044 HCPCS inpatient 627 407.55 ANTHEM HMO ANTHEM HMO 999999999 379.65 608.19 "Intermediate repair of wound of neck, hands, feet, or genitals, 7.6-12.5 cm" 2764794_1 CDM 0450 RC 12044 HCPCS inpatient 627 407.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 423.85 67.6 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 7.6-12.5 cm" 2764794_1 CDM 0450 RC 12044 HCPCS inpatient 627 407.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 379.65 608.19 Closed treatment of broken or growth plate separate of forearm bone at wrist with manipulation 2764795_1 CDM 0450 RC 25605 HCPCS inpatient 2116 1375.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1375.4 65 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken or growth plate separate of forearm bone at wrist with manipulation 2764795_1 CDM 0450 RC 25605 HCPCS inpatient 2116 1375.4 AETNA AETNA 1671.64 79 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken or growth plate separate of forearm bone at wrist with manipulation 2764795_1 CDM 0450 RC 25605 HCPCS inpatient 2116 1375.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1460.04 69 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken or growth plate separate of forearm bone at wrist with manipulation 2764795_1 CDM 0450 RC 25605 HCPCS inpatient 2116 1375.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2052.52 97 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken or growth plate separate of forearm bone at wrist with manipulation 2764795_1 CDM 0450 RC 25605 HCPCS inpatient 2116 1375.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1650.48 78 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken or growth plate separate of forearm bone at wrist with manipulation 2764795_1 CDM 0450 RC 25605 HCPCS inpatient 2116 1375.4 SIHO - ALL PLANS SIHO - ALL PLANS 1904.4 90 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken or growth plate separate of forearm bone at wrist with manipulation 2764795_1 CDM 0450 RC 25605 HCPCS inpatient 2116 1375.4 UMR - ALL PLANS UMR - ALL PLANS 1481.2 70 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken or growth plate separate of forearm bone at wrist with manipulation 2764795_1 CDM 0450 RC 25605 HCPCS inpatient 2116 1375.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1281.24 60.55 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken or growth plate separate of forearm bone at wrist with manipulation 2764795_1 CDM 0450 RC 25605 HCPCS inpatient 2116 1375.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1281.24 2052.52 Closed treatment of broken or growth plate separate of forearm bone at wrist with manipulation 2764795_1 CDM 0450 RC 25605 HCPCS inpatient 2116 1375.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1281.24 2052.52 Closed treatment of broken or growth plate separate of forearm bone at wrist with manipulation 2764795_1 CDM 0450 RC 25605 HCPCS inpatient 2116 1375.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1281.24 2052.52 Closed treatment of broken or growth plate separate of forearm bone at wrist with manipulation 2764795_1 CDM 0450 RC 25605 HCPCS inpatient 2116 1375.4 ANTHEM HMO ANTHEM HMO 999999999 1281.24 2052.52 Closed treatment of broken or growth plate separate of forearm bone at wrist with manipulation 2764795_1 CDM 0450 RC 25605 HCPCS inpatient 2116 1375.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1430.42 67.6 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken or growth plate separate of forearm bone at wrist with manipulation 2764795_1 CDM 0450 RC 25605 HCPCS inpatient 2116 1375.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1281.24 2052.52 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 2764796_1 CDM 0450 RC 12054 HCPCS inpatient 639 415.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 415.35 65 999999999 386.91 619.83 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 2764796_1 CDM 0450 RC 12054 HCPCS inpatient 639 415.35 AETNA AETNA 504.81 79 999999999 386.91 619.83 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 2764796_1 CDM 0450 RC 12054 HCPCS inpatient 639 415.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 440.91 69 999999999 386.91 619.83 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 2764796_1 CDM 0450 RC 12054 HCPCS inpatient 639 415.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 619.83 97 999999999 386.91 619.83 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 2764796_1 CDM 0450 RC 12054 HCPCS inpatient 639 415.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 498.42 78 999999999 386.91 619.83 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 2764796_1 CDM 0450 RC 12054 HCPCS inpatient 639 415.35 SIHO - ALL PLANS SIHO - ALL PLANS 575.1 90 999999999 386.91 619.83 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 2764796_1 CDM 0450 RC 12054 HCPCS inpatient 639 415.35 UMR - ALL PLANS UMR - ALL PLANS 447.3 70 999999999 386.91 619.83 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 2764796_1 CDM 0450 RC 12054 HCPCS inpatient 639 415.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 386.91 60.55 999999999 386.91 619.83 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 2764796_1 CDM 0450 RC 12054 HCPCS inpatient 639 415.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 386.91 619.83 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 2764796_1 CDM 0450 RC 12054 HCPCS inpatient 639 415.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 386.91 619.83 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 2764796_1 CDM 0450 RC 12054 HCPCS inpatient 639 415.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 386.91 619.83 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 2764796_1 CDM 0450 RC 12054 HCPCS inpatient 639 415.35 ANTHEM HMO ANTHEM HMO 999999999 386.91 619.83 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 2764796_1 CDM 0450 RC 12054 HCPCS inpatient 639 415.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 431.96 67.6 999999999 386.91 619.83 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 2764796_1 CDM 0450 RC 12054 HCPCS inpatient 639 415.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 386.91 619.83 Closed treatment of dislocated finger joint with manipulation 2764797_1 CDM 0450 RC 26770 HCPCS inpatient 363 235.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 235.95 65 999999999 219.8 352.11 percent of total billed charges Closed treatment of dislocated finger joint with manipulation 2764797_1 CDM 0450 RC 26770 HCPCS inpatient 363 235.95 AETNA AETNA 286.77 79 999999999 219.8 352.11 percent of total billed charges Closed treatment of dislocated finger joint with manipulation 2764797_1 CDM 0450 RC 26770 HCPCS inpatient 363 235.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 250.47 69 999999999 219.8 352.11 percent of total billed charges Closed treatment of dislocated finger joint with manipulation 2764797_1 CDM 0450 RC 26770 HCPCS inpatient 363 235.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 352.11 97 999999999 219.8 352.11 percent of total billed charges Closed treatment of dislocated finger joint with manipulation 2764797_1 CDM 0450 RC 26770 HCPCS inpatient 363 235.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 283.14 78 999999999 219.8 352.11 percent of total billed charges Closed treatment of dislocated finger joint with manipulation 2764797_1 CDM 0450 RC 26770 HCPCS inpatient 363 235.95 SIHO - ALL PLANS SIHO - ALL PLANS 326.7 90 999999999 219.8 352.11 percent of total billed charges Closed treatment of dislocated finger joint with manipulation 2764797_1 CDM 0450 RC 26770 HCPCS inpatient 363 235.95 UMR - ALL PLANS UMR - ALL PLANS 254.1 70 999999999 219.8 352.11 percent of total billed charges Closed treatment of dislocated finger joint with manipulation 2764797_1 CDM 0450 RC 26770 HCPCS inpatient 363 235.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 219.8 60.55 999999999 219.8 352.11 percent of total billed charges Closed treatment of dislocated finger joint with manipulation 2764797_1 CDM 0450 RC 26770 HCPCS inpatient 363 235.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 219.8 352.11 Closed treatment of dislocated finger joint with manipulation 2764797_1 CDM 0450 RC 26770 HCPCS inpatient 363 235.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 219.8 352.11 Closed treatment of dislocated finger joint with manipulation 2764797_1 CDM 0450 RC 26770 HCPCS inpatient 363 235.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 219.8 352.11 Closed treatment of dislocated finger joint with manipulation 2764797_1 CDM 0450 RC 26770 HCPCS inpatient 363 235.95 ANTHEM HMO ANTHEM HMO 999999999 219.8 352.11 Closed treatment of dislocated finger joint with manipulation 2764797_1 CDM 0450 RC 26770 HCPCS inpatient 363 235.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 245.39 67.6 999999999 219.8 352.11 percent of total billed charges Closed treatment of dislocated finger joint with manipulation 2764797_1 CDM 0450 RC 26770 HCPCS inpatient 363 235.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 219.8 352.11 Closed treatment of broken toe with manipulation 2764799_1 CDM 0450 RC 28515 HCPCS inpatient 386 250.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 250.9 65 999999999 233.72 374.42 percent of total billed charges Closed treatment of broken toe with manipulation 2764799_1 CDM 0450 RC 28515 HCPCS inpatient 386 250.9 AETNA AETNA 304.94 79 999999999 233.72 374.42 percent of total billed charges Closed treatment of broken toe with manipulation 2764799_1 CDM 0450 RC 28515 HCPCS inpatient 386 250.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 266.34 69 999999999 233.72 374.42 percent of total billed charges Closed treatment of broken toe with manipulation 2764799_1 CDM 0450 RC 28515 HCPCS inpatient 386 250.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 374.42 97 999999999 233.72 374.42 percent of total billed charges Closed treatment of broken toe with manipulation 2764799_1 CDM 0450 RC 28515 HCPCS inpatient 386 250.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.08 78 999999999 233.72 374.42 percent of total billed charges Closed treatment of broken toe with manipulation 2764799_1 CDM 0450 RC 28515 HCPCS inpatient 386 250.9 SIHO - ALL PLANS SIHO - ALL PLANS 347.4 90 999999999 233.72 374.42 percent of total billed charges Closed treatment of broken toe with manipulation 2764799_1 CDM 0450 RC 28515 HCPCS inpatient 386 250.9 UMR - ALL PLANS UMR - ALL PLANS 270.2 70 999999999 233.72 374.42 percent of total billed charges Closed treatment of broken toe with manipulation 2764799_1 CDM 0450 RC 28515 HCPCS inpatient 386 250.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 233.72 60.55 999999999 233.72 374.42 percent of total billed charges Closed treatment of broken toe with manipulation 2764799_1 CDM 0450 RC 28515 HCPCS inpatient 386 250.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 233.72 374.42 Closed treatment of broken toe with manipulation 2764799_1 CDM 0450 RC 28515 HCPCS inpatient 386 250.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 233.72 374.42 Closed treatment of broken toe with manipulation 2764799_1 CDM 0450 RC 28515 HCPCS inpatient 386 250.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 233.72 374.42 Closed treatment of broken toe with manipulation 2764799_1 CDM 0450 RC 28515 HCPCS inpatient 386 250.9 ANTHEM HMO ANTHEM HMO 999999999 233.72 374.42 Closed treatment of broken toe with manipulation 2764799_1 CDM 0450 RC 28515 HCPCS inpatient 386 250.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 260.94 67.6 999999999 233.72 374.42 percent of total billed charges Closed treatment of broken toe with manipulation 2764799_1 CDM 0450 RC 28515 HCPCS inpatient 386 250.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 233.72 374.42 Closed treatment of dislocated hip prosthesis 2764801_1 CDM 0450 RC 27265 HCPCS inpatient 509 330.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 330.85 65 999999999 308.2 493.73 percent of total billed charges Closed treatment of dislocated hip prosthesis 2764801_1 CDM 0450 RC 27265 HCPCS inpatient 509 330.85 AETNA AETNA 402.11 79 999999999 308.2 493.73 percent of total billed charges Closed treatment of dislocated hip prosthesis 2764801_1 CDM 0450 RC 27265 HCPCS inpatient 509 330.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 351.21 69 999999999 308.2 493.73 percent of total billed charges Closed treatment of dislocated hip prosthesis 2764801_1 CDM 0450 RC 27265 HCPCS inpatient 509 330.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 493.73 97 999999999 308.2 493.73 percent of total billed charges Closed treatment of dislocated hip prosthesis 2764801_1 CDM 0450 RC 27265 HCPCS inpatient 509 330.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 397.02 78 999999999 308.2 493.73 percent of total billed charges Closed treatment of dislocated hip prosthesis 2764801_1 CDM 0450 RC 27265 HCPCS inpatient 509 330.85 SIHO - ALL PLANS SIHO - ALL PLANS 458.1 90 999999999 308.2 493.73 percent of total billed charges Closed treatment of dislocated hip prosthesis 2764801_1 CDM 0450 RC 27265 HCPCS inpatient 509 330.85 UMR - ALL PLANS UMR - ALL PLANS 356.3 70 999999999 308.2 493.73 percent of total billed charges Closed treatment of dislocated hip prosthesis 2764801_1 CDM 0450 RC 27265 HCPCS inpatient 509 330.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 308.2 60.55 999999999 308.2 493.73 percent of total billed charges Closed treatment of dislocated hip prosthesis 2764801_1 CDM 0450 RC 27265 HCPCS inpatient 509 330.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 308.2 493.73 Closed treatment of dislocated hip prosthesis 2764801_1 CDM 0450 RC 27265 HCPCS inpatient 509 330.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 308.2 493.73 Closed treatment of dislocated hip prosthesis 2764801_1 CDM 0450 RC 27265 HCPCS inpatient 509 330.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 308.2 493.73 Closed treatment of dislocated hip prosthesis 2764801_1 CDM 0450 RC 27265 HCPCS inpatient 509 330.85 ANTHEM HMO ANTHEM HMO 999999999 308.2 493.73 Closed treatment of dislocated hip prosthesis 2764801_1 CDM 0450 RC 27265 HCPCS inpatient 509 330.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 344.08 67.6 999999999 308.2 493.73 percent of total billed charges Closed treatment of dislocated hip prosthesis 2764801_1 CDM 0450 RC 27265 HCPCS inpatient 509 330.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 308.2 493.73 Closed treatment of dislocated knee 2764803_1 CDM 0450 RC 27550 HCPCS inpatient 503 326.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 326.95 65 999999999 304.57 487.91 percent of total billed charges Closed treatment of dislocated knee 2764803_1 CDM 0450 RC 27550 HCPCS inpatient 503 326.95 AETNA AETNA 397.37 79 999999999 304.57 487.91 percent of total billed charges Closed treatment of dislocated knee 2764803_1 CDM 0450 RC 27550 HCPCS inpatient 503 326.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 347.07 69 999999999 304.57 487.91 percent of total billed charges Closed treatment of dislocated knee 2764803_1 CDM 0450 RC 27550 HCPCS inpatient 503 326.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 487.91 97 999999999 304.57 487.91 percent of total billed charges Closed treatment of dislocated knee 2764803_1 CDM 0450 RC 27550 HCPCS inpatient 503 326.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 392.34 78 999999999 304.57 487.91 percent of total billed charges Closed treatment of dislocated knee 2764803_1 CDM 0450 RC 27550 HCPCS inpatient 503 326.95 SIHO - ALL PLANS SIHO - ALL PLANS 452.7 90 999999999 304.57 487.91 percent of total billed charges Closed treatment of dislocated knee 2764803_1 CDM 0450 RC 27550 HCPCS inpatient 503 326.95 UMR - ALL PLANS UMR - ALL PLANS 352.1 70 999999999 304.57 487.91 percent of total billed charges Closed treatment of dislocated knee 2764803_1 CDM 0450 RC 27550 HCPCS inpatient 503 326.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 304.57 60.55 999999999 304.57 487.91 percent of total billed charges Closed treatment of dislocated knee 2764803_1 CDM 0450 RC 27550 HCPCS inpatient 503 326.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 304.57 487.91 Closed treatment of dislocated knee 2764803_1 CDM 0450 RC 27550 HCPCS inpatient 503 326.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 304.57 487.91 Closed treatment of dislocated knee 2764803_1 CDM 0450 RC 27550 HCPCS inpatient 503 326.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 304.57 487.91 Closed treatment of dislocated knee 2764803_1 CDM 0450 RC 27550 HCPCS inpatient 503 326.95 ANTHEM HMO ANTHEM HMO 999999999 304.57 487.91 Closed treatment of dislocated knee 2764803_1 CDM 0450 RC 27550 HCPCS inpatient 503 326.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 340.03 67.6 999999999 304.57 487.91 percent of total billed charges Closed treatment of dislocated knee 2764803_1 CDM 0450 RC 27550 HCPCS inpatient 503 326.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 304.57 487.91 Closed treatment of dislocated hand joint at base of finger with manipulation 2764805_1 CDM 0450 RC 26700 HCPCS inpatient 361 234.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 234.65 65 999999999 218.59 350.17 percent of total billed charges Closed treatment of dislocated hand joint at base of finger with manipulation 2764805_1 CDM 0450 RC 26700 HCPCS inpatient 361 234.65 AETNA AETNA 285.19 79 999999999 218.59 350.17 percent of total billed charges Closed treatment of dislocated hand joint at base of finger with manipulation 2764805_1 CDM 0450 RC 26700 HCPCS inpatient 361 234.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 249.09 69 999999999 218.59 350.17 percent of total billed charges Closed treatment of dislocated hand joint at base of finger with manipulation 2764805_1 CDM 0450 RC 26700 HCPCS inpatient 361 234.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 350.17 97 999999999 218.59 350.17 percent of total billed charges Closed treatment of dislocated hand joint at base of finger with manipulation 2764805_1 CDM 0450 RC 26700 HCPCS inpatient 361 234.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 281.58 78 999999999 218.59 350.17 percent of total billed charges Closed treatment of dislocated hand joint at base of finger with manipulation 2764805_1 CDM 0450 RC 26700 HCPCS inpatient 361 234.65 SIHO - ALL PLANS SIHO - ALL PLANS 324.9 90 999999999 218.59 350.17 percent of total billed charges Closed treatment of dislocated hand joint at base of finger with manipulation 2764805_1 CDM 0450 RC 26700 HCPCS inpatient 361 234.65 UMR - ALL PLANS UMR - ALL PLANS 252.7 70 999999999 218.59 350.17 percent of total billed charges Closed treatment of dislocated hand joint at base of finger with manipulation 2764805_1 CDM 0450 RC 26700 HCPCS inpatient 361 234.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 218.59 60.55 999999999 218.59 350.17 percent of total billed charges Closed treatment of dislocated hand joint at base of finger with manipulation 2764805_1 CDM 0450 RC 26700 HCPCS inpatient 361 234.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 218.59 350.17 Closed treatment of dislocated hand joint at base of finger with manipulation 2764805_1 CDM 0450 RC 26700 HCPCS inpatient 361 234.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 218.59 350.17 Closed treatment of dislocated hand joint at base of finger with manipulation 2764805_1 CDM 0450 RC 26700 HCPCS inpatient 361 234.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 218.59 350.17 Closed treatment of dislocated hand joint at base of finger with manipulation 2764805_1 CDM 0450 RC 26700 HCPCS inpatient 361 234.65 ANTHEM HMO ANTHEM HMO 999999999 218.59 350.17 Closed treatment of dislocated hand joint at base of finger with manipulation 2764805_1 CDM 0450 RC 26700 HCPCS inpatient 361 234.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 244.04 67.6 999999999 218.59 350.17 percent of total billed charges Closed treatment of dislocated hand joint at base of finger with manipulation 2764805_1 CDM 0450 RC 26700 HCPCS inpatient 361 234.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 218.59 350.17 Repair of dislocated elbow 2764808_1 CDM 0450 RC 24600 HCPCS inpatient 505 328.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 328.25 65 999999999 305.78 489.85 percent of total billed charges Repair of dislocated elbow 2764808_1 CDM 0450 RC 24600 HCPCS inpatient 505 328.25 AETNA AETNA 398.95 79 999999999 305.78 489.85 percent of total billed charges Repair of dislocated elbow 2764808_1 CDM 0450 RC 24600 HCPCS inpatient 505 328.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 348.45 69 999999999 305.78 489.85 percent of total billed charges Repair of dislocated elbow 2764808_1 CDM 0450 RC 24600 HCPCS inpatient 505 328.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 489.85 97 999999999 305.78 489.85 percent of total billed charges Repair of dislocated elbow 2764808_1 CDM 0450 RC 24600 HCPCS inpatient 505 328.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 393.9 78 999999999 305.78 489.85 percent of total billed charges Repair of dislocated elbow 2764808_1 CDM 0450 RC 24600 HCPCS inpatient 505 328.25 SIHO - ALL PLANS SIHO - ALL PLANS 454.5 90 999999999 305.78 489.85 percent of total billed charges Repair of dislocated elbow 2764808_1 CDM 0450 RC 24600 HCPCS inpatient 505 328.25 UMR - ALL PLANS UMR - ALL PLANS 353.5 70 999999999 305.78 489.85 percent of total billed charges Repair of dislocated elbow 2764808_1 CDM 0450 RC 24600 HCPCS inpatient 505 328.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 305.78 60.55 999999999 305.78 489.85 percent of total billed charges Repair of dislocated elbow 2764808_1 CDM 0450 RC 24600 HCPCS inpatient 505 328.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 305.78 489.85 Repair of dislocated elbow 2764808_1 CDM 0450 RC 24600 HCPCS inpatient 505 328.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 305.78 489.85 Repair of dislocated elbow 2764808_1 CDM 0450 RC 24600 HCPCS inpatient 505 328.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 305.78 489.85 Repair of dislocated elbow 2764808_1 CDM 0450 RC 24600 HCPCS inpatient 505 328.25 ANTHEM HMO ANTHEM HMO 999999999 305.78 489.85 Repair of dislocated elbow 2764808_1 CDM 0450 RC 24600 HCPCS inpatient 505 328.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 341.38 67.6 999999999 305.78 489.85 percent of total billed charges Repair of dislocated elbow 2764808_1 CDM 0450 RC 24600 HCPCS inpatient 505 328.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 305.78 489.85 "Closed treatment of dislocated forearm bone on thumb side at elbow with manipulation, child" 2764809_1 CDM 0450 RC 24640 HCPCS inpatient 553 359.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 359.45 65 999999999 334.84 536.41 percent of total billed charges "Closed treatment of dislocated forearm bone on thumb side at elbow with manipulation, child" 2764809_1 CDM 0450 RC 24640 HCPCS inpatient 553 359.45 AETNA AETNA 436.87 79 999999999 334.84 536.41 percent of total billed charges "Closed treatment of dislocated forearm bone on thumb side at elbow with manipulation, child" 2764809_1 CDM 0450 RC 24640 HCPCS inpatient 553 359.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 381.57 69 999999999 334.84 536.41 percent of total billed charges "Closed treatment of dislocated forearm bone on thumb side at elbow with manipulation, child" 2764809_1 CDM 0450 RC 24640 HCPCS inpatient 553 359.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 536.41 97 999999999 334.84 536.41 percent of total billed charges "Closed treatment of dislocated forearm bone on thumb side at elbow with manipulation, child" 2764809_1 CDM 0450 RC 24640 HCPCS inpatient 553 359.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 431.34 78 999999999 334.84 536.41 percent of total billed charges "Closed treatment of dislocated forearm bone on thumb side at elbow with manipulation, child" 2764809_1 CDM 0450 RC 24640 HCPCS inpatient 553 359.45 SIHO - ALL PLANS SIHO - ALL PLANS 497.7 90 999999999 334.84 536.41 percent of total billed charges "Closed treatment of dislocated forearm bone on thumb side at elbow with manipulation, child" 2764809_1 CDM 0450 RC 24640 HCPCS inpatient 553 359.45 UMR - ALL PLANS UMR - ALL PLANS 387.1 70 999999999 334.84 536.41 percent of total billed charges "Closed treatment of dislocated forearm bone on thumb side at elbow with manipulation, child" 2764809_1 CDM 0450 RC 24640 HCPCS inpatient 553 359.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 334.84 60.55 999999999 334.84 536.41 percent of total billed charges "Closed treatment of dislocated forearm bone on thumb side at elbow with manipulation, child" 2764809_1 CDM 0450 RC 24640 HCPCS inpatient 553 359.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 334.84 536.41 "Closed treatment of dislocated forearm bone on thumb side at elbow with manipulation, child" 2764809_1 CDM 0450 RC 24640 HCPCS inpatient 553 359.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 334.84 536.41 "Closed treatment of dislocated forearm bone on thumb side at elbow with manipulation, child" 2764809_1 CDM 0450 RC 24640 HCPCS inpatient 553 359.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 334.84 536.41 "Closed treatment of dislocated forearm bone on thumb side at elbow with manipulation, child" 2764809_1 CDM 0450 RC 24640 HCPCS inpatient 553 359.45 ANTHEM HMO ANTHEM HMO 999999999 334.84 536.41 "Closed treatment of dislocated forearm bone on thumb side at elbow with manipulation, child" 2764809_1 CDM 0450 RC 24640 HCPCS inpatient 553 359.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 373.83 67.6 999999999 334.84 536.41 percent of total billed charges "Closed treatment of dislocated forearm bone on thumb side at elbow with manipulation, child" 2764809_1 CDM 0450 RC 24640 HCPCS inpatient 553 359.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 334.84 536.41 Closed treatment of broken hand bone with manipulation 2764813_1 CDM 0450 RC 26605 HCPCS inpatient 470 305.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 305.5 65 999999999 284.59 455.9 percent of total billed charges Closed treatment of broken hand bone with manipulation 2764813_1 CDM 0450 RC 26605 HCPCS inpatient 470 305.5 AETNA AETNA 371.3 79 999999999 284.59 455.9 percent of total billed charges Closed treatment of broken hand bone with manipulation 2764813_1 CDM 0450 RC 26605 HCPCS inpatient 470 305.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 324.3 69 999999999 284.59 455.9 percent of total billed charges Closed treatment of broken hand bone with manipulation 2764813_1 CDM 0450 RC 26605 HCPCS inpatient 470 305.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 455.9 97 999999999 284.59 455.9 percent of total billed charges Closed treatment of broken hand bone with manipulation 2764813_1 CDM 0450 RC 26605 HCPCS inpatient 470 305.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 366.6 78 999999999 284.59 455.9 percent of total billed charges Closed treatment of broken hand bone with manipulation 2764813_1 CDM 0450 RC 26605 HCPCS inpatient 470 305.5 SIHO - ALL PLANS SIHO - ALL PLANS 423 90 999999999 284.59 455.9 percent of total billed charges Closed treatment of broken hand bone with manipulation 2764813_1 CDM 0450 RC 26605 HCPCS inpatient 470 305.5 UMR - ALL PLANS UMR - ALL PLANS 329 70 999999999 284.59 455.9 percent of total billed charges Closed treatment of broken hand bone with manipulation 2764813_1 CDM 0450 RC 26605 HCPCS inpatient 470 305.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 284.59 60.55 999999999 284.59 455.9 percent of total billed charges Closed treatment of broken hand bone with manipulation 2764813_1 CDM 0450 RC 26605 HCPCS inpatient 470 305.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 284.59 455.9 Closed treatment of broken hand bone with manipulation 2764813_1 CDM 0450 RC 26605 HCPCS inpatient 470 305.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 284.59 455.9 Closed treatment of broken hand bone with manipulation 2764813_1 CDM 0450 RC 26605 HCPCS inpatient 470 305.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 284.59 455.9 Closed treatment of broken hand bone with manipulation 2764813_1 CDM 0450 RC 26605 HCPCS inpatient 470 305.5 ANTHEM HMO ANTHEM HMO 999999999 284.59 455.9 Closed treatment of broken hand bone with manipulation 2764813_1 CDM 0450 RC 26605 HCPCS inpatient 470 305.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 317.72 67.6 999999999 284.59 455.9 percent of total billed charges Closed treatment of broken hand bone with manipulation 2764813_1 CDM 0450 RC 26605 HCPCS inpatient 470 305.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 284.59 455.9 Closed treatment of dislocated shoulder with manipulation 2764815_1 CDM 0450 RC 23650 HCPCS inpatient 361 234.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 234.65 65 999999999 218.59 350.17 percent of total billed charges Closed treatment of dislocated shoulder with manipulation 2764815_1 CDM 0450 RC 23650 HCPCS inpatient 361 234.65 AETNA AETNA 285.19 79 999999999 218.59 350.17 percent of total billed charges Closed treatment of dislocated shoulder with manipulation 2764815_1 CDM 0450 RC 23650 HCPCS inpatient 361 234.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 249.09 69 999999999 218.59 350.17 percent of total billed charges Closed treatment of dislocated shoulder with manipulation 2764815_1 CDM 0450 RC 23650 HCPCS inpatient 361 234.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 350.17 97 999999999 218.59 350.17 percent of total billed charges Closed treatment of dislocated shoulder with manipulation 2764815_1 CDM 0450 RC 23650 HCPCS inpatient 361 234.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 281.58 78 999999999 218.59 350.17 percent of total billed charges Closed treatment of dislocated shoulder with manipulation 2764815_1 CDM 0450 RC 23650 HCPCS inpatient 361 234.65 SIHO - ALL PLANS SIHO - ALL PLANS 324.9 90 999999999 218.59 350.17 percent of total billed charges Closed treatment of dislocated shoulder with manipulation 2764815_1 CDM 0450 RC 23650 HCPCS inpatient 361 234.65 UMR - ALL PLANS UMR - ALL PLANS 252.7 70 999999999 218.59 350.17 percent of total billed charges Closed treatment of dislocated shoulder with manipulation 2764815_1 CDM 0450 RC 23650 HCPCS inpatient 361 234.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 218.59 60.55 999999999 218.59 350.17 percent of total billed charges Closed treatment of dislocated shoulder with manipulation 2764815_1 CDM 0450 RC 23650 HCPCS inpatient 361 234.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 218.59 350.17 Closed treatment of dislocated shoulder with manipulation 2764815_1 CDM 0450 RC 23650 HCPCS inpatient 361 234.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 218.59 350.17 Closed treatment of dislocated shoulder with manipulation 2764815_1 CDM 0450 RC 23650 HCPCS inpatient 361 234.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 218.59 350.17 Closed treatment of dislocated shoulder with manipulation 2764815_1 CDM 0450 RC 23650 HCPCS inpatient 361 234.65 ANTHEM HMO ANTHEM HMO 999999999 218.59 350.17 Closed treatment of dislocated shoulder with manipulation 2764815_1 CDM 0450 RC 23650 HCPCS inpatient 361 234.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 244.04 67.6 999999999 218.59 350.17 percent of total billed charges Closed treatment of dislocated shoulder with manipulation 2764815_1 CDM 0450 RC 23650 HCPCS inpatient 361 234.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 218.59 350.17 Closed treatment of dislocated shoulder with manipulation under anesthesia 2764817_1 CDM 0450 RC 23655 HCPCS inpatient 2654 1725.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1725.1 65 999999999 1607 2574.38 percent of total billed charges Closed treatment of dislocated shoulder with manipulation under anesthesia 2764817_1 CDM 0450 RC 23655 HCPCS inpatient 2654 1725.1 AETNA AETNA 2096.66 79 999999999 1607 2574.38 percent of total billed charges Closed treatment of dislocated shoulder with manipulation under anesthesia 2764817_1 CDM 0450 RC 23655 HCPCS inpatient 2654 1725.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 1831.26 69 999999999 1607 2574.38 percent of total billed charges Closed treatment of dislocated shoulder with manipulation under anesthesia 2764817_1 CDM 0450 RC 23655 HCPCS inpatient 2654 1725.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2574.38 97 999999999 1607 2574.38 percent of total billed charges Closed treatment of dislocated shoulder with manipulation under anesthesia 2764817_1 CDM 0450 RC 23655 HCPCS inpatient 2654 1725.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 2070.12 78 999999999 1607 2574.38 percent of total billed charges Closed treatment of dislocated shoulder with manipulation under anesthesia 2764817_1 CDM 0450 RC 23655 HCPCS inpatient 2654 1725.1 SIHO - ALL PLANS SIHO - ALL PLANS 2388.6 90 999999999 1607 2574.38 percent of total billed charges Closed treatment of dislocated shoulder with manipulation under anesthesia 2764817_1 CDM 0450 RC 23655 HCPCS inpatient 2654 1725.1 UMR - ALL PLANS UMR - ALL PLANS 1857.8 70 999999999 1607 2574.38 percent of total billed charges Closed treatment of dislocated shoulder with manipulation under anesthesia 2764817_1 CDM 0450 RC 23655 HCPCS inpatient 2654 1725.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1607 60.55 999999999 1607 2574.38 percent of total billed charges Closed treatment of dislocated shoulder with manipulation under anesthesia 2764817_1 CDM 0450 RC 23655 HCPCS inpatient 2654 1725.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1607 2574.38 Closed treatment of dislocated shoulder with manipulation under anesthesia 2764817_1 CDM 0450 RC 23655 HCPCS inpatient 2654 1725.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1607 2574.38 Closed treatment of dislocated shoulder with manipulation under anesthesia 2764817_1 CDM 0450 RC 23655 HCPCS inpatient 2654 1725.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1607 2574.38 Closed treatment of dislocated shoulder with manipulation under anesthesia 2764817_1 CDM 0450 RC 23655 HCPCS inpatient 2654 1725.1 ANTHEM HMO ANTHEM HMO 999999999 1607 2574.38 Closed treatment of dislocated shoulder with manipulation under anesthesia 2764817_1 CDM 0450 RC 23655 HCPCS inpatient 2654 1725.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1794.1 67.6 999999999 1607 2574.38 percent of total billed charges Closed treatment of dislocated shoulder with manipulation under anesthesia 2764817_1 CDM 0450 RC 23655 HCPCS inpatient 2654 1725.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1607 2574.38 Closed treatment of dislocated kneecap 2764819_1 CDM 0450 RC 27560 HCPCS inpatient 505 328.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 328.25 65 999999999 305.78 489.85 percent of total billed charges Closed treatment of dislocated kneecap 2764819_1 CDM 0450 RC 27560 HCPCS inpatient 505 328.25 AETNA AETNA 398.95 79 999999999 305.78 489.85 percent of total billed charges Closed treatment of dislocated kneecap 2764819_1 CDM 0450 RC 27560 HCPCS inpatient 505 328.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 348.45 69 999999999 305.78 489.85 percent of total billed charges Closed treatment of dislocated kneecap 2764819_1 CDM 0450 RC 27560 HCPCS inpatient 505 328.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 489.85 97 999999999 305.78 489.85 percent of total billed charges Closed treatment of dislocated kneecap 2764819_1 CDM 0450 RC 27560 HCPCS inpatient 505 328.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 393.9 78 999999999 305.78 489.85 percent of total billed charges Closed treatment of dislocated kneecap 2764819_1 CDM 0450 RC 27560 HCPCS inpatient 505 328.25 SIHO - ALL PLANS SIHO - ALL PLANS 454.5 90 999999999 305.78 489.85 percent of total billed charges Closed treatment of dislocated kneecap 2764819_1 CDM 0450 RC 27560 HCPCS inpatient 505 328.25 UMR - ALL PLANS UMR - ALL PLANS 353.5 70 999999999 305.78 489.85 percent of total billed charges Closed treatment of dislocated kneecap 2764819_1 CDM 0450 RC 27560 HCPCS inpatient 505 328.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 305.78 60.55 999999999 305.78 489.85 percent of total billed charges Closed treatment of dislocated kneecap 2764819_1 CDM 0450 RC 27560 HCPCS inpatient 505 328.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 305.78 489.85 Closed treatment of dislocated kneecap 2764819_1 CDM 0450 RC 27560 HCPCS inpatient 505 328.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 305.78 489.85 Closed treatment of dislocated kneecap 2764819_1 CDM 0450 RC 27560 HCPCS inpatient 505 328.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 305.78 489.85 Closed treatment of dislocated kneecap 2764819_1 CDM 0450 RC 27560 HCPCS inpatient 505 328.25 ANTHEM HMO ANTHEM HMO 999999999 305.78 489.85 Closed treatment of dislocated kneecap 2764819_1 CDM 0450 RC 27560 HCPCS inpatient 505 328.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 341.38 67.6 999999999 305.78 489.85 percent of total billed charges Closed treatment of dislocated kneecap 2764819_1 CDM 0450 RC 27560 HCPCS inpatient 505 328.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 305.78 489.85 Closed treatment of broken finger or thumb at midportion or part near hand with manipulation 2764823_1 CDM 0450 RC 26725 HCPCS inpatient 387 251.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 251.55 65 999999999 234.33 375.39 percent of total billed charges Closed treatment of broken finger or thumb at midportion or part near hand with manipulation 2764823_1 CDM 0450 RC 26725 HCPCS inpatient 387 251.55 AETNA AETNA 305.73 79 999999999 234.33 375.39 percent of total billed charges Closed treatment of broken finger or thumb at midportion or part near hand with manipulation 2764823_1 CDM 0450 RC 26725 HCPCS inpatient 387 251.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.03 69 999999999 234.33 375.39 percent of total billed charges Closed treatment of broken finger or thumb at midportion or part near hand with manipulation 2764823_1 CDM 0450 RC 26725 HCPCS inpatient 387 251.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 375.39 97 999999999 234.33 375.39 percent of total billed charges Closed treatment of broken finger or thumb at midportion or part near hand with manipulation 2764823_1 CDM 0450 RC 26725 HCPCS inpatient 387 251.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.86 78 999999999 234.33 375.39 percent of total billed charges Closed treatment of broken finger or thumb at midportion or part near hand with manipulation 2764823_1 CDM 0450 RC 26725 HCPCS inpatient 387 251.55 SIHO - ALL PLANS SIHO - ALL PLANS 348.3 90 999999999 234.33 375.39 percent of total billed charges Closed treatment of broken finger or thumb at midportion or part near hand with manipulation 2764823_1 CDM 0450 RC 26725 HCPCS inpatient 387 251.55 UMR - ALL PLANS UMR - ALL PLANS 270.9 70 999999999 234.33 375.39 percent of total billed charges Closed treatment of broken finger or thumb at midportion or part near hand with manipulation 2764823_1 CDM 0450 RC 26725 HCPCS inpatient 387 251.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.33 60.55 999999999 234.33 375.39 percent of total billed charges Closed treatment of broken finger or thumb at midportion or part near hand with manipulation 2764823_1 CDM 0450 RC 26725 HCPCS inpatient 387 251.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.33 375.39 Closed treatment of broken finger or thumb at midportion or part near hand with manipulation 2764823_1 CDM 0450 RC 26725 HCPCS inpatient 387 251.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.33 375.39 Closed treatment of broken finger or thumb at midportion or part near hand with manipulation 2764823_1 CDM 0450 RC 26725 HCPCS inpatient 387 251.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.33 375.39 Closed treatment of broken finger or thumb at midportion or part near hand with manipulation 2764823_1 CDM 0450 RC 26725 HCPCS inpatient 387 251.55 ANTHEM HMO ANTHEM HMO 999999999 234.33 375.39 Closed treatment of broken finger or thumb at midportion or part near hand with manipulation 2764823_1 CDM 0450 RC 26725 HCPCS inpatient 387 251.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 261.61 67.6 999999999 234.33 375.39 percent of total billed charges Closed treatment of broken finger or thumb at midportion or part near hand with manipulation 2764823_1 CDM 0450 RC 26725 HCPCS inpatient 387 251.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.33 375.39 Closed treatment of broken midpart of forearm bone on thumb side with manipulation 2764825_1 CDM 0450 RC 25505 HCPCS inpatient 2116 1375.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1375.4 65 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken midpart of forearm bone on thumb side with manipulation 2764825_1 CDM 0450 RC 25505 HCPCS inpatient 2116 1375.4 AETNA AETNA 1671.64 79 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken midpart of forearm bone on thumb side with manipulation 2764825_1 CDM 0450 RC 25505 HCPCS inpatient 2116 1375.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1460.04 69 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken midpart of forearm bone on thumb side with manipulation 2764825_1 CDM 0450 RC 25505 HCPCS inpatient 2116 1375.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2052.52 97 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken midpart of forearm bone on thumb side with manipulation 2764825_1 CDM 0450 RC 25505 HCPCS inpatient 2116 1375.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1650.48 78 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken midpart of forearm bone on thumb side with manipulation 2764825_1 CDM 0450 RC 25505 HCPCS inpatient 2116 1375.4 SIHO - ALL PLANS SIHO - ALL PLANS 1904.4 90 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken midpart of forearm bone on thumb side with manipulation 2764825_1 CDM 0450 RC 25505 HCPCS inpatient 2116 1375.4 UMR - ALL PLANS UMR - ALL PLANS 1481.2 70 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken midpart of forearm bone on thumb side with manipulation 2764825_1 CDM 0450 RC 25505 HCPCS inpatient 2116 1375.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1281.24 60.55 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken midpart of forearm bone on thumb side with manipulation 2764825_1 CDM 0450 RC 25505 HCPCS inpatient 2116 1375.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1281.24 2052.52 Closed treatment of broken midpart of forearm bone on thumb side with manipulation 2764825_1 CDM 0450 RC 25505 HCPCS inpatient 2116 1375.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1281.24 2052.52 Closed treatment of broken midpart of forearm bone on thumb side with manipulation 2764825_1 CDM 0450 RC 25505 HCPCS inpatient 2116 1375.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1281.24 2052.52 Closed treatment of broken midpart of forearm bone on thumb side with manipulation 2764825_1 CDM 0450 RC 25505 HCPCS inpatient 2116 1375.4 ANTHEM HMO ANTHEM HMO 999999999 1281.24 2052.52 Closed treatment of broken midpart of forearm bone on thumb side with manipulation 2764825_1 CDM 0450 RC 25505 HCPCS inpatient 2116 1375.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1430.42 67.6 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken midpart of forearm bone on thumb side with manipulation 2764825_1 CDM 0450 RC 25505 HCPCS inpatient 2116 1375.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1281.24 2052.52 Closed treatment of 3 broken lower leg bones at ankle with manipulation 2764827_1 CDM 0450 RC 27818 HCPCS inpatient 2116 1375.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1375.4 65 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of 3 broken lower leg bones at ankle with manipulation 2764827_1 CDM 0450 RC 27818 HCPCS inpatient 2116 1375.4 AETNA AETNA 1671.64 79 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of 3 broken lower leg bones at ankle with manipulation 2764827_1 CDM 0450 RC 27818 HCPCS inpatient 2116 1375.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1460.04 69 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of 3 broken lower leg bones at ankle with manipulation 2764827_1 CDM 0450 RC 27818 HCPCS inpatient 2116 1375.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2052.52 97 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of 3 broken lower leg bones at ankle with manipulation 2764827_1 CDM 0450 RC 27818 HCPCS inpatient 2116 1375.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1650.48 78 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of 3 broken lower leg bones at ankle with manipulation 2764827_1 CDM 0450 RC 27818 HCPCS inpatient 2116 1375.4 SIHO - ALL PLANS SIHO - ALL PLANS 1904.4 90 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of 3 broken lower leg bones at ankle with manipulation 2764827_1 CDM 0450 RC 27818 HCPCS inpatient 2116 1375.4 UMR - ALL PLANS UMR - ALL PLANS 1481.2 70 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of 3 broken lower leg bones at ankle with manipulation 2764827_1 CDM 0450 RC 27818 HCPCS inpatient 2116 1375.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1281.24 60.55 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of 3 broken lower leg bones at ankle with manipulation 2764827_1 CDM 0450 RC 27818 HCPCS inpatient 2116 1375.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1281.24 2052.52 Closed treatment of 3 broken lower leg bones at ankle with manipulation 2764827_1 CDM 0450 RC 27818 HCPCS inpatient 2116 1375.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1281.24 2052.52 Closed treatment of 3 broken lower leg bones at ankle with manipulation 2764827_1 CDM 0450 RC 27818 HCPCS inpatient 2116 1375.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1281.24 2052.52 Closed treatment of 3 broken lower leg bones at ankle with manipulation 2764827_1 CDM 0450 RC 27818 HCPCS inpatient 2116 1375.4 ANTHEM HMO ANTHEM HMO 999999999 1281.24 2052.52 Closed treatment of 3 broken lower leg bones at ankle with manipulation 2764827_1 CDM 0450 RC 27818 HCPCS inpatient 2116 1375.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1430.42 67.6 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of 3 broken lower leg bones at ankle with manipulation 2764827_1 CDM 0450 RC 27818 HCPCS inpatient 2116 1375.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1281.24 2052.52 Closed treatment of dislocated joint in toe 2764833_1 CDM 0450 RC 28660 HCPCS inpatient 387 251.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 251.55 65 999999999 234.33 375.39 percent of total billed charges Closed treatment of dislocated joint in toe 2764833_1 CDM 0450 RC 28660 HCPCS inpatient 387 251.55 AETNA AETNA 305.73 79 999999999 234.33 375.39 percent of total billed charges Closed treatment of dislocated joint in toe 2764833_1 CDM 0450 RC 28660 HCPCS inpatient 387 251.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.03 69 999999999 234.33 375.39 percent of total billed charges Closed treatment of dislocated joint in toe 2764833_1 CDM 0450 RC 28660 HCPCS inpatient 387 251.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 375.39 97 999999999 234.33 375.39 percent of total billed charges Closed treatment of dislocated joint in toe 2764833_1 CDM 0450 RC 28660 HCPCS inpatient 387 251.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.86 78 999999999 234.33 375.39 percent of total billed charges Closed treatment of dislocated joint in toe 2764833_1 CDM 0450 RC 28660 HCPCS inpatient 387 251.55 SIHO - ALL PLANS SIHO - ALL PLANS 348.3 90 999999999 234.33 375.39 percent of total billed charges Closed treatment of dislocated joint in toe 2764833_1 CDM 0450 RC 28660 HCPCS inpatient 387 251.55 UMR - ALL PLANS UMR - ALL PLANS 270.9 70 999999999 234.33 375.39 percent of total billed charges Closed treatment of dislocated joint in toe 2764833_1 CDM 0450 RC 28660 HCPCS inpatient 387 251.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.33 60.55 999999999 234.33 375.39 percent of total billed charges Closed treatment of dislocated joint in toe 2764833_1 CDM 0450 RC 28660 HCPCS inpatient 387 251.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.33 375.39 Closed treatment of dislocated joint in toe 2764833_1 CDM 0450 RC 28660 HCPCS inpatient 387 251.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.33 375.39 Closed treatment of dislocated joint in toe 2764833_1 CDM 0450 RC 28660 HCPCS inpatient 387 251.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.33 375.39 Closed treatment of dislocated joint in toe 2764833_1 CDM 0450 RC 28660 HCPCS inpatient 387 251.55 ANTHEM HMO ANTHEM HMO 999999999 234.33 375.39 Closed treatment of dislocated joint in toe 2764833_1 CDM 0450 RC 28660 HCPCS inpatient 387 251.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 261.61 67.6 999999999 234.33 375.39 percent of total billed charges Closed treatment of dislocated joint in toe 2764833_1 CDM 0450 RC 28660 HCPCS inpatient 387 251.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.33 375.39 Change of breathing tube in windpipe 2764834_1 CDM 0450 RC 31502 HCPCS inpatient 545 354.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 354.25 65 999999999 330 528.65 percent of total billed charges Change of breathing tube in windpipe 2764834_1 CDM 0450 RC 31502 HCPCS inpatient 545 354.25 AETNA AETNA 430.55 79 999999999 330 528.65 percent of total billed charges Change of breathing tube in windpipe 2764834_1 CDM 0450 RC 31502 HCPCS inpatient 545 354.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 376.05 69 999999999 330 528.65 percent of total billed charges Change of breathing tube in windpipe 2764834_1 CDM 0450 RC 31502 HCPCS inpatient 545 354.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 528.65 97 999999999 330 528.65 percent of total billed charges Change of breathing tube in windpipe 2764834_1 CDM 0450 RC 31502 HCPCS inpatient 545 354.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 425.1 78 999999999 330 528.65 percent of total billed charges Change of breathing tube in windpipe 2764834_1 CDM 0450 RC 31502 HCPCS inpatient 545 354.25 SIHO - ALL PLANS SIHO - ALL PLANS 490.5 90 999999999 330 528.65 percent of total billed charges Change of breathing tube in windpipe 2764834_1 CDM 0450 RC 31502 HCPCS inpatient 545 354.25 UMR - ALL PLANS UMR - ALL PLANS 381.5 70 999999999 330 528.65 percent of total billed charges Change of breathing tube in windpipe 2764834_1 CDM 0450 RC 31502 HCPCS inpatient 545 354.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 330 60.55 999999999 330 528.65 percent of total billed charges Change of breathing tube in windpipe 2764834_1 CDM 0450 RC 31502 HCPCS inpatient 545 354.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 330 528.65 Change of breathing tube in windpipe 2764834_1 CDM 0450 RC 31502 HCPCS inpatient 545 354.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 330 528.65 Change of breathing tube in windpipe 2764834_1 CDM 0450 RC 31502 HCPCS inpatient 545 354.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 330 528.65 Change of breathing tube in windpipe 2764834_1 CDM 0450 RC 31502 HCPCS inpatient 545 354.25 ANTHEM HMO ANTHEM HMO 999999999 330 528.65 Change of breathing tube in windpipe 2764834_1 CDM 0450 RC 31502 HCPCS inpatient 545 354.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 368.42 67.6 999999999 330 528.65 percent of total billed charges Change of breathing tube in windpipe 2764834_1 CDM 0450 RC 31502 HCPCS inpatient 545 354.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 330 528.65 Closed treatment of broken outside lower leg bone at ankle with manipulation 2764835_1 CDM 0450 RC 27788 HCPCS inpatient 505 328.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 328.25 65 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken outside lower leg bone at ankle with manipulation 2764835_1 CDM 0450 RC 27788 HCPCS inpatient 505 328.25 AETNA AETNA 398.95 79 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken outside lower leg bone at ankle with manipulation 2764835_1 CDM 0450 RC 27788 HCPCS inpatient 505 328.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 348.45 69 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken outside lower leg bone at ankle with manipulation 2764835_1 CDM 0450 RC 27788 HCPCS inpatient 505 328.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 489.85 97 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken outside lower leg bone at ankle with manipulation 2764835_1 CDM 0450 RC 27788 HCPCS inpatient 505 328.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 393.9 78 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken outside lower leg bone at ankle with manipulation 2764835_1 CDM 0450 RC 27788 HCPCS inpatient 505 328.25 SIHO - ALL PLANS SIHO - ALL PLANS 454.5 90 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken outside lower leg bone at ankle with manipulation 2764835_1 CDM 0450 RC 27788 HCPCS inpatient 505 328.25 UMR - ALL PLANS UMR - ALL PLANS 353.5 70 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken outside lower leg bone at ankle with manipulation 2764835_1 CDM 0450 RC 27788 HCPCS inpatient 505 328.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 305.78 60.55 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken outside lower leg bone at ankle with manipulation 2764835_1 CDM 0450 RC 27788 HCPCS inpatient 505 328.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 305.78 489.85 Closed treatment of broken outside lower leg bone at ankle with manipulation 2764835_1 CDM 0450 RC 27788 HCPCS inpatient 505 328.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 305.78 489.85 Closed treatment of broken outside lower leg bone at ankle with manipulation 2764835_1 CDM 0450 RC 27788 HCPCS inpatient 505 328.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 305.78 489.85 Closed treatment of broken outside lower leg bone at ankle with manipulation 2764835_1 CDM 0450 RC 27788 HCPCS inpatient 505 328.25 ANTHEM HMO ANTHEM HMO 999999999 305.78 489.85 Closed treatment of broken outside lower leg bone at ankle with manipulation 2764835_1 CDM 0450 RC 27788 HCPCS inpatient 505 328.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 341.38 67.6 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken outside lower leg bone at ankle with manipulation 2764835_1 CDM 0450 RC 27788 HCPCS inpatient 505 328.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 305.78 489.85 Closed treatment of broken midpart of both forearm bones with manipulation 2764837_1 CDM 0450 RC 25565 HCPCS inpatient 2116 1375.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1375.4 65 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken midpart of both forearm bones with manipulation 2764837_1 CDM 0450 RC 25565 HCPCS inpatient 2116 1375.4 AETNA AETNA 1671.64 79 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken midpart of both forearm bones with manipulation 2764837_1 CDM 0450 RC 25565 HCPCS inpatient 2116 1375.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1460.04 69 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken midpart of both forearm bones with manipulation 2764837_1 CDM 0450 RC 25565 HCPCS inpatient 2116 1375.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2052.52 97 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken midpart of both forearm bones with manipulation 2764837_1 CDM 0450 RC 25565 HCPCS inpatient 2116 1375.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1650.48 78 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken midpart of both forearm bones with manipulation 2764837_1 CDM 0450 RC 25565 HCPCS inpatient 2116 1375.4 SIHO - ALL PLANS SIHO - ALL PLANS 1904.4 90 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken midpart of both forearm bones with manipulation 2764837_1 CDM 0450 RC 25565 HCPCS inpatient 2116 1375.4 UMR - ALL PLANS UMR - ALL PLANS 1481.2 70 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken midpart of both forearm bones with manipulation 2764837_1 CDM 0450 RC 25565 HCPCS inpatient 2116 1375.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1281.24 60.55 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken midpart of both forearm bones with manipulation 2764837_1 CDM 0450 RC 25565 HCPCS inpatient 2116 1375.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1281.24 2052.52 Closed treatment of broken midpart of both forearm bones with manipulation 2764837_1 CDM 0450 RC 25565 HCPCS inpatient 2116 1375.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1281.24 2052.52 Closed treatment of broken midpart of both forearm bones with manipulation 2764837_1 CDM 0450 RC 25565 HCPCS inpatient 2116 1375.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1281.24 2052.52 Closed treatment of broken midpart of both forearm bones with manipulation 2764837_1 CDM 0450 RC 25565 HCPCS inpatient 2116 1375.4 ANTHEM HMO ANTHEM HMO 999999999 1281.24 2052.52 Closed treatment of broken midpart of both forearm bones with manipulation 2764837_1 CDM 0450 RC 25565 HCPCS inpatient 2116 1375.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1430.42 67.6 999999999 1281.24 2052.52 percent of total billed charges Closed treatment of broken midpart of both forearm bones with manipulation 2764837_1 CDM 0450 RC 25565 HCPCS inpatient 2116 1375.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1281.24 2052.52 Complex control of nose bleed 2764839_1 CDM 0450 RC 30903 HCPCS inpatient 563 365.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 365.95 65 999999999 340.9 546.11 percent of total billed charges Complex control of nose bleed 2764839_1 CDM 0450 RC 30903 HCPCS inpatient 563 365.95 AETNA AETNA 444.77 79 999999999 340.9 546.11 percent of total billed charges Complex control of nose bleed 2764839_1 CDM 0450 RC 30903 HCPCS inpatient 563 365.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 388.47 69 999999999 340.9 546.11 percent of total billed charges Complex control of nose bleed 2764839_1 CDM 0450 RC 30903 HCPCS inpatient 563 365.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 546.11 97 999999999 340.9 546.11 percent of total billed charges Complex control of nose bleed 2764839_1 CDM 0450 RC 30903 HCPCS inpatient 563 365.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 439.14 78 999999999 340.9 546.11 percent of total billed charges Complex control of nose bleed 2764839_1 CDM 0450 RC 30903 HCPCS inpatient 563 365.95 SIHO - ALL PLANS SIHO - ALL PLANS 506.7 90 999999999 340.9 546.11 percent of total billed charges Complex control of nose bleed 2764839_1 CDM 0450 RC 30903 HCPCS inpatient 563 365.95 UMR - ALL PLANS UMR - ALL PLANS 394.1 70 999999999 340.9 546.11 percent of total billed charges Complex control of nose bleed 2764839_1 CDM 0450 RC 30903 HCPCS inpatient 563 365.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 340.9 60.55 999999999 340.9 546.11 percent of total billed charges Complex control of nose bleed 2764839_1 CDM 0450 RC 30903 HCPCS inpatient 563 365.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 340.9 546.11 Complex control of nose bleed 2764839_1 CDM 0450 RC 30903 HCPCS inpatient 563 365.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 340.9 546.11 Complex control of nose bleed 2764839_1 CDM 0450 RC 30903 HCPCS inpatient 563 365.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 340.9 546.11 Complex control of nose bleed 2764839_1 CDM 0450 RC 30903 HCPCS inpatient 563 365.95 ANTHEM HMO ANTHEM HMO 999999999 340.9 546.11 Complex control of nose bleed 2764839_1 CDM 0450 RC 30903 HCPCS inpatient 563 365.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 380.59 67.6 999999999 340.9 546.11 percent of total billed charges Complex control of nose bleed 2764839_1 CDM 0450 RC 30903 HCPCS inpatient 563 365.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 340.9 546.11 Initial control of nose bleed and insertion of packing 2764840_1 CDM 0450 RC 30905 HCPCS inpatient 479 311.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 311.35 65 999999999 290.03 464.63 percent of total billed charges Initial control of nose bleed and insertion of packing 2764840_1 CDM 0450 RC 30905 HCPCS inpatient 479 311.35 AETNA AETNA 378.41 79 999999999 290.03 464.63 percent of total billed charges Initial control of nose bleed and insertion of packing 2764840_1 CDM 0450 RC 30905 HCPCS inpatient 479 311.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 330.51 69 999999999 290.03 464.63 percent of total billed charges Initial control of nose bleed and insertion of packing 2764840_1 CDM 0450 RC 30905 HCPCS inpatient 479 311.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 464.63 97 999999999 290.03 464.63 percent of total billed charges Initial control of nose bleed and insertion of packing 2764840_1 CDM 0450 RC 30905 HCPCS inpatient 479 311.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 373.62 78 999999999 290.03 464.63 percent of total billed charges Initial control of nose bleed and insertion of packing 2764840_1 CDM 0450 RC 30905 HCPCS inpatient 479 311.35 SIHO - ALL PLANS SIHO - ALL PLANS 431.1 90 999999999 290.03 464.63 percent of total billed charges Initial control of nose bleed and insertion of packing 2764840_1 CDM 0450 RC 30905 HCPCS inpatient 479 311.35 UMR - ALL PLANS UMR - ALL PLANS 335.3 70 999999999 290.03 464.63 percent of total billed charges Initial control of nose bleed and insertion of packing 2764840_1 CDM 0450 RC 30905 HCPCS inpatient 479 311.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 290.03 60.55 999999999 290.03 464.63 percent of total billed charges Initial control of nose bleed and insertion of packing 2764840_1 CDM 0450 RC 30905 HCPCS inpatient 479 311.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 290.03 464.63 Initial control of nose bleed and insertion of packing 2764840_1 CDM 0450 RC 30905 HCPCS inpatient 479 311.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 290.03 464.63 Initial control of nose bleed and insertion of packing 2764840_1 CDM 0450 RC 30905 HCPCS inpatient 479 311.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 290.03 464.63 Initial control of nose bleed and insertion of packing 2764840_1 CDM 0450 RC 30905 HCPCS inpatient 479 311.35 ANTHEM HMO ANTHEM HMO 999999999 290.03 464.63 Initial control of nose bleed and insertion of packing 2764840_1 CDM 0450 RC 30905 HCPCS inpatient 479 311.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 323.8 67.6 999999999 290.03 464.63 percent of total billed charges Initial control of nose bleed and insertion of packing 2764840_1 CDM 0450 RC 30905 HCPCS inpatient 479 311.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 290.03 464.63 "Dressing change or removal of burn tissue, less than 5% of total body surface" 2764852_1 CDM 0450 RC 16020 HCPCS inpatient 390 253.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 253.5 65 999999999 236.15 378.3 percent of total billed charges "Dressing change or removal of burn tissue, less than 5% of total body surface" 2764852_1 CDM 0450 RC 16020 HCPCS inpatient 390 253.5 AETNA AETNA 308.1 79 999999999 236.15 378.3 percent of total billed charges "Dressing change or removal of burn tissue, less than 5% of total body surface" 2764852_1 CDM 0450 RC 16020 HCPCS inpatient 390 253.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 269.1 69 999999999 236.15 378.3 percent of total billed charges "Dressing change or removal of burn tissue, less than 5% of total body surface" 2764852_1 CDM 0450 RC 16020 HCPCS inpatient 390 253.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 378.3 97 999999999 236.15 378.3 percent of total billed charges "Dressing change or removal of burn tissue, less than 5% of total body surface" 2764852_1 CDM 0450 RC 16020 HCPCS inpatient 390 253.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 304.2 78 999999999 236.15 378.3 percent of total billed charges "Dressing change or removal of burn tissue, less than 5% of total body surface" 2764852_1 CDM 0450 RC 16020 HCPCS inpatient 390 253.5 SIHO - ALL PLANS SIHO - ALL PLANS 351 90 999999999 236.15 378.3 percent of total billed charges "Dressing change or removal of burn tissue, less than 5% of total body surface" 2764852_1 CDM 0450 RC 16020 HCPCS inpatient 390 253.5 UMR - ALL PLANS UMR - ALL PLANS 273 70 999999999 236.15 378.3 percent of total billed charges "Dressing change or removal of burn tissue, less than 5% of total body surface" 2764852_1 CDM 0450 RC 16020 HCPCS inpatient 390 253.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 236.15 60.55 999999999 236.15 378.3 percent of total billed charges "Dressing change or removal of burn tissue, less than 5% of total body surface" 2764852_1 CDM 0450 RC 16020 HCPCS inpatient 390 253.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 236.15 378.3 "Dressing change or removal of burn tissue, less than 5% of total body surface" 2764852_1 CDM 0450 RC 16020 HCPCS inpatient 390 253.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 236.15 378.3 "Dressing change or removal of burn tissue, less than 5% of total body surface" 2764852_1 CDM 0450 RC 16020 HCPCS inpatient 390 253.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 236.15 378.3 "Dressing change or removal of burn tissue, less than 5% of total body surface" 2764852_1 CDM 0450 RC 16020 HCPCS inpatient 390 253.5 ANTHEM HMO ANTHEM HMO 999999999 236.15 378.3 "Dressing change or removal of burn tissue, less than 5% of total body surface" 2764852_1 CDM 0450 RC 16020 HCPCS inpatient 390 253.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 263.64 67.6 999999999 236.15 378.3 percent of total billed charges "Dressing change or removal of burn tissue, less than 5% of total body surface" 2764852_1 CDM 0450 RC 16020 HCPCS inpatient 390 253.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 236.15 378.3 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770622_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 586.3 65 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770622_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 AETNA AETNA 712.58 79 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770622_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 622.38 69 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770622_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 874.94 97 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770622_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 703.56 78 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770622_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SIHO - ALL PLANS SIHO - ALL PLANS 811.8 90 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770622_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UMR - ALL PLANS UMR - ALL PLANS 631.4 70 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770622_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 546.16 60.55 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770622_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770622_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770622_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770622_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM HMO ANTHEM HMO 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770622_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 609.75 67.6 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770622_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 546.16 874.94 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770658_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770658_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770658_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770658_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770658_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770658_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770658_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770658_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770658_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770658_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770658_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770658_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770658_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770658_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770660_1 CDM 0390 RC P9017 HCPCS inpatient 343 222.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 222.95 65 999999999 207.69 332.71 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770660_1 CDM 0390 RC P9017 HCPCS inpatient 343 222.95 AETNA AETNA 270.97 79 999999999 207.69 332.71 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770660_1 CDM 0390 RC P9017 HCPCS inpatient 343 222.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 236.67 69 999999999 207.69 332.71 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770660_1 CDM 0390 RC P9017 HCPCS inpatient 343 222.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 332.71 97 999999999 207.69 332.71 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770660_1 CDM 0390 RC P9017 HCPCS inpatient 343 222.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 267.54 78 999999999 207.69 332.71 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770660_1 CDM 0390 RC P9017 HCPCS inpatient 343 222.95 SIHO - ALL PLANS SIHO - ALL PLANS 308.7 90 999999999 207.69 332.71 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770660_1 CDM 0390 RC P9017 HCPCS inpatient 343 222.95 UMR - ALL PLANS UMR - ALL PLANS 240.1 70 999999999 207.69 332.71 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770660_1 CDM 0390 RC P9017 HCPCS inpatient 343 222.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 207.69 60.55 999999999 207.69 332.71 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770660_1 CDM 0390 RC P9017 HCPCS inpatient 343 222.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 207.69 332.71 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770660_1 CDM 0390 RC P9017 HCPCS inpatient 343 222.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 207.69 332.71 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770660_1 CDM 0390 RC P9017 HCPCS inpatient 343 222.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 207.69 332.71 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770660_1 CDM 0390 RC P9017 HCPCS inpatient 343 222.95 ANTHEM HMO ANTHEM HMO 999999999 207.69 332.71 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770660_1 CDM 0390 RC P9017 HCPCS inpatient 343 222.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 231.87 67.6 999999999 207.69 332.71 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 2770660_1 CDM 0390 RC P9017 HCPCS inpatient 343 222.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 207.69 332.71 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770707_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 586.3 65 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770707_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 AETNA AETNA 712.58 79 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770707_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 622.38 69 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770707_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 874.94 97 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770707_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 703.56 78 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770707_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SIHO - ALL PLANS SIHO - ALL PLANS 811.8 90 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770707_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UMR - ALL PLANS UMR - ALL PLANS 631.4 70 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770707_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 546.16 60.55 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770707_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770707_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770707_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770707_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM HMO ANTHEM HMO 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770707_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 609.75 67.6 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770707_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 546.16 874.94 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770784_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1229.8 65 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770784_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 AETNA AETNA 1494.68 79 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770784_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1305.48 69 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770784_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1835.24 97 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770784_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1475.76 78 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770784_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 SIHO - ALL PLANS SIHO - ALL PLANS 1702.8 90 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770784_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 UMR - ALL PLANS UMR - ALL PLANS 1324.4 70 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770784_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1145.61 60.55 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770784_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770784_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770784_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770784_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM HMO ANTHEM HMO 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770784_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1278.99 67.6 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770784_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1145.61 1835.24 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770829_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 586.3 65 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770829_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 AETNA AETNA 712.58 79 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770829_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 622.38 69 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770829_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 874.94 97 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770829_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 703.56 78 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770829_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SIHO - ALL PLANS SIHO - ALL PLANS 811.8 90 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770829_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UMR - ALL PLANS UMR - ALL PLANS 631.4 70 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770829_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 546.16 60.55 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770829_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770829_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770829_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770829_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM HMO ANTHEM HMO 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770829_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 609.75 67.6 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770829_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770830_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 547.95 65 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770830_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 AETNA AETNA 665.97 79 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770830_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 581.67 69 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770830_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 817.71 97 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770830_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 657.54 78 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770830_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 SIHO - ALL PLANS SIHO - ALL PLANS 758.7 90 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770830_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 UMR - ALL PLANS UMR - ALL PLANS 590.1 70 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770830_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 510.44 60.55 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770830_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 510.44 817.71 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770830_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 510.44 817.71 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770830_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 510.44 817.71 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770830_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 ANTHEM HMO ANTHEM HMO 999999999 510.44 817.71 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770830_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 569.87 67.6 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770830_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 510.44 817.71 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770839_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 547.95 65 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770839_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 AETNA AETNA 665.97 79 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770839_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 581.67 69 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770839_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 817.71 97 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770839_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 657.54 78 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770839_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 SIHO - ALL PLANS SIHO - ALL PLANS 758.7 90 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770839_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 UMR - ALL PLANS UMR - ALL PLANS 590.1 70 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770839_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 510.44 60.55 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770839_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 510.44 817.71 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770839_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 510.44 817.71 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770839_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 510.44 817.71 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770839_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 ANTHEM HMO ANTHEM HMO 999999999 510.44 817.71 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770839_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 569.87 67.6 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770839_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 510.44 817.71 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770846_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 612.3 65 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770846_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 AETNA AETNA 744.18 79 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770846_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 649.98 69 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770846_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 913.74 97 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770846_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 734.76 78 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770846_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 SIHO - ALL PLANS SIHO - ALL PLANS 847.8 90 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770846_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 UMR - ALL PLANS UMR - ALL PLANS 659.4 70 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770846_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 570.38 60.55 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770846_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770846_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770846_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770846_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ANTHEM HMO ANTHEM HMO 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770846_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 636.79 67.6 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770846_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770847_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 612.3 65 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770847_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 AETNA AETNA 744.18 79 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770847_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 649.98 69 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770847_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 913.74 97 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770847_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 734.76 78 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770847_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 SIHO - ALL PLANS SIHO - ALL PLANS 847.8 90 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770847_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 UMR - ALL PLANS UMR - ALL PLANS 659.4 70 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770847_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 570.38 60.55 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770847_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770847_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770847_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770847_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ANTHEM HMO ANTHEM HMO 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770847_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 636.79 67.6 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770847_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770852_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 547.95 65 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770852_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 AETNA AETNA 665.97 79 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770852_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 581.67 69 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770852_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 817.71 97 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770852_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 657.54 78 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770852_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 SIHO - ALL PLANS SIHO - ALL PLANS 758.7 90 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770852_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 UMR - ALL PLANS UMR - ALL PLANS 590.1 70 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770852_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 510.44 60.55 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770852_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 510.44 817.71 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770852_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 510.44 817.71 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770852_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 510.44 817.71 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770852_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 ANTHEM HMO ANTHEM HMO 999999999 510.44 817.71 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770852_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 569.87 67.6 999999999 510.44 817.71 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770852_1 CDM 0390 RC P9016 HCPCS inpatient 843 547.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 510.44 817.71 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770853_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 612.3 65 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770853_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 AETNA AETNA 744.18 79 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770853_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 649.98 69 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770853_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 913.74 97 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770853_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 734.76 78 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770853_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 SIHO - ALL PLANS SIHO - ALL PLANS 847.8 90 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770853_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 UMR - ALL PLANS UMR - ALL PLANS 659.4 70 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770853_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 570.38 60.55 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770853_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770853_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770853_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770853_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ANTHEM HMO ANTHEM HMO 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770853_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 636.79 67.6 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770853_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770867_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 586.3 65 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770867_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 AETNA AETNA 712.58 79 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770867_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 622.38 69 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770867_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 874.94 97 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770867_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 703.56 78 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770867_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SIHO - ALL PLANS SIHO - ALL PLANS 811.8 90 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770867_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UMR - ALL PLANS UMR - ALL PLANS 631.4 70 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770867_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 546.16 60.55 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770867_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770867_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770867_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770867_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM HMO ANTHEM HMO 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770867_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 609.75 67.6 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770867_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770868_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 612.3 65 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770868_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 AETNA AETNA 744.18 79 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770868_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 649.98 69 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770868_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 913.74 97 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770868_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 734.76 78 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770868_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 SIHO - ALL PLANS SIHO - ALL PLANS 847.8 90 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770868_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 UMR - ALL PLANS UMR - ALL PLANS 659.4 70 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770868_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 570.38 60.55 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770868_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770868_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770868_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770868_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 ANTHEM HMO ANTHEM HMO 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770868_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 636.79 67.6 999999999 570.38 913.74 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770868_1 CDM 0390 RC P9040 HCPCS inpatient 942 612.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 570.38 913.74 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770875_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 586.3 65 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770875_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 AETNA AETNA 712.58 79 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770875_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 622.38 69 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770875_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 874.94 97 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770875_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 703.56 78 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770875_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SIHO - ALL PLANS SIHO - ALL PLANS 811.8 90 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770875_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UMR - ALL PLANS UMR - ALL PLANS 631.4 70 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770875_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 546.16 60.55 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770875_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770875_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770875_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770875_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM HMO ANTHEM HMO 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770875_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 609.75 67.6 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770875_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 546.16 874.94 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770901_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1229.8 65 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770901_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 AETNA AETNA 1494.68 79 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770901_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1305.48 69 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770901_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1835.24 97 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770901_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1475.76 78 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770901_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 SIHO - ALL PLANS SIHO - ALL PLANS 1702.8 90 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770901_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 UMR - ALL PLANS UMR - ALL PLANS 1324.4 70 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770901_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1145.61 60.55 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770901_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770901_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770901_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770901_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM HMO ANTHEM HMO 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770901_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1278.99 67.6 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770901_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770902_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1229.8 65 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770902_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 AETNA AETNA 1494.68 79 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770902_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1305.48 69 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770902_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1835.24 97 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770902_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1475.76 78 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770902_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 SIHO - ALL PLANS SIHO - ALL PLANS 1702.8 90 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770902_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 UMR - ALL PLANS UMR - ALL PLANS 1324.4 70 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770902_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1145.61 60.55 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770902_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770902_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770902_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770902_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM HMO ANTHEM HMO 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770902_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1278.99 67.6 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770902_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770903_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1229.8 65 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770903_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 AETNA AETNA 1494.68 79 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770903_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1305.48 69 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770903_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1835.24 97 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770903_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1475.76 78 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770903_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 SIHO - ALL PLANS SIHO - ALL PLANS 1702.8 90 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770903_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 UMR - ALL PLANS UMR - ALL PLANS 1324.4 70 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770903_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1145.61 60.55 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770903_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770903_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770903_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770903_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM HMO ANTHEM HMO 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770903_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1278.99 67.6 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770903_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1145.61 1835.24 "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770904_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1158.95 65 999999999 1079.61 1729.51 percent of total billed charges "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770904_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 AETNA AETNA 1408.57 79 999999999 1079.61 1729.51 percent of total billed charges "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770904_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1230.27 69 999999999 1079.61 1729.51 percent of total billed charges "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770904_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1729.51 97 999999999 1079.61 1729.51 percent of total billed charges "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770904_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1390.74 78 999999999 1079.61 1729.51 percent of total billed charges "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770904_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 SIHO - ALL PLANS SIHO - ALL PLANS 1604.7 90 999999999 1079.61 1729.51 percent of total billed charges "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770904_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 UMR - ALL PLANS UMR - ALL PLANS 1248.1 70 999999999 1079.61 1729.51 percent of total billed charges "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770904_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1079.61 60.55 999999999 1079.61 1729.51 percent of total billed charges "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770904_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1079.61 1729.51 "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770904_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1079.61 1729.51 "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770904_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1079.61 1729.51 "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770904_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 ANTHEM HMO ANTHEM HMO 999999999 1079.61 1729.51 "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770904_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1205.31 67.6 999999999 1079.61 1729.51 percent of total billed charges "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770904_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1079.61 1729.51 "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770905_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1158.95 65 999999999 1079.61 1729.51 percent of total billed charges "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770905_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 AETNA AETNA 1408.57 79 999999999 1079.61 1729.51 percent of total billed charges "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770905_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1230.27 69 999999999 1079.61 1729.51 percent of total billed charges "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770905_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1729.51 97 999999999 1079.61 1729.51 percent of total billed charges "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770905_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1390.74 78 999999999 1079.61 1729.51 percent of total billed charges "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770905_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 SIHO - ALL PLANS SIHO - ALL PLANS 1604.7 90 999999999 1079.61 1729.51 percent of total billed charges "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770905_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 UMR - ALL PLANS UMR - ALL PLANS 1248.1 70 999999999 1079.61 1729.51 percent of total billed charges "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770905_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1079.61 60.55 999999999 1079.61 1729.51 percent of total billed charges "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770905_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1079.61 1729.51 "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770905_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1079.61 1729.51 "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770905_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1079.61 1729.51 "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770905_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 ANTHEM HMO ANTHEM HMO 999999999 1079.61 1729.51 "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770905_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1205.31 67.6 999999999 1079.61 1729.51 percent of total billed charges "PLATELETS, LEUKOCYTES REDUCED, CMV-NEGATIVE, APHERESIS/PHERESIS, EACH UNIT" 2770905_1 CDM 0390 RC P9055 HCPCS inpatient 1783 1158.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1079.61 1729.51 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770907_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1171.3 65 999999999 1091.11 1747.94 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770907_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 AETNA AETNA 1423.58 79 999999999 1091.11 1747.94 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770907_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1243.38 69 999999999 1091.11 1747.94 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770907_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1747.94 97 999999999 1091.11 1747.94 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770907_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1405.56 78 999999999 1091.11 1747.94 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770907_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 SIHO - ALL PLANS SIHO - ALL PLANS 1621.8 90 999999999 1091.11 1747.94 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770907_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 UMR - ALL PLANS UMR - ALL PLANS 1261.4 70 999999999 1091.11 1747.94 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770907_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1091.11 60.55 999999999 1091.11 1747.94 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770907_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1091.11 1747.94 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770907_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1091.11 1747.94 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770907_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1091.11 1747.94 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770907_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 ANTHEM HMO ANTHEM HMO 999999999 1091.11 1747.94 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770907_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1218.15 67.6 999999999 1091.11 1747.94 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770907_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1091.11 1747.94 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770908_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1229.8 65 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770908_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 AETNA AETNA 1494.68 79 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770908_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1305.48 69 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770908_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1835.24 97 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770908_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1475.76 78 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770908_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 SIHO - ALL PLANS SIHO - ALL PLANS 1702.8 90 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770908_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 UMR - ALL PLANS UMR - ALL PLANS 1324.4 70 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770908_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1145.61 60.55 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770908_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770908_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770908_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770908_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM HMO ANTHEM HMO 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770908_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1278.99 67.6 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770908_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770909_1 CDM 0390 RC P9035 HCPCS inpatient 1955 1270.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1270.75 65 999999999 1183.75 1896.35 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770909_1 CDM 0390 RC P9035 HCPCS inpatient 1955 1270.75 AETNA AETNA 1544.45 79 999999999 1183.75 1896.35 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770909_1 CDM 0390 RC P9035 HCPCS inpatient 1955 1270.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1348.95 69 999999999 1183.75 1896.35 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770909_1 CDM 0390 RC P9035 HCPCS inpatient 1955 1270.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1896.35 97 999999999 1183.75 1896.35 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770909_1 CDM 0390 RC P9035 HCPCS inpatient 1955 1270.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1524.9 78 999999999 1183.75 1896.35 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770909_1 CDM 0390 RC P9035 HCPCS inpatient 1955 1270.75 SIHO - ALL PLANS SIHO - ALL PLANS 1759.5 90 999999999 1183.75 1896.35 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770909_1 CDM 0390 RC P9035 HCPCS inpatient 1955 1270.75 UMR - ALL PLANS UMR - ALL PLANS 1368.5 70 999999999 1183.75 1896.35 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770909_1 CDM 0390 RC P9035 HCPCS inpatient 1955 1270.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1183.75 60.55 999999999 1183.75 1896.35 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770909_1 CDM 0390 RC P9035 HCPCS inpatient 1955 1270.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1183.75 1896.35 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770909_1 CDM 0390 RC P9035 HCPCS inpatient 1955 1270.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1183.75 1896.35 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770909_1 CDM 0390 RC P9035 HCPCS inpatient 1955 1270.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1183.75 1896.35 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770909_1 CDM 0390 RC P9035 HCPCS inpatient 1955 1270.75 ANTHEM HMO ANTHEM HMO 999999999 1183.75 1896.35 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770909_1 CDM 0390 RC P9035 HCPCS inpatient 1955 1270.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1321.58 67.6 999999999 1183.75 1896.35 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770909_1 CDM 0390 RC P9035 HCPCS inpatient 1955 1270.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1183.75 1896.35 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770910_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1082.9 65 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770910_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 AETNA AETNA 1316.14 79 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770910_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1149.54 69 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770910_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1616.02 97 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770910_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1299.48 78 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770910_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 SIHO - ALL PLANS SIHO - ALL PLANS 1499.4 90 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770910_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 UMR - ALL PLANS UMR - ALL PLANS 1166.2 70 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770910_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1008.76 60.55 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770910_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770910_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770910_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770910_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM HMO ANTHEM HMO 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770910_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1126.22 67.6 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770910_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770911_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1277.9 65 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770911_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 AETNA AETNA 1553.14 79 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770911_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1356.54 69 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770911_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1907.02 97 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770911_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1533.48 78 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770911_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 SIHO - ALL PLANS SIHO - ALL PLANS 1769.4 90 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770911_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 UMR - ALL PLANS UMR - ALL PLANS 1376.2 70 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770911_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1190.41 60.55 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770911_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770911_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770911_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770911_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ANTHEM HMO ANTHEM HMO 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770911_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1329.02 67.6 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770911_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770912_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1277.9 65 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770912_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 AETNA AETNA 1553.14 79 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770912_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1356.54 69 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770912_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1907.02 97 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770912_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1533.48 78 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770912_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 SIHO - ALL PLANS SIHO - ALL PLANS 1769.4 90 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770912_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 UMR - ALL PLANS UMR - ALL PLANS 1376.2 70 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770912_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1190.41 60.55 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770912_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770912_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770912_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770912_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ANTHEM HMO ANTHEM HMO 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770912_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1329.02 67.6 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770912_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT" 2770913_1 CDM 0390 RC P9053 HCPCS inpatient 1966 1277.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1277.9 65 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT" 2770913_1 CDM 0390 RC P9053 HCPCS inpatient 1966 1277.9 AETNA AETNA 1553.14 79 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT" 2770913_1 CDM 0390 RC P9053 HCPCS inpatient 1966 1277.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1356.54 69 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT" 2770913_1 CDM 0390 RC P9053 HCPCS inpatient 1966 1277.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1907.02 97 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT" 2770913_1 CDM 0390 RC P9053 HCPCS inpatient 1966 1277.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1533.48 78 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT" 2770913_1 CDM 0390 RC P9053 HCPCS inpatient 1966 1277.9 SIHO - ALL PLANS SIHO - ALL PLANS 1769.4 90 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT" 2770913_1 CDM 0390 RC P9053 HCPCS inpatient 1966 1277.9 UMR - ALL PLANS UMR - ALL PLANS 1376.2 70 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT" 2770913_1 CDM 0390 RC P9053 HCPCS inpatient 1966 1277.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1190.41 60.55 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT" 2770913_1 CDM 0390 RC P9053 HCPCS inpatient 1966 1277.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT" 2770913_1 CDM 0390 RC P9053 HCPCS inpatient 1966 1277.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT" 2770913_1 CDM 0390 RC P9053 HCPCS inpatient 1966 1277.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT" 2770913_1 CDM 0390 RC P9053 HCPCS inpatient 1966 1277.9 ANTHEM HMO ANTHEM HMO 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT" 2770913_1 CDM 0390 RC P9053 HCPCS inpatient 1966 1277.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1329.02 67.6 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, CMV-NEGATIVE, IRRADIATED, EACH UNIT" 2770913_1 CDM 0390 RC P9053 HCPCS inpatient 1966 1277.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770914_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1277.9 65 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770914_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 AETNA AETNA 1553.14 79 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770914_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1356.54 69 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770914_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1907.02 97 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770914_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1533.48 78 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770914_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 SIHO - ALL PLANS SIHO - ALL PLANS 1769.4 90 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770914_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 UMR - ALL PLANS UMR - ALL PLANS 1376.2 70 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770914_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1190.41 60.55 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770914_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770914_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770914_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770914_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ANTHEM HMO ANTHEM HMO 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770914_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1329.02 67.6 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770914_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770915_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1277.9 65 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770915_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 AETNA AETNA 1553.14 79 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770915_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1356.54 69 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770915_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1907.02 97 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770915_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1533.48 78 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770915_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 SIHO - ALL PLANS SIHO - ALL PLANS 1769.4 90 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770915_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 UMR - ALL PLANS UMR - ALL PLANS 1376.2 70 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770915_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1190.41 60.55 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770915_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770915_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770915_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770915_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 ANTHEM HMO ANTHEM HMO 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770915_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1329.02 67.6 999999999 1190.41 1907.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770915_1 CDM 0390 RC P9037 HCPCS inpatient 1966 1277.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1190.41 1907.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770916_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1082.9 65 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770916_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 AETNA AETNA 1316.14 79 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770916_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1149.54 69 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770916_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1616.02 97 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770916_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1299.48 78 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770916_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 SIHO - ALL PLANS SIHO - ALL PLANS 1499.4 90 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770916_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 UMR - ALL PLANS UMR - ALL PLANS 1166.2 70 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770916_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1008.76 60.55 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770916_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770916_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770916_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770916_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM HMO ANTHEM HMO 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770916_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1126.22 67.6 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770916_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770917_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1229.8 65 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770917_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 AETNA AETNA 1494.68 79 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770917_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1305.48 69 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770917_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1835.24 97 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770917_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1475.76 78 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770917_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 SIHO - ALL PLANS SIHO - ALL PLANS 1702.8 90 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770917_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 UMR - ALL PLANS UMR - ALL PLANS 1324.4 70 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770917_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1145.61 60.55 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770917_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770917_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770917_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770917_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 ANTHEM HMO ANTHEM HMO 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770917_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1278.99 67.6 999999999 1145.61 1835.24 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2770917_1 CDM 0390 RC P9035 HCPCS inpatient 1892 1229.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1145.61 1835.24 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770918_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770918_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770918_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770918_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770918_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770918_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770918_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770918_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770918_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770918_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770918_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770918_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770918_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 2770918_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770977_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 586.3 65 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770977_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 AETNA AETNA 712.58 79 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770977_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 622.38 69 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770977_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 874.94 97 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770977_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 703.56 78 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770977_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SIHO - ALL PLANS SIHO - ALL PLANS 811.8 90 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770977_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UMR - ALL PLANS UMR - ALL PLANS 631.4 70 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770977_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 546.16 60.55 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770977_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770977_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770977_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770977_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM HMO ANTHEM HMO 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770977_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 609.75 67.6 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2770977_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 546.16 874.94 "INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.)" 2771013_1 CDM 0636 RC J2790 HCPCS inpatient 438 284.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 284.7 65 999999999 265.21 424.86 percent of total billed charges "INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.)" 2771013_1 CDM 0636 RC J2790 HCPCS inpatient 438 284.7 AETNA AETNA 346.02 79 999999999 265.21 424.86 percent of total billed charges "INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.)" 2771013_1 CDM 0636 RC J2790 HCPCS inpatient 438 284.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 302.22 69 999999999 265.21 424.86 percent of total billed charges "INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.)" 2771013_1 CDM 0636 RC J2790 HCPCS inpatient 438 284.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 424.86 97 999999999 265.21 424.86 percent of total billed charges "INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.)" 2771013_1 CDM 0636 RC J2790 HCPCS inpatient 438 284.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 341.64 78 999999999 265.21 424.86 percent of total billed charges "INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.)" 2771013_1 CDM 0636 RC J2790 HCPCS inpatient 438 284.7 SIHO - ALL PLANS SIHO - ALL PLANS 394.2 90 999999999 265.21 424.86 percent of total billed charges "INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.)" 2771013_1 CDM 0636 RC J2790 HCPCS inpatient 438 284.7 UMR - ALL PLANS UMR - ALL PLANS 306.6 70 999999999 265.21 424.86 percent of total billed charges "INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.)" 2771013_1 CDM 0636 RC J2790 HCPCS inpatient 438 284.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 265.21 60.55 999999999 265.21 424.86 percent of total billed charges "INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.)" 2771013_1 CDM 0636 RC J2790 HCPCS inpatient 438 284.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 265.21 424.86 "INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.)" 2771013_1 CDM 0636 RC J2790 HCPCS inpatient 438 284.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 265.21 424.86 "INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.)" 2771013_1 CDM 0636 RC J2790 HCPCS inpatient 438 284.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 265.21 424.86 "INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.)" 2771013_1 CDM 0636 RC J2790 HCPCS inpatient 438 284.7 ANTHEM HMO ANTHEM HMO 999999999 265.21 424.86 "INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.)" 2771013_1 CDM 0636 RC J2790 HCPCS inpatient 438 284.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 296.09 67.6 999999999 265.21 424.86 percent of total billed charges "INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.)" 2771013_1 CDM 0636 RC J2790 HCPCS inpatient 438 284.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 265.21 424.86 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2771049_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1171.3 65 999999999 1091.11 1747.94 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2771049_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 AETNA AETNA 1423.58 79 999999999 1091.11 1747.94 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2771049_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1243.38 69 999999999 1091.11 1747.94 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2771049_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1747.94 97 999999999 1091.11 1747.94 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2771049_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1405.56 78 999999999 1091.11 1747.94 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2771049_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 SIHO - ALL PLANS SIHO - ALL PLANS 1621.8 90 999999999 1091.11 1747.94 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2771049_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 UMR - ALL PLANS UMR - ALL PLANS 1261.4 70 999999999 1091.11 1747.94 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2771049_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1091.11 60.55 999999999 1091.11 1747.94 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2771049_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1091.11 1747.94 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2771049_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1091.11 1747.94 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2771049_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1091.11 1747.94 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2771049_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 ANTHEM HMO ANTHEM HMO 999999999 1091.11 1747.94 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2771049_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1218.15 67.6 999999999 1091.11 1747.94 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 2771049_1 CDM 0390 RC P9035 HCPCS inpatient 1802 1171.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1091.11 1747.94 "CRYOPRECIPITATE, EACH UNIT" 2771059_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 810.55 65 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 2771059_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 AETNA AETNA 985.13 79 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 2771059_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 860.43 69 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 2771059_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1209.59 97 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 2771059_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 972.66 78 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 2771059_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 SIHO - ALL PLANS SIHO - ALL PLANS 1122.3 90 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 2771059_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 UMR - ALL PLANS UMR - ALL PLANS 872.9 70 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 2771059_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 755.06 60.55 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 2771059_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 755.06 1209.59 "CRYOPRECIPITATE, EACH UNIT" 2771059_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 755.06 1209.59 "CRYOPRECIPITATE, EACH UNIT" 2771059_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 755.06 1209.59 "CRYOPRECIPITATE, EACH UNIT" 2771059_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 ANTHEM HMO ANTHEM HMO 999999999 755.06 1209.59 "CRYOPRECIPITATE, EACH UNIT" 2771059_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 842.97 67.6 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 2771059_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 755.06 1209.59 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771068_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 586.3 65 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771068_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 AETNA AETNA 712.58 79 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771068_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 622.38 69 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771068_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 874.94 97 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771068_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 703.56 78 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771068_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SIHO - ALL PLANS SIHO - ALL PLANS 811.8 90 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771068_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UMR - ALL PLANS UMR - ALL PLANS 631.4 70 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771068_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 546.16 60.55 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771068_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771068_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771068_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771068_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM HMO ANTHEM HMO 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771068_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 609.75 67.6 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771068_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771069_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 586.3 65 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771069_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 AETNA AETNA 712.58 79 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771069_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 622.38 69 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771069_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 874.94 97 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771069_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 703.56 78 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771069_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SIHO - ALL PLANS SIHO - ALL PLANS 811.8 90 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771069_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UMR - ALL PLANS UMR - ALL PLANS 631.4 70 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771069_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 546.16 60.55 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771069_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771069_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771069_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771069_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM HMO ANTHEM HMO 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771069_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 609.75 67.6 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771069_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771070_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 586.3 65 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771070_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 AETNA AETNA 712.58 79 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771070_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 622.38 69 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771070_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 874.94 97 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771070_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 703.56 78 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771070_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SIHO - ALL PLANS SIHO - ALL PLANS 811.8 90 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771070_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UMR - ALL PLANS UMR - ALL PLANS 631.4 70 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771070_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 546.16 60.55 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771070_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771070_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771070_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771070_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM HMO ANTHEM HMO 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771070_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 609.75 67.6 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771070_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771072_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 586.3 65 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771072_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 AETNA AETNA 712.58 79 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771072_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 622.38 69 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771072_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 874.94 97 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771072_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 703.56 78 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771072_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SIHO - ALL PLANS SIHO - ALL PLANS 811.8 90 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771072_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UMR - ALL PLANS UMR - ALL PLANS 631.4 70 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771072_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 546.16 60.55 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771072_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771072_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771072_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771072_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM HMO ANTHEM HMO 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771072_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 609.75 67.6 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771072_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771073_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 586.3 65 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771073_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 AETNA AETNA 712.58 79 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771073_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 622.38 69 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771073_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 874.94 97 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771073_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 703.56 78 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771073_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 SIHO - ALL PLANS SIHO - ALL PLANS 811.8 90 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771073_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UMR - ALL PLANS UMR - ALL PLANS 631.4 70 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771073_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 546.16 60.55 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771073_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771073_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771073_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771073_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 ANTHEM HMO ANTHEM HMO 999999999 546.16 874.94 "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771073_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 609.75 67.6 999999999 546.16 874.94 percent of total billed charges "RED BLOOD CELLS, LEUKOCYTES REDUCED, EACH UNIT" 2771073_1 CDM 0390 RC P9016 HCPCS inpatient 902 586.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 546.16 874.94 CT scan of face without contrast 2784747_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1369.55 65 999999999 1275.79 2043.79 percent of total billed charges CT scan of face without contrast 2784747_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 AETNA AETNA 1664.53 79 999999999 1275.79 2043.79 percent of total billed charges CT scan of face without contrast 2784747_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1453.83 69 999999999 1275.79 2043.79 percent of total billed charges CT scan of face without contrast 2784747_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2043.79 97 999999999 1275.79 2043.79 percent of total billed charges CT scan of face without contrast 2784747_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1643.46 78 999999999 1275.79 2043.79 percent of total billed charges CT scan of face without contrast 2784747_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 SIHO - ALL PLANS SIHO - ALL PLANS 1896.3 90 999999999 1275.79 2043.79 percent of total billed charges CT scan of face without contrast 2784747_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 UMR - ALL PLANS UMR - ALL PLANS 1474.9 70 999999999 1275.79 2043.79 percent of total billed charges CT scan of face without contrast 2784747_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1275.79 60.55 999999999 1275.79 2043.79 percent of total billed charges CT scan of face without contrast 2784747_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1275.79 2043.79 CT scan of face without contrast 2784747_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1275.79 2043.79 CT scan of face without contrast 2784747_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1275.79 2043.79 CT scan of face without contrast 2784747_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 ANTHEM HMO ANTHEM HMO 999999999 1275.79 2043.79 CT scan of face without contrast 2784747_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1424.33 67.6 999999999 1275.79 2043.79 percent of total billed charges CT scan of face without contrast 2784747_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1275.79 2043.79 CT scan of cranial cavity without contrast 2784762_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1280.5 65 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity without contrast 2784762_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 AETNA AETNA 1556.3 79 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity without contrast 2784762_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1359.3 69 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity without contrast 2784762_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1910.9 97 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity without contrast 2784762_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1536.6 78 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity without contrast 2784762_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 SIHO - ALL PLANS SIHO - ALL PLANS 1773 90 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity without contrast 2784762_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 UMR - ALL PLANS UMR - ALL PLANS 1379 70 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity without contrast 2784762_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1192.84 60.55 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity without contrast 2784762_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1192.84 1910.9 CT scan of cranial cavity without contrast 2784762_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1192.84 1910.9 CT scan of cranial cavity without contrast 2784762_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1192.84 1910.9 CT scan of cranial cavity without contrast 2784762_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 ANTHEM HMO ANTHEM HMO 999999999 1192.84 1910.9 CT scan of cranial cavity without contrast 2784762_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1331.72 67.6 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity without contrast 2784762_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1192.84 1910.9 Blood typing for Rh (D) antigen 2814901_1 CDM 0302 RC 86901 HCPCS inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges Blood typing for Rh (D) antigen 2814901_1 CDM 0302 RC 86901 HCPCS inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges Blood typing for Rh (D) antigen 2814901_1 CDM 0302 RC 86901 HCPCS inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges Blood typing for Rh (D) antigen 2814901_1 CDM 0302 RC 86901 HCPCS inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges Blood typing for Rh (D) antigen 2814901_1 CDM 0302 RC 86901 HCPCS inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges Blood typing for Rh (D) antigen 2814901_1 CDM 0302 RC 86901 HCPCS inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges Blood typing for Rh (D) antigen 2814901_1 CDM 0302 RC 86901 HCPCS inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges Blood typing for Rh (D) antigen 2814901_1 CDM 0302 RC 86901 HCPCS inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges Blood typing for Rh (D) antigen 2814901_1 CDM 0302 RC 86901 HCPCS inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 Blood typing for Rh (D) antigen 2814901_1 CDM 0302 RC 86901 HCPCS inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 Blood typing for Rh (D) antigen 2814901_1 CDM 0302 RC 86901 HCPCS inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 Blood typing for Rh (D) antigen 2814901_1 CDM 0302 RC 86901 HCPCS inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 Blood typing for Rh (D) antigen 2814901_1 CDM 0302 RC 86901 HCPCS inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges Blood typing for Rh (D) antigen 2814901_1 CDM 0302 RC 86901 HCPCS inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860603_1 CDM 0360 RC inpatient 1244.86 809.16 SELF PAY DISCOUNT SELF PAY DISCOUNT 809.16 65 999999999 753.76 1207.51 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860603_1 CDM 0360 RC inpatient 1244.86 809.16 AETNA AETNA 983.44 79 999999999 753.76 1207.51 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860603_1 CDM 0360 RC inpatient 1244.86 809.16 ENCORE - ALL PLANS ENCORE - ALL PLANS 858.95 69 999999999 753.76 1207.51 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860603_1 CDM 0360 RC inpatient 1244.86 809.16 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1207.51 97 999999999 753.76 1207.51 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860603_1 CDM 0360 RC inpatient 1244.86 809.16 HUMANA - ALL PLANS HUMANA - ALL PLANS 970.99 78 999999999 753.76 1207.51 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860603_1 CDM 0360 RC inpatient 1244.86 809.16 SIHO - ALL PLANS SIHO - ALL PLANS 1120.37 90 999999999 753.76 1207.51 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860603_1 CDM 0360 RC inpatient 1244.86 809.16 UMR - ALL PLANS UMR - ALL PLANS 871.4 70 999999999 753.76 1207.51 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860603_1 CDM 0360 RC inpatient 1244.86 809.16 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 753.76 60.55 999999999 753.76 1207.51 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860603_1 CDM 0360 RC inpatient 1244.86 809.16 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 753.76 1207.51 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860603_1 CDM 0360 RC inpatient 1244.86 809.16 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 753.76 1207.51 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860603_1 CDM 0360 RC inpatient 1244.86 809.16 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 753.76 1207.51 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860603_1 CDM 0360 RC inpatient 1244.86 809.16 ANTHEM HMO ANTHEM HMO 999999999 753.76 1207.51 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860603_1 CDM 0360 RC inpatient 1244.86 809.16 CIGNA - ALL PLANS CIGNA - ALL PLANS 841.53 67.6 999999999 753.76 1207.51 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860603_1 CDM 0360 RC inpatient 1244.86 809.16 UHC - ALL PLANS UHC - ALL PLANS 999999999 753.76 1207.51 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860604_1 CDM 0360 RC inpatient 2110.26 1371.67 SELF PAY DISCOUNT SELF PAY DISCOUNT 1371.67 65 999999999 1277.76 2046.95 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860604_1 CDM 0360 RC inpatient 2110.26 1371.67 AETNA AETNA 1667.11 79 999999999 1277.76 2046.95 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860604_1 CDM 0360 RC inpatient 2110.26 1371.67 ENCORE - ALL PLANS ENCORE - ALL PLANS 1456.08 69 999999999 1277.76 2046.95 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860604_1 CDM 0360 RC inpatient 2110.26 1371.67 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2046.95 97 999999999 1277.76 2046.95 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860604_1 CDM 0360 RC inpatient 2110.26 1371.67 HUMANA - ALL PLANS HUMANA - ALL PLANS 1646 78 999999999 1277.76 2046.95 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860604_1 CDM 0360 RC inpatient 2110.26 1371.67 SIHO - ALL PLANS SIHO - ALL PLANS 1899.23 90 999999999 1277.76 2046.95 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860604_1 CDM 0360 RC inpatient 2110.26 1371.67 UMR - ALL PLANS UMR - ALL PLANS 1477.18 70 999999999 1277.76 2046.95 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860604_1 CDM 0360 RC inpatient 2110.26 1371.67 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1277.76 60.55 999999999 1277.76 2046.95 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860604_1 CDM 0360 RC inpatient 2110.26 1371.67 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1277.76 2046.95 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860604_1 CDM 0360 RC inpatient 2110.26 1371.67 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1277.76 2046.95 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860604_1 CDM 0360 RC inpatient 2110.26 1371.67 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1277.76 2046.95 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860604_1 CDM 0360 RC inpatient 2110.26 1371.67 ANTHEM HMO ANTHEM HMO 999999999 1277.76 2046.95 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860604_1 CDM 0360 RC inpatient 2110.26 1371.67 CIGNA - ALL PLANS CIGNA - ALL PLANS 1426.54 67.6 999999999 1277.76 2046.95 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860604_1 CDM 0360 RC inpatient 2110.26 1371.67 UHC - ALL PLANS UHC - ALL PLANS 999999999 1277.76 2046.95 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860605_1 CDM 0360 RC inpatient 3280.03 2132.02 SELF PAY DISCOUNT SELF PAY DISCOUNT 2132.02 65 999999999 1986.06 3181.63 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860605_1 CDM 0360 RC inpatient 3280.03 2132.02 AETNA AETNA 2591.22 79 999999999 1986.06 3181.63 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860605_1 CDM 0360 RC inpatient 3280.03 2132.02 ENCORE - ALL PLANS ENCORE - ALL PLANS 2263.22 69 999999999 1986.06 3181.63 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860605_1 CDM 0360 RC inpatient 3280.03 2132.02 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3181.63 97 999999999 1986.06 3181.63 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860605_1 CDM 0360 RC inpatient 3280.03 2132.02 HUMANA - ALL PLANS HUMANA - ALL PLANS 2558.42 78 999999999 1986.06 3181.63 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860605_1 CDM 0360 RC inpatient 3280.03 2132.02 SIHO - ALL PLANS SIHO - ALL PLANS 2952.03 90 999999999 1986.06 3181.63 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860605_1 CDM 0360 RC inpatient 3280.03 2132.02 UMR - ALL PLANS UMR - ALL PLANS 2296.02 70 999999999 1986.06 3181.63 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860605_1 CDM 0360 RC inpatient 3280.03 2132.02 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1986.06 60.55 999999999 1986.06 3181.63 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860605_1 CDM 0360 RC inpatient 3280.03 2132.02 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1986.06 3181.63 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860605_1 CDM 0360 RC inpatient 3280.03 2132.02 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1986.06 3181.63 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860605_1 CDM 0360 RC inpatient 3280.03 2132.02 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1986.06 3181.63 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860605_1 CDM 0360 RC inpatient 3280.03 2132.02 ANTHEM HMO ANTHEM HMO 999999999 1986.06 3181.63 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860605_1 CDM 0360 RC inpatient 3280.03 2132.02 CIGNA - ALL PLANS CIGNA - ALL PLANS 2217.3 67.6 999999999 1986.06 3181.63 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860605_1 CDM 0360 RC inpatient 3280.03 2132.02 UHC - ALL PLANS UHC - ALL PLANS 999999999 1986.06 3181.63 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860606_1 CDM 0360 RC inpatient 2699.12 1754.43 SELF PAY DISCOUNT SELF PAY DISCOUNT 1754.43 65 999999999 1634.32 2618.15 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860606_1 CDM 0360 RC inpatient 2699.12 1754.43 AETNA AETNA 2132.3 79 999999999 1634.32 2618.15 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860606_1 CDM 0360 RC inpatient 2699.12 1754.43 ENCORE - ALL PLANS ENCORE - ALL PLANS 1862.39 69 999999999 1634.32 2618.15 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860606_1 CDM 0360 RC inpatient 2699.12 1754.43 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2618.15 97 999999999 1634.32 2618.15 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860606_1 CDM 0360 RC inpatient 2699.12 1754.43 HUMANA - ALL PLANS HUMANA - ALL PLANS 2105.31 78 999999999 1634.32 2618.15 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860606_1 CDM 0360 RC inpatient 2699.12 1754.43 SIHO - ALL PLANS SIHO - ALL PLANS 2429.21 90 999999999 1634.32 2618.15 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860606_1 CDM 0360 RC inpatient 2699.12 1754.43 UMR - ALL PLANS UMR - ALL PLANS 1889.38 70 999999999 1634.32 2618.15 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860606_1 CDM 0360 RC inpatient 2699.12 1754.43 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1634.32 60.55 999999999 1634.32 2618.15 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860606_1 CDM 0360 RC inpatient 2699.12 1754.43 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1634.32 2618.15 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860606_1 CDM 0360 RC inpatient 2699.12 1754.43 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1634.32 2618.15 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860606_1 CDM 0360 RC inpatient 2699.12 1754.43 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1634.32 2618.15 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860606_1 CDM 0360 RC inpatient 2699.12 1754.43 ANTHEM HMO ANTHEM HMO 999999999 1634.32 2618.15 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860606_1 CDM 0360 RC inpatient 2699.12 1754.43 CIGNA - ALL PLANS CIGNA - ALL PLANS 1824.61 67.6 999999999 1634.32 2618.15 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860606_1 CDM 0360 RC inpatient 2699.12 1754.43 UHC - ALL PLANS UHC - ALL PLANS 999999999 1634.32 2618.15 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860607_1 CDM 0360 RC inpatient 2895.28 1881.93 SELF PAY DISCOUNT SELF PAY DISCOUNT 1881.93 65 999999999 1753.09 2808.42 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860607_1 CDM 0360 RC inpatient 2895.28 1881.93 AETNA AETNA 2287.27 79 999999999 1753.09 2808.42 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860607_1 CDM 0360 RC inpatient 2895.28 1881.93 ENCORE - ALL PLANS ENCORE - ALL PLANS 1997.74 69 999999999 1753.09 2808.42 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860607_1 CDM 0360 RC inpatient 2895.28 1881.93 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2808.42 97 999999999 1753.09 2808.42 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860607_1 CDM 0360 RC inpatient 2895.28 1881.93 HUMANA - ALL PLANS HUMANA - ALL PLANS 2258.32 78 999999999 1753.09 2808.42 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860607_1 CDM 0360 RC inpatient 2895.28 1881.93 SIHO - ALL PLANS SIHO - ALL PLANS 2605.75 90 999999999 1753.09 2808.42 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860607_1 CDM 0360 RC inpatient 2895.28 1881.93 UMR - ALL PLANS UMR - ALL PLANS 2026.7 70 999999999 1753.09 2808.42 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860607_1 CDM 0360 RC inpatient 2895.28 1881.93 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1753.09 60.55 999999999 1753.09 2808.42 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860607_1 CDM 0360 RC inpatient 2895.28 1881.93 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1753.09 2808.42 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860607_1 CDM 0360 RC inpatient 2895.28 1881.93 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1753.09 2808.42 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860607_1 CDM 0360 RC inpatient 2895.28 1881.93 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1753.09 2808.42 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860607_1 CDM 0360 RC inpatient 2895.28 1881.93 ANTHEM HMO ANTHEM HMO 999999999 1753.09 2808.42 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860607_1 CDM 0360 RC inpatient 2895.28 1881.93 CIGNA - ALL PLANS CIGNA - ALL PLANS 1957.21 67.6 999999999 1753.09 2808.42 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2860607_1 CDM 0360 RC inpatient 2895.28 1881.93 UHC - ALL PLANS UHC - ALL PLANS 999999999 1753.09 2808.42 Diagnostic mammography of 1 breast 2884604_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 290.55 65 999999999 270.66 433.59 percent of total billed charges Diagnostic mammography of 1 breast 2884604_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 AETNA AETNA 353.13 79 999999999 270.66 433.59 percent of total billed charges Diagnostic mammography of 1 breast 2884604_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 308.43 69 999999999 270.66 433.59 percent of total billed charges Diagnostic mammography of 1 breast 2884604_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 433.59 97 999999999 270.66 433.59 percent of total billed charges Diagnostic mammography of 1 breast 2884604_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 348.66 78 999999999 270.66 433.59 percent of total billed charges Diagnostic mammography of 1 breast 2884604_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 SIHO - ALL PLANS SIHO - ALL PLANS 402.3 90 999999999 270.66 433.59 percent of total billed charges Diagnostic mammography of 1 breast 2884604_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 UMR - ALL PLANS UMR - ALL PLANS 312.9 70 999999999 270.66 433.59 percent of total billed charges Diagnostic mammography of 1 breast 2884604_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.66 60.55 999999999 270.66 433.59 percent of total billed charges Diagnostic mammography of 1 breast 2884604_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.66 433.59 Diagnostic mammography of 1 breast 2884604_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.66 433.59 Diagnostic mammography of 1 breast 2884604_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.66 433.59 Diagnostic mammography of 1 breast 2884604_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 ANTHEM HMO ANTHEM HMO 999999999 270.66 433.59 Diagnostic mammography of 1 breast 2884604_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 302.17 67.6 999999999 270.66 433.59 percent of total billed charges Diagnostic mammography of 1 breast 2884604_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.66 433.59 Diagnostic mammography of 1 breast 2884605_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 319.8 65 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884605_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 AETNA AETNA 388.68 79 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884605_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 339.48 69 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884605_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 477.24 97 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884605_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 383.76 78 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884605_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 SIHO - ALL PLANS SIHO - ALL PLANS 442.8 90 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884605_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 UMR - ALL PLANS UMR - ALL PLANS 344.4 70 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884605_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 297.91 60.55 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884605_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 297.91 477.24 Diagnostic mammography of 1 breast 2884605_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 297.91 477.24 Diagnostic mammography of 1 breast 2884605_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 297.91 477.24 Diagnostic mammography of 1 breast 2884605_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM HMO ANTHEM HMO 999999999 297.91 477.24 Diagnostic mammography of 1 breast 2884605_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 332.59 67.6 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884605_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 297.91 477.24 Diagnostic mammography of both breasts 2884607_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 377.65 65 999999999 351.8 563.57 percent of total billed charges Diagnostic mammography of both breasts 2884607_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 AETNA AETNA 458.99 79 999999999 351.8 563.57 percent of total billed charges Diagnostic mammography of both breasts 2884607_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 400.89 69 999999999 351.8 563.57 percent of total billed charges Diagnostic mammography of both breasts 2884607_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 563.57 97 999999999 351.8 563.57 percent of total billed charges Diagnostic mammography of both breasts 2884607_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 453.18 78 999999999 351.8 563.57 percent of total billed charges Diagnostic mammography of both breasts 2884607_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 SIHO - ALL PLANS SIHO - ALL PLANS 522.9 90 999999999 351.8 563.57 percent of total billed charges Diagnostic mammography of both breasts 2884607_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 UMR - ALL PLANS UMR - ALL PLANS 406.7 70 999999999 351.8 563.57 percent of total billed charges Diagnostic mammography of both breasts 2884607_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 351.8 60.55 999999999 351.8 563.57 percent of total billed charges Diagnostic mammography of both breasts 2884607_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 351.8 563.57 Diagnostic mammography of both breasts 2884607_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 351.8 563.57 Diagnostic mammography of both breasts 2884607_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 351.8 563.57 Diagnostic mammography of both breasts 2884607_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 ANTHEM HMO ANTHEM HMO 999999999 351.8 563.57 Diagnostic mammography of both breasts 2884607_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 392.76 67.6 999999999 351.8 563.57 percent of total billed charges Diagnostic mammography of both breasts 2884607_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 351.8 563.57 Diagnostic mammography of 1 breast 2884610_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 319.8 65 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884610_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 AETNA AETNA 388.68 79 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884610_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 339.48 69 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884610_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 477.24 97 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884610_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 383.76 78 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884610_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 SIHO - ALL PLANS SIHO - ALL PLANS 442.8 90 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884610_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 UMR - ALL PLANS UMR - ALL PLANS 344.4 70 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884610_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 297.91 60.55 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884610_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 297.91 477.24 Diagnostic mammography of 1 breast 2884610_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 297.91 477.24 Diagnostic mammography of 1 breast 2884610_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 297.91 477.24 Diagnostic mammography of 1 breast 2884610_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM HMO ANTHEM HMO 999999999 297.91 477.24 Diagnostic mammography of 1 breast 2884610_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 332.59 67.6 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884610_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 297.91 477.24 Diagnostic mammography of 1 breast 2884613_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 319.8 65 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884613_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 AETNA AETNA 388.68 79 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884613_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 339.48 69 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884613_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 477.24 97 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884613_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 383.76 78 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884613_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 SIHO - ALL PLANS SIHO - ALL PLANS 442.8 90 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884613_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 UMR - ALL PLANS UMR - ALL PLANS 344.4 70 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884613_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 297.91 60.55 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884613_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 297.91 477.24 Diagnostic mammography of 1 breast 2884613_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 297.91 477.24 Diagnostic mammography of 1 breast 2884613_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 297.91 477.24 Diagnostic mammography of 1 breast 2884613_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM HMO ANTHEM HMO 999999999 297.91 477.24 Diagnostic mammography of 1 breast 2884613_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 332.59 67.6 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 2884613_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 297.91 477.24 Diagnostic mammography of 1 breast 2884614_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 290.55 65 999999999 270.66 433.59 percent of total billed charges Diagnostic mammography of 1 breast 2884614_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 AETNA AETNA 353.13 79 999999999 270.66 433.59 percent of total billed charges Diagnostic mammography of 1 breast 2884614_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 308.43 69 999999999 270.66 433.59 percent of total billed charges Diagnostic mammography of 1 breast 2884614_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 433.59 97 999999999 270.66 433.59 percent of total billed charges Diagnostic mammography of 1 breast 2884614_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 348.66 78 999999999 270.66 433.59 percent of total billed charges Diagnostic mammography of 1 breast 2884614_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 SIHO - ALL PLANS SIHO - ALL PLANS 402.3 90 999999999 270.66 433.59 percent of total billed charges Diagnostic mammography of 1 breast 2884614_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 UMR - ALL PLANS UMR - ALL PLANS 312.9 70 999999999 270.66 433.59 percent of total billed charges Diagnostic mammography of 1 breast 2884614_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.66 60.55 999999999 270.66 433.59 percent of total billed charges Diagnostic mammography of 1 breast 2884614_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.66 433.59 Diagnostic mammography of 1 breast 2884614_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.66 433.59 Diagnostic mammography of 1 breast 2884614_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.66 433.59 Diagnostic mammography of 1 breast 2884614_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 ANTHEM HMO ANTHEM HMO 999999999 270.66 433.59 Diagnostic mammography of 1 breast 2884614_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 302.17 67.6 999999999 270.66 433.59 percent of total billed charges Diagnostic mammography of 1 breast 2884614_1 CDM 0401 RC 77065 HCPCS inpatient 447 290.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.66 433.59 Screening mammography 2884616_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 347.75 65 999999999 323.94 518.95 percent of total billed charges Screening mammography 2884616_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 AETNA AETNA 422.65 79 999999999 323.94 518.95 percent of total billed charges Screening mammography 2884616_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 369.15 69 999999999 323.94 518.95 percent of total billed charges Screening mammography 2884616_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 518.95 97 999999999 323.94 518.95 percent of total billed charges Screening mammography 2884616_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 417.3 78 999999999 323.94 518.95 percent of total billed charges Screening mammography 2884616_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 SIHO - ALL PLANS SIHO - ALL PLANS 481.5 90 999999999 323.94 518.95 percent of total billed charges Screening mammography 2884616_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 UMR - ALL PLANS UMR - ALL PLANS 374.5 70 999999999 323.94 518.95 percent of total billed charges Screening mammography 2884616_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 323.94 60.55 999999999 323.94 518.95 percent of total billed charges Screening mammography 2884616_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 323.94 518.95 Screening mammography 2884616_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 323.94 518.95 Screening mammography 2884616_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 323.94 518.95 Screening mammography 2884616_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ANTHEM HMO ANTHEM HMO 999999999 323.94 518.95 Screening mammography 2884616_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 361.66 67.6 999999999 323.94 518.95 percent of total billed charges Screening mammography 2884616_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 323.94 518.95 "Pathology examination of tissue using a microscope, limited examination" 295346_1 CDM 0312 RC 88300 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Pathology examination of tissue using a microscope, limited examination" 295346_1 CDM 0312 RC 88300 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Pathology examination of tissue using a microscope, limited examination" 295346_1 CDM 0312 RC 88300 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Pathology examination of tissue using a microscope, limited examination" 295346_1 CDM 0312 RC 88300 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Pathology examination of tissue using a microscope, limited examination" 295346_1 CDM 0312 RC 88300 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Pathology examination of tissue using a microscope, limited examination" 295346_1 CDM 0312 RC 88300 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Pathology examination of tissue using a microscope, limited examination" 295346_1 CDM 0312 RC 88300 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Pathology examination of tissue using a microscope, limited examination" 295346_1 CDM 0312 RC 88300 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Pathology examination of tissue using a microscope, limited examination" 295346_1 CDM 0312 RC 88300 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Pathology examination of tissue using a microscope, limited examination" 295346_1 CDM 0312 RC 88300 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Pathology examination of tissue using a microscope, limited examination" 295346_1 CDM 0312 RC 88300 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Pathology examination of tissue using a microscope, limited examination" 295346_1 CDM 0312 RC 88300 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Pathology examination of tissue using a microscope, limited examination" 295346_1 CDM 0312 RC 88300 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Pathology examination of tissue using a microscope, limited examination" 295346_1 CDM 0312 RC 88300 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 Pathology examination of tissue using a microscope 295348_1 CDM 0312 RC 88302 HCPCS inpatient 148 96.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 96.2 65 999999999 89.61 143.56 percent of total billed charges Pathology examination of tissue using a microscope 295348_1 CDM 0312 RC 88302 HCPCS inpatient 148 96.2 AETNA AETNA 116.92 79 999999999 89.61 143.56 percent of total billed charges Pathology examination of tissue using a microscope 295348_1 CDM 0312 RC 88302 HCPCS inpatient 148 96.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 102.12 69 999999999 89.61 143.56 percent of total billed charges Pathology examination of tissue using a microscope 295348_1 CDM 0312 RC 88302 HCPCS inpatient 148 96.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 143.56 97 999999999 89.61 143.56 percent of total billed charges Pathology examination of tissue using a microscope 295348_1 CDM 0312 RC 88302 HCPCS inpatient 148 96.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 115.44 78 999999999 89.61 143.56 percent of total billed charges Pathology examination of tissue using a microscope 295348_1 CDM 0312 RC 88302 HCPCS inpatient 148 96.2 SIHO - ALL PLANS SIHO - ALL PLANS 133.2 90 999999999 89.61 143.56 percent of total billed charges Pathology examination of tissue using a microscope 295348_1 CDM 0312 RC 88302 HCPCS inpatient 148 96.2 UMR - ALL PLANS UMR - ALL PLANS 103.6 70 999999999 89.61 143.56 percent of total billed charges Pathology examination of tissue using a microscope 295348_1 CDM 0312 RC 88302 HCPCS inpatient 148 96.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 89.61 60.55 999999999 89.61 143.56 percent of total billed charges Pathology examination of tissue using a microscope 295348_1 CDM 0312 RC 88302 HCPCS inpatient 148 96.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 89.61 143.56 Pathology examination of tissue using a microscope 295348_1 CDM 0312 RC 88302 HCPCS inpatient 148 96.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 89.61 143.56 Pathology examination of tissue using a microscope 295348_1 CDM 0312 RC 88302 HCPCS inpatient 148 96.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 89.61 143.56 Pathology examination of tissue using a microscope 295348_1 CDM 0312 RC 88302 HCPCS inpatient 148 96.2 ANTHEM HMO ANTHEM HMO 999999999 89.61 143.56 Pathology examination of tissue using a microscope 295348_1 CDM 0312 RC 88302 HCPCS inpatient 148 96.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 100.05 67.6 999999999 89.61 143.56 percent of total billed charges Pathology examination of tissue using a microscope 295348_1 CDM 0312 RC 88302 HCPCS inpatient 148 96.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 89.61 143.56 "Pathology examination of tissue using a microscope, moderately low complexity" 295350_1 CDM 0312 RC 88304 HCPCS inpatient 173 112.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 112.45 65 999999999 104.75 167.81 percent of total billed charges "Pathology examination of tissue using a microscope, moderately low complexity" 295350_1 CDM 0312 RC 88304 HCPCS inpatient 173 112.45 AETNA AETNA 136.67 79 999999999 104.75 167.81 percent of total billed charges "Pathology examination of tissue using a microscope, moderately low complexity" 295350_1 CDM 0312 RC 88304 HCPCS inpatient 173 112.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 119.37 69 999999999 104.75 167.81 percent of total billed charges "Pathology examination of tissue using a microscope, moderately low complexity" 295350_1 CDM 0312 RC 88304 HCPCS inpatient 173 112.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 167.81 97 999999999 104.75 167.81 percent of total billed charges "Pathology examination of tissue using a microscope, moderately low complexity" 295350_1 CDM 0312 RC 88304 HCPCS inpatient 173 112.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.94 78 999999999 104.75 167.81 percent of total billed charges "Pathology examination of tissue using a microscope, moderately low complexity" 295350_1 CDM 0312 RC 88304 HCPCS inpatient 173 112.45 SIHO - ALL PLANS SIHO - ALL PLANS 155.7 90 999999999 104.75 167.81 percent of total billed charges "Pathology examination of tissue using a microscope, moderately low complexity" 295350_1 CDM 0312 RC 88304 HCPCS inpatient 173 112.45 UMR - ALL PLANS UMR - ALL PLANS 121.1 70 999999999 104.75 167.81 percent of total billed charges "Pathology examination of tissue using a microscope, moderately low complexity" 295350_1 CDM 0312 RC 88304 HCPCS inpatient 173 112.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.75 60.55 999999999 104.75 167.81 percent of total billed charges "Pathology examination of tissue using a microscope, moderately low complexity" 295350_1 CDM 0312 RC 88304 HCPCS inpatient 173 112.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.75 167.81 "Pathology examination of tissue using a microscope, moderately low complexity" 295350_1 CDM 0312 RC 88304 HCPCS inpatient 173 112.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.75 167.81 "Pathology examination of tissue using a microscope, moderately low complexity" 295350_1 CDM 0312 RC 88304 HCPCS inpatient 173 112.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.75 167.81 "Pathology examination of tissue using a microscope, moderately low complexity" 295350_1 CDM 0312 RC 88304 HCPCS inpatient 173 112.45 ANTHEM HMO ANTHEM HMO 999999999 104.75 167.81 "Pathology examination of tissue using a microscope, moderately low complexity" 295350_1 CDM 0312 RC 88304 HCPCS inpatient 173 112.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.95 67.6 999999999 104.75 167.81 percent of total billed charges "Pathology examination of tissue using a microscope, moderately low complexity" 295350_1 CDM 0312 RC 88304 HCPCS inpatient 173 112.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.75 167.81 "Pathology examination of tissue using a microscope, intermediate complexity" 295352_1 CDM 0310 RC 88305 HCPCS inpatient 282 183.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 183.3 65 999999999 170.75 273.54 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 295352_1 CDM 0310 RC 88305 HCPCS inpatient 282 183.3 AETNA AETNA 222.78 79 999999999 170.75 273.54 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 295352_1 CDM 0310 RC 88305 HCPCS inpatient 282 183.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 194.58 69 999999999 170.75 273.54 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 295352_1 CDM 0310 RC 88305 HCPCS inpatient 282 183.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 273.54 97 999999999 170.75 273.54 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 295352_1 CDM 0310 RC 88305 HCPCS inpatient 282 183.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 219.96 78 999999999 170.75 273.54 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 295352_1 CDM 0310 RC 88305 HCPCS inpatient 282 183.3 SIHO - ALL PLANS SIHO - ALL PLANS 253.8 90 999999999 170.75 273.54 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 295352_1 CDM 0310 RC 88305 HCPCS inpatient 282 183.3 UMR - ALL PLANS UMR - ALL PLANS 197.4 70 999999999 170.75 273.54 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 295352_1 CDM 0310 RC 88305 HCPCS inpatient 282 183.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 170.75 60.55 999999999 170.75 273.54 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 295352_1 CDM 0310 RC 88305 HCPCS inpatient 282 183.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 170.75 273.54 "Pathology examination of tissue using a microscope, intermediate complexity" 295352_1 CDM 0310 RC 88305 HCPCS inpatient 282 183.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 170.75 273.54 "Pathology examination of tissue using a microscope, intermediate complexity" 295352_1 CDM 0310 RC 88305 HCPCS inpatient 282 183.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 170.75 273.54 "Pathology examination of tissue using a microscope, intermediate complexity" 295352_1 CDM 0310 RC 88305 HCPCS inpatient 282 183.3 ANTHEM HMO ANTHEM HMO 999999999 170.75 273.54 "Pathology examination of tissue using a microscope, intermediate complexity" 295352_1 CDM 0310 RC 88305 HCPCS inpatient 282 183.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 190.63 67.6 999999999 170.75 273.54 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 295352_1 CDM 0310 RC 88305 HCPCS inpatient 282 183.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 170.75 273.54 "Pathology examination of tissue using a microscope, moderately high complexity" 295354_1 CDM 0312 RC 88307 HCPCS inpatient 385 250.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 250.25 65 999999999 233.12 373.45 percent of total billed charges "Pathology examination of tissue using a microscope, moderately high complexity" 295354_1 CDM 0312 RC 88307 HCPCS inpatient 385 250.25 AETNA AETNA 304.15 79 999999999 233.12 373.45 percent of total billed charges "Pathology examination of tissue using a microscope, moderately high complexity" 295354_1 CDM 0312 RC 88307 HCPCS inpatient 385 250.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 265.65 69 999999999 233.12 373.45 percent of total billed charges "Pathology examination of tissue using a microscope, moderately high complexity" 295354_1 CDM 0312 RC 88307 HCPCS inpatient 385 250.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 373.45 97 999999999 233.12 373.45 percent of total billed charges "Pathology examination of tissue using a microscope, moderately high complexity" 295354_1 CDM 0312 RC 88307 HCPCS inpatient 385 250.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 300.3 78 999999999 233.12 373.45 percent of total billed charges "Pathology examination of tissue using a microscope, moderately high complexity" 295354_1 CDM 0312 RC 88307 HCPCS inpatient 385 250.25 SIHO - ALL PLANS SIHO - ALL PLANS 346.5 90 999999999 233.12 373.45 percent of total billed charges "Pathology examination of tissue using a microscope, moderately high complexity" 295354_1 CDM 0312 RC 88307 HCPCS inpatient 385 250.25 UMR - ALL PLANS UMR - ALL PLANS 269.5 70 999999999 233.12 373.45 percent of total billed charges "Pathology examination of tissue using a microscope, moderately high complexity" 295354_1 CDM 0312 RC 88307 HCPCS inpatient 385 250.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 233.12 60.55 999999999 233.12 373.45 percent of total billed charges "Pathology examination of tissue using a microscope, moderately high complexity" 295354_1 CDM 0312 RC 88307 HCPCS inpatient 385 250.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 233.12 373.45 "Pathology examination of tissue using a microscope, moderately high complexity" 295354_1 CDM 0312 RC 88307 HCPCS inpatient 385 250.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 233.12 373.45 "Pathology examination of tissue using a microscope, moderately high complexity" 295354_1 CDM 0312 RC 88307 HCPCS inpatient 385 250.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 233.12 373.45 "Pathology examination of tissue using a microscope, moderately high complexity" 295354_1 CDM 0312 RC 88307 HCPCS inpatient 385 250.25 ANTHEM HMO ANTHEM HMO 999999999 233.12 373.45 "Pathology examination of tissue using a microscope, moderately high complexity" 295354_1 CDM 0312 RC 88307 HCPCS inpatient 385 250.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 260.26 67.6 999999999 233.12 373.45 percent of total billed charges "Pathology examination of tissue using a microscope, moderately high complexity" 295354_1 CDM 0312 RC 88307 HCPCS inpatient 385 250.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 233.12 373.45 "Pathology examination of tissue using a microscope, high complexity" 295356_1 CDM 0312 RC 88309 HCPCS inpatient 764 496.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 496.6 65 999999999 462.6 741.08 percent of total billed charges "Pathology examination of tissue using a microscope, high complexity" 295356_1 CDM 0312 RC 88309 HCPCS inpatient 764 496.6 AETNA AETNA 603.56 79 999999999 462.6 741.08 percent of total billed charges "Pathology examination of tissue using a microscope, high complexity" 295356_1 CDM 0312 RC 88309 HCPCS inpatient 764 496.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 527.16 69 999999999 462.6 741.08 percent of total billed charges "Pathology examination of tissue using a microscope, high complexity" 295356_1 CDM 0312 RC 88309 HCPCS inpatient 764 496.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 741.08 97 999999999 462.6 741.08 percent of total billed charges "Pathology examination of tissue using a microscope, high complexity" 295356_1 CDM 0312 RC 88309 HCPCS inpatient 764 496.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 595.92 78 999999999 462.6 741.08 percent of total billed charges "Pathology examination of tissue using a microscope, high complexity" 295356_1 CDM 0312 RC 88309 HCPCS inpatient 764 496.6 SIHO - ALL PLANS SIHO - ALL PLANS 687.6 90 999999999 462.6 741.08 percent of total billed charges "Pathology examination of tissue using a microscope, high complexity" 295356_1 CDM 0312 RC 88309 HCPCS inpatient 764 496.6 UMR - ALL PLANS UMR - ALL PLANS 534.8 70 999999999 462.6 741.08 percent of total billed charges "Pathology examination of tissue using a microscope, high complexity" 295356_1 CDM 0312 RC 88309 HCPCS inpatient 764 496.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 462.6 60.55 999999999 462.6 741.08 percent of total billed charges "Pathology examination of tissue using a microscope, high complexity" 295356_1 CDM 0312 RC 88309 HCPCS inpatient 764 496.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 462.6 741.08 "Pathology examination of tissue using a microscope, high complexity" 295356_1 CDM 0312 RC 88309 HCPCS inpatient 764 496.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 462.6 741.08 "Pathology examination of tissue using a microscope, high complexity" 295356_1 CDM 0312 RC 88309 HCPCS inpatient 764 496.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 462.6 741.08 "Pathology examination of tissue using a microscope, high complexity" 295356_1 CDM 0312 RC 88309 HCPCS inpatient 764 496.6 ANTHEM HMO ANTHEM HMO 999999999 462.6 741.08 "Pathology examination of tissue using a microscope, high complexity" 295356_1 CDM 0312 RC 88309 HCPCS inpatient 764 496.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 516.46 67.6 999999999 462.6 741.08 percent of total billed charges "Pathology examination of tissue using a microscope, high complexity" 295356_1 CDM 0312 RC 88309 HCPCS inpatient 764 496.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 462.6 741.08 Preparation of tissue for examination by removing any calcium present 295360_1 CDM 0312 RC 88311 HCPCS inpatient 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges Preparation of tissue for examination by removing any calcium present 295360_1 CDM 0312 RC 88311 HCPCS inpatient 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges Preparation of tissue for examination by removing any calcium present 295360_1 CDM 0312 RC 88311 HCPCS inpatient 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges Preparation of tissue for examination by removing any calcium present 295360_1 CDM 0312 RC 88311 HCPCS inpatient 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges Preparation of tissue for examination by removing any calcium present 295360_1 CDM 0312 RC 88311 HCPCS inpatient 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges Preparation of tissue for examination by removing any calcium present 295360_1 CDM 0312 RC 88311 HCPCS inpatient 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges Preparation of tissue for examination by removing any calcium present 295360_1 CDM 0312 RC 88311 HCPCS inpatient 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges Preparation of tissue for examination by removing any calcium present 295360_1 CDM 0312 RC 88311 HCPCS inpatient 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges Preparation of tissue for examination by removing any calcium present 295360_1 CDM 0312 RC 88311 HCPCS inpatient 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 Preparation of tissue for examination by removing any calcium present 295360_1 CDM 0312 RC 88311 HCPCS inpatient 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 Preparation of tissue for examination by removing any calcium present 295360_1 CDM 0312 RC 88311 HCPCS inpatient 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 Preparation of tissue for examination by removing any calcium present 295360_1 CDM 0312 RC 88311 HCPCS inpatient 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 Preparation of tissue for examination by removing any calcium present 295360_1 CDM 0312 RC 88311 HCPCS inpatient 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges Preparation of tissue for examination by removing any calcium present 295360_1 CDM 0312 RC 88311 HCPCS inpatient 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 Special stained specimen slides to identify organisms including interpretation and report 295362_1 CDM 0310 RC 88312 HCPCS inpatient 315 204.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 204.75 65 999999999 190.73 305.55 percent of total billed charges Special stained specimen slides to identify organisms including interpretation and report 295362_1 CDM 0310 RC 88312 HCPCS inpatient 315 204.75 AETNA AETNA 248.85 79 999999999 190.73 305.55 percent of total billed charges Special stained specimen slides to identify organisms including interpretation and report 295362_1 CDM 0310 RC 88312 HCPCS inpatient 315 204.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 217.35 69 999999999 190.73 305.55 percent of total billed charges Special stained specimen slides to identify organisms including interpretation and report 295362_1 CDM 0310 RC 88312 HCPCS inpatient 315 204.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 305.55 97 999999999 190.73 305.55 percent of total billed charges Special stained specimen slides to identify organisms including interpretation and report 295362_1 CDM 0310 RC 88312 HCPCS inpatient 315 204.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 245.7 78 999999999 190.73 305.55 percent of total billed charges Special stained specimen slides to identify organisms including interpretation and report 295362_1 CDM 0310 RC 88312 HCPCS inpatient 315 204.75 SIHO - ALL PLANS SIHO - ALL PLANS 283.5 90 999999999 190.73 305.55 percent of total billed charges Special stained specimen slides to identify organisms including interpretation and report 295362_1 CDM 0310 RC 88312 HCPCS inpatient 315 204.75 UMR - ALL PLANS UMR - ALL PLANS 220.5 70 999999999 190.73 305.55 percent of total billed charges Special stained specimen slides to identify organisms including interpretation and report 295362_1 CDM 0310 RC 88312 HCPCS inpatient 315 204.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 190.73 60.55 999999999 190.73 305.55 percent of total billed charges Special stained specimen slides to identify organisms including interpretation and report 295362_1 CDM 0310 RC 88312 HCPCS inpatient 315 204.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 190.73 305.55 Special stained specimen slides to identify organisms including interpretation and report 295362_1 CDM 0310 RC 88312 HCPCS inpatient 315 204.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 190.73 305.55 Special stained specimen slides to identify organisms including interpretation and report 295362_1 CDM 0310 RC 88312 HCPCS inpatient 315 204.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 190.73 305.55 Special stained specimen slides to identify organisms including interpretation and report 295362_1 CDM 0310 RC 88312 HCPCS inpatient 315 204.75 ANTHEM HMO ANTHEM HMO 999999999 190.73 305.55 Special stained specimen slides to identify organisms including interpretation and report 295362_1 CDM 0310 RC 88312 HCPCS inpatient 315 204.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 212.94 67.6 999999999 190.73 305.55 percent of total billed charges Special stained specimen slides to identify organisms including interpretation and report 295362_1 CDM 0310 RC 88312 HCPCS inpatient 315 204.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 190.73 305.55 Special stained specimen slides to examine tissue including interpretation and report 295364_1 CDM 0312 RC 88313 HCPCS inpatient 144 93.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 93.6 65 999999999 87.19 139.68 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 295364_1 CDM 0312 RC 88313 HCPCS inpatient 144 93.6 AETNA AETNA 113.76 79 999999999 87.19 139.68 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 295364_1 CDM 0312 RC 88313 HCPCS inpatient 144 93.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 99.36 69 999999999 87.19 139.68 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 295364_1 CDM 0312 RC 88313 HCPCS inpatient 144 93.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 139.68 97 999999999 87.19 139.68 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 295364_1 CDM 0312 RC 88313 HCPCS inpatient 144 93.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 112.32 78 999999999 87.19 139.68 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 295364_1 CDM 0312 RC 88313 HCPCS inpatient 144 93.6 SIHO - ALL PLANS SIHO - ALL PLANS 129.6 90 999999999 87.19 139.68 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 295364_1 CDM 0312 RC 88313 HCPCS inpatient 144 93.6 UMR - ALL PLANS UMR - ALL PLANS 100.8 70 999999999 87.19 139.68 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 295364_1 CDM 0312 RC 88313 HCPCS inpatient 144 93.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.19 60.55 999999999 87.19 139.68 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 295364_1 CDM 0312 RC 88313 HCPCS inpatient 144 93.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.19 139.68 Special stained specimen slides to examine tissue including interpretation and report 295364_1 CDM 0312 RC 88313 HCPCS inpatient 144 93.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.19 139.68 Special stained specimen slides to examine tissue including interpretation and report 295364_1 CDM 0312 RC 88313 HCPCS inpatient 144 93.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.19 139.68 Special stained specimen slides to examine tissue including interpretation and report 295364_1 CDM 0312 RC 88313 HCPCS inpatient 144 93.6 ANTHEM HMO ANTHEM HMO 999999999 87.19 139.68 Special stained specimen slides to examine tissue including interpretation and report 295364_1 CDM 0312 RC 88313 HCPCS inpatient 144 93.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 97.34 67.6 999999999 87.19 139.68 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 295364_1 CDM 0312 RC 88313 HCPCS inpatient 144 93.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.19 139.68 "Special stained specimen slides to examine tissue, initial procedure" 295366_1 CDM 0310 RC 88342 HCPCS inpatient 430 279.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 279.5 65 999999999 260.37 417.1 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 295366_1 CDM 0310 RC 88342 HCPCS inpatient 430 279.5 AETNA AETNA 339.7 79 999999999 260.37 417.1 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 295366_1 CDM 0310 RC 88342 HCPCS inpatient 430 279.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 296.7 69 999999999 260.37 417.1 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 295366_1 CDM 0310 RC 88342 HCPCS inpatient 430 279.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 417.1 97 999999999 260.37 417.1 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 295366_1 CDM 0310 RC 88342 HCPCS inpatient 430 279.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 335.4 78 999999999 260.37 417.1 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 295366_1 CDM 0310 RC 88342 HCPCS inpatient 430 279.5 SIHO - ALL PLANS SIHO - ALL PLANS 387 90 999999999 260.37 417.1 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 295366_1 CDM 0310 RC 88342 HCPCS inpatient 430 279.5 UMR - ALL PLANS UMR - ALL PLANS 301 70 999999999 260.37 417.1 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 295366_1 CDM 0310 RC 88342 HCPCS inpatient 430 279.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 260.37 60.55 999999999 260.37 417.1 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 295366_1 CDM 0310 RC 88342 HCPCS inpatient 430 279.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 260.37 417.1 "Special stained specimen slides to examine tissue, initial procedure" 295366_1 CDM 0310 RC 88342 HCPCS inpatient 430 279.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 260.37 417.1 "Special stained specimen slides to examine tissue, initial procedure" 295366_1 CDM 0310 RC 88342 HCPCS inpatient 430 279.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 260.37 417.1 "Special stained specimen slides to examine tissue, initial procedure" 295366_1 CDM 0310 RC 88342 HCPCS inpatient 430 279.5 ANTHEM HMO ANTHEM HMO 999999999 260.37 417.1 "Special stained specimen slides to examine tissue, initial procedure" 295366_1 CDM 0310 RC 88342 HCPCS inpatient 430 279.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 290.68 67.6 999999999 260.37 417.1 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 295366_1 CDM 0310 RC 88342 HCPCS inpatient 430 279.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 260.37 417.1 "Cell examination of body fluid, smears" 295380_1 CDM 0312 RC 88104 HCPCS inpatient 221 143.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 143.65 65 999999999 133.82 214.37 percent of total billed charges "Cell examination of body fluid, smears" 295380_1 CDM 0312 RC 88104 HCPCS inpatient 221 143.65 AETNA AETNA 174.59 79 999999999 133.82 214.37 percent of total billed charges "Cell examination of body fluid, smears" 295380_1 CDM 0312 RC 88104 HCPCS inpatient 221 143.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 152.49 69 999999999 133.82 214.37 percent of total billed charges "Cell examination of body fluid, smears" 295380_1 CDM 0312 RC 88104 HCPCS inpatient 221 143.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 214.37 97 999999999 133.82 214.37 percent of total billed charges "Cell examination of body fluid, smears" 295380_1 CDM 0312 RC 88104 HCPCS inpatient 221 143.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 172.38 78 999999999 133.82 214.37 percent of total billed charges "Cell examination of body fluid, smears" 295380_1 CDM 0312 RC 88104 HCPCS inpatient 221 143.65 SIHO - ALL PLANS SIHO - ALL PLANS 198.9 90 999999999 133.82 214.37 percent of total billed charges "Cell examination of body fluid, smears" 295380_1 CDM 0312 RC 88104 HCPCS inpatient 221 143.65 UMR - ALL PLANS UMR - ALL PLANS 154.7 70 999999999 133.82 214.37 percent of total billed charges "Cell examination of body fluid, smears" 295380_1 CDM 0312 RC 88104 HCPCS inpatient 221 143.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 133.82 60.55 999999999 133.82 214.37 percent of total billed charges "Cell examination of body fluid, smears" 295380_1 CDM 0312 RC 88104 HCPCS inpatient 221 143.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 133.82 214.37 "Cell examination of body fluid, smears" 295380_1 CDM 0312 RC 88104 HCPCS inpatient 221 143.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 133.82 214.37 "Cell examination of body fluid, smears" 295380_1 CDM 0312 RC 88104 HCPCS inpatient 221 143.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 133.82 214.37 "Cell examination of body fluid, smears" 295380_1 CDM 0312 RC 88104 HCPCS inpatient 221 143.65 ANTHEM HMO ANTHEM HMO 999999999 133.82 214.37 "Cell examination of body fluid, smears" 295380_1 CDM 0312 RC 88104 HCPCS inpatient 221 143.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 149.4 67.6 999999999 133.82 214.37 percent of total billed charges "Cell examination of body fluid, smears" 295380_1 CDM 0312 RC 88104 HCPCS inpatient 221 143.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 133.82 214.37 Evaluation of fine needle aspirate 295386_1 CDM 0311 RC 88172 HCPCS inpatient 223 144.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 144.95 65 999999999 135.03 216.31 percent of total billed charges Evaluation of fine needle aspirate 295386_1 CDM 0311 RC 88172 HCPCS inpatient 223 144.95 AETNA AETNA 176.17 79 999999999 135.03 216.31 percent of total billed charges Evaluation of fine needle aspirate 295386_1 CDM 0311 RC 88172 HCPCS inpatient 223 144.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 153.87 69 999999999 135.03 216.31 percent of total billed charges Evaluation of fine needle aspirate 295386_1 CDM 0311 RC 88172 HCPCS inpatient 223 144.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 216.31 97 999999999 135.03 216.31 percent of total billed charges Evaluation of fine needle aspirate 295386_1 CDM 0311 RC 88172 HCPCS inpatient 223 144.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 173.94 78 999999999 135.03 216.31 percent of total billed charges Evaluation of fine needle aspirate 295386_1 CDM 0311 RC 88172 HCPCS inpatient 223 144.95 SIHO - ALL PLANS SIHO - ALL PLANS 200.7 90 999999999 135.03 216.31 percent of total billed charges Evaluation of fine needle aspirate 295386_1 CDM 0311 RC 88172 HCPCS inpatient 223 144.95 UMR - ALL PLANS UMR - ALL PLANS 156.1 70 999999999 135.03 216.31 percent of total billed charges Evaluation of fine needle aspirate 295386_1 CDM 0311 RC 88172 HCPCS inpatient 223 144.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 135.03 60.55 999999999 135.03 216.31 percent of total billed charges Evaluation of fine needle aspirate 295386_1 CDM 0311 RC 88172 HCPCS inpatient 223 144.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 135.03 216.31 Evaluation of fine needle aspirate 295386_1 CDM 0311 RC 88172 HCPCS inpatient 223 144.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 135.03 216.31 Evaluation of fine needle aspirate 295386_1 CDM 0311 RC 88172 HCPCS inpatient 223 144.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 135.03 216.31 Evaluation of fine needle aspirate 295386_1 CDM 0311 RC 88172 HCPCS inpatient 223 144.95 ANTHEM HMO ANTHEM HMO 999999999 135.03 216.31 Evaluation of fine needle aspirate 295386_1 CDM 0311 RC 88172 HCPCS inpatient 223 144.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 150.75 67.6 999999999 135.03 216.31 percent of total billed charges Evaluation of fine needle aspirate 295386_1 CDM 0311 RC 88172 HCPCS inpatient 223 144.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 135.03 216.31 Evaluation of fine needle aspirate with interpretation and report 295388_1 CDM 0311 RC 88173 HCPCS inpatient 258 167.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.7 65 999999999 156.22 250.26 percent of total billed charges Evaluation of fine needle aspirate with interpretation and report 295388_1 CDM 0311 RC 88173 HCPCS inpatient 258 167.7 AETNA AETNA 203.82 79 999999999 156.22 250.26 percent of total billed charges Evaluation of fine needle aspirate with interpretation and report 295388_1 CDM 0311 RC 88173 HCPCS inpatient 258 167.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 178.02 69 999999999 156.22 250.26 percent of total billed charges Evaluation of fine needle aspirate with interpretation and report 295388_1 CDM 0311 RC 88173 HCPCS inpatient 258 167.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 250.26 97 999999999 156.22 250.26 percent of total billed charges Evaluation of fine needle aspirate with interpretation and report 295388_1 CDM 0311 RC 88173 HCPCS inpatient 258 167.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 201.24 78 999999999 156.22 250.26 percent of total billed charges Evaluation of fine needle aspirate with interpretation and report 295388_1 CDM 0311 RC 88173 HCPCS inpatient 258 167.7 SIHO - ALL PLANS SIHO - ALL PLANS 232.2 90 999999999 156.22 250.26 percent of total billed charges Evaluation of fine needle aspirate with interpretation and report 295388_1 CDM 0311 RC 88173 HCPCS inpatient 258 167.7 UMR - ALL PLANS UMR - ALL PLANS 180.6 70 999999999 156.22 250.26 percent of total billed charges Evaluation of fine needle aspirate with interpretation and report 295388_1 CDM 0311 RC 88173 HCPCS inpatient 258 167.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 156.22 60.55 999999999 156.22 250.26 percent of total billed charges Evaluation of fine needle aspirate with interpretation and report 295388_1 CDM 0311 RC 88173 HCPCS inpatient 258 167.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 156.22 250.26 Evaluation of fine needle aspirate with interpretation and report 295388_1 CDM 0311 RC 88173 HCPCS inpatient 258 167.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 156.22 250.26 Evaluation of fine needle aspirate with interpretation and report 295388_1 CDM 0311 RC 88173 HCPCS inpatient 258 167.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 156.22 250.26 Evaluation of fine needle aspirate with interpretation and report 295388_1 CDM 0311 RC 88173 HCPCS inpatient 258 167.7 ANTHEM HMO ANTHEM HMO 999999999 156.22 250.26 Evaluation of fine needle aspirate with interpretation and report 295388_1 CDM 0311 RC 88173 HCPCS inpatient 258 167.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 174.41 67.6 999999999 156.22 250.26 percent of total billed charges Evaluation of fine needle aspirate with interpretation and report 295388_1 CDM 0311 RC 88173 HCPCS inpatient 258 167.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 156.22 250.26 Pap test 295392_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges Pap test 295392_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges Pap test 295392_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges Pap test 295392_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges Pap test 295392_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges Pap test 295392_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges Pap test 295392_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges Pap test 295392_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges Pap test 295392_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 Pap test 295392_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 Pap test 295392_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 Pap test 295392_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 Pap test 295392_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges Pap test 295392_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 "X-ray of hip, 2-3 views" 29736824_1 CDM 0320 RC 73502 HCPCS inpatient 365 237.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 237.25 65 999999999 221.01 354.05 percent of total billed charges "X-ray of hip, 2-3 views" 29736824_1 CDM 0320 RC 73502 HCPCS inpatient 365 237.25 AETNA AETNA 288.35 79 999999999 221.01 354.05 percent of total billed charges "X-ray of hip, 2-3 views" 29736824_1 CDM 0320 RC 73502 HCPCS inpatient 365 237.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 251.85 69 999999999 221.01 354.05 percent of total billed charges "X-ray of hip, 2-3 views" 29736824_1 CDM 0320 RC 73502 HCPCS inpatient 365 237.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 354.05 97 999999999 221.01 354.05 percent of total billed charges "X-ray of hip, 2-3 views" 29736824_1 CDM 0320 RC 73502 HCPCS inpatient 365 237.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 284.7 78 999999999 221.01 354.05 percent of total billed charges "X-ray of hip, 2-3 views" 29736824_1 CDM 0320 RC 73502 HCPCS inpatient 365 237.25 SIHO - ALL PLANS SIHO - ALL PLANS 328.5 90 999999999 221.01 354.05 percent of total billed charges "X-ray of hip, 2-3 views" 29736824_1 CDM 0320 RC 73502 HCPCS inpatient 365 237.25 UMR - ALL PLANS UMR - ALL PLANS 255.5 70 999999999 221.01 354.05 percent of total billed charges "X-ray of hip, 2-3 views" 29736824_1 CDM 0320 RC 73502 HCPCS inpatient 365 237.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 221.01 60.55 999999999 221.01 354.05 percent of total billed charges "X-ray of hip, 2-3 views" 29736824_1 CDM 0320 RC 73502 HCPCS inpatient 365 237.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 221.01 354.05 "X-ray of hip, 2-3 views" 29736824_1 CDM 0320 RC 73502 HCPCS inpatient 365 237.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 221.01 354.05 "X-ray of hip, 2-3 views" 29736824_1 CDM 0320 RC 73502 HCPCS inpatient 365 237.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 221.01 354.05 "X-ray of hip, 2-3 views" 29736824_1 CDM 0320 RC 73502 HCPCS inpatient 365 237.25 ANTHEM HMO ANTHEM HMO 999999999 221.01 354.05 "X-ray of hip, 2-3 views" 29736824_1 CDM 0320 RC 73502 HCPCS inpatient 365 237.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 246.74 67.6 999999999 221.01 354.05 percent of total billed charges "X-ray of hip, 2-3 views" 29736824_1 CDM 0320 RC 73502 HCPCS inpatient 365 237.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 221.01 354.05 "X-ray of joint between breast and collar bones, minimum of 2 views" 29854459_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 253.5 65 999999999 236.15 378.3 percent of total billed charges "X-ray of joint between breast and collar bones, minimum of 2 views" 29854459_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 AETNA AETNA 308.1 79 999999999 236.15 378.3 percent of total billed charges "X-ray of joint between breast and collar bones, minimum of 2 views" 29854459_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 269.1 69 999999999 236.15 378.3 percent of total billed charges "X-ray of joint between breast and collar bones, minimum of 2 views" 29854459_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 378.3 97 999999999 236.15 378.3 percent of total billed charges "X-ray of joint between breast and collar bones, minimum of 2 views" 29854459_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 304.2 78 999999999 236.15 378.3 percent of total billed charges "X-ray of joint between breast and collar bones, minimum of 2 views" 29854459_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 SIHO - ALL PLANS SIHO - ALL PLANS 351 90 999999999 236.15 378.3 percent of total billed charges "X-ray of joint between breast and collar bones, minimum of 2 views" 29854459_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 UMR - ALL PLANS UMR - ALL PLANS 273 70 999999999 236.15 378.3 percent of total billed charges "X-ray of joint between breast and collar bones, minimum of 2 views" 29854459_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 236.15 60.55 999999999 236.15 378.3 percent of total billed charges "X-ray of joint between breast and collar bones, minimum of 2 views" 29854459_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 236.15 378.3 "X-ray of joint between breast and collar bones, minimum of 2 views" 29854459_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 236.15 378.3 "X-ray of joint between breast and collar bones, minimum of 2 views" 29854459_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 236.15 378.3 "X-ray of joint between breast and collar bones, minimum of 2 views" 29854459_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 ANTHEM HMO ANTHEM HMO 999999999 236.15 378.3 "X-ray of joint between breast and collar bones, minimum of 2 views" 29854459_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 263.64 67.6 999999999 236.15 378.3 percent of total billed charges "X-ray of joint between breast and collar bones, minimum of 2 views" 29854459_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 236.15 378.3 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 29891590_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 29891590_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 29891590_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 29891590_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 29891590_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 29891590_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 29891590_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 29891590_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 29891590_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 29891590_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 29891590_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 29891590_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 29891590_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 29891590_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 Antiembolism Device Activity 32825608_1 CDM 0270 RC inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges Antiembolism Device Activity 32825608_1 CDM 0270 RC inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges Antiembolism Device Activity 32825608_1 CDM 0270 RC inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges Antiembolism Device Activity 32825608_1 CDM 0270 RC inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges Antiembolism Device Activity 32825608_1 CDM 0270 RC inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges Antiembolism Device Activity 32825608_1 CDM 0270 RC inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges Antiembolism Device Activity 32825608_1 CDM 0270 RC inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges Antiembolism Device Activity 32825608_1 CDM 0270 RC inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges Antiembolism Device Activity 32825608_1 CDM 0270 RC inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 Antiembolism Device Activity 32825608_1 CDM 0270 RC inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 Antiembolism Device Activity 32825608_1 CDM 0270 RC inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 Antiembolism Device Activity 32825608_1 CDM 0270 RC inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 Antiembolism Device Activity 32825608_1 CDM 0270 RC inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges Antiembolism Device Activity 32825608_1 CDM 0270 RC inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 Routine electrocardiogram (ECG) using at least 12 leads with tracing 32825611_1 CDM 0450 RC 93005 HCPCS inpatient 365 237.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 237.25 65 999999999 221.01 354.05 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 32825611_1 CDM 0450 RC 93005 HCPCS inpatient 365 237.25 AETNA AETNA 288.35 79 999999999 221.01 354.05 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 32825611_1 CDM 0450 RC 93005 HCPCS inpatient 365 237.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 251.85 69 999999999 221.01 354.05 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 32825611_1 CDM 0450 RC 93005 HCPCS inpatient 365 237.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 354.05 97 999999999 221.01 354.05 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 32825611_1 CDM 0450 RC 93005 HCPCS inpatient 365 237.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 284.7 78 999999999 221.01 354.05 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 32825611_1 CDM 0450 RC 93005 HCPCS inpatient 365 237.25 SIHO - ALL PLANS SIHO - ALL PLANS 328.5 90 999999999 221.01 354.05 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 32825611_1 CDM 0450 RC 93005 HCPCS inpatient 365 237.25 UMR - ALL PLANS UMR - ALL PLANS 255.5 70 999999999 221.01 354.05 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 32825611_1 CDM 0450 RC 93005 HCPCS inpatient 365 237.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 221.01 60.55 999999999 221.01 354.05 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 32825611_1 CDM 0450 RC 93005 HCPCS inpatient 365 237.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 221.01 354.05 Routine electrocardiogram (ECG) using at least 12 leads with tracing 32825611_1 CDM 0450 RC 93005 HCPCS inpatient 365 237.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 221.01 354.05 Routine electrocardiogram (ECG) using at least 12 leads with tracing 32825611_1 CDM 0450 RC 93005 HCPCS inpatient 365 237.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 221.01 354.05 Routine electrocardiogram (ECG) using at least 12 leads with tracing 32825611_1 CDM 0450 RC 93005 HCPCS inpatient 365 237.25 ANTHEM HMO ANTHEM HMO 999999999 221.01 354.05 Routine electrocardiogram (ECG) using at least 12 leads with tracing 32825611_1 CDM 0450 RC 93005 HCPCS inpatient 365 237.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 246.74 67.6 999999999 221.01 354.05 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 32825611_1 CDM 0450 RC 93005 HCPCS inpatient 365 237.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 221.01 354.05 Application of hot or cold packs 3412890_1 CDM 0430 RC 97010 HCPCS inpatient 120 78 SELF PAY DISCOUNT SELF PAY DISCOUNT 78 65 999999999 72.66 116.4 percent of total billed charges Application of hot or cold packs 3412890_1 CDM 0430 RC 97010 HCPCS inpatient 120 78 AETNA AETNA 94.8 79 999999999 72.66 116.4 percent of total billed charges Application of hot or cold packs 3412890_1 CDM 0430 RC 97010 HCPCS inpatient 120 78 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.8 69 999999999 72.66 116.4 percent of total billed charges Application of hot or cold packs 3412890_1 CDM 0430 RC 97010 HCPCS inpatient 120 78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.4 97 999999999 72.66 116.4 percent of total billed charges Application of hot or cold packs 3412890_1 CDM 0430 RC 97010 HCPCS inpatient 120 78 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.6 78 999999999 72.66 116.4 percent of total billed charges Application of hot or cold packs 3412890_1 CDM 0430 RC 97010 HCPCS inpatient 120 78 SIHO - ALL PLANS SIHO - ALL PLANS 108 90 999999999 72.66 116.4 percent of total billed charges Application of hot or cold packs 3412890_1 CDM 0430 RC 97010 HCPCS inpatient 120 78 UMR - ALL PLANS UMR - ALL PLANS 84 70 999999999 72.66 116.4 percent of total billed charges Application of hot or cold packs 3412890_1 CDM 0430 RC 97010 HCPCS inpatient 120 78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.66 60.55 999999999 72.66 116.4 percent of total billed charges Application of hot or cold packs 3412890_1 CDM 0430 RC 97010 HCPCS inpatient 120 78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.66 116.4 Application of hot or cold packs 3412890_1 CDM 0430 RC 97010 HCPCS inpatient 120 78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.66 116.4 Application of hot or cold packs 3412890_1 CDM 0430 RC 97010 HCPCS inpatient 120 78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.66 116.4 Application of hot or cold packs 3412890_1 CDM 0430 RC 97010 HCPCS inpatient 120 78 ANTHEM HMO ANTHEM HMO 999999999 72.66 116.4 Application of hot or cold packs 3412890_1 CDM 0430 RC 97010 HCPCS inpatient 120 78 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.12 67.6 999999999 72.66 116.4 percent of total billed charges Application of hot or cold packs 3412890_1 CDM 0430 RC 97010 HCPCS inpatient 120 78 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.66 116.4 Application of blood vessel compression device 3412894_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 3412894_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 3412894_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 3412894_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 3412894_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 3412894_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 3412894_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 3412894_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 3412894_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 Application of blood vessel compression device 3412894_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 Application of blood vessel compression device 3412894_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 Application of blood vessel compression device 3412894_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 Application of blood vessel compression device 3412894_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 3412894_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 Application of hot wax bath 3412896_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.95 65 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 3412896_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 AETNA AETNA 144.57 79 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 3412896_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.27 69 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 3412896_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.51 97 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 3412896_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 142.74 78 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 3412896_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 SIHO - ALL PLANS SIHO - ALL PLANS 164.7 90 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 3412896_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 UMR - ALL PLANS UMR - ALL PLANS 128.1 70 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 3412896_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.81 60.55 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 3412896_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.81 177.51 Application of hot wax bath 3412896_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.81 177.51 Application of hot wax bath 3412896_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.81 177.51 Application of hot wax bath 3412896_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 ANTHEM HMO ANTHEM HMO 999999999 110.81 177.51 Application of hot wax bath 3412896_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.71 67.6 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 3412896_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.81 177.51 Application of whirlpool therapy 3412898_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 3412898_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 3412898_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 3412898_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 3412898_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 3412898_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 3412898_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 3412898_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 3412898_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 Application of whirlpool therapy 3412898_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 Application of whirlpool therapy 3412898_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 Application of whirlpool therapy 3412898_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 Application of whirlpool therapy 3412898_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 3412898_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 Therapy procedure in a group setting 3412916_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 3412916_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 3412916_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 3412916_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 3412916_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 3412916_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 3412916_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 3412916_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 3412916_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 Therapy procedure in a group setting 3412916_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 Therapy procedure in a group setting 3412916_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 Therapy procedure in a group setting 3412916_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 Therapy procedure in a group setting 3412916_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 3412916_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 "Application of electrical stimulation with therapist present, each 15 minutes" 3412922_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 130.65 65 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 3412922_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 AETNA AETNA 158.79 79 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 3412922_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 138.69 69 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 3412922_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 194.97 97 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 3412922_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 156.78 78 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 3412922_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 SIHO - ALL PLANS SIHO - ALL PLANS 180.9 90 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 3412922_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 UMR - ALL PLANS UMR - ALL PLANS 140.7 70 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 3412922_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 121.71 60.55 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 3412922_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 121.71 194.97 "Application of electrical stimulation with therapist present, each 15 minutes" 3412922_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 121.71 194.97 "Application of electrical stimulation with therapist present, each 15 minutes" 3412922_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 121.71 194.97 "Application of electrical stimulation with therapist present, each 15 minutes" 3412922_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 ANTHEM HMO ANTHEM HMO 999999999 121.71 194.97 "Application of electrical stimulation with therapist present, each 15 minutes" 3412922_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 135.88 67.6 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 3412922_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 121.71 194.97 "Application of medication using electrical current, each 15 minutes" 3412924_1 CDM 0430 RC 97033 HCPCS inpatient 202 131.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 131.3 65 999999999 122.31 195.94 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 3412924_1 CDM 0430 RC 97033 HCPCS inpatient 202 131.3 AETNA AETNA 159.58 79 999999999 122.31 195.94 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 3412924_1 CDM 0430 RC 97033 HCPCS inpatient 202 131.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 139.38 69 999999999 122.31 195.94 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 3412924_1 CDM 0430 RC 97033 HCPCS inpatient 202 131.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 195.94 97 999999999 122.31 195.94 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 3412924_1 CDM 0430 RC 97033 HCPCS inpatient 202 131.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 157.56 78 999999999 122.31 195.94 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 3412924_1 CDM 0430 RC 97033 HCPCS inpatient 202 131.3 SIHO - ALL PLANS SIHO - ALL PLANS 181.8 90 999999999 122.31 195.94 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 3412924_1 CDM 0430 RC 97033 HCPCS inpatient 202 131.3 UMR - ALL PLANS UMR - ALL PLANS 141.4 70 999999999 122.31 195.94 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 3412924_1 CDM 0430 RC 97033 HCPCS inpatient 202 131.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 122.31 60.55 999999999 122.31 195.94 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 3412924_1 CDM 0430 RC 97033 HCPCS inpatient 202 131.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 122.31 195.94 "Application of medication using electrical current, each 15 minutes" 3412924_1 CDM 0430 RC 97033 HCPCS inpatient 202 131.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 122.31 195.94 "Application of medication using electrical current, each 15 minutes" 3412924_1 CDM 0430 RC 97033 HCPCS inpatient 202 131.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 122.31 195.94 "Application of medication using electrical current, each 15 minutes" 3412924_1 CDM 0430 RC 97033 HCPCS inpatient 202 131.3 ANTHEM HMO ANTHEM HMO 999999999 122.31 195.94 "Application of medication using electrical current, each 15 minutes" 3412924_1 CDM 0430 RC 97033 HCPCS inpatient 202 131.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 136.55 67.6 999999999 122.31 195.94 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 3412924_1 CDM 0430 RC 97033 HCPCS inpatient 202 131.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 122.31 195.94 "Application of hot and cold baths, each 15 minutes" 3412926_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 3412926_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 3412926_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 3412926_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 3412926_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 3412926_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 3412926_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 3412926_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 3412926_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 3412926_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 3412926_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 3412926_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 3412926_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 3412926_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 "Application of ultrasound, each 15 minutes" 3412928_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 3412928_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 3412928_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 3412928_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 3412928_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 3412928_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 3412928_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 3412928_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 3412928_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 "Application of ultrasound, each 15 minutes" 3412928_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 "Application of ultrasound, each 15 minutes" 3412928_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 "Application of ultrasound, each 15 minutes" 3412928_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 "Application of ultrasound, each 15 minutes" 3412928_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 3412928_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3412930_1 CDM 0430 RC 97110 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3412930_1 CDM 0430 RC 97110 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3412930_1 CDM 0430 RC 97110 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3412930_1 CDM 0430 RC 97110 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3412930_1 CDM 0430 RC 97110 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3412930_1 CDM 0430 RC 97110 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3412930_1 CDM 0430 RC 97110 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3412930_1 CDM 0430 RC 97110 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3412930_1 CDM 0430 RC 97110 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3412930_1 CDM 0430 RC 97110 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3412930_1 CDM 0430 RC 97110 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3412930_1 CDM 0430 RC 97110 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3412930_1 CDM 0430 RC 97110 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3412930_1 CDM 0430 RC 97110 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3412932_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3412932_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3412932_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3412932_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3412932_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3412932_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3412932_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3412932_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3412932_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3412932_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3412932_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3412932_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3412932_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3412932_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 "Therapy procedure using massage, each 15 minutes" 3412934_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 3412934_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 3412934_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 3412934_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 3412934_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 3412934_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 3412934_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 3412934_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 3412934_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 3412934_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 3412934_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 3412934_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 3412934_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 3412934_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 "Therapy procedure using manual technique, each 15 minutes" 3412936_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 3412936_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 3412936_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 3412936_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 3412936_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 3412936_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 3412936_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 3412936_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 3412936_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 "Therapy procedure using manual technique, each 15 minutes" 3412936_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 "Therapy procedure using manual technique, each 15 minutes" 3412936_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 "Therapy procedure using manual technique, each 15 minutes" 3412936_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 "Therapy procedure using manual technique, each 15 minutes" 3412936_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 3412936_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 Therapy procedure using functional activities 3412938_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 3412938_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 3412938_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 3412938_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 3412938_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 3412938_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 3412938_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 3412938_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 3412938_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 Therapy procedure using functional activities 3412938_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 Therapy procedure using functional activities 3412938_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 Therapy procedure using functional activities 3412938_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 Therapy procedure using functional activities 3412938_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 3412938_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 3412940_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 113.75 65 999999999 105.96 169.75 percent of total billed charges "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 3412940_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 AETNA AETNA 138.25 79 999999999 105.96 169.75 percent of total billed charges "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 3412940_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 120.75 69 999999999 105.96 169.75 percent of total billed charges "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 3412940_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 169.75 97 999999999 105.96 169.75 percent of total billed charges "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 3412940_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 136.5 78 999999999 105.96 169.75 percent of total billed charges "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 3412940_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 SIHO - ALL PLANS SIHO - ALL PLANS 157.5 90 999999999 105.96 169.75 percent of total billed charges "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 3412940_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 UMR - ALL PLANS UMR - ALL PLANS 122.5 70 999999999 105.96 169.75 percent of total billed charges "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 3412940_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 105.96 60.55 999999999 105.96 169.75 percent of total billed charges "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 3412940_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 105.96 169.75 "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 3412940_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 105.96 169.75 "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 3412940_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 105.96 169.75 "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 3412940_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 ANTHEM HMO ANTHEM HMO 999999999 105.96 169.75 "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 3412940_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.3 67.6 999999999 105.96 169.75 percent of total billed charges "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 3412940_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 105.96 169.75 "Training for self-care or home management, each 15 minutes" 3412946_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 129.35 65 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 3412946_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 AETNA AETNA 157.21 79 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 3412946_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 137.31 69 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 3412946_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 193.03 97 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 3412946_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 155.22 78 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 3412946_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 SIHO - ALL PLANS SIHO - ALL PLANS 179.1 90 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 3412946_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 UMR - ALL PLANS UMR - ALL PLANS 139.3 70 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 3412946_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 120.49 60.55 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 3412946_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 120.49 193.03 "Training for self-care or home management, each 15 minutes" 3412946_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 120.49 193.03 "Training for self-care or home management, each 15 minutes" 3412946_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 120.49 193.03 "Training for self-care or home management, each 15 minutes" 3412946_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 ANTHEM HMO ANTHEM HMO 999999999 120.49 193.03 "Training for self-care or home management, each 15 minutes" 3412946_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 134.52 67.6 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 3412946_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 120.49 193.03 "Evaluation for wheelchair, each 15 minutes" 3412950_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 3412950_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 3412950_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 3412950_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 3412950_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 3412950_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 3412950_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 3412950_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 3412950_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 3412950_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 3412950_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 3412950_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 3412950_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 3412950_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 "Evaluation for work hardening or conditioning, initial 2 hours" 3412952_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 382.2 65 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 3412952_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 AETNA AETNA 464.52 79 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 3412952_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 405.72 69 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 3412952_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 570.36 97 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 3412952_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 458.64 78 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 3412952_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 SIHO - ALL PLANS SIHO - ALL PLANS 529.2 90 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 3412952_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 UMR - ALL PLANS UMR - ALL PLANS 411.6 70 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 3412952_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 356.03 60.55 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 3412952_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 3412952_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 3412952_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 3412952_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 ANTHEM HMO ANTHEM HMO 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 3412952_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 397.49 67.6 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 3412952_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, each additional hour" 3412954_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 195.65 65 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 3412954_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 AETNA AETNA 237.79 79 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 3412954_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 207.69 69 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 3412954_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291.97 97 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 3412954_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 234.78 78 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 3412954_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 SIHO - ALL PLANS SIHO - ALL PLANS 270.9 90 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 3412954_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 UMR - ALL PLANS UMR - ALL PLANS 210.7 70 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 3412954_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.26 60.55 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 3412954_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 3412954_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 3412954_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 3412954_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 ANTHEM HMO ANTHEM HMO 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 3412954_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 203.48 67.6 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 3412954_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.26 291.97 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3412958_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3412958_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3412958_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3412958_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3412958_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3412958_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3412958_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3412958_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3412958_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3412958_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3412958_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3412958_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3412958_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3412958_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 "Re-evaluation for physical therapy, typically 20 minutes" 3432245_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 129.35 65 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 3432245_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 AETNA AETNA 157.21 79 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 3432245_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 137.31 69 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 3432245_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 193.03 97 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 3432245_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 155.22 78 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 3432245_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 SIHO - ALL PLANS SIHO - ALL PLANS 179.1 90 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 3432245_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 UMR - ALL PLANS UMR - ALL PLANS 139.3 70 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 3432245_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 120.49 60.55 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 3432245_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 120.49 193.03 "Re-evaluation for physical therapy, typically 20 minutes" 3432245_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 120.49 193.03 "Re-evaluation for physical therapy, typically 20 minutes" 3432245_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 120.49 193.03 "Re-evaluation for physical therapy, typically 20 minutes" 3432245_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 ANTHEM HMO ANTHEM HMO 999999999 120.49 193.03 "Re-evaluation for physical therapy, typically 20 minutes" 3432245_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 134.52 67.6 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 3432245_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 120.49 193.03 Application of hot or cold packs 3432247_1 CDM 0420 RC 97010 HCPCS inpatient 120 78 SELF PAY DISCOUNT SELF PAY DISCOUNT 78 65 999999999 72.66 116.4 percent of total billed charges Application of hot or cold packs 3432247_1 CDM 0420 RC 97010 HCPCS inpatient 120 78 AETNA AETNA 94.8 79 999999999 72.66 116.4 percent of total billed charges Application of hot or cold packs 3432247_1 CDM 0420 RC 97010 HCPCS inpatient 120 78 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.8 69 999999999 72.66 116.4 percent of total billed charges Application of hot or cold packs 3432247_1 CDM 0420 RC 97010 HCPCS inpatient 120 78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.4 97 999999999 72.66 116.4 percent of total billed charges Application of hot or cold packs 3432247_1 CDM 0420 RC 97010 HCPCS inpatient 120 78 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.6 78 999999999 72.66 116.4 percent of total billed charges Application of hot or cold packs 3432247_1 CDM 0420 RC 97010 HCPCS inpatient 120 78 SIHO - ALL PLANS SIHO - ALL PLANS 108 90 999999999 72.66 116.4 percent of total billed charges Application of hot or cold packs 3432247_1 CDM 0420 RC 97010 HCPCS inpatient 120 78 UMR - ALL PLANS UMR - ALL PLANS 84 70 999999999 72.66 116.4 percent of total billed charges Application of hot or cold packs 3432247_1 CDM 0420 RC 97010 HCPCS inpatient 120 78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.66 60.55 999999999 72.66 116.4 percent of total billed charges Application of hot or cold packs 3432247_1 CDM 0420 RC 97010 HCPCS inpatient 120 78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.66 116.4 Application of hot or cold packs 3432247_1 CDM 0420 RC 97010 HCPCS inpatient 120 78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.66 116.4 Application of hot or cold packs 3432247_1 CDM 0420 RC 97010 HCPCS inpatient 120 78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.66 116.4 Application of hot or cold packs 3432247_1 CDM 0420 RC 97010 HCPCS inpatient 120 78 ANTHEM HMO ANTHEM HMO 999999999 72.66 116.4 Application of hot or cold packs 3432247_1 CDM 0420 RC 97010 HCPCS inpatient 120 78 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.12 67.6 999999999 72.66 116.4 percent of total billed charges Application of hot or cold packs 3432247_1 CDM 0420 RC 97010 HCPCS inpatient 120 78 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.66 116.4 Application of mechanical traction 3432249_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 138.45 65 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 3432249_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 AETNA AETNA 168.27 79 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 3432249_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 146.97 69 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 3432249_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 206.61 97 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 3432249_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 166.14 78 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 3432249_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 SIHO - ALL PLANS SIHO - ALL PLANS 191.7 90 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 3432249_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 UMR - ALL PLANS UMR - ALL PLANS 149.1 70 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 3432249_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 128.97 60.55 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 3432249_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 128.97 206.61 Application of mechanical traction 3432249_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 128.97 206.61 Application of mechanical traction 3432249_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 128.97 206.61 Application of mechanical traction 3432249_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 ANTHEM HMO ANTHEM HMO 999999999 128.97 206.61 Application of mechanical traction 3432249_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 143.99 67.6 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 3432249_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 128.97 206.61 "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 3432251_1 CDM 0420 RC G0283 HCPCS inpatient 144 93.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 93.6 65 999999999 87.19 139.68 percent of total billed charges "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 3432251_1 CDM 0420 RC G0283 HCPCS inpatient 144 93.6 AETNA AETNA 113.76 79 999999999 87.19 139.68 percent of total billed charges "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 3432251_1 CDM 0420 RC G0283 HCPCS inpatient 144 93.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 99.36 69 999999999 87.19 139.68 percent of total billed charges "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 3432251_1 CDM 0420 RC G0283 HCPCS inpatient 144 93.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 139.68 97 999999999 87.19 139.68 percent of total billed charges "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 3432251_1 CDM 0420 RC G0283 HCPCS inpatient 144 93.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 112.32 78 999999999 87.19 139.68 percent of total billed charges "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 3432251_1 CDM 0420 RC G0283 HCPCS inpatient 144 93.6 SIHO - ALL PLANS SIHO - ALL PLANS 129.6 90 999999999 87.19 139.68 percent of total billed charges "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 3432251_1 CDM 0420 RC G0283 HCPCS inpatient 144 93.6 UMR - ALL PLANS UMR - ALL PLANS 100.8 70 999999999 87.19 139.68 percent of total billed charges "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 3432251_1 CDM 0420 RC G0283 HCPCS inpatient 144 93.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.19 60.55 999999999 87.19 139.68 percent of total billed charges "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 3432251_1 CDM 0420 RC G0283 HCPCS inpatient 144 93.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.19 139.68 "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 3432251_1 CDM 0420 RC G0283 HCPCS inpatient 144 93.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.19 139.68 "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 3432251_1 CDM 0420 RC G0283 HCPCS inpatient 144 93.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.19 139.68 "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 3432251_1 CDM 0420 RC G0283 HCPCS inpatient 144 93.6 ANTHEM HMO ANTHEM HMO 999999999 87.19 139.68 "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 3432251_1 CDM 0420 RC G0283 HCPCS inpatient 144 93.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 97.34 67.6 999999999 87.19 139.68 percent of total billed charges "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 3432251_1 CDM 0420 RC G0283 HCPCS inpatient 144 93.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.19 139.68 Application of hot wax bath 3432255_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.95 65 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 3432255_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 AETNA AETNA 144.57 79 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 3432255_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.27 69 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 3432255_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.51 97 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 3432255_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 142.74 78 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 3432255_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 SIHO - ALL PLANS SIHO - ALL PLANS 164.7 90 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 3432255_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 UMR - ALL PLANS UMR - ALL PLANS 128.1 70 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 3432255_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.81 60.55 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 3432255_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.81 177.51 Application of hot wax bath 3432255_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.81 177.51 Application of hot wax bath 3432255_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.81 177.51 Application of hot wax bath 3432255_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 ANTHEM HMO ANTHEM HMO 999999999 110.81 177.51 Application of hot wax bath 3432255_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.71 67.6 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 3432255_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.81 177.51 Application of whirlpool therapy 3432257_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 3432257_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 3432257_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 3432257_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 3432257_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 3432257_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 3432257_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 3432257_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 3432257_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 Application of whirlpool therapy 3432257_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 Application of whirlpool therapy 3432257_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 Application of whirlpool therapy 3432257_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 Application of whirlpool therapy 3432257_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 3432257_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 Biofeedback training 3432259_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 202.15 65 999999999 188.31 301.67 percent of total billed charges Biofeedback training 3432259_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 AETNA AETNA 245.69 79 999999999 188.31 301.67 percent of total billed charges Biofeedback training 3432259_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 214.59 69 999999999 188.31 301.67 percent of total billed charges Biofeedback training 3432259_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 301.67 97 999999999 188.31 301.67 percent of total billed charges Biofeedback training 3432259_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 242.58 78 999999999 188.31 301.67 percent of total billed charges Biofeedback training 3432259_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 SIHO - ALL PLANS SIHO - ALL PLANS 279.9 90 999999999 188.31 301.67 percent of total billed charges Biofeedback training 3432259_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 UMR - ALL PLANS UMR - ALL PLANS 217.7 70 999999999 188.31 301.67 percent of total billed charges Biofeedback training 3432259_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 188.31 60.55 999999999 188.31 301.67 percent of total billed charges Biofeedback training 3432259_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 188.31 301.67 Biofeedback training 3432259_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 188.31 301.67 Biofeedback training 3432259_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 188.31 301.67 Biofeedback training 3432259_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 ANTHEM HMO ANTHEM HMO 999999999 188.31 301.67 Biofeedback training 3432259_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 210.24 67.6 999999999 188.31 301.67 percent of total billed charges Biofeedback training 3432259_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 188.31 301.67 "BIOFEEDBACK TRAINING, PERINEAL MUSCLES, ANORECTAL OR URETHRAL SPHINCTER, INCLUDING EMG AND/OR MANOMETRY" 3432261_1 CDM 0420 RC 90911 HCPCS inpatient 425 276.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 276.25 65 999999999 257.34 412.25 percent of total billed charges "BIOFEEDBACK TRAINING, PERINEAL MUSCLES, ANORECTAL OR URETHRAL SPHINCTER, INCLUDING EMG AND/OR MANOMETRY" 3432261_1 CDM 0420 RC 90911 HCPCS inpatient 425 276.25 AETNA AETNA 335.75 79 999999999 257.34 412.25 percent of total billed charges "BIOFEEDBACK TRAINING, PERINEAL MUSCLES, ANORECTAL OR URETHRAL SPHINCTER, INCLUDING EMG AND/OR MANOMETRY" 3432261_1 CDM 0420 RC 90911 HCPCS inpatient 425 276.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 293.25 69 999999999 257.34 412.25 percent of total billed charges "BIOFEEDBACK TRAINING, PERINEAL MUSCLES, ANORECTAL OR URETHRAL SPHINCTER, INCLUDING EMG AND/OR MANOMETRY" 3432261_1 CDM 0420 RC 90911 HCPCS inpatient 425 276.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 412.25 97 999999999 257.34 412.25 percent of total billed charges "BIOFEEDBACK TRAINING, PERINEAL MUSCLES, ANORECTAL OR URETHRAL SPHINCTER, INCLUDING EMG AND/OR MANOMETRY" 3432261_1 CDM 0420 RC 90911 HCPCS inpatient 425 276.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 331.5 78 999999999 257.34 412.25 percent of total billed charges "BIOFEEDBACK TRAINING, PERINEAL MUSCLES, ANORECTAL OR URETHRAL SPHINCTER, INCLUDING EMG AND/OR MANOMETRY" 3432261_1 CDM 0420 RC 90911 HCPCS inpatient 425 276.25 SIHO - ALL PLANS SIHO - ALL PLANS 382.5 90 999999999 257.34 412.25 percent of total billed charges "BIOFEEDBACK TRAINING, PERINEAL MUSCLES, ANORECTAL OR URETHRAL SPHINCTER, INCLUDING EMG AND/OR MANOMETRY" 3432261_1 CDM 0420 RC 90911 HCPCS inpatient 425 276.25 UMR - ALL PLANS UMR - ALL PLANS 297.5 70 999999999 257.34 412.25 percent of total billed charges "BIOFEEDBACK TRAINING, PERINEAL MUSCLES, ANORECTAL OR URETHRAL SPHINCTER, INCLUDING EMG AND/OR MANOMETRY" 3432261_1 CDM 0420 RC 90911 HCPCS inpatient 425 276.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 257.34 60.55 999999999 257.34 412.25 percent of total billed charges "BIOFEEDBACK TRAINING, PERINEAL MUSCLES, ANORECTAL OR URETHRAL SPHINCTER, INCLUDING EMG AND/OR MANOMETRY" 3432261_1 CDM 0420 RC 90911 HCPCS inpatient 425 276.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 257.34 412.25 "BIOFEEDBACK TRAINING, PERINEAL MUSCLES, ANORECTAL OR URETHRAL SPHINCTER, INCLUDING EMG AND/OR MANOMETRY" 3432261_1 CDM 0420 RC 90911 HCPCS inpatient 425 276.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 257.34 412.25 "BIOFEEDBACK TRAINING, PERINEAL MUSCLES, ANORECTAL OR URETHRAL SPHINCTER, INCLUDING EMG AND/OR MANOMETRY" 3432261_1 CDM 0420 RC 90911 HCPCS inpatient 425 276.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 257.34 412.25 "BIOFEEDBACK TRAINING, PERINEAL MUSCLES, ANORECTAL OR URETHRAL SPHINCTER, INCLUDING EMG AND/OR MANOMETRY" 3432261_1 CDM 0420 RC 90911 HCPCS inpatient 425 276.25 ANTHEM HMO ANTHEM HMO 999999999 257.34 412.25 "BIOFEEDBACK TRAINING, PERINEAL MUSCLES, ANORECTAL OR URETHRAL SPHINCTER, INCLUDING EMG AND/OR MANOMETRY" 3432261_1 CDM 0420 RC 90911 HCPCS inpatient 425 276.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 287.3 67.6 999999999 257.34 412.25 percent of total billed charges "BIOFEEDBACK TRAINING, PERINEAL MUSCLES, ANORECTAL OR URETHRAL SPHINCTER, INCLUDING EMG AND/OR MANOMETRY" 3432261_1 CDM 0420 RC 90911 HCPCS inpatient 425 276.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 257.34 412.25 Therapy procedure in a group setting 3432275_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 3432275_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 3432275_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 3432275_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 3432275_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 3432275_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 3432275_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 3432275_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 3432275_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 Therapy procedure in a group setting 3432275_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 Therapy procedure in a group setting 3432275_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 Therapy procedure in a group setting 3432275_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 Therapy procedure in a group setting 3432275_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 3432275_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 "Application of medication using electrical current, each 15 minutes" 3432281_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 140.4 65 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 3432281_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 AETNA AETNA 170.64 79 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 3432281_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 149.04 69 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 3432281_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 209.52 97 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 3432281_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 168.48 78 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 3432281_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 SIHO - ALL PLANS SIHO - ALL PLANS 194.4 90 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 3432281_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 UMR - ALL PLANS UMR - ALL PLANS 151.2 70 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 3432281_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 130.79 60.55 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 3432281_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 3432281_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 3432281_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 3432281_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 ANTHEM HMO ANTHEM HMO 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 3432281_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 146.02 67.6 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 3432281_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 130.79 209.52 "Application of hot and cold baths, each 15 minutes" 3432283_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 3432283_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 3432283_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 3432283_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 3432283_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 3432283_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 3432283_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 3432283_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 3432283_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 3432283_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 3432283_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 3432283_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 3432283_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 3432283_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 "Application of ultrasound, each 15 minutes" 3432285_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 3432285_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 3432285_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 3432285_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 3432285_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 3432285_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 3432285_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 3432285_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 3432285_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 "Application of ultrasound, each 15 minutes" 3432285_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 "Application of ultrasound, each 15 minutes" 3432285_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 "Application of ultrasound, each 15 minutes" 3432285_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 "Application of ultrasound, each 15 minutes" 3432285_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 3432285_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3432287_1 CDM 0420 RC 97110 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3432287_1 CDM 0420 RC 97110 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3432287_1 CDM 0420 RC 97110 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3432287_1 CDM 0420 RC 97110 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3432287_1 CDM 0420 RC 97110 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3432287_1 CDM 0420 RC 97110 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3432287_1 CDM 0420 RC 97110 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3432287_1 CDM 0420 RC 97110 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3432287_1 CDM 0420 RC 97110 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3432287_1 CDM 0420 RC 97110 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3432287_1 CDM 0420 RC 97110 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3432287_1 CDM 0420 RC 97110 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3432287_1 CDM 0420 RC 97110 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 3432287_1 CDM 0420 RC 97110 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 "Therapy procedure for walking training, each 15 minutes" 3432293_1 CDM 0420 RC 97116 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 3432293_1 CDM 0420 RC 97116 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 3432293_1 CDM 0420 RC 97116 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 3432293_1 CDM 0420 RC 97116 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 3432293_1 CDM 0420 RC 97116 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 3432293_1 CDM 0420 RC 97116 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 3432293_1 CDM 0420 RC 97116 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 3432293_1 CDM 0420 RC 97116 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 3432293_1 CDM 0420 RC 97116 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 "Therapy procedure for walking training, each 15 minutes" 3432293_1 CDM 0420 RC 97116 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 "Therapy procedure for walking training, each 15 minutes" 3432293_1 CDM 0420 RC 97116 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 "Therapy procedure for walking training, each 15 minutes" 3432293_1 CDM 0420 RC 97116 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 "Therapy procedure for walking training, each 15 minutes" 3432293_1 CDM 0420 RC 97116 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 3432293_1 CDM 0420 RC 97116 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 "Therapy procedure using massage, each 15 minutes" 3432295_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 3432295_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 3432295_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 3432295_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 3432295_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 3432295_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 3432295_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 3432295_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 3432295_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 3432295_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 3432295_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 3432295_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 3432295_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 3432295_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3432297_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3432297_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3432297_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3432297_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3432297_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3432297_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3432297_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3432297_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3432297_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3432297_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3432297_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3432297_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3432297_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 3432297_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 "Therapy procedure using manual technique, each 15 minutes" 3432299_1 CDM 0420 RC 97140 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 3432299_1 CDM 0420 RC 97140 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 3432299_1 CDM 0420 RC 97140 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 3432299_1 CDM 0420 RC 97140 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 3432299_1 CDM 0420 RC 97140 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 3432299_1 CDM 0420 RC 97140 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 3432299_1 CDM 0420 RC 97140 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 3432299_1 CDM 0420 RC 97140 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 3432299_1 CDM 0420 RC 97140 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 "Therapy procedure using manual technique, each 15 minutes" 3432299_1 CDM 0420 RC 97140 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 "Therapy procedure using manual technique, each 15 minutes" 3432299_1 CDM 0420 RC 97140 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 "Therapy procedure using manual technique, each 15 minutes" 3432299_1 CDM 0420 RC 97140 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 "Therapy procedure using manual technique, each 15 minutes" 3432299_1 CDM 0420 RC 97140 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 3432299_1 CDM 0420 RC 97140 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 Therapy procedure using functional activities 3432301_1 CDM 0420 RC 97530 HCPCS inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 3432301_1 CDM 0420 RC 97530 HCPCS inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 3432301_1 CDM 0420 RC 97530 HCPCS inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 3432301_1 CDM 0420 RC 97530 HCPCS inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 3432301_1 CDM 0420 RC 97530 HCPCS inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 3432301_1 CDM 0420 RC 97530 HCPCS inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 3432301_1 CDM 0420 RC 97530 HCPCS inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 3432301_1 CDM 0420 RC 97530 HCPCS inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 3432301_1 CDM 0420 RC 97530 HCPCS inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 Therapy procedure using functional activities 3432301_1 CDM 0420 RC 97530 HCPCS inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 Therapy procedure using functional activities 3432301_1 CDM 0420 RC 97530 HCPCS inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 Therapy procedure using functional activities 3432301_1 CDM 0420 RC 97530 HCPCS inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 Therapy procedure using functional activities 3432301_1 CDM 0420 RC 97530 HCPCS inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 3432301_1 CDM 0420 RC 97530 HCPCS inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 "Training for self-care or home management, each 15 minutes" 3432305_1 CDM 0420 RC 97535 HCPCS inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges "Training for self-care or home management, each 15 minutes" 3432305_1 CDM 0420 RC 97535 HCPCS inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges "Training for self-care or home management, each 15 minutes" 3432305_1 CDM 0420 RC 97535 HCPCS inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges "Training for self-care or home management, each 15 minutes" 3432305_1 CDM 0420 RC 97535 HCPCS inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges "Training for self-care or home management, each 15 minutes" 3432305_1 CDM 0420 RC 97535 HCPCS inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges "Training for self-care or home management, each 15 minutes" 3432305_1 CDM 0420 RC 97535 HCPCS inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges "Training for self-care or home management, each 15 minutes" 3432305_1 CDM 0420 RC 97535 HCPCS inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges "Training for self-care or home management, each 15 minutes" 3432305_1 CDM 0420 RC 97535 HCPCS inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges "Training for self-care or home management, each 15 minutes" 3432305_1 CDM 0420 RC 97535 HCPCS inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 "Training for self-care or home management, each 15 minutes" 3432305_1 CDM 0420 RC 97535 HCPCS inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 "Training for self-care or home management, each 15 minutes" 3432305_1 CDM 0420 RC 97535 HCPCS inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 "Training for self-care or home management, each 15 minutes" 3432305_1 CDM 0420 RC 97535 HCPCS inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 "Training for self-care or home management, each 15 minutes" 3432305_1 CDM 0420 RC 97535 HCPCS inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges "Training for self-care or home management, each 15 minutes" 3432305_1 CDM 0420 RC 97535 HCPCS inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 "Evaluation for wheelchair, each 15 minutes" 3432309_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 3432309_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 3432309_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 3432309_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 3432309_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 3432309_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 3432309_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 3432309_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 3432309_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 3432309_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 3432309_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 3432309_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 3432309_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 3432309_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 "Evaluation for work hardening or conditioning, initial 2 hours" 3432311_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 382.2 65 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 3432311_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 AETNA AETNA 464.52 79 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 3432311_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 405.72 69 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 3432311_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 570.36 97 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 3432311_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 458.64 78 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 3432311_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 SIHO - ALL PLANS SIHO - ALL PLANS 529.2 90 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 3432311_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 UMR - ALL PLANS UMR - ALL PLANS 411.6 70 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 3432311_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 356.03 60.55 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 3432311_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 3432311_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 3432311_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 3432311_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 ANTHEM HMO ANTHEM HMO 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 3432311_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 397.49 67.6 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 3432311_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, each additional hour" 3432313_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 195.65 65 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 3432313_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 AETNA AETNA 237.79 79 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 3432313_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 207.69 69 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 3432313_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291.97 97 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 3432313_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 234.78 78 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 3432313_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 SIHO - ALL PLANS SIHO - ALL PLANS 270.9 90 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 3432313_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 UMR - ALL PLANS UMR - ALL PLANS 210.7 70 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 3432313_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.26 60.55 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 3432313_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 3432313_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 3432313_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 3432313_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 ANTHEM HMO ANTHEM HMO 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 3432313_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 203.48 67.6 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 3432313_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.26 291.97 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3432317_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3432317_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3432317_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3432317_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3432317_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3432317_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3432317_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3432317_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3432317_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3432317_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3432317_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3432317_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3432317_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 3432317_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 Complete ultrasound scan of pelvis 3450677_1 CDM 0402 RC 76856 HCPCS inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges Complete ultrasound scan of pelvis 3450677_1 CDM 0402 RC 76856 HCPCS inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges Complete ultrasound scan of pelvis 3450677_1 CDM 0402 RC 76856 HCPCS inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges Complete ultrasound scan of pelvis 3450677_1 CDM 0402 RC 76856 HCPCS inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges Complete ultrasound scan of pelvis 3450677_1 CDM 0402 RC 76856 HCPCS inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges Complete ultrasound scan of pelvis 3450677_1 CDM 0402 RC 76856 HCPCS inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges Complete ultrasound scan of pelvis 3450677_1 CDM 0402 RC 76856 HCPCS inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges Complete ultrasound scan of pelvis 3450677_1 CDM 0402 RC 76856 HCPCS inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges Complete ultrasound scan of pelvis 3450677_1 CDM 0402 RC 76856 HCPCS inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 Complete ultrasound scan of pelvis 3450677_1 CDM 0402 RC 76856 HCPCS inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 Complete ultrasound scan of pelvis 3450677_1 CDM 0402 RC 76856 HCPCS inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 Complete ultrasound scan of pelvis 3450677_1 CDM 0402 RC 76856 HCPCS inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 Complete ultrasound scan of pelvis 3450677_1 CDM 0402 RC 76856 HCPCS inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges Complete ultrasound scan of pelvis 3450677_1 CDM 0402 RC 76856 HCPCS inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 3456604_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 227.5 65 999999999 211.93 339.5 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 3456604_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 AETNA AETNA 276.5 79 999999999 211.93 339.5 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 3456604_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 241.5 69 999999999 211.93 339.5 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 3456604_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 339.5 97 999999999 211.93 339.5 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 3456604_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 273 78 999999999 211.93 339.5 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 3456604_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 SIHO - ALL PLANS SIHO - ALL PLANS 315 90 999999999 211.93 339.5 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 3456604_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 UMR - ALL PLANS UMR - ALL PLANS 245 70 999999999 211.93 339.5 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 3456604_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 211.93 60.55 999999999 211.93 339.5 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 3456604_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 211.93 339.5 "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 3456604_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 211.93 339.5 "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 3456604_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 211.93 339.5 "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 3456604_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 ANTHEM HMO ANTHEM HMO 999999999 211.93 339.5 "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 3456604_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 236.6 67.6 999999999 211.93 339.5 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 3456604_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 211.93 339.5 Treatment of swallowing and feeding disorder 3456606_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 227.5 65 999999999 211.93 339.5 percent of total billed charges Treatment of swallowing and feeding disorder 3456606_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 AETNA AETNA 276.5 79 999999999 211.93 339.5 percent of total billed charges Treatment of swallowing and feeding disorder 3456606_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 241.5 69 999999999 211.93 339.5 percent of total billed charges Treatment of swallowing and feeding disorder 3456606_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 339.5 97 999999999 211.93 339.5 percent of total billed charges Treatment of swallowing and feeding disorder 3456606_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 273 78 999999999 211.93 339.5 percent of total billed charges Treatment of swallowing and feeding disorder 3456606_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 SIHO - ALL PLANS SIHO - ALL PLANS 315 90 999999999 211.93 339.5 percent of total billed charges Treatment of swallowing and feeding disorder 3456606_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 UMR - ALL PLANS UMR - ALL PLANS 245 70 999999999 211.93 339.5 percent of total billed charges Treatment of swallowing and feeding disorder 3456606_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 211.93 60.55 999999999 211.93 339.5 percent of total billed charges Treatment of swallowing and feeding disorder 3456606_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 211.93 339.5 Treatment of swallowing and feeding disorder 3456606_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 211.93 339.5 Treatment of swallowing and feeding disorder 3456606_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 211.93 339.5 Treatment of swallowing and feeding disorder 3456606_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 ANTHEM HMO ANTHEM HMO 999999999 211.93 339.5 Treatment of swallowing and feeding disorder 3456606_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 236.6 67.6 999999999 211.93 339.5 percent of total billed charges Treatment of swallowing and feeding disorder 3456606_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 211.93 339.5 "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456614_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456614_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456614_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456614_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456614_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456614_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456614_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456614_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456614_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456614_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456614_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456614_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456614_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456614_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456616_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456616_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456616_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456616_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456616_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456616_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456616_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456616_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456616_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456616_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456616_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456616_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456616_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder in a group setting" 3456616_1 CDM 0440 RC 92508 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 Evaluation of swallowing function 3459155_1 CDM 0444 RC 92610 HCPCS inpatient 720 468 SELF PAY DISCOUNT SELF PAY DISCOUNT 468 65 999999999 435.96 698.4 percent of total billed charges Evaluation of swallowing function 3459155_1 CDM 0444 RC 92610 HCPCS inpatient 720 468 AETNA AETNA 568.8 79 999999999 435.96 698.4 percent of total billed charges Evaluation of swallowing function 3459155_1 CDM 0444 RC 92610 HCPCS inpatient 720 468 ENCORE - ALL PLANS ENCORE - ALL PLANS 496.8 69 999999999 435.96 698.4 percent of total billed charges Evaluation of swallowing function 3459155_1 CDM 0444 RC 92610 HCPCS inpatient 720 468 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 698.4 97 999999999 435.96 698.4 percent of total billed charges Evaluation of swallowing function 3459155_1 CDM 0444 RC 92610 HCPCS inpatient 720 468 HUMANA - ALL PLANS HUMANA - ALL PLANS 561.6 78 999999999 435.96 698.4 percent of total billed charges Evaluation of swallowing function 3459155_1 CDM 0444 RC 92610 HCPCS inpatient 720 468 SIHO - ALL PLANS SIHO - ALL PLANS 648 90 999999999 435.96 698.4 percent of total billed charges Evaluation of swallowing function 3459155_1 CDM 0444 RC 92610 HCPCS inpatient 720 468 UMR - ALL PLANS UMR - ALL PLANS 504 70 999999999 435.96 698.4 percent of total billed charges Evaluation of swallowing function 3459155_1 CDM 0444 RC 92610 HCPCS inpatient 720 468 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 435.96 60.55 999999999 435.96 698.4 percent of total billed charges Evaluation of swallowing function 3459155_1 CDM 0444 RC 92610 HCPCS inpatient 720 468 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 435.96 698.4 Evaluation of swallowing function 3459155_1 CDM 0444 RC 92610 HCPCS inpatient 720 468 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 435.96 698.4 Evaluation of swallowing function 3459155_1 CDM 0444 RC 92610 HCPCS inpatient 720 468 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 435.96 698.4 Evaluation of swallowing function 3459155_1 CDM 0444 RC 92610 HCPCS inpatient 720 468 ANTHEM HMO ANTHEM HMO 999999999 435.96 698.4 Evaluation of swallowing function 3459155_1 CDM 0444 RC 92610 HCPCS inpatient 720 468 CIGNA - ALL PLANS CIGNA - ALL PLANS 486.72 67.6 999999999 435.96 698.4 percent of total billed charges Evaluation of swallowing function 3459155_1 CDM 0444 RC 92610 HCPCS inpatient 720 468 UHC - ALL PLANS UHC - ALL PLANS 999999999 435.96 698.4 "Test to assess the loss of the ability to speak, write, and understand language" 3459167_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 251.55 65 999999999 234.33 375.39 percent of total billed charges "Test to assess the loss of the ability to speak, write, and understand language" 3459167_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 AETNA AETNA 305.73 79 999999999 234.33 375.39 percent of total billed charges "Test to assess the loss of the ability to speak, write, and understand language" 3459167_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.03 69 999999999 234.33 375.39 percent of total billed charges "Test to assess the loss of the ability to speak, write, and understand language" 3459167_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 375.39 97 999999999 234.33 375.39 percent of total billed charges "Test to assess the loss of the ability to speak, write, and understand language" 3459167_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.86 78 999999999 234.33 375.39 percent of total billed charges "Test to assess the loss of the ability to speak, write, and understand language" 3459167_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 SIHO - ALL PLANS SIHO - ALL PLANS 348.3 90 999999999 234.33 375.39 percent of total billed charges "Test to assess the loss of the ability to speak, write, and understand language" 3459167_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 UMR - ALL PLANS UMR - ALL PLANS 270.9 70 999999999 234.33 375.39 percent of total billed charges "Test to assess the loss of the ability to speak, write, and understand language" 3459167_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.33 60.55 999999999 234.33 375.39 percent of total billed charges "Test to assess the loss of the ability to speak, write, and understand language" 3459167_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.33 375.39 "Test to assess the loss of the ability to speak, write, and understand language" 3459167_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.33 375.39 "Test to assess the loss of the ability to speak, write, and understand language" 3459167_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.33 375.39 "Test to assess the loss of the ability to speak, write, and understand language" 3459167_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 ANTHEM HMO ANTHEM HMO 999999999 234.33 375.39 "Test to assess the loss of the ability to speak, write, and understand language" 3459167_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 261.61 67.6 999999999 234.33 375.39 percent of total billed charges "Test to assess the loss of the ability to speak, write, and understand language" 3459167_1 CDM 0440 RC 96105 HCPCS inpatient 387 251.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.33 375.39 Insertion of temporary bladder tube 36081926_1 CDM 0761 RC 51701 HCPCS inpatient 238 154.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.7 65 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 36081926_1 CDM 0761 RC 51701 HCPCS inpatient 238 154.7 AETNA AETNA 188.02 79 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 36081926_1 CDM 0761 RC 51701 HCPCS inpatient 238 154.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.22 69 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 36081926_1 CDM 0761 RC 51701 HCPCS inpatient 238 154.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 230.86 97 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 36081926_1 CDM 0761 RC 51701 HCPCS inpatient 238 154.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 185.64 78 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 36081926_1 CDM 0761 RC 51701 HCPCS inpatient 238 154.7 SIHO - ALL PLANS SIHO - ALL PLANS 214.2 90 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 36081926_1 CDM 0761 RC 51701 HCPCS inpatient 238 154.7 UMR - ALL PLANS UMR - ALL PLANS 166.6 70 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 36081926_1 CDM 0761 RC 51701 HCPCS inpatient 238 154.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.11 60.55 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 36081926_1 CDM 0761 RC 51701 HCPCS inpatient 238 154.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.11 230.86 Insertion of temporary bladder tube 36081926_1 CDM 0761 RC 51701 HCPCS inpatient 238 154.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.11 230.86 Insertion of temporary bladder tube 36081926_1 CDM 0761 RC 51701 HCPCS inpatient 238 154.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.11 230.86 Insertion of temporary bladder tube 36081926_1 CDM 0761 RC 51701 HCPCS inpatient 238 154.7 ANTHEM HMO ANTHEM HMO 999999999 144.11 230.86 Insertion of temporary bladder tube 36081926_1 CDM 0761 RC 51701 HCPCS inpatient 238 154.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.89 67.6 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 36081926_1 CDM 0761 RC 51701 HCPCS inpatient 238 154.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.11 230.86 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 36797637_1 CDM 0341 RC 78803 HCPCS inpatient 4194 2726.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 2726.1 65 999999999 2539.47 4068.18 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 36797637_1 CDM 0341 RC 78803 HCPCS inpatient 4194 2726.1 AETNA AETNA 3313.26 79 999999999 2539.47 4068.18 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 36797637_1 CDM 0341 RC 78803 HCPCS inpatient 4194 2726.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 2893.86 69 999999999 2539.47 4068.18 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 36797637_1 CDM 0341 RC 78803 HCPCS inpatient 4194 2726.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4068.18 97 999999999 2539.47 4068.18 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 36797637_1 CDM 0341 RC 78803 HCPCS inpatient 4194 2726.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 3271.32 78 999999999 2539.47 4068.18 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 36797637_1 CDM 0341 RC 78803 HCPCS inpatient 4194 2726.1 SIHO - ALL PLANS SIHO - ALL PLANS 3774.6 90 999999999 2539.47 4068.18 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 36797637_1 CDM 0341 RC 78803 HCPCS inpatient 4194 2726.1 UMR - ALL PLANS UMR - ALL PLANS 2935.8 70 999999999 2539.47 4068.18 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 36797637_1 CDM 0341 RC 78803 HCPCS inpatient 4194 2726.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2539.47 60.55 999999999 2539.47 4068.18 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 36797637_1 CDM 0341 RC 78803 HCPCS inpatient 4194 2726.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2539.47 4068.18 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 36797637_1 CDM 0341 RC 78803 HCPCS inpatient 4194 2726.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2539.47 4068.18 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 36797637_1 CDM 0341 RC 78803 HCPCS inpatient 4194 2726.1 ANTHEM HMO ANTHEM HMO 999999999 2539.47 4068.18 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 36797637_1 CDM 0341 RC 78803 HCPCS inpatient 4194 2726.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 2835.14 67.6 999999999 2539.47 4068.18 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 36797637_1 CDM 0341 RC 78803 HCPCS inpatient 4194 2726.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2539.47 4068.18 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 36797637_1 CDM 0341 RC 78803 HCPCS inpatient 4194 2726.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 2539.47 4068.18 Infrared analysis of stone 37930991_1 CDM 0301 RC 82365 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges Infrared analysis of stone 37930991_1 CDM 0301 RC 82365 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges Infrared analysis of stone 37930991_1 CDM 0301 RC 82365 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges Infrared analysis of stone 37930991_1 CDM 0301 RC 82365 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges Infrared analysis of stone 37930991_1 CDM 0301 RC 82365 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges Infrared analysis of stone 37930991_1 CDM 0301 RC 82365 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges Infrared analysis of stone 37930991_1 CDM 0301 RC 82365 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges Infrared analysis of stone 37930991_1 CDM 0301 RC 82365 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges Infrared analysis of stone 37930991_1 CDM 0301 RC 82365 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 Infrared analysis of stone 37930991_1 CDM 0301 RC 82365 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 Infrared analysis of stone 37930991_1 CDM 0301 RC 82365 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 Infrared analysis of stone 37930991_1 CDM 0301 RC 82365 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges Infrared analysis of stone 37930991_1 CDM 0301 RC 82365 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 Infrared analysis of stone 37930991_1 CDM 0301 RC 82365 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 Quantitation of therapeutic drug 37930992_1 CDM 0301 RC 80299 HCPCS inpatient 657 427.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 427.05 65 999999999 397.81 637.29 percent of total billed charges Quantitation of therapeutic drug 37930992_1 CDM 0301 RC 80299 HCPCS inpatient 657 427.05 AETNA AETNA 519.03 79 999999999 397.81 637.29 percent of total billed charges Quantitation of therapeutic drug 37930992_1 CDM 0301 RC 80299 HCPCS inpatient 657 427.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 453.33 69 999999999 397.81 637.29 percent of total billed charges Quantitation of therapeutic drug 37930992_1 CDM 0301 RC 80299 HCPCS inpatient 657 427.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 637.29 97 999999999 397.81 637.29 percent of total billed charges Quantitation of therapeutic drug 37930992_1 CDM 0301 RC 80299 HCPCS inpatient 657 427.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 512.46 78 999999999 397.81 637.29 percent of total billed charges Quantitation of therapeutic drug 37930992_1 CDM 0301 RC 80299 HCPCS inpatient 657 427.05 SIHO - ALL PLANS SIHO - ALL PLANS 591.3 90 999999999 397.81 637.29 percent of total billed charges Quantitation of therapeutic drug 37930992_1 CDM 0301 RC 80299 HCPCS inpatient 657 427.05 UMR - ALL PLANS UMR - ALL PLANS 459.9 70 999999999 397.81 637.29 percent of total billed charges Quantitation of therapeutic drug 37930992_1 CDM 0301 RC 80299 HCPCS inpatient 657 427.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 397.81 60.55 999999999 397.81 637.29 percent of total billed charges Quantitation of therapeutic drug 37930992_1 CDM 0301 RC 80299 HCPCS inpatient 657 427.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 397.81 637.29 Quantitation of therapeutic drug 37930992_1 CDM 0301 RC 80299 HCPCS inpatient 657 427.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 397.81 637.29 Quantitation of therapeutic drug 37930992_1 CDM 0301 RC 80299 HCPCS inpatient 657 427.05 ANTHEM HMO ANTHEM HMO 999999999 397.81 637.29 Quantitation of therapeutic drug 37930992_1 CDM 0301 RC 80299 HCPCS inpatient 657 427.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 444.13 67.6 999999999 397.81 637.29 percent of total billed charges Quantitation of therapeutic drug 37930992_1 CDM 0301 RC 80299 HCPCS inpatient 657 427.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 397.81 637.29 Quantitation of therapeutic drug 37930992_1 CDM 0301 RC 80299 HCPCS inpatient 657 427.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 397.81 637.29 Cyclosporine level 37930994_1 CDM 0300 RC 80158 HCPCS inpatient 245 159.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 159.25 65 999999999 148.35 237.65 percent of total billed charges Cyclosporine level 37930994_1 CDM 0300 RC 80158 HCPCS inpatient 245 159.25 AETNA AETNA 193.55 79 999999999 148.35 237.65 percent of total billed charges Cyclosporine level 37930994_1 CDM 0300 RC 80158 HCPCS inpatient 245 159.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 169.05 69 999999999 148.35 237.65 percent of total billed charges Cyclosporine level 37930994_1 CDM 0300 RC 80158 HCPCS inpatient 245 159.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 237.65 97 999999999 148.35 237.65 percent of total billed charges Cyclosporine level 37930994_1 CDM 0300 RC 80158 HCPCS inpatient 245 159.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 191.1 78 999999999 148.35 237.65 percent of total billed charges Cyclosporine level 37930994_1 CDM 0300 RC 80158 HCPCS inpatient 245 159.25 SIHO - ALL PLANS SIHO - ALL PLANS 220.5 90 999999999 148.35 237.65 percent of total billed charges Cyclosporine level 37930994_1 CDM 0300 RC 80158 HCPCS inpatient 245 159.25 UMR - ALL PLANS UMR - ALL PLANS 171.5 70 999999999 148.35 237.65 percent of total billed charges Cyclosporine level 37930994_1 CDM 0300 RC 80158 HCPCS inpatient 245 159.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 148.35 60.55 999999999 148.35 237.65 percent of total billed charges Cyclosporine level 37930994_1 CDM 0300 RC 80158 HCPCS inpatient 245 159.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 148.35 237.65 Cyclosporine level 37930994_1 CDM 0300 RC 80158 HCPCS inpatient 245 159.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 148.35 237.65 Cyclosporine level 37930994_1 CDM 0300 RC 80158 HCPCS inpatient 245 159.25 ANTHEM HMO ANTHEM HMO 999999999 148.35 237.65 Cyclosporine level 37930994_1 CDM 0300 RC 80158 HCPCS inpatient 245 159.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 165.62 67.6 999999999 148.35 237.65 percent of total billed charges Cyclosporine level 37930994_1 CDM 0300 RC 80158 HCPCS inpatient 245 159.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 148.35 237.65 Cyclosporine level 37930994_1 CDM 0300 RC 80158 HCPCS inpatient 245 159.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 148.35 237.65 Copper level 37930996_1 CDM 0301 RC 82525 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges Copper level 37930996_1 CDM 0301 RC 82525 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges Copper level 37930996_1 CDM 0301 RC 82525 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges Copper level 37930996_1 CDM 0301 RC 82525 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges Copper level 37930996_1 CDM 0301 RC 82525 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges Copper level 37930996_1 CDM 0301 RC 82525 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges Copper level 37930996_1 CDM 0301 RC 82525 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges Copper level 37930996_1 CDM 0301 RC 82525 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges Copper level 37930996_1 CDM 0301 RC 82525 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 Copper level 37930996_1 CDM 0301 RC 82525 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 Copper level 37930996_1 CDM 0301 RC 82525 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 Copper level 37930996_1 CDM 0301 RC 82525 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges Copper level 37930996_1 CDM 0301 RC 82525 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 Copper level 37930996_1 CDM 0301 RC 82525 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 Carboxyhemoglobin (protein) level 37930997_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 146.25 65 999999999 136.24 218.25 percent of total billed charges Carboxyhemoglobin (protein) level 37930997_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 AETNA AETNA 177.75 79 999999999 136.24 218.25 percent of total billed charges Carboxyhemoglobin (protein) level 37930997_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 155.25 69 999999999 136.24 218.25 percent of total billed charges Carboxyhemoglobin (protein) level 37930997_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 218.25 97 999999999 136.24 218.25 percent of total billed charges Carboxyhemoglobin (protein) level 37930997_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 175.5 78 999999999 136.24 218.25 percent of total billed charges Carboxyhemoglobin (protein) level 37930997_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 SIHO - ALL PLANS SIHO - ALL PLANS 202.5 90 999999999 136.24 218.25 percent of total billed charges Carboxyhemoglobin (protein) level 37930997_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 UMR - ALL PLANS UMR - ALL PLANS 157.5 70 999999999 136.24 218.25 percent of total billed charges Carboxyhemoglobin (protein) level 37930997_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 136.24 60.55 999999999 136.24 218.25 percent of total billed charges Carboxyhemoglobin (protein) level 37930997_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 136.24 218.25 Carboxyhemoglobin (protein) level 37930997_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 136.24 218.25 Carboxyhemoglobin (protein) level 37930997_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 ANTHEM HMO ANTHEM HMO 999999999 136.24 218.25 Carboxyhemoglobin (protein) level 37930997_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 152.1 67.6 999999999 136.24 218.25 percent of total billed charges Carboxyhemoglobin (protein) level 37930997_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 136.24 218.25 Carboxyhemoglobin (protein) level 37930997_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 136.24 218.25 Immunologic analysis technique on serum (immunofixation) 37930998_1 CDM 0302 RC 86334 HCPCS inpatient 288 187.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 187.2 65 999999999 174.38 279.36 percent of total billed charges Immunologic analysis technique on serum (immunofixation) 37930998_1 CDM 0302 RC 86334 HCPCS inpatient 288 187.2 AETNA AETNA 227.52 79 999999999 174.38 279.36 percent of total billed charges Immunologic analysis technique on serum (immunofixation) 37930998_1 CDM 0302 RC 86334 HCPCS inpatient 288 187.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 198.72 69 999999999 174.38 279.36 percent of total billed charges Immunologic analysis technique on serum (immunofixation) 37930998_1 CDM 0302 RC 86334 HCPCS inpatient 288 187.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 279.36 97 999999999 174.38 279.36 percent of total billed charges Immunologic analysis technique on serum (immunofixation) 37930998_1 CDM 0302 RC 86334 HCPCS inpatient 288 187.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 224.64 78 999999999 174.38 279.36 percent of total billed charges Immunologic analysis technique on serum (immunofixation) 37930998_1 CDM 0302 RC 86334 HCPCS inpatient 288 187.2 SIHO - ALL PLANS SIHO - ALL PLANS 259.2 90 999999999 174.38 279.36 percent of total billed charges Immunologic analysis technique on serum (immunofixation) 37930998_1 CDM 0302 RC 86334 HCPCS inpatient 288 187.2 UMR - ALL PLANS UMR - ALL PLANS 201.6 70 999999999 174.38 279.36 percent of total billed charges Immunologic analysis technique on serum (immunofixation) 37930998_1 CDM 0302 RC 86334 HCPCS inpatient 288 187.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 174.38 60.55 999999999 174.38 279.36 percent of total billed charges Immunologic analysis technique on serum (immunofixation) 37930998_1 CDM 0302 RC 86334 HCPCS inpatient 288 187.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 174.38 279.36 Immunologic analysis technique on serum (immunofixation) 37930998_1 CDM 0302 RC 86334 HCPCS inpatient 288 187.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 174.38 279.36 Immunologic analysis technique on serum (immunofixation) 37930998_1 CDM 0302 RC 86334 HCPCS inpatient 288 187.2 ANTHEM HMO ANTHEM HMO 999999999 174.38 279.36 Immunologic analysis technique on serum (immunofixation) 37930998_1 CDM 0302 RC 86334 HCPCS inpatient 288 187.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 194.69 67.6 999999999 174.38 279.36 percent of total billed charges Immunologic analysis technique on serum (immunofixation) 37930998_1 CDM 0302 RC 86334 HCPCS inpatient 288 187.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 174.38 279.36 Immunologic analysis technique on serum (immunofixation) 37930998_1 CDM 0302 RC 86334 HCPCS inpatient 288 187.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 174.38 279.36 "Immunologic analysis technique on body fluid, other fluids with concentration" 37930999_1 CDM 0302 RC 86335 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 37930999_1 CDM 0302 RC 86335 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 37930999_1 CDM 0302 RC 86335 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 37930999_1 CDM 0302 RC 86335 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 37930999_1 CDM 0302 RC 86335 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 37930999_1 CDM 0302 RC 86335 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 37930999_1 CDM 0302 RC 86335 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 37930999_1 CDM 0302 RC 86335 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 37930999_1 CDM 0302 RC 86335 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 "Immunologic analysis technique on body fluid, other fluids with concentration" 37930999_1 CDM 0302 RC 86335 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 "Immunologic analysis technique on body fluid, other fluids with concentration" 37930999_1 CDM 0302 RC 86335 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 "Immunologic analysis technique on body fluid, other fluids with concentration" 37930999_1 CDM 0302 RC 86335 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 37930999_1 CDM 0302 RC 86335 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 "Immunologic analysis technique on body fluid, other fluids with concentration" 37930999_1 CDM 0302 RC 86335 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 Urine osmolality (concentration) measurement 37931004_1 CDM 0301 RC 83935 HCPCS inpatient 167 108.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 108.55 65 999999999 101.12 161.99 percent of total billed charges Urine osmolality (concentration) measurement 37931004_1 CDM 0301 RC 83935 HCPCS inpatient 167 108.55 AETNA AETNA 131.93 79 999999999 101.12 161.99 percent of total billed charges Urine osmolality (concentration) measurement 37931004_1 CDM 0301 RC 83935 HCPCS inpatient 167 108.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.23 69 999999999 101.12 161.99 percent of total billed charges Urine osmolality (concentration) measurement 37931004_1 CDM 0301 RC 83935 HCPCS inpatient 167 108.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.99 97 999999999 101.12 161.99 percent of total billed charges Urine osmolality (concentration) measurement 37931004_1 CDM 0301 RC 83935 HCPCS inpatient 167 108.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 130.26 78 999999999 101.12 161.99 percent of total billed charges Urine osmolality (concentration) measurement 37931004_1 CDM 0301 RC 83935 HCPCS inpatient 167 108.55 SIHO - ALL PLANS SIHO - ALL PLANS 150.3 90 999999999 101.12 161.99 percent of total billed charges Urine osmolality (concentration) measurement 37931004_1 CDM 0301 RC 83935 HCPCS inpatient 167 108.55 UMR - ALL PLANS UMR - ALL PLANS 116.9 70 999999999 101.12 161.99 percent of total billed charges Urine osmolality (concentration) measurement 37931004_1 CDM 0301 RC 83935 HCPCS inpatient 167 108.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.12 60.55 999999999 101.12 161.99 percent of total billed charges Urine osmolality (concentration) measurement 37931004_1 CDM 0301 RC 83935 HCPCS inpatient 167 108.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.12 161.99 Urine osmolality (concentration) measurement 37931004_1 CDM 0301 RC 83935 HCPCS inpatient 167 108.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.12 161.99 Urine osmolality (concentration) measurement 37931004_1 CDM 0301 RC 83935 HCPCS inpatient 167 108.55 ANTHEM HMO ANTHEM HMO 999999999 101.12 161.99 Urine osmolality (concentration) measurement 37931004_1 CDM 0301 RC 83935 HCPCS inpatient 167 108.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.89 67.6 999999999 101.12 161.99 percent of total billed charges Urine osmolality (concentration) measurement 37931004_1 CDM 0301 RC 83935 HCPCS inpatient 167 108.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.12 161.99 Urine osmolality (concentration) measurement 37931004_1 CDM 0301 RC 83935 HCPCS inpatient 167 108.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.12 161.99 Levetiracetam level 37931007_1 CDM 0301 RC 80177 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges Levetiracetam level 37931007_1 CDM 0301 RC 80177 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges Levetiracetam level 37931007_1 CDM 0301 RC 80177 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges Levetiracetam level 37931007_1 CDM 0301 RC 80177 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges Levetiracetam level 37931007_1 CDM 0301 RC 80177 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges Levetiracetam level 37931007_1 CDM 0301 RC 80177 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges Levetiracetam level 37931007_1 CDM 0301 RC 80177 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges Levetiracetam level 37931007_1 CDM 0301 RC 80177 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges Levetiracetam level 37931007_1 CDM 0301 RC 80177 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 Levetiracetam level 37931007_1 CDM 0301 RC 80177 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 Levetiracetam level 37931007_1 CDM 0301 RC 80177 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 Levetiracetam level 37931007_1 CDM 0301 RC 80177 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges Levetiracetam level 37931007_1 CDM 0301 RC 80177 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 Levetiracetam level 37931007_1 CDM 0301 RC 80177 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 "Nephelometry, test method using light" 37931008_1 CDM 0301 RC 83883 HCPCS inpatient 216 140.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 140.4 65 999999999 130.79 209.52 percent of total billed charges "Nephelometry, test method using light" 37931008_1 CDM 0301 RC 83883 HCPCS inpatient 216 140.4 AETNA AETNA 170.64 79 999999999 130.79 209.52 percent of total billed charges "Nephelometry, test method using light" 37931008_1 CDM 0301 RC 83883 HCPCS inpatient 216 140.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 149.04 69 999999999 130.79 209.52 percent of total billed charges "Nephelometry, test method using light" 37931008_1 CDM 0301 RC 83883 HCPCS inpatient 216 140.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 209.52 97 999999999 130.79 209.52 percent of total billed charges "Nephelometry, test method using light" 37931008_1 CDM 0301 RC 83883 HCPCS inpatient 216 140.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 168.48 78 999999999 130.79 209.52 percent of total billed charges "Nephelometry, test method using light" 37931008_1 CDM 0301 RC 83883 HCPCS inpatient 216 140.4 SIHO - ALL PLANS SIHO - ALL PLANS 194.4 90 999999999 130.79 209.52 percent of total billed charges "Nephelometry, test method using light" 37931008_1 CDM 0301 RC 83883 HCPCS inpatient 216 140.4 UMR - ALL PLANS UMR - ALL PLANS 151.2 70 999999999 130.79 209.52 percent of total billed charges "Nephelometry, test method using light" 37931008_1 CDM 0301 RC 83883 HCPCS inpatient 216 140.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 130.79 60.55 999999999 130.79 209.52 percent of total billed charges "Nephelometry, test method using light" 37931008_1 CDM 0301 RC 83883 HCPCS inpatient 216 140.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 130.79 209.52 "Nephelometry, test method using light" 37931008_1 CDM 0301 RC 83883 HCPCS inpatient 216 140.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 130.79 209.52 "Nephelometry, test method using light" 37931008_1 CDM 0301 RC 83883 HCPCS inpatient 216 140.4 ANTHEM HMO ANTHEM HMO 999999999 130.79 209.52 "Nephelometry, test method using light" 37931008_1 CDM 0301 RC 83883 HCPCS inpatient 216 140.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 146.02 67.6 999999999 130.79 209.52 percent of total billed charges "Nephelometry, test method using light" 37931008_1 CDM 0301 RC 83883 HCPCS inpatient 216 140.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 130.79 209.52 "Nephelometry, test method using light" 37931008_1 CDM 0301 RC 83883 HCPCS inpatient 216 140.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 130.79 209.52 "Cortisol (hormone) measurement, free" 37931009_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 249.6 65 999999999 232.51 372.48 percent of total billed charges "Cortisol (hormone) measurement, free" 37931009_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 AETNA AETNA 303.36 79 999999999 232.51 372.48 percent of total billed charges "Cortisol (hormone) measurement, free" 37931009_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 264.96 69 999999999 232.51 372.48 percent of total billed charges "Cortisol (hormone) measurement, free" 37931009_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 372.48 97 999999999 232.51 372.48 percent of total billed charges "Cortisol (hormone) measurement, free" 37931009_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 299.52 78 999999999 232.51 372.48 percent of total billed charges "Cortisol (hormone) measurement, free" 37931009_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 SIHO - ALL PLANS SIHO - ALL PLANS 345.6 90 999999999 232.51 372.48 percent of total billed charges "Cortisol (hormone) measurement, free" 37931009_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 UMR - ALL PLANS UMR - ALL PLANS 268.8 70 999999999 232.51 372.48 percent of total billed charges "Cortisol (hormone) measurement, free" 37931009_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 232.51 60.55 999999999 232.51 372.48 percent of total billed charges "Cortisol (hormone) measurement, free" 37931009_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 232.51 372.48 "Cortisol (hormone) measurement, free" 37931009_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 232.51 372.48 "Cortisol (hormone) measurement, free" 37931009_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 ANTHEM HMO ANTHEM HMO 999999999 232.51 372.48 "Cortisol (hormone) measurement, free" 37931009_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 259.58 67.6 999999999 232.51 372.48 percent of total billed charges "Cortisol (hormone) measurement, free" 37931009_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 232.51 372.48 "Cortisol (hormone) measurement, free" 37931009_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 232.51 372.48 "Total protein level, urine" 37931012_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 37931012_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 37931012_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 37931012_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 37931012_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 37931012_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 37931012_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 37931012_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 37931012_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 "Total protein level, urine" 37931012_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 "Total protein level, urine" 37931012_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 "Total protein level, urine" 37931012_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 37931012_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 "Total protein level, urine" 37931012_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 Hemoglobin A1C level 37931013_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges Hemoglobin A1C level 37931013_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges Hemoglobin A1C level 37931013_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges Hemoglobin A1C level 37931013_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges Hemoglobin A1C level 37931013_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges Hemoglobin A1C level 37931013_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges Hemoglobin A1C level 37931013_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges Hemoglobin A1C level 37931013_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges Hemoglobin A1C level 37931013_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 Hemoglobin A1C level 37931013_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 Hemoglobin A1C level 37931013_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 Hemoglobin A1C level 37931013_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges Hemoglobin A1C level 37931013_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 Hemoglobin A1C level 37931013_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 "Hemoglobin analysis and measurement, chromatography" 37932771_1 CDM 0301 RC 83021 HCPCS inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges "Hemoglobin analysis and measurement, chromatography" 37932771_1 CDM 0301 RC 83021 HCPCS inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges "Hemoglobin analysis and measurement, chromatography" 37932771_1 CDM 0301 RC 83021 HCPCS inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges "Hemoglobin analysis and measurement, chromatography" 37932771_1 CDM 0301 RC 83021 HCPCS inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges "Hemoglobin analysis and measurement, chromatography" 37932771_1 CDM 0301 RC 83021 HCPCS inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges "Hemoglobin analysis and measurement, chromatography" 37932771_1 CDM 0301 RC 83021 HCPCS inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges "Hemoglobin analysis and measurement, chromatography" 37932771_1 CDM 0301 RC 83021 HCPCS inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges "Hemoglobin analysis and measurement, chromatography" 37932771_1 CDM 0301 RC 83021 HCPCS inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges "Hemoglobin analysis and measurement, chromatography" 37932771_1 CDM 0301 RC 83021 HCPCS inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 "Hemoglobin analysis and measurement, chromatography" 37932771_1 CDM 0301 RC 83021 HCPCS inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 "Hemoglobin analysis and measurement, chromatography" 37932771_1 CDM 0301 RC 83021 HCPCS inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 "Hemoglobin analysis and measurement, chromatography" 37932771_1 CDM 0301 RC 83021 HCPCS inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges "Hemoglobin analysis and measurement, chromatography" 37932771_1 CDM 0301 RC 83021 HCPCS inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 "Hemoglobin analysis and measurement, chromatography" 37932771_1 CDM 0301 RC 83021 HCPCS inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 Analysis test by nucleic acid for Hepatitis C virus 37940608_1 CDM 0306 RC 87902 HCPCS inpatient 1054 685.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 685.1 65 999999999 638.2 1022.38 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 37940608_1 CDM 0306 RC 87902 HCPCS inpatient 1054 685.1 AETNA AETNA 832.66 79 999999999 638.2 1022.38 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 37940608_1 CDM 0306 RC 87902 HCPCS inpatient 1054 685.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 727.26 69 999999999 638.2 1022.38 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 37940608_1 CDM 0306 RC 87902 HCPCS inpatient 1054 685.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1022.38 97 999999999 638.2 1022.38 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 37940608_1 CDM 0306 RC 87902 HCPCS inpatient 1054 685.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 822.12 78 999999999 638.2 1022.38 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 37940608_1 CDM 0306 RC 87902 HCPCS inpatient 1054 685.1 SIHO - ALL PLANS SIHO - ALL PLANS 948.6 90 999999999 638.2 1022.38 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 37940608_1 CDM 0306 RC 87902 HCPCS inpatient 1054 685.1 UMR - ALL PLANS UMR - ALL PLANS 737.8 70 999999999 638.2 1022.38 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 37940608_1 CDM 0306 RC 87902 HCPCS inpatient 1054 685.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 638.2 60.55 999999999 638.2 1022.38 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 37940608_1 CDM 0306 RC 87902 HCPCS inpatient 1054 685.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 638.2 1022.38 Analysis test by nucleic acid for Hepatitis C virus 37940608_1 CDM 0306 RC 87902 HCPCS inpatient 1054 685.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 638.2 1022.38 Analysis test by nucleic acid for Hepatitis C virus 37940608_1 CDM 0306 RC 87902 HCPCS inpatient 1054 685.1 ANTHEM HMO ANTHEM HMO 999999999 638.2 1022.38 Analysis test by nucleic acid for Hepatitis C virus 37940608_1 CDM 0306 RC 87902 HCPCS inpatient 1054 685.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 712.5 67.6 999999999 638.2 1022.38 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 37940608_1 CDM 0306 RC 87902 HCPCS inpatient 1054 685.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 638.2 1022.38 Analysis test by nucleic acid for Hepatitis C virus 37940608_1 CDM 0306 RC 87902 HCPCS inpatient 1054 685.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 638.2 1022.38 Protein S (clotting inhibitor) measurement 37940613_1 CDM 0305 RC 85306 HCPCS inpatient 315 204.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 204.75 65 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) measurement 37940613_1 CDM 0305 RC 85306 HCPCS inpatient 315 204.75 AETNA AETNA 248.85 79 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) measurement 37940613_1 CDM 0305 RC 85306 HCPCS inpatient 315 204.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 217.35 69 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) measurement 37940613_1 CDM 0305 RC 85306 HCPCS inpatient 315 204.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 305.55 97 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) measurement 37940613_1 CDM 0305 RC 85306 HCPCS inpatient 315 204.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 245.7 78 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) measurement 37940613_1 CDM 0305 RC 85306 HCPCS inpatient 315 204.75 SIHO - ALL PLANS SIHO - ALL PLANS 283.5 90 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) measurement 37940613_1 CDM 0305 RC 85306 HCPCS inpatient 315 204.75 UMR - ALL PLANS UMR - ALL PLANS 220.5 70 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) measurement 37940613_1 CDM 0305 RC 85306 HCPCS inpatient 315 204.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 190.73 60.55 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) measurement 37940613_1 CDM 0305 RC 85306 HCPCS inpatient 315 204.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 190.73 305.55 Protein S (clotting inhibitor) measurement 37940613_1 CDM 0305 RC 85306 HCPCS inpatient 315 204.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 190.73 305.55 Protein S (clotting inhibitor) measurement 37940613_1 CDM 0305 RC 85306 HCPCS inpatient 315 204.75 ANTHEM HMO ANTHEM HMO 999999999 190.73 305.55 Protein S (clotting inhibitor) measurement 37940613_1 CDM 0305 RC 85306 HCPCS inpatient 315 204.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 212.94 67.6 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) measurement 37940613_1 CDM 0305 RC 85306 HCPCS inpatient 315 204.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 190.73 305.55 Protein S (clotting inhibitor) measurement 37940613_1 CDM 0305 RC 85306 HCPCS inpatient 315 204.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 190.73 305.55 Activated protein resistance assay 37940614_1 CDM 0305 RC 85307 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges Activated protein resistance assay 37940614_1 CDM 0305 RC 85307 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges Activated protein resistance assay 37940614_1 CDM 0305 RC 85307 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges Activated protein resistance assay 37940614_1 CDM 0305 RC 85307 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges Activated protein resistance assay 37940614_1 CDM 0305 RC 85307 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges Activated protein resistance assay 37940614_1 CDM 0305 RC 85307 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges Activated protein resistance assay 37940614_1 CDM 0305 RC 85307 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges Activated protein resistance assay 37940614_1 CDM 0305 RC 85307 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges Activated protein resistance assay 37940614_1 CDM 0305 RC 85307 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 Activated protein resistance assay 37940614_1 CDM 0305 RC 85307 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 Activated protein resistance assay 37940614_1 CDM 0305 RC 85307 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 Activated protein resistance assay 37940614_1 CDM 0305 RC 85307 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges Activated protein resistance assay 37940614_1 CDM 0305 RC 85307 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 Activated protein resistance assay 37940614_1 CDM 0305 RC 85307 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 Clotting factor VIII (AHG) measurement 37940616_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges Clotting factor VIII (AHG) measurement 37940616_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges Clotting factor VIII (AHG) measurement 37940616_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges Clotting factor VIII (AHG) measurement 37940616_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges Clotting factor VIII (AHG) measurement 37940616_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges Clotting factor VIII (AHG) measurement 37940616_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges Clotting factor VIII (AHG) measurement 37940616_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges Clotting factor VIII (AHG) measurement 37940616_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges Clotting factor VIII (AHG) measurement 37940616_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 Clotting factor VIII (AHG) measurement 37940616_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 Clotting factor VIII (AHG) measurement 37940616_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 Clotting factor VIII (AHG) measurement 37940616_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges Clotting factor VIII (AHG) measurement 37940616_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 Clotting factor VIII (AHG) measurement 37940616_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 Clotting factor XI (PTA) measurement 37940618_1 CDM 0305 RC 85270 HCPCS inpatient 449 291.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 291.85 65 999999999 271.87 435.53 percent of total billed charges Clotting factor XI (PTA) measurement 37940618_1 CDM 0305 RC 85270 HCPCS inpatient 449 291.85 AETNA AETNA 354.71 79 999999999 271.87 435.53 percent of total billed charges Clotting factor XI (PTA) measurement 37940618_1 CDM 0305 RC 85270 HCPCS inpatient 449 291.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 309.81 69 999999999 271.87 435.53 percent of total billed charges Clotting factor XI (PTA) measurement 37940618_1 CDM 0305 RC 85270 HCPCS inpatient 449 291.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 435.53 97 999999999 271.87 435.53 percent of total billed charges Clotting factor XI (PTA) measurement 37940618_1 CDM 0305 RC 85270 HCPCS inpatient 449 291.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 350.22 78 999999999 271.87 435.53 percent of total billed charges Clotting factor XI (PTA) measurement 37940618_1 CDM 0305 RC 85270 HCPCS inpatient 449 291.85 SIHO - ALL PLANS SIHO - ALL PLANS 404.1 90 999999999 271.87 435.53 percent of total billed charges Clotting factor XI (PTA) measurement 37940618_1 CDM 0305 RC 85270 HCPCS inpatient 449 291.85 UMR - ALL PLANS UMR - ALL PLANS 314.3 70 999999999 271.87 435.53 percent of total billed charges Clotting factor XI (PTA) measurement 37940618_1 CDM 0305 RC 85270 HCPCS inpatient 449 291.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 271.87 60.55 999999999 271.87 435.53 percent of total billed charges Clotting factor XI (PTA) measurement 37940618_1 CDM 0305 RC 85270 HCPCS inpatient 449 291.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 271.87 435.53 Clotting factor XI (PTA) measurement 37940618_1 CDM 0305 RC 85270 HCPCS inpatient 449 291.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 271.87 435.53 Clotting factor XI (PTA) measurement 37940618_1 CDM 0305 RC 85270 HCPCS inpatient 449 291.85 ANTHEM HMO ANTHEM HMO 999999999 271.87 435.53 Clotting factor XI (PTA) measurement 37940618_1 CDM 0305 RC 85270 HCPCS inpatient 449 291.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 303.52 67.6 999999999 271.87 435.53 percent of total billed charges Clotting factor XI (PTA) measurement 37940618_1 CDM 0305 RC 85270 HCPCS inpatient 449 291.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 271.87 435.53 Clotting factor XI (PTA) measurement 37940618_1 CDM 0305 RC 85270 HCPCS inpatient 449 291.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 271.87 435.53 Fibrinogen (factor 1) activity measurement 37940619_1 CDM 0305 RC 85384 HCPCS inpatient 312 202.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 202.8 65 999999999 188.92 302.64 percent of total billed charges Fibrinogen (factor 1) activity measurement 37940619_1 CDM 0305 RC 85384 HCPCS inpatient 312 202.8 AETNA AETNA 246.48 79 999999999 188.92 302.64 percent of total billed charges Fibrinogen (factor 1) activity measurement 37940619_1 CDM 0305 RC 85384 HCPCS inpatient 312 202.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 215.28 69 999999999 188.92 302.64 percent of total billed charges Fibrinogen (factor 1) activity measurement 37940619_1 CDM 0305 RC 85384 HCPCS inpatient 312 202.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 302.64 97 999999999 188.92 302.64 percent of total billed charges Fibrinogen (factor 1) activity measurement 37940619_1 CDM 0305 RC 85384 HCPCS inpatient 312 202.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 243.36 78 999999999 188.92 302.64 percent of total billed charges Fibrinogen (factor 1) activity measurement 37940619_1 CDM 0305 RC 85384 HCPCS inpatient 312 202.8 SIHO - ALL PLANS SIHO - ALL PLANS 280.8 90 999999999 188.92 302.64 percent of total billed charges Fibrinogen (factor 1) activity measurement 37940619_1 CDM 0305 RC 85384 HCPCS inpatient 312 202.8 UMR - ALL PLANS UMR - ALL PLANS 218.4 70 999999999 188.92 302.64 percent of total billed charges Fibrinogen (factor 1) activity measurement 37940619_1 CDM 0305 RC 85384 HCPCS inpatient 312 202.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 188.92 60.55 999999999 188.92 302.64 percent of total billed charges Fibrinogen (factor 1) activity measurement 37940619_1 CDM 0305 RC 85384 HCPCS inpatient 312 202.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 188.92 302.64 Fibrinogen (factor 1) activity measurement 37940619_1 CDM 0305 RC 85384 HCPCS inpatient 312 202.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 188.92 302.64 Fibrinogen (factor 1) activity measurement 37940619_1 CDM 0305 RC 85384 HCPCS inpatient 312 202.8 ANTHEM HMO ANTHEM HMO 999999999 188.92 302.64 Fibrinogen (factor 1) activity measurement 37940619_1 CDM 0305 RC 85384 HCPCS inpatient 312 202.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 210.91 67.6 999999999 188.92 302.64 percent of total billed charges Fibrinogen (factor 1) activity measurement 37940619_1 CDM 0305 RC 85384 HCPCS inpatient 312 202.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 188.92 302.64 Fibrinogen (factor 1) activity measurement 37940619_1 CDM 0305 RC 85384 HCPCS inpatient 312 202.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 188.92 302.64 "Thrombin time, fibrinogen screening test, plasma" 37940621_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges "Thrombin time, fibrinogen screening test, plasma" 37940621_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges "Thrombin time, fibrinogen screening test, plasma" 37940621_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges "Thrombin time, fibrinogen screening test, plasma" 37940621_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges "Thrombin time, fibrinogen screening test, plasma" 37940621_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges "Thrombin time, fibrinogen screening test, plasma" 37940621_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges "Thrombin time, fibrinogen screening test, plasma" 37940621_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges "Thrombin time, fibrinogen screening test, plasma" 37940621_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges "Thrombin time, fibrinogen screening test, plasma" 37940621_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 "Thrombin time, fibrinogen screening test, plasma" 37940621_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 "Thrombin time, fibrinogen screening test, plasma" 37940621_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 "Thrombin time, fibrinogen screening test, plasma" 37940621_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges "Thrombin time, fibrinogen screening test, plasma" 37940621_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 "Thrombin time, fibrinogen screening test, plasma" 37940621_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 Protein C antigen (clotting inhibitor) measurement 37940635_1 CDM 0305 RC 85303 HCPCS inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges Protein C antigen (clotting inhibitor) measurement 37940635_1 CDM 0305 RC 85303 HCPCS inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges Protein C antigen (clotting inhibitor) measurement 37940635_1 CDM 0305 RC 85303 HCPCS inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges Protein C antigen (clotting inhibitor) measurement 37940635_1 CDM 0305 RC 85303 HCPCS inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges Protein C antigen (clotting inhibitor) measurement 37940635_1 CDM 0305 RC 85303 HCPCS inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges Protein C antigen (clotting inhibitor) measurement 37940635_1 CDM 0305 RC 85303 HCPCS inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges Protein C antigen (clotting inhibitor) measurement 37940635_1 CDM 0305 RC 85303 HCPCS inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges Protein C antigen (clotting inhibitor) measurement 37940635_1 CDM 0305 RC 85303 HCPCS inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges Protein C antigen (clotting inhibitor) measurement 37940635_1 CDM 0305 RC 85303 HCPCS inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 Protein C antigen (clotting inhibitor) measurement 37940635_1 CDM 0305 RC 85303 HCPCS inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 Protein C antigen (clotting inhibitor) measurement 37940635_1 CDM 0305 RC 85303 HCPCS inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 Protein C antigen (clotting inhibitor) measurement 37940635_1 CDM 0305 RC 85303 HCPCS inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges Protein C antigen (clotting inhibitor) measurement 37940635_1 CDM 0305 RC 85303 HCPCS inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 Protein C antigen (clotting inhibitor) measurement 37940635_1 CDM 0305 RC 85303 HCPCS inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 Antithrombin III antigen (clotting inhibitor) activity 37940636_1 CDM 0305 RC 85300 HCPCS inpatient 245 159.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 159.25 65 999999999 148.35 237.65 percent of total billed charges Antithrombin III antigen (clotting inhibitor) activity 37940636_1 CDM 0305 RC 85300 HCPCS inpatient 245 159.25 AETNA AETNA 193.55 79 999999999 148.35 237.65 percent of total billed charges Antithrombin III antigen (clotting inhibitor) activity 37940636_1 CDM 0305 RC 85300 HCPCS inpatient 245 159.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 169.05 69 999999999 148.35 237.65 percent of total billed charges Antithrombin III antigen (clotting inhibitor) activity 37940636_1 CDM 0305 RC 85300 HCPCS inpatient 245 159.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 237.65 97 999999999 148.35 237.65 percent of total billed charges Antithrombin III antigen (clotting inhibitor) activity 37940636_1 CDM 0305 RC 85300 HCPCS inpatient 245 159.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 191.1 78 999999999 148.35 237.65 percent of total billed charges Antithrombin III antigen (clotting inhibitor) activity 37940636_1 CDM 0305 RC 85300 HCPCS inpatient 245 159.25 SIHO - ALL PLANS SIHO - ALL PLANS 220.5 90 999999999 148.35 237.65 percent of total billed charges Antithrombin III antigen (clotting inhibitor) activity 37940636_1 CDM 0305 RC 85300 HCPCS inpatient 245 159.25 UMR - ALL PLANS UMR - ALL PLANS 171.5 70 999999999 148.35 237.65 percent of total billed charges Antithrombin III antigen (clotting inhibitor) activity 37940636_1 CDM 0305 RC 85300 HCPCS inpatient 245 159.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 148.35 60.55 999999999 148.35 237.65 percent of total billed charges Antithrombin III antigen (clotting inhibitor) activity 37940636_1 CDM 0305 RC 85300 HCPCS inpatient 245 159.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 148.35 237.65 Antithrombin III antigen (clotting inhibitor) activity 37940636_1 CDM 0305 RC 85300 HCPCS inpatient 245 159.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 148.35 237.65 Antithrombin III antigen (clotting inhibitor) activity 37940636_1 CDM 0305 RC 85300 HCPCS inpatient 245 159.25 ANTHEM HMO ANTHEM HMO 999999999 148.35 237.65 Antithrombin III antigen (clotting inhibitor) activity 37940636_1 CDM 0305 RC 85300 HCPCS inpatient 245 159.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 165.62 67.6 999999999 148.35 237.65 percent of total billed charges Antithrombin III antigen (clotting inhibitor) activity 37940636_1 CDM 0305 RC 85300 HCPCS inpatient 245 159.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 148.35 237.65 Antithrombin III antigen (clotting inhibitor) activity 37940636_1 CDM 0305 RC 85300 HCPCS inpatient 245 159.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 148.35 237.65 Analysis for antibody to aspergillus (fungus) 37940642_1 CDM 0302 RC 86606 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges Analysis for antibody to aspergillus (fungus) 37940642_1 CDM 0302 RC 86606 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges Analysis for antibody to aspergillus (fungus) 37940642_1 CDM 0302 RC 86606 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges Analysis for antibody to aspergillus (fungus) 37940642_1 CDM 0302 RC 86606 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges Analysis for antibody to aspergillus (fungus) 37940642_1 CDM 0302 RC 86606 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges Analysis for antibody to aspergillus (fungus) 37940642_1 CDM 0302 RC 86606 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges Analysis for antibody to aspergillus (fungus) 37940642_1 CDM 0302 RC 86606 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges Analysis for antibody to aspergillus (fungus) 37940642_1 CDM 0302 RC 86606 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges Analysis for antibody to aspergillus (fungus) 37940642_1 CDM 0302 RC 86606 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 Analysis for antibody to aspergillus (fungus) 37940642_1 CDM 0302 RC 86606 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 Analysis for antibody to aspergillus (fungus) 37940642_1 CDM 0302 RC 86606 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 Analysis for antibody to aspergillus (fungus) 37940642_1 CDM 0302 RC 86606 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges Analysis for antibody to aspergillus (fungus) 37940642_1 CDM 0302 RC 86606 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 Analysis for antibody to aspergillus (fungus) 37940642_1 CDM 0302 RC 86606 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 Measurement for Strep antibody (strep throat) 37940644_1 CDM 0302 RC 86060 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges Measurement for Strep antibody (strep throat) 37940644_1 CDM 0302 RC 86060 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges Measurement for Strep antibody (strep throat) 37940644_1 CDM 0302 RC 86060 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges Measurement for Strep antibody (strep throat) 37940644_1 CDM 0302 RC 86060 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges Measurement for Strep antibody (strep throat) 37940644_1 CDM 0302 RC 86060 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges Measurement for Strep antibody (strep throat) 37940644_1 CDM 0302 RC 86060 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges Measurement for Strep antibody (strep throat) 37940644_1 CDM 0302 RC 86060 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges Measurement for Strep antibody (strep throat) 37940644_1 CDM 0302 RC 86060 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges Measurement for Strep antibody (strep throat) 37940644_1 CDM 0302 RC 86060 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 Measurement for Strep antibody (strep throat) 37940644_1 CDM 0302 RC 86060 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 Measurement for Strep antibody (strep throat) 37940644_1 CDM 0302 RC 86060 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 Measurement for Strep antibody (strep throat) 37940644_1 CDM 0302 RC 86060 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges Measurement for Strep antibody (strep throat) 37940644_1 CDM 0302 RC 86060 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 Measurement for Strep antibody (strep throat) 37940644_1 CDM 0302 RC 86060 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 Analysis for antibody to Herpes simplex virus 37940645_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 37940645_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 37940645_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 37940645_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 37940645_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 37940645_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 37940645_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 37940645_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 37940645_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 37940645_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 37940645_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 37940645_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 37940645_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 37940645_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 "Measurement of complement (immune system proteins), antigen," 37940646_1 CDM 0302 RC 86160 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 37940646_1 CDM 0302 RC 86160 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 37940646_1 CDM 0302 RC 86160 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 37940646_1 CDM 0302 RC 86160 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 37940646_1 CDM 0302 RC 86160 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 37940646_1 CDM 0302 RC 86160 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 37940646_1 CDM 0302 RC 86160 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 37940646_1 CDM 0302 RC 86160 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 37940646_1 CDM 0302 RC 86160 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 "Measurement of complement (immune system proteins), antigen," 37940646_1 CDM 0302 RC 86160 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 "Measurement of complement (immune system proteins), antigen," 37940646_1 CDM 0302 RC 86160 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 "Measurement of complement (immune system proteins), antigen," 37940646_1 CDM 0302 RC 86160 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 37940646_1 CDM 0302 RC 86160 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 "Measurement of complement (immune system proteins), antigen," 37940646_1 CDM 0302 RC 86160 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 "Measurement of complement (immune system proteins), antigen," 37940647_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 37940647_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 37940647_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 37940647_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 37940647_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 37940647_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 37940647_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 37940647_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 37940647_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 37940647_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 37940647_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 37940647_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 37940647_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 37940647_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 "Measurement of substance using immunoassay technique, by radioimmunoassay" 37940648_1 CDM 0301 RC 83519 HCPCS inpatient 327 212.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 212.55 65 999999999 198 317.19 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 37940648_1 CDM 0301 RC 83519 HCPCS inpatient 327 212.55 AETNA AETNA 258.33 79 999999999 198 317.19 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 37940648_1 CDM 0301 RC 83519 HCPCS inpatient 327 212.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 225.63 69 999999999 198 317.19 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 37940648_1 CDM 0301 RC 83519 HCPCS inpatient 327 212.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 317.19 97 999999999 198 317.19 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 37940648_1 CDM 0301 RC 83519 HCPCS inpatient 327 212.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.06 78 999999999 198 317.19 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 37940648_1 CDM 0301 RC 83519 HCPCS inpatient 327 212.55 SIHO - ALL PLANS SIHO - ALL PLANS 294.3 90 999999999 198 317.19 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 37940648_1 CDM 0301 RC 83519 HCPCS inpatient 327 212.55 UMR - ALL PLANS UMR - ALL PLANS 228.9 70 999999999 198 317.19 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 37940648_1 CDM 0301 RC 83519 HCPCS inpatient 327 212.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198 60.55 999999999 198 317.19 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 37940648_1 CDM 0301 RC 83519 HCPCS inpatient 327 212.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198 317.19 "Measurement of substance using immunoassay technique, by radioimmunoassay" 37940648_1 CDM 0301 RC 83519 HCPCS inpatient 327 212.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198 317.19 "Measurement of substance using immunoassay technique, by radioimmunoassay" 37940648_1 CDM 0301 RC 83519 HCPCS inpatient 327 212.55 ANTHEM HMO ANTHEM HMO 999999999 198 317.19 "Measurement of substance using immunoassay technique, by radioimmunoassay" 37940648_1 CDM 0301 RC 83519 HCPCS inpatient 327 212.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.05 67.6 999999999 198 317.19 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 37940648_1 CDM 0301 RC 83519 HCPCS inpatient 327 212.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198 317.19 "Measurement of substance using immunoassay technique, by radioimmunoassay" 37940648_1 CDM 0301 RC 83519 HCPCS inpatient 327 212.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 198 317.19 Cardiolipin antibody (tissue antibody) measurement 37940652_1 CDM 0302 RC 86147 HCPCS inpatient 98 63.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.7 65 999999999 59.34 95.06 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940652_1 CDM 0302 RC 86147 HCPCS inpatient 98 63.7 AETNA AETNA 77.42 79 999999999 59.34 95.06 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940652_1 CDM 0302 RC 86147 HCPCS inpatient 98 63.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.62 69 999999999 59.34 95.06 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940652_1 CDM 0302 RC 86147 HCPCS inpatient 98 63.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.06 97 999999999 59.34 95.06 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940652_1 CDM 0302 RC 86147 HCPCS inpatient 98 63.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.44 78 999999999 59.34 95.06 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940652_1 CDM 0302 RC 86147 HCPCS inpatient 98 63.7 SIHO - ALL PLANS SIHO - ALL PLANS 88.2 90 999999999 59.34 95.06 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940652_1 CDM 0302 RC 86147 HCPCS inpatient 98 63.7 UMR - ALL PLANS UMR - ALL PLANS 68.6 70 999999999 59.34 95.06 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940652_1 CDM 0302 RC 86147 HCPCS inpatient 98 63.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.34 60.55 999999999 59.34 95.06 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940652_1 CDM 0302 RC 86147 HCPCS inpatient 98 63.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.34 95.06 Cardiolipin antibody (tissue antibody) measurement 37940652_1 CDM 0302 RC 86147 HCPCS inpatient 98 63.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.34 95.06 Cardiolipin antibody (tissue antibody) measurement 37940652_1 CDM 0302 RC 86147 HCPCS inpatient 98 63.7 ANTHEM HMO ANTHEM HMO 999999999 59.34 95.06 Cardiolipin antibody (tissue antibody) measurement 37940652_1 CDM 0302 RC 86147 HCPCS inpatient 98 63.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.25 67.6 999999999 59.34 95.06 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940652_1 CDM 0302 RC 86147 HCPCS inpatient 98 63.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.34 95.06 Cardiolipin antibody (tissue antibody) measurement 37940652_1 CDM 0302 RC 86147 HCPCS inpatient 98 63.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.34 95.06 Cardiolipin antibody (tissue antibody) measurement 37940653_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940653_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940653_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940653_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940653_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940653_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940653_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940653_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940653_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 37940653_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 37940653_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 37940653_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940653_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 37940653_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 37940654_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940654_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940654_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940654_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940654_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940654_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940654_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940654_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940654_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 37940654_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 37940654_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 37940654_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 37940654_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 37940654_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 Analysis for antibody to Rubeola (measles virus) 37940655_1 CDM 0302 RC 86765 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 37940655_1 CDM 0302 RC 86765 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 37940655_1 CDM 0302 RC 86765 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 37940655_1 CDM 0302 RC 86765 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 37940655_1 CDM 0302 RC 86765 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 37940655_1 CDM 0302 RC 86765 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 37940655_1 CDM 0302 RC 86765 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 37940655_1 CDM 0302 RC 86765 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 37940655_1 CDM 0302 RC 86765 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 Analysis for antibody to Rubeola (measles virus) 37940655_1 CDM 0302 RC 86765 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 Analysis for antibody to Rubeola (measles virus) 37940655_1 CDM 0302 RC 86765 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 Analysis for antibody to Rubeola (measles virus) 37940655_1 CDM 0302 RC 86765 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 37940655_1 CDM 0302 RC 86765 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 Analysis for antibody to Rubeola (measles virus) 37940655_1 CDM 0302 RC 86765 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 Measurement of antibody for rheumatoid arthritis assessment 37940656_1 CDM 0302 RC 86200 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges Measurement of antibody for rheumatoid arthritis assessment 37940656_1 CDM 0302 RC 86200 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges Measurement of antibody for rheumatoid arthritis assessment 37940656_1 CDM 0302 RC 86200 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges Measurement of antibody for rheumatoid arthritis assessment 37940656_1 CDM 0302 RC 86200 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges Measurement of antibody for rheumatoid arthritis assessment 37940656_1 CDM 0302 RC 86200 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges Measurement of antibody for rheumatoid arthritis assessment 37940656_1 CDM 0302 RC 86200 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges Measurement of antibody for rheumatoid arthritis assessment 37940656_1 CDM 0302 RC 86200 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges Measurement of antibody for rheumatoid arthritis assessment 37940656_1 CDM 0302 RC 86200 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges Measurement of antibody for rheumatoid arthritis assessment 37940656_1 CDM 0302 RC 86200 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 Measurement of antibody for rheumatoid arthritis assessment 37940656_1 CDM 0302 RC 86200 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 Measurement of antibody for rheumatoid arthritis assessment 37940656_1 CDM 0302 RC 86200 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 Measurement of antibody for rheumatoid arthritis assessment 37940656_1 CDM 0302 RC 86200 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges Measurement of antibody for rheumatoid arthritis assessment 37940656_1 CDM 0302 RC 86200 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 Measurement of antibody for rheumatoid arthritis assessment 37940656_1 CDM 0302 RC 86200 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 Gammaglobulin (immune system protein) measurement 37940660_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940660_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940660_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940660_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940660_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940660_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940660_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940660_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940660_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 37940660_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 37940660_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 37940660_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940660_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 37940660_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 37940661_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940661_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940661_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940661_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940661_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940661_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940661_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940661_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940661_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 37940661_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 37940661_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 37940661_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940661_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 37940661_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 37940662_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940662_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940662_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940662_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940662_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940662_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940662_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940662_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940662_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 37940662_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 37940662_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 37940662_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 37940662_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 37940662_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Haptoglobin (serum protein) level 37940664_1 CDM 0301 RC 83010 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges Haptoglobin (serum protein) level 37940664_1 CDM 0301 RC 83010 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges Haptoglobin (serum protein) level 37940664_1 CDM 0301 RC 83010 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges Haptoglobin (serum protein) level 37940664_1 CDM 0301 RC 83010 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges Haptoglobin (serum protein) level 37940664_1 CDM 0301 RC 83010 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges Haptoglobin (serum protein) level 37940664_1 CDM 0301 RC 83010 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges Haptoglobin (serum protein) level 37940664_1 CDM 0301 RC 83010 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges Haptoglobin (serum protein) level 37940664_1 CDM 0301 RC 83010 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges Haptoglobin (serum protein) level 37940664_1 CDM 0301 RC 83010 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 Haptoglobin (serum protein) level 37940664_1 CDM 0301 RC 83010 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 Haptoglobin (serum protein) level 37940664_1 CDM 0301 RC 83010 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 Haptoglobin (serum protein) level 37940664_1 CDM 0301 RC 83010 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges Haptoglobin (serum protein) level 37940664_1 CDM 0301 RC 83010 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 Haptoglobin (serum protein) level 37940664_1 CDM 0301 RC 83010 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 "Alpha-1-antitrypsin (protein) blood test, total" 37940665_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 87.1 65 999999999 81.14 129.98 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 37940665_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 AETNA AETNA 105.86 79 999999999 81.14 129.98 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 37940665_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 92.46 69 999999999 81.14 129.98 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 37940665_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.98 97 999999999 81.14 129.98 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 37940665_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 104.52 78 999999999 81.14 129.98 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 37940665_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 SIHO - ALL PLANS SIHO - ALL PLANS 120.6 90 999999999 81.14 129.98 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 37940665_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 UMR - ALL PLANS UMR - ALL PLANS 93.8 70 999999999 81.14 129.98 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 37940665_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 81.14 60.55 999999999 81.14 129.98 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 37940665_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 81.14 129.98 "Alpha-1-antitrypsin (protein) blood test, total" 37940665_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 81.14 129.98 "Alpha-1-antitrypsin (protein) blood test, total" 37940665_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 ANTHEM HMO ANTHEM HMO 999999999 81.14 129.98 "Alpha-1-antitrypsin (protein) blood test, total" 37940665_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 90.58 67.6 999999999 81.14 129.98 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 37940665_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 81.14 129.98 "Alpha-1-antitrypsin (protein) blood test, total" 37940665_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 81.14 129.98 "Antibody identification test, platelet antibodies" 37940666_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges "Antibody identification test, platelet antibodies" 37940666_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges "Antibody identification test, platelet antibodies" 37940666_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges "Antibody identification test, platelet antibodies" 37940666_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges "Antibody identification test, platelet antibodies" 37940666_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges "Antibody identification test, platelet antibodies" 37940666_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges "Antibody identification test, platelet antibodies" 37940666_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges "Antibody identification test, platelet antibodies" 37940666_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges "Antibody identification test, platelet antibodies" 37940666_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 "Antibody identification test, platelet antibodies" 37940666_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 "Antibody identification test, platelet antibodies" 37940666_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 "Antibody identification test, platelet antibodies" 37940666_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges "Antibody identification test, platelet antibodies" 37940666_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 "Antibody identification test, platelet antibodies" 37940666_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 Measurement of antibody to noninfectious agent 37940667_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 37940667_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 37940667_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 37940667_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 37940667_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 37940667_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 37940667_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 37940667_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 37940667_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 37940667_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 37940667_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 37940667_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 37940667_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 37940667_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 37940668_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 37940668_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 37940668_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 37940668_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 37940668_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 37940668_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 37940668_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 37940668_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 37940668_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 37940668_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 37940668_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 37940668_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 37940668_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 37940668_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Ceruloplasmin (protein) level 37940670_1 CDM 0301 RC 82390 HCPCS inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges Ceruloplasmin (protein) level 37940670_1 CDM 0301 RC 82390 HCPCS inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges Ceruloplasmin (protein) level 37940670_1 CDM 0301 RC 82390 HCPCS inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges Ceruloplasmin (protein) level 37940670_1 CDM 0301 RC 82390 HCPCS inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges Ceruloplasmin (protein) level 37940670_1 CDM 0301 RC 82390 HCPCS inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges Ceruloplasmin (protein) level 37940670_1 CDM 0301 RC 82390 HCPCS inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges Ceruloplasmin (protein) level 37940670_1 CDM 0301 RC 82390 HCPCS inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges Ceruloplasmin (protein) level 37940670_1 CDM 0301 RC 82390 HCPCS inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges Ceruloplasmin (protein) level 37940670_1 CDM 0301 RC 82390 HCPCS inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 Ceruloplasmin (protein) level 37940670_1 CDM 0301 RC 82390 HCPCS inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 Ceruloplasmin (protein) level 37940670_1 CDM 0301 RC 82390 HCPCS inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 Ceruloplasmin (protein) level 37940670_1 CDM 0301 RC 82390 HCPCS inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges Ceruloplasmin (protein) level 37940670_1 CDM 0301 RC 82390 HCPCS inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 Ceruloplasmin (protein) level 37940670_1 CDM 0301 RC 82390 HCPCS inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 Analysis for antibody to varicella-zoster virus (chicken pox) 37940672_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 37940672_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 37940672_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 37940672_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 37940672_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 37940672_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 37940672_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 37940672_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 37940672_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 37940672_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 37940672_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 37940672_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 37940672_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 37940672_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 Detection test by immunoassay with direct visual observation for other organism 37940673_1 CDM 0302 RC 87899 HCPCS inpatient 144 93.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 93.6 65 999999999 87.19 139.68 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 37940673_1 CDM 0302 RC 87899 HCPCS inpatient 144 93.6 AETNA AETNA 113.76 79 999999999 87.19 139.68 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 37940673_1 CDM 0302 RC 87899 HCPCS inpatient 144 93.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 99.36 69 999999999 87.19 139.68 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 37940673_1 CDM 0302 RC 87899 HCPCS inpatient 144 93.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 139.68 97 999999999 87.19 139.68 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 37940673_1 CDM 0302 RC 87899 HCPCS inpatient 144 93.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 112.32 78 999999999 87.19 139.68 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 37940673_1 CDM 0302 RC 87899 HCPCS inpatient 144 93.6 SIHO - ALL PLANS SIHO - ALL PLANS 129.6 90 999999999 87.19 139.68 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 37940673_1 CDM 0302 RC 87899 HCPCS inpatient 144 93.6 UMR - ALL PLANS UMR - ALL PLANS 100.8 70 999999999 87.19 139.68 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 37940673_1 CDM 0302 RC 87899 HCPCS inpatient 144 93.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.19 60.55 999999999 87.19 139.68 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 37940673_1 CDM 0302 RC 87899 HCPCS inpatient 144 93.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.19 139.68 Detection test by immunoassay with direct visual observation for other organism 37940673_1 CDM 0302 RC 87899 HCPCS inpatient 144 93.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.19 139.68 Detection test by immunoassay with direct visual observation for other organism 37940673_1 CDM 0302 RC 87899 HCPCS inpatient 144 93.6 ANTHEM HMO ANTHEM HMO 999999999 87.19 139.68 Detection test by immunoassay with direct visual observation for other organism 37940673_1 CDM 0302 RC 87899 HCPCS inpatient 144 93.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 97.34 67.6 999999999 87.19 139.68 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 37940673_1 CDM 0302 RC 87899 HCPCS inpatient 144 93.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.19 139.68 Detection test by immunoassay with direct visual observation for other organism 37940673_1 CDM 0302 RC 87899 HCPCS inpatient 144 93.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.19 139.68 Hepatitis B core antibody measurement 37940676_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 37940676_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 37940676_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 37940676_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 37940676_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 37940676_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 37940676_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 37940676_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 37940676_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 Hepatitis B core antibody measurement 37940676_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 Hepatitis B core antibody measurement 37940676_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 Hepatitis B core antibody measurement 37940676_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges Hepatitis B core antibody measurement 37940676_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 Hepatitis B core antibody measurement 37940676_1 CDM 0301 RC 86704 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 Detection test by immunoassay technique for hepatitis B surface antigen 37940677_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 37940677_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 37940677_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 37940677_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 37940677_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 37940677_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 37940677_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 37940677_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 37940677_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 Detection test by immunoassay technique for hepatitis B surface antigen 37940677_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 Detection test by immunoassay technique for hepatitis B surface antigen 37940677_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 Detection test by immunoassay technique for hepatitis B surface antigen 37940677_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 37940677_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 Detection test by immunoassay technique for hepatitis B surface antigen 37940677_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 Hepatitis B surface antibody measurement 37940678_1 CDM 0302 RC 86706 HCPCS inpatient 128 83.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 83.2 65 999999999 77.5 124.16 percent of total billed charges Hepatitis B surface antibody measurement 37940678_1 CDM 0302 RC 86706 HCPCS inpatient 128 83.2 AETNA AETNA 101.12 79 999999999 77.5 124.16 percent of total billed charges Hepatitis B surface antibody measurement 37940678_1 CDM 0302 RC 86706 HCPCS inpatient 128 83.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 88.32 69 999999999 77.5 124.16 percent of total billed charges Hepatitis B surface antibody measurement 37940678_1 CDM 0302 RC 86706 HCPCS inpatient 128 83.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 124.16 97 999999999 77.5 124.16 percent of total billed charges Hepatitis B surface antibody measurement 37940678_1 CDM 0302 RC 86706 HCPCS inpatient 128 83.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 99.84 78 999999999 77.5 124.16 percent of total billed charges Hepatitis B surface antibody measurement 37940678_1 CDM 0302 RC 86706 HCPCS inpatient 128 83.2 SIHO - ALL PLANS SIHO - ALL PLANS 115.2 90 999999999 77.5 124.16 percent of total billed charges Hepatitis B surface antibody measurement 37940678_1 CDM 0302 RC 86706 HCPCS inpatient 128 83.2 UMR - ALL PLANS UMR - ALL PLANS 89.6 70 999999999 77.5 124.16 percent of total billed charges Hepatitis B surface antibody measurement 37940678_1 CDM 0302 RC 86706 HCPCS inpatient 128 83.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 77.5 60.55 999999999 77.5 124.16 percent of total billed charges Hepatitis B surface antibody measurement 37940678_1 CDM 0302 RC 86706 HCPCS inpatient 128 83.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 77.5 124.16 Hepatitis B surface antibody measurement 37940678_1 CDM 0302 RC 86706 HCPCS inpatient 128 83.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 77.5 124.16 Hepatitis B surface antibody measurement 37940678_1 CDM 0302 RC 86706 HCPCS inpatient 128 83.2 ANTHEM HMO ANTHEM HMO 999999999 77.5 124.16 Hepatitis B surface antibody measurement 37940678_1 CDM 0302 RC 86706 HCPCS inpatient 128 83.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 86.53 67.6 999999999 77.5 124.16 percent of total billed charges Hepatitis B surface antibody measurement 37940678_1 CDM 0302 RC 86706 HCPCS inpatient 128 83.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 77.5 124.16 Hepatitis B surface antibody measurement 37940678_1 CDM 0302 RC 86706 HCPCS inpatient 128 83.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 77.5 124.16 Acute hepatitis panel 37940679_1 CDM 0301 RC 80074 HCPCS inpatient 294 191.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 191.1 65 999999999 178.02 285.18 percent of total billed charges Acute hepatitis panel 37940679_1 CDM 0301 RC 80074 HCPCS inpatient 294 191.1 AETNA AETNA 232.26 79 999999999 178.02 285.18 percent of total billed charges Acute hepatitis panel 37940679_1 CDM 0301 RC 80074 HCPCS inpatient 294 191.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 202.86 69 999999999 178.02 285.18 percent of total billed charges Acute hepatitis panel 37940679_1 CDM 0301 RC 80074 HCPCS inpatient 294 191.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 285.18 97 999999999 178.02 285.18 percent of total billed charges Acute hepatitis panel 37940679_1 CDM 0301 RC 80074 HCPCS inpatient 294 191.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 229.32 78 999999999 178.02 285.18 percent of total billed charges Acute hepatitis panel 37940679_1 CDM 0301 RC 80074 HCPCS inpatient 294 191.1 SIHO - ALL PLANS SIHO - ALL PLANS 264.6 90 999999999 178.02 285.18 percent of total billed charges Acute hepatitis panel 37940679_1 CDM 0301 RC 80074 HCPCS inpatient 294 191.1 UMR - ALL PLANS UMR - ALL PLANS 205.8 70 999999999 178.02 285.18 percent of total billed charges Acute hepatitis panel 37940679_1 CDM 0301 RC 80074 HCPCS inpatient 294 191.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 178.02 60.55 999999999 178.02 285.18 percent of total billed charges Acute hepatitis panel 37940679_1 CDM 0301 RC 80074 HCPCS inpatient 294 191.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 178.02 285.18 Acute hepatitis panel 37940679_1 CDM 0301 RC 80074 HCPCS inpatient 294 191.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 178.02 285.18 Acute hepatitis panel 37940679_1 CDM 0301 RC 80074 HCPCS inpatient 294 191.1 ANTHEM HMO ANTHEM HMO 999999999 178.02 285.18 Acute hepatitis panel 37940679_1 CDM 0301 RC 80074 HCPCS inpatient 294 191.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 198.74 67.6 999999999 178.02 285.18 percent of total billed charges Acute hepatitis panel 37940679_1 CDM 0301 RC 80074 HCPCS inpatient 294 191.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 178.02 285.18 Acute hepatitis panel 37940679_1 CDM 0301 RC 80074 HCPCS inpatient 294 191.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 178.02 285.18 Hepatitis C antibody measurement 37940681_1 CDM 0302 RC 86803 HCPCS inpatient 98 63.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.7 65 999999999 59.34 95.06 percent of total billed charges Hepatitis C antibody measurement 37940681_1 CDM 0302 RC 86803 HCPCS inpatient 98 63.7 AETNA AETNA 77.42 79 999999999 59.34 95.06 percent of total billed charges Hepatitis C antibody measurement 37940681_1 CDM 0302 RC 86803 HCPCS inpatient 98 63.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.62 69 999999999 59.34 95.06 percent of total billed charges Hepatitis C antibody measurement 37940681_1 CDM 0302 RC 86803 HCPCS inpatient 98 63.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.06 97 999999999 59.34 95.06 percent of total billed charges Hepatitis C antibody measurement 37940681_1 CDM 0302 RC 86803 HCPCS inpatient 98 63.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.44 78 999999999 59.34 95.06 percent of total billed charges Hepatitis C antibody measurement 37940681_1 CDM 0302 RC 86803 HCPCS inpatient 98 63.7 SIHO - ALL PLANS SIHO - ALL PLANS 88.2 90 999999999 59.34 95.06 percent of total billed charges Hepatitis C antibody measurement 37940681_1 CDM 0302 RC 86803 HCPCS inpatient 98 63.7 UMR - ALL PLANS UMR - ALL PLANS 68.6 70 999999999 59.34 95.06 percent of total billed charges Hepatitis C antibody measurement 37940681_1 CDM 0302 RC 86803 HCPCS inpatient 98 63.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.34 60.55 999999999 59.34 95.06 percent of total billed charges Hepatitis C antibody measurement 37940681_1 CDM 0302 RC 86803 HCPCS inpatient 98 63.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.34 95.06 Hepatitis C antibody measurement 37940681_1 CDM 0302 RC 86803 HCPCS inpatient 98 63.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.34 95.06 Hepatitis C antibody measurement 37940681_1 CDM 0302 RC 86803 HCPCS inpatient 98 63.7 ANTHEM HMO ANTHEM HMO 999999999 59.34 95.06 Hepatitis C antibody measurement 37940681_1 CDM 0302 RC 86803 HCPCS inpatient 98 63.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.25 67.6 999999999 59.34 95.06 percent of total billed charges Hepatitis C antibody measurement 37940681_1 CDM 0302 RC 86803 HCPCS inpatient 98 63.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.34 95.06 Hepatitis C antibody measurement 37940681_1 CDM 0302 RC 86803 HCPCS inpatient 98 63.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.34 95.06 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940682_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940682_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940682_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940682_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940682_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940682_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940682_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940682_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940682_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940682_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940682_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940682_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940682_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940682_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940683_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940683_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940683_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940683_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940683_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940683_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940683_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940683_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940683_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940683_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940683_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940683_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940683_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 37940683_1 CDM 0302 RC 86618 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 37940684_1 CDM 0306 RC 86617 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 37940684_1 CDM 0306 RC 86617 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 37940684_1 CDM 0306 RC 86617 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 37940684_1 CDM 0306 RC 86617 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 37940684_1 CDM 0306 RC 86617 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 37940684_1 CDM 0306 RC 86617 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 37940684_1 CDM 0306 RC 86617 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 37940684_1 CDM 0306 RC 86617 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 37940684_1 CDM 0306 RC 86617 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 37940684_1 CDM 0306 RC 86617 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 37940684_1 CDM 0306 RC 86617 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 37940684_1 CDM 0306 RC 86617 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 37940684_1 CDM 0306 RC 86617 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 37940684_1 CDM 0306 RC 86617 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 Analysis for antibody to mumps virus 37940687_1 CDM 0302 RC 86735 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 37940687_1 CDM 0302 RC 86735 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 37940687_1 CDM 0302 RC 86735 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 37940687_1 CDM 0302 RC 86735 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 37940687_1 CDM 0302 RC 86735 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 37940687_1 CDM 0302 RC 86735 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 37940687_1 CDM 0302 RC 86735 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 37940687_1 CDM 0302 RC 86735 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 37940687_1 CDM 0302 RC 86735 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 Analysis for antibody to mumps virus 37940687_1 CDM 0302 RC 86735 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 Analysis for antibody to mumps virus 37940687_1 CDM 0302 RC 86735 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 Analysis for antibody to mumps virus 37940687_1 CDM 0302 RC 86735 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 37940687_1 CDM 0302 RC 86735 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 Analysis for antibody to mumps virus 37940687_1 CDM 0302 RC 86735 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 37940692_1 CDM 0306 RC 87385 HCPCS inpatient 386 250.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 250.9 65 999999999 233.72 374.42 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 37940692_1 CDM 0306 RC 87385 HCPCS inpatient 386 250.9 AETNA AETNA 304.94 79 999999999 233.72 374.42 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 37940692_1 CDM 0306 RC 87385 HCPCS inpatient 386 250.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 266.34 69 999999999 233.72 374.42 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 37940692_1 CDM 0306 RC 87385 HCPCS inpatient 386 250.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 374.42 97 999999999 233.72 374.42 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 37940692_1 CDM 0306 RC 87385 HCPCS inpatient 386 250.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.08 78 999999999 233.72 374.42 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 37940692_1 CDM 0306 RC 87385 HCPCS inpatient 386 250.9 SIHO - ALL PLANS SIHO - ALL PLANS 347.4 90 999999999 233.72 374.42 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 37940692_1 CDM 0306 RC 87385 HCPCS inpatient 386 250.9 UMR - ALL PLANS UMR - ALL PLANS 270.2 70 999999999 233.72 374.42 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 37940692_1 CDM 0306 RC 87385 HCPCS inpatient 386 250.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 233.72 60.55 999999999 233.72 374.42 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 37940692_1 CDM 0306 RC 87385 HCPCS inpatient 386 250.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 233.72 374.42 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 37940692_1 CDM 0306 RC 87385 HCPCS inpatient 386 250.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 233.72 374.42 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 37940692_1 CDM 0306 RC 87385 HCPCS inpatient 386 250.9 ANTHEM HMO ANTHEM HMO 999999999 233.72 374.42 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 37940692_1 CDM 0306 RC 87385 HCPCS inpatient 386 250.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 260.94 67.6 999999999 233.72 374.42 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 37940692_1 CDM 0306 RC 87385 HCPCS inpatient 386 250.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 233.72 374.42 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 37940692_1 CDM 0306 RC 87385 HCPCS inpatient 386 250.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 233.72 374.42 Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 37948766_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 37948766_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 37948766_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 37948766_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 37948766_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 37948766_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 37948766_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 37948766_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 37948766_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 37948766_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 37948766_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 37948766_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 37948766_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 37948766_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 Screening test for antibody to noninfectious agent 37968025_1 CDM 0302 RC 86255 HCPCS inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges Screening test for antibody to noninfectious agent 37968025_1 CDM 0302 RC 86255 HCPCS inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges Screening test for antibody to noninfectious agent 37968025_1 CDM 0302 RC 86255 HCPCS inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges Screening test for antibody to noninfectious agent 37968025_1 CDM 0302 RC 86255 HCPCS inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges Screening test for antibody to noninfectious agent 37968025_1 CDM 0302 RC 86255 HCPCS inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges Screening test for antibody to noninfectious agent 37968025_1 CDM 0302 RC 86255 HCPCS inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges Screening test for antibody to noninfectious agent 37968025_1 CDM 0302 RC 86255 HCPCS inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges Screening test for antibody to noninfectious agent 37968025_1 CDM 0302 RC 86255 HCPCS inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges Screening test for antibody to noninfectious agent 37968025_1 CDM 0302 RC 86255 HCPCS inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 Screening test for antibody to noninfectious agent 37968025_1 CDM 0302 RC 86255 HCPCS inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 Screening test for antibody to noninfectious agent 37968025_1 CDM 0302 RC 86255 HCPCS inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 Screening test for antibody to noninfectious agent 37968025_1 CDM 0302 RC 86255 HCPCS inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges Screening test for antibody to noninfectious agent 37968025_1 CDM 0302 RC 86255 HCPCS inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 Screening test for antibody to noninfectious agent 37968025_1 CDM 0302 RC 86255 HCPCS inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 Screening test for autoimmune disorder 37977622_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977622_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977622_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977622_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977622_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977622_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977622_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977622_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977622_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 Screening test for autoimmune disorder 37977622_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 Screening test for autoimmune disorder 37977622_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 Screening test for autoimmune disorder 37977622_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977622_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 Screening test for autoimmune disorder 37977622_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 "Measurement of DNA antibody, native or double stranded" 37977623_1 CDM 0300 RC 86225 HCPCS inpatient 257 167.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.05 65 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 37977623_1 CDM 0300 RC 86225 HCPCS inpatient 257 167.05 AETNA AETNA 203.03 79 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 37977623_1 CDM 0300 RC 86225 HCPCS inpatient 257 167.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 177.33 69 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 37977623_1 CDM 0300 RC 86225 HCPCS inpatient 257 167.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 249.29 97 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 37977623_1 CDM 0300 RC 86225 HCPCS inpatient 257 167.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 200.46 78 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 37977623_1 CDM 0300 RC 86225 HCPCS inpatient 257 167.05 SIHO - ALL PLANS SIHO - ALL PLANS 231.3 90 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 37977623_1 CDM 0300 RC 86225 HCPCS inpatient 257 167.05 UMR - ALL PLANS UMR - ALL PLANS 179.9 70 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 37977623_1 CDM 0300 RC 86225 HCPCS inpatient 257 167.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.61 60.55 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 37977623_1 CDM 0300 RC 86225 HCPCS inpatient 257 167.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.61 249.29 "Measurement of DNA antibody, native or double stranded" 37977623_1 CDM 0300 RC 86225 HCPCS inpatient 257 167.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.61 249.29 "Measurement of DNA antibody, native or double stranded" 37977623_1 CDM 0300 RC 86225 HCPCS inpatient 257 167.05 ANTHEM HMO ANTHEM HMO 999999999 155.61 249.29 "Measurement of DNA antibody, native or double stranded" 37977623_1 CDM 0300 RC 86225 HCPCS inpatient 257 167.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.73 67.6 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 37977623_1 CDM 0300 RC 86225 HCPCS inpatient 257 167.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.61 249.29 "Measurement of DNA antibody, native or double stranded" 37977623_1 CDM 0300 RC 86225 HCPCS inpatient 257 167.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.61 249.29 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977624_1 CDM 0302 RC 86235 HCPCS inpatient 74 48.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.1 65 999999999 44.81 71.78 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977624_1 CDM 0302 RC 86235 HCPCS inpatient 74 48.1 AETNA AETNA 58.46 79 999999999 44.81 71.78 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977624_1 CDM 0302 RC 86235 HCPCS inpatient 74 48.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.06 69 999999999 44.81 71.78 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977624_1 CDM 0302 RC 86235 HCPCS inpatient 74 48.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 71.78 97 999999999 44.81 71.78 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977624_1 CDM 0302 RC 86235 HCPCS inpatient 74 48.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 57.72 78 999999999 44.81 71.78 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977624_1 CDM 0302 RC 86235 HCPCS inpatient 74 48.1 SIHO - ALL PLANS SIHO - ALL PLANS 66.6 90 999999999 44.81 71.78 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977624_1 CDM 0302 RC 86235 HCPCS inpatient 74 48.1 UMR - ALL PLANS UMR - ALL PLANS 51.8 70 999999999 44.81 71.78 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977624_1 CDM 0302 RC 86235 HCPCS inpatient 74 48.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.81 60.55 999999999 44.81 71.78 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977624_1 CDM 0302 RC 86235 HCPCS inpatient 74 48.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.81 71.78 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977624_1 CDM 0302 RC 86235 HCPCS inpatient 74 48.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.81 71.78 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977624_1 CDM 0302 RC 86235 HCPCS inpatient 74 48.1 ANTHEM HMO ANTHEM HMO 999999999 44.81 71.78 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977624_1 CDM 0302 RC 86235 HCPCS inpatient 74 48.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.02 67.6 999999999 44.81 71.78 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977624_1 CDM 0302 RC 86235 HCPCS inpatient 74 48.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.81 71.78 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977624_1 CDM 0302 RC 86235 HCPCS inpatient 74 48.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.81 71.78 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977654_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977654_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977654_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977654_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977654_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977654_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977654_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977654_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977654_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977654_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977654_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977654_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977654_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977654_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977657_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977657_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977657_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977657_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977657_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977657_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977657_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977657_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977657_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977657_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977657_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977657_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977657_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977657_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977660_1 CDM 0301 RC 86235 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977660_1 CDM 0301 RC 86235 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977660_1 CDM 0301 RC 86235 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977660_1 CDM 0301 RC 86235 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977660_1 CDM 0301 RC 86235 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977660_1 CDM 0301 RC 86235 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977660_1 CDM 0301 RC 86235 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977660_1 CDM 0301 RC 86235 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977660_1 CDM 0301 RC 86235 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977660_1 CDM 0301 RC 86235 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977660_1 CDM 0301 RC 86235 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977660_1 CDM 0301 RC 86235 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977660_1 CDM 0301 RC 86235 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977660_1 CDM 0301 RC 86235 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977661_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977661_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977661_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977661_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977661_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977661_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977661_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977661_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977661_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977661_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977661_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977661_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 37977661_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 "Measurement of antibody for assessment of autoimmune disorder, any method" 37977661_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 Screening test for autoimmune disorder 37977666_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977666_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977666_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977666_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977666_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977666_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977666_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977666_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977666_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 Screening test for autoimmune disorder 37977666_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 Screening test for autoimmune disorder 37977666_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 Screening test for autoimmune disorder 37977666_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977666_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 Screening test for autoimmune disorder 37977666_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 Screening test for autoimmune disorder 37977670_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977670_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977670_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977670_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977670_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977670_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977670_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977670_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977670_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 Screening test for autoimmune disorder 37977670_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 Screening test for autoimmune disorder 37977670_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 Screening test for autoimmune disorder 37977670_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges Screening test for autoimmune disorder 37977670_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 Screening test for autoimmune disorder 37977670_1 CDM 0302 RC 86038 HCPCS inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 37977672_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 37977672_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 37977672_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 37977672_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 37977672_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 37977672_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 37977672_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 37977672_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 37977672_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 37977672_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 37977672_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 37977672_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 37977672_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 37977672_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977673_1 CDM 0301 RC 86663 HCPCS inpatient 156 101.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.4 65 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977673_1 CDM 0301 RC 86663 HCPCS inpatient 156 101.4 AETNA AETNA 123.24 79 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977673_1 CDM 0301 RC 86663 HCPCS inpatient 156 101.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.64 69 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977673_1 CDM 0301 RC 86663 HCPCS inpatient 156 101.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 151.32 97 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977673_1 CDM 0301 RC 86663 HCPCS inpatient 156 101.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.68 78 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977673_1 CDM 0301 RC 86663 HCPCS inpatient 156 101.4 SIHO - ALL PLANS SIHO - ALL PLANS 140.4 90 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977673_1 CDM 0301 RC 86663 HCPCS inpatient 156 101.4 UMR - ALL PLANS UMR - ALL PLANS 109.2 70 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977673_1 CDM 0301 RC 86663 HCPCS inpatient 156 101.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.46 60.55 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977673_1 CDM 0301 RC 86663 HCPCS inpatient 156 101.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977673_1 CDM 0301 RC 86663 HCPCS inpatient 156 101.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977673_1 CDM 0301 RC 86663 HCPCS inpatient 156 101.4 ANTHEM HMO ANTHEM HMO 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977673_1 CDM 0301 RC 86663 HCPCS inpatient 156 101.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.46 67.6 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977673_1 CDM 0301 RC 86663 HCPCS inpatient 156 101.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977673_1 CDM 0301 RC 86663 HCPCS inpatient 156 101.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977674_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.4 65 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977674_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 AETNA AETNA 123.24 79 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977674_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.64 69 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977674_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 151.32 97 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977674_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.68 78 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977674_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 SIHO - ALL PLANS SIHO - ALL PLANS 140.4 90 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977674_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 UMR - ALL PLANS UMR - ALL PLANS 109.2 70 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977674_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.46 60.55 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977674_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977674_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977674_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 ANTHEM HMO ANTHEM HMO 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977674_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.46 67.6 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977674_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 37977674_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977675_1 CDM 0302 RC 86665 HCPCS inpatient 177 115.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.05 65 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977675_1 CDM 0302 RC 86665 HCPCS inpatient 177 115.05 AETNA AETNA 139.83 79 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977675_1 CDM 0302 RC 86665 HCPCS inpatient 177 115.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.13 69 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977675_1 CDM 0302 RC 86665 HCPCS inpatient 177 115.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 171.69 97 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977675_1 CDM 0302 RC 86665 HCPCS inpatient 177 115.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.06 78 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977675_1 CDM 0302 RC 86665 HCPCS inpatient 177 115.05 SIHO - ALL PLANS SIHO - ALL PLANS 159.3 90 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977675_1 CDM 0302 RC 86665 HCPCS inpatient 177 115.05 UMR - ALL PLANS UMR - ALL PLANS 123.9 70 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977675_1 CDM 0302 RC 86665 HCPCS inpatient 177 115.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.17 60.55 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977675_1 CDM 0302 RC 86665 HCPCS inpatient 177 115.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977675_1 CDM 0302 RC 86665 HCPCS inpatient 177 115.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977675_1 CDM 0302 RC 86665 HCPCS inpatient 177 115.05 ANTHEM HMO ANTHEM HMO 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977675_1 CDM 0302 RC 86665 HCPCS inpatient 177 115.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 119.65 67.6 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977675_1 CDM 0302 RC 86665 HCPCS inpatient 177 115.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977675_1 CDM 0302 RC 86665 HCPCS inpatient 177 115.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977676_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 104.65 65 999999999 97.49 156.17 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977676_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 AETNA AETNA 127.19 79 999999999 97.49 156.17 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977676_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 111.09 69 999999999 97.49 156.17 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977676_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 156.17 97 999999999 97.49 156.17 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977676_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 125.58 78 999999999 97.49 156.17 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977676_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 SIHO - ALL PLANS SIHO - ALL PLANS 144.9 90 999999999 97.49 156.17 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977676_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 UMR - ALL PLANS UMR - ALL PLANS 112.7 70 999999999 97.49 156.17 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977676_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 97.49 60.55 999999999 97.49 156.17 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977676_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 97.49 156.17 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977676_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 97.49 156.17 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977676_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 ANTHEM HMO ANTHEM HMO 999999999 97.49 156.17 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977676_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 97.49 156.17 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977676_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.84 67.6 999999999 97.49 156.17 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37977676_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 97.49 156.17 Angiotensin l - converting enzyme (ACE) level 37977678_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.95 65 999999999 110.81 177.51 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 37977678_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 AETNA AETNA 144.57 79 999999999 110.81 177.51 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 37977678_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.27 69 999999999 110.81 177.51 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 37977678_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.51 97 999999999 110.81 177.51 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 37977678_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 142.74 78 999999999 110.81 177.51 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 37977678_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 SIHO - ALL PLANS SIHO - ALL PLANS 164.7 90 999999999 110.81 177.51 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 37977678_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 UMR - ALL PLANS UMR - ALL PLANS 128.1 70 999999999 110.81 177.51 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 37977678_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.81 60.55 999999999 110.81 177.51 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 37977678_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.81 177.51 Angiotensin l - converting enzyme (ACE) level 37977678_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.81 177.51 Angiotensin l - converting enzyme (ACE) level 37977678_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 ANTHEM HMO ANTHEM HMO 999999999 110.81 177.51 Angiotensin l - converting enzyme (ACE) level 37977678_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.81 177.51 Angiotensin l - converting enzyme (ACE) level 37977678_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.71 67.6 999999999 110.81 177.51 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 37977678_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.81 177.51 Beta-2 microglobulin (protein) level 37977682_1 CDM 0301 RC 82232 HCPCS inpatient 172 111.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.8 65 999999999 104.15 166.84 percent of total billed charges Beta-2 microglobulin (protein) level 37977682_1 CDM 0301 RC 82232 HCPCS inpatient 172 111.8 AETNA AETNA 135.88 79 999999999 104.15 166.84 percent of total billed charges Beta-2 microglobulin (protein) level 37977682_1 CDM 0301 RC 82232 HCPCS inpatient 172 111.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 118.68 69 999999999 104.15 166.84 percent of total billed charges Beta-2 microglobulin (protein) level 37977682_1 CDM 0301 RC 82232 HCPCS inpatient 172 111.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 166.84 97 999999999 104.15 166.84 percent of total billed charges Beta-2 microglobulin (protein) level 37977682_1 CDM 0301 RC 82232 HCPCS inpatient 172 111.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.16 78 999999999 104.15 166.84 percent of total billed charges Beta-2 microglobulin (protein) level 37977682_1 CDM 0301 RC 82232 HCPCS inpatient 172 111.8 SIHO - ALL PLANS SIHO - ALL PLANS 154.8 90 999999999 104.15 166.84 percent of total billed charges Beta-2 microglobulin (protein) level 37977682_1 CDM 0301 RC 82232 HCPCS inpatient 172 111.8 UMR - ALL PLANS UMR - ALL PLANS 120.4 70 999999999 104.15 166.84 percent of total billed charges Beta-2 microglobulin (protein) level 37977682_1 CDM 0301 RC 82232 HCPCS inpatient 172 111.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.15 60.55 999999999 104.15 166.84 percent of total billed charges Beta-2 microglobulin (protein) level 37977682_1 CDM 0301 RC 82232 HCPCS inpatient 172 111.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.15 166.84 Beta-2 microglobulin (protein) level 37977682_1 CDM 0301 RC 82232 HCPCS inpatient 172 111.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.15 166.84 Beta-2 microglobulin (protein) level 37977682_1 CDM 0301 RC 82232 HCPCS inpatient 172 111.8 ANTHEM HMO ANTHEM HMO 999999999 104.15 166.84 Beta-2 microglobulin (protein) level 37977682_1 CDM 0301 RC 82232 HCPCS inpatient 172 111.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.15 166.84 Beta-2 microglobulin (protein) level 37977682_1 CDM 0301 RC 82232 HCPCS inpatient 172 111.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.27 67.6 999999999 104.15 166.84 percent of total billed charges Beta-2 microglobulin (protein) level 37977682_1 CDM 0301 RC 82232 HCPCS inpatient 172 111.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.15 166.84 "Thyroid hormone, T3 measurement, free" 37977683_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 183.95 65 999999999 171.36 274.51 percent of total billed charges "Thyroid hormone, T3 measurement, free" 37977683_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 AETNA AETNA 223.57 79 999999999 171.36 274.51 percent of total billed charges "Thyroid hormone, T3 measurement, free" 37977683_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 195.27 69 999999999 171.36 274.51 percent of total billed charges "Thyroid hormone, T3 measurement, free" 37977683_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 274.51 97 999999999 171.36 274.51 percent of total billed charges "Thyroid hormone, T3 measurement, free" 37977683_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 220.74 78 999999999 171.36 274.51 percent of total billed charges "Thyroid hormone, T3 measurement, free" 37977683_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 SIHO - ALL PLANS SIHO - ALL PLANS 254.7 90 999999999 171.36 274.51 percent of total billed charges "Thyroid hormone, T3 measurement, free" 37977683_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 UMR - ALL PLANS UMR - ALL PLANS 198.1 70 999999999 171.36 274.51 percent of total billed charges "Thyroid hormone, T3 measurement, free" 37977683_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 171.36 60.55 999999999 171.36 274.51 percent of total billed charges "Thyroid hormone, T3 measurement, free" 37977683_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 171.36 274.51 "Thyroid hormone, T3 measurement, free" 37977683_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 171.36 274.51 "Thyroid hormone, T3 measurement, free" 37977683_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 ANTHEM HMO ANTHEM HMO 999999999 171.36 274.51 "Thyroid hormone, T3 measurement, free" 37977683_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 171.36 274.51 "Thyroid hormone, T3 measurement, free" 37977683_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 191.31 67.6 999999999 171.36 274.51 percent of total billed charges "Thyroid hormone, T3 measurement, free" 37977683_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 171.36 274.51 Microsomal antibodies (autoantibody) measurement 37977814_1 CDM 0302 RC 86376 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges Microsomal antibodies (autoantibody) measurement 37977814_1 CDM 0302 RC 86376 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges Microsomal antibodies (autoantibody) measurement 37977814_1 CDM 0302 RC 86376 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges Microsomal antibodies (autoantibody) measurement 37977814_1 CDM 0302 RC 86376 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges Microsomal antibodies (autoantibody) measurement 37977814_1 CDM 0302 RC 86376 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges Microsomal antibodies (autoantibody) measurement 37977814_1 CDM 0302 RC 86376 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges Microsomal antibodies (autoantibody) measurement 37977814_1 CDM 0302 RC 86376 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges Microsomal antibodies (autoantibody) measurement 37977814_1 CDM 0302 RC 86376 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges Microsomal antibodies (autoantibody) measurement 37977814_1 CDM 0302 RC 86376 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 Microsomal antibodies (autoantibody) measurement 37977814_1 CDM 0302 RC 86376 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 Microsomal antibodies (autoantibody) measurement 37977814_1 CDM 0302 RC 86376 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 Microsomal antibodies (autoantibody) measurement 37977814_1 CDM 0302 RC 86376 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 Microsomal antibodies (autoantibody) measurement 37977814_1 CDM 0302 RC 86376 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges Microsomal antibodies (autoantibody) measurement 37977814_1 CDM 0302 RC 86376 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 Thyroglobulin (thyroid protein) antibody measurement 37977815_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 93.6 65 999999999 87.19 139.68 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 37977815_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 AETNA AETNA 113.76 79 999999999 87.19 139.68 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 37977815_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 99.36 69 999999999 87.19 139.68 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 37977815_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 139.68 97 999999999 87.19 139.68 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 37977815_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 112.32 78 999999999 87.19 139.68 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 37977815_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 SIHO - ALL PLANS SIHO - ALL PLANS 129.6 90 999999999 87.19 139.68 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 37977815_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 UMR - ALL PLANS UMR - ALL PLANS 100.8 70 999999999 87.19 139.68 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 37977815_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.19 60.55 999999999 87.19 139.68 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 37977815_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.19 139.68 Thyroglobulin (thyroid protein) antibody measurement 37977815_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.19 139.68 Thyroglobulin (thyroid protein) antibody measurement 37977815_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 ANTHEM HMO ANTHEM HMO 999999999 87.19 139.68 Thyroglobulin (thyroid protein) antibody measurement 37977815_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.19 139.68 Thyroglobulin (thyroid protein) antibody measurement 37977815_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 97.34 67.6 999999999 87.19 139.68 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 37977815_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.19 139.68 Adrenocorticotropic hormone (ACTH) level 37977816_1 CDM 0301 RC 82024 HCPCS inpatient 266 172.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 172.9 65 999999999 161.06 258.02 percent of total billed charges Adrenocorticotropic hormone (ACTH) level 37977816_1 CDM 0301 RC 82024 HCPCS inpatient 266 172.9 AETNA AETNA 210.14 79 999999999 161.06 258.02 percent of total billed charges Adrenocorticotropic hormone (ACTH) level 37977816_1 CDM 0301 RC 82024 HCPCS inpatient 266 172.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 183.54 69 999999999 161.06 258.02 percent of total billed charges Adrenocorticotropic hormone (ACTH) level 37977816_1 CDM 0301 RC 82024 HCPCS inpatient 266 172.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 258.02 97 999999999 161.06 258.02 percent of total billed charges Adrenocorticotropic hormone (ACTH) level 37977816_1 CDM 0301 RC 82024 HCPCS inpatient 266 172.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 207.48 78 999999999 161.06 258.02 percent of total billed charges Adrenocorticotropic hormone (ACTH) level 37977816_1 CDM 0301 RC 82024 HCPCS inpatient 266 172.9 SIHO - ALL PLANS SIHO - ALL PLANS 239.4 90 999999999 161.06 258.02 percent of total billed charges Adrenocorticotropic hormone (ACTH) level 37977816_1 CDM 0301 RC 82024 HCPCS inpatient 266 172.9 UMR - ALL PLANS UMR - ALL PLANS 186.2 70 999999999 161.06 258.02 percent of total billed charges Adrenocorticotropic hormone (ACTH) level 37977816_1 CDM 0301 RC 82024 HCPCS inpatient 266 172.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 161.06 60.55 999999999 161.06 258.02 percent of total billed charges Adrenocorticotropic hormone (ACTH) level 37977816_1 CDM 0301 RC 82024 HCPCS inpatient 266 172.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 161.06 258.02 Adrenocorticotropic hormone (ACTH) level 37977816_1 CDM 0301 RC 82024 HCPCS inpatient 266 172.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 161.06 258.02 Adrenocorticotropic hormone (ACTH) level 37977816_1 CDM 0301 RC 82024 HCPCS inpatient 266 172.9 ANTHEM HMO ANTHEM HMO 999999999 161.06 258.02 Adrenocorticotropic hormone (ACTH) level 37977816_1 CDM 0301 RC 82024 HCPCS inpatient 266 172.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 161.06 258.02 Adrenocorticotropic hormone (ACTH) level 37977816_1 CDM 0301 RC 82024 HCPCS inpatient 266 172.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 179.82 67.6 999999999 161.06 258.02 percent of total billed charges Adrenocorticotropic hormone (ACTH) level 37977816_1 CDM 0301 RC 82024 HCPCS inpatient 266 172.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 161.06 258.02 Erythropoietin (protein) level 37977818_1 CDM 0301 RC 82668 HCPCS inpatient 156 101.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.4 65 999999999 94.46 151.32 percent of total billed charges Erythropoietin (protein) level 37977818_1 CDM 0301 RC 82668 HCPCS inpatient 156 101.4 AETNA AETNA 123.24 79 999999999 94.46 151.32 percent of total billed charges Erythropoietin (protein) level 37977818_1 CDM 0301 RC 82668 HCPCS inpatient 156 101.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.64 69 999999999 94.46 151.32 percent of total billed charges Erythropoietin (protein) level 37977818_1 CDM 0301 RC 82668 HCPCS inpatient 156 101.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 151.32 97 999999999 94.46 151.32 percent of total billed charges Erythropoietin (protein) level 37977818_1 CDM 0301 RC 82668 HCPCS inpatient 156 101.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.68 78 999999999 94.46 151.32 percent of total billed charges Erythropoietin (protein) level 37977818_1 CDM 0301 RC 82668 HCPCS inpatient 156 101.4 SIHO - ALL PLANS SIHO - ALL PLANS 140.4 90 999999999 94.46 151.32 percent of total billed charges Erythropoietin (protein) level 37977818_1 CDM 0301 RC 82668 HCPCS inpatient 156 101.4 UMR - ALL PLANS UMR - ALL PLANS 109.2 70 999999999 94.46 151.32 percent of total billed charges Erythropoietin (protein) level 37977818_1 CDM 0301 RC 82668 HCPCS inpatient 156 101.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.46 60.55 999999999 94.46 151.32 percent of total billed charges Erythropoietin (protein) level 37977818_1 CDM 0301 RC 82668 HCPCS inpatient 156 101.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.46 151.32 Erythropoietin (protein) level 37977818_1 CDM 0301 RC 82668 HCPCS inpatient 156 101.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.46 151.32 Erythropoietin (protein) level 37977818_1 CDM 0301 RC 82668 HCPCS inpatient 156 101.4 ANTHEM HMO ANTHEM HMO 999999999 94.46 151.32 Erythropoietin (protein) level 37977818_1 CDM 0301 RC 82668 HCPCS inpatient 156 101.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.46 151.32 Erythropoietin (protein) level 37977818_1 CDM 0301 RC 82668 HCPCS inpatient 156 101.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.46 67.6 999999999 94.46 151.32 percent of total billed charges Erythropoietin (protein) level 37977818_1 CDM 0301 RC 82668 HCPCS inpatient 156 101.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.46 151.32 Gastrin (GI tract hormone) level 37977819_1 CDM 0301 RC 82941 HCPCS inpatient 296 192.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 192.4 65 999999999 179.23 287.12 percent of total billed charges Gastrin (GI tract hormone) level 37977819_1 CDM 0301 RC 82941 HCPCS inpatient 296 192.4 AETNA AETNA 233.84 79 999999999 179.23 287.12 percent of total billed charges Gastrin (GI tract hormone) level 37977819_1 CDM 0301 RC 82941 HCPCS inpatient 296 192.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 204.24 69 999999999 179.23 287.12 percent of total billed charges Gastrin (GI tract hormone) level 37977819_1 CDM 0301 RC 82941 HCPCS inpatient 296 192.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 287.12 97 999999999 179.23 287.12 percent of total billed charges Gastrin (GI tract hormone) level 37977819_1 CDM 0301 RC 82941 HCPCS inpatient 296 192.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 230.88 78 999999999 179.23 287.12 percent of total billed charges Gastrin (GI tract hormone) level 37977819_1 CDM 0301 RC 82941 HCPCS inpatient 296 192.4 SIHO - ALL PLANS SIHO - ALL PLANS 266.4 90 999999999 179.23 287.12 percent of total billed charges Gastrin (GI tract hormone) level 37977819_1 CDM 0301 RC 82941 HCPCS inpatient 296 192.4 UMR - ALL PLANS UMR - ALL PLANS 207.2 70 999999999 179.23 287.12 percent of total billed charges Gastrin (GI tract hormone) level 37977819_1 CDM 0301 RC 82941 HCPCS inpatient 296 192.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 179.23 60.55 999999999 179.23 287.12 percent of total billed charges Gastrin (GI tract hormone) level 37977819_1 CDM 0301 RC 82941 HCPCS inpatient 296 192.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 179.23 287.12 Gastrin (GI tract hormone) level 37977819_1 CDM 0301 RC 82941 HCPCS inpatient 296 192.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 179.23 287.12 Gastrin (GI tract hormone) level 37977819_1 CDM 0301 RC 82941 HCPCS inpatient 296 192.4 ANTHEM HMO ANTHEM HMO 999999999 179.23 287.12 Gastrin (GI tract hormone) level 37977819_1 CDM 0301 RC 82941 HCPCS inpatient 296 192.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 179.23 287.12 Gastrin (GI tract hormone) level 37977819_1 CDM 0301 RC 82941 HCPCS inpatient 296 192.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 200.1 67.6 999999999 179.23 287.12 percent of total billed charges Gastrin (GI tract hormone) level 37977819_1 CDM 0301 RC 82941 HCPCS inpatient 296 192.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 179.23 287.12 Tacrolimus level 37987455_1 CDM 0301 RC 80197 HCPCS inpatient 282 183.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 183.3 65 999999999 170.75 273.54 percent of total billed charges Tacrolimus level 37987455_1 CDM 0301 RC 80197 HCPCS inpatient 282 183.3 AETNA AETNA 222.78 79 999999999 170.75 273.54 percent of total billed charges Tacrolimus level 37987455_1 CDM 0301 RC 80197 HCPCS inpatient 282 183.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 194.58 69 999999999 170.75 273.54 percent of total billed charges Tacrolimus level 37987455_1 CDM 0301 RC 80197 HCPCS inpatient 282 183.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 273.54 97 999999999 170.75 273.54 percent of total billed charges Tacrolimus level 37987455_1 CDM 0301 RC 80197 HCPCS inpatient 282 183.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 219.96 78 999999999 170.75 273.54 percent of total billed charges Tacrolimus level 37987455_1 CDM 0301 RC 80197 HCPCS inpatient 282 183.3 SIHO - ALL PLANS SIHO - ALL PLANS 253.8 90 999999999 170.75 273.54 percent of total billed charges Tacrolimus level 37987455_1 CDM 0301 RC 80197 HCPCS inpatient 282 183.3 UMR - ALL PLANS UMR - ALL PLANS 197.4 70 999999999 170.75 273.54 percent of total billed charges Tacrolimus level 37987455_1 CDM 0301 RC 80197 HCPCS inpatient 282 183.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 170.75 60.55 999999999 170.75 273.54 percent of total billed charges Tacrolimus level 37987455_1 CDM 0301 RC 80197 HCPCS inpatient 282 183.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 170.75 273.54 Tacrolimus level 37987455_1 CDM 0301 RC 80197 HCPCS inpatient 282 183.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 170.75 273.54 Tacrolimus level 37987455_1 CDM 0301 RC 80197 HCPCS inpatient 282 183.3 ANTHEM HMO ANTHEM HMO 999999999 170.75 273.54 Tacrolimus level 37987455_1 CDM 0301 RC 80197 HCPCS inpatient 282 183.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 170.75 273.54 Tacrolimus level 37987455_1 CDM 0301 RC 80197 HCPCS inpatient 282 183.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 190.63 67.6 999999999 170.75 273.54 percent of total billed charges Tacrolimus level 37987455_1 CDM 0301 RC 80197 HCPCS inpatient 282 183.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 170.75 273.54 Aldosterone hormone level 37987456_1 CDM 0301 RC 82088 HCPCS inpatient 182 118.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.3 65 999999999 110.2 176.54 percent of total billed charges Aldosterone hormone level 37987456_1 CDM 0301 RC 82088 HCPCS inpatient 182 118.3 AETNA AETNA 143.78 79 999999999 110.2 176.54 percent of total billed charges Aldosterone hormone level 37987456_1 CDM 0301 RC 82088 HCPCS inpatient 182 118.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 125.58 69 999999999 110.2 176.54 percent of total billed charges Aldosterone hormone level 37987456_1 CDM 0301 RC 82088 HCPCS inpatient 182 118.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 176.54 97 999999999 110.2 176.54 percent of total billed charges Aldosterone hormone level 37987456_1 CDM 0301 RC 82088 HCPCS inpatient 182 118.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.96 78 999999999 110.2 176.54 percent of total billed charges Aldosterone hormone level 37987456_1 CDM 0301 RC 82088 HCPCS inpatient 182 118.3 SIHO - ALL PLANS SIHO - ALL PLANS 163.8 90 999999999 110.2 176.54 percent of total billed charges Aldosterone hormone level 37987456_1 CDM 0301 RC 82088 HCPCS inpatient 182 118.3 UMR - ALL PLANS UMR - ALL PLANS 127.4 70 999999999 110.2 176.54 percent of total billed charges Aldosterone hormone level 37987456_1 CDM 0301 RC 82088 HCPCS inpatient 182 118.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.2 60.55 999999999 110.2 176.54 percent of total billed charges Aldosterone hormone level 37987456_1 CDM 0301 RC 82088 HCPCS inpatient 182 118.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.2 176.54 Aldosterone hormone level 37987456_1 CDM 0301 RC 82088 HCPCS inpatient 182 118.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.2 176.54 Aldosterone hormone level 37987456_1 CDM 0301 RC 82088 HCPCS inpatient 182 118.3 ANTHEM HMO ANTHEM HMO 999999999 110.2 176.54 Aldosterone hormone level 37987456_1 CDM 0301 RC 82088 HCPCS inpatient 182 118.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.2 176.54 Aldosterone hormone level 37987456_1 CDM 0301 RC 82088 HCPCS inpatient 182 118.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.03 67.6 999999999 110.2 176.54 percent of total billed charges Aldosterone hormone level 37987456_1 CDM 0301 RC 82088 HCPCS inpatient 182 118.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.2 176.54 Renin (kidney enzyme) level 37987457_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 235.3 65 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 37987457_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 AETNA AETNA 285.98 79 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 37987457_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 249.78 69 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 37987457_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 351.14 97 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 37987457_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 282.36 78 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 37987457_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 SIHO - ALL PLANS SIHO - ALL PLANS 325.8 90 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 37987457_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 UMR - ALL PLANS UMR - ALL PLANS 253.4 70 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 37987457_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 219.19 60.55 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 37987457_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 219.19 351.14 Renin (kidney enzyme) level 37987457_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 219.19 351.14 Renin (kidney enzyme) level 37987457_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 ANTHEM HMO ANTHEM HMO 999999999 219.19 351.14 Renin (kidney enzyme) level 37987457_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 219.19 351.14 Renin (kidney enzyme) level 37987457_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 244.71 67.6 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 37987457_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 219.19 351.14 Measurement of total estradiol (hormone) 37987460_1 CDM 0300 RC 82670 HCPCS inpatient 288 187.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 187.2 65 999999999 174.38 279.36 percent of total billed charges Measurement of total estradiol (hormone) 37987460_1 CDM 0300 RC 82670 HCPCS inpatient 288 187.2 AETNA AETNA 227.52 79 999999999 174.38 279.36 percent of total billed charges Measurement of total estradiol (hormone) 37987460_1 CDM 0300 RC 82670 HCPCS inpatient 288 187.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 198.72 69 999999999 174.38 279.36 percent of total billed charges Measurement of total estradiol (hormone) 37987460_1 CDM 0300 RC 82670 HCPCS inpatient 288 187.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 279.36 97 999999999 174.38 279.36 percent of total billed charges Measurement of total estradiol (hormone) 37987460_1 CDM 0300 RC 82670 HCPCS inpatient 288 187.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 224.64 78 999999999 174.38 279.36 percent of total billed charges Measurement of total estradiol (hormone) 37987460_1 CDM 0300 RC 82670 HCPCS inpatient 288 187.2 SIHO - ALL PLANS SIHO - ALL PLANS 259.2 90 999999999 174.38 279.36 percent of total billed charges Measurement of total estradiol (hormone) 37987460_1 CDM 0300 RC 82670 HCPCS inpatient 288 187.2 UMR - ALL PLANS UMR - ALL PLANS 201.6 70 999999999 174.38 279.36 percent of total billed charges Measurement of total estradiol (hormone) 37987460_1 CDM 0300 RC 82670 HCPCS inpatient 288 187.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 174.38 60.55 999999999 174.38 279.36 percent of total billed charges Measurement of total estradiol (hormone) 37987460_1 CDM 0300 RC 82670 HCPCS inpatient 288 187.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 174.38 279.36 Measurement of total estradiol (hormone) 37987460_1 CDM 0300 RC 82670 HCPCS inpatient 288 187.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 174.38 279.36 Measurement of total estradiol (hormone) 37987460_1 CDM 0300 RC 82670 HCPCS inpatient 288 187.2 ANTHEM HMO ANTHEM HMO 999999999 174.38 279.36 Measurement of total estradiol (hormone) 37987460_1 CDM 0300 RC 82670 HCPCS inpatient 288 187.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 174.38 279.36 Measurement of total estradiol (hormone) 37987460_1 CDM 0300 RC 82670 HCPCS inpatient 288 187.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 194.69 67.6 999999999 174.38 279.36 percent of total billed charges Measurement of total estradiol (hormone) 37987460_1 CDM 0300 RC 82670 HCPCS inpatient 288 187.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 174.38 279.36 IgE (immune system protein) level 37987471_1 CDM 0301 RC 82785 HCPCS inpatient 234 152.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 152.1 65 999999999 141.69 226.98 percent of total billed charges IgE (immune system protein) level 37987471_1 CDM 0301 RC 82785 HCPCS inpatient 234 152.1 AETNA AETNA 184.86 79 999999999 141.69 226.98 percent of total billed charges IgE (immune system protein) level 37987471_1 CDM 0301 RC 82785 HCPCS inpatient 234 152.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 161.46 69 999999999 141.69 226.98 percent of total billed charges IgE (immune system protein) level 37987471_1 CDM 0301 RC 82785 HCPCS inpatient 234 152.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 226.98 97 999999999 141.69 226.98 percent of total billed charges IgE (immune system protein) level 37987471_1 CDM 0301 RC 82785 HCPCS inpatient 234 152.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 182.52 78 999999999 141.69 226.98 percent of total billed charges IgE (immune system protein) level 37987471_1 CDM 0301 RC 82785 HCPCS inpatient 234 152.1 SIHO - ALL PLANS SIHO - ALL PLANS 210.6 90 999999999 141.69 226.98 percent of total billed charges IgE (immune system protein) level 37987471_1 CDM 0301 RC 82785 HCPCS inpatient 234 152.1 UMR - ALL PLANS UMR - ALL PLANS 163.8 70 999999999 141.69 226.98 percent of total billed charges IgE (immune system protein) level 37987471_1 CDM 0301 RC 82785 HCPCS inpatient 234 152.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 141.69 60.55 999999999 141.69 226.98 percent of total billed charges IgE (immune system protein) level 37987471_1 CDM 0301 RC 82785 HCPCS inpatient 234 152.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 141.69 226.98 IgE (immune system protein) level 37987471_1 CDM 0301 RC 82785 HCPCS inpatient 234 152.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 141.69 226.98 IgE (immune system protein) level 37987471_1 CDM 0301 RC 82785 HCPCS inpatient 234 152.1 ANTHEM HMO ANTHEM HMO 999999999 141.69 226.98 IgE (immune system protein) level 37987471_1 CDM 0301 RC 82785 HCPCS inpatient 234 152.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 141.69 226.98 IgE (immune system protein) level 37987471_1 CDM 0301 RC 82785 HCPCS inpatient 234 152.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 158.18 67.6 999999999 141.69 226.98 percent of total billed charges IgE (immune system protein) level 37987471_1 CDM 0301 RC 82785 HCPCS inpatient 234 152.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 141.69 226.98 "Testosterone (hormone) level, total" 37987475_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges "Testosterone (hormone) level, total" 37987475_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges "Testosterone (hormone) level, total" 37987475_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges "Testosterone (hormone) level, total" 37987475_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges "Testosterone (hormone) level, total" 37987475_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges "Testosterone (hormone) level, total" 37987475_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges "Testosterone (hormone) level, total" 37987475_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges "Testosterone (hormone) level, total" 37987475_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges "Testosterone (hormone) level, total" 37987475_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 "Testosterone (hormone) level, total" 37987475_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 "Testosterone (hormone) level, total" 37987475_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 "Testosterone (hormone) level, total" 37987475_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 "Testosterone (hormone) level, total" 37987475_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges "Testosterone (hormone) level, total" 37987475_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 "Dihydroxyvitamin D, 1, 25 level" 37987479_1 CDM 0301 RC 82652 HCPCS inpatient 278 180.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 180.7 65 999999999 168.33 269.66 percent of total billed charges "Dihydroxyvitamin D, 1, 25 level" 37987479_1 CDM 0301 RC 82652 HCPCS inpatient 278 180.7 AETNA AETNA 219.62 79 999999999 168.33 269.66 percent of total billed charges "Dihydroxyvitamin D, 1, 25 level" 37987479_1 CDM 0301 RC 82652 HCPCS inpatient 278 180.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 191.82 69 999999999 168.33 269.66 percent of total billed charges "Dihydroxyvitamin D, 1, 25 level" 37987479_1 CDM 0301 RC 82652 HCPCS inpatient 278 180.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 269.66 97 999999999 168.33 269.66 percent of total billed charges "Dihydroxyvitamin D, 1, 25 level" 37987479_1 CDM 0301 RC 82652 HCPCS inpatient 278 180.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 216.84 78 999999999 168.33 269.66 percent of total billed charges "Dihydroxyvitamin D, 1, 25 level" 37987479_1 CDM 0301 RC 82652 HCPCS inpatient 278 180.7 SIHO - ALL PLANS SIHO - ALL PLANS 250.2 90 999999999 168.33 269.66 percent of total billed charges "Dihydroxyvitamin D, 1, 25 level" 37987479_1 CDM 0301 RC 82652 HCPCS inpatient 278 180.7 UMR - ALL PLANS UMR - ALL PLANS 194.6 70 999999999 168.33 269.66 percent of total billed charges "Dihydroxyvitamin D, 1, 25 level" 37987479_1 CDM 0301 RC 82652 HCPCS inpatient 278 180.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.33 60.55 999999999 168.33 269.66 percent of total billed charges "Dihydroxyvitamin D, 1, 25 level" 37987479_1 CDM 0301 RC 82652 HCPCS inpatient 278 180.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.33 269.66 "Dihydroxyvitamin D, 1, 25 level" 37987479_1 CDM 0301 RC 82652 HCPCS inpatient 278 180.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.33 269.66 "Dihydroxyvitamin D, 1, 25 level" 37987479_1 CDM 0301 RC 82652 HCPCS inpatient 278 180.7 ANTHEM HMO ANTHEM HMO 999999999 168.33 269.66 "Dihydroxyvitamin D, 1, 25 level" 37987479_1 CDM 0301 RC 82652 HCPCS inpatient 278 180.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.33 269.66 "Dihydroxyvitamin D, 1, 25 level" 37987479_1 CDM 0301 RC 82652 HCPCS inpatient 278 180.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 187.93 67.6 999999999 168.33 269.66 percent of total billed charges "Dihydroxyvitamin D, 1, 25 level" 37987479_1 CDM 0301 RC 82652 HCPCS inpatient 278 180.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.33 269.66 Homocysteine (amino acid) level 37987481_1 CDM 0301 RC 83090 HCPCS inpatient 223 144.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 144.95 65 999999999 135.03 216.31 percent of total billed charges Homocysteine (amino acid) level 37987481_1 CDM 0301 RC 83090 HCPCS inpatient 223 144.95 AETNA AETNA 176.17 79 999999999 135.03 216.31 percent of total billed charges Homocysteine (amino acid) level 37987481_1 CDM 0301 RC 83090 HCPCS inpatient 223 144.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 153.87 69 999999999 135.03 216.31 percent of total billed charges Homocysteine (amino acid) level 37987481_1 CDM 0301 RC 83090 HCPCS inpatient 223 144.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 216.31 97 999999999 135.03 216.31 percent of total billed charges Homocysteine (amino acid) level 37987481_1 CDM 0301 RC 83090 HCPCS inpatient 223 144.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 173.94 78 999999999 135.03 216.31 percent of total billed charges Homocysteine (amino acid) level 37987481_1 CDM 0301 RC 83090 HCPCS inpatient 223 144.95 SIHO - ALL PLANS SIHO - ALL PLANS 200.7 90 999999999 135.03 216.31 percent of total billed charges Homocysteine (amino acid) level 37987481_1 CDM 0301 RC 83090 HCPCS inpatient 223 144.95 UMR - ALL PLANS UMR - ALL PLANS 156.1 70 999999999 135.03 216.31 percent of total billed charges Homocysteine (amino acid) level 37987481_1 CDM 0301 RC 83090 HCPCS inpatient 223 144.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 135.03 60.55 999999999 135.03 216.31 percent of total billed charges Homocysteine (amino acid) level 37987481_1 CDM 0301 RC 83090 HCPCS inpatient 223 144.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 135.03 216.31 Homocysteine (amino acid) level 37987481_1 CDM 0301 RC 83090 HCPCS inpatient 223 144.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 135.03 216.31 Homocysteine (amino acid) level 37987481_1 CDM 0301 RC 83090 HCPCS inpatient 223 144.95 ANTHEM HMO ANTHEM HMO 999999999 135.03 216.31 Homocysteine (amino acid) level 37987481_1 CDM 0301 RC 83090 HCPCS inpatient 223 144.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 135.03 216.31 Homocysteine (amino acid) level 37987481_1 CDM 0301 RC 83090 HCPCS inpatient 223 144.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 150.75 67.6 999999999 135.03 216.31 percent of total billed charges Homocysteine (amino acid) level 37987481_1 CDM 0301 RC 83090 HCPCS inpatient 223 144.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 135.03 216.31 "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 37987482_1 CDM 0302 RC 86300 HCPCS inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 37987482_1 CDM 0302 RC 86300 HCPCS inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 37987482_1 CDM 0302 RC 86300 HCPCS inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 37987482_1 CDM 0302 RC 86300 HCPCS inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 37987482_1 CDM 0302 RC 86300 HCPCS inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 37987482_1 CDM 0302 RC 86300 HCPCS inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 37987482_1 CDM 0302 RC 86300 HCPCS inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 37987482_1 CDM 0302 RC 86300 HCPCS inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 37987482_1 CDM 0302 RC 86300 HCPCS inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 37987482_1 CDM 0302 RC 86300 HCPCS inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 37987482_1 CDM 0302 RC 86300 HCPCS inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 37987482_1 CDM 0302 RC 86300 HCPCS inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 37987482_1 CDM 0302 RC 86300 HCPCS inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 37987482_1 CDM 0302 RC 86300 HCPCS inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 "Gonadotropin, chorionic (reproductive hormone) level" 37987484_1 CDM 0302 RC 84702 HCPCS inpatient 182 118.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.3 65 999999999 110.2 176.54 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 37987484_1 CDM 0302 RC 84702 HCPCS inpatient 182 118.3 AETNA AETNA 143.78 79 999999999 110.2 176.54 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 37987484_1 CDM 0302 RC 84702 HCPCS inpatient 182 118.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 125.58 69 999999999 110.2 176.54 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 37987484_1 CDM 0302 RC 84702 HCPCS inpatient 182 118.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 176.54 97 999999999 110.2 176.54 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 37987484_1 CDM 0302 RC 84702 HCPCS inpatient 182 118.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.96 78 999999999 110.2 176.54 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 37987484_1 CDM 0302 RC 84702 HCPCS inpatient 182 118.3 SIHO - ALL PLANS SIHO - ALL PLANS 163.8 90 999999999 110.2 176.54 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 37987484_1 CDM 0302 RC 84702 HCPCS inpatient 182 118.3 UMR - ALL PLANS UMR - ALL PLANS 127.4 70 999999999 110.2 176.54 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 37987484_1 CDM 0302 RC 84702 HCPCS inpatient 182 118.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.2 60.55 999999999 110.2 176.54 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 37987484_1 CDM 0302 RC 84702 HCPCS inpatient 182 118.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.2 176.54 "Gonadotropin, chorionic (reproductive hormone) level" 37987484_1 CDM 0302 RC 84702 HCPCS inpatient 182 118.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.2 176.54 "Gonadotropin, chorionic (reproductive hormone) level" 37987484_1 CDM 0302 RC 84702 HCPCS inpatient 182 118.3 ANTHEM HMO ANTHEM HMO 999999999 110.2 176.54 "Gonadotropin, chorionic (reproductive hormone) level" 37987484_1 CDM 0302 RC 84702 HCPCS inpatient 182 118.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.2 176.54 "Gonadotropin, chorionic (reproductive hormone) level" 37987484_1 CDM 0302 RC 84702 HCPCS inpatient 182 118.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.03 67.6 999999999 110.2 176.54 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 37987484_1 CDM 0302 RC 84702 HCPCS inpatient 182 118.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.2 176.54 "Alpha-fetoprotein (AFP) level, serum" 37987488_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 37987488_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 37987488_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 37987488_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 37987488_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 37987488_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 37987488_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 37987488_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 37987488_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 "Alpha-fetoprotein (AFP) level, serum" 37987488_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 "Alpha-fetoprotein (AFP) level, serum" 37987488_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 "Alpha-fetoprotein (AFP) level, serum" 37987488_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 "Alpha-fetoprotein (AFP) level, serum" 37987488_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 37987488_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 37987489_1 CDM 0302 RC 86301 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 37987489_1 CDM 0302 RC 86301 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 37987489_1 CDM 0302 RC 86301 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 37987489_1 CDM 0302 RC 86301 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 37987489_1 CDM 0302 RC 86301 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 37987489_1 CDM 0302 RC 86301 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 37987489_1 CDM 0302 RC 86301 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 37987489_1 CDM 0302 RC 86301 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 37987489_1 CDM 0302 RC 86301 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 37987489_1 CDM 0302 RC 86301 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 37987489_1 CDM 0302 RC 86301 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 37987489_1 CDM 0302 RC 86301 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 37987489_1 CDM 0302 RC 86301 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 37987489_1 CDM 0302 RC 86301 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 Progesterone (reproductive hormone) level 37987490_1 CDM 0301 RC 84144 HCPCS inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges Progesterone (reproductive hormone) level 37987490_1 CDM 0301 RC 84144 HCPCS inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges Progesterone (reproductive hormone) level 37987490_1 CDM 0301 RC 84144 HCPCS inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges Progesterone (reproductive hormone) level 37987490_1 CDM 0301 RC 84144 HCPCS inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges Progesterone (reproductive hormone) level 37987490_1 CDM 0301 RC 84144 HCPCS inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges Progesterone (reproductive hormone) level 37987490_1 CDM 0301 RC 84144 HCPCS inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges Progesterone (reproductive hormone) level 37987490_1 CDM 0301 RC 84144 HCPCS inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges Progesterone (reproductive hormone) level 37987490_1 CDM 0301 RC 84144 HCPCS inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges Progesterone (reproductive hormone) level 37987490_1 CDM 0301 RC 84144 HCPCS inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 Progesterone (reproductive hormone) level 37987490_1 CDM 0301 RC 84144 HCPCS inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 Progesterone (reproductive hormone) level 37987490_1 CDM 0301 RC 84144 HCPCS inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 Progesterone (reproductive hormone) level 37987490_1 CDM 0301 RC 84144 HCPCS inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 Progesterone (reproductive hormone) level 37987490_1 CDM 0301 RC 84144 HCPCS inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges Progesterone (reproductive hormone) level 37987490_1 CDM 0301 RC 84144 HCPCS inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 37987491_1 CDM 0302 RC 86304 HCPCS inpatient 272 176.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 176.8 65 999999999 164.7 263.84 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 37987491_1 CDM 0302 RC 86304 HCPCS inpatient 272 176.8 AETNA AETNA 214.88 79 999999999 164.7 263.84 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 37987491_1 CDM 0302 RC 86304 HCPCS inpatient 272 176.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 187.68 69 999999999 164.7 263.84 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 37987491_1 CDM 0302 RC 86304 HCPCS inpatient 272 176.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 263.84 97 999999999 164.7 263.84 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 37987491_1 CDM 0302 RC 86304 HCPCS inpatient 272 176.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 212.16 78 999999999 164.7 263.84 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 37987491_1 CDM 0302 RC 86304 HCPCS inpatient 272 176.8 SIHO - ALL PLANS SIHO - ALL PLANS 244.8 90 999999999 164.7 263.84 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 37987491_1 CDM 0302 RC 86304 HCPCS inpatient 272 176.8 UMR - ALL PLANS UMR - ALL PLANS 190.4 70 999999999 164.7 263.84 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 37987491_1 CDM 0302 RC 86304 HCPCS inpatient 272 176.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 164.7 60.55 999999999 164.7 263.84 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 37987491_1 CDM 0302 RC 86304 HCPCS inpatient 272 176.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 164.7 263.84 "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 37987491_1 CDM 0302 RC 86304 HCPCS inpatient 272 176.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 164.7 263.84 "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 37987491_1 CDM 0302 RC 86304 HCPCS inpatient 272 176.8 ANTHEM HMO ANTHEM HMO 999999999 164.7 263.84 "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 37987491_1 CDM 0302 RC 86304 HCPCS inpatient 272 176.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 164.7 263.84 "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 37987491_1 CDM 0302 RC 86304 HCPCS inpatient 272 176.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 183.87 67.6 999999999 164.7 263.84 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 37987491_1 CDM 0302 RC 86304 HCPCS inpatient 272 176.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 164.7 263.84 Organic acid level 37997095_1 CDM 0301 RC 83921 HCPCS inpatient 243 157.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 157.95 65 999999999 147.14 235.71 percent of total billed charges Organic acid level 37997095_1 CDM 0301 RC 83921 HCPCS inpatient 243 157.95 AETNA AETNA 191.97 79 999999999 147.14 235.71 percent of total billed charges Organic acid level 37997095_1 CDM 0301 RC 83921 HCPCS inpatient 243 157.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 167.67 69 999999999 147.14 235.71 percent of total billed charges Organic acid level 37997095_1 CDM 0301 RC 83921 HCPCS inpatient 243 157.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 235.71 97 999999999 147.14 235.71 percent of total billed charges Organic acid level 37997095_1 CDM 0301 RC 83921 HCPCS inpatient 243 157.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 189.54 78 999999999 147.14 235.71 percent of total billed charges Organic acid level 37997095_1 CDM 0301 RC 83921 HCPCS inpatient 243 157.95 SIHO - ALL PLANS SIHO - ALL PLANS 218.7 90 999999999 147.14 235.71 percent of total billed charges Organic acid level 37997095_1 CDM 0301 RC 83921 HCPCS inpatient 243 157.95 UMR - ALL PLANS UMR - ALL PLANS 170.1 70 999999999 147.14 235.71 percent of total billed charges Organic acid level 37997095_1 CDM 0301 RC 83921 HCPCS inpatient 243 157.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.14 60.55 999999999 147.14 235.71 percent of total billed charges Organic acid level 37997095_1 CDM 0301 RC 83921 HCPCS inpatient 243 157.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.14 235.71 Organic acid level 37997095_1 CDM 0301 RC 83921 HCPCS inpatient 243 157.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.14 235.71 Organic acid level 37997095_1 CDM 0301 RC 83921 HCPCS inpatient 243 157.95 ANTHEM HMO ANTHEM HMO 999999999 147.14 235.71 Organic acid level 37997095_1 CDM 0301 RC 83921 HCPCS inpatient 243 157.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.14 235.71 Organic acid level 37997095_1 CDM 0301 RC 83921 HCPCS inpatient 243 157.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.27 67.6 999999999 147.14 235.71 percent of total billed charges Organic acid level 37997095_1 CDM 0301 RC 83921 HCPCS inpatient 243 157.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.14 235.71 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37997112_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 104.65 65 999999999 97.49 156.17 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37997112_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 AETNA AETNA 127.19 79 999999999 97.49 156.17 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37997112_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 111.09 69 999999999 97.49 156.17 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37997112_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 156.17 97 999999999 97.49 156.17 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37997112_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 125.58 78 999999999 97.49 156.17 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37997112_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 SIHO - ALL PLANS SIHO - ALL PLANS 144.9 90 999999999 97.49 156.17 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37997112_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 UMR - ALL PLANS UMR - ALL PLANS 112.7 70 999999999 97.49 156.17 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37997112_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 97.49 60.55 999999999 97.49 156.17 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37997112_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 97.49 156.17 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37997112_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 97.49 156.17 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37997112_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 ANTHEM HMO ANTHEM HMO 999999999 97.49 156.17 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37997112_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 97.49 156.17 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37997112_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.84 67.6 999999999 97.49 156.17 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 37997112_1 CDM 0302 RC 86665 HCPCS inpatient 161 104.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 97.49 156.17 Gene analysis (coagulation factor V) Leiden variant 37997330_1 CDM 0301 RC 81241 HCPCS inpatient 556 361.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 361.4 65 999999999 336.66 539.32 percent of total billed charges Gene analysis (coagulation factor V) Leiden variant 37997330_1 CDM 0301 RC 81241 HCPCS inpatient 556 361.4 AETNA AETNA 439.24 79 999999999 336.66 539.32 percent of total billed charges Gene analysis (coagulation factor V) Leiden variant 37997330_1 CDM 0301 RC 81241 HCPCS inpatient 556 361.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 383.64 69 999999999 336.66 539.32 percent of total billed charges Gene analysis (coagulation factor V) Leiden variant 37997330_1 CDM 0301 RC 81241 HCPCS inpatient 556 361.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 539.32 97 999999999 336.66 539.32 percent of total billed charges Gene analysis (coagulation factor V) Leiden variant 37997330_1 CDM 0301 RC 81241 HCPCS inpatient 556 361.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 433.68 78 999999999 336.66 539.32 percent of total billed charges Gene analysis (coagulation factor V) Leiden variant 37997330_1 CDM 0301 RC 81241 HCPCS inpatient 556 361.4 SIHO - ALL PLANS SIHO - ALL PLANS 500.4 90 999999999 336.66 539.32 percent of total billed charges Gene analysis (coagulation factor V) Leiden variant 37997330_1 CDM 0301 RC 81241 HCPCS inpatient 556 361.4 UMR - ALL PLANS UMR - ALL PLANS 389.2 70 999999999 336.66 539.32 percent of total billed charges Gene analysis (coagulation factor V) Leiden variant 37997330_1 CDM 0301 RC 81241 HCPCS inpatient 556 361.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 336.66 60.55 999999999 336.66 539.32 percent of total billed charges Gene analysis (coagulation factor V) Leiden variant 37997330_1 CDM 0301 RC 81241 HCPCS inpatient 556 361.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 336.66 539.32 Gene analysis (coagulation factor V) Leiden variant 37997330_1 CDM 0301 RC 81241 HCPCS inpatient 556 361.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 336.66 539.32 Gene analysis (coagulation factor V) Leiden variant 37997330_1 CDM 0301 RC 81241 HCPCS inpatient 556 361.4 ANTHEM HMO ANTHEM HMO 999999999 336.66 539.32 Gene analysis (coagulation factor V) Leiden variant 37997330_1 CDM 0301 RC 81241 HCPCS inpatient 556 361.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 336.66 539.32 Gene analysis (coagulation factor V) Leiden variant 37997330_1 CDM 0301 RC 81241 HCPCS inpatient 556 361.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 375.86 67.6 999999999 336.66 539.32 percent of total billed charges Gene analysis (coagulation factor V) Leiden variant 37997330_1 CDM 0301 RC 81241 HCPCS inpatient 556 361.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 336.66 539.32 "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 37997331_1 CDM 0306 RC 87529 HCPCS inpatient 418 271.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 271.7 65 999999999 253.1 405.46 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 37997331_1 CDM 0306 RC 87529 HCPCS inpatient 418 271.7 AETNA AETNA 330.22 79 999999999 253.1 405.46 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 37997331_1 CDM 0306 RC 87529 HCPCS inpatient 418 271.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 288.42 69 999999999 253.1 405.46 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 37997331_1 CDM 0306 RC 87529 HCPCS inpatient 418 271.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 405.46 97 999999999 253.1 405.46 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 37997331_1 CDM 0306 RC 87529 HCPCS inpatient 418 271.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 326.04 78 999999999 253.1 405.46 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 37997331_1 CDM 0306 RC 87529 HCPCS inpatient 418 271.7 SIHO - ALL PLANS SIHO - ALL PLANS 376.2 90 999999999 253.1 405.46 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 37997331_1 CDM 0306 RC 87529 HCPCS inpatient 418 271.7 UMR - ALL PLANS UMR - ALL PLANS 292.6 70 999999999 253.1 405.46 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 37997331_1 CDM 0306 RC 87529 HCPCS inpatient 418 271.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 253.1 60.55 999999999 253.1 405.46 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 37997331_1 CDM 0306 RC 87529 HCPCS inpatient 418 271.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 253.1 405.46 "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 37997331_1 CDM 0306 RC 87529 HCPCS inpatient 418 271.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 253.1 405.46 "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 37997331_1 CDM 0306 RC 87529 HCPCS inpatient 418 271.7 ANTHEM HMO ANTHEM HMO 999999999 253.1 405.46 "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 37997331_1 CDM 0306 RC 87529 HCPCS inpatient 418 271.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 253.1 405.46 "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 37997331_1 CDM 0306 RC 87529 HCPCS inpatient 418 271.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 282.57 67.6 999999999 253.1 405.46 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 37997331_1 CDM 0306 RC 87529 HCPCS inpatient 418 271.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 253.1 405.46 "Gene analysis (prothrombin, coagulation factor II) A variant" 37997332_1 CDM 0301 RC 81240 HCPCS inpatient 509 330.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 330.85 65 999999999 308.2 493.73 percent of total billed charges "Gene analysis (prothrombin, coagulation factor II) A variant" 37997332_1 CDM 0301 RC 81240 HCPCS inpatient 509 330.85 AETNA AETNA 402.11 79 999999999 308.2 493.73 percent of total billed charges "Gene analysis (prothrombin, coagulation factor II) A variant" 37997332_1 CDM 0301 RC 81240 HCPCS inpatient 509 330.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 351.21 69 999999999 308.2 493.73 percent of total billed charges "Gene analysis (prothrombin, coagulation factor II) A variant" 37997332_1 CDM 0301 RC 81240 HCPCS inpatient 509 330.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 493.73 97 999999999 308.2 493.73 percent of total billed charges "Gene analysis (prothrombin, coagulation factor II) A variant" 37997332_1 CDM 0301 RC 81240 HCPCS inpatient 509 330.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 397.02 78 999999999 308.2 493.73 percent of total billed charges "Gene analysis (prothrombin, coagulation factor II) A variant" 37997332_1 CDM 0301 RC 81240 HCPCS inpatient 509 330.85 SIHO - ALL PLANS SIHO - ALL PLANS 458.1 90 999999999 308.2 493.73 percent of total billed charges "Gene analysis (prothrombin, coagulation factor II) A variant" 37997332_1 CDM 0301 RC 81240 HCPCS inpatient 509 330.85 UMR - ALL PLANS UMR - ALL PLANS 356.3 70 999999999 308.2 493.73 percent of total billed charges "Gene analysis (prothrombin, coagulation factor II) A variant" 37997332_1 CDM 0301 RC 81240 HCPCS inpatient 509 330.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 308.2 60.55 999999999 308.2 493.73 percent of total billed charges "Gene analysis (prothrombin, coagulation factor II) A variant" 37997332_1 CDM 0301 RC 81240 HCPCS inpatient 509 330.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 308.2 493.73 "Gene analysis (prothrombin, coagulation factor II) A variant" 37997332_1 CDM 0301 RC 81240 HCPCS inpatient 509 330.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 308.2 493.73 "Gene analysis (prothrombin, coagulation factor II) A variant" 37997332_1 CDM 0301 RC 81240 HCPCS inpatient 509 330.85 ANTHEM HMO ANTHEM HMO 999999999 308.2 493.73 "Gene analysis (prothrombin, coagulation factor II) A variant" 37997332_1 CDM 0301 RC 81240 HCPCS inpatient 509 330.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 308.2 493.73 "Gene analysis (prothrombin, coagulation factor II) A variant" 37997332_1 CDM 0301 RC 81240 HCPCS inpatient 509 330.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 344.08 67.6 999999999 308.2 493.73 percent of total billed charges "Gene analysis (prothrombin, coagulation factor II) A variant" 37997332_1 CDM 0301 RC 81240 HCPCS inpatient 509 330.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 308.2 493.73 Analysis test by nucleic acid for Hepatitis C virus 37997333_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 726.05 65 999999999 676.34 1083.49 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 37997333_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 AETNA AETNA 882.43 79 999999999 676.34 1083.49 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 37997333_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 770.73 69 999999999 676.34 1083.49 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 37997333_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1083.49 97 999999999 676.34 1083.49 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 37997333_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 871.26 78 999999999 676.34 1083.49 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 37997333_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 SIHO - ALL PLANS SIHO - ALL PLANS 1005.3 90 999999999 676.34 1083.49 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 37997333_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 UMR - ALL PLANS UMR - ALL PLANS 781.9 70 999999999 676.34 1083.49 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 37997333_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 676.34 60.55 999999999 676.34 1083.49 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 37997333_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 676.34 1083.49 Analysis test by nucleic acid for Hepatitis C virus 37997333_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 676.34 1083.49 Analysis test by nucleic acid for Hepatitis C virus 37997333_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 ANTHEM HMO ANTHEM HMO 999999999 676.34 1083.49 Analysis test by nucleic acid for Hepatitis C virus 37997333_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 676.34 1083.49 Analysis test by nucleic acid for Hepatitis C virus 37997333_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 755.09 67.6 999999999 676.34 1083.49 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 37997333_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 676.34 1083.49 "Detection test by nucleic acid for Hepatitis C virus, amplified probe technique" 37997334_1 CDM 0301 RC 87521 HCPCS inpatient 430 279.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 279.5 65 999999999 260.37 417.1 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, amplified probe technique" 37997334_1 CDM 0301 RC 87521 HCPCS inpatient 430 279.5 AETNA AETNA 339.7 79 999999999 260.37 417.1 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, amplified probe technique" 37997334_1 CDM 0301 RC 87521 HCPCS inpatient 430 279.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 296.7 69 999999999 260.37 417.1 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, amplified probe technique" 37997334_1 CDM 0301 RC 87521 HCPCS inpatient 430 279.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 417.1 97 999999999 260.37 417.1 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, amplified probe technique" 37997334_1 CDM 0301 RC 87521 HCPCS inpatient 430 279.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 335.4 78 999999999 260.37 417.1 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, amplified probe technique" 37997334_1 CDM 0301 RC 87521 HCPCS inpatient 430 279.5 SIHO - ALL PLANS SIHO - ALL PLANS 387 90 999999999 260.37 417.1 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, amplified probe technique" 37997334_1 CDM 0301 RC 87521 HCPCS inpatient 430 279.5 UMR - ALL PLANS UMR - ALL PLANS 301 70 999999999 260.37 417.1 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, amplified probe technique" 37997334_1 CDM 0301 RC 87521 HCPCS inpatient 430 279.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 260.37 60.55 999999999 260.37 417.1 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, amplified probe technique" 37997334_1 CDM 0301 RC 87521 HCPCS inpatient 430 279.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 260.37 417.1 "Detection test by nucleic acid for Hepatitis C virus, amplified probe technique" 37997334_1 CDM 0301 RC 87521 HCPCS inpatient 430 279.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 260.37 417.1 "Detection test by nucleic acid for Hepatitis C virus, amplified probe technique" 37997334_1 CDM 0301 RC 87521 HCPCS inpatient 430 279.5 ANTHEM HMO ANTHEM HMO 999999999 260.37 417.1 "Detection test by nucleic acid for Hepatitis C virus, amplified probe technique" 37997334_1 CDM 0301 RC 87521 HCPCS inpatient 430 279.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 260.37 417.1 "Detection test by nucleic acid for Hepatitis C virus, amplified probe technique" 37997334_1 CDM 0301 RC 87521 HCPCS inpatient 430 279.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 290.68 67.6 999999999 260.37 417.1 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, amplified probe technique" 37997334_1 CDM 0301 RC 87521 HCPCS inpatient 430 279.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 260.37 417.1 Gene analysis (hemochromatosis) common variants 37997342_1 CDM 0301 RC 81256 HCPCS inpatient 650 422.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 422.5 65 999999999 393.58 630.5 percent of total billed charges Gene analysis (hemochromatosis) common variants 37997342_1 CDM 0301 RC 81256 HCPCS inpatient 650 422.5 AETNA AETNA 513.5 79 999999999 393.58 630.5 percent of total billed charges Gene analysis (hemochromatosis) common variants 37997342_1 CDM 0301 RC 81256 HCPCS inpatient 650 422.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 448.5 69 999999999 393.58 630.5 percent of total billed charges Gene analysis (hemochromatosis) common variants 37997342_1 CDM 0301 RC 81256 HCPCS inpatient 650 422.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 630.5 97 999999999 393.58 630.5 percent of total billed charges Gene analysis (hemochromatosis) common variants 37997342_1 CDM 0301 RC 81256 HCPCS inpatient 650 422.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 507 78 999999999 393.58 630.5 percent of total billed charges Gene analysis (hemochromatosis) common variants 37997342_1 CDM 0301 RC 81256 HCPCS inpatient 650 422.5 SIHO - ALL PLANS SIHO - ALL PLANS 585 90 999999999 393.58 630.5 percent of total billed charges Gene analysis (hemochromatosis) common variants 37997342_1 CDM 0301 RC 81256 HCPCS inpatient 650 422.5 UMR - ALL PLANS UMR - ALL PLANS 455 70 999999999 393.58 630.5 percent of total billed charges Gene analysis (hemochromatosis) common variants 37997342_1 CDM 0301 RC 81256 HCPCS inpatient 650 422.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 393.58 60.55 999999999 393.58 630.5 percent of total billed charges Gene analysis (hemochromatosis) common variants 37997342_1 CDM 0301 RC 81256 HCPCS inpatient 650 422.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 393.58 630.5 Gene analysis (hemochromatosis) common variants 37997342_1 CDM 0301 RC 81256 HCPCS inpatient 650 422.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 393.58 630.5 Gene analysis (hemochromatosis) common variants 37997342_1 CDM 0301 RC 81256 HCPCS inpatient 650 422.5 ANTHEM HMO ANTHEM HMO 999999999 393.58 630.5 Gene analysis (hemochromatosis) common variants 37997342_1 CDM 0301 RC 81256 HCPCS inpatient 650 422.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 393.58 630.5 Gene analysis (hemochromatosis) common variants 37997342_1 CDM 0301 RC 81256 HCPCS inpatient 650 422.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 439.4 67.6 999999999 393.58 630.5 percent of total billed charges Gene analysis (hemochromatosis) common variants 37997342_1 CDM 0301 RC 81256 HCPCS inpatient 650 422.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 393.58 630.5 "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 37997344_1 CDM 0301 RC 81291 HCPCS inpatient 636 413.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 413.4 65 999999999 385.1 616.92 percent of total billed charges "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 37997344_1 CDM 0301 RC 81291 HCPCS inpatient 636 413.4 AETNA AETNA 502.44 79 999999999 385.1 616.92 percent of total billed charges "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 37997344_1 CDM 0301 RC 81291 HCPCS inpatient 636 413.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 438.84 69 999999999 385.1 616.92 percent of total billed charges "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 37997344_1 CDM 0301 RC 81291 HCPCS inpatient 636 413.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 616.92 97 999999999 385.1 616.92 percent of total billed charges "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 37997344_1 CDM 0301 RC 81291 HCPCS inpatient 636 413.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 496.08 78 999999999 385.1 616.92 percent of total billed charges "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 37997344_1 CDM 0301 RC 81291 HCPCS inpatient 636 413.4 SIHO - ALL PLANS SIHO - ALL PLANS 572.4 90 999999999 385.1 616.92 percent of total billed charges "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 37997344_1 CDM 0301 RC 81291 HCPCS inpatient 636 413.4 UMR - ALL PLANS UMR - ALL PLANS 445.2 70 999999999 385.1 616.92 percent of total billed charges "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 37997344_1 CDM 0301 RC 81291 HCPCS inpatient 636 413.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 385.1 60.55 999999999 385.1 616.92 percent of total billed charges "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 37997344_1 CDM 0301 RC 81291 HCPCS inpatient 636 413.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 385.1 616.92 "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 37997344_1 CDM 0301 RC 81291 HCPCS inpatient 636 413.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 385.1 616.92 "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 37997344_1 CDM 0301 RC 81291 HCPCS inpatient 636 413.4 ANTHEM HMO ANTHEM HMO 999999999 385.1 616.92 "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 37997344_1 CDM 0301 RC 81291 HCPCS inpatient 636 413.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 385.1 616.92 "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 37997344_1 CDM 0301 RC 81291 HCPCS inpatient 636 413.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 429.94 67.6 999999999 385.1 616.92 percent of total billed charges "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 37997344_1 CDM 0301 RC 81291 HCPCS inpatient 636 413.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 385.1 616.92 "Detection test by nucleic acid for cytomegalovirus, quantification" 37997346_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.05 65 999999999 155.61 249.29 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 37997346_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 AETNA AETNA 203.03 79 999999999 155.61 249.29 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 37997346_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 177.33 69 999999999 155.61 249.29 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 37997346_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 249.29 97 999999999 155.61 249.29 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 37997346_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 200.46 78 999999999 155.61 249.29 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 37997346_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 SIHO - ALL PLANS SIHO - ALL PLANS 231.3 90 999999999 155.61 249.29 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 37997346_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 UMR - ALL PLANS UMR - ALL PLANS 179.9 70 999999999 155.61 249.29 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 37997346_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.61 60.55 999999999 155.61 249.29 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 37997346_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.61 249.29 "Detection test by nucleic acid for cytomegalovirus, quantification" 37997346_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.61 249.29 "Detection test by nucleic acid for cytomegalovirus, quantification" 37997346_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 ANTHEM HMO ANTHEM HMO 999999999 155.61 249.29 "Detection test by nucleic acid for cytomegalovirus, quantification" 37997346_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.61 249.29 "Detection test by nucleic acid for cytomegalovirus, quantification" 37997346_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.73 67.6 999999999 155.61 249.29 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 37997346_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.61 249.29 Gene analysis (Janus kinase 2) variant 37997353_1 CDM 0301 RC 81270 HCPCS inpatient 927 602.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 602.55 65 999999999 561.3 899.19 percent of total billed charges Gene analysis (Janus kinase 2) variant 37997353_1 CDM 0301 RC 81270 HCPCS inpatient 927 602.55 AETNA AETNA 732.33 79 999999999 561.3 899.19 percent of total billed charges Gene analysis (Janus kinase 2) variant 37997353_1 CDM 0301 RC 81270 HCPCS inpatient 927 602.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 639.63 69 999999999 561.3 899.19 percent of total billed charges Gene analysis (Janus kinase 2) variant 37997353_1 CDM 0301 RC 81270 HCPCS inpatient 927 602.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 899.19 97 999999999 561.3 899.19 percent of total billed charges Gene analysis (Janus kinase 2) variant 37997353_1 CDM 0301 RC 81270 HCPCS inpatient 927 602.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 723.06 78 999999999 561.3 899.19 percent of total billed charges Gene analysis (Janus kinase 2) variant 37997353_1 CDM 0301 RC 81270 HCPCS inpatient 927 602.55 SIHO - ALL PLANS SIHO - ALL PLANS 834.3 90 999999999 561.3 899.19 percent of total billed charges Gene analysis (Janus kinase 2) variant 37997353_1 CDM 0301 RC 81270 HCPCS inpatient 927 602.55 UMR - ALL PLANS UMR - ALL PLANS 648.9 70 999999999 561.3 899.19 percent of total billed charges Gene analysis (Janus kinase 2) variant 37997353_1 CDM 0301 RC 81270 HCPCS inpatient 927 602.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 561.3 60.55 999999999 561.3 899.19 percent of total billed charges Gene analysis (Janus kinase 2) variant 37997353_1 CDM 0301 RC 81270 HCPCS inpatient 927 602.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 561.3 899.19 Gene analysis (Janus kinase 2) variant 37997353_1 CDM 0301 RC 81270 HCPCS inpatient 927 602.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 561.3 899.19 Gene analysis (Janus kinase 2) variant 37997353_1 CDM 0301 RC 81270 HCPCS inpatient 927 602.55 ANTHEM HMO ANTHEM HMO 999999999 561.3 899.19 Gene analysis (Janus kinase 2) variant 37997353_1 CDM 0301 RC 81270 HCPCS inpatient 927 602.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 561.3 899.19 Gene analysis (Janus kinase 2) variant 37997353_1 CDM 0301 RC 81270 HCPCS inpatient 927 602.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 626.65 67.6 999999999 561.3 899.19 percent of total billed charges Gene analysis (Janus kinase 2) variant 37997353_1 CDM 0301 RC 81270 HCPCS inpatient 927 602.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 561.3 899.19 "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 37997360_1 CDM 0306 RC 87801 HCPCS inpatient 192 124.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 124.8 65 999999999 116.26 186.24 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 37997360_1 CDM 0306 RC 87801 HCPCS inpatient 192 124.8 AETNA AETNA 151.68 79 999999999 116.26 186.24 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 37997360_1 CDM 0306 RC 87801 HCPCS inpatient 192 124.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 132.48 69 999999999 116.26 186.24 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 37997360_1 CDM 0306 RC 87801 HCPCS inpatient 192 124.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 186.24 97 999999999 116.26 186.24 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 37997360_1 CDM 0306 RC 87801 HCPCS inpatient 192 124.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 149.76 78 999999999 116.26 186.24 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 37997360_1 CDM 0306 RC 87801 HCPCS inpatient 192 124.8 SIHO - ALL PLANS SIHO - ALL PLANS 172.8 90 999999999 116.26 186.24 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 37997360_1 CDM 0306 RC 87801 HCPCS inpatient 192 124.8 UMR - ALL PLANS UMR - ALL PLANS 134.4 70 999999999 116.26 186.24 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 37997360_1 CDM 0306 RC 87801 HCPCS inpatient 192 124.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.26 60.55 999999999 116.26 186.24 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 37997360_1 CDM 0306 RC 87801 HCPCS inpatient 192 124.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.26 186.24 "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 37997360_1 CDM 0306 RC 87801 HCPCS inpatient 192 124.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.26 186.24 "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 37997360_1 CDM 0306 RC 87801 HCPCS inpatient 192 124.8 ANTHEM HMO ANTHEM HMO 999999999 116.26 186.24 "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 37997360_1 CDM 0306 RC 87801 HCPCS inpatient 192 124.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.26 186.24 "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 37997360_1 CDM 0306 RC 87801 HCPCS inpatient 192 124.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 129.79 67.6 999999999 116.26 186.24 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 37997360_1 CDM 0306 RC 87801 HCPCS inpatient 192 124.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.26 186.24 "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 38006969_1 CDM 0306 RC 87476 HCPCS inpatient 435 282.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 282.75 65 999999999 263.39 421.95 percent of total billed charges "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 38006969_1 CDM 0306 RC 87476 HCPCS inpatient 435 282.75 AETNA AETNA 343.65 79 999999999 263.39 421.95 percent of total billed charges "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 38006969_1 CDM 0306 RC 87476 HCPCS inpatient 435 282.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 300.15 69 999999999 263.39 421.95 percent of total billed charges "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 38006969_1 CDM 0306 RC 87476 HCPCS inpatient 435 282.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 421.95 97 999999999 263.39 421.95 percent of total billed charges "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 38006969_1 CDM 0306 RC 87476 HCPCS inpatient 435 282.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 339.3 78 999999999 263.39 421.95 percent of total billed charges "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 38006969_1 CDM 0306 RC 87476 HCPCS inpatient 435 282.75 SIHO - ALL PLANS SIHO - ALL PLANS 391.5 90 999999999 263.39 421.95 percent of total billed charges "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 38006969_1 CDM 0306 RC 87476 HCPCS inpatient 435 282.75 UMR - ALL PLANS UMR - ALL PLANS 304.5 70 999999999 263.39 421.95 percent of total billed charges "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 38006969_1 CDM 0306 RC 87476 HCPCS inpatient 435 282.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 263.39 60.55 999999999 263.39 421.95 percent of total billed charges "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 38006969_1 CDM 0306 RC 87476 HCPCS inpatient 435 282.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 263.39 421.95 "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 38006969_1 CDM 0306 RC 87476 HCPCS inpatient 435 282.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 263.39 421.95 "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 38006969_1 CDM 0306 RC 87476 HCPCS inpatient 435 282.75 ANTHEM HMO ANTHEM HMO 999999999 263.39 421.95 "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 38006969_1 CDM 0306 RC 87476 HCPCS inpatient 435 282.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 263.39 421.95 "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 38006969_1 CDM 0306 RC 87476 HCPCS inpatient 435 282.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 294.06 67.6 999999999 263.39 421.95 percent of total billed charges "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 38006969_1 CDM 0306 RC 87476 HCPCS inpatient 435 282.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 263.39 421.95 Detection test by immunoassay technique for hepatitis Be surface antigen 38006983_1 CDM 0306 RC 87350 HCPCS inpatient 120 78 SELF PAY DISCOUNT SELF PAY DISCOUNT 78 65 999999999 72.66 116.4 percent of total billed charges Detection test by immunoassay technique for hepatitis Be surface antigen 38006983_1 CDM 0306 RC 87350 HCPCS inpatient 120 78 AETNA AETNA 94.8 79 999999999 72.66 116.4 percent of total billed charges Detection test by immunoassay technique for hepatitis Be surface antigen 38006983_1 CDM 0306 RC 87350 HCPCS inpatient 120 78 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.8 69 999999999 72.66 116.4 percent of total billed charges Detection test by immunoassay technique for hepatitis Be surface antigen 38006983_1 CDM 0306 RC 87350 HCPCS inpatient 120 78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.4 97 999999999 72.66 116.4 percent of total billed charges Detection test by immunoassay technique for hepatitis Be surface antigen 38006983_1 CDM 0306 RC 87350 HCPCS inpatient 120 78 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.6 78 999999999 72.66 116.4 percent of total billed charges Detection test by immunoassay technique for hepatitis Be surface antigen 38006983_1 CDM 0306 RC 87350 HCPCS inpatient 120 78 SIHO - ALL PLANS SIHO - ALL PLANS 108 90 999999999 72.66 116.4 percent of total billed charges Detection test by immunoassay technique for hepatitis Be surface antigen 38006983_1 CDM 0306 RC 87350 HCPCS inpatient 120 78 UMR - ALL PLANS UMR - ALL PLANS 84 70 999999999 72.66 116.4 percent of total billed charges Detection test by immunoassay technique for hepatitis Be surface antigen 38006983_1 CDM 0306 RC 87350 HCPCS inpatient 120 78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.66 60.55 999999999 72.66 116.4 percent of total billed charges Detection test by immunoassay technique for hepatitis Be surface antigen 38006983_1 CDM 0306 RC 87350 HCPCS inpatient 120 78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.66 116.4 Detection test by immunoassay technique for hepatitis Be surface antigen 38006983_1 CDM 0306 RC 87350 HCPCS inpatient 120 78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.66 116.4 Detection test by immunoassay technique for hepatitis Be surface antigen 38006983_1 CDM 0306 RC 87350 HCPCS inpatient 120 78 ANTHEM HMO ANTHEM HMO 999999999 72.66 116.4 Detection test by immunoassay technique for hepatitis Be surface antigen 38006983_1 CDM 0306 RC 87350 HCPCS inpatient 120 78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.66 116.4 Detection test by immunoassay technique for hepatitis Be surface antigen 38006983_1 CDM 0306 RC 87350 HCPCS inpatient 120 78 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.12 67.6 999999999 72.66 116.4 percent of total billed charges Detection test by immunoassay technique for hepatitis Be surface antigen 38006983_1 CDM 0306 RC 87350 HCPCS inpatient 120 78 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.66 116.4 Intrinsic factor (stomach protein) antibody measurement 38006984_1 CDM 0302 RC 86340 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges Intrinsic factor (stomach protein) antibody measurement 38006984_1 CDM 0302 RC 86340 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges Intrinsic factor (stomach protein) antibody measurement 38006984_1 CDM 0302 RC 86340 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges Intrinsic factor (stomach protein) antibody measurement 38006984_1 CDM 0302 RC 86340 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges Intrinsic factor (stomach protein) antibody measurement 38006984_1 CDM 0302 RC 86340 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges Intrinsic factor (stomach protein) antibody measurement 38006984_1 CDM 0302 RC 86340 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges Intrinsic factor (stomach protein) antibody measurement 38006984_1 CDM 0302 RC 86340 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges Intrinsic factor (stomach protein) antibody measurement 38006984_1 CDM 0302 RC 86340 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges Intrinsic factor (stomach protein) antibody measurement 38006984_1 CDM 0302 RC 86340 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 Intrinsic factor (stomach protein) antibody measurement 38006984_1 CDM 0302 RC 86340 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 Intrinsic factor (stomach protein) antibody measurement 38006984_1 CDM 0302 RC 86340 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 Intrinsic factor (stomach protein) antibody measurement 38006984_1 CDM 0302 RC 86340 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 Intrinsic factor (stomach protein) antibody measurement 38006984_1 CDM 0302 RC 86340 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges Intrinsic factor (stomach protein) antibody measurement 38006984_1 CDM 0302 RC 86340 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 Screening test for antibody to noninfectious agent 38006986_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 38006986_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 38006986_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 38006986_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 38006986_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 38006986_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 38006986_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 38006986_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 38006986_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 38006986_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 38006986_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 38006986_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 38006986_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 38006986_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 Calcitonin (hormone) level 38006987_1 CDM 0301 RC 82308 HCPCS inpatient 238 154.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.7 65 999999999 144.11 230.86 percent of total billed charges Calcitonin (hormone) level 38006987_1 CDM 0301 RC 82308 HCPCS inpatient 238 154.7 AETNA AETNA 188.02 79 999999999 144.11 230.86 percent of total billed charges Calcitonin (hormone) level 38006987_1 CDM 0301 RC 82308 HCPCS inpatient 238 154.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.22 69 999999999 144.11 230.86 percent of total billed charges Calcitonin (hormone) level 38006987_1 CDM 0301 RC 82308 HCPCS inpatient 238 154.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 230.86 97 999999999 144.11 230.86 percent of total billed charges Calcitonin (hormone) level 38006987_1 CDM 0301 RC 82308 HCPCS inpatient 238 154.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 185.64 78 999999999 144.11 230.86 percent of total billed charges Calcitonin (hormone) level 38006987_1 CDM 0301 RC 82308 HCPCS inpatient 238 154.7 SIHO - ALL PLANS SIHO - ALL PLANS 214.2 90 999999999 144.11 230.86 percent of total billed charges Calcitonin (hormone) level 38006987_1 CDM 0301 RC 82308 HCPCS inpatient 238 154.7 UMR - ALL PLANS UMR - ALL PLANS 166.6 70 999999999 144.11 230.86 percent of total billed charges Calcitonin (hormone) level 38006987_1 CDM 0301 RC 82308 HCPCS inpatient 238 154.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.11 60.55 999999999 144.11 230.86 percent of total billed charges Calcitonin (hormone) level 38006987_1 CDM 0301 RC 82308 HCPCS inpatient 238 154.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.11 230.86 Calcitonin (hormone) level 38006987_1 CDM 0301 RC 82308 HCPCS inpatient 238 154.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.11 230.86 Calcitonin (hormone) level 38006987_1 CDM 0301 RC 82308 HCPCS inpatient 238 154.7 ANTHEM HMO ANTHEM HMO 999999999 144.11 230.86 Calcitonin (hormone) level 38006987_1 CDM 0301 RC 82308 HCPCS inpatient 238 154.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.11 230.86 Calcitonin (hormone) level 38006987_1 CDM 0301 RC 82308 HCPCS inpatient 238 154.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.89 67.6 999999999 144.11 230.86 percent of total billed charges Calcitonin (hormone) level 38006987_1 CDM 0301 RC 82308 HCPCS inpatient 238 154.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.11 230.86 "Thyroid hormone, T3 measurement, reverse" 38006988_1 CDM 0301 RC 84482 HCPCS inpatient 306 198.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 198.9 65 999999999 185.28 296.82 percent of total billed charges "Thyroid hormone, T3 measurement, reverse" 38006988_1 CDM 0301 RC 84482 HCPCS inpatient 306 198.9 AETNA AETNA 241.74 79 999999999 185.28 296.82 percent of total billed charges "Thyroid hormone, T3 measurement, reverse" 38006988_1 CDM 0301 RC 84482 HCPCS inpatient 306 198.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 211.14 69 999999999 185.28 296.82 percent of total billed charges "Thyroid hormone, T3 measurement, reverse" 38006988_1 CDM 0301 RC 84482 HCPCS inpatient 306 198.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 296.82 97 999999999 185.28 296.82 percent of total billed charges "Thyroid hormone, T3 measurement, reverse" 38006988_1 CDM 0301 RC 84482 HCPCS inpatient 306 198.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 238.68 78 999999999 185.28 296.82 percent of total billed charges "Thyroid hormone, T3 measurement, reverse" 38006988_1 CDM 0301 RC 84482 HCPCS inpatient 306 198.9 SIHO - ALL PLANS SIHO - ALL PLANS 275.4 90 999999999 185.28 296.82 percent of total billed charges "Thyroid hormone, T3 measurement, reverse" 38006988_1 CDM 0301 RC 84482 HCPCS inpatient 306 198.9 UMR - ALL PLANS UMR - ALL PLANS 214.2 70 999999999 185.28 296.82 percent of total billed charges "Thyroid hormone, T3 measurement, reverse" 38006988_1 CDM 0301 RC 84482 HCPCS inpatient 306 198.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 185.28 60.55 999999999 185.28 296.82 percent of total billed charges "Thyroid hormone, T3 measurement, reverse" 38006988_1 CDM 0301 RC 84482 HCPCS inpatient 306 198.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 185.28 296.82 "Thyroid hormone, T3 measurement, reverse" 38006988_1 CDM 0301 RC 84482 HCPCS inpatient 306 198.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 185.28 296.82 "Thyroid hormone, T3 measurement, reverse" 38006988_1 CDM 0301 RC 84482 HCPCS inpatient 306 198.9 ANTHEM HMO ANTHEM HMO 999999999 185.28 296.82 "Thyroid hormone, T3 measurement, reverse" 38006988_1 CDM 0301 RC 84482 HCPCS inpatient 306 198.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 185.28 296.82 "Thyroid hormone, T3 measurement, reverse" 38006988_1 CDM 0301 RC 84482 HCPCS inpatient 306 198.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 206.86 67.6 999999999 185.28 296.82 percent of total billed charges "Thyroid hormone, T3 measurement, reverse" 38006988_1 CDM 0301 RC 84482 HCPCS inpatient 306 198.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 185.28 296.82 Measurement of DNA antibody 38006998_1 CDM 0301 RC 86215 HCPCS inpatient 257 167.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.05 65 999999999 155.61 249.29 percent of total billed charges Measurement of DNA antibody 38006998_1 CDM 0301 RC 86215 HCPCS inpatient 257 167.05 AETNA AETNA 203.03 79 999999999 155.61 249.29 percent of total billed charges Measurement of DNA antibody 38006998_1 CDM 0301 RC 86215 HCPCS inpatient 257 167.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 177.33 69 999999999 155.61 249.29 percent of total billed charges Measurement of DNA antibody 38006998_1 CDM 0301 RC 86215 HCPCS inpatient 257 167.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 249.29 97 999999999 155.61 249.29 percent of total billed charges Measurement of DNA antibody 38006998_1 CDM 0301 RC 86215 HCPCS inpatient 257 167.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 200.46 78 999999999 155.61 249.29 percent of total billed charges Measurement of DNA antibody 38006998_1 CDM 0301 RC 86215 HCPCS inpatient 257 167.05 SIHO - ALL PLANS SIHO - ALL PLANS 231.3 90 999999999 155.61 249.29 percent of total billed charges Measurement of DNA antibody 38006998_1 CDM 0301 RC 86215 HCPCS inpatient 257 167.05 UMR - ALL PLANS UMR - ALL PLANS 179.9 70 999999999 155.61 249.29 percent of total billed charges Measurement of DNA antibody 38006998_1 CDM 0301 RC 86215 HCPCS inpatient 257 167.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.61 60.55 999999999 155.61 249.29 percent of total billed charges Measurement of DNA antibody 38006998_1 CDM 0301 RC 86215 HCPCS inpatient 257 167.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.61 249.29 Measurement of DNA antibody 38006998_1 CDM 0301 RC 86215 HCPCS inpatient 257 167.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.61 249.29 Measurement of DNA antibody 38006998_1 CDM 0301 RC 86215 HCPCS inpatient 257 167.05 ANTHEM HMO ANTHEM HMO 999999999 155.61 249.29 Measurement of DNA antibody 38006998_1 CDM 0301 RC 86215 HCPCS inpatient 257 167.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.61 249.29 Measurement of DNA antibody 38006998_1 CDM 0301 RC 86215 HCPCS inpatient 257 167.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.73 67.6 999999999 155.61 249.29 percent of total billed charges Measurement of DNA antibody 38006998_1 CDM 0301 RC 86215 HCPCS inpatient 257 167.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.61 249.29 Hepatitis Be antibody measurement 38007007_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.95 65 999999999 110.81 177.51 percent of total billed charges Hepatitis Be antibody measurement 38007007_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 AETNA AETNA 144.57 79 999999999 110.81 177.51 percent of total billed charges Hepatitis Be antibody measurement 38007007_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.27 69 999999999 110.81 177.51 percent of total billed charges Hepatitis Be antibody measurement 38007007_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.51 97 999999999 110.81 177.51 percent of total billed charges Hepatitis Be antibody measurement 38007007_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 142.74 78 999999999 110.81 177.51 percent of total billed charges Hepatitis Be antibody measurement 38007007_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 SIHO - ALL PLANS SIHO - ALL PLANS 164.7 90 999999999 110.81 177.51 percent of total billed charges Hepatitis Be antibody measurement 38007007_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 UMR - ALL PLANS UMR - ALL PLANS 128.1 70 999999999 110.81 177.51 percent of total billed charges Hepatitis Be antibody measurement 38007007_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.81 60.55 999999999 110.81 177.51 percent of total billed charges Hepatitis Be antibody measurement 38007007_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.81 177.51 Hepatitis Be antibody measurement 38007007_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.81 177.51 Hepatitis Be antibody measurement 38007007_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 ANTHEM HMO ANTHEM HMO 999999999 110.81 177.51 Hepatitis Be antibody measurement 38007007_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.81 177.51 Hepatitis Be antibody measurement 38007007_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.71 67.6 999999999 110.81 177.51 percent of total billed charges Hepatitis Be antibody measurement 38007007_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.81 177.51 Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38007008_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38007008_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38007008_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38007008_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38007008_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38007008_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38007008_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38007008_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38007008_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38007008_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38007008_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38007008_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38007008_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38007008_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 "Protein C, (clotting inhibitor) activity" 38007015_1 CDM 0301 RC 85302 HCPCS inpatient 315 204.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 204.75 65 999999999 190.73 305.55 percent of total billed charges "Protein C, (clotting inhibitor) activity" 38007015_1 CDM 0301 RC 85302 HCPCS inpatient 315 204.75 AETNA AETNA 248.85 79 999999999 190.73 305.55 percent of total billed charges "Protein C, (clotting inhibitor) activity" 38007015_1 CDM 0301 RC 85302 HCPCS inpatient 315 204.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 217.35 69 999999999 190.73 305.55 percent of total billed charges "Protein C, (clotting inhibitor) activity" 38007015_1 CDM 0301 RC 85302 HCPCS inpatient 315 204.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 305.55 97 999999999 190.73 305.55 percent of total billed charges "Protein C, (clotting inhibitor) activity" 38007015_1 CDM 0301 RC 85302 HCPCS inpatient 315 204.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 245.7 78 999999999 190.73 305.55 percent of total billed charges "Protein C, (clotting inhibitor) activity" 38007015_1 CDM 0301 RC 85302 HCPCS inpatient 315 204.75 SIHO - ALL PLANS SIHO - ALL PLANS 283.5 90 999999999 190.73 305.55 percent of total billed charges "Protein C, (clotting inhibitor) activity" 38007015_1 CDM 0301 RC 85302 HCPCS inpatient 315 204.75 UMR - ALL PLANS UMR - ALL PLANS 220.5 70 999999999 190.73 305.55 percent of total billed charges "Protein C, (clotting inhibitor) activity" 38007015_1 CDM 0301 RC 85302 HCPCS inpatient 315 204.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 190.73 60.55 999999999 190.73 305.55 percent of total billed charges "Protein C, (clotting inhibitor) activity" 38007015_1 CDM 0301 RC 85302 HCPCS inpatient 315 204.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 190.73 305.55 "Protein C, (clotting inhibitor) activity" 38007015_1 CDM 0301 RC 85302 HCPCS inpatient 315 204.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 190.73 305.55 "Protein C, (clotting inhibitor) activity" 38007015_1 CDM 0301 RC 85302 HCPCS inpatient 315 204.75 ANTHEM HMO ANTHEM HMO 999999999 190.73 305.55 "Protein C, (clotting inhibitor) activity" 38007015_1 CDM 0301 RC 85302 HCPCS inpatient 315 204.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 190.73 305.55 "Protein C, (clotting inhibitor) activity" 38007015_1 CDM 0301 RC 85302 HCPCS inpatient 315 204.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 212.94 67.6 999999999 190.73 305.55 percent of total billed charges "Protein C, (clotting inhibitor) activity" 38007015_1 CDM 0301 RC 85302 HCPCS inpatient 315 204.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 190.73 305.55 "Detection test by nucleic acid for Hepatitis B virus, quantification" 38007019_1 CDM 0306 RC 87517 HCPCS inpatient 395 256.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 256.75 65 999999999 239.17 383.15 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 38007019_1 CDM 0306 RC 87517 HCPCS inpatient 395 256.75 AETNA AETNA 312.05 79 999999999 239.17 383.15 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 38007019_1 CDM 0306 RC 87517 HCPCS inpatient 395 256.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 272.55 69 999999999 239.17 383.15 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 38007019_1 CDM 0306 RC 87517 HCPCS inpatient 395 256.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 383.15 97 999999999 239.17 383.15 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 38007019_1 CDM 0306 RC 87517 HCPCS inpatient 395 256.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 308.1 78 999999999 239.17 383.15 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 38007019_1 CDM 0306 RC 87517 HCPCS inpatient 395 256.75 SIHO - ALL PLANS SIHO - ALL PLANS 355.5 90 999999999 239.17 383.15 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 38007019_1 CDM 0306 RC 87517 HCPCS inpatient 395 256.75 UMR - ALL PLANS UMR - ALL PLANS 276.5 70 999999999 239.17 383.15 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 38007019_1 CDM 0306 RC 87517 HCPCS inpatient 395 256.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 239.17 60.55 999999999 239.17 383.15 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 38007019_1 CDM 0306 RC 87517 HCPCS inpatient 395 256.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 239.17 383.15 "Detection test by nucleic acid for Hepatitis B virus, quantification" 38007019_1 CDM 0306 RC 87517 HCPCS inpatient 395 256.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 239.17 383.15 "Detection test by nucleic acid for Hepatitis B virus, quantification" 38007019_1 CDM 0306 RC 87517 HCPCS inpatient 395 256.75 ANTHEM HMO ANTHEM HMO 999999999 239.17 383.15 "Detection test by nucleic acid for Hepatitis B virus, quantification" 38007019_1 CDM 0306 RC 87517 HCPCS inpatient 395 256.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 239.17 383.15 "Detection test by nucleic acid for Hepatitis B virus, quantification" 38007019_1 CDM 0306 RC 87517 HCPCS inpatient 395 256.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 267.02 67.6 999999999 239.17 383.15 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 38007019_1 CDM 0306 RC 87517 HCPCS inpatient 395 256.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 239.17 383.15 Protein S (clotting inhibitor) level 38007021_1 CDM 0301 RC 85305 HCPCS inpatient 315 204.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 204.75 65 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) level 38007021_1 CDM 0301 RC 85305 HCPCS inpatient 315 204.75 AETNA AETNA 248.85 79 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) level 38007021_1 CDM 0301 RC 85305 HCPCS inpatient 315 204.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 217.35 69 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) level 38007021_1 CDM 0301 RC 85305 HCPCS inpatient 315 204.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 305.55 97 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) level 38007021_1 CDM 0301 RC 85305 HCPCS inpatient 315 204.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 245.7 78 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) level 38007021_1 CDM 0301 RC 85305 HCPCS inpatient 315 204.75 SIHO - ALL PLANS SIHO - ALL PLANS 283.5 90 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) level 38007021_1 CDM 0301 RC 85305 HCPCS inpatient 315 204.75 UMR - ALL PLANS UMR - ALL PLANS 220.5 70 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) level 38007021_1 CDM 0301 RC 85305 HCPCS inpatient 315 204.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 190.73 60.55 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) level 38007021_1 CDM 0301 RC 85305 HCPCS inpatient 315 204.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 190.73 305.55 Protein S (clotting inhibitor) level 38007021_1 CDM 0301 RC 85305 HCPCS inpatient 315 204.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 190.73 305.55 Protein S (clotting inhibitor) level 38007021_1 CDM 0301 RC 85305 HCPCS inpatient 315 204.75 ANTHEM HMO ANTHEM HMO 999999999 190.73 305.55 Protein S (clotting inhibitor) level 38007021_1 CDM 0301 RC 85305 HCPCS inpatient 315 204.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 190.73 305.55 Protein S (clotting inhibitor) level 38007021_1 CDM 0301 RC 85305 HCPCS inpatient 315 204.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 212.94 67.6 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) level 38007021_1 CDM 0301 RC 85305 HCPCS inpatient 315 204.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 190.73 305.55 "Red blood cell antibody detection test, direct" 38063237_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 38063237_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 38063237_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 38063237_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 38063237_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 38063237_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 38063237_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 38063237_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 38063237_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Red blood cell antibody detection test, direct" 38063237_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Red blood cell antibody detection test, direct" 38063237_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Red blood cell antibody detection test, direct" 38063237_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Red blood cell antibody detection test, direct" 38063237_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 38063237_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Red blood cell antibody detection test, direct" 38073036_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 38073036_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 38073036_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 38073036_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 38073036_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 38073036_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 38073036_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 38073036_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 38073036_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 "Red blood cell antibody detection test, direct" 38073036_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 "Red blood cell antibody detection test, direct" 38073036_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 "Red blood cell antibody detection test, direct" 38073036_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 "Red blood cell antibody detection test, direct" 38073036_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 38073036_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 "Red blood cell antibody detection test, direct" 38073037_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 38073037_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 38073037_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 38073037_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 38073037_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 38073037_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 38073037_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 38073037_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 38073037_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 "Red blood cell antibody detection test, direct" 38073037_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 "Red blood cell antibody detection test, direct" 38073037_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 "Red blood cell antibody detection test, direct" 38073037_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 "Red blood cell antibody detection test, direct" 38073037_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 38073037_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 "Analysis of substance using immunoassay technique, multiple step method" 38128300_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65 65 999999999 60.55 97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 38128300_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 AETNA AETNA 79 79 999999999 60.55 97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 38128300_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69 69 999999999 60.55 97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 38128300_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97 97 999999999 60.55 97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 38128300_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78 78 999999999 60.55 97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 38128300_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 SIHO - ALL PLANS SIHO - ALL PLANS 90 90 999999999 60.55 97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 38128300_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 UMR - ALL PLANS UMR - ALL PLANS 70 70 999999999 60.55 97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 38128300_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.55 60.55 999999999 60.55 97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 38128300_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.55 97 "Analysis of substance using immunoassay technique, multiple step method" 38128300_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.55 97 "Analysis of substance using immunoassay technique, multiple step method" 38128300_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 ANTHEM HMO ANTHEM HMO 999999999 60.55 97 "Analysis of substance using immunoassay technique, multiple step method" 38128300_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.55 97 "Analysis of substance using immunoassay technique, multiple step method" 38128300_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.6 67.6 999999999 60.55 97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 38128300_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.55 97 "Analysis of substance using immunoassay technique, multiple step method" 38128301_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 38128301_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 38128301_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 38128301_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 38128301_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 38128301_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 38128301_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 38128301_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 38128301_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 38128301_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 38128301_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 38128301_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 38128301_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 38128301_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 Tissue culture inoculation for virus isolation 38128305_1 CDM 0302 RC 87252 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges Tissue culture inoculation for virus isolation 38128305_1 CDM 0302 RC 87252 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges Tissue culture inoculation for virus isolation 38128305_1 CDM 0302 RC 87252 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges Tissue culture inoculation for virus isolation 38128305_1 CDM 0302 RC 87252 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges Tissue culture inoculation for virus isolation 38128305_1 CDM 0302 RC 87252 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges Tissue culture inoculation for virus isolation 38128305_1 CDM 0302 RC 87252 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges Tissue culture inoculation for virus isolation 38128305_1 CDM 0302 RC 87252 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges Tissue culture inoculation for virus isolation 38128305_1 CDM 0302 RC 87252 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges Tissue culture inoculation for virus isolation 38128305_1 CDM 0302 RC 87252 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 Tissue culture inoculation for virus isolation 38128305_1 CDM 0302 RC 87252 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 Tissue culture inoculation for virus isolation 38128305_1 CDM 0302 RC 87252 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 Tissue culture inoculation for virus isolation 38128305_1 CDM 0302 RC 87252 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 Tissue culture inoculation for virus isolation 38128305_1 CDM 0302 RC 87252 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges Tissue culture inoculation for virus isolation 38128305_1 CDM 0302 RC 87252 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 Thyroid hormone evaluation 38128308_1 CDM 0301 RC 84479 HCPCS inpatient 122 79.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.3 65 999999999 73.87 118.34 percent of total billed charges Thyroid hormone evaluation 38128308_1 CDM 0301 RC 84479 HCPCS inpatient 122 79.3 AETNA AETNA 96.38 79 999999999 73.87 118.34 percent of total billed charges Thyroid hormone evaluation 38128308_1 CDM 0301 RC 84479 HCPCS inpatient 122 79.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.18 69 999999999 73.87 118.34 percent of total billed charges Thyroid hormone evaluation 38128308_1 CDM 0301 RC 84479 HCPCS inpatient 122 79.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 118.34 97 999999999 73.87 118.34 percent of total billed charges Thyroid hormone evaluation 38128308_1 CDM 0301 RC 84479 HCPCS inpatient 122 79.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.16 78 999999999 73.87 118.34 percent of total billed charges Thyroid hormone evaluation 38128308_1 CDM 0301 RC 84479 HCPCS inpatient 122 79.3 SIHO - ALL PLANS SIHO - ALL PLANS 109.8 90 999999999 73.87 118.34 percent of total billed charges Thyroid hormone evaluation 38128308_1 CDM 0301 RC 84479 HCPCS inpatient 122 79.3 UMR - ALL PLANS UMR - ALL PLANS 85.4 70 999999999 73.87 118.34 percent of total billed charges Thyroid hormone evaluation 38128308_1 CDM 0301 RC 84479 HCPCS inpatient 122 79.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.87 60.55 999999999 73.87 118.34 percent of total billed charges Thyroid hormone evaluation 38128308_1 CDM 0301 RC 84479 HCPCS inpatient 122 79.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.87 118.34 Thyroid hormone evaluation 38128308_1 CDM 0301 RC 84479 HCPCS inpatient 122 79.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.87 118.34 Thyroid hormone evaluation 38128308_1 CDM 0301 RC 84479 HCPCS inpatient 122 79.3 ANTHEM HMO ANTHEM HMO 999999999 73.87 118.34 Thyroid hormone evaluation 38128308_1 CDM 0301 RC 84479 HCPCS inpatient 122 79.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.87 118.34 Thyroid hormone evaluation 38128308_1 CDM 0301 RC 84479 HCPCS inpatient 122 79.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 82.47 67.6 999999999 73.87 118.34 percent of total billed charges Thyroid hormone evaluation 38128308_1 CDM 0301 RC 84479 HCPCS inpatient 122 79.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.87 118.34 Analysis for antibody to protozoa (parasite) 38128310_1 CDM 0301 RC 86753 HCPCS inpatient 212 137.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 137.8 65 999999999 128.37 205.64 percent of total billed charges Analysis for antibody to protozoa (parasite) 38128310_1 CDM 0301 RC 86753 HCPCS inpatient 212 137.8 AETNA AETNA 167.48 79 999999999 128.37 205.64 percent of total billed charges Analysis for antibody to protozoa (parasite) 38128310_1 CDM 0301 RC 86753 HCPCS inpatient 212 137.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 146.28 69 999999999 128.37 205.64 percent of total billed charges Analysis for antibody to protozoa (parasite) 38128310_1 CDM 0301 RC 86753 HCPCS inpatient 212 137.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 205.64 97 999999999 128.37 205.64 percent of total billed charges Analysis for antibody to protozoa (parasite) 38128310_1 CDM 0301 RC 86753 HCPCS inpatient 212 137.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 165.36 78 999999999 128.37 205.64 percent of total billed charges Analysis for antibody to protozoa (parasite) 38128310_1 CDM 0301 RC 86753 HCPCS inpatient 212 137.8 SIHO - ALL PLANS SIHO - ALL PLANS 190.8 90 999999999 128.37 205.64 percent of total billed charges Analysis for antibody to protozoa (parasite) 38128310_1 CDM 0301 RC 86753 HCPCS inpatient 212 137.8 UMR - ALL PLANS UMR - ALL PLANS 148.4 70 999999999 128.37 205.64 percent of total billed charges Analysis for antibody to protozoa (parasite) 38128310_1 CDM 0301 RC 86753 HCPCS inpatient 212 137.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 128.37 60.55 999999999 128.37 205.64 percent of total billed charges Analysis for antibody to protozoa (parasite) 38128310_1 CDM 0301 RC 86753 HCPCS inpatient 212 137.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 128.37 205.64 Analysis for antibody to protozoa (parasite) 38128310_1 CDM 0301 RC 86753 HCPCS inpatient 212 137.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 128.37 205.64 Analysis for antibody to protozoa (parasite) 38128310_1 CDM 0301 RC 86753 HCPCS inpatient 212 137.8 ANTHEM HMO ANTHEM HMO 999999999 128.37 205.64 Analysis for antibody to protozoa (parasite) 38128310_1 CDM 0301 RC 86753 HCPCS inpatient 212 137.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 128.37 205.64 Analysis for antibody to protozoa (parasite) 38128310_1 CDM 0301 RC 86753 HCPCS inpatient 212 137.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 143.31 67.6 999999999 128.37 205.64 percent of total billed charges Analysis for antibody to protozoa (parasite) 38128310_1 CDM 0301 RC 86753 HCPCS inpatient 212 137.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 128.37 205.64 Miscellaneous Reference Lab Test SB 38128318_1 CDM 0300 RC inpatient 113.7 73.91 SELF PAY DISCOUNT SELF PAY DISCOUNT 73.91 65 999999999 68.85 110.29 percent of total billed charges Miscellaneous Reference Lab Test SB 38128318_1 CDM 0300 RC inpatient 113.7 73.91 AETNA AETNA 89.82 79 999999999 68.85 110.29 percent of total billed charges Miscellaneous Reference Lab Test SB 38128318_1 CDM 0300 RC inpatient 113.7 73.91 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.45 69 999999999 68.85 110.29 percent of total billed charges Miscellaneous Reference Lab Test SB 38128318_1 CDM 0300 RC inpatient 113.7 73.91 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.29 97 999999999 68.85 110.29 percent of total billed charges Miscellaneous Reference Lab Test SB 38128318_1 CDM 0300 RC inpatient 113.7 73.91 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.69 78 999999999 68.85 110.29 percent of total billed charges Miscellaneous Reference Lab Test SB 38128318_1 CDM 0300 RC inpatient 113.7 73.91 SIHO - ALL PLANS SIHO - ALL PLANS 102.33 90 999999999 68.85 110.29 percent of total billed charges Miscellaneous Reference Lab Test SB 38128318_1 CDM 0300 RC inpatient 113.7 73.91 UMR - ALL PLANS UMR - ALL PLANS 79.59 70 999999999 68.85 110.29 percent of total billed charges Miscellaneous Reference Lab Test SB 38128318_1 CDM 0300 RC inpatient 113.7 73.91 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 68.85 60.55 999999999 68.85 110.29 percent of total billed charges Miscellaneous Reference Lab Test SB 38128318_1 CDM 0300 RC inpatient 113.7 73.91 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 68.85 110.29 Miscellaneous Reference Lab Test SB 38128318_1 CDM 0300 RC inpatient 113.7 73.91 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 68.85 110.29 Miscellaneous Reference Lab Test SB 38128318_1 CDM 0300 RC inpatient 113.7 73.91 ANTHEM HMO ANTHEM HMO 999999999 68.85 110.29 Miscellaneous Reference Lab Test SB 38128318_1 CDM 0300 RC inpatient 113.7 73.91 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 68.85 110.29 Miscellaneous Reference Lab Test SB 38128318_1 CDM 0300 RC inpatient 113.7 73.91 CIGNA - ALL PLANS CIGNA - ALL PLANS 76.86 67.6 999999999 68.85 110.29 percent of total billed charges Miscellaneous Reference Lab Test SB 38128318_1 CDM 0300 RC inpatient 113.7 73.91 UHC - ALL PLANS UHC - ALL PLANS 999999999 68.85 110.29 Measurement of substance using immunoassay technique 38128328_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 64.35 65 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 38128328_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 AETNA AETNA 78.21 79 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 38128328_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 68.31 69 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 38128328_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 96.03 97 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 38128328_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 77.22 78 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 38128328_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 SIHO - ALL PLANS SIHO - ALL PLANS 89.1 90 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 38128328_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 UMR - ALL PLANS UMR - ALL PLANS 69.3 70 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 38128328_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.94 60.55 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 38128328_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.94 96.03 Measurement of substance using immunoassay technique 38128328_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.94 96.03 Measurement of substance using immunoassay technique 38128328_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM HMO ANTHEM HMO 999999999 59.94 96.03 Measurement of substance using immunoassay technique 38128328_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.94 96.03 Measurement of substance using immunoassay technique 38128328_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.92 67.6 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 38128328_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.94 96.03 Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38128329_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38128329_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38128329_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38128329_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38128329_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38128329_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38128329_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38128329_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38128329_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38128329_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38128329_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38128329_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38128329_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 38128329_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 "Antiepileptics levels, 1-3" 38128335_1 CDM 0301 RC 80339 HCPCS inpatient 256 166.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 166.4 65 999999999 155.01 248.32 percent of total billed charges "Antiepileptics levels, 1-3" 38128335_1 CDM 0301 RC 80339 HCPCS inpatient 256 166.4 AETNA AETNA 202.24 79 999999999 155.01 248.32 percent of total billed charges "Antiepileptics levels, 1-3" 38128335_1 CDM 0301 RC 80339 HCPCS inpatient 256 166.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 176.64 69 999999999 155.01 248.32 percent of total billed charges "Antiepileptics levels, 1-3" 38128335_1 CDM 0301 RC 80339 HCPCS inpatient 256 166.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 248.32 97 999999999 155.01 248.32 percent of total billed charges "Antiepileptics levels, 1-3" 38128335_1 CDM 0301 RC 80339 HCPCS inpatient 256 166.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 199.68 78 999999999 155.01 248.32 percent of total billed charges "Antiepileptics levels, 1-3" 38128335_1 CDM 0301 RC 80339 HCPCS inpatient 256 166.4 SIHO - ALL PLANS SIHO - ALL PLANS 230.4 90 999999999 155.01 248.32 percent of total billed charges "Antiepileptics levels, 1-3" 38128335_1 CDM 0301 RC 80339 HCPCS inpatient 256 166.4 UMR - ALL PLANS UMR - ALL PLANS 179.2 70 999999999 155.01 248.32 percent of total billed charges "Antiepileptics levels, 1-3" 38128335_1 CDM 0301 RC 80339 HCPCS inpatient 256 166.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.01 60.55 999999999 155.01 248.32 percent of total billed charges "Antiepileptics levels, 1-3" 38128335_1 CDM 0301 RC 80339 HCPCS inpatient 256 166.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.01 248.32 "Antiepileptics levels, 1-3" 38128335_1 CDM 0301 RC 80339 HCPCS inpatient 256 166.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.01 248.32 "Antiepileptics levels, 1-3" 38128335_1 CDM 0301 RC 80339 HCPCS inpatient 256 166.4 ANTHEM HMO ANTHEM HMO 999999999 155.01 248.32 "Antiepileptics levels, 1-3" 38128335_1 CDM 0301 RC 80339 HCPCS inpatient 256 166.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.01 248.32 "Antiepileptics levels, 1-3" 38128335_1 CDM 0301 RC 80339 HCPCS inpatient 256 166.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.06 67.6 999999999 155.01 248.32 percent of total billed charges "Antiepileptics levels, 1-3" 38128335_1 CDM 0301 RC 80339 HCPCS inpatient 256 166.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.01 248.32 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 38128395_1 CDM 0301 RC 87385 HCPCS inpatient 386 250.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 250.9 65 999999999 233.72 374.42 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 38128395_1 CDM 0301 RC 87385 HCPCS inpatient 386 250.9 AETNA AETNA 304.94 79 999999999 233.72 374.42 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 38128395_1 CDM 0301 RC 87385 HCPCS inpatient 386 250.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 266.34 69 999999999 233.72 374.42 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 38128395_1 CDM 0301 RC 87385 HCPCS inpatient 386 250.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 374.42 97 999999999 233.72 374.42 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 38128395_1 CDM 0301 RC 87385 HCPCS inpatient 386 250.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.08 78 999999999 233.72 374.42 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 38128395_1 CDM 0301 RC 87385 HCPCS inpatient 386 250.9 SIHO - ALL PLANS SIHO - ALL PLANS 347.4 90 999999999 233.72 374.42 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 38128395_1 CDM 0301 RC 87385 HCPCS inpatient 386 250.9 UMR - ALL PLANS UMR - ALL PLANS 270.2 70 999999999 233.72 374.42 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 38128395_1 CDM 0301 RC 87385 HCPCS inpatient 386 250.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 233.72 60.55 999999999 233.72 374.42 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 38128395_1 CDM 0301 RC 87385 HCPCS inpatient 386 250.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 233.72 374.42 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 38128395_1 CDM 0301 RC 87385 HCPCS inpatient 386 250.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 233.72 374.42 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 38128395_1 CDM 0301 RC 87385 HCPCS inpatient 386 250.9 ANTHEM HMO ANTHEM HMO 999999999 233.72 374.42 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 38128395_1 CDM 0301 RC 87385 HCPCS inpatient 386 250.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 233.72 374.42 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 38128395_1 CDM 0301 RC 87385 HCPCS inpatient 386 250.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 260.94 67.6 999999999 233.72 374.42 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 38128395_1 CDM 0301 RC 87385 HCPCS inpatient 386 250.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 233.72 374.42 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 38137937_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 38137937_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 38137937_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 38137937_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 38137937_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 38137937_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 38137937_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 38137937_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 38137937_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 38137937_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 38137937_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 38137937_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 38137937_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 38137937_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 Renin (kidney enzyme) level 38282212_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 235.3 65 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 38282212_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 AETNA AETNA 285.98 79 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 38282212_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 249.78 69 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 38282212_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 351.14 97 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 38282212_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 282.36 78 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 38282212_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 SIHO - ALL PLANS SIHO - ALL PLANS 325.8 90 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 38282212_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 UMR - ALL PLANS UMR - ALL PLANS 253.4 70 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 38282212_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 219.19 60.55 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 38282212_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 219.19 351.14 Renin (kidney enzyme) level 38282212_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 219.19 351.14 Renin (kidney enzyme) level 38282212_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 ANTHEM HMO ANTHEM HMO 999999999 219.19 351.14 Renin (kidney enzyme) level 38282212_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 219.19 351.14 Renin (kidney enzyme) level 38282212_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 244.71 67.6 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 38282212_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 219.19 351.14 Aldosterone hormone level 38282213_1 CDM 0301 RC 82088 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges Aldosterone hormone level 38282213_1 CDM 0301 RC 82088 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges Aldosterone hormone level 38282213_1 CDM 0301 RC 82088 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges Aldosterone hormone level 38282213_1 CDM 0301 RC 82088 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges Aldosterone hormone level 38282213_1 CDM 0301 RC 82088 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges Aldosterone hormone level 38282213_1 CDM 0301 RC 82088 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges Aldosterone hormone level 38282213_1 CDM 0301 RC 82088 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges Aldosterone hormone level 38282213_1 CDM 0301 RC 82088 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges Aldosterone hormone level 38282213_1 CDM 0301 RC 82088 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 Aldosterone hormone level 38282213_1 CDM 0301 RC 82088 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 Aldosterone hormone level 38282213_1 CDM 0301 RC 82088 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 Aldosterone hormone level 38282213_1 CDM 0301 RC 82088 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 Aldosterone hormone level 38282213_1 CDM 0301 RC 82088 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges Aldosterone hormone level 38282213_1 CDM 0301 RC 82088 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 Immunologic analysis for detection of antigen or antibody 38292509_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292509_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292509_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292509_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292509_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292509_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292509_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292509_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292509_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 38292509_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 38292509_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 38292509_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 38292509_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292509_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 38292510_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292510_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292510_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292510_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292510_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292510_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292510_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292510_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292510_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 38292510_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 38292510_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 38292510_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 38292510_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292510_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 38292511_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292511_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292511_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292511_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292511_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292511_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292511_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292511_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292511_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 38292511_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 38292511_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 38292511_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 38292511_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292511_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Analysis for antibody to aspergillus (fungus) 38292512_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 38292512_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 38292512_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 38292512_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 38292512_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 38292512_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 38292512_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 38292512_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 38292512_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 38292512_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 38292512_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 38292512_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 38292512_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 38292512_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 Immunologic analysis for detection of antigen or antibody 38292513_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292513_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292513_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292513_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292513_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292513_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292513_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292513_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292513_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 38292513_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 38292513_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 38292513_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 38292513_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 38292513_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Analysis for antibody to aspergillus (fungus) 38292514_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 38292514_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 38292514_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 38292514_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 38292514_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 38292514_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 38292514_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 38292514_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 38292514_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 38292514_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 38292514_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 38292514_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 38292514_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 38292514_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Red blood count automated, with additional calculations" 39290490_1 CDM 0305 RC 85046 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Red blood count automated, with additional calculations" 39290490_1 CDM 0305 RC 85046 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Red blood count automated, with additional calculations" 39290490_1 CDM 0305 RC 85046 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Red blood count automated, with additional calculations" 39290490_1 CDM 0305 RC 85046 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Red blood count automated, with additional calculations" 39290490_1 CDM 0305 RC 85046 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Red blood count automated, with additional calculations" 39290490_1 CDM 0305 RC 85046 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Red blood count automated, with additional calculations" 39290490_1 CDM 0305 RC 85046 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Red blood count automated, with additional calculations" 39290490_1 CDM 0305 RC 85046 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Red blood count automated, with additional calculations" 39290490_1 CDM 0305 RC 85046 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Red blood count automated, with additional calculations" 39290490_1 CDM 0305 RC 85046 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Red blood count automated, with additional calculations" 39290490_1 CDM 0305 RC 85046 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Red blood count automated, with additional calculations" 39290490_1 CDM 0305 RC 85046 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Red blood count automated, with additional calculations" 39290490_1 CDM 0305 RC 85046 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges "Red blood count automated, with additional calculations" 39290490_1 CDM 0305 RC 85046 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 Ultrasound of one leg arteries or artery grafts 39966764_1 CDM 0420 RC 93926 HCPCS inpatient 412 267.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 267.8 65 999999999 249.47 399.64 percent of total billed charges Ultrasound of one leg arteries or artery grafts 39966764_1 CDM 0420 RC 93926 HCPCS inpatient 412 267.8 AETNA AETNA 325.48 79 999999999 249.47 399.64 percent of total billed charges Ultrasound of one leg arteries or artery grafts 39966764_1 CDM 0420 RC 93926 HCPCS inpatient 412 267.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 284.28 69 999999999 249.47 399.64 percent of total billed charges Ultrasound of one leg arteries or artery grafts 39966764_1 CDM 0420 RC 93926 HCPCS inpatient 412 267.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 399.64 97 999999999 249.47 399.64 percent of total billed charges Ultrasound of one leg arteries or artery grafts 39966764_1 CDM 0420 RC 93926 HCPCS inpatient 412 267.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 321.36 78 999999999 249.47 399.64 percent of total billed charges Ultrasound of one leg arteries or artery grafts 39966764_1 CDM 0420 RC 93926 HCPCS inpatient 412 267.8 SIHO - ALL PLANS SIHO - ALL PLANS 370.8 90 999999999 249.47 399.64 percent of total billed charges Ultrasound of one leg arteries or artery grafts 39966764_1 CDM 0420 RC 93926 HCPCS inpatient 412 267.8 UMR - ALL PLANS UMR - ALL PLANS 288.4 70 999999999 249.47 399.64 percent of total billed charges Ultrasound of one leg arteries or artery grafts 39966764_1 CDM 0420 RC 93926 HCPCS inpatient 412 267.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 249.47 60.55 999999999 249.47 399.64 percent of total billed charges Ultrasound of one leg arteries or artery grafts 39966764_1 CDM 0420 RC 93926 HCPCS inpatient 412 267.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 249.47 399.64 Ultrasound of one leg arteries or artery grafts 39966764_1 CDM 0420 RC 93926 HCPCS inpatient 412 267.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 249.47 399.64 Ultrasound of one leg arteries or artery grafts 39966764_1 CDM 0420 RC 93926 HCPCS inpatient 412 267.8 ANTHEM HMO ANTHEM HMO 999999999 249.47 399.64 Ultrasound of one leg arteries or artery grafts 39966764_1 CDM 0420 RC 93926 HCPCS inpatient 412 267.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 249.47 399.64 Ultrasound of one leg arteries or artery grafts 39966764_1 CDM 0420 RC 93926 HCPCS inpatient 412 267.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 278.51 67.6 999999999 249.47 399.64 percent of total billed charges Ultrasound of one leg arteries or artery grafts 39966764_1 CDM 0420 RC 93926 HCPCS inpatient 412 267.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 249.47 399.64 Fungal culture (mold or yeast) 40052888_1 CDM 0306 RC 87102 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges Fungal culture (mold or yeast) 40052888_1 CDM 0306 RC 87102 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges Fungal culture (mold or yeast) 40052888_1 CDM 0306 RC 87102 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges Fungal culture (mold or yeast) 40052888_1 CDM 0306 RC 87102 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges Fungal culture (mold or yeast) 40052888_1 CDM 0306 RC 87102 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges Fungal culture (mold or yeast) 40052888_1 CDM 0306 RC 87102 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges Fungal culture (mold or yeast) 40052888_1 CDM 0306 RC 87102 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges Fungal culture (mold or yeast) 40052888_1 CDM 0306 RC 87102 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges Fungal culture (mold or yeast) 40052888_1 CDM 0306 RC 87102 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 Fungal culture (mold or yeast) 40052888_1 CDM 0306 RC 87102 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 Fungal culture (mold or yeast) 40052888_1 CDM 0306 RC 87102 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 Fungal culture (mold or yeast) 40052888_1 CDM 0306 RC 87102 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 Fungal culture (mold or yeast) 40052888_1 CDM 0306 RC 87102 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges Fungal culture (mold or yeast) 40052888_1 CDM 0306 RC 87102 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 Culture for acid-fast bacilli 40052890_1 CDM 0306 RC 87116 HCPCS inpatient 218 141.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 141.7 65 999999999 132 211.46 percent of total billed charges Culture for acid-fast bacilli 40052890_1 CDM 0306 RC 87116 HCPCS inpatient 218 141.7 AETNA AETNA 172.22 79 999999999 132 211.46 percent of total billed charges Culture for acid-fast bacilli 40052890_1 CDM 0306 RC 87116 HCPCS inpatient 218 141.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 150.42 69 999999999 132 211.46 percent of total billed charges Culture for acid-fast bacilli 40052890_1 CDM 0306 RC 87116 HCPCS inpatient 218 141.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 211.46 97 999999999 132 211.46 percent of total billed charges Culture for acid-fast bacilli 40052890_1 CDM 0306 RC 87116 HCPCS inpatient 218 141.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.04 78 999999999 132 211.46 percent of total billed charges Culture for acid-fast bacilli 40052890_1 CDM 0306 RC 87116 HCPCS inpatient 218 141.7 SIHO - ALL PLANS SIHO - ALL PLANS 196.2 90 999999999 132 211.46 percent of total billed charges Culture for acid-fast bacilli 40052890_1 CDM 0306 RC 87116 HCPCS inpatient 218 141.7 UMR - ALL PLANS UMR - ALL PLANS 152.6 70 999999999 132 211.46 percent of total billed charges Culture for acid-fast bacilli 40052890_1 CDM 0306 RC 87116 HCPCS inpatient 218 141.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132 60.55 999999999 132 211.46 percent of total billed charges Culture for acid-fast bacilli 40052890_1 CDM 0306 RC 87116 HCPCS inpatient 218 141.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132 211.46 Culture for acid-fast bacilli 40052890_1 CDM 0306 RC 87116 HCPCS inpatient 218 141.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132 211.46 Culture for acid-fast bacilli 40052890_1 CDM 0306 RC 87116 HCPCS inpatient 218 141.7 ANTHEM HMO ANTHEM HMO 999999999 132 211.46 Culture for acid-fast bacilli 40052890_1 CDM 0306 RC 87116 HCPCS inpatient 218 141.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132 211.46 Culture for acid-fast bacilli 40052890_1 CDM 0306 RC 87116 HCPCS inpatient 218 141.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 147.37 67.6 999999999 132 211.46 percent of total billed charges Culture for acid-fast bacilli 40052890_1 CDM 0306 RC 87116 HCPCS inpatient 218 141.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 132 211.46 Special fluorescent and/or acid fast stain for microorganism 40052951_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 84.5 65 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 40052951_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 AETNA AETNA 102.7 79 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 40052951_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.7 69 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 40052951_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 126.1 97 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 40052951_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 101.4 78 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 40052951_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 SIHO - ALL PLANS SIHO - ALL PLANS 117 90 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 40052951_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 UMR - ALL PLANS UMR - ALL PLANS 91 70 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 40052951_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.72 60.55 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 40052951_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.72 126.1 Special fluorescent and/or acid fast stain for microorganism 40052951_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.72 126.1 Special fluorescent and/or acid fast stain for microorganism 40052951_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 ANTHEM HMO ANTHEM HMO 999999999 78.72 126.1 Special fluorescent and/or acid fast stain for microorganism 40052951_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.72 126.1 Special fluorescent and/or acid fast stain for microorganism 40052951_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.88 67.6 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 40052951_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.72 126.1 "Analysis of urine, except immunoassays" 40052996_1 CDM 0307 RC 81005 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges "Analysis of urine, except immunoassays" 40052996_1 CDM 0307 RC 81005 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges "Analysis of urine, except immunoassays" 40052996_1 CDM 0307 RC 81005 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges "Analysis of urine, except immunoassays" 40052996_1 CDM 0307 RC 81005 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges "Analysis of urine, except immunoassays" 40052996_1 CDM 0307 RC 81005 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges "Analysis of urine, except immunoassays" 40052996_1 CDM 0307 RC 81005 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges "Analysis of urine, except immunoassays" 40052996_1 CDM 0307 RC 81005 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges "Analysis of urine, except immunoassays" 40052996_1 CDM 0307 RC 81005 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges "Analysis of urine, except immunoassays" 40052996_1 CDM 0307 RC 81005 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 "Analysis of urine, except immunoassays" 40052996_1 CDM 0307 RC 81005 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 "Analysis of urine, except immunoassays" 40052996_1 CDM 0307 RC 81005 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 "Analysis of urine, except immunoassays" 40052996_1 CDM 0307 RC 81005 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 "Analysis of urine, except immunoassays" 40052996_1 CDM 0307 RC 81005 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges "Analysis of urine, except immunoassays" 40052996_1 CDM 0307 RC 81005 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 "Protein measurement, body fluid" 40052998_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges "Protein measurement, body fluid" 40052998_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges "Protein measurement, body fluid" 40052998_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges "Protein measurement, body fluid" 40052998_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges "Protein measurement, body fluid" 40052998_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges "Protein measurement, body fluid" 40052998_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges "Protein measurement, body fluid" 40052998_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges "Protein measurement, body fluid" 40052998_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges "Protein measurement, body fluid" 40052998_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 "Protein measurement, body fluid" 40052998_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 "Protein measurement, body fluid" 40052998_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 "Protein measurement, body fluid" 40052998_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 "Protein measurement, body fluid" 40052998_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges "Protein measurement, body fluid" 40052998_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 "Clotting factor II prothrombin, measurement" 40053006_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 258.05 65 999999999 240.38 385.09 percent of total billed charges "Clotting factor II prothrombin, measurement" 40053006_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 AETNA AETNA 313.63 79 999999999 240.38 385.09 percent of total billed charges "Clotting factor II prothrombin, measurement" 40053006_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 273.93 69 999999999 240.38 385.09 percent of total billed charges "Clotting factor II prothrombin, measurement" 40053006_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 385.09 97 999999999 240.38 385.09 percent of total billed charges "Clotting factor II prothrombin, measurement" 40053006_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 309.66 78 999999999 240.38 385.09 percent of total billed charges "Clotting factor II prothrombin, measurement" 40053006_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 SIHO - ALL PLANS SIHO - ALL PLANS 357.3 90 999999999 240.38 385.09 percent of total billed charges "Clotting factor II prothrombin, measurement" 40053006_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 UMR - ALL PLANS UMR - ALL PLANS 277.9 70 999999999 240.38 385.09 percent of total billed charges "Clotting factor II prothrombin, measurement" 40053006_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 240.38 60.55 999999999 240.38 385.09 percent of total billed charges "Clotting factor II prothrombin, measurement" 40053006_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 240.38 385.09 "Clotting factor II prothrombin, measurement" 40053006_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 240.38 385.09 "Clotting factor II prothrombin, measurement" 40053006_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 ANTHEM HMO ANTHEM HMO 999999999 240.38 385.09 "Clotting factor II prothrombin, measurement" 40053006_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 240.38 385.09 "Clotting factor II prothrombin, measurement" 40053006_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 268.37 67.6 999999999 240.38 385.09 percent of total billed charges "Clotting factor II prothrombin, measurement" 40053006_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 240.38 385.09 "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 40053027_1 CDM 0302 RC 86812 HCPCS inpatient 268 174.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 174.2 65 999999999 162.27 259.96 percent of total billed charges "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 40053027_1 CDM 0302 RC 86812 HCPCS inpatient 268 174.2 AETNA AETNA 211.72 79 999999999 162.27 259.96 percent of total billed charges "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 40053027_1 CDM 0302 RC 86812 HCPCS inpatient 268 174.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.92 69 999999999 162.27 259.96 percent of total billed charges "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 40053027_1 CDM 0302 RC 86812 HCPCS inpatient 268 174.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 259.96 97 999999999 162.27 259.96 percent of total billed charges "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 40053027_1 CDM 0302 RC 86812 HCPCS inpatient 268 174.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 209.04 78 999999999 162.27 259.96 percent of total billed charges "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 40053027_1 CDM 0302 RC 86812 HCPCS inpatient 268 174.2 SIHO - ALL PLANS SIHO - ALL PLANS 241.2 90 999999999 162.27 259.96 percent of total billed charges "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 40053027_1 CDM 0302 RC 86812 HCPCS inpatient 268 174.2 UMR - ALL PLANS UMR - ALL PLANS 187.6 70 999999999 162.27 259.96 percent of total billed charges "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 40053027_1 CDM 0302 RC 86812 HCPCS inpatient 268 174.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 162.27 60.55 999999999 162.27 259.96 percent of total billed charges "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 40053027_1 CDM 0302 RC 86812 HCPCS inpatient 268 174.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 162.27 259.96 "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 40053027_1 CDM 0302 RC 86812 HCPCS inpatient 268 174.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 162.27 259.96 "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 40053027_1 CDM 0302 RC 86812 HCPCS inpatient 268 174.2 ANTHEM HMO ANTHEM HMO 999999999 162.27 259.96 "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 40053027_1 CDM 0302 RC 86812 HCPCS inpatient 268 174.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 162.27 259.96 "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 40053027_1 CDM 0302 RC 86812 HCPCS inpatient 268 174.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 181.17 67.6 999999999 162.27 259.96 percent of total billed charges "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 40053027_1 CDM 0302 RC 86812 HCPCS inpatient 268 174.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 162.27 259.96 G6PD (enzyme) level 40053038_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges G6PD (enzyme) level 40053038_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges G6PD (enzyme) level 40053038_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges G6PD (enzyme) level 40053038_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges G6PD (enzyme) level 40053038_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges G6PD (enzyme) level 40053038_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges G6PD (enzyme) level 40053038_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges G6PD (enzyme) level 40053038_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges G6PD (enzyme) level 40053038_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 G6PD (enzyme) level 40053038_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 G6PD (enzyme) level 40053038_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 G6PD (enzyme) level 40053038_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 G6PD (enzyme) level 40053038_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges G6PD (enzyme) level 40053038_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 Catecholamines (organic nitrogen) level 40053039_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 40053039_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 40053039_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 40053039_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 40053039_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 40053039_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 40053039_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 40053039_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 40053039_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 Catecholamines (organic nitrogen) level 40053039_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 Catecholamines (organic nitrogen) level 40053039_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 Catecholamines (organic nitrogen) level 40053039_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 Catecholamines (organic nitrogen) level 40053039_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 40053039_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 Metanephrines level 40053040_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 SELF PAY DISCOUNT SELF PAY DISCOUNT 156 65 999999999 145.32 232.8 percent of total billed charges Metanephrines level 40053040_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 AETNA AETNA 189.6 79 999999999 145.32 232.8 percent of total billed charges Metanephrines level 40053040_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 ENCORE - ALL PLANS ENCORE - ALL PLANS 165.6 69 999999999 145.32 232.8 percent of total billed charges Metanephrines level 40053040_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 232.8 97 999999999 145.32 232.8 percent of total billed charges Metanephrines level 40053040_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.2 78 999999999 145.32 232.8 percent of total billed charges Metanephrines level 40053040_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 SIHO - ALL PLANS SIHO - ALL PLANS 216 90 999999999 145.32 232.8 percent of total billed charges Metanephrines level 40053040_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 UMR - ALL PLANS UMR - ALL PLANS 168 70 999999999 145.32 232.8 percent of total billed charges Metanephrines level 40053040_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.32 60.55 999999999 145.32 232.8 percent of total billed charges Metanephrines level 40053040_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.32 232.8 Metanephrines level 40053040_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.32 232.8 Metanephrines level 40053040_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 ANTHEM HMO ANTHEM HMO 999999999 145.32 232.8 Metanephrines level 40053040_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.32 232.8 Metanephrines level 40053040_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.24 67.6 999999999 145.32 232.8 percent of total billed charges Metanephrines level 40053040_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.32 232.8 Copper level 40062653_1 CDM 0301 RC 82525 HCPCS inpatient 167 108.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 108.55 65 999999999 101.12 161.99 percent of total billed charges Copper level 40062653_1 CDM 0301 RC 82525 HCPCS inpatient 167 108.55 AETNA AETNA 131.93 79 999999999 101.12 161.99 percent of total billed charges Copper level 40062653_1 CDM 0301 RC 82525 HCPCS inpatient 167 108.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.23 69 999999999 101.12 161.99 percent of total billed charges Copper level 40062653_1 CDM 0301 RC 82525 HCPCS inpatient 167 108.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.99 97 999999999 101.12 161.99 percent of total billed charges Copper level 40062653_1 CDM 0301 RC 82525 HCPCS inpatient 167 108.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 130.26 78 999999999 101.12 161.99 percent of total billed charges Copper level 40062653_1 CDM 0301 RC 82525 HCPCS inpatient 167 108.55 SIHO - ALL PLANS SIHO - ALL PLANS 150.3 90 999999999 101.12 161.99 percent of total billed charges Copper level 40062653_1 CDM 0301 RC 82525 HCPCS inpatient 167 108.55 UMR - ALL PLANS UMR - ALL PLANS 116.9 70 999999999 101.12 161.99 percent of total billed charges Copper level 40062653_1 CDM 0301 RC 82525 HCPCS inpatient 167 108.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.12 60.55 999999999 101.12 161.99 percent of total billed charges Copper level 40062653_1 CDM 0301 RC 82525 HCPCS inpatient 167 108.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.12 161.99 Copper level 40062653_1 CDM 0301 RC 82525 HCPCS inpatient 167 108.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.12 161.99 Copper level 40062653_1 CDM 0301 RC 82525 HCPCS inpatient 167 108.55 ANTHEM HMO ANTHEM HMO 999999999 101.12 161.99 Copper level 40062653_1 CDM 0301 RC 82525 HCPCS inpatient 167 108.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.12 161.99 Copper level 40062653_1 CDM 0301 RC 82525 HCPCS inpatient 167 108.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.89 67.6 999999999 101.12 161.99 percent of total billed charges Copper level 40062653_1 CDM 0301 RC 82525 HCPCS inpatient 167 108.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.12 161.99 Metanephrines level 40062654_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 SELF PAY DISCOUNT SELF PAY DISCOUNT 156 65 999999999 145.32 232.8 percent of total billed charges Metanephrines level 40062654_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 AETNA AETNA 189.6 79 999999999 145.32 232.8 percent of total billed charges Metanephrines level 40062654_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 ENCORE - ALL PLANS ENCORE - ALL PLANS 165.6 69 999999999 145.32 232.8 percent of total billed charges Metanephrines level 40062654_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 232.8 97 999999999 145.32 232.8 percent of total billed charges Metanephrines level 40062654_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.2 78 999999999 145.32 232.8 percent of total billed charges Metanephrines level 40062654_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 SIHO - ALL PLANS SIHO - ALL PLANS 216 90 999999999 145.32 232.8 percent of total billed charges Metanephrines level 40062654_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 UMR - ALL PLANS UMR - ALL PLANS 168 70 999999999 145.32 232.8 percent of total billed charges Metanephrines level 40062654_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.32 60.55 999999999 145.32 232.8 percent of total billed charges Metanephrines level 40062654_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.32 232.8 Metanephrines level 40062654_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.32 232.8 Metanephrines level 40062654_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 ANTHEM HMO ANTHEM HMO 999999999 145.32 232.8 Metanephrines level 40062654_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.32 232.8 Metanephrines level 40062654_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.24 67.6 999999999 145.32 232.8 percent of total billed charges Metanephrines level 40062654_1 CDM 0301 RC 83835 HCPCS inpatient 240 156 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.32 232.8 "Measurement of substance using immunoassay technique, by radioimmunoassay" 40062668_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 195.65 65 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 40062668_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 AETNA AETNA 237.79 79 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 40062668_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 207.69 69 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 40062668_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291.97 97 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 40062668_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 234.78 78 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 40062668_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 SIHO - ALL PLANS SIHO - ALL PLANS 270.9 90 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 40062668_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 UMR - ALL PLANS UMR - ALL PLANS 210.7 70 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 40062668_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.26 60.55 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 40062668_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 40062668_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 40062668_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM HMO ANTHEM HMO 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 40062668_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 40062668_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 203.48 67.6 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 40062668_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.26 291.97 Cocaine level 40062670_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 287.3 65 999999999 267.63 428.74 percent of total billed charges Cocaine level 40062670_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 AETNA AETNA 349.18 79 999999999 267.63 428.74 percent of total billed charges Cocaine level 40062670_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 304.98 69 999999999 267.63 428.74 percent of total billed charges Cocaine level 40062670_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 428.74 97 999999999 267.63 428.74 percent of total billed charges Cocaine level 40062670_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 344.76 78 999999999 267.63 428.74 percent of total billed charges Cocaine level 40062670_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 SIHO - ALL PLANS SIHO - ALL PLANS 397.8 90 999999999 267.63 428.74 percent of total billed charges Cocaine level 40062670_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 UMR - ALL PLANS UMR - ALL PLANS 309.4 70 999999999 267.63 428.74 percent of total billed charges Cocaine level 40062670_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 267.63 60.55 999999999 267.63 428.74 percent of total billed charges Cocaine level 40062670_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 267.63 428.74 Cocaine level 40062670_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 267.63 428.74 Cocaine level 40062670_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 ANTHEM HMO ANTHEM HMO 999999999 267.63 428.74 Cocaine level 40062670_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 267.63 428.74 Cocaine level 40062670_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 298.79 67.6 999999999 267.63 428.74 percent of total billed charges Cocaine level 40062670_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 267.63 428.74 T cell count and ratio 40062782_1 CDM 0302 RC 86361 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges T cell count and ratio 40062782_1 CDM 0302 RC 86361 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges T cell count and ratio 40062782_1 CDM 0302 RC 86361 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges T cell count and ratio 40062782_1 CDM 0302 RC 86361 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges T cell count and ratio 40062782_1 CDM 0302 RC 86361 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges T cell count and ratio 40062782_1 CDM 0302 RC 86361 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges T cell count and ratio 40062782_1 CDM 0302 RC 86361 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges T cell count and ratio 40062782_1 CDM 0302 RC 86361 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges T cell count and ratio 40062782_1 CDM 0302 RC 86361 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 T cell count and ratio 40062782_1 CDM 0302 RC 86361 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 T cell count and ratio 40062782_1 CDM 0302 RC 86361 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 T cell count and ratio 40062782_1 CDM 0302 RC 86361 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 T cell count and ratio 40062782_1 CDM 0302 RC 86361 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges T cell count and ratio 40062782_1 CDM 0302 RC 86361 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 Analysis for antibody to mumps virus 40062784_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 40062784_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 40062784_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 40062784_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 40062784_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 40062784_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 40062784_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 40062784_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 40062784_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 Analysis for antibody to mumps virus 40062784_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 Analysis for antibody to mumps virus 40062784_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 Analysis for antibody to mumps virus 40062784_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 Analysis for antibody to mumps virus 40062784_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 40062784_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 "Bacterial culture, any source, except blood, anaerobic" 41292038_1 CDM 0306 RC 87075 HCPCS inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges "Bacterial culture, any source, except blood, anaerobic" 41292038_1 CDM 0306 RC 87075 HCPCS inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges "Bacterial culture, any source, except blood, anaerobic" 41292038_1 CDM 0306 RC 87075 HCPCS inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges "Bacterial culture, any source, except blood, anaerobic" 41292038_1 CDM 0306 RC 87075 HCPCS inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges "Bacterial culture, any source, except blood, anaerobic" 41292038_1 CDM 0306 RC 87075 HCPCS inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges "Bacterial culture, any source, except blood, anaerobic" 41292038_1 CDM 0306 RC 87075 HCPCS inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges "Bacterial culture, any source, except blood, anaerobic" 41292038_1 CDM 0306 RC 87075 HCPCS inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges "Bacterial culture, any source, except blood, anaerobic" 41292038_1 CDM 0306 RC 87075 HCPCS inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges "Bacterial culture, any source, except blood, anaerobic" 41292038_1 CDM 0306 RC 87075 HCPCS inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 "Bacterial culture, any source, except blood, anaerobic" 41292038_1 CDM 0306 RC 87075 HCPCS inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 "Bacterial culture, any source, except blood, anaerobic" 41292038_1 CDM 0306 RC 87075 HCPCS inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 "Bacterial culture, any source, except blood, anaerobic" 41292038_1 CDM 0306 RC 87075 HCPCS inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 "Bacterial culture, any source, except blood, anaerobic" 41292038_1 CDM 0306 RC 87075 HCPCS inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges "Bacterial culture, any source, except blood, anaerobic" 41292038_1 CDM 0306 RC 87075 HCPCS inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 "Bacterial culture, any other source except urine, blood or stool, aerobic" 41292039_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 69.55 65 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 41292039_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 AETNA AETNA 84.53 79 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 41292039_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.83 69 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 41292039_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 103.79 97 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 41292039_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 83.46 78 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 41292039_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 SIHO - ALL PLANS SIHO - ALL PLANS 96.3 90 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 41292039_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 UMR - ALL PLANS UMR - ALL PLANS 74.9 70 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 41292039_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.79 60.55 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 41292039_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 41292039_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 41292039_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM HMO ANTHEM HMO 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 41292039_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 41292039_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 72.33 67.6 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 41292039_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.79 103.79 "Folic acid level, serum" 41603007_1 CDM 0301 RC 82746 HCPCS inpatient 237 154.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.05 65 999999999 143.5 229.89 percent of total billed charges "Folic acid level, serum" 41603007_1 CDM 0301 RC 82746 HCPCS inpatient 237 154.05 AETNA AETNA 187.23 79 999999999 143.5 229.89 percent of total billed charges "Folic acid level, serum" 41603007_1 CDM 0301 RC 82746 HCPCS inpatient 237 154.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 163.53 69 999999999 143.5 229.89 percent of total billed charges "Folic acid level, serum" 41603007_1 CDM 0301 RC 82746 HCPCS inpatient 237 154.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 229.89 97 999999999 143.5 229.89 percent of total billed charges "Folic acid level, serum" 41603007_1 CDM 0301 RC 82746 HCPCS inpatient 237 154.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 184.86 78 999999999 143.5 229.89 percent of total billed charges "Folic acid level, serum" 41603007_1 CDM 0301 RC 82746 HCPCS inpatient 237 154.05 SIHO - ALL PLANS SIHO - ALL PLANS 213.3 90 999999999 143.5 229.89 percent of total billed charges "Folic acid level, serum" 41603007_1 CDM 0301 RC 82746 HCPCS inpatient 237 154.05 UMR - ALL PLANS UMR - ALL PLANS 165.9 70 999999999 143.5 229.89 percent of total billed charges "Folic acid level, serum" 41603007_1 CDM 0301 RC 82746 HCPCS inpatient 237 154.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 143.5 60.55 999999999 143.5 229.89 percent of total billed charges "Folic acid level, serum" 41603007_1 CDM 0301 RC 82746 HCPCS inpatient 237 154.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 143.5 229.89 "Folic acid level, serum" 41603007_1 CDM 0301 RC 82746 HCPCS inpatient 237 154.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 143.5 229.89 "Folic acid level, serum" 41603007_1 CDM 0301 RC 82746 HCPCS inpatient 237 154.05 ANTHEM HMO ANTHEM HMO 999999999 143.5 229.89 "Folic acid level, serum" 41603007_1 CDM 0301 RC 82746 HCPCS inpatient 237 154.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 143.5 229.89 "Folic acid level, serum" 41603007_1 CDM 0301 RC 82746 HCPCS inpatient 237 154.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.21 67.6 999999999 143.5 229.89 percent of total billed charges "Folic acid level, serum" 41603007_1 CDM 0301 RC 82746 HCPCS inpatient 237 154.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 143.5 229.89 Limited ultrasound scan of 1 breast 41789819_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 193.05 65 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789819_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 AETNA AETNA 234.63 79 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789819_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 204.93 69 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789819_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 288.09 97 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789819_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 231.66 78 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789819_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 SIHO - ALL PLANS SIHO - ALL PLANS 267.3 90 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789819_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 UMR - ALL PLANS UMR - ALL PLANS 207.9 70 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789819_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 179.83 60.55 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789819_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 179.83 288.09 Limited ultrasound scan of 1 breast 41789819_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 179.83 288.09 Limited ultrasound scan of 1 breast 41789819_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 ANTHEM HMO ANTHEM HMO 999999999 179.83 288.09 Limited ultrasound scan of 1 breast 41789819_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 179.83 288.09 Limited ultrasound scan of 1 breast 41789819_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 200.77 67.6 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789819_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 179.83 288.09 Limited ultrasound scan of 1 breast 41789822_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 193.05 65 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789822_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 AETNA AETNA 234.63 79 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789822_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 204.93 69 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789822_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 288.09 97 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789822_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 231.66 78 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789822_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 SIHO - ALL PLANS SIHO - ALL PLANS 267.3 90 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789822_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 UMR - ALL PLANS UMR - ALL PLANS 207.9 70 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789822_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 179.83 60.55 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789822_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 179.83 288.09 Limited ultrasound scan of 1 breast 41789822_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 179.83 288.09 Limited ultrasound scan of 1 breast 41789822_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 ANTHEM HMO ANTHEM HMO 999999999 179.83 288.09 Limited ultrasound scan of 1 breast 41789822_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 179.83 288.09 Limited ultrasound scan of 1 breast 41789822_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 200.77 67.6 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789822_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 179.83 288.09 Limited ultrasound scan of 1 breast 41789825_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 193.05 65 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789825_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 AETNA AETNA 234.63 79 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789825_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 204.93 69 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789825_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 288.09 97 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789825_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 231.66 78 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789825_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 SIHO - ALL PLANS SIHO - ALL PLANS 267.3 90 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789825_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 UMR - ALL PLANS UMR - ALL PLANS 207.9 70 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789825_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 179.83 60.55 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789825_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 179.83 288.09 Limited ultrasound scan of 1 breast 41789825_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 179.83 288.09 Limited ultrasound scan of 1 breast 41789825_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 ANTHEM HMO ANTHEM HMO 999999999 179.83 288.09 Limited ultrasound scan of 1 breast 41789825_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 179.83 288.09 Limited ultrasound scan of 1 breast 41789825_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 200.77 67.6 999999999 179.83 288.09 percent of total billed charges Limited ultrasound scan of 1 breast 41789825_1 CDM 0402 RC 76642 HCPCS inpatient 297 193.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 179.83 288.09 "X-ray of ribs on side of body, minimum of 3 views" 4198867_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 380.9 65 999999999 354.82 568.42 percent of total billed charges "X-ray of ribs on side of body, minimum of 3 views" 4198867_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 AETNA AETNA 462.94 79 999999999 354.82 568.42 percent of total billed charges "X-ray of ribs on side of body, minimum of 3 views" 4198867_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 404.34 69 999999999 354.82 568.42 percent of total billed charges "X-ray of ribs on side of body, minimum of 3 views" 4198867_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 568.42 97 999999999 354.82 568.42 percent of total billed charges "X-ray of ribs on side of body, minimum of 3 views" 4198867_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 457.08 78 999999999 354.82 568.42 percent of total billed charges "X-ray of ribs on side of body, minimum of 3 views" 4198867_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 SIHO - ALL PLANS SIHO - ALL PLANS 527.4 90 999999999 354.82 568.42 percent of total billed charges "X-ray of ribs on side of body, minimum of 3 views" 4198867_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 UMR - ALL PLANS UMR - ALL PLANS 410.2 70 999999999 354.82 568.42 percent of total billed charges "X-ray of ribs on side of body, minimum of 3 views" 4198867_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 354.82 60.55 999999999 354.82 568.42 percent of total billed charges "X-ray of ribs on side of body, minimum of 3 views" 4198867_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 354.82 568.42 "X-ray of ribs on side of body, minimum of 3 views" 4198867_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 354.82 568.42 "X-ray of ribs on side of body, minimum of 3 views" 4198867_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 ANTHEM HMO ANTHEM HMO 999999999 354.82 568.42 "X-ray of ribs on side of body, minimum of 3 views" 4198867_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 354.82 568.42 "X-ray of ribs on side of body, minimum of 3 views" 4198867_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 396.14 67.6 999999999 354.82 568.42 percent of total billed charges "X-ray of ribs on side of body, minimum of 3 views" 4198867_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 354.82 568.42 "X-ray of ribs on side of body, minimum of 3 views" 4198870_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 380.9 65 999999999 354.82 568.42 percent of total billed charges "X-ray of ribs on side of body, minimum of 3 views" 4198870_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 AETNA AETNA 462.94 79 999999999 354.82 568.42 percent of total billed charges "X-ray of ribs on side of body, minimum of 3 views" 4198870_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 404.34 69 999999999 354.82 568.42 percent of total billed charges "X-ray of ribs on side of body, minimum of 3 views" 4198870_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 568.42 97 999999999 354.82 568.42 percent of total billed charges "X-ray of ribs on side of body, minimum of 3 views" 4198870_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 457.08 78 999999999 354.82 568.42 percent of total billed charges "X-ray of ribs on side of body, minimum of 3 views" 4198870_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 SIHO - ALL PLANS SIHO - ALL PLANS 527.4 90 999999999 354.82 568.42 percent of total billed charges "X-ray of ribs on side of body, minimum of 3 views" 4198870_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 UMR - ALL PLANS UMR - ALL PLANS 410.2 70 999999999 354.82 568.42 percent of total billed charges "X-ray of ribs on side of body, minimum of 3 views" 4198870_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 354.82 60.55 999999999 354.82 568.42 percent of total billed charges "X-ray of ribs on side of body, minimum of 3 views" 4198870_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 354.82 568.42 "X-ray of ribs on side of body, minimum of 3 views" 4198870_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 354.82 568.42 "X-ray of ribs on side of body, minimum of 3 views" 4198870_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 ANTHEM HMO ANTHEM HMO 999999999 354.82 568.42 "X-ray of ribs on side of body, minimum of 3 views" 4198870_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 354.82 568.42 "X-ray of ribs on side of body, minimum of 3 views" 4198870_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 396.14 67.6 999999999 354.82 568.42 percent of total billed charges "X-ray of ribs on side of body, minimum of 3 views" 4198870_1 CDM 0320 RC 71101 HCPCS inpatient 586 380.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 354.82 568.42 X-ray of surgical specimen 4200776_1 CDM 0403 RC 76098 HCPCS inpatient 1040 676 SELF PAY DISCOUNT SELF PAY DISCOUNT 676 65 999999999 629.72 1008.8 percent of total billed charges X-ray of surgical specimen 4200776_1 CDM 0403 RC 76098 HCPCS inpatient 1040 676 AETNA AETNA 821.6 79 999999999 629.72 1008.8 percent of total billed charges X-ray of surgical specimen 4200776_1 CDM 0403 RC 76098 HCPCS inpatient 1040 676 ENCORE - ALL PLANS ENCORE - ALL PLANS 717.6 69 999999999 629.72 1008.8 percent of total billed charges X-ray of surgical specimen 4200776_1 CDM 0403 RC 76098 HCPCS inpatient 1040 676 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1008.8 97 999999999 629.72 1008.8 percent of total billed charges X-ray of surgical specimen 4200776_1 CDM 0403 RC 76098 HCPCS inpatient 1040 676 HUMANA - ALL PLANS HUMANA - ALL PLANS 811.2 78 999999999 629.72 1008.8 percent of total billed charges X-ray of surgical specimen 4200776_1 CDM 0403 RC 76098 HCPCS inpatient 1040 676 SIHO - ALL PLANS SIHO - ALL PLANS 936 90 999999999 629.72 1008.8 percent of total billed charges X-ray of surgical specimen 4200776_1 CDM 0403 RC 76098 HCPCS inpatient 1040 676 UMR - ALL PLANS UMR - ALL PLANS 728 70 999999999 629.72 1008.8 percent of total billed charges X-ray of surgical specimen 4200776_1 CDM 0403 RC 76098 HCPCS inpatient 1040 676 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 629.72 60.55 999999999 629.72 1008.8 percent of total billed charges X-ray of surgical specimen 4200776_1 CDM 0403 RC 76098 HCPCS inpatient 1040 676 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 629.72 1008.8 X-ray of surgical specimen 4200776_1 CDM 0403 RC 76098 HCPCS inpatient 1040 676 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 629.72 1008.8 X-ray of surgical specimen 4200776_1 CDM 0403 RC 76098 HCPCS inpatient 1040 676 ANTHEM HMO ANTHEM HMO 999999999 629.72 1008.8 X-ray of surgical specimen 4200776_1 CDM 0403 RC 76098 HCPCS inpatient 1040 676 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 629.72 1008.8 X-ray of surgical specimen 4200776_1 CDM 0403 RC 76098 HCPCS inpatient 1040 676 CIGNA - ALL PLANS CIGNA - ALL PLANS 703.04 67.6 999999999 629.72 1008.8 percent of total billed charges X-ray of surgical specimen 4200776_1 CDM 0403 RC 76098 HCPCS inpatient 1040 676 UHC - ALL PLANS UHC - ALL PLANS 999999999 629.72 1008.8 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 42902671_1 CDM 0110 RC G0378 HCPCS inpatient 1730 1124.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1124.5 65 999999999 1047.52 1678.1 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 42902671_1 CDM 0110 RC G0378 HCPCS inpatient 1730 1124.5 AETNA AETNA 1366.7 79 999999999 1047.52 1678.1 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 42902671_1 CDM 0110 RC G0378 HCPCS inpatient 1730 1124.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1193.7 69 999999999 1047.52 1678.1 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 42902671_1 CDM 0110 RC G0378 HCPCS inpatient 1730 1124.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1678.1 97 999999999 1047.52 1678.1 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 42902671_1 CDM 0110 RC G0378 HCPCS inpatient 1730 1124.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1349.4 78 999999999 1047.52 1678.1 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 42902671_1 CDM 0110 RC G0378 HCPCS inpatient 1730 1124.5 SIHO - ALL PLANS SIHO - ALL PLANS 1557 90 999999999 1047.52 1678.1 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 42902671_1 CDM 0110 RC G0378 HCPCS inpatient 1730 1124.5 UMR - ALL PLANS UMR - ALL PLANS 1211 70 999999999 1047.52 1678.1 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 42902671_1 CDM 0110 RC G0378 HCPCS inpatient 1730 1124.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1047.52 60.55 999999999 1047.52 1678.1 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 42902671_1 CDM 0110 RC G0378 HCPCS inpatient 1730 1124.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1047.52 1678.1 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 42902671_1 CDM 0110 RC G0378 HCPCS inpatient 1730 1124.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1047.52 1678.1 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 42902671_1 CDM 0110 RC G0378 HCPCS inpatient 1730 1124.5 ANTHEM HMO ANTHEM HMO 999999999 1047.52 1678.1 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 42902671_1 CDM 0110 RC G0378 HCPCS inpatient 1730 1124.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1047.52 1678.1 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 42902671_1 CDM 0110 RC G0378 HCPCS inpatient 1730 1124.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1169.48 67.6 999999999 1047.52 1678.1 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 42902671_1 CDM 0110 RC G0378 HCPCS inpatient 1730 1124.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1047.52 1678.1 "Blood test, basic group of blood chemicals (Calcium, total)" 43398237_1 CDM 0301 RC 80048 HCPCS inpatient 238 154.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.7 65 999999999 144.11 230.86 percent of total billed charges "Blood test, basic group of blood chemicals (Calcium, total)" 43398237_1 CDM 0301 RC 80048 HCPCS inpatient 238 154.7 AETNA AETNA 188.02 79 999999999 144.11 230.86 percent of total billed charges "Blood test, basic group of blood chemicals (Calcium, total)" 43398237_1 CDM 0301 RC 80048 HCPCS inpatient 238 154.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.22 69 999999999 144.11 230.86 percent of total billed charges "Blood test, basic group of blood chemicals (Calcium, total)" 43398237_1 CDM 0301 RC 80048 HCPCS inpatient 238 154.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 230.86 97 999999999 144.11 230.86 percent of total billed charges "Blood test, basic group of blood chemicals (Calcium, total)" 43398237_1 CDM 0301 RC 80048 HCPCS inpatient 238 154.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 185.64 78 999999999 144.11 230.86 percent of total billed charges "Blood test, basic group of blood chemicals (Calcium, total)" 43398237_1 CDM 0301 RC 80048 HCPCS inpatient 238 154.7 SIHO - ALL PLANS SIHO - ALL PLANS 214.2 90 999999999 144.11 230.86 percent of total billed charges "Blood test, basic group of blood chemicals (Calcium, total)" 43398237_1 CDM 0301 RC 80048 HCPCS inpatient 238 154.7 UMR - ALL PLANS UMR - ALL PLANS 166.6 70 999999999 144.11 230.86 percent of total billed charges "Blood test, basic group of blood chemicals (Calcium, total)" 43398237_1 CDM 0301 RC 80048 HCPCS inpatient 238 154.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.11 60.55 999999999 144.11 230.86 percent of total billed charges "Blood test, basic group of blood chemicals (Calcium, total)" 43398237_1 CDM 0301 RC 80048 HCPCS inpatient 238 154.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.11 230.86 "Blood test, basic group of blood chemicals (Calcium, total)" 43398237_1 CDM 0301 RC 80048 HCPCS inpatient 238 154.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.11 230.86 "Blood test, basic group of blood chemicals (Calcium, total)" 43398237_1 CDM 0301 RC 80048 HCPCS inpatient 238 154.7 ANTHEM HMO ANTHEM HMO 999999999 144.11 230.86 "Blood test, basic group of blood chemicals (Calcium, total)" 43398237_1 CDM 0301 RC 80048 HCPCS inpatient 238 154.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.11 230.86 "Blood test, basic group of blood chemicals (Calcium, total)" 43398237_1 CDM 0301 RC 80048 HCPCS inpatient 238 154.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.89 67.6 999999999 144.11 230.86 percent of total billed charges "Blood test, basic group of blood chemicals (Calcium, total)" 43398237_1 CDM 0301 RC 80048 HCPCS inpatient 238 154.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.11 230.86 "Blood test, comprehensive group of blood chemicals" 43398238_1 CDM 0301 RC 80053 HCPCS inpatient 210 136.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 136.5 65 999999999 127.16 203.7 percent of total billed charges "Blood test, comprehensive group of blood chemicals" 43398238_1 CDM 0301 RC 80053 HCPCS inpatient 210 136.5 AETNA AETNA 165.9 79 999999999 127.16 203.7 percent of total billed charges "Blood test, comprehensive group of blood chemicals" 43398238_1 CDM 0301 RC 80053 HCPCS inpatient 210 136.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 144.9 69 999999999 127.16 203.7 percent of total billed charges "Blood test, comprehensive group of blood chemicals" 43398238_1 CDM 0301 RC 80053 HCPCS inpatient 210 136.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 203.7 97 999999999 127.16 203.7 percent of total billed charges "Blood test, comprehensive group of blood chemicals" 43398238_1 CDM 0301 RC 80053 HCPCS inpatient 210 136.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 163.8 78 999999999 127.16 203.7 percent of total billed charges "Blood test, comprehensive group of blood chemicals" 43398238_1 CDM 0301 RC 80053 HCPCS inpatient 210 136.5 SIHO - ALL PLANS SIHO - ALL PLANS 189 90 999999999 127.16 203.7 percent of total billed charges "Blood test, comprehensive group of blood chemicals" 43398238_1 CDM 0301 RC 80053 HCPCS inpatient 210 136.5 UMR - ALL PLANS UMR - ALL PLANS 147 70 999999999 127.16 203.7 percent of total billed charges "Blood test, comprehensive group of blood chemicals" 43398238_1 CDM 0301 RC 80053 HCPCS inpatient 210 136.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.16 60.55 999999999 127.16 203.7 percent of total billed charges "Blood test, comprehensive group of blood chemicals" 43398238_1 CDM 0301 RC 80053 HCPCS inpatient 210 136.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.16 203.7 "Blood test, comprehensive group of blood chemicals" 43398238_1 CDM 0301 RC 80053 HCPCS inpatient 210 136.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.16 203.7 "Blood test, comprehensive group of blood chemicals" 43398238_1 CDM 0301 RC 80053 HCPCS inpatient 210 136.5 ANTHEM HMO ANTHEM HMO 999999999 127.16 203.7 "Blood test, comprehensive group of blood chemicals" 43398238_1 CDM 0301 RC 80053 HCPCS inpatient 210 136.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.16 203.7 "Blood test, comprehensive group of blood chemicals" 43398238_1 CDM 0301 RC 80053 HCPCS inpatient 210 136.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 141.96 67.6 999999999 127.16 203.7 percent of total billed charges "Blood test, comprehensive group of blood chemicals" 43398238_1 CDM 0301 RC 80053 HCPCS inpatient 210 136.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.16 203.7 Liver function blood test panel 43398239_1 CDM 0301 RC 80076 HCPCS inpatient 381 247.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 247.65 65 999999999 230.7 369.57 percent of total billed charges Liver function blood test panel 43398239_1 CDM 0301 RC 80076 HCPCS inpatient 381 247.65 AETNA AETNA 300.99 79 999999999 230.7 369.57 percent of total billed charges Liver function blood test panel 43398239_1 CDM 0301 RC 80076 HCPCS inpatient 381 247.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 262.89 69 999999999 230.7 369.57 percent of total billed charges Liver function blood test panel 43398239_1 CDM 0301 RC 80076 HCPCS inpatient 381 247.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 369.57 97 999999999 230.7 369.57 percent of total billed charges Liver function blood test panel 43398239_1 CDM 0301 RC 80076 HCPCS inpatient 381 247.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 297.18 78 999999999 230.7 369.57 percent of total billed charges Liver function blood test panel 43398239_1 CDM 0301 RC 80076 HCPCS inpatient 381 247.65 SIHO - ALL PLANS SIHO - ALL PLANS 342.9 90 999999999 230.7 369.57 percent of total billed charges Liver function blood test panel 43398239_1 CDM 0301 RC 80076 HCPCS inpatient 381 247.65 UMR - ALL PLANS UMR - ALL PLANS 266.7 70 999999999 230.7 369.57 percent of total billed charges Liver function blood test panel 43398239_1 CDM 0301 RC 80076 HCPCS inpatient 381 247.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 230.7 60.55 999999999 230.7 369.57 percent of total billed charges Liver function blood test panel 43398239_1 CDM 0301 RC 80076 HCPCS inpatient 381 247.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 230.7 369.57 Liver function blood test panel 43398239_1 CDM 0301 RC 80076 HCPCS inpatient 381 247.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 230.7 369.57 Liver function blood test panel 43398239_1 CDM 0301 RC 80076 HCPCS inpatient 381 247.65 ANTHEM HMO ANTHEM HMO 999999999 230.7 369.57 Liver function blood test panel 43398239_1 CDM 0301 RC 80076 HCPCS inpatient 381 247.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 230.7 369.57 Liver function blood test panel 43398239_1 CDM 0301 RC 80076 HCPCS inpatient 381 247.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 257.56 67.6 999999999 230.7 369.57 percent of total billed charges Liver function blood test panel 43398239_1 CDM 0301 RC 80076 HCPCS inpatient 381 247.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 230.7 369.57 Kidney function blood test panel 43398240_1 CDM 0301 RC 80069 HCPCS inpatient 265 172.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 172.25 65 999999999 160.46 257.05 percent of total billed charges Kidney function blood test panel 43398240_1 CDM 0301 RC 80069 HCPCS inpatient 265 172.25 AETNA AETNA 209.35 79 999999999 160.46 257.05 percent of total billed charges Kidney function blood test panel 43398240_1 CDM 0301 RC 80069 HCPCS inpatient 265 172.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 182.85 69 999999999 160.46 257.05 percent of total billed charges Kidney function blood test panel 43398240_1 CDM 0301 RC 80069 HCPCS inpatient 265 172.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 257.05 97 999999999 160.46 257.05 percent of total billed charges Kidney function blood test panel 43398240_1 CDM 0301 RC 80069 HCPCS inpatient 265 172.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 206.7 78 999999999 160.46 257.05 percent of total billed charges Kidney function blood test panel 43398240_1 CDM 0301 RC 80069 HCPCS inpatient 265 172.25 SIHO - ALL PLANS SIHO - ALL PLANS 238.5 90 999999999 160.46 257.05 percent of total billed charges Kidney function blood test panel 43398240_1 CDM 0301 RC 80069 HCPCS inpatient 265 172.25 UMR - ALL PLANS UMR - ALL PLANS 185.5 70 999999999 160.46 257.05 percent of total billed charges Kidney function blood test panel 43398240_1 CDM 0301 RC 80069 HCPCS inpatient 265 172.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 160.46 60.55 999999999 160.46 257.05 percent of total billed charges Kidney function blood test panel 43398240_1 CDM 0301 RC 80069 HCPCS inpatient 265 172.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 160.46 257.05 Kidney function blood test panel 43398240_1 CDM 0301 RC 80069 HCPCS inpatient 265 172.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 160.46 257.05 Kidney function blood test panel 43398240_1 CDM 0301 RC 80069 HCPCS inpatient 265 172.25 ANTHEM HMO ANTHEM HMO 999999999 160.46 257.05 Kidney function blood test panel 43398240_1 CDM 0301 RC 80069 HCPCS inpatient 265 172.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 160.46 257.05 Kidney function blood test panel 43398240_1 CDM 0301 RC 80069 HCPCS inpatient 265 172.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 179.14 67.6 999999999 160.46 257.05 percent of total billed charges Kidney function blood test panel 43398240_1 CDM 0301 RC 80069 HCPCS inpatient 265 172.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 160.46 257.05 "Testing for presence of drug, by chemistry analyzers" 43398245_1 CDM 0301 RC 80307 HCPCS inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 43398245_1 CDM 0301 RC 80307 HCPCS inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 43398245_1 CDM 0301 RC 80307 HCPCS inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 43398245_1 CDM 0301 RC 80307 HCPCS inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 43398245_1 CDM 0301 RC 80307 HCPCS inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 43398245_1 CDM 0301 RC 80307 HCPCS inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 43398245_1 CDM 0301 RC 80307 HCPCS inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 43398245_1 CDM 0301 RC 80307 HCPCS inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 43398245_1 CDM 0301 RC 80307 HCPCS inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 "Testing for presence of drug, by chemistry analyzers" 43398245_1 CDM 0301 RC 80307 HCPCS inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 "Testing for presence of drug, by chemistry analyzers" 43398245_1 CDM 0301 RC 80307 HCPCS inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 "Testing for presence of drug, by chemistry analyzers" 43398245_1 CDM 0301 RC 80307 HCPCS inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 "Testing for presence of drug, by chemistry analyzers" 43398245_1 CDM 0301 RC 80307 HCPCS inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 43398245_1 CDM 0301 RC 80307 HCPCS inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 Creatinine clearance measurement to test for kidney function 43398247_1 CDM 0301 RC 82575 HCPCS inpatient 193 125.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 125.45 65 999999999 116.86 187.21 percent of total billed charges Creatinine clearance measurement to test for kidney function 43398247_1 CDM 0301 RC 82575 HCPCS inpatient 193 125.45 AETNA AETNA 152.47 79 999999999 116.86 187.21 percent of total billed charges Creatinine clearance measurement to test for kidney function 43398247_1 CDM 0301 RC 82575 HCPCS inpatient 193 125.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.17 69 999999999 116.86 187.21 percent of total billed charges Creatinine clearance measurement to test for kidney function 43398247_1 CDM 0301 RC 82575 HCPCS inpatient 193 125.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 187.21 97 999999999 116.86 187.21 percent of total billed charges Creatinine clearance measurement to test for kidney function 43398247_1 CDM 0301 RC 82575 HCPCS inpatient 193 125.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 150.54 78 999999999 116.86 187.21 percent of total billed charges Creatinine clearance measurement to test for kidney function 43398247_1 CDM 0301 RC 82575 HCPCS inpatient 193 125.45 SIHO - ALL PLANS SIHO - ALL PLANS 173.7 90 999999999 116.86 187.21 percent of total billed charges Creatinine clearance measurement to test for kidney function 43398247_1 CDM 0301 RC 82575 HCPCS inpatient 193 125.45 UMR - ALL PLANS UMR - ALL PLANS 135.1 70 999999999 116.86 187.21 percent of total billed charges Creatinine clearance measurement to test for kidney function 43398247_1 CDM 0301 RC 82575 HCPCS inpatient 193 125.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.86 60.55 999999999 116.86 187.21 percent of total billed charges Creatinine clearance measurement to test for kidney function 43398247_1 CDM 0301 RC 82575 HCPCS inpatient 193 125.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.86 187.21 Creatinine clearance measurement to test for kidney function 43398247_1 CDM 0301 RC 82575 HCPCS inpatient 193 125.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.86 187.21 Creatinine clearance measurement to test for kidney function 43398247_1 CDM 0301 RC 82575 HCPCS inpatient 193 125.45 ANTHEM HMO ANTHEM HMO 999999999 116.86 187.21 Creatinine clearance measurement to test for kidney function 43398247_1 CDM 0301 RC 82575 HCPCS inpatient 193 125.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.86 187.21 Creatinine clearance measurement to test for kidney function 43398247_1 CDM 0301 RC 82575 HCPCS inpatient 193 125.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 130.47 67.6 999999999 116.86 187.21 percent of total billed charges Creatinine clearance measurement to test for kidney function 43398247_1 CDM 0301 RC 82575 HCPCS inpatient 193 125.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.86 187.21 "Fungal culture (mold or yeast) of skin, hair, or nail" 43398248_1 CDM 0306 RC 87101 HCPCS inpatient 221 143.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 143.65 65 999999999 133.82 214.37 percent of total billed charges "Fungal culture (mold or yeast) of skin, hair, or nail" 43398248_1 CDM 0306 RC 87101 HCPCS inpatient 221 143.65 AETNA AETNA 174.59 79 999999999 133.82 214.37 percent of total billed charges "Fungal culture (mold or yeast) of skin, hair, or nail" 43398248_1 CDM 0306 RC 87101 HCPCS inpatient 221 143.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 152.49 69 999999999 133.82 214.37 percent of total billed charges "Fungal culture (mold or yeast) of skin, hair, or nail" 43398248_1 CDM 0306 RC 87101 HCPCS inpatient 221 143.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 214.37 97 999999999 133.82 214.37 percent of total billed charges "Fungal culture (mold or yeast) of skin, hair, or nail" 43398248_1 CDM 0306 RC 87101 HCPCS inpatient 221 143.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 172.38 78 999999999 133.82 214.37 percent of total billed charges "Fungal culture (mold or yeast) of skin, hair, or nail" 43398248_1 CDM 0306 RC 87101 HCPCS inpatient 221 143.65 SIHO - ALL PLANS SIHO - ALL PLANS 198.9 90 999999999 133.82 214.37 percent of total billed charges "Fungal culture (mold or yeast) of skin, hair, or nail" 43398248_1 CDM 0306 RC 87101 HCPCS inpatient 221 143.65 UMR - ALL PLANS UMR - ALL PLANS 154.7 70 999999999 133.82 214.37 percent of total billed charges "Fungal culture (mold or yeast) of skin, hair, or nail" 43398248_1 CDM 0306 RC 87101 HCPCS inpatient 221 143.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 133.82 60.55 999999999 133.82 214.37 percent of total billed charges "Fungal culture (mold or yeast) of skin, hair, or nail" 43398248_1 CDM 0306 RC 87101 HCPCS inpatient 221 143.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 133.82 214.37 "Fungal culture (mold or yeast) of skin, hair, or nail" 43398248_1 CDM 0306 RC 87101 HCPCS inpatient 221 143.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 133.82 214.37 "Fungal culture (mold or yeast) of skin, hair, or nail" 43398248_1 CDM 0306 RC 87101 HCPCS inpatient 221 143.65 ANTHEM HMO ANTHEM HMO 999999999 133.82 214.37 "Fungal culture (mold or yeast) of skin, hair, or nail" 43398248_1 CDM 0306 RC 87101 HCPCS inpatient 221 143.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 133.82 214.37 "Fungal culture (mold or yeast) of skin, hair, or nail" 43398248_1 CDM 0306 RC 87101 HCPCS inpatient 221 143.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 149.4 67.6 999999999 133.82 214.37 percent of total billed charges "Fungal culture (mold or yeast) of skin, hair, or nail" 43398248_1 CDM 0306 RC 87101 HCPCS inpatient 221 143.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 133.82 214.37 "Blood test, lipids (cholesterol and triglycerides)" 43398250_1 CDM 0301 RC 80061 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 43398250_1 CDM 0301 RC 80061 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 43398250_1 CDM 0301 RC 80061 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 43398250_1 CDM 0301 RC 80061 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 43398250_1 CDM 0301 RC 80061 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 43398250_1 CDM 0301 RC 80061 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 43398250_1 CDM 0301 RC 80061 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 43398250_1 CDM 0301 RC 80061 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 43398250_1 CDM 0301 RC 80061 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 "Blood test, lipids (cholesterol and triglycerides)" 43398250_1 CDM 0301 RC 80061 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 "Blood test, lipids (cholesterol and triglycerides)" 43398250_1 CDM 0301 RC 80061 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 "Blood test, lipids (cholesterol and triglycerides)" 43398250_1 CDM 0301 RC 80061 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 "Blood test, lipids (cholesterol and triglycerides)" 43398250_1 CDM 0301 RC 80061 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 43398250_1 CDM 0301 RC 80061 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" 43398252_1 CDM 0301 RC 80051 HCPCS inpatient 96.5 62.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.73 65 999999999 58.43 93.61 percent of total billed charges "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" 43398252_1 CDM 0301 RC 80051 HCPCS inpatient 96.5 62.73 AETNA AETNA 76.24 79 999999999 58.43 93.61 percent of total billed charges "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" 43398252_1 CDM 0301 RC 80051 HCPCS inpatient 96.5 62.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.59 69 999999999 58.43 93.61 percent of total billed charges "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" 43398252_1 CDM 0301 RC 80051 HCPCS inpatient 96.5 62.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.61 97 999999999 58.43 93.61 percent of total billed charges "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" 43398252_1 CDM 0301 RC 80051 HCPCS inpatient 96.5 62.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 75.27 78 999999999 58.43 93.61 percent of total billed charges "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" 43398252_1 CDM 0301 RC 80051 HCPCS inpatient 96.5 62.73 SIHO - ALL PLANS SIHO - ALL PLANS 86.85 90 999999999 58.43 93.61 percent of total billed charges "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" 43398252_1 CDM 0301 RC 80051 HCPCS inpatient 96.5 62.73 UMR - ALL PLANS UMR - ALL PLANS 67.55 70 999999999 58.43 93.61 percent of total billed charges "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" 43398252_1 CDM 0301 RC 80051 HCPCS inpatient 96.5 62.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.43 60.55 999999999 58.43 93.61 percent of total billed charges "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" 43398252_1 CDM 0301 RC 80051 HCPCS inpatient 96.5 62.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.43 93.61 "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" 43398252_1 CDM 0301 RC 80051 HCPCS inpatient 96.5 62.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.43 93.61 "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" 43398252_1 CDM 0301 RC 80051 HCPCS inpatient 96.5 62.73 ANTHEM HMO ANTHEM HMO 999999999 58.43 93.61 "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" 43398252_1 CDM 0301 RC 80051 HCPCS inpatient 96.5 62.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.43 93.61 "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" 43398252_1 CDM 0301 RC 80051 HCPCS inpatient 96.5 62.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 65.23 67.6 999999999 58.43 93.61 percent of total billed charges "Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)" 43398252_1 CDM 0301 RC 80051 HCPCS inpatient 96.5 62.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.43 93.61 "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 43398260_1 CDM 0305 RC 85025 HCPCS inpatient 141 91.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 91.65 65 999999999 85.38 136.77 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 43398260_1 CDM 0305 RC 85025 HCPCS inpatient 141 91.65 AETNA AETNA 111.39 79 999999999 85.38 136.77 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 43398260_1 CDM 0305 RC 85025 HCPCS inpatient 141 91.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.29 69 999999999 85.38 136.77 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 43398260_1 CDM 0305 RC 85025 HCPCS inpatient 141 91.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 136.77 97 999999999 85.38 136.77 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 43398260_1 CDM 0305 RC 85025 HCPCS inpatient 141 91.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 109.98 78 999999999 85.38 136.77 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 43398260_1 CDM 0305 RC 85025 HCPCS inpatient 141 91.65 SIHO - ALL PLANS SIHO - ALL PLANS 126.9 90 999999999 85.38 136.77 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 43398260_1 CDM 0305 RC 85025 HCPCS inpatient 141 91.65 UMR - ALL PLANS UMR - ALL PLANS 98.7 70 999999999 85.38 136.77 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 43398260_1 CDM 0305 RC 85025 HCPCS inpatient 141 91.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.38 60.55 999999999 85.38 136.77 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 43398260_1 CDM 0305 RC 85025 HCPCS inpatient 141 91.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.38 136.77 "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 43398260_1 CDM 0305 RC 85025 HCPCS inpatient 141 91.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.38 136.77 "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 43398260_1 CDM 0305 RC 85025 HCPCS inpatient 141 91.65 ANTHEM HMO ANTHEM HMO 999999999 85.38 136.77 "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 43398260_1 CDM 0305 RC 85025 HCPCS inpatient 141 91.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.38 136.77 "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 43398260_1 CDM 0305 RC 85025 HCPCS inpatient 141 91.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.32 67.6 999999999 85.38 136.77 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 43398260_1 CDM 0305 RC 85025 HCPCS inpatient 141 91.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.38 136.77 "Manual urinalysis test with examination using microscope, automated" 43398271_1 CDM 0307 RC 81001 HCPCS inpatient 89 57.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.85 65 999999999 53.89 86.33 percent of total billed charges "Manual urinalysis test with examination using microscope, automated" 43398271_1 CDM 0307 RC 81001 HCPCS inpatient 89 57.85 AETNA AETNA 70.31 79 999999999 53.89 86.33 percent of total billed charges "Manual urinalysis test with examination using microscope, automated" 43398271_1 CDM 0307 RC 81001 HCPCS inpatient 89 57.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 61.41 69 999999999 53.89 86.33 percent of total billed charges "Manual urinalysis test with examination using microscope, automated" 43398271_1 CDM 0307 RC 81001 HCPCS inpatient 89 57.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 86.33 97 999999999 53.89 86.33 percent of total billed charges "Manual urinalysis test with examination using microscope, automated" 43398271_1 CDM 0307 RC 81001 HCPCS inpatient 89 57.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 69.42 78 999999999 53.89 86.33 percent of total billed charges "Manual urinalysis test with examination using microscope, automated" 43398271_1 CDM 0307 RC 81001 HCPCS inpatient 89 57.85 SIHO - ALL PLANS SIHO - ALL PLANS 80.1 90 999999999 53.89 86.33 percent of total billed charges "Manual urinalysis test with examination using microscope, automated" 43398271_1 CDM 0307 RC 81001 HCPCS inpatient 89 57.85 UMR - ALL PLANS UMR - ALL PLANS 62.3 70 999999999 53.89 86.33 percent of total billed charges "Manual urinalysis test with examination using microscope, automated" 43398271_1 CDM 0307 RC 81001 HCPCS inpatient 89 57.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.89 60.55 999999999 53.89 86.33 percent of total billed charges "Manual urinalysis test with examination using microscope, automated" 43398271_1 CDM 0307 RC 81001 HCPCS inpatient 89 57.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.89 86.33 "Manual urinalysis test with examination using microscope, automated" 43398271_1 CDM 0307 RC 81001 HCPCS inpatient 89 57.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.89 86.33 "Manual urinalysis test with examination using microscope, automated" 43398271_1 CDM 0307 RC 81001 HCPCS inpatient 89 57.85 ANTHEM HMO ANTHEM HMO 999999999 53.89 86.33 "Manual urinalysis test with examination using microscope, automated" 43398271_1 CDM 0307 RC 81001 HCPCS inpatient 89 57.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.89 86.33 "Manual urinalysis test with examination using microscope, automated" 43398271_1 CDM 0307 RC 81001 HCPCS inpatient 89 57.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.16 67.6 999999999 53.89 86.33 percent of total billed charges "Manual urinalysis test with examination using microscope, automated" 43398271_1 CDM 0307 RC 81001 HCPCS inpatient 89 57.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.89 86.33 Urinalysis using microscope 43398272_1 CDM 0307 RC 81015 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges Urinalysis using microscope 43398272_1 CDM 0307 RC 81015 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges Urinalysis using microscope 43398272_1 CDM 0307 RC 81015 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges Urinalysis using microscope 43398272_1 CDM 0307 RC 81015 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges Urinalysis using microscope 43398272_1 CDM 0307 RC 81015 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges Urinalysis using microscope 43398272_1 CDM 0307 RC 81015 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges Urinalysis using microscope 43398272_1 CDM 0307 RC 81015 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges Urinalysis using microscope 43398272_1 CDM 0307 RC 81015 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges Urinalysis using microscope 43398272_1 CDM 0307 RC 81015 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 Urinalysis using microscope 43398272_1 CDM 0307 RC 81015 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 Urinalysis using microscope 43398272_1 CDM 0307 RC 81015 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 Urinalysis using microscope 43398272_1 CDM 0307 RC 81015 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 Urinalysis using microscope 43398272_1 CDM 0307 RC 81015 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges Urinalysis using microscope 43398272_1 CDM 0307 RC 81015 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 Gonadotropin (reproductive hormone) analysis 43398280_1 CDM 0301 RC 84703 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges Gonadotropin (reproductive hormone) analysis 43398280_1 CDM 0301 RC 84703 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges Gonadotropin (reproductive hormone) analysis 43398280_1 CDM 0301 RC 84703 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges Gonadotropin (reproductive hormone) analysis 43398280_1 CDM 0301 RC 84703 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges Gonadotropin (reproductive hormone) analysis 43398280_1 CDM 0301 RC 84703 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges Gonadotropin (reproductive hormone) analysis 43398280_1 CDM 0301 RC 84703 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges Gonadotropin (reproductive hormone) analysis 43398280_1 CDM 0301 RC 84703 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges Gonadotropin (reproductive hormone) analysis 43398280_1 CDM 0301 RC 84703 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges Gonadotropin (reproductive hormone) analysis 43398280_1 CDM 0301 RC 84703 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 Gonadotropin (reproductive hormone) analysis 43398280_1 CDM 0301 RC 84703 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 Gonadotropin (reproductive hormone) analysis 43398280_1 CDM 0301 RC 84703 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 Gonadotropin (reproductive hormone) analysis 43398280_1 CDM 0301 RC 84703 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 Gonadotropin (reproductive hormone) analysis 43398280_1 CDM 0301 RC 84703 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges Gonadotropin (reproductive hormone) analysis 43398280_1 CDM 0301 RC 84703 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 Gonadotropin (reproductive hormone) analysis 43398288_1 CDM 0301 RC 84703 HCPCS inpatient 162 105.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 105.3 65 999999999 98.09 157.14 percent of total billed charges Gonadotropin (reproductive hormone) analysis 43398288_1 CDM 0301 RC 84703 HCPCS inpatient 162 105.3 AETNA AETNA 127.98 79 999999999 98.09 157.14 percent of total billed charges Gonadotropin (reproductive hormone) analysis 43398288_1 CDM 0301 RC 84703 HCPCS inpatient 162 105.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 111.78 69 999999999 98.09 157.14 percent of total billed charges Gonadotropin (reproductive hormone) analysis 43398288_1 CDM 0301 RC 84703 HCPCS inpatient 162 105.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 157.14 97 999999999 98.09 157.14 percent of total billed charges Gonadotropin (reproductive hormone) analysis 43398288_1 CDM 0301 RC 84703 HCPCS inpatient 162 105.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 126.36 78 999999999 98.09 157.14 percent of total billed charges Gonadotropin (reproductive hormone) analysis 43398288_1 CDM 0301 RC 84703 HCPCS inpatient 162 105.3 SIHO - ALL PLANS SIHO - ALL PLANS 145.8 90 999999999 98.09 157.14 percent of total billed charges Gonadotropin (reproductive hormone) analysis 43398288_1 CDM 0301 RC 84703 HCPCS inpatient 162 105.3 UMR - ALL PLANS UMR - ALL PLANS 113.4 70 999999999 98.09 157.14 percent of total billed charges Gonadotropin (reproductive hormone) analysis 43398288_1 CDM 0301 RC 84703 HCPCS inpatient 162 105.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 98.09 60.55 999999999 98.09 157.14 percent of total billed charges Gonadotropin (reproductive hormone) analysis 43398288_1 CDM 0301 RC 84703 HCPCS inpatient 162 105.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 98.09 157.14 Gonadotropin (reproductive hormone) analysis 43398288_1 CDM 0301 RC 84703 HCPCS inpatient 162 105.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 98.09 157.14 Gonadotropin (reproductive hormone) analysis 43398288_1 CDM 0301 RC 84703 HCPCS inpatient 162 105.3 ANTHEM HMO ANTHEM HMO 999999999 98.09 157.14 Gonadotropin (reproductive hormone) analysis 43398288_1 CDM 0301 RC 84703 HCPCS inpatient 162 105.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 98.09 157.14 Gonadotropin (reproductive hormone) analysis 43398288_1 CDM 0301 RC 84703 HCPCS inpatient 162 105.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 109.51 67.6 999999999 98.09 157.14 percent of total billed charges Gonadotropin (reproductive hormone) analysis 43398288_1 CDM 0301 RC 84703 HCPCS inpatient 162 105.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 98.09 157.14 "Detection test by immunoassay with direct visual observation for Streptococcus, group A (strep)" 43398289_1 CDM 0306 RC 87880 HCPCS inpatient 103 66.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.95 65 999999999 62.37 99.91 percent of total billed charges "Detection test by immunoassay with direct visual observation for Streptococcus, group A (strep)" 43398289_1 CDM 0306 RC 87880 HCPCS inpatient 103 66.95 AETNA AETNA 81.37 79 999999999 62.37 99.91 percent of total billed charges "Detection test by immunoassay with direct visual observation for Streptococcus, group A (strep)" 43398289_1 CDM 0306 RC 87880 HCPCS inpatient 103 66.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.07 69 999999999 62.37 99.91 percent of total billed charges "Detection test by immunoassay with direct visual observation for Streptococcus, group A (strep)" 43398289_1 CDM 0306 RC 87880 HCPCS inpatient 103 66.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 99.91 97 999999999 62.37 99.91 percent of total billed charges "Detection test by immunoassay with direct visual observation for Streptococcus, group A (strep)" 43398289_1 CDM 0306 RC 87880 HCPCS inpatient 103 66.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 80.34 78 999999999 62.37 99.91 percent of total billed charges "Detection test by immunoassay with direct visual observation for Streptococcus, group A (strep)" 43398289_1 CDM 0306 RC 87880 HCPCS inpatient 103 66.95 SIHO - ALL PLANS SIHO - ALL PLANS 92.7 90 999999999 62.37 99.91 percent of total billed charges "Detection test by immunoassay with direct visual observation for Streptococcus, group A (strep)" 43398289_1 CDM 0306 RC 87880 HCPCS inpatient 103 66.95 UMR - ALL PLANS UMR - ALL PLANS 72.1 70 999999999 62.37 99.91 percent of total billed charges "Detection test by immunoassay with direct visual observation for Streptococcus, group A (strep)" 43398289_1 CDM 0306 RC 87880 HCPCS inpatient 103 66.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.37 60.55 999999999 62.37 99.91 percent of total billed charges "Detection test by immunoassay with direct visual observation for Streptococcus, group A (strep)" 43398289_1 CDM 0306 RC 87880 HCPCS inpatient 103 66.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.37 99.91 "Detection test by immunoassay with direct visual observation for Streptococcus, group A (strep)" 43398289_1 CDM 0306 RC 87880 HCPCS inpatient 103 66.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.37 99.91 "Detection test by immunoassay with direct visual observation for Streptococcus, group A (strep)" 43398289_1 CDM 0306 RC 87880 HCPCS inpatient 103 66.95 ANTHEM HMO ANTHEM HMO 999999999 62.37 99.91 "Detection test by immunoassay with direct visual observation for Streptococcus, group A (strep)" 43398289_1 CDM 0306 RC 87880 HCPCS inpatient 103 66.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.37 99.91 "Detection test by immunoassay with direct visual observation for Streptococcus, group A (strep)" 43398289_1 CDM 0306 RC 87880 HCPCS inpatient 103 66.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 69.63 67.6 999999999 62.37 99.91 percent of total billed charges "Detection test by immunoassay with direct visual observation for Streptococcus, group A (strep)" 43398289_1 CDM 0306 RC 87880 HCPCS inpatient 103 66.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.37 99.91 Detection test by nucleic acid for multiple types influenza virus 43398290_1 CDM 0306 RC 87502 HCPCS inpatient 442 287.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 287.3 65 999999999 267.63 428.74 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 43398290_1 CDM 0306 RC 87502 HCPCS inpatient 442 287.3 AETNA AETNA 349.18 79 999999999 267.63 428.74 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 43398290_1 CDM 0306 RC 87502 HCPCS inpatient 442 287.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 304.98 69 999999999 267.63 428.74 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 43398290_1 CDM 0306 RC 87502 HCPCS inpatient 442 287.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 428.74 97 999999999 267.63 428.74 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 43398290_1 CDM 0306 RC 87502 HCPCS inpatient 442 287.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 344.76 78 999999999 267.63 428.74 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 43398290_1 CDM 0306 RC 87502 HCPCS inpatient 442 287.3 SIHO - ALL PLANS SIHO - ALL PLANS 397.8 90 999999999 267.63 428.74 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 43398290_1 CDM 0306 RC 87502 HCPCS inpatient 442 287.3 UMR - ALL PLANS UMR - ALL PLANS 309.4 70 999999999 267.63 428.74 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 43398290_1 CDM 0306 RC 87502 HCPCS inpatient 442 287.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 267.63 60.55 999999999 267.63 428.74 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 43398290_1 CDM 0306 RC 87502 HCPCS inpatient 442 287.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 267.63 428.74 Detection test by nucleic acid for multiple types influenza virus 43398290_1 CDM 0306 RC 87502 HCPCS inpatient 442 287.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 267.63 428.74 Detection test by nucleic acid for multiple types influenza virus 43398290_1 CDM 0306 RC 87502 HCPCS inpatient 442 287.3 ANTHEM HMO ANTHEM HMO 999999999 267.63 428.74 Detection test by nucleic acid for multiple types influenza virus 43398290_1 CDM 0306 RC 87502 HCPCS inpatient 442 287.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 267.63 428.74 Detection test by nucleic acid for multiple types influenza virus 43398290_1 CDM 0306 RC 87502 HCPCS inpatient 442 287.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 298.79 67.6 999999999 267.63 428.74 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 43398290_1 CDM 0306 RC 87502 HCPCS inpatient 442 287.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 267.63 428.74 Detection test by immunoassay with direct visual observation for respiratory syncytial virus 43398292_1 CDM 0302 RC 87807 HCPCS inpatient 323 209.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 209.95 65 999999999 195.58 313.31 percent of total billed charges Detection test by immunoassay with direct visual observation for respiratory syncytial virus 43398292_1 CDM 0302 RC 87807 HCPCS inpatient 323 209.95 AETNA AETNA 255.17 79 999999999 195.58 313.31 percent of total billed charges Detection test by immunoassay with direct visual observation for respiratory syncytial virus 43398292_1 CDM 0302 RC 87807 HCPCS inpatient 323 209.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 222.87 69 999999999 195.58 313.31 percent of total billed charges Detection test by immunoassay with direct visual observation for respiratory syncytial virus 43398292_1 CDM 0302 RC 87807 HCPCS inpatient 323 209.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 313.31 97 999999999 195.58 313.31 percent of total billed charges Detection test by immunoassay with direct visual observation for respiratory syncytial virus 43398292_1 CDM 0302 RC 87807 HCPCS inpatient 323 209.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 251.94 78 999999999 195.58 313.31 percent of total billed charges Detection test by immunoassay with direct visual observation for respiratory syncytial virus 43398292_1 CDM 0302 RC 87807 HCPCS inpatient 323 209.95 SIHO - ALL PLANS SIHO - ALL PLANS 290.7 90 999999999 195.58 313.31 percent of total billed charges Detection test by immunoassay with direct visual observation for respiratory syncytial virus 43398292_1 CDM 0302 RC 87807 HCPCS inpatient 323 209.95 UMR - ALL PLANS UMR - ALL PLANS 226.1 70 999999999 195.58 313.31 percent of total billed charges Detection test by immunoassay with direct visual observation for respiratory syncytial virus 43398292_1 CDM 0302 RC 87807 HCPCS inpatient 323 209.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 195.58 60.55 999999999 195.58 313.31 percent of total billed charges Detection test by immunoassay with direct visual observation for respiratory syncytial virus 43398292_1 CDM 0302 RC 87807 HCPCS inpatient 323 209.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 195.58 313.31 Detection test by immunoassay with direct visual observation for respiratory syncytial virus 43398292_1 CDM 0302 RC 87807 HCPCS inpatient 323 209.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 195.58 313.31 Detection test by immunoassay with direct visual observation for respiratory syncytial virus 43398292_1 CDM 0302 RC 87807 HCPCS inpatient 323 209.95 ANTHEM HMO ANTHEM HMO 999999999 195.58 313.31 Detection test by immunoassay with direct visual observation for respiratory syncytial virus 43398292_1 CDM 0302 RC 87807 HCPCS inpatient 323 209.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 195.58 313.31 Detection test by immunoassay with direct visual observation for respiratory syncytial virus 43398292_1 CDM 0302 RC 87807 HCPCS inpatient 323 209.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 218.35 67.6 999999999 195.58 313.31 percent of total billed charges Detection test by immunoassay with direct visual observation for respiratory syncytial virus 43398292_1 CDM 0302 RC 87807 HCPCS inpatient 323 209.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 195.58 313.31 "Test for detection of infectious agent antibody, qualitative or semiquantitative" 43398293_1 CDM 0302 RC 86318 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges "Test for detection of infectious agent antibody, qualitative or semiquantitative" 43398293_1 CDM 0302 RC 86318 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges "Test for detection of infectious agent antibody, qualitative or semiquantitative" 43398293_1 CDM 0302 RC 86318 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges "Test for detection of infectious agent antibody, qualitative or semiquantitative" 43398293_1 CDM 0302 RC 86318 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges "Test for detection of infectious agent antibody, qualitative or semiquantitative" 43398293_1 CDM 0302 RC 86318 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges "Test for detection of infectious agent antibody, qualitative or semiquantitative" 43398293_1 CDM 0302 RC 86318 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges "Test for detection of infectious agent antibody, qualitative or semiquantitative" 43398293_1 CDM 0302 RC 86318 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges "Test for detection of infectious agent antibody, qualitative or semiquantitative" 43398293_1 CDM 0302 RC 86318 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges "Test for detection of infectious agent antibody, qualitative or semiquantitative" 43398293_1 CDM 0302 RC 86318 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 "Test for detection of infectious agent antibody, qualitative or semiquantitative" 43398293_1 CDM 0302 RC 86318 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 "Test for detection of infectious agent antibody, qualitative or semiquantitative" 43398293_1 CDM 0302 RC 86318 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 "Test for detection of infectious agent antibody, qualitative or semiquantitative" 43398293_1 CDM 0302 RC 86318 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 "Test for detection of infectious agent antibody, qualitative or semiquantitative" 43398293_1 CDM 0302 RC 86318 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges "Test for detection of infectious agent antibody, qualitative or semiquantitative" 43398293_1 CDM 0302 RC 86318 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Iron binding capacity 43417471_1 CDM 0301 RC 83550 HCPCS inpatient 65 42.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.25 65 999999999 39.36 63.05 percent of total billed charges Iron binding capacity 43417471_1 CDM 0301 RC 83550 HCPCS inpatient 65 42.25 AETNA AETNA 51.35 79 999999999 39.36 63.05 percent of total billed charges Iron binding capacity 43417471_1 CDM 0301 RC 83550 HCPCS inpatient 65 42.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.85 69 999999999 39.36 63.05 percent of total billed charges Iron binding capacity 43417471_1 CDM 0301 RC 83550 HCPCS inpatient 65 42.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 63.05 97 999999999 39.36 63.05 percent of total billed charges Iron binding capacity 43417471_1 CDM 0301 RC 83550 HCPCS inpatient 65 42.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 50.7 78 999999999 39.36 63.05 percent of total billed charges Iron binding capacity 43417471_1 CDM 0301 RC 83550 HCPCS inpatient 65 42.25 SIHO - ALL PLANS SIHO - ALL PLANS 58.5 90 999999999 39.36 63.05 percent of total billed charges Iron binding capacity 43417471_1 CDM 0301 RC 83550 HCPCS inpatient 65 42.25 UMR - ALL PLANS UMR - ALL PLANS 45.5 70 999999999 39.36 63.05 percent of total billed charges Iron binding capacity 43417471_1 CDM 0301 RC 83550 HCPCS inpatient 65 42.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.36 60.55 999999999 39.36 63.05 percent of total billed charges Iron binding capacity 43417471_1 CDM 0301 RC 83550 HCPCS inpatient 65 42.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.36 63.05 Iron binding capacity 43417471_1 CDM 0301 RC 83550 HCPCS inpatient 65 42.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.36 63.05 Iron binding capacity 43417471_1 CDM 0301 RC 83550 HCPCS inpatient 65 42.25 ANTHEM HMO ANTHEM HMO 999999999 39.36 63.05 Iron binding capacity 43417471_1 CDM 0301 RC 83550 HCPCS inpatient 65 42.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.36 63.05 Iron binding capacity 43417471_1 CDM 0301 RC 83550 HCPCS inpatient 65 42.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.94 67.6 999999999 39.36 63.05 percent of total billed charges Iron binding capacity 43417471_1 CDM 0301 RC 83550 HCPCS inpatient 65 42.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.36 63.05 Iron level 43417472_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 113.1 65 999999999 105.36 168.78 percent of total billed charges Iron level 43417472_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 AETNA AETNA 137.46 79 999999999 105.36 168.78 percent of total billed charges Iron level 43417472_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 120.06 69 999999999 105.36 168.78 percent of total billed charges Iron level 43417472_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 168.78 97 999999999 105.36 168.78 percent of total billed charges Iron level 43417472_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 135.72 78 999999999 105.36 168.78 percent of total billed charges Iron level 43417472_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 SIHO - ALL PLANS SIHO - ALL PLANS 156.6 90 999999999 105.36 168.78 percent of total billed charges Iron level 43417472_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 UMR - ALL PLANS UMR - ALL PLANS 121.8 70 999999999 105.36 168.78 percent of total billed charges Iron level 43417472_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 105.36 60.55 999999999 105.36 168.78 percent of total billed charges Iron level 43417472_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 105.36 168.78 Iron level 43417472_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 105.36 168.78 Iron level 43417472_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 ANTHEM HMO ANTHEM HMO 999999999 105.36 168.78 Iron level 43417472_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 105.36 168.78 Iron level 43417472_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 117.62 67.6 999999999 105.36 168.78 percent of total billed charges Iron level 43417472_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 105.36 168.78 Transferrin (iron binding protein) level 43417474_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 SELF PAY DISCOUNT SELF PAY DISCOUNT 91 65 999999999 84.77 135.8 percent of total billed charges Transferrin (iron binding protein) level 43417474_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 AETNA AETNA 110.6 79 999999999 84.77 135.8 percent of total billed charges Transferrin (iron binding protein) level 43417474_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 ENCORE - ALL PLANS ENCORE - ALL PLANS 96.6 69 999999999 84.77 135.8 percent of total billed charges Transferrin (iron binding protein) level 43417474_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 135.8 97 999999999 84.77 135.8 percent of total billed charges Transferrin (iron binding protein) level 43417474_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 HUMANA - ALL PLANS HUMANA - ALL PLANS 109.2 78 999999999 84.77 135.8 percent of total billed charges Transferrin (iron binding protein) level 43417474_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 SIHO - ALL PLANS SIHO - ALL PLANS 126 90 999999999 84.77 135.8 percent of total billed charges Transferrin (iron binding protein) level 43417474_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 UMR - ALL PLANS UMR - ALL PLANS 98 70 999999999 84.77 135.8 percent of total billed charges Transferrin (iron binding protein) level 43417474_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 84.77 60.55 999999999 84.77 135.8 percent of total billed charges Transferrin (iron binding protein) level 43417474_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 84.77 135.8 Transferrin (iron binding protein) level 43417474_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 84.77 135.8 Transferrin (iron binding protein) level 43417474_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 ANTHEM HMO ANTHEM HMO 999999999 84.77 135.8 Transferrin (iron binding protein) level 43417474_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 84.77 135.8 Transferrin (iron binding protein) level 43417474_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 CIGNA - ALL PLANS CIGNA - ALL PLANS 94.64 67.6 999999999 84.77 135.8 percent of total billed charges Transferrin (iron binding protein) level 43417474_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 UHC - ALL PLANS UHC - ALL PLANS 999999999 84.77 135.8 CT scan of heart structure with contrast 44212749_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 299.65 65 999999999 279.14 447.17 percent of total billed charges CT scan of heart structure with contrast 44212749_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 AETNA AETNA 364.19 79 999999999 279.14 447.17 percent of total billed charges CT scan of heart structure with contrast 44212749_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 318.09 69 999999999 279.14 447.17 percent of total billed charges CT scan of heart structure with contrast 44212749_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 447.17 97 999999999 279.14 447.17 percent of total billed charges CT scan of heart structure with contrast 44212749_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 359.58 78 999999999 279.14 447.17 percent of total billed charges CT scan of heart structure with contrast 44212749_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 SIHO - ALL PLANS SIHO - ALL PLANS 414.9 90 999999999 279.14 447.17 percent of total billed charges CT scan of heart structure with contrast 44212749_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 UMR - ALL PLANS UMR - ALL PLANS 322.7 70 999999999 279.14 447.17 percent of total billed charges CT scan of heart structure with contrast 44212749_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 279.14 60.55 999999999 279.14 447.17 percent of total billed charges CT scan of heart structure with contrast 44212749_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 279.14 447.17 CT scan of heart structure with contrast 44212749_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 279.14 447.17 CT scan of heart structure with contrast 44212749_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 ANTHEM HMO ANTHEM HMO 999999999 279.14 447.17 CT scan of heart structure with contrast 44212749_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 279.14 447.17 CT scan of heart structure with contrast 44212749_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 311.64 67.6 999999999 279.14 447.17 percent of total billed charges CT scan of heart structure with contrast 44212749_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 279.14 447.17 99282 Level 2 FCT Charge 44474123_1 CDM 0450 RC inpatient 962 625.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 625.3 65 999999999 582.49 933.14 percent of total billed charges 99282 Level 2 FCT Charge 44474123_1 CDM 0450 RC inpatient 962 625.3 AETNA AETNA 759.98 79 999999999 582.49 933.14 percent of total billed charges 99282 Level 2 FCT Charge 44474123_1 CDM 0450 RC inpatient 962 625.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 663.78 69 999999999 582.49 933.14 percent of total billed charges 99282 Level 2 FCT Charge 44474123_1 CDM 0450 RC inpatient 962 625.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 933.14 97 999999999 582.49 933.14 percent of total billed charges 99282 Level 2 FCT Charge 44474123_1 CDM 0450 RC inpatient 962 625.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 750.36 78 999999999 582.49 933.14 percent of total billed charges 99282 Level 2 FCT Charge 44474123_1 CDM 0450 RC inpatient 962 625.3 SIHO - ALL PLANS SIHO - ALL PLANS 865.8 90 999999999 582.49 933.14 percent of total billed charges 99282 Level 2 FCT Charge 44474123_1 CDM 0450 RC inpatient 962 625.3 UMR - ALL PLANS UMR - ALL PLANS 673.4 70 999999999 582.49 933.14 percent of total billed charges 99282 Level 2 FCT Charge 44474123_1 CDM 0450 RC inpatient 962 625.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 582.49 60.55 999999999 582.49 933.14 percent of total billed charges 99282 Level 2 FCT Charge 44474123_1 CDM 0450 RC inpatient 962 625.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 582.49 933.14 99282 Level 2 FCT Charge 44474123_1 CDM 0450 RC inpatient 962 625.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 582.49 933.14 99282 Level 2 FCT Charge 44474123_1 CDM 0450 RC inpatient 962 625.3 ANTHEM HMO ANTHEM HMO 999999999 582.49 933.14 99282 Level 2 FCT Charge 44474123_1 CDM 0450 RC inpatient 962 625.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 582.49 933.14 99282 Level 2 FCT Charge 44474123_1 CDM 0450 RC inpatient 962 625.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 650.31 67.6 999999999 582.49 933.14 percent of total billed charges 99282 Level 2 FCT Charge 44474123_1 CDM 0450 RC inpatient 962 625.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 582.49 933.14 99283 Level 3 FCT Charge 44474124_1 CDM 0450 RC inpatient 1039.5 675.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 675.68 65 999999999 629.42 1008.32 percent of total billed charges 99283 Level 3 FCT Charge 44474124_1 CDM 0450 RC inpatient 1039.5 675.68 AETNA AETNA 821.21 79 999999999 629.42 1008.32 percent of total billed charges 99283 Level 3 FCT Charge 44474124_1 CDM 0450 RC inpatient 1039.5 675.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 717.26 69 999999999 629.42 1008.32 percent of total billed charges 99283 Level 3 FCT Charge 44474124_1 CDM 0450 RC inpatient 1039.5 675.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1008.32 97 999999999 629.42 1008.32 percent of total billed charges 99283 Level 3 FCT Charge 44474124_1 CDM 0450 RC inpatient 1039.5 675.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 810.81 78 999999999 629.42 1008.32 percent of total billed charges 99283 Level 3 FCT Charge 44474124_1 CDM 0450 RC inpatient 1039.5 675.68 SIHO - ALL PLANS SIHO - ALL PLANS 935.55 90 999999999 629.42 1008.32 percent of total billed charges 99283 Level 3 FCT Charge 44474124_1 CDM 0450 RC inpatient 1039.5 675.68 UMR - ALL PLANS UMR - ALL PLANS 727.65 70 999999999 629.42 1008.32 percent of total billed charges 99283 Level 3 FCT Charge 44474124_1 CDM 0450 RC inpatient 1039.5 675.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 629.42 60.55 999999999 629.42 1008.32 percent of total billed charges 99283 Level 3 FCT Charge 44474124_1 CDM 0450 RC inpatient 1039.5 675.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 629.42 1008.32 99283 Level 3 FCT Charge 44474124_1 CDM 0450 RC inpatient 1039.5 675.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 629.42 1008.32 99283 Level 3 FCT Charge 44474124_1 CDM 0450 RC inpatient 1039.5 675.68 ANTHEM HMO ANTHEM HMO 999999999 629.42 1008.32 99283 Level 3 FCT Charge 44474124_1 CDM 0450 RC inpatient 1039.5 675.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 629.42 1008.32 99283 Level 3 FCT Charge 44474124_1 CDM 0450 RC inpatient 1039.5 675.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 702.7 67.6 999999999 629.42 1008.32 percent of total billed charges 99283 Level 3 FCT Charge 44474124_1 CDM 0450 RC inpatient 1039.5 675.68 UHC - ALL PLANS UHC - ALL PLANS 999999999 629.42 1008.32 99284 Level 4 FCT Charge 44474125_1 CDM 0450 RC inpatient 1518.94 987.31 SELF PAY DISCOUNT SELF PAY DISCOUNT 987.31 65 999999999 919.72 1473.37 percent of total billed charges 99284 Level 4 FCT Charge 44474125_1 CDM 0450 RC inpatient 1518.94 987.31 AETNA AETNA 1199.96 79 999999999 919.72 1473.37 percent of total billed charges 99284 Level 4 FCT Charge 44474125_1 CDM 0450 RC inpatient 1518.94 987.31 ENCORE - ALL PLANS ENCORE - ALL PLANS 1048.07 69 999999999 919.72 1473.37 percent of total billed charges 99284 Level 4 FCT Charge 44474125_1 CDM 0450 RC inpatient 1518.94 987.31 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1473.37 97 999999999 919.72 1473.37 percent of total billed charges 99284 Level 4 FCT Charge 44474125_1 CDM 0450 RC inpatient 1518.94 987.31 HUMANA - ALL PLANS HUMANA - ALL PLANS 1184.77 78 999999999 919.72 1473.37 percent of total billed charges 99284 Level 4 FCT Charge 44474125_1 CDM 0450 RC inpatient 1518.94 987.31 SIHO - ALL PLANS SIHO - ALL PLANS 1367.05 90 999999999 919.72 1473.37 percent of total billed charges 99284 Level 4 FCT Charge 44474125_1 CDM 0450 RC inpatient 1518.94 987.31 UMR - ALL PLANS UMR - ALL PLANS 1063.26 70 999999999 919.72 1473.37 percent of total billed charges 99284 Level 4 FCT Charge 44474125_1 CDM 0450 RC inpatient 1518.94 987.31 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 919.72 60.55 999999999 919.72 1473.37 percent of total billed charges 99284 Level 4 FCT Charge 44474125_1 CDM 0450 RC inpatient 1518.94 987.31 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 919.72 1473.37 99284 Level 4 FCT Charge 44474125_1 CDM 0450 RC inpatient 1518.94 987.31 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 919.72 1473.37 99284 Level 4 FCT Charge 44474125_1 CDM 0450 RC inpatient 1518.94 987.31 ANTHEM HMO ANTHEM HMO 999999999 919.72 1473.37 99284 Level 4 FCT Charge 44474125_1 CDM 0450 RC inpatient 1518.94 987.31 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 919.72 1473.37 99284 Level 4 FCT Charge 44474125_1 CDM 0450 RC inpatient 1518.94 987.31 CIGNA - ALL PLANS CIGNA - ALL PLANS 1026.8 67.6 999999999 919.72 1473.37 percent of total billed charges 99284 Level 4 FCT Charge 44474125_1 CDM 0450 RC inpatient 1518.94 987.31 UHC - ALL PLANS UHC - ALL PLANS 999999999 919.72 1473.37 99285 Level 5 FCT Charge 44474126_1 CDM 0450 RC inpatient 2152.95 1399.42 SELF PAY DISCOUNT SELF PAY DISCOUNT 1399.42 65 999999999 1303.61 2088.36 percent of total billed charges 99285 Level 5 FCT Charge 44474126_1 CDM 0450 RC inpatient 2152.95 1399.42 AETNA AETNA 1700.83 79 999999999 1303.61 2088.36 percent of total billed charges 99285 Level 5 FCT Charge 44474126_1 CDM 0450 RC inpatient 2152.95 1399.42 ENCORE - ALL PLANS ENCORE - ALL PLANS 1485.54 69 999999999 1303.61 2088.36 percent of total billed charges 99285 Level 5 FCT Charge 44474126_1 CDM 0450 RC inpatient 2152.95 1399.42 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2088.36 97 999999999 1303.61 2088.36 percent of total billed charges 99285 Level 5 FCT Charge 44474126_1 CDM 0450 RC inpatient 2152.95 1399.42 HUMANA - ALL PLANS HUMANA - ALL PLANS 1679.3 78 999999999 1303.61 2088.36 percent of total billed charges 99285 Level 5 FCT Charge 44474126_1 CDM 0450 RC inpatient 2152.95 1399.42 SIHO - ALL PLANS SIHO - ALL PLANS 1937.66 90 999999999 1303.61 2088.36 percent of total billed charges 99285 Level 5 FCT Charge 44474126_1 CDM 0450 RC inpatient 2152.95 1399.42 UMR - ALL PLANS UMR - ALL PLANS 1507.07 70 999999999 1303.61 2088.36 percent of total billed charges 99285 Level 5 FCT Charge 44474126_1 CDM 0450 RC inpatient 2152.95 1399.42 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1303.61 60.55 999999999 1303.61 2088.36 percent of total billed charges 99285 Level 5 FCT Charge 44474126_1 CDM 0450 RC inpatient 2152.95 1399.42 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1303.61 2088.36 99285 Level 5 FCT Charge 44474126_1 CDM 0450 RC inpatient 2152.95 1399.42 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1303.61 2088.36 99285 Level 5 FCT Charge 44474126_1 CDM 0450 RC inpatient 2152.95 1399.42 ANTHEM HMO ANTHEM HMO 999999999 1303.61 2088.36 99285 Level 5 FCT Charge 44474126_1 CDM 0450 RC inpatient 2152.95 1399.42 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1303.61 2088.36 99285 Level 5 FCT Charge 44474126_1 CDM 0450 RC inpatient 2152.95 1399.42 CIGNA - ALL PLANS CIGNA - ALL PLANS 1455.39 67.6 999999999 1303.61 2088.36 percent of total billed charges 99285 Level 5 FCT Charge 44474126_1 CDM 0450 RC inpatient 2152.95 1399.42 UHC - ALL PLANS UHC - ALL PLANS 999999999 1303.61 2088.36 Critical Care FCT Charge 44474127_1 CDM 0450 RC inpatient 2951 1918.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1918.15 65 999999999 1786.83 2862.47 percent of total billed charges Critical Care FCT Charge 44474127_1 CDM 0450 RC inpatient 2951 1918.15 AETNA AETNA 2331.29 79 999999999 1786.83 2862.47 percent of total billed charges Critical Care FCT Charge 44474127_1 CDM 0450 RC inpatient 2951 1918.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 2036.19 69 999999999 1786.83 2862.47 percent of total billed charges Critical Care FCT Charge 44474127_1 CDM 0450 RC inpatient 2951 1918.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2862.47 97 999999999 1786.83 2862.47 percent of total billed charges Critical Care FCT Charge 44474127_1 CDM 0450 RC inpatient 2951 1918.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 2301.78 78 999999999 1786.83 2862.47 percent of total billed charges Critical Care FCT Charge 44474127_1 CDM 0450 RC inpatient 2951 1918.15 SIHO - ALL PLANS SIHO - ALL PLANS 2655.9 90 999999999 1786.83 2862.47 percent of total billed charges Critical Care FCT Charge 44474127_1 CDM 0450 RC inpatient 2951 1918.15 UMR - ALL PLANS UMR - ALL PLANS 2065.7 70 999999999 1786.83 2862.47 percent of total billed charges Critical Care FCT Charge 44474127_1 CDM 0450 RC inpatient 2951 1918.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1786.83 60.55 999999999 1786.83 2862.47 percent of total billed charges Critical Care FCT Charge 44474127_1 CDM 0450 RC inpatient 2951 1918.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1786.83 2862.47 Critical Care FCT Charge 44474127_1 CDM 0450 RC inpatient 2951 1918.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1786.83 2862.47 Critical Care FCT Charge 44474127_1 CDM 0450 RC inpatient 2951 1918.15 ANTHEM HMO ANTHEM HMO 999999999 1786.83 2862.47 Critical Care FCT Charge 44474127_1 CDM 0450 RC inpatient 2951 1918.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1786.83 2862.47 Critical Care FCT Charge 44474127_1 CDM 0450 RC inpatient 2951 1918.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1994.88 67.6 999999999 1786.83 2862.47 percent of total billed charges Critical Care FCT Charge 44474127_1 CDM 0450 RC inpatient 2951 1918.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1786.83 2862.47 "Infusion into a vein for hydration, 31-60 minutes" 44474129_1 CDM 0260 RC 96360 HCPCS inpatient 256 166.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 166.4 65 999999999 155.01 248.32 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 44474129_1 CDM 0260 RC 96360 HCPCS inpatient 256 166.4 AETNA AETNA 202.24 79 999999999 155.01 248.32 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 44474129_1 CDM 0260 RC 96360 HCPCS inpatient 256 166.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 176.64 69 999999999 155.01 248.32 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 44474129_1 CDM 0260 RC 96360 HCPCS inpatient 256 166.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 248.32 97 999999999 155.01 248.32 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 44474129_1 CDM 0260 RC 96360 HCPCS inpatient 256 166.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 199.68 78 999999999 155.01 248.32 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 44474129_1 CDM 0260 RC 96360 HCPCS inpatient 256 166.4 SIHO - ALL PLANS SIHO - ALL PLANS 230.4 90 999999999 155.01 248.32 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 44474129_1 CDM 0260 RC 96360 HCPCS inpatient 256 166.4 UMR - ALL PLANS UMR - ALL PLANS 179.2 70 999999999 155.01 248.32 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 44474129_1 CDM 0260 RC 96360 HCPCS inpatient 256 166.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.01 60.55 999999999 155.01 248.32 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 44474129_1 CDM 0260 RC 96360 HCPCS inpatient 256 166.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.01 248.32 "Infusion into a vein for hydration, 31-60 minutes" 44474129_1 CDM 0260 RC 96360 HCPCS inpatient 256 166.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.01 248.32 "Infusion into a vein for hydration, 31-60 minutes" 44474129_1 CDM 0260 RC 96360 HCPCS inpatient 256 166.4 ANTHEM HMO ANTHEM HMO 999999999 155.01 248.32 "Infusion into a vein for hydration, 31-60 minutes" 44474129_1 CDM 0260 RC 96360 HCPCS inpatient 256 166.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.01 248.32 "Infusion into a vein for hydration, 31-60 minutes" 44474129_1 CDM 0260 RC 96360 HCPCS inpatient 256 166.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.06 67.6 999999999 155.01 248.32 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 44474129_1 CDM 0260 RC 96360 HCPCS inpatient 256 166.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.01 248.32 "Infusion into a vein for hydration, each additional hour" 44474130_1 CDM 0260 RC 96361 HCPCS inpatient 85 55.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.25 65 999999999 51.47 82.45 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 44474130_1 CDM 0260 RC 96361 HCPCS inpatient 85 55.25 AETNA AETNA 67.15 79 999999999 51.47 82.45 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 44474130_1 CDM 0260 RC 96361 HCPCS inpatient 85 55.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 58.65 69 999999999 51.47 82.45 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 44474130_1 CDM 0260 RC 96361 HCPCS inpatient 85 55.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 82.45 97 999999999 51.47 82.45 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 44474130_1 CDM 0260 RC 96361 HCPCS inpatient 85 55.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 66.3 78 999999999 51.47 82.45 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 44474130_1 CDM 0260 RC 96361 HCPCS inpatient 85 55.25 SIHO - ALL PLANS SIHO - ALL PLANS 76.5 90 999999999 51.47 82.45 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 44474130_1 CDM 0260 RC 96361 HCPCS inpatient 85 55.25 UMR - ALL PLANS UMR - ALL PLANS 59.5 70 999999999 51.47 82.45 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 44474130_1 CDM 0260 RC 96361 HCPCS inpatient 85 55.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 51.47 60.55 999999999 51.47 82.45 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 44474130_1 CDM 0260 RC 96361 HCPCS inpatient 85 55.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 51.47 82.45 "Infusion into a vein for hydration, each additional hour" 44474130_1 CDM 0260 RC 96361 HCPCS inpatient 85 55.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 51.47 82.45 "Infusion into a vein for hydration, each additional hour" 44474130_1 CDM 0260 RC 96361 HCPCS inpatient 85 55.25 ANTHEM HMO ANTHEM HMO 999999999 51.47 82.45 "Infusion into a vein for hydration, each additional hour" 44474130_1 CDM 0260 RC 96361 HCPCS inpatient 85 55.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 51.47 82.45 "Infusion into a vein for hydration, each additional hour" 44474130_1 CDM 0260 RC 96361 HCPCS inpatient 85 55.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 57.46 67.6 999999999 51.47 82.45 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 44474130_1 CDM 0260 RC 96361 HCPCS inpatient 85 55.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 51.47 82.45 "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 44474131_1 CDM 0450 RC 96365 HCPCS inpatient 545 354.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 354.25 65 999999999 330 528.65 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 44474131_1 CDM 0450 RC 96365 HCPCS inpatient 545 354.25 AETNA AETNA 430.55 79 999999999 330 528.65 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 44474131_1 CDM 0450 RC 96365 HCPCS inpatient 545 354.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 376.05 69 999999999 330 528.65 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 44474131_1 CDM 0450 RC 96365 HCPCS inpatient 545 354.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 528.65 97 999999999 330 528.65 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 44474131_1 CDM 0450 RC 96365 HCPCS inpatient 545 354.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 425.1 78 999999999 330 528.65 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 44474131_1 CDM 0450 RC 96365 HCPCS inpatient 545 354.25 SIHO - ALL PLANS SIHO - ALL PLANS 490.5 90 999999999 330 528.65 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 44474131_1 CDM 0450 RC 96365 HCPCS inpatient 545 354.25 UMR - ALL PLANS UMR - ALL PLANS 381.5 70 999999999 330 528.65 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 44474131_1 CDM 0450 RC 96365 HCPCS inpatient 545 354.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 330 60.55 999999999 330 528.65 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 44474131_1 CDM 0450 RC 96365 HCPCS inpatient 545 354.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 330 528.65 "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 44474131_1 CDM 0450 RC 96365 HCPCS inpatient 545 354.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 330 528.65 "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 44474131_1 CDM 0450 RC 96365 HCPCS inpatient 545 354.25 ANTHEM HMO ANTHEM HMO 999999999 330 528.65 "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 44474131_1 CDM 0450 RC 96365 HCPCS inpatient 545 354.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 330 528.65 "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 44474131_1 CDM 0450 RC 96365 HCPCS inpatient 545 354.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 368.42 67.6 999999999 330 528.65 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 44474131_1 CDM 0450 RC 96365 HCPCS inpatient 545 354.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 330 528.65 "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 44474132_1 CDM 0260 RC 96366 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 44474132_1 CDM 0260 RC 96366 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 44474132_1 CDM 0260 RC 96366 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 44474132_1 CDM 0260 RC 96366 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 44474132_1 CDM 0260 RC 96366 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 44474132_1 CDM 0260 RC 96366 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 44474132_1 CDM 0260 RC 96366 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 44474132_1 CDM 0260 RC 96366 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 44474132_1 CDM 0260 RC 96366 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 44474132_1 CDM 0260 RC 96366 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 44474132_1 CDM 0260 RC 96366 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 44474132_1 CDM 0260 RC 96366 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 44474132_1 CDM 0260 RC 96366 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 44474132_1 CDM 0260 RC 96366 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 44474133_1 CDM 0450 RC 96367 HCPCS inpatient 96 62.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.4 65 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 44474133_1 CDM 0450 RC 96367 HCPCS inpatient 96 62.4 AETNA AETNA 75.84 79 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 44474133_1 CDM 0450 RC 96367 HCPCS inpatient 96 62.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.24 69 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 44474133_1 CDM 0450 RC 96367 HCPCS inpatient 96 62.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.12 97 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 44474133_1 CDM 0450 RC 96367 HCPCS inpatient 96 62.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.88 78 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 44474133_1 CDM 0450 RC 96367 HCPCS inpatient 96 62.4 SIHO - ALL PLANS SIHO - ALL PLANS 86.4 90 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 44474133_1 CDM 0450 RC 96367 HCPCS inpatient 96 62.4 UMR - ALL PLANS UMR - ALL PLANS 67.2 70 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 44474133_1 CDM 0450 RC 96367 HCPCS inpatient 96 62.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.13 60.55 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 44474133_1 CDM 0450 RC 96367 HCPCS inpatient 96 62.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.13 93.12 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 44474133_1 CDM 0450 RC 96367 HCPCS inpatient 96 62.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.13 93.12 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 44474133_1 CDM 0450 RC 96367 HCPCS inpatient 96 62.4 ANTHEM HMO ANTHEM HMO 999999999 58.13 93.12 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 44474133_1 CDM 0450 RC 96367 HCPCS inpatient 96 62.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.13 93.12 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 44474133_1 CDM 0450 RC 96367 HCPCS inpatient 96 62.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.9 67.6 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 44474133_1 CDM 0450 RC 96367 HCPCS inpatient 96 62.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.13 93.12 "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 44474134_1 CDM 0450 RC 96368 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 44474134_1 CDM 0450 RC 96368 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 44474134_1 CDM 0450 RC 96368 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 44474134_1 CDM 0450 RC 96368 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 44474134_1 CDM 0450 RC 96368 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 44474134_1 CDM 0450 RC 96368 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 44474134_1 CDM 0450 RC 96368 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 44474134_1 CDM 0450 RC 96368 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 44474134_1 CDM 0450 RC 96368 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 44474134_1 CDM 0450 RC 96368 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 44474134_1 CDM 0450 RC 96368 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 44474134_1 CDM 0450 RC 96368 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 44474134_1 CDM 0450 RC 96368 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 44474134_1 CDM 0450 RC 96368 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 Injection of drug or substance under skin or into muscle 44474135_1 CDM 0450 RC 96372 HCPCS inpatient 144 93.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 93.6 65 999999999 87.19 139.68 percent of total billed charges Injection of drug or substance under skin or into muscle 44474135_1 CDM 0450 RC 96372 HCPCS inpatient 144 93.6 AETNA AETNA 113.76 79 999999999 87.19 139.68 percent of total billed charges Injection of drug or substance under skin or into muscle 44474135_1 CDM 0450 RC 96372 HCPCS inpatient 144 93.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 99.36 69 999999999 87.19 139.68 percent of total billed charges Injection of drug or substance under skin or into muscle 44474135_1 CDM 0450 RC 96372 HCPCS inpatient 144 93.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 139.68 97 999999999 87.19 139.68 percent of total billed charges Injection of drug or substance under skin or into muscle 44474135_1 CDM 0450 RC 96372 HCPCS inpatient 144 93.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 112.32 78 999999999 87.19 139.68 percent of total billed charges Injection of drug or substance under skin or into muscle 44474135_1 CDM 0450 RC 96372 HCPCS inpatient 144 93.6 SIHO - ALL PLANS SIHO - ALL PLANS 129.6 90 999999999 87.19 139.68 percent of total billed charges Injection of drug or substance under skin or into muscle 44474135_1 CDM 0450 RC 96372 HCPCS inpatient 144 93.6 UMR - ALL PLANS UMR - ALL PLANS 100.8 70 999999999 87.19 139.68 percent of total billed charges Injection of drug or substance under skin or into muscle 44474135_1 CDM 0450 RC 96372 HCPCS inpatient 144 93.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.19 60.55 999999999 87.19 139.68 percent of total billed charges Injection of drug or substance under skin or into muscle 44474135_1 CDM 0450 RC 96372 HCPCS inpatient 144 93.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.19 139.68 Injection of drug or substance under skin or into muscle 44474135_1 CDM 0450 RC 96372 HCPCS inpatient 144 93.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.19 139.68 Injection of drug or substance under skin or into muscle 44474135_1 CDM 0450 RC 96372 HCPCS inpatient 144 93.6 ANTHEM HMO ANTHEM HMO 999999999 87.19 139.68 Injection of drug or substance under skin or into muscle 44474135_1 CDM 0450 RC 96372 HCPCS inpatient 144 93.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.19 139.68 Injection of drug or substance under skin or into muscle 44474135_1 CDM 0450 RC 96372 HCPCS inpatient 144 93.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 97.34 67.6 999999999 87.19 139.68 percent of total billed charges Injection of drug or substance under skin or into muscle 44474135_1 CDM 0450 RC 96372 HCPCS inpatient 144 93.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.19 139.68 Injection of drug or substance into vein 44474145_1 CDM 0450 RC 96374 HCPCS inpatient 207 134.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 134.55 65 999999999 125.34 200.79 percent of total billed charges Injection of drug or substance into vein 44474145_1 CDM 0450 RC 96374 HCPCS inpatient 207 134.55 AETNA AETNA 163.53 79 999999999 125.34 200.79 percent of total billed charges Injection of drug or substance into vein 44474145_1 CDM 0450 RC 96374 HCPCS inpatient 207 134.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.83 69 999999999 125.34 200.79 percent of total billed charges Injection of drug or substance into vein 44474145_1 CDM 0450 RC 96374 HCPCS inpatient 207 134.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 200.79 97 999999999 125.34 200.79 percent of total billed charges Injection of drug or substance into vein 44474145_1 CDM 0450 RC 96374 HCPCS inpatient 207 134.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 161.46 78 999999999 125.34 200.79 percent of total billed charges Injection of drug or substance into vein 44474145_1 CDM 0450 RC 96374 HCPCS inpatient 207 134.55 SIHO - ALL PLANS SIHO - ALL PLANS 186.3 90 999999999 125.34 200.79 percent of total billed charges Injection of drug or substance into vein 44474145_1 CDM 0450 RC 96374 HCPCS inpatient 207 134.55 UMR - ALL PLANS UMR - ALL PLANS 144.9 70 999999999 125.34 200.79 percent of total billed charges Injection of drug or substance into vein 44474145_1 CDM 0450 RC 96374 HCPCS inpatient 207 134.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 125.34 60.55 999999999 125.34 200.79 percent of total billed charges Injection of drug or substance into vein 44474145_1 CDM 0450 RC 96374 HCPCS inpatient 207 134.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 125.34 200.79 Injection of drug or substance into vein 44474145_1 CDM 0450 RC 96374 HCPCS inpatient 207 134.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 125.34 200.79 Injection of drug or substance into vein 44474145_1 CDM 0450 RC 96374 HCPCS inpatient 207 134.55 ANTHEM HMO ANTHEM HMO 999999999 125.34 200.79 Injection of drug or substance into vein 44474145_1 CDM 0450 RC 96374 HCPCS inpatient 207 134.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 125.34 200.79 Injection of drug or substance into vein 44474145_1 CDM 0450 RC 96374 HCPCS inpatient 207 134.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.93 67.6 999999999 125.34 200.79 percent of total billed charges Injection of drug or substance into vein 44474145_1 CDM 0450 RC 96374 HCPCS inpatient 207 134.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 125.34 200.79 Injection of additional new drug or substance into vein 44474146_1 CDM 0450 RC 96375 HCPCS inpatient 188 122.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.2 65 999999999 113.83 182.36 percent of total billed charges Injection of additional new drug or substance into vein 44474146_1 CDM 0450 RC 96375 HCPCS inpatient 188 122.2 AETNA AETNA 148.52 79 999999999 113.83 182.36 percent of total billed charges Injection of additional new drug or substance into vein 44474146_1 CDM 0450 RC 96375 HCPCS inpatient 188 122.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.72 69 999999999 113.83 182.36 percent of total billed charges Injection of additional new drug or substance into vein 44474146_1 CDM 0450 RC 96375 HCPCS inpatient 188 122.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 182.36 97 999999999 113.83 182.36 percent of total billed charges Injection of additional new drug or substance into vein 44474146_1 CDM 0450 RC 96375 HCPCS inpatient 188 122.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 146.64 78 999999999 113.83 182.36 percent of total billed charges Injection of additional new drug or substance into vein 44474146_1 CDM 0450 RC 96375 HCPCS inpatient 188 122.2 SIHO - ALL PLANS SIHO - ALL PLANS 169.2 90 999999999 113.83 182.36 percent of total billed charges Injection of additional new drug or substance into vein 44474146_1 CDM 0450 RC 96375 HCPCS inpatient 188 122.2 UMR - ALL PLANS UMR - ALL PLANS 131.6 70 999999999 113.83 182.36 percent of total billed charges Injection of additional new drug or substance into vein 44474146_1 CDM 0450 RC 96375 HCPCS inpatient 188 122.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.83 60.55 999999999 113.83 182.36 percent of total billed charges Injection of additional new drug or substance into vein 44474146_1 CDM 0450 RC 96375 HCPCS inpatient 188 122.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.83 182.36 Injection of additional new drug or substance into vein 44474146_1 CDM 0450 RC 96375 HCPCS inpatient 188 122.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.83 182.36 Injection of additional new drug or substance into vein 44474146_1 CDM 0450 RC 96375 HCPCS inpatient 188 122.2 ANTHEM HMO ANTHEM HMO 999999999 113.83 182.36 Injection of additional new drug or substance into vein 44474146_1 CDM 0450 RC 96375 HCPCS inpatient 188 122.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.83 182.36 Injection of additional new drug or substance into vein 44474146_1 CDM 0450 RC 96375 HCPCS inpatient 188 122.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.09 67.6 999999999 113.83 182.36 percent of total billed charges Injection of additional new drug or substance into vein 44474146_1 CDM 0450 RC 96375 HCPCS inpatient 188 122.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.83 182.36 Injection of additional drug or substance into vein provided in a facility 44474147_1 CDM 0450 RC 96376 HCPCS inpatient 104 67.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 67.6 65 999999999 62.97 100.88 percent of total billed charges Injection of additional drug or substance into vein provided in a facility 44474147_1 CDM 0450 RC 96376 HCPCS inpatient 104 67.6 AETNA AETNA 82.16 79 999999999 62.97 100.88 percent of total billed charges Injection of additional drug or substance into vein provided in a facility 44474147_1 CDM 0450 RC 96376 HCPCS inpatient 104 67.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.76 69 999999999 62.97 100.88 percent of total billed charges Injection of additional drug or substance into vein provided in a facility 44474147_1 CDM 0450 RC 96376 HCPCS inpatient 104 67.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 100.88 97 999999999 62.97 100.88 percent of total billed charges Injection of additional drug or substance into vein provided in a facility 44474147_1 CDM 0450 RC 96376 HCPCS inpatient 104 67.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.12 78 999999999 62.97 100.88 percent of total billed charges Injection of additional drug or substance into vein provided in a facility 44474147_1 CDM 0450 RC 96376 HCPCS inpatient 104 67.6 SIHO - ALL PLANS SIHO - ALL PLANS 93.6 90 999999999 62.97 100.88 percent of total billed charges Injection of additional drug or substance into vein provided in a facility 44474147_1 CDM 0450 RC 96376 HCPCS inpatient 104 67.6 UMR - ALL PLANS UMR - ALL PLANS 72.8 70 999999999 62.97 100.88 percent of total billed charges Injection of additional drug or substance into vein provided in a facility 44474147_1 CDM 0450 RC 96376 HCPCS inpatient 104 67.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.97 60.55 999999999 62.97 100.88 percent of total billed charges Injection of additional drug or substance into vein provided in a facility 44474147_1 CDM 0450 RC 96376 HCPCS inpatient 104 67.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.97 100.88 Injection of additional drug or substance into vein provided in a facility 44474147_1 CDM 0450 RC 96376 HCPCS inpatient 104 67.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.97 100.88 Injection of additional drug or substance into vein provided in a facility 44474147_1 CDM 0450 RC 96376 HCPCS inpatient 104 67.6 ANTHEM HMO ANTHEM HMO 999999999 62.97 100.88 Injection of additional drug or substance into vein provided in a facility 44474147_1 CDM 0450 RC 96376 HCPCS inpatient 104 67.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.97 100.88 Injection of additional drug or substance into vein provided in a facility 44474147_1 CDM 0450 RC 96376 HCPCS inpatient 104 67.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.3 67.6 999999999 62.97 100.88 percent of total billed charges Injection of additional drug or substance into vein provided in a facility 44474147_1 CDM 0450 RC 96376 HCPCS inpatient 104 67.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.97 100.88 Closed treatment of broken forearm (radius) bone at the wrist area on the thumb side of the wrist without manipulation 44992014_1 CDM 0450 RC 25600 HCPCS inpatient 503 326.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 326.95 65 999999999 304.57 487.91 percent of total billed charges Closed treatment of broken forearm (radius) bone at the wrist area on the thumb side of the wrist without manipulation 44992014_1 CDM 0450 RC 25600 HCPCS inpatient 503 326.95 AETNA AETNA 397.37 79 999999999 304.57 487.91 percent of total billed charges Closed treatment of broken forearm (radius) bone at the wrist area on the thumb side of the wrist without manipulation 44992014_1 CDM 0450 RC 25600 HCPCS inpatient 503 326.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 347.07 69 999999999 304.57 487.91 percent of total billed charges Closed treatment of broken forearm (radius) bone at the wrist area on the thumb side of the wrist without manipulation 44992014_1 CDM 0450 RC 25600 HCPCS inpatient 503 326.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 487.91 97 999999999 304.57 487.91 percent of total billed charges Closed treatment of broken forearm (radius) bone at the wrist area on the thumb side of the wrist without manipulation 44992014_1 CDM 0450 RC 25600 HCPCS inpatient 503 326.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 392.34 78 999999999 304.57 487.91 percent of total billed charges Closed treatment of broken forearm (radius) bone at the wrist area on the thumb side of the wrist without manipulation 44992014_1 CDM 0450 RC 25600 HCPCS inpatient 503 326.95 SIHO - ALL PLANS SIHO - ALL PLANS 452.7 90 999999999 304.57 487.91 percent of total billed charges Closed treatment of broken forearm (radius) bone at the wrist area on the thumb side of the wrist without manipulation 44992014_1 CDM 0450 RC 25600 HCPCS inpatient 503 326.95 UMR - ALL PLANS UMR - ALL PLANS 352.1 70 999999999 304.57 487.91 percent of total billed charges Closed treatment of broken forearm (radius) bone at the wrist area on the thumb side of the wrist without manipulation 44992014_1 CDM 0450 RC 25600 HCPCS inpatient 503 326.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 304.57 60.55 999999999 304.57 487.91 percent of total billed charges Closed treatment of broken forearm (radius) bone at the wrist area on the thumb side of the wrist without manipulation 44992014_1 CDM 0450 RC 25600 HCPCS inpatient 503 326.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 304.57 487.91 Closed treatment of broken forearm (radius) bone at the wrist area on the thumb side of the wrist without manipulation 44992014_1 CDM 0450 RC 25600 HCPCS inpatient 503 326.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 304.57 487.91 Closed treatment of broken forearm (radius) bone at the wrist area on the thumb side of the wrist without manipulation 44992014_1 CDM 0450 RC 25600 HCPCS inpatient 503 326.95 ANTHEM HMO ANTHEM HMO 999999999 304.57 487.91 Closed treatment of broken forearm (radius) bone at the wrist area on the thumb side of the wrist without manipulation 44992014_1 CDM 0450 RC 25600 HCPCS inpatient 503 326.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 304.57 487.91 Closed treatment of broken forearm (radius) bone at the wrist area on the thumb side of the wrist without manipulation 44992014_1 CDM 0450 RC 25600 HCPCS inpatient 503 326.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 340.03 67.6 999999999 304.57 487.91 percent of total billed charges Closed treatment of broken forearm (radius) bone at the wrist area on the thumb side of the wrist without manipulation 44992014_1 CDM 0450 RC 25600 HCPCS inpatient 503 326.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 304.57 487.91 "Folic acid level, RBC" 46039090_1 CDM 0301 RC 82747 HCPCS inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges "Folic acid level, RBC" 46039090_1 CDM 0301 RC 82747 HCPCS inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges "Folic acid level, RBC" 46039090_1 CDM 0301 RC 82747 HCPCS inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges "Folic acid level, RBC" 46039090_1 CDM 0301 RC 82747 HCPCS inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges "Folic acid level, RBC" 46039090_1 CDM 0301 RC 82747 HCPCS inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges "Folic acid level, RBC" 46039090_1 CDM 0301 RC 82747 HCPCS inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges "Folic acid level, RBC" 46039090_1 CDM 0301 RC 82747 HCPCS inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges "Folic acid level, RBC" 46039090_1 CDM 0301 RC 82747 HCPCS inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges "Folic acid level, RBC" 46039090_1 CDM 0301 RC 82747 HCPCS inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 "Folic acid level, RBC" 46039090_1 CDM 0301 RC 82747 HCPCS inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 "Folic acid level, RBC" 46039090_1 CDM 0301 RC 82747 HCPCS inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 "Folic acid level, RBC" 46039090_1 CDM 0301 RC 82747 HCPCS inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 "Folic acid level, RBC" 46039090_1 CDM 0301 RC 82747 HCPCS inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges "Folic acid level, RBC" 46039090_1 CDM 0301 RC 82747 HCPCS inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 X-ray of eye canal 4640891_1 CDM 0320 RC 70190 HCPCS inpatient 512 332.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 332.8 65 999999999 310.02 496.64 percent of total billed charges X-ray of eye canal 4640891_1 CDM 0320 RC 70190 HCPCS inpatient 512 332.8 AETNA AETNA 404.48 79 999999999 310.02 496.64 percent of total billed charges X-ray of eye canal 4640891_1 CDM 0320 RC 70190 HCPCS inpatient 512 332.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 353.28 69 999999999 310.02 496.64 percent of total billed charges X-ray of eye canal 4640891_1 CDM 0320 RC 70190 HCPCS inpatient 512 332.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 496.64 97 999999999 310.02 496.64 percent of total billed charges X-ray of eye canal 4640891_1 CDM 0320 RC 70190 HCPCS inpatient 512 332.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 399.36 78 999999999 310.02 496.64 percent of total billed charges X-ray of eye canal 4640891_1 CDM 0320 RC 70190 HCPCS inpatient 512 332.8 SIHO - ALL PLANS SIHO - ALL PLANS 460.8 90 999999999 310.02 496.64 percent of total billed charges X-ray of eye canal 4640891_1 CDM 0320 RC 70190 HCPCS inpatient 512 332.8 UMR - ALL PLANS UMR - ALL PLANS 358.4 70 999999999 310.02 496.64 percent of total billed charges X-ray of eye canal 4640891_1 CDM 0320 RC 70190 HCPCS inpatient 512 332.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 310.02 60.55 999999999 310.02 496.64 percent of total billed charges X-ray of eye canal 4640891_1 CDM 0320 RC 70190 HCPCS inpatient 512 332.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 310.02 496.64 X-ray of eye canal 4640891_1 CDM 0320 RC 70190 HCPCS inpatient 512 332.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 310.02 496.64 X-ray of eye canal 4640891_1 CDM 0320 RC 70190 HCPCS inpatient 512 332.8 ANTHEM HMO ANTHEM HMO 999999999 310.02 496.64 X-ray of eye canal 4640891_1 CDM 0320 RC 70190 HCPCS inpatient 512 332.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 310.02 496.64 X-ray of eye canal 4640891_1 CDM 0320 RC 70190 HCPCS inpatient 512 332.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 346.11 67.6 999999999 310.02 496.64 percent of total billed charges X-ray of eye canal 4640891_1 CDM 0320 RC 70190 HCPCS inpatient 512 332.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 310.02 496.64 Limited ultrasound scan of abdomen 4699019_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 651.3 65 999999999 606.71 971.94 percent of total billed charges Limited ultrasound scan of abdomen 4699019_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 AETNA AETNA 791.58 79 999999999 606.71 971.94 percent of total billed charges Limited ultrasound scan of abdomen 4699019_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 691.38 69 999999999 606.71 971.94 percent of total billed charges Limited ultrasound scan of abdomen 4699019_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 971.94 97 999999999 606.71 971.94 percent of total billed charges Limited ultrasound scan of abdomen 4699019_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 781.56 78 999999999 606.71 971.94 percent of total billed charges Limited ultrasound scan of abdomen 4699019_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 SIHO - ALL PLANS SIHO - ALL PLANS 901.8 90 999999999 606.71 971.94 percent of total billed charges Limited ultrasound scan of abdomen 4699019_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 UMR - ALL PLANS UMR - ALL PLANS 701.4 70 999999999 606.71 971.94 percent of total billed charges Limited ultrasound scan of abdomen 4699019_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 606.71 60.55 999999999 606.71 971.94 percent of total billed charges Limited ultrasound scan of abdomen 4699019_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 606.71 971.94 Limited ultrasound scan of abdomen 4699019_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 606.71 971.94 Limited ultrasound scan of abdomen 4699019_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 ANTHEM HMO ANTHEM HMO 999999999 606.71 971.94 Limited ultrasound scan of abdomen 4699019_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 606.71 971.94 Limited ultrasound scan of abdomen 4699019_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 677.35 67.6 999999999 606.71 971.94 percent of total billed charges Limited ultrasound scan of abdomen 4699019_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 606.71 971.94 "Coagulation assessment blood test, plasma or whole blood" 4717028_1 CDM 0305 RC 85730 HCPCS inpatient 123 79.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.95 65 999999999 74.48 119.31 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 4717028_1 CDM 0305 RC 85730 HCPCS inpatient 123 79.95 AETNA AETNA 97.17 79 999999999 74.48 119.31 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 4717028_1 CDM 0305 RC 85730 HCPCS inpatient 123 79.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.87 69 999999999 74.48 119.31 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 4717028_1 CDM 0305 RC 85730 HCPCS inpatient 123 79.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 119.31 97 999999999 74.48 119.31 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 4717028_1 CDM 0305 RC 85730 HCPCS inpatient 123 79.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.94 78 999999999 74.48 119.31 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 4717028_1 CDM 0305 RC 85730 HCPCS inpatient 123 79.95 SIHO - ALL PLANS SIHO - ALL PLANS 110.7 90 999999999 74.48 119.31 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 4717028_1 CDM 0305 RC 85730 HCPCS inpatient 123 79.95 UMR - ALL PLANS UMR - ALL PLANS 86.1 70 999999999 74.48 119.31 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 4717028_1 CDM 0305 RC 85730 HCPCS inpatient 123 79.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 74.48 60.55 999999999 74.48 119.31 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 4717028_1 CDM 0305 RC 85730 HCPCS inpatient 123 79.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 74.48 119.31 "Coagulation assessment blood test, plasma or whole blood" 4717028_1 CDM 0305 RC 85730 HCPCS inpatient 123 79.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 74.48 119.31 "Coagulation assessment blood test, plasma or whole blood" 4717028_1 CDM 0305 RC 85730 HCPCS inpatient 123 79.95 ANTHEM HMO ANTHEM HMO 999999999 74.48 119.31 "Coagulation assessment blood test, plasma or whole blood" 4717028_1 CDM 0305 RC 85730 HCPCS inpatient 123 79.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 74.48 119.31 "Coagulation assessment blood test, plasma or whole blood" 4717028_1 CDM 0305 RC 85730 HCPCS inpatient 123 79.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.15 67.6 999999999 74.48 119.31 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 4717028_1 CDM 0305 RC 85730 HCPCS inpatient 123 79.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 74.48 119.31 Body fluid cell count with cell identification 47245883_1 CDM 0301 RC 89051 HCPCS inpatient 265 172.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 172.25 65 999999999 160.46 257.05 percent of total billed charges Body fluid cell count with cell identification 47245883_1 CDM 0301 RC 89051 HCPCS inpatient 265 172.25 AETNA AETNA 209.35 79 999999999 160.46 257.05 percent of total billed charges Body fluid cell count with cell identification 47245883_1 CDM 0301 RC 89051 HCPCS inpatient 265 172.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 182.85 69 999999999 160.46 257.05 percent of total billed charges Body fluid cell count with cell identification 47245883_1 CDM 0301 RC 89051 HCPCS inpatient 265 172.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 257.05 97 999999999 160.46 257.05 percent of total billed charges Body fluid cell count with cell identification 47245883_1 CDM 0301 RC 89051 HCPCS inpatient 265 172.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 206.7 78 999999999 160.46 257.05 percent of total billed charges Body fluid cell count with cell identification 47245883_1 CDM 0301 RC 89051 HCPCS inpatient 265 172.25 SIHO - ALL PLANS SIHO - ALL PLANS 238.5 90 999999999 160.46 257.05 percent of total billed charges Body fluid cell count with cell identification 47245883_1 CDM 0301 RC 89051 HCPCS inpatient 265 172.25 UMR - ALL PLANS UMR - ALL PLANS 185.5 70 999999999 160.46 257.05 percent of total billed charges Body fluid cell count with cell identification 47245883_1 CDM 0301 RC 89051 HCPCS inpatient 265 172.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 160.46 60.55 999999999 160.46 257.05 percent of total billed charges Body fluid cell count with cell identification 47245883_1 CDM 0301 RC 89051 HCPCS inpatient 265 172.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 160.46 257.05 Body fluid cell count with cell identification 47245883_1 CDM 0301 RC 89051 HCPCS inpatient 265 172.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 160.46 257.05 Body fluid cell count with cell identification 47245883_1 CDM 0301 RC 89051 HCPCS inpatient 265 172.25 ANTHEM HMO ANTHEM HMO 999999999 160.46 257.05 Body fluid cell count with cell identification 47245883_1 CDM 0301 RC 89051 HCPCS inpatient 265 172.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 160.46 257.05 Body fluid cell count with cell identification 47245883_1 CDM 0301 RC 89051 HCPCS inpatient 265 172.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 179.14 67.6 999999999 160.46 257.05 percent of total billed charges Body fluid cell count with cell identification 47245883_1 CDM 0301 RC 89051 HCPCS inpatient 265 172.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 160.46 257.05 "Gonadotropin, chorionic (reproductive hormone) level" 47245884_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 SELF PAY DISCOUNT SELF PAY DISCOUNT 130 65 999999999 121.1 194 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 47245884_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 AETNA AETNA 158 79 999999999 121.1 194 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 47245884_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 ENCORE - ALL PLANS ENCORE - ALL PLANS 138 69 999999999 121.1 194 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 47245884_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 194 97 999999999 121.1 194 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 47245884_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 HUMANA - ALL PLANS HUMANA - ALL PLANS 156 78 999999999 121.1 194 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 47245884_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 SIHO - ALL PLANS SIHO - ALL PLANS 180 90 999999999 121.1 194 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 47245884_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 UMR - ALL PLANS UMR - ALL PLANS 140 70 999999999 121.1 194 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 47245884_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 121.1 60.55 999999999 121.1 194 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 47245884_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 121.1 194 "Gonadotropin, chorionic (reproductive hormone) level" 47245884_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 121.1 194 "Gonadotropin, chorionic (reproductive hormone) level" 47245884_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 ANTHEM HMO ANTHEM HMO 999999999 121.1 194 "Gonadotropin, chorionic (reproductive hormone) level" 47245884_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 121.1 194 "Gonadotropin, chorionic (reproductive hormone) level" 47245884_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 CIGNA - ALL PLANS CIGNA - ALL PLANS 135.2 67.6 999999999 121.1 194 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 47245884_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 UHC - ALL PLANS UHC - ALL PLANS 999999999 121.1 194 Syphilis detection test 47245885_1 CDM 0301 RC 86592 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges Syphilis detection test 47245885_1 CDM 0301 RC 86592 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges Syphilis detection test 47245885_1 CDM 0301 RC 86592 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges Syphilis detection test 47245885_1 CDM 0301 RC 86592 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges Syphilis detection test 47245885_1 CDM 0301 RC 86592 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges Syphilis detection test 47245885_1 CDM 0301 RC 86592 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges Syphilis detection test 47245885_1 CDM 0301 RC 86592 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges Syphilis detection test 47245885_1 CDM 0301 RC 86592 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges Syphilis detection test 47245885_1 CDM 0301 RC 86592 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 Syphilis detection test 47245885_1 CDM 0301 RC 86592 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 Syphilis detection test 47245885_1 CDM 0301 RC 86592 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 Syphilis detection test 47245885_1 CDM 0301 RC 86592 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 Syphilis detection test 47245885_1 CDM 0301 RC 86592 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges Syphilis detection test 47245885_1 CDM 0301 RC 86592 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 Smear for infectious agents 47245887_1 CDM 0306 RC 87210 HCPCS inpatient 94 61.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.1 65 999999999 56.92 91.18 percent of total billed charges Smear for infectious agents 47245887_1 CDM 0306 RC 87210 HCPCS inpatient 94 61.1 AETNA AETNA 74.26 79 999999999 56.92 91.18 percent of total billed charges Smear for infectious agents 47245887_1 CDM 0306 RC 87210 HCPCS inpatient 94 61.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.86 69 999999999 56.92 91.18 percent of total billed charges Smear for infectious agents 47245887_1 CDM 0306 RC 87210 HCPCS inpatient 94 61.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.18 97 999999999 56.92 91.18 percent of total billed charges Smear for infectious agents 47245887_1 CDM 0306 RC 87210 HCPCS inpatient 94 61.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.32 78 999999999 56.92 91.18 percent of total billed charges Smear for infectious agents 47245887_1 CDM 0306 RC 87210 HCPCS inpatient 94 61.1 SIHO - ALL PLANS SIHO - ALL PLANS 84.6 90 999999999 56.92 91.18 percent of total billed charges Smear for infectious agents 47245887_1 CDM 0306 RC 87210 HCPCS inpatient 94 61.1 UMR - ALL PLANS UMR - ALL PLANS 65.8 70 999999999 56.92 91.18 percent of total billed charges Smear for infectious agents 47245887_1 CDM 0306 RC 87210 HCPCS inpatient 94 61.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.92 60.55 999999999 56.92 91.18 percent of total billed charges Smear for infectious agents 47245887_1 CDM 0306 RC 87210 HCPCS inpatient 94 61.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.92 91.18 Smear for infectious agents 47245887_1 CDM 0306 RC 87210 HCPCS inpatient 94 61.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.92 91.18 Smear for infectious agents 47245887_1 CDM 0306 RC 87210 HCPCS inpatient 94 61.1 ANTHEM HMO ANTHEM HMO 999999999 56.92 91.18 Smear for infectious agents 47245887_1 CDM 0306 RC 87210 HCPCS inpatient 94 61.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.92 91.18 Smear for infectious agents 47245887_1 CDM 0306 RC 87210 HCPCS inpatient 94 61.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.54 67.6 999999999 56.92 91.18 percent of total billed charges Smear for infectious agents 47245887_1 CDM 0306 RC 87210 HCPCS inpatient 94 61.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.92 91.18 "Total protein level, urine" 47245900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 47245900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 47245900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 47245900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 47245900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 47245900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 47245900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 47245900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 47245900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 "Total protein level, urine" 47245900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 "Total protein level, urine" 47245900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 "Total protein level, urine" 47245900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 "Total protein level, urine" 47245900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 47245900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 Detection test by immunoassay technique for other organism 47245912_1 CDM 0306 RC 87449 HCPCS inpatient 89 57.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.85 65 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for other organism 47245912_1 CDM 0306 RC 87449 HCPCS inpatient 89 57.85 AETNA AETNA 70.31 79 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for other organism 47245912_1 CDM 0306 RC 87449 HCPCS inpatient 89 57.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 61.41 69 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for other organism 47245912_1 CDM 0306 RC 87449 HCPCS inpatient 89 57.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 86.33 97 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for other organism 47245912_1 CDM 0306 RC 87449 HCPCS inpatient 89 57.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 69.42 78 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for other organism 47245912_1 CDM 0306 RC 87449 HCPCS inpatient 89 57.85 SIHO - ALL PLANS SIHO - ALL PLANS 80.1 90 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for other organism 47245912_1 CDM 0306 RC 87449 HCPCS inpatient 89 57.85 UMR - ALL PLANS UMR - ALL PLANS 62.3 70 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for other organism 47245912_1 CDM 0306 RC 87449 HCPCS inpatient 89 57.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.89 60.55 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for other organism 47245912_1 CDM 0306 RC 87449 HCPCS inpatient 89 57.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.89 86.33 Detection test by immunoassay technique for other organism 47245912_1 CDM 0306 RC 87449 HCPCS inpatient 89 57.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.89 86.33 Detection test by immunoassay technique for other organism 47245912_1 CDM 0306 RC 87449 HCPCS inpatient 89 57.85 ANTHEM HMO ANTHEM HMO 999999999 53.89 86.33 Detection test by immunoassay technique for other organism 47245912_1 CDM 0306 RC 87449 HCPCS inpatient 89 57.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.89 86.33 Detection test by immunoassay technique for other organism 47245912_1 CDM 0306 RC 87449 HCPCS inpatient 89 57.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.16 67.6 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for other organism 47245912_1 CDM 0306 RC 87449 HCPCS inpatient 89 57.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.89 86.33 "Total protein level, urine" 47371484_1 CDM 0301 RC 84156 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges "Total protein level, urine" 47371484_1 CDM 0301 RC 84156 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges "Total protein level, urine" 47371484_1 CDM 0301 RC 84156 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges "Total protein level, urine" 47371484_1 CDM 0301 RC 84156 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges "Total protein level, urine" 47371484_1 CDM 0301 RC 84156 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges "Total protein level, urine" 47371484_1 CDM 0301 RC 84156 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges "Total protein level, urine" 47371484_1 CDM 0301 RC 84156 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges "Total protein level, urine" 47371484_1 CDM 0301 RC 84156 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges "Total protein level, urine" 47371484_1 CDM 0301 RC 84156 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 "Total protein level, urine" 47371484_1 CDM 0301 RC 84156 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 "Total protein level, urine" 47371484_1 CDM 0301 RC 84156 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 "Total protein level, urine" 47371484_1 CDM 0301 RC 84156 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 "Total protein level, urine" 47371484_1 CDM 0301 RC 84156 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges "Total protein level, urine" 47371484_1 CDM 0301 RC 84156 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 Creatinine level to test for kidney function or muscle injury 47371485_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 47371485_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 47371485_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 47371485_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 47371485_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 47371485_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 47371485_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 47371485_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 47371485_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 Creatinine level to test for kidney function or muscle injury 47371485_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 Creatinine level to test for kidney function or muscle injury 47371485_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 Creatinine level to test for kidney function or muscle injury 47371485_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 Creatinine level to test for kidney function or muscle injury 47371485_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 47371485_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 Identification of red blood cell antibodies 47500788_1 CDM 0302 RC 86870 HCPCS inpatient 456 296.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 296.4 65 999999999 276.11 442.32 percent of total billed charges Identification of red blood cell antibodies 47500788_1 CDM 0302 RC 86870 HCPCS inpatient 456 296.4 AETNA AETNA 360.24 79 999999999 276.11 442.32 percent of total billed charges Identification of red blood cell antibodies 47500788_1 CDM 0302 RC 86870 HCPCS inpatient 456 296.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 314.64 69 999999999 276.11 442.32 percent of total billed charges Identification of red blood cell antibodies 47500788_1 CDM 0302 RC 86870 HCPCS inpatient 456 296.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 442.32 97 999999999 276.11 442.32 percent of total billed charges Identification of red blood cell antibodies 47500788_1 CDM 0302 RC 86870 HCPCS inpatient 456 296.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 355.68 78 999999999 276.11 442.32 percent of total billed charges Identification of red blood cell antibodies 47500788_1 CDM 0302 RC 86870 HCPCS inpatient 456 296.4 SIHO - ALL PLANS SIHO - ALL PLANS 410.4 90 999999999 276.11 442.32 percent of total billed charges Identification of red blood cell antibodies 47500788_1 CDM 0302 RC 86870 HCPCS inpatient 456 296.4 UMR - ALL PLANS UMR - ALL PLANS 319.2 70 999999999 276.11 442.32 percent of total billed charges Identification of red blood cell antibodies 47500788_1 CDM 0302 RC 86870 HCPCS inpatient 456 296.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 276.11 60.55 999999999 276.11 442.32 percent of total billed charges Identification of red blood cell antibodies 47500788_1 CDM 0302 RC 86870 HCPCS inpatient 456 296.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 276.11 442.32 Identification of red blood cell antibodies 47500788_1 CDM 0302 RC 86870 HCPCS inpatient 456 296.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 276.11 442.32 Identification of red blood cell antibodies 47500788_1 CDM 0302 RC 86870 HCPCS inpatient 456 296.4 ANTHEM HMO ANTHEM HMO 999999999 276.11 442.32 Identification of red blood cell antibodies 47500788_1 CDM 0302 RC 86870 HCPCS inpatient 456 296.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 276.11 442.32 Identification of red blood cell antibodies 47500788_1 CDM 0302 RC 86870 HCPCS inpatient 456 296.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 308.26 67.6 999999999 276.11 442.32 percent of total billed charges Identification of red blood cell antibodies 47500788_1 CDM 0302 RC 86870 HCPCS inpatient 456 296.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 276.11 442.32 Test for exercise-induced lung stress 47552381_1 CDM 0410 RC 94618 HCPCS inpatient 298 193.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 193.7 65 999999999 180.44 289.06 percent of total billed charges Test for exercise-induced lung stress 47552381_1 CDM 0410 RC 94618 HCPCS inpatient 298 193.7 AETNA AETNA 235.42 79 999999999 180.44 289.06 percent of total billed charges Test for exercise-induced lung stress 47552381_1 CDM 0410 RC 94618 HCPCS inpatient 298 193.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 205.62 69 999999999 180.44 289.06 percent of total billed charges Test for exercise-induced lung stress 47552381_1 CDM 0410 RC 94618 HCPCS inpatient 298 193.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 289.06 97 999999999 180.44 289.06 percent of total billed charges Test for exercise-induced lung stress 47552381_1 CDM 0410 RC 94618 HCPCS inpatient 298 193.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 232.44 78 999999999 180.44 289.06 percent of total billed charges Test for exercise-induced lung stress 47552381_1 CDM 0410 RC 94618 HCPCS inpatient 298 193.7 SIHO - ALL PLANS SIHO - ALL PLANS 268.2 90 999999999 180.44 289.06 percent of total billed charges Test for exercise-induced lung stress 47552381_1 CDM 0410 RC 94618 HCPCS inpatient 298 193.7 UMR - ALL PLANS UMR - ALL PLANS 208.6 70 999999999 180.44 289.06 percent of total billed charges Test for exercise-induced lung stress 47552381_1 CDM 0410 RC 94618 HCPCS inpatient 298 193.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 180.44 60.55 999999999 180.44 289.06 percent of total billed charges Test for exercise-induced lung stress 47552381_1 CDM 0410 RC 94618 HCPCS inpatient 298 193.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 180.44 289.06 Test for exercise-induced lung stress 47552381_1 CDM 0410 RC 94618 HCPCS inpatient 298 193.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 180.44 289.06 Test for exercise-induced lung stress 47552381_1 CDM 0410 RC 94618 HCPCS inpatient 298 193.7 ANTHEM HMO ANTHEM HMO 999999999 180.44 289.06 Test for exercise-induced lung stress 47552381_1 CDM 0410 RC 94618 HCPCS inpatient 298 193.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 180.44 289.06 Test for exercise-induced lung stress 47552381_1 CDM 0410 RC 94618 HCPCS inpatient 298 193.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 201.45 67.6 999999999 180.44 289.06 percent of total billed charges Test for exercise-induced lung stress 47552381_1 CDM 0410 RC 94618 HCPCS inpatient 298 193.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 180.44 289.06 Application of hot or cold packs 47560552_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 47560552_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 47560552_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 47560552_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 47560552_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 47560552_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 47560552_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 47560552_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 47560552_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 Application of hot or cold packs 47560552_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 Application of hot or cold packs 47560552_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 Application of hot or cold packs 47560552_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 Application of hot or cold packs 47560552_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 47560552_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 "Evaluation for work hardening or conditioning, initial 2 hours" 47560566_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 382.2 65 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 47560566_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 AETNA AETNA 464.52 79 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 47560566_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 405.72 69 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 47560566_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 570.36 97 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 47560566_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 458.64 78 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 47560566_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 SIHO - ALL PLANS SIHO - ALL PLANS 529.2 90 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 47560566_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 UMR - ALL PLANS UMR - ALL PLANS 411.6 70 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 47560566_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 356.03 60.55 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 47560566_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 47560566_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 47560566_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 ANTHEM HMO ANTHEM HMO 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 47560566_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 47560566_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 397.49 67.6 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 47560566_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, each additional hour" 47560568_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 195.65 65 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 47560568_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 AETNA AETNA 237.79 79 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 47560568_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 207.69 69 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 47560568_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291.97 97 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 47560568_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 234.78 78 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 47560568_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 SIHO - ALL PLANS SIHO - ALL PLANS 270.9 90 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 47560568_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 UMR - ALL PLANS UMR - ALL PLANS 210.7 70 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 47560568_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.26 60.55 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 47560568_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 47560568_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 47560568_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 ANTHEM HMO ANTHEM HMO 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 47560568_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 47560568_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 203.48 67.6 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 47560568_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.26 291.97 Anti-Embolism Device 47586446_1 CDM 0270 RC inpatient 280 182 SELF PAY DISCOUNT SELF PAY DISCOUNT 182 65 999999999 169.54 271.6 percent of total billed charges Anti-Embolism Device 47586446_1 CDM 0270 RC inpatient 280 182 AETNA AETNA 221.2 79 999999999 169.54 271.6 percent of total billed charges Anti-Embolism Device 47586446_1 CDM 0270 RC inpatient 280 182 ENCORE - ALL PLANS ENCORE - ALL PLANS 193.2 69 999999999 169.54 271.6 percent of total billed charges Anti-Embolism Device 47586446_1 CDM 0270 RC inpatient 280 182 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 271.6 97 999999999 169.54 271.6 percent of total billed charges Anti-Embolism Device 47586446_1 CDM 0270 RC inpatient 280 182 HUMANA - ALL PLANS HUMANA - ALL PLANS 218.4 78 999999999 169.54 271.6 percent of total billed charges Anti-Embolism Device 47586446_1 CDM 0270 RC inpatient 280 182 SIHO - ALL PLANS SIHO - ALL PLANS 252 90 999999999 169.54 271.6 percent of total billed charges Anti-Embolism Device 47586446_1 CDM 0270 RC inpatient 280 182 UMR - ALL PLANS UMR - ALL PLANS 196 70 999999999 169.54 271.6 percent of total billed charges Anti-Embolism Device 47586446_1 CDM 0270 RC inpatient 280 182 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 169.54 60.55 999999999 169.54 271.6 percent of total billed charges Anti-Embolism Device 47586446_1 CDM 0270 RC inpatient 280 182 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 169.54 271.6 Anti-Embolism Device 47586446_1 CDM 0270 RC inpatient 280 182 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 169.54 271.6 Anti-Embolism Device 47586446_1 CDM 0270 RC inpatient 280 182 ANTHEM HMO ANTHEM HMO 999999999 169.54 271.6 Anti-Embolism Device 47586446_1 CDM 0270 RC inpatient 280 182 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 169.54 271.6 Anti-Embolism Device 47586446_1 CDM 0270 RC inpatient 280 182 CIGNA - ALL PLANS CIGNA - ALL PLANS 189.28 67.6 999999999 169.54 271.6 percent of total billed charges Anti-Embolism Device 47586446_1 CDM 0270 RC inpatient 280 182 UHC - ALL PLANS UHC - ALL PLANS 999999999 169.54 271.6 Insertion of temporary bladder tube 47586462_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.7 65 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 47586462_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 AETNA AETNA 188.02 79 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 47586462_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.22 69 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 47586462_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 230.86 97 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 47586462_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 185.64 78 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 47586462_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 SIHO - ALL PLANS SIHO - ALL PLANS 214.2 90 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 47586462_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 UMR - ALL PLANS UMR - ALL PLANS 166.6 70 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 47586462_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.11 60.55 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 47586462_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.11 230.86 Insertion of temporary bladder tube 47586462_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.11 230.86 Insertion of temporary bladder tube 47586462_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 ANTHEM HMO ANTHEM HMO 999999999 144.11 230.86 Insertion of temporary bladder tube 47586462_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.11 230.86 Insertion of temporary bladder tube 47586462_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.89 67.6 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 47586462_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.11 230.86 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 47586493_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 47586493_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 47586493_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 47586493_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 47586493_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 47586493_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 47586493_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 47586493_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 47586493_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 47586493_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 47586493_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 47586493_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 47586493_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 47586493_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 47586603_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 47586603_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 47586603_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 47586603_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 47586603_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 47586603_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 47586603_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 47586603_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 47586603_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 47586603_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 47586603_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 47586603_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 47586603_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 47586603_1 CDM 0420 RC 97112 HCPCS inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 Device Activity 47590673_1 CDM 0270 RC inpatient 280 182 SELF PAY DISCOUNT SELF PAY DISCOUNT 182 65 999999999 169.54 271.6 percent of total billed charges Device Activity 47590673_1 CDM 0270 RC inpatient 280 182 AETNA AETNA 221.2 79 999999999 169.54 271.6 percent of total billed charges Device Activity 47590673_1 CDM 0270 RC inpatient 280 182 ENCORE - ALL PLANS ENCORE - ALL PLANS 193.2 69 999999999 169.54 271.6 percent of total billed charges Device Activity 47590673_1 CDM 0270 RC inpatient 280 182 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 271.6 97 999999999 169.54 271.6 percent of total billed charges Device Activity 47590673_1 CDM 0270 RC inpatient 280 182 HUMANA - ALL PLANS HUMANA - ALL PLANS 218.4 78 999999999 169.54 271.6 percent of total billed charges Device Activity 47590673_1 CDM 0270 RC inpatient 280 182 SIHO - ALL PLANS SIHO - ALL PLANS 252 90 999999999 169.54 271.6 percent of total billed charges Device Activity 47590673_1 CDM 0270 RC inpatient 280 182 UMR - ALL PLANS UMR - ALL PLANS 196 70 999999999 169.54 271.6 percent of total billed charges Device Activity 47590673_1 CDM 0270 RC inpatient 280 182 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 169.54 60.55 999999999 169.54 271.6 percent of total billed charges Device Activity 47590673_1 CDM 0270 RC inpatient 280 182 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 169.54 271.6 Device Activity 47590673_1 CDM 0270 RC inpatient 280 182 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 169.54 271.6 Device Activity 47590673_1 CDM 0270 RC inpatient 280 182 ANTHEM HMO ANTHEM HMO 999999999 169.54 271.6 Device Activity 47590673_1 CDM 0270 RC inpatient 280 182 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 169.54 271.6 Device Activity 47590673_1 CDM 0270 RC inpatient 280 182 CIGNA - ALL PLANS CIGNA - ALL PLANS 189.28 67.6 999999999 169.54 271.6 percent of total billed charges Device Activity 47590673_1 CDM 0270 RC inpatient 280 182 UHC - ALL PLANS UHC - ALL PLANS 999999999 169.54 271.6 Injection of anesthetic agent and/or steroid into face nerve 47634558_1 CDM 0450 RC 64400 HCPCS inpatient 762 495.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 495.3 65 999999999 461.39 739.14 percent of total billed charges Injection of anesthetic agent and/or steroid into face nerve 47634558_1 CDM 0450 RC 64400 HCPCS inpatient 762 495.3 AETNA AETNA 601.98 79 999999999 461.39 739.14 percent of total billed charges Injection of anesthetic agent and/or steroid into face nerve 47634558_1 CDM 0450 RC 64400 HCPCS inpatient 762 495.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 525.78 69 999999999 461.39 739.14 percent of total billed charges Injection of anesthetic agent and/or steroid into face nerve 47634558_1 CDM 0450 RC 64400 HCPCS inpatient 762 495.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 739.14 97 999999999 461.39 739.14 percent of total billed charges Injection of anesthetic agent and/or steroid into face nerve 47634558_1 CDM 0450 RC 64400 HCPCS inpatient 762 495.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 594.36 78 999999999 461.39 739.14 percent of total billed charges Injection of anesthetic agent and/or steroid into face nerve 47634558_1 CDM 0450 RC 64400 HCPCS inpatient 762 495.3 SIHO - ALL PLANS SIHO - ALL PLANS 685.8 90 999999999 461.39 739.14 percent of total billed charges Injection of anesthetic agent and/or steroid into face nerve 47634558_1 CDM 0450 RC 64400 HCPCS inpatient 762 495.3 UMR - ALL PLANS UMR - ALL PLANS 533.4 70 999999999 461.39 739.14 percent of total billed charges Injection of anesthetic agent and/or steroid into face nerve 47634558_1 CDM 0450 RC 64400 HCPCS inpatient 762 495.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 461.39 60.55 999999999 461.39 739.14 percent of total billed charges Injection of anesthetic agent and/or steroid into face nerve 47634558_1 CDM 0450 RC 64400 HCPCS inpatient 762 495.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 461.39 739.14 Injection of anesthetic agent and/or steroid into face nerve 47634558_1 CDM 0450 RC 64400 HCPCS inpatient 762 495.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 461.39 739.14 Injection of anesthetic agent and/or steroid into face nerve 47634558_1 CDM 0450 RC 64400 HCPCS inpatient 762 495.3 ANTHEM HMO ANTHEM HMO 999999999 461.39 739.14 Injection of anesthetic agent and/or steroid into face nerve 47634558_1 CDM 0450 RC 64400 HCPCS inpatient 762 495.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 461.39 739.14 Injection of anesthetic agent and/or steroid into face nerve 47634558_1 CDM 0450 RC 64400 HCPCS inpatient 762 495.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 515.11 67.6 999999999 461.39 739.14 percent of total billed charges Injection of anesthetic agent and/or steroid into face nerve 47634558_1 CDM 0450 RC 64400 HCPCS inpatient 762 495.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 461.39 739.14 Drainage of fluid from abdominal cavity 47634628_1 CDM 0450 RC 49082 HCPCS inpatient 812 527.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 527.8 65 999999999 491.67 787.64 percent of total billed charges Drainage of fluid from abdominal cavity 47634628_1 CDM 0450 RC 49082 HCPCS inpatient 812 527.8 AETNA AETNA 641.48 79 999999999 491.67 787.64 percent of total billed charges Drainage of fluid from abdominal cavity 47634628_1 CDM 0450 RC 49082 HCPCS inpatient 812 527.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 560.28 69 999999999 491.67 787.64 percent of total billed charges Drainage of fluid from abdominal cavity 47634628_1 CDM 0450 RC 49082 HCPCS inpatient 812 527.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 787.64 97 999999999 491.67 787.64 percent of total billed charges Drainage of fluid from abdominal cavity 47634628_1 CDM 0450 RC 49082 HCPCS inpatient 812 527.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 633.36 78 999999999 491.67 787.64 percent of total billed charges Drainage of fluid from abdominal cavity 47634628_1 CDM 0450 RC 49082 HCPCS inpatient 812 527.8 SIHO - ALL PLANS SIHO - ALL PLANS 730.8 90 999999999 491.67 787.64 percent of total billed charges Drainage of fluid from abdominal cavity 47634628_1 CDM 0450 RC 49082 HCPCS inpatient 812 527.8 UMR - ALL PLANS UMR - ALL PLANS 568.4 70 999999999 491.67 787.64 percent of total billed charges Drainage of fluid from abdominal cavity 47634628_1 CDM 0450 RC 49082 HCPCS inpatient 812 527.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 491.67 60.55 999999999 491.67 787.64 percent of total billed charges Drainage of fluid from abdominal cavity 47634628_1 CDM 0450 RC 49082 HCPCS inpatient 812 527.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 491.67 787.64 Drainage of fluid from abdominal cavity 47634628_1 CDM 0450 RC 49082 HCPCS inpatient 812 527.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 491.67 787.64 Drainage of fluid from abdominal cavity 47634628_1 CDM 0450 RC 49082 HCPCS inpatient 812 527.8 ANTHEM HMO ANTHEM HMO 999999999 491.67 787.64 Drainage of fluid from abdominal cavity 47634628_1 CDM 0450 RC 49082 HCPCS inpatient 812 527.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 491.67 787.64 Drainage of fluid from abdominal cavity 47634628_1 CDM 0450 RC 49082 HCPCS inpatient 812 527.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 548.91 67.6 999999999 491.67 787.64 percent of total billed charges Drainage of fluid from abdominal cavity 47634628_1 CDM 0450 RC 49082 HCPCS inpatient 812 527.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 491.67 787.64 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 47680464_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 640.9 65 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 47680464_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 AETNA AETNA 778.94 79 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 47680464_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 680.34 69 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 47680464_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 956.42 97 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 47680464_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 769.08 78 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 47680464_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 SIHO - ALL PLANS SIHO - ALL PLANS 887.4 90 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 47680464_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 UMR - ALL PLANS UMR - ALL PLANS 690.2 70 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 47680464_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 597.02 60.55 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 47680464_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 597.02 956.42 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 47680464_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 597.02 956.42 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 47680464_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 ANTHEM HMO ANTHEM HMO 999999999 597.02 956.42 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 47680464_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 597.02 956.42 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 47680464_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 666.54 67.6 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 47680464_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 597.02 956.42 "Coagulation assessment blood test, plasma or whole blood" 47694385_1 CDM 0305 RC 85730 HCPCS inpatient 122 79.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.3 65 999999999 73.87 118.34 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 47694385_1 CDM 0305 RC 85730 HCPCS inpatient 122 79.3 AETNA AETNA 96.38 79 999999999 73.87 118.34 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 47694385_1 CDM 0305 RC 85730 HCPCS inpatient 122 79.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.18 69 999999999 73.87 118.34 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 47694385_1 CDM 0305 RC 85730 HCPCS inpatient 122 79.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 118.34 97 999999999 73.87 118.34 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 47694385_1 CDM 0305 RC 85730 HCPCS inpatient 122 79.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.16 78 999999999 73.87 118.34 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 47694385_1 CDM 0305 RC 85730 HCPCS inpatient 122 79.3 SIHO - ALL PLANS SIHO - ALL PLANS 109.8 90 999999999 73.87 118.34 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 47694385_1 CDM 0305 RC 85730 HCPCS inpatient 122 79.3 UMR - ALL PLANS UMR - ALL PLANS 85.4 70 999999999 73.87 118.34 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 47694385_1 CDM 0305 RC 85730 HCPCS inpatient 122 79.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.87 60.55 999999999 73.87 118.34 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 47694385_1 CDM 0305 RC 85730 HCPCS inpatient 122 79.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.87 118.34 "Coagulation assessment blood test, plasma or whole blood" 47694385_1 CDM 0305 RC 85730 HCPCS inpatient 122 79.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.87 118.34 "Coagulation assessment blood test, plasma or whole blood" 47694385_1 CDM 0305 RC 85730 HCPCS inpatient 122 79.3 ANTHEM HMO ANTHEM HMO 999999999 73.87 118.34 "Coagulation assessment blood test, plasma or whole blood" 47694385_1 CDM 0305 RC 85730 HCPCS inpatient 122 79.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.87 118.34 "Coagulation assessment blood test, plasma or whole blood" 47694385_1 CDM 0305 RC 85730 HCPCS inpatient 122 79.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 82.47 67.6 999999999 73.87 118.34 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 47694385_1 CDM 0305 RC 85730 HCPCS inpatient 122 79.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.87 118.34 "Urea nitrogen level to assess kidney function, urine" 47694410_1 CDM 0301 RC 84540 HCPCS inpatient 122 79.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.3 65 999999999 73.87 118.34 percent of total billed charges "Urea nitrogen level to assess kidney function, urine" 47694410_1 CDM 0301 RC 84540 HCPCS inpatient 122 79.3 AETNA AETNA 96.38 79 999999999 73.87 118.34 percent of total billed charges "Urea nitrogen level to assess kidney function, urine" 47694410_1 CDM 0301 RC 84540 HCPCS inpatient 122 79.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.18 69 999999999 73.87 118.34 percent of total billed charges "Urea nitrogen level to assess kidney function, urine" 47694410_1 CDM 0301 RC 84540 HCPCS inpatient 122 79.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 118.34 97 999999999 73.87 118.34 percent of total billed charges "Urea nitrogen level to assess kidney function, urine" 47694410_1 CDM 0301 RC 84540 HCPCS inpatient 122 79.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.16 78 999999999 73.87 118.34 percent of total billed charges "Urea nitrogen level to assess kidney function, urine" 47694410_1 CDM 0301 RC 84540 HCPCS inpatient 122 79.3 SIHO - ALL PLANS SIHO - ALL PLANS 109.8 90 999999999 73.87 118.34 percent of total billed charges "Urea nitrogen level to assess kidney function, urine" 47694410_1 CDM 0301 RC 84540 HCPCS inpatient 122 79.3 UMR - ALL PLANS UMR - ALL PLANS 85.4 70 999999999 73.87 118.34 percent of total billed charges "Urea nitrogen level to assess kidney function, urine" 47694410_1 CDM 0301 RC 84540 HCPCS inpatient 122 79.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.87 60.55 999999999 73.87 118.34 percent of total billed charges "Urea nitrogen level to assess kidney function, urine" 47694410_1 CDM 0301 RC 84540 HCPCS inpatient 122 79.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.87 118.34 "Urea nitrogen level to assess kidney function, urine" 47694410_1 CDM 0301 RC 84540 HCPCS inpatient 122 79.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.87 118.34 "Urea nitrogen level to assess kidney function, urine" 47694410_1 CDM 0301 RC 84540 HCPCS inpatient 122 79.3 ANTHEM HMO ANTHEM HMO 999999999 73.87 118.34 "Urea nitrogen level to assess kidney function, urine" 47694410_1 CDM 0301 RC 84540 HCPCS inpatient 122 79.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.87 118.34 "Urea nitrogen level to assess kidney function, urine" 47694410_1 CDM 0301 RC 84540 HCPCS inpatient 122 79.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 82.47 67.6 999999999 73.87 118.34 percent of total billed charges "Urea nitrogen level to assess kidney function, urine" 47694410_1 CDM 0301 RC 84540 HCPCS inpatient 122 79.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.87 118.34 "Cortisol (hormone) measurement, total" 47694425_1 CDM 0301 RC 82533 HCPCS inpatient 319 207.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 207.35 65 999999999 193.15 309.43 percent of total billed charges "Cortisol (hormone) measurement, total" 47694425_1 CDM 0301 RC 82533 HCPCS inpatient 319 207.35 AETNA AETNA 252.01 79 999999999 193.15 309.43 percent of total billed charges "Cortisol (hormone) measurement, total" 47694425_1 CDM 0301 RC 82533 HCPCS inpatient 319 207.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 220.11 69 999999999 193.15 309.43 percent of total billed charges "Cortisol (hormone) measurement, total" 47694425_1 CDM 0301 RC 82533 HCPCS inpatient 319 207.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 309.43 97 999999999 193.15 309.43 percent of total billed charges "Cortisol (hormone) measurement, total" 47694425_1 CDM 0301 RC 82533 HCPCS inpatient 319 207.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 248.82 78 999999999 193.15 309.43 percent of total billed charges "Cortisol (hormone) measurement, total" 47694425_1 CDM 0301 RC 82533 HCPCS inpatient 319 207.35 SIHO - ALL PLANS SIHO - ALL PLANS 287.1 90 999999999 193.15 309.43 percent of total billed charges "Cortisol (hormone) measurement, total" 47694425_1 CDM 0301 RC 82533 HCPCS inpatient 319 207.35 UMR - ALL PLANS UMR - ALL PLANS 223.3 70 999999999 193.15 309.43 percent of total billed charges "Cortisol (hormone) measurement, total" 47694425_1 CDM 0301 RC 82533 HCPCS inpatient 319 207.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 193.15 60.55 999999999 193.15 309.43 percent of total billed charges "Cortisol (hormone) measurement, total" 47694425_1 CDM 0301 RC 82533 HCPCS inpatient 319 207.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 193.15 309.43 "Cortisol (hormone) measurement, total" 47694425_1 CDM 0301 RC 82533 HCPCS inpatient 319 207.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 193.15 309.43 "Cortisol (hormone) measurement, total" 47694425_1 CDM 0301 RC 82533 HCPCS inpatient 319 207.35 ANTHEM HMO ANTHEM HMO 999999999 193.15 309.43 "Cortisol (hormone) measurement, total" 47694425_1 CDM 0301 RC 82533 HCPCS inpatient 319 207.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 193.15 309.43 "Cortisol (hormone) measurement, total" 47694425_1 CDM 0301 RC 82533 HCPCS inpatient 319 207.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 215.64 67.6 999999999 193.15 309.43 percent of total billed charges "Cortisol (hormone) measurement, total" 47694425_1 CDM 0301 RC 82533 HCPCS inpatient 319 207.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 193.15 309.43 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702663_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702663_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702663_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702663_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702663_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702663_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702663_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702663_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702663_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702663_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702663_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702663_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702663_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702663_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 "CRYOPRECIPITATE, EACH UNIT" 47702672_1 CDM 0390 RC P9012 HCPCS inpatient 250 162.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 162.5 65 999999999 151.38 242.5 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 47702672_1 CDM 0390 RC P9012 HCPCS inpatient 250 162.5 AETNA AETNA 197.5 79 999999999 151.38 242.5 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 47702672_1 CDM 0390 RC P9012 HCPCS inpatient 250 162.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 172.5 69 999999999 151.38 242.5 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 47702672_1 CDM 0390 RC P9012 HCPCS inpatient 250 162.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 242.5 97 999999999 151.38 242.5 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 47702672_1 CDM 0390 RC P9012 HCPCS inpatient 250 162.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 195 78 999999999 151.38 242.5 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 47702672_1 CDM 0390 RC P9012 HCPCS inpatient 250 162.5 SIHO - ALL PLANS SIHO - ALL PLANS 225 90 999999999 151.38 242.5 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 47702672_1 CDM 0390 RC P9012 HCPCS inpatient 250 162.5 UMR - ALL PLANS UMR - ALL PLANS 175 70 999999999 151.38 242.5 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 47702672_1 CDM 0390 RC P9012 HCPCS inpatient 250 162.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.38 60.55 999999999 151.38 242.5 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 47702672_1 CDM 0390 RC P9012 HCPCS inpatient 250 162.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.38 242.5 "CRYOPRECIPITATE, EACH UNIT" 47702672_1 CDM 0390 RC P9012 HCPCS inpatient 250 162.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.38 242.5 "CRYOPRECIPITATE, EACH UNIT" 47702672_1 CDM 0390 RC P9012 HCPCS inpatient 250 162.5 ANTHEM HMO ANTHEM HMO 999999999 151.38 242.5 "CRYOPRECIPITATE, EACH UNIT" 47702672_1 CDM 0390 RC P9012 HCPCS inpatient 250 162.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.38 242.5 "CRYOPRECIPITATE, EACH UNIT" 47702672_1 CDM 0390 RC P9012 HCPCS inpatient 250 162.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 169 67.6 999999999 151.38 242.5 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 47702672_1 CDM 0390 RC P9012 HCPCS inpatient 250 162.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.38 242.5 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702677_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702677_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702677_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702677_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702677_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702677_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702677_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702677_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702677_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702677_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702677_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702677_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702677_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702677_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702680_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702680_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702680_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702680_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702680_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702680_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702680_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702680_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702680_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702680_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702680_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702680_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702680_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47702680_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 Blood group typing (ABO) 47710414_1 CDM 0302 RC 86900 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges Blood group typing (ABO) 47710414_1 CDM 0302 RC 86900 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges Blood group typing (ABO) 47710414_1 CDM 0302 RC 86900 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges Blood group typing (ABO) 47710414_1 CDM 0302 RC 86900 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges Blood group typing (ABO) 47710414_1 CDM 0302 RC 86900 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges Blood group typing (ABO) 47710414_1 CDM 0302 RC 86900 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges Blood group typing (ABO) 47710414_1 CDM 0302 RC 86900 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges Blood group typing (ABO) 47710414_1 CDM 0302 RC 86900 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges Blood group typing (ABO) 47710414_1 CDM 0302 RC 86900 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 Blood group typing (ABO) 47710414_1 CDM 0302 RC 86900 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 Blood group typing (ABO) 47710414_1 CDM 0302 RC 86900 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 Blood group typing (ABO) 47710414_1 CDM 0302 RC 86900 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 Blood group typing (ABO) 47710414_1 CDM 0302 RC 86900 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges Blood group typing (ABO) 47710414_1 CDM 0302 RC 86900 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 Bill Miscellaneous 47710415_1 CDM 0300 RC inpatient 71.64 46.57 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.57 65 999999999 43.38 69.49 percent of total billed charges Bill Miscellaneous 47710415_1 CDM 0300 RC inpatient 71.64 46.57 AETNA AETNA 56.6 79 999999999 43.38 69.49 percent of total billed charges Bill Miscellaneous 47710415_1 CDM 0300 RC inpatient 71.64 46.57 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.43 69 999999999 43.38 69.49 percent of total billed charges Bill Miscellaneous 47710415_1 CDM 0300 RC inpatient 71.64 46.57 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.49 97 999999999 43.38 69.49 percent of total billed charges Bill Miscellaneous 47710415_1 CDM 0300 RC inpatient 71.64 46.57 HUMANA - ALL PLANS HUMANA - ALL PLANS 55.88 78 999999999 43.38 69.49 percent of total billed charges Bill Miscellaneous 47710415_1 CDM 0300 RC inpatient 71.64 46.57 SIHO - ALL PLANS SIHO - ALL PLANS 64.48 90 999999999 43.38 69.49 percent of total billed charges Bill Miscellaneous 47710415_1 CDM 0300 RC inpatient 71.64 46.57 UMR - ALL PLANS UMR - ALL PLANS 50.15 70 999999999 43.38 69.49 percent of total billed charges Bill Miscellaneous 47710415_1 CDM 0300 RC inpatient 71.64 46.57 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.38 60.55 999999999 43.38 69.49 percent of total billed charges Bill Miscellaneous 47710415_1 CDM 0300 RC inpatient 71.64 46.57 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.38 69.49 Bill Miscellaneous 47710415_1 CDM 0300 RC inpatient 71.64 46.57 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.38 69.49 Bill Miscellaneous 47710415_1 CDM 0300 RC inpatient 71.64 46.57 ANTHEM HMO ANTHEM HMO 999999999 43.38 69.49 Bill Miscellaneous 47710415_1 CDM 0300 RC inpatient 71.64 46.57 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.38 69.49 Bill Miscellaneous 47710415_1 CDM 0300 RC inpatient 71.64 46.57 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.43 67.6 999999999 43.38 69.49 percent of total billed charges Bill Miscellaneous 47710415_1 CDM 0300 RC inpatient 71.64 46.57 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.38 69.49 Detection test by immunoassay technique for Cryptosporidium (parasite) 47718430_1 CDM 0306 RC 87328 HCPCS inpatient 89 57.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.85 65 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for Cryptosporidium (parasite) 47718430_1 CDM 0306 RC 87328 HCPCS inpatient 89 57.85 AETNA AETNA 70.31 79 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for Cryptosporidium (parasite) 47718430_1 CDM 0306 RC 87328 HCPCS inpatient 89 57.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 61.41 69 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for Cryptosporidium (parasite) 47718430_1 CDM 0306 RC 87328 HCPCS inpatient 89 57.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 86.33 97 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for Cryptosporidium (parasite) 47718430_1 CDM 0306 RC 87328 HCPCS inpatient 89 57.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 69.42 78 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for Cryptosporidium (parasite) 47718430_1 CDM 0306 RC 87328 HCPCS inpatient 89 57.85 SIHO - ALL PLANS SIHO - ALL PLANS 80.1 90 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for Cryptosporidium (parasite) 47718430_1 CDM 0306 RC 87328 HCPCS inpatient 89 57.85 UMR - ALL PLANS UMR - ALL PLANS 62.3 70 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for Cryptosporidium (parasite) 47718430_1 CDM 0306 RC 87328 HCPCS inpatient 89 57.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.89 60.55 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for Cryptosporidium (parasite) 47718430_1 CDM 0306 RC 87328 HCPCS inpatient 89 57.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.89 86.33 Detection test by immunoassay technique for Cryptosporidium (parasite) 47718430_1 CDM 0306 RC 87328 HCPCS inpatient 89 57.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.89 86.33 Detection test by immunoassay technique for Cryptosporidium (parasite) 47718430_1 CDM 0306 RC 87328 HCPCS inpatient 89 57.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.89 86.33 Detection test by immunoassay technique for Cryptosporidium (parasite) 47718430_1 CDM 0306 RC 87328 HCPCS inpatient 89 57.85 ANTHEM HMO ANTHEM HMO 999999999 53.89 86.33 Detection test by immunoassay technique for Cryptosporidium (parasite) 47718430_1 CDM 0306 RC 87328 HCPCS inpatient 89 57.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.16 67.6 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for Cryptosporidium (parasite) 47718430_1 CDM 0306 RC 87328 HCPCS inpatient 89 57.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.89 86.33 Detection test by immunoassay technique for Giardia (intestinal parasite) 47718431_1 CDM 0306 RC 87329 HCPCS inpatient 89 57.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.85 65 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for Giardia (intestinal parasite) 47718431_1 CDM 0306 RC 87329 HCPCS inpatient 89 57.85 AETNA AETNA 70.31 79 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for Giardia (intestinal parasite) 47718431_1 CDM 0306 RC 87329 HCPCS inpatient 89 57.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 61.41 69 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for Giardia (intestinal parasite) 47718431_1 CDM 0306 RC 87329 HCPCS inpatient 89 57.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 86.33 97 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for Giardia (intestinal parasite) 47718431_1 CDM 0306 RC 87329 HCPCS inpatient 89 57.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 69.42 78 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for Giardia (intestinal parasite) 47718431_1 CDM 0306 RC 87329 HCPCS inpatient 89 57.85 SIHO - ALL PLANS SIHO - ALL PLANS 80.1 90 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for Giardia (intestinal parasite) 47718431_1 CDM 0306 RC 87329 HCPCS inpatient 89 57.85 UMR - ALL PLANS UMR - ALL PLANS 62.3 70 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for Giardia (intestinal parasite) 47718431_1 CDM 0306 RC 87329 HCPCS inpatient 89 57.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.89 60.55 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for Giardia (intestinal parasite) 47718431_1 CDM 0306 RC 87329 HCPCS inpatient 89 57.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.89 86.33 Detection test by immunoassay technique for Giardia (intestinal parasite) 47718431_1 CDM 0306 RC 87329 HCPCS inpatient 89 57.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.89 86.33 Detection test by immunoassay technique for Giardia (intestinal parasite) 47718431_1 CDM 0306 RC 87329 HCPCS inpatient 89 57.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.89 86.33 Detection test by immunoassay technique for Giardia (intestinal parasite) 47718431_1 CDM 0306 RC 87329 HCPCS inpatient 89 57.85 ANTHEM HMO ANTHEM HMO 999999999 53.89 86.33 Detection test by immunoassay technique for Giardia (intestinal parasite) 47718431_1 CDM 0306 RC 87329 HCPCS inpatient 89 57.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.16 67.6 999999999 53.89 86.33 percent of total billed charges Detection test by immunoassay technique for Giardia (intestinal parasite) 47718431_1 CDM 0306 RC 87329 HCPCS inpatient 89 57.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.89 86.33 Detection test by immunoassay with direct visual observation for other organism 47718540_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 47718540_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 47718540_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 47718540_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 47718540_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 47718540_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 47718540_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 47718540_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 47718540_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 Detection test by immunoassay with direct visual observation for other organism 47718540_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 Detection test by immunoassay with direct visual observation for other organism 47718540_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 Detection test by immunoassay with direct visual observation for other organism 47718540_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 Detection test by immunoassay with direct visual observation for other organism 47718540_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 47718540_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 Detection test by immunoassay with direct visual observation for other organism 47718541_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 47718541_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 47718541_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 47718541_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 47718541_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 47718541_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 47718541_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 47718541_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 47718541_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 Detection test by immunoassay with direct visual observation for other organism 47718541_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 Detection test by immunoassay with direct visual observation for other organism 47718541_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 Detection test by immunoassay with direct visual observation for other organism 47718541_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 Detection test by immunoassay with direct visual observation for other organism 47718541_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 47718541_1 CDM 0306 RC 87899 HCPCS inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 Bacterial urine culture 47726481_1 CDM 0306 RC 87088 HCPCS inpatient 56 36.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 36.4 65 999999999 33.91 54.32 percent of total billed charges Bacterial urine culture 47726481_1 CDM 0306 RC 87088 HCPCS inpatient 56 36.4 AETNA AETNA 44.24 79 999999999 33.91 54.32 percent of total billed charges Bacterial urine culture 47726481_1 CDM 0306 RC 87088 HCPCS inpatient 56 36.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 38.64 69 999999999 33.91 54.32 percent of total billed charges Bacterial urine culture 47726481_1 CDM 0306 RC 87088 HCPCS inpatient 56 36.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 54.32 97 999999999 33.91 54.32 percent of total billed charges Bacterial urine culture 47726481_1 CDM 0306 RC 87088 HCPCS inpatient 56 36.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 43.68 78 999999999 33.91 54.32 percent of total billed charges Bacterial urine culture 47726481_1 CDM 0306 RC 87088 HCPCS inpatient 56 36.4 SIHO - ALL PLANS SIHO - ALL PLANS 50.4 90 999999999 33.91 54.32 percent of total billed charges Bacterial urine culture 47726481_1 CDM 0306 RC 87088 HCPCS inpatient 56 36.4 UMR - ALL PLANS UMR - ALL PLANS 39.2 70 999999999 33.91 54.32 percent of total billed charges Bacterial urine culture 47726481_1 CDM 0306 RC 87088 HCPCS inpatient 56 36.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33.91 60.55 999999999 33.91 54.32 percent of total billed charges Bacterial urine culture 47726481_1 CDM 0306 RC 87088 HCPCS inpatient 56 36.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 33.91 54.32 Bacterial urine culture 47726481_1 CDM 0306 RC 87088 HCPCS inpatient 56 36.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 33.91 54.32 Bacterial urine culture 47726481_1 CDM 0306 RC 87088 HCPCS inpatient 56 36.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 33.91 54.32 Bacterial urine culture 47726481_1 CDM 0306 RC 87088 HCPCS inpatient 56 36.4 ANTHEM HMO ANTHEM HMO 999999999 33.91 54.32 Bacterial urine culture 47726481_1 CDM 0306 RC 87088 HCPCS inpatient 56 36.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 37.86 67.6 999999999 33.91 54.32 percent of total billed charges Bacterial urine culture 47726481_1 CDM 0306 RC 87088 HCPCS inpatient 56 36.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 33.91 54.32 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 47754432_1 CDM 0510 RC 99211 HCPCS inpatient 55 35.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 35.75 65 999999999 33.3 53.35 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 47754432_1 CDM 0510 RC 99211 HCPCS inpatient 55 35.75 AETNA AETNA 43.45 79 999999999 33.3 53.35 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 47754432_1 CDM 0510 RC 99211 HCPCS inpatient 55 35.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 37.95 69 999999999 33.3 53.35 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 47754432_1 CDM 0510 RC 99211 HCPCS inpatient 55 35.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 53.35 97 999999999 33.3 53.35 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 47754432_1 CDM 0510 RC 99211 HCPCS inpatient 55 35.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 42.9 78 999999999 33.3 53.35 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 47754432_1 CDM 0510 RC 99211 HCPCS inpatient 55 35.75 SIHO - ALL PLANS SIHO - ALL PLANS 49.5 90 999999999 33.3 53.35 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 47754432_1 CDM 0510 RC 99211 HCPCS inpatient 55 35.75 UMR - ALL PLANS UMR - ALL PLANS 38.5 70 999999999 33.3 53.35 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 47754432_1 CDM 0510 RC 99211 HCPCS inpatient 55 35.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33.3 60.55 999999999 33.3 53.35 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 47754432_1 CDM 0510 RC 99211 HCPCS inpatient 55 35.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 33.3 53.35 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 47754432_1 CDM 0510 RC 99211 HCPCS inpatient 55 35.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 33.3 53.35 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 47754432_1 CDM 0510 RC 99211 HCPCS inpatient 55 35.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 33.3 53.35 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 47754432_1 CDM 0510 RC 99211 HCPCS inpatient 55 35.75 ANTHEM HMO ANTHEM HMO 999999999 33.3 53.35 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 47754432_1 CDM 0510 RC 99211 HCPCS inpatient 55 35.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 37.18 67.6 999999999 33.3 53.35 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 47754432_1 CDM 0510 RC 99211 HCPCS inpatient 55 35.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 33.3 53.35 Interpretation and report of genetic testing 47770836_1 CDM 0311 RC 88291 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges Interpretation and report of genetic testing 47770836_1 CDM 0311 RC 88291 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges Interpretation and report of genetic testing 47770836_1 CDM 0311 RC 88291 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges Interpretation and report of genetic testing 47770836_1 CDM 0311 RC 88291 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges Interpretation and report of genetic testing 47770836_1 CDM 0311 RC 88291 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges Interpretation and report of genetic testing 47770836_1 CDM 0311 RC 88291 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges Interpretation and report of genetic testing 47770836_1 CDM 0311 RC 88291 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges Interpretation and report of genetic testing 47770836_1 CDM 0311 RC 88291 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges Interpretation and report of genetic testing 47770836_1 CDM 0311 RC 88291 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 Interpretation and report of genetic testing 47770836_1 CDM 0311 RC 88291 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 Interpretation and report of genetic testing 47770836_1 CDM 0311 RC 88291 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 Interpretation and report of genetic testing 47770836_1 CDM 0311 RC 88291 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 Interpretation and report of genetic testing 47770836_1 CDM 0311 RC 88291 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges Interpretation and report of genetic testing 47770836_1 CDM 0311 RC 88291 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 "Cell examination of specimen, selective cellular enhancement technique" 47770886_1 CDM 0312 RC 88112 HCPCS inpatient 312 202.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 202.8 65 999999999 188.92 302.64 percent of total billed charges "Cell examination of specimen, selective cellular enhancement technique" 47770886_1 CDM 0312 RC 88112 HCPCS inpatient 312 202.8 AETNA AETNA 246.48 79 999999999 188.92 302.64 percent of total billed charges "Cell examination of specimen, selective cellular enhancement technique" 47770886_1 CDM 0312 RC 88112 HCPCS inpatient 312 202.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 215.28 69 999999999 188.92 302.64 percent of total billed charges "Cell examination of specimen, selective cellular enhancement technique" 47770886_1 CDM 0312 RC 88112 HCPCS inpatient 312 202.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 302.64 97 999999999 188.92 302.64 percent of total billed charges "Cell examination of specimen, selective cellular enhancement technique" 47770886_1 CDM 0312 RC 88112 HCPCS inpatient 312 202.8 SIHO - ALL PLANS SIHO - ALL PLANS 280.8 90 999999999 188.92 302.64 percent of total billed charges "Cell examination of specimen, selective cellular enhancement technique" 47770886_1 CDM 0312 RC 88112 HCPCS inpatient 312 202.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 243.36 78 999999999 188.92 302.64 percent of total billed charges "Cell examination of specimen, selective cellular enhancement technique" 47770886_1 CDM 0312 RC 88112 HCPCS inpatient 312 202.8 UMR - ALL PLANS UMR - ALL PLANS 218.4 70 999999999 188.92 302.64 percent of total billed charges "Cell examination of specimen, selective cellular enhancement technique" 47770886_1 CDM 0312 RC 88112 HCPCS inpatient 312 202.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 188.92 60.55 999999999 188.92 302.64 percent of total billed charges "Cell examination of specimen, selective cellular enhancement technique" 47770886_1 CDM 0312 RC 88112 HCPCS inpatient 312 202.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 188.92 302.64 "Cell examination of specimen, selective cellular enhancement technique" 47770886_1 CDM 0312 RC 88112 HCPCS inpatient 312 202.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 188.92 302.64 "Cell examination of specimen, selective cellular enhancement technique" 47770886_1 CDM 0312 RC 88112 HCPCS inpatient 312 202.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 188.92 302.64 "Cell examination of specimen, selective cellular enhancement technique" 47770886_1 CDM 0312 RC 88112 HCPCS inpatient 312 202.8 ANTHEM HMO ANTHEM HMO 999999999 188.92 302.64 "Cell examination of specimen, selective cellular enhancement technique" 47770886_1 CDM 0312 RC 88112 HCPCS inpatient 312 202.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 210.91 67.6 999999999 188.92 302.64 percent of total billed charges "Cell examination of specimen, selective cellular enhancement technique" 47770886_1 CDM 0312 RC 88112 HCPCS inpatient 312 202.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 188.92 302.64 Aspiration and/or injection of fluid from small joint 47782393_1 CDM 0360 RC 20600 HCPCS inpatient 743 482.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 482.95 65 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from small joint 47782393_1 CDM 0360 RC 20600 HCPCS inpatient 743 482.95 AETNA AETNA 586.97 79 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from small joint 47782393_1 CDM 0360 RC 20600 HCPCS inpatient 743 482.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 512.67 69 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from small joint 47782393_1 CDM 0360 RC 20600 HCPCS inpatient 743 482.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 720.71 97 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from small joint 47782393_1 CDM 0360 RC 20600 HCPCS inpatient 743 482.95 SIHO - ALL PLANS SIHO - ALL PLANS 668.7 90 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from small joint 47782393_1 CDM 0360 RC 20600 HCPCS inpatient 743 482.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 579.54 78 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from small joint 47782393_1 CDM 0360 RC 20600 HCPCS inpatient 743 482.95 UMR - ALL PLANS UMR - ALL PLANS 520.1 70 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from small joint 47782393_1 CDM 0360 RC 20600 HCPCS inpatient 743 482.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 449.89 60.55 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from small joint 47782393_1 CDM 0360 RC 20600 HCPCS inpatient 743 482.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 449.89 720.71 Aspiration and/or injection of fluid from small joint 47782393_1 CDM 0360 RC 20600 HCPCS inpatient 743 482.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 449.89 720.71 Aspiration and/or injection of fluid from small joint 47782393_1 CDM 0360 RC 20600 HCPCS inpatient 743 482.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 449.89 720.71 Aspiration and/or injection of fluid from small joint 47782393_1 CDM 0360 RC 20600 HCPCS inpatient 743 482.95 ANTHEM HMO ANTHEM HMO 999999999 449.89 720.71 Aspiration and/or injection of fluid from small joint 47782393_1 CDM 0360 RC 20600 HCPCS inpatient 743 482.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 502.27 67.6 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from small joint 47782393_1 CDM 0360 RC 20600 HCPCS inpatient 743 482.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 449.89 720.71 Aspiration and/or injection of fluid from large joint 47782395_1 CDM 0360 RC 20610 HCPCS inpatient 743 482.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 482.95 65 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from large joint 47782395_1 CDM 0360 RC 20610 HCPCS inpatient 743 482.95 AETNA AETNA 586.97 79 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from large joint 47782395_1 CDM 0360 RC 20610 HCPCS inpatient 743 482.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 512.67 69 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from large joint 47782395_1 CDM 0360 RC 20610 HCPCS inpatient 743 482.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 720.71 97 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from large joint 47782395_1 CDM 0360 RC 20610 HCPCS inpatient 743 482.95 SIHO - ALL PLANS SIHO - ALL PLANS 668.7 90 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from large joint 47782395_1 CDM 0360 RC 20610 HCPCS inpatient 743 482.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 579.54 78 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from large joint 47782395_1 CDM 0360 RC 20610 HCPCS inpatient 743 482.95 UMR - ALL PLANS UMR - ALL PLANS 520.1 70 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from large joint 47782395_1 CDM 0360 RC 20610 HCPCS inpatient 743 482.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 449.89 60.55 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from large joint 47782395_1 CDM 0360 RC 20610 HCPCS inpatient 743 482.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 449.89 720.71 Aspiration and/or injection of fluid from large joint 47782395_1 CDM 0360 RC 20610 HCPCS inpatient 743 482.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 449.89 720.71 Aspiration and/or injection of fluid from large joint 47782395_1 CDM 0360 RC 20610 HCPCS inpatient 743 482.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 449.89 720.71 Aspiration and/or injection of fluid from large joint 47782395_1 CDM 0360 RC 20610 HCPCS inpatient 743 482.95 ANTHEM HMO ANTHEM HMO 999999999 449.89 720.71 Aspiration and/or injection of fluid from large joint 47782395_1 CDM 0360 RC 20610 HCPCS inpatient 743 482.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 502.27 67.6 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from large joint 47782395_1 CDM 0360 RC 20610 HCPCS inpatient 743 482.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 449.89 720.71 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47800377_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47800377_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47800377_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47800377_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47800377_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47800377_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47800377_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47800377_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47800377_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47800377_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47800377_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47800377_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47800377_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47800377_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 CT scan of blood vessels of head with contrast 47815028_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 AETNA AETNA 2399.23 79 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 47815028_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1974.05 65 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 47815028_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2945.89 97 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 47815028_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2095.53 69 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 47815028_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 2368.86 78 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 47815028_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 UMR - ALL PLANS UMR - ALL PLANS 2125.9 70 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 47815028_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 SIHO - ALL PLANS SIHO - ALL PLANS 2733.3 90 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 47815028_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1838.9 60.55 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 47815028_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1838.9 2945.89 CT scan of blood vessels of head with contrast 47815028_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1838.9 2945.89 CT scan of blood vessels of head with contrast 47815028_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1838.9 2945.89 CT scan of blood vessels of head with contrast 47815028_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 ANTHEM HMO ANTHEM HMO 999999999 1838.9 2945.89 CT scan of blood vessels of head with contrast 47815028_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2053.01 67.6 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 47815028_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1838.9 2945.89 Biopsy of large bowel using a flexible endoscope 47817058_1 CDM 0360 RC 45380 HCPCS inpatient 1513 983.45 AETNA AETNA 1195.27 79 999999999 916.12 1467.61 percent of total billed charges Biopsy of large bowel using a flexible endoscope 47817058_1 CDM 0360 RC 45380 HCPCS inpatient 1513 983.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 983.45 65 999999999 916.12 1467.61 percent of total billed charges Biopsy of large bowel using a flexible endoscope 47817058_1 CDM 0360 RC 45380 HCPCS inpatient 1513 983.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1467.61 97 999999999 916.12 1467.61 percent of total billed charges Biopsy of large bowel using a flexible endoscope 47817058_1 CDM 0360 RC 45380 HCPCS inpatient 1513 983.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1043.97 69 999999999 916.12 1467.61 percent of total billed charges Biopsy of large bowel using a flexible endoscope 47817058_1 CDM 0360 RC 45380 HCPCS inpatient 1513 983.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1180.14 78 999999999 916.12 1467.61 percent of total billed charges Biopsy of large bowel using a flexible endoscope 47817058_1 CDM 0360 RC 45380 HCPCS inpatient 1513 983.45 UMR - ALL PLANS UMR - ALL PLANS 1059.1 70 999999999 916.12 1467.61 percent of total billed charges Biopsy of large bowel using a flexible endoscope 47817058_1 CDM 0360 RC 45380 HCPCS inpatient 1513 983.45 SIHO - ALL PLANS SIHO - ALL PLANS 1361.7 90 999999999 916.12 1467.61 percent of total billed charges Biopsy of large bowel using a flexible endoscope 47817058_1 CDM 0360 RC 45380 HCPCS inpatient 1513 983.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 916.12 60.55 999999999 916.12 1467.61 percent of total billed charges Biopsy of large bowel using a flexible endoscope 47817058_1 CDM 0360 RC 45380 HCPCS inpatient 1513 983.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 916.12 1467.61 Biopsy of large bowel using a flexible endoscope 47817058_1 CDM 0360 RC 45380 HCPCS inpatient 1513 983.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 916.12 1467.61 Biopsy of large bowel using a flexible endoscope 47817058_1 CDM 0360 RC 45380 HCPCS inpatient 1513 983.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 916.12 1467.61 Biopsy of large bowel using a flexible endoscope 47817058_1 CDM 0360 RC 45380 HCPCS inpatient 1513 983.45 ANTHEM HMO ANTHEM HMO 999999999 916.12 1467.61 Biopsy of large bowel using a flexible endoscope 47817058_1 CDM 0360 RC 45380 HCPCS inpatient 1513 983.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1022.79 67.6 999999999 916.12 1467.61 percent of total billed charges Biopsy of large bowel using a flexible endoscope 47817058_1 CDM 0360 RC 45380 HCPCS inpatient 1513 983.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 916.12 1467.61 "Pathology examination of tissue using a microscope, intermediate complexity" 47824768_1 CDM 0312 RC 88305 HCPCS inpatient 278 180.7 AETNA AETNA 219.62 79 999999999 168.33 269.66 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 47824768_1 CDM 0312 RC 88305 HCPCS inpatient 278 180.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 180.7 65 999999999 168.33 269.66 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 47824768_1 CDM 0312 RC 88305 HCPCS inpatient 278 180.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 269.66 97 999999999 168.33 269.66 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 47824768_1 CDM 0312 RC 88305 HCPCS inpatient 278 180.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 191.82 69 999999999 168.33 269.66 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 47824768_1 CDM 0312 RC 88305 HCPCS inpatient 278 180.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 216.84 78 999999999 168.33 269.66 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 47824768_1 CDM 0312 RC 88305 HCPCS inpatient 278 180.7 UMR - ALL PLANS UMR - ALL PLANS 194.6 70 999999999 168.33 269.66 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 47824768_1 CDM 0312 RC 88305 HCPCS inpatient 278 180.7 SIHO - ALL PLANS SIHO - ALL PLANS 250.2 90 999999999 168.33 269.66 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 47824768_1 CDM 0312 RC 88305 HCPCS inpatient 278 180.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.33 60.55 999999999 168.33 269.66 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 47824768_1 CDM 0312 RC 88305 HCPCS inpatient 278 180.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.33 269.66 "Pathology examination of tissue using a microscope, intermediate complexity" 47824768_1 CDM 0312 RC 88305 HCPCS inpatient 278 180.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.33 269.66 "Pathology examination of tissue using a microscope, intermediate complexity" 47824768_1 CDM 0312 RC 88305 HCPCS inpatient 278 180.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.33 269.66 "Pathology examination of tissue using a microscope, intermediate complexity" 47824768_1 CDM 0312 RC 88305 HCPCS inpatient 278 180.7 ANTHEM HMO ANTHEM HMO 999999999 168.33 269.66 "Pathology examination of tissue using a microscope, intermediate complexity" 47824768_1 CDM 0312 RC 88305 HCPCS inpatient 278 180.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 187.93 67.6 999999999 168.33 269.66 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 47824768_1 CDM 0312 RC 88305 HCPCS inpatient 278 180.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.33 269.66 "CRYOPRECIPITATE, EACH UNIT" 47844387_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 AETNA AETNA 985.13 79 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 47844387_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 810.55 65 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 47844387_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1209.59 97 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 47844387_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 860.43 69 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 47844387_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 972.66 78 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 47844387_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 UMR - ALL PLANS UMR - ALL PLANS 872.9 70 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 47844387_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 SIHO - ALL PLANS SIHO - ALL PLANS 1122.3 90 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 47844387_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 755.06 60.55 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 47844387_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 755.06 1209.59 "CRYOPRECIPITATE, EACH UNIT" 47844387_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 755.06 1209.59 "CRYOPRECIPITATE, EACH UNIT" 47844387_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 755.06 1209.59 "CRYOPRECIPITATE, EACH UNIT" 47844387_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 ANTHEM HMO ANTHEM HMO 999999999 755.06 1209.59 "CRYOPRECIPITATE, EACH UNIT" 47844387_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 842.97 67.6 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 47844387_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 755.06 1209.59 "Blood unit compatibility test, antiglobulin technique" 47846650_1 CDM 0300 RC 86922 HCPCS inpatient 404 262.6 AETNA AETNA 319.16 79 999999999 244.62 391.88 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 47846650_1 CDM 0300 RC 86922 HCPCS inpatient 404 262.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 262.6 65 999999999 244.62 391.88 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 47846650_1 CDM 0300 RC 86922 HCPCS inpatient 404 262.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 391.88 97 999999999 244.62 391.88 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 47846650_1 CDM 0300 RC 86922 HCPCS inpatient 404 262.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 278.76 69 999999999 244.62 391.88 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 47846650_1 CDM 0300 RC 86922 HCPCS inpatient 404 262.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 315.12 78 999999999 244.62 391.88 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 47846650_1 CDM 0300 RC 86922 HCPCS inpatient 404 262.6 UMR - ALL PLANS UMR - ALL PLANS 282.8 70 999999999 244.62 391.88 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 47846650_1 CDM 0300 RC 86922 HCPCS inpatient 404 262.6 SIHO - ALL PLANS SIHO - ALL PLANS 363.6 90 999999999 244.62 391.88 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 47846650_1 CDM 0300 RC 86922 HCPCS inpatient 404 262.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 244.62 60.55 999999999 244.62 391.88 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 47846650_1 CDM 0300 RC 86922 HCPCS inpatient 404 262.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 244.62 391.88 "Blood unit compatibility test, antiglobulin technique" 47846650_1 CDM 0300 RC 86922 HCPCS inpatient 404 262.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 244.62 391.88 "Blood unit compatibility test, antiglobulin technique" 47846650_1 CDM 0300 RC 86922 HCPCS inpatient 404 262.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 244.62 391.88 "Blood unit compatibility test, antiglobulin technique" 47846650_1 CDM 0300 RC 86922 HCPCS inpatient 404 262.6 ANTHEM HMO ANTHEM HMO 999999999 244.62 391.88 "Blood unit compatibility test, antiglobulin technique" 47846650_1 CDM 0300 RC 86922 HCPCS inpatient 404 262.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 273.1 67.6 999999999 244.62 391.88 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 47846650_1 CDM 0300 RC 86922 HCPCS inpatient 404 262.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 244.62 391.88 "Blood unit compatibility test, immediate spin technique" 47846652_1 CDM 0300 RC 86920 HCPCS inpatient 404 262.6 AETNA AETNA 319.16 79 999999999 244.62 391.88 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 47846652_1 CDM 0300 RC 86920 HCPCS inpatient 404 262.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 262.6 65 999999999 244.62 391.88 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 47846652_1 CDM 0300 RC 86920 HCPCS inpatient 404 262.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 391.88 97 999999999 244.62 391.88 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 47846652_1 CDM 0300 RC 86920 HCPCS inpatient 404 262.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 278.76 69 999999999 244.62 391.88 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 47846652_1 CDM 0300 RC 86920 HCPCS inpatient 404 262.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 315.12 78 999999999 244.62 391.88 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 47846652_1 CDM 0300 RC 86920 HCPCS inpatient 404 262.6 UMR - ALL PLANS UMR - ALL PLANS 282.8 70 999999999 244.62 391.88 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 47846652_1 CDM 0300 RC 86920 HCPCS inpatient 404 262.6 SIHO - ALL PLANS SIHO - ALL PLANS 363.6 90 999999999 244.62 391.88 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 47846652_1 CDM 0300 RC 86920 HCPCS inpatient 404 262.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 244.62 60.55 999999999 244.62 391.88 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 47846652_1 CDM 0300 RC 86920 HCPCS inpatient 404 262.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 244.62 391.88 "Blood unit compatibility test, immediate spin technique" 47846652_1 CDM 0300 RC 86920 HCPCS inpatient 404 262.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 244.62 391.88 "Blood unit compatibility test, immediate spin technique" 47846652_1 CDM 0300 RC 86920 HCPCS inpatient 404 262.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 244.62 391.88 "Blood unit compatibility test, immediate spin technique" 47846652_1 CDM 0300 RC 86920 HCPCS inpatient 404 262.6 ANTHEM HMO ANTHEM HMO 999999999 244.62 391.88 "Blood unit compatibility test, immediate spin technique" 47846652_1 CDM 0300 RC 86920 HCPCS inpatient 404 262.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 273.1 67.6 999999999 244.62 391.88 percent of total billed charges "Blood unit compatibility test, immediate spin technique" 47846652_1 CDM 0300 RC 86920 HCPCS inpatient 404 262.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 244.62 391.88 Thawing of fresh frozen plasma unit 47870839_1 CDM 0390 RC 86927 HCPCS inpatient 640 416 AETNA AETNA 505.6 79 999999999 387.52 620.8 percent of total billed charges Thawing of fresh frozen plasma unit 47870839_1 CDM 0390 RC 86927 HCPCS inpatient 640 416 SELF PAY DISCOUNT SELF PAY DISCOUNT 416 65 999999999 387.52 620.8 percent of total billed charges Thawing of fresh frozen plasma unit 47870839_1 CDM 0390 RC 86927 HCPCS inpatient 640 416 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 620.8 97 999999999 387.52 620.8 percent of total billed charges Thawing of fresh frozen plasma unit 47870839_1 CDM 0390 RC 86927 HCPCS inpatient 640 416 ENCORE - ALL PLANS ENCORE - ALL PLANS 441.6 69 999999999 387.52 620.8 percent of total billed charges Thawing of fresh frozen plasma unit 47870839_1 CDM 0390 RC 86927 HCPCS inpatient 640 416 HUMANA - ALL PLANS HUMANA - ALL PLANS 499.2 78 999999999 387.52 620.8 percent of total billed charges Thawing of fresh frozen plasma unit 47870839_1 CDM 0390 RC 86927 HCPCS inpatient 640 416 UMR - ALL PLANS UMR - ALL PLANS 448 70 999999999 387.52 620.8 percent of total billed charges Thawing of fresh frozen plasma unit 47870839_1 CDM 0390 RC 86927 HCPCS inpatient 640 416 SIHO - ALL PLANS SIHO - ALL PLANS 576 90 999999999 387.52 620.8 percent of total billed charges Thawing of fresh frozen plasma unit 47870839_1 CDM 0390 RC 86927 HCPCS inpatient 640 416 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 387.52 60.55 999999999 387.52 620.8 percent of total billed charges Thawing of fresh frozen plasma unit 47870839_1 CDM 0390 RC 86927 HCPCS inpatient 640 416 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 387.52 620.8 Thawing of fresh frozen plasma unit 47870839_1 CDM 0390 RC 86927 HCPCS inpatient 640 416 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 387.52 620.8 Thawing of fresh frozen plasma unit 47870839_1 CDM 0390 RC 86927 HCPCS inpatient 640 416 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 387.52 620.8 Thawing of fresh frozen plasma unit 47870839_1 CDM 0390 RC 86927 HCPCS inpatient 640 416 ANTHEM HMO ANTHEM HMO 999999999 387.52 620.8 Thawing of fresh frozen plasma unit 47870839_1 CDM 0390 RC 86927 HCPCS inpatient 640 416 CIGNA - ALL PLANS CIGNA - ALL PLANS 432.64 67.6 999999999 387.52 620.8 percent of total billed charges Thawing of fresh frozen plasma unit 47870839_1 CDM 0390 RC 86927 HCPCS inpatient 640 416 UHC - ALL PLANS UHC - ALL PLANS 999999999 387.52 620.8 "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, rosette" 47872534_1 CDM 0305 RC 85461 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, rosette" 47872534_1 CDM 0305 RC 85461 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, rosette" 47872534_1 CDM 0305 RC 85461 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, rosette" 47872534_1 CDM 0305 RC 85461 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, rosette" 47872534_1 CDM 0305 RC 85461 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, rosette" 47872534_1 CDM 0305 RC 85461 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, rosette" 47872534_1 CDM 0305 RC 85461 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, rosette" 47872534_1 CDM 0305 RC 85461 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, rosette" 47872534_1 CDM 0305 RC 85461 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, rosette" 47872534_1 CDM 0305 RC 85461 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, rosette" 47872534_1 CDM 0305 RC 85461 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, rosette" 47872534_1 CDM 0305 RC 85461 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, rosette" 47872534_1 CDM 0305 RC 85461 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, rosette" 47872534_1 CDM 0305 RC 85461 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 "Complete blood cell count (red cells, white blood cell, platelets), automated test" 47872537_1 CDM 0305 RC 85027 HCPCS inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test" 47872537_1 CDM 0305 RC 85027 HCPCS inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test" 47872537_1 CDM 0305 RC 85027 HCPCS inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test" 47872537_1 CDM 0305 RC 85027 HCPCS inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test" 47872537_1 CDM 0305 RC 85027 HCPCS inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test" 47872537_1 CDM 0305 RC 85027 HCPCS inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test" 47872537_1 CDM 0305 RC 85027 HCPCS inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test" 47872537_1 CDM 0305 RC 85027 HCPCS inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test" 47872537_1 CDM 0305 RC 85027 HCPCS inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 "Complete blood cell count (red cells, white blood cell, platelets), automated test" 47872537_1 CDM 0305 RC 85027 HCPCS inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 "Complete blood cell count (red cells, white blood cell, platelets), automated test" 47872537_1 CDM 0305 RC 85027 HCPCS inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 "Complete blood cell count (red cells, white blood cell, platelets), automated test" 47872537_1 CDM 0305 RC 85027 HCPCS inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 "Complete blood cell count (red cells, white blood cell, platelets), automated test" 47872537_1 CDM 0305 RC 85027 HCPCS inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test" 47872537_1 CDM 0305 RC 85027 HCPCS inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 "Blood gases measurement, with O2 saturation" 47876639_1 CDM 0301 RC 82805 HCPCS inpatient 385 250.25 AETNA AETNA 304.15 79 999999999 233.12 373.45 percent of total billed charges "Blood gases measurement, with O2 saturation" 47876639_1 CDM 0301 RC 82805 HCPCS inpatient 385 250.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 250.25 65 999999999 233.12 373.45 percent of total billed charges "Blood gases measurement, with O2 saturation" 47876639_1 CDM 0301 RC 82805 HCPCS inpatient 385 250.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 373.45 97 999999999 233.12 373.45 percent of total billed charges "Blood gases measurement, with O2 saturation" 47876639_1 CDM 0301 RC 82805 HCPCS inpatient 385 250.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 265.65 69 999999999 233.12 373.45 percent of total billed charges "Blood gases measurement, with O2 saturation" 47876639_1 CDM 0301 RC 82805 HCPCS inpatient 385 250.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 300.3 78 999999999 233.12 373.45 percent of total billed charges "Blood gases measurement, with O2 saturation" 47876639_1 CDM 0301 RC 82805 HCPCS inpatient 385 250.25 UMR - ALL PLANS UMR - ALL PLANS 269.5 70 999999999 233.12 373.45 percent of total billed charges "Blood gases measurement, with O2 saturation" 47876639_1 CDM 0301 RC 82805 HCPCS inpatient 385 250.25 SIHO - ALL PLANS SIHO - ALL PLANS 346.5 90 999999999 233.12 373.45 percent of total billed charges "Blood gases measurement, with O2 saturation" 47876639_1 CDM 0301 RC 82805 HCPCS inpatient 385 250.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 233.12 60.55 999999999 233.12 373.45 percent of total billed charges "Blood gases measurement, with O2 saturation" 47876639_1 CDM 0301 RC 82805 HCPCS inpatient 385 250.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 233.12 373.45 "Blood gases measurement, with O2 saturation" 47876639_1 CDM 0301 RC 82805 HCPCS inpatient 385 250.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 233.12 373.45 "Blood gases measurement, with O2 saturation" 47876639_1 CDM 0301 RC 82805 HCPCS inpatient 385 250.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 233.12 373.45 "Blood gases measurement, with O2 saturation" 47876639_1 CDM 0301 RC 82805 HCPCS inpatient 385 250.25 ANTHEM HMO ANTHEM HMO 999999999 233.12 373.45 "Blood gases measurement, with O2 saturation" 47876639_1 CDM 0301 RC 82805 HCPCS inpatient 385 250.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 260.26 67.6 999999999 233.12 373.45 percent of total billed charges "Blood gases measurement, with O2 saturation" 47876639_1 CDM 0301 RC 82805 HCPCS inpatient 385 250.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 233.12 373.45 "Testosterone (hormone) level, total" 47886730_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges "Testosterone (hormone) level, total" 47886730_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges "Testosterone (hormone) level, total" 47886730_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges "Testosterone (hormone) level, total" 47886730_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges "Testosterone (hormone) level, total" 47886730_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges "Testosterone (hormone) level, total" 47886730_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges "Testosterone (hormone) level, total" 47886730_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges "Testosterone (hormone) level, total" 47886730_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges "Testosterone (hormone) level, total" 47886730_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 "Testosterone (hormone) level, total" 47886730_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 "Testosterone (hormone) level, total" 47886730_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 "Testosterone (hormone) level, total" 47886730_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 "Testosterone (hormone) level, total" 47886730_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges "Testosterone (hormone) level, total" 47886730_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 Crystal identification from tissue or body fluid 47886929_1 CDM 0309 RC 89060 HCPCS inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges Crystal identification from tissue or body fluid 47886929_1 CDM 0309 RC 89060 HCPCS inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges Crystal identification from tissue or body fluid 47886929_1 CDM 0309 RC 89060 HCPCS inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges Crystal identification from tissue or body fluid 47886929_1 CDM 0309 RC 89060 HCPCS inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges Crystal identification from tissue or body fluid 47886929_1 CDM 0309 RC 89060 HCPCS inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges Crystal identification from tissue or body fluid 47886929_1 CDM 0309 RC 89060 HCPCS inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges Crystal identification from tissue or body fluid 47886929_1 CDM 0309 RC 89060 HCPCS inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges Crystal identification from tissue or body fluid 47886929_1 CDM 0309 RC 89060 HCPCS inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges Crystal identification from tissue or body fluid 47886929_1 CDM 0309 RC 89060 HCPCS inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 Crystal identification from tissue or body fluid 47886929_1 CDM 0309 RC 89060 HCPCS inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 Crystal identification from tissue or body fluid 47886929_1 CDM 0309 RC 89060 HCPCS inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 Crystal identification from tissue or body fluid 47886929_1 CDM 0309 RC 89060 HCPCS inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 Crystal identification from tissue or body fluid 47886929_1 CDM 0309 RC 89060 HCPCS inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges Crystal identification from tissue or body fluid 47886929_1 CDM 0309 RC 89060 HCPCS inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 Nuclear medicine study of thyroid 47887098_1 CDM 0341 RC 78013 HCPCS inpatient 1049 681.85 AETNA AETNA 828.71 79 999999999 635.17 1017.53 percent of total billed charges Nuclear medicine study of thyroid 47887098_1 CDM 0341 RC 78013 HCPCS inpatient 1049 681.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 681.85 65 999999999 635.17 1017.53 percent of total billed charges Nuclear medicine study of thyroid 47887098_1 CDM 0341 RC 78013 HCPCS inpatient 1049 681.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1017.53 97 999999999 635.17 1017.53 percent of total billed charges Nuclear medicine study of thyroid 47887098_1 CDM 0341 RC 78013 HCPCS inpatient 1049 681.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 723.81 69 999999999 635.17 1017.53 percent of total billed charges Nuclear medicine study of thyroid 47887098_1 CDM 0341 RC 78013 HCPCS inpatient 1049 681.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 818.22 78 999999999 635.17 1017.53 percent of total billed charges Nuclear medicine study of thyroid 47887098_1 CDM 0341 RC 78013 HCPCS inpatient 1049 681.85 UMR - ALL PLANS UMR - ALL PLANS 734.3 70 999999999 635.17 1017.53 percent of total billed charges Nuclear medicine study of thyroid 47887098_1 CDM 0341 RC 78013 HCPCS inpatient 1049 681.85 SIHO - ALL PLANS SIHO - ALL PLANS 944.1 90 999999999 635.17 1017.53 percent of total billed charges Nuclear medicine study of thyroid 47887098_1 CDM 0341 RC 78013 HCPCS inpatient 1049 681.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 635.17 60.55 999999999 635.17 1017.53 percent of total billed charges Nuclear medicine study of thyroid 47887098_1 CDM 0341 RC 78013 HCPCS inpatient 1049 681.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 635.17 1017.53 Nuclear medicine study of thyroid 47887098_1 CDM 0341 RC 78013 HCPCS inpatient 1049 681.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 635.17 1017.53 Nuclear medicine study of thyroid 47887098_1 CDM 0341 RC 78013 HCPCS inpatient 1049 681.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 635.17 1017.53 Nuclear medicine study of thyroid 47887098_1 CDM 0341 RC 78013 HCPCS inpatient 1049 681.85 ANTHEM HMO ANTHEM HMO 999999999 635.17 1017.53 Nuclear medicine study of thyroid 47887098_1 CDM 0341 RC 78013 HCPCS inpatient 1049 681.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 709.12 67.6 999999999 635.17 1017.53 percent of total billed charges Nuclear medicine study of thyroid 47887098_1 CDM 0341 RC 78013 HCPCS inpatient 1049 681.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 635.17 1017.53 Nuclear medicine study of thyroid and thyroid function 47887104_1 CDM 0341 RC 78014 HCPCS inpatient 1289 837.85 AETNA AETNA 1018.31 79 999999999 780.49 1250.33 percent of total billed charges Nuclear medicine study of thyroid and thyroid function 47887104_1 CDM 0341 RC 78014 HCPCS inpatient 1289 837.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 837.85 65 999999999 780.49 1250.33 percent of total billed charges Nuclear medicine study of thyroid and thyroid function 47887104_1 CDM 0341 RC 78014 HCPCS inpatient 1289 837.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1250.33 97 999999999 780.49 1250.33 percent of total billed charges Nuclear medicine study of thyroid and thyroid function 47887104_1 CDM 0341 RC 78014 HCPCS inpatient 1289 837.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 889.41 69 999999999 780.49 1250.33 percent of total billed charges Nuclear medicine study of thyroid and thyroid function 47887104_1 CDM 0341 RC 78014 HCPCS inpatient 1289 837.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1005.42 78 999999999 780.49 1250.33 percent of total billed charges Nuclear medicine study of thyroid and thyroid function 47887104_1 CDM 0341 RC 78014 HCPCS inpatient 1289 837.85 UMR - ALL PLANS UMR - ALL PLANS 902.3 70 999999999 780.49 1250.33 percent of total billed charges Nuclear medicine study of thyroid and thyroid function 47887104_1 CDM 0341 RC 78014 HCPCS inpatient 1289 837.85 SIHO - ALL PLANS SIHO - ALL PLANS 1160.1 90 999999999 780.49 1250.33 percent of total billed charges Nuclear medicine study of thyroid and thyroid function 47887104_1 CDM 0341 RC 78014 HCPCS inpatient 1289 837.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 780.49 60.55 999999999 780.49 1250.33 percent of total billed charges Nuclear medicine study of thyroid and thyroid function 47887104_1 CDM 0341 RC 78014 HCPCS inpatient 1289 837.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 780.49 1250.33 Nuclear medicine study of thyroid and thyroid function 47887104_1 CDM 0341 RC 78014 HCPCS inpatient 1289 837.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 780.49 1250.33 Nuclear medicine study of thyroid and thyroid function 47887104_1 CDM 0341 RC 78014 HCPCS inpatient 1289 837.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 780.49 1250.33 Nuclear medicine study of thyroid and thyroid function 47887104_1 CDM 0341 RC 78014 HCPCS inpatient 1289 837.85 ANTHEM HMO ANTHEM HMO 999999999 780.49 1250.33 Nuclear medicine study of thyroid and thyroid function 47887104_1 CDM 0341 RC 78014 HCPCS inpatient 1289 837.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 871.36 67.6 999999999 780.49 1250.33 percent of total billed charges Nuclear medicine study of thyroid and thyroid function 47887104_1 CDM 0341 RC 78014 HCPCS inpatient 1289 837.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 780.49 1250.33 Nuclear medicine study of liver and bile duct system 47887202_1 CDM 0341 RC 78226 HCPCS inpatient 1870 1215.5 AETNA AETNA 1477.3 79 999999999 1132.29 1813.9 percent of total billed charges Nuclear medicine study of liver and bile duct system 47887202_1 CDM 0341 RC 78226 HCPCS inpatient 1870 1215.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1215.5 65 999999999 1132.29 1813.9 percent of total billed charges Nuclear medicine study of liver and bile duct system 47887202_1 CDM 0341 RC 78226 HCPCS inpatient 1870 1215.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1813.9 97 999999999 1132.29 1813.9 percent of total billed charges Nuclear medicine study of liver and bile duct system 47887202_1 CDM 0341 RC 78226 HCPCS inpatient 1870 1215.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1290.3 69 999999999 1132.29 1813.9 percent of total billed charges Nuclear medicine study of liver and bile duct system 47887202_1 CDM 0341 RC 78226 HCPCS inpatient 1870 1215.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1458.6 78 999999999 1132.29 1813.9 percent of total billed charges Nuclear medicine study of liver and bile duct system 47887202_1 CDM 0341 RC 78226 HCPCS inpatient 1870 1215.5 UMR - ALL PLANS UMR - ALL PLANS 1309 70 999999999 1132.29 1813.9 percent of total billed charges Nuclear medicine study of liver and bile duct system 47887202_1 CDM 0341 RC 78226 HCPCS inpatient 1870 1215.5 SIHO - ALL PLANS SIHO - ALL PLANS 1683 90 999999999 1132.29 1813.9 percent of total billed charges Nuclear medicine study of liver and bile duct system 47887202_1 CDM 0341 RC 78226 HCPCS inpatient 1870 1215.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1132.29 60.55 999999999 1132.29 1813.9 percent of total billed charges Nuclear medicine study of liver and bile duct system 47887202_1 CDM 0341 RC 78226 HCPCS inpatient 1870 1215.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1132.29 1813.9 Nuclear medicine study of liver and bile duct system 47887202_1 CDM 0341 RC 78226 HCPCS inpatient 1870 1215.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1132.29 1813.9 Nuclear medicine study of liver and bile duct system 47887202_1 CDM 0341 RC 78226 HCPCS inpatient 1870 1215.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1132.29 1813.9 Nuclear medicine study of liver and bile duct system 47887202_1 CDM 0341 RC 78226 HCPCS inpatient 1870 1215.5 ANTHEM HMO ANTHEM HMO 999999999 1132.29 1813.9 Nuclear medicine study of liver and bile duct system 47887202_1 CDM 0341 RC 78226 HCPCS inpatient 1870 1215.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1264.12 67.6 999999999 1132.29 1813.9 percent of total billed charges Nuclear medicine study of liver and bile duct system 47887202_1 CDM 0341 RC 78226 HCPCS inpatient 1870 1215.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1132.29 1813.9 Aspiration of fluid from chest cavity using imaging guidance 47903911_1 CDM 0450 RC 32555 HCPCS inpatient 1738 1129.7 AETNA AETNA 1373.02 79 999999999 1052.36 1685.86 percent of total billed charges Aspiration of fluid from chest cavity using imaging guidance 47903911_1 CDM 0450 RC 32555 HCPCS inpatient 1738 1129.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1129.7 65 999999999 1052.36 1685.86 percent of total billed charges Aspiration of fluid from chest cavity using imaging guidance 47903911_1 CDM 0450 RC 32555 HCPCS inpatient 1738 1129.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1685.86 97 999999999 1052.36 1685.86 percent of total billed charges Aspiration of fluid from chest cavity using imaging guidance 47903911_1 CDM 0450 RC 32555 HCPCS inpatient 1738 1129.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1199.22 69 999999999 1052.36 1685.86 percent of total billed charges Aspiration of fluid from chest cavity using imaging guidance 47903911_1 CDM 0450 RC 32555 HCPCS inpatient 1738 1129.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1355.64 78 999999999 1052.36 1685.86 percent of total billed charges Aspiration of fluid from chest cavity using imaging guidance 47903911_1 CDM 0450 RC 32555 HCPCS inpatient 1738 1129.7 UMR - ALL PLANS UMR - ALL PLANS 1216.6 70 999999999 1052.36 1685.86 percent of total billed charges Aspiration of fluid from chest cavity using imaging guidance 47903911_1 CDM 0450 RC 32555 HCPCS inpatient 1738 1129.7 SIHO - ALL PLANS SIHO - ALL PLANS 1564.2 90 999999999 1052.36 1685.86 percent of total billed charges Aspiration of fluid from chest cavity using imaging guidance 47903911_1 CDM 0450 RC 32555 HCPCS inpatient 1738 1129.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1052.36 60.55 999999999 1052.36 1685.86 percent of total billed charges Aspiration of fluid from chest cavity using imaging guidance 47903911_1 CDM 0450 RC 32555 HCPCS inpatient 1738 1129.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1052.36 1685.86 Aspiration of fluid from chest cavity using imaging guidance 47903911_1 CDM 0450 RC 32555 HCPCS inpatient 1738 1129.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1052.36 1685.86 Aspiration of fluid from chest cavity using imaging guidance 47903911_1 CDM 0450 RC 32555 HCPCS inpatient 1738 1129.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1052.36 1685.86 Aspiration of fluid from chest cavity using imaging guidance 47903911_1 CDM 0450 RC 32555 HCPCS inpatient 1738 1129.7 ANTHEM HMO ANTHEM HMO 999999999 1052.36 1685.86 Aspiration of fluid from chest cavity using imaging guidance 47903911_1 CDM 0450 RC 32555 HCPCS inpatient 1738 1129.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1174.89 67.6 999999999 1052.36 1685.86 percent of total billed charges Aspiration of fluid from chest cavity using imaging guidance 47903911_1 CDM 0450 RC 32555 HCPCS inpatient 1738 1129.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 1052.36 1685.86 "X-ray of knee, 3 views" 47904595_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 AETNA AETNA 386.31 79 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 47904595_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 317.85 65 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 47904595_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 474.33 97 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 47904595_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 337.41 69 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 47904595_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 381.42 78 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 47904595_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 UMR - ALL PLANS UMR - ALL PLANS 342.3 70 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 47904595_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 SIHO - ALL PLANS SIHO - ALL PLANS 440.1 90 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 47904595_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 296.09 60.55 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 47904595_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 296.09 474.33 "X-ray of knee, 3 views" 47904595_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 296.09 474.33 "X-ray of knee, 3 views" 47904595_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 296.09 474.33 "X-ray of knee, 3 views" 47904595_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ANTHEM HMO ANTHEM HMO 999999999 296.09 474.33 "X-ray of knee, 3 views" 47904595_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 330.56 67.6 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 47904595_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 296.09 474.33 "X-ray of ribs on both sides of body, minimum of 4 views" 47904610_1 CDM 0320 RC 71111 HCPCS inpatient 803 521.95 AETNA AETNA 634.37 79 999999999 486.22 778.91 percent of total billed charges "X-ray of ribs on both sides of body, minimum of 4 views" 47904610_1 CDM 0320 RC 71111 HCPCS inpatient 803 521.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 521.95 65 999999999 486.22 778.91 percent of total billed charges "X-ray of ribs on both sides of body, minimum of 4 views" 47904610_1 CDM 0320 RC 71111 HCPCS inpatient 803 521.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 778.91 97 999999999 486.22 778.91 percent of total billed charges "X-ray of ribs on both sides of body, minimum of 4 views" 47904610_1 CDM 0320 RC 71111 HCPCS inpatient 803 521.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 554.07 69 999999999 486.22 778.91 percent of total billed charges "X-ray of ribs on both sides of body, minimum of 4 views" 47904610_1 CDM 0320 RC 71111 HCPCS inpatient 803 521.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 626.34 78 999999999 486.22 778.91 percent of total billed charges "X-ray of ribs on both sides of body, minimum of 4 views" 47904610_1 CDM 0320 RC 71111 HCPCS inpatient 803 521.95 UMR - ALL PLANS UMR - ALL PLANS 562.1 70 999999999 486.22 778.91 percent of total billed charges "X-ray of ribs on both sides of body, minimum of 4 views" 47904610_1 CDM 0320 RC 71111 HCPCS inpatient 803 521.95 SIHO - ALL PLANS SIHO - ALL PLANS 722.7 90 999999999 486.22 778.91 percent of total billed charges "X-ray of ribs on both sides of body, minimum of 4 views" 47904610_1 CDM 0320 RC 71111 HCPCS inpatient 803 521.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 486.22 60.55 999999999 486.22 778.91 percent of total billed charges "X-ray of ribs on both sides of body, minimum of 4 views" 47904610_1 CDM 0320 RC 71111 HCPCS inpatient 803 521.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 486.22 778.91 "X-ray of ribs on both sides of body, minimum of 4 views" 47904610_1 CDM 0320 RC 71111 HCPCS inpatient 803 521.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 486.22 778.91 "X-ray of ribs on both sides of body, minimum of 4 views" 47904610_1 CDM 0320 RC 71111 HCPCS inpatient 803 521.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 486.22 778.91 "X-ray of ribs on both sides of body, minimum of 4 views" 47904610_1 CDM 0320 RC 71111 HCPCS inpatient 803 521.95 ANTHEM HMO ANTHEM HMO 999999999 486.22 778.91 "X-ray of ribs on both sides of body, minimum of 4 views" 47904610_1 CDM 0320 RC 71111 HCPCS inpatient 803 521.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 542.83 67.6 999999999 486.22 778.91 percent of total billed charges "X-ray of ribs on both sides of body, minimum of 4 views" 47904610_1 CDM 0320 RC 71111 HCPCS inpatient 803 521.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 486.22 778.91 "Ultrasound of heart with color-depicted blood flow, rate and valve function" 47915209_1 CDM 0483 RC 93325 HCPCS inpatient 1421.5 923.98 AETNA AETNA 1122.99 79 999999999 860.72 1378.86 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate and valve function" 47915209_1 CDM 0483 RC 93325 HCPCS inpatient 1421.5 923.98 SELF PAY DISCOUNT SELF PAY DISCOUNT 923.98 65 999999999 860.72 1378.86 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate and valve function" 47915209_1 CDM 0483 RC 93325 HCPCS inpatient 1421.5 923.98 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1378.86 97 999999999 860.72 1378.86 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate and valve function" 47915209_1 CDM 0483 RC 93325 HCPCS inpatient 1421.5 923.98 ENCORE - ALL PLANS ENCORE - ALL PLANS 980.84 69 999999999 860.72 1378.86 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate and valve function" 47915209_1 CDM 0483 RC 93325 HCPCS inpatient 1421.5 923.98 HUMANA - ALL PLANS HUMANA - ALL PLANS 1108.77 78 999999999 860.72 1378.86 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate and valve function" 47915209_1 CDM 0483 RC 93325 HCPCS inpatient 1421.5 923.98 UMR - ALL PLANS UMR - ALL PLANS 995.05 70 999999999 860.72 1378.86 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate and valve function" 47915209_1 CDM 0483 RC 93325 HCPCS inpatient 1421.5 923.98 SIHO - ALL PLANS SIHO - ALL PLANS 1279.35 90 999999999 860.72 1378.86 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate and valve function" 47915209_1 CDM 0483 RC 93325 HCPCS inpatient 1421.5 923.98 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 860.72 60.55 999999999 860.72 1378.86 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate and valve function" 47915209_1 CDM 0483 RC 93325 HCPCS inpatient 1421.5 923.98 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 860.72 1378.86 "Ultrasound of heart with color-depicted blood flow, rate and valve function" 47915209_1 CDM 0483 RC 93325 HCPCS inpatient 1421.5 923.98 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 860.72 1378.86 "Ultrasound of heart with color-depicted blood flow, rate and valve function" 47915209_1 CDM 0483 RC 93325 HCPCS inpatient 1421.5 923.98 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 860.72 1378.86 "Ultrasound of heart with color-depicted blood flow, rate and valve function" 47915209_1 CDM 0483 RC 93325 HCPCS inpatient 1421.5 923.98 ANTHEM HMO ANTHEM HMO 999999999 860.72 1378.86 "Ultrasound of heart with color-depicted blood flow, rate and valve function" 47915209_1 CDM 0483 RC 93325 HCPCS inpatient 1421.5 923.98 CIGNA - ALL PLANS CIGNA - ALL PLANS 960.93 67.6 999999999 860.72 1378.86 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate and valve function" 47915209_1 CDM 0483 RC 93325 HCPCS inpatient 1421.5 923.98 UHC - ALL PLANS UHC - ALL PLANS 999999999 860.72 1378.86 Aspiration and/or injection of fluid from medium joint 47922081_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 AETNA AETNA 533.25 79 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from medium joint 47922081_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 438.75 65 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from medium joint 47922081_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 654.75 97 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from medium joint 47922081_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 465.75 69 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from medium joint 47922081_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 526.5 78 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from medium joint 47922081_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 UMR - ALL PLANS UMR - ALL PLANS 472.5 70 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from medium joint 47922081_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 SIHO - ALL PLANS SIHO - ALL PLANS 607.5 90 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from medium joint 47922081_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 408.71 60.55 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from medium joint 47922081_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 408.71 654.75 Aspiration and/or injection of fluid from medium joint 47922081_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 408.71 654.75 Aspiration and/or injection of fluid from medium joint 47922081_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 408.71 654.75 Aspiration and/or injection of fluid from medium joint 47922081_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 ANTHEM HMO ANTHEM HMO 999999999 408.71 654.75 Aspiration and/or injection of fluid from medium joint 47922081_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 456.3 67.6 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from medium joint 47922081_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 408.71 654.75 "Ultrasound of heart with probe in esophagus, with report" 47950676_1 CDM 0480 RC 93312 HCPCS inpatient 2092 1359.8 AETNA AETNA 1652.68 79 999999999 1266.71 2029.24 percent of total billed charges "Ultrasound of heart with probe in esophagus, with report" 47950676_1 CDM 0480 RC 93312 HCPCS inpatient 2092 1359.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1359.8 65 999999999 1266.71 2029.24 percent of total billed charges "Ultrasound of heart with probe in esophagus, with report" 47950676_1 CDM 0480 RC 93312 HCPCS inpatient 2092 1359.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2029.24 97 999999999 1266.71 2029.24 percent of total billed charges "Ultrasound of heart with probe in esophagus, with report" 47950676_1 CDM 0480 RC 93312 HCPCS inpatient 2092 1359.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1443.48 69 999999999 1266.71 2029.24 percent of total billed charges "Ultrasound of heart with probe in esophagus, with report" 47950676_1 CDM 0480 RC 93312 HCPCS inpatient 2092 1359.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1631.76 78 999999999 1266.71 2029.24 percent of total billed charges "Ultrasound of heart with probe in esophagus, with report" 47950676_1 CDM 0480 RC 93312 HCPCS inpatient 2092 1359.8 UMR - ALL PLANS UMR - ALL PLANS 1464.4 70 999999999 1266.71 2029.24 percent of total billed charges "Ultrasound of heart with probe in esophagus, with report" 47950676_1 CDM 0480 RC 93312 HCPCS inpatient 2092 1359.8 SIHO - ALL PLANS SIHO - ALL PLANS 1882.8 90 999999999 1266.71 2029.24 percent of total billed charges "Ultrasound of heart with probe in esophagus, with report" 47950676_1 CDM 0480 RC 93312 HCPCS inpatient 2092 1359.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1266.71 60.55 999999999 1266.71 2029.24 percent of total billed charges "Ultrasound of heart with probe in esophagus, with report" 47950676_1 CDM 0480 RC 93312 HCPCS inpatient 2092 1359.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1266.71 2029.24 "Ultrasound of heart with probe in esophagus, with report" 47950676_1 CDM 0480 RC 93312 HCPCS inpatient 2092 1359.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1266.71 2029.24 "Ultrasound of heart with probe in esophagus, with report" 47950676_1 CDM 0480 RC 93312 HCPCS inpatient 2092 1359.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1266.71 2029.24 "Ultrasound of heart with probe in esophagus, with report" 47950676_1 CDM 0480 RC 93312 HCPCS inpatient 2092 1359.8 ANTHEM HMO ANTHEM HMO 999999999 1266.71 2029.24 "Ultrasound of heart with probe in esophagus, with report" 47950676_1 CDM 0480 RC 93312 HCPCS inpatient 2092 1359.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1414.19 67.6 999999999 1266.71 2029.24 percent of total billed charges "Ultrasound of heart with probe in esophagus, with report" 47950676_1 CDM 0480 RC 93312 HCPCS inpatient 2092 1359.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1266.71 2029.24 Electrocardiogram (ECG) 2-day continuous with report 47950677_1 CDM 0731 RC 93226 HCPCS inpatient 847.5 550.88 AETNA AETNA 669.53 79 999999999 513.16 822.08 percent of total billed charges Electrocardiogram (ECG) 2-day continuous with report 47950677_1 CDM 0731 RC 93226 HCPCS inpatient 847.5 550.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 550.88 65 999999999 513.16 822.08 percent of total billed charges Electrocardiogram (ECG) 2-day continuous with report 47950677_1 CDM 0731 RC 93226 HCPCS inpatient 847.5 550.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 822.08 97 999999999 513.16 822.08 percent of total billed charges Electrocardiogram (ECG) 2-day continuous with report 47950677_1 CDM 0731 RC 93226 HCPCS inpatient 847.5 550.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 584.78 69 999999999 513.16 822.08 percent of total billed charges Electrocardiogram (ECG) 2-day continuous with report 47950677_1 CDM 0731 RC 93226 HCPCS inpatient 847.5 550.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 661.05 78 999999999 513.16 822.08 percent of total billed charges Electrocardiogram (ECG) 2-day continuous with report 47950677_1 CDM 0731 RC 93226 HCPCS inpatient 847.5 550.88 UMR - ALL PLANS UMR - ALL PLANS 593.25 70 999999999 513.16 822.08 percent of total billed charges Electrocardiogram (ECG) 2-day continuous with report 47950677_1 CDM 0731 RC 93226 HCPCS inpatient 847.5 550.88 SIHO - ALL PLANS SIHO - ALL PLANS 762.75 90 999999999 513.16 822.08 percent of total billed charges Electrocardiogram (ECG) 2-day continuous with report 47950677_1 CDM 0731 RC 93226 HCPCS inpatient 847.5 550.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 513.16 60.55 999999999 513.16 822.08 percent of total billed charges Electrocardiogram (ECG) 2-day continuous with report 47950677_1 CDM 0731 RC 93226 HCPCS inpatient 847.5 550.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 513.16 822.08 Electrocardiogram (ECG) 2-day continuous with report 47950677_1 CDM 0731 RC 93226 HCPCS inpatient 847.5 550.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 513.16 822.08 Electrocardiogram (ECG) 2-day continuous with report 47950677_1 CDM 0731 RC 93226 HCPCS inpatient 847.5 550.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 513.16 822.08 Electrocardiogram (ECG) 2-day continuous with report 47950677_1 CDM 0731 RC 93226 HCPCS inpatient 847.5 550.88 ANTHEM HMO ANTHEM HMO 999999999 513.16 822.08 Electrocardiogram (ECG) 2-day continuous with report 47950677_1 CDM 0731 RC 93226 HCPCS inpatient 847.5 550.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 572.91 67.6 999999999 513.16 822.08 percent of total billed charges Electrocardiogram (ECG) 2-day continuous with report 47950677_1 CDM 0731 RC 93226 HCPCS inpatient 847.5 550.88 UHC - ALL PLANS UHC - ALL PLANS 999999999 513.16 822.08 "Screening test for compatible blood unit, using reagent serum" 47984487_1 CDM 0300 RC 86902 HCPCS inpatient 319 207.35 AETNA AETNA 252.01 79 999999999 193.15 309.43 percent of total billed charges "Screening test for compatible blood unit, using reagent serum" 47984487_1 CDM 0300 RC 86902 HCPCS inpatient 319 207.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 207.35 65 999999999 193.15 309.43 percent of total billed charges "Screening test for compatible blood unit, using reagent serum" 47984487_1 CDM 0300 RC 86902 HCPCS inpatient 319 207.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 309.43 97 999999999 193.15 309.43 percent of total billed charges "Screening test for compatible blood unit, using reagent serum" 47984487_1 CDM 0300 RC 86902 HCPCS inpatient 319 207.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 220.11 69 999999999 193.15 309.43 percent of total billed charges "Screening test for compatible blood unit, using reagent serum" 47984487_1 CDM 0300 RC 86902 HCPCS inpatient 319 207.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 248.82 78 999999999 193.15 309.43 percent of total billed charges "Screening test for compatible blood unit, using reagent serum" 47984487_1 CDM 0300 RC 86902 HCPCS inpatient 319 207.35 UMR - ALL PLANS UMR - ALL PLANS 223.3 70 999999999 193.15 309.43 percent of total billed charges "Screening test for compatible blood unit, using reagent serum" 47984487_1 CDM 0300 RC 86902 HCPCS inpatient 319 207.35 SIHO - ALL PLANS SIHO - ALL PLANS 287.1 90 999999999 193.15 309.43 percent of total billed charges "Screening test for compatible blood unit, using reagent serum" 47984487_1 CDM 0300 RC 86902 HCPCS inpatient 319 207.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 193.15 60.55 999999999 193.15 309.43 percent of total billed charges "Screening test for compatible blood unit, using reagent serum" 47984487_1 CDM 0300 RC 86902 HCPCS inpatient 319 207.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 193.15 309.43 "Screening test for compatible blood unit, using reagent serum" 47984487_1 CDM 0300 RC 86902 HCPCS inpatient 319 207.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 193.15 309.43 "Screening test for compatible blood unit, using reagent serum" 47984487_1 CDM 0300 RC 86902 HCPCS inpatient 319 207.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 193.15 309.43 "Screening test for compatible blood unit, using reagent serum" 47984487_1 CDM 0300 RC 86902 HCPCS inpatient 319 207.35 ANTHEM HMO ANTHEM HMO 999999999 193.15 309.43 "Screening test for compatible blood unit, using reagent serum" 47984487_1 CDM 0300 RC 86902 HCPCS inpatient 319 207.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 215.64 67.6 999999999 193.15 309.43 percent of total billed charges "Screening test for compatible blood unit, using reagent serum" 47984487_1 CDM 0300 RC 86902 HCPCS inpatient 319 207.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 193.15 309.43 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997065_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997065_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997065_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997065_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997065_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997065_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997065_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997065_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997065_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997065_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997065_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997065_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997065_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997065_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997068_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997068_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997068_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997068_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997068_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997068_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997068_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997068_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997068_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997068_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997068_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997068_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997068_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 47997068_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997151_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 AETNA AETNA 84.53 79 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997151_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 69.55 65 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997151_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 103.79 97 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997151_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.83 69 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997151_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 83.46 78 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997151_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 UMR - ALL PLANS UMR - ALL PLANS 74.9 70 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997151_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 SIHO - ALL PLANS SIHO - ALL PLANS 96.3 90 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997151_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.79 60.55 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997151_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997151_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997151_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997151_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM HMO ANTHEM HMO 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997151_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 72.33 67.6 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997151_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997157_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 AETNA AETNA 79 79 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997157_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65 65 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997157_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97 97 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997157_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69 69 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997157_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78 78 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997157_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 UMR - ALL PLANS UMR - ALL PLANS 70 70 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997157_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 SIHO - ALL PLANS SIHO - ALL PLANS 90 90 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997157_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.55 60.55 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997157_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.55 97 "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997157_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.55 97 "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997157_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.55 97 "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997157_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ANTHEM HMO ANTHEM HMO 999999999 60.55 97 "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997157_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.6 67.6 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 47997157_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.55 97 Microscopic examination for white blood cells 47997703_1 CDM 0309 RC 85008 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges Microscopic examination for white blood cells 47997703_1 CDM 0309 RC 85008 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges Microscopic examination for white blood cells 47997703_1 CDM 0309 RC 85008 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges Microscopic examination for white blood cells 47997703_1 CDM 0309 RC 85008 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges Microscopic examination for white blood cells 47997703_1 CDM 0309 RC 85008 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges Microscopic examination for white blood cells 47997703_1 CDM 0309 RC 85008 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges Microscopic examination for white blood cells 47997703_1 CDM 0309 RC 85008 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges Microscopic examination for white blood cells 47997703_1 CDM 0309 RC 85008 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges Microscopic examination for white blood cells 47997703_1 CDM 0309 RC 85008 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 Microscopic examination for white blood cells 47997703_1 CDM 0309 RC 85008 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 Microscopic examination for white blood cells 47997703_1 CDM 0309 RC 85008 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 Microscopic examination for white blood cells 47997703_1 CDM 0309 RC 85008 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 Microscopic examination for white blood cells 47997703_1 CDM 0309 RC 85008 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges Microscopic examination for white blood cells 47997703_1 CDM 0309 RC 85008 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 "X-ray of both hips, 2 views" 48005082_1 CDM 0320 RC 73521 HCPCS inpatient 812 527.8 AETNA AETNA 641.48 79 999999999 491.67 787.64 percent of total billed charges "X-ray of both hips, 2 views" 48005082_1 CDM 0320 RC 73521 HCPCS inpatient 812 527.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 527.8 65 999999999 491.67 787.64 percent of total billed charges "X-ray of both hips, 2 views" 48005082_1 CDM 0320 RC 73521 HCPCS inpatient 812 527.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 787.64 97 999999999 491.67 787.64 percent of total billed charges "X-ray of both hips, 2 views" 48005082_1 CDM 0320 RC 73521 HCPCS inpatient 812 527.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 560.28 69 999999999 491.67 787.64 percent of total billed charges "X-ray of both hips, 2 views" 48005082_1 CDM 0320 RC 73521 HCPCS inpatient 812 527.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 633.36 78 999999999 491.67 787.64 percent of total billed charges "X-ray of both hips, 2 views" 48005082_1 CDM 0320 RC 73521 HCPCS inpatient 812 527.8 UMR - ALL PLANS UMR - ALL PLANS 568.4 70 999999999 491.67 787.64 percent of total billed charges "X-ray of both hips, 2 views" 48005082_1 CDM 0320 RC 73521 HCPCS inpatient 812 527.8 SIHO - ALL PLANS SIHO - ALL PLANS 730.8 90 999999999 491.67 787.64 percent of total billed charges "X-ray of both hips, 2 views" 48005082_1 CDM 0320 RC 73521 HCPCS inpatient 812 527.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 491.67 60.55 999999999 491.67 787.64 percent of total billed charges "X-ray of both hips, 2 views" 48005082_1 CDM 0320 RC 73521 HCPCS inpatient 812 527.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 491.67 787.64 "X-ray of both hips, 2 views" 48005082_1 CDM 0320 RC 73521 HCPCS inpatient 812 527.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 491.67 787.64 "X-ray of both hips, 2 views" 48005082_1 CDM 0320 RC 73521 HCPCS inpatient 812 527.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 491.67 787.64 "X-ray of both hips, 2 views" 48005082_1 CDM 0320 RC 73521 HCPCS inpatient 812 527.8 ANTHEM HMO ANTHEM HMO 999999999 491.67 787.64 "X-ray of both hips, 2 views" 48005082_1 CDM 0320 RC 73521 HCPCS inpatient 812 527.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 548.91 67.6 999999999 491.67 787.64 percent of total billed charges "X-ray of both hips, 2 views" 48005082_1 CDM 0320 RC 73521 HCPCS inpatient 812 527.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 491.67 787.64 "X-ray of hip, 2-3 views" 48005094_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 AETNA AETNA 367.35 79 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 48005094_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 302.25 65 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 48005094_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 451.05 97 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 48005094_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 320.85 69 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 48005094_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 362.7 78 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 48005094_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 UMR - ALL PLANS UMR - ALL PLANS 325.5 70 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 48005094_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 SIHO - ALL PLANS SIHO - ALL PLANS 418.5 90 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 48005094_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 281.56 60.55 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 48005094_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 281.56 451.05 "X-ray of hip, 2-3 views" 48005094_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 281.56 451.05 "X-ray of hip, 2-3 views" 48005094_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 281.56 451.05 "X-ray of hip, 2-3 views" 48005094_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 ANTHEM HMO ANTHEM HMO 999999999 281.56 451.05 "X-ray of hip, 2-3 views" 48005094_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 314.34 67.6 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 48005094_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 281.56 451.05 "X-ray of hip, 2-3 views" 48005097_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 AETNA AETNA 367.35 79 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 48005097_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 302.25 65 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 48005097_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 451.05 97 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 48005097_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 320.85 69 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 48005097_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 362.7 78 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 48005097_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 UMR - ALL PLANS UMR - ALL PLANS 325.5 70 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 48005097_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 SIHO - ALL PLANS SIHO - ALL PLANS 418.5 90 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 48005097_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 281.56 60.55 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 48005097_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 281.56 451.05 "X-ray of hip, 2-3 views" 48005097_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 281.56 451.05 "X-ray of hip, 2-3 views" 48005097_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 281.56 451.05 "X-ray of hip, 2-3 views" 48005097_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 ANTHEM HMO ANTHEM HMO 999999999 281.56 451.05 "X-ray of hip, 2-3 views" 48005097_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 314.34 67.6 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 48005097_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 281.56 451.05 "X-ray of both hips, 2 views" 48005106_1 CDM 0320 RC 73521 HCPCS inpatient 868 564.2 AETNA AETNA 685.72 79 999999999 525.57 841.96 percent of total billed charges "X-ray of both hips, 2 views" 48005106_1 CDM 0320 RC 73521 HCPCS inpatient 868 564.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 564.2 65 999999999 525.57 841.96 percent of total billed charges "X-ray of both hips, 2 views" 48005106_1 CDM 0320 RC 73521 HCPCS inpatient 868 564.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 841.96 97 999999999 525.57 841.96 percent of total billed charges "X-ray of both hips, 2 views" 48005106_1 CDM 0320 RC 73521 HCPCS inpatient 868 564.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 598.92 69 999999999 525.57 841.96 percent of total billed charges "X-ray of both hips, 2 views" 48005106_1 CDM 0320 RC 73521 HCPCS inpatient 868 564.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 677.04 78 999999999 525.57 841.96 percent of total billed charges "X-ray of both hips, 2 views" 48005106_1 CDM 0320 RC 73521 HCPCS inpatient 868 564.2 UMR - ALL PLANS UMR - ALL PLANS 607.6 70 999999999 525.57 841.96 percent of total billed charges "X-ray of both hips, 2 views" 48005106_1 CDM 0320 RC 73521 HCPCS inpatient 868 564.2 SIHO - ALL PLANS SIHO - ALL PLANS 781.2 90 999999999 525.57 841.96 percent of total billed charges "X-ray of both hips, 2 views" 48005106_1 CDM 0320 RC 73521 HCPCS inpatient 868 564.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 525.57 60.55 999999999 525.57 841.96 percent of total billed charges "X-ray of both hips, 2 views" 48005106_1 CDM 0320 RC 73521 HCPCS inpatient 868 564.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 525.57 841.96 "X-ray of both hips, 2 views" 48005106_1 CDM 0320 RC 73521 HCPCS inpatient 868 564.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 525.57 841.96 "X-ray of both hips, 2 views" 48005106_1 CDM 0320 RC 73521 HCPCS inpatient 868 564.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 525.57 841.96 "X-ray of both hips, 2 views" 48005106_1 CDM 0320 RC 73521 HCPCS inpatient 868 564.2 ANTHEM HMO ANTHEM HMO 999999999 525.57 841.96 "X-ray of both hips, 2 views" 48005106_1 CDM 0320 RC 73521 HCPCS inpatient 868 564.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 586.77 67.6 999999999 525.57 841.96 percent of total billed charges "X-ray of both hips, 2 views" 48005106_1 CDM 0320 RC 73521 HCPCS inpatient 868 564.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 525.57 841.96 Insertion of temporary bladder tube 48005325_1 CDM 0761 RC 51701 HCPCS inpatient 236 153.4 AETNA AETNA 186.44 79 999999999 142.9 228.92 percent of total billed charges Insertion of temporary bladder tube 48005325_1 CDM 0761 RC 51701 HCPCS inpatient 236 153.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 153.4 65 999999999 142.9 228.92 percent of total billed charges Insertion of temporary bladder tube 48005325_1 CDM 0761 RC 51701 HCPCS inpatient 236 153.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 228.92 97 999999999 142.9 228.92 percent of total billed charges Insertion of temporary bladder tube 48005325_1 CDM 0761 RC 51701 HCPCS inpatient 236 153.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 162.84 69 999999999 142.9 228.92 percent of total billed charges Insertion of temporary bladder tube 48005325_1 CDM 0761 RC 51701 HCPCS inpatient 236 153.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 184.08 78 999999999 142.9 228.92 percent of total billed charges Insertion of temporary bladder tube 48005325_1 CDM 0761 RC 51701 HCPCS inpatient 236 153.4 UMR - ALL PLANS UMR - ALL PLANS 165.2 70 999999999 142.9 228.92 percent of total billed charges Insertion of temporary bladder tube 48005325_1 CDM 0761 RC 51701 HCPCS inpatient 236 153.4 SIHO - ALL PLANS SIHO - ALL PLANS 212.4 90 999999999 142.9 228.92 percent of total billed charges Insertion of temporary bladder tube 48005325_1 CDM 0761 RC 51701 HCPCS inpatient 236 153.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 142.9 60.55 999999999 142.9 228.92 percent of total billed charges Insertion of temporary bladder tube 48005325_1 CDM 0761 RC 51701 HCPCS inpatient 236 153.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 142.9 228.92 Insertion of temporary bladder tube 48005325_1 CDM 0761 RC 51701 HCPCS inpatient 236 153.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 142.9 228.92 Insertion of temporary bladder tube 48005325_1 CDM 0761 RC 51701 HCPCS inpatient 236 153.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 142.9 228.92 Insertion of temporary bladder tube 48005325_1 CDM 0761 RC 51701 HCPCS inpatient 236 153.4 ANTHEM HMO ANTHEM HMO 999999999 142.9 228.92 Insertion of temporary bladder tube 48005325_1 CDM 0761 RC 51701 HCPCS inpatient 236 153.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 159.54 67.6 999999999 142.9 228.92 percent of total billed charges Insertion of temporary bladder tube 48005325_1 CDM 0761 RC 51701 HCPCS inpatient 236 153.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 142.9 228.92 NURSERY - NEWBORN - LEVEL I 48019199_1 CDM 0171 RC inpatient 1068 694.2 AETNA AETNA 843.72 79 999999999 646.67 1035.96 percent of total billed charges NURSERY - NEWBORN - LEVEL I 48019199_1 CDM 0171 RC inpatient 1068 694.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 694.2 65 999999999 646.67 1035.96 percent of total billed charges NURSERY - NEWBORN - LEVEL I 48019199_1 CDM 0171 RC inpatient 1068 694.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1035.96 97 999999999 646.67 1035.96 percent of total billed charges NURSERY - NEWBORN - LEVEL I 48019199_1 CDM 0171 RC inpatient 1068 694.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 736.92 69 999999999 646.67 1035.96 percent of total billed charges NURSERY - NEWBORN - LEVEL I 48019199_1 CDM 0171 RC inpatient 1068 694.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 833.04 78 999999999 646.67 1035.96 percent of total billed charges NURSERY - NEWBORN - LEVEL I 48019199_1 CDM 0171 RC inpatient 1068 694.2 UMR - ALL PLANS UMR - ALL PLANS 747.6 70 999999999 646.67 1035.96 percent of total billed charges NURSERY - NEWBORN - LEVEL I 48019199_1 CDM 0171 RC inpatient 1068 694.2 SIHO - ALL PLANS SIHO - ALL PLANS 961.2 90 999999999 646.67 1035.96 percent of total billed charges NURSERY - NEWBORN - LEVEL I 48019199_1 CDM 0171 RC inpatient 1068 694.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 646.67 60.55 999999999 646.67 1035.96 percent of total billed charges NURSERY - NEWBORN - LEVEL I 48019199_1 CDM 0171 RC inpatient 1068 694.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 646.67 1035.96 NURSERY - NEWBORN - LEVEL I 48019199_1 CDM 0171 RC inpatient 1068 694.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 646.67 1035.96 NURSERY - NEWBORN - LEVEL I 48019199_1 CDM 0171 RC inpatient 1068 694.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 646.67 1035.96 NURSERY - NEWBORN - LEVEL I 48019199_1 CDM 0171 RC inpatient 1068 694.2 ANTHEM HMO ANTHEM HMO 999999999 646.67 1035.96 NURSERY - NEWBORN - LEVEL I 48019199_1 CDM 0171 RC inpatient 1068 694.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 721.97 67.6 999999999 646.67 1035.96 percent of total billed charges NURSERY - NEWBORN - LEVEL I 48019199_1 CDM 0171 RC inpatient 1068 694.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 646.67 1035.96 NURSERY - NEWBORN - LEVEL II 48019201_1 CDM 0172 RC inpatient 1618 1051.7 AETNA AETNA 1278.22 79 999999999 979.7 1569.46 percent of total billed charges NURSERY - NEWBORN - LEVEL II 48019201_1 CDM 0172 RC inpatient 1618 1051.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1051.7 65 999999999 979.7 1569.46 percent of total billed charges NURSERY - NEWBORN - LEVEL II 48019201_1 CDM 0172 RC inpatient 1618 1051.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1569.46 97 999999999 979.7 1569.46 percent of total billed charges NURSERY - NEWBORN - LEVEL II 48019201_1 CDM 0172 RC inpatient 1618 1051.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1116.42 69 999999999 979.7 1569.46 percent of total billed charges NURSERY - NEWBORN - LEVEL II 48019201_1 CDM 0172 RC inpatient 1618 1051.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1262.04 78 999999999 979.7 1569.46 percent of total billed charges NURSERY - NEWBORN - LEVEL II 48019201_1 CDM 0172 RC inpatient 1618 1051.7 UMR - ALL PLANS UMR - ALL PLANS 1132.6 70 999999999 979.7 1569.46 percent of total billed charges NURSERY - NEWBORN - LEVEL II 48019201_1 CDM 0172 RC inpatient 1618 1051.7 SIHO - ALL PLANS SIHO - ALL PLANS 1456.2 90 999999999 979.7 1569.46 percent of total billed charges NURSERY - NEWBORN - LEVEL II 48019201_1 CDM 0172 RC inpatient 1618 1051.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 979.7 60.55 999999999 979.7 1569.46 percent of total billed charges NURSERY - NEWBORN - LEVEL II 48019201_1 CDM 0172 RC inpatient 1618 1051.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 979.7 1569.46 NURSERY - NEWBORN - LEVEL II 48019201_1 CDM 0172 RC inpatient 1618 1051.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 979.7 1569.46 NURSERY - NEWBORN - LEVEL II 48019201_1 CDM 0172 RC inpatient 1618 1051.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 979.7 1569.46 NURSERY - NEWBORN - LEVEL II 48019201_1 CDM 0172 RC inpatient 1618 1051.7 ANTHEM HMO ANTHEM HMO 999999999 979.7 1569.46 NURSERY - NEWBORN - LEVEL II 48019201_1 CDM 0172 RC inpatient 1618 1051.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1093.77 67.6 999999999 979.7 1569.46 percent of total billed charges NURSERY - NEWBORN - LEVEL II 48019201_1 CDM 0172 RC inpatient 1618 1051.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 979.7 1569.46 Gentamicin (antibiotic) level 48019579_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 AETNA AETNA 259.12 79 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 48019579_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 213.2 65 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 48019579_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 318.16 97 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 48019579_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 226.32 69 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 48019579_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.84 78 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 48019579_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 UMR - ALL PLANS UMR - ALL PLANS 229.6 70 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 48019579_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 SIHO - ALL PLANS SIHO - ALL PLANS 295.2 90 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 48019579_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198.6 60.55 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 48019579_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198.6 318.16 Gentamicin (antibiotic) level 48019579_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198.6 318.16 Gentamicin (antibiotic) level 48019579_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198.6 318.16 Gentamicin (antibiotic) level 48019579_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 ANTHEM HMO ANTHEM HMO 999999999 198.6 318.16 Gentamicin (antibiotic) level 48019579_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.73 67.6 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 48019579_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 198.6 318.16 Insertion of stomach tube and aspiration of stomach contents 48049175_1 CDM 0450 RC 43753 HCPCS inpatient 611 397.15 AETNA AETNA 482.69 79 999999999 369.96 592.67 percent of total billed charges Insertion of stomach tube and aspiration of stomach contents 48049175_1 CDM 0450 RC 43753 HCPCS inpatient 611 397.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 397.15 65 999999999 369.96 592.67 percent of total billed charges Insertion of stomach tube and aspiration of stomach contents 48049175_1 CDM 0450 RC 43753 HCPCS inpatient 611 397.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 592.67 97 999999999 369.96 592.67 percent of total billed charges Insertion of stomach tube and aspiration of stomach contents 48049175_1 CDM 0450 RC 43753 HCPCS inpatient 611 397.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 421.59 69 999999999 369.96 592.67 percent of total billed charges Insertion of stomach tube and aspiration of stomach contents 48049175_1 CDM 0450 RC 43753 HCPCS inpatient 611 397.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 476.58 78 999999999 369.96 592.67 percent of total billed charges Insertion of stomach tube and aspiration of stomach contents 48049175_1 CDM 0450 RC 43753 HCPCS inpatient 611 397.15 UMR - ALL PLANS UMR - ALL PLANS 427.7 70 999999999 369.96 592.67 percent of total billed charges Insertion of stomach tube and aspiration of stomach contents 48049175_1 CDM 0450 RC 43753 HCPCS inpatient 611 397.15 SIHO - ALL PLANS SIHO - ALL PLANS 549.9 90 999999999 369.96 592.67 percent of total billed charges Insertion of stomach tube and aspiration of stomach contents 48049175_1 CDM 0450 RC 43753 HCPCS inpatient 611 397.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 369.96 60.55 999999999 369.96 592.67 percent of total billed charges Insertion of stomach tube and aspiration of stomach contents 48049175_1 CDM 0450 RC 43753 HCPCS inpatient 611 397.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 369.96 592.67 Insertion of stomach tube and aspiration of stomach contents 48049175_1 CDM 0450 RC 43753 HCPCS inpatient 611 397.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 369.96 592.67 Insertion of stomach tube and aspiration of stomach contents 48049175_1 CDM 0450 RC 43753 HCPCS inpatient 611 397.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 369.96 592.67 Insertion of stomach tube and aspiration of stomach contents 48049175_1 CDM 0450 RC 43753 HCPCS inpatient 611 397.15 ANTHEM HMO ANTHEM HMO 999999999 369.96 592.67 Insertion of stomach tube and aspiration of stomach contents 48049175_1 CDM 0450 RC 43753 HCPCS inpatient 611 397.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 413.04 67.6 999999999 369.96 592.67 percent of total billed charges Insertion of stomach tube and aspiration of stomach contents 48049175_1 CDM 0450 RC 43753 HCPCS inpatient 611 397.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 369.96 592.67 Emergency department visit for problem that may not require health care professional 48049187_1 CDM 0451 RC 99281 HCPCS inpatient 85 55.25 AETNA AETNA 67.15 79 999999999 51.47 82.45 percent of total billed charges Emergency department visit for problem that may not require health care professional 48049187_1 CDM 0451 RC 99281 HCPCS inpatient 85 55.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.25 65 999999999 51.47 82.45 percent of total billed charges Emergency department visit for problem that may not require health care professional 48049187_1 CDM 0451 RC 99281 HCPCS inpatient 85 55.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 82.45 97 999999999 51.47 82.45 percent of total billed charges Emergency department visit for problem that may not require health care professional 48049187_1 CDM 0451 RC 99281 HCPCS inpatient 85 55.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 58.65 69 999999999 51.47 82.45 percent of total billed charges Emergency department visit for problem that may not require health care professional 48049187_1 CDM 0451 RC 99281 HCPCS inpatient 85 55.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 66.3 78 999999999 51.47 82.45 percent of total billed charges Emergency department visit for problem that may not require health care professional 48049187_1 CDM 0451 RC 99281 HCPCS inpatient 85 55.25 UMR - ALL PLANS UMR - ALL PLANS 59.5 70 999999999 51.47 82.45 percent of total billed charges Emergency department visit for problem that may not require health care professional 48049187_1 CDM 0451 RC 99281 HCPCS inpatient 85 55.25 SIHO - ALL PLANS SIHO - ALL PLANS 76.5 90 999999999 51.47 82.45 percent of total billed charges Emergency department visit for problem that may not require health care professional 48049187_1 CDM 0451 RC 99281 HCPCS inpatient 85 55.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 51.47 60.55 999999999 51.47 82.45 percent of total billed charges Emergency department visit for problem that may not require health care professional 48049187_1 CDM 0451 RC 99281 HCPCS inpatient 85 55.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 51.47 82.45 Emergency department visit for problem that may not require health care professional 48049187_1 CDM 0451 RC 99281 HCPCS inpatient 85 55.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 51.47 82.45 Emergency department visit for problem that may not require health care professional 48049187_1 CDM 0451 RC 99281 HCPCS inpatient 85 55.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 51.47 82.45 Emergency department visit for problem that may not require health care professional 48049187_1 CDM 0451 RC 99281 HCPCS inpatient 85 55.25 ANTHEM HMO ANTHEM HMO 999999999 51.47 82.45 Emergency department visit for problem that may not require health care professional 48049187_1 CDM 0451 RC 99281 HCPCS inpatient 85 55.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 57.46 67.6 999999999 51.47 82.45 percent of total billed charges Emergency department visit for problem that may not require health care professional 48049187_1 CDM 0451 RC 99281 HCPCS inpatient 85 55.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 51.47 82.45 "Dressing change or removal of burn tissue, 5-10% of total body surface" 48049242_1 CDM 0450 RC 16025 HCPCS inpatient 398 258.7 AETNA AETNA 314.42 79 999999999 240.99 386.06 percent of total billed charges "Dressing change or removal of burn tissue, 5-10% of total body surface" 48049242_1 CDM 0450 RC 16025 HCPCS inpatient 398 258.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 258.7 65 999999999 240.99 386.06 percent of total billed charges "Dressing change or removal of burn tissue, 5-10% of total body surface" 48049242_1 CDM 0450 RC 16025 HCPCS inpatient 398 258.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 386.06 97 999999999 240.99 386.06 percent of total billed charges "Dressing change or removal of burn tissue, 5-10% of total body surface" 48049242_1 CDM 0450 RC 16025 HCPCS inpatient 398 258.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 274.62 69 999999999 240.99 386.06 percent of total billed charges "Dressing change or removal of burn tissue, 5-10% of total body surface" 48049242_1 CDM 0450 RC 16025 HCPCS inpatient 398 258.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 310.44 78 999999999 240.99 386.06 percent of total billed charges "Dressing change or removal of burn tissue, 5-10% of total body surface" 48049242_1 CDM 0450 RC 16025 HCPCS inpatient 398 258.7 UMR - ALL PLANS UMR - ALL PLANS 278.6 70 999999999 240.99 386.06 percent of total billed charges "Dressing change or removal of burn tissue, 5-10% of total body surface" 48049242_1 CDM 0450 RC 16025 HCPCS inpatient 398 258.7 SIHO - ALL PLANS SIHO - ALL PLANS 358.2 90 999999999 240.99 386.06 percent of total billed charges "Dressing change or removal of burn tissue, 5-10% of total body surface" 48049242_1 CDM 0450 RC 16025 HCPCS inpatient 398 258.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 240.99 60.55 999999999 240.99 386.06 percent of total billed charges "Dressing change or removal of burn tissue, 5-10% of total body surface" 48049242_1 CDM 0450 RC 16025 HCPCS inpatient 398 258.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 240.99 386.06 "Dressing change or removal of burn tissue, 5-10% of total body surface" 48049242_1 CDM 0450 RC 16025 HCPCS inpatient 398 258.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 240.99 386.06 "Dressing change or removal of burn tissue, 5-10% of total body surface" 48049242_1 CDM 0450 RC 16025 HCPCS inpatient 398 258.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 240.99 386.06 "Dressing change or removal of burn tissue, 5-10% of total body surface" 48049242_1 CDM 0450 RC 16025 HCPCS inpatient 398 258.7 ANTHEM HMO ANTHEM HMO 999999999 240.99 386.06 "Dressing change or removal of burn tissue, 5-10% of total body surface" 48049242_1 CDM 0450 RC 16025 HCPCS inpatient 398 258.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 269.05 67.6 999999999 240.99 386.06 percent of total billed charges "Dressing change or removal of burn tissue, 5-10% of total body surface" 48049242_1 CDM 0450 RC 16025 HCPCS inpatient 398 258.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 240.99 386.06 "Dressing change or removal of burn tissue, more than 10% of total body surface" 48049243_1 CDM 0450 RC 16030 HCPCS inpatient 411 267.15 AETNA AETNA 324.69 79 999999999 248.86 398.67 percent of total billed charges "Dressing change or removal of burn tissue, more than 10% of total body surface" 48049243_1 CDM 0450 RC 16030 HCPCS inpatient 411 267.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 267.15 65 999999999 248.86 398.67 percent of total billed charges "Dressing change or removal of burn tissue, more than 10% of total body surface" 48049243_1 CDM 0450 RC 16030 HCPCS inpatient 411 267.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 398.67 97 999999999 248.86 398.67 percent of total billed charges "Dressing change or removal of burn tissue, more than 10% of total body surface" 48049243_1 CDM 0450 RC 16030 HCPCS inpatient 411 267.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 283.59 69 999999999 248.86 398.67 percent of total billed charges "Dressing change or removal of burn tissue, more than 10% of total body surface" 48049243_1 CDM 0450 RC 16030 HCPCS inpatient 411 267.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 320.58 78 999999999 248.86 398.67 percent of total billed charges "Dressing change or removal of burn tissue, more than 10% of total body surface" 48049243_1 CDM 0450 RC 16030 HCPCS inpatient 411 267.15 UMR - ALL PLANS UMR - ALL PLANS 287.7 70 999999999 248.86 398.67 percent of total billed charges "Dressing change or removal of burn tissue, more than 10% of total body surface" 48049243_1 CDM 0450 RC 16030 HCPCS inpatient 411 267.15 SIHO - ALL PLANS SIHO - ALL PLANS 369.9 90 999999999 248.86 398.67 percent of total billed charges "Dressing change or removal of burn tissue, more than 10% of total body surface" 48049243_1 CDM 0450 RC 16030 HCPCS inpatient 411 267.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 248.86 60.55 999999999 248.86 398.67 percent of total billed charges "Dressing change or removal of burn tissue, more than 10% of total body surface" 48049243_1 CDM 0450 RC 16030 HCPCS inpatient 411 267.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 248.86 398.67 "Dressing change or removal of burn tissue, more than 10% of total body surface" 48049243_1 CDM 0450 RC 16030 HCPCS inpatient 411 267.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 248.86 398.67 "Dressing change or removal of burn tissue, more than 10% of total body surface" 48049243_1 CDM 0450 RC 16030 HCPCS inpatient 411 267.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 248.86 398.67 "Dressing change or removal of burn tissue, more than 10% of total body surface" 48049243_1 CDM 0450 RC 16030 HCPCS inpatient 411 267.15 ANTHEM HMO ANTHEM HMO 999999999 248.86 398.67 "Dressing change or removal of burn tissue, more than 10% of total body surface" 48049243_1 CDM 0450 RC 16030 HCPCS inpatient 411 267.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 277.84 67.6 999999999 248.86 398.67 percent of total billed charges "Dressing change or removal of burn tissue, more than 10% of total body surface" 48049243_1 CDM 0450 RC 16030 HCPCS inpatient 411 267.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 248.86 398.67 Application of chemical to stop tissue regrowth in wound 48049244_1 CDM 0450 RC 17250 HCPCS inpatient 492 319.8 AETNA AETNA 388.68 79 999999999 297.91 477.24 percent of total billed charges Application of chemical to stop tissue regrowth in wound 48049244_1 CDM 0450 RC 17250 HCPCS inpatient 492 319.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 319.8 65 999999999 297.91 477.24 percent of total billed charges Application of chemical to stop tissue regrowth in wound 48049244_1 CDM 0450 RC 17250 HCPCS inpatient 492 319.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 477.24 97 999999999 297.91 477.24 percent of total billed charges Application of chemical to stop tissue regrowth in wound 48049244_1 CDM 0450 RC 17250 HCPCS inpatient 492 319.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 339.48 69 999999999 297.91 477.24 percent of total billed charges Application of chemical to stop tissue regrowth in wound 48049244_1 CDM 0450 RC 17250 HCPCS inpatient 492 319.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 383.76 78 999999999 297.91 477.24 percent of total billed charges Application of chemical to stop tissue regrowth in wound 48049244_1 CDM 0450 RC 17250 HCPCS inpatient 492 319.8 UMR - ALL PLANS UMR - ALL PLANS 344.4 70 999999999 297.91 477.24 percent of total billed charges Application of chemical to stop tissue regrowth in wound 48049244_1 CDM 0450 RC 17250 HCPCS inpatient 492 319.8 SIHO - ALL PLANS SIHO - ALL PLANS 442.8 90 999999999 297.91 477.24 percent of total billed charges Application of chemical to stop tissue regrowth in wound 48049244_1 CDM 0450 RC 17250 HCPCS inpatient 492 319.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 297.91 60.55 999999999 297.91 477.24 percent of total billed charges Application of chemical to stop tissue regrowth in wound 48049244_1 CDM 0450 RC 17250 HCPCS inpatient 492 319.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 297.91 477.24 Application of chemical to stop tissue regrowth in wound 48049244_1 CDM 0450 RC 17250 HCPCS inpatient 492 319.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 297.91 477.24 Application of chemical to stop tissue regrowth in wound 48049244_1 CDM 0450 RC 17250 HCPCS inpatient 492 319.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 297.91 477.24 Application of chemical to stop tissue regrowth in wound 48049244_1 CDM 0450 RC 17250 HCPCS inpatient 492 319.8 ANTHEM HMO ANTHEM HMO 999999999 297.91 477.24 Application of chemical to stop tissue regrowth in wound 48049244_1 CDM 0450 RC 17250 HCPCS inpatient 492 319.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 332.59 67.6 999999999 297.91 477.24 percent of total billed charges Application of chemical to stop tissue regrowth in wound 48049244_1 CDM 0450 RC 17250 HCPCS inpatient 492 319.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 297.91 477.24 Closed treatment of broken hand bone 48049281_1 CDM 0450 RC 26600 HCPCS inpatient 505 328.25 AETNA AETNA 398.95 79 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken hand bone 48049281_1 CDM 0450 RC 26600 HCPCS inpatient 505 328.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 328.25 65 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken hand bone 48049281_1 CDM 0450 RC 26600 HCPCS inpatient 505 328.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 489.85 97 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken hand bone 48049281_1 CDM 0450 RC 26600 HCPCS inpatient 505 328.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 348.45 69 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken hand bone 48049281_1 CDM 0450 RC 26600 HCPCS inpatient 505 328.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 393.9 78 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken hand bone 48049281_1 CDM 0450 RC 26600 HCPCS inpatient 505 328.25 UMR - ALL PLANS UMR - ALL PLANS 353.5 70 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken hand bone 48049281_1 CDM 0450 RC 26600 HCPCS inpatient 505 328.25 SIHO - ALL PLANS SIHO - ALL PLANS 454.5 90 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken hand bone 48049281_1 CDM 0450 RC 26600 HCPCS inpatient 505 328.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 305.78 60.55 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken hand bone 48049281_1 CDM 0450 RC 26600 HCPCS inpatient 505 328.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 305.78 489.85 Closed treatment of broken hand bone 48049281_1 CDM 0450 RC 26600 HCPCS inpatient 505 328.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 305.78 489.85 Closed treatment of broken hand bone 48049281_1 CDM 0450 RC 26600 HCPCS inpatient 505 328.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 305.78 489.85 Closed treatment of broken hand bone 48049281_1 CDM 0450 RC 26600 HCPCS inpatient 505 328.25 ANTHEM HMO ANTHEM HMO 999999999 305.78 489.85 Closed treatment of broken hand bone 48049281_1 CDM 0450 RC 26600 HCPCS inpatient 505 328.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 341.38 67.6 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken hand bone 48049281_1 CDM 0450 RC 26600 HCPCS inpatient 505 328.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 305.78 489.85 Closed treatment of broken outside lower leg bone at ankle 48049301_1 CDM 0450 RC 27786 HCPCS inpatient 505 328.25 AETNA AETNA 398.95 79 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken outside lower leg bone at ankle 48049301_1 CDM 0450 RC 27786 HCPCS inpatient 505 328.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 328.25 65 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken outside lower leg bone at ankle 48049301_1 CDM 0450 RC 27786 HCPCS inpatient 505 328.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 489.85 97 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken outside lower leg bone at ankle 48049301_1 CDM 0450 RC 27786 HCPCS inpatient 505 328.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 348.45 69 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken outside lower leg bone at ankle 48049301_1 CDM 0450 RC 27786 HCPCS inpatient 505 328.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 393.9 78 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken outside lower leg bone at ankle 48049301_1 CDM 0450 RC 27786 HCPCS inpatient 505 328.25 UMR - ALL PLANS UMR - ALL PLANS 353.5 70 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken outside lower leg bone at ankle 48049301_1 CDM 0450 RC 27786 HCPCS inpatient 505 328.25 SIHO - ALL PLANS SIHO - ALL PLANS 454.5 90 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken outside lower leg bone at ankle 48049301_1 CDM 0450 RC 27786 HCPCS inpatient 505 328.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 305.78 60.55 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken outside lower leg bone at ankle 48049301_1 CDM 0450 RC 27786 HCPCS inpatient 505 328.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 305.78 489.85 Closed treatment of broken outside lower leg bone at ankle 48049301_1 CDM 0450 RC 27786 HCPCS inpatient 505 328.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 305.78 489.85 Closed treatment of broken outside lower leg bone at ankle 48049301_1 CDM 0450 RC 27786 HCPCS inpatient 505 328.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 305.78 489.85 Closed treatment of broken outside lower leg bone at ankle 48049301_1 CDM 0450 RC 27786 HCPCS inpatient 505 328.25 ANTHEM HMO ANTHEM HMO 999999999 305.78 489.85 Closed treatment of broken outside lower leg bone at ankle 48049301_1 CDM 0450 RC 27786 HCPCS inpatient 505 328.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 341.38 67.6 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken outside lower leg bone at ankle 48049301_1 CDM 0450 RC 27786 HCPCS inpatient 505 328.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 305.78 489.85 Closed treatment of broken great toe with manipulation 48049313_1 CDM 0450 RC 28495 HCPCS inpatient 387 251.55 AETNA AETNA 305.73 79 999999999 234.33 375.39 percent of total billed charges Closed treatment of broken great toe with manipulation 48049313_1 CDM 0450 RC 28495 HCPCS inpatient 387 251.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 251.55 65 999999999 234.33 375.39 percent of total billed charges Closed treatment of broken great toe with manipulation 48049313_1 CDM 0450 RC 28495 HCPCS inpatient 387 251.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 375.39 97 999999999 234.33 375.39 percent of total billed charges Closed treatment of broken great toe with manipulation 48049313_1 CDM 0450 RC 28495 HCPCS inpatient 387 251.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.03 69 999999999 234.33 375.39 percent of total billed charges Closed treatment of broken great toe with manipulation 48049313_1 CDM 0450 RC 28495 HCPCS inpatient 387 251.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.86 78 999999999 234.33 375.39 percent of total billed charges Closed treatment of broken great toe with manipulation 48049313_1 CDM 0450 RC 28495 HCPCS inpatient 387 251.55 UMR - ALL PLANS UMR - ALL PLANS 270.9 70 999999999 234.33 375.39 percent of total billed charges Closed treatment of broken great toe with manipulation 48049313_1 CDM 0450 RC 28495 HCPCS inpatient 387 251.55 SIHO - ALL PLANS SIHO - ALL PLANS 348.3 90 999999999 234.33 375.39 percent of total billed charges Closed treatment of broken great toe with manipulation 48049313_1 CDM 0450 RC 28495 HCPCS inpatient 387 251.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.33 60.55 999999999 234.33 375.39 percent of total billed charges Closed treatment of broken great toe with manipulation 48049313_1 CDM 0450 RC 28495 HCPCS inpatient 387 251.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.33 375.39 Closed treatment of broken great toe with manipulation 48049313_1 CDM 0450 RC 28495 HCPCS inpatient 387 251.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.33 375.39 Closed treatment of broken great toe with manipulation 48049313_1 CDM 0450 RC 28495 HCPCS inpatient 387 251.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.33 375.39 Closed treatment of broken great toe with manipulation 48049313_1 CDM 0450 RC 28495 HCPCS inpatient 387 251.55 ANTHEM HMO ANTHEM HMO 999999999 234.33 375.39 Closed treatment of broken great toe with manipulation 48049313_1 CDM 0450 RC 28495 HCPCS inpatient 387 251.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 261.61 67.6 999999999 234.33 375.39 percent of total billed charges Closed treatment of broken great toe with manipulation 48049313_1 CDM 0450 RC 28495 HCPCS inpatient 387 251.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.33 375.39 Closed treatment of dislocated joint between toe and foot 48049316_1 CDM 0450 RC 28630 HCPCS inpatient 388 252.2 AETNA AETNA 306.52 79 999999999 234.93 376.36 percent of total billed charges Closed treatment of dislocated joint between toe and foot 48049316_1 CDM 0450 RC 28630 HCPCS inpatient 388 252.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 252.2 65 999999999 234.93 376.36 percent of total billed charges Closed treatment of dislocated joint between toe and foot 48049316_1 CDM 0450 RC 28630 HCPCS inpatient 388 252.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 376.36 97 999999999 234.93 376.36 percent of total billed charges Closed treatment of dislocated joint between toe and foot 48049316_1 CDM 0450 RC 28630 HCPCS inpatient 388 252.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.72 69 999999999 234.93 376.36 percent of total billed charges Closed treatment of dislocated joint between toe and foot 48049316_1 CDM 0450 RC 28630 HCPCS inpatient 388 252.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 302.64 78 999999999 234.93 376.36 percent of total billed charges Closed treatment of dislocated joint between toe and foot 48049316_1 CDM 0450 RC 28630 HCPCS inpatient 388 252.2 UMR - ALL PLANS UMR - ALL PLANS 271.6 70 999999999 234.93 376.36 percent of total billed charges Closed treatment of dislocated joint between toe and foot 48049316_1 CDM 0450 RC 28630 HCPCS inpatient 388 252.2 SIHO - ALL PLANS SIHO - ALL PLANS 349.2 90 999999999 234.93 376.36 percent of total billed charges Closed treatment of dislocated joint between toe and foot 48049316_1 CDM 0450 RC 28630 HCPCS inpatient 388 252.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.93 60.55 999999999 234.93 376.36 percent of total billed charges Closed treatment of dislocated joint between toe and foot 48049316_1 CDM 0450 RC 28630 HCPCS inpatient 388 252.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.93 376.36 Closed treatment of dislocated joint between toe and foot 48049316_1 CDM 0450 RC 28630 HCPCS inpatient 388 252.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.93 376.36 Closed treatment of dislocated joint between toe and foot 48049316_1 CDM 0450 RC 28630 HCPCS inpatient 388 252.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.93 376.36 Closed treatment of dislocated joint between toe and foot 48049316_1 CDM 0450 RC 28630 HCPCS inpatient 388 252.2 ANTHEM HMO ANTHEM HMO 999999999 234.93 376.36 Closed treatment of dislocated joint between toe and foot 48049316_1 CDM 0450 RC 28630 HCPCS inpatient 388 252.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 262.29 67.6 999999999 234.93 376.36 percent of total billed charges Closed treatment of dislocated joint between toe and foot 48049316_1 CDM 0450 RC 28630 HCPCS inpatient 388 252.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.93 376.36 Emergent incision of windpipe through neck for insertion of breathing tube 48049338_1 CDM 0450 RC 31603 HCPCS inpatient 1829 1188.85 AETNA AETNA 1444.91 79 999999999 1107.46 1774.13 percent of total billed charges Emergent incision of windpipe through neck for insertion of breathing tube 48049338_1 CDM 0450 RC 31603 HCPCS inpatient 1829 1188.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1188.85 65 999999999 1107.46 1774.13 percent of total billed charges Emergent incision of windpipe through neck for insertion of breathing tube 48049338_1 CDM 0450 RC 31603 HCPCS inpatient 1829 1188.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1774.13 97 999999999 1107.46 1774.13 percent of total billed charges Emergent incision of windpipe through neck for insertion of breathing tube 48049338_1 CDM 0450 RC 31603 HCPCS inpatient 1829 1188.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1262.01 69 999999999 1107.46 1774.13 percent of total billed charges Emergent incision of windpipe through neck for insertion of breathing tube 48049338_1 CDM 0450 RC 31603 HCPCS inpatient 1829 1188.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1426.62 78 999999999 1107.46 1774.13 percent of total billed charges Emergent incision of windpipe through neck for insertion of breathing tube 48049338_1 CDM 0450 RC 31603 HCPCS inpatient 1829 1188.85 UMR - ALL PLANS UMR - ALL PLANS 1280.3 70 999999999 1107.46 1774.13 percent of total billed charges Emergent incision of windpipe through neck for insertion of breathing tube 48049338_1 CDM 0450 RC 31603 HCPCS inpatient 1829 1188.85 SIHO - ALL PLANS SIHO - ALL PLANS 1646.1 90 999999999 1107.46 1774.13 percent of total billed charges Emergent incision of windpipe through neck for insertion of breathing tube 48049338_1 CDM 0450 RC 31603 HCPCS inpatient 1829 1188.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1107.46 60.55 999999999 1107.46 1774.13 percent of total billed charges Emergent incision of windpipe through neck for insertion of breathing tube 48049338_1 CDM 0450 RC 31603 HCPCS inpatient 1829 1188.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1107.46 1774.13 Emergent incision of windpipe through neck for insertion of breathing tube 48049338_1 CDM 0450 RC 31603 HCPCS inpatient 1829 1188.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1107.46 1774.13 Emergent incision of windpipe through neck for insertion of breathing tube 48049338_1 CDM 0450 RC 31603 HCPCS inpatient 1829 1188.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1107.46 1774.13 Emergent incision of windpipe through neck for insertion of breathing tube 48049338_1 CDM 0450 RC 31603 HCPCS inpatient 1829 1188.85 ANTHEM HMO ANTHEM HMO 999999999 1107.46 1774.13 Emergent incision of windpipe through neck for insertion of breathing tube 48049338_1 CDM 0450 RC 31603 HCPCS inpatient 1829 1188.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1236.4 67.6 999999999 1107.46 1774.13 percent of total billed charges Emergent incision of windpipe through neck for insertion of breathing tube 48049338_1 CDM 0450 RC 31603 HCPCS inpatient 1829 1188.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1107.46 1774.13 Drainage of abscess near tonsil 48049354_1 CDM 0450 RC 42700 HCPCS inpatient 430 279.5 AETNA AETNA 339.7 79 999999999 260.37 417.1 percent of total billed charges Drainage of abscess near tonsil 48049354_1 CDM 0450 RC 42700 HCPCS inpatient 430 279.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 279.5 65 999999999 260.37 417.1 percent of total billed charges Drainage of abscess near tonsil 48049354_1 CDM 0450 RC 42700 HCPCS inpatient 430 279.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 417.1 97 999999999 260.37 417.1 percent of total billed charges Drainage of abscess near tonsil 48049354_1 CDM 0450 RC 42700 HCPCS inpatient 430 279.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 296.7 69 999999999 260.37 417.1 percent of total billed charges Drainage of abscess near tonsil 48049354_1 CDM 0450 RC 42700 HCPCS inpatient 430 279.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 335.4 78 999999999 260.37 417.1 percent of total billed charges Drainage of abscess near tonsil 48049354_1 CDM 0450 RC 42700 HCPCS inpatient 430 279.5 UMR - ALL PLANS UMR - ALL PLANS 301 70 999999999 260.37 417.1 percent of total billed charges Drainage of abscess near tonsil 48049354_1 CDM 0450 RC 42700 HCPCS inpatient 430 279.5 SIHO - ALL PLANS SIHO - ALL PLANS 387 90 999999999 260.37 417.1 percent of total billed charges Drainage of abscess near tonsil 48049354_1 CDM 0450 RC 42700 HCPCS inpatient 430 279.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 260.37 60.55 999999999 260.37 417.1 percent of total billed charges Drainage of abscess near tonsil 48049354_1 CDM 0450 RC 42700 HCPCS inpatient 430 279.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 260.37 417.1 Drainage of abscess near tonsil 48049354_1 CDM 0450 RC 42700 HCPCS inpatient 430 279.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 260.37 417.1 Drainage of abscess near tonsil 48049354_1 CDM 0450 RC 42700 HCPCS inpatient 430 279.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 260.37 417.1 Drainage of abscess near tonsil 48049354_1 CDM 0450 RC 42700 HCPCS inpatient 430 279.5 ANTHEM HMO ANTHEM HMO 999999999 260.37 417.1 Drainage of abscess near tonsil 48049354_1 CDM 0450 RC 42700 HCPCS inpatient 430 279.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 290.68 67.6 999999999 260.37 417.1 percent of total billed charges Drainage of abscess near tonsil 48049354_1 CDM 0450 RC 42700 HCPCS inpatient 430 279.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 260.37 417.1 Removal of foreign body in anus using an endoscope 48049360_1 CDM 0450 RC 46608 HCPCS inpatient 519 337.35 AETNA AETNA 410.01 79 999999999 314.25 503.43 percent of total billed charges Removal of foreign body in anus using an endoscope 48049360_1 CDM 0450 RC 46608 HCPCS inpatient 519 337.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 337.35 65 999999999 314.25 503.43 percent of total billed charges Removal of foreign body in anus using an endoscope 48049360_1 CDM 0450 RC 46608 HCPCS inpatient 519 337.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 503.43 97 999999999 314.25 503.43 percent of total billed charges Removal of foreign body in anus using an endoscope 48049360_1 CDM 0450 RC 46608 HCPCS inpatient 519 337.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 358.11 69 999999999 314.25 503.43 percent of total billed charges Removal of foreign body in anus using an endoscope 48049360_1 CDM 0450 RC 46608 HCPCS inpatient 519 337.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 404.82 78 999999999 314.25 503.43 percent of total billed charges Removal of foreign body in anus using an endoscope 48049360_1 CDM 0450 RC 46608 HCPCS inpatient 519 337.35 UMR - ALL PLANS UMR - ALL PLANS 363.3 70 999999999 314.25 503.43 percent of total billed charges Removal of foreign body in anus using an endoscope 48049360_1 CDM 0450 RC 46608 HCPCS inpatient 519 337.35 SIHO - ALL PLANS SIHO - ALL PLANS 467.1 90 999999999 314.25 503.43 percent of total billed charges Removal of foreign body in anus using an endoscope 48049360_1 CDM 0450 RC 46608 HCPCS inpatient 519 337.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 314.25 60.55 999999999 314.25 503.43 percent of total billed charges Removal of foreign body in anus using an endoscope 48049360_1 CDM 0450 RC 46608 HCPCS inpatient 519 337.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 314.25 503.43 Removal of foreign body in anus using an endoscope 48049360_1 CDM 0450 RC 46608 HCPCS inpatient 519 337.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 314.25 503.43 Removal of foreign body in anus using an endoscope 48049360_1 CDM 0450 RC 46608 HCPCS inpatient 519 337.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 314.25 503.43 Removal of foreign body in anus using an endoscope 48049360_1 CDM 0450 RC 46608 HCPCS inpatient 519 337.35 ANTHEM HMO ANTHEM HMO 999999999 314.25 503.43 Removal of foreign body in anus using an endoscope 48049360_1 CDM 0450 RC 46608 HCPCS inpatient 519 337.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 350.84 67.6 999999999 314.25 503.43 percent of total billed charges Removal of foreign body in anus using an endoscope 48049360_1 CDM 0450 RC 46608 HCPCS inpatient 519 337.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 314.25 503.43 Temporary pacemaker to regulate heart beat 48049387_1 CDM 0450 RC 92953 HCPCS inpatient 1029 668.85 AETNA AETNA 812.91 79 999999999 623.06 998.13 percent of total billed charges Temporary pacemaker to regulate heart beat 48049387_1 CDM 0450 RC 92953 HCPCS inpatient 1029 668.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 668.85 65 999999999 623.06 998.13 percent of total billed charges Temporary pacemaker to regulate heart beat 48049387_1 CDM 0450 RC 92953 HCPCS inpatient 1029 668.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 998.13 97 999999999 623.06 998.13 percent of total billed charges Temporary pacemaker to regulate heart beat 48049387_1 CDM 0450 RC 92953 HCPCS inpatient 1029 668.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 710.01 69 999999999 623.06 998.13 percent of total billed charges Temporary pacemaker to regulate heart beat 48049387_1 CDM 0450 RC 92953 HCPCS inpatient 1029 668.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 802.62 78 999999999 623.06 998.13 percent of total billed charges Temporary pacemaker to regulate heart beat 48049387_1 CDM 0450 RC 92953 HCPCS inpatient 1029 668.85 UMR - ALL PLANS UMR - ALL PLANS 720.3 70 999999999 623.06 998.13 percent of total billed charges Temporary pacemaker to regulate heart beat 48049387_1 CDM 0450 RC 92953 HCPCS inpatient 1029 668.85 SIHO - ALL PLANS SIHO - ALL PLANS 926.1 90 999999999 623.06 998.13 percent of total billed charges Temporary pacemaker to regulate heart beat 48049387_1 CDM 0450 RC 92953 HCPCS inpatient 1029 668.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 623.06 60.55 999999999 623.06 998.13 percent of total billed charges Temporary pacemaker to regulate heart beat 48049387_1 CDM 0450 RC 92953 HCPCS inpatient 1029 668.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 623.06 998.13 Temporary pacemaker to regulate heart beat 48049387_1 CDM 0450 RC 92953 HCPCS inpatient 1029 668.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 623.06 998.13 Temporary pacemaker to regulate heart beat 48049387_1 CDM 0450 RC 92953 HCPCS inpatient 1029 668.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 623.06 998.13 Temporary pacemaker to regulate heart beat 48049387_1 CDM 0450 RC 92953 HCPCS inpatient 1029 668.85 ANTHEM HMO ANTHEM HMO 999999999 623.06 998.13 Temporary pacemaker to regulate heart beat 48049387_1 CDM 0450 RC 92953 HCPCS inpatient 1029 668.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 695.6 67.6 999999999 623.06 998.13 percent of total billed charges Temporary pacemaker to regulate heart beat 48049387_1 CDM 0450 RC 92953 HCPCS inpatient 1029 668.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 623.06 998.13 "Use of a drug to induce depression of consciousness by physician performing a procedure (younger than 5 years), initial 15 minutes" 48049399_1 CDM 0450 RC 99151 HCPCS inpatient 267 173.55 AETNA AETNA 210.93 79 999999999 161.67 258.99 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure (younger than 5 years), initial 15 minutes" 48049399_1 CDM 0450 RC 99151 HCPCS inpatient 267 173.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 173.55 65 999999999 161.67 258.99 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure (younger than 5 years), initial 15 minutes" 48049399_1 CDM 0450 RC 99151 HCPCS inpatient 267 173.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 258.99 97 999999999 161.67 258.99 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure (younger than 5 years), initial 15 minutes" 48049399_1 CDM 0450 RC 99151 HCPCS inpatient 267 173.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.23 69 999999999 161.67 258.99 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure (younger than 5 years), initial 15 minutes" 48049399_1 CDM 0450 RC 99151 HCPCS inpatient 267 173.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 208.26 78 999999999 161.67 258.99 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure (younger than 5 years), initial 15 minutes" 48049399_1 CDM 0450 RC 99151 HCPCS inpatient 267 173.55 UMR - ALL PLANS UMR - ALL PLANS 186.9 70 999999999 161.67 258.99 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure (younger than 5 years), initial 15 minutes" 48049399_1 CDM 0450 RC 99151 HCPCS inpatient 267 173.55 SIHO - ALL PLANS SIHO - ALL PLANS 240.3 90 999999999 161.67 258.99 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure (younger than 5 years), initial 15 minutes" 48049399_1 CDM 0450 RC 99151 HCPCS inpatient 267 173.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 161.67 60.55 999999999 161.67 258.99 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure (younger than 5 years), initial 15 minutes" 48049399_1 CDM 0450 RC 99151 HCPCS inpatient 267 173.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 161.67 258.99 "Use of a drug to induce depression of consciousness by physician performing a procedure (younger than 5 years), initial 15 minutes" 48049399_1 CDM 0450 RC 99151 HCPCS inpatient 267 173.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 161.67 258.99 "Use of a drug to induce depression of consciousness by physician performing a procedure (younger than 5 years), initial 15 minutes" 48049399_1 CDM 0450 RC 99151 HCPCS inpatient 267 173.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 161.67 258.99 "Use of a drug to induce depression of consciousness by physician performing a procedure (younger than 5 years), initial 15 minutes" 48049399_1 CDM 0450 RC 99151 HCPCS inpatient 267 173.55 ANTHEM HMO ANTHEM HMO 999999999 161.67 258.99 "Use of a drug to induce depression of consciousness by physician performing a procedure (younger than 5 years), initial 15 minutes" 48049399_1 CDM 0450 RC 99151 HCPCS inpatient 267 173.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 180.49 67.6 999999999 161.67 258.99 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure (younger than 5 years), initial 15 minutes" 48049399_1 CDM 0450 RC 99151 HCPCS inpatient 267 173.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 161.67 258.99 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48073234_1 CDM 0450 RC 93005 HCPCS inpatient 316 205.4 AETNA AETNA 249.64 79 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48073234_1 CDM 0450 RC 93005 HCPCS inpatient 316 205.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 205.4 65 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48073234_1 CDM 0450 RC 93005 HCPCS inpatient 316 205.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 306.52 97 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48073234_1 CDM 0450 RC 93005 HCPCS inpatient 316 205.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 218.04 69 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48073234_1 CDM 0450 RC 93005 HCPCS inpatient 316 205.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 246.48 78 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48073234_1 CDM 0450 RC 93005 HCPCS inpatient 316 205.4 UMR - ALL PLANS UMR - ALL PLANS 221.2 70 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48073234_1 CDM 0450 RC 93005 HCPCS inpatient 316 205.4 SIHO - ALL PLANS SIHO - ALL PLANS 284.4 90 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48073234_1 CDM 0450 RC 93005 HCPCS inpatient 316 205.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 191.34 60.55 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48073234_1 CDM 0450 RC 93005 HCPCS inpatient 316 205.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48073234_1 CDM 0450 RC 93005 HCPCS inpatient 316 205.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48073234_1 CDM 0450 RC 93005 HCPCS inpatient 316 205.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48073234_1 CDM 0450 RC 93005 HCPCS inpatient 316 205.4 ANTHEM HMO ANTHEM HMO 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48073234_1 CDM 0450 RC 93005 HCPCS inpatient 316 205.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 213.62 67.6 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48073234_1 CDM 0450 RC 93005 HCPCS inpatient 316 205.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 191.34 306.52 Transfusion of blood or blood products 48073240_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 AETNA AETNA 981.18 79 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48073240_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 807.3 65 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48073240_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1204.74 97 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48073240_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 856.98 69 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48073240_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 968.76 78 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48073240_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 UMR - ALL PLANS UMR - ALL PLANS 869.4 70 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48073240_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 SIHO - ALL PLANS SIHO - ALL PLANS 1117.8 90 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48073240_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 752.03 60.55 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48073240_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 752.03 1204.74 Transfusion of blood or blood products 48073240_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 752.03 1204.74 Transfusion of blood or blood products 48073240_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 752.03 1204.74 Transfusion of blood or blood products 48073240_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM HMO ANTHEM HMO 999999999 752.03 1204.74 Transfusion of blood or blood products 48073240_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 839.59 67.6 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48073240_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 752.03 1204.74 Removal of sample of amniotic fluid surrounding fetus for diagnosis 48075163_1 CDM 0721 RC 59000 HCPCS inpatient 1167 758.55 AETNA AETNA 921.93 79 999999999 706.62 1131.99 percent of total billed charges Removal of sample of amniotic fluid surrounding fetus for diagnosis 48075163_1 CDM 0721 RC 59000 HCPCS inpatient 1167 758.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 758.55 65 999999999 706.62 1131.99 percent of total billed charges Removal of sample of amniotic fluid surrounding fetus for diagnosis 48075163_1 CDM 0721 RC 59000 HCPCS inpatient 1167 758.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1131.99 97 999999999 706.62 1131.99 percent of total billed charges Removal of sample of amniotic fluid surrounding fetus for diagnosis 48075163_1 CDM 0721 RC 59000 HCPCS inpatient 1167 758.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 805.23 69 999999999 706.62 1131.99 percent of total billed charges Removal of sample of amniotic fluid surrounding fetus for diagnosis 48075163_1 CDM 0721 RC 59000 HCPCS inpatient 1167 758.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 910.26 78 999999999 706.62 1131.99 percent of total billed charges Removal of sample of amniotic fluid surrounding fetus for diagnosis 48075163_1 CDM 0721 RC 59000 HCPCS inpatient 1167 758.55 UMR - ALL PLANS UMR - ALL PLANS 816.9 70 999999999 706.62 1131.99 percent of total billed charges Removal of sample of amniotic fluid surrounding fetus for diagnosis 48075163_1 CDM 0721 RC 59000 HCPCS inpatient 1167 758.55 SIHO - ALL PLANS SIHO - ALL PLANS 1050.3 90 999999999 706.62 1131.99 percent of total billed charges Removal of sample of amniotic fluid surrounding fetus for diagnosis 48075163_1 CDM 0721 RC 59000 HCPCS inpatient 1167 758.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 706.62 60.55 999999999 706.62 1131.99 percent of total billed charges Removal of sample of amniotic fluid surrounding fetus for diagnosis 48075163_1 CDM 0721 RC 59000 HCPCS inpatient 1167 758.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 706.62 1131.99 Removal of sample of amniotic fluid surrounding fetus for diagnosis 48075163_1 CDM 0721 RC 59000 HCPCS inpatient 1167 758.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 706.62 1131.99 Removal of sample of amniotic fluid surrounding fetus for diagnosis 48075163_1 CDM 0721 RC 59000 HCPCS inpatient 1167 758.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 706.62 1131.99 Removal of sample of amniotic fluid surrounding fetus for diagnosis 48075163_1 CDM 0721 RC 59000 HCPCS inpatient 1167 758.55 ANTHEM HMO ANTHEM HMO 999999999 706.62 1131.99 Removal of sample of amniotic fluid surrounding fetus for diagnosis 48075163_1 CDM 0721 RC 59000 HCPCS inpatient 1167 758.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 788.89 67.6 999999999 706.62 1131.99 percent of total billed charges Removal of sample of amniotic fluid surrounding fetus for diagnosis 48075163_1 CDM 0721 RC 59000 HCPCS inpatient 1167 758.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 706.62 1131.99 Injection of blood or blood clot into spinal canal 48075169_1 CDM 0510 RC 62273 HCPCS inpatient 1176 764.4 AETNA AETNA 929.04 79 999999999 712.07 1140.72 percent of total billed charges Injection of blood or blood clot into spinal canal 48075169_1 CDM 0510 RC 62273 HCPCS inpatient 1176 764.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 764.4 65 999999999 712.07 1140.72 percent of total billed charges Injection of blood or blood clot into spinal canal 48075169_1 CDM 0510 RC 62273 HCPCS inpatient 1176 764.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1140.72 97 999999999 712.07 1140.72 percent of total billed charges Injection of blood or blood clot into spinal canal 48075169_1 CDM 0510 RC 62273 HCPCS inpatient 1176 764.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 811.44 69 999999999 712.07 1140.72 percent of total billed charges Injection of blood or blood clot into spinal canal 48075169_1 CDM 0510 RC 62273 HCPCS inpatient 1176 764.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 917.28 78 999999999 712.07 1140.72 percent of total billed charges Injection of blood or blood clot into spinal canal 48075169_1 CDM 0510 RC 62273 HCPCS inpatient 1176 764.4 UMR - ALL PLANS UMR - ALL PLANS 823.2 70 999999999 712.07 1140.72 percent of total billed charges Injection of blood or blood clot into spinal canal 48075169_1 CDM 0510 RC 62273 HCPCS inpatient 1176 764.4 SIHO - ALL PLANS SIHO - ALL PLANS 1058.4 90 999999999 712.07 1140.72 percent of total billed charges Injection of blood or blood clot into spinal canal 48075169_1 CDM 0510 RC 62273 HCPCS inpatient 1176 764.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 712.07 60.55 999999999 712.07 1140.72 percent of total billed charges Injection of blood or blood clot into spinal canal 48075169_1 CDM 0510 RC 62273 HCPCS inpatient 1176 764.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 712.07 1140.72 Injection of blood or blood clot into spinal canal 48075169_1 CDM 0510 RC 62273 HCPCS inpatient 1176 764.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 712.07 1140.72 Injection of blood or blood clot into spinal canal 48075169_1 CDM 0510 RC 62273 HCPCS inpatient 1176 764.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 712.07 1140.72 Injection of blood or blood clot into spinal canal 48075169_1 CDM 0510 RC 62273 HCPCS inpatient 1176 764.4 ANTHEM HMO ANTHEM HMO 999999999 712.07 1140.72 Injection of blood or blood clot into spinal canal 48075169_1 CDM 0510 RC 62273 HCPCS inpatient 1176 764.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 794.98 67.6 999999999 712.07 1140.72 percent of total billed charges Injection of blood or blood clot into spinal canal 48075169_1 CDM 0510 RC 62273 HCPCS inpatient 1176 764.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 712.07 1140.72 Amylase (enzyme) level 48088200_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Amylase (enzyme) level 48088200_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Amylase (enzyme) level 48088200_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Amylase (enzyme) level 48088200_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Amylase (enzyme) level 48088200_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Amylase (enzyme) level 48088200_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Amylase (enzyme) level 48088200_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Amylase (enzyme) level 48088200_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Amylase (enzyme) level 48088200_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Amylase (enzyme) level 48088200_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Amylase (enzyme) level 48088200_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Amylase (enzyme) level 48088200_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Amylase (enzyme) level 48088200_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Amylase (enzyme) level 48088200_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Glucose (sugar) level on body fluid 48088205_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48088205_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48088205_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48088205_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48088205_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48088205_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48088205_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48088205_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48088205_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 Glucose (sugar) level on body fluid 48088205_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 Glucose (sugar) level on body fluid 48088205_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 Glucose (sugar) level on body fluid 48088205_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 Glucose (sugar) level on body fluid 48088205_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48088205_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 Lactate dehydrogenase (enzyme) level 48088206_1 CDM 0300 RC 83615 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges Lactate dehydrogenase (enzyme) level 48088206_1 CDM 0300 RC 83615 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges Lactate dehydrogenase (enzyme) level 48088206_1 CDM 0300 RC 83615 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges Lactate dehydrogenase (enzyme) level 48088206_1 CDM 0300 RC 83615 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges Lactate dehydrogenase (enzyme) level 48088206_1 CDM 0300 RC 83615 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges Lactate dehydrogenase (enzyme) level 48088206_1 CDM 0300 RC 83615 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges Lactate dehydrogenase (enzyme) level 48088206_1 CDM 0300 RC 83615 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges Lactate dehydrogenase (enzyme) level 48088206_1 CDM 0300 RC 83615 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges Lactate dehydrogenase (enzyme) level 48088206_1 CDM 0300 RC 83615 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 Lactate dehydrogenase (enzyme) level 48088206_1 CDM 0300 RC 83615 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 Lactate dehydrogenase (enzyme) level 48088206_1 CDM 0300 RC 83615 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 Lactate dehydrogenase (enzyme) level 48088206_1 CDM 0300 RC 83615 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 Lactate dehydrogenase (enzyme) level 48088206_1 CDM 0300 RC 83615 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges Lactate dehydrogenase (enzyme) level 48088206_1 CDM 0300 RC 83615 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 "Total protein level, body fluid" 48088207_1 CDM 0301 RC 84157 HCPCS inpatient 151 98.15 AETNA AETNA 119.29 79 999999999 91.43 146.47 percent of total billed charges "Total protein level, body fluid" 48088207_1 CDM 0301 RC 84157 HCPCS inpatient 151 98.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.15 65 999999999 91.43 146.47 percent of total billed charges "Total protein level, body fluid" 48088207_1 CDM 0301 RC 84157 HCPCS inpatient 151 98.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 146.47 97 999999999 91.43 146.47 percent of total billed charges "Total protein level, body fluid" 48088207_1 CDM 0301 RC 84157 HCPCS inpatient 151 98.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.19 69 999999999 91.43 146.47 percent of total billed charges "Total protein level, body fluid" 48088207_1 CDM 0301 RC 84157 HCPCS inpatient 151 98.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 117.78 78 999999999 91.43 146.47 percent of total billed charges "Total protein level, body fluid" 48088207_1 CDM 0301 RC 84157 HCPCS inpatient 151 98.15 UMR - ALL PLANS UMR - ALL PLANS 105.7 70 999999999 91.43 146.47 percent of total billed charges "Total protein level, body fluid" 48088207_1 CDM 0301 RC 84157 HCPCS inpatient 151 98.15 SIHO - ALL PLANS SIHO - ALL PLANS 135.9 90 999999999 91.43 146.47 percent of total billed charges "Total protein level, body fluid" 48088207_1 CDM 0301 RC 84157 HCPCS inpatient 151 98.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 91.43 60.55 999999999 91.43 146.47 percent of total billed charges "Total protein level, body fluid" 48088207_1 CDM 0301 RC 84157 HCPCS inpatient 151 98.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 91.43 146.47 "Total protein level, body fluid" 48088207_1 CDM 0301 RC 84157 HCPCS inpatient 151 98.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 91.43 146.47 "Total protein level, body fluid" 48088207_1 CDM 0301 RC 84157 HCPCS inpatient 151 98.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 91.43 146.47 "Total protein level, body fluid" 48088207_1 CDM 0301 RC 84157 HCPCS inpatient 151 98.15 ANTHEM HMO ANTHEM HMO 999999999 91.43 146.47 "Total protein level, body fluid" 48088207_1 CDM 0301 RC 84157 HCPCS inpatient 151 98.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.08 67.6 999999999 91.43 146.47 percent of total billed charges "Total protein level, body fluid" 48088207_1 CDM 0301 RC 84157 HCPCS inpatient 151 98.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 91.43 146.47 "Total protein level, body fluid" 48088210_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 AETNA AETNA 127.19 79 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48088210_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 104.65 65 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48088210_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 156.17 97 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48088210_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 111.09 69 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48088210_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 125.58 78 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48088210_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 UMR - ALL PLANS UMR - ALL PLANS 112.7 70 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48088210_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 SIHO - ALL PLANS SIHO - ALL PLANS 144.9 90 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48088210_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 97.49 60.55 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48088210_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 97.49 156.17 "Total protein level, body fluid" 48088210_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 97.49 156.17 "Total protein level, body fluid" 48088210_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 97.49 156.17 "Total protein level, body fluid" 48088210_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 ANTHEM HMO ANTHEM HMO 999999999 97.49 156.17 "Total protein level, body fluid" 48088210_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.84 67.6 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48088210_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 97.49 156.17 Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48089857_1 CDM 0301 RC 87338 HCPCS inpatient 298 193.7 AETNA AETNA 235.42 79 999999999 180.44 289.06 percent of total billed charges Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48089857_1 CDM 0301 RC 87338 HCPCS inpatient 298 193.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 193.7 65 999999999 180.44 289.06 percent of total billed charges Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48089857_1 CDM 0301 RC 87338 HCPCS inpatient 298 193.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 289.06 97 999999999 180.44 289.06 percent of total billed charges Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48089857_1 CDM 0301 RC 87338 HCPCS inpatient 298 193.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 205.62 69 999999999 180.44 289.06 percent of total billed charges Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48089857_1 CDM 0301 RC 87338 HCPCS inpatient 298 193.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 232.44 78 999999999 180.44 289.06 percent of total billed charges Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48089857_1 CDM 0301 RC 87338 HCPCS inpatient 298 193.7 UMR - ALL PLANS UMR - ALL PLANS 208.6 70 999999999 180.44 289.06 percent of total billed charges Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48089857_1 CDM 0301 RC 87338 HCPCS inpatient 298 193.7 SIHO - ALL PLANS SIHO - ALL PLANS 268.2 90 999999999 180.44 289.06 percent of total billed charges Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48089857_1 CDM 0301 RC 87338 HCPCS inpatient 298 193.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 180.44 60.55 999999999 180.44 289.06 percent of total billed charges Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48089857_1 CDM 0301 RC 87338 HCPCS inpatient 298 193.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 180.44 289.06 Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48089857_1 CDM 0301 RC 87338 HCPCS inpatient 298 193.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 180.44 289.06 Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48089857_1 CDM 0301 RC 87338 HCPCS inpatient 298 193.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 180.44 289.06 Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48089857_1 CDM 0301 RC 87338 HCPCS inpatient 298 193.7 ANTHEM HMO ANTHEM HMO 999999999 180.44 289.06 Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48089857_1 CDM 0301 RC 87338 HCPCS inpatient 298 193.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 201.45 67.6 999999999 180.44 289.06 percent of total billed charges Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48089857_1 CDM 0301 RC 87338 HCPCS inpatient 298 193.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 180.44 289.06 "Red blood cell antibody detection test, direct" 48108972_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 48108972_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 48108972_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 48108972_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 48108972_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 48108972_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 48108972_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 48108972_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 48108972_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Red blood cell antibody detection test, direct" 48108972_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Red blood cell antibody detection test, direct" 48108972_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Red blood cell antibody detection test, direct" 48108972_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Red blood cell antibody detection test, direct" 48108972_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 48108972_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 Complete ultrasound scan of abdomen 48109082_1 CDM 0320 RC 76700 HCPCS inpatient 1623 1054.95 AETNA AETNA 1282.17 79 999999999 982.73 1574.31 percent of total billed charges Complete ultrasound scan of abdomen 48109082_1 CDM 0320 RC 76700 HCPCS inpatient 1623 1054.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1054.95 65 999999999 982.73 1574.31 percent of total billed charges Complete ultrasound scan of abdomen 48109082_1 CDM 0320 RC 76700 HCPCS inpatient 1623 1054.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1574.31 97 999999999 982.73 1574.31 percent of total billed charges Complete ultrasound scan of abdomen 48109082_1 CDM 0320 RC 76700 HCPCS inpatient 1623 1054.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1119.87 69 999999999 982.73 1574.31 percent of total billed charges Complete ultrasound scan of abdomen 48109082_1 CDM 0320 RC 76700 HCPCS inpatient 1623 1054.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1265.94 78 999999999 982.73 1574.31 percent of total billed charges Complete ultrasound scan of abdomen 48109082_1 CDM 0320 RC 76700 HCPCS inpatient 1623 1054.95 UMR - ALL PLANS UMR - ALL PLANS 1136.1 70 999999999 982.73 1574.31 percent of total billed charges Complete ultrasound scan of abdomen 48109082_1 CDM 0320 RC 76700 HCPCS inpatient 1623 1054.95 SIHO - ALL PLANS SIHO - ALL PLANS 1460.7 90 999999999 982.73 1574.31 percent of total billed charges Complete ultrasound scan of abdomen 48109082_1 CDM 0320 RC 76700 HCPCS inpatient 1623 1054.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 982.73 60.55 999999999 982.73 1574.31 percent of total billed charges Complete ultrasound scan of abdomen 48109082_1 CDM 0320 RC 76700 HCPCS inpatient 1623 1054.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 982.73 1574.31 Complete ultrasound scan of abdomen 48109082_1 CDM 0320 RC 76700 HCPCS inpatient 1623 1054.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 982.73 1574.31 Complete ultrasound scan of abdomen 48109082_1 CDM 0320 RC 76700 HCPCS inpatient 1623 1054.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 982.73 1574.31 Complete ultrasound scan of abdomen 48109082_1 CDM 0320 RC 76700 HCPCS inpatient 1623 1054.95 ANTHEM HMO ANTHEM HMO 999999999 982.73 1574.31 Complete ultrasound scan of abdomen 48109082_1 CDM 0320 RC 76700 HCPCS inpatient 1623 1054.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1097.15 67.6 999999999 982.73 1574.31 percent of total billed charges Complete ultrasound scan of abdomen 48109082_1 CDM 0320 RC 76700 HCPCS inpatient 1623 1054.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 982.73 1574.31 Review by radiologist of CT guidance for needle placement 48151427_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 AETNA AETNA 1334.31 79 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48151427_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.85 65 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48151427_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1638.33 97 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48151427_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1165.41 69 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48151427_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1317.42 78 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48151427_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UMR - ALL PLANS UMR - ALL PLANS 1182.3 70 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48151427_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SIHO - ALL PLANS SIHO - ALL PLANS 1520.1 90 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48151427_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.69 60.55 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48151427_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48151427_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48151427_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48151427_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM HMO ANTHEM HMO 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48151427_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.76 67.6 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48151427_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48151429_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 AETNA AETNA 1334.31 79 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48151429_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.85 65 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48151429_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1638.33 97 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48151429_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1165.41 69 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48151429_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1317.42 78 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48151429_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UMR - ALL PLANS UMR - ALL PLANS 1182.3 70 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48151429_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SIHO - ALL PLANS SIHO - ALL PLANS 1520.1 90 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48151429_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.69 60.55 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48151429_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48151429_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48151429_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48151429_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM HMO ANTHEM HMO 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48151429_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.76 67.6 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48151429_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.69 1638.33 Ultrasonic guidance for needle placement 48151440_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 AETNA AETNA 762.35 79 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48151440_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 627.25 65 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48151440_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 936.05 97 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48151440_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 665.85 69 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48151440_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 752.7 78 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48151440_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UMR - ALL PLANS UMR - ALL PLANS 675.5 70 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48151440_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SIHO - ALL PLANS SIHO - ALL PLANS 868.5 90 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48151440_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 584.31 60.55 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48151440_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48151440_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48151440_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48151440_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM HMO ANTHEM HMO 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48151440_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 652.34 67.6 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48151440_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 584.31 936.05 Limited ultrasound scan of joint or other extremity structure except blood vessels 48151452_1 CDM 0402 RC 76882 HCPCS inpatient 866 562.9 AETNA AETNA 684.14 79 999999999 524.36 840.02 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48151452_1 CDM 0402 RC 76882 HCPCS inpatient 866 562.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 562.9 65 999999999 524.36 840.02 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48151452_1 CDM 0402 RC 76882 HCPCS inpatient 866 562.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 840.02 97 999999999 524.36 840.02 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48151452_1 CDM 0402 RC 76882 HCPCS inpatient 866 562.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 597.54 69 999999999 524.36 840.02 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48151452_1 CDM 0402 RC 76882 HCPCS inpatient 866 562.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 675.48 78 999999999 524.36 840.02 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48151452_1 CDM 0402 RC 76882 HCPCS inpatient 866 562.9 UMR - ALL PLANS UMR - ALL PLANS 606.2 70 999999999 524.36 840.02 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48151452_1 CDM 0402 RC 76882 HCPCS inpatient 866 562.9 SIHO - ALL PLANS SIHO - ALL PLANS 779.4 90 999999999 524.36 840.02 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48151452_1 CDM 0402 RC 76882 HCPCS inpatient 866 562.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 524.36 60.55 999999999 524.36 840.02 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48151452_1 CDM 0402 RC 76882 HCPCS inpatient 866 562.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 524.36 840.02 Limited ultrasound scan of joint or other extremity structure except blood vessels 48151452_1 CDM 0402 RC 76882 HCPCS inpatient 866 562.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 524.36 840.02 Limited ultrasound scan of joint or other extremity structure except blood vessels 48151452_1 CDM 0402 RC 76882 HCPCS inpatient 866 562.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 524.36 840.02 Limited ultrasound scan of joint or other extremity structure except blood vessels 48151452_1 CDM 0402 RC 76882 HCPCS inpatient 866 562.9 ANTHEM HMO ANTHEM HMO 999999999 524.36 840.02 Limited ultrasound scan of joint or other extremity structure except blood vessels 48151452_1 CDM 0402 RC 76882 HCPCS inpatient 866 562.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 585.42 67.6 999999999 524.36 840.02 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48151452_1 CDM 0402 RC 76882 HCPCS inpatient 866 562.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 524.36 840.02 Limited ultrasound scan of joint or other extremity structure except blood vessels 48151455_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 AETNA AETNA 630.42 79 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48151455_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 518.7 65 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48151455_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 774.06 97 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48151455_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 550.62 69 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48151455_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 622.44 78 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48151455_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 UMR - ALL PLANS UMR - ALL PLANS 558.6 70 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48151455_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 SIHO - ALL PLANS SIHO - ALL PLANS 718.2 90 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48151455_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 483.19 60.55 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48151455_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 483.19 774.06 Limited ultrasound scan of joint or other extremity structure except blood vessels 48151455_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 483.19 774.06 Limited ultrasound scan of joint or other extremity structure except blood vessels 48151455_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 483.19 774.06 Limited ultrasound scan of joint or other extremity structure except blood vessels 48151455_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 ANTHEM HMO ANTHEM HMO 999999999 483.19 774.06 Limited ultrasound scan of joint or other extremity structure except blood vessels 48151455_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 539.45 67.6 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48151455_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 483.19 774.06 Complete ultrasound of within the brain blood flow 48151553_1 CDM 0921 RC 93886 HCPCS inpatient 699 454.35 AETNA AETNA 552.21 79 999999999 423.24 678.03 percent of total billed charges Complete ultrasound of within the brain blood flow 48151553_1 CDM 0921 RC 93886 HCPCS inpatient 699 454.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 454.35 65 999999999 423.24 678.03 percent of total billed charges Complete ultrasound of within the brain blood flow 48151553_1 CDM 0921 RC 93886 HCPCS inpatient 699 454.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 678.03 97 999999999 423.24 678.03 percent of total billed charges Complete ultrasound of within the brain blood flow 48151553_1 CDM 0921 RC 93886 HCPCS inpatient 699 454.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 482.31 69 999999999 423.24 678.03 percent of total billed charges Complete ultrasound of within the brain blood flow 48151553_1 CDM 0921 RC 93886 HCPCS inpatient 699 454.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 545.22 78 999999999 423.24 678.03 percent of total billed charges Complete ultrasound of within the brain blood flow 48151553_1 CDM 0921 RC 93886 HCPCS inpatient 699 454.35 UMR - ALL PLANS UMR - ALL PLANS 489.3 70 999999999 423.24 678.03 percent of total billed charges Complete ultrasound of within the brain blood flow 48151553_1 CDM 0921 RC 93886 HCPCS inpatient 699 454.35 SIHO - ALL PLANS SIHO - ALL PLANS 629.1 90 999999999 423.24 678.03 percent of total billed charges Complete ultrasound of within the brain blood flow 48151553_1 CDM 0921 RC 93886 HCPCS inpatient 699 454.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 423.24 60.55 999999999 423.24 678.03 percent of total billed charges Complete ultrasound of within the brain blood flow 48151553_1 CDM 0921 RC 93886 HCPCS inpatient 699 454.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 423.24 678.03 Complete ultrasound of within the brain blood flow 48151553_1 CDM 0921 RC 93886 HCPCS inpatient 699 454.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 423.24 678.03 Complete ultrasound of within the brain blood flow 48151553_1 CDM 0921 RC 93886 HCPCS inpatient 699 454.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 423.24 678.03 Complete ultrasound of within the brain blood flow 48151553_1 CDM 0921 RC 93886 HCPCS inpatient 699 454.35 ANTHEM HMO ANTHEM HMO 999999999 423.24 678.03 Complete ultrasound of within the brain blood flow 48151553_1 CDM 0921 RC 93886 HCPCS inpatient 699 454.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 472.52 67.6 999999999 423.24 678.03 percent of total billed charges Complete ultrasound of within the brain blood flow 48151553_1 CDM 0921 RC 93886 HCPCS inpatient 699 454.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 423.24 678.03 Ultrasound of within the brain blood flow 48151556_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 AETNA AETNA 327.06 79 999999999 250.68 401.58 percent of total billed charges Ultrasound of within the brain blood flow 48151556_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 269.1 65 999999999 250.68 401.58 percent of total billed charges Ultrasound of within the brain blood flow 48151556_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 401.58 97 999999999 250.68 401.58 percent of total billed charges Ultrasound of within the brain blood flow 48151556_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 285.66 69 999999999 250.68 401.58 percent of total billed charges Ultrasound of within the brain blood flow 48151556_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 322.92 78 999999999 250.68 401.58 percent of total billed charges Ultrasound of within the brain blood flow 48151556_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 UMR - ALL PLANS UMR - ALL PLANS 289.8 70 999999999 250.68 401.58 percent of total billed charges Ultrasound of within the brain blood flow 48151556_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 SIHO - ALL PLANS SIHO - ALL PLANS 372.6 90 999999999 250.68 401.58 percent of total billed charges Ultrasound of within the brain blood flow 48151556_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 250.68 60.55 999999999 250.68 401.58 percent of total billed charges Ultrasound of within the brain blood flow 48151556_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 250.68 401.58 Ultrasound of within the brain blood flow 48151556_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 250.68 401.58 Ultrasound of within the brain blood flow 48151556_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 250.68 401.58 Ultrasound of within the brain blood flow 48151556_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 ANTHEM HMO ANTHEM HMO 999999999 250.68 401.58 Ultrasound of within the brain blood flow 48151556_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 279.86 67.6 999999999 250.68 401.58 percent of total billed charges Ultrasound of within the brain blood flow 48151556_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 250.68 401.58 "Imaging guidance for procedure, 60 minutes or less" 48151562_1 CDM 0320 RC 76000 HCPCS inpatient 1718 1116.7 AETNA AETNA 1357.22 79 999999999 1040.25 1666.46 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 48151562_1 CDM 0320 RC 76000 HCPCS inpatient 1718 1116.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1116.7 65 999999999 1040.25 1666.46 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 48151562_1 CDM 0320 RC 76000 HCPCS inpatient 1718 1116.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1666.46 97 999999999 1040.25 1666.46 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 48151562_1 CDM 0320 RC 76000 HCPCS inpatient 1718 1116.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1185.42 69 999999999 1040.25 1666.46 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 48151562_1 CDM 0320 RC 76000 HCPCS inpatient 1718 1116.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1340.04 78 999999999 1040.25 1666.46 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 48151562_1 CDM 0320 RC 76000 HCPCS inpatient 1718 1116.7 UMR - ALL PLANS UMR - ALL PLANS 1202.6 70 999999999 1040.25 1666.46 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 48151562_1 CDM 0320 RC 76000 HCPCS inpatient 1718 1116.7 SIHO - ALL PLANS SIHO - ALL PLANS 1546.2 90 999999999 1040.25 1666.46 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 48151562_1 CDM 0320 RC 76000 HCPCS inpatient 1718 1116.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1040.25 60.55 999999999 1040.25 1666.46 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 48151562_1 CDM 0320 RC 76000 HCPCS inpatient 1718 1116.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1040.25 1666.46 "Imaging guidance for procedure, 60 minutes or less" 48151562_1 CDM 0320 RC 76000 HCPCS inpatient 1718 1116.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1040.25 1666.46 "Imaging guidance for procedure, 60 minutes or less" 48151562_1 CDM 0320 RC 76000 HCPCS inpatient 1718 1116.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1040.25 1666.46 "Imaging guidance for procedure, 60 minutes or less" 48151562_1 CDM 0320 RC 76000 HCPCS inpatient 1718 1116.7 ANTHEM HMO ANTHEM HMO 999999999 1040.25 1666.46 "Imaging guidance for procedure, 60 minutes or less" 48151562_1 CDM 0320 RC 76000 HCPCS inpatient 1718 1116.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1161.37 67.6 999999999 1040.25 1666.46 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 48151562_1 CDM 0320 RC 76000 HCPCS inpatient 1718 1116.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 1040.25 1666.46 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48162711_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48162711_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48162711_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48162711_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48162711_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48162711_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48162711_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48162711_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48162711_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48162711_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48162711_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48162711_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48162711_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48162711_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 "Creatine kinase (cardiac enzyme) level, total" 48165070_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 48165070_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 48165070_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 48165070_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 48165070_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 48165070_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 48165070_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 48165070_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 48165070_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 "Creatine kinase (cardiac enzyme) level, total" 48165070_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 "Creatine kinase (cardiac enzyme) level, total" 48165070_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 "Creatine kinase (cardiac enzyme) level, total" 48165070_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 "Creatine kinase (cardiac enzyme) level, total" 48165070_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 48165070_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 Blood osmolality (concentration) measurement 48165072_1 CDM 0301 RC 83930 HCPCS inpatient 166 107.9 AETNA AETNA 131.14 79 999999999 100.51 161.02 percent of total billed charges Blood osmolality (concentration) measurement 48165072_1 CDM 0301 RC 83930 HCPCS inpatient 166 107.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.9 65 999999999 100.51 161.02 percent of total billed charges Blood osmolality (concentration) measurement 48165072_1 CDM 0301 RC 83930 HCPCS inpatient 166 107.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.02 97 999999999 100.51 161.02 percent of total billed charges Blood osmolality (concentration) measurement 48165072_1 CDM 0301 RC 83930 HCPCS inpatient 166 107.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 114.54 69 999999999 100.51 161.02 percent of total billed charges Blood osmolality (concentration) measurement 48165072_1 CDM 0301 RC 83930 HCPCS inpatient 166 107.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 129.48 78 999999999 100.51 161.02 percent of total billed charges Blood osmolality (concentration) measurement 48165072_1 CDM 0301 RC 83930 HCPCS inpatient 166 107.9 UMR - ALL PLANS UMR - ALL PLANS 116.2 70 999999999 100.51 161.02 percent of total billed charges Blood osmolality (concentration) measurement 48165072_1 CDM 0301 RC 83930 HCPCS inpatient 166 107.9 SIHO - ALL PLANS SIHO - ALL PLANS 149.4 90 999999999 100.51 161.02 percent of total billed charges Blood osmolality (concentration) measurement 48165072_1 CDM 0301 RC 83930 HCPCS inpatient 166 107.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 100.51 60.55 999999999 100.51 161.02 percent of total billed charges Blood osmolality (concentration) measurement 48165072_1 CDM 0301 RC 83930 HCPCS inpatient 166 107.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 100.51 161.02 Blood osmolality (concentration) measurement 48165072_1 CDM 0301 RC 83930 HCPCS inpatient 166 107.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 100.51 161.02 Blood osmolality (concentration) measurement 48165072_1 CDM 0301 RC 83930 HCPCS inpatient 166 107.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 100.51 161.02 Blood osmolality (concentration) measurement 48165072_1 CDM 0301 RC 83930 HCPCS inpatient 166 107.9 ANTHEM HMO ANTHEM HMO 999999999 100.51 161.02 Blood osmolality (concentration) measurement 48165072_1 CDM 0301 RC 83930 HCPCS inpatient 166 107.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.22 67.6 999999999 100.51 161.02 percent of total billed charges Blood osmolality (concentration) measurement 48165072_1 CDM 0301 RC 83930 HCPCS inpatient 166 107.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 100.51 161.02 Rheumatoid factor level 48165073_1 CDM 0302 RC 86431 HCPCS inpatient 89 57.85 AETNA AETNA 70.31 79 999999999 53.89 86.33 percent of total billed charges Rheumatoid factor level 48165073_1 CDM 0302 RC 86431 HCPCS inpatient 89 57.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.85 65 999999999 53.89 86.33 percent of total billed charges Rheumatoid factor level 48165073_1 CDM 0302 RC 86431 HCPCS inpatient 89 57.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 86.33 97 999999999 53.89 86.33 percent of total billed charges Rheumatoid factor level 48165073_1 CDM 0302 RC 86431 HCPCS inpatient 89 57.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 61.41 69 999999999 53.89 86.33 percent of total billed charges Rheumatoid factor level 48165073_1 CDM 0302 RC 86431 HCPCS inpatient 89 57.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 69.42 78 999999999 53.89 86.33 percent of total billed charges Rheumatoid factor level 48165073_1 CDM 0302 RC 86431 HCPCS inpatient 89 57.85 UMR - ALL PLANS UMR - ALL PLANS 62.3 70 999999999 53.89 86.33 percent of total billed charges Rheumatoid factor level 48165073_1 CDM 0302 RC 86431 HCPCS inpatient 89 57.85 SIHO - ALL PLANS SIHO - ALL PLANS 80.1 90 999999999 53.89 86.33 percent of total billed charges Rheumatoid factor level 48165073_1 CDM 0302 RC 86431 HCPCS inpatient 89 57.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.89 60.55 999999999 53.89 86.33 percent of total billed charges Rheumatoid factor level 48165073_1 CDM 0302 RC 86431 HCPCS inpatient 89 57.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.89 86.33 Rheumatoid factor level 48165073_1 CDM 0302 RC 86431 HCPCS inpatient 89 57.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.89 86.33 Rheumatoid factor level 48165073_1 CDM 0302 RC 86431 HCPCS inpatient 89 57.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.89 86.33 Rheumatoid factor level 48165073_1 CDM 0302 RC 86431 HCPCS inpatient 89 57.85 ANTHEM HMO ANTHEM HMO 999999999 53.89 86.33 Rheumatoid factor level 48165073_1 CDM 0302 RC 86431 HCPCS inpatient 89 57.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.16 67.6 999999999 53.89 86.33 percent of total billed charges Rheumatoid factor level 48165073_1 CDM 0302 RC 86431 HCPCS inpatient 89 57.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.89 86.33 Low dose CT scan of chest for lung cancer screening 48220773_1 CDM 0352 RC 71271 HCPCS inpatient 378 245.7 AETNA AETNA 298.62 79 999999999 228.88 366.66 percent of total billed charges Low dose CT scan of chest for lung cancer screening 48220773_1 CDM 0352 RC 71271 HCPCS inpatient 378 245.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 245.7 65 999999999 228.88 366.66 percent of total billed charges Low dose CT scan of chest for lung cancer screening 48220773_1 CDM 0352 RC 71271 HCPCS inpatient 378 245.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 366.66 97 999999999 228.88 366.66 percent of total billed charges Low dose CT scan of chest for lung cancer screening 48220773_1 CDM 0352 RC 71271 HCPCS inpatient 378 245.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 260.82 69 999999999 228.88 366.66 percent of total billed charges Low dose CT scan of chest for lung cancer screening 48220773_1 CDM 0352 RC 71271 HCPCS inpatient 378 245.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 294.84 78 999999999 228.88 366.66 percent of total billed charges Low dose CT scan of chest for lung cancer screening 48220773_1 CDM 0352 RC 71271 HCPCS inpatient 378 245.7 UMR - ALL PLANS UMR - ALL PLANS 264.6 70 999999999 228.88 366.66 percent of total billed charges Low dose CT scan of chest for lung cancer screening 48220773_1 CDM 0352 RC 71271 HCPCS inpatient 378 245.7 SIHO - ALL PLANS SIHO - ALL PLANS 340.2 90 999999999 228.88 366.66 percent of total billed charges Low dose CT scan of chest for lung cancer screening 48220773_1 CDM 0352 RC 71271 HCPCS inpatient 378 245.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 228.88 60.55 999999999 228.88 366.66 percent of total billed charges Low dose CT scan of chest for lung cancer screening 48220773_1 CDM 0352 RC 71271 HCPCS inpatient 378 245.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 228.88 366.66 Low dose CT scan of chest for lung cancer screening 48220773_1 CDM 0352 RC 71271 HCPCS inpatient 378 245.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 228.88 366.66 Low dose CT scan of chest for lung cancer screening 48220773_1 CDM 0352 RC 71271 HCPCS inpatient 378 245.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 228.88 366.66 Low dose CT scan of chest for lung cancer screening 48220773_1 CDM 0352 RC 71271 HCPCS inpatient 378 245.7 ANTHEM HMO ANTHEM HMO 999999999 228.88 366.66 Low dose CT scan of chest for lung cancer screening 48220773_1 CDM 0352 RC 71271 HCPCS inpatient 378 245.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 255.53 67.6 999999999 228.88 366.66 percent of total billed charges Low dose CT scan of chest for lung cancer screening 48220773_1 CDM 0352 RC 71271 HCPCS inpatient 378 245.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 228.88 366.66 Amylase (enzyme) level 48242330_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 48242330_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 48242330_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 48242330_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 48242330_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 48242330_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 48242330_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 48242330_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 48242330_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 Amylase (enzyme) level 48242330_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 Amylase (enzyme) level 48242330_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 Amylase (enzyme) level 48242330_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 Amylase (enzyme) level 48242330_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 48242330_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 Glucose (sugar) level on body fluid 48242335_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48242335_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48242335_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48242335_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48242335_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48242335_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48242335_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48242335_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48242335_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 Glucose (sugar) level on body fluid 48242335_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 Glucose (sugar) level on body fluid 48242335_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 Glucose (sugar) level on body fluid 48242335_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 Glucose (sugar) level on body fluid 48242335_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48242335_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 "Total protein level, body fluid" 48242336_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 AETNA AETNA 127.19 79 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48242336_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 104.65 65 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48242336_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 156.17 97 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48242336_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 111.09 69 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48242336_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 125.58 78 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48242336_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 UMR - ALL PLANS UMR - ALL PLANS 112.7 70 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48242336_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 SIHO - ALL PLANS SIHO - ALL PLANS 144.9 90 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48242336_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 97.49 60.55 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48242336_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 97.49 156.17 "Total protein level, body fluid" 48242336_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 97.49 156.17 "Total protein level, body fluid" 48242336_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 97.49 156.17 "Total protein level, body fluid" 48242336_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 ANTHEM HMO ANTHEM HMO 999999999 97.49 156.17 "Total protein level, body fluid" 48242336_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.84 67.6 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48242336_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 97.49 156.17 Screening mammography 48251378_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 AETNA AETNA 383.94 79 999999999 294.27 471.42 percent of total billed charges Screening mammography 48251378_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 315.9 65 999999999 294.27 471.42 percent of total billed charges Screening mammography 48251378_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 471.42 97 999999999 294.27 471.42 percent of total billed charges Screening mammography 48251378_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 335.34 69 999999999 294.27 471.42 percent of total billed charges Screening mammography 48251378_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 379.08 78 999999999 294.27 471.42 percent of total billed charges Screening mammography 48251378_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 UMR - ALL PLANS UMR - ALL PLANS 340.2 70 999999999 294.27 471.42 percent of total billed charges Screening mammography 48251378_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 SIHO - ALL PLANS SIHO - ALL PLANS 437.4 90 999999999 294.27 471.42 percent of total billed charges Screening mammography 48251378_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 294.27 60.55 999999999 294.27 471.42 percent of total billed charges Screening mammography 48251378_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 294.27 471.42 Screening mammography 48251378_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 294.27 471.42 Screening mammography 48251378_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 294.27 471.42 Screening mammography 48251378_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 ANTHEM HMO ANTHEM HMO 999999999 294.27 471.42 Screening mammography 48251378_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 328.54 67.6 999999999 294.27 471.42 percent of total billed charges Screening mammography 48251378_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 294.27 471.42 Screening mammography 48251381_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 AETNA AETNA 383.94 79 999999999 294.27 471.42 percent of total billed charges Screening mammography 48251381_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 315.9 65 999999999 294.27 471.42 percent of total billed charges Screening mammography 48251381_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 471.42 97 999999999 294.27 471.42 percent of total billed charges Screening mammography 48251381_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 335.34 69 999999999 294.27 471.42 percent of total billed charges Screening mammography 48251381_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 379.08 78 999999999 294.27 471.42 percent of total billed charges Screening mammography 48251381_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 UMR - ALL PLANS UMR - ALL PLANS 340.2 70 999999999 294.27 471.42 percent of total billed charges Screening mammography 48251381_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 SIHO - ALL PLANS SIHO - ALL PLANS 437.4 90 999999999 294.27 471.42 percent of total billed charges Screening mammography 48251381_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 294.27 60.55 999999999 294.27 471.42 percent of total billed charges Screening mammography 48251381_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 294.27 471.42 Screening mammography 48251381_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 294.27 471.42 Screening mammography 48251381_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 294.27 471.42 Screening mammography 48251381_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 ANTHEM HMO ANTHEM HMO 999999999 294.27 471.42 Screening mammography 48251381_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 328.54 67.6 999999999 294.27 471.42 percent of total billed charges Screening mammography 48251381_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 294.27 471.42 "CRYOPRECIPITATE, EACH UNIT" 48252811_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 AETNA AETNA 985.13 79 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 48252811_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 810.55 65 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 48252811_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1209.59 97 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 48252811_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 860.43 69 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 48252811_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 972.66 78 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 48252811_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 UMR - ALL PLANS UMR - ALL PLANS 872.9 70 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 48252811_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 SIHO - ALL PLANS SIHO - ALL PLANS 1122.3 90 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 48252811_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 755.06 60.55 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 48252811_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 755.06 1209.59 "CRYOPRECIPITATE, EACH UNIT" 48252811_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 755.06 1209.59 "CRYOPRECIPITATE, EACH UNIT" 48252811_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 755.06 1209.59 "CRYOPRECIPITATE, EACH UNIT" 48252811_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 ANTHEM HMO ANTHEM HMO 999999999 755.06 1209.59 "CRYOPRECIPITATE, EACH UNIT" 48252811_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 842.97 67.6 999999999 755.06 1209.59 percent of total billed charges "CRYOPRECIPITATE, EACH UNIT" 48252811_1 CDM 0390 RC P9012 HCPCS inpatient 1247 810.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 755.06 1209.59 Fetal monitoring during labor by consulting physician 48253374_1 CDM 0761 RC 59050 HCPCS inpatient 176 114.4 AETNA AETNA 139.04 79 999999999 106.57 170.72 percent of total billed charges Fetal monitoring during labor by consulting physician 48253374_1 CDM 0761 RC 59050 HCPCS inpatient 176 114.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 114.4 65 999999999 106.57 170.72 percent of total billed charges Fetal monitoring during labor by consulting physician 48253374_1 CDM 0761 RC 59050 HCPCS inpatient 176 114.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 170.72 97 999999999 106.57 170.72 percent of total billed charges Fetal monitoring during labor by consulting physician 48253374_1 CDM 0761 RC 59050 HCPCS inpatient 176 114.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 121.44 69 999999999 106.57 170.72 percent of total billed charges Fetal monitoring during labor by consulting physician 48253374_1 CDM 0761 RC 59050 HCPCS inpatient 176 114.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 137.28 78 999999999 106.57 170.72 percent of total billed charges Fetal monitoring during labor by consulting physician 48253374_1 CDM 0761 RC 59050 HCPCS inpatient 176 114.4 UMR - ALL PLANS UMR - ALL PLANS 123.2 70 999999999 106.57 170.72 percent of total billed charges Fetal monitoring during labor by consulting physician 48253374_1 CDM 0761 RC 59050 HCPCS inpatient 176 114.4 SIHO - ALL PLANS SIHO - ALL PLANS 158.4 90 999999999 106.57 170.72 percent of total billed charges Fetal monitoring during labor by consulting physician 48253374_1 CDM 0761 RC 59050 HCPCS inpatient 176 114.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 106.57 60.55 999999999 106.57 170.72 percent of total billed charges Fetal monitoring during labor by consulting physician 48253374_1 CDM 0761 RC 59050 HCPCS inpatient 176 114.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 106.57 170.72 Fetal monitoring during labor by consulting physician 48253374_1 CDM 0761 RC 59050 HCPCS inpatient 176 114.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 106.57 170.72 Fetal monitoring during labor by consulting physician 48253374_1 CDM 0761 RC 59050 HCPCS inpatient 176 114.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 106.57 170.72 Fetal monitoring during labor by consulting physician 48253374_1 CDM 0761 RC 59050 HCPCS inpatient 176 114.4 ANTHEM HMO ANTHEM HMO 999999999 106.57 170.72 Fetal monitoring during labor by consulting physician 48253374_1 CDM 0761 RC 59050 HCPCS inpatient 176 114.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.98 67.6 999999999 106.57 170.72 percent of total billed charges Fetal monitoring during labor by consulting physician 48253374_1 CDM 0761 RC 59050 HCPCS inpatient 176 114.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 106.57 170.72 BILIRUBIN LAMP CHARGE 48253401_1 CDM 0920 RC inpatient 230 149.5 AETNA AETNA 181.7 79 999999999 139.27 223.1 percent of total billed charges BILIRUBIN LAMP CHARGE 48253401_1 CDM 0920 RC inpatient 230 149.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 149.5 65 999999999 139.27 223.1 percent of total billed charges BILIRUBIN LAMP CHARGE 48253401_1 CDM 0920 RC inpatient 230 149.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 223.1 97 999999999 139.27 223.1 percent of total billed charges BILIRUBIN LAMP CHARGE 48253401_1 CDM 0920 RC inpatient 230 149.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 158.7 69 999999999 139.27 223.1 percent of total billed charges BILIRUBIN LAMP CHARGE 48253401_1 CDM 0920 RC inpatient 230 149.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 179.4 78 999999999 139.27 223.1 percent of total billed charges BILIRUBIN LAMP CHARGE 48253401_1 CDM 0920 RC inpatient 230 149.5 UMR - ALL PLANS UMR - ALL PLANS 161 70 999999999 139.27 223.1 percent of total billed charges BILIRUBIN LAMP CHARGE 48253401_1 CDM 0920 RC inpatient 230 149.5 SIHO - ALL PLANS SIHO - ALL PLANS 207 90 999999999 139.27 223.1 percent of total billed charges BILIRUBIN LAMP CHARGE 48253401_1 CDM 0920 RC inpatient 230 149.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 139.27 60.55 999999999 139.27 223.1 percent of total billed charges BILIRUBIN LAMP CHARGE 48253401_1 CDM 0920 RC inpatient 230 149.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 139.27 223.1 BILIRUBIN LAMP CHARGE 48253401_1 CDM 0920 RC inpatient 230 149.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 139.27 223.1 BILIRUBIN LAMP CHARGE 48253401_1 CDM 0920 RC inpatient 230 149.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 139.27 223.1 BILIRUBIN LAMP CHARGE 48253401_1 CDM 0920 RC inpatient 230 149.5 ANTHEM HMO ANTHEM HMO 999999999 139.27 223.1 BILIRUBIN LAMP CHARGE 48253401_1 CDM 0920 RC inpatient 230 149.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 155.48 67.6 999999999 139.27 223.1 percent of total billed charges BILIRUBIN LAMP CHARGE 48253401_1 CDM 0920 RC inpatient 230 149.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 139.27 223.1 BF Spec Grav 48253557_1 CDM 0301 RC inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges BF Spec Grav 48253557_1 CDM 0301 RC inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges BF Spec Grav 48253557_1 CDM 0301 RC inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges BF Spec Grav 48253557_1 CDM 0301 RC inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges BF Spec Grav 48253557_1 CDM 0301 RC inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges BF Spec Grav 48253557_1 CDM 0301 RC inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges BF Spec Grav 48253557_1 CDM 0301 RC inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges BF Spec Grav 48253557_1 CDM 0301 RC inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges BF Spec Grav 48253557_1 CDM 0301 RC inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 BF Spec Grav 48253557_1 CDM 0301 RC inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 BF Spec Grav 48253557_1 CDM 0301 RC inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 BF Spec Grav 48253557_1 CDM 0301 RC inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 BF Spec Grav 48253557_1 CDM 0301 RC inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges BF Spec Grav 48253557_1 CDM 0301 RC inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 68084-0372-01 - acetaminophen-codeine 300 mg-30 mg Tab [JOHN] 48260182_1 CDM 0250 RC 68084-0372-01 NDC inpatient 1 UN 1.6 1.04 AETNA AETNA 1.26 79 999999999 0.97 1.55 percent of total billed charges 68084-0372-01 - acetaminophen-codeine 300 mg-30 mg Tab [JOHN] 48260182_1 CDM 0250 RC 68084-0372-01 NDC inpatient 1 UN 1.6 1.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.04 65 999999999 0.97 1.55 percent of total billed charges 68084-0372-01 - acetaminophen-codeine 300 mg-30 mg Tab [JOHN] 48260182_1 CDM 0250 RC 68084-0372-01 NDC inpatient 1 UN 1.6 1.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.55 97 999999999 0.97 1.55 percent of total billed charges 68084-0372-01 - acetaminophen-codeine 300 mg-30 mg Tab [JOHN] 48260182_1 CDM 0250 RC 68084-0372-01 NDC inpatient 1 UN 1.6 1.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.1 69 999999999 0.97 1.55 percent of total billed charges 68084-0372-01 - acetaminophen-codeine 300 mg-30 mg Tab [JOHN] 48260182_1 CDM 0250 RC 68084-0372-01 NDC inpatient 1 UN 1.6 1.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.25 78 999999999 0.97 1.55 percent of total billed charges 68084-0372-01 - acetaminophen-codeine 300 mg-30 mg Tab [JOHN] 48260182_1 CDM 0250 RC 68084-0372-01 NDC inpatient 1 UN 1.6 1.04 UMR - ALL PLANS UMR - ALL PLANS 1.12 70 999999999 0.97 1.55 percent of total billed charges 68084-0372-01 - acetaminophen-codeine 300 mg-30 mg Tab [JOHN] 48260182_1 CDM 0250 RC 68084-0372-01 NDC inpatient 1 UN 1.6 1.04 SIHO - ALL PLANS SIHO - ALL PLANS 1.44 90 999999999 0.97 1.55 percent of total billed charges 68084-0372-01 - acetaminophen-codeine 300 mg-30 mg Tab [JOHN] 48260182_1 CDM 0250 RC 68084-0372-01 NDC inpatient 1 UN 1.6 1.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.97 60.55 999999999 0.97 1.55 percent of total billed charges 68084-0372-01 - acetaminophen-codeine 300 mg-30 mg Tab [JOHN] 48260182_1 CDM 0250 RC 68084-0372-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.97 1.55 68084-0372-01 - acetaminophen-codeine 300 mg-30 mg Tab [JOHN] 48260182_1 CDM 0250 RC 68084-0372-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.97 1.55 68084-0372-01 - acetaminophen-codeine 300 mg-30 mg Tab [JOHN] 48260182_1 CDM 0250 RC 68084-0372-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.97 1.55 68084-0372-01 - acetaminophen-codeine 300 mg-30 mg Tab [JOHN] 48260182_1 CDM 0250 RC 68084-0372-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM HMO ANTHEM HMO 999999999 0.97 1.55 68084-0372-01 - acetaminophen-codeine 300 mg-30 mg Tab [JOHN] 48260182_1 CDM 0250 RC 68084-0372-01 NDC inpatient 1 UN 1.6 1.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.08 67.6 999999999 0.97 1.55 percent of total billed charges 68084-0372-01 - acetaminophen-codeine 300 mg-30 mg Tab [JOHN] 48260182_1 CDM 0250 RC 68084-0372-01 NDC inpatient 1 UN 1.6 1.04 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.97 1.55 HYDROCODONE-ACETAMN 7.5-325/15 48260184_1 CDM 0250 RC 66689-0023-50 NDC inpatient 1 UN 17.1 11.12 AETNA AETNA 13.51 79 999999999 10.35 16.59 percent of total billed charges HYDROCODONE-ACETAMN 7.5-325/15 48260184_1 CDM 0250 RC 66689-0023-50 NDC inpatient 1 UN 17.1 11.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.12 65 999999999 10.35 16.59 percent of total billed charges HYDROCODONE-ACETAMN 7.5-325/15 48260184_1 CDM 0250 RC 66689-0023-50 NDC inpatient 1 UN 17.1 11.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16.59 97 999999999 10.35 16.59 percent of total billed charges HYDROCODONE-ACETAMN 7.5-325/15 48260184_1 CDM 0250 RC 66689-0023-50 NDC inpatient 1 UN 17.1 11.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.8 69 999999999 10.35 16.59 percent of total billed charges HYDROCODONE-ACETAMN 7.5-325/15 48260184_1 CDM 0250 RC 66689-0023-50 NDC inpatient 1 UN 17.1 11.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.34 78 999999999 10.35 16.59 percent of total billed charges HYDROCODONE-ACETAMN 7.5-325/15 48260184_1 CDM 0250 RC 66689-0023-50 NDC inpatient 1 UN 17.1 11.12 UMR - ALL PLANS UMR - ALL PLANS 11.97 70 999999999 10.35 16.59 percent of total billed charges HYDROCODONE-ACETAMN 7.5-325/15 48260184_1 CDM 0250 RC 66689-0023-50 NDC inpatient 1 UN 17.1 11.12 SIHO - ALL PLANS SIHO - ALL PLANS 15.39 90 999999999 10.35 16.59 percent of total billed charges HYDROCODONE-ACETAMN 7.5-325/15 48260184_1 CDM 0250 RC 66689-0023-50 NDC inpatient 1 UN 17.1 11.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.35 60.55 999999999 10.35 16.59 percent of total billed charges HYDROCODONE-ACETAMN 7.5-325/15 48260184_1 CDM 0250 RC 66689-0023-50 NDC inpatient 1 UN 17.1 11.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.35 16.59 HYDROCODONE-ACETAMN 7.5-325/15 48260184_1 CDM 0250 RC 66689-0023-50 NDC inpatient 1 UN 17.1 11.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.35 16.59 HYDROCODONE-ACETAMN 7.5-325/15 48260184_1 CDM 0250 RC 66689-0023-50 NDC inpatient 1 UN 17.1 11.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.35 16.59 HYDROCODONE-ACETAMN 7.5-325/15 48260184_1 CDM 0250 RC 66689-0023-50 NDC inpatient 1 UN 17.1 11.12 ANTHEM HMO ANTHEM HMO 999999999 10.35 16.59 HYDROCODONE-ACETAMN 7.5-325/15 48260184_1 CDM 0250 RC 66689-0023-50 NDC inpatient 1 UN 17.1 11.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.56 67.6 999999999 10.35 16.59 percent of total billed charges HYDROCODONE-ACETAMN 7.5-325/15 48260184_1 CDM 0250 RC 66689-0023-50 NDC inpatient 1 UN 17.1 11.12 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.35 16.59 ACETIC ACID 0.25% IRRIG SOLN 48260190_1 CDM 0250 RC 00338-0656-04 NDC inpatient 1 UN 24.37 15.84 AETNA AETNA 19.25 79 999999999 14.76 23.64 percent of total billed charges ACETIC ACID 0.25% IRRIG SOLN 48260190_1 CDM 0250 RC 00338-0656-04 NDC inpatient 1 UN 24.37 15.84 SELF PAY DISCOUNT SELF PAY DISCOUNT 15.84 65 999999999 14.76 23.64 percent of total billed charges ACETIC ACID 0.25% IRRIG SOLN 48260190_1 CDM 0250 RC 00338-0656-04 NDC inpatient 1 UN 24.37 15.84 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23.64 97 999999999 14.76 23.64 percent of total billed charges ACETIC ACID 0.25% IRRIG SOLN 48260190_1 CDM 0250 RC 00338-0656-04 NDC inpatient 1 UN 24.37 15.84 ENCORE - ALL PLANS ENCORE - ALL PLANS 16.82 69 999999999 14.76 23.64 percent of total billed charges ACETIC ACID 0.25% IRRIG SOLN 48260190_1 CDM 0250 RC 00338-0656-04 NDC inpatient 1 UN 24.37 15.84 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.01 78 999999999 14.76 23.64 percent of total billed charges ACETIC ACID 0.25% IRRIG SOLN 48260190_1 CDM 0250 RC 00338-0656-04 NDC inpatient 1 UN 24.37 15.84 UMR - ALL PLANS UMR - ALL PLANS 17.06 70 999999999 14.76 23.64 percent of total billed charges ACETIC ACID 0.25% IRRIG SOLN 48260190_1 CDM 0250 RC 00338-0656-04 NDC inpatient 1 UN 24.37 15.84 SIHO - ALL PLANS SIHO - ALL PLANS 21.93 90 999999999 14.76 23.64 percent of total billed charges ACETIC ACID 0.25% IRRIG SOLN 48260190_1 CDM 0250 RC 00338-0656-04 NDC inpatient 1 UN 24.37 15.84 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.76 60.55 999999999 14.76 23.64 percent of total billed charges ACETIC ACID 0.25% IRRIG SOLN 48260190_1 CDM 0250 RC 00338-0656-04 NDC inpatient 1 UN 24.37 15.84 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.76 23.64 ACETIC ACID 0.25% IRRIG SOLN 48260190_1 CDM 0250 RC 00338-0656-04 NDC inpatient 1 UN 24.37 15.84 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.76 23.64 ACETIC ACID 0.25% IRRIG SOLN 48260190_1 CDM 0250 RC 00338-0656-04 NDC inpatient 1 UN 24.37 15.84 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.76 23.64 ACETIC ACID 0.25% IRRIG SOLN 48260190_1 CDM 0250 RC 00338-0656-04 NDC inpatient 1 UN 24.37 15.84 ANTHEM HMO ANTHEM HMO 999999999 14.76 23.64 ACETIC ACID 0.25% IRRIG SOLN 48260190_1 CDM 0250 RC 00338-0656-04 NDC inpatient 1 UN 24.37 15.84 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.47 67.6 999999999 14.76 23.64 percent of total billed charges ACETIC ACID 0.25% IRRIG SOLN 48260190_1 CDM 0250 RC 00338-0656-04 NDC inpatient 1 UN 24.37 15.84 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.76 23.64 ACETYLCYSTEINE 20% VIAL 48260193_1 CDM 0250 RC 00409-3308-03 NDC inpatient 1 UN 43.29 28.14 AETNA AETNA 34.2 79 999999999 26.21 41.99 percent of total billed charges ACETYLCYSTEINE 20% VIAL 48260193_1 CDM 0250 RC 00409-3308-03 NDC inpatient 1 UN 43.29 28.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 28.14 65 999999999 26.21 41.99 percent of total billed charges ACETYLCYSTEINE 20% VIAL 48260193_1 CDM 0250 RC 00409-3308-03 NDC inpatient 1 UN 43.29 28.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 41.99 97 999999999 26.21 41.99 percent of total billed charges ACETYLCYSTEINE 20% VIAL 48260193_1 CDM 0250 RC 00409-3308-03 NDC inpatient 1 UN 43.29 28.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 29.87 69 999999999 26.21 41.99 percent of total billed charges ACETYLCYSTEINE 20% VIAL 48260193_1 CDM 0250 RC 00409-3308-03 NDC inpatient 1 UN 43.29 28.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 33.77 78 999999999 26.21 41.99 percent of total billed charges ACETYLCYSTEINE 20% VIAL 48260193_1 CDM 0250 RC 00409-3308-03 NDC inpatient 1 UN 43.29 28.14 UMR - ALL PLANS UMR - ALL PLANS 30.3 70 999999999 26.21 41.99 percent of total billed charges ACETYLCYSTEINE 20% VIAL 48260193_1 CDM 0250 RC 00409-3308-03 NDC inpatient 1 UN 43.29 28.14 SIHO - ALL PLANS SIHO - ALL PLANS 38.96 90 999999999 26.21 41.99 percent of total billed charges ACETYLCYSTEINE 20% VIAL 48260193_1 CDM 0250 RC 00409-3308-03 NDC inpatient 1 UN 43.29 28.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26.21 60.55 999999999 26.21 41.99 percent of total billed charges ACETYLCYSTEINE 20% VIAL 48260193_1 CDM 0250 RC 00409-3308-03 NDC inpatient 1 UN 43.29 28.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26.21 41.99 ACETYLCYSTEINE 20% VIAL 48260193_1 CDM 0250 RC 00409-3308-03 NDC inpatient 1 UN 43.29 28.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26.21 41.99 ACETYLCYSTEINE 20% VIAL 48260193_1 CDM 0250 RC 00409-3308-03 NDC inpatient 1 UN 43.29 28.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26.21 41.99 ACETYLCYSTEINE 20% VIAL 48260193_1 CDM 0250 RC 00409-3308-03 NDC inpatient 1 UN 43.29 28.14 ANTHEM HMO ANTHEM HMO 999999999 26.21 41.99 ACETYLCYSTEINE 20% VIAL 48260193_1 CDM 0250 RC 00409-3308-03 NDC inpatient 1 UN 43.29 28.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 29.26 67.6 999999999 26.21 41.99 percent of total billed charges ACETYLCYSTEINE 20% VIAL 48260193_1 CDM 0250 RC 00409-3308-03 NDC inpatient 1 UN 43.29 28.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 26.21 41.99 "ACYCLOVIR 1,000 MG/20 ML VIAL" 48260195_1 CDM 0250 RC 63323-0325-20 NDC inpatient 1 UN 44.32 28.81 AETNA AETNA 35.01 79 999999999 26.84 42.99 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 48260195_1 CDM 0250 RC 63323-0325-20 NDC inpatient 1 UN 44.32 28.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 28.81 65 999999999 26.84 42.99 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 48260195_1 CDM 0250 RC 63323-0325-20 NDC inpatient 1 UN 44.32 28.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 42.99 97 999999999 26.84 42.99 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 48260195_1 CDM 0250 RC 63323-0325-20 NDC inpatient 1 UN 44.32 28.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 30.58 69 999999999 26.84 42.99 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 48260195_1 CDM 0250 RC 63323-0325-20 NDC inpatient 1 UN 44.32 28.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 34.57 78 999999999 26.84 42.99 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 48260195_1 CDM 0250 RC 63323-0325-20 NDC inpatient 1 UN 44.32 28.81 UMR - ALL PLANS UMR - ALL PLANS 31.02 70 999999999 26.84 42.99 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 48260195_1 CDM 0250 RC 63323-0325-20 NDC inpatient 1 UN 44.32 28.81 SIHO - ALL PLANS SIHO - ALL PLANS 39.89 90 999999999 26.84 42.99 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 48260195_1 CDM 0250 RC 63323-0325-20 NDC inpatient 1 UN 44.32 28.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26.84 60.55 999999999 26.84 42.99 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 48260195_1 CDM 0250 RC 63323-0325-20 NDC inpatient 1 UN 44.32 28.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26.84 42.99 "ACYCLOVIR 1,000 MG/20 ML VIAL" 48260195_1 CDM 0250 RC 63323-0325-20 NDC inpatient 1 UN 44.32 28.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26.84 42.99 "ACYCLOVIR 1,000 MG/20 ML VIAL" 48260195_1 CDM 0250 RC 63323-0325-20 NDC inpatient 1 UN 44.32 28.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26.84 42.99 "ACYCLOVIR 1,000 MG/20 ML VIAL" 48260195_1 CDM 0250 RC 63323-0325-20 NDC inpatient 1 UN 44.32 28.81 ANTHEM HMO ANTHEM HMO 999999999 26.84 42.99 "ACYCLOVIR 1,000 MG/20 ML VIAL" 48260195_1 CDM 0250 RC 63323-0325-20 NDC inpatient 1 UN 44.32 28.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 29.96 67.6 999999999 26.84 42.99 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 48260195_1 CDM 0250 RC 63323-0325-20 NDC inpatient 1 UN 44.32 28.81 UHC - ALL PLANS UHC - ALL PLANS 999999999 26.84 42.99 MAG-AL PLUS XS SUSP 30 ML CUP 48260200_1 CDM 0250 RC 00121-1762-30 NDC inpatient 1 UN 5.08 3.3 AETNA AETNA 4.01 79 999999999 3.08 4.93 percent of total billed charges MAG-AL PLUS XS SUSP 30 ML CUP 48260200_1 CDM 0250 RC 00121-1762-30 NDC inpatient 1 UN 5.08 3.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.3 65 999999999 3.08 4.93 percent of total billed charges MAG-AL PLUS XS SUSP 30 ML CUP 48260200_1 CDM 0250 RC 00121-1762-30 NDC inpatient 1 UN 5.08 3.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4.93 97 999999999 3.08 4.93 percent of total billed charges MAG-AL PLUS XS SUSP 30 ML CUP 48260200_1 CDM 0250 RC 00121-1762-30 NDC inpatient 1 UN 5.08 3.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.51 69 999999999 3.08 4.93 percent of total billed charges MAG-AL PLUS XS SUSP 30 ML CUP 48260200_1 CDM 0250 RC 00121-1762-30 NDC inpatient 1 UN 5.08 3.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.96 78 999999999 3.08 4.93 percent of total billed charges MAG-AL PLUS XS SUSP 30 ML CUP 48260200_1 CDM 0250 RC 00121-1762-30 NDC inpatient 1 UN 5.08 3.3 UMR - ALL PLANS UMR - ALL PLANS 3.56 70 999999999 3.08 4.93 percent of total billed charges MAG-AL PLUS XS SUSP 30 ML CUP 48260200_1 CDM 0250 RC 00121-1762-30 NDC inpatient 1 UN 5.08 3.3 SIHO - ALL PLANS SIHO - ALL PLANS 4.57 90 999999999 3.08 4.93 percent of total billed charges MAG-AL PLUS XS SUSP 30 ML CUP 48260200_1 CDM 0250 RC 00121-1762-30 NDC inpatient 1 UN 5.08 3.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.08 60.55 999999999 3.08 4.93 percent of total billed charges MAG-AL PLUS XS SUSP 30 ML CUP 48260200_1 CDM 0250 RC 00121-1762-30 NDC inpatient 1 UN 5.08 3.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.08 4.93 MAG-AL PLUS XS SUSP 30 ML CUP 48260200_1 CDM 0250 RC 00121-1762-30 NDC inpatient 1 UN 5.08 3.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.08 4.93 MAG-AL PLUS XS SUSP 30 ML CUP 48260200_1 CDM 0250 RC 00121-1762-30 NDC inpatient 1 UN 5.08 3.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.08 4.93 MAG-AL PLUS XS SUSP 30 ML CUP 48260200_1 CDM 0250 RC 00121-1762-30 NDC inpatient 1 UN 5.08 3.3 ANTHEM HMO ANTHEM HMO 999999999 3.08 4.93 MAG-AL PLUS XS SUSP 30 ML CUP 48260200_1 CDM 0250 RC 00121-1762-30 NDC inpatient 1 UN 5.08 3.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.43 67.6 999999999 3.08 4.93 percent of total billed charges MAG-AL PLUS XS SUSP 30 ML CUP 48260200_1 CDM 0250 RC 00121-1762-30 NDC inpatient 1 UN 5.08 3.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.08 4.93 ALBUTEROL 2.5 MG/0.5 ML SOL 48260206_1 CDM 0250 RC 00487-9901-30 NDC inpatient 1 UN 1.47 0.96 AETNA AETNA 1.16 79 999999999 0.89 1.43 percent of total billed charges ALBUTEROL 2.5 MG/0.5 ML SOL 48260206_1 CDM 0250 RC 00487-9901-30 NDC inpatient 1 UN 1.47 0.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.96 65 999999999 0.89 1.43 percent of total billed charges ALBUTEROL 2.5 MG/0.5 ML SOL 48260206_1 CDM 0250 RC 00487-9901-30 NDC inpatient 1 UN 1.47 0.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.43 97 999999999 0.89 1.43 percent of total billed charges ALBUTEROL 2.5 MG/0.5 ML SOL 48260206_1 CDM 0250 RC 00487-9901-30 NDC inpatient 1 UN 1.47 0.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.01 69 999999999 0.89 1.43 percent of total billed charges ALBUTEROL 2.5 MG/0.5 ML SOL 48260206_1 CDM 0250 RC 00487-9901-30 NDC inpatient 1 UN 1.47 0.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.15 78 999999999 0.89 1.43 percent of total billed charges ALBUTEROL 2.5 MG/0.5 ML SOL 48260206_1 CDM 0250 RC 00487-9901-30 NDC inpatient 1 UN 1.47 0.96 UMR - ALL PLANS UMR - ALL PLANS 1.03 70 999999999 0.89 1.43 percent of total billed charges ALBUTEROL 2.5 MG/0.5 ML SOL 48260206_1 CDM 0250 RC 00487-9901-30 NDC inpatient 1 UN 1.47 0.96 SIHO - ALL PLANS SIHO - ALL PLANS 1.32 90 999999999 0.89 1.43 percent of total billed charges ALBUTEROL 2.5 MG/0.5 ML SOL 48260206_1 CDM 0250 RC 00487-9901-30 NDC inpatient 1 UN 1.47 0.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.89 60.55 999999999 0.89 1.43 percent of total billed charges ALBUTEROL 2.5 MG/0.5 ML SOL 48260206_1 CDM 0250 RC 00487-9901-30 NDC inpatient 1 UN 1.47 0.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.89 1.43 ALBUTEROL 2.5 MG/0.5 ML SOL 48260206_1 CDM 0250 RC 00487-9901-30 NDC inpatient 1 UN 1.47 0.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.89 1.43 ALBUTEROL 2.5 MG/0.5 ML SOL 48260206_1 CDM 0250 RC 00487-9901-30 NDC inpatient 1 UN 1.47 0.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.89 1.43 ALBUTEROL 2.5 MG/0.5 ML SOL 48260206_1 CDM 0250 RC 00487-9901-30 NDC inpatient 1 UN 1.47 0.96 ANTHEM HMO ANTHEM HMO 999999999 0.89 1.43 ALBUTEROL 2.5 MG/0.5 ML SOL 48260206_1 CDM 0250 RC 00487-9901-30 NDC inpatient 1 UN 1.47 0.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.99 67.6 999999999 0.89 1.43 percent of total billed charges ALBUTEROL 2.5 MG/0.5 ML SOL 48260206_1 CDM 0250 RC 00487-9901-30 NDC inpatient 1 UN 1.47 0.96 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.89 1.43 00904-5860-61 - ALPRAZolam 1 mg Tab [JOHN] 48260215_1 CDM 0250 RC 00904-5860-61 NDC inpatient 1 UN 1.75 1.14 AETNA AETNA 1.38 79 999999999 1.06 1.7 percent of total billed charges 00904-5860-61 - ALPRAZolam 1 mg Tab [JOHN] 48260215_1 CDM 0250 RC 00904-5860-61 NDC inpatient 1 UN 1.75 1.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.14 65 999999999 1.06 1.7 percent of total billed charges 00904-5860-61 - ALPRAZolam 1 mg Tab [JOHN] 48260215_1 CDM 0250 RC 00904-5860-61 NDC inpatient 1 UN 1.75 1.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.7 97 999999999 1.06 1.7 percent of total billed charges 00904-5860-61 - ALPRAZolam 1 mg Tab [JOHN] 48260215_1 CDM 0250 RC 00904-5860-61 NDC inpatient 1 UN 1.75 1.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.21 69 999999999 1.06 1.7 percent of total billed charges 00904-5860-61 - ALPRAZolam 1 mg Tab [JOHN] 48260215_1 CDM 0250 RC 00904-5860-61 NDC inpatient 1 UN 1.75 1.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.37 78 999999999 1.06 1.7 percent of total billed charges 00904-5860-61 - ALPRAZolam 1 mg Tab [JOHN] 48260215_1 CDM 0250 RC 00904-5860-61 NDC inpatient 1 UN 1.75 1.14 UMR - ALL PLANS UMR - ALL PLANS 1.23 70 999999999 1.06 1.7 percent of total billed charges 00904-5860-61 - ALPRAZolam 1 mg Tab [JOHN] 48260215_1 CDM 0250 RC 00904-5860-61 NDC inpatient 1 UN 1.75 1.14 SIHO - ALL PLANS SIHO - ALL PLANS 1.58 90 999999999 1.06 1.7 percent of total billed charges 00904-5860-61 - ALPRAZolam 1 mg Tab [JOHN] 48260215_1 CDM 0250 RC 00904-5860-61 NDC inpatient 1 UN 1.75 1.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.06 60.55 999999999 1.06 1.7 percent of total billed charges 00904-5860-61 - ALPRAZolam 1 mg Tab [JOHN] 48260215_1 CDM 0250 RC 00904-5860-61 NDC inpatient 1 UN 1.75 1.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.06 1.7 00904-5860-61 - ALPRAZolam 1 mg Tab [JOHN] 48260215_1 CDM 0250 RC 00904-5860-61 NDC inpatient 1 UN 1.75 1.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.06 1.7 00904-5860-61 - ALPRAZolam 1 mg Tab [JOHN] 48260215_1 CDM 0250 RC 00904-5860-61 NDC inpatient 1 UN 1.75 1.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.06 1.7 00904-5860-61 - ALPRAZolam 1 mg Tab [JOHN] 48260215_1 CDM 0250 RC 00904-5860-61 NDC inpatient 1 UN 1.75 1.14 ANTHEM HMO ANTHEM HMO 999999999 1.06 1.7 00904-5860-61 - ALPRAZolam 1 mg Tab [JOHN] 48260215_1 CDM 0250 RC 00904-5860-61 NDC inpatient 1 UN 1.75 1.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.18 67.6 999999999 1.06 1.7 percent of total billed charges 00904-5860-61 - ALPRAZolam 1 mg Tab [JOHN] 48260215_1 CDM 0250 RC 00904-5860-61 NDC inpatient 1 UN 1.75 1.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.06 1.7 "INJECTION, ALTEPLASE RECOMBINANT, 1 MG" 48260217_1 CDM 0250 RC 50242-0085-27 NDC J2997 HCPCS inpatient 100 UN 35080.21 22802.14 AETNA AETNA 27713.37 79 999999999 21241.07 34027.8 percent of total billed charges "INJECTION, ALTEPLASE RECOMBINANT, 1 MG" 48260217_1 CDM 0250 RC 50242-0085-27 NDC J2997 HCPCS inpatient 100 UN 35080.21 22802.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 22802.14 65 999999999 21241.07 34027.8 percent of total billed charges "INJECTION, ALTEPLASE RECOMBINANT, 1 MG" 48260217_1 CDM 0250 RC 50242-0085-27 NDC J2997 HCPCS inpatient 100 UN 35080.21 22802.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34027.8 97 999999999 21241.07 34027.8 percent of total billed charges "INJECTION, ALTEPLASE RECOMBINANT, 1 MG" 48260217_1 CDM 0250 RC 50242-0085-27 NDC J2997 HCPCS inpatient 100 UN 35080.21 22802.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 24205.34 69 999999999 21241.07 34027.8 percent of total billed charges "INJECTION, ALTEPLASE RECOMBINANT, 1 MG" 48260217_1 CDM 0250 RC 50242-0085-27 NDC J2997 HCPCS inpatient 100 UN 35080.21 22802.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 27362.56 78 999999999 21241.07 34027.8 percent of total billed charges "INJECTION, ALTEPLASE RECOMBINANT, 1 MG" 48260217_1 CDM 0250 RC 50242-0085-27 NDC J2997 HCPCS inpatient 100 UN 35080.21 22802.14 UMR - ALL PLANS UMR - ALL PLANS 24556.15 70 999999999 21241.07 34027.8 percent of total billed charges "INJECTION, ALTEPLASE RECOMBINANT, 1 MG" 48260217_1 CDM 0250 RC 50242-0085-27 NDC J2997 HCPCS inpatient 100 UN 35080.21 22802.14 SIHO - ALL PLANS SIHO - ALL PLANS 31572.19 90 999999999 21241.07 34027.8 percent of total billed charges "INJECTION, ALTEPLASE RECOMBINANT, 1 MG" 48260217_1 CDM 0250 RC 50242-0085-27 NDC J2997 HCPCS inpatient 100 UN 35080.21 22802.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21241.07 60.55 999999999 21241.07 34027.8 percent of total billed charges "INJECTION, ALTEPLASE RECOMBINANT, 1 MG" 48260217_1 CDM 0250 RC 50242-0085-27 NDC J2997 HCPCS inpatient 100 UN 35080.21 22802.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21241.07 34027.8 "INJECTION, ALTEPLASE RECOMBINANT, 1 MG" 48260217_1 CDM 0250 RC 50242-0085-27 NDC J2997 HCPCS inpatient 100 UN 35080.21 22802.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21241.07 34027.8 "INJECTION, ALTEPLASE RECOMBINANT, 1 MG" 48260217_1 CDM 0250 RC 50242-0085-27 NDC J2997 HCPCS inpatient 100 UN 35080.21 22802.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21241.07 34027.8 "INJECTION, ALTEPLASE RECOMBINANT, 1 MG" 48260217_1 CDM 0250 RC 50242-0085-27 NDC J2997 HCPCS inpatient 100 UN 35080.21 22802.14 ANTHEM HMO ANTHEM HMO 999999999 21241.07 34027.8 "INJECTION, ALTEPLASE RECOMBINANT, 1 MG" 48260217_1 CDM 0250 RC 50242-0085-27 NDC J2997 HCPCS inpatient 100 UN 35080.21 22802.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 23714.22 67.6 999999999 21241.07 34027.8 percent of total billed charges "INJECTION, ALTEPLASE RECOMBINANT, 1 MG" 48260217_1 CDM 0250 RC 50242-0085-27 NDC J2997 HCPCS inpatient 100 UN 35080.21 22802.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 21241.07 34027.8 CATHFLO ACTIVASE 2 MG VIAL 48260218_1 CDM 0250 RC 50242-0041-64 NDC inpatient 1 UN 760.43 494.28 AETNA AETNA 600.74 79 999999999 460.44 737.62 percent of total billed charges CATHFLO ACTIVASE 2 MG VIAL 48260218_1 CDM 0250 RC 50242-0041-64 NDC inpatient 1 UN 760.43 494.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 494.28 65 999999999 460.44 737.62 percent of total billed charges CATHFLO ACTIVASE 2 MG VIAL 48260218_1 CDM 0250 RC 50242-0041-64 NDC inpatient 1 UN 760.43 494.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 737.62 97 999999999 460.44 737.62 percent of total billed charges CATHFLO ACTIVASE 2 MG VIAL 48260218_1 CDM 0250 RC 50242-0041-64 NDC inpatient 1 UN 760.43 494.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 524.7 69 999999999 460.44 737.62 percent of total billed charges CATHFLO ACTIVASE 2 MG VIAL 48260218_1 CDM 0250 RC 50242-0041-64 NDC inpatient 1 UN 760.43 494.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 593.14 78 999999999 460.44 737.62 percent of total billed charges CATHFLO ACTIVASE 2 MG VIAL 48260218_1 CDM 0250 RC 50242-0041-64 NDC inpatient 1 UN 760.43 494.28 UMR - ALL PLANS UMR - ALL PLANS 532.3 70 999999999 460.44 737.62 percent of total billed charges CATHFLO ACTIVASE 2 MG VIAL 48260218_1 CDM 0250 RC 50242-0041-64 NDC inpatient 1 UN 760.43 494.28 SIHO - ALL PLANS SIHO - ALL PLANS 684.39 90 999999999 460.44 737.62 percent of total billed charges CATHFLO ACTIVASE 2 MG VIAL 48260218_1 CDM 0250 RC 50242-0041-64 NDC inpatient 1 UN 760.43 494.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 460.44 60.55 999999999 460.44 737.62 percent of total billed charges CATHFLO ACTIVASE 2 MG VIAL 48260218_1 CDM 0250 RC 50242-0041-64 NDC inpatient 1 UN 760.43 494.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 460.44 737.62 CATHFLO ACTIVASE 2 MG VIAL 48260218_1 CDM 0250 RC 50242-0041-64 NDC inpatient 1 UN 760.43 494.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 460.44 737.62 CATHFLO ACTIVASE 2 MG VIAL 48260218_1 CDM 0250 RC 50242-0041-64 NDC inpatient 1 UN 760.43 494.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 460.44 737.62 CATHFLO ACTIVASE 2 MG VIAL 48260218_1 CDM 0250 RC 50242-0041-64 NDC inpatient 1 UN 760.43 494.28 ANTHEM HMO ANTHEM HMO 999999999 460.44 737.62 CATHFLO ACTIVASE 2 MG VIAL 48260218_1 CDM 0250 RC 50242-0041-64 NDC inpatient 1 UN 760.43 494.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 514.05 67.6 999999999 460.44 737.62 percent of total billed charges CATHFLO ACTIVASE 2 MG VIAL 48260218_1 CDM 0250 RC 50242-0041-64 NDC inpatient 1 UN 760.43 494.28 UHC - ALL PLANS UHC - ALL PLANS 999999999 460.44 737.62 "INJECTION, AMIKACIN SULFATE, 100 MG" 48260224_1 CDM 0250 RC 00703-9040-03 NDC J0278 HCPCS inpatient 10 UN 69.66 45.28 AETNA AETNA 55.03 79 999999999 42.18 67.57 percent of total billed charges "INJECTION, AMIKACIN SULFATE, 100 MG" 48260224_1 CDM 0250 RC 00703-9040-03 NDC J0278 HCPCS inpatient 10 UN 69.66 45.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.28 65 999999999 42.18 67.57 percent of total billed charges "INJECTION, AMIKACIN SULFATE, 100 MG" 48260224_1 CDM 0250 RC 00703-9040-03 NDC J0278 HCPCS inpatient 10 UN 69.66 45.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.57 97 999999999 42.18 67.57 percent of total billed charges "INJECTION, AMIKACIN SULFATE, 100 MG" 48260224_1 CDM 0250 RC 00703-9040-03 NDC J0278 HCPCS inpatient 10 UN 69.66 45.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.07 69 999999999 42.18 67.57 percent of total billed charges "INJECTION, AMIKACIN SULFATE, 100 MG" 48260224_1 CDM 0250 RC 00703-9040-03 NDC J0278 HCPCS inpatient 10 UN 69.66 45.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.33 78 999999999 42.18 67.57 percent of total billed charges "INJECTION, AMIKACIN SULFATE, 100 MG" 48260224_1 CDM 0250 RC 00703-9040-03 NDC J0278 HCPCS inpatient 10 UN 69.66 45.28 UMR - ALL PLANS UMR - ALL PLANS 48.76 70 999999999 42.18 67.57 percent of total billed charges "INJECTION, AMIKACIN SULFATE, 100 MG" 48260224_1 CDM 0250 RC 00703-9040-03 NDC J0278 HCPCS inpatient 10 UN 69.66 45.28 SIHO - ALL PLANS SIHO - ALL PLANS 62.69 90 999999999 42.18 67.57 percent of total billed charges "INJECTION, AMIKACIN SULFATE, 100 MG" 48260224_1 CDM 0250 RC 00703-9040-03 NDC J0278 HCPCS inpatient 10 UN 69.66 45.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.18 60.55 999999999 42.18 67.57 percent of total billed charges "INJECTION, AMIKACIN SULFATE, 100 MG" 48260224_1 CDM 0250 RC 00703-9040-03 NDC J0278 HCPCS inpatient 10 UN 69.66 45.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.18 67.57 "INJECTION, AMIKACIN SULFATE, 100 MG" 48260224_1 CDM 0250 RC 00703-9040-03 NDC J0278 HCPCS inpatient 10 UN 69.66 45.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.18 67.57 "INJECTION, AMIKACIN SULFATE, 100 MG" 48260224_1 CDM 0250 RC 00703-9040-03 NDC J0278 HCPCS inpatient 10 UN 69.66 45.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.18 67.57 "INJECTION, AMIKACIN SULFATE, 100 MG" 48260224_1 CDM 0250 RC 00703-9040-03 NDC J0278 HCPCS inpatient 10 UN 69.66 45.28 ANTHEM HMO ANTHEM HMO 999999999 42.18 67.57 "INJECTION, AMIKACIN SULFATE, 100 MG" 48260224_1 CDM 0250 RC 00703-9040-03 NDC J0278 HCPCS inpatient 10 UN 69.66 45.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.09 67.6 999999999 42.18 67.57 percent of total billed charges "INJECTION, AMIKACIN SULFATE, 100 MG" 48260224_1 CDM 0250 RC 00703-9040-03 NDC J0278 HCPCS inpatient 10 UN 69.66 45.28 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.18 67.57 CLINIMIX E 5%-20% SOLUTION 48260228_1 CDM 0250 RC 00338-1125-04 NDC inpatient 1 UN 449.99 292.49 AETNA AETNA 355.49 79 999999999 272.47 436.49 percent of total billed charges CLINIMIX E 5%-20% SOLUTION 48260228_1 CDM 0250 RC 00338-1125-04 NDC inpatient 1 UN 449.99 292.49 SELF PAY DISCOUNT SELF PAY DISCOUNT 292.49 65 999999999 272.47 436.49 percent of total billed charges CLINIMIX E 5%-20% SOLUTION 48260228_1 CDM 0250 RC 00338-1125-04 NDC inpatient 1 UN 449.99 292.49 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 436.49 97 999999999 272.47 436.49 percent of total billed charges CLINIMIX E 5%-20% SOLUTION 48260228_1 CDM 0250 RC 00338-1125-04 NDC inpatient 1 UN 449.99 292.49 ENCORE - ALL PLANS ENCORE - ALL PLANS 310.49 69 999999999 272.47 436.49 percent of total billed charges CLINIMIX E 5%-20% SOLUTION 48260228_1 CDM 0250 RC 00338-1125-04 NDC inpatient 1 UN 449.99 292.49 HUMANA - ALL PLANS HUMANA - ALL PLANS 350.99 78 999999999 272.47 436.49 percent of total billed charges CLINIMIX E 5%-20% SOLUTION 48260228_1 CDM 0250 RC 00338-1125-04 NDC inpatient 1 UN 449.99 292.49 UMR - ALL PLANS UMR - ALL PLANS 314.99 70 999999999 272.47 436.49 percent of total billed charges CLINIMIX E 5%-20% SOLUTION 48260228_1 CDM 0250 RC 00338-1125-04 NDC inpatient 1 UN 449.99 292.49 SIHO - ALL PLANS SIHO - ALL PLANS 404.99 90 999999999 272.47 436.49 percent of total billed charges CLINIMIX E 5%-20% SOLUTION 48260228_1 CDM 0250 RC 00338-1125-04 NDC inpatient 1 UN 449.99 292.49 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 272.47 60.55 999999999 272.47 436.49 percent of total billed charges CLINIMIX E 5%-20% SOLUTION 48260228_1 CDM 0250 RC 00338-1125-04 NDC inpatient 1 UN 449.99 292.49 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 272.47 436.49 CLINIMIX E 5%-20% SOLUTION 48260228_1 CDM 0250 RC 00338-1125-04 NDC inpatient 1 UN 449.99 292.49 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 272.47 436.49 CLINIMIX E 5%-20% SOLUTION 48260228_1 CDM 0250 RC 00338-1125-04 NDC inpatient 1 UN 449.99 292.49 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 272.47 436.49 CLINIMIX E 5%-20% SOLUTION 48260228_1 CDM 0250 RC 00338-1125-04 NDC inpatient 1 UN 449.99 292.49 ANTHEM HMO ANTHEM HMO 999999999 272.47 436.49 CLINIMIX E 5%-20% SOLUTION 48260228_1 CDM 0250 RC 00338-1125-04 NDC inpatient 1 UN 449.99 292.49 CIGNA - ALL PLANS CIGNA - ALL PLANS 304.19 67.6 999999999 272.47 436.49 percent of total billed charges CLINIMIX E 5%-20% SOLUTION 48260228_1 CDM 0250 RC 00338-1125-04 NDC inpatient 1 UN 449.99 292.49 UHC - ALL PLANS UHC - ALL PLANS 999999999 272.47 436.49 AMINOPHYLLINE 250 MG/10 ML VL 48260231_1 CDM 0250 RC 00409-5921-01 NDC inpatient 1 UN 72.76 47.29 AETNA AETNA 57.48 79 999999999 44.06 70.58 percent of total billed charges AMINOPHYLLINE 250 MG/10 ML VL 48260231_1 CDM 0250 RC 00409-5921-01 NDC inpatient 1 UN 72.76 47.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.29 65 999999999 44.06 70.58 percent of total billed charges AMINOPHYLLINE 250 MG/10 ML VL 48260231_1 CDM 0250 RC 00409-5921-01 NDC inpatient 1 UN 72.76 47.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.58 97 999999999 44.06 70.58 percent of total billed charges AMINOPHYLLINE 250 MG/10 ML VL 48260231_1 CDM 0250 RC 00409-5921-01 NDC inpatient 1 UN 72.76 47.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.2 69 999999999 44.06 70.58 percent of total billed charges AMINOPHYLLINE 250 MG/10 ML VL 48260231_1 CDM 0250 RC 00409-5921-01 NDC inpatient 1 UN 72.76 47.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.75 78 999999999 44.06 70.58 percent of total billed charges AMINOPHYLLINE 250 MG/10 ML VL 48260231_1 CDM 0250 RC 00409-5921-01 NDC inpatient 1 UN 72.76 47.29 UMR - ALL PLANS UMR - ALL PLANS 50.93 70 999999999 44.06 70.58 percent of total billed charges AMINOPHYLLINE 250 MG/10 ML VL 48260231_1 CDM 0250 RC 00409-5921-01 NDC inpatient 1 UN 72.76 47.29 SIHO - ALL PLANS SIHO - ALL PLANS 65.48 90 999999999 44.06 70.58 percent of total billed charges AMINOPHYLLINE 250 MG/10 ML VL 48260231_1 CDM 0250 RC 00409-5921-01 NDC inpatient 1 UN 72.76 47.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.06 60.55 999999999 44.06 70.58 percent of total billed charges AMINOPHYLLINE 250 MG/10 ML VL 48260231_1 CDM 0250 RC 00409-5921-01 NDC inpatient 1 UN 72.76 47.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.06 70.58 AMINOPHYLLINE 250 MG/10 ML VL 48260231_1 CDM 0250 RC 00409-5921-01 NDC inpatient 1 UN 72.76 47.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.06 70.58 AMINOPHYLLINE 250 MG/10 ML VL 48260231_1 CDM 0250 RC 00409-5921-01 NDC inpatient 1 UN 72.76 47.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.06 70.58 AMINOPHYLLINE 250 MG/10 ML VL 48260231_1 CDM 0250 RC 00409-5921-01 NDC inpatient 1 UN 72.76 47.29 ANTHEM HMO ANTHEM HMO 999999999 44.06 70.58 AMINOPHYLLINE 250 MG/10 ML VL 48260231_1 CDM 0250 RC 00409-5921-01 NDC inpatient 1 UN 72.76 47.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.19 67.6 999999999 44.06 70.58 percent of total billed charges AMINOPHYLLINE 250 MG/10 ML VL 48260231_1 CDM 0250 RC 00409-5921-01 NDC inpatient 1 UN 72.76 47.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.06 70.58 AMIODARONE 150 MG/3 ML VIAL 48260232_1 CDM 0250 RC 67457-0153-03 NDC inpatient 1 UN 35.08 22.8 AETNA AETNA 27.71 79 999999999 21.24 34.03 percent of total billed charges AMIODARONE 150 MG/3 ML VIAL 48260232_1 CDM 0250 RC 67457-0153-03 NDC inpatient 1 UN 35.08 22.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.8 65 999999999 21.24 34.03 percent of total billed charges AMIODARONE 150 MG/3 ML VIAL 48260232_1 CDM 0250 RC 67457-0153-03 NDC inpatient 1 UN 35.08 22.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34.03 97 999999999 21.24 34.03 percent of total billed charges AMIODARONE 150 MG/3 ML VIAL 48260232_1 CDM 0250 RC 67457-0153-03 NDC inpatient 1 UN 35.08 22.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.21 69 999999999 21.24 34.03 percent of total billed charges AMIODARONE 150 MG/3 ML VIAL 48260232_1 CDM 0250 RC 67457-0153-03 NDC inpatient 1 UN 35.08 22.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.36 78 999999999 21.24 34.03 percent of total billed charges AMIODARONE 150 MG/3 ML VIAL 48260232_1 CDM 0250 RC 67457-0153-03 NDC inpatient 1 UN 35.08 22.8 UMR - ALL PLANS UMR - ALL PLANS 24.56 70 999999999 21.24 34.03 percent of total billed charges AMIODARONE 150 MG/3 ML VIAL 48260232_1 CDM 0250 RC 67457-0153-03 NDC inpatient 1 UN 35.08 22.8 SIHO - ALL PLANS SIHO - ALL PLANS 31.57 90 999999999 21.24 34.03 percent of total billed charges AMIODARONE 150 MG/3 ML VIAL 48260232_1 CDM 0250 RC 67457-0153-03 NDC inpatient 1 UN 35.08 22.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.24 60.55 999999999 21.24 34.03 percent of total billed charges AMIODARONE 150 MG/3 ML VIAL 48260232_1 CDM 0250 RC 67457-0153-03 NDC inpatient 1 UN 35.08 22.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.24 34.03 AMIODARONE 150 MG/3 ML VIAL 48260232_1 CDM 0250 RC 67457-0153-03 NDC inpatient 1 UN 35.08 22.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.24 34.03 AMIODARONE 150 MG/3 ML VIAL 48260232_1 CDM 0250 RC 67457-0153-03 NDC inpatient 1 UN 35.08 22.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.24 34.03 AMIODARONE 150 MG/3 ML VIAL 48260232_1 CDM 0250 RC 67457-0153-03 NDC inpatient 1 UN 35.08 22.8 ANTHEM HMO ANTHEM HMO 999999999 21.24 34.03 AMIODARONE 150 MG/3 ML VIAL 48260232_1 CDM 0250 RC 67457-0153-03 NDC inpatient 1 UN 35.08 22.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 23.71 67.6 999999999 21.24 34.03 percent of total billed charges AMIODARONE 150 MG/3 ML VIAL 48260232_1 CDM 0250 RC 67457-0153-03 NDC inpatient 1 UN 35.08 22.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.24 34.03 AMIODARONE HCL 200 MG TABLET 48260233_1 CDM 0250 RC 68084-0371-01 NDC inpatient 1 UN 1.03 0.67 AETNA AETNA 0.81 79 999999999 0.62 1 percent of total billed charges AMIODARONE HCL 200 MG TABLET 48260233_1 CDM 0250 RC 68084-0371-01 NDC inpatient 1 UN 1.03 0.67 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.67 65 999999999 0.62 1 percent of total billed charges AMIODARONE HCL 200 MG TABLET 48260233_1 CDM 0250 RC 68084-0371-01 NDC inpatient 1 UN 1.03 0.67 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1 97 999999999 0.62 1 percent of total billed charges AMIODARONE HCL 200 MG TABLET 48260233_1 CDM 0250 RC 68084-0371-01 NDC inpatient 1 UN 1.03 0.67 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.71 69 999999999 0.62 1 percent of total billed charges AMIODARONE HCL 200 MG TABLET 48260233_1 CDM 0250 RC 68084-0371-01 NDC inpatient 1 UN 1.03 0.67 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.8 78 999999999 0.62 1 percent of total billed charges AMIODARONE HCL 200 MG TABLET 48260233_1 CDM 0250 RC 68084-0371-01 NDC inpatient 1 UN 1.03 0.67 UMR - ALL PLANS UMR - ALL PLANS 0.72 70 999999999 0.62 1 percent of total billed charges AMIODARONE HCL 200 MG TABLET 48260233_1 CDM 0250 RC 68084-0371-01 NDC inpatient 1 UN 1.03 0.67 SIHO - ALL PLANS SIHO - ALL PLANS 0.93 90 999999999 0.62 1 percent of total billed charges AMIODARONE HCL 200 MG TABLET 48260233_1 CDM 0250 RC 68084-0371-01 NDC inpatient 1 UN 1.03 0.67 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.62 60.55 999999999 0.62 1 percent of total billed charges AMIODARONE HCL 200 MG TABLET 48260233_1 CDM 0250 RC 68084-0371-01 NDC inpatient 1 UN 1.03 0.67 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.62 1 AMIODARONE HCL 200 MG TABLET 48260233_1 CDM 0250 RC 68084-0371-01 NDC inpatient 1 UN 1.03 0.67 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.62 1 AMIODARONE HCL 200 MG TABLET 48260233_1 CDM 0250 RC 68084-0371-01 NDC inpatient 1 UN 1.03 0.67 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.62 1 AMIODARONE HCL 200 MG TABLET 48260233_1 CDM 0250 RC 68084-0371-01 NDC inpatient 1 UN 1.03 0.67 ANTHEM HMO ANTHEM HMO 999999999 0.62 1 AMIODARONE HCL 200 MG TABLET 48260233_1 CDM 0250 RC 68084-0371-01 NDC inpatient 1 UN 1.03 0.67 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.7 67.6 999999999 0.62 1 percent of total billed charges AMIODARONE HCL 200 MG TABLET 48260233_1 CDM 0250 RC 68084-0371-01 NDC inpatient 1 UN 1.03 0.67 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.62 1 NEXTERONE 150 MG/100 ML BAG 48260235_1 CDM 0250 RC 43066-0150-10 NDC inpatient 1 UN 205.82 133.78 AETNA AETNA 162.6 79 999999999 124.62 199.65 percent of total billed charges NEXTERONE 150 MG/100 ML BAG 48260235_1 CDM 0250 RC 43066-0150-10 NDC inpatient 1 UN 205.82 133.78 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.78 65 999999999 124.62 199.65 percent of total billed charges NEXTERONE 150 MG/100 ML BAG 48260235_1 CDM 0250 RC 43066-0150-10 NDC inpatient 1 UN 205.82 133.78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.65 97 999999999 124.62 199.65 percent of total billed charges NEXTERONE 150 MG/100 ML BAG 48260235_1 CDM 0250 RC 43066-0150-10 NDC inpatient 1 UN 205.82 133.78 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.02 69 999999999 124.62 199.65 percent of total billed charges NEXTERONE 150 MG/100 ML BAG 48260235_1 CDM 0250 RC 43066-0150-10 NDC inpatient 1 UN 205.82 133.78 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.54 78 999999999 124.62 199.65 percent of total billed charges NEXTERONE 150 MG/100 ML BAG 48260235_1 CDM 0250 RC 43066-0150-10 NDC inpatient 1 UN 205.82 133.78 UMR - ALL PLANS UMR - ALL PLANS 144.07 70 999999999 124.62 199.65 percent of total billed charges NEXTERONE 150 MG/100 ML BAG 48260235_1 CDM 0250 RC 43066-0150-10 NDC inpatient 1 UN 205.82 133.78 SIHO - ALL PLANS SIHO - ALL PLANS 185.24 90 999999999 124.62 199.65 percent of total billed charges NEXTERONE 150 MG/100 ML BAG 48260235_1 CDM 0250 RC 43066-0150-10 NDC inpatient 1 UN 205.82 133.78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.62 60.55 999999999 124.62 199.65 percent of total billed charges NEXTERONE 150 MG/100 ML BAG 48260235_1 CDM 0250 RC 43066-0150-10 NDC inpatient 1 UN 205.82 133.78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.62 199.65 NEXTERONE 150 MG/100 ML BAG 48260235_1 CDM 0250 RC 43066-0150-10 NDC inpatient 1 UN 205.82 133.78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.62 199.65 NEXTERONE 150 MG/100 ML BAG 48260235_1 CDM 0250 RC 43066-0150-10 NDC inpatient 1 UN 205.82 133.78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.62 199.65 NEXTERONE 150 MG/100 ML BAG 48260235_1 CDM 0250 RC 43066-0150-10 NDC inpatient 1 UN 205.82 133.78 ANTHEM HMO ANTHEM HMO 999999999 124.62 199.65 NEXTERONE 150 MG/100 ML BAG 48260235_1 CDM 0250 RC 43066-0150-10 NDC inpatient 1 UN 205.82 133.78 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.13 67.6 999999999 124.62 199.65 percent of total billed charges NEXTERONE 150 MG/100 ML BAG 48260235_1 CDM 0250 RC 43066-0150-10 NDC inpatient 1 UN 205.82 133.78 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.62 199.65 NEXTERONE 360 MG/200 ML BAG 48260236_1 CDM 0250 RC 43066-0360-20 NDC inpatient 1 UN 258.31 167.9 AETNA AETNA 204.06 79 999999999 156.41 250.56 percent of total billed charges NEXTERONE 360 MG/200 ML BAG 48260236_1 CDM 0250 RC 43066-0360-20 NDC inpatient 1 UN 258.31 167.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.9 65 999999999 156.41 250.56 percent of total billed charges NEXTERONE 360 MG/200 ML BAG 48260236_1 CDM 0250 RC 43066-0360-20 NDC inpatient 1 UN 258.31 167.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 250.56 97 999999999 156.41 250.56 percent of total billed charges NEXTERONE 360 MG/200 ML BAG 48260236_1 CDM 0250 RC 43066-0360-20 NDC inpatient 1 UN 258.31 167.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 178.23 69 999999999 156.41 250.56 percent of total billed charges NEXTERONE 360 MG/200 ML BAG 48260236_1 CDM 0250 RC 43066-0360-20 NDC inpatient 1 UN 258.31 167.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 201.48 78 999999999 156.41 250.56 percent of total billed charges NEXTERONE 360 MG/200 ML BAG 48260236_1 CDM 0250 RC 43066-0360-20 NDC inpatient 1 UN 258.31 167.9 UMR - ALL PLANS UMR - ALL PLANS 180.82 70 999999999 156.41 250.56 percent of total billed charges NEXTERONE 360 MG/200 ML BAG 48260236_1 CDM 0250 RC 43066-0360-20 NDC inpatient 1 UN 258.31 167.9 SIHO - ALL PLANS SIHO - ALL PLANS 232.48 90 999999999 156.41 250.56 percent of total billed charges NEXTERONE 360 MG/200 ML BAG 48260236_1 CDM 0250 RC 43066-0360-20 NDC inpatient 1 UN 258.31 167.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 156.41 60.55 999999999 156.41 250.56 percent of total billed charges NEXTERONE 360 MG/200 ML BAG 48260236_1 CDM 0250 RC 43066-0360-20 NDC inpatient 1 UN 258.31 167.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 156.41 250.56 NEXTERONE 360 MG/200 ML BAG 48260236_1 CDM 0250 RC 43066-0360-20 NDC inpatient 1 UN 258.31 167.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 156.41 250.56 NEXTERONE 360 MG/200 ML BAG 48260236_1 CDM 0250 RC 43066-0360-20 NDC inpatient 1 UN 258.31 167.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 156.41 250.56 NEXTERONE 360 MG/200 ML BAG 48260236_1 CDM 0250 RC 43066-0360-20 NDC inpatient 1 UN 258.31 167.9 ANTHEM HMO ANTHEM HMO 999999999 156.41 250.56 NEXTERONE 360 MG/200 ML BAG 48260236_1 CDM 0250 RC 43066-0360-20 NDC inpatient 1 UN 258.31 167.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 174.62 67.6 999999999 156.41 250.56 percent of total billed charges NEXTERONE 360 MG/200 ML BAG 48260236_1 CDM 0250 RC 43066-0360-20 NDC inpatient 1 UN 258.31 167.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 156.41 250.56 AMOXICILLIN 500 MG CAPSULE 48260243_1 CDM 0250 RC 00781-2613-01 NDC inpatient 1 UN 1.36 0.88 AETNA AETNA 1.07 79 999999999 0.82 1.32 percent of total billed charges AMOXICILLIN 500 MG CAPSULE 48260243_1 CDM 0250 RC 00781-2613-01 NDC inpatient 1 UN 1.36 0.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.88 65 999999999 0.82 1.32 percent of total billed charges AMOXICILLIN 500 MG CAPSULE 48260243_1 CDM 0250 RC 00781-2613-01 NDC inpatient 1 UN 1.36 0.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.32 97 999999999 0.82 1.32 percent of total billed charges AMOXICILLIN 500 MG CAPSULE 48260243_1 CDM 0250 RC 00781-2613-01 NDC inpatient 1 UN 1.36 0.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.94 69 999999999 0.82 1.32 percent of total billed charges AMOXICILLIN 500 MG CAPSULE 48260243_1 CDM 0250 RC 00781-2613-01 NDC inpatient 1 UN 1.36 0.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.06 78 999999999 0.82 1.32 percent of total billed charges AMOXICILLIN 500 MG CAPSULE 48260243_1 CDM 0250 RC 00781-2613-01 NDC inpatient 1 UN 1.36 0.88 UMR - ALL PLANS UMR - ALL PLANS 0.95 70 999999999 0.82 1.32 percent of total billed charges AMOXICILLIN 500 MG CAPSULE 48260243_1 CDM 0250 RC 00781-2613-01 NDC inpatient 1 UN 1.36 0.88 SIHO - ALL PLANS SIHO - ALL PLANS 1.22 90 999999999 0.82 1.32 percent of total billed charges AMOXICILLIN 500 MG CAPSULE 48260243_1 CDM 0250 RC 00781-2613-01 NDC inpatient 1 UN 1.36 0.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.82 60.55 999999999 0.82 1.32 percent of total billed charges AMOXICILLIN 500 MG CAPSULE 48260243_1 CDM 0250 RC 00781-2613-01 NDC inpatient 1 UN 1.36 0.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.82 1.32 AMOXICILLIN 500 MG CAPSULE 48260243_1 CDM 0250 RC 00781-2613-01 NDC inpatient 1 UN 1.36 0.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.82 1.32 AMOXICILLIN 500 MG CAPSULE 48260243_1 CDM 0250 RC 00781-2613-01 NDC inpatient 1 UN 1.36 0.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.82 1.32 AMOXICILLIN 500 MG CAPSULE 48260243_1 CDM 0250 RC 00781-2613-01 NDC inpatient 1 UN 1.36 0.88 ANTHEM HMO ANTHEM HMO 999999999 0.82 1.32 AMOXICILLIN 500 MG CAPSULE 48260243_1 CDM 0250 RC 00781-2613-01 NDC inpatient 1 UN 1.36 0.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.92 67.6 999999999 0.82 1.32 percent of total billed charges AMOXICILLIN 500 MG CAPSULE 48260243_1 CDM 0250 RC 00781-2613-01 NDC inpatient 1 UN 1.36 0.88 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.82 1.32 AMOXICILLIN 250 MG/5 ML SUSP 48260244_1 CDM 0250 RC 00143-9889-01 NDC inpatient 1 UN 8.41 5.47 AETNA AETNA 6.64 79 999999999 5.09 8.16 percent of total billed charges AMOXICILLIN 250 MG/5 ML SUSP 48260244_1 CDM 0250 RC 00143-9889-01 NDC inpatient 1 UN 8.41 5.47 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.47 65 999999999 5.09 8.16 percent of total billed charges AMOXICILLIN 250 MG/5 ML SUSP 48260244_1 CDM 0250 RC 00143-9889-01 NDC inpatient 1 UN 8.41 5.47 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.16 97 999999999 5.09 8.16 percent of total billed charges AMOXICILLIN 250 MG/5 ML SUSP 48260244_1 CDM 0250 RC 00143-9889-01 NDC inpatient 1 UN 8.41 5.47 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.8 69 999999999 5.09 8.16 percent of total billed charges AMOXICILLIN 250 MG/5 ML SUSP 48260244_1 CDM 0250 RC 00143-9889-01 NDC inpatient 1 UN 8.41 5.47 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.56 78 999999999 5.09 8.16 percent of total billed charges AMOXICILLIN 250 MG/5 ML SUSP 48260244_1 CDM 0250 RC 00143-9889-01 NDC inpatient 1 UN 8.41 5.47 UMR - ALL PLANS UMR - ALL PLANS 5.89 70 999999999 5.09 8.16 percent of total billed charges AMOXICILLIN 250 MG/5 ML SUSP 48260244_1 CDM 0250 RC 00143-9889-01 NDC inpatient 1 UN 8.41 5.47 SIHO - ALL PLANS SIHO - ALL PLANS 7.57 90 999999999 5.09 8.16 percent of total billed charges AMOXICILLIN 250 MG/5 ML SUSP 48260244_1 CDM 0250 RC 00143-9889-01 NDC inpatient 1 UN 8.41 5.47 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.09 60.55 999999999 5.09 8.16 percent of total billed charges AMOXICILLIN 250 MG/5 ML SUSP 48260244_1 CDM 0250 RC 00143-9889-01 NDC inpatient 1 UN 8.41 5.47 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.09 8.16 AMOXICILLIN 250 MG/5 ML SUSP 48260244_1 CDM 0250 RC 00143-9889-01 NDC inpatient 1 UN 8.41 5.47 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.09 8.16 AMOXICILLIN 250 MG/5 ML SUSP 48260244_1 CDM 0250 RC 00143-9889-01 NDC inpatient 1 UN 8.41 5.47 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.09 8.16 AMOXICILLIN 250 MG/5 ML SUSP 48260244_1 CDM 0250 RC 00143-9889-01 NDC inpatient 1 UN 8.41 5.47 ANTHEM HMO ANTHEM HMO 999999999 5.09 8.16 AMOXICILLIN 250 MG/5 ML SUSP 48260244_1 CDM 0250 RC 00143-9889-01 NDC inpatient 1 UN 8.41 5.47 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.69 67.6 999999999 5.09 8.16 percent of total billed charges AMOXICILLIN 250 MG/5 ML SUSP 48260244_1 CDM 0250 RC 00143-9889-01 NDC inpatient 1 UN 8.41 5.47 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.09 8.16 AMOXICILLIN 400 MG/5 ML SUSP 48260245_1 CDM 0250 RC 00143-9887-01 NDC inpatient 1 UN 8.79 5.71 AETNA AETNA 6.94 79 999999999 5.32 8.53 percent of total billed charges AMOXICILLIN 400 MG/5 ML SUSP 48260245_1 CDM 0250 RC 00143-9887-01 NDC inpatient 1 UN 8.79 5.71 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.71 65 999999999 5.32 8.53 percent of total billed charges AMOXICILLIN 400 MG/5 ML SUSP 48260245_1 CDM 0250 RC 00143-9887-01 NDC inpatient 1 UN 8.79 5.71 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.53 97 999999999 5.32 8.53 percent of total billed charges AMOXICILLIN 400 MG/5 ML SUSP 48260245_1 CDM 0250 RC 00143-9887-01 NDC inpatient 1 UN 8.79 5.71 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.07 69 999999999 5.32 8.53 percent of total billed charges AMOXICILLIN 400 MG/5 ML SUSP 48260245_1 CDM 0250 RC 00143-9887-01 NDC inpatient 1 UN 8.79 5.71 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.86 78 999999999 5.32 8.53 percent of total billed charges AMOXICILLIN 400 MG/5 ML SUSP 48260245_1 CDM 0250 RC 00143-9887-01 NDC inpatient 1 UN 8.79 5.71 UMR - ALL PLANS UMR - ALL PLANS 6.15 70 999999999 5.32 8.53 percent of total billed charges AMOXICILLIN 400 MG/5 ML SUSP 48260245_1 CDM 0250 RC 00143-9887-01 NDC inpatient 1 UN 8.79 5.71 SIHO - ALL PLANS SIHO - ALL PLANS 7.91 90 999999999 5.32 8.53 percent of total billed charges AMOXICILLIN 400 MG/5 ML SUSP 48260245_1 CDM 0250 RC 00143-9887-01 NDC inpatient 1 UN 8.79 5.71 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.32 60.55 999999999 5.32 8.53 percent of total billed charges AMOXICILLIN 400 MG/5 ML SUSP 48260245_1 CDM 0250 RC 00143-9887-01 NDC inpatient 1 UN 8.79 5.71 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.32 8.53 AMOXICILLIN 400 MG/5 ML SUSP 48260245_1 CDM 0250 RC 00143-9887-01 NDC inpatient 1 UN 8.79 5.71 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.32 8.53 AMOXICILLIN 400 MG/5 ML SUSP 48260245_1 CDM 0250 RC 00143-9887-01 NDC inpatient 1 UN 8.79 5.71 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.32 8.53 AMOXICILLIN 400 MG/5 ML SUSP 48260245_1 CDM 0250 RC 00143-9887-01 NDC inpatient 1 UN 8.79 5.71 ANTHEM HMO ANTHEM HMO 999999999 5.32 8.53 AMOXICILLIN 400 MG/5 ML SUSP 48260245_1 CDM 0250 RC 00143-9887-01 NDC inpatient 1 UN 8.79 5.71 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.94 67.6 999999999 5.32 8.53 percent of total billed charges AMOXICILLIN 400 MG/5 ML SUSP 48260245_1 CDM 0250 RC 00143-9887-01 NDC inpatient 1 UN 8.79 5.71 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.32 8.53 AMOX-CLAV 250-62.5 MG/5 ML SUS 48260246_1 CDM 0250 RC 60432-0065-75 NDC inpatient 1 UN 111.34 72.37 AETNA AETNA 87.96 79 999999999 67.42 108 percent of total billed charges AMOX-CLAV 250-62.5 MG/5 ML SUS 48260246_1 CDM 0250 RC 60432-0065-75 NDC inpatient 1 UN 111.34 72.37 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.37 65 999999999 67.42 108 percent of total billed charges AMOX-CLAV 250-62.5 MG/5 ML SUS 48260246_1 CDM 0250 RC 60432-0065-75 NDC inpatient 1 UN 111.34 72.37 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108 97 999999999 67.42 108 percent of total billed charges AMOX-CLAV 250-62.5 MG/5 ML SUS 48260246_1 CDM 0250 RC 60432-0065-75 NDC inpatient 1 UN 111.34 72.37 ENCORE - ALL PLANS ENCORE - ALL PLANS 76.82 69 999999999 67.42 108 percent of total billed charges AMOX-CLAV 250-62.5 MG/5 ML SUS 48260246_1 CDM 0250 RC 60432-0065-75 NDC inpatient 1 UN 111.34 72.37 HUMANA - ALL PLANS HUMANA - ALL PLANS 86.85 78 999999999 67.42 108 percent of total billed charges AMOX-CLAV 250-62.5 MG/5 ML SUS 48260246_1 CDM 0250 RC 60432-0065-75 NDC inpatient 1 UN 111.34 72.37 UMR - ALL PLANS UMR - ALL PLANS 77.94 70 999999999 67.42 108 percent of total billed charges AMOX-CLAV 250-62.5 MG/5 ML SUS 48260246_1 CDM 0250 RC 60432-0065-75 NDC inpatient 1 UN 111.34 72.37 SIHO - ALL PLANS SIHO - ALL PLANS 100.21 90 999999999 67.42 108 percent of total billed charges AMOX-CLAV 250-62.5 MG/5 ML SUS 48260246_1 CDM 0250 RC 60432-0065-75 NDC inpatient 1 UN 111.34 72.37 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.42 60.55 999999999 67.42 108 percent of total billed charges AMOX-CLAV 250-62.5 MG/5 ML SUS 48260246_1 CDM 0250 RC 60432-0065-75 NDC inpatient 1 UN 111.34 72.37 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.42 108 AMOX-CLAV 250-62.5 MG/5 ML SUS 48260246_1 CDM 0250 RC 60432-0065-75 NDC inpatient 1 UN 111.34 72.37 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.42 108 AMOX-CLAV 250-62.5 MG/5 ML SUS 48260246_1 CDM 0250 RC 60432-0065-75 NDC inpatient 1 UN 111.34 72.37 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.42 108 AMOX-CLAV 250-62.5 MG/5 ML SUS 48260246_1 CDM 0250 RC 60432-0065-75 NDC inpatient 1 UN 111.34 72.37 ANTHEM HMO ANTHEM HMO 999999999 67.42 108 AMOX-CLAV 250-62.5 MG/5 ML SUS 48260246_1 CDM 0250 RC 60432-0065-75 NDC inpatient 1 UN 111.34 72.37 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.27 67.6 999999999 67.42 108 percent of total billed charges AMOX-CLAV 250-62.5 MG/5 ML SUS 48260246_1 CDM 0250 RC 60432-0065-75 NDC inpatient 1 UN 111.34 72.37 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.42 108 AMPICILLIN 1 GM VIAL 48260254_1 CDM 0250 RC 00781-9404-95 NDC inpatient 1 UN 47.7 31.01 AETNA AETNA 37.68 79 999999999 28.88 46.27 percent of total billed charges AMPICILLIN 1 GM VIAL 48260254_1 CDM 0250 RC 00781-9404-95 NDC inpatient 1 UN 47.7 31.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.01 65 999999999 28.88 46.27 percent of total billed charges AMPICILLIN 1 GM VIAL 48260254_1 CDM 0250 RC 00781-9404-95 NDC inpatient 1 UN 47.7 31.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 46.27 97 999999999 28.88 46.27 percent of total billed charges AMPICILLIN 1 GM VIAL 48260254_1 CDM 0250 RC 00781-9404-95 NDC inpatient 1 UN 47.7 31.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 32.91 69 999999999 28.88 46.27 percent of total billed charges AMPICILLIN 1 GM VIAL 48260254_1 CDM 0250 RC 00781-9404-95 NDC inpatient 1 UN 47.7 31.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 37.21 78 999999999 28.88 46.27 percent of total billed charges AMPICILLIN 1 GM VIAL 48260254_1 CDM 0250 RC 00781-9404-95 NDC inpatient 1 UN 47.7 31.01 UMR - ALL PLANS UMR - ALL PLANS 33.39 70 999999999 28.88 46.27 percent of total billed charges AMPICILLIN 1 GM VIAL 48260254_1 CDM 0250 RC 00781-9404-95 NDC inpatient 1 UN 47.7 31.01 SIHO - ALL PLANS SIHO - ALL PLANS 42.93 90 999999999 28.88 46.27 percent of total billed charges AMPICILLIN 1 GM VIAL 48260254_1 CDM 0250 RC 00781-9404-95 NDC inpatient 1 UN 47.7 31.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 28.88 60.55 999999999 28.88 46.27 percent of total billed charges AMPICILLIN 1 GM VIAL 48260254_1 CDM 0250 RC 00781-9404-95 NDC inpatient 1 UN 47.7 31.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 28.88 46.27 AMPICILLIN 1 GM VIAL 48260254_1 CDM 0250 RC 00781-9404-95 NDC inpatient 1 UN 47.7 31.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 28.88 46.27 AMPICILLIN 1 GM VIAL 48260254_1 CDM 0250 RC 00781-9404-95 NDC inpatient 1 UN 47.7 31.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 28.88 46.27 AMPICILLIN 1 GM VIAL 48260254_1 CDM 0250 RC 00781-9404-95 NDC inpatient 1 UN 47.7 31.01 ANTHEM HMO ANTHEM HMO 999999999 28.88 46.27 AMPICILLIN 1 GM VIAL 48260254_1 CDM 0250 RC 00781-9404-95 NDC inpatient 1 UN 47.7 31.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 32.25 67.6 999999999 28.88 46.27 percent of total billed charges AMPICILLIN 1 GM VIAL 48260254_1 CDM 0250 RC 00781-9404-95 NDC inpatient 1 UN 47.7 31.01 UHC - ALL PLANS UHC - ALL PLANS 999999999 28.88 46.27 AMPICILLIN 500 MG CAPSULE 48260257_1 CDM 0250 RC 00781-2145-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges AMPICILLIN 500 MG CAPSULE 48260257_1 CDM 0250 RC 00781-2145-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges AMPICILLIN 500 MG CAPSULE 48260257_1 CDM 0250 RC 00781-2145-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges AMPICILLIN 500 MG CAPSULE 48260257_1 CDM 0250 RC 00781-2145-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges AMPICILLIN 500 MG CAPSULE 48260257_1 CDM 0250 RC 00781-2145-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges AMPICILLIN 500 MG CAPSULE 48260257_1 CDM 0250 RC 00781-2145-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges AMPICILLIN 500 MG CAPSULE 48260257_1 CDM 0250 RC 00781-2145-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges AMPICILLIN 500 MG CAPSULE 48260257_1 CDM 0250 RC 00781-2145-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges AMPICILLIN 500 MG CAPSULE 48260257_1 CDM 0250 RC 00781-2145-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 AMPICILLIN 500 MG CAPSULE 48260257_1 CDM 0250 RC 00781-2145-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 AMPICILLIN 500 MG CAPSULE 48260257_1 CDM 0250 RC 00781-2145-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 AMPICILLIN 500 MG CAPSULE 48260257_1 CDM 0250 RC 00781-2145-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 AMPICILLIN 500 MG CAPSULE 48260257_1 CDM 0250 RC 00781-2145-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges AMPICILLIN 500 MG CAPSULE 48260257_1 CDM 0250 RC 00781-2145-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 BUTALB-ACETAMIN-CAFF 50-325-40 48260267_1 CDM 0250 RC 51862-0179-01 NDC inpatient 1 UN 17.15 11.15 AETNA AETNA 13.55 79 999999999 10.38 16.64 percent of total billed charges BUTALB-ACETAMIN-CAFF 50-325-40 48260267_1 CDM 0250 RC 51862-0179-01 NDC inpatient 1 UN 17.15 11.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.15 65 999999999 10.38 16.64 percent of total billed charges BUTALB-ACETAMIN-CAFF 50-325-40 48260267_1 CDM 0250 RC 51862-0179-01 NDC inpatient 1 UN 17.15 11.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16.64 97 999999999 10.38 16.64 percent of total billed charges BUTALB-ACETAMIN-CAFF 50-325-40 48260267_1 CDM 0250 RC 51862-0179-01 NDC inpatient 1 UN 17.15 11.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.83 69 999999999 10.38 16.64 percent of total billed charges BUTALB-ACETAMIN-CAFF 50-325-40 48260267_1 CDM 0250 RC 51862-0179-01 NDC inpatient 1 UN 17.15 11.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.38 78 999999999 10.38 16.64 percent of total billed charges BUTALB-ACETAMIN-CAFF 50-325-40 48260267_1 CDM 0250 RC 51862-0179-01 NDC inpatient 1 UN 17.15 11.15 UMR - ALL PLANS UMR - ALL PLANS 12.01 70 999999999 10.38 16.64 percent of total billed charges BUTALB-ACETAMIN-CAFF 50-325-40 48260267_1 CDM 0250 RC 51862-0179-01 NDC inpatient 1 UN 17.15 11.15 SIHO - ALL PLANS SIHO - ALL PLANS 15.44 90 999999999 10.38 16.64 percent of total billed charges BUTALB-ACETAMIN-CAFF 50-325-40 48260267_1 CDM 0250 RC 51862-0179-01 NDC inpatient 1 UN 17.15 11.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.38 60.55 999999999 10.38 16.64 percent of total billed charges BUTALB-ACETAMIN-CAFF 50-325-40 48260267_1 CDM 0250 RC 51862-0179-01 NDC inpatient 1 UN 17.15 11.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.38 16.64 BUTALB-ACETAMIN-CAFF 50-325-40 48260267_1 CDM 0250 RC 51862-0179-01 NDC inpatient 1 UN 17.15 11.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.38 16.64 BUTALB-ACETAMIN-CAFF 50-325-40 48260267_1 CDM 0250 RC 51862-0179-01 NDC inpatient 1 UN 17.15 11.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.38 16.64 BUTALB-ACETAMIN-CAFF 50-325-40 48260267_1 CDM 0250 RC 51862-0179-01 NDC inpatient 1 UN 17.15 11.15 ANTHEM HMO ANTHEM HMO 999999999 10.38 16.64 BUTALB-ACETAMIN-CAFF 50-325-40 48260267_1 CDM 0250 RC 51862-0179-01 NDC inpatient 1 UN 17.15 11.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.59 67.6 999999999 10.38 16.64 percent of total billed charges BUTALB-ACETAMIN-CAFF 50-325-40 48260267_1 CDM 0250 RC 51862-0179-01 NDC inpatient 1 UN 17.15 11.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.38 16.64 BROVANA 15 MCG/2 ML SOLUTION 48260271_1 CDM 0250 RC 63402-0911-30 NDC inpatient 1 UN 49.92 32.45 AETNA AETNA 39.44 79 999999999 30.23 48.42 percent of total billed charges BROVANA 15 MCG/2 ML SOLUTION 48260271_1 CDM 0250 RC 63402-0911-30 NDC inpatient 1 UN 49.92 32.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.45 65 999999999 30.23 48.42 percent of total billed charges BROVANA 15 MCG/2 ML SOLUTION 48260271_1 CDM 0250 RC 63402-0911-30 NDC inpatient 1 UN 49.92 32.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.42 97 999999999 30.23 48.42 percent of total billed charges BROVANA 15 MCG/2 ML SOLUTION 48260271_1 CDM 0250 RC 63402-0911-30 NDC inpatient 1 UN 49.92 32.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.44 69 999999999 30.23 48.42 percent of total billed charges BROVANA 15 MCG/2 ML SOLUTION 48260271_1 CDM 0250 RC 63402-0911-30 NDC inpatient 1 UN 49.92 32.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 38.94 78 999999999 30.23 48.42 percent of total billed charges BROVANA 15 MCG/2 ML SOLUTION 48260271_1 CDM 0250 RC 63402-0911-30 NDC inpatient 1 UN 49.92 32.45 UMR - ALL PLANS UMR - ALL PLANS 34.94 70 999999999 30.23 48.42 percent of total billed charges BROVANA 15 MCG/2 ML SOLUTION 48260271_1 CDM 0250 RC 63402-0911-30 NDC inpatient 1 UN 49.92 32.45 SIHO - ALL PLANS SIHO - ALL PLANS 44.93 90 999999999 30.23 48.42 percent of total billed charges BROVANA 15 MCG/2 ML SOLUTION 48260271_1 CDM 0250 RC 63402-0911-30 NDC inpatient 1 UN 49.92 32.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.23 60.55 999999999 30.23 48.42 percent of total billed charges BROVANA 15 MCG/2 ML SOLUTION 48260271_1 CDM 0250 RC 63402-0911-30 NDC inpatient 1 UN 49.92 32.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.23 48.42 BROVANA 15 MCG/2 ML SOLUTION 48260271_1 CDM 0250 RC 63402-0911-30 NDC inpatient 1 UN 49.92 32.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.23 48.42 BROVANA 15 MCG/2 ML SOLUTION 48260271_1 CDM 0250 RC 63402-0911-30 NDC inpatient 1 UN 49.92 32.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.23 48.42 BROVANA 15 MCG/2 ML SOLUTION 48260271_1 CDM 0250 RC 63402-0911-30 NDC inpatient 1 UN 49.92 32.45 ANTHEM HMO ANTHEM HMO 999999999 30.23 48.42 BROVANA 15 MCG/2 ML SOLUTION 48260271_1 CDM 0250 RC 63402-0911-30 NDC inpatient 1 UN 49.92 32.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.75 67.6 999999999 30.23 48.42 percent of total billed charges BROVANA 15 MCG/2 ML SOLUTION 48260271_1 CDM 0250 RC 63402-0911-30 NDC inpatient 1 UN 49.92 32.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.23 48.42 ASPIRIN 300 MG SUPPOSITORY 48260281_1 CDM 0250 RC 00574-7034-12 NDC inpatient 1 UN 5.77 3.75 AETNA AETNA 4.56 79 999999999 3.49 5.6 percent of total billed charges ASPIRIN 300 MG SUPPOSITORY 48260281_1 CDM 0250 RC 00574-7034-12 NDC inpatient 1 UN 5.77 3.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.75 65 999999999 3.49 5.6 percent of total billed charges ASPIRIN 300 MG SUPPOSITORY 48260281_1 CDM 0250 RC 00574-7034-12 NDC inpatient 1 UN 5.77 3.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.6 97 999999999 3.49 5.6 percent of total billed charges ASPIRIN 300 MG SUPPOSITORY 48260281_1 CDM 0250 RC 00574-7034-12 NDC inpatient 1 UN 5.77 3.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.98 69 999999999 3.49 5.6 percent of total billed charges ASPIRIN 300 MG SUPPOSITORY 48260281_1 CDM 0250 RC 00574-7034-12 NDC inpatient 1 UN 5.77 3.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.5 78 999999999 3.49 5.6 percent of total billed charges ASPIRIN 300 MG SUPPOSITORY 48260281_1 CDM 0250 RC 00574-7034-12 NDC inpatient 1 UN 5.77 3.75 UMR - ALL PLANS UMR - ALL PLANS 4.04 70 999999999 3.49 5.6 percent of total billed charges ASPIRIN 300 MG SUPPOSITORY 48260281_1 CDM 0250 RC 00574-7034-12 NDC inpatient 1 UN 5.77 3.75 SIHO - ALL PLANS SIHO - ALL PLANS 5.19 90 999999999 3.49 5.6 percent of total billed charges ASPIRIN 300 MG SUPPOSITORY 48260281_1 CDM 0250 RC 00574-7034-12 NDC inpatient 1 UN 5.77 3.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.49 60.55 999999999 3.49 5.6 percent of total billed charges ASPIRIN 300 MG SUPPOSITORY 48260281_1 CDM 0250 RC 00574-7034-12 NDC inpatient 1 UN 5.77 3.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.49 5.6 ASPIRIN 300 MG SUPPOSITORY 48260281_1 CDM 0250 RC 00574-7034-12 NDC inpatient 1 UN 5.77 3.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.49 5.6 ASPIRIN 300 MG SUPPOSITORY 48260281_1 CDM 0250 RC 00574-7034-12 NDC inpatient 1 UN 5.77 3.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.49 5.6 ASPIRIN 300 MG SUPPOSITORY 48260281_1 CDM 0250 RC 00574-7034-12 NDC inpatient 1 UN 5.77 3.75 ANTHEM HMO ANTHEM HMO 999999999 3.49 5.6 ASPIRIN 300 MG SUPPOSITORY 48260281_1 CDM 0250 RC 00574-7034-12 NDC inpatient 1 UN 5.77 3.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.9 67.6 999999999 3.49 5.6 percent of total billed charges ASPIRIN 300 MG SUPPOSITORY 48260281_1 CDM 0250 RC 00574-7034-12 NDC inpatient 1 UN 5.77 3.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.49 5.6 ASPIRIN 600 MG SUPPOSITORY 48260283_1 CDM 0250 RC 00574-7036-12 NDC inpatient 1 UN 5.22 3.39 AETNA AETNA 4.12 79 999999999 3.16 5.06 percent of total billed charges ASPIRIN 600 MG SUPPOSITORY 48260283_1 CDM 0250 RC 00574-7036-12 NDC inpatient 1 UN 5.22 3.39 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.39 65 999999999 3.16 5.06 percent of total billed charges ASPIRIN 600 MG SUPPOSITORY 48260283_1 CDM 0250 RC 00574-7036-12 NDC inpatient 1 UN 5.22 3.39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.06 97 999999999 3.16 5.06 percent of total billed charges ASPIRIN 600 MG SUPPOSITORY 48260283_1 CDM 0250 RC 00574-7036-12 NDC inpatient 1 UN 5.22 3.39 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.6 69 999999999 3.16 5.06 percent of total billed charges ASPIRIN 600 MG SUPPOSITORY 48260283_1 CDM 0250 RC 00574-7036-12 NDC inpatient 1 UN 5.22 3.39 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.07 78 999999999 3.16 5.06 percent of total billed charges ASPIRIN 600 MG SUPPOSITORY 48260283_1 CDM 0250 RC 00574-7036-12 NDC inpatient 1 UN 5.22 3.39 UMR - ALL PLANS UMR - ALL PLANS 3.65 70 999999999 3.16 5.06 percent of total billed charges ASPIRIN 600 MG SUPPOSITORY 48260283_1 CDM 0250 RC 00574-7036-12 NDC inpatient 1 UN 5.22 3.39 SIHO - ALL PLANS SIHO - ALL PLANS 4.7 90 999999999 3.16 5.06 percent of total billed charges ASPIRIN 600 MG SUPPOSITORY 48260283_1 CDM 0250 RC 00574-7036-12 NDC inpatient 1 UN 5.22 3.39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.16 60.55 999999999 3.16 5.06 percent of total billed charges ASPIRIN 600 MG SUPPOSITORY 48260283_1 CDM 0250 RC 00574-7036-12 NDC inpatient 1 UN 5.22 3.39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.16 5.06 ASPIRIN 600 MG SUPPOSITORY 48260283_1 CDM 0250 RC 00574-7036-12 NDC inpatient 1 UN 5.22 3.39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.16 5.06 ASPIRIN 600 MG SUPPOSITORY 48260283_1 CDM 0250 RC 00574-7036-12 NDC inpatient 1 UN 5.22 3.39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.16 5.06 ASPIRIN 600 MG SUPPOSITORY 48260283_1 CDM 0250 RC 00574-7036-12 NDC inpatient 1 UN 5.22 3.39 ANTHEM HMO ANTHEM HMO 999999999 3.16 5.06 ASPIRIN 600 MG SUPPOSITORY 48260283_1 CDM 0250 RC 00574-7036-12 NDC inpatient 1 UN 5.22 3.39 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.53 67.6 999999999 3.16 5.06 percent of total billed charges ASPIRIN 600 MG SUPPOSITORY 48260283_1 CDM 0250 RC 00574-7036-12 NDC inpatient 1 UN 5.22 3.39 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.16 5.06 ATENOLOL 25 MG TABLET 48260285_1 CDM 0250 RC 51079-0759-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ATENOLOL 25 MG TABLET 48260285_1 CDM 0250 RC 51079-0759-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ATENOLOL 25 MG TABLET 48260285_1 CDM 0250 RC 51079-0759-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ATENOLOL 25 MG TABLET 48260285_1 CDM 0250 RC 51079-0759-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ATENOLOL 25 MG TABLET 48260285_1 CDM 0250 RC 51079-0759-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ATENOLOL 25 MG TABLET 48260285_1 CDM 0250 RC 51079-0759-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ATENOLOL 25 MG TABLET 48260285_1 CDM 0250 RC 51079-0759-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ATENOLOL 25 MG TABLET 48260285_1 CDM 0250 RC 51079-0759-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ATENOLOL 25 MG TABLET 48260285_1 CDM 0250 RC 51079-0759-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ATENOLOL 25 MG TABLET 48260285_1 CDM 0250 RC 51079-0759-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ATENOLOL 25 MG TABLET 48260285_1 CDM 0250 RC 51079-0759-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ATENOLOL 25 MG TABLET 48260285_1 CDM 0250 RC 51079-0759-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ATENOLOL 25 MG TABLET 48260285_1 CDM 0250 RC 51079-0759-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges ATENOLOL 25 MG TABLET 48260285_1 CDM 0250 RC 51079-0759-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ATORVASTATIN 10 MG TABLET 48260286_1 CDM 0250 RC 68084-0097-01 NDC inpatient 1 UN 1.99 1.29 AETNA AETNA 1.57 79 999999999 1.2 1.93 percent of total billed charges ATORVASTATIN 10 MG TABLET 48260286_1 CDM 0250 RC 68084-0097-01 NDC inpatient 1 UN 1.99 1.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.29 65 999999999 1.2 1.93 percent of total billed charges ATORVASTATIN 10 MG TABLET 48260286_1 CDM 0250 RC 68084-0097-01 NDC inpatient 1 UN 1.99 1.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.93 97 999999999 1.2 1.93 percent of total billed charges ATORVASTATIN 10 MG TABLET 48260286_1 CDM 0250 RC 68084-0097-01 NDC inpatient 1 UN 1.99 1.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.37 69 999999999 1.2 1.93 percent of total billed charges ATORVASTATIN 10 MG TABLET 48260286_1 CDM 0250 RC 68084-0097-01 NDC inpatient 1 UN 1.99 1.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.55 78 999999999 1.2 1.93 percent of total billed charges ATORVASTATIN 10 MG TABLET 48260286_1 CDM 0250 RC 68084-0097-01 NDC inpatient 1 UN 1.99 1.29 UMR - ALL PLANS UMR - ALL PLANS 1.39 70 999999999 1.2 1.93 percent of total billed charges ATORVASTATIN 10 MG TABLET 48260286_1 CDM 0250 RC 68084-0097-01 NDC inpatient 1 UN 1.99 1.29 SIHO - ALL PLANS SIHO - ALL PLANS 1.79 90 999999999 1.2 1.93 percent of total billed charges ATORVASTATIN 10 MG TABLET 48260286_1 CDM 0250 RC 68084-0097-01 NDC inpatient 1 UN 1.99 1.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.2 60.55 999999999 1.2 1.93 percent of total billed charges ATORVASTATIN 10 MG TABLET 48260286_1 CDM 0250 RC 68084-0097-01 NDC inpatient 1 UN 1.99 1.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.2 1.93 ATORVASTATIN 10 MG TABLET 48260286_1 CDM 0250 RC 68084-0097-01 NDC inpatient 1 UN 1.99 1.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.2 1.93 ATORVASTATIN 10 MG TABLET 48260286_1 CDM 0250 RC 68084-0097-01 NDC inpatient 1 UN 1.99 1.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.2 1.93 ATORVASTATIN 10 MG TABLET 48260286_1 CDM 0250 RC 68084-0097-01 NDC inpatient 1 UN 1.99 1.29 ANTHEM HMO ANTHEM HMO 999999999 1.2 1.93 ATORVASTATIN 10 MG TABLET 48260286_1 CDM 0250 RC 68084-0097-01 NDC inpatient 1 UN 1.99 1.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.2 1.93 percent of total billed charges ATORVASTATIN 10 MG TABLET 48260286_1 CDM 0250 RC 68084-0097-01 NDC inpatient 1 UN 1.99 1.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.2 1.93 ATORVASTATIN 20 MG TABLET 48260287_1 CDM 0250 RC 68084-0098-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 20 MG TABLET 48260287_1 CDM 0250 RC 68084-0098-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 20 MG TABLET 48260287_1 CDM 0250 RC 68084-0098-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 20 MG TABLET 48260287_1 CDM 0250 RC 68084-0098-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 20 MG TABLET 48260287_1 CDM 0250 RC 68084-0098-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 20 MG TABLET 48260287_1 CDM 0250 RC 68084-0098-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 20 MG TABLET 48260287_1 CDM 0250 RC 68084-0098-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 20 MG TABLET 48260287_1 CDM 0250 RC 68084-0098-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 20 MG TABLET 48260287_1 CDM 0250 RC 68084-0098-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ATORVASTATIN 20 MG TABLET 48260287_1 CDM 0250 RC 68084-0098-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ATORVASTATIN 20 MG TABLET 48260287_1 CDM 0250 RC 68084-0098-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ATORVASTATIN 20 MG TABLET 48260287_1 CDM 0250 RC 68084-0098-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ATORVASTATIN 20 MG TABLET 48260287_1 CDM 0250 RC 68084-0098-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 20 MG TABLET 48260287_1 CDM 0250 RC 68084-0098-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ATROPINE 0.4 MG/ML VIAL 48260291_1 CDM 0250 RC 00517-0401-25 NDC inpatient 1 UN 38.01 24.71 AETNA AETNA 30.03 79 999999999 23.02 36.87 percent of total billed charges ATROPINE 0.4 MG/ML VIAL 48260291_1 CDM 0250 RC 00517-0401-25 NDC inpatient 1 UN 38.01 24.71 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.71 65 999999999 23.02 36.87 percent of total billed charges ATROPINE 0.4 MG/ML VIAL 48260291_1 CDM 0250 RC 00517-0401-25 NDC inpatient 1 UN 38.01 24.71 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 36.87 97 999999999 23.02 36.87 percent of total billed charges ATROPINE 0.4 MG/ML VIAL 48260291_1 CDM 0250 RC 00517-0401-25 NDC inpatient 1 UN 38.01 24.71 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.23 69 999999999 23.02 36.87 percent of total billed charges ATROPINE 0.4 MG/ML VIAL 48260291_1 CDM 0250 RC 00517-0401-25 NDC inpatient 1 UN 38.01 24.71 HUMANA - ALL PLANS HUMANA - ALL PLANS 29.65 78 999999999 23.02 36.87 percent of total billed charges ATROPINE 0.4 MG/ML VIAL 48260291_1 CDM 0250 RC 00517-0401-25 NDC inpatient 1 UN 38.01 24.71 UMR - ALL PLANS UMR - ALL PLANS 26.61 70 999999999 23.02 36.87 percent of total billed charges ATROPINE 0.4 MG/ML VIAL 48260291_1 CDM 0250 RC 00517-0401-25 NDC inpatient 1 UN 38.01 24.71 SIHO - ALL PLANS SIHO - ALL PLANS 34.21 90 999999999 23.02 36.87 percent of total billed charges ATROPINE 0.4 MG/ML VIAL 48260291_1 CDM 0250 RC 00517-0401-25 NDC inpatient 1 UN 38.01 24.71 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.02 60.55 999999999 23.02 36.87 percent of total billed charges ATROPINE 0.4 MG/ML VIAL 48260291_1 CDM 0250 RC 00517-0401-25 NDC inpatient 1 UN 38.01 24.71 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.02 36.87 ATROPINE 0.4 MG/ML VIAL 48260291_1 CDM 0250 RC 00517-0401-25 NDC inpatient 1 UN 38.01 24.71 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.02 36.87 ATROPINE 0.4 MG/ML VIAL 48260291_1 CDM 0250 RC 00517-0401-25 NDC inpatient 1 UN 38.01 24.71 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.02 36.87 ATROPINE 0.4 MG/ML VIAL 48260291_1 CDM 0250 RC 00517-0401-25 NDC inpatient 1 UN 38.01 24.71 ANTHEM HMO ANTHEM HMO 999999999 23.02 36.87 ATROPINE 0.4 MG/ML VIAL 48260291_1 CDM 0250 RC 00517-0401-25 NDC inpatient 1 UN 38.01 24.71 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.69 67.6 999999999 23.02 36.87 percent of total billed charges ATROPINE 0.4 MG/ML VIAL 48260291_1 CDM 0250 RC 00517-0401-25 NDC inpatient 1 UN 38.01 24.71 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.02 36.87 ATROPINE 8 MG/20 ML VIAL 48260292_1 CDM 0250 RC 00641-6006-10 NDC inpatient 1 UN 155.53 101.09 AETNA AETNA 122.87 79 999999999 94.17 150.86 percent of total billed charges ATROPINE 8 MG/20 ML VIAL 48260292_1 CDM 0250 RC 00641-6006-10 NDC inpatient 1 UN 155.53 101.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.09 65 999999999 94.17 150.86 percent of total billed charges ATROPINE 8 MG/20 ML VIAL 48260292_1 CDM 0250 RC 00641-6006-10 NDC inpatient 1 UN 155.53 101.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 150.86 97 999999999 94.17 150.86 percent of total billed charges ATROPINE 8 MG/20 ML VIAL 48260292_1 CDM 0250 RC 00641-6006-10 NDC inpatient 1 UN 155.53 101.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.32 69 999999999 94.17 150.86 percent of total billed charges ATROPINE 8 MG/20 ML VIAL 48260292_1 CDM 0250 RC 00641-6006-10 NDC inpatient 1 UN 155.53 101.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.31 78 999999999 94.17 150.86 percent of total billed charges ATROPINE 8 MG/20 ML VIAL 48260292_1 CDM 0250 RC 00641-6006-10 NDC inpatient 1 UN 155.53 101.09 UMR - ALL PLANS UMR - ALL PLANS 108.87 70 999999999 94.17 150.86 percent of total billed charges ATROPINE 8 MG/20 ML VIAL 48260292_1 CDM 0250 RC 00641-6006-10 NDC inpatient 1 UN 155.53 101.09 SIHO - ALL PLANS SIHO - ALL PLANS 139.98 90 999999999 94.17 150.86 percent of total billed charges ATROPINE 8 MG/20 ML VIAL 48260292_1 CDM 0250 RC 00641-6006-10 NDC inpatient 1 UN 155.53 101.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.17 60.55 999999999 94.17 150.86 percent of total billed charges ATROPINE 8 MG/20 ML VIAL 48260292_1 CDM 0250 RC 00641-6006-10 NDC inpatient 1 UN 155.53 101.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.17 150.86 ATROPINE 8 MG/20 ML VIAL 48260292_1 CDM 0250 RC 00641-6006-10 NDC inpatient 1 UN 155.53 101.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.17 150.86 ATROPINE 8 MG/20 ML VIAL 48260292_1 CDM 0250 RC 00641-6006-10 NDC inpatient 1 UN 155.53 101.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.17 150.86 ATROPINE 8 MG/20 ML VIAL 48260292_1 CDM 0250 RC 00641-6006-10 NDC inpatient 1 UN 155.53 101.09 ANTHEM HMO ANTHEM HMO 999999999 94.17 150.86 ATROPINE 8 MG/20 ML VIAL 48260292_1 CDM 0250 RC 00641-6006-10 NDC inpatient 1 UN 155.53 101.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.14 67.6 999999999 94.17 150.86 percent of total billed charges ATROPINE 8 MG/20 ML VIAL 48260292_1 CDM 0250 RC 00641-6006-10 NDC inpatient 1 UN 155.53 101.09 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.17 150.86 76329-3339-01 - atropine 0.1 mg/mL Inj Sol [JOHN] 48260293_1 CDM 0250 RC 76329-3339-01 NDC inpatient 1 UN 58.56 38.06 AETNA AETNA 46.26 79 999999999 35.46 56.8 percent of total billed charges 76329-3339-01 - atropine 0.1 mg/mL Inj Sol [JOHN] 48260293_1 CDM 0250 RC 76329-3339-01 NDC inpatient 1 UN 58.56 38.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 38.06 65 999999999 35.46 56.8 percent of total billed charges 76329-3339-01 - atropine 0.1 mg/mL Inj Sol [JOHN] 48260293_1 CDM 0250 RC 76329-3339-01 NDC inpatient 1 UN 58.56 38.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.8 97 999999999 35.46 56.8 percent of total billed charges 76329-3339-01 - atropine 0.1 mg/mL Inj Sol [JOHN] 48260293_1 CDM 0250 RC 76329-3339-01 NDC inpatient 1 UN 58.56 38.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.41 69 999999999 35.46 56.8 percent of total billed charges 76329-3339-01 - atropine 0.1 mg/mL Inj Sol [JOHN] 48260293_1 CDM 0250 RC 76329-3339-01 NDC inpatient 1 UN 58.56 38.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.68 78 999999999 35.46 56.8 percent of total billed charges 76329-3339-01 - atropine 0.1 mg/mL Inj Sol [JOHN] 48260293_1 CDM 0250 RC 76329-3339-01 NDC inpatient 1 UN 58.56 38.06 UMR - ALL PLANS UMR - ALL PLANS 40.99 70 999999999 35.46 56.8 percent of total billed charges 76329-3339-01 - atropine 0.1 mg/mL Inj Sol [JOHN] 48260293_1 CDM 0250 RC 76329-3339-01 NDC inpatient 1 UN 58.56 38.06 SIHO - ALL PLANS SIHO - ALL PLANS 52.7 90 999999999 35.46 56.8 percent of total billed charges 76329-3339-01 - atropine 0.1 mg/mL Inj Sol [JOHN] 48260293_1 CDM 0250 RC 76329-3339-01 NDC inpatient 1 UN 58.56 38.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.46 60.55 999999999 35.46 56.8 percent of total billed charges 76329-3339-01 - atropine 0.1 mg/mL Inj Sol [JOHN] 48260293_1 CDM 0250 RC 76329-3339-01 NDC inpatient 1 UN 58.56 38.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.46 56.8 76329-3339-01 - atropine 0.1 mg/mL Inj Sol [JOHN] 48260293_1 CDM 0250 RC 76329-3339-01 NDC inpatient 1 UN 58.56 38.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.46 56.8 76329-3339-01 - atropine 0.1 mg/mL Inj Sol [JOHN] 48260293_1 CDM 0250 RC 76329-3339-01 NDC inpatient 1 UN 58.56 38.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.46 56.8 76329-3339-01 - atropine 0.1 mg/mL Inj Sol [JOHN] 48260293_1 CDM 0250 RC 76329-3339-01 NDC inpatient 1 UN 58.56 38.06 ANTHEM HMO ANTHEM HMO 999999999 35.46 56.8 76329-3339-01 - atropine 0.1 mg/mL Inj Sol [JOHN] 48260293_1 CDM 0250 RC 76329-3339-01 NDC inpatient 1 UN 58.56 38.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.59 67.6 999999999 35.46 56.8 percent of total billed charges 76329-3339-01 - atropine 0.1 mg/mL Inj Sol [JOHN] 48260293_1 CDM 0250 RC 76329-3339-01 NDC inpatient 1 UN 58.56 38.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.46 56.8 ATROPINE 1 MG/ML VIAL 48260294_1 CDM 0250 RC 00517-1010-25 NDC inpatient 1 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges ATROPINE 1 MG/ML VIAL 48260294_1 CDM 0250 RC 00517-1010-25 NDC inpatient 1 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges ATROPINE 1 MG/ML VIAL 48260294_1 CDM 0250 RC 00517-1010-25 NDC inpatient 1 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges ATROPINE 1 MG/ML VIAL 48260294_1 CDM 0250 RC 00517-1010-25 NDC inpatient 1 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges ATROPINE 1 MG/ML VIAL 48260294_1 CDM 0250 RC 00517-1010-25 NDC inpatient 1 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges ATROPINE 1 MG/ML VIAL 48260294_1 CDM 0250 RC 00517-1010-25 NDC inpatient 1 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges ATROPINE 1 MG/ML VIAL 48260294_1 CDM 0250 RC 00517-1010-25 NDC inpatient 1 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges ATROPINE 1 MG/ML VIAL 48260294_1 CDM 0250 RC 00517-1010-25 NDC inpatient 1 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges ATROPINE 1 MG/ML VIAL 48260294_1 CDM 0250 RC 00517-1010-25 NDC inpatient 1 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 ATROPINE 1 MG/ML VIAL 48260294_1 CDM 0250 RC 00517-1010-25 NDC inpatient 1 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 ATROPINE 1 MG/ML VIAL 48260294_1 CDM 0250 RC 00517-1010-25 NDC inpatient 1 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 ATROPINE 1 MG/ML VIAL 48260294_1 CDM 0250 RC 00517-1010-25 NDC inpatient 1 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 ATROPINE 1 MG/ML VIAL 48260294_1 CDM 0250 RC 00517-1010-25 NDC inpatient 1 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges ATROPINE 1 MG/ML VIAL 48260294_1 CDM 0250 RC 00517-1010-25 NDC inpatient 1 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 "INJECTION, AZACITIDINE, 1 MG" 48260300_1 CDM 0636 RC 59572-0102-01 NDC J9025 HCPCS inpatient 100 UN 2779.62 1806.75 AETNA AETNA 2195.9 79 999999999 1683.06 2696.23 percent of total billed charges "INJECTION, AZACITIDINE, 1 MG" 48260300_1 CDM 0636 RC 59572-0102-01 NDC J9025 HCPCS inpatient 100 UN 2779.62 1806.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1806.75 65 999999999 1683.06 2696.23 percent of total billed charges "INJECTION, AZACITIDINE, 1 MG" 48260300_1 CDM 0636 RC 59572-0102-01 NDC J9025 HCPCS inpatient 100 UN 2779.62 1806.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2696.23 97 999999999 1683.06 2696.23 percent of total billed charges "INJECTION, AZACITIDINE, 1 MG" 48260300_1 CDM 0636 RC 59572-0102-01 NDC J9025 HCPCS inpatient 100 UN 2779.62 1806.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1917.94 69 999999999 1683.06 2696.23 percent of total billed charges "INJECTION, AZACITIDINE, 1 MG" 48260300_1 CDM 0636 RC 59572-0102-01 NDC J9025 HCPCS inpatient 100 UN 2779.62 1806.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 2168.1 78 999999999 1683.06 2696.23 percent of total billed charges "INJECTION, AZACITIDINE, 1 MG" 48260300_1 CDM 0636 RC 59572-0102-01 NDC J9025 HCPCS inpatient 100 UN 2779.62 1806.75 UMR - ALL PLANS UMR - ALL PLANS 1945.73 70 999999999 1683.06 2696.23 percent of total billed charges "INJECTION, AZACITIDINE, 1 MG" 48260300_1 CDM 0636 RC 59572-0102-01 NDC J9025 HCPCS inpatient 100 UN 2779.62 1806.75 SIHO - ALL PLANS SIHO - ALL PLANS 2501.66 90 999999999 1683.06 2696.23 percent of total billed charges "INJECTION, AZACITIDINE, 1 MG" 48260300_1 CDM 0636 RC 59572-0102-01 NDC J9025 HCPCS inpatient 100 UN 2779.62 1806.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1683.06 60.55 999999999 1683.06 2696.23 percent of total billed charges "INJECTION, AZACITIDINE, 1 MG" 48260300_1 CDM 0636 RC 59572-0102-01 NDC J9025 HCPCS inpatient 100 UN 2779.62 1806.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1683.06 2696.23 "INJECTION, AZACITIDINE, 1 MG" 48260300_1 CDM 0636 RC 59572-0102-01 NDC J9025 HCPCS inpatient 100 UN 2779.62 1806.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1683.06 2696.23 "INJECTION, AZACITIDINE, 1 MG" 48260300_1 CDM 0636 RC 59572-0102-01 NDC J9025 HCPCS inpatient 100 UN 2779.62 1806.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1683.06 2696.23 "INJECTION, AZACITIDINE, 1 MG" 48260300_1 CDM 0636 RC 59572-0102-01 NDC J9025 HCPCS inpatient 100 UN 2779.62 1806.75 ANTHEM HMO ANTHEM HMO 999999999 1683.06 2696.23 "INJECTION, AZACITIDINE, 1 MG" 48260300_1 CDM 0636 RC 59572-0102-01 NDC J9025 HCPCS inpatient 100 UN 2779.62 1806.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1879.02 67.6 999999999 1683.06 2696.23 percent of total billed charges "INJECTION, AZACITIDINE, 1 MG" 48260300_1 CDM 0636 RC 59572-0102-01 NDC J9025 HCPCS inpatient 100 UN 2779.62 1806.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1683.06 2696.23 50268-0098-15 - azithromycin 250 mg Tab [JOHN] 48260304_1 CDM 0250 RC 50268-0098-15 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 50268-0098-15 - azithromycin 250 mg Tab [JOHN] 48260304_1 CDM 0250 RC 50268-0098-15 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 50268-0098-15 - azithromycin 250 mg Tab [JOHN] 48260304_1 CDM 0250 RC 50268-0098-15 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 50268-0098-15 - azithromycin 250 mg Tab [JOHN] 48260304_1 CDM 0250 RC 50268-0098-15 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 50268-0098-15 - azithromycin 250 mg Tab [JOHN] 48260304_1 CDM 0250 RC 50268-0098-15 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 50268-0098-15 - azithromycin 250 mg Tab [JOHN] 48260304_1 CDM 0250 RC 50268-0098-15 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 50268-0098-15 - azithromycin 250 mg Tab [JOHN] 48260304_1 CDM 0250 RC 50268-0098-15 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 50268-0098-15 - azithromycin 250 mg Tab [JOHN] 48260304_1 CDM 0250 RC 50268-0098-15 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 50268-0098-15 - azithromycin 250 mg Tab [JOHN] 48260304_1 CDM 0250 RC 50268-0098-15 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 50268-0098-15 - azithromycin 250 mg Tab [JOHN] 48260304_1 CDM 0250 RC 50268-0098-15 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 50268-0098-15 - azithromycin 250 mg Tab [JOHN] 48260304_1 CDM 0250 RC 50268-0098-15 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 50268-0098-15 - azithromycin 250 mg Tab [JOHN] 48260304_1 CDM 0250 RC 50268-0098-15 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 50268-0098-15 - azithromycin 250 mg Tab [JOHN] 48260304_1 CDM 0250 RC 50268-0098-15 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 50268-0098-15 - azithromycin 250 mg Tab [JOHN] 48260304_1 CDM 0250 RC 50268-0098-15 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 BACITRACIN 500 UNIT/GM OPHTH 48260311_1 CDM 0250 RC 00574-4022-35 NDC inpatient 1 UN 439.32 285.56 AETNA AETNA 347.06 79 999999999 266.01 426.14 percent of total billed charges BACITRACIN 500 UNIT/GM OPHTH 48260311_1 CDM 0250 RC 00574-4022-35 NDC inpatient 1 UN 439.32 285.56 SELF PAY DISCOUNT SELF PAY DISCOUNT 285.56 65 999999999 266.01 426.14 percent of total billed charges BACITRACIN 500 UNIT/GM OPHTH 48260311_1 CDM 0250 RC 00574-4022-35 NDC inpatient 1 UN 439.32 285.56 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 426.14 97 999999999 266.01 426.14 percent of total billed charges BACITRACIN 500 UNIT/GM OPHTH 48260311_1 CDM 0250 RC 00574-4022-35 NDC inpatient 1 UN 439.32 285.56 ENCORE - ALL PLANS ENCORE - ALL PLANS 303.13 69 999999999 266.01 426.14 percent of total billed charges BACITRACIN 500 UNIT/GM OPHTH 48260311_1 CDM 0250 RC 00574-4022-35 NDC inpatient 1 UN 439.32 285.56 HUMANA - ALL PLANS HUMANA - ALL PLANS 342.67 78 999999999 266.01 426.14 percent of total billed charges BACITRACIN 500 UNIT/GM OPHTH 48260311_1 CDM 0250 RC 00574-4022-35 NDC inpatient 1 UN 439.32 285.56 UMR - ALL PLANS UMR - ALL PLANS 307.52 70 999999999 266.01 426.14 percent of total billed charges BACITRACIN 500 UNIT/GM OPHTH 48260311_1 CDM 0250 RC 00574-4022-35 NDC inpatient 1 UN 439.32 285.56 SIHO - ALL PLANS SIHO - ALL PLANS 395.39 90 999999999 266.01 426.14 percent of total billed charges BACITRACIN 500 UNIT/GM OPHTH 48260311_1 CDM 0250 RC 00574-4022-35 NDC inpatient 1 UN 439.32 285.56 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 266.01 60.55 999999999 266.01 426.14 percent of total billed charges BACITRACIN 500 UNIT/GM OPHTH 48260311_1 CDM 0250 RC 00574-4022-35 NDC inpatient 1 UN 439.32 285.56 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 266.01 426.14 BACITRACIN 500 UNIT/GM OPHTH 48260311_1 CDM 0250 RC 00574-4022-35 NDC inpatient 1 UN 439.32 285.56 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 266.01 426.14 BACITRACIN 500 UNIT/GM OPHTH 48260311_1 CDM 0250 RC 00574-4022-35 NDC inpatient 1 UN 439.32 285.56 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 266.01 426.14 BACITRACIN 500 UNIT/GM OPHTH 48260311_1 CDM 0250 RC 00574-4022-35 NDC inpatient 1 UN 439.32 285.56 ANTHEM HMO ANTHEM HMO 999999999 266.01 426.14 BACITRACIN 500 UNIT/GM OPHTH 48260311_1 CDM 0250 RC 00574-4022-35 NDC inpatient 1 UN 439.32 285.56 CIGNA - ALL PLANS CIGNA - ALL PLANS 296.98 67.6 999999999 266.01 426.14 percent of total billed charges BACITRACIN 500 UNIT/GM OPHTH 48260311_1 CDM 0250 RC 00574-4022-35 NDC inpatient 1 UN 439.32 285.56 UHC - ALL PLANS UHC - ALL PLANS 999999999 266.01 426.14 00168-0011-31 - bacitracin topical zinc 500 units/g Oin 28.35 gm [JOHN] 48260312_1 CDM 0250 RC 00168-0011-31 NDC inpatient 1 UN 10.17 6.61 AETNA AETNA 8.03 79 999999999 6.16 9.86 percent of total billed charges 00168-0011-31 - bacitracin topical zinc 500 units/g Oin 28.35 gm [JOHN] 48260312_1 CDM 0250 RC 00168-0011-31 NDC inpatient 1 UN 10.17 6.61 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.61 65 999999999 6.16 9.86 percent of total billed charges 00168-0011-31 - bacitracin topical zinc 500 units/g Oin 28.35 gm [JOHN] 48260312_1 CDM 0250 RC 00168-0011-31 NDC inpatient 1 UN 10.17 6.61 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.86 97 999999999 6.16 9.86 percent of total billed charges 00168-0011-31 - bacitracin topical zinc 500 units/g Oin 28.35 gm [JOHN] 48260312_1 CDM 0250 RC 00168-0011-31 NDC inpatient 1 UN 10.17 6.61 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.02 69 999999999 6.16 9.86 percent of total billed charges 00168-0011-31 - bacitracin topical zinc 500 units/g Oin 28.35 gm [JOHN] 48260312_1 CDM 0250 RC 00168-0011-31 NDC inpatient 1 UN 10.17 6.61 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.93 78 999999999 6.16 9.86 percent of total billed charges 00168-0011-31 - bacitracin topical zinc 500 units/g Oin 28.35 gm [JOHN] 48260312_1 CDM 0250 RC 00168-0011-31 NDC inpatient 1 UN 10.17 6.61 UMR - ALL PLANS UMR - ALL PLANS 7.12 70 999999999 6.16 9.86 percent of total billed charges 00168-0011-31 - bacitracin topical zinc 500 units/g Oin 28.35 gm [JOHN] 48260312_1 CDM 0250 RC 00168-0011-31 NDC inpatient 1 UN 10.17 6.61 SIHO - ALL PLANS SIHO - ALL PLANS 9.15 90 999999999 6.16 9.86 percent of total billed charges 00168-0011-31 - bacitracin topical zinc 500 units/g Oin 28.35 gm [JOHN] 48260312_1 CDM 0250 RC 00168-0011-31 NDC inpatient 1 UN 10.17 6.61 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.16 60.55 999999999 6.16 9.86 percent of total billed charges 00168-0011-31 - bacitracin topical zinc 500 units/g Oin 28.35 gm [JOHN] 48260312_1 CDM 0250 RC 00168-0011-31 NDC inpatient 1 UN 10.17 6.61 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.16 9.86 00168-0011-31 - bacitracin topical zinc 500 units/g Oin 28.35 gm [JOHN] 48260312_1 CDM 0250 RC 00168-0011-31 NDC inpatient 1 UN 10.17 6.61 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.16 9.86 00168-0011-31 - bacitracin topical zinc 500 units/g Oin 28.35 gm [JOHN] 48260312_1 CDM 0250 RC 00168-0011-31 NDC inpatient 1 UN 10.17 6.61 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.16 9.86 00168-0011-31 - bacitracin topical zinc 500 units/g Oin 28.35 gm [JOHN] 48260312_1 CDM 0250 RC 00168-0011-31 NDC inpatient 1 UN 10.17 6.61 ANTHEM HMO ANTHEM HMO 999999999 6.16 9.86 00168-0011-31 - bacitracin topical zinc 500 units/g Oin 28.35 gm [JOHN] 48260312_1 CDM 0250 RC 00168-0011-31 NDC inpatient 1 UN 10.17 6.61 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.87 67.6 999999999 6.16 9.86 percent of total billed charges 00168-0011-31 - bacitracin topical zinc 500 units/g Oin 28.35 gm [JOHN] 48260312_1 CDM 0250 RC 00168-0011-31 NDC inpatient 1 UN 10.17 6.61 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.16 9.86 00168-0012-09 - bacitracin/neomycin/polymyxin B Top Oint [JOHN] 48260315_1 CDM 0250 RC 00168-0012-09 NDC inpatient 1 UN 121.34 78.87 AETNA AETNA 95.86 79 999999999 73.47 117.7 percent of total billed charges 00168-0012-09 - bacitracin/neomycin/polymyxin B Top Oint [JOHN] 48260315_1 CDM 0250 RC 00168-0012-09 NDC inpatient 1 UN 121.34 78.87 SELF PAY DISCOUNT SELF PAY DISCOUNT 78.87 65 999999999 73.47 117.7 percent of total billed charges 00168-0012-09 - bacitracin/neomycin/polymyxin B Top Oint [JOHN] 48260315_1 CDM 0250 RC 00168-0012-09 NDC inpatient 1 UN 121.34 78.87 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 117.7 97 999999999 73.47 117.7 percent of total billed charges 00168-0012-09 - bacitracin/neomycin/polymyxin B Top Oint [JOHN] 48260315_1 CDM 0250 RC 00168-0012-09 NDC inpatient 1 UN 121.34 78.87 ENCORE - ALL PLANS ENCORE - ALL PLANS 83.72 69 999999999 73.47 117.7 percent of total billed charges 00168-0012-09 - bacitracin/neomycin/polymyxin B Top Oint [JOHN] 48260315_1 CDM 0250 RC 00168-0012-09 NDC inpatient 1 UN 121.34 78.87 HUMANA - ALL PLANS HUMANA - ALL PLANS 94.65 78 999999999 73.47 117.7 percent of total billed charges 00168-0012-09 - bacitracin/neomycin/polymyxin B Top Oint [JOHN] 48260315_1 CDM 0250 RC 00168-0012-09 NDC inpatient 1 UN 121.34 78.87 UMR - ALL PLANS UMR - ALL PLANS 84.94 70 999999999 73.47 117.7 percent of total billed charges 00168-0012-09 - bacitracin/neomycin/polymyxin B Top Oint [JOHN] 48260315_1 CDM 0250 RC 00168-0012-09 NDC inpatient 1 UN 121.34 78.87 SIHO - ALL PLANS SIHO - ALL PLANS 109.21 90 999999999 73.47 117.7 percent of total billed charges 00168-0012-09 - bacitracin/neomycin/polymyxin B Top Oint [JOHN] 48260315_1 CDM 0250 RC 00168-0012-09 NDC inpatient 1 UN 121.34 78.87 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.47 60.55 999999999 73.47 117.7 percent of total billed charges 00168-0012-09 - bacitracin/neomycin/polymyxin B Top Oint [JOHN] 48260315_1 CDM 0250 RC 00168-0012-09 NDC inpatient 1 UN 121.34 78.87 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.47 117.7 00168-0012-09 - bacitracin/neomycin/polymyxin B Top Oint [JOHN] 48260315_1 CDM 0250 RC 00168-0012-09 NDC inpatient 1 UN 121.34 78.87 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.47 117.7 00168-0012-09 - bacitracin/neomycin/polymyxin B Top Oint [JOHN] 48260315_1 CDM 0250 RC 00168-0012-09 NDC inpatient 1 UN 121.34 78.87 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.47 117.7 00168-0012-09 - bacitracin/neomycin/polymyxin B Top Oint [JOHN] 48260315_1 CDM 0250 RC 00168-0012-09 NDC inpatient 1 UN 121.34 78.87 ANTHEM HMO ANTHEM HMO 999999999 73.47 117.7 00168-0012-09 - bacitracin/neomycin/polymyxin B Top Oint [JOHN] 48260315_1 CDM 0250 RC 00168-0012-09 NDC inpatient 1 UN 121.34 78.87 CIGNA - ALL PLANS CIGNA - ALL PLANS 82.03 67.6 999999999 73.47 117.7 percent of total billed charges 00168-0012-09 - bacitracin/neomycin/polymyxin B Top Oint [JOHN] 48260315_1 CDM 0250 RC 00168-0012-09 NDC inpatient 1 UN 121.34 78.87 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.47 117.7 BELLADONNA-OPIUM 16.2-60 SUPP 48260319_1 CDM 0250 RC 00574-7040-12 NDC inpatient 1 UN 119.15 77.45 AETNA AETNA 94.13 79 999999999 72.15 115.58 percent of total billed charges BELLADONNA-OPIUM 16.2-60 SUPP 48260319_1 CDM 0250 RC 00574-7040-12 NDC inpatient 1 UN 119.15 77.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.45 65 999999999 72.15 115.58 percent of total billed charges BELLADONNA-OPIUM 16.2-60 SUPP 48260319_1 CDM 0250 RC 00574-7040-12 NDC inpatient 1 UN 119.15 77.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.58 97 999999999 72.15 115.58 percent of total billed charges BELLADONNA-OPIUM 16.2-60 SUPP 48260319_1 CDM 0250 RC 00574-7040-12 NDC inpatient 1 UN 119.15 77.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.21 69 999999999 72.15 115.58 percent of total billed charges BELLADONNA-OPIUM 16.2-60 SUPP 48260319_1 CDM 0250 RC 00574-7040-12 NDC inpatient 1 UN 119.15 77.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.94 78 999999999 72.15 115.58 percent of total billed charges BELLADONNA-OPIUM 16.2-60 SUPP 48260319_1 CDM 0250 RC 00574-7040-12 NDC inpatient 1 UN 119.15 77.45 UMR - ALL PLANS UMR - ALL PLANS 83.41 70 999999999 72.15 115.58 percent of total billed charges BELLADONNA-OPIUM 16.2-60 SUPP 48260319_1 CDM 0250 RC 00574-7040-12 NDC inpatient 1 UN 119.15 77.45 SIHO - ALL PLANS SIHO - ALL PLANS 107.24 90 999999999 72.15 115.58 percent of total billed charges BELLADONNA-OPIUM 16.2-60 SUPP 48260319_1 CDM 0250 RC 00574-7040-12 NDC inpatient 1 UN 119.15 77.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.15 60.55 999999999 72.15 115.58 percent of total billed charges BELLADONNA-OPIUM 16.2-60 SUPP 48260319_1 CDM 0250 RC 00574-7040-12 NDC inpatient 1 UN 119.15 77.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.15 115.58 BELLADONNA-OPIUM 16.2-60 SUPP 48260319_1 CDM 0250 RC 00574-7040-12 NDC inpatient 1 UN 119.15 77.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.15 115.58 BELLADONNA-OPIUM 16.2-60 SUPP 48260319_1 CDM 0250 RC 00574-7040-12 NDC inpatient 1 UN 119.15 77.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.15 115.58 BELLADONNA-OPIUM 16.2-60 SUPP 48260319_1 CDM 0250 RC 00574-7040-12 NDC inpatient 1 UN 119.15 77.45 ANTHEM HMO ANTHEM HMO 999999999 72.15 115.58 BELLADONNA-OPIUM 16.2-60 SUPP 48260319_1 CDM 0250 RC 00574-7040-12 NDC inpatient 1 UN 119.15 77.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.55 67.6 999999999 72.15 115.58 percent of total billed charges BELLADONNA-OPIUM 16.2-60 SUPP 48260319_1 CDM 0250 RC 00574-7040-12 NDC inpatient 1 UN 119.15 77.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.15 115.58 BETAMETHASONE SP-AC 30 MG/5 ML 48260330_1 CDM 0250 RC 00517-0720-01 NDC inpatient 1 UN 168.12 109.28 AETNA AETNA 132.81 79 999999999 101.8 163.08 percent of total billed charges BETAMETHASONE SP-AC 30 MG/5 ML 48260330_1 CDM 0250 RC 00517-0720-01 NDC inpatient 1 UN 168.12 109.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.28 65 999999999 101.8 163.08 percent of total billed charges BETAMETHASONE SP-AC 30 MG/5 ML 48260330_1 CDM 0250 RC 00517-0720-01 NDC inpatient 1 UN 168.12 109.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 163.08 97 999999999 101.8 163.08 percent of total billed charges BETAMETHASONE SP-AC 30 MG/5 ML 48260330_1 CDM 0250 RC 00517-0720-01 NDC inpatient 1 UN 168.12 109.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 116 69 999999999 101.8 163.08 percent of total billed charges BETAMETHASONE SP-AC 30 MG/5 ML 48260330_1 CDM 0250 RC 00517-0720-01 NDC inpatient 1 UN 168.12 109.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.13 78 999999999 101.8 163.08 percent of total billed charges BETAMETHASONE SP-AC 30 MG/5 ML 48260330_1 CDM 0250 RC 00517-0720-01 NDC inpatient 1 UN 168.12 109.28 UMR - ALL PLANS UMR - ALL PLANS 117.68 70 999999999 101.8 163.08 percent of total billed charges BETAMETHASONE SP-AC 30 MG/5 ML 48260330_1 CDM 0250 RC 00517-0720-01 NDC inpatient 1 UN 168.12 109.28 SIHO - ALL PLANS SIHO - ALL PLANS 151.31 90 999999999 101.8 163.08 percent of total billed charges BETAMETHASONE SP-AC 30 MG/5 ML 48260330_1 CDM 0250 RC 00517-0720-01 NDC inpatient 1 UN 168.12 109.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.8 60.55 999999999 101.8 163.08 percent of total billed charges BETAMETHASONE SP-AC 30 MG/5 ML 48260330_1 CDM 0250 RC 00517-0720-01 NDC inpatient 1 UN 168.12 109.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.8 163.08 BETAMETHASONE SP-AC 30 MG/5 ML 48260330_1 CDM 0250 RC 00517-0720-01 NDC inpatient 1 UN 168.12 109.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.8 163.08 BETAMETHASONE SP-AC 30 MG/5 ML 48260330_1 CDM 0250 RC 00517-0720-01 NDC inpatient 1 UN 168.12 109.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.8 163.08 BETAMETHASONE SP-AC 30 MG/5 ML 48260330_1 CDM 0250 RC 00517-0720-01 NDC inpatient 1 UN 168.12 109.28 ANTHEM HMO ANTHEM HMO 999999999 101.8 163.08 BETAMETHASONE SP-AC 30 MG/5 ML 48260330_1 CDM 0250 RC 00517-0720-01 NDC inpatient 1 UN 168.12 109.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.65 67.6 999999999 101.8 163.08 percent of total billed charges BETAMETHASONE SP-AC 30 MG/5 ML 48260330_1 CDM 0250 RC 00517-0720-01 NDC inpatient 1 UN 168.12 109.28 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.8 163.08 CLOTRIMAZOLE-BETAMETHASONE CRM 48260331_1 CDM 0250 RC 00168-0258-46 NDC inpatient 1 UN 55 35.75 AETNA AETNA 43.45 79 999999999 33.3 53.35 percent of total billed charges CLOTRIMAZOLE-BETAMETHASONE CRM 48260331_1 CDM 0250 RC 00168-0258-46 NDC inpatient 1 UN 55 35.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 35.75 65 999999999 33.3 53.35 percent of total billed charges CLOTRIMAZOLE-BETAMETHASONE CRM 48260331_1 CDM 0250 RC 00168-0258-46 NDC inpatient 1 UN 55 35.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 53.35 97 999999999 33.3 53.35 percent of total billed charges CLOTRIMAZOLE-BETAMETHASONE CRM 48260331_1 CDM 0250 RC 00168-0258-46 NDC inpatient 1 UN 55 35.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 37.95 69 999999999 33.3 53.35 percent of total billed charges CLOTRIMAZOLE-BETAMETHASONE CRM 48260331_1 CDM 0250 RC 00168-0258-46 NDC inpatient 1 UN 55 35.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 42.9 78 999999999 33.3 53.35 percent of total billed charges CLOTRIMAZOLE-BETAMETHASONE CRM 48260331_1 CDM 0250 RC 00168-0258-46 NDC inpatient 1 UN 55 35.75 UMR - ALL PLANS UMR - ALL PLANS 38.5 70 999999999 33.3 53.35 percent of total billed charges CLOTRIMAZOLE-BETAMETHASONE CRM 48260331_1 CDM 0250 RC 00168-0258-46 NDC inpatient 1 UN 55 35.75 SIHO - ALL PLANS SIHO - ALL PLANS 49.5 90 999999999 33.3 53.35 percent of total billed charges CLOTRIMAZOLE-BETAMETHASONE CRM 48260331_1 CDM 0250 RC 00168-0258-46 NDC inpatient 1 UN 55 35.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33.3 60.55 999999999 33.3 53.35 percent of total billed charges CLOTRIMAZOLE-BETAMETHASONE CRM 48260331_1 CDM 0250 RC 00168-0258-46 NDC inpatient 1 UN 55 35.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 33.3 53.35 CLOTRIMAZOLE-BETAMETHASONE CRM 48260331_1 CDM 0250 RC 00168-0258-46 NDC inpatient 1 UN 55 35.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 33.3 53.35 CLOTRIMAZOLE-BETAMETHASONE CRM 48260331_1 CDM 0250 RC 00168-0258-46 NDC inpatient 1 UN 55 35.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 33.3 53.35 CLOTRIMAZOLE-BETAMETHASONE CRM 48260331_1 CDM 0250 RC 00168-0258-46 NDC inpatient 1 UN 55 35.75 ANTHEM HMO ANTHEM HMO 999999999 33.3 53.35 CLOTRIMAZOLE-BETAMETHASONE CRM 48260331_1 CDM 0250 RC 00168-0258-46 NDC inpatient 1 UN 55 35.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 37.18 67.6 999999999 33.3 53.35 percent of total billed charges CLOTRIMAZOLE-BETAMETHASONE CRM 48260331_1 CDM 0250 RC 00168-0258-46 NDC inpatient 1 UN 55 35.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 33.3 53.35 "INJECTION, BEVACIZUMAB, 10 MG" 48260336_1 CDM 0636 RC 50242-0060-01 NDC J9035 HCPCS inpatient 10 UN 3803.24 2472.11 AETNA AETNA 3004.56 79 999999999 2302.86 3689.14 percent of total billed charges "INJECTION, BEVACIZUMAB, 10 MG" 48260336_1 CDM 0636 RC 50242-0060-01 NDC J9035 HCPCS inpatient 10 UN 3803.24 2472.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 2472.11 65 999999999 2302.86 3689.14 percent of total billed charges "INJECTION, BEVACIZUMAB, 10 MG" 48260336_1 CDM 0636 RC 50242-0060-01 NDC J9035 HCPCS inpatient 10 UN 3803.24 2472.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3689.14 97 999999999 2302.86 3689.14 percent of total billed charges "INJECTION, BEVACIZUMAB, 10 MG" 48260336_1 CDM 0636 RC 50242-0060-01 NDC J9035 HCPCS inpatient 10 UN 3803.24 2472.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 2624.24 69 999999999 2302.86 3689.14 percent of total billed charges "INJECTION, BEVACIZUMAB, 10 MG" 48260336_1 CDM 0636 RC 50242-0060-01 NDC J9035 HCPCS inpatient 10 UN 3803.24 2472.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 2966.53 78 999999999 2302.86 3689.14 percent of total billed charges "INJECTION, BEVACIZUMAB, 10 MG" 48260336_1 CDM 0636 RC 50242-0060-01 NDC J9035 HCPCS inpatient 10 UN 3803.24 2472.11 UMR - ALL PLANS UMR - ALL PLANS 2662.27 70 999999999 2302.86 3689.14 percent of total billed charges "INJECTION, BEVACIZUMAB, 10 MG" 48260336_1 CDM 0636 RC 50242-0060-01 NDC J9035 HCPCS inpatient 10 UN 3803.24 2472.11 SIHO - ALL PLANS SIHO - ALL PLANS 3422.92 90 999999999 2302.86 3689.14 percent of total billed charges "INJECTION, BEVACIZUMAB, 10 MG" 48260336_1 CDM 0636 RC 50242-0060-01 NDC J9035 HCPCS inpatient 10 UN 3803.24 2472.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2302.86 60.55 999999999 2302.86 3689.14 percent of total billed charges "INJECTION, BEVACIZUMAB, 10 MG" 48260336_1 CDM 0636 RC 50242-0060-01 NDC J9035 HCPCS inpatient 10 UN 3803.24 2472.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2302.86 3689.14 "INJECTION, BEVACIZUMAB, 10 MG" 48260336_1 CDM 0636 RC 50242-0060-01 NDC J9035 HCPCS inpatient 10 UN 3803.24 2472.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2302.86 3689.14 "INJECTION, BEVACIZUMAB, 10 MG" 48260336_1 CDM 0636 RC 50242-0060-01 NDC J9035 HCPCS inpatient 10 UN 3803.24 2472.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2302.86 3689.14 "INJECTION, BEVACIZUMAB, 10 MG" 48260336_1 CDM 0636 RC 50242-0060-01 NDC J9035 HCPCS inpatient 10 UN 3803.24 2472.11 ANTHEM HMO ANTHEM HMO 999999999 2302.86 3689.14 "INJECTION, BEVACIZUMAB, 10 MG" 48260336_1 CDM 0636 RC 50242-0060-01 NDC J9035 HCPCS inpatient 10 UN 3803.24 2472.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 2570.99 67.6 999999999 2302.86 3689.14 percent of total billed charges "INJECTION, BEVACIZUMAB, 10 MG" 48260336_1 CDM 0636 RC 50242-0060-01 NDC J9035 HCPCS inpatient 10 UN 3803.24 2472.11 UHC - ALL PLANS UHC - ALL PLANS 999999999 2302.86 3689.14 "INJECTION, BEVACIZUMAB, 10 MG" 48260337_1 CDM 0636 RC 50242-0061-01 NDC J9035 HCPCS inpatient 40 UN 15166.37 9858.14 AETNA AETNA 11981.43 79 999999999 9183.24 14711.38 percent of total billed charges "INJECTION, BEVACIZUMAB, 10 MG" 48260337_1 CDM 0636 RC 50242-0061-01 NDC J9035 HCPCS inpatient 40 UN 15166.37 9858.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 9858.14 65 999999999 9183.24 14711.38 percent of total billed charges "INJECTION, BEVACIZUMAB, 10 MG" 48260337_1 CDM 0636 RC 50242-0061-01 NDC J9035 HCPCS inpatient 40 UN 15166.37 9858.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14711.38 97 999999999 9183.24 14711.38 percent of total billed charges "INJECTION, BEVACIZUMAB, 10 MG" 48260337_1 CDM 0636 RC 50242-0061-01 NDC J9035 HCPCS inpatient 40 UN 15166.37 9858.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 10464.8 69 999999999 9183.24 14711.38 percent of total billed charges "INJECTION, BEVACIZUMAB, 10 MG" 48260337_1 CDM 0636 RC 50242-0061-01 NDC J9035 HCPCS inpatient 40 UN 15166.37 9858.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 11829.77 78 999999999 9183.24 14711.38 percent of total billed charges "INJECTION, BEVACIZUMAB, 10 MG" 48260337_1 CDM 0636 RC 50242-0061-01 NDC J9035 HCPCS inpatient 40 UN 15166.37 9858.14 UMR - ALL PLANS UMR - ALL PLANS 10616.46 70 999999999 9183.24 14711.38 percent of total billed charges "INJECTION, BEVACIZUMAB, 10 MG" 48260337_1 CDM 0636 RC 50242-0061-01 NDC J9035 HCPCS inpatient 40 UN 15166.37 9858.14 SIHO - ALL PLANS SIHO - ALL PLANS 13649.73 90 999999999 9183.24 14711.38 percent of total billed charges "INJECTION, BEVACIZUMAB, 10 MG" 48260337_1 CDM 0636 RC 50242-0061-01 NDC J9035 HCPCS inpatient 40 UN 15166.37 9858.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9183.24 60.55 999999999 9183.24 14711.38 percent of total billed charges "INJECTION, BEVACIZUMAB, 10 MG" 48260337_1 CDM 0636 RC 50242-0061-01 NDC J9035 HCPCS inpatient 40 UN 15166.37 9858.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9183.24 14711.38 "INJECTION, BEVACIZUMAB, 10 MG" 48260337_1 CDM 0636 RC 50242-0061-01 NDC J9035 HCPCS inpatient 40 UN 15166.37 9858.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9183.24 14711.38 "INJECTION, BEVACIZUMAB, 10 MG" 48260337_1 CDM 0636 RC 50242-0061-01 NDC J9035 HCPCS inpatient 40 UN 15166.37 9858.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9183.24 14711.38 "INJECTION, BEVACIZUMAB, 10 MG" 48260337_1 CDM 0636 RC 50242-0061-01 NDC J9035 HCPCS inpatient 40 UN 15166.37 9858.14 ANTHEM HMO ANTHEM HMO 999999999 9183.24 14711.38 "INJECTION, BEVACIZUMAB, 10 MG" 48260337_1 CDM 0636 RC 50242-0061-01 NDC J9035 HCPCS inpatient 40 UN 15166.37 9858.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 10252.47 67.6 999999999 9183.24 14711.38 percent of total billed charges "INJECTION, BEVACIZUMAB, 10 MG" 48260337_1 CDM 0636 RC 50242-0061-01 NDC J9035 HCPCS inpatient 40 UN 15166.37 9858.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 9183.24 14711.38 LUMIGAN 0.01% EYE DROPS 48260339_1 CDM 0250 RC 00023-3205-03 NDC inpatient 1 UN 291.02 189.16 AETNA AETNA 229.91 79 999999999 176.21 282.29 percent of total billed charges LUMIGAN 0.01% EYE DROPS 48260339_1 CDM 0250 RC 00023-3205-03 NDC inpatient 1 UN 291.02 189.16 SELF PAY DISCOUNT SELF PAY DISCOUNT 189.16 65 999999999 176.21 282.29 percent of total billed charges LUMIGAN 0.01% EYE DROPS 48260339_1 CDM 0250 RC 00023-3205-03 NDC inpatient 1 UN 291.02 189.16 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 282.29 97 999999999 176.21 282.29 percent of total billed charges LUMIGAN 0.01% EYE DROPS 48260339_1 CDM 0250 RC 00023-3205-03 NDC inpatient 1 UN 291.02 189.16 ENCORE - ALL PLANS ENCORE - ALL PLANS 200.8 69 999999999 176.21 282.29 percent of total billed charges LUMIGAN 0.01% EYE DROPS 48260339_1 CDM 0250 RC 00023-3205-03 NDC inpatient 1 UN 291.02 189.16 HUMANA - ALL PLANS HUMANA - ALL PLANS 227 78 999999999 176.21 282.29 percent of total billed charges LUMIGAN 0.01% EYE DROPS 48260339_1 CDM 0250 RC 00023-3205-03 NDC inpatient 1 UN 291.02 189.16 UMR - ALL PLANS UMR - ALL PLANS 203.71 70 999999999 176.21 282.29 percent of total billed charges LUMIGAN 0.01% EYE DROPS 48260339_1 CDM 0250 RC 00023-3205-03 NDC inpatient 1 UN 291.02 189.16 SIHO - ALL PLANS SIHO - ALL PLANS 261.92 90 999999999 176.21 282.29 percent of total billed charges LUMIGAN 0.01% EYE DROPS 48260339_1 CDM 0250 RC 00023-3205-03 NDC inpatient 1 UN 291.02 189.16 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 176.21 60.55 999999999 176.21 282.29 percent of total billed charges LUMIGAN 0.01% EYE DROPS 48260339_1 CDM 0250 RC 00023-3205-03 NDC inpatient 1 UN 291.02 189.16 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 176.21 282.29 LUMIGAN 0.01% EYE DROPS 48260339_1 CDM 0250 RC 00023-3205-03 NDC inpatient 1 UN 291.02 189.16 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 176.21 282.29 LUMIGAN 0.01% EYE DROPS 48260339_1 CDM 0250 RC 00023-3205-03 NDC inpatient 1 UN 291.02 189.16 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 176.21 282.29 LUMIGAN 0.01% EYE DROPS 48260339_1 CDM 0250 RC 00023-3205-03 NDC inpatient 1 UN 291.02 189.16 ANTHEM HMO ANTHEM HMO 999999999 176.21 282.29 LUMIGAN 0.01% EYE DROPS 48260339_1 CDM 0250 RC 00023-3205-03 NDC inpatient 1 UN 291.02 189.16 CIGNA - ALL PLANS CIGNA - ALL PLANS 196.73 67.6 999999999 176.21 282.29 percent of total billed charges LUMIGAN 0.01% EYE DROPS 48260339_1 CDM 0250 RC 00023-3205-03 NDC inpatient 1 UN 291.02 189.16 UHC - ALL PLANS UHC - ALL PLANS 999999999 176.21 282.29 00904-1313-09 - bismuth subsalicylate 262 mg/15 mL Oral Susp [JOHN] 48260342_1 CDM 0250 RC 00904-1313-09 NDC inpatient 1 UN 3.84 2.5 AETNA AETNA 3.03 79 999999999 2.33 3.72 percent of total billed charges 00904-1313-09 - bismuth subsalicylate 262 mg/15 mL Oral Susp [JOHN] 48260342_1 CDM 0250 RC 00904-1313-09 NDC inpatient 1 UN 3.84 2.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.5 65 999999999 2.33 3.72 percent of total billed charges 00904-1313-09 - bismuth subsalicylate 262 mg/15 mL Oral Susp [JOHN] 48260342_1 CDM 0250 RC 00904-1313-09 NDC inpatient 1 UN 3.84 2.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.72 97 999999999 2.33 3.72 percent of total billed charges 00904-1313-09 - bismuth subsalicylate 262 mg/15 mL Oral Susp [JOHN] 48260342_1 CDM 0250 RC 00904-1313-09 NDC inpatient 1 UN 3.84 2.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.65 69 999999999 2.33 3.72 percent of total billed charges 00904-1313-09 - bismuth subsalicylate 262 mg/15 mL Oral Susp [JOHN] 48260342_1 CDM 0250 RC 00904-1313-09 NDC inpatient 1 UN 3.84 2.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 3 78 999999999 2.33 3.72 percent of total billed charges 00904-1313-09 - bismuth subsalicylate 262 mg/15 mL Oral Susp [JOHN] 48260342_1 CDM 0250 RC 00904-1313-09 NDC inpatient 1 UN 3.84 2.5 UMR - ALL PLANS UMR - ALL PLANS 2.69 70 999999999 2.33 3.72 percent of total billed charges 00904-1313-09 - bismuth subsalicylate 262 mg/15 mL Oral Susp [JOHN] 48260342_1 CDM 0250 RC 00904-1313-09 NDC inpatient 1 UN 3.84 2.5 SIHO - ALL PLANS SIHO - ALL PLANS 3.46 90 999999999 2.33 3.72 percent of total billed charges 00904-1313-09 - bismuth subsalicylate 262 mg/15 mL Oral Susp [JOHN] 48260342_1 CDM 0250 RC 00904-1313-09 NDC inpatient 1 UN 3.84 2.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.33 60.55 999999999 2.33 3.72 percent of total billed charges 00904-1313-09 - bismuth subsalicylate 262 mg/15 mL Oral Susp [JOHN] 48260342_1 CDM 0250 RC 00904-1313-09 NDC inpatient 1 UN 3.84 2.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.33 3.72 00904-1313-09 - bismuth subsalicylate 262 mg/15 mL Oral Susp [JOHN] 48260342_1 CDM 0250 RC 00904-1313-09 NDC inpatient 1 UN 3.84 2.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.33 3.72 00904-1313-09 - bismuth subsalicylate 262 mg/15 mL Oral Susp [JOHN] 48260342_1 CDM 0250 RC 00904-1313-09 NDC inpatient 1 UN 3.84 2.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.33 3.72 00904-1313-09 - bismuth subsalicylate 262 mg/15 mL Oral Susp [JOHN] 48260342_1 CDM 0250 RC 00904-1313-09 NDC inpatient 1 UN 3.84 2.5 ANTHEM HMO ANTHEM HMO 999999999 2.33 3.72 00904-1313-09 - bismuth subsalicylate 262 mg/15 mL Oral Susp [JOHN] 48260342_1 CDM 0250 RC 00904-1313-09 NDC inpatient 1 UN 3.84 2.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.6 67.6 999999999 2.33 3.72 percent of total billed charges 00904-1313-09 - bismuth subsalicylate 262 mg/15 mL Oral Susp [JOHN] 48260342_1 CDM 0250 RC 00904-1313-09 NDC inpatient 1 UN 3.84 2.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.33 3.72 BISOPROLOL FUMARATE 5 MG TAB 48260343_1 CDM 0250 RC 29300-0126-13 NDC inpatient 1 UN 2.43 1.58 AETNA AETNA 1.92 79 999999999 1.47 2.36 percent of total billed charges BISOPROLOL FUMARATE 5 MG TAB 48260343_1 CDM 0250 RC 29300-0126-13 NDC inpatient 1 UN 2.43 1.58 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.58 65 999999999 1.47 2.36 percent of total billed charges BISOPROLOL FUMARATE 5 MG TAB 48260343_1 CDM 0250 RC 29300-0126-13 NDC inpatient 1 UN 2.43 1.58 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.36 97 999999999 1.47 2.36 percent of total billed charges BISOPROLOL FUMARATE 5 MG TAB 48260343_1 CDM 0250 RC 29300-0126-13 NDC inpatient 1 UN 2.43 1.58 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.68 69 999999999 1.47 2.36 percent of total billed charges BISOPROLOL FUMARATE 5 MG TAB 48260343_1 CDM 0250 RC 29300-0126-13 NDC inpatient 1 UN 2.43 1.58 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.9 78 999999999 1.47 2.36 percent of total billed charges BISOPROLOL FUMARATE 5 MG TAB 48260343_1 CDM 0250 RC 29300-0126-13 NDC inpatient 1 UN 2.43 1.58 UMR - ALL PLANS UMR - ALL PLANS 1.7 70 999999999 1.47 2.36 percent of total billed charges BISOPROLOL FUMARATE 5 MG TAB 48260343_1 CDM 0250 RC 29300-0126-13 NDC inpatient 1 UN 2.43 1.58 SIHO - ALL PLANS SIHO - ALL PLANS 2.19 90 999999999 1.47 2.36 percent of total billed charges BISOPROLOL FUMARATE 5 MG TAB 48260343_1 CDM 0250 RC 29300-0126-13 NDC inpatient 1 UN 2.43 1.58 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.47 60.55 999999999 1.47 2.36 percent of total billed charges BISOPROLOL FUMARATE 5 MG TAB 48260343_1 CDM 0250 RC 29300-0126-13 NDC inpatient 1 UN 2.43 1.58 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.47 2.36 BISOPROLOL FUMARATE 5 MG TAB 48260343_1 CDM 0250 RC 29300-0126-13 NDC inpatient 1 UN 2.43 1.58 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.47 2.36 BISOPROLOL FUMARATE 5 MG TAB 48260343_1 CDM 0250 RC 29300-0126-13 NDC inpatient 1 UN 2.43 1.58 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.47 2.36 BISOPROLOL FUMARATE 5 MG TAB 48260343_1 CDM 0250 RC 29300-0126-13 NDC inpatient 1 UN 2.43 1.58 ANTHEM HMO ANTHEM HMO 999999999 1.47 2.36 BISOPROLOL FUMARATE 5 MG TAB 48260343_1 CDM 0250 RC 29300-0126-13 NDC inpatient 1 UN 2.43 1.58 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.64 67.6 999999999 1.47 2.36 percent of total billed charges BISOPROLOL FUMARATE 5 MG TAB 48260343_1 CDM 0250 RC 29300-0126-13 NDC inpatient 1 UN 2.43 1.58 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.47 2.36 BISOPROLOL-HCTZ 10-6.25 MG TAB 48260344_1 CDM 0250 RC 29300-0189-13 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 10-6.25 MG TAB 48260344_1 CDM 0250 RC 29300-0189-13 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 10-6.25 MG TAB 48260344_1 CDM 0250 RC 29300-0189-13 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 10-6.25 MG TAB 48260344_1 CDM 0250 RC 29300-0189-13 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 10-6.25 MG TAB 48260344_1 CDM 0250 RC 29300-0189-13 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 10-6.25 MG TAB 48260344_1 CDM 0250 RC 29300-0189-13 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 10-6.25 MG TAB 48260344_1 CDM 0250 RC 29300-0189-13 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 10-6.25 MG TAB 48260344_1 CDM 0250 RC 29300-0189-13 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 10-6.25 MG TAB 48260344_1 CDM 0250 RC 29300-0189-13 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 BISOPROLOL-HCTZ 10-6.25 MG TAB 48260344_1 CDM 0250 RC 29300-0189-13 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 BISOPROLOL-HCTZ 10-6.25 MG TAB 48260344_1 CDM 0250 RC 29300-0189-13 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 BISOPROLOL-HCTZ 10-6.25 MG TAB 48260344_1 CDM 0250 RC 29300-0189-13 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 BISOPROLOL-HCTZ 10-6.25 MG TAB 48260344_1 CDM 0250 RC 29300-0189-13 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 10-6.25 MG TAB 48260344_1 CDM 0250 RC 29300-0189-13 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 BISOPROLOL-HCTZ 2.5-6.25 MG TB 48260345_1 CDM 0250 RC 29300-0187-13 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 2.5-6.25 MG TB 48260345_1 CDM 0250 RC 29300-0187-13 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 2.5-6.25 MG TB 48260345_1 CDM 0250 RC 29300-0187-13 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 2.5-6.25 MG TB 48260345_1 CDM 0250 RC 29300-0187-13 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 2.5-6.25 MG TB 48260345_1 CDM 0250 RC 29300-0187-13 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 2.5-6.25 MG TB 48260345_1 CDM 0250 RC 29300-0187-13 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 2.5-6.25 MG TB 48260345_1 CDM 0250 RC 29300-0187-13 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 2.5-6.25 MG TB 48260345_1 CDM 0250 RC 29300-0187-13 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 2.5-6.25 MG TB 48260345_1 CDM 0250 RC 29300-0187-13 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 BISOPROLOL-HCTZ 2.5-6.25 MG TB 48260345_1 CDM 0250 RC 29300-0187-13 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 BISOPROLOL-HCTZ 2.5-6.25 MG TB 48260345_1 CDM 0250 RC 29300-0187-13 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 BISOPROLOL-HCTZ 2.5-6.25 MG TB 48260345_1 CDM 0250 RC 29300-0187-13 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 BISOPROLOL-HCTZ 2.5-6.25 MG TB 48260345_1 CDM 0250 RC 29300-0187-13 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 2.5-6.25 MG TB 48260345_1 CDM 0250 RC 29300-0187-13 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 BISOPROLOL-HCTZ 5-6.25 MG TAB 48260346_1 CDM 0250 RC 29300-0188-13 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 5-6.25 MG TAB 48260346_1 CDM 0250 RC 29300-0188-13 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 5-6.25 MG TAB 48260346_1 CDM 0250 RC 29300-0188-13 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 5-6.25 MG TAB 48260346_1 CDM 0250 RC 29300-0188-13 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 5-6.25 MG TAB 48260346_1 CDM 0250 RC 29300-0188-13 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 5-6.25 MG TAB 48260346_1 CDM 0250 RC 29300-0188-13 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 5-6.25 MG TAB 48260346_1 CDM 0250 RC 29300-0188-13 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 5-6.25 MG TAB 48260346_1 CDM 0250 RC 29300-0188-13 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 5-6.25 MG TAB 48260346_1 CDM 0250 RC 29300-0188-13 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 BISOPROLOL-HCTZ 5-6.25 MG TAB 48260346_1 CDM 0250 RC 29300-0188-13 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 BISOPROLOL-HCTZ 5-6.25 MG TAB 48260346_1 CDM 0250 RC 29300-0188-13 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 BISOPROLOL-HCTZ 5-6.25 MG TAB 48260346_1 CDM 0250 RC 29300-0188-13 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 BISOPROLOL-HCTZ 5-6.25 MG TAB 48260346_1 CDM 0250 RC 29300-0188-13 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges BISOPROLOL-HCTZ 5-6.25 MG TAB 48260346_1 CDM 0250 RC 29300-0188-13 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, BORTEZOMIB, 0.1 MG" 48260349_1 CDM 0636 RC 63020-0049-01 NDC J9041 HCPCS inpatient 35 UN 7664.25 4981.76 AETNA AETNA 6054.76 79 999999999 4640.7 7434.32 percent of total billed charges "INJECTION, BORTEZOMIB, 0.1 MG" 48260349_1 CDM 0636 RC 63020-0049-01 NDC J9041 HCPCS inpatient 35 UN 7664.25 4981.76 SELF PAY DISCOUNT SELF PAY DISCOUNT 4981.76 65 999999999 4640.7 7434.32 percent of total billed charges "INJECTION, BORTEZOMIB, 0.1 MG" 48260349_1 CDM 0636 RC 63020-0049-01 NDC J9041 HCPCS inpatient 35 UN 7664.25 4981.76 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7434.32 97 999999999 4640.7 7434.32 percent of total billed charges "INJECTION, BORTEZOMIB, 0.1 MG" 48260349_1 CDM 0636 RC 63020-0049-01 NDC J9041 HCPCS inpatient 35 UN 7664.25 4981.76 ENCORE - ALL PLANS ENCORE - ALL PLANS 5288.33 69 999999999 4640.7 7434.32 percent of total billed charges "INJECTION, BORTEZOMIB, 0.1 MG" 48260349_1 CDM 0636 RC 63020-0049-01 NDC J9041 HCPCS inpatient 35 UN 7664.25 4981.76 HUMANA - ALL PLANS HUMANA - ALL PLANS 5978.12 78 999999999 4640.7 7434.32 percent of total billed charges "INJECTION, BORTEZOMIB, 0.1 MG" 48260349_1 CDM 0636 RC 63020-0049-01 NDC J9041 HCPCS inpatient 35 UN 7664.25 4981.76 UMR - ALL PLANS UMR - ALL PLANS 5364.98 70 999999999 4640.7 7434.32 percent of total billed charges "INJECTION, BORTEZOMIB, 0.1 MG" 48260349_1 CDM 0636 RC 63020-0049-01 NDC J9041 HCPCS inpatient 35 UN 7664.25 4981.76 SIHO - ALL PLANS SIHO - ALL PLANS 6897.83 90 999999999 4640.7 7434.32 percent of total billed charges "INJECTION, BORTEZOMIB, 0.1 MG" 48260349_1 CDM 0636 RC 63020-0049-01 NDC J9041 HCPCS inpatient 35 UN 7664.25 4981.76 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4640.7 60.55 999999999 4640.7 7434.32 percent of total billed charges "INJECTION, BORTEZOMIB, 0.1 MG" 48260349_1 CDM 0636 RC 63020-0049-01 NDC J9041 HCPCS inpatient 35 UN 7664.25 4981.76 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4640.7 7434.32 "INJECTION, BORTEZOMIB, 0.1 MG" 48260349_1 CDM 0636 RC 63020-0049-01 NDC J9041 HCPCS inpatient 35 UN 7664.25 4981.76 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4640.7 7434.32 "INJECTION, BORTEZOMIB, 0.1 MG" 48260349_1 CDM 0636 RC 63020-0049-01 NDC J9041 HCPCS inpatient 35 UN 7664.25 4981.76 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4640.7 7434.32 "INJECTION, BORTEZOMIB, 0.1 MG" 48260349_1 CDM 0636 RC 63020-0049-01 NDC J9041 HCPCS inpatient 35 UN 7664.25 4981.76 ANTHEM HMO ANTHEM HMO 999999999 4640.7 7434.32 "INJECTION, BORTEZOMIB, 0.1 MG" 48260349_1 CDM 0636 RC 63020-0049-01 NDC J9041 HCPCS inpatient 35 UN 7664.25 4981.76 CIGNA - ALL PLANS CIGNA - ALL PLANS 5181.03 67.6 999999999 4640.7 7434.32 percent of total billed charges "INJECTION, BORTEZOMIB, 0.1 MG" 48260349_1 CDM 0636 RC 63020-0049-01 NDC J9041 HCPCS inpatient 35 UN 7664.25 4981.76 UHC - ALL PLANS UHC - ALL PLANS 999999999 4640.7 7434.32 BRIMONIDINE 0.2% EYE DROP 48260352_1 CDM 0250 RC 24208-0411-05 NDC inpatient 1 UN 10 6.5 AETNA AETNA 7.9 79 999999999 6.06 9.7 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 48260352_1 CDM 0250 RC 24208-0411-05 NDC inpatient 1 UN 10 6.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.5 65 999999999 6.06 9.7 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 48260352_1 CDM 0250 RC 24208-0411-05 NDC inpatient 1 UN 10 6.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.7 97 999999999 6.06 9.7 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 48260352_1 CDM 0250 RC 24208-0411-05 NDC inpatient 1 UN 10 6.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.9 69 999999999 6.06 9.7 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 48260352_1 CDM 0250 RC 24208-0411-05 NDC inpatient 1 UN 10 6.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.8 78 999999999 6.06 9.7 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 48260352_1 CDM 0250 RC 24208-0411-05 NDC inpatient 1 UN 10 6.5 UMR - ALL PLANS UMR - ALL PLANS 7 70 999999999 6.06 9.7 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 48260352_1 CDM 0250 RC 24208-0411-05 NDC inpatient 1 UN 10 6.5 SIHO - ALL PLANS SIHO - ALL PLANS 9 90 999999999 6.06 9.7 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 48260352_1 CDM 0250 RC 24208-0411-05 NDC inpatient 1 UN 10 6.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.06 60.55 999999999 6.06 9.7 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 48260352_1 CDM 0250 RC 24208-0411-05 NDC inpatient 1 UN 10 6.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.06 9.7 BRIMONIDINE 0.2% EYE DROP 48260352_1 CDM 0250 RC 24208-0411-05 NDC inpatient 1 UN 10 6.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.06 9.7 BRIMONIDINE 0.2% EYE DROP 48260352_1 CDM 0250 RC 24208-0411-05 NDC inpatient 1 UN 10 6.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.06 9.7 BRIMONIDINE 0.2% EYE DROP 48260352_1 CDM 0250 RC 24208-0411-05 NDC inpatient 1 UN 10 6.5 ANTHEM HMO ANTHEM HMO 999999999 6.06 9.7 BRIMONIDINE 0.2% EYE DROP 48260352_1 CDM 0250 RC 24208-0411-05 NDC inpatient 1 UN 10 6.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.76 67.6 999999999 6.06 9.7 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 48260352_1 CDM 0250 RC 24208-0411-05 NDC inpatient 1 UN 10 6.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.06 9.7 COMBIGAN 0.2%-0.5% EYE DROPS 48260353_1 CDM 0250 RC 00023-9211-05 NDC inpatient 1 UN 264.56 171.96 AETNA AETNA 209 79 999999999 160.19 256.62 percent of total billed charges COMBIGAN 0.2%-0.5% EYE DROPS 48260353_1 CDM 0250 RC 00023-9211-05 NDC inpatient 1 UN 264.56 171.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 171.96 65 999999999 160.19 256.62 percent of total billed charges COMBIGAN 0.2%-0.5% EYE DROPS 48260353_1 CDM 0250 RC 00023-9211-05 NDC inpatient 1 UN 264.56 171.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 256.62 97 999999999 160.19 256.62 percent of total billed charges COMBIGAN 0.2%-0.5% EYE DROPS 48260353_1 CDM 0250 RC 00023-9211-05 NDC inpatient 1 UN 264.56 171.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 182.55 69 999999999 160.19 256.62 percent of total billed charges COMBIGAN 0.2%-0.5% EYE DROPS 48260353_1 CDM 0250 RC 00023-9211-05 NDC inpatient 1 UN 264.56 171.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 206.36 78 999999999 160.19 256.62 percent of total billed charges COMBIGAN 0.2%-0.5% EYE DROPS 48260353_1 CDM 0250 RC 00023-9211-05 NDC inpatient 1 UN 264.56 171.96 UMR - ALL PLANS UMR - ALL PLANS 185.19 70 999999999 160.19 256.62 percent of total billed charges COMBIGAN 0.2%-0.5% EYE DROPS 48260353_1 CDM 0250 RC 00023-9211-05 NDC inpatient 1 UN 264.56 171.96 SIHO - ALL PLANS SIHO - ALL PLANS 238.1 90 999999999 160.19 256.62 percent of total billed charges COMBIGAN 0.2%-0.5% EYE DROPS 48260353_1 CDM 0250 RC 00023-9211-05 NDC inpatient 1 UN 264.56 171.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 160.19 60.55 999999999 160.19 256.62 percent of total billed charges COMBIGAN 0.2%-0.5% EYE DROPS 48260353_1 CDM 0250 RC 00023-9211-05 NDC inpatient 1 UN 264.56 171.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 160.19 256.62 COMBIGAN 0.2%-0.5% EYE DROPS 48260353_1 CDM 0250 RC 00023-9211-05 NDC inpatient 1 UN 264.56 171.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 160.19 256.62 COMBIGAN 0.2%-0.5% EYE DROPS 48260353_1 CDM 0250 RC 00023-9211-05 NDC inpatient 1 UN 264.56 171.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 160.19 256.62 COMBIGAN 0.2%-0.5% EYE DROPS 48260353_1 CDM 0250 RC 00023-9211-05 NDC inpatient 1 UN 264.56 171.96 ANTHEM HMO ANTHEM HMO 999999999 160.19 256.62 COMBIGAN 0.2%-0.5% EYE DROPS 48260353_1 CDM 0250 RC 00023-9211-05 NDC inpatient 1 UN 264.56 171.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 178.84 67.6 999999999 160.19 256.62 percent of total billed charges COMBIGAN 0.2%-0.5% EYE DROPS 48260353_1 CDM 0250 RC 00023-9211-05 NDC inpatient 1 UN 264.56 171.96 UHC - ALL PLANS UHC - ALL PLANS 999999999 160.19 256.62 BUPIVACAINE 0.5% VIAL 48260360_1 CDM 0250 RC 00409-1162-02 NDC inpatient 1 UN 25.31 16.45 AETNA AETNA 19.99 79 999999999 15.33 24.55 percent of total billed charges BUPIVACAINE 0.5% VIAL 48260360_1 CDM 0250 RC 00409-1162-02 NDC inpatient 1 UN 25.31 16.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.45 65 999999999 15.33 24.55 percent of total billed charges BUPIVACAINE 0.5% VIAL 48260360_1 CDM 0250 RC 00409-1162-02 NDC inpatient 1 UN 25.31 16.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.55 97 999999999 15.33 24.55 percent of total billed charges BUPIVACAINE 0.5% VIAL 48260360_1 CDM 0250 RC 00409-1162-02 NDC inpatient 1 UN 25.31 16.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.46 69 999999999 15.33 24.55 percent of total billed charges BUPIVACAINE 0.5% VIAL 48260360_1 CDM 0250 RC 00409-1162-02 NDC inpatient 1 UN 25.31 16.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.74 78 999999999 15.33 24.55 percent of total billed charges BUPIVACAINE 0.5% VIAL 48260360_1 CDM 0250 RC 00409-1162-02 NDC inpatient 1 UN 25.31 16.45 UMR - ALL PLANS UMR - ALL PLANS 17.72 70 999999999 15.33 24.55 percent of total billed charges BUPIVACAINE 0.5% VIAL 48260360_1 CDM 0250 RC 00409-1162-02 NDC inpatient 1 UN 25.31 16.45 SIHO - ALL PLANS SIHO - ALL PLANS 22.78 90 999999999 15.33 24.55 percent of total billed charges BUPIVACAINE 0.5% VIAL 48260360_1 CDM 0250 RC 00409-1162-02 NDC inpatient 1 UN 25.31 16.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.33 60.55 999999999 15.33 24.55 percent of total billed charges BUPIVACAINE 0.5% VIAL 48260360_1 CDM 0250 RC 00409-1162-02 NDC inpatient 1 UN 25.31 16.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.33 24.55 BUPIVACAINE 0.5% VIAL 48260360_1 CDM 0250 RC 00409-1162-02 NDC inpatient 1 UN 25.31 16.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.33 24.55 BUPIVACAINE 0.5% VIAL 48260360_1 CDM 0250 RC 00409-1162-02 NDC inpatient 1 UN 25.31 16.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.33 24.55 BUPIVACAINE 0.5% VIAL 48260360_1 CDM 0250 RC 00409-1162-02 NDC inpatient 1 UN 25.31 16.45 ANTHEM HMO ANTHEM HMO 999999999 15.33 24.55 BUPIVACAINE 0.5% VIAL 48260360_1 CDM 0250 RC 00409-1162-02 NDC inpatient 1 UN 25.31 16.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.11 67.6 999999999 15.33 24.55 percent of total billed charges BUPIVACAINE 0.5% VIAL 48260360_1 CDM 0250 RC 00409-1162-02 NDC inpatient 1 UN 25.31 16.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.33 24.55 "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48260364_1 CDM 0250 RC 65250-0266-20 NDC C9290 HCPCS inpatient 266 UN 1618.28 1051.88 AETNA AETNA 1278.44 79 999999999 979.87 1569.73 percent of total billed charges "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48260364_1 CDM 0250 RC 65250-0266-20 NDC C9290 HCPCS inpatient 266 UN 1618.28 1051.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 1051.88 65 999999999 979.87 1569.73 percent of total billed charges "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48260364_1 CDM 0250 RC 65250-0266-20 NDC C9290 HCPCS inpatient 266 UN 1618.28 1051.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1569.73 97 999999999 979.87 1569.73 percent of total billed charges "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48260364_1 CDM 0250 RC 65250-0266-20 NDC C9290 HCPCS inpatient 266 UN 1618.28 1051.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 1116.61 69 999999999 979.87 1569.73 percent of total billed charges "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48260364_1 CDM 0250 RC 65250-0266-20 NDC C9290 HCPCS inpatient 266 UN 1618.28 1051.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 1262.26 78 999999999 979.87 1569.73 percent of total billed charges "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48260364_1 CDM 0250 RC 65250-0266-20 NDC C9290 HCPCS inpatient 266 UN 1618.28 1051.88 UMR - ALL PLANS UMR - ALL PLANS 1132.8 70 999999999 979.87 1569.73 percent of total billed charges "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48260364_1 CDM 0250 RC 65250-0266-20 NDC C9290 HCPCS inpatient 266 UN 1618.28 1051.88 SIHO - ALL PLANS SIHO - ALL PLANS 1456.45 90 999999999 979.87 1569.73 percent of total billed charges "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48260364_1 CDM 0250 RC 65250-0266-20 NDC C9290 HCPCS inpatient 266 UN 1618.28 1051.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 979.87 60.55 999999999 979.87 1569.73 percent of total billed charges "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48260364_1 CDM 0250 RC 65250-0266-20 NDC C9290 HCPCS inpatient 266 UN 1618.28 1051.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 979.87 1569.73 "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48260364_1 CDM 0250 RC 65250-0266-20 NDC C9290 HCPCS inpatient 266 UN 1618.28 1051.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 979.87 1569.73 "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48260364_1 CDM 0250 RC 65250-0266-20 NDC C9290 HCPCS inpatient 266 UN 1618.28 1051.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 979.87 1569.73 "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48260364_1 CDM 0250 RC 65250-0266-20 NDC C9290 HCPCS inpatient 266 UN 1618.28 1051.88 ANTHEM HMO ANTHEM HMO 999999999 979.87 1569.73 "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48260364_1 CDM 0250 RC 65250-0266-20 NDC C9290 HCPCS inpatient 266 UN 1618.28 1051.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 1093.96 67.6 999999999 979.87 1569.73 percent of total billed charges "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48260364_1 CDM 0250 RC 65250-0266-20 NDC C9290 HCPCS inpatient 266 UN 1618.28 1051.88 UHC - ALL PLANS UHC - ALL PLANS 999999999 979.87 1569.73 SENSORC MPF 0.75%-EPI 1:200000 48260367_1 CDM 0250 RC 63323-0460-37 NDC inpatient 1 UN 34.68 22.54 AETNA AETNA 27.4 79 999999999 21 33.64 percent of total billed charges SENSORC MPF 0.75%-EPI 1:200000 48260367_1 CDM 0250 RC 63323-0460-37 NDC inpatient 1 UN 34.68 22.54 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.54 65 999999999 21 33.64 percent of total billed charges SENSORC MPF 0.75%-EPI 1:200000 48260367_1 CDM 0250 RC 63323-0460-37 NDC inpatient 1 UN 34.68 22.54 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33.64 97 999999999 21 33.64 percent of total billed charges SENSORC MPF 0.75%-EPI 1:200000 48260367_1 CDM 0250 RC 63323-0460-37 NDC inpatient 1 UN 34.68 22.54 ENCORE - ALL PLANS ENCORE - ALL PLANS 23.93 69 999999999 21 33.64 percent of total billed charges SENSORC MPF 0.75%-EPI 1:200000 48260367_1 CDM 0250 RC 63323-0460-37 NDC inpatient 1 UN 34.68 22.54 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.05 78 999999999 21 33.64 percent of total billed charges SENSORC MPF 0.75%-EPI 1:200000 48260367_1 CDM 0250 RC 63323-0460-37 NDC inpatient 1 UN 34.68 22.54 UMR - ALL PLANS UMR - ALL PLANS 24.28 70 999999999 21 33.64 percent of total billed charges SENSORC MPF 0.75%-EPI 1:200000 48260367_1 CDM 0250 RC 63323-0460-37 NDC inpatient 1 UN 34.68 22.54 SIHO - ALL PLANS SIHO - ALL PLANS 31.21 90 999999999 21 33.64 percent of total billed charges SENSORC MPF 0.75%-EPI 1:200000 48260367_1 CDM 0250 RC 63323-0460-37 NDC inpatient 1 UN 34.68 22.54 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21 60.55 999999999 21 33.64 percent of total billed charges SENSORC MPF 0.75%-EPI 1:200000 48260367_1 CDM 0250 RC 63323-0460-37 NDC inpatient 1 UN 34.68 22.54 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21 33.64 SENSORC MPF 0.75%-EPI 1:200000 48260367_1 CDM 0250 RC 63323-0460-37 NDC inpatient 1 UN 34.68 22.54 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21 33.64 SENSORC MPF 0.75%-EPI 1:200000 48260367_1 CDM 0250 RC 63323-0460-37 NDC inpatient 1 UN 34.68 22.54 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21 33.64 SENSORC MPF 0.75%-EPI 1:200000 48260367_1 CDM 0250 RC 63323-0460-37 NDC inpatient 1 UN 34.68 22.54 ANTHEM HMO ANTHEM HMO 999999999 21 33.64 SENSORC MPF 0.75%-EPI 1:200000 48260367_1 CDM 0250 RC 63323-0460-37 NDC inpatient 1 UN 34.68 22.54 CIGNA - ALL PLANS CIGNA - ALL PLANS 23.44 67.6 999999999 21 33.64 percent of total billed charges SENSORC MPF 0.75%-EPI 1:200000 48260367_1 CDM 0250 RC 63323-0460-37 NDC inpatient 1 UN 34.68 22.54 UHC - ALL PLANS UHC - ALL PLANS 999999999 21 33.64 BUSPIRONE HCL 10 MG TABLET 48260371_1 CDM 0250 RC 51079-0986-20 NDC inpatient 1 UN 1.62 1.05 AETNA AETNA 1.28 79 999999999 0.98 1.57 percent of total billed charges BUSPIRONE HCL 10 MG TABLET 48260371_1 CDM 0250 RC 51079-0986-20 NDC inpatient 1 UN 1.62 1.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.05 65 999999999 0.98 1.57 percent of total billed charges BUSPIRONE HCL 10 MG TABLET 48260371_1 CDM 0250 RC 51079-0986-20 NDC inpatient 1 UN 1.62 1.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.57 97 999999999 0.98 1.57 percent of total billed charges BUSPIRONE HCL 10 MG TABLET 48260371_1 CDM 0250 RC 51079-0986-20 NDC inpatient 1 UN 1.62 1.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.12 69 999999999 0.98 1.57 percent of total billed charges BUSPIRONE HCL 10 MG TABLET 48260371_1 CDM 0250 RC 51079-0986-20 NDC inpatient 1 UN 1.62 1.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.26 78 999999999 0.98 1.57 percent of total billed charges BUSPIRONE HCL 10 MG TABLET 48260371_1 CDM 0250 RC 51079-0986-20 NDC inpatient 1 UN 1.62 1.05 UMR - ALL PLANS UMR - ALL PLANS 1.13 70 999999999 0.98 1.57 percent of total billed charges BUSPIRONE HCL 10 MG TABLET 48260371_1 CDM 0250 RC 51079-0986-20 NDC inpatient 1 UN 1.62 1.05 SIHO - ALL PLANS SIHO - ALL PLANS 1.46 90 999999999 0.98 1.57 percent of total billed charges BUSPIRONE HCL 10 MG TABLET 48260371_1 CDM 0250 RC 51079-0986-20 NDC inpatient 1 UN 1.62 1.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.98 60.55 999999999 0.98 1.57 percent of total billed charges BUSPIRONE HCL 10 MG TABLET 48260371_1 CDM 0250 RC 51079-0986-20 NDC inpatient 1 UN 1.62 1.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.98 1.57 BUSPIRONE HCL 10 MG TABLET 48260371_1 CDM 0250 RC 51079-0986-20 NDC inpatient 1 UN 1.62 1.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.98 1.57 BUSPIRONE HCL 10 MG TABLET 48260371_1 CDM 0250 RC 51079-0986-20 NDC inpatient 1 UN 1.62 1.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.98 1.57 BUSPIRONE HCL 10 MG TABLET 48260371_1 CDM 0250 RC 51079-0986-20 NDC inpatient 1 UN 1.62 1.05 ANTHEM HMO ANTHEM HMO 999999999 0.98 1.57 BUSPIRONE HCL 10 MG TABLET 48260371_1 CDM 0250 RC 51079-0986-20 NDC inpatient 1 UN 1.62 1.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.1 67.6 999999999 0.98 1.57 percent of total billed charges BUSPIRONE HCL 10 MG TABLET 48260371_1 CDM 0250 RC 51079-0986-20 NDC inpatient 1 UN 1.62 1.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.98 1.57 BUSPIRONE HCL 5 MG TABLET 48260372_1 CDM 0250 RC 51079-0985-20 NDC inpatient 1 UN 1.43 0.93 AETNA AETNA 1.13 79 999999999 0.87 1.39 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 48260372_1 CDM 0250 RC 51079-0985-20 NDC inpatient 1 UN 1.43 0.93 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.93 65 999999999 0.87 1.39 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 48260372_1 CDM 0250 RC 51079-0985-20 NDC inpatient 1 UN 1.43 0.93 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.39 97 999999999 0.87 1.39 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 48260372_1 CDM 0250 RC 51079-0985-20 NDC inpatient 1 UN 1.43 0.93 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.99 69 999999999 0.87 1.39 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 48260372_1 CDM 0250 RC 51079-0985-20 NDC inpatient 1 UN 1.43 0.93 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.12 78 999999999 0.87 1.39 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 48260372_1 CDM 0250 RC 51079-0985-20 NDC inpatient 1 UN 1.43 0.93 UMR - ALL PLANS UMR - ALL PLANS 1 70 999999999 0.87 1.39 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 48260372_1 CDM 0250 RC 51079-0985-20 NDC inpatient 1 UN 1.43 0.93 SIHO - ALL PLANS SIHO - ALL PLANS 1.29 90 999999999 0.87 1.39 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 48260372_1 CDM 0250 RC 51079-0985-20 NDC inpatient 1 UN 1.43 0.93 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.87 60.55 999999999 0.87 1.39 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 48260372_1 CDM 0250 RC 51079-0985-20 NDC inpatient 1 UN 1.43 0.93 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.87 1.39 BUSPIRONE HCL 5 MG TABLET 48260372_1 CDM 0250 RC 51079-0985-20 NDC inpatient 1 UN 1.43 0.93 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.87 1.39 BUSPIRONE HCL 5 MG TABLET 48260372_1 CDM 0250 RC 51079-0985-20 NDC inpatient 1 UN 1.43 0.93 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.87 1.39 BUSPIRONE HCL 5 MG TABLET 48260372_1 CDM 0250 RC 51079-0985-20 NDC inpatient 1 UN 1.43 0.93 ANTHEM HMO ANTHEM HMO 999999999 0.87 1.39 BUSPIRONE HCL 5 MG TABLET 48260372_1 CDM 0250 RC 51079-0985-20 NDC inpatient 1 UN 1.43 0.93 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.97 67.6 999999999 0.87 1.39 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 48260372_1 CDM 0250 RC 51079-0985-20 NDC inpatient 1 UN 1.43 0.93 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.87 1.39 CAPSAICIN 0.025% CREAM 48260389_1 CDM 0250 RC 00536-2525-25 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CAPSAICIN 0.025% CREAM 48260389_1 CDM 0250 RC 00536-2525-25 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CAPSAICIN 0.025% CREAM 48260389_1 CDM 0250 RC 00536-2525-25 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CAPSAICIN 0.025% CREAM 48260389_1 CDM 0250 RC 00536-2525-25 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CAPSAICIN 0.025% CREAM 48260389_1 CDM 0250 RC 00536-2525-25 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CAPSAICIN 0.025% CREAM 48260389_1 CDM 0250 RC 00536-2525-25 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CAPSAICIN 0.025% CREAM 48260389_1 CDM 0250 RC 00536-2525-25 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CAPSAICIN 0.025% CREAM 48260389_1 CDM 0250 RC 00536-2525-25 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CAPSAICIN 0.025% CREAM 48260389_1 CDM 0250 RC 00536-2525-25 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CAPSAICIN 0.025% CREAM 48260389_1 CDM 0250 RC 00536-2525-25 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CAPSAICIN 0.025% CREAM 48260389_1 CDM 0250 RC 00536-2525-25 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CAPSAICIN 0.025% CREAM 48260389_1 CDM 0250 RC 00536-2525-25 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CAPSAICIN 0.025% CREAM 48260389_1 CDM 0250 RC 00536-2525-25 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CAPSAICIN 0.025% CREAM 48260389_1 CDM 0250 RC 00536-2525-25 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CARBAMAZEPINE ER 100 MG CAP 48260392_1 CDM 0250 RC 66993-0407-32 NDC inpatient 1 UN 5.87 3.82 AETNA AETNA 4.64 79 999999999 3.55 5.69 percent of total billed charges CARBAMAZEPINE ER 100 MG CAP 48260392_1 CDM 0250 RC 66993-0407-32 NDC inpatient 1 UN 5.87 3.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.82 65 999999999 3.55 5.69 percent of total billed charges CARBAMAZEPINE ER 100 MG CAP 48260392_1 CDM 0250 RC 66993-0407-32 NDC inpatient 1 UN 5.87 3.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.69 97 999999999 3.55 5.69 percent of total billed charges CARBAMAZEPINE ER 100 MG CAP 48260392_1 CDM 0250 RC 66993-0407-32 NDC inpatient 1 UN 5.87 3.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.05 69 999999999 3.55 5.69 percent of total billed charges CARBAMAZEPINE ER 100 MG CAP 48260392_1 CDM 0250 RC 66993-0407-32 NDC inpatient 1 UN 5.87 3.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.58 78 999999999 3.55 5.69 percent of total billed charges CARBAMAZEPINE ER 100 MG CAP 48260392_1 CDM 0250 RC 66993-0407-32 NDC inpatient 1 UN 5.87 3.82 UMR - ALL PLANS UMR - ALL PLANS 4.11 70 999999999 3.55 5.69 percent of total billed charges CARBAMAZEPINE ER 100 MG CAP 48260392_1 CDM 0250 RC 66993-0407-32 NDC inpatient 1 UN 5.87 3.82 SIHO - ALL PLANS SIHO - ALL PLANS 5.28 90 999999999 3.55 5.69 percent of total billed charges CARBAMAZEPINE ER 100 MG CAP 48260392_1 CDM 0250 RC 66993-0407-32 NDC inpatient 1 UN 5.87 3.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.55 60.55 999999999 3.55 5.69 percent of total billed charges CARBAMAZEPINE ER 100 MG CAP 48260392_1 CDM 0250 RC 66993-0407-32 NDC inpatient 1 UN 5.87 3.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.55 5.69 CARBAMAZEPINE ER 100 MG CAP 48260392_1 CDM 0250 RC 66993-0407-32 NDC inpatient 1 UN 5.87 3.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.55 5.69 CARBAMAZEPINE ER 100 MG CAP 48260392_1 CDM 0250 RC 66993-0407-32 NDC inpatient 1 UN 5.87 3.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.55 5.69 CARBAMAZEPINE ER 100 MG CAP 48260392_1 CDM 0250 RC 66993-0407-32 NDC inpatient 1 UN 5.87 3.82 ANTHEM HMO ANTHEM HMO 999999999 3.55 5.69 CARBAMAZEPINE ER 100 MG CAP 48260392_1 CDM 0250 RC 66993-0407-32 NDC inpatient 1 UN 5.87 3.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.97 67.6 999999999 3.55 5.69 percent of total billed charges CARBAMAZEPINE ER 100 MG CAP 48260392_1 CDM 0250 RC 66993-0407-32 NDC inpatient 1 UN 5.87 3.82 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.55 5.69 CARBIDOPA-LEVODOPA 25-100 TAB 48260398_1 CDM 0250 RC 68084-0093-01 NDC inpatient 1 UN 1.81 1.18 AETNA AETNA 1.43 79 999999999 1.1 1.76 percent of total billed charges CARBIDOPA-LEVODOPA 25-100 TAB 48260398_1 CDM 0250 RC 68084-0093-01 NDC inpatient 1 UN 1.81 1.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.18 65 999999999 1.1 1.76 percent of total billed charges CARBIDOPA-LEVODOPA 25-100 TAB 48260398_1 CDM 0250 RC 68084-0093-01 NDC inpatient 1 UN 1.81 1.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.76 97 999999999 1.1 1.76 percent of total billed charges CARBIDOPA-LEVODOPA 25-100 TAB 48260398_1 CDM 0250 RC 68084-0093-01 NDC inpatient 1 UN 1.81 1.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.25 69 999999999 1.1 1.76 percent of total billed charges CARBIDOPA-LEVODOPA 25-100 TAB 48260398_1 CDM 0250 RC 68084-0093-01 NDC inpatient 1 UN 1.81 1.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.41 78 999999999 1.1 1.76 percent of total billed charges CARBIDOPA-LEVODOPA 25-100 TAB 48260398_1 CDM 0250 RC 68084-0093-01 NDC inpatient 1 UN 1.81 1.18 UMR - ALL PLANS UMR - ALL PLANS 1.27 70 999999999 1.1 1.76 percent of total billed charges CARBIDOPA-LEVODOPA 25-100 TAB 48260398_1 CDM 0250 RC 68084-0093-01 NDC inpatient 1 UN 1.81 1.18 SIHO - ALL PLANS SIHO - ALL PLANS 1.63 90 999999999 1.1 1.76 percent of total billed charges CARBIDOPA-LEVODOPA 25-100 TAB 48260398_1 CDM 0250 RC 68084-0093-01 NDC inpatient 1 UN 1.81 1.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.1 60.55 999999999 1.1 1.76 percent of total billed charges CARBIDOPA-LEVODOPA 25-100 TAB 48260398_1 CDM 0250 RC 68084-0093-01 NDC inpatient 1 UN 1.81 1.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.1 1.76 CARBIDOPA-LEVODOPA 25-100 TAB 48260398_1 CDM 0250 RC 68084-0093-01 NDC inpatient 1 UN 1.81 1.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.1 1.76 CARBIDOPA-LEVODOPA 25-100 TAB 48260398_1 CDM 0250 RC 68084-0093-01 NDC inpatient 1 UN 1.81 1.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.1 1.76 CARBIDOPA-LEVODOPA 25-100 TAB 48260398_1 CDM 0250 RC 68084-0093-01 NDC inpatient 1 UN 1.81 1.18 ANTHEM HMO ANTHEM HMO 999999999 1.1 1.76 CARBIDOPA-LEVODOPA 25-100 TAB 48260398_1 CDM 0250 RC 68084-0093-01 NDC inpatient 1 UN 1.81 1.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.22 67.6 999999999 1.1 1.76 percent of total billed charges CARBIDOPA-LEVODOPA 25-100 TAB 48260398_1 CDM 0250 RC 68084-0093-01 NDC inpatient 1 UN 1.81 1.18 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.1 1.76 CARBIDOPA-LEVODOPA 25-250 TAB 48260401_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVODOPA 25-250 TAB 48260401_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVODOPA 25-250 TAB 48260401_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVODOPA 25-250 TAB 48260401_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVODOPA 25-250 TAB 48260401_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVODOPA 25-250 TAB 48260401_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVODOPA 25-250 TAB 48260401_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVODOPA 25-250 TAB 48260401_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVODOPA 25-250 TAB 48260401_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CARBIDOPA-LEVODOPA 25-250 TAB 48260401_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CARBIDOPA-LEVODOPA 25-250 TAB 48260401_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CARBIDOPA-LEVODOPA 25-250 TAB 48260401_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CARBIDOPA-LEVODOPA 25-250 TAB 48260401_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVODOPA 25-250 TAB 48260401_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CARBIDOPA-LEVO ER 50-200 TAB 48260402_1 CDM 0250 RC 51079-0923-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO ER 50-200 TAB 48260402_1 CDM 0250 RC 51079-0923-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO ER 50-200 TAB 48260402_1 CDM 0250 RC 51079-0923-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO ER 50-200 TAB 48260402_1 CDM 0250 RC 51079-0923-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO ER 50-200 TAB 48260402_1 CDM 0250 RC 51079-0923-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO ER 50-200 TAB 48260402_1 CDM 0250 RC 51079-0923-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO ER 50-200 TAB 48260402_1 CDM 0250 RC 51079-0923-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO ER 50-200 TAB 48260402_1 CDM 0250 RC 51079-0923-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO ER 50-200 TAB 48260402_1 CDM 0250 RC 51079-0923-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CARBIDOPA-LEVO ER 50-200 TAB 48260402_1 CDM 0250 RC 51079-0923-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CARBIDOPA-LEVO ER 50-200 TAB 48260402_1 CDM 0250 RC 51079-0923-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CARBIDOPA-LEVO ER 50-200 TAB 48260402_1 CDM 0250 RC 51079-0923-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CARBIDOPA-LEVO ER 50-200 TAB 48260402_1 CDM 0250 RC 51079-0923-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO ER 50-200 TAB 48260402_1 CDM 0250 RC 51079-0923-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 HEMABATE 250 MCG/ML AMPUL 48260405_1 CDM 0250 RC 00009-0856-08 NDC inpatient 1 UN 1598.79 1039.21 AETNA AETNA 1263.04 79 999999999 968.07 1550.83 percent of total billed charges HEMABATE 250 MCG/ML AMPUL 48260405_1 CDM 0250 RC 00009-0856-08 NDC inpatient 1 UN 1598.79 1039.21 SELF PAY DISCOUNT SELF PAY DISCOUNT 1039.21 65 999999999 968.07 1550.83 percent of total billed charges HEMABATE 250 MCG/ML AMPUL 48260405_1 CDM 0250 RC 00009-0856-08 NDC inpatient 1 UN 1598.79 1039.21 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1550.83 97 999999999 968.07 1550.83 percent of total billed charges HEMABATE 250 MCG/ML AMPUL 48260405_1 CDM 0250 RC 00009-0856-08 NDC inpatient 1 UN 1598.79 1039.21 ENCORE - ALL PLANS ENCORE - ALL PLANS 1103.17 69 999999999 968.07 1550.83 percent of total billed charges HEMABATE 250 MCG/ML AMPUL 48260405_1 CDM 0250 RC 00009-0856-08 NDC inpatient 1 UN 1598.79 1039.21 HUMANA - ALL PLANS HUMANA - ALL PLANS 1247.06 78 999999999 968.07 1550.83 percent of total billed charges HEMABATE 250 MCG/ML AMPUL 48260405_1 CDM 0250 RC 00009-0856-08 NDC inpatient 1 UN 1598.79 1039.21 UMR - ALL PLANS UMR - ALL PLANS 1119.15 70 999999999 968.07 1550.83 percent of total billed charges HEMABATE 250 MCG/ML AMPUL 48260405_1 CDM 0250 RC 00009-0856-08 NDC inpatient 1 UN 1598.79 1039.21 SIHO - ALL PLANS SIHO - ALL PLANS 1438.91 90 999999999 968.07 1550.83 percent of total billed charges HEMABATE 250 MCG/ML AMPUL 48260405_1 CDM 0250 RC 00009-0856-08 NDC inpatient 1 UN 1598.79 1039.21 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 968.07 60.55 999999999 968.07 1550.83 percent of total billed charges HEMABATE 250 MCG/ML AMPUL 48260405_1 CDM 0250 RC 00009-0856-08 NDC inpatient 1 UN 1598.79 1039.21 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 968.07 1550.83 HEMABATE 250 MCG/ML AMPUL 48260405_1 CDM 0250 RC 00009-0856-08 NDC inpatient 1 UN 1598.79 1039.21 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 968.07 1550.83 HEMABATE 250 MCG/ML AMPUL 48260405_1 CDM 0250 RC 00009-0856-08 NDC inpatient 1 UN 1598.79 1039.21 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 968.07 1550.83 HEMABATE 250 MCG/ML AMPUL 48260405_1 CDM 0250 RC 00009-0856-08 NDC inpatient 1 UN 1598.79 1039.21 ANTHEM HMO ANTHEM HMO 999999999 968.07 1550.83 HEMABATE 250 MCG/ML AMPUL 48260405_1 CDM 0250 RC 00009-0856-08 NDC inpatient 1 UN 1598.79 1039.21 CIGNA - ALL PLANS CIGNA - ALL PLANS 1080.78 67.6 999999999 968.07 1550.83 percent of total billed charges HEMABATE 250 MCG/ML AMPUL 48260405_1 CDM 0250 RC 00009-0856-08 NDC inpatient 1 UN 1598.79 1039.21 UHC - ALL PLANS UHC - ALL PLANS 999999999 968.07 1550.83 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260417_1 CDM 0250 RC 00264-3103-11 NDC J0690 HCPCS inpatient 2 UN 84.76 55.09 AETNA AETNA 66.96 79 999999999 51.32 82.22 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260417_1 CDM 0250 RC 00264-3103-11 NDC J0690 HCPCS inpatient 2 UN 84.76 55.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.09 65 999999999 51.32 82.22 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260417_1 CDM 0250 RC 00264-3103-11 NDC J0690 HCPCS inpatient 2 UN 84.76 55.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 82.22 97 999999999 51.32 82.22 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260417_1 CDM 0250 RC 00264-3103-11 NDC J0690 HCPCS inpatient 2 UN 84.76 55.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 58.48 69 999999999 51.32 82.22 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260417_1 CDM 0250 RC 00264-3103-11 NDC J0690 HCPCS inpatient 2 UN 84.76 55.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 66.11 78 999999999 51.32 82.22 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260417_1 CDM 0250 RC 00264-3103-11 NDC J0690 HCPCS inpatient 2 UN 84.76 55.09 UMR - ALL PLANS UMR - ALL PLANS 59.33 70 999999999 51.32 82.22 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260417_1 CDM 0250 RC 00264-3103-11 NDC J0690 HCPCS inpatient 2 UN 84.76 55.09 SIHO - ALL PLANS SIHO - ALL PLANS 76.28 90 999999999 51.32 82.22 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260417_1 CDM 0250 RC 00264-3103-11 NDC J0690 HCPCS inpatient 2 UN 84.76 55.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 51.32 60.55 999999999 51.32 82.22 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260417_1 CDM 0250 RC 00264-3103-11 NDC J0690 HCPCS inpatient 2 UN 84.76 55.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 51.32 82.22 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260417_1 CDM 0250 RC 00264-3103-11 NDC J0690 HCPCS inpatient 2 UN 84.76 55.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 51.32 82.22 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260417_1 CDM 0250 RC 00264-3103-11 NDC J0690 HCPCS inpatient 2 UN 84.76 55.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 51.32 82.22 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260417_1 CDM 0250 RC 00264-3103-11 NDC J0690 HCPCS inpatient 2 UN 84.76 55.09 ANTHEM HMO ANTHEM HMO 999999999 51.32 82.22 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260417_1 CDM 0250 RC 00264-3103-11 NDC J0690 HCPCS inpatient 2 UN 84.76 55.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 57.3 67.6 999999999 51.32 82.22 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260417_1 CDM 0250 RC 00264-3103-11 NDC J0690 HCPCS inpatient 2 UN 84.76 55.09 UHC - ALL PLANS UHC - ALL PLANS 999999999 51.32 82.22 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260419_1 CDM 0250 RC 00409-2585-01 NDC J0690 HCPCS inpatient 2 UN 27.09 17.61 AETNA AETNA 21.4 79 999999999 16.4 26.28 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260419_1 CDM 0250 RC 00409-2585-01 NDC J0690 HCPCS inpatient 2 UN 27.09 17.61 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.61 65 999999999 16.4 26.28 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260419_1 CDM 0250 RC 00409-2585-01 NDC J0690 HCPCS inpatient 2 UN 27.09 17.61 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26.28 97 999999999 16.4 26.28 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260419_1 CDM 0250 RC 00409-2585-01 NDC J0690 HCPCS inpatient 2 UN 27.09 17.61 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.69 69 999999999 16.4 26.28 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260419_1 CDM 0250 RC 00409-2585-01 NDC J0690 HCPCS inpatient 2 UN 27.09 17.61 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.13 78 999999999 16.4 26.28 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260419_1 CDM 0250 RC 00409-2585-01 NDC J0690 HCPCS inpatient 2 UN 27.09 17.61 UMR - ALL PLANS UMR - ALL PLANS 18.96 70 999999999 16.4 26.28 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260419_1 CDM 0250 RC 00409-2585-01 NDC J0690 HCPCS inpatient 2 UN 27.09 17.61 SIHO - ALL PLANS SIHO - ALL PLANS 24.38 90 999999999 16.4 26.28 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260419_1 CDM 0250 RC 00409-2585-01 NDC J0690 HCPCS inpatient 2 UN 27.09 17.61 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.4 60.55 999999999 16.4 26.28 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260419_1 CDM 0250 RC 00409-2585-01 NDC J0690 HCPCS inpatient 2 UN 27.09 17.61 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.4 26.28 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260419_1 CDM 0250 RC 00409-2585-01 NDC J0690 HCPCS inpatient 2 UN 27.09 17.61 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.4 26.28 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260419_1 CDM 0250 RC 00409-2585-01 NDC J0690 HCPCS inpatient 2 UN 27.09 17.61 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.4 26.28 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260419_1 CDM 0250 RC 00409-2585-01 NDC J0690 HCPCS inpatient 2 UN 27.09 17.61 ANTHEM HMO ANTHEM HMO 999999999 16.4 26.28 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260419_1 CDM 0250 RC 00409-2585-01 NDC J0690 HCPCS inpatient 2 UN 27.09 17.61 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.31 67.6 999999999 16.4 26.28 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48260419_1 CDM 0250 RC 00409-2585-01 NDC J0690 HCPCS inpatient 2 UN 27.09 17.61 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.4 26.28 CEFOXITIN 2 GM PIGGYBACK BAG 48260426_1 CDM 0250 RC 00264-3125-11 NDC inpatient 1 UN 141.92 92.25 AETNA AETNA 112.12 79 999999999 85.93 137.66 percent of total billed charges CEFOXITIN 2 GM PIGGYBACK BAG 48260426_1 CDM 0250 RC 00264-3125-11 NDC inpatient 1 UN 141.92 92.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.25 65 999999999 85.93 137.66 percent of total billed charges CEFOXITIN 2 GM PIGGYBACK BAG 48260426_1 CDM 0250 RC 00264-3125-11 NDC inpatient 1 UN 141.92 92.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.66 97 999999999 85.93 137.66 percent of total billed charges CEFOXITIN 2 GM PIGGYBACK BAG 48260426_1 CDM 0250 RC 00264-3125-11 NDC inpatient 1 UN 141.92 92.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.92 69 999999999 85.93 137.66 percent of total billed charges CEFOXITIN 2 GM PIGGYBACK BAG 48260426_1 CDM 0250 RC 00264-3125-11 NDC inpatient 1 UN 141.92 92.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.7 78 999999999 85.93 137.66 percent of total billed charges CEFOXITIN 2 GM PIGGYBACK BAG 48260426_1 CDM 0250 RC 00264-3125-11 NDC inpatient 1 UN 141.92 92.25 UMR - ALL PLANS UMR - ALL PLANS 99.34 70 999999999 85.93 137.66 percent of total billed charges CEFOXITIN 2 GM PIGGYBACK BAG 48260426_1 CDM 0250 RC 00264-3125-11 NDC inpatient 1 UN 141.92 92.25 SIHO - ALL PLANS SIHO - ALL PLANS 127.73 90 999999999 85.93 137.66 percent of total billed charges CEFOXITIN 2 GM PIGGYBACK BAG 48260426_1 CDM 0250 RC 00264-3125-11 NDC inpatient 1 UN 141.92 92.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.93 60.55 999999999 85.93 137.66 percent of total billed charges CEFOXITIN 2 GM PIGGYBACK BAG 48260426_1 CDM 0250 RC 00264-3125-11 NDC inpatient 1 UN 141.92 92.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.93 137.66 CEFOXITIN 2 GM PIGGYBACK BAG 48260426_1 CDM 0250 RC 00264-3125-11 NDC inpatient 1 UN 141.92 92.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.93 137.66 CEFOXITIN 2 GM PIGGYBACK BAG 48260426_1 CDM 0250 RC 00264-3125-11 NDC inpatient 1 UN 141.92 92.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.93 137.66 CEFOXITIN 2 GM PIGGYBACK BAG 48260426_1 CDM 0250 RC 00264-3125-11 NDC inpatient 1 UN 141.92 92.25 ANTHEM HMO ANTHEM HMO 999999999 85.93 137.66 CEFOXITIN 2 GM PIGGYBACK BAG 48260426_1 CDM 0250 RC 00264-3125-11 NDC inpatient 1 UN 141.92 92.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.94 67.6 999999999 85.93 137.66 percent of total billed charges CEFOXITIN 2 GM PIGGYBACK BAG 48260426_1 CDM 0250 RC 00264-3125-11 NDC inpatient 1 UN 141.92 92.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.93 137.66 CEFOXITIN 1 GM PIGGYBACK BAG 48260428_1 CDM 0250 RC 00264-3123-11 NDC inpatient 1 UN 100.06 65.04 AETNA AETNA 79.05 79 999999999 60.59 97.06 percent of total billed charges CEFOXITIN 1 GM PIGGYBACK BAG 48260428_1 CDM 0250 RC 00264-3123-11 NDC inpatient 1 UN 100.06 65.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.04 65 999999999 60.59 97.06 percent of total billed charges CEFOXITIN 1 GM PIGGYBACK BAG 48260428_1 CDM 0250 RC 00264-3123-11 NDC inpatient 1 UN 100.06 65.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.06 97 999999999 60.59 97.06 percent of total billed charges CEFOXITIN 1 GM PIGGYBACK BAG 48260428_1 CDM 0250 RC 00264-3123-11 NDC inpatient 1 UN 100.06 65.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.04 69 999999999 60.59 97.06 percent of total billed charges CEFOXITIN 1 GM PIGGYBACK BAG 48260428_1 CDM 0250 RC 00264-3123-11 NDC inpatient 1 UN 100.06 65.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.05 78 999999999 60.59 97.06 percent of total billed charges CEFOXITIN 1 GM PIGGYBACK BAG 48260428_1 CDM 0250 RC 00264-3123-11 NDC inpatient 1 UN 100.06 65.04 UMR - ALL PLANS UMR - ALL PLANS 70.04 70 999999999 60.59 97.06 percent of total billed charges CEFOXITIN 1 GM PIGGYBACK BAG 48260428_1 CDM 0250 RC 00264-3123-11 NDC inpatient 1 UN 100.06 65.04 SIHO - ALL PLANS SIHO - ALL PLANS 90.05 90 999999999 60.59 97.06 percent of total billed charges CEFOXITIN 1 GM PIGGYBACK BAG 48260428_1 CDM 0250 RC 00264-3123-11 NDC inpatient 1 UN 100.06 65.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.59 60.55 999999999 60.59 97.06 percent of total billed charges CEFOXITIN 1 GM PIGGYBACK BAG 48260428_1 CDM 0250 RC 00264-3123-11 NDC inpatient 1 UN 100.06 65.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.59 97.06 CEFOXITIN 1 GM PIGGYBACK BAG 48260428_1 CDM 0250 RC 00264-3123-11 NDC inpatient 1 UN 100.06 65.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.59 97.06 CEFOXITIN 1 GM PIGGYBACK BAG 48260428_1 CDM 0250 RC 00264-3123-11 NDC inpatient 1 UN 100.06 65.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.59 97.06 CEFOXITIN 1 GM PIGGYBACK BAG 48260428_1 CDM 0250 RC 00264-3123-11 NDC inpatient 1 UN 100.06 65.04 ANTHEM HMO ANTHEM HMO 999999999 60.59 97.06 CEFOXITIN 1 GM PIGGYBACK BAG 48260428_1 CDM 0250 RC 00264-3123-11 NDC inpatient 1 UN 100.06 65.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.64 67.6 999999999 60.59 97.06 percent of total billed charges CEFOXITIN 1 GM PIGGYBACK BAG 48260428_1 CDM 0250 RC 00264-3123-11 NDC inpatient 1 UN 100.06 65.04 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.59 97.06 CEFUROXIME AXETIL 250 MG TAB 48260435_1 CDM 0250 RC 68180-0302-60 NDC inpatient 1 UN 7.51 4.88 AETNA AETNA 5.93 79 999999999 4.55 7.28 percent of total billed charges CEFUROXIME AXETIL 250 MG TAB 48260435_1 CDM 0250 RC 68180-0302-60 NDC inpatient 1 UN 7.51 4.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.88 65 999999999 4.55 7.28 percent of total billed charges CEFUROXIME AXETIL 250 MG TAB 48260435_1 CDM 0250 RC 68180-0302-60 NDC inpatient 1 UN 7.51 4.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7.28 97 999999999 4.55 7.28 percent of total billed charges CEFUROXIME AXETIL 250 MG TAB 48260435_1 CDM 0250 RC 68180-0302-60 NDC inpatient 1 UN 7.51 4.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.18 69 999999999 4.55 7.28 percent of total billed charges CEFUROXIME AXETIL 250 MG TAB 48260435_1 CDM 0250 RC 68180-0302-60 NDC inpatient 1 UN 7.51 4.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 5.86 78 999999999 4.55 7.28 percent of total billed charges CEFUROXIME AXETIL 250 MG TAB 48260435_1 CDM 0250 RC 68180-0302-60 NDC inpatient 1 UN 7.51 4.88 UMR - ALL PLANS UMR - ALL PLANS 5.26 70 999999999 4.55 7.28 percent of total billed charges CEFUROXIME AXETIL 250 MG TAB 48260435_1 CDM 0250 RC 68180-0302-60 NDC inpatient 1 UN 7.51 4.88 SIHO - ALL PLANS SIHO - ALL PLANS 6.76 90 999999999 4.55 7.28 percent of total billed charges CEFUROXIME AXETIL 250 MG TAB 48260435_1 CDM 0250 RC 68180-0302-60 NDC inpatient 1 UN 7.51 4.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.55 60.55 999999999 4.55 7.28 percent of total billed charges CEFUROXIME AXETIL 250 MG TAB 48260435_1 CDM 0250 RC 68180-0302-60 NDC inpatient 1 UN 7.51 4.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.55 7.28 CEFUROXIME AXETIL 250 MG TAB 48260435_1 CDM 0250 RC 68180-0302-60 NDC inpatient 1 UN 7.51 4.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.55 7.28 CEFUROXIME AXETIL 250 MG TAB 48260435_1 CDM 0250 RC 68180-0302-60 NDC inpatient 1 UN 7.51 4.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.55 7.28 CEFUROXIME AXETIL 250 MG TAB 48260435_1 CDM 0250 RC 68180-0302-60 NDC inpatient 1 UN 7.51 4.88 ANTHEM HMO ANTHEM HMO 999999999 4.55 7.28 CEFUROXIME AXETIL 250 MG TAB 48260435_1 CDM 0250 RC 68180-0302-60 NDC inpatient 1 UN 7.51 4.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.08 67.6 999999999 4.55 7.28 percent of total billed charges CEFUROXIME AXETIL 250 MG TAB 48260435_1 CDM 0250 RC 68180-0302-60 NDC inpatient 1 UN 7.51 4.88 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.55 7.28 CHLORDIAZEPOXIDE 10 MG CAPSULE 48260447_1 CDM 0250 RC 51079-0375-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 10 MG CAPSULE 48260447_1 CDM 0250 RC 51079-0375-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 10 MG CAPSULE 48260447_1 CDM 0250 RC 51079-0375-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 10 MG CAPSULE 48260447_1 CDM 0250 RC 51079-0375-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 10 MG CAPSULE 48260447_1 CDM 0250 RC 51079-0375-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 10 MG CAPSULE 48260447_1 CDM 0250 RC 51079-0375-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 10 MG CAPSULE 48260447_1 CDM 0250 RC 51079-0375-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 10 MG CAPSULE 48260447_1 CDM 0250 RC 51079-0375-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 10 MG CAPSULE 48260447_1 CDM 0250 RC 51079-0375-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CHLORDIAZEPOXIDE 10 MG CAPSULE 48260447_1 CDM 0250 RC 51079-0375-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CHLORDIAZEPOXIDE 10 MG CAPSULE 48260447_1 CDM 0250 RC 51079-0375-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CHLORDIAZEPOXIDE 10 MG CAPSULE 48260447_1 CDM 0250 RC 51079-0375-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CHLORDIAZEPOXIDE 10 MG CAPSULE 48260447_1 CDM 0250 RC 51079-0375-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 10 MG CAPSULE 48260447_1 CDM 0250 RC 51079-0375-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CHLORDIAZEPOXIDE 25 MG CAPSULE 48260448_1 CDM 0250 RC 51079-0141-20 NDC inpatient 1 UN 1.93 1.25 AETNA AETNA 1.52 79 999999999 1.17 1.87 percent of total billed charges CHLORDIAZEPOXIDE 25 MG CAPSULE 48260448_1 CDM 0250 RC 51079-0141-20 NDC inpatient 1 UN 1.93 1.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.25 65 999999999 1.17 1.87 percent of total billed charges CHLORDIAZEPOXIDE 25 MG CAPSULE 48260448_1 CDM 0250 RC 51079-0141-20 NDC inpatient 1 UN 1.93 1.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.87 97 999999999 1.17 1.87 percent of total billed charges CHLORDIAZEPOXIDE 25 MG CAPSULE 48260448_1 CDM 0250 RC 51079-0141-20 NDC inpatient 1 UN 1.93 1.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.51 78 999999999 1.17 1.87 percent of total billed charges CHLORDIAZEPOXIDE 25 MG CAPSULE 48260448_1 CDM 0250 RC 51079-0141-20 NDC inpatient 1 UN 1.93 1.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.33 69 999999999 1.17 1.87 percent of total billed charges CHLORDIAZEPOXIDE 25 MG CAPSULE 48260448_1 CDM 0250 RC 51079-0141-20 NDC inpatient 1 UN 1.93 1.25 UMR - ALL PLANS UMR - ALL PLANS 1.35 70 999999999 1.17 1.87 percent of total billed charges CHLORDIAZEPOXIDE 25 MG CAPSULE 48260448_1 CDM 0250 RC 51079-0141-20 NDC inpatient 1 UN 1.93 1.25 SIHO - ALL PLANS SIHO - ALL PLANS 1.74 90 999999999 1.17 1.87 percent of total billed charges CHLORDIAZEPOXIDE 25 MG CAPSULE 48260448_1 CDM 0250 RC 51079-0141-20 NDC inpatient 1 UN 1.93 1.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.17 60.55 999999999 1.17 1.87 percent of total billed charges CHLORDIAZEPOXIDE 25 MG CAPSULE 48260448_1 CDM 0250 RC 51079-0141-20 NDC inpatient 1 UN 1.93 1.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.17 1.87 CHLORDIAZEPOXIDE 25 MG CAPSULE 48260448_1 CDM 0250 RC 51079-0141-20 NDC inpatient 1 UN 1.93 1.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.17 1.87 CHLORDIAZEPOXIDE 25 MG CAPSULE 48260448_1 CDM 0250 RC 51079-0141-20 NDC inpatient 1 UN 1.93 1.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.17 1.87 CHLORDIAZEPOXIDE 25 MG CAPSULE 48260448_1 CDM 0250 RC 51079-0141-20 NDC inpatient 1 UN 1.93 1.25 ANTHEM HMO ANTHEM HMO 999999999 1.17 1.87 CHLORDIAZEPOXIDE 25 MG CAPSULE 48260448_1 CDM 0250 RC 51079-0141-20 NDC inpatient 1 UN 1.93 1.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.3 67.6 999999999 1.17 1.87 percent of total billed charges CHLORDIAZEPOXIDE 25 MG CAPSULE 48260448_1 CDM 0250 RC 51079-0141-20 NDC inpatient 1 UN 1.93 1.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.17 1.87 CHLORDIAZEPOXIDE 5 MG CAPSULE 48260449_1 CDM 0250 RC 51079-0374-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 5 MG CAPSULE 48260449_1 CDM 0250 RC 51079-0374-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 5 MG CAPSULE 48260449_1 CDM 0250 RC 51079-0374-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 5 MG CAPSULE 48260449_1 CDM 0250 RC 51079-0374-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 5 MG CAPSULE 48260449_1 CDM 0250 RC 51079-0374-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 5 MG CAPSULE 48260449_1 CDM 0250 RC 51079-0374-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 5 MG CAPSULE 48260449_1 CDM 0250 RC 51079-0374-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 5 MG CAPSULE 48260449_1 CDM 0250 RC 51079-0374-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 5 MG CAPSULE 48260449_1 CDM 0250 RC 51079-0374-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CHLORDIAZEPOXIDE 5 MG CAPSULE 48260449_1 CDM 0250 RC 51079-0374-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CHLORDIAZEPOXIDE 5 MG CAPSULE 48260449_1 CDM 0250 RC 51079-0374-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CHLORDIAZEPOXIDE 5 MG CAPSULE 48260449_1 CDM 0250 RC 51079-0374-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CHLORDIAZEPOXIDE 5 MG CAPSULE 48260449_1 CDM 0250 RC 51079-0374-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 5 MG CAPSULE 48260449_1 CDM 0250 RC 51079-0374-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 48878-0620-02 - chlorhexidine Top 0.12% Liq 15 mL [JOHN] 48260452_1 CDM 0250 RC 48878-0620-02 NDC inpatient 1 UN 11.85 7.7 AETNA AETNA 9.36 79 999999999 7.18 11.49 percent of total billed charges 48878-0620-02 - chlorhexidine Top 0.12% Liq 15 mL [JOHN] 48260452_1 CDM 0250 RC 48878-0620-02 NDC inpatient 1 UN 11.85 7.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.7 65 999999999 7.18 11.49 percent of total billed charges 48878-0620-02 - chlorhexidine Top 0.12% Liq 15 mL [JOHN] 48260452_1 CDM 0250 RC 48878-0620-02 NDC inpatient 1 UN 11.85 7.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11.49 97 999999999 7.18 11.49 percent of total billed charges 48878-0620-02 - chlorhexidine Top 0.12% Liq 15 mL [JOHN] 48260452_1 CDM 0250 RC 48878-0620-02 NDC inpatient 1 UN 11.85 7.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.24 78 999999999 7.18 11.49 percent of total billed charges 48878-0620-02 - chlorhexidine Top 0.12% Liq 15 mL [JOHN] 48260452_1 CDM 0250 RC 48878-0620-02 NDC inpatient 1 UN 11.85 7.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.18 69 999999999 7.18 11.49 percent of total billed charges 48878-0620-02 - chlorhexidine Top 0.12% Liq 15 mL [JOHN] 48260452_1 CDM 0250 RC 48878-0620-02 NDC inpatient 1 UN 11.85 7.7 UMR - ALL PLANS UMR - ALL PLANS 8.3 70 999999999 7.18 11.49 percent of total billed charges 48878-0620-02 - chlorhexidine Top 0.12% Liq 15 mL [JOHN] 48260452_1 CDM 0250 RC 48878-0620-02 NDC inpatient 1 UN 11.85 7.7 SIHO - ALL PLANS SIHO - ALL PLANS 10.67 90 999999999 7.18 11.49 percent of total billed charges 48878-0620-02 - chlorhexidine Top 0.12% Liq 15 mL [JOHN] 48260452_1 CDM 0250 RC 48878-0620-02 NDC inpatient 1 UN 11.85 7.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.18 60.55 999999999 7.18 11.49 percent of total billed charges 48878-0620-02 - chlorhexidine Top 0.12% Liq 15 mL [JOHN] 48260452_1 CDM 0250 RC 48878-0620-02 NDC inpatient 1 UN 11.85 7.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.18 11.49 48878-0620-02 - chlorhexidine Top 0.12% Liq 15 mL [JOHN] 48260452_1 CDM 0250 RC 48878-0620-02 NDC inpatient 1 UN 11.85 7.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.18 11.49 48878-0620-02 - chlorhexidine Top 0.12% Liq 15 mL [JOHN] 48260452_1 CDM 0250 RC 48878-0620-02 NDC inpatient 1 UN 11.85 7.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.18 11.49 48878-0620-02 - chlorhexidine Top 0.12% Liq 15 mL [JOHN] 48260452_1 CDM 0250 RC 48878-0620-02 NDC inpatient 1 UN 11.85 7.7 ANTHEM HMO ANTHEM HMO 999999999 7.18 11.49 48878-0620-02 - chlorhexidine Top 0.12% Liq 15 mL [JOHN] 48260452_1 CDM 0250 RC 48878-0620-02 NDC inpatient 1 UN 11.85 7.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.01 67.6 999999999 7.18 11.49 percent of total billed charges 48878-0620-02 - chlorhexidine Top 0.12% Liq 15 mL [JOHN] 48260452_1 CDM 0250 RC 48878-0620-02 NDC inpatient 1 UN 11.85 7.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.18 11.49 CHLORPROMAZINE 25 MG/ML AMP 48260457_1 CDM 0250 RC 00641-1397-35 NDC inpatient 1 UN 1344.66 874.03 AETNA AETNA 1062.28 79 999999999 814.19 1304.32 percent of total billed charges CHLORPROMAZINE 25 MG/ML AMP 48260457_1 CDM 0250 RC 00641-1397-35 NDC inpatient 1 UN 1344.66 874.03 SELF PAY DISCOUNT SELF PAY DISCOUNT 874.03 65 999999999 814.19 1304.32 percent of total billed charges CHLORPROMAZINE 25 MG/ML AMP 48260457_1 CDM 0250 RC 00641-1397-35 NDC inpatient 1 UN 1344.66 874.03 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1304.32 97 999999999 814.19 1304.32 percent of total billed charges CHLORPROMAZINE 25 MG/ML AMP 48260457_1 CDM 0250 RC 00641-1397-35 NDC inpatient 1 UN 1344.66 874.03 HUMANA - ALL PLANS HUMANA - ALL PLANS 1048.83 78 999999999 814.19 1304.32 percent of total billed charges CHLORPROMAZINE 25 MG/ML AMP 48260457_1 CDM 0250 RC 00641-1397-35 NDC inpatient 1 UN 1344.66 874.03 ENCORE - ALL PLANS ENCORE - ALL PLANS 927.82 69 999999999 814.19 1304.32 percent of total billed charges CHLORPROMAZINE 25 MG/ML AMP 48260457_1 CDM 0250 RC 00641-1397-35 NDC inpatient 1 UN 1344.66 874.03 UMR - ALL PLANS UMR - ALL PLANS 941.26 70 999999999 814.19 1304.32 percent of total billed charges CHLORPROMAZINE 25 MG/ML AMP 48260457_1 CDM 0250 RC 00641-1397-35 NDC inpatient 1 UN 1344.66 874.03 SIHO - ALL PLANS SIHO - ALL PLANS 1210.19 90 999999999 814.19 1304.32 percent of total billed charges CHLORPROMAZINE 25 MG/ML AMP 48260457_1 CDM 0250 RC 00641-1397-35 NDC inpatient 1 UN 1344.66 874.03 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 814.19 60.55 999999999 814.19 1304.32 percent of total billed charges CHLORPROMAZINE 25 MG/ML AMP 48260457_1 CDM 0250 RC 00641-1397-35 NDC inpatient 1 UN 1344.66 874.03 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 814.19 1304.32 CHLORPROMAZINE 25 MG/ML AMP 48260457_1 CDM 0250 RC 00641-1397-35 NDC inpatient 1 UN 1344.66 874.03 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 814.19 1304.32 CHLORPROMAZINE 25 MG/ML AMP 48260457_1 CDM 0250 RC 00641-1397-35 NDC inpatient 1 UN 1344.66 874.03 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 814.19 1304.32 CHLORPROMAZINE 25 MG/ML AMP 48260457_1 CDM 0250 RC 00641-1397-35 NDC inpatient 1 UN 1344.66 874.03 ANTHEM HMO ANTHEM HMO 999999999 814.19 1304.32 CHLORPROMAZINE 25 MG/ML AMP 48260457_1 CDM 0250 RC 00641-1397-35 NDC inpatient 1 UN 1344.66 874.03 CIGNA - ALL PLANS CIGNA - ALL PLANS 908.99 67.6 999999999 814.19 1304.32 percent of total billed charges CHLORPROMAZINE 25 MG/ML AMP 48260457_1 CDM 0250 RC 00641-1397-35 NDC inpatient 1 UN 1344.66 874.03 UHC - ALL PLANS UHC - ALL PLANS 999999999 814.19 1304.32 CHOLESTYRAMINE PACKET 48260463_1 CDM 0250 RC 00185-0940-98 NDC inpatient 1 UN 9.35 6.08 AETNA AETNA 7.39 79 999999999 5.66 9.07 percent of total billed charges CHOLESTYRAMINE PACKET 48260463_1 CDM 0250 RC 00185-0940-98 NDC inpatient 1 UN 9.35 6.08 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.08 65 999999999 5.66 9.07 percent of total billed charges CHOLESTYRAMINE PACKET 48260463_1 CDM 0250 RC 00185-0940-98 NDC inpatient 1 UN 9.35 6.08 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.07 97 999999999 5.66 9.07 percent of total billed charges CHOLESTYRAMINE PACKET 48260463_1 CDM 0250 RC 00185-0940-98 NDC inpatient 1 UN 9.35 6.08 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.29 78 999999999 5.66 9.07 percent of total billed charges CHOLESTYRAMINE PACKET 48260463_1 CDM 0250 RC 00185-0940-98 NDC inpatient 1 UN 9.35 6.08 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.45 69 999999999 5.66 9.07 percent of total billed charges CHOLESTYRAMINE PACKET 48260463_1 CDM 0250 RC 00185-0940-98 NDC inpatient 1 UN 9.35 6.08 UMR - ALL PLANS UMR - ALL PLANS 6.55 70 999999999 5.66 9.07 percent of total billed charges CHOLESTYRAMINE PACKET 48260463_1 CDM 0250 RC 00185-0940-98 NDC inpatient 1 UN 9.35 6.08 SIHO - ALL PLANS SIHO - ALL PLANS 8.42 90 999999999 5.66 9.07 percent of total billed charges CHOLESTYRAMINE PACKET 48260463_1 CDM 0250 RC 00185-0940-98 NDC inpatient 1 UN 9.35 6.08 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.66 60.55 999999999 5.66 9.07 percent of total billed charges CHOLESTYRAMINE PACKET 48260463_1 CDM 0250 RC 00185-0940-98 NDC inpatient 1 UN 9.35 6.08 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.66 9.07 CHOLESTYRAMINE PACKET 48260463_1 CDM 0250 RC 00185-0940-98 NDC inpatient 1 UN 9.35 6.08 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.66 9.07 CHOLESTYRAMINE PACKET 48260463_1 CDM 0250 RC 00185-0940-98 NDC inpatient 1 UN 9.35 6.08 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.66 9.07 CHOLESTYRAMINE PACKET 48260463_1 CDM 0250 RC 00185-0940-98 NDC inpatient 1 UN 9.35 6.08 ANTHEM HMO ANTHEM HMO 999999999 5.66 9.07 CHOLESTYRAMINE PACKET 48260463_1 CDM 0250 RC 00185-0940-98 NDC inpatient 1 UN 9.35 6.08 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.32 67.6 999999999 5.66 9.07 percent of total billed charges CHOLESTYRAMINE PACKET 48260463_1 CDM 0250 RC 00185-0940-98 NDC inpatient 1 UN 9.35 6.08 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.66 9.07 CILOSTAZOL 100 MG TABLET 48260465_1 CDM 0250 RC 00093-2064-06 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CILOSTAZOL 100 MG TABLET 48260465_1 CDM 0250 RC 00093-2064-06 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CILOSTAZOL 100 MG TABLET 48260465_1 CDM 0250 RC 00093-2064-06 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CILOSTAZOL 100 MG TABLET 48260465_1 CDM 0250 RC 00093-2064-06 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CILOSTAZOL 100 MG TABLET 48260465_1 CDM 0250 RC 00093-2064-06 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CILOSTAZOL 100 MG TABLET 48260465_1 CDM 0250 RC 00093-2064-06 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CILOSTAZOL 100 MG TABLET 48260465_1 CDM 0250 RC 00093-2064-06 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CILOSTAZOL 100 MG TABLET 48260465_1 CDM 0250 RC 00093-2064-06 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CILOSTAZOL 100 MG TABLET 48260465_1 CDM 0250 RC 00093-2064-06 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CILOSTAZOL 100 MG TABLET 48260465_1 CDM 0250 RC 00093-2064-06 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CILOSTAZOL 100 MG TABLET 48260465_1 CDM 0250 RC 00093-2064-06 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CILOSTAZOL 100 MG TABLET 48260465_1 CDM 0250 RC 00093-2064-06 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CILOSTAZOL 100 MG TABLET 48260465_1 CDM 0250 RC 00093-2064-06 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CILOSTAZOL 100 MG TABLET 48260465_1 CDM 0250 RC 00093-2064-06 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 68084-0069-01 - ciprofloxacin 250 mg Tab [JOHN] 48260468_1 CDM 0250 RC 68084-0069-01 NDC inpatient 1 UN 1.22 0.79 AETNA AETNA 0.96 79 999999999 0.74 1.18 percent of total billed charges 68084-0069-01 - ciprofloxacin 250 mg Tab [JOHN] 48260468_1 CDM 0250 RC 68084-0069-01 NDC inpatient 1 UN 1.22 0.79 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.79 65 999999999 0.74 1.18 percent of total billed charges 68084-0069-01 - ciprofloxacin 250 mg Tab [JOHN] 48260468_1 CDM 0250 RC 68084-0069-01 NDC inpatient 1 UN 1.22 0.79 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.18 97 999999999 0.74 1.18 percent of total billed charges 68084-0069-01 - ciprofloxacin 250 mg Tab [JOHN] 48260468_1 CDM 0250 RC 68084-0069-01 NDC inpatient 1 UN 1.22 0.79 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.95 78 999999999 0.74 1.18 percent of total billed charges 68084-0069-01 - ciprofloxacin 250 mg Tab [JOHN] 48260468_1 CDM 0250 RC 68084-0069-01 NDC inpatient 1 UN 1.22 0.79 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.84 69 999999999 0.74 1.18 percent of total billed charges 68084-0069-01 - ciprofloxacin 250 mg Tab [JOHN] 48260468_1 CDM 0250 RC 68084-0069-01 NDC inpatient 1 UN 1.22 0.79 UMR - ALL PLANS UMR - ALL PLANS 0.85 70 999999999 0.74 1.18 percent of total billed charges 68084-0069-01 - ciprofloxacin 250 mg Tab [JOHN] 48260468_1 CDM 0250 RC 68084-0069-01 NDC inpatient 1 UN 1.22 0.79 SIHO - ALL PLANS SIHO - ALL PLANS 1.1 90 999999999 0.74 1.18 percent of total billed charges 68084-0069-01 - ciprofloxacin 250 mg Tab [JOHN] 48260468_1 CDM 0250 RC 68084-0069-01 NDC inpatient 1 UN 1.22 0.79 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.74 60.55 999999999 0.74 1.18 percent of total billed charges 68084-0069-01 - ciprofloxacin 250 mg Tab [JOHN] 48260468_1 CDM 0250 RC 68084-0069-01 NDC inpatient 1 UN 1.22 0.79 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.74 1.18 68084-0069-01 - ciprofloxacin 250 mg Tab [JOHN] 48260468_1 CDM 0250 RC 68084-0069-01 NDC inpatient 1 UN 1.22 0.79 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.74 1.18 68084-0069-01 - ciprofloxacin 250 mg Tab [JOHN] 48260468_1 CDM 0250 RC 68084-0069-01 NDC inpatient 1 UN 1.22 0.79 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.74 1.18 68084-0069-01 - ciprofloxacin 250 mg Tab [JOHN] 48260468_1 CDM 0250 RC 68084-0069-01 NDC inpatient 1 UN 1.22 0.79 ANTHEM HMO ANTHEM HMO 999999999 0.74 1.18 68084-0069-01 - ciprofloxacin 250 mg Tab [JOHN] 48260468_1 CDM 0250 RC 68084-0069-01 NDC inpatient 1 UN 1.22 0.79 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.82 67.6 999999999 0.74 1.18 percent of total billed charges 68084-0069-01 - ciprofloxacin 250 mg Tab [JOHN] 48260468_1 CDM 0250 RC 68084-0069-01 NDC inpatient 1 UN 1.22 0.79 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.74 1.18 CIPROFLOXACIN HCL 500 MG TAB 48260471_1 CDM 0250 RC 68084-0070-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CIPROFLOXACIN HCL 500 MG TAB 48260471_1 CDM 0250 RC 68084-0070-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CIPROFLOXACIN HCL 500 MG TAB 48260471_1 CDM 0250 RC 68084-0070-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CIPROFLOXACIN HCL 500 MG TAB 48260471_1 CDM 0250 RC 68084-0070-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CIPROFLOXACIN HCL 500 MG TAB 48260471_1 CDM 0250 RC 68084-0070-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CIPROFLOXACIN HCL 500 MG TAB 48260471_1 CDM 0250 RC 68084-0070-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CIPROFLOXACIN HCL 500 MG TAB 48260471_1 CDM 0250 RC 68084-0070-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CIPROFLOXACIN HCL 500 MG TAB 48260471_1 CDM 0250 RC 68084-0070-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CIPROFLOXACIN HCL 500 MG TAB 48260471_1 CDM 0250 RC 68084-0070-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CIPROFLOXACIN HCL 500 MG TAB 48260471_1 CDM 0250 RC 68084-0070-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CIPROFLOXACIN HCL 500 MG TAB 48260471_1 CDM 0250 RC 68084-0070-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CIPROFLOXACIN HCL 500 MG TAB 48260471_1 CDM 0250 RC 68084-0070-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CIPROFLOXACIN HCL 500 MG TAB 48260471_1 CDM 0250 RC 68084-0070-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CIPROFLOXACIN HCL 500 MG TAB 48260471_1 CDM 0250 RC 68084-0070-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CIPROFLOXACIN 0.3% EYE DROP 48260472_1 CDM 0250 RC 61314-0656-05 NDC inpatient 1 UN 25.1 16.32 AETNA AETNA 19.83 79 999999999 15.2 24.35 percent of total billed charges CIPROFLOXACIN 0.3% EYE DROP 48260472_1 CDM 0250 RC 61314-0656-05 NDC inpatient 1 UN 25.1 16.32 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.32 65 999999999 15.2 24.35 percent of total billed charges CIPROFLOXACIN 0.3% EYE DROP 48260472_1 CDM 0250 RC 61314-0656-05 NDC inpatient 1 UN 25.1 16.32 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.35 97 999999999 15.2 24.35 percent of total billed charges CIPROFLOXACIN 0.3% EYE DROP 48260472_1 CDM 0250 RC 61314-0656-05 NDC inpatient 1 UN 25.1 16.32 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.58 78 999999999 15.2 24.35 percent of total billed charges CIPROFLOXACIN 0.3% EYE DROP 48260472_1 CDM 0250 RC 61314-0656-05 NDC inpatient 1 UN 25.1 16.32 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.32 69 999999999 15.2 24.35 percent of total billed charges CIPROFLOXACIN 0.3% EYE DROP 48260472_1 CDM 0250 RC 61314-0656-05 NDC inpatient 1 UN 25.1 16.32 UMR - ALL PLANS UMR - ALL PLANS 17.57 70 999999999 15.2 24.35 percent of total billed charges CIPROFLOXACIN 0.3% EYE DROP 48260472_1 CDM 0250 RC 61314-0656-05 NDC inpatient 1 UN 25.1 16.32 SIHO - ALL PLANS SIHO - ALL PLANS 22.59 90 999999999 15.2 24.35 percent of total billed charges CIPROFLOXACIN 0.3% EYE DROP 48260472_1 CDM 0250 RC 61314-0656-05 NDC inpatient 1 UN 25.1 16.32 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.2 60.55 999999999 15.2 24.35 percent of total billed charges CIPROFLOXACIN 0.3% EYE DROP 48260472_1 CDM 0250 RC 61314-0656-05 NDC inpatient 1 UN 25.1 16.32 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.2 24.35 CIPROFLOXACIN 0.3% EYE DROP 48260472_1 CDM 0250 RC 61314-0656-05 NDC inpatient 1 UN 25.1 16.32 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.2 24.35 CIPROFLOXACIN 0.3% EYE DROP 48260472_1 CDM 0250 RC 61314-0656-05 NDC inpatient 1 UN 25.1 16.32 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.2 24.35 CIPROFLOXACIN 0.3% EYE DROP 48260472_1 CDM 0250 RC 61314-0656-05 NDC inpatient 1 UN 25.1 16.32 ANTHEM HMO ANTHEM HMO 999999999 15.2 24.35 CIPROFLOXACIN 0.3% EYE DROP 48260472_1 CDM 0250 RC 61314-0656-05 NDC inpatient 1 UN 25.1 16.32 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.97 67.6 999999999 15.2 24.35 percent of total billed charges CIPROFLOXACIN 0.3% EYE DROP 48260472_1 CDM 0250 RC 61314-0656-05 NDC inpatient 1 UN 25.1 16.32 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.2 24.35 00065-8533-02 - ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp [JOHN] 48260473_1 CDM 0250 RC 00065-8533-02 NDC inpatient 1 UN 348.49 226.52 AETNA AETNA 275.31 79 999999999 211.01 338.04 percent of total billed charges 00065-8533-02 - ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp [JOHN] 48260473_1 CDM 0250 RC 00065-8533-02 NDC inpatient 1 UN 348.49 226.52 SELF PAY DISCOUNT SELF PAY DISCOUNT 226.52 65 999999999 211.01 338.04 percent of total billed charges 00065-8533-02 - ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp [JOHN] 48260473_1 CDM 0250 RC 00065-8533-02 NDC inpatient 1 UN 348.49 226.52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 338.04 97 999999999 211.01 338.04 percent of total billed charges 00065-8533-02 - ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp [JOHN] 48260473_1 CDM 0250 RC 00065-8533-02 NDC inpatient 1 UN 348.49 226.52 HUMANA - ALL PLANS HUMANA - ALL PLANS 271.82 78 999999999 211.01 338.04 percent of total billed charges 00065-8533-02 - ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp [JOHN] 48260473_1 CDM 0250 RC 00065-8533-02 NDC inpatient 1 UN 348.49 226.52 ENCORE - ALL PLANS ENCORE - ALL PLANS 240.46 69 999999999 211.01 338.04 percent of total billed charges 00065-8533-02 - ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp [JOHN] 48260473_1 CDM 0250 RC 00065-8533-02 NDC inpatient 1 UN 348.49 226.52 UMR - ALL PLANS UMR - ALL PLANS 243.94 70 999999999 211.01 338.04 percent of total billed charges 00065-8533-02 - ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp [JOHN] 48260473_1 CDM 0250 RC 00065-8533-02 NDC inpatient 1 UN 348.49 226.52 SIHO - ALL PLANS SIHO - ALL PLANS 313.64 90 999999999 211.01 338.04 percent of total billed charges 00065-8533-02 - ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp [JOHN] 48260473_1 CDM 0250 RC 00065-8533-02 NDC inpatient 1 UN 348.49 226.52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 211.01 60.55 999999999 211.01 338.04 percent of total billed charges 00065-8533-02 - ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp [JOHN] 48260473_1 CDM 0250 RC 00065-8533-02 NDC inpatient 1 UN 348.49 226.52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 211.01 338.04 00065-8533-02 - ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp [JOHN] 48260473_1 CDM 0250 RC 00065-8533-02 NDC inpatient 1 UN 348.49 226.52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 211.01 338.04 00065-8533-02 - ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp [JOHN] 48260473_1 CDM 0250 RC 00065-8533-02 NDC inpatient 1 UN 348.49 226.52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 211.01 338.04 00065-8533-02 - ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp [JOHN] 48260473_1 CDM 0250 RC 00065-8533-02 NDC inpatient 1 UN 348.49 226.52 ANTHEM HMO ANTHEM HMO 999999999 211.01 338.04 00065-8533-02 - ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp [JOHN] 48260473_1 CDM 0250 RC 00065-8533-02 NDC inpatient 1 UN 348.49 226.52 CIGNA - ALL PLANS CIGNA - ALL PLANS 235.58 67.6 999999999 211.01 338.04 percent of total billed charges 00065-8533-02 - ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp [JOHN] 48260473_1 CDM 0250 RC 00065-8533-02 NDC inpatient 1 UN 348.49 226.52 UHC - ALL PLANS UHC - ALL PLANS 999999999 211.01 338.04 NIMBEX 200 MG/20 ML VIAL 48260475_1 CDM 0250 RC 00074-4382-20 NDC inpatient 1 UN 559.33 363.56 AETNA AETNA 441.87 79 999999999 338.67 542.55 percent of total billed charges NIMBEX 200 MG/20 ML VIAL 48260475_1 CDM 0250 RC 00074-4382-20 NDC inpatient 1 UN 559.33 363.56 SELF PAY DISCOUNT SELF PAY DISCOUNT 363.56 65 999999999 338.67 542.55 percent of total billed charges NIMBEX 200 MG/20 ML VIAL 48260475_1 CDM 0250 RC 00074-4382-20 NDC inpatient 1 UN 559.33 363.56 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 542.55 97 999999999 338.67 542.55 percent of total billed charges NIMBEX 200 MG/20 ML VIAL 48260475_1 CDM 0250 RC 00074-4382-20 NDC inpatient 1 UN 559.33 363.56 HUMANA - ALL PLANS HUMANA - ALL PLANS 436.28 78 999999999 338.67 542.55 percent of total billed charges NIMBEX 200 MG/20 ML VIAL 48260475_1 CDM 0250 RC 00074-4382-20 NDC inpatient 1 UN 559.33 363.56 ENCORE - ALL PLANS ENCORE - ALL PLANS 385.94 69 999999999 338.67 542.55 percent of total billed charges NIMBEX 200 MG/20 ML VIAL 48260475_1 CDM 0250 RC 00074-4382-20 NDC inpatient 1 UN 559.33 363.56 UMR - ALL PLANS UMR - ALL PLANS 391.53 70 999999999 338.67 542.55 percent of total billed charges NIMBEX 200 MG/20 ML VIAL 48260475_1 CDM 0250 RC 00074-4382-20 NDC inpatient 1 UN 559.33 363.56 SIHO - ALL PLANS SIHO - ALL PLANS 503.4 90 999999999 338.67 542.55 percent of total billed charges NIMBEX 200 MG/20 ML VIAL 48260475_1 CDM 0250 RC 00074-4382-20 NDC inpatient 1 UN 559.33 363.56 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 338.67 60.55 999999999 338.67 542.55 percent of total billed charges NIMBEX 200 MG/20 ML VIAL 48260475_1 CDM 0250 RC 00074-4382-20 NDC inpatient 1 UN 559.33 363.56 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 338.67 542.55 NIMBEX 200 MG/20 ML VIAL 48260475_1 CDM 0250 RC 00074-4382-20 NDC inpatient 1 UN 559.33 363.56 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 338.67 542.55 NIMBEX 200 MG/20 ML VIAL 48260475_1 CDM 0250 RC 00074-4382-20 NDC inpatient 1 UN 559.33 363.56 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 338.67 542.55 NIMBEX 200 MG/20 ML VIAL 48260475_1 CDM 0250 RC 00074-4382-20 NDC inpatient 1 UN 559.33 363.56 ANTHEM HMO ANTHEM HMO 999999999 338.67 542.55 NIMBEX 200 MG/20 ML VIAL 48260475_1 CDM 0250 RC 00074-4382-20 NDC inpatient 1 UN 559.33 363.56 CIGNA - ALL PLANS CIGNA - ALL PLANS 378.11 67.6 999999999 338.67 542.55 percent of total billed charges NIMBEX 200 MG/20 ML VIAL 48260475_1 CDM 0250 RC 00074-4382-20 NDC inpatient 1 UN 559.33 363.56 UHC - ALL PLANS UHC - ALL PLANS 999999999 338.67 542.55 SOD CITRATE-CITRIC ACID CUP 48260482_1 CDM 0250 RC 00121-0595-15 NDC inpatient 1 UN 13.37 8.69 AETNA AETNA 10.56 79 999999999 8.1 12.97 percent of total billed charges SOD CITRATE-CITRIC ACID CUP 48260482_1 CDM 0250 RC 00121-0595-15 NDC inpatient 1 UN 13.37 8.69 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.69 65 999999999 8.1 12.97 percent of total billed charges SOD CITRATE-CITRIC ACID CUP 48260482_1 CDM 0250 RC 00121-0595-15 NDC inpatient 1 UN 13.37 8.69 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.97 97 999999999 8.1 12.97 percent of total billed charges SOD CITRATE-CITRIC ACID CUP 48260482_1 CDM 0250 RC 00121-0595-15 NDC inpatient 1 UN 13.37 8.69 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.43 78 999999999 8.1 12.97 percent of total billed charges SOD CITRATE-CITRIC ACID CUP 48260482_1 CDM 0250 RC 00121-0595-15 NDC inpatient 1 UN 13.37 8.69 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.23 69 999999999 8.1 12.97 percent of total billed charges SOD CITRATE-CITRIC ACID CUP 48260482_1 CDM 0250 RC 00121-0595-15 NDC inpatient 1 UN 13.37 8.69 UMR - ALL PLANS UMR - ALL PLANS 9.36 70 999999999 8.1 12.97 percent of total billed charges SOD CITRATE-CITRIC ACID CUP 48260482_1 CDM 0250 RC 00121-0595-15 NDC inpatient 1 UN 13.37 8.69 SIHO - ALL PLANS SIHO - ALL PLANS 12.03 90 999999999 8.1 12.97 percent of total billed charges SOD CITRATE-CITRIC ACID CUP 48260482_1 CDM 0250 RC 00121-0595-15 NDC inpatient 1 UN 13.37 8.69 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.1 60.55 999999999 8.1 12.97 percent of total billed charges SOD CITRATE-CITRIC ACID CUP 48260482_1 CDM 0250 RC 00121-0595-15 NDC inpatient 1 UN 13.37 8.69 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.1 12.97 SOD CITRATE-CITRIC ACID CUP 48260482_1 CDM 0250 RC 00121-0595-15 NDC inpatient 1 UN 13.37 8.69 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.1 12.97 SOD CITRATE-CITRIC ACID CUP 48260482_1 CDM 0250 RC 00121-0595-15 NDC inpatient 1 UN 13.37 8.69 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.1 12.97 SOD CITRATE-CITRIC ACID CUP 48260482_1 CDM 0250 RC 00121-0595-15 NDC inpatient 1 UN 13.37 8.69 ANTHEM HMO ANTHEM HMO 999999999 8.1 12.97 SOD CITRATE-CITRIC ACID CUP 48260482_1 CDM 0250 RC 00121-0595-15 NDC inpatient 1 UN 13.37 8.69 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.04 67.6 999999999 8.1 12.97 percent of total billed charges SOD CITRATE-CITRIC ACID CUP 48260482_1 CDM 0250 RC 00121-0595-15 NDC inpatient 1 UN 13.37 8.69 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.1 12.97 "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 48260496_1 CDM 0250 RC 51079-0299-20 NDC J0735 HCPCS inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 48260496_1 CDM 0250 RC 51079-0299-20 NDC J0735 HCPCS inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 48260496_1 CDM 0250 RC 51079-0299-20 NDC J0735 HCPCS inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 48260496_1 CDM 0250 RC 51079-0299-20 NDC J0735 HCPCS inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 48260496_1 CDM 0250 RC 51079-0299-20 NDC J0735 HCPCS inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 48260496_1 CDM 0250 RC 51079-0299-20 NDC J0735 HCPCS inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 48260496_1 CDM 0250 RC 51079-0299-20 NDC J0735 HCPCS inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 48260496_1 CDM 0250 RC 51079-0299-20 NDC J0735 HCPCS inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 48260496_1 CDM 0250 RC 51079-0299-20 NDC J0735 HCPCS inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 48260496_1 CDM 0250 RC 51079-0299-20 NDC J0735 HCPCS inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 48260496_1 CDM 0250 RC 51079-0299-20 NDC J0735 HCPCS inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 48260496_1 CDM 0250 RC 51079-0299-20 NDC J0735 HCPCS inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 48260496_1 CDM 0250 RC 51079-0299-20 NDC J0735 HCPCS inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 48260496_1 CDM 0250 RC 51079-0299-20 NDC J0735 HCPCS inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 00527-1728-74 - cocaine Top 40 mg/mL Sol [JOHN] 48260505_1 CDM 0250 RC 00527-1728-74 NDC inpatient 1 UN 979.69 636.8 AETNA AETNA 773.96 79 999999999 593.2 950.3 percent of total billed charges 00527-1728-74 - cocaine Top 40 mg/mL Sol [JOHN] 48260505_1 CDM 0250 RC 00527-1728-74 NDC inpatient 1 UN 979.69 636.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 636.8 65 999999999 593.2 950.3 percent of total billed charges 00527-1728-74 - cocaine Top 40 mg/mL Sol [JOHN] 48260505_1 CDM 0250 RC 00527-1728-74 NDC inpatient 1 UN 979.69 636.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 950.3 97 999999999 593.2 950.3 percent of total billed charges 00527-1728-74 - cocaine Top 40 mg/mL Sol [JOHN] 48260505_1 CDM 0250 RC 00527-1728-74 NDC inpatient 1 UN 979.69 636.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 764.16 78 999999999 593.2 950.3 percent of total billed charges 00527-1728-74 - cocaine Top 40 mg/mL Sol [JOHN] 48260505_1 CDM 0250 RC 00527-1728-74 NDC inpatient 1 UN 979.69 636.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 675.99 69 999999999 593.2 950.3 percent of total billed charges 00527-1728-74 - cocaine Top 40 mg/mL Sol [JOHN] 48260505_1 CDM 0250 RC 00527-1728-74 NDC inpatient 1 UN 979.69 636.8 UMR - ALL PLANS UMR - ALL PLANS 685.78 70 999999999 593.2 950.3 percent of total billed charges 00527-1728-74 - cocaine Top 40 mg/mL Sol [JOHN] 48260505_1 CDM 0250 RC 00527-1728-74 NDC inpatient 1 UN 979.69 636.8 SIHO - ALL PLANS SIHO - ALL PLANS 881.72 90 999999999 593.2 950.3 percent of total billed charges 00527-1728-74 - cocaine Top 40 mg/mL Sol [JOHN] 48260505_1 CDM 0250 RC 00527-1728-74 NDC inpatient 1 UN 979.69 636.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 593.2 60.55 999999999 593.2 950.3 percent of total billed charges 00527-1728-74 - cocaine Top 40 mg/mL Sol [JOHN] 48260505_1 CDM 0250 RC 00527-1728-74 NDC inpatient 1 UN 979.69 636.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 593.2 950.3 00527-1728-74 - cocaine Top 40 mg/mL Sol [JOHN] 48260505_1 CDM 0250 RC 00527-1728-74 NDC inpatient 1 UN 979.69 636.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 593.2 950.3 00527-1728-74 - cocaine Top 40 mg/mL Sol [JOHN] 48260505_1 CDM 0250 RC 00527-1728-74 NDC inpatient 1 UN 979.69 636.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 593.2 950.3 00527-1728-74 - cocaine Top 40 mg/mL Sol [JOHN] 48260505_1 CDM 0250 RC 00527-1728-74 NDC inpatient 1 UN 979.69 636.8 ANTHEM HMO ANTHEM HMO 999999999 593.2 950.3 00527-1728-74 - cocaine Top 40 mg/mL Sol [JOHN] 48260505_1 CDM 0250 RC 00527-1728-74 NDC inpatient 1 UN 979.69 636.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 662.27 67.6 999999999 593.2 950.3 percent of total billed charges 00527-1728-74 - cocaine Top 40 mg/mL Sol [JOHN] 48260505_1 CDM 0250 RC 00527-1728-74 NDC inpatient 1 UN 979.69 636.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 593.2 950.3 GUAIFEN-CODEINE 100-10 MG/5 ML 48260507_1 CDM 0250 RC 00121-1775-05 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges GUAIFEN-CODEINE 100-10 MG/5 ML 48260507_1 CDM 0250 RC 00121-1775-05 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges GUAIFEN-CODEINE 100-10 MG/5 ML 48260507_1 CDM 0250 RC 00121-1775-05 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges GUAIFEN-CODEINE 100-10 MG/5 ML 48260507_1 CDM 0250 RC 00121-1775-05 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges GUAIFEN-CODEINE 100-10 MG/5 ML 48260507_1 CDM 0250 RC 00121-1775-05 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges GUAIFEN-CODEINE 100-10 MG/5 ML 48260507_1 CDM 0250 RC 00121-1775-05 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges GUAIFEN-CODEINE 100-10 MG/5 ML 48260507_1 CDM 0250 RC 00121-1775-05 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges GUAIFEN-CODEINE 100-10 MG/5 ML 48260507_1 CDM 0250 RC 00121-1775-05 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges GUAIFEN-CODEINE 100-10 MG/5 ML 48260507_1 CDM 0250 RC 00121-1775-05 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 GUAIFEN-CODEINE 100-10 MG/5 ML 48260507_1 CDM 0250 RC 00121-1775-05 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 GUAIFEN-CODEINE 100-10 MG/5 ML 48260507_1 CDM 0250 RC 00121-1775-05 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 GUAIFEN-CODEINE 100-10 MG/5 ML 48260507_1 CDM 0250 RC 00121-1775-05 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 GUAIFEN-CODEINE 100-10 MG/5 ML 48260507_1 CDM 0250 RC 00121-1775-05 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges GUAIFEN-CODEINE 100-10 MG/5 ML 48260507_1 CDM 0250 RC 00121-1775-05 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 COLCRYS 0.6 MG TABLET 48260508_1 CDM 0250 RC 64764-0119-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges COLCRYS 0.6 MG TABLET 48260508_1 CDM 0250 RC 64764-0119-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges COLCRYS 0.6 MG TABLET 48260508_1 CDM 0250 RC 64764-0119-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges COLCRYS 0.6 MG TABLET 48260508_1 CDM 0250 RC 64764-0119-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges COLCRYS 0.6 MG TABLET 48260508_1 CDM 0250 RC 64764-0119-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges COLCRYS 0.6 MG TABLET 48260508_1 CDM 0250 RC 64764-0119-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges COLCRYS 0.6 MG TABLET 48260508_1 CDM 0250 RC 64764-0119-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges COLCRYS 0.6 MG TABLET 48260508_1 CDM 0250 RC 64764-0119-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges COLCRYS 0.6 MG TABLET 48260508_1 CDM 0250 RC 64764-0119-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 COLCRYS 0.6 MG TABLET 48260508_1 CDM 0250 RC 64764-0119-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 COLCRYS 0.6 MG TABLET 48260508_1 CDM 0250 RC 64764-0119-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 COLCRYS 0.6 MG TABLET 48260508_1 CDM 0250 RC 64764-0119-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 COLCRYS 0.6 MG TABLET 48260508_1 CDM 0250 RC 64764-0119-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges COLCRYS 0.6 MG TABLET 48260508_1 CDM 0250 RC 64764-0119-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 PREMARIN VAGINAL CREAM-APPL 48260516_1 CDM 0250 RC 00046-0872-21 NDC inpatient 1 UN 1132.44 736.09 AETNA AETNA 894.63 79 999999999 685.69 1098.47 percent of total billed charges PREMARIN VAGINAL CREAM-APPL 48260516_1 CDM 0250 RC 00046-0872-21 NDC inpatient 1 UN 1132.44 736.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 736.09 65 999999999 685.69 1098.47 percent of total billed charges PREMARIN VAGINAL CREAM-APPL 48260516_1 CDM 0250 RC 00046-0872-21 NDC inpatient 1 UN 1132.44 736.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1098.47 97 999999999 685.69 1098.47 percent of total billed charges PREMARIN VAGINAL CREAM-APPL 48260516_1 CDM 0250 RC 00046-0872-21 NDC inpatient 1 UN 1132.44 736.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 883.3 78 999999999 685.69 1098.47 percent of total billed charges PREMARIN VAGINAL CREAM-APPL 48260516_1 CDM 0250 RC 00046-0872-21 NDC inpatient 1 UN 1132.44 736.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 781.38 69 999999999 685.69 1098.47 percent of total billed charges PREMARIN VAGINAL CREAM-APPL 48260516_1 CDM 0250 RC 00046-0872-21 NDC inpatient 1 UN 1132.44 736.09 UMR - ALL PLANS UMR - ALL PLANS 792.71 70 999999999 685.69 1098.47 percent of total billed charges PREMARIN VAGINAL CREAM-APPL 48260516_1 CDM 0250 RC 00046-0872-21 NDC inpatient 1 UN 1132.44 736.09 SIHO - ALL PLANS SIHO - ALL PLANS 1019.2 90 999999999 685.69 1098.47 percent of total billed charges PREMARIN VAGINAL CREAM-APPL 48260516_1 CDM 0250 RC 00046-0872-21 NDC inpatient 1 UN 1132.44 736.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 685.69 60.55 999999999 685.69 1098.47 percent of total billed charges PREMARIN VAGINAL CREAM-APPL 48260516_1 CDM 0250 RC 00046-0872-21 NDC inpatient 1 UN 1132.44 736.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 685.69 1098.47 PREMARIN VAGINAL CREAM-APPL 48260516_1 CDM 0250 RC 00046-0872-21 NDC inpatient 1 UN 1132.44 736.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 685.69 1098.47 PREMARIN VAGINAL CREAM-APPL 48260516_1 CDM 0250 RC 00046-0872-21 NDC inpatient 1 UN 1132.44 736.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 685.69 1098.47 PREMARIN VAGINAL CREAM-APPL 48260516_1 CDM 0250 RC 00046-0872-21 NDC inpatient 1 UN 1132.44 736.09 ANTHEM HMO ANTHEM HMO 999999999 685.69 1098.47 PREMARIN VAGINAL CREAM-APPL 48260516_1 CDM 0250 RC 00046-0872-21 NDC inpatient 1 UN 1132.44 736.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 765.53 67.6 999999999 685.69 1098.47 percent of total billed charges PREMARIN VAGINAL CREAM-APPL 48260516_1 CDM 0250 RC 00046-0872-21 NDC inpatient 1 UN 1132.44 736.09 UHC - ALL PLANS UHC - ALL PLANS 999999999 685.69 1098.47 "CYANOCOBALAMIN 1,000 MCG/ML VL" 48260520_1 CDM 0250 RC 63323-0044-01 NDC inpatient 1 UN 30.24 19.66 AETNA AETNA 23.89 79 999999999 18.31 29.33 percent of total billed charges "CYANOCOBALAMIN 1,000 MCG/ML VL" 48260520_1 CDM 0250 RC 63323-0044-01 NDC inpatient 1 UN 30.24 19.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.66 65 999999999 18.31 29.33 percent of total billed charges "CYANOCOBALAMIN 1,000 MCG/ML VL" 48260520_1 CDM 0250 RC 63323-0044-01 NDC inpatient 1 UN 30.24 19.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.33 97 999999999 18.31 29.33 percent of total billed charges "CYANOCOBALAMIN 1,000 MCG/ML VL" 48260520_1 CDM 0250 RC 63323-0044-01 NDC inpatient 1 UN 30.24 19.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.59 78 999999999 18.31 29.33 percent of total billed charges "CYANOCOBALAMIN 1,000 MCG/ML VL" 48260520_1 CDM 0250 RC 63323-0044-01 NDC inpatient 1 UN 30.24 19.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.87 69 999999999 18.31 29.33 percent of total billed charges "CYANOCOBALAMIN 1,000 MCG/ML VL" 48260520_1 CDM 0250 RC 63323-0044-01 NDC inpatient 1 UN 30.24 19.66 UMR - ALL PLANS UMR - ALL PLANS 21.17 70 999999999 18.31 29.33 percent of total billed charges "CYANOCOBALAMIN 1,000 MCG/ML VL" 48260520_1 CDM 0250 RC 63323-0044-01 NDC inpatient 1 UN 30.24 19.66 SIHO - ALL PLANS SIHO - ALL PLANS 27.22 90 999999999 18.31 29.33 percent of total billed charges "CYANOCOBALAMIN 1,000 MCG/ML VL" 48260520_1 CDM 0250 RC 63323-0044-01 NDC inpatient 1 UN 30.24 19.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.31 60.55 999999999 18.31 29.33 percent of total billed charges "CYANOCOBALAMIN 1,000 MCG/ML VL" 48260520_1 CDM 0250 RC 63323-0044-01 NDC inpatient 1 UN 30.24 19.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.31 29.33 "CYANOCOBALAMIN 1,000 MCG/ML VL" 48260520_1 CDM 0250 RC 63323-0044-01 NDC inpatient 1 UN 30.24 19.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.31 29.33 "CYANOCOBALAMIN 1,000 MCG/ML VL" 48260520_1 CDM 0250 RC 63323-0044-01 NDC inpatient 1 UN 30.24 19.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.31 29.33 "CYANOCOBALAMIN 1,000 MCG/ML VL" 48260520_1 CDM 0250 RC 63323-0044-01 NDC inpatient 1 UN 30.24 19.66 ANTHEM HMO ANTHEM HMO 999999999 18.31 29.33 "CYANOCOBALAMIN 1,000 MCG/ML VL" 48260520_1 CDM 0250 RC 63323-0044-01 NDC inpatient 1 UN 30.24 19.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.44 67.6 999999999 18.31 29.33 percent of total billed charges "CYANOCOBALAMIN 1,000 MCG/ML VL" 48260520_1 CDM 0250 RC 63323-0044-01 NDC inpatient 1 UN 30.24 19.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.31 29.33 RESTASIS 0.05% EYE EMULSION 48260527_1 CDM 0250 RC 00023-9163-30 NDC inpatient 1 UN 425.21 276.39 AETNA AETNA 335.92 79 999999999 257.46 412.45 percent of total billed charges RESTASIS 0.05% EYE EMULSION 48260527_1 CDM 0250 RC 00023-9163-30 NDC inpatient 1 UN 425.21 276.39 SELF PAY DISCOUNT SELF PAY DISCOUNT 276.39 65 999999999 257.46 412.45 percent of total billed charges RESTASIS 0.05% EYE EMULSION 48260527_1 CDM 0250 RC 00023-9163-30 NDC inpatient 1 UN 425.21 276.39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 412.45 97 999999999 257.46 412.45 percent of total billed charges RESTASIS 0.05% EYE EMULSION 48260527_1 CDM 0250 RC 00023-9163-30 NDC inpatient 1 UN 425.21 276.39 HUMANA - ALL PLANS HUMANA - ALL PLANS 331.66 78 999999999 257.46 412.45 percent of total billed charges RESTASIS 0.05% EYE EMULSION 48260527_1 CDM 0250 RC 00023-9163-30 NDC inpatient 1 UN 425.21 276.39 ENCORE - ALL PLANS ENCORE - ALL PLANS 293.39 69 999999999 257.46 412.45 percent of total billed charges RESTASIS 0.05% EYE EMULSION 48260527_1 CDM 0250 RC 00023-9163-30 NDC inpatient 1 UN 425.21 276.39 UMR - ALL PLANS UMR - ALL PLANS 297.65 70 999999999 257.46 412.45 percent of total billed charges RESTASIS 0.05% EYE EMULSION 48260527_1 CDM 0250 RC 00023-9163-30 NDC inpatient 1 UN 425.21 276.39 SIHO - ALL PLANS SIHO - ALL PLANS 382.69 90 999999999 257.46 412.45 percent of total billed charges RESTASIS 0.05% EYE EMULSION 48260527_1 CDM 0250 RC 00023-9163-30 NDC inpatient 1 UN 425.21 276.39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 257.46 60.55 999999999 257.46 412.45 percent of total billed charges RESTASIS 0.05% EYE EMULSION 48260527_1 CDM 0250 RC 00023-9163-30 NDC inpatient 1 UN 425.21 276.39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 257.46 412.45 RESTASIS 0.05% EYE EMULSION 48260527_1 CDM 0250 RC 00023-9163-30 NDC inpatient 1 UN 425.21 276.39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 257.46 412.45 RESTASIS 0.05% EYE EMULSION 48260527_1 CDM 0250 RC 00023-9163-30 NDC inpatient 1 UN 425.21 276.39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 257.46 412.45 RESTASIS 0.05% EYE EMULSION 48260527_1 CDM 0250 RC 00023-9163-30 NDC inpatient 1 UN 425.21 276.39 ANTHEM HMO ANTHEM HMO 999999999 257.46 412.45 RESTASIS 0.05% EYE EMULSION 48260527_1 CDM 0250 RC 00023-9163-30 NDC inpatient 1 UN 425.21 276.39 CIGNA - ALL PLANS CIGNA - ALL PLANS 287.44 67.6 999999999 257.46 412.45 percent of total billed charges RESTASIS 0.05% EYE EMULSION 48260527_1 CDM 0250 RC 00023-9163-30 NDC inpatient 1 UN 425.21 276.39 UHC - ALL PLANS UHC - ALL PLANS 999999999 257.46 412.45 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260542_1 CDM 0250 RC 55513-0013-04 NDC J0881 HCPCS inpatient 100 UN 1830.49 1189.82 AETNA AETNA 1446.09 79 999999999 1108.36 1775.58 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260542_1 CDM 0250 RC 55513-0013-04 NDC J0881 HCPCS inpatient 100 UN 1830.49 1189.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 1189.82 65 999999999 1108.36 1775.58 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260542_1 CDM 0250 RC 55513-0013-04 NDC J0881 HCPCS inpatient 100 UN 1830.49 1189.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1775.58 97 999999999 1108.36 1775.58 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260542_1 CDM 0250 RC 55513-0013-04 NDC J0881 HCPCS inpatient 100 UN 1830.49 1189.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 1427.78 78 999999999 1108.36 1775.58 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260542_1 CDM 0250 RC 55513-0013-04 NDC J0881 HCPCS inpatient 100 UN 1830.49 1189.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 1263.04 69 999999999 1108.36 1775.58 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260542_1 CDM 0250 RC 55513-0013-04 NDC J0881 HCPCS inpatient 100 UN 1830.49 1189.82 UMR - ALL PLANS UMR - ALL PLANS 1281.34 70 999999999 1108.36 1775.58 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260542_1 CDM 0250 RC 55513-0013-04 NDC J0881 HCPCS inpatient 100 UN 1830.49 1189.82 SIHO - ALL PLANS SIHO - ALL PLANS 1647.44 90 999999999 1108.36 1775.58 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260542_1 CDM 0250 RC 55513-0013-04 NDC J0881 HCPCS inpatient 100 UN 1830.49 1189.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1108.36 60.55 999999999 1108.36 1775.58 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260542_1 CDM 0250 RC 55513-0013-04 NDC J0881 HCPCS inpatient 100 UN 1830.49 1189.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1108.36 1775.58 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260542_1 CDM 0250 RC 55513-0013-04 NDC J0881 HCPCS inpatient 100 UN 1830.49 1189.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1108.36 1775.58 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260542_1 CDM 0250 RC 55513-0013-04 NDC J0881 HCPCS inpatient 100 UN 1830.49 1189.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1108.36 1775.58 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260542_1 CDM 0250 RC 55513-0013-04 NDC J0881 HCPCS inpatient 100 UN 1830.49 1189.82 ANTHEM HMO ANTHEM HMO 999999999 1108.36 1775.58 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260542_1 CDM 0250 RC 55513-0013-04 NDC J0881 HCPCS inpatient 100 UN 1830.49 1189.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 1237.41 67.6 999999999 1108.36 1775.58 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260542_1 CDM 0250 RC 55513-0013-04 NDC J0881 HCPCS inpatient 100 UN 1830.49 1189.82 UHC - ALL PLANS UHC - ALL PLANS 999999999 1108.36 1775.58 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260543_1 CDM 0250 RC 55513-0028-01 NDC J0881 HCPCS inpatient 200 UN 3776.54 2454.75 AETNA AETNA 2983.47 79 999999999 2286.7 3663.24 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260543_1 CDM 0250 RC 55513-0028-01 NDC J0881 HCPCS inpatient 200 UN 3776.54 2454.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 2454.75 65 999999999 2286.7 3663.24 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260543_1 CDM 0250 RC 55513-0028-01 NDC J0881 HCPCS inpatient 200 UN 3776.54 2454.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3663.24 97 999999999 2286.7 3663.24 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260543_1 CDM 0250 RC 55513-0028-01 NDC J0881 HCPCS inpatient 200 UN 3776.54 2454.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 2945.7 78 999999999 2286.7 3663.24 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260543_1 CDM 0250 RC 55513-0028-01 NDC J0881 HCPCS inpatient 200 UN 3776.54 2454.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 2605.81 69 999999999 2286.7 3663.24 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260543_1 CDM 0250 RC 55513-0028-01 NDC J0881 HCPCS inpatient 200 UN 3776.54 2454.75 UMR - ALL PLANS UMR - ALL PLANS 2643.58 70 999999999 2286.7 3663.24 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260543_1 CDM 0250 RC 55513-0028-01 NDC J0881 HCPCS inpatient 200 UN 3776.54 2454.75 SIHO - ALL PLANS SIHO - ALL PLANS 3398.89 90 999999999 2286.7 3663.24 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260543_1 CDM 0250 RC 55513-0028-01 NDC J0881 HCPCS inpatient 200 UN 3776.54 2454.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2286.7 60.55 999999999 2286.7 3663.24 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260543_1 CDM 0250 RC 55513-0028-01 NDC J0881 HCPCS inpatient 200 UN 3776.54 2454.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2286.7 3663.24 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260543_1 CDM 0250 RC 55513-0028-01 NDC J0881 HCPCS inpatient 200 UN 3776.54 2454.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2286.7 3663.24 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260543_1 CDM 0250 RC 55513-0028-01 NDC J0881 HCPCS inpatient 200 UN 3776.54 2454.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2286.7 3663.24 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260543_1 CDM 0250 RC 55513-0028-01 NDC J0881 HCPCS inpatient 200 UN 3776.54 2454.75 ANTHEM HMO ANTHEM HMO 999999999 2286.7 3663.24 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260543_1 CDM 0250 RC 55513-0028-01 NDC J0881 HCPCS inpatient 200 UN 3776.54 2454.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 2552.94 67.6 999999999 2286.7 3663.24 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260543_1 CDM 0250 RC 55513-0028-01 NDC J0881 HCPCS inpatient 200 UN 3776.54 2454.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 2286.7 3663.24 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260544_1 CDM 0250 RC 55513-0111-01 NDC J0881 HCPCS inpatient 300 UN 5061.65 3290.07 AETNA AETNA 3998.7 79 999999999 3064.83 4909.8 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260544_1 CDM 0250 RC 55513-0111-01 NDC J0881 HCPCS inpatient 300 UN 5061.65 3290.07 SELF PAY DISCOUNT SELF PAY DISCOUNT 3290.07 65 999999999 3064.83 4909.8 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260544_1 CDM 0250 RC 55513-0111-01 NDC J0881 HCPCS inpatient 300 UN 5061.65 3290.07 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4909.8 97 999999999 3064.83 4909.8 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260544_1 CDM 0250 RC 55513-0111-01 NDC J0881 HCPCS inpatient 300 UN 5061.65 3290.07 HUMANA - ALL PLANS HUMANA - ALL PLANS 3948.09 78 999999999 3064.83 4909.8 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260544_1 CDM 0250 RC 55513-0111-01 NDC J0881 HCPCS inpatient 300 UN 5061.65 3290.07 ENCORE - ALL PLANS ENCORE - ALL PLANS 3492.54 69 999999999 3064.83 4909.8 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260544_1 CDM 0250 RC 55513-0111-01 NDC J0881 HCPCS inpatient 300 UN 5061.65 3290.07 UMR - ALL PLANS UMR - ALL PLANS 3543.16 70 999999999 3064.83 4909.8 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260544_1 CDM 0250 RC 55513-0111-01 NDC J0881 HCPCS inpatient 300 UN 5061.65 3290.07 SIHO - ALL PLANS SIHO - ALL PLANS 4555.49 90 999999999 3064.83 4909.8 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260544_1 CDM 0250 RC 55513-0111-01 NDC J0881 HCPCS inpatient 300 UN 5061.65 3290.07 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3064.83 4909.8 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260544_1 CDM 0250 RC 55513-0111-01 NDC J0881 HCPCS inpatient 300 UN 5061.65 3290.07 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3064.83 60.55 999999999 3064.83 4909.8 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260544_1 CDM 0250 RC 55513-0111-01 NDC J0881 HCPCS inpatient 300 UN 5061.65 3290.07 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3064.83 4909.8 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260544_1 CDM 0250 RC 55513-0111-01 NDC J0881 HCPCS inpatient 300 UN 5061.65 3290.07 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3064.83 4909.8 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260544_1 CDM 0250 RC 55513-0111-01 NDC J0881 HCPCS inpatient 300 UN 5061.65 3290.07 ANTHEM HMO ANTHEM HMO 999999999 3064.83 4909.8 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260544_1 CDM 0250 RC 55513-0111-01 NDC J0881 HCPCS inpatient 300 UN 5061.65 3290.07 CIGNA - ALL PLANS CIGNA - ALL PLANS 3421.68 67.6 999999999 3064.83 4909.8 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260544_1 CDM 0250 RC 55513-0111-01 NDC J0881 HCPCS inpatient 300 UN 5061.65 3290.07 UHC - ALL PLANS UHC - ALL PLANS 999999999 3064.83 4909.8 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260545_1 CDM 0250 RC 55513-0032-01 NDC J0881 HCPCS inpatient 500 UN 4155.62 2701.15 AETNA AETNA 3282.94 79 999999999 2516.23 4030.95 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260545_1 CDM 0250 RC 55513-0032-01 NDC J0881 HCPCS inpatient 500 UN 4155.62 2701.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 2701.15 65 999999999 2516.23 4030.95 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260545_1 CDM 0250 RC 55513-0032-01 NDC J0881 HCPCS inpatient 500 UN 4155.62 2701.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4030.95 97 999999999 2516.23 4030.95 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260545_1 CDM 0250 RC 55513-0032-01 NDC J0881 HCPCS inpatient 500 UN 4155.62 2701.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 3241.38 78 999999999 2516.23 4030.95 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260545_1 CDM 0250 RC 55513-0032-01 NDC J0881 HCPCS inpatient 500 UN 4155.62 2701.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 2867.38 69 999999999 2516.23 4030.95 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260545_1 CDM 0250 RC 55513-0032-01 NDC J0881 HCPCS inpatient 500 UN 4155.62 2701.15 UMR - ALL PLANS UMR - ALL PLANS 2908.93 70 999999999 2516.23 4030.95 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260545_1 CDM 0250 RC 55513-0032-01 NDC J0881 HCPCS inpatient 500 UN 4155.62 2701.15 SIHO - ALL PLANS SIHO - ALL PLANS 3740.06 90 999999999 2516.23 4030.95 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260545_1 CDM 0250 RC 55513-0032-01 NDC J0881 HCPCS inpatient 500 UN 4155.62 2701.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2516.23 4030.95 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260545_1 CDM 0250 RC 55513-0032-01 NDC J0881 HCPCS inpatient 500 UN 4155.62 2701.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2516.23 60.55 999999999 2516.23 4030.95 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260545_1 CDM 0250 RC 55513-0032-01 NDC J0881 HCPCS inpatient 500 UN 4155.62 2701.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2516.23 4030.95 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260545_1 CDM 0250 RC 55513-0032-01 NDC J0881 HCPCS inpatient 500 UN 4155.62 2701.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2516.23 4030.95 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260545_1 CDM 0250 RC 55513-0032-01 NDC J0881 HCPCS inpatient 500 UN 4155.62 2701.15 ANTHEM HMO ANTHEM HMO 999999999 2516.23 4030.95 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260545_1 CDM 0250 RC 55513-0032-01 NDC J0881 HCPCS inpatient 500 UN 4155.62 2701.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 2809.2 67.6 999999999 2516.23 4030.95 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 48260545_1 CDM 0250 RC 55513-0032-01 NDC J0881 HCPCS inpatient 500 UN 4155.62 2701.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 2516.23 4030.95 "INJECTION, DENOSUMAB, 1 MG" 48260552_1 CDM 0636 RC 55513-0730-01 NDC J0897 HCPCS inpatient 120 UN 6430.41 4179.77 AETNA AETNA 5080.02 79 999999999 3893.61 6237.5 percent of total billed charges "INJECTION, DENOSUMAB, 1 MG" 48260552_1 CDM 0636 RC 55513-0730-01 NDC J0897 HCPCS inpatient 120 UN 6430.41 4179.77 SELF PAY DISCOUNT SELF PAY DISCOUNT 4179.77 65 999999999 3893.61 6237.5 percent of total billed charges "INJECTION, DENOSUMAB, 1 MG" 48260552_1 CDM 0636 RC 55513-0730-01 NDC J0897 HCPCS inpatient 120 UN 6430.41 4179.77 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6237.5 97 999999999 3893.61 6237.5 percent of total billed charges "INJECTION, DENOSUMAB, 1 MG" 48260552_1 CDM 0636 RC 55513-0730-01 NDC J0897 HCPCS inpatient 120 UN 6430.41 4179.77 HUMANA - ALL PLANS HUMANA - ALL PLANS 5015.72 78 999999999 3893.61 6237.5 percent of total billed charges "INJECTION, DENOSUMAB, 1 MG" 48260552_1 CDM 0636 RC 55513-0730-01 NDC J0897 HCPCS inpatient 120 UN 6430.41 4179.77 ENCORE - ALL PLANS ENCORE - ALL PLANS 4436.98 69 999999999 3893.61 6237.5 percent of total billed charges "INJECTION, DENOSUMAB, 1 MG" 48260552_1 CDM 0636 RC 55513-0730-01 NDC J0897 HCPCS inpatient 120 UN 6430.41 4179.77 UMR - ALL PLANS UMR - ALL PLANS 4501.29 70 999999999 3893.61 6237.5 percent of total billed charges "INJECTION, DENOSUMAB, 1 MG" 48260552_1 CDM 0636 RC 55513-0730-01 NDC J0897 HCPCS inpatient 120 UN 6430.41 4179.77 SIHO - ALL PLANS SIHO - ALL PLANS 5787.37 90 999999999 3893.61 6237.5 percent of total billed charges "INJECTION, DENOSUMAB, 1 MG" 48260552_1 CDM 0636 RC 55513-0730-01 NDC J0897 HCPCS inpatient 120 UN 6430.41 4179.77 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3893.61 6237.5 "INJECTION, DENOSUMAB, 1 MG" 48260552_1 CDM 0636 RC 55513-0730-01 NDC J0897 HCPCS inpatient 120 UN 6430.41 4179.77 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3893.61 60.55 999999999 3893.61 6237.5 percent of total billed charges "INJECTION, DENOSUMAB, 1 MG" 48260552_1 CDM 0636 RC 55513-0730-01 NDC J0897 HCPCS inpatient 120 UN 6430.41 4179.77 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3893.61 6237.5 "INJECTION, DENOSUMAB, 1 MG" 48260552_1 CDM 0636 RC 55513-0730-01 NDC J0897 HCPCS inpatient 120 UN 6430.41 4179.77 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3893.61 6237.5 "INJECTION, DENOSUMAB, 1 MG" 48260552_1 CDM 0636 RC 55513-0730-01 NDC J0897 HCPCS inpatient 120 UN 6430.41 4179.77 ANTHEM HMO ANTHEM HMO 999999999 3893.61 6237.5 "INJECTION, DENOSUMAB, 1 MG" 48260552_1 CDM 0636 RC 55513-0730-01 NDC J0897 HCPCS inpatient 120 UN 6430.41 4179.77 CIGNA - ALL PLANS CIGNA - ALL PLANS 4346.96 67.6 999999999 3893.61 6237.5 percent of total billed charges "INJECTION, DENOSUMAB, 1 MG" 48260552_1 CDM 0636 RC 55513-0730-01 NDC J0897 HCPCS inpatient 120 UN 6430.41 4179.77 UHC - ALL PLANS UHC - ALL PLANS 999999999 3893.61 6237.5 "INJECTION, DENOSUMAB, 1 MG" 48260553_1 CDM 0636 RC 55513-0710-01 NDC J0897 HCPCS inpatient 60 UN 6820.94 4433.61 AETNA AETNA 5388.54 79 999999999 4130.08 6616.31 percent of total billed charges "INJECTION, DENOSUMAB, 1 MG" 48260553_1 CDM 0636 RC 55513-0710-01 NDC J0897 HCPCS inpatient 60 UN 6820.94 4433.61 SELF PAY DISCOUNT SELF PAY DISCOUNT 4433.61 65 999999999 4130.08 6616.31 percent of total billed charges "INJECTION, DENOSUMAB, 1 MG" 48260553_1 CDM 0636 RC 55513-0710-01 NDC J0897 HCPCS inpatient 60 UN 6820.94 4433.61 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6616.31 97 999999999 4130.08 6616.31 percent of total billed charges "INJECTION, DENOSUMAB, 1 MG" 48260553_1 CDM 0636 RC 55513-0710-01 NDC J0897 HCPCS inpatient 60 UN 6820.94 4433.61 HUMANA - ALL PLANS HUMANA - ALL PLANS 5320.33 78 999999999 4130.08 6616.31 percent of total billed charges "INJECTION, DENOSUMAB, 1 MG" 48260553_1 CDM 0636 RC 55513-0710-01 NDC J0897 HCPCS inpatient 60 UN 6820.94 4433.61 ENCORE - ALL PLANS ENCORE - ALL PLANS 4706.45 69 999999999 4130.08 6616.31 percent of total billed charges "INJECTION, DENOSUMAB, 1 MG" 48260553_1 CDM 0636 RC 55513-0710-01 NDC J0897 HCPCS inpatient 60 UN 6820.94 4433.61 UMR - ALL PLANS UMR - ALL PLANS 4774.66 70 999999999 4130.08 6616.31 percent of total billed charges "INJECTION, DENOSUMAB, 1 MG" 48260553_1 CDM 0636 RC 55513-0710-01 NDC J0897 HCPCS inpatient 60 UN 6820.94 4433.61 SIHO - ALL PLANS SIHO - ALL PLANS 6138.85 90 999999999 4130.08 6616.31 percent of total billed charges "INJECTION, DENOSUMAB, 1 MG" 48260553_1 CDM 0636 RC 55513-0710-01 NDC J0897 HCPCS inpatient 60 UN 6820.94 4433.61 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4130.08 6616.31 "INJECTION, DENOSUMAB, 1 MG" 48260553_1 CDM 0636 RC 55513-0710-01 NDC J0897 HCPCS inpatient 60 UN 6820.94 4433.61 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4130.08 60.55 999999999 4130.08 6616.31 percent of total billed charges "INJECTION, DENOSUMAB, 1 MG" 48260553_1 CDM 0636 RC 55513-0710-01 NDC J0897 HCPCS inpatient 60 UN 6820.94 4433.61 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4130.08 6616.31 "INJECTION, DENOSUMAB, 1 MG" 48260553_1 CDM 0636 RC 55513-0710-01 NDC J0897 HCPCS inpatient 60 UN 6820.94 4433.61 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4130.08 6616.31 "INJECTION, DENOSUMAB, 1 MG" 48260553_1 CDM 0636 RC 55513-0710-01 NDC J0897 HCPCS inpatient 60 UN 6820.94 4433.61 ANTHEM HMO ANTHEM HMO 999999999 4130.08 6616.31 "INJECTION, DENOSUMAB, 1 MG" 48260553_1 CDM 0636 RC 55513-0710-01 NDC J0897 HCPCS inpatient 60 UN 6820.94 4433.61 CIGNA - ALL PLANS CIGNA - ALL PLANS 4610.96 67.6 999999999 4130.08 6616.31 percent of total billed charges "INJECTION, DENOSUMAB, 1 MG" 48260553_1 CDM 0636 RC 55513-0710-01 NDC J0897 HCPCS inpatient 60 UN 6820.94 4433.61 UHC - ALL PLANS UHC - ALL PLANS 999999999 4130.08 6616.31 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260559_1 CDM 0250 RC 00641-0367-25 NDC J1100 HCPCS inpatient 10 UN 19.62 12.75 AETNA AETNA 15.5 79 999999999 11.88 19.03 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260559_1 CDM 0250 RC 00641-0367-25 NDC J1100 HCPCS inpatient 10 UN 19.62 12.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.75 65 999999999 11.88 19.03 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260559_1 CDM 0250 RC 00641-0367-25 NDC J1100 HCPCS inpatient 10 UN 19.62 12.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.03 97 999999999 11.88 19.03 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260559_1 CDM 0250 RC 00641-0367-25 NDC J1100 HCPCS inpatient 10 UN 19.62 12.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.3 78 999999999 11.88 19.03 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260559_1 CDM 0250 RC 00641-0367-25 NDC J1100 HCPCS inpatient 10 UN 19.62 12.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.54 69 999999999 11.88 19.03 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260559_1 CDM 0250 RC 00641-0367-25 NDC J1100 HCPCS inpatient 10 UN 19.62 12.75 UMR - ALL PLANS UMR - ALL PLANS 13.73 70 999999999 11.88 19.03 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260559_1 CDM 0250 RC 00641-0367-25 NDC J1100 HCPCS inpatient 10 UN 19.62 12.75 SIHO - ALL PLANS SIHO - ALL PLANS 17.66 90 999999999 11.88 19.03 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260559_1 CDM 0250 RC 00641-0367-25 NDC J1100 HCPCS inpatient 10 UN 19.62 12.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.88 19.03 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260559_1 CDM 0250 RC 00641-0367-25 NDC J1100 HCPCS inpatient 10 UN 19.62 12.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.88 60.55 999999999 11.88 19.03 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260559_1 CDM 0250 RC 00641-0367-25 NDC J1100 HCPCS inpatient 10 UN 19.62 12.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.88 19.03 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260559_1 CDM 0250 RC 00641-0367-25 NDC J1100 HCPCS inpatient 10 UN 19.62 12.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.88 19.03 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260559_1 CDM 0250 RC 00641-0367-25 NDC J1100 HCPCS inpatient 10 UN 19.62 12.75 ANTHEM HMO ANTHEM HMO 999999999 11.88 19.03 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260559_1 CDM 0250 RC 00641-0367-25 NDC J1100 HCPCS inpatient 10 UN 19.62 12.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.26 67.6 999999999 11.88 19.03 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260559_1 CDM 0250 RC 00641-0367-25 NDC J1100 HCPCS inpatient 10 UN 19.62 12.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.88 19.03 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260562_1 CDM 0250 RC 63323-0165-01 NDC J1100 HCPCS inpatient 4 UN 21.64 14.07 AETNA AETNA 17.1 79 999999999 13.1 20.99 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260562_1 CDM 0250 RC 63323-0165-01 NDC J1100 HCPCS inpatient 4 UN 21.64 14.07 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.07 65 999999999 13.1 20.99 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260562_1 CDM 0250 RC 63323-0165-01 NDC J1100 HCPCS inpatient 4 UN 21.64 14.07 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20.99 97 999999999 13.1 20.99 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260562_1 CDM 0250 RC 63323-0165-01 NDC J1100 HCPCS inpatient 4 UN 21.64 14.07 HUMANA - ALL PLANS HUMANA - ALL PLANS 16.88 78 999999999 13.1 20.99 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260562_1 CDM 0250 RC 63323-0165-01 NDC J1100 HCPCS inpatient 4 UN 21.64 14.07 ENCORE - ALL PLANS ENCORE - ALL PLANS 14.93 69 999999999 13.1 20.99 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260562_1 CDM 0250 RC 63323-0165-01 NDC J1100 HCPCS inpatient 4 UN 21.64 14.07 UMR - ALL PLANS UMR - ALL PLANS 15.15 70 999999999 13.1 20.99 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260562_1 CDM 0250 RC 63323-0165-01 NDC J1100 HCPCS inpatient 4 UN 21.64 14.07 SIHO - ALL PLANS SIHO - ALL PLANS 19.48 90 999999999 13.1 20.99 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260562_1 CDM 0250 RC 63323-0165-01 NDC J1100 HCPCS inpatient 4 UN 21.64 14.07 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.1 20.99 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260562_1 CDM 0250 RC 63323-0165-01 NDC J1100 HCPCS inpatient 4 UN 21.64 14.07 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.1 60.55 999999999 13.1 20.99 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260562_1 CDM 0250 RC 63323-0165-01 NDC J1100 HCPCS inpatient 4 UN 21.64 14.07 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.1 20.99 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260562_1 CDM 0250 RC 63323-0165-01 NDC J1100 HCPCS inpatient 4 UN 21.64 14.07 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.1 20.99 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260562_1 CDM 0250 RC 63323-0165-01 NDC J1100 HCPCS inpatient 4 UN 21.64 14.07 ANTHEM HMO ANTHEM HMO 999999999 13.1 20.99 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260562_1 CDM 0250 RC 63323-0165-01 NDC J1100 HCPCS inpatient 4 UN 21.64 14.07 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.63 67.6 999999999 13.1 20.99 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48260562_1 CDM 0250 RC 63323-0165-01 NDC J1100 HCPCS inpatient 4 UN 21.64 14.07 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.1 20.99 "DEXAMETHASONE, ORAL, 0.25 MG" 48260563_1 CDM 0250 RC 00054-8175-25 NDC J8540 HCPCS inpatient 1 UN 3.87 2.52 AETNA AETNA 3.06 79 999999999 2.34 3.75 percent of total billed charges "DEXAMETHASONE, ORAL, 0.25 MG" 48260563_1 CDM 0250 RC 00054-8175-25 NDC J8540 HCPCS inpatient 1 UN 3.87 2.52 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.52 65 999999999 2.34 3.75 percent of total billed charges "DEXAMETHASONE, ORAL, 0.25 MG" 48260563_1 CDM 0250 RC 00054-8175-25 NDC J8540 HCPCS inpatient 1 UN 3.87 2.52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.75 97 999999999 2.34 3.75 percent of total billed charges "DEXAMETHASONE, ORAL, 0.25 MG" 48260563_1 CDM 0250 RC 00054-8175-25 NDC J8540 HCPCS inpatient 1 UN 3.87 2.52 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.02 78 999999999 2.34 3.75 percent of total billed charges "DEXAMETHASONE, ORAL, 0.25 MG" 48260563_1 CDM 0250 RC 00054-8175-25 NDC J8540 HCPCS inpatient 1 UN 3.87 2.52 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.67 69 999999999 2.34 3.75 percent of total billed charges "DEXAMETHASONE, ORAL, 0.25 MG" 48260563_1 CDM 0250 RC 00054-8175-25 NDC J8540 HCPCS inpatient 1 UN 3.87 2.52 UMR - ALL PLANS UMR - ALL PLANS 2.71 70 999999999 2.34 3.75 percent of total billed charges "DEXAMETHASONE, ORAL, 0.25 MG" 48260563_1 CDM 0250 RC 00054-8175-25 NDC J8540 HCPCS inpatient 1 UN 3.87 2.52 SIHO - ALL PLANS SIHO - ALL PLANS 3.48 90 999999999 2.34 3.75 percent of total billed charges "DEXAMETHASONE, ORAL, 0.25 MG" 48260563_1 CDM 0250 RC 00054-8175-25 NDC J8540 HCPCS inpatient 1 UN 3.87 2.52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.34 3.75 "DEXAMETHASONE, ORAL, 0.25 MG" 48260563_1 CDM 0250 RC 00054-8175-25 NDC J8540 HCPCS inpatient 1 UN 3.87 2.52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.34 60.55 999999999 2.34 3.75 percent of total billed charges "DEXAMETHASONE, ORAL, 0.25 MG" 48260563_1 CDM 0250 RC 00054-8175-25 NDC J8540 HCPCS inpatient 1 UN 3.87 2.52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.34 3.75 "DEXAMETHASONE, ORAL, 0.25 MG" 48260563_1 CDM 0250 RC 00054-8175-25 NDC J8540 HCPCS inpatient 1 UN 3.87 2.52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.34 3.75 "DEXAMETHASONE, ORAL, 0.25 MG" 48260563_1 CDM 0250 RC 00054-8175-25 NDC J8540 HCPCS inpatient 1 UN 3.87 2.52 ANTHEM HMO ANTHEM HMO 999999999 2.34 3.75 "DEXAMETHASONE, ORAL, 0.25 MG" 48260563_1 CDM 0250 RC 00054-8175-25 NDC J8540 HCPCS inpatient 1 UN 3.87 2.52 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.62 67.6 999999999 2.34 3.75 percent of total billed charges "DEXAMETHASONE, ORAL, 0.25 MG" 48260563_1 CDM 0250 RC 00054-8175-25 NDC J8540 HCPCS inpatient 1 UN 3.87 2.52 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.34 3.75 00065-0648-35 - dexamethasone-tobramycin Ophth 0.1%-0.3% Oint [JOHN] 48260565_1 CDM 0250 RC 00065-0648-35 NDC inpatient 1 UN 1011.08 657.2 AETNA AETNA 798.75 79 999999999 612.21 980.75 percent of total billed charges 00065-0648-35 - dexamethasone-tobramycin Ophth 0.1%-0.3% Oint [JOHN] 48260565_1 CDM 0250 RC 00065-0648-35 NDC inpatient 1 UN 1011.08 657.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 657.2 65 999999999 612.21 980.75 percent of total billed charges 00065-0648-35 - dexamethasone-tobramycin Ophth 0.1%-0.3% Oint [JOHN] 48260565_1 CDM 0250 RC 00065-0648-35 NDC inpatient 1 UN 1011.08 657.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 980.75 97 999999999 612.21 980.75 percent of total billed charges 00065-0648-35 - dexamethasone-tobramycin Ophth 0.1%-0.3% Oint [JOHN] 48260565_1 CDM 0250 RC 00065-0648-35 NDC inpatient 1 UN 1011.08 657.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 788.64 78 999999999 612.21 980.75 percent of total billed charges 00065-0648-35 - dexamethasone-tobramycin Ophth 0.1%-0.3% Oint [JOHN] 48260565_1 CDM 0250 RC 00065-0648-35 NDC inpatient 1 UN 1011.08 657.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 697.65 69 999999999 612.21 980.75 percent of total billed charges 00065-0648-35 - dexamethasone-tobramycin Ophth 0.1%-0.3% Oint [JOHN] 48260565_1 CDM 0250 RC 00065-0648-35 NDC inpatient 1 UN 1011.08 657.2 UMR - ALL PLANS UMR - ALL PLANS 707.76 70 999999999 612.21 980.75 percent of total billed charges 00065-0648-35 - dexamethasone-tobramycin Ophth 0.1%-0.3% Oint [JOHN] 48260565_1 CDM 0250 RC 00065-0648-35 NDC inpatient 1 UN 1011.08 657.2 SIHO - ALL PLANS SIHO - ALL PLANS 909.97 90 999999999 612.21 980.75 percent of total billed charges 00065-0648-35 - dexamethasone-tobramycin Ophth 0.1%-0.3% Oint [JOHN] 48260565_1 CDM 0250 RC 00065-0648-35 NDC inpatient 1 UN 1011.08 657.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 612.21 980.75 00065-0648-35 - dexamethasone-tobramycin Ophth 0.1%-0.3% Oint [JOHN] 48260565_1 CDM 0250 RC 00065-0648-35 NDC inpatient 1 UN 1011.08 657.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 612.21 60.55 999999999 612.21 980.75 percent of total billed charges 00065-0648-35 - dexamethasone-tobramycin Ophth 0.1%-0.3% Oint [JOHN] 48260565_1 CDM 0250 RC 00065-0648-35 NDC inpatient 1 UN 1011.08 657.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 612.21 980.75 00065-0648-35 - dexamethasone-tobramycin Ophth 0.1%-0.3% Oint [JOHN] 48260565_1 CDM 0250 RC 00065-0648-35 NDC inpatient 1 UN 1011.08 657.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 612.21 980.75 00065-0648-35 - dexamethasone-tobramycin Ophth 0.1%-0.3% Oint [JOHN] 48260565_1 CDM 0250 RC 00065-0648-35 NDC inpatient 1 UN 1011.08 657.2 ANTHEM HMO ANTHEM HMO 999999999 612.21 980.75 00065-0648-35 - dexamethasone-tobramycin Ophth 0.1%-0.3% Oint [JOHN] 48260565_1 CDM 0250 RC 00065-0648-35 NDC inpatient 1 UN 1011.08 657.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 683.49 67.6 999999999 612.21 980.75 percent of total billed charges 00065-0648-35 - dexamethasone-tobramycin Ophth 0.1%-0.3% Oint [JOHN] 48260565_1 CDM 0250 RC 00065-0648-35 NDC inpatient 1 UN 1011.08 657.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 612.21 980.75 TOBRAMYCIN-DEXAMETH OPHTH SUSP 48260566_1 CDM 0250 RC 24208-0295-25 NDC inpatient 1 UN 102.13 66.38 AETNA AETNA 80.68 79 999999999 61.84 99.07 percent of total billed charges TOBRAMYCIN-DEXAMETH OPHTH SUSP 48260566_1 CDM 0250 RC 24208-0295-25 NDC inpatient 1 UN 102.13 66.38 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.38 65 999999999 61.84 99.07 percent of total billed charges TOBRAMYCIN-DEXAMETH OPHTH SUSP 48260566_1 CDM 0250 RC 24208-0295-25 NDC inpatient 1 UN 102.13 66.38 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 99.07 97 999999999 61.84 99.07 percent of total billed charges TOBRAMYCIN-DEXAMETH OPHTH SUSP 48260566_1 CDM 0250 RC 24208-0295-25 NDC inpatient 1 UN 102.13 66.38 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.66 78 999999999 61.84 99.07 percent of total billed charges TOBRAMYCIN-DEXAMETH OPHTH SUSP 48260566_1 CDM 0250 RC 24208-0295-25 NDC inpatient 1 UN 102.13 66.38 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.47 69 999999999 61.84 99.07 percent of total billed charges TOBRAMYCIN-DEXAMETH OPHTH SUSP 48260566_1 CDM 0250 RC 24208-0295-25 NDC inpatient 1 UN 102.13 66.38 UMR - ALL PLANS UMR - ALL PLANS 71.49 70 999999999 61.84 99.07 percent of total billed charges TOBRAMYCIN-DEXAMETH OPHTH SUSP 48260566_1 CDM 0250 RC 24208-0295-25 NDC inpatient 1 UN 102.13 66.38 SIHO - ALL PLANS SIHO - ALL PLANS 91.92 90 999999999 61.84 99.07 percent of total billed charges TOBRAMYCIN-DEXAMETH OPHTH SUSP 48260566_1 CDM 0250 RC 24208-0295-25 NDC inpatient 1 UN 102.13 66.38 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.84 99.07 TOBRAMYCIN-DEXAMETH OPHTH SUSP 48260566_1 CDM 0250 RC 24208-0295-25 NDC inpatient 1 UN 102.13 66.38 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.84 60.55 999999999 61.84 99.07 percent of total billed charges TOBRAMYCIN-DEXAMETH OPHTH SUSP 48260566_1 CDM 0250 RC 24208-0295-25 NDC inpatient 1 UN 102.13 66.38 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.84 99.07 TOBRAMYCIN-DEXAMETH OPHTH SUSP 48260566_1 CDM 0250 RC 24208-0295-25 NDC inpatient 1 UN 102.13 66.38 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.84 99.07 TOBRAMYCIN-DEXAMETH OPHTH SUSP 48260566_1 CDM 0250 RC 24208-0295-25 NDC inpatient 1 UN 102.13 66.38 ANTHEM HMO ANTHEM HMO 999999999 61.84 99.07 TOBRAMYCIN-DEXAMETH OPHTH SUSP 48260566_1 CDM 0250 RC 24208-0295-25 NDC inpatient 1 UN 102.13 66.38 CIGNA - ALL PLANS CIGNA - ALL PLANS 69.04 67.6 999999999 61.84 99.07 percent of total billed charges TOBRAMYCIN-DEXAMETH OPHTH SUSP 48260566_1 CDM 0250 RC 24208-0295-25 NDC inpatient 1 UN 102.13 66.38 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.84 99.07 DEXTROSE 10%-WATER IV SOLUTION 48260569_1 CDM 0250 RC 00338-0023-04 NDC inpatient 1 UN 67.07 43.6 AETNA AETNA 52.99 79 999999999 40.61 65.06 percent of total billed charges DEXTROSE 10%-WATER IV SOLUTION 48260569_1 CDM 0250 RC 00338-0023-04 NDC inpatient 1 UN 67.07 43.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 43.6 65 999999999 40.61 65.06 percent of total billed charges DEXTROSE 10%-WATER IV SOLUTION 48260569_1 CDM 0250 RC 00338-0023-04 NDC inpatient 1 UN 67.07 43.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.06 97 999999999 40.61 65.06 percent of total billed charges DEXTROSE 10%-WATER IV SOLUTION 48260569_1 CDM 0250 RC 00338-0023-04 NDC inpatient 1 UN 67.07 43.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 52.31 78 999999999 40.61 65.06 percent of total billed charges DEXTROSE 10%-WATER IV SOLUTION 48260569_1 CDM 0250 RC 00338-0023-04 NDC inpatient 1 UN 67.07 43.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.28 69 999999999 40.61 65.06 percent of total billed charges DEXTROSE 10%-WATER IV SOLUTION 48260569_1 CDM 0250 RC 00338-0023-04 NDC inpatient 1 UN 67.07 43.6 UMR - ALL PLANS UMR - ALL PLANS 46.95 70 999999999 40.61 65.06 percent of total billed charges DEXTROSE 10%-WATER IV SOLUTION 48260569_1 CDM 0250 RC 00338-0023-04 NDC inpatient 1 UN 67.07 43.6 SIHO - ALL PLANS SIHO - ALL PLANS 60.36 90 999999999 40.61 65.06 percent of total billed charges DEXTROSE 10%-WATER IV SOLUTION 48260569_1 CDM 0250 RC 00338-0023-04 NDC inpatient 1 UN 67.07 43.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 40.61 65.06 DEXTROSE 10%-WATER IV SOLUTION 48260569_1 CDM 0250 RC 00338-0023-04 NDC inpatient 1 UN 67.07 43.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 40.61 60.55 999999999 40.61 65.06 percent of total billed charges DEXTROSE 10%-WATER IV SOLUTION 48260569_1 CDM 0250 RC 00338-0023-04 NDC inpatient 1 UN 67.07 43.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 40.61 65.06 DEXTROSE 10%-WATER IV SOLUTION 48260569_1 CDM 0250 RC 00338-0023-04 NDC inpatient 1 UN 67.07 43.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 40.61 65.06 DEXTROSE 10%-WATER IV SOLUTION 48260569_1 CDM 0250 RC 00338-0023-04 NDC inpatient 1 UN 67.07 43.6 ANTHEM HMO ANTHEM HMO 999999999 40.61 65.06 DEXTROSE 10%-WATER IV SOLUTION 48260569_1 CDM 0250 RC 00338-0023-04 NDC inpatient 1 UN 67.07 43.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.34 67.6 999999999 40.61 65.06 percent of total billed charges DEXTROSE 10%-WATER IV SOLUTION 48260569_1 CDM 0250 RC 00338-0023-04 NDC inpatient 1 UN 67.07 43.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 40.61 65.06 DEXTROSE 5%-0.45% NACL IV SOLN 48260573_1 CDM 0258 RC 00338-0085-04 NDC inpatient 1 UN 57.44 37.34 AETNA AETNA 45.38 79 999999999 34.78 55.72 percent of total billed charges DEXTROSE 5%-0.45% NACL IV SOLN 48260573_1 CDM 0258 RC 00338-0085-04 NDC inpatient 1 UN 57.44 37.34 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.34 65 999999999 34.78 55.72 percent of total billed charges DEXTROSE 5%-0.45% NACL IV SOLN 48260573_1 CDM 0258 RC 00338-0085-04 NDC inpatient 1 UN 57.44 37.34 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.72 97 999999999 34.78 55.72 percent of total billed charges DEXTROSE 5%-0.45% NACL IV SOLN 48260573_1 CDM 0258 RC 00338-0085-04 NDC inpatient 1 UN 57.44 37.34 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.8 78 999999999 34.78 55.72 percent of total billed charges DEXTROSE 5%-0.45% NACL IV SOLN 48260573_1 CDM 0258 RC 00338-0085-04 NDC inpatient 1 UN 57.44 37.34 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.63 69 999999999 34.78 55.72 percent of total billed charges DEXTROSE 5%-0.45% NACL IV SOLN 48260573_1 CDM 0258 RC 00338-0085-04 NDC inpatient 1 UN 57.44 37.34 UMR - ALL PLANS UMR - ALL PLANS 40.21 70 999999999 34.78 55.72 percent of total billed charges DEXTROSE 5%-0.45% NACL IV SOLN 48260573_1 CDM 0258 RC 00338-0085-04 NDC inpatient 1 UN 57.44 37.34 SIHO - ALL PLANS SIHO - ALL PLANS 51.7 90 999999999 34.78 55.72 percent of total billed charges DEXTROSE 5%-0.45% NACL IV SOLN 48260573_1 CDM 0258 RC 00338-0085-04 NDC inpatient 1 UN 57.44 37.34 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.78 55.72 DEXTROSE 5%-0.45% NACL IV SOLN 48260573_1 CDM 0258 RC 00338-0085-04 NDC inpatient 1 UN 57.44 37.34 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.78 60.55 999999999 34.78 55.72 percent of total billed charges DEXTROSE 5%-0.45% NACL IV SOLN 48260573_1 CDM 0258 RC 00338-0085-04 NDC inpatient 1 UN 57.44 37.34 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.78 55.72 DEXTROSE 5%-0.45% NACL IV SOLN 48260573_1 CDM 0258 RC 00338-0085-04 NDC inpatient 1 UN 57.44 37.34 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.78 55.72 DEXTROSE 5%-0.45% NACL IV SOLN 48260573_1 CDM 0258 RC 00338-0085-04 NDC inpatient 1 UN 57.44 37.34 ANTHEM HMO ANTHEM HMO 999999999 34.78 55.72 DEXTROSE 5%-0.45% NACL IV SOLN 48260573_1 CDM 0258 RC 00338-0085-04 NDC inpatient 1 UN 57.44 37.34 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.83 67.6 999999999 34.78 55.72 percent of total billed charges DEXTROSE 5%-0.45% NACL IV SOLN 48260573_1 CDM 0258 RC 00338-0085-04 NDC inpatient 1 UN 57.44 37.34 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.78 55.72 00409-7904-09 - Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [JOHN] 48260575_1 CDM 0258 RC 00409-7904-09 NDC inpatient 1 UN 57.79 37.56 AETNA AETNA 45.65 79 999999999 34.99 56.06 percent of total billed charges 00409-7904-09 - Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [JOHN] 48260575_1 CDM 0258 RC 00409-7904-09 NDC inpatient 1 UN 57.79 37.56 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.56 65 999999999 34.99 56.06 percent of total billed charges 00409-7904-09 - Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [JOHN] 48260575_1 CDM 0258 RC 00409-7904-09 NDC inpatient 1 UN 57.79 37.56 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.06 97 999999999 34.99 56.06 percent of total billed charges 00409-7904-09 - Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [JOHN] 48260575_1 CDM 0258 RC 00409-7904-09 NDC inpatient 1 UN 57.79 37.56 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.08 78 999999999 34.99 56.06 percent of total billed charges 00409-7904-09 - Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [JOHN] 48260575_1 CDM 0258 RC 00409-7904-09 NDC inpatient 1 UN 57.79 37.56 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.88 69 999999999 34.99 56.06 percent of total billed charges 00409-7904-09 - Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [JOHN] 48260575_1 CDM 0258 RC 00409-7904-09 NDC inpatient 1 UN 57.79 37.56 UMR - ALL PLANS UMR - ALL PLANS 40.45 70 999999999 34.99 56.06 percent of total billed charges 00409-7904-09 - Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [JOHN] 48260575_1 CDM 0258 RC 00409-7904-09 NDC inpatient 1 UN 57.79 37.56 SIHO - ALL PLANS SIHO - ALL PLANS 52.01 90 999999999 34.99 56.06 percent of total billed charges 00409-7904-09 - Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [JOHN] 48260575_1 CDM 0258 RC 00409-7904-09 NDC inpatient 1 UN 57.79 37.56 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.99 56.06 00409-7904-09 - Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [JOHN] 48260575_1 CDM 0258 RC 00409-7904-09 NDC inpatient 1 UN 57.79 37.56 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.99 60.55 999999999 34.99 56.06 percent of total billed charges 00409-7904-09 - Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [JOHN] 48260575_1 CDM 0258 RC 00409-7904-09 NDC inpatient 1 UN 57.79 37.56 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.99 56.06 00409-7904-09 - Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [JOHN] 48260575_1 CDM 0258 RC 00409-7904-09 NDC inpatient 1 UN 57.79 37.56 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.99 56.06 00409-7904-09 - Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [JOHN] 48260575_1 CDM 0258 RC 00409-7904-09 NDC inpatient 1 UN 57.79 37.56 ANTHEM HMO ANTHEM HMO 999999999 34.99 56.06 00409-7904-09 - Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [JOHN] 48260575_1 CDM 0258 RC 00409-7904-09 NDC inpatient 1 UN 57.79 37.56 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.07 67.6 999999999 34.99 56.06 percent of total billed charges 00409-7904-09 - Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [JOHN] 48260575_1 CDM 0258 RC 00409-7904-09 NDC inpatient 1 UN 57.79 37.56 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.99 56.06 DIAZEPAM 50 MG/10 ML VIAL 48260582_1 CDM 0250 RC 00409-3213-12 NDC inpatient 1 UN 189.29 123.04 AETNA AETNA 149.54 79 999999999 114.62 183.61 percent of total billed charges DIAZEPAM 50 MG/10 ML VIAL 48260582_1 CDM 0250 RC 00409-3213-12 NDC inpatient 1 UN 189.29 123.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 123.04 65 999999999 114.62 183.61 percent of total billed charges DIAZEPAM 50 MG/10 ML VIAL 48260582_1 CDM 0250 RC 00409-3213-12 NDC inpatient 1 UN 189.29 123.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 183.61 97 999999999 114.62 183.61 percent of total billed charges DIAZEPAM 50 MG/10 ML VIAL 48260582_1 CDM 0250 RC 00409-3213-12 NDC inpatient 1 UN 189.29 123.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 147.65 78 999999999 114.62 183.61 percent of total billed charges DIAZEPAM 50 MG/10 ML VIAL 48260582_1 CDM 0250 RC 00409-3213-12 NDC inpatient 1 UN 189.29 123.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 130.61 69 999999999 114.62 183.61 percent of total billed charges DIAZEPAM 50 MG/10 ML VIAL 48260582_1 CDM 0250 RC 00409-3213-12 NDC inpatient 1 UN 189.29 123.04 UMR - ALL PLANS UMR - ALL PLANS 132.5 70 999999999 114.62 183.61 percent of total billed charges DIAZEPAM 50 MG/10 ML VIAL 48260582_1 CDM 0250 RC 00409-3213-12 NDC inpatient 1 UN 189.29 123.04 SIHO - ALL PLANS SIHO - ALL PLANS 170.36 90 999999999 114.62 183.61 percent of total billed charges DIAZEPAM 50 MG/10 ML VIAL 48260582_1 CDM 0250 RC 00409-3213-12 NDC inpatient 1 UN 189.29 123.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 114.62 183.61 DIAZEPAM 50 MG/10 ML VIAL 48260582_1 CDM 0250 RC 00409-3213-12 NDC inpatient 1 UN 189.29 123.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 114.62 60.55 999999999 114.62 183.61 percent of total billed charges DIAZEPAM 50 MG/10 ML VIAL 48260582_1 CDM 0250 RC 00409-3213-12 NDC inpatient 1 UN 189.29 123.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 114.62 183.61 DIAZEPAM 50 MG/10 ML VIAL 48260582_1 CDM 0250 RC 00409-3213-12 NDC inpatient 1 UN 189.29 123.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 114.62 183.61 DIAZEPAM 50 MG/10 ML VIAL 48260582_1 CDM 0250 RC 00409-3213-12 NDC inpatient 1 UN 189.29 123.04 ANTHEM HMO ANTHEM HMO 999999999 114.62 183.61 DIAZEPAM 50 MG/10 ML VIAL 48260582_1 CDM 0250 RC 00409-3213-12 NDC inpatient 1 UN 189.29 123.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.96 67.6 999999999 114.62 183.61 percent of total billed charges DIAZEPAM 50 MG/10 ML VIAL 48260582_1 CDM 0250 RC 00409-3213-12 NDC inpatient 1 UN 189.29 123.04 UHC - ALL PLANS UHC - ALL PLANS 999999999 114.62 183.61 DIGIFAB 40 MG VIAL 48260595_1 CDM 0250 RC 50633-0120-11 NDC inpatient 1 UN 15229.36 9899.08 AETNA AETNA 12031.19 79 999999999 9221.38 14772.48 percent of total billed charges DIGIFAB 40 MG VIAL 48260595_1 CDM 0250 RC 50633-0120-11 NDC inpatient 1 UN 15229.36 9899.08 SELF PAY DISCOUNT SELF PAY DISCOUNT 9899.08 65 999999999 9221.38 14772.48 percent of total billed charges DIGIFAB 40 MG VIAL 48260595_1 CDM 0250 RC 50633-0120-11 NDC inpatient 1 UN 15229.36 9899.08 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14772.48 97 999999999 9221.38 14772.48 percent of total billed charges DIGIFAB 40 MG VIAL 48260595_1 CDM 0250 RC 50633-0120-11 NDC inpatient 1 UN 15229.36 9899.08 HUMANA - ALL PLANS HUMANA - ALL PLANS 11878.9 78 999999999 9221.38 14772.48 percent of total billed charges DIGIFAB 40 MG VIAL 48260595_1 CDM 0250 RC 50633-0120-11 NDC inpatient 1 UN 15229.36 9899.08 ENCORE - ALL PLANS ENCORE - ALL PLANS 10508.26 69 999999999 9221.38 14772.48 percent of total billed charges DIGIFAB 40 MG VIAL 48260595_1 CDM 0250 RC 50633-0120-11 NDC inpatient 1 UN 15229.36 9899.08 UMR - ALL PLANS UMR - ALL PLANS 10660.55 70 999999999 9221.38 14772.48 percent of total billed charges DIGIFAB 40 MG VIAL 48260595_1 CDM 0250 RC 50633-0120-11 NDC inpatient 1 UN 15229.36 9899.08 SIHO - ALL PLANS SIHO - ALL PLANS 13706.42 90 999999999 9221.38 14772.48 percent of total billed charges DIGIFAB 40 MG VIAL 48260595_1 CDM 0250 RC 50633-0120-11 NDC inpatient 1 UN 15229.36 9899.08 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9221.38 14772.48 DIGIFAB 40 MG VIAL 48260595_1 CDM 0250 RC 50633-0120-11 NDC inpatient 1 UN 15229.36 9899.08 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9221.38 60.55 999999999 9221.38 14772.48 percent of total billed charges DIGIFAB 40 MG VIAL 48260595_1 CDM 0250 RC 50633-0120-11 NDC inpatient 1 UN 15229.36 9899.08 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9221.38 14772.48 DIGIFAB 40 MG VIAL 48260595_1 CDM 0250 RC 50633-0120-11 NDC inpatient 1 UN 15229.36 9899.08 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9221.38 14772.48 DIGIFAB 40 MG VIAL 48260595_1 CDM 0250 RC 50633-0120-11 NDC inpatient 1 UN 15229.36 9899.08 ANTHEM HMO ANTHEM HMO 999999999 9221.38 14772.48 DIGIFAB 40 MG VIAL 48260595_1 CDM 0250 RC 50633-0120-11 NDC inpatient 1 UN 15229.36 9899.08 CIGNA - ALL PLANS CIGNA - ALL PLANS 10295.05 67.6 999999999 9221.38 14772.48 percent of total billed charges DIGIFAB 40 MG VIAL 48260595_1 CDM 0250 RC 50633-0120-11 NDC inpatient 1 UN 15229.36 9899.08 UHC - ALL PLANS UHC - ALL PLANS 999999999 9221.38 14772.48 49884-0831-09 - dilTIAZem 240 mg/24 hours ERCap [JOHN] 48260601_1 CDM 0250 RC 49884-0831-09 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 49884-0831-09 - dilTIAZem 240 mg/24 hours ERCap [JOHN] 48260601_1 CDM 0250 RC 49884-0831-09 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 49884-0831-09 - dilTIAZem 240 mg/24 hours ERCap [JOHN] 48260601_1 CDM 0250 RC 49884-0831-09 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 49884-0831-09 - dilTIAZem 240 mg/24 hours ERCap [JOHN] 48260601_1 CDM 0250 RC 49884-0831-09 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 49884-0831-09 - dilTIAZem 240 mg/24 hours ERCap [JOHN] 48260601_1 CDM 0250 RC 49884-0831-09 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 49884-0831-09 - dilTIAZem 240 mg/24 hours ERCap [JOHN] 48260601_1 CDM 0250 RC 49884-0831-09 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 49884-0831-09 - dilTIAZem 240 mg/24 hours ERCap [JOHN] 48260601_1 CDM 0250 RC 49884-0831-09 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 49884-0831-09 - dilTIAZem 240 mg/24 hours ERCap [JOHN] 48260601_1 CDM 0250 RC 49884-0831-09 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 49884-0831-09 - dilTIAZem 240 mg/24 hours ERCap [JOHN] 48260601_1 CDM 0250 RC 49884-0831-09 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 49884-0831-09 - dilTIAZem 240 mg/24 hours ERCap [JOHN] 48260601_1 CDM 0250 RC 49884-0831-09 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 49884-0831-09 - dilTIAZem 240 mg/24 hours ERCap [JOHN] 48260601_1 CDM 0250 RC 49884-0831-09 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 49884-0831-09 - dilTIAZem 240 mg/24 hours ERCap [JOHN] 48260601_1 CDM 0250 RC 49884-0831-09 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 49884-0831-09 - dilTIAZem 240 mg/24 hours ERCap [JOHN] 48260601_1 CDM 0250 RC 49884-0831-09 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 49884-0831-09 - dilTIAZem 240 mg/24 hours ERCap [JOHN] 48260601_1 CDM 0250 RC 49884-0831-09 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 DILTIAZEM 12HR ER 60 MG CAP 48260604_1 CDM 0250 RC 00378-6060-01 NDC inpatient 1 UN 10.17 6.61 AETNA AETNA 8.03 79 999999999 6.16 9.86 percent of total billed charges DILTIAZEM 12HR ER 60 MG CAP 48260604_1 CDM 0250 RC 00378-6060-01 NDC inpatient 1 UN 10.17 6.61 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.61 65 999999999 6.16 9.86 percent of total billed charges DILTIAZEM 12HR ER 60 MG CAP 48260604_1 CDM 0250 RC 00378-6060-01 NDC inpatient 1 UN 10.17 6.61 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.86 97 999999999 6.16 9.86 percent of total billed charges DILTIAZEM 12HR ER 60 MG CAP 48260604_1 CDM 0250 RC 00378-6060-01 NDC inpatient 1 UN 10.17 6.61 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.93 78 999999999 6.16 9.86 percent of total billed charges DILTIAZEM 12HR ER 60 MG CAP 48260604_1 CDM 0250 RC 00378-6060-01 NDC inpatient 1 UN 10.17 6.61 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.02 69 999999999 6.16 9.86 percent of total billed charges DILTIAZEM 12HR ER 60 MG CAP 48260604_1 CDM 0250 RC 00378-6060-01 NDC inpatient 1 UN 10.17 6.61 UMR - ALL PLANS UMR - ALL PLANS 7.12 70 999999999 6.16 9.86 percent of total billed charges DILTIAZEM 12HR ER 60 MG CAP 48260604_1 CDM 0250 RC 00378-6060-01 NDC inpatient 1 UN 10.17 6.61 SIHO - ALL PLANS SIHO - ALL PLANS 9.15 90 999999999 6.16 9.86 percent of total billed charges DILTIAZEM 12HR ER 60 MG CAP 48260604_1 CDM 0250 RC 00378-6060-01 NDC inpatient 1 UN 10.17 6.61 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.16 9.86 DILTIAZEM 12HR ER 60 MG CAP 48260604_1 CDM 0250 RC 00378-6060-01 NDC inpatient 1 UN 10.17 6.61 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.16 60.55 999999999 6.16 9.86 percent of total billed charges DILTIAZEM 12HR ER 60 MG CAP 48260604_1 CDM 0250 RC 00378-6060-01 NDC inpatient 1 UN 10.17 6.61 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.16 9.86 DILTIAZEM 12HR ER 60 MG CAP 48260604_1 CDM 0250 RC 00378-6060-01 NDC inpatient 1 UN 10.17 6.61 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.16 9.86 DILTIAZEM 12HR ER 60 MG CAP 48260604_1 CDM 0250 RC 00378-6060-01 NDC inpatient 1 UN 10.17 6.61 ANTHEM HMO ANTHEM HMO 999999999 6.16 9.86 DILTIAZEM 12HR ER 60 MG CAP 48260604_1 CDM 0250 RC 00378-6060-01 NDC inpatient 1 UN 10.17 6.61 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.87 67.6 999999999 6.16 9.86 percent of total billed charges DILTIAZEM 12HR ER 60 MG CAP 48260604_1 CDM 0250 RC 00378-6060-01 NDC inpatient 1 UN 10.17 6.61 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.16 9.86 63739-0080-10 - dilTIAZem 60 mg Tab [JOHN] 48260605_1 CDM 0250 RC 63739-0080-10 NDC inpatient 1 UN 1.48 0.96 AETNA AETNA 1.17 79 999999999 0.9 1.44 percent of total billed charges 63739-0080-10 - dilTIAZem 60 mg Tab [JOHN] 48260605_1 CDM 0250 RC 63739-0080-10 NDC inpatient 1 UN 1.48 0.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.96 65 999999999 0.9 1.44 percent of total billed charges 63739-0080-10 - dilTIAZem 60 mg Tab [JOHN] 48260605_1 CDM 0250 RC 63739-0080-10 NDC inpatient 1 UN 1.48 0.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.44 97 999999999 0.9 1.44 percent of total billed charges 63739-0080-10 - dilTIAZem 60 mg Tab [JOHN] 48260605_1 CDM 0250 RC 63739-0080-10 NDC inpatient 1 UN 1.48 0.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.15 78 999999999 0.9 1.44 percent of total billed charges 63739-0080-10 - dilTIAZem 60 mg Tab [JOHN] 48260605_1 CDM 0250 RC 63739-0080-10 NDC inpatient 1 UN 1.48 0.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.02 69 999999999 0.9 1.44 percent of total billed charges 63739-0080-10 - dilTIAZem 60 mg Tab [JOHN] 48260605_1 CDM 0250 RC 63739-0080-10 NDC inpatient 1 UN 1.48 0.96 UMR - ALL PLANS UMR - ALL PLANS 1.04 70 999999999 0.9 1.44 percent of total billed charges 63739-0080-10 - dilTIAZem 60 mg Tab [JOHN] 48260605_1 CDM 0250 RC 63739-0080-10 NDC inpatient 1 UN 1.48 0.96 SIHO - ALL PLANS SIHO - ALL PLANS 1.33 90 999999999 0.9 1.44 percent of total billed charges 63739-0080-10 - dilTIAZem 60 mg Tab [JOHN] 48260605_1 CDM 0250 RC 63739-0080-10 NDC inpatient 1 UN 1.48 0.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.9 1.44 63739-0080-10 - dilTIAZem 60 mg Tab [JOHN] 48260605_1 CDM 0250 RC 63739-0080-10 NDC inpatient 1 UN 1.48 0.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.9 60.55 999999999 0.9 1.44 percent of total billed charges 63739-0080-10 - dilTIAZem 60 mg Tab [JOHN] 48260605_1 CDM 0250 RC 63739-0080-10 NDC inpatient 1 UN 1.48 0.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.9 1.44 63739-0080-10 - dilTIAZem 60 mg Tab [JOHN] 48260605_1 CDM 0250 RC 63739-0080-10 NDC inpatient 1 UN 1.48 0.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.9 1.44 63739-0080-10 - dilTIAZem 60 mg Tab [JOHN] 48260605_1 CDM 0250 RC 63739-0080-10 NDC inpatient 1 UN 1.48 0.96 ANTHEM HMO ANTHEM HMO 999999999 0.9 1.44 63739-0080-10 - dilTIAZem 60 mg Tab [JOHN] 48260605_1 CDM 0250 RC 63739-0080-10 NDC inpatient 1 UN 1.48 0.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 1 67.6 999999999 0.9 1.44 percent of total billed charges 63739-0080-10 - dilTIAZem 60 mg Tab [JOHN] 48260605_1 CDM 0250 RC 63739-0080-10 NDC inpatient 1 UN 1.48 0.96 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.9 1.44 DILTIAZEM 100 MG ADD-VAN VIAL 48260607_1 CDM 0250 RC 00409-4350-03 NDC inpatient 1 UN 98 63.7 AETNA AETNA 77.42 79 999999999 59.34 95.06 percent of total billed charges DILTIAZEM 100 MG ADD-VAN VIAL 48260607_1 CDM 0250 RC 00409-4350-03 NDC inpatient 1 UN 98 63.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.7 65 999999999 59.34 95.06 percent of total billed charges DILTIAZEM 100 MG ADD-VAN VIAL 48260607_1 CDM 0250 RC 00409-4350-03 NDC inpatient 1 UN 98 63.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.06 97 999999999 59.34 95.06 percent of total billed charges DILTIAZEM 100 MG ADD-VAN VIAL 48260607_1 CDM 0250 RC 00409-4350-03 NDC inpatient 1 UN 98 63.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.44 78 999999999 59.34 95.06 percent of total billed charges DILTIAZEM 100 MG ADD-VAN VIAL 48260607_1 CDM 0250 RC 00409-4350-03 NDC inpatient 1 UN 98 63.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.62 69 999999999 59.34 95.06 percent of total billed charges DILTIAZEM 100 MG ADD-VAN VIAL 48260607_1 CDM 0250 RC 00409-4350-03 NDC inpatient 1 UN 98 63.7 UMR - ALL PLANS UMR - ALL PLANS 68.6 70 999999999 59.34 95.06 percent of total billed charges DILTIAZEM 100 MG ADD-VAN VIAL 48260607_1 CDM 0250 RC 00409-4350-03 NDC inpatient 1 UN 98 63.7 SIHO - ALL PLANS SIHO - ALL PLANS 88.2 90 999999999 59.34 95.06 percent of total billed charges DILTIAZEM 100 MG ADD-VAN VIAL 48260607_1 CDM 0250 RC 00409-4350-03 NDC inpatient 1 UN 98 63.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.34 95.06 DILTIAZEM 100 MG ADD-VAN VIAL 48260607_1 CDM 0250 RC 00409-4350-03 NDC inpatient 1 UN 98 63.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.34 60.55 999999999 59.34 95.06 percent of total billed charges DILTIAZEM 100 MG ADD-VAN VIAL 48260607_1 CDM 0250 RC 00409-4350-03 NDC inpatient 1 UN 98 63.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.34 95.06 DILTIAZEM 100 MG ADD-VAN VIAL 48260607_1 CDM 0250 RC 00409-4350-03 NDC inpatient 1 UN 98 63.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.34 95.06 DILTIAZEM 100 MG ADD-VAN VIAL 48260607_1 CDM 0250 RC 00409-4350-03 NDC inpatient 1 UN 98 63.7 ANTHEM HMO ANTHEM HMO 999999999 59.34 95.06 DILTIAZEM 100 MG ADD-VAN VIAL 48260607_1 CDM 0250 RC 00409-4350-03 NDC inpatient 1 UN 98 63.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.25 67.6 999999999 59.34 95.06 percent of total billed charges DILTIAZEM 100 MG ADD-VAN VIAL 48260607_1 CDM 0250 RC 00409-4350-03 NDC inpatient 1 UN 98 63.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.34 95.06 "INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG" 48260627_1 CDM 0250 RC 00338-1077-02 NDC J1250 HCPCS inpatient 4 UN 117.83 76.59 AETNA AETNA 93.09 79 999999999 71.35 114.3 percent of total billed charges "INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG" 48260627_1 CDM 0250 RC 00338-1077-02 NDC J1250 HCPCS inpatient 4 UN 117.83 76.59 SELF PAY DISCOUNT SELF PAY DISCOUNT 76.59 65 999999999 71.35 114.3 percent of total billed charges "INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG" 48260627_1 CDM 0250 RC 00338-1077-02 NDC J1250 HCPCS inpatient 4 UN 117.83 76.59 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 114.3 97 999999999 71.35 114.3 percent of total billed charges "INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG" 48260627_1 CDM 0250 RC 00338-1077-02 NDC J1250 HCPCS inpatient 4 UN 117.83 76.59 HUMANA - ALL PLANS HUMANA - ALL PLANS 91.91 78 999999999 71.35 114.3 percent of total billed charges "INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG" 48260627_1 CDM 0250 RC 00338-1077-02 NDC J1250 HCPCS inpatient 4 UN 117.83 76.59 ENCORE - ALL PLANS ENCORE - ALL PLANS 81.3 69 999999999 71.35 114.3 percent of total billed charges "INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG" 48260627_1 CDM 0250 RC 00338-1077-02 NDC J1250 HCPCS inpatient 4 UN 117.83 76.59 UMR - ALL PLANS UMR - ALL PLANS 82.48 70 999999999 71.35 114.3 percent of total billed charges "INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG" 48260627_1 CDM 0250 RC 00338-1077-02 NDC J1250 HCPCS inpatient 4 UN 117.83 76.59 SIHO - ALL PLANS SIHO - ALL PLANS 106.05 90 999999999 71.35 114.3 percent of total billed charges "INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG" 48260627_1 CDM 0250 RC 00338-1077-02 NDC J1250 HCPCS inpatient 4 UN 117.83 76.59 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 71.35 114.3 "INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG" 48260627_1 CDM 0250 RC 00338-1077-02 NDC J1250 HCPCS inpatient 4 UN 117.83 76.59 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 71.35 60.55 999999999 71.35 114.3 percent of total billed charges "INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG" 48260627_1 CDM 0250 RC 00338-1077-02 NDC J1250 HCPCS inpatient 4 UN 117.83 76.59 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 71.35 114.3 "INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG" 48260627_1 CDM 0250 RC 00338-1077-02 NDC J1250 HCPCS inpatient 4 UN 117.83 76.59 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 71.35 114.3 "INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG" 48260627_1 CDM 0250 RC 00338-1077-02 NDC J1250 HCPCS inpatient 4 UN 117.83 76.59 ANTHEM HMO ANTHEM HMO 999999999 71.35 114.3 "INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG" 48260627_1 CDM 0250 RC 00338-1077-02 NDC J1250 HCPCS inpatient 4 UN 117.83 76.59 CIGNA - ALL PLANS CIGNA - ALL PLANS 79.65 67.6 999999999 71.35 114.3 percent of total billed charges "INJECTION, DOBUTAMINE HYDROCHLORIDE, PER 250 MG" 48260627_1 CDM 0250 RC 00338-1077-02 NDC J1250 HCPCS inpatient 4 UN 117.83 76.59 UHC - ALL PLANS UHC - ALL PLANS 999999999 71.35 114.3 "INJECTION, DOPAMINE HCL, 40 MG" 48260637_1 CDM 0258 RC 00338-1007-02 NDC J1265 HCPCS inpatient 1 UN 98.95 64.32 AETNA AETNA 78.17 79 999999999 59.91 95.98 percent of total billed charges "INJECTION, DOPAMINE HCL, 40 MG" 48260637_1 CDM 0258 RC 00338-1007-02 NDC J1265 HCPCS inpatient 1 UN 98.95 64.32 SELF PAY DISCOUNT SELF PAY DISCOUNT 64.32 65 999999999 59.91 95.98 percent of total billed charges "INJECTION, DOPAMINE HCL, 40 MG" 48260637_1 CDM 0258 RC 00338-1007-02 NDC J1265 HCPCS inpatient 1 UN 98.95 64.32 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.98 97 999999999 59.91 95.98 percent of total billed charges "INJECTION, DOPAMINE HCL, 40 MG" 48260637_1 CDM 0258 RC 00338-1007-02 NDC J1265 HCPCS inpatient 1 UN 98.95 64.32 HUMANA - ALL PLANS HUMANA - ALL PLANS 77.18 78 999999999 59.91 95.98 percent of total billed charges "INJECTION, DOPAMINE HCL, 40 MG" 48260637_1 CDM 0258 RC 00338-1007-02 NDC J1265 HCPCS inpatient 1 UN 98.95 64.32 ENCORE - ALL PLANS ENCORE - ALL PLANS 68.28 69 999999999 59.91 95.98 percent of total billed charges "INJECTION, DOPAMINE HCL, 40 MG" 48260637_1 CDM 0258 RC 00338-1007-02 NDC J1265 HCPCS inpatient 1 UN 98.95 64.32 UMR - ALL PLANS UMR - ALL PLANS 69.27 70 999999999 59.91 95.98 percent of total billed charges "INJECTION, DOPAMINE HCL, 40 MG" 48260637_1 CDM 0258 RC 00338-1007-02 NDC J1265 HCPCS inpatient 1 UN 98.95 64.32 SIHO - ALL PLANS SIHO - ALL PLANS 89.06 90 999999999 59.91 95.98 percent of total billed charges "INJECTION, DOPAMINE HCL, 40 MG" 48260637_1 CDM 0258 RC 00338-1007-02 NDC J1265 HCPCS inpatient 1 UN 98.95 64.32 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.91 95.98 "INJECTION, DOPAMINE HCL, 40 MG" 48260637_1 CDM 0258 RC 00338-1007-02 NDC J1265 HCPCS inpatient 1 UN 98.95 64.32 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.91 60.55 999999999 59.91 95.98 percent of total billed charges "INJECTION, DOPAMINE HCL, 40 MG" 48260637_1 CDM 0258 RC 00338-1007-02 NDC J1265 HCPCS inpatient 1 UN 98.95 64.32 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.91 95.98 "INJECTION, DOPAMINE HCL, 40 MG" 48260637_1 CDM 0258 RC 00338-1007-02 NDC J1265 HCPCS inpatient 1 UN 98.95 64.32 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.91 95.98 "INJECTION, DOPAMINE HCL, 40 MG" 48260637_1 CDM 0258 RC 00338-1007-02 NDC J1265 HCPCS inpatient 1 UN 98.95 64.32 ANTHEM HMO ANTHEM HMO 999999999 59.91 95.98 "INJECTION, DOPAMINE HCL, 40 MG" 48260637_1 CDM 0258 RC 00338-1007-02 NDC J1265 HCPCS inpatient 1 UN 98.95 64.32 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.89 67.6 999999999 59.91 95.98 percent of total billed charges "INJECTION, DOPAMINE HCL, 40 MG" 48260637_1 CDM 0258 RC 00338-1007-02 NDC J1265 HCPCS inpatient 1 UN 98.95 64.32 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.91 95.98 DORZOLAMIDE HCL 2% EYE DROPS 48260638_1 CDM 0250 RC 61314-0019-10 NDC inpatient 1 UN 79.68 51.79 AETNA AETNA 62.95 79 999999999 48.25 77.29 percent of total billed charges DORZOLAMIDE HCL 2% EYE DROPS 48260638_1 CDM 0250 RC 61314-0019-10 NDC inpatient 1 UN 79.68 51.79 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.79 65 999999999 48.25 77.29 percent of total billed charges DORZOLAMIDE HCL 2% EYE DROPS 48260638_1 CDM 0250 RC 61314-0019-10 NDC inpatient 1 UN 79.68 51.79 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.29 97 999999999 48.25 77.29 percent of total billed charges DORZOLAMIDE HCL 2% EYE DROPS 48260638_1 CDM 0250 RC 61314-0019-10 NDC inpatient 1 UN 79.68 51.79 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.15 78 999999999 48.25 77.29 percent of total billed charges DORZOLAMIDE HCL 2% EYE DROPS 48260638_1 CDM 0250 RC 61314-0019-10 NDC inpatient 1 UN 79.68 51.79 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.98 69 999999999 48.25 77.29 percent of total billed charges DORZOLAMIDE HCL 2% EYE DROPS 48260638_1 CDM 0250 RC 61314-0019-10 NDC inpatient 1 UN 79.68 51.79 UMR - ALL PLANS UMR - ALL PLANS 55.78 70 999999999 48.25 77.29 percent of total billed charges DORZOLAMIDE HCL 2% EYE DROPS 48260638_1 CDM 0250 RC 61314-0019-10 NDC inpatient 1 UN 79.68 51.79 SIHO - ALL PLANS SIHO - ALL PLANS 71.71 90 999999999 48.25 77.29 percent of total billed charges DORZOLAMIDE HCL 2% EYE DROPS 48260638_1 CDM 0250 RC 61314-0019-10 NDC inpatient 1 UN 79.68 51.79 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.25 77.29 DORZOLAMIDE HCL 2% EYE DROPS 48260638_1 CDM 0250 RC 61314-0019-10 NDC inpatient 1 UN 79.68 51.79 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.25 60.55 999999999 48.25 77.29 percent of total billed charges DORZOLAMIDE HCL 2% EYE DROPS 48260638_1 CDM 0250 RC 61314-0019-10 NDC inpatient 1 UN 79.68 51.79 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.25 77.29 DORZOLAMIDE HCL 2% EYE DROPS 48260638_1 CDM 0250 RC 61314-0019-10 NDC inpatient 1 UN 79.68 51.79 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.25 77.29 DORZOLAMIDE HCL 2% EYE DROPS 48260638_1 CDM 0250 RC 61314-0019-10 NDC inpatient 1 UN 79.68 51.79 ANTHEM HMO ANTHEM HMO 999999999 48.25 77.29 DORZOLAMIDE HCL 2% EYE DROPS 48260638_1 CDM 0250 RC 61314-0019-10 NDC inpatient 1 UN 79.68 51.79 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.86 67.6 999999999 48.25 77.29 percent of total billed charges DORZOLAMIDE HCL 2% EYE DROPS 48260638_1 CDM 0250 RC 61314-0019-10 NDC inpatient 1 UN 79.68 51.79 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.25 77.29 DOXEPIN 10 MG CAPSULE 48260643_1 CDM 0250 RC 51079-0436-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges DOXEPIN 10 MG CAPSULE 48260643_1 CDM 0250 RC 51079-0436-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges DOXEPIN 10 MG CAPSULE 48260643_1 CDM 0250 RC 51079-0436-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges DOXEPIN 10 MG CAPSULE 48260643_1 CDM 0250 RC 51079-0436-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges DOXEPIN 10 MG CAPSULE 48260643_1 CDM 0250 RC 51079-0436-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges DOXEPIN 10 MG CAPSULE 48260643_1 CDM 0250 RC 51079-0436-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges DOXEPIN 10 MG CAPSULE 48260643_1 CDM 0250 RC 51079-0436-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges DOXEPIN 10 MG CAPSULE 48260643_1 CDM 0250 RC 51079-0436-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 DOXEPIN 10 MG CAPSULE 48260643_1 CDM 0250 RC 51079-0436-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges DOXEPIN 10 MG CAPSULE 48260643_1 CDM 0250 RC 51079-0436-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 DOXEPIN 10 MG CAPSULE 48260643_1 CDM 0250 RC 51079-0436-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 DOXEPIN 10 MG CAPSULE 48260643_1 CDM 0250 RC 51079-0436-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 DOXEPIN 10 MG CAPSULE 48260643_1 CDM 0250 RC 51079-0436-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges DOXEPIN 10 MG CAPSULE 48260643_1 CDM 0250 RC 51079-0436-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 DOXY 100 MG VIAL 48260649_1 CDM 0250 RC 63323-0130-13 NDC inpatient 1 UN 103.26 67.12 AETNA AETNA 81.58 79 999999999 62.52 100.16 percent of total billed charges DOXY 100 MG VIAL 48260649_1 CDM 0250 RC 63323-0130-13 NDC inpatient 1 UN 103.26 67.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 67.12 65 999999999 62.52 100.16 percent of total billed charges DOXY 100 MG VIAL 48260649_1 CDM 0250 RC 63323-0130-13 NDC inpatient 1 UN 103.26 67.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 100.16 97 999999999 62.52 100.16 percent of total billed charges DOXY 100 MG VIAL 48260649_1 CDM 0250 RC 63323-0130-13 NDC inpatient 1 UN 103.26 67.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 80.54 78 999999999 62.52 100.16 percent of total billed charges DOXY 100 MG VIAL 48260649_1 CDM 0250 RC 63323-0130-13 NDC inpatient 1 UN 103.26 67.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.25 69 999999999 62.52 100.16 percent of total billed charges DOXY 100 MG VIAL 48260649_1 CDM 0250 RC 63323-0130-13 NDC inpatient 1 UN 103.26 67.12 UMR - ALL PLANS UMR - ALL PLANS 72.28 70 999999999 62.52 100.16 percent of total billed charges DOXY 100 MG VIAL 48260649_1 CDM 0250 RC 63323-0130-13 NDC inpatient 1 UN 103.26 67.12 SIHO - ALL PLANS SIHO - ALL PLANS 92.93 90 999999999 62.52 100.16 percent of total billed charges DOXY 100 MG VIAL 48260649_1 CDM 0250 RC 63323-0130-13 NDC inpatient 1 UN 103.26 67.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.52 100.16 DOXY 100 MG VIAL 48260649_1 CDM 0250 RC 63323-0130-13 NDC inpatient 1 UN 103.26 67.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.52 60.55 999999999 62.52 100.16 percent of total billed charges DOXY 100 MG VIAL 48260649_1 CDM 0250 RC 63323-0130-13 NDC inpatient 1 UN 103.26 67.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.52 100.16 DOXY 100 MG VIAL 48260649_1 CDM 0250 RC 63323-0130-13 NDC inpatient 1 UN 103.26 67.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.52 100.16 DOXY 100 MG VIAL 48260649_1 CDM 0250 RC 63323-0130-13 NDC inpatient 1 UN 103.26 67.12 ANTHEM HMO ANTHEM HMO 999999999 62.52 100.16 DOXY 100 MG VIAL 48260649_1 CDM 0250 RC 63323-0130-13 NDC inpatient 1 UN 103.26 67.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 69.8 67.6 999999999 62.52 100.16 percent of total billed charges DOXY 100 MG VIAL 48260649_1 CDM 0250 RC 63323-0130-13 NDC inpatient 1 UN 103.26 67.12 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.52 100.16 "54162-0600-02 - emollients, Top Crm [JOHN]" 48260655_1 CDM 0250 RC 54162-0600-02 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges "54162-0600-02 - emollients, Top Crm [JOHN]" 48260655_1 CDM 0250 RC 54162-0600-02 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges "54162-0600-02 - emollients, Top Crm [JOHN]" 48260655_1 CDM 0250 RC 54162-0600-02 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges "54162-0600-02 - emollients, Top Crm [JOHN]" 48260655_1 CDM 0250 RC 54162-0600-02 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges "54162-0600-02 - emollients, Top Crm [JOHN]" 48260655_1 CDM 0250 RC 54162-0600-02 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges "54162-0600-02 - emollients, Top Crm [JOHN]" 48260655_1 CDM 0250 RC 54162-0600-02 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges "54162-0600-02 - emollients, Top Crm [JOHN]" 48260655_1 CDM 0250 RC 54162-0600-02 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges "54162-0600-02 - emollients, Top Crm [JOHN]" 48260655_1 CDM 0250 RC 54162-0600-02 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 "54162-0600-02 - emollients, Top Crm [JOHN]" 48260655_1 CDM 0250 RC 54162-0600-02 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges "54162-0600-02 - emollients, Top Crm [JOHN]" 48260655_1 CDM 0250 RC 54162-0600-02 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 "54162-0600-02 - emollients, Top Crm [JOHN]" 48260655_1 CDM 0250 RC 54162-0600-02 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 "54162-0600-02 - emollients, Top Crm [JOHN]" 48260655_1 CDM 0250 RC 54162-0600-02 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 "54162-0600-02 - emollients, Top Crm [JOHN]" 48260655_1 CDM 0250 RC 54162-0600-02 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "54162-0600-02 - emollients, Top Crm [JOHN]" 48260655_1 CDM 0250 RC 54162-0600-02 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 17478-0515-00 - ePHEDrine 50 mg/mL Inj Sol [JOHN] 48260671_1 CDM 0250 RC 17478-0515-00 NDC inpatient 1 UN 113.42 73.72 AETNA AETNA 89.6 79 999999999 68.68 110.02 percent of total billed charges 17478-0515-00 - ePHEDrine 50 mg/mL Inj Sol [JOHN] 48260671_1 CDM 0250 RC 17478-0515-00 NDC inpatient 1 UN 113.42 73.72 SELF PAY DISCOUNT SELF PAY DISCOUNT 73.72 65 999999999 68.68 110.02 percent of total billed charges 17478-0515-00 - ePHEDrine 50 mg/mL Inj Sol [JOHN] 48260671_1 CDM 0250 RC 17478-0515-00 NDC inpatient 1 UN 113.42 73.72 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.02 97 999999999 68.68 110.02 percent of total billed charges 17478-0515-00 - ePHEDrine 50 mg/mL Inj Sol [JOHN] 48260671_1 CDM 0250 RC 17478-0515-00 NDC inpatient 1 UN 113.42 73.72 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.47 78 999999999 68.68 110.02 percent of total billed charges 17478-0515-00 - ePHEDrine 50 mg/mL Inj Sol [JOHN] 48260671_1 CDM 0250 RC 17478-0515-00 NDC inpatient 1 UN 113.42 73.72 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.26 69 999999999 68.68 110.02 percent of total billed charges 17478-0515-00 - ePHEDrine 50 mg/mL Inj Sol [JOHN] 48260671_1 CDM 0250 RC 17478-0515-00 NDC inpatient 1 UN 113.42 73.72 UMR - ALL PLANS UMR - ALL PLANS 79.39 70 999999999 68.68 110.02 percent of total billed charges 17478-0515-00 - ePHEDrine 50 mg/mL Inj Sol [JOHN] 48260671_1 CDM 0250 RC 17478-0515-00 NDC inpatient 1 UN 113.42 73.72 SIHO - ALL PLANS SIHO - ALL PLANS 102.08 90 999999999 68.68 110.02 percent of total billed charges 17478-0515-00 - ePHEDrine 50 mg/mL Inj Sol [JOHN] 48260671_1 CDM 0250 RC 17478-0515-00 NDC inpatient 1 UN 113.42 73.72 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 68.68 110.02 17478-0515-00 - ePHEDrine 50 mg/mL Inj Sol [JOHN] 48260671_1 CDM 0250 RC 17478-0515-00 NDC inpatient 1 UN 113.42 73.72 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 68.68 60.55 999999999 68.68 110.02 percent of total billed charges 17478-0515-00 - ePHEDrine 50 mg/mL Inj Sol [JOHN] 48260671_1 CDM 0250 RC 17478-0515-00 NDC inpatient 1 UN 113.42 73.72 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 68.68 110.02 17478-0515-00 - ePHEDrine 50 mg/mL Inj Sol [JOHN] 48260671_1 CDM 0250 RC 17478-0515-00 NDC inpatient 1 UN 113.42 73.72 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 68.68 110.02 17478-0515-00 - ePHEDrine 50 mg/mL Inj Sol [JOHN] 48260671_1 CDM 0250 RC 17478-0515-00 NDC inpatient 1 UN 113.42 73.72 ANTHEM HMO ANTHEM HMO 999999999 68.68 110.02 17478-0515-00 - ePHEDrine 50 mg/mL Inj Sol [JOHN] 48260671_1 CDM 0250 RC 17478-0515-00 NDC inpatient 1 UN 113.42 73.72 CIGNA - ALL PLANS CIGNA - ALL PLANS 76.67 67.6 999999999 68.68 110.02 percent of total billed charges 17478-0515-00 - ePHEDrine 50 mg/mL Inj Sol [JOHN] 48260671_1 CDM 0250 RC 17478-0515-00 NDC inpatient 1 UN 113.42 73.72 UHC - ALL PLANS UHC - ALL PLANS 999999999 68.68 110.02 ADRENALIN 1 MG/ML VIAL 48260674_1 CDM 0250 RC 42023-0159-25 NDC inpatient 1 UN 81.63 53.06 AETNA AETNA 64.49 79 999999999 49.43 79.18 percent of total billed charges ADRENALIN 1 MG/ML VIAL 48260674_1 CDM 0250 RC 42023-0159-25 NDC inpatient 1 UN 81.63 53.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.06 65 999999999 49.43 79.18 percent of total billed charges ADRENALIN 1 MG/ML VIAL 48260674_1 CDM 0250 RC 42023-0159-25 NDC inpatient 1 UN 81.63 53.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.18 97 999999999 49.43 79.18 percent of total billed charges ADRENALIN 1 MG/ML VIAL 48260674_1 CDM 0250 RC 42023-0159-25 NDC inpatient 1 UN 81.63 53.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.67 78 999999999 49.43 79.18 percent of total billed charges ADRENALIN 1 MG/ML VIAL 48260674_1 CDM 0250 RC 42023-0159-25 NDC inpatient 1 UN 81.63 53.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.32 69 999999999 49.43 79.18 percent of total billed charges ADRENALIN 1 MG/ML VIAL 48260674_1 CDM 0250 RC 42023-0159-25 NDC inpatient 1 UN 81.63 53.06 UMR - ALL PLANS UMR - ALL PLANS 57.14 70 999999999 49.43 79.18 percent of total billed charges ADRENALIN 1 MG/ML VIAL 48260674_1 CDM 0250 RC 42023-0159-25 NDC inpatient 1 UN 81.63 53.06 SIHO - ALL PLANS SIHO - ALL PLANS 73.47 90 999999999 49.43 79.18 percent of total billed charges ADRENALIN 1 MG/ML VIAL 48260674_1 CDM 0250 RC 42023-0159-25 NDC inpatient 1 UN 81.63 53.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.43 79.18 ADRENALIN 1 MG/ML VIAL 48260674_1 CDM 0250 RC 42023-0159-25 NDC inpatient 1 UN 81.63 53.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.43 60.55 999999999 49.43 79.18 percent of total billed charges ADRENALIN 1 MG/ML VIAL 48260674_1 CDM 0250 RC 42023-0159-25 NDC inpatient 1 UN 81.63 53.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.43 79.18 ADRENALIN 1 MG/ML VIAL 48260674_1 CDM 0250 RC 42023-0159-25 NDC inpatient 1 UN 81.63 53.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.43 79.18 ADRENALIN 1 MG/ML VIAL 48260674_1 CDM 0250 RC 42023-0159-25 NDC inpatient 1 UN 81.63 53.06 ANTHEM HMO ANTHEM HMO 999999999 49.43 79.18 ADRENALIN 1 MG/ML VIAL 48260674_1 CDM 0250 RC 42023-0159-25 NDC inpatient 1 UN 81.63 53.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.18 67.6 999999999 49.43 79.18 percent of total billed charges ADRENALIN 1 MG/ML VIAL 48260674_1 CDM 0250 RC 42023-0159-25 NDC inpatient 1 UN 81.63 53.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.43 79.18 ADRENALIN 1 MG/ML NASAL SOLN 48260676_1 CDM 0250 RC 42023-0103-01 NDC inpatient 1 UN 1248.39 811.45 AETNA AETNA 986.23 79 999999999 755.9 1210.94 percent of total billed charges ADRENALIN 1 MG/ML NASAL SOLN 48260676_1 CDM 0250 RC 42023-0103-01 NDC inpatient 1 UN 1248.39 811.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 811.45 65 999999999 755.9 1210.94 percent of total billed charges ADRENALIN 1 MG/ML NASAL SOLN 48260676_1 CDM 0250 RC 42023-0103-01 NDC inpatient 1 UN 1248.39 811.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1210.94 97 999999999 755.9 1210.94 percent of total billed charges ADRENALIN 1 MG/ML NASAL SOLN 48260676_1 CDM 0250 RC 42023-0103-01 NDC inpatient 1 UN 1248.39 811.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 973.74 78 999999999 755.9 1210.94 percent of total billed charges ADRENALIN 1 MG/ML NASAL SOLN 48260676_1 CDM 0250 RC 42023-0103-01 NDC inpatient 1 UN 1248.39 811.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 861.39 69 999999999 755.9 1210.94 percent of total billed charges ADRENALIN 1 MG/ML NASAL SOLN 48260676_1 CDM 0250 RC 42023-0103-01 NDC inpatient 1 UN 1248.39 811.45 UMR - ALL PLANS UMR - ALL PLANS 873.87 70 999999999 755.9 1210.94 percent of total billed charges ADRENALIN 1 MG/ML NASAL SOLN 48260676_1 CDM 0250 RC 42023-0103-01 NDC inpatient 1 UN 1248.39 811.45 SIHO - ALL PLANS SIHO - ALL PLANS 1123.55 90 999999999 755.9 1210.94 percent of total billed charges ADRENALIN 1 MG/ML NASAL SOLN 48260676_1 CDM 0250 RC 42023-0103-01 NDC inpatient 1 UN 1248.39 811.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 755.9 1210.94 ADRENALIN 1 MG/ML NASAL SOLN 48260676_1 CDM 0250 RC 42023-0103-01 NDC inpatient 1 UN 1248.39 811.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 755.9 60.55 999999999 755.9 1210.94 percent of total billed charges ADRENALIN 1 MG/ML NASAL SOLN 48260676_1 CDM 0250 RC 42023-0103-01 NDC inpatient 1 UN 1248.39 811.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 755.9 1210.94 ADRENALIN 1 MG/ML NASAL SOLN 48260676_1 CDM 0250 RC 42023-0103-01 NDC inpatient 1 UN 1248.39 811.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 755.9 1210.94 ADRENALIN 1 MG/ML NASAL SOLN 48260676_1 CDM 0250 RC 42023-0103-01 NDC inpatient 1 UN 1248.39 811.45 ANTHEM HMO ANTHEM HMO 999999999 755.9 1210.94 ADRENALIN 1 MG/ML NASAL SOLN 48260676_1 CDM 0250 RC 42023-0103-01 NDC inpatient 1 UN 1248.39 811.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 843.91 67.6 999999999 755.9 1210.94 percent of total billed charges ADRENALIN 1 MG/ML NASAL SOLN 48260676_1 CDM 0250 RC 42023-0103-01 NDC inpatient 1 UN 1248.39 811.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 755.9 1210.94 "LIDOCAINE 1%-EPI 1:100,000" 48260677_1 CDM 0250 RC 00409-3178-01 NDC inpatient 1 UN 21.87 14.22 AETNA AETNA 17.28 79 999999999 13.24 21.21 percent of total billed charges "LIDOCAINE 1%-EPI 1:100,000" 48260677_1 CDM 0250 RC 00409-3178-01 NDC inpatient 1 UN 21.87 14.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.22 65 999999999 13.24 21.21 percent of total billed charges "LIDOCAINE 1%-EPI 1:100,000" 48260677_1 CDM 0250 RC 00409-3178-01 NDC inpatient 1 UN 21.87 14.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21.21 97 999999999 13.24 21.21 percent of total billed charges "LIDOCAINE 1%-EPI 1:100,000" 48260677_1 CDM 0250 RC 00409-3178-01 NDC inpatient 1 UN 21.87 14.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.06 78 999999999 13.24 21.21 percent of total billed charges "LIDOCAINE 1%-EPI 1:100,000" 48260677_1 CDM 0250 RC 00409-3178-01 NDC inpatient 1 UN 21.87 14.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.09 69 999999999 13.24 21.21 percent of total billed charges "LIDOCAINE 1%-EPI 1:100,000" 48260677_1 CDM 0250 RC 00409-3178-01 NDC inpatient 1 UN 21.87 14.22 UMR - ALL PLANS UMR - ALL PLANS 15.31 70 999999999 13.24 21.21 percent of total billed charges "LIDOCAINE 1%-EPI 1:100,000" 48260677_1 CDM 0250 RC 00409-3178-01 NDC inpatient 1 UN 21.87 14.22 SIHO - ALL PLANS SIHO - ALL PLANS 19.68 90 999999999 13.24 21.21 percent of total billed charges "LIDOCAINE 1%-EPI 1:100,000" 48260677_1 CDM 0250 RC 00409-3178-01 NDC inpatient 1 UN 21.87 14.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.24 21.21 "LIDOCAINE 1%-EPI 1:100,000" 48260677_1 CDM 0250 RC 00409-3178-01 NDC inpatient 1 UN 21.87 14.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.24 60.55 999999999 13.24 21.21 percent of total billed charges "LIDOCAINE 1%-EPI 1:100,000" 48260677_1 CDM 0250 RC 00409-3178-01 NDC inpatient 1 UN 21.87 14.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.24 21.21 "LIDOCAINE 1%-EPI 1:100,000" 48260677_1 CDM 0250 RC 00409-3178-01 NDC inpatient 1 UN 21.87 14.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.24 21.21 "LIDOCAINE 1%-EPI 1:100,000" 48260677_1 CDM 0250 RC 00409-3178-01 NDC inpatient 1 UN 21.87 14.22 ANTHEM HMO ANTHEM HMO 999999999 13.24 21.21 "LIDOCAINE 1%-EPI 1:100,000" 48260677_1 CDM 0250 RC 00409-3178-01 NDC inpatient 1 UN 21.87 14.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.78 67.6 999999999 13.24 21.21 percent of total billed charges "LIDOCAINE 1%-EPI 1:100,000" 48260677_1 CDM 0250 RC 00409-3178-01 NDC inpatient 1 UN 21.87 14.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.24 21.21 "BREVIBLOC 2,500 MG/250 ML BAG" 48260695_1 CDM 0250 RC 10019-0055-61 NDC inpatient 1 UN 709.59 461.23 AETNA AETNA 560.58 79 999999999 429.66 688.3 percent of total billed charges "BREVIBLOC 2,500 MG/250 ML BAG" 48260695_1 CDM 0250 RC 10019-0055-61 NDC inpatient 1 UN 709.59 461.23 SELF PAY DISCOUNT SELF PAY DISCOUNT 461.23 65 999999999 429.66 688.3 percent of total billed charges "BREVIBLOC 2,500 MG/250 ML BAG" 48260695_1 CDM 0250 RC 10019-0055-61 NDC inpatient 1 UN 709.59 461.23 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 688.3 97 999999999 429.66 688.3 percent of total billed charges "BREVIBLOC 2,500 MG/250 ML BAG" 48260695_1 CDM 0250 RC 10019-0055-61 NDC inpatient 1 UN 709.59 461.23 HUMANA - ALL PLANS HUMANA - ALL PLANS 553.48 78 999999999 429.66 688.3 percent of total billed charges "BREVIBLOC 2,500 MG/250 ML BAG" 48260695_1 CDM 0250 RC 10019-0055-61 NDC inpatient 1 UN 709.59 461.23 ENCORE - ALL PLANS ENCORE - ALL PLANS 489.62 69 999999999 429.66 688.3 percent of total billed charges "BREVIBLOC 2,500 MG/250 ML BAG" 48260695_1 CDM 0250 RC 10019-0055-61 NDC inpatient 1 UN 709.59 461.23 UMR - ALL PLANS UMR - ALL PLANS 496.71 70 999999999 429.66 688.3 percent of total billed charges "BREVIBLOC 2,500 MG/250 ML BAG" 48260695_1 CDM 0250 RC 10019-0055-61 NDC inpatient 1 UN 709.59 461.23 SIHO - ALL PLANS SIHO - ALL PLANS 638.63 90 999999999 429.66 688.3 percent of total billed charges "BREVIBLOC 2,500 MG/250 ML BAG" 48260695_1 CDM 0250 RC 10019-0055-61 NDC inpatient 1 UN 709.59 461.23 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 429.66 688.3 "BREVIBLOC 2,500 MG/250 ML BAG" 48260695_1 CDM 0250 RC 10019-0055-61 NDC inpatient 1 UN 709.59 461.23 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 429.66 60.55 999999999 429.66 688.3 percent of total billed charges "BREVIBLOC 2,500 MG/250 ML BAG" 48260695_1 CDM 0250 RC 10019-0055-61 NDC inpatient 1 UN 709.59 461.23 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 429.66 688.3 "BREVIBLOC 2,500 MG/250 ML BAG" 48260695_1 CDM 0250 RC 10019-0055-61 NDC inpatient 1 UN 709.59 461.23 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 429.66 688.3 "BREVIBLOC 2,500 MG/250 ML BAG" 48260695_1 CDM 0250 RC 10019-0055-61 NDC inpatient 1 UN 709.59 461.23 ANTHEM HMO ANTHEM HMO 999999999 429.66 688.3 "BREVIBLOC 2,500 MG/250 ML BAG" 48260695_1 CDM 0250 RC 10019-0055-61 NDC inpatient 1 UN 709.59 461.23 CIGNA - ALL PLANS CIGNA - ALL PLANS 479.68 67.6 999999999 429.66 688.3 percent of total billed charges "BREVIBLOC 2,500 MG/250 ML BAG" 48260695_1 CDM 0250 RC 10019-0055-61 NDC inpatient 1 UN 709.59 461.23 UHC - ALL PLANS UHC - ALL PLANS 999999999 429.66 688.3 "ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIES" 48260703_1 CDM 0278 RC 00052-0272-01 NDC J7307 HCPCS inpatient 1 UN 3184.96 2070.22 AETNA AETNA 2516.12 79 999999999 1928.49 3089.41 percent of total billed charges "ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIES" 48260703_1 CDM 0278 RC 00052-0272-01 NDC J7307 HCPCS inpatient 1 UN 3184.96 2070.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 2070.22 65 999999999 1928.49 3089.41 percent of total billed charges "ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIES" 48260703_1 CDM 0278 RC 00052-0272-01 NDC J7307 HCPCS inpatient 1 UN 3184.96 2070.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3089.41 97 999999999 1928.49 3089.41 percent of total billed charges "ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIES" 48260703_1 CDM 0278 RC 00052-0272-01 NDC J7307 HCPCS inpatient 1 UN 3184.96 2070.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 2484.27 78 999999999 1928.49 3089.41 percent of total billed charges "ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIES" 48260703_1 CDM 0278 RC 00052-0272-01 NDC J7307 HCPCS inpatient 1 UN 3184.96 2070.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 2197.62 69 999999999 1928.49 3089.41 percent of total billed charges "ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIES" 48260703_1 CDM 0278 RC 00052-0272-01 NDC J7307 HCPCS inpatient 1 UN 3184.96 2070.22 UMR - ALL PLANS UMR - ALL PLANS 2229.47 70 999999999 1928.49 3089.41 percent of total billed charges "ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIES" 48260703_1 CDM 0278 RC 00052-0272-01 NDC J7307 HCPCS inpatient 1 UN 3184.96 2070.22 SIHO - ALL PLANS SIHO - ALL PLANS 2866.46 90 999999999 1928.49 3089.41 percent of total billed charges "ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIES" 48260703_1 CDM 0278 RC 00052-0272-01 NDC J7307 HCPCS inpatient 1 UN 3184.96 2070.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1928.49 3089.41 "ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIES" 48260703_1 CDM 0278 RC 00052-0272-01 NDC J7307 HCPCS inpatient 1 UN 3184.96 2070.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1928.49 60.55 999999999 1928.49 3089.41 percent of total billed charges "ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIES" 48260703_1 CDM 0278 RC 00052-0272-01 NDC J7307 HCPCS inpatient 1 UN 3184.96 2070.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1928.49 3089.41 "ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIES" 48260703_1 CDM 0278 RC 00052-0272-01 NDC J7307 HCPCS inpatient 1 UN 3184.96 2070.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1928.49 3089.41 "ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIES" 48260703_1 CDM 0278 RC 00052-0272-01 NDC J7307 HCPCS inpatient 1 UN 3184.96 2070.22 ANTHEM HMO ANTHEM HMO 999999999 1928.49 3089.41 "ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIES" 48260703_1 CDM 0278 RC 00052-0272-01 NDC J7307 HCPCS inpatient 1 UN 3184.96 2070.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 2153.03 67.6 999999999 1928.49 3089.41 percent of total billed charges "ETONOGESTREL (CONTRACEPTIVE) IMPLANT SYSTEM, INCLUDING IMPLANT AND SUPPLIES" 48260703_1 CDM 0278 RC 00052-0272-01 NDC J7307 HCPCS inpatient 1 UN 3184.96 2070.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 1928.49 3089.41 FAMOTIDINE 20 MG/2 ML VIAL 48260707_1 CDM 0250 RC 63323-0739-12 NDC inpatient 1 UN 19.96 12.97 AETNA AETNA 15.77 79 999999999 12.09 19.36 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 48260707_1 CDM 0250 RC 63323-0739-12 NDC inpatient 1 UN 19.96 12.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.97 65 999999999 12.09 19.36 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 48260707_1 CDM 0250 RC 63323-0739-12 NDC inpatient 1 UN 19.96 12.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.36 97 999999999 12.09 19.36 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 48260707_1 CDM 0250 RC 63323-0739-12 NDC inpatient 1 UN 19.96 12.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.57 78 999999999 12.09 19.36 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 48260707_1 CDM 0250 RC 63323-0739-12 NDC inpatient 1 UN 19.96 12.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.77 69 999999999 12.09 19.36 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 48260707_1 CDM 0250 RC 63323-0739-12 NDC inpatient 1 UN 19.96 12.97 UMR - ALL PLANS UMR - ALL PLANS 13.97 70 999999999 12.09 19.36 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 48260707_1 CDM 0250 RC 63323-0739-12 NDC inpatient 1 UN 19.96 12.97 SIHO - ALL PLANS SIHO - ALL PLANS 17.96 90 999999999 12.09 19.36 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 48260707_1 CDM 0250 RC 63323-0739-12 NDC inpatient 1 UN 19.96 12.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.09 19.36 FAMOTIDINE 20 MG/2 ML VIAL 48260707_1 CDM 0250 RC 63323-0739-12 NDC inpatient 1 UN 19.96 12.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.09 60.55 999999999 12.09 19.36 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 48260707_1 CDM 0250 RC 63323-0739-12 NDC inpatient 1 UN 19.96 12.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.09 19.36 FAMOTIDINE 20 MG/2 ML VIAL 48260707_1 CDM 0250 RC 63323-0739-12 NDC inpatient 1 UN 19.96 12.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.09 19.36 FAMOTIDINE 20 MG/2 ML VIAL 48260707_1 CDM 0250 RC 63323-0739-12 NDC inpatient 1 UN 19.96 12.97 ANTHEM HMO ANTHEM HMO 999999999 12.09 19.36 FAMOTIDINE 20 MG/2 ML VIAL 48260707_1 CDM 0250 RC 63323-0739-12 NDC inpatient 1 UN 19.96 12.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.49 67.6 999999999 12.09 19.36 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 48260707_1 CDM 0250 RC 63323-0739-12 NDC inpatient 1 UN 19.96 12.97 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.09 19.36 ULORIC 40 MG TABLET 48260711_1 CDM 0250 RC 64764-0918-30 NDC inpatient 1 UN 48.99 31.84 AETNA AETNA 38.7 79 999999999 29.66 47.52 percent of total billed charges ULORIC 40 MG TABLET 48260711_1 CDM 0250 RC 64764-0918-30 NDC inpatient 1 UN 48.99 31.84 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.84 65 999999999 29.66 47.52 percent of total billed charges ULORIC 40 MG TABLET 48260711_1 CDM 0250 RC 64764-0918-30 NDC inpatient 1 UN 48.99 31.84 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 47.52 97 999999999 29.66 47.52 percent of total billed charges ULORIC 40 MG TABLET 48260711_1 CDM 0250 RC 64764-0918-30 NDC inpatient 1 UN 48.99 31.84 HUMANA - ALL PLANS HUMANA - ALL PLANS 38.21 78 999999999 29.66 47.52 percent of total billed charges ULORIC 40 MG TABLET 48260711_1 CDM 0250 RC 64764-0918-30 NDC inpatient 1 UN 48.99 31.84 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.8 69 999999999 29.66 47.52 percent of total billed charges ULORIC 40 MG TABLET 48260711_1 CDM 0250 RC 64764-0918-30 NDC inpatient 1 UN 48.99 31.84 UMR - ALL PLANS UMR - ALL PLANS 34.29 70 999999999 29.66 47.52 percent of total billed charges ULORIC 40 MG TABLET 48260711_1 CDM 0250 RC 64764-0918-30 NDC inpatient 1 UN 48.99 31.84 SIHO - ALL PLANS SIHO - ALL PLANS 44.09 90 999999999 29.66 47.52 percent of total billed charges ULORIC 40 MG TABLET 48260711_1 CDM 0250 RC 64764-0918-30 NDC inpatient 1 UN 48.99 31.84 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.66 47.52 ULORIC 40 MG TABLET 48260711_1 CDM 0250 RC 64764-0918-30 NDC inpatient 1 UN 48.99 31.84 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.66 60.55 999999999 29.66 47.52 percent of total billed charges ULORIC 40 MG TABLET 48260711_1 CDM 0250 RC 64764-0918-30 NDC inpatient 1 UN 48.99 31.84 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.66 47.52 ULORIC 40 MG TABLET 48260711_1 CDM 0250 RC 64764-0918-30 NDC inpatient 1 UN 48.99 31.84 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.66 47.52 ULORIC 40 MG TABLET 48260711_1 CDM 0250 RC 64764-0918-30 NDC inpatient 1 UN 48.99 31.84 ANTHEM HMO ANTHEM HMO 999999999 29.66 47.52 ULORIC 40 MG TABLET 48260711_1 CDM 0250 RC 64764-0918-30 NDC inpatient 1 UN 48.99 31.84 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.12 67.6 999999999 29.66 47.52 percent of total billed charges ULORIC 40 MG TABLET 48260711_1 CDM 0250 RC 64764-0918-30 NDC inpatient 1 UN 48.99 31.84 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.66 47.52 "INJECTION, FENTANYL CITRATE, 0.1 MG" 48260714_1 CDM 0250 RC 00641-6027-25 NDC J3010 HCPCS inpatient 1 UN 20.07 13.05 AETNA AETNA 15.86 79 999999999 12.15 19.47 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48260714_1 CDM 0250 RC 00641-6027-25 NDC J3010 HCPCS inpatient 1 UN 20.07 13.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 13.05 65 999999999 12.15 19.47 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48260714_1 CDM 0250 RC 00641-6027-25 NDC J3010 HCPCS inpatient 1 UN 20.07 13.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.47 97 999999999 12.15 19.47 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48260714_1 CDM 0250 RC 00641-6027-25 NDC J3010 HCPCS inpatient 1 UN 20.07 13.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.65 78 999999999 12.15 19.47 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48260714_1 CDM 0250 RC 00641-6027-25 NDC J3010 HCPCS inpatient 1 UN 20.07 13.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.85 69 999999999 12.15 19.47 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48260714_1 CDM 0250 RC 00641-6027-25 NDC J3010 HCPCS inpatient 1 UN 20.07 13.05 UMR - ALL PLANS UMR - ALL PLANS 14.05 70 999999999 12.15 19.47 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48260714_1 CDM 0250 RC 00641-6027-25 NDC J3010 HCPCS inpatient 1 UN 20.07 13.05 SIHO - ALL PLANS SIHO - ALL PLANS 18.06 90 999999999 12.15 19.47 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48260714_1 CDM 0250 RC 00641-6027-25 NDC J3010 HCPCS inpatient 1 UN 20.07 13.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.15 19.47 "INJECTION, FENTANYL CITRATE, 0.1 MG" 48260714_1 CDM 0250 RC 00641-6027-25 NDC J3010 HCPCS inpatient 1 UN 20.07 13.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.15 60.55 999999999 12.15 19.47 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48260714_1 CDM 0250 RC 00641-6027-25 NDC J3010 HCPCS inpatient 1 UN 20.07 13.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.15 19.47 "INJECTION, FENTANYL CITRATE, 0.1 MG" 48260714_1 CDM 0250 RC 00641-6027-25 NDC J3010 HCPCS inpatient 1 UN 20.07 13.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.15 19.47 "INJECTION, FENTANYL CITRATE, 0.1 MG" 48260714_1 CDM 0250 RC 00641-6027-25 NDC J3010 HCPCS inpatient 1 UN 20.07 13.05 ANTHEM HMO ANTHEM HMO 999999999 12.15 19.47 "INJECTION, FENTANYL CITRATE, 0.1 MG" 48260714_1 CDM 0250 RC 00641-6027-25 NDC J3010 HCPCS inpatient 1 UN 20.07 13.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.57 67.6 999999999 12.15 19.47 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48260714_1 CDM 0250 RC 00641-6027-25 NDC J3010 HCPCS inpatient 1 UN 20.07 13.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.15 19.47 00781-7240-55 - fentaNYL 12 mcg/hr TD film ER [JOHN] 48260717_1 CDM 0250 RC 00781-7240-55 NDC inpatient 1 UN 55.99 36.39 AETNA AETNA 44.23 79 999999999 33.9 54.31 percent of total billed charges 00781-7240-55 - fentaNYL 12 mcg/hr TD film ER [JOHN] 48260717_1 CDM 0250 RC 00781-7240-55 NDC inpatient 1 UN 55.99 36.39 SELF PAY DISCOUNT SELF PAY DISCOUNT 36.39 65 999999999 33.9 54.31 percent of total billed charges 00781-7240-55 - fentaNYL 12 mcg/hr TD film ER [JOHN] 48260717_1 CDM 0250 RC 00781-7240-55 NDC inpatient 1 UN 55.99 36.39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 54.31 97 999999999 33.9 54.31 percent of total billed charges 00781-7240-55 - fentaNYL 12 mcg/hr TD film ER [JOHN] 48260717_1 CDM 0250 RC 00781-7240-55 NDC inpatient 1 UN 55.99 36.39 HUMANA - ALL PLANS HUMANA - ALL PLANS 43.67 78 999999999 33.9 54.31 percent of total billed charges 00781-7240-55 - fentaNYL 12 mcg/hr TD film ER [JOHN] 48260717_1 CDM 0250 RC 00781-7240-55 NDC inpatient 1 UN 55.99 36.39 ENCORE - ALL PLANS ENCORE - ALL PLANS 38.63 69 999999999 33.9 54.31 percent of total billed charges 00781-7240-55 - fentaNYL 12 mcg/hr TD film ER [JOHN] 48260717_1 CDM 0250 RC 00781-7240-55 NDC inpatient 1 UN 55.99 36.39 UMR - ALL PLANS UMR - ALL PLANS 39.19 70 999999999 33.9 54.31 percent of total billed charges 00781-7240-55 - fentaNYL 12 mcg/hr TD film ER [JOHN] 48260717_1 CDM 0250 RC 00781-7240-55 NDC inpatient 1 UN 55.99 36.39 SIHO - ALL PLANS SIHO - ALL PLANS 50.39 90 999999999 33.9 54.31 percent of total billed charges 00781-7240-55 - fentaNYL 12 mcg/hr TD film ER [JOHN] 48260717_1 CDM 0250 RC 00781-7240-55 NDC inpatient 1 UN 55.99 36.39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 33.9 54.31 00781-7240-55 - fentaNYL 12 mcg/hr TD film ER [JOHN] 48260717_1 CDM 0250 RC 00781-7240-55 NDC inpatient 1 UN 55.99 36.39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33.9 60.55 999999999 33.9 54.31 percent of total billed charges 00781-7240-55 - fentaNYL 12 mcg/hr TD film ER [JOHN] 48260717_1 CDM 0250 RC 00781-7240-55 NDC inpatient 1 UN 55.99 36.39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 33.9 54.31 00781-7240-55 - fentaNYL 12 mcg/hr TD film ER [JOHN] 48260717_1 CDM 0250 RC 00781-7240-55 NDC inpatient 1 UN 55.99 36.39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 33.9 54.31 00781-7240-55 - fentaNYL 12 mcg/hr TD film ER [JOHN] 48260717_1 CDM 0250 RC 00781-7240-55 NDC inpatient 1 UN 55.99 36.39 ANTHEM HMO ANTHEM HMO 999999999 33.9 54.31 00781-7240-55 - fentaNYL 12 mcg/hr TD film ER [JOHN] 48260717_1 CDM 0250 RC 00781-7240-55 NDC inpatient 1 UN 55.99 36.39 CIGNA - ALL PLANS CIGNA - ALL PLANS 37.85 67.6 999999999 33.9 54.31 percent of total billed charges 00781-7240-55 - fentaNYL 12 mcg/hr TD film ER [JOHN] 48260717_1 CDM 0250 RC 00781-7240-55 NDC inpatient 1 UN 55.99 36.39 UHC - ALL PLANS UHC - ALL PLANS 999999999 33.9 54.31 FERROUS SULF 300 MG/5 ML CUP 48260720_1 CDM 0250 RC 00121-0530-05 NDC inpatient 1 UN 11.74 7.63 AETNA AETNA 9.27 79 999999999 7.11 11.39 percent of total billed charges FERROUS SULF 300 MG/5 ML CUP 48260720_1 CDM 0250 RC 00121-0530-05 NDC inpatient 1 UN 11.74 7.63 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.63 65 999999999 7.11 11.39 percent of total billed charges FERROUS SULF 300 MG/5 ML CUP 48260720_1 CDM 0250 RC 00121-0530-05 NDC inpatient 1 UN 11.74 7.63 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11.39 97 999999999 7.11 11.39 percent of total billed charges FERROUS SULF 300 MG/5 ML CUP 48260720_1 CDM 0250 RC 00121-0530-05 NDC inpatient 1 UN 11.74 7.63 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.16 78 999999999 7.11 11.39 percent of total billed charges FERROUS SULF 300 MG/5 ML CUP 48260720_1 CDM 0250 RC 00121-0530-05 NDC inpatient 1 UN 11.74 7.63 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.1 69 999999999 7.11 11.39 percent of total billed charges FERROUS SULF 300 MG/5 ML CUP 48260720_1 CDM 0250 RC 00121-0530-05 NDC inpatient 1 UN 11.74 7.63 UMR - ALL PLANS UMR - ALL PLANS 8.22 70 999999999 7.11 11.39 percent of total billed charges FERROUS SULF 300 MG/5 ML CUP 48260720_1 CDM 0250 RC 00121-0530-05 NDC inpatient 1 UN 11.74 7.63 SIHO - ALL PLANS SIHO - ALL PLANS 10.57 90 999999999 7.11 11.39 percent of total billed charges FERROUS SULF 300 MG/5 ML CUP 48260720_1 CDM 0250 RC 00121-0530-05 NDC inpatient 1 UN 11.74 7.63 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.11 11.39 FERROUS SULF 300 MG/5 ML CUP 48260720_1 CDM 0250 RC 00121-0530-05 NDC inpatient 1 UN 11.74 7.63 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.11 60.55 999999999 7.11 11.39 percent of total billed charges FERROUS SULF 300 MG/5 ML CUP 48260720_1 CDM 0250 RC 00121-0530-05 NDC inpatient 1 UN 11.74 7.63 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.11 11.39 FERROUS SULF 300 MG/5 ML CUP 48260720_1 CDM 0250 RC 00121-0530-05 NDC inpatient 1 UN 11.74 7.63 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.11 11.39 FERROUS SULF 300 MG/5 ML CUP 48260720_1 CDM 0250 RC 00121-0530-05 NDC inpatient 1 UN 11.74 7.63 ANTHEM HMO ANTHEM HMO 999999999 7.11 11.39 FERROUS SULF 300 MG/5 ML CUP 48260720_1 CDM 0250 RC 00121-0530-05 NDC inpatient 1 UN 11.74 7.63 CIGNA - ALL PLANS CIGNA - ALL PLANS 7.94 67.6 999999999 7.11 11.39 percent of total billed charges FERROUS SULF 300 MG/5 ML CUP 48260720_1 CDM 0250 RC 00121-0530-05 NDC inpatient 1 UN 11.74 7.63 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.11 11.39 "INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE)" 48260722_1 CDM 0250 RC 59338-0775-01 NDC Q0138 HCPCS inpatient 510 UN 4516.09 2935.46 AETNA AETNA 3567.71 79 999999999 2734.49 4380.61 percent of total billed charges "INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE)" 48260722_1 CDM 0250 RC 59338-0775-01 NDC Q0138 HCPCS inpatient 510 UN 4516.09 2935.46 SELF PAY DISCOUNT SELF PAY DISCOUNT 2935.46 65 999999999 2734.49 4380.61 percent of total billed charges "INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE)" 48260722_1 CDM 0250 RC 59338-0775-01 NDC Q0138 HCPCS inpatient 510 UN 4516.09 2935.46 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4380.61 97 999999999 2734.49 4380.61 percent of total billed charges "INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE)" 48260722_1 CDM 0250 RC 59338-0775-01 NDC Q0138 HCPCS inpatient 510 UN 4516.09 2935.46 HUMANA - ALL PLANS HUMANA - ALL PLANS 3522.55 78 999999999 2734.49 4380.61 percent of total billed charges "INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE)" 48260722_1 CDM 0250 RC 59338-0775-01 NDC Q0138 HCPCS inpatient 510 UN 4516.09 2935.46 ENCORE - ALL PLANS ENCORE - ALL PLANS 3116.1 69 999999999 2734.49 4380.61 percent of total billed charges "INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE)" 48260722_1 CDM 0250 RC 59338-0775-01 NDC Q0138 HCPCS inpatient 510 UN 4516.09 2935.46 UMR - ALL PLANS UMR - ALL PLANS 3161.26 70 999999999 2734.49 4380.61 percent of total billed charges "INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE)" 48260722_1 CDM 0250 RC 59338-0775-01 NDC Q0138 HCPCS inpatient 510 UN 4516.09 2935.46 SIHO - ALL PLANS SIHO - ALL PLANS 4064.48 90 999999999 2734.49 4380.61 percent of total billed charges "INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE)" 48260722_1 CDM 0250 RC 59338-0775-01 NDC Q0138 HCPCS inpatient 510 UN 4516.09 2935.46 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2734.49 4380.61 "INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE)" 48260722_1 CDM 0250 RC 59338-0775-01 NDC Q0138 HCPCS inpatient 510 UN 4516.09 2935.46 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2734.49 60.55 999999999 2734.49 4380.61 percent of total billed charges "INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE)" 48260722_1 CDM 0250 RC 59338-0775-01 NDC Q0138 HCPCS inpatient 510 UN 4516.09 2935.46 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2734.49 4380.61 "INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE)" 48260722_1 CDM 0250 RC 59338-0775-01 NDC Q0138 HCPCS inpatient 510 UN 4516.09 2935.46 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2734.49 4380.61 "INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE)" 48260722_1 CDM 0250 RC 59338-0775-01 NDC Q0138 HCPCS inpatient 510 UN 4516.09 2935.46 ANTHEM HMO ANTHEM HMO 999999999 2734.49 4380.61 "INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE)" 48260722_1 CDM 0250 RC 59338-0775-01 NDC Q0138 HCPCS inpatient 510 UN 4516.09 2935.46 CIGNA - ALL PLANS CIGNA - ALL PLANS 3052.88 67.6 999999999 2734.49 4380.61 percent of total billed charges "INJECTION, FERUMOXYTOL, FOR TREATMENT OF IRON DEFICIENCY ANEMIA, 1 MG (NON-ESRD USE)" 48260722_1 CDM 0250 RC 59338-0775-01 NDC Q0138 HCPCS inpatient 510 UN 4516.09 2935.46 UHC - ALL PLANS UHC - ALL PLANS 999999999 2734.49 4380.61 DIFICID 200 MG TABLET 48260723_1 CDM 0250 RC 52015-0080-01 NDC inpatient 1 UN 860.64 559.42 AETNA AETNA 679.91 79 999999999 521.12 834.82 percent of total billed charges DIFICID 200 MG TABLET 48260723_1 CDM 0250 RC 52015-0080-01 NDC inpatient 1 UN 860.64 559.42 SELF PAY DISCOUNT SELF PAY DISCOUNT 559.42 65 999999999 521.12 834.82 percent of total billed charges DIFICID 200 MG TABLET 48260723_1 CDM 0250 RC 52015-0080-01 NDC inpatient 1 UN 860.64 559.42 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 834.82 97 999999999 521.12 834.82 percent of total billed charges DIFICID 200 MG TABLET 48260723_1 CDM 0250 RC 52015-0080-01 NDC inpatient 1 UN 860.64 559.42 HUMANA - ALL PLANS HUMANA - ALL PLANS 671.3 78 999999999 521.12 834.82 percent of total billed charges DIFICID 200 MG TABLET 48260723_1 CDM 0250 RC 52015-0080-01 NDC inpatient 1 UN 860.64 559.42 ENCORE - ALL PLANS ENCORE - ALL PLANS 593.84 69 999999999 521.12 834.82 percent of total billed charges DIFICID 200 MG TABLET 48260723_1 CDM 0250 RC 52015-0080-01 NDC inpatient 1 UN 860.64 559.42 UMR - ALL PLANS UMR - ALL PLANS 602.45 70 999999999 521.12 834.82 percent of total billed charges DIFICID 200 MG TABLET 48260723_1 CDM 0250 RC 52015-0080-01 NDC inpatient 1 UN 860.64 559.42 SIHO - ALL PLANS SIHO - ALL PLANS 774.58 90 999999999 521.12 834.82 percent of total billed charges DIFICID 200 MG TABLET 48260723_1 CDM 0250 RC 52015-0080-01 NDC inpatient 1 UN 860.64 559.42 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 521.12 834.82 DIFICID 200 MG TABLET 48260723_1 CDM 0250 RC 52015-0080-01 NDC inpatient 1 UN 860.64 559.42 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 521.12 60.55 999999999 521.12 834.82 percent of total billed charges DIFICID 200 MG TABLET 48260723_1 CDM 0250 RC 52015-0080-01 NDC inpatient 1 UN 860.64 559.42 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 521.12 834.82 DIFICID 200 MG TABLET 48260723_1 CDM 0250 RC 52015-0080-01 NDC inpatient 1 UN 860.64 559.42 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 521.12 834.82 DIFICID 200 MG TABLET 48260723_1 CDM 0250 RC 52015-0080-01 NDC inpatient 1 UN 860.64 559.42 ANTHEM HMO ANTHEM HMO 999999999 521.12 834.82 DIFICID 200 MG TABLET 48260723_1 CDM 0250 RC 52015-0080-01 NDC inpatient 1 UN 860.64 559.42 CIGNA - ALL PLANS CIGNA - ALL PLANS 581.79 67.6 999999999 521.12 834.82 percent of total billed charges DIFICID 200 MG TABLET 48260723_1 CDM 0250 RC 52015-0080-01 NDC inpatient 1 UN 860.64 559.42 UHC - ALL PLANS UHC - ALL PLANS 999999999 521.12 834.82 "INJECTION, FILGRASTIM (G-CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM" 48260724_1 CDM 0250 RC 55513-0530-10 NDC J1442 HCPCS inpatient 300 UN 1567.86 1019.11 AETNA AETNA 1238.61 79 999999999 949.34 1520.82 percent of total billed charges "INJECTION, FILGRASTIM (G-CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM" 48260724_1 CDM 0250 RC 55513-0530-10 NDC J1442 HCPCS inpatient 300 UN 1567.86 1019.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 1019.11 65 999999999 949.34 1520.82 percent of total billed charges "INJECTION, FILGRASTIM (G-CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM" 48260724_1 CDM 0250 RC 55513-0530-10 NDC J1442 HCPCS inpatient 300 UN 1567.86 1019.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1520.82 97 999999999 949.34 1520.82 percent of total billed charges "INJECTION, FILGRASTIM (G-CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM" 48260724_1 CDM 0250 RC 55513-0530-10 NDC J1442 HCPCS inpatient 300 UN 1567.86 1019.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 1222.93 78 999999999 949.34 1520.82 percent of total billed charges "INJECTION, FILGRASTIM (G-CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM" 48260724_1 CDM 0250 RC 55513-0530-10 NDC J1442 HCPCS inpatient 300 UN 1567.86 1019.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 1081.82 69 999999999 949.34 1520.82 percent of total billed charges "INJECTION, FILGRASTIM (G-CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM" 48260724_1 CDM 0250 RC 55513-0530-10 NDC J1442 HCPCS inpatient 300 UN 1567.86 1019.11 UMR - ALL PLANS UMR - ALL PLANS 1097.5 70 999999999 949.34 1520.82 percent of total billed charges "INJECTION, FILGRASTIM (G-CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM" 48260724_1 CDM 0250 RC 55513-0530-10 NDC J1442 HCPCS inpatient 300 UN 1567.86 1019.11 SIHO - ALL PLANS SIHO - ALL PLANS 1411.07 90 999999999 949.34 1520.82 percent of total billed charges "INJECTION, FILGRASTIM (G-CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM" 48260724_1 CDM 0250 RC 55513-0530-10 NDC J1442 HCPCS inpatient 300 UN 1567.86 1019.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 949.34 1520.82 "INJECTION, FILGRASTIM (G-CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM" 48260724_1 CDM 0250 RC 55513-0530-10 NDC J1442 HCPCS inpatient 300 UN 1567.86 1019.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 949.34 60.55 999999999 949.34 1520.82 percent of total billed charges "INJECTION, FILGRASTIM (G-CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM" 48260724_1 CDM 0250 RC 55513-0530-10 NDC J1442 HCPCS inpatient 300 UN 1567.86 1019.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 949.34 1520.82 "INJECTION, FILGRASTIM (G-CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM" 48260724_1 CDM 0250 RC 55513-0530-10 NDC J1442 HCPCS inpatient 300 UN 1567.86 1019.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 949.34 1520.82 "INJECTION, FILGRASTIM (G-CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM" 48260724_1 CDM 0250 RC 55513-0530-10 NDC J1442 HCPCS inpatient 300 UN 1567.86 1019.11 ANTHEM HMO ANTHEM HMO 999999999 949.34 1520.82 "INJECTION, FILGRASTIM (G-CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM" 48260724_1 CDM 0250 RC 55513-0530-10 NDC J1442 HCPCS inpatient 300 UN 1567.86 1019.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 1059.87 67.6 999999999 949.34 1520.82 percent of total billed charges "INJECTION, FILGRASTIM (G-CSF), EXCLUDES BIOSIMILARS, 1 MICROGRAM" 48260724_1 CDM 0250 RC 55513-0530-10 NDC J1442 HCPCS inpatient 300 UN 1567.86 1019.11 UHC - ALL PLANS UHC - ALL PLANS 999999999 949.34 1520.82 FLECAINIDE ACETATE 100 MG TAB 48260728_1 CDM 0250 RC 00054-0011-21 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges FLECAINIDE ACETATE 100 MG TAB 48260728_1 CDM 0250 RC 00054-0011-21 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges FLECAINIDE ACETATE 100 MG TAB 48260728_1 CDM 0250 RC 00054-0011-21 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges FLECAINIDE ACETATE 100 MG TAB 48260728_1 CDM 0250 RC 00054-0011-21 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges FLECAINIDE ACETATE 100 MG TAB 48260728_1 CDM 0250 RC 00054-0011-21 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges FLECAINIDE ACETATE 100 MG TAB 48260728_1 CDM 0250 RC 00054-0011-21 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges FLECAINIDE ACETATE 100 MG TAB 48260728_1 CDM 0250 RC 00054-0011-21 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges FLECAINIDE ACETATE 100 MG TAB 48260728_1 CDM 0250 RC 00054-0011-21 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 FLECAINIDE ACETATE 100 MG TAB 48260728_1 CDM 0250 RC 00054-0011-21 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges FLECAINIDE ACETATE 100 MG TAB 48260728_1 CDM 0250 RC 00054-0011-21 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 FLECAINIDE ACETATE 100 MG TAB 48260728_1 CDM 0250 RC 00054-0011-21 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 FLECAINIDE ACETATE 100 MG TAB 48260728_1 CDM 0250 RC 00054-0011-21 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 FLECAINIDE ACETATE 100 MG TAB 48260728_1 CDM 0250 RC 00054-0011-21 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges FLECAINIDE ACETATE 100 MG TAB 48260728_1 CDM 0250 RC 00054-0011-21 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 FUL-GLO 1 MG OPTH STRIP 48260736_1 CDM 0250 RC 17478-0404-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges FUL-GLO 1 MG OPTH STRIP 48260736_1 CDM 0250 RC 17478-0404-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges FUL-GLO 1 MG OPTH STRIP 48260736_1 CDM 0250 RC 17478-0404-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges FUL-GLO 1 MG OPTH STRIP 48260736_1 CDM 0250 RC 17478-0404-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges FUL-GLO 1 MG OPTH STRIP 48260736_1 CDM 0250 RC 17478-0404-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges FUL-GLO 1 MG OPTH STRIP 48260736_1 CDM 0250 RC 17478-0404-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges FUL-GLO 1 MG OPTH STRIP 48260736_1 CDM 0250 RC 17478-0404-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges FUL-GLO 1 MG OPTH STRIP 48260736_1 CDM 0250 RC 17478-0404-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 FUL-GLO 1 MG OPTH STRIP 48260736_1 CDM 0250 RC 17478-0404-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges FUL-GLO 1 MG OPTH STRIP 48260736_1 CDM 0250 RC 17478-0404-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 FUL-GLO 1 MG OPTH STRIP 48260736_1 CDM 0250 RC 17478-0404-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 FUL-GLO 1 MG OPTH STRIP 48260736_1 CDM 0250 RC 17478-0404-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 FUL-GLO 1 MG OPTH STRIP 48260736_1 CDM 0250 RC 17478-0404-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges FUL-GLO 1 MG OPTH STRIP 48260736_1 CDM 0250 RC 17478-0404-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, FLUOROURACIL, 500 MG" 48260738_1 CDM 0636 RC 63323-0117-20 NDC J9190 HCPCS inpatient 2 UN 66.09 42.96 AETNA AETNA 52.21 79 999999999 40.02 64.11 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 48260738_1 CDM 0636 RC 63323-0117-20 NDC J9190 HCPCS inpatient 2 UN 66.09 42.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.96 65 999999999 40.02 64.11 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 48260738_1 CDM 0636 RC 63323-0117-20 NDC J9190 HCPCS inpatient 2 UN 66.09 42.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.11 97 999999999 40.02 64.11 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 48260738_1 CDM 0636 RC 63323-0117-20 NDC J9190 HCPCS inpatient 2 UN 66.09 42.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.55 78 999999999 40.02 64.11 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 48260738_1 CDM 0636 RC 63323-0117-20 NDC J9190 HCPCS inpatient 2 UN 66.09 42.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.6 69 999999999 40.02 64.11 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 48260738_1 CDM 0636 RC 63323-0117-20 NDC J9190 HCPCS inpatient 2 UN 66.09 42.96 UMR - ALL PLANS UMR - ALL PLANS 46.26 70 999999999 40.02 64.11 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 48260738_1 CDM 0636 RC 63323-0117-20 NDC J9190 HCPCS inpatient 2 UN 66.09 42.96 SIHO - ALL PLANS SIHO - ALL PLANS 59.48 90 999999999 40.02 64.11 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 48260738_1 CDM 0636 RC 63323-0117-20 NDC J9190 HCPCS inpatient 2 UN 66.09 42.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 40.02 64.11 "INJECTION, FLUOROURACIL, 500 MG" 48260738_1 CDM 0636 RC 63323-0117-20 NDC J9190 HCPCS inpatient 2 UN 66.09 42.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 40.02 60.55 999999999 40.02 64.11 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 48260738_1 CDM 0636 RC 63323-0117-20 NDC J9190 HCPCS inpatient 2 UN 66.09 42.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 40.02 64.11 "INJECTION, FLUOROURACIL, 500 MG" 48260738_1 CDM 0636 RC 63323-0117-20 NDC J9190 HCPCS inpatient 2 UN 66.09 42.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 40.02 64.11 "INJECTION, FLUOROURACIL, 500 MG" 48260738_1 CDM 0636 RC 63323-0117-20 NDC J9190 HCPCS inpatient 2 UN 66.09 42.96 ANTHEM HMO ANTHEM HMO 999999999 40.02 64.11 "INJECTION, FLUOROURACIL, 500 MG" 48260738_1 CDM 0636 RC 63323-0117-20 NDC J9190 HCPCS inpatient 2 UN 66.09 42.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.68 67.6 999999999 40.02 64.11 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 48260738_1 CDM 0636 RC 63323-0117-20 NDC J9190 HCPCS inpatient 2 UN 66.09 42.96 UHC - ALL PLANS UHC - ALL PLANS 999999999 40.02 64.11 FLUOXETINE HCL 10 MG CAPSULE 48260741_1 CDM 0250 RC 00904-5784-61 NDC inpatient 1 UN 1.55 1.01 AETNA AETNA 1.22 79 999999999 0.94 1.5 percent of total billed charges FLUOXETINE HCL 10 MG CAPSULE 48260741_1 CDM 0250 RC 00904-5784-61 NDC inpatient 1 UN 1.55 1.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.01 65 999999999 0.94 1.5 percent of total billed charges FLUOXETINE HCL 10 MG CAPSULE 48260741_1 CDM 0250 RC 00904-5784-61 NDC inpatient 1 UN 1.55 1.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.5 97 999999999 0.94 1.5 percent of total billed charges FLUOXETINE HCL 10 MG CAPSULE 48260741_1 CDM 0250 RC 00904-5784-61 NDC inpatient 1 UN 1.55 1.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.21 78 999999999 0.94 1.5 percent of total billed charges FLUOXETINE HCL 10 MG CAPSULE 48260741_1 CDM 0250 RC 00904-5784-61 NDC inpatient 1 UN 1.55 1.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.07 69 999999999 0.94 1.5 percent of total billed charges FLUOXETINE HCL 10 MG CAPSULE 48260741_1 CDM 0250 RC 00904-5784-61 NDC inpatient 1 UN 1.55 1.01 UMR - ALL PLANS UMR - ALL PLANS 1.09 70 999999999 0.94 1.5 percent of total billed charges FLUOXETINE HCL 10 MG CAPSULE 48260741_1 CDM 0250 RC 00904-5784-61 NDC inpatient 1 UN 1.55 1.01 SIHO - ALL PLANS SIHO - ALL PLANS 1.4 90 999999999 0.94 1.5 percent of total billed charges FLUOXETINE HCL 10 MG CAPSULE 48260741_1 CDM 0250 RC 00904-5784-61 NDC inpatient 1 UN 1.55 1.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.94 1.5 FLUOXETINE HCL 10 MG CAPSULE 48260741_1 CDM 0250 RC 00904-5784-61 NDC inpatient 1 UN 1.55 1.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.94 60.55 999999999 0.94 1.5 percent of total billed charges FLUOXETINE HCL 10 MG CAPSULE 48260741_1 CDM 0250 RC 00904-5784-61 NDC inpatient 1 UN 1.55 1.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.94 1.5 FLUOXETINE HCL 10 MG CAPSULE 48260741_1 CDM 0250 RC 00904-5784-61 NDC inpatient 1 UN 1.55 1.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.94 1.5 FLUOXETINE HCL 10 MG CAPSULE 48260741_1 CDM 0250 RC 00904-5784-61 NDC inpatient 1 UN 1.55 1.01 ANTHEM HMO ANTHEM HMO 999999999 0.94 1.5 FLUOXETINE HCL 10 MG CAPSULE 48260741_1 CDM 0250 RC 00904-5784-61 NDC inpatient 1 UN 1.55 1.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.05 67.6 999999999 0.94 1.5 percent of total billed charges FLUOXETINE HCL 10 MG CAPSULE 48260741_1 CDM 0250 RC 00904-5784-61 NDC inpatient 1 UN 1.55 1.01 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.94 1.5 FLUOXETINE HCL 20 MG CAPSULE 48260742_1 CDM 0250 RC 68084-0605-01 NDC inpatient 1 UN 1.12 0.73 AETNA AETNA 0.88 79 999999999 0.68 1.09 percent of total billed charges FLUOXETINE HCL 20 MG CAPSULE 48260742_1 CDM 0250 RC 68084-0605-01 NDC inpatient 1 UN 1.12 0.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.73 65 999999999 0.68 1.09 percent of total billed charges FLUOXETINE HCL 20 MG CAPSULE 48260742_1 CDM 0250 RC 68084-0605-01 NDC inpatient 1 UN 1.12 0.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.09 97 999999999 0.68 1.09 percent of total billed charges FLUOXETINE HCL 20 MG CAPSULE 48260742_1 CDM 0250 RC 68084-0605-01 NDC inpatient 1 UN 1.12 0.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.87 78 999999999 0.68 1.09 percent of total billed charges FLUOXETINE HCL 20 MG CAPSULE 48260742_1 CDM 0250 RC 68084-0605-01 NDC inpatient 1 UN 1.12 0.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.77 69 999999999 0.68 1.09 percent of total billed charges FLUOXETINE HCL 20 MG CAPSULE 48260742_1 CDM 0250 RC 68084-0605-01 NDC inpatient 1 UN 1.12 0.73 UMR - ALL PLANS UMR - ALL PLANS 0.78 70 999999999 0.68 1.09 percent of total billed charges FLUOXETINE HCL 20 MG CAPSULE 48260742_1 CDM 0250 RC 68084-0605-01 NDC inpatient 1 UN 1.12 0.73 SIHO - ALL PLANS SIHO - ALL PLANS 1.01 90 999999999 0.68 1.09 percent of total billed charges FLUOXETINE HCL 20 MG CAPSULE 48260742_1 CDM 0250 RC 68084-0605-01 NDC inpatient 1 UN 1.12 0.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.68 1.09 FLUOXETINE HCL 20 MG CAPSULE 48260742_1 CDM 0250 RC 68084-0605-01 NDC inpatient 1 UN 1.12 0.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.68 60.55 999999999 0.68 1.09 percent of total billed charges FLUOXETINE HCL 20 MG CAPSULE 48260742_1 CDM 0250 RC 68084-0605-01 NDC inpatient 1 UN 1.12 0.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.68 1.09 FLUOXETINE HCL 20 MG CAPSULE 48260742_1 CDM 0250 RC 68084-0605-01 NDC inpatient 1 UN 1.12 0.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.68 1.09 FLUOXETINE HCL 20 MG CAPSULE 48260742_1 CDM 0250 RC 68084-0605-01 NDC inpatient 1 UN 1.12 0.73 ANTHEM HMO ANTHEM HMO 999999999 0.68 1.09 FLUOXETINE HCL 20 MG CAPSULE 48260742_1 CDM 0250 RC 68084-0605-01 NDC inpatient 1 UN 1.12 0.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.76 67.6 999999999 0.68 1.09 percent of total billed charges FLUOXETINE HCL 20 MG CAPSULE 48260742_1 CDM 0250 RC 68084-0605-01 NDC inpatient 1 UN 1.12 0.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.68 1.09 FLOVENT HFA 110 MCG INHALER 48260744_1 CDM 0250 RC 00173-0719-20 NDC inpatient 1 UN 10.11 6.57 AETNA AETNA 7.99 79 999999999 6.12 9.81 percent of total billed charges FLOVENT HFA 110 MCG INHALER 48260744_1 CDM 0250 RC 00173-0719-20 NDC inpatient 1 UN 10.11 6.57 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.57 65 999999999 6.12 9.81 percent of total billed charges FLOVENT HFA 110 MCG INHALER 48260744_1 CDM 0250 RC 00173-0719-20 NDC inpatient 1 UN 10.11 6.57 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.81 97 999999999 6.12 9.81 percent of total billed charges FLOVENT HFA 110 MCG INHALER 48260744_1 CDM 0250 RC 00173-0719-20 NDC inpatient 1 UN 10.11 6.57 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.89 78 999999999 6.12 9.81 percent of total billed charges FLOVENT HFA 110 MCG INHALER 48260744_1 CDM 0250 RC 00173-0719-20 NDC inpatient 1 UN 10.11 6.57 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.98 69 999999999 6.12 9.81 percent of total billed charges FLOVENT HFA 110 MCG INHALER 48260744_1 CDM 0250 RC 00173-0719-20 NDC inpatient 1 UN 10.11 6.57 UMR - ALL PLANS UMR - ALL PLANS 7.08 70 999999999 6.12 9.81 percent of total billed charges FLOVENT HFA 110 MCG INHALER 48260744_1 CDM 0250 RC 00173-0719-20 NDC inpatient 1 UN 10.11 6.57 SIHO - ALL PLANS SIHO - ALL PLANS 9.1 90 999999999 6.12 9.81 percent of total billed charges FLOVENT HFA 110 MCG INHALER 48260744_1 CDM 0250 RC 00173-0719-20 NDC inpatient 1 UN 10.11 6.57 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.12 9.81 FLOVENT HFA 110 MCG INHALER 48260744_1 CDM 0250 RC 00173-0719-20 NDC inpatient 1 UN 10.11 6.57 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.12 60.55 999999999 6.12 9.81 percent of total billed charges FLOVENT HFA 110 MCG INHALER 48260744_1 CDM 0250 RC 00173-0719-20 NDC inpatient 1 UN 10.11 6.57 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.12 9.81 FLOVENT HFA 110 MCG INHALER 48260744_1 CDM 0250 RC 00173-0719-20 NDC inpatient 1 UN 10.11 6.57 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.12 9.81 FLOVENT HFA 110 MCG INHALER 48260744_1 CDM 0250 RC 00173-0719-20 NDC inpatient 1 UN 10.11 6.57 ANTHEM HMO ANTHEM HMO 999999999 6.12 9.81 FLOVENT HFA 110 MCG INHALER 48260744_1 CDM 0250 RC 00173-0719-20 NDC inpatient 1 UN 10.11 6.57 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.83 67.6 999999999 6.12 9.81 percent of total billed charges FLOVENT HFA 110 MCG INHALER 48260744_1 CDM 0250 RC 00173-0719-20 NDC inpatient 1 UN 10.11 6.57 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.12 9.81 FLOVENT HFA 220 MCG INHALER 48260745_1 CDM 0250 RC 00173-0720-20 NDC inpatient 1 UN 580.64 377.42 AETNA AETNA 458.71 79 999999999 351.58 563.22 percent of total billed charges FLOVENT HFA 220 MCG INHALER 48260745_1 CDM 0250 RC 00173-0720-20 NDC inpatient 1 UN 580.64 377.42 SELF PAY DISCOUNT SELF PAY DISCOUNT 377.42 65 999999999 351.58 563.22 percent of total billed charges FLOVENT HFA 220 MCG INHALER 48260745_1 CDM 0250 RC 00173-0720-20 NDC inpatient 1 UN 580.64 377.42 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 563.22 97 999999999 351.58 563.22 percent of total billed charges FLOVENT HFA 220 MCG INHALER 48260745_1 CDM 0250 RC 00173-0720-20 NDC inpatient 1 UN 580.64 377.42 HUMANA - ALL PLANS HUMANA - ALL PLANS 452.9 78 999999999 351.58 563.22 percent of total billed charges FLOVENT HFA 220 MCG INHALER 48260745_1 CDM 0250 RC 00173-0720-20 NDC inpatient 1 UN 580.64 377.42 ENCORE - ALL PLANS ENCORE - ALL PLANS 400.64 69 999999999 351.58 563.22 percent of total billed charges FLOVENT HFA 220 MCG INHALER 48260745_1 CDM 0250 RC 00173-0720-20 NDC inpatient 1 UN 580.64 377.42 UMR - ALL PLANS UMR - ALL PLANS 406.45 70 999999999 351.58 563.22 percent of total billed charges FLOVENT HFA 220 MCG INHALER 48260745_1 CDM 0250 RC 00173-0720-20 NDC inpatient 1 UN 580.64 377.42 SIHO - ALL PLANS SIHO - ALL PLANS 522.58 90 999999999 351.58 563.22 percent of total billed charges FLOVENT HFA 220 MCG INHALER 48260745_1 CDM 0250 RC 00173-0720-20 NDC inpatient 1 UN 580.64 377.42 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 351.58 563.22 FLOVENT HFA 220 MCG INHALER 48260745_1 CDM 0250 RC 00173-0720-20 NDC inpatient 1 UN 580.64 377.42 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 351.58 60.55 999999999 351.58 563.22 percent of total billed charges FLOVENT HFA 220 MCG INHALER 48260745_1 CDM 0250 RC 00173-0720-20 NDC inpatient 1 UN 580.64 377.42 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 351.58 563.22 FLOVENT HFA 220 MCG INHALER 48260745_1 CDM 0250 RC 00173-0720-20 NDC inpatient 1 UN 580.64 377.42 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 351.58 563.22 FLOVENT HFA 220 MCG INHALER 48260745_1 CDM 0250 RC 00173-0720-20 NDC inpatient 1 UN 580.64 377.42 ANTHEM HMO ANTHEM HMO 999999999 351.58 563.22 FLOVENT HFA 220 MCG INHALER 48260745_1 CDM 0250 RC 00173-0720-20 NDC inpatient 1 UN 580.64 377.42 CIGNA - ALL PLANS CIGNA - ALL PLANS 392.51 67.6 999999999 351.58 563.22 percent of total billed charges FLOVENT HFA 220 MCG INHALER 48260745_1 CDM 0250 RC 00173-0720-20 NDC inpatient 1 UN 580.64 377.42 UHC - ALL PLANS UHC - ALL PLANS 999999999 351.58 563.22 FLOVENT HFA 44 MCG INHALER 48260746_1 CDM 0250 RC 00173-0718-20 NDC inpatient 1 UN 275.15 178.85 AETNA AETNA 217.37 79 999999999 166.6 266.9 percent of total billed charges FLOVENT HFA 44 MCG INHALER 48260746_1 CDM 0250 RC 00173-0718-20 NDC inpatient 1 UN 275.15 178.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.85 65 999999999 166.6 266.9 percent of total billed charges FLOVENT HFA 44 MCG INHALER 48260746_1 CDM 0250 RC 00173-0718-20 NDC inpatient 1 UN 275.15 178.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 266.9 97 999999999 166.6 266.9 percent of total billed charges FLOVENT HFA 44 MCG INHALER 48260746_1 CDM 0250 RC 00173-0718-20 NDC inpatient 1 UN 275.15 178.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.85 69 999999999 166.6 266.9 percent of total billed charges FLOVENT HFA 44 MCG INHALER 48260746_1 CDM 0250 RC 00173-0718-20 NDC inpatient 1 UN 275.15 178.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 214.62 78 999999999 166.6 266.9 percent of total billed charges FLOVENT HFA 44 MCG INHALER 48260746_1 CDM 0250 RC 00173-0718-20 NDC inpatient 1 UN 275.15 178.85 UMR - ALL PLANS UMR - ALL PLANS 192.61 70 999999999 166.6 266.9 percent of total billed charges FLOVENT HFA 44 MCG INHALER 48260746_1 CDM 0250 RC 00173-0718-20 NDC inpatient 1 UN 275.15 178.85 SIHO - ALL PLANS SIHO - ALL PLANS 247.64 90 999999999 166.6 266.9 percent of total billed charges FLOVENT HFA 44 MCG INHALER 48260746_1 CDM 0250 RC 00173-0718-20 NDC inpatient 1 UN 275.15 178.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 166.6 266.9 FLOVENT HFA 44 MCG INHALER 48260746_1 CDM 0250 RC 00173-0718-20 NDC inpatient 1 UN 275.15 178.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 166.6 60.55 999999999 166.6 266.9 percent of total billed charges FLOVENT HFA 44 MCG INHALER 48260746_1 CDM 0250 RC 00173-0718-20 NDC inpatient 1 UN 275.15 178.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 166.6 266.9 FLOVENT HFA 44 MCG INHALER 48260746_1 CDM 0250 RC 00173-0718-20 NDC inpatient 1 UN 275.15 178.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 166.6 266.9 FLOVENT HFA 44 MCG INHALER 48260746_1 CDM 0250 RC 00173-0718-20 NDC inpatient 1 UN 275.15 178.85 ANTHEM HMO ANTHEM HMO 999999999 166.6 266.9 FLOVENT HFA 44 MCG INHALER 48260746_1 CDM 0250 RC 00173-0718-20 NDC inpatient 1 UN 275.15 178.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 186 67.6 999999999 166.6 266.9 percent of total billed charges FLOVENT HFA 44 MCG INHALER 48260746_1 CDM 0250 RC 00173-0718-20 NDC inpatient 1 UN 275.15 178.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 166.6 266.9 ADVAIR HFA 115-21 MCG INHALER 48260748_1 CDM 0250 RC 00173-0716-22 NDC inpatient 1 UN 49.72 32.32 AETNA AETNA 39.28 79 999999999 30.11 48.23 percent of total billed charges ADVAIR HFA 115-21 MCG INHALER 48260748_1 CDM 0250 RC 00173-0716-22 NDC inpatient 1 UN 49.72 32.32 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.32 65 999999999 30.11 48.23 percent of total billed charges ADVAIR HFA 115-21 MCG INHALER 48260748_1 CDM 0250 RC 00173-0716-22 NDC inpatient 1 UN 49.72 32.32 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.23 97 999999999 30.11 48.23 percent of total billed charges ADVAIR HFA 115-21 MCG INHALER 48260748_1 CDM 0250 RC 00173-0716-22 NDC inpatient 1 UN 49.72 32.32 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.31 69 999999999 30.11 48.23 percent of total billed charges ADVAIR HFA 115-21 MCG INHALER 48260748_1 CDM 0250 RC 00173-0716-22 NDC inpatient 1 UN 49.72 32.32 HUMANA - ALL PLANS HUMANA - ALL PLANS 38.78 78 999999999 30.11 48.23 percent of total billed charges ADVAIR HFA 115-21 MCG INHALER 48260748_1 CDM 0250 RC 00173-0716-22 NDC inpatient 1 UN 49.72 32.32 UMR - ALL PLANS UMR - ALL PLANS 34.8 70 999999999 30.11 48.23 percent of total billed charges ADVAIR HFA 115-21 MCG INHALER 48260748_1 CDM 0250 RC 00173-0716-22 NDC inpatient 1 UN 49.72 32.32 SIHO - ALL PLANS SIHO - ALL PLANS 44.75 90 999999999 30.11 48.23 percent of total billed charges ADVAIR HFA 115-21 MCG INHALER 48260748_1 CDM 0250 RC 00173-0716-22 NDC inpatient 1 UN 49.72 32.32 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.11 48.23 ADVAIR HFA 115-21 MCG INHALER 48260748_1 CDM 0250 RC 00173-0716-22 NDC inpatient 1 UN 49.72 32.32 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.11 60.55 999999999 30.11 48.23 percent of total billed charges ADVAIR HFA 115-21 MCG INHALER 48260748_1 CDM 0250 RC 00173-0716-22 NDC inpatient 1 UN 49.72 32.32 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.11 48.23 ADVAIR HFA 115-21 MCG INHALER 48260748_1 CDM 0250 RC 00173-0716-22 NDC inpatient 1 UN 49.72 32.32 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.11 48.23 ADVAIR HFA 115-21 MCG INHALER 48260748_1 CDM 0250 RC 00173-0716-22 NDC inpatient 1 UN 49.72 32.32 ANTHEM HMO ANTHEM HMO 999999999 30.11 48.23 ADVAIR HFA 115-21 MCG INHALER 48260748_1 CDM 0250 RC 00173-0716-22 NDC inpatient 1 UN 49.72 32.32 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.61 67.6 999999999 30.11 48.23 percent of total billed charges ADVAIR HFA 115-21 MCG INHALER 48260748_1 CDM 0250 RC 00173-0716-22 NDC inpatient 1 UN 49.72 32.32 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.11 48.23 ADVAIR HFA 230-21 MCG INHALER 48260749_1 CDM 0250 RC 00173-0717-20 NDC inpatient 1 UN 49.32 32.06 AETNA AETNA 38.96 79 999999999 29.86 47.84 percent of total billed charges ADVAIR HFA 230-21 MCG INHALER 48260749_1 CDM 0250 RC 00173-0717-20 NDC inpatient 1 UN 49.32 32.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.06 65 999999999 29.86 47.84 percent of total billed charges ADVAIR HFA 230-21 MCG INHALER 48260749_1 CDM 0250 RC 00173-0717-20 NDC inpatient 1 UN 49.32 32.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 47.84 97 999999999 29.86 47.84 percent of total billed charges ADVAIR HFA 230-21 MCG INHALER 48260749_1 CDM 0250 RC 00173-0717-20 NDC inpatient 1 UN 49.32 32.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.03 69 999999999 29.86 47.84 percent of total billed charges ADVAIR HFA 230-21 MCG INHALER 48260749_1 CDM 0250 RC 00173-0717-20 NDC inpatient 1 UN 49.32 32.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 38.47 78 999999999 29.86 47.84 percent of total billed charges ADVAIR HFA 230-21 MCG INHALER 48260749_1 CDM 0250 RC 00173-0717-20 NDC inpatient 1 UN 49.32 32.06 UMR - ALL PLANS UMR - ALL PLANS 34.52 70 999999999 29.86 47.84 percent of total billed charges ADVAIR HFA 230-21 MCG INHALER 48260749_1 CDM 0250 RC 00173-0717-20 NDC inpatient 1 UN 49.32 32.06 SIHO - ALL PLANS SIHO - ALL PLANS 44.39 90 999999999 29.86 47.84 percent of total billed charges ADVAIR HFA 230-21 MCG INHALER 48260749_1 CDM 0250 RC 00173-0717-20 NDC inpatient 1 UN 49.32 32.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.86 47.84 ADVAIR HFA 230-21 MCG INHALER 48260749_1 CDM 0250 RC 00173-0717-20 NDC inpatient 1 UN 49.32 32.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.86 60.55 999999999 29.86 47.84 percent of total billed charges ADVAIR HFA 230-21 MCG INHALER 48260749_1 CDM 0250 RC 00173-0717-20 NDC inpatient 1 UN 49.32 32.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.86 47.84 ADVAIR HFA 230-21 MCG INHALER 48260749_1 CDM 0250 RC 00173-0717-20 NDC inpatient 1 UN 49.32 32.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.86 47.84 ADVAIR HFA 230-21 MCG INHALER 48260749_1 CDM 0250 RC 00173-0717-20 NDC inpatient 1 UN 49.32 32.06 ANTHEM HMO ANTHEM HMO 999999999 29.86 47.84 ADVAIR HFA 230-21 MCG INHALER 48260749_1 CDM 0250 RC 00173-0717-20 NDC inpatient 1 UN 49.32 32.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.34 67.6 999999999 29.86 47.84 percent of total billed charges ADVAIR HFA 230-21 MCG INHALER 48260749_1 CDM 0250 RC 00173-0717-20 NDC inpatient 1 UN 49.32 32.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.86 47.84 ADVAIR HFA 45-21 MCG INHALER 48260750_1 CDM 0250 RC 00173-0715-20 NDC inpatient 1 UN 263.42 171.22 AETNA AETNA 208.1 79 999999999 159.5 255.52 percent of total billed charges ADVAIR HFA 45-21 MCG INHALER 48260750_1 CDM 0250 RC 00173-0715-20 NDC inpatient 1 UN 263.42 171.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 171.22 65 999999999 159.5 255.52 percent of total billed charges ADVAIR HFA 45-21 MCG INHALER 48260750_1 CDM 0250 RC 00173-0715-20 NDC inpatient 1 UN 263.42 171.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 255.52 97 999999999 159.5 255.52 percent of total billed charges ADVAIR HFA 45-21 MCG INHALER 48260750_1 CDM 0250 RC 00173-0715-20 NDC inpatient 1 UN 263.42 171.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 181.76 69 999999999 159.5 255.52 percent of total billed charges ADVAIR HFA 45-21 MCG INHALER 48260750_1 CDM 0250 RC 00173-0715-20 NDC inpatient 1 UN 263.42 171.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 205.47 78 999999999 159.5 255.52 percent of total billed charges ADVAIR HFA 45-21 MCG INHALER 48260750_1 CDM 0250 RC 00173-0715-20 NDC inpatient 1 UN 263.42 171.22 UMR - ALL PLANS UMR - ALL PLANS 184.39 70 999999999 159.5 255.52 percent of total billed charges ADVAIR HFA 45-21 MCG INHALER 48260750_1 CDM 0250 RC 00173-0715-20 NDC inpatient 1 UN 263.42 171.22 SIHO - ALL PLANS SIHO - ALL PLANS 237.08 90 999999999 159.5 255.52 percent of total billed charges ADVAIR HFA 45-21 MCG INHALER 48260750_1 CDM 0250 RC 00173-0715-20 NDC inpatient 1 UN 263.42 171.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 159.5 255.52 ADVAIR HFA 45-21 MCG INHALER 48260750_1 CDM 0250 RC 00173-0715-20 NDC inpatient 1 UN 263.42 171.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 159.5 60.55 999999999 159.5 255.52 percent of total billed charges ADVAIR HFA 45-21 MCG INHALER 48260750_1 CDM 0250 RC 00173-0715-20 NDC inpatient 1 UN 263.42 171.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 159.5 255.52 ADVAIR HFA 45-21 MCG INHALER 48260750_1 CDM 0250 RC 00173-0715-20 NDC inpatient 1 UN 263.42 171.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 159.5 255.52 ADVAIR HFA 45-21 MCG INHALER 48260750_1 CDM 0250 RC 00173-0715-20 NDC inpatient 1 UN 263.42 171.22 ANTHEM HMO ANTHEM HMO 999999999 159.5 255.52 ADVAIR HFA 45-21 MCG INHALER 48260750_1 CDM 0250 RC 00173-0715-20 NDC inpatient 1 UN 263.42 171.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 178.07 67.6 999999999 159.5 255.52 percent of total billed charges ADVAIR HFA 45-21 MCG INHALER 48260750_1 CDM 0250 RC 00173-0715-20 NDC inpatient 1 UN 263.42 171.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 159.5 255.52 FUROSEMIDE 100 MG/10 ML VIAL 48260763_1 CDM 0250 RC 00409-6102-27 NDC inpatient 1 UN 19.25 12.51 AETNA AETNA 15.21 79 999999999 11.66 18.67 percent of total billed charges FUROSEMIDE 100 MG/10 ML VIAL 48260763_1 CDM 0250 RC 00409-6102-27 NDC inpatient 1 UN 19.25 12.51 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.51 65 999999999 11.66 18.67 percent of total billed charges FUROSEMIDE 100 MG/10 ML VIAL 48260763_1 CDM 0250 RC 00409-6102-27 NDC inpatient 1 UN 19.25 12.51 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 18.67 97 999999999 11.66 18.67 percent of total billed charges FUROSEMIDE 100 MG/10 ML VIAL 48260763_1 CDM 0250 RC 00409-6102-27 NDC inpatient 1 UN 19.25 12.51 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.28 69 999999999 11.66 18.67 percent of total billed charges FUROSEMIDE 100 MG/10 ML VIAL 48260763_1 CDM 0250 RC 00409-6102-27 NDC inpatient 1 UN 19.25 12.51 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.02 78 999999999 11.66 18.67 percent of total billed charges FUROSEMIDE 100 MG/10 ML VIAL 48260763_1 CDM 0250 RC 00409-6102-27 NDC inpatient 1 UN 19.25 12.51 UMR - ALL PLANS UMR - ALL PLANS 13.48 70 999999999 11.66 18.67 percent of total billed charges FUROSEMIDE 100 MG/10 ML VIAL 48260763_1 CDM 0250 RC 00409-6102-27 NDC inpatient 1 UN 19.25 12.51 SIHO - ALL PLANS SIHO - ALL PLANS 17.33 90 999999999 11.66 18.67 percent of total billed charges FUROSEMIDE 100 MG/10 ML VIAL 48260763_1 CDM 0250 RC 00409-6102-27 NDC inpatient 1 UN 19.25 12.51 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.66 18.67 FUROSEMIDE 100 MG/10 ML VIAL 48260763_1 CDM 0250 RC 00409-6102-27 NDC inpatient 1 UN 19.25 12.51 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.66 60.55 999999999 11.66 18.67 percent of total billed charges FUROSEMIDE 100 MG/10 ML VIAL 48260763_1 CDM 0250 RC 00409-6102-27 NDC inpatient 1 UN 19.25 12.51 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.66 18.67 FUROSEMIDE 100 MG/10 ML VIAL 48260763_1 CDM 0250 RC 00409-6102-27 NDC inpatient 1 UN 19.25 12.51 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.66 18.67 FUROSEMIDE 100 MG/10 ML VIAL 48260763_1 CDM 0250 RC 00409-6102-27 NDC inpatient 1 UN 19.25 12.51 ANTHEM HMO ANTHEM HMO 999999999 11.66 18.67 FUROSEMIDE 100 MG/10 ML VIAL 48260763_1 CDM 0250 RC 00409-6102-27 NDC inpatient 1 UN 19.25 12.51 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.01 67.6 999999999 11.66 18.67 percent of total billed charges FUROSEMIDE 100 MG/10 ML VIAL 48260763_1 CDM 0250 RC 00409-6102-27 NDC inpatient 1 UN 19.25 12.51 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.66 18.67 FUROSEMIDE 20 MG/2 ML VIAL 48260764_1 CDM 0250 RC 00409-6102-25 NDC inpatient 1 UN 16.46 10.7 AETNA AETNA 13 79 999999999 9.97 15.97 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 48260764_1 CDM 0250 RC 00409-6102-25 NDC inpatient 1 UN 16.46 10.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.7 65 999999999 9.97 15.97 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 48260764_1 CDM 0250 RC 00409-6102-25 NDC inpatient 1 UN 16.46 10.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15.97 97 999999999 9.97 15.97 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 48260764_1 CDM 0250 RC 00409-6102-25 NDC inpatient 1 UN 16.46 10.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.36 69 999999999 9.97 15.97 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 48260764_1 CDM 0250 RC 00409-6102-25 NDC inpatient 1 UN 16.46 10.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.84 78 999999999 9.97 15.97 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 48260764_1 CDM 0250 RC 00409-6102-25 NDC inpatient 1 UN 16.46 10.7 UMR - ALL PLANS UMR - ALL PLANS 11.52 70 999999999 9.97 15.97 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 48260764_1 CDM 0250 RC 00409-6102-25 NDC inpatient 1 UN 16.46 10.7 SIHO - ALL PLANS SIHO - ALL PLANS 14.81 90 999999999 9.97 15.97 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 48260764_1 CDM 0250 RC 00409-6102-25 NDC inpatient 1 UN 16.46 10.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.97 15.97 FUROSEMIDE 20 MG/2 ML VIAL 48260764_1 CDM 0250 RC 00409-6102-25 NDC inpatient 1 UN 16.46 10.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.97 60.55 999999999 9.97 15.97 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 48260764_1 CDM 0250 RC 00409-6102-25 NDC inpatient 1 UN 16.46 10.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.97 15.97 FUROSEMIDE 20 MG/2 ML VIAL 48260764_1 CDM 0250 RC 00409-6102-25 NDC inpatient 1 UN 16.46 10.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.97 15.97 FUROSEMIDE 20 MG/2 ML VIAL 48260764_1 CDM 0250 RC 00409-6102-25 NDC inpatient 1 UN 16.46 10.7 ANTHEM HMO ANTHEM HMO 999999999 9.97 15.97 FUROSEMIDE 20 MG/2 ML VIAL 48260764_1 CDM 0250 RC 00409-6102-25 NDC inpatient 1 UN 16.46 10.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.13 67.6 999999999 9.97 15.97 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 48260764_1 CDM 0250 RC 00409-6102-25 NDC inpatient 1 UN 16.46 10.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.97 15.97 FUROSEMIDE 20 MG TABLET 48260769_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 1.79 1.16 AETNA AETNA 1.41 79 999999999 1.08 1.74 percent of total billed charges FUROSEMIDE 20 MG TABLET 48260769_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 1.79 1.16 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.16 65 999999999 1.08 1.74 percent of total billed charges FUROSEMIDE 20 MG TABLET 48260769_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 1.79 1.16 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.74 97 999999999 1.08 1.74 percent of total billed charges FUROSEMIDE 20 MG TABLET 48260769_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 1.79 1.16 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.24 69 999999999 1.08 1.74 percent of total billed charges FUROSEMIDE 20 MG TABLET 48260769_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 1.79 1.16 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.4 78 999999999 1.08 1.74 percent of total billed charges FUROSEMIDE 20 MG TABLET 48260769_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 1.79 1.16 UMR - ALL PLANS UMR - ALL PLANS 1.25 70 999999999 1.08 1.74 percent of total billed charges FUROSEMIDE 20 MG TABLET 48260769_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 1.79 1.16 SIHO - ALL PLANS SIHO - ALL PLANS 1.61 90 999999999 1.08 1.74 percent of total billed charges FUROSEMIDE 20 MG TABLET 48260769_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 1.79 1.16 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.08 1.74 FUROSEMIDE 20 MG TABLET 48260769_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 1.79 1.16 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.08 60.55 999999999 1.08 1.74 percent of total billed charges FUROSEMIDE 20 MG TABLET 48260769_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 1.79 1.16 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.08 1.74 FUROSEMIDE 20 MG TABLET 48260769_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 1.79 1.16 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.08 1.74 FUROSEMIDE 20 MG TABLET 48260769_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 1.79 1.16 ANTHEM HMO ANTHEM HMO 999999999 1.08 1.74 FUROSEMIDE 20 MG TABLET 48260769_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 1.79 1.16 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.21 67.6 999999999 1.08 1.74 percent of total billed charges FUROSEMIDE 20 MG TABLET 48260769_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 1.79 1.16 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.08 1.74 "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 48260782_1 CDM 0636 RC 00781-3283-79 NDC J9201 HCPCS inpatient 5 UN 2473.78 1607.96 AETNA AETNA 1954.29 79 999999999 1497.87 2399.57 percent of total billed charges "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 48260782_1 CDM 0636 RC 00781-3283-79 NDC J9201 HCPCS inpatient 5 UN 2473.78 1607.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 1607.96 65 999999999 1497.87 2399.57 percent of total billed charges "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 48260782_1 CDM 0636 RC 00781-3283-79 NDC J9201 HCPCS inpatient 5 UN 2473.78 1607.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2399.57 97 999999999 1497.87 2399.57 percent of total billed charges "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 48260782_1 CDM 0636 RC 00781-3283-79 NDC J9201 HCPCS inpatient 5 UN 2473.78 1607.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 1706.91 69 999999999 1497.87 2399.57 percent of total billed charges "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 48260782_1 CDM 0636 RC 00781-3283-79 NDC J9201 HCPCS inpatient 5 UN 2473.78 1607.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 1929.55 78 999999999 1497.87 2399.57 percent of total billed charges "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 48260782_1 CDM 0636 RC 00781-3283-79 NDC J9201 HCPCS inpatient 5 UN 2473.78 1607.96 UMR - ALL PLANS UMR - ALL PLANS 1731.65 70 999999999 1497.87 2399.57 percent of total billed charges "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 48260782_1 CDM 0636 RC 00781-3283-79 NDC J9201 HCPCS inpatient 5 UN 2473.78 1607.96 SIHO - ALL PLANS SIHO - ALL PLANS 2226.4 90 999999999 1497.87 2399.57 percent of total billed charges "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 48260782_1 CDM 0636 RC 00781-3283-79 NDC J9201 HCPCS inpatient 5 UN 2473.78 1607.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1497.87 2399.57 "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 48260782_1 CDM 0636 RC 00781-3283-79 NDC J9201 HCPCS inpatient 5 UN 2473.78 1607.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1497.87 60.55 999999999 1497.87 2399.57 percent of total billed charges "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 48260782_1 CDM 0636 RC 00781-3283-79 NDC J9201 HCPCS inpatient 5 UN 2473.78 1607.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1497.87 2399.57 "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 48260782_1 CDM 0636 RC 00781-3283-79 NDC J9201 HCPCS inpatient 5 UN 2473.78 1607.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1497.87 2399.57 "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 48260782_1 CDM 0636 RC 00781-3283-79 NDC J9201 HCPCS inpatient 5 UN 2473.78 1607.96 ANTHEM HMO ANTHEM HMO 999999999 1497.87 2399.57 "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 48260782_1 CDM 0636 RC 00781-3283-79 NDC J9201 HCPCS inpatient 5 UN 2473.78 1607.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 1672.28 67.6 999999999 1497.87 2399.57 percent of total billed charges "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 48260782_1 CDM 0636 RC 00781-3283-79 NDC J9201 HCPCS inpatient 5 UN 2473.78 1607.96 UHC - ALL PLANS UHC - ALL PLANS 999999999 1497.87 2399.57 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260786_1 CDM 0250 RC 00338-0507-48 NDC J1580 HCPCS inpatient 1 UN 62.36 40.53 AETNA AETNA 49.26 79 999999999 37.76 60.49 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260786_1 CDM 0250 RC 00338-0507-48 NDC J1580 HCPCS inpatient 1 UN 62.36 40.53 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.53 65 999999999 37.76 60.49 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260786_1 CDM 0250 RC 00338-0507-48 NDC J1580 HCPCS inpatient 1 UN 62.36 40.53 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 60.49 97 999999999 37.76 60.49 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260786_1 CDM 0250 RC 00338-0507-48 NDC J1580 HCPCS inpatient 1 UN 62.36 40.53 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.03 69 999999999 37.76 60.49 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260786_1 CDM 0250 RC 00338-0507-48 NDC J1580 HCPCS inpatient 1 UN 62.36 40.53 HUMANA - ALL PLANS HUMANA - ALL PLANS 48.64 78 999999999 37.76 60.49 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260786_1 CDM 0250 RC 00338-0507-48 NDC J1580 HCPCS inpatient 1 UN 62.36 40.53 UMR - ALL PLANS UMR - ALL PLANS 43.65 70 999999999 37.76 60.49 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260786_1 CDM 0250 RC 00338-0507-48 NDC J1580 HCPCS inpatient 1 UN 62.36 40.53 SIHO - ALL PLANS SIHO - ALL PLANS 56.12 90 999999999 37.76 60.49 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260786_1 CDM 0250 RC 00338-0507-48 NDC J1580 HCPCS inpatient 1 UN 62.36 40.53 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 37.76 60.49 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260786_1 CDM 0250 RC 00338-0507-48 NDC J1580 HCPCS inpatient 1 UN 62.36 40.53 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 37.76 60.55 999999999 37.76 60.49 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260786_1 CDM 0250 RC 00338-0507-48 NDC J1580 HCPCS inpatient 1 UN 62.36 40.53 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 37.76 60.49 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260786_1 CDM 0250 RC 00338-0507-48 NDC J1580 HCPCS inpatient 1 UN 62.36 40.53 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 37.76 60.49 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260786_1 CDM 0250 RC 00338-0507-48 NDC J1580 HCPCS inpatient 1 UN 62.36 40.53 ANTHEM HMO ANTHEM HMO 999999999 37.76 60.49 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260786_1 CDM 0250 RC 00338-0507-48 NDC J1580 HCPCS inpatient 1 UN 62.36 40.53 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.16 67.6 999999999 37.76 60.49 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260786_1 CDM 0250 RC 00338-0507-48 NDC J1580 HCPCS inpatient 1 UN 62.36 40.53 UHC - ALL PLANS UHC - ALL PLANS 999999999 37.76 60.49 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260787_1 CDM 0250 RC 63323-0173-02 NDC J1580 HCPCS inpatient 1 UN 27.22 17.69 AETNA AETNA 21.5 79 999999999 16.48 26.4 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260787_1 CDM 0250 RC 63323-0173-02 NDC J1580 HCPCS inpatient 1 UN 27.22 17.69 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.69 65 999999999 16.48 26.4 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260787_1 CDM 0250 RC 63323-0173-02 NDC J1580 HCPCS inpatient 1 UN 27.22 17.69 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26.4 97 999999999 16.48 26.4 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260787_1 CDM 0250 RC 63323-0173-02 NDC J1580 HCPCS inpatient 1 UN 27.22 17.69 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.78 69 999999999 16.48 26.4 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260787_1 CDM 0250 RC 63323-0173-02 NDC J1580 HCPCS inpatient 1 UN 27.22 17.69 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.23 78 999999999 16.48 26.4 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260787_1 CDM 0250 RC 63323-0173-02 NDC J1580 HCPCS inpatient 1 UN 27.22 17.69 UMR - ALL PLANS UMR - ALL PLANS 19.05 70 999999999 16.48 26.4 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260787_1 CDM 0250 RC 63323-0173-02 NDC J1580 HCPCS inpatient 1 UN 27.22 17.69 SIHO - ALL PLANS SIHO - ALL PLANS 24.5 90 999999999 16.48 26.4 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260787_1 CDM 0250 RC 63323-0173-02 NDC J1580 HCPCS inpatient 1 UN 27.22 17.69 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.48 26.4 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260787_1 CDM 0250 RC 63323-0173-02 NDC J1580 HCPCS inpatient 1 UN 27.22 17.69 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.48 60.55 999999999 16.48 26.4 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260787_1 CDM 0250 RC 63323-0173-02 NDC J1580 HCPCS inpatient 1 UN 27.22 17.69 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.48 26.4 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260787_1 CDM 0250 RC 63323-0173-02 NDC J1580 HCPCS inpatient 1 UN 27.22 17.69 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.48 26.4 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260787_1 CDM 0250 RC 63323-0173-02 NDC J1580 HCPCS inpatient 1 UN 27.22 17.69 ANTHEM HMO ANTHEM HMO 999999999 16.48 26.4 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260787_1 CDM 0250 RC 63323-0173-02 NDC J1580 HCPCS inpatient 1 UN 27.22 17.69 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.4 67.6 999999999 16.48 26.4 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260787_1 CDM 0250 RC 63323-0173-02 NDC J1580 HCPCS inpatient 1 UN 27.22 17.69 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.48 26.4 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260789_1 CDM 0250 RC 00338-0509-41 NDC J1580 HCPCS inpatient 1 UN 62.32 40.51 AETNA AETNA 49.23 79 999999999 37.73 60.45 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260789_1 CDM 0250 RC 00338-0509-41 NDC J1580 HCPCS inpatient 1 UN 62.32 40.51 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.51 65 999999999 37.73 60.45 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260789_1 CDM 0250 RC 00338-0509-41 NDC J1580 HCPCS inpatient 1 UN 62.32 40.51 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 60.45 97 999999999 37.73 60.45 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260789_1 CDM 0250 RC 00338-0509-41 NDC J1580 HCPCS inpatient 1 UN 62.32 40.51 ENCORE - ALL PLANS ENCORE - ALL PLANS 43 69 999999999 37.73 60.45 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260789_1 CDM 0250 RC 00338-0509-41 NDC J1580 HCPCS inpatient 1 UN 62.32 40.51 HUMANA - ALL PLANS HUMANA - ALL PLANS 48.61 78 999999999 37.73 60.45 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260789_1 CDM 0250 RC 00338-0509-41 NDC J1580 HCPCS inpatient 1 UN 62.32 40.51 UMR - ALL PLANS UMR - ALL PLANS 43.62 70 999999999 37.73 60.45 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260789_1 CDM 0250 RC 00338-0509-41 NDC J1580 HCPCS inpatient 1 UN 62.32 40.51 SIHO - ALL PLANS SIHO - ALL PLANS 56.09 90 999999999 37.73 60.45 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260789_1 CDM 0250 RC 00338-0509-41 NDC J1580 HCPCS inpatient 1 UN 62.32 40.51 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 37.73 60.45 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260789_1 CDM 0250 RC 00338-0509-41 NDC J1580 HCPCS inpatient 1 UN 62.32 40.51 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 37.73 60.55 999999999 37.73 60.45 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260789_1 CDM 0250 RC 00338-0509-41 NDC J1580 HCPCS inpatient 1 UN 62.32 40.51 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 37.73 60.45 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260789_1 CDM 0250 RC 00338-0509-41 NDC J1580 HCPCS inpatient 1 UN 62.32 40.51 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 37.73 60.45 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260789_1 CDM 0250 RC 00338-0509-41 NDC J1580 HCPCS inpatient 1 UN 62.32 40.51 ANTHEM HMO ANTHEM HMO 999999999 37.73 60.45 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260789_1 CDM 0250 RC 00338-0509-41 NDC J1580 HCPCS inpatient 1 UN 62.32 40.51 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.13 67.6 999999999 37.73 60.45 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48260789_1 CDM 0250 RC 00338-0509-41 NDC J1580 HCPCS inpatient 1 UN 62.32 40.51 UHC - ALL PLANS UHC - ALL PLANS 999999999 37.73 60.45 GLIPIZIDE ER 5 MG TABLET 48260799_1 CDM 0250 RC 00591-0844-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges GLIPIZIDE ER 5 MG TABLET 48260799_1 CDM 0250 RC 00591-0844-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges GLIPIZIDE ER 5 MG TABLET 48260799_1 CDM 0250 RC 00591-0844-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges GLIPIZIDE ER 5 MG TABLET 48260799_1 CDM 0250 RC 00591-0844-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges GLIPIZIDE ER 5 MG TABLET 48260799_1 CDM 0250 RC 00591-0844-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges GLIPIZIDE ER 5 MG TABLET 48260799_1 CDM 0250 RC 00591-0844-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges GLIPIZIDE ER 5 MG TABLET 48260799_1 CDM 0250 RC 00591-0844-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges GLIPIZIDE ER 5 MG TABLET 48260799_1 CDM 0250 RC 00591-0844-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 GLIPIZIDE ER 5 MG TABLET 48260799_1 CDM 0250 RC 00591-0844-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges GLIPIZIDE ER 5 MG TABLET 48260799_1 CDM 0250 RC 00591-0844-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 GLIPIZIDE ER 5 MG TABLET 48260799_1 CDM 0250 RC 00591-0844-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 GLIPIZIDE ER 5 MG TABLET 48260799_1 CDM 0250 RC 00591-0844-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 GLIPIZIDE ER 5 MG TABLET 48260799_1 CDM 0250 RC 00591-0844-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges GLIPIZIDE ER 5 MG TABLET 48260799_1 CDM 0250 RC 00591-0844-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 HALOPERIDOL LAC 5 MG/ML AMPUL 48260822_1 CDM 0250 RC 10147-0911-01 NDC inpatient 1 UN 44.88 29.17 AETNA AETNA 35.46 79 999999999 27.17 43.53 percent of total billed charges HALOPERIDOL LAC 5 MG/ML AMPUL 48260822_1 CDM 0250 RC 10147-0911-01 NDC inpatient 1 UN 44.88 29.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 29.17 65 999999999 27.17 43.53 percent of total billed charges HALOPERIDOL LAC 5 MG/ML AMPUL 48260822_1 CDM 0250 RC 10147-0911-01 NDC inpatient 1 UN 44.88 29.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 43.53 97 999999999 27.17 43.53 percent of total billed charges HALOPERIDOL LAC 5 MG/ML AMPUL 48260822_1 CDM 0250 RC 10147-0911-01 NDC inpatient 1 UN 44.88 29.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 30.97 69 999999999 27.17 43.53 percent of total billed charges HALOPERIDOL LAC 5 MG/ML AMPUL 48260822_1 CDM 0250 RC 10147-0911-01 NDC inpatient 1 UN 44.88 29.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 35.01 78 999999999 27.17 43.53 percent of total billed charges HALOPERIDOL LAC 5 MG/ML AMPUL 48260822_1 CDM 0250 RC 10147-0911-01 NDC inpatient 1 UN 44.88 29.17 UMR - ALL PLANS UMR - ALL PLANS 31.42 70 999999999 27.17 43.53 percent of total billed charges HALOPERIDOL LAC 5 MG/ML AMPUL 48260822_1 CDM 0250 RC 10147-0911-01 NDC inpatient 1 UN 44.88 29.17 SIHO - ALL PLANS SIHO - ALL PLANS 40.39 90 999999999 27.17 43.53 percent of total billed charges HALOPERIDOL LAC 5 MG/ML AMPUL 48260822_1 CDM 0250 RC 10147-0911-01 NDC inpatient 1 UN 44.88 29.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 27.17 43.53 HALOPERIDOL LAC 5 MG/ML AMPUL 48260822_1 CDM 0250 RC 10147-0911-01 NDC inpatient 1 UN 44.88 29.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27.17 60.55 999999999 27.17 43.53 percent of total billed charges HALOPERIDOL LAC 5 MG/ML AMPUL 48260822_1 CDM 0250 RC 10147-0911-01 NDC inpatient 1 UN 44.88 29.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 27.17 43.53 HALOPERIDOL LAC 5 MG/ML AMPUL 48260822_1 CDM 0250 RC 10147-0911-01 NDC inpatient 1 UN 44.88 29.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 27.17 43.53 HALOPERIDOL LAC 5 MG/ML AMPUL 48260822_1 CDM 0250 RC 10147-0911-01 NDC inpatient 1 UN 44.88 29.17 ANTHEM HMO ANTHEM HMO 999999999 27.17 43.53 HALOPERIDOL LAC 5 MG/ML AMPUL 48260822_1 CDM 0250 RC 10147-0911-01 NDC inpatient 1 UN 44.88 29.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 30.34 67.6 999999999 27.17 43.53 percent of total billed charges HALOPERIDOL LAC 5 MG/ML AMPUL 48260822_1 CDM 0250 RC 10147-0911-01 NDC inpatient 1 UN 44.88 29.17 UHC - ALL PLANS UHC - ALL PLANS 999999999 27.17 43.53 "HEPARIN 2,000 UNIT/2 ML VIAL" 48260824_1 CDM 0250 RC 63323-0276-02 NDC inpatient 1 UN 40.64 26.42 AETNA AETNA 32.11 79 999999999 24.61 39.42 percent of total billed charges "HEPARIN 2,000 UNIT/2 ML VIAL" 48260824_1 CDM 0250 RC 63323-0276-02 NDC inpatient 1 UN 40.64 26.42 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.42 65 999999999 24.61 39.42 percent of total billed charges "HEPARIN 2,000 UNIT/2 ML VIAL" 48260824_1 CDM 0250 RC 63323-0276-02 NDC inpatient 1 UN 40.64 26.42 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39.42 97 999999999 24.61 39.42 percent of total billed charges "HEPARIN 2,000 UNIT/2 ML VIAL" 48260824_1 CDM 0250 RC 63323-0276-02 NDC inpatient 1 UN 40.64 26.42 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.04 69 999999999 24.61 39.42 percent of total billed charges "HEPARIN 2,000 UNIT/2 ML VIAL" 48260824_1 CDM 0250 RC 63323-0276-02 NDC inpatient 1 UN 40.64 26.42 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.7 78 999999999 24.61 39.42 percent of total billed charges "HEPARIN 2,000 UNIT/2 ML VIAL" 48260824_1 CDM 0250 RC 63323-0276-02 NDC inpatient 1 UN 40.64 26.42 UMR - ALL PLANS UMR - ALL PLANS 28.45 70 999999999 24.61 39.42 percent of total billed charges "HEPARIN 2,000 UNIT/2 ML VIAL" 48260824_1 CDM 0250 RC 63323-0276-02 NDC inpatient 1 UN 40.64 26.42 SIHO - ALL PLANS SIHO - ALL PLANS 36.58 90 999999999 24.61 39.42 percent of total billed charges "HEPARIN 2,000 UNIT/2 ML VIAL" 48260824_1 CDM 0250 RC 63323-0276-02 NDC inpatient 1 UN 40.64 26.42 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.61 39.42 "HEPARIN 2,000 UNIT/2 ML VIAL" 48260824_1 CDM 0250 RC 63323-0276-02 NDC inpatient 1 UN 40.64 26.42 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.61 60.55 999999999 24.61 39.42 percent of total billed charges "HEPARIN 2,000 UNIT/2 ML VIAL" 48260824_1 CDM 0250 RC 63323-0276-02 NDC inpatient 1 UN 40.64 26.42 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.61 39.42 "HEPARIN 2,000 UNIT/2 ML VIAL" 48260824_1 CDM 0250 RC 63323-0276-02 NDC inpatient 1 UN 40.64 26.42 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.61 39.42 "HEPARIN 2,000 UNIT/2 ML VIAL" 48260824_1 CDM 0250 RC 63323-0276-02 NDC inpatient 1 UN 40.64 26.42 ANTHEM HMO ANTHEM HMO 999999999 24.61 39.42 "HEPARIN 2,000 UNIT/2 ML VIAL" 48260824_1 CDM 0250 RC 63323-0276-02 NDC inpatient 1 UN 40.64 26.42 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.47 67.6 999999999 24.61 39.42 percent of total billed charges "HEPARIN 2,000 UNIT/2 ML VIAL" 48260824_1 CDM 0250 RC 63323-0276-02 NDC inpatient 1 UN 40.64 26.42 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.61 39.42 "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 48260828_1 CDM 0258 RC 00409-7650-62 NDC J1644 HCPCS inpatient 1 UN 77.76 50.54 AETNA AETNA 61.43 79 999999999 47.08 75.43 percent of total billed charges "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 48260828_1 CDM 0258 RC 00409-7650-62 NDC J1644 HCPCS inpatient 1 UN 77.76 50.54 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.54 65 999999999 47.08 75.43 percent of total billed charges "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 48260828_1 CDM 0258 RC 00409-7650-62 NDC J1644 HCPCS inpatient 1 UN 77.76 50.54 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 75.43 97 999999999 47.08 75.43 percent of total billed charges "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 48260828_1 CDM 0258 RC 00409-7650-62 NDC J1644 HCPCS inpatient 1 UN 77.76 50.54 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.65 69 999999999 47.08 75.43 percent of total billed charges "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 48260828_1 CDM 0258 RC 00409-7650-62 NDC J1644 HCPCS inpatient 1 UN 77.76 50.54 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.65 78 999999999 47.08 75.43 percent of total billed charges "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 48260828_1 CDM 0258 RC 00409-7650-62 NDC J1644 HCPCS inpatient 1 UN 77.76 50.54 UMR - ALL PLANS UMR - ALL PLANS 54.43 70 999999999 47.08 75.43 percent of total billed charges "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 48260828_1 CDM 0258 RC 00409-7650-62 NDC J1644 HCPCS inpatient 1 UN 77.76 50.54 SIHO - ALL PLANS SIHO - ALL PLANS 69.98 90 999999999 47.08 75.43 percent of total billed charges "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 48260828_1 CDM 0258 RC 00409-7650-62 NDC J1644 HCPCS inpatient 1 UN 77.76 50.54 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.08 75.43 "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 48260828_1 CDM 0258 RC 00409-7650-62 NDC J1644 HCPCS inpatient 1 UN 77.76 50.54 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.08 60.55 999999999 47.08 75.43 percent of total billed charges "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 48260828_1 CDM 0258 RC 00409-7650-62 NDC J1644 HCPCS inpatient 1 UN 77.76 50.54 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.08 75.43 "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 48260828_1 CDM 0258 RC 00409-7650-62 NDC J1644 HCPCS inpatient 1 UN 77.76 50.54 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.08 75.43 "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 48260828_1 CDM 0258 RC 00409-7650-62 NDC J1644 HCPCS inpatient 1 UN 77.76 50.54 ANTHEM HMO ANTHEM HMO 999999999 47.08 75.43 "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 48260828_1 CDM 0258 RC 00409-7650-62 NDC J1644 HCPCS inpatient 1 UN 77.76 50.54 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.57 67.6 999999999 47.08 75.43 percent of total billed charges "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 48260828_1 CDM 0258 RC 00409-7650-62 NDC J1644 HCPCS inpatient 1 UN 77.76 50.54 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.08 75.43 "Hepatitis B vaccine, adult dosage (3 dose schedule)" 48260832_1 CDM 0250 RC 58160-0821-52 NDC 90746 HCPCS inpatient 1 UN 69.45 45.14 AETNA AETNA 54.87 79 999999999 42.05 67.37 percent of total billed charges "Hepatitis B vaccine, adult dosage (3 dose schedule)" 48260832_1 CDM 0250 RC 58160-0821-52 NDC 90746 HCPCS inpatient 1 UN 69.45 45.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.14 65 999999999 42.05 67.37 percent of total billed charges "Hepatitis B vaccine, adult dosage (3 dose schedule)" 48260832_1 CDM 0250 RC 58160-0821-52 NDC 90746 HCPCS inpatient 1 UN 69.45 45.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.37 97 999999999 42.05 67.37 percent of total billed charges "Hepatitis B vaccine, adult dosage (3 dose schedule)" 48260832_1 CDM 0250 RC 58160-0821-52 NDC 90746 HCPCS inpatient 1 UN 69.45 45.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 47.92 69 999999999 42.05 67.37 percent of total billed charges "Hepatitis B vaccine, adult dosage (3 dose schedule)" 48260832_1 CDM 0250 RC 58160-0821-52 NDC 90746 HCPCS inpatient 1 UN 69.45 45.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.17 78 999999999 42.05 67.37 percent of total billed charges "Hepatitis B vaccine, adult dosage (3 dose schedule)" 48260832_1 CDM 0250 RC 58160-0821-52 NDC 90746 HCPCS inpatient 1 UN 69.45 45.14 UMR - ALL PLANS UMR - ALL PLANS 48.62 70 999999999 42.05 67.37 percent of total billed charges "Hepatitis B vaccine, adult dosage (3 dose schedule)" 48260832_1 CDM 0250 RC 58160-0821-52 NDC 90746 HCPCS inpatient 1 UN 69.45 45.14 SIHO - ALL PLANS SIHO - ALL PLANS 62.51 90 999999999 42.05 67.37 percent of total billed charges "Hepatitis B vaccine, adult dosage (3 dose schedule)" 48260832_1 CDM 0250 RC 58160-0821-52 NDC 90746 HCPCS inpatient 1 UN 69.45 45.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.05 67.37 "Hepatitis B vaccine, adult dosage (3 dose schedule)" 48260832_1 CDM 0250 RC 58160-0821-52 NDC 90746 HCPCS inpatient 1 UN 69.45 45.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.05 60.55 999999999 42.05 67.37 percent of total billed charges "Hepatitis B vaccine, adult dosage (3 dose schedule)" 48260832_1 CDM 0250 RC 58160-0821-52 NDC 90746 HCPCS inpatient 1 UN 69.45 45.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.05 67.37 "Hepatitis B vaccine, adult dosage (3 dose schedule)" 48260832_1 CDM 0250 RC 58160-0821-52 NDC 90746 HCPCS inpatient 1 UN 69.45 45.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.05 67.37 "Hepatitis B vaccine, adult dosage (3 dose schedule)" 48260832_1 CDM 0250 RC 58160-0821-52 NDC 90746 HCPCS inpatient 1 UN 69.45 45.14 ANTHEM HMO ANTHEM HMO 999999999 42.05 67.37 "Hepatitis B vaccine, adult dosage (3 dose schedule)" 48260832_1 CDM 0250 RC 58160-0821-52 NDC 90746 HCPCS inpatient 1 UN 69.45 45.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 46.95 67.6 999999999 42.05 67.37 percent of total billed charges "Hepatitis B vaccine, adult dosage (3 dose schedule)" 48260832_1 CDM 0250 RC 58160-0821-52 NDC 90746 HCPCS inpatient 1 UN 69.45 45.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.05 67.37 HYDRALAZINE 20 MG/ML VIAL 48260840_1 CDM 0250 RC 63323-0614-55 NDC inpatient 1 UN 35.07 22.8 AETNA AETNA 27.71 79 999999999 21.23 34.02 percent of total billed charges HYDRALAZINE 20 MG/ML VIAL 48260840_1 CDM 0250 RC 63323-0614-55 NDC inpatient 1 UN 35.07 22.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.8 65 999999999 21.23 34.02 percent of total billed charges HYDRALAZINE 20 MG/ML VIAL 48260840_1 CDM 0250 RC 63323-0614-55 NDC inpatient 1 UN 35.07 22.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34.02 97 999999999 21.23 34.02 percent of total billed charges HYDRALAZINE 20 MG/ML VIAL 48260840_1 CDM 0250 RC 63323-0614-55 NDC inpatient 1 UN 35.07 22.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.2 69 999999999 21.23 34.02 percent of total billed charges HYDRALAZINE 20 MG/ML VIAL 48260840_1 CDM 0250 RC 63323-0614-55 NDC inpatient 1 UN 35.07 22.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.35 78 999999999 21.23 34.02 percent of total billed charges HYDRALAZINE 20 MG/ML VIAL 48260840_1 CDM 0250 RC 63323-0614-55 NDC inpatient 1 UN 35.07 22.8 UMR - ALL PLANS UMR - ALL PLANS 24.55 70 999999999 21.23 34.02 percent of total billed charges HYDRALAZINE 20 MG/ML VIAL 48260840_1 CDM 0250 RC 63323-0614-55 NDC inpatient 1 UN 35.07 22.8 SIHO - ALL PLANS SIHO - ALL PLANS 31.56 90 999999999 21.23 34.02 percent of total billed charges HYDRALAZINE 20 MG/ML VIAL 48260840_1 CDM 0250 RC 63323-0614-55 NDC inpatient 1 UN 35.07 22.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.23 34.02 HYDRALAZINE 20 MG/ML VIAL 48260840_1 CDM 0250 RC 63323-0614-55 NDC inpatient 1 UN 35.07 22.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.23 60.55 999999999 21.23 34.02 percent of total billed charges HYDRALAZINE 20 MG/ML VIAL 48260840_1 CDM 0250 RC 63323-0614-55 NDC inpatient 1 UN 35.07 22.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.23 34.02 HYDRALAZINE 20 MG/ML VIAL 48260840_1 CDM 0250 RC 63323-0614-55 NDC inpatient 1 UN 35.07 22.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.23 34.02 HYDRALAZINE 20 MG/ML VIAL 48260840_1 CDM 0250 RC 63323-0614-55 NDC inpatient 1 UN 35.07 22.8 ANTHEM HMO ANTHEM HMO 999999999 21.23 34.02 HYDRALAZINE 20 MG/ML VIAL 48260840_1 CDM 0250 RC 63323-0614-55 NDC inpatient 1 UN 35.07 22.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 23.71 67.6 999999999 21.23 34.02 percent of total billed charges HYDRALAZINE 20 MG/ML VIAL 48260840_1 CDM 0250 RC 63323-0614-55 NDC inpatient 1 UN 35.07 22.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.23 34.02 TRIAMTERENE-HCTZ 75-50 MG TAB 48260845_1 CDM 0250 RC 51079-0433-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 75-50 MG TAB 48260845_1 CDM 0250 RC 51079-0433-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 75-50 MG TAB 48260845_1 CDM 0250 RC 51079-0433-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 75-50 MG TAB 48260845_1 CDM 0250 RC 51079-0433-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 75-50 MG TAB 48260845_1 CDM 0250 RC 51079-0433-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 75-50 MG TAB 48260845_1 CDM 0250 RC 51079-0433-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 75-50 MG TAB 48260845_1 CDM 0250 RC 51079-0433-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 75-50 MG TAB 48260845_1 CDM 0250 RC 51079-0433-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 TRIAMTERENE-HCTZ 75-50 MG TAB 48260845_1 CDM 0250 RC 51079-0433-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 75-50 MG TAB 48260845_1 CDM 0250 RC 51079-0433-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 TRIAMTERENE-HCTZ 75-50 MG TAB 48260845_1 CDM 0250 RC 51079-0433-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 TRIAMTERENE-HCTZ 75-50 MG TAB 48260845_1 CDM 0250 RC 51079-0433-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 TRIAMTERENE-HCTZ 75-50 MG TAB 48260845_1 CDM 0250 RC 51079-0433-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 75-50 MG TAB 48260845_1 CDM 0250 RC 51079-0433-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 SOLU-CORTEF 100 MG ACT-O-VIAL 48260849_1 CDM 0250 RC 00009-0011-04 NDC inpatient 1 UN 66.38 43.15 AETNA AETNA 52.44 79 999999999 40.19 64.39 percent of total billed charges SOLU-CORTEF 100 MG ACT-O-VIAL 48260849_1 CDM 0250 RC 00009-0011-04 NDC inpatient 1 UN 66.38 43.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 43.15 65 999999999 40.19 64.39 percent of total billed charges SOLU-CORTEF 100 MG ACT-O-VIAL 48260849_1 CDM 0250 RC 00009-0011-04 NDC inpatient 1 UN 66.38 43.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.39 97 999999999 40.19 64.39 percent of total billed charges SOLU-CORTEF 100 MG ACT-O-VIAL 48260849_1 CDM 0250 RC 00009-0011-04 NDC inpatient 1 UN 66.38 43.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.8 69 999999999 40.19 64.39 percent of total billed charges SOLU-CORTEF 100 MG ACT-O-VIAL 48260849_1 CDM 0250 RC 00009-0011-04 NDC inpatient 1 UN 66.38 43.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.78 78 999999999 40.19 64.39 percent of total billed charges SOLU-CORTEF 100 MG ACT-O-VIAL 48260849_1 CDM 0250 RC 00009-0011-04 NDC inpatient 1 UN 66.38 43.15 UMR - ALL PLANS UMR - ALL PLANS 46.47 70 999999999 40.19 64.39 percent of total billed charges SOLU-CORTEF 100 MG ACT-O-VIAL 48260849_1 CDM 0250 RC 00009-0011-04 NDC inpatient 1 UN 66.38 43.15 SIHO - ALL PLANS SIHO - ALL PLANS 59.74 90 999999999 40.19 64.39 percent of total billed charges SOLU-CORTEF 100 MG ACT-O-VIAL 48260849_1 CDM 0250 RC 00009-0011-04 NDC inpatient 1 UN 66.38 43.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 40.19 64.39 SOLU-CORTEF 100 MG ACT-O-VIAL 48260849_1 CDM 0250 RC 00009-0011-04 NDC inpatient 1 UN 66.38 43.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 40.19 60.55 999999999 40.19 64.39 percent of total billed charges SOLU-CORTEF 100 MG ACT-O-VIAL 48260849_1 CDM 0250 RC 00009-0011-04 NDC inpatient 1 UN 66.38 43.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 40.19 64.39 SOLU-CORTEF 100 MG ACT-O-VIAL 48260849_1 CDM 0250 RC 00009-0011-04 NDC inpatient 1 UN 66.38 43.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 40.19 64.39 SOLU-CORTEF 100 MG ACT-O-VIAL 48260849_1 CDM 0250 RC 00009-0011-04 NDC inpatient 1 UN 66.38 43.15 ANTHEM HMO ANTHEM HMO 999999999 40.19 64.39 SOLU-CORTEF 100 MG ACT-O-VIAL 48260849_1 CDM 0250 RC 00009-0011-04 NDC inpatient 1 UN 66.38 43.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.87 67.6 999999999 40.19 64.39 percent of total billed charges SOLU-CORTEF 100 MG ACT-O-VIAL 48260849_1 CDM 0250 RC 00009-0011-04 NDC inpatient 1 UN 66.38 43.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 40.19 64.39 SOLU-CORTEF 250 MG ACT-O-VIAL 48260850_1 CDM 0250 RC 00009-0013-06 NDC inpatient 1 UN 120.95 78.62 AETNA AETNA 95.55 79 999999999 73.24 117.32 percent of total billed charges SOLU-CORTEF 250 MG ACT-O-VIAL 48260850_1 CDM 0250 RC 00009-0013-06 NDC inpatient 1 UN 120.95 78.62 SELF PAY DISCOUNT SELF PAY DISCOUNT 78.62 65 999999999 73.24 117.32 percent of total billed charges SOLU-CORTEF 250 MG ACT-O-VIAL 48260850_1 CDM 0250 RC 00009-0013-06 NDC inpatient 1 UN 120.95 78.62 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 117.32 97 999999999 73.24 117.32 percent of total billed charges SOLU-CORTEF 250 MG ACT-O-VIAL 48260850_1 CDM 0250 RC 00009-0013-06 NDC inpatient 1 UN 120.95 78.62 ENCORE - ALL PLANS ENCORE - ALL PLANS 83.46 69 999999999 73.24 117.32 percent of total billed charges SOLU-CORTEF 250 MG ACT-O-VIAL 48260850_1 CDM 0250 RC 00009-0013-06 NDC inpatient 1 UN 120.95 78.62 HUMANA - ALL PLANS HUMANA - ALL PLANS 94.34 78 999999999 73.24 117.32 percent of total billed charges SOLU-CORTEF 250 MG ACT-O-VIAL 48260850_1 CDM 0250 RC 00009-0013-06 NDC inpatient 1 UN 120.95 78.62 UMR - ALL PLANS UMR - ALL PLANS 84.67 70 999999999 73.24 117.32 percent of total billed charges SOLU-CORTEF 250 MG ACT-O-VIAL 48260850_1 CDM 0250 RC 00009-0013-06 NDC inpatient 1 UN 120.95 78.62 SIHO - ALL PLANS SIHO - ALL PLANS 108.86 90 999999999 73.24 117.32 percent of total billed charges SOLU-CORTEF 250 MG ACT-O-VIAL 48260850_1 CDM 0250 RC 00009-0013-06 NDC inpatient 1 UN 120.95 78.62 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.24 117.32 SOLU-CORTEF 250 MG ACT-O-VIAL 48260850_1 CDM 0250 RC 00009-0013-06 NDC inpatient 1 UN 120.95 78.62 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.24 60.55 999999999 73.24 117.32 percent of total billed charges SOLU-CORTEF 250 MG ACT-O-VIAL 48260850_1 CDM 0250 RC 00009-0013-06 NDC inpatient 1 UN 120.95 78.62 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.24 117.32 SOLU-CORTEF 250 MG ACT-O-VIAL 48260850_1 CDM 0250 RC 00009-0013-06 NDC inpatient 1 UN 120.95 78.62 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.24 117.32 SOLU-CORTEF 250 MG ACT-O-VIAL 48260850_1 CDM 0250 RC 00009-0013-06 NDC inpatient 1 UN 120.95 78.62 ANTHEM HMO ANTHEM HMO 999999999 73.24 117.32 SOLU-CORTEF 250 MG ACT-O-VIAL 48260850_1 CDM 0250 RC 00009-0013-06 NDC inpatient 1 UN 120.95 78.62 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.76 67.6 999999999 73.24 117.32 percent of total billed charges SOLU-CORTEF 250 MG ACT-O-VIAL 48260850_1 CDM 0250 RC 00009-0013-06 NDC inpatient 1 UN 120.95 78.62 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.24 117.32 ANUCORT-HC 25 MG SUPPOSITORY 48260852_1 CDM 0250 RC 00713-0503-12 NDC inpatient 1 UN 12.8 8.32 AETNA AETNA 10.11 79 999999999 7.75 12.42 percent of total billed charges ANUCORT-HC 25 MG SUPPOSITORY 48260852_1 CDM 0250 RC 00713-0503-12 NDC inpatient 1 UN 12.8 8.32 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.32 65 999999999 7.75 12.42 percent of total billed charges ANUCORT-HC 25 MG SUPPOSITORY 48260852_1 CDM 0250 RC 00713-0503-12 NDC inpatient 1 UN 12.8 8.32 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.42 97 999999999 7.75 12.42 percent of total billed charges ANUCORT-HC 25 MG SUPPOSITORY 48260852_1 CDM 0250 RC 00713-0503-12 NDC inpatient 1 UN 12.8 8.32 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.83 69 999999999 7.75 12.42 percent of total billed charges ANUCORT-HC 25 MG SUPPOSITORY 48260852_1 CDM 0250 RC 00713-0503-12 NDC inpatient 1 UN 12.8 8.32 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.98 78 999999999 7.75 12.42 percent of total billed charges ANUCORT-HC 25 MG SUPPOSITORY 48260852_1 CDM 0250 RC 00713-0503-12 NDC inpatient 1 UN 12.8 8.32 UMR - ALL PLANS UMR - ALL PLANS 8.96 70 999999999 7.75 12.42 percent of total billed charges ANUCORT-HC 25 MG SUPPOSITORY 48260852_1 CDM 0250 RC 00713-0503-12 NDC inpatient 1 UN 12.8 8.32 SIHO - ALL PLANS SIHO - ALL PLANS 11.52 90 999999999 7.75 12.42 percent of total billed charges ANUCORT-HC 25 MG SUPPOSITORY 48260852_1 CDM 0250 RC 00713-0503-12 NDC inpatient 1 UN 12.8 8.32 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.75 12.42 ANUCORT-HC 25 MG SUPPOSITORY 48260852_1 CDM 0250 RC 00713-0503-12 NDC inpatient 1 UN 12.8 8.32 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.75 60.55 999999999 7.75 12.42 percent of total billed charges ANUCORT-HC 25 MG SUPPOSITORY 48260852_1 CDM 0250 RC 00713-0503-12 NDC inpatient 1 UN 12.8 8.32 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.75 12.42 ANUCORT-HC 25 MG SUPPOSITORY 48260852_1 CDM 0250 RC 00713-0503-12 NDC inpatient 1 UN 12.8 8.32 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.75 12.42 ANUCORT-HC 25 MG SUPPOSITORY 48260852_1 CDM 0250 RC 00713-0503-12 NDC inpatient 1 UN 12.8 8.32 ANTHEM HMO ANTHEM HMO 999999999 7.75 12.42 ANUCORT-HC 25 MG SUPPOSITORY 48260852_1 CDM 0250 RC 00713-0503-12 NDC inpatient 1 UN 12.8 8.32 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.65 67.6 999999999 7.75 12.42 percent of total billed charges ANUCORT-HC 25 MG SUPPOSITORY 48260852_1 CDM 0250 RC 00713-0503-12 NDC inpatient 1 UN 12.8 8.32 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.75 12.42 HYDROCORTISONE 1% CREAM 48260853_1 CDM 0250 RC 45802-0438-03 NDC inpatient 1 UN 6.46 4.2 AETNA AETNA 5.1 79 999999999 3.91 6.27 percent of total billed charges HYDROCORTISONE 1% CREAM 48260853_1 CDM 0250 RC 45802-0438-03 NDC inpatient 1 UN 6.46 4.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.2 65 999999999 3.91 6.27 percent of total billed charges HYDROCORTISONE 1% CREAM 48260853_1 CDM 0250 RC 45802-0438-03 NDC inpatient 1 UN 6.46 4.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.27 97 999999999 3.91 6.27 percent of total billed charges HYDROCORTISONE 1% CREAM 48260853_1 CDM 0250 RC 45802-0438-03 NDC inpatient 1 UN 6.46 4.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.46 69 999999999 3.91 6.27 percent of total billed charges HYDROCORTISONE 1% CREAM 48260853_1 CDM 0250 RC 45802-0438-03 NDC inpatient 1 UN 6.46 4.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 5.04 78 999999999 3.91 6.27 percent of total billed charges HYDROCORTISONE 1% CREAM 48260853_1 CDM 0250 RC 45802-0438-03 NDC inpatient 1 UN 6.46 4.2 UMR - ALL PLANS UMR - ALL PLANS 4.52 70 999999999 3.91 6.27 percent of total billed charges HYDROCORTISONE 1% CREAM 48260853_1 CDM 0250 RC 45802-0438-03 NDC inpatient 1 UN 6.46 4.2 SIHO - ALL PLANS SIHO - ALL PLANS 5.81 90 999999999 3.91 6.27 percent of total billed charges HYDROCORTISONE 1% CREAM 48260853_1 CDM 0250 RC 45802-0438-03 NDC inpatient 1 UN 6.46 4.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.91 6.27 HYDROCORTISONE 1% CREAM 48260853_1 CDM 0250 RC 45802-0438-03 NDC inpatient 1 UN 6.46 4.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.91 60.55 999999999 3.91 6.27 percent of total billed charges HYDROCORTISONE 1% CREAM 48260853_1 CDM 0250 RC 45802-0438-03 NDC inpatient 1 UN 6.46 4.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.91 6.27 HYDROCORTISONE 1% CREAM 48260853_1 CDM 0250 RC 45802-0438-03 NDC inpatient 1 UN 6.46 4.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.91 6.27 HYDROCORTISONE 1% CREAM 48260853_1 CDM 0250 RC 45802-0438-03 NDC inpatient 1 UN 6.46 4.2 ANTHEM HMO ANTHEM HMO 999999999 3.91 6.27 HYDROCORTISONE 1% CREAM 48260853_1 CDM 0250 RC 45802-0438-03 NDC inpatient 1 UN 6.46 4.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.37 67.6 999999999 3.91 6.27 percent of total billed charges HYDROCORTISONE 1% CREAM 48260853_1 CDM 0250 RC 45802-0438-03 NDC inpatient 1 UN 6.46 4.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.91 6.27 NEOMYCIN-POLYMYXIN-HC EAR SUSP 48260857_1 CDM 0250 RC 24208-0635-62 NDC inpatient 1 UN 110.13 71.58 AETNA AETNA 87 79 999999999 66.68 106.83 percent of total billed charges NEOMYCIN-POLYMYXIN-HC EAR SUSP 48260857_1 CDM 0250 RC 24208-0635-62 NDC inpatient 1 UN 110.13 71.58 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.58 65 999999999 66.68 106.83 percent of total billed charges NEOMYCIN-POLYMYXIN-HC EAR SUSP 48260857_1 CDM 0250 RC 24208-0635-62 NDC inpatient 1 UN 110.13 71.58 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.83 97 999999999 66.68 106.83 percent of total billed charges NEOMYCIN-POLYMYXIN-HC EAR SUSP 48260857_1 CDM 0250 RC 24208-0635-62 NDC inpatient 1 UN 110.13 71.58 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.99 69 999999999 66.68 106.83 percent of total billed charges NEOMYCIN-POLYMYXIN-HC EAR SUSP 48260857_1 CDM 0250 RC 24208-0635-62 NDC inpatient 1 UN 110.13 71.58 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.9 78 999999999 66.68 106.83 percent of total billed charges NEOMYCIN-POLYMYXIN-HC EAR SUSP 48260857_1 CDM 0250 RC 24208-0635-62 NDC inpatient 1 UN 110.13 71.58 UMR - ALL PLANS UMR - ALL PLANS 77.09 70 999999999 66.68 106.83 percent of total billed charges NEOMYCIN-POLYMYXIN-HC EAR SUSP 48260857_1 CDM 0250 RC 24208-0635-62 NDC inpatient 1 UN 110.13 71.58 SIHO - ALL PLANS SIHO - ALL PLANS 99.12 90 999999999 66.68 106.83 percent of total billed charges NEOMYCIN-POLYMYXIN-HC EAR SUSP 48260857_1 CDM 0250 RC 24208-0635-62 NDC inpatient 1 UN 110.13 71.58 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.68 106.83 NEOMYCIN-POLYMYXIN-HC EAR SUSP 48260857_1 CDM 0250 RC 24208-0635-62 NDC inpatient 1 UN 110.13 71.58 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.68 60.55 999999999 66.68 106.83 percent of total billed charges NEOMYCIN-POLYMYXIN-HC EAR SUSP 48260857_1 CDM 0250 RC 24208-0635-62 NDC inpatient 1 UN 110.13 71.58 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.68 106.83 NEOMYCIN-POLYMYXIN-HC EAR SUSP 48260857_1 CDM 0250 RC 24208-0635-62 NDC inpatient 1 UN 110.13 71.58 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.68 106.83 NEOMYCIN-POLYMYXIN-HC EAR SUSP 48260857_1 CDM 0250 RC 24208-0635-62 NDC inpatient 1 UN 110.13 71.58 ANTHEM HMO ANTHEM HMO 999999999 66.68 106.83 NEOMYCIN-POLYMYXIN-HC EAR SUSP 48260857_1 CDM 0250 RC 24208-0635-62 NDC inpatient 1 UN 110.13 71.58 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.45 67.6 999999999 66.68 106.83 percent of total billed charges NEOMYCIN-POLYMYXIN-HC EAR SUSP 48260857_1 CDM 0250 RC 24208-0635-62 NDC inpatient 1 UN 110.13 71.58 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.68 106.83 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260859_1 CDM 0250 RC 00409-1283-31 NDC J1170 HCPCS inpatient 1 UN 27.5 17.88 AETNA AETNA 21.73 79 999999999 16.65 26.68 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260859_1 CDM 0250 RC 00409-1283-31 NDC J1170 HCPCS inpatient 1 UN 27.5 17.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.88 65 999999999 16.65 26.68 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260859_1 CDM 0250 RC 00409-1283-31 NDC J1170 HCPCS inpatient 1 UN 27.5 17.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26.68 97 999999999 16.65 26.68 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260859_1 CDM 0250 RC 00409-1283-31 NDC J1170 HCPCS inpatient 1 UN 27.5 17.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.98 69 999999999 16.65 26.68 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260859_1 CDM 0250 RC 00409-1283-31 NDC J1170 HCPCS inpatient 1 UN 27.5 17.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.45 78 999999999 16.65 26.68 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260859_1 CDM 0250 RC 00409-1283-31 NDC J1170 HCPCS inpatient 1 UN 27.5 17.88 UMR - ALL PLANS UMR - ALL PLANS 19.25 70 999999999 16.65 26.68 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260859_1 CDM 0250 RC 00409-1283-31 NDC J1170 HCPCS inpatient 1 UN 27.5 17.88 SIHO - ALL PLANS SIHO - ALL PLANS 24.75 90 999999999 16.65 26.68 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260859_1 CDM 0250 RC 00409-1283-31 NDC J1170 HCPCS inpatient 1 UN 27.5 17.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.65 26.68 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260859_1 CDM 0250 RC 00409-1283-31 NDC J1170 HCPCS inpatient 1 UN 27.5 17.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.65 60.55 999999999 16.65 26.68 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260859_1 CDM 0250 RC 00409-1283-31 NDC J1170 HCPCS inpatient 1 UN 27.5 17.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.65 26.68 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260859_1 CDM 0250 RC 00409-1283-31 NDC J1170 HCPCS inpatient 1 UN 27.5 17.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.65 26.68 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260859_1 CDM 0250 RC 00409-1283-31 NDC J1170 HCPCS inpatient 1 UN 27.5 17.88 ANTHEM HMO ANTHEM HMO 999999999 16.65 26.68 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260859_1 CDM 0250 RC 00409-1283-31 NDC J1170 HCPCS inpatient 1 UN 27.5 17.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.59 67.6 999999999 16.65 26.68 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260859_1 CDM 0250 RC 00409-1283-31 NDC J1170 HCPCS inpatient 1 UN 27.5 17.88 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.65 26.68 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260861_1 CDM 0250 RC 00409-3365-01 NDC J1170 HCPCS inpatient 1 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260861_1 CDM 0250 RC 00409-3365-01 NDC J1170 HCPCS inpatient 1 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260861_1 CDM 0250 RC 00409-3365-01 NDC J1170 HCPCS inpatient 1 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260861_1 CDM 0250 RC 00409-3365-01 NDC J1170 HCPCS inpatient 1 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260861_1 CDM 0250 RC 00409-3365-01 NDC J1170 HCPCS inpatient 1 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260861_1 CDM 0250 RC 00409-3365-01 NDC J1170 HCPCS inpatient 1 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260861_1 CDM 0250 RC 00409-3365-01 NDC J1170 HCPCS inpatient 1 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260861_1 CDM 0250 RC 00409-3365-01 NDC J1170 HCPCS inpatient 1 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260861_1 CDM 0250 RC 00409-3365-01 NDC J1170 HCPCS inpatient 1 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260861_1 CDM 0250 RC 00409-3365-01 NDC J1170 HCPCS inpatient 1 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260861_1 CDM 0250 RC 00409-3365-01 NDC J1170 HCPCS inpatient 1 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260861_1 CDM 0250 RC 00409-3365-01 NDC J1170 HCPCS inpatient 1 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260861_1 CDM 0250 RC 00409-3365-01 NDC J1170 HCPCS inpatient 1 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 48260861_1 CDM 0250 RC 00409-3365-01 NDC J1170 HCPCS inpatient 1 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 HYDROMORPHONE 2 MG TABLET 48260862_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.67 1.09 AETNA AETNA 1.32 79 999999999 1.01 1.62 percent of total billed charges HYDROMORPHONE 2 MG TABLET 48260862_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.67 1.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.09 65 999999999 1.01 1.62 percent of total billed charges HYDROMORPHONE 2 MG TABLET 48260862_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.67 1.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.62 97 999999999 1.01 1.62 percent of total billed charges HYDROMORPHONE 2 MG TABLET 48260862_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.67 1.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.15 69 999999999 1.01 1.62 percent of total billed charges HYDROMORPHONE 2 MG TABLET 48260862_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.67 1.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.3 78 999999999 1.01 1.62 percent of total billed charges HYDROMORPHONE 2 MG TABLET 48260862_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.67 1.09 UMR - ALL PLANS UMR - ALL PLANS 1.17 70 999999999 1.01 1.62 percent of total billed charges HYDROMORPHONE 2 MG TABLET 48260862_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.67 1.09 SIHO - ALL PLANS SIHO - ALL PLANS 1.5 90 999999999 1.01 1.62 percent of total billed charges HYDROMORPHONE 2 MG TABLET 48260862_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.67 1.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.01 1.62 HYDROMORPHONE 2 MG TABLET 48260862_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.67 1.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.01 60.55 999999999 1.01 1.62 percent of total billed charges HYDROMORPHONE 2 MG TABLET 48260862_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.67 1.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.01 1.62 HYDROMORPHONE 2 MG TABLET 48260862_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.67 1.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.01 1.62 HYDROMORPHONE 2 MG TABLET 48260862_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.67 1.09 ANTHEM HMO ANTHEM HMO 999999999 1.01 1.62 HYDROMORPHONE 2 MG TABLET 48260862_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.67 1.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.13 67.6 999999999 1.01 1.62 percent of total billed charges HYDROMORPHONE 2 MG TABLET 48260862_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.67 1.09 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.01 1.62 68084-0472-01 - HYDROmorphone 4 mg Tab [JOHN] 48260863_1 CDM 0250 RC 68084-0472-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 68084-0472-01 - HYDROmorphone 4 mg Tab [JOHN] 48260863_1 CDM 0250 RC 68084-0472-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 68084-0472-01 - HYDROmorphone 4 mg Tab [JOHN] 48260863_1 CDM 0250 RC 68084-0472-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 68084-0472-01 - HYDROmorphone 4 mg Tab [JOHN] 48260863_1 CDM 0250 RC 68084-0472-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 68084-0472-01 - HYDROmorphone 4 mg Tab [JOHN] 48260863_1 CDM 0250 RC 68084-0472-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 68084-0472-01 - HYDROmorphone 4 mg Tab [JOHN] 48260863_1 CDM 0250 RC 68084-0472-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 68084-0472-01 - HYDROmorphone 4 mg Tab [JOHN] 48260863_1 CDM 0250 RC 68084-0472-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 68084-0472-01 - HYDROmorphone 4 mg Tab [JOHN] 48260863_1 CDM 0250 RC 68084-0472-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 68084-0472-01 - HYDROmorphone 4 mg Tab [JOHN] 48260863_1 CDM 0250 RC 68084-0472-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 68084-0472-01 - HYDROmorphone 4 mg Tab [JOHN] 48260863_1 CDM 0250 RC 68084-0472-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 68084-0472-01 - HYDROmorphone 4 mg Tab [JOHN] 48260863_1 CDM 0250 RC 68084-0472-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 68084-0472-01 - HYDROmorphone 4 mg Tab [JOHN] 48260863_1 CDM 0250 RC 68084-0472-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 68084-0472-01 - HYDROmorphone 4 mg Tab [JOHN] 48260863_1 CDM 0250 RC 68084-0472-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 68084-0472-01 - HYDROmorphone 4 mg Tab [JOHN] 48260863_1 CDM 0250 RC 68084-0472-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "HYDROXYUREA, ORAL, 500 MG" 48260866_1 CDM 0250 RC 49884-0724-01 NDC S0176 HCPCS inpatient 1 UN 1.84 1.2 AETNA AETNA 1.45 79 999999999 1.11 1.78 percent of total billed charges "HYDROXYUREA, ORAL, 500 MG" 48260866_1 CDM 0250 RC 49884-0724-01 NDC S0176 HCPCS inpatient 1 UN 1.84 1.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.2 65 999999999 1.11 1.78 percent of total billed charges "HYDROXYUREA, ORAL, 500 MG" 48260866_1 CDM 0250 RC 49884-0724-01 NDC S0176 HCPCS inpatient 1 UN 1.84 1.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.78 97 999999999 1.11 1.78 percent of total billed charges "HYDROXYUREA, ORAL, 500 MG" 48260866_1 CDM 0250 RC 49884-0724-01 NDC S0176 HCPCS inpatient 1 UN 1.84 1.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.27 69 999999999 1.11 1.78 percent of total billed charges "HYDROXYUREA, ORAL, 500 MG" 48260866_1 CDM 0250 RC 49884-0724-01 NDC S0176 HCPCS inpatient 1 UN 1.84 1.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.44 78 999999999 1.11 1.78 percent of total billed charges "HYDROXYUREA, ORAL, 500 MG" 48260866_1 CDM 0250 RC 49884-0724-01 NDC S0176 HCPCS inpatient 1 UN 1.84 1.2 UMR - ALL PLANS UMR - ALL PLANS 1.29 70 999999999 1.11 1.78 percent of total billed charges "HYDROXYUREA, ORAL, 500 MG" 48260866_1 CDM 0250 RC 49884-0724-01 NDC S0176 HCPCS inpatient 1 UN 1.84 1.2 SIHO - ALL PLANS SIHO - ALL PLANS 1.66 90 999999999 1.11 1.78 percent of total billed charges "HYDROXYUREA, ORAL, 500 MG" 48260866_1 CDM 0250 RC 49884-0724-01 NDC S0176 HCPCS inpatient 1 UN 1.84 1.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.11 1.78 "HYDROXYUREA, ORAL, 500 MG" 48260866_1 CDM 0250 RC 49884-0724-01 NDC S0176 HCPCS inpatient 1 UN 1.84 1.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.11 60.55 999999999 1.11 1.78 percent of total billed charges "HYDROXYUREA, ORAL, 500 MG" 48260866_1 CDM 0250 RC 49884-0724-01 NDC S0176 HCPCS inpatient 1 UN 1.84 1.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.11 1.78 "HYDROXYUREA, ORAL, 500 MG" 48260866_1 CDM 0250 RC 49884-0724-01 NDC S0176 HCPCS inpatient 1 UN 1.84 1.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.11 1.78 "HYDROXYUREA, ORAL, 500 MG" 48260866_1 CDM 0250 RC 49884-0724-01 NDC S0176 HCPCS inpatient 1 UN 1.84 1.2 ANTHEM HMO ANTHEM HMO 999999999 1.11 1.78 "HYDROXYUREA, ORAL, 500 MG" 48260866_1 CDM 0250 RC 49884-0724-01 NDC S0176 HCPCS inpatient 1 UN 1.84 1.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.24 67.6 999999999 1.11 1.78 percent of total billed charges "HYDROXYUREA, ORAL, 500 MG" 48260866_1 CDM 0250 RC 49884-0724-01 NDC S0176 HCPCS inpatient 1 UN 1.84 1.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.11 1.78 HYDROXYZINE HCL 10 MG TABLET 48260867_1 CDM 0250 RC 00093-5060-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges HYDROXYZINE HCL 10 MG TABLET 48260867_1 CDM 0250 RC 00093-5060-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges HYDROXYZINE HCL 10 MG TABLET 48260867_1 CDM 0250 RC 00093-5060-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges HYDROXYZINE HCL 10 MG TABLET 48260867_1 CDM 0250 RC 00093-5060-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges HYDROXYZINE HCL 10 MG TABLET 48260867_1 CDM 0250 RC 00093-5060-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges HYDROXYZINE HCL 10 MG TABLET 48260867_1 CDM 0250 RC 00093-5060-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges HYDROXYZINE HCL 10 MG TABLET 48260867_1 CDM 0250 RC 00093-5060-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges HYDROXYZINE HCL 10 MG TABLET 48260867_1 CDM 0250 RC 00093-5060-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 HYDROXYZINE HCL 10 MG TABLET 48260867_1 CDM 0250 RC 00093-5060-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges HYDROXYZINE HCL 10 MG TABLET 48260867_1 CDM 0250 RC 00093-5060-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 HYDROXYZINE HCL 10 MG TABLET 48260867_1 CDM 0250 RC 00093-5060-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 HYDROXYZINE HCL 10 MG TABLET 48260867_1 CDM 0250 RC 00093-5060-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 HYDROXYZINE HCL 10 MG TABLET 48260867_1 CDM 0250 RC 00093-5060-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges HYDROXYZINE HCL 10 MG TABLET 48260867_1 CDM 0250 RC 00093-5060-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 HYDROXYZINE HCL 25 MG TABLET 48260868_1 CDM 0250 RC 68084-0254-01 NDC inpatient 1 UN 1.96 1.27 AETNA AETNA 1.55 79 999999999 1.19 1.9 percent of total billed charges HYDROXYZINE HCL 25 MG TABLET 48260868_1 CDM 0250 RC 68084-0254-01 NDC inpatient 1 UN 1.96 1.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.27 65 999999999 1.19 1.9 percent of total billed charges HYDROXYZINE HCL 25 MG TABLET 48260868_1 CDM 0250 RC 68084-0254-01 NDC inpatient 1 UN 1.96 1.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.9 97 999999999 1.19 1.9 percent of total billed charges HYDROXYZINE HCL 25 MG TABLET 48260868_1 CDM 0250 RC 68084-0254-01 NDC inpatient 1 UN 1.96 1.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.35 69 999999999 1.19 1.9 percent of total billed charges HYDROXYZINE HCL 25 MG TABLET 48260868_1 CDM 0250 RC 68084-0254-01 NDC inpatient 1 UN 1.96 1.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.53 78 999999999 1.19 1.9 percent of total billed charges HYDROXYZINE HCL 25 MG TABLET 48260868_1 CDM 0250 RC 68084-0254-01 NDC inpatient 1 UN 1.96 1.27 UMR - ALL PLANS UMR - ALL PLANS 1.37 70 999999999 1.19 1.9 percent of total billed charges HYDROXYZINE HCL 25 MG TABLET 48260868_1 CDM 0250 RC 68084-0254-01 NDC inpatient 1 UN 1.96 1.27 SIHO - ALL PLANS SIHO - ALL PLANS 1.76 90 999999999 1.19 1.9 percent of total billed charges HYDROXYZINE HCL 25 MG TABLET 48260868_1 CDM 0250 RC 68084-0254-01 NDC inpatient 1 UN 1.96 1.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.19 1.9 HYDROXYZINE HCL 25 MG TABLET 48260868_1 CDM 0250 RC 68084-0254-01 NDC inpatient 1 UN 1.96 1.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.19 60.55 999999999 1.19 1.9 percent of total billed charges HYDROXYZINE HCL 25 MG TABLET 48260868_1 CDM 0250 RC 68084-0254-01 NDC inpatient 1 UN 1.96 1.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.19 1.9 HYDROXYZINE HCL 25 MG TABLET 48260868_1 CDM 0250 RC 68084-0254-01 NDC inpatient 1 UN 1.96 1.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.19 1.9 HYDROXYZINE HCL 25 MG TABLET 48260868_1 CDM 0250 RC 68084-0254-01 NDC inpatient 1 UN 1.96 1.27 ANTHEM HMO ANTHEM HMO 999999999 1.19 1.9 HYDROXYZINE HCL 25 MG TABLET 48260868_1 CDM 0250 RC 68084-0254-01 NDC inpatient 1 UN 1.96 1.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.33 67.6 999999999 1.19 1.9 percent of total billed charges HYDROXYZINE HCL 25 MG TABLET 48260868_1 CDM 0250 RC 68084-0254-01 NDC inpatient 1 UN 1.96 1.27 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.19 1.9 HYDROXYZINE HCL 50 MG TABLET 48260869_1 CDM 0250 RC 68084-0255-01 NDC inpatient 1 UN 1.96 1.27 AETNA AETNA 1.55 79 999999999 1.19 1.9 percent of total billed charges HYDROXYZINE HCL 50 MG TABLET 48260869_1 CDM 0250 RC 68084-0255-01 NDC inpatient 1 UN 1.96 1.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.27 65 999999999 1.19 1.9 percent of total billed charges HYDROXYZINE HCL 50 MG TABLET 48260869_1 CDM 0250 RC 68084-0255-01 NDC inpatient 1 UN 1.96 1.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.9 97 999999999 1.19 1.9 percent of total billed charges HYDROXYZINE HCL 50 MG TABLET 48260869_1 CDM 0250 RC 68084-0255-01 NDC inpatient 1 UN 1.96 1.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.35 69 999999999 1.19 1.9 percent of total billed charges HYDROXYZINE HCL 50 MG TABLET 48260869_1 CDM 0250 RC 68084-0255-01 NDC inpatient 1 UN 1.96 1.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.53 78 999999999 1.19 1.9 percent of total billed charges HYDROXYZINE HCL 50 MG TABLET 48260869_1 CDM 0250 RC 68084-0255-01 NDC inpatient 1 UN 1.96 1.27 UMR - ALL PLANS UMR - ALL PLANS 1.37 70 999999999 1.19 1.9 percent of total billed charges HYDROXYZINE HCL 50 MG TABLET 48260869_1 CDM 0250 RC 68084-0255-01 NDC inpatient 1 UN 1.96 1.27 SIHO - ALL PLANS SIHO - ALL PLANS 1.76 90 999999999 1.19 1.9 percent of total billed charges HYDROXYZINE HCL 50 MG TABLET 48260869_1 CDM 0250 RC 68084-0255-01 NDC inpatient 1 UN 1.96 1.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.19 1.9 HYDROXYZINE HCL 50 MG TABLET 48260869_1 CDM 0250 RC 68084-0255-01 NDC inpatient 1 UN 1.96 1.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.19 60.55 999999999 1.19 1.9 percent of total billed charges HYDROXYZINE HCL 50 MG TABLET 48260869_1 CDM 0250 RC 68084-0255-01 NDC inpatient 1 UN 1.96 1.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.19 1.9 HYDROXYZINE HCL 50 MG TABLET 48260869_1 CDM 0250 RC 68084-0255-01 NDC inpatient 1 UN 1.96 1.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.19 1.9 HYDROXYZINE HCL 50 MG TABLET 48260869_1 CDM 0250 RC 68084-0255-01 NDC inpatient 1 UN 1.96 1.27 ANTHEM HMO ANTHEM HMO 999999999 1.19 1.9 HYDROXYZINE HCL 50 MG TABLET 48260869_1 CDM 0250 RC 68084-0255-01 NDC inpatient 1 UN 1.96 1.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.33 67.6 999999999 1.19 1.9 percent of total billed charges HYDROXYZINE HCL 50 MG TABLET 48260869_1 CDM 0250 RC 68084-0255-01 NDC inpatient 1 UN 1.96 1.27 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.19 1.9 HYOSYNE 0.125 MG/ML DROP 48260873_1 CDM 0250 RC 54838-0506-15 NDC inpatient 1 UN 71.1 46.22 AETNA AETNA 56.17 79 999999999 43.05 68.97 percent of total billed charges HYOSYNE 0.125 MG/ML DROP 48260873_1 CDM 0250 RC 54838-0506-15 NDC inpatient 1 UN 71.1 46.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.22 65 999999999 43.05 68.97 percent of total billed charges HYOSYNE 0.125 MG/ML DROP 48260873_1 CDM 0250 RC 54838-0506-15 NDC inpatient 1 UN 71.1 46.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 68.97 97 999999999 43.05 68.97 percent of total billed charges HYOSYNE 0.125 MG/ML DROP 48260873_1 CDM 0250 RC 54838-0506-15 NDC inpatient 1 UN 71.1 46.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.06 69 999999999 43.05 68.97 percent of total billed charges HYOSYNE 0.125 MG/ML DROP 48260873_1 CDM 0250 RC 54838-0506-15 NDC inpatient 1 UN 71.1 46.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 55.46 78 999999999 43.05 68.97 percent of total billed charges HYOSYNE 0.125 MG/ML DROP 48260873_1 CDM 0250 RC 54838-0506-15 NDC inpatient 1 UN 71.1 46.22 UMR - ALL PLANS UMR - ALL PLANS 49.77 70 999999999 43.05 68.97 percent of total billed charges HYOSYNE 0.125 MG/ML DROP 48260873_1 CDM 0250 RC 54838-0506-15 NDC inpatient 1 UN 71.1 46.22 SIHO - ALL PLANS SIHO - ALL PLANS 63.99 90 999999999 43.05 68.97 percent of total billed charges HYOSYNE 0.125 MG/ML DROP 48260873_1 CDM 0250 RC 54838-0506-15 NDC inpatient 1 UN 71.1 46.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.05 68.97 HYOSYNE 0.125 MG/ML DROP 48260873_1 CDM 0250 RC 54838-0506-15 NDC inpatient 1 UN 71.1 46.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.05 60.55 999999999 43.05 68.97 percent of total billed charges HYOSYNE 0.125 MG/ML DROP 48260873_1 CDM 0250 RC 54838-0506-15 NDC inpatient 1 UN 71.1 46.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.05 68.97 HYOSYNE 0.125 MG/ML DROP 48260873_1 CDM 0250 RC 54838-0506-15 NDC inpatient 1 UN 71.1 46.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.05 68.97 HYOSYNE 0.125 MG/ML DROP 48260873_1 CDM 0250 RC 54838-0506-15 NDC inpatient 1 UN 71.1 46.22 ANTHEM HMO ANTHEM HMO 999999999 43.05 68.97 HYOSYNE 0.125 MG/ML DROP 48260873_1 CDM 0250 RC 54838-0506-15 NDC inpatient 1 UN 71.1 46.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.06 67.6 999999999 43.05 68.97 percent of total billed charges HYOSYNE 0.125 MG/ML DROP 48260873_1 CDM 0250 RC 54838-0506-15 NDC inpatient 1 UN 71.1 46.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.05 68.97 00472-1270-94 - ibuprofen 100 mg/5 mL Oral Susp [JOHN] 48260874_1 CDM 0250 RC 00472-1270-94 NDC inpatient 1 UN 22.75 14.79 AETNA AETNA 17.97 79 999999999 13.78 22.07 percent of total billed charges 00472-1270-94 - ibuprofen 100 mg/5 mL Oral Susp [JOHN] 48260874_1 CDM 0250 RC 00472-1270-94 NDC inpatient 1 UN 22.75 14.79 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.79 65 999999999 13.78 22.07 percent of total billed charges 00472-1270-94 - ibuprofen 100 mg/5 mL Oral Susp [JOHN] 48260874_1 CDM 0250 RC 00472-1270-94 NDC inpatient 1 UN 22.75 14.79 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22.07 97 999999999 13.78 22.07 percent of total billed charges 00472-1270-94 - ibuprofen 100 mg/5 mL Oral Susp [JOHN] 48260874_1 CDM 0250 RC 00472-1270-94 NDC inpatient 1 UN 22.75 14.79 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.7 69 999999999 13.78 22.07 percent of total billed charges 00472-1270-94 - ibuprofen 100 mg/5 mL Oral Susp [JOHN] 48260874_1 CDM 0250 RC 00472-1270-94 NDC inpatient 1 UN 22.75 14.79 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.75 78 999999999 13.78 22.07 percent of total billed charges 00472-1270-94 - ibuprofen 100 mg/5 mL Oral Susp [JOHN] 48260874_1 CDM 0250 RC 00472-1270-94 NDC inpatient 1 UN 22.75 14.79 UMR - ALL PLANS UMR - ALL PLANS 15.93 70 999999999 13.78 22.07 percent of total billed charges 00472-1270-94 - ibuprofen 100 mg/5 mL Oral Susp [JOHN] 48260874_1 CDM 0250 RC 00472-1270-94 NDC inpatient 1 UN 22.75 14.79 SIHO - ALL PLANS SIHO - ALL PLANS 20.48 90 999999999 13.78 22.07 percent of total billed charges 00472-1270-94 - ibuprofen 100 mg/5 mL Oral Susp [JOHN] 48260874_1 CDM 0250 RC 00472-1270-94 NDC inpatient 1 UN 22.75 14.79 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.78 22.07 00472-1270-94 - ibuprofen 100 mg/5 mL Oral Susp [JOHN] 48260874_1 CDM 0250 RC 00472-1270-94 NDC inpatient 1 UN 22.75 14.79 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.78 60.55 999999999 13.78 22.07 percent of total billed charges 00472-1270-94 - ibuprofen 100 mg/5 mL Oral Susp [JOHN] 48260874_1 CDM 0250 RC 00472-1270-94 NDC inpatient 1 UN 22.75 14.79 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.78 22.07 00472-1270-94 - ibuprofen 100 mg/5 mL Oral Susp [JOHN] 48260874_1 CDM 0250 RC 00472-1270-94 NDC inpatient 1 UN 22.75 14.79 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.78 22.07 00472-1270-94 - ibuprofen 100 mg/5 mL Oral Susp [JOHN] 48260874_1 CDM 0250 RC 00472-1270-94 NDC inpatient 1 UN 22.75 14.79 ANTHEM HMO ANTHEM HMO 999999999 13.78 22.07 00472-1270-94 - ibuprofen 100 mg/5 mL Oral Susp [JOHN] 48260874_1 CDM 0250 RC 00472-1270-94 NDC inpatient 1 UN 22.75 14.79 CIGNA - ALL PLANS CIGNA - ALL PLANS 15.38 67.6 999999999 13.78 22.07 percent of total billed charges 00472-1270-94 - ibuprofen 100 mg/5 mL Oral Susp [JOHN] 48260874_1 CDM 0250 RC 00472-1270-94 NDC inpatient 1 UN 22.75 14.79 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.78 22.07 "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260885_1 CDM 0636 RC 44206-0437-10 NDC J1459 HCPCS inpatient 20 UN 1747.46 1135.85 AETNA AETNA 1380.49 79 999999999 1058.09 1695.04 percent of total billed charges "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260885_1 CDM 0636 RC 44206-0437-10 NDC J1459 HCPCS inpatient 20 UN 1747.46 1135.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1135.85 65 999999999 1058.09 1695.04 percent of total billed charges "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260885_1 CDM 0636 RC 44206-0437-10 NDC J1459 HCPCS inpatient 20 UN 1747.46 1135.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1695.04 97 999999999 1058.09 1695.04 percent of total billed charges "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260885_1 CDM 0636 RC 44206-0437-10 NDC J1459 HCPCS inpatient 20 UN 1747.46 1135.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1205.75 69 999999999 1058.09 1695.04 percent of total billed charges "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260885_1 CDM 0636 RC 44206-0437-10 NDC J1459 HCPCS inpatient 20 UN 1747.46 1135.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1363.02 78 999999999 1058.09 1695.04 percent of total billed charges "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260885_1 CDM 0636 RC 44206-0437-10 NDC J1459 HCPCS inpatient 20 UN 1747.46 1135.85 UMR - ALL PLANS UMR - ALL PLANS 1223.22 70 999999999 1058.09 1695.04 percent of total billed charges "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260885_1 CDM 0636 RC 44206-0437-10 NDC J1459 HCPCS inpatient 20 UN 1747.46 1135.85 SIHO - ALL PLANS SIHO - ALL PLANS 1572.71 90 999999999 1058.09 1695.04 percent of total billed charges "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260885_1 CDM 0636 RC 44206-0437-10 NDC J1459 HCPCS inpatient 20 UN 1747.46 1135.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1058.09 1695.04 "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260885_1 CDM 0636 RC 44206-0437-10 NDC J1459 HCPCS inpatient 20 UN 1747.46 1135.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1058.09 60.55 999999999 1058.09 1695.04 percent of total billed charges "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260885_1 CDM 0636 RC 44206-0437-10 NDC J1459 HCPCS inpatient 20 UN 1747.46 1135.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1058.09 1695.04 "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260885_1 CDM 0636 RC 44206-0437-10 NDC J1459 HCPCS inpatient 20 UN 1747.46 1135.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1058.09 1695.04 "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260885_1 CDM 0636 RC 44206-0437-10 NDC J1459 HCPCS inpatient 20 UN 1747.46 1135.85 ANTHEM HMO ANTHEM HMO 999999999 1058.09 1695.04 "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260885_1 CDM 0636 RC 44206-0437-10 NDC J1459 HCPCS inpatient 20 UN 1747.46 1135.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1181.28 67.6 999999999 1058.09 1695.04 percent of total billed charges "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260885_1 CDM 0636 RC 44206-0437-10 NDC J1459 HCPCS inpatient 20 UN 1747.46 1135.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1058.09 1695.04 "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260886_1 CDM 0636 RC 44206-0438-20 NDC J1459 HCPCS inpatient 40 UN 3817.11 2481.12 AETNA AETNA 3015.52 79 999999999 2311.26 3702.6 percent of total billed charges "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260886_1 CDM 0636 RC 44206-0438-20 NDC J1459 HCPCS inpatient 40 UN 3817.11 2481.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 2481.12 65 999999999 2311.26 3702.6 percent of total billed charges "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260886_1 CDM 0636 RC 44206-0438-20 NDC J1459 HCPCS inpatient 40 UN 3817.11 2481.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3702.6 97 999999999 2311.26 3702.6 percent of total billed charges "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260886_1 CDM 0636 RC 44206-0438-20 NDC J1459 HCPCS inpatient 40 UN 3817.11 2481.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 2633.81 69 999999999 2311.26 3702.6 percent of total billed charges "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260886_1 CDM 0636 RC 44206-0438-20 NDC J1459 HCPCS inpatient 40 UN 3817.11 2481.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 2977.35 78 999999999 2311.26 3702.6 percent of total billed charges "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260886_1 CDM 0636 RC 44206-0438-20 NDC J1459 HCPCS inpatient 40 UN 3817.11 2481.12 UMR - ALL PLANS UMR - ALL PLANS 2671.98 70 999999999 2311.26 3702.6 percent of total billed charges "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260886_1 CDM 0636 RC 44206-0438-20 NDC J1459 HCPCS inpatient 40 UN 3817.11 2481.12 SIHO - ALL PLANS SIHO - ALL PLANS 3435.4 90 999999999 2311.26 3702.6 percent of total billed charges "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260886_1 CDM 0636 RC 44206-0438-20 NDC J1459 HCPCS inpatient 40 UN 3817.11 2481.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2311.26 3702.6 "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260886_1 CDM 0636 RC 44206-0438-20 NDC J1459 HCPCS inpatient 40 UN 3817.11 2481.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2311.26 60.55 999999999 2311.26 3702.6 percent of total billed charges "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260886_1 CDM 0636 RC 44206-0438-20 NDC J1459 HCPCS inpatient 40 UN 3817.11 2481.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2311.26 3702.6 "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260886_1 CDM 0636 RC 44206-0438-20 NDC J1459 HCPCS inpatient 40 UN 3817.11 2481.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2311.26 3702.6 "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260886_1 CDM 0636 RC 44206-0438-20 NDC J1459 HCPCS inpatient 40 UN 3817.11 2481.12 ANTHEM HMO ANTHEM HMO 999999999 2311.26 3702.6 "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260886_1 CDM 0636 RC 44206-0438-20 NDC J1459 HCPCS inpatient 40 UN 3817.11 2481.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 2580.37 67.6 999999999 2311.26 3702.6 percent of total billed charges "INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 48260886_1 CDM 0636 RC 44206-0438-20 NDC J1459 HCPCS inpatient 40 UN 3817.11 2481.12 UHC - ALL PLANS UHC - ALL PLANS 999999999 2311.26 3702.6 "INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MG" 48260900_1 CDM 0636 RC 57894-0030-01 NDC J1745 HCPCS inpatient 10 UN 5207.91 3385.14 AETNA AETNA 4114.25 79 999999999 3153.39 5051.67 percent of total billed charges "INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MG" 48260900_1 CDM 0636 RC 57894-0030-01 NDC J1745 HCPCS inpatient 10 UN 5207.91 3385.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 3385.14 65 999999999 3153.39 5051.67 percent of total billed charges "INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MG" 48260900_1 CDM 0636 RC 57894-0030-01 NDC J1745 HCPCS inpatient 10 UN 5207.91 3385.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5051.67 97 999999999 3153.39 5051.67 percent of total billed charges "INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MG" 48260900_1 CDM 0636 RC 57894-0030-01 NDC J1745 HCPCS inpatient 10 UN 5207.91 3385.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 3593.46 69 999999999 3153.39 5051.67 percent of total billed charges "INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MG" 48260900_1 CDM 0636 RC 57894-0030-01 NDC J1745 HCPCS inpatient 10 UN 5207.91 3385.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 4062.17 78 999999999 3153.39 5051.67 percent of total billed charges "INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MG" 48260900_1 CDM 0636 RC 57894-0030-01 NDC J1745 HCPCS inpatient 10 UN 5207.91 3385.14 UMR - ALL PLANS UMR - ALL PLANS 3645.54 70 999999999 3153.39 5051.67 percent of total billed charges "INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MG" 48260900_1 CDM 0636 RC 57894-0030-01 NDC J1745 HCPCS inpatient 10 UN 5207.91 3385.14 SIHO - ALL PLANS SIHO - ALL PLANS 4687.12 90 999999999 3153.39 5051.67 percent of total billed charges "INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MG" 48260900_1 CDM 0636 RC 57894-0030-01 NDC J1745 HCPCS inpatient 10 UN 5207.91 3385.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3153.39 5051.67 "INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MG" 48260900_1 CDM 0636 RC 57894-0030-01 NDC J1745 HCPCS inpatient 10 UN 5207.91 3385.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3153.39 60.55 999999999 3153.39 5051.67 percent of total billed charges "INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MG" 48260900_1 CDM 0636 RC 57894-0030-01 NDC J1745 HCPCS inpatient 10 UN 5207.91 3385.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3153.39 5051.67 "INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MG" 48260900_1 CDM 0636 RC 57894-0030-01 NDC J1745 HCPCS inpatient 10 UN 5207.91 3385.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3153.39 5051.67 "INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MG" 48260900_1 CDM 0636 RC 57894-0030-01 NDC J1745 HCPCS inpatient 10 UN 5207.91 3385.14 ANTHEM HMO ANTHEM HMO 999999999 3153.39 5051.67 "INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MG" 48260900_1 CDM 0636 RC 57894-0030-01 NDC J1745 HCPCS inpatient 10 UN 5207.91 3385.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 3520.55 67.6 999999999 3153.39 5051.67 percent of total billed charges "INJECTION, INFLIXIMAB, EXCLUDES BIOSIMILAR, 10 MG" 48260900_1 CDM 0636 RC 57894-0030-01 NDC J1745 HCPCS inpatient 10 UN 5207.91 3385.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 3153.39 5051.67 NOVOLOG MIX 70-30 VIAL 48260904_1 CDM 0250 RC 00169-3685-12 NDC inpatient 1 UN 3.87 2.52 AETNA AETNA 3.06 79 999999999 2.34 3.75 percent of total billed charges NOVOLOG MIX 70-30 VIAL 48260904_1 CDM 0250 RC 00169-3685-12 NDC inpatient 1 UN 3.87 2.52 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.52 65 999999999 2.34 3.75 percent of total billed charges NOVOLOG MIX 70-30 VIAL 48260904_1 CDM 0250 RC 00169-3685-12 NDC inpatient 1 UN 3.87 2.52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.75 97 999999999 2.34 3.75 percent of total billed charges NOVOLOG MIX 70-30 VIAL 48260904_1 CDM 0250 RC 00169-3685-12 NDC inpatient 1 UN 3.87 2.52 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.67 69 999999999 2.34 3.75 percent of total billed charges NOVOLOG MIX 70-30 VIAL 48260904_1 CDM 0250 RC 00169-3685-12 NDC inpatient 1 UN 3.87 2.52 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.02 78 999999999 2.34 3.75 percent of total billed charges NOVOLOG MIX 70-30 VIAL 48260904_1 CDM 0250 RC 00169-3685-12 NDC inpatient 1 UN 3.87 2.52 UMR - ALL PLANS UMR - ALL PLANS 2.71 70 999999999 2.34 3.75 percent of total billed charges NOVOLOG MIX 70-30 VIAL 48260904_1 CDM 0250 RC 00169-3685-12 NDC inpatient 1 UN 3.87 2.52 SIHO - ALL PLANS SIHO - ALL PLANS 3.48 90 999999999 2.34 3.75 percent of total billed charges NOVOLOG MIX 70-30 VIAL 48260904_1 CDM 0250 RC 00169-3685-12 NDC inpatient 1 UN 3.87 2.52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.34 3.75 NOVOLOG MIX 70-30 VIAL 48260904_1 CDM 0250 RC 00169-3685-12 NDC inpatient 1 UN 3.87 2.52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.34 60.55 999999999 2.34 3.75 percent of total billed charges NOVOLOG MIX 70-30 VIAL 48260904_1 CDM 0250 RC 00169-3685-12 NDC inpatient 1 UN 3.87 2.52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.34 3.75 NOVOLOG MIX 70-30 VIAL 48260904_1 CDM 0250 RC 00169-3685-12 NDC inpatient 1 UN 3.87 2.52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.34 3.75 NOVOLOG MIX 70-30 VIAL 48260904_1 CDM 0250 RC 00169-3685-12 NDC inpatient 1 UN 3.87 2.52 ANTHEM HMO ANTHEM HMO 999999999 2.34 3.75 NOVOLOG MIX 70-30 VIAL 48260904_1 CDM 0250 RC 00169-3685-12 NDC inpatient 1 UN 3.87 2.52 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.62 67.6 999999999 2.34 3.75 percent of total billed charges NOVOLOG MIX 70-30 VIAL 48260904_1 CDM 0250 RC 00169-3685-12 NDC inpatient 1 UN 3.87 2.52 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.34 3.75 LEVEMIR 100 UNIT/ML VIAL 48260905_1 CDM 0250 RC 00169-3687-12 NDC inpatient 1 UN 9.47 6.16 AETNA AETNA 7.48 79 999999999 5.73 9.19 percent of total billed charges LEVEMIR 100 UNIT/ML VIAL 48260905_1 CDM 0250 RC 00169-3687-12 NDC inpatient 1 UN 9.47 6.16 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.16 65 999999999 5.73 9.19 percent of total billed charges LEVEMIR 100 UNIT/ML VIAL 48260905_1 CDM 0250 RC 00169-3687-12 NDC inpatient 1 UN 9.47 6.16 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.19 97 999999999 5.73 9.19 percent of total billed charges LEVEMIR 100 UNIT/ML VIAL 48260905_1 CDM 0250 RC 00169-3687-12 NDC inpatient 1 UN 9.47 6.16 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.53 69 999999999 5.73 9.19 percent of total billed charges LEVEMIR 100 UNIT/ML VIAL 48260905_1 CDM 0250 RC 00169-3687-12 NDC inpatient 1 UN 9.47 6.16 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.39 78 999999999 5.73 9.19 percent of total billed charges LEVEMIR 100 UNIT/ML VIAL 48260905_1 CDM 0250 RC 00169-3687-12 NDC inpatient 1 UN 9.47 6.16 UMR - ALL PLANS UMR - ALL PLANS 6.63 70 999999999 5.73 9.19 percent of total billed charges LEVEMIR 100 UNIT/ML VIAL 48260905_1 CDM 0250 RC 00169-3687-12 NDC inpatient 1 UN 9.47 6.16 SIHO - ALL PLANS SIHO - ALL PLANS 8.52 90 999999999 5.73 9.19 percent of total billed charges LEVEMIR 100 UNIT/ML VIAL 48260905_1 CDM 0250 RC 00169-3687-12 NDC inpatient 1 UN 9.47 6.16 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.73 9.19 LEVEMIR 100 UNIT/ML VIAL 48260905_1 CDM 0250 RC 00169-3687-12 NDC inpatient 1 UN 9.47 6.16 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.73 60.55 999999999 5.73 9.19 percent of total billed charges LEVEMIR 100 UNIT/ML VIAL 48260905_1 CDM 0250 RC 00169-3687-12 NDC inpatient 1 UN 9.47 6.16 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.73 9.19 LEVEMIR 100 UNIT/ML VIAL 48260905_1 CDM 0250 RC 00169-3687-12 NDC inpatient 1 UN 9.47 6.16 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.73 9.19 LEVEMIR 100 UNIT/ML VIAL 48260905_1 CDM 0250 RC 00169-3687-12 NDC inpatient 1 UN 9.47 6.16 ANTHEM HMO ANTHEM HMO 999999999 5.73 9.19 LEVEMIR 100 UNIT/ML VIAL 48260905_1 CDM 0250 RC 00169-3687-12 NDC inpatient 1 UN 9.47 6.16 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.4 67.6 999999999 5.73 9.19 percent of total billed charges LEVEMIR 100 UNIT/ML VIAL 48260905_1 CDM 0250 RC 00169-3687-12 NDC inpatient 1 UN 9.47 6.16 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.73 9.19 LANTUS 100 UNIT/ML VIAL 48260906_1 CDM 0250 RC 00088-2220-33 NDC inpatient 1 UN 6.05 3.93 AETNA AETNA 4.78 79 999999999 3.66 5.87 percent of total billed charges LANTUS 100 UNIT/ML VIAL 48260906_1 CDM 0250 RC 00088-2220-33 NDC inpatient 1 UN 6.05 3.93 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.93 65 999999999 3.66 5.87 percent of total billed charges LANTUS 100 UNIT/ML VIAL 48260906_1 CDM 0250 RC 00088-2220-33 NDC inpatient 1 UN 6.05 3.93 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.87 97 999999999 3.66 5.87 percent of total billed charges LANTUS 100 UNIT/ML VIAL 48260906_1 CDM 0250 RC 00088-2220-33 NDC inpatient 1 UN 6.05 3.93 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.17 69 999999999 3.66 5.87 percent of total billed charges LANTUS 100 UNIT/ML VIAL 48260906_1 CDM 0250 RC 00088-2220-33 NDC inpatient 1 UN 6.05 3.93 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.72 78 999999999 3.66 5.87 percent of total billed charges LANTUS 100 UNIT/ML VIAL 48260906_1 CDM 0250 RC 00088-2220-33 NDC inpatient 1 UN 6.05 3.93 UMR - ALL PLANS UMR - ALL PLANS 4.24 70 999999999 3.66 5.87 percent of total billed charges LANTUS 100 UNIT/ML VIAL 48260906_1 CDM 0250 RC 00088-2220-33 NDC inpatient 1 UN 6.05 3.93 SIHO - ALL PLANS SIHO - ALL PLANS 5.45 90 999999999 3.66 5.87 percent of total billed charges LANTUS 100 UNIT/ML VIAL 48260906_1 CDM 0250 RC 00088-2220-33 NDC inpatient 1 UN 6.05 3.93 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.66 5.87 LANTUS 100 UNIT/ML VIAL 48260906_1 CDM 0250 RC 00088-2220-33 NDC inpatient 1 UN 6.05 3.93 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.66 60.55 999999999 3.66 5.87 percent of total billed charges LANTUS 100 UNIT/ML VIAL 48260906_1 CDM 0250 RC 00088-2220-33 NDC inpatient 1 UN 6.05 3.93 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.66 5.87 LANTUS 100 UNIT/ML VIAL 48260906_1 CDM 0250 RC 00088-2220-33 NDC inpatient 1 UN 6.05 3.93 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.66 5.87 LANTUS 100 UNIT/ML VIAL 48260906_1 CDM 0250 RC 00088-2220-33 NDC inpatient 1 UN 6.05 3.93 ANTHEM HMO ANTHEM HMO 999999999 3.66 5.87 LANTUS 100 UNIT/ML VIAL 48260906_1 CDM 0250 RC 00088-2220-33 NDC inpatient 1 UN 6.05 3.93 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.09 67.6 999999999 3.66 5.87 percent of total billed charges LANTUS 100 UNIT/ML VIAL 48260906_1 CDM 0250 RC 00088-2220-33 NDC inpatient 1 UN 6.05 3.93 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.66 5.87 HUMULIN R 100 UNIT/ML VIAL 48260909_1 CDM 0250 RC 00002-8215-17 NDC inpatient 1 UN 41.52 26.99 AETNA AETNA 32.8 79 999999999 25.14 40.27 percent of total billed charges HUMULIN R 100 UNIT/ML VIAL 48260909_1 CDM 0250 RC 00002-8215-17 NDC inpatient 1 UN 41.52 26.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.99 65 999999999 25.14 40.27 percent of total billed charges HUMULIN R 100 UNIT/ML VIAL 48260909_1 CDM 0250 RC 00002-8215-17 NDC inpatient 1 UN 41.52 26.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 40.27 97 999999999 25.14 40.27 percent of total billed charges HUMULIN R 100 UNIT/ML VIAL 48260909_1 CDM 0250 RC 00002-8215-17 NDC inpatient 1 UN 41.52 26.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.65 69 999999999 25.14 40.27 percent of total billed charges HUMULIN R 100 UNIT/ML VIAL 48260909_1 CDM 0250 RC 00002-8215-17 NDC inpatient 1 UN 41.52 26.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 32.39 78 999999999 25.14 40.27 percent of total billed charges HUMULIN R 100 UNIT/ML VIAL 48260909_1 CDM 0250 RC 00002-8215-17 NDC inpatient 1 UN 41.52 26.99 UMR - ALL PLANS UMR - ALL PLANS 29.06 70 999999999 25.14 40.27 percent of total billed charges HUMULIN R 100 UNIT/ML VIAL 48260909_1 CDM 0250 RC 00002-8215-17 NDC inpatient 1 UN 41.52 26.99 SIHO - ALL PLANS SIHO - ALL PLANS 37.37 90 999999999 25.14 40.27 percent of total billed charges HUMULIN R 100 UNIT/ML VIAL 48260909_1 CDM 0250 RC 00002-8215-17 NDC inpatient 1 UN 41.52 26.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 25.14 40.27 HUMULIN R 100 UNIT/ML VIAL 48260909_1 CDM 0250 RC 00002-8215-17 NDC inpatient 1 UN 41.52 26.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 25.14 60.55 999999999 25.14 40.27 percent of total billed charges HUMULIN R 100 UNIT/ML VIAL 48260909_1 CDM 0250 RC 00002-8215-17 NDC inpatient 1 UN 41.52 26.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 25.14 40.27 HUMULIN R 100 UNIT/ML VIAL 48260909_1 CDM 0250 RC 00002-8215-17 NDC inpatient 1 UN 41.52 26.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 25.14 40.27 HUMULIN R 100 UNIT/ML VIAL 48260909_1 CDM 0250 RC 00002-8215-17 NDC inpatient 1 UN 41.52 26.99 ANTHEM HMO ANTHEM HMO 999999999 25.14 40.27 HUMULIN R 100 UNIT/ML VIAL 48260909_1 CDM 0250 RC 00002-8215-17 NDC inpatient 1 UN 41.52 26.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 28.07 67.6 999999999 25.14 40.27 percent of total billed charges HUMULIN R 100 UNIT/ML VIAL 48260909_1 CDM 0250 RC 00002-8215-17 NDC inpatient 1 UN 41.52 26.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 25.14 40.27 IPRATROPIUM BR 0.02% SOLN 48260921_1 CDM 0250 RC 00487-9801-01 NDC inpatient 1 UN 1.98 1.29 AETNA AETNA 1.56 79 999999999 1.2 1.92 percent of total billed charges IPRATROPIUM BR 0.02% SOLN 48260921_1 CDM 0250 RC 00487-9801-01 NDC inpatient 1 UN 1.98 1.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.29 65 999999999 1.2 1.92 percent of total billed charges IPRATROPIUM BR 0.02% SOLN 48260921_1 CDM 0250 RC 00487-9801-01 NDC inpatient 1 UN 1.98 1.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.92 97 999999999 1.2 1.92 percent of total billed charges IPRATROPIUM BR 0.02% SOLN 48260921_1 CDM 0250 RC 00487-9801-01 NDC inpatient 1 UN 1.98 1.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.37 69 999999999 1.2 1.92 percent of total billed charges IPRATROPIUM BR 0.02% SOLN 48260921_1 CDM 0250 RC 00487-9801-01 NDC inpatient 1 UN 1.98 1.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.54 78 999999999 1.2 1.92 percent of total billed charges IPRATROPIUM BR 0.02% SOLN 48260921_1 CDM 0250 RC 00487-9801-01 NDC inpatient 1 UN 1.98 1.29 UMR - ALL PLANS UMR - ALL PLANS 1.39 70 999999999 1.2 1.92 percent of total billed charges IPRATROPIUM BR 0.02% SOLN 48260921_1 CDM 0250 RC 00487-9801-01 NDC inpatient 1 UN 1.98 1.29 SIHO - ALL PLANS SIHO - ALL PLANS 1.78 90 999999999 1.2 1.92 percent of total billed charges IPRATROPIUM BR 0.02% SOLN 48260921_1 CDM 0250 RC 00487-9801-01 NDC inpatient 1 UN 1.98 1.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.2 1.92 IPRATROPIUM BR 0.02% SOLN 48260921_1 CDM 0250 RC 00487-9801-01 NDC inpatient 1 UN 1.98 1.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.2 60.55 999999999 1.2 1.92 percent of total billed charges IPRATROPIUM BR 0.02% SOLN 48260921_1 CDM 0250 RC 00487-9801-01 NDC inpatient 1 UN 1.98 1.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.2 1.92 IPRATROPIUM BR 0.02% SOLN 48260921_1 CDM 0250 RC 00487-9801-01 NDC inpatient 1 UN 1.98 1.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.2 1.92 IPRATROPIUM BR 0.02% SOLN 48260921_1 CDM 0250 RC 00487-9801-01 NDC inpatient 1 UN 1.98 1.29 ANTHEM HMO ANTHEM HMO 999999999 1.2 1.92 IPRATROPIUM BR 0.02% SOLN 48260921_1 CDM 0250 RC 00487-9801-01 NDC inpatient 1 UN 1.98 1.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.34 67.6 999999999 1.2 1.92 percent of total billed charges IPRATROPIUM BR 0.02% SOLN 48260921_1 CDM 0250 RC 00487-9801-01 NDC inpatient 1 UN 1.98 1.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.2 1.92 "INJECTION, IRON SUCROSE, 1 MG" 48260929_1 CDM 0250 RC 00517-2340-10 NDC J1756 HCPCS inpatient 100 UN 157.34 102.27 AETNA AETNA 124.3 79 999999999 95.27 152.62 percent of total billed charges "INJECTION, IRON SUCROSE, 1 MG" 48260929_1 CDM 0250 RC 00517-2340-10 NDC J1756 HCPCS inpatient 100 UN 157.34 102.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.27 65 999999999 95.27 152.62 percent of total billed charges "INJECTION, IRON SUCROSE, 1 MG" 48260929_1 CDM 0250 RC 00517-2340-10 NDC J1756 HCPCS inpatient 100 UN 157.34 102.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 152.62 97 999999999 95.27 152.62 percent of total billed charges "INJECTION, IRON SUCROSE, 1 MG" 48260929_1 CDM 0250 RC 00517-2340-10 NDC J1756 HCPCS inpatient 100 UN 157.34 102.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 108.56 69 999999999 95.27 152.62 percent of total billed charges "INJECTION, IRON SUCROSE, 1 MG" 48260929_1 CDM 0250 RC 00517-2340-10 NDC J1756 HCPCS inpatient 100 UN 157.34 102.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 122.73 78 999999999 95.27 152.62 percent of total billed charges "INJECTION, IRON SUCROSE, 1 MG" 48260929_1 CDM 0250 RC 00517-2340-10 NDC J1756 HCPCS inpatient 100 UN 157.34 102.27 UMR - ALL PLANS UMR - ALL PLANS 110.14 70 999999999 95.27 152.62 percent of total billed charges "INJECTION, IRON SUCROSE, 1 MG" 48260929_1 CDM 0250 RC 00517-2340-10 NDC J1756 HCPCS inpatient 100 UN 157.34 102.27 SIHO - ALL PLANS SIHO - ALL PLANS 141.61 90 999999999 95.27 152.62 percent of total billed charges "INJECTION, IRON SUCROSE, 1 MG" 48260929_1 CDM 0250 RC 00517-2340-10 NDC J1756 HCPCS inpatient 100 UN 157.34 102.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.27 152.62 "INJECTION, IRON SUCROSE, 1 MG" 48260929_1 CDM 0250 RC 00517-2340-10 NDC J1756 HCPCS inpatient 100 UN 157.34 102.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.27 60.55 999999999 95.27 152.62 percent of total billed charges "INJECTION, IRON SUCROSE, 1 MG" 48260929_1 CDM 0250 RC 00517-2340-10 NDC J1756 HCPCS inpatient 100 UN 157.34 102.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.27 152.62 "INJECTION, IRON SUCROSE, 1 MG" 48260929_1 CDM 0250 RC 00517-2340-10 NDC J1756 HCPCS inpatient 100 UN 157.34 102.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.27 152.62 "INJECTION, IRON SUCROSE, 1 MG" 48260929_1 CDM 0250 RC 00517-2340-10 NDC J1756 HCPCS inpatient 100 UN 157.34 102.27 ANTHEM HMO ANTHEM HMO 999999999 95.27 152.62 "INJECTION, IRON SUCROSE, 1 MG" 48260929_1 CDM 0250 RC 00517-2340-10 NDC J1756 HCPCS inpatient 100 UN 157.34 102.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.36 67.6 999999999 95.27 152.62 percent of total billed charges "INJECTION, IRON SUCROSE, 1 MG" 48260929_1 CDM 0250 RC 00517-2340-10 NDC J1756 HCPCS inpatient 100 UN 157.34 102.27 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.27 152.62 ISOSORBIDE MONONIT 20 MG TAB 48260937_1 CDM 0250 RC 62175-0107-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE MONONIT 20 MG TAB 48260937_1 CDM 0250 RC 62175-0107-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE MONONIT 20 MG TAB 48260937_1 CDM 0250 RC 62175-0107-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE MONONIT 20 MG TAB 48260937_1 CDM 0250 RC 62175-0107-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE MONONIT 20 MG TAB 48260937_1 CDM 0250 RC 62175-0107-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE MONONIT 20 MG TAB 48260937_1 CDM 0250 RC 62175-0107-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE MONONIT 20 MG TAB 48260937_1 CDM 0250 RC 62175-0107-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE MONONIT 20 MG TAB 48260937_1 CDM 0250 RC 62175-0107-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ISOSORBIDE MONONIT 20 MG TAB 48260937_1 CDM 0250 RC 62175-0107-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE MONONIT 20 MG TAB 48260937_1 CDM 0250 RC 62175-0107-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ISOSORBIDE MONONIT 20 MG TAB 48260937_1 CDM 0250 RC 62175-0107-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ISOSORBIDE MONONIT 20 MG TAB 48260937_1 CDM 0250 RC 62175-0107-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ISOSORBIDE MONONIT 20 MG TAB 48260937_1 CDM 0250 RC 62175-0107-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE MONONIT 20 MG TAB 48260937_1 CDM 0250 RC 62175-0107-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 61553-0320-70 - ketamine 50 mg/5 mL-NS IV Sol [JOHN] 48260945_1 CDM 0250 RC 61553-0320-70 NDC inpatient 1 UN 35.61 23.15 AETNA AETNA 28.13 79 999999999 21.56 34.54 percent of total billed charges 61553-0320-70 - ketamine 50 mg/5 mL-NS IV Sol [JOHN] 48260945_1 CDM 0250 RC 61553-0320-70 NDC inpatient 1 UN 35.61 23.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 23.15 65 999999999 21.56 34.54 percent of total billed charges 61553-0320-70 - ketamine 50 mg/5 mL-NS IV Sol [JOHN] 48260945_1 CDM 0250 RC 61553-0320-70 NDC inpatient 1 UN 35.61 23.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34.54 97 999999999 21.56 34.54 percent of total billed charges 61553-0320-70 - ketamine 50 mg/5 mL-NS IV Sol [JOHN] 48260945_1 CDM 0250 RC 61553-0320-70 NDC inpatient 1 UN 35.61 23.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.57 69 999999999 21.56 34.54 percent of total billed charges 61553-0320-70 - ketamine 50 mg/5 mL-NS IV Sol [JOHN] 48260945_1 CDM 0250 RC 61553-0320-70 NDC inpatient 1 UN 35.61 23.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.78 78 999999999 21.56 34.54 percent of total billed charges 61553-0320-70 - ketamine 50 mg/5 mL-NS IV Sol [JOHN] 48260945_1 CDM 0250 RC 61553-0320-70 NDC inpatient 1 UN 35.61 23.15 UMR - ALL PLANS UMR - ALL PLANS 24.93 70 999999999 21.56 34.54 percent of total billed charges 61553-0320-70 - ketamine 50 mg/5 mL-NS IV Sol [JOHN] 48260945_1 CDM 0250 RC 61553-0320-70 NDC inpatient 1 UN 35.61 23.15 SIHO - ALL PLANS SIHO - ALL PLANS 32.05 90 999999999 21.56 34.54 percent of total billed charges 61553-0320-70 - ketamine 50 mg/5 mL-NS IV Sol [JOHN] 48260945_1 CDM 0250 RC 61553-0320-70 NDC inpatient 1 UN 35.61 23.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.56 34.54 61553-0320-70 - ketamine 50 mg/5 mL-NS IV Sol [JOHN] 48260945_1 CDM 0250 RC 61553-0320-70 NDC inpatient 1 UN 35.61 23.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.56 60.55 999999999 21.56 34.54 percent of total billed charges 61553-0320-70 - ketamine 50 mg/5 mL-NS IV Sol [JOHN] 48260945_1 CDM 0250 RC 61553-0320-70 NDC inpatient 1 UN 35.61 23.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.56 34.54 61553-0320-70 - ketamine 50 mg/5 mL-NS IV Sol [JOHN] 48260945_1 CDM 0250 RC 61553-0320-70 NDC inpatient 1 UN 35.61 23.15 ANTHEM HMO ANTHEM HMO 999999999 21.56 34.54 61553-0320-70 - ketamine 50 mg/5 mL-NS IV Sol [JOHN] 48260945_1 CDM 0250 RC 61553-0320-70 NDC inpatient 1 UN 35.61 23.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.56 34.54 61553-0320-70 - ketamine 50 mg/5 mL-NS IV Sol [JOHN] 48260945_1 CDM 0250 RC 61553-0320-70 NDC inpatient 1 UN 35.61 23.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 24.07 67.6 999999999 21.56 34.54 percent of total billed charges 61553-0320-70 - ketamine 50 mg/5 mL-NS IV Sol [JOHN] 48260945_1 CDM 0250 RC 61553-0320-70 NDC inpatient 1 UN 35.61 23.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.56 34.54 KETAMINE 500 MG/10 ML VIAL 48260946_1 CDM 0250 RC 67457-0001-10 NDC inpatient 1 UN 51.26 33.32 AETNA AETNA 40.5 79 999999999 31.04 49.72 percent of total billed charges KETAMINE 500 MG/10 ML VIAL 48260946_1 CDM 0250 RC 67457-0001-10 NDC inpatient 1 UN 51.26 33.32 SELF PAY DISCOUNT SELF PAY DISCOUNT 33.32 65 999999999 31.04 49.72 percent of total billed charges KETAMINE 500 MG/10 ML VIAL 48260946_1 CDM 0250 RC 67457-0001-10 NDC inpatient 1 UN 51.26 33.32 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 49.72 97 999999999 31.04 49.72 percent of total billed charges KETAMINE 500 MG/10 ML VIAL 48260946_1 CDM 0250 RC 67457-0001-10 NDC inpatient 1 UN 51.26 33.32 ENCORE - ALL PLANS ENCORE - ALL PLANS 35.37 69 999999999 31.04 49.72 percent of total billed charges KETAMINE 500 MG/10 ML VIAL 48260946_1 CDM 0250 RC 67457-0001-10 NDC inpatient 1 UN 51.26 33.32 HUMANA - ALL PLANS HUMANA - ALL PLANS 39.98 78 999999999 31.04 49.72 percent of total billed charges KETAMINE 500 MG/10 ML VIAL 48260946_1 CDM 0250 RC 67457-0001-10 NDC inpatient 1 UN 51.26 33.32 UMR - ALL PLANS UMR - ALL PLANS 35.88 70 999999999 31.04 49.72 percent of total billed charges KETAMINE 500 MG/10 ML VIAL 48260946_1 CDM 0250 RC 67457-0001-10 NDC inpatient 1 UN 51.26 33.32 SIHO - ALL PLANS SIHO - ALL PLANS 46.13 90 999999999 31.04 49.72 percent of total billed charges KETAMINE 500 MG/10 ML VIAL 48260946_1 CDM 0250 RC 67457-0001-10 NDC inpatient 1 UN 51.26 33.32 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 31.04 49.72 KETAMINE 500 MG/10 ML VIAL 48260946_1 CDM 0250 RC 67457-0001-10 NDC inpatient 1 UN 51.26 33.32 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 31.04 60.55 999999999 31.04 49.72 percent of total billed charges KETAMINE 500 MG/10 ML VIAL 48260946_1 CDM 0250 RC 67457-0001-10 NDC inpatient 1 UN 51.26 33.32 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 31.04 49.72 KETAMINE 500 MG/10 ML VIAL 48260946_1 CDM 0250 RC 67457-0001-10 NDC inpatient 1 UN 51.26 33.32 ANTHEM HMO ANTHEM HMO 999999999 31.04 49.72 KETAMINE 500 MG/10 ML VIAL 48260946_1 CDM 0250 RC 67457-0001-10 NDC inpatient 1 UN 51.26 33.32 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 31.04 49.72 KETAMINE 500 MG/10 ML VIAL 48260946_1 CDM 0250 RC 67457-0001-10 NDC inpatient 1 UN 51.26 33.32 CIGNA - ALL PLANS CIGNA - ALL PLANS 34.65 67.6 999999999 31.04 49.72 percent of total billed charges KETAMINE 500 MG/10 ML VIAL 48260946_1 CDM 0250 RC 67457-0001-10 NDC inpatient 1 UN 51.26 33.32 UHC - ALL PLANS UHC - ALL PLANS 999999999 31.04 49.72 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48260950_1 CDM 0250 RC 00409-3795-01 NDC J1885 HCPCS inpatient 2 UN 31.36 20.38 AETNA AETNA 24.77 79 999999999 18.99 30.42 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48260950_1 CDM 0250 RC 00409-3795-01 NDC J1885 HCPCS inpatient 2 UN 31.36 20.38 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.38 65 999999999 18.99 30.42 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48260950_1 CDM 0250 RC 00409-3795-01 NDC J1885 HCPCS inpatient 2 UN 31.36 20.38 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.42 97 999999999 18.99 30.42 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48260950_1 CDM 0250 RC 00409-3795-01 NDC J1885 HCPCS inpatient 2 UN 31.36 20.38 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.64 69 999999999 18.99 30.42 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48260950_1 CDM 0250 RC 00409-3795-01 NDC J1885 HCPCS inpatient 2 UN 31.36 20.38 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.46 78 999999999 18.99 30.42 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48260950_1 CDM 0250 RC 00409-3795-01 NDC J1885 HCPCS inpatient 2 UN 31.36 20.38 UMR - ALL PLANS UMR - ALL PLANS 21.95 70 999999999 18.99 30.42 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48260950_1 CDM 0250 RC 00409-3795-01 NDC J1885 HCPCS inpatient 2 UN 31.36 20.38 SIHO - ALL PLANS SIHO - ALL PLANS 28.22 90 999999999 18.99 30.42 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48260950_1 CDM 0250 RC 00409-3795-01 NDC J1885 HCPCS inpatient 2 UN 31.36 20.38 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.99 30.42 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48260950_1 CDM 0250 RC 00409-3795-01 NDC J1885 HCPCS inpatient 2 UN 31.36 20.38 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.99 60.55 999999999 18.99 30.42 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48260950_1 CDM 0250 RC 00409-3795-01 NDC J1885 HCPCS inpatient 2 UN 31.36 20.38 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.99 30.42 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48260950_1 CDM 0250 RC 00409-3795-01 NDC J1885 HCPCS inpatient 2 UN 31.36 20.38 ANTHEM HMO ANTHEM HMO 999999999 18.99 30.42 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48260950_1 CDM 0250 RC 00409-3795-01 NDC J1885 HCPCS inpatient 2 UN 31.36 20.38 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.99 30.42 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48260950_1 CDM 0250 RC 00409-3795-01 NDC J1885 HCPCS inpatient 2 UN 31.36 20.38 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.2 67.6 999999999 18.99 30.42 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48260950_1 CDM 0250 RC 00409-3795-01 NDC J1885 HCPCS inpatient 2 UN 31.36 20.38 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.99 30.42 00185-0010-01 - labetalol 100 mg Tab [JOHN] 48260954_1 CDM 0250 RC 00185-0010-01 NDC inpatient 1 UN 1.4 0.91 AETNA AETNA 1.11 79 999999999 0.85 1.36 percent of total billed charges 00185-0010-01 - labetalol 100 mg Tab [JOHN] 48260954_1 CDM 0250 RC 00185-0010-01 NDC inpatient 1 UN 1.4 0.91 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.91 65 999999999 0.85 1.36 percent of total billed charges 00185-0010-01 - labetalol 100 mg Tab [JOHN] 48260954_1 CDM 0250 RC 00185-0010-01 NDC inpatient 1 UN 1.4 0.91 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.36 97 999999999 0.85 1.36 percent of total billed charges 00185-0010-01 - labetalol 100 mg Tab [JOHN] 48260954_1 CDM 0250 RC 00185-0010-01 NDC inpatient 1 UN 1.4 0.91 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.97 69 999999999 0.85 1.36 percent of total billed charges 00185-0010-01 - labetalol 100 mg Tab [JOHN] 48260954_1 CDM 0250 RC 00185-0010-01 NDC inpatient 1 UN 1.4 0.91 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.09 78 999999999 0.85 1.36 percent of total billed charges 00185-0010-01 - labetalol 100 mg Tab [JOHN] 48260954_1 CDM 0250 RC 00185-0010-01 NDC inpatient 1 UN 1.4 0.91 UMR - ALL PLANS UMR - ALL PLANS 0.98 70 999999999 0.85 1.36 percent of total billed charges 00185-0010-01 - labetalol 100 mg Tab [JOHN] 48260954_1 CDM 0250 RC 00185-0010-01 NDC inpatient 1 UN 1.4 0.91 SIHO - ALL PLANS SIHO - ALL PLANS 1.26 90 999999999 0.85 1.36 percent of total billed charges 00185-0010-01 - labetalol 100 mg Tab [JOHN] 48260954_1 CDM 0250 RC 00185-0010-01 NDC inpatient 1 UN 1.4 0.91 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.85 1.36 00185-0010-01 - labetalol 100 mg Tab [JOHN] 48260954_1 CDM 0250 RC 00185-0010-01 NDC inpatient 1 UN 1.4 0.91 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.85 60.55 999999999 0.85 1.36 percent of total billed charges 00185-0010-01 - labetalol 100 mg Tab [JOHN] 48260954_1 CDM 0250 RC 00185-0010-01 NDC inpatient 1 UN 1.4 0.91 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.85 1.36 00185-0010-01 - labetalol 100 mg Tab [JOHN] 48260954_1 CDM 0250 RC 00185-0010-01 NDC inpatient 1 UN 1.4 0.91 ANTHEM HMO ANTHEM HMO 999999999 0.85 1.36 00185-0010-01 - labetalol 100 mg Tab [JOHN] 48260954_1 CDM 0250 RC 00185-0010-01 NDC inpatient 1 UN 1.4 0.91 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.85 1.36 00185-0010-01 - labetalol 100 mg Tab [JOHN] 48260954_1 CDM 0250 RC 00185-0010-01 NDC inpatient 1 UN 1.4 0.91 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.95 67.6 999999999 0.85 1.36 percent of total billed charges 00185-0010-01 - labetalol 100 mg Tab [JOHN] 48260954_1 CDM 0250 RC 00185-0010-01 NDC inpatient 1 UN 1.4 0.91 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.85 1.36 VIMPAT 200 MG/20 ML VIAL 48260955_1 CDM 0250 RC 00131-1810-67 NDC inpatient 1 UN 32.18 20.92 AETNA AETNA 25.42 79 999999999 19.49 31.21 percent of total billed charges VIMPAT 200 MG/20 ML VIAL 48260955_1 CDM 0250 RC 00131-1810-67 NDC inpatient 1 UN 32.18 20.92 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.92 65 999999999 19.49 31.21 percent of total billed charges VIMPAT 200 MG/20 ML VIAL 48260955_1 CDM 0250 RC 00131-1810-67 NDC inpatient 1 UN 32.18 20.92 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31.21 97 999999999 19.49 31.21 percent of total billed charges VIMPAT 200 MG/20 ML VIAL 48260955_1 CDM 0250 RC 00131-1810-67 NDC inpatient 1 UN 32.18 20.92 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.2 69 999999999 19.49 31.21 percent of total billed charges VIMPAT 200 MG/20 ML VIAL 48260955_1 CDM 0250 RC 00131-1810-67 NDC inpatient 1 UN 32.18 20.92 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.1 78 999999999 19.49 31.21 percent of total billed charges VIMPAT 200 MG/20 ML VIAL 48260955_1 CDM 0250 RC 00131-1810-67 NDC inpatient 1 UN 32.18 20.92 UMR - ALL PLANS UMR - ALL PLANS 22.53 70 999999999 19.49 31.21 percent of total billed charges VIMPAT 200 MG/20 ML VIAL 48260955_1 CDM 0250 RC 00131-1810-67 NDC inpatient 1 UN 32.18 20.92 SIHO - ALL PLANS SIHO - ALL PLANS 28.96 90 999999999 19.49 31.21 percent of total billed charges VIMPAT 200 MG/20 ML VIAL 48260955_1 CDM 0250 RC 00131-1810-67 NDC inpatient 1 UN 32.18 20.92 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.49 31.21 VIMPAT 200 MG/20 ML VIAL 48260955_1 CDM 0250 RC 00131-1810-67 NDC inpatient 1 UN 32.18 20.92 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.49 60.55 999999999 19.49 31.21 percent of total billed charges VIMPAT 200 MG/20 ML VIAL 48260955_1 CDM 0250 RC 00131-1810-67 NDC inpatient 1 UN 32.18 20.92 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.49 31.21 VIMPAT 200 MG/20 ML VIAL 48260955_1 CDM 0250 RC 00131-1810-67 NDC inpatient 1 UN 32.18 20.92 ANTHEM HMO ANTHEM HMO 999999999 19.49 31.21 VIMPAT 200 MG/20 ML VIAL 48260955_1 CDM 0250 RC 00131-1810-67 NDC inpatient 1 UN 32.18 20.92 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.49 31.21 VIMPAT 200 MG/20 ML VIAL 48260955_1 CDM 0250 RC 00131-1810-67 NDC inpatient 1 UN 32.18 20.92 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.75 67.6 999999999 19.49 31.21 percent of total billed charges VIMPAT 200 MG/20 ML VIAL 48260955_1 CDM 0250 RC 00131-1810-67 NDC inpatient 1 UN 32.18 20.92 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.49 31.21 "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 48260973_1 CDM 0636 RC 00703-5145-91 NDC J0640 HCPCS inpatient 7 UN 88.39 57.45 AETNA AETNA 69.83 79 999999999 53.52 85.74 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 48260973_1 CDM 0636 RC 00703-5145-91 NDC J0640 HCPCS inpatient 7 UN 88.39 57.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.45 65 999999999 53.52 85.74 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 48260973_1 CDM 0636 RC 00703-5145-91 NDC J0640 HCPCS inpatient 7 UN 88.39 57.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.74 97 999999999 53.52 85.74 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 48260973_1 CDM 0636 RC 00703-5145-91 NDC J0640 HCPCS inpatient 7 UN 88.39 57.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.99 69 999999999 53.52 85.74 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 48260973_1 CDM 0636 RC 00703-5145-91 NDC J0640 HCPCS inpatient 7 UN 88.39 57.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.94 78 999999999 53.52 85.74 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 48260973_1 CDM 0636 RC 00703-5145-91 NDC J0640 HCPCS inpatient 7 UN 88.39 57.45 UMR - ALL PLANS UMR - ALL PLANS 61.87 70 999999999 53.52 85.74 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 48260973_1 CDM 0636 RC 00703-5145-91 NDC J0640 HCPCS inpatient 7 UN 88.39 57.45 SIHO - ALL PLANS SIHO - ALL PLANS 79.55 90 999999999 53.52 85.74 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 48260973_1 CDM 0636 RC 00703-5145-91 NDC J0640 HCPCS inpatient 7 UN 88.39 57.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.52 85.74 "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 48260973_1 CDM 0636 RC 00703-5145-91 NDC J0640 HCPCS inpatient 7 UN 88.39 57.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.52 60.55 999999999 53.52 85.74 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 48260973_1 CDM 0636 RC 00703-5145-91 NDC J0640 HCPCS inpatient 7 UN 88.39 57.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.52 85.74 "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 48260973_1 CDM 0636 RC 00703-5145-91 NDC J0640 HCPCS inpatient 7 UN 88.39 57.45 ANTHEM HMO ANTHEM HMO 999999999 53.52 85.74 "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 48260973_1 CDM 0636 RC 00703-5145-91 NDC J0640 HCPCS inpatient 7 UN 88.39 57.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.52 85.74 "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 48260973_1 CDM 0636 RC 00703-5145-91 NDC J0640 HCPCS inpatient 7 UN 88.39 57.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.75 67.6 999999999 53.52 85.74 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 48260973_1 CDM 0636 RC 00703-5145-91 NDC J0640 HCPCS inpatient 7 UN 88.39 57.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.52 85.74 "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 48260977_1 CDM 0636 RC 00074-3642-03 NDC J9217 HCPCS inpatient 1 UN 851.52 553.49 AETNA AETNA 672.7 79 999999999 515.6 825.97 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 48260977_1 CDM 0636 RC 00074-3642-03 NDC J9217 HCPCS inpatient 1 UN 851.52 553.49 SELF PAY DISCOUNT SELF PAY DISCOUNT 553.49 65 999999999 515.6 825.97 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 48260977_1 CDM 0636 RC 00074-3642-03 NDC J9217 HCPCS inpatient 1 UN 851.52 553.49 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 825.97 97 999999999 515.6 825.97 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 48260977_1 CDM 0636 RC 00074-3642-03 NDC J9217 HCPCS inpatient 1 UN 851.52 553.49 ENCORE - ALL PLANS ENCORE - ALL PLANS 587.55 69 999999999 515.6 825.97 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 48260977_1 CDM 0636 RC 00074-3642-03 NDC J9217 HCPCS inpatient 1 UN 851.52 553.49 HUMANA - ALL PLANS HUMANA - ALL PLANS 664.19 78 999999999 515.6 825.97 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 48260977_1 CDM 0636 RC 00074-3642-03 NDC J9217 HCPCS inpatient 1 UN 851.52 553.49 UMR - ALL PLANS UMR - ALL PLANS 596.06 70 999999999 515.6 825.97 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 48260977_1 CDM 0636 RC 00074-3642-03 NDC J9217 HCPCS inpatient 1 UN 851.52 553.49 SIHO - ALL PLANS SIHO - ALL PLANS 766.37 90 999999999 515.6 825.97 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 48260977_1 CDM 0636 RC 00074-3642-03 NDC J9217 HCPCS inpatient 1 UN 851.52 553.49 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 515.6 825.97 "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 48260977_1 CDM 0636 RC 00074-3642-03 NDC J9217 HCPCS inpatient 1 UN 851.52 553.49 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 515.6 60.55 999999999 515.6 825.97 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 48260977_1 CDM 0636 RC 00074-3642-03 NDC J9217 HCPCS inpatient 1 UN 851.52 553.49 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 515.6 825.97 "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 48260977_1 CDM 0636 RC 00074-3642-03 NDC J9217 HCPCS inpatient 1 UN 851.52 553.49 ANTHEM HMO ANTHEM HMO 999999999 515.6 825.97 "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 48260977_1 CDM 0636 RC 00074-3642-03 NDC J9217 HCPCS inpatient 1 UN 851.52 553.49 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 515.6 825.97 "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 48260977_1 CDM 0636 RC 00074-3642-03 NDC J9217 HCPCS inpatient 1 UN 851.52 553.49 CIGNA - ALL PLANS CIGNA - ALL PLANS 575.63 67.6 999999999 515.6 825.97 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 48260977_1 CDM 0636 RC 00074-3642-03 NDC J9217 HCPCS inpatient 1 UN 851.52 553.49 UHC - ALL PLANS UHC - ALL PLANS 999999999 515.6 825.97 LEVOBUNOLOL 0.5% EYE DROPS 48260988_1 CDM 0250 RC 24208-0505-05 NDC inpatient 1 UN 41.98 27.29 AETNA AETNA 33.16 79 999999999 25.42 40.72 percent of total billed charges LEVOBUNOLOL 0.5% EYE DROPS 48260988_1 CDM 0250 RC 24208-0505-05 NDC inpatient 1 UN 41.98 27.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 27.29 65 999999999 25.42 40.72 percent of total billed charges LEVOBUNOLOL 0.5% EYE DROPS 48260988_1 CDM 0250 RC 24208-0505-05 NDC inpatient 1 UN 41.98 27.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 40.72 97 999999999 25.42 40.72 percent of total billed charges LEVOBUNOLOL 0.5% EYE DROPS 48260988_1 CDM 0250 RC 24208-0505-05 NDC inpatient 1 UN 41.98 27.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.97 69 999999999 25.42 40.72 percent of total billed charges LEVOBUNOLOL 0.5% EYE DROPS 48260988_1 CDM 0250 RC 24208-0505-05 NDC inpatient 1 UN 41.98 27.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 32.74 78 999999999 25.42 40.72 percent of total billed charges LEVOBUNOLOL 0.5% EYE DROPS 48260988_1 CDM 0250 RC 24208-0505-05 NDC inpatient 1 UN 41.98 27.29 UMR - ALL PLANS UMR - ALL PLANS 29.39 70 999999999 25.42 40.72 percent of total billed charges LEVOBUNOLOL 0.5% EYE DROPS 48260988_1 CDM 0250 RC 24208-0505-05 NDC inpatient 1 UN 41.98 27.29 SIHO - ALL PLANS SIHO - ALL PLANS 37.78 90 999999999 25.42 40.72 percent of total billed charges LEVOBUNOLOL 0.5% EYE DROPS 48260988_1 CDM 0250 RC 24208-0505-05 NDC inpatient 1 UN 41.98 27.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 25.42 40.72 LEVOBUNOLOL 0.5% EYE DROPS 48260988_1 CDM 0250 RC 24208-0505-05 NDC inpatient 1 UN 41.98 27.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 25.42 60.55 999999999 25.42 40.72 percent of total billed charges LEVOBUNOLOL 0.5% EYE DROPS 48260988_1 CDM 0250 RC 24208-0505-05 NDC inpatient 1 UN 41.98 27.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 25.42 40.72 LEVOBUNOLOL 0.5% EYE DROPS 48260988_1 CDM 0250 RC 24208-0505-05 NDC inpatient 1 UN 41.98 27.29 ANTHEM HMO ANTHEM HMO 999999999 25.42 40.72 LEVOBUNOLOL 0.5% EYE DROPS 48260988_1 CDM 0250 RC 24208-0505-05 NDC inpatient 1 UN 41.98 27.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 25.42 40.72 LEVOBUNOLOL 0.5% EYE DROPS 48260988_1 CDM 0250 RC 24208-0505-05 NDC inpatient 1 UN 41.98 27.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 28.38 67.6 999999999 25.42 40.72 percent of total billed charges LEVOBUNOLOL 0.5% EYE DROPS 48260988_1 CDM 0250 RC 24208-0505-05 NDC inpatient 1 UN 41.98 27.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 25.42 40.72 "LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, 52 MG" 48260996_1 CDM 0250 RC 50419-0421-01 NDC J7302 HCPCS inpatient 1 UN 2102.04 1366.33 AETNA AETNA 1660.61 79 999999999 1272.79 2038.98 percent of total billed charges "LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, 52 MG" 48260996_1 CDM 0250 RC 50419-0421-01 NDC J7302 HCPCS inpatient 1 UN 2102.04 1366.33 SELF PAY DISCOUNT SELF PAY DISCOUNT 1366.33 65 999999999 1272.79 2038.98 percent of total billed charges "LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, 52 MG" 48260996_1 CDM 0250 RC 50419-0421-01 NDC J7302 HCPCS inpatient 1 UN 2102.04 1366.33 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2038.98 97 999999999 1272.79 2038.98 percent of total billed charges "LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, 52 MG" 48260996_1 CDM 0250 RC 50419-0421-01 NDC J7302 HCPCS inpatient 1 UN 2102.04 1366.33 ENCORE - ALL PLANS ENCORE - ALL PLANS 1450.41 69 999999999 1272.79 2038.98 percent of total billed charges "LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, 52 MG" 48260996_1 CDM 0250 RC 50419-0421-01 NDC J7302 HCPCS inpatient 1 UN 2102.04 1366.33 HUMANA - ALL PLANS HUMANA - ALL PLANS 1639.59 78 999999999 1272.79 2038.98 percent of total billed charges "LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, 52 MG" 48260996_1 CDM 0250 RC 50419-0421-01 NDC J7302 HCPCS inpatient 1 UN 2102.04 1366.33 UMR - ALL PLANS UMR - ALL PLANS 1471.43 70 999999999 1272.79 2038.98 percent of total billed charges "LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, 52 MG" 48260996_1 CDM 0250 RC 50419-0421-01 NDC J7302 HCPCS inpatient 1 UN 2102.04 1366.33 SIHO - ALL PLANS SIHO - ALL PLANS 1891.84 90 999999999 1272.79 2038.98 percent of total billed charges "LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, 52 MG" 48260996_1 CDM 0250 RC 50419-0421-01 NDC J7302 HCPCS inpatient 1 UN 2102.04 1366.33 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1272.79 2038.98 "LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, 52 MG" 48260996_1 CDM 0250 RC 50419-0421-01 NDC J7302 HCPCS inpatient 1 UN 2102.04 1366.33 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1272.79 60.55 999999999 1272.79 2038.98 percent of total billed charges "LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, 52 MG" 48260996_1 CDM 0250 RC 50419-0421-01 NDC J7302 HCPCS inpatient 1 UN 2102.04 1366.33 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1272.79 2038.98 "LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, 52 MG" 48260996_1 CDM 0250 RC 50419-0421-01 NDC J7302 HCPCS inpatient 1 UN 2102.04 1366.33 ANTHEM HMO ANTHEM HMO 999999999 1272.79 2038.98 "LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, 52 MG" 48260996_1 CDM 0250 RC 50419-0421-01 NDC J7302 HCPCS inpatient 1 UN 2102.04 1366.33 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1272.79 2038.98 "LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, 52 MG" 48260996_1 CDM 0250 RC 50419-0421-01 NDC J7302 HCPCS inpatient 1 UN 2102.04 1366.33 CIGNA - ALL PLANS CIGNA - ALL PLANS 1420.98 67.6 999999999 1272.79 2038.98 percent of total billed charges "LEVONORGESTREL-RELEASING INTRAUTERINE CONTRACEPTIVE SYSTEM, 52 MG" 48260996_1 CDM 0250 RC 50419-0421-01 NDC J7302 HCPCS inpatient 1 UN 2102.04 1366.33 UHC - ALL PLANS UHC - ALL PLANS 999999999 1272.79 2038.98 LEVOTHYROXINE 88 MCG TABLET 48261008_1 CDM 0250 RC 00781-5183-92 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 88 MCG TABLET 48261008_1 CDM 0250 RC 00781-5183-92 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 88 MCG TABLET 48261008_1 CDM 0250 RC 00781-5183-92 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 88 MCG TABLET 48261008_1 CDM 0250 RC 00781-5183-92 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 88 MCG TABLET 48261008_1 CDM 0250 RC 00781-5183-92 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 88 MCG TABLET 48261008_1 CDM 0250 RC 00781-5183-92 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 88 MCG TABLET 48261008_1 CDM 0250 RC 00781-5183-92 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 88 MCG TABLET 48261008_1 CDM 0250 RC 00781-5183-92 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LEVOTHYROXINE 88 MCG TABLET 48261008_1 CDM 0250 RC 00781-5183-92 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 88 MCG TABLET 48261008_1 CDM 0250 RC 00781-5183-92 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 88 MCG TABLET 48261008_1 CDM 0250 RC 00781-5183-92 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LEVOTHYROXINE 88 MCG TABLET 48261008_1 CDM 0250 RC 00781-5183-92 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 88 MCG TABLET 48261008_1 CDM 0250 RC 00781-5183-92 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 88 MCG TABLET 48261008_1 CDM 0250 RC 00781-5183-92 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 LIDOCAINE HCL 0.5% VIAL 48261012_1 CDM 0250 RC 00409-4278-01 NDC inpatient 1 UN 30.24 19.66 AETNA AETNA 23.89 79 999999999 18.31 29.33 percent of total billed charges LIDOCAINE HCL 0.5% VIAL 48261012_1 CDM 0250 RC 00409-4278-01 NDC inpatient 1 UN 30.24 19.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.66 65 999999999 18.31 29.33 percent of total billed charges LIDOCAINE HCL 0.5% VIAL 48261012_1 CDM 0250 RC 00409-4278-01 NDC inpatient 1 UN 30.24 19.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.33 97 999999999 18.31 29.33 percent of total billed charges LIDOCAINE HCL 0.5% VIAL 48261012_1 CDM 0250 RC 00409-4278-01 NDC inpatient 1 UN 30.24 19.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.87 69 999999999 18.31 29.33 percent of total billed charges LIDOCAINE HCL 0.5% VIAL 48261012_1 CDM 0250 RC 00409-4278-01 NDC inpatient 1 UN 30.24 19.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.59 78 999999999 18.31 29.33 percent of total billed charges LIDOCAINE HCL 0.5% VIAL 48261012_1 CDM 0250 RC 00409-4278-01 NDC inpatient 1 UN 30.24 19.66 UMR - ALL PLANS UMR - ALL PLANS 21.17 70 999999999 18.31 29.33 percent of total billed charges LIDOCAINE HCL 0.5% VIAL 48261012_1 CDM 0250 RC 00409-4278-01 NDC inpatient 1 UN 30.24 19.66 SIHO - ALL PLANS SIHO - ALL PLANS 27.22 90 999999999 18.31 29.33 percent of total billed charges LIDOCAINE HCL 0.5% VIAL 48261012_1 CDM 0250 RC 00409-4278-01 NDC inpatient 1 UN 30.24 19.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.31 29.33 LIDOCAINE HCL 0.5% VIAL 48261012_1 CDM 0250 RC 00409-4278-01 NDC inpatient 1 UN 30.24 19.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.31 60.55 999999999 18.31 29.33 percent of total billed charges LIDOCAINE HCL 0.5% VIAL 48261012_1 CDM 0250 RC 00409-4278-01 NDC inpatient 1 UN 30.24 19.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.31 29.33 LIDOCAINE HCL 0.5% VIAL 48261012_1 CDM 0250 RC 00409-4278-01 NDC inpatient 1 UN 30.24 19.66 ANTHEM HMO ANTHEM HMO 999999999 18.31 29.33 LIDOCAINE HCL 0.5% VIAL 48261012_1 CDM 0250 RC 00409-4278-01 NDC inpatient 1 UN 30.24 19.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.31 29.33 LIDOCAINE HCL 0.5% VIAL 48261012_1 CDM 0250 RC 00409-4278-01 NDC inpatient 1 UN 30.24 19.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.44 67.6 999999999 18.31 29.33 percent of total billed charges LIDOCAINE HCL 0.5% VIAL 48261012_1 CDM 0250 RC 00409-4278-01 NDC inpatient 1 UN 30.24 19.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.31 29.33 63323-0492-05 - lidocaine 1% PF Inj Sol 5 mL [JOHN] 48261015_1 CDM 0250 RC 63323-0492-05 NDC inpatient 1 UN 48.27 31.38 AETNA AETNA 38.13 79 999999999 29.23 46.82 percent of total billed charges 63323-0492-05 - lidocaine 1% PF Inj Sol 5 mL [JOHN] 48261015_1 CDM 0250 RC 63323-0492-05 NDC inpatient 1 UN 48.27 31.38 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.38 65 999999999 29.23 46.82 percent of total billed charges 63323-0492-05 - lidocaine 1% PF Inj Sol 5 mL [JOHN] 48261015_1 CDM 0250 RC 63323-0492-05 NDC inpatient 1 UN 48.27 31.38 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 46.82 97 999999999 29.23 46.82 percent of total billed charges 63323-0492-05 - lidocaine 1% PF Inj Sol 5 mL [JOHN] 48261015_1 CDM 0250 RC 63323-0492-05 NDC inpatient 1 UN 48.27 31.38 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.31 69 999999999 29.23 46.82 percent of total billed charges 63323-0492-05 - lidocaine 1% PF Inj Sol 5 mL [JOHN] 48261015_1 CDM 0250 RC 63323-0492-05 NDC inpatient 1 UN 48.27 31.38 HUMANA - ALL PLANS HUMANA - ALL PLANS 37.65 78 999999999 29.23 46.82 percent of total billed charges 63323-0492-05 - lidocaine 1% PF Inj Sol 5 mL [JOHN] 48261015_1 CDM 0250 RC 63323-0492-05 NDC inpatient 1 UN 48.27 31.38 UMR - ALL PLANS UMR - ALL PLANS 33.79 70 999999999 29.23 46.82 percent of total billed charges 63323-0492-05 - lidocaine 1% PF Inj Sol 5 mL [JOHN] 48261015_1 CDM 0250 RC 63323-0492-05 NDC inpatient 1 UN 48.27 31.38 SIHO - ALL PLANS SIHO - ALL PLANS 43.44 90 999999999 29.23 46.82 percent of total billed charges 63323-0492-05 - lidocaine 1% PF Inj Sol 5 mL [JOHN] 48261015_1 CDM 0250 RC 63323-0492-05 NDC inpatient 1 UN 48.27 31.38 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.23 46.82 63323-0492-05 - lidocaine 1% PF Inj Sol 5 mL [JOHN] 48261015_1 CDM 0250 RC 63323-0492-05 NDC inpatient 1 UN 48.27 31.38 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.23 60.55 999999999 29.23 46.82 percent of total billed charges 63323-0492-05 - lidocaine 1% PF Inj Sol 5 mL [JOHN] 48261015_1 CDM 0250 RC 63323-0492-05 NDC inpatient 1 UN 48.27 31.38 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.23 46.82 63323-0492-05 - lidocaine 1% PF Inj Sol 5 mL [JOHN] 48261015_1 CDM 0250 RC 63323-0492-05 NDC inpatient 1 UN 48.27 31.38 ANTHEM HMO ANTHEM HMO 999999999 29.23 46.82 63323-0492-05 - lidocaine 1% PF Inj Sol 5 mL [JOHN] 48261015_1 CDM 0250 RC 63323-0492-05 NDC inpatient 1 UN 48.27 31.38 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.23 46.82 63323-0492-05 - lidocaine 1% PF Inj Sol 5 mL [JOHN] 48261015_1 CDM 0250 RC 63323-0492-05 NDC inpatient 1 UN 48.27 31.38 CIGNA - ALL PLANS CIGNA - ALL PLANS 32.63 67.6 999999999 29.23 46.82 percent of total billed charges 63323-0492-05 - lidocaine 1% PF Inj Sol 5 mL [JOHN] 48261015_1 CDM 0250 RC 63323-0492-05 NDC inpatient 1 UN 48.27 31.38 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.23 46.82 LIDOCAINE HCL 1% 300 MG/30 ML 48261018_1 CDM 0250 RC 00409-4279-02 NDC inpatient 1 UN 28.24 18.36 AETNA AETNA 22.31 79 999999999 17.1 27.39 percent of total billed charges LIDOCAINE HCL 1% 300 MG/30 ML 48261018_1 CDM 0250 RC 00409-4279-02 NDC inpatient 1 UN 28.24 18.36 SELF PAY DISCOUNT SELF PAY DISCOUNT 18.36 65 999999999 17.1 27.39 percent of total billed charges LIDOCAINE HCL 1% 300 MG/30 ML 48261018_1 CDM 0250 RC 00409-4279-02 NDC inpatient 1 UN 28.24 18.36 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 27.39 97 999999999 17.1 27.39 percent of total billed charges LIDOCAINE HCL 1% 300 MG/30 ML 48261018_1 CDM 0250 RC 00409-4279-02 NDC inpatient 1 UN 28.24 18.36 ENCORE - ALL PLANS ENCORE - ALL PLANS 19.49 69 999999999 17.1 27.39 percent of total billed charges LIDOCAINE HCL 1% 300 MG/30 ML 48261018_1 CDM 0250 RC 00409-4279-02 NDC inpatient 1 UN 28.24 18.36 HUMANA - ALL PLANS HUMANA - ALL PLANS 22.03 78 999999999 17.1 27.39 percent of total billed charges LIDOCAINE HCL 1% 300 MG/30 ML 48261018_1 CDM 0250 RC 00409-4279-02 NDC inpatient 1 UN 28.24 18.36 UMR - ALL PLANS UMR - ALL PLANS 19.77 70 999999999 17.1 27.39 percent of total billed charges LIDOCAINE HCL 1% 300 MG/30 ML 48261018_1 CDM 0250 RC 00409-4279-02 NDC inpatient 1 UN 28.24 18.36 SIHO - ALL PLANS SIHO - ALL PLANS 25.42 90 999999999 17.1 27.39 percent of total billed charges LIDOCAINE HCL 1% 300 MG/30 ML 48261018_1 CDM 0250 RC 00409-4279-02 NDC inpatient 1 UN 28.24 18.36 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 17.1 27.39 LIDOCAINE HCL 1% 300 MG/30 ML 48261018_1 CDM 0250 RC 00409-4279-02 NDC inpatient 1 UN 28.24 18.36 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17.1 60.55 999999999 17.1 27.39 percent of total billed charges LIDOCAINE HCL 1% 300 MG/30 ML 48261018_1 CDM 0250 RC 00409-4279-02 NDC inpatient 1 UN 28.24 18.36 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 17.1 27.39 LIDOCAINE HCL 1% 300 MG/30 ML 48261018_1 CDM 0250 RC 00409-4279-02 NDC inpatient 1 UN 28.24 18.36 ANTHEM HMO ANTHEM HMO 999999999 17.1 27.39 LIDOCAINE HCL 1% 300 MG/30 ML 48261018_1 CDM 0250 RC 00409-4279-02 NDC inpatient 1 UN 28.24 18.36 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 17.1 27.39 LIDOCAINE HCL 1% 300 MG/30 ML 48261018_1 CDM 0250 RC 00409-4279-02 NDC inpatient 1 UN 28.24 18.36 CIGNA - ALL PLANS CIGNA - ALL PLANS 19.09 67.6 999999999 17.1 27.39 percent of total billed charges LIDOCAINE HCL 1% 300 MG/30 ML 48261018_1 CDM 0250 RC 00409-4279-02 NDC inpatient 1 UN 28.24 18.36 UHC - ALL PLANS UHC - ALL PLANS 999999999 17.1 27.39 LIDOCAINE HCL 2% VIAL 48261020_1 CDM 0250 RC 00409-4277-01 NDC inpatient 1 UN 25.34 16.47 AETNA AETNA 20.02 79 999999999 15.34 24.58 percent of total billed charges LIDOCAINE HCL 2% VIAL 48261020_1 CDM 0250 RC 00409-4277-01 NDC inpatient 1 UN 25.34 16.47 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.47 65 999999999 15.34 24.58 percent of total billed charges LIDOCAINE HCL 2% VIAL 48261020_1 CDM 0250 RC 00409-4277-01 NDC inpatient 1 UN 25.34 16.47 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.58 97 999999999 15.34 24.58 percent of total billed charges LIDOCAINE HCL 2% VIAL 48261020_1 CDM 0250 RC 00409-4277-01 NDC inpatient 1 UN 25.34 16.47 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.48 69 999999999 15.34 24.58 percent of total billed charges LIDOCAINE HCL 2% VIAL 48261020_1 CDM 0250 RC 00409-4277-01 NDC inpatient 1 UN 25.34 16.47 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.77 78 999999999 15.34 24.58 percent of total billed charges LIDOCAINE HCL 2% VIAL 48261020_1 CDM 0250 RC 00409-4277-01 NDC inpatient 1 UN 25.34 16.47 UMR - ALL PLANS UMR - ALL PLANS 17.74 70 999999999 15.34 24.58 percent of total billed charges LIDOCAINE HCL 2% VIAL 48261020_1 CDM 0250 RC 00409-4277-01 NDC inpatient 1 UN 25.34 16.47 SIHO - ALL PLANS SIHO - ALL PLANS 22.81 90 999999999 15.34 24.58 percent of total billed charges LIDOCAINE HCL 2% VIAL 48261020_1 CDM 0250 RC 00409-4277-01 NDC inpatient 1 UN 25.34 16.47 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.34 24.58 LIDOCAINE HCL 2% VIAL 48261020_1 CDM 0250 RC 00409-4277-01 NDC inpatient 1 UN 25.34 16.47 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.34 60.55 999999999 15.34 24.58 percent of total billed charges LIDOCAINE HCL 2% VIAL 48261020_1 CDM 0250 RC 00409-4277-01 NDC inpatient 1 UN 25.34 16.47 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.34 24.58 LIDOCAINE HCL 2% VIAL 48261020_1 CDM 0250 RC 00409-4277-01 NDC inpatient 1 UN 25.34 16.47 ANTHEM HMO ANTHEM HMO 999999999 15.34 24.58 LIDOCAINE HCL 2% VIAL 48261020_1 CDM 0250 RC 00409-4277-01 NDC inpatient 1 UN 25.34 16.47 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.34 24.58 LIDOCAINE HCL 2% VIAL 48261020_1 CDM 0250 RC 00409-4277-01 NDC inpatient 1 UN 25.34 16.47 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.13 67.6 999999999 15.34 24.58 percent of total billed charges LIDOCAINE HCL 2% VIAL 48261020_1 CDM 0250 RC 00409-4277-01 NDC inpatient 1 UN 25.34 16.47 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.34 24.58 63323-0495-05 - lidocaine 2% PF Inj Sol 5 mL [JOHN] 48261021_1 CDM 0250 RC 63323-0495-05 NDC inpatient 1 UN 22.5 14.63 AETNA AETNA 17.78 79 999999999 13.62 21.83 percent of total billed charges 63323-0495-05 - lidocaine 2% PF Inj Sol 5 mL [JOHN] 48261021_1 CDM 0250 RC 63323-0495-05 NDC inpatient 1 UN 22.5 14.63 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.63 65 999999999 13.62 21.83 percent of total billed charges 63323-0495-05 - lidocaine 2% PF Inj Sol 5 mL [JOHN] 48261021_1 CDM 0250 RC 63323-0495-05 NDC inpatient 1 UN 22.5 14.63 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21.83 97 999999999 13.62 21.83 percent of total billed charges 63323-0495-05 - lidocaine 2% PF Inj Sol 5 mL [JOHN] 48261021_1 CDM 0250 RC 63323-0495-05 NDC inpatient 1 UN 22.5 14.63 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.53 69 999999999 13.62 21.83 percent of total billed charges 63323-0495-05 - lidocaine 2% PF Inj Sol 5 mL [JOHN] 48261021_1 CDM 0250 RC 63323-0495-05 NDC inpatient 1 UN 22.5 14.63 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.55 78 999999999 13.62 21.83 percent of total billed charges 63323-0495-05 - lidocaine 2% PF Inj Sol 5 mL [JOHN] 48261021_1 CDM 0250 RC 63323-0495-05 NDC inpatient 1 UN 22.5 14.63 UMR - ALL PLANS UMR - ALL PLANS 15.75 70 999999999 13.62 21.83 percent of total billed charges 63323-0495-05 - lidocaine 2% PF Inj Sol 5 mL [JOHN] 48261021_1 CDM 0250 RC 63323-0495-05 NDC inpatient 1 UN 22.5 14.63 SIHO - ALL PLANS SIHO - ALL PLANS 20.25 90 999999999 13.62 21.83 percent of total billed charges 63323-0495-05 - lidocaine 2% PF Inj Sol 5 mL [JOHN] 48261021_1 CDM 0250 RC 63323-0495-05 NDC inpatient 1 UN 22.5 14.63 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.62 21.83 63323-0495-05 - lidocaine 2% PF Inj Sol 5 mL [JOHN] 48261021_1 CDM 0250 RC 63323-0495-05 NDC inpatient 1 UN 22.5 14.63 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.62 60.55 999999999 13.62 21.83 percent of total billed charges 63323-0495-05 - lidocaine 2% PF Inj Sol 5 mL [JOHN] 48261021_1 CDM 0250 RC 63323-0495-05 NDC inpatient 1 UN 22.5 14.63 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.62 21.83 63323-0495-05 - lidocaine 2% PF Inj Sol 5 mL [JOHN] 48261021_1 CDM 0250 RC 63323-0495-05 NDC inpatient 1 UN 22.5 14.63 ANTHEM HMO ANTHEM HMO 999999999 13.62 21.83 63323-0495-05 - lidocaine 2% PF Inj Sol 5 mL [JOHN] 48261021_1 CDM 0250 RC 63323-0495-05 NDC inpatient 1 UN 22.5 14.63 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.62 21.83 63323-0495-05 - lidocaine 2% PF Inj Sol 5 mL [JOHN] 48261021_1 CDM 0250 RC 63323-0495-05 NDC inpatient 1 UN 22.5 14.63 CIGNA - ALL PLANS CIGNA - ALL PLANS 15.21 67.6 999999999 13.62 21.83 percent of total billed charges 63323-0495-05 - lidocaine 2% PF Inj Sol 5 mL [JOHN] 48261021_1 CDM 0250 RC 63323-0495-05 NDC inpatient 1 UN 22.5 14.63 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.62 21.83 LIDOCAINE HCL 4% AMPUL 48261022_1 CDM 0250 RC 00409-4283-01 NDC inpatient 1 UN 32.74 21.28 AETNA AETNA 25.86 79 999999999 19.82 31.76 percent of total billed charges LIDOCAINE HCL 4% AMPUL 48261022_1 CDM 0250 RC 00409-4283-01 NDC inpatient 1 UN 32.74 21.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.28 65 999999999 19.82 31.76 percent of total billed charges LIDOCAINE HCL 4% AMPUL 48261022_1 CDM 0250 RC 00409-4283-01 NDC inpatient 1 UN 32.74 21.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31.76 97 999999999 19.82 31.76 percent of total billed charges LIDOCAINE HCL 4% AMPUL 48261022_1 CDM 0250 RC 00409-4283-01 NDC inpatient 1 UN 32.74 21.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.59 69 999999999 19.82 31.76 percent of total billed charges LIDOCAINE HCL 4% AMPUL 48261022_1 CDM 0250 RC 00409-4283-01 NDC inpatient 1 UN 32.74 21.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.54 78 999999999 19.82 31.76 percent of total billed charges LIDOCAINE HCL 4% AMPUL 48261022_1 CDM 0250 RC 00409-4283-01 NDC inpatient 1 UN 32.74 21.28 UMR - ALL PLANS UMR - ALL PLANS 22.92 70 999999999 19.82 31.76 percent of total billed charges LIDOCAINE HCL 4% AMPUL 48261022_1 CDM 0250 RC 00409-4283-01 NDC inpatient 1 UN 32.74 21.28 SIHO - ALL PLANS SIHO - ALL PLANS 29.47 90 999999999 19.82 31.76 percent of total billed charges LIDOCAINE HCL 4% AMPUL 48261022_1 CDM 0250 RC 00409-4283-01 NDC inpatient 1 UN 32.74 21.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.82 31.76 LIDOCAINE HCL 4% AMPUL 48261022_1 CDM 0250 RC 00409-4283-01 NDC inpatient 1 UN 32.74 21.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.82 60.55 999999999 19.82 31.76 percent of total billed charges LIDOCAINE HCL 4% AMPUL 48261022_1 CDM 0250 RC 00409-4283-01 NDC inpatient 1 UN 32.74 21.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.82 31.76 LIDOCAINE HCL 4% AMPUL 48261022_1 CDM 0250 RC 00409-4283-01 NDC inpatient 1 UN 32.74 21.28 ANTHEM HMO ANTHEM HMO 999999999 19.82 31.76 LIDOCAINE HCL 4% AMPUL 48261022_1 CDM 0250 RC 00409-4283-01 NDC inpatient 1 UN 32.74 21.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.82 31.76 LIDOCAINE HCL 4% AMPUL 48261022_1 CDM 0250 RC 00409-4283-01 NDC inpatient 1 UN 32.74 21.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.13 67.6 999999999 19.82 31.76 percent of total billed charges LIDOCAINE HCL 4% AMPUL 48261022_1 CDM 0250 RC 00409-4283-01 NDC inpatient 1 UN 32.74 21.28 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.82 31.76 LIDOCAINE HCL 2% JELLY 48261024_1 CDM 0250 RC 17478-0711-30 NDC inpatient 1 UN 370.5 240.83 AETNA AETNA 292.7 79 999999999 224.34 359.39 percent of total billed charges LIDOCAINE HCL 2% JELLY 48261024_1 CDM 0250 RC 17478-0711-30 NDC inpatient 1 UN 370.5 240.83 SELF PAY DISCOUNT SELF PAY DISCOUNT 240.83 65 999999999 224.34 359.39 percent of total billed charges LIDOCAINE HCL 2% JELLY 48261024_1 CDM 0250 RC 17478-0711-30 NDC inpatient 1 UN 370.5 240.83 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 359.39 97 999999999 224.34 359.39 percent of total billed charges LIDOCAINE HCL 2% JELLY 48261024_1 CDM 0250 RC 17478-0711-30 NDC inpatient 1 UN 370.5 240.83 ENCORE - ALL PLANS ENCORE - ALL PLANS 255.65 69 999999999 224.34 359.39 percent of total billed charges LIDOCAINE HCL 2% JELLY 48261024_1 CDM 0250 RC 17478-0711-30 NDC inpatient 1 UN 370.5 240.83 HUMANA - ALL PLANS HUMANA - ALL PLANS 288.99 78 999999999 224.34 359.39 percent of total billed charges LIDOCAINE HCL 2% JELLY 48261024_1 CDM 0250 RC 17478-0711-30 NDC inpatient 1 UN 370.5 240.83 UMR - ALL PLANS UMR - ALL PLANS 259.35 70 999999999 224.34 359.39 percent of total billed charges LIDOCAINE HCL 2% JELLY 48261024_1 CDM 0250 RC 17478-0711-30 NDC inpatient 1 UN 370.5 240.83 SIHO - ALL PLANS SIHO - ALL PLANS 333.45 90 999999999 224.34 359.39 percent of total billed charges LIDOCAINE HCL 2% JELLY 48261024_1 CDM 0250 RC 17478-0711-30 NDC inpatient 1 UN 370.5 240.83 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 224.34 359.39 LIDOCAINE HCL 2% JELLY 48261024_1 CDM 0250 RC 17478-0711-30 NDC inpatient 1 UN 370.5 240.83 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 224.34 60.55 999999999 224.34 359.39 percent of total billed charges LIDOCAINE HCL 2% JELLY 48261024_1 CDM 0250 RC 17478-0711-30 NDC inpatient 1 UN 370.5 240.83 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 224.34 359.39 LIDOCAINE HCL 2% JELLY 48261024_1 CDM 0250 RC 17478-0711-30 NDC inpatient 1 UN 370.5 240.83 ANTHEM HMO ANTHEM HMO 999999999 224.34 359.39 LIDOCAINE HCL 2% JELLY 48261024_1 CDM 0250 RC 17478-0711-30 NDC inpatient 1 UN 370.5 240.83 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 224.34 359.39 LIDOCAINE HCL 2% JELLY 48261024_1 CDM 0250 RC 17478-0711-30 NDC inpatient 1 UN 370.5 240.83 CIGNA - ALL PLANS CIGNA - ALL PLANS 250.46 67.6 999999999 224.34 359.39 percent of total billed charges LIDOCAINE HCL 2% JELLY 48261024_1 CDM 0250 RC 17478-0711-30 NDC inpatient 1 UN 370.5 240.83 UHC - ALL PLANS UHC - ALL PLANS 999999999 224.34 359.39 LIDOCAINE HCL 2% JELLY URO-JET 48261025_1 CDM 0250 RC 76329-3013-05 NDC inpatient 1 UN 26.36 17.13 AETNA AETNA 20.82 79 999999999 15.96 25.57 percent of total billed charges LIDOCAINE HCL 2% JELLY URO-JET 48261025_1 CDM 0250 RC 76329-3013-05 NDC inpatient 1 UN 26.36 17.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.13 65 999999999 15.96 25.57 percent of total billed charges LIDOCAINE HCL 2% JELLY URO-JET 48261025_1 CDM 0250 RC 76329-3013-05 NDC inpatient 1 UN 26.36 17.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.57 97 999999999 15.96 25.57 percent of total billed charges LIDOCAINE HCL 2% JELLY URO-JET 48261025_1 CDM 0250 RC 76329-3013-05 NDC inpatient 1 UN 26.36 17.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.19 69 999999999 15.96 25.57 percent of total billed charges LIDOCAINE HCL 2% JELLY URO-JET 48261025_1 CDM 0250 RC 76329-3013-05 NDC inpatient 1 UN 26.36 17.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.56 78 999999999 15.96 25.57 percent of total billed charges LIDOCAINE HCL 2% JELLY URO-JET 48261025_1 CDM 0250 RC 76329-3013-05 NDC inpatient 1 UN 26.36 17.13 UMR - ALL PLANS UMR - ALL PLANS 18.45 70 999999999 15.96 25.57 percent of total billed charges LIDOCAINE HCL 2% JELLY URO-JET 48261025_1 CDM 0250 RC 76329-3013-05 NDC inpatient 1 UN 26.36 17.13 SIHO - ALL PLANS SIHO - ALL PLANS 23.72 90 999999999 15.96 25.57 percent of total billed charges LIDOCAINE HCL 2% JELLY URO-JET 48261025_1 CDM 0250 RC 76329-3013-05 NDC inpatient 1 UN 26.36 17.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.96 25.57 LIDOCAINE HCL 2% JELLY URO-JET 48261025_1 CDM 0250 RC 76329-3013-05 NDC inpatient 1 UN 26.36 17.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.96 60.55 999999999 15.96 25.57 percent of total billed charges LIDOCAINE HCL 2% JELLY URO-JET 48261025_1 CDM 0250 RC 76329-3013-05 NDC inpatient 1 UN 26.36 17.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.96 25.57 LIDOCAINE HCL 2% JELLY URO-JET 48261025_1 CDM 0250 RC 76329-3013-05 NDC inpatient 1 UN 26.36 17.13 ANTHEM HMO ANTHEM HMO 999999999 15.96 25.57 LIDOCAINE HCL 2% JELLY URO-JET 48261025_1 CDM 0250 RC 76329-3013-05 NDC inpatient 1 UN 26.36 17.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.96 25.57 LIDOCAINE HCL 2% JELLY URO-JET 48261025_1 CDM 0250 RC 76329-3013-05 NDC inpatient 1 UN 26.36 17.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.82 67.6 999999999 15.96 25.57 percent of total billed charges LIDOCAINE HCL 2% JELLY URO-JET 48261025_1 CDM 0250 RC 76329-3013-05 NDC inpatient 1 UN 26.36 17.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.96 25.57 LIDOCAINE-PRILOCAINE CREAM 48261031_1 CDM 0250 RC 00115-1468-60 NDC inpatient 1 UN 10.39 6.75 AETNA AETNA 8.21 79 999999999 6.29 10.08 percent of total billed charges LIDOCAINE-PRILOCAINE CREAM 48261031_1 CDM 0250 RC 00115-1468-60 NDC inpatient 1 UN 10.39 6.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.75 65 999999999 6.29 10.08 percent of total billed charges LIDOCAINE-PRILOCAINE CREAM 48261031_1 CDM 0250 RC 00115-1468-60 NDC inpatient 1 UN 10.39 6.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10.08 97 999999999 6.29 10.08 percent of total billed charges LIDOCAINE-PRILOCAINE CREAM 48261031_1 CDM 0250 RC 00115-1468-60 NDC inpatient 1 UN 10.39 6.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.17 69 999999999 6.29 10.08 percent of total billed charges LIDOCAINE-PRILOCAINE CREAM 48261031_1 CDM 0250 RC 00115-1468-60 NDC inpatient 1 UN 10.39 6.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 8.1 78 999999999 6.29 10.08 percent of total billed charges LIDOCAINE-PRILOCAINE CREAM 48261031_1 CDM 0250 RC 00115-1468-60 NDC inpatient 1 UN 10.39 6.75 UMR - ALL PLANS UMR - ALL PLANS 7.27 70 999999999 6.29 10.08 percent of total billed charges LIDOCAINE-PRILOCAINE CREAM 48261031_1 CDM 0250 RC 00115-1468-60 NDC inpatient 1 UN 10.39 6.75 SIHO - ALL PLANS SIHO - ALL PLANS 9.35 90 999999999 6.29 10.08 percent of total billed charges LIDOCAINE-PRILOCAINE CREAM 48261031_1 CDM 0250 RC 00115-1468-60 NDC inpatient 1 UN 10.39 6.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.29 10.08 LIDOCAINE-PRILOCAINE CREAM 48261031_1 CDM 0250 RC 00115-1468-60 NDC inpatient 1 UN 10.39 6.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.29 60.55 999999999 6.29 10.08 percent of total billed charges LIDOCAINE-PRILOCAINE CREAM 48261031_1 CDM 0250 RC 00115-1468-60 NDC inpatient 1 UN 10.39 6.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.29 10.08 LIDOCAINE-PRILOCAINE CREAM 48261031_1 CDM 0250 RC 00115-1468-60 NDC inpatient 1 UN 10.39 6.75 ANTHEM HMO ANTHEM HMO 999999999 6.29 10.08 LIDOCAINE-PRILOCAINE CREAM 48261031_1 CDM 0250 RC 00115-1468-60 NDC inpatient 1 UN 10.39 6.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.29 10.08 LIDOCAINE-PRILOCAINE CREAM 48261031_1 CDM 0250 RC 00115-1468-60 NDC inpatient 1 UN 10.39 6.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 7.02 67.6 999999999 6.29 10.08 percent of total billed charges LIDOCAINE-PRILOCAINE CREAM 48261031_1 CDM 0250 RC 00115-1468-60 NDC inpatient 1 UN 10.39 6.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.29 10.08 CYTOMEL 25 MCG TABLET 48261037_1 CDM 0250 RC 60793-0116-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CYTOMEL 25 MCG TABLET 48261037_1 CDM 0250 RC 60793-0116-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CYTOMEL 25 MCG TABLET 48261037_1 CDM 0250 RC 60793-0116-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CYTOMEL 25 MCG TABLET 48261037_1 CDM 0250 RC 60793-0116-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CYTOMEL 25 MCG TABLET 48261037_1 CDM 0250 RC 60793-0116-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CYTOMEL 25 MCG TABLET 48261037_1 CDM 0250 RC 60793-0116-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CYTOMEL 25 MCG TABLET 48261037_1 CDM 0250 RC 60793-0116-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CYTOMEL 25 MCG TABLET 48261037_1 CDM 0250 RC 60793-0116-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CYTOMEL 25 MCG TABLET 48261037_1 CDM 0250 RC 60793-0116-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CYTOMEL 25 MCG TABLET 48261037_1 CDM 0250 RC 60793-0116-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CYTOMEL 25 MCG TABLET 48261037_1 CDM 0250 RC 60793-0116-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CYTOMEL 25 MCG TABLET 48261037_1 CDM 0250 RC 60793-0116-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CYTOMEL 25 MCG TABLET 48261037_1 CDM 0250 RC 60793-0116-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CYTOMEL 25 MCG TABLET 48261037_1 CDM 0250 RC 60793-0116-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 VICTOZA 2-PAK 18 MG/3 ML PEN 48261038_1 CDM 0250 RC 00169-4060-12 NDC inpatient 1 UN 1643.01 1067.96 AETNA AETNA 1297.98 79 999999999 994.84 1593.72 percent of total billed charges VICTOZA 2-PAK 18 MG/3 ML PEN 48261038_1 CDM 0250 RC 00169-4060-12 NDC inpatient 1 UN 1643.01 1067.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 1067.96 65 999999999 994.84 1593.72 percent of total billed charges VICTOZA 2-PAK 18 MG/3 ML PEN 48261038_1 CDM 0250 RC 00169-4060-12 NDC inpatient 1 UN 1643.01 1067.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1593.72 97 999999999 994.84 1593.72 percent of total billed charges VICTOZA 2-PAK 18 MG/3 ML PEN 48261038_1 CDM 0250 RC 00169-4060-12 NDC inpatient 1 UN 1643.01 1067.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 1133.68 69 999999999 994.84 1593.72 percent of total billed charges VICTOZA 2-PAK 18 MG/3 ML PEN 48261038_1 CDM 0250 RC 00169-4060-12 NDC inpatient 1 UN 1643.01 1067.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 1281.55 78 999999999 994.84 1593.72 percent of total billed charges VICTOZA 2-PAK 18 MG/3 ML PEN 48261038_1 CDM 0250 RC 00169-4060-12 NDC inpatient 1 UN 1643.01 1067.96 UMR - ALL PLANS UMR - ALL PLANS 1150.11 70 999999999 994.84 1593.72 percent of total billed charges VICTOZA 2-PAK 18 MG/3 ML PEN 48261038_1 CDM 0250 RC 00169-4060-12 NDC inpatient 1 UN 1643.01 1067.96 SIHO - ALL PLANS SIHO - ALL PLANS 1478.71 90 999999999 994.84 1593.72 percent of total billed charges VICTOZA 2-PAK 18 MG/3 ML PEN 48261038_1 CDM 0250 RC 00169-4060-12 NDC inpatient 1 UN 1643.01 1067.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 994.84 1593.72 VICTOZA 2-PAK 18 MG/3 ML PEN 48261038_1 CDM 0250 RC 00169-4060-12 NDC inpatient 1 UN 1643.01 1067.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 994.84 60.55 999999999 994.84 1593.72 percent of total billed charges VICTOZA 2-PAK 18 MG/3 ML PEN 48261038_1 CDM 0250 RC 00169-4060-12 NDC inpatient 1 UN 1643.01 1067.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 994.84 1593.72 VICTOZA 2-PAK 18 MG/3 ML PEN 48261038_1 CDM 0250 RC 00169-4060-12 NDC inpatient 1 UN 1643.01 1067.96 ANTHEM HMO ANTHEM HMO 999999999 994.84 1593.72 VICTOZA 2-PAK 18 MG/3 ML PEN 48261038_1 CDM 0250 RC 00169-4060-12 NDC inpatient 1 UN 1643.01 1067.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 994.84 1593.72 VICTOZA 2-PAK 18 MG/3 ML PEN 48261038_1 CDM 0250 RC 00169-4060-12 NDC inpatient 1 UN 1643.01 1067.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 1110.67 67.6 999999999 994.84 1593.72 percent of total billed charges VICTOZA 2-PAK 18 MG/3 ML PEN 48261038_1 CDM 0250 RC 00169-4060-12 NDC inpatient 1 UN 1643.01 1067.96 UHC - ALL PLANS UHC - ALL PLANS 999999999 994.84 1593.72 LOPERAMIDE 2 MG CAPSULE 48261045_1 CDM 0250 RC 51079-0690-20 NDC inpatient 1 UN 2.29 1.49 AETNA AETNA 1.81 79 999999999 1.39 2.22 percent of total billed charges LOPERAMIDE 2 MG CAPSULE 48261045_1 CDM 0250 RC 51079-0690-20 NDC inpatient 1 UN 2.29 1.49 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.49 65 999999999 1.39 2.22 percent of total billed charges LOPERAMIDE 2 MG CAPSULE 48261045_1 CDM 0250 RC 51079-0690-20 NDC inpatient 1 UN 2.29 1.49 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.22 97 999999999 1.39 2.22 percent of total billed charges LOPERAMIDE 2 MG CAPSULE 48261045_1 CDM 0250 RC 51079-0690-20 NDC inpatient 1 UN 2.29 1.49 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.58 69 999999999 1.39 2.22 percent of total billed charges LOPERAMIDE 2 MG CAPSULE 48261045_1 CDM 0250 RC 51079-0690-20 NDC inpatient 1 UN 2.29 1.49 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.79 78 999999999 1.39 2.22 percent of total billed charges LOPERAMIDE 2 MG CAPSULE 48261045_1 CDM 0250 RC 51079-0690-20 NDC inpatient 1 UN 2.29 1.49 UMR - ALL PLANS UMR - ALL PLANS 1.6 70 999999999 1.39 2.22 percent of total billed charges LOPERAMIDE 2 MG CAPSULE 48261045_1 CDM 0250 RC 51079-0690-20 NDC inpatient 1 UN 2.29 1.49 SIHO - ALL PLANS SIHO - ALL PLANS 2.06 90 999999999 1.39 2.22 percent of total billed charges LOPERAMIDE 2 MG CAPSULE 48261045_1 CDM 0250 RC 51079-0690-20 NDC inpatient 1 UN 2.29 1.49 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.39 2.22 LOPERAMIDE 2 MG CAPSULE 48261045_1 CDM 0250 RC 51079-0690-20 NDC inpatient 1 UN 2.29 1.49 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.39 60.55 999999999 1.39 2.22 percent of total billed charges LOPERAMIDE 2 MG CAPSULE 48261045_1 CDM 0250 RC 51079-0690-20 NDC inpatient 1 UN 2.29 1.49 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.39 2.22 LOPERAMIDE 2 MG CAPSULE 48261045_1 CDM 0250 RC 51079-0690-20 NDC inpatient 1 UN 2.29 1.49 ANTHEM HMO ANTHEM HMO 999999999 1.39 2.22 LOPERAMIDE 2 MG CAPSULE 48261045_1 CDM 0250 RC 51079-0690-20 NDC inpatient 1 UN 2.29 1.49 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.39 2.22 LOPERAMIDE 2 MG CAPSULE 48261045_1 CDM 0250 RC 51079-0690-20 NDC inpatient 1 UN 2.29 1.49 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.55 67.6 999999999 1.39 2.22 percent of total billed charges LOPERAMIDE 2 MG CAPSULE 48261045_1 CDM 0250 RC 51079-0690-20 NDC inpatient 1 UN 2.29 1.49 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.39 2.22 LORATADINE 10 MG TABLET 48261046_1 CDM 0250 RC 68084-0248-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LORATADINE 10 MG TABLET 48261046_1 CDM 0250 RC 68084-0248-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LORATADINE 10 MG TABLET 48261046_1 CDM 0250 RC 68084-0248-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LORATADINE 10 MG TABLET 48261046_1 CDM 0250 RC 68084-0248-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LORATADINE 10 MG TABLET 48261046_1 CDM 0250 RC 68084-0248-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LORATADINE 10 MG TABLET 48261046_1 CDM 0250 RC 68084-0248-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LORATADINE 10 MG TABLET 48261046_1 CDM 0250 RC 68084-0248-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LORATADINE 10 MG TABLET 48261046_1 CDM 0250 RC 68084-0248-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LORATADINE 10 MG TABLET 48261046_1 CDM 0250 RC 68084-0248-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LORATADINE 10 MG TABLET 48261046_1 CDM 0250 RC 68084-0248-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LORATADINE 10 MG TABLET 48261046_1 CDM 0250 RC 68084-0248-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LORATADINE 10 MG TABLET 48261046_1 CDM 0250 RC 68084-0248-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LORATADINE 10 MG TABLET 48261046_1 CDM 0250 RC 68084-0248-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges LORATADINE 10 MG TABLET 48261046_1 CDM 0250 RC 68084-0248-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, LORAZEPAM, 2 MG" 48261049_1 CDM 0250 RC 00641-6048-25 NDC J2060 HCPCS inpatient 1 UN 19.85 12.9 AETNA AETNA 15.68 79 999999999 12.02 19.25 percent of total billed charges "INJECTION, LORAZEPAM, 2 MG" 48261049_1 CDM 0250 RC 00641-6048-25 NDC J2060 HCPCS inpatient 1 UN 19.85 12.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.9 65 999999999 12.02 19.25 percent of total billed charges "INJECTION, LORAZEPAM, 2 MG" 48261049_1 CDM 0250 RC 00641-6048-25 NDC J2060 HCPCS inpatient 1 UN 19.85 12.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.25 97 999999999 12.02 19.25 percent of total billed charges "INJECTION, LORAZEPAM, 2 MG" 48261049_1 CDM 0250 RC 00641-6048-25 NDC J2060 HCPCS inpatient 1 UN 19.85 12.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.7 69 999999999 12.02 19.25 percent of total billed charges "INJECTION, LORAZEPAM, 2 MG" 48261049_1 CDM 0250 RC 00641-6048-25 NDC J2060 HCPCS inpatient 1 UN 19.85 12.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.48 78 999999999 12.02 19.25 percent of total billed charges "INJECTION, LORAZEPAM, 2 MG" 48261049_1 CDM 0250 RC 00641-6048-25 NDC J2060 HCPCS inpatient 1 UN 19.85 12.9 UMR - ALL PLANS UMR - ALL PLANS 13.9 70 999999999 12.02 19.25 percent of total billed charges "INJECTION, LORAZEPAM, 2 MG" 48261049_1 CDM 0250 RC 00641-6048-25 NDC J2060 HCPCS inpatient 1 UN 19.85 12.9 SIHO - ALL PLANS SIHO - ALL PLANS 17.87 90 999999999 12.02 19.25 percent of total billed charges "INJECTION, LORAZEPAM, 2 MG" 48261049_1 CDM 0250 RC 00641-6048-25 NDC J2060 HCPCS inpatient 1 UN 19.85 12.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.02 19.25 "INJECTION, LORAZEPAM, 2 MG" 48261049_1 CDM 0250 RC 00641-6048-25 NDC J2060 HCPCS inpatient 1 UN 19.85 12.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.02 60.55 999999999 12.02 19.25 percent of total billed charges "INJECTION, LORAZEPAM, 2 MG" 48261049_1 CDM 0250 RC 00641-6048-25 NDC J2060 HCPCS inpatient 1 UN 19.85 12.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.02 19.25 "INJECTION, LORAZEPAM, 2 MG" 48261049_1 CDM 0250 RC 00641-6048-25 NDC J2060 HCPCS inpatient 1 UN 19.85 12.9 ANTHEM HMO ANTHEM HMO 999999999 12.02 19.25 "INJECTION, LORAZEPAM, 2 MG" 48261049_1 CDM 0250 RC 00641-6048-25 NDC J2060 HCPCS inpatient 1 UN 19.85 12.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.02 19.25 "INJECTION, LORAZEPAM, 2 MG" 48261049_1 CDM 0250 RC 00641-6048-25 NDC J2060 HCPCS inpatient 1 UN 19.85 12.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.42 67.6 999999999 12.02 19.25 percent of total billed charges "INJECTION, LORAZEPAM, 2 MG" 48261049_1 CDM 0250 RC 00641-6048-25 NDC J2060 HCPCS inpatient 1 UN 19.85 12.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.02 19.25 LORAZEPAM INTENSOL 2 MG/ML 48261051_1 CDM 0250 RC 00054-3532-44 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LORAZEPAM INTENSOL 2 MG/ML 48261051_1 CDM 0250 RC 00054-3532-44 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LORAZEPAM INTENSOL 2 MG/ML 48261051_1 CDM 0250 RC 00054-3532-44 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LORAZEPAM INTENSOL 2 MG/ML 48261051_1 CDM 0250 RC 00054-3532-44 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LORAZEPAM INTENSOL 2 MG/ML 48261051_1 CDM 0250 RC 00054-3532-44 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LORAZEPAM INTENSOL 2 MG/ML 48261051_1 CDM 0250 RC 00054-3532-44 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LORAZEPAM INTENSOL 2 MG/ML 48261051_1 CDM 0250 RC 00054-3532-44 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LORAZEPAM INTENSOL 2 MG/ML 48261051_1 CDM 0250 RC 00054-3532-44 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LORAZEPAM INTENSOL 2 MG/ML 48261051_1 CDM 0250 RC 00054-3532-44 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LORAZEPAM INTENSOL 2 MG/ML 48261051_1 CDM 0250 RC 00054-3532-44 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LORAZEPAM INTENSOL 2 MG/ML 48261051_1 CDM 0250 RC 00054-3532-44 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LORAZEPAM INTENSOL 2 MG/ML 48261051_1 CDM 0250 RC 00054-3532-44 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LORAZEPAM INTENSOL 2 MG/ML 48261051_1 CDM 0250 RC 00054-3532-44 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges LORAZEPAM INTENSOL 2 MG/ML 48261051_1 CDM 0250 RC 00054-3532-44 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 LOSARTAN POTASSIUM 25 MG TAB 48261052_1 CDM 0250 RC 68084-0346-01 NDC inpatient 1 UN 1.82 1.18 AETNA AETNA 1.44 79 999999999 1.1 1.77 percent of total billed charges LOSARTAN POTASSIUM 25 MG TAB 48261052_1 CDM 0250 RC 68084-0346-01 NDC inpatient 1 UN 1.82 1.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.18 65 999999999 1.1 1.77 percent of total billed charges LOSARTAN POTASSIUM 25 MG TAB 48261052_1 CDM 0250 RC 68084-0346-01 NDC inpatient 1 UN 1.82 1.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.77 97 999999999 1.1 1.77 percent of total billed charges LOSARTAN POTASSIUM 25 MG TAB 48261052_1 CDM 0250 RC 68084-0346-01 NDC inpatient 1 UN 1.82 1.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.26 69 999999999 1.1 1.77 percent of total billed charges LOSARTAN POTASSIUM 25 MG TAB 48261052_1 CDM 0250 RC 68084-0346-01 NDC inpatient 1 UN 1.82 1.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.42 78 999999999 1.1 1.77 percent of total billed charges LOSARTAN POTASSIUM 25 MG TAB 48261052_1 CDM 0250 RC 68084-0346-01 NDC inpatient 1 UN 1.82 1.18 UMR - ALL PLANS UMR - ALL PLANS 1.27 70 999999999 1.1 1.77 percent of total billed charges LOSARTAN POTASSIUM 25 MG TAB 48261052_1 CDM 0250 RC 68084-0346-01 NDC inpatient 1 UN 1.82 1.18 SIHO - ALL PLANS SIHO - ALL PLANS 1.64 90 999999999 1.1 1.77 percent of total billed charges LOSARTAN POTASSIUM 25 MG TAB 48261052_1 CDM 0250 RC 68084-0346-01 NDC inpatient 1 UN 1.82 1.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.1 1.77 LOSARTAN POTASSIUM 25 MG TAB 48261052_1 CDM 0250 RC 68084-0346-01 NDC inpatient 1 UN 1.82 1.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.1 60.55 999999999 1.1 1.77 percent of total billed charges LOSARTAN POTASSIUM 25 MG TAB 48261052_1 CDM 0250 RC 68084-0346-01 NDC inpatient 1 UN 1.82 1.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.1 1.77 LOSARTAN POTASSIUM 25 MG TAB 48261052_1 CDM 0250 RC 68084-0346-01 NDC inpatient 1 UN 1.82 1.18 ANTHEM HMO ANTHEM HMO 999999999 1.1 1.77 LOSARTAN POTASSIUM 25 MG TAB 48261052_1 CDM 0250 RC 68084-0346-01 NDC inpatient 1 UN 1.82 1.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.1 1.77 LOSARTAN POTASSIUM 25 MG TAB 48261052_1 CDM 0250 RC 68084-0346-01 NDC inpatient 1 UN 1.82 1.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.23 67.6 999999999 1.1 1.77 percent of total billed charges LOSARTAN POTASSIUM 25 MG TAB 48261052_1 CDM 0250 RC 68084-0346-01 NDC inpatient 1 UN 1.82 1.18 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.1 1.77 LOSARTAN POTASSIUM 50 MG TAB 48261053_1 CDM 0250 RC 68084-0347-01 NDC inpatient 1 UN 1.28 0.83 AETNA AETNA 1.01 79 999999999 0.78 1.24 percent of total billed charges LOSARTAN POTASSIUM 50 MG TAB 48261053_1 CDM 0250 RC 68084-0347-01 NDC inpatient 1 UN 1.28 0.83 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.83 65 999999999 0.78 1.24 percent of total billed charges LOSARTAN POTASSIUM 50 MG TAB 48261053_1 CDM 0250 RC 68084-0347-01 NDC inpatient 1 UN 1.28 0.83 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.24 97 999999999 0.78 1.24 percent of total billed charges LOSARTAN POTASSIUM 50 MG TAB 48261053_1 CDM 0250 RC 68084-0347-01 NDC inpatient 1 UN 1.28 0.83 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.88 69 999999999 0.78 1.24 percent of total billed charges LOSARTAN POTASSIUM 50 MG TAB 48261053_1 CDM 0250 RC 68084-0347-01 NDC inpatient 1 UN 1.28 0.83 HUMANA - ALL PLANS HUMANA - ALL PLANS 1 78 999999999 0.78 1.24 percent of total billed charges LOSARTAN POTASSIUM 50 MG TAB 48261053_1 CDM 0250 RC 68084-0347-01 NDC inpatient 1 UN 1.28 0.83 UMR - ALL PLANS UMR - ALL PLANS 0.9 70 999999999 0.78 1.24 percent of total billed charges LOSARTAN POTASSIUM 50 MG TAB 48261053_1 CDM 0250 RC 68084-0347-01 NDC inpatient 1 UN 1.28 0.83 SIHO - ALL PLANS SIHO - ALL PLANS 1.15 90 999999999 0.78 1.24 percent of total billed charges LOSARTAN POTASSIUM 50 MG TAB 48261053_1 CDM 0250 RC 68084-0347-01 NDC inpatient 1 UN 1.28 0.83 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.78 1.24 LOSARTAN POTASSIUM 50 MG TAB 48261053_1 CDM 0250 RC 68084-0347-01 NDC inpatient 1 UN 1.28 0.83 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.78 60.55 999999999 0.78 1.24 percent of total billed charges LOSARTAN POTASSIUM 50 MG TAB 48261053_1 CDM 0250 RC 68084-0347-01 NDC inpatient 1 UN 1.28 0.83 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.78 1.24 LOSARTAN POTASSIUM 50 MG TAB 48261053_1 CDM 0250 RC 68084-0347-01 NDC inpatient 1 UN 1.28 0.83 ANTHEM HMO ANTHEM HMO 999999999 0.78 1.24 LOSARTAN POTASSIUM 50 MG TAB 48261053_1 CDM 0250 RC 68084-0347-01 NDC inpatient 1 UN 1.28 0.83 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.78 1.24 LOSARTAN POTASSIUM 50 MG TAB 48261053_1 CDM 0250 RC 68084-0347-01 NDC inpatient 1 UN 1.28 0.83 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.87 67.6 999999999 0.78 1.24 percent of total billed charges LOSARTAN POTASSIUM 50 MG TAB 48261053_1 CDM 0250 RC 68084-0347-01 NDC inpatient 1 UN 1.28 0.83 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.78 1.24 AMITIZA 8 MCG CAPSULE 48261055_1 CDM 0250 RC 64764-0080-60 NDC inpatient 1 UN 27.27 17.73 AETNA AETNA 21.54 79 999999999 16.51 26.45 percent of total billed charges AMITIZA 8 MCG CAPSULE 48261055_1 CDM 0250 RC 64764-0080-60 NDC inpatient 1 UN 27.27 17.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.73 65 999999999 16.51 26.45 percent of total billed charges AMITIZA 8 MCG CAPSULE 48261055_1 CDM 0250 RC 64764-0080-60 NDC inpatient 1 UN 27.27 17.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26.45 97 999999999 16.51 26.45 percent of total billed charges AMITIZA 8 MCG CAPSULE 48261055_1 CDM 0250 RC 64764-0080-60 NDC inpatient 1 UN 27.27 17.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.82 69 999999999 16.51 26.45 percent of total billed charges AMITIZA 8 MCG CAPSULE 48261055_1 CDM 0250 RC 64764-0080-60 NDC inpatient 1 UN 27.27 17.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.27 78 999999999 16.51 26.45 percent of total billed charges AMITIZA 8 MCG CAPSULE 48261055_1 CDM 0250 RC 64764-0080-60 NDC inpatient 1 UN 27.27 17.73 UMR - ALL PLANS UMR - ALL PLANS 19.09 70 999999999 16.51 26.45 percent of total billed charges AMITIZA 8 MCG CAPSULE 48261055_1 CDM 0250 RC 64764-0080-60 NDC inpatient 1 UN 27.27 17.73 SIHO - ALL PLANS SIHO - ALL PLANS 24.54 90 999999999 16.51 26.45 percent of total billed charges AMITIZA 8 MCG CAPSULE 48261055_1 CDM 0250 RC 64764-0080-60 NDC inpatient 1 UN 27.27 17.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.51 26.45 AMITIZA 8 MCG CAPSULE 48261055_1 CDM 0250 RC 64764-0080-60 NDC inpatient 1 UN 27.27 17.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.51 60.55 999999999 16.51 26.45 percent of total billed charges AMITIZA 8 MCG CAPSULE 48261055_1 CDM 0250 RC 64764-0080-60 NDC inpatient 1 UN 27.27 17.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.51 26.45 AMITIZA 8 MCG CAPSULE 48261055_1 CDM 0250 RC 64764-0080-60 NDC inpatient 1 UN 27.27 17.73 ANTHEM HMO ANTHEM HMO 999999999 16.51 26.45 AMITIZA 8 MCG CAPSULE 48261055_1 CDM 0250 RC 64764-0080-60 NDC inpatient 1 UN 27.27 17.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.51 26.45 AMITIZA 8 MCG CAPSULE 48261055_1 CDM 0250 RC 64764-0080-60 NDC inpatient 1 UN 27.27 17.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.43 67.6 999999999 16.51 26.45 percent of total billed charges AMITIZA 8 MCG CAPSULE 48261055_1 CDM 0250 RC 64764-0080-60 NDC inpatient 1 UN 27.27 17.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.51 26.45 MILK OF MAGNESIA SUSPENSION 48261057_1 CDM 0250 RC 00121-0431-30 NDC inpatient 1 UN 8.69 5.65 AETNA AETNA 6.87 79 999999999 5.26 8.43 percent of total billed charges MILK OF MAGNESIA SUSPENSION 48261057_1 CDM 0250 RC 00121-0431-30 NDC inpatient 1 UN 8.69 5.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.65 65 999999999 5.26 8.43 percent of total billed charges MILK OF MAGNESIA SUSPENSION 48261057_1 CDM 0250 RC 00121-0431-30 NDC inpatient 1 UN 8.69 5.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.43 97 999999999 5.26 8.43 percent of total billed charges MILK OF MAGNESIA SUSPENSION 48261057_1 CDM 0250 RC 00121-0431-30 NDC inpatient 1 UN 8.69 5.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 6 69 999999999 5.26 8.43 percent of total billed charges MILK OF MAGNESIA SUSPENSION 48261057_1 CDM 0250 RC 00121-0431-30 NDC inpatient 1 UN 8.69 5.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.78 78 999999999 5.26 8.43 percent of total billed charges MILK OF MAGNESIA SUSPENSION 48261057_1 CDM 0250 RC 00121-0431-30 NDC inpatient 1 UN 8.69 5.65 UMR - ALL PLANS UMR - ALL PLANS 6.08 70 999999999 5.26 8.43 percent of total billed charges MILK OF MAGNESIA SUSPENSION 48261057_1 CDM 0250 RC 00121-0431-30 NDC inpatient 1 UN 8.69 5.65 SIHO - ALL PLANS SIHO - ALL PLANS 7.82 90 999999999 5.26 8.43 percent of total billed charges MILK OF MAGNESIA SUSPENSION 48261057_1 CDM 0250 RC 00121-0431-30 NDC inpatient 1 UN 8.69 5.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.26 8.43 MILK OF MAGNESIA SUSPENSION 48261057_1 CDM 0250 RC 00121-0431-30 NDC inpatient 1 UN 8.69 5.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.26 60.55 999999999 5.26 8.43 percent of total billed charges MILK OF MAGNESIA SUSPENSION 48261057_1 CDM 0250 RC 00121-0431-30 NDC inpatient 1 UN 8.69 5.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.26 8.43 MILK OF MAGNESIA SUSPENSION 48261057_1 CDM 0250 RC 00121-0431-30 NDC inpatient 1 UN 8.69 5.65 ANTHEM HMO ANTHEM HMO 999999999 5.26 8.43 MILK OF MAGNESIA SUSPENSION 48261057_1 CDM 0250 RC 00121-0431-30 NDC inpatient 1 UN 8.69 5.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.26 8.43 MILK OF MAGNESIA SUSPENSION 48261057_1 CDM 0250 RC 00121-0431-30 NDC inpatient 1 UN 8.69 5.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.87 67.6 999999999 5.26 8.43 percent of total billed charges MILK OF MAGNESIA SUSPENSION 48261057_1 CDM 0250 RC 00121-0431-30 NDC inpatient 1 UN 8.69 5.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.26 8.43 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48261059_1 CDM 0258 RC 00409-6729-23 NDC J3475 HCPCS inpatient 8 UN 72.26 46.97 AETNA AETNA 57.09 79 999999999 43.75 70.09 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48261059_1 CDM 0258 RC 00409-6729-23 NDC J3475 HCPCS inpatient 8 UN 72.26 46.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.97 65 999999999 43.75 70.09 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48261059_1 CDM 0258 RC 00409-6729-23 NDC J3475 HCPCS inpatient 8 UN 72.26 46.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.09 97 999999999 43.75 70.09 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48261059_1 CDM 0258 RC 00409-6729-23 NDC J3475 HCPCS inpatient 8 UN 72.26 46.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.86 69 999999999 43.75 70.09 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48261059_1 CDM 0258 RC 00409-6729-23 NDC J3475 HCPCS inpatient 8 UN 72.26 46.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.36 78 999999999 43.75 70.09 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48261059_1 CDM 0258 RC 00409-6729-23 NDC J3475 HCPCS inpatient 8 UN 72.26 46.97 UMR - ALL PLANS UMR - ALL PLANS 50.58 70 999999999 43.75 70.09 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48261059_1 CDM 0258 RC 00409-6729-23 NDC J3475 HCPCS inpatient 8 UN 72.26 46.97 SIHO - ALL PLANS SIHO - ALL PLANS 65.03 90 999999999 43.75 70.09 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48261059_1 CDM 0258 RC 00409-6729-23 NDC J3475 HCPCS inpatient 8 UN 72.26 46.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.75 70.09 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48261059_1 CDM 0258 RC 00409-6729-23 NDC J3475 HCPCS inpatient 8 UN 72.26 46.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.75 60.55 999999999 43.75 70.09 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48261059_1 CDM 0258 RC 00409-6729-23 NDC J3475 HCPCS inpatient 8 UN 72.26 46.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.75 70.09 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48261059_1 CDM 0258 RC 00409-6729-23 NDC J3475 HCPCS inpatient 8 UN 72.26 46.97 ANTHEM HMO ANTHEM HMO 999999999 43.75 70.09 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48261059_1 CDM 0258 RC 00409-6729-23 NDC J3475 HCPCS inpatient 8 UN 72.26 46.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.75 70.09 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48261059_1 CDM 0258 RC 00409-6729-23 NDC J3475 HCPCS inpatient 8 UN 72.26 46.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.85 67.6 999999999 43.75 70.09 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48261059_1 CDM 0258 RC 00409-6729-23 NDC J3475 HCPCS inpatient 8 UN 72.26 46.97 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.75 70.09 MAGNESIUM SULFATE 50% SYRINGE 48261063_1 CDM 0250 RC 00409-1754-10 NDC inpatient 1 UN 41.05 26.68 AETNA AETNA 32.43 79 999999999 24.86 39.82 percent of total billed charges MAGNESIUM SULFATE 50% SYRINGE 48261063_1 CDM 0250 RC 00409-1754-10 NDC inpatient 1 UN 41.05 26.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.68 65 999999999 24.86 39.82 percent of total billed charges MAGNESIUM SULFATE 50% SYRINGE 48261063_1 CDM 0250 RC 00409-1754-10 NDC inpatient 1 UN 41.05 26.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39.82 97 999999999 24.86 39.82 percent of total billed charges MAGNESIUM SULFATE 50% SYRINGE 48261063_1 CDM 0250 RC 00409-1754-10 NDC inpatient 1 UN 41.05 26.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.32 69 999999999 24.86 39.82 percent of total billed charges MAGNESIUM SULFATE 50% SYRINGE 48261063_1 CDM 0250 RC 00409-1754-10 NDC inpatient 1 UN 41.05 26.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 32.02 78 999999999 24.86 39.82 percent of total billed charges MAGNESIUM SULFATE 50% SYRINGE 48261063_1 CDM 0250 RC 00409-1754-10 NDC inpatient 1 UN 41.05 26.68 UMR - ALL PLANS UMR - ALL PLANS 28.74 70 999999999 24.86 39.82 percent of total billed charges MAGNESIUM SULFATE 50% SYRINGE 48261063_1 CDM 0250 RC 00409-1754-10 NDC inpatient 1 UN 41.05 26.68 SIHO - ALL PLANS SIHO - ALL PLANS 36.95 90 999999999 24.86 39.82 percent of total billed charges MAGNESIUM SULFATE 50% SYRINGE 48261063_1 CDM 0250 RC 00409-1754-10 NDC inpatient 1 UN 41.05 26.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.86 39.82 MAGNESIUM SULFATE 50% SYRINGE 48261063_1 CDM 0250 RC 00409-1754-10 NDC inpatient 1 UN 41.05 26.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.86 60.55 999999999 24.86 39.82 percent of total billed charges MAGNESIUM SULFATE 50% SYRINGE 48261063_1 CDM 0250 RC 00409-1754-10 NDC inpatient 1 UN 41.05 26.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.86 39.82 MAGNESIUM SULFATE 50% SYRINGE 48261063_1 CDM 0250 RC 00409-1754-10 NDC inpatient 1 UN 41.05 26.68 ANTHEM HMO ANTHEM HMO 999999999 24.86 39.82 MAGNESIUM SULFATE 50% SYRINGE 48261063_1 CDM 0250 RC 00409-1754-10 NDC inpatient 1 UN 41.05 26.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.86 39.82 MAGNESIUM SULFATE 50% SYRINGE 48261063_1 CDM 0250 RC 00409-1754-10 NDC inpatient 1 UN 41.05 26.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.75 67.6 999999999 24.86 39.82 percent of total billed charges MAGNESIUM SULFATE 50% SYRINGE 48261063_1 CDM 0250 RC 00409-1754-10 NDC inpatient 1 UN 41.05 26.68 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.86 39.82 M-M-R II VACCINE VIAL 48261066_1 CDM 0250 RC 00006-4681-00 NDC inpatient 1 UN 114.67 74.54 AETNA AETNA 90.59 79 999999999 69.43 111.23 percent of total billed charges M-M-R II VACCINE VIAL 48261066_1 CDM 0250 RC 00006-4681-00 NDC inpatient 1 UN 114.67 74.54 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.54 65 999999999 69.43 111.23 percent of total billed charges M-M-R II VACCINE VIAL 48261066_1 CDM 0250 RC 00006-4681-00 NDC inpatient 1 UN 114.67 74.54 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 111.23 97 999999999 69.43 111.23 percent of total billed charges M-M-R II VACCINE VIAL 48261066_1 CDM 0250 RC 00006-4681-00 NDC inpatient 1 UN 114.67 74.54 ENCORE - ALL PLANS ENCORE - ALL PLANS 79.12 69 999999999 69.43 111.23 percent of total billed charges M-M-R II VACCINE VIAL 48261066_1 CDM 0250 RC 00006-4681-00 NDC inpatient 1 UN 114.67 74.54 HUMANA - ALL PLANS HUMANA - ALL PLANS 89.44 78 999999999 69.43 111.23 percent of total billed charges M-M-R II VACCINE VIAL 48261066_1 CDM 0250 RC 00006-4681-00 NDC inpatient 1 UN 114.67 74.54 UMR - ALL PLANS UMR - ALL PLANS 80.27 70 999999999 69.43 111.23 percent of total billed charges M-M-R II VACCINE VIAL 48261066_1 CDM 0250 RC 00006-4681-00 NDC inpatient 1 UN 114.67 74.54 SIHO - ALL PLANS SIHO - ALL PLANS 103.2 90 999999999 69.43 111.23 percent of total billed charges M-M-R II VACCINE VIAL 48261066_1 CDM 0250 RC 00006-4681-00 NDC inpatient 1 UN 114.67 74.54 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.43 111.23 M-M-R II VACCINE VIAL 48261066_1 CDM 0250 RC 00006-4681-00 NDC inpatient 1 UN 114.67 74.54 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.43 60.55 999999999 69.43 111.23 percent of total billed charges M-M-R II VACCINE VIAL 48261066_1 CDM 0250 RC 00006-4681-00 NDC inpatient 1 UN 114.67 74.54 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.43 111.23 M-M-R II VACCINE VIAL 48261066_1 CDM 0250 RC 00006-4681-00 NDC inpatient 1 UN 114.67 74.54 ANTHEM HMO ANTHEM HMO 999999999 69.43 111.23 M-M-R II VACCINE VIAL 48261066_1 CDM 0250 RC 00006-4681-00 NDC inpatient 1 UN 114.67 74.54 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.43 111.23 M-M-R II VACCINE VIAL 48261066_1 CDM 0250 RC 00006-4681-00 NDC inpatient 1 UN 114.67 74.54 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.52 67.6 999999999 69.43 111.23 percent of total billed charges M-M-R II VACCINE VIAL 48261066_1 CDM 0250 RC 00006-4681-00 NDC inpatient 1 UN 114.67 74.54 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.43 111.23 "PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS" 48261072_1 CDM 0250 RC 51079-0434-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges "PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS" 48261072_1 CDM 0250 RC 51079-0434-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges "PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS" 48261072_1 CDM 0250 RC 51079-0434-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges "PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS" 48261072_1 CDM 0250 RC 51079-0434-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges "PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS" 48261072_1 CDM 0250 RC 51079-0434-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges "PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS" 48261072_1 CDM 0250 RC 51079-0434-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges "PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS" 48261072_1 CDM 0250 RC 51079-0434-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges "PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS" 48261072_1 CDM 0250 RC 51079-0434-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 "PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS" 48261072_1 CDM 0250 RC 51079-0434-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges "PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS" 48261072_1 CDM 0250 RC 51079-0434-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 "PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS" 48261072_1 CDM 0250 RC 51079-0434-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 "PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS" 48261072_1 CDM 0250 RC 51079-0434-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 "PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS" 48261072_1 CDM 0250 RC 51079-0434-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "PRESCRIPTION DRUG, ORAL, CHEMOTHERAPEUTIC, NOS" 48261072_1 CDM 0250 RC 51079-0434-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 MEGESTROL ACET 40 MG/ML SUSP 48261073_1 CDM 0250 RC 49884-0907-38 NDC inpatient 1 UN 8.99 5.84 AETNA AETNA 7.1 79 999999999 5.44 8.72 percent of total billed charges MEGESTROL ACET 40 MG/ML SUSP 48261073_1 CDM 0250 RC 49884-0907-38 NDC inpatient 1 UN 8.99 5.84 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.84 65 999999999 5.44 8.72 percent of total billed charges MEGESTROL ACET 40 MG/ML SUSP 48261073_1 CDM 0250 RC 49884-0907-38 NDC inpatient 1 UN 8.99 5.84 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.72 97 999999999 5.44 8.72 percent of total billed charges MEGESTROL ACET 40 MG/ML SUSP 48261073_1 CDM 0250 RC 49884-0907-38 NDC inpatient 1 UN 8.99 5.84 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.2 69 999999999 5.44 8.72 percent of total billed charges MEGESTROL ACET 40 MG/ML SUSP 48261073_1 CDM 0250 RC 49884-0907-38 NDC inpatient 1 UN 8.99 5.84 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.01 78 999999999 5.44 8.72 percent of total billed charges MEGESTROL ACET 40 MG/ML SUSP 48261073_1 CDM 0250 RC 49884-0907-38 NDC inpatient 1 UN 8.99 5.84 UMR - ALL PLANS UMR - ALL PLANS 6.29 70 999999999 5.44 8.72 percent of total billed charges MEGESTROL ACET 40 MG/ML SUSP 48261073_1 CDM 0250 RC 49884-0907-38 NDC inpatient 1 UN 8.99 5.84 SIHO - ALL PLANS SIHO - ALL PLANS 8.09 90 999999999 5.44 8.72 percent of total billed charges MEGESTROL ACET 40 MG/ML SUSP 48261073_1 CDM 0250 RC 49884-0907-38 NDC inpatient 1 UN 8.99 5.84 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.44 8.72 MEGESTROL ACET 40 MG/ML SUSP 48261073_1 CDM 0250 RC 49884-0907-38 NDC inpatient 1 UN 8.99 5.84 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.44 60.55 999999999 5.44 8.72 percent of total billed charges MEGESTROL ACET 40 MG/ML SUSP 48261073_1 CDM 0250 RC 49884-0907-38 NDC inpatient 1 UN 8.99 5.84 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.44 8.72 MEGESTROL ACET 40 MG/ML SUSP 48261073_1 CDM 0250 RC 49884-0907-38 NDC inpatient 1 UN 8.99 5.84 ANTHEM HMO ANTHEM HMO 999999999 5.44 8.72 MEGESTROL ACET 40 MG/ML SUSP 48261073_1 CDM 0250 RC 49884-0907-38 NDC inpatient 1 UN 8.99 5.84 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.44 8.72 MEGESTROL ACET 40 MG/ML SUSP 48261073_1 CDM 0250 RC 49884-0907-38 NDC inpatient 1 UN 8.99 5.84 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.08 67.6 999999999 5.44 8.72 percent of total billed charges MEGESTROL ACET 40 MG/ML SUSP 48261073_1 CDM 0250 RC 49884-0907-38 NDC inpatient 1 UN 8.99 5.84 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.44 8.72 "INJECTION, MEROPENEM, 100 MG" 48261087_1 CDM 0250 RC 63323-0507-21 NDC J2185 HCPCS inpatient 5 UN 36.7 23.86 AETNA AETNA 28.99 79 999999999 22.22 35.6 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 48261087_1 CDM 0250 RC 63323-0507-21 NDC J2185 HCPCS inpatient 5 UN 36.7 23.86 SELF PAY DISCOUNT SELF PAY DISCOUNT 23.86 65 999999999 22.22 35.6 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 48261087_1 CDM 0250 RC 63323-0507-21 NDC J2185 HCPCS inpatient 5 UN 36.7 23.86 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.6 97 999999999 22.22 35.6 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 48261087_1 CDM 0250 RC 63323-0507-21 NDC J2185 HCPCS inpatient 5 UN 36.7 23.86 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.32 69 999999999 22.22 35.6 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 48261087_1 CDM 0250 RC 63323-0507-21 NDC J2185 HCPCS inpatient 5 UN 36.7 23.86 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.63 78 999999999 22.22 35.6 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 48261087_1 CDM 0250 RC 63323-0507-21 NDC J2185 HCPCS inpatient 5 UN 36.7 23.86 UMR - ALL PLANS UMR - ALL PLANS 25.69 70 999999999 22.22 35.6 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 48261087_1 CDM 0250 RC 63323-0507-21 NDC J2185 HCPCS inpatient 5 UN 36.7 23.86 SIHO - ALL PLANS SIHO - ALL PLANS 33.03 90 999999999 22.22 35.6 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 48261087_1 CDM 0250 RC 63323-0507-21 NDC J2185 HCPCS inpatient 5 UN 36.7 23.86 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.22 35.6 "INJECTION, MEROPENEM, 100 MG" 48261087_1 CDM 0250 RC 63323-0507-21 NDC J2185 HCPCS inpatient 5 UN 36.7 23.86 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.22 60.55 999999999 22.22 35.6 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 48261087_1 CDM 0250 RC 63323-0507-21 NDC J2185 HCPCS inpatient 5 UN 36.7 23.86 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.22 35.6 "INJECTION, MEROPENEM, 100 MG" 48261087_1 CDM 0250 RC 63323-0507-21 NDC J2185 HCPCS inpatient 5 UN 36.7 23.86 ANTHEM HMO ANTHEM HMO 999999999 22.22 35.6 "INJECTION, MEROPENEM, 100 MG" 48261087_1 CDM 0250 RC 63323-0507-21 NDC J2185 HCPCS inpatient 5 UN 36.7 23.86 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.22 35.6 "INJECTION, MEROPENEM, 100 MG" 48261087_1 CDM 0250 RC 63323-0507-21 NDC J2185 HCPCS inpatient 5 UN 36.7 23.86 CIGNA - ALL PLANS CIGNA - ALL PLANS 24.81 67.6 999999999 22.22 35.6 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 48261087_1 CDM 0250 RC 63323-0507-21 NDC J2185 HCPCS inpatient 5 UN 36.7 23.86 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.22 35.6 50268-0531-15 - metFORMIN 500 mg ER Tab [JOHN] 48261092_1 CDM 0250 RC 50268-0531-15 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 50268-0531-15 - metFORMIN 500 mg ER Tab [JOHN] 48261092_1 CDM 0250 RC 50268-0531-15 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 50268-0531-15 - metFORMIN 500 mg ER Tab [JOHN] 48261092_1 CDM 0250 RC 50268-0531-15 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 50268-0531-15 - metFORMIN 500 mg ER Tab [JOHN] 48261092_1 CDM 0250 RC 50268-0531-15 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 50268-0531-15 - metFORMIN 500 mg ER Tab [JOHN] 48261092_1 CDM 0250 RC 50268-0531-15 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 50268-0531-15 - metFORMIN 500 mg ER Tab [JOHN] 48261092_1 CDM 0250 RC 50268-0531-15 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 50268-0531-15 - metFORMIN 500 mg ER Tab [JOHN] 48261092_1 CDM 0250 RC 50268-0531-15 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 50268-0531-15 - metFORMIN 500 mg ER Tab [JOHN] 48261092_1 CDM 0250 RC 50268-0531-15 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 50268-0531-15 - metFORMIN 500 mg ER Tab [JOHN] 48261092_1 CDM 0250 RC 50268-0531-15 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 50268-0531-15 - metFORMIN 500 mg ER Tab [JOHN] 48261092_1 CDM 0250 RC 50268-0531-15 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 50268-0531-15 - metFORMIN 500 mg ER Tab [JOHN] 48261092_1 CDM 0250 RC 50268-0531-15 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 50268-0531-15 - metFORMIN 500 mg ER Tab [JOHN] 48261092_1 CDM 0250 RC 50268-0531-15 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 50268-0531-15 - metFORMIN 500 mg ER Tab [JOHN] 48261092_1 CDM 0250 RC 50268-0531-15 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 50268-0531-15 - metFORMIN 500 mg ER Tab [JOHN] 48261092_1 CDM 0250 RC 50268-0531-15 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 METHIMAZOLE 10 MG TABLET 48261097_1 CDM 0250 RC 49884-0641-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges METHIMAZOLE 10 MG TABLET 48261097_1 CDM 0250 RC 49884-0641-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges METHIMAZOLE 10 MG TABLET 48261097_1 CDM 0250 RC 49884-0641-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges METHIMAZOLE 10 MG TABLET 48261097_1 CDM 0250 RC 49884-0641-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges METHIMAZOLE 10 MG TABLET 48261097_1 CDM 0250 RC 49884-0641-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges METHIMAZOLE 10 MG TABLET 48261097_1 CDM 0250 RC 49884-0641-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges METHIMAZOLE 10 MG TABLET 48261097_1 CDM 0250 RC 49884-0641-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges METHIMAZOLE 10 MG TABLET 48261097_1 CDM 0250 RC 49884-0641-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 METHIMAZOLE 10 MG TABLET 48261097_1 CDM 0250 RC 49884-0641-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges METHIMAZOLE 10 MG TABLET 48261097_1 CDM 0250 RC 49884-0641-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 METHIMAZOLE 10 MG TABLET 48261097_1 CDM 0250 RC 49884-0641-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 METHIMAZOLE 10 MG TABLET 48261097_1 CDM 0250 RC 49884-0641-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 METHIMAZOLE 10 MG TABLET 48261097_1 CDM 0250 RC 49884-0641-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges METHIMAZOLE 10 MG TABLET 48261097_1 CDM 0250 RC 49884-0641-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 METHYLENE BLUE 1% VIAL 48261104_1 CDM 0250 RC 17478-0504-10 NDC inpatient 1 UN 666.45 433.19 AETNA AETNA 526.5 79 999999999 403.54 646.46 percent of total billed charges METHYLENE BLUE 1% VIAL 48261104_1 CDM 0250 RC 17478-0504-10 NDC inpatient 1 UN 666.45 433.19 SELF PAY DISCOUNT SELF PAY DISCOUNT 433.19 65 999999999 403.54 646.46 percent of total billed charges METHYLENE BLUE 1% VIAL 48261104_1 CDM 0250 RC 17478-0504-10 NDC inpatient 1 UN 666.45 433.19 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 646.46 97 999999999 403.54 646.46 percent of total billed charges METHYLENE BLUE 1% VIAL 48261104_1 CDM 0250 RC 17478-0504-10 NDC inpatient 1 UN 666.45 433.19 ENCORE - ALL PLANS ENCORE - ALL PLANS 459.85 69 999999999 403.54 646.46 percent of total billed charges METHYLENE BLUE 1% VIAL 48261104_1 CDM 0250 RC 17478-0504-10 NDC inpatient 1 UN 666.45 433.19 HUMANA - ALL PLANS HUMANA - ALL PLANS 519.83 78 999999999 403.54 646.46 percent of total billed charges METHYLENE BLUE 1% VIAL 48261104_1 CDM 0250 RC 17478-0504-10 NDC inpatient 1 UN 666.45 433.19 UMR - ALL PLANS UMR - ALL PLANS 466.52 70 999999999 403.54 646.46 percent of total billed charges METHYLENE BLUE 1% VIAL 48261104_1 CDM 0250 RC 17478-0504-10 NDC inpatient 1 UN 666.45 433.19 SIHO - ALL PLANS SIHO - ALL PLANS 599.81 90 999999999 403.54 646.46 percent of total billed charges METHYLENE BLUE 1% VIAL 48261104_1 CDM 0250 RC 17478-0504-10 NDC inpatient 1 UN 666.45 433.19 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 403.54 646.46 METHYLENE BLUE 1% VIAL 48261104_1 CDM 0250 RC 17478-0504-10 NDC inpatient 1 UN 666.45 433.19 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 403.54 60.55 999999999 403.54 646.46 percent of total billed charges METHYLENE BLUE 1% VIAL 48261104_1 CDM 0250 RC 17478-0504-10 NDC inpatient 1 UN 666.45 433.19 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 403.54 646.46 METHYLENE BLUE 1% VIAL 48261104_1 CDM 0250 RC 17478-0504-10 NDC inpatient 1 UN 666.45 433.19 ANTHEM HMO ANTHEM HMO 999999999 403.54 646.46 METHYLENE BLUE 1% VIAL 48261104_1 CDM 0250 RC 17478-0504-10 NDC inpatient 1 UN 666.45 433.19 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 403.54 646.46 METHYLENE BLUE 1% VIAL 48261104_1 CDM 0250 RC 17478-0504-10 NDC inpatient 1 UN 666.45 433.19 CIGNA - ALL PLANS CIGNA - ALL PLANS 450.52 67.6 999999999 403.54 646.46 percent of total billed charges METHYLENE BLUE 1% VIAL 48261104_1 CDM 0250 RC 17478-0504-10 NDC inpatient 1 UN 666.45 433.19 UHC - ALL PLANS UHC - ALL PLANS 999999999 403.54 646.46 RELISTOR 12 MG/0.6 ML VIAL 48261107_1 CDM 0250 RC 65649-0551-02 NDC inpatient 1 UN 667.43 433.83 AETNA AETNA 527.27 79 999999999 404.13 647.41 percent of total billed charges RELISTOR 12 MG/0.6 ML VIAL 48261107_1 CDM 0250 RC 65649-0551-02 NDC inpatient 1 UN 667.43 433.83 SELF PAY DISCOUNT SELF PAY DISCOUNT 433.83 65 999999999 404.13 647.41 percent of total billed charges RELISTOR 12 MG/0.6 ML VIAL 48261107_1 CDM 0250 RC 65649-0551-02 NDC inpatient 1 UN 667.43 433.83 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 647.41 97 999999999 404.13 647.41 percent of total billed charges RELISTOR 12 MG/0.6 ML VIAL 48261107_1 CDM 0250 RC 65649-0551-02 NDC inpatient 1 UN 667.43 433.83 ENCORE - ALL PLANS ENCORE - ALL PLANS 460.53 69 999999999 404.13 647.41 percent of total billed charges RELISTOR 12 MG/0.6 ML VIAL 48261107_1 CDM 0250 RC 65649-0551-02 NDC inpatient 1 UN 667.43 433.83 HUMANA - ALL PLANS HUMANA - ALL PLANS 520.6 78 999999999 404.13 647.41 percent of total billed charges RELISTOR 12 MG/0.6 ML VIAL 48261107_1 CDM 0250 RC 65649-0551-02 NDC inpatient 1 UN 667.43 433.83 UMR - ALL PLANS UMR - ALL PLANS 467.2 70 999999999 404.13 647.41 percent of total billed charges RELISTOR 12 MG/0.6 ML VIAL 48261107_1 CDM 0250 RC 65649-0551-02 NDC inpatient 1 UN 667.43 433.83 SIHO - ALL PLANS SIHO - ALL PLANS 600.69 90 999999999 404.13 647.41 percent of total billed charges RELISTOR 12 MG/0.6 ML VIAL 48261107_1 CDM 0250 RC 65649-0551-02 NDC inpatient 1 UN 667.43 433.83 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 404.13 647.41 RELISTOR 12 MG/0.6 ML VIAL 48261107_1 CDM 0250 RC 65649-0551-02 NDC inpatient 1 UN 667.43 433.83 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 404.13 60.55 999999999 404.13 647.41 percent of total billed charges RELISTOR 12 MG/0.6 ML VIAL 48261107_1 CDM 0250 RC 65649-0551-02 NDC inpatient 1 UN 667.43 433.83 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 404.13 647.41 RELISTOR 12 MG/0.6 ML VIAL 48261107_1 CDM 0250 RC 65649-0551-02 NDC inpatient 1 UN 667.43 433.83 ANTHEM HMO ANTHEM HMO 999999999 404.13 647.41 RELISTOR 12 MG/0.6 ML VIAL 48261107_1 CDM 0250 RC 65649-0551-02 NDC inpatient 1 UN 667.43 433.83 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 404.13 647.41 RELISTOR 12 MG/0.6 ML VIAL 48261107_1 CDM 0250 RC 65649-0551-02 NDC inpatient 1 UN 667.43 433.83 CIGNA - ALL PLANS CIGNA - ALL PLANS 451.18 67.6 999999999 404.13 647.41 percent of total billed charges RELISTOR 12 MG/0.6 ML VIAL 48261107_1 CDM 0250 RC 65649-0551-02 NDC inpatient 1 UN 667.43 433.83 UHC - ALL PLANS UHC - ALL PLANS 999999999 404.13 647.41 SOLU-MEDROL 1 GRAM VIAL 48261109_1 CDM 0250 RC 00009-0698-01 NDC inpatient 1 UN 138.66 90.13 AETNA AETNA 109.54 79 999999999 83.96 134.5 percent of total billed charges SOLU-MEDROL 1 GRAM VIAL 48261109_1 CDM 0250 RC 00009-0698-01 NDC inpatient 1 UN 138.66 90.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 90.13 65 999999999 83.96 134.5 percent of total billed charges SOLU-MEDROL 1 GRAM VIAL 48261109_1 CDM 0250 RC 00009-0698-01 NDC inpatient 1 UN 138.66 90.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 134.5 97 999999999 83.96 134.5 percent of total billed charges SOLU-MEDROL 1 GRAM VIAL 48261109_1 CDM 0250 RC 00009-0698-01 NDC inpatient 1 UN 138.66 90.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.68 69 999999999 83.96 134.5 percent of total billed charges SOLU-MEDROL 1 GRAM VIAL 48261109_1 CDM 0250 RC 00009-0698-01 NDC inpatient 1 UN 138.66 90.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 108.15 78 999999999 83.96 134.5 percent of total billed charges SOLU-MEDROL 1 GRAM VIAL 48261109_1 CDM 0250 RC 00009-0698-01 NDC inpatient 1 UN 138.66 90.13 UMR - ALL PLANS UMR - ALL PLANS 97.06 70 999999999 83.96 134.5 percent of total billed charges SOLU-MEDROL 1 GRAM VIAL 48261109_1 CDM 0250 RC 00009-0698-01 NDC inpatient 1 UN 138.66 90.13 SIHO - ALL PLANS SIHO - ALL PLANS 124.79 90 999999999 83.96 134.5 percent of total billed charges SOLU-MEDROL 1 GRAM VIAL 48261109_1 CDM 0250 RC 00009-0698-01 NDC inpatient 1 UN 138.66 90.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 83.96 134.5 SOLU-MEDROL 1 GRAM VIAL 48261109_1 CDM 0250 RC 00009-0698-01 NDC inpatient 1 UN 138.66 90.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 83.96 60.55 999999999 83.96 134.5 percent of total billed charges SOLU-MEDROL 1 GRAM VIAL 48261109_1 CDM 0250 RC 00009-0698-01 NDC inpatient 1 UN 138.66 90.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 83.96 134.5 SOLU-MEDROL 1 GRAM VIAL 48261109_1 CDM 0250 RC 00009-0698-01 NDC inpatient 1 UN 138.66 90.13 ANTHEM HMO ANTHEM HMO 999999999 83.96 134.5 SOLU-MEDROL 1 GRAM VIAL 48261109_1 CDM 0250 RC 00009-0698-01 NDC inpatient 1 UN 138.66 90.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 83.96 134.5 SOLU-MEDROL 1 GRAM VIAL 48261109_1 CDM 0250 RC 00009-0698-01 NDC inpatient 1 UN 138.66 90.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.73 67.6 999999999 83.96 134.5 percent of total billed charges SOLU-MEDROL 1 GRAM VIAL 48261109_1 CDM 0250 RC 00009-0698-01 NDC inpatient 1 UN 138.66 90.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 83.96 134.5 DEPO-MEDROL 40 MG/ML VIAL 48261110_1 CDM 0250 RC 00009-3073-23 NDC inpatient 1 UN 42.44 27.59 AETNA AETNA 33.53 79 999999999 25.7 41.17 percent of total billed charges DEPO-MEDROL 40 MG/ML VIAL 48261110_1 CDM 0250 RC 00009-3073-23 NDC inpatient 1 UN 42.44 27.59 SELF PAY DISCOUNT SELF PAY DISCOUNT 27.59 65 999999999 25.7 41.17 percent of total billed charges DEPO-MEDROL 40 MG/ML VIAL 48261110_1 CDM 0250 RC 00009-3073-23 NDC inpatient 1 UN 42.44 27.59 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 41.17 97 999999999 25.7 41.17 percent of total billed charges DEPO-MEDROL 40 MG/ML VIAL 48261110_1 CDM 0250 RC 00009-3073-23 NDC inpatient 1 UN 42.44 27.59 ENCORE - ALL PLANS ENCORE - ALL PLANS 29.28 69 999999999 25.7 41.17 percent of total billed charges DEPO-MEDROL 40 MG/ML VIAL 48261110_1 CDM 0250 RC 00009-3073-23 NDC inpatient 1 UN 42.44 27.59 HUMANA - ALL PLANS HUMANA - ALL PLANS 33.1 78 999999999 25.7 41.17 percent of total billed charges DEPO-MEDROL 40 MG/ML VIAL 48261110_1 CDM 0250 RC 00009-3073-23 NDC inpatient 1 UN 42.44 27.59 UMR - ALL PLANS UMR - ALL PLANS 29.71 70 999999999 25.7 41.17 percent of total billed charges DEPO-MEDROL 40 MG/ML VIAL 48261110_1 CDM 0250 RC 00009-3073-23 NDC inpatient 1 UN 42.44 27.59 SIHO - ALL PLANS SIHO - ALL PLANS 38.2 90 999999999 25.7 41.17 percent of total billed charges DEPO-MEDROL 40 MG/ML VIAL 48261110_1 CDM 0250 RC 00009-3073-23 NDC inpatient 1 UN 42.44 27.59 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 25.7 41.17 DEPO-MEDROL 40 MG/ML VIAL 48261110_1 CDM 0250 RC 00009-3073-23 NDC inpatient 1 UN 42.44 27.59 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 25.7 60.55 999999999 25.7 41.17 percent of total billed charges DEPO-MEDROL 40 MG/ML VIAL 48261110_1 CDM 0250 RC 00009-3073-23 NDC inpatient 1 UN 42.44 27.59 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 25.7 41.17 DEPO-MEDROL 40 MG/ML VIAL 48261110_1 CDM 0250 RC 00009-3073-23 NDC inpatient 1 UN 42.44 27.59 ANTHEM HMO ANTHEM HMO 999999999 25.7 41.17 DEPO-MEDROL 40 MG/ML VIAL 48261110_1 CDM 0250 RC 00009-3073-23 NDC inpatient 1 UN 42.44 27.59 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 25.7 41.17 DEPO-MEDROL 40 MG/ML VIAL 48261110_1 CDM 0250 RC 00009-3073-23 NDC inpatient 1 UN 42.44 27.59 CIGNA - ALL PLANS CIGNA - ALL PLANS 28.69 67.6 999999999 25.7 41.17 percent of total billed charges DEPO-MEDROL 40 MG/ML VIAL 48261110_1 CDM 0250 RC 00009-3073-23 NDC inpatient 1 UN 42.44 27.59 UHC - ALL PLANS UHC - ALL PLANS 999999999 25.7 41.17 SOLU-MEDROL 125 MG VIAL 48261111_1 CDM 0250 RC 00009-0047-26 NDC inpatient 1 UN 54.17 35.21 AETNA AETNA 42.79 79 999999999 32.8 52.54 percent of total billed charges SOLU-MEDROL 125 MG VIAL 48261111_1 CDM 0250 RC 00009-0047-26 NDC inpatient 1 UN 54.17 35.21 SELF PAY DISCOUNT SELF PAY DISCOUNT 35.21 65 999999999 32.8 52.54 percent of total billed charges SOLU-MEDROL 125 MG VIAL 48261111_1 CDM 0250 RC 00009-0047-26 NDC inpatient 1 UN 54.17 35.21 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 52.54 97 999999999 32.8 52.54 percent of total billed charges SOLU-MEDROL 125 MG VIAL 48261111_1 CDM 0250 RC 00009-0047-26 NDC inpatient 1 UN 54.17 35.21 ENCORE - ALL PLANS ENCORE - ALL PLANS 37.38 69 999999999 32.8 52.54 percent of total billed charges SOLU-MEDROL 125 MG VIAL 48261111_1 CDM 0250 RC 00009-0047-26 NDC inpatient 1 UN 54.17 35.21 HUMANA - ALL PLANS HUMANA - ALL PLANS 42.25 78 999999999 32.8 52.54 percent of total billed charges SOLU-MEDROL 125 MG VIAL 48261111_1 CDM 0250 RC 00009-0047-26 NDC inpatient 1 UN 54.17 35.21 UMR - ALL PLANS UMR - ALL PLANS 37.92 70 999999999 32.8 52.54 percent of total billed charges SOLU-MEDROL 125 MG VIAL 48261111_1 CDM 0250 RC 00009-0047-26 NDC inpatient 1 UN 54.17 35.21 SIHO - ALL PLANS SIHO - ALL PLANS 48.75 90 999999999 32.8 52.54 percent of total billed charges SOLU-MEDROL 125 MG VIAL 48261111_1 CDM 0250 RC 00009-0047-26 NDC inpatient 1 UN 54.17 35.21 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.8 52.54 SOLU-MEDROL 125 MG VIAL 48261111_1 CDM 0250 RC 00009-0047-26 NDC inpatient 1 UN 54.17 35.21 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.8 60.55 999999999 32.8 52.54 percent of total billed charges SOLU-MEDROL 125 MG VIAL 48261111_1 CDM 0250 RC 00009-0047-26 NDC inpatient 1 UN 54.17 35.21 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.8 52.54 SOLU-MEDROL 125 MG VIAL 48261111_1 CDM 0250 RC 00009-0047-26 NDC inpatient 1 UN 54.17 35.21 ANTHEM HMO ANTHEM HMO 999999999 32.8 52.54 SOLU-MEDROL 125 MG VIAL 48261111_1 CDM 0250 RC 00009-0047-26 NDC inpatient 1 UN 54.17 35.21 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.8 52.54 SOLU-MEDROL 125 MG VIAL 48261111_1 CDM 0250 RC 00009-0047-26 NDC inpatient 1 UN 54.17 35.21 CIGNA - ALL PLANS CIGNA - ALL PLANS 36.62 67.6 999999999 32.8 52.54 percent of total billed charges SOLU-MEDROL 125 MG VIAL 48261111_1 CDM 0250 RC 00009-0047-26 NDC inpatient 1 UN 54.17 35.21 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.8 52.54 SOLU-MEDROL 40 MG VIAL 48261112_1 CDM 0250 RC 00009-0039-32 NDC inpatient 1 UN 36.71 23.86 AETNA AETNA 29 79 999999999 22.23 35.61 percent of total billed charges SOLU-MEDROL 40 MG VIAL 48261112_1 CDM 0250 RC 00009-0039-32 NDC inpatient 1 UN 36.71 23.86 SELF PAY DISCOUNT SELF PAY DISCOUNT 23.86 65 999999999 22.23 35.61 percent of total billed charges SOLU-MEDROL 40 MG VIAL 48261112_1 CDM 0250 RC 00009-0039-32 NDC inpatient 1 UN 36.71 23.86 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.61 97 999999999 22.23 35.61 percent of total billed charges SOLU-MEDROL 40 MG VIAL 48261112_1 CDM 0250 RC 00009-0039-32 NDC inpatient 1 UN 36.71 23.86 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.33 69 999999999 22.23 35.61 percent of total billed charges SOLU-MEDROL 40 MG VIAL 48261112_1 CDM 0250 RC 00009-0039-32 NDC inpatient 1 UN 36.71 23.86 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.63 78 999999999 22.23 35.61 percent of total billed charges SOLU-MEDROL 40 MG VIAL 48261112_1 CDM 0250 RC 00009-0039-32 NDC inpatient 1 UN 36.71 23.86 UMR - ALL PLANS UMR - ALL PLANS 25.7 70 999999999 22.23 35.61 percent of total billed charges SOLU-MEDROL 40 MG VIAL 48261112_1 CDM 0250 RC 00009-0039-32 NDC inpatient 1 UN 36.71 23.86 SIHO - ALL PLANS SIHO - ALL PLANS 33.04 90 999999999 22.23 35.61 percent of total billed charges SOLU-MEDROL 40 MG VIAL 48261112_1 CDM 0250 RC 00009-0039-32 NDC inpatient 1 UN 36.71 23.86 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.23 35.61 SOLU-MEDROL 40 MG VIAL 48261112_1 CDM 0250 RC 00009-0039-32 NDC inpatient 1 UN 36.71 23.86 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.23 60.55 999999999 22.23 35.61 percent of total billed charges SOLU-MEDROL 40 MG VIAL 48261112_1 CDM 0250 RC 00009-0039-32 NDC inpatient 1 UN 36.71 23.86 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.23 35.61 SOLU-MEDROL 40 MG VIAL 48261112_1 CDM 0250 RC 00009-0039-32 NDC inpatient 1 UN 36.71 23.86 ANTHEM HMO ANTHEM HMO 999999999 22.23 35.61 SOLU-MEDROL 40 MG VIAL 48261112_1 CDM 0250 RC 00009-0039-32 NDC inpatient 1 UN 36.71 23.86 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.23 35.61 SOLU-MEDROL 40 MG VIAL 48261112_1 CDM 0250 RC 00009-0039-32 NDC inpatient 1 UN 36.71 23.86 CIGNA - ALL PLANS CIGNA - ALL PLANS 24.82 67.6 999999999 22.23 35.61 percent of total billed charges SOLU-MEDROL 40 MG VIAL 48261112_1 CDM 0250 RC 00009-0039-32 NDC inpatient 1 UN 36.71 23.86 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.23 35.61 SOLU-MEDROL 500 MG VIAL 48261115_1 CDM 0250 RC 00009-0758-01 NDC inpatient 1 UN 58.19 37.82 AETNA AETNA 45.97 79 999999999 35.23 56.44 percent of total billed charges SOLU-MEDROL 500 MG VIAL 48261115_1 CDM 0250 RC 00009-0758-01 NDC inpatient 1 UN 58.19 37.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.82 65 999999999 35.23 56.44 percent of total billed charges SOLU-MEDROL 500 MG VIAL 48261115_1 CDM 0250 RC 00009-0758-01 NDC inpatient 1 UN 58.19 37.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.44 97 999999999 35.23 56.44 percent of total billed charges SOLU-MEDROL 500 MG VIAL 48261115_1 CDM 0250 RC 00009-0758-01 NDC inpatient 1 UN 58.19 37.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.15 69 999999999 35.23 56.44 percent of total billed charges SOLU-MEDROL 500 MG VIAL 48261115_1 CDM 0250 RC 00009-0758-01 NDC inpatient 1 UN 58.19 37.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.39 78 999999999 35.23 56.44 percent of total billed charges SOLU-MEDROL 500 MG VIAL 48261115_1 CDM 0250 RC 00009-0758-01 NDC inpatient 1 UN 58.19 37.82 UMR - ALL PLANS UMR - ALL PLANS 40.73 70 999999999 35.23 56.44 percent of total billed charges SOLU-MEDROL 500 MG VIAL 48261115_1 CDM 0250 RC 00009-0758-01 NDC inpatient 1 UN 58.19 37.82 SIHO - ALL PLANS SIHO - ALL PLANS 52.37 90 999999999 35.23 56.44 percent of total billed charges SOLU-MEDROL 500 MG VIAL 48261115_1 CDM 0250 RC 00009-0758-01 NDC inpatient 1 UN 58.19 37.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.23 56.44 SOLU-MEDROL 500 MG VIAL 48261115_1 CDM 0250 RC 00009-0758-01 NDC inpatient 1 UN 58.19 37.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.23 60.55 999999999 35.23 56.44 percent of total billed charges SOLU-MEDROL 500 MG VIAL 48261115_1 CDM 0250 RC 00009-0758-01 NDC inpatient 1 UN 58.19 37.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.23 56.44 SOLU-MEDROL 500 MG VIAL 48261115_1 CDM 0250 RC 00009-0758-01 NDC inpatient 1 UN 58.19 37.82 ANTHEM HMO ANTHEM HMO 999999999 35.23 56.44 SOLU-MEDROL 500 MG VIAL 48261115_1 CDM 0250 RC 00009-0758-01 NDC inpatient 1 UN 58.19 37.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.23 56.44 SOLU-MEDROL 500 MG VIAL 48261115_1 CDM 0250 RC 00009-0758-01 NDC inpatient 1 UN 58.19 37.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.34 67.6 999999999 35.23 56.44 percent of total billed charges SOLU-MEDROL 500 MG VIAL 48261115_1 CDM 0250 RC 00009-0758-01 NDC inpatient 1 UN 58.19 37.82 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.23 56.44 METOCLOPRAMIDE 5 MG TABLET 48261119_1 CDM 0250 RC 00093-2204-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 5 MG TABLET 48261119_1 CDM 0250 RC 00093-2204-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 5 MG TABLET 48261119_1 CDM 0250 RC 00093-2204-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 5 MG TABLET 48261119_1 CDM 0250 RC 00093-2204-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 5 MG TABLET 48261119_1 CDM 0250 RC 00093-2204-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 5 MG TABLET 48261119_1 CDM 0250 RC 00093-2204-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 5 MG TABLET 48261119_1 CDM 0250 RC 00093-2204-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 5 MG TABLET 48261119_1 CDM 0250 RC 00093-2204-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 METOCLOPRAMIDE 5 MG TABLET 48261119_1 CDM 0250 RC 00093-2204-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 5 MG TABLET 48261119_1 CDM 0250 RC 00093-2204-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 METOCLOPRAMIDE 5 MG TABLET 48261119_1 CDM 0250 RC 00093-2204-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 METOCLOPRAMIDE 5 MG TABLET 48261119_1 CDM 0250 RC 00093-2204-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 METOCLOPRAMIDE 5 MG TABLET 48261119_1 CDM 0250 RC 00093-2204-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 5 MG TABLET 48261119_1 CDM 0250 RC 00093-2204-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 METOCLOPRAMIDE 10 MG/2 ML VIAL 48261120_1 CDM 0250 RC 00409-3414-01 NDC inpatient 1 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges METOCLOPRAMIDE 10 MG/2 ML VIAL 48261120_1 CDM 0250 RC 00409-3414-01 NDC inpatient 1 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges METOCLOPRAMIDE 10 MG/2 ML VIAL 48261120_1 CDM 0250 RC 00409-3414-01 NDC inpatient 1 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges METOCLOPRAMIDE 10 MG/2 ML VIAL 48261120_1 CDM 0250 RC 00409-3414-01 NDC inpatient 1 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges METOCLOPRAMIDE 10 MG/2 ML VIAL 48261120_1 CDM 0250 RC 00409-3414-01 NDC inpatient 1 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges METOCLOPRAMIDE 10 MG/2 ML VIAL 48261120_1 CDM 0250 RC 00409-3414-01 NDC inpatient 1 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges METOCLOPRAMIDE 10 MG/2 ML VIAL 48261120_1 CDM 0250 RC 00409-3414-01 NDC inpatient 1 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges METOCLOPRAMIDE 10 MG/2 ML VIAL 48261120_1 CDM 0250 RC 00409-3414-01 NDC inpatient 1 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 METOCLOPRAMIDE 10 MG/2 ML VIAL 48261120_1 CDM 0250 RC 00409-3414-01 NDC inpatient 1 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges METOCLOPRAMIDE 10 MG/2 ML VIAL 48261120_1 CDM 0250 RC 00409-3414-01 NDC inpatient 1 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 METOCLOPRAMIDE 10 MG/2 ML VIAL 48261120_1 CDM 0250 RC 00409-3414-01 NDC inpatient 1 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 METOCLOPRAMIDE 10 MG/2 ML VIAL 48261120_1 CDM 0250 RC 00409-3414-01 NDC inpatient 1 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 METOCLOPRAMIDE 10 MG/2 ML VIAL 48261120_1 CDM 0250 RC 00409-3414-01 NDC inpatient 1 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges METOCLOPRAMIDE 10 MG/2 ML VIAL 48261120_1 CDM 0250 RC 00409-3414-01 NDC inpatient 1 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 METOPROLOL TARTRATE 25 MG TAB 48261129_1 CDM 0250 RC 62584-0265-01 NDC inpatient 1 UN 1.5 0.98 AETNA AETNA 1.19 79 999999999 0.91 1.46 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 48261129_1 CDM 0250 RC 62584-0265-01 NDC inpatient 1 UN 1.5 0.98 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.98 65 999999999 0.91 1.46 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 48261129_1 CDM 0250 RC 62584-0265-01 NDC inpatient 1 UN 1.5 0.98 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.46 97 999999999 0.91 1.46 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 48261129_1 CDM 0250 RC 62584-0265-01 NDC inpatient 1 UN 1.5 0.98 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.04 69 999999999 0.91 1.46 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 48261129_1 CDM 0250 RC 62584-0265-01 NDC inpatient 1 UN 1.5 0.98 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.17 78 999999999 0.91 1.46 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 48261129_1 CDM 0250 RC 62584-0265-01 NDC inpatient 1 UN 1.5 0.98 UMR - ALL PLANS UMR - ALL PLANS 1.05 70 999999999 0.91 1.46 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 48261129_1 CDM 0250 RC 62584-0265-01 NDC inpatient 1 UN 1.5 0.98 SIHO - ALL PLANS SIHO - ALL PLANS 1.35 90 999999999 0.91 1.46 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 48261129_1 CDM 0250 RC 62584-0265-01 NDC inpatient 1 UN 1.5 0.98 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.91 1.46 METOPROLOL TARTRATE 25 MG TAB 48261129_1 CDM 0250 RC 62584-0265-01 NDC inpatient 1 UN 1.5 0.98 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.91 60.55 999999999 0.91 1.46 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 48261129_1 CDM 0250 RC 62584-0265-01 NDC inpatient 1 UN 1.5 0.98 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.91 1.46 METOPROLOL TARTRATE 25 MG TAB 48261129_1 CDM 0250 RC 62584-0265-01 NDC inpatient 1 UN 1.5 0.98 ANTHEM HMO ANTHEM HMO 999999999 0.91 1.46 METOPROLOL TARTRATE 25 MG TAB 48261129_1 CDM 0250 RC 62584-0265-01 NDC inpatient 1 UN 1.5 0.98 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.91 1.46 METOPROLOL TARTRATE 25 MG TAB 48261129_1 CDM 0250 RC 62584-0265-01 NDC inpatient 1 UN 1.5 0.98 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.01 67.6 999999999 0.91 1.46 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 48261129_1 CDM 0250 RC 62584-0265-01 NDC inpatient 1 UN 1.5 0.98 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.91 1.46 METRONIDAZOLE 500 MG/100 ML 48261131_1 CDM 0250 RC 00409-7811-24 NDC inpatient 1 UN 56.92 37 AETNA AETNA 44.97 79 999999999 34.47 55.21 percent of total billed charges METRONIDAZOLE 500 MG/100 ML 48261131_1 CDM 0250 RC 00409-7811-24 NDC inpatient 1 UN 56.92 37 SELF PAY DISCOUNT SELF PAY DISCOUNT 37 65 999999999 34.47 55.21 percent of total billed charges METRONIDAZOLE 500 MG/100 ML 48261131_1 CDM 0250 RC 00409-7811-24 NDC inpatient 1 UN 56.92 37 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.21 97 999999999 34.47 55.21 percent of total billed charges METRONIDAZOLE 500 MG/100 ML 48261131_1 CDM 0250 RC 00409-7811-24 NDC inpatient 1 UN 56.92 37 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.27 69 999999999 34.47 55.21 percent of total billed charges METRONIDAZOLE 500 MG/100 ML 48261131_1 CDM 0250 RC 00409-7811-24 NDC inpatient 1 UN 56.92 37 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.4 78 999999999 34.47 55.21 percent of total billed charges METRONIDAZOLE 500 MG/100 ML 48261131_1 CDM 0250 RC 00409-7811-24 NDC inpatient 1 UN 56.92 37 UMR - ALL PLANS UMR - ALL PLANS 39.84 70 999999999 34.47 55.21 percent of total billed charges METRONIDAZOLE 500 MG/100 ML 48261131_1 CDM 0250 RC 00409-7811-24 NDC inpatient 1 UN 56.92 37 SIHO - ALL PLANS SIHO - ALL PLANS 51.23 90 999999999 34.47 55.21 percent of total billed charges METRONIDAZOLE 500 MG/100 ML 48261131_1 CDM 0250 RC 00409-7811-24 NDC inpatient 1 UN 56.92 37 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.47 55.21 METRONIDAZOLE 500 MG/100 ML 48261131_1 CDM 0250 RC 00409-7811-24 NDC inpatient 1 UN 56.92 37 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.47 60.55 999999999 34.47 55.21 percent of total billed charges METRONIDAZOLE 500 MG/100 ML 48261131_1 CDM 0250 RC 00409-7811-24 NDC inpatient 1 UN 56.92 37 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.47 55.21 METRONIDAZOLE 500 MG/100 ML 48261131_1 CDM 0250 RC 00409-7811-24 NDC inpatient 1 UN 56.92 37 ANTHEM HMO ANTHEM HMO 999999999 34.47 55.21 METRONIDAZOLE 500 MG/100 ML 48261131_1 CDM 0250 RC 00409-7811-24 NDC inpatient 1 UN 56.92 37 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.47 55.21 METRONIDAZOLE 500 MG/100 ML 48261131_1 CDM 0250 RC 00409-7811-24 NDC inpatient 1 UN 56.92 37 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.48 67.6 999999999 34.47 55.21 percent of total billed charges METRONIDAZOLE 500 MG/100 ML 48261131_1 CDM 0250 RC 00409-7811-24 NDC inpatient 1 UN 56.92 37 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.47 55.21 "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48261136_1 CDM 0250 RC 00469-3211-10 NDC J2248 HCPCS inpatient 100 UN 477.97 310.68 AETNA AETNA 377.6 79 999999999 289.41 463.63 percent of total billed charges "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48261136_1 CDM 0250 RC 00469-3211-10 NDC J2248 HCPCS inpatient 100 UN 477.97 310.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 310.68 65 999999999 289.41 463.63 percent of total billed charges "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48261136_1 CDM 0250 RC 00469-3211-10 NDC J2248 HCPCS inpatient 100 UN 477.97 310.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 463.63 97 999999999 289.41 463.63 percent of total billed charges "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48261136_1 CDM 0250 RC 00469-3211-10 NDC J2248 HCPCS inpatient 100 UN 477.97 310.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 329.8 69 999999999 289.41 463.63 percent of total billed charges "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48261136_1 CDM 0250 RC 00469-3211-10 NDC J2248 HCPCS inpatient 100 UN 477.97 310.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 372.82 78 999999999 289.41 463.63 percent of total billed charges "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48261136_1 CDM 0250 RC 00469-3211-10 NDC J2248 HCPCS inpatient 100 UN 477.97 310.68 UMR - ALL PLANS UMR - ALL PLANS 334.58 70 999999999 289.41 463.63 percent of total billed charges "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48261136_1 CDM 0250 RC 00469-3211-10 NDC J2248 HCPCS inpatient 100 UN 477.97 310.68 SIHO - ALL PLANS SIHO - ALL PLANS 430.17 90 999999999 289.41 463.63 percent of total billed charges "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48261136_1 CDM 0250 RC 00469-3211-10 NDC J2248 HCPCS inpatient 100 UN 477.97 310.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 289.41 463.63 "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48261136_1 CDM 0250 RC 00469-3211-10 NDC J2248 HCPCS inpatient 100 UN 477.97 310.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 289.41 60.55 999999999 289.41 463.63 percent of total billed charges "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48261136_1 CDM 0250 RC 00469-3211-10 NDC J2248 HCPCS inpatient 100 UN 477.97 310.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 289.41 463.63 "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48261136_1 CDM 0250 RC 00469-3211-10 NDC J2248 HCPCS inpatient 100 UN 477.97 310.68 ANTHEM HMO ANTHEM HMO 999999999 289.41 463.63 "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48261136_1 CDM 0250 RC 00469-3211-10 NDC J2248 HCPCS inpatient 100 UN 477.97 310.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 289.41 463.63 "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48261136_1 CDM 0250 RC 00469-3211-10 NDC J2248 HCPCS inpatient 100 UN 477.97 310.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 323.11 67.6 999999999 289.41 463.63 percent of total billed charges "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48261136_1 CDM 0250 RC 00469-3211-10 NDC J2248 HCPCS inpatient 100 UN 477.97 310.68 UHC - ALL PLANS UHC - ALL PLANS 999999999 289.41 463.63 00472-0735-56 - miconazole Top 2% Crm [JOHN] 48261138_1 CDM 0250 RC 00472-0735-56 NDC inpatient 1 UN 9.22 5.99 AETNA AETNA 7.28 79 999999999 5.58 8.94 percent of total billed charges 00472-0735-56 - miconazole Top 2% Crm [JOHN] 48261138_1 CDM 0250 RC 00472-0735-56 NDC inpatient 1 UN 9.22 5.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.99 65 999999999 5.58 8.94 percent of total billed charges 00472-0735-56 - miconazole Top 2% Crm [JOHN] 48261138_1 CDM 0250 RC 00472-0735-56 NDC inpatient 1 UN 9.22 5.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.94 97 999999999 5.58 8.94 percent of total billed charges 00472-0735-56 - miconazole Top 2% Crm [JOHN] 48261138_1 CDM 0250 RC 00472-0735-56 NDC inpatient 1 UN 9.22 5.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.36 69 999999999 5.58 8.94 percent of total billed charges 00472-0735-56 - miconazole Top 2% Crm [JOHN] 48261138_1 CDM 0250 RC 00472-0735-56 NDC inpatient 1 UN 9.22 5.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.19 78 999999999 5.58 8.94 percent of total billed charges 00472-0735-56 - miconazole Top 2% Crm [JOHN] 48261138_1 CDM 0250 RC 00472-0735-56 NDC inpatient 1 UN 9.22 5.99 UMR - ALL PLANS UMR - ALL PLANS 6.45 70 999999999 5.58 8.94 percent of total billed charges 00472-0735-56 - miconazole Top 2% Crm [JOHN] 48261138_1 CDM 0250 RC 00472-0735-56 NDC inpatient 1 UN 9.22 5.99 SIHO - ALL PLANS SIHO - ALL PLANS 8.3 90 999999999 5.58 8.94 percent of total billed charges 00472-0735-56 - miconazole Top 2% Crm [JOHN] 48261138_1 CDM 0250 RC 00472-0735-56 NDC inpatient 1 UN 9.22 5.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.58 8.94 00472-0735-56 - miconazole Top 2% Crm [JOHN] 48261138_1 CDM 0250 RC 00472-0735-56 NDC inpatient 1 UN 9.22 5.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.58 60.55 999999999 5.58 8.94 percent of total billed charges 00472-0735-56 - miconazole Top 2% Crm [JOHN] 48261138_1 CDM 0250 RC 00472-0735-56 NDC inpatient 1 UN 9.22 5.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.58 8.94 00472-0735-56 - miconazole Top 2% Crm [JOHN] 48261138_1 CDM 0250 RC 00472-0735-56 NDC inpatient 1 UN 9.22 5.99 ANTHEM HMO ANTHEM HMO 999999999 5.58 8.94 00472-0735-56 - miconazole Top 2% Crm [JOHN] 48261138_1 CDM 0250 RC 00472-0735-56 NDC inpatient 1 UN 9.22 5.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.58 8.94 00472-0735-56 - miconazole Top 2% Crm [JOHN] 48261138_1 CDM 0250 RC 00472-0735-56 NDC inpatient 1 UN 9.22 5.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.23 67.6 999999999 5.58 8.94 percent of total billed charges 00472-0735-56 - miconazole Top 2% Crm [JOHN] 48261138_1 CDM 0250 RC 00472-0735-56 NDC inpatient 1 UN 9.22 5.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.58 8.94 MIDAZOLAM HCL 5 MG/5 ML VIAL 48261141_1 CDM 0250 RC 00409-2305-50 NDC inpatient 1 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges MIDAZOLAM HCL 5 MG/5 ML VIAL 48261141_1 CDM 0250 RC 00409-2305-50 NDC inpatient 1 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges MIDAZOLAM HCL 5 MG/5 ML VIAL 48261141_1 CDM 0250 RC 00409-2305-50 NDC inpatient 1 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges MIDAZOLAM HCL 5 MG/5 ML VIAL 48261141_1 CDM 0250 RC 00409-2305-50 NDC inpatient 1 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges MIDAZOLAM HCL 5 MG/5 ML VIAL 48261141_1 CDM 0250 RC 00409-2305-50 NDC inpatient 1 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges MIDAZOLAM HCL 5 MG/5 ML VIAL 48261141_1 CDM 0250 RC 00409-2305-50 NDC inpatient 1 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges MIDAZOLAM HCL 5 MG/5 ML VIAL 48261141_1 CDM 0250 RC 00409-2305-50 NDC inpatient 1 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges MIDAZOLAM HCL 5 MG/5 ML VIAL 48261141_1 CDM 0250 RC 00409-2305-50 NDC inpatient 1 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 MIDAZOLAM HCL 5 MG/5 ML VIAL 48261141_1 CDM 0250 RC 00409-2305-50 NDC inpatient 1 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges MIDAZOLAM HCL 5 MG/5 ML VIAL 48261141_1 CDM 0250 RC 00409-2305-50 NDC inpatient 1 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 MIDAZOLAM HCL 5 MG/5 ML VIAL 48261141_1 CDM 0250 RC 00409-2305-50 NDC inpatient 1 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 MIDAZOLAM HCL 5 MG/5 ML VIAL 48261141_1 CDM 0250 RC 00409-2305-50 NDC inpatient 1 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 MIDAZOLAM HCL 5 MG/5 ML VIAL 48261141_1 CDM 0250 RC 00409-2305-50 NDC inpatient 1 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges MIDAZOLAM HCL 5 MG/5 ML VIAL 48261141_1 CDM 0250 RC 00409-2305-50 NDC inpatient 1 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 "INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG" 48261143_1 CDM 0250 RC 00409-2308-50 NDC J2250 HCPCS inpatient 1 UN 21.21 13.79 AETNA AETNA 16.76 79 999999999 12.84 20.57 percent of total billed charges "INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG" 48261143_1 CDM 0250 RC 00409-2308-50 NDC J2250 HCPCS inpatient 1 UN 21.21 13.79 SELF PAY DISCOUNT SELF PAY DISCOUNT 13.79 65 999999999 12.84 20.57 percent of total billed charges "INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG" 48261143_1 CDM 0250 RC 00409-2308-50 NDC J2250 HCPCS inpatient 1 UN 21.21 13.79 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20.57 97 999999999 12.84 20.57 percent of total billed charges "INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG" 48261143_1 CDM 0250 RC 00409-2308-50 NDC J2250 HCPCS inpatient 1 UN 21.21 13.79 ENCORE - ALL PLANS ENCORE - ALL PLANS 14.63 69 999999999 12.84 20.57 percent of total billed charges "INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG" 48261143_1 CDM 0250 RC 00409-2308-50 NDC J2250 HCPCS inpatient 1 UN 21.21 13.79 HUMANA - ALL PLANS HUMANA - ALL PLANS 16.54 78 999999999 12.84 20.57 percent of total billed charges "INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG" 48261143_1 CDM 0250 RC 00409-2308-50 NDC J2250 HCPCS inpatient 1 UN 21.21 13.79 UMR - ALL PLANS UMR - ALL PLANS 14.85 70 999999999 12.84 20.57 percent of total billed charges "INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG" 48261143_1 CDM 0250 RC 00409-2308-50 NDC J2250 HCPCS inpatient 1 UN 21.21 13.79 SIHO - ALL PLANS SIHO - ALL PLANS 19.09 90 999999999 12.84 20.57 percent of total billed charges "INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG" 48261143_1 CDM 0250 RC 00409-2308-50 NDC J2250 HCPCS inpatient 1 UN 21.21 13.79 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.84 20.57 "INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG" 48261143_1 CDM 0250 RC 00409-2308-50 NDC J2250 HCPCS inpatient 1 UN 21.21 13.79 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.84 60.55 999999999 12.84 20.57 percent of total billed charges "INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG" 48261143_1 CDM 0250 RC 00409-2308-50 NDC J2250 HCPCS inpatient 1 UN 21.21 13.79 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.84 20.57 "INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG" 48261143_1 CDM 0250 RC 00409-2308-50 NDC J2250 HCPCS inpatient 1 UN 21.21 13.79 ANTHEM HMO ANTHEM HMO 999999999 12.84 20.57 "INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG" 48261143_1 CDM 0250 RC 00409-2308-50 NDC J2250 HCPCS inpatient 1 UN 21.21 13.79 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.84 20.57 "INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG" 48261143_1 CDM 0250 RC 00409-2308-50 NDC J2250 HCPCS inpatient 1 UN 21.21 13.79 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.34 67.6 999999999 12.84 20.57 percent of total billed charges "INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG" 48261143_1 CDM 0250 RC 00409-2308-50 NDC J2250 HCPCS inpatient 1 UN 21.21 13.79 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.84 20.57 SAVELLA 50 MG TABLET 48261147_1 CDM 0250 RC 00456-1550-60 NDC inpatient 1 UN 16.56 10.76 AETNA AETNA 13.08 79 999999999 10.03 16.06 percent of total billed charges SAVELLA 50 MG TABLET 48261147_1 CDM 0250 RC 00456-1550-60 NDC inpatient 1 UN 16.56 10.76 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.76 65 999999999 10.03 16.06 percent of total billed charges SAVELLA 50 MG TABLET 48261147_1 CDM 0250 RC 00456-1550-60 NDC inpatient 1 UN 16.56 10.76 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16.06 97 999999999 10.03 16.06 percent of total billed charges SAVELLA 50 MG TABLET 48261147_1 CDM 0250 RC 00456-1550-60 NDC inpatient 1 UN 16.56 10.76 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.43 69 999999999 10.03 16.06 percent of total billed charges SAVELLA 50 MG TABLET 48261147_1 CDM 0250 RC 00456-1550-60 NDC inpatient 1 UN 16.56 10.76 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.92 78 999999999 10.03 16.06 percent of total billed charges SAVELLA 50 MG TABLET 48261147_1 CDM 0250 RC 00456-1550-60 NDC inpatient 1 UN 16.56 10.76 UMR - ALL PLANS UMR - ALL PLANS 11.59 70 999999999 10.03 16.06 percent of total billed charges SAVELLA 50 MG TABLET 48261147_1 CDM 0250 RC 00456-1550-60 NDC inpatient 1 UN 16.56 10.76 SIHO - ALL PLANS SIHO - ALL PLANS 14.9 90 999999999 10.03 16.06 percent of total billed charges SAVELLA 50 MG TABLET 48261147_1 CDM 0250 RC 00456-1550-60 NDC inpatient 1 UN 16.56 10.76 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.03 16.06 SAVELLA 50 MG TABLET 48261147_1 CDM 0250 RC 00456-1550-60 NDC inpatient 1 UN 16.56 10.76 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.03 60.55 999999999 10.03 16.06 percent of total billed charges SAVELLA 50 MG TABLET 48261147_1 CDM 0250 RC 00456-1550-60 NDC inpatient 1 UN 16.56 10.76 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.03 16.06 SAVELLA 50 MG TABLET 48261147_1 CDM 0250 RC 00456-1550-60 NDC inpatient 1 UN 16.56 10.76 ANTHEM HMO ANTHEM HMO 999999999 10.03 16.06 SAVELLA 50 MG TABLET 48261147_1 CDM 0250 RC 00456-1550-60 NDC inpatient 1 UN 16.56 10.76 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.03 16.06 SAVELLA 50 MG TABLET 48261147_1 CDM 0250 RC 00456-1550-60 NDC inpatient 1 UN 16.56 10.76 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.19 67.6 999999999 10.03 16.06 percent of total billed charges SAVELLA 50 MG TABLET 48261147_1 CDM 0250 RC 00456-1550-60 NDC inpatient 1 UN 16.56 10.76 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.03 16.06 MIRTAZAPINE 15 MG TABLET 48261152_1 CDM 0250 RC 68084-0119-01 NDC inpatient 1 UN 1.8 1.17 AETNA AETNA 1.42 79 999999999 1.09 1.75 percent of total billed charges MIRTAZAPINE 15 MG TABLET 48261152_1 CDM 0250 RC 68084-0119-01 NDC inpatient 1 UN 1.8 1.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.17 65 999999999 1.09 1.75 percent of total billed charges MIRTAZAPINE 15 MG TABLET 48261152_1 CDM 0250 RC 68084-0119-01 NDC inpatient 1 UN 1.8 1.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.75 97 999999999 1.09 1.75 percent of total billed charges MIRTAZAPINE 15 MG TABLET 48261152_1 CDM 0250 RC 68084-0119-01 NDC inpatient 1 UN 1.8 1.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.24 69 999999999 1.09 1.75 percent of total billed charges MIRTAZAPINE 15 MG TABLET 48261152_1 CDM 0250 RC 68084-0119-01 NDC inpatient 1 UN 1.8 1.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.4 78 999999999 1.09 1.75 percent of total billed charges MIRTAZAPINE 15 MG TABLET 48261152_1 CDM 0250 RC 68084-0119-01 NDC inpatient 1 UN 1.8 1.17 UMR - ALL PLANS UMR - ALL PLANS 1.26 70 999999999 1.09 1.75 percent of total billed charges MIRTAZAPINE 15 MG TABLET 48261152_1 CDM 0250 RC 68084-0119-01 NDC inpatient 1 UN 1.8 1.17 SIHO - ALL PLANS SIHO - ALL PLANS 1.62 90 999999999 1.09 1.75 percent of total billed charges MIRTAZAPINE 15 MG TABLET 48261152_1 CDM 0250 RC 68084-0119-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.09 1.75 MIRTAZAPINE 15 MG TABLET 48261152_1 CDM 0250 RC 68084-0119-01 NDC inpatient 1 UN 1.8 1.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.09 60.55 999999999 1.09 1.75 percent of total billed charges MIRTAZAPINE 15 MG TABLET 48261152_1 CDM 0250 RC 68084-0119-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.09 1.75 MIRTAZAPINE 15 MG TABLET 48261152_1 CDM 0250 RC 68084-0119-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM HMO ANTHEM HMO 999999999 1.09 1.75 MIRTAZAPINE 15 MG TABLET 48261152_1 CDM 0250 RC 68084-0119-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.09 1.75 MIRTAZAPINE 15 MG TABLET 48261152_1 CDM 0250 RC 68084-0119-01 NDC inpatient 1 UN 1.8 1.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.22 67.6 999999999 1.09 1.75 percent of total billed charges MIRTAZAPINE 15 MG TABLET 48261152_1 CDM 0250 RC 68084-0119-01 NDC inpatient 1 UN 1.8 1.17 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.09 1.75 MOEXIPRIL HCL 7.5 MG TABLET 48261158_1 CDM 0250 RC 00093-0017-01 NDC inpatient 1 UN 2.62 1.7 AETNA AETNA 2.07 79 999999999 1.59 2.54 percent of total billed charges MOEXIPRIL HCL 7.5 MG TABLET 48261158_1 CDM 0250 RC 00093-0017-01 NDC inpatient 1 UN 2.62 1.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.7 65 999999999 1.59 2.54 percent of total billed charges MOEXIPRIL HCL 7.5 MG TABLET 48261158_1 CDM 0250 RC 00093-0017-01 NDC inpatient 1 UN 2.62 1.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.54 97 999999999 1.59 2.54 percent of total billed charges MOEXIPRIL HCL 7.5 MG TABLET 48261158_1 CDM 0250 RC 00093-0017-01 NDC inpatient 1 UN 2.62 1.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.81 69 999999999 1.59 2.54 percent of total billed charges MOEXIPRIL HCL 7.5 MG TABLET 48261158_1 CDM 0250 RC 00093-0017-01 NDC inpatient 1 UN 2.62 1.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.04 78 999999999 1.59 2.54 percent of total billed charges MOEXIPRIL HCL 7.5 MG TABLET 48261158_1 CDM 0250 RC 00093-0017-01 NDC inpatient 1 UN 2.62 1.7 UMR - ALL PLANS UMR - ALL PLANS 1.83 70 999999999 1.59 2.54 percent of total billed charges MOEXIPRIL HCL 7.5 MG TABLET 48261158_1 CDM 0250 RC 00093-0017-01 NDC inpatient 1 UN 2.62 1.7 SIHO - ALL PLANS SIHO - ALL PLANS 2.36 90 999999999 1.59 2.54 percent of total billed charges MOEXIPRIL HCL 7.5 MG TABLET 48261158_1 CDM 0250 RC 00093-0017-01 NDC inpatient 1 UN 2.62 1.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.59 2.54 MOEXIPRIL HCL 7.5 MG TABLET 48261158_1 CDM 0250 RC 00093-0017-01 NDC inpatient 1 UN 2.62 1.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.59 60.55 999999999 1.59 2.54 percent of total billed charges MOEXIPRIL HCL 7.5 MG TABLET 48261158_1 CDM 0250 RC 00093-0017-01 NDC inpatient 1 UN 2.62 1.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.59 2.54 MOEXIPRIL HCL 7.5 MG TABLET 48261158_1 CDM 0250 RC 00093-0017-01 NDC inpatient 1 UN 2.62 1.7 ANTHEM HMO ANTHEM HMO 999999999 1.59 2.54 MOEXIPRIL HCL 7.5 MG TABLET 48261158_1 CDM 0250 RC 00093-0017-01 NDC inpatient 1 UN 2.62 1.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.59 2.54 MOEXIPRIL HCL 7.5 MG TABLET 48261158_1 CDM 0250 RC 00093-0017-01 NDC inpatient 1 UN 2.62 1.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.77 67.6 999999999 1.59 2.54 percent of total billed charges MOEXIPRIL HCL 7.5 MG TABLET 48261158_1 CDM 0250 RC 00093-0017-01 NDC inpatient 1 UN 2.62 1.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.59 2.54 68084-0406-01 - morphine 100 mg ER Tab [JOHN] 48261163_1 CDM 0250 RC 68084-0406-01 NDC inpatient 1 UN 15.27 9.93 AETNA AETNA 12.06 79 999999999 9.25 14.81 percent of total billed charges 68084-0406-01 - morphine 100 mg ER Tab [JOHN] 48261163_1 CDM 0250 RC 68084-0406-01 NDC inpatient 1 UN 15.27 9.93 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.93 65 999999999 9.25 14.81 percent of total billed charges 68084-0406-01 - morphine 100 mg ER Tab [JOHN] 48261163_1 CDM 0250 RC 68084-0406-01 NDC inpatient 1 UN 15.27 9.93 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14.81 97 999999999 9.25 14.81 percent of total billed charges 68084-0406-01 - morphine 100 mg ER Tab [JOHN] 48261163_1 CDM 0250 RC 68084-0406-01 NDC inpatient 1 UN 15.27 9.93 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.54 69 999999999 9.25 14.81 percent of total billed charges 68084-0406-01 - morphine 100 mg ER Tab [JOHN] 48261163_1 CDM 0250 RC 68084-0406-01 NDC inpatient 1 UN 15.27 9.93 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.91 78 999999999 9.25 14.81 percent of total billed charges 68084-0406-01 - morphine 100 mg ER Tab [JOHN] 48261163_1 CDM 0250 RC 68084-0406-01 NDC inpatient 1 UN 15.27 9.93 UMR - ALL PLANS UMR - ALL PLANS 10.69 70 999999999 9.25 14.81 percent of total billed charges 68084-0406-01 - morphine 100 mg ER Tab [JOHN] 48261163_1 CDM 0250 RC 68084-0406-01 NDC inpatient 1 UN 15.27 9.93 SIHO - ALL PLANS SIHO - ALL PLANS 13.74 90 999999999 9.25 14.81 percent of total billed charges 68084-0406-01 - morphine 100 mg ER Tab [JOHN] 48261163_1 CDM 0250 RC 68084-0406-01 NDC inpatient 1 UN 15.27 9.93 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.25 14.81 68084-0406-01 - morphine 100 mg ER Tab [JOHN] 48261163_1 CDM 0250 RC 68084-0406-01 NDC inpatient 1 UN 15.27 9.93 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.25 60.55 999999999 9.25 14.81 percent of total billed charges 68084-0406-01 - morphine 100 mg ER Tab [JOHN] 48261163_1 CDM 0250 RC 68084-0406-01 NDC inpatient 1 UN 15.27 9.93 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.25 14.81 68084-0406-01 - morphine 100 mg ER Tab [JOHN] 48261163_1 CDM 0250 RC 68084-0406-01 NDC inpatient 1 UN 15.27 9.93 ANTHEM HMO ANTHEM HMO 999999999 9.25 14.81 68084-0406-01 - morphine 100 mg ER Tab [JOHN] 48261163_1 CDM 0250 RC 68084-0406-01 NDC inpatient 1 UN 15.27 9.93 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.25 14.81 68084-0406-01 - morphine 100 mg ER Tab [JOHN] 48261163_1 CDM 0250 RC 68084-0406-01 NDC inpatient 1 UN 15.27 9.93 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.32 67.6 999999999 9.25 14.81 percent of total billed charges 68084-0406-01 - morphine 100 mg ER Tab [JOHN] 48261163_1 CDM 0250 RC 68084-0406-01 NDC inpatient 1 UN 15.27 9.93 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.25 14.81 MORPHINE SULFATE IR 15 MG TAB 48261164_1 CDM 0250 RC 00054-0235-24 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges MORPHINE SULFATE IR 15 MG TAB 48261164_1 CDM 0250 RC 00054-0235-24 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges MORPHINE SULFATE IR 15 MG TAB 48261164_1 CDM 0250 RC 00054-0235-24 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges MORPHINE SULFATE IR 15 MG TAB 48261164_1 CDM 0250 RC 00054-0235-24 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges MORPHINE SULFATE IR 15 MG TAB 48261164_1 CDM 0250 RC 00054-0235-24 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges MORPHINE SULFATE IR 15 MG TAB 48261164_1 CDM 0250 RC 00054-0235-24 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges MORPHINE SULFATE IR 15 MG TAB 48261164_1 CDM 0250 RC 00054-0235-24 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges MORPHINE SULFATE IR 15 MG TAB 48261164_1 CDM 0250 RC 00054-0235-24 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 MORPHINE SULFATE IR 15 MG TAB 48261164_1 CDM 0250 RC 00054-0235-24 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges MORPHINE SULFATE IR 15 MG TAB 48261164_1 CDM 0250 RC 00054-0235-24 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 MORPHINE SULFATE IR 15 MG TAB 48261164_1 CDM 0250 RC 00054-0235-24 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 MORPHINE SULFATE IR 15 MG TAB 48261164_1 CDM 0250 RC 00054-0235-24 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 MORPHINE SULFATE IR 15 MG TAB 48261164_1 CDM 0250 RC 00054-0235-24 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges MORPHINE SULFATE IR 15 MG TAB 48261164_1 CDM 0250 RC 00054-0235-24 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 00409-2029-02 - morphine 1 mg/mL preservative-free Sol 30 mL PCA [JOHN] 48261167_1 CDM 0250 RC 00409-2029-02 NDC inpatient 1 UN 55.8 36.27 AETNA AETNA 44.08 79 999999999 33.79 54.13 percent of total billed charges 00409-2029-02 - morphine 1 mg/mL preservative-free Sol 30 mL PCA [JOHN] 48261167_1 CDM 0250 RC 00409-2029-02 NDC inpatient 1 UN 55.8 36.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 36.27 65 999999999 33.79 54.13 percent of total billed charges 00409-2029-02 - morphine 1 mg/mL preservative-free Sol 30 mL PCA [JOHN] 48261167_1 CDM 0250 RC 00409-2029-02 NDC inpatient 1 UN 55.8 36.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 54.13 97 999999999 33.79 54.13 percent of total billed charges 00409-2029-02 - morphine 1 mg/mL preservative-free Sol 30 mL PCA [JOHN] 48261167_1 CDM 0250 RC 00409-2029-02 NDC inpatient 1 UN 55.8 36.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 38.5 69 999999999 33.79 54.13 percent of total billed charges 00409-2029-02 - morphine 1 mg/mL preservative-free Sol 30 mL PCA [JOHN] 48261167_1 CDM 0250 RC 00409-2029-02 NDC inpatient 1 UN 55.8 36.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 43.52 78 999999999 33.79 54.13 percent of total billed charges 00409-2029-02 - morphine 1 mg/mL preservative-free Sol 30 mL PCA [JOHN] 48261167_1 CDM 0250 RC 00409-2029-02 NDC inpatient 1 UN 55.8 36.27 UMR - ALL PLANS UMR - ALL PLANS 39.06 70 999999999 33.79 54.13 percent of total billed charges 00409-2029-02 - morphine 1 mg/mL preservative-free Sol 30 mL PCA [JOHN] 48261167_1 CDM 0250 RC 00409-2029-02 NDC inpatient 1 UN 55.8 36.27 SIHO - ALL PLANS SIHO - ALL PLANS 50.22 90 999999999 33.79 54.13 percent of total billed charges 00409-2029-02 - morphine 1 mg/mL preservative-free Sol 30 mL PCA [JOHN] 48261167_1 CDM 0250 RC 00409-2029-02 NDC inpatient 1 UN 55.8 36.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 33.79 54.13 00409-2029-02 - morphine 1 mg/mL preservative-free Sol 30 mL PCA [JOHN] 48261167_1 CDM 0250 RC 00409-2029-02 NDC inpatient 1 UN 55.8 36.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33.79 60.55 999999999 33.79 54.13 percent of total billed charges 00409-2029-02 - morphine 1 mg/mL preservative-free Sol 30 mL PCA [JOHN] 48261167_1 CDM 0250 RC 00409-2029-02 NDC inpatient 1 UN 55.8 36.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 33.79 54.13 00409-2029-02 - morphine 1 mg/mL preservative-free Sol 30 mL PCA [JOHN] 48261167_1 CDM 0250 RC 00409-2029-02 NDC inpatient 1 UN 55.8 36.27 ANTHEM HMO ANTHEM HMO 999999999 33.79 54.13 00409-2029-02 - morphine 1 mg/mL preservative-free Sol 30 mL PCA [JOHN] 48261167_1 CDM 0250 RC 00409-2029-02 NDC inpatient 1 UN 55.8 36.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 33.79 54.13 00409-2029-02 - morphine 1 mg/mL preservative-free Sol 30 mL PCA [JOHN] 48261167_1 CDM 0250 RC 00409-2029-02 NDC inpatient 1 UN 55.8 36.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 37.72 67.6 999999999 33.79 54.13 percent of total billed charges 00409-2029-02 - morphine 1 mg/mL preservative-free Sol 30 mL PCA [JOHN] 48261167_1 CDM 0250 RC 00409-2029-02 NDC inpatient 1 UN 55.8 36.27 UHC - ALL PLANS UHC - ALL PLANS 999999999 33.79 54.13 MORPHINE 10 MG/ML CARPUJECT 48261168_1 CDM 0250 RC 00409-1893-01 NDC inpatient 1 UN 4.73 3.07 AETNA AETNA 3.74 79 999999999 2.86 4.59 percent of total billed charges MORPHINE 10 MG/ML CARPUJECT 48261168_1 CDM 0250 RC 00409-1893-01 NDC inpatient 1 UN 4.73 3.07 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.07 65 999999999 2.86 4.59 percent of total billed charges MORPHINE 10 MG/ML CARPUJECT 48261168_1 CDM 0250 RC 00409-1893-01 NDC inpatient 1 UN 4.73 3.07 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4.59 97 999999999 2.86 4.59 percent of total billed charges MORPHINE 10 MG/ML CARPUJECT 48261168_1 CDM 0250 RC 00409-1893-01 NDC inpatient 1 UN 4.73 3.07 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.26 69 999999999 2.86 4.59 percent of total billed charges MORPHINE 10 MG/ML CARPUJECT 48261168_1 CDM 0250 RC 00409-1893-01 NDC inpatient 1 UN 4.73 3.07 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.69 78 999999999 2.86 4.59 percent of total billed charges MORPHINE 10 MG/ML CARPUJECT 48261168_1 CDM 0250 RC 00409-1893-01 NDC inpatient 1 UN 4.73 3.07 UMR - ALL PLANS UMR - ALL PLANS 3.31 70 999999999 2.86 4.59 percent of total billed charges MORPHINE 10 MG/ML CARPUJECT 48261168_1 CDM 0250 RC 00409-1893-01 NDC inpatient 1 UN 4.73 3.07 SIHO - ALL PLANS SIHO - ALL PLANS 4.26 90 999999999 2.86 4.59 percent of total billed charges MORPHINE 10 MG/ML CARPUJECT 48261168_1 CDM 0250 RC 00409-1893-01 NDC inpatient 1 UN 4.73 3.07 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.86 4.59 MORPHINE 10 MG/ML CARPUJECT 48261168_1 CDM 0250 RC 00409-1893-01 NDC inpatient 1 UN 4.73 3.07 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.86 60.55 999999999 2.86 4.59 percent of total billed charges MORPHINE 10 MG/ML CARPUJECT 48261168_1 CDM 0250 RC 00409-1893-01 NDC inpatient 1 UN 4.73 3.07 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.86 4.59 MORPHINE 10 MG/ML CARPUJECT 48261168_1 CDM 0250 RC 00409-1893-01 NDC inpatient 1 UN 4.73 3.07 ANTHEM HMO ANTHEM HMO 999999999 2.86 4.59 MORPHINE 10 MG/ML CARPUJECT 48261168_1 CDM 0250 RC 00409-1893-01 NDC inpatient 1 UN 4.73 3.07 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.86 4.59 MORPHINE 10 MG/ML CARPUJECT 48261168_1 CDM 0250 RC 00409-1893-01 NDC inpatient 1 UN 4.73 3.07 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.2 67.6 999999999 2.86 4.59 percent of total billed charges MORPHINE 10 MG/ML CARPUJECT 48261168_1 CDM 0250 RC 00409-1893-01 NDC inpatient 1 UN 4.73 3.07 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.86 4.59 MORPHINE 2 MG/ML CARPUJECT 48261169_1 CDM 0250 RC 00409-1890-01 NDC inpatient 1 UN 21.61 14.05 AETNA AETNA 17.07 79 999999999 13.08 20.96 percent of total billed charges MORPHINE 2 MG/ML CARPUJECT 48261169_1 CDM 0250 RC 00409-1890-01 NDC inpatient 1 UN 21.61 14.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.05 65 999999999 13.08 20.96 percent of total billed charges MORPHINE 2 MG/ML CARPUJECT 48261169_1 CDM 0250 RC 00409-1890-01 NDC inpatient 1 UN 21.61 14.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20.96 97 999999999 13.08 20.96 percent of total billed charges MORPHINE 2 MG/ML CARPUJECT 48261169_1 CDM 0250 RC 00409-1890-01 NDC inpatient 1 UN 21.61 14.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 14.91 69 999999999 13.08 20.96 percent of total billed charges MORPHINE 2 MG/ML CARPUJECT 48261169_1 CDM 0250 RC 00409-1890-01 NDC inpatient 1 UN 21.61 14.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 16.86 78 999999999 13.08 20.96 percent of total billed charges MORPHINE 2 MG/ML CARPUJECT 48261169_1 CDM 0250 RC 00409-1890-01 NDC inpatient 1 UN 21.61 14.05 UMR - ALL PLANS UMR - ALL PLANS 15.13 70 999999999 13.08 20.96 percent of total billed charges MORPHINE 2 MG/ML CARPUJECT 48261169_1 CDM 0250 RC 00409-1890-01 NDC inpatient 1 UN 21.61 14.05 SIHO - ALL PLANS SIHO - ALL PLANS 19.45 90 999999999 13.08 20.96 percent of total billed charges MORPHINE 2 MG/ML CARPUJECT 48261169_1 CDM 0250 RC 00409-1890-01 NDC inpatient 1 UN 21.61 14.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.08 20.96 MORPHINE 2 MG/ML CARPUJECT 48261169_1 CDM 0250 RC 00409-1890-01 NDC inpatient 1 UN 21.61 14.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.08 60.55 999999999 13.08 20.96 percent of total billed charges MORPHINE 2 MG/ML CARPUJECT 48261169_1 CDM 0250 RC 00409-1890-01 NDC inpatient 1 UN 21.61 14.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.08 20.96 MORPHINE 2 MG/ML CARPUJECT 48261169_1 CDM 0250 RC 00409-1890-01 NDC inpatient 1 UN 21.61 14.05 ANTHEM HMO ANTHEM HMO 999999999 13.08 20.96 MORPHINE 2 MG/ML CARPUJECT 48261169_1 CDM 0250 RC 00409-1890-01 NDC inpatient 1 UN 21.61 14.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.08 20.96 MORPHINE 2 MG/ML CARPUJECT 48261169_1 CDM 0250 RC 00409-1890-01 NDC inpatient 1 UN 21.61 14.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.61 67.6 999999999 13.08 20.96 percent of total billed charges MORPHINE 2 MG/ML CARPUJECT 48261169_1 CDM 0250 RC 00409-1890-01 NDC inpatient 1 UN 21.61 14.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.08 20.96 MORPHINE 4 MG/ML CARPUJECT 48261170_1 CDM 0250 RC 00409-1891-01 NDC inpatient 1 UN 6.41 4.17 AETNA AETNA 5.06 79 999999999 3.88 6.22 percent of total billed charges MORPHINE 4 MG/ML CARPUJECT 48261170_1 CDM 0250 RC 00409-1891-01 NDC inpatient 1 UN 6.41 4.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.17 65 999999999 3.88 6.22 percent of total billed charges MORPHINE 4 MG/ML CARPUJECT 48261170_1 CDM 0250 RC 00409-1891-01 NDC inpatient 1 UN 6.41 4.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.22 97 999999999 3.88 6.22 percent of total billed charges MORPHINE 4 MG/ML CARPUJECT 48261170_1 CDM 0250 RC 00409-1891-01 NDC inpatient 1 UN 6.41 4.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.42 69 999999999 3.88 6.22 percent of total billed charges MORPHINE 4 MG/ML CARPUJECT 48261170_1 CDM 0250 RC 00409-1891-01 NDC inpatient 1 UN 6.41 4.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 5 78 999999999 3.88 6.22 percent of total billed charges MORPHINE 4 MG/ML CARPUJECT 48261170_1 CDM 0250 RC 00409-1891-01 NDC inpatient 1 UN 6.41 4.17 UMR - ALL PLANS UMR - ALL PLANS 4.49 70 999999999 3.88 6.22 percent of total billed charges MORPHINE 4 MG/ML CARPUJECT 48261170_1 CDM 0250 RC 00409-1891-01 NDC inpatient 1 UN 6.41 4.17 SIHO - ALL PLANS SIHO - ALL PLANS 5.77 90 999999999 3.88 6.22 percent of total billed charges MORPHINE 4 MG/ML CARPUJECT 48261170_1 CDM 0250 RC 00409-1891-01 NDC inpatient 1 UN 6.41 4.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.88 6.22 MORPHINE 4 MG/ML CARPUJECT 48261170_1 CDM 0250 RC 00409-1891-01 NDC inpatient 1 UN 6.41 4.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.88 60.55 999999999 3.88 6.22 percent of total billed charges MORPHINE 4 MG/ML CARPUJECT 48261170_1 CDM 0250 RC 00409-1891-01 NDC inpatient 1 UN 6.41 4.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.88 6.22 MORPHINE 4 MG/ML CARPUJECT 48261170_1 CDM 0250 RC 00409-1891-01 NDC inpatient 1 UN 6.41 4.17 ANTHEM HMO ANTHEM HMO 999999999 3.88 6.22 MORPHINE 4 MG/ML CARPUJECT 48261170_1 CDM 0250 RC 00409-1891-01 NDC inpatient 1 UN 6.41 4.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.88 6.22 MORPHINE 4 MG/ML CARPUJECT 48261170_1 CDM 0250 RC 00409-1891-01 NDC inpatient 1 UN 6.41 4.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.33 67.6 999999999 3.88 6.22 percent of total billed charges MORPHINE 4 MG/ML CARPUJECT 48261170_1 CDM 0250 RC 00409-1891-01 NDC inpatient 1 UN 6.41 4.17 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.88 6.22 MORPHINE SULF ER 30 MG TABLET 48261171_1 CDM 0250 RC 00406-8330-62 NDC inpatient 1 UN 3.73 2.42 AETNA AETNA 2.95 79 999999999 2.26 3.62 percent of total billed charges MORPHINE SULF ER 30 MG TABLET 48261171_1 CDM 0250 RC 00406-8330-62 NDC inpatient 1 UN 3.73 2.42 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.42 65 999999999 2.26 3.62 percent of total billed charges MORPHINE SULF ER 30 MG TABLET 48261171_1 CDM 0250 RC 00406-8330-62 NDC inpatient 1 UN 3.73 2.42 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.62 97 999999999 2.26 3.62 percent of total billed charges MORPHINE SULF ER 30 MG TABLET 48261171_1 CDM 0250 RC 00406-8330-62 NDC inpatient 1 UN 3.73 2.42 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.57 69 999999999 2.26 3.62 percent of total billed charges MORPHINE SULF ER 30 MG TABLET 48261171_1 CDM 0250 RC 00406-8330-62 NDC inpatient 1 UN 3.73 2.42 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.91 78 999999999 2.26 3.62 percent of total billed charges MORPHINE SULF ER 30 MG TABLET 48261171_1 CDM 0250 RC 00406-8330-62 NDC inpatient 1 UN 3.73 2.42 UMR - ALL PLANS UMR - ALL PLANS 2.61 70 999999999 2.26 3.62 percent of total billed charges MORPHINE SULF ER 30 MG TABLET 48261171_1 CDM 0250 RC 00406-8330-62 NDC inpatient 1 UN 3.73 2.42 SIHO - ALL PLANS SIHO - ALL PLANS 3.36 90 999999999 2.26 3.62 percent of total billed charges MORPHINE SULF ER 30 MG TABLET 48261171_1 CDM 0250 RC 00406-8330-62 NDC inpatient 1 UN 3.73 2.42 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.26 3.62 MORPHINE SULF ER 30 MG TABLET 48261171_1 CDM 0250 RC 00406-8330-62 NDC inpatient 1 UN 3.73 2.42 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.26 60.55 999999999 2.26 3.62 percent of total billed charges MORPHINE SULF ER 30 MG TABLET 48261171_1 CDM 0250 RC 00406-8330-62 NDC inpatient 1 UN 3.73 2.42 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.26 3.62 MORPHINE SULF ER 30 MG TABLET 48261171_1 CDM 0250 RC 00406-8330-62 NDC inpatient 1 UN 3.73 2.42 ANTHEM HMO ANTHEM HMO 999999999 2.26 3.62 MORPHINE SULF ER 30 MG TABLET 48261171_1 CDM 0250 RC 00406-8330-62 NDC inpatient 1 UN 3.73 2.42 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.26 3.62 MORPHINE SULF ER 30 MG TABLET 48261171_1 CDM 0250 RC 00406-8330-62 NDC inpatient 1 UN 3.73 2.42 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.52 67.6 999999999 2.26 3.62 percent of total billed charges MORPHINE SULF ER 30 MG TABLET 48261171_1 CDM 0250 RC 00406-8330-62 NDC inpatient 1 UN 3.73 2.42 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.26 3.62 MORPHINE SULFATE IR 30 MG TAB 48261172_1 CDM 0250 RC 00054-0236-24 NDC inpatient 1 UN 5.73 3.72 AETNA AETNA 4.53 79 999999999 3.47 5.56 percent of total billed charges MORPHINE SULFATE IR 30 MG TAB 48261172_1 CDM 0250 RC 00054-0236-24 NDC inpatient 1 UN 5.73 3.72 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.72 65 999999999 3.47 5.56 percent of total billed charges MORPHINE SULFATE IR 30 MG TAB 48261172_1 CDM 0250 RC 00054-0236-24 NDC inpatient 1 UN 5.73 3.72 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.56 97 999999999 3.47 5.56 percent of total billed charges MORPHINE SULFATE IR 30 MG TAB 48261172_1 CDM 0250 RC 00054-0236-24 NDC inpatient 1 UN 5.73 3.72 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.95 69 999999999 3.47 5.56 percent of total billed charges MORPHINE SULFATE IR 30 MG TAB 48261172_1 CDM 0250 RC 00054-0236-24 NDC inpatient 1 UN 5.73 3.72 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.47 78 999999999 3.47 5.56 percent of total billed charges MORPHINE SULFATE IR 30 MG TAB 48261172_1 CDM 0250 RC 00054-0236-24 NDC inpatient 1 UN 5.73 3.72 UMR - ALL PLANS UMR - ALL PLANS 4.01 70 999999999 3.47 5.56 percent of total billed charges MORPHINE SULFATE IR 30 MG TAB 48261172_1 CDM 0250 RC 00054-0236-24 NDC inpatient 1 UN 5.73 3.72 SIHO - ALL PLANS SIHO - ALL PLANS 5.16 90 999999999 3.47 5.56 percent of total billed charges MORPHINE SULFATE IR 30 MG TAB 48261172_1 CDM 0250 RC 00054-0236-24 NDC inpatient 1 UN 5.73 3.72 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.47 5.56 MORPHINE SULFATE IR 30 MG TAB 48261172_1 CDM 0250 RC 00054-0236-24 NDC inpatient 1 UN 5.73 3.72 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.47 60.55 999999999 3.47 5.56 percent of total billed charges MORPHINE SULFATE IR 30 MG TAB 48261172_1 CDM 0250 RC 00054-0236-24 NDC inpatient 1 UN 5.73 3.72 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.47 5.56 MORPHINE SULFATE IR 30 MG TAB 48261172_1 CDM 0250 RC 00054-0236-24 NDC inpatient 1 UN 5.73 3.72 ANTHEM HMO ANTHEM HMO 999999999 3.47 5.56 MORPHINE SULFATE IR 30 MG TAB 48261172_1 CDM 0250 RC 00054-0236-24 NDC inpatient 1 UN 5.73 3.72 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.47 5.56 MORPHINE SULFATE IR 30 MG TAB 48261172_1 CDM 0250 RC 00054-0236-24 NDC inpatient 1 UN 5.73 3.72 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.87 67.6 999999999 3.47 5.56 percent of total billed charges MORPHINE SULFATE IR 30 MG TAB 48261172_1 CDM 0250 RC 00054-0236-24 NDC inpatient 1 UN 5.73 3.72 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.47 5.56 FOLBEE TABLET 48261174_1 CDM 0250 RC 51991-0084-90 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges FOLBEE TABLET 48261174_1 CDM 0250 RC 51991-0084-90 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges FOLBEE TABLET 48261174_1 CDM 0250 RC 51991-0084-90 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges FOLBEE TABLET 48261174_1 CDM 0250 RC 51991-0084-90 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges FOLBEE TABLET 48261174_1 CDM 0250 RC 51991-0084-90 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges FOLBEE TABLET 48261174_1 CDM 0250 RC 51991-0084-90 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges FOLBEE TABLET 48261174_1 CDM 0250 RC 51991-0084-90 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges FOLBEE TABLET 48261174_1 CDM 0250 RC 51991-0084-90 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 FOLBEE TABLET 48261174_1 CDM 0250 RC 51991-0084-90 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges FOLBEE TABLET 48261174_1 CDM 0250 RC 51991-0084-90 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 FOLBEE TABLET 48261174_1 CDM 0250 RC 51991-0084-90 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 FOLBEE TABLET 48261174_1 CDM 0250 RC 51991-0084-90 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 FOLBEE TABLET 48261174_1 CDM 0250 RC 51991-0084-90 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges FOLBEE TABLET 48261174_1 CDM 0250 RC 51991-0084-90 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 INFUVITE ADULT VIAL 48261175_1 CDM 0250 RC 54643-5649-01 NDC inpatient 1 UN 53.37 34.69 AETNA AETNA 42.16 79 999999999 32.32 51.77 percent of total billed charges INFUVITE ADULT VIAL 48261175_1 CDM 0250 RC 54643-5649-01 NDC inpatient 1 UN 53.37 34.69 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.69 65 999999999 32.32 51.77 percent of total billed charges INFUVITE ADULT VIAL 48261175_1 CDM 0250 RC 54643-5649-01 NDC inpatient 1 UN 53.37 34.69 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.77 97 999999999 32.32 51.77 percent of total billed charges INFUVITE ADULT VIAL 48261175_1 CDM 0250 RC 54643-5649-01 NDC inpatient 1 UN 53.37 34.69 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.83 69 999999999 32.32 51.77 percent of total billed charges INFUVITE ADULT VIAL 48261175_1 CDM 0250 RC 54643-5649-01 NDC inpatient 1 UN 53.37 34.69 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.63 78 999999999 32.32 51.77 percent of total billed charges INFUVITE ADULT VIAL 48261175_1 CDM 0250 RC 54643-5649-01 NDC inpatient 1 UN 53.37 34.69 UMR - ALL PLANS UMR - ALL PLANS 37.36 70 999999999 32.32 51.77 percent of total billed charges INFUVITE ADULT VIAL 48261175_1 CDM 0250 RC 54643-5649-01 NDC inpatient 1 UN 53.37 34.69 SIHO - ALL PLANS SIHO - ALL PLANS 48.03 90 999999999 32.32 51.77 percent of total billed charges INFUVITE ADULT VIAL 48261175_1 CDM 0250 RC 54643-5649-01 NDC inpatient 1 UN 53.37 34.69 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.32 51.77 INFUVITE ADULT VIAL 48261175_1 CDM 0250 RC 54643-5649-01 NDC inpatient 1 UN 53.37 34.69 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.32 60.55 999999999 32.32 51.77 percent of total billed charges INFUVITE ADULT VIAL 48261175_1 CDM 0250 RC 54643-5649-01 NDC inpatient 1 UN 53.37 34.69 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.32 51.77 INFUVITE ADULT VIAL 48261175_1 CDM 0250 RC 54643-5649-01 NDC inpatient 1 UN 53.37 34.69 ANTHEM HMO ANTHEM HMO 999999999 32.32 51.77 INFUVITE ADULT VIAL 48261175_1 CDM 0250 RC 54643-5649-01 NDC inpatient 1 UN 53.37 34.69 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.32 51.77 INFUVITE ADULT VIAL 48261175_1 CDM 0250 RC 54643-5649-01 NDC inpatient 1 UN 53.37 34.69 CIGNA - ALL PLANS CIGNA - ALL PLANS 36.08 67.6 999999999 32.32 51.77 percent of total billed charges INFUVITE ADULT VIAL 48261175_1 CDM 0250 RC 54643-5649-01 NDC inpatient 1 UN 53.37 34.69 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.32 51.77 RENO CAPS SOFTGEL 48261176_1 CDM 0250 RC 63044-0622-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges RENO CAPS SOFTGEL 48261176_1 CDM 0250 RC 63044-0622-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges RENO CAPS SOFTGEL 48261176_1 CDM 0250 RC 63044-0622-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges RENO CAPS SOFTGEL 48261176_1 CDM 0250 RC 63044-0622-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges RENO CAPS SOFTGEL 48261176_1 CDM 0250 RC 63044-0622-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges RENO CAPS SOFTGEL 48261176_1 CDM 0250 RC 63044-0622-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges RENO CAPS SOFTGEL 48261176_1 CDM 0250 RC 63044-0622-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges RENO CAPS SOFTGEL 48261176_1 CDM 0250 RC 63044-0622-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 RENO CAPS SOFTGEL 48261176_1 CDM 0250 RC 63044-0622-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges RENO CAPS SOFTGEL 48261176_1 CDM 0250 RC 63044-0622-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 RENO CAPS SOFTGEL 48261176_1 CDM 0250 RC 63044-0622-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 RENO CAPS SOFTGEL 48261176_1 CDM 0250 RC 63044-0622-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 RENO CAPS SOFTGEL 48261176_1 CDM 0250 RC 63044-0622-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges RENO CAPS SOFTGEL 48261176_1 CDM 0250 RC 63044-0622-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "PRENATAL VITAMINS, 30-DAY SUPPLY" 48261182_1 CDM 0250 RC 00904-5313-60 NDC S0197 HCPCS inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges "PRENATAL VITAMINS, 30-DAY SUPPLY" 48261182_1 CDM 0250 RC 00904-5313-60 NDC S0197 HCPCS inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges "PRENATAL VITAMINS, 30-DAY SUPPLY" 48261182_1 CDM 0250 RC 00904-5313-60 NDC S0197 HCPCS inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges "PRENATAL VITAMINS, 30-DAY SUPPLY" 48261182_1 CDM 0250 RC 00904-5313-60 NDC S0197 HCPCS inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges "PRENATAL VITAMINS, 30-DAY SUPPLY" 48261182_1 CDM 0250 RC 00904-5313-60 NDC S0197 HCPCS inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges "PRENATAL VITAMINS, 30-DAY SUPPLY" 48261182_1 CDM 0250 RC 00904-5313-60 NDC S0197 HCPCS inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges "PRENATAL VITAMINS, 30-DAY SUPPLY" 48261182_1 CDM 0250 RC 00904-5313-60 NDC S0197 HCPCS inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges "PRENATAL VITAMINS, 30-DAY SUPPLY" 48261182_1 CDM 0250 RC 00904-5313-60 NDC S0197 HCPCS inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 "PRENATAL VITAMINS, 30-DAY SUPPLY" 48261182_1 CDM 0250 RC 00904-5313-60 NDC S0197 HCPCS inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges "PRENATAL VITAMINS, 30-DAY SUPPLY" 48261182_1 CDM 0250 RC 00904-5313-60 NDC S0197 HCPCS inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 "PRENATAL VITAMINS, 30-DAY SUPPLY" 48261182_1 CDM 0250 RC 00904-5313-60 NDC S0197 HCPCS inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 "PRENATAL VITAMINS, 30-DAY SUPPLY" 48261182_1 CDM 0250 RC 00904-5313-60 NDC S0197 HCPCS inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 "PRENATAL VITAMINS, 30-DAY SUPPLY" 48261182_1 CDM 0250 RC 00904-5313-60 NDC S0197 HCPCS inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "PRENATAL VITAMINS, 30-DAY SUPPLY" 48261182_1 CDM 0250 RC 00904-5313-60 NDC S0197 HCPCS inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 00456-1405-01 - nebivolol 5 mg Tab [JOHN] 48261197_1 CDM 0250 RC 00456-1405-01 NDC inpatient 1 UN 22.87 14.87 AETNA AETNA 18.07 79 999999999 13.85 22.18 percent of total billed charges 00456-1405-01 - nebivolol 5 mg Tab [JOHN] 48261197_1 CDM 0250 RC 00456-1405-01 NDC inpatient 1 UN 22.87 14.87 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.87 65 999999999 13.85 22.18 percent of total billed charges 00456-1405-01 - nebivolol 5 mg Tab [JOHN] 48261197_1 CDM 0250 RC 00456-1405-01 NDC inpatient 1 UN 22.87 14.87 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22.18 97 999999999 13.85 22.18 percent of total billed charges 00456-1405-01 - nebivolol 5 mg Tab [JOHN] 48261197_1 CDM 0250 RC 00456-1405-01 NDC inpatient 1 UN 22.87 14.87 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.78 69 999999999 13.85 22.18 percent of total billed charges 00456-1405-01 - nebivolol 5 mg Tab [JOHN] 48261197_1 CDM 0250 RC 00456-1405-01 NDC inpatient 1 UN 22.87 14.87 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.84 78 999999999 13.85 22.18 percent of total billed charges 00456-1405-01 - nebivolol 5 mg Tab [JOHN] 48261197_1 CDM 0250 RC 00456-1405-01 NDC inpatient 1 UN 22.87 14.87 UMR - ALL PLANS UMR - ALL PLANS 16.01 70 999999999 13.85 22.18 percent of total billed charges 00456-1405-01 - nebivolol 5 mg Tab [JOHN] 48261197_1 CDM 0250 RC 00456-1405-01 NDC inpatient 1 UN 22.87 14.87 SIHO - ALL PLANS SIHO - ALL PLANS 20.58 90 999999999 13.85 22.18 percent of total billed charges 00456-1405-01 - nebivolol 5 mg Tab [JOHN] 48261197_1 CDM 0250 RC 00456-1405-01 NDC inpatient 1 UN 22.87 14.87 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.85 22.18 00456-1405-01 - nebivolol 5 mg Tab [JOHN] 48261197_1 CDM 0250 RC 00456-1405-01 NDC inpatient 1 UN 22.87 14.87 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.85 60.55 999999999 13.85 22.18 percent of total billed charges 00456-1405-01 - nebivolol 5 mg Tab [JOHN] 48261197_1 CDM 0250 RC 00456-1405-01 NDC inpatient 1 UN 22.87 14.87 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.85 22.18 00456-1405-01 - nebivolol 5 mg Tab [JOHN] 48261197_1 CDM 0250 RC 00456-1405-01 NDC inpatient 1 UN 22.87 14.87 ANTHEM HMO ANTHEM HMO 999999999 13.85 22.18 00456-1405-01 - nebivolol 5 mg Tab [JOHN] 48261197_1 CDM 0250 RC 00456-1405-01 NDC inpatient 1 UN 22.87 14.87 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.85 22.18 00456-1405-01 - nebivolol 5 mg Tab [JOHN] 48261197_1 CDM 0250 RC 00456-1405-01 NDC inpatient 1 UN 22.87 14.87 CIGNA - ALL PLANS CIGNA - ALL PLANS 15.46 67.6 999999999 13.85 22.18 percent of total billed charges 00456-1405-01 - nebivolol 5 mg Tab [JOHN] 48261197_1 CDM 0250 RC 00456-1405-01 NDC inpatient 1 UN 22.87 14.87 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.85 22.18 CARDENE-NACL 20 MG/200 ML SOLN 48261206_1 CDM 0250 RC 10122-0313-10 NDC inpatient 1 UN 264.41 171.87 AETNA AETNA 208.88 79 999999999 160.1 256.48 percent of total billed charges CARDENE-NACL 20 MG/200 ML SOLN 48261206_1 CDM 0250 RC 10122-0313-10 NDC inpatient 1 UN 264.41 171.87 SELF PAY DISCOUNT SELF PAY DISCOUNT 171.87 65 999999999 160.1 256.48 percent of total billed charges CARDENE-NACL 20 MG/200 ML SOLN 48261206_1 CDM 0250 RC 10122-0313-10 NDC inpatient 1 UN 264.41 171.87 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 256.48 97 999999999 160.1 256.48 percent of total billed charges CARDENE-NACL 20 MG/200 ML SOLN 48261206_1 CDM 0250 RC 10122-0313-10 NDC inpatient 1 UN 264.41 171.87 ENCORE - ALL PLANS ENCORE - ALL PLANS 182.44 69 999999999 160.1 256.48 percent of total billed charges CARDENE-NACL 20 MG/200 ML SOLN 48261206_1 CDM 0250 RC 10122-0313-10 NDC inpatient 1 UN 264.41 171.87 HUMANA - ALL PLANS HUMANA - ALL PLANS 206.24 78 999999999 160.1 256.48 percent of total billed charges CARDENE-NACL 20 MG/200 ML SOLN 48261206_1 CDM 0250 RC 10122-0313-10 NDC inpatient 1 UN 264.41 171.87 UMR - ALL PLANS UMR - ALL PLANS 185.09 70 999999999 160.1 256.48 percent of total billed charges CARDENE-NACL 20 MG/200 ML SOLN 48261206_1 CDM 0250 RC 10122-0313-10 NDC inpatient 1 UN 264.41 171.87 SIHO - ALL PLANS SIHO - ALL PLANS 237.97 90 999999999 160.1 256.48 percent of total billed charges CARDENE-NACL 20 MG/200 ML SOLN 48261206_1 CDM 0250 RC 10122-0313-10 NDC inpatient 1 UN 264.41 171.87 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 160.1 256.48 CARDENE-NACL 20 MG/200 ML SOLN 48261206_1 CDM 0250 RC 10122-0313-10 NDC inpatient 1 UN 264.41 171.87 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 160.1 60.55 999999999 160.1 256.48 percent of total billed charges CARDENE-NACL 20 MG/200 ML SOLN 48261206_1 CDM 0250 RC 10122-0313-10 NDC inpatient 1 UN 264.41 171.87 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 160.1 256.48 CARDENE-NACL 20 MG/200 ML SOLN 48261206_1 CDM 0250 RC 10122-0313-10 NDC inpatient 1 UN 264.41 171.87 ANTHEM HMO ANTHEM HMO 999999999 160.1 256.48 CARDENE-NACL 20 MG/200 ML SOLN 48261206_1 CDM 0250 RC 10122-0313-10 NDC inpatient 1 UN 264.41 171.87 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 160.1 256.48 CARDENE-NACL 20 MG/200 ML SOLN 48261206_1 CDM 0250 RC 10122-0313-10 NDC inpatient 1 UN 264.41 171.87 CIGNA - ALL PLANS CIGNA - ALL PLANS 178.74 67.6 999999999 160.1 256.48 percent of total billed charges CARDENE-NACL 20 MG/200 ML SOLN 48261206_1 CDM 0250 RC 10122-0313-10 NDC inpatient 1 UN 264.41 171.87 UHC - ALL PLANS UHC - ALL PLANS 999999999 160.1 256.48 NTG 0.2 MG/ML IN D5W 48261226_1 CDM 0250 RC 00338-1049-02 NDC inpatient 1 UN 109.36 71.08 AETNA AETNA 86.39 79 999999999 66.22 106.08 percent of total billed charges NTG 0.2 MG/ML IN D5W 48261226_1 CDM 0250 RC 00338-1049-02 NDC inpatient 1 UN 109.36 71.08 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.08 65 999999999 66.22 106.08 percent of total billed charges NTG 0.2 MG/ML IN D5W 48261226_1 CDM 0250 RC 00338-1049-02 NDC inpatient 1 UN 109.36 71.08 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.08 97 999999999 66.22 106.08 percent of total billed charges NTG 0.2 MG/ML IN D5W 48261226_1 CDM 0250 RC 00338-1049-02 NDC inpatient 1 UN 109.36 71.08 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.46 69 999999999 66.22 106.08 percent of total billed charges NTG 0.2 MG/ML IN D5W 48261226_1 CDM 0250 RC 00338-1049-02 NDC inpatient 1 UN 109.36 71.08 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.3 78 999999999 66.22 106.08 percent of total billed charges NTG 0.2 MG/ML IN D5W 48261226_1 CDM 0250 RC 00338-1049-02 NDC inpatient 1 UN 109.36 71.08 UMR - ALL PLANS UMR - ALL PLANS 76.55 70 999999999 66.22 106.08 percent of total billed charges NTG 0.2 MG/ML IN D5W 48261226_1 CDM 0250 RC 00338-1049-02 NDC inpatient 1 UN 109.36 71.08 SIHO - ALL PLANS SIHO - ALL PLANS 98.42 90 999999999 66.22 106.08 percent of total billed charges NTG 0.2 MG/ML IN D5W 48261226_1 CDM 0250 RC 00338-1049-02 NDC inpatient 1 UN 109.36 71.08 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.22 106.08 NTG 0.2 MG/ML IN D5W 48261226_1 CDM 0250 RC 00338-1049-02 NDC inpatient 1 UN 109.36 71.08 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.22 60.55 999999999 66.22 106.08 percent of total billed charges NTG 0.2 MG/ML IN D5W 48261226_1 CDM 0250 RC 00338-1049-02 NDC inpatient 1 UN 109.36 71.08 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.22 106.08 NTG 0.2 MG/ML IN D5W 48261226_1 CDM 0250 RC 00338-1049-02 NDC inpatient 1 UN 109.36 71.08 ANTHEM HMO ANTHEM HMO 999999999 66.22 106.08 NTG 0.2 MG/ML IN D5W 48261226_1 CDM 0250 RC 00338-1049-02 NDC inpatient 1 UN 109.36 71.08 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.22 106.08 NTG 0.2 MG/ML IN D5W 48261226_1 CDM 0250 RC 00338-1049-02 NDC inpatient 1 UN 109.36 71.08 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.93 67.6 999999999 66.22 106.08 percent of total billed charges NTG 0.2 MG/ML IN D5W 48261226_1 CDM 0250 RC 00338-1049-02 NDC inpatient 1 UN 109.36 71.08 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.22 106.08 "NYSTATIN 500,000 UNIT/5 ML CUP" 48261232_1 CDM 0250 RC 66689-0037-50 NDC inpatient 1 UN 6.57 4.27 AETNA AETNA 5.19 79 999999999 3.98 6.37 percent of total billed charges "NYSTATIN 500,000 UNIT/5 ML CUP" 48261232_1 CDM 0250 RC 66689-0037-50 NDC inpatient 1 UN 6.57 4.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.27 65 999999999 3.98 6.37 percent of total billed charges "NYSTATIN 500,000 UNIT/5 ML CUP" 48261232_1 CDM 0250 RC 66689-0037-50 NDC inpatient 1 UN 6.57 4.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.37 97 999999999 3.98 6.37 percent of total billed charges "NYSTATIN 500,000 UNIT/5 ML CUP" 48261232_1 CDM 0250 RC 66689-0037-50 NDC inpatient 1 UN 6.57 4.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.53 69 999999999 3.98 6.37 percent of total billed charges "NYSTATIN 500,000 UNIT/5 ML CUP" 48261232_1 CDM 0250 RC 66689-0037-50 NDC inpatient 1 UN 6.57 4.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 5.12 78 999999999 3.98 6.37 percent of total billed charges "NYSTATIN 500,000 UNIT/5 ML CUP" 48261232_1 CDM 0250 RC 66689-0037-50 NDC inpatient 1 UN 6.57 4.27 UMR - ALL PLANS UMR - ALL PLANS 4.6 70 999999999 3.98 6.37 percent of total billed charges "NYSTATIN 500,000 UNIT/5 ML CUP" 48261232_1 CDM 0250 RC 66689-0037-50 NDC inpatient 1 UN 6.57 4.27 SIHO - ALL PLANS SIHO - ALL PLANS 5.91 90 999999999 3.98 6.37 percent of total billed charges "NYSTATIN 500,000 UNIT/5 ML CUP" 48261232_1 CDM 0250 RC 66689-0037-50 NDC inpatient 1 UN 6.57 4.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.98 6.37 "NYSTATIN 500,000 UNIT/5 ML CUP" 48261232_1 CDM 0250 RC 66689-0037-50 NDC inpatient 1 UN 6.57 4.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.98 60.55 999999999 3.98 6.37 percent of total billed charges "NYSTATIN 500,000 UNIT/5 ML CUP" 48261232_1 CDM 0250 RC 66689-0037-50 NDC inpatient 1 UN 6.57 4.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.98 6.37 "NYSTATIN 500,000 UNIT/5 ML CUP" 48261232_1 CDM 0250 RC 66689-0037-50 NDC inpatient 1 UN 6.57 4.27 ANTHEM HMO ANTHEM HMO 999999999 3.98 6.37 "NYSTATIN 500,000 UNIT/5 ML CUP" 48261232_1 CDM 0250 RC 66689-0037-50 NDC inpatient 1 UN 6.57 4.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.98 6.37 "NYSTATIN 500,000 UNIT/5 ML CUP" 48261232_1 CDM 0250 RC 66689-0037-50 NDC inpatient 1 UN 6.57 4.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.44 67.6 999999999 3.98 6.37 percent of total billed charges "NYSTATIN 500,000 UNIT/5 ML CUP" 48261232_1 CDM 0250 RC 66689-0037-50 NDC inpatient 1 UN 6.57 4.27 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.98 6.37 REFRESH LACRI-LUBE OINTMENT 48261239_1 CDM 0250 RC 00023-0312-04 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges REFRESH LACRI-LUBE OINTMENT 48261239_1 CDM 0250 RC 00023-0312-04 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges REFRESH LACRI-LUBE OINTMENT 48261239_1 CDM 0250 RC 00023-0312-04 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges REFRESH LACRI-LUBE OINTMENT 48261239_1 CDM 0250 RC 00023-0312-04 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges REFRESH LACRI-LUBE OINTMENT 48261239_1 CDM 0250 RC 00023-0312-04 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges REFRESH LACRI-LUBE OINTMENT 48261239_1 CDM 0250 RC 00023-0312-04 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges REFRESH LACRI-LUBE OINTMENT 48261239_1 CDM 0250 RC 00023-0312-04 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges REFRESH LACRI-LUBE OINTMENT 48261239_1 CDM 0250 RC 00023-0312-04 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 REFRESH LACRI-LUBE OINTMENT 48261239_1 CDM 0250 RC 00023-0312-04 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges REFRESH LACRI-LUBE OINTMENT 48261239_1 CDM 0250 RC 00023-0312-04 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 REFRESH LACRI-LUBE OINTMENT 48261239_1 CDM 0250 RC 00023-0312-04 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 REFRESH LACRI-LUBE OINTMENT 48261239_1 CDM 0250 RC 00023-0312-04 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 REFRESH LACRI-LUBE OINTMENT 48261239_1 CDM 0250 RC 00023-0312-04 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges REFRESH LACRI-LUBE OINTMENT 48261239_1 CDM 0250 RC 00023-0312-04 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ZYPREXA 10 MG VIAL 48261243_1 CDM 0250 RC 00002-7597-01 NDC inpatient 1 UN 231.09 150.21 AETNA AETNA 182.56 79 999999999 139.93 224.16 percent of total billed charges ZYPREXA 10 MG VIAL 48261243_1 CDM 0250 RC 00002-7597-01 NDC inpatient 1 UN 231.09 150.21 SELF PAY DISCOUNT SELF PAY DISCOUNT 150.21 65 999999999 139.93 224.16 percent of total billed charges ZYPREXA 10 MG VIAL 48261243_1 CDM 0250 RC 00002-7597-01 NDC inpatient 1 UN 231.09 150.21 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 224.16 97 999999999 139.93 224.16 percent of total billed charges ZYPREXA 10 MG VIAL 48261243_1 CDM 0250 RC 00002-7597-01 NDC inpatient 1 UN 231.09 150.21 ENCORE - ALL PLANS ENCORE - ALL PLANS 159.45 69 999999999 139.93 224.16 percent of total billed charges ZYPREXA 10 MG VIAL 48261243_1 CDM 0250 RC 00002-7597-01 NDC inpatient 1 UN 231.09 150.21 HUMANA - ALL PLANS HUMANA - ALL PLANS 180.25 78 999999999 139.93 224.16 percent of total billed charges ZYPREXA 10 MG VIAL 48261243_1 CDM 0250 RC 00002-7597-01 NDC inpatient 1 UN 231.09 150.21 UMR - ALL PLANS UMR - ALL PLANS 161.76 70 999999999 139.93 224.16 percent of total billed charges ZYPREXA 10 MG VIAL 48261243_1 CDM 0250 RC 00002-7597-01 NDC inpatient 1 UN 231.09 150.21 SIHO - ALL PLANS SIHO - ALL PLANS 207.98 90 999999999 139.93 224.16 percent of total billed charges ZYPREXA 10 MG VIAL 48261243_1 CDM 0250 RC 00002-7597-01 NDC inpatient 1 UN 231.09 150.21 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 139.93 224.16 ZYPREXA 10 MG VIAL 48261243_1 CDM 0250 RC 00002-7597-01 NDC inpatient 1 UN 231.09 150.21 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 139.93 60.55 999999999 139.93 224.16 percent of total billed charges ZYPREXA 10 MG VIAL 48261243_1 CDM 0250 RC 00002-7597-01 NDC inpatient 1 UN 231.09 150.21 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 139.93 224.16 ZYPREXA 10 MG VIAL 48261243_1 CDM 0250 RC 00002-7597-01 NDC inpatient 1 UN 231.09 150.21 ANTHEM HMO ANTHEM HMO 999999999 139.93 224.16 ZYPREXA 10 MG VIAL 48261243_1 CDM 0250 RC 00002-7597-01 NDC inpatient 1 UN 231.09 150.21 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 139.93 224.16 ZYPREXA 10 MG VIAL 48261243_1 CDM 0250 RC 00002-7597-01 NDC inpatient 1 UN 231.09 150.21 CIGNA - ALL PLANS CIGNA - ALL PLANS 156.22 67.6 999999999 139.93 224.16 percent of total billed charges ZYPREXA 10 MG VIAL 48261243_1 CDM 0250 RC 00002-7597-01 NDC inpatient 1 UN 231.09 150.21 UHC - ALL PLANS UHC - ALL PLANS 999999999 139.93 224.16 "INJECTION, ONABOTULINUMTOXINA, 1 UNIT" 48261248_1 CDM 0250 RC 00023-1145-01 NDC J0585 HCPCS inpatient 1 UN 2770.25 1800.66 AETNA AETNA 2188.5 79 999999999 1677.39 2687.14 percent of total billed charges "INJECTION, ONABOTULINUMTOXINA, 1 UNIT" 48261248_1 CDM 0250 RC 00023-1145-01 NDC J0585 HCPCS inpatient 1 UN 2770.25 1800.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 1800.66 65 999999999 1677.39 2687.14 percent of total billed charges "INJECTION, ONABOTULINUMTOXINA, 1 UNIT" 48261248_1 CDM 0250 RC 00023-1145-01 NDC J0585 HCPCS inpatient 1 UN 2770.25 1800.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2687.14 97 999999999 1677.39 2687.14 percent of total billed charges "INJECTION, ONABOTULINUMTOXINA, 1 UNIT" 48261248_1 CDM 0250 RC 00023-1145-01 NDC J0585 HCPCS inpatient 1 UN 2770.25 1800.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 1911.47 69 999999999 1677.39 2687.14 percent of total billed charges "INJECTION, ONABOTULINUMTOXINA, 1 UNIT" 48261248_1 CDM 0250 RC 00023-1145-01 NDC J0585 HCPCS inpatient 1 UN 2770.25 1800.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 2160.8 78 999999999 1677.39 2687.14 percent of total billed charges "INJECTION, ONABOTULINUMTOXINA, 1 UNIT" 48261248_1 CDM 0250 RC 00023-1145-01 NDC J0585 HCPCS inpatient 1 UN 2770.25 1800.66 UMR - ALL PLANS UMR - ALL PLANS 1939.18 70 999999999 1677.39 2687.14 percent of total billed charges "INJECTION, ONABOTULINUMTOXINA, 1 UNIT" 48261248_1 CDM 0250 RC 00023-1145-01 NDC J0585 HCPCS inpatient 1 UN 2770.25 1800.66 SIHO - ALL PLANS SIHO - ALL PLANS 2493.23 90 999999999 1677.39 2687.14 percent of total billed charges "INJECTION, ONABOTULINUMTOXINA, 1 UNIT" 48261248_1 CDM 0250 RC 00023-1145-01 NDC J0585 HCPCS inpatient 1 UN 2770.25 1800.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1677.39 2687.14 "INJECTION, ONABOTULINUMTOXINA, 1 UNIT" 48261248_1 CDM 0250 RC 00023-1145-01 NDC J0585 HCPCS inpatient 1 UN 2770.25 1800.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1677.39 60.55 999999999 1677.39 2687.14 percent of total billed charges "INJECTION, ONABOTULINUMTOXINA, 1 UNIT" 48261248_1 CDM 0250 RC 00023-1145-01 NDC J0585 HCPCS inpatient 1 UN 2770.25 1800.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1677.39 2687.14 "INJECTION, ONABOTULINUMTOXINA, 1 UNIT" 48261248_1 CDM 0250 RC 00023-1145-01 NDC J0585 HCPCS inpatient 1 UN 2770.25 1800.66 ANTHEM HMO ANTHEM HMO 999999999 1677.39 2687.14 "INJECTION, ONABOTULINUMTOXINA, 1 UNIT" 48261248_1 CDM 0250 RC 00023-1145-01 NDC J0585 HCPCS inpatient 1 UN 2770.25 1800.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1677.39 2687.14 "INJECTION, ONABOTULINUMTOXINA, 1 UNIT" 48261248_1 CDM 0250 RC 00023-1145-01 NDC J0585 HCPCS inpatient 1 UN 2770.25 1800.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 1872.69 67.6 999999999 1677.39 2687.14 percent of total billed charges "INJECTION, ONABOTULINUMTOXINA, 1 UNIT" 48261248_1 CDM 0250 RC 00023-1145-01 NDC J0585 HCPCS inpatient 1 UN 2770.25 1800.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 1677.39 2687.14 "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 48261250_1 CDM 0250 RC 00641-6080-25 NDC J2405 HCPCS inpatient 4 UN 19.65 12.77 AETNA AETNA 15.52 79 999999999 11.9 19.06 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 48261250_1 CDM 0250 RC 00641-6080-25 NDC J2405 HCPCS inpatient 4 UN 19.65 12.77 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.77 65 999999999 11.9 19.06 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 48261250_1 CDM 0250 RC 00641-6080-25 NDC J2405 HCPCS inpatient 4 UN 19.65 12.77 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.06 97 999999999 11.9 19.06 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 48261250_1 CDM 0250 RC 00641-6080-25 NDC J2405 HCPCS inpatient 4 UN 19.65 12.77 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.56 69 999999999 11.9 19.06 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 48261250_1 CDM 0250 RC 00641-6080-25 NDC J2405 HCPCS inpatient 4 UN 19.65 12.77 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.33 78 999999999 11.9 19.06 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 48261250_1 CDM 0250 RC 00641-6080-25 NDC J2405 HCPCS inpatient 4 UN 19.65 12.77 UMR - ALL PLANS UMR - ALL PLANS 13.76 70 999999999 11.9 19.06 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 48261250_1 CDM 0250 RC 00641-6080-25 NDC J2405 HCPCS inpatient 4 UN 19.65 12.77 SIHO - ALL PLANS SIHO - ALL PLANS 17.69 90 999999999 11.9 19.06 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 48261250_1 CDM 0250 RC 00641-6080-25 NDC J2405 HCPCS inpatient 4 UN 19.65 12.77 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.9 19.06 "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 48261250_1 CDM 0250 RC 00641-6080-25 NDC J2405 HCPCS inpatient 4 UN 19.65 12.77 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.9 60.55 999999999 11.9 19.06 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 48261250_1 CDM 0250 RC 00641-6080-25 NDC J2405 HCPCS inpatient 4 UN 19.65 12.77 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.9 19.06 "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 48261250_1 CDM 0250 RC 00641-6080-25 NDC J2405 HCPCS inpatient 4 UN 19.65 12.77 ANTHEM HMO ANTHEM HMO 999999999 11.9 19.06 "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 48261250_1 CDM 0250 RC 00641-6080-25 NDC J2405 HCPCS inpatient 4 UN 19.65 12.77 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.9 19.06 "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 48261250_1 CDM 0250 RC 00641-6080-25 NDC J2405 HCPCS inpatient 4 UN 19.65 12.77 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.28 67.6 999999999 11.9 19.06 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 48261250_1 CDM 0250 RC 00641-6080-25 NDC J2405 HCPCS inpatient 4 UN 19.65 12.77 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.9 19.06 OXYBUTYNIN 5 MG TABLET 48261263_1 CDM 0250 RC 68084-0400-01 NDC inpatient 1 UN 1.89 1.23 AETNA AETNA 1.49 79 999999999 1.14 1.83 percent of total billed charges OXYBUTYNIN 5 MG TABLET 48261263_1 CDM 0250 RC 68084-0400-01 NDC inpatient 1 UN 1.89 1.23 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.23 65 999999999 1.14 1.83 percent of total billed charges OXYBUTYNIN 5 MG TABLET 48261263_1 CDM 0250 RC 68084-0400-01 NDC inpatient 1 UN 1.89 1.23 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.83 97 999999999 1.14 1.83 percent of total billed charges OXYBUTYNIN 5 MG TABLET 48261263_1 CDM 0250 RC 68084-0400-01 NDC inpatient 1 UN 1.89 1.23 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.3 69 999999999 1.14 1.83 percent of total billed charges OXYBUTYNIN 5 MG TABLET 48261263_1 CDM 0250 RC 68084-0400-01 NDC inpatient 1 UN 1.89 1.23 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.47 78 999999999 1.14 1.83 percent of total billed charges OXYBUTYNIN 5 MG TABLET 48261263_1 CDM 0250 RC 68084-0400-01 NDC inpatient 1 UN 1.89 1.23 UMR - ALL PLANS UMR - ALL PLANS 1.32 70 999999999 1.14 1.83 percent of total billed charges OXYBUTYNIN 5 MG TABLET 48261263_1 CDM 0250 RC 68084-0400-01 NDC inpatient 1 UN 1.89 1.23 SIHO - ALL PLANS SIHO - ALL PLANS 1.7 90 999999999 1.14 1.83 percent of total billed charges OXYBUTYNIN 5 MG TABLET 48261263_1 CDM 0250 RC 68084-0400-01 NDC inpatient 1 UN 1.89 1.23 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.14 1.83 OXYBUTYNIN 5 MG TABLET 48261263_1 CDM 0250 RC 68084-0400-01 NDC inpatient 1 UN 1.89 1.23 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.14 60.55 999999999 1.14 1.83 percent of total billed charges OXYBUTYNIN 5 MG TABLET 48261263_1 CDM 0250 RC 68084-0400-01 NDC inpatient 1 UN 1.89 1.23 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.14 1.83 OXYBUTYNIN 5 MG TABLET 48261263_1 CDM 0250 RC 68084-0400-01 NDC inpatient 1 UN 1.89 1.23 ANTHEM HMO ANTHEM HMO 999999999 1.14 1.83 OXYBUTYNIN 5 MG TABLET 48261263_1 CDM 0250 RC 68084-0400-01 NDC inpatient 1 UN 1.89 1.23 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.14 1.83 OXYBUTYNIN 5 MG TABLET 48261263_1 CDM 0250 RC 68084-0400-01 NDC inpatient 1 UN 1.89 1.23 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.28 67.6 999999999 1.14 1.83 percent of total billed charges OXYBUTYNIN 5 MG TABLET 48261263_1 CDM 0250 RC 68084-0400-01 NDC inpatient 1 UN 1.89 1.23 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.14 1.83 OXYCONTIN ER 10 MG TABLET 48261266_1 CDM 0250 RC 59011-0410-20 NDC inpatient 1 UN 15.84 10.3 AETNA AETNA 12.51 79 999999999 9.59 15.36 percent of total billed charges OXYCONTIN ER 10 MG TABLET 48261266_1 CDM 0250 RC 59011-0410-20 NDC inpatient 1 UN 15.84 10.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.3 65 999999999 9.59 15.36 percent of total billed charges OXYCONTIN ER 10 MG TABLET 48261266_1 CDM 0250 RC 59011-0410-20 NDC inpatient 1 UN 15.84 10.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15.36 97 999999999 9.59 15.36 percent of total billed charges OXYCONTIN ER 10 MG TABLET 48261266_1 CDM 0250 RC 59011-0410-20 NDC inpatient 1 UN 15.84 10.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.93 69 999999999 9.59 15.36 percent of total billed charges OXYCONTIN ER 10 MG TABLET 48261266_1 CDM 0250 RC 59011-0410-20 NDC inpatient 1 UN 15.84 10.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.36 78 999999999 9.59 15.36 percent of total billed charges OXYCONTIN ER 10 MG TABLET 48261266_1 CDM 0250 RC 59011-0410-20 NDC inpatient 1 UN 15.84 10.3 UMR - ALL PLANS UMR - ALL PLANS 11.09 70 999999999 9.59 15.36 percent of total billed charges OXYCONTIN ER 10 MG TABLET 48261266_1 CDM 0250 RC 59011-0410-20 NDC inpatient 1 UN 15.84 10.3 SIHO - ALL PLANS SIHO - ALL PLANS 14.26 90 999999999 9.59 15.36 percent of total billed charges OXYCONTIN ER 10 MG TABLET 48261266_1 CDM 0250 RC 59011-0410-20 NDC inpatient 1 UN 15.84 10.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.59 15.36 OXYCONTIN ER 10 MG TABLET 48261266_1 CDM 0250 RC 59011-0410-20 NDC inpatient 1 UN 15.84 10.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.59 60.55 999999999 9.59 15.36 percent of total billed charges OXYCONTIN ER 10 MG TABLET 48261266_1 CDM 0250 RC 59011-0410-20 NDC inpatient 1 UN 15.84 10.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.59 15.36 OXYCONTIN ER 10 MG TABLET 48261266_1 CDM 0250 RC 59011-0410-20 NDC inpatient 1 UN 15.84 10.3 ANTHEM HMO ANTHEM HMO 999999999 9.59 15.36 OXYCONTIN ER 10 MG TABLET 48261266_1 CDM 0250 RC 59011-0410-20 NDC inpatient 1 UN 15.84 10.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.59 15.36 OXYCONTIN ER 10 MG TABLET 48261266_1 CDM 0250 RC 59011-0410-20 NDC inpatient 1 UN 15.84 10.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.71 67.6 999999999 9.59 15.36 percent of total billed charges OXYCONTIN ER 10 MG TABLET 48261266_1 CDM 0250 RC 59011-0410-20 NDC inpatient 1 UN 15.84 10.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.59 15.36 OXYCODONE HCL (IR) 5 MG TABLET 48261270_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 48261270_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 48261270_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 48261270_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 48261270_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 48261270_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 48261270_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 48261270_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 OXYCODONE HCL (IR) 5 MG TABLET 48261270_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 48261270_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 OXYCODONE HCL (IR) 5 MG TABLET 48261270_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 OXYCODONE HCL (IR) 5 MG TABLET 48261270_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 OXYCODONE HCL (IR) 5 MG TABLET 48261270_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 48261270_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 OXYCONTIN ER 15 MG TABLET 48261271_1 CDM 0250 RC 59011-0415-20 NDC inpatient 1 UN 23.3 15.15 AETNA AETNA 18.41 79 999999999 14.11 22.6 percent of total billed charges OXYCONTIN ER 15 MG TABLET 48261271_1 CDM 0250 RC 59011-0415-20 NDC inpatient 1 UN 23.3 15.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 15.15 65 999999999 14.11 22.6 percent of total billed charges OXYCONTIN ER 15 MG TABLET 48261271_1 CDM 0250 RC 59011-0415-20 NDC inpatient 1 UN 23.3 15.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22.6 97 999999999 14.11 22.6 percent of total billed charges OXYCONTIN ER 15 MG TABLET 48261271_1 CDM 0250 RC 59011-0415-20 NDC inpatient 1 UN 23.3 15.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 16.08 69 999999999 14.11 22.6 percent of total billed charges OXYCONTIN ER 15 MG TABLET 48261271_1 CDM 0250 RC 59011-0415-20 NDC inpatient 1 UN 23.3 15.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 18.17 78 999999999 14.11 22.6 percent of total billed charges OXYCONTIN ER 15 MG TABLET 48261271_1 CDM 0250 RC 59011-0415-20 NDC inpatient 1 UN 23.3 15.15 UMR - ALL PLANS UMR - ALL PLANS 16.31 70 999999999 14.11 22.6 percent of total billed charges OXYCONTIN ER 15 MG TABLET 48261271_1 CDM 0250 RC 59011-0415-20 NDC inpatient 1 UN 23.3 15.15 SIHO - ALL PLANS SIHO - ALL PLANS 20.97 90 999999999 14.11 22.6 percent of total billed charges OXYCONTIN ER 15 MG TABLET 48261271_1 CDM 0250 RC 59011-0415-20 NDC inpatient 1 UN 23.3 15.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.11 22.6 OXYCONTIN ER 15 MG TABLET 48261271_1 CDM 0250 RC 59011-0415-20 NDC inpatient 1 UN 23.3 15.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.11 60.55 999999999 14.11 22.6 percent of total billed charges OXYCONTIN ER 15 MG TABLET 48261271_1 CDM 0250 RC 59011-0415-20 NDC inpatient 1 UN 23.3 15.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.11 22.6 OXYCONTIN ER 15 MG TABLET 48261271_1 CDM 0250 RC 59011-0415-20 NDC inpatient 1 UN 23.3 15.15 ANTHEM HMO ANTHEM HMO 999999999 14.11 22.6 OXYCONTIN ER 15 MG TABLET 48261271_1 CDM 0250 RC 59011-0415-20 NDC inpatient 1 UN 23.3 15.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.11 22.6 OXYCONTIN ER 15 MG TABLET 48261271_1 CDM 0250 RC 59011-0415-20 NDC inpatient 1 UN 23.3 15.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 15.75 67.6 999999999 14.11 22.6 percent of total billed charges OXYCONTIN ER 15 MG TABLET 48261271_1 CDM 0250 RC 59011-0415-20 NDC inpatient 1 UN 23.3 15.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.11 22.6 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48261273_1 CDM 0250 RC 63323-0012-01 NDC J2590 HCPCS inpatient 1 UN 9.92 6.45 AETNA AETNA 7.84 79 999999999 6.01 9.62 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48261273_1 CDM 0250 RC 63323-0012-01 NDC J2590 HCPCS inpatient 1 UN 9.92 6.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.45 65 999999999 6.01 9.62 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48261273_1 CDM 0250 RC 63323-0012-01 NDC J2590 HCPCS inpatient 1 UN 9.92 6.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.62 97 999999999 6.01 9.62 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48261273_1 CDM 0250 RC 63323-0012-01 NDC J2590 HCPCS inpatient 1 UN 9.92 6.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.84 69 999999999 6.01 9.62 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48261273_1 CDM 0250 RC 63323-0012-01 NDC J2590 HCPCS inpatient 1 UN 9.92 6.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.74 78 999999999 6.01 9.62 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48261273_1 CDM 0250 RC 63323-0012-01 NDC J2590 HCPCS inpatient 1 UN 9.92 6.45 UMR - ALL PLANS UMR - ALL PLANS 6.94 70 999999999 6.01 9.62 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48261273_1 CDM 0250 RC 63323-0012-01 NDC J2590 HCPCS inpatient 1 UN 9.92 6.45 SIHO - ALL PLANS SIHO - ALL PLANS 8.93 90 999999999 6.01 9.62 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48261273_1 CDM 0250 RC 63323-0012-01 NDC J2590 HCPCS inpatient 1 UN 9.92 6.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.01 9.62 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48261273_1 CDM 0250 RC 63323-0012-01 NDC J2590 HCPCS inpatient 1 UN 9.92 6.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.01 60.55 999999999 6.01 9.62 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48261273_1 CDM 0250 RC 63323-0012-01 NDC J2590 HCPCS inpatient 1 UN 9.92 6.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.01 9.62 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48261273_1 CDM 0250 RC 63323-0012-01 NDC J2590 HCPCS inpatient 1 UN 9.92 6.45 ANTHEM HMO ANTHEM HMO 999999999 6.01 9.62 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48261273_1 CDM 0250 RC 63323-0012-01 NDC J2590 HCPCS inpatient 1 UN 9.92 6.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.01 9.62 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48261273_1 CDM 0250 RC 63323-0012-01 NDC J2590 HCPCS inpatient 1 UN 9.92 6.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.71 67.6 999999999 6.01 9.62 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48261273_1 CDM 0250 RC 63323-0012-01 NDC J2590 HCPCS inpatient 1 UN 9.92 6.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.01 9.62 "INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG" 48261278_1 CDM 0636 RC 68817-0134-50 NDC J9264 HCPCS inpatient 100 UN 6467.62 4203.95 AETNA AETNA 5109.42 79 999999999 3916.14 6273.59 percent of total billed charges "INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG" 48261278_1 CDM 0636 RC 68817-0134-50 NDC J9264 HCPCS inpatient 100 UN 6467.62 4203.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 4203.95 65 999999999 3916.14 6273.59 percent of total billed charges "INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG" 48261278_1 CDM 0636 RC 68817-0134-50 NDC J9264 HCPCS inpatient 100 UN 6467.62 4203.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6273.59 97 999999999 3916.14 6273.59 percent of total billed charges "INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG" 48261278_1 CDM 0636 RC 68817-0134-50 NDC J9264 HCPCS inpatient 100 UN 6467.62 4203.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 4462.66 69 999999999 3916.14 6273.59 percent of total billed charges "INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG" 48261278_1 CDM 0636 RC 68817-0134-50 NDC J9264 HCPCS inpatient 100 UN 6467.62 4203.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 5044.74 78 999999999 3916.14 6273.59 percent of total billed charges "INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG" 48261278_1 CDM 0636 RC 68817-0134-50 NDC J9264 HCPCS inpatient 100 UN 6467.62 4203.95 UMR - ALL PLANS UMR - ALL PLANS 4527.33 70 999999999 3916.14 6273.59 percent of total billed charges "INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG" 48261278_1 CDM 0636 RC 68817-0134-50 NDC J9264 HCPCS inpatient 100 UN 6467.62 4203.95 SIHO - ALL PLANS SIHO - ALL PLANS 5820.86 90 999999999 3916.14 6273.59 percent of total billed charges "INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG" 48261278_1 CDM 0636 RC 68817-0134-50 NDC J9264 HCPCS inpatient 100 UN 6467.62 4203.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3916.14 6273.59 "INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG" 48261278_1 CDM 0636 RC 68817-0134-50 NDC J9264 HCPCS inpatient 100 UN 6467.62 4203.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3916.14 60.55 999999999 3916.14 6273.59 percent of total billed charges "INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG" 48261278_1 CDM 0636 RC 68817-0134-50 NDC J9264 HCPCS inpatient 100 UN 6467.62 4203.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3916.14 6273.59 "INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG" 48261278_1 CDM 0636 RC 68817-0134-50 NDC J9264 HCPCS inpatient 100 UN 6467.62 4203.95 ANTHEM HMO ANTHEM HMO 999999999 3916.14 6273.59 "INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG" 48261278_1 CDM 0636 RC 68817-0134-50 NDC J9264 HCPCS inpatient 100 UN 6467.62 4203.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3916.14 6273.59 "INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG" 48261278_1 CDM 0636 RC 68817-0134-50 NDC J9264 HCPCS inpatient 100 UN 6467.62 4203.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 4372.11 67.6 999999999 3916.14 6273.59 percent of total billed charges "INJECTION, PACLITAXEL PROTEIN-BOUND PARTICLES, 1 MG" 48261278_1 CDM 0636 RC 68817-0134-50 NDC J9264 HCPCS inpatient 100 UN 6467.62 4203.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 3916.14 6273.59 "INJECTION, PANITUMUMAB, 10 MG" 48261283_1 CDM 0636 RC 55513-0954-01 NDC J9303 HCPCS inpatient 10 UN 5762.16 3745.4 AETNA AETNA 4552.11 79 999999999 3488.99 5589.3 percent of total billed charges "INJECTION, PANITUMUMAB, 10 MG" 48261283_1 CDM 0636 RC 55513-0954-01 NDC J9303 HCPCS inpatient 10 UN 5762.16 3745.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 3745.4 65 999999999 3488.99 5589.3 percent of total billed charges "INJECTION, PANITUMUMAB, 10 MG" 48261283_1 CDM 0636 RC 55513-0954-01 NDC J9303 HCPCS inpatient 10 UN 5762.16 3745.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5589.3 97 999999999 3488.99 5589.3 percent of total billed charges "INJECTION, PANITUMUMAB, 10 MG" 48261283_1 CDM 0636 RC 55513-0954-01 NDC J9303 HCPCS inpatient 10 UN 5762.16 3745.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 3975.89 69 999999999 3488.99 5589.3 percent of total billed charges "INJECTION, PANITUMUMAB, 10 MG" 48261283_1 CDM 0636 RC 55513-0954-01 NDC J9303 HCPCS inpatient 10 UN 5762.16 3745.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 4494.48 78 999999999 3488.99 5589.3 percent of total billed charges "INJECTION, PANITUMUMAB, 10 MG" 48261283_1 CDM 0636 RC 55513-0954-01 NDC J9303 HCPCS inpatient 10 UN 5762.16 3745.4 UMR - ALL PLANS UMR - ALL PLANS 4033.51 70 999999999 3488.99 5589.3 percent of total billed charges "INJECTION, PANITUMUMAB, 10 MG" 48261283_1 CDM 0636 RC 55513-0954-01 NDC J9303 HCPCS inpatient 10 UN 5762.16 3745.4 SIHO - ALL PLANS SIHO - ALL PLANS 5185.94 90 999999999 3488.99 5589.3 percent of total billed charges "INJECTION, PANITUMUMAB, 10 MG" 48261283_1 CDM 0636 RC 55513-0954-01 NDC J9303 HCPCS inpatient 10 UN 5762.16 3745.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3488.99 5589.3 "INJECTION, PANITUMUMAB, 10 MG" 48261283_1 CDM 0636 RC 55513-0954-01 NDC J9303 HCPCS inpatient 10 UN 5762.16 3745.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3488.99 60.55 999999999 3488.99 5589.3 percent of total billed charges "INJECTION, PANITUMUMAB, 10 MG" 48261283_1 CDM 0636 RC 55513-0954-01 NDC J9303 HCPCS inpatient 10 UN 5762.16 3745.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3488.99 5589.3 "INJECTION, PANITUMUMAB, 10 MG" 48261283_1 CDM 0636 RC 55513-0954-01 NDC J9303 HCPCS inpatient 10 UN 5762.16 3745.4 ANTHEM HMO ANTHEM HMO 999999999 3488.99 5589.3 "INJECTION, PANITUMUMAB, 10 MG" 48261283_1 CDM 0636 RC 55513-0954-01 NDC J9303 HCPCS inpatient 10 UN 5762.16 3745.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3488.99 5589.3 "INJECTION, PANITUMUMAB, 10 MG" 48261283_1 CDM 0636 RC 55513-0954-01 NDC J9303 HCPCS inpatient 10 UN 5762.16 3745.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 3895.22 67.6 999999999 3488.99 5589.3 percent of total billed charges "INJECTION, PANITUMUMAB, 10 MG" 48261283_1 CDM 0636 RC 55513-0954-01 NDC J9303 HCPCS inpatient 10 UN 5762.16 3745.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 3488.99 5589.3 "INJECTION, PANITUMUMAB, 10 MG" 48261285_1 CDM 0636 RC 55513-0956-01 NDC J9303 HCPCS inpatient 40 UN 22898.59 14884.08 AETNA AETNA 18089.89 79 999999999 13865.1 22211.63 percent of total billed charges "INJECTION, PANITUMUMAB, 10 MG" 48261285_1 CDM 0636 RC 55513-0956-01 NDC J9303 HCPCS inpatient 40 UN 22898.59 14884.08 SELF PAY DISCOUNT SELF PAY DISCOUNT 14884.08 65 999999999 13865.1 22211.63 percent of total billed charges "INJECTION, PANITUMUMAB, 10 MG" 48261285_1 CDM 0636 RC 55513-0956-01 NDC J9303 HCPCS inpatient 40 UN 22898.59 14884.08 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22211.63 97 999999999 13865.1 22211.63 percent of total billed charges "INJECTION, PANITUMUMAB, 10 MG" 48261285_1 CDM 0636 RC 55513-0956-01 NDC J9303 HCPCS inpatient 40 UN 22898.59 14884.08 ENCORE - ALL PLANS ENCORE - ALL PLANS 15800.03 69 999999999 13865.1 22211.63 percent of total billed charges "INJECTION, PANITUMUMAB, 10 MG" 48261285_1 CDM 0636 RC 55513-0956-01 NDC J9303 HCPCS inpatient 40 UN 22898.59 14884.08 HUMANA - ALL PLANS HUMANA - ALL PLANS 17860.9 78 999999999 13865.1 22211.63 percent of total billed charges "INJECTION, PANITUMUMAB, 10 MG" 48261285_1 CDM 0636 RC 55513-0956-01 NDC J9303 HCPCS inpatient 40 UN 22898.59 14884.08 UMR - ALL PLANS UMR - ALL PLANS 16029.01 70 999999999 13865.1 22211.63 percent of total billed charges "INJECTION, PANITUMUMAB, 10 MG" 48261285_1 CDM 0636 RC 55513-0956-01 NDC J9303 HCPCS inpatient 40 UN 22898.59 14884.08 SIHO - ALL PLANS SIHO - ALL PLANS 20608.73 90 999999999 13865.1 22211.63 percent of total billed charges "INJECTION, PANITUMUMAB, 10 MG" 48261285_1 CDM 0636 RC 55513-0956-01 NDC J9303 HCPCS inpatient 40 UN 22898.59 14884.08 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13865.1 22211.63 "INJECTION, PANITUMUMAB, 10 MG" 48261285_1 CDM 0636 RC 55513-0956-01 NDC J9303 HCPCS inpatient 40 UN 22898.59 14884.08 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13865.1 60.55 999999999 13865.1 22211.63 percent of total billed charges "INJECTION, PANITUMUMAB, 10 MG" 48261285_1 CDM 0636 RC 55513-0956-01 NDC J9303 HCPCS inpatient 40 UN 22898.59 14884.08 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13865.1 22211.63 "INJECTION, PANITUMUMAB, 10 MG" 48261285_1 CDM 0636 RC 55513-0956-01 NDC J9303 HCPCS inpatient 40 UN 22898.59 14884.08 ANTHEM HMO ANTHEM HMO 999999999 13865.1 22211.63 "INJECTION, PANITUMUMAB, 10 MG" 48261285_1 CDM 0636 RC 55513-0956-01 NDC J9303 HCPCS inpatient 40 UN 22898.59 14884.08 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13865.1 22211.63 "INJECTION, PANITUMUMAB, 10 MG" 48261285_1 CDM 0636 RC 55513-0956-01 NDC J9303 HCPCS inpatient 40 UN 22898.59 14884.08 CIGNA - ALL PLANS CIGNA - ALL PLANS 15479.45 67.6 999999999 13865.1 22211.63 percent of total billed charges "INJECTION, PANITUMUMAB, 10 MG" 48261285_1 CDM 0636 RC 55513-0956-01 NDC J9303 HCPCS inpatient 40 UN 22898.59 14884.08 UHC - ALL PLANS UHC - ALL PLANS 999999999 13865.1 22211.63 PROTONIX 40 MG SUSPENSION 48261286_1 CDM 0250 RC 00008-0844-02 NDC inpatient 1 UN 63.39 41.2 AETNA AETNA 50.08 79 999999999 38.38 61.49 percent of total billed charges PROTONIX 40 MG SUSPENSION 48261286_1 CDM 0250 RC 00008-0844-02 NDC inpatient 1 UN 63.39 41.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.2 65 999999999 38.38 61.49 percent of total billed charges PROTONIX 40 MG SUSPENSION 48261286_1 CDM 0250 RC 00008-0844-02 NDC inpatient 1 UN 63.39 41.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.49 97 999999999 38.38 61.49 percent of total billed charges PROTONIX 40 MG SUSPENSION 48261286_1 CDM 0250 RC 00008-0844-02 NDC inpatient 1 UN 63.39 41.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.74 69 999999999 38.38 61.49 percent of total billed charges PROTONIX 40 MG SUSPENSION 48261286_1 CDM 0250 RC 00008-0844-02 NDC inpatient 1 UN 63.39 41.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.44 78 999999999 38.38 61.49 percent of total billed charges PROTONIX 40 MG SUSPENSION 48261286_1 CDM 0250 RC 00008-0844-02 NDC inpatient 1 UN 63.39 41.2 UMR - ALL PLANS UMR - ALL PLANS 44.37 70 999999999 38.38 61.49 percent of total billed charges PROTONIX 40 MG SUSPENSION 48261286_1 CDM 0250 RC 00008-0844-02 NDC inpatient 1 UN 63.39 41.2 SIHO - ALL PLANS SIHO - ALL PLANS 57.05 90 999999999 38.38 61.49 percent of total billed charges PROTONIX 40 MG SUSPENSION 48261286_1 CDM 0250 RC 00008-0844-02 NDC inpatient 1 UN 63.39 41.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.38 61.49 PROTONIX 40 MG SUSPENSION 48261286_1 CDM 0250 RC 00008-0844-02 NDC inpatient 1 UN 63.39 41.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.38 60.55 999999999 38.38 61.49 percent of total billed charges PROTONIX 40 MG SUSPENSION 48261286_1 CDM 0250 RC 00008-0844-02 NDC inpatient 1 UN 63.39 41.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.38 61.49 PROTONIX 40 MG SUSPENSION 48261286_1 CDM 0250 RC 00008-0844-02 NDC inpatient 1 UN 63.39 41.2 ANTHEM HMO ANTHEM HMO 999999999 38.38 61.49 PROTONIX 40 MG SUSPENSION 48261286_1 CDM 0250 RC 00008-0844-02 NDC inpatient 1 UN 63.39 41.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.38 61.49 PROTONIX 40 MG SUSPENSION 48261286_1 CDM 0250 RC 00008-0844-02 NDC inpatient 1 UN 63.39 41.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.85 67.6 999999999 38.38 61.49 percent of total billed charges PROTONIX 40 MG SUSPENSION 48261286_1 CDM 0250 RC 00008-0844-02 NDC inpatient 1 UN 63.39 41.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.38 61.49 PAROXETINE HCL 20 MG TABLET 48261291_1 CDM 0250 RC 68084-0045-01 NDC inpatient 1 UN 1.25 0.81 AETNA AETNA 0.99 79 999999999 0.76 1.21 percent of total billed charges PAROXETINE HCL 20 MG TABLET 48261291_1 CDM 0250 RC 68084-0045-01 NDC inpatient 1 UN 1.25 0.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.81 65 999999999 0.76 1.21 percent of total billed charges PAROXETINE HCL 20 MG TABLET 48261291_1 CDM 0250 RC 68084-0045-01 NDC inpatient 1 UN 1.25 0.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.21 97 999999999 0.76 1.21 percent of total billed charges PAROXETINE HCL 20 MG TABLET 48261291_1 CDM 0250 RC 68084-0045-01 NDC inpatient 1 UN 1.25 0.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.86 69 999999999 0.76 1.21 percent of total billed charges PAROXETINE HCL 20 MG TABLET 48261291_1 CDM 0250 RC 68084-0045-01 NDC inpatient 1 UN 1.25 0.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.98 78 999999999 0.76 1.21 percent of total billed charges PAROXETINE HCL 20 MG TABLET 48261291_1 CDM 0250 RC 68084-0045-01 NDC inpatient 1 UN 1.25 0.81 UMR - ALL PLANS UMR - ALL PLANS 0.88 70 999999999 0.76 1.21 percent of total billed charges PAROXETINE HCL 20 MG TABLET 48261291_1 CDM 0250 RC 68084-0045-01 NDC inpatient 1 UN 1.25 0.81 SIHO - ALL PLANS SIHO - ALL PLANS 1.13 90 999999999 0.76 1.21 percent of total billed charges PAROXETINE HCL 20 MG TABLET 48261291_1 CDM 0250 RC 68084-0045-01 NDC inpatient 1 UN 1.25 0.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.76 1.21 PAROXETINE HCL 20 MG TABLET 48261291_1 CDM 0250 RC 68084-0045-01 NDC inpatient 1 UN 1.25 0.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.76 60.55 999999999 0.76 1.21 percent of total billed charges PAROXETINE HCL 20 MG TABLET 48261291_1 CDM 0250 RC 68084-0045-01 NDC inpatient 1 UN 1.25 0.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.76 1.21 PAROXETINE HCL 20 MG TABLET 48261291_1 CDM 0250 RC 68084-0045-01 NDC inpatient 1 UN 1.25 0.81 ANTHEM HMO ANTHEM HMO 999999999 0.76 1.21 PAROXETINE HCL 20 MG TABLET 48261291_1 CDM 0250 RC 68084-0045-01 NDC inpatient 1 UN 1.25 0.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.76 1.21 PAROXETINE HCL 20 MG TABLET 48261291_1 CDM 0250 RC 68084-0045-01 NDC inpatient 1 UN 1.25 0.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.85 67.6 999999999 0.76 1.21 percent of total billed charges PAROXETINE HCL 20 MG TABLET 48261291_1 CDM 0250 RC 68084-0045-01 NDC inpatient 1 UN 1.25 0.81 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.76 1.21 "INJECTION, PEGFILGRASTIM, 6 MG" 48261293_1 CDM 0636 RC 55513-0190-01 NDC J2505 HCPCS inpatient 1 UN 16458.36 10697.93 AETNA AETNA 13002.1 79 999999999 9965.54 15964.61 percent of total billed charges "INJECTION, PEGFILGRASTIM, 6 MG" 48261293_1 CDM 0636 RC 55513-0190-01 NDC J2505 HCPCS inpatient 1 UN 16458.36 10697.93 SELF PAY DISCOUNT SELF PAY DISCOUNT 10697.93 65 999999999 9965.54 15964.61 percent of total billed charges "INJECTION, PEGFILGRASTIM, 6 MG" 48261293_1 CDM 0636 RC 55513-0190-01 NDC J2505 HCPCS inpatient 1 UN 16458.36 10697.93 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15964.61 97 999999999 9965.54 15964.61 percent of total billed charges "INJECTION, PEGFILGRASTIM, 6 MG" 48261293_1 CDM 0636 RC 55513-0190-01 NDC J2505 HCPCS inpatient 1 UN 16458.36 10697.93 ENCORE - ALL PLANS ENCORE - ALL PLANS 11356.27 69 999999999 9965.54 15964.61 percent of total billed charges "INJECTION, PEGFILGRASTIM, 6 MG" 48261293_1 CDM 0636 RC 55513-0190-01 NDC J2505 HCPCS inpatient 1 UN 16458.36 10697.93 HUMANA - ALL PLANS HUMANA - ALL PLANS 12837.52 78 999999999 9965.54 15964.61 percent of total billed charges "INJECTION, PEGFILGRASTIM, 6 MG" 48261293_1 CDM 0636 RC 55513-0190-01 NDC J2505 HCPCS inpatient 1 UN 16458.36 10697.93 UMR - ALL PLANS UMR - ALL PLANS 11520.85 70 999999999 9965.54 15964.61 percent of total billed charges "INJECTION, PEGFILGRASTIM, 6 MG" 48261293_1 CDM 0636 RC 55513-0190-01 NDC J2505 HCPCS inpatient 1 UN 16458.36 10697.93 SIHO - ALL PLANS SIHO - ALL PLANS 14812.52 90 999999999 9965.54 15964.61 percent of total billed charges "INJECTION, PEGFILGRASTIM, 6 MG" 48261293_1 CDM 0636 RC 55513-0190-01 NDC J2505 HCPCS inpatient 1 UN 16458.36 10697.93 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9965.54 15964.61 "INJECTION, PEGFILGRASTIM, 6 MG" 48261293_1 CDM 0636 RC 55513-0190-01 NDC J2505 HCPCS inpatient 1 UN 16458.36 10697.93 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9965.54 60.55 999999999 9965.54 15964.61 percent of total billed charges "INJECTION, PEGFILGRASTIM, 6 MG" 48261293_1 CDM 0636 RC 55513-0190-01 NDC J2505 HCPCS inpatient 1 UN 16458.36 10697.93 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9965.54 15964.61 "INJECTION, PEGFILGRASTIM, 6 MG" 48261293_1 CDM 0636 RC 55513-0190-01 NDC J2505 HCPCS inpatient 1 UN 16458.36 10697.93 ANTHEM HMO ANTHEM HMO 999999999 9965.54 15964.61 "INJECTION, PEGFILGRASTIM, 6 MG" 48261293_1 CDM 0636 RC 55513-0190-01 NDC J2505 HCPCS inpatient 1 UN 16458.36 10697.93 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9965.54 15964.61 "INJECTION, PEGFILGRASTIM, 6 MG" 48261293_1 CDM 0636 RC 55513-0190-01 NDC J2505 HCPCS inpatient 1 UN 16458.36 10697.93 CIGNA - ALL PLANS CIGNA - ALL PLANS 11125.85 67.6 999999999 9965.54 15964.61 percent of total billed charges "INJECTION, PEGFILGRASTIM, 6 MG" 48261293_1 CDM 0636 RC 55513-0190-01 NDC J2505 HCPCS inpatient 1 UN 16458.36 10697.93 UHC - ALL PLANS UHC - ALL PLANS 999999999 9965.54 15964.61 "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261294_1 CDM 0636 RC 00002-7623-01 NDC J9305 HCPCS inpatient 50 UN 17006.94 11054.51 AETNA AETNA 13435.48 79 999999999 10297.7 16496.73 percent of total billed charges "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261294_1 CDM 0636 RC 00002-7623-01 NDC J9305 HCPCS inpatient 50 UN 17006.94 11054.51 SELF PAY DISCOUNT SELF PAY DISCOUNT 11054.51 65 999999999 10297.7 16496.73 percent of total billed charges "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261294_1 CDM 0636 RC 00002-7623-01 NDC J9305 HCPCS inpatient 50 UN 17006.94 11054.51 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16496.73 97 999999999 10297.7 16496.73 percent of total billed charges "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261294_1 CDM 0636 RC 00002-7623-01 NDC J9305 HCPCS inpatient 50 UN 17006.94 11054.51 ENCORE - ALL PLANS ENCORE - ALL PLANS 11734.79 69 999999999 10297.7 16496.73 percent of total billed charges "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261294_1 CDM 0636 RC 00002-7623-01 NDC J9305 HCPCS inpatient 50 UN 17006.94 11054.51 HUMANA - ALL PLANS HUMANA - ALL PLANS 13265.41 78 999999999 10297.7 16496.73 percent of total billed charges "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261294_1 CDM 0636 RC 00002-7623-01 NDC J9305 HCPCS inpatient 50 UN 17006.94 11054.51 UMR - ALL PLANS UMR - ALL PLANS 11904.86 70 999999999 10297.7 16496.73 percent of total billed charges "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261294_1 CDM 0636 RC 00002-7623-01 NDC J9305 HCPCS inpatient 50 UN 17006.94 11054.51 SIHO - ALL PLANS SIHO - ALL PLANS 15306.25 90 999999999 10297.7 16496.73 percent of total billed charges "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261294_1 CDM 0636 RC 00002-7623-01 NDC J9305 HCPCS inpatient 50 UN 17006.94 11054.51 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10297.7 16496.73 "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261294_1 CDM 0636 RC 00002-7623-01 NDC J9305 HCPCS inpatient 50 UN 17006.94 11054.51 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10297.7 60.55 999999999 10297.7 16496.73 percent of total billed charges "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261294_1 CDM 0636 RC 00002-7623-01 NDC J9305 HCPCS inpatient 50 UN 17006.94 11054.51 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10297.7 16496.73 "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261294_1 CDM 0636 RC 00002-7623-01 NDC J9305 HCPCS inpatient 50 UN 17006.94 11054.51 ANTHEM HMO ANTHEM HMO 999999999 10297.7 16496.73 "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261294_1 CDM 0636 RC 00002-7623-01 NDC J9305 HCPCS inpatient 50 UN 17006.94 11054.51 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10297.7 16496.73 "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261294_1 CDM 0636 RC 00002-7623-01 NDC J9305 HCPCS inpatient 50 UN 17006.94 11054.51 CIGNA - ALL PLANS CIGNA - ALL PLANS 11496.69 67.6 999999999 10297.7 16496.73 percent of total billed charges "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261294_1 CDM 0636 RC 00002-7623-01 NDC J9305 HCPCS inpatient 50 UN 17006.94 11054.51 UHC - ALL PLANS UHC - ALL PLANS 999999999 10297.7 16496.73 "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261295_1 CDM 0636 RC 00002-7640-01 NDC J9305 HCPCS inpatient 10 UN 9032.6 5871.19 AETNA AETNA 7135.75 79 999999999 5469.24 8761.62 percent of total billed charges "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261295_1 CDM 0636 RC 00002-7640-01 NDC J9305 HCPCS inpatient 10 UN 9032.6 5871.19 SELF PAY DISCOUNT SELF PAY DISCOUNT 5871.19 65 999999999 5469.24 8761.62 percent of total billed charges "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261295_1 CDM 0636 RC 00002-7640-01 NDC J9305 HCPCS inpatient 10 UN 9032.6 5871.19 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8761.62 97 999999999 5469.24 8761.62 percent of total billed charges "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261295_1 CDM 0636 RC 00002-7640-01 NDC J9305 HCPCS inpatient 10 UN 9032.6 5871.19 ENCORE - ALL PLANS ENCORE - ALL PLANS 6232.49 69 999999999 5469.24 8761.62 percent of total billed charges "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261295_1 CDM 0636 RC 00002-7640-01 NDC J9305 HCPCS inpatient 10 UN 9032.6 5871.19 HUMANA - ALL PLANS HUMANA - ALL PLANS 7045.43 78 999999999 5469.24 8761.62 percent of total billed charges "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261295_1 CDM 0636 RC 00002-7640-01 NDC J9305 HCPCS inpatient 10 UN 9032.6 5871.19 UMR - ALL PLANS UMR - ALL PLANS 6322.82 70 999999999 5469.24 8761.62 percent of total billed charges "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261295_1 CDM 0636 RC 00002-7640-01 NDC J9305 HCPCS inpatient 10 UN 9032.6 5871.19 SIHO - ALL PLANS SIHO - ALL PLANS 8129.34 90 999999999 5469.24 8761.62 percent of total billed charges "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261295_1 CDM 0636 RC 00002-7640-01 NDC J9305 HCPCS inpatient 10 UN 9032.6 5871.19 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5469.24 8761.62 "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261295_1 CDM 0636 RC 00002-7640-01 NDC J9305 HCPCS inpatient 10 UN 9032.6 5871.19 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5469.24 60.55 999999999 5469.24 8761.62 percent of total billed charges "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261295_1 CDM 0636 RC 00002-7640-01 NDC J9305 HCPCS inpatient 10 UN 9032.6 5871.19 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5469.24 8761.62 "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261295_1 CDM 0636 RC 00002-7640-01 NDC J9305 HCPCS inpatient 10 UN 9032.6 5871.19 ANTHEM HMO ANTHEM HMO 999999999 5469.24 8761.62 "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261295_1 CDM 0636 RC 00002-7640-01 NDC J9305 HCPCS inpatient 10 UN 9032.6 5871.19 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5469.24 8761.62 "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261295_1 CDM 0636 RC 00002-7640-01 NDC J9305 HCPCS inpatient 10 UN 9032.6 5871.19 CIGNA - ALL PLANS CIGNA - ALL PLANS 6106.04 67.6 999999999 5469.24 8761.62 percent of total billed charges "INJECTION, PEMETREXED, NOT OTHERWISE SPECIFIED, 10 MG" 48261295_1 CDM 0636 RC 00002-7640-01 NDC J9305 HCPCS inpatient 10 UN 9032.6 5871.19 UHC - ALL PLANS UHC - ALL PLANS 999999999 5469.24 8761.62 "INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS" 48261296_1 CDM 0250 RC 60793-0701-10 NDC J0561 HCPCS inpatient 12 UN 430.19 279.62 AETNA AETNA 339.85 79 999999999 260.48 417.28 percent of total billed charges "INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS" 48261296_1 CDM 0250 RC 60793-0701-10 NDC J0561 HCPCS inpatient 12 UN 430.19 279.62 SELF PAY DISCOUNT SELF PAY DISCOUNT 279.62 65 999999999 260.48 417.28 percent of total billed charges "INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS" 48261296_1 CDM 0250 RC 60793-0701-10 NDC J0561 HCPCS inpatient 12 UN 430.19 279.62 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 417.28 97 999999999 260.48 417.28 percent of total billed charges "INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS" 48261296_1 CDM 0250 RC 60793-0701-10 NDC J0561 HCPCS inpatient 12 UN 430.19 279.62 ENCORE - ALL PLANS ENCORE - ALL PLANS 296.83 69 999999999 260.48 417.28 percent of total billed charges "INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS" 48261296_1 CDM 0250 RC 60793-0701-10 NDC J0561 HCPCS inpatient 12 UN 430.19 279.62 HUMANA - ALL PLANS HUMANA - ALL PLANS 335.55 78 999999999 260.48 417.28 percent of total billed charges "INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS" 48261296_1 CDM 0250 RC 60793-0701-10 NDC J0561 HCPCS inpatient 12 UN 430.19 279.62 UMR - ALL PLANS UMR - ALL PLANS 301.13 70 999999999 260.48 417.28 percent of total billed charges "INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS" 48261296_1 CDM 0250 RC 60793-0701-10 NDC J0561 HCPCS inpatient 12 UN 430.19 279.62 SIHO - ALL PLANS SIHO - ALL PLANS 387.17 90 999999999 260.48 417.28 percent of total billed charges "INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS" 48261296_1 CDM 0250 RC 60793-0701-10 NDC J0561 HCPCS inpatient 12 UN 430.19 279.62 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 260.48 417.28 "INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS" 48261296_1 CDM 0250 RC 60793-0701-10 NDC J0561 HCPCS inpatient 12 UN 430.19 279.62 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 260.48 60.55 999999999 260.48 417.28 percent of total billed charges "INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS" 48261296_1 CDM 0250 RC 60793-0701-10 NDC J0561 HCPCS inpatient 12 UN 430.19 279.62 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 260.48 417.28 "INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS" 48261296_1 CDM 0250 RC 60793-0701-10 NDC J0561 HCPCS inpatient 12 UN 430.19 279.62 ANTHEM HMO ANTHEM HMO 999999999 260.48 417.28 "INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS" 48261296_1 CDM 0250 RC 60793-0701-10 NDC J0561 HCPCS inpatient 12 UN 430.19 279.62 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 260.48 417.28 "INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS" 48261296_1 CDM 0250 RC 60793-0701-10 NDC J0561 HCPCS inpatient 12 UN 430.19 279.62 CIGNA - ALL PLANS CIGNA - ALL PLANS 290.81 67.6 999999999 260.48 417.28 percent of total billed charges "INJECTION, PENICILLIN G BENZATHINE, 100,000 UNITS" 48261296_1 CDM 0250 RC 60793-0701-10 NDC J0561 HCPCS inpatient 12 UN 430.19 279.62 UHC - ALL PLANS UHC - ALL PLANS 999999999 260.48 417.28 PFIZERPEN 5 MILLION UNIT VIAL 48261297_1 CDM 0250 RC 00049-0520-22 NDC inpatient 1 UN 46.27 30.08 AETNA AETNA 36.55 79 999999999 28.02 44.88 percent of total billed charges PFIZERPEN 5 MILLION UNIT VIAL 48261297_1 CDM 0250 RC 00049-0520-22 NDC inpatient 1 UN 46.27 30.08 SELF PAY DISCOUNT SELF PAY DISCOUNT 30.08 65 999999999 28.02 44.88 percent of total billed charges PFIZERPEN 5 MILLION UNIT VIAL 48261297_1 CDM 0250 RC 00049-0520-22 NDC inpatient 1 UN 46.27 30.08 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 44.88 97 999999999 28.02 44.88 percent of total billed charges PFIZERPEN 5 MILLION UNIT VIAL 48261297_1 CDM 0250 RC 00049-0520-22 NDC inpatient 1 UN 46.27 30.08 ENCORE - ALL PLANS ENCORE - ALL PLANS 31.93 69 999999999 28.02 44.88 percent of total billed charges PFIZERPEN 5 MILLION UNIT VIAL 48261297_1 CDM 0250 RC 00049-0520-22 NDC inpatient 1 UN 46.27 30.08 HUMANA - ALL PLANS HUMANA - ALL PLANS 36.09 78 999999999 28.02 44.88 percent of total billed charges PFIZERPEN 5 MILLION UNIT VIAL 48261297_1 CDM 0250 RC 00049-0520-22 NDC inpatient 1 UN 46.27 30.08 UMR - ALL PLANS UMR - ALL PLANS 32.39 70 999999999 28.02 44.88 percent of total billed charges PFIZERPEN 5 MILLION UNIT VIAL 48261297_1 CDM 0250 RC 00049-0520-22 NDC inpatient 1 UN 46.27 30.08 SIHO - ALL PLANS SIHO - ALL PLANS 41.64 90 999999999 28.02 44.88 percent of total billed charges PFIZERPEN 5 MILLION UNIT VIAL 48261297_1 CDM 0250 RC 00049-0520-22 NDC inpatient 1 UN 46.27 30.08 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 28.02 44.88 PFIZERPEN 5 MILLION UNIT VIAL 48261297_1 CDM 0250 RC 00049-0520-22 NDC inpatient 1 UN 46.27 30.08 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 28.02 60.55 999999999 28.02 44.88 percent of total billed charges PFIZERPEN 5 MILLION UNIT VIAL 48261297_1 CDM 0250 RC 00049-0520-22 NDC inpatient 1 UN 46.27 30.08 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 28.02 44.88 PFIZERPEN 5 MILLION UNIT VIAL 48261297_1 CDM 0250 RC 00049-0520-22 NDC inpatient 1 UN 46.27 30.08 ANTHEM HMO ANTHEM HMO 999999999 28.02 44.88 PFIZERPEN 5 MILLION UNIT VIAL 48261297_1 CDM 0250 RC 00049-0520-22 NDC inpatient 1 UN 46.27 30.08 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 28.02 44.88 PFIZERPEN 5 MILLION UNIT VIAL 48261297_1 CDM 0250 RC 00049-0520-22 NDC inpatient 1 UN 46.27 30.08 CIGNA - ALL PLANS CIGNA - ALL PLANS 31.28 67.6 999999999 28.02 44.88 percent of total billed charges PFIZERPEN 5 MILLION UNIT VIAL 48261297_1 CDM 0250 RC 00049-0520-22 NDC inpatient 1 UN 46.27 30.08 UHC - ALL PLANS UHC - ALL PLANS 999999999 28.02 44.88 PENTOXIFYLLINE ER 400 MG TAB 48261301_1 CDM 0250 RC 00904-5448-61 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges PENTOXIFYLLINE ER 400 MG TAB 48261301_1 CDM 0250 RC 00904-5448-61 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges PENTOXIFYLLINE ER 400 MG TAB 48261301_1 CDM 0250 RC 00904-5448-61 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges PENTOXIFYLLINE ER 400 MG TAB 48261301_1 CDM 0250 RC 00904-5448-61 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges PENTOXIFYLLINE ER 400 MG TAB 48261301_1 CDM 0250 RC 00904-5448-61 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges PENTOXIFYLLINE ER 400 MG TAB 48261301_1 CDM 0250 RC 00904-5448-61 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges PENTOXIFYLLINE ER 400 MG TAB 48261301_1 CDM 0250 RC 00904-5448-61 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges PENTOXIFYLLINE ER 400 MG TAB 48261301_1 CDM 0250 RC 00904-5448-61 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 PENTOXIFYLLINE ER 400 MG TAB 48261301_1 CDM 0250 RC 00904-5448-61 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges PENTOXIFYLLINE ER 400 MG TAB 48261301_1 CDM 0250 RC 00904-5448-61 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 PENTOXIFYLLINE ER 400 MG TAB 48261301_1 CDM 0250 RC 00904-5448-61 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 PENTOXIFYLLINE ER 400 MG TAB 48261301_1 CDM 0250 RC 00904-5448-61 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 PENTOXIFYLLINE ER 400 MG TAB 48261301_1 CDM 0250 RC 00904-5448-61 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges PENTOXIFYLLINE ER 400 MG TAB 48261301_1 CDM 0250 RC 00904-5448-61 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, PERTUZUMAB, 1 MG" 48261303_1 CDM 0636 RC 50242-0145-01 NDC J9306 HCPCS inpatient 420 UN 4653.35 3024.68 AETNA AETNA 3676.15 79 999999999 2817.6 4513.75 percent of total billed charges "INJECTION, PERTUZUMAB, 1 MG" 48261303_1 CDM 0636 RC 50242-0145-01 NDC J9306 HCPCS inpatient 420 UN 4653.35 3024.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 3024.68 65 999999999 2817.6 4513.75 percent of total billed charges "INJECTION, PERTUZUMAB, 1 MG" 48261303_1 CDM 0636 RC 50242-0145-01 NDC J9306 HCPCS inpatient 420 UN 4653.35 3024.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4513.75 97 999999999 2817.6 4513.75 percent of total billed charges "INJECTION, PERTUZUMAB, 1 MG" 48261303_1 CDM 0636 RC 50242-0145-01 NDC J9306 HCPCS inpatient 420 UN 4653.35 3024.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 3629.61 78 999999999 2817.6 4513.75 percent of total billed charges "INJECTION, PERTUZUMAB, 1 MG" 48261303_1 CDM 0636 RC 50242-0145-01 NDC J9306 HCPCS inpatient 420 UN 4653.35 3024.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 3210.81 69 999999999 2817.6 4513.75 percent of total billed charges "INJECTION, PERTUZUMAB, 1 MG" 48261303_1 CDM 0636 RC 50242-0145-01 NDC J9306 HCPCS inpatient 420 UN 4653.35 3024.68 UMR - ALL PLANS UMR - ALL PLANS 3257.35 70 999999999 2817.6 4513.75 percent of total billed charges "INJECTION, PERTUZUMAB, 1 MG" 48261303_1 CDM 0636 RC 50242-0145-01 NDC J9306 HCPCS inpatient 420 UN 4653.35 3024.68 SIHO - ALL PLANS SIHO - ALL PLANS 4188.02 90 999999999 2817.6 4513.75 percent of total billed charges "INJECTION, PERTUZUMAB, 1 MG" 48261303_1 CDM 0636 RC 50242-0145-01 NDC J9306 HCPCS inpatient 420 UN 4653.35 3024.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2817.6 4513.75 "INJECTION, PERTUZUMAB, 1 MG" 48261303_1 CDM 0636 RC 50242-0145-01 NDC J9306 HCPCS inpatient 420 UN 4653.35 3024.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2817.6 60.55 999999999 2817.6 4513.75 percent of total billed charges "INJECTION, PERTUZUMAB, 1 MG" 48261303_1 CDM 0636 RC 50242-0145-01 NDC J9306 HCPCS inpatient 420 UN 4653.35 3024.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2817.6 4513.75 "INJECTION, PERTUZUMAB, 1 MG" 48261303_1 CDM 0636 RC 50242-0145-01 NDC J9306 HCPCS inpatient 420 UN 4653.35 3024.68 ANTHEM HMO ANTHEM HMO 999999999 2817.6 4513.75 "INJECTION, PERTUZUMAB, 1 MG" 48261303_1 CDM 0636 RC 50242-0145-01 NDC J9306 HCPCS inpatient 420 UN 4653.35 3024.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2817.6 4513.75 "INJECTION, PERTUZUMAB, 1 MG" 48261303_1 CDM 0636 RC 50242-0145-01 NDC J9306 HCPCS inpatient 420 UN 4653.35 3024.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 3145.66 67.6 999999999 2817.6 4513.75 percent of total billed charges "INJECTION, PERTUZUMAB, 1 MG" 48261303_1 CDM 0636 RC 50242-0145-01 NDC J9306 HCPCS inpatient 420 UN 4653.35 3024.68 UHC - ALL PLANS UHC - ALL PLANS 999999999 2817.6 4513.75 PHENOBARBITAL 65 MG/ML VIAL 48261309_1 CDM 0250 RC 00641-0476-25 NDC inpatient 1 UN 96.56 62.76 AETNA AETNA 76.28 79 999999999 58.47 93.66 percent of total billed charges PHENOBARBITAL 65 MG/ML VIAL 48261309_1 CDM 0250 RC 00641-0476-25 NDC inpatient 1 UN 96.56 62.76 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.76 65 999999999 58.47 93.66 percent of total billed charges PHENOBARBITAL 65 MG/ML VIAL 48261309_1 CDM 0250 RC 00641-0476-25 NDC inpatient 1 UN 96.56 62.76 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.66 97 999999999 58.47 93.66 percent of total billed charges PHENOBARBITAL 65 MG/ML VIAL 48261309_1 CDM 0250 RC 00641-0476-25 NDC inpatient 1 UN 96.56 62.76 HUMANA - ALL PLANS HUMANA - ALL PLANS 75.32 78 999999999 58.47 93.66 percent of total billed charges PHENOBARBITAL 65 MG/ML VIAL 48261309_1 CDM 0250 RC 00641-0476-25 NDC inpatient 1 UN 96.56 62.76 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.63 69 999999999 58.47 93.66 percent of total billed charges PHENOBARBITAL 65 MG/ML VIAL 48261309_1 CDM 0250 RC 00641-0476-25 NDC inpatient 1 UN 96.56 62.76 UMR - ALL PLANS UMR - ALL PLANS 67.59 70 999999999 58.47 93.66 percent of total billed charges PHENOBARBITAL 65 MG/ML VIAL 48261309_1 CDM 0250 RC 00641-0476-25 NDC inpatient 1 UN 96.56 62.76 SIHO - ALL PLANS SIHO - ALL PLANS 86.9 90 999999999 58.47 93.66 percent of total billed charges PHENOBARBITAL 65 MG/ML VIAL 48261309_1 CDM 0250 RC 00641-0476-25 NDC inpatient 1 UN 96.56 62.76 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.47 93.66 PHENOBARBITAL 65 MG/ML VIAL 48261309_1 CDM 0250 RC 00641-0476-25 NDC inpatient 1 UN 96.56 62.76 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.47 60.55 999999999 58.47 93.66 percent of total billed charges PHENOBARBITAL 65 MG/ML VIAL 48261309_1 CDM 0250 RC 00641-0476-25 NDC inpatient 1 UN 96.56 62.76 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.47 93.66 PHENOBARBITAL 65 MG/ML VIAL 48261309_1 CDM 0250 RC 00641-0476-25 NDC inpatient 1 UN 96.56 62.76 ANTHEM HMO ANTHEM HMO 999999999 58.47 93.66 PHENOBARBITAL 65 MG/ML VIAL 48261309_1 CDM 0250 RC 00641-0476-25 NDC inpatient 1 UN 96.56 62.76 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.47 93.66 PHENOBARBITAL 65 MG/ML VIAL 48261309_1 CDM 0250 RC 00641-0476-25 NDC inpatient 1 UN 96.56 62.76 CIGNA - ALL PLANS CIGNA - ALL PLANS 65.27 67.6 999999999 58.47 93.66 percent of total billed charges PHENOBARBITAL 65 MG/ML VIAL 48261309_1 CDM 0250 RC 00641-0476-25 NDC inpatient 1 UN 96.56 62.76 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.47 93.66 "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 48261313_1 CDM 0250 RC 00641-6142-25 NDC J2370 HCPCS inpatient 1 UN 34.06 22.14 AETNA AETNA 26.91 79 999999999 20.62 33.04 percent of total billed charges "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 48261313_1 CDM 0250 RC 00641-6142-25 NDC J2370 HCPCS inpatient 1 UN 34.06 22.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.14 65 999999999 20.62 33.04 percent of total billed charges "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 48261313_1 CDM 0250 RC 00641-6142-25 NDC J2370 HCPCS inpatient 1 UN 34.06 22.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33.04 97 999999999 20.62 33.04 percent of total billed charges "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 48261313_1 CDM 0250 RC 00641-6142-25 NDC J2370 HCPCS inpatient 1 UN 34.06 22.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 26.57 78 999999999 20.62 33.04 percent of total billed charges "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 48261313_1 CDM 0250 RC 00641-6142-25 NDC J2370 HCPCS inpatient 1 UN 34.06 22.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 23.5 69 999999999 20.62 33.04 percent of total billed charges "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 48261313_1 CDM 0250 RC 00641-6142-25 NDC J2370 HCPCS inpatient 1 UN 34.06 22.14 UMR - ALL PLANS UMR - ALL PLANS 23.84 70 999999999 20.62 33.04 percent of total billed charges "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 48261313_1 CDM 0250 RC 00641-6142-25 NDC J2370 HCPCS inpatient 1 UN 34.06 22.14 SIHO - ALL PLANS SIHO - ALL PLANS 30.65 90 999999999 20.62 33.04 percent of total billed charges "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 48261313_1 CDM 0250 RC 00641-6142-25 NDC J2370 HCPCS inpatient 1 UN 34.06 22.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.62 33.04 "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 48261313_1 CDM 0250 RC 00641-6142-25 NDC J2370 HCPCS inpatient 1 UN 34.06 22.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.62 60.55 999999999 20.62 33.04 percent of total billed charges "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 48261313_1 CDM 0250 RC 00641-6142-25 NDC J2370 HCPCS inpatient 1 UN 34.06 22.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.62 33.04 "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 48261313_1 CDM 0250 RC 00641-6142-25 NDC J2370 HCPCS inpatient 1 UN 34.06 22.14 ANTHEM HMO ANTHEM HMO 999999999 20.62 33.04 "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 48261313_1 CDM 0250 RC 00641-6142-25 NDC J2370 HCPCS inpatient 1 UN 34.06 22.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.62 33.04 "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 48261313_1 CDM 0250 RC 00641-6142-25 NDC J2370 HCPCS inpatient 1 UN 34.06 22.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 23.02 67.6 999999999 20.62 33.04 percent of total billed charges "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 48261313_1 CDM 0250 RC 00641-6142-25 NDC J2370 HCPCS inpatient 1 UN 34.06 22.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.62 33.04 DILANTIN 100 MG CAPSULE 48261318_1 CDM 0250 RC 00071-0369-40 NDC inpatient 1 UN 6.36 4.13 AETNA AETNA 5.02 79 999999999 3.85 6.17 percent of total billed charges DILANTIN 100 MG CAPSULE 48261318_1 CDM 0250 RC 00071-0369-40 NDC inpatient 1 UN 6.36 4.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.13 65 999999999 3.85 6.17 percent of total billed charges DILANTIN 100 MG CAPSULE 48261318_1 CDM 0250 RC 00071-0369-40 NDC inpatient 1 UN 6.36 4.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.17 97 999999999 3.85 6.17 percent of total billed charges DILANTIN 100 MG CAPSULE 48261318_1 CDM 0250 RC 00071-0369-40 NDC inpatient 1 UN 6.36 4.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.96 78 999999999 3.85 6.17 percent of total billed charges DILANTIN 100 MG CAPSULE 48261318_1 CDM 0250 RC 00071-0369-40 NDC inpatient 1 UN 6.36 4.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.39 69 999999999 3.85 6.17 percent of total billed charges DILANTIN 100 MG CAPSULE 48261318_1 CDM 0250 RC 00071-0369-40 NDC inpatient 1 UN 6.36 4.13 UMR - ALL PLANS UMR - ALL PLANS 4.45 70 999999999 3.85 6.17 percent of total billed charges DILANTIN 100 MG CAPSULE 48261318_1 CDM 0250 RC 00071-0369-40 NDC inpatient 1 UN 6.36 4.13 SIHO - ALL PLANS SIHO - ALL PLANS 5.72 90 999999999 3.85 6.17 percent of total billed charges DILANTIN 100 MG CAPSULE 48261318_1 CDM 0250 RC 00071-0369-40 NDC inpatient 1 UN 6.36 4.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.85 6.17 DILANTIN 100 MG CAPSULE 48261318_1 CDM 0250 RC 00071-0369-40 NDC inpatient 1 UN 6.36 4.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.85 60.55 999999999 3.85 6.17 percent of total billed charges DILANTIN 100 MG CAPSULE 48261318_1 CDM 0250 RC 00071-0369-40 NDC inpatient 1 UN 6.36 4.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.85 6.17 DILANTIN 100 MG CAPSULE 48261318_1 CDM 0250 RC 00071-0369-40 NDC inpatient 1 UN 6.36 4.13 ANTHEM HMO ANTHEM HMO 999999999 3.85 6.17 DILANTIN 100 MG CAPSULE 48261318_1 CDM 0250 RC 00071-0369-40 NDC inpatient 1 UN 6.36 4.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.85 6.17 DILANTIN 100 MG CAPSULE 48261318_1 CDM 0250 RC 00071-0369-40 NDC inpatient 1 UN 6.36 4.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.3 67.6 999999999 3.85 6.17 percent of total billed charges DILANTIN 100 MG CAPSULE 48261318_1 CDM 0250 RC 00071-0369-40 NDC inpatient 1 UN 6.36 4.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.85 6.17 00071-2214-20 - phenytoin 125 mg/5 mL Oral Susp [JOHN] 48261323_1 CDM 0250 RC 00071-2214-20 NDC inpatient 1 UN 12.74 8.28 AETNA AETNA 10.06 79 999999999 7.71 12.36 percent of total billed charges 00071-2214-20 - phenytoin 125 mg/5 mL Oral Susp [JOHN] 48261323_1 CDM 0250 RC 00071-2214-20 NDC inpatient 1 UN 12.74 8.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.28 65 999999999 7.71 12.36 percent of total billed charges 00071-2214-20 - phenytoin 125 mg/5 mL Oral Susp [JOHN] 48261323_1 CDM 0250 RC 00071-2214-20 NDC inpatient 1 UN 12.74 8.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.36 97 999999999 7.71 12.36 percent of total billed charges 00071-2214-20 - phenytoin 125 mg/5 mL Oral Susp [JOHN] 48261323_1 CDM 0250 RC 00071-2214-20 NDC inpatient 1 UN 12.74 8.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.94 78 999999999 7.71 12.36 percent of total billed charges 00071-2214-20 - phenytoin 125 mg/5 mL Oral Susp [JOHN] 48261323_1 CDM 0250 RC 00071-2214-20 NDC inpatient 1 UN 12.74 8.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.79 69 999999999 7.71 12.36 percent of total billed charges 00071-2214-20 - phenytoin 125 mg/5 mL Oral Susp [JOHN] 48261323_1 CDM 0250 RC 00071-2214-20 NDC inpatient 1 UN 12.74 8.28 UMR - ALL PLANS UMR - ALL PLANS 8.92 70 999999999 7.71 12.36 percent of total billed charges 00071-2214-20 - phenytoin 125 mg/5 mL Oral Susp [JOHN] 48261323_1 CDM 0250 RC 00071-2214-20 NDC inpatient 1 UN 12.74 8.28 SIHO - ALL PLANS SIHO - ALL PLANS 11.47 90 999999999 7.71 12.36 percent of total billed charges 00071-2214-20 - phenytoin 125 mg/5 mL Oral Susp [JOHN] 48261323_1 CDM 0250 RC 00071-2214-20 NDC inpatient 1 UN 12.74 8.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.71 12.36 00071-2214-20 - phenytoin 125 mg/5 mL Oral Susp [JOHN] 48261323_1 CDM 0250 RC 00071-2214-20 NDC inpatient 1 UN 12.74 8.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.71 60.55 999999999 7.71 12.36 percent of total billed charges 00071-2214-20 - phenytoin 125 mg/5 mL Oral Susp [JOHN] 48261323_1 CDM 0250 RC 00071-2214-20 NDC inpatient 1 UN 12.74 8.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.71 12.36 00071-2214-20 - phenytoin 125 mg/5 mL Oral Susp [JOHN] 48261323_1 CDM 0250 RC 00071-2214-20 NDC inpatient 1 UN 12.74 8.28 ANTHEM HMO ANTHEM HMO 999999999 7.71 12.36 00071-2214-20 - phenytoin 125 mg/5 mL Oral Susp [JOHN] 48261323_1 CDM 0250 RC 00071-2214-20 NDC inpatient 1 UN 12.74 8.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.71 12.36 00071-2214-20 - phenytoin 125 mg/5 mL Oral Susp [JOHN] 48261323_1 CDM 0250 RC 00071-2214-20 NDC inpatient 1 UN 12.74 8.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.61 67.6 999999999 7.71 12.36 percent of total billed charges 00071-2214-20 - phenytoin 125 mg/5 mL Oral Susp [JOHN] 48261323_1 CDM 0250 RC 00071-2214-20 NDC inpatient 1 UN 12.74 8.28 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.71 12.36 PHYTONADIONE 1 MG/0.5 ML SYR 48261325_1 CDM 0250 RC 76329-1240-01 NDC inpatient 1 UN 112.66 73.23 AETNA AETNA 89 79 999999999 68.22 109.28 percent of total billed charges PHYTONADIONE 1 MG/0.5 ML SYR 48261325_1 CDM 0250 RC 76329-1240-01 NDC inpatient 1 UN 112.66 73.23 SELF PAY DISCOUNT SELF PAY DISCOUNT 73.23 65 999999999 68.22 109.28 percent of total billed charges PHYTONADIONE 1 MG/0.5 ML SYR 48261325_1 CDM 0250 RC 76329-1240-01 NDC inpatient 1 UN 112.66 73.23 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 109.28 97 999999999 68.22 109.28 percent of total billed charges PHYTONADIONE 1 MG/0.5 ML SYR 48261325_1 CDM 0250 RC 76329-1240-01 NDC inpatient 1 UN 112.66 73.23 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.87 78 999999999 68.22 109.28 percent of total billed charges PHYTONADIONE 1 MG/0.5 ML SYR 48261325_1 CDM 0250 RC 76329-1240-01 NDC inpatient 1 UN 112.66 73.23 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.74 69 999999999 68.22 109.28 percent of total billed charges PHYTONADIONE 1 MG/0.5 ML SYR 48261325_1 CDM 0250 RC 76329-1240-01 NDC inpatient 1 UN 112.66 73.23 UMR - ALL PLANS UMR - ALL PLANS 78.86 70 999999999 68.22 109.28 percent of total billed charges PHYTONADIONE 1 MG/0.5 ML SYR 48261325_1 CDM 0250 RC 76329-1240-01 NDC inpatient 1 UN 112.66 73.23 SIHO - ALL PLANS SIHO - ALL PLANS 101.39 90 999999999 68.22 109.28 percent of total billed charges PHYTONADIONE 1 MG/0.5 ML SYR 48261325_1 CDM 0250 RC 76329-1240-01 NDC inpatient 1 UN 112.66 73.23 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 68.22 109.28 PHYTONADIONE 1 MG/0.5 ML SYR 48261325_1 CDM 0250 RC 76329-1240-01 NDC inpatient 1 UN 112.66 73.23 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 68.22 60.55 999999999 68.22 109.28 percent of total billed charges PHYTONADIONE 1 MG/0.5 ML SYR 48261325_1 CDM 0250 RC 76329-1240-01 NDC inpatient 1 UN 112.66 73.23 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 68.22 109.28 PHYTONADIONE 1 MG/0.5 ML SYR 48261325_1 CDM 0250 RC 76329-1240-01 NDC inpatient 1 UN 112.66 73.23 ANTHEM HMO ANTHEM HMO 999999999 68.22 109.28 PHYTONADIONE 1 MG/0.5 ML SYR 48261325_1 CDM 0250 RC 76329-1240-01 NDC inpatient 1 UN 112.66 73.23 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 68.22 109.28 PHYTONADIONE 1 MG/0.5 ML SYR 48261325_1 CDM 0250 RC 76329-1240-01 NDC inpatient 1 UN 112.66 73.23 CIGNA - ALL PLANS CIGNA - ALL PLANS 76.16 67.6 999999999 68.22 109.28 percent of total billed charges PHYTONADIONE 1 MG/0.5 ML SYR 48261325_1 CDM 0250 RC 76329-1240-01 NDC inpatient 1 UN 112.66 73.23 UHC - ALL PLANS UHC - ALL PLANS 999999999 68.22 109.28 VITAMIN K-1 10 MG/ML AMPUL 48261326_1 CDM 0250 RC 00409-9158-01 NDC inpatient 1 UN 135.77 88.25 AETNA AETNA 107.26 79 999999999 82.21 131.7 percent of total billed charges VITAMIN K-1 10 MG/ML AMPUL 48261326_1 CDM 0250 RC 00409-9158-01 NDC inpatient 1 UN 135.77 88.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.25 65 999999999 82.21 131.7 percent of total billed charges VITAMIN K-1 10 MG/ML AMPUL 48261326_1 CDM 0250 RC 00409-9158-01 NDC inpatient 1 UN 135.77 88.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.7 97 999999999 82.21 131.7 percent of total billed charges VITAMIN K-1 10 MG/ML AMPUL 48261326_1 CDM 0250 RC 00409-9158-01 NDC inpatient 1 UN 135.77 88.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 105.9 78 999999999 82.21 131.7 percent of total billed charges VITAMIN K-1 10 MG/ML AMPUL 48261326_1 CDM 0250 RC 00409-9158-01 NDC inpatient 1 UN 135.77 88.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.68 69 999999999 82.21 131.7 percent of total billed charges VITAMIN K-1 10 MG/ML AMPUL 48261326_1 CDM 0250 RC 00409-9158-01 NDC inpatient 1 UN 135.77 88.25 UMR - ALL PLANS UMR - ALL PLANS 95.04 70 999999999 82.21 131.7 percent of total billed charges VITAMIN K-1 10 MG/ML AMPUL 48261326_1 CDM 0250 RC 00409-9158-01 NDC inpatient 1 UN 135.77 88.25 SIHO - ALL PLANS SIHO - ALL PLANS 122.19 90 999999999 82.21 131.7 percent of total billed charges VITAMIN K-1 10 MG/ML AMPUL 48261326_1 CDM 0250 RC 00409-9158-01 NDC inpatient 1 UN 135.77 88.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.21 60.55 999999999 82.21 131.7 percent of total billed charges VITAMIN K-1 10 MG/ML AMPUL 48261326_1 CDM 0250 RC 00409-9158-01 NDC inpatient 1 UN 135.77 88.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.21 131.7 VITAMIN K-1 10 MG/ML AMPUL 48261326_1 CDM 0250 RC 00409-9158-01 NDC inpatient 1 UN 135.77 88.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.21 131.7 VITAMIN K-1 10 MG/ML AMPUL 48261326_1 CDM 0250 RC 00409-9158-01 NDC inpatient 1 UN 135.77 88.25 ANTHEM HMO ANTHEM HMO 999999999 82.21 131.7 VITAMIN K-1 10 MG/ML AMPUL 48261326_1 CDM 0250 RC 00409-9158-01 NDC inpatient 1 UN 135.77 88.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.21 131.7 VITAMIN K-1 10 MG/ML AMPUL 48261326_1 CDM 0250 RC 00409-9158-01 NDC inpatient 1 UN 135.77 88.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.78 67.6 999999999 82.21 131.7 percent of total billed charges VITAMIN K-1 10 MG/ML AMPUL 48261326_1 CDM 0250 RC 00409-9158-01 NDC inpatient 1 UN 135.77 88.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.21 131.7 MEPHYTON 5 MG TABLET 48261327_1 CDM 0250 RC 00187-1704-05 NDC inpatient 1 UN 131.65 85.57 AETNA AETNA 104 79 999999999 79.71 127.7 percent of total billed charges MEPHYTON 5 MG TABLET 48261327_1 CDM 0250 RC 00187-1704-05 NDC inpatient 1 UN 131.65 85.57 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.57 65 999999999 79.71 127.7 percent of total billed charges MEPHYTON 5 MG TABLET 48261327_1 CDM 0250 RC 00187-1704-05 NDC inpatient 1 UN 131.65 85.57 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.7 97 999999999 79.71 127.7 percent of total billed charges MEPHYTON 5 MG TABLET 48261327_1 CDM 0250 RC 00187-1704-05 NDC inpatient 1 UN 131.65 85.57 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.69 78 999999999 79.71 127.7 percent of total billed charges MEPHYTON 5 MG TABLET 48261327_1 CDM 0250 RC 00187-1704-05 NDC inpatient 1 UN 131.65 85.57 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.84 69 999999999 79.71 127.7 percent of total billed charges MEPHYTON 5 MG TABLET 48261327_1 CDM 0250 RC 00187-1704-05 NDC inpatient 1 UN 131.65 85.57 UMR - ALL PLANS UMR - ALL PLANS 92.16 70 999999999 79.71 127.7 percent of total billed charges MEPHYTON 5 MG TABLET 48261327_1 CDM 0250 RC 00187-1704-05 NDC inpatient 1 UN 131.65 85.57 SIHO - ALL PLANS SIHO - ALL PLANS 118.49 90 999999999 79.71 127.7 percent of total billed charges MEPHYTON 5 MG TABLET 48261327_1 CDM 0250 RC 00187-1704-05 NDC inpatient 1 UN 131.65 85.57 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.71 60.55 999999999 79.71 127.7 percent of total billed charges MEPHYTON 5 MG TABLET 48261327_1 CDM 0250 RC 00187-1704-05 NDC inpatient 1 UN 131.65 85.57 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.71 127.7 MEPHYTON 5 MG TABLET 48261327_1 CDM 0250 RC 00187-1704-05 NDC inpatient 1 UN 131.65 85.57 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.71 127.7 MEPHYTON 5 MG TABLET 48261327_1 CDM 0250 RC 00187-1704-05 NDC inpatient 1 UN 131.65 85.57 ANTHEM HMO ANTHEM HMO 999999999 79.71 127.7 MEPHYTON 5 MG TABLET 48261327_1 CDM 0250 RC 00187-1704-05 NDC inpatient 1 UN 131.65 85.57 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.71 127.7 MEPHYTON 5 MG TABLET 48261327_1 CDM 0250 RC 00187-1704-05 NDC inpatient 1 UN 131.65 85.57 CIGNA - ALL PLANS CIGNA - ALL PLANS 89 67.6 999999999 79.71 127.7 percent of total billed charges MEPHYTON 5 MG TABLET 48261327_1 CDM 0250 RC 00187-1704-05 NDC inpatient 1 UN 131.65 85.57 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.71 127.7 62175-0446-01 - polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [JOHN] 48261342_1 CDM 0250 RC 62175-0446-01 NDC inpatient 1 UN 35.53 23.09 AETNA AETNA 28.07 79 999999999 21.51 34.46 percent of total billed charges 62175-0446-01 - polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [JOHN] 48261342_1 CDM 0250 RC 62175-0446-01 NDC inpatient 1 UN 35.53 23.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 23.09 65 999999999 21.51 34.46 percent of total billed charges 62175-0446-01 - polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [JOHN] 48261342_1 CDM 0250 RC 62175-0446-01 NDC inpatient 1 UN 35.53 23.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34.46 97 999999999 21.51 34.46 percent of total billed charges 62175-0446-01 - polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [JOHN] 48261342_1 CDM 0250 RC 62175-0446-01 NDC inpatient 1 UN 35.53 23.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.71 78 999999999 21.51 34.46 percent of total billed charges 62175-0446-01 - polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [JOHN] 48261342_1 CDM 0250 RC 62175-0446-01 NDC inpatient 1 UN 35.53 23.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.52 69 999999999 21.51 34.46 percent of total billed charges 62175-0446-01 - polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [JOHN] 48261342_1 CDM 0250 RC 62175-0446-01 NDC inpatient 1 UN 35.53 23.09 UMR - ALL PLANS UMR - ALL PLANS 24.87 70 999999999 21.51 34.46 percent of total billed charges 62175-0446-01 - polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [JOHN] 48261342_1 CDM 0250 RC 62175-0446-01 NDC inpatient 1 UN 35.53 23.09 SIHO - ALL PLANS SIHO - ALL PLANS 31.98 90 999999999 21.51 34.46 percent of total billed charges 62175-0446-01 - polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [JOHN] 48261342_1 CDM 0250 RC 62175-0446-01 NDC inpatient 1 UN 35.53 23.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.51 60.55 999999999 21.51 34.46 percent of total billed charges 62175-0446-01 - polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [JOHN] 48261342_1 CDM 0250 RC 62175-0446-01 NDC inpatient 1 UN 35.53 23.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.51 34.46 62175-0446-01 - polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [JOHN] 48261342_1 CDM 0250 RC 62175-0446-01 NDC inpatient 1 UN 35.53 23.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.51 34.46 62175-0446-01 - polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [JOHN] 48261342_1 CDM 0250 RC 62175-0446-01 NDC inpatient 1 UN 35.53 23.09 ANTHEM HMO ANTHEM HMO 999999999 21.51 34.46 62175-0446-01 - polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [JOHN] 48261342_1 CDM 0250 RC 62175-0446-01 NDC inpatient 1 UN 35.53 23.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.51 34.46 62175-0446-01 - polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [JOHN] 48261342_1 CDM 0250 RC 62175-0446-01 NDC inpatient 1 UN 35.53 23.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 24.02 67.6 999999999 21.51 34.46 percent of total billed charges 62175-0446-01 - polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [JOHN] 48261342_1 CDM 0250 RC 62175-0446-01 NDC inpatient 1 UN 35.53 23.09 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.51 34.46 POTASSIUM CL 40 MEQ/20 ML CONC 48261348_1 CDM 0250 RC 00409-6653-05 NDC inpatient 1 UN 36.55 23.76 AETNA AETNA 28.87 79 999999999 22.13 35.45 percent of total billed charges POTASSIUM CL 40 MEQ/20 ML CONC 48261348_1 CDM 0250 RC 00409-6653-05 NDC inpatient 1 UN 36.55 23.76 SELF PAY DISCOUNT SELF PAY DISCOUNT 23.76 65 999999999 22.13 35.45 percent of total billed charges POTASSIUM CL 40 MEQ/20 ML CONC 48261348_1 CDM 0250 RC 00409-6653-05 NDC inpatient 1 UN 36.55 23.76 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.45 97 999999999 22.13 35.45 percent of total billed charges POTASSIUM CL 40 MEQ/20 ML CONC 48261348_1 CDM 0250 RC 00409-6653-05 NDC inpatient 1 UN 36.55 23.76 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.51 78 999999999 22.13 35.45 percent of total billed charges POTASSIUM CL 40 MEQ/20 ML CONC 48261348_1 CDM 0250 RC 00409-6653-05 NDC inpatient 1 UN 36.55 23.76 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.22 69 999999999 22.13 35.45 percent of total billed charges POTASSIUM CL 40 MEQ/20 ML CONC 48261348_1 CDM 0250 RC 00409-6653-05 NDC inpatient 1 UN 36.55 23.76 UMR - ALL PLANS UMR - ALL PLANS 25.59 70 999999999 22.13 35.45 percent of total billed charges POTASSIUM CL 40 MEQ/20 ML CONC 48261348_1 CDM 0250 RC 00409-6653-05 NDC inpatient 1 UN 36.55 23.76 SIHO - ALL PLANS SIHO - ALL PLANS 32.9 90 999999999 22.13 35.45 percent of total billed charges POTASSIUM CL 40 MEQ/20 ML CONC 48261348_1 CDM 0250 RC 00409-6653-05 NDC inpatient 1 UN 36.55 23.76 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.13 60.55 999999999 22.13 35.45 percent of total billed charges POTASSIUM CL 40 MEQ/20 ML CONC 48261348_1 CDM 0250 RC 00409-6653-05 NDC inpatient 1 UN 36.55 23.76 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.13 35.45 POTASSIUM CL 40 MEQ/20 ML CONC 48261348_1 CDM 0250 RC 00409-6653-05 NDC inpatient 1 UN 36.55 23.76 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.13 35.45 POTASSIUM CL 40 MEQ/20 ML CONC 48261348_1 CDM 0250 RC 00409-6653-05 NDC inpatient 1 UN 36.55 23.76 ANTHEM HMO ANTHEM HMO 999999999 22.13 35.45 POTASSIUM CL 40 MEQ/20 ML CONC 48261348_1 CDM 0250 RC 00409-6653-05 NDC inpatient 1 UN 36.55 23.76 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.13 35.45 POTASSIUM CL 40 MEQ/20 ML CONC 48261348_1 CDM 0250 RC 00409-6653-05 NDC inpatient 1 UN 36.55 23.76 CIGNA - ALL PLANS CIGNA - ALL PLANS 24.71 67.6 999999999 22.13 35.45 percent of total billed charges POTASSIUM CL 40 MEQ/20 ML CONC 48261348_1 CDM 0250 RC 00409-6653-05 NDC inpatient 1 UN 36.55 23.76 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.13 35.45 00409-7074-26 - potassium chloride 10 mEq/100 mL IV Sol [JOHN] 48261350_1 CDM 0250 RC 00409-7074-26 NDC inpatient 1 UN 61.13 39.73 AETNA AETNA 48.29 79 999999999 37.01 59.3 percent of total billed charges 00409-7074-26 - potassium chloride 10 mEq/100 mL IV Sol [JOHN] 48261350_1 CDM 0250 RC 00409-7074-26 NDC inpatient 1 UN 61.13 39.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.73 65 999999999 37.01 59.3 percent of total billed charges 00409-7074-26 - potassium chloride 10 mEq/100 mL IV Sol [JOHN] 48261350_1 CDM 0250 RC 00409-7074-26 NDC inpatient 1 UN 61.13 39.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59.3 97 999999999 37.01 59.3 percent of total billed charges 00409-7074-26 - potassium chloride 10 mEq/100 mL IV Sol [JOHN] 48261350_1 CDM 0250 RC 00409-7074-26 NDC inpatient 1 UN 61.13 39.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.68 78 999999999 37.01 59.3 percent of total billed charges 00409-7074-26 - potassium chloride 10 mEq/100 mL IV Sol [JOHN] 48261350_1 CDM 0250 RC 00409-7074-26 NDC inpatient 1 UN 61.13 39.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.18 69 999999999 37.01 59.3 percent of total billed charges 00409-7074-26 - potassium chloride 10 mEq/100 mL IV Sol [JOHN] 48261350_1 CDM 0250 RC 00409-7074-26 NDC inpatient 1 UN 61.13 39.73 UMR - ALL PLANS UMR - ALL PLANS 42.79 70 999999999 37.01 59.3 percent of total billed charges 00409-7074-26 - potassium chloride 10 mEq/100 mL IV Sol [JOHN] 48261350_1 CDM 0250 RC 00409-7074-26 NDC inpatient 1 UN 61.13 39.73 SIHO - ALL PLANS SIHO - ALL PLANS 55.02 90 999999999 37.01 59.3 percent of total billed charges 00409-7074-26 - potassium chloride 10 mEq/100 mL IV Sol [JOHN] 48261350_1 CDM 0250 RC 00409-7074-26 NDC inpatient 1 UN 61.13 39.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 37.01 60.55 999999999 37.01 59.3 percent of total billed charges 00409-7074-26 - potassium chloride 10 mEq/100 mL IV Sol [JOHN] 48261350_1 CDM 0250 RC 00409-7074-26 NDC inpatient 1 UN 61.13 39.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 37.01 59.3 00409-7074-26 - potassium chloride 10 mEq/100 mL IV Sol [JOHN] 48261350_1 CDM 0250 RC 00409-7074-26 NDC inpatient 1 UN 61.13 39.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 37.01 59.3 00409-7074-26 - potassium chloride 10 mEq/100 mL IV Sol [JOHN] 48261350_1 CDM 0250 RC 00409-7074-26 NDC inpatient 1 UN 61.13 39.73 ANTHEM HMO ANTHEM HMO 999999999 37.01 59.3 00409-7074-26 - potassium chloride 10 mEq/100 mL IV Sol [JOHN] 48261350_1 CDM 0250 RC 00409-7074-26 NDC inpatient 1 UN 61.13 39.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 37.01 59.3 00409-7074-26 - potassium chloride 10 mEq/100 mL IV Sol [JOHN] 48261350_1 CDM 0250 RC 00409-7074-26 NDC inpatient 1 UN 61.13 39.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.32 67.6 999999999 37.01 59.3 percent of total billed charges 00409-7074-26 - potassium chloride 10 mEq/100 mL IV Sol [JOHN] 48261350_1 CDM 0250 RC 00409-7074-26 NDC inpatient 1 UN 61.13 39.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 37.01 59.3 PHOSPHA 250 NEUTRAL TABLET 48261357_1 CDM 0250 RC 64980-0104-01 NDC inpatient 1 UN 1.71 1.11 AETNA AETNA 1.35 79 999999999 1.04 1.66 percent of total billed charges PHOSPHA 250 NEUTRAL TABLET 48261357_1 CDM 0250 RC 64980-0104-01 NDC inpatient 1 UN 1.71 1.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.11 65 999999999 1.04 1.66 percent of total billed charges PHOSPHA 250 NEUTRAL TABLET 48261357_1 CDM 0250 RC 64980-0104-01 NDC inpatient 1 UN 1.71 1.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.66 97 999999999 1.04 1.66 percent of total billed charges PHOSPHA 250 NEUTRAL TABLET 48261357_1 CDM 0250 RC 64980-0104-01 NDC inpatient 1 UN 1.71 1.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.33 78 999999999 1.04 1.66 percent of total billed charges PHOSPHA 250 NEUTRAL TABLET 48261357_1 CDM 0250 RC 64980-0104-01 NDC inpatient 1 UN 1.71 1.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.18 69 999999999 1.04 1.66 percent of total billed charges PHOSPHA 250 NEUTRAL TABLET 48261357_1 CDM 0250 RC 64980-0104-01 NDC inpatient 1 UN 1.71 1.11 UMR - ALL PLANS UMR - ALL PLANS 1.2 70 999999999 1.04 1.66 percent of total billed charges PHOSPHA 250 NEUTRAL TABLET 48261357_1 CDM 0250 RC 64980-0104-01 NDC inpatient 1 UN 1.71 1.11 SIHO - ALL PLANS SIHO - ALL PLANS 1.54 90 999999999 1.04 1.66 percent of total billed charges PHOSPHA 250 NEUTRAL TABLET 48261357_1 CDM 0250 RC 64980-0104-01 NDC inpatient 1 UN 1.71 1.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.04 60.55 999999999 1.04 1.66 percent of total billed charges PHOSPHA 250 NEUTRAL TABLET 48261357_1 CDM 0250 RC 64980-0104-01 NDC inpatient 1 UN 1.71 1.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.04 1.66 PHOSPHA 250 NEUTRAL TABLET 48261357_1 CDM 0250 RC 64980-0104-01 NDC inpatient 1 UN 1.71 1.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.04 1.66 PHOSPHA 250 NEUTRAL TABLET 48261357_1 CDM 0250 RC 64980-0104-01 NDC inpatient 1 UN 1.71 1.11 ANTHEM HMO ANTHEM HMO 999999999 1.04 1.66 PHOSPHA 250 NEUTRAL TABLET 48261357_1 CDM 0250 RC 64980-0104-01 NDC inpatient 1 UN 1.71 1.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.04 1.66 PHOSPHA 250 NEUTRAL TABLET 48261357_1 CDM 0250 RC 64980-0104-01 NDC inpatient 1 UN 1.71 1.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.16 67.6 999999999 1.04 1.66 percent of total billed charges PHOSPHA 250 NEUTRAL TABLET 48261357_1 CDM 0250 RC 64980-0104-01 NDC inpatient 1 UN 1.71 1.11 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.04 1.66 "PREDNISOLONE ORAL, PER 5 MG" 48261367_1 CDM 0250 RC 00121-0759-08 NDC J7510 HCPCS inpatient 1 UN 2.55 1.66 AETNA AETNA 2.01 79 999999999 1.54 2.47 percent of total billed charges "PREDNISOLONE ORAL, PER 5 MG" 48261367_1 CDM 0250 RC 00121-0759-08 NDC J7510 HCPCS inpatient 1 UN 2.55 1.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.66 65 999999999 1.54 2.47 percent of total billed charges "PREDNISOLONE ORAL, PER 5 MG" 48261367_1 CDM 0250 RC 00121-0759-08 NDC J7510 HCPCS inpatient 1 UN 2.55 1.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.47 97 999999999 1.54 2.47 percent of total billed charges "PREDNISOLONE ORAL, PER 5 MG" 48261367_1 CDM 0250 RC 00121-0759-08 NDC J7510 HCPCS inpatient 1 UN 2.55 1.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.99 78 999999999 1.54 2.47 percent of total billed charges "PREDNISOLONE ORAL, PER 5 MG" 48261367_1 CDM 0250 RC 00121-0759-08 NDC J7510 HCPCS inpatient 1 UN 2.55 1.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.76 69 999999999 1.54 2.47 percent of total billed charges "PREDNISOLONE ORAL, PER 5 MG" 48261367_1 CDM 0250 RC 00121-0759-08 NDC J7510 HCPCS inpatient 1 UN 2.55 1.66 UMR - ALL PLANS UMR - ALL PLANS 1.79 70 999999999 1.54 2.47 percent of total billed charges "PREDNISOLONE ORAL, PER 5 MG" 48261367_1 CDM 0250 RC 00121-0759-08 NDC J7510 HCPCS inpatient 1 UN 2.55 1.66 SIHO - ALL PLANS SIHO - ALL PLANS 2.3 90 999999999 1.54 2.47 percent of total billed charges "PREDNISOLONE ORAL, PER 5 MG" 48261367_1 CDM 0250 RC 00121-0759-08 NDC J7510 HCPCS inpatient 1 UN 2.55 1.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.54 60.55 999999999 1.54 2.47 percent of total billed charges "PREDNISOLONE ORAL, PER 5 MG" 48261367_1 CDM 0250 RC 00121-0759-08 NDC J7510 HCPCS inpatient 1 UN 2.55 1.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.54 2.47 "PREDNISOLONE ORAL, PER 5 MG" 48261367_1 CDM 0250 RC 00121-0759-08 NDC J7510 HCPCS inpatient 1 UN 2.55 1.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.54 2.47 "PREDNISOLONE ORAL, PER 5 MG" 48261367_1 CDM 0250 RC 00121-0759-08 NDC J7510 HCPCS inpatient 1 UN 2.55 1.66 ANTHEM HMO ANTHEM HMO 999999999 1.54 2.47 "PREDNISOLONE ORAL, PER 5 MG" 48261367_1 CDM 0250 RC 00121-0759-08 NDC J7510 HCPCS inpatient 1 UN 2.55 1.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.54 2.47 "PREDNISOLONE ORAL, PER 5 MG" 48261367_1 CDM 0250 RC 00121-0759-08 NDC J7510 HCPCS inpatient 1 UN 2.55 1.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.72 67.6 999999999 1.54 2.47 percent of total billed charges "PREDNISOLONE ORAL, PER 5 MG" 48261367_1 CDM 0250 RC 00121-0759-08 NDC J7510 HCPCS inpatient 1 UN 2.55 1.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.54 2.47 PREDNISONE 2.5 MG TABLET 48261372_1 CDM 0250 RC 00054-8740-25 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges PREDNISONE 2.5 MG TABLET 48261372_1 CDM 0250 RC 00054-8740-25 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges PREDNISONE 2.5 MG TABLET 48261372_1 CDM 0250 RC 00054-8740-25 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges PREDNISONE 2.5 MG TABLET 48261372_1 CDM 0250 RC 00054-8740-25 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges PREDNISONE 2.5 MG TABLET 48261372_1 CDM 0250 RC 00054-8740-25 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges PREDNISONE 2.5 MG TABLET 48261372_1 CDM 0250 RC 00054-8740-25 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges PREDNISONE 2.5 MG TABLET 48261372_1 CDM 0250 RC 00054-8740-25 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges PREDNISONE 2.5 MG TABLET 48261372_1 CDM 0250 RC 00054-8740-25 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges PREDNISONE 2.5 MG TABLET 48261372_1 CDM 0250 RC 00054-8740-25 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 PREDNISONE 2.5 MG TABLET 48261372_1 CDM 0250 RC 00054-8740-25 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 PREDNISONE 2.5 MG TABLET 48261372_1 CDM 0250 RC 00054-8740-25 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 PREDNISONE 2.5 MG TABLET 48261372_1 CDM 0250 RC 00054-8740-25 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 PREDNISONE 2.5 MG TABLET 48261372_1 CDM 0250 RC 00054-8740-25 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges PREDNISONE 2.5 MG TABLET 48261372_1 CDM 0250 RC 00054-8740-25 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "PREDNISONE, IMMEDIATE RELEASE OR DELAYED RELEASE, ORAL, 1 MG" 48261374_1 CDM 0250 RC 00054-8724-25 NDC J7512 HCPCS inpatient 1 UN 1.67 1.09 AETNA AETNA 1.32 79 999999999 1.01 1.62 percent of total billed charges "PREDNISONE, IMMEDIATE RELEASE OR DELAYED RELEASE, ORAL, 1 MG" 48261374_1 CDM 0250 RC 00054-8724-25 NDC J7512 HCPCS inpatient 1 UN 1.67 1.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.09 65 999999999 1.01 1.62 percent of total billed charges "PREDNISONE, IMMEDIATE RELEASE OR DELAYED RELEASE, ORAL, 1 MG" 48261374_1 CDM 0250 RC 00054-8724-25 NDC J7512 HCPCS inpatient 1 UN 1.67 1.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.62 97 999999999 1.01 1.62 percent of total billed charges "PREDNISONE, IMMEDIATE RELEASE OR DELAYED RELEASE, ORAL, 1 MG" 48261374_1 CDM 0250 RC 00054-8724-25 NDC J7512 HCPCS inpatient 1 UN 1.67 1.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.3 78 999999999 1.01 1.62 percent of total billed charges "PREDNISONE, IMMEDIATE RELEASE OR DELAYED RELEASE, ORAL, 1 MG" 48261374_1 CDM 0250 RC 00054-8724-25 NDC J7512 HCPCS inpatient 1 UN 1.67 1.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.15 69 999999999 1.01 1.62 percent of total billed charges "PREDNISONE, IMMEDIATE RELEASE OR DELAYED RELEASE, ORAL, 1 MG" 48261374_1 CDM 0250 RC 00054-8724-25 NDC J7512 HCPCS inpatient 1 UN 1.67 1.09 UMR - ALL PLANS UMR - ALL PLANS 1.17 70 999999999 1.01 1.62 percent of total billed charges "PREDNISONE, IMMEDIATE RELEASE OR DELAYED RELEASE, ORAL, 1 MG" 48261374_1 CDM 0250 RC 00054-8724-25 NDC J7512 HCPCS inpatient 1 UN 1.67 1.09 SIHO - ALL PLANS SIHO - ALL PLANS 1.5 90 999999999 1.01 1.62 percent of total billed charges "PREDNISONE, IMMEDIATE RELEASE OR DELAYED RELEASE, ORAL, 1 MG" 48261374_1 CDM 0250 RC 00054-8724-25 NDC J7512 HCPCS inpatient 1 UN 1.67 1.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.01 60.55 999999999 1.01 1.62 percent of total billed charges "PREDNISONE, IMMEDIATE RELEASE OR DELAYED RELEASE, ORAL, 1 MG" 48261374_1 CDM 0250 RC 00054-8724-25 NDC J7512 HCPCS inpatient 1 UN 1.67 1.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.01 1.62 "PREDNISONE, IMMEDIATE RELEASE OR DELAYED RELEASE, ORAL, 1 MG" 48261374_1 CDM 0250 RC 00054-8724-25 NDC J7512 HCPCS inpatient 1 UN 1.67 1.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.01 1.62 "PREDNISONE, IMMEDIATE RELEASE OR DELAYED RELEASE, ORAL, 1 MG" 48261374_1 CDM 0250 RC 00054-8724-25 NDC J7512 HCPCS inpatient 1 UN 1.67 1.09 ANTHEM HMO ANTHEM HMO 999999999 1.01 1.62 "PREDNISONE, IMMEDIATE RELEASE OR DELAYED RELEASE, ORAL, 1 MG" 48261374_1 CDM 0250 RC 00054-8724-25 NDC J7512 HCPCS inpatient 1 UN 1.67 1.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.01 1.62 "PREDNISONE, IMMEDIATE RELEASE OR DELAYED RELEASE, ORAL, 1 MG" 48261374_1 CDM 0250 RC 00054-8724-25 NDC J7512 HCPCS inpatient 1 UN 1.67 1.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.13 67.6 999999999 1.01 1.62 percent of total billed charges "PREDNISONE, IMMEDIATE RELEASE OR DELAYED RELEASE, ORAL, 1 MG" 48261374_1 CDM 0250 RC 00054-8724-25 NDC J7512 HCPCS inpatient 1 UN 1.67 1.09 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.01 1.62 LYRICA 25 MG CAPSULE 48261375_1 CDM 0250 RC 00071-1012-68 NDC inpatient 1 UN 33.09 21.51 AETNA AETNA 26.14 79 999999999 20.04 32.1 percent of total billed charges LYRICA 25 MG CAPSULE 48261375_1 CDM 0250 RC 00071-1012-68 NDC inpatient 1 UN 33.09 21.51 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.51 65 999999999 20.04 32.1 percent of total billed charges LYRICA 25 MG CAPSULE 48261375_1 CDM 0250 RC 00071-1012-68 NDC inpatient 1 UN 33.09 21.51 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.1 97 999999999 20.04 32.1 percent of total billed charges LYRICA 25 MG CAPSULE 48261375_1 CDM 0250 RC 00071-1012-68 NDC inpatient 1 UN 33.09 21.51 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.81 78 999999999 20.04 32.1 percent of total billed charges LYRICA 25 MG CAPSULE 48261375_1 CDM 0250 RC 00071-1012-68 NDC inpatient 1 UN 33.09 21.51 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.83 69 999999999 20.04 32.1 percent of total billed charges LYRICA 25 MG CAPSULE 48261375_1 CDM 0250 RC 00071-1012-68 NDC inpatient 1 UN 33.09 21.51 UMR - ALL PLANS UMR - ALL PLANS 23.16 70 999999999 20.04 32.1 percent of total billed charges LYRICA 25 MG CAPSULE 48261375_1 CDM 0250 RC 00071-1012-68 NDC inpatient 1 UN 33.09 21.51 SIHO - ALL PLANS SIHO - ALL PLANS 29.78 90 999999999 20.04 32.1 percent of total billed charges LYRICA 25 MG CAPSULE 48261375_1 CDM 0250 RC 00071-1012-68 NDC inpatient 1 UN 33.09 21.51 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.04 60.55 999999999 20.04 32.1 percent of total billed charges LYRICA 25 MG CAPSULE 48261375_1 CDM 0250 RC 00071-1012-68 NDC inpatient 1 UN 33.09 21.51 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.04 32.1 LYRICA 25 MG CAPSULE 48261375_1 CDM 0250 RC 00071-1012-68 NDC inpatient 1 UN 33.09 21.51 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.04 32.1 LYRICA 25 MG CAPSULE 48261375_1 CDM 0250 RC 00071-1012-68 NDC inpatient 1 UN 33.09 21.51 ANTHEM HMO ANTHEM HMO 999999999 20.04 32.1 LYRICA 25 MG CAPSULE 48261375_1 CDM 0250 RC 00071-1012-68 NDC inpatient 1 UN 33.09 21.51 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.04 32.1 LYRICA 25 MG CAPSULE 48261375_1 CDM 0250 RC 00071-1012-68 NDC inpatient 1 UN 33.09 21.51 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.37 67.6 999999999 20.04 32.1 percent of total billed charges LYRICA 25 MG CAPSULE 48261375_1 CDM 0250 RC 00071-1012-68 NDC inpatient 1 UN 33.09 21.51 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.04 32.1 "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48261387_1 CDM 0250 RC 68084-0155-01 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48261387_1 CDM 0250 RC 68084-0155-01 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48261387_1 CDM 0250 RC 68084-0155-01 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48261387_1 CDM 0250 RC 68084-0155-01 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48261387_1 CDM 0250 RC 68084-0155-01 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48261387_1 CDM 0250 RC 68084-0155-01 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48261387_1 CDM 0250 RC 68084-0155-01 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48261387_1 CDM 0250 RC 68084-0155-01 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48261387_1 CDM 0250 RC 68084-0155-01 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48261387_1 CDM 0250 RC 68084-0155-01 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48261387_1 CDM 0250 RC 68084-0155-01 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48261387_1 CDM 0250 RC 68084-0155-01 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48261387_1 CDM 0250 RC 68084-0155-01 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48261387_1 CDM 0250 RC 68084-0155-01 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 PROTAMINE 50 MG/5 ML VIAL 48261402_1 CDM 0250 RC 63323-0229-15 NDC inpatient 1 UN 57.94 37.66 AETNA AETNA 45.77 79 999999999 35.08 56.2 percent of total billed charges PROTAMINE 50 MG/5 ML VIAL 48261402_1 CDM 0250 RC 63323-0229-15 NDC inpatient 1 UN 57.94 37.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.66 65 999999999 35.08 56.2 percent of total billed charges PROTAMINE 50 MG/5 ML VIAL 48261402_1 CDM 0250 RC 63323-0229-15 NDC inpatient 1 UN 57.94 37.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.2 97 999999999 35.08 56.2 percent of total billed charges PROTAMINE 50 MG/5 ML VIAL 48261402_1 CDM 0250 RC 63323-0229-15 NDC inpatient 1 UN 57.94 37.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.19 78 999999999 35.08 56.2 percent of total billed charges PROTAMINE 50 MG/5 ML VIAL 48261402_1 CDM 0250 RC 63323-0229-15 NDC inpatient 1 UN 57.94 37.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.98 69 999999999 35.08 56.2 percent of total billed charges PROTAMINE 50 MG/5 ML VIAL 48261402_1 CDM 0250 RC 63323-0229-15 NDC inpatient 1 UN 57.94 37.66 UMR - ALL PLANS UMR - ALL PLANS 40.56 70 999999999 35.08 56.2 percent of total billed charges PROTAMINE 50 MG/5 ML VIAL 48261402_1 CDM 0250 RC 63323-0229-15 NDC inpatient 1 UN 57.94 37.66 SIHO - ALL PLANS SIHO - ALL PLANS 52.15 90 999999999 35.08 56.2 percent of total billed charges PROTAMINE 50 MG/5 ML VIAL 48261402_1 CDM 0250 RC 63323-0229-15 NDC inpatient 1 UN 57.94 37.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.08 60.55 999999999 35.08 56.2 percent of total billed charges PROTAMINE 50 MG/5 ML VIAL 48261402_1 CDM 0250 RC 63323-0229-15 NDC inpatient 1 UN 57.94 37.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.08 56.2 PROTAMINE 50 MG/5 ML VIAL 48261402_1 CDM 0250 RC 63323-0229-15 NDC inpatient 1 UN 57.94 37.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.08 56.2 PROTAMINE 50 MG/5 ML VIAL 48261402_1 CDM 0250 RC 63323-0229-15 NDC inpatient 1 UN 57.94 37.66 ANTHEM HMO ANTHEM HMO 999999999 35.08 56.2 PROTAMINE 50 MG/5 ML VIAL 48261402_1 CDM 0250 RC 63323-0229-15 NDC inpatient 1 UN 57.94 37.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.08 56.2 PROTAMINE 50 MG/5 ML VIAL 48261402_1 CDM 0250 RC 63323-0229-15 NDC inpatient 1 UN 57.94 37.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.17 67.6 999999999 35.08 56.2 percent of total billed charges PROTAMINE 50 MG/5 ML VIAL 48261402_1 CDM 0250 RC 63323-0229-15 NDC inpatient 1 UN 57.94 37.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.08 56.2 S2 RACEPINEPHRINE 2.25% SOLN 48261417_1 CDM 0250 RC 00487-5901-99 NDC inpatient 1 UN 6.68 4.34 AETNA AETNA 5.28 79 999999999 4.04 6.48 percent of total billed charges S2 RACEPINEPHRINE 2.25% SOLN 48261417_1 CDM 0250 RC 00487-5901-99 NDC inpatient 1 UN 6.68 4.34 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.34 65 999999999 4.04 6.48 percent of total billed charges S2 RACEPINEPHRINE 2.25% SOLN 48261417_1 CDM 0250 RC 00487-5901-99 NDC inpatient 1 UN 6.68 4.34 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.48 97 999999999 4.04 6.48 percent of total billed charges S2 RACEPINEPHRINE 2.25% SOLN 48261417_1 CDM 0250 RC 00487-5901-99 NDC inpatient 1 UN 6.68 4.34 HUMANA - ALL PLANS HUMANA - ALL PLANS 5.21 78 999999999 4.04 6.48 percent of total billed charges S2 RACEPINEPHRINE 2.25% SOLN 48261417_1 CDM 0250 RC 00487-5901-99 NDC inpatient 1 UN 6.68 4.34 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.61 69 999999999 4.04 6.48 percent of total billed charges S2 RACEPINEPHRINE 2.25% SOLN 48261417_1 CDM 0250 RC 00487-5901-99 NDC inpatient 1 UN 6.68 4.34 UMR - ALL PLANS UMR - ALL PLANS 4.68 70 999999999 4.04 6.48 percent of total billed charges S2 RACEPINEPHRINE 2.25% SOLN 48261417_1 CDM 0250 RC 00487-5901-99 NDC inpatient 1 UN 6.68 4.34 SIHO - ALL PLANS SIHO - ALL PLANS 6.01 90 999999999 4.04 6.48 percent of total billed charges S2 RACEPINEPHRINE 2.25% SOLN 48261417_1 CDM 0250 RC 00487-5901-99 NDC inpatient 1 UN 6.68 4.34 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.04 60.55 999999999 4.04 6.48 percent of total billed charges S2 RACEPINEPHRINE 2.25% SOLN 48261417_1 CDM 0250 RC 00487-5901-99 NDC inpatient 1 UN 6.68 4.34 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.04 6.48 S2 RACEPINEPHRINE 2.25% SOLN 48261417_1 CDM 0250 RC 00487-5901-99 NDC inpatient 1 UN 6.68 4.34 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.04 6.48 S2 RACEPINEPHRINE 2.25% SOLN 48261417_1 CDM 0250 RC 00487-5901-99 NDC inpatient 1 UN 6.68 4.34 ANTHEM HMO ANTHEM HMO 999999999 4.04 6.48 S2 RACEPINEPHRINE 2.25% SOLN 48261417_1 CDM 0250 RC 00487-5901-99 NDC inpatient 1 UN 6.68 4.34 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.04 6.48 S2 RACEPINEPHRINE 2.25% SOLN 48261417_1 CDM 0250 RC 00487-5901-99 NDC inpatient 1 UN 6.68 4.34 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.52 67.6 999999999 4.04 6.48 percent of total billed charges S2 RACEPINEPHRINE 2.25% SOLN 48261417_1 CDM 0250 RC 00487-5901-99 NDC inpatient 1 UN 6.68 4.34 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.04 6.48 "INJECTION, REGADENOSON, 0.1 MG" 48261428_1 CDM 0250 RC 00469-6501-89 NDC J2785 HCPCS inpatient 4 UN 1139.37 740.59 AETNA AETNA 900.1 79 999999999 689.89 1105.19 percent of total billed charges "INJECTION, REGADENOSON, 0.1 MG" 48261428_1 CDM 0250 RC 00469-6501-89 NDC J2785 HCPCS inpatient 4 UN 1139.37 740.59 SELF PAY DISCOUNT SELF PAY DISCOUNT 740.59 65 999999999 689.89 1105.19 percent of total billed charges "INJECTION, REGADENOSON, 0.1 MG" 48261428_1 CDM 0250 RC 00469-6501-89 NDC J2785 HCPCS inpatient 4 UN 1139.37 740.59 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1105.19 97 999999999 689.89 1105.19 percent of total billed charges "INJECTION, REGADENOSON, 0.1 MG" 48261428_1 CDM 0250 RC 00469-6501-89 NDC J2785 HCPCS inpatient 4 UN 1139.37 740.59 HUMANA - ALL PLANS HUMANA - ALL PLANS 888.71 78 999999999 689.89 1105.19 percent of total billed charges "INJECTION, REGADENOSON, 0.1 MG" 48261428_1 CDM 0250 RC 00469-6501-89 NDC J2785 HCPCS inpatient 4 UN 1139.37 740.59 ENCORE - ALL PLANS ENCORE - ALL PLANS 786.17 69 999999999 689.89 1105.19 percent of total billed charges "INJECTION, REGADENOSON, 0.1 MG" 48261428_1 CDM 0250 RC 00469-6501-89 NDC J2785 HCPCS inpatient 4 UN 1139.37 740.59 UMR - ALL PLANS UMR - ALL PLANS 797.56 70 999999999 689.89 1105.19 percent of total billed charges "INJECTION, REGADENOSON, 0.1 MG" 48261428_1 CDM 0250 RC 00469-6501-89 NDC J2785 HCPCS inpatient 4 UN 1139.37 740.59 SIHO - ALL PLANS SIHO - ALL PLANS 1025.43 90 999999999 689.89 1105.19 percent of total billed charges "INJECTION, REGADENOSON, 0.1 MG" 48261428_1 CDM 0250 RC 00469-6501-89 NDC J2785 HCPCS inpatient 4 UN 1139.37 740.59 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 689.89 60.55 999999999 689.89 1105.19 percent of total billed charges "INJECTION, REGADENOSON, 0.1 MG" 48261428_1 CDM 0250 RC 00469-6501-89 NDC J2785 HCPCS inpatient 4 UN 1139.37 740.59 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 689.89 1105.19 "INJECTION, REGADENOSON, 0.1 MG" 48261428_1 CDM 0250 RC 00469-6501-89 NDC J2785 HCPCS inpatient 4 UN 1139.37 740.59 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 689.89 1105.19 "INJECTION, REGADENOSON, 0.1 MG" 48261428_1 CDM 0250 RC 00469-6501-89 NDC J2785 HCPCS inpatient 4 UN 1139.37 740.59 ANTHEM HMO ANTHEM HMO 999999999 689.89 1105.19 "INJECTION, REGADENOSON, 0.1 MG" 48261428_1 CDM 0250 RC 00469-6501-89 NDC J2785 HCPCS inpatient 4 UN 1139.37 740.59 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 689.89 1105.19 "INJECTION, REGADENOSON, 0.1 MG" 48261428_1 CDM 0250 RC 00469-6501-89 NDC J2785 HCPCS inpatient 4 UN 1139.37 740.59 CIGNA - ALL PLANS CIGNA - ALL PLANS 770.21 67.6 999999999 689.89 1105.19 percent of total billed charges "INJECTION, REGADENOSON, 0.1 MG" 48261428_1 CDM 0250 RC 00469-6501-89 NDC J2785 HCPCS inpatient 4 UN 1139.37 740.59 UHC - ALL PLANS UHC - ALL PLANS 999999999 689.89 1105.19 XIFAXAN 550 MG TABLET 48261432_1 CDM 0250 RC 65649-0303-03 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges XIFAXAN 550 MG TABLET 48261432_1 CDM 0250 RC 65649-0303-03 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges XIFAXAN 550 MG TABLET 48261432_1 CDM 0250 RC 65649-0303-03 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges XIFAXAN 550 MG TABLET 48261432_1 CDM 0250 RC 65649-0303-03 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges XIFAXAN 550 MG TABLET 48261432_1 CDM 0250 RC 65649-0303-03 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges XIFAXAN 550 MG TABLET 48261432_1 CDM 0250 RC 65649-0303-03 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges XIFAXAN 550 MG TABLET 48261432_1 CDM 0250 RC 65649-0303-03 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges XIFAXAN 550 MG TABLET 48261432_1 CDM 0250 RC 65649-0303-03 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges XIFAXAN 550 MG TABLET 48261432_1 CDM 0250 RC 65649-0303-03 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 XIFAXAN 550 MG TABLET 48261432_1 CDM 0250 RC 65649-0303-03 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 XIFAXAN 550 MG TABLET 48261432_1 CDM 0250 RC 65649-0303-03 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 XIFAXAN 550 MG TABLET 48261432_1 CDM 0250 RC 65649-0303-03 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 XIFAXAN 550 MG TABLET 48261432_1 CDM 0250 RC 65649-0303-03 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges XIFAXAN 550 MG TABLET 48261432_1 CDM 0250 RC 65649-0303-03 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 RISPERIDONE 0.25 MG TABLET 48261433_1 CDM 0250 RC 68084-0270-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges RISPERIDONE 0.25 MG TABLET 48261433_1 CDM 0250 RC 68084-0270-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges RISPERIDONE 0.25 MG TABLET 48261433_1 CDM 0250 RC 68084-0270-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges RISPERIDONE 0.25 MG TABLET 48261433_1 CDM 0250 RC 68084-0270-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges RISPERIDONE 0.25 MG TABLET 48261433_1 CDM 0250 RC 68084-0270-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges RISPERIDONE 0.25 MG TABLET 48261433_1 CDM 0250 RC 68084-0270-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges RISPERIDONE 0.25 MG TABLET 48261433_1 CDM 0250 RC 68084-0270-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges RISPERIDONE 0.25 MG TABLET 48261433_1 CDM 0250 RC 68084-0270-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges RISPERIDONE 0.25 MG TABLET 48261433_1 CDM 0250 RC 68084-0270-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 RISPERIDONE 0.25 MG TABLET 48261433_1 CDM 0250 RC 68084-0270-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 RISPERIDONE 0.25 MG TABLET 48261433_1 CDM 0250 RC 68084-0270-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 RISPERIDONE 0.25 MG TABLET 48261433_1 CDM 0250 RC 68084-0270-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 RISPERIDONE 0.25 MG TABLET 48261433_1 CDM 0250 RC 68084-0270-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges RISPERIDONE 0.25 MG TABLET 48261433_1 CDM 0250 RC 68084-0270-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 RISPERIDONE 0.5 MG TABLET 48261434_1 CDM 0250 RC 68084-0271-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges RISPERIDONE 0.5 MG TABLET 48261434_1 CDM 0250 RC 68084-0271-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges RISPERIDONE 0.5 MG TABLET 48261434_1 CDM 0250 RC 68084-0271-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges RISPERIDONE 0.5 MG TABLET 48261434_1 CDM 0250 RC 68084-0271-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges RISPERIDONE 0.5 MG TABLET 48261434_1 CDM 0250 RC 68084-0271-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges RISPERIDONE 0.5 MG TABLET 48261434_1 CDM 0250 RC 68084-0271-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges RISPERIDONE 0.5 MG TABLET 48261434_1 CDM 0250 RC 68084-0271-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges RISPERIDONE 0.5 MG TABLET 48261434_1 CDM 0250 RC 68084-0271-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges RISPERIDONE 0.5 MG TABLET 48261434_1 CDM 0250 RC 68084-0271-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 RISPERIDONE 0.5 MG TABLET 48261434_1 CDM 0250 RC 68084-0271-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 RISPERIDONE 0.5 MG TABLET 48261434_1 CDM 0250 RC 68084-0271-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 RISPERIDONE 0.5 MG TABLET 48261434_1 CDM 0250 RC 68084-0271-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 RISPERIDONE 0.5 MG TABLET 48261434_1 CDM 0250 RC 68084-0271-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges RISPERIDONE 0.5 MG TABLET 48261434_1 CDM 0250 RC 68084-0271-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 RISPERIDONE 1 MG/ML SOLUTION 48261436_1 CDM 0250 RC 65162-0673-84 NDC inpatient 1 UN 127.68 82.99 AETNA AETNA 100.87 79 999999999 77.31 123.85 percent of total billed charges RISPERIDONE 1 MG/ML SOLUTION 48261436_1 CDM 0250 RC 65162-0673-84 NDC inpatient 1 UN 127.68 82.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 82.99 65 999999999 77.31 123.85 percent of total billed charges RISPERIDONE 1 MG/ML SOLUTION 48261436_1 CDM 0250 RC 65162-0673-84 NDC inpatient 1 UN 127.68 82.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 123.85 97 999999999 77.31 123.85 percent of total billed charges RISPERIDONE 1 MG/ML SOLUTION 48261436_1 CDM 0250 RC 65162-0673-84 NDC inpatient 1 UN 127.68 82.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 99.59 78 999999999 77.31 123.85 percent of total billed charges RISPERIDONE 1 MG/ML SOLUTION 48261436_1 CDM 0250 RC 65162-0673-84 NDC inpatient 1 UN 127.68 82.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 88.1 69 999999999 77.31 123.85 percent of total billed charges RISPERIDONE 1 MG/ML SOLUTION 48261436_1 CDM 0250 RC 65162-0673-84 NDC inpatient 1 UN 127.68 82.99 UMR - ALL PLANS UMR - ALL PLANS 89.38 70 999999999 77.31 123.85 percent of total billed charges RISPERIDONE 1 MG/ML SOLUTION 48261436_1 CDM 0250 RC 65162-0673-84 NDC inpatient 1 UN 127.68 82.99 SIHO - ALL PLANS SIHO - ALL PLANS 114.91 90 999999999 77.31 123.85 percent of total billed charges RISPERIDONE 1 MG/ML SOLUTION 48261436_1 CDM 0250 RC 65162-0673-84 NDC inpatient 1 UN 127.68 82.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 77.31 60.55 999999999 77.31 123.85 percent of total billed charges RISPERIDONE 1 MG/ML SOLUTION 48261436_1 CDM 0250 RC 65162-0673-84 NDC inpatient 1 UN 127.68 82.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 77.31 123.85 RISPERIDONE 1 MG/ML SOLUTION 48261436_1 CDM 0250 RC 65162-0673-84 NDC inpatient 1 UN 127.68 82.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 77.31 123.85 RISPERIDONE 1 MG/ML SOLUTION 48261436_1 CDM 0250 RC 65162-0673-84 NDC inpatient 1 UN 127.68 82.99 ANTHEM HMO ANTHEM HMO 999999999 77.31 123.85 RISPERIDONE 1 MG/ML SOLUTION 48261436_1 CDM 0250 RC 65162-0673-84 NDC inpatient 1 UN 127.68 82.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 77.31 123.85 RISPERIDONE 1 MG/ML SOLUTION 48261436_1 CDM 0250 RC 65162-0673-84 NDC inpatient 1 UN 127.68 82.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 86.31 67.6 999999999 77.31 123.85 percent of total billed charges RISPERIDONE 1 MG/ML SOLUTION 48261436_1 CDM 0250 RC 65162-0673-84 NDC inpatient 1 UN 127.68 82.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 77.31 123.85 RITUXIMAB INJECTION 48261437_1 CDM 0636 RC 50242-0051-21 NDC J9310 HCPCS inpatient 10 UN 3694.33 2401.31 AETNA AETNA 2918.52 79 999999999 2236.92 3583.5 percent of total billed charges RITUXIMAB INJECTION 48261437_1 CDM 0636 RC 50242-0051-21 NDC J9310 HCPCS inpatient 10 UN 3694.33 2401.31 SELF PAY DISCOUNT SELF PAY DISCOUNT 2401.31 65 999999999 2236.92 3583.5 percent of total billed charges RITUXIMAB INJECTION 48261437_1 CDM 0636 RC 50242-0051-21 NDC J9310 HCPCS inpatient 10 UN 3694.33 2401.31 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3583.5 97 999999999 2236.92 3583.5 percent of total billed charges RITUXIMAB INJECTION 48261437_1 CDM 0636 RC 50242-0051-21 NDC J9310 HCPCS inpatient 10 UN 3694.33 2401.31 HUMANA - ALL PLANS HUMANA - ALL PLANS 2881.58 78 999999999 2236.92 3583.5 percent of total billed charges RITUXIMAB INJECTION 48261437_1 CDM 0636 RC 50242-0051-21 NDC J9310 HCPCS inpatient 10 UN 3694.33 2401.31 ENCORE - ALL PLANS ENCORE - ALL PLANS 2549.09 69 999999999 2236.92 3583.5 percent of total billed charges RITUXIMAB INJECTION 48261437_1 CDM 0636 RC 50242-0051-21 NDC J9310 HCPCS inpatient 10 UN 3694.33 2401.31 UMR - ALL PLANS UMR - ALL PLANS 2586.03 70 999999999 2236.92 3583.5 percent of total billed charges RITUXIMAB INJECTION 48261437_1 CDM 0636 RC 50242-0051-21 NDC J9310 HCPCS inpatient 10 UN 3694.33 2401.31 SIHO - ALL PLANS SIHO - ALL PLANS 3324.9 90 999999999 2236.92 3583.5 percent of total billed charges RITUXIMAB INJECTION 48261437_1 CDM 0636 RC 50242-0051-21 NDC J9310 HCPCS inpatient 10 UN 3694.33 2401.31 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2236.92 60.55 999999999 2236.92 3583.5 percent of total billed charges RITUXIMAB INJECTION 48261437_1 CDM 0636 RC 50242-0051-21 NDC J9310 HCPCS inpatient 10 UN 3694.33 2401.31 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2236.92 3583.5 RITUXIMAB INJECTION 48261437_1 CDM 0636 RC 50242-0051-21 NDC J9310 HCPCS inpatient 10 UN 3694.33 2401.31 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2236.92 3583.5 RITUXIMAB INJECTION 48261437_1 CDM 0636 RC 50242-0051-21 NDC J9310 HCPCS inpatient 10 UN 3694.33 2401.31 ANTHEM HMO ANTHEM HMO 999999999 2236.92 3583.5 RITUXIMAB INJECTION 48261437_1 CDM 0636 RC 50242-0051-21 NDC J9310 HCPCS inpatient 10 UN 3694.33 2401.31 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2236.92 3583.5 RITUXIMAB INJECTION 48261437_1 CDM 0636 RC 50242-0051-21 NDC J9310 HCPCS inpatient 10 UN 3694.33 2401.31 CIGNA - ALL PLANS CIGNA - ALL PLANS 2497.37 67.6 999999999 2236.92 3583.5 percent of total billed charges RITUXIMAB INJECTION 48261437_1 CDM 0636 RC 50242-0051-21 NDC J9310 HCPCS inpatient 10 UN 3694.33 2401.31 UHC - ALL PLANS UHC - ALL PLANS 999999999 2236.92 3583.5 "INJECTION, RITUXIMAB, 10 MG" 48261438_1 CDM 0636 RC 50242-0053-06 NDC J9312 HCPCS inpatient 50 UN 22363.6 14536.34 AETNA AETNA 17667.24 79 999999999 13541.16 21692.69 percent of total billed charges "INJECTION, RITUXIMAB, 10 MG" 48261438_1 CDM 0636 RC 50242-0053-06 NDC J9312 HCPCS inpatient 50 UN 22363.6 14536.34 SELF PAY DISCOUNT SELF PAY DISCOUNT 14536.34 65 999999999 13541.16 21692.69 percent of total billed charges "INJECTION, RITUXIMAB, 10 MG" 48261438_1 CDM 0636 RC 50242-0053-06 NDC J9312 HCPCS inpatient 50 UN 22363.6 14536.34 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21692.69 97 999999999 13541.16 21692.69 percent of total billed charges "INJECTION, RITUXIMAB, 10 MG" 48261438_1 CDM 0636 RC 50242-0053-06 NDC J9312 HCPCS inpatient 50 UN 22363.6 14536.34 HUMANA - ALL PLANS HUMANA - ALL PLANS 17443.61 78 999999999 13541.16 21692.69 percent of total billed charges "INJECTION, RITUXIMAB, 10 MG" 48261438_1 CDM 0636 RC 50242-0053-06 NDC J9312 HCPCS inpatient 50 UN 22363.6 14536.34 ENCORE - ALL PLANS ENCORE - ALL PLANS 15430.88 69 999999999 13541.16 21692.69 percent of total billed charges "INJECTION, RITUXIMAB, 10 MG" 48261438_1 CDM 0636 RC 50242-0053-06 NDC J9312 HCPCS inpatient 50 UN 22363.6 14536.34 UMR - ALL PLANS UMR - ALL PLANS 15654.52 70 999999999 13541.16 21692.69 percent of total billed charges "INJECTION, RITUXIMAB, 10 MG" 48261438_1 CDM 0636 RC 50242-0053-06 NDC J9312 HCPCS inpatient 50 UN 22363.6 14536.34 SIHO - ALL PLANS SIHO - ALL PLANS 20127.24 90 999999999 13541.16 21692.69 percent of total billed charges "INJECTION, RITUXIMAB, 10 MG" 48261438_1 CDM 0636 RC 50242-0053-06 NDC J9312 HCPCS inpatient 50 UN 22363.6 14536.34 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13541.16 60.55 999999999 13541.16 21692.69 percent of total billed charges "INJECTION, RITUXIMAB, 10 MG" 48261438_1 CDM 0636 RC 50242-0053-06 NDC J9312 HCPCS inpatient 50 UN 22363.6 14536.34 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13541.16 21692.69 "INJECTION, RITUXIMAB, 10 MG" 48261438_1 CDM 0636 RC 50242-0053-06 NDC J9312 HCPCS inpatient 50 UN 22363.6 14536.34 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13541.16 21692.69 "INJECTION, RITUXIMAB, 10 MG" 48261438_1 CDM 0636 RC 50242-0053-06 NDC J9312 HCPCS inpatient 50 UN 22363.6 14536.34 ANTHEM HMO ANTHEM HMO 999999999 13541.16 21692.69 "INJECTION, RITUXIMAB, 10 MG" 48261438_1 CDM 0636 RC 50242-0053-06 NDC J9312 HCPCS inpatient 50 UN 22363.6 14536.34 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13541.16 21692.69 "INJECTION, RITUXIMAB, 10 MG" 48261438_1 CDM 0636 RC 50242-0053-06 NDC J9312 HCPCS inpatient 50 UN 22363.6 14536.34 CIGNA - ALL PLANS CIGNA - ALL PLANS 15117.79 67.6 999999999 13541.16 21692.69 percent of total billed charges "INJECTION, RITUXIMAB, 10 MG" 48261438_1 CDM 0636 RC 50242-0053-06 NDC J9312 HCPCS inpatient 50 UN 22363.6 14536.34 UHC - ALL PLANS UHC - ALL PLANS 999999999 13541.16 21692.69 XARELTO 10 MG TABLET 48261439_1 CDM 0250 RC 50458-0580-10 NDC inpatient 1 UN 53.73 34.92 AETNA AETNA 42.45 79 999999999 32.53 52.12 percent of total billed charges XARELTO 10 MG TABLET 48261439_1 CDM 0250 RC 50458-0580-10 NDC inpatient 1 UN 53.73 34.92 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.92 65 999999999 32.53 52.12 percent of total billed charges XARELTO 10 MG TABLET 48261439_1 CDM 0250 RC 50458-0580-10 NDC inpatient 1 UN 53.73 34.92 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 52.12 97 999999999 32.53 52.12 percent of total billed charges XARELTO 10 MG TABLET 48261439_1 CDM 0250 RC 50458-0580-10 NDC inpatient 1 UN 53.73 34.92 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.91 78 999999999 32.53 52.12 percent of total billed charges XARELTO 10 MG TABLET 48261439_1 CDM 0250 RC 50458-0580-10 NDC inpatient 1 UN 53.73 34.92 ENCORE - ALL PLANS ENCORE - ALL PLANS 37.07 69 999999999 32.53 52.12 percent of total billed charges XARELTO 10 MG TABLET 48261439_1 CDM 0250 RC 50458-0580-10 NDC inpatient 1 UN 53.73 34.92 UMR - ALL PLANS UMR - ALL PLANS 37.61 70 999999999 32.53 52.12 percent of total billed charges XARELTO 10 MG TABLET 48261439_1 CDM 0250 RC 50458-0580-10 NDC inpatient 1 UN 53.73 34.92 SIHO - ALL PLANS SIHO - ALL PLANS 48.36 90 999999999 32.53 52.12 percent of total billed charges XARELTO 10 MG TABLET 48261439_1 CDM 0250 RC 50458-0580-10 NDC inpatient 1 UN 53.73 34.92 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.53 60.55 999999999 32.53 52.12 percent of total billed charges XARELTO 10 MG TABLET 48261439_1 CDM 0250 RC 50458-0580-10 NDC inpatient 1 UN 53.73 34.92 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.53 52.12 XARELTO 10 MG TABLET 48261439_1 CDM 0250 RC 50458-0580-10 NDC inpatient 1 UN 53.73 34.92 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.53 52.12 XARELTO 10 MG TABLET 48261439_1 CDM 0250 RC 50458-0580-10 NDC inpatient 1 UN 53.73 34.92 ANTHEM HMO ANTHEM HMO 999999999 32.53 52.12 XARELTO 10 MG TABLET 48261439_1 CDM 0250 RC 50458-0580-10 NDC inpatient 1 UN 53.73 34.92 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.53 52.12 XARELTO 10 MG TABLET 48261439_1 CDM 0250 RC 50458-0580-10 NDC inpatient 1 UN 53.73 34.92 CIGNA - ALL PLANS CIGNA - ALL PLANS 36.32 67.6 999999999 32.53 52.12 percent of total billed charges XARELTO 10 MG TABLET 48261439_1 CDM 0250 RC 50458-0580-10 NDC inpatient 1 UN 53.73 34.92 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.53 52.12 XARELTO 15 MG TABLET 48261440_1 CDM 0250 RC 50458-0578-30 NDC inpatient 1 UN 52.51 34.13 AETNA AETNA 41.48 79 999999999 31.79 50.93 percent of total billed charges XARELTO 15 MG TABLET 48261440_1 CDM 0250 RC 50458-0578-30 NDC inpatient 1 UN 52.51 34.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.13 65 999999999 31.79 50.93 percent of total billed charges XARELTO 15 MG TABLET 48261440_1 CDM 0250 RC 50458-0578-30 NDC inpatient 1 UN 52.51 34.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 50.93 97 999999999 31.79 50.93 percent of total billed charges XARELTO 15 MG TABLET 48261440_1 CDM 0250 RC 50458-0578-30 NDC inpatient 1 UN 52.51 34.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 40.96 78 999999999 31.79 50.93 percent of total billed charges XARELTO 15 MG TABLET 48261440_1 CDM 0250 RC 50458-0578-30 NDC inpatient 1 UN 52.51 34.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.23 69 999999999 31.79 50.93 percent of total billed charges XARELTO 15 MG TABLET 48261440_1 CDM 0250 RC 50458-0578-30 NDC inpatient 1 UN 52.51 34.13 UMR - ALL PLANS UMR - ALL PLANS 36.76 70 999999999 31.79 50.93 percent of total billed charges XARELTO 15 MG TABLET 48261440_1 CDM 0250 RC 50458-0578-30 NDC inpatient 1 UN 52.51 34.13 SIHO - ALL PLANS SIHO - ALL PLANS 47.26 90 999999999 31.79 50.93 percent of total billed charges XARELTO 15 MG TABLET 48261440_1 CDM 0250 RC 50458-0578-30 NDC inpatient 1 UN 52.51 34.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 31.79 60.55 999999999 31.79 50.93 percent of total billed charges XARELTO 15 MG TABLET 48261440_1 CDM 0250 RC 50458-0578-30 NDC inpatient 1 UN 52.51 34.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 31.79 50.93 XARELTO 15 MG TABLET 48261440_1 CDM 0250 RC 50458-0578-30 NDC inpatient 1 UN 52.51 34.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 31.79 50.93 XARELTO 15 MG TABLET 48261440_1 CDM 0250 RC 50458-0578-30 NDC inpatient 1 UN 52.51 34.13 ANTHEM HMO ANTHEM HMO 999999999 31.79 50.93 XARELTO 15 MG TABLET 48261440_1 CDM 0250 RC 50458-0578-30 NDC inpatient 1 UN 52.51 34.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 31.79 50.93 XARELTO 15 MG TABLET 48261440_1 CDM 0250 RC 50458-0578-30 NDC inpatient 1 UN 52.51 34.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.5 67.6 999999999 31.79 50.93 percent of total billed charges XARELTO 15 MG TABLET 48261440_1 CDM 0250 RC 50458-0578-30 NDC inpatient 1 UN 52.51 34.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 31.79 50.93 ROCURONIUM 50 MG/5 ML VIAL 48261445_1 CDM 0250 RC 00409-9558-49 NDC inpatient 1 UN 12.75 8.29 AETNA AETNA 10.07 79 999999999 7.72 12.37 percent of total billed charges ROCURONIUM 50 MG/5 ML VIAL 48261445_1 CDM 0250 RC 00409-9558-49 NDC inpatient 1 UN 12.75 8.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.29 65 999999999 7.72 12.37 percent of total billed charges ROCURONIUM 50 MG/5 ML VIAL 48261445_1 CDM 0250 RC 00409-9558-49 NDC inpatient 1 UN 12.75 8.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.37 97 999999999 7.72 12.37 percent of total billed charges ROCURONIUM 50 MG/5 ML VIAL 48261445_1 CDM 0250 RC 00409-9558-49 NDC inpatient 1 UN 12.75 8.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.95 78 999999999 7.72 12.37 percent of total billed charges ROCURONIUM 50 MG/5 ML VIAL 48261445_1 CDM 0250 RC 00409-9558-49 NDC inpatient 1 UN 12.75 8.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.8 69 999999999 7.72 12.37 percent of total billed charges ROCURONIUM 50 MG/5 ML VIAL 48261445_1 CDM 0250 RC 00409-9558-49 NDC inpatient 1 UN 12.75 8.29 UMR - ALL PLANS UMR - ALL PLANS 8.93 70 999999999 7.72 12.37 percent of total billed charges ROCURONIUM 50 MG/5 ML VIAL 48261445_1 CDM 0250 RC 00409-9558-49 NDC inpatient 1 UN 12.75 8.29 SIHO - ALL PLANS SIHO - ALL PLANS 11.48 90 999999999 7.72 12.37 percent of total billed charges ROCURONIUM 50 MG/5 ML VIAL 48261445_1 CDM 0250 RC 00409-9558-49 NDC inpatient 1 UN 12.75 8.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.72 60.55 999999999 7.72 12.37 percent of total billed charges ROCURONIUM 50 MG/5 ML VIAL 48261445_1 CDM 0250 RC 00409-9558-49 NDC inpatient 1 UN 12.75 8.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.72 12.37 ROCURONIUM 50 MG/5 ML VIAL 48261445_1 CDM 0250 RC 00409-9558-49 NDC inpatient 1 UN 12.75 8.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.72 12.37 ROCURONIUM 50 MG/5 ML VIAL 48261445_1 CDM 0250 RC 00409-9558-49 NDC inpatient 1 UN 12.75 8.29 ANTHEM HMO ANTHEM HMO 999999999 7.72 12.37 ROCURONIUM 50 MG/5 ML VIAL 48261445_1 CDM 0250 RC 00409-9558-49 NDC inpatient 1 UN 12.75 8.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.72 12.37 ROCURONIUM 50 MG/5 ML VIAL 48261445_1 CDM 0250 RC 00409-9558-49 NDC inpatient 1 UN 12.75 8.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.62 67.6 999999999 7.72 12.37 percent of total billed charges ROCURONIUM 50 MG/5 ML VIAL 48261445_1 CDM 0250 RC 00409-9558-49 NDC inpatient 1 UN 12.75 8.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.72 12.37 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 48261452_1 CDM 0250 RC 61553-0270-60 NDC J2795 HCPCS inpatient 1200 UN 3382.15 2198.4 AETNA AETNA 2671.9 79 999999999 2047.89 3280.69 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 48261452_1 CDM 0250 RC 61553-0270-60 NDC J2795 HCPCS inpatient 1200 UN 3382.15 2198.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 2198.4 65 999999999 2047.89 3280.69 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 48261452_1 CDM 0250 RC 61553-0270-60 NDC J2795 HCPCS inpatient 1200 UN 3382.15 2198.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3280.69 97 999999999 2047.89 3280.69 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 48261452_1 CDM 0250 RC 61553-0270-60 NDC J2795 HCPCS inpatient 1200 UN 3382.15 2198.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 2638.08 78 999999999 2047.89 3280.69 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 48261452_1 CDM 0250 RC 61553-0270-60 NDC J2795 HCPCS inpatient 1200 UN 3382.15 2198.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 2333.68 69 999999999 2047.89 3280.69 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 48261452_1 CDM 0250 RC 61553-0270-60 NDC J2795 HCPCS inpatient 1200 UN 3382.15 2198.4 UMR - ALL PLANS UMR - ALL PLANS 2367.51 70 999999999 2047.89 3280.69 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 48261452_1 CDM 0250 RC 61553-0270-60 NDC J2795 HCPCS inpatient 1200 UN 3382.15 2198.4 SIHO - ALL PLANS SIHO - ALL PLANS 3043.94 90 999999999 2047.89 3280.69 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 48261452_1 CDM 0250 RC 61553-0270-60 NDC J2795 HCPCS inpatient 1200 UN 3382.15 2198.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2047.89 60.55 999999999 2047.89 3280.69 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 48261452_1 CDM 0250 RC 61553-0270-60 NDC J2795 HCPCS inpatient 1200 UN 3382.15 2198.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2047.89 3280.69 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 48261452_1 CDM 0250 RC 61553-0270-60 NDC J2795 HCPCS inpatient 1200 UN 3382.15 2198.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2047.89 3280.69 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 48261452_1 CDM 0250 RC 61553-0270-60 NDC J2795 HCPCS inpatient 1200 UN 3382.15 2198.4 ANTHEM HMO ANTHEM HMO 999999999 2047.89 3280.69 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 48261452_1 CDM 0250 RC 61553-0270-60 NDC J2795 HCPCS inpatient 1200 UN 3382.15 2198.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2047.89 3280.69 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 48261452_1 CDM 0250 RC 61553-0270-60 NDC J2795 HCPCS inpatient 1200 UN 3382.15 2198.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 2286.33 67.6 999999999 2047.89 3280.69 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 48261452_1 CDM 0250 RC 61553-0270-60 NDC J2795 HCPCS inpatient 1200 UN 3382.15 2198.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 2047.89 3280.69 JANUVIA 100 MG TABLET 48261474_1 CDM 0250 RC 00006-0277-28 NDC inpatient 1 UN 70.26 45.67 AETNA AETNA 55.51 79 999999999 42.54 68.15 percent of total billed charges JANUVIA 100 MG TABLET 48261474_1 CDM 0250 RC 00006-0277-28 NDC inpatient 1 UN 70.26 45.67 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.67 65 999999999 42.54 68.15 percent of total billed charges JANUVIA 100 MG TABLET 48261474_1 CDM 0250 RC 00006-0277-28 NDC inpatient 1 UN 70.26 45.67 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 68.15 97 999999999 42.54 68.15 percent of total billed charges JANUVIA 100 MG TABLET 48261474_1 CDM 0250 RC 00006-0277-28 NDC inpatient 1 UN 70.26 45.67 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.8 78 999999999 42.54 68.15 percent of total billed charges JANUVIA 100 MG TABLET 48261474_1 CDM 0250 RC 00006-0277-28 NDC inpatient 1 UN 70.26 45.67 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.48 69 999999999 42.54 68.15 percent of total billed charges JANUVIA 100 MG TABLET 48261474_1 CDM 0250 RC 00006-0277-28 NDC inpatient 1 UN 70.26 45.67 UMR - ALL PLANS UMR - ALL PLANS 49.18 70 999999999 42.54 68.15 percent of total billed charges JANUVIA 100 MG TABLET 48261474_1 CDM 0250 RC 00006-0277-28 NDC inpatient 1 UN 70.26 45.67 SIHO - ALL PLANS SIHO - ALL PLANS 63.23 90 999999999 42.54 68.15 percent of total billed charges JANUVIA 100 MG TABLET 48261474_1 CDM 0250 RC 00006-0277-28 NDC inpatient 1 UN 70.26 45.67 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.54 60.55 999999999 42.54 68.15 percent of total billed charges JANUVIA 100 MG TABLET 48261474_1 CDM 0250 RC 00006-0277-28 NDC inpatient 1 UN 70.26 45.67 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.54 68.15 JANUVIA 100 MG TABLET 48261474_1 CDM 0250 RC 00006-0277-28 NDC inpatient 1 UN 70.26 45.67 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.54 68.15 JANUVIA 100 MG TABLET 48261474_1 CDM 0250 RC 00006-0277-28 NDC inpatient 1 UN 70.26 45.67 ANTHEM HMO ANTHEM HMO 999999999 42.54 68.15 JANUVIA 100 MG TABLET 48261474_1 CDM 0250 RC 00006-0277-28 NDC inpatient 1 UN 70.26 45.67 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.54 68.15 JANUVIA 100 MG TABLET 48261474_1 CDM 0250 RC 00006-0277-28 NDC inpatient 1 UN 70.26 45.67 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.5 67.6 999999999 42.54 68.15 percent of total billed charges JANUVIA 100 MG TABLET 48261474_1 CDM 0250 RC 00006-0277-28 NDC inpatient 1 UN 70.26 45.67 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.54 68.15 SODIUM BICARBONATE 8.4% VIAL 48261479_1 CDM 0250 RC 00409-6625-02 NDC inpatient 1 UN 38.25 24.86 AETNA AETNA 30.22 79 999999999 23.16 37.1 percent of total billed charges SODIUM BICARBONATE 8.4% VIAL 48261479_1 CDM 0250 RC 00409-6625-02 NDC inpatient 1 UN 38.25 24.86 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.86 65 999999999 23.16 37.1 percent of total billed charges SODIUM BICARBONATE 8.4% VIAL 48261479_1 CDM 0250 RC 00409-6625-02 NDC inpatient 1 UN 38.25 24.86 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37.1 97 999999999 23.16 37.1 percent of total billed charges SODIUM BICARBONATE 8.4% VIAL 48261479_1 CDM 0250 RC 00409-6625-02 NDC inpatient 1 UN 38.25 24.86 HUMANA - ALL PLANS HUMANA - ALL PLANS 29.84 78 999999999 23.16 37.1 percent of total billed charges SODIUM BICARBONATE 8.4% VIAL 48261479_1 CDM 0250 RC 00409-6625-02 NDC inpatient 1 UN 38.25 24.86 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.39 69 999999999 23.16 37.1 percent of total billed charges SODIUM BICARBONATE 8.4% VIAL 48261479_1 CDM 0250 RC 00409-6625-02 NDC inpatient 1 UN 38.25 24.86 UMR - ALL PLANS UMR - ALL PLANS 26.78 70 999999999 23.16 37.1 percent of total billed charges SODIUM BICARBONATE 8.4% VIAL 48261479_1 CDM 0250 RC 00409-6625-02 NDC inpatient 1 UN 38.25 24.86 SIHO - ALL PLANS SIHO - ALL PLANS 34.43 90 999999999 23.16 37.1 percent of total billed charges SODIUM BICARBONATE 8.4% VIAL 48261479_1 CDM 0250 RC 00409-6625-02 NDC inpatient 1 UN 38.25 24.86 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.16 60.55 999999999 23.16 37.1 percent of total billed charges SODIUM BICARBONATE 8.4% VIAL 48261479_1 CDM 0250 RC 00409-6625-02 NDC inpatient 1 UN 38.25 24.86 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.16 37.1 SODIUM BICARBONATE 8.4% VIAL 48261479_1 CDM 0250 RC 00409-6625-02 NDC inpatient 1 UN 38.25 24.86 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.16 37.1 SODIUM BICARBONATE 8.4% VIAL 48261479_1 CDM 0250 RC 00409-6625-02 NDC inpatient 1 UN 38.25 24.86 ANTHEM HMO ANTHEM HMO 999999999 23.16 37.1 SODIUM BICARBONATE 8.4% VIAL 48261479_1 CDM 0250 RC 00409-6625-02 NDC inpatient 1 UN 38.25 24.86 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.16 37.1 SODIUM BICARBONATE 8.4% VIAL 48261479_1 CDM 0250 RC 00409-6625-02 NDC inpatient 1 UN 38.25 24.86 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.86 67.6 999999999 23.16 37.1 percent of total billed charges SODIUM BICARBONATE 8.4% VIAL 48261479_1 CDM 0250 RC 00409-6625-02 NDC inpatient 1 UN 38.25 24.86 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.16 37.1 SODIUM CHLORIDE 0.9% SOL-EXCEL 48261485_1 CDM 0250 RC 00264-7800-20 NDC inpatient 1 UN 61.59 40.03 AETNA AETNA 48.66 79 999999999 37.29 59.74 percent of total billed charges SODIUM CHLORIDE 0.9% SOL-EXCEL 48261485_1 CDM 0250 RC 00264-7800-20 NDC inpatient 1 UN 61.59 40.03 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.03 65 999999999 37.29 59.74 percent of total billed charges SODIUM CHLORIDE 0.9% SOL-EXCEL 48261485_1 CDM 0250 RC 00264-7800-20 NDC inpatient 1 UN 61.59 40.03 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59.74 97 999999999 37.29 59.74 percent of total billed charges SODIUM CHLORIDE 0.9% SOL-EXCEL 48261485_1 CDM 0250 RC 00264-7800-20 NDC inpatient 1 UN 61.59 40.03 HUMANA - ALL PLANS HUMANA - ALL PLANS 48.04 78 999999999 37.29 59.74 percent of total billed charges SODIUM CHLORIDE 0.9% SOL-EXCEL 48261485_1 CDM 0250 RC 00264-7800-20 NDC inpatient 1 UN 61.59 40.03 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.5 69 999999999 37.29 59.74 percent of total billed charges SODIUM CHLORIDE 0.9% SOL-EXCEL 48261485_1 CDM 0250 RC 00264-7800-20 NDC inpatient 1 UN 61.59 40.03 UMR - ALL PLANS UMR - ALL PLANS 43.11 70 999999999 37.29 59.74 percent of total billed charges SODIUM CHLORIDE 0.9% SOL-EXCEL 48261485_1 CDM 0250 RC 00264-7800-20 NDC inpatient 1 UN 61.59 40.03 SIHO - ALL PLANS SIHO - ALL PLANS 55.43 90 999999999 37.29 59.74 percent of total billed charges SODIUM CHLORIDE 0.9% SOL-EXCEL 48261485_1 CDM 0250 RC 00264-7800-20 NDC inpatient 1 UN 61.59 40.03 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 37.29 60.55 999999999 37.29 59.74 percent of total billed charges SODIUM CHLORIDE 0.9% SOL-EXCEL 48261485_1 CDM 0250 RC 00264-7800-20 NDC inpatient 1 UN 61.59 40.03 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 37.29 59.74 SODIUM CHLORIDE 0.9% SOL-EXCEL 48261485_1 CDM 0250 RC 00264-7800-20 NDC inpatient 1 UN 61.59 40.03 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 37.29 59.74 SODIUM CHLORIDE 0.9% SOL-EXCEL 48261485_1 CDM 0250 RC 00264-7800-20 NDC inpatient 1 UN 61.59 40.03 ANTHEM HMO ANTHEM HMO 999999999 37.29 59.74 SODIUM CHLORIDE 0.9% SOL-EXCEL 48261485_1 CDM 0250 RC 00264-7800-20 NDC inpatient 1 UN 61.59 40.03 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 37.29 59.74 SODIUM CHLORIDE 0.9% SOL-EXCEL 48261485_1 CDM 0250 RC 00264-7800-20 NDC inpatient 1 UN 61.59 40.03 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.63 67.6 999999999 37.29 59.74 percent of total billed charges SODIUM CHLORIDE 0.9% SOL-EXCEL 48261485_1 CDM 0250 RC 00264-7800-20 NDC inpatient 1 UN 61.59 40.03 UHC - ALL PLANS UHC - ALL PLANS 999999999 37.29 59.74 SODIUM CHLORIDE 0.9% SOLUTION 48261487_1 CDM 0250 RC 00338-0049-03 NDC inpatient 1 UN 59.05 38.38 AETNA AETNA 46.65 79 999999999 35.75 57.28 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 48261487_1 CDM 0250 RC 00338-0049-03 NDC inpatient 1 UN 59.05 38.38 SELF PAY DISCOUNT SELF PAY DISCOUNT 38.38 65 999999999 35.75 57.28 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 48261487_1 CDM 0250 RC 00338-0049-03 NDC inpatient 1 UN 59.05 38.38 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 57.28 97 999999999 35.75 57.28 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 48261487_1 CDM 0250 RC 00338-0049-03 NDC inpatient 1 UN 59.05 38.38 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.06 78 999999999 35.75 57.28 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 48261487_1 CDM 0250 RC 00338-0049-03 NDC inpatient 1 UN 59.05 38.38 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.74 69 999999999 35.75 57.28 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 48261487_1 CDM 0250 RC 00338-0049-03 NDC inpatient 1 UN 59.05 38.38 UMR - ALL PLANS UMR - ALL PLANS 41.34 70 999999999 35.75 57.28 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 48261487_1 CDM 0250 RC 00338-0049-03 NDC inpatient 1 UN 59.05 38.38 SIHO - ALL PLANS SIHO - ALL PLANS 53.15 90 999999999 35.75 57.28 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 48261487_1 CDM 0250 RC 00338-0049-03 NDC inpatient 1 UN 59.05 38.38 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.75 60.55 999999999 35.75 57.28 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 48261487_1 CDM 0250 RC 00338-0049-03 NDC inpatient 1 UN 59.05 38.38 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.75 57.28 SODIUM CHLORIDE 0.9% SOLUTION 48261487_1 CDM 0250 RC 00338-0049-03 NDC inpatient 1 UN 59.05 38.38 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.75 57.28 SODIUM CHLORIDE 0.9% SOLUTION 48261487_1 CDM 0250 RC 00338-0049-03 NDC inpatient 1 UN 59.05 38.38 ANTHEM HMO ANTHEM HMO 999999999 35.75 57.28 SODIUM CHLORIDE 0.9% SOLUTION 48261487_1 CDM 0250 RC 00338-0049-03 NDC inpatient 1 UN 59.05 38.38 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.75 57.28 SODIUM CHLORIDE 0.9% SOLUTION 48261487_1 CDM 0250 RC 00338-0049-03 NDC inpatient 1 UN 59.05 38.38 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.92 67.6 999999999 35.75 57.28 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 48261487_1 CDM 0250 RC 00338-0049-03 NDC inpatient 1 UN 59.05 38.38 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.75 57.28 SODIUM CHLORIDE 0.9% SOLUTION 48261489_1 CDM 0250 RC 00338-0553-11 NDC inpatient 1 UN 64.27 41.78 AETNA AETNA 50.77 79 999999999 38.92 62.34 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 48261489_1 CDM 0250 RC 00338-0553-11 NDC inpatient 1 UN 64.27 41.78 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.78 65 999999999 38.92 62.34 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 48261489_1 CDM 0250 RC 00338-0553-11 NDC inpatient 1 UN 64.27 41.78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 62.34 97 999999999 38.92 62.34 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 48261489_1 CDM 0250 RC 00338-0553-11 NDC inpatient 1 UN 64.27 41.78 HUMANA - ALL PLANS HUMANA - ALL PLANS 50.13 78 999999999 38.92 62.34 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 48261489_1 CDM 0250 RC 00338-0553-11 NDC inpatient 1 UN 64.27 41.78 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.35 69 999999999 38.92 62.34 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 48261489_1 CDM 0250 RC 00338-0553-11 NDC inpatient 1 UN 64.27 41.78 UMR - ALL PLANS UMR - ALL PLANS 44.99 70 999999999 38.92 62.34 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 48261489_1 CDM 0250 RC 00338-0553-11 NDC inpatient 1 UN 64.27 41.78 SIHO - ALL PLANS SIHO - ALL PLANS 57.84 90 999999999 38.92 62.34 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 48261489_1 CDM 0250 RC 00338-0553-11 NDC inpatient 1 UN 64.27 41.78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.92 60.55 999999999 38.92 62.34 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 48261489_1 CDM 0250 RC 00338-0553-11 NDC inpatient 1 UN 64.27 41.78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.92 62.34 SODIUM CHLORIDE 0.9% SOLUTION 48261489_1 CDM 0250 RC 00338-0553-11 NDC inpatient 1 UN 64.27 41.78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.92 62.34 SODIUM CHLORIDE 0.9% SOLUTION 48261489_1 CDM 0250 RC 00338-0553-11 NDC inpatient 1 UN 64.27 41.78 ANTHEM HMO ANTHEM HMO 999999999 38.92 62.34 SODIUM CHLORIDE 0.9% SOLUTION 48261489_1 CDM 0250 RC 00338-0553-11 NDC inpatient 1 UN 64.27 41.78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.92 62.34 SODIUM CHLORIDE 0.9% SOLUTION 48261489_1 CDM 0250 RC 00338-0553-11 NDC inpatient 1 UN 64.27 41.78 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.45 67.6 999999999 38.92 62.34 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 48261489_1 CDM 0250 RC 00338-0553-11 NDC inpatient 1 UN 64.27 41.78 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.92 62.34 SODIUM CHLORIDE 3% IV SOLN 48261496_1 CDM 0250 RC 00338-0054-03 NDC inpatient 1 UN 54.38 35.35 AETNA AETNA 42.96 79 999999999 32.93 52.75 percent of total billed charges SODIUM CHLORIDE 3% IV SOLN 48261496_1 CDM 0250 RC 00338-0054-03 NDC inpatient 1 UN 54.38 35.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 35.35 65 999999999 32.93 52.75 percent of total billed charges SODIUM CHLORIDE 3% IV SOLN 48261496_1 CDM 0250 RC 00338-0054-03 NDC inpatient 1 UN 54.38 35.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 52.75 97 999999999 32.93 52.75 percent of total billed charges SODIUM CHLORIDE 3% IV SOLN 48261496_1 CDM 0250 RC 00338-0054-03 NDC inpatient 1 UN 54.38 35.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 42.42 78 999999999 32.93 52.75 percent of total billed charges SODIUM CHLORIDE 3% IV SOLN 48261496_1 CDM 0250 RC 00338-0054-03 NDC inpatient 1 UN 54.38 35.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 37.52 69 999999999 32.93 52.75 percent of total billed charges SODIUM CHLORIDE 3% IV SOLN 48261496_1 CDM 0250 RC 00338-0054-03 NDC inpatient 1 UN 54.38 35.35 UMR - ALL PLANS UMR - ALL PLANS 38.07 70 999999999 32.93 52.75 percent of total billed charges SODIUM CHLORIDE 3% IV SOLN 48261496_1 CDM 0250 RC 00338-0054-03 NDC inpatient 1 UN 54.38 35.35 SIHO - ALL PLANS SIHO - ALL PLANS 48.94 90 999999999 32.93 52.75 percent of total billed charges SODIUM CHLORIDE 3% IV SOLN 48261496_1 CDM 0250 RC 00338-0054-03 NDC inpatient 1 UN 54.38 35.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.93 60.55 999999999 32.93 52.75 percent of total billed charges SODIUM CHLORIDE 3% IV SOLN 48261496_1 CDM 0250 RC 00338-0054-03 NDC inpatient 1 UN 54.38 35.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.93 52.75 SODIUM CHLORIDE 3% IV SOLN 48261496_1 CDM 0250 RC 00338-0054-03 NDC inpatient 1 UN 54.38 35.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.93 52.75 SODIUM CHLORIDE 3% IV SOLN 48261496_1 CDM 0250 RC 00338-0054-03 NDC inpatient 1 UN 54.38 35.35 ANTHEM HMO ANTHEM HMO 999999999 32.93 52.75 SODIUM CHLORIDE 3% IV SOLN 48261496_1 CDM 0250 RC 00338-0054-03 NDC inpatient 1 UN 54.38 35.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.93 52.75 SODIUM CHLORIDE 3% IV SOLN 48261496_1 CDM 0250 RC 00338-0054-03 NDC inpatient 1 UN 54.38 35.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 36.76 67.6 999999999 32.93 52.75 percent of total billed charges SODIUM CHLORIDE 3% IV SOLN 48261496_1 CDM 0250 RC 00338-0054-03 NDC inpatient 1 UN 54.38 35.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.93 52.75 00409-1966-04 - sodium chloride bacteriostatic 0.9% Inj Sol 10 mL [JOHN] 48261497_1 CDM 0250 RC 00409-1966-04 NDC inpatient 1 UN 27.08 17.6 AETNA AETNA 21.39 79 999999999 16.4 26.27 percent of total billed charges 00409-1966-04 - sodium chloride bacteriostatic 0.9% Inj Sol 10 mL [JOHN] 48261497_1 CDM 0250 RC 00409-1966-04 NDC inpatient 1 UN 27.08 17.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.6 65 999999999 16.4 26.27 percent of total billed charges 00409-1966-04 - sodium chloride bacteriostatic 0.9% Inj Sol 10 mL [JOHN] 48261497_1 CDM 0250 RC 00409-1966-04 NDC inpatient 1 UN 27.08 17.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26.27 97 999999999 16.4 26.27 percent of total billed charges 00409-1966-04 - sodium chloride bacteriostatic 0.9% Inj Sol 10 mL [JOHN] 48261497_1 CDM 0250 RC 00409-1966-04 NDC inpatient 1 UN 27.08 17.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.12 78 999999999 16.4 26.27 percent of total billed charges 00409-1966-04 - sodium chloride bacteriostatic 0.9% Inj Sol 10 mL [JOHN] 48261497_1 CDM 0250 RC 00409-1966-04 NDC inpatient 1 UN 27.08 17.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.69 69 999999999 16.4 26.27 percent of total billed charges 00409-1966-04 - sodium chloride bacteriostatic 0.9% Inj Sol 10 mL [JOHN] 48261497_1 CDM 0250 RC 00409-1966-04 NDC inpatient 1 UN 27.08 17.6 UMR - ALL PLANS UMR - ALL PLANS 18.96 70 999999999 16.4 26.27 percent of total billed charges 00409-1966-04 - sodium chloride bacteriostatic 0.9% Inj Sol 10 mL [JOHN] 48261497_1 CDM 0250 RC 00409-1966-04 NDC inpatient 1 UN 27.08 17.6 SIHO - ALL PLANS SIHO - ALL PLANS 24.37 90 999999999 16.4 26.27 percent of total billed charges 00409-1966-04 - sodium chloride bacteriostatic 0.9% Inj Sol 10 mL [JOHN] 48261497_1 CDM 0250 RC 00409-1966-04 NDC inpatient 1 UN 27.08 17.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.4 60.55 999999999 16.4 26.27 percent of total billed charges 00409-1966-04 - sodium chloride bacteriostatic 0.9% Inj Sol 10 mL [JOHN] 48261497_1 CDM 0250 RC 00409-1966-04 NDC inpatient 1 UN 27.08 17.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.4 26.27 00409-1966-04 - sodium chloride bacteriostatic 0.9% Inj Sol 10 mL [JOHN] 48261497_1 CDM 0250 RC 00409-1966-04 NDC inpatient 1 UN 27.08 17.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.4 26.27 00409-1966-04 - sodium chloride bacteriostatic 0.9% Inj Sol 10 mL [JOHN] 48261497_1 CDM 0250 RC 00409-1966-04 NDC inpatient 1 UN 27.08 17.6 ANTHEM HMO ANTHEM HMO 999999999 16.4 26.27 00409-1966-04 - sodium chloride bacteriostatic 0.9% Inj Sol 10 mL [JOHN] 48261497_1 CDM 0250 RC 00409-1966-04 NDC inpatient 1 UN 27.08 17.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.4 26.27 00409-1966-04 - sodium chloride bacteriostatic 0.9% Inj Sol 10 mL [JOHN] 48261497_1 CDM 0250 RC 00409-1966-04 NDC inpatient 1 UN 27.08 17.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.31 67.6 999999999 16.4 26.27 percent of total billed charges 00409-1966-04 - sodium chloride bacteriostatic 0.9% Inj Sol 10 mL [JOHN] 48261497_1 CDM 0250 RC 00409-1966-04 NDC inpatient 1 UN 27.08 17.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.4 26.27 DEEP SEA 0.65% NOSE SPRAY 48261498_1 CDM 0250 RC 00904-3865-75 NDC inpatient 1 UN 1.51 0.98 AETNA AETNA 1.19 79 999999999 0.91 1.46 percent of total billed charges DEEP SEA 0.65% NOSE SPRAY 48261498_1 CDM 0250 RC 00904-3865-75 NDC inpatient 1 UN 1.51 0.98 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.98 65 999999999 0.91 1.46 percent of total billed charges DEEP SEA 0.65% NOSE SPRAY 48261498_1 CDM 0250 RC 00904-3865-75 NDC inpatient 1 UN 1.51 0.98 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.46 97 999999999 0.91 1.46 percent of total billed charges DEEP SEA 0.65% NOSE SPRAY 48261498_1 CDM 0250 RC 00904-3865-75 NDC inpatient 1 UN 1.51 0.98 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.18 78 999999999 0.91 1.46 percent of total billed charges DEEP SEA 0.65% NOSE SPRAY 48261498_1 CDM 0250 RC 00904-3865-75 NDC inpatient 1 UN 1.51 0.98 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.04 69 999999999 0.91 1.46 percent of total billed charges DEEP SEA 0.65% NOSE SPRAY 48261498_1 CDM 0250 RC 00904-3865-75 NDC inpatient 1 UN 1.51 0.98 UMR - ALL PLANS UMR - ALL PLANS 1.06 70 999999999 0.91 1.46 percent of total billed charges DEEP SEA 0.65% NOSE SPRAY 48261498_1 CDM 0250 RC 00904-3865-75 NDC inpatient 1 UN 1.51 0.98 SIHO - ALL PLANS SIHO - ALL PLANS 1.36 90 999999999 0.91 1.46 percent of total billed charges DEEP SEA 0.65% NOSE SPRAY 48261498_1 CDM 0250 RC 00904-3865-75 NDC inpatient 1 UN 1.51 0.98 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.91 60.55 999999999 0.91 1.46 percent of total billed charges DEEP SEA 0.65% NOSE SPRAY 48261498_1 CDM 0250 RC 00904-3865-75 NDC inpatient 1 UN 1.51 0.98 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.91 1.46 DEEP SEA 0.65% NOSE SPRAY 48261498_1 CDM 0250 RC 00904-3865-75 NDC inpatient 1 UN 1.51 0.98 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.91 1.46 DEEP SEA 0.65% NOSE SPRAY 48261498_1 CDM 0250 RC 00904-3865-75 NDC inpatient 1 UN 1.51 0.98 ANTHEM HMO ANTHEM HMO 999999999 0.91 1.46 DEEP SEA 0.65% NOSE SPRAY 48261498_1 CDM 0250 RC 00904-3865-75 NDC inpatient 1 UN 1.51 0.98 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.91 1.46 DEEP SEA 0.65% NOSE SPRAY 48261498_1 CDM 0250 RC 00904-3865-75 NDC inpatient 1 UN 1.51 0.98 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.02 67.6 999999999 0.91 1.46 percent of total billed charges DEEP SEA 0.65% NOSE SPRAY 48261498_1 CDM 0250 RC 00904-3865-75 NDC inpatient 1 UN 1.51 0.98 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.91 1.46 HYSEPT 0.25% SOLUTION 48261503_1 CDM 0250 RC 39328-0063-25 NDC inpatient 1 UN 47.7 31.01 AETNA AETNA 37.68 79 999999999 28.88 46.27 percent of total billed charges HYSEPT 0.25% SOLUTION 48261503_1 CDM 0250 RC 39328-0063-25 NDC inpatient 1 UN 47.7 31.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.01 65 999999999 28.88 46.27 percent of total billed charges HYSEPT 0.25% SOLUTION 48261503_1 CDM 0250 RC 39328-0063-25 NDC inpatient 1 UN 47.7 31.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 46.27 97 999999999 28.88 46.27 percent of total billed charges HYSEPT 0.25% SOLUTION 48261503_1 CDM 0250 RC 39328-0063-25 NDC inpatient 1 UN 47.7 31.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 37.21 78 999999999 28.88 46.27 percent of total billed charges HYSEPT 0.25% SOLUTION 48261503_1 CDM 0250 RC 39328-0063-25 NDC inpatient 1 UN 47.7 31.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 32.91 69 999999999 28.88 46.27 percent of total billed charges HYSEPT 0.25% SOLUTION 48261503_1 CDM 0250 RC 39328-0063-25 NDC inpatient 1 UN 47.7 31.01 UMR - ALL PLANS UMR - ALL PLANS 33.39 70 999999999 28.88 46.27 percent of total billed charges HYSEPT 0.25% SOLUTION 48261503_1 CDM 0250 RC 39328-0063-25 NDC inpatient 1 UN 47.7 31.01 SIHO - ALL PLANS SIHO - ALL PLANS 42.93 90 999999999 28.88 46.27 percent of total billed charges HYSEPT 0.25% SOLUTION 48261503_1 CDM 0250 RC 39328-0063-25 NDC inpatient 1 UN 47.7 31.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 28.88 60.55 999999999 28.88 46.27 percent of total billed charges HYSEPT 0.25% SOLUTION 48261503_1 CDM 0250 RC 39328-0063-25 NDC inpatient 1 UN 47.7 31.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 28.88 46.27 HYSEPT 0.25% SOLUTION 48261503_1 CDM 0250 RC 39328-0063-25 NDC inpatient 1 UN 47.7 31.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 28.88 46.27 HYSEPT 0.25% SOLUTION 48261503_1 CDM 0250 RC 39328-0063-25 NDC inpatient 1 UN 47.7 31.01 ANTHEM HMO ANTHEM HMO 999999999 28.88 46.27 HYSEPT 0.25% SOLUTION 48261503_1 CDM 0250 RC 39328-0063-25 NDC inpatient 1 UN 47.7 31.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 28.88 46.27 HYSEPT 0.25% SOLUTION 48261503_1 CDM 0250 RC 39328-0063-25 NDC inpatient 1 UN 47.7 31.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 32.25 67.6 999999999 28.88 46.27 percent of total billed charges HYSEPT 0.25% SOLUTION 48261503_1 CDM 0250 RC 39328-0063-25 NDC inpatient 1 UN 47.7 31.01 UHC - ALL PLANS UHC - ALL PLANS 999999999 28.88 46.27 00603-5770-21 - sotalol 120 mg Tab [JOHN] 48261511_1 CDM 0250 RC 00603-5770-21 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 00603-5770-21 - sotalol 120 mg Tab [JOHN] 48261511_1 CDM 0250 RC 00603-5770-21 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 00603-5770-21 - sotalol 120 mg Tab [JOHN] 48261511_1 CDM 0250 RC 00603-5770-21 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 00603-5770-21 - sotalol 120 mg Tab [JOHN] 48261511_1 CDM 0250 RC 00603-5770-21 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 00603-5770-21 - sotalol 120 mg Tab [JOHN] 48261511_1 CDM 0250 RC 00603-5770-21 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 00603-5770-21 - sotalol 120 mg Tab [JOHN] 48261511_1 CDM 0250 RC 00603-5770-21 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 00603-5770-21 - sotalol 120 mg Tab [JOHN] 48261511_1 CDM 0250 RC 00603-5770-21 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 00603-5770-21 - sotalol 120 mg Tab [JOHN] 48261511_1 CDM 0250 RC 00603-5770-21 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 00603-5770-21 - sotalol 120 mg Tab [JOHN] 48261511_1 CDM 0250 RC 00603-5770-21 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 00603-5770-21 - sotalol 120 mg Tab [JOHN] 48261511_1 CDM 0250 RC 00603-5770-21 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 00603-5770-21 - sotalol 120 mg Tab [JOHN] 48261511_1 CDM 0250 RC 00603-5770-21 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 00603-5770-21 - sotalol 120 mg Tab [JOHN] 48261511_1 CDM 0250 RC 00603-5770-21 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 00603-5770-21 - sotalol 120 mg Tab [JOHN] 48261511_1 CDM 0250 RC 00603-5770-21 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 00603-5770-21 - sotalol 120 mg Tab [JOHN] 48261511_1 CDM 0250 RC 00603-5770-21 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 SPIRONOLACTONE 25 MG TABLET 48261514_1 CDM 0250 RC 51079-0103-20 NDC inpatient 1 UN 1.42 0.92 AETNA AETNA 1.12 79 999999999 0.86 1.38 percent of total billed charges SPIRONOLACTONE 25 MG TABLET 48261514_1 CDM 0250 RC 51079-0103-20 NDC inpatient 1 UN 1.42 0.92 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.92 65 999999999 0.86 1.38 percent of total billed charges SPIRONOLACTONE 25 MG TABLET 48261514_1 CDM 0250 RC 51079-0103-20 NDC inpatient 1 UN 1.42 0.92 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.38 97 999999999 0.86 1.38 percent of total billed charges SPIRONOLACTONE 25 MG TABLET 48261514_1 CDM 0250 RC 51079-0103-20 NDC inpatient 1 UN 1.42 0.92 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.11 78 999999999 0.86 1.38 percent of total billed charges SPIRONOLACTONE 25 MG TABLET 48261514_1 CDM 0250 RC 51079-0103-20 NDC inpatient 1 UN 1.42 0.92 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.98 69 999999999 0.86 1.38 percent of total billed charges SPIRONOLACTONE 25 MG TABLET 48261514_1 CDM 0250 RC 51079-0103-20 NDC inpatient 1 UN 1.42 0.92 UMR - ALL PLANS UMR - ALL PLANS 0.99 70 999999999 0.86 1.38 percent of total billed charges SPIRONOLACTONE 25 MG TABLET 48261514_1 CDM 0250 RC 51079-0103-20 NDC inpatient 1 UN 1.42 0.92 SIHO - ALL PLANS SIHO - ALL PLANS 1.28 90 999999999 0.86 1.38 percent of total billed charges SPIRONOLACTONE 25 MG TABLET 48261514_1 CDM 0250 RC 51079-0103-20 NDC inpatient 1 UN 1.42 0.92 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.86 60.55 999999999 0.86 1.38 percent of total billed charges SPIRONOLACTONE 25 MG TABLET 48261514_1 CDM 0250 RC 51079-0103-20 NDC inpatient 1 UN 1.42 0.92 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.86 1.38 SPIRONOLACTONE 25 MG TABLET 48261514_1 CDM 0250 RC 51079-0103-20 NDC inpatient 1 UN 1.42 0.92 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.86 1.38 SPIRONOLACTONE 25 MG TABLET 48261514_1 CDM 0250 RC 51079-0103-20 NDC inpatient 1 UN 1.42 0.92 ANTHEM HMO ANTHEM HMO 999999999 0.86 1.38 SPIRONOLACTONE 25 MG TABLET 48261514_1 CDM 0250 RC 51079-0103-20 NDC inpatient 1 UN 1.42 0.92 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.86 1.38 SPIRONOLACTONE 25 MG TABLET 48261514_1 CDM 0250 RC 51079-0103-20 NDC inpatient 1 UN 1.42 0.92 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.96 67.6 999999999 0.86 1.38 percent of total billed charges SPIRONOLACTONE 25 MG TABLET 48261514_1 CDM 0250 RC 51079-0103-20 NDC inpatient 1 UN 1.42 0.92 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.86 1.38 SULFAMETHOXAZOLE-TMP IV VIAL 48261520_1 CDM 0250 RC 00703-9503-03 NDC inpatient 1 UN 32.47 21.11 AETNA AETNA 25.65 79 999999999 19.66 31.5 percent of total billed charges SULFAMETHOXAZOLE-TMP IV VIAL 48261520_1 CDM 0250 RC 00703-9503-03 NDC inpatient 1 UN 32.47 21.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.11 65 999999999 19.66 31.5 percent of total billed charges SULFAMETHOXAZOLE-TMP IV VIAL 48261520_1 CDM 0250 RC 00703-9503-03 NDC inpatient 1 UN 32.47 21.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31.5 97 999999999 19.66 31.5 percent of total billed charges SULFAMETHOXAZOLE-TMP IV VIAL 48261520_1 CDM 0250 RC 00703-9503-03 NDC inpatient 1 UN 32.47 21.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.33 78 999999999 19.66 31.5 percent of total billed charges SULFAMETHOXAZOLE-TMP IV VIAL 48261520_1 CDM 0250 RC 00703-9503-03 NDC inpatient 1 UN 32.47 21.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.4 69 999999999 19.66 31.5 percent of total billed charges SULFAMETHOXAZOLE-TMP IV VIAL 48261520_1 CDM 0250 RC 00703-9503-03 NDC inpatient 1 UN 32.47 21.11 UMR - ALL PLANS UMR - ALL PLANS 22.73 70 999999999 19.66 31.5 percent of total billed charges SULFAMETHOXAZOLE-TMP IV VIAL 48261520_1 CDM 0250 RC 00703-9503-03 NDC inpatient 1 UN 32.47 21.11 SIHO - ALL PLANS SIHO - ALL PLANS 29.22 90 999999999 19.66 31.5 percent of total billed charges SULFAMETHOXAZOLE-TMP IV VIAL 48261520_1 CDM 0250 RC 00703-9503-03 NDC inpatient 1 UN 32.47 21.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.66 60.55 999999999 19.66 31.5 percent of total billed charges SULFAMETHOXAZOLE-TMP IV VIAL 48261520_1 CDM 0250 RC 00703-9503-03 NDC inpatient 1 UN 32.47 21.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.66 31.5 SULFAMETHOXAZOLE-TMP IV VIAL 48261520_1 CDM 0250 RC 00703-9503-03 NDC inpatient 1 UN 32.47 21.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.66 31.5 SULFAMETHOXAZOLE-TMP IV VIAL 48261520_1 CDM 0250 RC 00703-9503-03 NDC inpatient 1 UN 32.47 21.11 ANTHEM HMO ANTHEM HMO 999999999 19.66 31.5 SULFAMETHOXAZOLE-TMP IV VIAL 48261520_1 CDM 0250 RC 00703-9503-03 NDC inpatient 1 UN 32.47 21.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.66 31.5 SULFAMETHOXAZOLE-TMP IV VIAL 48261520_1 CDM 0250 RC 00703-9503-03 NDC inpatient 1 UN 32.47 21.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.95 67.6 999999999 19.66 31.5 percent of total billed charges SULFAMETHOXAZOLE-TMP IV VIAL 48261520_1 CDM 0250 RC 00703-9503-03 NDC inpatient 1 UN 32.47 21.11 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.66 31.5 MICARDIS 40 MG TABLET 48261531_1 CDM 0250 RC 00597-0040-37 NDC inpatient 1 UN 21.6 14.04 AETNA AETNA 17.06 79 999999999 13.08 20.95 percent of total billed charges MICARDIS 40 MG TABLET 48261531_1 CDM 0250 RC 00597-0040-37 NDC inpatient 1 UN 21.6 14.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.04 65 999999999 13.08 20.95 percent of total billed charges MICARDIS 40 MG TABLET 48261531_1 CDM 0250 RC 00597-0040-37 NDC inpatient 1 UN 21.6 14.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20.95 97 999999999 13.08 20.95 percent of total billed charges MICARDIS 40 MG TABLET 48261531_1 CDM 0250 RC 00597-0040-37 NDC inpatient 1 UN 21.6 14.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 16.85 78 999999999 13.08 20.95 percent of total billed charges MICARDIS 40 MG TABLET 48261531_1 CDM 0250 RC 00597-0040-37 NDC inpatient 1 UN 21.6 14.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 14.9 69 999999999 13.08 20.95 percent of total billed charges MICARDIS 40 MG TABLET 48261531_1 CDM 0250 RC 00597-0040-37 NDC inpatient 1 UN 21.6 14.04 UMR - ALL PLANS UMR - ALL PLANS 15.12 70 999999999 13.08 20.95 percent of total billed charges MICARDIS 40 MG TABLET 48261531_1 CDM 0250 RC 00597-0040-37 NDC inpatient 1 UN 21.6 14.04 SIHO - ALL PLANS SIHO - ALL PLANS 19.44 90 999999999 13.08 20.95 percent of total billed charges MICARDIS 40 MG TABLET 48261531_1 CDM 0250 RC 00597-0040-37 NDC inpatient 1 UN 21.6 14.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.08 60.55 999999999 13.08 20.95 percent of total billed charges MICARDIS 40 MG TABLET 48261531_1 CDM 0250 RC 00597-0040-37 NDC inpatient 1 UN 21.6 14.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.08 20.95 MICARDIS 40 MG TABLET 48261531_1 CDM 0250 RC 00597-0040-37 NDC inpatient 1 UN 21.6 14.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.08 20.95 MICARDIS 40 MG TABLET 48261531_1 CDM 0250 RC 00597-0040-37 NDC inpatient 1 UN 21.6 14.04 ANTHEM HMO ANTHEM HMO 999999999 13.08 20.95 MICARDIS 40 MG TABLET 48261531_1 CDM 0250 RC 00597-0040-37 NDC inpatient 1 UN 21.6 14.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.08 20.95 MICARDIS 40 MG TABLET 48261531_1 CDM 0250 RC 00597-0040-37 NDC inpatient 1 UN 21.6 14.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.6 67.6 999999999 13.08 20.95 percent of total billed charges MICARDIS 40 MG TABLET 48261531_1 CDM 0250 RC 00597-0040-37 NDC inpatient 1 UN 21.6 14.04 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.08 20.95 00904-6126-61 - terazosin 1 mg Cap [JOHN] 48261535_1 CDM 0250 RC 00904-6126-61 NDC inpatient 1 UN 1.23 0.8 AETNA AETNA 0.97 79 999999999 0.74 1.19 percent of total billed charges 00904-6126-61 - terazosin 1 mg Cap [JOHN] 48261535_1 CDM 0250 RC 00904-6126-61 NDC inpatient 1 UN 1.23 0.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.8 65 999999999 0.74 1.19 percent of total billed charges 00904-6126-61 - terazosin 1 mg Cap [JOHN] 48261535_1 CDM 0250 RC 00904-6126-61 NDC inpatient 1 UN 1.23 0.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.19 97 999999999 0.74 1.19 percent of total billed charges 00904-6126-61 - terazosin 1 mg Cap [JOHN] 48261535_1 CDM 0250 RC 00904-6126-61 NDC inpatient 1 UN 1.23 0.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.96 78 999999999 0.74 1.19 percent of total billed charges 00904-6126-61 - terazosin 1 mg Cap [JOHN] 48261535_1 CDM 0250 RC 00904-6126-61 NDC inpatient 1 UN 1.23 0.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.85 69 999999999 0.74 1.19 percent of total billed charges 00904-6126-61 - terazosin 1 mg Cap [JOHN] 48261535_1 CDM 0250 RC 00904-6126-61 NDC inpatient 1 UN 1.23 0.8 UMR - ALL PLANS UMR - ALL PLANS 0.86 70 999999999 0.74 1.19 percent of total billed charges 00904-6126-61 - terazosin 1 mg Cap [JOHN] 48261535_1 CDM 0250 RC 00904-6126-61 NDC inpatient 1 UN 1.23 0.8 SIHO - ALL PLANS SIHO - ALL PLANS 1.11 90 999999999 0.74 1.19 percent of total billed charges 00904-6126-61 - terazosin 1 mg Cap [JOHN] 48261535_1 CDM 0250 RC 00904-6126-61 NDC inpatient 1 UN 1.23 0.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.74 60.55 999999999 0.74 1.19 percent of total billed charges 00904-6126-61 - terazosin 1 mg Cap [JOHN] 48261535_1 CDM 0250 RC 00904-6126-61 NDC inpatient 1 UN 1.23 0.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.74 1.19 00904-6126-61 - terazosin 1 mg Cap [JOHN] 48261535_1 CDM 0250 RC 00904-6126-61 NDC inpatient 1 UN 1.23 0.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.74 1.19 00904-6126-61 - terazosin 1 mg Cap [JOHN] 48261535_1 CDM 0250 RC 00904-6126-61 NDC inpatient 1 UN 1.23 0.8 ANTHEM HMO ANTHEM HMO 999999999 0.74 1.19 00904-6126-61 - terazosin 1 mg Cap [JOHN] 48261535_1 CDM 0250 RC 00904-6126-61 NDC inpatient 1 UN 1.23 0.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.74 1.19 00904-6126-61 - terazosin 1 mg Cap [JOHN] 48261535_1 CDM 0250 RC 00904-6126-61 NDC inpatient 1 UN 1.23 0.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.83 67.6 999999999 0.74 1.19 percent of total billed charges 00904-6126-61 - terazosin 1 mg Cap [JOHN] 48261535_1 CDM 0250 RC 00904-6126-61 NDC inpatient 1 UN 1.23 0.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.74 1.19 "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48261545_1 CDM 0250 RC 58160-0842-52 NDC 90715 HCPCS inpatient 1 UN 56.85 36.95 AETNA AETNA 44.91 79 999999999 34.42 55.14 percent of total billed charges "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48261545_1 CDM 0250 RC 58160-0842-52 NDC 90715 HCPCS inpatient 1 UN 56.85 36.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 36.95 65 999999999 34.42 55.14 percent of total billed charges "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48261545_1 CDM 0250 RC 58160-0842-52 NDC 90715 HCPCS inpatient 1 UN 56.85 36.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.14 97 999999999 34.42 55.14 percent of total billed charges "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48261545_1 CDM 0250 RC 58160-0842-52 NDC 90715 HCPCS inpatient 1 UN 56.85 36.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.34 78 999999999 34.42 55.14 percent of total billed charges "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48261545_1 CDM 0250 RC 58160-0842-52 NDC 90715 HCPCS inpatient 1 UN 56.85 36.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.23 69 999999999 34.42 55.14 percent of total billed charges "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48261545_1 CDM 0250 RC 58160-0842-52 NDC 90715 HCPCS inpatient 1 UN 56.85 36.95 UMR - ALL PLANS UMR - ALL PLANS 39.8 70 999999999 34.42 55.14 percent of total billed charges "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48261545_1 CDM 0250 RC 58160-0842-52 NDC 90715 HCPCS inpatient 1 UN 56.85 36.95 SIHO - ALL PLANS SIHO - ALL PLANS 51.17 90 999999999 34.42 55.14 percent of total billed charges "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48261545_1 CDM 0250 RC 58160-0842-52 NDC 90715 HCPCS inpatient 1 UN 56.85 36.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.42 60.55 999999999 34.42 55.14 percent of total billed charges "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48261545_1 CDM 0250 RC 58160-0842-52 NDC 90715 HCPCS inpatient 1 UN 56.85 36.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.42 55.14 "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48261545_1 CDM 0250 RC 58160-0842-52 NDC 90715 HCPCS inpatient 1 UN 56.85 36.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.42 55.14 "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48261545_1 CDM 0250 RC 58160-0842-52 NDC 90715 HCPCS inpatient 1 UN 56.85 36.95 ANTHEM HMO ANTHEM HMO 999999999 34.42 55.14 "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48261545_1 CDM 0250 RC 58160-0842-52 NDC 90715 HCPCS inpatient 1 UN 56.85 36.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.42 55.14 "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48261545_1 CDM 0250 RC 58160-0842-52 NDC 90715 HCPCS inpatient 1 UN 56.85 36.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.43 67.6 999999999 34.42 55.14 percent of total billed charges "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48261545_1 CDM 0250 RC 58160-0842-52 NDC 90715 HCPCS inpatient 1 UN 56.85 36.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.42 55.14 "THROMBIN-JMI 5,000 UNITS VIAL" 48261559_1 CDM 0250 RC 60793-0215-05 NDC inpatient 1 UN 220.43 143.28 AETNA AETNA 174.14 79 999999999 133.47 213.82 percent of total billed charges "THROMBIN-JMI 5,000 UNITS VIAL" 48261559_1 CDM 0250 RC 60793-0215-05 NDC inpatient 1 UN 220.43 143.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 143.28 65 999999999 133.47 213.82 percent of total billed charges "THROMBIN-JMI 5,000 UNITS VIAL" 48261559_1 CDM 0250 RC 60793-0215-05 NDC inpatient 1 UN 220.43 143.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 213.82 97 999999999 133.47 213.82 percent of total billed charges "THROMBIN-JMI 5,000 UNITS VIAL" 48261559_1 CDM 0250 RC 60793-0215-05 NDC inpatient 1 UN 220.43 143.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 171.94 78 999999999 133.47 213.82 percent of total billed charges "THROMBIN-JMI 5,000 UNITS VIAL" 48261559_1 CDM 0250 RC 60793-0215-05 NDC inpatient 1 UN 220.43 143.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 152.1 69 999999999 133.47 213.82 percent of total billed charges "THROMBIN-JMI 5,000 UNITS VIAL" 48261559_1 CDM 0250 RC 60793-0215-05 NDC inpatient 1 UN 220.43 143.28 UMR - ALL PLANS UMR - ALL PLANS 154.3 70 999999999 133.47 213.82 percent of total billed charges "THROMBIN-JMI 5,000 UNITS VIAL" 48261559_1 CDM 0250 RC 60793-0215-05 NDC inpatient 1 UN 220.43 143.28 SIHO - ALL PLANS SIHO - ALL PLANS 198.39 90 999999999 133.47 213.82 percent of total billed charges "THROMBIN-JMI 5,000 UNITS VIAL" 48261559_1 CDM 0250 RC 60793-0215-05 NDC inpatient 1 UN 220.43 143.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 133.47 60.55 999999999 133.47 213.82 percent of total billed charges "THROMBIN-JMI 5,000 UNITS VIAL" 48261559_1 CDM 0250 RC 60793-0215-05 NDC inpatient 1 UN 220.43 143.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 133.47 213.82 "THROMBIN-JMI 5,000 UNITS VIAL" 48261559_1 CDM 0250 RC 60793-0215-05 NDC inpatient 1 UN 220.43 143.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 133.47 213.82 "THROMBIN-JMI 5,000 UNITS VIAL" 48261559_1 CDM 0250 RC 60793-0215-05 NDC inpatient 1 UN 220.43 143.28 ANTHEM HMO ANTHEM HMO 999999999 133.47 213.82 "THROMBIN-JMI 5,000 UNITS VIAL" 48261559_1 CDM 0250 RC 60793-0215-05 NDC inpatient 1 UN 220.43 143.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 133.47 213.82 "THROMBIN-JMI 5,000 UNITS VIAL" 48261559_1 CDM 0250 RC 60793-0215-05 NDC inpatient 1 UN 220.43 143.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 149.01 67.6 999999999 133.47 213.82 percent of total billed charges "THROMBIN-JMI 5,000 UNITS VIAL" 48261559_1 CDM 0250 RC 60793-0215-05 NDC inpatient 1 UN 220.43 143.28 UHC - ALL PLANS UHC - ALL PLANS 999999999 133.47 213.82 BRILINTA 90 MG TABLET 48261561_1 CDM 0250 RC 00186-0777-39 NDC inpatient 1 UN 29.22 18.99 AETNA AETNA 23.08 79 999999999 17.69 28.34 percent of total billed charges BRILINTA 90 MG TABLET 48261561_1 CDM 0250 RC 00186-0777-39 NDC inpatient 1 UN 29.22 18.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 18.99 65 999999999 17.69 28.34 percent of total billed charges BRILINTA 90 MG TABLET 48261561_1 CDM 0250 RC 00186-0777-39 NDC inpatient 1 UN 29.22 18.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 28.34 97 999999999 17.69 28.34 percent of total billed charges BRILINTA 90 MG TABLET 48261561_1 CDM 0250 RC 00186-0777-39 NDC inpatient 1 UN 29.22 18.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 22.79 78 999999999 17.69 28.34 percent of total billed charges BRILINTA 90 MG TABLET 48261561_1 CDM 0250 RC 00186-0777-39 NDC inpatient 1 UN 29.22 18.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.16 69 999999999 17.69 28.34 percent of total billed charges BRILINTA 90 MG TABLET 48261561_1 CDM 0250 RC 00186-0777-39 NDC inpatient 1 UN 29.22 18.99 UMR - ALL PLANS UMR - ALL PLANS 20.45 70 999999999 17.69 28.34 percent of total billed charges BRILINTA 90 MG TABLET 48261561_1 CDM 0250 RC 00186-0777-39 NDC inpatient 1 UN 29.22 18.99 SIHO - ALL PLANS SIHO - ALL PLANS 26.3 90 999999999 17.69 28.34 percent of total billed charges BRILINTA 90 MG TABLET 48261561_1 CDM 0250 RC 00186-0777-39 NDC inpatient 1 UN 29.22 18.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17.69 60.55 999999999 17.69 28.34 percent of total billed charges BRILINTA 90 MG TABLET 48261561_1 CDM 0250 RC 00186-0777-39 NDC inpatient 1 UN 29.22 18.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 17.69 28.34 BRILINTA 90 MG TABLET 48261561_1 CDM 0250 RC 00186-0777-39 NDC inpatient 1 UN 29.22 18.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 17.69 28.34 BRILINTA 90 MG TABLET 48261561_1 CDM 0250 RC 00186-0777-39 NDC inpatient 1 UN 29.22 18.99 ANTHEM HMO ANTHEM HMO 999999999 17.69 28.34 BRILINTA 90 MG TABLET 48261561_1 CDM 0250 RC 00186-0777-39 NDC inpatient 1 UN 29.22 18.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 17.69 28.34 BRILINTA 90 MG TABLET 48261561_1 CDM 0250 RC 00186-0777-39 NDC inpatient 1 UN 29.22 18.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 19.75 67.6 999999999 17.69 28.34 percent of total billed charges BRILINTA 90 MG TABLET 48261561_1 CDM 0250 RC 00186-0777-39 NDC inpatient 1 UN 29.22 18.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 17.69 28.34 TIMOLOL 0.5% GFS GEL-SOLUTION 48261566_1 CDM 0250 RC 61314-0225-05 NDC inpatient 1 UN 232.17 150.91 AETNA AETNA 183.41 79 999999999 140.58 225.2 percent of total billed charges TIMOLOL 0.5% GFS GEL-SOLUTION 48261566_1 CDM 0250 RC 61314-0225-05 NDC inpatient 1 UN 232.17 150.91 SELF PAY DISCOUNT SELF PAY DISCOUNT 150.91 65 999999999 140.58 225.2 percent of total billed charges TIMOLOL 0.5% GFS GEL-SOLUTION 48261566_1 CDM 0250 RC 61314-0225-05 NDC inpatient 1 UN 232.17 150.91 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 225.2 97 999999999 140.58 225.2 percent of total billed charges TIMOLOL 0.5% GFS GEL-SOLUTION 48261566_1 CDM 0250 RC 61314-0225-05 NDC inpatient 1 UN 232.17 150.91 HUMANA - ALL PLANS HUMANA - ALL PLANS 181.09 78 999999999 140.58 225.2 percent of total billed charges TIMOLOL 0.5% GFS GEL-SOLUTION 48261566_1 CDM 0250 RC 61314-0225-05 NDC inpatient 1 UN 232.17 150.91 ENCORE - ALL PLANS ENCORE - ALL PLANS 160.2 69 999999999 140.58 225.2 percent of total billed charges TIMOLOL 0.5% GFS GEL-SOLUTION 48261566_1 CDM 0250 RC 61314-0225-05 NDC inpatient 1 UN 232.17 150.91 UMR - ALL PLANS UMR - ALL PLANS 162.52 70 999999999 140.58 225.2 percent of total billed charges TIMOLOL 0.5% GFS GEL-SOLUTION 48261566_1 CDM 0250 RC 61314-0225-05 NDC inpatient 1 UN 232.17 150.91 SIHO - ALL PLANS SIHO - ALL PLANS 208.95 90 999999999 140.58 225.2 percent of total billed charges TIMOLOL 0.5% GFS GEL-SOLUTION 48261566_1 CDM 0250 RC 61314-0225-05 NDC inpatient 1 UN 232.17 150.91 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 140.58 60.55 999999999 140.58 225.2 percent of total billed charges TIMOLOL 0.5% GFS GEL-SOLUTION 48261566_1 CDM 0250 RC 61314-0225-05 NDC inpatient 1 UN 232.17 150.91 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 140.58 225.2 TIMOLOL 0.5% GFS GEL-SOLUTION 48261566_1 CDM 0250 RC 61314-0225-05 NDC inpatient 1 UN 232.17 150.91 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 140.58 225.2 TIMOLOL 0.5% GFS GEL-SOLUTION 48261566_1 CDM 0250 RC 61314-0225-05 NDC inpatient 1 UN 232.17 150.91 ANTHEM HMO ANTHEM HMO 999999999 140.58 225.2 TIMOLOL 0.5% GFS GEL-SOLUTION 48261566_1 CDM 0250 RC 61314-0225-05 NDC inpatient 1 UN 232.17 150.91 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 140.58 225.2 TIMOLOL 0.5% GFS GEL-SOLUTION 48261566_1 CDM 0250 RC 61314-0225-05 NDC inpatient 1 UN 232.17 150.91 CIGNA - ALL PLANS CIGNA - ALL PLANS 156.95 67.6 999999999 140.58 225.2 percent of total billed charges TIMOLOL 0.5% GFS GEL-SOLUTION 48261566_1 CDM 0250 RC 61314-0225-05 NDC inpatient 1 UN 232.17 150.91 UHC - ALL PLANS UHC - ALL PLANS 999999999 140.58 225.2 SPIRIVA HANDIHALER 18 MCG CAP 48261568_1 CDM 0250 RC 00597-0075-75 NDC inpatient 1 UN 203.92 132.55 AETNA AETNA 161.1 79 999999999 123.47 197.8 percent of total billed charges SPIRIVA HANDIHALER 18 MCG CAP 48261568_1 CDM 0250 RC 00597-0075-75 NDC inpatient 1 UN 203.92 132.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.55 65 999999999 123.47 197.8 percent of total billed charges SPIRIVA HANDIHALER 18 MCG CAP 48261568_1 CDM 0250 RC 00597-0075-75 NDC inpatient 1 UN 203.92 132.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.8 97 999999999 123.47 197.8 percent of total billed charges SPIRIVA HANDIHALER 18 MCG CAP 48261568_1 CDM 0250 RC 00597-0075-75 NDC inpatient 1 UN 203.92 132.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.06 78 999999999 123.47 197.8 percent of total billed charges SPIRIVA HANDIHALER 18 MCG CAP 48261568_1 CDM 0250 RC 00597-0075-75 NDC inpatient 1 UN 203.92 132.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.7 69 999999999 123.47 197.8 percent of total billed charges SPIRIVA HANDIHALER 18 MCG CAP 48261568_1 CDM 0250 RC 00597-0075-75 NDC inpatient 1 UN 203.92 132.55 UMR - ALL PLANS UMR - ALL PLANS 142.74 70 999999999 123.47 197.8 percent of total billed charges SPIRIVA HANDIHALER 18 MCG CAP 48261568_1 CDM 0250 RC 00597-0075-75 NDC inpatient 1 UN 203.92 132.55 SIHO - ALL PLANS SIHO - ALL PLANS 183.53 90 999999999 123.47 197.8 percent of total billed charges SPIRIVA HANDIHALER 18 MCG CAP 48261568_1 CDM 0250 RC 00597-0075-75 NDC inpatient 1 UN 203.92 132.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.47 60.55 999999999 123.47 197.8 percent of total billed charges SPIRIVA HANDIHALER 18 MCG CAP 48261568_1 CDM 0250 RC 00597-0075-75 NDC inpatient 1 UN 203.92 132.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.47 197.8 SPIRIVA HANDIHALER 18 MCG CAP 48261568_1 CDM 0250 RC 00597-0075-75 NDC inpatient 1 UN 203.92 132.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.47 197.8 SPIRIVA HANDIHALER 18 MCG CAP 48261568_1 CDM 0250 RC 00597-0075-75 NDC inpatient 1 UN 203.92 132.55 ANTHEM HMO ANTHEM HMO 999999999 123.47 197.8 SPIRIVA HANDIHALER 18 MCG CAP 48261568_1 CDM 0250 RC 00597-0075-75 NDC inpatient 1 UN 203.92 132.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.47 197.8 SPIRIVA HANDIHALER 18 MCG CAP 48261568_1 CDM 0250 RC 00597-0075-75 NDC inpatient 1 UN 203.92 132.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.85 67.6 999999999 123.47 197.8 percent of total billed charges SPIRIVA HANDIHALER 18 MCG CAP 48261568_1 CDM 0250 RC 00597-0075-75 NDC inpatient 1 UN 203.92 132.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.47 197.8 TOBREX 0.3% EYE OINTMENT 48261572_1 CDM 0250 RC 00065-0644-35 NDC inpatient 1 UN 299.91 194.94 AETNA AETNA 236.93 79 999999999 181.6 290.91 percent of total billed charges TOBREX 0.3% EYE OINTMENT 48261572_1 CDM 0250 RC 00065-0644-35 NDC inpatient 1 UN 299.91 194.94 SELF PAY DISCOUNT SELF PAY DISCOUNT 194.94 65 999999999 181.6 290.91 percent of total billed charges TOBREX 0.3% EYE OINTMENT 48261572_1 CDM 0250 RC 00065-0644-35 NDC inpatient 1 UN 299.91 194.94 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 290.91 97 999999999 181.6 290.91 percent of total billed charges TOBREX 0.3% EYE OINTMENT 48261572_1 CDM 0250 RC 00065-0644-35 NDC inpatient 1 UN 299.91 194.94 HUMANA - ALL PLANS HUMANA - ALL PLANS 233.93 78 999999999 181.6 290.91 percent of total billed charges TOBREX 0.3% EYE OINTMENT 48261572_1 CDM 0250 RC 00065-0644-35 NDC inpatient 1 UN 299.91 194.94 ENCORE - ALL PLANS ENCORE - ALL PLANS 206.94 69 999999999 181.6 290.91 percent of total billed charges TOBREX 0.3% EYE OINTMENT 48261572_1 CDM 0250 RC 00065-0644-35 NDC inpatient 1 UN 299.91 194.94 UMR - ALL PLANS UMR - ALL PLANS 209.94 70 999999999 181.6 290.91 percent of total billed charges TOBREX 0.3% EYE OINTMENT 48261572_1 CDM 0250 RC 00065-0644-35 NDC inpatient 1 UN 299.91 194.94 SIHO - ALL PLANS SIHO - ALL PLANS 269.92 90 999999999 181.6 290.91 percent of total billed charges TOBREX 0.3% EYE OINTMENT 48261572_1 CDM 0250 RC 00065-0644-35 NDC inpatient 1 UN 299.91 194.94 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 181.6 60.55 999999999 181.6 290.91 percent of total billed charges TOBREX 0.3% EYE OINTMENT 48261572_1 CDM 0250 RC 00065-0644-35 NDC inpatient 1 UN 299.91 194.94 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 181.6 290.91 TOBREX 0.3% EYE OINTMENT 48261572_1 CDM 0250 RC 00065-0644-35 NDC inpatient 1 UN 299.91 194.94 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 181.6 290.91 TOBREX 0.3% EYE OINTMENT 48261572_1 CDM 0250 RC 00065-0644-35 NDC inpatient 1 UN 299.91 194.94 ANTHEM HMO ANTHEM HMO 999999999 181.6 290.91 TOBREX 0.3% EYE OINTMENT 48261572_1 CDM 0250 RC 00065-0644-35 NDC inpatient 1 UN 299.91 194.94 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 181.6 290.91 TOBREX 0.3% EYE OINTMENT 48261572_1 CDM 0250 RC 00065-0644-35 NDC inpatient 1 UN 299.91 194.94 CIGNA - ALL PLANS CIGNA - ALL PLANS 202.74 67.6 999999999 181.6 290.91 percent of total billed charges TOBREX 0.3% EYE OINTMENT 48261572_1 CDM 0250 RC 00065-0644-35 NDC inpatient 1 UN 299.91 194.94 UHC - ALL PLANS UHC - ALL PLANS 999999999 181.6 290.91 SAMSCA 15 MG TABLET 48261576_1 CDM 0250 RC 59148-0020-50 NDC inpatient 1 UN 1156.31 751.6 AETNA AETNA 913.48 79 999999999 700.15 1121.62 percent of total billed charges SAMSCA 15 MG TABLET 48261576_1 CDM 0250 RC 59148-0020-50 NDC inpatient 1 UN 1156.31 751.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 751.6 65 999999999 700.15 1121.62 percent of total billed charges SAMSCA 15 MG TABLET 48261576_1 CDM 0250 RC 59148-0020-50 NDC inpatient 1 UN 1156.31 751.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1121.62 97 999999999 700.15 1121.62 percent of total billed charges SAMSCA 15 MG TABLET 48261576_1 CDM 0250 RC 59148-0020-50 NDC inpatient 1 UN 1156.31 751.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 901.92 78 999999999 700.15 1121.62 percent of total billed charges SAMSCA 15 MG TABLET 48261576_1 CDM 0250 RC 59148-0020-50 NDC inpatient 1 UN 1156.31 751.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 797.85 69 999999999 700.15 1121.62 percent of total billed charges SAMSCA 15 MG TABLET 48261576_1 CDM 0250 RC 59148-0020-50 NDC inpatient 1 UN 1156.31 751.6 UMR - ALL PLANS UMR - ALL PLANS 809.42 70 999999999 700.15 1121.62 percent of total billed charges SAMSCA 15 MG TABLET 48261576_1 CDM 0250 RC 59148-0020-50 NDC inpatient 1 UN 1156.31 751.6 SIHO - ALL PLANS SIHO - ALL PLANS 1040.68 90 999999999 700.15 1121.62 percent of total billed charges SAMSCA 15 MG TABLET 48261576_1 CDM 0250 RC 59148-0020-50 NDC inpatient 1 UN 1156.31 751.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 700.15 60.55 999999999 700.15 1121.62 percent of total billed charges SAMSCA 15 MG TABLET 48261576_1 CDM 0250 RC 59148-0020-50 NDC inpatient 1 UN 1156.31 751.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 700.15 1121.62 SAMSCA 15 MG TABLET 48261576_1 CDM 0250 RC 59148-0020-50 NDC inpatient 1 UN 1156.31 751.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 700.15 1121.62 SAMSCA 15 MG TABLET 48261576_1 CDM 0250 RC 59148-0020-50 NDC inpatient 1 UN 1156.31 751.6 ANTHEM HMO ANTHEM HMO 999999999 700.15 1121.62 SAMSCA 15 MG TABLET 48261576_1 CDM 0250 RC 59148-0020-50 NDC inpatient 1 UN 1156.31 751.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 700.15 1121.62 SAMSCA 15 MG TABLET 48261576_1 CDM 0250 RC 59148-0020-50 NDC inpatient 1 UN 1156.31 751.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 781.67 67.6 999999999 700.15 1121.62 percent of total billed charges SAMSCA 15 MG TABLET 48261576_1 CDM 0250 RC 59148-0020-50 NDC inpatient 1 UN 1156.31 751.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 700.15 1121.62 TORSEMIDE 100 MG TABLET 48261580_1 CDM 0250 RC 31722-0532-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges TORSEMIDE 100 MG TABLET 48261580_1 CDM 0250 RC 31722-0532-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges TORSEMIDE 100 MG TABLET 48261580_1 CDM 0250 RC 31722-0532-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges TORSEMIDE 100 MG TABLET 48261580_1 CDM 0250 RC 31722-0532-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges TORSEMIDE 100 MG TABLET 48261580_1 CDM 0250 RC 31722-0532-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges TORSEMIDE 100 MG TABLET 48261580_1 CDM 0250 RC 31722-0532-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges TORSEMIDE 100 MG TABLET 48261580_1 CDM 0250 RC 31722-0532-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges TORSEMIDE 100 MG TABLET 48261580_1 CDM 0250 RC 31722-0532-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges TORSEMIDE 100 MG TABLET 48261580_1 CDM 0250 RC 31722-0532-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 TORSEMIDE 100 MG TABLET 48261580_1 CDM 0250 RC 31722-0532-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 TORSEMIDE 100 MG TABLET 48261580_1 CDM 0250 RC 31722-0532-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 TORSEMIDE 100 MG TABLET 48261580_1 CDM 0250 RC 31722-0532-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 TORSEMIDE 100 MG TABLET 48261580_1 CDM 0250 RC 31722-0532-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges TORSEMIDE 100 MG TABLET 48261580_1 CDM 0250 RC 31722-0532-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 TRIAMCINOLONE 0.1% CREAM 48261594_1 CDM 0250 RC 45802-0064-36 NDC inpatient 1 UN 20.57 13.37 AETNA AETNA 16.25 79 999999999 12.46 19.95 percent of total billed charges TRIAMCINOLONE 0.1% CREAM 48261594_1 CDM 0250 RC 45802-0064-36 NDC inpatient 1 UN 20.57 13.37 SELF PAY DISCOUNT SELF PAY DISCOUNT 13.37 65 999999999 12.46 19.95 percent of total billed charges TRIAMCINOLONE 0.1% CREAM 48261594_1 CDM 0250 RC 45802-0064-36 NDC inpatient 1 UN 20.57 13.37 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.95 97 999999999 12.46 19.95 percent of total billed charges TRIAMCINOLONE 0.1% CREAM 48261594_1 CDM 0250 RC 45802-0064-36 NDC inpatient 1 UN 20.57 13.37 HUMANA - ALL PLANS HUMANA - ALL PLANS 16.04 78 999999999 12.46 19.95 percent of total billed charges TRIAMCINOLONE 0.1% CREAM 48261594_1 CDM 0250 RC 45802-0064-36 NDC inpatient 1 UN 20.57 13.37 ENCORE - ALL PLANS ENCORE - ALL PLANS 14.19 69 999999999 12.46 19.95 percent of total billed charges TRIAMCINOLONE 0.1% CREAM 48261594_1 CDM 0250 RC 45802-0064-36 NDC inpatient 1 UN 20.57 13.37 UMR - ALL PLANS UMR - ALL PLANS 14.4 70 999999999 12.46 19.95 percent of total billed charges TRIAMCINOLONE 0.1% CREAM 48261594_1 CDM 0250 RC 45802-0064-36 NDC inpatient 1 UN 20.57 13.37 SIHO - ALL PLANS SIHO - ALL PLANS 18.51 90 999999999 12.46 19.95 percent of total billed charges TRIAMCINOLONE 0.1% CREAM 48261594_1 CDM 0250 RC 45802-0064-36 NDC inpatient 1 UN 20.57 13.37 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.46 60.55 999999999 12.46 19.95 percent of total billed charges TRIAMCINOLONE 0.1% CREAM 48261594_1 CDM 0250 RC 45802-0064-36 NDC inpatient 1 UN 20.57 13.37 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.46 19.95 TRIAMCINOLONE 0.1% CREAM 48261594_1 CDM 0250 RC 45802-0064-36 NDC inpatient 1 UN 20.57 13.37 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.46 19.95 TRIAMCINOLONE 0.1% CREAM 48261594_1 CDM 0250 RC 45802-0064-36 NDC inpatient 1 UN 20.57 13.37 ANTHEM HMO ANTHEM HMO 999999999 12.46 19.95 TRIAMCINOLONE 0.1% CREAM 48261594_1 CDM 0250 RC 45802-0064-36 NDC inpatient 1 UN 20.57 13.37 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.46 19.95 TRIAMCINOLONE 0.1% CREAM 48261594_1 CDM 0250 RC 45802-0064-36 NDC inpatient 1 UN 20.57 13.37 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.91 67.6 999999999 12.46 19.95 percent of total billed charges TRIAMCINOLONE 0.1% CREAM 48261594_1 CDM 0250 RC 45802-0064-36 NDC inpatient 1 UN 20.57 13.37 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.46 19.95 TRIAMCINOLONE 0.1% OINTMENT 48261595_1 CDM 0250 RC 45802-0055-36 NDC inpatient 1 UN 22.94 14.91 AETNA AETNA 18.12 79 999999999 13.89 22.25 percent of total billed charges TRIAMCINOLONE 0.1% OINTMENT 48261595_1 CDM 0250 RC 45802-0055-36 NDC inpatient 1 UN 22.94 14.91 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.91 65 999999999 13.89 22.25 percent of total billed charges TRIAMCINOLONE 0.1% OINTMENT 48261595_1 CDM 0250 RC 45802-0055-36 NDC inpatient 1 UN 22.94 14.91 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22.25 97 999999999 13.89 22.25 percent of total billed charges TRIAMCINOLONE 0.1% OINTMENT 48261595_1 CDM 0250 RC 45802-0055-36 NDC inpatient 1 UN 22.94 14.91 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.89 78 999999999 13.89 22.25 percent of total billed charges TRIAMCINOLONE 0.1% OINTMENT 48261595_1 CDM 0250 RC 45802-0055-36 NDC inpatient 1 UN 22.94 14.91 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.83 69 999999999 13.89 22.25 percent of total billed charges TRIAMCINOLONE 0.1% OINTMENT 48261595_1 CDM 0250 RC 45802-0055-36 NDC inpatient 1 UN 22.94 14.91 UMR - ALL PLANS UMR - ALL PLANS 16.06 70 999999999 13.89 22.25 percent of total billed charges TRIAMCINOLONE 0.1% OINTMENT 48261595_1 CDM 0250 RC 45802-0055-36 NDC inpatient 1 UN 22.94 14.91 SIHO - ALL PLANS SIHO - ALL PLANS 20.65 90 999999999 13.89 22.25 percent of total billed charges TRIAMCINOLONE 0.1% OINTMENT 48261595_1 CDM 0250 RC 45802-0055-36 NDC inpatient 1 UN 22.94 14.91 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.89 60.55 999999999 13.89 22.25 percent of total billed charges TRIAMCINOLONE 0.1% OINTMENT 48261595_1 CDM 0250 RC 45802-0055-36 NDC inpatient 1 UN 22.94 14.91 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.89 22.25 TRIAMCINOLONE 0.1% OINTMENT 48261595_1 CDM 0250 RC 45802-0055-36 NDC inpatient 1 UN 22.94 14.91 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.89 22.25 TRIAMCINOLONE 0.1% OINTMENT 48261595_1 CDM 0250 RC 45802-0055-36 NDC inpatient 1 UN 22.94 14.91 ANTHEM HMO ANTHEM HMO 999999999 13.89 22.25 TRIAMCINOLONE 0.1% OINTMENT 48261595_1 CDM 0250 RC 45802-0055-36 NDC inpatient 1 UN 22.94 14.91 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.89 22.25 TRIAMCINOLONE 0.1% OINTMENT 48261595_1 CDM 0250 RC 45802-0055-36 NDC inpatient 1 UN 22.94 14.91 CIGNA - ALL PLANS CIGNA - ALL PLANS 15.51 67.6 999999999 13.89 22.25 percent of total billed charges TRIAMCINOLONE 0.1% OINTMENT 48261595_1 CDM 0250 RC 45802-0055-36 NDC inpatient 1 UN 22.94 14.91 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.89 22.25 ATRAC-TAIN CREAM 48261602_1 CDM 0250 RC 11701-0022-14 NDC inpatient 1 UN 54.2 35.23 AETNA AETNA 42.82 79 999999999 32.82 52.57 percent of total billed charges ATRAC-TAIN CREAM 48261602_1 CDM 0250 RC 11701-0022-14 NDC inpatient 1 UN 54.2 35.23 SELF PAY DISCOUNT SELF PAY DISCOUNT 35.23 65 999999999 32.82 52.57 percent of total billed charges ATRAC-TAIN CREAM 48261602_1 CDM 0250 RC 11701-0022-14 NDC inpatient 1 UN 54.2 35.23 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 52.57 97 999999999 32.82 52.57 percent of total billed charges ATRAC-TAIN CREAM 48261602_1 CDM 0250 RC 11701-0022-14 NDC inpatient 1 UN 54.2 35.23 HUMANA - ALL PLANS HUMANA - ALL PLANS 42.28 78 999999999 32.82 52.57 percent of total billed charges ATRAC-TAIN CREAM 48261602_1 CDM 0250 RC 11701-0022-14 NDC inpatient 1 UN 54.2 35.23 ENCORE - ALL PLANS ENCORE - ALL PLANS 37.4 69 999999999 32.82 52.57 percent of total billed charges ATRAC-TAIN CREAM 48261602_1 CDM 0250 RC 11701-0022-14 NDC inpatient 1 UN 54.2 35.23 UMR - ALL PLANS UMR - ALL PLANS 37.94 70 999999999 32.82 52.57 percent of total billed charges ATRAC-TAIN CREAM 48261602_1 CDM 0250 RC 11701-0022-14 NDC inpatient 1 UN 54.2 35.23 SIHO - ALL PLANS SIHO - ALL PLANS 48.78 90 999999999 32.82 52.57 percent of total billed charges ATRAC-TAIN CREAM 48261602_1 CDM 0250 RC 11701-0022-14 NDC inpatient 1 UN 54.2 35.23 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.82 60.55 999999999 32.82 52.57 percent of total billed charges ATRAC-TAIN CREAM 48261602_1 CDM 0250 RC 11701-0022-14 NDC inpatient 1 UN 54.2 35.23 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.82 52.57 ATRAC-TAIN CREAM 48261602_1 CDM 0250 RC 11701-0022-14 NDC inpatient 1 UN 54.2 35.23 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.82 52.57 ATRAC-TAIN CREAM 48261602_1 CDM 0250 RC 11701-0022-14 NDC inpatient 1 UN 54.2 35.23 ANTHEM HMO ANTHEM HMO 999999999 32.82 52.57 ATRAC-TAIN CREAM 48261602_1 CDM 0250 RC 11701-0022-14 NDC inpatient 1 UN 54.2 35.23 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.82 52.57 ATRAC-TAIN CREAM 48261602_1 CDM 0250 RC 11701-0022-14 NDC inpatient 1 UN 54.2 35.23 CIGNA - ALL PLANS CIGNA - ALL PLANS 36.64 67.6 999999999 32.82 52.57 percent of total billed charges ATRAC-TAIN CREAM 48261602_1 CDM 0250 RC 11701-0022-14 NDC inpatient 1 UN 54.2 35.23 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.82 52.57 VALACYCLOVIR HCL 500 MG TABLET 48261603_1 CDM 0250 RC 51079-0093-03 NDC inpatient 1 UN 12.52 8.14 AETNA AETNA 9.89 79 999999999 7.58 12.14 percent of total billed charges VALACYCLOVIR HCL 500 MG TABLET 48261603_1 CDM 0250 RC 51079-0093-03 NDC inpatient 1 UN 12.52 8.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.14 65 999999999 7.58 12.14 percent of total billed charges VALACYCLOVIR HCL 500 MG TABLET 48261603_1 CDM 0250 RC 51079-0093-03 NDC inpatient 1 UN 12.52 8.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.14 97 999999999 7.58 12.14 percent of total billed charges VALACYCLOVIR HCL 500 MG TABLET 48261603_1 CDM 0250 RC 51079-0093-03 NDC inpatient 1 UN 12.52 8.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.77 78 999999999 7.58 12.14 percent of total billed charges VALACYCLOVIR HCL 500 MG TABLET 48261603_1 CDM 0250 RC 51079-0093-03 NDC inpatient 1 UN 12.52 8.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.64 69 999999999 7.58 12.14 percent of total billed charges VALACYCLOVIR HCL 500 MG TABLET 48261603_1 CDM 0250 RC 51079-0093-03 NDC inpatient 1 UN 12.52 8.14 UMR - ALL PLANS UMR - ALL PLANS 8.76 70 999999999 7.58 12.14 percent of total billed charges VALACYCLOVIR HCL 500 MG TABLET 48261603_1 CDM 0250 RC 51079-0093-03 NDC inpatient 1 UN 12.52 8.14 SIHO - ALL PLANS SIHO - ALL PLANS 11.27 90 999999999 7.58 12.14 percent of total billed charges VALACYCLOVIR HCL 500 MG TABLET 48261603_1 CDM 0250 RC 51079-0093-03 NDC inpatient 1 UN 12.52 8.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.58 60.55 999999999 7.58 12.14 percent of total billed charges VALACYCLOVIR HCL 500 MG TABLET 48261603_1 CDM 0250 RC 51079-0093-03 NDC inpatient 1 UN 12.52 8.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.58 12.14 VALACYCLOVIR HCL 500 MG TABLET 48261603_1 CDM 0250 RC 51079-0093-03 NDC inpatient 1 UN 12.52 8.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.58 12.14 VALACYCLOVIR HCL 500 MG TABLET 48261603_1 CDM 0250 RC 51079-0093-03 NDC inpatient 1 UN 12.52 8.14 ANTHEM HMO ANTHEM HMO 999999999 7.58 12.14 VALACYCLOVIR HCL 500 MG TABLET 48261603_1 CDM 0250 RC 51079-0093-03 NDC inpatient 1 UN 12.52 8.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.58 12.14 VALACYCLOVIR HCL 500 MG TABLET 48261603_1 CDM 0250 RC 51079-0093-03 NDC inpatient 1 UN 12.52 8.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.46 67.6 999999999 7.58 12.14 percent of total billed charges VALACYCLOVIR HCL 500 MG TABLET 48261603_1 CDM 0250 RC 51079-0093-03 NDC inpatient 1 UN 12.52 8.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.58 12.14 "INJECTION, VANCOMYCIN HCL, 500 MG" 48261609_1 CDM 0250 RC 61553-0202-02 NDC J3370 HCPCS inpatient 2 UN 96.06 62.44 AETNA AETNA 75.89 79 999999999 58.16 93.18 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 48261609_1 CDM 0250 RC 61553-0202-02 NDC J3370 HCPCS inpatient 2 UN 96.06 62.44 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.44 65 999999999 58.16 93.18 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 48261609_1 CDM 0250 RC 61553-0202-02 NDC J3370 HCPCS inpatient 2 UN 96.06 62.44 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.18 97 999999999 58.16 93.18 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 48261609_1 CDM 0250 RC 61553-0202-02 NDC J3370 HCPCS inpatient 2 UN 96.06 62.44 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.93 78 999999999 58.16 93.18 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 48261609_1 CDM 0250 RC 61553-0202-02 NDC J3370 HCPCS inpatient 2 UN 96.06 62.44 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.28 69 999999999 58.16 93.18 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 48261609_1 CDM 0250 RC 61553-0202-02 NDC J3370 HCPCS inpatient 2 UN 96.06 62.44 UMR - ALL PLANS UMR - ALL PLANS 67.24 70 999999999 58.16 93.18 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 48261609_1 CDM 0250 RC 61553-0202-02 NDC J3370 HCPCS inpatient 2 UN 96.06 62.44 SIHO - ALL PLANS SIHO - ALL PLANS 86.45 90 999999999 58.16 93.18 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 48261609_1 CDM 0250 RC 61553-0202-02 NDC J3370 HCPCS inpatient 2 UN 96.06 62.44 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.16 60.55 999999999 58.16 93.18 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 48261609_1 CDM 0250 RC 61553-0202-02 NDC J3370 HCPCS inpatient 2 UN 96.06 62.44 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.16 93.18 "INJECTION, VANCOMYCIN HCL, 500 MG" 48261609_1 CDM 0250 RC 61553-0202-02 NDC J3370 HCPCS inpatient 2 UN 96.06 62.44 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.16 93.18 "INJECTION, VANCOMYCIN HCL, 500 MG" 48261609_1 CDM 0250 RC 61553-0202-02 NDC J3370 HCPCS inpatient 2 UN 96.06 62.44 ANTHEM HMO ANTHEM HMO 999999999 58.16 93.18 "INJECTION, VANCOMYCIN HCL, 500 MG" 48261609_1 CDM 0250 RC 61553-0202-02 NDC J3370 HCPCS inpatient 2 UN 96.06 62.44 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.16 93.18 "INJECTION, VANCOMYCIN HCL, 500 MG" 48261609_1 CDM 0250 RC 61553-0202-02 NDC J3370 HCPCS inpatient 2 UN 96.06 62.44 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.94 67.6 999999999 58.16 93.18 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 48261609_1 CDM 0250 RC 61553-0202-02 NDC J3370 HCPCS inpatient 2 UN 96.06 62.44 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.16 93.18 CHANTIX 0.5 MG TABLET 48261615_1 CDM 0250 RC 00069-0468-56 NDC inpatient 1 UN 35.18 22.87 AETNA AETNA 27.79 79 999999999 21.3 34.12 percent of total billed charges CHANTIX 0.5 MG TABLET 48261615_1 CDM 0250 RC 00069-0468-56 NDC inpatient 1 UN 35.18 22.87 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.87 65 999999999 21.3 34.12 percent of total billed charges CHANTIX 0.5 MG TABLET 48261615_1 CDM 0250 RC 00069-0468-56 NDC inpatient 1 UN 35.18 22.87 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34.12 97 999999999 21.3 34.12 percent of total billed charges CHANTIX 0.5 MG TABLET 48261615_1 CDM 0250 RC 00069-0468-56 NDC inpatient 1 UN 35.18 22.87 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.44 78 999999999 21.3 34.12 percent of total billed charges CHANTIX 0.5 MG TABLET 48261615_1 CDM 0250 RC 00069-0468-56 NDC inpatient 1 UN 35.18 22.87 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.27 69 999999999 21.3 34.12 percent of total billed charges CHANTIX 0.5 MG TABLET 48261615_1 CDM 0250 RC 00069-0468-56 NDC inpatient 1 UN 35.18 22.87 UMR - ALL PLANS UMR - ALL PLANS 24.63 70 999999999 21.3 34.12 percent of total billed charges CHANTIX 0.5 MG TABLET 48261615_1 CDM 0250 RC 00069-0468-56 NDC inpatient 1 UN 35.18 22.87 SIHO - ALL PLANS SIHO - ALL PLANS 31.66 90 999999999 21.3 34.12 percent of total billed charges CHANTIX 0.5 MG TABLET 48261615_1 CDM 0250 RC 00069-0468-56 NDC inpatient 1 UN 35.18 22.87 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.3 60.55 999999999 21.3 34.12 percent of total billed charges CHANTIX 0.5 MG TABLET 48261615_1 CDM 0250 RC 00069-0468-56 NDC inpatient 1 UN 35.18 22.87 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.3 34.12 CHANTIX 0.5 MG TABLET 48261615_1 CDM 0250 RC 00069-0468-56 NDC inpatient 1 UN 35.18 22.87 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.3 34.12 CHANTIX 0.5 MG TABLET 48261615_1 CDM 0250 RC 00069-0468-56 NDC inpatient 1 UN 35.18 22.87 ANTHEM HMO ANTHEM HMO 999999999 21.3 34.12 CHANTIX 0.5 MG TABLET 48261615_1 CDM 0250 RC 00069-0468-56 NDC inpatient 1 UN 35.18 22.87 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.3 34.12 CHANTIX 0.5 MG TABLET 48261615_1 CDM 0250 RC 00069-0468-56 NDC inpatient 1 UN 35.18 22.87 CIGNA - ALL PLANS CIGNA - ALL PLANS 23.78 67.6 999999999 21.3 34.12 percent of total billed charges CHANTIX 0.5 MG TABLET 48261615_1 CDM 0250 RC 00069-0468-56 NDC inpatient 1 UN 35.18 22.87 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.3 34.12 CHANTIX 1 MG TABLET 48261616_1 CDM 0250 RC 00069-0469-56 NDC inpatient 1 UN 35.28 22.93 AETNA AETNA 27.87 79 999999999 21.36 34.22 percent of total billed charges CHANTIX 1 MG TABLET 48261616_1 CDM 0250 RC 00069-0469-56 NDC inpatient 1 UN 35.28 22.93 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.93 65 999999999 21.36 34.22 percent of total billed charges CHANTIX 1 MG TABLET 48261616_1 CDM 0250 RC 00069-0469-56 NDC inpatient 1 UN 35.28 22.93 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34.22 97 999999999 21.36 34.22 percent of total billed charges CHANTIX 1 MG TABLET 48261616_1 CDM 0250 RC 00069-0469-56 NDC inpatient 1 UN 35.28 22.93 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.52 78 999999999 21.36 34.22 percent of total billed charges CHANTIX 1 MG TABLET 48261616_1 CDM 0250 RC 00069-0469-56 NDC inpatient 1 UN 35.28 22.93 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.34 69 999999999 21.36 34.22 percent of total billed charges CHANTIX 1 MG TABLET 48261616_1 CDM 0250 RC 00069-0469-56 NDC inpatient 1 UN 35.28 22.93 UMR - ALL PLANS UMR - ALL PLANS 24.7 70 999999999 21.36 34.22 percent of total billed charges CHANTIX 1 MG TABLET 48261616_1 CDM 0250 RC 00069-0469-56 NDC inpatient 1 UN 35.28 22.93 SIHO - ALL PLANS SIHO - ALL PLANS 31.75 90 999999999 21.36 34.22 percent of total billed charges CHANTIX 1 MG TABLET 48261616_1 CDM 0250 RC 00069-0469-56 NDC inpatient 1 UN 35.28 22.93 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.36 60.55 999999999 21.36 34.22 percent of total billed charges CHANTIX 1 MG TABLET 48261616_1 CDM 0250 RC 00069-0469-56 NDC inpatient 1 UN 35.28 22.93 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.36 34.22 CHANTIX 1 MG TABLET 48261616_1 CDM 0250 RC 00069-0469-56 NDC inpatient 1 UN 35.28 22.93 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.36 34.22 CHANTIX 1 MG TABLET 48261616_1 CDM 0250 RC 00069-0469-56 NDC inpatient 1 UN 35.28 22.93 ANTHEM HMO ANTHEM HMO 999999999 21.36 34.22 CHANTIX 1 MG TABLET 48261616_1 CDM 0250 RC 00069-0469-56 NDC inpatient 1 UN 35.28 22.93 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.36 34.22 CHANTIX 1 MG TABLET 48261616_1 CDM 0250 RC 00069-0469-56 NDC inpatient 1 UN 35.28 22.93 CIGNA - ALL PLANS CIGNA - ALL PLANS 23.85 67.6 999999999 21.36 34.22 percent of total billed charges CHANTIX 1 MG TABLET 48261616_1 CDM 0250 RC 00069-0469-56 NDC inpatient 1 UN 35.28 22.93 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.36 34.22 00904-2924-61 - verapamil 120 mg Tab [JOHN] 48261627_1 CDM 0250 RC 00904-2924-61 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 00904-2924-61 - verapamil 120 mg Tab [JOHN] 48261627_1 CDM 0250 RC 00904-2924-61 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 00904-2924-61 - verapamil 120 mg Tab [JOHN] 48261627_1 CDM 0250 RC 00904-2924-61 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 00904-2924-61 - verapamil 120 mg Tab [JOHN] 48261627_1 CDM 0250 RC 00904-2924-61 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 00904-2924-61 - verapamil 120 mg Tab [JOHN] 48261627_1 CDM 0250 RC 00904-2924-61 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 00904-2924-61 - verapamil 120 mg Tab [JOHN] 48261627_1 CDM 0250 RC 00904-2924-61 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 00904-2924-61 - verapamil 120 mg Tab [JOHN] 48261627_1 CDM 0250 RC 00904-2924-61 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 00904-2924-61 - verapamil 120 mg Tab [JOHN] 48261627_1 CDM 0250 RC 00904-2924-61 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 00904-2924-61 - verapamil 120 mg Tab [JOHN] 48261627_1 CDM 0250 RC 00904-2924-61 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 00904-2924-61 - verapamil 120 mg Tab [JOHN] 48261627_1 CDM 0250 RC 00904-2924-61 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 00904-2924-61 - verapamil 120 mg Tab [JOHN] 48261627_1 CDM 0250 RC 00904-2924-61 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 00904-2924-61 - verapamil 120 mg Tab [JOHN] 48261627_1 CDM 0250 RC 00904-2924-61 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 00904-2924-61 - verapamil 120 mg Tab [JOHN] 48261627_1 CDM 0250 RC 00904-2924-61 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 00904-2924-61 - verapamil 120 mg Tab [JOHN] 48261627_1 CDM 0250 RC 00904-2924-61 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 VERAPAMIL 40 MG TABLET 48261629_1 CDM 0250 RC 00591-0404-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges VERAPAMIL 40 MG TABLET 48261629_1 CDM 0250 RC 00591-0404-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges VERAPAMIL 40 MG TABLET 48261629_1 CDM 0250 RC 00591-0404-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges VERAPAMIL 40 MG TABLET 48261629_1 CDM 0250 RC 00591-0404-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges VERAPAMIL 40 MG TABLET 48261629_1 CDM 0250 RC 00591-0404-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges VERAPAMIL 40 MG TABLET 48261629_1 CDM 0250 RC 00591-0404-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges VERAPAMIL 40 MG TABLET 48261629_1 CDM 0250 RC 00591-0404-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges VERAPAMIL 40 MG TABLET 48261629_1 CDM 0250 RC 00591-0404-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges VERAPAMIL 40 MG TABLET 48261629_1 CDM 0250 RC 00591-0404-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 VERAPAMIL 40 MG TABLET 48261629_1 CDM 0250 RC 00591-0404-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 VERAPAMIL 40 MG TABLET 48261629_1 CDM 0250 RC 00591-0404-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 VERAPAMIL 40 MG TABLET 48261629_1 CDM 0250 RC 00591-0404-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 VERAPAMIL 40 MG TABLET 48261629_1 CDM 0250 RC 00591-0404-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges VERAPAMIL 40 MG TABLET 48261629_1 CDM 0250 RC 00591-0404-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 00904-2920-61 - verapamil 80 mg Tab [JOHN] 48261630_1 CDM 0250 RC 00904-2920-61 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 00904-2920-61 - verapamil 80 mg Tab [JOHN] 48261630_1 CDM 0250 RC 00904-2920-61 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 00904-2920-61 - verapamil 80 mg Tab [JOHN] 48261630_1 CDM 0250 RC 00904-2920-61 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 00904-2920-61 - verapamil 80 mg Tab [JOHN] 48261630_1 CDM 0250 RC 00904-2920-61 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 00904-2920-61 - verapamil 80 mg Tab [JOHN] 48261630_1 CDM 0250 RC 00904-2920-61 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 00904-2920-61 - verapamil 80 mg Tab [JOHN] 48261630_1 CDM 0250 RC 00904-2920-61 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 00904-2920-61 - verapamil 80 mg Tab [JOHN] 48261630_1 CDM 0250 RC 00904-2920-61 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 00904-2920-61 - verapamil 80 mg Tab [JOHN] 48261630_1 CDM 0250 RC 00904-2920-61 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 00904-2920-61 - verapamil 80 mg Tab [JOHN] 48261630_1 CDM 0250 RC 00904-2920-61 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 00904-2920-61 - verapamil 80 mg Tab [JOHN] 48261630_1 CDM 0250 RC 00904-2920-61 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 00904-2920-61 - verapamil 80 mg Tab [JOHN] 48261630_1 CDM 0250 RC 00904-2920-61 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 00904-2920-61 - verapamil 80 mg Tab [JOHN] 48261630_1 CDM 0250 RC 00904-2920-61 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 00904-2920-61 - verapamil 80 mg Tab [JOHN] 48261630_1 CDM 0250 RC 00904-2920-61 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 00904-2920-61 - verapamil 80 mg Tab [JOHN] 48261630_1 CDM 0250 RC 00904-2920-61 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, VINBLASTINE SULFATE, 1 MG" 48261631_1 CDM 0636 RC 63323-0278-10 NDC J9360 HCPCS inpatient 10 UN 205.35 133.48 AETNA AETNA 162.23 79 999999999 124.34 199.19 percent of total billed charges "INJECTION, VINBLASTINE SULFATE, 1 MG" 48261631_1 CDM 0636 RC 63323-0278-10 NDC J9360 HCPCS inpatient 10 UN 205.35 133.48 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.48 65 999999999 124.34 199.19 percent of total billed charges "INJECTION, VINBLASTINE SULFATE, 1 MG" 48261631_1 CDM 0636 RC 63323-0278-10 NDC J9360 HCPCS inpatient 10 UN 205.35 133.48 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.19 97 999999999 124.34 199.19 percent of total billed charges "INJECTION, VINBLASTINE SULFATE, 1 MG" 48261631_1 CDM 0636 RC 63323-0278-10 NDC J9360 HCPCS inpatient 10 UN 205.35 133.48 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.17 78 999999999 124.34 199.19 percent of total billed charges "INJECTION, VINBLASTINE SULFATE, 1 MG" 48261631_1 CDM 0636 RC 63323-0278-10 NDC J9360 HCPCS inpatient 10 UN 205.35 133.48 ENCORE - ALL PLANS ENCORE - ALL PLANS 141.69 69 999999999 124.34 199.19 percent of total billed charges "INJECTION, VINBLASTINE SULFATE, 1 MG" 48261631_1 CDM 0636 RC 63323-0278-10 NDC J9360 HCPCS inpatient 10 UN 205.35 133.48 UMR - ALL PLANS UMR - ALL PLANS 143.75 70 999999999 124.34 199.19 percent of total billed charges "INJECTION, VINBLASTINE SULFATE, 1 MG" 48261631_1 CDM 0636 RC 63323-0278-10 NDC J9360 HCPCS inpatient 10 UN 205.35 133.48 SIHO - ALL PLANS SIHO - ALL PLANS 184.82 90 999999999 124.34 199.19 percent of total billed charges "INJECTION, VINBLASTINE SULFATE, 1 MG" 48261631_1 CDM 0636 RC 63323-0278-10 NDC J9360 HCPCS inpatient 10 UN 205.35 133.48 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.34 60.55 999999999 124.34 199.19 percent of total billed charges "INJECTION, VINBLASTINE SULFATE, 1 MG" 48261631_1 CDM 0636 RC 63323-0278-10 NDC J9360 HCPCS inpatient 10 UN 205.35 133.48 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.34 199.19 "INJECTION, VINBLASTINE SULFATE, 1 MG" 48261631_1 CDM 0636 RC 63323-0278-10 NDC J9360 HCPCS inpatient 10 UN 205.35 133.48 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.34 199.19 "INJECTION, VINBLASTINE SULFATE, 1 MG" 48261631_1 CDM 0636 RC 63323-0278-10 NDC J9360 HCPCS inpatient 10 UN 205.35 133.48 ANTHEM HMO ANTHEM HMO 999999999 124.34 199.19 "INJECTION, VINBLASTINE SULFATE, 1 MG" 48261631_1 CDM 0636 RC 63323-0278-10 NDC J9360 HCPCS inpatient 10 UN 205.35 133.48 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.34 199.19 "INJECTION, VINBLASTINE SULFATE, 1 MG" 48261631_1 CDM 0636 RC 63323-0278-10 NDC J9360 HCPCS inpatient 10 UN 205.35 133.48 CIGNA - ALL PLANS CIGNA - ALL PLANS 138.82 67.6 999999999 124.34 199.19 percent of total billed charges "INJECTION, VINBLASTINE SULFATE, 1 MG" 48261631_1 CDM 0636 RC 63323-0278-10 NDC J9360 HCPCS inpatient 10 UN 205.35 133.48 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.34 199.19 00056-0176-75 - warfarin 2.5 mg Tab [JOHN] 48261640_1 CDM 0250 RC 00056-0176-75 NDC inpatient 1 UN 1.91 1.24 AETNA AETNA 1.51 79 999999999 1.16 1.85 percent of total billed charges 00056-0176-75 - warfarin 2.5 mg Tab [JOHN] 48261640_1 CDM 0250 RC 00056-0176-75 NDC inpatient 1 UN 1.91 1.24 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.24 65 999999999 1.16 1.85 percent of total billed charges 00056-0176-75 - warfarin 2.5 mg Tab [JOHN] 48261640_1 CDM 0250 RC 00056-0176-75 NDC inpatient 1 UN 1.91 1.24 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.85 97 999999999 1.16 1.85 percent of total billed charges 00056-0176-75 - warfarin 2.5 mg Tab [JOHN] 48261640_1 CDM 0250 RC 00056-0176-75 NDC inpatient 1 UN 1.91 1.24 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.49 78 999999999 1.16 1.85 percent of total billed charges 00056-0176-75 - warfarin 2.5 mg Tab [JOHN] 48261640_1 CDM 0250 RC 00056-0176-75 NDC inpatient 1 UN 1.91 1.24 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.32 69 999999999 1.16 1.85 percent of total billed charges 00056-0176-75 - warfarin 2.5 mg Tab [JOHN] 48261640_1 CDM 0250 RC 00056-0176-75 NDC inpatient 1 UN 1.91 1.24 UMR - ALL PLANS UMR - ALL PLANS 1.34 70 999999999 1.16 1.85 percent of total billed charges 00056-0176-75 - warfarin 2.5 mg Tab [JOHN] 48261640_1 CDM 0250 RC 00056-0176-75 NDC inpatient 1 UN 1.91 1.24 SIHO - ALL PLANS SIHO - ALL PLANS 1.72 90 999999999 1.16 1.85 percent of total billed charges 00056-0176-75 - warfarin 2.5 mg Tab [JOHN] 48261640_1 CDM 0250 RC 00056-0176-75 NDC inpatient 1 UN 1.91 1.24 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.16 60.55 999999999 1.16 1.85 percent of total billed charges 00056-0176-75 - warfarin 2.5 mg Tab [JOHN] 48261640_1 CDM 0250 RC 00056-0176-75 NDC inpatient 1 UN 1.91 1.24 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.16 1.85 00056-0176-75 - warfarin 2.5 mg Tab [JOHN] 48261640_1 CDM 0250 RC 00056-0176-75 NDC inpatient 1 UN 1.91 1.24 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.16 1.85 00056-0176-75 - warfarin 2.5 mg Tab [JOHN] 48261640_1 CDM 0250 RC 00056-0176-75 NDC inpatient 1 UN 1.91 1.24 ANTHEM HMO ANTHEM HMO 999999999 1.16 1.85 00056-0176-75 - warfarin 2.5 mg Tab [JOHN] 48261640_1 CDM 0250 RC 00056-0176-75 NDC inpatient 1 UN 1.91 1.24 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.16 1.85 00056-0176-75 - warfarin 2.5 mg Tab [JOHN] 48261640_1 CDM 0250 RC 00056-0176-75 NDC inpatient 1 UN 1.91 1.24 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.29 67.6 999999999 1.16 1.85 percent of total billed charges 00056-0176-75 - warfarin 2.5 mg Tab [JOHN] 48261640_1 CDM 0250 RC 00056-0176-75 NDC inpatient 1 UN 1.91 1.24 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.16 1.85 00056-0170-75 - warfarin 2 mg Tab [JOHN] 48261641_1 CDM 0250 RC 00056-0170-75 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 00056-0170-75 - warfarin 2 mg Tab [JOHN] 48261641_1 CDM 0250 RC 00056-0170-75 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 00056-0170-75 - warfarin 2 mg Tab [JOHN] 48261641_1 CDM 0250 RC 00056-0170-75 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 00056-0170-75 - warfarin 2 mg Tab [JOHN] 48261641_1 CDM 0250 RC 00056-0170-75 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 00056-0170-75 - warfarin 2 mg Tab [JOHN] 48261641_1 CDM 0250 RC 00056-0170-75 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 00056-0170-75 - warfarin 2 mg Tab [JOHN] 48261641_1 CDM 0250 RC 00056-0170-75 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 00056-0170-75 - warfarin 2 mg Tab [JOHN] 48261641_1 CDM 0250 RC 00056-0170-75 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 00056-0170-75 - warfarin 2 mg Tab [JOHN] 48261641_1 CDM 0250 RC 00056-0170-75 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 00056-0170-75 - warfarin 2 mg Tab [JOHN] 48261641_1 CDM 0250 RC 00056-0170-75 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 00056-0170-75 - warfarin 2 mg Tab [JOHN] 48261641_1 CDM 0250 RC 00056-0170-75 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 00056-0170-75 - warfarin 2 mg Tab [JOHN] 48261641_1 CDM 0250 RC 00056-0170-75 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 00056-0170-75 - warfarin 2 mg Tab [JOHN] 48261641_1 CDM 0250 RC 00056-0170-75 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 00056-0170-75 - warfarin 2 mg Tab [JOHN] 48261641_1 CDM 0250 RC 00056-0170-75 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 00056-0170-75 - warfarin 2 mg Tab [JOHN] 48261641_1 CDM 0250 RC 00056-0170-75 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 00056-0168-75 - warfarin 4 mg Tab [JOHN] 48261643_1 CDM 0250 RC 00056-0168-75 NDC inpatient 1 UN 1.76 1.14 AETNA AETNA 1.39 79 999999999 1.07 1.71 percent of total billed charges 00056-0168-75 - warfarin 4 mg Tab [JOHN] 48261643_1 CDM 0250 RC 00056-0168-75 NDC inpatient 1 UN 1.76 1.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.14 65 999999999 1.07 1.71 percent of total billed charges 00056-0168-75 - warfarin 4 mg Tab [JOHN] 48261643_1 CDM 0250 RC 00056-0168-75 NDC inpatient 1 UN 1.76 1.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.71 97 999999999 1.07 1.71 percent of total billed charges 00056-0168-75 - warfarin 4 mg Tab [JOHN] 48261643_1 CDM 0250 RC 00056-0168-75 NDC inpatient 1 UN 1.76 1.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.37 78 999999999 1.07 1.71 percent of total billed charges 00056-0168-75 - warfarin 4 mg Tab [JOHN] 48261643_1 CDM 0250 RC 00056-0168-75 NDC inpatient 1 UN 1.76 1.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.21 69 999999999 1.07 1.71 percent of total billed charges 00056-0168-75 - warfarin 4 mg Tab [JOHN] 48261643_1 CDM 0250 RC 00056-0168-75 NDC inpatient 1 UN 1.76 1.14 UMR - ALL PLANS UMR - ALL PLANS 1.23 70 999999999 1.07 1.71 percent of total billed charges 00056-0168-75 - warfarin 4 mg Tab [JOHN] 48261643_1 CDM 0250 RC 00056-0168-75 NDC inpatient 1 UN 1.76 1.14 SIHO - ALL PLANS SIHO - ALL PLANS 1.58 90 999999999 1.07 1.71 percent of total billed charges 00056-0168-75 - warfarin 4 mg Tab [JOHN] 48261643_1 CDM 0250 RC 00056-0168-75 NDC inpatient 1 UN 1.76 1.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.07 60.55 999999999 1.07 1.71 percent of total billed charges 00056-0168-75 - warfarin 4 mg Tab [JOHN] 48261643_1 CDM 0250 RC 00056-0168-75 NDC inpatient 1 UN 1.76 1.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.07 1.71 00056-0168-75 - warfarin 4 mg Tab [JOHN] 48261643_1 CDM 0250 RC 00056-0168-75 NDC inpatient 1 UN 1.76 1.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.07 1.71 00056-0168-75 - warfarin 4 mg Tab [JOHN] 48261643_1 CDM 0250 RC 00056-0168-75 NDC inpatient 1 UN 1.76 1.14 ANTHEM HMO ANTHEM HMO 999999999 1.07 1.71 00056-0168-75 - warfarin 4 mg Tab [JOHN] 48261643_1 CDM 0250 RC 00056-0168-75 NDC inpatient 1 UN 1.76 1.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.07 1.71 00056-0168-75 - warfarin 4 mg Tab [JOHN] 48261643_1 CDM 0250 RC 00056-0168-75 NDC inpatient 1 UN 1.76 1.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.19 67.6 999999999 1.07 1.71 percent of total billed charges 00056-0168-75 - warfarin 4 mg Tab [JOHN] 48261643_1 CDM 0250 RC 00056-0168-75 NDC inpatient 1 UN 1.76 1.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.07 1.71 00056-0172-75 - warfarin 5 mg Tab [JOHN] 48261644_1 CDM 0250 RC 00056-0172-75 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 00056-0172-75 - warfarin 5 mg Tab [JOHN] 48261644_1 CDM 0250 RC 00056-0172-75 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 00056-0172-75 - warfarin 5 mg Tab [JOHN] 48261644_1 CDM 0250 RC 00056-0172-75 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 00056-0172-75 - warfarin 5 mg Tab [JOHN] 48261644_1 CDM 0250 RC 00056-0172-75 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 00056-0172-75 - warfarin 5 mg Tab [JOHN] 48261644_1 CDM 0250 RC 00056-0172-75 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 00056-0172-75 - warfarin 5 mg Tab [JOHN] 48261644_1 CDM 0250 RC 00056-0172-75 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 00056-0172-75 - warfarin 5 mg Tab [JOHN] 48261644_1 CDM 0250 RC 00056-0172-75 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 00056-0172-75 - warfarin 5 mg Tab [JOHN] 48261644_1 CDM 0250 RC 00056-0172-75 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 00056-0172-75 - warfarin 5 mg Tab [JOHN] 48261644_1 CDM 0250 RC 00056-0172-75 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 00056-0172-75 - warfarin 5 mg Tab [JOHN] 48261644_1 CDM 0250 RC 00056-0172-75 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 00056-0172-75 - warfarin 5 mg Tab [JOHN] 48261644_1 CDM 0250 RC 00056-0172-75 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 00056-0172-75 - warfarin 5 mg Tab [JOHN] 48261644_1 CDM 0250 RC 00056-0172-75 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 00056-0172-75 - warfarin 5 mg Tab [JOHN] 48261644_1 CDM 0250 RC 00056-0172-75 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 00056-0172-75 - warfarin 5 mg Tab [JOHN] 48261644_1 CDM 0250 RC 00056-0172-75 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 49884-0303-02 - zafirlukast 10 mg Tab [JOHN] 48261646_1 CDM 0250 RC 49884-0303-02 NDC inpatient 1 UN 6.07 3.95 AETNA AETNA 4.8 79 999999999 3.68 5.89 percent of total billed charges 49884-0303-02 - zafirlukast 10 mg Tab [JOHN] 48261646_1 CDM 0250 RC 49884-0303-02 NDC inpatient 1 UN 6.07 3.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.95 65 999999999 3.68 5.89 percent of total billed charges 49884-0303-02 - zafirlukast 10 mg Tab [JOHN] 48261646_1 CDM 0250 RC 49884-0303-02 NDC inpatient 1 UN 6.07 3.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.89 97 999999999 3.68 5.89 percent of total billed charges 49884-0303-02 - zafirlukast 10 mg Tab [JOHN] 48261646_1 CDM 0250 RC 49884-0303-02 NDC inpatient 1 UN 6.07 3.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.73 78 999999999 3.68 5.89 percent of total billed charges 49884-0303-02 - zafirlukast 10 mg Tab [JOHN] 48261646_1 CDM 0250 RC 49884-0303-02 NDC inpatient 1 UN 6.07 3.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.19 69 999999999 3.68 5.89 percent of total billed charges 49884-0303-02 - zafirlukast 10 mg Tab [JOHN] 48261646_1 CDM 0250 RC 49884-0303-02 NDC inpatient 1 UN 6.07 3.95 UMR - ALL PLANS UMR - ALL PLANS 4.25 70 999999999 3.68 5.89 percent of total billed charges 49884-0303-02 - zafirlukast 10 mg Tab [JOHN] 48261646_1 CDM 0250 RC 49884-0303-02 NDC inpatient 1 UN 6.07 3.95 SIHO - ALL PLANS SIHO - ALL PLANS 5.46 90 999999999 3.68 5.89 percent of total billed charges 49884-0303-02 - zafirlukast 10 mg Tab [JOHN] 48261646_1 CDM 0250 RC 49884-0303-02 NDC inpatient 1 UN 6.07 3.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.68 60.55 999999999 3.68 5.89 percent of total billed charges 49884-0303-02 - zafirlukast 10 mg Tab [JOHN] 48261646_1 CDM 0250 RC 49884-0303-02 NDC inpatient 1 UN 6.07 3.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.68 5.89 49884-0303-02 - zafirlukast 10 mg Tab [JOHN] 48261646_1 CDM 0250 RC 49884-0303-02 NDC inpatient 1 UN 6.07 3.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.68 5.89 49884-0303-02 - zafirlukast 10 mg Tab [JOHN] 48261646_1 CDM 0250 RC 49884-0303-02 NDC inpatient 1 UN 6.07 3.95 ANTHEM HMO ANTHEM HMO 999999999 3.68 5.89 49884-0303-02 - zafirlukast 10 mg Tab [JOHN] 48261646_1 CDM 0250 RC 49884-0303-02 NDC inpatient 1 UN 6.07 3.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.68 5.89 49884-0303-02 - zafirlukast 10 mg Tab [JOHN] 48261646_1 CDM 0250 RC 49884-0303-02 NDC inpatient 1 UN 6.07 3.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.1 67.6 999999999 3.68 5.89 percent of total billed charges 49884-0303-02 - zafirlukast 10 mg Tab [JOHN] 48261646_1 CDM 0250 RC 49884-0303-02 NDC inpatient 1 UN 6.07 3.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.68 5.89 GEODON 20 MG/ML VIAL 48261654_1 CDM 0250 RC 00049-3920-83 NDC inpatient 1 UN 251.94 163.76 AETNA AETNA 199.03 79 999999999 152.55 244.38 percent of total billed charges GEODON 20 MG/ML VIAL 48261654_1 CDM 0250 RC 00049-3920-83 NDC inpatient 1 UN 251.94 163.76 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.76 65 999999999 152.55 244.38 percent of total billed charges GEODON 20 MG/ML VIAL 48261654_1 CDM 0250 RC 00049-3920-83 NDC inpatient 1 UN 251.94 163.76 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.38 97 999999999 152.55 244.38 percent of total billed charges GEODON 20 MG/ML VIAL 48261654_1 CDM 0250 RC 00049-3920-83 NDC inpatient 1 UN 251.94 163.76 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.51 78 999999999 152.55 244.38 percent of total billed charges GEODON 20 MG/ML VIAL 48261654_1 CDM 0250 RC 00049-3920-83 NDC inpatient 1 UN 251.94 163.76 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.84 69 999999999 152.55 244.38 percent of total billed charges GEODON 20 MG/ML VIAL 48261654_1 CDM 0250 RC 00049-3920-83 NDC inpatient 1 UN 251.94 163.76 UMR - ALL PLANS UMR - ALL PLANS 176.36 70 999999999 152.55 244.38 percent of total billed charges GEODON 20 MG/ML VIAL 48261654_1 CDM 0250 RC 00049-3920-83 NDC inpatient 1 UN 251.94 163.76 SIHO - ALL PLANS SIHO - ALL PLANS 226.75 90 999999999 152.55 244.38 percent of total billed charges GEODON 20 MG/ML VIAL 48261654_1 CDM 0250 RC 00049-3920-83 NDC inpatient 1 UN 251.94 163.76 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.55 60.55 999999999 152.55 244.38 percent of total billed charges GEODON 20 MG/ML VIAL 48261654_1 CDM 0250 RC 00049-3920-83 NDC inpatient 1 UN 251.94 163.76 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.55 244.38 GEODON 20 MG/ML VIAL 48261654_1 CDM 0250 RC 00049-3920-83 NDC inpatient 1 UN 251.94 163.76 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.55 244.38 GEODON 20 MG/ML VIAL 48261654_1 CDM 0250 RC 00049-3920-83 NDC inpatient 1 UN 251.94 163.76 ANTHEM HMO ANTHEM HMO 999999999 152.55 244.38 GEODON 20 MG/ML VIAL 48261654_1 CDM 0250 RC 00049-3920-83 NDC inpatient 1 UN 251.94 163.76 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.55 244.38 GEODON 20 MG/ML VIAL 48261654_1 CDM 0250 RC 00049-3920-83 NDC inpatient 1 UN 251.94 163.76 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.31 67.6 999999999 152.55 244.38 percent of total billed charges GEODON 20 MG/ML VIAL 48261654_1 CDM 0250 RC 00049-3920-83 NDC inpatient 1 UN 251.94 163.76 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.55 244.38 ZOLPIDEM TARTRATE 5 MG TABLET 48261657_1 CDM 0250 RC 00904-6082-61 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ZOLPIDEM TARTRATE 5 MG TABLET 48261657_1 CDM 0250 RC 00904-6082-61 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ZOLPIDEM TARTRATE 5 MG TABLET 48261657_1 CDM 0250 RC 00904-6082-61 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ZOLPIDEM TARTRATE 5 MG TABLET 48261657_1 CDM 0250 RC 00904-6082-61 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ZOLPIDEM TARTRATE 5 MG TABLET 48261657_1 CDM 0250 RC 00904-6082-61 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ZOLPIDEM TARTRATE 5 MG TABLET 48261657_1 CDM 0250 RC 00904-6082-61 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ZOLPIDEM TARTRATE 5 MG TABLET 48261657_1 CDM 0250 RC 00904-6082-61 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ZOLPIDEM TARTRATE 5 MG TABLET 48261657_1 CDM 0250 RC 00904-6082-61 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ZOLPIDEM TARTRATE 5 MG TABLET 48261657_1 CDM 0250 RC 00904-6082-61 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ZOLPIDEM TARTRATE 5 MG TABLET 48261657_1 CDM 0250 RC 00904-6082-61 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ZOLPIDEM TARTRATE 5 MG TABLET 48261657_1 CDM 0250 RC 00904-6082-61 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ZOLPIDEM TARTRATE 5 MG TABLET 48261657_1 CDM 0250 RC 00904-6082-61 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ZOLPIDEM TARTRATE 5 MG TABLET 48261657_1 CDM 0250 RC 00904-6082-61 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges ZOLPIDEM TARTRATE 5 MG TABLET 48261657_1 CDM 0250 RC 00904-6082-61 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48261797_1 CDM 0258 RC 00338-0017-02 NDC J7060 HCPCS inpatient 1 UN 63.78 41.46 AETNA AETNA 50.39 79 999999999 38.62 61.87 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48261797_1 CDM 0258 RC 00338-0017-02 NDC J7060 HCPCS inpatient 1 UN 63.78 41.46 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.46 65 999999999 38.62 61.87 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48261797_1 CDM 0258 RC 00338-0017-02 NDC J7060 HCPCS inpatient 1 UN 63.78 41.46 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.87 97 999999999 38.62 61.87 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48261797_1 CDM 0258 RC 00338-0017-02 NDC J7060 HCPCS inpatient 1 UN 63.78 41.46 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.75 78 999999999 38.62 61.87 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48261797_1 CDM 0258 RC 00338-0017-02 NDC J7060 HCPCS inpatient 1 UN 63.78 41.46 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.01 69 999999999 38.62 61.87 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48261797_1 CDM 0258 RC 00338-0017-02 NDC J7060 HCPCS inpatient 1 UN 63.78 41.46 UMR - ALL PLANS UMR - ALL PLANS 44.65 70 999999999 38.62 61.87 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48261797_1 CDM 0258 RC 00338-0017-02 NDC J7060 HCPCS inpatient 1 UN 63.78 41.46 SIHO - ALL PLANS SIHO - ALL PLANS 57.4 90 999999999 38.62 61.87 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48261797_1 CDM 0258 RC 00338-0017-02 NDC J7060 HCPCS inpatient 1 UN 63.78 41.46 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.62 60.55 999999999 38.62 61.87 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48261797_1 CDM 0258 RC 00338-0017-02 NDC J7060 HCPCS inpatient 1 UN 63.78 41.46 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.62 61.87 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48261797_1 CDM 0258 RC 00338-0017-02 NDC J7060 HCPCS inpatient 1 UN 63.78 41.46 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.62 61.87 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48261797_1 CDM 0258 RC 00338-0017-02 NDC J7060 HCPCS inpatient 1 UN 63.78 41.46 ANTHEM HMO ANTHEM HMO 999999999 38.62 61.87 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48261797_1 CDM 0258 RC 00338-0017-02 NDC J7060 HCPCS inpatient 1 UN 63.78 41.46 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.62 61.87 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48261797_1 CDM 0258 RC 00338-0017-02 NDC J7060 HCPCS inpatient 1 UN 63.78 41.46 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.12 67.6 999999999 38.62 61.87 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48261797_1 CDM 0258 RC 00338-0017-02 NDC J7060 HCPCS inpatient 1 UN 63.78 41.46 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.62 61.87 DEXTROSE 5%-0.2% NACL IV SOLN 48262086_1 CDM 0258 RC 00338-0077-04 NDC inpatient 1 UN 64.11 41.67 AETNA AETNA 50.65 79 999999999 38.82 62.19 percent of total billed charges DEXTROSE 5%-0.2% NACL IV SOLN 48262086_1 CDM 0258 RC 00338-0077-04 NDC inpatient 1 UN 64.11 41.67 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.67 65 999999999 38.82 62.19 percent of total billed charges DEXTROSE 5%-0.2% NACL IV SOLN 48262086_1 CDM 0258 RC 00338-0077-04 NDC inpatient 1 UN 64.11 41.67 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 62.19 97 999999999 38.82 62.19 percent of total billed charges DEXTROSE 5%-0.2% NACL IV SOLN 48262086_1 CDM 0258 RC 00338-0077-04 NDC inpatient 1 UN 64.11 41.67 HUMANA - ALL PLANS HUMANA - ALL PLANS 50.01 78 999999999 38.82 62.19 percent of total billed charges DEXTROSE 5%-0.2% NACL IV SOLN 48262086_1 CDM 0258 RC 00338-0077-04 NDC inpatient 1 UN 64.11 41.67 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.24 69 999999999 38.82 62.19 percent of total billed charges DEXTROSE 5%-0.2% NACL IV SOLN 48262086_1 CDM 0258 RC 00338-0077-04 NDC inpatient 1 UN 64.11 41.67 UMR - ALL PLANS UMR - ALL PLANS 44.88 70 999999999 38.82 62.19 percent of total billed charges DEXTROSE 5%-0.2% NACL IV SOLN 48262086_1 CDM 0258 RC 00338-0077-04 NDC inpatient 1 UN 64.11 41.67 SIHO - ALL PLANS SIHO - ALL PLANS 57.7 90 999999999 38.82 62.19 percent of total billed charges DEXTROSE 5%-0.2% NACL IV SOLN 48262086_1 CDM 0258 RC 00338-0077-04 NDC inpatient 1 UN 64.11 41.67 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.82 60.55 999999999 38.82 62.19 percent of total billed charges DEXTROSE 5%-0.2% NACL IV SOLN 48262086_1 CDM 0258 RC 00338-0077-04 NDC inpatient 1 UN 64.11 41.67 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.82 62.19 DEXTROSE 5%-0.2% NACL IV SOLN 48262086_1 CDM 0258 RC 00338-0077-04 NDC inpatient 1 UN 64.11 41.67 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.82 62.19 DEXTROSE 5%-0.2% NACL IV SOLN 48262086_1 CDM 0258 RC 00338-0077-04 NDC inpatient 1 UN 64.11 41.67 ANTHEM HMO ANTHEM HMO 999999999 38.82 62.19 DEXTROSE 5%-0.2% NACL IV SOLN 48262086_1 CDM 0258 RC 00338-0077-04 NDC inpatient 1 UN 64.11 41.67 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.82 62.19 DEXTROSE 5%-0.2% NACL IV SOLN 48262086_1 CDM 0258 RC 00338-0077-04 NDC inpatient 1 UN 64.11 41.67 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.34 67.6 999999999 38.82 62.19 percent of total billed charges DEXTROSE 5%-0.2% NACL IV SOLN 48262086_1 CDM 0258 RC 00338-0077-04 NDC inpatient 1 UN 64.11 41.67 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.82 62.19 LACTATED RINGERS INJECTION 48262098_1 CDM 0250 RC 00338-0117-04 NDC inpatient 1 UN 63.26 41.12 AETNA AETNA 49.98 79 999999999 38.3 61.36 percent of total billed charges LACTATED RINGERS INJECTION 48262098_1 CDM 0250 RC 00338-0117-04 NDC inpatient 1 UN 63.26 41.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.12 65 999999999 38.3 61.36 percent of total billed charges LACTATED RINGERS INJECTION 48262098_1 CDM 0250 RC 00338-0117-04 NDC inpatient 1 UN 63.26 41.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.36 97 999999999 38.3 61.36 percent of total billed charges LACTATED RINGERS INJECTION 48262098_1 CDM 0250 RC 00338-0117-04 NDC inpatient 1 UN 63.26 41.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.34 78 999999999 38.3 61.36 percent of total billed charges LACTATED RINGERS INJECTION 48262098_1 CDM 0250 RC 00338-0117-04 NDC inpatient 1 UN 63.26 41.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.65 69 999999999 38.3 61.36 percent of total billed charges LACTATED RINGERS INJECTION 48262098_1 CDM 0250 RC 00338-0117-04 NDC inpatient 1 UN 63.26 41.12 UMR - ALL PLANS UMR - ALL PLANS 44.28 70 999999999 38.3 61.36 percent of total billed charges LACTATED RINGERS INJECTION 48262098_1 CDM 0250 RC 00338-0117-04 NDC inpatient 1 UN 63.26 41.12 SIHO - ALL PLANS SIHO - ALL PLANS 56.93 90 999999999 38.3 61.36 percent of total billed charges LACTATED RINGERS INJECTION 48262098_1 CDM 0250 RC 00338-0117-04 NDC inpatient 1 UN 63.26 41.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.3 60.55 999999999 38.3 61.36 percent of total billed charges LACTATED RINGERS INJECTION 48262098_1 CDM 0250 RC 00338-0117-04 NDC inpatient 1 UN 63.26 41.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.3 61.36 LACTATED RINGERS INJECTION 48262098_1 CDM 0250 RC 00338-0117-04 NDC inpatient 1 UN 63.26 41.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.3 61.36 LACTATED RINGERS INJECTION 48262098_1 CDM 0250 RC 00338-0117-04 NDC inpatient 1 UN 63.26 41.12 ANTHEM HMO ANTHEM HMO 999999999 38.3 61.36 LACTATED RINGERS INJECTION 48262098_1 CDM 0250 RC 00338-0117-04 NDC inpatient 1 UN 63.26 41.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.3 61.36 LACTATED RINGERS INJECTION 48262098_1 CDM 0250 RC 00338-0117-04 NDC inpatient 1 UN 63.26 41.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.76 67.6 999999999 38.3 61.36 percent of total billed charges LACTATED RINGERS INJECTION 48262098_1 CDM 0250 RC 00338-0117-04 NDC inpatient 1 UN 63.26 41.12 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.3 61.36 "RINGERS LACTATE INFUSION, UP TO 1000 CC" 48262116_1 CDM 0258 RC 00338-0125-04 NDC J7120 HCPCS inpatient 1 UN 62.16 40.4 AETNA AETNA 49.11 79 999999999 37.64 60.3 percent of total billed charges "RINGERS LACTATE INFUSION, UP TO 1000 CC" 48262116_1 CDM 0258 RC 00338-0125-04 NDC J7120 HCPCS inpatient 1 UN 62.16 40.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.4 65 999999999 37.64 60.3 percent of total billed charges "RINGERS LACTATE INFUSION, UP TO 1000 CC" 48262116_1 CDM 0258 RC 00338-0125-04 NDC J7120 HCPCS inpatient 1 UN 62.16 40.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 60.3 97 999999999 37.64 60.3 percent of total billed charges "RINGERS LACTATE INFUSION, UP TO 1000 CC" 48262116_1 CDM 0258 RC 00338-0125-04 NDC J7120 HCPCS inpatient 1 UN 62.16 40.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 48.48 78 999999999 37.64 60.3 percent of total billed charges "RINGERS LACTATE INFUSION, UP TO 1000 CC" 48262116_1 CDM 0258 RC 00338-0125-04 NDC J7120 HCPCS inpatient 1 UN 62.16 40.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.89 69 999999999 37.64 60.3 percent of total billed charges "RINGERS LACTATE INFUSION, UP TO 1000 CC" 48262116_1 CDM 0258 RC 00338-0125-04 NDC J7120 HCPCS inpatient 1 UN 62.16 40.4 UMR - ALL PLANS UMR - ALL PLANS 43.51 70 999999999 37.64 60.3 percent of total billed charges "RINGERS LACTATE INFUSION, UP TO 1000 CC" 48262116_1 CDM 0258 RC 00338-0125-04 NDC J7120 HCPCS inpatient 1 UN 62.16 40.4 SIHO - ALL PLANS SIHO - ALL PLANS 55.94 90 999999999 37.64 60.3 percent of total billed charges "RINGERS LACTATE INFUSION, UP TO 1000 CC" 48262116_1 CDM 0258 RC 00338-0125-04 NDC J7120 HCPCS inpatient 1 UN 62.16 40.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 37.64 60.55 999999999 37.64 60.3 percent of total billed charges "RINGERS LACTATE INFUSION, UP TO 1000 CC" 48262116_1 CDM 0258 RC 00338-0125-04 NDC J7120 HCPCS inpatient 1 UN 62.16 40.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 37.64 60.3 "RINGERS LACTATE INFUSION, UP TO 1000 CC" 48262116_1 CDM 0258 RC 00338-0125-04 NDC J7120 HCPCS inpatient 1 UN 62.16 40.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 37.64 60.3 "RINGERS LACTATE INFUSION, UP TO 1000 CC" 48262116_1 CDM 0258 RC 00338-0125-04 NDC J7120 HCPCS inpatient 1 UN 62.16 40.4 ANTHEM HMO ANTHEM HMO 999999999 37.64 60.3 "RINGERS LACTATE INFUSION, UP TO 1000 CC" 48262116_1 CDM 0258 RC 00338-0125-04 NDC J7120 HCPCS inpatient 1 UN 62.16 40.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 37.64 60.3 "RINGERS LACTATE INFUSION, UP TO 1000 CC" 48262116_1 CDM 0258 RC 00338-0125-04 NDC J7120 HCPCS inpatient 1 UN 62.16 40.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.02 67.6 999999999 37.64 60.3 percent of total billed charges "RINGERS LACTATE INFUSION, UP TO 1000 CC" 48262116_1 CDM 0258 RC 00338-0125-04 NDC J7120 HCPCS inpatient 1 UN 62.16 40.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 37.64 60.3 POTASSIUM CL 20 MEQ-0.45% NACL 48262164_1 CDM 0250 RC 00338-0704-34 NDC inpatient 1 UN 65.66 42.68 AETNA AETNA 51.87 79 999999999 39.76 63.69 percent of total billed charges POTASSIUM CL 20 MEQ-0.45% NACL 48262164_1 CDM 0250 RC 00338-0704-34 NDC inpatient 1 UN 65.66 42.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.68 65 999999999 39.76 63.69 percent of total billed charges POTASSIUM CL 20 MEQ-0.45% NACL 48262164_1 CDM 0250 RC 00338-0704-34 NDC inpatient 1 UN 65.66 42.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 63.69 97 999999999 39.76 63.69 percent of total billed charges POTASSIUM CL 20 MEQ-0.45% NACL 48262164_1 CDM 0250 RC 00338-0704-34 NDC inpatient 1 UN 65.66 42.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.21 78 999999999 39.76 63.69 percent of total billed charges POTASSIUM CL 20 MEQ-0.45% NACL 48262164_1 CDM 0250 RC 00338-0704-34 NDC inpatient 1 UN 65.66 42.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.31 69 999999999 39.76 63.69 percent of total billed charges POTASSIUM CL 20 MEQ-0.45% NACL 48262164_1 CDM 0250 RC 00338-0704-34 NDC inpatient 1 UN 65.66 42.68 UMR - ALL PLANS UMR - ALL PLANS 45.96 70 999999999 39.76 63.69 percent of total billed charges POTASSIUM CL 20 MEQ-0.45% NACL 48262164_1 CDM 0250 RC 00338-0704-34 NDC inpatient 1 UN 65.66 42.68 SIHO - ALL PLANS SIHO - ALL PLANS 59.09 90 999999999 39.76 63.69 percent of total billed charges POTASSIUM CL 20 MEQ-0.45% NACL 48262164_1 CDM 0250 RC 00338-0704-34 NDC inpatient 1 UN 65.66 42.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.76 60.55 999999999 39.76 63.69 percent of total billed charges POTASSIUM CL 20 MEQ-0.45% NACL 48262164_1 CDM 0250 RC 00338-0704-34 NDC inpatient 1 UN 65.66 42.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.76 63.69 POTASSIUM CL 20 MEQ-0.45% NACL 48262164_1 CDM 0250 RC 00338-0704-34 NDC inpatient 1 UN 65.66 42.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.76 63.69 POTASSIUM CL 20 MEQ-0.45% NACL 48262164_1 CDM 0250 RC 00338-0704-34 NDC inpatient 1 UN 65.66 42.68 ANTHEM HMO ANTHEM HMO 999999999 39.76 63.69 POTASSIUM CL 20 MEQ-0.45% NACL 48262164_1 CDM 0250 RC 00338-0704-34 NDC inpatient 1 UN 65.66 42.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.39 67.6 999999999 39.76 63.69 percent of total billed charges POTASSIUM CL 20 MEQ-0.45% NACL 48262164_1 CDM 0250 RC 00338-0704-34 NDC inpatient 1 UN 65.66 42.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.76 63.69 POTASSIUM CL 20 MEQ-0.45% NACL 48262164_1 CDM 0250 RC 00338-0704-34 NDC inpatient 1 UN 65.66 42.68 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.76 63.69 CLINIMIX E 4.25%-10% SOLUTION 48262188_1 CDM 0250 RC 00338-1115-04 NDC inpatient 1 UN 449.99 292.49 AETNA AETNA 355.49 79 999999999 272.47 436.49 percent of total billed charges CLINIMIX E 4.25%-10% SOLUTION 48262188_1 CDM 0250 RC 00338-1115-04 NDC inpatient 1 UN 449.99 292.49 SELF PAY DISCOUNT SELF PAY DISCOUNT 292.49 65 999999999 272.47 436.49 percent of total billed charges CLINIMIX E 4.25%-10% SOLUTION 48262188_1 CDM 0250 RC 00338-1115-04 NDC inpatient 1 UN 449.99 292.49 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 436.49 97 999999999 272.47 436.49 percent of total billed charges CLINIMIX E 4.25%-10% SOLUTION 48262188_1 CDM 0250 RC 00338-1115-04 NDC inpatient 1 UN 449.99 292.49 HUMANA - ALL PLANS HUMANA - ALL PLANS 350.99 78 999999999 272.47 436.49 percent of total billed charges CLINIMIX E 4.25%-10% SOLUTION 48262188_1 CDM 0250 RC 00338-1115-04 NDC inpatient 1 UN 449.99 292.49 ENCORE - ALL PLANS ENCORE - ALL PLANS 310.49 69 999999999 272.47 436.49 percent of total billed charges CLINIMIX E 4.25%-10% SOLUTION 48262188_1 CDM 0250 RC 00338-1115-04 NDC inpatient 1 UN 449.99 292.49 UMR - ALL PLANS UMR - ALL PLANS 314.99 70 999999999 272.47 436.49 percent of total billed charges CLINIMIX E 4.25%-10% SOLUTION 48262188_1 CDM 0250 RC 00338-1115-04 NDC inpatient 1 UN 449.99 292.49 SIHO - ALL PLANS SIHO - ALL PLANS 404.99 90 999999999 272.47 436.49 percent of total billed charges CLINIMIX E 4.25%-10% SOLUTION 48262188_1 CDM 0250 RC 00338-1115-04 NDC inpatient 1 UN 449.99 292.49 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 272.47 60.55 999999999 272.47 436.49 percent of total billed charges CLINIMIX E 4.25%-10% SOLUTION 48262188_1 CDM 0250 RC 00338-1115-04 NDC inpatient 1 UN 449.99 292.49 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 272.47 436.49 CLINIMIX E 4.25%-10% SOLUTION 48262188_1 CDM 0250 RC 00338-1115-04 NDC inpatient 1 UN 449.99 292.49 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 272.47 436.49 CLINIMIX E 4.25%-10% SOLUTION 48262188_1 CDM 0250 RC 00338-1115-04 NDC inpatient 1 UN 449.99 292.49 ANTHEM HMO ANTHEM HMO 999999999 272.47 436.49 CLINIMIX E 4.25%-10% SOLUTION 48262188_1 CDM 0250 RC 00338-1115-04 NDC inpatient 1 UN 449.99 292.49 CIGNA - ALL PLANS CIGNA - ALL PLANS 304.19 67.6 999999999 272.47 436.49 percent of total billed charges CLINIMIX E 4.25%-10% SOLUTION 48262188_1 CDM 0250 RC 00338-1115-04 NDC inpatient 1 UN 449.99 292.49 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 272.47 436.49 CLINIMIX E 4.25%-10% SOLUTION 48262188_1 CDM 0250 RC 00338-1115-04 NDC inpatient 1 UN 449.99 292.49 UHC - ALL PLANS UHC - ALL PLANS 999999999 272.47 436.49 CERVIDIL 10 MG VAGINAL INSRT 48262189_1 CDM 0250 RC 55566-2800-01 NDC inpatient 1 UN 1207.82 785.08 AETNA AETNA 954.18 79 999999999 731.34 1171.59 percent of total billed charges CERVIDIL 10 MG VAGINAL INSRT 48262189_1 CDM 0250 RC 55566-2800-01 NDC inpatient 1 UN 1207.82 785.08 SELF PAY DISCOUNT SELF PAY DISCOUNT 785.08 65 999999999 731.34 1171.59 percent of total billed charges CERVIDIL 10 MG VAGINAL INSRT 48262189_1 CDM 0250 RC 55566-2800-01 NDC inpatient 1 UN 1207.82 785.08 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1171.59 97 999999999 731.34 1171.59 percent of total billed charges CERVIDIL 10 MG VAGINAL INSRT 48262189_1 CDM 0250 RC 55566-2800-01 NDC inpatient 1 UN 1207.82 785.08 HUMANA - ALL PLANS HUMANA - ALL PLANS 942.1 78 999999999 731.34 1171.59 percent of total billed charges CERVIDIL 10 MG VAGINAL INSRT 48262189_1 CDM 0250 RC 55566-2800-01 NDC inpatient 1 UN 1207.82 785.08 ENCORE - ALL PLANS ENCORE - ALL PLANS 833.4 69 999999999 731.34 1171.59 percent of total billed charges CERVIDIL 10 MG VAGINAL INSRT 48262189_1 CDM 0250 RC 55566-2800-01 NDC inpatient 1 UN 1207.82 785.08 UMR - ALL PLANS UMR - ALL PLANS 845.47 70 999999999 731.34 1171.59 percent of total billed charges CERVIDIL 10 MG VAGINAL INSRT 48262189_1 CDM 0250 RC 55566-2800-01 NDC inpatient 1 UN 1207.82 785.08 SIHO - ALL PLANS SIHO - ALL PLANS 1087.04 90 999999999 731.34 1171.59 percent of total billed charges CERVIDIL 10 MG VAGINAL INSRT 48262189_1 CDM 0250 RC 55566-2800-01 NDC inpatient 1 UN 1207.82 785.08 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 731.34 60.55 999999999 731.34 1171.59 percent of total billed charges CERVIDIL 10 MG VAGINAL INSRT 48262189_1 CDM 0250 RC 55566-2800-01 NDC inpatient 1 UN 1207.82 785.08 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 731.34 1171.59 CERVIDIL 10 MG VAGINAL INSRT 48262189_1 CDM 0250 RC 55566-2800-01 NDC inpatient 1 UN 1207.82 785.08 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 731.34 1171.59 CERVIDIL 10 MG VAGINAL INSRT 48262189_1 CDM 0250 RC 55566-2800-01 NDC inpatient 1 UN 1207.82 785.08 ANTHEM HMO ANTHEM HMO 999999999 731.34 1171.59 CERVIDIL 10 MG VAGINAL INSRT 48262189_1 CDM 0250 RC 55566-2800-01 NDC inpatient 1 UN 1207.82 785.08 CIGNA - ALL PLANS CIGNA - ALL PLANS 816.49 67.6 999999999 731.34 1171.59 percent of total billed charges CERVIDIL 10 MG VAGINAL INSRT 48262189_1 CDM 0250 RC 55566-2800-01 NDC inpatient 1 UN 1207.82 785.08 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 731.34 1171.59 CERVIDIL 10 MG VAGINAL INSRT 48262189_1 CDM 0250 RC 55566-2800-01 NDC inpatient 1 UN 1207.82 785.08 UHC - ALL PLANS UHC - ALL PLANS 999999999 731.34 1171.59 DOXEPIN 25 MG CAPSULE 48262201_1 CDM 0250 RC 51079-0437-20 NDC inpatient 1 UN 2.82 1.83 AETNA AETNA 2.23 79 999999999 1.71 2.74 percent of total billed charges DOXEPIN 25 MG CAPSULE 48262201_1 CDM 0250 RC 51079-0437-20 NDC inpatient 1 UN 2.82 1.83 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.83 65 999999999 1.71 2.74 percent of total billed charges DOXEPIN 25 MG CAPSULE 48262201_1 CDM 0250 RC 51079-0437-20 NDC inpatient 1 UN 2.82 1.83 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.74 97 999999999 1.71 2.74 percent of total billed charges DOXEPIN 25 MG CAPSULE 48262201_1 CDM 0250 RC 51079-0437-20 NDC inpatient 1 UN 2.82 1.83 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.2 78 999999999 1.71 2.74 percent of total billed charges DOXEPIN 25 MG CAPSULE 48262201_1 CDM 0250 RC 51079-0437-20 NDC inpatient 1 UN 2.82 1.83 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.95 69 999999999 1.71 2.74 percent of total billed charges DOXEPIN 25 MG CAPSULE 48262201_1 CDM 0250 RC 51079-0437-20 NDC inpatient 1 UN 2.82 1.83 UMR - ALL PLANS UMR - ALL PLANS 1.97 70 999999999 1.71 2.74 percent of total billed charges DOXEPIN 25 MG CAPSULE 48262201_1 CDM 0250 RC 51079-0437-20 NDC inpatient 1 UN 2.82 1.83 SIHO - ALL PLANS SIHO - ALL PLANS 2.54 90 999999999 1.71 2.74 percent of total billed charges DOXEPIN 25 MG CAPSULE 48262201_1 CDM 0250 RC 51079-0437-20 NDC inpatient 1 UN 2.82 1.83 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.71 60.55 999999999 1.71 2.74 percent of total billed charges DOXEPIN 25 MG CAPSULE 48262201_1 CDM 0250 RC 51079-0437-20 NDC inpatient 1 UN 2.82 1.83 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.71 2.74 DOXEPIN 25 MG CAPSULE 48262201_1 CDM 0250 RC 51079-0437-20 NDC inpatient 1 UN 2.82 1.83 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.71 2.74 DOXEPIN 25 MG CAPSULE 48262201_1 CDM 0250 RC 51079-0437-20 NDC inpatient 1 UN 2.82 1.83 ANTHEM HMO ANTHEM HMO 999999999 1.71 2.74 DOXEPIN 25 MG CAPSULE 48262201_1 CDM 0250 RC 51079-0437-20 NDC inpatient 1 UN 2.82 1.83 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.91 67.6 999999999 1.71 2.74 percent of total billed charges DOXEPIN 25 MG CAPSULE 48262201_1 CDM 0250 RC 51079-0437-20 NDC inpatient 1 UN 2.82 1.83 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.71 2.74 DOXEPIN 25 MG CAPSULE 48262201_1 CDM 0250 RC 51079-0437-20 NDC inpatient 1 UN 2.82 1.83 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.71 2.74 WATER FOR INJECTION VIAL 48262202_1 CDM 0250 RC 00409-4887-20 NDC inpatient 1 UN 25.05 16.28 AETNA AETNA 19.79 79 999999999 15.17 24.3 percent of total billed charges WATER FOR INJECTION VIAL 48262202_1 CDM 0250 RC 00409-4887-20 NDC inpatient 1 UN 25.05 16.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.28 65 999999999 15.17 24.3 percent of total billed charges WATER FOR INJECTION VIAL 48262202_1 CDM 0250 RC 00409-4887-20 NDC inpatient 1 UN 25.05 16.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.3 97 999999999 15.17 24.3 percent of total billed charges WATER FOR INJECTION VIAL 48262202_1 CDM 0250 RC 00409-4887-20 NDC inpatient 1 UN 25.05 16.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.54 78 999999999 15.17 24.3 percent of total billed charges WATER FOR INJECTION VIAL 48262202_1 CDM 0250 RC 00409-4887-20 NDC inpatient 1 UN 25.05 16.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.28 69 999999999 15.17 24.3 percent of total billed charges WATER FOR INJECTION VIAL 48262202_1 CDM 0250 RC 00409-4887-20 NDC inpatient 1 UN 25.05 16.28 UMR - ALL PLANS UMR - ALL PLANS 17.54 70 999999999 15.17 24.3 percent of total billed charges WATER FOR INJECTION VIAL 48262202_1 CDM 0250 RC 00409-4887-20 NDC inpatient 1 UN 25.05 16.28 SIHO - ALL PLANS SIHO - ALL PLANS 22.55 90 999999999 15.17 24.3 percent of total billed charges WATER FOR INJECTION VIAL 48262202_1 CDM 0250 RC 00409-4887-20 NDC inpatient 1 UN 25.05 16.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.17 60.55 999999999 15.17 24.3 percent of total billed charges WATER FOR INJECTION VIAL 48262202_1 CDM 0250 RC 00409-4887-20 NDC inpatient 1 UN 25.05 16.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.17 24.3 WATER FOR INJECTION VIAL 48262202_1 CDM 0250 RC 00409-4887-20 NDC inpatient 1 UN 25.05 16.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.17 24.3 WATER FOR INJECTION VIAL 48262202_1 CDM 0250 RC 00409-4887-20 NDC inpatient 1 UN 25.05 16.28 ANTHEM HMO ANTHEM HMO 999999999 15.17 24.3 WATER FOR INJECTION VIAL 48262202_1 CDM 0250 RC 00409-4887-20 NDC inpatient 1 UN 25.05 16.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.93 67.6 999999999 15.17 24.3 percent of total billed charges WATER FOR INJECTION VIAL 48262202_1 CDM 0250 RC 00409-4887-20 NDC inpatient 1 UN 25.05 16.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.17 24.3 WATER FOR INJECTION VIAL 48262202_1 CDM 0250 RC 00409-4887-20 NDC inpatient 1 UN 25.05 16.28 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.17 24.3 00409-7993-09 - Dextrose 5% with 0.45% NaCl and KCl 10 mEq/l IV Sol 1000 mL [JOHN] 48262231_1 CDM 0258 RC 00409-7993-09 NDC inpatient 1 UN 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges 00409-7993-09 - Dextrose 5% with 0.45% NaCl and KCl 10 mEq/l IV Sol 1000 mL [JOHN] 48262231_1 CDM 0258 RC 00409-7993-09 NDC inpatient 1 UN 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges 00409-7993-09 - Dextrose 5% with 0.45% NaCl and KCl 10 mEq/l IV Sol 1000 mL [JOHN] 48262231_1 CDM 0258 RC 00409-7993-09 NDC inpatient 1 UN 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges 00409-7993-09 - Dextrose 5% with 0.45% NaCl and KCl 10 mEq/l IV Sol 1000 mL [JOHN] 48262231_1 CDM 0258 RC 00409-7993-09 NDC inpatient 1 UN 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges 00409-7993-09 - Dextrose 5% with 0.45% NaCl and KCl 10 mEq/l IV Sol 1000 mL [JOHN] 48262231_1 CDM 0258 RC 00409-7993-09 NDC inpatient 1 UN 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges 00409-7993-09 - Dextrose 5% with 0.45% NaCl and KCl 10 mEq/l IV Sol 1000 mL [JOHN] 48262231_1 CDM 0258 RC 00409-7993-09 NDC inpatient 1 UN 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges 00409-7993-09 - Dextrose 5% with 0.45% NaCl and KCl 10 mEq/l IV Sol 1000 mL [JOHN] 48262231_1 CDM 0258 RC 00409-7993-09 NDC inpatient 1 UN 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges 00409-7993-09 - Dextrose 5% with 0.45% NaCl and KCl 10 mEq/l IV Sol 1000 mL [JOHN] 48262231_1 CDM 0258 RC 00409-7993-09 NDC inpatient 1 UN 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges 00409-7993-09 - Dextrose 5% with 0.45% NaCl and KCl 10 mEq/l IV Sol 1000 mL [JOHN] 48262231_1 CDM 0258 RC 00409-7993-09 NDC inpatient 1 UN 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 00409-7993-09 - Dextrose 5% with 0.45% NaCl and KCl 10 mEq/l IV Sol 1000 mL [JOHN] 48262231_1 CDM 0258 RC 00409-7993-09 NDC inpatient 1 UN 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 00409-7993-09 - Dextrose 5% with 0.45% NaCl and KCl 10 mEq/l IV Sol 1000 mL [JOHN] 48262231_1 CDM 0258 RC 00409-7993-09 NDC inpatient 1 UN 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 00409-7993-09 - Dextrose 5% with 0.45% NaCl and KCl 10 mEq/l IV Sol 1000 mL [JOHN] 48262231_1 CDM 0258 RC 00409-7993-09 NDC inpatient 1 UN 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges 00409-7993-09 - Dextrose 5% with 0.45% NaCl and KCl 10 mEq/l IV Sol 1000 mL [JOHN] 48262231_1 CDM 0258 RC 00409-7993-09 NDC inpatient 1 UN 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 00409-7993-09 - Dextrose 5% with 0.45% NaCl and KCl 10 mEq/l IV Sol 1000 mL [JOHN] 48262231_1 CDM 0258 RC 00409-7993-09 NDC inpatient 1 UN 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 87701-4077-65 - FERROUS SULFATE 160 MG TAB [JOHN] 48262290_1 CDM 0250 RC 87701-4077-65 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 87701-4077-65 - FERROUS SULFATE 160 MG TAB [JOHN] 48262290_1 CDM 0250 RC 87701-4077-65 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 87701-4077-65 - FERROUS SULFATE 160 MG TAB [JOHN] 48262290_1 CDM 0250 RC 87701-4077-65 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 87701-4077-65 - FERROUS SULFATE 160 MG TAB [JOHN] 48262290_1 CDM 0250 RC 87701-4077-65 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 87701-4077-65 - FERROUS SULFATE 160 MG TAB [JOHN] 48262290_1 CDM 0250 RC 87701-4077-65 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 87701-4077-65 - FERROUS SULFATE 160 MG TAB [JOHN] 48262290_1 CDM 0250 RC 87701-4077-65 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 87701-4077-65 - FERROUS SULFATE 160 MG TAB [JOHN] 48262290_1 CDM 0250 RC 87701-4077-65 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 87701-4077-65 - FERROUS SULFATE 160 MG TAB [JOHN] 48262290_1 CDM 0250 RC 87701-4077-65 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 87701-4077-65 - FERROUS SULFATE 160 MG TAB [JOHN] 48262290_1 CDM 0250 RC 87701-4077-65 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 87701-4077-65 - FERROUS SULFATE 160 MG TAB [JOHN] 48262290_1 CDM 0250 RC 87701-4077-65 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 87701-4077-65 - FERROUS SULFATE 160 MG TAB [JOHN] 48262290_1 CDM 0250 RC 87701-4077-65 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 87701-4077-65 - FERROUS SULFATE 160 MG TAB [JOHN] 48262290_1 CDM 0250 RC 87701-4077-65 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 87701-4077-65 - FERROUS SULFATE 160 MG TAB [JOHN] 48262290_1 CDM 0250 RC 87701-4077-65 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 87701-4077-65 - FERROUS SULFATE 160 MG TAB [JOHN] 48262290_1 CDM 0250 RC 87701-4077-65 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 00004-0068-50-HALF - clonazePAM 0.25 MG TAB [JOHN] 48262298_1 CDM 0250 RC 00004-0068-50 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 00004-0068-50-HALF - clonazePAM 0.25 MG TAB [JOHN] 48262298_1 CDM 0250 RC 00004-0068-50 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 00004-0068-50-HALF - clonazePAM 0.25 MG TAB [JOHN] 48262298_1 CDM 0250 RC 00004-0068-50 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 00004-0068-50-HALF - clonazePAM 0.25 MG TAB [JOHN] 48262298_1 CDM 0250 RC 00004-0068-50 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 00004-0068-50-HALF - clonazePAM 0.25 MG TAB [JOHN] 48262298_1 CDM 0250 RC 00004-0068-50 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 00004-0068-50-HALF - clonazePAM 0.25 MG TAB [JOHN] 48262298_1 CDM 0250 RC 00004-0068-50 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 00004-0068-50-HALF - clonazePAM 0.25 MG TAB [JOHN] 48262298_1 CDM 0250 RC 00004-0068-50 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 00004-0068-50-HALF - clonazePAM 0.25 MG TAB [JOHN] 48262298_1 CDM 0250 RC 00004-0068-50 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 00004-0068-50-HALF - clonazePAM 0.25 MG TAB [JOHN] 48262298_1 CDM 0250 RC 00004-0068-50 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 00004-0068-50-HALF - clonazePAM 0.25 MG TAB [JOHN] 48262298_1 CDM 0250 RC 00004-0068-50 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 00004-0068-50-HALF - clonazePAM 0.25 MG TAB [JOHN] 48262298_1 CDM 0250 RC 00004-0068-50 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 00004-0068-50-HALF - clonazePAM 0.25 MG TAB [JOHN] 48262298_1 CDM 0250 RC 00004-0068-50 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 00004-0068-50-HALF - clonazePAM 0.25 MG TAB [JOHN] 48262298_1 CDM 0250 RC 00004-0068-50 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 00004-0068-50-HALF - clonazePAM 0.25 MG TAB [JOHN] 48262298_1 CDM 0250 RC 00004-0068-50 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 Closed treatment of dislocated hip 48262938_1 CDM 0450 RC 27250 HCPCS inpatient 509 330.85 AETNA AETNA 402.11 79 999999999 308.2 493.73 percent of total billed charges Closed treatment of dislocated hip 48262938_1 CDM 0450 RC 27250 HCPCS inpatient 509 330.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 330.85 65 999999999 308.2 493.73 percent of total billed charges Closed treatment of dislocated hip 48262938_1 CDM 0450 RC 27250 HCPCS inpatient 509 330.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 493.73 97 999999999 308.2 493.73 percent of total billed charges Closed treatment of dislocated hip 48262938_1 CDM 0450 RC 27250 HCPCS inpatient 509 330.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 397.02 78 999999999 308.2 493.73 percent of total billed charges Closed treatment of dislocated hip 48262938_1 CDM 0450 RC 27250 HCPCS inpatient 509 330.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 351.21 69 999999999 308.2 493.73 percent of total billed charges Closed treatment of dislocated hip 48262938_1 CDM 0450 RC 27250 HCPCS inpatient 509 330.85 UMR - ALL PLANS UMR - ALL PLANS 356.3 70 999999999 308.2 493.73 percent of total billed charges Closed treatment of dislocated hip 48262938_1 CDM 0450 RC 27250 HCPCS inpatient 509 330.85 SIHO - ALL PLANS SIHO - ALL PLANS 458.1 90 999999999 308.2 493.73 percent of total billed charges Closed treatment of dislocated hip 48262938_1 CDM 0450 RC 27250 HCPCS inpatient 509 330.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 308.2 60.55 999999999 308.2 493.73 percent of total billed charges Closed treatment of dislocated hip 48262938_1 CDM 0450 RC 27250 HCPCS inpatient 509 330.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 308.2 493.73 Closed treatment of dislocated hip 48262938_1 CDM 0450 RC 27250 HCPCS inpatient 509 330.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 308.2 493.73 Closed treatment of dislocated hip 48262938_1 CDM 0450 RC 27250 HCPCS inpatient 509 330.85 ANTHEM HMO ANTHEM HMO 999999999 308.2 493.73 Closed treatment of dislocated hip 48262938_1 CDM 0450 RC 27250 HCPCS inpatient 509 330.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 344.08 67.6 999999999 308.2 493.73 percent of total billed charges Closed treatment of dislocated hip 48262938_1 CDM 0450 RC 27250 HCPCS inpatient 509 330.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 308.2 493.73 Closed treatment of dislocated hip 48262938_1 CDM 0450 RC 27250 HCPCS inpatient 509 330.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 308.2 493.73 Diagnostic exam of anus using an endoscope 48262979_1 CDM 0450 RC 46600 HCPCS inpatient 134 87.1 AETNA AETNA 105.86 79 999999999 81.14 129.98 percent of total billed charges Diagnostic exam of anus using an endoscope 48262979_1 CDM 0450 RC 46600 HCPCS inpatient 134 87.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 87.1 65 999999999 81.14 129.98 percent of total billed charges Diagnostic exam of anus using an endoscope 48262979_1 CDM 0450 RC 46600 HCPCS inpatient 134 87.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.98 97 999999999 81.14 129.98 percent of total billed charges Diagnostic exam of anus using an endoscope 48262979_1 CDM 0450 RC 46600 HCPCS inpatient 134 87.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 104.52 78 999999999 81.14 129.98 percent of total billed charges Diagnostic exam of anus using an endoscope 48262979_1 CDM 0450 RC 46600 HCPCS inpatient 134 87.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 92.46 69 999999999 81.14 129.98 percent of total billed charges Diagnostic exam of anus using an endoscope 48262979_1 CDM 0450 RC 46600 HCPCS inpatient 134 87.1 UMR - ALL PLANS UMR - ALL PLANS 93.8 70 999999999 81.14 129.98 percent of total billed charges Diagnostic exam of anus using an endoscope 48262979_1 CDM 0450 RC 46600 HCPCS inpatient 134 87.1 SIHO - ALL PLANS SIHO - ALL PLANS 120.6 90 999999999 81.14 129.98 percent of total billed charges Diagnostic exam of anus using an endoscope 48262979_1 CDM 0450 RC 46600 HCPCS inpatient 134 87.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 81.14 60.55 999999999 81.14 129.98 percent of total billed charges Diagnostic exam of anus using an endoscope 48262979_1 CDM 0450 RC 46600 HCPCS inpatient 134 87.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 81.14 129.98 Diagnostic exam of anus using an endoscope 48262979_1 CDM 0450 RC 46600 HCPCS inpatient 134 87.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 81.14 129.98 Diagnostic exam of anus using an endoscope 48262979_1 CDM 0450 RC 46600 HCPCS inpatient 134 87.1 ANTHEM HMO ANTHEM HMO 999999999 81.14 129.98 Diagnostic exam of anus using an endoscope 48262979_1 CDM 0450 RC 46600 HCPCS inpatient 134 87.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 90.58 67.6 999999999 81.14 129.98 percent of total billed charges Diagnostic exam of anus using an endoscope 48262979_1 CDM 0450 RC 46600 HCPCS inpatient 134 87.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 81.14 129.98 Diagnostic exam of anus using an endoscope 48262979_1 CDM 0450 RC 46600 HCPCS inpatient 134 87.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 81.14 129.98 Injection of anesthetic agent and/or steroid into other nerve or branch 48262983_1 CDM 0450 RC 64450 HCPCS inpatient 830 539.5 AETNA AETNA 655.7 79 999999999 502.57 805.1 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48262983_1 CDM 0450 RC 64450 HCPCS inpatient 830 539.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 539.5 65 999999999 502.57 805.1 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48262983_1 CDM 0450 RC 64450 HCPCS inpatient 830 539.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 805.1 97 999999999 502.57 805.1 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48262983_1 CDM 0450 RC 64450 HCPCS inpatient 830 539.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 647.4 78 999999999 502.57 805.1 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48262983_1 CDM 0450 RC 64450 HCPCS inpatient 830 539.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 572.7 69 999999999 502.57 805.1 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48262983_1 CDM 0450 RC 64450 HCPCS inpatient 830 539.5 UMR - ALL PLANS UMR - ALL PLANS 581 70 999999999 502.57 805.1 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48262983_1 CDM 0450 RC 64450 HCPCS inpatient 830 539.5 SIHO - ALL PLANS SIHO - ALL PLANS 747 90 999999999 502.57 805.1 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48262983_1 CDM 0450 RC 64450 HCPCS inpatient 830 539.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 502.57 60.55 999999999 502.57 805.1 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48262983_1 CDM 0450 RC 64450 HCPCS inpatient 830 539.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 502.57 805.1 Injection of anesthetic agent and/or steroid into other nerve or branch 48262983_1 CDM 0450 RC 64450 HCPCS inpatient 830 539.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 502.57 805.1 Injection of anesthetic agent and/or steroid into other nerve or branch 48262983_1 CDM 0450 RC 64450 HCPCS inpatient 830 539.5 ANTHEM HMO ANTHEM HMO 999999999 502.57 805.1 Injection of anesthetic agent and/or steroid into other nerve or branch 48262983_1 CDM 0450 RC 64450 HCPCS inpatient 830 539.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 561.08 67.6 999999999 502.57 805.1 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48262983_1 CDM 0450 RC 64450 HCPCS inpatient 830 539.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 502.57 805.1 Injection of anesthetic agent and/or steroid into other nerve or branch 48262983_1 CDM 0450 RC 64450 HCPCS inpatient 830 539.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 502.57 805.1 00024-5401-34-HALF - ZOLPIDEM 2.5 MG TAB [JOHN] 48263041_1 CDM 0250 RC 00024-5401-34 NDC inpatient 1 UN 7.11 4.62 AETNA AETNA 5.62 79 999999999 4.31 6.9 percent of total billed charges 00024-5401-34-HALF - ZOLPIDEM 2.5 MG TAB [JOHN] 48263041_1 CDM 0250 RC 00024-5401-34 NDC inpatient 1 UN 7.11 4.62 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.62 65 999999999 4.31 6.9 percent of total billed charges 00024-5401-34-HALF - ZOLPIDEM 2.5 MG TAB [JOHN] 48263041_1 CDM 0250 RC 00024-5401-34 NDC inpatient 1 UN 7.11 4.62 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.9 97 999999999 4.31 6.9 percent of total billed charges 00024-5401-34-HALF - ZOLPIDEM 2.5 MG TAB [JOHN] 48263041_1 CDM 0250 RC 00024-5401-34 NDC inpatient 1 UN 7.11 4.62 HUMANA - ALL PLANS HUMANA - ALL PLANS 5.55 78 999999999 4.31 6.9 percent of total billed charges 00024-5401-34-HALF - ZOLPIDEM 2.5 MG TAB [JOHN] 48263041_1 CDM 0250 RC 00024-5401-34 NDC inpatient 1 UN 7.11 4.62 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.91 69 999999999 4.31 6.9 percent of total billed charges 00024-5401-34-HALF - ZOLPIDEM 2.5 MG TAB [JOHN] 48263041_1 CDM 0250 RC 00024-5401-34 NDC inpatient 1 UN 7.11 4.62 UMR - ALL PLANS UMR - ALL PLANS 4.98 70 999999999 4.31 6.9 percent of total billed charges 00024-5401-34-HALF - ZOLPIDEM 2.5 MG TAB [JOHN] 48263041_1 CDM 0250 RC 00024-5401-34 NDC inpatient 1 UN 7.11 4.62 SIHO - ALL PLANS SIHO - ALL PLANS 6.4 90 999999999 4.31 6.9 percent of total billed charges 00024-5401-34-HALF - ZOLPIDEM 2.5 MG TAB [JOHN] 48263041_1 CDM 0250 RC 00024-5401-34 NDC inpatient 1 UN 7.11 4.62 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.31 60.55 999999999 4.31 6.9 percent of total billed charges 00024-5401-34-HALF - ZOLPIDEM 2.5 MG TAB [JOHN] 48263041_1 CDM 0250 RC 00024-5401-34 NDC inpatient 1 UN 7.11 4.62 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.31 6.9 00024-5401-34-HALF - ZOLPIDEM 2.5 MG TAB [JOHN] 48263041_1 CDM 0250 RC 00024-5401-34 NDC inpatient 1 UN 7.11 4.62 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.31 6.9 00024-5401-34-HALF - ZOLPIDEM 2.5 MG TAB [JOHN] 48263041_1 CDM 0250 RC 00024-5401-34 NDC inpatient 1 UN 7.11 4.62 ANTHEM HMO ANTHEM HMO 999999999 4.31 6.9 00024-5401-34-HALF - ZOLPIDEM 2.5 MG TAB [JOHN] 48263041_1 CDM 0250 RC 00024-5401-34 NDC inpatient 1 UN 7.11 4.62 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.81 67.6 999999999 4.31 6.9 percent of total billed charges 00024-5401-34-HALF - ZOLPIDEM 2.5 MG TAB [JOHN] 48263041_1 CDM 0250 RC 00024-5401-34 NDC inpatient 1 UN 7.11 4.62 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.31 6.9 00024-5401-34-HALF - ZOLPIDEM 2.5 MG TAB [JOHN] 48263041_1 CDM 0250 RC 00024-5401-34 NDC inpatient 1 UN 7.11 4.62 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.31 6.9 CYTOTEC 100 MCG TABLET 48263048_1 CDM 0250 RC 00025-1451-34 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CYTOTEC 100 MCG TABLET 48263048_1 CDM 0250 RC 00025-1451-34 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CYTOTEC 100 MCG TABLET 48263048_1 CDM 0250 RC 00025-1451-34 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CYTOTEC 100 MCG TABLET 48263048_1 CDM 0250 RC 00025-1451-34 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CYTOTEC 100 MCG TABLET 48263048_1 CDM 0250 RC 00025-1451-34 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CYTOTEC 100 MCG TABLET 48263048_1 CDM 0250 RC 00025-1451-34 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CYTOTEC 100 MCG TABLET 48263048_1 CDM 0250 RC 00025-1451-34 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CYTOTEC 100 MCG TABLET 48263048_1 CDM 0250 RC 00025-1451-34 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CYTOTEC 100 MCG TABLET 48263048_1 CDM 0250 RC 00025-1451-34 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CYTOTEC 100 MCG TABLET 48263048_1 CDM 0250 RC 00025-1451-34 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CYTOTEC 100 MCG TABLET 48263048_1 CDM 0250 RC 00025-1451-34 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CYTOTEC 100 MCG TABLET 48263048_1 CDM 0250 RC 00025-1451-34 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CYTOTEC 100 MCG TABLET 48263048_1 CDM 0250 RC 00025-1451-34 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CYTOTEC 100 MCG TABLET 48263048_1 CDM 0250 RC 00025-1451-34 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 00034-0518-10-HALF - MORPHINE SULFATE 7.5 MG TAB [JOHN] 48263055_1 CDM 0250 RC 00034-0518-10 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 00034-0518-10-HALF - MORPHINE SULFATE 7.5 MG TAB [JOHN] 48263055_1 CDM 0250 RC 00034-0518-10 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 00034-0518-10-HALF - MORPHINE SULFATE 7.5 MG TAB [JOHN] 48263055_1 CDM 0250 RC 00034-0518-10 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 00034-0518-10-HALF - MORPHINE SULFATE 7.5 MG TAB [JOHN] 48263055_1 CDM 0250 RC 00034-0518-10 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 00034-0518-10-HALF - MORPHINE SULFATE 7.5 MG TAB [JOHN] 48263055_1 CDM 0250 RC 00034-0518-10 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 00034-0518-10-HALF - MORPHINE SULFATE 7.5 MG TAB [JOHN] 48263055_1 CDM 0250 RC 00034-0518-10 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 00034-0518-10-HALF - MORPHINE SULFATE 7.5 MG TAB [JOHN] 48263055_1 CDM 0250 RC 00034-0518-10 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 00034-0518-10-HALF - MORPHINE SULFATE 7.5 MG TAB [JOHN] 48263055_1 CDM 0250 RC 00034-0518-10 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 00034-0518-10-HALF - MORPHINE SULFATE 7.5 MG TAB [JOHN] 48263055_1 CDM 0250 RC 00034-0518-10 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 00034-0518-10-HALF - MORPHINE SULFATE 7.5 MG TAB [JOHN] 48263055_1 CDM 0250 RC 00034-0518-10 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 00034-0518-10-HALF - MORPHINE SULFATE 7.5 MG TAB [JOHN] 48263055_1 CDM 0250 RC 00034-0518-10 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 00034-0518-10-HALF - MORPHINE SULFATE 7.5 MG TAB [JOHN] 48263055_1 CDM 0250 RC 00034-0518-10 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 00034-0518-10-HALF - MORPHINE SULFATE 7.5 MG TAB [JOHN] 48263055_1 CDM 0250 RC 00034-0518-10 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 00034-0518-10-HALF - MORPHINE SULFATE 7.5 MG TAB [JOHN] 48263055_1 CDM 0250 RC 00034-0518-10 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 00045-0659-10-HALF - traMADol HCL 25 MG TAB [JOHN] 48263070_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 00045-0659-10-HALF - traMADol HCL 25 MG TAB [JOHN] 48263070_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 00045-0659-10-HALF - traMADol HCL 25 MG TAB [JOHN] 48263070_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 00045-0659-10-HALF - traMADol HCL 25 MG TAB [JOHN] 48263070_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 00045-0659-10-HALF - traMADol HCL 25 MG TAB [JOHN] 48263070_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 00045-0659-10-HALF - traMADol HCL 25 MG TAB [JOHN] 48263070_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 00045-0659-10-HALF - traMADol HCL 25 MG TAB [JOHN] 48263070_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 00045-0659-10-HALF - traMADol HCL 25 MG TAB [JOHN] 48263070_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 00045-0659-10-HALF - traMADol HCL 25 MG TAB [JOHN] 48263070_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 00045-0659-10-HALF - traMADol HCL 25 MG TAB [JOHN] 48263070_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 00045-0659-10-HALF - traMADol HCL 25 MG TAB [JOHN] 48263070_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 00045-0659-10-HALF - traMADol HCL 25 MG TAB [JOHN] 48263070_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 00045-0659-10-HALF - traMADol HCL 25 MG TAB [JOHN] 48263070_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 00045-0659-10-HALF - traMADol HCL 25 MG TAB [JOHN] 48263070_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 00045-0659-10-QTR - traMADol HCL 12.5 MG TAB [JOHN] 48263100_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 00045-0659-10-QTR - traMADol HCL 12.5 MG TAB [JOHN] 48263100_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 00045-0659-10-QTR - traMADol HCL 12.5 MG TAB [JOHN] 48263100_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 00045-0659-10-QTR - traMADol HCL 12.5 MG TAB [JOHN] 48263100_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 00045-0659-10-QTR - traMADol HCL 12.5 MG TAB [JOHN] 48263100_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 00045-0659-10-QTR - traMADol HCL 12.5 MG TAB [JOHN] 48263100_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 00045-0659-10-QTR - traMADol HCL 12.5 MG TAB [JOHN] 48263100_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 00045-0659-10-QTR - traMADol HCL 12.5 MG TAB [JOHN] 48263100_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 00045-0659-10-QTR - traMADol HCL 12.5 MG TAB [JOHN] 48263100_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 00045-0659-10-QTR - traMADol HCL 12.5 MG TAB [JOHN] 48263100_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 00045-0659-10-QTR - traMADol HCL 12.5 MG TAB [JOHN] 48263100_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 00045-0659-10-QTR - traMADol HCL 12.5 MG TAB [JOHN] 48263100_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 00045-0659-10-QTR - traMADol HCL 12.5 MG TAB [JOHN] 48263100_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 00045-0659-10-QTR - traMADol HCL 12.5 MG TAB [JOHN] 48263100_1 CDM 0250 RC 00045-0659-10 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 74312-0209-90 - CO Q-10 Q-SORB COENZYME 200 MG CAP [JOHN] 48263220_1 CDM 0250 RC 74312-0209-90 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 74312-0209-90 - CO Q-10 Q-SORB COENZYME 200 MG CAP [JOHN] 48263220_1 CDM 0250 RC 74312-0209-90 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 74312-0209-90 - CO Q-10 Q-SORB COENZYME 200 MG CAP [JOHN] 48263220_1 CDM 0250 RC 74312-0209-90 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 74312-0209-90 - CO Q-10 Q-SORB COENZYME 200 MG CAP [JOHN] 48263220_1 CDM 0250 RC 74312-0209-90 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 74312-0209-90 - CO Q-10 Q-SORB COENZYME 200 MG CAP [JOHN] 48263220_1 CDM 0250 RC 74312-0209-90 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 74312-0209-90 - CO Q-10 Q-SORB COENZYME 200 MG CAP [JOHN] 48263220_1 CDM 0250 RC 74312-0209-90 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 74312-0209-90 - CO Q-10 Q-SORB COENZYME 200 MG CAP [JOHN] 48263220_1 CDM 0250 RC 74312-0209-90 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 74312-0209-90 - CO Q-10 Q-SORB COENZYME 200 MG CAP [JOHN] 48263220_1 CDM 0250 RC 74312-0209-90 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 74312-0209-90 - CO Q-10 Q-SORB COENZYME 200 MG CAP [JOHN] 48263220_1 CDM 0250 RC 74312-0209-90 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 74312-0209-90 - CO Q-10 Q-SORB COENZYME 200 MG CAP [JOHN] 48263220_1 CDM 0250 RC 74312-0209-90 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 74312-0209-90 - CO Q-10 Q-SORB COENZYME 200 MG CAP [JOHN] 48263220_1 CDM 0250 RC 74312-0209-90 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 74312-0209-90 - CO Q-10 Q-SORB COENZYME 200 MG CAP [JOHN] 48263220_1 CDM 0250 RC 74312-0209-90 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 74312-0209-90 - CO Q-10 Q-SORB COENZYME 200 MG CAP [JOHN] 48263220_1 CDM 0250 RC 74312-0209-90 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 74312-0209-90 - CO Q-10 Q-SORB COENZYME 200 MG CAP [JOHN] 48263220_1 CDM 0250 RC 74312-0209-90 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 68084-0359-01-HALF - diazePAM 1 mg tab [JOHN] 48263246_1 CDM 0250 RC 68084-0359-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 68084-0359-01-HALF - diazePAM 1 mg tab [JOHN] 48263246_1 CDM 0250 RC 68084-0359-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 68084-0359-01-HALF - diazePAM 1 mg tab [JOHN] 48263246_1 CDM 0250 RC 68084-0359-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 68084-0359-01-HALF - diazePAM 1 mg tab [JOHN] 48263246_1 CDM 0250 RC 68084-0359-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 68084-0359-01-HALF - diazePAM 1 mg tab [JOHN] 48263246_1 CDM 0250 RC 68084-0359-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 68084-0359-01-HALF - diazePAM 1 mg tab [JOHN] 48263246_1 CDM 0250 RC 68084-0359-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 68084-0359-01-HALF - diazePAM 1 mg tab [JOHN] 48263246_1 CDM 0250 RC 68084-0359-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 68084-0359-01-HALF - diazePAM 1 mg tab [JOHN] 48263246_1 CDM 0250 RC 68084-0359-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 68084-0359-01-HALF - diazePAM 1 mg tab [JOHN] 48263246_1 CDM 0250 RC 68084-0359-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 68084-0359-01-HALF - diazePAM 1 mg tab [JOHN] 48263246_1 CDM 0250 RC 68084-0359-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 68084-0359-01-HALF - diazePAM 1 mg tab [JOHN] 48263246_1 CDM 0250 RC 68084-0359-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 68084-0359-01-HALF - diazePAM 1 mg tab [JOHN] 48263246_1 CDM 0250 RC 68084-0359-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 68084-0359-01-HALF - diazePAM 1 mg tab [JOHN] 48263246_1 CDM 0250 RC 68084-0359-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 68084-0359-01-HALF - diazePAM 1 mg tab [JOHN] 48263246_1 CDM 0250 RC 68084-0359-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 64764-0246-00 - NF-LUBIPROSTONE 24 MCG CAP [JOHN] 48263248_1 CDM 0250 RC 64764-0246-00 NDC inpatient 1 UN 27.27 17.73 AETNA AETNA 21.54 79 999999999 16.51 26.45 percent of total billed charges 64764-0246-00 - NF-LUBIPROSTONE 24 MCG CAP [JOHN] 48263248_1 CDM 0250 RC 64764-0246-00 NDC inpatient 1 UN 27.27 17.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.73 65 999999999 16.51 26.45 percent of total billed charges 64764-0246-00 - NF-LUBIPROSTONE 24 MCG CAP [JOHN] 48263248_1 CDM 0250 RC 64764-0246-00 NDC inpatient 1 UN 27.27 17.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26.45 97 999999999 16.51 26.45 percent of total billed charges 64764-0246-00 - NF-LUBIPROSTONE 24 MCG CAP [JOHN] 48263248_1 CDM 0250 RC 64764-0246-00 NDC inpatient 1 UN 27.27 17.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.27 78 999999999 16.51 26.45 percent of total billed charges 64764-0246-00 - NF-LUBIPROSTONE 24 MCG CAP [JOHN] 48263248_1 CDM 0250 RC 64764-0246-00 NDC inpatient 1 UN 27.27 17.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.82 69 999999999 16.51 26.45 percent of total billed charges 64764-0246-00 - NF-LUBIPROSTONE 24 MCG CAP [JOHN] 48263248_1 CDM 0250 RC 64764-0246-00 NDC inpatient 1 UN 27.27 17.73 UMR - ALL PLANS UMR - ALL PLANS 19.09 70 999999999 16.51 26.45 percent of total billed charges 64764-0246-00 - NF-LUBIPROSTONE 24 MCG CAP [JOHN] 48263248_1 CDM 0250 RC 64764-0246-00 NDC inpatient 1 UN 27.27 17.73 SIHO - ALL PLANS SIHO - ALL PLANS 24.54 90 999999999 16.51 26.45 percent of total billed charges 64764-0246-00 - NF-LUBIPROSTONE 24 MCG CAP [JOHN] 48263248_1 CDM 0250 RC 64764-0246-00 NDC inpatient 1 UN 27.27 17.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.51 60.55 999999999 16.51 26.45 percent of total billed charges 64764-0246-00 - NF-LUBIPROSTONE 24 MCG CAP [JOHN] 48263248_1 CDM 0250 RC 64764-0246-00 NDC inpatient 1 UN 27.27 17.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.51 26.45 64764-0246-00 - NF-LUBIPROSTONE 24 MCG CAP [JOHN] 48263248_1 CDM 0250 RC 64764-0246-00 NDC inpatient 1 UN 27.27 17.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.51 26.45 64764-0246-00 - NF-LUBIPROSTONE 24 MCG CAP [JOHN] 48263248_1 CDM 0250 RC 64764-0246-00 NDC inpatient 1 UN 27.27 17.73 ANTHEM HMO ANTHEM HMO 999999999 16.51 26.45 64764-0246-00 - NF-LUBIPROSTONE 24 MCG CAP [JOHN] 48263248_1 CDM 0250 RC 64764-0246-00 NDC inpatient 1 UN 27.27 17.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.43 67.6 999999999 16.51 26.45 percent of total billed charges 64764-0246-00 - NF-LUBIPROSTONE 24 MCG CAP [JOHN] 48263248_1 CDM 0250 RC 64764-0246-00 NDC inpatient 1 UN 27.27 17.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.51 26.45 64764-0246-00 - NF-LUBIPROSTONE 24 MCG CAP [JOHN] 48263248_1 CDM 0250 RC 64764-0246-00 NDC inpatient 1 UN 27.27 17.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.51 26.45 Review by radiologist of CT guidance for needle placement 48263275_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 AETNA AETNA 1334.31 79 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48263275_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.85 65 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48263275_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1638.33 97 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48263275_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1317.42 78 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48263275_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1165.41 69 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48263275_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UMR - ALL PLANS UMR - ALL PLANS 1182.3 70 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48263275_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SIHO - ALL PLANS SIHO - ALL PLANS 1520.1 90 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48263275_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.69 60.55 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48263275_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48263275_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48263275_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM HMO ANTHEM HMO 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48263275_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.76 67.6 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48263275_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48263275_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.69 1638.33 "Urinalysis, manual test" 48263310_1 CDM 0307 RC 81002 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges "Urinalysis, manual test" 48263310_1 CDM 0307 RC 81002 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges "Urinalysis, manual test" 48263310_1 CDM 0307 RC 81002 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges "Urinalysis, manual test" 48263310_1 CDM 0307 RC 81002 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges "Urinalysis, manual test" 48263310_1 CDM 0307 RC 81002 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges "Urinalysis, manual test" 48263310_1 CDM 0307 RC 81002 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges "Urinalysis, manual test" 48263310_1 CDM 0307 RC 81002 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges "Urinalysis, manual test" 48263310_1 CDM 0307 RC 81002 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges "Urinalysis, manual test" 48263310_1 CDM 0307 RC 81002 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 "Urinalysis, manual test" 48263310_1 CDM 0307 RC 81002 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 "Urinalysis, manual test" 48263310_1 CDM 0307 RC 81002 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 "Urinalysis, manual test" 48263310_1 CDM 0307 RC 81002 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges "Urinalysis, manual test" 48263310_1 CDM 0307 RC 81002 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 "Urinalysis, manual test" 48263310_1 CDM 0307 RC 81002 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 00615-1540-13-HALF - PROMETHAZINE 12.5 MG TAB [JOHN] 48263623_1 CDM 0250 RC 00615-1540-13 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 00615-1540-13-HALF - PROMETHAZINE 12.5 MG TAB [JOHN] 48263623_1 CDM 0250 RC 00615-1540-13 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 00615-1540-13-HALF - PROMETHAZINE 12.5 MG TAB [JOHN] 48263623_1 CDM 0250 RC 00615-1540-13 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 00615-1540-13-HALF - PROMETHAZINE 12.5 MG TAB [JOHN] 48263623_1 CDM 0250 RC 00615-1540-13 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 00615-1540-13-HALF - PROMETHAZINE 12.5 MG TAB [JOHN] 48263623_1 CDM 0250 RC 00615-1540-13 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 00615-1540-13-HALF - PROMETHAZINE 12.5 MG TAB [JOHN] 48263623_1 CDM 0250 RC 00615-1540-13 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 00615-1540-13-HALF - PROMETHAZINE 12.5 MG TAB [JOHN] 48263623_1 CDM 0250 RC 00615-1540-13 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 00615-1540-13-HALF - PROMETHAZINE 12.5 MG TAB [JOHN] 48263623_1 CDM 0250 RC 00615-1540-13 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 00615-1540-13-HALF - PROMETHAZINE 12.5 MG TAB [JOHN] 48263623_1 CDM 0250 RC 00615-1540-13 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 00615-1540-13-HALF - PROMETHAZINE 12.5 MG TAB [JOHN] 48263623_1 CDM 0250 RC 00615-1540-13 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 00615-1540-13-HALF - PROMETHAZINE 12.5 MG TAB [JOHN] 48263623_1 CDM 0250 RC 00615-1540-13 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 00615-1540-13-HALF - PROMETHAZINE 12.5 MG TAB [JOHN] 48263623_1 CDM 0250 RC 00615-1540-13 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 00615-1540-13-HALF - PROMETHAZINE 12.5 MG TAB [JOHN] 48263623_1 CDM 0250 RC 00615-1540-13 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 00615-1540-13-HALF - PROMETHAZINE 12.5 MG TAB [JOHN] 48263623_1 CDM 0250 RC 00615-1540-13 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 00781-1326-13-HALF - ALPRAZolam 0.125 MG TAB [JOHN] 48263645_1 CDM 0250 RC 00781-1326-13 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 00781-1326-13-HALF - ALPRAZolam 0.125 MG TAB [JOHN] 48263645_1 CDM 0250 RC 00781-1326-13 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 00781-1326-13-HALF - ALPRAZolam 0.125 MG TAB [JOHN] 48263645_1 CDM 0250 RC 00781-1326-13 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 00781-1326-13-HALF - ALPRAZolam 0.125 MG TAB [JOHN] 48263645_1 CDM 0250 RC 00781-1326-13 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 00781-1326-13-HALF - ALPRAZolam 0.125 MG TAB [JOHN] 48263645_1 CDM 0250 RC 00781-1326-13 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 00781-1326-13-HALF - ALPRAZolam 0.125 MG TAB [JOHN] 48263645_1 CDM 0250 RC 00781-1326-13 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 00781-1326-13-HALF - ALPRAZolam 0.125 MG TAB [JOHN] 48263645_1 CDM 0250 RC 00781-1326-13 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 00781-1326-13-HALF - ALPRAZolam 0.125 MG TAB [JOHN] 48263645_1 CDM 0250 RC 00781-1326-13 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 00781-1326-13-HALF - ALPRAZolam 0.125 MG TAB [JOHN] 48263645_1 CDM 0250 RC 00781-1326-13 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 00781-1326-13-HALF - ALPRAZolam 0.125 MG TAB [JOHN] 48263645_1 CDM 0250 RC 00781-1326-13 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 00781-1326-13-HALF - ALPRAZolam 0.125 MG TAB [JOHN] 48263645_1 CDM 0250 RC 00781-1326-13 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 00781-1326-13-HALF - ALPRAZolam 0.125 MG TAB [JOHN] 48263645_1 CDM 0250 RC 00781-1326-13 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 00781-1326-13-HALF - ALPRAZolam 0.125 MG TAB [JOHN] 48263645_1 CDM 0250 RC 00781-1326-13 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 00781-1326-13-HALF - ALPRAZolam 0.125 MG TAB [JOHN] 48263645_1 CDM 0250 RC 00781-1326-13 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 51079-0417-21-HALF - LORazepam 0.25 MG TAB [JOHN] 48263671_1 CDM 0250 RC 51079-0417-21 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 51079-0417-21-HALF - LORazepam 0.25 MG TAB [JOHN] 48263671_1 CDM 0250 RC 51079-0417-21 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 51079-0417-21-HALF - LORazepam 0.25 MG TAB [JOHN] 48263671_1 CDM 0250 RC 51079-0417-21 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 51079-0417-21-HALF - LORazepam 0.25 MG TAB [JOHN] 48263671_1 CDM 0250 RC 51079-0417-21 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 51079-0417-21-HALF - LORazepam 0.25 MG TAB [JOHN] 48263671_1 CDM 0250 RC 51079-0417-21 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 51079-0417-21-HALF - LORazepam 0.25 MG TAB [JOHN] 48263671_1 CDM 0250 RC 51079-0417-21 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 51079-0417-21-HALF - LORazepam 0.25 MG TAB [JOHN] 48263671_1 CDM 0250 RC 51079-0417-21 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 51079-0417-21-HALF - LORazepam 0.25 MG TAB [JOHN] 48263671_1 CDM 0250 RC 51079-0417-21 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 51079-0417-21-HALF - LORazepam 0.25 MG TAB [JOHN] 48263671_1 CDM 0250 RC 51079-0417-21 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 51079-0417-21-HALF - LORazepam 0.25 MG TAB [JOHN] 48263671_1 CDM 0250 RC 51079-0417-21 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 51079-0417-21-HALF - LORazepam 0.25 MG TAB [JOHN] 48263671_1 CDM 0250 RC 51079-0417-21 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 51079-0417-21-HALF - LORazepam 0.25 MG TAB [JOHN] 48263671_1 CDM 0250 RC 51079-0417-21 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 51079-0417-21-HALF - LORazepam 0.25 MG TAB [JOHN] 48263671_1 CDM 0250 RC 51079-0417-21 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 51079-0417-21-HALF - LORazepam 0.25 MG TAB [JOHN] 48263671_1 CDM 0250 RC 51079-0417-21 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 DIAZEPAM 5 MG TABLET 48263699_1 CDM 0250 RC 51079-0285-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges DIAZEPAM 5 MG TABLET 48263699_1 CDM 0250 RC 51079-0285-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges DIAZEPAM 5 MG TABLET 48263699_1 CDM 0250 RC 51079-0285-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges DIAZEPAM 5 MG TABLET 48263699_1 CDM 0250 RC 51079-0285-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges DIAZEPAM 5 MG TABLET 48263699_1 CDM 0250 RC 51079-0285-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges DIAZEPAM 5 MG TABLET 48263699_1 CDM 0250 RC 51079-0285-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges DIAZEPAM 5 MG TABLET 48263699_1 CDM 0250 RC 51079-0285-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges DIAZEPAM 5 MG TABLET 48263699_1 CDM 0250 RC 51079-0285-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges DIAZEPAM 5 MG TABLET 48263699_1 CDM 0250 RC 51079-0285-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 DIAZEPAM 5 MG TABLET 48263699_1 CDM 0250 RC 51079-0285-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 DIAZEPAM 5 MG TABLET 48263699_1 CDM 0250 RC 51079-0285-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 DIAZEPAM 5 MG TABLET 48263699_1 CDM 0250 RC 51079-0285-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges DIAZEPAM 5 MG TABLET 48263699_1 CDM 0250 RC 51079-0285-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 DIAZEPAM 5 MG TABLET 48263699_1 CDM 0250 RC 51079-0285-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 00781-1371-13-HALF - metoprolol tartrate 12.5 mg tab [JOHN] 48263704_1 CDM 0250 RC 00781-1371-13 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 00781-1371-13-HALF - metoprolol tartrate 12.5 mg tab [JOHN] 48263704_1 CDM 0250 RC 00781-1371-13 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 00781-1371-13-HALF - metoprolol tartrate 12.5 mg tab [JOHN] 48263704_1 CDM 0250 RC 00781-1371-13 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 00781-1371-13-HALF - metoprolol tartrate 12.5 mg tab [JOHN] 48263704_1 CDM 0250 RC 00781-1371-13 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 00781-1371-13-HALF - metoprolol tartrate 12.5 mg tab [JOHN] 48263704_1 CDM 0250 RC 00781-1371-13 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 00781-1371-13-HALF - metoprolol tartrate 12.5 mg tab [JOHN] 48263704_1 CDM 0250 RC 00781-1371-13 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 00781-1371-13-HALF - metoprolol tartrate 12.5 mg tab [JOHN] 48263704_1 CDM 0250 RC 00781-1371-13 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 00781-1371-13-HALF - metoprolol tartrate 12.5 mg tab [JOHN] 48263704_1 CDM 0250 RC 00781-1371-13 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 00781-1371-13-HALF - metoprolol tartrate 12.5 mg tab [JOHN] 48263704_1 CDM 0250 RC 00781-1371-13 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 00781-1371-13-HALF - metoprolol tartrate 12.5 mg tab [JOHN] 48263704_1 CDM 0250 RC 00781-1371-13 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 00781-1371-13-HALF - metoprolol tartrate 12.5 mg tab [JOHN] 48263704_1 CDM 0250 RC 00781-1371-13 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 00781-1371-13-HALF - metoprolol tartrate 12.5 mg tab [JOHN] 48263704_1 CDM 0250 RC 00781-1371-13 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 00781-1371-13-HALF - metoprolol tartrate 12.5 mg tab [JOHN] 48263704_1 CDM 0250 RC 00781-1371-13 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 00781-1371-13-HALF - metoprolol tartrate 12.5 mg tab [JOHN] 48263704_1 CDM 0250 RC 00781-1371-13 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 HYDROMORPHONE 2 MG TABLET 48263732_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.8 1.17 AETNA AETNA 1.42 79 999999999 1.09 1.75 percent of total billed charges HYDROMORPHONE 2 MG TABLET 48263732_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.8 1.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.17 65 999999999 1.09 1.75 percent of total billed charges HYDROMORPHONE 2 MG TABLET 48263732_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.8 1.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.75 97 999999999 1.09 1.75 percent of total billed charges HYDROMORPHONE 2 MG TABLET 48263732_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.8 1.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.4 78 999999999 1.09 1.75 percent of total billed charges HYDROMORPHONE 2 MG TABLET 48263732_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.8 1.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.24 69 999999999 1.09 1.75 percent of total billed charges HYDROMORPHONE 2 MG TABLET 48263732_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.8 1.17 UMR - ALL PLANS UMR - ALL PLANS 1.26 70 999999999 1.09 1.75 percent of total billed charges HYDROMORPHONE 2 MG TABLET 48263732_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.8 1.17 SIHO - ALL PLANS SIHO - ALL PLANS 1.62 90 999999999 1.09 1.75 percent of total billed charges HYDROMORPHONE 2 MG TABLET 48263732_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.8 1.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.09 60.55 999999999 1.09 1.75 percent of total billed charges HYDROMORPHONE 2 MG TABLET 48263732_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.8 1.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.09 1.75 HYDROMORPHONE 2 MG TABLET 48263732_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.8 1.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.09 1.75 HYDROMORPHONE 2 MG TABLET 48263732_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.8 1.17 ANTHEM HMO ANTHEM HMO 999999999 1.09 1.75 HYDROMORPHONE 2 MG TABLET 48263732_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.8 1.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.22 67.6 999999999 1.09 1.75 percent of total billed charges HYDROMORPHONE 2 MG TABLET 48263732_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.8 1.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.09 1.75 HYDROMORPHONE 2 MG TABLET 48263732_1 CDM 0250 RC 42858-0301-25 NDC inpatient 1 UN 1.8 1.17 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.09 1.75 FLORASTOR 250 MG CAPSULE 48263734_1 CDM 0250 RC 04142-0000-07 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges FLORASTOR 250 MG CAPSULE 48263734_1 CDM 0250 RC 04142-0000-07 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges FLORASTOR 250 MG CAPSULE 48263734_1 CDM 0250 RC 04142-0000-07 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges FLORASTOR 250 MG CAPSULE 48263734_1 CDM 0250 RC 04142-0000-07 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges FLORASTOR 250 MG CAPSULE 48263734_1 CDM 0250 RC 04142-0000-07 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges FLORASTOR 250 MG CAPSULE 48263734_1 CDM 0250 RC 04142-0000-07 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges FLORASTOR 250 MG CAPSULE 48263734_1 CDM 0250 RC 04142-0000-07 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges FLORASTOR 250 MG CAPSULE 48263734_1 CDM 0250 RC 04142-0000-07 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges FLORASTOR 250 MG CAPSULE 48263734_1 CDM 0250 RC 04142-0000-07 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 FLORASTOR 250 MG CAPSULE 48263734_1 CDM 0250 RC 04142-0000-07 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 FLORASTOR 250 MG CAPSULE 48263734_1 CDM 0250 RC 04142-0000-07 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 FLORASTOR 250 MG CAPSULE 48263734_1 CDM 0250 RC 04142-0000-07 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges FLORASTOR 250 MG CAPSULE 48263734_1 CDM 0250 RC 04142-0000-07 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 FLORASTOR 250 MG CAPSULE 48263734_1 CDM 0250 RC 04142-0000-07 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, DAPTOMYCIN, 1 MG" 48263978_1 CDM 0250 RC 67919-0011-01C NDC J0878 HCPCS inpatient 1 UN 4.06 2.64 AETNA AETNA 3.21 79 999999999 2.46 3.94 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 48263978_1 CDM 0250 RC 67919-0011-01C NDC J0878 HCPCS inpatient 1 UN 4.06 2.64 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.64 65 999999999 2.46 3.94 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 48263978_1 CDM 0250 RC 67919-0011-01C NDC J0878 HCPCS inpatient 1 UN 4.06 2.64 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.94 97 999999999 2.46 3.94 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 48263978_1 CDM 0250 RC 67919-0011-01C NDC J0878 HCPCS inpatient 1 UN 4.06 2.64 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.17 78 999999999 2.46 3.94 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 48263978_1 CDM 0250 RC 67919-0011-01C NDC J0878 HCPCS inpatient 1 UN 4.06 2.64 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.8 69 999999999 2.46 3.94 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 48263978_1 CDM 0250 RC 67919-0011-01C NDC J0878 HCPCS inpatient 1 UN 4.06 2.64 UMR - ALL PLANS UMR - ALL PLANS 2.84 70 999999999 2.46 3.94 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 48263978_1 CDM 0250 RC 67919-0011-01C NDC J0878 HCPCS inpatient 1 UN 4.06 2.64 SIHO - ALL PLANS SIHO - ALL PLANS 3.65 90 999999999 2.46 3.94 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 48263978_1 CDM 0250 RC 67919-0011-01C NDC J0878 HCPCS inpatient 1 UN 4.06 2.64 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.46 60.55 999999999 2.46 3.94 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 48263978_1 CDM 0250 RC 67919-0011-01C NDC J0878 HCPCS inpatient 1 UN 4.06 2.64 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.46 3.94 "INJECTION, DAPTOMYCIN, 1 MG" 48263978_1 CDM 0250 RC 67919-0011-01C NDC J0878 HCPCS inpatient 1 UN 4.06 2.64 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.46 3.94 "INJECTION, DAPTOMYCIN, 1 MG" 48263978_1 CDM 0250 RC 67919-0011-01C NDC J0878 HCPCS inpatient 1 UN 4.06 2.64 ANTHEM HMO ANTHEM HMO 999999999 2.46 3.94 "INJECTION, DAPTOMYCIN, 1 MG" 48263978_1 CDM 0250 RC 67919-0011-01C NDC J0878 HCPCS inpatient 1 UN 4.06 2.64 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.74 67.6 999999999 2.46 3.94 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 48263978_1 CDM 0250 RC 67919-0011-01C NDC J0878 HCPCS inpatient 1 UN 4.06 2.64 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.46 3.94 "INJECTION, DAPTOMYCIN, 1 MG" 48263978_1 CDM 0250 RC 67919-0011-01C NDC J0878 HCPCS inpatient 1 UN 4.06 2.64 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.46 3.94 PFIZERPEN 5 MILLION UNIT VIAL 48264225_1 CDM 0250 RC 00049-0520-83 NDC inpatient 1 UN 40.83 26.54 AETNA AETNA 32.26 79 999999999 24.72 39.61 percent of total billed charges PFIZERPEN 5 MILLION UNIT VIAL 48264225_1 CDM 0250 RC 00049-0520-83 NDC inpatient 1 UN 40.83 26.54 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.54 65 999999999 24.72 39.61 percent of total billed charges PFIZERPEN 5 MILLION UNIT VIAL 48264225_1 CDM 0250 RC 00049-0520-83 NDC inpatient 1 UN 40.83 26.54 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39.61 97 999999999 24.72 39.61 percent of total billed charges PFIZERPEN 5 MILLION UNIT VIAL 48264225_1 CDM 0250 RC 00049-0520-83 NDC inpatient 1 UN 40.83 26.54 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.85 78 999999999 24.72 39.61 percent of total billed charges PFIZERPEN 5 MILLION UNIT VIAL 48264225_1 CDM 0250 RC 00049-0520-83 NDC inpatient 1 UN 40.83 26.54 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.17 69 999999999 24.72 39.61 percent of total billed charges PFIZERPEN 5 MILLION UNIT VIAL 48264225_1 CDM 0250 RC 00049-0520-83 NDC inpatient 1 UN 40.83 26.54 UMR - ALL PLANS UMR - ALL PLANS 28.58 70 999999999 24.72 39.61 percent of total billed charges PFIZERPEN 5 MILLION UNIT VIAL 48264225_1 CDM 0250 RC 00049-0520-83 NDC inpatient 1 UN 40.83 26.54 SIHO - ALL PLANS SIHO - ALL PLANS 36.75 90 999999999 24.72 39.61 percent of total billed charges PFIZERPEN 5 MILLION UNIT VIAL 48264225_1 CDM 0250 RC 00049-0520-83 NDC inpatient 1 UN 40.83 26.54 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.72 60.55 999999999 24.72 39.61 percent of total billed charges PFIZERPEN 5 MILLION UNIT VIAL 48264225_1 CDM 0250 RC 00049-0520-83 NDC inpatient 1 UN 40.83 26.54 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.72 39.61 PFIZERPEN 5 MILLION UNIT VIAL 48264225_1 CDM 0250 RC 00049-0520-83 NDC inpatient 1 UN 40.83 26.54 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.72 39.61 PFIZERPEN 5 MILLION UNIT VIAL 48264225_1 CDM 0250 RC 00049-0520-83 NDC inpatient 1 UN 40.83 26.54 ANTHEM HMO ANTHEM HMO 999999999 24.72 39.61 PFIZERPEN 5 MILLION UNIT VIAL 48264225_1 CDM 0250 RC 00049-0520-83 NDC inpatient 1 UN 40.83 26.54 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.6 67.6 999999999 24.72 39.61 percent of total billed charges PFIZERPEN 5 MILLION UNIT VIAL 48264225_1 CDM 0250 RC 00049-0520-83 NDC inpatient 1 UN 40.83 26.54 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.72 39.61 PFIZERPEN 5 MILLION UNIT VIAL 48264225_1 CDM 0250 RC 00049-0520-83 NDC inpatient 1 UN 40.83 26.54 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.72 39.61 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48264236_1 CDM 0720 RC inpatient 828 538.2 AETNA AETNA 654.12 79 999999999 501.35 803.16 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48264236_1 CDM 0720 RC inpatient 828 538.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 538.2 65 999999999 501.35 803.16 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48264236_1 CDM 0720 RC inpatient 828 538.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 803.16 97 999999999 501.35 803.16 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48264236_1 CDM 0720 RC inpatient 828 538.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 645.84 78 999999999 501.35 803.16 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48264236_1 CDM 0720 RC inpatient 828 538.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 571.32 69 999999999 501.35 803.16 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48264236_1 CDM 0720 RC inpatient 828 538.2 UMR - ALL PLANS UMR - ALL PLANS 579.6 70 999999999 501.35 803.16 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48264236_1 CDM 0720 RC inpatient 828 538.2 SIHO - ALL PLANS SIHO - ALL PLANS 745.2 90 999999999 501.35 803.16 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48264236_1 CDM 0720 RC inpatient 828 538.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 501.35 60.55 999999999 501.35 803.16 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48264236_1 CDM 0720 RC inpatient 828 538.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 501.35 803.16 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48264236_1 CDM 0720 RC inpatient 828 538.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 501.35 803.16 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48264236_1 CDM 0720 RC inpatient 828 538.2 ANTHEM HMO ANTHEM HMO 999999999 501.35 803.16 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48264236_1 CDM 0720 RC inpatient 828 538.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 559.73 67.6 999999999 501.35 803.16 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48264236_1 CDM 0720 RC inpatient 828 538.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 501.35 803.16 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48264236_1 CDM 0720 RC inpatient 828 538.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 501.35 803.16 00338-0049-48A - SODIUM CHLORIDE 0.9% 100 ML BAG [JOHN] 48269865_1 CDM 0250 RC 00338-0049-48A NDC inpatient 1 UN 57.8 37.57 AETNA AETNA 45.66 79 999999999 35 56.07 percent of total billed charges 00338-0049-48A - SODIUM CHLORIDE 0.9% 100 ML BAG [JOHN] 48269865_1 CDM 0250 RC 00338-0049-48A NDC inpatient 1 UN 57.8 37.57 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.57 65 999999999 35 56.07 percent of total billed charges 00338-0049-48A - SODIUM CHLORIDE 0.9% 100 ML BAG [JOHN] 48269865_1 CDM 0250 RC 00338-0049-48A NDC inpatient 1 UN 57.8 37.57 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.07 97 999999999 35 56.07 percent of total billed charges 00338-0049-48A - SODIUM CHLORIDE 0.9% 100 ML BAG [JOHN] 48269865_1 CDM 0250 RC 00338-0049-48A NDC inpatient 1 UN 57.8 37.57 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.08 78 999999999 35 56.07 percent of total billed charges 00338-0049-48A - SODIUM CHLORIDE 0.9% 100 ML BAG [JOHN] 48269865_1 CDM 0250 RC 00338-0049-48A NDC inpatient 1 UN 57.8 37.57 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.88 69 999999999 35 56.07 percent of total billed charges 00338-0049-48A - SODIUM CHLORIDE 0.9% 100 ML BAG [JOHN] 48269865_1 CDM 0250 RC 00338-0049-48A NDC inpatient 1 UN 57.8 37.57 UMR - ALL PLANS UMR - ALL PLANS 40.46 70 999999999 35 56.07 percent of total billed charges 00338-0049-48A - SODIUM CHLORIDE 0.9% 100 ML BAG [JOHN] 48269865_1 CDM 0250 RC 00338-0049-48A NDC inpatient 1 UN 57.8 37.57 SIHO - ALL PLANS SIHO - ALL PLANS 52.02 90 999999999 35 56.07 percent of total billed charges 00338-0049-48A - SODIUM CHLORIDE 0.9% 100 ML BAG [JOHN] 48269865_1 CDM 0250 RC 00338-0049-48A NDC inpatient 1 UN 57.8 37.57 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35 60.55 999999999 35 56.07 percent of total billed charges 00338-0049-48A - SODIUM CHLORIDE 0.9% 100 ML BAG [JOHN] 48269865_1 CDM 0250 RC 00338-0049-48A NDC inpatient 1 UN 57.8 37.57 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35 56.07 00338-0049-48A - SODIUM CHLORIDE 0.9% 100 ML BAG [JOHN] 48269865_1 CDM 0250 RC 00338-0049-48A NDC inpatient 1 UN 57.8 37.57 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35 56.07 00338-0049-48A - SODIUM CHLORIDE 0.9% 100 ML BAG [JOHN] 48269865_1 CDM 0250 RC 00338-0049-48A NDC inpatient 1 UN 57.8 37.57 ANTHEM HMO ANTHEM HMO 999999999 35 56.07 00338-0049-48A - SODIUM CHLORIDE 0.9% 100 ML BAG [JOHN] 48269865_1 CDM 0250 RC 00338-0049-48A NDC inpatient 1 UN 57.8 37.57 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.07 67.6 999999999 35 56.07 percent of total billed charges 00338-0049-48A - SODIUM CHLORIDE 0.9% 100 ML BAG [JOHN] 48269865_1 CDM 0250 RC 00338-0049-48A NDC inpatient 1 UN 57.8 37.57 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35 56.07 00338-0049-48A - SODIUM CHLORIDE 0.9% 100 ML BAG [JOHN] 48269865_1 CDM 0250 RC 00338-0049-48A NDC inpatient 1 UN 57.8 37.57 UHC - ALL PLANS UHC - ALL PLANS 999999999 35 56.07 Concentration of specimen for infectious agents 48274252_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges Concentration of specimen for infectious agents 48274252_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges Concentration of specimen for infectious agents 48274252_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges Concentration of specimen for infectious agents 48274252_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges Concentration of specimen for infectious agents 48274252_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges Concentration of specimen for infectious agents 48274252_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges Concentration of specimen for infectious agents 48274252_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges Concentration of specimen for infectious agents 48274252_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges Concentration of specimen for infectious agents 48274252_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 Concentration of specimen for infectious agents 48274252_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 Concentration of specimen for infectious agents 48274252_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 Concentration of specimen for infectious agents 48274252_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges Concentration of specimen for infectious agents 48274252_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 Concentration of specimen for infectious agents 48274252_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "RED BLOOD CELLS, WASHED, EACH UNIT" 48274450_1 CDM 0390 RC P9022 HCPCS inpatient 854 555.1 AETNA AETNA 674.66 79 999999999 517.1 828.38 percent of total billed charges "RED BLOOD CELLS, WASHED, EACH UNIT" 48274450_1 CDM 0390 RC P9022 HCPCS inpatient 854 555.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 555.1 65 999999999 517.1 828.38 percent of total billed charges "RED BLOOD CELLS, WASHED, EACH UNIT" 48274450_1 CDM 0390 RC P9022 HCPCS inpatient 854 555.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 828.38 97 999999999 517.1 828.38 percent of total billed charges "RED BLOOD CELLS, WASHED, EACH UNIT" 48274450_1 CDM 0390 RC P9022 HCPCS inpatient 854 555.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 666.12 78 999999999 517.1 828.38 percent of total billed charges "RED BLOOD CELLS, WASHED, EACH UNIT" 48274450_1 CDM 0390 RC P9022 HCPCS inpatient 854 555.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 589.26 69 999999999 517.1 828.38 percent of total billed charges "RED BLOOD CELLS, WASHED, EACH UNIT" 48274450_1 CDM 0390 RC P9022 HCPCS inpatient 854 555.1 UMR - ALL PLANS UMR - ALL PLANS 597.8 70 999999999 517.1 828.38 percent of total billed charges "RED BLOOD CELLS, WASHED, EACH UNIT" 48274450_1 CDM 0390 RC P9022 HCPCS inpatient 854 555.1 SIHO - ALL PLANS SIHO - ALL PLANS 768.6 90 999999999 517.1 828.38 percent of total billed charges "RED BLOOD CELLS, WASHED, EACH UNIT" 48274450_1 CDM 0390 RC P9022 HCPCS inpatient 854 555.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 517.1 60.55 999999999 517.1 828.38 percent of total billed charges "RED BLOOD CELLS, WASHED, EACH UNIT" 48274450_1 CDM 0390 RC P9022 HCPCS inpatient 854 555.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 517.1 828.38 "RED BLOOD CELLS, WASHED, EACH UNIT" 48274450_1 CDM 0390 RC P9022 HCPCS inpatient 854 555.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 517.1 828.38 "RED BLOOD CELLS, WASHED, EACH UNIT" 48274450_1 CDM 0390 RC P9022 HCPCS inpatient 854 555.1 ANTHEM HMO ANTHEM HMO 999999999 517.1 828.38 "RED BLOOD CELLS, WASHED, EACH UNIT" 48274450_1 CDM 0390 RC P9022 HCPCS inpatient 854 555.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 577.3 67.6 999999999 517.1 828.38 percent of total billed charges "RED BLOOD CELLS, WASHED, EACH UNIT" 48274450_1 CDM 0390 RC P9022 HCPCS inpatient 854 555.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 517.1 828.38 "RED BLOOD CELLS, WASHED, EACH UNIT" 48274450_1 CDM 0390 RC P9022 HCPCS inpatient 854 555.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 517.1 828.38 "RED BLOOD CELLS, WASHED, EACH UNIT" 48274452_1 CDM 0390 RC P9022 HCPCS inpatient 1050 682.5 AETNA AETNA 829.5 79 999999999 635.78 1018.5 percent of total billed charges "RED BLOOD CELLS, WASHED, EACH UNIT" 48274452_1 CDM 0390 RC P9022 HCPCS inpatient 1050 682.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 682.5 65 999999999 635.78 1018.5 percent of total billed charges "RED BLOOD CELLS, WASHED, EACH UNIT" 48274452_1 CDM 0390 RC P9022 HCPCS inpatient 1050 682.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1018.5 97 999999999 635.78 1018.5 percent of total billed charges "RED BLOOD CELLS, WASHED, EACH UNIT" 48274452_1 CDM 0390 RC P9022 HCPCS inpatient 1050 682.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 819 78 999999999 635.78 1018.5 percent of total billed charges "RED BLOOD CELLS, WASHED, EACH UNIT" 48274452_1 CDM 0390 RC P9022 HCPCS inpatient 1050 682.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 724.5 69 999999999 635.78 1018.5 percent of total billed charges "RED BLOOD CELLS, WASHED, EACH UNIT" 48274452_1 CDM 0390 RC P9022 HCPCS inpatient 1050 682.5 UMR - ALL PLANS UMR - ALL PLANS 735 70 999999999 635.78 1018.5 percent of total billed charges "RED BLOOD CELLS, WASHED, EACH UNIT" 48274452_1 CDM 0390 RC P9022 HCPCS inpatient 1050 682.5 SIHO - ALL PLANS SIHO - ALL PLANS 945 90 999999999 635.78 1018.5 percent of total billed charges "RED BLOOD CELLS, WASHED, EACH UNIT" 48274452_1 CDM 0390 RC P9022 HCPCS inpatient 1050 682.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 635.78 60.55 999999999 635.78 1018.5 percent of total billed charges "RED BLOOD CELLS, WASHED, EACH UNIT" 48274452_1 CDM 0390 RC P9022 HCPCS inpatient 1050 682.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 635.78 1018.5 "RED BLOOD CELLS, WASHED, EACH UNIT" 48274452_1 CDM 0390 RC P9022 HCPCS inpatient 1050 682.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 635.78 1018.5 "RED BLOOD CELLS, WASHED, EACH UNIT" 48274452_1 CDM 0390 RC P9022 HCPCS inpatient 1050 682.5 ANTHEM HMO ANTHEM HMO 999999999 635.78 1018.5 "RED BLOOD CELLS, WASHED, EACH UNIT" 48274452_1 CDM 0390 RC P9022 HCPCS inpatient 1050 682.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 709.8 67.6 999999999 635.78 1018.5 percent of total billed charges "RED BLOOD CELLS, WASHED, EACH UNIT" 48274452_1 CDM 0390 RC P9022 HCPCS inpatient 1050 682.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 635.78 1018.5 "RED BLOOD CELLS, WASHED, EACH UNIT" 48274452_1 CDM 0390 RC P9022 HCPCS inpatient 1050 682.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 635.78 1018.5 "Blood gas, oxygen saturation measurement" 48289621_1 CDM 0301 RC 82810 HCPCS inpatient 210 136.5 AETNA AETNA 165.9 79 999999999 127.16 203.7 percent of total billed charges "Blood gas, oxygen saturation measurement" 48289621_1 CDM 0301 RC 82810 HCPCS inpatient 210 136.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 136.5 65 999999999 127.16 203.7 percent of total billed charges "Blood gas, oxygen saturation measurement" 48289621_1 CDM 0301 RC 82810 HCPCS inpatient 210 136.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 203.7 97 999999999 127.16 203.7 percent of total billed charges "Blood gas, oxygen saturation measurement" 48289621_1 CDM 0301 RC 82810 HCPCS inpatient 210 136.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 163.8 78 999999999 127.16 203.7 percent of total billed charges "Blood gas, oxygen saturation measurement" 48289621_1 CDM 0301 RC 82810 HCPCS inpatient 210 136.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 144.9 69 999999999 127.16 203.7 percent of total billed charges "Blood gas, oxygen saturation measurement" 48289621_1 CDM 0301 RC 82810 HCPCS inpatient 210 136.5 UMR - ALL PLANS UMR - ALL PLANS 147 70 999999999 127.16 203.7 percent of total billed charges "Blood gas, oxygen saturation measurement" 48289621_1 CDM 0301 RC 82810 HCPCS inpatient 210 136.5 SIHO - ALL PLANS SIHO - ALL PLANS 189 90 999999999 127.16 203.7 percent of total billed charges "Blood gas, oxygen saturation measurement" 48289621_1 CDM 0301 RC 82810 HCPCS inpatient 210 136.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.16 60.55 999999999 127.16 203.7 percent of total billed charges "Blood gas, oxygen saturation measurement" 48289621_1 CDM 0301 RC 82810 HCPCS inpatient 210 136.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.16 203.7 "Blood gas, oxygen saturation measurement" 48289621_1 CDM 0301 RC 82810 HCPCS inpatient 210 136.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.16 203.7 "Blood gas, oxygen saturation measurement" 48289621_1 CDM 0301 RC 82810 HCPCS inpatient 210 136.5 ANTHEM HMO ANTHEM HMO 999999999 127.16 203.7 "Blood gas, oxygen saturation measurement" 48289621_1 CDM 0301 RC 82810 HCPCS inpatient 210 136.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 141.96 67.6 999999999 127.16 203.7 percent of total billed charges "Blood gas, oxygen saturation measurement" 48289621_1 CDM 0301 RC 82810 HCPCS inpatient 210 136.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.16 203.7 "Blood gas, oxygen saturation measurement" 48289621_1 CDM 0301 RC 82810 HCPCS inpatient 210 136.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.16 203.7 Cervicovaginal secretion of placenta protein 48289623_1 CDM 0301 RC 84112 HCPCS inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges Cervicovaginal secretion of placenta protein 48289623_1 CDM 0301 RC 84112 HCPCS inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges Cervicovaginal secretion of placenta protein 48289623_1 CDM 0301 RC 84112 HCPCS inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges Cervicovaginal secretion of placenta protein 48289623_1 CDM 0301 RC 84112 HCPCS inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges Cervicovaginal secretion of placenta protein 48289623_1 CDM 0301 RC 84112 HCPCS inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges Cervicovaginal secretion of placenta protein 48289623_1 CDM 0301 RC 84112 HCPCS inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges Cervicovaginal secretion of placenta protein 48289623_1 CDM 0301 RC 84112 HCPCS inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges Cervicovaginal secretion of placenta protein 48289623_1 CDM 0301 RC 84112 HCPCS inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges Cervicovaginal secretion of placenta protein 48289623_1 CDM 0301 RC 84112 HCPCS inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 Cervicovaginal secretion of placenta protein 48289623_1 CDM 0301 RC 84112 HCPCS inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 Cervicovaginal secretion of placenta protein 48289623_1 CDM 0301 RC 84112 HCPCS inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 Cervicovaginal secretion of placenta protein 48289623_1 CDM 0301 RC 84112 HCPCS inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges Cervicovaginal secretion of placenta protein 48289623_1 CDM 0301 RC 84112 HCPCS inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 Cervicovaginal secretion of placenta protein 48289623_1 CDM 0301 RC 84112 HCPCS inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 Blood creatinine level 48289624_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 AETNA AETNA 96.38 79 999999999 73.87 118.34 percent of total billed charges Blood creatinine level 48289624_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.3 65 999999999 73.87 118.34 percent of total billed charges Blood creatinine level 48289624_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 118.34 97 999999999 73.87 118.34 percent of total billed charges Blood creatinine level 48289624_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.16 78 999999999 73.87 118.34 percent of total billed charges Blood creatinine level 48289624_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.18 69 999999999 73.87 118.34 percent of total billed charges Blood creatinine level 48289624_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 UMR - ALL PLANS UMR - ALL PLANS 85.4 70 999999999 73.87 118.34 percent of total billed charges Blood creatinine level 48289624_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 SIHO - ALL PLANS SIHO - ALL PLANS 109.8 90 999999999 73.87 118.34 percent of total billed charges Blood creatinine level 48289624_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.87 60.55 999999999 73.87 118.34 percent of total billed charges Blood creatinine level 48289624_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.87 118.34 Blood creatinine level 48289624_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.87 118.34 Blood creatinine level 48289624_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 ANTHEM HMO ANTHEM HMO 999999999 73.87 118.34 Blood creatinine level 48289624_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 82.47 67.6 999999999 73.87 118.34 percent of total billed charges Blood creatinine level 48289624_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.87 118.34 Blood creatinine level 48289624_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.87 118.34 "Blood unit compatibility test, antiglobulin technique" 48305857_1 CDM 0300 RC 86922 HCPCS inpatient 432 280.8 AETNA AETNA 341.28 79 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 48305857_1 CDM 0300 RC 86922 HCPCS inpatient 432 280.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 280.8 65 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 48305857_1 CDM 0300 RC 86922 HCPCS inpatient 432 280.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 419.04 97 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 48305857_1 CDM 0300 RC 86922 HCPCS inpatient 432 280.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 336.96 78 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 48305857_1 CDM 0300 RC 86922 HCPCS inpatient 432 280.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 298.08 69 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 48305857_1 CDM 0300 RC 86922 HCPCS inpatient 432 280.8 UMR - ALL PLANS UMR - ALL PLANS 302.4 70 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 48305857_1 CDM 0300 RC 86922 HCPCS inpatient 432 280.8 SIHO - ALL PLANS SIHO - ALL PLANS 388.8 90 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 48305857_1 CDM 0300 RC 86922 HCPCS inpatient 432 280.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 261.58 60.55 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 48305857_1 CDM 0300 RC 86922 HCPCS inpatient 432 280.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 261.58 419.04 "Blood unit compatibility test, antiglobulin technique" 48305857_1 CDM 0300 RC 86922 HCPCS inpatient 432 280.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 261.58 419.04 "Blood unit compatibility test, antiglobulin technique" 48305857_1 CDM 0300 RC 86922 HCPCS inpatient 432 280.8 ANTHEM HMO ANTHEM HMO 999999999 261.58 419.04 "Blood unit compatibility test, antiglobulin technique" 48305857_1 CDM 0300 RC 86922 HCPCS inpatient 432 280.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 292.03 67.6 999999999 261.58 419.04 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 48305857_1 CDM 0300 RC 86922 HCPCS inpatient 432 280.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 261.58 419.04 "Blood unit compatibility test, antiglobulin technique" 48305857_1 CDM 0300 RC 86922 HCPCS inpatient 432 280.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 261.58 419.04 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48307834_1 CDM 0206 RC G0378 HCPCS inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48307834_1 CDM 0206 RC G0378 HCPCS inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48307834_1 CDM 0206 RC G0378 HCPCS inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48307834_1 CDM 0206 RC G0378 HCPCS inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48307834_1 CDM 0206 RC G0378 HCPCS inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48307834_1 CDM 0206 RC G0378 HCPCS inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48307834_1 CDM 0206 RC G0378 HCPCS inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48307834_1 CDM 0206 RC G0378 HCPCS inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48307834_1 CDM 0206 RC G0378 HCPCS inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48307834_1 CDM 0206 RC G0378 HCPCS inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48307834_1 CDM 0206 RC G0378 HCPCS inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48307834_1 CDM 0206 RC G0378 HCPCS inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48307834_1 CDM 0206 RC G0378 HCPCS inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48307834_1 CDM 0206 RC G0378 HCPCS inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 Aspiration of fluid from chest cavity 48310174_1 CDM 0450 RC 32554 HCPCS inpatient 1477 960.05 AETNA AETNA 1166.83 79 999999999 894.32 1432.69 percent of total billed charges Aspiration of fluid from chest cavity 48310174_1 CDM 0450 RC 32554 HCPCS inpatient 1477 960.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 960.05 65 999999999 894.32 1432.69 percent of total billed charges Aspiration of fluid from chest cavity 48310174_1 CDM 0450 RC 32554 HCPCS inpatient 1477 960.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1432.69 97 999999999 894.32 1432.69 percent of total billed charges Aspiration of fluid from chest cavity 48310174_1 CDM 0450 RC 32554 HCPCS inpatient 1477 960.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1152.06 78 999999999 894.32 1432.69 percent of total billed charges Aspiration of fluid from chest cavity 48310174_1 CDM 0450 RC 32554 HCPCS inpatient 1477 960.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1019.13 69 999999999 894.32 1432.69 percent of total billed charges Aspiration of fluid from chest cavity 48310174_1 CDM 0450 RC 32554 HCPCS inpatient 1477 960.05 UMR - ALL PLANS UMR - ALL PLANS 1033.9 70 999999999 894.32 1432.69 percent of total billed charges Aspiration of fluid from chest cavity 48310174_1 CDM 0450 RC 32554 HCPCS inpatient 1477 960.05 SIHO - ALL PLANS SIHO - ALL PLANS 1329.3 90 999999999 894.32 1432.69 percent of total billed charges Aspiration of fluid from chest cavity 48310174_1 CDM 0450 RC 32554 HCPCS inpatient 1477 960.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 894.32 60.55 999999999 894.32 1432.69 percent of total billed charges Aspiration of fluid from chest cavity 48310174_1 CDM 0450 RC 32554 HCPCS inpatient 1477 960.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 894.32 1432.69 Aspiration of fluid from chest cavity 48310174_1 CDM 0450 RC 32554 HCPCS inpatient 1477 960.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 894.32 1432.69 Aspiration of fluid from chest cavity 48310174_1 CDM 0450 RC 32554 HCPCS inpatient 1477 960.05 ANTHEM HMO ANTHEM HMO 999999999 894.32 1432.69 Aspiration of fluid from chest cavity 48310174_1 CDM 0450 RC 32554 HCPCS inpatient 1477 960.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 998.45 67.6 999999999 894.32 1432.69 percent of total billed charges Aspiration of fluid from chest cavity 48310174_1 CDM 0450 RC 32554 HCPCS inpatient 1477 960.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 894.32 1432.69 Aspiration of fluid from chest cavity 48310174_1 CDM 0450 RC 32554 HCPCS inpatient 1477 960.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 894.32 1432.69 "Repair of lacerated floor of mouth and/or tongue, 2.5 cm or less" 48310310_1 CDM 0450 RC 41250 HCPCS inpatient 391 254.15 AETNA AETNA 308.89 79 999999999 236.75 379.27 percent of total billed charges "Repair of lacerated floor of mouth and/or tongue, 2.5 cm or less" 48310310_1 CDM 0450 RC 41250 HCPCS inpatient 391 254.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 254.15 65 999999999 236.75 379.27 percent of total billed charges "Repair of lacerated floor of mouth and/or tongue, 2.5 cm or less" 48310310_1 CDM 0450 RC 41250 HCPCS inpatient 391 254.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 379.27 97 999999999 236.75 379.27 percent of total billed charges "Repair of lacerated floor of mouth and/or tongue, 2.5 cm or less" 48310310_1 CDM 0450 RC 41250 HCPCS inpatient 391 254.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 304.98 78 999999999 236.75 379.27 percent of total billed charges "Repair of lacerated floor of mouth and/or tongue, 2.5 cm or less" 48310310_1 CDM 0450 RC 41250 HCPCS inpatient 391 254.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 269.79 69 999999999 236.75 379.27 percent of total billed charges "Repair of lacerated floor of mouth and/or tongue, 2.5 cm or less" 48310310_1 CDM 0450 RC 41250 HCPCS inpatient 391 254.15 UMR - ALL PLANS UMR - ALL PLANS 273.7 70 999999999 236.75 379.27 percent of total billed charges "Repair of lacerated floor of mouth and/or tongue, 2.5 cm or less" 48310310_1 CDM 0450 RC 41250 HCPCS inpatient 391 254.15 SIHO - ALL PLANS SIHO - ALL PLANS 351.9 90 999999999 236.75 379.27 percent of total billed charges "Repair of lacerated floor of mouth and/or tongue, 2.5 cm or less" 48310310_1 CDM 0450 RC 41250 HCPCS inpatient 391 254.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 236.75 60.55 999999999 236.75 379.27 percent of total billed charges "Repair of lacerated floor of mouth and/or tongue, 2.5 cm or less" 48310310_1 CDM 0450 RC 41250 HCPCS inpatient 391 254.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 236.75 379.27 "Repair of lacerated floor of mouth and/or tongue, 2.5 cm or less" 48310310_1 CDM 0450 RC 41250 HCPCS inpatient 391 254.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 236.75 379.27 "Repair of lacerated floor of mouth and/or tongue, 2.5 cm or less" 48310310_1 CDM 0450 RC 41250 HCPCS inpatient 391 254.15 ANTHEM HMO ANTHEM HMO 999999999 236.75 379.27 "Repair of lacerated floor of mouth and/or tongue, 2.5 cm or less" 48310310_1 CDM 0450 RC 41250 HCPCS inpatient 391 254.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 264.32 67.6 999999999 236.75 379.27 percent of total billed charges "Repair of lacerated floor of mouth and/or tongue, 2.5 cm or less" 48310310_1 CDM 0450 RC 41250 HCPCS inpatient 391 254.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 236.75 379.27 "Repair of lacerated floor of mouth and/or tongue, 2.5 cm or less" 48310310_1 CDM 0450 RC 41250 HCPCS inpatient 391 254.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 236.75 379.27 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312366_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312366_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312366_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312366_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312366_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312366_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312366_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312366_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312366_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312366_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312366_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312366_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312366_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312366_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312367_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312367_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312367_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312367_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312367_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312367_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312367_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312367_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312367_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312367_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312367_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312367_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312367_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312367_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312368_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312368_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312368_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312368_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312368_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312368_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312368_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312368_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312368_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312368_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312368_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312368_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312368_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312368_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312711_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312711_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312711_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312711_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312711_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312711_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312711_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312711_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312711_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312711_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312711_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312711_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312711_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312711_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312712_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312712_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312712_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312712_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312712_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312712_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312712_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312712_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312712_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312712_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312712_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312712_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48312712_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48312712_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 MRI scan of blood vessels of head without contrast 48315311_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 AETNA AETNA 2351.04 79 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of head without contrast 48315311_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1934.4 65 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of head without contrast 48315311_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2886.72 97 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of head without contrast 48315311_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 2321.28 78 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of head without contrast 48315311_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 2053.44 69 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of head without contrast 48315311_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 UMR - ALL PLANS UMR - ALL PLANS 2083.2 70 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of head without contrast 48315311_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 SIHO - ALL PLANS SIHO - ALL PLANS 2678.4 90 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of head without contrast 48315311_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1801.97 60.55 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of head without contrast 48315311_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1801.97 2886.72 MRI scan of blood vessels of head without contrast 48315311_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1801.97 2886.72 MRI scan of blood vessels of head without contrast 48315311_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 ANTHEM HMO ANTHEM HMO 999999999 1801.97 2886.72 MRI scan of blood vessels of head without contrast 48315311_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 2011.78 67.6 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of head without contrast 48315311_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1801.97 2886.72 MRI scan of blood vessels of head without contrast 48315311_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1801.97 2886.72 Ultrasound study of arm or leg veins with compression and maneuvers 48315393_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 AETNA AETNA 2208.84 79 999999999 1692.98 2712.12 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 48315393_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1817.4 65 999999999 1692.98 2712.12 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 48315393_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2712.12 97 999999999 1692.98 2712.12 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 48315393_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1929.24 69 999999999 1692.98 2712.12 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 48315393_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 2180.88 78 999999999 1692.98 2712.12 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 48315393_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 UMR - ALL PLANS UMR - ALL PLANS 1957.2 70 999999999 1692.98 2712.12 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 48315393_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 SIHO - ALL PLANS SIHO - ALL PLANS 2516.4 90 999999999 1692.98 2712.12 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 48315393_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1692.98 60.55 999999999 1692.98 2712.12 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 48315393_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1692.98 2712.12 Ultrasound study of arm or leg veins with compression and maneuvers 48315393_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1692.98 2712.12 Ultrasound study of arm or leg veins with compression and maneuvers 48315393_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 ANTHEM HMO ANTHEM HMO 999999999 1692.98 2712.12 Ultrasound study of arm or leg veins with compression and maneuvers 48315393_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1890.1 67.6 999999999 1692.98 2712.12 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 48315393_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1692.98 2712.12 Ultrasound study of arm or leg veins with compression and maneuvers 48315393_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1692.98 2712.12 Ultrasound study of one arm or leg veins with compression and maneuvers 48315397_1 CDM 0921 RC 93971 HCPCS inpatient 1430 929.5 AETNA AETNA 1129.7 79 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48315397_1 CDM 0921 RC 93971 HCPCS inpatient 1430 929.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 929.5 65 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48315397_1 CDM 0921 RC 93971 HCPCS inpatient 1430 929.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1387.1 97 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48315397_1 CDM 0921 RC 93971 HCPCS inpatient 1430 929.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 986.7 69 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48315397_1 CDM 0921 RC 93971 HCPCS inpatient 1430 929.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1115.4 78 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48315397_1 CDM 0921 RC 93971 HCPCS inpatient 1430 929.5 UMR - ALL PLANS UMR - ALL PLANS 1001 70 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48315397_1 CDM 0921 RC 93971 HCPCS inpatient 1430 929.5 SIHO - ALL PLANS SIHO - ALL PLANS 1287 90 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48315397_1 CDM 0921 RC 93971 HCPCS inpatient 1430 929.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 865.87 60.55 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48315397_1 CDM 0921 RC 93971 HCPCS inpatient 1430 929.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 865.87 1387.1 Ultrasound study of one arm or leg veins with compression and maneuvers 48315397_1 CDM 0921 RC 93971 HCPCS inpatient 1430 929.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 865.87 1387.1 Ultrasound study of one arm or leg veins with compression and maneuvers 48315397_1 CDM 0921 RC 93971 HCPCS inpatient 1430 929.5 ANTHEM HMO ANTHEM HMO 999999999 865.87 1387.1 Ultrasound study of one arm or leg veins with compression and maneuvers 48315397_1 CDM 0921 RC 93971 HCPCS inpatient 1430 929.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 966.68 67.6 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48315397_1 CDM 0921 RC 93971 HCPCS inpatient 1430 929.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 865.87 1387.1 Ultrasound study of one arm or leg veins with compression and maneuvers 48315397_1 CDM 0921 RC 93971 HCPCS inpatient 1430 929.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 865.87 1387.1 Ultrasound study of one arm or leg veins with compression and maneuvers 48315401_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 AETNA AETNA 1129.7 79 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48315401_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 929.5 65 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48315401_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1387.1 97 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48315401_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 986.7 69 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48315401_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1115.4 78 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48315401_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 UMR - ALL PLANS UMR - ALL PLANS 1001 70 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48315401_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 SIHO - ALL PLANS SIHO - ALL PLANS 1287 90 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48315401_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 865.87 60.55 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48315401_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 865.87 1387.1 Ultrasound study of one arm or leg veins with compression and maneuvers 48315401_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 865.87 1387.1 Ultrasound study of one arm or leg veins with compression and maneuvers 48315401_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 ANTHEM HMO ANTHEM HMO 999999999 865.87 1387.1 Ultrasound study of one arm or leg veins with compression and maneuvers 48315401_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 966.68 67.6 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48315401_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 865.87 1387.1 Ultrasound study of one arm or leg veins with compression and maneuvers 48315401_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 865.87 1387.1 "Removal of foreign body from tissue, accessed beneath the skin, simple" 48329638_1 CDM 0510 RC 10120 HCPCS inpatient 957 622.05 AETNA AETNA 756.03 79 999999999 579.46 928.29 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48329638_1 CDM 0510 RC 10120 HCPCS inpatient 957 622.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 622.05 65 999999999 579.46 928.29 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48329638_1 CDM 0510 RC 10120 HCPCS inpatient 957 622.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 928.29 97 999999999 579.46 928.29 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48329638_1 CDM 0510 RC 10120 HCPCS inpatient 957 622.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 660.33 69 999999999 579.46 928.29 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48329638_1 CDM 0510 RC 10120 HCPCS inpatient 957 622.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 746.46 78 999999999 579.46 928.29 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48329638_1 CDM 0510 RC 10120 HCPCS inpatient 957 622.05 UMR - ALL PLANS UMR - ALL PLANS 669.9 70 999999999 579.46 928.29 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48329638_1 CDM 0510 RC 10120 HCPCS inpatient 957 622.05 SIHO - ALL PLANS SIHO - ALL PLANS 861.3 90 999999999 579.46 928.29 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48329638_1 CDM 0510 RC 10120 HCPCS inpatient 957 622.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 579.46 60.55 999999999 579.46 928.29 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48329638_1 CDM 0510 RC 10120 HCPCS inpatient 957 622.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 579.46 928.29 "Removal of foreign body from tissue, accessed beneath the skin, simple" 48329638_1 CDM 0510 RC 10120 HCPCS inpatient 957 622.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 579.46 928.29 "Removal of foreign body from tissue, accessed beneath the skin, simple" 48329638_1 CDM 0510 RC 10120 HCPCS inpatient 957 622.05 ANTHEM HMO ANTHEM HMO 999999999 579.46 928.29 "Removal of foreign body from tissue, accessed beneath the skin, simple" 48329638_1 CDM 0510 RC 10120 HCPCS inpatient 957 622.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 646.93 67.6 999999999 579.46 928.29 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48329638_1 CDM 0510 RC 10120 HCPCS inpatient 957 622.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 579.46 928.29 "Removal of foreign body from tissue, accessed beneath the skin, simple" 48329638_1 CDM 0510 RC 10120 HCPCS inpatient 957 622.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 579.46 928.29 Insertion of needle for infusion into bone 48329698_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 AETNA AETNA 293.09 79 999999999 224.64 359.87 percent of total billed charges Insertion of needle for infusion into bone 48329698_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 241.15 65 999999999 224.64 359.87 percent of total billed charges Insertion of needle for infusion into bone 48329698_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 359.87 97 999999999 224.64 359.87 percent of total billed charges Insertion of needle for infusion into bone 48329698_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 255.99 69 999999999 224.64 359.87 percent of total billed charges Insertion of needle for infusion into bone 48329698_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 289.38 78 999999999 224.64 359.87 percent of total billed charges Insertion of needle for infusion into bone 48329698_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 UMR - ALL PLANS UMR - ALL PLANS 259.7 70 999999999 224.64 359.87 percent of total billed charges Insertion of needle for infusion into bone 48329698_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 SIHO - ALL PLANS SIHO - ALL PLANS 333.9 90 999999999 224.64 359.87 percent of total billed charges Insertion of needle for infusion into bone 48329698_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 224.64 60.55 999999999 224.64 359.87 percent of total billed charges Insertion of needle for infusion into bone 48329698_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 224.64 359.87 Insertion of needle for infusion into bone 48329698_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 224.64 359.87 Insertion of needle for infusion into bone 48329698_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 ANTHEM HMO ANTHEM HMO 999999999 224.64 359.87 Insertion of needle for infusion into bone 48329698_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 250.8 67.6 999999999 224.64 359.87 percent of total billed charges Insertion of needle for infusion into bone 48329698_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 224.64 359.87 Insertion of needle for infusion into bone 48329698_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 224.64 359.87 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48332604_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48332604_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48332604_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48332604_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48332604_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48332604_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48332604_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48332604_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48332604_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48332604_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48332604_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48332604_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48332604_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48332604_1 CDM 0301 RC 82274 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 "X-ray of chest, 2 views" 48333337_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 AETNA AETNA 366.56 79 999999999 280.95 450.08 percent of total billed charges "X-ray of chest, 2 views" 48333337_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 301.6 65 999999999 280.95 450.08 percent of total billed charges "X-ray of chest, 2 views" 48333337_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 450.08 97 999999999 280.95 450.08 percent of total billed charges "X-ray of chest, 2 views" 48333337_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 320.16 69 999999999 280.95 450.08 percent of total billed charges "X-ray of chest, 2 views" 48333337_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 361.92 78 999999999 280.95 450.08 percent of total billed charges "X-ray of chest, 2 views" 48333337_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 UMR - ALL PLANS UMR - ALL PLANS 324.8 70 999999999 280.95 450.08 percent of total billed charges "X-ray of chest, 2 views" 48333337_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 SIHO - ALL PLANS SIHO - ALL PLANS 417.6 90 999999999 280.95 450.08 percent of total billed charges "X-ray of chest, 2 views" 48333337_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 280.95 60.55 999999999 280.95 450.08 percent of total billed charges "X-ray of chest, 2 views" 48333337_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 280.95 450.08 "X-ray of chest, 2 views" 48333337_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 280.95 450.08 "X-ray of chest, 2 views" 48333337_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 ANTHEM HMO ANTHEM HMO 999999999 280.95 450.08 "X-ray of chest, 2 views" 48333337_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 313.66 67.6 999999999 280.95 450.08 percent of total billed charges "X-ray of chest, 2 views" 48333337_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 280.95 450.08 "X-ray of chest, 2 views" 48333337_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 280.95 450.08 Simple control of nose bleed 48334131_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 AETNA AETNA 444.77 79 999999999 340.9 546.11 percent of total billed charges Simple control of nose bleed 48334131_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 365.95 65 999999999 340.9 546.11 percent of total billed charges Simple control of nose bleed 48334131_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 546.11 97 999999999 340.9 546.11 percent of total billed charges Simple control of nose bleed 48334131_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 388.47 69 999999999 340.9 546.11 percent of total billed charges Simple control of nose bleed 48334131_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 439.14 78 999999999 340.9 546.11 percent of total billed charges Simple control of nose bleed 48334131_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 UMR - ALL PLANS UMR - ALL PLANS 394.1 70 999999999 340.9 546.11 percent of total billed charges Simple control of nose bleed 48334131_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 SIHO - ALL PLANS SIHO - ALL PLANS 506.7 90 999999999 340.9 546.11 percent of total billed charges Simple control of nose bleed 48334131_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 340.9 60.55 999999999 340.9 546.11 percent of total billed charges Simple control of nose bleed 48334131_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 340.9 546.11 Simple control of nose bleed 48334131_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 340.9 546.11 Simple control of nose bleed 48334131_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 ANTHEM HMO ANTHEM HMO 999999999 340.9 546.11 Simple control of nose bleed 48334131_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 380.59 67.6 999999999 340.9 546.11 percent of total billed charges Simple control of nose bleed 48334131_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 340.9 546.11 Simple control of nose bleed 48334131_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 340.9 546.11 Tissue preparation for culture 48336465_1 CDM 0306 RC 87176 HCPCS inpatient 43 27.95 AETNA AETNA 33.97 79 999999999 26.04 41.71 percent of total billed charges Tissue preparation for culture 48336465_1 CDM 0306 RC 87176 HCPCS inpatient 43 27.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 27.95 65 999999999 26.04 41.71 percent of total billed charges Tissue preparation for culture 48336465_1 CDM 0306 RC 87176 HCPCS inpatient 43 27.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 41.71 97 999999999 26.04 41.71 percent of total billed charges Tissue preparation for culture 48336465_1 CDM 0306 RC 87176 HCPCS inpatient 43 27.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 29.67 69 999999999 26.04 41.71 percent of total billed charges Tissue preparation for culture 48336465_1 CDM 0306 RC 87176 HCPCS inpatient 43 27.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 33.54 78 999999999 26.04 41.71 percent of total billed charges Tissue preparation for culture 48336465_1 CDM 0306 RC 87176 HCPCS inpatient 43 27.95 UMR - ALL PLANS UMR - ALL PLANS 30.1 70 999999999 26.04 41.71 percent of total billed charges Tissue preparation for culture 48336465_1 CDM 0306 RC 87176 HCPCS inpatient 43 27.95 SIHO - ALL PLANS SIHO - ALL PLANS 38.7 90 999999999 26.04 41.71 percent of total billed charges Tissue preparation for culture 48336465_1 CDM 0306 RC 87176 HCPCS inpatient 43 27.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26.04 60.55 999999999 26.04 41.71 percent of total billed charges Tissue preparation for culture 48336465_1 CDM 0306 RC 87176 HCPCS inpatient 43 27.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26.04 41.71 Tissue preparation for culture 48336465_1 CDM 0306 RC 87176 HCPCS inpatient 43 27.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26.04 41.71 Tissue preparation for culture 48336465_1 CDM 0306 RC 87176 HCPCS inpatient 43 27.95 ANTHEM HMO ANTHEM HMO 999999999 26.04 41.71 Tissue preparation for culture 48336465_1 CDM 0306 RC 87176 HCPCS inpatient 43 27.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 29.07 67.6 999999999 26.04 41.71 percent of total billed charges Tissue preparation for culture 48336465_1 CDM 0306 RC 87176 HCPCS inpatient 43 27.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26.04 41.71 Tissue preparation for culture 48336465_1 CDM 0306 RC 87176 HCPCS inpatient 43 27.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 26.04 41.71 "Blood test, thyroid stimulating hormone (TSH)" 48350130_1 CDM 0301 RC 84443 HCPCS inpatient 234 152.1 AETNA AETNA 184.86 79 999999999 141.69 226.98 percent of total billed charges "Blood test, thyroid stimulating hormone (TSH)" 48350130_1 CDM 0301 RC 84443 HCPCS inpatient 234 152.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 152.1 65 999999999 141.69 226.98 percent of total billed charges "Blood test, thyroid stimulating hormone (TSH)" 48350130_1 CDM 0301 RC 84443 HCPCS inpatient 234 152.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 226.98 97 999999999 141.69 226.98 percent of total billed charges "Blood test, thyroid stimulating hormone (TSH)" 48350130_1 CDM 0301 RC 84443 HCPCS inpatient 234 152.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 161.46 69 999999999 141.69 226.98 percent of total billed charges "Blood test, thyroid stimulating hormone (TSH)" 48350130_1 CDM 0301 RC 84443 HCPCS inpatient 234 152.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 182.52 78 999999999 141.69 226.98 percent of total billed charges "Blood test, thyroid stimulating hormone (TSH)" 48350130_1 CDM 0301 RC 84443 HCPCS inpatient 234 152.1 UMR - ALL PLANS UMR - ALL PLANS 163.8 70 999999999 141.69 226.98 percent of total billed charges "Blood test, thyroid stimulating hormone (TSH)" 48350130_1 CDM 0301 RC 84443 HCPCS inpatient 234 152.1 SIHO - ALL PLANS SIHO - ALL PLANS 210.6 90 999999999 141.69 226.98 percent of total billed charges "Blood test, thyroid stimulating hormone (TSH)" 48350130_1 CDM 0301 RC 84443 HCPCS inpatient 234 152.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 141.69 60.55 999999999 141.69 226.98 percent of total billed charges "Blood test, thyroid stimulating hormone (TSH)" 48350130_1 CDM 0301 RC 84443 HCPCS inpatient 234 152.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 141.69 226.98 "Blood test, thyroid stimulating hormone (TSH)" 48350130_1 CDM 0301 RC 84443 HCPCS inpatient 234 152.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 141.69 226.98 "Blood test, thyroid stimulating hormone (TSH)" 48350130_1 CDM 0301 RC 84443 HCPCS inpatient 234 152.1 ANTHEM HMO ANTHEM HMO 999999999 141.69 226.98 "Blood test, thyroid stimulating hormone (TSH)" 48350130_1 CDM 0301 RC 84443 HCPCS inpatient 234 152.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 158.18 67.6 999999999 141.69 226.98 percent of total billed charges "Blood test, thyroid stimulating hormone (TSH)" 48350130_1 CDM 0301 RC 84443 HCPCS inpatient 234 152.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 141.69 226.98 "Blood test, thyroid stimulating hormone (TSH)" 48350130_1 CDM 0301 RC 84443 HCPCS inpatient 234 152.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 141.69 226.98 Hydroxyindolacetic acid (product of metabolism) level 48356738_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 AETNA AETNA 324.69 79 999999999 248.86 398.67 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 48356738_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 267.15 65 999999999 248.86 398.67 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 48356738_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 398.67 97 999999999 248.86 398.67 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 48356738_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 283.59 69 999999999 248.86 398.67 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 48356738_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 320.58 78 999999999 248.86 398.67 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 48356738_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 UMR - ALL PLANS UMR - ALL PLANS 287.7 70 999999999 248.86 398.67 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 48356738_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 SIHO - ALL PLANS SIHO - ALL PLANS 369.9 90 999999999 248.86 398.67 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 48356738_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 248.86 60.55 999999999 248.86 398.67 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 48356738_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 248.86 398.67 Hydroxyindolacetic acid (product of metabolism) level 48356738_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 248.86 398.67 Hydroxyindolacetic acid (product of metabolism) level 48356738_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 ANTHEM HMO ANTHEM HMO 999999999 248.86 398.67 Hydroxyindolacetic acid (product of metabolism) level 48356738_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 277.84 67.6 999999999 248.86 398.67 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 48356738_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 248.86 398.67 Hydroxyindolacetic acid (product of metabolism) level 48356738_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 248.86 398.67 Aldolase (enzyme) level 48356739_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges Aldolase (enzyme) level 48356739_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges Aldolase (enzyme) level 48356739_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges Aldolase (enzyme) level 48356739_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges Aldolase (enzyme) level 48356739_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges Aldolase (enzyme) level 48356739_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges Aldolase (enzyme) level 48356739_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges Aldolase (enzyme) level 48356739_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges Aldolase (enzyme) level 48356739_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 Aldolase (enzyme) level 48356739_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 Aldolase (enzyme) level 48356739_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 Aldolase (enzyme) level 48356739_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges Aldolase (enzyme) level 48356739_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 Aldolase (enzyme) level 48356739_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356742_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356742_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356742_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356742_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356742_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356742_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356742_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356742_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356742_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356742_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356742_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356742_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356742_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356742_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356743_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356743_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356743_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356743_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356743_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356743_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356743_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356743_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356743_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356743_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356743_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356743_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356743_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356743_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356744_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356744_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356744_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356744_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356744_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356744_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356744_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356744_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356744_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356744_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356744_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356744_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356744_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356744_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356747_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356747_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356747_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356747_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356747_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356747_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356747_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356747_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356747_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356747_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356747_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356747_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356747_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356747_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356748_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356748_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356748_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356748_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356748_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356748_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356748_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356748_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356748_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356748_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356748_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356748_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356748_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356748_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356749_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356749_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356749_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356749_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356749_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356749_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356749_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356749_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356749_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356749_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356749_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356749_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356749_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356749_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356750_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356750_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356750_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356750_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356750_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356750_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356750_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356750_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356750_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356750_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356750_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356750_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356750_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356750_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356752_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356752_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356752_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356752_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356752_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356752_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356752_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356752_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356752_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356752_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356752_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356752_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356752_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356752_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356754_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356754_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356754_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356754_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356754_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356754_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356754_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356754_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356754_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356754_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356754_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356754_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356754_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356754_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356755_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356755_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356755_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356755_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356755_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356755_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356755_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356755_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356755_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356755_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356755_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356755_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356755_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356755_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356758_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356758_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356758_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356758_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356758_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356758_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356758_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356758_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356758_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356758_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356758_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356758_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356758_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356758_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356760_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356760_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356760_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356760_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356760_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356760_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356760_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356760_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356760_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356760_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356760_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356760_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356760_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356760_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356766_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356766_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356766_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356766_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356766_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356766_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356766_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356766_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356766_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356766_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356766_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356766_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356766_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356766_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356767_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356767_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356767_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356767_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356767_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356767_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356767_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356767_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356767_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356767_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356767_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356767_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356767_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356767_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgG) to allergic substance, each allergen" 48356768_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 AETNA AETNA 45.03 79 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 48356768_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.05 65 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 48356768_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.29 97 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 48356768_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.33 69 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 48356768_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.46 78 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 48356768_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UMR - ALL PLANS UMR - ALL PLANS 39.9 70 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 48356768_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 SIHO - ALL PLANS SIHO - ALL PLANS 51.3 90 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 48356768_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.51 60.55 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 48356768_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 48356768_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 48356768_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM HMO ANTHEM HMO 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 48356768_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.53 67.6 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 48356768_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 48356768_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.51 55.29 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356769_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356769_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356769_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356769_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356769_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356769_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356769_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356769_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356769_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356769_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356769_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356769_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356769_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356769_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356772_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356772_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356772_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356772_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356772_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356772_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356772_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356772_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356772_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356772_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356772_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356772_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356772_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356772_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356773_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356773_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356773_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356773_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356773_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356773_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356773_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356773_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356773_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356773_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356773_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356773_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356773_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356773_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356774_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356774_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356774_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356774_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356774_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356774_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356774_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356774_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356774_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356774_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356774_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356774_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356774_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356774_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356775_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356775_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356775_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356775_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356775_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356775_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356775_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356775_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356775_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356775_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356775_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356775_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356775_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356775_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356776_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356776_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356776_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356776_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356776_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356776_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356776_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356776_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356776_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356776_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356776_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356776_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356776_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356776_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356777_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356777_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356777_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356777_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356777_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356777_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356777_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356777_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356777_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356777_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356777_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356777_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356777_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356777_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356778_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356778_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356778_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356778_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356778_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356778_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356778_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356778_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356778_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356778_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356778_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356778_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356778_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356778_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356779_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356779_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356779_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356779_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356779_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356779_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356779_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356779_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356779_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356779_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356779_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356779_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356779_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356779_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356781_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356781_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356781_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356781_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356781_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356781_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356781_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356781_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356781_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356781_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356781_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356781_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356781_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356781_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgG) to allergic substance, each allergen" 48356782_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 AETNA AETNA 41.87 79 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 48356782_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.45 65 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 48356782_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.41 97 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 48356782_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.57 69 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 48356782_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.34 78 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 48356782_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UMR - ALL PLANS UMR - ALL PLANS 37.1 70 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 48356782_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SIHO - ALL PLANS SIHO - ALL PLANS 47.7 90 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 48356782_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.09 60.55 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 48356782_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 48356782_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 48356782_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM HMO ANTHEM HMO 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 48356782_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.83 67.6 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 48356782_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 48356782_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.09 51.41 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356783_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356783_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356783_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356783_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356783_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356783_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356783_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356783_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356783_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356783_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356783_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356783_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356783_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356783_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356784_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356784_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356784_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356784_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356784_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356784_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356784_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356784_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356784_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356784_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356784_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356784_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356784_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356784_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356785_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356785_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356785_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356785_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356785_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356785_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356785_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356785_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356785_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356785_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356785_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356785_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356785_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356785_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356788_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356788_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356788_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356788_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356788_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356788_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356788_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356788_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356788_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356788_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356788_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356788_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356788_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356788_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356789_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356789_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356789_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356789_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356789_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356789_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356789_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356789_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356789_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356789_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356789_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356789_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356789_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356789_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356790_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356790_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356790_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356790_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356790_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356790_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356790_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356790_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356790_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356790_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356790_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356790_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356790_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356790_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356791_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356791_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356791_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356791_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356791_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356791_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356791_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356791_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356791_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356791_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356791_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356791_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356791_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356791_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356792_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356792_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356792_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356792_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356792_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356792_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356792_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356792_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356792_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356792_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356792_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356792_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356792_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356792_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356793_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356793_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356793_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356793_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356793_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356793_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356793_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356793_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356793_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356793_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356793_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356793_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356793_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356793_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356794_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356794_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356794_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356794_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356794_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356794_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356794_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356794_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356794_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356794_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356794_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356794_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356794_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356794_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356795_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356795_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356795_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356795_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356795_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356795_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356795_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356795_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356795_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356795_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356795_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356795_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356795_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356795_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356796_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356796_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356796_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356796_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356796_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356796_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356796_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356796_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356796_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356796_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356796_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356796_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356796_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356796_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356798_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356798_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356798_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356798_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356798_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356798_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356798_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356798_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356798_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356798_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356798_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356798_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356798_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356798_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356799_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356799_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356799_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356799_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356799_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356799_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356799_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356799_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356799_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356799_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356799_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356799_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356799_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356799_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356800_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356800_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356800_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356800_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356800_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356800_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356800_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356800_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356800_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356800_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356800_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356800_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356800_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356800_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356801_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356801_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356801_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356801_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356801_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356801_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356801_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356801_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356801_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356801_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356801_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356801_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356801_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356801_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356802_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356802_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356802_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356802_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356802_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356802_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356802_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356802_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356802_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356802_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356802_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356802_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356802_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356802_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356803_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356803_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356803_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356803_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356803_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356803_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356803_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356803_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356803_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356803_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356803_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356803_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356803_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356803_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356804_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356804_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356804_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356804_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356804_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356804_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356804_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356804_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356804_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356804_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356804_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356804_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356804_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356804_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356805_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356805_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356805_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356805_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356805_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356805_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356805_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356805_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356805_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356805_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356805_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356805_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356805_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356805_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356806_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356806_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356806_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356806_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356806_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356806_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356806_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356806_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356806_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356806_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356806_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356806_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356806_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356806_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356807_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356807_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356807_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356807_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356807_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356807_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356807_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356807_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356807_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356807_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356807_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356807_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356807_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356807_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356808_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356808_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356808_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356808_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356808_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356808_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356808_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356808_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356808_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356808_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356808_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356808_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356808_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356808_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356809_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356809_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356809_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356809_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356809_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356809_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356809_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356809_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356809_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356809_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356809_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356809_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356809_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356809_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356811_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356811_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356811_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356811_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356811_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356811_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356811_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356811_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356811_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356811_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356811_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356811_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356811_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356811_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356812_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356812_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356812_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356812_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356812_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356812_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356812_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356812_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356812_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356812_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356812_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356812_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356812_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356812_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356813_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356813_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356813_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356813_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356813_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356813_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356813_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356813_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356813_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356813_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356813_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356813_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356813_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356813_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356814_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356814_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356814_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356814_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356814_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356814_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356814_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356814_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356814_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356814_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356814_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356814_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356814_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356814_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356816_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356816_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356816_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356816_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356816_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356816_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356816_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356816_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356816_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356816_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356816_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356816_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356816_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356816_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356817_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356817_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356817_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356817_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356817_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356817_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356817_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356817_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356817_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356817_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356817_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356817_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356817_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356817_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356818_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356818_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356818_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356818_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356818_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356818_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356818_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356818_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356818_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356818_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356818_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356818_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356818_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356818_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356820_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356820_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356820_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356820_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356820_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356820_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356820_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356820_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356820_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356820_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356820_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356820_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356820_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356820_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356823_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356823_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356823_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356823_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356823_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356823_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356823_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356823_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356823_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356823_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356823_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356823_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356823_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48356823_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Translocation analysis (BCR/ABL1) major breakpoint 48356825_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 AETNA AETNA 402.11 79 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 48356825_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 330.85 65 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 48356825_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 493.73 97 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 48356825_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 351.21 69 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 48356825_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 397.02 78 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 48356825_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 UMR - ALL PLANS UMR - ALL PLANS 356.3 70 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 48356825_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 SIHO - ALL PLANS SIHO - ALL PLANS 458.1 90 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 48356825_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 308.2 60.55 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 48356825_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 308.2 493.73 Translocation analysis (BCR/ABL1) major breakpoint 48356825_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 308.2 493.73 Translocation analysis (BCR/ABL1) major breakpoint 48356825_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 ANTHEM HMO ANTHEM HMO 999999999 308.2 493.73 Translocation analysis (BCR/ABL1) major breakpoint 48356825_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 344.08 67.6 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 48356825_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 308.2 493.73 Translocation analysis (BCR/ABL1) major breakpoint 48356825_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 308.2 493.73 "Calcium level, ionized" 48356829_1 CDM 0301 RC 82330 HCPCS inpatient 359 233.35 AETNA AETNA 283.61 79 999999999 217.37 348.23 percent of total billed charges "Calcium level, ionized" 48356829_1 CDM 0301 RC 82330 HCPCS inpatient 359 233.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 233.35 65 999999999 217.37 348.23 percent of total billed charges "Calcium level, ionized" 48356829_1 CDM 0301 RC 82330 HCPCS inpatient 359 233.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 348.23 97 999999999 217.37 348.23 percent of total billed charges "Calcium level, ionized" 48356829_1 CDM 0301 RC 82330 HCPCS inpatient 359 233.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 247.71 69 999999999 217.37 348.23 percent of total billed charges "Calcium level, ionized" 48356829_1 CDM 0301 RC 82330 HCPCS inpatient 359 233.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 280.02 78 999999999 217.37 348.23 percent of total billed charges "Calcium level, ionized" 48356829_1 CDM 0301 RC 82330 HCPCS inpatient 359 233.35 UMR - ALL PLANS UMR - ALL PLANS 251.3 70 999999999 217.37 348.23 percent of total billed charges "Calcium level, ionized" 48356829_1 CDM 0301 RC 82330 HCPCS inpatient 359 233.35 SIHO - ALL PLANS SIHO - ALL PLANS 323.1 90 999999999 217.37 348.23 percent of total billed charges "Calcium level, ionized" 48356829_1 CDM 0301 RC 82330 HCPCS inpatient 359 233.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 217.37 60.55 999999999 217.37 348.23 percent of total billed charges "Calcium level, ionized" 48356829_1 CDM 0301 RC 82330 HCPCS inpatient 359 233.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 217.37 348.23 "Calcium level, ionized" 48356829_1 CDM 0301 RC 82330 HCPCS inpatient 359 233.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 217.37 348.23 "Calcium level, ionized" 48356829_1 CDM 0301 RC 82330 HCPCS inpatient 359 233.35 ANTHEM HMO ANTHEM HMO 999999999 217.37 348.23 "Calcium level, ionized" 48356829_1 CDM 0301 RC 82330 HCPCS inpatient 359 233.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 242.68 67.6 999999999 217.37 348.23 percent of total billed charges "Calcium level, ionized" 48356829_1 CDM 0301 RC 82330 HCPCS inpatient 359 233.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 217.37 348.23 "Calcium level, ionized" 48356829_1 CDM 0301 RC 82330 HCPCS inpatient 359 233.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 217.37 348.23 "Measurement of antibody for assessment of autoimmune disorder, any method" 48356833_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48356833_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48356833_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48356833_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48356833_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48356833_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48356833_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48356833_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48356833_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 "Measurement of antibody for assessment of autoimmune disorder, any method" 48356833_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 "Measurement of antibody for assessment of autoimmune disorder, any method" 48356833_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 "Measurement of antibody for assessment of autoimmune disorder, any method" 48356833_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48356833_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 "Measurement of antibody for assessment of autoimmune disorder, any method" 48356833_1 CDM 0301 RC 86235 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 "Testing for presence of drug, by chemistry analyzers" 48356838_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48356838_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48356838_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48356838_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48356838_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48356838_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48356838_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48356838_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48356838_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 48356838_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 48356838_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 48356838_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48356838_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 48356838_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 Cryoglobulin (protein) measurement 48356840_1 CDM 0301 RC 82595 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges Cryoglobulin (protein) measurement 48356840_1 CDM 0301 RC 82595 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges Cryoglobulin (protein) measurement 48356840_1 CDM 0301 RC 82595 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges Cryoglobulin (protein) measurement 48356840_1 CDM 0301 RC 82595 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges Cryoglobulin (protein) measurement 48356840_1 CDM 0301 RC 82595 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges Cryoglobulin (protein) measurement 48356840_1 CDM 0301 RC 82595 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges Cryoglobulin (protein) measurement 48356840_1 CDM 0301 RC 82595 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges Cryoglobulin (protein) measurement 48356840_1 CDM 0301 RC 82595 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges Cryoglobulin (protein) measurement 48356840_1 CDM 0301 RC 82595 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 Cryoglobulin (protein) measurement 48356840_1 CDM 0301 RC 82595 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 Cryoglobulin (protein) measurement 48356840_1 CDM 0301 RC 82595 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 Cryoglobulin (protein) measurement 48356840_1 CDM 0301 RC 82595 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges Cryoglobulin (protein) measurement 48356840_1 CDM 0301 RC 82595 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 Cryoglobulin (protein) measurement 48356840_1 CDM 0301 RC 82595 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 48356844_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 AETNA AETNA 546.68 79 999999999 419.01 671.24 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 48356844_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 449.8 65 999999999 419.01 671.24 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 48356844_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 671.24 97 999999999 419.01 671.24 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 48356844_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 477.48 69 999999999 419.01 671.24 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 48356844_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 539.76 78 999999999 419.01 671.24 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 48356844_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 UMR - ALL PLANS UMR - ALL PLANS 484.4 70 999999999 419.01 671.24 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 48356844_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 SIHO - ALL PLANS SIHO - ALL PLANS 622.8 90 999999999 419.01 671.24 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 48356844_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 419.01 60.55 999999999 419.01 671.24 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 48356844_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 419.01 671.24 Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 48356844_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 419.01 671.24 Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 48356844_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 ANTHEM HMO ANTHEM HMO 999999999 419.01 671.24 Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 48356844_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 467.79 67.6 999999999 419.01 671.24 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 48356844_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 419.01 671.24 Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 48356844_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 419.01 671.24 Dehydroepiandrosterone (DHEA-S) hormone level 48356845_1 CDM 0301 RC 82627 HCPCS inpatient 228 148.2 AETNA AETNA 180.12 79 999999999 138.05 221.16 percent of total billed charges Dehydroepiandrosterone (DHEA-S) hormone level 48356845_1 CDM 0301 RC 82627 HCPCS inpatient 228 148.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 148.2 65 999999999 138.05 221.16 percent of total billed charges Dehydroepiandrosterone (DHEA-S) hormone level 48356845_1 CDM 0301 RC 82627 HCPCS inpatient 228 148.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 221.16 97 999999999 138.05 221.16 percent of total billed charges Dehydroepiandrosterone (DHEA-S) hormone level 48356845_1 CDM 0301 RC 82627 HCPCS inpatient 228 148.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 157.32 69 999999999 138.05 221.16 percent of total billed charges Dehydroepiandrosterone (DHEA-S) hormone level 48356845_1 CDM 0301 RC 82627 HCPCS inpatient 228 148.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 177.84 78 999999999 138.05 221.16 percent of total billed charges Dehydroepiandrosterone (DHEA-S) hormone level 48356845_1 CDM 0301 RC 82627 HCPCS inpatient 228 148.2 UMR - ALL PLANS UMR - ALL PLANS 159.6 70 999999999 138.05 221.16 percent of total billed charges Dehydroepiandrosterone (DHEA-S) hormone level 48356845_1 CDM 0301 RC 82627 HCPCS inpatient 228 148.2 SIHO - ALL PLANS SIHO - ALL PLANS 205.2 90 999999999 138.05 221.16 percent of total billed charges Dehydroepiandrosterone (DHEA-S) hormone level 48356845_1 CDM 0301 RC 82627 HCPCS inpatient 228 148.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 138.05 60.55 999999999 138.05 221.16 percent of total billed charges Dehydroepiandrosterone (DHEA-S) hormone level 48356845_1 CDM 0301 RC 82627 HCPCS inpatient 228 148.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 138.05 221.16 Dehydroepiandrosterone (DHEA-S) hormone level 48356845_1 CDM 0301 RC 82627 HCPCS inpatient 228 148.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 138.05 221.16 Dehydroepiandrosterone (DHEA-S) hormone level 48356845_1 CDM 0301 RC 82627 HCPCS inpatient 228 148.2 ANTHEM HMO ANTHEM HMO 999999999 138.05 221.16 Dehydroepiandrosterone (DHEA-S) hormone level 48356845_1 CDM 0301 RC 82627 HCPCS inpatient 228 148.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 154.13 67.6 999999999 138.05 221.16 percent of total billed charges Dehydroepiandrosterone (DHEA-S) hormone level 48356845_1 CDM 0301 RC 82627 HCPCS inpatient 228 148.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 138.05 221.16 Dehydroepiandrosterone (DHEA-S) hormone level 48356845_1 CDM 0301 RC 82627 HCPCS inpatient 228 148.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 138.05 221.16 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 48356848_1 CDM 0302 RC 86664 HCPCS inpatient 156 101.4 AETNA AETNA 123.24 79 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 48356848_1 CDM 0302 RC 86664 HCPCS inpatient 156 101.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.4 65 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 48356848_1 CDM 0302 RC 86664 HCPCS inpatient 156 101.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 151.32 97 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 48356848_1 CDM 0302 RC 86664 HCPCS inpatient 156 101.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.64 69 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 48356848_1 CDM 0302 RC 86664 HCPCS inpatient 156 101.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.68 78 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 48356848_1 CDM 0302 RC 86664 HCPCS inpatient 156 101.4 UMR - ALL PLANS UMR - ALL PLANS 109.2 70 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 48356848_1 CDM 0302 RC 86664 HCPCS inpatient 156 101.4 SIHO - ALL PLANS SIHO - ALL PLANS 140.4 90 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 48356848_1 CDM 0302 RC 86664 HCPCS inpatient 156 101.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.46 60.55 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 48356848_1 CDM 0302 RC 86664 HCPCS inpatient 156 101.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 48356848_1 CDM 0302 RC 86664 HCPCS inpatient 156 101.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 48356848_1 CDM 0302 RC 86664 HCPCS inpatient 156 101.4 ANTHEM HMO ANTHEM HMO 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 48356848_1 CDM 0302 RC 86664 HCPCS inpatient 156 101.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.46 67.6 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 48356848_1 CDM 0302 RC 86664 HCPCS inpatient 156 101.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 48356848_1 CDM 0302 RC 86664 HCPCS inpatient 156 101.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.46 151.32 "Stool fat or lipids analysis, qualitative" 48356853_1 CDM 0301 RC 82705 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Stool fat or lipids analysis, qualitative" 48356853_1 CDM 0301 RC 82705 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Stool fat or lipids analysis, qualitative" 48356853_1 CDM 0301 RC 82705 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Stool fat or lipids analysis, qualitative" 48356853_1 CDM 0301 RC 82705 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Stool fat or lipids analysis, qualitative" 48356853_1 CDM 0301 RC 82705 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Stool fat or lipids analysis, qualitative" 48356853_1 CDM 0301 RC 82705 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Stool fat or lipids analysis, qualitative" 48356853_1 CDM 0301 RC 82705 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Stool fat or lipids analysis, qualitative" 48356853_1 CDM 0301 RC 82705 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Stool fat or lipids analysis, qualitative" 48356853_1 CDM 0301 RC 82705 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Stool fat or lipids analysis, qualitative" 48356853_1 CDM 0301 RC 82705 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Stool fat or lipids analysis, qualitative" 48356853_1 CDM 0301 RC 82705 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Stool fat or lipids analysis, qualitative" 48356853_1 CDM 0301 RC 82705 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Stool fat or lipids analysis, qualitative" 48356853_1 CDM 0301 RC 82705 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Stool fat or lipids analysis, qualitative" 48356853_1 CDM 0301 RC 82705 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of substance using immunoassay technique, by radioimmunoassay" 48356856_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 AETNA AETNA 237.79 79 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 48356856_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 195.65 65 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 48356856_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291.97 97 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 48356856_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 207.69 69 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 48356856_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 234.78 78 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 48356856_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 UMR - ALL PLANS UMR - ALL PLANS 210.7 70 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 48356856_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 SIHO - ALL PLANS SIHO - ALL PLANS 270.9 90 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 48356856_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.26 60.55 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 48356856_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 48356856_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 48356856_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM HMO ANTHEM HMO 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 48356856_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 203.48 67.6 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 48356856_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 48356856_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.26 291.97 Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48356858_1 CDM 0306 RC 87338 HCPCS inpatient 319 207.35 AETNA AETNA 252.01 79 999999999 193.15 309.43 percent of total billed charges Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48356858_1 CDM 0306 RC 87338 HCPCS inpatient 319 207.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 207.35 65 999999999 193.15 309.43 percent of total billed charges Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48356858_1 CDM 0306 RC 87338 HCPCS inpatient 319 207.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 309.43 97 999999999 193.15 309.43 percent of total billed charges Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48356858_1 CDM 0306 RC 87338 HCPCS inpatient 319 207.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 220.11 69 999999999 193.15 309.43 percent of total billed charges Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48356858_1 CDM 0306 RC 87338 HCPCS inpatient 319 207.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 248.82 78 999999999 193.15 309.43 percent of total billed charges Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48356858_1 CDM 0306 RC 87338 HCPCS inpatient 319 207.35 UMR - ALL PLANS UMR - ALL PLANS 223.3 70 999999999 193.15 309.43 percent of total billed charges Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48356858_1 CDM 0306 RC 87338 HCPCS inpatient 319 207.35 SIHO - ALL PLANS SIHO - ALL PLANS 287.1 90 999999999 193.15 309.43 percent of total billed charges Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48356858_1 CDM 0306 RC 87338 HCPCS inpatient 319 207.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 193.15 60.55 999999999 193.15 309.43 percent of total billed charges Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48356858_1 CDM 0306 RC 87338 HCPCS inpatient 319 207.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 193.15 309.43 Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48356858_1 CDM 0306 RC 87338 HCPCS inpatient 319 207.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 193.15 309.43 Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48356858_1 CDM 0306 RC 87338 HCPCS inpatient 319 207.35 ANTHEM HMO ANTHEM HMO 999999999 193.15 309.43 Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48356858_1 CDM 0306 RC 87338 HCPCS inpatient 319 207.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 215.64 67.6 999999999 193.15 309.43 percent of total billed charges Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48356858_1 CDM 0306 RC 87338 HCPCS inpatient 319 207.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 193.15 309.43 Detection test by immunoassay technique for Helicobacter pylori (GI tract bacteria) in stool 48356858_1 CDM 0306 RC 87338 HCPCS inpatient 319 207.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 193.15 309.43 Breath test analysis for helicobacter pylori 48356859_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 AETNA AETNA 234.63 79 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 48356859_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 193.05 65 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 48356859_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 288.09 97 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 48356859_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 204.93 69 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 48356859_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 231.66 78 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 48356859_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 UMR - ALL PLANS UMR - ALL PLANS 207.9 70 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 48356859_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 SIHO - ALL PLANS SIHO - ALL PLANS 267.3 90 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 48356859_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 179.83 60.55 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 48356859_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 179.83 288.09 Breath test analysis for helicobacter pylori 48356859_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 179.83 288.09 Breath test analysis for helicobacter pylori 48356859_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 ANTHEM HMO ANTHEM HMO 999999999 179.83 288.09 Breath test analysis for helicobacter pylori 48356859_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 200.77 67.6 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 48356859_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 179.83 288.09 Breath test analysis for helicobacter pylori 48356859_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 179.83 288.09 Plasma hemoglobin level 48356860_1 CDM 0301 RC 83051 HCPCS inpatient 49 31.85 AETNA AETNA 38.71 79 999999999 29.67 47.53 percent of total billed charges Plasma hemoglobin level 48356860_1 CDM 0301 RC 83051 HCPCS inpatient 49 31.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.85 65 999999999 29.67 47.53 percent of total billed charges Plasma hemoglobin level 48356860_1 CDM 0301 RC 83051 HCPCS inpatient 49 31.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 47.53 97 999999999 29.67 47.53 percent of total billed charges Plasma hemoglobin level 48356860_1 CDM 0301 RC 83051 HCPCS inpatient 49 31.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.81 69 999999999 29.67 47.53 percent of total billed charges Plasma hemoglobin level 48356860_1 CDM 0301 RC 83051 HCPCS inpatient 49 31.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 38.22 78 999999999 29.67 47.53 percent of total billed charges Plasma hemoglobin level 48356860_1 CDM 0301 RC 83051 HCPCS inpatient 49 31.85 UMR - ALL PLANS UMR - ALL PLANS 34.3 70 999999999 29.67 47.53 percent of total billed charges Plasma hemoglobin level 48356860_1 CDM 0301 RC 83051 HCPCS inpatient 49 31.85 SIHO - ALL PLANS SIHO - ALL PLANS 44.1 90 999999999 29.67 47.53 percent of total billed charges Plasma hemoglobin level 48356860_1 CDM 0301 RC 83051 HCPCS inpatient 49 31.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.67 60.55 999999999 29.67 47.53 percent of total billed charges Plasma hemoglobin level 48356860_1 CDM 0301 RC 83051 HCPCS inpatient 49 31.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.67 47.53 Plasma hemoglobin level 48356860_1 CDM 0301 RC 83051 HCPCS inpatient 49 31.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.67 47.53 Plasma hemoglobin level 48356860_1 CDM 0301 RC 83051 HCPCS inpatient 49 31.85 ANTHEM HMO ANTHEM HMO 999999999 29.67 47.53 Plasma hemoglobin level 48356860_1 CDM 0301 RC 83051 HCPCS inpatient 49 31.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.12 67.6 999999999 29.67 47.53 percent of total billed charges Plasma hemoglobin level 48356860_1 CDM 0301 RC 83051 HCPCS inpatient 49 31.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.67 47.53 Plasma hemoglobin level 48356860_1 CDM 0301 RC 83051 HCPCS inpatient 49 31.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.67 47.53 Measurement of Hepatitis A antibody (IgM) 48356861_1 CDM 0302 RC 86709 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 48356861_1 CDM 0302 RC 86709 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 48356861_1 CDM 0302 RC 86709 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 48356861_1 CDM 0302 RC 86709 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 48356861_1 CDM 0302 RC 86709 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 48356861_1 CDM 0302 RC 86709 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 48356861_1 CDM 0302 RC 86709 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 48356861_1 CDM 0302 RC 86709 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 48356861_1 CDM 0302 RC 86709 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 Measurement of Hepatitis A antibody (IgM) 48356861_1 CDM 0302 RC 86709 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 Measurement of Hepatitis A antibody (IgM) 48356861_1 CDM 0302 RC 86709 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 Measurement of Hepatitis A antibody (IgM) 48356861_1 CDM 0302 RC 86709 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 48356861_1 CDM 0302 RC 86709 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 Measurement of Hepatitis A antibody (IgM) 48356861_1 CDM 0302 RC 86709 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 "Detection test by nucleic acid for Hepatitis C virus, quantification" 48356862_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 AETNA AETNA 198.29 79 999999999 151.98 243.47 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 48356862_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.15 65 999999999 151.98 243.47 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 48356862_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 243.47 97 999999999 151.98 243.47 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 48356862_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.19 69 999999999 151.98 243.47 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 48356862_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 195.78 78 999999999 151.98 243.47 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 48356862_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 UMR - ALL PLANS UMR - ALL PLANS 175.7 70 999999999 151.98 243.47 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 48356862_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 SIHO - ALL PLANS SIHO - ALL PLANS 225.9 90 999999999 151.98 243.47 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 48356862_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.98 60.55 999999999 151.98 243.47 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 48356862_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.98 243.47 "Detection test by nucleic acid for Hepatitis C virus, quantification" 48356862_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.98 243.47 "Detection test by nucleic acid for Hepatitis C virus, quantification" 48356862_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 ANTHEM HMO ANTHEM HMO 999999999 151.98 243.47 "Detection test by nucleic acid for Hepatitis C virus, quantification" 48356862_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 169.68 67.6 999999999 151.98 243.47 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 48356862_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.98 243.47 "Detection test by nucleic acid for Hepatitis C virus, quantification" 48356862_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.98 243.47 Analysis test by nucleic acid for Hepatitis C virus 48356863_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 AETNA AETNA 882.43 79 999999999 676.34 1083.49 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 48356863_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 726.05 65 999999999 676.34 1083.49 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 48356863_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1083.49 97 999999999 676.34 1083.49 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 48356863_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 770.73 69 999999999 676.34 1083.49 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 48356863_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 871.26 78 999999999 676.34 1083.49 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 48356863_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 UMR - ALL PLANS UMR - ALL PLANS 781.9 70 999999999 676.34 1083.49 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 48356863_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 SIHO - ALL PLANS SIHO - ALL PLANS 1005.3 90 999999999 676.34 1083.49 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 48356863_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 676.34 60.55 999999999 676.34 1083.49 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 48356863_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 676.34 1083.49 Analysis test by nucleic acid for Hepatitis C virus 48356863_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 676.34 1083.49 Analysis test by nucleic acid for Hepatitis C virus 48356863_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 ANTHEM HMO ANTHEM HMO 999999999 676.34 1083.49 Analysis test by nucleic acid for Hepatitis C virus 48356863_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 755.09 67.6 999999999 676.34 1083.49 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 48356863_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 676.34 1083.49 Analysis test by nucleic acid for Hepatitis C virus 48356863_1 CDM 0306 RC 87902 HCPCS inpatient 1117 726.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 676.34 1083.49 "Microscopic genetic analysis of tissue, manual, initial procedure" 48356864_1 CDM 0301 RC 88368 HCPCS inpatient 1200 780 AETNA AETNA 948 79 999999999 726.6 1164 percent of total billed charges "Microscopic genetic analysis of tissue, manual, initial procedure" 48356864_1 CDM 0301 RC 88368 HCPCS inpatient 1200 780 SELF PAY DISCOUNT SELF PAY DISCOUNT 780 65 999999999 726.6 1164 percent of total billed charges "Microscopic genetic analysis of tissue, manual, initial procedure" 48356864_1 CDM 0301 RC 88368 HCPCS inpatient 1200 780 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1164 97 999999999 726.6 1164 percent of total billed charges "Microscopic genetic analysis of tissue, manual, initial procedure" 48356864_1 CDM 0301 RC 88368 HCPCS inpatient 1200 780 ENCORE - ALL PLANS ENCORE - ALL PLANS 828 69 999999999 726.6 1164 percent of total billed charges "Microscopic genetic analysis of tissue, manual, initial procedure" 48356864_1 CDM 0301 RC 88368 HCPCS inpatient 1200 780 HUMANA - ALL PLANS HUMANA - ALL PLANS 936 78 999999999 726.6 1164 percent of total billed charges "Microscopic genetic analysis of tissue, manual, initial procedure" 48356864_1 CDM 0301 RC 88368 HCPCS inpatient 1200 780 UMR - ALL PLANS UMR - ALL PLANS 840 70 999999999 726.6 1164 percent of total billed charges "Microscopic genetic analysis of tissue, manual, initial procedure" 48356864_1 CDM 0301 RC 88368 HCPCS inpatient 1200 780 SIHO - ALL PLANS SIHO - ALL PLANS 1080 90 999999999 726.6 1164 percent of total billed charges "Microscopic genetic analysis of tissue, manual, initial procedure" 48356864_1 CDM 0301 RC 88368 HCPCS inpatient 1200 780 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 726.6 60.55 999999999 726.6 1164 percent of total billed charges "Microscopic genetic analysis of tissue, manual, initial procedure" 48356864_1 CDM 0301 RC 88368 HCPCS inpatient 1200 780 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 726.6 1164 "Microscopic genetic analysis of tissue, manual, initial procedure" 48356864_1 CDM 0301 RC 88368 HCPCS inpatient 1200 780 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 726.6 1164 "Microscopic genetic analysis of tissue, manual, initial procedure" 48356864_1 CDM 0301 RC 88368 HCPCS inpatient 1200 780 ANTHEM HMO ANTHEM HMO 999999999 726.6 1164 "Microscopic genetic analysis of tissue, manual, initial procedure" 48356864_1 CDM 0301 RC 88368 HCPCS inpatient 1200 780 CIGNA - ALL PLANS CIGNA - ALL PLANS 811.2 67.6 999999999 726.6 1164 percent of total billed charges "Microscopic genetic analysis of tissue, manual, initial procedure" 48356864_1 CDM 0301 RC 88368 HCPCS inpatient 1200 780 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 726.6 1164 "Microscopic genetic analysis of tissue, manual, initial procedure" 48356864_1 CDM 0301 RC 88368 HCPCS inpatient 1200 780 UHC - ALL PLANS UHC - ALL PLANS 999999999 726.6 1164 "Analysis for antibody to Herpes simplex virus, type 1" 48356868_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 48356868_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 48356868_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 48356868_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 48356868_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 48356868_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 48356868_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 48356868_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 48356868_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 "Analysis for antibody to Herpes simplex virus, type 1" 48356868_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 "Analysis for antibody to Herpes simplex virus, type 1" 48356868_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 "Analysis for antibody to Herpes simplex virus, type 1" 48356868_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 48356868_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 "Analysis for antibody to Herpes simplex virus, type 1" 48356868_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 "Analysis for antibody to Herpes simplex virus, type 2" 48356869_1 CDM 0302 RC 86696 HCPCS inpatient 98 63.7 AETNA AETNA 77.42 79 999999999 59.34 95.06 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 2" 48356869_1 CDM 0302 RC 86696 HCPCS inpatient 98 63.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.7 65 999999999 59.34 95.06 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 2" 48356869_1 CDM 0302 RC 86696 HCPCS inpatient 98 63.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.06 97 999999999 59.34 95.06 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 2" 48356869_1 CDM 0302 RC 86696 HCPCS inpatient 98 63.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.62 69 999999999 59.34 95.06 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 2" 48356869_1 CDM 0302 RC 86696 HCPCS inpatient 98 63.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.44 78 999999999 59.34 95.06 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 2" 48356869_1 CDM 0302 RC 86696 HCPCS inpatient 98 63.7 UMR - ALL PLANS UMR - ALL PLANS 68.6 70 999999999 59.34 95.06 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 2" 48356869_1 CDM 0302 RC 86696 HCPCS inpatient 98 63.7 SIHO - ALL PLANS SIHO - ALL PLANS 88.2 90 999999999 59.34 95.06 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 2" 48356869_1 CDM 0302 RC 86696 HCPCS inpatient 98 63.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.34 60.55 999999999 59.34 95.06 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 2" 48356869_1 CDM 0302 RC 86696 HCPCS inpatient 98 63.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.34 95.06 "Analysis for antibody to Herpes simplex virus, type 2" 48356869_1 CDM 0302 RC 86696 HCPCS inpatient 98 63.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.34 95.06 "Analysis for antibody to Herpes simplex virus, type 2" 48356869_1 CDM 0302 RC 86696 HCPCS inpatient 98 63.7 ANTHEM HMO ANTHEM HMO 999999999 59.34 95.06 "Analysis for antibody to Herpes simplex virus, type 2" 48356869_1 CDM 0302 RC 86696 HCPCS inpatient 98 63.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.25 67.6 999999999 59.34 95.06 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 2" 48356869_1 CDM 0302 RC 86696 HCPCS inpatient 98 63.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.34 95.06 "Analysis for antibody to Herpes simplex virus, type 2" 48356869_1 CDM 0302 RC 86696 HCPCS inpatient 98 63.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.34 95.06 "Detection test by nucleic acid for HIV-1 virus, quantification" 48356870_1 CDM 0306 RC 87536 HCPCS inpatient 330 214.5 AETNA AETNA 260.7 79 999999999 199.82 320.1 percent of total billed charges "Detection test by nucleic acid for HIV-1 virus, quantification" 48356870_1 CDM 0306 RC 87536 HCPCS inpatient 330 214.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 214.5 65 999999999 199.82 320.1 percent of total billed charges "Detection test by nucleic acid for HIV-1 virus, quantification" 48356870_1 CDM 0306 RC 87536 HCPCS inpatient 330 214.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 320.1 97 999999999 199.82 320.1 percent of total billed charges "Detection test by nucleic acid for HIV-1 virus, quantification" 48356870_1 CDM 0306 RC 87536 HCPCS inpatient 330 214.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 227.7 69 999999999 199.82 320.1 percent of total billed charges "Detection test by nucleic acid for HIV-1 virus, quantification" 48356870_1 CDM 0306 RC 87536 HCPCS inpatient 330 214.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 257.4 78 999999999 199.82 320.1 percent of total billed charges "Detection test by nucleic acid for HIV-1 virus, quantification" 48356870_1 CDM 0306 RC 87536 HCPCS inpatient 330 214.5 UMR - ALL PLANS UMR - ALL PLANS 231 70 999999999 199.82 320.1 percent of total billed charges "Detection test by nucleic acid for HIV-1 virus, quantification" 48356870_1 CDM 0306 RC 87536 HCPCS inpatient 330 214.5 SIHO - ALL PLANS SIHO - ALL PLANS 297 90 999999999 199.82 320.1 percent of total billed charges "Detection test by nucleic acid for HIV-1 virus, quantification" 48356870_1 CDM 0306 RC 87536 HCPCS inpatient 330 214.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 199.82 60.55 999999999 199.82 320.1 percent of total billed charges "Detection test by nucleic acid for HIV-1 virus, quantification" 48356870_1 CDM 0306 RC 87536 HCPCS inpatient 330 214.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 199.82 320.1 "Detection test by nucleic acid for HIV-1 virus, quantification" 48356870_1 CDM 0306 RC 87536 HCPCS inpatient 330 214.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 199.82 320.1 "Detection test by nucleic acid for HIV-1 virus, quantification" 48356870_1 CDM 0306 RC 87536 HCPCS inpatient 330 214.5 ANTHEM HMO ANTHEM HMO 999999999 199.82 320.1 "Detection test by nucleic acid for HIV-1 virus, quantification" 48356870_1 CDM 0306 RC 87536 HCPCS inpatient 330 214.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 223.08 67.6 999999999 199.82 320.1 percent of total billed charges "Detection test by nucleic acid for HIV-1 virus, quantification" 48356870_1 CDM 0306 RC 87536 HCPCS inpatient 330 214.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 199.82 320.1 "Detection test by nucleic acid for HIV-1 virus, quantification" 48356870_1 CDM 0306 RC 87536 HCPCS inpatient 330 214.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 199.82 320.1 Somatomedin (growth factor) level 48356874_1 CDM 0301 RC 84305 HCPCS inpatient 299 194.35 AETNA AETNA 236.21 79 999999999 181.04 290.03 percent of total billed charges Somatomedin (growth factor) level 48356874_1 CDM 0301 RC 84305 HCPCS inpatient 299 194.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 194.35 65 999999999 181.04 290.03 percent of total billed charges Somatomedin (growth factor) level 48356874_1 CDM 0301 RC 84305 HCPCS inpatient 299 194.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 290.03 97 999999999 181.04 290.03 percent of total billed charges Somatomedin (growth factor) level 48356874_1 CDM 0301 RC 84305 HCPCS inpatient 299 194.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 206.31 69 999999999 181.04 290.03 percent of total billed charges Somatomedin (growth factor) level 48356874_1 CDM 0301 RC 84305 HCPCS inpatient 299 194.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 233.22 78 999999999 181.04 290.03 percent of total billed charges Somatomedin (growth factor) level 48356874_1 CDM 0301 RC 84305 HCPCS inpatient 299 194.35 UMR - ALL PLANS UMR - ALL PLANS 209.3 70 999999999 181.04 290.03 percent of total billed charges Somatomedin (growth factor) level 48356874_1 CDM 0301 RC 84305 HCPCS inpatient 299 194.35 SIHO - ALL PLANS SIHO - ALL PLANS 269.1 90 999999999 181.04 290.03 percent of total billed charges Somatomedin (growth factor) level 48356874_1 CDM 0301 RC 84305 HCPCS inpatient 299 194.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 181.04 60.55 999999999 181.04 290.03 percent of total billed charges Somatomedin (growth factor) level 48356874_1 CDM 0301 RC 84305 HCPCS inpatient 299 194.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 181.04 290.03 Somatomedin (growth factor) level 48356874_1 CDM 0301 RC 84305 HCPCS inpatient 299 194.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 181.04 290.03 Somatomedin (growth factor) level 48356874_1 CDM 0301 RC 84305 HCPCS inpatient 299 194.35 ANTHEM HMO ANTHEM HMO 999999999 181.04 290.03 Somatomedin (growth factor) level 48356874_1 CDM 0301 RC 84305 HCPCS inpatient 299 194.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 202.12 67.6 999999999 181.04 290.03 percent of total billed charges Somatomedin (growth factor) level 48356874_1 CDM 0301 RC 84305 HCPCS inpatient 299 194.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 181.04 290.03 Somatomedin (growth factor) level 48356874_1 CDM 0301 RC 84305 HCPCS inpatient 299 194.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 181.04 290.03 Lamotrigine level 48356876_1 CDM 0301 RC 80175 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges Lamotrigine level 48356876_1 CDM 0301 RC 80175 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges Lamotrigine level 48356876_1 CDM 0301 RC 80175 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges Lamotrigine level 48356876_1 CDM 0301 RC 80175 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges Lamotrigine level 48356876_1 CDM 0301 RC 80175 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges Lamotrigine level 48356876_1 CDM 0301 RC 80175 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges Lamotrigine level 48356876_1 CDM 0301 RC 80175 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges Lamotrigine level 48356876_1 CDM 0301 RC 80175 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges Lamotrigine level 48356876_1 CDM 0301 RC 80175 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 Lamotrigine level 48356876_1 CDM 0301 RC 80175 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 Lamotrigine level 48356876_1 CDM 0301 RC 80175 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 Lamotrigine level 48356876_1 CDM 0301 RC 80175 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges Lamotrigine level 48356876_1 CDM 0301 RC 80175 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 Lamotrigine level 48356876_1 CDM 0301 RC 80175 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 LDL cholesterol level 48356877_1 CDM 0301 RC 83721 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges LDL cholesterol level 48356877_1 CDM 0301 RC 83721 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges LDL cholesterol level 48356877_1 CDM 0301 RC 83721 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges LDL cholesterol level 48356877_1 CDM 0301 RC 83721 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges LDL cholesterol level 48356877_1 CDM 0301 RC 83721 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges LDL cholesterol level 48356877_1 CDM 0301 RC 83721 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges LDL cholesterol level 48356877_1 CDM 0301 RC 83721 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges LDL cholesterol level 48356877_1 CDM 0301 RC 83721 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges LDL cholesterol level 48356877_1 CDM 0301 RC 83721 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 LDL cholesterol level 48356877_1 CDM 0301 RC 83721 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 LDL cholesterol level 48356877_1 CDM 0301 RC 83721 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 LDL cholesterol level 48356877_1 CDM 0301 RC 83721 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges LDL cholesterol level 48356877_1 CDM 0301 RC 83721 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 LDL cholesterol level 48356877_1 CDM 0301 RC 83721 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 "Measurement of DNA antibody, native or double stranded" 48356879_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 AETNA AETNA 203.03 79 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 48356879_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.05 65 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 48356879_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 249.29 97 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 48356879_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 177.33 69 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 48356879_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 200.46 78 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 48356879_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 SIHO - ALL PLANS SIHO - ALL PLANS 231.3 90 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 48356879_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 UMR - ALL PLANS UMR - ALL PLANS 179.9 70 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 48356879_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.61 60.55 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 48356879_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.61 249.29 "Measurement of DNA antibody, native or double stranded" 48356879_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.61 249.29 "Measurement of DNA antibody, native or double stranded" 48356879_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 ANTHEM HMO ANTHEM HMO 999999999 155.61 249.29 "Measurement of DNA antibody, native or double stranded" 48356879_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.73 67.6 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 48356879_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.61 249.29 "Measurement of DNA antibody, native or double stranded" 48356879_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.61 249.29 Myoglobin (muscle protein) level 48356884_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges Myoglobin (muscle protein) level 48356884_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges Myoglobin (muscle protein) level 48356884_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges Myoglobin (muscle protein) level 48356884_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges Myoglobin (muscle protein) level 48356884_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges Myoglobin (muscle protein) level 48356884_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges Myoglobin (muscle protein) level 48356884_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges Myoglobin (muscle protein) level 48356884_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges Myoglobin (muscle protein) level 48356884_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 Myoglobin (muscle protein) level 48356884_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 Myoglobin (muscle protein) level 48356884_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 Myoglobin (muscle protein) level 48356884_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges Myoglobin (muscle protein) level 48356884_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 Myoglobin (muscle protein) level 48356884_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 Oxcarbazepine level 48356892_1 CDM 0301 RC 80183 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges Oxcarbazepine level 48356892_1 CDM 0301 RC 80183 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges Oxcarbazepine level 48356892_1 CDM 0301 RC 80183 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges Oxcarbazepine level 48356892_1 CDM 0301 RC 80183 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges Oxcarbazepine level 48356892_1 CDM 0301 RC 80183 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges Oxcarbazepine level 48356892_1 CDM 0301 RC 80183 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges Oxcarbazepine level 48356892_1 CDM 0301 RC 80183 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges Oxcarbazepine level 48356892_1 CDM 0301 RC 80183 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges Oxcarbazepine level 48356892_1 CDM 0301 RC 80183 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 Oxcarbazepine level 48356892_1 CDM 0301 RC 80183 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 Oxcarbazepine level 48356892_1 CDM 0301 RC 80183 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 Oxcarbazepine level 48356892_1 CDM 0301 RC 80183 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges Oxcarbazepine level 48356892_1 CDM 0301 RC 80183 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 Oxcarbazepine level 48356892_1 CDM 0301 RC 80183 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 "Testing for presence of drug, by chemistry analyzers" 48356894_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 AETNA AETNA 161.16 79 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48356894_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.6 65 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48356894_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.88 97 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48356894_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.76 69 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48356894_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.12 78 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48356894_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 SIHO - ALL PLANS SIHO - ALL PLANS 183.6 90 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48356894_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 UMR - ALL PLANS UMR - ALL PLANS 142.8 70 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48356894_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.52 60.55 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48356894_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.52 197.88 "Testing for presence of drug, by chemistry analyzers" 48356894_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.52 197.88 "Testing for presence of drug, by chemistry analyzers" 48356894_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 ANTHEM HMO ANTHEM HMO 999999999 123.52 197.88 "Testing for presence of drug, by chemistry analyzers" 48356894_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.9 67.6 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48356894_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.52 197.88 "Testing for presence of drug, by chemistry analyzers" 48356894_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.52 197.88 "Carbohydrate analysis, single qualitative" 48356900_1 CDM 0301 RC 84376 HCPCS inpatient 129 83.85 AETNA AETNA 101.91 79 999999999 78.11 125.13 percent of total billed charges "Carbohydrate analysis, single qualitative" 48356900_1 CDM 0301 RC 84376 HCPCS inpatient 129 83.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 83.85 65 999999999 78.11 125.13 percent of total billed charges "Carbohydrate analysis, single qualitative" 48356900_1 CDM 0301 RC 84376 HCPCS inpatient 129 83.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 125.13 97 999999999 78.11 125.13 percent of total billed charges "Carbohydrate analysis, single qualitative" 48356900_1 CDM 0301 RC 84376 HCPCS inpatient 129 83.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.01 69 999999999 78.11 125.13 percent of total billed charges "Carbohydrate analysis, single qualitative" 48356900_1 CDM 0301 RC 84376 HCPCS inpatient 129 83.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 100.62 78 999999999 78.11 125.13 percent of total billed charges "Carbohydrate analysis, single qualitative" 48356900_1 CDM 0301 RC 84376 HCPCS inpatient 129 83.85 SIHO - ALL PLANS SIHO - ALL PLANS 116.1 90 999999999 78.11 125.13 percent of total billed charges "Carbohydrate analysis, single qualitative" 48356900_1 CDM 0301 RC 84376 HCPCS inpatient 129 83.85 UMR - ALL PLANS UMR - ALL PLANS 90.3 70 999999999 78.11 125.13 percent of total billed charges "Carbohydrate analysis, single qualitative" 48356900_1 CDM 0301 RC 84376 HCPCS inpatient 129 83.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.11 60.55 999999999 78.11 125.13 percent of total billed charges "Carbohydrate analysis, single qualitative" 48356900_1 CDM 0301 RC 84376 HCPCS inpatient 129 83.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.11 125.13 "Carbohydrate analysis, single qualitative" 48356900_1 CDM 0301 RC 84376 HCPCS inpatient 129 83.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.11 125.13 "Carbohydrate analysis, single qualitative" 48356900_1 CDM 0301 RC 84376 HCPCS inpatient 129 83.85 ANTHEM HMO ANTHEM HMO 999999999 78.11 125.13 "Carbohydrate analysis, single qualitative" 48356900_1 CDM 0301 RC 84376 HCPCS inpatient 129 83.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.2 67.6 999999999 78.11 125.13 percent of total billed charges "Carbohydrate analysis, single qualitative" 48356900_1 CDM 0301 RC 84376 HCPCS inpatient 129 83.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.11 125.13 "Carbohydrate analysis, single qualitative" 48356900_1 CDM 0301 RC 84376 HCPCS inpatient 129 83.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.11 125.13 Detection test by immunoassay technique for rotavirus 48356902_1 CDM 0306 RC 87425 HCPCS inpatient 317 206.05 AETNA AETNA 250.43 79 999999999 191.94 307.49 percent of total billed charges Detection test by immunoassay technique for rotavirus 48356902_1 CDM 0306 RC 87425 HCPCS inpatient 317 206.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 206.05 65 999999999 191.94 307.49 percent of total billed charges Detection test by immunoassay technique for rotavirus 48356902_1 CDM 0306 RC 87425 HCPCS inpatient 317 206.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 307.49 97 999999999 191.94 307.49 percent of total billed charges Detection test by immunoassay technique for rotavirus 48356902_1 CDM 0306 RC 87425 HCPCS inpatient 317 206.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 218.73 69 999999999 191.94 307.49 percent of total billed charges Detection test by immunoassay technique for rotavirus 48356902_1 CDM 0306 RC 87425 HCPCS inpatient 317 206.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 247.26 78 999999999 191.94 307.49 percent of total billed charges Detection test by immunoassay technique for rotavirus 48356902_1 CDM 0306 RC 87425 HCPCS inpatient 317 206.05 SIHO - ALL PLANS SIHO - ALL PLANS 285.3 90 999999999 191.94 307.49 percent of total billed charges Detection test by immunoassay technique for rotavirus 48356902_1 CDM 0306 RC 87425 HCPCS inpatient 317 206.05 UMR - ALL PLANS UMR - ALL PLANS 221.9 70 999999999 191.94 307.49 percent of total billed charges Detection test by immunoassay technique for rotavirus 48356902_1 CDM 0306 RC 87425 HCPCS inpatient 317 206.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 191.94 60.55 999999999 191.94 307.49 percent of total billed charges Detection test by immunoassay technique for rotavirus 48356902_1 CDM 0306 RC 87425 HCPCS inpatient 317 206.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 191.94 307.49 Detection test by immunoassay technique for rotavirus 48356902_1 CDM 0306 RC 87425 HCPCS inpatient 317 206.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 191.94 307.49 Detection test by immunoassay technique for rotavirus 48356902_1 CDM 0306 RC 87425 HCPCS inpatient 317 206.05 ANTHEM HMO ANTHEM HMO 999999999 191.94 307.49 Detection test by immunoassay technique for rotavirus 48356902_1 CDM 0306 RC 87425 HCPCS inpatient 317 206.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 214.29 67.6 999999999 191.94 307.49 percent of total billed charges Detection test by immunoassay technique for rotavirus 48356902_1 CDM 0306 RC 87425 HCPCS inpatient 317 206.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 191.94 307.49 Detection test by immunoassay technique for rotavirus 48356902_1 CDM 0306 RC 87425 HCPCS inpatient 317 206.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 191.94 307.49 Sex hormone binding globulin (protein) level 48356903_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges Sex hormone binding globulin (protein) level 48356903_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges Sex hormone binding globulin (protein) level 48356903_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges Sex hormone binding globulin (protein) level 48356903_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges Sex hormone binding globulin (protein) level 48356903_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges Sex hormone binding globulin (protein) level 48356903_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges Sex hormone binding globulin (protein) level 48356903_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges Sex hormone binding globulin (protein) level 48356903_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges Sex hormone binding globulin (protein) level 48356903_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 Sex hormone binding globulin (protein) level 48356903_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 Sex hormone binding globulin (protein) level 48356903_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 Sex hormone binding globulin (protein) level 48356903_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges Sex hormone binding globulin (protein) level 48356903_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 Sex hormone binding globulin (protein) level 48356903_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 Sirolimus level 48356904_1 CDM 0301 RC 80195 HCPCS inpatient 247 160.55 AETNA AETNA 195.13 79 999999999 149.56 239.59 percent of total billed charges Sirolimus level 48356904_1 CDM 0301 RC 80195 HCPCS inpatient 247 160.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 160.55 65 999999999 149.56 239.59 percent of total billed charges Sirolimus level 48356904_1 CDM 0301 RC 80195 HCPCS inpatient 247 160.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 239.59 97 999999999 149.56 239.59 percent of total billed charges Sirolimus level 48356904_1 CDM 0301 RC 80195 HCPCS inpatient 247 160.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 170.43 69 999999999 149.56 239.59 percent of total billed charges Sirolimus level 48356904_1 CDM 0301 RC 80195 HCPCS inpatient 247 160.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 192.66 78 999999999 149.56 239.59 percent of total billed charges Sirolimus level 48356904_1 CDM 0301 RC 80195 HCPCS inpatient 247 160.55 SIHO - ALL PLANS SIHO - ALL PLANS 222.3 90 999999999 149.56 239.59 percent of total billed charges Sirolimus level 48356904_1 CDM 0301 RC 80195 HCPCS inpatient 247 160.55 UMR - ALL PLANS UMR - ALL PLANS 172.9 70 999999999 149.56 239.59 percent of total billed charges Sirolimus level 48356904_1 CDM 0301 RC 80195 HCPCS inpatient 247 160.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 149.56 60.55 999999999 149.56 239.59 percent of total billed charges Sirolimus level 48356904_1 CDM 0301 RC 80195 HCPCS inpatient 247 160.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 149.56 239.59 Sirolimus level 48356904_1 CDM 0301 RC 80195 HCPCS inpatient 247 160.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 149.56 239.59 Sirolimus level 48356904_1 CDM 0301 RC 80195 HCPCS inpatient 247 160.55 ANTHEM HMO ANTHEM HMO 999999999 149.56 239.59 Sirolimus level 48356904_1 CDM 0301 RC 80195 HCPCS inpatient 247 160.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 166.97 67.6 999999999 149.56 239.59 percent of total billed charges Sirolimus level 48356904_1 CDM 0301 RC 80195 HCPCS inpatient 247 160.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 149.56 239.59 Sirolimus level 48356904_1 CDM 0301 RC 80195 HCPCS inpatient 247 160.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 149.56 239.59 "Cannabinoids levels, natural" 48356909_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 48356909_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 48356909_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 48356909_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 48356909_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 48356909_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 48356909_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 48356909_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 48356909_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 "Cannabinoids levels, natural" 48356909_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 "Cannabinoids levels, natural" 48356909_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 "Cannabinoids levels, natural" 48356909_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 48356909_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 "Cannabinoids levels, natural" 48356909_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 "Analysis of substance using immunoassay technique, multiple step method" 48356912_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48356912_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48356912_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48356912_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48356912_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48356912_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48356912_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48356912_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48356912_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48356912_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48356912_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48356912_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48356912_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48356912_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48356913_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48356913_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48356913_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48356913_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48356913_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48356913_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48356913_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48356913_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48356913_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48356913_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48356913_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48356913_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48356913_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48356913_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 Syphilis detection test 48356915_1 CDM 0302 RC 86592 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges Syphilis detection test 48356915_1 CDM 0302 RC 86592 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges Syphilis detection test 48356915_1 CDM 0302 RC 86592 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges Syphilis detection test 48356915_1 CDM 0302 RC 86592 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges Syphilis detection test 48356915_1 CDM 0302 RC 86592 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges Syphilis detection test 48356915_1 CDM 0302 RC 86592 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges Syphilis detection test 48356915_1 CDM 0302 RC 86592 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges Syphilis detection test 48356915_1 CDM 0302 RC 86592 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges Syphilis detection test 48356915_1 CDM 0302 RC 86592 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 Syphilis detection test 48356915_1 CDM 0302 RC 86592 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 Syphilis detection test 48356915_1 CDM 0302 RC 86592 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 Syphilis detection test 48356915_1 CDM 0302 RC 86592 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges Syphilis detection test 48356915_1 CDM 0302 RC 86592 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 Syphilis detection test 48356915_1 CDM 0302 RC 86592 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 Vitamin A level 48356918_1 CDM 0301 RC 84590 HCPCS inpatient 170 110.5 AETNA AETNA 134.3 79 999999999 102.94 164.9 percent of total billed charges Vitamin A level 48356918_1 CDM 0301 RC 84590 HCPCS inpatient 170 110.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.5 65 999999999 102.94 164.9 percent of total billed charges Vitamin A level 48356918_1 CDM 0301 RC 84590 HCPCS inpatient 170 110.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.9 97 999999999 102.94 164.9 percent of total billed charges Vitamin A level 48356918_1 CDM 0301 RC 84590 HCPCS inpatient 170 110.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.3 69 999999999 102.94 164.9 percent of total billed charges Vitamin A level 48356918_1 CDM 0301 RC 84590 HCPCS inpatient 170 110.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.6 78 999999999 102.94 164.9 percent of total billed charges Vitamin A level 48356918_1 CDM 0301 RC 84590 HCPCS inpatient 170 110.5 SIHO - ALL PLANS SIHO - ALL PLANS 153 90 999999999 102.94 164.9 percent of total billed charges Vitamin A level 48356918_1 CDM 0301 RC 84590 HCPCS inpatient 170 110.5 UMR - ALL PLANS UMR - ALL PLANS 119 70 999999999 102.94 164.9 percent of total billed charges Vitamin A level 48356918_1 CDM 0301 RC 84590 HCPCS inpatient 170 110.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.94 60.55 999999999 102.94 164.9 percent of total billed charges Vitamin A level 48356918_1 CDM 0301 RC 84590 HCPCS inpatient 170 110.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.94 164.9 Vitamin A level 48356918_1 CDM 0301 RC 84590 HCPCS inpatient 170 110.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.94 164.9 Vitamin A level 48356918_1 CDM 0301 RC 84590 HCPCS inpatient 170 110.5 ANTHEM HMO ANTHEM HMO 999999999 102.94 164.9 Vitamin A level 48356918_1 CDM 0301 RC 84590 HCPCS inpatient 170 110.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.92 67.6 999999999 102.94 164.9 percent of total billed charges Vitamin A level 48356918_1 CDM 0301 RC 84590 HCPCS inpatient 170 110.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.94 164.9 Vitamin A level 48356918_1 CDM 0301 RC 84590 HCPCS inpatient 170 110.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.94 164.9 Vitamin B-1 (thiamine) level 48356919_1 CDM 0301 RC 84425 HCPCS inpatient 241 156.65 AETNA AETNA 190.39 79 999999999 145.93 233.77 percent of total billed charges Vitamin B-1 (thiamine) level 48356919_1 CDM 0301 RC 84425 HCPCS inpatient 241 156.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 156.65 65 999999999 145.93 233.77 percent of total billed charges Vitamin B-1 (thiamine) level 48356919_1 CDM 0301 RC 84425 HCPCS inpatient 241 156.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 233.77 97 999999999 145.93 233.77 percent of total billed charges Vitamin B-1 (thiamine) level 48356919_1 CDM 0301 RC 84425 HCPCS inpatient 241 156.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 166.29 69 999999999 145.93 233.77 percent of total billed charges Vitamin B-1 (thiamine) level 48356919_1 CDM 0301 RC 84425 HCPCS inpatient 241 156.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.98 78 999999999 145.93 233.77 percent of total billed charges Vitamin B-1 (thiamine) level 48356919_1 CDM 0301 RC 84425 HCPCS inpatient 241 156.65 SIHO - ALL PLANS SIHO - ALL PLANS 216.9 90 999999999 145.93 233.77 percent of total billed charges Vitamin B-1 (thiamine) level 48356919_1 CDM 0301 RC 84425 HCPCS inpatient 241 156.65 UMR - ALL PLANS UMR - ALL PLANS 168.7 70 999999999 145.93 233.77 percent of total billed charges Vitamin B-1 (thiamine) level 48356919_1 CDM 0301 RC 84425 HCPCS inpatient 241 156.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.93 60.55 999999999 145.93 233.77 percent of total billed charges Vitamin B-1 (thiamine) level 48356919_1 CDM 0301 RC 84425 HCPCS inpatient 241 156.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.93 233.77 Vitamin B-1 (thiamine) level 48356919_1 CDM 0301 RC 84425 HCPCS inpatient 241 156.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.93 233.77 Vitamin B-1 (thiamine) level 48356919_1 CDM 0301 RC 84425 HCPCS inpatient 241 156.65 ANTHEM HMO ANTHEM HMO 999999999 145.93 233.77 Vitamin B-1 (thiamine) level 48356919_1 CDM 0301 RC 84425 HCPCS inpatient 241 156.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.92 67.6 999999999 145.93 233.77 percent of total billed charges Vitamin B-1 (thiamine) level 48356919_1 CDM 0301 RC 84425 HCPCS inpatient 241 156.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.93 233.77 Vitamin B-1 (thiamine) level 48356919_1 CDM 0301 RC 84425 HCPCS inpatient 241 156.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.93 233.77 Vitamin E level 48356920_1 CDM 0301 RC 84446 HCPCS inpatient 171 111.15 AETNA AETNA 135.09 79 999999999 103.54 165.87 percent of total billed charges Vitamin E level 48356920_1 CDM 0301 RC 84446 HCPCS inpatient 171 111.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.15 65 999999999 103.54 165.87 percent of total billed charges Vitamin E level 48356920_1 CDM 0301 RC 84446 HCPCS inpatient 171 111.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 165.87 97 999999999 103.54 165.87 percent of total billed charges Vitamin E level 48356920_1 CDM 0301 RC 84446 HCPCS inpatient 171 111.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.99 69 999999999 103.54 165.87 percent of total billed charges Vitamin E level 48356920_1 CDM 0301 RC 84446 HCPCS inpatient 171 111.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 133.38 78 999999999 103.54 165.87 percent of total billed charges Vitamin E level 48356920_1 CDM 0301 RC 84446 HCPCS inpatient 171 111.15 SIHO - ALL PLANS SIHO - ALL PLANS 153.9 90 999999999 103.54 165.87 percent of total billed charges Vitamin E level 48356920_1 CDM 0301 RC 84446 HCPCS inpatient 171 111.15 UMR - ALL PLANS UMR - ALL PLANS 119.7 70 999999999 103.54 165.87 percent of total billed charges Vitamin E level 48356920_1 CDM 0301 RC 84446 HCPCS inpatient 171 111.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 103.54 60.55 999999999 103.54 165.87 percent of total billed charges Vitamin E level 48356920_1 CDM 0301 RC 84446 HCPCS inpatient 171 111.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 103.54 165.87 Vitamin E level 48356920_1 CDM 0301 RC 84446 HCPCS inpatient 171 111.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 103.54 165.87 Vitamin E level 48356920_1 CDM 0301 RC 84446 HCPCS inpatient 171 111.15 ANTHEM HMO ANTHEM HMO 999999999 103.54 165.87 Vitamin E level 48356920_1 CDM 0301 RC 84446 HCPCS inpatient 171 111.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 115.6 67.6 999999999 103.54 165.87 percent of total billed charges Vitamin E level 48356920_1 CDM 0301 RC 84446 HCPCS inpatient 171 111.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 103.54 165.87 Vitamin E level 48356920_1 CDM 0301 RC 84446 HCPCS inpatient 171 111.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 103.54 165.87 Clotting factor VIII (VW factor) antigen 48356921_1 CDM 0301 RC 85246 HCPCS inpatient 167 108.55 AETNA AETNA 131.93 79 999999999 101.12 161.99 percent of total billed charges Clotting factor VIII (VW factor) antigen 48356921_1 CDM 0301 RC 85246 HCPCS inpatient 167 108.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 108.55 65 999999999 101.12 161.99 percent of total billed charges Clotting factor VIII (VW factor) antigen 48356921_1 CDM 0301 RC 85246 HCPCS inpatient 167 108.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.99 97 999999999 101.12 161.99 percent of total billed charges Clotting factor VIII (VW factor) antigen 48356921_1 CDM 0301 RC 85246 HCPCS inpatient 167 108.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.23 69 999999999 101.12 161.99 percent of total billed charges Clotting factor VIII (VW factor) antigen 48356921_1 CDM 0301 RC 85246 HCPCS inpatient 167 108.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 130.26 78 999999999 101.12 161.99 percent of total billed charges Clotting factor VIII (VW factor) antigen 48356921_1 CDM 0301 RC 85246 HCPCS inpatient 167 108.55 SIHO - ALL PLANS SIHO - ALL PLANS 150.3 90 999999999 101.12 161.99 percent of total billed charges Clotting factor VIII (VW factor) antigen 48356921_1 CDM 0301 RC 85246 HCPCS inpatient 167 108.55 UMR - ALL PLANS UMR - ALL PLANS 116.9 70 999999999 101.12 161.99 percent of total billed charges Clotting factor VIII (VW factor) antigen 48356921_1 CDM 0301 RC 85246 HCPCS inpatient 167 108.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.12 60.55 999999999 101.12 161.99 percent of total billed charges Clotting factor VIII (VW factor) antigen 48356921_1 CDM 0301 RC 85246 HCPCS inpatient 167 108.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.12 161.99 Clotting factor VIII (VW factor) antigen 48356921_1 CDM 0301 RC 85246 HCPCS inpatient 167 108.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.12 161.99 Clotting factor VIII (VW factor) antigen 48356921_1 CDM 0301 RC 85246 HCPCS inpatient 167 108.55 ANTHEM HMO ANTHEM HMO 999999999 101.12 161.99 Clotting factor VIII (VW factor) antigen 48356921_1 CDM 0301 RC 85246 HCPCS inpatient 167 108.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.89 67.6 999999999 101.12 161.99 percent of total billed charges Clotting factor VIII (VW factor) antigen 48356921_1 CDM 0301 RC 85246 HCPCS inpatient 167 108.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.12 161.99 Clotting factor VIII (VW factor) antigen 48356921_1 CDM 0301 RC 85246 HCPCS inpatient 167 108.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.12 161.99 Zinc level 48356924_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 AETNA AETNA 157.21 79 999999999 120.49 193.03 percent of total billed charges Zinc level 48356924_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 129.35 65 999999999 120.49 193.03 percent of total billed charges Zinc level 48356924_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 193.03 97 999999999 120.49 193.03 percent of total billed charges Zinc level 48356924_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 137.31 69 999999999 120.49 193.03 percent of total billed charges Zinc level 48356924_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 155.22 78 999999999 120.49 193.03 percent of total billed charges Zinc level 48356924_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 SIHO - ALL PLANS SIHO - ALL PLANS 179.1 90 999999999 120.49 193.03 percent of total billed charges Zinc level 48356924_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 UMR - ALL PLANS UMR - ALL PLANS 139.3 70 999999999 120.49 193.03 percent of total billed charges Zinc level 48356924_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 120.49 60.55 999999999 120.49 193.03 percent of total billed charges Zinc level 48356924_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 120.49 193.03 Zinc level 48356924_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 120.49 193.03 Zinc level 48356924_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 ANTHEM HMO ANTHEM HMO 999999999 120.49 193.03 Zinc level 48356924_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 134.52 67.6 999999999 120.49 193.03 percent of total billed charges Zinc level 48356924_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 120.49 193.03 Zinc level 48356924_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 120.49 193.03 Zinc level 48356925_1 CDM 0301 RC 84630 HCPCS inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges Zinc level 48356925_1 CDM 0301 RC 84630 HCPCS inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges Zinc level 48356925_1 CDM 0301 RC 84630 HCPCS inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges Zinc level 48356925_1 CDM 0301 RC 84630 HCPCS inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges Zinc level 48356925_1 CDM 0301 RC 84630 HCPCS inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges Zinc level 48356925_1 CDM 0301 RC 84630 HCPCS inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges Zinc level 48356925_1 CDM 0301 RC 84630 HCPCS inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges Zinc level 48356925_1 CDM 0301 RC 84630 HCPCS inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges Zinc level 48356925_1 CDM 0301 RC 84630 HCPCS inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 Zinc level 48356925_1 CDM 0301 RC 84630 HCPCS inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 Zinc level 48356925_1 CDM 0301 RC 84630 HCPCS inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 Zinc level 48356925_1 CDM 0301 RC 84630 HCPCS inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges Zinc level 48356925_1 CDM 0301 RC 84630 HCPCS inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 Zinc level 48356925_1 CDM 0301 RC 84630 HCPCS inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48364648_1 CDM 0450 RC 99156 HCPCS inpatient 562 365.3 AETNA AETNA 443.98 79 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48364648_1 CDM 0450 RC 99156 HCPCS inpatient 562 365.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 365.3 65 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48364648_1 CDM 0450 RC 99156 HCPCS inpatient 562 365.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 545.14 97 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48364648_1 CDM 0450 RC 99156 HCPCS inpatient 562 365.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 387.78 69 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48364648_1 CDM 0450 RC 99156 HCPCS inpatient 562 365.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 438.36 78 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48364648_1 CDM 0450 RC 99156 HCPCS inpatient 562 365.3 SIHO - ALL PLANS SIHO - ALL PLANS 505.8 90 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48364648_1 CDM 0450 RC 99156 HCPCS inpatient 562 365.3 UMR - ALL PLANS UMR - ALL PLANS 393.4 70 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48364648_1 CDM 0450 RC 99156 HCPCS inpatient 562 365.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 340.29 60.55 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48364648_1 CDM 0450 RC 99156 HCPCS inpatient 562 365.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 340.29 545.14 "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48364648_1 CDM 0450 RC 99156 HCPCS inpatient 562 365.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 340.29 545.14 "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48364648_1 CDM 0450 RC 99156 HCPCS inpatient 562 365.3 ANTHEM HMO ANTHEM HMO 999999999 340.29 545.14 "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48364648_1 CDM 0450 RC 99156 HCPCS inpatient 562 365.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 379.91 67.6 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48364648_1 CDM 0450 RC 99156 HCPCS inpatient 562 365.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 340.29 545.14 "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48364648_1 CDM 0450 RC 99156 HCPCS inpatient 562 365.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 340.29 545.14 Vaginal delivery 48373270_1 CDM 0450 RC 59409 HCPCS inpatient 2535 1647.75 AETNA AETNA 2002.65 79 999999999 1534.94 2458.95 percent of total billed charges Vaginal delivery 48373270_1 CDM 0450 RC 59409 HCPCS inpatient 2535 1647.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1647.75 65 999999999 1534.94 2458.95 percent of total billed charges Vaginal delivery 48373270_1 CDM 0450 RC 59409 HCPCS inpatient 2535 1647.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2458.95 97 999999999 1534.94 2458.95 percent of total billed charges Vaginal delivery 48373270_1 CDM 0450 RC 59409 HCPCS inpatient 2535 1647.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1749.15 69 999999999 1534.94 2458.95 percent of total billed charges Vaginal delivery 48373270_1 CDM 0450 RC 59409 HCPCS inpatient 2535 1647.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1977.3 78 999999999 1534.94 2458.95 percent of total billed charges Vaginal delivery 48373270_1 CDM 0450 RC 59409 HCPCS inpatient 2535 1647.75 SIHO - ALL PLANS SIHO - ALL PLANS 2281.5 90 999999999 1534.94 2458.95 percent of total billed charges Vaginal delivery 48373270_1 CDM 0450 RC 59409 HCPCS inpatient 2535 1647.75 UMR - ALL PLANS UMR - ALL PLANS 1774.5 70 999999999 1534.94 2458.95 percent of total billed charges Vaginal delivery 48373270_1 CDM 0450 RC 59409 HCPCS inpatient 2535 1647.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1534.94 60.55 999999999 1534.94 2458.95 percent of total billed charges Vaginal delivery 48373270_1 CDM 0450 RC 59409 HCPCS inpatient 2535 1647.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1534.94 2458.95 Vaginal delivery 48373270_1 CDM 0450 RC 59409 HCPCS inpatient 2535 1647.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1534.94 2458.95 Vaginal delivery 48373270_1 CDM 0450 RC 59409 HCPCS inpatient 2535 1647.75 ANTHEM HMO ANTHEM HMO 999999999 1534.94 2458.95 Vaginal delivery 48373270_1 CDM 0450 RC 59409 HCPCS inpatient 2535 1647.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1713.66 67.6 999999999 1534.94 2458.95 percent of total billed charges Vaginal delivery 48373270_1 CDM 0450 RC 59409 HCPCS inpatient 2535 1647.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1534.94 2458.95 Vaginal delivery 48373270_1 CDM 0450 RC 59409 HCPCS inpatient 2535 1647.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1534.94 2458.95 Analysis for antibody to HIV-1 and HIV-2 virus 48377413_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 AETNA AETNA 121.66 79 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 48377413_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.1 65 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 48377413_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 149.38 97 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 48377413_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.26 69 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 48377413_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.12 78 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 48377413_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 SIHO - ALL PLANS SIHO - ALL PLANS 138.6 90 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 48377413_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 UMR - ALL PLANS UMR - ALL PLANS 107.8 70 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 48377413_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.25 60.55 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 48377413_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.25 149.38 Analysis for antibody to HIV-1 and HIV-2 virus 48377413_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.25 149.38 Analysis for antibody to HIV-1 and HIV-2 virus 48377413_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 ANTHEM HMO ANTHEM HMO 999999999 93.25 149.38 Analysis for antibody to HIV-1 and HIV-2 virus 48377413_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.1 67.6 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 48377413_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.25 149.38 Analysis for antibody to HIV-1 and HIV-2 virus 48377413_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.25 149.38 "Creatine kinase (cardiac enzyme) level, total" 48377759_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 48377759_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 48377759_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 48377759_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 48377759_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 48377759_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 48377759_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 48377759_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 48377759_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 "Creatine kinase (cardiac enzyme) level, total" 48377759_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 "Creatine kinase (cardiac enzyme) level, total" 48377759_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 "Creatine kinase (cardiac enzyme) level, total" 48377759_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 48377759_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 "Creatine kinase (cardiac enzyme) level, total" 48377759_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 Placement of strapping to elbow or wrist 48382184_1 CDM 0420 RC 29260 HCPCS inpatient 404 262.6 AETNA AETNA 319.16 79 999999999 244.62 391.88 percent of total billed charges Placement of strapping to elbow or wrist 48382184_1 CDM 0420 RC 29260 HCPCS inpatient 404 262.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 262.6 65 999999999 244.62 391.88 percent of total billed charges Placement of strapping to elbow or wrist 48382184_1 CDM 0420 RC 29260 HCPCS inpatient 404 262.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 391.88 97 999999999 244.62 391.88 percent of total billed charges Placement of strapping to elbow or wrist 48382184_1 CDM 0420 RC 29260 HCPCS inpatient 404 262.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 278.76 69 999999999 244.62 391.88 percent of total billed charges Placement of strapping to elbow or wrist 48382184_1 CDM 0420 RC 29260 HCPCS inpatient 404 262.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 315.12 78 999999999 244.62 391.88 percent of total billed charges Placement of strapping to elbow or wrist 48382184_1 CDM 0420 RC 29260 HCPCS inpatient 404 262.6 SIHO - ALL PLANS SIHO - ALL PLANS 363.6 90 999999999 244.62 391.88 percent of total billed charges Placement of strapping to elbow or wrist 48382184_1 CDM 0420 RC 29260 HCPCS inpatient 404 262.6 UMR - ALL PLANS UMR - ALL PLANS 282.8 70 999999999 244.62 391.88 percent of total billed charges Placement of strapping to elbow or wrist 48382184_1 CDM 0420 RC 29260 HCPCS inpatient 404 262.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 244.62 60.55 999999999 244.62 391.88 percent of total billed charges Placement of strapping to elbow or wrist 48382184_1 CDM 0420 RC 29260 HCPCS inpatient 404 262.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 244.62 391.88 Placement of strapping to elbow or wrist 48382184_1 CDM 0420 RC 29260 HCPCS inpatient 404 262.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 244.62 391.88 Placement of strapping to elbow or wrist 48382184_1 CDM 0420 RC 29260 HCPCS inpatient 404 262.6 ANTHEM HMO ANTHEM HMO 999999999 244.62 391.88 Placement of strapping to elbow or wrist 48382184_1 CDM 0420 RC 29260 HCPCS inpatient 404 262.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 273.1 67.6 999999999 244.62 391.88 percent of total billed charges Placement of strapping to elbow or wrist 48382184_1 CDM 0420 RC 29260 HCPCS inpatient 404 262.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 244.62 391.88 Placement of strapping to elbow or wrist 48382184_1 CDM 0420 RC 29260 HCPCS inpatient 404 262.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 244.62 391.88 Placement of strapping to knee 48382185_1 CDM 0420 RC 29530 HCPCS inpatient 161 104.65 AETNA AETNA 127.19 79 999999999 97.49 156.17 percent of total billed charges Placement of strapping to knee 48382185_1 CDM 0420 RC 29530 HCPCS inpatient 161 104.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 104.65 65 999999999 97.49 156.17 percent of total billed charges Placement of strapping to knee 48382185_1 CDM 0420 RC 29530 HCPCS inpatient 161 104.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 156.17 97 999999999 97.49 156.17 percent of total billed charges Placement of strapping to knee 48382185_1 CDM 0420 RC 29530 HCPCS inpatient 161 104.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 111.09 69 999999999 97.49 156.17 percent of total billed charges Placement of strapping to knee 48382185_1 CDM 0420 RC 29530 HCPCS inpatient 161 104.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 125.58 78 999999999 97.49 156.17 percent of total billed charges Placement of strapping to knee 48382185_1 CDM 0420 RC 29530 HCPCS inpatient 161 104.65 SIHO - ALL PLANS SIHO - ALL PLANS 144.9 90 999999999 97.49 156.17 percent of total billed charges Placement of strapping to knee 48382185_1 CDM 0420 RC 29530 HCPCS inpatient 161 104.65 UMR - ALL PLANS UMR - ALL PLANS 112.7 70 999999999 97.49 156.17 percent of total billed charges Placement of strapping to knee 48382185_1 CDM 0420 RC 29530 HCPCS inpatient 161 104.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 97.49 60.55 999999999 97.49 156.17 percent of total billed charges Placement of strapping to knee 48382185_1 CDM 0420 RC 29530 HCPCS inpatient 161 104.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 97.49 156.17 Placement of strapping to knee 48382185_1 CDM 0420 RC 29530 HCPCS inpatient 161 104.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 97.49 156.17 Placement of strapping to knee 48382185_1 CDM 0420 RC 29530 HCPCS inpatient 161 104.65 ANTHEM HMO ANTHEM HMO 999999999 97.49 156.17 Placement of strapping to knee 48382185_1 CDM 0420 RC 29530 HCPCS inpatient 161 104.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.84 67.6 999999999 97.49 156.17 percent of total billed charges Placement of strapping to knee 48382185_1 CDM 0420 RC 29530 HCPCS inpatient 161 104.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 97.49 156.17 Placement of strapping to knee 48382185_1 CDM 0420 RC 29530 HCPCS inpatient 161 104.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 97.49 156.17 Other physical medicine or rehabilitation service or procedure 48382187_1 CDM 0420 RC 97799 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges Other physical medicine or rehabilitation service or procedure 48382187_1 CDM 0420 RC 97799 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges Other physical medicine or rehabilitation service or procedure 48382187_1 CDM 0420 RC 97799 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges Other physical medicine or rehabilitation service or procedure 48382187_1 CDM 0420 RC 97799 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges Other physical medicine or rehabilitation service or procedure 48382187_1 CDM 0420 RC 97799 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges Other physical medicine or rehabilitation service or procedure 48382187_1 CDM 0420 RC 97799 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges Other physical medicine or rehabilitation service or procedure 48382187_1 CDM 0420 RC 97799 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges Other physical medicine or rehabilitation service or procedure 48382187_1 CDM 0420 RC 97799 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges Other physical medicine or rehabilitation service or procedure 48382187_1 CDM 0420 RC 97799 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 Other physical medicine or rehabilitation service or procedure 48382187_1 CDM 0420 RC 97799 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 Other physical medicine or rehabilitation service or procedure 48382187_1 CDM 0420 RC 97799 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 Other physical medicine or rehabilitation service or procedure 48382187_1 CDM 0420 RC 97799 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges Other physical medicine or rehabilitation service or procedure 48382187_1 CDM 0420 RC 97799 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 Other physical medicine or rehabilitation service or procedure 48382187_1 CDM 0420 RC 97799 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 Turning of fetus through external manipulation 48383425_1 CDM 0721 RC 59412 HCPCS inpatient 1139 740.35 AETNA AETNA 899.81 79 999999999 689.66 1104.83 percent of total billed charges Turning of fetus through external manipulation 48383425_1 CDM 0721 RC 59412 HCPCS inpatient 1139 740.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 740.35 65 999999999 689.66 1104.83 percent of total billed charges Turning of fetus through external manipulation 48383425_1 CDM 0721 RC 59412 HCPCS inpatient 1139 740.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1104.83 97 999999999 689.66 1104.83 percent of total billed charges Turning of fetus through external manipulation 48383425_1 CDM 0721 RC 59412 HCPCS inpatient 1139 740.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 785.91 69 999999999 689.66 1104.83 percent of total billed charges Turning of fetus through external manipulation 48383425_1 CDM 0721 RC 59412 HCPCS inpatient 1139 740.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 888.42 78 999999999 689.66 1104.83 percent of total billed charges Turning of fetus through external manipulation 48383425_1 CDM 0721 RC 59412 HCPCS inpatient 1139 740.35 SIHO - ALL PLANS SIHO - ALL PLANS 1025.1 90 999999999 689.66 1104.83 percent of total billed charges Turning of fetus through external manipulation 48383425_1 CDM 0721 RC 59412 HCPCS inpatient 1139 740.35 UMR - ALL PLANS UMR - ALL PLANS 797.3 70 999999999 689.66 1104.83 percent of total billed charges Turning of fetus through external manipulation 48383425_1 CDM 0721 RC 59412 HCPCS inpatient 1139 740.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 689.66 60.55 999999999 689.66 1104.83 percent of total billed charges Turning of fetus through external manipulation 48383425_1 CDM 0721 RC 59412 HCPCS inpatient 1139 740.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 689.66 1104.83 Turning of fetus through external manipulation 48383425_1 CDM 0721 RC 59412 HCPCS inpatient 1139 740.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 689.66 1104.83 Turning of fetus through external manipulation 48383425_1 CDM 0721 RC 59412 HCPCS inpatient 1139 740.35 ANTHEM HMO ANTHEM HMO 999999999 689.66 1104.83 Turning of fetus through external manipulation 48383425_1 CDM 0721 RC 59412 HCPCS inpatient 1139 740.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 769.96 67.6 999999999 689.66 1104.83 percent of total billed charges Turning of fetus through external manipulation 48383425_1 CDM 0721 RC 59412 HCPCS inpatient 1139 740.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 689.66 1104.83 Turning of fetus through external manipulation 48383425_1 CDM 0721 RC 59412 HCPCS inpatient 1139 740.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 689.66 1104.83 "Irradiation of blood product, each unit" 48383961_1 CDM 0300 RC 86945 HCPCS inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges "Irradiation of blood product, each unit" 48383961_1 CDM 0300 RC 86945 HCPCS inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges "Irradiation of blood product, each unit" 48383961_1 CDM 0300 RC 86945 HCPCS inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges "Irradiation of blood product, each unit" 48383961_1 CDM 0300 RC 86945 HCPCS inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges "Irradiation of blood product, each unit" 48383961_1 CDM 0300 RC 86945 HCPCS inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges "Irradiation of blood product, each unit" 48383961_1 CDM 0300 RC 86945 HCPCS inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges "Irradiation of blood product, each unit" 48383961_1 CDM 0300 RC 86945 HCPCS inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges "Irradiation of blood product, each unit" 48383961_1 CDM 0300 RC 86945 HCPCS inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges "Irradiation of blood product, each unit" 48383961_1 CDM 0300 RC 86945 HCPCS inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 "Irradiation of blood product, each unit" 48383961_1 CDM 0300 RC 86945 HCPCS inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 "Irradiation of blood product, each unit" 48383961_1 CDM 0300 RC 86945 HCPCS inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 "Irradiation of blood product, each unit" 48383961_1 CDM 0300 RC 86945 HCPCS inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges "Irradiation of blood product, each unit" 48383961_1 CDM 0300 RC 86945 HCPCS inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 "Irradiation of blood product, each unit" 48383961_1 CDM 0300 RC 86945 HCPCS inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 Placement of strapping to ankle or foot 48384767_1 CDM 0420 RC 29540 HCPCS inpatient 218 141.7 AETNA AETNA 172.22 79 999999999 132 211.46 percent of total billed charges Placement of strapping to ankle or foot 48384767_1 CDM 0420 RC 29540 HCPCS inpatient 218 141.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 141.7 65 999999999 132 211.46 percent of total billed charges Placement of strapping to ankle or foot 48384767_1 CDM 0420 RC 29540 HCPCS inpatient 218 141.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 211.46 97 999999999 132 211.46 percent of total billed charges Placement of strapping to ankle or foot 48384767_1 CDM 0420 RC 29540 HCPCS inpatient 218 141.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 150.42 69 999999999 132 211.46 percent of total billed charges Placement of strapping to ankle or foot 48384767_1 CDM 0420 RC 29540 HCPCS inpatient 218 141.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.04 78 999999999 132 211.46 percent of total billed charges Placement of strapping to ankle or foot 48384767_1 CDM 0420 RC 29540 HCPCS inpatient 218 141.7 SIHO - ALL PLANS SIHO - ALL PLANS 196.2 90 999999999 132 211.46 percent of total billed charges Placement of strapping to ankle or foot 48384767_1 CDM 0420 RC 29540 HCPCS inpatient 218 141.7 UMR - ALL PLANS UMR - ALL PLANS 152.6 70 999999999 132 211.46 percent of total billed charges Placement of strapping to ankle or foot 48384767_1 CDM 0420 RC 29540 HCPCS inpatient 218 141.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132 60.55 999999999 132 211.46 percent of total billed charges Placement of strapping to ankle or foot 48384767_1 CDM 0420 RC 29540 HCPCS inpatient 218 141.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132 211.46 Placement of strapping to ankle or foot 48384767_1 CDM 0420 RC 29540 HCPCS inpatient 218 141.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132 211.46 Placement of strapping to ankle or foot 48384767_1 CDM 0420 RC 29540 HCPCS inpatient 218 141.7 ANTHEM HMO ANTHEM HMO 999999999 132 211.46 Placement of strapping to ankle or foot 48384767_1 CDM 0420 RC 29540 HCPCS inpatient 218 141.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 147.37 67.6 999999999 132 211.46 percent of total billed charges Placement of strapping to ankle or foot 48384767_1 CDM 0420 RC 29540 HCPCS inpatient 218 141.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132 211.46 Placement of strapping to ankle or foot 48384767_1 CDM 0420 RC 29540 HCPCS inpatient 218 141.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 132 211.46 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48387394_1 CDM 0390 RC P9017 HCPCS inpatient 350 227.5 AETNA AETNA 276.5 79 999999999 211.93 339.5 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48387394_1 CDM 0390 RC P9017 HCPCS inpatient 350 227.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 227.5 65 999999999 211.93 339.5 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48387394_1 CDM 0390 RC P9017 HCPCS inpatient 350 227.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 339.5 97 999999999 211.93 339.5 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48387394_1 CDM 0390 RC P9017 HCPCS inpatient 350 227.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 241.5 69 999999999 211.93 339.5 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48387394_1 CDM 0390 RC P9017 HCPCS inpatient 350 227.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 273 78 999999999 211.93 339.5 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48387394_1 CDM 0390 RC P9017 HCPCS inpatient 350 227.5 SIHO - ALL PLANS SIHO - ALL PLANS 315 90 999999999 211.93 339.5 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48387394_1 CDM 0390 RC P9017 HCPCS inpatient 350 227.5 UMR - ALL PLANS UMR - ALL PLANS 245 70 999999999 211.93 339.5 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48387394_1 CDM 0390 RC P9017 HCPCS inpatient 350 227.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 211.93 60.55 999999999 211.93 339.5 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48387394_1 CDM 0390 RC P9017 HCPCS inpatient 350 227.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 211.93 339.5 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48387394_1 CDM 0390 RC P9017 HCPCS inpatient 350 227.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 211.93 339.5 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48387394_1 CDM 0390 RC P9017 HCPCS inpatient 350 227.5 ANTHEM HMO ANTHEM HMO 999999999 211.93 339.5 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48387394_1 CDM 0390 RC P9017 HCPCS inpatient 350 227.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 236.6 67.6 999999999 211.93 339.5 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48387394_1 CDM 0390 RC P9017 HCPCS inpatient 350 227.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 211.93 339.5 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48387394_1 CDM 0390 RC P9017 HCPCS inpatient 350 227.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 211.93 339.5 Reticulated (young) platelet measurement 48387591_1 CDM 0305 RC 85055 HCPCS inpatient 58 37.7 AETNA AETNA 45.82 79 999999999 35.12 56.26 percent of total billed charges Reticulated (young) platelet measurement 48387591_1 CDM 0305 RC 85055 HCPCS inpatient 58 37.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.7 65 999999999 35.12 56.26 percent of total billed charges Reticulated (young) platelet measurement 48387591_1 CDM 0305 RC 85055 HCPCS inpatient 58 37.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.26 97 999999999 35.12 56.26 percent of total billed charges Reticulated (young) platelet measurement 48387591_1 CDM 0305 RC 85055 HCPCS inpatient 58 37.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.02 69 999999999 35.12 56.26 percent of total billed charges Reticulated (young) platelet measurement 48387591_1 CDM 0305 RC 85055 HCPCS inpatient 58 37.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.24 78 999999999 35.12 56.26 percent of total billed charges Reticulated (young) platelet measurement 48387591_1 CDM 0305 RC 85055 HCPCS inpatient 58 37.7 SIHO - ALL PLANS SIHO - ALL PLANS 52.2 90 999999999 35.12 56.26 percent of total billed charges Reticulated (young) platelet measurement 48387591_1 CDM 0305 RC 85055 HCPCS inpatient 58 37.7 UMR - ALL PLANS UMR - ALL PLANS 40.6 70 999999999 35.12 56.26 percent of total billed charges Reticulated (young) platelet measurement 48387591_1 CDM 0305 RC 85055 HCPCS inpatient 58 37.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.12 60.55 999999999 35.12 56.26 percent of total billed charges Reticulated (young) platelet measurement 48387591_1 CDM 0305 RC 85055 HCPCS inpatient 58 37.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.12 56.26 Reticulated (young) platelet measurement 48387591_1 CDM 0305 RC 85055 HCPCS inpatient 58 37.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.12 56.26 Reticulated (young) platelet measurement 48387591_1 CDM 0305 RC 85055 HCPCS inpatient 58 37.7 ANTHEM HMO ANTHEM HMO 999999999 35.12 56.26 Reticulated (young) platelet measurement 48387591_1 CDM 0305 RC 85055 HCPCS inpatient 58 37.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.21 67.6 999999999 35.12 56.26 percent of total billed charges Reticulated (young) platelet measurement 48387591_1 CDM 0305 RC 85055 HCPCS inpatient 58 37.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.12 56.26 Reticulated (young) platelet measurement 48387591_1 CDM 0305 RC 85055 HCPCS inpatient 58 37.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.12 56.26 Microscopic examination for white blood cells with manual cell count 48394544_1 CDM 0305 RC 85007 HCPCS inpatient 85 55.25 AETNA AETNA 67.15 79 999999999 51.47 82.45 percent of total billed charges Microscopic examination for white blood cells with manual cell count 48394544_1 CDM 0305 RC 85007 HCPCS inpatient 85 55.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.25 65 999999999 51.47 82.45 percent of total billed charges Microscopic examination for white blood cells with manual cell count 48394544_1 CDM 0305 RC 85007 HCPCS inpatient 85 55.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 82.45 97 999999999 51.47 82.45 percent of total billed charges Microscopic examination for white blood cells with manual cell count 48394544_1 CDM 0305 RC 85007 HCPCS inpatient 85 55.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 58.65 69 999999999 51.47 82.45 percent of total billed charges Microscopic examination for white blood cells with manual cell count 48394544_1 CDM 0305 RC 85007 HCPCS inpatient 85 55.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 66.3 78 999999999 51.47 82.45 percent of total billed charges Microscopic examination for white blood cells with manual cell count 48394544_1 CDM 0305 RC 85007 HCPCS inpatient 85 55.25 SIHO - ALL PLANS SIHO - ALL PLANS 76.5 90 999999999 51.47 82.45 percent of total billed charges Microscopic examination for white blood cells with manual cell count 48394544_1 CDM 0305 RC 85007 HCPCS inpatient 85 55.25 UMR - ALL PLANS UMR - ALL PLANS 59.5 70 999999999 51.47 82.45 percent of total billed charges Microscopic examination for white blood cells with manual cell count 48394544_1 CDM 0305 RC 85007 HCPCS inpatient 85 55.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 51.47 60.55 999999999 51.47 82.45 percent of total billed charges Microscopic examination for white blood cells with manual cell count 48394544_1 CDM 0305 RC 85007 HCPCS inpatient 85 55.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 51.47 82.45 Microscopic examination for white blood cells with manual cell count 48394544_1 CDM 0305 RC 85007 HCPCS inpatient 85 55.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 51.47 82.45 Microscopic examination for white blood cells with manual cell count 48394544_1 CDM 0305 RC 85007 HCPCS inpatient 85 55.25 ANTHEM HMO ANTHEM HMO 999999999 51.47 82.45 Microscopic examination for white blood cells with manual cell count 48394544_1 CDM 0305 RC 85007 HCPCS inpatient 85 55.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 57.46 67.6 999999999 51.47 82.45 percent of total billed charges Microscopic examination for white blood cells with manual cell count 48394544_1 CDM 0305 RC 85007 HCPCS inpatient 85 55.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 51.47 82.45 Microscopic examination for white blood cells with manual cell count 48394544_1 CDM 0305 RC 85007 HCPCS inpatient 85 55.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 51.47 82.45 AMPICILLIN 500 MG VIAL 48394925_1 CDM 0250 RC 00781-9407-95 NDC inpatient 1 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges AMPICILLIN 500 MG VIAL 48394925_1 CDM 0250 RC 00781-9407-95 NDC inpatient 1 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges AMPICILLIN 500 MG VIAL 48394925_1 CDM 0250 RC 00781-9407-95 NDC inpatient 1 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges AMPICILLIN 500 MG VIAL 48394925_1 CDM 0250 RC 00781-9407-95 NDC inpatient 1 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges AMPICILLIN 500 MG VIAL 48394925_1 CDM 0250 RC 00781-9407-95 NDC inpatient 1 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges AMPICILLIN 500 MG VIAL 48394925_1 CDM 0250 RC 00781-9407-95 NDC inpatient 1 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges AMPICILLIN 500 MG VIAL 48394925_1 CDM 0250 RC 00781-9407-95 NDC inpatient 1 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges AMPICILLIN 500 MG VIAL 48394925_1 CDM 0250 RC 00781-9407-95 NDC inpatient 1 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges AMPICILLIN 500 MG VIAL 48394925_1 CDM 0250 RC 00781-9407-95 NDC inpatient 1 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 AMPICILLIN 500 MG VIAL 48394925_1 CDM 0250 RC 00781-9407-95 NDC inpatient 1 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 AMPICILLIN 500 MG VIAL 48394925_1 CDM 0250 RC 00781-9407-95 NDC inpatient 1 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 AMPICILLIN 500 MG VIAL 48394925_1 CDM 0250 RC 00781-9407-95 NDC inpatient 1 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges AMPICILLIN 500 MG VIAL 48394925_1 CDM 0250 RC 00781-9407-95 NDC inpatient 1 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 AMPICILLIN 500 MG VIAL 48394925_1 CDM 0250 RC 00781-9407-95 NDC inpatient 1 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 Ultrasound of one arm arteries or artery grafts 48396406_1 CDM 0402 RC 93931 HCPCS inpatient 391 254.15 AETNA AETNA 308.89 79 999999999 236.75 379.27 percent of total billed charges Ultrasound of one arm arteries or artery grafts 48396406_1 CDM 0402 RC 93931 HCPCS inpatient 391 254.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 254.15 65 999999999 236.75 379.27 percent of total billed charges Ultrasound of one arm arteries or artery grafts 48396406_1 CDM 0402 RC 93931 HCPCS inpatient 391 254.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 379.27 97 999999999 236.75 379.27 percent of total billed charges Ultrasound of one arm arteries or artery grafts 48396406_1 CDM 0402 RC 93931 HCPCS inpatient 391 254.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 269.79 69 999999999 236.75 379.27 percent of total billed charges Ultrasound of one arm arteries or artery grafts 48396406_1 CDM 0402 RC 93931 HCPCS inpatient 391 254.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 304.98 78 999999999 236.75 379.27 percent of total billed charges Ultrasound of one arm arteries or artery grafts 48396406_1 CDM 0402 RC 93931 HCPCS inpatient 391 254.15 SIHO - ALL PLANS SIHO - ALL PLANS 351.9 90 999999999 236.75 379.27 percent of total billed charges Ultrasound of one arm arteries or artery grafts 48396406_1 CDM 0402 RC 93931 HCPCS inpatient 391 254.15 UMR - ALL PLANS UMR - ALL PLANS 273.7 70 999999999 236.75 379.27 percent of total billed charges Ultrasound of one arm arteries or artery grafts 48396406_1 CDM 0402 RC 93931 HCPCS inpatient 391 254.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 236.75 60.55 999999999 236.75 379.27 percent of total billed charges Ultrasound of one arm arteries or artery grafts 48396406_1 CDM 0402 RC 93931 HCPCS inpatient 391 254.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 236.75 379.27 Ultrasound of one arm arteries or artery grafts 48396406_1 CDM 0402 RC 93931 HCPCS inpatient 391 254.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 236.75 379.27 Ultrasound of one arm arteries or artery grafts 48396406_1 CDM 0402 RC 93931 HCPCS inpatient 391 254.15 ANTHEM HMO ANTHEM HMO 999999999 236.75 379.27 Ultrasound of one arm arteries or artery grafts 48396406_1 CDM 0402 RC 93931 HCPCS inpatient 391 254.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 264.32 67.6 999999999 236.75 379.27 percent of total billed charges Ultrasound of one arm arteries or artery grafts 48396406_1 CDM 0402 RC 93931 HCPCS inpatient 391 254.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 236.75 379.27 Ultrasound of one arm arteries or artery grafts 48396406_1 CDM 0402 RC 93931 HCPCS inpatient 391 254.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 236.75 379.27 Ultrasonic guidance for needle placement 48401863_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48401863_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48401863_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48401863_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48401863_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48401863_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48401863_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48401863_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48401863_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48401863_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48401863_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48401863_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48401863_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48401863_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Removal of impacted ear wax by washing 48416035_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 AETNA AETNA 114.55 79 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 48416035_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.25 65 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 48416035_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 140.65 97 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 48416035_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.05 69 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 48416035_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.1 78 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 48416035_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 SIHO - ALL PLANS SIHO - ALL PLANS 130.5 90 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 48416035_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 UMR - ALL PLANS UMR - ALL PLANS 101.5 70 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 48416035_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.8 60.55 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 48416035_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.8 140.65 Removal of impacted ear wax by washing 48416035_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.8 140.65 Removal of impacted ear wax by washing 48416035_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 ANTHEM HMO ANTHEM HMO 999999999 87.8 140.65 Removal of impacted ear wax by washing 48416035_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.02 67.6 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 48416035_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.8 140.65 Removal of impacted ear wax by washing 48416035_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.8 140.65 "Red blood cell antibody detection test, direct" 48419467_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 48419467_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 48419467_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 48419467_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 48419467_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 48419467_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 48419467_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 48419467_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 48419467_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 "Red blood cell antibody detection test, direct" 48419467_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 "Red blood cell antibody detection test, direct" 48419467_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 "Red blood cell antibody detection test, direct" 48419467_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 48419467_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 "Red blood cell antibody detection test, direct" 48419467_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 "Red blood cell antibody detection test, direct" 48419470_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 48419470_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 48419470_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 48419470_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 48419470_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 48419470_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 48419470_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 48419470_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 48419470_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Red blood cell antibody detection test, direct" 48419470_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Red blood cell antibody detection test, direct" 48419470_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Red blood cell antibody detection test, direct" 48419470_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Red blood cell antibody detection test, direct" 48419470_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Red blood cell antibody detection test, direct" 48419470_1 CDM 0302 RC 86880 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 Blood typing for red blood cell antigens 48419477_1 CDM 0302 RC 86905 HCPCS inpatient 319 207.35 AETNA AETNA 252.01 79 999999999 193.15 309.43 percent of total billed charges Blood typing for red blood cell antigens 48419477_1 CDM 0302 RC 86905 HCPCS inpatient 319 207.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 207.35 65 999999999 193.15 309.43 percent of total billed charges Blood typing for red blood cell antigens 48419477_1 CDM 0302 RC 86905 HCPCS inpatient 319 207.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 309.43 97 999999999 193.15 309.43 percent of total billed charges Blood typing for red blood cell antigens 48419477_1 CDM 0302 RC 86905 HCPCS inpatient 319 207.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 220.11 69 999999999 193.15 309.43 percent of total billed charges Blood typing for red blood cell antigens 48419477_1 CDM 0302 RC 86905 HCPCS inpatient 319 207.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 248.82 78 999999999 193.15 309.43 percent of total billed charges Blood typing for red blood cell antigens 48419477_1 CDM 0302 RC 86905 HCPCS inpatient 319 207.35 SIHO - ALL PLANS SIHO - ALL PLANS 287.1 90 999999999 193.15 309.43 percent of total billed charges Blood typing for red blood cell antigens 48419477_1 CDM 0302 RC 86905 HCPCS inpatient 319 207.35 UMR - ALL PLANS UMR - ALL PLANS 223.3 70 999999999 193.15 309.43 percent of total billed charges Blood typing for red blood cell antigens 48419477_1 CDM 0302 RC 86905 HCPCS inpatient 319 207.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 193.15 60.55 999999999 193.15 309.43 percent of total billed charges Blood typing for red blood cell antigens 48419477_1 CDM 0302 RC 86905 HCPCS inpatient 319 207.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 193.15 309.43 Blood typing for red blood cell antigens 48419477_1 CDM 0302 RC 86905 HCPCS inpatient 319 207.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 193.15 309.43 Blood typing for red blood cell antigens 48419477_1 CDM 0302 RC 86905 HCPCS inpatient 319 207.35 ANTHEM HMO ANTHEM HMO 999999999 193.15 309.43 Blood typing for red blood cell antigens 48419477_1 CDM 0302 RC 86905 HCPCS inpatient 319 207.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 215.64 67.6 999999999 193.15 309.43 percent of total billed charges Blood typing for red blood cell antigens 48419477_1 CDM 0302 RC 86905 HCPCS inpatient 319 207.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 193.15 309.43 Blood typing for red blood cell antigens 48419477_1 CDM 0302 RC 86905 HCPCS inpatient 319 207.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 193.15 309.43 "Red blood cell antibody detection test, direct" 48419491_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 48419491_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 48419491_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 48419491_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 48419491_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 48419491_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 48419491_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 48419491_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 48419491_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 "Red blood cell antibody detection test, direct" 48419491_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 "Red blood cell antibody detection test, direct" 48419491_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 "Red blood cell antibody detection test, direct" 48419491_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges "Red blood cell antibody detection test, direct" 48419491_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 "Red blood cell antibody detection test, direct" 48419491_1 CDM 0302 RC 86880 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 Red blood cell antibody level 48419513_1 CDM 0302 RC 86886 HCPCS inpatient 188 122.2 AETNA AETNA 148.52 79 999999999 113.83 182.36 percent of total billed charges Red blood cell antibody level 48419513_1 CDM 0302 RC 86886 HCPCS inpatient 188 122.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.2 65 999999999 113.83 182.36 percent of total billed charges Red blood cell antibody level 48419513_1 CDM 0302 RC 86886 HCPCS inpatient 188 122.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 182.36 97 999999999 113.83 182.36 percent of total billed charges Red blood cell antibody level 48419513_1 CDM 0302 RC 86886 HCPCS inpatient 188 122.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.72 69 999999999 113.83 182.36 percent of total billed charges Red blood cell antibody level 48419513_1 CDM 0302 RC 86886 HCPCS inpatient 188 122.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 146.64 78 999999999 113.83 182.36 percent of total billed charges Red blood cell antibody level 48419513_1 CDM 0302 RC 86886 HCPCS inpatient 188 122.2 SIHO - ALL PLANS SIHO - ALL PLANS 169.2 90 999999999 113.83 182.36 percent of total billed charges Red blood cell antibody level 48419513_1 CDM 0302 RC 86886 HCPCS inpatient 188 122.2 UMR - ALL PLANS UMR - ALL PLANS 131.6 70 999999999 113.83 182.36 percent of total billed charges Red blood cell antibody level 48419513_1 CDM 0302 RC 86886 HCPCS inpatient 188 122.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.83 60.55 999999999 113.83 182.36 percent of total billed charges Red blood cell antibody level 48419513_1 CDM 0302 RC 86886 HCPCS inpatient 188 122.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.83 182.36 Red blood cell antibody level 48419513_1 CDM 0302 RC 86886 HCPCS inpatient 188 122.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.83 182.36 Red blood cell antibody level 48419513_1 CDM 0302 RC 86886 HCPCS inpatient 188 122.2 ANTHEM HMO ANTHEM HMO 999999999 113.83 182.36 Red blood cell antibody level 48419513_1 CDM 0302 RC 86886 HCPCS inpatient 188 122.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.09 67.6 999999999 113.83 182.36 percent of total billed charges Red blood cell antibody level 48419513_1 CDM 0302 RC 86886 HCPCS inpatient 188 122.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.83 182.36 Red blood cell antibody level 48419513_1 CDM 0302 RC 86886 HCPCS inpatient 188 122.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.83 182.36 Blood typing for red blood cell antigens 48419521_1 CDM 0300 RC 86905 HCPCS inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges Blood typing for red blood cell antigens 48419521_1 CDM 0300 RC 86905 HCPCS inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges Blood typing for red blood cell antigens 48419521_1 CDM 0300 RC 86905 HCPCS inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges Blood typing for red blood cell antigens 48419521_1 CDM 0300 RC 86905 HCPCS inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges Blood typing for red blood cell antigens 48419521_1 CDM 0300 RC 86905 HCPCS inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges Blood typing for red blood cell antigens 48419521_1 CDM 0300 RC 86905 HCPCS inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges Blood typing for red blood cell antigens 48419521_1 CDM 0300 RC 86905 HCPCS inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges Blood typing for red blood cell antigens 48419521_1 CDM 0300 RC 86905 HCPCS inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges Blood typing for red blood cell antigens 48419521_1 CDM 0300 RC 86905 HCPCS inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 Blood typing for red blood cell antigens 48419521_1 CDM 0300 RC 86905 HCPCS inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 Blood typing for red blood cell antigens 48419521_1 CDM 0300 RC 86905 HCPCS inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 Blood typing for red blood cell antigens 48419521_1 CDM 0300 RC 86905 HCPCS inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges Blood typing for red blood cell antigens 48419521_1 CDM 0300 RC 86905 HCPCS inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 Blood typing for red blood cell antigens 48419521_1 CDM 0300 RC 86905 HCPCS inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 48419526_1 CDM 0300 RC 86971 HCPCS inpatient 385 250.25 AETNA AETNA 304.15 79 999999999 233.12 373.45 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 48419526_1 CDM 0300 RC 86971 HCPCS inpatient 385 250.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 250.25 65 999999999 233.12 373.45 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 48419526_1 CDM 0300 RC 86971 HCPCS inpatient 385 250.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 373.45 97 999999999 233.12 373.45 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 48419526_1 CDM 0300 RC 86971 HCPCS inpatient 385 250.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 265.65 69 999999999 233.12 373.45 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 48419526_1 CDM 0300 RC 86971 HCPCS inpatient 385 250.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 300.3 78 999999999 233.12 373.45 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 48419526_1 CDM 0300 RC 86971 HCPCS inpatient 385 250.25 SIHO - ALL PLANS SIHO - ALL PLANS 346.5 90 999999999 233.12 373.45 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 48419526_1 CDM 0300 RC 86971 HCPCS inpatient 385 250.25 UMR - ALL PLANS UMR - ALL PLANS 269.5 70 999999999 233.12 373.45 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 48419526_1 CDM 0300 RC 86971 HCPCS inpatient 385 250.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 233.12 60.55 999999999 233.12 373.45 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 48419526_1 CDM 0300 RC 86971 HCPCS inpatient 385 250.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 233.12 373.45 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 48419526_1 CDM 0300 RC 86971 HCPCS inpatient 385 250.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 233.12 373.45 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 48419526_1 CDM 0300 RC 86971 HCPCS inpatient 385 250.25 ANTHEM HMO ANTHEM HMO 999999999 233.12 373.45 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 48419526_1 CDM 0300 RC 86971 HCPCS inpatient 385 250.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 260.26 67.6 999999999 233.12 373.45 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 48419526_1 CDM 0300 RC 86971 HCPCS inpatient 385 250.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 233.12 373.45 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 48419526_1 CDM 0300 RC 86971 HCPCS inpatient 385 250.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 233.12 373.45 Removal of antibodies from surface of red blood cell 48419528_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 AETNA AETNA 421.86 79 999999999 323.34 517.98 percent of total billed charges Removal of antibodies from surface of red blood cell 48419528_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 347.1 65 999999999 323.34 517.98 percent of total billed charges Removal of antibodies from surface of red blood cell 48419528_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 517.98 97 999999999 323.34 517.98 percent of total billed charges Removal of antibodies from surface of red blood cell 48419528_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 368.46 69 999999999 323.34 517.98 percent of total billed charges Removal of antibodies from surface of red blood cell 48419528_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 416.52 78 999999999 323.34 517.98 percent of total billed charges Removal of antibodies from surface of red blood cell 48419528_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 SIHO - ALL PLANS SIHO - ALL PLANS 480.6 90 999999999 323.34 517.98 percent of total billed charges Removal of antibodies from surface of red blood cell 48419528_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 UMR - ALL PLANS UMR - ALL PLANS 373.8 70 999999999 323.34 517.98 percent of total billed charges Removal of antibodies from surface of red blood cell 48419528_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 323.34 60.55 999999999 323.34 517.98 percent of total billed charges Removal of antibodies from surface of red blood cell 48419528_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 323.34 517.98 Removal of antibodies from surface of red blood cell 48419528_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 323.34 517.98 Removal of antibodies from surface of red blood cell 48419528_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 ANTHEM HMO ANTHEM HMO 999999999 323.34 517.98 Removal of antibodies from surface of red blood cell 48419528_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 360.98 67.6 999999999 323.34 517.98 percent of total billed charges Removal of antibodies from surface of red blood cell 48419528_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 323.34 517.98 Removal of antibodies from surface of red blood cell 48419528_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 323.34 517.98 Blood gases measurement 48421427_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 AETNA AETNA 206.19 79 999999999 158.04 253.17 percent of total billed charges Blood gases measurement 48421427_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 169.65 65 999999999 158.04 253.17 percent of total billed charges Blood gases measurement 48421427_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 253.17 97 999999999 158.04 253.17 percent of total billed charges Blood gases measurement 48421427_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.09 69 999999999 158.04 253.17 percent of total billed charges Blood gases measurement 48421427_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 203.58 78 999999999 158.04 253.17 percent of total billed charges Blood gases measurement 48421427_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 SIHO - ALL PLANS SIHO - ALL PLANS 234.9 90 999999999 158.04 253.17 percent of total billed charges Blood gases measurement 48421427_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 UMR - ALL PLANS UMR - ALL PLANS 182.7 70 999999999 158.04 253.17 percent of total billed charges Blood gases measurement 48421427_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.04 60.55 999999999 158.04 253.17 percent of total billed charges Blood gases measurement 48421427_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.04 253.17 Blood gases measurement 48421427_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.04 253.17 Blood gases measurement 48421427_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 ANTHEM HMO ANTHEM HMO 999999999 158.04 253.17 Blood gases measurement 48421427_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 176.44 67.6 999999999 158.04 253.17 percent of total billed charges Blood gases measurement 48421427_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.04 253.17 Blood gases measurement 48421427_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.04 253.17 Blood gases measurement 48429458_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 AETNA AETNA 206.19 79 999999999 158.04 253.17 percent of total billed charges Blood gases measurement 48429458_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 169.65 65 999999999 158.04 253.17 percent of total billed charges Blood gases measurement 48429458_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 253.17 97 999999999 158.04 253.17 percent of total billed charges Blood gases measurement 48429458_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.09 69 999999999 158.04 253.17 percent of total billed charges Blood gases measurement 48429458_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 203.58 78 999999999 158.04 253.17 percent of total billed charges Blood gases measurement 48429458_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 SIHO - ALL PLANS SIHO - ALL PLANS 234.9 90 999999999 158.04 253.17 percent of total billed charges Blood gases measurement 48429458_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 UMR - ALL PLANS UMR - ALL PLANS 182.7 70 999999999 158.04 253.17 percent of total billed charges Blood gases measurement 48429458_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.04 60.55 999999999 158.04 253.17 percent of total billed charges Blood gases measurement 48429458_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.04 253.17 Blood gases measurement 48429458_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.04 253.17 Blood gases measurement 48429458_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 ANTHEM HMO ANTHEM HMO 999999999 158.04 253.17 Blood gases measurement 48429458_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 176.44 67.6 999999999 158.04 253.17 percent of total billed charges Blood gases measurement 48429458_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.04 253.17 Blood gases measurement 48429458_1 CDM 0301 RC 82803 HCPCS inpatient 261 169.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.04 253.17 "Bone marrow, smear interpretation" 48435155_1 CDM 0312 RC 85097 HCPCS inpatient 1145 744.25 AETNA AETNA 904.55 79 999999999 693.3 1110.65 percent of total billed charges "Bone marrow, smear interpretation" 48435155_1 CDM 0312 RC 85097 HCPCS inpatient 1145 744.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 744.25 65 999999999 693.3 1110.65 percent of total billed charges "Bone marrow, smear interpretation" 48435155_1 CDM 0312 RC 85097 HCPCS inpatient 1145 744.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1110.65 97 999999999 693.3 1110.65 percent of total billed charges "Bone marrow, smear interpretation" 48435155_1 CDM 0312 RC 85097 HCPCS inpatient 1145 744.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 790.05 69 999999999 693.3 1110.65 percent of total billed charges "Bone marrow, smear interpretation" 48435155_1 CDM 0312 RC 85097 HCPCS inpatient 1145 744.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 893.1 78 999999999 693.3 1110.65 percent of total billed charges "Bone marrow, smear interpretation" 48435155_1 CDM 0312 RC 85097 HCPCS inpatient 1145 744.25 SIHO - ALL PLANS SIHO - ALL PLANS 1030.5 90 999999999 693.3 1110.65 percent of total billed charges "Bone marrow, smear interpretation" 48435155_1 CDM 0312 RC 85097 HCPCS inpatient 1145 744.25 UMR - ALL PLANS UMR - ALL PLANS 801.5 70 999999999 693.3 1110.65 percent of total billed charges "Bone marrow, smear interpretation" 48435155_1 CDM 0312 RC 85097 HCPCS inpatient 1145 744.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 693.3 60.55 999999999 693.3 1110.65 percent of total billed charges "Bone marrow, smear interpretation" 48435155_1 CDM 0312 RC 85097 HCPCS inpatient 1145 744.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 693.3 1110.65 "Bone marrow, smear interpretation" 48435155_1 CDM 0312 RC 85097 HCPCS inpatient 1145 744.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 693.3 1110.65 "Bone marrow, smear interpretation" 48435155_1 CDM 0312 RC 85097 HCPCS inpatient 1145 744.25 ANTHEM HMO ANTHEM HMO 999999999 693.3 1110.65 "Bone marrow, smear interpretation" 48435155_1 CDM 0312 RC 85097 HCPCS inpatient 1145 744.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 774.02 67.6 999999999 693.3 1110.65 percent of total billed charges "Bone marrow, smear interpretation" 48435155_1 CDM 0312 RC 85097 HCPCS inpatient 1145 744.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 693.3 1110.65 "Bone marrow, smear interpretation" 48435155_1 CDM 0312 RC 85097 HCPCS inpatient 1145 744.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 693.3 1110.65 "Creatine kinase (cardiac enzyme) level, MB fraction only" 48440521_1 CDM 0301 RC 82553 HCPCS inpatient 261 169.65 AETNA AETNA 206.19 79 999999999 158.04 253.17 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 48440521_1 CDM 0301 RC 82553 HCPCS inpatient 261 169.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 169.65 65 999999999 158.04 253.17 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 48440521_1 CDM 0301 RC 82553 HCPCS inpatient 261 169.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 253.17 97 999999999 158.04 253.17 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 48440521_1 CDM 0301 RC 82553 HCPCS inpatient 261 169.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.09 69 999999999 158.04 253.17 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 48440521_1 CDM 0301 RC 82553 HCPCS inpatient 261 169.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 203.58 78 999999999 158.04 253.17 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 48440521_1 CDM 0301 RC 82553 HCPCS inpatient 261 169.65 SIHO - ALL PLANS SIHO - ALL PLANS 234.9 90 999999999 158.04 253.17 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 48440521_1 CDM 0301 RC 82553 HCPCS inpatient 261 169.65 UMR - ALL PLANS UMR - ALL PLANS 182.7 70 999999999 158.04 253.17 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 48440521_1 CDM 0301 RC 82553 HCPCS inpatient 261 169.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.04 60.55 999999999 158.04 253.17 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 48440521_1 CDM 0301 RC 82553 HCPCS inpatient 261 169.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.04 253.17 "Creatine kinase (cardiac enzyme) level, MB fraction only" 48440521_1 CDM 0301 RC 82553 HCPCS inpatient 261 169.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.04 253.17 "Creatine kinase (cardiac enzyme) level, MB fraction only" 48440521_1 CDM 0301 RC 82553 HCPCS inpatient 261 169.65 ANTHEM HMO ANTHEM HMO 999999999 158.04 253.17 "Creatine kinase (cardiac enzyme) level, MB fraction only" 48440521_1 CDM 0301 RC 82553 HCPCS inpatient 261 169.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 176.44 67.6 999999999 158.04 253.17 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 48440521_1 CDM 0301 RC 82553 HCPCS inpatient 261 169.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.04 253.17 "Creatine kinase (cardiac enzyme) level, MB fraction only" 48440521_1 CDM 0301 RC 82553 HCPCS inpatient 261 169.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.04 253.17 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48440707_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48440707_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48440707_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48440707_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48440707_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48440707_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48440707_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48440707_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48440707_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48440707_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48440707_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48440707_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48440707_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48440707_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 RECOVERY ROOM - GENERAL CLASSIFICATION 48440826_1 CDM 0710 RC inpatient 12.79 8.31 AETNA AETNA 10.1 79 999999999 7.74 12.41 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440826_1 CDM 0710 RC inpatient 12.79 8.31 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.31 65 999999999 7.74 12.41 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440826_1 CDM 0710 RC inpatient 12.79 8.31 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.41 97 999999999 7.74 12.41 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440826_1 CDM 0710 RC inpatient 12.79 8.31 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.83 69 999999999 7.74 12.41 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440826_1 CDM 0710 RC inpatient 12.79 8.31 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.98 78 999999999 7.74 12.41 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440826_1 CDM 0710 RC inpatient 12.79 8.31 SIHO - ALL PLANS SIHO - ALL PLANS 11.51 90 999999999 7.74 12.41 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440826_1 CDM 0710 RC inpatient 12.79 8.31 UMR - ALL PLANS UMR - ALL PLANS 8.95 70 999999999 7.74 12.41 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440826_1 CDM 0710 RC inpatient 12.79 8.31 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.74 60.55 999999999 7.74 12.41 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440826_1 CDM 0710 RC inpatient 12.79 8.31 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.74 12.41 RECOVERY ROOM - GENERAL CLASSIFICATION 48440826_1 CDM 0710 RC inpatient 12.79 8.31 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.74 12.41 RECOVERY ROOM - GENERAL CLASSIFICATION 48440826_1 CDM 0710 RC inpatient 12.79 8.31 ANTHEM HMO ANTHEM HMO 999999999 7.74 12.41 RECOVERY ROOM - GENERAL CLASSIFICATION 48440826_1 CDM 0710 RC inpatient 12.79 8.31 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.65 67.6 999999999 7.74 12.41 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440826_1 CDM 0710 RC inpatient 12.79 8.31 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.74 12.41 RECOVERY ROOM - GENERAL CLASSIFICATION 48440826_1 CDM 0710 RC inpatient 12.79 8.31 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.74 12.41 RECOVERY ROOM - GENERAL CLASSIFICATION 48440839_1 CDM 0710 RC inpatient 26.87 17.47 AETNA AETNA 21.23 79 999999999 16.27 26.06 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440839_1 CDM 0710 RC inpatient 26.87 17.47 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.47 65 999999999 16.27 26.06 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440839_1 CDM 0710 RC inpatient 26.87 17.47 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26.06 97 999999999 16.27 26.06 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440839_1 CDM 0710 RC inpatient 26.87 17.47 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.54 69 999999999 16.27 26.06 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440839_1 CDM 0710 RC inpatient 26.87 17.47 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.96 78 999999999 16.27 26.06 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440839_1 CDM 0710 RC inpatient 26.87 17.47 SIHO - ALL PLANS SIHO - ALL PLANS 24.18 90 999999999 16.27 26.06 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440839_1 CDM 0710 RC inpatient 26.87 17.47 UMR - ALL PLANS UMR - ALL PLANS 18.81 70 999999999 16.27 26.06 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440839_1 CDM 0710 RC inpatient 26.87 17.47 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.27 60.55 999999999 16.27 26.06 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440839_1 CDM 0710 RC inpatient 26.87 17.47 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.27 26.06 RECOVERY ROOM - GENERAL CLASSIFICATION 48440839_1 CDM 0710 RC inpatient 26.87 17.47 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.27 26.06 RECOVERY ROOM - GENERAL CLASSIFICATION 48440839_1 CDM 0710 RC inpatient 26.87 17.47 ANTHEM HMO ANTHEM HMO 999999999 16.27 26.06 RECOVERY ROOM - GENERAL CLASSIFICATION 48440839_1 CDM 0710 RC inpatient 26.87 17.47 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.16 67.6 999999999 16.27 26.06 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440839_1 CDM 0710 RC inpatient 26.87 17.47 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.27 26.06 RECOVERY ROOM - GENERAL CLASSIFICATION 48440839_1 CDM 0710 RC inpatient 26.87 17.47 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.27 26.06 RECOVERY ROOM - GENERAL CLASSIFICATION 48440864_1 CDM 0710 RC inpatient 13.94 9.06 AETNA AETNA 11.01 79 999999999 8.44 13.52 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440864_1 CDM 0710 RC inpatient 13.94 9.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.06 65 999999999 8.44 13.52 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440864_1 CDM 0710 RC inpatient 13.94 9.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13.52 97 999999999 8.44 13.52 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440864_1 CDM 0710 RC inpatient 13.94 9.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.62 69 999999999 8.44 13.52 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440864_1 CDM 0710 RC inpatient 13.94 9.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.87 78 999999999 8.44 13.52 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440864_1 CDM 0710 RC inpatient 13.94 9.06 SIHO - ALL PLANS SIHO - ALL PLANS 12.55 90 999999999 8.44 13.52 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440864_1 CDM 0710 RC inpatient 13.94 9.06 UMR - ALL PLANS UMR - ALL PLANS 9.76 70 999999999 8.44 13.52 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440864_1 CDM 0710 RC inpatient 13.94 9.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.44 60.55 999999999 8.44 13.52 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440864_1 CDM 0710 RC inpatient 13.94 9.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.44 13.52 RECOVERY ROOM - GENERAL CLASSIFICATION 48440864_1 CDM 0710 RC inpatient 13.94 9.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.44 13.52 RECOVERY ROOM - GENERAL CLASSIFICATION 48440864_1 CDM 0710 RC inpatient 13.94 9.06 ANTHEM HMO ANTHEM HMO 999999999 8.44 13.52 RECOVERY ROOM - GENERAL CLASSIFICATION 48440864_1 CDM 0710 RC inpatient 13.94 9.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.42 67.6 999999999 8.44 13.52 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48440864_1 CDM 0710 RC inpatient 13.94 9.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.44 13.52 RECOVERY ROOM - GENERAL CLASSIFICATION 48440864_1 CDM 0710 RC inpatient 13.94 9.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.44 13.52 FOLIC ACID 5 MG/ML VIAL 48442504_1 CDM 0250 RC 63323-0184-10 NDC inpatient 1 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges FOLIC ACID 5 MG/ML VIAL 48442504_1 CDM 0250 RC 63323-0184-10 NDC inpatient 1 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges FOLIC ACID 5 MG/ML VIAL 48442504_1 CDM 0250 RC 63323-0184-10 NDC inpatient 1 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges FOLIC ACID 5 MG/ML VIAL 48442504_1 CDM 0250 RC 63323-0184-10 NDC inpatient 1 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges FOLIC ACID 5 MG/ML VIAL 48442504_1 CDM 0250 RC 63323-0184-10 NDC inpatient 1 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges FOLIC ACID 5 MG/ML VIAL 48442504_1 CDM 0250 RC 63323-0184-10 NDC inpatient 1 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges FOLIC ACID 5 MG/ML VIAL 48442504_1 CDM 0250 RC 63323-0184-10 NDC inpatient 1 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges FOLIC ACID 5 MG/ML VIAL 48442504_1 CDM 0250 RC 63323-0184-10 NDC inpatient 1 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges FOLIC ACID 5 MG/ML VIAL 48442504_1 CDM 0250 RC 63323-0184-10 NDC inpatient 1 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 FOLIC ACID 5 MG/ML VIAL 48442504_1 CDM 0250 RC 63323-0184-10 NDC inpatient 1 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 FOLIC ACID 5 MG/ML VIAL 48442504_1 CDM 0250 RC 63323-0184-10 NDC inpatient 1 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 FOLIC ACID 5 MG/ML VIAL 48442504_1 CDM 0250 RC 63323-0184-10 NDC inpatient 1 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges FOLIC ACID 5 MG/ML VIAL 48442504_1 CDM 0250 RC 63323-0184-10 NDC inpatient 1 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 FOLIC ACID 5 MG/ML VIAL 48442504_1 CDM 0250 RC 63323-0184-10 NDC inpatient 1 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452321_1 CDM 0943 RC 93798 HCPCS inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452321_1 CDM 0943 RC 93798 HCPCS inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452321_1 CDM 0943 RC 93798 HCPCS inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452321_1 CDM 0943 RC 93798 HCPCS inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452321_1 CDM 0943 RC 93798 HCPCS inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452321_1 CDM 0943 RC 93798 HCPCS inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452321_1 CDM 0943 RC 93798 HCPCS inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452321_1 CDM 0943 RC 93798 HCPCS inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452321_1 CDM 0943 RC 93798 HCPCS inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452321_1 CDM 0943 RC 93798 HCPCS inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452321_1 CDM 0943 RC 93798 HCPCS inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452321_1 CDM 0943 RC 93798 HCPCS inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452321_1 CDM 0943 RC 93798 HCPCS inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452321_1 CDM 0943 RC 93798 HCPCS inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452322_1 CDM 0943 RC 93798 HCPCS inpatient 227 147.55 AETNA AETNA 179.33 79 999999999 137.45 220.19 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452322_1 CDM 0943 RC 93798 HCPCS inpatient 227 147.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 147.55 65 999999999 137.45 220.19 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452322_1 CDM 0943 RC 93798 HCPCS inpatient 227 147.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 220.19 97 999999999 137.45 220.19 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452322_1 CDM 0943 RC 93798 HCPCS inpatient 227 147.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 156.63 69 999999999 137.45 220.19 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452322_1 CDM 0943 RC 93798 HCPCS inpatient 227 147.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 177.06 78 999999999 137.45 220.19 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452322_1 CDM 0943 RC 93798 HCPCS inpatient 227 147.55 SIHO - ALL PLANS SIHO - ALL PLANS 204.3 90 999999999 137.45 220.19 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452322_1 CDM 0943 RC 93798 HCPCS inpatient 227 147.55 UMR - ALL PLANS UMR - ALL PLANS 158.9 70 999999999 137.45 220.19 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452322_1 CDM 0943 RC 93798 HCPCS inpatient 227 147.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 137.45 60.55 999999999 137.45 220.19 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452322_1 CDM 0943 RC 93798 HCPCS inpatient 227 147.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 137.45 220.19 "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452322_1 CDM 0943 RC 93798 HCPCS inpatient 227 147.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 137.45 220.19 "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452322_1 CDM 0943 RC 93798 HCPCS inpatient 227 147.55 ANTHEM HMO ANTHEM HMO 999999999 137.45 220.19 "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452322_1 CDM 0943 RC 93798 HCPCS inpatient 227 147.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 153.45 67.6 999999999 137.45 220.19 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452322_1 CDM 0943 RC 93798 HCPCS inpatient 227 147.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 137.45 220.19 "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48452322_1 CDM 0943 RC 93798 HCPCS inpatient 227 147.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 137.45 220.19 "New patient office or other outpatient visit, 15-29 minutes" 48452326_1 CDM 0510 RC 99202 HCPCS inpatient 229 148.85 AETNA AETNA 180.91 79 999999999 138.66 222.13 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48452326_1 CDM 0510 RC 99202 HCPCS inpatient 229 148.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 148.85 65 999999999 138.66 222.13 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48452326_1 CDM 0510 RC 99202 HCPCS inpatient 229 148.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 222.13 97 999999999 138.66 222.13 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48452326_1 CDM 0510 RC 99202 HCPCS inpatient 229 148.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 158.01 69 999999999 138.66 222.13 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48452326_1 CDM 0510 RC 99202 HCPCS inpatient 229 148.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 178.62 78 999999999 138.66 222.13 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48452326_1 CDM 0510 RC 99202 HCPCS inpatient 229 148.85 SIHO - ALL PLANS SIHO - ALL PLANS 206.1 90 999999999 138.66 222.13 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48452326_1 CDM 0510 RC 99202 HCPCS inpatient 229 148.85 UMR - ALL PLANS UMR - ALL PLANS 160.3 70 999999999 138.66 222.13 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48452326_1 CDM 0510 RC 99202 HCPCS inpatient 229 148.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 138.66 60.55 999999999 138.66 222.13 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48452326_1 CDM 0510 RC 99202 HCPCS inpatient 229 148.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 138.66 222.13 "New patient office or other outpatient visit, 15-29 minutes" 48452326_1 CDM 0510 RC 99202 HCPCS inpatient 229 148.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 138.66 222.13 "New patient office or other outpatient visit, 15-29 minutes" 48452326_1 CDM 0510 RC 99202 HCPCS inpatient 229 148.85 ANTHEM HMO ANTHEM HMO 999999999 138.66 222.13 "New patient office or other outpatient visit, 15-29 minutes" 48452326_1 CDM 0510 RC 99202 HCPCS inpatient 229 148.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 154.8 67.6 999999999 138.66 222.13 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48452326_1 CDM 0510 RC 99202 HCPCS inpatient 229 148.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 138.66 222.13 "New patient office or other outpatient visit, 15-29 minutes" 48452326_1 CDM 0510 RC 99202 HCPCS inpatient 229 148.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 138.66 222.13 "New patient office or other outpatient visit, 15-29 minutes" 48452327_1 CDM 0510 RC 99202 HCPCS inpatient 344 223.6 AETNA AETNA 271.76 79 999999999 208.29 333.68 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48452327_1 CDM 0510 RC 99202 HCPCS inpatient 344 223.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 223.6 65 999999999 208.29 333.68 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48452327_1 CDM 0510 RC 99202 HCPCS inpatient 344 223.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 333.68 97 999999999 208.29 333.68 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48452327_1 CDM 0510 RC 99202 HCPCS inpatient 344 223.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 237.36 69 999999999 208.29 333.68 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48452327_1 CDM 0510 RC 99202 HCPCS inpatient 344 223.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 268.32 78 999999999 208.29 333.68 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48452327_1 CDM 0510 RC 99202 HCPCS inpatient 344 223.6 SIHO - ALL PLANS SIHO - ALL PLANS 309.6 90 999999999 208.29 333.68 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48452327_1 CDM 0510 RC 99202 HCPCS inpatient 344 223.6 UMR - ALL PLANS UMR - ALL PLANS 240.8 70 999999999 208.29 333.68 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48452327_1 CDM 0510 RC 99202 HCPCS inpatient 344 223.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 208.29 60.55 999999999 208.29 333.68 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48452327_1 CDM 0510 RC 99202 HCPCS inpatient 344 223.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 208.29 333.68 "New patient office or other outpatient visit, 15-29 minutes" 48452327_1 CDM 0510 RC 99202 HCPCS inpatient 344 223.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 208.29 333.68 "New patient office or other outpatient visit, 15-29 minutes" 48452327_1 CDM 0510 RC 99202 HCPCS inpatient 344 223.6 ANTHEM HMO ANTHEM HMO 999999999 208.29 333.68 "New patient office or other outpatient visit, 15-29 minutes" 48452327_1 CDM 0510 RC 99202 HCPCS inpatient 344 223.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 232.54 67.6 999999999 208.29 333.68 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48452327_1 CDM 0510 RC 99202 HCPCS inpatient 344 223.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 208.29 333.68 "New patient office or other outpatient visit, 15-29 minutes" 48452327_1 CDM 0510 RC 99202 HCPCS inpatient 344 223.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 208.29 333.68 "New patient office or other outpatient visit, 30-44 minutes" 48452328_1 CDM 0510 RC 99203 HCPCS inpatient 389 252.85 AETNA AETNA 307.31 79 999999999 235.54 377.33 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 48452328_1 CDM 0510 RC 99203 HCPCS inpatient 389 252.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 252.85 65 999999999 235.54 377.33 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 48452328_1 CDM 0510 RC 99203 HCPCS inpatient 389 252.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 377.33 97 999999999 235.54 377.33 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 48452328_1 CDM 0510 RC 99203 HCPCS inpatient 389 252.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 268.41 69 999999999 235.54 377.33 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 48452328_1 CDM 0510 RC 99203 HCPCS inpatient 389 252.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 303.42 78 999999999 235.54 377.33 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 48452328_1 CDM 0510 RC 99203 HCPCS inpatient 389 252.85 SIHO - ALL PLANS SIHO - ALL PLANS 350.1 90 999999999 235.54 377.33 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 48452328_1 CDM 0510 RC 99203 HCPCS inpatient 389 252.85 UMR - ALL PLANS UMR - ALL PLANS 272.3 70 999999999 235.54 377.33 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 48452328_1 CDM 0510 RC 99203 HCPCS inpatient 389 252.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 235.54 60.55 999999999 235.54 377.33 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 48452328_1 CDM 0510 RC 99203 HCPCS inpatient 389 252.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 235.54 377.33 "New patient office or other outpatient visit, 30-44 minutes" 48452328_1 CDM 0510 RC 99203 HCPCS inpatient 389 252.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 235.54 377.33 "New patient office or other outpatient visit, 30-44 minutes" 48452328_1 CDM 0510 RC 99203 HCPCS inpatient 389 252.85 ANTHEM HMO ANTHEM HMO 999999999 235.54 377.33 "New patient office or other outpatient visit, 30-44 minutes" 48452328_1 CDM 0510 RC 99203 HCPCS inpatient 389 252.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 262.96 67.6 999999999 235.54 377.33 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 48452328_1 CDM 0510 RC 99203 HCPCS inpatient 389 252.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 235.54 377.33 "New patient office or other outpatient visit, 30-44 minutes" 48452328_1 CDM 0510 RC 99203 HCPCS inpatient 389 252.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 235.54 377.33 "New patient office or other outpatient visit, 45-59 minutes" 48452329_1 CDM 0510 RC 99204 HCPCS inpatient 486 315.9 AETNA AETNA 383.94 79 999999999 294.27 471.42 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 48452329_1 CDM 0510 RC 99204 HCPCS inpatient 486 315.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 315.9 65 999999999 294.27 471.42 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 48452329_1 CDM 0510 RC 99204 HCPCS inpatient 486 315.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 471.42 97 999999999 294.27 471.42 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 48452329_1 CDM 0510 RC 99204 HCPCS inpatient 486 315.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 335.34 69 999999999 294.27 471.42 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 48452329_1 CDM 0510 RC 99204 HCPCS inpatient 486 315.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 379.08 78 999999999 294.27 471.42 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 48452329_1 CDM 0510 RC 99204 HCPCS inpatient 486 315.9 SIHO - ALL PLANS SIHO - ALL PLANS 437.4 90 999999999 294.27 471.42 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 48452329_1 CDM 0510 RC 99204 HCPCS inpatient 486 315.9 UMR - ALL PLANS UMR - ALL PLANS 340.2 70 999999999 294.27 471.42 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 48452329_1 CDM 0510 RC 99204 HCPCS inpatient 486 315.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 294.27 60.55 999999999 294.27 471.42 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 48452329_1 CDM 0510 RC 99204 HCPCS inpatient 486 315.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 294.27 471.42 "New patient office or other outpatient visit, 45-59 minutes" 48452329_1 CDM 0510 RC 99204 HCPCS inpatient 486 315.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 294.27 471.42 "New patient office or other outpatient visit, 45-59 minutes" 48452329_1 CDM 0510 RC 99204 HCPCS inpatient 486 315.9 ANTHEM HMO ANTHEM HMO 999999999 294.27 471.42 "New patient office or other outpatient visit, 45-59 minutes" 48452329_1 CDM 0510 RC 99204 HCPCS inpatient 486 315.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 328.54 67.6 999999999 294.27 471.42 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 48452329_1 CDM 0510 RC 99204 HCPCS inpatient 486 315.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 294.27 471.42 "New patient office or other outpatient visit, 45-59 minutes" 48452329_1 CDM 0510 RC 99204 HCPCS inpatient 486 315.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 294.27 471.42 "New patient office or other outpatient visit, 60-74 minutes" 48452330_1 CDM 0510 RC 99205 HCPCS inpatient 446 289.9 AETNA AETNA 352.34 79 999999999 270.05 432.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 48452330_1 CDM 0510 RC 99205 HCPCS inpatient 446 289.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 289.9 65 999999999 270.05 432.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 48452330_1 CDM 0510 RC 99205 HCPCS inpatient 446 289.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 432.62 97 999999999 270.05 432.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 48452330_1 CDM 0510 RC 99205 HCPCS inpatient 446 289.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 307.74 69 999999999 270.05 432.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 48452330_1 CDM 0510 RC 99205 HCPCS inpatient 446 289.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 347.88 78 999999999 270.05 432.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 48452330_1 CDM 0510 RC 99205 HCPCS inpatient 446 289.9 SIHO - ALL PLANS SIHO - ALL PLANS 401.4 90 999999999 270.05 432.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 48452330_1 CDM 0510 RC 99205 HCPCS inpatient 446 289.9 UMR - ALL PLANS UMR - ALL PLANS 312.2 70 999999999 270.05 432.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 48452330_1 CDM 0510 RC 99205 HCPCS inpatient 446 289.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.05 60.55 999999999 270.05 432.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 48452330_1 CDM 0510 RC 99205 HCPCS inpatient 446 289.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.05 432.62 "New patient office or other outpatient visit, 60-74 minutes" 48452330_1 CDM 0510 RC 99205 HCPCS inpatient 446 289.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.05 432.62 "New patient office or other outpatient visit, 60-74 minutes" 48452330_1 CDM 0510 RC 99205 HCPCS inpatient 446 289.9 ANTHEM HMO ANTHEM HMO 999999999 270.05 432.62 "New patient office or other outpatient visit, 60-74 minutes" 48452330_1 CDM 0510 RC 99205 HCPCS inpatient 446 289.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 301.5 67.6 999999999 270.05 432.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 48452330_1 CDM 0510 RC 99205 HCPCS inpatient 446 289.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.05 432.62 "New patient office or other outpatient visit, 60-74 minutes" 48452330_1 CDM 0510 RC 99205 HCPCS inpatient 446 289.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.05 432.62 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48452331_1 CDM 0510 RC 99211 HCPCS inpatient 342 222.3 AETNA AETNA 270.18 79 999999999 207.08 331.74 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48452331_1 CDM 0510 RC 99211 HCPCS inpatient 342 222.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 222.3 65 999999999 207.08 331.74 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48452331_1 CDM 0510 RC 99211 HCPCS inpatient 342 222.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 331.74 97 999999999 207.08 331.74 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48452331_1 CDM 0510 RC 99211 HCPCS inpatient 342 222.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 235.98 69 999999999 207.08 331.74 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48452331_1 CDM 0510 RC 99211 HCPCS inpatient 342 222.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 266.76 78 999999999 207.08 331.74 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48452331_1 CDM 0510 RC 99211 HCPCS inpatient 342 222.3 SIHO - ALL PLANS SIHO - ALL PLANS 307.8 90 999999999 207.08 331.74 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48452331_1 CDM 0510 RC 99211 HCPCS inpatient 342 222.3 UMR - ALL PLANS UMR - ALL PLANS 239.4 70 999999999 207.08 331.74 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48452331_1 CDM 0510 RC 99211 HCPCS inpatient 342 222.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 207.08 60.55 999999999 207.08 331.74 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48452331_1 CDM 0510 RC 99211 HCPCS inpatient 342 222.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 207.08 331.74 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48452331_1 CDM 0510 RC 99211 HCPCS inpatient 342 222.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 207.08 331.74 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48452331_1 CDM 0510 RC 99211 HCPCS inpatient 342 222.3 ANTHEM HMO ANTHEM HMO 999999999 207.08 331.74 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48452331_1 CDM 0510 RC 99211 HCPCS inpatient 342 222.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 231.19 67.6 999999999 207.08 331.74 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48452331_1 CDM 0510 RC 99211 HCPCS inpatient 342 222.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 207.08 331.74 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48452331_1 CDM 0510 RC 99211 HCPCS inpatient 342 222.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 207.08 331.74 "Established patient office or other outpatient visit, 10-19 minutes" 48452332_1 CDM 0510 RC 99212 HCPCS inpatient 344 223.6 AETNA AETNA 271.76 79 999999999 208.29 333.68 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 48452332_1 CDM 0510 RC 99212 HCPCS inpatient 344 223.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 223.6 65 999999999 208.29 333.68 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 48452332_1 CDM 0510 RC 99212 HCPCS inpatient 344 223.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 333.68 97 999999999 208.29 333.68 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 48452332_1 CDM 0510 RC 99212 HCPCS inpatient 344 223.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 237.36 69 999999999 208.29 333.68 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 48452332_1 CDM 0510 RC 99212 HCPCS inpatient 344 223.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 268.32 78 999999999 208.29 333.68 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 48452332_1 CDM 0510 RC 99212 HCPCS inpatient 344 223.6 SIHO - ALL PLANS SIHO - ALL PLANS 309.6 90 999999999 208.29 333.68 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 48452332_1 CDM 0510 RC 99212 HCPCS inpatient 344 223.6 UMR - ALL PLANS UMR - ALL PLANS 240.8 70 999999999 208.29 333.68 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 48452332_1 CDM 0510 RC 99212 HCPCS inpatient 344 223.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 208.29 60.55 999999999 208.29 333.68 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 48452332_1 CDM 0510 RC 99212 HCPCS inpatient 344 223.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 208.29 333.68 "Established patient office or other outpatient visit, 10-19 minutes" 48452332_1 CDM 0510 RC 99212 HCPCS inpatient 344 223.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 208.29 333.68 "Established patient office or other outpatient visit, 10-19 minutes" 48452332_1 CDM 0510 RC 99212 HCPCS inpatient 344 223.6 ANTHEM HMO ANTHEM HMO 999999999 208.29 333.68 "Established patient office or other outpatient visit, 10-19 minutes" 48452332_1 CDM 0510 RC 99212 HCPCS inpatient 344 223.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 232.54 67.6 999999999 208.29 333.68 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 48452332_1 CDM 0510 RC 99212 HCPCS inpatient 344 223.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 208.29 333.68 "Established patient office or other outpatient visit, 10-19 minutes" 48452332_1 CDM 0510 RC 99212 HCPCS inpatient 344 223.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 208.29 333.68 "Established patient office or other outpatient visit, 20-29 minutes" 48452333_1 CDM 0510 RC 99213 HCPCS inpatient 451 293.15 AETNA AETNA 356.29 79 999999999 273.08 437.47 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48452333_1 CDM 0510 RC 99213 HCPCS inpatient 451 293.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 293.15 65 999999999 273.08 437.47 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48452333_1 CDM 0510 RC 99213 HCPCS inpatient 451 293.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 437.47 97 999999999 273.08 437.47 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48452333_1 CDM 0510 RC 99213 HCPCS inpatient 451 293.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 311.19 69 999999999 273.08 437.47 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48452333_1 CDM 0510 RC 99213 HCPCS inpatient 451 293.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 351.78 78 999999999 273.08 437.47 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48452333_1 CDM 0510 RC 99213 HCPCS inpatient 451 293.15 SIHO - ALL PLANS SIHO - ALL PLANS 405.9 90 999999999 273.08 437.47 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48452333_1 CDM 0510 RC 99213 HCPCS inpatient 451 293.15 UMR - ALL PLANS UMR - ALL PLANS 315.7 70 999999999 273.08 437.47 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48452333_1 CDM 0510 RC 99213 HCPCS inpatient 451 293.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 273.08 60.55 999999999 273.08 437.47 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48452333_1 CDM 0510 RC 99213 HCPCS inpatient 451 293.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 273.08 437.47 "Established patient office or other outpatient visit, 20-29 minutes" 48452333_1 CDM 0510 RC 99213 HCPCS inpatient 451 293.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 273.08 437.47 "Established patient office or other outpatient visit, 20-29 minutes" 48452333_1 CDM 0510 RC 99213 HCPCS inpatient 451 293.15 ANTHEM HMO ANTHEM HMO 999999999 273.08 437.47 "Established patient office or other outpatient visit, 20-29 minutes" 48452333_1 CDM 0510 RC 99213 HCPCS inpatient 451 293.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 304.88 67.6 999999999 273.08 437.47 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48452333_1 CDM 0510 RC 99213 HCPCS inpatient 451 293.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 273.08 437.47 "Established patient office or other outpatient visit, 20-29 minutes" 48452333_1 CDM 0510 RC 99213 HCPCS inpatient 451 293.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 273.08 437.47 "Established patient office or other outpatient visit, 30-39 minutes" 48452334_1 CDM 0510 RC 99214 HCPCS inpatient 499 324.35 AETNA AETNA 394.21 79 999999999 302.14 484.03 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48452334_1 CDM 0510 RC 99214 HCPCS inpatient 499 324.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 324.35 65 999999999 302.14 484.03 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48452334_1 CDM 0510 RC 99214 HCPCS inpatient 499 324.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 484.03 97 999999999 302.14 484.03 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48452334_1 CDM 0510 RC 99214 HCPCS inpatient 499 324.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 344.31 69 999999999 302.14 484.03 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48452334_1 CDM 0510 RC 99214 HCPCS inpatient 499 324.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 389.22 78 999999999 302.14 484.03 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48452334_1 CDM 0510 RC 99214 HCPCS inpatient 499 324.35 SIHO - ALL PLANS SIHO - ALL PLANS 449.1 90 999999999 302.14 484.03 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48452334_1 CDM 0510 RC 99214 HCPCS inpatient 499 324.35 UMR - ALL PLANS UMR - ALL PLANS 349.3 70 999999999 302.14 484.03 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48452334_1 CDM 0510 RC 99214 HCPCS inpatient 499 324.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 302.14 60.55 999999999 302.14 484.03 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48452334_1 CDM 0510 RC 99214 HCPCS inpatient 499 324.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 302.14 484.03 "Established patient office or other outpatient visit, 30-39 minutes" 48452334_1 CDM 0510 RC 99214 HCPCS inpatient 499 324.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 302.14 484.03 "Established patient office or other outpatient visit, 30-39 minutes" 48452334_1 CDM 0510 RC 99214 HCPCS inpatient 499 324.35 ANTHEM HMO ANTHEM HMO 999999999 302.14 484.03 "Established patient office or other outpatient visit, 30-39 minutes" 48452334_1 CDM 0510 RC 99214 HCPCS inpatient 499 324.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 337.32 67.6 999999999 302.14 484.03 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48452334_1 CDM 0510 RC 99214 HCPCS inpatient 499 324.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 302.14 484.03 "Established patient office or other outpatient visit, 30-39 minutes" 48452334_1 CDM 0510 RC 99214 HCPCS inpatient 499 324.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 302.14 484.03 "Established patient office or other outpatient visit, 40-54 minutes" 48452335_1 CDM 0510 RC 99215 HCPCS inpatient 572 371.8 AETNA AETNA 451.88 79 999999999 346.35 554.84 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 48452335_1 CDM 0510 RC 99215 HCPCS inpatient 572 371.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 371.8 65 999999999 346.35 554.84 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 48452335_1 CDM 0510 RC 99215 HCPCS inpatient 572 371.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 554.84 97 999999999 346.35 554.84 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 48452335_1 CDM 0510 RC 99215 HCPCS inpatient 572 371.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 394.68 69 999999999 346.35 554.84 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 48452335_1 CDM 0510 RC 99215 HCPCS inpatient 572 371.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 446.16 78 999999999 346.35 554.84 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 48452335_1 CDM 0510 RC 99215 HCPCS inpatient 572 371.8 SIHO - ALL PLANS SIHO - ALL PLANS 514.8 90 999999999 346.35 554.84 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 48452335_1 CDM 0510 RC 99215 HCPCS inpatient 572 371.8 UMR - ALL PLANS UMR - ALL PLANS 400.4 70 999999999 346.35 554.84 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 48452335_1 CDM 0510 RC 99215 HCPCS inpatient 572 371.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 346.35 60.55 999999999 346.35 554.84 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 48452335_1 CDM 0510 RC 99215 HCPCS inpatient 572 371.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 346.35 554.84 "Established patient office or other outpatient visit, 40-54 minutes" 48452335_1 CDM 0510 RC 99215 HCPCS inpatient 572 371.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 346.35 554.84 "Established patient office or other outpatient visit, 40-54 minutes" 48452335_1 CDM 0510 RC 99215 HCPCS inpatient 572 371.8 ANTHEM HMO ANTHEM HMO 999999999 346.35 554.84 "Established patient office or other outpatient visit, 40-54 minutes" 48452335_1 CDM 0510 RC 99215 HCPCS inpatient 572 371.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 386.67 67.6 999999999 346.35 554.84 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 48452335_1 CDM 0510 RC 99215 HCPCS inpatient 572 371.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 346.35 554.84 "Established patient office or other outpatient visit, 40-54 minutes" 48452335_1 CDM 0510 RC 99215 HCPCS inpatient 572 371.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 346.35 554.84 "Therapy procedure for nutrition management, each 15 minutes" 48452336_1 CDM 0942 RC 97802 HCPCS inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 48452336_1 CDM 0942 RC 97802 HCPCS inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 48452336_1 CDM 0942 RC 97802 HCPCS inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 48452336_1 CDM 0942 RC 97802 HCPCS inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 48452336_1 CDM 0942 RC 97802 HCPCS inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 48452336_1 CDM 0942 RC 97802 HCPCS inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 48452336_1 CDM 0942 RC 97802 HCPCS inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 48452336_1 CDM 0942 RC 97802 HCPCS inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 48452336_1 CDM 0942 RC 97802 HCPCS inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 "Therapy procedure for nutrition management, each 15 minutes" 48452336_1 CDM 0942 RC 97802 HCPCS inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 "Therapy procedure for nutrition management, each 15 minutes" 48452336_1 CDM 0942 RC 97802 HCPCS inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 "Therapy procedure for nutrition management, each 15 minutes" 48452336_1 CDM 0942 RC 97802 HCPCS inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 48452336_1 CDM 0942 RC 97802 HCPCS inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 "Therapy procedure for nutrition management, each 15 minutes" 48452336_1 CDM 0942 RC 97802 HCPCS inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 "Therapy procedure for nutrition management with group, each 30 minutes" 48452337_1 CDM 0942 RC 97804 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452337_1 CDM 0942 RC 97804 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452337_1 CDM 0942 RC 97804 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452337_1 CDM 0942 RC 97804 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452337_1 CDM 0942 RC 97804 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452337_1 CDM 0942 RC 97804 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452337_1 CDM 0942 RC 97804 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452337_1 CDM 0942 RC 97804 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452337_1 CDM 0942 RC 97804 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 "Therapy procedure for nutrition management with group, each 30 minutes" 48452337_1 CDM 0942 RC 97804 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 "Therapy procedure for nutrition management with group, each 30 minutes" 48452337_1 CDM 0942 RC 97804 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 "Therapy procedure for nutrition management with group, each 30 minutes" 48452337_1 CDM 0942 RC 97804 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452337_1 CDM 0942 RC 97804 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 "Therapy procedure for nutrition management with group, each 30 minutes" 48452337_1 CDM 0942 RC 97804 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 "Therapy procedure for nutrition management with group, each 30 minutes" 48452338_1 CDM 0942 RC 97804 HCPCS inpatient 46 29.9 AETNA AETNA 36.34 79 999999999 27.85 44.62 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452338_1 CDM 0942 RC 97804 HCPCS inpatient 46 29.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 29.9 65 999999999 27.85 44.62 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452338_1 CDM 0942 RC 97804 HCPCS inpatient 46 29.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 44.62 97 999999999 27.85 44.62 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452338_1 CDM 0942 RC 97804 HCPCS inpatient 46 29.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 31.74 69 999999999 27.85 44.62 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452338_1 CDM 0942 RC 97804 HCPCS inpatient 46 29.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 35.88 78 999999999 27.85 44.62 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452338_1 CDM 0942 RC 97804 HCPCS inpatient 46 29.9 SIHO - ALL PLANS SIHO - ALL PLANS 41.4 90 999999999 27.85 44.62 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452338_1 CDM 0942 RC 97804 HCPCS inpatient 46 29.9 UMR - ALL PLANS UMR - ALL PLANS 32.2 70 999999999 27.85 44.62 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452338_1 CDM 0942 RC 97804 HCPCS inpatient 46 29.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27.85 60.55 999999999 27.85 44.62 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452338_1 CDM 0942 RC 97804 HCPCS inpatient 46 29.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 27.85 44.62 "Therapy procedure for nutrition management with group, each 30 minutes" 48452338_1 CDM 0942 RC 97804 HCPCS inpatient 46 29.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 27.85 44.62 "Therapy procedure for nutrition management with group, each 30 minutes" 48452338_1 CDM 0942 RC 97804 HCPCS inpatient 46 29.9 ANTHEM HMO ANTHEM HMO 999999999 27.85 44.62 "Therapy procedure for nutrition management with group, each 30 minutes" 48452338_1 CDM 0942 RC 97804 HCPCS inpatient 46 29.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 31.1 67.6 999999999 27.85 44.62 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452338_1 CDM 0942 RC 97804 HCPCS inpatient 46 29.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 27.85 44.62 "Therapy procedure for nutrition management with group, each 30 minutes" 48452338_1 CDM 0942 RC 97804 HCPCS inpatient 46 29.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 27.85 44.62 REV - IHS-MOA CLINIC VISIT 48452339_1 CDM 0510 RC inpatient 140 91 AETNA AETNA 110.6 79 999999999 84.77 135.8 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452339_1 CDM 0510 RC inpatient 140 91 SELF PAY DISCOUNT SELF PAY DISCOUNT 91 65 999999999 84.77 135.8 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452339_1 CDM 0510 RC inpatient 140 91 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 135.8 97 999999999 84.77 135.8 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452339_1 CDM 0510 RC inpatient 140 91 ENCORE - ALL PLANS ENCORE - ALL PLANS 96.6 69 999999999 84.77 135.8 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452339_1 CDM 0510 RC inpatient 140 91 HUMANA - ALL PLANS HUMANA - ALL PLANS 109.2 78 999999999 84.77 135.8 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452339_1 CDM 0510 RC inpatient 140 91 SIHO - ALL PLANS SIHO - ALL PLANS 126 90 999999999 84.77 135.8 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452339_1 CDM 0510 RC inpatient 140 91 UMR - ALL PLANS UMR - ALL PLANS 98 70 999999999 84.77 135.8 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452339_1 CDM 0510 RC inpatient 140 91 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 84.77 60.55 999999999 84.77 135.8 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452339_1 CDM 0510 RC inpatient 140 91 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 84.77 135.8 REV - IHS-MOA CLINIC VISIT 48452339_1 CDM 0510 RC inpatient 140 91 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 84.77 135.8 REV - IHS-MOA CLINIC VISIT 48452339_1 CDM 0510 RC inpatient 140 91 ANTHEM HMO ANTHEM HMO 999999999 84.77 135.8 REV - IHS-MOA CLINIC VISIT 48452339_1 CDM 0510 RC inpatient 140 91 CIGNA - ALL PLANS CIGNA - ALL PLANS 94.64 67.6 999999999 84.77 135.8 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452339_1 CDM 0510 RC inpatient 140 91 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 84.77 135.8 REV - IHS-MOA CLINIC VISIT 48452339_1 CDM 0510 RC inpatient 140 91 UHC - ALL PLANS UHC - ALL PLANS 999999999 84.77 135.8 REV - IHS-MOA CLINIC VISIT 48452340_1 CDM 0510 RC inpatient 250 162.5 AETNA AETNA 197.5 79 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452340_1 CDM 0510 RC inpatient 250 162.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 162.5 65 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452340_1 CDM 0510 RC inpatient 250 162.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 242.5 97 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452340_1 CDM 0510 RC inpatient 250 162.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 172.5 69 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452340_1 CDM 0510 RC inpatient 250 162.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 195 78 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452340_1 CDM 0510 RC inpatient 250 162.5 SIHO - ALL PLANS SIHO - ALL PLANS 225 90 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452340_1 CDM 0510 RC inpatient 250 162.5 UMR - ALL PLANS UMR - ALL PLANS 175 70 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452340_1 CDM 0510 RC inpatient 250 162.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.38 60.55 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452340_1 CDM 0510 RC inpatient 250 162.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.38 242.5 REV - IHS-MOA CLINIC VISIT 48452340_1 CDM 0510 RC inpatient 250 162.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.38 242.5 REV - IHS-MOA CLINIC VISIT 48452340_1 CDM 0510 RC inpatient 250 162.5 ANTHEM HMO ANTHEM HMO 999999999 151.38 242.5 REV - IHS-MOA CLINIC VISIT 48452340_1 CDM 0510 RC inpatient 250 162.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 169 67.6 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452340_1 CDM 0510 RC inpatient 250 162.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.38 242.5 REV - IHS-MOA CLINIC VISIT 48452340_1 CDM 0510 RC inpatient 250 162.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.38 242.5 REV - IHS-MOA CLINIC VISIT 48452341_1 CDM 0510 RC inpatient 207 134.55 AETNA AETNA 163.53 79 999999999 125.34 200.79 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452341_1 CDM 0510 RC inpatient 207 134.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 134.55 65 999999999 125.34 200.79 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452341_1 CDM 0510 RC inpatient 207 134.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 200.79 97 999999999 125.34 200.79 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452341_1 CDM 0510 RC inpatient 207 134.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.83 69 999999999 125.34 200.79 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452341_1 CDM 0510 RC inpatient 207 134.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 161.46 78 999999999 125.34 200.79 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452341_1 CDM 0510 RC inpatient 207 134.55 SIHO - ALL PLANS SIHO - ALL PLANS 186.3 90 999999999 125.34 200.79 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452341_1 CDM 0510 RC inpatient 207 134.55 UMR - ALL PLANS UMR - ALL PLANS 144.9 70 999999999 125.34 200.79 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452341_1 CDM 0510 RC inpatient 207 134.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 125.34 60.55 999999999 125.34 200.79 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452341_1 CDM 0510 RC inpatient 207 134.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 125.34 200.79 REV - IHS-MOA CLINIC VISIT 48452341_1 CDM 0510 RC inpatient 207 134.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 125.34 200.79 REV - IHS-MOA CLINIC VISIT 48452341_1 CDM 0510 RC inpatient 207 134.55 ANTHEM HMO ANTHEM HMO 999999999 125.34 200.79 REV - IHS-MOA CLINIC VISIT 48452341_1 CDM 0510 RC inpatient 207 134.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.93 67.6 999999999 125.34 200.79 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452341_1 CDM 0510 RC inpatient 207 134.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 125.34 200.79 REV - IHS-MOA CLINIC VISIT 48452341_1 CDM 0510 RC inpatient 207 134.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 125.34 200.79 REV - IHS-MOA CLINIC VISIT 48452342_1 CDM 0510 RC inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452342_1 CDM 0510 RC inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452342_1 CDM 0510 RC inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452342_1 CDM 0510 RC inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452342_1 CDM 0510 RC inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452342_1 CDM 0510 RC inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452342_1 CDM 0510 RC inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452342_1 CDM 0510 RC inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452342_1 CDM 0510 RC inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 REV - IHS-MOA CLINIC VISIT 48452342_1 CDM 0510 RC inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 REV - IHS-MOA CLINIC VISIT 48452342_1 CDM 0510 RC inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 REV - IHS-MOA CLINIC VISIT 48452342_1 CDM 0510 RC inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452342_1 CDM 0510 RC inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 REV - IHS-MOA CLINIC VISIT 48452342_1 CDM 0510 RC inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 REV - IHS-MOA CLINIC VISIT 48452343_1 CDM 0510 RC inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452343_1 CDM 0510 RC inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452343_1 CDM 0510 RC inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452343_1 CDM 0510 RC inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452343_1 CDM 0510 RC inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452343_1 CDM 0510 RC inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452343_1 CDM 0510 RC inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452343_1 CDM 0510 RC inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452343_1 CDM 0510 RC inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 REV - IHS-MOA CLINIC VISIT 48452343_1 CDM 0510 RC inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 REV - IHS-MOA CLINIC VISIT 48452343_1 CDM 0510 RC inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 REV - IHS-MOA CLINIC VISIT 48452343_1 CDM 0510 RC inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452343_1 CDM 0510 RC inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 REV - IHS-MOA CLINIC VISIT 48452343_1 CDM 0510 RC inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 REV - IHS-MOA CLINIC VISIT 48452344_1 CDM 0510 RC inpatient 196 127.4 AETNA AETNA 154.84 79 999999999 118.68 190.12 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452344_1 CDM 0510 RC inpatient 196 127.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 127.4 65 999999999 118.68 190.12 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452344_1 CDM 0510 RC inpatient 196 127.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 190.12 97 999999999 118.68 190.12 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452344_1 CDM 0510 RC inpatient 196 127.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 135.24 69 999999999 118.68 190.12 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452344_1 CDM 0510 RC inpatient 196 127.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 152.88 78 999999999 118.68 190.12 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452344_1 CDM 0510 RC inpatient 196 127.4 SIHO - ALL PLANS SIHO - ALL PLANS 176.4 90 999999999 118.68 190.12 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452344_1 CDM 0510 RC inpatient 196 127.4 UMR - ALL PLANS UMR - ALL PLANS 137.2 70 999999999 118.68 190.12 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452344_1 CDM 0510 RC inpatient 196 127.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 118.68 60.55 999999999 118.68 190.12 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452344_1 CDM 0510 RC inpatient 196 127.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 118.68 190.12 REV - IHS-MOA CLINIC VISIT 48452344_1 CDM 0510 RC inpatient 196 127.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 118.68 190.12 REV - IHS-MOA CLINIC VISIT 48452344_1 CDM 0510 RC inpatient 196 127.4 ANTHEM HMO ANTHEM HMO 999999999 118.68 190.12 REV - IHS-MOA CLINIC VISIT 48452344_1 CDM 0510 RC inpatient 196 127.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 132.5 67.6 999999999 118.68 190.12 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452344_1 CDM 0510 RC inpatient 196 127.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 118.68 190.12 REV - IHS-MOA CLINIC VISIT 48452344_1 CDM 0510 RC inpatient 196 127.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 118.68 190.12 Continuous monitoring of blood sugar level in tissue fluid using sensor under skin with provider supplied equipment 48452368_1 CDM 0510 RC 95250 HCPCS inpatient 426 276.9 AETNA AETNA 336.54 79 999999999 257.94 413.22 percent of total billed charges Continuous monitoring of blood sugar level in tissue fluid using sensor under skin with provider supplied equipment 48452368_1 CDM 0510 RC 95250 HCPCS inpatient 426 276.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 276.9 65 999999999 257.94 413.22 percent of total billed charges Continuous monitoring of blood sugar level in tissue fluid using sensor under skin with provider supplied equipment 48452368_1 CDM 0510 RC 95250 HCPCS inpatient 426 276.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 413.22 97 999999999 257.94 413.22 percent of total billed charges Continuous monitoring of blood sugar level in tissue fluid using sensor under skin with provider supplied equipment 48452368_1 CDM 0510 RC 95250 HCPCS inpatient 426 276.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 293.94 69 999999999 257.94 413.22 percent of total billed charges Continuous monitoring of blood sugar level in tissue fluid using sensor under skin with provider supplied equipment 48452368_1 CDM 0510 RC 95250 HCPCS inpatient 426 276.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 332.28 78 999999999 257.94 413.22 percent of total billed charges Continuous monitoring of blood sugar level in tissue fluid using sensor under skin with provider supplied equipment 48452368_1 CDM 0510 RC 95250 HCPCS inpatient 426 276.9 SIHO - ALL PLANS SIHO - ALL PLANS 383.4 90 999999999 257.94 413.22 percent of total billed charges Continuous monitoring of blood sugar level in tissue fluid using sensor under skin with provider supplied equipment 48452368_1 CDM 0510 RC 95250 HCPCS inpatient 426 276.9 UMR - ALL PLANS UMR - ALL PLANS 298.2 70 999999999 257.94 413.22 percent of total billed charges Continuous monitoring of blood sugar level in tissue fluid using sensor under skin with provider supplied equipment 48452368_1 CDM 0510 RC 95250 HCPCS inpatient 426 276.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 257.94 60.55 999999999 257.94 413.22 percent of total billed charges Continuous monitoring of blood sugar level in tissue fluid using sensor under skin with provider supplied equipment 48452368_1 CDM 0510 RC 95250 HCPCS inpatient 426 276.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 257.94 413.22 Continuous monitoring of blood sugar level in tissue fluid using sensor under skin with provider supplied equipment 48452368_1 CDM 0510 RC 95250 HCPCS inpatient 426 276.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 257.94 413.22 Continuous monitoring of blood sugar level in tissue fluid using sensor under skin with provider supplied equipment 48452368_1 CDM 0510 RC 95250 HCPCS inpatient 426 276.9 ANTHEM HMO ANTHEM HMO 999999999 257.94 413.22 Continuous monitoring of blood sugar level in tissue fluid using sensor under skin with provider supplied equipment 48452368_1 CDM 0510 RC 95250 HCPCS inpatient 426 276.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 287.98 67.6 999999999 257.94 413.22 percent of total billed charges Continuous monitoring of blood sugar level in tissue fluid using sensor under skin with provider supplied equipment 48452368_1 CDM 0510 RC 95250 HCPCS inpatient 426 276.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 257.94 413.22 Continuous monitoring of blood sugar level in tissue fluid using sensor under skin with provider supplied equipment 48452368_1 CDM 0510 RC 95250 HCPCS inpatient 426 276.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 257.94 413.22 "Therapy procedure for nutrition management with group, each 30 minutes" 48452369_1 CDM 0761 RC 97804 HCPCS inpatient 89 57.85 AETNA AETNA 70.31 79 999999999 53.89 86.33 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452369_1 CDM 0761 RC 97804 HCPCS inpatient 89 57.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.85 65 999999999 53.89 86.33 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452369_1 CDM 0761 RC 97804 HCPCS inpatient 89 57.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 86.33 97 999999999 53.89 86.33 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452369_1 CDM 0761 RC 97804 HCPCS inpatient 89 57.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 61.41 69 999999999 53.89 86.33 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452369_1 CDM 0761 RC 97804 HCPCS inpatient 89 57.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 69.42 78 999999999 53.89 86.33 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452369_1 CDM 0761 RC 97804 HCPCS inpatient 89 57.85 SIHO - ALL PLANS SIHO - ALL PLANS 80.1 90 999999999 53.89 86.33 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452369_1 CDM 0761 RC 97804 HCPCS inpatient 89 57.85 UMR - ALL PLANS UMR - ALL PLANS 62.3 70 999999999 53.89 86.33 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452369_1 CDM 0761 RC 97804 HCPCS inpatient 89 57.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.89 60.55 999999999 53.89 86.33 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452369_1 CDM 0761 RC 97804 HCPCS inpatient 89 57.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.89 86.33 "Therapy procedure for nutrition management with group, each 30 minutes" 48452369_1 CDM 0761 RC 97804 HCPCS inpatient 89 57.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.89 86.33 "Therapy procedure for nutrition management with group, each 30 minutes" 48452369_1 CDM 0761 RC 97804 HCPCS inpatient 89 57.85 ANTHEM HMO ANTHEM HMO 999999999 53.89 86.33 "Therapy procedure for nutrition management with group, each 30 minutes" 48452369_1 CDM 0761 RC 97804 HCPCS inpatient 89 57.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.16 67.6 999999999 53.89 86.33 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452369_1 CDM 0761 RC 97804 HCPCS inpatient 89 57.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.89 86.33 "Therapy procedure for nutrition management with group, each 30 minutes" 48452369_1 CDM 0761 RC 97804 HCPCS inpatient 89 57.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.89 86.33 REV - IHS-MOA CLINIC VISIT 48452370_1 CDM 0510 RC inpatient 327 212.55 AETNA AETNA 258.33 79 999999999 198 317.19 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452370_1 CDM 0510 RC inpatient 327 212.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 212.55 65 999999999 198 317.19 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452370_1 CDM 0510 RC inpatient 327 212.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 317.19 97 999999999 198 317.19 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452370_1 CDM 0510 RC inpatient 327 212.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 225.63 69 999999999 198 317.19 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452370_1 CDM 0510 RC inpatient 327 212.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.06 78 999999999 198 317.19 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452370_1 CDM 0510 RC inpatient 327 212.55 SIHO - ALL PLANS SIHO - ALL PLANS 294.3 90 999999999 198 317.19 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452370_1 CDM 0510 RC inpatient 327 212.55 UMR - ALL PLANS UMR - ALL PLANS 228.9 70 999999999 198 317.19 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452370_1 CDM 0510 RC inpatient 327 212.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198 60.55 999999999 198 317.19 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452370_1 CDM 0510 RC inpatient 327 212.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198 317.19 REV - IHS-MOA CLINIC VISIT 48452370_1 CDM 0510 RC inpatient 327 212.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198 317.19 REV - IHS-MOA CLINIC VISIT 48452370_1 CDM 0510 RC inpatient 327 212.55 ANTHEM HMO ANTHEM HMO 999999999 198 317.19 REV - IHS-MOA CLINIC VISIT 48452370_1 CDM 0510 RC inpatient 327 212.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.05 67.6 999999999 198 317.19 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452370_1 CDM 0510 RC inpatient 327 212.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198 317.19 REV - IHS-MOA CLINIC VISIT 48452370_1 CDM 0510 RC inpatient 327 212.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 198 317.19 REV - IHS-MOA CLINIC VISIT 48452371_1 CDM 0510 RC inpatient 24 15.6 AETNA AETNA 18.96 79 999999999 14.53 23.28 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452371_1 CDM 0510 RC inpatient 24 15.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 15.6 65 999999999 14.53 23.28 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452371_1 CDM 0510 RC inpatient 24 15.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23.28 97 999999999 14.53 23.28 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452371_1 CDM 0510 RC inpatient 24 15.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 16.56 69 999999999 14.53 23.28 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452371_1 CDM 0510 RC inpatient 24 15.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 18.72 78 999999999 14.53 23.28 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452371_1 CDM 0510 RC inpatient 24 15.6 SIHO - ALL PLANS SIHO - ALL PLANS 21.6 90 999999999 14.53 23.28 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452371_1 CDM 0510 RC inpatient 24 15.6 UMR - ALL PLANS UMR - ALL PLANS 16.8 70 999999999 14.53 23.28 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452371_1 CDM 0510 RC inpatient 24 15.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.53 60.55 999999999 14.53 23.28 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452371_1 CDM 0510 RC inpatient 24 15.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.53 23.28 REV - IHS-MOA CLINIC VISIT 48452371_1 CDM 0510 RC inpatient 24 15.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.53 23.28 REV - IHS-MOA CLINIC VISIT 48452371_1 CDM 0510 RC inpatient 24 15.6 ANTHEM HMO ANTHEM HMO 999999999 14.53 23.28 REV - IHS-MOA CLINIC VISIT 48452371_1 CDM 0510 RC inpatient 24 15.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.22 67.6 999999999 14.53 23.28 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452371_1 CDM 0510 RC inpatient 24 15.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.53 23.28 REV - IHS-MOA CLINIC VISIT 48452371_1 CDM 0510 RC inpatient 24 15.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.53 23.28 REV - IHS-MOA CLINIC VISIT 48452372_1 CDM 0510 RC inpatient 487 316.55 AETNA AETNA 384.73 79 999999999 294.88 472.39 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452372_1 CDM 0510 RC inpatient 487 316.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 316.55 65 999999999 294.88 472.39 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452372_1 CDM 0510 RC inpatient 487 316.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 472.39 97 999999999 294.88 472.39 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452372_1 CDM 0510 RC inpatient 487 316.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 336.03 69 999999999 294.88 472.39 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452372_1 CDM 0510 RC inpatient 487 316.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 379.86 78 999999999 294.88 472.39 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452372_1 CDM 0510 RC inpatient 487 316.55 SIHO - ALL PLANS SIHO - ALL PLANS 438.3 90 999999999 294.88 472.39 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452372_1 CDM 0510 RC inpatient 487 316.55 UMR - ALL PLANS UMR - ALL PLANS 340.9 70 999999999 294.88 472.39 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452372_1 CDM 0510 RC inpatient 487 316.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 294.88 60.55 999999999 294.88 472.39 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452372_1 CDM 0510 RC inpatient 487 316.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 294.88 472.39 REV - IHS-MOA CLINIC VISIT 48452372_1 CDM 0510 RC inpatient 487 316.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 294.88 472.39 REV - IHS-MOA CLINIC VISIT 48452372_1 CDM 0510 RC inpatient 487 316.55 ANTHEM HMO ANTHEM HMO 999999999 294.88 472.39 REV - IHS-MOA CLINIC VISIT 48452372_1 CDM 0510 RC inpatient 487 316.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 329.21 67.6 999999999 294.88 472.39 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48452372_1 CDM 0510 RC inpatient 487 316.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 294.88 472.39 REV - IHS-MOA CLINIC VISIT 48452372_1 CDM 0510 RC inpatient 487 316.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 294.88 472.39 "Therapy procedure for nutrition management with group, each 30 minutes" 48452373_1 CDM 0942 RC 97804 HCPCS inpatient 121 78.65 AETNA AETNA 95.59 79 999999999 73.27 117.37 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452373_1 CDM 0942 RC 97804 HCPCS inpatient 121 78.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 78.65 65 999999999 73.27 117.37 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452373_1 CDM 0942 RC 97804 HCPCS inpatient 121 78.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 117.37 97 999999999 73.27 117.37 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452373_1 CDM 0942 RC 97804 HCPCS inpatient 121 78.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 83.49 69 999999999 73.27 117.37 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452373_1 CDM 0942 RC 97804 HCPCS inpatient 121 78.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 94.38 78 999999999 73.27 117.37 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452373_1 CDM 0942 RC 97804 HCPCS inpatient 121 78.65 SIHO - ALL PLANS SIHO - ALL PLANS 108.9 90 999999999 73.27 117.37 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452373_1 CDM 0942 RC 97804 HCPCS inpatient 121 78.65 UMR - ALL PLANS UMR - ALL PLANS 84.7 70 999999999 73.27 117.37 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452373_1 CDM 0942 RC 97804 HCPCS inpatient 121 78.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.27 60.55 999999999 73.27 117.37 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452373_1 CDM 0942 RC 97804 HCPCS inpatient 121 78.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.27 117.37 "Therapy procedure for nutrition management with group, each 30 minutes" 48452373_1 CDM 0942 RC 97804 HCPCS inpatient 121 78.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.27 117.37 "Therapy procedure for nutrition management with group, each 30 minutes" 48452373_1 CDM 0942 RC 97804 HCPCS inpatient 121 78.65 ANTHEM HMO ANTHEM HMO 999999999 73.27 117.37 "Therapy procedure for nutrition management with group, each 30 minutes" 48452373_1 CDM 0942 RC 97804 HCPCS inpatient 121 78.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.8 67.6 999999999 73.27 117.37 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 48452373_1 CDM 0942 RC 97804 HCPCS inpatient 121 78.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.27 117.37 "Therapy procedure for nutrition management with group, each 30 minutes" 48452373_1 CDM 0942 RC 97804 HCPCS inpatient 121 78.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.27 117.37 "Therapy procedure for nutrition management, each 15 minutes" 48452374_1 CDM 0942 RC 97802 HCPCS inpatient 89 57.85 AETNA AETNA 70.31 79 999999999 53.89 86.33 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 48452374_1 CDM 0942 RC 97802 HCPCS inpatient 89 57.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.85 65 999999999 53.89 86.33 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 48452374_1 CDM 0942 RC 97802 HCPCS inpatient 89 57.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 86.33 97 999999999 53.89 86.33 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 48452374_1 CDM 0942 RC 97802 HCPCS inpatient 89 57.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 61.41 69 999999999 53.89 86.33 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 48452374_1 CDM 0942 RC 97802 HCPCS inpatient 89 57.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 69.42 78 999999999 53.89 86.33 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 48452374_1 CDM 0942 RC 97802 HCPCS inpatient 89 57.85 SIHO - ALL PLANS SIHO - ALL PLANS 80.1 90 999999999 53.89 86.33 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 48452374_1 CDM 0942 RC 97802 HCPCS inpatient 89 57.85 UMR - ALL PLANS UMR - ALL PLANS 62.3 70 999999999 53.89 86.33 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 48452374_1 CDM 0942 RC 97802 HCPCS inpatient 89 57.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.89 60.55 999999999 53.89 86.33 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 48452374_1 CDM 0942 RC 97802 HCPCS inpatient 89 57.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.89 86.33 "Therapy procedure for nutrition management, each 15 minutes" 48452374_1 CDM 0942 RC 97802 HCPCS inpatient 89 57.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.89 86.33 "Therapy procedure for nutrition management, each 15 minutes" 48452374_1 CDM 0942 RC 97802 HCPCS inpatient 89 57.85 ANTHEM HMO ANTHEM HMO 999999999 53.89 86.33 "Therapy procedure for nutrition management, each 15 minutes" 48452374_1 CDM 0942 RC 97802 HCPCS inpatient 89 57.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.16 67.6 999999999 53.89 86.33 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 48452374_1 CDM 0942 RC 97802 HCPCS inpatient 89 57.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.89 86.33 "Therapy procedure for nutrition management, each 15 minutes" 48452374_1 CDM 0942 RC 97802 HCPCS inpatient 89 57.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.89 86.33 "Therapy procedure reassessment for nutrition management, each 15 minutes" 48452375_1 CDM 0942 RC 97803 HCPCS inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges "Therapy procedure reassessment for nutrition management, each 15 minutes" 48452375_1 CDM 0942 RC 97803 HCPCS inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges "Therapy procedure reassessment for nutrition management, each 15 minutes" 48452375_1 CDM 0942 RC 97803 HCPCS inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges "Therapy procedure reassessment for nutrition management, each 15 minutes" 48452375_1 CDM 0942 RC 97803 HCPCS inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges "Therapy procedure reassessment for nutrition management, each 15 minutes" 48452375_1 CDM 0942 RC 97803 HCPCS inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges "Therapy procedure reassessment for nutrition management, each 15 minutes" 48452375_1 CDM 0942 RC 97803 HCPCS inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges "Therapy procedure reassessment for nutrition management, each 15 minutes" 48452375_1 CDM 0942 RC 97803 HCPCS inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges "Therapy procedure reassessment for nutrition management, each 15 minutes" 48452375_1 CDM 0942 RC 97803 HCPCS inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges "Therapy procedure reassessment for nutrition management, each 15 minutes" 48452375_1 CDM 0942 RC 97803 HCPCS inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 "Therapy procedure reassessment for nutrition management, each 15 minutes" 48452375_1 CDM 0942 RC 97803 HCPCS inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 "Therapy procedure reassessment for nutrition management, each 15 minutes" 48452375_1 CDM 0942 RC 97803 HCPCS inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 "Therapy procedure reassessment for nutrition management, each 15 minutes" 48452375_1 CDM 0942 RC 97803 HCPCS inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges "Therapy procedure reassessment for nutrition management, each 15 minutes" 48452375_1 CDM 0942 RC 97803 HCPCS inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 "Therapy procedure reassessment for nutrition management, each 15 minutes" 48452375_1 CDM 0942 RC 97803 HCPCS inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 Simple or single drainage of skin abscess 48452409_1 CDM 0510 RC 10060 HCPCS inpatient 549 356.85 AETNA AETNA 433.71 79 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 48452409_1 CDM 0510 RC 10060 HCPCS inpatient 549 356.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 356.85 65 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 48452409_1 CDM 0510 RC 10060 HCPCS inpatient 549 356.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 532.53 97 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 48452409_1 CDM 0510 RC 10060 HCPCS inpatient 549 356.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 378.81 69 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 48452409_1 CDM 0510 RC 10060 HCPCS inpatient 549 356.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 428.22 78 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 48452409_1 CDM 0510 RC 10060 HCPCS inpatient 549 356.85 SIHO - ALL PLANS SIHO - ALL PLANS 494.1 90 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 48452409_1 CDM 0510 RC 10060 HCPCS inpatient 549 356.85 UMR - ALL PLANS UMR - ALL PLANS 384.3 70 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 48452409_1 CDM 0510 RC 10060 HCPCS inpatient 549 356.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 332.42 60.55 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 48452409_1 CDM 0510 RC 10060 HCPCS inpatient 549 356.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 332.42 532.53 Simple or single drainage of skin abscess 48452409_1 CDM 0510 RC 10060 HCPCS inpatient 549 356.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 332.42 532.53 Simple or single drainage of skin abscess 48452409_1 CDM 0510 RC 10060 HCPCS inpatient 549 356.85 ANTHEM HMO ANTHEM HMO 999999999 332.42 532.53 Simple or single drainage of skin abscess 48452409_1 CDM 0510 RC 10060 HCPCS inpatient 549 356.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 371.12 67.6 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 48452409_1 CDM 0510 RC 10060 HCPCS inpatient 549 356.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 332.42 532.53 Simple or single drainage of skin abscess 48452409_1 CDM 0510 RC 10060 HCPCS inpatient 549 356.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 332.42 532.53 "Removal of skin and tissue, 20.0 sq cm or less" 48452410_1 CDM 0510 RC 11042 HCPCS inpatient 2061 1339.65 AETNA AETNA 1628.19 79 999999999 1247.94 1999.17 percent of total billed charges "Removal of skin and tissue, 20.0 sq cm or less" 48452410_1 CDM 0510 RC 11042 HCPCS inpatient 2061 1339.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1339.65 65 999999999 1247.94 1999.17 percent of total billed charges "Removal of skin and tissue, 20.0 sq cm or less" 48452410_1 CDM 0510 RC 11042 HCPCS inpatient 2061 1339.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1999.17 97 999999999 1247.94 1999.17 percent of total billed charges "Removal of skin and tissue, 20.0 sq cm or less" 48452410_1 CDM 0510 RC 11042 HCPCS inpatient 2061 1339.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1422.09 69 999999999 1247.94 1999.17 percent of total billed charges "Removal of skin and tissue, 20.0 sq cm or less" 48452410_1 CDM 0510 RC 11042 HCPCS inpatient 2061 1339.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1607.58 78 999999999 1247.94 1999.17 percent of total billed charges "Removal of skin and tissue, 20.0 sq cm or less" 48452410_1 CDM 0510 RC 11042 HCPCS inpatient 2061 1339.65 SIHO - ALL PLANS SIHO - ALL PLANS 1854.9 90 999999999 1247.94 1999.17 percent of total billed charges "Removal of skin and tissue, 20.0 sq cm or less" 48452410_1 CDM 0510 RC 11042 HCPCS inpatient 2061 1339.65 UMR - ALL PLANS UMR - ALL PLANS 1442.7 70 999999999 1247.94 1999.17 percent of total billed charges "Removal of skin and tissue, 20.0 sq cm or less" 48452410_1 CDM 0510 RC 11042 HCPCS inpatient 2061 1339.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1247.94 60.55 999999999 1247.94 1999.17 percent of total billed charges "Removal of skin and tissue, 20.0 sq cm or less" 48452410_1 CDM 0510 RC 11042 HCPCS inpatient 2061 1339.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1247.94 1999.17 "Removal of skin and tissue, 20.0 sq cm or less" 48452410_1 CDM 0510 RC 11042 HCPCS inpatient 2061 1339.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1247.94 1999.17 "Removal of skin and tissue, 20.0 sq cm or less" 48452410_1 CDM 0510 RC 11042 HCPCS inpatient 2061 1339.65 ANTHEM HMO ANTHEM HMO 999999999 1247.94 1999.17 "Removal of skin and tissue, 20.0 sq cm or less" 48452410_1 CDM 0510 RC 11042 HCPCS inpatient 2061 1339.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1393.24 67.6 999999999 1247.94 1999.17 percent of total billed charges "Removal of skin and tissue, 20.0 sq cm or less" 48452410_1 CDM 0510 RC 11042 HCPCS inpatient 2061 1339.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1247.94 1999.17 "Removal of skin and tissue, 20.0 sq cm or less" 48452410_1 CDM 0510 RC 11042 HCPCS inpatient 2061 1339.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1247.94 1999.17 "Removal of muscle and/or tissue, 20.0 sq cm or less" 48452411_1 CDM 0510 RC 11043 HCPCS inpatient 777 505.05 AETNA AETNA 613.83 79 999999999 470.47 753.69 percent of total billed charges "Removal of muscle and/or tissue, 20.0 sq cm or less" 48452411_1 CDM 0510 RC 11043 HCPCS inpatient 777 505.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 505.05 65 999999999 470.47 753.69 percent of total billed charges "Removal of muscle and/or tissue, 20.0 sq cm or less" 48452411_1 CDM 0510 RC 11043 HCPCS inpatient 777 505.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 753.69 97 999999999 470.47 753.69 percent of total billed charges "Removal of muscle and/or tissue, 20.0 sq cm or less" 48452411_1 CDM 0510 RC 11043 HCPCS inpatient 777 505.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 536.13 69 999999999 470.47 753.69 percent of total billed charges "Removal of muscle and/or tissue, 20.0 sq cm or less" 48452411_1 CDM 0510 RC 11043 HCPCS inpatient 777 505.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 606.06 78 999999999 470.47 753.69 percent of total billed charges "Removal of muscle and/or tissue, 20.0 sq cm or less" 48452411_1 CDM 0510 RC 11043 HCPCS inpatient 777 505.05 SIHO - ALL PLANS SIHO - ALL PLANS 699.3 90 999999999 470.47 753.69 percent of total billed charges "Removal of muscle and/or tissue, 20.0 sq cm or less" 48452411_1 CDM 0510 RC 11043 HCPCS inpatient 777 505.05 UMR - ALL PLANS UMR - ALL PLANS 543.9 70 999999999 470.47 753.69 percent of total billed charges "Removal of muscle and/or tissue, 20.0 sq cm or less" 48452411_1 CDM 0510 RC 11043 HCPCS inpatient 777 505.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 470.47 60.55 999999999 470.47 753.69 percent of total billed charges "Removal of muscle and/or tissue, 20.0 sq cm or less" 48452411_1 CDM 0510 RC 11043 HCPCS inpatient 777 505.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 470.47 753.69 "Removal of muscle and/or tissue, 20.0 sq cm or less" 48452411_1 CDM 0510 RC 11043 HCPCS inpatient 777 505.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 470.47 753.69 "Removal of muscle and/or tissue, 20.0 sq cm or less" 48452411_1 CDM 0510 RC 11043 HCPCS inpatient 777 505.05 ANTHEM HMO ANTHEM HMO 999999999 470.47 753.69 "Removal of muscle and/or tissue, 20.0 sq cm or less" 48452411_1 CDM 0510 RC 11043 HCPCS inpatient 777 505.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 525.25 67.6 999999999 470.47 753.69 percent of total billed charges "Removal of muscle and/or tissue, 20.0 sq cm or less" 48452411_1 CDM 0510 RC 11043 HCPCS inpatient 777 505.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 470.47 753.69 "Removal of muscle and/or tissue, 20.0 sq cm or less" 48452411_1 CDM 0510 RC 11043 HCPCS inpatient 777 505.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 470.47 753.69 "Removal of bone, 20.0 sq cm or less" 48452412_1 CDM 0510 RC 11044 HCPCS inpatient 1999 1299.35 AETNA AETNA 1579.21 79 999999999 1210.39 1939.03 percent of total billed charges "Removal of bone, 20.0 sq cm or less" 48452412_1 CDM 0510 RC 11044 HCPCS inpatient 1999 1299.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1299.35 65 999999999 1210.39 1939.03 percent of total billed charges "Removal of bone, 20.0 sq cm or less" 48452412_1 CDM 0510 RC 11044 HCPCS inpatient 1999 1299.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1939.03 97 999999999 1210.39 1939.03 percent of total billed charges "Removal of bone, 20.0 sq cm or less" 48452412_1 CDM 0510 RC 11044 HCPCS inpatient 1999 1299.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1379.31 69 999999999 1210.39 1939.03 percent of total billed charges "Removal of bone, 20.0 sq cm or less" 48452412_1 CDM 0510 RC 11044 HCPCS inpatient 1999 1299.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1559.22 78 999999999 1210.39 1939.03 percent of total billed charges "Removal of bone, 20.0 sq cm or less" 48452412_1 CDM 0510 RC 11044 HCPCS inpatient 1999 1299.35 SIHO - ALL PLANS SIHO - ALL PLANS 1799.1 90 999999999 1210.39 1939.03 percent of total billed charges "Removal of bone, 20.0 sq cm or less" 48452412_1 CDM 0510 RC 11044 HCPCS inpatient 1999 1299.35 UMR - ALL PLANS UMR - ALL PLANS 1399.3 70 999999999 1210.39 1939.03 percent of total billed charges "Removal of bone, 20.0 sq cm or less" 48452412_1 CDM 0510 RC 11044 HCPCS inpatient 1999 1299.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1210.39 60.55 999999999 1210.39 1939.03 percent of total billed charges "Removal of bone, 20.0 sq cm or less" 48452412_1 CDM 0510 RC 11044 HCPCS inpatient 1999 1299.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1210.39 1939.03 "Removal of bone, 20.0 sq cm or less" 48452412_1 CDM 0510 RC 11044 HCPCS inpatient 1999 1299.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1210.39 1939.03 "Removal of bone, 20.0 sq cm or less" 48452412_1 CDM 0510 RC 11044 HCPCS inpatient 1999 1299.35 ANTHEM HMO ANTHEM HMO 999999999 1210.39 1939.03 "Removal of bone, 20.0 sq cm or less" 48452412_1 CDM 0510 RC 11044 HCPCS inpatient 1999 1299.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1351.32 67.6 999999999 1210.39 1939.03 percent of total billed charges "Removal of bone, 20.0 sq cm or less" 48452412_1 CDM 0510 RC 11044 HCPCS inpatient 1999 1299.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1210.39 1939.03 "Removal of bone, 20.0 sq cm or less" 48452412_1 CDM 0510 RC 11044 HCPCS inpatient 1999 1299.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1210.39 1939.03 "Removal of skin and tissue, each additional 20.0 sq cm or less" 48452413_1 CDM 0510 RC 11045 HCPCS inpatient 647 420.55 AETNA AETNA 511.13 79 999999999 391.76 627.59 percent of total billed charges "Removal of skin and tissue, each additional 20.0 sq cm or less" 48452413_1 CDM 0510 RC 11045 HCPCS inpatient 647 420.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 420.55 65 999999999 391.76 627.59 percent of total billed charges "Removal of skin and tissue, each additional 20.0 sq cm or less" 48452413_1 CDM 0510 RC 11045 HCPCS inpatient 647 420.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 627.59 97 999999999 391.76 627.59 percent of total billed charges "Removal of skin and tissue, each additional 20.0 sq cm or less" 48452413_1 CDM 0510 RC 11045 HCPCS inpatient 647 420.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 446.43 69 999999999 391.76 627.59 percent of total billed charges "Removal of skin and tissue, each additional 20.0 sq cm or less" 48452413_1 CDM 0510 RC 11045 HCPCS inpatient 647 420.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 504.66 78 999999999 391.76 627.59 percent of total billed charges "Removal of skin and tissue, each additional 20.0 sq cm or less" 48452413_1 CDM 0510 RC 11045 HCPCS inpatient 647 420.55 SIHO - ALL PLANS SIHO - ALL PLANS 582.3 90 999999999 391.76 627.59 percent of total billed charges "Removal of skin and tissue, each additional 20.0 sq cm or less" 48452413_1 CDM 0510 RC 11045 HCPCS inpatient 647 420.55 UMR - ALL PLANS UMR - ALL PLANS 452.9 70 999999999 391.76 627.59 percent of total billed charges "Removal of skin and tissue, each additional 20.0 sq cm or less" 48452413_1 CDM 0510 RC 11045 HCPCS inpatient 647 420.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 391.76 60.55 999999999 391.76 627.59 percent of total billed charges "Removal of skin and tissue, each additional 20.0 sq cm or less" 48452413_1 CDM 0510 RC 11045 HCPCS inpatient 647 420.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 391.76 627.59 "Removal of skin and tissue, each additional 20.0 sq cm or less" 48452413_1 CDM 0510 RC 11045 HCPCS inpatient 647 420.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 391.76 627.59 "Removal of skin and tissue, each additional 20.0 sq cm or less" 48452413_1 CDM 0510 RC 11045 HCPCS inpatient 647 420.55 ANTHEM HMO ANTHEM HMO 999999999 391.76 627.59 "Removal of skin and tissue, each additional 20.0 sq cm or less" 48452413_1 CDM 0510 RC 11045 HCPCS inpatient 647 420.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 437.37 67.6 999999999 391.76 627.59 percent of total billed charges "Removal of skin and tissue, each additional 20.0 sq cm or less" 48452413_1 CDM 0510 RC 11045 HCPCS inpatient 647 420.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 391.76 627.59 "Removal of skin and tissue, each additional 20.0 sq cm or less" 48452413_1 CDM 0510 RC 11045 HCPCS inpatient 647 420.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 391.76 627.59 "Removal of muscle and/or tissue, each additional 20.0 sq cm or less" 48452414_1 CDM 0510 RC 11046 HCPCS inpatient 471 306.15 AETNA AETNA 372.09 79 999999999 285.19 456.87 percent of total billed charges "Removal of muscle and/or tissue, each additional 20.0 sq cm or less" 48452414_1 CDM 0510 RC 11046 HCPCS inpatient 471 306.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 306.15 65 999999999 285.19 456.87 percent of total billed charges "Removal of muscle and/or tissue, each additional 20.0 sq cm or less" 48452414_1 CDM 0510 RC 11046 HCPCS inpatient 471 306.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 456.87 97 999999999 285.19 456.87 percent of total billed charges "Removal of muscle and/or tissue, each additional 20.0 sq cm or less" 48452414_1 CDM 0510 RC 11046 HCPCS inpatient 471 306.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 324.99 69 999999999 285.19 456.87 percent of total billed charges "Removal of muscle and/or tissue, each additional 20.0 sq cm or less" 48452414_1 CDM 0510 RC 11046 HCPCS inpatient 471 306.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 367.38 78 999999999 285.19 456.87 percent of total billed charges "Removal of muscle and/or tissue, each additional 20.0 sq cm or less" 48452414_1 CDM 0510 RC 11046 HCPCS inpatient 471 306.15 SIHO - ALL PLANS SIHO - ALL PLANS 423.9 90 999999999 285.19 456.87 percent of total billed charges "Removal of muscle and/or tissue, each additional 20.0 sq cm or less" 48452414_1 CDM 0510 RC 11046 HCPCS inpatient 471 306.15 UMR - ALL PLANS UMR - ALL PLANS 329.7 70 999999999 285.19 456.87 percent of total billed charges "Removal of muscle and/or tissue, each additional 20.0 sq cm or less" 48452414_1 CDM 0510 RC 11046 HCPCS inpatient 471 306.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 285.19 60.55 999999999 285.19 456.87 percent of total billed charges "Removal of muscle and/or tissue, each additional 20.0 sq cm or less" 48452414_1 CDM 0510 RC 11046 HCPCS inpatient 471 306.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 285.19 456.87 "Removal of muscle and/or tissue, each additional 20.0 sq cm or less" 48452414_1 CDM 0510 RC 11046 HCPCS inpatient 471 306.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 285.19 456.87 "Removal of muscle and/or tissue, each additional 20.0 sq cm or less" 48452414_1 CDM 0510 RC 11046 HCPCS inpatient 471 306.15 ANTHEM HMO ANTHEM HMO 999999999 285.19 456.87 "Removal of muscle and/or tissue, each additional 20.0 sq cm or less" 48452414_1 CDM 0510 RC 11046 HCPCS inpatient 471 306.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 318.4 67.6 999999999 285.19 456.87 percent of total billed charges "Removal of muscle and/or tissue, each additional 20.0 sq cm or less" 48452414_1 CDM 0510 RC 11046 HCPCS inpatient 471 306.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 285.19 456.87 "Removal of muscle and/or tissue, each additional 20.0 sq cm or less" 48452414_1 CDM 0510 RC 11046 HCPCS inpatient 471 306.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 285.19 456.87 "Removal of noncancer thickened skin growth, 1 growth" 48452415_1 CDM 0510 RC 11055 HCPCS inpatient 447 290.55 AETNA AETNA 353.13 79 999999999 270.66 433.59 percent of total billed charges "Removal of noncancer thickened skin growth, 1 growth" 48452415_1 CDM 0510 RC 11055 HCPCS inpatient 447 290.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 290.55 65 999999999 270.66 433.59 percent of total billed charges "Removal of noncancer thickened skin growth, 1 growth" 48452415_1 CDM 0510 RC 11055 HCPCS inpatient 447 290.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 433.59 97 999999999 270.66 433.59 percent of total billed charges "Removal of noncancer thickened skin growth, 1 growth" 48452415_1 CDM 0510 RC 11055 HCPCS inpatient 447 290.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 308.43 69 999999999 270.66 433.59 percent of total billed charges "Removal of noncancer thickened skin growth, 1 growth" 48452415_1 CDM 0510 RC 11055 HCPCS inpatient 447 290.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 348.66 78 999999999 270.66 433.59 percent of total billed charges "Removal of noncancer thickened skin growth, 1 growth" 48452415_1 CDM 0510 RC 11055 HCPCS inpatient 447 290.55 SIHO - ALL PLANS SIHO - ALL PLANS 402.3 90 999999999 270.66 433.59 percent of total billed charges "Removal of noncancer thickened skin growth, 1 growth" 48452415_1 CDM 0510 RC 11055 HCPCS inpatient 447 290.55 UMR - ALL PLANS UMR - ALL PLANS 312.9 70 999999999 270.66 433.59 percent of total billed charges "Removal of noncancer thickened skin growth, 1 growth" 48452415_1 CDM 0510 RC 11055 HCPCS inpatient 447 290.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.66 60.55 999999999 270.66 433.59 percent of total billed charges "Removal of noncancer thickened skin growth, 1 growth" 48452415_1 CDM 0510 RC 11055 HCPCS inpatient 447 290.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.66 433.59 "Removal of noncancer thickened skin growth, 1 growth" 48452415_1 CDM 0510 RC 11055 HCPCS inpatient 447 290.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.66 433.59 "Removal of noncancer thickened skin growth, 1 growth" 48452415_1 CDM 0510 RC 11055 HCPCS inpatient 447 290.55 ANTHEM HMO ANTHEM HMO 999999999 270.66 433.59 "Removal of noncancer thickened skin growth, 1 growth" 48452415_1 CDM 0510 RC 11055 HCPCS inpatient 447 290.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 302.17 67.6 999999999 270.66 433.59 percent of total billed charges "Removal of noncancer thickened skin growth, 1 growth" 48452415_1 CDM 0510 RC 11055 HCPCS inpatient 447 290.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.66 433.59 "Removal of noncancer thickened skin growth, 1 growth" 48452415_1 CDM 0510 RC 11055 HCPCS inpatient 447 290.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.66 433.59 "Removal of noncancer thickened skin growth, 2-4 growths" 48452416_1 CDM 0510 RC 11056 HCPCS inpatient 258 167.7 AETNA AETNA 203.82 79 999999999 156.22 250.26 percent of total billed charges "Removal of noncancer thickened skin growth, 2-4 growths" 48452416_1 CDM 0510 RC 11056 HCPCS inpatient 258 167.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.7 65 999999999 156.22 250.26 percent of total billed charges "Removal of noncancer thickened skin growth, 2-4 growths" 48452416_1 CDM 0510 RC 11056 HCPCS inpatient 258 167.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 250.26 97 999999999 156.22 250.26 percent of total billed charges "Removal of noncancer thickened skin growth, 2-4 growths" 48452416_1 CDM 0510 RC 11056 HCPCS inpatient 258 167.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 178.02 69 999999999 156.22 250.26 percent of total billed charges "Removal of noncancer thickened skin growth, 2-4 growths" 48452416_1 CDM 0510 RC 11056 HCPCS inpatient 258 167.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 201.24 78 999999999 156.22 250.26 percent of total billed charges "Removal of noncancer thickened skin growth, 2-4 growths" 48452416_1 CDM 0510 RC 11056 HCPCS inpatient 258 167.7 SIHO - ALL PLANS SIHO - ALL PLANS 232.2 90 999999999 156.22 250.26 percent of total billed charges "Removal of noncancer thickened skin growth, 2-4 growths" 48452416_1 CDM 0510 RC 11056 HCPCS inpatient 258 167.7 UMR - ALL PLANS UMR - ALL PLANS 180.6 70 999999999 156.22 250.26 percent of total billed charges "Removal of noncancer thickened skin growth, 2-4 growths" 48452416_1 CDM 0510 RC 11056 HCPCS inpatient 258 167.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 156.22 60.55 999999999 156.22 250.26 percent of total billed charges "Removal of noncancer thickened skin growth, 2-4 growths" 48452416_1 CDM 0510 RC 11056 HCPCS inpatient 258 167.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 156.22 250.26 "Removal of noncancer thickened skin growth, 2-4 growths" 48452416_1 CDM 0510 RC 11056 HCPCS inpatient 258 167.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 156.22 250.26 "Removal of noncancer thickened skin growth, 2-4 growths" 48452416_1 CDM 0510 RC 11056 HCPCS inpatient 258 167.7 ANTHEM HMO ANTHEM HMO 999999999 156.22 250.26 "Removal of noncancer thickened skin growth, 2-4 growths" 48452416_1 CDM 0510 RC 11056 HCPCS inpatient 258 167.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 174.41 67.6 999999999 156.22 250.26 percent of total billed charges "Removal of noncancer thickened skin growth, 2-4 growths" 48452416_1 CDM 0510 RC 11056 HCPCS inpatient 258 167.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 156.22 250.26 "Removal of noncancer thickened skin growth, 2-4 growths" 48452416_1 CDM 0510 RC 11056 HCPCS inpatient 258 167.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 156.22 250.26 "Removal of noncancer thickened skin growth, more than 4 growths" 48452417_1 CDM 0510 RC 11057 HCPCS inpatient 456 296.4 AETNA AETNA 360.24 79 999999999 276.11 442.32 percent of total billed charges "Removal of noncancer thickened skin growth, more than 4 growths" 48452417_1 CDM 0510 RC 11057 HCPCS inpatient 456 296.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 296.4 65 999999999 276.11 442.32 percent of total billed charges "Removal of noncancer thickened skin growth, more than 4 growths" 48452417_1 CDM 0510 RC 11057 HCPCS inpatient 456 296.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 442.32 97 999999999 276.11 442.32 percent of total billed charges "Removal of noncancer thickened skin growth, more than 4 growths" 48452417_1 CDM 0510 RC 11057 HCPCS inpatient 456 296.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 314.64 69 999999999 276.11 442.32 percent of total billed charges "Removal of noncancer thickened skin growth, more than 4 growths" 48452417_1 CDM 0510 RC 11057 HCPCS inpatient 456 296.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 355.68 78 999999999 276.11 442.32 percent of total billed charges "Removal of noncancer thickened skin growth, more than 4 growths" 48452417_1 CDM 0510 RC 11057 HCPCS inpatient 456 296.4 SIHO - ALL PLANS SIHO - ALL PLANS 410.4 90 999999999 276.11 442.32 percent of total billed charges "Removal of noncancer thickened skin growth, more than 4 growths" 48452417_1 CDM 0510 RC 11057 HCPCS inpatient 456 296.4 UMR - ALL PLANS UMR - ALL PLANS 319.2 70 999999999 276.11 442.32 percent of total billed charges "Removal of noncancer thickened skin growth, more than 4 growths" 48452417_1 CDM 0510 RC 11057 HCPCS inpatient 456 296.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 276.11 60.55 999999999 276.11 442.32 percent of total billed charges "Removal of noncancer thickened skin growth, more than 4 growths" 48452417_1 CDM 0510 RC 11057 HCPCS inpatient 456 296.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 276.11 442.32 "Removal of noncancer thickened skin growth, more than 4 growths" 48452417_1 CDM 0510 RC 11057 HCPCS inpatient 456 296.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 276.11 442.32 "Removal of noncancer thickened skin growth, more than 4 growths" 48452417_1 CDM 0510 RC 11057 HCPCS inpatient 456 296.4 ANTHEM HMO ANTHEM HMO 999999999 276.11 442.32 "Removal of noncancer thickened skin growth, more than 4 growths" 48452417_1 CDM 0510 RC 11057 HCPCS inpatient 456 296.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 308.26 67.6 999999999 276.11 442.32 percent of total billed charges "Removal of noncancer thickened skin growth, more than 4 growths" 48452417_1 CDM 0510 RC 11057 HCPCS inpatient 456 296.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 276.11 442.32 "Removal of noncancer thickened skin growth, more than 4 growths" 48452417_1 CDM 0510 RC 11057 HCPCS inpatient 456 296.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 276.11 442.32 BIOPSY SKIN LESION 48452418_1 CDM 0510 RC 11100 HCPCS inpatient 692 449.8 AETNA AETNA 546.68 79 999999999 419.01 671.24 percent of total billed charges BIOPSY SKIN LESION 48452418_1 CDM 0510 RC 11100 HCPCS inpatient 692 449.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 449.8 65 999999999 419.01 671.24 percent of total billed charges BIOPSY SKIN LESION 48452418_1 CDM 0510 RC 11100 HCPCS inpatient 692 449.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 671.24 97 999999999 419.01 671.24 percent of total billed charges BIOPSY SKIN LESION 48452418_1 CDM 0510 RC 11100 HCPCS inpatient 692 449.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 477.48 69 999999999 419.01 671.24 percent of total billed charges BIOPSY SKIN LESION 48452418_1 CDM 0510 RC 11100 HCPCS inpatient 692 449.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 539.76 78 999999999 419.01 671.24 percent of total billed charges BIOPSY SKIN LESION 48452418_1 CDM 0510 RC 11100 HCPCS inpatient 692 449.8 SIHO - ALL PLANS SIHO - ALL PLANS 622.8 90 999999999 419.01 671.24 percent of total billed charges BIOPSY SKIN LESION 48452418_1 CDM 0510 RC 11100 HCPCS inpatient 692 449.8 UMR - ALL PLANS UMR - ALL PLANS 484.4 70 999999999 419.01 671.24 percent of total billed charges BIOPSY SKIN LESION 48452418_1 CDM 0510 RC 11100 HCPCS inpatient 692 449.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 419.01 60.55 999999999 419.01 671.24 percent of total billed charges BIOPSY SKIN LESION 48452418_1 CDM 0510 RC 11100 HCPCS inpatient 692 449.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 419.01 671.24 BIOPSY SKIN LESION 48452418_1 CDM 0510 RC 11100 HCPCS inpatient 692 449.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 419.01 671.24 BIOPSY SKIN LESION 48452418_1 CDM 0510 RC 11100 HCPCS inpatient 692 449.8 ANTHEM HMO ANTHEM HMO 999999999 419.01 671.24 BIOPSY SKIN LESION 48452418_1 CDM 0510 RC 11100 HCPCS inpatient 692 449.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 467.79 67.6 999999999 419.01 671.24 percent of total billed charges BIOPSY SKIN LESION 48452418_1 CDM 0510 RC 11100 HCPCS inpatient 692 449.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 419.01 671.24 BIOPSY SKIN LESION 48452418_1 CDM 0510 RC 11100 HCPCS inpatient 692 449.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 419.01 671.24 BIOPSY SKIN ADD-ON 48452419_1 CDM 0510 RC 11101 HCPCS inpatient 258 167.7 AETNA AETNA 203.82 79 999999999 156.22 250.26 percent of total billed charges BIOPSY SKIN ADD-ON 48452419_1 CDM 0510 RC 11101 HCPCS inpatient 258 167.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.7 65 999999999 156.22 250.26 percent of total billed charges BIOPSY SKIN ADD-ON 48452419_1 CDM 0510 RC 11101 HCPCS inpatient 258 167.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 250.26 97 999999999 156.22 250.26 percent of total billed charges BIOPSY SKIN ADD-ON 48452419_1 CDM 0510 RC 11101 HCPCS inpatient 258 167.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 178.02 69 999999999 156.22 250.26 percent of total billed charges BIOPSY SKIN ADD-ON 48452419_1 CDM 0510 RC 11101 HCPCS inpatient 258 167.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 201.24 78 999999999 156.22 250.26 percent of total billed charges BIOPSY SKIN ADD-ON 48452419_1 CDM 0510 RC 11101 HCPCS inpatient 258 167.7 SIHO - ALL PLANS SIHO - ALL PLANS 232.2 90 999999999 156.22 250.26 percent of total billed charges BIOPSY SKIN ADD-ON 48452419_1 CDM 0510 RC 11101 HCPCS inpatient 258 167.7 UMR - ALL PLANS UMR - ALL PLANS 180.6 70 999999999 156.22 250.26 percent of total billed charges BIOPSY SKIN ADD-ON 48452419_1 CDM 0510 RC 11101 HCPCS inpatient 258 167.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 156.22 60.55 999999999 156.22 250.26 percent of total billed charges BIOPSY SKIN ADD-ON 48452419_1 CDM 0510 RC 11101 HCPCS inpatient 258 167.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 156.22 250.26 BIOPSY SKIN ADD-ON 48452419_1 CDM 0510 RC 11101 HCPCS inpatient 258 167.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 156.22 250.26 BIOPSY SKIN ADD-ON 48452419_1 CDM 0510 RC 11101 HCPCS inpatient 258 167.7 ANTHEM HMO ANTHEM HMO 999999999 156.22 250.26 BIOPSY SKIN ADD-ON 48452419_1 CDM 0510 RC 11101 HCPCS inpatient 258 167.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 174.41 67.6 999999999 156.22 250.26 percent of total billed charges BIOPSY SKIN ADD-ON 48452419_1 CDM 0510 RC 11101 HCPCS inpatient 258 167.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 156.22 250.26 BIOPSY SKIN ADD-ON 48452419_1 CDM 0510 RC 11101 HCPCS inpatient 258 167.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 156.22 250.26 "Removal of fingernails or toenails, 1-5 nails" 48452420_1 CDM 0510 RC 11720 HCPCS inpatient 258 167.7 AETNA AETNA 203.82 79 999999999 156.22 250.26 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 48452420_1 CDM 0510 RC 11720 HCPCS inpatient 258 167.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.7 65 999999999 156.22 250.26 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 48452420_1 CDM 0510 RC 11720 HCPCS inpatient 258 167.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 250.26 97 999999999 156.22 250.26 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 48452420_1 CDM 0510 RC 11720 HCPCS inpatient 258 167.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 178.02 69 999999999 156.22 250.26 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 48452420_1 CDM 0510 RC 11720 HCPCS inpatient 258 167.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 201.24 78 999999999 156.22 250.26 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 48452420_1 CDM 0510 RC 11720 HCPCS inpatient 258 167.7 SIHO - ALL PLANS SIHO - ALL PLANS 232.2 90 999999999 156.22 250.26 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 48452420_1 CDM 0510 RC 11720 HCPCS inpatient 258 167.7 UMR - ALL PLANS UMR - ALL PLANS 180.6 70 999999999 156.22 250.26 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 48452420_1 CDM 0510 RC 11720 HCPCS inpatient 258 167.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 156.22 60.55 999999999 156.22 250.26 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 48452420_1 CDM 0510 RC 11720 HCPCS inpatient 258 167.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 156.22 250.26 "Removal of fingernails or toenails, 1-5 nails" 48452420_1 CDM 0510 RC 11720 HCPCS inpatient 258 167.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 156.22 250.26 "Removal of fingernails or toenails, 1-5 nails" 48452420_1 CDM 0510 RC 11720 HCPCS inpatient 258 167.7 ANTHEM HMO ANTHEM HMO 999999999 156.22 250.26 "Removal of fingernails or toenails, 1-5 nails" 48452420_1 CDM 0510 RC 11720 HCPCS inpatient 258 167.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 174.41 67.6 999999999 156.22 250.26 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 48452420_1 CDM 0510 RC 11720 HCPCS inpatient 258 167.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 156.22 250.26 "Removal of fingernails or toenails, 1-5 nails" 48452420_1 CDM 0510 RC 11720 HCPCS inpatient 258 167.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 156.22 250.26 "Simple separation of fingernail or toenail from nail bed, first nail" 48452421_1 CDM 0510 RC 11730 HCPCS inpatient 258 167.7 AETNA AETNA 203.82 79 999999999 156.22 250.26 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48452421_1 CDM 0510 RC 11730 HCPCS inpatient 258 167.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.7 65 999999999 156.22 250.26 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48452421_1 CDM 0510 RC 11730 HCPCS inpatient 258 167.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 250.26 97 999999999 156.22 250.26 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48452421_1 CDM 0510 RC 11730 HCPCS inpatient 258 167.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 178.02 69 999999999 156.22 250.26 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48452421_1 CDM 0510 RC 11730 HCPCS inpatient 258 167.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 201.24 78 999999999 156.22 250.26 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48452421_1 CDM 0510 RC 11730 HCPCS inpatient 258 167.7 SIHO - ALL PLANS SIHO - ALL PLANS 232.2 90 999999999 156.22 250.26 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48452421_1 CDM 0510 RC 11730 HCPCS inpatient 258 167.7 UMR - ALL PLANS UMR - ALL PLANS 180.6 70 999999999 156.22 250.26 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48452421_1 CDM 0510 RC 11730 HCPCS inpatient 258 167.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 156.22 60.55 999999999 156.22 250.26 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48452421_1 CDM 0510 RC 11730 HCPCS inpatient 258 167.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 156.22 250.26 "Simple separation of fingernail or toenail from nail bed, first nail" 48452421_1 CDM 0510 RC 11730 HCPCS inpatient 258 167.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 156.22 250.26 "Simple separation of fingernail or toenail from nail bed, first nail" 48452421_1 CDM 0510 RC 11730 HCPCS inpatient 258 167.7 ANTHEM HMO ANTHEM HMO 999999999 156.22 250.26 "Simple separation of fingernail or toenail from nail bed, first nail" 48452421_1 CDM 0510 RC 11730 HCPCS inpatient 258 167.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 174.41 67.6 999999999 156.22 250.26 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48452421_1 CDM 0510 RC 11730 HCPCS inpatient 258 167.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 156.22 250.26 "Simple separation of fingernail or toenail from nail bed, first nail" 48452421_1 CDM 0510 RC 11730 HCPCS inpatient 258 167.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 156.22 250.26 "Skin graft to tip of finger or toe, 2.0 cm or less" 48452422_1 CDM 0361 RC 15050 HCPCS inpatient 1297 843.05 AETNA AETNA 1024.63 79 999999999 785.33 1258.09 percent of total billed charges "Skin graft to tip of finger or toe, 2.0 cm or less" 48452422_1 CDM 0361 RC 15050 HCPCS inpatient 1297 843.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 843.05 65 999999999 785.33 1258.09 percent of total billed charges "Skin graft to tip of finger or toe, 2.0 cm or less" 48452422_1 CDM 0361 RC 15050 HCPCS inpatient 1297 843.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1258.09 97 999999999 785.33 1258.09 percent of total billed charges "Skin graft to tip of finger or toe, 2.0 cm or less" 48452422_1 CDM 0361 RC 15050 HCPCS inpatient 1297 843.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 894.93 69 999999999 785.33 1258.09 percent of total billed charges "Skin graft to tip of finger or toe, 2.0 cm or less" 48452422_1 CDM 0361 RC 15050 HCPCS inpatient 1297 843.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1011.66 78 999999999 785.33 1258.09 percent of total billed charges "Skin graft to tip of finger or toe, 2.0 cm or less" 48452422_1 CDM 0361 RC 15050 HCPCS inpatient 1297 843.05 SIHO - ALL PLANS SIHO - ALL PLANS 1167.3 90 999999999 785.33 1258.09 percent of total billed charges "Skin graft to tip of finger or toe, 2.0 cm or less" 48452422_1 CDM 0361 RC 15050 HCPCS inpatient 1297 843.05 UMR - ALL PLANS UMR - ALL PLANS 907.9 70 999999999 785.33 1258.09 percent of total billed charges "Skin graft to tip of finger or toe, 2.0 cm or less" 48452422_1 CDM 0361 RC 15050 HCPCS inpatient 1297 843.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 785.33 60.55 999999999 785.33 1258.09 percent of total billed charges "Skin graft to tip of finger or toe, 2.0 cm or less" 48452422_1 CDM 0361 RC 15050 HCPCS inpatient 1297 843.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 785.33 1258.09 "Skin graft to tip of finger or toe, 2.0 cm or less" 48452422_1 CDM 0361 RC 15050 HCPCS inpatient 1297 843.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 785.33 1258.09 "Skin graft to tip of finger or toe, 2.0 cm or less" 48452422_1 CDM 0361 RC 15050 HCPCS inpatient 1297 843.05 ANTHEM HMO ANTHEM HMO 999999999 785.33 1258.09 "Skin graft to tip of finger or toe, 2.0 cm or less" 48452422_1 CDM 0361 RC 15050 HCPCS inpatient 1297 843.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 876.77 67.6 999999999 785.33 1258.09 percent of total billed charges "Skin graft to tip of finger or toe, 2.0 cm or less" 48452422_1 CDM 0361 RC 15050 HCPCS inpatient 1297 843.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 785.33 1258.09 "Skin graft to tip of finger or toe, 2.0 cm or less" 48452422_1 CDM 0361 RC 15050 HCPCS inpatient 1297 843.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 785.33 1258.09 "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452423_1 CDM 0361 RC 15271 HCPCS inpatient 1697 1103.05 AETNA AETNA 1340.63 79 999999999 1027.53 1646.09 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452423_1 CDM 0361 RC 15271 HCPCS inpatient 1697 1103.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1103.05 65 999999999 1027.53 1646.09 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452423_1 CDM 0361 RC 15271 HCPCS inpatient 1697 1103.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1646.09 97 999999999 1027.53 1646.09 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452423_1 CDM 0361 RC 15271 HCPCS inpatient 1697 1103.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1170.93 69 999999999 1027.53 1646.09 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452423_1 CDM 0361 RC 15271 HCPCS inpatient 1697 1103.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1323.66 78 999999999 1027.53 1646.09 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452423_1 CDM 0361 RC 15271 HCPCS inpatient 1697 1103.05 SIHO - ALL PLANS SIHO - ALL PLANS 1527.3 90 999999999 1027.53 1646.09 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452423_1 CDM 0361 RC 15271 HCPCS inpatient 1697 1103.05 UMR - ALL PLANS UMR - ALL PLANS 1187.9 70 999999999 1027.53 1646.09 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452423_1 CDM 0361 RC 15271 HCPCS inpatient 1697 1103.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1027.53 60.55 999999999 1027.53 1646.09 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452423_1 CDM 0361 RC 15271 HCPCS inpatient 1697 1103.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1027.53 1646.09 "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452423_1 CDM 0361 RC 15271 HCPCS inpatient 1697 1103.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1027.53 1646.09 "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452423_1 CDM 0361 RC 15271 HCPCS inpatient 1697 1103.05 ANTHEM HMO ANTHEM HMO 999999999 1027.53 1646.09 "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452423_1 CDM 0361 RC 15271 HCPCS inpatient 1697 1103.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1147.17 67.6 999999999 1027.53 1646.09 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452423_1 CDM 0361 RC 15271 HCPCS inpatient 1697 1103.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1027.53 1646.09 "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452423_1 CDM 0361 RC 15271 HCPCS inpatient 1697 1103.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1027.53 1646.09 "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452424_1 CDM 0361 RC 15272 HCPCS inpatient 351 228.15 AETNA AETNA 277.29 79 999999999 212.53 340.47 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452424_1 CDM 0361 RC 15272 HCPCS inpatient 351 228.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 228.15 65 999999999 212.53 340.47 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452424_1 CDM 0361 RC 15272 HCPCS inpatient 351 228.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 340.47 97 999999999 212.53 340.47 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452424_1 CDM 0361 RC 15272 HCPCS inpatient 351 228.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 242.19 69 999999999 212.53 340.47 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452424_1 CDM 0361 RC 15272 HCPCS inpatient 351 228.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 273.78 78 999999999 212.53 340.47 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452424_1 CDM 0361 RC 15272 HCPCS inpatient 351 228.15 SIHO - ALL PLANS SIHO - ALL PLANS 315.9 90 999999999 212.53 340.47 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452424_1 CDM 0361 RC 15272 HCPCS inpatient 351 228.15 UMR - ALL PLANS UMR - ALL PLANS 245.7 70 999999999 212.53 340.47 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452424_1 CDM 0361 RC 15272 HCPCS inpatient 351 228.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 212.53 60.55 999999999 212.53 340.47 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452424_1 CDM 0361 RC 15272 HCPCS inpatient 351 228.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 212.53 340.47 "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452424_1 CDM 0361 RC 15272 HCPCS inpatient 351 228.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 212.53 340.47 "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452424_1 CDM 0361 RC 15272 HCPCS inpatient 351 228.15 ANTHEM HMO ANTHEM HMO 999999999 212.53 340.47 "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452424_1 CDM 0361 RC 15272 HCPCS inpatient 351 228.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 237.28 67.6 999999999 212.53 340.47 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452424_1 CDM 0361 RC 15272 HCPCS inpatient 351 228.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 212.53 340.47 "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452424_1 CDM 0361 RC 15272 HCPCS inpatient 351 228.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 212.53 340.47 "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, 100.0 sq cm or 1% body area for infants and children, or less" 48452425_1 CDM 0361 RC 15273 HCPCS inpatient 1301 845.65 AETNA AETNA 1027.79 79 999999999 787.76 1261.97 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, 100.0 sq cm or 1% body area for infants and children, or less" 48452425_1 CDM 0361 RC 15273 HCPCS inpatient 1301 845.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 845.65 65 999999999 787.76 1261.97 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, 100.0 sq cm or 1% body area for infants and children, or less" 48452425_1 CDM 0361 RC 15273 HCPCS inpatient 1301 845.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1261.97 97 999999999 787.76 1261.97 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, 100.0 sq cm or 1% body area for infants and children, or less" 48452425_1 CDM 0361 RC 15273 HCPCS inpatient 1301 845.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 897.69 69 999999999 787.76 1261.97 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, 100.0 sq cm or 1% body area for infants and children, or less" 48452425_1 CDM 0361 RC 15273 HCPCS inpatient 1301 845.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1014.78 78 999999999 787.76 1261.97 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, 100.0 sq cm or 1% body area for infants and children, or less" 48452425_1 CDM 0361 RC 15273 HCPCS inpatient 1301 845.65 SIHO - ALL PLANS SIHO - ALL PLANS 1170.9 90 999999999 787.76 1261.97 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, 100.0 sq cm or 1% body area for infants and children, or less" 48452425_1 CDM 0361 RC 15273 HCPCS inpatient 1301 845.65 UMR - ALL PLANS UMR - ALL PLANS 910.7 70 999999999 787.76 1261.97 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, 100.0 sq cm or 1% body area for infants and children, or less" 48452425_1 CDM 0361 RC 15273 HCPCS inpatient 1301 845.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 787.76 60.55 999999999 787.76 1261.97 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, 100.0 sq cm or 1% body area for infants and children, or less" 48452425_1 CDM 0361 RC 15273 HCPCS inpatient 1301 845.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 787.76 1261.97 "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, 100.0 sq cm or 1% body area for infants and children, or less" 48452425_1 CDM 0361 RC 15273 HCPCS inpatient 1301 845.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 787.76 1261.97 "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, 100.0 sq cm or 1% body area for infants and children, or less" 48452425_1 CDM 0361 RC 15273 HCPCS inpatient 1301 845.65 ANTHEM HMO ANTHEM HMO 999999999 787.76 1261.97 "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, 100.0 sq cm or 1% body area for infants and children, or less" 48452425_1 CDM 0361 RC 15273 HCPCS inpatient 1301 845.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 879.48 67.6 999999999 787.76 1261.97 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, 100.0 sq cm or 1% body area for infants and children, or less" 48452425_1 CDM 0361 RC 15273 HCPCS inpatient 1301 845.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 787.76 1261.97 "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, 100.0 sq cm or 1% body area for infants and children, or less" 48452425_1 CDM 0361 RC 15273 HCPCS inpatient 1301 845.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 787.76 1261.97 "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452426_1 CDM 0361 RC 15274 HCPCS inpatient 856 556.4 AETNA AETNA 676.24 79 999999999 518.31 830.32 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452426_1 CDM 0361 RC 15274 HCPCS inpatient 856 556.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 556.4 65 999999999 518.31 830.32 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452426_1 CDM 0361 RC 15274 HCPCS inpatient 856 556.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 830.32 97 999999999 518.31 830.32 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452426_1 CDM 0361 RC 15274 HCPCS inpatient 856 556.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 590.64 69 999999999 518.31 830.32 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452426_1 CDM 0361 RC 15274 HCPCS inpatient 856 556.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 667.68 78 999999999 518.31 830.32 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452426_1 CDM 0361 RC 15274 HCPCS inpatient 856 556.4 SIHO - ALL PLANS SIHO - ALL PLANS 770.4 90 999999999 518.31 830.32 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452426_1 CDM 0361 RC 15274 HCPCS inpatient 856 556.4 UMR - ALL PLANS UMR - ALL PLANS 599.2 70 999999999 518.31 830.32 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452426_1 CDM 0361 RC 15274 HCPCS inpatient 856 556.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 518.31 60.55 999999999 518.31 830.32 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452426_1 CDM 0361 RC 15274 HCPCS inpatient 856 556.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 518.31 830.32 "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452426_1 CDM 0361 RC 15274 HCPCS inpatient 856 556.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 518.31 830.32 "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452426_1 CDM 0361 RC 15274 HCPCS inpatient 856 556.4 ANTHEM HMO ANTHEM HMO 999999999 518.31 830.32 "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452426_1 CDM 0361 RC 15274 HCPCS inpatient 856 556.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 578.66 67.6 999999999 518.31 830.32 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452426_1 CDM 0361 RC 15274 HCPCS inpatient 856 556.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 518.31 830.32 "Skin substitute graft to wound 100.0 sq cm or more of trunk, arms, or legs, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452426_1 CDM 0361 RC 15274 HCPCS inpatient 856 556.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 518.31 830.32 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452427_1 CDM 0361 RC 15275 HCPCS inpatient 2070 1345.5 AETNA AETNA 1635.3 79 999999999 1253.39 2007.9 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452427_1 CDM 0361 RC 15275 HCPCS inpatient 2070 1345.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1345.5 65 999999999 1253.39 2007.9 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452427_1 CDM 0361 RC 15275 HCPCS inpatient 2070 1345.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2007.9 97 999999999 1253.39 2007.9 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452427_1 CDM 0361 RC 15275 HCPCS inpatient 2070 1345.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1428.3 69 999999999 1253.39 2007.9 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452427_1 CDM 0361 RC 15275 HCPCS inpatient 2070 1345.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1614.6 78 999999999 1253.39 2007.9 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452427_1 CDM 0361 RC 15275 HCPCS inpatient 2070 1345.5 SIHO - ALL PLANS SIHO - ALL PLANS 1863 90 999999999 1253.39 2007.9 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452427_1 CDM 0361 RC 15275 HCPCS inpatient 2070 1345.5 UMR - ALL PLANS UMR - ALL PLANS 1449 70 999999999 1253.39 2007.9 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452427_1 CDM 0361 RC 15275 HCPCS inpatient 2070 1345.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1253.39 60.55 999999999 1253.39 2007.9 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452427_1 CDM 0361 RC 15275 HCPCS inpatient 2070 1345.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1253.39 2007.9 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452427_1 CDM 0361 RC 15275 HCPCS inpatient 2070 1345.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1253.39 2007.9 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452427_1 CDM 0361 RC 15275 HCPCS inpatient 2070 1345.5 ANTHEM HMO ANTHEM HMO 999999999 1253.39 2007.9 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452427_1 CDM 0361 RC 15275 HCPCS inpatient 2070 1345.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1399.32 67.6 999999999 1253.39 2007.9 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452427_1 CDM 0361 RC 15275 HCPCS inpatient 2070 1345.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1253.39 2007.9 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 48452427_1 CDM 0361 RC 15275 HCPCS inpatient 2070 1345.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1253.39 2007.9 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452428_1 CDM 0361 RC 15276 HCPCS inpatient 351 228.15 AETNA AETNA 277.29 79 999999999 212.53 340.47 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452428_1 CDM 0361 RC 15276 HCPCS inpatient 351 228.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 228.15 65 999999999 212.53 340.47 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452428_1 CDM 0361 RC 15276 HCPCS inpatient 351 228.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 340.47 97 999999999 212.53 340.47 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452428_1 CDM 0361 RC 15276 HCPCS inpatient 351 228.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 242.19 69 999999999 212.53 340.47 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452428_1 CDM 0361 RC 15276 HCPCS inpatient 351 228.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 273.78 78 999999999 212.53 340.47 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452428_1 CDM 0361 RC 15276 HCPCS inpatient 351 228.15 SIHO - ALL PLANS SIHO - ALL PLANS 315.9 90 999999999 212.53 340.47 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452428_1 CDM 0361 RC 15276 HCPCS inpatient 351 228.15 UMR - ALL PLANS UMR - ALL PLANS 245.7 70 999999999 212.53 340.47 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452428_1 CDM 0361 RC 15276 HCPCS inpatient 351 228.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 212.53 60.55 999999999 212.53 340.47 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452428_1 CDM 0361 RC 15276 HCPCS inpatient 351 228.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 212.53 340.47 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452428_1 CDM 0361 RC 15276 HCPCS inpatient 351 228.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 212.53 340.47 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452428_1 CDM 0361 RC 15276 HCPCS inpatient 351 228.15 ANTHEM HMO ANTHEM HMO 999999999 212.53 340.47 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452428_1 CDM 0361 RC 15276 HCPCS inpatient 351 228.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 237.28 67.6 999999999 212.53 340.47 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452428_1 CDM 0361 RC 15276 HCPCS inpatient 351 228.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 212.53 340.47 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 48452428_1 CDM 0361 RC 15276 HCPCS inpatient 351 228.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 212.53 340.47 "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 48452429_1 CDM 0361 RC 15277 HCPCS inpatient 1301 845.65 AETNA AETNA 1027.79 79 999999999 787.76 1261.97 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 48452429_1 CDM 0361 RC 15277 HCPCS inpatient 1301 845.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 845.65 65 999999999 787.76 1261.97 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 48452429_1 CDM 0361 RC 15277 HCPCS inpatient 1301 845.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1261.97 97 999999999 787.76 1261.97 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 48452429_1 CDM 0361 RC 15277 HCPCS inpatient 1301 845.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 897.69 69 999999999 787.76 1261.97 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 48452429_1 CDM 0361 RC 15277 HCPCS inpatient 1301 845.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1014.78 78 999999999 787.76 1261.97 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 48452429_1 CDM 0361 RC 15277 HCPCS inpatient 1301 845.65 SIHO - ALL PLANS SIHO - ALL PLANS 1170.9 90 999999999 787.76 1261.97 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 48452429_1 CDM 0361 RC 15277 HCPCS inpatient 1301 845.65 UMR - ALL PLANS UMR - ALL PLANS 910.7 70 999999999 787.76 1261.97 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 48452429_1 CDM 0361 RC 15277 HCPCS inpatient 1301 845.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 787.76 60.55 999999999 787.76 1261.97 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 48452429_1 CDM 0361 RC 15277 HCPCS inpatient 1301 845.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 787.76 1261.97 "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 48452429_1 CDM 0361 RC 15277 HCPCS inpatient 1301 845.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 787.76 1261.97 "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 48452429_1 CDM 0361 RC 15277 HCPCS inpatient 1301 845.65 ANTHEM HMO ANTHEM HMO 999999999 787.76 1261.97 "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 48452429_1 CDM 0361 RC 15277 HCPCS inpatient 1301 845.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 879.48 67.6 999999999 787.76 1261.97 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 48452429_1 CDM 0361 RC 15277 HCPCS inpatient 1301 845.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 787.76 1261.97 "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 48452429_1 CDM 0361 RC 15277 HCPCS inpatient 1301 845.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 787.76 1261.97 "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452430_1 CDM 0361 RC 15278 HCPCS inpatient 856 556.4 AETNA AETNA 676.24 79 999999999 518.31 830.32 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452430_1 CDM 0361 RC 15278 HCPCS inpatient 856 556.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 556.4 65 999999999 518.31 830.32 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452430_1 CDM 0361 RC 15278 HCPCS inpatient 856 556.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 830.32 97 999999999 518.31 830.32 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452430_1 CDM 0361 RC 15278 HCPCS inpatient 856 556.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 590.64 69 999999999 518.31 830.32 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452430_1 CDM 0361 RC 15278 HCPCS inpatient 856 556.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 667.68 78 999999999 518.31 830.32 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452430_1 CDM 0361 RC 15278 HCPCS inpatient 856 556.4 SIHO - ALL PLANS SIHO - ALL PLANS 770.4 90 999999999 518.31 830.32 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452430_1 CDM 0361 RC 15278 HCPCS inpatient 856 556.4 UMR - ALL PLANS UMR - ALL PLANS 599.2 70 999999999 518.31 830.32 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452430_1 CDM 0361 RC 15278 HCPCS inpatient 856 556.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 518.31 60.55 999999999 518.31 830.32 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452430_1 CDM 0361 RC 15278 HCPCS inpatient 856 556.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 518.31 830.32 "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452430_1 CDM 0361 RC 15278 HCPCS inpatient 856 556.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 518.31 830.32 "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452430_1 CDM 0361 RC 15278 HCPCS inpatient 856 556.4 ANTHEM HMO ANTHEM HMO 999999999 518.31 830.32 "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452430_1 CDM 0361 RC 15278 HCPCS inpatient 856 556.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 578.66 67.6 999999999 518.31 830.32 percent of total billed charges "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452430_1 CDM 0361 RC 15278 HCPCS inpatient 856 556.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 518.31 830.32 "Skin substitute graft to wound 100.0 sq cm or more of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 100.0 sq cm or 1% body area for infants and children, or less" 48452430_1 CDM 0361 RC 15278 HCPCS inpatient 856 556.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 518.31 830.32 First degree burn treatment 48452431_1 CDM 0510 RC 16000 HCPCS inpatient 257 167.05 AETNA AETNA 203.03 79 999999999 155.61 249.29 percent of total billed charges First degree burn treatment 48452431_1 CDM 0510 RC 16000 HCPCS inpatient 257 167.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.05 65 999999999 155.61 249.29 percent of total billed charges First degree burn treatment 48452431_1 CDM 0510 RC 16000 HCPCS inpatient 257 167.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 249.29 97 999999999 155.61 249.29 percent of total billed charges First degree burn treatment 48452431_1 CDM 0510 RC 16000 HCPCS inpatient 257 167.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 177.33 69 999999999 155.61 249.29 percent of total billed charges First degree burn treatment 48452431_1 CDM 0510 RC 16000 HCPCS inpatient 257 167.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 200.46 78 999999999 155.61 249.29 percent of total billed charges First degree burn treatment 48452431_1 CDM 0510 RC 16000 HCPCS inpatient 257 167.05 SIHO - ALL PLANS SIHO - ALL PLANS 231.3 90 999999999 155.61 249.29 percent of total billed charges First degree burn treatment 48452431_1 CDM 0510 RC 16000 HCPCS inpatient 257 167.05 UMR - ALL PLANS UMR - ALL PLANS 179.9 70 999999999 155.61 249.29 percent of total billed charges First degree burn treatment 48452431_1 CDM 0510 RC 16000 HCPCS inpatient 257 167.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.61 60.55 999999999 155.61 249.29 percent of total billed charges First degree burn treatment 48452431_1 CDM 0510 RC 16000 HCPCS inpatient 257 167.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.61 249.29 First degree burn treatment 48452431_1 CDM 0510 RC 16000 HCPCS inpatient 257 167.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.61 249.29 First degree burn treatment 48452431_1 CDM 0510 RC 16000 HCPCS inpatient 257 167.05 ANTHEM HMO ANTHEM HMO 999999999 155.61 249.29 First degree burn treatment 48452431_1 CDM 0510 RC 16000 HCPCS inpatient 257 167.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.73 67.6 999999999 155.61 249.29 percent of total billed charges First degree burn treatment 48452431_1 CDM 0510 RC 16000 HCPCS inpatient 257 167.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.61 249.29 First degree burn treatment 48452431_1 CDM 0510 RC 16000 HCPCS inpatient 257 167.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.61 249.29 "Dressing change or removal of burn tissue, less than 5% of total body surface" 48452432_1 CDM 0510 RC 16020 HCPCS inpatient 421 273.65 AETNA AETNA 332.59 79 999999999 254.92 408.37 percent of total billed charges "Dressing change or removal of burn tissue, less than 5% of total body surface" 48452432_1 CDM 0510 RC 16020 HCPCS inpatient 421 273.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 273.65 65 999999999 254.92 408.37 percent of total billed charges "Dressing change or removal of burn tissue, less than 5% of total body surface" 48452432_1 CDM 0510 RC 16020 HCPCS inpatient 421 273.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 408.37 97 999999999 254.92 408.37 percent of total billed charges "Dressing change or removal of burn tissue, less than 5% of total body surface" 48452432_1 CDM 0510 RC 16020 HCPCS inpatient 421 273.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 290.49 69 999999999 254.92 408.37 percent of total billed charges "Dressing change or removal of burn tissue, less than 5% of total body surface" 48452432_1 CDM 0510 RC 16020 HCPCS inpatient 421 273.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 328.38 78 999999999 254.92 408.37 percent of total billed charges "Dressing change or removal of burn tissue, less than 5% of total body surface" 48452432_1 CDM 0510 RC 16020 HCPCS inpatient 421 273.65 SIHO - ALL PLANS SIHO - ALL PLANS 378.9 90 999999999 254.92 408.37 percent of total billed charges "Dressing change or removal of burn tissue, less than 5% of total body surface" 48452432_1 CDM 0510 RC 16020 HCPCS inpatient 421 273.65 UMR - ALL PLANS UMR - ALL PLANS 294.7 70 999999999 254.92 408.37 percent of total billed charges "Dressing change or removal of burn tissue, less than 5% of total body surface" 48452432_1 CDM 0510 RC 16020 HCPCS inpatient 421 273.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 254.92 60.55 999999999 254.92 408.37 percent of total billed charges "Dressing change or removal of burn tissue, less than 5% of total body surface" 48452432_1 CDM 0510 RC 16020 HCPCS inpatient 421 273.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 254.92 408.37 "Dressing change or removal of burn tissue, less than 5% of total body surface" 48452432_1 CDM 0510 RC 16020 HCPCS inpatient 421 273.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 254.92 408.37 "Dressing change or removal of burn tissue, less than 5% of total body surface" 48452432_1 CDM 0510 RC 16020 HCPCS inpatient 421 273.65 ANTHEM HMO ANTHEM HMO 999999999 254.92 408.37 "Dressing change or removal of burn tissue, less than 5% of total body surface" 48452432_1 CDM 0510 RC 16020 HCPCS inpatient 421 273.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 284.6 67.6 999999999 254.92 408.37 percent of total billed charges "Dressing change or removal of burn tissue, less than 5% of total body surface" 48452432_1 CDM 0510 RC 16020 HCPCS inpatient 421 273.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 254.92 408.37 "Dressing change or removal of burn tissue, less than 5% of total body surface" 48452432_1 CDM 0510 RC 16020 HCPCS inpatient 421 273.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 254.92 408.37 "Dressing change or removal of burn tissue, 5-10% of total body surface" 48452433_1 CDM 0510 RC 16025 HCPCS inpatient 398 258.7 AETNA AETNA 314.42 79 999999999 240.99 386.06 percent of total billed charges "Dressing change or removal of burn tissue, 5-10% of total body surface" 48452433_1 CDM 0510 RC 16025 HCPCS inpatient 398 258.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 258.7 65 999999999 240.99 386.06 percent of total billed charges "Dressing change or removal of burn tissue, 5-10% of total body surface" 48452433_1 CDM 0510 RC 16025 HCPCS inpatient 398 258.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 386.06 97 999999999 240.99 386.06 percent of total billed charges "Dressing change or removal of burn tissue, 5-10% of total body surface" 48452433_1 CDM 0510 RC 16025 HCPCS inpatient 398 258.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 274.62 69 999999999 240.99 386.06 percent of total billed charges "Dressing change or removal of burn tissue, 5-10% of total body surface" 48452433_1 CDM 0510 RC 16025 HCPCS inpatient 398 258.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 310.44 78 999999999 240.99 386.06 percent of total billed charges "Dressing change or removal of burn tissue, 5-10% of total body surface" 48452433_1 CDM 0510 RC 16025 HCPCS inpatient 398 258.7 SIHO - ALL PLANS SIHO - ALL PLANS 358.2 90 999999999 240.99 386.06 percent of total billed charges "Dressing change or removal of burn tissue, 5-10% of total body surface" 48452433_1 CDM 0510 RC 16025 HCPCS inpatient 398 258.7 UMR - ALL PLANS UMR - ALL PLANS 278.6 70 999999999 240.99 386.06 percent of total billed charges "Dressing change or removal of burn tissue, 5-10% of total body surface" 48452433_1 CDM 0510 RC 16025 HCPCS inpatient 398 258.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 240.99 60.55 999999999 240.99 386.06 percent of total billed charges "Dressing change or removal of burn tissue, 5-10% of total body surface" 48452433_1 CDM 0510 RC 16025 HCPCS inpatient 398 258.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 240.99 386.06 "Dressing change or removal of burn tissue, 5-10% of total body surface" 48452433_1 CDM 0510 RC 16025 HCPCS inpatient 398 258.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 240.99 386.06 "Dressing change or removal of burn tissue, 5-10% of total body surface" 48452433_1 CDM 0510 RC 16025 HCPCS inpatient 398 258.7 ANTHEM HMO ANTHEM HMO 999999999 240.99 386.06 "Dressing change or removal of burn tissue, 5-10% of total body surface" 48452433_1 CDM 0510 RC 16025 HCPCS inpatient 398 258.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 269.05 67.6 999999999 240.99 386.06 percent of total billed charges "Dressing change or removal of burn tissue, 5-10% of total body surface" 48452433_1 CDM 0510 RC 16025 HCPCS inpatient 398 258.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 240.99 386.06 "Dressing change or removal of burn tissue, 5-10% of total body surface" 48452433_1 CDM 0510 RC 16025 HCPCS inpatient 398 258.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 240.99 386.06 Application of chemical to stop tissue regrowth in wound 48452434_1 CDM 0510 RC 17250 HCPCS inpatient 492 319.8 AETNA AETNA 388.68 79 999999999 297.91 477.24 percent of total billed charges Application of chemical to stop tissue regrowth in wound 48452434_1 CDM 0510 RC 17250 HCPCS inpatient 492 319.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 319.8 65 999999999 297.91 477.24 percent of total billed charges Application of chemical to stop tissue regrowth in wound 48452434_1 CDM 0510 RC 17250 HCPCS inpatient 492 319.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 477.24 97 999999999 297.91 477.24 percent of total billed charges Application of chemical to stop tissue regrowth in wound 48452434_1 CDM 0510 RC 17250 HCPCS inpatient 492 319.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 339.48 69 999999999 297.91 477.24 percent of total billed charges Application of chemical to stop tissue regrowth in wound 48452434_1 CDM 0510 RC 17250 HCPCS inpatient 492 319.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 383.76 78 999999999 297.91 477.24 percent of total billed charges Application of chemical to stop tissue regrowth in wound 48452434_1 CDM 0510 RC 17250 HCPCS inpatient 492 319.8 SIHO - ALL PLANS SIHO - ALL PLANS 442.8 90 999999999 297.91 477.24 percent of total billed charges Application of chemical to stop tissue regrowth in wound 48452434_1 CDM 0510 RC 17250 HCPCS inpatient 492 319.8 UMR - ALL PLANS UMR - ALL PLANS 344.4 70 999999999 297.91 477.24 percent of total billed charges Application of chemical to stop tissue regrowth in wound 48452434_1 CDM 0510 RC 17250 HCPCS inpatient 492 319.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 297.91 60.55 999999999 297.91 477.24 percent of total billed charges Application of chemical to stop tissue regrowth in wound 48452434_1 CDM 0510 RC 17250 HCPCS inpatient 492 319.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 297.91 477.24 Application of chemical to stop tissue regrowth in wound 48452434_1 CDM 0510 RC 17250 HCPCS inpatient 492 319.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 297.91 477.24 Application of chemical to stop tissue regrowth in wound 48452434_1 CDM 0510 RC 17250 HCPCS inpatient 492 319.8 ANTHEM HMO ANTHEM HMO 999999999 297.91 477.24 Application of chemical to stop tissue regrowth in wound 48452434_1 CDM 0510 RC 17250 HCPCS inpatient 492 319.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 332.59 67.6 999999999 297.91 477.24 percent of total billed charges Application of chemical to stop tissue regrowth in wound 48452434_1 CDM 0510 RC 17250 HCPCS inpatient 492 319.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 297.91 477.24 Application of chemical to stop tissue regrowth in wound 48452434_1 CDM 0510 RC 17250 HCPCS inpatient 492 319.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 297.91 477.24 Biopsy of bone using needle or trocar 48452435_1 CDM 0510 RC 20220 HCPCS inpatient 2041 1326.65 AETNA AETNA 1612.39 79 999999999 1235.83 1979.77 percent of total billed charges Biopsy of bone using needle or trocar 48452435_1 CDM 0510 RC 20220 HCPCS inpatient 2041 1326.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1326.65 65 999999999 1235.83 1979.77 percent of total billed charges Biopsy of bone using needle or trocar 48452435_1 CDM 0510 RC 20220 HCPCS inpatient 2041 1326.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1979.77 97 999999999 1235.83 1979.77 percent of total billed charges Biopsy of bone using needle or trocar 48452435_1 CDM 0510 RC 20220 HCPCS inpatient 2041 1326.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1408.29 69 999999999 1235.83 1979.77 percent of total billed charges Biopsy of bone using needle or trocar 48452435_1 CDM 0510 RC 20220 HCPCS inpatient 2041 1326.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1591.98 78 999999999 1235.83 1979.77 percent of total billed charges Biopsy of bone using needle or trocar 48452435_1 CDM 0510 RC 20220 HCPCS inpatient 2041 1326.65 SIHO - ALL PLANS SIHO - ALL PLANS 1836.9 90 999999999 1235.83 1979.77 percent of total billed charges Biopsy of bone using needle or trocar 48452435_1 CDM 0510 RC 20220 HCPCS inpatient 2041 1326.65 UMR - ALL PLANS UMR - ALL PLANS 1428.7 70 999999999 1235.83 1979.77 percent of total billed charges Biopsy of bone using needle or trocar 48452435_1 CDM 0510 RC 20220 HCPCS inpatient 2041 1326.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1235.83 60.55 999999999 1235.83 1979.77 percent of total billed charges Biopsy of bone using needle or trocar 48452435_1 CDM 0510 RC 20220 HCPCS inpatient 2041 1326.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1235.83 1979.77 Biopsy of bone using needle or trocar 48452435_1 CDM 0510 RC 20220 HCPCS inpatient 2041 1326.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1235.83 1979.77 Biopsy of bone using needle or trocar 48452435_1 CDM 0510 RC 20220 HCPCS inpatient 2041 1326.65 ANTHEM HMO ANTHEM HMO 999999999 1235.83 1979.77 Biopsy of bone using needle or trocar 48452435_1 CDM 0510 RC 20220 HCPCS inpatient 2041 1326.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1379.72 67.6 999999999 1235.83 1979.77 percent of total billed charges Biopsy of bone using needle or trocar 48452435_1 CDM 0510 RC 20220 HCPCS inpatient 2041 1326.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1235.83 1979.77 Biopsy of bone using needle or trocar 48452435_1 CDM 0510 RC 20220 HCPCS inpatient 2041 1326.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1235.83 1979.77 Biopsy of surface bone 48452436_1 CDM 0510 RC 20240 HCPCS inpatient 3831 2490.15 AETNA AETNA 3026.49 79 999999999 2319.67 3716.07 percent of total billed charges Biopsy of surface bone 48452436_1 CDM 0510 RC 20240 HCPCS inpatient 3831 2490.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 2490.15 65 999999999 2319.67 3716.07 percent of total billed charges Biopsy of surface bone 48452436_1 CDM 0510 RC 20240 HCPCS inpatient 3831 2490.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3716.07 97 999999999 2319.67 3716.07 percent of total billed charges Biopsy of surface bone 48452436_1 CDM 0510 RC 20240 HCPCS inpatient 3831 2490.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 2643.39 69 999999999 2319.67 3716.07 percent of total billed charges Biopsy of surface bone 48452436_1 CDM 0510 RC 20240 HCPCS inpatient 3831 2490.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 2988.18 78 999999999 2319.67 3716.07 percent of total billed charges Biopsy of surface bone 48452436_1 CDM 0510 RC 20240 HCPCS inpatient 3831 2490.15 SIHO - ALL PLANS SIHO - ALL PLANS 3447.9 90 999999999 2319.67 3716.07 percent of total billed charges Biopsy of surface bone 48452436_1 CDM 0510 RC 20240 HCPCS inpatient 3831 2490.15 UMR - ALL PLANS UMR - ALL PLANS 2681.7 70 999999999 2319.67 3716.07 percent of total billed charges Biopsy of surface bone 48452436_1 CDM 0510 RC 20240 HCPCS inpatient 3831 2490.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2319.67 60.55 999999999 2319.67 3716.07 percent of total billed charges Biopsy of surface bone 48452436_1 CDM 0510 RC 20240 HCPCS inpatient 3831 2490.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2319.67 3716.07 Biopsy of surface bone 48452436_1 CDM 0510 RC 20240 HCPCS inpatient 3831 2490.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2319.67 3716.07 Biopsy of surface bone 48452436_1 CDM 0510 RC 20240 HCPCS inpatient 3831 2490.15 ANTHEM HMO ANTHEM HMO 999999999 2319.67 3716.07 Biopsy of surface bone 48452436_1 CDM 0510 RC 20240 HCPCS inpatient 3831 2490.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 2589.76 67.6 999999999 2319.67 3716.07 percent of total billed charges Biopsy of surface bone 48452436_1 CDM 0510 RC 20240 HCPCS inpatient 3831 2490.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2319.67 3716.07 Biopsy of surface bone 48452436_1 CDM 0510 RC 20240 HCPCS inpatient 3831 2490.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 2319.67 3716.07 "Application of walking cast covering foot, ankle, and lower leg" 48452437_1 CDM 0510 RC 29445 HCPCS inpatient 796 517.4 AETNA AETNA 628.84 79 999999999 481.98 772.12 percent of total billed charges "Application of walking cast covering foot, ankle, and lower leg" 48452437_1 CDM 0510 RC 29445 HCPCS inpatient 796 517.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 517.4 65 999999999 481.98 772.12 percent of total billed charges "Application of walking cast covering foot, ankle, and lower leg" 48452437_1 CDM 0510 RC 29445 HCPCS inpatient 796 517.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 772.12 97 999999999 481.98 772.12 percent of total billed charges "Application of walking cast covering foot, ankle, and lower leg" 48452437_1 CDM 0510 RC 29445 HCPCS inpatient 796 517.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 549.24 69 999999999 481.98 772.12 percent of total billed charges "Application of walking cast covering foot, ankle, and lower leg" 48452437_1 CDM 0510 RC 29445 HCPCS inpatient 796 517.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 620.88 78 999999999 481.98 772.12 percent of total billed charges "Application of walking cast covering foot, ankle, and lower leg" 48452437_1 CDM 0510 RC 29445 HCPCS inpatient 796 517.4 SIHO - ALL PLANS SIHO - ALL PLANS 716.4 90 999999999 481.98 772.12 percent of total billed charges "Application of walking cast covering foot, ankle, and lower leg" 48452437_1 CDM 0510 RC 29445 HCPCS inpatient 796 517.4 UMR - ALL PLANS UMR - ALL PLANS 557.2 70 999999999 481.98 772.12 percent of total billed charges "Application of walking cast covering foot, ankle, and lower leg" 48452437_1 CDM 0510 RC 29445 HCPCS inpatient 796 517.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 481.98 60.55 999999999 481.98 772.12 percent of total billed charges "Application of walking cast covering foot, ankle, and lower leg" 48452437_1 CDM 0510 RC 29445 HCPCS inpatient 796 517.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 481.98 772.12 "Application of walking cast covering foot, ankle, and lower leg" 48452437_1 CDM 0510 RC 29445 HCPCS inpatient 796 517.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 481.98 772.12 "Application of walking cast covering foot, ankle, and lower leg" 48452437_1 CDM 0510 RC 29445 HCPCS inpatient 796 517.4 ANTHEM HMO ANTHEM HMO 999999999 481.98 772.12 "Application of walking cast covering foot, ankle, and lower leg" 48452437_1 CDM 0510 RC 29445 HCPCS inpatient 796 517.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 538.1 67.6 999999999 481.98 772.12 percent of total billed charges "Application of walking cast covering foot, ankle, and lower leg" 48452437_1 CDM 0510 RC 29445 HCPCS inpatient 796 517.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 481.98 772.12 "Application of walking cast covering foot, ankle, and lower leg" 48452437_1 CDM 0510 RC 29445 HCPCS inpatient 796 517.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 481.98 772.12 "Strapping, Unna boot" 48452438_1 CDM 0510 RC 29580 HCPCS inpatient 378 245.7 AETNA AETNA 298.62 79 999999999 228.88 366.66 percent of total billed charges "Strapping, Unna boot" 48452438_1 CDM 0510 RC 29580 HCPCS inpatient 378 245.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 245.7 65 999999999 228.88 366.66 percent of total billed charges "Strapping, Unna boot" 48452438_1 CDM 0510 RC 29580 HCPCS inpatient 378 245.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 366.66 97 999999999 228.88 366.66 percent of total billed charges "Strapping, Unna boot" 48452438_1 CDM 0510 RC 29580 HCPCS inpatient 378 245.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 260.82 69 999999999 228.88 366.66 percent of total billed charges "Strapping, Unna boot" 48452438_1 CDM 0510 RC 29580 HCPCS inpatient 378 245.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 294.84 78 999999999 228.88 366.66 percent of total billed charges "Strapping, Unna boot" 48452438_1 CDM 0510 RC 29580 HCPCS inpatient 378 245.7 SIHO - ALL PLANS SIHO - ALL PLANS 340.2 90 999999999 228.88 366.66 percent of total billed charges "Strapping, Unna boot" 48452438_1 CDM 0510 RC 29580 HCPCS inpatient 378 245.7 UMR - ALL PLANS UMR - ALL PLANS 264.6 70 999999999 228.88 366.66 percent of total billed charges "Strapping, Unna boot" 48452438_1 CDM 0510 RC 29580 HCPCS inpatient 378 245.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 228.88 60.55 999999999 228.88 366.66 percent of total billed charges "Strapping, Unna boot" 48452438_1 CDM 0510 RC 29580 HCPCS inpatient 378 245.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 228.88 366.66 "Strapping, Unna boot" 48452438_1 CDM 0510 RC 29580 HCPCS inpatient 378 245.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 228.88 366.66 "Strapping, Unna boot" 48452438_1 CDM 0510 RC 29580 HCPCS inpatient 378 245.7 ANTHEM HMO ANTHEM HMO 999999999 228.88 366.66 "Strapping, Unna boot" 48452438_1 CDM 0510 RC 29580 HCPCS inpatient 378 245.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 255.53 67.6 999999999 228.88 366.66 percent of total billed charges "Strapping, Unna boot" 48452438_1 CDM 0510 RC 29580 HCPCS inpatient 378 245.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 228.88 366.66 "Strapping, Unna boot" 48452438_1 CDM 0510 RC 29580 HCPCS inpatient 378 245.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 228.88 366.66 "Strapping, Unna boot" 48452439_1 CDM 0510 RC 29580 HCPCS inpatient 762 495.3 AETNA AETNA 601.98 79 999999999 461.39 739.14 percent of total billed charges "Strapping, Unna boot" 48452439_1 CDM 0510 RC 29580 HCPCS inpatient 762 495.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 495.3 65 999999999 461.39 739.14 percent of total billed charges "Strapping, Unna boot" 48452439_1 CDM 0510 RC 29580 HCPCS inpatient 762 495.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 739.14 97 999999999 461.39 739.14 percent of total billed charges "Strapping, Unna boot" 48452439_1 CDM 0510 RC 29580 HCPCS inpatient 762 495.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 525.78 69 999999999 461.39 739.14 percent of total billed charges "Strapping, Unna boot" 48452439_1 CDM 0510 RC 29580 HCPCS inpatient 762 495.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 594.36 78 999999999 461.39 739.14 percent of total billed charges "Strapping, Unna boot" 48452439_1 CDM 0510 RC 29580 HCPCS inpatient 762 495.3 SIHO - ALL PLANS SIHO - ALL PLANS 685.8 90 999999999 461.39 739.14 percent of total billed charges "Strapping, Unna boot" 48452439_1 CDM 0510 RC 29580 HCPCS inpatient 762 495.3 UMR - ALL PLANS UMR - ALL PLANS 533.4 70 999999999 461.39 739.14 percent of total billed charges "Strapping, Unna boot" 48452439_1 CDM 0510 RC 29580 HCPCS inpatient 762 495.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 461.39 60.55 999999999 461.39 739.14 percent of total billed charges "Strapping, Unna boot" 48452439_1 CDM 0510 RC 29580 HCPCS inpatient 762 495.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 461.39 739.14 "Strapping, Unna boot" 48452439_1 CDM 0510 RC 29580 HCPCS inpatient 762 495.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 461.39 739.14 "Strapping, Unna boot" 48452439_1 CDM 0510 RC 29580 HCPCS inpatient 762 495.3 ANTHEM HMO ANTHEM HMO 999999999 461.39 739.14 "Strapping, Unna boot" 48452439_1 CDM 0510 RC 29580 HCPCS inpatient 762 495.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 515.11 67.6 999999999 461.39 739.14 percent of total billed charges "Strapping, Unna boot" 48452439_1 CDM 0510 RC 29580 HCPCS inpatient 762 495.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 461.39 739.14 "Strapping, Unna boot" 48452439_1 CDM 0510 RC 29580 HCPCS inpatient 762 495.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 461.39 739.14 "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452440_1 CDM 0510 RC 29581 HCPCS inpatient 339 220.35 AETNA AETNA 267.81 79 999999999 205.26 328.83 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452440_1 CDM 0510 RC 29581 HCPCS inpatient 339 220.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 220.35 65 999999999 205.26 328.83 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452440_1 CDM 0510 RC 29581 HCPCS inpatient 339 220.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 328.83 97 999999999 205.26 328.83 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452440_1 CDM 0510 RC 29581 HCPCS inpatient 339 220.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 233.91 69 999999999 205.26 328.83 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452440_1 CDM 0510 RC 29581 HCPCS inpatient 339 220.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 264.42 78 999999999 205.26 328.83 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452440_1 CDM 0510 RC 29581 HCPCS inpatient 339 220.35 SIHO - ALL PLANS SIHO - ALL PLANS 305.1 90 999999999 205.26 328.83 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452440_1 CDM 0510 RC 29581 HCPCS inpatient 339 220.35 UMR - ALL PLANS UMR - ALL PLANS 237.3 70 999999999 205.26 328.83 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452440_1 CDM 0510 RC 29581 HCPCS inpatient 339 220.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.26 60.55 999999999 205.26 328.83 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452440_1 CDM 0510 RC 29581 HCPCS inpatient 339 220.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.26 328.83 "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452440_1 CDM 0510 RC 29581 HCPCS inpatient 339 220.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.26 328.83 "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452440_1 CDM 0510 RC 29581 HCPCS inpatient 339 220.35 ANTHEM HMO ANTHEM HMO 999999999 205.26 328.83 "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452440_1 CDM 0510 RC 29581 HCPCS inpatient 339 220.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.16 67.6 999999999 205.26 328.83 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452440_1 CDM 0510 RC 29581 HCPCS inpatient 339 220.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.26 328.83 "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452440_1 CDM 0510 RC 29581 HCPCS inpatient 339 220.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.26 328.83 "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452441_1 CDM 0510 RC 29581 HCPCS inpatient 672 436.8 AETNA AETNA 530.88 79 999999999 406.9 651.84 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452441_1 CDM 0510 RC 29581 HCPCS inpatient 672 436.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 436.8 65 999999999 406.9 651.84 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452441_1 CDM 0510 RC 29581 HCPCS inpatient 672 436.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 651.84 97 999999999 406.9 651.84 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452441_1 CDM 0510 RC 29581 HCPCS inpatient 672 436.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 463.68 69 999999999 406.9 651.84 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452441_1 CDM 0510 RC 29581 HCPCS inpatient 672 436.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 524.16 78 999999999 406.9 651.84 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452441_1 CDM 0510 RC 29581 HCPCS inpatient 672 436.8 SIHO - ALL PLANS SIHO - ALL PLANS 604.8 90 999999999 406.9 651.84 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452441_1 CDM 0510 RC 29581 HCPCS inpatient 672 436.8 UMR - ALL PLANS UMR - ALL PLANS 470.4 70 999999999 406.9 651.84 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452441_1 CDM 0510 RC 29581 HCPCS inpatient 672 436.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 406.9 60.55 999999999 406.9 651.84 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452441_1 CDM 0510 RC 29581 HCPCS inpatient 672 436.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 406.9 651.84 "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452441_1 CDM 0510 RC 29581 HCPCS inpatient 672 436.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 406.9 651.84 "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452441_1 CDM 0510 RC 29581 HCPCS inpatient 672 436.8 ANTHEM HMO ANTHEM HMO 999999999 406.9 651.84 "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452441_1 CDM 0510 RC 29581 HCPCS inpatient 672 436.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 454.27 67.6 999999999 406.9 651.84 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452441_1 CDM 0510 RC 29581 HCPCS inpatient 672 436.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 406.9 651.84 "Application of vein wound compression bandages on lower leg, ankle, and foot" 48452441_1 CDM 0510 RC 29581 HCPCS inpatient 672 436.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 406.9 651.84 Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 48452442_1 CDM 0510 RC 36465 HCPCS inpatient 879 571.35 AETNA AETNA 694.41 79 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 48452442_1 CDM 0510 RC 36465 HCPCS inpatient 879 571.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 571.35 65 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 48452442_1 CDM 0510 RC 36465 HCPCS inpatient 879 571.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 852.63 97 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 48452442_1 CDM 0510 RC 36465 HCPCS inpatient 879 571.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 606.51 69 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 48452442_1 CDM 0510 RC 36465 HCPCS inpatient 879 571.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 685.62 78 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 48452442_1 CDM 0510 RC 36465 HCPCS inpatient 879 571.35 SIHO - ALL PLANS SIHO - ALL PLANS 791.1 90 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 48452442_1 CDM 0510 RC 36465 HCPCS inpatient 879 571.35 UMR - ALL PLANS UMR - ALL PLANS 615.3 70 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 48452442_1 CDM 0510 RC 36465 HCPCS inpatient 879 571.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 532.23 60.55 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 48452442_1 CDM 0510 RC 36465 HCPCS inpatient 879 571.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 48452442_1 CDM 0510 RC 36465 HCPCS inpatient 879 571.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 48452442_1 CDM 0510 RC 36465 HCPCS inpatient 879 571.35 ANTHEM HMO ANTHEM HMO 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 48452442_1 CDM 0510 RC 36465 HCPCS inpatient 879 571.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 594.2 67.6 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 48452442_1 CDM 0510 RC 36465 HCPCS inpatient 879 571.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 48452442_1 CDM 0510 RC 36465 HCPCS inpatient 879 571.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein 48452443_1 CDM 0510 RC 36470 HCPCS inpatient 1757 1142.05 AETNA AETNA 1388.03 79 999999999 1063.86 1704.29 percent of total billed charges Injection of chemical agent into single incompetent vein 48452443_1 CDM 0510 RC 36470 HCPCS inpatient 1757 1142.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1142.05 65 999999999 1063.86 1704.29 percent of total billed charges Injection of chemical agent into single incompetent vein 48452443_1 CDM 0510 RC 36470 HCPCS inpatient 1757 1142.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1704.29 97 999999999 1063.86 1704.29 percent of total billed charges Injection of chemical agent into single incompetent vein 48452443_1 CDM 0510 RC 36470 HCPCS inpatient 1757 1142.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1212.33 69 999999999 1063.86 1704.29 percent of total billed charges Injection of chemical agent into single incompetent vein 48452443_1 CDM 0510 RC 36470 HCPCS inpatient 1757 1142.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1370.46 78 999999999 1063.86 1704.29 percent of total billed charges Injection of chemical agent into single incompetent vein 48452443_1 CDM 0510 RC 36470 HCPCS inpatient 1757 1142.05 SIHO - ALL PLANS SIHO - ALL PLANS 1581.3 90 999999999 1063.86 1704.29 percent of total billed charges Injection of chemical agent into single incompetent vein 48452443_1 CDM 0510 RC 36470 HCPCS inpatient 1757 1142.05 UMR - ALL PLANS UMR - ALL PLANS 1229.9 70 999999999 1063.86 1704.29 percent of total billed charges Injection of chemical agent into single incompetent vein 48452443_1 CDM 0510 RC 36470 HCPCS inpatient 1757 1142.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1063.86 60.55 999999999 1063.86 1704.29 percent of total billed charges Injection of chemical agent into single incompetent vein 48452443_1 CDM 0510 RC 36470 HCPCS inpatient 1757 1142.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1063.86 1704.29 Injection of chemical agent into single incompetent vein 48452443_1 CDM 0510 RC 36470 HCPCS inpatient 1757 1142.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1063.86 1704.29 Injection of chemical agent into single incompetent vein 48452443_1 CDM 0510 RC 36470 HCPCS inpatient 1757 1142.05 ANTHEM HMO ANTHEM HMO 999999999 1063.86 1704.29 Injection of chemical agent into single incompetent vein 48452443_1 CDM 0510 RC 36470 HCPCS inpatient 1757 1142.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1187.73 67.6 999999999 1063.86 1704.29 percent of total billed charges Injection of chemical agent into single incompetent vein 48452443_1 CDM 0510 RC 36470 HCPCS inpatient 1757 1142.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1063.86 1704.29 Injection of chemical agent into single incompetent vein 48452443_1 CDM 0510 RC 36470 HCPCS inpatient 1757 1142.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1063.86 1704.29 Injection of chemical agent into multiple incompetent veins of leg 48452444_1 CDM 0510 RC 36471 HCPCS inpatient 908 590.2 AETNA AETNA 717.32 79 999999999 549.79 880.76 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 48452444_1 CDM 0510 RC 36471 HCPCS inpatient 908 590.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 590.2 65 999999999 549.79 880.76 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 48452444_1 CDM 0510 RC 36471 HCPCS inpatient 908 590.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 880.76 97 999999999 549.79 880.76 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 48452444_1 CDM 0510 RC 36471 HCPCS inpatient 908 590.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 626.52 69 999999999 549.79 880.76 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 48452444_1 CDM 0510 RC 36471 HCPCS inpatient 908 590.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 708.24 78 999999999 549.79 880.76 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 48452444_1 CDM 0510 RC 36471 HCPCS inpatient 908 590.2 SIHO - ALL PLANS SIHO - ALL PLANS 817.2 90 999999999 549.79 880.76 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 48452444_1 CDM 0510 RC 36471 HCPCS inpatient 908 590.2 UMR - ALL PLANS UMR - ALL PLANS 635.6 70 999999999 549.79 880.76 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 48452444_1 CDM 0510 RC 36471 HCPCS inpatient 908 590.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 549.79 60.55 999999999 549.79 880.76 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 48452444_1 CDM 0510 RC 36471 HCPCS inpatient 908 590.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 549.79 880.76 Injection of chemical agent into multiple incompetent veins of leg 48452444_1 CDM 0510 RC 36471 HCPCS inpatient 908 590.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 549.79 880.76 Injection of chemical agent into multiple incompetent veins of leg 48452444_1 CDM 0510 RC 36471 HCPCS inpatient 908 590.2 ANTHEM HMO ANTHEM HMO 999999999 549.79 880.76 Injection of chemical agent into multiple incompetent veins of leg 48452444_1 CDM 0510 RC 36471 HCPCS inpatient 908 590.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 613.81 67.6 999999999 549.79 880.76 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 48452444_1 CDM 0510 RC 36471 HCPCS inpatient 908 590.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 549.79 880.76 Injection of chemical agent into multiple incompetent veins of leg 48452444_1 CDM 0510 RC 36471 HCPCS inpatient 908 590.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 549.79 880.76 Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 48452445_1 CDM 0510 RC 36466 HCPCS inpatient 454 295.1 AETNA AETNA 358.66 79 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 48452445_1 CDM 0510 RC 36466 HCPCS inpatient 454 295.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 295.1 65 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 48452445_1 CDM 0510 RC 36466 HCPCS inpatient 454 295.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 440.38 97 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 48452445_1 CDM 0510 RC 36466 HCPCS inpatient 454 295.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 313.26 69 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 48452445_1 CDM 0510 RC 36466 HCPCS inpatient 454 295.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 354.12 78 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 48452445_1 CDM 0510 RC 36466 HCPCS inpatient 454 295.1 SIHO - ALL PLANS SIHO - ALL PLANS 408.6 90 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 48452445_1 CDM 0510 RC 36466 HCPCS inpatient 454 295.1 UMR - ALL PLANS UMR - ALL PLANS 317.8 70 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 48452445_1 CDM 0510 RC 36466 HCPCS inpatient 454 295.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 274.9 60.55 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 48452445_1 CDM 0510 RC 36466 HCPCS inpatient 454 295.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 274.9 440.38 Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 48452445_1 CDM 0510 RC 36466 HCPCS inpatient 454 295.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 274.9 440.38 Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 48452445_1 CDM 0510 RC 36466 HCPCS inpatient 454 295.1 ANTHEM HMO ANTHEM HMO 999999999 274.9 440.38 Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 48452445_1 CDM 0510 RC 36466 HCPCS inpatient 454 295.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 306.9 67.6 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 48452445_1 CDM 0510 RC 36466 HCPCS inpatient 454 295.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 274.9 440.38 Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 48452445_1 CDM 0510 RC 36466 HCPCS inpatient 454 295.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 274.9 440.38 Removal of impacted ear wax 48452449_1 CDM 0510 RC 69210 HCPCS inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges Removal of impacted ear wax 48452449_1 CDM 0510 RC 69210 HCPCS inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges Removal of impacted ear wax 48452449_1 CDM 0510 RC 69210 HCPCS inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges Removal of impacted ear wax 48452449_1 CDM 0510 RC 69210 HCPCS inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges Removal of impacted ear wax 48452449_1 CDM 0510 RC 69210 HCPCS inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges Removal of impacted ear wax 48452449_1 CDM 0510 RC 69210 HCPCS inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges Removal of impacted ear wax 48452449_1 CDM 0510 RC 69210 HCPCS inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges Removal of impacted ear wax 48452449_1 CDM 0510 RC 69210 HCPCS inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges Removal of impacted ear wax 48452449_1 CDM 0510 RC 69210 HCPCS inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 Removal of impacted ear wax 48452449_1 CDM 0510 RC 69210 HCPCS inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 Removal of impacted ear wax 48452449_1 CDM 0510 RC 69210 HCPCS inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 Removal of impacted ear wax 48452449_1 CDM 0510 RC 69210 HCPCS inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges Removal of impacted ear wax 48452449_1 CDM 0510 RC 69210 HCPCS inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 Removal of impacted ear wax 48452449_1 CDM 0510 RC 69210 HCPCS inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 Complete ultrasound scan of joint 48452450_1 CDM 0921 RC 76881 HCPCS inpatient 1573 1022.45 AETNA AETNA 1242.67 79 999999999 952.45 1525.81 percent of total billed charges Complete ultrasound scan of joint 48452450_1 CDM 0921 RC 76881 HCPCS inpatient 1573 1022.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1022.45 65 999999999 952.45 1525.81 percent of total billed charges Complete ultrasound scan of joint 48452450_1 CDM 0921 RC 76881 HCPCS inpatient 1573 1022.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1525.81 97 999999999 952.45 1525.81 percent of total billed charges Complete ultrasound scan of joint 48452450_1 CDM 0921 RC 76881 HCPCS inpatient 1573 1022.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1085.37 69 999999999 952.45 1525.81 percent of total billed charges Complete ultrasound scan of joint 48452450_1 CDM 0921 RC 76881 HCPCS inpatient 1573 1022.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1226.94 78 999999999 952.45 1525.81 percent of total billed charges Complete ultrasound scan of joint 48452450_1 CDM 0921 RC 76881 HCPCS inpatient 1573 1022.45 SIHO - ALL PLANS SIHO - ALL PLANS 1415.7 90 999999999 952.45 1525.81 percent of total billed charges Complete ultrasound scan of joint 48452450_1 CDM 0921 RC 76881 HCPCS inpatient 1573 1022.45 UMR - ALL PLANS UMR - ALL PLANS 1101.1 70 999999999 952.45 1525.81 percent of total billed charges Complete ultrasound scan of joint 48452450_1 CDM 0921 RC 76881 HCPCS inpatient 1573 1022.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 952.45 60.55 999999999 952.45 1525.81 percent of total billed charges Complete ultrasound scan of joint 48452450_1 CDM 0921 RC 76881 HCPCS inpatient 1573 1022.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 952.45 1525.81 Complete ultrasound scan of joint 48452450_1 CDM 0921 RC 76881 HCPCS inpatient 1573 1022.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 952.45 1525.81 Complete ultrasound scan of joint 48452450_1 CDM 0921 RC 76881 HCPCS inpatient 1573 1022.45 ANTHEM HMO ANTHEM HMO 999999999 952.45 1525.81 Complete ultrasound scan of joint 48452450_1 CDM 0921 RC 76881 HCPCS inpatient 1573 1022.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1063.35 67.6 999999999 952.45 1525.81 percent of total billed charges Complete ultrasound scan of joint 48452450_1 CDM 0921 RC 76881 HCPCS inpatient 1573 1022.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 952.45 1525.81 Complete ultrasound scan of joint 48452450_1 CDM 0921 RC 76881 HCPCS inpatient 1573 1022.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 952.45 1525.81 Ultrasound study of arm and leg arteries 48452451_1 CDM 0921 RC 93922 HCPCS inpatient 578 375.7 AETNA AETNA 456.62 79 999999999 349.98 560.66 percent of total billed charges Ultrasound study of arm and leg arteries 48452451_1 CDM 0921 RC 93922 HCPCS inpatient 578 375.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 375.7 65 999999999 349.98 560.66 percent of total billed charges Ultrasound study of arm and leg arteries 48452451_1 CDM 0921 RC 93922 HCPCS inpatient 578 375.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 560.66 97 999999999 349.98 560.66 percent of total billed charges Ultrasound study of arm and leg arteries 48452451_1 CDM 0921 RC 93922 HCPCS inpatient 578 375.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 398.82 69 999999999 349.98 560.66 percent of total billed charges Ultrasound study of arm and leg arteries 48452451_1 CDM 0921 RC 93922 HCPCS inpatient 578 375.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 450.84 78 999999999 349.98 560.66 percent of total billed charges Ultrasound study of arm and leg arteries 48452451_1 CDM 0921 RC 93922 HCPCS inpatient 578 375.7 SIHO - ALL PLANS SIHO - ALL PLANS 520.2 90 999999999 349.98 560.66 percent of total billed charges Ultrasound study of arm and leg arteries 48452451_1 CDM 0921 RC 93922 HCPCS inpatient 578 375.7 UMR - ALL PLANS UMR - ALL PLANS 404.6 70 999999999 349.98 560.66 percent of total billed charges Ultrasound study of arm and leg arteries 48452451_1 CDM 0921 RC 93922 HCPCS inpatient 578 375.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 349.98 60.55 999999999 349.98 560.66 percent of total billed charges Ultrasound study of arm and leg arteries 48452451_1 CDM 0921 RC 93922 HCPCS inpatient 578 375.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 349.98 560.66 Ultrasound study of arm and leg arteries 48452451_1 CDM 0921 RC 93922 HCPCS inpatient 578 375.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 349.98 560.66 Ultrasound study of arm and leg arteries 48452451_1 CDM 0921 RC 93922 HCPCS inpatient 578 375.7 ANTHEM HMO ANTHEM HMO 999999999 349.98 560.66 Ultrasound study of arm and leg arteries 48452451_1 CDM 0921 RC 93922 HCPCS inpatient 578 375.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 390.73 67.6 999999999 349.98 560.66 percent of total billed charges Ultrasound study of arm and leg arteries 48452451_1 CDM 0921 RC 93922 HCPCS inpatient 578 375.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 349.98 560.66 Ultrasound study of arm and leg arteries 48452451_1 CDM 0921 RC 93922 HCPCS inpatient 578 375.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 349.98 560.66 Complete ultrasound study of arm and leg arteries 48452452_1 CDM 0921 RC 93923 HCPCS inpatient 1085 705.25 AETNA AETNA 857.15 79 999999999 656.97 1052.45 percent of total billed charges Complete ultrasound study of arm and leg arteries 48452452_1 CDM 0921 RC 93923 HCPCS inpatient 1085 705.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 705.25 65 999999999 656.97 1052.45 percent of total billed charges Complete ultrasound study of arm and leg arteries 48452452_1 CDM 0921 RC 93923 HCPCS inpatient 1085 705.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1052.45 97 999999999 656.97 1052.45 percent of total billed charges Complete ultrasound study of arm and leg arteries 48452452_1 CDM 0921 RC 93923 HCPCS inpatient 1085 705.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 748.65 69 999999999 656.97 1052.45 percent of total billed charges Complete ultrasound study of arm and leg arteries 48452452_1 CDM 0921 RC 93923 HCPCS inpatient 1085 705.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 846.3 78 999999999 656.97 1052.45 percent of total billed charges Complete ultrasound study of arm and leg arteries 48452452_1 CDM 0921 RC 93923 HCPCS inpatient 1085 705.25 SIHO - ALL PLANS SIHO - ALL PLANS 976.5 90 999999999 656.97 1052.45 percent of total billed charges Complete ultrasound study of arm and leg arteries 48452452_1 CDM 0921 RC 93923 HCPCS inpatient 1085 705.25 UMR - ALL PLANS UMR - ALL PLANS 759.5 70 999999999 656.97 1052.45 percent of total billed charges Complete ultrasound study of arm and leg arteries 48452452_1 CDM 0921 RC 93923 HCPCS inpatient 1085 705.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 656.97 60.55 999999999 656.97 1052.45 percent of total billed charges Complete ultrasound study of arm and leg arteries 48452452_1 CDM 0921 RC 93923 HCPCS inpatient 1085 705.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 656.97 1052.45 Complete ultrasound study of arm and leg arteries 48452452_1 CDM 0921 RC 93923 HCPCS inpatient 1085 705.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 656.97 1052.45 Complete ultrasound study of arm and leg arteries 48452452_1 CDM 0921 RC 93923 HCPCS inpatient 1085 705.25 ANTHEM HMO ANTHEM HMO 999999999 656.97 1052.45 Complete ultrasound study of arm and leg arteries 48452452_1 CDM 0921 RC 93923 HCPCS inpatient 1085 705.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 733.46 67.6 999999999 656.97 1052.45 percent of total billed charges Complete ultrasound study of arm and leg arteries 48452452_1 CDM 0921 RC 93923 HCPCS inpatient 1085 705.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 656.97 1052.45 Complete ultrasound study of arm and leg arteries 48452452_1 CDM 0921 RC 93923 HCPCS inpatient 1085 705.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 656.97 1052.45 Ultrasound study of arm or leg veins with compression and maneuvers 48452453_1 CDM 0921 RC 93970 HCPCS inpatient 690 448.5 AETNA AETNA 545.1 79 999999999 417.8 669.3 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 48452453_1 CDM 0921 RC 93970 HCPCS inpatient 690 448.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 448.5 65 999999999 417.8 669.3 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 48452453_1 CDM 0921 RC 93970 HCPCS inpatient 690 448.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 669.3 97 999999999 417.8 669.3 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 48452453_1 CDM 0921 RC 93970 HCPCS inpatient 690 448.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 476.1 69 999999999 417.8 669.3 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 48452453_1 CDM 0921 RC 93970 HCPCS inpatient 690 448.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 538.2 78 999999999 417.8 669.3 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 48452453_1 CDM 0921 RC 93970 HCPCS inpatient 690 448.5 SIHO - ALL PLANS SIHO - ALL PLANS 621 90 999999999 417.8 669.3 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 48452453_1 CDM 0921 RC 93970 HCPCS inpatient 690 448.5 UMR - ALL PLANS UMR - ALL PLANS 483 70 999999999 417.8 669.3 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 48452453_1 CDM 0921 RC 93970 HCPCS inpatient 690 448.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 417.8 60.55 999999999 417.8 669.3 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 48452453_1 CDM 0921 RC 93970 HCPCS inpatient 690 448.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 417.8 669.3 Ultrasound study of arm or leg veins with compression and maneuvers 48452453_1 CDM 0921 RC 93970 HCPCS inpatient 690 448.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 417.8 669.3 Ultrasound study of arm or leg veins with compression and maneuvers 48452453_1 CDM 0921 RC 93970 HCPCS inpatient 690 448.5 ANTHEM HMO ANTHEM HMO 999999999 417.8 669.3 Ultrasound study of arm or leg veins with compression and maneuvers 48452453_1 CDM 0921 RC 93970 HCPCS inpatient 690 448.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 466.44 67.6 999999999 417.8 669.3 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 48452453_1 CDM 0921 RC 93970 HCPCS inpatient 690 448.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 417.8 669.3 Ultrasound study of arm or leg veins with compression and maneuvers 48452453_1 CDM 0921 RC 93970 HCPCS inpatient 690 448.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 417.8 669.3 Ultrasound study of one arm or leg veins with compression and maneuvers 48452454_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 AETNA AETNA 1027 79 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48452454_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 SELF PAY DISCOUNT SELF PAY DISCOUNT 845 65 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48452454_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1261 97 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48452454_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 ENCORE - ALL PLANS ENCORE - ALL PLANS 897 69 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48452454_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 HUMANA - ALL PLANS HUMANA - ALL PLANS 1014 78 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48452454_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 SIHO - ALL PLANS SIHO - ALL PLANS 1170 90 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48452454_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 UMR - ALL PLANS UMR - ALL PLANS 910 70 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48452454_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 787.15 60.55 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48452454_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 787.15 1261 Ultrasound study of one arm or leg veins with compression and maneuvers 48452454_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 787.15 1261 Ultrasound study of one arm or leg veins with compression and maneuvers 48452454_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 ANTHEM HMO ANTHEM HMO 999999999 787.15 1261 Ultrasound study of one arm or leg veins with compression and maneuvers 48452454_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 CIGNA - ALL PLANS CIGNA - ALL PLANS 878.8 67.6 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 48452454_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 787.15 1261 Ultrasound study of one arm or leg veins with compression and maneuvers 48452454_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 UHC - ALL PLANS UHC - ALL PLANS 999999999 787.15 1261 "Removal of tissue from wound, 20.0 sq cm or less" 48452455_1 CDM 0510 RC 97597 HCPCS inpatient 495 321.75 AETNA AETNA 391.05 79 999999999 299.72 480.15 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 48452455_1 CDM 0510 RC 97597 HCPCS inpatient 495 321.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 321.75 65 999999999 299.72 480.15 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 48452455_1 CDM 0510 RC 97597 HCPCS inpatient 495 321.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 480.15 97 999999999 299.72 480.15 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 48452455_1 CDM 0510 RC 97597 HCPCS inpatient 495 321.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 341.55 69 999999999 299.72 480.15 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 48452455_1 CDM 0510 RC 97597 HCPCS inpatient 495 321.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 386.1 78 999999999 299.72 480.15 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 48452455_1 CDM 0510 RC 97597 HCPCS inpatient 495 321.75 SIHO - ALL PLANS SIHO - ALL PLANS 445.5 90 999999999 299.72 480.15 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 48452455_1 CDM 0510 RC 97597 HCPCS inpatient 495 321.75 UMR - ALL PLANS UMR - ALL PLANS 346.5 70 999999999 299.72 480.15 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 48452455_1 CDM 0510 RC 97597 HCPCS inpatient 495 321.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 299.72 60.55 999999999 299.72 480.15 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 48452455_1 CDM 0510 RC 97597 HCPCS inpatient 495 321.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 299.72 480.15 "Removal of tissue from wound, 20.0 sq cm or less" 48452455_1 CDM 0510 RC 97597 HCPCS inpatient 495 321.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 299.72 480.15 "Removal of tissue from wound, 20.0 sq cm or less" 48452455_1 CDM 0510 RC 97597 HCPCS inpatient 495 321.75 ANTHEM HMO ANTHEM HMO 999999999 299.72 480.15 "Removal of tissue from wound, 20.0 sq cm or less" 48452455_1 CDM 0510 RC 97597 HCPCS inpatient 495 321.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 334.62 67.6 999999999 299.72 480.15 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 48452455_1 CDM 0510 RC 97597 HCPCS inpatient 495 321.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 299.72 480.15 "Removal of tissue from wound, 20.0 sq cm or less" 48452455_1 CDM 0510 RC 97597 HCPCS inpatient 495 321.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 299.72 480.15 "Removal of tissue from wound, each additional 20.0 sq cm" 48452456_1 CDM 0510 RC 97598 HCPCS inpatient 492 319.8 AETNA AETNA 388.68 79 999999999 297.91 477.24 percent of total billed charges "Removal of tissue from wound, each additional 20.0 sq cm" 48452456_1 CDM 0510 RC 97598 HCPCS inpatient 492 319.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 319.8 65 999999999 297.91 477.24 percent of total billed charges "Removal of tissue from wound, each additional 20.0 sq cm" 48452456_1 CDM 0510 RC 97598 HCPCS inpatient 492 319.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 477.24 97 999999999 297.91 477.24 percent of total billed charges "Removal of tissue from wound, each additional 20.0 sq cm" 48452456_1 CDM 0510 RC 97598 HCPCS inpatient 492 319.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 339.48 69 999999999 297.91 477.24 percent of total billed charges "Removal of tissue from wound, each additional 20.0 sq cm" 48452456_1 CDM 0510 RC 97598 HCPCS inpatient 492 319.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 383.76 78 999999999 297.91 477.24 percent of total billed charges "Removal of tissue from wound, each additional 20.0 sq cm" 48452456_1 CDM 0510 RC 97598 HCPCS inpatient 492 319.8 SIHO - ALL PLANS SIHO - ALL PLANS 442.8 90 999999999 297.91 477.24 percent of total billed charges "Removal of tissue from wound, each additional 20.0 sq cm" 48452456_1 CDM 0510 RC 97598 HCPCS inpatient 492 319.8 UMR - ALL PLANS UMR - ALL PLANS 344.4 70 999999999 297.91 477.24 percent of total billed charges "Removal of tissue from wound, each additional 20.0 sq cm" 48452456_1 CDM 0510 RC 97598 HCPCS inpatient 492 319.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 297.91 60.55 999999999 297.91 477.24 percent of total billed charges "Removal of tissue from wound, each additional 20.0 sq cm" 48452456_1 CDM 0510 RC 97598 HCPCS inpatient 492 319.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 297.91 477.24 "Removal of tissue from wound, each additional 20.0 sq cm" 48452456_1 CDM 0510 RC 97598 HCPCS inpatient 492 319.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 297.91 477.24 "Removal of tissue from wound, each additional 20.0 sq cm" 48452456_1 CDM 0510 RC 97598 HCPCS inpatient 492 319.8 ANTHEM HMO ANTHEM HMO 999999999 297.91 477.24 "Removal of tissue from wound, each additional 20.0 sq cm" 48452456_1 CDM 0510 RC 97598 HCPCS inpatient 492 319.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 332.59 67.6 999999999 297.91 477.24 percent of total billed charges "Removal of tissue from wound, each additional 20.0 sq cm" 48452456_1 CDM 0510 RC 97598 HCPCS inpatient 492 319.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 297.91 477.24 "Removal of tissue from wound, each additional 20.0 sq cm" 48452456_1 CDM 0510 RC 97598 HCPCS inpatient 492 319.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 297.91 477.24 "Therapy procedure using a special bandage and vacuum pump, surface area 50.0 sq cm or less" 48452457_1 CDM 0510 RC 97605 HCPCS inpatient 280 182 AETNA AETNA 221.2 79 999999999 169.54 271.6 percent of total billed charges "Therapy procedure using a special bandage and vacuum pump, surface area 50.0 sq cm or less" 48452457_1 CDM 0510 RC 97605 HCPCS inpatient 280 182 SELF PAY DISCOUNT SELF PAY DISCOUNT 182 65 999999999 169.54 271.6 percent of total billed charges "Therapy procedure using a special bandage and vacuum pump, surface area 50.0 sq cm or less" 48452457_1 CDM 0510 RC 97605 HCPCS inpatient 280 182 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 271.6 97 999999999 169.54 271.6 percent of total billed charges "Therapy procedure using a special bandage and vacuum pump, surface area 50.0 sq cm or less" 48452457_1 CDM 0510 RC 97605 HCPCS inpatient 280 182 ENCORE - ALL PLANS ENCORE - ALL PLANS 193.2 69 999999999 169.54 271.6 percent of total billed charges "Therapy procedure using a special bandage and vacuum pump, surface area 50.0 sq cm or less" 48452457_1 CDM 0510 RC 97605 HCPCS inpatient 280 182 HUMANA - ALL PLANS HUMANA - ALL PLANS 218.4 78 999999999 169.54 271.6 percent of total billed charges "Therapy procedure using a special bandage and vacuum pump, surface area 50.0 sq cm or less" 48452457_1 CDM 0510 RC 97605 HCPCS inpatient 280 182 SIHO - ALL PLANS SIHO - ALL PLANS 252 90 999999999 169.54 271.6 percent of total billed charges "Therapy procedure using a special bandage and vacuum pump, surface area 50.0 sq cm or less" 48452457_1 CDM 0510 RC 97605 HCPCS inpatient 280 182 UMR - ALL PLANS UMR - ALL PLANS 196 70 999999999 169.54 271.6 percent of total billed charges "Therapy procedure using a special bandage and vacuum pump, surface area 50.0 sq cm or less" 48452457_1 CDM 0510 RC 97605 HCPCS inpatient 280 182 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 169.54 60.55 999999999 169.54 271.6 percent of total billed charges "Therapy procedure using a special bandage and vacuum pump, surface area 50.0 sq cm or less" 48452457_1 CDM 0510 RC 97605 HCPCS inpatient 280 182 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 169.54 271.6 "Therapy procedure using a special bandage and vacuum pump, surface area 50.0 sq cm or less" 48452457_1 CDM 0510 RC 97605 HCPCS inpatient 280 182 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 169.54 271.6 "Therapy procedure using a special bandage and vacuum pump, surface area 50.0 sq cm or less" 48452457_1 CDM 0510 RC 97605 HCPCS inpatient 280 182 ANTHEM HMO ANTHEM HMO 999999999 169.54 271.6 "Therapy procedure using a special bandage and vacuum pump, surface area 50.0 sq cm or less" 48452457_1 CDM 0510 RC 97605 HCPCS inpatient 280 182 CIGNA - ALL PLANS CIGNA - ALL PLANS 189.28 67.6 999999999 169.54 271.6 percent of total billed charges "Therapy procedure using a special bandage and vacuum pump, surface area 50.0 sq cm or less" 48452457_1 CDM 0510 RC 97605 HCPCS inpatient 280 182 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 169.54 271.6 "Therapy procedure using a special bandage and vacuum pump, surface area 50.0 sq cm or less" 48452457_1 CDM 0510 RC 97605 HCPCS inpatient 280 182 UHC - ALL PLANS UHC - ALL PLANS 999999999 169.54 271.6 "Therapy procedure using a special bandage and vacuum pump, surface area more than 50.0 sq cm" 48452458_1 CDM 0510 RC 97606 HCPCS inpatient 426 276.9 AETNA AETNA 336.54 79 999999999 257.94 413.22 percent of total billed charges "Therapy procedure using a special bandage and vacuum pump, surface area more than 50.0 sq cm" 48452458_1 CDM 0510 RC 97606 HCPCS inpatient 426 276.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 276.9 65 999999999 257.94 413.22 percent of total billed charges "Therapy procedure using a special bandage and vacuum pump, surface area more than 50.0 sq cm" 48452458_1 CDM 0510 RC 97606 HCPCS inpatient 426 276.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 413.22 97 999999999 257.94 413.22 percent of total billed charges "Therapy procedure using a special bandage and vacuum pump, surface area more than 50.0 sq cm" 48452458_1 CDM 0510 RC 97606 HCPCS inpatient 426 276.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 293.94 69 999999999 257.94 413.22 percent of total billed charges "Therapy procedure using a special bandage and vacuum pump, surface area more than 50.0 sq cm" 48452458_1 CDM 0510 RC 97606 HCPCS inpatient 426 276.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 332.28 78 999999999 257.94 413.22 percent of total billed charges "Therapy procedure using a special bandage and vacuum pump, surface area more than 50.0 sq cm" 48452458_1 CDM 0510 RC 97606 HCPCS inpatient 426 276.9 SIHO - ALL PLANS SIHO - ALL PLANS 383.4 90 999999999 257.94 413.22 percent of total billed charges "Therapy procedure using a special bandage and vacuum pump, surface area more than 50.0 sq cm" 48452458_1 CDM 0510 RC 97606 HCPCS inpatient 426 276.9 UMR - ALL PLANS UMR - ALL PLANS 298.2 70 999999999 257.94 413.22 percent of total billed charges "Therapy procedure using a special bandage and vacuum pump, surface area more than 50.0 sq cm" 48452458_1 CDM 0510 RC 97606 HCPCS inpatient 426 276.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 257.94 60.55 999999999 257.94 413.22 percent of total billed charges "Therapy procedure using a special bandage and vacuum pump, surface area more than 50.0 sq cm" 48452458_1 CDM 0510 RC 97606 HCPCS inpatient 426 276.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 257.94 413.22 "Therapy procedure using a special bandage and vacuum pump, surface area more than 50.0 sq cm" 48452458_1 CDM 0510 RC 97606 HCPCS inpatient 426 276.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 257.94 413.22 "Therapy procedure using a special bandage and vacuum pump, surface area more than 50.0 sq cm" 48452458_1 CDM 0510 RC 97606 HCPCS inpatient 426 276.9 ANTHEM HMO ANTHEM HMO 999999999 257.94 413.22 "Therapy procedure using a special bandage and vacuum pump, surface area more than 50.0 sq cm" 48452458_1 CDM 0510 RC 97606 HCPCS inpatient 426 276.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 287.98 67.6 999999999 257.94 413.22 percent of total billed charges "Therapy procedure using a special bandage and vacuum pump, surface area more than 50.0 sq cm" 48452458_1 CDM 0510 RC 97606 HCPCS inpatient 426 276.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 257.94 413.22 "Therapy procedure using a special bandage and vacuum pump, surface area more than 50.0 sq cm" 48452458_1 CDM 0510 RC 97606 HCPCS inpatient 426 276.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 257.94 413.22 "HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL" 48452459_1 CDM 0413 RC G0277 HCPCS inpatient 743 482.95 AETNA AETNA 586.97 79 999999999 449.89 720.71 percent of total billed charges "HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL" 48452459_1 CDM 0413 RC G0277 HCPCS inpatient 743 482.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 482.95 65 999999999 449.89 720.71 percent of total billed charges "HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL" 48452459_1 CDM 0413 RC G0277 HCPCS inpatient 743 482.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 720.71 97 999999999 449.89 720.71 percent of total billed charges "HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL" 48452459_1 CDM 0413 RC G0277 HCPCS inpatient 743 482.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 512.67 69 999999999 449.89 720.71 percent of total billed charges "HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL" 48452459_1 CDM 0413 RC G0277 HCPCS inpatient 743 482.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 579.54 78 999999999 449.89 720.71 percent of total billed charges "HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL" 48452459_1 CDM 0413 RC G0277 HCPCS inpatient 743 482.95 SIHO - ALL PLANS SIHO - ALL PLANS 668.7 90 999999999 449.89 720.71 percent of total billed charges "HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL" 48452459_1 CDM 0413 RC G0277 HCPCS inpatient 743 482.95 UMR - ALL PLANS UMR - ALL PLANS 520.1 70 999999999 449.89 720.71 percent of total billed charges "HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL" 48452459_1 CDM 0413 RC G0277 HCPCS inpatient 743 482.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 449.89 60.55 999999999 449.89 720.71 percent of total billed charges "HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL" 48452459_1 CDM 0413 RC G0277 HCPCS inpatient 743 482.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 449.89 720.71 "HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL" 48452459_1 CDM 0413 RC G0277 HCPCS inpatient 743 482.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 449.89 720.71 "HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL" 48452459_1 CDM 0413 RC G0277 HCPCS inpatient 743 482.95 ANTHEM HMO ANTHEM HMO 999999999 449.89 720.71 "HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL" 48452459_1 CDM 0413 RC G0277 HCPCS inpatient 743 482.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 502.27 67.6 999999999 449.89 720.71 percent of total billed charges "HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL" 48452459_1 CDM 0413 RC G0277 HCPCS inpatient 743 482.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 449.89 720.71 "HYPERBARIC OXYGEN UNDER PRESSURE, FULL BODY CHAMBER, PER 30 MINUTE INTERVAL" 48452459_1 CDM 0413 RC G0277 HCPCS inpatient 743 482.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 449.89 720.71 UNCLASSIFIED DRUGS 48452460_1 CDM 0636 RC J3490 HCPCS inpatient 207 134.55 AETNA AETNA 163.53 79 999999999 125.34 200.79 percent of total billed charges UNCLASSIFIED DRUGS 48452460_1 CDM 0636 RC J3490 HCPCS inpatient 207 134.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 134.55 65 999999999 125.34 200.79 percent of total billed charges UNCLASSIFIED DRUGS 48452460_1 CDM 0636 RC J3490 HCPCS inpatient 207 134.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 200.79 97 999999999 125.34 200.79 percent of total billed charges UNCLASSIFIED DRUGS 48452460_1 CDM 0636 RC J3490 HCPCS inpatient 207 134.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.83 69 999999999 125.34 200.79 percent of total billed charges UNCLASSIFIED DRUGS 48452460_1 CDM 0636 RC J3490 HCPCS inpatient 207 134.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 161.46 78 999999999 125.34 200.79 percent of total billed charges UNCLASSIFIED DRUGS 48452460_1 CDM 0636 RC J3490 HCPCS inpatient 207 134.55 SIHO - ALL PLANS SIHO - ALL PLANS 186.3 90 999999999 125.34 200.79 percent of total billed charges UNCLASSIFIED DRUGS 48452460_1 CDM 0636 RC J3490 HCPCS inpatient 207 134.55 UMR - ALL PLANS UMR - ALL PLANS 144.9 70 999999999 125.34 200.79 percent of total billed charges UNCLASSIFIED DRUGS 48452460_1 CDM 0636 RC J3490 HCPCS inpatient 207 134.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 125.34 60.55 999999999 125.34 200.79 percent of total billed charges UNCLASSIFIED DRUGS 48452460_1 CDM 0636 RC J3490 HCPCS inpatient 207 134.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 125.34 200.79 UNCLASSIFIED DRUGS 48452460_1 CDM 0636 RC J3490 HCPCS inpatient 207 134.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 125.34 200.79 UNCLASSIFIED DRUGS 48452460_1 CDM 0636 RC J3490 HCPCS inpatient 207 134.55 ANTHEM HMO ANTHEM HMO 999999999 125.34 200.79 UNCLASSIFIED DRUGS 48452460_1 CDM 0636 RC J3490 HCPCS inpatient 207 134.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.93 67.6 999999999 125.34 200.79 percent of total billed charges UNCLASSIFIED DRUGS 48452460_1 CDM 0636 RC J3490 HCPCS inpatient 207 134.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 125.34 200.79 UNCLASSIFIED DRUGS 48452460_1 CDM 0636 RC J3490 HCPCS inpatient 207 134.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 125.34 200.79 "APLIGRAF, PER SQUARE CENTIMETER" 48452461_1 CDM 0636 RC Q4101 HCPCS inpatient 6730 4374.5 AETNA AETNA 5316.7 79 999999999 4075.02 6528.1 percent of total billed charges "APLIGRAF, PER SQUARE CENTIMETER" 48452461_1 CDM 0636 RC Q4101 HCPCS inpatient 6730 4374.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 4374.5 65 999999999 4075.02 6528.1 percent of total billed charges "APLIGRAF, PER SQUARE CENTIMETER" 48452461_1 CDM 0636 RC Q4101 HCPCS inpatient 6730 4374.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6528.1 97 999999999 4075.02 6528.1 percent of total billed charges "APLIGRAF, PER SQUARE CENTIMETER" 48452461_1 CDM 0636 RC Q4101 HCPCS inpatient 6730 4374.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 4643.7 69 999999999 4075.02 6528.1 percent of total billed charges "APLIGRAF, PER SQUARE CENTIMETER" 48452461_1 CDM 0636 RC Q4101 HCPCS inpatient 6730 4374.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 5249.4 78 999999999 4075.02 6528.1 percent of total billed charges "APLIGRAF, PER SQUARE CENTIMETER" 48452461_1 CDM 0636 RC Q4101 HCPCS inpatient 6730 4374.5 UMR - ALL PLANS UMR - ALL PLANS 4711 70 999999999 4075.02 6528.1 percent of total billed charges "APLIGRAF, PER SQUARE CENTIMETER" 48452461_1 CDM 0636 RC Q4101 HCPCS inpatient 6730 4374.5 SIHO - ALL PLANS SIHO - ALL PLANS 6057 90 999999999 4075.02 6528.1 percent of total billed charges "APLIGRAF, PER SQUARE CENTIMETER" 48452461_1 CDM 0636 RC Q4101 HCPCS inpatient 6730 4374.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4075.02 60.55 999999999 4075.02 6528.1 percent of total billed charges "APLIGRAF, PER SQUARE CENTIMETER" 48452461_1 CDM 0636 RC Q4101 HCPCS inpatient 6730 4374.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4075.02 6528.1 "APLIGRAF, PER SQUARE CENTIMETER" 48452461_1 CDM 0636 RC Q4101 HCPCS inpatient 6730 4374.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4075.02 6528.1 "APLIGRAF, PER SQUARE CENTIMETER" 48452461_1 CDM 0636 RC Q4101 HCPCS inpatient 6730 4374.5 ANTHEM HMO ANTHEM HMO 999999999 4075.02 6528.1 "APLIGRAF, PER SQUARE CENTIMETER" 48452461_1 CDM 0636 RC Q4101 HCPCS inpatient 6730 4374.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 4549.48 67.6 999999999 4075.02 6528.1 percent of total billed charges "APLIGRAF, PER SQUARE CENTIMETER" 48452461_1 CDM 0636 RC Q4101 HCPCS inpatient 6730 4374.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4075.02 6528.1 "APLIGRAF, PER SQUARE CENTIMETER" 48452461_1 CDM 0636 RC Q4101 HCPCS inpatient 6730 4374.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 4075.02 6528.1 EPIFIX OR EPICORD 48452462_1 CDM 0636 RC Q4131 HCPCS inpatient 2124 1380.6 AETNA AETNA 1677.96 79 999999999 1286.08 2060.28 percent of total billed charges EPIFIX OR EPICORD 48452462_1 CDM 0636 RC Q4131 HCPCS inpatient 2124 1380.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1380.6 65 999999999 1286.08 2060.28 percent of total billed charges EPIFIX OR EPICORD 48452462_1 CDM 0636 RC Q4131 HCPCS inpatient 2124 1380.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2060.28 97 999999999 1286.08 2060.28 percent of total billed charges EPIFIX OR EPICORD 48452462_1 CDM 0636 RC Q4131 HCPCS inpatient 2124 1380.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1465.56 69 999999999 1286.08 2060.28 percent of total billed charges EPIFIX OR EPICORD 48452462_1 CDM 0636 RC Q4131 HCPCS inpatient 2124 1380.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1656.72 78 999999999 1286.08 2060.28 percent of total billed charges EPIFIX OR EPICORD 48452462_1 CDM 0636 RC Q4131 HCPCS inpatient 2124 1380.6 UMR - ALL PLANS UMR - ALL PLANS 1486.8 70 999999999 1286.08 2060.28 percent of total billed charges EPIFIX OR EPICORD 48452462_1 CDM 0636 RC Q4131 HCPCS inpatient 2124 1380.6 SIHO - ALL PLANS SIHO - ALL PLANS 1911.6 90 999999999 1286.08 2060.28 percent of total billed charges EPIFIX OR EPICORD 48452462_1 CDM 0636 RC Q4131 HCPCS inpatient 2124 1380.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1286.08 60.55 999999999 1286.08 2060.28 percent of total billed charges EPIFIX OR EPICORD 48452462_1 CDM 0636 RC Q4131 HCPCS inpatient 2124 1380.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1286.08 2060.28 EPIFIX OR EPICORD 48452462_1 CDM 0636 RC Q4131 HCPCS inpatient 2124 1380.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1286.08 2060.28 EPIFIX OR EPICORD 48452462_1 CDM 0636 RC Q4131 HCPCS inpatient 2124 1380.6 ANTHEM HMO ANTHEM HMO 999999999 1286.08 2060.28 EPIFIX OR EPICORD 48452462_1 CDM 0636 RC Q4131 HCPCS inpatient 2124 1380.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1435.82 67.6 999999999 1286.08 2060.28 percent of total billed charges EPIFIX OR EPICORD 48452462_1 CDM 0636 RC Q4131 HCPCS inpatient 2124 1380.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1286.08 2060.28 EPIFIX OR EPICORD 48452462_1 CDM 0636 RC Q4131 HCPCS inpatient 2124 1380.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1286.08 2060.28 EPIFIX OR EPICORD 48452463_1 CDM 0636 RC Q4131 HCPCS inpatient 3053 1984.45 AETNA AETNA 2411.87 79 999999999 1848.59 2961.41 percent of total billed charges EPIFIX OR EPICORD 48452463_1 CDM 0636 RC Q4131 HCPCS inpatient 3053 1984.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1984.45 65 999999999 1848.59 2961.41 percent of total billed charges EPIFIX OR EPICORD 48452463_1 CDM 0636 RC Q4131 HCPCS inpatient 3053 1984.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2961.41 97 999999999 1848.59 2961.41 percent of total billed charges EPIFIX OR EPICORD 48452463_1 CDM 0636 RC Q4131 HCPCS inpatient 3053 1984.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 2106.57 69 999999999 1848.59 2961.41 percent of total billed charges EPIFIX OR EPICORD 48452463_1 CDM 0636 RC Q4131 HCPCS inpatient 3053 1984.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 2381.34 78 999999999 1848.59 2961.41 percent of total billed charges EPIFIX OR EPICORD 48452463_1 CDM 0636 RC Q4131 HCPCS inpatient 3053 1984.45 UMR - ALL PLANS UMR - ALL PLANS 2137.1 70 999999999 1848.59 2961.41 percent of total billed charges EPIFIX OR EPICORD 48452463_1 CDM 0636 RC Q4131 HCPCS inpatient 3053 1984.45 SIHO - ALL PLANS SIHO - ALL PLANS 2747.7 90 999999999 1848.59 2961.41 percent of total billed charges EPIFIX OR EPICORD 48452463_1 CDM 0636 RC Q4131 HCPCS inpatient 3053 1984.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1848.59 60.55 999999999 1848.59 2961.41 percent of total billed charges EPIFIX OR EPICORD 48452463_1 CDM 0636 RC Q4131 HCPCS inpatient 3053 1984.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1848.59 2961.41 EPIFIX OR EPICORD 48452463_1 CDM 0636 RC Q4131 HCPCS inpatient 3053 1984.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1848.59 2961.41 EPIFIX OR EPICORD 48452463_1 CDM 0636 RC Q4131 HCPCS inpatient 3053 1984.45 ANTHEM HMO ANTHEM HMO 999999999 1848.59 2961.41 EPIFIX OR EPICORD 48452463_1 CDM 0636 RC Q4131 HCPCS inpatient 3053 1984.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 2063.83 67.6 999999999 1848.59 2961.41 percent of total billed charges EPIFIX OR EPICORD 48452463_1 CDM 0636 RC Q4131 HCPCS inpatient 3053 1984.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1848.59 2961.41 EPIFIX OR EPICORD 48452463_1 CDM 0636 RC Q4131 HCPCS inpatient 3053 1984.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1848.59 2961.41 EPIFIX OR EPICORD 48452464_1 CDM 0636 RC Q4131 HCPCS inpatient 3547 2305.55 AETNA AETNA 2802.13 79 999999999 2147.71 3440.59 percent of total billed charges EPIFIX OR EPICORD 48452464_1 CDM 0636 RC Q4131 HCPCS inpatient 3547 2305.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 2305.55 65 999999999 2147.71 3440.59 percent of total billed charges EPIFIX OR EPICORD 48452464_1 CDM 0636 RC Q4131 HCPCS inpatient 3547 2305.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3440.59 97 999999999 2147.71 3440.59 percent of total billed charges EPIFIX OR EPICORD 48452464_1 CDM 0636 RC Q4131 HCPCS inpatient 3547 2305.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 2447.43 69 999999999 2147.71 3440.59 percent of total billed charges EPIFIX OR EPICORD 48452464_1 CDM 0636 RC Q4131 HCPCS inpatient 3547 2305.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 2766.66 78 999999999 2147.71 3440.59 percent of total billed charges EPIFIX OR EPICORD 48452464_1 CDM 0636 RC Q4131 HCPCS inpatient 3547 2305.55 UMR - ALL PLANS UMR - ALL PLANS 2482.9 70 999999999 2147.71 3440.59 percent of total billed charges EPIFIX OR EPICORD 48452464_1 CDM 0636 RC Q4131 HCPCS inpatient 3547 2305.55 SIHO - ALL PLANS SIHO - ALL PLANS 3192.3 90 999999999 2147.71 3440.59 percent of total billed charges EPIFIX OR EPICORD 48452464_1 CDM 0636 RC Q4131 HCPCS inpatient 3547 2305.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2147.71 60.55 999999999 2147.71 3440.59 percent of total billed charges EPIFIX OR EPICORD 48452464_1 CDM 0636 RC Q4131 HCPCS inpatient 3547 2305.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2147.71 3440.59 EPIFIX OR EPICORD 48452464_1 CDM 0636 RC Q4131 HCPCS inpatient 3547 2305.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2147.71 3440.59 EPIFIX OR EPICORD 48452464_1 CDM 0636 RC Q4131 HCPCS inpatient 3547 2305.55 ANTHEM HMO ANTHEM HMO 999999999 2147.71 3440.59 EPIFIX OR EPICORD 48452464_1 CDM 0636 RC Q4131 HCPCS inpatient 3547 2305.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 2397.77 67.6 999999999 2147.71 3440.59 percent of total billed charges EPIFIX OR EPICORD 48452464_1 CDM 0636 RC Q4131 HCPCS inpatient 3547 2305.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2147.71 3440.59 EPIFIX OR EPICORD 48452464_1 CDM 0636 RC Q4131 HCPCS inpatient 3547 2305.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 2147.71 3440.59 EPIFIX OR EPICORD 48452465_1 CDM 0636 RC Q4131 HCPCS inpatient 3983 2588.95 AETNA AETNA 3146.57 79 999999999 2411.71 3863.51 percent of total billed charges EPIFIX OR EPICORD 48452465_1 CDM 0636 RC Q4131 HCPCS inpatient 3983 2588.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 2588.95 65 999999999 2411.71 3863.51 percent of total billed charges EPIFIX OR EPICORD 48452465_1 CDM 0636 RC Q4131 HCPCS inpatient 3983 2588.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3863.51 97 999999999 2411.71 3863.51 percent of total billed charges EPIFIX OR EPICORD 48452465_1 CDM 0636 RC Q4131 HCPCS inpatient 3983 2588.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 2748.27 69 999999999 2411.71 3863.51 percent of total billed charges EPIFIX OR EPICORD 48452465_1 CDM 0636 RC Q4131 HCPCS inpatient 3983 2588.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 3106.74 78 999999999 2411.71 3863.51 percent of total billed charges EPIFIX OR EPICORD 48452465_1 CDM 0636 RC Q4131 HCPCS inpatient 3983 2588.95 UMR - ALL PLANS UMR - ALL PLANS 2788.1 70 999999999 2411.71 3863.51 percent of total billed charges EPIFIX OR EPICORD 48452465_1 CDM 0636 RC Q4131 HCPCS inpatient 3983 2588.95 SIHO - ALL PLANS SIHO - ALL PLANS 3584.7 90 999999999 2411.71 3863.51 percent of total billed charges EPIFIX OR EPICORD 48452465_1 CDM 0636 RC Q4131 HCPCS inpatient 3983 2588.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2411.71 60.55 999999999 2411.71 3863.51 percent of total billed charges EPIFIX OR EPICORD 48452465_1 CDM 0636 RC Q4131 HCPCS inpatient 3983 2588.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2411.71 3863.51 EPIFIX OR EPICORD 48452465_1 CDM 0636 RC Q4131 HCPCS inpatient 3983 2588.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2411.71 3863.51 EPIFIX OR EPICORD 48452465_1 CDM 0636 RC Q4131 HCPCS inpatient 3983 2588.95 ANTHEM HMO ANTHEM HMO 999999999 2411.71 3863.51 EPIFIX OR EPICORD 48452465_1 CDM 0636 RC Q4131 HCPCS inpatient 3983 2588.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 2692.51 67.6 999999999 2411.71 3863.51 percent of total billed charges EPIFIX OR EPICORD 48452465_1 CDM 0636 RC Q4131 HCPCS inpatient 3983 2588.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2411.71 3863.51 EPIFIX OR EPICORD 48452465_1 CDM 0636 RC Q4131 HCPCS inpatient 3983 2588.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 2411.71 3863.51 EPIFIX OR EPICORD 48452466_1 CDM 0636 RC Q4131 HCPCS inpatient 3702 2406.3 AETNA AETNA 2924.58 79 999999999 2241.56 3590.94 percent of total billed charges EPIFIX OR EPICORD 48452466_1 CDM 0636 RC Q4131 HCPCS inpatient 3702 2406.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 2406.3 65 999999999 2241.56 3590.94 percent of total billed charges EPIFIX OR EPICORD 48452466_1 CDM 0636 RC Q4131 HCPCS inpatient 3702 2406.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3590.94 97 999999999 2241.56 3590.94 percent of total billed charges EPIFIX OR EPICORD 48452466_1 CDM 0636 RC Q4131 HCPCS inpatient 3702 2406.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 2554.38 69 999999999 2241.56 3590.94 percent of total billed charges EPIFIX OR EPICORD 48452466_1 CDM 0636 RC Q4131 HCPCS inpatient 3702 2406.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 2887.56 78 999999999 2241.56 3590.94 percent of total billed charges EPIFIX OR EPICORD 48452466_1 CDM 0636 RC Q4131 HCPCS inpatient 3702 2406.3 UMR - ALL PLANS UMR - ALL PLANS 2591.4 70 999999999 2241.56 3590.94 percent of total billed charges EPIFIX OR EPICORD 48452466_1 CDM 0636 RC Q4131 HCPCS inpatient 3702 2406.3 SIHO - ALL PLANS SIHO - ALL PLANS 3331.8 90 999999999 2241.56 3590.94 percent of total billed charges EPIFIX OR EPICORD 48452466_1 CDM 0636 RC Q4131 HCPCS inpatient 3702 2406.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2241.56 60.55 999999999 2241.56 3590.94 percent of total billed charges EPIFIX OR EPICORD 48452466_1 CDM 0636 RC Q4131 HCPCS inpatient 3702 2406.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2241.56 3590.94 EPIFIX OR EPICORD 48452466_1 CDM 0636 RC Q4131 HCPCS inpatient 3702 2406.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2241.56 3590.94 EPIFIX OR EPICORD 48452466_1 CDM 0636 RC Q4131 HCPCS inpatient 3702 2406.3 ANTHEM HMO ANTHEM HMO 999999999 2241.56 3590.94 EPIFIX OR EPICORD 48452466_1 CDM 0636 RC Q4131 HCPCS inpatient 3702 2406.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 2502.55 67.6 999999999 2241.56 3590.94 percent of total billed charges EPIFIX OR EPICORD 48452466_1 CDM 0636 RC Q4131 HCPCS inpatient 3702 2406.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2241.56 3590.94 EPIFIX OR EPICORD 48452466_1 CDM 0636 RC Q4131 HCPCS inpatient 3702 2406.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 2241.56 3590.94 EPIFIX OR EPICORD 48452467_1 CDM 0636 RC Q4131 HCPCS inpatient 4011 2607.15 AETNA AETNA 3168.69 79 999999999 2428.66 3890.67 percent of total billed charges EPIFIX OR EPICORD 48452467_1 CDM 0636 RC Q4131 HCPCS inpatient 4011 2607.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 2607.15 65 999999999 2428.66 3890.67 percent of total billed charges EPIFIX OR EPICORD 48452467_1 CDM 0636 RC Q4131 HCPCS inpatient 4011 2607.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3890.67 97 999999999 2428.66 3890.67 percent of total billed charges EPIFIX OR EPICORD 48452467_1 CDM 0636 RC Q4131 HCPCS inpatient 4011 2607.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 2767.59 69 999999999 2428.66 3890.67 percent of total billed charges EPIFIX OR EPICORD 48452467_1 CDM 0636 RC Q4131 HCPCS inpatient 4011 2607.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 3128.58 78 999999999 2428.66 3890.67 percent of total billed charges EPIFIX OR EPICORD 48452467_1 CDM 0636 RC Q4131 HCPCS inpatient 4011 2607.15 UMR - ALL PLANS UMR - ALL PLANS 2807.7 70 999999999 2428.66 3890.67 percent of total billed charges EPIFIX OR EPICORD 48452467_1 CDM 0636 RC Q4131 HCPCS inpatient 4011 2607.15 SIHO - ALL PLANS SIHO - ALL PLANS 3609.9 90 999999999 2428.66 3890.67 percent of total billed charges EPIFIX OR EPICORD 48452467_1 CDM 0636 RC Q4131 HCPCS inpatient 4011 2607.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2428.66 60.55 999999999 2428.66 3890.67 percent of total billed charges EPIFIX OR EPICORD 48452467_1 CDM 0636 RC Q4131 HCPCS inpatient 4011 2607.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2428.66 3890.67 EPIFIX OR EPICORD 48452467_1 CDM 0636 RC Q4131 HCPCS inpatient 4011 2607.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2428.66 3890.67 EPIFIX OR EPICORD 48452467_1 CDM 0636 RC Q4131 HCPCS inpatient 4011 2607.15 ANTHEM HMO ANTHEM HMO 999999999 2428.66 3890.67 EPIFIX OR EPICORD 48452467_1 CDM 0636 RC Q4131 HCPCS inpatient 4011 2607.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 2711.44 67.6 999999999 2428.66 3890.67 percent of total billed charges EPIFIX OR EPICORD 48452467_1 CDM 0636 RC Q4131 HCPCS inpatient 4011 2607.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2428.66 3890.67 EPIFIX OR EPICORD 48452467_1 CDM 0636 RC Q4131 HCPCS inpatient 4011 2607.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 2428.66 3890.67 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455976_1 CDM 0250 RC 63323-0162-14 NDC J1885 HCPCS inpatient 4 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455976_1 CDM 0250 RC 63323-0162-14 NDC J1885 HCPCS inpatient 4 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455976_1 CDM 0250 RC 63323-0162-14 NDC J1885 HCPCS inpatient 4 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455976_1 CDM 0250 RC 63323-0162-14 NDC J1885 HCPCS inpatient 4 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455976_1 CDM 0250 RC 63323-0162-14 NDC J1885 HCPCS inpatient 4 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455976_1 CDM 0250 RC 63323-0162-14 NDC J1885 HCPCS inpatient 4 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455976_1 CDM 0250 RC 63323-0162-14 NDC J1885 HCPCS inpatient 4 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455976_1 CDM 0250 RC 63323-0162-14 NDC J1885 HCPCS inpatient 4 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455976_1 CDM 0250 RC 63323-0162-14 NDC J1885 HCPCS inpatient 4 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455976_1 CDM 0250 RC 63323-0162-14 NDC J1885 HCPCS inpatient 4 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455976_1 CDM 0250 RC 63323-0162-14 NDC J1885 HCPCS inpatient 4 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455976_1 CDM 0250 RC 63323-0162-14 NDC J1885 HCPCS inpatient 4 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455976_1 CDM 0250 RC 63323-0162-14 NDC J1885 HCPCS inpatient 4 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455976_1 CDM 0250 RC 63323-0162-14 NDC J1885 HCPCS inpatient 4 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455977_1 CDM 0250 RC 63323-0162-12 NDC J1885 HCPCS inpatient 2 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455977_1 CDM 0250 RC 63323-0162-12 NDC J1885 HCPCS inpatient 2 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455977_1 CDM 0250 RC 63323-0162-12 NDC J1885 HCPCS inpatient 2 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455977_1 CDM 0250 RC 63323-0162-12 NDC J1885 HCPCS inpatient 2 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455977_1 CDM 0250 RC 63323-0162-12 NDC J1885 HCPCS inpatient 2 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455977_1 CDM 0250 RC 63323-0162-12 NDC J1885 HCPCS inpatient 2 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455977_1 CDM 0250 RC 63323-0162-12 NDC J1885 HCPCS inpatient 2 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455977_1 CDM 0250 RC 63323-0162-12 NDC J1885 HCPCS inpatient 2 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455977_1 CDM 0250 RC 63323-0162-12 NDC J1885 HCPCS inpatient 2 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455977_1 CDM 0250 RC 63323-0162-12 NDC J1885 HCPCS inpatient 2 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455977_1 CDM 0250 RC 63323-0162-12 NDC J1885 HCPCS inpatient 2 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455977_1 CDM 0250 RC 63323-0162-12 NDC J1885 HCPCS inpatient 2 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455977_1 CDM 0250 RC 63323-0162-12 NDC J1885 HCPCS inpatient 2 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 48455977_1 CDM 0250 RC 63323-0162-12 NDC J1885 HCPCS inpatient 2 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 DESMOPRESSIN ACETATE 0.2 MG TB 48455982_1 CDM 0250 RC 68084-0604-21 NDC inpatient 1 UN 7.93 5.15 AETNA AETNA 6.26 79 999999999 4.8 7.69 percent of total billed charges DESMOPRESSIN ACETATE 0.2 MG TB 48455982_1 CDM 0250 RC 68084-0604-21 NDC inpatient 1 UN 7.93 5.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.15 65 999999999 4.8 7.69 percent of total billed charges DESMOPRESSIN ACETATE 0.2 MG TB 48455982_1 CDM 0250 RC 68084-0604-21 NDC inpatient 1 UN 7.93 5.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7.69 97 999999999 4.8 7.69 percent of total billed charges DESMOPRESSIN ACETATE 0.2 MG TB 48455982_1 CDM 0250 RC 68084-0604-21 NDC inpatient 1 UN 7.93 5.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.47 69 999999999 4.8 7.69 percent of total billed charges DESMOPRESSIN ACETATE 0.2 MG TB 48455982_1 CDM 0250 RC 68084-0604-21 NDC inpatient 1 UN 7.93 5.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.19 78 999999999 4.8 7.69 percent of total billed charges DESMOPRESSIN ACETATE 0.2 MG TB 48455982_1 CDM 0250 RC 68084-0604-21 NDC inpatient 1 UN 7.93 5.15 UMR - ALL PLANS UMR - ALL PLANS 5.55 70 999999999 4.8 7.69 percent of total billed charges DESMOPRESSIN ACETATE 0.2 MG TB 48455982_1 CDM 0250 RC 68084-0604-21 NDC inpatient 1 UN 7.93 5.15 SIHO - ALL PLANS SIHO - ALL PLANS 7.14 90 999999999 4.8 7.69 percent of total billed charges DESMOPRESSIN ACETATE 0.2 MG TB 48455982_1 CDM 0250 RC 68084-0604-21 NDC inpatient 1 UN 7.93 5.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.8 60.55 999999999 4.8 7.69 percent of total billed charges DESMOPRESSIN ACETATE 0.2 MG TB 48455982_1 CDM 0250 RC 68084-0604-21 NDC inpatient 1 UN 7.93 5.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.8 7.69 DESMOPRESSIN ACETATE 0.2 MG TB 48455982_1 CDM 0250 RC 68084-0604-21 NDC inpatient 1 UN 7.93 5.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.8 7.69 DESMOPRESSIN ACETATE 0.2 MG TB 48455982_1 CDM 0250 RC 68084-0604-21 NDC inpatient 1 UN 7.93 5.15 ANTHEM HMO ANTHEM HMO 999999999 4.8 7.69 DESMOPRESSIN ACETATE 0.2 MG TB 48455982_1 CDM 0250 RC 68084-0604-21 NDC inpatient 1 UN 7.93 5.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.36 67.6 999999999 4.8 7.69 percent of total billed charges DESMOPRESSIN ACETATE 0.2 MG TB 48455982_1 CDM 0250 RC 68084-0604-21 NDC inpatient 1 UN 7.93 5.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.8 7.69 DESMOPRESSIN ACETATE 0.2 MG TB 48455982_1 CDM 0250 RC 68084-0604-21 NDC inpatient 1 UN 7.93 5.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.8 7.69 "63323-0542-01 - heparin 10,000 units/mL Inj Sol [JOHN]" 48455999_1 CDM 0250 RC 63323-0542-01 NDC inpatient 1 UN 32.69 21.25 AETNA AETNA 25.83 79 999999999 19.79 31.71 percent of total billed charges "63323-0542-01 - heparin 10,000 units/mL Inj Sol [JOHN]" 48455999_1 CDM 0250 RC 63323-0542-01 NDC inpatient 1 UN 32.69 21.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.25 65 999999999 19.79 31.71 percent of total billed charges "63323-0542-01 - heparin 10,000 units/mL Inj Sol [JOHN]" 48455999_1 CDM 0250 RC 63323-0542-01 NDC inpatient 1 UN 32.69 21.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31.71 97 999999999 19.79 31.71 percent of total billed charges "63323-0542-01 - heparin 10,000 units/mL Inj Sol [JOHN]" 48455999_1 CDM 0250 RC 63323-0542-01 NDC inpatient 1 UN 32.69 21.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.56 69 999999999 19.79 31.71 percent of total billed charges "63323-0542-01 - heparin 10,000 units/mL Inj Sol [JOHN]" 48455999_1 CDM 0250 RC 63323-0542-01 NDC inpatient 1 UN 32.69 21.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.5 78 999999999 19.79 31.71 percent of total billed charges "63323-0542-01 - heparin 10,000 units/mL Inj Sol [JOHN]" 48455999_1 CDM 0250 RC 63323-0542-01 NDC inpatient 1 UN 32.69 21.25 UMR - ALL PLANS UMR - ALL PLANS 22.88 70 999999999 19.79 31.71 percent of total billed charges "63323-0542-01 - heparin 10,000 units/mL Inj Sol [JOHN]" 48455999_1 CDM 0250 RC 63323-0542-01 NDC inpatient 1 UN 32.69 21.25 SIHO - ALL PLANS SIHO - ALL PLANS 29.42 90 999999999 19.79 31.71 percent of total billed charges "63323-0542-01 - heparin 10,000 units/mL Inj Sol [JOHN]" 48455999_1 CDM 0250 RC 63323-0542-01 NDC inpatient 1 UN 32.69 21.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.79 60.55 999999999 19.79 31.71 percent of total billed charges "63323-0542-01 - heparin 10,000 units/mL Inj Sol [JOHN]" 48455999_1 CDM 0250 RC 63323-0542-01 NDC inpatient 1 UN 32.69 21.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.79 31.71 "63323-0542-01 - heparin 10,000 units/mL Inj Sol [JOHN]" 48455999_1 CDM 0250 RC 63323-0542-01 NDC inpatient 1 UN 32.69 21.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.79 31.71 "63323-0542-01 - heparin 10,000 units/mL Inj Sol [JOHN]" 48455999_1 CDM 0250 RC 63323-0542-01 NDC inpatient 1 UN 32.69 21.25 ANTHEM HMO ANTHEM HMO 999999999 19.79 31.71 "63323-0542-01 - heparin 10,000 units/mL Inj Sol [JOHN]" 48455999_1 CDM 0250 RC 63323-0542-01 NDC inpatient 1 UN 32.69 21.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.1 67.6 999999999 19.79 31.71 percent of total billed charges "63323-0542-01 - heparin 10,000 units/mL Inj Sol [JOHN]" 48455999_1 CDM 0250 RC 63323-0542-01 NDC inpatient 1 UN 32.69 21.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.79 31.71 "63323-0542-01 - heparin 10,000 units/mL Inj Sol [JOHN]" 48455999_1 CDM 0250 RC 63323-0542-01 NDC inpatient 1 UN 32.69 21.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.79 31.71 LEVOTHYROXINE 100 MCG VIAL 48456016_1 CDM 0250 RC 63323-0649-16 NDC inpatient 1 UN 374.4 243.36 AETNA AETNA 295.78 79 999999999 226.7 363.17 percent of total billed charges LEVOTHYROXINE 100 MCG VIAL 48456016_1 CDM 0250 RC 63323-0649-16 NDC inpatient 1 UN 374.4 243.36 SELF PAY DISCOUNT SELF PAY DISCOUNT 243.36 65 999999999 226.7 363.17 percent of total billed charges LEVOTHYROXINE 100 MCG VIAL 48456016_1 CDM 0250 RC 63323-0649-16 NDC inpatient 1 UN 374.4 243.36 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 363.17 97 999999999 226.7 363.17 percent of total billed charges LEVOTHYROXINE 100 MCG VIAL 48456016_1 CDM 0250 RC 63323-0649-16 NDC inpatient 1 UN 374.4 243.36 ENCORE - ALL PLANS ENCORE - ALL PLANS 258.34 69 999999999 226.7 363.17 percent of total billed charges LEVOTHYROXINE 100 MCG VIAL 48456016_1 CDM 0250 RC 63323-0649-16 NDC inpatient 1 UN 374.4 243.36 HUMANA - ALL PLANS HUMANA - ALL PLANS 292.03 78 999999999 226.7 363.17 percent of total billed charges LEVOTHYROXINE 100 MCG VIAL 48456016_1 CDM 0250 RC 63323-0649-16 NDC inpatient 1 UN 374.4 243.36 UMR - ALL PLANS UMR - ALL PLANS 262.08 70 999999999 226.7 363.17 percent of total billed charges LEVOTHYROXINE 100 MCG VIAL 48456016_1 CDM 0250 RC 63323-0649-16 NDC inpatient 1 UN 374.4 243.36 SIHO - ALL PLANS SIHO - ALL PLANS 336.96 90 999999999 226.7 363.17 percent of total billed charges LEVOTHYROXINE 100 MCG VIAL 48456016_1 CDM 0250 RC 63323-0649-16 NDC inpatient 1 UN 374.4 243.36 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 226.7 60.55 999999999 226.7 363.17 percent of total billed charges LEVOTHYROXINE 100 MCG VIAL 48456016_1 CDM 0250 RC 63323-0649-16 NDC inpatient 1 UN 374.4 243.36 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 226.7 363.17 LEVOTHYROXINE 100 MCG VIAL 48456016_1 CDM 0250 RC 63323-0649-16 NDC inpatient 1 UN 374.4 243.36 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 226.7 363.17 LEVOTHYROXINE 100 MCG VIAL 48456016_1 CDM 0250 RC 63323-0649-16 NDC inpatient 1 UN 374.4 243.36 ANTHEM HMO ANTHEM HMO 999999999 226.7 363.17 LEVOTHYROXINE 100 MCG VIAL 48456016_1 CDM 0250 RC 63323-0649-16 NDC inpatient 1 UN 374.4 243.36 CIGNA - ALL PLANS CIGNA - ALL PLANS 253.09 67.6 999999999 226.7 363.17 percent of total billed charges LEVOTHYROXINE 100 MCG VIAL 48456016_1 CDM 0250 RC 63323-0649-16 NDC inpatient 1 UN 374.4 243.36 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 226.7 363.17 LEVOTHYROXINE 100 MCG VIAL 48456016_1 CDM 0250 RC 63323-0649-16 NDC inpatient 1 UN 374.4 243.36 UHC - ALL PLANS UHC - ALL PLANS 999999999 226.7 363.17 63323-0540-57 - heparin 1000 units/mL Inj 10 mL Sol [JOHN] 48456019_1 CDM 0250 RC 63323-0540-57 NDC inpatient 1 UN 30.73 19.97 AETNA AETNA 24.28 79 999999999 18.61 29.81 percent of total billed charges 63323-0540-57 - heparin 1000 units/mL Inj 10 mL Sol [JOHN] 48456019_1 CDM 0250 RC 63323-0540-57 NDC inpatient 1 UN 30.73 19.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.97 65 999999999 18.61 29.81 percent of total billed charges 63323-0540-57 - heparin 1000 units/mL Inj 10 mL Sol [JOHN] 48456019_1 CDM 0250 RC 63323-0540-57 NDC inpatient 1 UN 30.73 19.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.81 97 999999999 18.61 29.81 percent of total billed charges 63323-0540-57 - heparin 1000 units/mL Inj 10 mL Sol [JOHN] 48456019_1 CDM 0250 RC 63323-0540-57 NDC inpatient 1 UN 30.73 19.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.2 69 999999999 18.61 29.81 percent of total billed charges 63323-0540-57 - heparin 1000 units/mL Inj 10 mL Sol [JOHN] 48456019_1 CDM 0250 RC 63323-0540-57 NDC inpatient 1 UN 30.73 19.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.97 78 999999999 18.61 29.81 percent of total billed charges 63323-0540-57 - heparin 1000 units/mL Inj 10 mL Sol [JOHN] 48456019_1 CDM 0250 RC 63323-0540-57 NDC inpatient 1 UN 30.73 19.97 UMR - ALL PLANS UMR - ALL PLANS 21.51 70 999999999 18.61 29.81 percent of total billed charges 63323-0540-57 - heparin 1000 units/mL Inj 10 mL Sol [JOHN] 48456019_1 CDM 0250 RC 63323-0540-57 NDC inpatient 1 UN 30.73 19.97 SIHO - ALL PLANS SIHO - ALL PLANS 27.66 90 999999999 18.61 29.81 percent of total billed charges 63323-0540-57 - heparin 1000 units/mL Inj 10 mL Sol [JOHN] 48456019_1 CDM 0250 RC 63323-0540-57 NDC inpatient 1 UN 30.73 19.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.61 60.55 999999999 18.61 29.81 percent of total billed charges 63323-0540-57 - heparin 1000 units/mL Inj 10 mL Sol [JOHN] 48456019_1 CDM 0250 RC 63323-0540-57 NDC inpatient 1 UN 30.73 19.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.61 29.81 63323-0540-57 - heparin 1000 units/mL Inj 10 mL Sol [JOHN] 48456019_1 CDM 0250 RC 63323-0540-57 NDC inpatient 1 UN 30.73 19.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.61 29.81 63323-0540-57 - heparin 1000 units/mL Inj 10 mL Sol [JOHN] 48456019_1 CDM 0250 RC 63323-0540-57 NDC inpatient 1 UN 30.73 19.97 ANTHEM HMO ANTHEM HMO 999999999 18.61 29.81 63323-0540-57 - heparin 1000 units/mL Inj 10 mL Sol [JOHN] 48456019_1 CDM 0250 RC 63323-0540-57 NDC inpatient 1 UN 30.73 19.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.77 67.6 999999999 18.61 29.81 percent of total billed charges 63323-0540-57 - heparin 1000 units/mL Inj 10 mL Sol [JOHN] 48456019_1 CDM 0250 RC 63323-0540-57 NDC inpatient 1 UN 30.73 19.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.61 29.81 63323-0540-57 - heparin 1000 units/mL Inj 10 mL Sol [JOHN] 48456019_1 CDM 0250 RC 63323-0540-57 NDC inpatient 1 UN 30.73 19.97 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.61 29.81 NICARDIPINE 25 MG/10 ML VIAL 48456020_1 CDM 0250 RC 00143-9593-10 NDC inpatient 1 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges NICARDIPINE 25 MG/10 ML VIAL 48456020_1 CDM 0250 RC 00143-9593-10 NDC inpatient 1 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges NICARDIPINE 25 MG/10 ML VIAL 48456020_1 CDM 0250 RC 00143-9593-10 NDC inpatient 1 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges NICARDIPINE 25 MG/10 ML VIAL 48456020_1 CDM 0250 RC 00143-9593-10 NDC inpatient 1 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges NICARDIPINE 25 MG/10 ML VIAL 48456020_1 CDM 0250 RC 00143-9593-10 NDC inpatient 1 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges NICARDIPINE 25 MG/10 ML VIAL 48456020_1 CDM 0250 RC 00143-9593-10 NDC inpatient 1 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges NICARDIPINE 25 MG/10 ML VIAL 48456020_1 CDM 0250 RC 00143-9593-10 NDC inpatient 1 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges NICARDIPINE 25 MG/10 ML VIAL 48456020_1 CDM 0250 RC 00143-9593-10 NDC inpatient 1 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges NICARDIPINE 25 MG/10 ML VIAL 48456020_1 CDM 0250 RC 00143-9593-10 NDC inpatient 1 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 NICARDIPINE 25 MG/10 ML VIAL 48456020_1 CDM 0250 RC 00143-9593-10 NDC inpatient 1 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 NICARDIPINE 25 MG/10 ML VIAL 48456020_1 CDM 0250 RC 00143-9593-10 NDC inpatient 1 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 NICARDIPINE 25 MG/10 ML VIAL 48456020_1 CDM 0250 RC 00143-9593-10 NDC inpatient 1 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges NICARDIPINE 25 MG/10 ML VIAL 48456020_1 CDM 0250 RC 00143-9593-10 NDC inpatient 1 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 NICARDIPINE 25 MG/10 ML VIAL 48456020_1 CDM 0250 RC 00143-9593-10 NDC inpatient 1 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 "INJECTION, ENOXAPARIN SODIUM, 10 MG" 48456026_1 CDM 0250 RC 63323-0568-95 NDC J1650 HCPCS inpatient 10 UN 61.05 39.68 AETNA AETNA 48.23 79 999999999 36.97 59.22 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 48456026_1 CDM 0250 RC 63323-0568-95 NDC J1650 HCPCS inpatient 10 UN 61.05 39.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.68 65 999999999 36.97 59.22 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 48456026_1 CDM 0250 RC 63323-0568-95 NDC J1650 HCPCS inpatient 10 UN 61.05 39.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59.22 97 999999999 36.97 59.22 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 48456026_1 CDM 0250 RC 63323-0568-95 NDC J1650 HCPCS inpatient 10 UN 61.05 39.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.12 69 999999999 36.97 59.22 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 48456026_1 CDM 0250 RC 63323-0568-95 NDC J1650 HCPCS inpatient 10 UN 61.05 39.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.62 78 999999999 36.97 59.22 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 48456026_1 CDM 0250 RC 63323-0568-95 NDC J1650 HCPCS inpatient 10 UN 61.05 39.68 UMR - ALL PLANS UMR - ALL PLANS 42.74 70 999999999 36.97 59.22 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 48456026_1 CDM 0250 RC 63323-0568-95 NDC J1650 HCPCS inpatient 10 UN 61.05 39.68 SIHO - ALL PLANS SIHO - ALL PLANS 54.95 90 999999999 36.97 59.22 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 48456026_1 CDM 0250 RC 63323-0568-95 NDC J1650 HCPCS inpatient 10 UN 61.05 39.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.97 60.55 999999999 36.97 59.22 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 48456026_1 CDM 0250 RC 63323-0568-95 NDC J1650 HCPCS inpatient 10 UN 61.05 39.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.97 59.22 "INJECTION, ENOXAPARIN SODIUM, 10 MG" 48456026_1 CDM 0250 RC 63323-0568-95 NDC J1650 HCPCS inpatient 10 UN 61.05 39.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.97 59.22 "INJECTION, ENOXAPARIN SODIUM, 10 MG" 48456026_1 CDM 0250 RC 63323-0568-95 NDC J1650 HCPCS inpatient 10 UN 61.05 39.68 ANTHEM HMO ANTHEM HMO 999999999 36.97 59.22 "INJECTION, ENOXAPARIN SODIUM, 10 MG" 48456026_1 CDM 0250 RC 63323-0568-95 NDC J1650 HCPCS inpatient 10 UN 61.05 39.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.27 67.6 999999999 36.97 59.22 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 48456026_1 CDM 0250 RC 63323-0568-95 NDC J1650 HCPCS inpatient 10 UN 61.05 39.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.97 59.22 "INJECTION, ENOXAPARIN SODIUM, 10 MG" 48456026_1 CDM 0250 RC 63323-0568-95 NDC J1650 HCPCS inpatient 10 UN 61.05 39.68 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.97 59.22 63323-0568-99 - enoxaparin 80 mg/0.8 mL SC Sol [JOHN] 48456028_1 CDM 0250 RC 63323-0568-99 NDC inpatient 1 UN 52.2 33.93 AETNA AETNA 41.24 79 999999999 31.61 50.63 percent of total billed charges 63323-0568-99 - enoxaparin 80 mg/0.8 mL SC Sol [JOHN] 48456028_1 CDM 0250 RC 63323-0568-99 NDC inpatient 1 UN 52.2 33.93 SELF PAY DISCOUNT SELF PAY DISCOUNT 33.93 65 999999999 31.61 50.63 percent of total billed charges 63323-0568-99 - enoxaparin 80 mg/0.8 mL SC Sol [JOHN] 48456028_1 CDM 0250 RC 63323-0568-99 NDC inpatient 1 UN 52.2 33.93 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 50.63 97 999999999 31.61 50.63 percent of total billed charges 63323-0568-99 - enoxaparin 80 mg/0.8 mL SC Sol [JOHN] 48456028_1 CDM 0250 RC 63323-0568-99 NDC inpatient 1 UN 52.2 33.93 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.02 69 999999999 31.61 50.63 percent of total billed charges 63323-0568-99 - enoxaparin 80 mg/0.8 mL SC Sol [JOHN] 48456028_1 CDM 0250 RC 63323-0568-99 NDC inpatient 1 UN 52.2 33.93 HUMANA - ALL PLANS HUMANA - ALL PLANS 40.72 78 999999999 31.61 50.63 percent of total billed charges 63323-0568-99 - enoxaparin 80 mg/0.8 mL SC Sol [JOHN] 48456028_1 CDM 0250 RC 63323-0568-99 NDC inpatient 1 UN 52.2 33.93 UMR - ALL PLANS UMR - ALL PLANS 36.54 70 999999999 31.61 50.63 percent of total billed charges 63323-0568-99 - enoxaparin 80 mg/0.8 mL SC Sol [JOHN] 48456028_1 CDM 0250 RC 63323-0568-99 NDC inpatient 1 UN 52.2 33.93 SIHO - ALL PLANS SIHO - ALL PLANS 46.98 90 999999999 31.61 50.63 percent of total billed charges 63323-0568-99 - enoxaparin 80 mg/0.8 mL SC Sol [JOHN] 48456028_1 CDM 0250 RC 63323-0568-99 NDC inpatient 1 UN 52.2 33.93 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 31.61 60.55 999999999 31.61 50.63 percent of total billed charges 63323-0568-99 - enoxaparin 80 mg/0.8 mL SC Sol [JOHN] 48456028_1 CDM 0250 RC 63323-0568-99 NDC inpatient 1 UN 52.2 33.93 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 31.61 50.63 63323-0568-99 - enoxaparin 80 mg/0.8 mL SC Sol [JOHN] 48456028_1 CDM 0250 RC 63323-0568-99 NDC inpatient 1 UN 52.2 33.93 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 31.61 50.63 63323-0568-99 - enoxaparin 80 mg/0.8 mL SC Sol [JOHN] 48456028_1 CDM 0250 RC 63323-0568-99 NDC inpatient 1 UN 52.2 33.93 ANTHEM HMO ANTHEM HMO 999999999 31.61 50.63 63323-0568-99 - enoxaparin 80 mg/0.8 mL SC Sol [JOHN] 48456028_1 CDM 0250 RC 63323-0568-99 NDC inpatient 1 UN 52.2 33.93 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.29 67.6 999999999 31.61 50.63 percent of total billed charges 63323-0568-99 - enoxaparin 80 mg/0.8 mL SC Sol [JOHN] 48456028_1 CDM 0250 RC 63323-0568-99 NDC inpatient 1 UN 52.2 33.93 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 31.61 50.63 63323-0568-99 - enoxaparin 80 mg/0.8 mL SC Sol [JOHN] 48456028_1 CDM 0250 RC 63323-0568-99 NDC inpatient 1 UN 52.2 33.93 UHC - ALL PLANS UHC - ALL PLANS 999999999 31.61 50.63 63323-0568-98 - enoxaparin 60 mg/0.6 mL SC Sol [JOHN] 48456029_1 CDM 0250 RC 63323-0568-98 NDC inpatient 1 UN 43.46 28.25 AETNA AETNA 34.33 79 999999999 26.32 42.16 percent of total billed charges 63323-0568-98 - enoxaparin 60 mg/0.6 mL SC Sol [JOHN] 48456029_1 CDM 0250 RC 63323-0568-98 NDC inpatient 1 UN 43.46 28.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 28.25 65 999999999 26.32 42.16 percent of total billed charges 63323-0568-98 - enoxaparin 60 mg/0.6 mL SC Sol [JOHN] 48456029_1 CDM 0250 RC 63323-0568-98 NDC inpatient 1 UN 43.46 28.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 42.16 97 999999999 26.32 42.16 percent of total billed charges 63323-0568-98 - enoxaparin 60 mg/0.6 mL SC Sol [JOHN] 48456029_1 CDM 0250 RC 63323-0568-98 NDC inpatient 1 UN 43.46 28.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 29.99 69 999999999 26.32 42.16 percent of total billed charges 63323-0568-98 - enoxaparin 60 mg/0.6 mL SC Sol [JOHN] 48456029_1 CDM 0250 RC 63323-0568-98 NDC inpatient 1 UN 43.46 28.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 33.9 78 999999999 26.32 42.16 percent of total billed charges 63323-0568-98 - enoxaparin 60 mg/0.6 mL SC Sol [JOHN] 48456029_1 CDM 0250 RC 63323-0568-98 NDC inpatient 1 UN 43.46 28.25 UMR - ALL PLANS UMR - ALL PLANS 30.42 70 999999999 26.32 42.16 percent of total billed charges 63323-0568-98 - enoxaparin 60 mg/0.6 mL SC Sol [JOHN] 48456029_1 CDM 0250 RC 63323-0568-98 NDC inpatient 1 UN 43.46 28.25 SIHO - ALL PLANS SIHO - ALL PLANS 39.11 90 999999999 26.32 42.16 percent of total billed charges 63323-0568-98 - enoxaparin 60 mg/0.6 mL SC Sol [JOHN] 48456029_1 CDM 0250 RC 63323-0568-98 NDC inpatient 1 UN 43.46 28.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26.32 60.55 999999999 26.32 42.16 percent of total billed charges 63323-0568-98 - enoxaparin 60 mg/0.6 mL SC Sol [JOHN] 48456029_1 CDM 0250 RC 63323-0568-98 NDC inpatient 1 UN 43.46 28.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26.32 42.16 63323-0568-98 - enoxaparin 60 mg/0.6 mL SC Sol [JOHN] 48456029_1 CDM 0250 RC 63323-0568-98 NDC inpatient 1 UN 43.46 28.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26.32 42.16 63323-0568-98 - enoxaparin 60 mg/0.6 mL SC Sol [JOHN] 48456029_1 CDM 0250 RC 63323-0568-98 NDC inpatient 1 UN 43.46 28.25 ANTHEM HMO ANTHEM HMO 999999999 26.32 42.16 63323-0568-98 - enoxaparin 60 mg/0.6 mL SC Sol [JOHN] 48456029_1 CDM 0250 RC 63323-0568-98 NDC inpatient 1 UN 43.46 28.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 29.38 67.6 999999999 26.32 42.16 percent of total billed charges 63323-0568-98 - enoxaparin 60 mg/0.6 mL SC Sol [JOHN] 48456029_1 CDM 0250 RC 63323-0568-98 NDC inpatient 1 UN 43.46 28.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26.32 42.16 63323-0568-98 - enoxaparin 60 mg/0.6 mL SC Sol [JOHN] 48456029_1 CDM 0250 RC 63323-0568-98 NDC inpatient 1 UN 43.46 28.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 26.32 42.16 POTASSIUM CL 40 MEQ/20 ML CONC 48456032_1 CDM 0250 RC 63323-0965-20 NDC inpatient 1 UN 26.28 17.08 AETNA AETNA 20.76 79 999999999 15.91 25.49 percent of total billed charges POTASSIUM CL 40 MEQ/20 ML CONC 48456032_1 CDM 0250 RC 63323-0965-20 NDC inpatient 1 UN 26.28 17.08 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.08 65 999999999 15.91 25.49 percent of total billed charges POTASSIUM CL 40 MEQ/20 ML CONC 48456032_1 CDM 0250 RC 63323-0965-20 NDC inpatient 1 UN 26.28 17.08 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.49 97 999999999 15.91 25.49 percent of total billed charges POTASSIUM CL 40 MEQ/20 ML CONC 48456032_1 CDM 0250 RC 63323-0965-20 NDC inpatient 1 UN 26.28 17.08 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.13 69 999999999 15.91 25.49 percent of total billed charges POTASSIUM CL 40 MEQ/20 ML CONC 48456032_1 CDM 0250 RC 63323-0965-20 NDC inpatient 1 UN 26.28 17.08 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.5 78 999999999 15.91 25.49 percent of total billed charges POTASSIUM CL 40 MEQ/20 ML CONC 48456032_1 CDM 0250 RC 63323-0965-20 NDC inpatient 1 UN 26.28 17.08 UMR - ALL PLANS UMR - ALL PLANS 18.4 70 999999999 15.91 25.49 percent of total billed charges POTASSIUM CL 40 MEQ/20 ML CONC 48456032_1 CDM 0250 RC 63323-0965-20 NDC inpatient 1 UN 26.28 17.08 SIHO - ALL PLANS SIHO - ALL PLANS 23.65 90 999999999 15.91 25.49 percent of total billed charges POTASSIUM CL 40 MEQ/20 ML CONC 48456032_1 CDM 0250 RC 63323-0965-20 NDC inpatient 1 UN 26.28 17.08 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.91 60.55 999999999 15.91 25.49 percent of total billed charges POTASSIUM CL 40 MEQ/20 ML CONC 48456032_1 CDM 0250 RC 63323-0965-20 NDC inpatient 1 UN 26.28 17.08 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.91 25.49 POTASSIUM CL 40 MEQ/20 ML CONC 48456032_1 CDM 0250 RC 63323-0965-20 NDC inpatient 1 UN 26.28 17.08 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.91 25.49 POTASSIUM CL 40 MEQ/20 ML CONC 48456032_1 CDM 0250 RC 63323-0965-20 NDC inpatient 1 UN 26.28 17.08 ANTHEM HMO ANTHEM HMO 999999999 15.91 25.49 POTASSIUM CL 40 MEQ/20 ML CONC 48456032_1 CDM 0250 RC 63323-0965-20 NDC inpatient 1 UN 26.28 17.08 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.77 67.6 999999999 15.91 25.49 percent of total billed charges POTASSIUM CL 40 MEQ/20 ML CONC 48456032_1 CDM 0250 RC 63323-0965-20 NDC inpatient 1 UN 26.28 17.08 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.91 25.49 POTASSIUM CL 40 MEQ/20 ML CONC 48456032_1 CDM 0250 RC 63323-0965-20 NDC inpatient 1 UN 26.28 17.08 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.91 25.49 POTASSIUM CL 20 MEQ/10 ML CONC 48456034_1 CDM 0250 RC 63323-0965-10 NDC inpatient 1 UN 19.92 12.95 AETNA AETNA 15.74 79 999999999 12.06 19.32 percent of total billed charges POTASSIUM CL 20 MEQ/10 ML CONC 48456034_1 CDM 0250 RC 63323-0965-10 NDC inpatient 1 UN 19.92 12.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.95 65 999999999 12.06 19.32 percent of total billed charges POTASSIUM CL 20 MEQ/10 ML CONC 48456034_1 CDM 0250 RC 63323-0965-10 NDC inpatient 1 UN 19.92 12.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.32 97 999999999 12.06 19.32 percent of total billed charges POTASSIUM CL 20 MEQ/10 ML CONC 48456034_1 CDM 0250 RC 63323-0965-10 NDC inpatient 1 UN 19.92 12.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.74 69 999999999 12.06 19.32 percent of total billed charges POTASSIUM CL 20 MEQ/10 ML CONC 48456034_1 CDM 0250 RC 63323-0965-10 NDC inpatient 1 UN 19.92 12.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.54 78 999999999 12.06 19.32 percent of total billed charges POTASSIUM CL 20 MEQ/10 ML CONC 48456034_1 CDM 0250 RC 63323-0965-10 NDC inpatient 1 UN 19.92 12.95 UMR - ALL PLANS UMR - ALL PLANS 13.94 70 999999999 12.06 19.32 percent of total billed charges POTASSIUM CL 20 MEQ/10 ML CONC 48456034_1 CDM 0250 RC 63323-0965-10 NDC inpatient 1 UN 19.92 12.95 SIHO - ALL PLANS SIHO - ALL PLANS 17.93 90 999999999 12.06 19.32 percent of total billed charges POTASSIUM CL 20 MEQ/10 ML CONC 48456034_1 CDM 0250 RC 63323-0965-10 NDC inpatient 1 UN 19.92 12.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.06 60.55 999999999 12.06 19.32 percent of total billed charges POTASSIUM CL 20 MEQ/10 ML CONC 48456034_1 CDM 0250 RC 63323-0965-10 NDC inpatient 1 UN 19.92 12.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.06 19.32 POTASSIUM CL 20 MEQ/10 ML CONC 48456034_1 CDM 0250 RC 63323-0965-10 NDC inpatient 1 UN 19.92 12.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.06 19.32 POTASSIUM CL 20 MEQ/10 ML CONC 48456034_1 CDM 0250 RC 63323-0965-10 NDC inpatient 1 UN 19.92 12.95 ANTHEM HMO ANTHEM HMO 999999999 12.06 19.32 POTASSIUM CL 20 MEQ/10 ML CONC 48456034_1 CDM 0250 RC 63323-0965-10 NDC inpatient 1 UN 19.92 12.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.47 67.6 999999999 12.06 19.32 percent of total billed charges POTASSIUM CL 20 MEQ/10 ML CONC 48456034_1 CDM 0250 RC 63323-0965-10 NDC inpatient 1 UN 19.92 12.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.06 19.32 POTASSIUM CL 20 MEQ/10 ML CONC 48456034_1 CDM 0250 RC 63323-0965-10 NDC inpatient 1 UN 19.92 12.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.06 19.32 POTASSIUM ACET 40 MEQ/20 ML VL 48456035_1 CDM 0250 RC 00409-8183-25 NDC inpatient 1 UN 30.82 20.03 AETNA AETNA 24.35 79 999999999 18.66 29.9 percent of total billed charges POTASSIUM ACET 40 MEQ/20 ML VL 48456035_1 CDM 0250 RC 00409-8183-25 NDC inpatient 1 UN 30.82 20.03 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.03 65 999999999 18.66 29.9 percent of total billed charges POTASSIUM ACET 40 MEQ/20 ML VL 48456035_1 CDM 0250 RC 00409-8183-25 NDC inpatient 1 UN 30.82 20.03 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.9 97 999999999 18.66 29.9 percent of total billed charges POTASSIUM ACET 40 MEQ/20 ML VL 48456035_1 CDM 0250 RC 00409-8183-25 NDC inpatient 1 UN 30.82 20.03 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.27 69 999999999 18.66 29.9 percent of total billed charges POTASSIUM ACET 40 MEQ/20 ML VL 48456035_1 CDM 0250 RC 00409-8183-25 NDC inpatient 1 UN 30.82 20.03 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.04 78 999999999 18.66 29.9 percent of total billed charges POTASSIUM ACET 40 MEQ/20 ML VL 48456035_1 CDM 0250 RC 00409-8183-25 NDC inpatient 1 UN 30.82 20.03 UMR - ALL PLANS UMR - ALL PLANS 21.57 70 999999999 18.66 29.9 percent of total billed charges POTASSIUM ACET 40 MEQ/20 ML VL 48456035_1 CDM 0250 RC 00409-8183-25 NDC inpatient 1 UN 30.82 20.03 SIHO - ALL PLANS SIHO - ALL PLANS 27.74 90 999999999 18.66 29.9 percent of total billed charges POTASSIUM ACET 40 MEQ/20 ML VL 48456035_1 CDM 0250 RC 00409-8183-25 NDC inpatient 1 UN 30.82 20.03 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.66 60.55 999999999 18.66 29.9 percent of total billed charges POTASSIUM ACET 40 MEQ/20 ML VL 48456035_1 CDM 0250 RC 00409-8183-25 NDC inpatient 1 UN 30.82 20.03 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.66 29.9 POTASSIUM ACET 40 MEQ/20 ML VL 48456035_1 CDM 0250 RC 00409-8183-25 NDC inpatient 1 UN 30.82 20.03 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.66 29.9 POTASSIUM ACET 40 MEQ/20 ML VL 48456035_1 CDM 0250 RC 00409-8183-25 NDC inpatient 1 UN 30.82 20.03 ANTHEM HMO ANTHEM HMO 999999999 18.66 29.9 POTASSIUM ACET 40 MEQ/20 ML VL 48456035_1 CDM 0250 RC 00409-8183-25 NDC inpatient 1 UN 30.82 20.03 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.83 67.6 999999999 18.66 29.9 percent of total billed charges POTASSIUM ACET 40 MEQ/20 ML VL 48456035_1 CDM 0250 RC 00409-8183-25 NDC inpatient 1 UN 30.82 20.03 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.66 29.9 POTASSIUM ACET 40 MEQ/20 ML VL 48456035_1 CDM 0250 RC 00409-8183-25 NDC inpatient 1 UN 30.82 20.03 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.66 29.9 "INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG" 48456037_1 CDM 0250 RC 76329-3369-01 NDC J2310 HCPCS inpatient 1 UN 123.54 80.3 AETNA AETNA 97.6 79 999999999 74.8 119.83 percent of total billed charges "INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG" 48456037_1 CDM 0250 RC 76329-3369-01 NDC J2310 HCPCS inpatient 1 UN 123.54 80.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.3 65 999999999 74.8 119.83 percent of total billed charges "INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG" 48456037_1 CDM 0250 RC 76329-3369-01 NDC J2310 HCPCS inpatient 1 UN 123.54 80.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 119.83 97 999999999 74.8 119.83 percent of total billed charges "INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG" 48456037_1 CDM 0250 RC 76329-3369-01 NDC J2310 HCPCS inpatient 1 UN 123.54 80.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.24 69 999999999 74.8 119.83 percent of total billed charges "INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG" 48456037_1 CDM 0250 RC 76329-3369-01 NDC J2310 HCPCS inpatient 1 UN 123.54 80.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.36 78 999999999 74.8 119.83 percent of total billed charges "INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG" 48456037_1 CDM 0250 RC 76329-3369-01 NDC J2310 HCPCS inpatient 1 UN 123.54 80.3 UMR - ALL PLANS UMR - ALL PLANS 86.48 70 999999999 74.8 119.83 percent of total billed charges "INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG" 48456037_1 CDM 0250 RC 76329-3369-01 NDC J2310 HCPCS inpatient 1 UN 123.54 80.3 SIHO - ALL PLANS SIHO - ALL PLANS 111.19 90 999999999 74.8 119.83 percent of total billed charges "INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG" 48456037_1 CDM 0250 RC 76329-3369-01 NDC J2310 HCPCS inpatient 1 UN 123.54 80.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 74.8 60.55 999999999 74.8 119.83 percent of total billed charges "INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG" 48456037_1 CDM 0250 RC 76329-3369-01 NDC J2310 HCPCS inpatient 1 UN 123.54 80.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 74.8 119.83 "INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG" 48456037_1 CDM 0250 RC 76329-3369-01 NDC J2310 HCPCS inpatient 1 UN 123.54 80.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 74.8 119.83 "INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG" 48456037_1 CDM 0250 RC 76329-3369-01 NDC J2310 HCPCS inpatient 1 UN 123.54 80.3 ANTHEM HMO ANTHEM HMO 999999999 74.8 119.83 "INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG" 48456037_1 CDM 0250 RC 76329-3369-01 NDC J2310 HCPCS inpatient 1 UN 123.54 80.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.51 67.6 999999999 74.8 119.83 percent of total billed charges "INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG" 48456037_1 CDM 0250 RC 76329-3369-01 NDC J2310 HCPCS inpatient 1 UN 123.54 80.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 74.8 119.83 "INJECTION, NALOXONE HYDROCHLORIDE, PER 1 MG" 48456037_1 CDM 0250 RC 76329-3369-01 NDC J2310 HCPCS inpatient 1 UN 123.54 80.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 74.8 119.83 "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48456041_1 CDM 0250 RC 00469-3211-99 NDC J2248 HCPCS inpatient 100 UN 311.46 202.45 AETNA AETNA 246.05 79 999999999 188.59 302.12 percent of total billed charges "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48456041_1 CDM 0250 RC 00469-3211-99 NDC J2248 HCPCS inpatient 100 UN 311.46 202.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 202.45 65 999999999 188.59 302.12 percent of total billed charges "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48456041_1 CDM 0250 RC 00469-3211-99 NDC J2248 HCPCS inpatient 100 UN 311.46 202.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 302.12 97 999999999 188.59 302.12 percent of total billed charges "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48456041_1 CDM 0250 RC 00469-3211-99 NDC J2248 HCPCS inpatient 100 UN 311.46 202.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 214.91 69 999999999 188.59 302.12 percent of total billed charges "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48456041_1 CDM 0250 RC 00469-3211-99 NDC J2248 HCPCS inpatient 100 UN 311.46 202.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 242.94 78 999999999 188.59 302.12 percent of total billed charges "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48456041_1 CDM 0250 RC 00469-3211-99 NDC J2248 HCPCS inpatient 100 UN 311.46 202.45 UMR - ALL PLANS UMR - ALL PLANS 218.02 70 999999999 188.59 302.12 percent of total billed charges "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48456041_1 CDM 0250 RC 00469-3211-99 NDC J2248 HCPCS inpatient 100 UN 311.46 202.45 SIHO - ALL PLANS SIHO - ALL PLANS 280.31 90 999999999 188.59 302.12 percent of total billed charges "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48456041_1 CDM 0250 RC 00469-3211-99 NDC J2248 HCPCS inpatient 100 UN 311.46 202.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 188.59 60.55 999999999 188.59 302.12 percent of total billed charges "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48456041_1 CDM 0250 RC 00469-3211-99 NDC J2248 HCPCS inpatient 100 UN 311.46 202.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 188.59 302.12 "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48456041_1 CDM 0250 RC 00469-3211-99 NDC J2248 HCPCS inpatient 100 UN 311.46 202.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 188.59 302.12 "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48456041_1 CDM 0250 RC 00469-3211-99 NDC J2248 HCPCS inpatient 100 UN 311.46 202.45 ANTHEM HMO ANTHEM HMO 999999999 188.59 302.12 "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48456041_1 CDM 0250 RC 00469-3211-99 NDC J2248 HCPCS inpatient 100 UN 311.46 202.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 210.55 67.6 999999999 188.59 302.12 percent of total billed charges "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48456041_1 CDM 0250 RC 00469-3211-99 NDC J2248 HCPCS inpatient 100 UN 311.46 202.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 188.59 302.12 "INJECTION, MICAFUNGIN SODIUM, 1 MG" 48456041_1 CDM 0250 RC 00469-3211-99 NDC J2248 HCPCS inpatient 100 UN 311.46 202.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 188.59 302.12 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48456048_1 CDM 0250 RC 42023-0116-02 NDC J2590 HCPCS inpatient 10 UN 82.34 53.52 AETNA AETNA 65.05 79 999999999 49.86 79.87 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48456048_1 CDM 0250 RC 42023-0116-02 NDC J2590 HCPCS inpatient 10 UN 82.34 53.52 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.52 65 999999999 49.86 79.87 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48456048_1 CDM 0250 RC 42023-0116-02 NDC J2590 HCPCS inpatient 10 UN 82.34 53.52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.87 97 999999999 49.86 79.87 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48456048_1 CDM 0250 RC 42023-0116-02 NDC J2590 HCPCS inpatient 10 UN 82.34 53.52 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.81 69 999999999 49.86 79.87 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48456048_1 CDM 0250 RC 42023-0116-02 NDC J2590 HCPCS inpatient 10 UN 82.34 53.52 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.23 78 999999999 49.86 79.87 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48456048_1 CDM 0250 RC 42023-0116-02 NDC J2590 HCPCS inpatient 10 UN 82.34 53.52 UMR - ALL PLANS UMR - ALL PLANS 57.64 70 999999999 49.86 79.87 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48456048_1 CDM 0250 RC 42023-0116-02 NDC J2590 HCPCS inpatient 10 UN 82.34 53.52 SIHO - ALL PLANS SIHO - ALL PLANS 74.11 90 999999999 49.86 79.87 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48456048_1 CDM 0250 RC 42023-0116-02 NDC J2590 HCPCS inpatient 10 UN 82.34 53.52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.86 60.55 999999999 49.86 79.87 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48456048_1 CDM 0250 RC 42023-0116-02 NDC J2590 HCPCS inpatient 10 UN 82.34 53.52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.86 79.87 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48456048_1 CDM 0250 RC 42023-0116-02 NDC J2590 HCPCS inpatient 10 UN 82.34 53.52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.86 79.87 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48456048_1 CDM 0250 RC 42023-0116-02 NDC J2590 HCPCS inpatient 10 UN 82.34 53.52 ANTHEM HMO ANTHEM HMO 999999999 49.86 79.87 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48456048_1 CDM 0250 RC 42023-0116-02 NDC J2590 HCPCS inpatient 10 UN 82.34 53.52 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.66 67.6 999999999 49.86 79.87 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48456048_1 CDM 0250 RC 42023-0116-02 NDC J2590 HCPCS inpatient 10 UN 82.34 53.52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.86 79.87 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48456048_1 CDM 0250 RC 42023-0116-02 NDC J2590 HCPCS inpatient 10 UN 82.34 53.52 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.86 79.87 OLANZAPINE 10 MG VIAL 48456050_1 CDM 0250 RC 00781-3159-72 NDC inpatient 1 UN 118.98 77.34 AETNA AETNA 93.99 79 999999999 72.04 115.41 percent of total billed charges OLANZAPINE 10 MG VIAL 48456050_1 CDM 0250 RC 00781-3159-72 NDC inpatient 1 UN 118.98 77.34 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.34 65 999999999 72.04 115.41 percent of total billed charges OLANZAPINE 10 MG VIAL 48456050_1 CDM 0250 RC 00781-3159-72 NDC inpatient 1 UN 118.98 77.34 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.41 97 999999999 72.04 115.41 percent of total billed charges OLANZAPINE 10 MG VIAL 48456050_1 CDM 0250 RC 00781-3159-72 NDC inpatient 1 UN 118.98 77.34 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.1 69 999999999 72.04 115.41 percent of total billed charges OLANZAPINE 10 MG VIAL 48456050_1 CDM 0250 RC 00781-3159-72 NDC inpatient 1 UN 118.98 77.34 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.8 78 999999999 72.04 115.41 percent of total billed charges OLANZAPINE 10 MG VIAL 48456050_1 CDM 0250 RC 00781-3159-72 NDC inpatient 1 UN 118.98 77.34 UMR - ALL PLANS UMR - ALL PLANS 83.29 70 999999999 72.04 115.41 percent of total billed charges OLANZAPINE 10 MG VIAL 48456050_1 CDM 0250 RC 00781-3159-72 NDC inpatient 1 UN 118.98 77.34 SIHO - ALL PLANS SIHO - ALL PLANS 107.08 90 999999999 72.04 115.41 percent of total billed charges OLANZAPINE 10 MG VIAL 48456050_1 CDM 0250 RC 00781-3159-72 NDC inpatient 1 UN 118.98 77.34 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.04 60.55 999999999 72.04 115.41 percent of total billed charges OLANZAPINE 10 MG VIAL 48456050_1 CDM 0250 RC 00781-3159-72 NDC inpatient 1 UN 118.98 77.34 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.04 115.41 OLANZAPINE 10 MG VIAL 48456050_1 CDM 0250 RC 00781-3159-72 NDC inpatient 1 UN 118.98 77.34 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.04 115.41 OLANZAPINE 10 MG VIAL 48456050_1 CDM 0250 RC 00781-3159-72 NDC inpatient 1 UN 118.98 77.34 ANTHEM HMO ANTHEM HMO 999999999 72.04 115.41 OLANZAPINE 10 MG VIAL 48456050_1 CDM 0250 RC 00781-3159-72 NDC inpatient 1 UN 118.98 77.34 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.43 67.6 999999999 72.04 115.41 percent of total billed charges OLANZAPINE 10 MG VIAL 48456050_1 CDM 0250 RC 00781-3159-72 NDC inpatient 1 UN 118.98 77.34 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.04 115.41 OLANZAPINE 10 MG VIAL 48456050_1 CDM 0250 RC 00781-3159-72 NDC inpatient 1 UN 118.98 77.34 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.04 115.41 POTASSIUM PHOSP 45 MMOL/15 ML 48456055_1 CDM 0250 RC 00409-7295-01 NDC inpatient 1 UN 87.65 56.97 AETNA AETNA 69.24 79 999999999 53.07 85.02 percent of total billed charges POTASSIUM PHOSP 45 MMOL/15 ML 48456055_1 CDM 0250 RC 00409-7295-01 NDC inpatient 1 UN 87.65 56.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.97 65 999999999 53.07 85.02 percent of total billed charges POTASSIUM PHOSP 45 MMOL/15 ML 48456055_1 CDM 0250 RC 00409-7295-01 NDC inpatient 1 UN 87.65 56.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.02 97 999999999 53.07 85.02 percent of total billed charges POTASSIUM PHOSP 45 MMOL/15 ML 48456055_1 CDM 0250 RC 00409-7295-01 NDC inpatient 1 UN 87.65 56.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.48 69 999999999 53.07 85.02 percent of total billed charges POTASSIUM PHOSP 45 MMOL/15 ML 48456055_1 CDM 0250 RC 00409-7295-01 NDC inpatient 1 UN 87.65 56.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.37 78 999999999 53.07 85.02 percent of total billed charges POTASSIUM PHOSP 45 MMOL/15 ML 48456055_1 CDM 0250 RC 00409-7295-01 NDC inpatient 1 UN 87.65 56.97 UMR - ALL PLANS UMR - ALL PLANS 61.36 70 999999999 53.07 85.02 percent of total billed charges POTASSIUM PHOSP 45 MMOL/15 ML 48456055_1 CDM 0250 RC 00409-7295-01 NDC inpatient 1 UN 87.65 56.97 SIHO - ALL PLANS SIHO - ALL PLANS 78.89 90 999999999 53.07 85.02 percent of total billed charges POTASSIUM PHOSP 45 MMOL/15 ML 48456055_1 CDM 0250 RC 00409-7295-01 NDC inpatient 1 UN 87.65 56.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.07 60.55 999999999 53.07 85.02 percent of total billed charges POTASSIUM PHOSP 45 MMOL/15 ML 48456055_1 CDM 0250 RC 00409-7295-01 NDC inpatient 1 UN 87.65 56.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.07 85.02 POTASSIUM PHOSP 45 MMOL/15 ML 48456055_1 CDM 0250 RC 00409-7295-01 NDC inpatient 1 UN 87.65 56.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.07 85.02 POTASSIUM PHOSP 45 MMOL/15 ML 48456055_1 CDM 0250 RC 00409-7295-01 NDC inpatient 1 UN 87.65 56.97 ANTHEM HMO ANTHEM HMO 999999999 53.07 85.02 POTASSIUM PHOSP 45 MMOL/15 ML 48456055_1 CDM 0250 RC 00409-7295-01 NDC inpatient 1 UN 87.65 56.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.25 67.6 999999999 53.07 85.02 percent of total billed charges POTASSIUM PHOSP 45 MMOL/15 ML 48456055_1 CDM 0250 RC 00409-7295-01 NDC inpatient 1 UN 87.65 56.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.07 85.02 POTASSIUM PHOSP 45 MMOL/15 ML 48456055_1 CDM 0250 RC 00409-7295-01 NDC inpatient 1 UN 87.65 56.97 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.07 85.02 63323-0187-30 - sodium chloride 23.4% IV Sol 30 mL [JOHN] 48456057_1 CDM 0250 RC 63323-0187-30 NDC inpatient 1 UN 38.84 25.25 AETNA AETNA 30.68 79 999999999 23.52 37.67 percent of total billed charges 63323-0187-30 - sodium chloride 23.4% IV Sol 30 mL [JOHN] 48456057_1 CDM 0250 RC 63323-0187-30 NDC inpatient 1 UN 38.84 25.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 25.25 65 999999999 23.52 37.67 percent of total billed charges 63323-0187-30 - sodium chloride 23.4% IV Sol 30 mL [JOHN] 48456057_1 CDM 0250 RC 63323-0187-30 NDC inpatient 1 UN 38.84 25.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37.67 97 999999999 23.52 37.67 percent of total billed charges 63323-0187-30 - sodium chloride 23.4% IV Sol 30 mL [JOHN] 48456057_1 CDM 0250 RC 63323-0187-30 NDC inpatient 1 UN 38.84 25.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.8 69 999999999 23.52 37.67 percent of total billed charges 63323-0187-30 - sodium chloride 23.4% IV Sol 30 mL [JOHN] 48456057_1 CDM 0250 RC 63323-0187-30 NDC inpatient 1 UN 38.84 25.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 30.3 78 999999999 23.52 37.67 percent of total billed charges 63323-0187-30 - sodium chloride 23.4% IV Sol 30 mL [JOHN] 48456057_1 CDM 0250 RC 63323-0187-30 NDC inpatient 1 UN 38.84 25.25 UMR - ALL PLANS UMR - ALL PLANS 27.19 70 999999999 23.52 37.67 percent of total billed charges 63323-0187-30 - sodium chloride 23.4% IV Sol 30 mL [JOHN] 48456057_1 CDM 0250 RC 63323-0187-30 NDC inpatient 1 UN 38.84 25.25 SIHO - ALL PLANS SIHO - ALL PLANS 34.96 90 999999999 23.52 37.67 percent of total billed charges 63323-0187-30 - sodium chloride 23.4% IV Sol 30 mL [JOHN] 48456057_1 CDM 0250 RC 63323-0187-30 NDC inpatient 1 UN 38.84 25.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.52 60.55 999999999 23.52 37.67 percent of total billed charges 63323-0187-30 - sodium chloride 23.4% IV Sol 30 mL [JOHN] 48456057_1 CDM 0250 RC 63323-0187-30 NDC inpatient 1 UN 38.84 25.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.52 37.67 63323-0187-30 - sodium chloride 23.4% IV Sol 30 mL [JOHN] 48456057_1 CDM 0250 RC 63323-0187-30 NDC inpatient 1 UN 38.84 25.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.52 37.67 63323-0187-30 - sodium chloride 23.4% IV Sol 30 mL [JOHN] 48456057_1 CDM 0250 RC 63323-0187-30 NDC inpatient 1 UN 38.84 25.25 ANTHEM HMO ANTHEM HMO 999999999 23.52 37.67 63323-0187-30 - sodium chloride 23.4% IV Sol 30 mL [JOHN] 48456057_1 CDM 0250 RC 63323-0187-30 NDC inpatient 1 UN 38.84 25.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 26.26 67.6 999999999 23.52 37.67 percent of total billed charges 63323-0187-30 - sodium chloride 23.4% IV Sol 30 mL [JOHN] 48456057_1 CDM 0250 RC 63323-0187-30 NDC inpatient 1 UN 38.84 25.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.52 37.67 63323-0187-30 - sodium chloride 23.4% IV Sol 30 mL [JOHN] 48456057_1 CDM 0250 RC 63323-0187-30 NDC inpatient 1 UN 38.84 25.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.52 37.67 SODIUM PHOSPHATE 15 MMOL/5 ML 48456058_1 CDM 0250 RC 63323-0170-05 NDC inpatient 1 UN 99.27 64.53 AETNA AETNA 78.42 79 999999999 60.11 96.29 percent of total billed charges SODIUM PHOSPHATE 15 MMOL/5 ML 48456058_1 CDM 0250 RC 63323-0170-05 NDC inpatient 1 UN 99.27 64.53 SELF PAY DISCOUNT SELF PAY DISCOUNT 64.53 65 999999999 60.11 96.29 percent of total billed charges SODIUM PHOSPHATE 15 MMOL/5 ML 48456058_1 CDM 0250 RC 63323-0170-05 NDC inpatient 1 UN 99.27 64.53 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 96.29 97 999999999 60.11 96.29 percent of total billed charges SODIUM PHOSPHATE 15 MMOL/5 ML 48456058_1 CDM 0250 RC 63323-0170-05 NDC inpatient 1 UN 99.27 64.53 ENCORE - ALL PLANS ENCORE - ALL PLANS 68.5 69 999999999 60.11 96.29 percent of total billed charges SODIUM PHOSPHATE 15 MMOL/5 ML 48456058_1 CDM 0250 RC 63323-0170-05 NDC inpatient 1 UN 99.27 64.53 HUMANA - ALL PLANS HUMANA - ALL PLANS 77.43 78 999999999 60.11 96.29 percent of total billed charges SODIUM PHOSPHATE 15 MMOL/5 ML 48456058_1 CDM 0250 RC 63323-0170-05 NDC inpatient 1 UN 99.27 64.53 UMR - ALL PLANS UMR - ALL PLANS 69.49 70 999999999 60.11 96.29 percent of total billed charges SODIUM PHOSPHATE 15 MMOL/5 ML 48456058_1 CDM 0250 RC 63323-0170-05 NDC inpatient 1 UN 99.27 64.53 SIHO - ALL PLANS SIHO - ALL PLANS 89.34 90 999999999 60.11 96.29 percent of total billed charges SODIUM PHOSPHATE 15 MMOL/5 ML 48456058_1 CDM 0250 RC 63323-0170-05 NDC inpatient 1 UN 99.27 64.53 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.11 60.55 999999999 60.11 96.29 percent of total billed charges SODIUM PHOSPHATE 15 MMOL/5 ML 48456058_1 CDM 0250 RC 63323-0170-05 NDC inpatient 1 UN 99.27 64.53 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.11 96.29 SODIUM PHOSPHATE 15 MMOL/5 ML 48456058_1 CDM 0250 RC 63323-0170-05 NDC inpatient 1 UN 99.27 64.53 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.11 96.29 SODIUM PHOSPHATE 15 MMOL/5 ML 48456058_1 CDM 0250 RC 63323-0170-05 NDC inpatient 1 UN 99.27 64.53 ANTHEM HMO ANTHEM HMO 999999999 60.11 96.29 SODIUM PHOSPHATE 15 MMOL/5 ML 48456058_1 CDM 0250 RC 63323-0170-05 NDC inpatient 1 UN 99.27 64.53 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.11 67.6 999999999 60.11 96.29 percent of total billed charges SODIUM PHOSPHATE 15 MMOL/5 ML 48456058_1 CDM 0250 RC 63323-0170-05 NDC inpatient 1 UN 99.27 64.53 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.11 96.29 SODIUM PHOSPHATE 15 MMOL/5 ML 48456058_1 CDM 0250 RC 63323-0170-05 NDC inpatient 1 UN 99.27 64.53 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.11 96.29 PIPERACIL-TAZOBACT 2.25 GM VL 48456059_1 CDM 0250 RC 55150-0119-30 NDC inpatient 1 UN 32.02 20.81 AETNA AETNA 25.3 79 999999999 19.39 31.06 percent of total billed charges PIPERACIL-TAZOBACT 2.25 GM VL 48456059_1 CDM 0250 RC 55150-0119-30 NDC inpatient 1 UN 32.02 20.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.81 65 999999999 19.39 31.06 percent of total billed charges PIPERACIL-TAZOBACT 2.25 GM VL 48456059_1 CDM 0250 RC 55150-0119-30 NDC inpatient 1 UN 32.02 20.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31.06 97 999999999 19.39 31.06 percent of total billed charges PIPERACIL-TAZOBACT 2.25 GM VL 48456059_1 CDM 0250 RC 55150-0119-30 NDC inpatient 1 UN 32.02 20.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.09 69 999999999 19.39 31.06 percent of total billed charges PIPERACIL-TAZOBACT 2.25 GM VL 48456059_1 CDM 0250 RC 55150-0119-30 NDC inpatient 1 UN 32.02 20.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.98 78 999999999 19.39 31.06 percent of total billed charges PIPERACIL-TAZOBACT 2.25 GM VL 48456059_1 CDM 0250 RC 55150-0119-30 NDC inpatient 1 UN 32.02 20.81 UMR - ALL PLANS UMR - ALL PLANS 22.41 70 999999999 19.39 31.06 percent of total billed charges PIPERACIL-TAZOBACT 2.25 GM VL 48456059_1 CDM 0250 RC 55150-0119-30 NDC inpatient 1 UN 32.02 20.81 SIHO - ALL PLANS SIHO - ALL PLANS 28.82 90 999999999 19.39 31.06 percent of total billed charges PIPERACIL-TAZOBACT 2.25 GM VL 48456059_1 CDM 0250 RC 55150-0119-30 NDC inpatient 1 UN 32.02 20.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.39 60.55 999999999 19.39 31.06 percent of total billed charges PIPERACIL-TAZOBACT 2.25 GM VL 48456059_1 CDM 0250 RC 55150-0119-30 NDC inpatient 1 UN 32.02 20.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.39 31.06 PIPERACIL-TAZOBACT 2.25 GM VL 48456059_1 CDM 0250 RC 55150-0119-30 NDC inpatient 1 UN 32.02 20.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.39 31.06 PIPERACIL-TAZOBACT 2.25 GM VL 48456059_1 CDM 0250 RC 55150-0119-30 NDC inpatient 1 UN 32.02 20.81 ANTHEM HMO ANTHEM HMO 999999999 19.39 31.06 PIPERACIL-TAZOBACT 2.25 GM VL 48456059_1 CDM 0250 RC 55150-0119-30 NDC inpatient 1 UN 32.02 20.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.65 67.6 999999999 19.39 31.06 percent of total billed charges PIPERACIL-TAZOBACT 2.25 GM VL 48456059_1 CDM 0250 RC 55150-0119-30 NDC inpatient 1 UN 32.02 20.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.39 31.06 PIPERACIL-TAZOBACT 2.25 GM VL 48456059_1 CDM 0250 RC 55150-0119-30 NDC inpatient 1 UN 32.02 20.81 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.39 31.06 PIPERACIL-TAZOBACT 3.375 GM VL 48456061_1 CDM 0250 RC 44567-0802-10 NDC inpatient 1 UN 37.15 24.15 AETNA AETNA 29.35 79 999999999 22.49 36.04 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 48456061_1 CDM 0250 RC 44567-0802-10 NDC inpatient 1 UN 37.15 24.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.15 65 999999999 22.49 36.04 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 48456061_1 CDM 0250 RC 44567-0802-10 NDC inpatient 1 UN 37.15 24.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 36.04 97 999999999 22.49 36.04 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 48456061_1 CDM 0250 RC 44567-0802-10 NDC inpatient 1 UN 37.15 24.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.63 69 999999999 22.49 36.04 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 48456061_1 CDM 0250 RC 44567-0802-10 NDC inpatient 1 UN 37.15 24.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.98 78 999999999 22.49 36.04 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 48456061_1 CDM 0250 RC 44567-0802-10 NDC inpatient 1 UN 37.15 24.15 UMR - ALL PLANS UMR - ALL PLANS 26.01 70 999999999 22.49 36.04 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 48456061_1 CDM 0250 RC 44567-0802-10 NDC inpatient 1 UN 37.15 24.15 SIHO - ALL PLANS SIHO - ALL PLANS 33.44 90 999999999 22.49 36.04 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 48456061_1 CDM 0250 RC 44567-0802-10 NDC inpatient 1 UN 37.15 24.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.49 60.55 999999999 22.49 36.04 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 48456061_1 CDM 0250 RC 44567-0802-10 NDC inpatient 1 UN 37.15 24.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.49 36.04 PIPERACIL-TAZOBACT 3.375 GM VL 48456061_1 CDM 0250 RC 44567-0802-10 NDC inpatient 1 UN 37.15 24.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.49 36.04 PIPERACIL-TAZOBACT 3.375 GM VL 48456061_1 CDM 0250 RC 44567-0802-10 NDC inpatient 1 UN 37.15 24.15 ANTHEM HMO ANTHEM HMO 999999999 22.49 36.04 PIPERACIL-TAZOBACT 3.375 GM VL 48456061_1 CDM 0250 RC 44567-0802-10 NDC inpatient 1 UN 37.15 24.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.11 67.6 999999999 22.49 36.04 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 48456061_1 CDM 0250 RC 44567-0802-10 NDC inpatient 1 UN 37.15 24.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.49 36.04 PIPERACIL-TAZOBACT 3.375 GM VL 48456061_1 CDM 0250 RC 44567-0802-10 NDC inpatient 1 UN 37.15 24.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.49 36.04 "INJECTION, PROPOFOL, 10 MG" 48456071_1 CDM 0250 RC 63323-0269-37 NDC J2704 HCPCS inpatient 20 UN 26.49 17.22 AETNA AETNA 20.93 79 999999999 16.04 25.7 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 48456071_1 CDM 0250 RC 63323-0269-37 NDC J2704 HCPCS inpatient 20 UN 26.49 17.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.22 65 999999999 16.04 25.7 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 48456071_1 CDM 0250 RC 63323-0269-37 NDC J2704 HCPCS inpatient 20 UN 26.49 17.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.7 97 999999999 16.04 25.7 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 48456071_1 CDM 0250 RC 63323-0269-37 NDC J2704 HCPCS inpatient 20 UN 26.49 17.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.28 69 999999999 16.04 25.7 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 48456071_1 CDM 0250 RC 63323-0269-37 NDC J2704 HCPCS inpatient 20 UN 26.49 17.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.66 78 999999999 16.04 25.7 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 48456071_1 CDM 0250 RC 63323-0269-37 NDC J2704 HCPCS inpatient 20 UN 26.49 17.22 UMR - ALL PLANS UMR - ALL PLANS 18.54 70 999999999 16.04 25.7 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 48456071_1 CDM 0250 RC 63323-0269-37 NDC J2704 HCPCS inpatient 20 UN 26.49 17.22 SIHO - ALL PLANS SIHO - ALL PLANS 23.84 90 999999999 16.04 25.7 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 48456071_1 CDM 0250 RC 63323-0269-37 NDC J2704 HCPCS inpatient 20 UN 26.49 17.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.04 60.55 999999999 16.04 25.7 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 48456071_1 CDM 0250 RC 63323-0269-37 NDC J2704 HCPCS inpatient 20 UN 26.49 17.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.04 25.7 "INJECTION, PROPOFOL, 10 MG" 48456071_1 CDM 0250 RC 63323-0269-37 NDC J2704 HCPCS inpatient 20 UN 26.49 17.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.04 25.7 "INJECTION, PROPOFOL, 10 MG" 48456071_1 CDM 0250 RC 63323-0269-37 NDC J2704 HCPCS inpatient 20 UN 26.49 17.22 ANTHEM HMO ANTHEM HMO 999999999 16.04 25.7 "INJECTION, PROPOFOL, 10 MG" 48456071_1 CDM 0250 RC 63323-0269-37 NDC J2704 HCPCS inpatient 20 UN 26.49 17.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.91 67.6 999999999 16.04 25.7 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 48456071_1 CDM 0250 RC 63323-0269-37 NDC J2704 HCPCS inpatient 20 UN 26.49 17.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.04 25.7 "INJECTION, PROPOFOL, 10 MG" 48456071_1 CDM 0250 RC 63323-0269-37 NDC J2704 HCPCS inpatient 20 UN 26.49 17.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.04 25.7 PROMETHAZINE 25 MG/ML VIAL 48456079_1 CDM 0250 RC 00641-0955-25 NDC inpatient 1 UN 20.07 13.05 AETNA AETNA 15.86 79 999999999 12.15 19.47 percent of total billed charges PROMETHAZINE 25 MG/ML VIAL 48456079_1 CDM 0250 RC 00641-0955-25 NDC inpatient 1 UN 20.07 13.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 13.05 65 999999999 12.15 19.47 percent of total billed charges PROMETHAZINE 25 MG/ML VIAL 48456079_1 CDM 0250 RC 00641-0955-25 NDC inpatient 1 UN 20.07 13.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.47 97 999999999 12.15 19.47 percent of total billed charges PROMETHAZINE 25 MG/ML VIAL 48456079_1 CDM 0250 RC 00641-0955-25 NDC inpatient 1 UN 20.07 13.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.85 69 999999999 12.15 19.47 percent of total billed charges PROMETHAZINE 25 MG/ML VIAL 48456079_1 CDM 0250 RC 00641-0955-25 NDC inpatient 1 UN 20.07 13.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.65 78 999999999 12.15 19.47 percent of total billed charges PROMETHAZINE 25 MG/ML VIAL 48456079_1 CDM 0250 RC 00641-0955-25 NDC inpatient 1 UN 20.07 13.05 UMR - ALL PLANS UMR - ALL PLANS 14.05 70 999999999 12.15 19.47 percent of total billed charges PROMETHAZINE 25 MG/ML VIAL 48456079_1 CDM 0250 RC 00641-0955-25 NDC inpatient 1 UN 20.07 13.05 SIHO - ALL PLANS SIHO - ALL PLANS 18.06 90 999999999 12.15 19.47 percent of total billed charges PROMETHAZINE 25 MG/ML VIAL 48456079_1 CDM 0250 RC 00641-0955-25 NDC inpatient 1 UN 20.07 13.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.15 60.55 999999999 12.15 19.47 percent of total billed charges PROMETHAZINE 25 MG/ML VIAL 48456079_1 CDM 0250 RC 00641-0955-25 NDC inpatient 1 UN 20.07 13.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.15 19.47 PROMETHAZINE 25 MG/ML VIAL 48456079_1 CDM 0250 RC 00641-0955-25 NDC inpatient 1 UN 20.07 13.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.15 19.47 PROMETHAZINE 25 MG/ML VIAL 48456079_1 CDM 0250 RC 00641-0955-25 NDC inpatient 1 UN 20.07 13.05 ANTHEM HMO ANTHEM HMO 999999999 12.15 19.47 PROMETHAZINE 25 MG/ML VIAL 48456079_1 CDM 0250 RC 00641-0955-25 NDC inpatient 1 UN 20.07 13.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.57 67.6 999999999 12.15 19.47 percent of total billed charges PROMETHAZINE 25 MG/ML VIAL 48456079_1 CDM 0250 RC 00641-0955-25 NDC inpatient 1 UN 20.07 13.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.15 19.47 PROMETHAZINE 25 MG/ML VIAL 48456079_1 CDM 0250 RC 00641-0955-25 NDC inpatient 1 UN 20.07 13.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.15 19.47 VALPROATE SOD 500 MG/5 ML VL 48456081_1 CDM 0250 RC 00143-9637-10 NDC inpatient 1 UN 1.71 1.11 AETNA AETNA 1.35 79 999999999 1.04 1.66 percent of total billed charges VALPROATE SOD 500 MG/5 ML VL 48456081_1 CDM 0250 RC 00143-9637-10 NDC inpatient 1 UN 1.71 1.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.11 65 999999999 1.04 1.66 percent of total billed charges VALPROATE SOD 500 MG/5 ML VL 48456081_1 CDM 0250 RC 00143-9637-10 NDC inpatient 1 UN 1.71 1.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.66 97 999999999 1.04 1.66 percent of total billed charges VALPROATE SOD 500 MG/5 ML VL 48456081_1 CDM 0250 RC 00143-9637-10 NDC inpatient 1 UN 1.71 1.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.18 69 999999999 1.04 1.66 percent of total billed charges VALPROATE SOD 500 MG/5 ML VL 48456081_1 CDM 0250 RC 00143-9637-10 NDC inpatient 1 UN 1.71 1.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.33 78 999999999 1.04 1.66 percent of total billed charges VALPROATE SOD 500 MG/5 ML VL 48456081_1 CDM 0250 RC 00143-9637-10 NDC inpatient 1 UN 1.71 1.11 UMR - ALL PLANS UMR - ALL PLANS 1.2 70 999999999 1.04 1.66 percent of total billed charges VALPROATE SOD 500 MG/5 ML VL 48456081_1 CDM 0250 RC 00143-9637-10 NDC inpatient 1 UN 1.71 1.11 SIHO - ALL PLANS SIHO - ALL PLANS 1.54 90 999999999 1.04 1.66 percent of total billed charges VALPROATE SOD 500 MG/5 ML VL 48456081_1 CDM 0250 RC 00143-9637-10 NDC inpatient 1 UN 1.71 1.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.04 60.55 999999999 1.04 1.66 percent of total billed charges VALPROATE SOD 500 MG/5 ML VL 48456081_1 CDM 0250 RC 00143-9637-10 NDC inpatient 1 UN 1.71 1.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.04 1.66 VALPROATE SOD 500 MG/5 ML VL 48456081_1 CDM 0250 RC 00143-9637-10 NDC inpatient 1 UN 1.71 1.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.04 1.66 VALPROATE SOD 500 MG/5 ML VL 48456081_1 CDM 0250 RC 00143-9637-10 NDC inpatient 1 UN 1.71 1.11 ANTHEM HMO ANTHEM HMO 999999999 1.04 1.66 VALPROATE SOD 500 MG/5 ML VL 48456081_1 CDM 0250 RC 00143-9637-10 NDC inpatient 1 UN 1.71 1.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.16 67.6 999999999 1.04 1.66 percent of total billed charges VALPROATE SOD 500 MG/5 ML VL 48456081_1 CDM 0250 RC 00143-9637-10 NDC inpatient 1 UN 1.71 1.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.04 1.66 VALPROATE SOD 500 MG/5 ML VL 48456081_1 CDM 0250 RC 00143-9637-10 NDC inpatient 1 UN 1.71 1.11 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.04 1.66 ACETAMINOP-CODEINE 120-12 MG/5 48456097_1 CDM 0250 RC 50383-0079-16 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ACETAMINOP-CODEINE 120-12 MG/5 48456097_1 CDM 0250 RC 50383-0079-16 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ACETAMINOP-CODEINE 120-12 MG/5 48456097_1 CDM 0250 RC 50383-0079-16 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ACETAMINOP-CODEINE 120-12 MG/5 48456097_1 CDM 0250 RC 50383-0079-16 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ACETAMINOP-CODEINE 120-12 MG/5 48456097_1 CDM 0250 RC 50383-0079-16 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ACETAMINOP-CODEINE 120-12 MG/5 48456097_1 CDM 0250 RC 50383-0079-16 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ACETAMINOP-CODEINE 120-12 MG/5 48456097_1 CDM 0250 RC 50383-0079-16 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ACETAMINOP-CODEINE 120-12 MG/5 48456097_1 CDM 0250 RC 50383-0079-16 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ACETAMINOP-CODEINE 120-12 MG/5 48456097_1 CDM 0250 RC 50383-0079-16 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ACETAMINOP-CODEINE 120-12 MG/5 48456097_1 CDM 0250 RC 50383-0079-16 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ACETAMINOP-CODEINE 120-12 MG/5 48456097_1 CDM 0250 RC 50383-0079-16 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ACETAMINOP-CODEINE 120-12 MG/5 48456097_1 CDM 0250 RC 50383-0079-16 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges ACETAMINOP-CODEINE 120-12 MG/5 48456097_1 CDM 0250 RC 50383-0079-16 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ACETAMINOP-CODEINE 120-12 MG/5 48456097_1 CDM 0250 RC 50383-0079-16 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456098_1 CDM 0250 RC 25021-0143-30 NDC J0295 HCPCS inpatient 2 UN 60.08 39.05 AETNA AETNA 47.46 79 999999999 36.38 58.28 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456098_1 CDM 0250 RC 25021-0143-30 NDC J0295 HCPCS inpatient 2 UN 60.08 39.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.05 65 999999999 36.38 58.28 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456098_1 CDM 0250 RC 25021-0143-30 NDC J0295 HCPCS inpatient 2 UN 60.08 39.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.28 97 999999999 36.38 58.28 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456098_1 CDM 0250 RC 25021-0143-30 NDC J0295 HCPCS inpatient 2 UN 60.08 39.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.46 69 999999999 36.38 58.28 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456098_1 CDM 0250 RC 25021-0143-30 NDC J0295 HCPCS inpatient 2 UN 60.08 39.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.86 78 999999999 36.38 58.28 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456098_1 CDM 0250 RC 25021-0143-30 NDC J0295 HCPCS inpatient 2 UN 60.08 39.05 UMR - ALL PLANS UMR - ALL PLANS 42.06 70 999999999 36.38 58.28 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456098_1 CDM 0250 RC 25021-0143-30 NDC J0295 HCPCS inpatient 2 UN 60.08 39.05 SIHO - ALL PLANS SIHO - ALL PLANS 54.07 90 999999999 36.38 58.28 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456098_1 CDM 0250 RC 25021-0143-30 NDC J0295 HCPCS inpatient 2 UN 60.08 39.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.38 60.55 999999999 36.38 58.28 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456098_1 CDM 0250 RC 25021-0143-30 NDC J0295 HCPCS inpatient 2 UN 60.08 39.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.38 58.28 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456098_1 CDM 0250 RC 25021-0143-30 NDC J0295 HCPCS inpatient 2 UN 60.08 39.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.38 58.28 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456098_1 CDM 0250 RC 25021-0143-30 NDC J0295 HCPCS inpatient 2 UN 60.08 39.05 ANTHEM HMO ANTHEM HMO 999999999 36.38 58.28 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456098_1 CDM 0250 RC 25021-0143-30 NDC J0295 HCPCS inpatient 2 UN 60.08 39.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.61 67.6 999999999 36.38 58.28 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456098_1 CDM 0250 RC 25021-0143-30 NDC J0295 HCPCS inpatient 2 UN 60.08 39.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.38 58.28 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456098_1 CDM 0250 RC 25021-0143-30 NDC J0295 HCPCS inpatient 2 UN 60.08 39.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.38 58.28 AMOXICILLIN 125 MG/5 ML SUSP 48456100_1 CDM 0250 RC 00781-6039-55 NDC inpatient 1 UN 13.44 8.74 AETNA AETNA 10.62 79 999999999 8.14 13.04 percent of total billed charges AMOXICILLIN 125 MG/5 ML SUSP 48456100_1 CDM 0250 RC 00781-6039-55 NDC inpatient 1 UN 13.44 8.74 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.74 65 999999999 8.14 13.04 percent of total billed charges AMOXICILLIN 125 MG/5 ML SUSP 48456100_1 CDM 0250 RC 00781-6039-55 NDC inpatient 1 UN 13.44 8.74 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13.04 97 999999999 8.14 13.04 percent of total billed charges AMOXICILLIN 125 MG/5 ML SUSP 48456100_1 CDM 0250 RC 00781-6039-55 NDC inpatient 1 UN 13.44 8.74 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.27 69 999999999 8.14 13.04 percent of total billed charges AMOXICILLIN 125 MG/5 ML SUSP 48456100_1 CDM 0250 RC 00781-6039-55 NDC inpatient 1 UN 13.44 8.74 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.48 78 999999999 8.14 13.04 percent of total billed charges AMOXICILLIN 125 MG/5 ML SUSP 48456100_1 CDM 0250 RC 00781-6039-55 NDC inpatient 1 UN 13.44 8.74 UMR - ALL PLANS UMR - ALL PLANS 9.41 70 999999999 8.14 13.04 percent of total billed charges AMOXICILLIN 125 MG/5 ML SUSP 48456100_1 CDM 0250 RC 00781-6039-55 NDC inpatient 1 UN 13.44 8.74 SIHO - ALL PLANS SIHO - ALL PLANS 12.1 90 999999999 8.14 13.04 percent of total billed charges AMOXICILLIN 125 MG/5 ML SUSP 48456100_1 CDM 0250 RC 00781-6039-55 NDC inpatient 1 UN 13.44 8.74 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.14 60.55 999999999 8.14 13.04 percent of total billed charges AMOXICILLIN 125 MG/5 ML SUSP 48456100_1 CDM 0250 RC 00781-6039-55 NDC inpatient 1 UN 13.44 8.74 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.14 13.04 AMOXICILLIN 125 MG/5 ML SUSP 48456100_1 CDM 0250 RC 00781-6039-55 NDC inpatient 1 UN 13.44 8.74 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.14 13.04 AMOXICILLIN 125 MG/5 ML SUSP 48456100_1 CDM 0250 RC 00781-6039-55 NDC inpatient 1 UN 13.44 8.74 ANTHEM HMO ANTHEM HMO 999999999 8.14 13.04 AMOXICILLIN 125 MG/5 ML SUSP 48456100_1 CDM 0250 RC 00781-6039-55 NDC inpatient 1 UN 13.44 8.74 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.09 67.6 999999999 8.14 13.04 percent of total billed charges AMOXICILLIN 125 MG/5 ML SUSP 48456100_1 CDM 0250 RC 00781-6039-55 NDC inpatient 1 UN 13.44 8.74 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.14 13.04 AMOXICILLIN 125 MG/5 ML SUSP 48456100_1 CDM 0250 RC 00781-6039-55 NDC inpatient 1 UN 13.44 8.74 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.14 13.04 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456102_1 CDM 0250 RC 00049-0014-83 NDC J0295 HCPCS inpatient 2 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456102_1 CDM 0250 RC 00049-0014-83 NDC J0295 HCPCS inpatient 2 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456102_1 CDM 0250 RC 00049-0014-83 NDC J0295 HCPCS inpatient 2 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456102_1 CDM 0250 RC 00049-0014-83 NDC J0295 HCPCS inpatient 2 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456102_1 CDM 0250 RC 00049-0014-83 NDC J0295 HCPCS inpatient 2 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456102_1 CDM 0250 RC 00049-0014-83 NDC J0295 HCPCS inpatient 2 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456102_1 CDM 0250 RC 00049-0014-83 NDC J0295 HCPCS inpatient 2 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456102_1 CDM 0250 RC 00049-0014-83 NDC J0295 HCPCS inpatient 2 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456102_1 CDM 0250 RC 00049-0014-83 NDC J0295 HCPCS inpatient 2 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456102_1 CDM 0250 RC 00049-0014-83 NDC J0295 HCPCS inpatient 2 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456102_1 CDM 0250 RC 00049-0014-83 NDC J0295 HCPCS inpatient 2 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456102_1 CDM 0250 RC 00049-0014-83 NDC J0295 HCPCS inpatient 2 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456102_1 CDM 0250 RC 00049-0014-83 NDC J0295 HCPCS inpatient 2 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456102_1 CDM 0250 RC 00049-0014-83 NDC J0295 HCPCS inpatient 2 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456106_1 CDM 0250 RC 00641-6116-10 NDC J0295 HCPCS inpatient 1 UN 32.36 21.03 AETNA AETNA 25.56 79 999999999 19.59 31.39 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456106_1 CDM 0250 RC 00641-6116-10 NDC J0295 HCPCS inpatient 1 UN 32.36 21.03 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.03 65 999999999 19.59 31.39 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456106_1 CDM 0250 RC 00641-6116-10 NDC J0295 HCPCS inpatient 1 UN 32.36 21.03 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31.39 97 999999999 19.59 31.39 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456106_1 CDM 0250 RC 00641-6116-10 NDC J0295 HCPCS inpatient 1 UN 32.36 21.03 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.33 69 999999999 19.59 31.39 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456106_1 CDM 0250 RC 00641-6116-10 NDC J0295 HCPCS inpatient 1 UN 32.36 21.03 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.24 78 999999999 19.59 31.39 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456106_1 CDM 0250 RC 00641-6116-10 NDC J0295 HCPCS inpatient 1 UN 32.36 21.03 UMR - ALL PLANS UMR - ALL PLANS 22.65 70 999999999 19.59 31.39 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456106_1 CDM 0250 RC 00641-6116-10 NDC J0295 HCPCS inpatient 1 UN 32.36 21.03 SIHO - ALL PLANS SIHO - ALL PLANS 29.12 90 999999999 19.59 31.39 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456106_1 CDM 0250 RC 00641-6116-10 NDC J0295 HCPCS inpatient 1 UN 32.36 21.03 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.59 60.55 999999999 19.59 31.39 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456106_1 CDM 0250 RC 00641-6116-10 NDC J0295 HCPCS inpatient 1 UN 32.36 21.03 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.59 31.39 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456106_1 CDM 0250 RC 00641-6116-10 NDC J0295 HCPCS inpatient 1 UN 32.36 21.03 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.59 31.39 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456106_1 CDM 0250 RC 00641-6116-10 NDC J0295 HCPCS inpatient 1 UN 32.36 21.03 ANTHEM HMO ANTHEM HMO 999999999 19.59 31.39 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456106_1 CDM 0250 RC 00641-6116-10 NDC J0295 HCPCS inpatient 1 UN 32.36 21.03 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.88 67.6 999999999 19.59 31.39 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456106_1 CDM 0250 RC 00641-6116-10 NDC J0295 HCPCS inpatient 1 UN 32.36 21.03 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.59 31.39 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 48456106_1 CDM 0250 RC 00641-6116-10 NDC J0295 HCPCS inpatient 1 UN 32.36 21.03 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.59 31.39 CEPHALEXIN 250 MG/5 ML SUSP 48456107_1 CDM 0250 RC 00093-4177-73 NDC inpatient 1 UN 47.17 30.66 AETNA AETNA 37.26 79 999999999 28.56 45.75 percent of total billed charges CEPHALEXIN 250 MG/5 ML SUSP 48456107_1 CDM 0250 RC 00093-4177-73 NDC inpatient 1 UN 47.17 30.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 30.66 65 999999999 28.56 45.75 percent of total billed charges CEPHALEXIN 250 MG/5 ML SUSP 48456107_1 CDM 0250 RC 00093-4177-73 NDC inpatient 1 UN 47.17 30.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 45.75 97 999999999 28.56 45.75 percent of total billed charges CEPHALEXIN 250 MG/5 ML SUSP 48456107_1 CDM 0250 RC 00093-4177-73 NDC inpatient 1 UN 47.17 30.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 32.55 69 999999999 28.56 45.75 percent of total billed charges CEPHALEXIN 250 MG/5 ML SUSP 48456107_1 CDM 0250 RC 00093-4177-73 NDC inpatient 1 UN 47.17 30.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 36.79 78 999999999 28.56 45.75 percent of total billed charges CEPHALEXIN 250 MG/5 ML SUSP 48456107_1 CDM 0250 RC 00093-4177-73 NDC inpatient 1 UN 47.17 30.66 UMR - ALL PLANS UMR - ALL PLANS 33.02 70 999999999 28.56 45.75 percent of total billed charges CEPHALEXIN 250 MG/5 ML SUSP 48456107_1 CDM 0250 RC 00093-4177-73 NDC inpatient 1 UN 47.17 30.66 SIHO - ALL PLANS SIHO - ALL PLANS 42.45 90 999999999 28.56 45.75 percent of total billed charges CEPHALEXIN 250 MG/5 ML SUSP 48456107_1 CDM 0250 RC 00093-4177-73 NDC inpatient 1 UN 47.17 30.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 28.56 60.55 999999999 28.56 45.75 percent of total billed charges CEPHALEXIN 250 MG/5 ML SUSP 48456107_1 CDM 0250 RC 00093-4177-73 NDC inpatient 1 UN 47.17 30.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 28.56 45.75 CEPHALEXIN 250 MG/5 ML SUSP 48456107_1 CDM 0250 RC 00093-4177-73 NDC inpatient 1 UN 47.17 30.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 28.56 45.75 CEPHALEXIN 250 MG/5 ML SUSP 48456107_1 CDM 0250 RC 00093-4177-73 NDC inpatient 1 UN 47.17 30.66 ANTHEM HMO ANTHEM HMO 999999999 28.56 45.75 CEPHALEXIN 250 MG/5 ML SUSP 48456107_1 CDM 0250 RC 00093-4177-73 NDC inpatient 1 UN 47.17 30.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 31.89 67.6 999999999 28.56 45.75 percent of total billed charges CEPHALEXIN 250 MG/5 ML SUSP 48456107_1 CDM 0250 RC 00093-4177-73 NDC inpatient 1 UN 47.17 30.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 28.56 45.75 CEPHALEXIN 250 MG/5 ML SUSP 48456107_1 CDM 0250 RC 00093-4177-73 NDC inpatient 1 UN 47.17 30.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 28.56 45.75 GUAIFENESIN-DM 100-10 MG/5 ML 48456114_1 CDM 0250 RC 00121-0638-05 NDC inpatient 1 UN 7.08 4.6 AETNA AETNA 5.59 79 999999999 4.29 6.87 percent of total billed charges GUAIFENESIN-DM 100-10 MG/5 ML 48456114_1 CDM 0250 RC 00121-0638-05 NDC inpatient 1 UN 7.08 4.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.6 65 999999999 4.29 6.87 percent of total billed charges GUAIFENESIN-DM 100-10 MG/5 ML 48456114_1 CDM 0250 RC 00121-0638-05 NDC inpatient 1 UN 7.08 4.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.87 97 999999999 4.29 6.87 percent of total billed charges GUAIFENESIN-DM 100-10 MG/5 ML 48456114_1 CDM 0250 RC 00121-0638-05 NDC inpatient 1 UN 7.08 4.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.89 69 999999999 4.29 6.87 percent of total billed charges GUAIFENESIN-DM 100-10 MG/5 ML 48456114_1 CDM 0250 RC 00121-0638-05 NDC inpatient 1 UN 7.08 4.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 5.52 78 999999999 4.29 6.87 percent of total billed charges GUAIFENESIN-DM 100-10 MG/5 ML 48456114_1 CDM 0250 RC 00121-0638-05 NDC inpatient 1 UN 7.08 4.6 UMR - ALL PLANS UMR - ALL PLANS 4.96 70 999999999 4.29 6.87 percent of total billed charges GUAIFENESIN-DM 100-10 MG/5 ML 48456114_1 CDM 0250 RC 00121-0638-05 NDC inpatient 1 UN 7.08 4.6 SIHO - ALL PLANS SIHO - ALL PLANS 6.37 90 999999999 4.29 6.87 percent of total billed charges GUAIFENESIN-DM 100-10 MG/5 ML 48456114_1 CDM 0250 RC 00121-0638-05 NDC inpatient 1 UN 7.08 4.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.29 60.55 999999999 4.29 6.87 percent of total billed charges GUAIFENESIN-DM 100-10 MG/5 ML 48456114_1 CDM 0250 RC 00121-0638-05 NDC inpatient 1 UN 7.08 4.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.29 6.87 GUAIFENESIN-DM 100-10 MG/5 ML 48456114_1 CDM 0250 RC 00121-0638-05 NDC inpatient 1 UN 7.08 4.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.29 6.87 GUAIFENESIN-DM 100-10 MG/5 ML 48456114_1 CDM 0250 RC 00121-0638-05 NDC inpatient 1 UN 7.08 4.6 ANTHEM HMO ANTHEM HMO 999999999 4.29 6.87 GUAIFENESIN-DM 100-10 MG/5 ML 48456114_1 CDM 0250 RC 00121-0638-05 NDC inpatient 1 UN 7.08 4.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.79 67.6 999999999 4.29 6.87 percent of total billed charges GUAIFENESIN-DM 100-10 MG/5 ML 48456114_1 CDM 0250 RC 00121-0638-05 NDC inpatient 1 UN 7.08 4.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.29 6.87 GUAIFENESIN-DM 100-10 MG/5 ML 48456114_1 CDM 0250 RC 00121-0638-05 NDC inpatient 1 UN 7.08 4.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.29 6.87 LIDOCAINE 2% VISCOUS SOLN 48456118_1 CDM 0250 RC 50383-0775-17 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LIDOCAINE 2% VISCOUS SOLN 48456118_1 CDM 0250 RC 50383-0775-17 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LIDOCAINE 2% VISCOUS SOLN 48456118_1 CDM 0250 RC 50383-0775-17 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LIDOCAINE 2% VISCOUS SOLN 48456118_1 CDM 0250 RC 50383-0775-17 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LIDOCAINE 2% VISCOUS SOLN 48456118_1 CDM 0250 RC 50383-0775-17 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LIDOCAINE 2% VISCOUS SOLN 48456118_1 CDM 0250 RC 50383-0775-17 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LIDOCAINE 2% VISCOUS SOLN 48456118_1 CDM 0250 RC 50383-0775-17 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LIDOCAINE 2% VISCOUS SOLN 48456118_1 CDM 0250 RC 50383-0775-17 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LIDOCAINE 2% VISCOUS SOLN 48456118_1 CDM 0250 RC 50383-0775-17 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LIDOCAINE 2% VISCOUS SOLN 48456118_1 CDM 0250 RC 50383-0775-17 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LIDOCAINE 2% VISCOUS SOLN 48456118_1 CDM 0250 RC 50383-0775-17 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LIDOCAINE 2% VISCOUS SOLN 48456118_1 CDM 0250 RC 50383-0775-17 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges LIDOCAINE 2% VISCOUS SOLN 48456118_1 CDM 0250 RC 50383-0775-17 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LIDOCAINE 2% VISCOUS SOLN 48456118_1 CDM 0250 RC 50383-0775-17 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 MUCINEX DM ER 600-30 MG TABLET 48456120_1 CDM 0250 RC 63824-0056-34 NDC inpatient 1 UN 1.1 0.72 AETNA AETNA 0.87 79 999999999 0.67 1.07 percent of total billed charges MUCINEX DM ER 600-30 MG TABLET 48456120_1 CDM 0250 RC 63824-0056-34 NDC inpatient 1 UN 1.1 0.72 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.72 65 999999999 0.67 1.07 percent of total billed charges MUCINEX DM ER 600-30 MG TABLET 48456120_1 CDM 0250 RC 63824-0056-34 NDC inpatient 1 UN 1.1 0.72 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.07 97 999999999 0.67 1.07 percent of total billed charges MUCINEX DM ER 600-30 MG TABLET 48456120_1 CDM 0250 RC 63824-0056-34 NDC inpatient 1 UN 1.1 0.72 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.76 69 999999999 0.67 1.07 percent of total billed charges MUCINEX DM ER 600-30 MG TABLET 48456120_1 CDM 0250 RC 63824-0056-34 NDC inpatient 1 UN 1.1 0.72 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.86 78 999999999 0.67 1.07 percent of total billed charges MUCINEX DM ER 600-30 MG TABLET 48456120_1 CDM 0250 RC 63824-0056-34 NDC inpatient 1 UN 1.1 0.72 UMR - ALL PLANS UMR - ALL PLANS 0.77 70 999999999 0.67 1.07 percent of total billed charges MUCINEX DM ER 600-30 MG TABLET 48456120_1 CDM 0250 RC 63824-0056-34 NDC inpatient 1 UN 1.1 0.72 SIHO - ALL PLANS SIHO - ALL PLANS 0.99 90 999999999 0.67 1.07 percent of total billed charges MUCINEX DM ER 600-30 MG TABLET 48456120_1 CDM 0250 RC 63824-0056-34 NDC inpatient 1 UN 1.1 0.72 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.67 60.55 999999999 0.67 1.07 percent of total billed charges MUCINEX DM ER 600-30 MG TABLET 48456120_1 CDM 0250 RC 63824-0056-34 NDC inpatient 1 UN 1.1 0.72 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.67 1.07 MUCINEX DM ER 600-30 MG TABLET 48456120_1 CDM 0250 RC 63824-0056-34 NDC inpatient 1 UN 1.1 0.72 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.67 1.07 MUCINEX DM ER 600-30 MG TABLET 48456120_1 CDM 0250 RC 63824-0056-34 NDC inpatient 1 UN 1.1 0.72 ANTHEM HMO ANTHEM HMO 999999999 0.67 1.07 MUCINEX DM ER 600-30 MG TABLET 48456120_1 CDM 0250 RC 63824-0056-34 NDC inpatient 1 UN 1.1 0.72 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.74 67.6 999999999 0.67 1.07 percent of total billed charges MUCINEX DM ER 600-30 MG TABLET 48456120_1 CDM 0250 RC 63824-0056-34 NDC inpatient 1 UN 1.1 0.72 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.67 1.07 MUCINEX DM ER 600-30 MG TABLET 48456120_1 CDM 0250 RC 63824-0056-34 NDC inpatient 1 UN 1.1 0.72 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.67 1.07 HYDRALAZINE 10 MG TABLET 48456122_1 CDM 0250 RC 00904-6440-61 NDC inpatient 1 UN 1.82 1.18 AETNA AETNA 1.44 79 999999999 1.1 1.77 percent of total billed charges HYDRALAZINE 10 MG TABLET 48456122_1 CDM 0250 RC 00904-6440-61 NDC inpatient 1 UN 1.82 1.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.18 65 999999999 1.1 1.77 percent of total billed charges HYDRALAZINE 10 MG TABLET 48456122_1 CDM 0250 RC 00904-6440-61 NDC inpatient 1 UN 1.82 1.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.77 97 999999999 1.1 1.77 percent of total billed charges HYDRALAZINE 10 MG TABLET 48456122_1 CDM 0250 RC 00904-6440-61 NDC inpatient 1 UN 1.82 1.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.26 69 999999999 1.1 1.77 percent of total billed charges HYDRALAZINE 10 MG TABLET 48456122_1 CDM 0250 RC 00904-6440-61 NDC inpatient 1 UN 1.82 1.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.42 78 999999999 1.1 1.77 percent of total billed charges HYDRALAZINE 10 MG TABLET 48456122_1 CDM 0250 RC 00904-6440-61 NDC inpatient 1 UN 1.82 1.18 UMR - ALL PLANS UMR - ALL PLANS 1.27 70 999999999 1.1 1.77 percent of total billed charges HYDRALAZINE 10 MG TABLET 48456122_1 CDM 0250 RC 00904-6440-61 NDC inpatient 1 UN 1.82 1.18 SIHO - ALL PLANS SIHO - ALL PLANS 1.64 90 999999999 1.1 1.77 percent of total billed charges HYDRALAZINE 10 MG TABLET 48456122_1 CDM 0250 RC 00904-6440-61 NDC inpatient 1 UN 1.82 1.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.1 60.55 999999999 1.1 1.77 percent of total billed charges HYDRALAZINE 10 MG TABLET 48456122_1 CDM 0250 RC 00904-6440-61 NDC inpatient 1 UN 1.82 1.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.1 1.77 HYDRALAZINE 10 MG TABLET 48456122_1 CDM 0250 RC 00904-6440-61 NDC inpatient 1 UN 1.82 1.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.1 1.77 HYDRALAZINE 10 MG TABLET 48456122_1 CDM 0250 RC 00904-6440-61 NDC inpatient 1 UN 1.82 1.18 ANTHEM HMO ANTHEM HMO 999999999 1.1 1.77 HYDRALAZINE 10 MG TABLET 48456122_1 CDM 0250 RC 00904-6440-61 NDC inpatient 1 UN 1.82 1.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.23 67.6 999999999 1.1 1.77 percent of total billed charges HYDRALAZINE 10 MG TABLET 48456122_1 CDM 0250 RC 00904-6440-61 NDC inpatient 1 UN 1.82 1.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.1 1.77 HYDRALAZINE 10 MG TABLET 48456122_1 CDM 0250 RC 00904-6440-61 NDC inpatient 1 UN 1.82 1.18 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.1 1.77 HYDRALAZINE 25 MG TABLET 48456128_1 CDM 0250 RC 62584-0733-01 NDC inpatient 1 UN 1.8 1.17 AETNA AETNA 1.42 79 999999999 1.09 1.75 percent of total billed charges HYDRALAZINE 25 MG TABLET 48456128_1 CDM 0250 RC 62584-0733-01 NDC inpatient 1 UN 1.8 1.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.17 65 999999999 1.09 1.75 percent of total billed charges HYDRALAZINE 25 MG TABLET 48456128_1 CDM 0250 RC 62584-0733-01 NDC inpatient 1 UN 1.8 1.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.75 97 999999999 1.09 1.75 percent of total billed charges HYDRALAZINE 25 MG TABLET 48456128_1 CDM 0250 RC 62584-0733-01 NDC inpatient 1 UN 1.8 1.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.24 69 999999999 1.09 1.75 percent of total billed charges HYDRALAZINE 25 MG TABLET 48456128_1 CDM 0250 RC 62584-0733-01 NDC inpatient 1 UN 1.8 1.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.4 78 999999999 1.09 1.75 percent of total billed charges HYDRALAZINE 25 MG TABLET 48456128_1 CDM 0250 RC 62584-0733-01 NDC inpatient 1 UN 1.8 1.17 UMR - ALL PLANS UMR - ALL PLANS 1.26 70 999999999 1.09 1.75 percent of total billed charges HYDRALAZINE 25 MG TABLET 48456128_1 CDM 0250 RC 62584-0733-01 NDC inpatient 1 UN 1.8 1.17 SIHO - ALL PLANS SIHO - ALL PLANS 1.62 90 999999999 1.09 1.75 percent of total billed charges HYDRALAZINE 25 MG TABLET 48456128_1 CDM 0250 RC 62584-0733-01 NDC inpatient 1 UN 1.8 1.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.09 60.55 999999999 1.09 1.75 percent of total billed charges HYDRALAZINE 25 MG TABLET 48456128_1 CDM 0250 RC 62584-0733-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.09 1.75 HYDRALAZINE 25 MG TABLET 48456128_1 CDM 0250 RC 62584-0733-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.09 1.75 HYDRALAZINE 25 MG TABLET 48456128_1 CDM 0250 RC 62584-0733-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM HMO ANTHEM HMO 999999999 1.09 1.75 HYDRALAZINE 25 MG TABLET 48456128_1 CDM 0250 RC 62584-0733-01 NDC inpatient 1 UN 1.8 1.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.22 67.6 999999999 1.09 1.75 percent of total billed charges HYDRALAZINE 25 MG TABLET 48456128_1 CDM 0250 RC 62584-0733-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.09 1.75 HYDRALAZINE 25 MG TABLET 48456128_1 CDM 0250 RC 62584-0733-01 NDC inpatient 1 UN 1.8 1.17 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.09 1.75 HYDRALAZINE 50 MG TABLET 48456132_1 CDM 0250 RC 00904-6442-61 NDC inpatient 1 UN 1.27 0.83 AETNA AETNA 1 79 999999999 0.77 1.23 percent of total billed charges HYDRALAZINE 50 MG TABLET 48456132_1 CDM 0250 RC 00904-6442-61 NDC inpatient 1 UN 1.27 0.83 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.83 65 999999999 0.77 1.23 percent of total billed charges HYDRALAZINE 50 MG TABLET 48456132_1 CDM 0250 RC 00904-6442-61 NDC inpatient 1 UN 1.27 0.83 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.23 97 999999999 0.77 1.23 percent of total billed charges HYDRALAZINE 50 MG TABLET 48456132_1 CDM 0250 RC 00904-6442-61 NDC inpatient 1 UN 1.27 0.83 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.88 69 999999999 0.77 1.23 percent of total billed charges HYDRALAZINE 50 MG TABLET 48456132_1 CDM 0250 RC 00904-6442-61 NDC inpatient 1 UN 1.27 0.83 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.99 78 999999999 0.77 1.23 percent of total billed charges HYDRALAZINE 50 MG TABLET 48456132_1 CDM 0250 RC 00904-6442-61 NDC inpatient 1 UN 1.27 0.83 UMR - ALL PLANS UMR - ALL PLANS 0.89 70 999999999 0.77 1.23 percent of total billed charges HYDRALAZINE 50 MG TABLET 48456132_1 CDM 0250 RC 00904-6442-61 NDC inpatient 1 UN 1.27 0.83 SIHO - ALL PLANS SIHO - ALL PLANS 1.14 90 999999999 0.77 1.23 percent of total billed charges HYDRALAZINE 50 MG TABLET 48456132_1 CDM 0250 RC 00904-6442-61 NDC inpatient 1 UN 1.27 0.83 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.77 60.55 999999999 0.77 1.23 percent of total billed charges HYDRALAZINE 50 MG TABLET 48456132_1 CDM 0250 RC 00904-6442-61 NDC inpatient 1 UN 1.27 0.83 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.77 1.23 HYDRALAZINE 50 MG TABLET 48456132_1 CDM 0250 RC 00904-6442-61 NDC inpatient 1 UN 1.27 0.83 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.77 1.23 HYDRALAZINE 50 MG TABLET 48456132_1 CDM 0250 RC 00904-6442-61 NDC inpatient 1 UN 1.27 0.83 ANTHEM HMO ANTHEM HMO 999999999 0.77 1.23 HYDRALAZINE 50 MG TABLET 48456132_1 CDM 0250 RC 00904-6442-61 NDC inpatient 1 UN 1.27 0.83 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.86 67.6 999999999 0.77 1.23 percent of total billed charges HYDRALAZINE 50 MG TABLET 48456132_1 CDM 0250 RC 00904-6442-61 NDC inpatient 1 UN 1.27 0.83 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.77 1.23 HYDRALAZINE 50 MG TABLET 48456132_1 CDM 0250 RC 00904-6442-61 NDC inpatient 1 UN 1.27 0.83 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.77 1.23 HYDROCHLOROTHIAZIDE 12.5 MG CP 48456134_1 CDM 0250 RC 51079-0776-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges HYDROCHLOROTHIAZIDE 12.5 MG CP 48456134_1 CDM 0250 RC 51079-0776-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges HYDROCHLOROTHIAZIDE 12.5 MG CP 48456134_1 CDM 0250 RC 51079-0776-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges HYDROCHLOROTHIAZIDE 12.5 MG CP 48456134_1 CDM 0250 RC 51079-0776-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges HYDROCHLOROTHIAZIDE 12.5 MG CP 48456134_1 CDM 0250 RC 51079-0776-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges HYDROCHLOROTHIAZIDE 12.5 MG CP 48456134_1 CDM 0250 RC 51079-0776-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges HYDROCHLOROTHIAZIDE 12.5 MG CP 48456134_1 CDM 0250 RC 51079-0776-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges HYDROCHLOROTHIAZIDE 12.5 MG CP 48456134_1 CDM 0250 RC 51079-0776-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges HYDROCHLOROTHIAZIDE 12.5 MG CP 48456134_1 CDM 0250 RC 51079-0776-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 HYDROCHLOROTHIAZIDE 12.5 MG CP 48456134_1 CDM 0250 RC 51079-0776-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 HYDROCHLOROTHIAZIDE 12.5 MG CP 48456134_1 CDM 0250 RC 51079-0776-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 HYDROCHLOROTHIAZIDE 12.5 MG CP 48456134_1 CDM 0250 RC 51079-0776-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges HYDROCHLOROTHIAZIDE 12.5 MG CP 48456134_1 CDM 0250 RC 51079-0776-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 HYDROCHLOROTHIAZIDE 12.5 MG CP 48456134_1 CDM 0250 RC 51079-0776-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 HYDROXYCHLOROQUINE 200 MG TAB 48456143_1 CDM 0250 RC 68382-0096-01 NDC inpatient 1 UN 1.93 1.25 AETNA AETNA 1.52 79 999999999 1.17 1.87 percent of total billed charges HYDROXYCHLOROQUINE 200 MG TAB 48456143_1 CDM 0250 RC 68382-0096-01 NDC inpatient 1 UN 1.93 1.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.25 65 999999999 1.17 1.87 percent of total billed charges HYDROXYCHLOROQUINE 200 MG TAB 48456143_1 CDM 0250 RC 68382-0096-01 NDC inpatient 1 UN 1.93 1.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.87 97 999999999 1.17 1.87 percent of total billed charges HYDROXYCHLOROQUINE 200 MG TAB 48456143_1 CDM 0250 RC 68382-0096-01 NDC inpatient 1 UN 1.93 1.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.33 69 999999999 1.17 1.87 percent of total billed charges HYDROXYCHLOROQUINE 200 MG TAB 48456143_1 CDM 0250 RC 68382-0096-01 NDC inpatient 1 UN 1.93 1.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.51 78 999999999 1.17 1.87 percent of total billed charges HYDROXYCHLOROQUINE 200 MG TAB 48456143_1 CDM 0250 RC 68382-0096-01 NDC inpatient 1 UN 1.93 1.25 UMR - ALL PLANS UMR - ALL PLANS 1.35 70 999999999 1.17 1.87 percent of total billed charges HYDROXYCHLOROQUINE 200 MG TAB 48456143_1 CDM 0250 RC 68382-0096-01 NDC inpatient 1 UN 1.93 1.25 SIHO - ALL PLANS SIHO - ALL PLANS 1.74 90 999999999 1.17 1.87 percent of total billed charges HYDROXYCHLOROQUINE 200 MG TAB 48456143_1 CDM 0250 RC 68382-0096-01 NDC inpatient 1 UN 1.93 1.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.17 60.55 999999999 1.17 1.87 percent of total billed charges HYDROXYCHLOROQUINE 200 MG TAB 48456143_1 CDM 0250 RC 68382-0096-01 NDC inpatient 1 UN 1.93 1.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.17 1.87 HYDROXYCHLOROQUINE 200 MG TAB 48456143_1 CDM 0250 RC 68382-0096-01 NDC inpatient 1 UN 1.93 1.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.17 1.87 HYDROXYCHLOROQUINE 200 MG TAB 48456143_1 CDM 0250 RC 68382-0096-01 NDC inpatient 1 UN 1.93 1.25 ANTHEM HMO ANTHEM HMO 999999999 1.17 1.87 HYDROXYCHLOROQUINE 200 MG TAB 48456143_1 CDM 0250 RC 68382-0096-01 NDC inpatient 1 UN 1.93 1.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.3 67.6 999999999 1.17 1.87 percent of total billed charges HYDROXYCHLOROQUINE 200 MG TAB 48456143_1 CDM 0250 RC 68382-0096-01 NDC inpatient 1 UN 1.93 1.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.17 1.87 HYDROXYCHLOROQUINE 200 MG TAB 48456143_1 CDM 0250 RC 68382-0096-01 NDC inpatient 1 UN 1.93 1.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.17 1.87 PRIMIDONE 50 MG TABLET 48456165_1 CDM 0250 RC 00527-1301-01 NDC inpatient 1 UN 1.8 1.17 AETNA AETNA 1.42 79 999999999 1.09 1.75 percent of total billed charges PRIMIDONE 50 MG TABLET 48456165_1 CDM 0250 RC 00527-1301-01 NDC inpatient 1 UN 1.8 1.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.17 65 999999999 1.09 1.75 percent of total billed charges PRIMIDONE 50 MG TABLET 48456165_1 CDM 0250 RC 00527-1301-01 NDC inpatient 1 UN 1.8 1.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.75 97 999999999 1.09 1.75 percent of total billed charges PRIMIDONE 50 MG TABLET 48456165_1 CDM 0250 RC 00527-1301-01 NDC inpatient 1 UN 1.8 1.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.24 69 999999999 1.09 1.75 percent of total billed charges PRIMIDONE 50 MG TABLET 48456165_1 CDM 0250 RC 00527-1301-01 NDC inpatient 1 UN 1.8 1.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.4 78 999999999 1.09 1.75 percent of total billed charges PRIMIDONE 50 MG TABLET 48456165_1 CDM 0250 RC 00527-1301-01 NDC inpatient 1 UN 1.8 1.17 UMR - ALL PLANS UMR - ALL PLANS 1.26 70 999999999 1.09 1.75 percent of total billed charges PRIMIDONE 50 MG TABLET 48456165_1 CDM 0250 RC 00527-1301-01 NDC inpatient 1 UN 1.8 1.17 SIHO - ALL PLANS SIHO - ALL PLANS 1.62 90 999999999 1.09 1.75 percent of total billed charges PRIMIDONE 50 MG TABLET 48456165_1 CDM 0250 RC 00527-1301-01 NDC inpatient 1 UN 1.8 1.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.09 60.55 999999999 1.09 1.75 percent of total billed charges PRIMIDONE 50 MG TABLET 48456165_1 CDM 0250 RC 00527-1301-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.09 1.75 PRIMIDONE 50 MG TABLET 48456165_1 CDM 0250 RC 00527-1301-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.09 1.75 PRIMIDONE 50 MG TABLET 48456165_1 CDM 0250 RC 00527-1301-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM HMO ANTHEM HMO 999999999 1.09 1.75 PRIMIDONE 50 MG TABLET 48456165_1 CDM 0250 RC 00527-1301-01 NDC inpatient 1 UN 1.8 1.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.22 67.6 999999999 1.09 1.75 percent of total billed charges PRIMIDONE 50 MG TABLET 48456165_1 CDM 0250 RC 00527-1301-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.09 1.75 PRIMIDONE 50 MG TABLET 48456165_1 CDM 0250 RC 00527-1301-01 NDC inpatient 1 UN 1.8 1.17 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.09 1.75 PROBENECID 500 MG TABLET 48456167_1 CDM 0250 RC 00527-1367-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges PROBENECID 500 MG TABLET 48456167_1 CDM 0250 RC 00527-1367-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges PROBENECID 500 MG TABLET 48456167_1 CDM 0250 RC 00527-1367-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges PROBENECID 500 MG TABLET 48456167_1 CDM 0250 RC 00527-1367-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges PROBENECID 500 MG TABLET 48456167_1 CDM 0250 RC 00527-1367-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges PROBENECID 500 MG TABLET 48456167_1 CDM 0250 RC 00527-1367-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges PROBENECID 500 MG TABLET 48456167_1 CDM 0250 RC 00527-1367-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges PROBENECID 500 MG TABLET 48456167_1 CDM 0250 RC 00527-1367-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges PROBENECID 500 MG TABLET 48456167_1 CDM 0250 RC 00527-1367-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 PROBENECID 500 MG TABLET 48456167_1 CDM 0250 RC 00527-1367-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 PROBENECID 500 MG TABLET 48456167_1 CDM 0250 RC 00527-1367-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 PROBENECID 500 MG TABLET 48456167_1 CDM 0250 RC 00527-1367-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges PROBENECID 500 MG TABLET 48456167_1 CDM 0250 RC 00527-1367-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 PROBENECID 500 MG TABLET 48456167_1 CDM 0250 RC 00527-1367-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 THIAMINE 200 MG/2 ML VIAL 48456169_1 CDM 0250 RC 63323-0013-09 NDC inpatient 1 UN 36.81 23.93 AETNA AETNA 29.08 79 999999999 22.29 35.71 percent of total billed charges THIAMINE 200 MG/2 ML VIAL 48456169_1 CDM 0250 RC 63323-0013-09 NDC inpatient 1 UN 36.81 23.93 SELF PAY DISCOUNT SELF PAY DISCOUNT 23.93 65 999999999 22.29 35.71 percent of total billed charges THIAMINE 200 MG/2 ML VIAL 48456169_1 CDM 0250 RC 63323-0013-09 NDC inpatient 1 UN 36.81 23.93 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.71 97 999999999 22.29 35.71 percent of total billed charges THIAMINE 200 MG/2 ML VIAL 48456169_1 CDM 0250 RC 63323-0013-09 NDC inpatient 1 UN 36.81 23.93 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.4 69 999999999 22.29 35.71 percent of total billed charges THIAMINE 200 MG/2 ML VIAL 48456169_1 CDM 0250 RC 63323-0013-09 NDC inpatient 1 UN 36.81 23.93 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.71 78 999999999 22.29 35.71 percent of total billed charges THIAMINE 200 MG/2 ML VIAL 48456169_1 CDM 0250 RC 63323-0013-09 NDC inpatient 1 UN 36.81 23.93 UMR - ALL PLANS UMR - ALL PLANS 25.77 70 999999999 22.29 35.71 percent of total billed charges THIAMINE 200 MG/2 ML VIAL 48456169_1 CDM 0250 RC 63323-0013-09 NDC inpatient 1 UN 36.81 23.93 SIHO - ALL PLANS SIHO - ALL PLANS 33.13 90 999999999 22.29 35.71 percent of total billed charges THIAMINE 200 MG/2 ML VIAL 48456169_1 CDM 0250 RC 63323-0013-09 NDC inpatient 1 UN 36.81 23.93 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.29 60.55 999999999 22.29 35.71 percent of total billed charges THIAMINE 200 MG/2 ML VIAL 48456169_1 CDM 0250 RC 63323-0013-09 NDC inpatient 1 UN 36.81 23.93 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.29 35.71 THIAMINE 200 MG/2 ML VIAL 48456169_1 CDM 0250 RC 63323-0013-09 NDC inpatient 1 UN 36.81 23.93 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.29 35.71 THIAMINE 200 MG/2 ML VIAL 48456169_1 CDM 0250 RC 63323-0013-09 NDC inpatient 1 UN 36.81 23.93 ANTHEM HMO ANTHEM HMO 999999999 22.29 35.71 THIAMINE 200 MG/2 ML VIAL 48456169_1 CDM 0250 RC 63323-0013-09 NDC inpatient 1 UN 36.81 23.93 CIGNA - ALL PLANS CIGNA - ALL PLANS 24.88 67.6 999999999 22.29 35.71 percent of total billed charges THIAMINE 200 MG/2 ML VIAL 48456169_1 CDM 0250 RC 63323-0013-09 NDC inpatient 1 UN 36.81 23.93 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.29 35.71 THIAMINE 200 MG/2 ML VIAL 48456169_1 CDM 0250 RC 63323-0013-09 NDC inpatient 1 UN 36.81 23.93 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.29 35.71 "PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48456175_1 CDM 0250 RC 59746-0113-06 NDC Q0164 HCPCS inpatient 1 UN 1.6 1.04 AETNA AETNA 1.26 79 999999999 0.97 1.55 percent of total billed charges "PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48456175_1 CDM 0250 RC 59746-0113-06 NDC Q0164 HCPCS inpatient 1 UN 1.6 1.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.04 65 999999999 0.97 1.55 percent of total billed charges "PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48456175_1 CDM 0250 RC 59746-0113-06 NDC Q0164 HCPCS inpatient 1 UN 1.6 1.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.55 97 999999999 0.97 1.55 percent of total billed charges "PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48456175_1 CDM 0250 RC 59746-0113-06 NDC Q0164 HCPCS inpatient 1 UN 1.6 1.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.1 69 999999999 0.97 1.55 percent of total billed charges "PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48456175_1 CDM 0250 RC 59746-0113-06 NDC Q0164 HCPCS inpatient 1 UN 1.6 1.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.25 78 999999999 0.97 1.55 percent of total billed charges "PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48456175_1 CDM 0250 RC 59746-0113-06 NDC Q0164 HCPCS inpatient 1 UN 1.6 1.04 UMR - ALL PLANS UMR - ALL PLANS 1.12 70 999999999 0.97 1.55 percent of total billed charges "PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48456175_1 CDM 0250 RC 59746-0113-06 NDC Q0164 HCPCS inpatient 1 UN 1.6 1.04 SIHO - ALL PLANS SIHO - ALL PLANS 1.44 90 999999999 0.97 1.55 percent of total billed charges "PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48456175_1 CDM 0250 RC 59746-0113-06 NDC Q0164 HCPCS inpatient 1 UN 1.6 1.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.97 60.55 999999999 0.97 1.55 percent of total billed charges "PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48456175_1 CDM 0250 RC 59746-0113-06 NDC Q0164 HCPCS inpatient 1 UN 1.6 1.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.97 1.55 "PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48456175_1 CDM 0250 RC 59746-0113-06 NDC Q0164 HCPCS inpatient 1 UN 1.6 1.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.97 1.55 "PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48456175_1 CDM 0250 RC 59746-0113-06 NDC Q0164 HCPCS inpatient 1 UN 1.6 1.04 ANTHEM HMO ANTHEM HMO 999999999 0.97 1.55 "PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48456175_1 CDM 0250 RC 59746-0113-06 NDC Q0164 HCPCS inpatient 1 UN 1.6 1.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.08 67.6 999999999 0.97 1.55 percent of total billed charges "PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48456175_1 CDM 0250 RC 59746-0113-06 NDC Q0164 HCPCS inpatient 1 UN 1.6 1.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.97 1.55 "PROCHLORPERAZINE MALEATE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48456175_1 CDM 0250 RC 59746-0113-06 NDC Q0164 HCPCS inpatient 1 UN 1.6 1.04 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.97 1.55 PROPYLTHIOURACIL 50 MG TABLET 48456183_1 CDM 0250 RC 67253-0651-10 NDC inpatient 1 UN 2.58 1.68 AETNA AETNA 2.04 79 999999999 1.56 2.5 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 48456183_1 CDM 0250 RC 67253-0651-10 NDC inpatient 1 UN 2.58 1.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.68 65 999999999 1.56 2.5 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 48456183_1 CDM 0250 RC 67253-0651-10 NDC inpatient 1 UN 2.58 1.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.5 97 999999999 1.56 2.5 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 48456183_1 CDM 0250 RC 67253-0651-10 NDC inpatient 1 UN 2.58 1.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.78 69 999999999 1.56 2.5 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 48456183_1 CDM 0250 RC 67253-0651-10 NDC inpatient 1 UN 2.58 1.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.01 78 999999999 1.56 2.5 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 48456183_1 CDM 0250 RC 67253-0651-10 NDC inpatient 1 UN 2.58 1.68 UMR - ALL PLANS UMR - ALL PLANS 1.81 70 999999999 1.56 2.5 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 48456183_1 CDM 0250 RC 67253-0651-10 NDC inpatient 1 UN 2.58 1.68 SIHO - ALL PLANS SIHO - ALL PLANS 2.32 90 999999999 1.56 2.5 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 48456183_1 CDM 0250 RC 67253-0651-10 NDC inpatient 1 UN 2.58 1.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.56 60.55 999999999 1.56 2.5 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 48456183_1 CDM 0250 RC 67253-0651-10 NDC inpatient 1 UN 2.58 1.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.56 2.5 PROPYLTHIOURACIL 50 MG TABLET 48456183_1 CDM 0250 RC 67253-0651-10 NDC inpatient 1 UN 2.58 1.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.56 2.5 PROPYLTHIOURACIL 50 MG TABLET 48456183_1 CDM 0250 RC 67253-0651-10 NDC inpatient 1 UN 2.58 1.68 ANTHEM HMO ANTHEM HMO 999999999 1.56 2.5 PROPYLTHIOURACIL 50 MG TABLET 48456183_1 CDM 0250 RC 67253-0651-10 NDC inpatient 1 UN 2.58 1.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.74 67.6 999999999 1.56 2.5 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 48456183_1 CDM 0250 RC 67253-0651-10 NDC inpatient 1 UN 2.58 1.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.56 2.5 PROPYLTHIOURACIL 50 MG TABLET 48456183_1 CDM 0250 RC 67253-0651-10 NDC inpatient 1 UN 2.58 1.68 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.56 2.5 "INJECTION, ZOLEDRONIC ACID, 1 MG" 48456185_1 CDM 0636 RC 25021-0830-82 NDC J3489 HCPCS inpatient 5 UN 428.48 278.51 AETNA AETNA 338.5 79 999999999 259.44 415.63 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 48456185_1 CDM 0636 RC 25021-0830-82 NDC J3489 HCPCS inpatient 5 UN 428.48 278.51 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.51 65 999999999 259.44 415.63 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 48456185_1 CDM 0636 RC 25021-0830-82 NDC J3489 HCPCS inpatient 5 UN 428.48 278.51 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.63 97 999999999 259.44 415.63 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 48456185_1 CDM 0636 RC 25021-0830-82 NDC J3489 HCPCS inpatient 5 UN 428.48 278.51 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.65 69 999999999 259.44 415.63 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 48456185_1 CDM 0636 RC 25021-0830-82 NDC J3489 HCPCS inpatient 5 UN 428.48 278.51 HUMANA - ALL PLANS HUMANA - ALL PLANS 334.21 78 999999999 259.44 415.63 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 48456185_1 CDM 0636 RC 25021-0830-82 NDC J3489 HCPCS inpatient 5 UN 428.48 278.51 UMR - ALL PLANS UMR - ALL PLANS 299.94 70 999999999 259.44 415.63 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 48456185_1 CDM 0636 RC 25021-0830-82 NDC J3489 HCPCS inpatient 5 UN 428.48 278.51 SIHO - ALL PLANS SIHO - ALL PLANS 385.63 90 999999999 259.44 415.63 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 48456185_1 CDM 0636 RC 25021-0830-82 NDC J3489 HCPCS inpatient 5 UN 428.48 278.51 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.44 60.55 999999999 259.44 415.63 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 48456185_1 CDM 0636 RC 25021-0830-82 NDC J3489 HCPCS inpatient 5 UN 428.48 278.51 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.44 415.63 "INJECTION, ZOLEDRONIC ACID, 1 MG" 48456185_1 CDM 0636 RC 25021-0830-82 NDC J3489 HCPCS inpatient 5 UN 428.48 278.51 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.44 415.63 "INJECTION, ZOLEDRONIC ACID, 1 MG" 48456185_1 CDM 0636 RC 25021-0830-82 NDC J3489 HCPCS inpatient 5 UN 428.48 278.51 ANTHEM HMO ANTHEM HMO 999999999 259.44 415.63 "INJECTION, ZOLEDRONIC ACID, 1 MG" 48456185_1 CDM 0636 RC 25021-0830-82 NDC J3489 HCPCS inpatient 5 UN 428.48 278.51 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.65 67.6 999999999 259.44 415.63 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 48456185_1 CDM 0636 RC 25021-0830-82 NDC J3489 HCPCS inpatient 5 UN 428.48 278.51 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.44 415.63 "INJECTION, ZOLEDRONIC ACID, 1 MG" 48456185_1 CDM 0636 RC 25021-0830-82 NDC J3489 HCPCS inpatient 5 UN 428.48 278.51 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.44 415.63 HYOSCYAMINE SULF 0.125 MG TAB 48456309_1 CDM 0250 RC 43199-0013-01 NDC inpatient 1 UN 2.07 1.35 AETNA AETNA 1.64 79 999999999 1.25 2.01 percent of total billed charges HYOSCYAMINE SULF 0.125 MG TAB 48456309_1 CDM 0250 RC 43199-0013-01 NDC inpatient 1 UN 2.07 1.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.35 65 999999999 1.25 2.01 percent of total billed charges HYOSCYAMINE SULF 0.125 MG TAB 48456309_1 CDM 0250 RC 43199-0013-01 NDC inpatient 1 UN 2.07 1.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.01 97 999999999 1.25 2.01 percent of total billed charges HYOSCYAMINE SULF 0.125 MG TAB 48456309_1 CDM 0250 RC 43199-0013-01 NDC inpatient 1 UN 2.07 1.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.43 69 999999999 1.25 2.01 percent of total billed charges HYOSCYAMINE SULF 0.125 MG TAB 48456309_1 CDM 0250 RC 43199-0013-01 NDC inpatient 1 UN 2.07 1.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.61 78 999999999 1.25 2.01 percent of total billed charges HYOSCYAMINE SULF 0.125 MG TAB 48456309_1 CDM 0250 RC 43199-0013-01 NDC inpatient 1 UN 2.07 1.35 UMR - ALL PLANS UMR - ALL PLANS 1.45 70 999999999 1.25 2.01 percent of total billed charges HYOSCYAMINE SULF 0.125 MG TAB 48456309_1 CDM 0250 RC 43199-0013-01 NDC inpatient 1 UN 2.07 1.35 SIHO - ALL PLANS SIHO - ALL PLANS 1.86 90 999999999 1.25 2.01 percent of total billed charges HYOSCYAMINE SULF 0.125 MG TAB 48456309_1 CDM 0250 RC 43199-0013-01 NDC inpatient 1 UN 2.07 1.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.25 60.55 999999999 1.25 2.01 percent of total billed charges HYOSCYAMINE SULF 0.125 MG TAB 48456309_1 CDM 0250 RC 43199-0013-01 NDC inpatient 1 UN 2.07 1.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.25 2.01 HYOSCYAMINE SULF 0.125 MG TAB 48456309_1 CDM 0250 RC 43199-0013-01 NDC inpatient 1 UN 2.07 1.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.25 2.01 HYOSCYAMINE SULF 0.125 MG TAB 48456309_1 CDM 0250 RC 43199-0013-01 NDC inpatient 1 UN 2.07 1.35 ANTHEM HMO ANTHEM HMO 999999999 1.25 2.01 HYOSCYAMINE SULF 0.125 MG TAB 48456309_1 CDM 0250 RC 43199-0013-01 NDC inpatient 1 UN 2.07 1.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.4 67.6 999999999 1.25 2.01 percent of total billed charges HYOSCYAMINE SULF 0.125 MG TAB 48456309_1 CDM 0250 RC 43199-0013-01 NDC inpatient 1 UN 2.07 1.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.25 2.01 HYOSCYAMINE SULF 0.125 MG TAB 48456309_1 CDM 0250 RC 43199-0013-01 NDC inpatient 1 UN 2.07 1.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.25 2.01 ISOSORBIDE MONONIT ER 30 MG TB 48456315_1 CDM 0250 RC 68084-0591-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE MONONIT ER 30 MG TB 48456315_1 CDM 0250 RC 68084-0591-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE MONONIT ER 30 MG TB 48456315_1 CDM 0250 RC 68084-0591-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE MONONIT ER 30 MG TB 48456315_1 CDM 0250 RC 68084-0591-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE MONONIT ER 30 MG TB 48456315_1 CDM 0250 RC 68084-0591-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE MONONIT ER 30 MG TB 48456315_1 CDM 0250 RC 68084-0591-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE MONONIT ER 30 MG TB 48456315_1 CDM 0250 RC 68084-0591-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE MONONIT ER 30 MG TB 48456315_1 CDM 0250 RC 68084-0591-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE MONONIT ER 30 MG TB 48456315_1 CDM 0250 RC 68084-0591-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ISOSORBIDE MONONIT ER 30 MG TB 48456315_1 CDM 0250 RC 68084-0591-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ISOSORBIDE MONONIT ER 30 MG TB 48456315_1 CDM 0250 RC 68084-0591-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ISOSORBIDE MONONIT ER 30 MG TB 48456315_1 CDM 0250 RC 68084-0591-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE MONONIT ER 30 MG TB 48456315_1 CDM 0250 RC 68084-0591-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ISOSORBIDE MONONIT ER 30 MG TB 48456315_1 CDM 0250 RC 68084-0591-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ISOSORBIDE MONONIT ER 60 MG TB 48456317_1 CDM 0250 RC 68084-0592-01 NDC inpatient 1 UN 1.98 1.29 AETNA AETNA 1.56 79 999999999 1.2 1.92 percent of total billed charges ISOSORBIDE MONONIT ER 60 MG TB 48456317_1 CDM 0250 RC 68084-0592-01 NDC inpatient 1 UN 1.98 1.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.29 65 999999999 1.2 1.92 percent of total billed charges ISOSORBIDE MONONIT ER 60 MG TB 48456317_1 CDM 0250 RC 68084-0592-01 NDC inpatient 1 UN 1.98 1.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.92 97 999999999 1.2 1.92 percent of total billed charges ISOSORBIDE MONONIT ER 60 MG TB 48456317_1 CDM 0250 RC 68084-0592-01 NDC inpatient 1 UN 1.98 1.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.37 69 999999999 1.2 1.92 percent of total billed charges ISOSORBIDE MONONIT ER 60 MG TB 48456317_1 CDM 0250 RC 68084-0592-01 NDC inpatient 1 UN 1.98 1.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.54 78 999999999 1.2 1.92 percent of total billed charges ISOSORBIDE MONONIT ER 60 MG TB 48456317_1 CDM 0250 RC 68084-0592-01 NDC inpatient 1 UN 1.98 1.29 UMR - ALL PLANS UMR - ALL PLANS 1.39 70 999999999 1.2 1.92 percent of total billed charges ISOSORBIDE MONONIT ER 60 MG TB 48456317_1 CDM 0250 RC 68084-0592-01 NDC inpatient 1 UN 1.98 1.29 SIHO - ALL PLANS SIHO - ALL PLANS 1.78 90 999999999 1.2 1.92 percent of total billed charges ISOSORBIDE MONONIT ER 60 MG TB 48456317_1 CDM 0250 RC 68084-0592-01 NDC inpatient 1 UN 1.98 1.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.2 60.55 999999999 1.2 1.92 percent of total billed charges ISOSORBIDE MONONIT ER 60 MG TB 48456317_1 CDM 0250 RC 68084-0592-01 NDC inpatient 1 UN 1.98 1.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.2 1.92 ISOSORBIDE MONONIT ER 60 MG TB 48456317_1 CDM 0250 RC 68084-0592-01 NDC inpatient 1 UN 1.98 1.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.2 1.92 ISOSORBIDE MONONIT ER 60 MG TB 48456317_1 CDM 0250 RC 68084-0592-01 NDC inpatient 1 UN 1.98 1.29 ANTHEM HMO ANTHEM HMO 999999999 1.2 1.92 ISOSORBIDE MONONIT ER 60 MG TB 48456317_1 CDM 0250 RC 68084-0592-01 NDC inpatient 1 UN 1.98 1.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.34 67.6 999999999 1.2 1.92 percent of total billed charges ISOSORBIDE MONONIT ER 60 MG TB 48456317_1 CDM 0250 RC 68084-0592-01 NDC inpatient 1 UN 1.98 1.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.2 1.92 ISOSORBIDE MONONIT ER 60 MG TB 48456317_1 CDM 0250 RC 68084-0592-01 NDC inpatient 1 UN 1.98 1.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.2 1.92 OLANZAPINE 2.5 MG TABLET 48456318_1 CDM 0250 RC 55111-0163-30 NDC inpatient 1 UN 1.48 0.96 AETNA AETNA 1.17 79 999999999 0.9 1.44 percent of total billed charges OLANZAPINE 2.5 MG TABLET 48456318_1 CDM 0250 RC 55111-0163-30 NDC inpatient 1 UN 1.48 0.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.96 65 999999999 0.9 1.44 percent of total billed charges OLANZAPINE 2.5 MG TABLET 48456318_1 CDM 0250 RC 55111-0163-30 NDC inpatient 1 UN 1.48 0.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.44 97 999999999 0.9 1.44 percent of total billed charges OLANZAPINE 2.5 MG TABLET 48456318_1 CDM 0250 RC 55111-0163-30 NDC inpatient 1 UN 1.48 0.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.02 69 999999999 0.9 1.44 percent of total billed charges OLANZAPINE 2.5 MG TABLET 48456318_1 CDM 0250 RC 55111-0163-30 NDC inpatient 1 UN 1.48 0.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.15 78 999999999 0.9 1.44 percent of total billed charges OLANZAPINE 2.5 MG TABLET 48456318_1 CDM 0250 RC 55111-0163-30 NDC inpatient 1 UN 1.48 0.96 UMR - ALL PLANS UMR - ALL PLANS 1.04 70 999999999 0.9 1.44 percent of total billed charges OLANZAPINE 2.5 MG TABLET 48456318_1 CDM 0250 RC 55111-0163-30 NDC inpatient 1 UN 1.48 0.96 SIHO - ALL PLANS SIHO - ALL PLANS 1.33 90 999999999 0.9 1.44 percent of total billed charges OLANZAPINE 2.5 MG TABLET 48456318_1 CDM 0250 RC 55111-0163-30 NDC inpatient 1 UN 1.48 0.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.9 60.55 999999999 0.9 1.44 percent of total billed charges OLANZAPINE 2.5 MG TABLET 48456318_1 CDM 0250 RC 55111-0163-30 NDC inpatient 1 UN 1.48 0.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.9 1.44 OLANZAPINE 2.5 MG TABLET 48456318_1 CDM 0250 RC 55111-0163-30 NDC inpatient 1 UN 1.48 0.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.9 1.44 OLANZAPINE 2.5 MG TABLET 48456318_1 CDM 0250 RC 55111-0163-30 NDC inpatient 1 UN 1.48 0.96 ANTHEM HMO ANTHEM HMO 999999999 0.9 1.44 OLANZAPINE 2.5 MG TABLET 48456318_1 CDM 0250 RC 55111-0163-30 NDC inpatient 1 UN 1.48 0.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 1 67.6 999999999 0.9 1.44 percent of total billed charges OLANZAPINE 2.5 MG TABLET 48456318_1 CDM 0250 RC 55111-0163-30 NDC inpatient 1 UN 1.48 0.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.9 1.44 OLANZAPINE 2.5 MG TABLET 48456318_1 CDM 0250 RC 55111-0163-30 NDC inpatient 1 UN 1.48 0.96 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.9 1.44 QUINAPRIL 20 MG TABLET 48456332_1 CDM 0250 RC 68001-0187-05 NDC inpatient 1 UN 1.03 0.67 AETNA AETNA 0.81 79 999999999 0.62 1 percent of total billed charges QUINAPRIL 20 MG TABLET 48456332_1 CDM 0250 RC 68001-0187-05 NDC inpatient 1 UN 1.03 0.67 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.67 65 999999999 0.62 1 percent of total billed charges QUINAPRIL 20 MG TABLET 48456332_1 CDM 0250 RC 68001-0187-05 NDC inpatient 1 UN 1.03 0.67 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1 97 999999999 0.62 1 percent of total billed charges QUINAPRIL 20 MG TABLET 48456332_1 CDM 0250 RC 68001-0187-05 NDC inpatient 1 UN 1.03 0.67 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.71 69 999999999 0.62 1 percent of total billed charges QUINAPRIL 20 MG TABLET 48456332_1 CDM 0250 RC 68001-0187-05 NDC inpatient 1 UN 1.03 0.67 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.8 78 999999999 0.62 1 percent of total billed charges QUINAPRIL 20 MG TABLET 48456332_1 CDM 0250 RC 68001-0187-05 NDC inpatient 1 UN 1.03 0.67 UMR - ALL PLANS UMR - ALL PLANS 0.72 70 999999999 0.62 1 percent of total billed charges QUINAPRIL 20 MG TABLET 48456332_1 CDM 0250 RC 68001-0187-05 NDC inpatient 1 UN 1.03 0.67 SIHO - ALL PLANS SIHO - ALL PLANS 0.93 90 999999999 0.62 1 percent of total billed charges QUINAPRIL 20 MG TABLET 48456332_1 CDM 0250 RC 68001-0187-05 NDC inpatient 1 UN 1.03 0.67 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.62 60.55 999999999 0.62 1 percent of total billed charges QUINAPRIL 20 MG TABLET 48456332_1 CDM 0250 RC 68001-0187-05 NDC inpatient 1 UN 1.03 0.67 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.62 1 QUINAPRIL 20 MG TABLET 48456332_1 CDM 0250 RC 68001-0187-05 NDC inpatient 1 UN 1.03 0.67 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.62 1 QUINAPRIL 20 MG TABLET 48456332_1 CDM 0250 RC 68001-0187-05 NDC inpatient 1 UN 1.03 0.67 ANTHEM HMO ANTHEM HMO 999999999 0.62 1 QUINAPRIL 20 MG TABLET 48456332_1 CDM 0250 RC 68001-0187-05 NDC inpatient 1 UN 1.03 0.67 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.7 67.6 999999999 0.62 1 percent of total billed charges QUINAPRIL 20 MG TABLET 48456332_1 CDM 0250 RC 68001-0187-05 NDC inpatient 1 UN 1.03 0.67 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.62 1 QUINAPRIL 20 MG TABLET 48456332_1 CDM 0250 RC 68001-0187-05 NDC inpatient 1 UN 1.03 0.67 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.62 1 AMIODARONE 150 MG/3 ML VIAL 48456334_1 CDM 0250 RC 63323-0616-03 NDC inpatient 1 UN 22.76 14.79 AETNA AETNA 17.98 79 999999999 13.78 22.08 percent of total billed charges AMIODARONE 150 MG/3 ML VIAL 48456334_1 CDM 0250 RC 63323-0616-03 NDC inpatient 1 UN 22.76 14.79 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.79 65 999999999 13.78 22.08 percent of total billed charges AMIODARONE 150 MG/3 ML VIAL 48456334_1 CDM 0250 RC 63323-0616-03 NDC inpatient 1 UN 22.76 14.79 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22.08 97 999999999 13.78 22.08 percent of total billed charges AMIODARONE 150 MG/3 ML VIAL 48456334_1 CDM 0250 RC 63323-0616-03 NDC inpatient 1 UN 22.76 14.79 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.7 69 999999999 13.78 22.08 percent of total billed charges AMIODARONE 150 MG/3 ML VIAL 48456334_1 CDM 0250 RC 63323-0616-03 NDC inpatient 1 UN 22.76 14.79 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.75 78 999999999 13.78 22.08 percent of total billed charges AMIODARONE 150 MG/3 ML VIAL 48456334_1 CDM 0250 RC 63323-0616-03 NDC inpatient 1 UN 22.76 14.79 UMR - ALL PLANS UMR - ALL PLANS 15.93 70 999999999 13.78 22.08 percent of total billed charges AMIODARONE 150 MG/3 ML VIAL 48456334_1 CDM 0250 RC 63323-0616-03 NDC inpatient 1 UN 22.76 14.79 SIHO - ALL PLANS SIHO - ALL PLANS 20.48 90 999999999 13.78 22.08 percent of total billed charges AMIODARONE 150 MG/3 ML VIAL 48456334_1 CDM 0250 RC 63323-0616-03 NDC inpatient 1 UN 22.76 14.79 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.78 60.55 999999999 13.78 22.08 percent of total billed charges AMIODARONE 150 MG/3 ML VIAL 48456334_1 CDM 0250 RC 63323-0616-03 NDC inpatient 1 UN 22.76 14.79 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.78 22.08 AMIODARONE 150 MG/3 ML VIAL 48456334_1 CDM 0250 RC 63323-0616-03 NDC inpatient 1 UN 22.76 14.79 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.78 22.08 AMIODARONE 150 MG/3 ML VIAL 48456334_1 CDM 0250 RC 63323-0616-03 NDC inpatient 1 UN 22.76 14.79 ANTHEM HMO ANTHEM HMO 999999999 13.78 22.08 AMIODARONE 150 MG/3 ML VIAL 48456334_1 CDM 0250 RC 63323-0616-03 NDC inpatient 1 UN 22.76 14.79 CIGNA - ALL PLANS CIGNA - ALL PLANS 15.39 67.6 999999999 13.78 22.08 percent of total billed charges AMIODARONE 150 MG/3 ML VIAL 48456334_1 CDM 0250 RC 63323-0616-03 NDC inpatient 1 UN 22.76 14.79 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.78 22.08 AMIODARONE 150 MG/3 ML VIAL 48456334_1 CDM 0250 RC 63323-0616-03 NDC inpatient 1 UN 22.76 14.79 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.78 22.08 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48456347_1 CDM 0250 RC 00143-9923-90 NDC J0690 HCPCS inpatient 1 UN 25.45 16.54 AETNA AETNA 20.11 79 999999999 15.41 24.69 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48456347_1 CDM 0250 RC 00143-9923-90 NDC J0690 HCPCS inpatient 1 UN 25.45 16.54 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.54 65 999999999 15.41 24.69 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48456347_1 CDM 0250 RC 00143-9923-90 NDC J0690 HCPCS inpatient 1 UN 25.45 16.54 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.69 97 999999999 15.41 24.69 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48456347_1 CDM 0250 RC 00143-9923-90 NDC J0690 HCPCS inpatient 1 UN 25.45 16.54 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.56 69 999999999 15.41 24.69 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48456347_1 CDM 0250 RC 00143-9923-90 NDC J0690 HCPCS inpatient 1 UN 25.45 16.54 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.85 78 999999999 15.41 24.69 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48456347_1 CDM 0250 RC 00143-9923-90 NDC J0690 HCPCS inpatient 1 UN 25.45 16.54 UMR - ALL PLANS UMR - ALL PLANS 17.82 70 999999999 15.41 24.69 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48456347_1 CDM 0250 RC 00143-9923-90 NDC J0690 HCPCS inpatient 1 UN 25.45 16.54 SIHO - ALL PLANS SIHO - ALL PLANS 22.91 90 999999999 15.41 24.69 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48456347_1 CDM 0250 RC 00143-9923-90 NDC J0690 HCPCS inpatient 1 UN 25.45 16.54 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.41 60.55 999999999 15.41 24.69 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48456347_1 CDM 0250 RC 00143-9923-90 NDC J0690 HCPCS inpatient 1 UN 25.45 16.54 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.41 24.69 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48456347_1 CDM 0250 RC 00143-9923-90 NDC J0690 HCPCS inpatient 1 UN 25.45 16.54 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.41 24.69 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48456347_1 CDM 0250 RC 00143-9923-90 NDC J0690 HCPCS inpatient 1 UN 25.45 16.54 ANTHEM HMO ANTHEM HMO 999999999 15.41 24.69 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48456347_1 CDM 0250 RC 00143-9923-90 NDC J0690 HCPCS inpatient 1 UN 25.45 16.54 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.2 67.6 999999999 15.41 24.69 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48456347_1 CDM 0250 RC 00143-9923-90 NDC J0690 HCPCS inpatient 1 UN 25.45 16.54 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.41 24.69 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48456347_1 CDM 0250 RC 00143-9923-90 NDC J0690 HCPCS inpatient 1 UN 25.45 16.54 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.41 24.69 00641-6161-01 - bumetanide 0.25 mg/mL Inj Sol [JOHN] 48456355_1 CDM 0250 RC 00641-6161-01 NDC inpatient 1 UN 24.9 16.19 AETNA AETNA 19.67 79 999999999 15.08 24.15 percent of total billed charges 00641-6161-01 - bumetanide 0.25 mg/mL Inj Sol [JOHN] 48456355_1 CDM 0250 RC 00641-6161-01 NDC inpatient 1 UN 24.9 16.19 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.19 65 999999999 15.08 24.15 percent of total billed charges 00641-6161-01 - bumetanide 0.25 mg/mL Inj Sol [JOHN] 48456355_1 CDM 0250 RC 00641-6161-01 NDC inpatient 1 UN 24.9 16.19 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.15 97 999999999 15.08 24.15 percent of total billed charges 00641-6161-01 - bumetanide 0.25 mg/mL Inj Sol [JOHN] 48456355_1 CDM 0250 RC 00641-6161-01 NDC inpatient 1 UN 24.9 16.19 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.18 69 999999999 15.08 24.15 percent of total billed charges 00641-6161-01 - bumetanide 0.25 mg/mL Inj Sol [JOHN] 48456355_1 CDM 0250 RC 00641-6161-01 NDC inpatient 1 UN 24.9 16.19 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.42 78 999999999 15.08 24.15 percent of total billed charges 00641-6161-01 - bumetanide 0.25 mg/mL Inj Sol [JOHN] 48456355_1 CDM 0250 RC 00641-6161-01 NDC inpatient 1 UN 24.9 16.19 UMR - ALL PLANS UMR - ALL PLANS 17.43 70 999999999 15.08 24.15 percent of total billed charges 00641-6161-01 - bumetanide 0.25 mg/mL Inj Sol [JOHN] 48456355_1 CDM 0250 RC 00641-6161-01 NDC inpatient 1 UN 24.9 16.19 SIHO - ALL PLANS SIHO - ALL PLANS 22.41 90 999999999 15.08 24.15 percent of total billed charges 00641-6161-01 - bumetanide 0.25 mg/mL Inj Sol [JOHN] 48456355_1 CDM 0250 RC 00641-6161-01 NDC inpatient 1 UN 24.9 16.19 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.08 60.55 999999999 15.08 24.15 percent of total billed charges 00641-6161-01 - bumetanide 0.25 mg/mL Inj Sol [JOHN] 48456355_1 CDM 0250 RC 00641-6161-01 NDC inpatient 1 UN 24.9 16.19 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.08 24.15 00641-6161-01 - bumetanide 0.25 mg/mL Inj Sol [JOHN] 48456355_1 CDM 0250 RC 00641-6161-01 NDC inpatient 1 UN 24.9 16.19 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.08 24.15 00641-6161-01 - bumetanide 0.25 mg/mL Inj Sol [JOHN] 48456355_1 CDM 0250 RC 00641-6161-01 NDC inpatient 1 UN 24.9 16.19 ANTHEM HMO ANTHEM HMO 999999999 15.08 24.15 00641-6161-01 - bumetanide 0.25 mg/mL Inj Sol [JOHN] 48456355_1 CDM 0250 RC 00641-6161-01 NDC inpatient 1 UN 24.9 16.19 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.83 67.6 999999999 15.08 24.15 percent of total billed charges 00641-6161-01 - bumetanide 0.25 mg/mL Inj Sol [JOHN] 48456355_1 CDM 0250 RC 00641-6161-01 NDC inpatient 1 UN 24.9 16.19 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.08 24.15 00641-6161-01 - bumetanide 0.25 mg/mL Inj Sol [JOHN] 48456355_1 CDM 0250 RC 00641-6161-01 NDC inpatient 1 UN 24.9 16.19 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.08 24.15 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456387_1 CDM 0250 RC 00409-7332-01 NDC J0696 HCPCS inpatient 4 UN 25.8 16.77 AETNA AETNA 20.38 79 999999999 15.62 25.03 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456387_1 CDM 0250 RC 00409-7332-01 NDC J0696 HCPCS inpatient 4 UN 25.8 16.77 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.77 65 999999999 15.62 25.03 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456387_1 CDM 0250 RC 00409-7332-01 NDC J0696 HCPCS inpatient 4 UN 25.8 16.77 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.03 97 999999999 15.62 25.03 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456387_1 CDM 0250 RC 00409-7332-01 NDC J0696 HCPCS inpatient 4 UN 25.8 16.77 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.8 69 999999999 15.62 25.03 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456387_1 CDM 0250 RC 00409-7332-01 NDC J0696 HCPCS inpatient 4 UN 25.8 16.77 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.12 78 999999999 15.62 25.03 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456387_1 CDM 0250 RC 00409-7332-01 NDC J0696 HCPCS inpatient 4 UN 25.8 16.77 UMR - ALL PLANS UMR - ALL PLANS 18.06 70 999999999 15.62 25.03 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456387_1 CDM 0250 RC 00409-7332-01 NDC J0696 HCPCS inpatient 4 UN 25.8 16.77 SIHO - ALL PLANS SIHO - ALL PLANS 23.22 90 999999999 15.62 25.03 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456387_1 CDM 0250 RC 00409-7332-01 NDC J0696 HCPCS inpatient 4 UN 25.8 16.77 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.62 60.55 999999999 15.62 25.03 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456387_1 CDM 0250 RC 00409-7332-01 NDC J0696 HCPCS inpatient 4 UN 25.8 16.77 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.62 25.03 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456387_1 CDM 0250 RC 00409-7332-01 NDC J0696 HCPCS inpatient 4 UN 25.8 16.77 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.62 25.03 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456387_1 CDM 0250 RC 00409-7332-01 NDC J0696 HCPCS inpatient 4 UN 25.8 16.77 ANTHEM HMO ANTHEM HMO 999999999 15.62 25.03 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456387_1 CDM 0250 RC 00409-7332-01 NDC J0696 HCPCS inpatient 4 UN 25.8 16.77 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.44 67.6 999999999 15.62 25.03 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456387_1 CDM 0250 RC 00409-7332-01 NDC J0696 HCPCS inpatient 4 UN 25.8 16.77 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.62 25.03 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456387_1 CDM 0250 RC 00409-7332-01 NDC J0696 HCPCS inpatient 4 UN 25.8 16.77 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.62 25.03 LEVOFLOXACIN 250 MG TABLET 48456403_1 CDM 0250 RC 65862-0536-50 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 250 MG TABLET 48456403_1 CDM 0250 RC 65862-0536-50 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 250 MG TABLET 48456403_1 CDM 0250 RC 65862-0536-50 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 250 MG TABLET 48456403_1 CDM 0250 RC 65862-0536-50 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 250 MG TABLET 48456403_1 CDM 0250 RC 65862-0536-50 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 250 MG TABLET 48456403_1 CDM 0250 RC 65862-0536-50 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 250 MG TABLET 48456403_1 CDM 0250 RC 65862-0536-50 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 250 MG TABLET 48456403_1 CDM 0250 RC 65862-0536-50 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 250 MG TABLET 48456403_1 CDM 0250 RC 65862-0536-50 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LEVOFLOXACIN 250 MG TABLET 48456403_1 CDM 0250 RC 65862-0536-50 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LEVOFLOXACIN 250 MG TABLET 48456403_1 CDM 0250 RC 65862-0536-50 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LEVOFLOXACIN 250 MG TABLET 48456403_1 CDM 0250 RC 65862-0536-50 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 250 MG TABLET 48456403_1 CDM 0250 RC 65862-0536-50 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LEVOFLOXACIN 250 MG TABLET 48456403_1 CDM 0250 RC 65862-0536-50 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456405_1 CDM 0250 RC 00409-7337-01 NDC J0696 HCPCS inpatient 1 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456405_1 CDM 0250 RC 00409-7337-01 NDC J0696 HCPCS inpatient 1 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456405_1 CDM 0250 RC 00409-7337-01 NDC J0696 HCPCS inpatient 1 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456405_1 CDM 0250 RC 00409-7337-01 NDC J0696 HCPCS inpatient 1 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456405_1 CDM 0250 RC 00409-7337-01 NDC J0696 HCPCS inpatient 1 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456405_1 CDM 0250 RC 00409-7337-01 NDC J0696 HCPCS inpatient 1 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456405_1 CDM 0250 RC 00409-7337-01 NDC J0696 HCPCS inpatient 1 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456405_1 CDM 0250 RC 00409-7337-01 NDC J0696 HCPCS inpatient 1 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456405_1 CDM 0250 RC 00409-7337-01 NDC J0696 HCPCS inpatient 1 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456405_1 CDM 0250 RC 00409-7337-01 NDC J0696 HCPCS inpatient 1 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456405_1 CDM 0250 RC 00409-7337-01 NDC J0696 HCPCS inpatient 1 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456405_1 CDM 0250 RC 00409-7337-01 NDC J0696 HCPCS inpatient 1 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456405_1 CDM 0250 RC 00409-7337-01 NDC J0696 HCPCS inpatient 1 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 48456405_1 CDM 0250 RC 00409-7337-01 NDC J0696 HCPCS inpatient 1 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 CEFTAZIDIME 2 GM VIAL 48456415_1 CDM 0250 RC 44567-0236-10 NDC inpatient 1 UN 46.1 29.97 AETNA AETNA 36.42 79 999999999 27.91 44.72 percent of total billed charges CEFTAZIDIME 2 GM VIAL 48456415_1 CDM 0250 RC 44567-0236-10 NDC inpatient 1 UN 46.1 29.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 29.97 65 999999999 27.91 44.72 percent of total billed charges CEFTAZIDIME 2 GM VIAL 48456415_1 CDM 0250 RC 44567-0236-10 NDC inpatient 1 UN 46.1 29.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 44.72 97 999999999 27.91 44.72 percent of total billed charges CEFTAZIDIME 2 GM VIAL 48456415_1 CDM 0250 RC 44567-0236-10 NDC inpatient 1 UN 46.1 29.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 31.81 69 999999999 27.91 44.72 percent of total billed charges CEFTAZIDIME 2 GM VIAL 48456415_1 CDM 0250 RC 44567-0236-10 NDC inpatient 1 UN 46.1 29.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 35.96 78 999999999 27.91 44.72 percent of total billed charges CEFTAZIDIME 2 GM VIAL 48456415_1 CDM 0250 RC 44567-0236-10 NDC inpatient 1 UN 46.1 29.97 UMR - ALL PLANS UMR - ALL PLANS 32.27 70 999999999 27.91 44.72 percent of total billed charges CEFTAZIDIME 2 GM VIAL 48456415_1 CDM 0250 RC 44567-0236-10 NDC inpatient 1 UN 46.1 29.97 SIHO - ALL PLANS SIHO - ALL PLANS 41.49 90 999999999 27.91 44.72 percent of total billed charges CEFTAZIDIME 2 GM VIAL 48456415_1 CDM 0250 RC 44567-0236-10 NDC inpatient 1 UN 46.1 29.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27.91 60.55 999999999 27.91 44.72 percent of total billed charges CEFTAZIDIME 2 GM VIAL 48456415_1 CDM 0250 RC 44567-0236-10 NDC inpatient 1 UN 46.1 29.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 27.91 44.72 CEFTAZIDIME 2 GM VIAL 48456415_1 CDM 0250 RC 44567-0236-10 NDC inpatient 1 UN 46.1 29.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 27.91 44.72 CEFTAZIDIME 2 GM VIAL 48456415_1 CDM 0250 RC 44567-0236-10 NDC inpatient 1 UN 46.1 29.97 ANTHEM HMO ANTHEM HMO 999999999 27.91 44.72 CEFTAZIDIME 2 GM VIAL 48456415_1 CDM 0250 RC 44567-0236-10 NDC inpatient 1 UN 46.1 29.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 31.16 67.6 999999999 27.91 44.72 percent of total billed charges CEFTAZIDIME 2 GM VIAL 48456415_1 CDM 0250 RC 44567-0236-10 NDC inpatient 1 UN 46.1 29.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 27.91 44.72 CEFTAZIDIME 2 GM VIAL 48456415_1 CDM 0250 RC 44567-0236-10 NDC inpatient 1 UN 46.1 29.97 UHC - ALL PLANS UHC - ALL PLANS 999999999 27.91 44.72 TAZICEF 1 GRAM VIAL 48456419_1 CDM 0250 RC 00409-5082-16 NDC inpatient 1 UN 34.65 22.52 AETNA AETNA 27.37 79 999999999 20.98 33.61 percent of total billed charges TAZICEF 1 GRAM VIAL 48456419_1 CDM 0250 RC 00409-5082-16 NDC inpatient 1 UN 34.65 22.52 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.52 65 999999999 20.98 33.61 percent of total billed charges TAZICEF 1 GRAM VIAL 48456419_1 CDM 0250 RC 00409-5082-16 NDC inpatient 1 UN 34.65 22.52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33.61 97 999999999 20.98 33.61 percent of total billed charges TAZICEF 1 GRAM VIAL 48456419_1 CDM 0250 RC 00409-5082-16 NDC inpatient 1 UN 34.65 22.52 ENCORE - ALL PLANS ENCORE - ALL PLANS 23.91 69 999999999 20.98 33.61 percent of total billed charges TAZICEF 1 GRAM VIAL 48456419_1 CDM 0250 RC 00409-5082-16 NDC inpatient 1 UN 34.65 22.52 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.03 78 999999999 20.98 33.61 percent of total billed charges TAZICEF 1 GRAM VIAL 48456419_1 CDM 0250 RC 00409-5082-16 NDC inpatient 1 UN 34.65 22.52 UMR - ALL PLANS UMR - ALL PLANS 24.26 70 999999999 20.98 33.61 percent of total billed charges TAZICEF 1 GRAM VIAL 48456419_1 CDM 0250 RC 00409-5082-16 NDC inpatient 1 UN 34.65 22.52 SIHO - ALL PLANS SIHO - ALL PLANS 31.19 90 999999999 20.98 33.61 percent of total billed charges TAZICEF 1 GRAM VIAL 48456419_1 CDM 0250 RC 00409-5082-16 NDC inpatient 1 UN 34.65 22.52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.98 60.55 999999999 20.98 33.61 percent of total billed charges TAZICEF 1 GRAM VIAL 48456419_1 CDM 0250 RC 00409-5082-16 NDC inpatient 1 UN 34.65 22.52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.98 33.61 TAZICEF 1 GRAM VIAL 48456419_1 CDM 0250 RC 00409-5082-16 NDC inpatient 1 UN 34.65 22.52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.98 33.61 TAZICEF 1 GRAM VIAL 48456419_1 CDM 0250 RC 00409-5082-16 NDC inpatient 1 UN 34.65 22.52 ANTHEM HMO ANTHEM HMO 999999999 20.98 33.61 TAZICEF 1 GRAM VIAL 48456419_1 CDM 0250 RC 00409-5082-16 NDC inpatient 1 UN 34.65 22.52 CIGNA - ALL PLANS CIGNA - ALL PLANS 23.42 67.6 999999999 20.98 33.61 percent of total billed charges TAZICEF 1 GRAM VIAL 48456419_1 CDM 0250 RC 00409-5082-16 NDC inpatient 1 UN 34.65 22.52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.98 33.61 TAZICEF 1 GRAM VIAL 48456419_1 CDM 0250 RC 00409-5082-16 NDC inpatient 1 UN 34.65 22.52 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.98 33.61 LIDOCAINE 5% PATCH 48456437_1 CDM 0250 RC 00591-2679-30 NDC inpatient 1 UN 7.81 5.08 AETNA AETNA 6.17 79 999999999 4.73 7.58 percent of total billed charges LIDOCAINE 5% PATCH 48456437_1 CDM 0250 RC 00591-2679-30 NDC inpatient 1 UN 7.81 5.08 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.08 65 999999999 4.73 7.58 percent of total billed charges LIDOCAINE 5% PATCH 48456437_1 CDM 0250 RC 00591-2679-30 NDC inpatient 1 UN 7.81 5.08 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7.58 97 999999999 4.73 7.58 percent of total billed charges LIDOCAINE 5% PATCH 48456437_1 CDM 0250 RC 00591-2679-30 NDC inpatient 1 UN 7.81 5.08 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.39 69 999999999 4.73 7.58 percent of total billed charges LIDOCAINE 5% PATCH 48456437_1 CDM 0250 RC 00591-2679-30 NDC inpatient 1 UN 7.81 5.08 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.09 78 999999999 4.73 7.58 percent of total billed charges LIDOCAINE 5% PATCH 48456437_1 CDM 0250 RC 00591-2679-30 NDC inpatient 1 UN 7.81 5.08 UMR - ALL PLANS UMR - ALL PLANS 5.47 70 999999999 4.73 7.58 percent of total billed charges LIDOCAINE 5% PATCH 48456437_1 CDM 0250 RC 00591-2679-30 NDC inpatient 1 UN 7.81 5.08 SIHO - ALL PLANS SIHO - ALL PLANS 7.03 90 999999999 4.73 7.58 percent of total billed charges LIDOCAINE 5% PATCH 48456437_1 CDM 0250 RC 00591-2679-30 NDC inpatient 1 UN 7.81 5.08 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.73 60.55 999999999 4.73 7.58 percent of total billed charges LIDOCAINE 5% PATCH 48456437_1 CDM 0250 RC 00591-2679-30 NDC inpatient 1 UN 7.81 5.08 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.73 7.58 LIDOCAINE 5% PATCH 48456437_1 CDM 0250 RC 00591-2679-30 NDC inpatient 1 UN 7.81 5.08 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.73 7.58 LIDOCAINE 5% PATCH 48456437_1 CDM 0250 RC 00591-2679-30 NDC inpatient 1 UN 7.81 5.08 ANTHEM HMO ANTHEM HMO 999999999 4.73 7.58 LIDOCAINE 5% PATCH 48456437_1 CDM 0250 RC 00591-2679-30 NDC inpatient 1 UN 7.81 5.08 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.28 67.6 999999999 4.73 7.58 percent of total billed charges LIDOCAINE 5% PATCH 48456437_1 CDM 0250 RC 00591-2679-30 NDC inpatient 1 UN 7.81 5.08 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.73 7.58 LIDOCAINE 5% PATCH 48456437_1 CDM 0250 RC 00591-2679-30 NDC inpatient 1 UN 7.81 5.08 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.73 7.58 LISINOPRIL 5 MG TABLET 48456442_1 CDM 0250 RC 68084-0196-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LISINOPRIL 5 MG TABLET 48456442_1 CDM 0250 RC 68084-0196-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LISINOPRIL 5 MG TABLET 48456442_1 CDM 0250 RC 68084-0196-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LISINOPRIL 5 MG TABLET 48456442_1 CDM 0250 RC 68084-0196-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LISINOPRIL 5 MG TABLET 48456442_1 CDM 0250 RC 68084-0196-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LISINOPRIL 5 MG TABLET 48456442_1 CDM 0250 RC 68084-0196-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LISINOPRIL 5 MG TABLET 48456442_1 CDM 0250 RC 68084-0196-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LISINOPRIL 5 MG TABLET 48456442_1 CDM 0250 RC 68084-0196-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LISINOPRIL 5 MG TABLET 48456442_1 CDM 0250 RC 68084-0196-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LISINOPRIL 5 MG TABLET 48456442_1 CDM 0250 RC 68084-0196-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LISINOPRIL 5 MG TABLET 48456442_1 CDM 0250 RC 68084-0196-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LISINOPRIL 5 MG TABLET 48456442_1 CDM 0250 RC 68084-0196-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges LISINOPRIL 5 MG TABLET 48456442_1 CDM 0250 RC 68084-0196-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LISINOPRIL 5 MG TABLET 48456442_1 CDM 0250 RC 68084-0196-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 OXCARBAZEPINE 300 MG TABLET 48456447_1 CDM 0250 RC 68462-0138-01 NDC inpatient 1 UN 1.41 0.92 AETNA AETNA 1.11 79 999999999 0.85 1.37 percent of total billed charges OXCARBAZEPINE 300 MG TABLET 48456447_1 CDM 0250 RC 68462-0138-01 NDC inpatient 1 UN 1.41 0.92 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.92 65 999999999 0.85 1.37 percent of total billed charges OXCARBAZEPINE 300 MG TABLET 48456447_1 CDM 0250 RC 68462-0138-01 NDC inpatient 1 UN 1.41 0.92 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.37 97 999999999 0.85 1.37 percent of total billed charges OXCARBAZEPINE 300 MG TABLET 48456447_1 CDM 0250 RC 68462-0138-01 NDC inpatient 1 UN 1.41 0.92 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.97 69 999999999 0.85 1.37 percent of total billed charges OXCARBAZEPINE 300 MG TABLET 48456447_1 CDM 0250 RC 68462-0138-01 NDC inpatient 1 UN 1.41 0.92 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.1 78 999999999 0.85 1.37 percent of total billed charges OXCARBAZEPINE 300 MG TABLET 48456447_1 CDM 0250 RC 68462-0138-01 NDC inpatient 1 UN 1.41 0.92 UMR - ALL PLANS UMR - ALL PLANS 0.99 70 999999999 0.85 1.37 percent of total billed charges OXCARBAZEPINE 300 MG TABLET 48456447_1 CDM 0250 RC 68462-0138-01 NDC inpatient 1 UN 1.41 0.92 SIHO - ALL PLANS SIHO - ALL PLANS 1.27 90 999999999 0.85 1.37 percent of total billed charges OXCARBAZEPINE 300 MG TABLET 48456447_1 CDM 0250 RC 68462-0138-01 NDC inpatient 1 UN 1.41 0.92 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.85 60.55 999999999 0.85 1.37 percent of total billed charges OXCARBAZEPINE 300 MG TABLET 48456447_1 CDM 0250 RC 68462-0138-01 NDC inpatient 1 UN 1.41 0.92 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.85 1.37 OXCARBAZEPINE 300 MG TABLET 48456447_1 CDM 0250 RC 68462-0138-01 NDC inpatient 1 UN 1.41 0.92 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.85 1.37 OXCARBAZEPINE 300 MG TABLET 48456447_1 CDM 0250 RC 68462-0138-01 NDC inpatient 1 UN 1.41 0.92 ANTHEM HMO ANTHEM HMO 999999999 0.85 1.37 OXCARBAZEPINE 300 MG TABLET 48456447_1 CDM 0250 RC 68462-0138-01 NDC inpatient 1 UN 1.41 0.92 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.95 67.6 999999999 0.85 1.37 percent of total billed charges OXCARBAZEPINE 300 MG TABLET 48456447_1 CDM 0250 RC 68462-0138-01 NDC inpatient 1 UN 1.41 0.92 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.85 1.37 OXCARBAZEPINE 300 MG TABLET 48456447_1 CDM 0250 RC 68462-0138-01 NDC inpatient 1 UN 1.41 0.92 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.85 1.37 PENICILLIN VK 250 MG TABLET 48456463_1 CDM 0250 RC 00781-1205-01 NDC inpatient 1 UN 1.29 0.84 AETNA AETNA 1.02 79 999999999 0.78 1.25 percent of total billed charges PENICILLIN VK 250 MG TABLET 48456463_1 CDM 0250 RC 00781-1205-01 NDC inpatient 1 UN 1.29 0.84 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.84 65 999999999 0.78 1.25 percent of total billed charges PENICILLIN VK 250 MG TABLET 48456463_1 CDM 0250 RC 00781-1205-01 NDC inpatient 1 UN 1.29 0.84 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.25 97 999999999 0.78 1.25 percent of total billed charges PENICILLIN VK 250 MG TABLET 48456463_1 CDM 0250 RC 00781-1205-01 NDC inpatient 1 UN 1.29 0.84 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.89 69 999999999 0.78 1.25 percent of total billed charges PENICILLIN VK 250 MG TABLET 48456463_1 CDM 0250 RC 00781-1205-01 NDC inpatient 1 UN 1.29 0.84 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.01 78 999999999 0.78 1.25 percent of total billed charges PENICILLIN VK 250 MG TABLET 48456463_1 CDM 0250 RC 00781-1205-01 NDC inpatient 1 UN 1.29 0.84 UMR - ALL PLANS UMR - ALL PLANS 0.9 70 999999999 0.78 1.25 percent of total billed charges PENICILLIN VK 250 MG TABLET 48456463_1 CDM 0250 RC 00781-1205-01 NDC inpatient 1 UN 1.29 0.84 SIHO - ALL PLANS SIHO - ALL PLANS 1.16 90 999999999 0.78 1.25 percent of total billed charges PENICILLIN VK 250 MG TABLET 48456463_1 CDM 0250 RC 00781-1205-01 NDC inpatient 1 UN 1.29 0.84 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.78 60.55 999999999 0.78 1.25 percent of total billed charges PENICILLIN VK 250 MG TABLET 48456463_1 CDM 0250 RC 00781-1205-01 NDC inpatient 1 UN 1.29 0.84 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.78 1.25 PENICILLIN VK 250 MG TABLET 48456463_1 CDM 0250 RC 00781-1205-01 NDC inpatient 1 UN 1.29 0.84 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.78 1.25 PENICILLIN VK 250 MG TABLET 48456463_1 CDM 0250 RC 00781-1205-01 NDC inpatient 1 UN 1.29 0.84 ANTHEM HMO ANTHEM HMO 999999999 0.78 1.25 PENICILLIN VK 250 MG TABLET 48456463_1 CDM 0250 RC 00781-1205-01 NDC inpatient 1 UN 1.29 0.84 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.87 67.6 999999999 0.78 1.25 percent of total billed charges PENICILLIN VK 250 MG TABLET 48456463_1 CDM 0250 RC 00781-1205-01 NDC inpatient 1 UN 1.29 0.84 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.78 1.25 PENICILLIN VK 250 MG TABLET 48456463_1 CDM 0250 RC 00781-1205-01 NDC inpatient 1 UN 1.29 0.84 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.78 1.25 DIPHENHYDRAMINE 50 MG/ML VIAL 48456474_1 CDM 0250 RC 00641-0376-25 NDC inpatient 1 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges DIPHENHYDRAMINE 50 MG/ML VIAL 48456474_1 CDM 0250 RC 00641-0376-25 NDC inpatient 1 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges DIPHENHYDRAMINE 50 MG/ML VIAL 48456474_1 CDM 0250 RC 00641-0376-25 NDC inpatient 1 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges DIPHENHYDRAMINE 50 MG/ML VIAL 48456474_1 CDM 0250 RC 00641-0376-25 NDC inpatient 1 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges DIPHENHYDRAMINE 50 MG/ML VIAL 48456474_1 CDM 0250 RC 00641-0376-25 NDC inpatient 1 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges DIPHENHYDRAMINE 50 MG/ML VIAL 48456474_1 CDM 0250 RC 00641-0376-25 NDC inpatient 1 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges DIPHENHYDRAMINE 50 MG/ML VIAL 48456474_1 CDM 0250 RC 00641-0376-25 NDC inpatient 1 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges DIPHENHYDRAMINE 50 MG/ML VIAL 48456474_1 CDM 0250 RC 00641-0376-25 NDC inpatient 1 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges DIPHENHYDRAMINE 50 MG/ML VIAL 48456474_1 CDM 0250 RC 00641-0376-25 NDC inpatient 1 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 DIPHENHYDRAMINE 50 MG/ML VIAL 48456474_1 CDM 0250 RC 00641-0376-25 NDC inpatient 1 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 DIPHENHYDRAMINE 50 MG/ML VIAL 48456474_1 CDM 0250 RC 00641-0376-25 NDC inpatient 1 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 DIPHENHYDRAMINE 50 MG/ML VIAL 48456474_1 CDM 0250 RC 00641-0376-25 NDC inpatient 1 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges DIPHENHYDRAMINE 50 MG/ML VIAL 48456474_1 CDM 0250 RC 00641-0376-25 NDC inpatient 1 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 DIPHENHYDRAMINE 50 MG/ML VIAL 48456474_1 CDM 0250 RC 00641-0376-25 NDC inpatient 1 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 MELOXICAM 7.5 MG TABLET 48456480_1 CDM 0250 RC 68382-0050-01 NDC inpatient 1 UN 1.15 0.75 AETNA AETNA 0.91 79 999999999 0.7 1.12 percent of total billed charges MELOXICAM 7.5 MG TABLET 48456480_1 CDM 0250 RC 68382-0050-01 NDC inpatient 1 UN 1.15 0.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.75 65 999999999 0.7 1.12 percent of total billed charges MELOXICAM 7.5 MG TABLET 48456480_1 CDM 0250 RC 68382-0050-01 NDC inpatient 1 UN 1.15 0.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.12 97 999999999 0.7 1.12 percent of total billed charges MELOXICAM 7.5 MG TABLET 48456480_1 CDM 0250 RC 68382-0050-01 NDC inpatient 1 UN 1.15 0.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.79 69 999999999 0.7 1.12 percent of total billed charges MELOXICAM 7.5 MG TABLET 48456480_1 CDM 0250 RC 68382-0050-01 NDC inpatient 1 UN 1.15 0.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.9 78 999999999 0.7 1.12 percent of total billed charges MELOXICAM 7.5 MG TABLET 48456480_1 CDM 0250 RC 68382-0050-01 NDC inpatient 1 UN 1.15 0.75 UMR - ALL PLANS UMR - ALL PLANS 0.81 70 999999999 0.7 1.12 percent of total billed charges MELOXICAM 7.5 MG TABLET 48456480_1 CDM 0250 RC 68382-0050-01 NDC inpatient 1 UN 1.15 0.75 SIHO - ALL PLANS SIHO - ALL PLANS 1.04 90 999999999 0.7 1.12 percent of total billed charges MELOXICAM 7.5 MG TABLET 48456480_1 CDM 0250 RC 68382-0050-01 NDC inpatient 1 UN 1.15 0.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.7 60.55 999999999 0.7 1.12 percent of total billed charges MELOXICAM 7.5 MG TABLET 48456480_1 CDM 0250 RC 68382-0050-01 NDC inpatient 1 UN 1.15 0.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.7 1.12 MELOXICAM 7.5 MG TABLET 48456480_1 CDM 0250 RC 68382-0050-01 NDC inpatient 1 UN 1.15 0.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.7 1.12 MELOXICAM 7.5 MG TABLET 48456480_1 CDM 0250 RC 68382-0050-01 NDC inpatient 1 UN 1.15 0.75 ANTHEM HMO ANTHEM HMO 999999999 0.7 1.12 MELOXICAM 7.5 MG TABLET 48456480_1 CDM 0250 RC 68382-0050-01 NDC inpatient 1 UN 1.15 0.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.78 67.6 999999999 0.7 1.12 percent of total billed charges MELOXICAM 7.5 MG TABLET 48456480_1 CDM 0250 RC 68382-0050-01 NDC inpatient 1 UN 1.15 0.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.7 1.12 MELOXICAM 7.5 MG TABLET 48456480_1 CDM 0250 RC 68382-0050-01 NDC inpatient 1 UN 1.15 0.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.7 1.12 MEMANTINE HCL 5 MG TABLET 48456481_1 CDM 0250 RC 60687-0173-57 NDC inpatient 1 UN 1.26 0.82 AETNA AETNA 1 79 999999999 0.76 1.22 percent of total billed charges MEMANTINE HCL 5 MG TABLET 48456481_1 CDM 0250 RC 60687-0173-57 NDC inpatient 1 UN 1.26 0.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.82 65 999999999 0.76 1.22 percent of total billed charges MEMANTINE HCL 5 MG TABLET 48456481_1 CDM 0250 RC 60687-0173-57 NDC inpatient 1 UN 1.26 0.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.22 97 999999999 0.76 1.22 percent of total billed charges MEMANTINE HCL 5 MG TABLET 48456481_1 CDM 0250 RC 60687-0173-57 NDC inpatient 1 UN 1.26 0.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.87 69 999999999 0.76 1.22 percent of total billed charges MEMANTINE HCL 5 MG TABLET 48456481_1 CDM 0250 RC 60687-0173-57 NDC inpatient 1 UN 1.26 0.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.98 78 999999999 0.76 1.22 percent of total billed charges MEMANTINE HCL 5 MG TABLET 48456481_1 CDM 0250 RC 60687-0173-57 NDC inpatient 1 UN 1.26 0.82 UMR - ALL PLANS UMR - ALL PLANS 0.88 70 999999999 0.76 1.22 percent of total billed charges MEMANTINE HCL 5 MG TABLET 48456481_1 CDM 0250 RC 60687-0173-57 NDC inpatient 1 UN 1.26 0.82 SIHO - ALL PLANS SIHO - ALL PLANS 1.13 90 999999999 0.76 1.22 percent of total billed charges MEMANTINE HCL 5 MG TABLET 48456481_1 CDM 0250 RC 60687-0173-57 NDC inpatient 1 UN 1.26 0.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.76 60.55 999999999 0.76 1.22 percent of total billed charges MEMANTINE HCL 5 MG TABLET 48456481_1 CDM 0250 RC 60687-0173-57 NDC inpatient 1 UN 1.26 0.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.76 1.22 MEMANTINE HCL 5 MG TABLET 48456481_1 CDM 0250 RC 60687-0173-57 NDC inpatient 1 UN 1.26 0.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.76 1.22 MEMANTINE HCL 5 MG TABLET 48456481_1 CDM 0250 RC 60687-0173-57 NDC inpatient 1 UN 1.26 0.82 ANTHEM HMO ANTHEM HMO 999999999 0.76 1.22 MEMANTINE HCL 5 MG TABLET 48456481_1 CDM 0250 RC 60687-0173-57 NDC inpatient 1 UN 1.26 0.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.85 67.6 999999999 0.76 1.22 percent of total billed charges MEMANTINE HCL 5 MG TABLET 48456481_1 CDM 0250 RC 60687-0173-57 NDC inpatient 1 UN 1.26 0.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.76 1.22 MEMANTINE HCL 5 MG TABLET 48456481_1 CDM 0250 RC 60687-0173-57 NDC inpatient 1 UN 1.26 0.82 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.76 1.22 FLUMAZENIL 0.5 MG/5 ML VIAL 48456550_1 CDM 0250 RC 00143-9684-10 NDC inpatient 1 UN 32.21 20.94 AETNA AETNA 25.45 79 999999999 19.5 31.24 percent of total billed charges FLUMAZENIL 0.5 MG/5 ML VIAL 48456550_1 CDM 0250 RC 00143-9684-10 NDC inpatient 1 UN 32.21 20.94 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.94 65 999999999 19.5 31.24 percent of total billed charges FLUMAZENIL 0.5 MG/5 ML VIAL 48456550_1 CDM 0250 RC 00143-9684-10 NDC inpatient 1 UN 32.21 20.94 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31.24 97 999999999 19.5 31.24 percent of total billed charges FLUMAZENIL 0.5 MG/5 ML VIAL 48456550_1 CDM 0250 RC 00143-9684-10 NDC inpatient 1 UN 32.21 20.94 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.22 69 999999999 19.5 31.24 percent of total billed charges FLUMAZENIL 0.5 MG/5 ML VIAL 48456550_1 CDM 0250 RC 00143-9684-10 NDC inpatient 1 UN 32.21 20.94 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.12 78 999999999 19.5 31.24 percent of total billed charges FLUMAZENIL 0.5 MG/5 ML VIAL 48456550_1 CDM 0250 RC 00143-9684-10 NDC inpatient 1 UN 32.21 20.94 UMR - ALL PLANS UMR - ALL PLANS 22.55 70 999999999 19.5 31.24 percent of total billed charges FLUMAZENIL 0.5 MG/5 ML VIAL 48456550_1 CDM 0250 RC 00143-9684-10 NDC inpatient 1 UN 32.21 20.94 SIHO - ALL PLANS SIHO - ALL PLANS 28.99 90 999999999 19.5 31.24 percent of total billed charges FLUMAZENIL 0.5 MG/5 ML VIAL 48456550_1 CDM 0250 RC 00143-9684-10 NDC inpatient 1 UN 32.21 20.94 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.5 60.55 999999999 19.5 31.24 percent of total billed charges FLUMAZENIL 0.5 MG/5 ML VIAL 48456550_1 CDM 0250 RC 00143-9684-10 NDC inpatient 1 UN 32.21 20.94 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.5 31.24 FLUMAZENIL 0.5 MG/5 ML VIAL 48456550_1 CDM 0250 RC 00143-9684-10 NDC inpatient 1 UN 32.21 20.94 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.5 31.24 FLUMAZENIL 0.5 MG/5 ML VIAL 48456550_1 CDM 0250 RC 00143-9684-10 NDC inpatient 1 UN 32.21 20.94 ANTHEM HMO ANTHEM HMO 999999999 19.5 31.24 FLUMAZENIL 0.5 MG/5 ML VIAL 48456550_1 CDM 0250 RC 00143-9684-10 NDC inpatient 1 UN 32.21 20.94 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.77 67.6 999999999 19.5 31.24 percent of total billed charges FLUMAZENIL 0.5 MG/5 ML VIAL 48456550_1 CDM 0250 RC 00143-9684-10 NDC inpatient 1 UN 32.21 20.94 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.5 31.24 FLUMAZENIL 0.5 MG/5 ML VIAL 48456550_1 CDM 0250 RC 00143-9684-10 NDC inpatient 1 UN 32.21 20.94 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.5 31.24 "HEPARIN SOD 5,000 UNIT/ML VIAL" 48456553_1 CDM 0250 RC 00641-0400-12 NDC inpatient 1 UN 28.3 18.4 AETNA AETNA 22.36 79 999999999 17.14 27.45 percent of total billed charges "HEPARIN SOD 5,000 UNIT/ML VIAL" 48456553_1 CDM 0250 RC 00641-0400-12 NDC inpatient 1 UN 28.3 18.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 18.4 65 999999999 17.14 27.45 percent of total billed charges "HEPARIN SOD 5,000 UNIT/ML VIAL" 48456553_1 CDM 0250 RC 00641-0400-12 NDC inpatient 1 UN 28.3 18.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 27.45 97 999999999 17.14 27.45 percent of total billed charges "HEPARIN SOD 5,000 UNIT/ML VIAL" 48456553_1 CDM 0250 RC 00641-0400-12 NDC inpatient 1 UN 28.3 18.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 19.53 69 999999999 17.14 27.45 percent of total billed charges "HEPARIN SOD 5,000 UNIT/ML VIAL" 48456553_1 CDM 0250 RC 00641-0400-12 NDC inpatient 1 UN 28.3 18.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 22.07 78 999999999 17.14 27.45 percent of total billed charges "HEPARIN SOD 5,000 UNIT/ML VIAL" 48456553_1 CDM 0250 RC 00641-0400-12 NDC inpatient 1 UN 28.3 18.4 UMR - ALL PLANS UMR - ALL PLANS 19.81 70 999999999 17.14 27.45 percent of total billed charges "HEPARIN SOD 5,000 UNIT/ML VIAL" 48456553_1 CDM 0250 RC 00641-0400-12 NDC inpatient 1 UN 28.3 18.4 SIHO - ALL PLANS SIHO - ALL PLANS 25.47 90 999999999 17.14 27.45 percent of total billed charges "HEPARIN SOD 5,000 UNIT/ML VIAL" 48456553_1 CDM 0250 RC 00641-0400-12 NDC inpatient 1 UN 28.3 18.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17.14 60.55 999999999 17.14 27.45 percent of total billed charges "HEPARIN SOD 5,000 UNIT/ML VIAL" 48456553_1 CDM 0250 RC 00641-0400-12 NDC inpatient 1 UN 28.3 18.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 17.14 27.45 "HEPARIN SOD 5,000 UNIT/ML VIAL" 48456553_1 CDM 0250 RC 00641-0400-12 NDC inpatient 1 UN 28.3 18.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 17.14 27.45 "HEPARIN SOD 5,000 UNIT/ML VIAL" 48456553_1 CDM 0250 RC 00641-0400-12 NDC inpatient 1 UN 28.3 18.4 ANTHEM HMO ANTHEM HMO 999999999 17.14 27.45 "HEPARIN SOD 5,000 UNIT/ML VIAL" 48456553_1 CDM 0250 RC 00641-0400-12 NDC inpatient 1 UN 28.3 18.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 19.13 67.6 999999999 17.14 27.45 percent of total billed charges "HEPARIN SOD 5,000 UNIT/ML VIAL" 48456553_1 CDM 0250 RC 00641-0400-12 NDC inpatient 1 UN 28.3 18.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 17.14 27.45 "HEPARIN SOD 5,000 UNIT/ML VIAL" 48456553_1 CDM 0250 RC 00641-0400-12 NDC inpatient 1 UN 28.3 18.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 17.14 27.45 ROOM & BOARD - PRIVATE (ONE BED) - PEDIATRIC 48456576_1 CDM 0113 RC inpatient 1618 1051.7 AETNA AETNA 1278.22 79 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - PEDIATRIC 48456576_1 CDM 0113 RC inpatient 1618 1051.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1051.7 65 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - PEDIATRIC 48456576_1 CDM 0113 RC inpatient 1618 1051.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1569.46 97 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - PEDIATRIC 48456576_1 CDM 0113 RC inpatient 1618 1051.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1116.42 69 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - PEDIATRIC 48456576_1 CDM 0113 RC inpatient 1618 1051.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1262.04 78 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - PEDIATRIC 48456576_1 CDM 0113 RC inpatient 1618 1051.7 UMR - ALL PLANS UMR - ALL PLANS 1132.6 70 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - PEDIATRIC 48456576_1 CDM 0113 RC inpatient 1618 1051.7 SIHO - ALL PLANS SIHO - ALL PLANS 1456.2 90 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - PEDIATRIC 48456576_1 CDM 0113 RC inpatient 1618 1051.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 979.7 60.55 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - PEDIATRIC 48456576_1 CDM 0113 RC inpatient 1618 1051.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 979.7 1569.46 ROOM & BOARD - PRIVATE (ONE BED) - PEDIATRIC 48456576_1 CDM 0113 RC inpatient 1618 1051.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 979.7 1569.46 ROOM & BOARD - PRIVATE (ONE BED) - PEDIATRIC 48456576_1 CDM 0113 RC inpatient 1618 1051.7 ANTHEM HMO ANTHEM HMO 999999999 979.7 1569.46 ROOM & BOARD - PRIVATE (ONE BED) - PEDIATRIC 48456576_1 CDM 0113 RC inpatient 1618 1051.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1093.77 67.6 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - PEDIATRIC 48456576_1 CDM 0113 RC inpatient 1618 1051.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 979.7 1569.46 ROOM & BOARD - PRIVATE (ONE BED) - PEDIATRIC 48456576_1 CDM 0113 RC inpatient 1618 1051.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 979.7 1569.46 METAXALONE 800 MG TABLET 48456625_1 CDM 0250 RC 68084-0135-21 NDC inpatient 1 UN 17.37 11.29 AETNA AETNA 13.72 79 999999999 10.52 16.85 percent of total billed charges METAXALONE 800 MG TABLET 48456625_1 CDM 0250 RC 68084-0135-21 NDC inpatient 1 UN 17.37 11.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.29 65 999999999 10.52 16.85 percent of total billed charges METAXALONE 800 MG TABLET 48456625_1 CDM 0250 RC 68084-0135-21 NDC inpatient 1 UN 17.37 11.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16.85 97 999999999 10.52 16.85 percent of total billed charges METAXALONE 800 MG TABLET 48456625_1 CDM 0250 RC 68084-0135-21 NDC inpatient 1 UN 17.37 11.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.99 69 999999999 10.52 16.85 percent of total billed charges METAXALONE 800 MG TABLET 48456625_1 CDM 0250 RC 68084-0135-21 NDC inpatient 1 UN 17.37 11.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.55 78 999999999 10.52 16.85 percent of total billed charges METAXALONE 800 MG TABLET 48456625_1 CDM 0250 RC 68084-0135-21 NDC inpatient 1 UN 17.37 11.29 UMR - ALL PLANS UMR - ALL PLANS 12.16 70 999999999 10.52 16.85 percent of total billed charges METAXALONE 800 MG TABLET 48456625_1 CDM 0250 RC 68084-0135-21 NDC inpatient 1 UN 17.37 11.29 SIHO - ALL PLANS SIHO - ALL PLANS 15.63 90 999999999 10.52 16.85 percent of total billed charges METAXALONE 800 MG TABLET 48456625_1 CDM 0250 RC 68084-0135-21 NDC inpatient 1 UN 17.37 11.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.52 60.55 999999999 10.52 16.85 percent of total billed charges METAXALONE 800 MG TABLET 48456625_1 CDM 0250 RC 68084-0135-21 NDC inpatient 1 UN 17.37 11.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.52 16.85 METAXALONE 800 MG TABLET 48456625_1 CDM 0250 RC 68084-0135-21 NDC inpatient 1 UN 17.37 11.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.52 16.85 METAXALONE 800 MG TABLET 48456625_1 CDM 0250 RC 68084-0135-21 NDC inpatient 1 UN 17.37 11.29 ANTHEM HMO ANTHEM HMO 999999999 10.52 16.85 METAXALONE 800 MG TABLET 48456625_1 CDM 0250 RC 68084-0135-21 NDC inpatient 1 UN 17.37 11.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.74 67.6 999999999 10.52 16.85 percent of total billed charges METAXALONE 800 MG TABLET 48456625_1 CDM 0250 RC 68084-0135-21 NDC inpatient 1 UN 17.37 11.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.52 16.85 METAXALONE 800 MG TABLET 48456625_1 CDM 0250 RC 68084-0135-21 NDC inpatient 1 UN 17.37 11.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.52 16.85 METFORMIN HCL 500 MG TABLET 48456626_1 CDM 0250 RC 60687-0155-01 NDC inpatient 1 UN 1.4 0.91 AETNA AETNA 1.11 79 999999999 0.85 1.36 percent of total billed charges METFORMIN HCL 500 MG TABLET 48456626_1 CDM 0250 RC 60687-0155-01 NDC inpatient 1 UN 1.4 0.91 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.91 65 999999999 0.85 1.36 percent of total billed charges METFORMIN HCL 500 MG TABLET 48456626_1 CDM 0250 RC 60687-0155-01 NDC inpatient 1 UN 1.4 0.91 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.36 97 999999999 0.85 1.36 percent of total billed charges METFORMIN HCL 500 MG TABLET 48456626_1 CDM 0250 RC 60687-0155-01 NDC inpatient 1 UN 1.4 0.91 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.97 69 999999999 0.85 1.36 percent of total billed charges METFORMIN HCL 500 MG TABLET 48456626_1 CDM 0250 RC 60687-0155-01 NDC inpatient 1 UN 1.4 0.91 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.09 78 999999999 0.85 1.36 percent of total billed charges METFORMIN HCL 500 MG TABLET 48456626_1 CDM 0250 RC 60687-0155-01 NDC inpatient 1 UN 1.4 0.91 UMR - ALL PLANS UMR - ALL PLANS 0.98 70 999999999 0.85 1.36 percent of total billed charges METFORMIN HCL 500 MG TABLET 48456626_1 CDM 0250 RC 60687-0155-01 NDC inpatient 1 UN 1.4 0.91 SIHO - ALL PLANS SIHO - ALL PLANS 1.26 90 999999999 0.85 1.36 percent of total billed charges METFORMIN HCL 500 MG TABLET 48456626_1 CDM 0250 RC 60687-0155-01 NDC inpatient 1 UN 1.4 0.91 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.85 60.55 999999999 0.85 1.36 percent of total billed charges METFORMIN HCL 500 MG TABLET 48456626_1 CDM 0250 RC 60687-0155-01 NDC inpatient 1 UN 1.4 0.91 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.85 1.36 METFORMIN HCL 500 MG TABLET 48456626_1 CDM 0250 RC 60687-0155-01 NDC inpatient 1 UN 1.4 0.91 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.85 1.36 METFORMIN HCL 500 MG TABLET 48456626_1 CDM 0250 RC 60687-0155-01 NDC inpatient 1 UN 1.4 0.91 ANTHEM HMO ANTHEM HMO 999999999 0.85 1.36 METFORMIN HCL 500 MG TABLET 48456626_1 CDM 0250 RC 60687-0155-01 NDC inpatient 1 UN 1.4 0.91 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.95 67.6 999999999 0.85 1.36 percent of total billed charges METFORMIN HCL 500 MG TABLET 48456626_1 CDM 0250 RC 60687-0155-01 NDC inpatient 1 UN 1.4 0.91 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.85 1.36 METFORMIN HCL 500 MG TABLET 48456626_1 CDM 0250 RC 60687-0155-01 NDC inpatient 1 UN 1.4 0.91 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.85 1.36 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48456634_1 CDM 0250 RC 00409-1207-25 NDC J1580 HCPCS inpatient 1 UN 8.33 5.41 AETNA AETNA 6.58 79 999999999 5.04 8.08 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48456634_1 CDM 0250 RC 00409-1207-25 NDC J1580 HCPCS inpatient 1 UN 8.33 5.41 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.41 65 999999999 5.04 8.08 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48456634_1 CDM 0250 RC 00409-1207-25 NDC J1580 HCPCS inpatient 1 UN 8.33 5.41 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.08 97 999999999 5.04 8.08 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48456634_1 CDM 0250 RC 00409-1207-25 NDC J1580 HCPCS inpatient 1 UN 8.33 5.41 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.75 69 999999999 5.04 8.08 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48456634_1 CDM 0250 RC 00409-1207-25 NDC J1580 HCPCS inpatient 1 UN 8.33 5.41 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.5 78 999999999 5.04 8.08 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48456634_1 CDM 0250 RC 00409-1207-25 NDC J1580 HCPCS inpatient 1 UN 8.33 5.41 UMR - ALL PLANS UMR - ALL PLANS 5.83 70 999999999 5.04 8.08 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48456634_1 CDM 0250 RC 00409-1207-25 NDC J1580 HCPCS inpatient 1 UN 8.33 5.41 SIHO - ALL PLANS SIHO - ALL PLANS 7.5 90 999999999 5.04 8.08 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48456634_1 CDM 0250 RC 00409-1207-25 NDC J1580 HCPCS inpatient 1 UN 8.33 5.41 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.04 60.55 999999999 5.04 8.08 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48456634_1 CDM 0250 RC 00409-1207-25 NDC J1580 HCPCS inpatient 1 UN 8.33 5.41 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.04 8.08 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48456634_1 CDM 0250 RC 00409-1207-25 NDC J1580 HCPCS inpatient 1 UN 8.33 5.41 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.04 8.08 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48456634_1 CDM 0250 RC 00409-1207-25 NDC J1580 HCPCS inpatient 1 UN 8.33 5.41 ANTHEM HMO ANTHEM HMO 999999999 5.04 8.08 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48456634_1 CDM 0250 RC 00409-1207-25 NDC J1580 HCPCS inpatient 1 UN 8.33 5.41 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.63 67.6 999999999 5.04 8.08 percent of total billed charges "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48456634_1 CDM 0250 RC 00409-1207-25 NDC J1580 HCPCS inpatient 1 UN 8.33 5.41 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.04 8.08 "INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG" 48456634_1 CDM 0250 RC 00409-1207-25 NDC J1580 HCPCS inpatient 1 UN 8.33 5.41 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.04 8.08 PHENAZOPYRIDINE 100 MG TAB 48456637_1 CDM 0250 RC 51293-0810-01 NDC inpatient 1 UN 3.37 2.19 AETNA AETNA 2.66 79 999999999 2.04 3.27 percent of total billed charges PHENAZOPYRIDINE 100 MG TAB 48456637_1 CDM 0250 RC 51293-0810-01 NDC inpatient 1 UN 3.37 2.19 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.19 65 999999999 2.04 3.27 percent of total billed charges PHENAZOPYRIDINE 100 MG TAB 48456637_1 CDM 0250 RC 51293-0810-01 NDC inpatient 1 UN 3.37 2.19 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.27 97 999999999 2.04 3.27 percent of total billed charges PHENAZOPYRIDINE 100 MG TAB 48456637_1 CDM 0250 RC 51293-0810-01 NDC inpatient 1 UN 3.37 2.19 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.33 69 999999999 2.04 3.27 percent of total billed charges PHENAZOPYRIDINE 100 MG TAB 48456637_1 CDM 0250 RC 51293-0810-01 NDC inpatient 1 UN 3.37 2.19 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.63 78 999999999 2.04 3.27 percent of total billed charges PHENAZOPYRIDINE 100 MG TAB 48456637_1 CDM 0250 RC 51293-0810-01 NDC inpatient 1 UN 3.37 2.19 UMR - ALL PLANS UMR - ALL PLANS 2.36 70 999999999 2.04 3.27 percent of total billed charges PHENAZOPYRIDINE 100 MG TAB 48456637_1 CDM 0250 RC 51293-0810-01 NDC inpatient 1 UN 3.37 2.19 SIHO - ALL PLANS SIHO - ALL PLANS 3.03 90 999999999 2.04 3.27 percent of total billed charges PHENAZOPYRIDINE 100 MG TAB 48456637_1 CDM 0250 RC 51293-0810-01 NDC inpatient 1 UN 3.37 2.19 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.04 60.55 999999999 2.04 3.27 percent of total billed charges PHENAZOPYRIDINE 100 MG TAB 48456637_1 CDM 0250 RC 51293-0810-01 NDC inpatient 1 UN 3.37 2.19 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.04 3.27 PHENAZOPYRIDINE 100 MG TAB 48456637_1 CDM 0250 RC 51293-0810-01 NDC inpatient 1 UN 3.37 2.19 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.04 3.27 PHENAZOPYRIDINE 100 MG TAB 48456637_1 CDM 0250 RC 51293-0810-01 NDC inpatient 1 UN 3.37 2.19 ANTHEM HMO ANTHEM HMO 999999999 2.04 3.27 PHENAZOPYRIDINE 100 MG TAB 48456637_1 CDM 0250 RC 51293-0810-01 NDC inpatient 1 UN 3.37 2.19 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.28 67.6 999999999 2.04 3.27 percent of total billed charges PHENAZOPYRIDINE 100 MG TAB 48456637_1 CDM 0250 RC 51293-0810-01 NDC inpatient 1 UN 3.37 2.19 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.04 3.27 PHENAZOPYRIDINE 100 MG TAB 48456637_1 CDM 0250 RC 51293-0810-01 NDC inpatient 1 UN 3.37 2.19 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.04 3.27 METOCLOPRAMIDE 10 MG TABLET 48456659_1 CDM 0250 RC 68084-0676-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 10 MG TABLET 48456659_1 CDM 0250 RC 68084-0676-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 10 MG TABLET 48456659_1 CDM 0250 RC 68084-0676-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 10 MG TABLET 48456659_1 CDM 0250 RC 68084-0676-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 10 MG TABLET 48456659_1 CDM 0250 RC 68084-0676-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 10 MG TABLET 48456659_1 CDM 0250 RC 68084-0676-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 10 MG TABLET 48456659_1 CDM 0250 RC 68084-0676-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 10 MG TABLET 48456659_1 CDM 0250 RC 68084-0676-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 10 MG TABLET 48456659_1 CDM 0250 RC 68084-0676-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 METOCLOPRAMIDE 10 MG TABLET 48456659_1 CDM 0250 RC 68084-0676-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 METOCLOPRAMIDE 10 MG TABLET 48456659_1 CDM 0250 RC 68084-0676-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 METOCLOPRAMIDE 10 MG TABLET 48456659_1 CDM 0250 RC 68084-0676-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 10 MG TABLET 48456659_1 CDM 0250 RC 68084-0676-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 METOCLOPRAMIDE 10 MG TABLET 48456659_1 CDM 0250 RC 68084-0676-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 FUROSEMIDE 40 MG/4 ML VIAL 48456660_1 CDM 0250 RC 00409-6102-26 NDC inpatient 1 UN 18.37 11.94 AETNA AETNA 14.51 79 999999999 11.12 17.82 percent of total billed charges FUROSEMIDE 40 MG/4 ML VIAL 48456660_1 CDM 0250 RC 00409-6102-26 NDC inpatient 1 UN 18.37 11.94 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.94 65 999999999 11.12 17.82 percent of total billed charges FUROSEMIDE 40 MG/4 ML VIAL 48456660_1 CDM 0250 RC 00409-6102-26 NDC inpatient 1 UN 18.37 11.94 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.82 97 999999999 11.12 17.82 percent of total billed charges FUROSEMIDE 40 MG/4 ML VIAL 48456660_1 CDM 0250 RC 00409-6102-26 NDC inpatient 1 UN 18.37 11.94 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.68 69 999999999 11.12 17.82 percent of total billed charges FUROSEMIDE 40 MG/4 ML VIAL 48456660_1 CDM 0250 RC 00409-6102-26 NDC inpatient 1 UN 18.37 11.94 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.33 78 999999999 11.12 17.82 percent of total billed charges FUROSEMIDE 40 MG/4 ML VIAL 48456660_1 CDM 0250 RC 00409-6102-26 NDC inpatient 1 UN 18.37 11.94 UMR - ALL PLANS UMR - ALL PLANS 12.86 70 999999999 11.12 17.82 percent of total billed charges FUROSEMIDE 40 MG/4 ML VIAL 48456660_1 CDM 0250 RC 00409-6102-26 NDC inpatient 1 UN 18.37 11.94 SIHO - ALL PLANS SIHO - ALL PLANS 16.53 90 999999999 11.12 17.82 percent of total billed charges FUROSEMIDE 40 MG/4 ML VIAL 48456660_1 CDM 0250 RC 00409-6102-26 NDC inpatient 1 UN 18.37 11.94 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.12 60.55 999999999 11.12 17.82 percent of total billed charges FUROSEMIDE 40 MG/4 ML VIAL 48456660_1 CDM 0250 RC 00409-6102-26 NDC inpatient 1 UN 18.37 11.94 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.12 17.82 FUROSEMIDE 40 MG/4 ML VIAL 48456660_1 CDM 0250 RC 00409-6102-26 NDC inpatient 1 UN 18.37 11.94 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.12 17.82 FUROSEMIDE 40 MG/4 ML VIAL 48456660_1 CDM 0250 RC 00409-6102-26 NDC inpatient 1 UN 18.37 11.94 ANTHEM HMO ANTHEM HMO 999999999 11.12 17.82 FUROSEMIDE 40 MG/4 ML VIAL 48456660_1 CDM 0250 RC 00409-6102-26 NDC inpatient 1 UN 18.37 11.94 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.42 67.6 999999999 11.12 17.82 percent of total billed charges FUROSEMIDE 40 MG/4 ML VIAL 48456660_1 CDM 0250 RC 00409-6102-26 NDC inpatient 1 UN 18.37 11.94 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.12 17.82 FUROSEMIDE 40 MG/4 ML VIAL 48456660_1 CDM 0250 RC 00409-6102-26 NDC inpatient 1 UN 18.37 11.94 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.12 17.82 METHOCARBAMOL 750 MG TABLET 48456661_1 CDM 0250 RC 31722-0534-01 NDC inpatient 1 UN 1.6 1.04 AETNA AETNA 1.26 79 999999999 0.97 1.55 percent of total billed charges METHOCARBAMOL 750 MG TABLET 48456661_1 CDM 0250 RC 31722-0534-01 NDC inpatient 1 UN 1.6 1.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.04 65 999999999 0.97 1.55 percent of total billed charges METHOCARBAMOL 750 MG TABLET 48456661_1 CDM 0250 RC 31722-0534-01 NDC inpatient 1 UN 1.6 1.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.55 97 999999999 0.97 1.55 percent of total billed charges METHOCARBAMOL 750 MG TABLET 48456661_1 CDM 0250 RC 31722-0534-01 NDC inpatient 1 UN 1.6 1.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.1 69 999999999 0.97 1.55 percent of total billed charges METHOCARBAMOL 750 MG TABLET 48456661_1 CDM 0250 RC 31722-0534-01 NDC inpatient 1 UN 1.6 1.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.25 78 999999999 0.97 1.55 percent of total billed charges METHOCARBAMOL 750 MG TABLET 48456661_1 CDM 0250 RC 31722-0534-01 NDC inpatient 1 UN 1.6 1.04 UMR - ALL PLANS UMR - ALL PLANS 1.12 70 999999999 0.97 1.55 percent of total billed charges METHOCARBAMOL 750 MG TABLET 48456661_1 CDM 0250 RC 31722-0534-01 NDC inpatient 1 UN 1.6 1.04 SIHO - ALL PLANS SIHO - ALL PLANS 1.44 90 999999999 0.97 1.55 percent of total billed charges METHOCARBAMOL 750 MG TABLET 48456661_1 CDM 0250 RC 31722-0534-01 NDC inpatient 1 UN 1.6 1.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.97 60.55 999999999 0.97 1.55 percent of total billed charges METHOCARBAMOL 750 MG TABLET 48456661_1 CDM 0250 RC 31722-0534-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.97 1.55 METHOCARBAMOL 750 MG TABLET 48456661_1 CDM 0250 RC 31722-0534-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.97 1.55 METHOCARBAMOL 750 MG TABLET 48456661_1 CDM 0250 RC 31722-0534-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM HMO ANTHEM HMO 999999999 0.97 1.55 METHOCARBAMOL 750 MG TABLET 48456661_1 CDM 0250 RC 31722-0534-01 NDC inpatient 1 UN 1.6 1.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.08 67.6 999999999 0.97 1.55 percent of total billed charges METHOCARBAMOL 750 MG TABLET 48456661_1 CDM 0250 RC 31722-0534-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.97 1.55 METHOCARBAMOL 750 MG TABLET 48456661_1 CDM 0250 RC 31722-0534-01 NDC inpatient 1 UN 1.6 1.04 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.97 1.55 METOPROLOL TARTRATE 25 MG TAB 48456675_1 CDM 0250 RC 51079-0255-20 NDC inpatient 1 UN 1.52 0.99 AETNA AETNA 1.2 79 999999999 0.92 1.47 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 48456675_1 CDM 0250 RC 51079-0255-20 NDC inpatient 1 UN 1.52 0.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.99 65 999999999 0.92 1.47 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 48456675_1 CDM 0250 RC 51079-0255-20 NDC inpatient 1 UN 1.52 0.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.47 97 999999999 0.92 1.47 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 48456675_1 CDM 0250 RC 51079-0255-20 NDC inpatient 1 UN 1.52 0.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.05 69 999999999 0.92 1.47 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 48456675_1 CDM 0250 RC 51079-0255-20 NDC inpatient 1 UN 1.52 0.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.19 78 999999999 0.92 1.47 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 48456675_1 CDM 0250 RC 51079-0255-20 NDC inpatient 1 UN 1.52 0.99 UMR - ALL PLANS UMR - ALL PLANS 1.06 70 999999999 0.92 1.47 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 48456675_1 CDM 0250 RC 51079-0255-20 NDC inpatient 1 UN 1.52 0.99 SIHO - ALL PLANS SIHO - ALL PLANS 1.37 90 999999999 0.92 1.47 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 48456675_1 CDM 0250 RC 51079-0255-20 NDC inpatient 1 UN 1.52 0.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.92 60.55 999999999 0.92 1.47 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 48456675_1 CDM 0250 RC 51079-0255-20 NDC inpatient 1 UN 1.52 0.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.92 1.47 METOPROLOL TARTRATE 25 MG TAB 48456675_1 CDM 0250 RC 51079-0255-20 NDC inpatient 1 UN 1.52 0.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.92 1.47 METOPROLOL TARTRATE 25 MG TAB 48456675_1 CDM 0250 RC 51079-0255-20 NDC inpatient 1 UN 1.52 0.99 ANTHEM HMO ANTHEM HMO 999999999 0.92 1.47 METOPROLOL TARTRATE 25 MG TAB 48456675_1 CDM 0250 RC 51079-0255-20 NDC inpatient 1 UN 1.52 0.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.03 67.6 999999999 0.92 1.47 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 48456675_1 CDM 0250 RC 51079-0255-20 NDC inpatient 1 UN 1.52 0.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.92 1.47 METOPROLOL TARTRATE 25 MG TAB 48456675_1 CDM 0250 RC 51079-0255-20 NDC inpatient 1 UN 1.52 0.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.92 1.47 METRONIDAZOLE 250 MG TABLET 48456690_1 CDM 0250 RC 00904-1453-61 NDC inpatient 1 UN 1.04 0.68 AETNA AETNA 0.82 79 999999999 0.63 1.01 percent of total billed charges METRONIDAZOLE 250 MG TABLET 48456690_1 CDM 0250 RC 00904-1453-61 NDC inpatient 1 UN 1.04 0.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.68 65 999999999 0.63 1.01 percent of total billed charges METRONIDAZOLE 250 MG TABLET 48456690_1 CDM 0250 RC 00904-1453-61 NDC inpatient 1 UN 1.04 0.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.01 97 999999999 0.63 1.01 percent of total billed charges METRONIDAZOLE 250 MG TABLET 48456690_1 CDM 0250 RC 00904-1453-61 NDC inpatient 1 UN 1.04 0.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.72 69 999999999 0.63 1.01 percent of total billed charges METRONIDAZOLE 250 MG TABLET 48456690_1 CDM 0250 RC 00904-1453-61 NDC inpatient 1 UN 1.04 0.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.81 78 999999999 0.63 1.01 percent of total billed charges METRONIDAZOLE 250 MG TABLET 48456690_1 CDM 0250 RC 00904-1453-61 NDC inpatient 1 UN 1.04 0.68 UMR - ALL PLANS UMR - ALL PLANS 0.73 70 999999999 0.63 1.01 percent of total billed charges METRONIDAZOLE 250 MG TABLET 48456690_1 CDM 0250 RC 00904-1453-61 NDC inpatient 1 UN 1.04 0.68 SIHO - ALL PLANS SIHO - ALL PLANS 0.94 90 999999999 0.63 1.01 percent of total billed charges METRONIDAZOLE 250 MG TABLET 48456690_1 CDM 0250 RC 00904-1453-61 NDC inpatient 1 UN 1.04 0.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.63 60.55 999999999 0.63 1.01 percent of total billed charges METRONIDAZOLE 250 MG TABLET 48456690_1 CDM 0250 RC 00904-1453-61 NDC inpatient 1 UN 1.04 0.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.63 1.01 METRONIDAZOLE 250 MG TABLET 48456690_1 CDM 0250 RC 00904-1453-61 NDC inpatient 1 UN 1.04 0.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.63 1.01 METRONIDAZOLE 250 MG TABLET 48456690_1 CDM 0250 RC 00904-1453-61 NDC inpatient 1 UN 1.04 0.68 ANTHEM HMO ANTHEM HMO 999999999 0.63 1.01 METRONIDAZOLE 250 MG TABLET 48456690_1 CDM 0250 RC 00904-1453-61 NDC inpatient 1 UN 1.04 0.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.7 67.6 999999999 0.63 1.01 percent of total billed charges METRONIDAZOLE 250 MG TABLET 48456690_1 CDM 0250 RC 00904-1453-61 NDC inpatient 1 UN 1.04 0.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.63 1.01 METRONIDAZOLE 250 MG TABLET 48456690_1 CDM 0250 RC 00904-1453-61 NDC inpatient 1 UN 1.04 0.68 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.63 1.01 MINOXIDIL 2.5 MG TABLET 48456704_1 CDM 0250 RC 53489-0386-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges MINOXIDIL 2.5 MG TABLET 48456704_1 CDM 0250 RC 53489-0386-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges MINOXIDIL 2.5 MG TABLET 48456704_1 CDM 0250 RC 53489-0386-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges MINOXIDIL 2.5 MG TABLET 48456704_1 CDM 0250 RC 53489-0386-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges MINOXIDIL 2.5 MG TABLET 48456704_1 CDM 0250 RC 53489-0386-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges MINOXIDIL 2.5 MG TABLET 48456704_1 CDM 0250 RC 53489-0386-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges MINOXIDIL 2.5 MG TABLET 48456704_1 CDM 0250 RC 53489-0386-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges MINOXIDIL 2.5 MG TABLET 48456704_1 CDM 0250 RC 53489-0386-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges MINOXIDIL 2.5 MG TABLET 48456704_1 CDM 0250 RC 53489-0386-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 MINOXIDIL 2.5 MG TABLET 48456704_1 CDM 0250 RC 53489-0386-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 MINOXIDIL 2.5 MG TABLET 48456704_1 CDM 0250 RC 53489-0386-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 MINOXIDIL 2.5 MG TABLET 48456704_1 CDM 0250 RC 53489-0386-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges MINOXIDIL 2.5 MG TABLET 48456704_1 CDM 0250 RC 53489-0386-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 MINOXIDIL 2.5 MG TABLET 48456704_1 CDM 0250 RC 53489-0386-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 BRIMONIDINE TARTRATE 0.15% DRP 48457370_1 CDM 0250 RC 61314-0144-05 NDC inpatient 1 UN 197.06 128.09 AETNA AETNA 155.68 79 999999999 119.32 191.15 percent of total billed charges BRIMONIDINE TARTRATE 0.15% DRP 48457370_1 CDM 0250 RC 61314-0144-05 NDC inpatient 1 UN 197.06 128.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.09 65 999999999 119.32 191.15 percent of total billed charges BRIMONIDINE TARTRATE 0.15% DRP 48457370_1 CDM 0250 RC 61314-0144-05 NDC inpatient 1 UN 197.06 128.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 191.15 97 999999999 119.32 191.15 percent of total billed charges BRIMONIDINE TARTRATE 0.15% DRP 48457370_1 CDM 0250 RC 61314-0144-05 NDC inpatient 1 UN 197.06 128.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 135.97 69 999999999 119.32 191.15 percent of total billed charges BRIMONIDINE TARTRATE 0.15% DRP 48457370_1 CDM 0250 RC 61314-0144-05 NDC inpatient 1 UN 197.06 128.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 153.71 78 999999999 119.32 191.15 percent of total billed charges BRIMONIDINE TARTRATE 0.15% DRP 48457370_1 CDM 0250 RC 61314-0144-05 NDC inpatient 1 UN 197.06 128.09 UMR - ALL PLANS UMR - ALL PLANS 137.94 70 999999999 119.32 191.15 percent of total billed charges BRIMONIDINE TARTRATE 0.15% DRP 48457370_1 CDM 0250 RC 61314-0144-05 NDC inpatient 1 UN 197.06 128.09 SIHO - ALL PLANS SIHO - ALL PLANS 177.35 90 999999999 119.32 191.15 percent of total billed charges BRIMONIDINE TARTRATE 0.15% DRP 48457370_1 CDM 0250 RC 61314-0144-05 NDC inpatient 1 UN 197.06 128.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.32 60.55 999999999 119.32 191.15 percent of total billed charges BRIMONIDINE TARTRATE 0.15% DRP 48457370_1 CDM 0250 RC 61314-0144-05 NDC inpatient 1 UN 197.06 128.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.32 191.15 BRIMONIDINE TARTRATE 0.15% DRP 48457370_1 CDM 0250 RC 61314-0144-05 NDC inpatient 1 UN 197.06 128.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.32 191.15 BRIMONIDINE TARTRATE 0.15% DRP 48457370_1 CDM 0250 RC 61314-0144-05 NDC inpatient 1 UN 197.06 128.09 ANTHEM HMO ANTHEM HMO 999999999 119.32 191.15 BRIMONIDINE TARTRATE 0.15% DRP 48457370_1 CDM 0250 RC 61314-0144-05 NDC inpatient 1 UN 197.06 128.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.21 67.6 999999999 119.32 191.15 percent of total billed charges BRIMONIDINE TARTRATE 0.15% DRP 48457370_1 CDM 0250 RC 61314-0144-05 NDC inpatient 1 UN 197.06 128.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.32 191.15 BRIMONIDINE TARTRATE 0.15% DRP 48457370_1 CDM 0250 RC 61314-0144-05 NDC inpatient 1 UN 197.06 128.09 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.32 191.15 FLUOROMETHOLONE 0.1% EYE DROP 48457376_1 CDM 0250 RC 60758-0880-05 NDC inpatient 1 UN 99.92 64.95 AETNA AETNA 78.94 79 999999999 60.5 96.92 percent of total billed charges FLUOROMETHOLONE 0.1% EYE DROP 48457376_1 CDM 0250 RC 60758-0880-05 NDC inpatient 1 UN 99.92 64.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 64.95 65 999999999 60.5 96.92 percent of total billed charges FLUOROMETHOLONE 0.1% EYE DROP 48457376_1 CDM 0250 RC 60758-0880-05 NDC inpatient 1 UN 99.92 64.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 96.92 97 999999999 60.5 96.92 percent of total billed charges FLUOROMETHOLONE 0.1% EYE DROP 48457376_1 CDM 0250 RC 60758-0880-05 NDC inpatient 1 UN 99.92 64.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 68.94 69 999999999 60.5 96.92 percent of total billed charges FLUOROMETHOLONE 0.1% EYE DROP 48457376_1 CDM 0250 RC 60758-0880-05 NDC inpatient 1 UN 99.92 64.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 77.94 78 999999999 60.5 96.92 percent of total billed charges FLUOROMETHOLONE 0.1% EYE DROP 48457376_1 CDM 0250 RC 60758-0880-05 NDC inpatient 1 UN 99.92 64.95 UMR - ALL PLANS UMR - ALL PLANS 69.94 70 999999999 60.5 96.92 percent of total billed charges FLUOROMETHOLONE 0.1% EYE DROP 48457376_1 CDM 0250 RC 60758-0880-05 NDC inpatient 1 UN 99.92 64.95 SIHO - ALL PLANS SIHO - ALL PLANS 89.93 90 999999999 60.5 96.92 percent of total billed charges FLUOROMETHOLONE 0.1% EYE DROP 48457376_1 CDM 0250 RC 60758-0880-05 NDC inpatient 1 UN 99.92 64.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.5 60.55 999999999 60.5 96.92 percent of total billed charges FLUOROMETHOLONE 0.1% EYE DROP 48457376_1 CDM 0250 RC 60758-0880-05 NDC inpatient 1 UN 99.92 64.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.5 96.92 FLUOROMETHOLONE 0.1% EYE DROP 48457376_1 CDM 0250 RC 60758-0880-05 NDC inpatient 1 UN 99.92 64.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.5 96.92 FLUOROMETHOLONE 0.1% EYE DROP 48457376_1 CDM 0250 RC 60758-0880-05 NDC inpatient 1 UN 99.92 64.95 ANTHEM HMO ANTHEM HMO 999999999 60.5 96.92 FLUOROMETHOLONE 0.1% EYE DROP 48457376_1 CDM 0250 RC 60758-0880-05 NDC inpatient 1 UN 99.92 64.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.55 67.6 999999999 60.5 96.92 percent of total billed charges FLUOROMETHOLONE 0.1% EYE DROP 48457376_1 CDM 0250 RC 60758-0880-05 NDC inpatient 1 UN 99.92 64.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.5 96.92 FLUOROMETHOLONE 0.1% EYE DROP 48457376_1 CDM 0250 RC 60758-0880-05 NDC inpatient 1 UN 99.92 64.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.5 96.92 UNCLASSIFIED DRUGS 48457380_1 CDM 0250 RC 54799-0431-05 NDC J3490 HCPCS inpatient 1 UN 164.54 106.95 AETNA AETNA 129.99 79 999999999 99.63 159.6 percent of total billed charges UNCLASSIFIED DRUGS 48457380_1 CDM 0250 RC 54799-0431-05 NDC J3490 HCPCS inpatient 1 UN 164.54 106.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.95 65 999999999 99.63 159.6 percent of total billed charges UNCLASSIFIED DRUGS 48457380_1 CDM 0250 RC 54799-0431-05 NDC J3490 HCPCS inpatient 1 UN 164.54 106.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.6 97 999999999 99.63 159.6 percent of total billed charges UNCLASSIFIED DRUGS 48457380_1 CDM 0250 RC 54799-0431-05 NDC J3490 HCPCS inpatient 1 UN 164.54 106.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.53 69 999999999 99.63 159.6 percent of total billed charges UNCLASSIFIED DRUGS 48457380_1 CDM 0250 RC 54799-0431-05 NDC J3490 HCPCS inpatient 1 UN 164.54 106.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.34 78 999999999 99.63 159.6 percent of total billed charges UNCLASSIFIED DRUGS 48457380_1 CDM 0250 RC 54799-0431-05 NDC J3490 HCPCS inpatient 1 UN 164.54 106.95 UMR - ALL PLANS UMR - ALL PLANS 115.18 70 999999999 99.63 159.6 percent of total billed charges UNCLASSIFIED DRUGS 48457380_1 CDM 0250 RC 54799-0431-05 NDC J3490 HCPCS inpatient 1 UN 164.54 106.95 SIHO - ALL PLANS SIHO - ALL PLANS 148.09 90 999999999 99.63 159.6 percent of total billed charges UNCLASSIFIED DRUGS 48457380_1 CDM 0250 RC 54799-0431-05 NDC J3490 HCPCS inpatient 1 UN 164.54 106.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.63 60.55 999999999 99.63 159.6 percent of total billed charges UNCLASSIFIED DRUGS 48457380_1 CDM 0250 RC 54799-0431-05 NDC J3490 HCPCS inpatient 1 UN 164.54 106.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.63 159.6 UNCLASSIFIED DRUGS 48457380_1 CDM 0250 RC 54799-0431-05 NDC J3490 HCPCS inpatient 1 UN 164.54 106.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.63 159.6 UNCLASSIFIED DRUGS 48457380_1 CDM 0250 RC 54799-0431-05 NDC J3490 HCPCS inpatient 1 UN 164.54 106.95 ANTHEM HMO ANTHEM HMO 999999999 99.63 159.6 UNCLASSIFIED DRUGS 48457380_1 CDM 0250 RC 54799-0431-05 NDC J3490 HCPCS inpatient 1 UN 164.54 106.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.23 67.6 999999999 99.63 159.6 percent of total billed charges UNCLASSIFIED DRUGS 48457380_1 CDM 0250 RC 54799-0431-05 NDC J3490 HCPCS inpatient 1 UN 164.54 106.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.63 159.6 UNCLASSIFIED DRUGS 48457380_1 CDM 0250 RC 54799-0431-05 NDC J3490 HCPCS inpatient 1 UN 164.54 106.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.63 159.6 K-PHOS ORIGINAL TABLET 48457387_1 CDM 0250 RC 00486-1111-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges K-PHOS ORIGINAL TABLET 48457387_1 CDM 0250 RC 00486-1111-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges K-PHOS ORIGINAL TABLET 48457387_1 CDM 0250 RC 00486-1111-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges K-PHOS ORIGINAL TABLET 48457387_1 CDM 0250 RC 00486-1111-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges K-PHOS ORIGINAL TABLET 48457387_1 CDM 0250 RC 00486-1111-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges K-PHOS ORIGINAL TABLET 48457387_1 CDM 0250 RC 00486-1111-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges K-PHOS ORIGINAL TABLET 48457387_1 CDM 0250 RC 00486-1111-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges K-PHOS ORIGINAL TABLET 48457387_1 CDM 0250 RC 00486-1111-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges K-PHOS ORIGINAL TABLET 48457387_1 CDM 0250 RC 00486-1111-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 K-PHOS ORIGINAL TABLET 48457387_1 CDM 0250 RC 00486-1111-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 K-PHOS ORIGINAL TABLET 48457387_1 CDM 0250 RC 00486-1111-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 K-PHOS ORIGINAL TABLET 48457387_1 CDM 0250 RC 00486-1111-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges K-PHOS ORIGINAL TABLET 48457387_1 CDM 0250 RC 00486-1111-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 K-PHOS ORIGINAL TABLET 48457387_1 CDM 0250 RC 00486-1111-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 NAPROXEN 250 MG TABLET 48457519_1 CDM 0250 RC 68462-0188-01 NDC inpatient 1 UN 1.71 1.11 AETNA AETNA 1.35 79 999999999 1.04 1.66 percent of total billed charges NAPROXEN 250 MG TABLET 48457519_1 CDM 0250 RC 68462-0188-01 NDC inpatient 1 UN 1.71 1.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.11 65 999999999 1.04 1.66 percent of total billed charges NAPROXEN 250 MG TABLET 48457519_1 CDM 0250 RC 68462-0188-01 NDC inpatient 1 UN 1.71 1.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.66 97 999999999 1.04 1.66 percent of total billed charges NAPROXEN 250 MG TABLET 48457519_1 CDM 0250 RC 68462-0188-01 NDC inpatient 1 UN 1.71 1.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.18 69 999999999 1.04 1.66 percent of total billed charges NAPROXEN 250 MG TABLET 48457519_1 CDM 0250 RC 68462-0188-01 NDC inpatient 1 UN 1.71 1.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.33 78 999999999 1.04 1.66 percent of total billed charges NAPROXEN 250 MG TABLET 48457519_1 CDM 0250 RC 68462-0188-01 NDC inpatient 1 UN 1.71 1.11 UMR - ALL PLANS UMR - ALL PLANS 1.2 70 999999999 1.04 1.66 percent of total billed charges NAPROXEN 250 MG TABLET 48457519_1 CDM 0250 RC 68462-0188-01 NDC inpatient 1 UN 1.71 1.11 SIHO - ALL PLANS SIHO - ALL PLANS 1.54 90 999999999 1.04 1.66 percent of total billed charges NAPROXEN 250 MG TABLET 48457519_1 CDM 0250 RC 68462-0188-01 NDC inpatient 1 UN 1.71 1.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.04 60.55 999999999 1.04 1.66 percent of total billed charges NAPROXEN 250 MG TABLET 48457519_1 CDM 0250 RC 68462-0188-01 NDC inpatient 1 UN 1.71 1.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.04 1.66 NAPROXEN 250 MG TABLET 48457519_1 CDM 0250 RC 68462-0188-01 NDC inpatient 1 UN 1.71 1.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.04 1.66 NAPROXEN 250 MG TABLET 48457519_1 CDM 0250 RC 68462-0188-01 NDC inpatient 1 UN 1.71 1.11 ANTHEM HMO ANTHEM HMO 999999999 1.04 1.66 NAPROXEN 250 MG TABLET 48457519_1 CDM 0250 RC 68462-0188-01 NDC inpatient 1 UN 1.71 1.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.16 67.6 999999999 1.04 1.66 percent of total billed charges NAPROXEN 250 MG TABLET 48457519_1 CDM 0250 RC 68462-0188-01 NDC inpatient 1 UN 1.71 1.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.04 1.66 NAPROXEN 250 MG TABLET 48457519_1 CDM 0250 RC 68462-0188-01 NDC inpatient 1 UN 1.71 1.11 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.04 1.66 NEO-SYNEPHRINE 0.5% SPRAY 48457569_1 CDM 0250 RC 69536-0050-15 NDC inpatient 1 UN 14.11 9.17 AETNA AETNA 11.15 79 999999999 8.54 13.69 percent of total billed charges NEO-SYNEPHRINE 0.5% SPRAY 48457569_1 CDM 0250 RC 69536-0050-15 NDC inpatient 1 UN 14.11 9.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.17 65 999999999 8.54 13.69 percent of total billed charges NEO-SYNEPHRINE 0.5% SPRAY 48457569_1 CDM 0250 RC 69536-0050-15 NDC inpatient 1 UN 14.11 9.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13.69 97 999999999 8.54 13.69 percent of total billed charges NEO-SYNEPHRINE 0.5% SPRAY 48457569_1 CDM 0250 RC 69536-0050-15 NDC inpatient 1 UN 14.11 9.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.74 69 999999999 8.54 13.69 percent of total billed charges NEO-SYNEPHRINE 0.5% SPRAY 48457569_1 CDM 0250 RC 69536-0050-15 NDC inpatient 1 UN 14.11 9.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.01 78 999999999 8.54 13.69 percent of total billed charges NEO-SYNEPHRINE 0.5% SPRAY 48457569_1 CDM 0250 RC 69536-0050-15 NDC inpatient 1 UN 14.11 9.17 UMR - ALL PLANS UMR - ALL PLANS 9.88 70 999999999 8.54 13.69 percent of total billed charges NEO-SYNEPHRINE 0.5% SPRAY 48457569_1 CDM 0250 RC 69536-0050-15 NDC inpatient 1 UN 14.11 9.17 SIHO - ALL PLANS SIHO - ALL PLANS 12.7 90 999999999 8.54 13.69 percent of total billed charges NEO-SYNEPHRINE 0.5% SPRAY 48457569_1 CDM 0250 RC 69536-0050-15 NDC inpatient 1 UN 14.11 9.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.54 60.55 999999999 8.54 13.69 percent of total billed charges NEO-SYNEPHRINE 0.5% SPRAY 48457569_1 CDM 0250 RC 69536-0050-15 NDC inpatient 1 UN 14.11 9.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.54 13.69 NEO-SYNEPHRINE 0.5% SPRAY 48457569_1 CDM 0250 RC 69536-0050-15 NDC inpatient 1 UN 14.11 9.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.54 13.69 NEO-SYNEPHRINE 0.5% SPRAY 48457569_1 CDM 0250 RC 69536-0050-15 NDC inpatient 1 UN 14.11 9.17 ANTHEM HMO ANTHEM HMO 999999999 8.54 13.69 NEO-SYNEPHRINE 0.5% SPRAY 48457569_1 CDM 0250 RC 69536-0050-15 NDC inpatient 1 UN 14.11 9.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.54 67.6 999999999 8.54 13.69 percent of total billed charges NEO-SYNEPHRINE 0.5% SPRAY 48457569_1 CDM 0250 RC 69536-0050-15 NDC inpatient 1 UN 14.11 9.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.54 13.69 NEO-SYNEPHRINE 0.5% SPRAY 48457569_1 CDM 0250 RC 69536-0050-15 NDC inpatient 1 UN 14.11 9.17 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.54 13.69 HURRICAINE 20% GEL 48457578_1 CDM 0250 RC 00283-0293-31 NDC inpatient 1 UN 14.59 9.48 AETNA AETNA 11.53 79 999999999 8.83 14.15 percent of total billed charges HURRICAINE 20% GEL 48457578_1 CDM 0250 RC 00283-0293-31 NDC inpatient 1 UN 14.59 9.48 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.48 65 999999999 8.83 14.15 percent of total billed charges HURRICAINE 20% GEL 48457578_1 CDM 0250 RC 00283-0293-31 NDC inpatient 1 UN 14.59 9.48 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14.15 97 999999999 8.83 14.15 percent of total billed charges HURRICAINE 20% GEL 48457578_1 CDM 0250 RC 00283-0293-31 NDC inpatient 1 UN 14.59 9.48 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.07 69 999999999 8.83 14.15 percent of total billed charges HURRICAINE 20% GEL 48457578_1 CDM 0250 RC 00283-0293-31 NDC inpatient 1 UN 14.59 9.48 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.38 78 999999999 8.83 14.15 percent of total billed charges HURRICAINE 20% GEL 48457578_1 CDM 0250 RC 00283-0293-31 NDC inpatient 1 UN 14.59 9.48 UMR - ALL PLANS UMR - ALL PLANS 10.21 70 999999999 8.83 14.15 percent of total billed charges HURRICAINE 20% GEL 48457578_1 CDM 0250 RC 00283-0293-31 NDC inpatient 1 UN 14.59 9.48 SIHO - ALL PLANS SIHO - ALL PLANS 13.13 90 999999999 8.83 14.15 percent of total billed charges HURRICAINE 20% GEL 48457578_1 CDM 0250 RC 00283-0293-31 NDC inpatient 1 UN 14.59 9.48 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.83 60.55 999999999 8.83 14.15 percent of total billed charges HURRICAINE 20% GEL 48457578_1 CDM 0250 RC 00283-0293-31 NDC inpatient 1 UN 14.59 9.48 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.83 14.15 HURRICAINE 20% GEL 48457578_1 CDM 0250 RC 00283-0293-31 NDC inpatient 1 UN 14.59 9.48 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.83 14.15 HURRICAINE 20% GEL 48457578_1 CDM 0250 RC 00283-0293-31 NDC inpatient 1 UN 14.59 9.48 ANTHEM HMO ANTHEM HMO 999999999 8.83 14.15 HURRICAINE 20% GEL 48457578_1 CDM 0250 RC 00283-0293-31 NDC inpatient 1 UN 14.59 9.48 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.86 67.6 999999999 8.83 14.15 percent of total billed charges HURRICAINE 20% GEL 48457578_1 CDM 0250 RC 00283-0293-31 NDC inpatient 1 UN 14.59 9.48 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.83 14.15 HURRICAINE 20% GEL 48457578_1 CDM 0250 RC 00283-0293-31 NDC inpatient 1 UN 14.59 9.48 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.83 14.15 METOCLOPRAMIDE 10 MG/10 ML CUP 48457606_1 CDM 0250 RC 00121-1576-10 NDC inpatient 1 UN 5.63 3.66 AETNA AETNA 4.45 79 999999999 3.41 5.46 percent of total billed charges METOCLOPRAMIDE 10 MG/10 ML CUP 48457606_1 CDM 0250 RC 00121-1576-10 NDC inpatient 1 UN 5.63 3.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.66 65 999999999 3.41 5.46 percent of total billed charges METOCLOPRAMIDE 10 MG/10 ML CUP 48457606_1 CDM 0250 RC 00121-1576-10 NDC inpatient 1 UN 5.63 3.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.46 97 999999999 3.41 5.46 percent of total billed charges METOCLOPRAMIDE 10 MG/10 ML CUP 48457606_1 CDM 0250 RC 00121-1576-10 NDC inpatient 1 UN 5.63 3.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.88 69 999999999 3.41 5.46 percent of total billed charges METOCLOPRAMIDE 10 MG/10 ML CUP 48457606_1 CDM 0250 RC 00121-1576-10 NDC inpatient 1 UN 5.63 3.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.39 78 999999999 3.41 5.46 percent of total billed charges METOCLOPRAMIDE 10 MG/10 ML CUP 48457606_1 CDM 0250 RC 00121-1576-10 NDC inpatient 1 UN 5.63 3.66 UMR - ALL PLANS UMR - ALL PLANS 3.94 70 999999999 3.41 5.46 percent of total billed charges METOCLOPRAMIDE 10 MG/10 ML CUP 48457606_1 CDM 0250 RC 00121-1576-10 NDC inpatient 1 UN 5.63 3.66 SIHO - ALL PLANS SIHO - ALL PLANS 5.07 90 999999999 3.41 5.46 percent of total billed charges METOCLOPRAMIDE 10 MG/10 ML CUP 48457606_1 CDM 0250 RC 00121-1576-10 NDC inpatient 1 UN 5.63 3.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.41 60.55 999999999 3.41 5.46 percent of total billed charges METOCLOPRAMIDE 10 MG/10 ML CUP 48457606_1 CDM 0250 RC 00121-1576-10 NDC inpatient 1 UN 5.63 3.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.41 5.46 METOCLOPRAMIDE 10 MG/10 ML CUP 48457606_1 CDM 0250 RC 00121-1576-10 NDC inpatient 1 UN 5.63 3.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.41 5.46 METOCLOPRAMIDE 10 MG/10 ML CUP 48457606_1 CDM 0250 RC 00121-1576-10 NDC inpatient 1 UN 5.63 3.66 ANTHEM HMO ANTHEM HMO 999999999 3.41 5.46 METOCLOPRAMIDE 10 MG/10 ML CUP 48457606_1 CDM 0250 RC 00121-1576-10 NDC inpatient 1 UN 5.63 3.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.81 67.6 999999999 3.41 5.46 percent of total billed charges METOCLOPRAMIDE 10 MG/10 ML CUP 48457606_1 CDM 0250 RC 00121-1576-10 NDC inpatient 1 UN 5.63 3.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.41 5.46 METOCLOPRAMIDE 10 MG/10 ML CUP 48457606_1 CDM 0250 RC 00121-1576-10 NDC inpatient 1 UN 5.63 3.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.41 5.46 POLYETHYLENE GLYCOL 3350 POWD 48457610_1 CDM 0250 RC 45802-0868-02 NDC inpatient 1 UN 23.63 15.36 AETNA AETNA 18.67 79 999999999 14.31 22.92 percent of total billed charges POLYETHYLENE GLYCOL 3350 POWD 48457610_1 CDM 0250 RC 45802-0868-02 NDC inpatient 1 UN 23.63 15.36 SELF PAY DISCOUNT SELF PAY DISCOUNT 15.36 65 999999999 14.31 22.92 percent of total billed charges POLYETHYLENE GLYCOL 3350 POWD 48457610_1 CDM 0250 RC 45802-0868-02 NDC inpatient 1 UN 23.63 15.36 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22.92 97 999999999 14.31 22.92 percent of total billed charges POLYETHYLENE GLYCOL 3350 POWD 48457610_1 CDM 0250 RC 45802-0868-02 NDC inpatient 1 UN 23.63 15.36 ENCORE - ALL PLANS ENCORE - ALL PLANS 16.3 69 999999999 14.31 22.92 percent of total billed charges POLYETHYLENE GLYCOL 3350 POWD 48457610_1 CDM 0250 RC 45802-0868-02 NDC inpatient 1 UN 23.63 15.36 HUMANA - ALL PLANS HUMANA - ALL PLANS 18.43 78 999999999 14.31 22.92 percent of total billed charges POLYETHYLENE GLYCOL 3350 POWD 48457610_1 CDM 0250 RC 45802-0868-02 NDC inpatient 1 UN 23.63 15.36 UMR - ALL PLANS UMR - ALL PLANS 16.54 70 999999999 14.31 22.92 percent of total billed charges POLYETHYLENE GLYCOL 3350 POWD 48457610_1 CDM 0250 RC 45802-0868-02 NDC inpatient 1 UN 23.63 15.36 SIHO - ALL PLANS SIHO - ALL PLANS 21.27 90 999999999 14.31 22.92 percent of total billed charges POLYETHYLENE GLYCOL 3350 POWD 48457610_1 CDM 0250 RC 45802-0868-02 NDC inpatient 1 UN 23.63 15.36 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.31 60.55 999999999 14.31 22.92 percent of total billed charges POLYETHYLENE GLYCOL 3350 POWD 48457610_1 CDM 0250 RC 45802-0868-02 NDC inpatient 1 UN 23.63 15.36 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.31 22.92 POLYETHYLENE GLYCOL 3350 POWD 48457610_1 CDM 0250 RC 45802-0868-02 NDC inpatient 1 UN 23.63 15.36 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.31 22.92 POLYETHYLENE GLYCOL 3350 POWD 48457610_1 CDM 0250 RC 45802-0868-02 NDC inpatient 1 UN 23.63 15.36 ANTHEM HMO ANTHEM HMO 999999999 14.31 22.92 POLYETHYLENE GLYCOL 3350 POWD 48457610_1 CDM 0250 RC 45802-0868-02 NDC inpatient 1 UN 23.63 15.36 CIGNA - ALL PLANS CIGNA - ALL PLANS 15.97 67.6 999999999 14.31 22.92 percent of total billed charges POLYETHYLENE GLYCOL 3350 POWD 48457610_1 CDM 0250 RC 45802-0868-02 NDC inpatient 1 UN 23.63 15.36 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.31 22.92 POLYETHYLENE GLYCOL 3350 POWD 48457610_1 CDM 0250 RC 45802-0868-02 NDC inpatient 1 UN 23.63 15.36 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.31 22.92 00904-5894-30 - simethicone 40 mg/0.6 mL Oral Liq [JOHN] 48457621_1 CDM 0250 RC 00904-5894-30 NDC inpatient 1 UN 8.27 5.38 AETNA AETNA 6.53 79 999999999 5.01 8.02 percent of total billed charges 00904-5894-30 - simethicone 40 mg/0.6 mL Oral Liq [JOHN] 48457621_1 CDM 0250 RC 00904-5894-30 NDC inpatient 1 UN 8.27 5.38 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.38 65 999999999 5.01 8.02 percent of total billed charges 00904-5894-30 - simethicone 40 mg/0.6 mL Oral Liq [JOHN] 48457621_1 CDM 0250 RC 00904-5894-30 NDC inpatient 1 UN 8.27 5.38 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.02 97 999999999 5.01 8.02 percent of total billed charges 00904-5894-30 - simethicone 40 mg/0.6 mL Oral Liq [JOHN] 48457621_1 CDM 0250 RC 00904-5894-30 NDC inpatient 1 UN 8.27 5.38 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.71 69 999999999 5.01 8.02 percent of total billed charges 00904-5894-30 - simethicone 40 mg/0.6 mL Oral Liq [JOHN] 48457621_1 CDM 0250 RC 00904-5894-30 NDC inpatient 1 UN 8.27 5.38 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.45 78 999999999 5.01 8.02 percent of total billed charges 00904-5894-30 - simethicone 40 mg/0.6 mL Oral Liq [JOHN] 48457621_1 CDM 0250 RC 00904-5894-30 NDC inpatient 1 UN 8.27 5.38 UMR - ALL PLANS UMR - ALL PLANS 5.79 70 999999999 5.01 8.02 percent of total billed charges 00904-5894-30 - simethicone 40 mg/0.6 mL Oral Liq [JOHN] 48457621_1 CDM 0250 RC 00904-5894-30 NDC inpatient 1 UN 8.27 5.38 SIHO - ALL PLANS SIHO - ALL PLANS 7.44 90 999999999 5.01 8.02 percent of total billed charges 00904-5894-30 - simethicone 40 mg/0.6 mL Oral Liq [JOHN] 48457621_1 CDM 0250 RC 00904-5894-30 NDC inpatient 1 UN 8.27 5.38 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.01 60.55 999999999 5.01 8.02 percent of total billed charges 00904-5894-30 - simethicone 40 mg/0.6 mL Oral Liq [JOHN] 48457621_1 CDM 0250 RC 00904-5894-30 NDC inpatient 1 UN 8.27 5.38 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.01 8.02 00904-5894-30 - simethicone 40 mg/0.6 mL Oral Liq [JOHN] 48457621_1 CDM 0250 RC 00904-5894-30 NDC inpatient 1 UN 8.27 5.38 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.01 8.02 00904-5894-30 - simethicone 40 mg/0.6 mL Oral Liq [JOHN] 48457621_1 CDM 0250 RC 00904-5894-30 NDC inpatient 1 UN 8.27 5.38 ANTHEM HMO ANTHEM HMO 999999999 5.01 8.02 00904-5894-30 - simethicone 40 mg/0.6 mL Oral Liq [JOHN] 48457621_1 CDM 0250 RC 00904-5894-30 NDC inpatient 1 UN 8.27 5.38 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.59 67.6 999999999 5.01 8.02 percent of total billed charges 00904-5894-30 - simethicone 40 mg/0.6 mL Oral Liq [JOHN] 48457621_1 CDM 0250 RC 00904-5894-30 NDC inpatient 1 UN 8.27 5.38 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.01 8.02 00904-5894-30 - simethicone 40 mg/0.6 mL Oral Liq [JOHN] 48457621_1 CDM 0250 RC 00904-5894-30 NDC inpatient 1 UN 8.27 5.38 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.01 8.02 SUCRALFATE 1 GM/10 ML SUSP 48457628_1 CDM 0250 RC 00121-0747-10 NDC inpatient 1 UN 42.28 27.48 AETNA AETNA 33.4 79 999999999 25.6 41.01 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP 48457628_1 CDM 0250 RC 00121-0747-10 NDC inpatient 1 UN 42.28 27.48 SELF PAY DISCOUNT SELF PAY DISCOUNT 27.48 65 999999999 25.6 41.01 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP 48457628_1 CDM 0250 RC 00121-0747-10 NDC inpatient 1 UN 42.28 27.48 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 41.01 97 999999999 25.6 41.01 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP 48457628_1 CDM 0250 RC 00121-0747-10 NDC inpatient 1 UN 42.28 27.48 ENCORE - ALL PLANS ENCORE - ALL PLANS 29.17 69 999999999 25.6 41.01 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP 48457628_1 CDM 0250 RC 00121-0747-10 NDC inpatient 1 UN 42.28 27.48 HUMANA - ALL PLANS HUMANA - ALL PLANS 32.98 78 999999999 25.6 41.01 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP 48457628_1 CDM 0250 RC 00121-0747-10 NDC inpatient 1 UN 42.28 27.48 UMR - ALL PLANS UMR - ALL PLANS 29.6 70 999999999 25.6 41.01 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP 48457628_1 CDM 0250 RC 00121-0747-10 NDC inpatient 1 UN 42.28 27.48 SIHO - ALL PLANS SIHO - ALL PLANS 38.05 90 999999999 25.6 41.01 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP 48457628_1 CDM 0250 RC 00121-0747-10 NDC inpatient 1 UN 42.28 27.48 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 25.6 60.55 999999999 25.6 41.01 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP 48457628_1 CDM 0250 RC 00121-0747-10 NDC inpatient 1 UN 42.28 27.48 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 25.6 41.01 SUCRALFATE 1 GM/10 ML SUSP 48457628_1 CDM 0250 RC 00121-0747-10 NDC inpatient 1 UN 42.28 27.48 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 25.6 41.01 SUCRALFATE 1 GM/10 ML SUSP 48457628_1 CDM 0250 RC 00121-0747-10 NDC inpatient 1 UN 42.28 27.48 ANTHEM HMO ANTHEM HMO 999999999 25.6 41.01 SUCRALFATE 1 GM/10 ML SUSP 48457628_1 CDM 0250 RC 00121-0747-10 NDC inpatient 1 UN 42.28 27.48 CIGNA - ALL PLANS CIGNA - ALL PLANS 28.58 67.6 999999999 25.6 41.01 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP 48457628_1 CDM 0250 RC 00121-0747-10 NDC inpatient 1 UN 42.28 27.48 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 25.6 41.01 SUCRALFATE 1 GM/10 ML SUSP 48457628_1 CDM 0250 RC 00121-0747-10 NDC inpatient 1 UN 42.28 27.48 UHC - ALL PLANS UHC - ALL PLANS 999999999 25.6 41.01 VALPROIC ACID 250 MG/5 ML SOLN 48457630_1 CDM 0250 RC 68094-0193-61 NDC inpatient 1 UN 2.43 1.58 AETNA AETNA 1.92 79 999999999 1.47 2.36 percent of total billed charges VALPROIC ACID 250 MG/5 ML SOLN 48457630_1 CDM 0250 RC 68094-0193-61 NDC inpatient 1 UN 2.43 1.58 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.58 65 999999999 1.47 2.36 percent of total billed charges VALPROIC ACID 250 MG/5 ML SOLN 48457630_1 CDM 0250 RC 68094-0193-61 NDC inpatient 1 UN 2.43 1.58 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.36 97 999999999 1.47 2.36 percent of total billed charges VALPROIC ACID 250 MG/5 ML SOLN 48457630_1 CDM 0250 RC 68094-0193-61 NDC inpatient 1 UN 2.43 1.58 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.68 69 999999999 1.47 2.36 percent of total billed charges VALPROIC ACID 250 MG/5 ML SOLN 48457630_1 CDM 0250 RC 68094-0193-61 NDC inpatient 1 UN 2.43 1.58 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.9 78 999999999 1.47 2.36 percent of total billed charges VALPROIC ACID 250 MG/5 ML SOLN 48457630_1 CDM 0250 RC 68094-0193-61 NDC inpatient 1 UN 2.43 1.58 UMR - ALL PLANS UMR - ALL PLANS 1.7 70 999999999 1.47 2.36 percent of total billed charges VALPROIC ACID 250 MG/5 ML SOLN 48457630_1 CDM 0250 RC 68094-0193-61 NDC inpatient 1 UN 2.43 1.58 SIHO - ALL PLANS SIHO - ALL PLANS 2.19 90 999999999 1.47 2.36 percent of total billed charges VALPROIC ACID 250 MG/5 ML SOLN 48457630_1 CDM 0250 RC 68094-0193-61 NDC inpatient 1 UN 2.43 1.58 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.47 60.55 999999999 1.47 2.36 percent of total billed charges VALPROIC ACID 250 MG/5 ML SOLN 48457630_1 CDM 0250 RC 68094-0193-61 NDC inpatient 1 UN 2.43 1.58 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.47 2.36 VALPROIC ACID 250 MG/5 ML SOLN 48457630_1 CDM 0250 RC 68094-0193-61 NDC inpatient 1 UN 2.43 1.58 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.47 2.36 VALPROIC ACID 250 MG/5 ML SOLN 48457630_1 CDM 0250 RC 68094-0193-61 NDC inpatient 1 UN 2.43 1.58 ANTHEM HMO ANTHEM HMO 999999999 1.47 2.36 VALPROIC ACID 250 MG/5 ML SOLN 48457630_1 CDM 0250 RC 68094-0193-61 NDC inpatient 1 UN 2.43 1.58 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.64 67.6 999999999 1.47 2.36 percent of total billed charges VALPROIC ACID 250 MG/5 ML SOLN 48457630_1 CDM 0250 RC 68094-0193-61 NDC inpatient 1 UN 2.43 1.58 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.47 2.36 VALPROIC ACID 250 MG/5 ML SOLN 48457630_1 CDM 0250 RC 68094-0193-61 NDC inpatient 1 UN 2.43 1.58 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.47 2.36 ACETYLCYSTEINE 20% VIAL 48457649_1 CDM 0250 RC 63323-0692-10 NDC inpatient 1 UN 54.06 35.14 AETNA AETNA 42.71 79 999999999 32.73 52.44 percent of total billed charges ACETYLCYSTEINE 20% VIAL 48457649_1 CDM 0250 RC 63323-0692-10 NDC inpatient 1 UN 54.06 35.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 35.14 65 999999999 32.73 52.44 percent of total billed charges ACETYLCYSTEINE 20% VIAL 48457649_1 CDM 0250 RC 63323-0692-10 NDC inpatient 1 UN 54.06 35.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 52.44 97 999999999 32.73 52.44 percent of total billed charges ACETYLCYSTEINE 20% VIAL 48457649_1 CDM 0250 RC 63323-0692-10 NDC inpatient 1 UN 54.06 35.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 37.3 69 999999999 32.73 52.44 percent of total billed charges ACETYLCYSTEINE 20% VIAL 48457649_1 CDM 0250 RC 63323-0692-10 NDC inpatient 1 UN 54.06 35.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 42.17 78 999999999 32.73 52.44 percent of total billed charges ACETYLCYSTEINE 20% VIAL 48457649_1 CDM 0250 RC 63323-0692-10 NDC inpatient 1 UN 54.06 35.14 UMR - ALL PLANS UMR - ALL PLANS 37.84 70 999999999 32.73 52.44 percent of total billed charges ACETYLCYSTEINE 20% VIAL 48457649_1 CDM 0250 RC 63323-0692-10 NDC inpatient 1 UN 54.06 35.14 SIHO - ALL PLANS SIHO - ALL PLANS 48.65 90 999999999 32.73 52.44 percent of total billed charges ACETYLCYSTEINE 20% VIAL 48457649_1 CDM 0250 RC 63323-0692-10 NDC inpatient 1 UN 54.06 35.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.73 60.55 999999999 32.73 52.44 percent of total billed charges ACETYLCYSTEINE 20% VIAL 48457649_1 CDM 0250 RC 63323-0692-10 NDC inpatient 1 UN 54.06 35.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.73 52.44 ACETYLCYSTEINE 20% VIAL 48457649_1 CDM 0250 RC 63323-0692-10 NDC inpatient 1 UN 54.06 35.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.73 52.44 ACETYLCYSTEINE 20% VIAL 48457649_1 CDM 0250 RC 63323-0692-10 NDC inpatient 1 UN 54.06 35.14 ANTHEM HMO ANTHEM HMO 999999999 32.73 52.44 ACETYLCYSTEINE 20% VIAL 48457649_1 CDM 0250 RC 63323-0692-10 NDC inpatient 1 UN 54.06 35.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 36.54 67.6 999999999 32.73 52.44 percent of total billed charges ACETYLCYSTEINE 20% VIAL 48457649_1 CDM 0250 RC 63323-0692-10 NDC inpatient 1 UN 54.06 35.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.73 52.44 ACETYLCYSTEINE 20% VIAL 48457649_1 CDM 0250 RC 63323-0692-10 NDC inpatient 1 UN 54.06 35.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.73 52.44 COLESTIPOL HCL 1 GM TABLET 48457662_1 CDM 0250 RC 59762-0450-01 NDC inpatient 1 UN 3.35 2.18 AETNA AETNA 2.65 79 999999999 2.03 3.25 percent of total billed charges COLESTIPOL HCL 1 GM TABLET 48457662_1 CDM 0250 RC 59762-0450-01 NDC inpatient 1 UN 3.35 2.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.18 65 999999999 2.03 3.25 percent of total billed charges COLESTIPOL HCL 1 GM TABLET 48457662_1 CDM 0250 RC 59762-0450-01 NDC inpatient 1 UN 3.35 2.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.25 97 999999999 2.03 3.25 percent of total billed charges COLESTIPOL HCL 1 GM TABLET 48457662_1 CDM 0250 RC 59762-0450-01 NDC inpatient 1 UN 3.35 2.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.31 69 999999999 2.03 3.25 percent of total billed charges COLESTIPOL HCL 1 GM TABLET 48457662_1 CDM 0250 RC 59762-0450-01 NDC inpatient 1 UN 3.35 2.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.61 78 999999999 2.03 3.25 percent of total billed charges COLESTIPOL HCL 1 GM TABLET 48457662_1 CDM 0250 RC 59762-0450-01 NDC inpatient 1 UN 3.35 2.18 UMR - ALL PLANS UMR - ALL PLANS 2.35 70 999999999 2.03 3.25 percent of total billed charges COLESTIPOL HCL 1 GM TABLET 48457662_1 CDM 0250 RC 59762-0450-01 NDC inpatient 1 UN 3.35 2.18 SIHO - ALL PLANS SIHO - ALL PLANS 3.02 90 999999999 2.03 3.25 percent of total billed charges COLESTIPOL HCL 1 GM TABLET 48457662_1 CDM 0250 RC 59762-0450-01 NDC inpatient 1 UN 3.35 2.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.03 60.55 999999999 2.03 3.25 percent of total billed charges COLESTIPOL HCL 1 GM TABLET 48457662_1 CDM 0250 RC 59762-0450-01 NDC inpatient 1 UN 3.35 2.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.03 3.25 COLESTIPOL HCL 1 GM TABLET 48457662_1 CDM 0250 RC 59762-0450-01 NDC inpatient 1 UN 3.35 2.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.03 3.25 COLESTIPOL HCL 1 GM TABLET 48457662_1 CDM 0250 RC 59762-0450-01 NDC inpatient 1 UN 3.35 2.18 ANTHEM HMO ANTHEM HMO 999999999 2.03 3.25 COLESTIPOL HCL 1 GM TABLET 48457662_1 CDM 0250 RC 59762-0450-01 NDC inpatient 1 UN 3.35 2.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.26 67.6 999999999 2.03 3.25 percent of total billed charges COLESTIPOL HCL 1 GM TABLET 48457662_1 CDM 0250 RC 59762-0450-01 NDC inpatient 1 UN 3.35 2.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.03 3.25 COLESTIPOL HCL 1 GM TABLET 48457662_1 CDM 0250 RC 59762-0450-01 NDC inpatient 1 UN 3.35 2.18 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.03 3.25 IPRATROPIUM 0.03% SPRAY 48457678_1 CDM 0250 RC 00054-0045-44 NDC inpatient 1 UN 115.33 74.96 AETNA AETNA 91.11 79 999999999 69.83 111.87 percent of total billed charges IPRATROPIUM 0.03% SPRAY 48457678_1 CDM 0250 RC 00054-0045-44 NDC inpatient 1 UN 115.33 74.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.96 65 999999999 69.83 111.87 percent of total billed charges IPRATROPIUM 0.03% SPRAY 48457678_1 CDM 0250 RC 00054-0045-44 NDC inpatient 1 UN 115.33 74.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 111.87 97 999999999 69.83 111.87 percent of total billed charges IPRATROPIUM 0.03% SPRAY 48457678_1 CDM 0250 RC 00054-0045-44 NDC inpatient 1 UN 115.33 74.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 79.58 69 999999999 69.83 111.87 percent of total billed charges IPRATROPIUM 0.03% SPRAY 48457678_1 CDM 0250 RC 00054-0045-44 NDC inpatient 1 UN 115.33 74.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 89.96 78 999999999 69.83 111.87 percent of total billed charges IPRATROPIUM 0.03% SPRAY 48457678_1 CDM 0250 RC 00054-0045-44 NDC inpatient 1 UN 115.33 74.96 UMR - ALL PLANS UMR - ALL PLANS 80.73 70 999999999 69.83 111.87 percent of total billed charges IPRATROPIUM 0.03% SPRAY 48457678_1 CDM 0250 RC 00054-0045-44 NDC inpatient 1 UN 115.33 74.96 SIHO - ALL PLANS SIHO - ALL PLANS 103.8 90 999999999 69.83 111.87 percent of total billed charges IPRATROPIUM 0.03% SPRAY 48457678_1 CDM 0250 RC 00054-0045-44 NDC inpatient 1 UN 115.33 74.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.83 60.55 999999999 69.83 111.87 percent of total billed charges IPRATROPIUM 0.03% SPRAY 48457678_1 CDM 0250 RC 00054-0045-44 NDC inpatient 1 UN 115.33 74.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.83 111.87 IPRATROPIUM 0.03% SPRAY 48457678_1 CDM 0250 RC 00054-0045-44 NDC inpatient 1 UN 115.33 74.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.83 111.87 IPRATROPIUM 0.03% SPRAY 48457678_1 CDM 0250 RC 00054-0045-44 NDC inpatient 1 UN 115.33 74.96 ANTHEM HMO ANTHEM HMO 999999999 69.83 111.87 IPRATROPIUM 0.03% SPRAY 48457678_1 CDM 0250 RC 00054-0045-44 NDC inpatient 1 UN 115.33 74.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.96 67.6 999999999 69.83 111.87 percent of total billed charges IPRATROPIUM 0.03% SPRAY 48457678_1 CDM 0250 RC 00054-0045-44 NDC inpatient 1 UN 115.33 74.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.83 111.87 IPRATROPIUM 0.03% SPRAY 48457678_1 CDM 0250 RC 00054-0045-44 NDC inpatient 1 UN 115.33 74.96 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.83 111.87 "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48457690_1 CDM 0250 RC 17478-0171-30 NDC J7614 HCPCS inpatient 1 UN 12.05 7.83 AETNA AETNA 9.52 79 999999999 7.3 11.69 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48457690_1 CDM 0250 RC 17478-0171-30 NDC J7614 HCPCS inpatient 1 UN 12.05 7.83 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.83 65 999999999 7.3 11.69 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48457690_1 CDM 0250 RC 17478-0171-30 NDC J7614 HCPCS inpatient 1 UN 12.05 7.83 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11.69 97 999999999 7.3 11.69 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48457690_1 CDM 0250 RC 17478-0171-30 NDC J7614 HCPCS inpatient 1 UN 12.05 7.83 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.31 69 999999999 7.3 11.69 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48457690_1 CDM 0250 RC 17478-0171-30 NDC J7614 HCPCS inpatient 1 UN 12.05 7.83 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.4 78 999999999 7.3 11.69 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48457690_1 CDM 0250 RC 17478-0171-30 NDC J7614 HCPCS inpatient 1 UN 12.05 7.83 UMR - ALL PLANS UMR - ALL PLANS 8.44 70 999999999 7.3 11.69 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48457690_1 CDM 0250 RC 17478-0171-30 NDC J7614 HCPCS inpatient 1 UN 12.05 7.83 SIHO - ALL PLANS SIHO - ALL PLANS 10.85 90 999999999 7.3 11.69 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48457690_1 CDM 0250 RC 17478-0171-30 NDC J7614 HCPCS inpatient 1 UN 12.05 7.83 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.3 60.55 999999999 7.3 11.69 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48457690_1 CDM 0250 RC 17478-0171-30 NDC J7614 HCPCS inpatient 1 UN 12.05 7.83 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.3 11.69 "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48457690_1 CDM 0250 RC 17478-0171-30 NDC J7614 HCPCS inpatient 1 UN 12.05 7.83 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.3 11.69 "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48457690_1 CDM 0250 RC 17478-0171-30 NDC J7614 HCPCS inpatient 1 UN 12.05 7.83 ANTHEM HMO ANTHEM HMO 999999999 7.3 11.69 "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48457690_1 CDM 0250 RC 17478-0171-30 NDC J7614 HCPCS inpatient 1 UN 12.05 7.83 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.15 67.6 999999999 7.3 11.69 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48457690_1 CDM 0250 RC 17478-0171-30 NDC J7614 HCPCS inpatient 1 UN 12.05 7.83 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.3 11.69 "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48457690_1 CDM 0250 RC 17478-0171-30 NDC J7614 HCPCS inpatient 1 UN 12.05 7.83 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.3 11.69 MUCINEX ER 600 MG TABLET 48457721_1 CDM 0250 RC 68084-0572-01 NDC inpatient 1 UN 2.13 1.38 AETNA AETNA 1.68 79 999999999 1.29 2.07 percent of total billed charges MUCINEX ER 600 MG TABLET 48457721_1 CDM 0250 RC 68084-0572-01 NDC inpatient 1 UN 2.13 1.38 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.38 65 999999999 1.29 2.07 percent of total billed charges MUCINEX ER 600 MG TABLET 48457721_1 CDM 0250 RC 68084-0572-01 NDC inpatient 1 UN 2.13 1.38 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.07 97 999999999 1.29 2.07 percent of total billed charges MUCINEX ER 600 MG TABLET 48457721_1 CDM 0250 RC 68084-0572-01 NDC inpatient 1 UN 2.13 1.38 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.47 69 999999999 1.29 2.07 percent of total billed charges MUCINEX ER 600 MG TABLET 48457721_1 CDM 0250 RC 68084-0572-01 NDC inpatient 1 UN 2.13 1.38 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.66 78 999999999 1.29 2.07 percent of total billed charges MUCINEX ER 600 MG TABLET 48457721_1 CDM 0250 RC 68084-0572-01 NDC inpatient 1 UN 2.13 1.38 UMR - ALL PLANS UMR - ALL PLANS 1.49 70 999999999 1.29 2.07 percent of total billed charges MUCINEX ER 600 MG TABLET 48457721_1 CDM 0250 RC 68084-0572-01 NDC inpatient 1 UN 2.13 1.38 SIHO - ALL PLANS SIHO - ALL PLANS 1.92 90 999999999 1.29 2.07 percent of total billed charges MUCINEX ER 600 MG TABLET 48457721_1 CDM 0250 RC 68084-0572-01 NDC inpatient 1 UN 2.13 1.38 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.29 60.55 999999999 1.29 2.07 percent of total billed charges MUCINEX ER 600 MG TABLET 48457721_1 CDM 0250 RC 68084-0572-01 NDC inpatient 1 UN 2.13 1.38 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.29 2.07 MUCINEX ER 600 MG TABLET 48457721_1 CDM 0250 RC 68084-0572-01 NDC inpatient 1 UN 2.13 1.38 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.29 2.07 MUCINEX ER 600 MG TABLET 48457721_1 CDM 0250 RC 68084-0572-01 NDC inpatient 1 UN 2.13 1.38 ANTHEM HMO ANTHEM HMO 999999999 1.29 2.07 MUCINEX ER 600 MG TABLET 48457721_1 CDM 0250 RC 68084-0572-01 NDC inpatient 1 UN 2.13 1.38 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.44 67.6 999999999 1.29 2.07 percent of total billed charges MUCINEX ER 600 MG TABLET 48457721_1 CDM 0250 RC 68084-0572-01 NDC inpatient 1 UN 2.13 1.38 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.29 2.07 MUCINEX ER 600 MG TABLET 48457721_1 CDM 0250 RC 68084-0572-01 NDC inpatient 1 UN 2.13 1.38 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.29 2.07 ALLOPURINOL 100 MG TABLET 48457734_1 CDM 0250 RC 51079-0205-20 NDC inpatient 1 UN 1.83 1.19 AETNA AETNA 1.45 79 999999999 1.11 1.78 percent of total billed charges ALLOPURINOL 100 MG TABLET 48457734_1 CDM 0250 RC 51079-0205-20 NDC inpatient 1 UN 1.83 1.19 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.19 65 999999999 1.11 1.78 percent of total billed charges ALLOPURINOL 100 MG TABLET 48457734_1 CDM 0250 RC 51079-0205-20 NDC inpatient 1 UN 1.83 1.19 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.78 97 999999999 1.11 1.78 percent of total billed charges ALLOPURINOL 100 MG TABLET 48457734_1 CDM 0250 RC 51079-0205-20 NDC inpatient 1 UN 1.83 1.19 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.26 69 999999999 1.11 1.78 percent of total billed charges ALLOPURINOL 100 MG TABLET 48457734_1 CDM 0250 RC 51079-0205-20 NDC inpatient 1 UN 1.83 1.19 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.43 78 999999999 1.11 1.78 percent of total billed charges ALLOPURINOL 100 MG TABLET 48457734_1 CDM 0250 RC 51079-0205-20 NDC inpatient 1 UN 1.83 1.19 UMR - ALL PLANS UMR - ALL PLANS 1.28 70 999999999 1.11 1.78 percent of total billed charges ALLOPURINOL 100 MG TABLET 48457734_1 CDM 0250 RC 51079-0205-20 NDC inpatient 1 UN 1.83 1.19 SIHO - ALL PLANS SIHO - ALL PLANS 1.65 90 999999999 1.11 1.78 percent of total billed charges ALLOPURINOL 100 MG TABLET 48457734_1 CDM 0250 RC 51079-0205-20 NDC inpatient 1 UN 1.83 1.19 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.11 60.55 999999999 1.11 1.78 percent of total billed charges ALLOPURINOL 100 MG TABLET 48457734_1 CDM 0250 RC 51079-0205-20 NDC inpatient 1 UN 1.83 1.19 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.11 1.78 ALLOPURINOL 100 MG TABLET 48457734_1 CDM 0250 RC 51079-0205-20 NDC inpatient 1 UN 1.83 1.19 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.11 1.78 ALLOPURINOL 100 MG TABLET 48457734_1 CDM 0250 RC 51079-0205-20 NDC inpatient 1 UN 1.83 1.19 ANTHEM HMO ANTHEM HMO 999999999 1.11 1.78 ALLOPURINOL 100 MG TABLET 48457734_1 CDM 0250 RC 51079-0205-20 NDC inpatient 1 UN 1.83 1.19 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.24 67.6 999999999 1.11 1.78 percent of total billed charges ALLOPURINOL 100 MG TABLET 48457734_1 CDM 0250 RC 51079-0205-20 NDC inpatient 1 UN 1.83 1.19 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.11 1.78 ALLOPURINOL 100 MG TABLET 48457734_1 CDM 0250 RC 51079-0205-20 NDC inpatient 1 UN 1.83 1.19 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.11 1.78 DICLOFENAC SOD DR 75 MG TAB 48457744_1 CDM 0250 RC 68001-0281-06 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges DICLOFENAC SOD DR 75 MG TAB 48457744_1 CDM 0250 RC 68001-0281-06 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges DICLOFENAC SOD DR 75 MG TAB 48457744_1 CDM 0250 RC 68001-0281-06 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges DICLOFENAC SOD DR 75 MG TAB 48457744_1 CDM 0250 RC 68001-0281-06 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges DICLOFENAC SOD DR 75 MG TAB 48457744_1 CDM 0250 RC 68001-0281-06 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges DICLOFENAC SOD DR 75 MG TAB 48457744_1 CDM 0250 RC 68001-0281-06 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges DICLOFENAC SOD DR 75 MG TAB 48457744_1 CDM 0250 RC 68001-0281-06 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges DICLOFENAC SOD DR 75 MG TAB 48457744_1 CDM 0250 RC 68001-0281-06 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges DICLOFENAC SOD DR 75 MG TAB 48457744_1 CDM 0250 RC 68001-0281-06 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 DICLOFENAC SOD DR 75 MG TAB 48457744_1 CDM 0250 RC 68001-0281-06 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 DICLOFENAC SOD DR 75 MG TAB 48457744_1 CDM 0250 RC 68001-0281-06 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 DICLOFENAC SOD DR 75 MG TAB 48457744_1 CDM 0250 RC 68001-0281-06 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges DICLOFENAC SOD DR 75 MG TAB 48457744_1 CDM 0250 RC 68001-0281-06 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 DICLOFENAC SOD DR 75 MG TAB 48457744_1 CDM 0250 RC 68001-0281-06 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 68084-0762-01 - gabapentin 300 mg Cap [JOHN] 48457761_1 CDM 0250 RC 68084-0762-01 NDC inpatient 1 UN 1.79 1.16 AETNA AETNA 1.41 79 999999999 1.08 1.74 percent of total billed charges 68084-0762-01 - gabapentin 300 mg Cap [JOHN] 48457761_1 CDM 0250 RC 68084-0762-01 NDC inpatient 1 UN 1.79 1.16 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.16 65 999999999 1.08 1.74 percent of total billed charges 68084-0762-01 - gabapentin 300 mg Cap [JOHN] 48457761_1 CDM 0250 RC 68084-0762-01 NDC inpatient 1 UN 1.79 1.16 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.74 97 999999999 1.08 1.74 percent of total billed charges 68084-0762-01 - gabapentin 300 mg Cap [JOHN] 48457761_1 CDM 0250 RC 68084-0762-01 NDC inpatient 1 UN 1.79 1.16 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.24 69 999999999 1.08 1.74 percent of total billed charges 68084-0762-01 - gabapentin 300 mg Cap [JOHN] 48457761_1 CDM 0250 RC 68084-0762-01 NDC inpatient 1 UN 1.79 1.16 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.4 78 999999999 1.08 1.74 percent of total billed charges 68084-0762-01 - gabapentin 300 mg Cap [JOHN] 48457761_1 CDM 0250 RC 68084-0762-01 NDC inpatient 1 UN 1.79 1.16 UMR - ALL PLANS UMR - ALL PLANS 1.25 70 999999999 1.08 1.74 percent of total billed charges 68084-0762-01 - gabapentin 300 mg Cap [JOHN] 48457761_1 CDM 0250 RC 68084-0762-01 NDC inpatient 1 UN 1.79 1.16 SIHO - ALL PLANS SIHO - ALL PLANS 1.61 90 999999999 1.08 1.74 percent of total billed charges 68084-0762-01 - gabapentin 300 mg Cap [JOHN] 48457761_1 CDM 0250 RC 68084-0762-01 NDC inpatient 1 UN 1.79 1.16 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.08 60.55 999999999 1.08 1.74 percent of total billed charges 68084-0762-01 - gabapentin 300 mg Cap [JOHN] 48457761_1 CDM 0250 RC 68084-0762-01 NDC inpatient 1 UN 1.79 1.16 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.08 1.74 68084-0762-01 - gabapentin 300 mg Cap [JOHN] 48457761_1 CDM 0250 RC 68084-0762-01 NDC inpatient 1 UN 1.79 1.16 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.08 1.74 68084-0762-01 - gabapentin 300 mg Cap [JOHN] 48457761_1 CDM 0250 RC 68084-0762-01 NDC inpatient 1 UN 1.79 1.16 ANTHEM HMO ANTHEM HMO 999999999 1.08 1.74 68084-0762-01 - gabapentin 300 mg Cap [JOHN] 48457761_1 CDM 0250 RC 68084-0762-01 NDC inpatient 1 UN 1.79 1.16 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.21 67.6 999999999 1.08 1.74 percent of total billed charges 68084-0762-01 - gabapentin 300 mg Cap [JOHN] 48457761_1 CDM 0250 RC 68084-0762-01 NDC inpatient 1 UN 1.79 1.16 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.08 1.74 68084-0762-01 - gabapentin 300 mg Cap [JOHN] 48457761_1 CDM 0250 RC 68084-0762-01 NDC inpatient 1 UN 1.79 1.16 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.08 1.74 ANASTROZOLE 1 MG TABLET 48457765_1 CDM 0250 RC 68001-0155-04 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ANASTROZOLE 1 MG TABLET 48457765_1 CDM 0250 RC 68001-0155-04 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ANASTROZOLE 1 MG TABLET 48457765_1 CDM 0250 RC 68001-0155-04 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ANASTROZOLE 1 MG TABLET 48457765_1 CDM 0250 RC 68001-0155-04 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ANASTROZOLE 1 MG TABLET 48457765_1 CDM 0250 RC 68001-0155-04 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ANASTROZOLE 1 MG TABLET 48457765_1 CDM 0250 RC 68001-0155-04 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ANASTROZOLE 1 MG TABLET 48457765_1 CDM 0250 RC 68001-0155-04 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ANASTROZOLE 1 MG TABLET 48457765_1 CDM 0250 RC 68001-0155-04 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ANASTROZOLE 1 MG TABLET 48457765_1 CDM 0250 RC 68001-0155-04 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ANASTROZOLE 1 MG TABLET 48457765_1 CDM 0250 RC 68001-0155-04 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ANASTROZOLE 1 MG TABLET 48457765_1 CDM 0250 RC 68001-0155-04 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ANASTROZOLE 1 MG TABLET 48457765_1 CDM 0250 RC 68001-0155-04 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges ANASTROZOLE 1 MG TABLET 48457765_1 CDM 0250 RC 68001-0155-04 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ANASTROZOLE 1 MG TABLET 48457765_1 CDM 0250 RC 68001-0155-04 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CLOPIDOGREL 75 MG TABLET 48457770_1 CDM 0250 RC 68084-0536-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CLOPIDOGREL 75 MG TABLET 48457770_1 CDM 0250 RC 68084-0536-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CLOPIDOGREL 75 MG TABLET 48457770_1 CDM 0250 RC 68084-0536-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CLOPIDOGREL 75 MG TABLET 48457770_1 CDM 0250 RC 68084-0536-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CLOPIDOGREL 75 MG TABLET 48457770_1 CDM 0250 RC 68084-0536-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CLOPIDOGREL 75 MG TABLET 48457770_1 CDM 0250 RC 68084-0536-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CLOPIDOGREL 75 MG TABLET 48457770_1 CDM 0250 RC 68084-0536-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CLOPIDOGREL 75 MG TABLET 48457770_1 CDM 0250 RC 68084-0536-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CLOPIDOGREL 75 MG TABLET 48457770_1 CDM 0250 RC 68084-0536-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CLOPIDOGREL 75 MG TABLET 48457770_1 CDM 0250 RC 68084-0536-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CLOPIDOGREL 75 MG TABLET 48457770_1 CDM 0250 RC 68084-0536-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CLOPIDOGREL 75 MG TABLET 48457770_1 CDM 0250 RC 68084-0536-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CLOPIDOGREL 75 MG TABLET 48457770_1 CDM 0250 RC 68084-0536-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CLOPIDOGREL 75 MG TABLET 48457770_1 CDM 0250 RC 68084-0536-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 HYSEPT 0.50% SOLUTION 48457776_1 CDM 0250 RC 39328-0062-50 NDC inpatient 1 UN 47.7 31.01 AETNA AETNA 37.68 79 999999999 28.88 46.27 percent of total billed charges HYSEPT 0.50% SOLUTION 48457776_1 CDM 0250 RC 39328-0062-50 NDC inpatient 1 UN 47.7 31.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.01 65 999999999 28.88 46.27 percent of total billed charges HYSEPT 0.50% SOLUTION 48457776_1 CDM 0250 RC 39328-0062-50 NDC inpatient 1 UN 47.7 31.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 46.27 97 999999999 28.88 46.27 percent of total billed charges HYSEPT 0.50% SOLUTION 48457776_1 CDM 0250 RC 39328-0062-50 NDC inpatient 1 UN 47.7 31.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 32.91 69 999999999 28.88 46.27 percent of total billed charges HYSEPT 0.50% SOLUTION 48457776_1 CDM 0250 RC 39328-0062-50 NDC inpatient 1 UN 47.7 31.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 37.21 78 999999999 28.88 46.27 percent of total billed charges HYSEPT 0.50% SOLUTION 48457776_1 CDM 0250 RC 39328-0062-50 NDC inpatient 1 UN 47.7 31.01 UMR - ALL PLANS UMR - ALL PLANS 33.39 70 999999999 28.88 46.27 percent of total billed charges HYSEPT 0.50% SOLUTION 48457776_1 CDM 0250 RC 39328-0062-50 NDC inpatient 1 UN 47.7 31.01 SIHO - ALL PLANS SIHO - ALL PLANS 42.93 90 999999999 28.88 46.27 percent of total billed charges HYSEPT 0.50% SOLUTION 48457776_1 CDM 0250 RC 39328-0062-50 NDC inpatient 1 UN 47.7 31.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 28.88 60.55 999999999 28.88 46.27 percent of total billed charges HYSEPT 0.50% SOLUTION 48457776_1 CDM 0250 RC 39328-0062-50 NDC inpatient 1 UN 47.7 31.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 28.88 46.27 HYSEPT 0.50% SOLUTION 48457776_1 CDM 0250 RC 39328-0062-50 NDC inpatient 1 UN 47.7 31.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 28.88 46.27 HYSEPT 0.50% SOLUTION 48457776_1 CDM 0250 RC 39328-0062-50 NDC inpatient 1 UN 47.7 31.01 ANTHEM HMO ANTHEM HMO 999999999 28.88 46.27 HYSEPT 0.50% SOLUTION 48457776_1 CDM 0250 RC 39328-0062-50 NDC inpatient 1 UN 47.7 31.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 32.25 67.6 999999999 28.88 46.27 percent of total billed charges HYSEPT 0.50% SOLUTION 48457776_1 CDM 0250 RC 39328-0062-50 NDC inpatient 1 UN 47.7 31.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 28.88 46.27 HYSEPT 0.50% SOLUTION 48457776_1 CDM 0250 RC 39328-0062-50 NDC inpatient 1 UN 47.7 31.01 UHC - ALL PLANS UHC - ALL PLANS 999999999 28.88 46.27 CITALOPRAM HBR 20 MG TABLET 48457777_1 CDM 0250 RC 00904-6085-61 NDC inpatient 1 UN 1.3 0.85 AETNA AETNA 1.03 79 999999999 0.79 1.26 percent of total billed charges CITALOPRAM HBR 20 MG TABLET 48457777_1 CDM 0250 RC 00904-6085-61 NDC inpatient 1 UN 1.3 0.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.85 65 999999999 0.79 1.26 percent of total billed charges CITALOPRAM HBR 20 MG TABLET 48457777_1 CDM 0250 RC 00904-6085-61 NDC inpatient 1 UN 1.3 0.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.26 97 999999999 0.79 1.26 percent of total billed charges CITALOPRAM HBR 20 MG TABLET 48457777_1 CDM 0250 RC 00904-6085-61 NDC inpatient 1 UN 1.3 0.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.9 69 999999999 0.79 1.26 percent of total billed charges CITALOPRAM HBR 20 MG TABLET 48457777_1 CDM 0250 RC 00904-6085-61 NDC inpatient 1 UN 1.3 0.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.01 78 999999999 0.79 1.26 percent of total billed charges CITALOPRAM HBR 20 MG TABLET 48457777_1 CDM 0250 RC 00904-6085-61 NDC inpatient 1 UN 1.3 0.85 UMR - ALL PLANS UMR - ALL PLANS 0.91 70 999999999 0.79 1.26 percent of total billed charges CITALOPRAM HBR 20 MG TABLET 48457777_1 CDM 0250 RC 00904-6085-61 NDC inpatient 1 UN 1.3 0.85 SIHO - ALL PLANS SIHO - ALL PLANS 1.17 90 999999999 0.79 1.26 percent of total billed charges CITALOPRAM HBR 20 MG TABLET 48457777_1 CDM 0250 RC 00904-6085-61 NDC inpatient 1 UN 1.3 0.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.79 60.55 999999999 0.79 1.26 percent of total billed charges CITALOPRAM HBR 20 MG TABLET 48457777_1 CDM 0250 RC 00904-6085-61 NDC inpatient 1 UN 1.3 0.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.79 1.26 CITALOPRAM HBR 20 MG TABLET 48457777_1 CDM 0250 RC 00904-6085-61 NDC inpatient 1 UN 1.3 0.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.79 1.26 CITALOPRAM HBR 20 MG TABLET 48457777_1 CDM 0250 RC 00904-6085-61 NDC inpatient 1 UN 1.3 0.85 ANTHEM HMO ANTHEM HMO 999999999 0.79 1.26 CITALOPRAM HBR 20 MG TABLET 48457777_1 CDM 0250 RC 00904-6085-61 NDC inpatient 1 UN 1.3 0.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.88 67.6 999999999 0.79 1.26 percent of total billed charges CITALOPRAM HBR 20 MG TABLET 48457777_1 CDM 0250 RC 00904-6085-61 NDC inpatient 1 UN 1.3 0.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.79 1.26 CITALOPRAM HBR 20 MG TABLET 48457777_1 CDM 0250 RC 00904-6085-61 NDC inpatient 1 UN 1.3 0.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.79 1.26 63739-0079-10 - dilTIAZem 30 mg Tab [JOHN] 48457778_1 CDM 0250 RC 63739-0079-10 NDC inpatient 1 UN 1.28 0.83 AETNA AETNA 1.01 79 999999999 0.78 1.24 percent of total billed charges 63739-0079-10 - dilTIAZem 30 mg Tab [JOHN] 48457778_1 CDM 0250 RC 63739-0079-10 NDC inpatient 1 UN 1.28 0.83 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.83 65 999999999 0.78 1.24 percent of total billed charges 63739-0079-10 - dilTIAZem 30 mg Tab [JOHN] 48457778_1 CDM 0250 RC 63739-0079-10 NDC inpatient 1 UN 1.28 0.83 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.24 97 999999999 0.78 1.24 percent of total billed charges 63739-0079-10 - dilTIAZem 30 mg Tab [JOHN] 48457778_1 CDM 0250 RC 63739-0079-10 NDC inpatient 1 UN 1.28 0.83 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.88 69 999999999 0.78 1.24 percent of total billed charges 63739-0079-10 - dilTIAZem 30 mg Tab [JOHN] 48457778_1 CDM 0250 RC 63739-0079-10 NDC inpatient 1 UN 1.28 0.83 HUMANA - ALL PLANS HUMANA - ALL PLANS 1 78 999999999 0.78 1.24 percent of total billed charges 63739-0079-10 - dilTIAZem 30 mg Tab [JOHN] 48457778_1 CDM 0250 RC 63739-0079-10 NDC inpatient 1 UN 1.28 0.83 UMR - ALL PLANS UMR - ALL PLANS 0.9 70 999999999 0.78 1.24 percent of total billed charges 63739-0079-10 - dilTIAZem 30 mg Tab [JOHN] 48457778_1 CDM 0250 RC 63739-0079-10 NDC inpatient 1 UN 1.28 0.83 SIHO - ALL PLANS SIHO - ALL PLANS 1.15 90 999999999 0.78 1.24 percent of total billed charges 63739-0079-10 - dilTIAZem 30 mg Tab [JOHN] 48457778_1 CDM 0250 RC 63739-0079-10 NDC inpatient 1 UN 1.28 0.83 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.78 60.55 999999999 0.78 1.24 percent of total billed charges 63739-0079-10 - dilTIAZem 30 mg Tab [JOHN] 48457778_1 CDM 0250 RC 63739-0079-10 NDC inpatient 1 UN 1.28 0.83 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.78 1.24 63739-0079-10 - dilTIAZem 30 mg Tab [JOHN] 48457778_1 CDM 0250 RC 63739-0079-10 NDC inpatient 1 UN 1.28 0.83 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.78 1.24 63739-0079-10 - dilTIAZem 30 mg Tab [JOHN] 48457778_1 CDM 0250 RC 63739-0079-10 NDC inpatient 1 UN 1.28 0.83 ANTHEM HMO ANTHEM HMO 999999999 0.78 1.24 63739-0079-10 - dilTIAZem 30 mg Tab [JOHN] 48457778_1 CDM 0250 RC 63739-0079-10 NDC inpatient 1 UN 1.28 0.83 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.87 67.6 999999999 0.78 1.24 percent of total billed charges 63739-0079-10 - dilTIAZem 30 mg Tab [JOHN] 48457778_1 CDM 0250 RC 63739-0079-10 NDC inpatient 1 UN 1.28 0.83 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.78 1.24 63739-0079-10 - dilTIAZem 30 mg Tab [JOHN] 48457778_1 CDM 0250 RC 63739-0079-10 NDC inpatient 1 UN 1.28 0.83 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.78 1.24 AMOX-CLAV 500-125 MG TABLET 48457780_1 CDM 0250 RC 65862-0502-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges AMOX-CLAV 500-125 MG TABLET 48457780_1 CDM 0250 RC 65862-0502-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges AMOX-CLAV 500-125 MG TABLET 48457780_1 CDM 0250 RC 65862-0502-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges AMOX-CLAV 500-125 MG TABLET 48457780_1 CDM 0250 RC 65862-0502-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges AMOX-CLAV 500-125 MG TABLET 48457780_1 CDM 0250 RC 65862-0502-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges AMOX-CLAV 500-125 MG TABLET 48457780_1 CDM 0250 RC 65862-0502-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges AMOX-CLAV 500-125 MG TABLET 48457780_1 CDM 0250 RC 65862-0502-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges AMOX-CLAV 500-125 MG TABLET 48457780_1 CDM 0250 RC 65862-0502-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges AMOX-CLAV 500-125 MG TABLET 48457780_1 CDM 0250 RC 65862-0502-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 AMOX-CLAV 500-125 MG TABLET 48457780_1 CDM 0250 RC 65862-0502-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 AMOX-CLAV 500-125 MG TABLET 48457780_1 CDM 0250 RC 65862-0502-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 AMOX-CLAV 500-125 MG TABLET 48457780_1 CDM 0250 RC 65862-0502-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges AMOX-CLAV 500-125 MG TABLET 48457780_1 CDM 0250 RC 65862-0502-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 AMOX-CLAV 500-125 MG TABLET 48457780_1 CDM 0250 RC 65862-0502-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 FLUCONAZOLE 200 MG TABLET 48457781_1 CDM 0250 RC 68001-0254-04 NDC inpatient 1 UN 2.13 1.38 AETNA AETNA 1.68 79 999999999 1.29 2.07 percent of total billed charges FLUCONAZOLE 200 MG TABLET 48457781_1 CDM 0250 RC 68001-0254-04 NDC inpatient 1 UN 2.13 1.38 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.38 65 999999999 1.29 2.07 percent of total billed charges FLUCONAZOLE 200 MG TABLET 48457781_1 CDM 0250 RC 68001-0254-04 NDC inpatient 1 UN 2.13 1.38 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.07 97 999999999 1.29 2.07 percent of total billed charges FLUCONAZOLE 200 MG TABLET 48457781_1 CDM 0250 RC 68001-0254-04 NDC inpatient 1 UN 2.13 1.38 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.47 69 999999999 1.29 2.07 percent of total billed charges FLUCONAZOLE 200 MG TABLET 48457781_1 CDM 0250 RC 68001-0254-04 NDC inpatient 1 UN 2.13 1.38 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.66 78 999999999 1.29 2.07 percent of total billed charges FLUCONAZOLE 200 MG TABLET 48457781_1 CDM 0250 RC 68001-0254-04 NDC inpatient 1 UN 2.13 1.38 UMR - ALL PLANS UMR - ALL PLANS 1.49 70 999999999 1.29 2.07 percent of total billed charges FLUCONAZOLE 200 MG TABLET 48457781_1 CDM 0250 RC 68001-0254-04 NDC inpatient 1 UN 2.13 1.38 SIHO - ALL PLANS SIHO - ALL PLANS 1.92 90 999999999 1.29 2.07 percent of total billed charges FLUCONAZOLE 200 MG TABLET 48457781_1 CDM 0250 RC 68001-0254-04 NDC inpatient 1 UN 2.13 1.38 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.29 60.55 999999999 1.29 2.07 percent of total billed charges FLUCONAZOLE 200 MG TABLET 48457781_1 CDM 0250 RC 68001-0254-04 NDC inpatient 1 UN 2.13 1.38 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.29 2.07 FLUCONAZOLE 200 MG TABLET 48457781_1 CDM 0250 RC 68001-0254-04 NDC inpatient 1 UN 2.13 1.38 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.29 2.07 FLUCONAZOLE 200 MG TABLET 48457781_1 CDM 0250 RC 68001-0254-04 NDC inpatient 1 UN 2.13 1.38 ANTHEM HMO ANTHEM HMO 999999999 1.29 2.07 FLUCONAZOLE 200 MG TABLET 48457781_1 CDM 0250 RC 68001-0254-04 NDC inpatient 1 UN 2.13 1.38 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.44 67.6 999999999 1.29 2.07 percent of total billed charges FLUCONAZOLE 200 MG TABLET 48457781_1 CDM 0250 RC 68001-0254-04 NDC inpatient 1 UN 2.13 1.38 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.29 2.07 FLUCONAZOLE 200 MG TABLET 48457781_1 CDM 0250 RC 68001-0254-04 NDC inpatient 1 UN 2.13 1.38 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.29 2.07 ATORVASTATIN 40 MG TABLET 48457782_1 CDM 0250 RC 68084-0099-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 40 MG TABLET 48457782_1 CDM 0250 RC 68084-0099-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 40 MG TABLET 48457782_1 CDM 0250 RC 68084-0099-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 40 MG TABLET 48457782_1 CDM 0250 RC 68084-0099-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 40 MG TABLET 48457782_1 CDM 0250 RC 68084-0099-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 40 MG TABLET 48457782_1 CDM 0250 RC 68084-0099-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 40 MG TABLET 48457782_1 CDM 0250 RC 68084-0099-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 40 MG TABLET 48457782_1 CDM 0250 RC 68084-0099-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 40 MG TABLET 48457782_1 CDM 0250 RC 68084-0099-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ATORVASTATIN 40 MG TABLET 48457782_1 CDM 0250 RC 68084-0099-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ATORVASTATIN 40 MG TABLET 48457782_1 CDM 0250 RC 68084-0099-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ATORVASTATIN 40 MG TABLET 48457782_1 CDM 0250 RC 68084-0099-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 40 MG TABLET 48457782_1 CDM 0250 RC 68084-0099-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ATORVASTATIN 40 MG TABLET 48457782_1 CDM 0250 RC 68084-0099-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 FOLIC ACID 1 MG TABLET 48457784_1 CDM 0250 RC 62584-0897-01 NDC inpatient 1 UN 1.99 1.29 AETNA AETNA 1.57 79 999999999 1.2 1.93 percent of total billed charges FOLIC ACID 1 MG TABLET 48457784_1 CDM 0250 RC 62584-0897-01 NDC inpatient 1 UN 1.99 1.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.29 65 999999999 1.2 1.93 percent of total billed charges FOLIC ACID 1 MG TABLET 48457784_1 CDM 0250 RC 62584-0897-01 NDC inpatient 1 UN 1.99 1.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.93 97 999999999 1.2 1.93 percent of total billed charges FOLIC ACID 1 MG TABLET 48457784_1 CDM 0250 RC 62584-0897-01 NDC inpatient 1 UN 1.99 1.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.37 69 999999999 1.2 1.93 percent of total billed charges FOLIC ACID 1 MG TABLET 48457784_1 CDM 0250 RC 62584-0897-01 NDC inpatient 1 UN 1.99 1.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.55 78 999999999 1.2 1.93 percent of total billed charges FOLIC ACID 1 MG TABLET 48457784_1 CDM 0250 RC 62584-0897-01 NDC inpatient 1 UN 1.99 1.29 UMR - ALL PLANS UMR - ALL PLANS 1.39 70 999999999 1.2 1.93 percent of total billed charges FOLIC ACID 1 MG TABLET 48457784_1 CDM 0250 RC 62584-0897-01 NDC inpatient 1 UN 1.99 1.29 SIHO - ALL PLANS SIHO - ALL PLANS 1.79 90 999999999 1.2 1.93 percent of total billed charges FOLIC ACID 1 MG TABLET 48457784_1 CDM 0250 RC 62584-0897-01 NDC inpatient 1 UN 1.99 1.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.2 60.55 999999999 1.2 1.93 percent of total billed charges FOLIC ACID 1 MG TABLET 48457784_1 CDM 0250 RC 62584-0897-01 NDC inpatient 1 UN 1.99 1.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.2 1.93 FOLIC ACID 1 MG TABLET 48457784_1 CDM 0250 RC 62584-0897-01 NDC inpatient 1 UN 1.99 1.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.2 1.93 FOLIC ACID 1 MG TABLET 48457784_1 CDM 0250 RC 62584-0897-01 NDC inpatient 1 UN 1.99 1.29 ANTHEM HMO ANTHEM HMO 999999999 1.2 1.93 FOLIC ACID 1 MG TABLET 48457784_1 CDM 0250 RC 62584-0897-01 NDC inpatient 1 UN 1.99 1.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.2 1.93 percent of total billed charges FOLIC ACID 1 MG TABLET 48457784_1 CDM 0250 RC 62584-0897-01 NDC inpatient 1 UN 1.99 1.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.2 1.93 FOLIC ACID 1 MG TABLET 48457784_1 CDM 0250 RC 62584-0897-01 NDC inpatient 1 UN 1.99 1.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.2 1.93 HYDROCORTISONE 1% OINTMENT 48457786_1 CDM 0250 RC 45802-0276-03 NDC inpatient 1 UN 8.5 5.53 AETNA AETNA 6.72 79 999999999 5.15 8.25 percent of total billed charges HYDROCORTISONE 1% OINTMENT 48457786_1 CDM 0250 RC 45802-0276-03 NDC inpatient 1 UN 8.5 5.53 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.53 65 999999999 5.15 8.25 percent of total billed charges HYDROCORTISONE 1% OINTMENT 48457786_1 CDM 0250 RC 45802-0276-03 NDC inpatient 1 UN 8.5 5.53 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.25 97 999999999 5.15 8.25 percent of total billed charges HYDROCORTISONE 1% OINTMENT 48457786_1 CDM 0250 RC 45802-0276-03 NDC inpatient 1 UN 8.5 5.53 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.87 69 999999999 5.15 8.25 percent of total billed charges HYDROCORTISONE 1% OINTMENT 48457786_1 CDM 0250 RC 45802-0276-03 NDC inpatient 1 UN 8.5 5.53 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.63 78 999999999 5.15 8.25 percent of total billed charges HYDROCORTISONE 1% OINTMENT 48457786_1 CDM 0250 RC 45802-0276-03 NDC inpatient 1 UN 8.5 5.53 UMR - ALL PLANS UMR - ALL PLANS 5.95 70 999999999 5.15 8.25 percent of total billed charges HYDROCORTISONE 1% OINTMENT 48457786_1 CDM 0250 RC 45802-0276-03 NDC inpatient 1 UN 8.5 5.53 SIHO - ALL PLANS SIHO - ALL PLANS 7.65 90 999999999 5.15 8.25 percent of total billed charges HYDROCORTISONE 1% OINTMENT 48457786_1 CDM 0250 RC 45802-0276-03 NDC inpatient 1 UN 8.5 5.53 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.15 60.55 999999999 5.15 8.25 percent of total billed charges HYDROCORTISONE 1% OINTMENT 48457786_1 CDM 0250 RC 45802-0276-03 NDC inpatient 1 UN 8.5 5.53 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.15 8.25 HYDROCORTISONE 1% OINTMENT 48457786_1 CDM 0250 RC 45802-0276-03 NDC inpatient 1 UN 8.5 5.53 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.15 8.25 HYDROCORTISONE 1% OINTMENT 48457786_1 CDM 0250 RC 45802-0276-03 NDC inpatient 1 UN 8.5 5.53 ANTHEM HMO ANTHEM HMO 999999999 5.15 8.25 HYDROCORTISONE 1% OINTMENT 48457786_1 CDM 0250 RC 45802-0276-03 NDC inpatient 1 UN 8.5 5.53 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.75 67.6 999999999 5.15 8.25 percent of total billed charges HYDROCORTISONE 1% OINTMENT 48457786_1 CDM 0250 RC 45802-0276-03 NDC inpatient 1 UN 8.5 5.53 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.15 8.25 HYDROCORTISONE 1% OINTMENT 48457786_1 CDM 0250 RC 45802-0276-03 NDC inpatient 1 UN 8.5 5.53 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.15 8.25 ATENOLOL 50 MG TABLET 48457787_1 CDM 0250 RC 51079-0684-20 NDC inpatient 1 UN 1.7 1.11 AETNA AETNA 1.34 79 999999999 1.03 1.65 percent of total billed charges ATENOLOL 50 MG TABLET 48457787_1 CDM 0250 RC 51079-0684-20 NDC inpatient 1 UN 1.7 1.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.11 65 999999999 1.03 1.65 percent of total billed charges ATENOLOL 50 MG TABLET 48457787_1 CDM 0250 RC 51079-0684-20 NDC inpatient 1 UN 1.7 1.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.65 97 999999999 1.03 1.65 percent of total billed charges ATENOLOL 50 MG TABLET 48457787_1 CDM 0250 RC 51079-0684-20 NDC inpatient 1 UN 1.7 1.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.17 69 999999999 1.03 1.65 percent of total billed charges ATENOLOL 50 MG TABLET 48457787_1 CDM 0250 RC 51079-0684-20 NDC inpatient 1 UN 1.7 1.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.33 78 999999999 1.03 1.65 percent of total billed charges ATENOLOL 50 MG TABLET 48457787_1 CDM 0250 RC 51079-0684-20 NDC inpatient 1 UN 1.7 1.11 UMR - ALL PLANS UMR - ALL PLANS 1.19 70 999999999 1.03 1.65 percent of total billed charges ATENOLOL 50 MG TABLET 48457787_1 CDM 0250 RC 51079-0684-20 NDC inpatient 1 UN 1.7 1.11 SIHO - ALL PLANS SIHO - ALL PLANS 1.53 90 999999999 1.03 1.65 percent of total billed charges ATENOLOL 50 MG TABLET 48457787_1 CDM 0250 RC 51079-0684-20 NDC inpatient 1 UN 1.7 1.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.03 60.55 999999999 1.03 1.65 percent of total billed charges ATENOLOL 50 MG TABLET 48457787_1 CDM 0250 RC 51079-0684-20 NDC inpatient 1 UN 1.7 1.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.03 1.65 ATENOLOL 50 MG TABLET 48457787_1 CDM 0250 RC 51079-0684-20 NDC inpatient 1 UN 1.7 1.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.03 1.65 ATENOLOL 50 MG TABLET 48457787_1 CDM 0250 RC 51079-0684-20 NDC inpatient 1 UN 1.7 1.11 ANTHEM HMO ANTHEM HMO 999999999 1.03 1.65 ATENOLOL 50 MG TABLET 48457787_1 CDM 0250 RC 51079-0684-20 NDC inpatient 1 UN 1.7 1.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.15 67.6 999999999 1.03 1.65 percent of total billed charges ATENOLOL 50 MG TABLET 48457787_1 CDM 0250 RC 51079-0684-20 NDC inpatient 1 UN 1.7 1.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.03 1.65 ATENOLOL 50 MG TABLET 48457787_1 CDM 0250 RC 51079-0684-20 NDC inpatient 1 UN 1.7 1.11 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.03 1.65 FUROSEMIDE 40 MG TABLET 48457789_1 CDM 0250 RC 51079-0073-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 40 MG TABLET 48457789_1 CDM 0250 RC 51079-0073-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 40 MG TABLET 48457789_1 CDM 0250 RC 51079-0073-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 40 MG TABLET 48457789_1 CDM 0250 RC 51079-0073-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 40 MG TABLET 48457789_1 CDM 0250 RC 51079-0073-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 40 MG TABLET 48457789_1 CDM 0250 RC 51079-0073-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 40 MG TABLET 48457789_1 CDM 0250 RC 51079-0073-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 40 MG TABLET 48457789_1 CDM 0250 RC 51079-0073-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 40 MG TABLET 48457789_1 CDM 0250 RC 51079-0073-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 FUROSEMIDE 40 MG TABLET 48457789_1 CDM 0250 RC 51079-0073-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 FUROSEMIDE 40 MG TABLET 48457789_1 CDM 0250 RC 51079-0073-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 FUROSEMIDE 40 MG TABLET 48457789_1 CDM 0250 RC 51079-0073-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 40 MG TABLET 48457789_1 CDM 0250 RC 51079-0073-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 FUROSEMIDE 40 MG TABLET 48457789_1 CDM 0250 RC 51079-0073-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 FUROSEMIDE 80 MG TABLET 48457790_1 CDM 0250 RC 51079-0527-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 80 MG TABLET 48457790_1 CDM 0250 RC 51079-0527-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 80 MG TABLET 48457790_1 CDM 0250 RC 51079-0527-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 80 MG TABLET 48457790_1 CDM 0250 RC 51079-0527-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 80 MG TABLET 48457790_1 CDM 0250 RC 51079-0527-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 80 MG TABLET 48457790_1 CDM 0250 RC 51079-0527-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 80 MG TABLET 48457790_1 CDM 0250 RC 51079-0527-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 80 MG TABLET 48457790_1 CDM 0250 RC 51079-0527-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 80 MG TABLET 48457790_1 CDM 0250 RC 51079-0527-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 FUROSEMIDE 80 MG TABLET 48457790_1 CDM 0250 RC 51079-0527-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 FUROSEMIDE 80 MG TABLET 48457790_1 CDM 0250 RC 51079-0527-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 FUROSEMIDE 80 MG TABLET 48457790_1 CDM 0250 RC 51079-0527-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 80 MG TABLET 48457790_1 CDM 0250 RC 51079-0527-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 FUROSEMIDE 80 MG TABLET 48457790_1 CDM 0250 RC 51079-0527-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 68084-0636-25 - FENOFIBRATE 145 MG TAB [JOHN] 48457796_1 CDM 0250 RC 68084-0636-25 NDC inpatient 1 UN 8.91 5.79 AETNA AETNA 7.04 79 999999999 5.4 8.64 percent of total billed charges 68084-0636-25 - FENOFIBRATE 145 MG TAB [JOHN] 48457796_1 CDM 0250 RC 68084-0636-25 NDC inpatient 1 UN 8.91 5.79 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.79 65 999999999 5.4 8.64 percent of total billed charges 68084-0636-25 - FENOFIBRATE 145 MG TAB [JOHN] 48457796_1 CDM 0250 RC 68084-0636-25 NDC inpatient 1 UN 8.91 5.79 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.64 97 999999999 5.4 8.64 percent of total billed charges 68084-0636-25 - FENOFIBRATE 145 MG TAB [JOHN] 48457796_1 CDM 0250 RC 68084-0636-25 NDC inpatient 1 UN 8.91 5.79 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.15 69 999999999 5.4 8.64 percent of total billed charges 68084-0636-25 - FENOFIBRATE 145 MG TAB [JOHN] 48457796_1 CDM 0250 RC 68084-0636-25 NDC inpatient 1 UN 8.91 5.79 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.95 78 999999999 5.4 8.64 percent of total billed charges 68084-0636-25 - FENOFIBRATE 145 MG TAB [JOHN] 48457796_1 CDM 0250 RC 68084-0636-25 NDC inpatient 1 UN 8.91 5.79 UMR - ALL PLANS UMR - ALL PLANS 6.24 70 999999999 5.4 8.64 percent of total billed charges 68084-0636-25 - FENOFIBRATE 145 MG TAB [JOHN] 48457796_1 CDM 0250 RC 68084-0636-25 NDC inpatient 1 UN 8.91 5.79 SIHO - ALL PLANS SIHO - ALL PLANS 8.02 90 999999999 5.4 8.64 percent of total billed charges 68084-0636-25 - FENOFIBRATE 145 MG TAB [JOHN] 48457796_1 CDM 0250 RC 68084-0636-25 NDC inpatient 1 UN 8.91 5.79 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.4 60.55 999999999 5.4 8.64 percent of total billed charges 68084-0636-25 - FENOFIBRATE 145 MG TAB [JOHN] 48457796_1 CDM 0250 RC 68084-0636-25 NDC inpatient 1 UN 8.91 5.79 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.4 8.64 68084-0636-25 - FENOFIBRATE 145 MG TAB [JOHN] 48457796_1 CDM 0250 RC 68084-0636-25 NDC inpatient 1 UN 8.91 5.79 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.4 8.64 68084-0636-25 - FENOFIBRATE 145 MG TAB [JOHN] 48457796_1 CDM 0250 RC 68084-0636-25 NDC inpatient 1 UN 8.91 5.79 ANTHEM HMO ANTHEM HMO 999999999 5.4 8.64 68084-0636-25 - FENOFIBRATE 145 MG TAB [JOHN] 48457796_1 CDM 0250 RC 68084-0636-25 NDC inpatient 1 UN 8.91 5.79 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.02 67.6 999999999 5.4 8.64 percent of total billed charges 68084-0636-25 - FENOFIBRATE 145 MG TAB [JOHN] 48457796_1 CDM 0250 RC 68084-0636-25 NDC inpatient 1 UN 8.91 5.79 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.4 8.64 68084-0636-25 - FENOFIBRATE 145 MG TAB [JOHN] 48457796_1 CDM 0250 RC 68084-0636-25 NDC inpatient 1 UN 8.91 5.79 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.4 8.64 LIDOCAINE HCL 2% JELLY 48457798_1 CDM 0250 RC 17478-0711-10 NDC inpatient 1 UN 31.17 20.26 AETNA AETNA 24.62 79 999999999 18.87 30.23 percent of total billed charges LIDOCAINE HCL 2% JELLY 48457798_1 CDM 0250 RC 17478-0711-10 NDC inpatient 1 UN 31.17 20.26 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.26 65 999999999 18.87 30.23 percent of total billed charges LIDOCAINE HCL 2% JELLY 48457798_1 CDM 0250 RC 17478-0711-10 NDC inpatient 1 UN 31.17 20.26 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.23 97 999999999 18.87 30.23 percent of total billed charges LIDOCAINE HCL 2% JELLY 48457798_1 CDM 0250 RC 17478-0711-10 NDC inpatient 1 UN 31.17 20.26 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.51 69 999999999 18.87 30.23 percent of total billed charges LIDOCAINE HCL 2% JELLY 48457798_1 CDM 0250 RC 17478-0711-10 NDC inpatient 1 UN 31.17 20.26 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.31 78 999999999 18.87 30.23 percent of total billed charges LIDOCAINE HCL 2% JELLY 48457798_1 CDM 0250 RC 17478-0711-10 NDC inpatient 1 UN 31.17 20.26 UMR - ALL PLANS UMR - ALL PLANS 21.82 70 999999999 18.87 30.23 percent of total billed charges LIDOCAINE HCL 2% JELLY 48457798_1 CDM 0250 RC 17478-0711-10 NDC inpatient 1 UN 31.17 20.26 SIHO - ALL PLANS SIHO - ALL PLANS 28.05 90 999999999 18.87 30.23 percent of total billed charges LIDOCAINE HCL 2% JELLY 48457798_1 CDM 0250 RC 17478-0711-10 NDC inpatient 1 UN 31.17 20.26 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.87 60.55 999999999 18.87 30.23 percent of total billed charges LIDOCAINE HCL 2% JELLY 48457798_1 CDM 0250 RC 17478-0711-10 NDC inpatient 1 UN 31.17 20.26 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.87 30.23 LIDOCAINE HCL 2% JELLY 48457798_1 CDM 0250 RC 17478-0711-10 NDC inpatient 1 UN 31.17 20.26 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.87 30.23 LIDOCAINE HCL 2% JELLY 48457798_1 CDM 0250 RC 17478-0711-10 NDC inpatient 1 UN 31.17 20.26 ANTHEM HMO ANTHEM HMO 999999999 18.87 30.23 LIDOCAINE HCL 2% JELLY 48457798_1 CDM 0250 RC 17478-0711-10 NDC inpatient 1 UN 31.17 20.26 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.07 67.6 999999999 18.87 30.23 percent of total billed charges LIDOCAINE HCL 2% JELLY 48457798_1 CDM 0250 RC 17478-0711-10 NDC inpatient 1 UN 31.17 20.26 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.87 30.23 LIDOCAINE HCL 2% JELLY 48457798_1 CDM 0250 RC 17478-0711-10 NDC inpatient 1 UN 31.17 20.26 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.87 30.23 CEPHALEXIN 500 MG CAPSULE 48457802_1 CDM 0250 RC 60687-0163-01 NDC inpatient 1 UN 1.83 1.19 AETNA AETNA 1.45 79 999999999 1.11 1.78 percent of total billed charges CEPHALEXIN 500 MG CAPSULE 48457802_1 CDM 0250 RC 60687-0163-01 NDC inpatient 1 UN 1.83 1.19 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.19 65 999999999 1.11 1.78 percent of total billed charges CEPHALEXIN 500 MG CAPSULE 48457802_1 CDM 0250 RC 60687-0163-01 NDC inpatient 1 UN 1.83 1.19 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.78 97 999999999 1.11 1.78 percent of total billed charges CEPHALEXIN 500 MG CAPSULE 48457802_1 CDM 0250 RC 60687-0163-01 NDC inpatient 1 UN 1.83 1.19 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.26 69 999999999 1.11 1.78 percent of total billed charges CEPHALEXIN 500 MG CAPSULE 48457802_1 CDM 0250 RC 60687-0163-01 NDC inpatient 1 UN 1.83 1.19 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.43 78 999999999 1.11 1.78 percent of total billed charges CEPHALEXIN 500 MG CAPSULE 48457802_1 CDM 0250 RC 60687-0163-01 NDC inpatient 1 UN 1.83 1.19 UMR - ALL PLANS UMR - ALL PLANS 1.28 70 999999999 1.11 1.78 percent of total billed charges CEPHALEXIN 500 MG CAPSULE 48457802_1 CDM 0250 RC 60687-0163-01 NDC inpatient 1 UN 1.83 1.19 SIHO - ALL PLANS SIHO - ALL PLANS 1.65 90 999999999 1.11 1.78 percent of total billed charges CEPHALEXIN 500 MG CAPSULE 48457802_1 CDM 0250 RC 60687-0163-01 NDC inpatient 1 UN 1.83 1.19 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.11 60.55 999999999 1.11 1.78 percent of total billed charges CEPHALEXIN 500 MG CAPSULE 48457802_1 CDM 0250 RC 60687-0163-01 NDC inpatient 1 UN 1.83 1.19 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.11 1.78 CEPHALEXIN 500 MG CAPSULE 48457802_1 CDM 0250 RC 60687-0163-01 NDC inpatient 1 UN 1.83 1.19 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.11 1.78 CEPHALEXIN 500 MG CAPSULE 48457802_1 CDM 0250 RC 60687-0163-01 NDC inpatient 1 UN 1.83 1.19 ANTHEM HMO ANTHEM HMO 999999999 1.11 1.78 CEPHALEXIN 500 MG CAPSULE 48457802_1 CDM 0250 RC 60687-0163-01 NDC inpatient 1 UN 1.83 1.19 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.24 67.6 999999999 1.11 1.78 percent of total billed charges CEPHALEXIN 500 MG CAPSULE 48457802_1 CDM 0250 RC 60687-0163-01 NDC inpatient 1 UN 1.83 1.19 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.11 1.78 CEPHALEXIN 500 MG CAPSULE 48457802_1 CDM 0250 RC 60687-0163-01 NDC inpatient 1 UN 1.83 1.19 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.11 1.78 ESCITALOPRAM 10 MG TABLET 48457817_1 CDM 0250 RC 68084-0617-01 NDC inpatient 1 UN 1.32 0.86 AETNA AETNA 1.04 79 999999999 0.8 1.28 percent of total billed charges ESCITALOPRAM 10 MG TABLET 48457817_1 CDM 0250 RC 68084-0617-01 NDC inpatient 1 UN 1.32 0.86 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.86 65 999999999 0.8 1.28 percent of total billed charges ESCITALOPRAM 10 MG TABLET 48457817_1 CDM 0250 RC 68084-0617-01 NDC inpatient 1 UN 1.32 0.86 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.28 97 999999999 0.8 1.28 percent of total billed charges ESCITALOPRAM 10 MG TABLET 48457817_1 CDM 0250 RC 68084-0617-01 NDC inpatient 1 UN 1.32 0.86 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.91 69 999999999 0.8 1.28 percent of total billed charges ESCITALOPRAM 10 MG TABLET 48457817_1 CDM 0250 RC 68084-0617-01 NDC inpatient 1 UN 1.32 0.86 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.03 78 999999999 0.8 1.28 percent of total billed charges ESCITALOPRAM 10 MG TABLET 48457817_1 CDM 0250 RC 68084-0617-01 NDC inpatient 1 UN 1.32 0.86 UMR - ALL PLANS UMR - ALL PLANS 0.92 70 999999999 0.8 1.28 percent of total billed charges ESCITALOPRAM 10 MG TABLET 48457817_1 CDM 0250 RC 68084-0617-01 NDC inpatient 1 UN 1.32 0.86 SIHO - ALL PLANS SIHO - ALL PLANS 1.19 90 999999999 0.8 1.28 percent of total billed charges ESCITALOPRAM 10 MG TABLET 48457817_1 CDM 0250 RC 68084-0617-01 NDC inpatient 1 UN 1.32 0.86 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.8 60.55 999999999 0.8 1.28 percent of total billed charges ESCITALOPRAM 10 MG TABLET 48457817_1 CDM 0250 RC 68084-0617-01 NDC inpatient 1 UN 1.32 0.86 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.8 1.28 ESCITALOPRAM 10 MG TABLET 48457817_1 CDM 0250 RC 68084-0617-01 NDC inpatient 1 UN 1.32 0.86 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.8 1.28 ESCITALOPRAM 10 MG TABLET 48457817_1 CDM 0250 RC 68084-0617-01 NDC inpatient 1 UN 1.32 0.86 ANTHEM HMO ANTHEM HMO 999999999 0.8 1.28 ESCITALOPRAM 10 MG TABLET 48457817_1 CDM 0250 RC 68084-0617-01 NDC inpatient 1 UN 1.32 0.86 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.89 67.6 999999999 0.8 1.28 percent of total billed charges ESCITALOPRAM 10 MG TABLET 48457817_1 CDM 0250 RC 68084-0617-01 NDC inpatient 1 UN 1.32 0.86 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.8 1.28 ESCITALOPRAM 10 MG TABLET 48457817_1 CDM 0250 RC 68084-0617-01 NDC inpatient 1 UN 1.32 0.86 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.8 1.28 MUPIROCIN 2% OINTMENT 48457818_1 CDM 0250 RC 68462-0180-22 NDC inpatient 1 UN 16.43 10.68 AETNA AETNA 12.98 79 999999999 9.95 15.94 percent of total billed charges MUPIROCIN 2% OINTMENT 48457818_1 CDM 0250 RC 68462-0180-22 NDC inpatient 1 UN 16.43 10.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.68 65 999999999 9.95 15.94 percent of total billed charges MUPIROCIN 2% OINTMENT 48457818_1 CDM 0250 RC 68462-0180-22 NDC inpatient 1 UN 16.43 10.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15.94 97 999999999 9.95 15.94 percent of total billed charges MUPIROCIN 2% OINTMENT 48457818_1 CDM 0250 RC 68462-0180-22 NDC inpatient 1 UN 16.43 10.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.34 69 999999999 9.95 15.94 percent of total billed charges MUPIROCIN 2% OINTMENT 48457818_1 CDM 0250 RC 68462-0180-22 NDC inpatient 1 UN 16.43 10.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.82 78 999999999 9.95 15.94 percent of total billed charges MUPIROCIN 2% OINTMENT 48457818_1 CDM 0250 RC 68462-0180-22 NDC inpatient 1 UN 16.43 10.68 UMR - ALL PLANS UMR - ALL PLANS 11.5 70 999999999 9.95 15.94 percent of total billed charges MUPIROCIN 2% OINTMENT 48457818_1 CDM 0250 RC 68462-0180-22 NDC inpatient 1 UN 16.43 10.68 SIHO - ALL PLANS SIHO - ALL PLANS 14.79 90 999999999 9.95 15.94 percent of total billed charges MUPIROCIN 2% OINTMENT 48457818_1 CDM 0250 RC 68462-0180-22 NDC inpatient 1 UN 16.43 10.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.95 60.55 999999999 9.95 15.94 percent of total billed charges MUPIROCIN 2% OINTMENT 48457818_1 CDM 0250 RC 68462-0180-22 NDC inpatient 1 UN 16.43 10.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.95 15.94 MUPIROCIN 2% OINTMENT 48457818_1 CDM 0250 RC 68462-0180-22 NDC inpatient 1 UN 16.43 10.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.95 15.94 MUPIROCIN 2% OINTMENT 48457818_1 CDM 0250 RC 68462-0180-22 NDC inpatient 1 UN 16.43 10.68 ANTHEM HMO ANTHEM HMO 999999999 9.95 15.94 MUPIROCIN 2% OINTMENT 48457818_1 CDM 0250 RC 68462-0180-22 NDC inpatient 1 UN 16.43 10.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.11 67.6 999999999 9.95 15.94 percent of total billed charges MUPIROCIN 2% OINTMENT 48457818_1 CDM 0250 RC 68462-0180-22 NDC inpatient 1 UN 16.43 10.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.95 15.94 MUPIROCIN 2% OINTMENT 48457818_1 CDM 0250 RC 68462-0180-22 NDC inpatient 1 UN 16.43 10.68 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.95 15.94 NITRO-BID 2% OINTMENT 48457819_1 CDM 0250 RC 00281-0326-08 NDC inpatient 1 UN 9.81 6.38 AETNA AETNA 7.75 79 999999999 5.94 9.52 percent of total billed charges NITRO-BID 2% OINTMENT 48457819_1 CDM 0250 RC 00281-0326-08 NDC inpatient 1 UN 9.81 6.38 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.38 65 999999999 5.94 9.52 percent of total billed charges NITRO-BID 2% OINTMENT 48457819_1 CDM 0250 RC 00281-0326-08 NDC inpatient 1 UN 9.81 6.38 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.52 97 999999999 5.94 9.52 percent of total billed charges NITRO-BID 2% OINTMENT 48457819_1 CDM 0250 RC 00281-0326-08 NDC inpatient 1 UN 9.81 6.38 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.77 69 999999999 5.94 9.52 percent of total billed charges NITRO-BID 2% OINTMENT 48457819_1 CDM 0250 RC 00281-0326-08 NDC inpatient 1 UN 9.81 6.38 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.65 78 999999999 5.94 9.52 percent of total billed charges NITRO-BID 2% OINTMENT 48457819_1 CDM 0250 RC 00281-0326-08 NDC inpatient 1 UN 9.81 6.38 UMR - ALL PLANS UMR - ALL PLANS 6.87 70 999999999 5.94 9.52 percent of total billed charges NITRO-BID 2% OINTMENT 48457819_1 CDM 0250 RC 00281-0326-08 NDC inpatient 1 UN 9.81 6.38 SIHO - ALL PLANS SIHO - ALL PLANS 8.83 90 999999999 5.94 9.52 percent of total billed charges NITRO-BID 2% OINTMENT 48457819_1 CDM 0250 RC 00281-0326-08 NDC inpatient 1 UN 9.81 6.38 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.94 60.55 999999999 5.94 9.52 percent of total billed charges NITRO-BID 2% OINTMENT 48457819_1 CDM 0250 RC 00281-0326-08 NDC inpatient 1 UN 9.81 6.38 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.94 9.52 NITRO-BID 2% OINTMENT 48457819_1 CDM 0250 RC 00281-0326-08 NDC inpatient 1 UN 9.81 6.38 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.94 9.52 NITRO-BID 2% OINTMENT 48457819_1 CDM 0250 RC 00281-0326-08 NDC inpatient 1 UN 9.81 6.38 ANTHEM HMO ANTHEM HMO 999999999 5.94 9.52 NITRO-BID 2% OINTMENT 48457819_1 CDM 0250 RC 00281-0326-08 NDC inpatient 1 UN 9.81 6.38 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.63 67.6 999999999 5.94 9.52 percent of total billed charges NITRO-BID 2% OINTMENT 48457819_1 CDM 0250 RC 00281-0326-08 NDC inpatient 1 UN 9.81 6.38 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.94 9.52 NITRO-BID 2% OINTMENT 48457819_1 CDM 0250 RC 00281-0326-08 NDC inpatient 1 UN 9.81 6.38 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.94 9.52 ESTRADIOL 0.05 MG PATCH (1/WK) 48457820_1 CDM 0250 RC 00378-3350-99 NDC inpatient 1 UN 62.36 40.53 AETNA AETNA 49.26 79 999999999 37.76 60.49 percent of total billed charges ESTRADIOL 0.05 MG PATCH (1/WK) 48457820_1 CDM 0250 RC 00378-3350-99 NDC inpatient 1 UN 62.36 40.53 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.53 65 999999999 37.76 60.49 percent of total billed charges ESTRADIOL 0.05 MG PATCH (1/WK) 48457820_1 CDM 0250 RC 00378-3350-99 NDC inpatient 1 UN 62.36 40.53 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 60.49 97 999999999 37.76 60.49 percent of total billed charges ESTRADIOL 0.05 MG PATCH (1/WK) 48457820_1 CDM 0250 RC 00378-3350-99 NDC inpatient 1 UN 62.36 40.53 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.03 69 999999999 37.76 60.49 percent of total billed charges ESTRADIOL 0.05 MG PATCH (1/WK) 48457820_1 CDM 0250 RC 00378-3350-99 NDC inpatient 1 UN 62.36 40.53 HUMANA - ALL PLANS HUMANA - ALL PLANS 48.64 78 999999999 37.76 60.49 percent of total billed charges ESTRADIOL 0.05 MG PATCH (1/WK) 48457820_1 CDM 0250 RC 00378-3350-99 NDC inpatient 1 UN 62.36 40.53 UMR - ALL PLANS UMR - ALL PLANS 43.65 70 999999999 37.76 60.49 percent of total billed charges ESTRADIOL 0.05 MG PATCH (1/WK) 48457820_1 CDM 0250 RC 00378-3350-99 NDC inpatient 1 UN 62.36 40.53 SIHO - ALL PLANS SIHO - ALL PLANS 56.12 90 999999999 37.76 60.49 percent of total billed charges ESTRADIOL 0.05 MG PATCH (1/WK) 48457820_1 CDM 0250 RC 00378-3350-99 NDC inpatient 1 UN 62.36 40.53 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 37.76 60.55 999999999 37.76 60.49 percent of total billed charges ESTRADIOL 0.05 MG PATCH (1/WK) 48457820_1 CDM 0250 RC 00378-3350-99 NDC inpatient 1 UN 62.36 40.53 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 37.76 60.49 ESTRADIOL 0.05 MG PATCH (1/WK) 48457820_1 CDM 0250 RC 00378-3350-99 NDC inpatient 1 UN 62.36 40.53 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 37.76 60.49 ESTRADIOL 0.05 MG PATCH (1/WK) 48457820_1 CDM 0250 RC 00378-3350-99 NDC inpatient 1 UN 62.36 40.53 ANTHEM HMO ANTHEM HMO 999999999 37.76 60.49 ESTRADIOL 0.05 MG PATCH (1/WK) 48457820_1 CDM 0250 RC 00378-3350-99 NDC inpatient 1 UN 62.36 40.53 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.16 67.6 999999999 37.76 60.49 percent of total billed charges ESTRADIOL 0.05 MG PATCH (1/WK) 48457820_1 CDM 0250 RC 00378-3350-99 NDC inpatient 1 UN 62.36 40.53 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 37.76 60.49 ESTRADIOL 0.05 MG PATCH (1/WK) 48457820_1 CDM 0250 RC 00378-3350-99 NDC inpatient 1 UN 62.36 40.53 UHC - ALL PLANS UHC - ALL PLANS 999999999 37.76 60.49 SILVER SULFADIAZINE 1% CREAM 48458005_1 CDM 0250 RC 67877-0124-25 NDC inpatient 1 UN 33.16 21.55 AETNA AETNA 26.2 79 999999999 20.08 32.17 percent of total billed charges SILVER SULFADIAZINE 1% CREAM 48458005_1 CDM 0250 RC 67877-0124-25 NDC inpatient 1 UN 33.16 21.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.55 65 999999999 20.08 32.17 percent of total billed charges SILVER SULFADIAZINE 1% CREAM 48458005_1 CDM 0250 RC 67877-0124-25 NDC inpatient 1 UN 33.16 21.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.17 97 999999999 20.08 32.17 percent of total billed charges SILVER SULFADIAZINE 1% CREAM 48458005_1 CDM 0250 RC 67877-0124-25 NDC inpatient 1 UN 33.16 21.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.88 69 999999999 20.08 32.17 percent of total billed charges SILVER SULFADIAZINE 1% CREAM 48458005_1 CDM 0250 RC 67877-0124-25 NDC inpatient 1 UN 33.16 21.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.86 78 999999999 20.08 32.17 percent of total billed charges SILVER SULFADIAZINE 1% CREAM 48458005_1 CDM 0250 RC 67877-0124-25 NDC inpatient 1 UN 33.16 21.55 UMR - ALL PLANS UMR - ALL PLANS 23.21 70 999999999 20.08 32.17 percent of total billed charges SILVER SULFADIAZINE 1% CREAM 48458005_1 CDM 0250 RC 67877-0124-25 NDC inpatient 1 UN 33.16 21.55 SIHO - ALL PLANS SIHO - ALL PLANS 29.84 90 999999999 20.08 32.17 percent of total billed charges SILVER SULFADIAZINE 1% CREAM 48458005_1 CDM 0250 RC 67877-0124-25 NDC inpatient 1 UN 33.16 21.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.08 60.55 999999999 20.08 32.17 percent of total billed charges SILVER SULFADIAZINE 1% CREAM 48458005_1 CDM 0250 RC 67877-0124-25 NDC inpatient 1 UN 33.16 21.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.08 32.17 SILVER SULFADIAZINE 1% CREAM 48458005_1 CDM 0250 RC 67877-0124-25 NDC inpatient 1 UN 33.16 21.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.08 32.17 SILVER SULFADIAZINE 1% CREAM 48458005_1 CDM 0250 RC 67877-0124-25 NDC inpatient 1 UN 33.16 21.55 ANTHEM HMO ANTHEM HMO 999999999 20.08 32.17 SILVER SULFADIAZINE 1% CREAM 48458005_1 CDM 0250 RC 67877-0124-25 NDC inpatient 1 UN 33.16 21.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.42 67.6 999999999 20.08 32.17 percent of total billed charges SILVER SULFADIAZINE 1% CREAM 48458005_1 CDM 0250 RC 67877-0124-25 NDC inpatient 1 UN 33.16 21.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.08 32.17 SILVER SULFADIAZINE 1% CREAM 48458005_1 CDM 0250 RC 67877-0124-25 NDC inpatient 1 UN 33.16 21.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.08 32.17 SILVER SULFADIAZINE 1% CREAM 48458006_1 CDM 0250 RC 67877-0124-05 NDC inpatient 1 UN 45.48 29.56 AETNA AETNA 35.93 79 999999999 27.54 44.12 percent of total billed charges SILVER SULFADIAZINE 1% CREAM 48458006_1 CDM 0250 RC 67877-0124-05 NDC inpatient 1 UN 45.48 29.56 SELF PAY DISCOUNT SELF PAY DISCOUNT 29.56 65 999999999 27.54 44.12 percent of total billed charges SILVER SULFADIAZINE 1% CREAM 48458006_1 CDM 0250 RC 67877-0124-05 NDC inpatient 1 UN 45.48 29.56 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 44.12 97 999999999 27.54 44.12 percent of total billed charges SILVER SULFADIAZINE 1% CREAM 48458006_1 CDM 0250 RC 67877-0124-05 NDC inpatient 1 UN 45.48 29.56 ENCORE - ALL PLANS ENCORE - ALL PLANS 31.38 69 999999999 27.54 44.12 percent of total billed charges SILVER SULFADIAZINE 1% CREAM 48458006_1 CDM 0250 RC 67877-0124-05 NDC inpatient 1 UN 45.48 29.56 HUMANA - ALL PLANS HUMANA - ALL PLANS 35.47 78 999999999 27.54 44.12 percent of total billed charges SILVER SULFADIAZINE 1% CREAM 48458006_1 CDM 0250 RC 67877-0124-05 NDC inpatient 1 UN 45.48 29.56 UMR - ALL PLANS UMR - ALL PLANS 31.84 70 999999999 27.54 44.12 percent of total billed charges SILVER SULFADIAZINE 1% CREAM 48458006_1 CDM 0250 RC 67877-0124-05 NDC inpatient 1 UN 45.48 29.56 SIHO - ALL PLANS SIHO - ALL PLANS 40.93 90 999999999 27.54 44.12 percent of total billed charges SILVER SULFADIAZINE 1% CREAM 48458006_1 CDM 0250 RC 67877-0124-05 NDC inpatient 1 UN 45.48 29.56 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27.54 60.55 999999999 27.54 44.12 percent of total billed charges SILVER SULFADIAZINE 1% CREAM 48458006_1 CDM 0250 RC 67877-0124-05 NDC inpatient 1 UN 45.48 29.56 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 27.54 44.12 SILVER SULFADIAZINE 1% CREAM 48458006_1 CDM 0250 RC 67877-0124-05 NDC inpatient 1 UN 45.48 29.56 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 27.54 44.12 SILVER SULFADIAZINE 1% CREAM 48458006_1 CDM 0250 RC 67877-0124-05 NDC inpatient 1 UN 45.48 29.56 ANTHEM HMO ANTHEM HMO 999999999 27.54 44.12 SILVER SULFADIAZINE 1% CREAM 48458006_1 CDM 0250 RC 67877-0124-05 NDC inpatient 1 UN 45.48 29.56 CIGNA - ALL PLANS CIGNA - ALL PLANS 30.74 67.6 999999999 27.54 44.12 percent of total billed charges SILVER SULFADIAZINE 1% CREAM 48458006_1 CDM 0250 RC 67877-0124-05 NDC inpatient 1 UN 45.48 29.56 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 27.54 44.12 SILVER SULFADIAZINE 1% CREAM 48458006_1 CDM 0250 RC 67877-0124-05 NDC inpatient 1 UN 45.48 29.56 UHC - ALL PLANS UHC - ALL PLANS 999999999 27.54 44.12 ENTRESTO 24 MG-26 MG TABLET 48458008_1 CDM 0250 RC 00078-0659-20 NDC inpatient 1 UN 41.49 26.97 AETNA AETNA 32.78 79 999999999 25.12 40.25 percent of total billed charges ENTRESTO 24 MG-26 MG TABLET 48458008_1 CDM 0250 RC 00078-0659-20 NDC inpatient 1 UN 41.49 26.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.97 65 999999999 25.12 40.25 percent of total billed charges ENTRESTO 24 MG-26 MG TABLET 48458008_1 CDM 0250 RC 00078-0659-20 NDC inpatient 1 UN 41.49 26.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 40.25 97 999999999 25.12 40.25 percent of total billed charges ENTRESTO 24 MG-26 MG TABLET 48458008_1 CDM 0250 RC 00078-0659-20 NDC inpatient 1 UN 41.49 26.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.63 69 999999999 25.12 40.25 percent of total billed charges ENTRESTO 24 MG-26 MG TABLET 48458008_1 CDM 0250 RC 00078-0659-20 NDC inpatient 1 UN 41.49 26.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 32.36 78 999999999 25.12 40.25 percent of total billed charges ENTRESTO 24 MG-26 MG TABLET 48458008_1 CDM 0250 RC 00078-0659-20 NDC inpatient 1 UN 41.49 26.97 UMR - ALL PLANS UMR - ALL PLANS 29.04 70 999999999 25.12 40.25 percent of total billed charges ENTRESTO 24 MG-26 MG TABLET 48458008_1 CDM 0250 RC 00078-0659-20 NDC inpatient 1 UN 41.49 26.97 SIHO - ALL PLANS SIHO - ALL PLANS 37.34 90 999999999 25.12 40.25 percent of total billed charges ENTRESTO 24 MG-26 MG TABLET 48458008_1 CDM 0250 RC 00078-0659-20 NDC inpatient 1 UN 41.49 26.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 25.12 60.55 999999999 25.12 40.25 percent of total billed charges ENTRESTO 24 MG-26 MG TABLET 48458008_1 CDM 0250 RC 00078-0659-20 NDC inpatient 1 UN 41.49 26.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 25.12 40.25 ENTRESTO 24 MG-26 MG TABLET 48458008_1 CDM 0250 RC 00078-0659-20 NDC inpatient 1 UN 41.49 26.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 25.12 40.25 ENTRESTO 24 MG-26 MG TABLET 48458008_1 CDM 0250 RC 00078-0659-20 NDC inpatient 1 UN 41.49 26.97 ANTHEM HMO ANTHEM HMO 999999999 25.12 40.25 ENTRESTO 24 MG-26 MG TABLET 48458008_1 CDM 0250 RC 00078-0659-20 NDC inpatient 1 UN 41.49 26.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 28.05 67.6 999999999 25.12 40.25 percent of total billed charges ENTRESTO 24 MG-26 MG TABLET 48458008_1 CDM 0250 RC 00078-0659-20 NDC inpatient 1 UN 41.49 26.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 25.12 40.25 ENTRESTO 24 MG-26 MG TABLET 48458008_1 CDM 0250 RC 00078-0659-20 NDC inpatient 1 UN 41.49 26.97 UHC - ALL PLANS UHC - ALL PLANS 999999999 25.12 40.25 VENELEX OINTMENT 48458022_1 CDM 0250 RC 58980-0780-11 NDC inpatient 1 UN 86.99 56.54 AETNA AETNA 68.72 79 999999999 52.67 84.38 percent of total billed charges VENELEX OINTMENT 48458022_1 CDM 0250 RC 58980-0780-11 NDC inpatient 1 UN 86.99 56.54 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.54 65 999999999 52.67 84.38 percent of total billed charges VENELEX OINTMENT 48458022_1 CDM 0250 RC 58980-0780-11 NDC inpatient 1 UN 86.99 56.54 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.38 97 999999999 52.67 84.38 percent of total billed charges VENELEX OINTMENT 48458022_1 CDM 0250 RC 58980-0780-11 NDC inpatient 1 UN 86.99 56.54 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.02 69 999999999 52.67 84.38 percent of total billed charges VENELEX OINTMENT 48458022_1 CDM 0250 RC 58980-0780-11 NDC inpatient 1 UN 86.99 56.54 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.85 78 999999999 52.67 84.38 percent of total billed charges VENELEX OINTMENT 48458022_1 CDM 0250 RC 58980-0780-11 NDC inpatient 1 UN 86.99 56.54 UMR - ALL PLANS UMR - ALL PLANS 60.89 70 999999999 52.67 84.38 percent of total billed charges VENELEX OINTMENT 48458022_1 CDM 0250 RC 58980-0780-11 NDC inpatient 1 UN 86.99 56.54 SIHO - ALL PLANS SIHO - ALL PLANS 78.29 90 999999999 52.67 84.38 percent of total billed charges VENELEX OINTMENT 48458022_1 CDM 0250 RC 58980-0780-11 NDC inpatient 1 UN 86.99 56.54 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.67 60.55 999999999 52.67 84.38 percent of total billed charges VENELEX OINTMENT 48458022_1 CDM 0250 RC 58980-0780-11 NDC inpatient 1 UN 86.99 56.54 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.67 84.38 VENELEX OINTMENT 48458022_1 CDM 0250 RC 58980-0780-11 NDC inpatient 1 UN 86.99 56.54 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.67 84.38 VENELEX OINTMENT 48458022_1 CDM 0250 RC 58980-0780-11 NDC inpatient 1 UN 86.99 56.54 ANTHEM HMO ANTHEM HMO 999999999 52.67 84.38 VENELEX OINTMENT 48458022_1 CDM 0250 RC 58980-0780-11 NDC inpatient 1 UN 86.99 56.54 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.67 84.38 percent of total billed charges VENELEX OINTMENT 48458022_1 CDM 0250 RC 58980-0780-11 NDC inpatient 1 UN 86.99 56.54 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.67 84.38 VENELEX OINTMENT 48458022_1 CDM 0250 RC 58980-0780-11 NDC inpatient 1 UN 86.99 56.54 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.67 84.38 BUPIVACAINE 0.25% VIAL 48458025_1 CDM 0250 RC 00409-1159-02 NDC inpatient 1 UN 24.83 16.14 AETNA AETNA 19.62 79 999999999 15.03 24.09 percent of total billed charges BUPIVACAINE 0.25% VIAL 48458025_1 CDM 0250 RC 00409-1159-02 NDC inpatient 1 UN 24.83 16.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.14 65 999999999 15.03 24.09 percent of total billed charges BUPIVACAINE 0.25% VIAL 48458025_1 CDM 0250 RC 00409-1159-02 NDC inpatient 1 UN 24.83 16.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.09 97 999999999 15.03 24.09 percent of total billed charges BUPIVACAINE 0.25% VIAL 48458025_1 CDM 0250 RC 00409-1159-02 NDC inpatient 1 UN 24.83 16.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.13 69 999999999 15.03 24.09 percent of total billed charges BUPIVACAINE 0.25% VIAL 48458025_1 CDM 0250 RC 00409-1159-02 NDC inpatient 1 UN 24.83 16.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.37 78 999999999 15.03 24.09 percent of total billed charges BUPIVACAINE 0.25% VIAL 48458025_1 CDM 0250 RC 00409-1159-02 NDC inpatient 1 UN 24.83 16.14 UMR - ALL PLANS UMR - ALL PLANS 17.38 70 999999999 15.03 24.09 percent of total billed charges BUPIVACAINE 0.25% VIAL 48458025_1 CDM 0250 RC 00409-1159-02 NDC inpatient 1 UN 24.83 16.14 SIHO - ALL PLANS SIHO - ALL PLANS 22.35 90 999999999 15.03 24.09 percent of total billed charges BUPIVACAINE 0.25% VIAL 48458025_1 CDM 0250 RC 00409-1159-02 NDC inpatient 1 UN 24.83 16.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.03 60.55 999999999 15.03 24.09 percent of total billed charges BUPIVACAINE 0.25% VIAL 48458025_1 CDM 0250 RC 00409-1159-02 NDC inpatient 1 UN 24.83 16.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.03 24.09 BUPIVACAINE 0.25% VIAL 48458025_1 CDM 0250 RC 00409-1159-02 NDC inpatient 1 UN 24.83 16.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.03 24.09 BUPIVACAINE 0.25% VIAL 48458025_1 CDM 0250 RC 00409-1159-02 NDC inpatient 1 UN 24.83 16.14 ANTHEM HMO ANTHEM HMO 999999999 15.03 24.09 BUPIVACAINE 0.25% VIAL 48458025_1 CDM 0250 RC 00409-1159-02 NDC inpatient 1 UN 24.83 16.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.79 67.6 999999999 15.03 24.09 percent of total billed charges BUPIVACAINE 0.25% VIAL 48458025_1 CDM 0250 RC 00409-1159-02 NDC inpatient 1 UN 24.83 16.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.03 24.09 BUPIVACAINE 0.25% VIAL 48458025_1 CDM 0250 RC 00409-1159-02 NDC inpatient 1 UN 24.83 16.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.03 24.09 "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48458028_1 CDM 0250 RC 00409-9045-17 NDC C9290 HCPCS inpatient 266 UN 30.78 20.01 AETNA AETNA 24.32 79 999999999 18.64 29.86 percent of total billed charges "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48458028_1 CDM 0250 RC 00409-9045-17 NDC C9290 HCPCS inpatient 266 UN 30.78 20.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.01 65 999999999 18.64 29.86 percent of total billed charges "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48458028_1 CDM 0250 RC 00409-9045-17 NDC C9290 HCPCS inpatient 266 UN 30.78 20.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.86 97 999999999 18.64 29.86 percent of total billed charges "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48458028_1 CDM 0250 RC 00409-9045-17 NDC C9290 HCPCS inpatient 266 UN 30.78 20.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.24 69 999999999 18.64 29.86 percent of total billed charges "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48458028_1 CDM 0250 RC 00409-9045-17 NDC C9290 HCPCS inpatient 266 UN 30.78 20.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.01 78 999999999 18.64 29.86 percent of total billed charges "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48458028_1 CDM 0250 RC 00409-9045-17 NDC C9290 HCPCS inpatient 266 UN 30.78 20.01 UMR - ALL PLANS UMR - ALL PLANS 21.55 70 999999999 18.64 29.86 percent of total billed charges "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48458028_1 CDM 0250 RC 00409-9045-17 NDC C9290 HCPCS inpatient 266 UN 30.78 20.01 SIHO - ALL PLANS SIHO - ALL PLANS 27.7 90 999999999 18.64 29.86 percent of total billed charges "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48458028_1 CDM 0250 RC 00409-9045-17 NDC C9290 HCPCS inpatient 266 UN 30.78 20.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.64 60.55 999999999 18.64 29.86 percent of total billed charges "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48458028_1 CDM 0250 RC 00409-9045-17 NDC C9290 HCPCS inpatient 266 UN 30.78 20.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.64 29.86 "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48458028_1 CDM 0250 RC 00409-9045-17 NDC C9290 HCPCS inpatient 266 UN 30.78 20.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.64 29.86 "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48458028_1 CDM 0250 RC 00409-9045-17 NDC C9290 HCPCS inpatient 266 UN 30.78 20.01 ANTHEM HMO ANTHEM HMO 999999999 18.64 29.86 "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48458028_1 CDM 0250 RC 00409-9045-17 NDC C9290 HCPCS inpatient 266 UN 30.78 20.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.81 67.6 999999999 18.64 29.86 percent of total billed charges "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48458028_1 CDM 0250 RC 00409-9045-17 NDC C9290 HCPCS inpatient 266 UN 30.78 20.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.64 29.86 "INJECTION, BUPIVACAINE LIPOSOME, 1 MG" 48458028_1 CDM 0250 RC 00409-9045-17 NDC C9290 HCPCS inpatient 266 UN 30.78 20.01 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.64 29.86 DONEPEZIL HCL 23 MG TABLET 48458031_1 CDM 0250 RC 33342-0061-07 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges DONEPEZIL HCL 23 MG TABLET 48458031_1 CDM 0250 RC 33342-0061-07 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges DONEPEZIL HCL 23 MG TABLET 48458031_1 CDM 0250 RC 33342-0061-07 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges DONEPEZIL HCL 23 MG TABLET 48458031_1 CDM 0250 RC 33342-0061-07 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges DONEPEZIL HCL 23 MG TABLET 48458031_1 CDM 0250 RC 33342-0061-07 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges DONEPEZIL HCL 23 MG TABLET 48458031_1 CDM 0250 RC 33342-0061-07 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges DONEPEZIL HCL 23 MG TABLET 48458031_1 CDM 0250 RC 33342-0061-07 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges DONEPEZIL HCL 23 MG TABLET 48458031_1 CDM 0250 RC 33342-0061-07 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges DONEPEZIL HCL 23 MG TABLET 48458031_1 CDM 0250 RC 33342-0061-07 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 DONEPEZIL HCL 23 MG TABLET 48458031_1 CDM 0250 RC 33342-0061-07 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 DONEPEZIL HCL 23 MG TABLET 48458031_1 CDM 0250 RC 33342-0061-07 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 DONEPEZIL HCL 23 MG TABLET 48458031_1 CDM 0250 RC 33342-0061-07 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges DONEPEZIL HCL 23 MG TABLET 48458031_1 CDM 0250 RC 33342-0061-07 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 DONEPEZIL HCL 23 MG TABLET 48458031_1 CDM 0250 RC 33342-0061-07 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 DULOXETINE HCL DR 20 MG CAP 48458034_1 CDM 0250 RC 68084-0675-21 NDC inpatient 1 UN 2.41 1.57 AETNA AETNA 1.9 79 999999999 1.46 2.34 percent of total billed charges DULOXETINE HCL DR 20 MG CAP 48458034_1 CDM 0250 RC 68084-0675-21 NDC inpatient 1 UN 2.41 1.57 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.57 65 999999999 1.46 2.34 percent of total billed charges DULOXETINE HCL DR 20 MG CAP 48458034_1 CDM 0250 RC 68084-0675-21 NDC inpatient 1 UN 2.41 1.57 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.34 97 999999999 1.46 2.34 percent of total billed charges DULOXETINE HCL DR 20 MG CAP 48458034_1 CDM 0250 RC 68084-0675-21 NDC inpatient 1 UN 2.41 1.57 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.66 69 999999999 1.46 2.34 percent of total billed charges DULOXETINE HCL DR 20 MG CAP 48458034_1 CDM 0250 RC 68084-0675-21 NDC inpatient 1 UN 2.41 1.57 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.88 78 999999999 1.46 2.34 percent of total billed charges DULOXETINE HCL DR 20 MG CAP 48458034_1 CDM 0250 RC 68084-0675-21 NDC inpatient 1 UN 2.41 1.57 UMR - ALL PLANS UMR - ALL PLANS 1.69 70 999999999 1.46 2.34 percent of total billed charges DULOXETINE HCL DR 20 MG CAP 48458034_1 CDM 0250 RC 68084-0675-21 NDC inpatient 1 UN 2.41 1.57 SIHO - ALL PLANS SIHO - ALL PLANS 2.17 90 999999999 1.46 2.34 percent of total billed charges DULOXETINE HCL DR 20 MG CAP 48458034_1 CDM 0250 RC 68084-0675-21 NDC inpatient 1 UN 2.41 1.57 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.46 60.55 999999999 1.46 2.34 percent of total billed charges DULOXETINE HCL DR 20 MG CAP 48458034_1 CDM 0250 RC 68084-0675-21 NDC inpatient 1 UN 2.41 1.57 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.46 2.34 DULOXETINE HCL DR 20 MG CAP 48458034_1 CDM 0250 RC 68084-0675-21 NDC inpatient 1 UN 2.41 1.57 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.46 2.34 DULOXETINE HCL DR 20 MG CAP 48458034_1 CDM 0250 RC 68084-0675-21 NDC inpatient 1 UN 2.41 1.57 ANTHEM HMO ANTHEM HMO 999999999 1.46 2.34 DULOXETINE HCL DR 20 MG CAP 48458034_1 CDM 0250 RC 68084-0675-21 NDC inpatient 1 UN 2.41 1.57 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.63 67.6 999999999 1.46 2.34 percent of total billed charges DULOXETINE HCL DR 20 MG CAP 48458034_1 CDM 0250 RC 68084-0675-21 NDC inpatient 1 UN 2.41 1.57 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.46 2.34 DULOXETINE HCL DR 20 MG CAP 48458034_1 CDM 0250 RC 68084-0675-21 NDC inpatient 1 UN 2.41 1.57 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.46 2.34 BUPIVACAINE 0.75% VIAL 48458036_1 CDM 0250 RC 55150-0171-10 NDC inpatient 1 UN 25.88 16.82 AETNA AETNA 20.45 79 999999999 15.67 25.1 percent of total billed charges BUPIVACAINE 0.75% VIAL 48458036_1 CDM 0250 RC 55150-0171-10 NDC inpatient 1 UN 25.88 16.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.82 65 999999999 15.67 25.1 percent of total billed charges BUPIVACAINE 0.75% VIAL 48458036_1 CDM 0250 RC 55150-0171-10 NDC inpatient 1 UN 25.88 16.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.1 97 999999999 15.67 25.1 percent of total billed charges BUPIVACAINE 0.75% VIAL 48458036_1 CDM 0250 RC 55150-0171-10 NDC inpatient 1 UN 25.88 16.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.86 69 999999999 15.67 25.1 percent of total billed charges BUPIVACAINE 0.75% VIAL 48458036_1 CDM 0250 RC 55150-0171-10 NDC inpatient 1 UN 25.88 16.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.19 78 999999999 15.67 25.1 percent of total billed charges BUPIVACAINE 0.75% VIAL 48458036_1 CDM 0250 RC 55150-0171-10 NDC inpatient 1 UN 25.88 16.82 UMR - ALL PLANS UMR - ALL PLANS 18.12 70 999999999 15.67 25.1 percent of total billed charges BUPIVACAINE 0.75% VIAL 48458036_1 CDM 0250 RC 55150-0171-10 NDC inpatient 1 UN 25.88 16.82 SIHO - ALL PLANS SIHO - ALL PLANS 23.29 90 999999999 15.67 25.1 percent of total billed charges BUPIVACAINE 0.75% VIAL 48458036_1 CDM 0250 RC 55150-0171-10 NDC inpatient 1 UN 25.88 16.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.67 60.55 999999999 15.67 25.1 percent of total billed charges BUPIVACAINE 0.75% VIAL 48458036_1 CDM 0250 RC 55150-0171-10 NDC inpatient 1 UN 25.88 16.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.67 25.1 BUPIVACAINE 0.75% VIAL 48458036_1 CDM 0250 RC 55150-0171-10 NDC inpatient 1 UN 25.88 16.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.67 25.1 BUPIVACAINE 0.75% VIAL 48458036_1 CDM 0250 RC 55150-0171-10 NDC inpatient 1 UN 25.88 16.82 ANTHEM HMO ANTHEM HMO 999999999 15.67 25.1 BUPIVACAINE 0.75% VIAL 48458036_1 CDM 0250 RC 55150-0171-10 NDC inpatient 1 UN 25.88 16.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.49 67.6 999999999 15.67 25.1 percent of total billed charges BUPIVACAINE 0.75% VIAL 48458036_1 CDM 0250 RC 55150-0171-10 NDC inpatient 1 UN 25.88 16.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.67 25.1 BUPIVACAINE 0.75% VIAL 48458036_1 CDM 0250 RC 55150-0171-10 NDC inpatient 1 UN 25.88 16.82 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.67 25.1 DIVALPROEX SOD DR 250 MG TAB 48458038_1 CDM 0250 RC 68084-0776-01 NDC inpatient 1 UN 1.27 0.83 AETNA AETNA 1 79 999999999 0.77 1.23 percent of total billed charges DIVALPROEX SOD DR 250 MG TAB 48458038_1 CDM 0250 RC 68084-0776-01 NDC inpatient 1 UN 1.27 0.83 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.83 65 999999999 0.77 1.23 percent of total billed charges DIVALPROEX SOD DR 250 MG TAB 48458038_1 CDM 0250 RC 68084-0776-01 NDC inpatient 1 UN 1.27 0.83 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.23 97 999999999 0.77 1.23 percent of total billed charges DIVALPROEX SOD DR 250 MG TAB 48458038_1 CDM 0250 RC 68084-0776-01 NDC inpatient 1 UN 1.27 0.83 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.88 69 999999999 0.77 1.23 percent of total billed charges DIVALPROEX SOD DR 250 MG TAB 48458038_1 CDM 0250 RC 68084-0776-01 NDC inpatient 1 UN 1.27 0.83 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.99 78 999999999 0.77 1.23 percent of total billed charges DIVALPROEX SOD DR 250 MG TAB 48458038_1 CDM 0250 RC 68084-0776-01 NDC inpatient 1 UN 1.27 0.83 UMR - ALL PLANS UMR - ALL PLANS 0.89 70 999999999 0.77 1.23 percent of total billed charges DIVALPROEX SOD DR 250 MG TAB 48458038_1 CDM 0250 RC 68084-0776-01 NDC inpatient 1 UN 1.27 0.83 SIHO - ALL PLANS SIHO - ALL PLANS 1.14 90 999999999 0.77 1.23 percent of total billed charges DIVALPROEX SOD DR 250 MG TAB 48458038_1 CDM 0250 RC 68084-0776-01 NDC inpatient 1 UN 1.27 0.83 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.77 60.55 999999999 0.77 1.23 percent of total billed charges DIVALPROEX SOD DR 250 MG TAB 48458038_1 CDM 0250 RC 68084-0776-01 NDC inpatient 1 UN 1.27 0.83 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.77 1.23 DIVALPROEX SOD DR 250 MG TAB 48458038_1 CDM 0250 RC 68084-0776-01 NDC inpatient 1 UN 1.27 0.83 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.77 1.23 DIVALPROEX SOD DR 250 MG TAB 48458038_1 CDM 0250 RC 68084-0776-01 NDC inpatient 1 UN 1.27 0.83 ANTHEM HMO ANTHEM HMO 999999999 0.77 1.23 DIVALPROEX SOD DR 250 MG TAB 48458038_1 CDM 0250 RC 68084-0776-01 NDC inpatient 1 UN 1.27 0.83 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.86 67.6 999999999 0.77 1.23 percent of total billed charges DIVALPROEX SOD DR 250 MG TAB 48458038_1 CDM 0250 RC 68084-0776-01 NDC inpatient 1 UN 1.27 0.83 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.77 1.23 DIVALPROEX SOD DR 250 MG TAB 48458038_1 CDM 0250 RC 68084-0776-01 NDC inpatient 1 UN 1.27 0.83 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.77 1.23 BUPIVACAIN 0.75%-DEXTROS 8.25% 48458039_1 CDM 0250 RC 00409-3613-01 NDC inpatient 1 UN 9.67 6.29 AETNA AETNA 7.64 79 999999999 5.86 9.38 percent of total billed charges BUPIVACAIN 0.75%-DEXTROS 8.25% 48458039_1 CDM 0250 RC 00409-3613-01 NDC inpatient 1 UN 9.67 6.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.29 65 999999999 5.86 9.38 percent of total billed charges BUPIVACAIN 0.75%-DEXTROS 8.25% 48458039_1 CDM 0250 RC 00409-3613-01 NDC inpatient 1 UN 9.67 6.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.38 97 999999999 5.86 9.38 percent of total billed charges BUPIVACAIN 0.75%-DEXTROS 8.25% 48458039_1 CDM 0250 RC 00409-3613-01 NDC inpatient 1 UN 9.67 6.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.67 69 999999999 5.86 9.38 percent of total billed charges BUPIVACAIN 0.75%-DEXTROS 8.25% 48458039_1 CDM 0250 RC 00409-3613-01 NDC inpatient 1 UN 9.67 6.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.54 78 999999999 5.86 9.38 percent of total billed charges BUPIVACAIN 0.75%-DEXTROS 8.25% 48458039_1 CDM 0250 RC 00409-3613-01 NDC inpatient 1 UN 9.67 6.29 UMR - ALL PLANS UMR - ALL PLANS 6.77 70 999999999 5.86 9.38 percent of total billed charges BUPIVACAIN 0.75%-DEXTROS 8.25% 48458039_1 CDM 0250 RC 00409-3613-01 NDC inpatient 1 UN 9.67 6.29 SIHO - ALL PLANS SIHO - ALL PLANS 8.7 90 999999999 5.86 9.38 percent of total billed charges BUPIVACAIN 0.75%-DEXTROS 8.25% 48458039_1 CDM 0250 RC 00409-3613-01 NDC inpatient 1 UN 9.67 6.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.86 60.55 999999999 5.86 9.38 percent of total billed charges BUPIVACAIN 0.75%-DEXTROS 8.25% 48458039_1 CDM 0250 RC 00409-3613-01 NDC inpatient 1 UN 9.67 6.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.86 9.38 BUPIVACAIN 0.75%-DEXTROS 8.25% 48458039_1 CDM 0250 RC 00409-3613-01 NDC inpatient 1 UN 9.67 6.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.86 9.38 BUPIVACAIN 0.75%-DEXTROS 8.25% 48458039_1 CDM 0250 RC 00409-3613-01 NDC inpatient 1 UN 9.67 6.29 ANTHEM HMO ANTHEM HMO 999999999 5.86 9.38 BUPIVACAIN 0.75%-DEXTROS 8.25% 48458039_1 CDM 0250 RC 00409-3613-01 NDC inpatient 1 UN 9.67 6.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.54 67.6 999999999 5.86 9.38 percent of total billed charges BUPIVACAIN 0.75%-DEXTROS 8.25% 48458039_1 CDM 0250 RC 00409-3613-01 NDC inpatient 1 UN 9.67 6.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.86 9.38 BUPIVACAIN 0.75%-DEXTROS 8.25% 48458039_1 CDM 0250 RC 00409-3613-01 NDC inpatient 1 UN 9.67 6.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.86 9.38 LIDOCAINE HCL 1% VIAL 48458046_1 CDM 0250 RC 00409-4276-01 NDC inpatient 1 UN 19.37 12.59 AETNA AETNA 15.3 79 999999999 11.73 18.79 percent of total billed charges LIDOCAINE HCL 1% VIAL 48458046_1 CDM 0250 RC 00409-4276-01 NDC inpatient 1 UN 19.37 12.59 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.59 65 999999999 11.73 18.79 percent of total billed charges LIDOCAINE HCL 1% VIAL 48458046_1 CDM 0250 RC 00409-4276-01 NDC inpatient 1 UN 19.37 12.59 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 18.79 97 999999999 11.73 18.79 percent of total billed charges LIDOCAINE HCL 1% VIAL 48458046_1 CDM 0250 RC 00409-4276-01 NDC inpatient 1 UN 19.37 12.59 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.37 69 999999999 11.73 18.79 percent of total billed charges LIDOCAINE HCL 1% VIAL 48458046_1 CDM 0250 RC 00409-4276-01 NDC inpatient 1 UN 19.37 12.59 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.11 78 999999999 11.73 18.79 percent of total billed charges LIDOCAINE HCL 1% VIAL 48458046_1 CDM 0250 RC 00409-4276-01 NDC inpatient 1 UN 19.37 12.59 UMR - ALL PLANS UMR - ALL PLANS 13.56 70 999999999 11.73 18.79 percent of total billed charges LIDOCAINE HCL 1% VIAL 48458046_1 CDM 0250 RC 00409-4276-01 NDC inpatient 1 UN 19.37 12.59 SIHO - ALL PLANS SIHO - ALL PLANS 17.43 90 999999999 11.73 18.79 percent of total billed charges LIDOCAINE HCL 1% VIAL 48458046_1 CDM 0250 RC 00409-4276-01 NDC inpatient 1 UN 19.37 12.59 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.73 60.55 999999999 11.73 18.79 percent of total billed charges LIDOCAINE HCL 1% VIAL 48458046_1 CDM 0250 RC 00409-4276-01 NDC inpatient 1 UN 19.37 12.59 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.73 18.79 LIDOCAINE HCL 1% VIAL 48458046_1 CDM 0250 RC 00409-4276-01 NDC inpatient 1 UN 19.37 12.59 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.73 18.79 LIDOCAINE HCL 1% VIAL 48458046_1 CDM 0250 RC 00409-4276-01 NDC inpatient 1 UN 19.37 12.59 ANTHEM HMO ANTHEM HMO 999999999 11.73 18.79 LIDOCAINE HCL 1% VIAL 48458046_1 CDM 0250 RC 00409-4276-01 NDC inpatient 1 UN 19.37 12.59 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.09 67.6 999999999 11.73 18.79 percent of total billed charges LIDOCAINE HCL 1% VIAL 48458046_1 CDM 0250 RC 00409-4276-01 NDC inpatient 1 UN 19.37 12.59 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.73 18.79 LIDOCAINE HCL 1% VIAL 48458046_1 CDM 0250 RC 00409-4276-01 NDC inpatient 1 UN 19.37 12.59 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.73 18.79 BACLOFEN 10 MG TABLET 48458056_1 CDM 0250 RC 68084-0855-01 NDC inpatient 1 UN 1.62 1.05 AETNA AETNA 1.28 79 999999999 0.98 1.57 percent of total billed charges BACLOFEN 10 MG TABLET 48458056_1 CDM 0250 RC 68084-0855-01 NDC inpatient 1 UN 1.62 1.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.05 65 999999999 0.98 1.57 percent of total billed charges BACLOFEN 10 MG TABLET 48458056_1 CDM 0250 RC 68084-0855-01 NDC inpatient 1 UN 1.62 1.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.57 97 999999999 0.98 1.57 percent of total billed charges BACLOFEN 10 MG TABLET 48458056_1 CDM 0250 RC 68084-0855-01 NDC inpatient 1 UN 1.62 1.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.12 69 999999999 0.98 1.57 percent of total billed charges BACLOFEN 10 MG TABLET 48458056_1 CDM 0250 RC 68084-0855-01 NDC inpatient 1 UN 1.62 1.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.26 78 999999999 0.98 1.57 percent of total billed charges BACLOFEN 10 MG TABLET 48458056_1 CDM 0250 RC 68084-0855-01 NDC inpatient 1 UN 1.62 1.05 UMR - ALL PLANS UMR - ALL PLANS 1.13 70 999999999 0.98 1.57 percent of total billed charges BACLOFEN 10 MG TABLET 48458056_1 CDM 0250 RC 68084-0855-01 NDC inpatient 1 UN 1.62 1.05 SIHO - ALL PLANS SIHO - ALL PLANS 1.46 90 999999999 0.98 1.57 percent of total billed charges BACLOFEN 10 MG TABLET 48458056_1 CDM 0250 RC 68084-0855-01 NDC inpatient 1 UN 1.62 1.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.98 60.55 999999999 0.98 1.57 percent of total billed charges BACLOFEN 10 MG TABLET 48458056_1 CDM 0250 RC 68084-0855-01 NDC inpatient 1 UN 1.62 1.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.98 1.57 BACLOFEN 10 MG TABLET 48458056_1 CDM 0250 RC 68084-0855-01 NDC inpatient 1 UN 1.62 1.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.98 1.57 BACLOFEN 10 MG TABLET 48458056_1 CDM 0250 RC 68084-0855-01 NDC inpatient 1 UN 1.62 1.05 ANTHEM HMO ANTHEM HMO 999999999 0.98 1.57 BACLOFEN 10 MG TABLET 48458056_1 CDM 0250 RC 68084-0855-01 NDC inpatient 1 UN 1.62 1.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.1 67.6 999999999 0.98 1.57 percent of total billed charges BACLOFEN 10 MG TABLET 48458056_1 CDM 0250 RC 68084-0855-01 NDC inpatient 1 UN 1.62 1.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.98 1.57 BACLOFEN 10 MG TABLET 48458056_1 CDM 0250 RC 68084-0855-01 NDC inpatient 1 UN 1.62 1.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.98 1.57 AMOX-CLAV 875-125 MG TABLET 48458058_1 CDM 0250 RC 65862-0503-20 NDC inpatient 1 UN 1.99 1.29 AETNA AETNA 1.57 79 999999999 1.2 1.93 percent of total billed charges AMOX-CLAV 875-125 MG TABLET 48458058_1 CDM 0250 RC 65862-0503-20 NDC inpatient 1 UN 1.99 1.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.29 65 999999999 1.2 1.93 percent of total billed charges AMOX-CLAV 875-125 MG TABLET 48458058_1 CDM 0250 RC 65862-0503-20 NDC inpatient 1 UN 1.99 1.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.93 97 999999999 1.2 1.93 percent of total billed charges AMOX-CLAV 875-125 MG TABLET 48458058_1 CDM 0250 RC 65862-0503-20 NDC inpatient 1 UN 1.99 1.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.37 69 999999999 1.2 1.93 percent of total billed charges AMOX-CLAV 875-125 MG TABLET 48458058_1 CDM 0250 RC 65862-0503-20 NDC inpatient 1 UN 1.99 1.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.55 78 999999999 1.2 1.93 percent of total billed charges AMOX-CLAV 875-125 MG TABLET 48458058_1 CDM 0250 RC 65862-0503-20 NDC inpatient 1 UN 1.99 1.29 UMR - ALL PLANS UMR - ALL PLANS 1.39 70 999999999 1.2 1.93 percent of total billed charges AMOX-CLAV 875-125 MG TABLET 48458058_1 CDM 0250 RC 65862-0503-20 NDC inpatient 1 UN 1.99 1.29 SIHO - ALL PLANS SIHO - ALL PLANS 1.79 90 999999999 1.2 1.93 percent of total billed charges AMOX-CLAV 875-125 MG TABLET 48458058_1 CDM 0250 RC 65862-0503-20 NDC inpatient 1 UN 1.99 1.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.2 60.55 999999999 1.2 1.93 percent of total billed charges AMOX-CLAV 875-125 MG TABLET 48458058_1 CDM 0250 RC 65862-0503-20 NDC inpatient 1 UN 1.99 1.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.2 1.93 AMOX-CLAV 875-125 MG TABLET 48458058_1 CDM 0250 RC 65862-0503-20 NDC inpatient 1 UN 1.99 1.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.2 1.93 AMOX-CLAV 875-125 MG TABLET 48458058_1 CDM 0250 RC 65862-0503-20 NDC inpatient 1 UN 1.99 1.29 ANTHEM HMO ANTHEM HMO 999999999 1.2 1.93 AMOX-CLAV 875-125 MG TABLET 48458058_1 CDM 0250 RC 65862-0503-20 NDC inpatient 1 UN 1.99 1.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.2 1.93 percent of total billed charges AMOX-CLAV 875-125 MG TABLET 48458058_1 CDM 0250 RC 65862-0503-20 NDC inpatient 1 UN 1.99 1.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.2 1.93 AMOX-CLAV 875-125 MG TABLET 48458058_1 CDM 0250 RC 65862-0503-20 NDC inpatient 1 UN 1.99 1.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.2 1.93 "XYLOCAINE 2%-EPI 1:200,000" 48458074_1 CDM 0250 RC 63323-0489-27 NDC inpatient 10 UN 72.5 47.13 AETNA AETNA 57.28 79 999999999 43.9 70.33 percent of total billed charges "XYLOCAINE 2%-EPI 1:200,000" 48458074_1 CDM 0250 RC 63323-0489-27 NDC inpatient 10 UN 72.5 47.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.13 65 999999999 43.9 70.33 percent of total billed charges "XYLOCAINE 2%-EPI 1:200,000" 48458074_1 CDM 0250 RC 63323-0489-27 NDC inpatient 10 UN 72.5 47.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.33 97 999999999 43.9 70.33 percent of total billed charges "XYLOCAINE 2%-EPI 1:200,000" 48458074_1 CDM 0250 RC 63323-0489-27 NDC inpatient 10 UN 72.5 47.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.03 69 999999999 43.9 70.33 percent of total billed charges "XYLOCAINE 2%-EPI 1:200,000" 48458074_1 CDM 0250 RC 63323-0489-27 NDC inpatient 10 UN 72.5 47.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.55 78 999999999 43.9 70.33 percent of total billed charges "XYLOCAINE 2%-EPI 1:200,000" 48458074_1 CDM 0250 RC 63323-0489-27 NDC inpatient 10 UN 72.5 47.13 UMR - ALL PLANS UMR - ALL PLANS 50.75 70 999999999 43.9 70.33 percent of total billed charges "XYLOCAINE 2%-EPI 1:200,000" 48458074_1 CDM 0250 RC 63323-0489-27 NDC inpatient 10 UN 72.5 47.13 SIHO - ALL PLANS SIHO - ALL PLANS 65.25 90 999999999 43.9 70.33 percent of total billed charges "XYLOCAINE 2%-EPI 1:200,000" 48458074_1 CDM 0250 RC 63323-0489-27 NDC inpatient 10 UN 72.5 47.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.9 60.55 999999999 43.9 70.33 percent of total billed charges "XYLOCAINE 2%-EPI 1:200,000" 48458074_1 CDM 0250 RC 63323-0489-27 NDC inpatient 10 UN 72.5 47.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.9 70.33 "XYLOCAINE 2%-EPI 1:200,000" 48458074_1 CDM 0250 RC 63323-0489-27 NDC inpatient 10 UN 72.5 47.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.9 70.33 "XYLOCAINE 2%-EPI 1:200,000" 48458074_1 CDM 0250 RC 63323-0489-27 NDC inpatient 10 UN 72.5 47.13 ANTHEM HMO ANTHEM HMO 999999999 43.9 70.33 "XYLOCAINE 2%-EPI 1:200,000" 48458074_1 CDM 0250 RC 63323-0489-27 NDC inpatient 10 UN 72.5 47.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.01 67.6 999999999 43.9 70.33 percent of total billed charges "XYLOCAINE 2%-EPI 1:200,000" 48458074_1 CDM 0250 RC 63323-0489-27 NDC inpatient 10 UN 72.5 47.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.9 70.33 "XYLOCAINE 2%-EPI 1:200,000" 48458074_1 CDM 0250 RC 63323-0489-27 NDC inpatient 10 UN 72.5 47.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.9 70.33 NP THYROID 30 MG TABLET 48458105_1 CDM 0250 RC 42192-0329-01 NDC inpatient 1 UN 2.41 1.57 AETNA AETNA 1.9 79 999999999 1.46 2.34 percent of total billed charges NP THYROID 30 MG TABLET 48458105_1 CDM 0250 RC 42192-0329-01 NDC inpatient 1 UN 2.41 1.57 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.57 65 999999999 1.46 2.34 percent of total billed charges NP THYROID 30 MG TABLET 48458105_1 CDM 0250 RC 42192-0329-01 NDC inpatient 1 UN 2.41 1.57 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.34 97 999999999 1.46 2.34 percent of total billed charges NP THYROID 30 MG TABLET 48458105_1 CDM 0250 RC 42192-0329-01 NDC inpatient 1 UN 2.41 1.57 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.66 69 999999999 1.46 2.34 percent of total billed charges NP THYROID 30 MG TABLET 48458105_1 CDM 0250 RC 42192-0329-01 NDC inpatient 1 UN 2.41 1.57 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.88 78 999999999 1.46 2.34 percent of total billed charges NP THYROID 30 MG TABLET 48458105_1 CDM 0250 RC 42192-0329-01 NDC inpatient 1 UN 2.41 1.57 UMR - ALL PLANS UMR - ALL PLANS 1.69 70 999999999 1.46 2.34 percent of total billed charges NP THYROID 30 MG TABLET 48458105_1 CDM 0250 RC 42192-0329-01 NDC inpatient 1 UN 2.41 1.57 SIHO - ALL PLANS SIHO - ALL PLANS 2.17 90 999999999 1.46 2.34 percent of total billed charges NP THYROID 30 MG TABLET 48458105_1 CDM 0250 RC 42192-0329-01 NDC inpatient 1 UN 2.41 1.57 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.46 60.55 999999999 1.46 2.34 percent of total billed charges NP THYROID 30 MG TABLET 48458105_1 CDM 0250 RC 42192-0329-01 NDC inpatient 1 UN 2.41 1.57 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.46 2.34 NP THYROID 30 MG TABLET 48458105_1 CDM 0250 RC 42192-0329-01 NDC inpatient 1 UN 2.41 1.57 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.46 2.34 NP THYROID 30 MG TABLET 48458105_1 CDM 0250 RC 42192-0329-01 NDC inpatient 1 UN 2.41 1.57 ANTHEM HMO ANTHEM HMO 999999999 1.46 2.34 NP THYROID 30 MG TABLET 48458105_1 CDM 0250 RC 42192-0329-01 NDC inpatient 1 UN 2.41 1.57 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.63 67.6 999999999 1.46 2.34 percent of total billed charges NP THYROID 30 MG TABLET 48458105_1 CDM 0250 RC 42192-0329-01 NDC inpatient 1 UN 2.41 1.57 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.46 2.34 NP THYROID 30 MG TABLET 48458105_1 CDM 0250 RC 42192-0329-01 NDC inpatient 1 UN 2.41 1.57 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.46 2.34 TIZANIDINE HCL 4 MG TABLET 48458109_1 CDM 0250 RC 68084-0645-01 NDC inpatient 1 UN 1.75 1.14 AETNA AETNA 1.38 79 999999999 1.06 1.7 percent of total billed charges TIZANIDINE HCL 4 MG TABLET 48458109_1 CDM 0250 RC 68084-0645-01 NDC inpatient 1 UN 1.75 1.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.14 65 999999999 1.06 1.7 percent of total billed charges TIZANIDINE HCL 4 MG TABLET 48458109_1 CDM 0250 RC 68084-0645-01 NDC inpatient 1 UN 1.75 1.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.7 97 999999999 1.06 1.7 percent of total billed charges TIZANIDINE HCL 4 MG TABLET 48458109_1 CDM 0250 RC 68084-0645-01 NDC inpatient 1 UN 1.75 1.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.21 69 999999999 1.06 1.7 percent of total billed charges TIZANIDINE HCL 4 MG TABLET 48458109_1 CDM 0250 RC 68084-0645-01 NDC inpatient 1 UN 1.75 1.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.37 78 999999999 1.06 1.7 percent of total billed charges TIZANIDINE HCL 4 MG TABLET 48458109_1 CDM 0250 RC 68084-0645-01 NDC inpatient 1 UN 1.75 1.14 UMR - ALL PLANS UMR - ALL PLANS 1.23 70 999999999 1.06 1.7 percent of total billed charges TIZANIDINE HCL 4 MG TABLET 48458109_1 CDM 0250 RC 68084-0645-01 NDC inpatient 1 UN 1.75 1.14 SIHO - ALL PLANS SIHO - ALL PLANS 1.58 90 999999999 1.06 1.7 percent of total billed charges TIZANIDINE HCL 4 MG TABLET 48458109_1 CDM 0250 RC 68084-0645-01 NDC inpatient 1 UN 1.75 1.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.06 60.55 999999999 1.06 1.7 percent of total billed charges TIZANIDINE HCL 4 MG TABLET 48458109_1 CDM 0250 RC 68084-0645-01 NDC inpatient 1 UN 1.75 1.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.06 1.7 TIZANIDINE HCL 4 MG TABLET 48458109_1 CDM 0250 RC 68084-0645-01 NDC inpatient 1 UN 1.75 1.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.06 1.7 TIZANIDINE HCL 4 MG TABLET 48458109_1 CDM 0250 RC 68084-0645-01 NDC inpatient 1 UN 1.75 1.14 ANTHEM HMO ANTHEM HMO 999999999 1.06 1.7 TIZANIDINE HCL 4 MG TABLET 48458109_1 CDM 0250 RC 68084-0645-01 NDC inpatient 1 UN 1.75 1.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.18 67.6 999999999 1.06 1.7 percent of total billed charges TIZANIDINE HCL 4 MG TABLET 48458109_1 CDM 0250 RC 68084-0645-01 NDC inpatient 1 UN 1.75 1.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.06 1.7 TIZANIDINE HCL 4 MG TABLET 48458109_1 CDM 0250 RC 68084-0645-01 NDC inpatient 1 UN 1.75 1.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.06 1.7 TORSEMIDE 20 MG TABLET 48460393_1 CDM 0250 RC 68084-0539-01 NDC inpatient 1 UN 1.39 0.9 AETNA AETNA 1.1 79 999999999 0.84 1.35 percent of total billed charges TORSEMIDE 20 MG TABLET 48460393_1 CDM 0250 RC 68084-0539-01 NDC inpatient 1 UN 1.39 0.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.9 65 999999999 0.84 1.35 percent of total billed charges TORSEMIDE 20 MG TABLET 48460393_1 CDM 0250 RC 68084-0539-01 NDC inpatient 1 UN 1.39 0.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.35 97 999999999 0.84 1.35 percent of total billed charges TORSEMIDE 20 MG TABLET 48460393_1 CDM 0250 RC 68084-0539-01 NDC inpatient 1 UN 1.39 0.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.96 69 999999999 0.84 1.35 percent of total billed charges TORSEMIDE 20 MG TABLET 48460393_1 CDM 0250 RC 68084-0539-01 NDC inpatient 1 UN 1.39 0.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.08 78 999999999 0.84 1.35 percent of total billed charges TORSEMIDE 20 MG TABLET 48460393_1 CDM 0250 RC 68084-0539-01 NDC inpatient 1 UN 1.39 0.9 UMR - ALL PLANS UMR - ALL PLANS 0.97 70 999999999 0.84 1.35 percent of total billed charges TORSEMIDE 20 MG TABLET 48460393_1 CDM 0250 RC 68084-0539-01 NDC inpatient 1 UN 1.39 0.9 SIHO - ALL PLANS SIHO - ALL PLANS 1.25 90 999999999 0.84 1.35 percent of total billed charges TORSEMIDE 20 MG TABLET 48460393_1 CDM 0250 RC 68084-0539-01 NDC inpatient 1 UN 1.39 0.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.84 60.55 999999999 0.84 1.35 percent of total billed charges TORSEMIDE 20 MG TABLET 48460393_1 CDM 0250 RC 68084-0539-01 NDC inpatient 1 UN 1.39 0.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.84 1.35 TORSEMIDE 20 MG TABLET 48460393_1 CDM 0250 RC 68084-0539-01 NDC inpatient 1 UN 1.39 0.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.84 1.35 TORSEMIDE 20 MG TABLET 48460393_1 CDM 0250 RC 68084-0539-01 NDC inpatient 1 UN 1.39 0.9 ANTHEM HMO ANTHEM HMO 999999999 0.84 1.35 TORSEMIDE 20 MG TABLET 48460393_1 CDM 0250 RC 68084-0539-01 NDC inpatient 1 UN 1.39 0.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.94 67.6 999999999 0.84 1.35 percent of total billed charges TORSEMIDE 20 MG TABLET 48460393_1 CDM 0250 RC 68084-0539-01 NDC inpatient 1 UN 1.39 0.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.84 1.35 TORSEMIDE 20 MG TABLET 48460393_1 CDM 0250 RC 68084-0539-01 NDC inpatient 1 UN 1.39 0.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.84 1.35 TERAZOSIN 10 MG CAPSULE 48460396_1 CDM 0250 RC 59746-0386-06 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges TERAZOSIN 10 MG CAPSULE 48460396_1 CDM 0250 RC 59746-0386-06 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges TERAZOSIN 10 MG CAPSULE 48460396_1 CDM 0250 RC 59746-0386-06 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges TERAZOSIN 10 MG CAPSULE 48460396_1 CDM 0250 RC 59746-0386-06 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges TERAZOSIN 10 MG CAPSULE 48460396_1 CDM 0250 RC 59746-0386-06 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges TERAZOSIN 10 MG CAPSULE 48460396_1 CDM 0250 RC 59746-0386-06 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges TERAZOSIN 10 MG CAPSULE 48460396_1 CDM 0250 RC 59746-0386-06 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges TERAZOSIN 10 MG CAPSULE 48460396_1 CDM 0250 RC 59746-0386-06 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges TERAZOSIN 10 MG CAPSULE 48460396_1 CDM 0250 RC 59746-0386-06 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 TERAZOSIN 10 MG CAPSULE 48460396_1 CDM 0250 RC 59746-0386-06 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 TERAZOSIN 10 MG CAPSULE 48460396_1 CDM 0250 RC 59746-0386-06 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 TERAZOSIN 10 MG CAPSULE 48460396_1 CDM 0250 RC 59746-0386-06 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges TERAZOSIN 10 MG CAPSULE 48460396_1 CDM 0250 RC 59746-0386-06 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 TERAZOSIN 10 MG CAPSULE 48460396_1 CDM 0250 RC 59746-0386-06 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 SPIRONOLACTONE 100 MG TABLET 48460402_1 CDM 0250 RC 53746-0515-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges SPIRONOLACTONE 100 MG TABLET 48460402_1 CDM 0250 RC 53746-0515-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges SPIRONOLACTONE 100 MG TABLET 48460402_1 CDM 0250 RC 53746-0515-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges SPIRONOLACTONE 100 MG TABLET 48460402_1 CDM 0250 RC 53746-0515-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges SPIRONOLACTONE 100 MG TABLET 48460402_1 CDM 0250 RC 53746-0515-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges SPIRONOLACTONE 100 MG TABLET 48460402_1 CDM 0250 RC 53746-0515-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges SPIRONOLACTONE 100 MG TABLET 48460402_1 CDM 0250 RC 53746-0515-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges SPIRONOLACTONE 100 MG TABLET 48460402_1 CDM 0250 RC 53746-0515-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges SPIRONOLACTONE 100 MG TABLET 48460402_1 CDM 0250 RC 53746-0515-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 SPIRONOLACTONE 100 MG TABLET 48460402_1 CDM 0250 RC 53746-0515-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 SPIRONOLACTONE 100 MG TABLET 48460402_1 CDM 0250 RC 53746-0515-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 SPIRONOLACTONE 100 MG TABLET 48460402_1 CDM 0250 RC 53746-0515-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges SPIRONOLACTONE 100 MG TABLET 48460402_1 CDM 0250 RC 53746-0515-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 SPIRONOLACTONE 100 MG TABLET 48460402_1 CDM 0250 RC 53746-0515-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 SUCRALFATE 1 GM TABLET 48460404_1 CDM 0250 RC 51079-0753-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges SUCRALFATE 1 GM TABLET 48460404_1 CDM 0250 RC 51079-0753-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges SUCRALFATE 1 GM TABLET 48460404_1 CDM 0250 RC 51079-0753-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges SUCRALFATE 1 GM TABLET 48460404_1 CDM 0250 RC 51079-0753-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges SUCRALFATE 1 GM TABLET 48460404_1 CDM 0250 RC 51079-0753-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges SUCRALFATE 1 GM TABLET 48460404_1 CDM 0250 RC 51079-0753-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges SUCRALFATE 1 GM TABLET 48460404_1 CDM 0250 RC 51079-0753-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges SUCRALFATE 1 GM TABLET 48460404_1 CDM 0250 RC 51079-0753-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges SUCRALFATE 1 GM TABLET 48460404_1 CDM 0250 RC 51079-0753-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 SUCRALFATE 1 GM TABLET 48460404_1 CDM 0250 RC 51079-0753-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 SUCRALFATE 1 GM TABLET 48460404_1 CDM 0250 RC 51079-0753-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 SUCRALFATE 1 GM TABLET 48460404_1 CDM 0250 RC 51079-0753-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges SUCRALFATE 1 GM TABLET 48460404_1 CDM 0250 RC 51079-0753-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 SUCRALFATE 1 GM TABLET 48460404_1 CDM 0250 RC 51079-0753-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CARBIDOPA-LEVO ER 25-100 TAB 48460872_1 CDM 0250 RC 68084-0281-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO ER 25-100 TAB 48460872_1 CDM 0250 RC 68084-0281-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO ER 25-100 TAB 48460872_1 CDM 0250 RC 68084-0281-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO ER 25-100 TAB 48460872_1 CDM 0250 RC 68084-0281-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO ER 25-100 TAB 48460872_1 CDM 0250 RC 68084-0281-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO ER 25-100 TAB 48460872_1 CDM 0250 RC 68084-0281-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO ER 25-100 TAB 48460872_1 CDM 0250 RC 68084-0281-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO ER 25-100 TAB 48460872_1 CDM 0250 RC 68084-0281-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO ER 25-100 TAB 48460872_1 CDM 0250 RC 68084-0281-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CARBIDOPA-LEVO ER 25-100 TAB 48460872_1 CDM 0250 RC 68084-0281-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CARBIDOPA-LEVO ER 25-100 TAB 48460872_1 CDM 0250 RC 68084-0281-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CARBIDOPA-LEVO ER 25-100 TAB 48460872_1 CDM 0250 RC 68084-0281-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO ER 25-100 TAB 48460872_1 CDM 0250 RC 68084-0281-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CARBIDOPA-LEVO ER 25-100 TAB 48460872_1 CDM 0250 RC 68084-0281-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 VENLAFAXINE HCL 50 MG TABLET 48460875_1 CDM 0250 RC 68001-0159-00 NDC inpatient 1 UN 1.18 0.77 AETNA AETNA 0.93 79 999999999 0.71 1.14 percent of total billed charges VENLAFAXINE HCL 50 MG TABLET 48460875_1 CDM 0250 RC 68001-0159-00 NDC inpatient 1 UN 1.18 0.77 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.77 65 999999999 0.71 1.14 percent of total billed charges VENLAFAXINE HCL 50 MG TABLET 48460875_1 CDM 0250 RC 68001-0159-00 NDC inpatient 1 UN 1.18 0.77 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.14 97 999999999 0.71 1.14 percent of total billed charges VENLAFAXINE HCL 50 MG TABLET 48460875_1 CDM 0250 RC 68001-0159-00 NDC inpatient 1 UN 1.18 0.77 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.81 69 999999999 0.71 1.14 percent of total billed charges VENLAFAXINE HCL 50 MG TABLET 48460875_1 CDM 0250 RC 68001-0159-00 NDC inpatient 1 UN 1.18 0.77 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.92 78 999999999 0.71 1.14 percent of total billed charges VENLAFAXINE HCL 50 MG TABLET 48460875_1 CDM 0250 RC 68001-0159-00 NDC inpatient 1 UN 1.18 0.77 UMR - ALL PLANS UMR - ALL PLANS 0.83 70 999999999 0.71 1.14 percent of total billed charges VENLAFAXINE HCL 50 MG TABLET 48460875_1 CDM 0250 RC 68001-0159-00 NDC inpatient 1 UN 1.18 0.77 SIHO - ALL PLANS SIHO - ALL PLANS 1.06 90 999999999 0.71 1.14 percent of total billed charges VENLAFAXINE HCL 50 MG TABLET 48460875_1 CDM 0250 RC 68001-0159-00 NDC inpatient 1 UN 1.18 0.77 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.71 60.55 999999999 0.71 1.14 percent of total billed charges VENLAFAXINE HCL 50 MG TABLET 48460875_1 CDM 0250 RC 68001-0159-00 NDC inpatient 1 UN 1.18 0.77 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.71 1.14 VENLAFAXINE HCL 50 MG TABLET 48460875_1 CDM 0250 RC 68001-0159-00 NDC inpatient 1 UN 1.18 0.77 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.71 1.14 VENLAFAXINE HCL 50 MG TABLET 48460875_1 CDM 0250 RC 68001-0159-00 NDC inpatient 1 UN 1.18 0.77 ANTHEM HMO ANTHEM HMO 999999999 0.71 1.14 VENLAFAXINE HCL 50 MG TABLET 48460875_1 CDM 0250 RC 68001-0159-00 NDC inpatient 1 UN 1.18 0.77 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.8 67.6 999999999 0.71 1.14 percent of total billed charges VENLAFAXINE HCL 50 MG TABLET 48460875_1 CDM 0250 RC 68001-0159-00 NDC inpatient 1 UN 1.18 0.77 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.71 1.14 VENLAFAXINE HCL 50 MG TABLET 48460875_1 CDM 0250 RC 68001-0159-00 NDC inpatient 1 UN 1.18 0.77 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.71 1.14 VENLAFAXINE HCL 75 MG TABLET 48460876_1 CDM 0250 RC 68001-0160-00 NDC inpatient 1 UN 1.07 0.7 AETNA AETNA 0.85 79 999999999 0.65 1.04 percent of total billed charges VENLAFAXINE HCL 75 MG TABLET 48460876_1 CDM 0250 RC 68001-0160-00 NDC inpatient 1 UN 1.07 0.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.7 65 999999999 0.65 1.04 percent of total billed charges VENLAFAXINE HCL 75 MG TABLET 48460876_1 CDM 0250 RC 68001-0160-00 NDC inpatient 1 UN 1.07 0.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.04 97 999999999 0.65 1.04 percent of total billed charges VENLAFAXINE HCL 75 MG TABLET 48460876_1 CDM 0250 RC 68001-0160-00 NDC inpatient 1 UN 1.07 0.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.74 69 999999999 0.65 1.04 percent of total billed charges VENLAFAXINE HCL 75 MG TABLET 48460876_1 CDM 0250 RC 68001-0160-00 NDC inpatient 1 UN 1.07 0.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.83 78 999999999 0.65 1.04 percent of total billed charges VENLAFAXINE HCL 75 MG TABLET 48460876_1 CDM 0250 RC 68001-0160-00 NDC inpatient 1 UN 1.07 0.7 UMR - ALL PLANS UMR - ALL PLANS 0.75 70 999999999 0.65 1.04 percent of total billed charges VENLAFAXINE HCL 75 MG TABLET 48460876_1 CDM 0250 RC 68001-0160-00 NDC inpatient 1 UN 1.07 0.7 SIHO - ALL PLANS SIHO - ALL PLANS 0.96 90 999999999 0.65 1.04 percent of total billed charges VENLAFAXINE HCL 75 MG TABLET 48460876_1 CDM 0250 RC 68001-0160-00 NDC inpatient 1 UN 1.07 0.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.65 60.55 999999999 0.65 1.04 percent of total billed charges VENLAFAXINE HCL 75 MG TABLET 48460876_1 CDM 0250 RC 68001-0160-00 NDC inpatient 1 UN 1.07 0.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.65 1.04 VENLAFAXINE HCL 75 MG TABLET 48460876_1 CDM 0250 RC 68001-0160-00 NDC inpatient 1 UN 1.07 0.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.65 1.04 VENLAFAXINE HCL 75 MG TABLET 48460876_1 CDM 0250 RC 68001-0160-00 NDC inpatient 1 UN 1.07 0.7 ANTHEM HMO ANTHEM HMO 999999999 0.65 1.04 VENLAFAXINE HCL 75 MG TABLET 48460876_1 CDM 0250 RC 68001-0160-00 NDC inpatient 1 UN 1.07 0.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.72 67.6 999999999 0.65 1.04 percent of total billed charges VENLAFAXINE HCL 75 MG TABLET 48460876_1 CDM 0250 RC 68001-0160-00 NDC inpatient 1 UN 1.07 0.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.65 1.04 VENLAFAXINE HCL 75 MG TABLET 48460876_1 CDM 0250 RC 68001-0160-00 NDC inpatient 1 UN 1.07 0.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.65 1.04 VENLAFAXINE HCL ER 75 MG CAP 48460880_1 CDM 0250 RC 68084-0709-01 NDC inpatient 1 UN 1.53 0.99 AETNA AETNA 1.21 79 999999999 0.93 1.48 percent of total billed charges VENLAFAXINE HCL ER 75 MG CAP 48460880_1 CDM 0250 RC 68084-0709-01 NDC inpatient 1 UN 1.53 0.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.99 65 999999999 0.93 1.48 percent of total billed charges VENLAFAXINE HCL ER 75 MG CAP 48460880_1 CDM 0250 RC 68084-0709-01 NDC inpatient 1 UN 1.53 0.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.48 97 999999999 0.93 1.48 percent of total billed charges VENLAFAXINE HCL ER 75 MG CAP 48460880_1 CDM 0250 RC 68084-0709-01 NDC inpatient 1 UN 1.53 0.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.06 69 999999999 0.93 1.48 percent of total billed charges VENLAFAXINE HCL ER 75 MG CAP 48460880_1 CDM 0250 RC 68084-0709-01 NDC inpatient 1 UN 1.53 0.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.19 78 999999999 0.93 1.48 percent of total billed charges VENLAFAXINE HCL ER 75 MG CAP 48460880_1 CDM 0250 RC 68084-0709-01 NDC inpatient 1 UN 1.53 0.99 UMR - ALL PLANS UMR - ALL PLANS 1.07 70 999999999 0.93 1.48 percent of total billed charges VENLAFAXINE HCL ER 75 MG CAP 48460880_1 CDM 0250 RC 68084-0709-01 NDC inpatient 1 UN 1.53 0.99 SIHO - ALL PLANS SIHO - ALL PLANS 1.38 90 999999999 0.93 1.48 percent of total billed charges VENLAFAXINE HCL ER 75 MG CAP 48460880_1 CDM 0250 RC 68084-0709-01 NDC inpatient 1 UN 1.53 0.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.93 60.55 999999999 0.93 1.48 percent of total billed charges VENLAFAXINE HCL ER 75 MG CAP 48460880_1 CDM 0250 RC 68084-0709-01 NDC inpatient 1 UN 1.53 0.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.93 1.48 VENLAFAXINE HCL ER 75 MG CAP 48460880_1 CDM 0250 RC 68084-0709-01 NDC inpatient 1 UN 1.53 0.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.93 1.48 VENLAFAXINE HCL ER 75 MG CAP 48460880_1 CDM 0250 RC 68084-0709-01 NDC inpatient 1 UN 1.53 0.99 ANTHEM HMO ANTHEM HMO 999999999 0.93 1.48 VENLAFAXINE HCL ER 75 MG CAP 48460880_1 CDM 0250 RC 68084-0709-01 NDC inpatient 1 UN 1.53 0.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.03 67.6 999999999 0.93 1.48 percent of total billed charges VENLAFAXINE HCL ER 75 MG CAP 48460880_1 CDM 0250 RC 68084-0709-01 NDC inpatient 1 UN 1.53 0.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.93 1.48 VENLAFAXINE HCL ER 75 MG CAP 48460880_1 CDM 0250 RC 68084-0709-01 NDC inpatient 1 UN 1.53 0.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.93 1.48 00056-0169-75 - warfarin 1 mg Tab [JOHN] 48460896_1 CDM 0250 RC 00056-0169-75 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 00056-0169-75 - warfarin 1 mg Tab [JOHN] 48460896_1 CDM 0250 RC 00056-0169-75 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 00056-0169-75 - warfarin 1 mg Tab [JOHN] 48460896_1 CDM 0250 RC 00056-0169-75 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 00056-0169-75 - warfarin 1 mg Tab [JOHN] 48460896_1 CDM 0250 RC 00056-0169-75 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 00056-0169-75 - warfarin 1 mg Tab [JOHN] 48460896_1 CDM 0250 RC 00056-0169-75 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 00056-0169-75 - warfarin 1 mg Tab [JOHN] 48460896_1 CDM 0250 RC 00056-0169-75 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 00056-0169-75 - warfarin 1 mg Tab [JOHN] 48460896_1 CDM 0250 RC 00056-0169-75 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 00056-0169-75 - warfarin 1 mg Tab [JOHN] 48460896_1 CDM 0250 RC 00056-0169-75 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 00056-0169-75 - warfarin 1 mg Tab [JOHN] 48460896_1 CDM 0250 RC 00056-0169-75 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 00056-0169-75 - warfarin 1 mg Tab [JOHN] 48460896_1 CDM 0250 RC 00056-0169-75 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 00056-0169-75 - warfarin 1 mg Tab [JOHN] 48460896_1 CDM 0250 RC 00056-0169-75 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 00056-0169-75 - warfarin 1 mg Tab [JOHN] 48460896_1 CDM 0250 RC 00056-0169-75 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 00056-0169-75 - warfarin 1 mg Tab [JOHN] 48460896_1 CDM 0250 RC 00056-0169-75 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 00056-0169-75 - warfarin 1 mg Tab [JOHN] 48460896_1 CDM 0250 RC 00056-0169-75 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 00056-0188-75 - warfarin 3 mg Tab [JOHN] 48460897_1 CDM 0250 RC 00056-0188-75 NDC inpatient 1 UN 1.6 1.04 AETNA AETNA 1.26 79 999999999 0.97 1.55 percent of total billed charges 00056-0188-75 - warfarin 3 mg Tab [JOHN] 48460897_1 CDM 0250 RC 00056-0188-75 NDC inpatient 1 UN 1.6 1.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.04 65 999999999 0.97 1.55 percent of total billed charges 00056-0188-75 - warfarin 3 mg Tab [JOHN] 48460897_1 CDM 0250 RC 00056-0188-75 NDC inpatient 1 UN 1.6 1.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.55 97 999999999 0.97 1.55 percent of total billed charges 00056-0188-75 - warfarin 3 mg Tab [JOHN] 48460897_1 CDM 0250 RC 00056-0188-75 NDC inpatient 1 UN 1.6 1.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.1 69 999999999 0.97 1.55 percent of total billed charges 00056-0188-75 - warfarin 3 mg Tab [JOHN] 48460897_1 CDM 0250 RC 00056-0188-75 NDC inpatient 1 UN 1.6 1.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.25 78 999999999 0.97 1.55 percent of total billed charges 00056-0188-75 - warfarin 3 mg Tab [JOHN] 48460897_1 CDM 0250 RC 00056-0188-75 NDC inpatient 1 UN 1.6 1.04 UMR - ALL PLANS UMR - ALL PLANS 1.12 70 999999999 0.97 1.55 percent of total billed charges 00056-0188-75 - warfarin 3 mg Tab [JOHN] 48460897_1 CDM 0250 RC 00056-0188-75 NDC inpatient 1 UN 1.6 1.04 SIHO - ALL PLANS SIHO - ALL PLANS 1.44 90 999999999 0.97 1.55 percent of total billed charges 00056-0188-75 - warfarin 3 mg Tab [JOHN] 48460897_1 CDM 0250 RC 00056-0188-75 NDC inpatient 1 UN 1.6 1.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.97 60.55 999999999 0.97 1.55 percent of total billed charges 00056-0188-75 - warfarin 3 mg Tab [JOHN] 48460897_1 CDM 0250 RC 00056-0188-75 NDC inpatient 1 UN 1.6 1.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.97 1.55 00056-0188-75 - warfarin 3 mg Tab [JOHN] 48460897_1 CDM 0250 RC 00056-0188-75 NDC inpatient 1 UN 1.6 1.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.97 1.55 00056-0188-75 - warfarin 3 mg Tab [JOHN] 48460897_1 CDM 0250 RC 00056-0188-75 NDC inpatient 1 UN 1.6 1.04 ANTHEM HMO ANTHEM HMO 999999999 0.97 1.55 00056-0188-75 - warfarin 3 mg Tab [JOHN] 48460897_1 CDM 0250 RC 00056-0188-75 NDC inpatient 1 UN 1.6 1.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.08 67.6 999999999 0.97 1.55 percent of total billed charges 00056-0188-75 - warfarin 3 mg Tab [JOHN] 48460897_1 CDM 0250 RC 00056-0188-75 NDC inpatient 1 UN 1.6 1.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.97 1.55 00056-0188-75 - warfarin 3 mg Tab [JOHN] 48460897_1 CDM 0250 RC 00056-0188-75 NDC inpatient 1 UN 1.6 1.04 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.97 1.55 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48460905_1 CDM 0250 RC 00264-3105-11 NDC J0690 HCPCS inpatient 4 UN 90.96 59.12 AETNA AETNA 71.86 79 999999999 55.08 88.23 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48460905_1 CDM 0250 RC 00264-3105-11 NDC J0690 HCPCS inpatient 4 UN 90.96 59.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.12 65 999999999 55.08 88.23 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48460905_1 CDM 0250 RC 00264-3105-11 NDC J0690 HCPCS inpatient 4 UN 90.96 59.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.23 97 999999999 55.08 88.23 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48460905_1 CDM 0250 RC 00264-3105-11 NDC J0690 HCPCS inpatient 4 UN 90.96 59.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.76 69 999999999 55.08 88.23 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48460905_1 CDM 0250 RC 00264-3105-11 NDC J0690 HCPCS inpatient 4 UN 90.96 59.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.95 78 999999999 55.08 88.23 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48460905_1 CDM 0250 RC 00264-3105-11 NDC J0690 HCPCS inpatient 4 UN 90.96 59.12 UMR - ALL PLANS UMR - ALL PLANS 63.67 70 999999999 55.08 88.23 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48460905_1 CDM 0250 RC 00264-3105-11 NDC J0690 HCPCS inpatient 4 UN 90.96 59.12 SIHO - ALL PLANS SIHO - ALL PLANS 81.86 90 999999999 55.08 88.23 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48460905_1 CDM 0250 RC 00264-3105-11 NDC J0690 HCPCS inpatient 4 UN 90.96 59.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.08 60.55 999999999 55.08 88.23 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48460905_1 CDM 0250 RC 00264-3105-11 NDC J0690 HCPCS inpatient 4 UN 90.96 59.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.08 88.23 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48460905_1 CDM 0250 RC 00264-3105-11 NDC J0690 HCPCS inpatient 4 UN 90.96 59.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.08 88.23 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48460905_1 CDM 0250 RC 00264-3105-11 NDC J0690 HCPCS inpatient 4 UN 90.96 59.12 ANTHEM HMO ANTHEM HMO 999999999 55.08 88.23 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48460905_1 CDM 0250 RC 00264-3105-11 NDC J0690 HCPCS inpatient 4 UN 90.96 59.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.49 67.6 999999999 55.08 88.23 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48460905_1 CDM 0250 RC 00264-3105-11 NDC J0690 HCPCS inpatient 4 UN 90.96 59.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.08 88.23 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 48460905_1 CDM 0250 RC 00264-3105-11 NDC J0690 HCPCS inpatient 4 UN 90.96 59.12 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.08 88.23 CIPROFLOXACIN 400 MG/200ML-D5W 48460912_1 CDM 0250 RC 36000-0009-24 NDC inpatient 1 UN 59.59 38.73 AETNA AETNA 47.08 79 999999999 36.08 57.8 percent of total billed charges CIPROFLOXACIN 400 MG/200ML-D5W 48460912_1 CDM 0250 RC 36000-0009-24 NDC inpatient 1 UN 59.59 38.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 38.73 65 999999999 36.08 57.8 percent of total billed charges CIPROFLOXACIN 400 MG/200ML-D5W 48460912_1 CDM 0250 RC 36000-0009-24 NDC inpatient 1 UN 59.59 38.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 57.8 97 999999999 36.08 57.8 percent of total billed charges CIPROFLOXACIN 400 MG/200ML-D5W 48460912_1 CDM 0250 RC 36000-0009-24 NDC inpatient 1 UN 59.59 38.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.12 69 999999999 36.08 57.8 percent of total billed charges CIPROFLOXACIN 400 MG/200ML-D5W 48460912_1 CDM 0250 RC 36000-0009-24 NDC inpatient 1 UN 59.59 38.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.48 78 999999999 36.08 57.8 percent of total billed charges CIPROFLOXACIN 400 MG/200ML-D5W 48460912_1 CDM 0250 RC 36000-0009-24 NDC inpatient 1 UN 59.59 38.73 UMR - ALL PLANS UMR - ALL PLANS 41.71 70 999999999 36.08 57.8 percent of total billed charges CIPROFLOXACIN 400 MG/200ML-D5W 48460912_1 CDM 0250 RC 36000-0009-24 NDC inpatient 1 UN 59.59 38.73 SIHO - ALL PLANS SIHO - ALL PLANS 53.63 90 999999999 36.08 57.8 percent of total billed charges CIPROFLOXACIN 400 MG/200ML-D5W 48460912_1 CDM 0250 RC 36000-0009-24 NDC inpatient 1 UN 59.59 38.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.08 60.55 999999999 36.08 57.8 percent of total billed charges CIPROFLOXACIN 400 MG/200ML-D5W 48460912_1 CDM 0250 RC 36000-0009-24 NDC inpatient 1 UN 59.59 38.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.08 57.8 CIPROFLOXACIN 400 MG/200ML-D5W 48460912_1 CDM 0250 RC 36000-0009-24 NDC inpatient 1 UN 59.59 38.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.08 57.8 CIPROFLOXACIN 400 MG/200ML-D5W 48460912_1 CDM 0250 RC 36000-0009-24 NDC inpatient 1 UN 59.59 38.73 ANTHEM HMO ANTHEM HMO 999999999 36.08 57.8 CIPROFLOXACIN 400 MG/200ML-D5W 48460912_1 CDM 0250 RC 36000-0009-24 NDC inpatient 1 UN 59.59 38.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.28 67.6 999999999 36.08 57.8 percent of total billed charges CIPROFLOXACIN 400 MG/200ML-D5W 48460912_1 CDM 0250 RC 36000-0009-24 NDC inpatient 1 UN 59.59 38.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.08 57.8 CIPROFLOXACIN 400 MG/200ML-D5W 48460912_1 CDM 0250 RC 36000-0009-24 NDC inpatient 1 UN 59.59 38.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.08 57.8 "INJECTION, LEVOFLOXACIN, 250 MG" 48460915_1 CDM 0250 RC 00143-9721-01 NDC J1956 HCPCS inpatient 2 UN 59.12 38.43 AETNA AETNA 46.7 79 999999999 35.8 57.35 percent of total billed charges "INJECTION, LEVOFLOXACIN, 250 MG" 48460915_1 CDM 0250 RC 00143-9721-01 NDC J1956 HCPCS inpatient 2 UN 59.12 38.43 SELF PAY DISCOUNT SELF PAY DISCOUNT 38.43 65 999999999 35.8 57.35 percent of total billed charges "INJECTION, LEVOFLOXACIN, 250 MG" 48460915_1 CDM 0250 RC 00143-9721-01 NDC J1956 HCPCS inpatient 2 UN 59.12 38.43 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 57.35 97 999999999 35.8 57.35 percent of total billed charges "INJECTION, LEVOFLOXACIN, 250 MG" 48460915_1 CDM 0250 RC 00143-9721-01 NDC J1956 HCPCS inpatient 2 UN 59.12 38.43 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.79 69 999999999 35.8 57.35 percent of total billed charges "INJECTION, LEVOFLOXACIN, 250 MG" 48460915_1 CDM 0250 RC 00143-9721-01 NDC J1956 HCPCS inpatient 2 UN 59.12 38.43 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.11 78 999999999 35.8 57.35 percent of total billed charges "INJECTION, LEVOFLOXACIN, 250 MG" 48460915_1 CDM 0250 RC 00143-9721-01 NDC J1956 HCPCS inpatient 2 UN 59.12 38.43 UMR - ALL PLANS UMR - ALL PLANS 41.38 70 999999999 35.8 57.35 percent of total billed charges "INJECTION, LEVOFLOXACIN, 250 MG" 48460915_1 CDM 0250 RC 00143-9721-01 NDC J1956 HCPCS inpatient 2 UN 59.12 38.43 SIHO - ALL PLANS SIHO - ALL PLANS 53.21 90 999999999 35.8 57.35 percent of total billed charges "INJECTION, LEVOFLOXACIN, 250 MG" 48460915_1 CDM 0250 RC 00143-9721-01 NDC J1956 HCPCS inpatient 2 UN 59.12 38.43 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.8 60.55 999999999 35.8 57.35 percent of total billed charges "INJECTION, LEVOFLOXACIN, 250 MG" 48460915_1 CDM 0250 RC 00143-9721-01 NDC J1956 HCPCS inpatient 2 UN 59.12 38.43 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.8 57.35 "INJECTION, LEVOFLOXACIN, 250 MG" 48460915_1 CDM 0250 RC 00143-9721-01 NDC J1956 HCPCS inpatient 2 UN 59.12 38.43 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.8 57.35 "INJECTION, LEVOFLOXACIN, 250 MG" 48460915_1 CDM 0250 RC 00143-9721-01 NDC J1956 HCPCS inpatient 2 UN 59.12 38.43 ANTHEM HMO ANTHEM HMO 999999999 35.8 57.35 "INJECTION, LEVOFLOXACIN, 250 MG" 48460915_1 CDM 0250 RC 00143-9721-01 NDC J1956 HCPCS inpatient 2 UN 59.12 38.43 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.97 67.6 999999999 35.8 57.35 percent of total billed charges "INJECTION, LEVOFLOXACIN, 250 MG" 48460915_1 CDM 0250 RC 00143-9721-01 NDC J1956 HCPCS inpatient 2 UN 59.12 38.43 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.8 57.35 "INJECTION, LEVOFLOXACIN, 250 MG" 48460915_1 CDM 0250 RC 00143-9721-01 NDC J1956 HCPCS inpatient 2 UN 59.12 38.43 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.8 57.35 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48460923_1 CDM 0250 RC 00409-6729-24 NDC J3475 HCPCS inpatient 4 UN 95.11 61.82 AETNA AETNA 75.14 79 999999999 57.59 92.26 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48460923_1 CDM 0250 RC 00409-6729-24 NDC J3475 HCPCS inpatient 4 UN 95.11 61.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.82 65 999999999 57.59 92.26 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48460923_1 CDM 0250 RC 00409-6729-24 NDC J3475 HCPCS inpatient 4 UN 95.11 61.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 92.26 97 999999999 57.59 92.26 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48460923_1 CDM 0250 RC 00409-6729-24 NDC J3475 HCPCS inpatient 4 UN 95.11 61.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 65.63 69 999999999 57.59 92.26 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48460923_1 CDM 0250 RC 00409-6729-24 NDC J3475 HCPCS inpatient 4 UN 95.11 61.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.19 78 999999999 57.59 92.26 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48460923_1 CDM 0250 RC 00409-6729-24 NDC J3475 HCPCS inpatient 4 UN 95.11 61.82 UMR - ALL PLANS UMR - ALL PLANS 66.58 70 999999999 57.59 92.26 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48460923_1 CDM 0250 RC 00409-6729-24 NDC J3475 HCPCS inpatient 4 UN 95.11 61.82 SIHO - ALL PLANS SIHO - ALL PLANS 85.6 90 999999999 57.59 92.26 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48460923_1 CDM 0250 RC 00409-6729-24 NDC J3475 HCPCS inpatient 4 UN 95.11 61.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 57.59 60.55 999999999 57.59 92.26 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48460923_1 CDM 0250 RC 00409-6729-24 NDC J3475 HCPCS inpatient 4 UN 95.11 61.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 57.59 92.26 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48460923_1 CDM 0250 RC 00409-6729-24 NDC J3475 HCPCS inpatient 4 UN 95.11 61.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 57.59 92.26 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48460923_1 CDM 0250 RC 00409-6729-24 NDC J3475 HCPCS inpatient 4 UN 95.11 61.82 ANTHEM HMO ANTHEM HMO 999999999 57.59 92.26 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48460923_1 CDM 0250 RC 00409-6729-24 NDC J3475 HCPCS inpatient 4 UN 95.11 61.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.29 67.6 999999999 57.59 92.26 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48460923_1 CDM 0250 RC 00409-6729-24 NDC J3475 HCPCS inpatient 4 UN 95.11 61.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 57.59 92.26 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48460923_1 CDM 0250 RC 00409-6729-24 NDC J3475 HCPCS inpatient 4 UN 95.11 61.82 UHC - ALL PLANS UHC - ALL PLANS 999999999 57.59 92.26 CLINDAMYCIN 600 MG/50 ML-D5W 48460951_1 CDM 0250 RC 00781-9221-09 NDC inpatient 1 UN 82.58 53.68 AETNA AETNA 65.24 79 999999999 50 80.1 percent of total billed charges CLINDAMYCIN 600 MG/50 ML-D5W 48460951_1 CDM 0250 RC 00781-9221-09 NDC inpatient 1 UN 82.58 53.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.68 65 999999999 50 80.1 percent of total billed charges CLINDAMYCIN 600 MG/50 ML-D5W 48460951_1 CDM 0250 RC 00781-9221-09 NDC inpatient 1 UN 82.58 53.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.1 97 999999999 50 80.1 percent of total billed charges CLINDAMYCIN 600 MG/50 ML-D5W 48460951_1 CDM 0250 RC 00781-9221-09 NDC inpatient 1 UN 82.58 53.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.98 69 999999999 50 80.1 percent of total billed charges CLINDAMYCIN 600 MG/50 ML-D5W 48460951_1 CDM 0250 RC 00781-9221-09 NDC inpatient 1 UN 82.58 53.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.41 78 999999999 50 80.1 percent of total billed charges CLINDAMYCIN 600 MG/50 ML-D5W 48460951_1 CDM 0250 RC 00781-9221-09 NDC inpatient 1 UN 82.58 53.68 UMR - ALL PLANS UMR - ALL PLANS 57.81 70 999999999 50 80.1 percent of total billed charges CLINDAMYCIN 600 MG/50 ML-D5W 48460951_1 CDM 0250 RC 00781-9221-09 NDC inpatient 1 UN 82.58 53.68 SIHO - ALL PLANS SIHO - ALL PLANS 74.32 90 999999999 50 80.1 percent of total billed charges CLINDAMYCIN 600 MG/50 ML-D5W 48460951_1 CDM 0250 RC 00781-9221-09 NDC inpatient 1 UN 82.58 53.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50 60.55 999999999 50 80.1 percent of total billed charges CLINDAMYCIN 600 MG/50 ML-D5W 48460951_1 CDM 0250 RC 00781-9221-09 NDC inpatient 1 UN 82.58 53.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50 80.1 CLINDAMYCIN 600 MG/50 ML-D5W 48460951_1 CDM 0250 RC 00781-9221-09 NDC inpatient 1 UN 82.58 53.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50 80.1 CLINDAMYCIN 600 MG/50 ML-D5W 48460951_1 CDM 0250 RC 00781-9221-09 NDC inpatient 1 UN 82.58 53.68 ANTHEM HMO ANTHEM HMO 999999999 50 80.1 CLINDAMYCIN 600 MG/50 ML-D5W 48460951_1 CDM 0250 RC 00781-9221-09 NDC inpatient 1 UN 82.58 53.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.82 67.6 999999999 50 80.1 percent of total billed charges CLINDAMYCIN 600 MG/50 ML-D5W 48460951_1 CDM 0250 RC 00781-9221-09 NDC inpatient 1 UN 82.58 53.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50 80.1 CLINDAMYCIN 600 MG/50 ML-D5W 48460951_1 CDM 0250 RC 00781-9221-09 NDC inpatient 1 UN 82.58 53.68 UHC - ALL PLANS UHC - ALL PLANS 999999999 50 80.1 CLINDAMYCIN 900 MG/50 ML-D5W 48460952_1 CDM 0250 RC 00781-9222-09 NDC inpatient 1 UN 79.06 51.39 AETNA AETNA 62.46 79 999999999 47.87 76.69 percent of total billed charges CLINDAMYCIN 900 MG/50 ML-D5W 48460952_1 CDM 0250 RC 00781-9222-09 NDC inpatient 1 UN 79.06 51.39 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.39 65 999999999 47.87 76.69 percent of total billed charges CLINDAMYCIN 900 MG/50 ML-D5W 48460952_1 CDM 0250 RC 00781-9222-09 NDC inpatient 1 UN 79.06 51.39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.69 97 999999999 47.87 76.69 percent of total billed charges CLINDAMYCIN 900 MG/50 ML-D5W 48460952_1 CDM 0250 RC 00781-9222-09 NDC inpatient 1 UN 79.06 51.39 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.55 69 999999999 47.87 76.69 percent of total billed charges CLINDAMYCIN 900 MG/50 ML-D5W 48460952_1 CDM 0250 RC 00781-9222-09 NDC inpatient 1 UN 79.06 51.39 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.67 78 999999999 47.87 76.69 percent of total billed charges CLINDAMYCIN 900 MG/50 ML-D5W 48460952_1 CDM 0250 RC 00781-9222-09 NDC inpatient 1 UN 79.06 51.39 UMR - ALL PLANS UMR - ALL PLANS 55.34 70 999999999 47.87 76.69 percent of total billed charges CLINDAMYCIN 900 MG/50 ML-D5W 48460952_1 CDM 0250 RC 00781-9222-09 NDC inpatient 1 UN 79.06 51.39 SIHO - ALL PLANS SIHO - ALL PLANS 71.15 90 999999999 47.87 76.69 percent of total billed charges CLINDAMYCIN 900 MG/50 ML-D5W 48460952_1 CDM 0250 RC 00781-9222-09 NDC inpatient 1 UN 79.06 51.39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.87 60.55 999999999 47.87 76.69 percent of total billed charges CLINDAMYCIN 900 MG/50 ML-D5W 48460952_1 CDM 0250 RC 00781-9222-09 NDC inpatient 1 UN 79.06 51.39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.87 76.69 CLINDAMYCIN 900 MG/50 ML-D5W 48460952_1 CDM 0250 RC 00781-9222-09 NDC inpatient 1 UN 79.06 51.39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.87 76.69 CLINDAMYCIN 900 MG/50 ML-D5W 48460952_1 CDM 0250 RC 00781-9222-09 NDC inpatient 1 UN 79.06 51.39 ANTHEM HMO ANTHEM HMO 999999999 47.87 76.69 CLINDAMYCIN 900 MG/50 ML-D5W 48460952_1 CDM 0250 RC 00781-9222-09 NDC inpatient 1 UN 79.06 51.39 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.44 67.6 999999999 47.87 76.69 percent of total billed charges CLINDAMYCIN 900 MG/50 ML-D5W 48460952_1 CDM 0250 RC 00781-9222-09 NDC inpatient 1 UN 79.06 51.39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.87 76.69 CLINDAMYCIN 900 MG/50 ML-D5W 48460952_1 CDM 0250 RC 00781-9222-09 NDC inpatient 1 UN 79.06 51.39 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.87 76.69 OXYCODONE-ACETAMINOPHN 7.5-325 48460966_1 CDM 0250 RC 68084-0699-01 NDC inpatient 1 UN 2.45 1.59 AETNA AETNA 1.94 79 999999999 1.48 2.38 percent of total billed charges OXYCODONE-ACETAMINOPHN 7.5-325 48460966_1 CDM 0250 RC 68084-0699-01 NDC inpatient 1 UN 2.45 1.59 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.59 65 999999999 1.48 2.38 percent of total billed charges OXYCODONE-ACETAMINOPHN 7.5-325 48460966_1 CDM 0250 RC 68084-0699-01 NDC inpatient 1 UN 2.45 1.59 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.38 97 999999999 1.48 2.38 percent of total billed charges OXYCODONE-ACETAMINOPHN 7.5-325 48460966_1 CDM 0250 RC 68084-0699-01 NDC inpatient 1 UN 2.45 1.59 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.69 69 999999999 1.48 2.38 percent of total billed charges OXYCODONE-ACETAMINOPHN 7.5-325 48460966_1 CDM 0250 RC 68084-0699-01 NDC inpatient 1 UN 2.45 1.59 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.91 78 999999999 1.48 2.38 percent of total billed charges OXYCODONE-ACETAMINOPHN 7.5-325 48460966_1 CDM 0250 RC 68084-0699-01 NDC inpatient 1 UN 2.45 1.59 UMR - ALL PLANS UMR - ALL PLANS 1.72 70 999999999 1.48 2.38 percent of total billed charges OXYCODONE-ACETAMINOPHN 7.5-325 48460966_1 CDM 0250 RC 68084-0699-01 NDC inpatient 1 UN 2.45 1.59 SIHO - ALL PLANS SIHO - ALL PLANS 2.21 90 999999999 1.48 2.38 percent of total billed charges OXYCODONE-ACETAMINOPHN 7.5-325 48460966_1 CDM 0250 RC 68084-0699-01 NDC inpatient 1 UN 2.45 1.59 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.48 60.55 999999999 1.48 2.38 percent of total billed charges OXYCODONE-ACETAMINOPHN 7.5-325 48460966_1 CDM 0250 RC 68084-0699-01 NDC inpatient 1 UN 2.45 1.59 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.48 2.38 OXYCODONE-ACETAMINOPHN 7.5-325 48460966_1 CDM 0250 RC 68084-0699-01 NDC inpatient 1 UN 2.45 1.59 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.48 2.38 OXYCODONE-ACETAMINOPHN 7.5-325 48460966_1 CDM 0250 RC 68084-0699-01 NDC inpatient 1 UN 2.45 1.59 ANTHEM HMO ANTHEM HMO 999999999 1.48 2.38 OXYCODONE-ACETAMINOPHN 7.5-325 48460966_1 CDM 0250 RC 68084-0699-01 NDC inpatient 1 UN 2.45 1.59 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.66 67.6 999999999 1.48 2.38 percent of total billed charges OXYCODONE-ACETAMINOPHN 7.5-325 48460966_1 CDM 0250 RC 68084-0699-01 NDC inpatient 1 UN 2.45 1.59 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.48 2.38 OXYCODONE-ACETAMINOPHN 7.5-325 48460966_1 CDM 0250 RC 68084-0699-01 NDC inpatient 1 UN 2.45 1.59 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.48 2.38 "INJECTION, FENTANYL CITRATE, 0.1 MG" 48460968_1 CDM 0250 RC 00409-9094-25 NDC J3010 HCPCS inpatient 3 UN 9.68 6.29 AETNA AETNA 7.65 79 999999999 5.86 9.39 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48460968_1 CDM 0250 RC 00409-9094-25 NDC J3010 HCPCS inpatient 3 UN 9.68 6.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.29 65 999999999 5.86 9.39 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48460968_1 CDM 0250 RC 00409-9094-25 NDC J3010 HCPCS inpatient 3 UN 9.68 6.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.39 97 999999999 5.86 9.39 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48460968_1 CDM 0250 RC 00409-9094-25 NDC J3010 HCPCS inpatient 3 UN 9.68 6.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.68 69 999999999 5.86 9.39 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48460968_1 CDM 0250 RC 00409-9094-25 NDC J3010 HCPCS inpatient 3 UN 9.68 6.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.55 78 999999999 5.86 9.39 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48460968_1 CDM 0250 RC 00409-9094-25 NDC J3010 HCPCS inpatient 3 UN 9.68 6.29 UMR - ALL PLANS UMR - ALL PLANS 6.78 70 999999999 5.86 9.39 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48460968_1 CDM 0250 RC 00409-9094-25 NDC J3010 HCPCS inpatient 3 UN 9.68 6.29 SIHO - ALL PLANS SIHO - ALL PLANS 8.71 90 999999999 5.86 9.39 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48460968_1 CDM 0250 RC 00409-9094-25 NDC J3010 HCPCS inpatient 3 UN 9.68 6.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.86 60.55 999999999 5.86 9.39 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48460968_1 CDM 0250 RC 00409-9094-25 NDC J3010 HCPCS inpatient 3 UN 9.68 6.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.86 9.39 "INJECTION, FENTANYL CITRATE, 0.1 MG" 48460968_1 CDM 0250 RC 00409-9094-25 NDC J3010 HCPCS inpatient 3 UN 9.68 6.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.86 9.39 "INJECTION, FENTANYL CITRATE, 0.1 MG" 48460968_1 CDM 0250 RC 00409-9094-25 NDC J3010 HCPCS inpatient 3 UN 9.68 6.29 ANTHEM HMO ANTHEM HMO 999999999 5.86 9.39 "INJECTION, FENTANYL CITRATE, 0.1 MG" 48460968_1 CDM 0250 RC 00409-9094-25 NDC J3010 HCPCS inpatient 3 UN 9.68 6.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.54 67.6 999999999 5.86 9.39 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48460968_1 CDM 0250 RC 00409-9094-25 NDC J3010 HCPCS inpatient 3 UN 9.68 6.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.86 9.39 "INJECTION, FENTANYL CITRATE, 0.1 MG" 48460968_1 CDM 0250 RC 00409-9094-25 NDC J3010 HCPCS inpatient 3 UN 9.68 6.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.86 9.39 TRAMADOL HCL 50 MG TABLET 48460977_1 CDM 0250 RC 68084-0808-01 NDC inpatient 1 UN 1.76 1.14 AETNA AETNA 1.39 79 999999999 1.07 1.71 percent of total billed charges TRAMADOL HCL 50 MG TABLET 48460977_1 CDM 0250 RC 68084-0808-01 NDC inpatient 1 UN 1.76 1.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.14 65 999999999 1.07 1.71 percent of total billed charges TRAMADOL HCL 50 MG TABLET 48460977_1 CDM 0250 RC 68084-0808-01 NDC inpatient 1 UN 1.76 1.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.71 97 999999999 1.07 1.71 percent of total billed charges TRAMADOL HCL 50 MG TABLET 48460977_1 CDM 0250 RC 68084-0808-01 NDC inpatient 1 UN 1.76 1.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.21 69 999999999 1.07 1.71 percent of total billed charges TRAMADOL HCL 50 MG TABLET 48460977_1 CDM 0250 RC 68084-0808-01 NDC inpatient 1 UN 1.76 1.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.37 78 999999999 1.07 1.71 percent of total billed charges TRAMADOL HCL 50 MG TABLET 48460977_1 CDM 0250 RC 68084-0808-01 NDC inpatient 1 UN 1.76 1.14 UMR - ALL PLANS UMR - ALL PLANS 1.23 70 999999999 1.07 1.71 percent of total billed charges TRAMADOL HCL 50 MG TABLET 48460977_1 CDM 0250 RC 68084-0808-01 NDC inpatient 1 UN 1.76 1.14 SIHO - ALL PLANS SIHO - ALL PLANS 1.58 90 999999999 1.07 1.71 percent of total billed charges TRAMADOL HCL 50 MG TABLET 48460977_1 CDM 0250 RC 68084-0808-01 NDC inpatient 1 UN 1.76 1.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.07 60.55 999999999 1.07 1.71 percent of total billed charges TRAMADOL HCL 50 MG TABLET 48460977_1 CDM 0250 RC 68084-0808-01 NDC inpatient 1 UN 1.76 1.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.07 1.71 TRAMADOL HCL 50 MG TABLET 48460977_1 CDM 0250 RC 68084-0808-01 NDC inpatient 1 UN 1.76 1.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.07 1.71 TRAMADOL HCL 50 MG TABLET 48460977_1 CDM 0250 RC 68084-0808-01 NDC inpatient 1 UN 1.76 1.14 ANTHEM HMO ANTHEM HMO 999999999 1.07 1.71 TRAMADOL HCL 50 MG TABLET 48460977_1 CDM 0250 RC 68084-0808-01 NDC inpatient 1 UN 1.76 1.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.19 67.6 999999999 1.07 1.71 percent of total billed charges TRAMADOL HCL 50 MG TABLET 48460977_1 CDM 0250 RC 68084-0808-01 NDC inpatient 1 UN 1.76 1.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.07 1.71 TRAMADOL HCL 50 MG TABLET 48460977_1 CDM 0250 RC 68084-0808-01 NDC inpatient 1 UN 1.76 1.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.07 1.71 00904-5880-61 - diazePAM 5 mg Tab [JOHN] 48460995_1 CDM 0250 RC 00904-5880-61 NDC inpatient 1 UN 1.7 1.11 AETNA AETNA 1.34 79 999999999 1.03 1.65 percent of total billed charges 00904-5880-61 - diazePAM 5 mg Tab [JOHN] 48460995_1 CDM 0250 RC 00904-5880-61 NDC inpatient 1 UN 1.7 1.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.11 65 999999999 1.03 1.65 percent of total billed charges 00904-5880-61 - diazePAM 5 mg Tab [JOHN] 48460995_1 CDM 0250 RC 00904-5880-61 NDC inpatient 1 UN 1.7 1.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.65 97 999999999 1.03 1.65 percent of total billed charges 00904-5880-61 - diazePAM 5 mg Tab [JOHN] 48460995_1 CDM 0250 RC 00904-5880-61 NDC inpatient 1 UN 1.7 1.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.17 69 999999999 1.03 1.65 percent of total billed charges 00904-5880-61 - diazePAM 5 mg Tab [JOHN] 48460995_1 CDM 0250 RC 00904-5880-61 NDC inpatient 1 UN 1.7 1.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.33 78 999999999 1.03 1.65 percent of total billed charges 00904-5880-61 - diazePAM 5 mg Tab [JOHN] 48460995_1 CDM 0250 RC 00904-5880-61 NDC inpatient 1 UN 1.7 1.11 UMR - ALL PLANS UMR - ALL PLANS 1.19 70 999999999 1.03 1.65 percent of total billed charges 00904-5880-61 - diazePAM 5 mg Tab [JOHN] 48460995_1 CDM 0250 RC 00904-5880-61 NDC inpatient 1 UN 1.7 1.11 SIHO - ALL PLANS SIHO - ALL PLANS 1.53 90 999999999 1.03 1.65 percent of total billed charges 00904-5880-61 - diazePAM 5 mg Tab [JOHN] 48460995_1 CDM 0250 RC 00904-5880-61 NDC inpatient 1 UN 1.7 1.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.03 60.55 999999999 1.03 1.65 percent of total billed charges 00904-5880-61 - diazePAM 5 mg Tab [JOHN] 48460995_1 CDM 0250 RC 00904-5880-61 NDC inpatient 1 UN 1.7 1.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.03 1.65 00904-5880-61 - diazePAM 5 mg Tab [JOHN] 48460995_1 CDM 0250 RC 00904-5880-61 NDC inpatient 1 UN 1.7 1.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.03 1.65 00904-5880-61 - diazePAM 5 mg Tab [JOHN] 48460995_1 CDM 0250 RC 00904-5880-61 NDC inpatient 1 UN 1.7 1.11 ANTHEM HMO ANTHEM HMO 999999999 1.03 1.65 00904-5880-61 - diazePAM 5 mg Tab [JOHN] 48460995_1 CDM 0250 RC 00904-5880-61 NDC inpatient 1 UN 1.7 1.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.15 67.6 999999999 1.03 1.65 percent of total billed charges 00904-5880-61 - diazePAM 5 mg Tab [JOHN] 48460995_1 CDM 0250 RC 00904-5880-61 NDC inpatient 1 UN 1.7 1.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.03 1.65 00904-5880-61 - diazePAM 5 mg Tab [JOHN] 48460995_1 CDM 0250 RC 00904-5880-61 NDC inpatient 1 UN 1.7 1.11 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.03 1.65 00409-9257-39 - Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [JOHN] 48461051_1 CDM 0250 RC 00409-9257-39 NDC inpatient 1 UN 56.7 36.86 AETNA AETNA 44.79 79 999999999 34.33 55 percent of total billed charges 00409-9257-39 - Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [JOHN] 48461051_1 CDM 0250 RC 00409-9257-39 NDC inpatient 1 UN 56.7 36.86 SELF PAY DISCOUNT SELF PAY DISCOUNT 36.86 65 999999999 34.33 55 percent of total billed charges 00409-9257-39 - Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [JOHN] 48461051_1 CDM 0250 RC 00409-9257-39 NDC inpatient 1 UN 56.7 36.86 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.12 69 999999999 34.33 55 percent of total billed charges 00409-9257-39 - Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [JOHN] 48461051_1 CDM 0250 RC 00409-9257-39 NDC inpatient 1 UN 56.7 36.86 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55 97 999999999 34.33 55 percent of total billed charges 00409-9257-39 - Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [JOHN] 48461051_1 CDM 0250 RC 00409-9257-39 NDC inpatient 1 UN 56.7 36.86 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.23 78 999999999 34.33 55 percent of total billed charges 00409-9257-39 - Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [JOHN] 48461051_1 CDM 0250 RC 00409-9257-39 NDC inpatient 1 UN 56.7 36.86 UMR - ALL PLANS UMR - ALL PLANS 39.69 70 999999999 34.33 55 percent of total billed charges 00409-9257-39 - Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [JOHN] 48461051_1 CDM 0250 RC 00409-9257-39 NDC inpatient 1 UN 56.7 36.86 SIHO - ALL PLANS SIHO - ALL PLANS 51.03 90 999999999 34.33 55 percent of total billed charges 00409-9257-39 - Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [JOHN] 48461051_1 CDM 0250 RC 00409-9257-39 NDC inpatient 1 UN 56.7 36.86 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.33 60.55 999999999 34.33 55 percent of total billed charges 00409-9257-39 - Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [JOHN] 48461051_1 CDM 0250 RC 00409-9257-39 NDC inpatient 1 UN 56.7 36.86 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.33 55 00409-9257-39 - Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [JOHN] 48461051_1 CDM 0250 RC 00409-9257-39 NDC inpatient 1 UN 56.7 36.86 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.33 55 00409-9257-39 - Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [JOHN] 48461051_1 CDM 0250 RC 00409-9257-39 NDC inpatient 1 UN 56.7 36.86 ANTHEM HMO ANTHEM HMO 999999999 34.33 55 00409-9257-39 - Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [JOHN] 48461051_1 CDM 0250 RC 00409-9257-39 NDC inpatient 1 UN 56.7 36.86 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.33 67.6 999999999 34.33 55 percent of total billed charges 00409-9257-39 - Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [JOHN] 48461051_1 CDM 0250 RC 00409-9257-39 NDC inpatient 1 UN 56.7 36.86 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.33 55 00409-9257-39 - Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [JOHN] 48461051_1 CDM 0250 RC 00409-9257-39 NDC inpatient 1 UN 56.7 36.86 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.33 55 INTRALIPID 20% IV FAT EMUL 48461053_1 CDM 0250 RC 00338-0519-09 NDC inpatient 1 UN 177.32 115.26 AETNA AETNA 140.08 79 999999999 107.37 172 percent of total billed charges INTRALIPID 20% IV FAT EMUL 48461053_1 CDM 0250 RC 00338-0519-09 NDC inpatient 1 UN 177.32 115.26 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.26 65 999999999 107.37 172 percent of total billed charges INTRALIPID 20% IV FAT EMUL 48461053_1 CDM 0250 RC 00338-0519-09 NDC inpatient 1 UN 177.32 115.26 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.35 69 999999999 107.37 172 percent of total billed charges INTRALIPID 20% IV FAT EMUL 48461053_1 CDM 0250 RC 00338-0519-09 NDC inpatient 1 UN 177.32 115.26 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172 97 999999999 107.37 172 percent of total billed charges INTRALIPID 20% IV FAT EMUL 48461053_1 CDM 0250 RC 00338-0519-09 NDC inpatient 1 UN 177.32 115.26 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.31 78 999999999 107.37 172 percent of total billed charges INTRALIPID 20% IV FAT EMUL 48461053_1 CDM 0250 RC 00338-0519-09 NDC inpatient 1 UN 177.32 115.26 UMR - ALL PLANS UMR - ALL PLANS 124.12 70 999999999 107.37 172 percent of total billed charges INTRALIPID 20% IV FAT EMUL 48461053_1 CDM 0250 RC 00338-0519-09 NDC inpatient 1 UN 177.32 115.26 SIHO - ALL PLANS SIHO - ALL PLANS 159.59 90 999999999 107.37 172 percent of total billed charges INTRALIPID 20% IV FAT EMUL 48461053_1 CDM 0250 RC 00338-0519-09 NDC inpatient 1 UN 177.32 115.26 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.37 60.55 999999999 107.37 172 percent of total billed charges INTRALIPID 20% IV FAT EMUL 48461053_1 CDM 0250 RC 00338-0519-09 NDC inpatient 1 UN 177.32 115.26 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.37 172 INTRALIPID 20% IV FAT EMUL 48461053_1 CDM 0250 RC 00338-0519-09 NDC inpatient 1 UN 177.32 115.26 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.37 172 INTRALIPID 20% IV FAT EMUL 48461053_1 CDM 0250 RC 00338-0519-09 NDC inpatient 1 UN 177.32 115.26 ANTHEM HMO ANTHEM HMO 999999999 107.37 172 INTRALIPID 20% IV FAT EMUL 48461053_1 CDM 0250 RC 00338-0519-09 NDC inpatient 1 UN 177.32 115.26 CIGNA - ALL PLANS CIGNA - ALL PLANS 119.87 67.6 999999999 107.37 172 percent of total billed charges INTRALIPID 20% IV FAT EMUL 48461053_1 CDM 0250 RC 00338-0519-09 NDC inpatient 1 UN 177.32 115.26 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.37 172 INTRALIPID 20% IV FAT EMUL 48461053_1 CDM 0250 RC 00338-0519-09 NDC inpatient 1 UN 177.32 115.26 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.37 172 "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 48461055_1 CDM 0250 RC 00002-7510-01 NDC J1817 HCPCS inpatient 20 UN 270.71 175.96 AETNA AETNA 213.86 79 999999999 163.91 262.59 percent of total billed charges "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 48461055_1 CDM 0250 RC 00002-7510-01 NDC J1817 HCPCS inpatient 20 UN 270.71 175.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 175.96 65 999999999 163.91 262.59 percent of total billed charges "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 48461055_1 CDM 0250 RC 00002-7510-01 NDC J1817 HCPCS inpatient 20 UN 270.71 175.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 186.79 69 999999999 163.91 262.59 percent of total billed charges "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 48461055_1 CDM 0250 RC 00002-7510-01 NDC J1817 HCPCS inpatient 20 UN 270.71 175.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 262.59 97 999999999 163.91 262.59 percent of total billed charges "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 48461055_1 CDM 0250 RC 00002-7510-01 NDC J1817 HCPCS inpatient 20 UN 270.71 175.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 211.15 78 999999999 163.91 262.59 percent of total billed charges "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 48461055_1 CDM 0250 RC 00002-7510-01 NDC J1817 HCPCS inpatient 20 UN 270.71 175.96 UMR - ALL PLANS UMR - ALL PLANS 189.5 70 999999999 163.91 262.59 percent of total billed charges "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 48461055_1 CDM 0250 RC 00002-7510-01 NDC J1817 HCPCS inpatient 20 UN 270.71 175.96 SIHO - ALL PLANS SIHO - ALL PLANS 243.64 90 999999999 163.91 262.59 percent of total billed charges "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 48461055_1 CDM 0250 RC 00002-7510-01 NDC J1817 HCPCS inpatient 20 UN 270.71 175.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 163.91 60.55 999999999 163.91 262.59 percent of total billed charges "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 48461055_1 CDM 0250 RC 00002-7510-01 NDC J1817 HCPCS inpatient 20 UN 270.71 175.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 163.91 262.59 "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 48461055_1 CDM 0250 RC 00002-7510-01 NDC J1817 HCPCS inpatient 20 UN 270.71 175.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 163.91 262.59 "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 48461055_1 CDM 0250 RC 00002-7510-01 NDC J1817 HCPCS inpatient 20 UN 270.71 175.96 ANTHEM HMO ANTHEM HMO 999999999 163.91 262.59 "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 48461055_1 CDM 0250 RC 00002-7510-01 NDC J1817 HCPCS inpatient 20 UN 270.71 175.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 183 67.6 999999999 163.91 262.59 percent of total billed charges "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 48461055_1 CDM 0250 RC 00002-7510-01 NDC J1817 HCPCS inpatient 20 UN 270.71 175.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 163.91 262.59 "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 48461055_1 CDM 0250 RC 00002-7510-01 NDC J1817 HCPCS inpatient 20 UN 270.71 175.96 UHC - ALL PLANS UHC - ALL PLANS 999999999 163.91 262.59 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 48461066_1 CDM 0258 RC 00338-0089-04 NDC J7042 HCPCS inpatient 1 UN 61.91 40.24 AETNA AETNA 48.91 79 999999999 37.49 60.05 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 48461066_1 CDM 0258 RC 00338-0089-04 NDC J7042 HCPCS inpatient 1 UN 61.91 40.24 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.24 65 999999999 37.49 60.05 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 48461066_1 CDM 0258 RC 00338-0089-04 NDC J7042 HCPCS inpatient 1 UN 61.91 40.24 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.72 69 999999999 37.49 60.05 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 48461066_1 CDM 0258 RC 00338-0089-04 NDC J7042 HCPCS inpatient 1 UN 61.91 40.24 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 60.05 97 999999999 37.49 60.05 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 48461066_1 CDM 0258 RC 00338-0089-04 NDC J7042 HCPCS inpatient 1 UN 61.91 40.24 HUMANA - ALL PLANS HUMANA - ALL PLANS 48.29 78 999999999 37.49 60.05 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 48461066_1 CDM 0258 RC 00338-0089-04 NDC J7042 HCPCS inpatient 1 UN 61.91 40.24 UMR - ALL PLANS UMR - ALL PLANS 43.34 70 999999999 37.49 60.05 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 48461066_1 CDM 0258 RC 00338-0089-04 NDC J7042 HCPCS inpatient 1 UN 61.91 40.24 SIHO - ALL PLANS SIHO - ALL PLANS 55.72 90 999999999 37.49 60.05 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 48461066_1 CDM 0258 RC 00338-0089-04 NDC J7042 HCPCS inpatient 1 UN 61.91 40.24 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 37.49 60.55 999999999 37.49 60.05 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 48461066_1 CDM 0258 RC 00338-0089-04 NDC J7042 HCPCS inpatient 1 UN 61.91 40.24 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 37.49 60.05 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 48461066_1 CDM 0258 RC 00338-0089-04 NDC J7042 HCPCS inpatient 1 UN 61.91 40.24 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 37.49 60.05 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 48461066_1 CDM 0258 RC 00338-0089-04 NDC J7042 HCPCS inpatient 1 UN 61.91 40.24 ANTHEM HMO ANTHEM HMO 999999999 37.49 60.05 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 48461066_1 CDM 0258 RC 00338-0089-04 NDC J7042 HCPCS inpatient 1 UN 61.91 40.24 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.85 67.6 999999999 37.49 60.05 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 48461066_1 CDM 0258 RC 00338-0089-04 NDC J7042 HCPCS inpatient 1 UN 61.91 40.24 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 37.49 60.05 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 48461066_1 CDM 0258 RC 00338-0089-04 NDC J7042 HCPCS inpatient 1 UN 61.91 40.24 UHC - ALL PLANS UHC - ALL PLANS 999999999 37.49 60.05 "INJECTION, MITOMYCIN, 5 MG" 48461089_1 CDM 0636 RC 16729-0247-11 NDC J9280 HCPCS inpatient 4 UN 795.09 516.81 AETNA AETNA 628.12 79 999999999 481.43 771.24 percent of total billed charges "INJECTION, MITOMYCIN, 5 MG" 48461089_1 CDM 0636 RC 16729-0247-11 NDC J9280 HCPCS inpatient 4 UN 795.09 516.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 516.81 65 999999999 481.43 771.24 percent of total billed charges "INJECTION, MITOMYCIN, 5 MG" 48461089_1 CDM 0636 RC 16729-0247-11 NDC J9280 HCPCS inpatient 4 UN 795.09 516.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 548.61 69 999999999 481.43 771.24 percent of total billed charges "INJECTION, MITOMYCIN, 5 MG" 48461089_1 CDM 0636 RC 16729-0247-11 NDC J9280 HCPCS inpatient 4 UN 795.09 516.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 771.24 97 999999999 481.43 771.24 percent of total billed charges "INJECTION, MITOMYCIN, 5 MG" 48461089_1 CDM 0636 RC 16729-0247-11 NDC J9280 HCPCS inpatient 4 UN 795.09 516.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 620.17 78 999999999 481.43 771.24 percent of total billed charges "INJECTION, MITOMYCIN, 5 MG" 48461089_1 CDM 0636 RC 16729-0247-11 NDC J9280 HCPCS inpatient 4 UN 795.09 516.81 UMR - ALL PLANS UMR - ALL PLANS 556.56 70 999999999 481.43 771.24 percent of total billed charges "INJECTION, MITOMYCIN, 5 MG" 48461089_1 CDM 0636 RC 16729-0247-11 NDC J9280 HCPCS inpatient 4 UN 795.09 516.81 SIHO - ALL PLANS SIHO - ALL PLANS 715.58 90 999999999 481.43 771.24 percent of total billed charges "INJECTION, MITOMYCIN, 5 MG" 48461089_1 CDM 0636 RC 16729-0247-11 NDC J9280 HCPCS inpatient 4 UN 795.09 516.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 481.43 60.55 999999999 481.43 771.24 percent of total billed charges "INJECTION, MITOMYCIN, 5 MG" 48461089_1 CDM 0636 RC 16729-0247-11 NDC J9280 HCPCS inpatient 4 UN 795.09 516.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 481.43 771.24 "INJECTION, MITOMYCIN, 5 MG" 48461089_1 CDM 0636 RC 16729-0247-11 NDC J9280 HCPCS inpatient 4 UN 795.09 516.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 481.43 771.24 "INJECTION, MITOMYCIN, 5 MG" 48461089_1 CDM 0636 RC 16729-0247-11 NDC J9280 HCPCS inpatient 4 UN 795.09 516.81 ANTHEM HMO ANTHEM HMO 999999999 481.43 771.24 "INJECTION, MITOMYCIN, 5 MG" 48461089_1 CDM 0636 RC 16729-0247-11 NDC J9280 HCPCS inpatient 4 UN 795.09 516.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 537.48 67.6 999999999 481.43 771.24 percent of total billed charges "INJECTION, MITOMYCIN, 5 MG" 48461089_1 CDM 0636 RC 16729-0247-11 NDC J9280 HCPCS inpatient 4 UN 795.09 516.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 481.43 771.24 "INJECTION, MITOMYCIN, 5 MG" 48461089_1 CDM 0636 RC 16729-0247-11 NDC J9280 HCPCS inpatient 4 UN 795.09 516.81 UHC - ALL PLANS UHC - ALL PLANS 999999999 481.43 771.24 TDVAX VIAL 48461101_1 CDM 0250 RC 13533-0131-01 NDC inpatient 1 UN 90.06 58.54 AETNA AETNA 71.15 79 999999999 54.53 87.36 percent of total billed charges TDVAX VIAL 48461101_1 CDM 0250 RC 13533-0131-01 NDC inpatient 1 UN 90.06 58.54 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.54 65 999999999 54.53 87.36 percent of total billed charges TDVAX VIAL 48461101_1 CDM 0250 RC 13533-0131-01 NDC inpatient 1 UN 90.06 58.54 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.14 69 999999999 54.53 87.36 percent of total billed charges TDVAX VIAL 48461101_1 CDM 0250 RC 13533-0131-01 NDC inpatient 1 UN 90.06 58.54 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.36 97 999999999 54.53 87.36 percent of total billed charges TDVAX VIAL 48461101_1 CDM 0250 RC 13533-0131-01 NDC inpatient 1 UN 90.06 58.54 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.25 78 999999999 54.53 87.36 percent of total billed charges TDVAX VIAL 48461101_1 CDM 0250 RC 13533-0131-01 NDC inpatient 1 UN 90.06 58.54 UMR - ALL PLANS UMR - ALL PLANS 63.04 70 999999999 54.53 87.36 percent of total billed charges TDVAX VIAL 48461101_1 CDM 0250 RC 13533-0131-01 NDC inpatient 1 UN 90.06 58.54 SIHO - ALL PLANS SIHO - ALL PLANS 81.05 90 999999999 54.53 87.36 percent of total billed charges TDVAX VIAL 48461101_1 CDM 0250 RC 13533-0131-01 NDC inpatient 1 UN 90.06 58.54 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.53 60.55 999999999 54.53 87.36 percent of total billed charges TDVAX VIAL 48461101_1 CDM 0250 RC 13533-0131-01 NDC inpatient 1 UN 90.06 58.54 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.53 87.36 TDVAX VIAL 48461101_1 CDM 0250 RC 13533-0131-01 NDC inpatient 1 UN 90.06 58.54 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.53 87.36 TDVAX VIAL 48461101_1 CDM 0250 RC 13533-0131-01 NDC inpatient 1 UN 90.06 58.54 ANTHEM HMO ANTHEM HMO 999999999 54.53 87.36 TDVAX VIAL 48461101_1 CDM 0250 RC 13533-0131-01 NDC inpatient 1 UN 90.06 58.54 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.88 67.6 999999999 54.53 87.36 percent of total billed charges TDVAX VIAL 48461101_1 CDM 0250 RC 13533-0131-01 NDC inpatient 1 UN 90.06 58.54 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.53 87.36 TDVAX VIAL 48461101_1 CDM 0250 RC 13533-0131-01 NDC inpatient 1 UN 90.06 58.54 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.53 87.36 VASOSTRICT 20 UNIT/ML VIAL 48461126_1 CDM 0250 RC 42023-0164-25 NDC inpatient 1 UN 978.76 636.19 AETNA AETNA 773.22 79 999999999 592.64 949.4 percent of total billed charges VASOSTRICT 20 UNIT/ML VIAL 48461126_1 CDM 0250 RC 42023-0164-25 NDC inpatient 1 UN 978.76 636.19 SELF PAY DISCOUNT SELF PAY DISCOUNT 636.19 65 999999999 592.64 949.4 percent of total billed charges VASOSTRICT 20 UNIT/ML VIAL 48461126_1 CDM 0250 RC 42023-0164-25 NDC inpatient 1 UN 978.76 636.19 ENCORE - ALL PLANS ENCORE - ALL PLANS 675.34 69 999999999 592.64 949.4 percent of total billed charges VASOSTRICT 20 UNIT/ML VIAL 48461126_1 CDM 0250 RC 42023-0164-25 NDC inpatient 1 UN 978.76 636.19 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 949.4 97 999999999 592.64 949.4 percent of total billed charges VASOSTRICT 20 UNIT/ML VIAL 48461126_1 CDM 0250 RC 42023-0164-25 NDC inpatient 1 UN 978.76 636.19 HUMANA - ALL PLANS HUMANA - ALL PLANS 763.43 78 999999999 592.64 949.4 percent of total billed charges VASOSTRICT 20 UNIT/ML VIAL 48461126_1 CDM 0250 RC 42023-0164-25 NDC inpatient 1 UN 978.76 636.19 UMR - ALL PLANS UMR - ALL PLANS 685.13 70 999999999 592.64 949.4 percent of total billed charges VASOSTRICT 20 UNIT/ML VIAL 48461126_1 CDM 0250 RC 42023-0164-25 NDC inpatient 1 UN 978.76 636.19 SIHO - ALL PLANS SIHO - ALL PLANS 880.88 90 999999999 592.64 949.4 percent of total billed charges VASOSTRICT 20 UNIT/ML VIAL 48461126_1 CDM 0250 RC 42023-0164-25 NDC inpatient 1 UN 978.76 636.19 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 592.64 60.55 999999999 592.64 949.4 percent of total billed charges VASOSTRICT 20 UNIT/ML VIAL 48461126_1 CDM 0250 RC 42023-0164-25 NDC inpatient 1 UN 978.76 636.19 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 592.64 949.4 VASOSTRICT 20 UNIT/ML VIAL 48461126_1 CDM 0250 RC 42023-0164-25 NDC inpatient 1 UN 978.76 636.19 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 592.64 949.4 VASOSTRICT 20 UNIT/ML VIAL 48461126_1 CDM 0250 RC 42023-0164-25 NDC inpatient 1 UN 978.76 636.19 ANTHEM HMO ANTHEM HMO 999999999 592.64 949.4 VASOSTRICT 20 UNIT/ML VIAL 48461126_1 CDM 0250 RC 42023-0164-25 NDC inpatient 1 UN 978.76 636.19 CIGNA - ALL PLANS CIGNA - ALL PLANS 661.64 67.6 999999999 592.64 949.4 percent of total billed charges VASOSTRICT 20 UNIT/ML VIAL 48461126_1 CDM 0250 RC 42023-0164-25 NDC inpatient 1 UN 978.76 636.19 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 592.64 949.4 VASOSTRICT 20 UNIT/ML VIAL 48461126_1 CDM 0250 RC 42023-0164-25 NDC inpatient 1 UN 978.76 636.19 UHC - ALL PLANS UHC - ALL PLANS 999999999 592.64 949.4 LATANOPROST 0.005% EYE DROPS 48461134_1 CDM 0250 RC 61314-0547-01 NDC inpatient 1 UN 11.75 7.64 AETNA AETNA 9.28 79 999999999 7.11 11.4 percent of total billed charges LATANOPROST 0.005% EYE DROPS 48461134_1 CDM 0250 RC 61314-0547-01 NDC inpatient 1 UN 11.75 7.64 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.64 65 999999999 7.11 11.4 percent of total billed charges LATANOPROST 0.005% EYE DROPS 48461134_1 CDM 0250 RC 61314-0547-01 NDC inpatient 1 UN 11.75 7.64 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.11 69 999999999 7.11 11.4 percent of total billed charges LATANOPROST 0.005% EYE DROPS 48461134_1 CDM 0250 RC 61314-0547-01 NDC inpatient 1 UN 11.75 7.64 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11.4 97 999999999 7.11 11.4 percent of total billed charges LATANOPROST 0.005% EYE DROPS 48461134_1 CDM 0250 RC 61314-0547-01 NDC inpatient 1 UN 11.75 7.64 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.17 78 999999999 7.11 11.4 percent of total billed charges LATANOPROST 0.005% EYE DROPS 48461134_1 CDM 0250 RC 61314-0547-01 NDC inpatient 1 UN 11.75 7.64 UMR - ALL PLANS UMR - ALL PLANS 8.23 70 999999999 7.11 11.4 percent of total billed charges LATANOPROST 0.005% EYE DROPS 48461134_1 CDM 0250 RC 61314-0547-01 NDC inpatient 1 UN 11.75 7.64 SIHO - ALL PLANS SIHO - ALL PLANS 10.58 90 999999999 7.11 11.4 percent of total billed charges LATANOPROST 0.005% EYE DROPS 48461134_1 CDM 0250 RC 61314-0547-01 NDC inpatient 1 UN 11.75 7.64 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.11 60.55 999999999 7.11 11.4 percent of total billed charges LATANOPROST 0.005% EYE DROPS 48461134_1 CDM 0250 RC 61314-0547-01 NDC inpatient 1 UN 11.75 7.64 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.11 11.4 LATANOPROST 0.005% EYE DROPS 48461134_1 CDM 0250 RC 61314-0547-01 NDC inpatient 1 UN 11.75 7.64 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.11 11.4 LATANOPROST 0.005% EYE DROPS 48461134_1 CDM 0250 RC 61314-0547-01 NDC inpatient 1 UN 11.75 7.64 ANTHEM HMO ANTHEM HMO 999999999 7.11 11.4 LATANOPROST 0.005% EYE DROPS 48461134_1 CDM 0250 RC 61314-0547-01 NDC inpatient 1 UN 11.75 7.64 CIGNA - ALL PLANS CIGNA - ALL PLANS 7.94 67.6 999999999 7.11 11.4 percent of total billed charges LATANOPROST 0.005% EYE DROPS 48461134_1 CDM 0250 RC 61314-0547-01 NDC inpatient 1 UN 11.75 7.64 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.11 11.4 LATANOPROST 0.005% EYE DROPS 48461134_1 CDM 0250 RC 61314-0547-01 NDC inpatient 1 UN 11.75 7.64 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.11 11.4 "INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG" 48461142_1 CDM 0250 RC 63323-0377-01 NDC J2354 HCPCS inpatient 20 UN 62.32 40.51 AETNA AETNA 49.23 79 999999999 37.73 60.45 percent of total billed charges "INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG" 48461142_1 CDM 0250 RC 63323-0377-01 NDC J2354 HCPCS inpatient 20 UN 62.32 40.51 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.51 65 999999999 37.73 60.45 percent of total billed charges "INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG" 48461142_1 CDM 0250 RC 63323-0377-01 NDC J2354 HCPCS inpatient 20 UN 62.32 40.51 ENCORE - ALL PLANS ENCORE - ALL PLANS 43 69 999999999 37.73 60.45 percent of total billed charges "INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG" 48461142_1 CDM 0250 RC 63323-0377-01 NDC J2354 HCPCS inpatient 20 UN 62.32 40.51 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 60.45 97 999999999 37.73 60.45 percent of total billed charges "INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG" 48461142_1 CDM 0250 RC 63323-0377-01 NDC J2354 HCPCS inpatient 20 UN 62.32 40.51 HUMANA - ALL PLANS HUMANA - ALL PLANS 48.61 78 999999999 37.73 60.45 percent of total billed charges "INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG" 48461142_1 CDM 0250 RC 63323-0377-01 NDC J2354 HCPCS inpatient 20 UN 62.32 40.51 UMR - ALL PLANS UMR - ALL PLANS 43.62 70 999999999 37.73 60.45 percent of total billed charges "INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG" 48461142_1 CDM 0250 RC 63323-0377-01 NDC J2354 HCPCS inpatient 20 UN 62.32 40.51 SIHO - ALL PLANS SIHO - ALL PLANS 56.09 90 999999999 37.73 60.45 percent of total billed charges "INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG" 48461142_1 CDM 0250 RC 63323-0377-01 NDC J2354 HCPCS inpatient 20 UN 62.32 40.51 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 37.73 60.55 999999999 37.73 60.45 percent of total billed charges "INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG" 48461142_1 CDM 0250 RC 63323-0377-01 NDC J2354 HCPCS inpatient 20 UN 62.32 40.51 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 37.73 60.45 "INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG" 48461142_1 CDM 0250 RC 63323-0377-01 NDC J2354 HCPCS inpatient 20 UN 62.32 40.51 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 37.73 60.45 "INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG" 48461142_1 CDM 0250 RC 63323-0377-01 NDC J2354 HCPCS inpatient 20 UN 62.32 40.51 ANTHEM HMO ANTHEM HMO 999999999 37.73 60.45 "INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG" 48461142_1 CDM 0250 RC 63323-0377-01 NDC J2354 HCPCS inpatient 20 UN 62.32 40.51 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.13 67.6 999999999 37.73 60.45 percent of total billed charges "INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG" 48461142_1 CDM 0250 RC 63323-0377-01 NDC J2354 HCPCS inpatient 20 UN 62.32 40.51 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 37.73 60.45 "INJECTION, OCTREOTIDE, NON-DEPOT FORM FOR SUBCUTANEOUS OR INTRAVENOUS INJECTION, 25 MCG" 48461142_1 CDM 0250 RC 63323-0377-01 NDC J2354 HCPCS inpatient 20 UN 62.32 40.51 UHC - ALL PLANS UHC - ALL PLANS 999999999 37.73 60.45 CEREBYX 100 MG PE/2 ML VIAL 48461143_1 CDM 0250 RC 00069-5471-02 NDC inpatient 1 UN 16.45 10.69 AETNA AETNA 13 79 999999999 9.96 15.96 percent of total billed charges CEREBYX 100 MG PE/2 ML VIAL 48461143_1 CDM 0250 RC 00069-5471-02 NDC inpatient 1 UN 16.45 10.69 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.69 65 999999999 9.96 15.96 percent of total billed charges CEREBYX 100 MG PE/2 ML VIAL 48461143_1 CDM 0250 RC 00069-5471-02 NDC inpatient 1 UN 16.45 10.69 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.35 69 999999999 9.96 15.96 percent of total billed charges CEREBYX 100 MG PE/2 ML VIAL 48461143_1 CDM 0250 RC 00069-5471-02 NDC inpatient 1 UN 16.45 10.69 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15.96 97 999999999 9.96 15.96 percent of total billed charges CEREBYX 100 MG PE/2 ML VIAL 48461143_1 CDM 0250 RC 00069-5471-02 NDC inpatient 1 UN 16.45 10.69 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.83 78 999999999 9.96 15.96 percent of total billed charges CEREBYX 100 MG PE/2 ML VIAL 48461143_1 CDM 0250 RC 00069-5471-02 NDC inpatient 1 UN 16.45 10.69 UMR - ALL PLANS UMR - ALL PLANS 11.52 70 999999999 9.96 15.96 percent of total billed charges CEREBYX 100 MG PE/2 ML VIAL 48461143_1 CDM 0250 RC 00069-5471-02 NDC inpatient 1 UN 16.45 10.69 SIHO - ALL PLANS SIHO - ALL PLANS 14.81 90 999999999 9.96 15.96 percent of total billed charges CEREBYX 100 MG PE/2 ML VIAL 48461143_1 CDM 0250 RC 00069-5471-02 NDC inpatient 1 UN 16.45 10.69 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.96 60.55 999999999 9.96 15.96 percent of total billed charges CEREBYX 100 MG PE/2 ML VIAL 48461143_1 CDM 0250 RC 00069-5471-02 NDC inpatient 1 UN 16.45 10.69 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.96 15.96 CEREBYX 100 MG PE/2 ML VIAL 48461143_1 CDM 0250 RC 00069-5471-02 NDC inpatient 1 UN 16.45 10.69 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.96 15.96 CEREBYX 100 MG PE/2 ML VIAL 48461143_1 CDM 0250 RC 00069-5471-02 NDC inpatient 1 UN 16.45 10.69 ANTHEM HMO ANTHEM HMO 999999999 9.96 15.96 CEREBYX 100 MG PE/2 ML VIAL 48461143_1 CDM 0250 RC 00069-5471-02 NDC inpatient 1 UN 16.45 10.69 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.12 67.6 999999999 9.96 15.96 percent of total billed charges CEREBYX 100 MG PE/2 ML VIAL 48461143_1 CDM 0250 RC 00069-5471-02 NDC inpatient 1 UN 16.45 10.69 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.96 15.96 CEREBYX 100 MG PE/2 ML VIAL 48461143_1 CDM 0250 RC 00069-5471-02 NDC inpatient 1 UN 16.45 10.69 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.96 15.96 CEREBYX 500 MG PE/10 ML VIAL 48461144_1 CDM 0250 RC 00069-5474-02 NDC inpatient 1 UN 83.3 54.15 AETNA AETNA 65.81 79 999999999 50.44 80.8 percent of total billed charges CEREBYX 500 MG PE/10 ML VIAL 48461144_1 CDM 0250 RC 00069-5474-02 NDC inpatient 1 UN 83.3 54.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 54.15 65 999999999 50.44 80.8 percent of total billed charges CEREBYX 500 MG PE/10 ML VIAL 48461144_1 CDM 0250 RC 00069-5474-02 NDC inpatient 1 UN 83.3 54.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.48 69 999999999 50.44 80.8 percent of total billed charges CEREBYX 500 MG PE/10 ML VIAL 48461144_1 CDM 0250 RC 00069-5474-02 NDC inpatient 1 UN 83.3 54.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.8 97 999999999 50.44 80.8 percent of total billed charges CEREBYX 500 MG PE/10 ML VIAL 48461144_1 CDM 0250 RC 00069-5474-02 NDC inpatient 1 UN 83.3 54.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.97 78 999999999 50.44 80.8 percent of total billed charges CEREBYX 500 MG PE/10 ML VIAL 48461144_1 CDM 0250 RC 00069-5474-02 NDC inpatient 1 UN 83.3 54.15 UMR - ALL PLANS UMR - ALL PLANS 58.31 70 999999999 50.44 80.8 percent of total billed charges CEREBYX 500 MG PE/10 ML VIAL 48461144_1 CDM 0250 RC 00069-5474-02 NDC inpatient 1 UN 83.3 54.15 SIHO - ALL PLANS SIHO - ALL PLANS 74.97 90 999999999 50.44 80.8 percent of total billed charges CEREBYX 500 MG PE/10 ML VIAL 48461144_1 CDM 0250 RC 00069-5474-02 NDC inpatient 1 UN 83.3 54.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.44 60.55 999999999 50.44 80.8 percent of total billed charges CEREBYX 500 MG PE/10 ML VIAL 48461144_1 CDM 0250 RC 00069-5474-02 NDC inpatient 1 UN 83.3 54.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.44 80.8 CEREBYX 500 MG PE/10 ML VIAL 48461144_1 CDM 0250 RC 00069-5474-02 NDC inpatient 1 UN 83.3 54.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.44 80.8 CEREBYX 500 MG PE/10 ML VIAL 48461144_1 CDM 0250 RC 00069-5474-02 NDC inpatient 1 UN 83.3 54.15 ANTHEM HMO ANTHEM HMO 999999999 50.44 80.8 CEREBYX 500 MG PE/10 ML VIAL 48461144_1 CDM 0250 RC 00069-5474-02 NDC inpatient 1 UN 83.3 54.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.31 67.6 999999999 50.44 80.8 percent of total billed charges CEREBYX 500 MG PE/10 ML VIAL 48461144_1 CDM 0250 RC 00069-5474-02 NDC inpatient 1 UN 83.3 54.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.44 80.8 CEREBYX 500 MG PE/10 ML VIAL 48461144_1 CDM 0250 RC 00069-5474-02 NDC inpatient 1 UN 83.3 54.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.44 80.8 PROMETHEGAN 12.5 MG SUPPOS 48461149_1 CDM 0250 RC 00713-0536-12 NDC inpatient 1 UN 16.17 10.51 AETNA AETNA 12.77 79 999999999 9.79 15.68 percent of total billed charges PROMETHEGAN 12.5 MG SUPPOS 48461149_1 CDM 0250 RC 00713-0536-12 NDC inpatient 1 UN 16.17 10.51 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.51 65 999999999 9.79 15.68 percent of total billed charges PROMETHEGAN 12.5 MG SUPPOS 48461149_1 CDM 0250 RC 00713-0536-12 NDC inpatient 1 UN 16.17 10.51 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.16 69 999999999 9.79 15.68 percent of total billed charges PROMETHEGAN 12.5 MG SUPPOS 48461149_1 CDM 0250 RC 00713-0536-12 NDC inpatient 1 UN 16.17 10.51 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15.68 97 999999999 9.79 15.68 percent of total billed charges PROMETHEGAN 12.5 MG SUPPOS 48461149_1 CDM 0250 RC 00713-0536-12 NDC inpatient 1 UN 16.17 10.51 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.61 78 999999999 9.79 15.68 percent of total billed charges PROMETHEGAN 12.5 MG SUPPOS 48461149_1 CDM 0250 RC 00713-0536-12 NDC inpatient 1 UN 16.17 10.51 UMR - ALL PLANS UMR - ALL PLANS 11.32 70 999999999 9.79 15.68 percent of total billed charges PROMETHEGAN 12.5 MG SUPPOS 48461149_1 CDM 0250 RC 00713-0536-12 NDC inpatient 1 UN 16.17 10.51 SIHO - ALL PLANS SIHO - ALL PLANS 14.55 90 999999999 9.79 15.68 percent of total billed charges PROMETHEGAN 12.5 MG SUPPOS 48461149_1 CDM 0250 RC 00713-0536-12 NDC inpatient 1 UN 16.17 10.51 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.79 60.55 999999999 9.79 15.68 percent of total billed charges PROMETHEGAN 12.5 MG SUPPOS 48461149_1 CDM 0250 RC 00713-0536-12 NDC inpatient 1 UN 16.17 10.51 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.79 15.68 PROMETHEGAN 12.5 MG SUPPOS 48461149_1 CDM 0250 RC 00713-0536-12 NDC inpatient 1 UN 16.17 10.51 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.79 15.68 PROMETHEGAN 12.5 MG SUPPOS 48461149_1 CDM 0250 RC 00713-0536-12 NDC inpatient 1 UN 16.17 10.51 ANTHEM HMO ANTHEM HMO 999999999 9.79 15.68 PROMETHEGAN 12.5 MG SUPPOS 48461149_1 CDM 0250 RC 00713-0536-12 NDC inpatient 1 UN 16.17 10.51 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.93 67.6 999999999 9.79 15.68 percent of total billed charges PROMETHEGAN 12.5 MG SUPPOS 48461149_1 CDM 0250 RC 00713-0536-12 NDC inpatient 1 UN 16.17 10.51 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.79 15.68 PROMETHEGAN 12.5 MG SUPPOS 48461149_1 CDM 0250 RC 00713-0536-12 NDC inpatient 1 UN 16.17 10.51 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.79 15.68 LORAZEPAM 20 MG/10 ML VIAL 48461182_1 CDM 0250 RC 00641-6050-10 NDC inpatient 1 UN 26.74 17.38 AETNA AETNA 21.12 79 999999999 16.19 25.94 percent of total billed charges LORAZEPAM 20 MG/10 ML VIAL 48461182_1 CDM 0250 RC 00641-6050-10 NDC inpatient 1 UN 26.74 17.38 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.38 65 999999999 16.19 25.94 percent of total billed charges LORAZEPAM 20 MG/10 ML VIAL 48461182_1 CDM 0250 RC 00641-6050-10 NDC inpatient 1 UN 26.74 17.38 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.45 69 999999999 16.19 25.94 percent of total billed charges LORAZEPAM 20 MG/10 ML VIAL 48461182_1 CDM 0250 RC 00641-6050-10 NDC inpatient 1 UN 26.74 17.38 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.94 97 999999999 16.19 25.94 percent of total billed charges LORAZEPAM 20 MG/10 ML VIAL 48461182_1 CDM 0250 RC 00641-6050-10 NDC inpatient 1 UN 26.74 17.38 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.86 78 999999999 16.19 25.94 percent of total billed charges LORAZEPAM 20 MG/10 ML VIAL 48461182_1 CDM 0250 RC 00641-6050-10 NDC inpatient 1 UN 26.74 17.38 UMR - ALL PLANS UMR - ALL PLANS 18.72 70 999999999 16.19 25.94 percent of total billed charges LORAZEPAM 20 MG/10 ML VIAL 48461182_1 CDM 0250 RC 00641-6050-10 NDC inpatient 1 UN 26.74 17.38 SIHO - ALL PLANS SIHO - ALL PLANS 24.07 90 999999999 16.19 25.94 percent of total billed charges LORAZEPAM 20 MG/10 ML VIAL 48461182_1 CDM 0250 RC 00641-6050-10 NDC inpatient 1 UN 26.74 17.38 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.19 60.55 999999999 16.19 25.94 percent of total billed charges LORAZEPAM 20 MG/10 ML VIAL 48461182_1 CDM 0250 RC 00641-6050-10 NDC inpatient 1 UN 26.74 17.38 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.19 25.94 LORAZEPAM 20 MG/10 ML VIAL 48461182_1 CDM 0250 RC 00641-6050-10 NDC inpatient 1 UN 26.74 17.38 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.19 25.94 LORAZEPAM 20 MG/10 ML VIAL 48461182_1 CDM 0250 RC 00641-6050-10 NDC inpatient 1 UN 26.74 17.38 ANTHEM HMO ANTHEM HMO 999999999 16.19 25.94 LORAZEPAM 20 MG/10 ML VIAL 48461182_1 CDM 0250 RC 00641-6050-10 NDC inpatient 1 UN 26.74 17.38 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.08 67.6 999999999 16.19 25.94 percent of total billed charges LORAZEPAM 20 MG/10 ML VIAL 48461182_1 CDM 0250 RC 00641-6050-10 NDC inpatient 1 UN 26.74 17.38 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.19 25.94 LORAZEPAM 20 MG/10 ML VIAL 48461182_1 CDM 0250 RC 00641-6050-10 NDC inpatient 1 UN 26.74 17.38 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.19 25.94 "Blood gas, oxygen saturation measurement" 48465012_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 AETNA AETNA 177.75 79 999999999 136.24 218.25 percent of total billed charges "Blood gas, oxygen saturation measurement" 48465012_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 146.25 65 999999999 136.24 218.25 percent of total billed charges "Blood gas, oxygen saturation measurement" 48465012_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 155.25 69 999999999 136.24 218.25 percent of total billed charges "Blood gas, oxygen saturation measurement" 48465012_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 218.25 97 999999999 136.24 218.25 percent of total billed charges "Blood gas, oxygen saturation measurement" 48465012_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 175.5 78 999999999 136.24 218.25 percent of total billed charges "Blood gas, oxygen saturation measurement" 48465012_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 UMR - ALL PLANS UMR - ALL PLANS 157.5 70 999999999 136.24 218.25 percent of total billed charges "Blood gas, oxygen saturation measurement" 48465012_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 SIHO - ALL PLANS SIHO - ALL PLANS 202.5 90 999999999 136.24 218.25 percent of total billed charges "Blood gas, oxygen saturation measurement" 48465012_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 136.24 60.55 999999999 136.24 218.25 percent of total billed charges "Blood gas, oxygen saturation measurement" 48465012_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 136.24 218.25 "Blood gas, oxygen saturation measurement" 48465012_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 136.24 218.25 "Blood gas, oxygen saturation measurement" 48465012_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 ANTHEM HMO ANTHEM HMO 999999999 136.24 218.25 "Blood gas, oxygen saturation measurement" 48465012_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 152.1 67.6 999999999 136.24 218.25 percent of total billed charges "Blood gas, oxygen saturation measurement" 48465012_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 136.24 218.25 "Blood gas, oxygen saturation measurement" 48465012_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 136.24 218.25 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465499_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465499_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465499_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465499_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465499_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465499_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465499_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465499_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465499_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465499_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465499_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465499_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465499_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465499_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465524_1 CDM 0306 RC 87186 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465524_1 CDM 0306 RC 87186 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465524_1 CDM 0306 RC 87186 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465524_1 CDM 0306 RC 87186 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465524_1 CDM 0306 RC 87186 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465524_1 CDM 0306 RC 87186 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465524_1 CDM 0306 RC 87186 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465524_1 CDM 0306 RC 87186 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465524_1 CDM 0306 RC 87186 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465524_1 CDM 0306 RC 87186 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465524_1 CDM 0306 RC 87186 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465524_1 CDM 0306 RC 87186 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465524_1 CDM 0306 RC 87186 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465524_1 CDM 0306 RC 87186 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465543_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465543_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465543_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465543_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465543_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465543_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465543_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465543_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465543_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465543_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465543_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465543_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465543_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), microdilution or agar dilution" 48465543_1 CDM 0306 RC 87186 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 LABOR ROOM/DELIVERY - BIRTHING CENTER 48476979_1 CDM 0724 RC inpatient 5658 3677.7 AETNA AETNA 4469.82 79 999999999 3425.92 5488.26 percent of total billed charges LABOR ROOM/DELIVERY - BIRTHING CENTER 48476979_1 CDM 0724 RC inpatient 5658 3677.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 3677.7 65 999999999 3425.92 5488.26 percent of total billed charges LABOR ROOM/DELIVERY - BIRTHING CENTER 48476979_1 CDM 0724 RC inpatient 5658 3677.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 3904.02 69 999999999 3425.92 5488.26 percent of total billed charges LABOR ROOM/DELIVERY - BIRTHING CENTER 48476979_1 CDM 0724 RC inpatient 5658 3677.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5488.26 97 999999999 3425.92 5488.26 percent of total billed charges LABOR ROOM/DELIVERY - BIRTHING CENTER 48476979_1 CDM 0724 RC inpatient 5658 3677.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 4413.24 78 999999999 3425.92 5488.26 percent of total billed charges LABOR ROOM/DELIVERY - BIRTHING CENTER 48476979_1 CDM 0724 RC inpatient 5658 3677.7 UMR - ALL PLANS UMR - ALL PLANS 3960.6 70 999999999 3425.92 5488.26 percent of total billed charges LABOR ROOM/DELIVERY - BIRTHING CENTER 48476979_1 CDM 0724 RC inpatient 5658 3677.7 SIHO - ALL PLANS SIHO - ALL PLANS 5092.2 90 999999999 3425.92 5488.26 percent of total billed charges LABOR ROOM/DELIVERY - BIRTHING CENTER 48476979_1 CDM 0724 RC inpatient 5658 3677.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3425.92 60.55 999999999 3425.92 5488.26 percent of total billed charges LABOR ROOM/DELIVERY - BIRTHING CENTER 48476979_1 CDM 0724 RC inpatient 5658 3677.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3425.92 5488.26 LABOR ROOM/DELIVERY - BIRTHING CENTER 48476979_1 CDM 0724 RC inpatient 5658 3677.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3425.92 5488.26 LABOR ROOM/DELIVERY - BIRTHING CENTER 48476979_1 CDM 0724 RC inpatient 5658 3677.7 ANTHEM HMO ANTHEM HMO 999999999 3425.92 5488.26 LABOR ROOM/DELIVERY - BIRTHING CENTER 48476979_1 CDM 0724 RC inpatient 5658 3677.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 3824.81 67.6 999999999 3425.92 5488.26 percent of total billed charges LABOR ROOM/DELIVERY - BIRTHING CENTER 48476979_1 CDM 0724 RC inpatient 5658 3677.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3425.92 5488.26 LABOR ROOM/DELIVERY - BIRTHING CENTER 48476979_1 CDM 0724 RC inpatient 5658 3677.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 3425.92 5488.26 LABOR ROOM/DELIVERY - BIRTHING CENTER 48476983_1 CDM 0724 RC inpatient 2833 1841.45 AETNA AETNA 2238.07 79 999999999 1715.38 2748.01 percent of total billed charges LABOR ROOM/DELIVERY - BIRTHING CENTER 48476983_1 CDM 0724 RC inpatient 2833 1841.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1841.45 65 999999999 1715.38 2748.01 percent of total billed charges LABOR ROOM/DELIVERY - BIRTHING CENTER 48476983_1 CDM 0724 RC inpatient 2833 1841.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1954.77 69 999999999 1715.38 2748.01 percent of total billed charges LABOR ROOM/DELIVERY - BIRTHING CENTER 48476983_1 CDM 0724 RC inpatient 2833 1841.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2748.01 97 999999999 1715.38 2748.01 percent of total billed charges LABOR ROOM/DELIVERY - BIRTHING CENTER 48476983_1 CDM 0724 RC inpatient 2833 1841.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 2209.74 78 999999999 1715.38 2748.01 percent of total billed charges LABOR ROOM/DELIVERY - BIRTHING CENTER 48476983_1 CDM 0724 RC inpatient 2833 1841.45 UMR - ALL PLANS UMR - ALL PLANS 1983.1 70 999999999 1715.38 2748.01 percent of total billed charges LABOR ROOM/DELIVERY - BIRTHING CENTER 48476983_1 CDM 0724 RC inpatient 2833 1841.45 SIHO - ALL PLANS SIHO - ALL PLANS 2549.7 90 999999999 1715.38 2748.01 percent of total billed charges LABOR ROOM/DELIVERY - BIRTHING CENTER 48476983_1 CDM 0724 RC inpatient 2833 1841.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1715.38 60.55 999999999 1715.38 2748.01 percent of total billed charges LABOR ROOM/DELIVERY - BIRTHING CENTER 48476983_1 CDM 0724 RC inpatient 2833 1841.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1715.38 2748.01 LABOR ROOM/DELIVERY - BIRTHING CENTER 48476983_1 CDM 0724 RC inpatient 2833 1841.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1715.38 2748.01 LABOR ROOM/DELIVERY - BIRTHING CENTER 48476983_1 CDM 0724 RC inpatient 2833 1841.45 ANTHEM HMO ANTHEM HMO 999999999 1715.38 2748.01 LABOR ROOM/DELIVERY - BIRTHING CENTER 48476983_1 CDM 0724 RC inpatient 2833 1841.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1915.11 67.6 999999999 1715.38 2748.01 percent of total billed charges LABOR ROOM/DELIVERY - BIRTHING CENTER 48476983_1 CDM 0724 RC inpatient 2833 1841.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1715.38 2748.01 LABOR ROOM/DELIVERY - BIRTHING CENTER 48476983_1 CDM 0724 RC inpatient 2833 1841.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1715.38 2748.01 MAG SULFATE INFUSION Charge 48477038_1 CDM 0260 RC inpatient 420 273 AETNA AETNA 331.8 79 999999999 254.31 407.4 percent of total billed charges MAG SULFATE INFUSION Charge 48477038_1 CDM 0260 RC inpatient 420 273 SELF PAY DISCOUNT SELF PAY DISCOUNT 273 65 999999999 254.31 407.4 percent of total billed charges MAG SULFATE INFUSION Charge 48477038_1 CDM 0260 RC inpatient 420 273 ENCORE - ALL PLANS ENCORE - ALL PLANS 289.8 69 999999999 254.31 407.4 percent of total billed charges MAG SULFATE INFUSION Charge 48477038_1 CDM 0260 RC inpatient 420 273 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 407.4 97 999999999 254.31 407.4 percent of total billed charges MAG SULFATE INFUSION Charge 48477038_1 CDM 0260 RC inpatient 420 273 HUMANA - ALL PLANS HUMANA - ALL PLANS 327.6 78 999999999 254.31 407.4 percent of total billed charges MAG SULFATE INFUSION Charge 48477038_1 CDM 0260 RC inpatient 420 273 UMR - ALL PLANS UMR - ALL PLANS 294 70 999999999 254.31 407.4 percent of total billed charges MAG SULFATE INFUSION Charge 48477038_1 CDM 0260 RC inpatient 420 273 SIHO - ALL PLANS SIHO - ALL PLANS 378 90 999999999 254.31 407.4 percent of total billed charges MAG SULFATE INFUSION Charge 48477038_1 CDM 0260 RC inpatient 420 273 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 254.31 60.55 999999999 254.31 407.4 percent of total billed charges MAG SULFATE INFUSION Charge 48477038_1 CDM 0260 RC inpatient 420 273 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 254.31 407.4 MAG SULFATE INFUSION Charge 48477038_1 CDM 0260 RC inpatient 420 273 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 254.31 407.4 MAG SULFATE INFUSION Charge 48477038_1 CDM 0260 RC inpatient 420 273 ANTHEM HMO ANTHEM HMO 999999999 254.31 407.4 MAG SULFATE INFUSION Charge 48477038_1 CDM 0260 RC inpatient 420 273 CIGNA - ALL PLANS CIGNA - ALL PLANS 283.92 67.6 999999999 254.31 407.4 percent of total billed charges MAG SULFATE INFUSION Charge 48477038_1 CDM 0260 RC inpatient 420 273 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 254.31 407.4 MAG SULFATE INFUSION Charge 48477038_1 CDM 0260 RC inpatient 420 273 UHC - ALL PLANS UHC - ALL PLANS 999999999 254.31 407.4 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477039_1 CDM 0720 RC inpatient 420 273 AETNA AETNA 331.8 79 999999999 254.31 407.4 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477039_1 CDM 0720 RC inpatient 420 273 SELF PAY DISCOUNT SELF PAY DISCOUNT 273 65 999999999 254.31 407.4 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477039_1 CDM 0720 RC inpatient 420 273 ENCORE - ALL PLANS ENCORE - ALL PLANS 289.8 69 999999999 254.31 407.4 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477039_1 CDM 0720 RC inpatient 420 273 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 407.4 97 999999999 254.31 407.4 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477039_1 CDM 0720 RC inpatient 420 273 HUMANA - ALL PLANS HUMANA - ALL PLANS 327.6 78 999999999 254.31 407.4 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477039_1 CDM 0720 RC inpatient 420 273 UMR - ALL PLANS UMR - ALL PLANS 294 70 999999999 254.31 407.4 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477039_1 CDM 0720 RC inpatient 420 273 SIHO - ALL PLANS SIHO - ALL PLANS 378 90 999999999 254.31 407.4 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477039_1 CDM 0720 RC inpatient 420 273 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 254.31 60.55 999999999 254.31 407.4 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477039_1 CDM 0720 RC inpatient 420 273 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 254.31 407.4 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477039_1 CDM 0720 RC inpatient 420 273 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 254.31 407.4 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477039_1 CDM 0720 RC inpatient 420 273 ANTHEM HMO ANTHEM HMO 999999999 254.31 407.4 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477039_1 CDM 0720 RC inpatient 420 273 CIGNA - ALL PLANS CIGNA - ALL PLANS 283.92 67.6 999999999 254.31 407.4 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477039_1 CDM 0720 RC inpatient 420 273 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 254.31 407.4 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477039_1 CDM 0720 RC inpatient 420 273 UHC - ALL PLANS UHC - ALL PLANS 999999999 254.31 407.4 Fetal monitoring during labor by consulting physician 48477040_1 CDM 0721 RC 59050 HCPCS inpatient 165 107.25 AETNA AETNA 130.35 79 999999999 99.91 160.05 percent of total billed charges Fetal monitoring during labor by consulting physician 48477040_1 CDM 0721 RC 59050 HCPCS inpatient 165 107.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.25 65 999999999 99.91 160.05 percent of total billed charges Fetal monitoring during labor by consulting physician 48477040_1 CDM 0721 RC 59050 HCPCS inpatient 165 107.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.85 69 999999999 99.91 160.05 percent of total billed charges Fetal monitoring during labor by consulting physician 48477040_1 CDM 0721 RC 59050 HCPCS inpatient 165 107.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 160.05 97 999999999 99.91 160.05 percent of total billed charges Fetal monitoring during labor by consulting physician 48477040_1 CDM 0721 RC 59050 HCPCS inpatient 165 107.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.7 78 999999999 99.91 160.05 percent of total billed charges Fetal monitoring during labor by consulting physician 48477040_1 CDM 0721 RC 59050 HCPCS inpatient 165 107.25 UMR - ALL PLANS UMR - ALL PLANS 115.5 70 999999999 99.91 160.05 percent of total billed charges Fetal monitoring during labor by consulting physician 48477040_1 CDM 0721 RC 59050 HCPCS inpatient 165 107.25 SIHO - ALL PLANS SIHO - ALL PLANS 148.5 90 999999999 99.91 160.05 percent of total billed charges Fetal monitoring during labor by consulting physician 48477040_1 CDM 0721 RC 59050 HCPCS inpatient 165 107.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.91 60.55 999999999 99.91 160.05 percent of total billed charges Fetal monitoring during labor by consulting physician 48477040_1 CDM 0721 RC 59050 HCPCS inpatient 165 107.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.91 160.05 Fetal monitoring during labor by consulting physician 48477040_1 CDM 0721 RC 59050 HCPCS inpatient 165 107.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.91 160.05 Fetal monitoring during labor by consulting physician 48477040_1 CDM 0721 RC 59050 HCPCS inpatient 165 107.25 ANTHEM HMO ANTHEM HMO 999999999 99.91 160.05 Fetal monitoring during labor by consulting physician 48477040_1 CDM 0721 RC 59050 HCPCS inpatient 165 107.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.54 67.6 999999999 99.91 160.05 percent of total billed charges Fetal monitoring during labor by consulting physician 48477040_1 CDM 0721 RC 59050 HCPCS inpatient 165 107.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.91 160.05 Fetal monitoring during labor by consulting physician 48477040_1 CDM 0721 RC 59050 HCPCS inpatient 165 107.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.91 160.05 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477041_1 CDM 0720 RC inpatient 2844 1848.6 AETNA AETNA 2246.76 79 999999999 1722.04 2758.68 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477041_1 CDM 0720 RC inpatient 2844 1848.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1848.6 65 999999999 1722.04 2758.68 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477041_1 CDM 0720 RC inpatient 2844 1848.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1962.36 69 999999999 1722.04 2758.68 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477041_1 CDM 0720 RC inpatient 2844 1848.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2758.68 97 999999999 1722.04 2758.68 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477041_1 CDM 0720 RC inpatient 2844 1848.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 2218.32 78 999999999 1722.04 2758.68 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477041_1 CDM 0720 RC inpatient 2844 1848.6 UMR - ALL PLANS UMR - ALL PLANS 1990.8 70 999999999 1722.04 2758.68 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477041_1 CDM 0720 RC inpatient 2844 1848.6 SIHO - ALL PLANS SIHO - ALL PLANS 2559.6 90 999999999 1722.04 2758.68 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477041_1 CDM 0720 RC inpatient 2844 1848.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1722.04 60.55 999999999 1722.04 2758.68 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477041_1 CDM 0720 RC inpatient 2844 1848.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1722.04 2758.68 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477041_1 CDM 0720 RC inpatient 2844 1848.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1722.04 2758.68 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477041_1 CDM 0720 RC inpatient 2844 1848.6 ANTHEM HMO ANTHEM HMO 999999999 1722.04 2758.68 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477041_1 CDM 0720 RC inpatient 2844 1848.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1922.54 67.6 999999999 1722.04 2758.68 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477041_1 CDM 0720 RC inpatient 2844 1848.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1722.04 2758.68 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48477041_1 CDM 0720 RC inpatient 2844 1848.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1722.04 2758.68 RECOVERY ROOM - GENERAL CLASSIFICATION 48477042_1 CDM 0710 RC inpatient 713 463.45 AETNA AETNA 563.27 79 999999999 431.72 691.61 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48477042_1 CDM 0710 RC inpatient 713 463.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 463.45 65 999999999 431.72 691.61 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48477042_1 CDM 0710 RC inpatient 713 463.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 491.97 69 999999999 431.72 691.61 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48477042_1 CDM 0710 RC inpatient 713 463.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 691.61 97 999999999 431.72 691.61 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48477042_1 CDM 0710 RC inpatient 713 463.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 556.14 78 999999999 431.72 691.61 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48477042_1 CDM 0710 RC inpatient 713 463.45 UMR - ALL PLANS UMR - ALL PLANS 499.1 70 999999999 431.72 691.61 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48477042_1 CDM 0710 RC inpatient 713 463.45 SIHO - ALL PLANS SIHO - ALL PLANS 641.7 90 999999999 431.72 691.61 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48477042_1 CDM 0710 RC inpatient 713 463.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 431.72 60.55 999999999 431.72 691.61 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48477042_1 CDM 0710 RC inpatient 713 463.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 431.72 691.61 RECOVERY ROOM - GENERAL CLASSIFICATION 48477042_1 CDM 0710 RC inpatient 713 463.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 431.72 691.61 RECOVERY ROOM - GENERAL CLASSIFICATION 48477042_1 CDM 0710 RC inpatient 713 463.45 ANTHEM HMO ANTHEM HMO 999999999 431.72 691.61 RECOVERY ROOM - GENERAL CLASSIFICATION 48477042_1 CDM 0710 RC inpatient 713 463.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 481.99 67.6 999999999 431.72 691.61 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48477042_1 CDM 0710 RC inpatient 713 463.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 431.72 691.61 RECOVERY ROOM - GENERAL CLASSIFICATION 48477042_1 CDM 0710 RC inpatient 713 463.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 431.72 691.61 Emergency department visit for problem that may not require health care professional 48477067_1 CDM 0451 RC 99281 HCPCS inpatient 1336 868.4 AETNA AETNA 1055.44 79 999999999 808.95 1295.92 percent of total billed charges Emergency department visit for problem that may not require health care professional 48477067_1 CDM 0451 RC 99281 HCPCS inpatient 1336 868.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 868.4 65 999999999 808.95 1295.92 percent of total billed charges Emergency department visit for problem that may not require health care professional 48477067_1 CDM 0451 RC 99281 HCPCS inpatient 1336 868.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 921.84 69 999999999 808.95 1295.92 percent of total billed charges Emergency department visit for problem that may not require health care professional 48477067_1 CDM 0451 RC 99281 HCPCS inpatient 1336 868.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1295.92 97 999999999 808.95 1295.92 percent of total billed charges Emergency department visit for problem that may not require health care professional 48477067_1 CDM 0451 RC 99281 HCPCS inpatient 1336 868.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1042.08 78 999999999 808.95 1295.92 percent of total billed charges Emergency department visit for problem that may not require health care professional 48477067_1 CDM 0451 RC 99281 HCPCS inpatient 1336 868.4 UMR - ALL PLANS UMR - ALL PLANS 935.2 70 999999999 808.95 1295.92 percent of total billed charges Emergency department visit for problem that may not require health care professional 48477067_1 CDM 0451 RC 99281 HCPCS inpatient 1336 868.4 SIHO - ALL PLANS SIHO - ALL PLANS 1202.4 90 999999999 808.95 1295.92 percent of total billed charges Emergency department visit for problem that may not require health care professional 48477067_1 CDM 0451 RC 99281 HCPCS inpatient 1336 868.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 808.95 60.55 999999999 808.95 1295.92 percent of total billed charges Emergency department visit for problem that may not require health care professional 48477067_1 CDM 0451 RC 99281 HCPCS inpatient 1336 868.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 808.95 1295.92 Emergency department visit for problem that may not require health care professional 48477067_1 CDM 0451 RC 99281 HCPCS inpatient 1336 868.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 808.95 1295.92 Emergency department visit for problem that may not require health care professional 48477067_1 CDM 0451 RC 99281 HCPCS inpatient 1336 868.4 ANTHEM HMO ANTHEM HMO 999999999 808.95 1295.92 Emergency department visit for problem that may not require health care professional 48477067_1 CDM 0451 RC 99281 HCPCS inpatient 1336 868.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 903.14 67.6 999999999 808.95 1295.92 percent of total billed charges Emergency department visit for problem that may not require health care professional 48477067_1 CDM 0451 RC 99281 HCPCS inpatient 1336 868.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 808.95 1295.92 Emergency department visit for problem that may not require health care professional 48477067_1 CDM 0451 RC 99281 HCPCS inpatient 1336 868.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 808.95 1295.92 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48477070_1 CDM 0721 RC G0463 HCPCS inpatient 344 223.6 AETNA AETNA 271.76 79 999999999 208.29 333.68 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48477070_1 CDM 0721 RC G0463 HCPCS inpatient 344 223.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 223.6 65 999999999 208.29 333.68 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48477070_1 CDM 0721 RC G0463 HCPCS inpatient 344 223.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 237.36 69 999999999 208.29 333.68 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48477070_1 CDM 0721 RC G0463 HCPCS inpatient 344 223.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 333.68 97 999999999 208.29 333.68 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48477070_1 CDM 0721 RC G0463 HCPCS inpatient 344 223.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 268.32 78 999999999 208.29 333.68 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48477070_1 CDM 0721 RC G0463 HCPCS inpatient 344 223.6 UMR - ALL PLANS UMR - ALL PLANS 240.8 70 999999999 208.29 333.68 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48477070_1 CDM 0721 RC G0463 HCPCS inpatient 344 223.6 SIHO - ALL PLANS SIHO - ALL PLANS 309.6 90 999999999 208.29 333.68 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48477070_1 CDM 0721 RC G0463 HCPCS inpatient 344 223.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 208.29 60.55 999999999 208.29 333.68 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48477070_1 CDM 0721 RC G0463 HCPCS inpatient 344 223.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 208.29 333.68 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48477070_1 CDM 0721 RC G0463 HCPCS inpatient 344 223.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 208.29 333.68 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48477070_1 CDM 0721 RC G0463 HCPCS inpatient 344 223.6 ANTHEM HMO ANTHEM HMO 999999999 208.29 333.68 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48477070_1 CDM 0721 RC G0463 HCPCS inpatient 344 223.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 232.54 67.6 999999999 208.29 333.68 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48477070_1 CDM 0721 RC G0463 HCPCS inpatient 344 223.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 208.29 333.68 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48477070_1 CDM 0721 RC G0463 HCPCS inpatient 344 223.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 208.29 333.68 "Use of a drug to induce depression of consciousness by physician performing a procedure (5 years or older), initial 15 minutes" 48491314_1 CDM 0450 RC 99152 HCPCS inpatient 315 204.75 AETNA AETNA 248.85 79 999999999 190.73 305.55 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure (5 years or older), initial 15 minutes" 48491314_1 CDM 0450 RC 99152 HCPCS inpatient 315 204.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 204.75 65 999999999 190.73 305.55 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure (5 years or older), initial 15 minutes" 48491314_1 CDM 0450 RC 99152 HCPCS inpatient 315 204.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 305.55 97 999999999 190.73 305.55 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure (5 years or older), initial 15 minutes" 48491314_1 CDM 0450 RC 99152 HCPCS inpatient 315 204.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 217.35 69 999999999 190.73 305.55 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure (5 years or older), initial 15 minutes" 48491314_1 CDM 0450 RC 99152 HCPCS inpatient 315 204.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 245.7 78 999999999 190.73 305.55 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure (5 years or older), initial 15 minutes" 48491314_1 CDM 0450 RC 99152 HCPCS inpatient 315 204.75 UMR - ALL PLANS UMR - ALL PLANS 220.5 70 999999999 190.73 305.55 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure (5 years or older), initial 15 minutes" 48491314_1 CDM 0450 RC 99152 HCPCS inpatient 315 204.75 SIHO - ALL PLANS SIHO - ALL PLANS 283.5 90 999999999 190.73 305.55 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure (5 years or older), initial 15 minutes" 48491314_1 CDM 0450 RC 99152 HCPCS inpatient 315 204.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 190.73 60.55 999999999 190.73 305.55 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure (5 years or older), initial 15 minutes" 48491314_1 CDM 0450 RC 99152 HCPCS inpatient 315 204.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 190.73 305.55 "Use of a drug to induce depression of consciousness by physician performing a procedure (5 years or older), initial 15 minutes" 48491314_1 CDM 0450 RC 99152 HCPCS inpatient 315 204.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 190.73 305.55 "Use of a drug to induce depression of consciousness by physician performing a procedure (5 years or older), initial 15 minutes" 48491314_1 CDM 0450 RC 99152 HCPCS inpatient 315 204.75 ANTHEM HMO ANTHEM HMO 999999999 190.73 305.55 "Use of a drug to induce depression of consciousness by physician performing a procedure (5 years or older), initial 15 minutes" 48491314_1 CDM 0450 RC 99152 HCPCS inpatient 315 204.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 212.94 67.6 999999999 190.73 305.55 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure (5 years or older), initial 15 minutes" 48491314_1 CDM 0450 RC 99152 HCPCS inpatient 315 204.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 190.73 305.55 "Use of a drug to induce depression of consciousness by physician performing a procedure (5 years or older), initial 15 minutes" 48491314_1 CDM 0450 RC 99152 HCPCS inpatient 315 204.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 190.73 305.55 MOD SEDAT PHYS/QHP EA 15 MIN 48491315_1 CDM 0450 RC 99145 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges MOD SEDAT PHYS/QHP EA 15 MIN 48491315_1 CDM 0450 RC 99145 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges MOD SEDAT PHYS/QHP EA 15 MIN 48491315_1 CDM 0450 RC 99145 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges MOD SEDAT PHYS/QHP EA 15 MIN 48491315_1 CDM 0450 RC 99145 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges MOD SEDAT PHYS/QHP EA 15 MIN 48491315_1 CDM 0450 RC 99145 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges MOD SEDAT PHYS/QHP EA 15 MIN 48491315_1 CDM 0450 RC 99145 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges MOD SEDAT PHYS/QHP EA 15 MIN 48491315_1 CDM 0450 RC 99145 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges MOD SEDAT PHYS/QHP EA 15 MIN 48491315_1 CDM 0450 RC 99145 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges MOD SEDAT PHYS/QHP EA 15 MIN 48491315_1 CDM 0450 RC 99145 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 MOD SEDAT PHYS/QHP EA 15 MIN 48491315_1 CDM 0450 RC 99145 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 MOD SEDAT PHYS/QHP EA 15 MIN 48491315_1 CDM 0450 RC 99145 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 MOD SEDAT PHYS/QHP EA 15 MIN 48491315_1 CDM 0450 RC 99145 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges MOD SEDAT PHYS/QHP EA 15 MIN 48491315_1 CDM 0450 RC 99145 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 MOD SEDAT PHYS/QHP EA 15 MIN 48491315_1 CDM 0450 RC 99145 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Removal of impacted ear wax by washing 48497606_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 AETNA AETNA 114.55 79 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 48497606_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.25 65 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 48497606_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 140.65 97 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 48497606_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.05 69 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 48497606_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.1 78 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 48497606_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 UMR - ALL PLANS UMR - ALL PLANS 101.5 70 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 48497606_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 SIHO - ALL PLANS SIHO - ALL PLANS 130.5 90 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 48497606_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.8 60.55 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 48497606_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.8 140.65 Removal of impacted ear wax by washing 48497606_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.8 140.65 Removal of impacted ear wax by washing 48497606_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 ANTHEM HMO ANTHEM HMO 999999999 87.8 140.65 Removal of impacted ear wax by washing 48497606_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.02 67.6 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 48497606_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.8 140.65 Removal of impacted ear wax by washing 48497606_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.8 140.65 Removal of antibodies from surface of red blood cell 48498135_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 AETNA AETNA 421.86 79 999999999 323.34 517.98 percent of total billed charges Removal of antibodies from surface of red blood cell 48498135_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 347.1 65 999999999 323.34 517.98 percent of total billed charges Removal of antibodies from surface of red blood cell 48498135_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 517.98 97 999999999 323.34 517.98 percent of total billed charges Removal of antibodies from surface of red blood cell 48498135_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 368.46 69 999999999 323.34 517.98 percent of total billed charges Removal of antibodies from surface of red blood cell 48498135_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 416.52 78 999999999 323.34 517.98 percent of total billed charges Removal of antibodies from surface of red blood cell 48498135_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 UMR - ALL PLANS UMR - ALL PLANS 373.8 70 999999999 323.34 517.98 percent of total billed charges Removal of antibodies from surface of red blood cell 48498135_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 SIHO - ALL PLANS SIHO - ALL PLANS 480.6 90 999999999 323.34 517.98 percent of total billed charges Removal of antibodies from surface of red blood cell 48498135_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 323.34 60.55 999999999 323.34 517.98 percent of total billed charges Removal of antibodies from surface of red blood cell 48498135_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 323.34 517.98 Removal of antibodies from surface of red blood cell 48498135_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 323.34 517.98 Removal of antibodies from surface of red blood cell 48498135_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 ANTHEM HMO ANTHEM HMO 999999999 323.34 517.98 Removal of antibodies from surface of red blood cell 48498135_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 360.98 67.6 999999999 323.34 517.98 percent of total billed charges Removal of antibodies from surface of red blood cell 48498135_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 323.34 517.98 Removal of antibodies from surface of red blood cell 48498135_1 CDM 0302 RC 86860 HCPCS inpatient 534 347.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 323.34 517.98 Identification of red blood cell antibodies 48498136_1 CDM 0302 RC 86870 HCPCS inpatient 488 317.2 AETNA AETNA 385.52 79 999999999 295.48 473.36 percent of total billed charges Identification of red blood cell antibodies 48498136_1 CDM 0302 RC 86870 HCPCS inpatient 488 317.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 317.2 65 999999999 295.48 473.36 percent of total billed charges Identification of red blood cell antibodies 48498136_1 CDM 0302 RC 86870 HCPCS inpatient 488 317.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 473.36 97 999999999 295.48 473.36 percent of total billed charges Identification of red blood cell antibodies 48498136_1 CDM 0302 RC 86870 HCPCS inpatient 488 317.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 336.72 69 999999999 295.48 473.36 percent of total billed charges Identification of red blood cell antibodies 48498136_1 CDM 0302 RC 86870 HCPCS inpatient 488 317.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 380.64 78 999999999 295.48 473.36 percent of total billed charges Identification of red blood cell antibodies 48498136_1 CDM 0302 RC 86870 HCPCS inpatient 488 317.2 UMR - ALL PLANS UMR - ALL PLANS 341.6 70 999999999 295.48 473.36 percent of total billed charges Identification of red blood cell antibodies 48498136_1 CDM 0302 RC 86870 HCPCS inpatient 488 317.2 SIHO - ALL PLANS SIHO - ALL PLANS 439.2 90 999999999 295.48 473.36 percent of total billed charges Identification of red blood cell antibodies 48498136_1 CDM 0302 RC 86870 HCPCS inpatient 488 317.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 295.48 60.55 999999999 295.48 473.36 percent of total billed charges Identification of red blood cell antibodies 48498136_1 CDM 0302 RC 86870 HCPCS inpatient 488 317.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 295.48 473.36 Identification of red blood cell antibodies 48498136_1 CDM 0302 RC 86870 HCPCS inpatient 488 317.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 295.48 473.36 Identification of red blood cell antibodies 48498136_1 CDM 0302 RC 86870 HCPCS inpatient 488 317.2 ANTHEM HMO ANTHEM HMO 999999999 295.48 473.36 Identification of red blood cell antibodies 48498136_1 CDM 0302 RC 86870 HCPCS inpatient 488 317.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 329.89 67.6 999999999 295.48 473.36 percent of total billed charges Identification of red blood cell antibodies 48498136_1 CDM 0302 RC 86870 HCPCS inpatient 488 317.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 295.48 473.36 Identification of red blood cell antibodies 48498136_1 CDM 0302 RC 86870 HCPCS inpatient 488 317.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 295.48 473.36 "Red blood cell antibody detection test, direct" 48498137_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48498137_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48498137_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48498137_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48498137_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48498137_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48498137_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48498137_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48498137_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Red blood cell antibody detection test, direct" 48498137_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Red blood cell antibody detection test, direct" 48498137_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Red blood cell antibody detection test, direct" 48498137_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48498137_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Red blood cell antibody detection test, direct" 48498137_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 Blood typing for red blood cell antigens 48498138_1 CDM 0302 RC 86905 HCPCS inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges Blood typing for red blood cell antigens 48498138_1 CDM 0302 RC 86905 HCPCS inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges Blood typing for red blood cell antigens 48498138_1 CDM 0302 RC 86905 HCPCS inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges Blood typing for red blood cell antigens 48498138_1 CDM 0302 RC 86905 HCPCS inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges Blood typing for red blood cell antigens 48498138_1 CDM 0302 RC 86905 HCPCS inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges Blood typing for red blood cell antigens 48498138_1 CDM 0302 RC 86905 HCPCS inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges Blood typing for red blood cell antigens 48498138_1 CDM 0302 RC 86905 HCPCS inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges Blood typing for red blood cell antigens 48498138_1 CDM 0302 RC 86905 HCPCS inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges Blood typing for red blood cell antigens 48498138_1 CDM 0302 RC 86905 HCPCS inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 Blood typing for red blood cell antigens 48498138_1 CDM 0302 RC 86905 HCPCS inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 Blood typing for red blood cell antigens 48498138_1 CDM 0302 RC 86905 HCPCS inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 Blood typing for red blood cell antigens 48498138_1 CDM 0302 RC 86905 HCPCS inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges Blood typing for red blood cell antigens 48498138_1 CDM 0302 RC 86905 HCPCS inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 Blood typing for red blood cell antigens 48498138_1 CDM 0302 RC 86905 HCPCS inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 "Red blood cell antibody detection test, direct" 48498139_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48498139_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48498139_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48498139_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48498139_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48498139_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48498139_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48498139_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48498139_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Red blood cell antibody detection test, direct" 48498139_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Red blood cell antibody detection test, direct" 48498139_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Red blood cell antibody detection test, direct" 48498139_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48498139_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Red blood cell antibody detection test, direct" 48498139_1 CDM 0302 RC 86880 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 Topiramate level 48498140_1 CDM 0300 RC 80201 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges Topiramate level 48498140_1 CDM 0300 RC 80201 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges Topiramate level 48498140_1 CDM 0300 RC 80201 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges Topiramate level 48498140_1 CDM 0300 RC 80201 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges Topiramate level 48498140_1 CDM 0300 RC 80201 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges Topiramate level 48498140_1 CDM 0300 RC 80201 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges Topiramate level 48498140_1 CDM 0300 RC 80201 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges Topiramate level 48498140_1 CDM 0300 RC 80201 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges Topiramate level 48498140_1 CDM 0300 RC 80201 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 Topiramate level 48498140_1 CDM 0300 RC 80201 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 Topiramate level 48498140_1 CDM 0300 RC 80201 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 Topiramate level 48498140_1 CDM 0300 RC 80201 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges Topiramate level 48498140_1 CDM 0300 RC 80201 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 Topiramate level 48498140_1 CDM 0300 RC 80201 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 "Cortisol (hormone) measurement, free" 48498142_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 AETNA AETNA 303.36 79 999999999 232.51 372.48 percent of total billed charges "Cortisol (hormone) measurement, free" 48498142_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 249.6 65 999999999 232.51 372.48 percent of total billed charges "Cortisol (hormone) measurement, free" 48498142_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 372.48 97 999999999 232.51 372.48 percent of total billed charges "Cortisol (hormone) measurement, free" 48498142_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 264.96 69 999999999 232.51 372.48 percent of total billed charges "Cortisol (hormone) measurement, free" 48498142_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 299.52 78 999999999 232.51 372.48 percent of total billed charges "Cortisol (hormone) measurement, free" 48498142_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 UMR - ALL PLANS UMR - ALL PLANS 268.8 70 999999999 232.51 372.48 percent of total billed charges "Cortisol (hormone) measurement, free" 48498142_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 SIHO - ALL PLANS SIHO - ALL PLANS 345.6 90 999999999 232.51 372.48 percent of total billed charges "Cortisol (hormone) measurement, free" 48498142_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 232.51 60.55 999999999 232.51 372.48 percent of total billed charges "Cortisol (hormone) measurement, free" 48498142_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 232.51 372.48 "Cortisol (hormone) measurement, free" 48498142_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 232.51 372.48 "Cortisol (hormone) measurement, free" 48498142_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 ANTHEM HMO ANTHEM HMO 999999999 232.51 372.48 "Cortisol (hormone) measurement, free" 48498142_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 259.58 67.6 999999999 232.51 372.48 percent of total billed charges "Cortisol (hormone) measurement, free" 48498142_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 232.51 372.48 "Cortisol (hormone) measurement, free" 48498142_1 CDM 0301 RC 82530 HCPCS inpatient 384 249.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 232.51 372.48 Myoglobin (muscle protein) level 48498143_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges Myoglobin (muscle protein) level 48498143_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges Myoglobin (muscle protein) level 48498143_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges Myoglobin (muscle protein) level 48498143_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges Myoglobin (muscle protein) level 48498143_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges Myoglobin (muscle protein) level 48498143_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges Myoglobin (muscle protein) level 48498143_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges Myoglobin (muscle protein) level 48498143_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges Myoglobin (muscle protein) level 48498143_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 Myoglobin (muscle protein) level 48498143_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 Myoglobin (muscle protein) level 48498143_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 Myoglobin (muscle protein) level 48498143_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges Myoglobin (muscle protein) level 48498143_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 Myoglobin (muscle protein) level 48498143_1 CDM 0301 RC 83874 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 Red blood cell sickling measurement 48498144_1 CDM 0305 RC 85660 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges Red blood cell sickling measurement 48498144_1 CDM 0305 RC 85660 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges Red blood cell sickling measurement 48498144_1 CDM 0305 RC 85660 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges Red blood cell sickling measurement 48498144_1 CDM 0305 RC 85660 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges Red blood cell sickling measurement 48498144_1 CDM 0305 RC 85660 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges Red blood cell sickling measurement 48498144_1 CDM 0305 RC 85660 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges Red blood cell sickling measurement 48498144_1 CDM 0305 RC 85660 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges Red blood cell sickling measurement 48498144_1 CDM 0305 RC 85660 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges Red blood cell sickling measurement 48498144_1 CDM 0305 RC 85660 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 Red blood cell sickling measurement 48498144_1 CDM 0305 RC 85660 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 Red blood cell sickling measurement 48498144_1 CDM 0305 RC 85660 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 Red blood cell sickling measurement 48498144_1 CDM 0305 RC 85660 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges Red blood cell sickling measurement 48498144_1 CDM 0305 RC 85660 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 Red blood cell sickling measurement 48498144_1 CDM 0305 RC 85660 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 Red blood cell antibody level 48498145_1 CDM 0302 RC 86886 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges Red blood cell antibody level 48498145_1 CDM 0302 RC 86886 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges Red blood cell antibody level 48498145_1 CDM 0302 RC 86886 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges Red blood cell antibody level 48498145_1 CDM 0302 RC 86886 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges Red blood cell antibody level 48498145_1 CDM 0302 RC 86886 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges Red blood cell antibody level 48498145_1 CDM 0302 RC 86886 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges Red blood cell antibody level 48498145_1 CDM 0302 RC 86886 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges Red blood cell antibody level 48498145_1 CDM 0302 RC 86886 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges Red blood cell antibody level 48498145_1 CDM 0302 RC 86886 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 Red blood cell antibody level 48498145_1 CDM 0302 RC 86886 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 Red blood cell antibody level 48498145_1 CDM 0302 RC 86886 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 Red blood cell antibody level 48498145_1 CDM 0302 RC 86886 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges Red blood cell antibody level 48498145_1 CDM 0302 RC 86886 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 Red blood cell antibody level 48498145_1 CDM 0302 RC 86886 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 Measurement of cold agglutinin (protein) to screen for infection or disease 48498146_1 CDM 0302 RC 86156 HCPCS inpatient 179 116.35 AETNA AETNA 141.41 79 999999999 108.38 173.63 percent of total billed charges Measurement of cold agglutinin (protein) to screen for infection or disease 48498146_1 CDM 0302 RC 86156 HCPCS inpatient 179 116.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 116.35 65 999999999 108.38 173.63 percent of total billed charges Measurement of cold agglutinin (protein) to screen for infection or disease 48498146_1 CDM 0302 RC 86156 HCPCS inpatient 179 116.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 173.63 97 999999999 108.38 173.63 percent of total billed charges Measurement of cold agglutinin (protein) to screen for infection or disease 48498146_1 CDM 0302 RC 86156 HCPCS inpatient 179 116.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 123.51 69 999999999 108.38 173.63 percent of total billed charges Measurement of cold agglutinin (protein) to screen for infection or disease 48498146_1 CDM 0302 RC 86156 HCPCS inpatient 179 116.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 139.62 78 999999999 108.38 173.63 percent of total billed charges Measurement of cold agglutinin (protein) to screen for infection or disease 48498146_1 CDM 0302 RC 86156 HCPCS inpatient 179 116.35 UMR - ALL PLANS UMR - ALL PLANS 125.3 70 999999999 108.38 173.63 percent of total billed charges Measurement of cold agglutinin (protein) to screen for infection or disease 48498146_1 CDM 0302 RC 86156 HCPCS inpatient 179 116.35 SIHO - ALL PLANS SIHO - ALL PLANS 161.1 90 999999999 108.38 173.63 percent of total billed charges Measurement of cold agglutinin (protein) to screen for infection or disease 48498146_1 CDM 0302 RC 86156 HCPCS inpatient 179 116.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.38 60.55 999999999 108.38 173.63 percent of total billed charges Measurement of cold agglutinin (protein) to screen for infection or disease 48498146_1 CDM 0302 RC 86156 HCPCS inpatient 179 116.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.38 173.63 Measurement of cold agglutinin (protein) to screen for infection or disease 48498146_1 CDM 0302 RC 86156 HCPCS inpatient 179 116.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.38 173.63 Measurement of cold agglutinin (protein) to screen for infection or disease 48498146_1 CDM 0302 RC 86156 HCPCS inpatient 179 116.35 ANTHEM HMO ANTHEM HMO 999999999 108.38 173.63 Measurement of cold agglutinin (protein) to screen for infection or disease 48498146_1 CDM 0302 RC 86156 HCPCS inpatient 179 116.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 121 67.6 999999999 108.38 173.63 percent of total billed charges Measurement of cold agglutinin (protein) to screen for infection or disease 48498146_1 CDM 0302 RC 86156 HCPCS inpatient 179 116.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.38 173.63 Measurement of cold agglutinin (protein) to screen for infection or disease 48498146_1 CDM 0302 RC 86156 HCPCS inpatient 179 116.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.38 173.63 Breath test analysis for helicobacter pylori 48498147_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 AETNA AETNA 234.63 79 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 48498147_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 193.05 65 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 48498147_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 288.09 97 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 48498147_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 204.93 69 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 48498147_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 231.66 78 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 48498147_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 UMR - ALL PLANS UMR - ALL PLANS 207.9 70 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 48498147_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 SIHO - ALL PLANS SIHO - ALL PLANS 267.3 90 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 48498147_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 179.83 60.55 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 48498147_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 179.83 288.09 Breath test analysis for helicobacter pylori 48498147_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 179.83 288.09 Breath test analysis for helicobacter pylori 48498147_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 ANTHEM HMO ANTHEM HMO 999999999 179.83 288.09 Breath test analysis for helicobacter pylori 48498147_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 200.77 67.6 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 48498147_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 179.83 288.09 Breath test analysis for helicobacter pylori 48498147_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 179.83 288.09 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 48498149_1 CDM 0301 RC 86146 HCPCS inpatient 103 66.95 AETNA AETNA 81.37 79 999999999 62.37 99.91 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 48498149_1 CDM 0301 RC 86146 HCPCS inpatient 103 66.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.95 65 999999999 62.37 99.91 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 48498149_1 CDM 0301 RC 86146 HCPCS inpatient 103 66.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 99.91 97 999999999 62.37 99.91 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 48498149_1 CDM 0301 RC 86146 HCPCS inpatient 103 66.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.07 69 999999999 62.37 99.91 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 48498149_1 CDM 0301 RC 86146 HCPCS inpatient 103 66.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 80.34 78 999999999 62.37 99.91 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 48498149_1 CDM 0301 RC 86146 HCPCS inpatient 103 66.95 UMR - ALL PLANS UMR - ALL PLANS 72.1 70 999999999 62.37 99.91 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 48498149_1 CDM 0301 RC 86146 HCPCS inpatient 103 66.95 SIHO - ALL PLANS SIHO - ALL PLANS 92.7 90 999999999 62.37 99.91 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 48498149_1 CDM 0301 RC 86146 HCPCS inpatient 103 66.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.37 60.55 999999999 62.37 99.91 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 48498149_1 CDM 0301 RC 86146 HCPCS inpatient 103 66.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.37 99.91 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 48498149_1 CDM 0301 RC 86146 HCPCS inpatient 103 66.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.37 99.91 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 48498149_1 CDM 0301 RC 86146 HCPCS inpatient 103 66.95 ANTHEM HMO ANTHEM HMO 999999999 62.37 99.91 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 48498149_1 CDM 0301 RC 86146 HCPCS inpatient 103 66.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 69.63 67.6 999999999 62.37 99.91 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 48498149_1 CDM 0301 RC 86146 HCPCS inpatient 103 66.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.37 99.91 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 48498149_1 CDM 0301 RC 86146 HCPCS inpatient 103 66.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.37 99.91 "Analysis for antibody, Treponema pallidum" 48498150_1 CDM 0305 RC 86780 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges "Analysis for antibody, Treponema pallidum" 48498150_1 CDM 0305 RC 86780 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges "Analysis for antibody, Treponema pallidum" 48498150_1 CDM 0305 RC 86780 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges "Analysis for antibody, Treponema pallidum" 48498150_1 CDM 0305 RC 86780 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges "Analysis for antibody, Treponema pallidum" 48498150_1 CDM 0305 RC 86780 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges "Analysis for antibody, Treponema pallidum" 48498150_1 CDM 0305 RC 86780 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges "Analysis for antibody, Treponema pallidum" 48498150_1 CDM 0305 RC 86780 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges "Analysis for antibody, Treponema pallidum" 48498150_1 CDM 0305 RC 86780 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges "Analysis for antibody, Treponema pallidum" 48498150_1 CDM 0305 RC 86780 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 "Analysis for antibody, Treponema pallidum" 48498150_1 CDM 0305 RC 86780 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 "Analysis for antibody, Treponema pallidum" 48498150_1 CDM 0305 RC 86780 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 "Analysis for antibody, Treponema pallidum" 48498150_1 CDM 0305 RC 86780 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges "Analysis for antibody, Treponema pallidum" 48498150_1 CDM 0305 RC 86780 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 "Analysis for antibody, Treponema pallidum" 48498150_1 CDM 0305 RC 86780 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 Screening test for presence of antibody 48498155_1 CDM 0302 RC 86403 HCPCS inpatient 134 87.1 AETNA AETNA 105.86 79 999999999 81.14 129.98 percent of total billed charges Screening test for presence of antibody 48498155_1 CDM 0302 RC 86403 HCPCS inpatient 134 87.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 87.1 65 999999999 81.14 129.98 percent of total billed charges Screening test for presence of antibody 48498155_1 CDM 0302 RC 86403 HCPCS inpatient 134 87.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.98 97 999999999 81.14 129.98 percent of total billed charges Screening test for presence of antibody 48498155_1 CDM 0302 RC 86403 HCPCS inpatient 134 87.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 92.46 69 999999999 81.14 129.98 percent of total billed charges Screening test for presence of antibody 48498155_1 CDM 0302 RC 86403 HCPCS inpatient 134 87.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 104.52 78 999999999 81.14 129.98 percent of total billed charges Screening test for presence of antibody 48498155_1 CDM 0302 RC 86403 HCPCS inpatient 134 87.1 UMR - ALL PLANS UMR - ALL PLANS 93.8 70 999999999 81.14 129.98 percent of total billed charges Screening test for presence of antibody 48498155_1 CDM 0302 RC 86403 HCPCS inpatient 134 87.1 SIHO - ALL PLANS SIHO - ALL PLANS 120.6 90 999999999 81.14 129.98 percent of total billed charges Screening test for presence of antibody 48498155_1 CDM 0302 RC 86403 HCPCS inpatient 134 87.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 81.14 60.55 999999999 81.14 129.98 percent of total billed charges Screening test for presence of antibody 48498155_1 CDM 0302 RC 86403 HCPCS inpatient 134 87.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 81.14 129.98 Screening test for presence of antibody 48498155_1 CDM 0302 RC 86403 HCPCS inpatient 134 87.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 81.14 129.98 Screening test for presence of antibody 48498155_1 CDM 0302 RC 86403 HCPCS inpatient 134 87.1 ANTHEM HMO ANTHEM HMO 999999999 81.14 129.98 Screening test for presence of antibody 48498155_1 CDM 0302 RC 86403 HCPCS inpatient 134 87.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 90.58 67.6 999999999 81.14 129.98 percent of total billed charges Screening test for presence of antibody 48498155_1 CDM 0302 RC 86403 HCPCS inpatient 134 87.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 81.14 129.98 Screening test for presence of antibody 48498155_1 CDM 0302 RC 86403 HCPCS inpatient 134 87.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 81.14 129.98 Screening test for antibody to noninfectious agent 48498157_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498157_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498157_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498157_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498157_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498157_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498157_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498157_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498157_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 48498157_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 48498157_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 48498157_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498157_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 48498157_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 "Analysis of substance using immunoassay technique, multiple step method" 48498158_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48498158_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48498158_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48498158_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48498158_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48498158_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48498158_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48498158_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48498158_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48498158_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48498158_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48498158_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48498158_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48498158_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 Measurement of Hepatitis A antibody 48498159_1 CDM 0302 RC 86708 HCPCS inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges Measurement of Hepatitis A antibody 48498159_1 CDM 0302 RC 86708 HCPCS inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges Measurement of Hepatitis A antibody 48498159_1 CDM 0302 RC 86708 HCPCS inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges Measurement of Hepatitis A antibody 48498159_1 CDM 0302 RC 86708 HCPCS inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges Measurement of Hepatitis A antibody 48498159_1 CDM 0302 RC 86708 HCPCS inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges Measurement of Hepatitis A antibody 48498159_1 CDM 0302 RC 86708 HCPCS inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges Measurement of Hepatitis A antibody 48498159_1 CDM 0302 RC 86708 HCPCS inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges Measurement of Hepatitis A antibody 48498159_1 CDM 0302 RC 86708 HCPCS inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges Measurement of Hepatitis A antibody 48498159_1 CDM 0302 RC 86708 HCPCS inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 Measurement of Hepatitis A antibody 48498159_1 CDM 0302 RC 86708 HCPCS inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 Measurement of Hepatitis A antibody 48498159_1 CDM 0302 RC 86708 HCPCS inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 Measurement of Hepatitis A antibody 48498159_1 CDM 0302 RC 86708 HCPCS inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges Measurement of Hepatitis A antibody 48498159_1 CDM 0302 RC 86708 HCPCS inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 Measurement of Hepatitis A antibody 48498159_1 CDM 0302 RC 86708 HCPCS inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498163_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498163_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498163_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498163_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498163_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498163_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498163_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498163_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498163_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498163_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498163_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498163_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498163_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498163_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498164_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498164_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498164_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498164_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498164_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498164_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498164_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498164_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498164_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498164_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498164_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498164_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498164_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498164_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498165_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498165_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498165_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498165_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498165_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498165_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498165_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498165_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498165_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498165_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498165_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498165_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498165_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498165_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of complement (immune system proteins), total hemolytic" 48498166_1 CDM 0302 RC 86162 HCPCS inpatient 370 240.5 AETNA AETNA 292.3 79 999999999 224.04 358.9 percent of total billed charges "Measurement of complement (immune system proteins), total hemolytic" 48498166_1 CDM 0302 RC 86162 HCPCS inpatient 370 240.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 240.5 65 999999999 224.04 358.9 percent of total billed charges "Measurement of complement (immune system proteins), total hemolytic" 48498166_1 CDM 0302 RC 86162 HCPCS inpatient 370 240.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 358.9 97 999999999 224.04 358.9 percent of total billed charges "Measurement of complement (immune system proteins), total hemolytic" 48498166_1 CDM 0302 RC 86162 HCPCS inpatient 370 240.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 255.3 69 999999999 224.04 358.9 percent of total billed charges "Measurement of complement (immune system proteins), total hemolytic" 48498166_1 CDM 0302 RC 86162 HCPCS inpatient 370 240.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 288.6 78 999999999 224.04 358.9 percent of total billed charges "Measurement of complement (immune system proteins), total hemolytic" 48498166_1 CDM 0302 RC 86162 HCPCS inpatient 370 240.5 UMR - ALL PLANS UMR - ALL PLANS 259 70 999999999 224.04 358.9 percent of total billed charges "Measurement of complement (immune system proteins), total hemolytic" 48498166_1 CDM 0302 RC 86162 HCPCS inpatient 370 240.5 SIHO - ALL PLANS SIHO - ALL PLANS 333 90 999999999 224.04 358.9 percent of total billed charges "Measurement of complement (immune system proteins), total hemolytic" 48498166_1 CDM 0302 RC 86162 HCPCS inpatient 370 240.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 224.04 60.55 999999999 224.04 358.9 percent of total billed charges "Measurement of complement (immune system proteins), total hemolytic" 48498166_1 CDM 0302 RC 86162 HCPCS inpatient 370 240.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 224.04 358.9 "Measurement of complement (immune system proteins), total hemolytic" 48498166_1 CDM 0302 RC 86162 HCPCS inpatient 370 240.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 224.04 358.9 "Measurement of complement (immune system proteins), total hemolytic" 48498166_1 CDM 0302 RC 86162 HCPCS inpatient 370 240.5 ANTHEM HMO ANTHEM HMO 999999999 224.04 358.9 "Measurement of complement (immune system proteins), total hemolytic" 48498166_1 CDM 0302 RC 86162 HCPCS inpatient 370 240.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 250.12 67.6 999999999 224.04 358.9 percent of total billed charges "Measurement of complement (immune system proteins), total hemolytic" 48498166_1 CDM 0302 RC 86162 HCPCS inpatient 370 240.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 224.04 358.9 "Measurement of complement (immune system proteins), total hemolytic" 48498166_1 CDM 0302 RC 86162 HCPCS inpatient 370 240.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 224.04 358.9 "Valproic acid level, total" 48498167_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges "Valproic acid level, total" 48498167_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges "Valproic acid level, total" 48498167_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges "Valproic acid level, total" 48498167_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges "Valproic acid level, total" 48498167_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges "Valproic acid level, total" 48498167_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges "Valproic acid level, total" 48498167_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges "Valproic acid level, total" 48498167_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges "Valproic acid level, total" 48498167_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 "Valproic acid level, total" 48498167_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 "Valproic acid level, total" 48498167_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 "Valproic acid level, total" 48498167_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges "Valproic acid level, total" 48498167_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 "Valproic acid level, total" 48498167_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 48498168_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 48498168_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 48498168_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 48498168_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 48498168_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 48498168_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 48498168_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 48498168_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 48498168_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 48498168_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 48498168_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 48498168_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 48498168_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 48498168_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 "Thyroid hormone, T3 measurement, total" 48498169_1 CDM 0301 RC 84480 HCPCS inpatient 355 230.75 AETNA AETNA 280.45 79 999999999 214.95 344.35 percent of total billed charges "Thyroid hormone, T3 measurement, total" 48498169_1 CDM 0301 RC 84480 HCPCS inpatient 355 230.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 230.75 65 999999999 214.95 344.35 percent of total billed charges "Thyroid hormone, T3 measurement, total" 48498169_1 CDM 0301 RC 84480 HCPCS inpatient 355 230.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 344.35 97 999999999 214.95 344.35 percent of total billed charges "Thyroid hormone, T3 measurement, total" 48498169_1 CDM 0301 RC 84480 HCPCS inpatient 355 230.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 244.95 69 999999999 214.95 344.35 percent of total billed charges "Thyroid hormone, T3 measurement, total" 48498169_1 CDM 0301 RC 84480 HCPCS inpatient 355 230.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 276.9 78 999999999 214.95 344.35 percent of total billed charges "Thyroid hormone, T3 measurement, total" 48498169_1 CDM 0301 RC 84480 HCPCS inpatient 355 230.75 UMR - ALL PLANS UMR - ALL PLANS 248.5 70 999999999 214.95 344.35 percent of total billed charges "Thyroid hormone, T3 measurement, total" 48498169_1 CDM 0301 RC 84480 HCPCS inpatient 355 230.75 SIHO - ALL PLANS SIHO - ALL PLANS 319.5 90 999999999 214.95 344.35 percent of total billed charges "Thyroid hormone, T3 measurement, total" 48498169_1 CDM 0301 RC 84480 HCPCS inpatient 355 230.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 214.95 60.55 999999999 214.95 344.35 percent of total billed charges "Thyroid hormone, T3 measurement, total" 48498169_1 CDM 0301 RC 84480 HCPCS inpatient 355 230.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 214.95 344.35 "Thyroid hormone, T3 measurement, total" 48498169_1 CDM 0301 RC 84480 HCPCS inpatient 355 230.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 214.95 344.35 "Thyroid hormone, T3 measurement, total" 48498169_1 CDM 0301 RC 84480 HCPCS inpatient 355 230.75 ANTHEM HMO ANTHEM HMO 999999999 214.95 344.35 "Thyroid hormone, T3 measurement, total" 48498169_1 CDM 0301 RC 84480 HCPCS inpatient 355 230.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 239.98 67.6 999999999 214.95 344.35 percent of total billed charges "Thyroid hormone, T3 measurement, total" 48498169_1 CDM 0301 RC 84480 HCPCS inpatient 355 230.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 214.95 344.35 "Thyroid hormone, T3 measurement, total" 48498169_1 CDM 0301 RC 84480 HCPCS inpatient 355 230.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 214.95 344.35 "Alpha-fetoprotein (AFP) level, serum" 48498170_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 48498170_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 48498170_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 48498170_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 48498170_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 48498170_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 48498170_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 48498170_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 48498170_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 "Alpha-fetoprotein (AFP) level, serum" 48498170_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 "Alpha-fetoprotein (AFP) level, serum" 48498170_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 "Alpha-fetoprotein (AFP) level, serum" 48498170_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 48498170_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 "Alpha-fetoprotein (AFP) level, serum" 48498170_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 "Tuberculosis test, gamma interferon" 48498171_1 CDM 0302 RC 86480 HCPCS inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges "Tuberculosis test, gamma interferon" 48498171_1 CDM 0302 RC 86480 HCPCS inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges "Tuberculosis test, gamma interferon" 48498171_1 CDM 0302 RC 86480 HCPCS inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges "Tuberculosis test, gamma interferon" 48498171_1 CDM 0302 RC 86480 HCPCS inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges "Tuberculosis test, gamma interferon" 48498171_1 CDM 0302 RC 86480 HCPCS inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges "Tuberculosis test, gamma interferon" 48498171_1 CDM 0302 RC 86480 HCPCS inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges "Tuberculosis test, gamma interferon" 48498171_1 CDM 0302 RC 86480 HCPCS inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges "Tuberculosis test, gamma interferon" 48498171_1 CDM 0302 RC 86480 HCPCS inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges "Tuberculosis test, gamma interferon" 48498171_1 CDM 0302 RC 86480 HCPCS inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 "Tuberculosis test, gamma interferon" 48498171_1 CDM 0302 RC 86480 HCPCS inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 "Tuberculosis test, gamma interferon" 48498171_1 CDM 0302 RC 86480 HCPCS inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 "Tuberculosis test, gamma interferon" 48498171_1 CDM 0302 RC 86480 HCPCS inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges "Tuberculosis test, gamma interferon" 48498171_1 CDM 0302 RC 86480 HCPCS inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 "Tuberculosis test, gamma interferon" 48498171_1 CDM 0302 RC 86480 HCPCS inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 Ethylene glycol (antifreeze) measurement 48498172_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 AETNA AETNA 190.39 79 999999999 145.93 233.77 percent of total billed charges Ethylene glycol (antifreeze) measurement 48498172_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 156.65 65 999999999 145.93 233.77 percent of total billed charges Ethylene glycol (antifreeze) measurement 48498172_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 233.77 97 999999999 145.93 233.77 percent of total billed charges Ethylene glycol (antifreeze) measurement 48498172_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 166.29 69 999999999 145.93 233.77 percent of total billed charges Ethylene glycol (antifreeze) measurement 48498172_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.98 78 999999999 145.93 233.77 percent of total billed charges Ethylene glycol (antifreeze) measurement 48498172_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 UMR - ALL PLANS UMR - ALL PLANS 168.7 70 999999999 145.93 233.77 percent of total billed charges Ethylene glycol (antifreeze) measurement 48498172_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 SIHO - ALL PLANS SIHO - ALL PLANS 216.9 90 999999999 145.93 233.77 percent of total billed charges Ethylene glycol (antifreeze) measurement 48498172_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.93 60.55 999999999 145.93 233.77 percent of total billed charges Ethylene glycol (antifreeze) measurement 48498172_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.93 233.77 Ethylene glycol (antifreeze) measurement 48498172_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.93 233.77 Ethylene glycol (antifreeze) measurement 48498172_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 ANTHEM HMO ANTHEM HMO 999999999 145.93 233.77 Ethylene glycol (antifreeze) measurement 48498172_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.92 67.6 999999999 145.93 233.77 percent of total billed charges Ethylene glycol (antifreeze) measurement 48498172_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.93 233.77 Ethylene glycol (antifreeze) measurement 48498172_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.93 233.77 Primidone level 48498173_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 AETNA AETNA 131.14 79 999999999 100.51 161.02 percent of total billed charges Primidone level 48498173_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.9 65 999999999 100.51 161.02 percent of total billed charges Primidone level 48498173_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.02 97 999999999 100.51 161.02 percent of total billed charges Primidone level 48498173_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 114.54 69 999999999 100.51 161.02 percent of total billed charges Primidone level 48498173_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 129.48 78 999999999 100.51 161.02 percent of total billed charges Primidone level 48498173_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 UMR - ALL PLANS UMR - ALL PLANS 116.2 70 999999999 100.51 161.02 percent of total billed charges Primidone level 48498173_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 SIHO - ALL PLANS SIHO - ALL PLANS 149.4 90 999999999 100.51 161.02 percent of total billed charges Primidone level 48498173_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 100.51 60.55 999999999 100.51 161.02 percent of total billed charges Primidone level 48498173_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 100.51 161.02 Primidone level 48498173_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 100.51 161.02 Primidone level 48498173_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 ANTHEM HMO ANTHEM HMO 999999999 100.51 161.02 Primidone level 48498173_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.22 67.6 999999999 100.51 161.02 percent of total billed charges Primidone level 48498173_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 100.51 161.02 Primidone level 48498173_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 100.51 161.02 "Testing for presence of drug, by chemistry analyzers" 48498174_1 CDM 0300 RC 80307 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48498174_1 CDM 0300 RC 80307 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48498174_1 CDM 0300 RC 80307 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48498174_1 CDM 0300 RC 80307 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48498174_1 CDM 0300 RC 80307 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48498174_1 CDM 0300 RC 80307 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48498174_1 CDM 0300 RC 80307 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48498174_1 CDM 0300 RC 80307 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48498174_1 CDM 0300 RC 80307 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 "Testing for presence of drug, by chemistry analyzers" 48498174_1 CDM 0300 RC 80307 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 "Testing for presence of drug, by chemistry analyzers" 48498174_1 CDM 0300 RC 80307 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 "Testing for presence of drug, by chemistry analyzers" 48498174_1 CDM 0300 RC 80307 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48498174_1 CDM 0300 RC 80307 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 "Testing for presence of drug, by chemistry analyzers" 48498174_1 CDM 0300 RC 80307 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 "Detection test by nucleic acid for organism, quantification" 48498180_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 AETNA AETNA 428.18 79 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 48498180_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 352.3 65 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 48498180_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 525.74 97 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 48498180_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 373.98 69 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 48498180_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 422.76 78 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 48498180_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 UMR - ALL PLANS UMR - ALL PLANS 379.4 70 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 48498180_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 SIHO - ALL PLANS SIHO - ALL PLANS 487.8 90 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 48498180_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 328.18 60.55 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 48498180_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 48498180_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 48498180_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ANTHEM HMO ANTHEM HMO 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 48498180_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 366.39 67.6 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 48498180_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 48498180_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 48498181_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 AETNA AETNA 428.18 79 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 48498181_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 352.3 65 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 48498181_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 525.74 97 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 48498181_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 373.98 69 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 48498181_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 422.76 78 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 48498181_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 UMR - ALL PLANS UMR - ALL PLANS 379.4 70 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 48498181_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 SIHO - ALL PLANS SIHO - ALL PLANS 487.8 90 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 48498181_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 328.18 60.55 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 48498181_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 48498181_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 48498181_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ANTHEM HMO ANTHEM HMO 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 48498181_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 366.39 67.6 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 48498181_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 48498181_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 328.18 525.74 "Detection test by nucleic acid for cytomegalovirus, quantification" 48498182_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 AETNA AETNA 203.03 79 999999999 155.61 249.29 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 48498182_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.05 65 999999999 155.61 249.29 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 48498182_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 249.29 97 999999999 155.61 249.29 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 48498182_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 177.33 69 999999999 155.61 249.29 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 48498182_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 200.46 78 999999999 155.61 249.29 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 48498182_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 UMR - ALL PLANS UMR - ALL PLANS 179.9 70 999999999 155.61 249.29 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 48498182_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 SIHO - ALL PLANS SIHO - ALL PLANS 231.3 90 999999999 155.61 249.29 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 48498182_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.61 60.55 999999999 155.61 249.29 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 48498182_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.61 249.29 "Detection test by nucleic acid for cytomegalovirus, quantification" 48498182_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.61 249.29 "Detection test by nucleic acid for cytomegalovirus, quantification" 48498182_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 ANTHEM HMO ANTHEM HMO 999999999 155.61 249.29 "Detection test by nucleic acid for cytomegalovirus, quantification" 48498182_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.73 67.6 999999999 155.61 249.29 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 48498182_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.61 249.29 "Detection test by nucleic acid for cytomegalovirus, quantification" 48498182_1 CDM 0306 RC 87497 HCPCS inpatient 257 167.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.61 249.29 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" 48498184_1 CDM 0306 RC 87631 HCPCS inpatient 762 495.3 AETNA AETNA 601.98 79 999999999 461.39 739.14 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" 48498184_1 CDM 0306 RC 87631 HCPCS inpatient 762 495.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 495.3 65 999999999 461.39 739.14 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" 48498184_1 CDM 0306 RC 87631 HCPCS inpatient 762 495.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 739.14 97 999999999 461.39 739.14 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" 48498184_1 CDM 0306 RC 87631 HCPCS inpatient 762 495.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 525.78 69 999999999 461.39 739.14 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" 48498184_1 CDM 0306 RC 87631 HCPCS inpatient 762 495.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 594.36 78 999999999 461.39 739.14 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" 48498184_1 CDM 0306 RC 87631 HCPCS inpatient 762 495.3 UMR - ALL PLANS UMR - ALL PLANS 533.4 70 999999999 461.39 739.14 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" 48498184_1 CDM 0306 RC 87631 HCPCS inpatient 762 495.3 SIHO - ALL PLANS SIHO - ALL PLANS 685.8 90 999999999 461.39 739.14 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" 48498184_1 CDM 0306 RC 87631 HCPCS inpatient 762 495.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 461.39 60.55 999999999 461.39 739.14 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" 48498184_1 CDM 0306 RC 87631 HCPCS inpatient 762 495.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 461.39 739.14 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" 48498184_1 CDM 0306 RC 87631 HCPCS inpatient 762 495.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 461.39 739.14 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" 48498184_1 CDM 0306 RC 87631 HCPCS inpatient 762 495.3 ANTHEM HMO ANTHEM HMO 999999999 461.39 739.14 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" 48498184_1 CDM 0306 RC 87631 HCPCS inpatient 762 495.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 515.11 67.6 999999999 461.39 739.14 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" 48498184_1 CDM 0306 RC 87631 HCPCS inpatient 762 495.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 461.39 739.14 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 3-5 targets" 48498184_1 CDM 0306 RC 87631 HCPCS inpatient 762 495.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 461.39 739.14 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure" 48498185_1 CDM 0310 RC 88367 HCPCS inpatient 938 609.7 AETNA AETNA 741.02 79 999999999 567.96 909.86 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure" 48498185_1 CDM 0310 RC 88367 HCPCS inpatient 938 609.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 609.7 65 999999999 567.96 909.86 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure" 48498185_1 CDM 0310 RC 88367 HCPCS inpatient 938 609.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 909.86 97 999999999 567.96 909.86 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure" 48498185_1 CDM 0310 RC 88367 HCPCS inpatient 938 609.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 647.22 69 999999999 567.96 909.86 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure" 48498185_1 CDM 0310 RC 88367 HCPCS inpatient 938 609.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 731.64 78 999999999 567.96 909.86 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure" 48498185_1 CDM 0310 RC 88367 HCPCS inpatient 938 609.7 UMR - ALL PLANS UMR - ALL PLANS 656.6 70 999999999 567.96 909.86 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure" 48498185_1 CDM 0310 RC 88367 HCPCS inpatient 938 609.7 SIHO - ALL PLANS SIHO - ALL PLANS 844.2 90 999999999 567.96 909.86 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure" 48498185_1 CDM 0310 RC 88367 HCPCS inpatient 938 609.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 567.96 60.55 999999999 567.96 909.86 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure" 48498185_1 CDM 0310 RC 88367 HCPCS inpatient 938 609.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 567.96 909.86 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure" 48498185_1 CDM 0310 RC 88367 HCPCS inpatient 938 609.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 567.96 909.86 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure" 48498185_1 CDM 0310 RC 88367 HCPCS inpatient 938 609.7 ANTHEM HMO ANTHEM HMO 999999999 567.96 909.86 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure" 48498185_1 CDM 0310 RC 88367 HCPCS inpatient 938 609.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 634.09 67.6 999999999 567.96 909.86 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure" 48498185_1 CDM 0310 RC 88367 HCPCS inpatient 938 609.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 567.96 909.86 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure" 48498185_1 CDM 0310 RC 88367 HCPCS inpatient 938 609.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 567.96 909.86 "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 48498186_1 CDM 0306 RC 87498 HCPCS inpatient 361 234.65 AETNA AETNA 285.19 79 999999999 218.59 350.17 percent of total billed charges "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 48498186_1 CDM 0306 RC 87498 HCPCS inpatient 361 234.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 234.65 65 999999999 218.59 350.17 percent of total billed charges "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 48498186_1 CDM 0306 RC 87498 HCPCS inpatient 361 234.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 350.17 97 999999999 218.59 350.17 percent of total billed charges "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 48498186_1 CDM 0306 RC 87498 HCPCS inpatient 361 234.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 249.09 69 999999999 218.59 350.17 percent of total billed charges "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 48498186_1 CDM 0306 RC 87498 HCPCS inpatient 361 234.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 281.58 78 999999999 218.59 350.17 percent of total billed charges "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 48498186_1 CDM 0306 RC 87498 HCPCS inpatient 361 234.65 UMR - ALL PLANS UMR - ALL PLANS 252.7 70 999999999 218.59 350.17 percent of total billed charges "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 48498186_1 CDM 0306 RC 87498 HCPCS inpatient 361 234.65 SIHO - ALL PLANS SIHO - ALL PLANS 324.9 90 999999999 218.59 350.17 percent of total billed charges "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 48498186_1 CDM 0306 RC 87498 HCPCS inpatient 361 234.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 218.59 60.55 999999999 218.59 350.17 percent of total billed charges "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 48498186_1 CDM 0306 RC 87498 HCPCS inpatient 361 234.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 218.59 350.17 "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 48498186_1 CDM 0306 RC 87498 HCPCS inpatient 361 234.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 218.59 350.17 "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 48498186_1 CDM 0306 RC 87498 HCPCS inpatient 361 234.65 ANTHEM HMO ANTHEM HMO 999999999 218.59 350.17 "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 48498186_1 CDM 0306 RC 87498 HCPCS inpatient 361 234.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 244.04 67.6 999999999 218.59 350.17 percent of total billed charges "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 48498186_1 CDM 0306 RC 87498 HCPCS inpatient 361 234.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 218.59 350.17 "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 48498186_1 CDM 0306 RC 87498 HCPCS inpatient 361 234.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 218.59 350.17 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 48498187_1 CDM 0312 RC 88374 HCPCS inpatient 893 580.45 AETNA AETNA 705.47 79 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 48498187_1 CDM 0312 RC 88374 HCPCS inpatient 893 580.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 580.45 65 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 48498187_1 CDM 0312 RC 88374 HCPCS inpatient 893 580.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 866.21 97 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 48498187_1 CDM 0312 RC 88374 HCPCS inpatient 893 580.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 616.17 69 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 48498187_1 CDM 0312 RC 88374 HCPCS inpatient 893 580.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 696.54 78 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 48498187_1 CDM 0312 RC 88374 HCPCS inpatient 893 580.45 UMR - ALL PLANS UMR - ALL PLANS 625.1 70 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 48498187_1 CDM 0312 RC 88374 HCPCS inpatient 893 580.45 SIHO - ALL PLANS SIHO - ALL PLANS 803.7 90 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 48498187_1 CDM 0312 RC 88374 HCPCS inpatient 893 580.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 540.71 60.55 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 48498187_1 CDM 0312 RC 88374 HCPCS inpatient 893 580.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 48498187_1 CDM 0312 RC 88374 HCPCS inpatient 893 580.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 48498187_1 CDM 0312 RC 88374 HCPCS inpatient 893 580.45 ANTHEM HMO ANTHEM HMO 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 48498187_1 CDM 0312 RC 88374 HCPCS inpatient 893 580.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 603.67 67.6 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 48498187_1 CDM 0312 RC 88374 HCPCS inpatient 893 580.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 48498187_1 CDM 0312 RC 88374 HCPCS inpatient 893 580.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 540.71 866.21 Examination of stool for meat fibers 48498189_1 CDM 0309 RC 89160 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges Examination of stool for meat fibers 48498189_1 CDM 0309 RC 89160 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges Examination of stool for meat fibers 48498189_1 CDM 0309 RC 89160 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges Examination of stool for meat fibers 48498189_1 CDM 0309 RC 89160 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges Examination of stool for meat fibers 48498189_1 CDM 0309 RC 89160 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges Examination of stool for meat fibers 48498189_1 CDM 0309 RC 89160 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges Examination of stool for meat fibers 48498189_1 CDM 0309 RC 89160 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges Examination of stool for meat fibers 48498189_1 CDM 0309 RC 89160 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges Examination of stool for meat fibers 48498189_1 CDM 0309 RC 89160 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 Examination of stool for meat fibers 48498189_1 CDM 0309 RC 89160 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 Examination of stool for meat fibers 48498189_1 CDM 0309 RC 89160 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 Examination of stool for meat fibers 48498189_1 CDM 0309 RC 89160 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges Examination of stool for meat fibers 48498189_1 CDM 0309 RC 89160 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 Examination of stool for meat fibers 48498189_1 CDM 0309 RC 89160 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 Measurement of substance using immunoassay technique 48498190_1 CDM 0301 RC 83520 HCPCS inpatient 327 212.55 AETNA AETNA 258.33 79 999999999 198 317.19 percent of total billed charges Measurement of substance using immunoassay technique 48498190_1 CDM 0301 RC 83520 HCPCS inpatient 327 212.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 212.55 65 999999999 198 317.19 percent of total billed charges Measurement of substance using immunoassay technique 48498190_1 CDM 0301 RC 83520 HCPCS inpatient 327 212.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 317.19 97 999999999 198 317.19 percent of total billed charges Measurement of substance using immunoassay technique 48498190_1 CDM 0301 RC 83520 HCPCS inpatient 327 212.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 225.63 69 999999999 198 317.19 percent of total billed charges Measurement of substance using immunoassay technique 48498190_1 CDM 0301 RC 83520 HCPCS inpatient 327 212.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.06 78 999999999 198 317.19 percent of total billed charges Measurement of substance using immunoassay technique 48498190_1 CDM 0301 RC 83520 HCPCS inpatient 327 212.55 UMR - ALL PLANS UMR - ALL PLANS 228.9 70 999999999 198 317.19 percent of total billed charges Measurement of substance using immunoassay technique 48498190_1 CDM 0301 RC 83520 HCPCS inpatient 327 212.55 SIHO - ALL PLANS SIHO - ALL PLANS 294.3 90 999999999 198 317.19 percent of total billed charges Measurement of substance using immunoassay technique 48498190_1 CDM 0301 RC 83520 HCPCS inpatient 327 212.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198 60.55 999999999 198 317.19 percent of total billed charges Measurement of substance using immunoassay technique 48498190_1 CDM 0301 RC 83520 HCPCS inpatient 327 212.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198 317.19 Measurement of substance using immunoassay technique 48498190_1 CDM 0301 RC 83520 HCPCS inpatient 327 212.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198 317.19 Measurement of substance using immunoassay technique 48498190_1 CDM 0301 RC 83520 HCPCS inpatient 327 212.55 ANTHEM HMO ANTHEM HMO 999999999 198 317.19 Measurement of substance using immunoassay technique 48498190_1 CDM 0301 RC 83520 HCPCS inpatient 327 212.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.05 67.6 999999999 198 317.19 percent of total billed charges Measurement of substance using immunoassay technique 48498190_1 CDM 0301 RC 83520 HCPCS inpatient 327 212.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198 317.19 Measurement of substance using immunoassay technique 48498190_1 CDM 0301 RC 83520 HCPCS inpatient 327 212.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 198 317.19 "Protein measurement, immunological probe for band identification" 48498191_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 AETNA AETNA 138.25 79 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 48498191_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 113.75 65 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 48498191_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 169.75 97 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 48498191_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 120.75 69 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 48498191_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 136.5 78 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 48498191_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 UMR - ALL PLANS UMR - ALL PLANS 122.5 70 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 48498191_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 SIHO - ALL PLANS SIHO - ALL PLANS 157.5 90 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 48498191_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 105.96 60.55 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 48498191_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 105.96 169.75 "Protein measurement, immunological probe for band identification" 48498191_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 105.96 169.75 "Protein measurement, immunological probe for band identification" 48498191_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ANTHEM HMO ANTHEM HMO 999999999 105.96 169.75 "Protein measurement, immunological probe for band identification" 48498191_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.3 67.6 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 48498191_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 105.96 169.75 "Protein measurement, immunological probe for band identification" 48498191_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 105.96 169.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 48498192_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 48498192_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 48498192_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 48498192_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 48498192_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 48498192_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 48498192_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 48498192_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 48498192_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 48498192_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 48498192_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 48498192_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 48498192_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 48498192_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Detection test by immunoassay technique for other organism 48498193_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 48498193_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 48498193_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 48498193_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 48498193_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 48498193_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 48498193_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 48498193_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 48498193_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 Detection test by immunoassay technique for other organism 48498193_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 Detection test by immunoassay technique for other organism 48498193_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 Detection test by immunoassay technique for other organism 48498193_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 48498193_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 Detection test by immunoassay technique for other organism 48498193_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 "Electrophoresis, laboratory testing technique" 48498194_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges "Electrophoresis, laboratory testing technique" 48498194_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges "Electrophoresis, laboratory testing technique" 48498194_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges "Electrophoresis, laboratory testing technique" 48498194_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges "Electrophoresis, laboratory testing technique" 48498194_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges "Electrophoresis, laboratory testing technique" 48498194_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges "Electrophoresis, laboratory testing technique" 48498194_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges "Electrophoresis, laboratory testing technique" 48498194_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges "Electrophoresis, laboratory testing technique" 48498194_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 "Electrophoresis, laboratory testing technique" 48498194_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 "Electrophoresis, laboratory testing technique" 48498194_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 "Electrophoresis, laboratory testing technique" 48498194_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges "Electrophoresis, laboratory testing technique" 48498194_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 "Electrophoresis, laboratory testing technique" 48498194_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Chemical receptor analysis 48498195_1 CDM 0301 RC 84238 HCPCS inpatient 310 201.5 AETNA AETNA 244.9 79 999999999 187.71 300.7 percent of total billed charges Chemical receptor analysis 48498195_1 CDM 0301 RC 84238 HCPCS inpatient 310 201.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 201.5 65 999999999 187.71 300.7 percent of total billed charges Chemical receptor analysis 48498195_1 CDM 0301 RC 84238 HCPCS inpatient 310 201.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 300.7 97 999999999 187.71 300.7 percent of total billed charges Chemical receptor analysis 48498195_1 CDM 0301 RC 84238 HCPCS inpatient 310 201.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 213.9 69 999999999 187.71 300.7 percent of total billed charges Chemical receptor analysis 48498195_1 CDM 0301 RC 84238 HCPCS inpatient 310 201.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 241.8 78 999999999 187.71 300.7 percent of total billed charges Chemical receptor analysis 48498195_1 CDM 0301 RC 84238 HCPCS inpatient 310 201.5 UMR - ALL PLANS UMR - ALL PLANS 217 70 999999999 187.71 300.7 percent of total billed charges Chemical receptor analysis 48498195_1 CDM 0301 RC 84238 HCPCS inpatient 310 201.5 SIHO - ALL PLANS SIHO - ALL PLANS 279 90 999999999 187.71 300.7 percent of total billed charges Chemical receptor analysis 48498195_1 CDM 0301 RC 84238 HCPCS inpatient 310 201.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 187.71 60.55 999999999 187.71 300.7 percent of total billed charges Chemical receptor analysis 48498195_1 CDM 0301 RC 84238 HCPCS inpatient 310 201.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 187.71 300.7 Chemical receptor analysis 48498195_1 CDM 0301 RC 84238 HCPCS inpatient 310 201.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 187.71 300.7 Chemical receptor analysis 48498195_1 CDM 0301 RC 84238 HCPCS inpatient 310 201.5 ANTHEM HMO ANTHEM HMO 999999999 187.71 300.7 Chemical receptor analysis 48498195_1 CDM 0301 RC 84238 HCPCS inpatient 310 201.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 209.56 67.6 999999999 187.71 300.7 percent of total billed charges Chemical receptor analysis 48498195_1 CDM 0301 RC 84238 HCPCS inpatient 310 201.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 187.71 300.7 Chemical receptor analysis 48498195_1 CDM 0301 RC 84238 HCPCS inpatient 310 201.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 187.71 300.7 Catecholamines (organic nitrogen) level 48498196_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 48498196_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 48498196_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 48498196_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 48498196_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 48498196_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 48498196_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 48498196_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 48498196_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 Catecholamines (organic nitrogen) level 48498196_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 Catecholamines (organic nitrogen) level 48498196_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 Catecholamines (organic nitrogen) level 48498196_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 48498196_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 Catecholamines (organic nitrogen) level 48498196_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 48498197_1 CDM 0301 RC 82480 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 48498197_1 CDM 0301 RC 82480 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 48498197_1 CDM 0301 RC 82480 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 48498197_1 CDM 0301 RC 82480 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 48498197_1 CDM 0301 RC 82480 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 48498197_1 CDM 0301 RC 82480 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 48498197_1 CDM 0301 RC 82480 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 48498197_1 CDM 0301 RC 82480 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 48498197_1 CDM 0301 RC 82480 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 48498197_1 CDM 0301 RC 82480 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 48498197_1 CDM 0301 RC 82480 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 48498197_1 CDM 0301 RC 82480 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 48498197_1 CDM 0301 RC 82480 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 48498197_1 CDM 0301 RC 82480 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 Immune complex measurement 48498198_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 AETNA AETNA 189.6 79 999999999 145.32 232.8 percent of total billed charges Immune complex measurement 48498198_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 SELF PAY DISCOUNT SELF PAY DISCOUNT 156 65 999999999 145.32 232.8 percent of total billed charges Immune complex measurement 48498198_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 232.8 97 999999999 145.32 232.8 percent of total billed charges Immune complex measurement 48498198_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 ENCORE - ALL PLANS ENCORE - ALL PLANS 165.6 69 999999999 145.32 232.8 percent of total billed charges Immune complex measurement 48498198_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.2 78 999999999 145.32 232.8 percent of total billed charges Immune complex measurement 48498198_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 UMR - ALL PLANS UMR - ALL PLANS 168 70 999999999 145.32 232.8 percent of total billed charges Immune complex measurement 48498198_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 SIHO - ALL PLANS SIHO - ALL PLANS 216 90 999999999 145.32 232.8 percent of total billed charges Immune complex measurement 48498198_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.32 60.55 999999999 145.32 232.8 percent of total billed charges Immune complex measurement 48498198_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.32 232.8 Immune complex measurement 48498198_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.32 232.8 Immune complex measurement 48498198_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 ANTHEM HMO ANTHEM HMO 999999999 145.32 232.8 Immune complex measurement 48498198_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.24 67.6 999999999 145.32 232.8 percent of total billed charges Immune complex measurement 48498198_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.32 232.8 Immune complex measurement 48498198_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.32 232.8 "Detection of infectious agent antibody, quantitative" 48498200_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 AETNA AETNA 58.46 79 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498200_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.1 65 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498200_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 71.78 97 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498200_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.06 69 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498200_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 57.72 78 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498200_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 UMR - ALL PLANS UMR - ALL PLANS 51.8 70 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498200_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 SIHO - ALL PLANS SIHO - ALL PLANS 66.6 90 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498200_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.81 60.55 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498200_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 48498200_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 48498200_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 ANTHEM HMO ANTHEM HMO 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 48498200_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.02 67.6 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498200_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 48498200_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 48498201_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498201_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498201_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498201_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498201_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498201_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498201_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498201_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498201_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 48498201_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 48498201_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 48498201_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498201_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 48498201_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 48498202_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498202_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498202_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498202_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498202_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498202_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498202_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498202_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498202_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 48498202_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 48498202_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 48498202_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 48498202_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 48498202_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 Angiotensin l - converting enzyme (ACE) level 48498203_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 AETNA AETNA 144.57 79 999999999 110.81 177.51 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 48498203_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.95 65 999999999 110.81 177.51 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 48498203_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.51 97 999999999 110.81 177.51 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 48498203_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.27 69 999999999 110.81 177.51 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 48498203_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 142.74 78 999999999 110.81 177.51 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 48498203_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 UMR - ALL PLANS UMR - ALL PLANS 128.1 70 999999999 110.81 177.51 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 48498203_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 SIHO - ALL PLANS SIHO - ALL PLANS 164.7 90 999999999 110.81 177.51 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 48498203_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.81 60.55 999999999 110.81 177.51 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 48498203_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.81 177.51 Angiotensin l - converting enzyme (ACE) level 48498203_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.81 177.51 Angiotensin l - converting enzyme (ACE) level 48498203_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 ANTHEM HMO ANTHEM HMO 999999999 110.81 177.51 Angiotensin l - converting enzyme (ACE) level 48498203_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.71 67.6 999999999 110.81 177.51 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 48498203_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.81 177.51 Angiotensin l - converting enzyme (ACE) level 48498203_1 CDM 0301 RC 82164 HCPCS inpatient 183 118.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.81 177.51 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 48498204_1 CDM 0301 RC 86618 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 48498204_1 CDM 0301 RC 86618 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 48498204_1 CDM 0301 RC 86618 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 48498204_1 CDM 0301 RC 86618 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 48498204_1 CDM 0301 RC 86618 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 48498204_1 CDM 0301 RC 86618 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 48498204_1 CDM 0301 RC 86618 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 48498204_1 CDM 0301 RC 86618 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 48498204_1 CDM 0301 RC 86618 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 48498204_1 CDM 0301 RC 86618 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 48498204_1 CDM 0301 RC 86618 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 48498204_1 CDM 0301 RC 86618 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 48498204_1 CDM 0301 RC 86618 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 48498204_1 CDM 0301 RC 86618 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 Microsomal antibodies (autoantibody) measurement 48498205_1 CDM 0301 RC 86376 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges Microsomal antibodies (autoantibody) measurement 48498205_1 CDM 0301 RC 86376 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges Microsomal antibodies (autoantibody) measurement 48498205_1 CDM 0301 RC 86376 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges Microsomal antibodies (autoantibody) measurement 48498205_1 CDM 0301 RC 86376 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges Microsomal antibodies (autoantibody) measurement 48498205_1 CDM 0301 RC 86376 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges Microsomal antibodies (autoantibody) measurement 48498205_1 CDM 0301 RC 86376 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges Microsomal antibodies (autoantibody) measurement 48498205_1 CDM 0301 RC 86376 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges Microsomal antibodies (autoantibody) measurement 48498205_1 CDM 0301 RC 86376 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges Microsomal antibodies (autoantibody) measurement 48498205_1 CDM 0301 RC 86376 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 Microsomal antibodies (autoantibody) measurement 48498205_1 CDM 0301 RC 86376 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 Microsomal antibodies (autoantibody) measurement 48498205_1 CDM 0301 RC 86376 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 Microsomal antibodies (autoantibody) measurement 48498205_1 CDM 0301 RC 86376 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges Microsomal antibodies (autoantibody) measurement 48498205_1 CDM 0301 RC 86376 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 Microsomal antibodies (autoantibody) measurement 48498205_1 CDM 0301 RC 86376 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 Analysis for antibody to West Nile virus 48498206_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 AETNA AETNA 161.16 79 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 48498206_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.6 65 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 48498206_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.88 97 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 48498206_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.76 69 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 48498206_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.12 78 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 48498206_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 UMR - ALL PLANS UMR - ALL PLANS 142.8 70 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 48498206_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 SIHO - ALL PLANS SIHO - ALL PLANS 183.6 90 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 48498206_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.52 60.55 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 48498206_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.52 197.88 Analysis for antibody to West Nile virus 48498206_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.52 197.88 Analysis for antibody to West Nile virus 48498206_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 ANTHEM HMO ANTHEM HMO 999999999 123.52 197.88 Analysis for antibody to West Nile virus 48498206_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.9 67.6 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 48498206_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.52 197.88 Analysis for antibody to West Nile virus 48498206_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.52 197.88 "Hydroxyprogesterone, 17-D (synthetic hormone) level" 48498207_1 CDM 0301 RC 83498 HCPCS inpatient 228 148.2 AETNA AETNA 180.12 79 999999999 138.05 221.16 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 48498207_1 CDM 0301 RC 83498 HCPCS inpatient 228 148.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 148.2 65 999999999 138.05 221.16 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 48498207_1 CDM 0301 RC 83498 HCPCS inpatient 228 148.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 221.16 97 999999999 138.05 221.16 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 48498207_1 CDM 0301 RC 83498 HCPCS inpatient 228 148.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 157.32 69 999999999 138.05 221.16 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 48498207_1 CDM 0301 RC 83498 HCPCS inpatient 228 148.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 177.84 78 999999999 138.05 221.16 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 48498207_1 CDM 0301 RC 83498 HCPCS inpatient 228 148.2 UMR - ALL PLANS UMR - ALL PLANS 159.6 70 999999999 138.05 221.16 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 48498207_1 CDM 0301 RC 83498 HCPCS inpatient 228 148.2 SIHO - ALL PLANS SIHO - ALL PLANS 205.2 90 999999999 138.05 221.16 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 48498207_1 CDM 0301 RC 83498 HCPCS inpatient 228 148.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 138.05 60.55 999999999 138.05 221.16 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 48498207_1 CDM 0301 RC 83498 HCPCS inpatient 228 148.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 138.05 221.16 "Hydroxyprogesterone, 17-D (synthetic hormone) level" 48498207_1 CDM 0301 RC 83498 HCPCS inpatient 228 148.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 138.05 221.16 "Hydroxyprogesterone, 17-D (synthetic hormone) level" 48498207_1 CDM 0301 RC 83498 HCPCS inpatient 228 148.2 ANTHEM HMO ANTHEM HMO 999999999 138.05 221.16 "Hydroxyprogesterone, 17-D (synthetic hormone) level" 48498207_1 CDM 0301 RC 83498 HCPCS inpatient 228 148.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 154.13 67.6 999999999 138.05 221.16 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 48498207_1 CDM 0301 RC 83498 HCPCS inpatient 228 148.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 138.05 221.16 "Hydroxyprogesterone, 17-D (synthetic hormone) level" 48498207_1 CDM 0301 RC 83498 HCPCS inpatient 228 148.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 138.05 221.16 Thyroid stimulating immune globulins (thyroid related protein) level 48498208_1 CDM 0301 RC 84445 HCPCS inpatient 412 267.8 AETNA AETNA 325.48 79 999999999 249.47 399.64 percent of total billed charges Thyroid stimulating immune globulins (thyroid related protein) level 48498208_1 CDM 0301 RC 84445 HCPCS inpatient 412 267.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 267.8 65 999999999 249.47 399.64 percent of total billed charges Thyroid stimulating immune globulins (thyroid related protein) level 48498208_1 CDM 0301 RC 84445 HCPCS inpatient 412 267.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 399.64 97 999999999 249.47 399.64 percent of total billed charges Thyroid stimulating immune globulins (thyroid related protein) level 48498208_1 CDM 0301 RC 84445 HCPCS inpatient 412 267.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 284.28 69 999999999 249.47 399.64 percent of total billed charges Thyroid stimulating immune globulins (thyroid related protein) level 48498208_1 CDM 0301 RC 84445 HCPCS inpatient 412 267.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 321.36 78 999999999 249.47 399.64 percent of total billed charges Thyroid stimulating immune globulins (thyroid related protein) level 48498208_1 CDM 0301 RC 84445 HCPCS inpatient 412 267.8 UMR - ALL PLANS UMR - ALL PLANS 288.4 70 999999999 249.47 399.64 percent of total billed charges Thyroid stimulating immune globulins (thyroid related protein) level 48498208_1 CDM 0301 RC 84445 HCPCS inpatient 412 267.8 SIHO - ALL PLANS SIHO - ALL PLANS 370.8 90 999999999 249.47 399.64 percent of total billed charges Thyroid stimulating immune globulins (thyroid related protein) level 48498208_1 CDM 0301 RC 84445 HCPCS inpatient 412 267.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 249.47 60.55 999999999 249.47 399.64 percent of total billed charges Thyroid stimulating immune globulins (thyroid related protein) level 48498208_1 CDM 0301 RC 84445 HCPCS inpatient 412 267.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 249.47 399.64 Thyroid stimulating immune globulins (thyroid related protein) level 48498208_1 CDM 0301 RC 84445 HCPCS inpatient 412 267.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 249.47 399.64 Thyroid stimulating immune globulins (thyroid related protein) level 48498208_1 CDM 0301 RC 84445 HCPCS inpatient 412 267.8 ANTHEM HMO ANTHEM HMO 999999999 249.47 399.64 Thyroid stimulating immune globulins (thyroid related protein) level 48498208_1 CDM 0301 RC 84445 HCPCS inpatient 412 267.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 278.51 67.6 999999999 249.47 399.64 percent of total billed charges Thyroid stimulating immune globulins (thyroid related protein) level 48498208_1 CDM 0301 RC 84445 HCPCS inpatient 412 267.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 249.47 399.64 Thyroid stimulating immune globulins (thyroid related protein) level 48498208_1 CDM 0301 RC 84445 HCPCS inpatient 412 267.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 249.47 399.64 Islet cell (pancreas) antibody measurement 48498209_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 AETNA AETNA 282.03 79 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 48498209_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 232.05 65 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 48498209_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 346.29 97 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 48498209_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 246.33 69 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 48498209_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 278.46 78 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 48498209_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 UMR - ALL PLANS UMR - ALL PLANS 249.9 70 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 48498209_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 SIHO - ALL PLANS SIHO - ALL PLANS 321.3 90 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 48498209_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 216.16 60.55 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 48498209_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 216.16 346.29 Islet cell (pancreas) antibody measurement 48498209_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 216.16 346.29 Islet cell (pancreas) antibody measurement 48498209_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 ANTHEM HMO ANTHEM HMO 999999999 216.16 346.29 Islet cell (pancreas) antibody measurement 48498209_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 241.33 67.6 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 48498209_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 216.16 346.29 Islet cell (pancreas) antibody measurement 48498209_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 216.16 346.29 Vitamin B-6 level 48498210_1 CDM 0301 RC 84207 HCPCS inpatient 238 154.7 AETNA AETNA 188.02 79 999999999 144.11 230.86 percent of total billed charges Vitamin B-6 level 48498210_1 CDM 0301 RC 84207 HCPCS inpatient 238 154.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.7 65 999999999 144.11 230.86 percent of total billed charges Vitamin B-6 level 48498210_1 CDM 0301 RC 84207 HCPCS inpatient 238 154.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 230.86 97 999999999 144.11 230.86 percent of total billed charges Vitamin B-6 level 48498210_1 CDM 0301 RC 84207 HCPCS inpatient 238 154.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.22 69 999999999 144.11 230.86 percent of total billed charges Vitamin B-6 level 48498210_1 CDM 0301 RC 84207 HCPCS inpatient 238 154.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 185.64 78 999999999 144.11 230.86 percent of total billed charges Vitamin B-6 level 48498210_1 CDM 0301 RC 84207 HCPCS inpatient 238 154.7 UMR - ALL PLANS UMR - ALL PLANS 166.6 70 999999999 144.11 230.86 percent of total billed charges Vitamin B-6 level 48498210_1 CDM 0301 RC 84207 HCPCS inpatient 238 154.7 SIHO - ALL PLANS SIHO - ALL PLANS 214.2 90 999999999 144.11 230.86 percent of total billed charges Vitamin B-6 level 48498210_1 CDM 0301 RC 84207 HCPCS inpatient 238 154.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.11 60.55 999999999 144.11 230.86 percent of total billed charges Vitamin B-6 level 48498210_1 CDM 0301 RC 84207 HCPCS inpatient 238 154.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.11 230.86 Vitamin B-6 level 48498210_1 CDM 0301 RC 84207 HCPCS inpatient 238 154.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.11 230.86 Vitamin B-6 level 48498210_1 CDM 0301 RC 84207 HCPCS inpatient 238 154.7 ANTHEM HMO ANTHEM HMO 999999999 144.11 230.86 Vitamin B-6 level 48498210_1 CDM 0301 RC 84207 HCPCS inpatient 238 154.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.89 67.6 999999999 144.11 230.86 percent of total billed charges Vitamin B-6 level 48498210_1 CDM 0301 RC 84207 HCPCS inpatient 238 154.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.11 230.86 Vitamin B-6 level 48498210_1 CDM 0301 RC 84207 HCPCS inpatient 238 154.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.11 230.86 Insulin antibody measurement 48498213_1 CDM 0302 RC 86337 HCPCS inpatient 250 162.5 AETNA AETNA 197.5 79 999999999 151.38 242.5 percent of total billed charges Insulin antibody measurement 48498213_1 CDM 0302 RC 86337 HCPCS inpatient 250 162.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 162.5 65 999999999 151.38 242.5 percent of total billed charges Insulin antibody measurement 48498213_1 CDM 0302 RC 86337 HCPCS inpatient 250 162.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 242.5 97 999999999 151.38 242.5 percent of total billed charges Insulin antibody measurement 48498213_1 CDM 0302 RC 86337 HCPCS inpatient 250 162.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 172.5 69 999999999 151.38 242.5 percent of total billed charges Insulin antibody measurement 48498213_1 CDM 0302 RC 86337 HCPCS inpatient 250 162.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 195 78 999999999 151.38 242.5 percent of total billed charges Insulin antibody measurement 48498213_1 CDM 0302 RC 86337 HCPCS inpatient 250 162.5 UMR - ALL PLANS UMR - ALL PLANS 175 70 999999999 151.38 242.5 percent of total billed charges Insulin antibody measurement 48498213_1 CDM 0302 RC 86337 HCPCS inpatient 250 162.5 SIHO - ALL PLANS SIHO - ALL PLANS 225 90 999999999 151.38 242.5 percent of total billed charges Insulin antibody measurement 48498213_1 CDM 0302 RC 86337 HCPCS inpatient 250 162.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.38 60.55 999999999 151.38 242.5 percent of total billed charges Insulin antibody measurement 48498213_1 CDM 0302 RC 86337 HCPCS inpatient 250 162.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.38 242.5 Insulin antibody measurement 48498213_1 CDM 0302 RC 86337 HCPCS inpatient 250 162.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.38 242.5 Insulin antibody measurement 48498213_1 CDM 0302 RC 86337 HCPCS inpatient 250 162.5 ANTHEM HMO ANTHEM HMO 999999999 151.38 242.5 Insulin antibody measurement 48498213_1 CDM 0302 RC 86337 HCPCS inpatient 250 162.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 169 67.6 999999999 151.38 242.5 percent of total billed charges Insulin antibody measurement 48498213_1 CDM 0302 RC 86337 HCPCS inpatient 250 162.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.38 242.5 Insulin antibody measurement 48498213_1 CDM 0302 RC 86337 HCPCS inpatient 250 162.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.38 242.5 Platelet function test 48498214_1 CDM 0305 RC 85597 HCPCS inpatient 334 217.1 AETNA AETNA 263.86 79 999999999 202.24 323.98 percent of total billed charges Platelet function test 48498214_1 CDM 0305 RC 85597 HCPCS inpatient 334 217.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 217.1 65 999999999 202.24 323.98 percent of total billed charges Platelet function test 48498214_1 CDM 0305 RC 85597 HCPCS inpatient 334 217.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 323.98 97 999999999 202.24 323.98 percent of total billed charges Platelet function test 48498214_1 CDM 0305 RC 85597 HCPCS inpatient 334 217.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 230.46 69 999999999 202.24 323.98 percent of total billed charges Platelet function test 48498214_1 CDM 0305 RC 85597 HCPCS inpatient 334 217.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 260.52 78 999999999 202.24 323.98 percent of total billed charges Platelet function test 48498214_1 CDM 0305 RC 85597 HCPCS inpatient 334 217.1 UMR - ALL PLANS UMR - ALL PLANS 233.8 70 999999999 202.24 323.98 percent of total billed charges Platelet function test 48498214_1 CDM 0305 RC 85597 HCPCS inpatient 334 217.1 SIHO - ALL PLANS SIHO - ALL PLANS 300.6 90 999999999 202.24 323.98 percent of total billed charges Platelet function test 48498214_1 CDM 0305 RC 85597 HCPCS inpatient 334 217.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 202.24 60.55 999999999 202.24 323.98 percent of total billed charges Platelet function test 48498214_1 CDM 0305 RC 85597 HCPCS inpatient 334 217.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 202.24 323.98 Platelet function test 48498214_1 CDM 0305 RC 85597 HCPCS inpatient 334 217.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 202.24 323.98 Platelet function test 48498214_1 CDM 0305 RC 85597 HCPCS inpatient 334 217.1 ANTHEM HMO ANTHEM HMO 999999999 202.24 323.98 Platelet function test 48498214_1 CDM 0305 RC 85597 HCPCS inpatient 334 217.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 225.78 67.6 999999999 202.24 323.98 percent of total billed charges Platelet function test 48498214_1 CDM 0305 RC 85597 HCPCS inpatient 334 217.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 202.24 323.98 Platelet function test 48498214_1 CDM 0305 RC 85597 HCPCS inpatient 334 217.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 202.24 323.98 Mass spectrometry (laboratory testing method) 48498217_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges Mass spectrometry (laboratory testing method) 48498217_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges Mass spectrometry (laboratory testing method) 48498217_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges Mass spectrometry (laboratory testing method) 48498217_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges Mass spectrometry (laboratory testing method) 48498217_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges Mass spectrometry (laboratory testing method) 48498217_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges Mass spectrometry (laboratory testing method) 48498217_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges Mass spectrometry (laboratory testing method) 48498217_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges Mass spectrometry (laboratory testing method) 48498217_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 Mass spectrometry (laboratory testing method) 48498217_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 Mass spectrometry (laboratory testing method) 48498217_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 Mass spectrometry (laboratory testing method) 48498217_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges Mass spectrometry (laboratory testing method) 48498217_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 Mass spectrometry (laboratory testing method) 48498217_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 "Collagen cross links test, (urine test to evaluate bone health)" 48498218_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 48498218_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 48498218_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 48498218_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 48498218_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 48498218_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 48498218_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 48498218_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 48498218_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 "Collagen cross links test, (urine test to evaluate bone health)" 48498218_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 "Collagen cross links test, (urine test to evaluate bone health)" 48498218_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 "Collagen cross links test, (urine test to evaluate bone health)" 48498218_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 48498218_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 "Collagen cross links test, (urine test to evaluate bone health)" 48498218_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 Screening test for antibody to noninfectious agent 48498219_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498219_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498219_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498219_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498219_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498219_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498219_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498219_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498219_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 48498219_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 48498219_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 48498219_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498219_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 48498219_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 "Detection test by nucleic acid for organism, amplified probe technique" 48498220_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 48498220_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 48498220_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 48498220_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 48498220_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 48498220_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 48498220_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 48498220_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 48498220_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 48498220_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 48498220_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 48498220_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 48498220_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 48498220_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 Immune complex measurement 48498221_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 AETNA AETNA 189.6 79 999999999 145.32 232.8 percent of total billed charges Immune complex measurement 48498221_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 SELF PAY DISCOUNT SELF PAY DISCOUNT 156 65 999999999 145.32 232.8 percent of total billed charges Immune complex measurement 48498221_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 232.8 97 999999999 145.32 232.8 percent of total billed charges Immune complex measurement 48498221_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 ENCORE - ALL PLANS ENCORE - ALL PLANS 165.6 69 999999999 145.32 232.8 percent of total billed charges Immune complex measurement 48498221_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.2 78 999999999 145.32 232.8 percent of total billed charges Immune complex measurement 48498221_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 UMR - ALL PLANS UMR - ALL PLANS 168 70 999999999 145.32 232.8 percent of total billed charges Immune complex measurement 48498221_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 SIHO - ALL PLANS SIHO - ALL PLANS 216 90 999999999 145.32 232.8 percent of total billed charges Immune complex measurement 48498221_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.32 60.55 999999999 145.32 232.8 percent of total billed charges Immune complex measurement 48498221_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.32 232.8 Immune complex measurement 48498221_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.32 232.8 Immune complex measurement 48498221_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 ANTHEM HMO ANTHEM HMO 999999999 145.32 232.8 Immune complex measurement 48498221_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.24 67.6 999999999 145.32 232.8 percent of total billed charges Immune complex measurement 48498221_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.32 232.8 Immune complex measurement 48498221_1 CDM 0302 RC 86332 HCPCS inpatient 240 156 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.32 232.8 "Antiepileptics levels, 1-3" 48498222_1 CDM 0306 RC 80339 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges "Antiepileptics levels, 1-3" 48498222_1 CDM 0306 RC 80339 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges "Antiepileptics levels, 1-3" 48498222_1 CDM 0306 RC 80339 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges "Antiepileptics levels, 1-3" 48498222_1 CDM 0306 RC 80339 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges "Antiepileptics levels, 1-3" 48498222_1 CDM 0306 RC 80339 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges "Antiepileptics levels, 1-3" 48498222_1 CDM 0306 RC 80339 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges "Antiepileptics levels, 1-3" 48498222_1 CDM 0306 RC 80339 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges "Antiepileptics levels, 1-3" 48498222_1 CDM 0306 RC 80339 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges "Antiepileptics levels, 1-3" 48498222_1 CDM 0306 RC 80339 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 "Antiepileptics levels, 1-3" 48498222_1 CDM 0306 RC 80339 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 "Antiepileptics levels, 1-3" 48498222_1 CDM 0306 RC 80339 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 "Antiepileptics levels, 1-3" 48498222_1 CDM 0306 RC 80339 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges "Antiepileptics levels, 1-3" 48498222_1 CDM 0306 RC 80339 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 "Antiepileptics levels, 1-3" 48498222_1 CDM 0306 RC 80339 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 Alkaloids levels 48498223_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges Alkaloids levels 48498223_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges Alkaloids levels 48498223_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges Alkaloids levels 48498223_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges Alkaloids levels 48498223_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges Alkaloids levels 48498223_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges Alkaloids levels 48498223_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges Alkaloids levels 48498223_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges Alkaloids levels 48498223_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 Alkaloids levels 48498223_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 Alkaloids levels 48498223_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 Alkaloids levels 48498223_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges Alkaloids levels 48498223_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 Alkaloids levels 48498223_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 Measurement of substance using immunoassay technique 48498224_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 AETNA AETNA 78.21 79 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 48498224_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 64.35 65 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 48498224_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 96.03 97 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 48498224_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 68.31 69 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 48498224_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 77.22 78 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 48498224_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 UMR - ALL PLANS UMR - ALL PLANS 69.3 70 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 48498224_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 SIHO - ALL PLANS SIHO - ALL PLANS 89.1 90 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 48498224_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.94 60.55 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 48498224_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.94 96.03 Measurement of substance using immunoassay technique 48498224_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.94 96.03 Measurement of substance using immunoassay technique 48498224_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM HMO ANTHEM HMO 999999999 59.94 96.03 Measurement of substance using immunoassay technique 48498224_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.92 67.6 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 48498224_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.94 96.03 Measurement of substance using immunoassay technique 48498224_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.94 96.03 Gabapentin level 48498225_1 CDM 0301 RC 80171 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges Gabapentin level 48498225_1 CDM 0301 RC 80171 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges Gabapentin level 48498225_1 CDM 0301 RC 80171 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges Gabapentin level 48498225_1 CDM 0301 RC 80171 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges Gabapentin level 48498225_1 CDM 0301 RC 80171 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges Gabapentin level 48498225_1 CDM 0301 RC 80171 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges Gabapentin level 48498225_1 CDM 0301 RC 80171 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges Gabapentin level 48498225_1 CDM 0301 RC 80171 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges Gabapentin level 48498225_1 CDM 0301 RC 80171 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 Gabapentin level 48498225_1 CDM 0301 RC 80171 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 Gabapentin level 48498225_1 CDM 0301 RC 80171 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 Gabapentin level 48498225_1 CDM 0301 RC 80171 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges Gabapentin level 48498225_1 CDM 0301 RC 80171 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 Gabapentin level 48498225_1 CDM 0301 RC 80171 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 Measurement of immune substance (oligoclonal bands) 48498226_1 CDM 0301 RC 83916 HCPCS inpatient 172 111.8 AETNA AETNA 135.88 79 999999999 104.15 166.84 percent of total billed charges Measurement of immune substance (oligoclonal bands) 48498226_1 CDM 0301 RC 83916 HCPCS inpatient 172 111.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.8 65 999999999 104.15 166.84 percent of total billed charges Measurement of immune substance (oligoclonal bands) 48498226_1 CDM 0301 RC 83916 HCPCS inpatient 172 111.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 166.84 97 999999999 104.15 166.84 percent of total billed charges Measurement of immune substance (oligoclonal bands) 48498226_1 CDM 0301 RC 83916 HCPCS inpatient 172 111.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 118.68 69 999999999 104.15 166.84 percent of total billed charges Measurement of immune substance (oligoclonal bands) 48498226_1 CDM 0301 RC 83916 HCPCS inpatient 172 111.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.16 78 999999999 104.15 166.84 percent of total billed charges Measurement of immune substance (oligoclonal bands) 48498226_1 CDM 0301 RC 83916 HCPCS inpatient 172 111.8 UMR - ALL PLANS UMR - ALL PLANS 120.4 70 999999999 104.15 166.84 percent of total billed charges Measurement of immune substance (oligoclonal bands) 48498226_1 CDM 0301 RC 83916 HCPCS inpatient 172 111.8 SIHO - ALL PLANS SIHO - ALL PLANS 154.8 90 999999999 104.15 166.84 percent of total billed charges Measurement of immune substance (oligoclonal bands) 48498226_1 CDM 0301 RC 83916 HCPCS inpatient 172 111.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.15 60.55 999999999 104.15 166.84 percent of total billed charges Measurement of immune substance (oligoclonal bands) 48498226_1 CDM 0301 RC 83916 HCPCS inpatient 172 111.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.15 166.84 Measurement of immune substance (oligoclonal bands) 48498226_1 CDM 0301 RC 83916 HCPCS inpatient 172 111.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.15 166.84 Measurement of immune substance (oligoclonal bands) 48498226_1 CDM 0301 RC 83916 HCPCS inpatient 172 111.8 ANTHEM HMO ANTHEM HMO 999999999 104.15 166.84 Measurement of immune substance (oligoclonal bands) 48498226_1 CDM 0301 RC 83916 HCPCS inpatient 172 111.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.27 67.6 999999999 104.15 166.84 percent of total billed charges Measurement of immune substance (oligoclonal bands) 48498226_1 CDM 0301 RC 83916 HCPCS inpatient 172 111.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.15 166.84 Measurement of immune substance (oligoclonal bands) 48498226_1 CDM 0301 RC 83916 HCPCS inpatient 172 111.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.15 166.84 Androstenedione (hormone) level 48498228_1 CDM 0301 RC 82157 HCPCS inpatient 244 158.6 AETNA AETNA 192.76 79 999999999 147.74 236.68 percent of total billed charges Androstenedione (hormone) level 48498228_1 CDM 0301 RC 82157 HCPCS inpatient 244 158.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 158.6 65 999999999 147.74 236.68 percent of total billed charges Androstenedione (hormone) level 48498228_1 CDM 0301 RC 82157 HCPCS inpatient 244 158.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 236.68 97 999999999 147.74 236.68 percent of total billed charges Androstenedione (hormone) level 48498228_1 CDM 0301 RC 82157 HCPCS inpatient 244 158.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 168.36 69 999999999 147.74 236.68 percent of total billed charges Androstenedione (hormone) level 48498228_1 CDM 0301 RC 82157 HCPCS inpatient 244 158.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 190.32 78 999999999 147.74 236.68 percent of total billed charges Androstenedione (hormone) level 48498228_1 CDM 0301 RC 82157 HCPCS inpatient 244 158.6 UMR - ALL PLANS UMR - ALL PLANS 170.8 70 999999999 147.74 236.68 percent of total billed charges Androstenedione (hormone) level 48498228_1 CDM 0301 RC 82157 HCPCS inpatient 244 158.6 SIHO - ALL PLANS SIHO - ALL PLANS 219.6 90 999999999 147.74 236.68 percent of total billed charges Androstenedione (hormone) level 48498228_1 CDM 0301 RC 82157 HCPCS inpatient 244 158.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.74 60.55 999999999 147.74 236.68 percent of total billed charges Androstenedione (hormone) level 48498228_1 CDM 0301 RC 82157 HCPCS inpatient 244 158.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.74 236.68 Androstenedione (hormone) level 48498228_1 CDM 0301 RC 82157 HCPCS inpatient 244 158.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.74 236.68 Androstenedione (hormone) level 48498228_1 CDM 0301 RC 82157 HCPCS inpatient 244 158.6 ANTHEM HMO ANTHEM HMO 999999999 147.74 236.68 Androstenedione (hormone) level 48498228_1 CDM 0301 RC 82157 HCPCS inpatient 244 158.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.94 67.6 999999999 147.74 236.68 percent of total billed charges Androstenedione (hormone) level 48498228_1 CDM 0301 RC 82157 HCPCS inpatient 244 158.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.74 236.68 Androstenedione (hormone) level 48498228_1 CDM 0301 RC 82157 HCPCS inpatient 244 158.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.74 236.68 Measurement of substance using immunoassay technique 48498229_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 AETNA AETNA 144.57 79 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 48498229_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.95 65 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 48498229_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.51 97 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 48498229_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.27 69 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 48498229_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 142.74 78 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 48498229_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 UMR - ALL PLANS UMR - ALL PLANS 128.1 70 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 48498229_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 SIHO - ALL PLANS SIHO - ALL PLANS 164.7 90 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 48498229_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.81 60.55 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 48498229_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.81 177.51 Measurement of substance using immunoassay technique 48498229_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.81 177.51 Measurement of substance using immunoassay technique 48498229_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM HMO ANTHEM HMO 999999999 110.81 177.51 Measurement of substance using immunoassay technique 48498229_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.71 67.6 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 48498229_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.81 177.51 Measurement of substance using immunoassay technique 48498229_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.81 177.51 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 48498232_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 AETNA AETNA 211.72 79 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 48498232_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 174.2 65 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 48498232_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 259.96 97 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 48498232_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.92 69 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 48498232_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 209.04 78 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 48498232_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 UMR - ALL PLANS UMR - ALL PLANS 187.6 70 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 48498232_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 SIHO - ALL PLANS SIHO - ALL PLANS 241.2 90 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 48498232_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 162.27 60.55 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 48498232_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 162.27 259.96 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 48498232_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 162.27 259.96 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 48498232_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 ANTHEM HMO ANTHEM HMO 999999999 162.27 259.96 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 48498232_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 181.17 67.6 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 48498232_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 162.27 259.96 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 48498232_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 162.27 259.96 Stool calprotectin (protein) level 48498234_1 CDM 0301 RC 83993 HCPCS inpatient 474 308.1 AETNA AETNA 374.46 79 999999999 287.01 459.78 percent of total billed charges Stool calprotectin (protein) level 48498234_1 CDM 0301 RC 83993 HCPCS inpatient 474 308.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 308.1 65 999999999 287.01 459.78 percent of total billed charges Stool calprotectin (protein) level 48498234_1 CDM 0301 RC 83993 HCPCS inpatient 474 308.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 459.78 97 999999999 287.01 459.78 percent of total billed charges Stool calprotectin (protein) level 48498234_1 CDM 0301 RC 83993 HCPCS inpatient 474 308.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 327.06 69 999999999 287.01 459.78 percent of total billed charges Stool calprotectin (protein) level 48498234_1 CDM 0301 RC 83993 HCPCS inpatient 474 308.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 369.72 78 999999999 287.01 459.78 percent of total billed charges Stool calprotectin (protein) level 48498234_1 CDM 0301 RC 83993 HCPCS inpatient 474 308.1 UMR - ALL PLANS UMR - ALL PLANS 331.8 70 999999999 287.01 459.78 percent of total billed charges Stool calprotectin (protein) level 48498234_1 CDM 0301 RC 83993 HCPCS inpatient 474 308.1 SIHO - ALL PLANS SIHO - ALL PLANS 426.6 90 999999999 287.01 459.78 percent of total billed charges Stool calprotectin (protein) level 48498234_1 CDM 0301 RC 83993 HCPCS inpatient 474 308.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 287.01 60.55 999999999 287.01 459.78 percent of total billed charges Stool calprotectin (protein) level 48498234_1 CDM 0301 RC 83993 HCPCS inpatient 474 308.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 287.01 459.78 Stool calprotectin (protein) level 48498234_1 CDM 0301 RC 83993 HCPCS inpatient 474 308.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 287.01 459.78 Stool calprotectin (protein) level 48498234_1 CDM 0301 RC 83993 HCPCS inpatient 474 308.1 ANTHEM HMO ANTHEM HMO 999999999 287.01 459.78 Stool calprotectin (protein) level 48498234_1 CDM 0301 RC 83993 HCPCS inpatient 474 308.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 320.42 67.6 999999999 287.01 459.78 percent of total billed charges Stool calprotectin (protein) level 48498234_1 CDM 0301 RC 83993 HCPCS inpatient 474 308.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 287.01 459.78 Stool calprotectin (protein) level 48498234_1 CDM 0301 RC 83993 HCPCS inpatient 474 308.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 287.01 459.78 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498235_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498235_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498235_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498235_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498235_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498235_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498235_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498235_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498235_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498235_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498235_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498235_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498235_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 48498235_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Islet cell (pancreas) antibody measurement 48498237_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 AETNA AETNA 282.03 79 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 48498237_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 232.05 65 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 48498237_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 346.29 97 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 48498237_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 246.33 69 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 48498237_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 278.46 78 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 48498237_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 UMR - ALL PLANS UMR - ALL PLANS 249.9 70 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 48498237_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 SIHO - ALL PLANS SIHO - ALL PLANS 321.3 90 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 48498237_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 216.16 60.55 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 48498237_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 216.16 346.29 Islet cell (pancreas) antibody measurement 48498237_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 216.16 346.29 Islet cell (pancreas) antibody measurement 48498237_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 ANTHEM HMO ANTHEM HMO 999999999 216.16 346.29 Islet cell (pancreas) antibody measurement 48498237_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 241.33 67.6 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 48498237_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 216.16 346.29 Islet cell (pancreas) antibody measurement 48498237_1 CDM 0302 RC 86341 HCPCS inpatient 357 232.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 216.16 346.29 Screening test for antibody to noninfectious agent 48498239_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498239_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498239_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498239_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498239_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498239_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498239_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498239_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498239_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 48498239_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 48498239_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 48498239_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498239_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 48498239_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 "Analysis of substance using immunoassay technique, multiple step method" 48498240_1 CDM 0301 RC 83516 HCPCS inpatient 496 322.4 AETNA AETNA 391.84 79 999999999 300.33 481.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48498240_1 CDM 0301 RC 83516 HCPCS inpatient 496 322.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 322.4 65 999999999 300.33 481.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48498240_1 CDM 0301 RC 83516 HCPCS inpatient 496 322.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 481.12 97 999999999 300.33 481.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48498240_1 CDM 0301 RC 83516 HCPCS inpatient 496 322.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 342.24 69 999999999 300.33 481.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48498240_1 CDM 0301 RC 83516 HCPCS inpatient 496 322.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 386.88 78 999999999 300.33 481.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48498240_1 CDM 0301 RC 83516 HCPCS inpatient 496 322.4 UMR - ALL PLANS UMR - ALL PLANS 347.2 70 999999999 300.33 481.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48498240_1 CDM 0301 RC 83516 HCPCS inpatient 496 322.4 SIHO - ALL PLANS SIHO - ALL PLANS 446.4 90 999999999 300.33 481.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48498240_1 CDM 0301 RC 83516 HCPCS inpatient 496 322.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 300.33 60.55 999999999 300.33 481.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48498240_1 CDM 0301 RC 83516 HCPCS inpatient 496 322.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 300.33 481.12 "Analysis of substance using immunoassay technique, multiple step method" 48498240_1 CDM 0301 RC 83516 HCPCS inpatient 496 322.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 300.33 481.12 "Analysis of substance using immunoassay technique, multiple step method" 48498240_1 CDM 0301 RC 83516 HCPCS inpatient 496 322.4 ANTHEM HMO ANTHEM HMO 999999999 300.33 481.12 "Analysis of substance using immunoassay technique, multiple step method" 48498240_1 CDM 0301 RC 83516 HCPCS inpatient 496 322.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 335.3 67.6 999999999 300.33 481.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48498240_1 CDM 0301 RC 83516 HCPCS inpatient 496 322.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 300.33 481.12 "Analysis of substance using immunoassay technique, multiple step method" 48498240_1 CDM 0301 RC 83516 HCPCS inpatient 496 322.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 300.33 481.12 "Urinalysis, manual test" 48498242_1 CDM 0307 RC 81002 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges "Urinalysis, manual test" 48498242_1 CDM 0307 RC 81002 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges "Urinalysis, manual test" 48498242_1 CDM 0307 RC 81002 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges "Urinalysis, manual test" 48498242_1 CDM 0307 RC 81002 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges "Urinalysis, manual test" 48498242_1 CDM 0307 RC 81002 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges "Urinalysis, manual test" 48498242_1 CDM 0307 RC 81002 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges "Urinalysis, manual test" 48498242_1 CDM 0307 RC 81002 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges "Urinalysis, manual test" 48498242_1 CDM 0307 RC 81002 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges "Urinalysis, manual test" 48498242_1 CDM 0307 RC 81002 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 "Urinalysis, manual test" 48498242_1 CDM 0307 RC 81002 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 "Urinalysis, manual test" 48498242_1 CDM 0307 RC 81002 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 "Urinalysis, manual test" 48498242_1 CDM 0307 RC 81002 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges "Urinalysis, manual test" 48498242_1 CDM 0307 RC 81002 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 "Urinalysis, manual test" 48498242_1 CDM 0307 RC 81002 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 "Benzodiazepines levels, 1-12" 48498245_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 AETNA AETNA 138.25 79 999999999 105.96 169.75 percent of total billed charges "Benzodiazepines levels, 1-12" 48498245_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 113.75 65 999999999 105.96 169.75 percent of total billed charges "Benzodiazepines levels, 1-12" 48498245_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 169.75 97 999999999 105.96 169.75 percent of total billed charges "Benzodiazepines levels, 1-12" 48498245_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 120.75 69 999999999 105.96 169.75 percent of total billed charges "Benzodiazepines levels, 1-12" 48498245_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 136.5 78 999999999 105.96 169.75 percent of total billed charges "Benzodiazepines levels, 1-12" 48498245_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 UMR - ALL PLANS UMR - ALL PLANS 122.5 70 999999999 105.96 169.75 percent of total billed charges "Benzodiazepines levels, 1-12" 48498245_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 SIHO - ALL PLANS SIHO - ALL PLANS 157.5 90 999999999 105.96 169.75 percent of total billed charges "Benzodiazepines levels, 1-12" 48498245_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 105.96 60.55 999999999 105.96 169.75 percent of total billed charges "Benzodiazepines levels, 1-12" 48498245_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 105.96 169.75 "Benzodiazepines levels, 1-12" 48498245_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 105.96 169.75 "Benzodiazepines levels, 1-12" 48498245_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 ANTHEM HMO ANTHEM HMO 999999999 105.96 169.75 "Benzodiazepines levels, 1-12" 48498245_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.3 67.6 999999999 105.96 169.75 percent of total billed charges "Benzodiazepines levels, 1-12" 48498245_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 105.96 169.75 "Benzodiazepines levels, 1-12" 48498245_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 105.96 169.75 Screening test for antibody to noninfectious agent 48498246_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498246_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498246_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498246_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498246_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498246_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498246_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498246_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498246_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 48498246_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 48498246_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 48498246_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 48498246_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 48498246_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 Methadone level 48498247_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 AETNA AETNA 166.69 79 999999999 127.76 204.67 percent of total billed charges Methadone level 48498247_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 137.15 65 999999999 127.76 204.67 percent of total billed charges Methadone level 48498247_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 204.67 97 999999999 127.76 204.67 percent of total billed charges Methadone level 48498247_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 145.59 69 999999999 127.76 204.67 percent of total billed charges Methadone level 48498247_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 164.58 78 999999999 127.76 204.67 percent of total billed charges Methadone level 48498247_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 UMR - ALL PLANS UMR - ALL PLANS 147.7 70 999999999 127.76 204.67 percent of total billed charges Methadone level 48498247_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 SIHO - ALL PLANS SIHO - ALL PLANS 189.9 90 999999999 127.76 204.67 percent of total billed charges Methadone level 48498247_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.76 60.55 999999999 127.76 204.67 percent of total billed charges Methadone level 48498247_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.76 204.67 Methadone level 48498247_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.76 204.67 Methadone level 48498247_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ANTHEM HMO ANTHEM HMO 999999999 127.76 204.67 Methadone level 48498247_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 142.64 67.6 999999999 127.76 204.67 percent of total billed charges Methadone level 48498247_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.76 204.67 Methadone level 48498247_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.76 204.67 "Amphetamines levels, 5 or more" 48498248_1 CDM 0301 RC 80326 HCPCS inpatient 266 172.9 AETNA AETNA 210.14 79 999999999 161.06 258.02 percent of total billed charges "Amphetamines levels, 5 or more" 48498248_1 CDM 0301 RC 80326 HCPCS inpatient 266 172.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 172.9 65 999999999 161.06 258.02 percent of total billed charges "Amphetamines levels, 5 or more" 48498248_1 CDM 0301 RC 80326 HCPCS inpatient 266 172.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 258.02 97 999999999 161.06 258.02 percent of total billed charges "Amphetamines levels, 5 or more" 48498248_1 CDM 0301 RC 80326 HCPCS inpatient 266 172.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 183.54 69 999999999 161.06 258.02 percent of total billed charges "Amphetamines levels, 5 or more" 48498248_1 CDM 0301 RC 80326 HCPCS inpatient 266 172.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 207.48 78 999999999 161.06 258.02 percent of total billed charges "Amphetamines levels, 5 or more" 48498248_1 CDM 0301 RC 80326 HCPCS inpatient 266 172.9 UMR - ALL PLANS UMR - ALL PLANS 186.2 70 999999999 161.06 258.02 percent of total billed charges "Amphetamines levels, 5 or more" 48498248_1 CDM 0301 RC 80326 HCPCS inpatient 266 172.9 SIHO - ALL PLANS SIHO - ALL PLANS 239.4 90 999999999 161.06 258.02 percent of total billed charges "Amphetamines levels, 5 or more" 48498248_1 CDM 0301 RC 80326 HCPCS inpatient 266 172.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 161.06 60.55 999999999 161.06 258.02 percent of total billed charges "Amphetamines levels, 5 or more" 48498248_1 CDM 0301 RC 80326 HCPCS inpatient 266 172.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 161.06 258.02 "Amphetamines levels, 5 or more" 48498248_1 CDM 0301 RC 80326 HCPCS inpatient 266 172.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 161.06 258.02 "Amphetamines levels, 5 or more" 48498248_1 CDM 0301 RC 80326 HCPCS inpatient 266 172.9 ANTHEM HMO ANTHEM HMO 999999999 161.06 258.02 "Amphetamines levels, 5 or more" 48498248_1 CDM 0301 RC 80326 HCPCS inpatient 266 172.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 179.82 67.6 999999999 161.06 258.02 percent of total billed charges "Amphetamines levels, 5 or more" 48498248_1 CDM 0301 RC 80326 HCPCS inpatient 266 172.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 161.06 258.02 "Amphetamines levels, 5 or more" 48498248_1 CDM 0301 RC 80326 HCPCS inpatient 266 172.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 161.06 258.02 PCP drug level 48498249_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges PCP drug level 48498249_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges PCP drug level 48498249_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges PCP drug level 48498249_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges PCP drug level 48498249_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges PCP drug level 48498249_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges PCP drug level 48498249_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges PCP drug level 48498249_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges PCP drug level 48498249_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 PCP drug level 48498249_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 PCP drug level 48498249_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 PCP drug level 48498249_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges PCP drug level 48498249_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 PCP drug level 48498249_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 Propoxyphene level 48498250_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 AETNA AETNA 148.52 79 999999999 113.83 182.36 percent of total billed charges Propoxyphene level 48498250_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.2 65 999999999 113.83 182.36 percent of total billed charges Propoxyphene level 48498250_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 182.36 97 999999999 113.83 182.36 percent of total billed charges Propoxyphene level 48498250_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.72 69 999999999 113.83 182.36 percent of total billed charges Propoxyphene level 48498250_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 146.64 78 999999999 113.83 182.36 percent of total billed charges Propoxyphene level 48498250_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 UMR - ALL PLANS UMR - ALL PLANS 131.6 70 999999999 113.83 182.36 percent of total billed charges Propoxyphene level 48498250_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 SIHO - ALL PLANS SIHO - ALL PLANS 169.2 90 999999999 113.83 182.36 percent of total billed charges Propoxyphene level 48498250_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.83 60.55 999999999 113.83 182.36 percent of total billed charges Propoxyphene level 48498250_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.83 182.36 Propoxyphene level 48498250_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.83 182.36 Propoxyphene level 48498250_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 ANTHEM HMO ANTHEM HMO 999999999 113.83 182.36 Propoxyphene level 48498250_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.09 67.6 999999999 113.83 182.36 percent of total billed charges Propoxyphene level 48498250_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.83 182.36 Propoxyphene level 48498250_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.83 182.36 "Testing for presence of drug, by chemistry analyzers" 48498251_1 CDM 0301 RC 80307 HCPCS inpatient 268 174.2 AETNA AETNA 211.72 79 999999999 162.27 259.96 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48498251_1 CDM 0301 RC 80307 HCPCS inpatient 268 174.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 174.2 65 999999999 162.27 259.96 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48498251_1 CDM 0301 RC 80307 HCPCS inpatient 268 174.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 259.96 97 999999999 162.27 259.96 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48498251_1 CDM 0301 RC 80307 HCPCS inpatient 268 174.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.92 69 999999999 162.27 259.96 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48498251_1 CDM 0301 RC 80307 HCPCS inpatient 268 174.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 209.04 78 999999999 162.27 259.96 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48498251_1 CDM 0301 RC 80307 HCPCS inpatient 268 174.2 UMR - ALL PLANS UMR - ALL PLANS 187.6 70 999999999 162.27 259.96 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48498251_1 CDM 0301 RC 80307 HCPCS inpatient 268 174.2 SIHO - ALL PLANS SIHO - ALL PLANS 241.2 90 999999999 162.27 259.96 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48498251_1 CDM 0301 RC 80307 HCPCS inpatient 268 174.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 162.27 60.55 999999999 162.27 259.96 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48498251_1 CDM 0301 RC 80307 HCPCS inpatient 268 174.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 162.27 259.96 "Testing for presence of drug, by chemistry analyzers" 48498251_1 CDM 0301 RC 80307 HCPCS inpatient 268 174.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 162.27 259.96 "Testing for presence of drug, by chemistry analyzers" 48498251_1 CDM 0301 RC 80307 HCPCS inpatient 268 174.2 ANTHEM HMO ANTHEM HMO 999999999 162.27 259.96 "Testing for presence of drug, by chemistry analyzers" 48498251_1 CDM 0301 RC 80307 HCPCS inpatient 268 174.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 181.17 67.6 999999999 162.27 259.96 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48498251_1 CDM 0301 RC 80307 HCPCS inpatient 268 174.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 162.27 259.96 "Testing for presence of drug, by chemistry analyzers" 48498251_1 CDM 0301 RC 80307 HCPCS inpatient 268 174.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 162.27 259.96 Tacrolimus level 48498252_1 CDM 0301 RC 80197 HCPCS inpatient 191 124.15 AETNA AETNA 150.89 79 999999999 115.65 185.27 percent of total billed charges Tacrolimus level 48498252_1 CDM 0301 RC 80197 HCPCS inpatient 191 124.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 124.15 65 999999999 115.65 185.27 percent of total billed charges Tacrolimus level 48498252_1 CDM 0301 RC 80197 HCPCS inpatient 191 124.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 185.27 97 999999999 115.65 185.27 percent of total billed charges Tacrolimus level 48498252_1 CDM 0301 RC 80197 HCPCS inpatient 191 124.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 131.79 69 999999999 115.65 185.27 percent of total billed charges Tacrolimus level 48498252_1 CDM 0301 RC 80197 HCPCS inpatient 191 124.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 148.98 78 999999999 115.65 185.27 percent of total billed charges Tacrolimus level 48498252_1 CDM 0301 RC 80197 HCPCS inpatient 191 124.15 UMR - ALL PLANS UMR - ALL PLANS 133.7 70 999999999 115.65 185.27 percent of total billed charges Tacrolimus level 48498252_1 CDM 0301 RC 80197 HCPCS inpatient 191 124.15 SIHO - ALL PLANS SIHO - ALL PLANS 171.9 90 999999999 115.65 185.27 percent of total billed charges Tacrolimus level 48498252_1 CDM 0301 RC 80197 HCPCS inpatient 191 124.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 115.65 60.55 999999999 115.65 185.27 percent of total billed charges Tacrolimus level 48498252_1 CDM 0301 RC 80197 HCPCS inpatient 191 124.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 115.65 185.27 Tacrolimus level 48498252_1 CDM 0301 RC 80197 HCPCS inpatient 191 124.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 115.65 185.27 Tacrolimus level 48498252_1 CDM 0301 RC 80197 HCPCS inpatient 191 124.15 ANTHEM HMO ANTHEM HMO 999999999 115.65 185.27 Tacrolimus level 48498252_1 CDM 0301 RC 80197 HCPCS inpatient 191 124.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 129.12 67.6 999999999 115.65 185.27 percent of total billed charges Tacrolimus level 48498252_1 CDM 0301 RC 80197 HCPCS inpatient 191 124.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 115.65 185.27 Tacrolimus level 48498252_1 CDM 0301 RC 80197 HCPCS inpatient 191 124.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 115.65 185.27 Measurement of antibody to noninfectious agent 48498253_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 48498253_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 48498253_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 48498253_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 48498253_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 48498253_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 48498253_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 48498253_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 48498253_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 48498253_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 48498253_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 48498253_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 48498253_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 48498253_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498254_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498254_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498254_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498254_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498254_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498254_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498254_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498254_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498254_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498254_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498254_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498254_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498254_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498254_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498255_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498255_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498255_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498255_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498255_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498255_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498255_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498255_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498255_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498255_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498255_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498255_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498255_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498255_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498256_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498256_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498256_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498256_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498256_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498256_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498256_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498256_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498256_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498256_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498256_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498256_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498256_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498256_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498257_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498257_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498257_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498257_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498257_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498257_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498257_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498257_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498257_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498257_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498257_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498257_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498257_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 48498257_1 CDM 0302 RC 86638 HCPCS inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 48500839_1 CDM 0402 RC 76805 HCPCS inpatient 1044 678.6 AETNA AETNA 824.76 79 999999999 632.14 1012.68 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 48500839_1 CDM 0402 RC 76805 HCPCS inpatient 1044 678.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 678.6 65 999999999 632.14 1012.68 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 48500839_1 CDM 0402 RC 76805 HCPCS inpatient 1044 678.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1012.68 97 999999999 632.14 1012.68 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 48500839_1 CDM 0402 RC 76805 HCPCS inpatient 1044 678.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 720.36 69 999999999 632.14 1012.68 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 48500839_1 CDM 0402 RC 76805 HCPCS inpatient 1044 678.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 814.32 78 999999999 632.14 1012.68 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 48500839_1 CDM 0402 RC 76805 HCPCS inpatient 1044 678.6 UMR - ALL PLANS UMR - ALL PLANS 730.8 70 999999999 632.14 1012.68 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 48500839_1 CDM 0402 RC 76805 HCPCS inpatient 1044 678.6 SIHO - ALL PLANS SIHO - ALL PLANS 939.6 90 999999999 632.14 1012.68 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 48500839_1 CDM 0402 RC 76805 HCPCS inpatient 1044 678.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 632.14 60.55 999999999 632.14 1012.68 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 48500839_1 CDM 0402 RC 76805 HCPCS inpatient 1044 678.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 632.14 1012.68 "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 48500839_1 CDM 0402 RC 76805 HCPCS inpatient 1044 678.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 632.14 1012.68 "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 48500839_1 CDM 0402 RC 76805 HCPCS inpatient 1044 678.6 ANTHEM HMO ANTHEM HMO 999999999 632.14 1012.68 "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 48500839_1 CDM 0402 RC 76805 HCPCS inpatient 1044 678.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 705.74 67.6 999999999 632.14 1012.68 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 48500839_1 CDM 0402 RC 76805 HCPCS inpatient 1044 678.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 632.14 1012.68 "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 48500839_1 CDM 0402 RC 76805 HCPCS inpatient 1044 678.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 632.14 1012.68 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503817_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503817_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503817_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503817_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503817_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503817_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503817_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503817_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503817_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503817_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503817_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503817_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503817_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503817_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503818_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 AETNA AETNA 89.27 79 999999999 68.42 109.61 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503818_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 73.45 65 999999999 68.42 109.61 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503818_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 109.61 97 999999999 68.42 109.61 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503818_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.97 69 999999999 68.42 109.61 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503818_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.14 78 999999999 68.42 109.61 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503818_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 UMR - ALL PLANS UMR - ALL PLANS 79.1 70 999999999 68.42 109.61 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503818_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 SIHO - ALL PLANS SIHO - ALL PLANS 101.7 90 999999999 68.42 109.61 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503818_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 68.42 60.55 999999999 68.42 109.61 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503818_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 68.42 109.61 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503818_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 68.42 109.61 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503818_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 ANTHEM HMO ANTHEM HMO 999999999 68.42 109.61 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503818_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 76.39 67.6 999999999 68.42 109.61 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503818_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 68.42 109.61 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503818_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 68.42 109.61 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503822_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 AETNA AETNA 89.27 79 999999999 68.42 109.61 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503822_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 73.45 65 999999999 68.42 109.61 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503822_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 109.61 97 999999999 68.42 109.61 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503822_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.97 69 999999999 68.42 109.61 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503822_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.14 78 999999999 68.42 109.61 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503822_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 UMR - ALL PLANS UMR - ALL PLANS 79.1 70 999999999 68.42 109.61 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503822_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 SIHO - ALL PLANS SIHO - ALL PLANS 101.7 90 999999999 68.42 109.61 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503822_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 68.42 60.55 999999999 68.42 109.61 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503822_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 68.42 109.61 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503822_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 68.42 109.61 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503822_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 ANTHEM HMO ANTHEM HMO 999999999 68.42 109.61 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503822_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 76.39 67.6 999999999 68.42 109.61 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503822_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 68.42 109.61 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48503822_1 CDM 0311 RC 88175 HCPCS inpatient 113 73.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 68.42 109.61 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503823_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503823_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503823_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503823_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503823_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503823_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503823_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503823_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503823_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503823_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503823_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503823_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503823_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503823_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503824_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503824_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503824_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503824_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503824_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503824_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503824_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503824_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503824_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503824_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503824_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503824_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503824_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48503824_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 CRANIAL NEUROSTIM COMPLEX 48506110_1 CDM 0360 RC 95974 HCPCS inpatient 442 287.3 AETNA AETNA 349.18 79 999999999 267.63 428.74 percent of total billed charges CRANIAL NEUROSTIM COMPLEX 48506110_1 CDM 0360 RC 95974 HCPCS inpatient 442 287.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 287.3 65 999999999 267.63 428.74 percent of total billed charges CRANIAL NEUROSTIM COMPLEX 48506110_1 CDM 0360 RC 95974 HCPCS inpatient 442 287.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 428.74 97 999999999 267.63 428.74 percent of total billed charges CRANIAL NEUROSTIM COMPLEX 48506110_1 CDM 0360 RC 95974 HCPCS inpatient 442 287.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 304.98 69 999999999 267.63 428.74 percent of total billed charges CRANIAL NEUROSTIM COMPLEX 48506110_1 CDM 0360 RC 95974 HCPCS inpatient 442 287.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 344.76 78 999999999 267.63 428.74 percent of total billed charges CRANIAL NEUROSTIM COMPLEX 48506110_1 CDM 0360 RC 95974 HCPCS inpatient 442 287.3 UMR - ALL PLANS UMR - ALL PLANS 309.4 70 999999999 267.63 428.74 percent of total billed charges CRANIAL NEUROSTIM COMPLEX 48506110_1 CDM 0360 RC 95974 HCPCS inpatient 442 287.3 SIHO - ALL PLANS SIHO - ALL PLANS 397.8 90 999999999 267.63 428.74 percent of total billed charges CRANIAL NEUROSTIM COMPLEX 48506110_1 CDM 0360 RC 95974 HCPCS inpatient 442 287.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 267.63 60.55 999999999 267.63 428.74 percent of total billed charges CRANIAL NEUROSTIM COMPLEX 48506110_1 CDM 0360 RC 95974 HCPCS inpatient 442 287.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 267.63 428.74 CRANIAL NEUROSTIM COMPLEX 48506110_1 CDM 0360 RC 95974 HCPCS inpatient 442 287.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 267.63 428.74 CRANIAL NEUROSTIM COMPLEX 48506110_1 CDM 0360 RC 95974 HCPCS inpatient 442 287.3 ANTHEM HMO ANTHEM HMO 999999999 267.63 428.74 CRANIAL NEUROSTIM COMPLEX 48506110_1 CDM 0360 RC 95974 HCPCS inpatient 442 287.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 298.79 67.6 999999999 267.63 428.74 percent of total billed charges CRANIAL NEUROSTIM COMPLEX 48506110_1 CDM 0360 RC 95974 HCPCS inpatient 442 287.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 267.63 428.74 CRANIAL NEUROSTIM COMPLEX 48506110_1 CDM 0360 RC 95974 HCPCS inpatient 442 287.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 267.63 428.74 Closed treatment of broken shoulder blade with manipulation 48506347_1 CDM 0450 RC 23575 HCPCS inpatient 1373 892.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 892.45 65 999999999 831.35 1331.81 percent of total billed charges Closed treatment of broken shoulder blade with manipulation 48506347_1 CDM 0450 RC 23575 HCPCS inpatient 1373 892.45 AETNA AETNA 1084.67 79 999999999 831.35 1331.81 percent of total billed charges Closed treatment of broken shoulder blade with manipulation 48506347_1 CDM 0450 RC 23575 HCPCS inpatient 1373 892.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1331.81 97 999999999 831.35 1331.81 percent of total billed charges Closed treatment of broken shoulder blade with manipulation 48506347_1 CDM 0450 RC 23575 HCPCS inpatient 1373 892.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 947.37 69 999999999 831.35 1331.81 percent of total billed charges Closed treatment of broken shoulder blade with manipulation 48506347_1 CDM 0450 RC 23575 HCPCS inpatient 1373 892.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1070.94 78 999999999 831.35 1331.81 percent of total billed charges Closed treatment of broken shoulder blade with manipulation 48506347_1 CDM 0450 RC 23575 HCPCS inpatient 1373 892.45 SIHO - ALL PLANS SIHO - ALL PLANS 1235.7 90 999999999 831.35 1331.81 percent of total billed charges Closed treatment of broken shoulder blade with manipulation 48506347_1 CDM 0450 RC 23575 HCPCS inpatient 1373 892.45 UMR - ALL PLANS UMR - ALL PLANS 961.1 70 999999999 831.35 1331.81 percent of total billed charges Closed treatment of broken shoulder blade with manipulation 48506347_1 CDM 0450 RC 23575 HCPCS inpatient 1373 892.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 831.35 60.55 999999999 831.35 1331.81 percent of total billed charges Closed treatment of broken shoulder blade with manipulation 48506347_1 CDM 0450 RC 23575 HCPCS inpatient 1373 892.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 831.35 1331.81 Closed treatment of broken shoulder blade with manipulation 48506347_1 CDM 0450 RC 23575 HCPCS inpatient 1373 892.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 831.35 1331.81 Closed treatment of broken shoulder blade with manipulation 48506347_1 CDM 0450 RC 23575 HCPCS inpatient 1373 892.45 ANTHEM HMO ANTHEM HMO 999999999 831.35 1331.81 Closed treatment of broken shoulder blade with manipulation 48506347_1 CDM 0450 RC 23575 HCPCS inpatient 1373 892.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 928.15 67.6 999999999 831.35 1331.81 percent of total billed charges Closed treatment of broken shoulder blade with manipulation 48506347_1 CDM 0450 RC 23575 HCPCS inpatient 1373 892.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 831.35 1331.81 Closed treatment of broken shoulder blade with manipulation 48506347_1 CDM 0450 RC 23575 HCPCS inpatient 1373 892.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 831.35 1331.81 Drainage of deep abscess or blood accumulation of upper arm or elbow 48506348_1 CDM 0450 RC 23930 HCPCS inpatient 2684 1744.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1744.6 65 999999999 1625.16 2603.48 percent of total billed charges Drainage of deep abscess or blood accumulation of upper arm or elbow 48506348_1 CDM 0450 RC 23930 HCPCS inpatient 2684 1744.6 AETNA AETNA 2120.36 79 999999999 1625.16 2603.48 percent of total billed charges Drainage of deep abscess or blood accumulation of upper arm or elbow 48506348_1 CDM 0450 RC 23930 HCPCS inpatient 2684 1744.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2603.48 97 999999999 1625.16 2603.48 percent of total billed charges Drainage of deep abscess or blood accumulation of upper arm or elbow 48506348_1 CDM 0450 RC 23930 HCPCS inpatient 2684 1744.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1851.96 69 999999999 1625.16 2603.48 percent of total billed charges Drainage of deep abscess or blood accumulation of upper arm or elbow 48506348_1 CDM 0450 RC 23930 HCPCS inpatient 2684 1744.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 2093.52 78 999999999 1625.16 2603.48 percent of total billed charges Drainage of deep abscess or blood accumulation of upper arm or elbow 48506348_1 CDM 0450 RC 23930 HCPCS inpatient 2684 1744.6 SIHO - ALL PLANS SIHO - ALL PLANS 2415.6 90 999999999 1625.16 2603.48 percent of total billed charges Drainage of deep abscess or blood accumulation of upper arm or elbow 48506348_1 CDM 0450 RC 23930 HCPCS inpatient 2684 1744.6 UMR - ALL PLANS UMR - ALL PLANS 1878.8 70 999999999 1625.16 2603.48 percent of total billed charges Drainage of deep abscess or blood accumulation of upper arm or elbow 48506348_1 CDM 0450 RC 23930 HCPCS inpatient 2684 1744.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1625.16 60.55 999999999 1625.16 2603.48 percent of total billed charges Drainage of deep abscess or blood accumulation of upper arm or elbow 48506348_1 CDM 0450 RC 23930 HCPCS inpatient 2684 1744.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1625.16 2603.48 Drainage of deep abscess or blood accumulation of upper arm or elbow 48506348_1 CDM 0450 RC 23930 HCPCS inpatient 2684 1744.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1625.16 2603.48 Drainage of deep abscess or blood accumulation of upper arm or elbow 48506348_1 CDM 0450 RC 23930 HCPCS inpatient 2684 1744.6 ANTHEM HMO ANTHEM HMO 999999999 1625.16 2603.48 Drainage of deep abscess or blood accumulation of upper arm or elbow 48506348_1 CDM 0450 RC 23930 HCPCS inpatient 2684 1744.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1814.38 67.6 999999999 1625.16 2603.48 percent of total billed charges Drainage of deep abscess or blood accumulation of upper arm or elbow 48506348_1 CDM 0450 RC 23930 HCPCS inpatient 2684 1744.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1625.16 2603.48 Drainage of deep abscess or blood accumulation of upper arm or elbow 48506348_1 CDM 0450 RC 23930 HCPCS inpatient 2684 1744.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1625.16 2603.48 Closed treatment of broken midpart of both forearm bones 48506350_1 CDM 0450 RC 25560 HCPCS inpatient 505 328.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 328.25 65 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken midpart of both forearm bones 48506350_1 CDM 0450 RC 25560 HCPCS inpatient 505 328.25 AETNA AETNA 398.95 79 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken midpart of both forearm bones 48506350_1 CDM 0450 RC 25560 HCPCS inpatient 505 328.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 489.85 97 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken midpart of both forearm bones 48506350_1 CDM 0450 RC 25560 HCPCS inpatient 505 328.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 348.45 69 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken midpart of both forearm bones 48506350_1 CDM 0450 RC 25560 HCPCS inpatient 505 328.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 393.9 78 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken midpart of both forearm bones 48506350_1 CDM 0450 RC 25560 HCPCS inpatient 505 328.25 SIHO - ALL PLANS SIHO - ALL PLANS 454.5 90 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken midpart of both forearm bones 48506350_1 CDM 0450 RC 25560 HCPCS inpatient 505 328.25 UMR - ALL PLANS UMR - ALL PLANS 353.5 70 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken midpart of both forearm bones 48506350_1 CDM 0450 RC 25560 HCPCS inpatient 505 328.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 305.78 60.55 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken midpart of both forearm bones 48506350_1 CDM 0450 RC 25560 HCPCS inpatient 505 328.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 305.78 489.85 Closed treatment of broken midpart of both forearm bones 48506350_1 CDM 0450 RC 25560 HCPCS inpatient 505 328.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 305.78 489.85 Closed treatment of broken midpart of both forearm bones 48506350_1 CDM 0450 RC 25560 HCPCS inpatient 505 328.25 ANTHEM HMO ANTHEM HMO 999999999 305.78 489.85 Closed treatment of broken midpart of both forearm bones 48506350_1 CDM 0450 RC 25560 HCPCS inpatient 505 328.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 341.38 67.6 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken midpart of both forearm bones 48506350_1 CDM 0450 RC 25560 HCPCS inpatient 505 328.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 305.78 489.85 Closed treatment of broken midpart of both forearm bones 48506350_1 CDM 0450 RC 25560 HCPCS inpatient 505 328.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 305.78 489.85 Closed treatment of broken base of forearm bone on small finger side at wrist 48506351_1 CDM 0450 RC 25650 HCPCS inpatient 505 328.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 328.25 65 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken base of forearm bone on small finger side at wrist 48506351_1 CDM 0450 RC 25650 HCPCS inpatient 505 328.25 AETNA AETNA 398.95 79 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken base of forearm bone on small finger side at wrist 48506351_1 CDM 0450 RC 25650 HCPCS inpatient 505 328.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 489.85 97 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken base of forearm bone on small finger side at wrist 48506351_1 CDM 0450 RC 25650 HCPCS inpatient 505 328.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 348.45 69 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken base of forearm bone on small finger side at wrist 48506351_1 CDM 0450 RC 25650 HCPCS inpatient 505 328.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 393.9 78 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken base of forearm bone on small finger side at wrist 48506351_1 CDM 0450 RC 25650 HCPCS inpatient 505 328.25 SIHO - ALL PLANS SIHO - ALL PLANS 454.5 90 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken base of forearm bone on small finger side at wrist 48506351_1 CDM 0450 RC 25650 HCPCS inpatient 505 328.25 UMR - ALL PLANS UMR - ALL PLANS 353.5 70 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken base of forearm bone on small finger side at wrist 48506351_1 CDM 0450 RC 25650 HCPCS inpatient 505 328.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 305.78 60.55 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken base of forearm bone on small finger side at wrist 48506351_1 CDM 0450 RC 25650 HCPCS inpatient 505 328.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 305.78 489.85 Closed treatment of broken base of forearm bone on small finger side at wrist 48506351_1 CDM 0450 RC 25650 HCPCS inpatient 505 328.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 305.78 489.85 Closed treatment of broken base of forearm bone on small finger side at wrist 48506351_1 CDM 0450 RC 25650 HCPCS inpatient 505 328.25 ANTHEM HMO ANTHEM HMO 999999999 305.78 489.85 Closed treatment of broken base of forearm bone on small finger side at wrist 48506351_1 CDM 0450 RC 25650 HCPCS inpatient 505 328.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 341.38 67.6 999999999 305.78 489.85 percent of total billed charges Closed treatment of broken base of forearm bone on small finger side at wrist 48506351_1 CDM 0450 RC 25650 HCPCS inpatient 505 328.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 305.78 489.85 Closed treatment of broken base of forearm bone on small finger side at wrist 48506351_1 CDM 0450 RC 25650 HCPCS inpatient 505 328.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 305.78 489.85 Drainage of infected fluid-filled sac (bursa) of leg or ankle 48506352_1 CDM 0450 RC 27604 HCPCS inpatient 3383 2198.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 2198.95 65 999999999 2048.41 3281.51 percent of total billed charges Drainage of infected fluid-filled sac (bursa) of leg or ankle 48506352_1 CDM 0450 RC 27604 HCPCS inpatient 3383 2198.95 AETNA AETNA 2672.57 79 999999999 2048.41 3281.51 percent of total billed charges Drainage of infected fluid-filled sac (bursa) of leg or ankle 48506352_1 CDM 0450 RC 27604 HCPCS inpatient 3383 2198.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3281.51 97 999999999 2048.41 3281.51 percent of total billed charges Drainage of infected fluid-filled sac (bursa) of leg or ankle 48506352_1 CDM 0450 RC 27604 HCPCS inpatient 3383 2198.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 2334.27 69 999999999 2048.41 3281.51 percent of total billed charges Drainage of infected fluid-filled sac (bursa) of leg or ankle 48506352_1 CDM 0450 RC 27604 HCPCS inpatient 3383 2198.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 2638.74 78 999999999 2048.41 3281.51 percent of total billed charges Drainage of infected fluid-filled sac (bursa) of leg or ankle 48506352_1 CDM 0450 RC 27604 HCPCS inpatient 3383 2198.95 SIHO - ALL PLANS SIHO - ALL PLANS 3044.7 90 999999999 2048.41 3281.51 percent of total billed charges Drainage of infected fluid-filled sac (bursa) of leg or ankle 48506352_1 CDM 0450 RC 27604 HCPCS inpatient 3383 2198.95 UMR - ALL PLANS UMR - ALL PLANS 2368.1 70 999999999 2048.41 3281.51 percent of total billed charges Drainage of infected fluid-filled sac (bursa) of leg or ankle 48506352_1 CDM 0450 RC 27604 HCPCS inpatient 3383 2198.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2048.41 60.55 999999999 2048.41 3281.51 percent of total billed charges Drainage of infected fluid-filled sac (bursa) of leg or ankle 48506352_1 CDM 0450 RC 27604 HCPCS inpatient 3383 2198.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2048.41 3281.51 Drainage of infected fluid-filled sac (bursa) of leg or ankle 48506352_1 CDM 0450 RC 27604 HCPCS inpatient 3383 2198.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2048.41 3281.51 Drainage of infected fluid-filled sac (bursa) of leg or ankle 48506352_1 CDM 0450 RC 27604 HCPCS inpatient 3383 2198.95 ANTHEM HMO ANTHEM HMO 999999999 2048.41 3281.51 Drainage of infected fluid-filled sac (bursa) of leg or ankle 48506352_1 CDM 0450 RC 27604 HCPCS inpatient 3383 2198.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 2286.91 67.6 999999999 2048.41 3281.51 percent of total billed charges Drainage of infected fluid-filled sac (bursa) of leg or ankle 48506352_1 CDM 0450 RC 27604 HCPCS inpatient 3383 2198.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2048.41 3281.51 Drainage of infected fluid-filled sac (bursa) of leg or ankle 48506352_1 CDM 0450 RC 27604 HCPCS inpatient 3383 2198.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 2048.41 3281.51 Closed treatment of dislocated ankle joint 48506353_1 CDM 0450 RC 28570 HCPCS inpatient 505 328.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 328.25 65 999999999 305.78 489.85 percent of total billed charges Closed treatment of dislocated ankle joint 48506353_1 CDM 0450 RC 28570 HCPCS inpatient 505 328.25 AETNA AETNA 398.95 79 999999999 305.78 489.85 percent of total billed charges Closed treatment of dislocated ankle joint 48506353_1 CDM 0450 RC 28570 HCPCS inpatient 505 328.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 489.85 97 999999999 305.78 489.85 percent of total billed charges Closed treatment of dislocated ankle joint 48506353_1 CDM 0450 RC 28570 HCPCS inpatient 505 328.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 348.45 69 999999999 305.78 489.85 percent of total billed charges Closed treatment of dislocated ankle joint 48506353_1 CDM 0450 RC 28570 HCPCS inpatient 505 328.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 393.9 78 999999999 305.78 489.85 percent of total billed charges Closed treatment of dislocated ankle joint 48506353_1 CDM 0450 RC 28570 HCPCS inpatient 505 328.25 SIHO - ALL PLANS SIHO - ALL PLANS 454.5 90 999999999 305.78 489.85 percent of total billed charges Closed treatment of dislocated ankle joint 48506353_1 CDM 0450 RC 28570 HCPCS inpatient 505 328.25 UMR - ALL PLANS UMR - ALL PLANS 353.5 70 999999999 305.78 489.85 percent of total billed charges Closed treatment of dislocated ankle joint 48506353_1 CDM 0450 RC 28570 HCPCS inpatient 505 328.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 305.78 60.55 999999999 305.78 489.85 percent of total billed charges Closed treatment of dislocated ankle joint 48506353_1 CDM 0450 RC 28570 HCPCS inpatient 505 328.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 305.78 489.85 Closed treatment of dislocated ankle joint 48506353_1 CDM 0450 RC 28570 HCPCS inpatient 505 328.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 305.78 489.85 Closed treatment of dislocated ankle joint 48506353_1 CDM 0450 RC 28570 HCPCS inpatient 505 328.25 ANTHEM HMO ANTHEM HMO 999999999 305.78 489.85 Closed treatment of dislocated ankle joint 48506353_1 CDM 0450 RC 28570 HCPCS inpatient 505 328.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 341.38 67.6 999999999 305.78 489.85 percent of total billed charges Closed treatment of dislocated ankle joint 48506353_1 CDM 0450 RC 28570 HCPCS inpatient 505 328.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 305.78 489.85 Closed treatment of dislocated ankle joint 48506353_1 CDM 0450 RC 28570 HCPCS inpatient 505 328.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 305.78 489.85 Removal or cutting of full arm or leg cast 48506354_1 CDM 0450 RC 29705 HCPCS inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges Removal or cutting of full arm or leg cast 48506354_1 CDM 0450 RC 29705 HCPCS inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges Removal or cutting of full arm or leg cast 48506354_1 CDM 0450 RC 29705 HCPCS inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges Removal or cutting of full arm or leg cast 48506354_1 CDM 0450 RC 29705 HCPCS inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges Removal or cutting of full arm or leg cast 48506354_1 CDM 0450 RC 29705 HCPCS inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges Removal or cutting of full arm or leg cast 48506354_1 CDM 0450 RC 29705 HCPCS inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges Removal or cutting of full arm or leg cast 48506354_1 CDM 0450 RC 29705 HCPCS inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges Removal or cutting of full arm or leg cast 48506354_1 CDM 0450 RC 29705 HCPCS inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges Removal or cutting of full arm or leg cast 48506354_1 CDM 0450 RC 29705 HCPCS inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 Removal or cutting of full arm or leg cast 48506354_1 CDM 0450 RC 29705 HCPCS inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 Removal or cutting of full arm or leg cast 48506354_1 CDM 0450 RC 29705 HCPCS inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 Removal or cutting of full arm or leg cast 48506354_1 CDM 0450 RC 29705 HCPCS inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges Removal or cutting of full arm or leg cast 48506354_1 CDM 0450 RC 29705 HCPCS inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 Removal or cutting of full arm or leg cast 48506354_1 CDM 0450 RC 29705 HCPCS inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 Biopsy of lip 48506355_1 CDM 0450 RC 40490 HCPCS inpatient 1179 766.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 766.35 65 999999999 713.88 1143.63 percent of total billed charges Biopsy of lip 48506355_1 CDM 0450 RC 40490 HCPCS inpatient 1179 766.35 AETNA AETNA 931.41 79 999999999 713.88 1143.63 percent of total billed charges Biopsy of lip 48506355_1 CDM 0450 RC 40490 HCPCS inpatient 1179 766.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1143.63 97 999999999 713.88 1143.63 percent of total billed charges Biopsy of lip 48506355_1 CDM 0450 RC 40490 HCPCS inpatient 1179 766.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 813.51 69 999999999 713.88 1143.63 percent of total billed charges Biopsy of lip 48506355_1 CDM 0450 RC 40490 HCPCS inpatient 1179 766.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 919.62 78 999999999 713.88 1143.63 percent of total billed charges Biopsy of lip 48506355_1 CDM 0450 RC 40490 HCPCS inpatient 1179 766.35 SIHO - ALL PLANS SIHO - ALL PLANS 1061.1 90 999999999 713.88 1143.63 percent of total billed charges Biopsy of lip 48506355_1 CDM 0450 RC 40490 HCPCS inpatient 1179 766.35 UMR - ALL PLANS UMR - ALL PLANS 825.3 70 999999999 713.88 1143.63 percent of total billed charges Biopsy of lip 48506355_1 CDM 0450 RC 40490 HCPCS inpatient 1179 766.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 713.88 60.55 999999999 713.88 1143.63 percent of total billed charges Biopsy of lip 48506355_1 CDM 0450 RC 40490 HCPCS inpatient 1179 766.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 713.88 1143.63 Biopsy of lip 48506355_1 CDM 0450 RC 40490 HCPCS inpatient 1179 766.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 713.88 1143.63 Biopsy of lip 48506355_1 CDM 0450 RC 40490 HCPCS inpatient 1179 766.35 ANTHEM HMO ANTHEM HMO 999999999 713.88 1143.63 Biopsy of lip 48506355_1 CDM 0450 RC 40490 HCPCS inpatient 1179 766.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 797 67.6 999999999 713.88 1143.63 percent of total billed charges Biopsy of lip 48506355_1 CDM 0450 RC 40490 HCPCS inpatient 1179 766.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 713.88 1143.63 Biopsy of lip 48506355_1 CDM 0450 RC 40490 HCPCS inpatient 1179 766.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 713.88 1143.63 "Drainage of abscess, cyst, or blood accumulation of side of tongue from inside mouth" 48506356_1 CDM 0450 RC 41000 HCPCS inpatient 2714 1764.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1764.1 65 999999999 1643.33 2632.58 percent of total billed charges "Drainage of abscess, cyst, or blood accumulation of side of tongue from inside mouth" 48506356_1 CDM 0450 RC 41000 HCPCS inpatient 2714 1764.1 AETNA AETNA 2144.06 79 999999999 1643.33 2632.58 percent of total billed charges "Drainage of abscess, cyst, or blood accumulation of side of tongue from inside mouth" 48506356_1 CDM 0450 RC 41000 HCPCS inpatient 2714 1764.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2632.58 97 999999999 1643.33 2632.58 percent of total billed charges "Drainage of abscess, cyst, or blood accumulation of side of tongue from inside mouth" 48506356_1 CDM 0450 RC 41000 HCPCS inpatient 2714 1764.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 1872.66 69 999999999 1643.33 2632.58 percent of total billed charges "Drainage of abscess, cyst, or blood accumulation of side of tongue from inside mouth" 48506356_1 CDM 0450 RC 41000 HCPCS inpatient 2714 1764.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 2116.92 78 999999999 1643.33 2632.58 percent of total billed charges "Drainage of abscess, cyst, or blood accumulation of side of tongue from inside mouth" 48506356_1 CDM 0450 RC 41000 HCPCS inpatient 2714 1764.1 SIHO - ALL PLANS SIHO - ALL PLANS 2442.6 90 999999999 1643.33 2632.58 percent of total billed charges "Drainage of abscess, cyst, or blood accumulation of side of tongue from inside mouth" 48506356_1 CDM 0450 RC 41000 HCPCS inpatient 2714 1764.1 UMR - ALL PLANS UMR - ALL PLANS 1899.8 70 999999999 1643.33 2632.58 percent of total billed charges "Drainage of abscess, cyst, or blood accumulation of side of tongue from inside mouth" 48506356_1 CDM 0450 RC 41000 HCPCS inpatient 2714 1764.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1643.33 60.55 999999999 1643.33 2632.58 percent of total billed charges "Drainage of abscess, cyst, or blood accumulation of side of tongue from inside mouth" 48506356_1 CDM 0450 RC 41000 HCPCS inpatient 2714 1764.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1643.33 2632.58 "Drainage of abscess, cyst, or blood accumulation of side of tongue from inside mouth" 48506356_1 CDM 0450 RC 41000 HCPCS inpatient 2714 1764.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1643.33 2632.58 "Drainage of abscess, cyst, or blood accumulation of side of tongue from inside mouth" 48506356_1 CDM 0450 RC 41000 HCPCS inpatient 2714 1764.1 ANTHEM HMO ANTHEM HMO 999999999 1643.33 2632.58 "Drainage of abscess, cyst, or blood accumulation of side of tongue from inside mouth" 48506356_1 CDM 0450 RC 41000 HCPCS inpatient 2714 1764.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1834.66 67.6 999999999 1643.33 2632.58 percent of total billed charges "Drainage of abscess, cyst, or blood accumulation of side of tongue from inside mouth" 48506356_1 CDM 0450 RC 41000 HCPCS inpatient 2714 1764.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1643.33 2632.58 "Drainage of abscess, cyst, or blood accumulation of side of tongue from inside mouth" 48506356_1 CDM 0450 RC 41000 HCPCS inpatient 2714 1764.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1643.33 2632.58 Complicated removal of saliva gland stone from inside mouth 48506357_1 CDM 0450 RC 42335 HCPCS inpatient 2714 1764.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1764.1 65 999999999 1643.33 2632.58 percent of total billed charges Complicated removal of saliva gland stone from inside mouth 48506357_1 CDM 0450 RC 42335 HCPCS inpatient 2714 1764.1 AETNA AETNA 2144.06 79 999999999 1643.33 2632.58 percent of total billed charges Complicated removal of saliva gland stone from inside mouth 48506357_1 CDM 0450 RC 42335 HCPCS inpatient 2714 1764.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2632.58 97 999999999 1643.33 2632.58 percent of total billed charges Complicated removal of saliva gland stone from inside mouth 48506357_1 CDM 0450 RC 42335 HCPCS inpatient 2714 1764.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 1872.66 69 999999999 1643.33 2632.58 percent of total billed charges Complicated removal of saliva gland stone from inside mouth 48506357_1 CDM 0450 RC 42335 HCPCS inpatient 2714 1764.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 2116.92 78 999999999 1643.33 2632.58 percent of total billed charges Complicated removal of saliva gland stone from inside mouth 48506357_1 CDM 0450 RC 42335 HCPCS inpatient 2714 1764.1 SIHO - ALL PLANS SIHO - ALL PLANS 2442.6 90 999999999 1643.33 2632.58 percent of total billed charges Complicated removal of saliva gland stone from inside mouth 48506357_1 CDM 0450 RC 42335 HCPCS inpatient 2714 1764.1 UMR - ALL PLANS UMR - ALL PLANS 1899.8 70 999999999 1643.33 2632.58 percent of total billed charges Complicated removal of saliva gland stone from inside mouth 48506357_1 CDM 0450 RC 42335 HCPCS inpatient 2714 1764.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1643.33 60.55 999999999 1643.33 2632.58 percent of total billed charges Complicated removal of saliva gland stone from inside mouth 48506357_1 CDM 0450 RC 42335 HCPCS inpatient 2714 1764.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1643.33 2632.58 Complicated removal of saliva gland stone from inside mouth 48506357_1 CDM 0450 RC 42335 HCPCS inpatient 2714 1764.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1643.33 2632.58 Complicated removal of saliva gland stone from inside mouth 48506357_1 CDM 0450 RC 42335 HCPCS inpatient 2714 1764.1 ANTHEM HMO ANTHEM HMO 999999999 1643.33 2632.58 Complicated removal of saliva gland stone from inside mouth 48506357_1 CDM 0450 RC 42335 HCPCS inpatient 2714 1764.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1834.66 67.6 999999999 1643.33 2632.58 percent of total billed charges Complicated removal of saliva gland stone from inside mouth 48506357_1 CDM 0450 RC 42335 HCPCS inpatient 2714 1764.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1643.33 2632.58 Complicated removal of saliva gland stone from inside mouth 48506357_1 CDM 0450 RC 42335 HCPCS inpatient 2714 1764.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1643.33 2632.58 Dilation of stomach and/or small bowel using long gastrointestinal tube 48506358_1 CDM 0450 RC 44500 HCPCS inpatient 1883 1223.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1223.95 65 999999999 1140.16 1826.51 percent of total billed charges Dilation of stomach and/or small bowel using long gastrointestinal tube 48506358_1 CDM 0450 RC 44500 HCPCS inpatient 1883 1223.95 AETNA AETNA 1487.57 79 999999999 1140.16 1826.51 percent of total billed charges Dilation of stomach and/or small bowel using long gastrointestinal tube 48506358_1 CDM 0450 RC 44500 HCPCS inpatient 1883 1223.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1826.51 97 999999999 1140.16 1826.51 percent of total billed charges Dilation of stomach and/or small bowel using long gastrointestinal tube 48506358_1 CDM 0450 RC 44500 HCPCS inpatient 1883 1223.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1299.27 69 999999999 1140.16 1826.51 percent of total billed charges Dilation of stomach and/or small bowel using long gastrointestinal tube 48506358_1 CDM 0450 RC 44500 HCPCS inpatient 1883 1223.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1468.74 78 999999999 1140.16 1826.51 percent of total billed charges Dilation of stomach and/or small bowel using long gastrointestinal tube 48506358_1 CDM 0450 RC 44500 HCPCS inpatient 1883 1223.95 SIHO - ALL PLANS SIHO - ALL PLANS 1694.7 90 999999999 1140.16 1826.51 percent of total billed charges Dilation of stomach and/or small bowel using long gastrointestinal tube 48506358_1 CDM 0450 RC 44500 HCPCS inpatient 1883 1223.95 UMR - ALL PLANS UMR - ALL PLANS 1318.1 70 999999999 1140.16 1826.51 percent of total billed charges Dilation of stomach and/or small bowel using long gastrointestinal tube 48506358_1 CDM 0450 RC 44500 HCPCS inpatient 1883 1223.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1140.16 60.55 999999999 1140.16 1826.51 percent of total billed charges Dilation of stomach and/or small bowel using long gastrointestinal tube 48506358_1 CDM 0450 RC 44500 HCPCS inpatient 1883 1223.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1140.16 1826.51 Dilation of stomach and/or small bowel using long gastrointestinal tube 48506358_1 CDM 0450 RC 44500 HCPCS inpatient 1883 1223.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1140.16 1826.51 Dilation of stomach and/or small bowel using long gastrointestinal tube 48506358_1 CDM 0450 RC 44500 HCPCS inpatient 1883 1223.95 ANTHEM HMO ANTHEM HMO 999999999 1140.16 1826.51 Dilation of stomach and/or small bowel using long gastrointestinal tube 48506358_1 CDM 0450 RC 44500 HCPCS inpatient 1883 1223.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1272.91 67.6 999999999 1140.16 1826.51 percent of total billed charges Dilation of stomach and/or small bowel using long gastrointestinal tube 48506358_1 CDM 0450 RC 44500 HCPCS inpatient 1883 1223.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1140.16 1826.51 Dilation of stomach and/or small bowel using long gastrointestinal tube 48506358_1 CDM 0450 RC 44500 HCPCS inpatient 1883 1223.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1140.16 1826.51 Delivery of placenta 48506359_1 CDM 0450 RC 59414 HCPCS inpatient 2721 1768.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1768.65 65 999999999 1647.57 2639.37 percent of total billed charges Delivery of placenta 48506359_1 CDM 0450 RC 59414 HCPCS inpatient 2721 1768.65 AETNA AETNA 2149.59 79 999999999 1647.57 2639.37 percent of total billed charges Delivery of placenta 48506359_1 CDM 0450 RC 59414 HCPCS inpatient 2721 1768.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2639.37 97 999999999 1647.57 2639.37 percent of total billed charges Delivery of placenta 48506359_1 CDM 0450 RC 59414 HCPCS inpatient 2721 1768.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1877.49 69 999999999 1647.57 2639.37 percent of total billed charges Delivery of placenta 48506359_1 CDM 0450 RC 59414 HCPCS inpatient 2721 1768.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2122.38 78 999999999 1647.57 2639.37 percent of total billed charges Delivery of placenta 48506359_1 CDM 0450 RC 59414 HCPCS inpatient 2721 1768.65 SIHO - ALL PLANS SIHO - ALL PLANS 2448.9 90 999999999 1647.57 2639.37 percent of total billed charges Delivery of placenta 48506359_1 CDM 0450 RC 59414 HCPCS inpatient 2721 1768.65 UMR - ALL PLANS UMR - ALL PLANS 1904.7 70 999999999 1647.57 2639.37 percent of total billed charges Delivery of placenta 48506359_1 CDM 0450 RC 59414 HCPCS inpatient 2721 1768.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1647.57 60.55 999999999 1647.57 2639.37 percent of total billed charges Delivery of placenta 48506359_1 CDM 0450 RC 59414 HCPCS inpatient 2721 1768.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1647.57 2639.37 Delivery of placenta 48506359_1 CDM 0450 RC 59414 HCPCS inpatient 2721 1768.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1647.57 2639.37 Delivery of placenta 48506359_1 CDM 0450 RC 59414 HCPCS inpatient 2721 1768.65 ANTHEM HMO ANTHEM HMO 999999999 1647.57 2639.37 Delivery of placenta 48506359_1 CDM 0450 RC 59414 HCPCS inpatient 2721 1768.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1839.4 67.6 999999999 1647.57 2639.37 percent of total billed charges Delivery of placenta 48506359_1 CDM 0450 RC 59414 HCPCS inpatient 2721 1768.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1647.57 2639.37 Delivery of placenta 48506359_1 CDM 0450 RC 59414 HCPCS inpatient 2721 1768.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1647.57 2639.37 Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 48506360_1 CDM 0450 RC 64421 HCPCS inpatient 766 497.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 497.9 65 999999999 463.81 743.02 percent of total billed charges Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 48506360_1 CDM 0450 RC 64421 HCPCS inpatient 766 497.9 AETNA AETNA 605.14 79 999999999 463.81 743.02 percent of total billed charges Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 48506360_1 CDM 0450 RC 64421 HCPCS inpatient 766 497.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 743.02 97 999999999 463.81 743.02 percent of total billed charges Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 48506360_1 CDM 0450 RC 64421 HCPCS inpatient 766 497.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 528.54 69 999999999 463.81 743.02 percent of total billed charges Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 48506360_1 CDM 0450 RC 64421 HCPCS inpatient 766 497.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 597.48 78 999999999 463.81 743.02 percent of total billed charges Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 48506360_1 CDM 0450 RC 64421 HCPCS inpatient 766 497.9 SIHO - ALL PLANS SIHO - ALL PLANS 689.4 90 999999999 463.81 743.02 percent of total billed charges Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 48506360_1 CDM 0450 RC 64421 HCPCS inpatient 766 497.9 UMR - ALL PLANS UMR - ALL PLANS 536.2 70 999999999 463.81 743.02 percent of total billed charges Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 48506360_1 CDM 0450 RC 64421 HCPCS inpatient 766 497.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 463.81 60.55 999999999 463.81 743.02 percent of total billed charges Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 48506360_1 CDM 0450 RC 64421 HCPCS inpatient 766 497.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 463.81 743.02 Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 48506360_1 CDM 0450 RC 64421 HCPCS inpatient 766 497.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 463.81 743.02 Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 48506360_1 CDM 0450 RC 64421 HCPCS inpatient 766 497.9 ANTHEM HMO ANTHEM HMO 999999999 463.81 743.02 Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 48506360_1 CDM 0450 RC 64421 HCPCS inpatient 766 497.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 517.82 67.6 999999999 463.81 743.02 percent of total billed charges Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 48506360_1 CDM 0450 RC 64421 HCPCS inpatient 766 497.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 463.81 743.02 Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 48506360_1 CDM 0450 RC 64421 HCPCS inpatient 766 497.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 463.81 743.02 Ultrasonic guidance for blood vessel access 48506361_1 CDM 0402 RC 76937 HCPCS inpatient 523 339.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 339.95 65 999999999 316.68 507.31 percent of total billed charges Ultrasonic guidance for blood vessel access 48506361_1 CDM 0402 RC 76937 HCPCS inpatient 523 339.95 AETNA AETNA 413.17 79 999999999 316.68 507.31 percent of total billed charges Ultrasonic guidance for blood vessel access 48506361_1 CDM 0402 RC 76937 HCPCS inpatient 523 339.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 507.31 97 999999999 316.68 507.31 percent of total billed charges Ultrasonic guidance for blood vessel access 48506361_1 CDM 0402 RC 76937 HCPCS inpatient 523 339.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 360.87 69 999999999 316.68 507.31 percent of total billed charges Ultrasonic guidance for blood vessel access 48506361_1 CDM 0402 RC 76937 HCPCS inpatient 523 339.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 407.94 78 999999999 316.68 507.31 percent of total billed charges Ultrasonic guidance for blood vessel access 48506361_1 CDM 0402 RC 76937 HCPCS inpatient 523 339.95 SIHO - ALL PLANS SIHO - ALL PLANS 470.7 90 999999999 316.68 507.31 percent of total billed charges Ultrasonic guidance for blood vessel access 48506361_1 CDM 0402 RC 76937 HCPCS inpatient 523 339.95 UMR - ALL PLANS UMR - ALL PLANS 366.1 70 999999999 316.68 507.31 percent of total billed charges Ultrasonic guidance for blood vessel access 48506361_1 CDM 0402 RC 76937 HCPCS inpatient 523 339.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 316.68 60.55 999999999 316.68 507.31 percent of total billed charges Ultrasonic guidance for blood vessel access 48506361_1 CDM 0402 RC 76937 HCPCS inpatient 523 339.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 316.68 507.31 Ultrasonic guidance for blood vessel access 48506361_1 CDM 0402 RC 76937 HCPCS inpatient 523 339.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 316.68 507.31 Ultrasonic guidance for blood vessel access 48506361_1 CDM 0402 RC 76937 HCPCS inpatient 523 339.95 ANTHEM HMO ANTHEM HMO 999999999 316.68 507.31 Ultrasonic guidance for blood vessel access 48506361_1 CDM 0402 RC 76937 HCPCS inpatient 523 339.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 353.55 67.6 999999999 316.68 507.31 percent of total billed charges Ultrasonic guidance for blood vessel access 48506361_1 CDM 0402 RC 76937 HCPCS inpatient 523 339.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 316.68 507.31 Ultrasonic guidance for blood vessel access 48506361_1 CDM 0402 RC 76937 HCPCS inpatient 523 339.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 316.68 507.31 Test to measure oxygen level in blood using ear or finger device 48506362_1 CDM 0460 RC 94760 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 48506362_1 CDM 0460 RC 94760 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 48506362_1 CDM 0460 RC 94760 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 48506362_1 CDM 0460 RC 94760 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 48506362_1 CDM 0460 RC 94760 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 48506362_1 CDM 0460 RC 94760 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 48506362_1 CDM 0460 RC 94760 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 48506362_1 CDM 0460 RC 94760 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 48506362_1 CDM 0460 RC 94760 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Test to measure oxygen level in blood using ear or finger device 48506362_1 CDM 0460 RC 94760 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Test to measure oxygen level in blood using ear or finger device 48506362_1 CDM 0460 RC 94760 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Test to measure oxygen level in blood using ear or finger device 48506362_1 CDM 0460 RC 94760 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 48506362_1 CDM 0460 RC 94760 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Test to measure oxygen level in blood using ear or finger device 48506362_1 CDM 0460 RC 94760 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Use of a drug to induce depression of consciousness by physician not performing a procedure, each additional 15 minutes" 48506363_1 CDM 0450 RC 99157 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure, each additional 15 minutes" 48506363_1 CDM 0450 RC 99157 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure, each additional 15 minutes" 48506363_1 CDM 0450 RC 99157 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure, each additional 15 minutes" 48506363_1 CDM 0450 RC 99157 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure, each additional 15 minutes" 48506363_1 CDM 0450 RC 99157 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure, each additional 15 minutes" 48506363_1 CDM 0450 RC 99157 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure, each additional 15 minutes" 48506363_1 CDM 0450 RC 99157 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure, each additional 15 minutes" 48506363_1 CDM 0450 RC 99157 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure, each additional 15 minutes" 48506363_1 CDM 0450 RC 99157 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 "Use of a drug to induce depression of consciousness by physician not performing a procedure, each additional 15 minutes" 48506363_1 CDM 0450 RC 99157 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 "Use of a drug to induce depression of consciousness by physician not performing a procedure, each additional 15 minutes" 48506363_1 CDM 0450 RC 99157 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 "Use of a drug to induce depression of consciousness by physician not performing a procedure, each additional 15 minutes" 48506363_1 CDM 0450 RC 99157 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure, each additional 15 minutes" 48506363_1 CDM 0450 RC 99157 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 "Use of a drug to induce depression of consciousness by physician not performing a procedure, each additional 15 minutes" 48506363_1 CDM 0450 RC 99157 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Fungal blood culture (mold or yeast) 48506372_1 CDM 0306 RC 87103 HCPCS inpatient 138 89.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.7 65 999999999 83.56 133.86 percent of total billed charges Fungal blood culture (mold or yeast) 48506372_1 CDM 0306 RC 87103 HCPCS inpatient 138 89.7 AETNA AETNA 109.02 79 999999999 83.56 133.86 percent of total billed charges Fungal blood culture (mold or yeast) 48506372_1 CDM 0306 RC 87103 HCPCS inpatient 138 89.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 133.86 97 999999999 83.56 133.86 percent of total billed charges Fungal blood culture (mold or yeast) 48506372_1 CDM 0306 RC 87103 HCPCS inpatient 138 89.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.22 69 999999999 83.56 133.86 percent of total billed charges Fungal blood culture (mold or yeast) 48506372_1 CDM 0306 RC 87103 HCPCS inpatient 138 89.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 107.64 78 999999999 83.56 133.86 percent of total billed charges Fungal blood culture (mold or yeast) 48506372_1 CDM 0306 RC 87103 HCPCS inpatient 138 89.7 SIHO - ALL PLANS SIHO - ALL PLANS 124.2 90 999999999 83.56 133.86 percent of total billed charges Fungal blood culture (mold or yeast) 48506372_1 CDM 0306 RC 87103 HCPCS inpatient 138 89.7 UMR - ALL PLANS UMR - ALL PLANS 96.6 70 999999999 83.56 133.86 percent of total billed charges Fungal blood culture (mold or yeast) 48506372_1 CDM 0306 RC 87103 HCPCS inpatient 138 89.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 83.56 60.55 999999999 83.56 133.86 percent of total billed charges Fungal blood culture (mold or yeast) 48506372_1 CDM 0306 RC 87103 HCPCS inpatient 138 89.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 83.56 133.86 Fungal blood culture (mold or yeast) 48506372_1 CDM 0306 RC 87103 HCPCS inpatient 138 89.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 83.56 133.86 Fungal blood culture (mold or yeast) 48506372_1 CDM 0306 RC 87103 HCPCS inpatient 138 89.7 ANTHEM HMO ANTHEM HMO 999999999 83.56 133.86 Fungal blood culture (mold or yeast) 48506372_1 CDM 0306 RC 87103 HCPCS inpatient 138 89.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.29 67.6 999999999 83.56 133.86 percent of total billed charges Fungal blood culture (mold or yeast) 48506372_1 CDM 0306 RC 87103 HCPCS inpatient 138 89.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 83.56 133.86 Fungal blood culture (mold or yeast) 48506372_1 CDM 0306 RC 87103 HCPCS inpatient 138 89.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 83.56 133.86 Pinworm test 48506414_1 CDM 0306 RC 87172 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges Pinworm test 48506414_1 CDM 0306 RC 87172 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges Pinworm test 48506414_1 CDM 0306 RC 87172 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges Pinworm test 48506414_1 CDM 0306 RC 87172 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges Pinworm test 48506414_1 CDM 0306 RC 87172 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges Pinworm test 48506414_1 CDM 0306 RC 87172 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges Pinworm test 48506414_1 CDM 0306 RC 87172 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges Pinworm test 48506414_1 CDM 0306 RC 87172 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges Pinworm test 48506414_1 CDM 0306 RC 87172 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 Pinworm test 48506414_1 CDM 0306 RC 87172 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 Pinworm test 48506414_1 CDM 0306 RC 87172 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 Pinworm test 48506414_1 CDM 0306 RC 87172 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges Pinworm test 48506414_1 CDM 0306 RC 87172 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 Pinworm test 48506414_1 CDM 0306 RC 87172 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 Fetal monitoring during labor by consulting physician 48507475_1 CDM 0721 RC 59050 HCPCS inpatient 194 126.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 126.1 65 999999999 117.47 188.18 percent of total billed charges Fetal monitoring during labor by consulting physician 48507475_1 CDM 0721 RC 59050 HCPCS inpatient 194 126.1 AETNA AETNA 153.26 79 999999999 117.47 188.18 percent of total billed charges Fetal monitoring during labor by consulting physician 48507475_1 CDM 0721 RC 59050 HCPCS inpatient 194 126.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 188.18 97 999999999 117.47 188.18 percent of total billed charges Fetal monitoring during labor by consulting physician 48507475_1 CDM 0721 RC 59050 HCPCS inpatient 194 126.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.86 69 999999999 117.47 188.18 percent of total billed charges Fetal monitoring during labor by consulting physician 48507475_1 CDM 0721 RC 59050 HCPCS inpatient 194 126.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 151.32 78 999999999 117.47 188.18 percent of total billed charges Fetal monitoring during labor by consulting physician 48507475_1 CDM 0721 RC 59050 HCPCS inpatient 194 126.1 SIHO - ALL PLANS SIHO - ALL PLANS 174.6 90 999999999 117.47 188.18 percent of total billed charges Fetal monitoring during labor by consulting physician 48507475_1 CDM 0721 RC 59050 HCPCS inpatient 194 126.1 UMR - ALL PLANS UMR - ALL PLANS 135.8 70 999999999 117.47 188.18 percent of total billed charges Fetal monitoring during labor by consulting physician 48507475_1 CDM 0721 RC 59050 HCPCS inpatient 194 126.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 117.47 60.55 999999999 117.47 188.18 percent of total billed charges Fetal monitoring during labor by consulting physician 48507475_1 CDM 0721 RC 59050 HCPCS inpatient 194 126.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 117.47 188.18 Fetal monitoring during labor by consulting physician 48507475_1 CDM 0721 RC 59050 HCPCS inpatient 194 126.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 117.47 188.18 Fetal monitoring during labor by consulting physician 48507475_1 CDM 0721 RC 59050 HCPCS inpatient 194 126.1 ANTHEM HMO ANTHEM HMO 999999999 117.47 188.18 Fetal monitoring during labor by consulting physician 48507475_1 CDM 0721 RC 59050 HCPCS inpatient 194 126.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 131.14 67.6 999999999 117.47 188.18 percent of total billed charges Fetal monitoring during labor by consulting physician 48507475_1 CDM 0721 RC 59050 HCPCS inpatient 194 126.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 117.47 188.18 Fetal monitoring during labor by consulting physician 48507475_1 CDM 0721 RC 59050 HCPCS inpatient 194 126.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 117.47 188.18 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507476_1 CDM 0510 RC G0463 HCPCS inpatient 317 206.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 206.05 65 999999999 191.94 307.49 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507476_1 CDM 0510 RC G0463 HCPCS inpatient 317 206.05 AETNA AETNA 250.43 79 999999999 191.94 307.49 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507476_1 CDM 0510 RC G0463 HCPCS inpatient 317 206.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 307.49 97 999999999 191.94 307.49 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507476_1 CDM 0510 RC G0463 HCPCS inpatient 317 206.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 218.73 69 999999999 191.94 307.49 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507476_1 CDM 0510 RC G0463 HCPCS inpatient 317 206.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 247.26 78 999999999 191.94 307.49 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507476_1 CDM 0510 RC G0463 HCPCS inpatient 317 206.05 SIHO - ALL PLANS SIHO - ALL PLANS 285.3 90 999999999 191.94 307.49 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507476_1 CDM 0510 RC G0463 HCPCS inpatient 317 206.05 UMR - ALL PLANS UMR - ALL PLANS 221.9 70 999999999 191.94 307.49 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507476_1 CDM 0510 RC G0463 HCPCS inpatient 317 206.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 191.94 60.55 999999999 191.94 307.49 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507476_1 CDM 0510 RC G0463 HCPCS inpatient 317 206.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 191.94 307.49 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507476_1 CDM 0510 RC G0463 HCPCS inpatient 317 206.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 191.94 307.49 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507476_1 CDM 0510 RC G0463 HCPCS inpatient 317 206.05 ANTHEM HMO ANTHEM HMO 999999999 191.94 307.49 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507476_1 CDM 0510 RC G0463 HCPCS inpatient 317 206.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 214.29 67.6 999999999 191.94 307.49 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507476_1 CDM 0510 RC G0463 HCPCS inpatient 317 206.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 191.94 307.49 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507476_1 CDM 0510 RC G0463 HCPCS inpatient 317 206.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 191.94 307.49 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507480_1 CDM 0510 RC G0463 HCPCS inpatient 416 270.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 270.4 65 999999999 251.89 403.52 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507480_1 CDM 0510 RC G0463 HCPCS inpatient 416 270.4 AETNA AETNA 328.64 79 999999999 251.89 403.52 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507480_1 CDM 0510 RC G0463 HCPCS inpatient 416 270.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 403.52 97 999999999 251.89 403.52 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507480_1 CDM 0510 RC G0463 HCPCS inpatient 416 270.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 287.04 69 999999999 251.89 403.52 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507480_1 CDM 0510 RC G0463 HCPCS inpatient 416 270.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 324.48 78 999999999 251.89 403.52 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507480_1 CDM 0510 RC G0463 HCPCS inpatient 416 270.4 SIHO - ALL PLANS SIHO - ALL PLANS 374.4 90 999999999 251.89 403.52 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507480_1 CDM 0510 RC G0463 HCPCS inpatient 416 270.4 UMR - ALL PLANS UMR - ALL PLANS 291.2 70 999999999 251.89 403.52 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507480_1 CDM 0510 RC G0463 HCPCS inpatient 416 270.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 251.89 60.55 999999999 251.89 403.52 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507480_1 CDM 0510 RC G0463 HCPCS inpatient 416 270.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 251.89 403.52 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507480_1 CDM 0510 RC G0463 HCPCS inpatient 416 270.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 251.89 403.52 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507480_1 CDM 0510 RC G0463 HCPCS inpatient 416 270.4 ANTHEM HMO ANTHEM HMO 999999999 251.89 403.52 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507480_1 CDM 0510 RC G0463 HCPCS inpatient 416 270.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 281.22 67.6 999999999 251.89 403.52 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507480_1 CDM 0510 RC G0463 HCPCS inpatient 416 270.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 251.89 403.52 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507480_1 CDM 0510 RC G0463 HCPCS inpatient 416 270.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 251.89 403.52 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507481_1 CDM 0510 RC G0463 HCPCS inpatient 454 295.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 295.1 65 999999999 274.9 440.38 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507481_1 CDM 0510 RC G0463 HCPCS inpatient 454 295.1 AETNA AETNA 358.66 79 999999999 274.9 440.38 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507481_1 CDM 0510 RC G0463 HCPCS inpatient 454 295.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 440.38 97 999999999 274.9 440.38 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507481_1 CDM 0510 RC G0463 HCPCS inpatient 454 295.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 313.26 69 999999999 274.9 440.38 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507481_1 CDM 0510 RC G0463 HCPCS inpatient 454 295.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 354.12 78 999999999 274.9 440.38 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507481_1 CDM 0510 RC G0463 HCPCS inpatient 454 295.1 SIHO - ALL PLANS SIHO - ALL PLANS 408.6 90 999999999 274.9 440.38 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507481_1 CDM 0510 RC G0463 HCPCS inpatient 454 295.1 UMR - ALL PLANS UMR - ALL PLANS 317.8 70 999999999 274.9 440.38 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507481_1 CDM 0510 RC G0463 HCPCS inpatient 454 295.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 274.9 60.55 999999999 274.9 440.38 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507481_1 CDM 0510 RC G0463 HCPCS inpatient 454 295.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 274.9 440.38 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507481_1 CDM 0510 RC G0463 HCPCS inpatient 454 295.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 274.9 440.38 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507481_1 CDM 0510 RC G0463 HCPCS inpatient 454 295.1 ANTHEM HMO ANTHEM HMO 999999999 274.9 440.38 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507481_1 CDM 0510 RC G0463 HCPCS inpatient 454 295.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 306.9 67.6 999999999 274.9 440.38 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507481_1 CDM 0510 RC G0463 HCPCS inpatient 454 295.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 274.9 440.38 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507481_1 CDM 0510 RC G0463 HCPCS inpatient 454 295.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 274.9 440.38 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507485_1 CDM 0761 RC G0463 HCPCS inpatient 1253 814.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 814.45 65 999999999 758.69 1215.41 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507485_1 CDM 0761 RC G0463 HCPCS inpatient 1253 814.45 AETNA AETNA 989.87 79 999999999 758.69 1215.41 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507485_1 CDM 0761 RC G0463 HCPCS inpatient 1253 814.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1215.41 97 999999999 758.69 1215.41 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507485_1 CDM 0761 RC G0463 HCPCS inpatient 1253 814.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 864.57 69 999999999 758.69 1215.41 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507485_1 CDM 0761 RC G0463 HCPCS inpatient 1253 814.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 977.34 78 999999999 758.69 1215.41 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507485_1 CDM 0761 RC G0463 HCPCS inpatient 1253 814.45 SIHO - ALL PLANS SIHO - ALL PLANS 1127.7 90 999999999 758.69 1215.41 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507485_1 CDM 0761 RC G0463 HCPCS inpatient 1253 814.45 UMR - ALL PLANS UMR - ALL PLANS 877.1 70 999999999 758.69 1215.41 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507485_1 CDM 0761 RC G0463 HCPCS inpatient 1253 814.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 758.69 60.55 999999999 758.69 1215.41 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507485_1 CDM 0761 RC G0463 HCPCS inpatient 1253 814.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 758.69 1215.41 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507485_1 CDM 0761 RC G0463 HCPCS inpatient 1253 814.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 758.69 1215.41 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507485_1 CDM 0761 RC G0463 HCPCS inpatient 1253 814.45 ANTHEM HMO ANTHEM HMO 999999999 758.69 1215.41 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507485_1 CDM 0761 RC G0463 HCPCS inpatient 1253 814.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 847.03 67.6 999999999 758.69 1215.41 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507485_1 CDM 0761 RC G0463 HCPCS inpatient 1253 814.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 758.69 1215.41 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48507485_1 CDM 0761 RC G0463 HCPCS inpatient 1253 814.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 758.69 1215.41 SPECIALTY SERVICES - TREATMENT ROOM 48507486_1 CDM 0761 RC inpatient 96 62.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.4 65 999999999 58.13 93.12 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48507486_1 CDM 0761 RC inpatient 96 62.4 AETNA AETNA 75.84 79 999999999 58.13 93.12 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48507486_1 CDM 0761 RC inpatient 96 62.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.12 97 999999999 58.13 93.12 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48507486_1 CDM 0761 RC inpatient 96 62.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.24 69 999999999 58.13 93.12 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48507486_1 CDM 0761 RC inpatient 96 62.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.88 78 999999999 58.13 93.12 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48507486_1 CDM 0761 RC inpatient 96 62.4 SIHO - ALL PLANS SIHO - ALL PLANS 86.4 90 999999999 58.13 93.12 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48507486_1 CDM 0761 RC inpatient 96 62.4 UMR - ALL PLANS UMR - ALL PLANS 67.2 70 999999999 58.13 93.12 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48507486_1 CDM 0761 RC inpatient 96 62.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.13 60.55 999999999 58.13 93.12 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48507486_1 CDM 0761 RC inpatient 96 62.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.13 93.12 SPECIALTY SERVICES - TREATMENT ROOM 48507486_1 CDM 0761 RC inpatient 96 62.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.13 93.12 SPECIALTY SERVICES - TREATMENT ROOM 48507486_1 CDM 0761 RC inpatient 96 62.4 ANTHEM HMO ANTHEM HMO 999999999 58.13 93.12 SPECIALTY SERVICES - TREATMENT ROOM 48507486_1 CDM 0761 RC inpatient 96 62.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.9 67.6 999999999 58.13 93.12 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48507486_1 CDM 0761 RC inpatient 96 62.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.13 93.12 SPECIALTY SERVICES - TREATMENT ROOM 48507486_1 CDM 0761 RC inpatient 96 62.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.13 93.12 Electrocardiogram (ECG) 1 to 3 leads 48507500_1 CDM 0730 RC 93041 HCPCS inpatient 251 163.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.15 65 999999999 151.98 243.47 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads 48507500_1 CDM 0730 RC 93041 HCPCS inpatient 251 163.15 AETNA AETNA 198.29 79 999999999 151.98 243.47 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads 48507500_1 CDM 0730 RC 93041 HCPCS inpatient 251 163.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 243.47 97 999999999 151.98 243.47 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads 48507500_1 CDM 0730 RC 93041 HCPCS inpatient 251 163.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.19 69 999999999 151.98 243.47 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads 48507500_1 CDM 0730 RC 93041 HCPCS inpatient 251 163.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 195.78 78 999999999 151.98 243.47 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads 48507500_1 CDM 0730 RC 93041 HCPCS inpatient 251 163.15 SIHO - ALL PLANS SIHO - ALL PLANS 225.9 90 999999999 151.98 243.47 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads 48507500_1 CDM 0730 RC 93041 HCPCS inpatient 251 163.15 UMR - ALL PLANS UMR - ALL PLANS 175.7 70 999999999 151.98 243.47 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads 48507500_1 CDM 0730 RC 93041 HCPCS inpatient 251 163.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.98 60.55 999999999 151.98 243.47 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads 48507500_1 CDM 0730 RC 93041 HCPCS inpatient 251 163.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.98 243.47 Electrocardiogram (ECG) 1 to 3 leads 48507500_1 CDM 0730 RC 93041 HCPCS inpatient 251 163.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.98 243.47 Electrocardiogram (ECG) 1 to 3 leads 48507500_1 CDM 0730 RC 93041 HCPCS inpatient 251 163.15 ANTHEM HMO ANTHEM HMO 999999999 151.98 243.47 Electrocardiogram (ECG) 1 to 3 leads 48507500_1 CDM 0730 RC 93041 HCPCS inpatient 251 163.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 169.68 67.6 999999999 151.98 243.47 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads 48507500_1 CDM 0730 RC 93041 HCPCS inpatient 251 163.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.98 243.47 Electrocardiogram (ECG) 1 to 3 leads 48507500_1 CDM 0730 RC 93041 HCPCS inpatient 251 163.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.98 243.47 Continuous Passive Motion 48507874_1 CDM 0947 RC inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges Continuous Passive Motion 48507874_1 CDM 0947 RC inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges Continuous Passive Motion 48507874_1 CDM 0947 RC inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges Continuous Passive Motion 48507874_1 CDM 0947 RC inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges Continuous Passive Motion 48507874_1 CDM 0947 RC inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges Continuous Passive Motion 48507874_1 CDM 0947 RC inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges Continuous Passive Motion 48507874_1 CDM 0947 RC inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges Continuous Passive Motion 48507874_1 CDM 0947 RC inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges Continuous Passive Motion 48507874_1 CDM 0947 RC inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 Continuous Passive Motion 48507874_1 CDM 0947 RC inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 Continuous Passive Motion 48507874_1 CDM 0947 RC inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 Continuous Passive Motion 48507874_1 CDM 0947 RC inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges Continuous Passive Motion 48507874_1 CDM 0947 RC inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 Continuous Passive Motion 48507874_1 CDM 0947 RC inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 "RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED" 48526044_1 CDM 0343 RC A4641 HCPCS inpatient 601 390.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 390.65 65 999999999 363.91 582.97 percent of total billed charges "RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED" 48526044_1 CDM 0343 RC A4641 HCPCS inpatient 601 390.65 AETNA AETNA 474.79 79 999999999 363.91 582.97 percent of total billed charges "RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED" 48526044_1 CDM 0343 RC A4641 HCPCS inpatient 601 390.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 582.97 97 999999999 363.91 582.97 percent of total billed charges "RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED" 48526044_1 CDM 0343 RC A4641 HCPCS inpatient 601 390.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 414.69 69 999999999 363.91 582.97 percent of total billed charges "RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED" 48526044_1 CDM 0343 RC A4641 HCPCS inpatient 601 390.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 468.78 78 999999999 363.91 582.97 percent of total billed charges "RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED" 48526044_1 CDM 0343 RC A4641 HCPCS inpatient 601 390.65 SIHO - ALL PLANS SIHO - ALL PLANS 540.9 90 999999999 363.91 582.97 percent of total billed charges "RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED" 48526044_1 CDM 0343 RC A4641 HCPCS inpatient 601 390.65 UMR - ALL PLANS UMR - ALL PLANS 420.7 70 999999999 363.91 582.97 percent of total billed charges "RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED" 48526044_1 CDM 0343 RC A4641 HCPCS inpatient 601 390.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 363.91 60.55 999999999 363.91 582.97 percent of total billed charges "RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED" 48526044_1 CDM 0343 RC A4641 HCPCS inpatient 601 390.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 363.91 582.97 "RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED" 48526044_1 CDM 0343 RC A4641 HCPCS inpatient 601 390.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 363.91 582.97 "RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED" 48526044_1 CDM 0343 RC A4641 HCPCS inpatient 601 390.65 ANTHEM HMO ANTHEM HMO 999999999 363.91 582.97 "RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED" 48526044_1 CDM 0343 RC A4641 HCPCS inpatient 601 390.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 406.28 67.6 999999999 363.91 582.97 percent of total billed charges "RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED" 48526044_1 CDM 0343 RC A4641 HCPCS inpatient 601 390.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 363.91 582.97 "RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED" 48526044_1 CDM 0343 RC A4641 HCPCS inpatient 601 390.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 363.91 582.97 "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48526050_1 CDM 0278 RC A4648 HCPCS inpatient 469 304.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 304.85 65 999999999 283.98 454.93 percent of total billed charges "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48526050_1 CDM 0278 RC A4648 HCPCS inpatient 469 304.85 AETNA AETNA 370.51 79 999999999 283.98 454.93 percent of total billed charges "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48526050_1 CDM 0278 RC A4648 HCPCS inpatient 469 304.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 454.93 97 999999999 283.98 454.93 percent of total billed charges "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48526050_1 CDM 0278 RC A4648 HCPCS inpatient 469 304.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 323.61 69 999999999 283.98 454.93 percent of total billed charges "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48526050_1 CDM 0278 RC A4648 HCPCS inpatient 469 304.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 365.82 78 999999999 283.98 454.93 percent of total billed charges "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48526050_1 CDM 0278 RC A4648 HCPCS inpatient 469 304.85 SIHO - ALL PLANS SIHO - ALL PLANS 422.1 90 999999999 283.98 454.93 percent of total billed charges "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48526050_1 CDM 0278 RC A4648 HCPCS inpatient 469 304.85 UMR - ALL PLANS UMR - ALL PLANS 328.3 70 999999999 283.98 454.93 percent of total billed charges "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48526050_1 CDM 0278 RC A4648 HCPCS inpatient 469 304.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 283.98 60.55 999999999 283.98 454.93 percent of total billed charges "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48526050_1 CDM 0278 RC A4648 HCPCS inpatient 469 304.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 283.98 454.93 "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48526050_1 CDM 0278 RC A4648 HCPCS inpatient 469 304.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 283.98 454.93 "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48526050_1 CDM 0278 RC A4648 HCPCS inpatient 469 304.85 ANTHEM HMO ANTHEM HMO 999999999 283.98 454.93 "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48526050_1 CDM 0278 RC A4648 HCPCS inpatient 469 304.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 317.04 67.6 999999999 283.98 454.93 percent of total billed charges "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48526050_1 CDM 0278 RC A4648 HCPCS inpatient 469 304.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 283.98 454.93 "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48526050_1 CDM 0278 RC A4648 HCPCS inpatient 469 304.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 283.98 454.93 "TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE" 48526053_1 CDM 0343 RC A9500 HCPCS inpatient 418 271.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 271.7 65 999999999 253.1 405.46 percent of total billed charges "TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE" 48526053_1 CDM 0343 RC A9500 HCPCS inpatient 418 271.7 AETNA AETNA 330.22 79 999999999 253.1 405.46 percent of total billed charges "TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE" 48526053_1 CDM 0343 RC A9500 HCPCS inpatient 418 271.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 405.46 97 999999999 253.1 405.46 percent of total billed charges "TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE" 48526053_1 CDM 0343 RC A9500 HCPCS inpatient 418 271.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 288.42 69 999999999 253.1 405.46 percent of total billed charges "TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE" 48526053_1 CDM 0343 RC A9500 HCPCS inpatient 418 271.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 326.04 78 999999999 253.1 405.46 percent of total billed charges "TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE" 48526053_1 CDM 0343 RC A9500 HCPCS inpatient 418 271.7 SIHO - ALL PLANS SIHO - ALL PLANS 376.2 90 999999999 253.1 405.46 percent of total billed charges "TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE" 48526053_1 CDM 0343 RC A9500 HCPCS inpatient 418 271.7 UMR - ALL PLANS UMR - ALL PLANS 292.6 70 999999999 253.1 405.46 percent of total billed charges "TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE" 48526053_1 CDM 0343 RC A9500 HCPCS inpatient 418 271.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 253.1 60.55 999999999 253.1 405.46 percent of total billed charges "TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE" 48526053_1 CDM 0343 RC A9500 HCPCS inpatient 418 271.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 253.1 405.46 "TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE" 48526053_1 CDM 0343 RC A9500 HCPCS inpatient 418 271.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 253.1 405.46 "TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE" 48526053_1 CDM 0343 RC A9500 HCPCS inpatient 418 271.7 ANTHEM HMO ANTHEM HMO 999999999 253.1 405.46 "TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE" 48526053_1 CDM 0343 RC A9500 HCPCS inpatient 418 271.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 282.57 67.6 999999999 253.1 405.46 percent of total billed charges "TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE" 48526053_1 CDM 0343 RC A9500 HCPCS inpatient 418 271.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 253.1 405.46 "TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE" 48526053_1 CDM 0343 RC A9500 HCPCS inpatient 418 271.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 253.1 405.46 "TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE" 48526056_1 CDM 0343 RC A9502 HCPCS inpatient 420 273 SELF PAY DISCOUNT SELF PAY DISCOUNT 273 65 999999999 254.31 407.4 percent of total billed charges "TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE" 48526056_1 CDM 0343 RC A9502 HCPCS inpatient 420 273 AETNA AETNA 331.8 79 999999999 254.31 407.4 percent of total billed charges "TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE" 48526056_1 CDM 0343 RC A9502 HCPCS inpatient 420 273 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 407.4 97 999999999 254.31 407.4 percent of total billed charges "TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE" 48526056_1 CDM 0343 RC A9502 HCPCS inpatient 420 273 ENCORE - ALL PLANS ENCORE - ALL PLANS 289.8 69 999999999 254.31 407.4 percent of total billed charges "TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE" 48526056_1 CDM 0343 RC A9502 HCPCS inpatient 420 273 HUMANA - ALL PLANS HUMANA - ALL PLANS 327.6 78 999999999 254.31 407.4 percent of total billed charges "TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE" 48526056_1 CDM 0343 RC A9502 HCPCS inpatient 420 273 SIHO - ALL PLANS SIHO - ALL PLANS 378 90 999999999 254.31 407.4 percent of total billed charges "TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE" 48526056_1 CDM 0343 RC A9502 HCPCS inpatient 420 273 UMR - ALL PLANS UMR - ALL PLANS 294 70 999999999 254.31 407.4 percent of total billed charges "TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE" 48526056_1 CDM 0343 RC A9502 HCPCS inpatient 420 273 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 254.31 60.55 999999999 254.31 407.4 percent of total billed charges "TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE" 48526056_1 CDM 0343 RC A9502 HCPCS inpatient 420 273 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 254.31 407.4 "TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE" 48526056_1 CDM 0343 RC A9502 HCPCS inpatient 420 273 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 254.31 407.4 "TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE" 48526056_1 CDM 0343 RC A9502 HCPCS inpatient 420 273 ANTHEM HMO ANTHEM HMO 999999999 254.31 407.4 "TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE" 48526056_1 CDM 0343 RC A9502 HCPCS inpatient 420 273 CIGNA - ALL PLANS CIGNA - ALL PLANS 283.92 67.6 999999999 254.31 407.4 percent of total billed charges "TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE" 48526056_1 CDM 0343 RC A9502 HCPCS inpatient 420 273 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 254.31 407.4 "TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE" 48526056_1 CDM 0343 RC A9502 HCPCS inpatient 420 273 UHC - ALL PLANS UHC - ALL PLANS 999999999 254.31 407.4 "TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES" 48526058_1 CDM 0343 RC A9503 HCPCS inpatient 265 172.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 172.25 65 999999999 160.46 257.05 percent of total billed charges "TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES" 48526058_1 CDM 0343 RC A9503 HCPCS inpatient 265 172.25 AETNA AETNA 209.35 79 999999999 160.46 257.05 percent of total billed charges "TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES" 48526058_1 CDM 0343 RC A9503 HCPCS inpatient 265 172.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 257.05 97 999999999 160.46 257.05 percent of total billed charges "TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES" 48526058_1 CDM 0343 RC A9503 HCPCS inpatient 265 172.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 182.85 69 999999999 160.46 257.05 percent of total billed charges "TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES" 48526058_1 CDM 0343 RC A9503 HCPCS inpatient 265 172.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 206.7 78 999999999 160.46 257.05 percent of total billed charges "TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES" 48526058_1 CDM 0343 RC A9503 HCPCS inpatient 265 172.25 SIHO - ALL PLANS SIHO - ALL PLANS 238.5 90 999999999 160.46 257.05 percent of total billed charges "TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES" 48526058_1 CDM 0343 RC A9503 HCPCS inpatient 265 172.25 UMR - ALL PLANS UMR - ALL PLANS 185.5 70 999999999 160.46 257.05 percent of total billed charges "TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES" 48526058_1 CDM 0343 RC A9503 HCPCS inpatient 265 172.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 160.46 60.55 999999999 160.46 257.05 percent of total billed charges "TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES" 48526058_1 CDM 0343 RC A9503 HCPCS inpatient 265 172.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 160.46 257.05 "TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES" 48526058_1 CDM 0343 RC A9503 HCPCS inpatient 265 172.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 160.46 257.05 "TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES" 48526058_1 CDM 0343 RC A9503 HCPCS inpatient 265 172.25 ANTHEM HMO ANTHEM HMO 999999999 160.46 257.05 "TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES" 48526058_1 CDM 0343 RC A9503 HCPCS inpatient 265 172.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 179.14 67.6 999999999 160.46 257.05 percent of total billed charges "TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES" 48526058_1 CDM 0343 RC A9503 HCPCS inpatient 265 172.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 160.46 257.05 "TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES" 48526058_1 CDM 0343 RC A9503 HCPCS inpatient 265 172.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 160.46 257.05 "THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE" 48526061_1 CDM 0636 RC A9505 HCPCS inpatient 349 226.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 226.85 65 999999999 211.32 338.53 percent of total billed charges "THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE" 48526061_1 CDM 0636 RC A9505 HCPCS inpatient 349 226.85 AETNA AETNA 275.71 79 999999999 211.32 338.53 percent of total billed charges "THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE" 48526061_1 CDM 0636 RC A9505 HCPCS inpatient 349 226.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 338.53 97 999999999 211.32 338.53 percent of total billed charges "THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE" 48526061_1 CDM 0636 RC A9505 HCPCS inpatient 349 226.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 240.81 69 999999999 211.32 338.53 percent of total billed charges "THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE" 48526061_1 CDM 0636 RC A9505 HCPCS inpatient 349 226.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 272.22 78 999999999 211.32 338.53 percent of total billed charges "THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE" 48526061_1 CDM 0636 RC A9505 HCPCS inpatient 349 226.85 SIHO - ALL PLANS SIHO - ALL PLANS 314.1 90 999999999 211.32 338.53 percent of total billed charges "THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE" 48526061_1 CDM 0636 RC A9505 HCPCS inpatient 349 226.85 UMR - ALL PLANS UMR - ALL PLANS 244.3 70 999999999 211.32 338.53 percent of total billed charges "THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE" 48526061_1 CDM 0636 RC A9505 HCPCS inpatient 349 226.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 211.32 60.55 999999999 211.32 338.53 percent of total billed charges "THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE" 48526061_1 CDM 0636 RC A9505 HCPCS inpatient 349 226.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 211.32 338.53 "THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE" 48526061_1 CDM 0636 RC A9505 HCPCS inpatient 349 226.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 211.32 338.53 "THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE" 48526061_1 CDM 0636 RC A9505 HCPCS inpatient 349 226.85 ANTHEM HMO ANTHEM HMO 999999999 211.32 338.53 "THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE" 48526061_1 CDM 0636 RC A9505 HCPCS inpatient 349 226.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 235.92 67.6 999999999 211.32 338.53 percent of total billed charges "THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE" 48526061_1 CDM 0636 RC A9505 HCPCS inpatient 349 226.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 211.32 338.53 "THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE" 48526061_1 CDM 0636 RC A9505 HCPCS inpatient 349 226.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 211.32 338.53 "TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE" 48526063_1 CDM 0636 RC A9512 HCPCS inpatient 227 147.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 147.55 65 999999999 137.45 220.19 percent of total billed charges "TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE" 48526063_1 CDM 0636 RC A9512 HCPCS inpatient 227 147.55 AETNA AETNA 179.33 79 999999999 137.45 220.19 percent of total billed charges "TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE" 48526063_1 CDM 0636 RC A9512 HCPCS inpatient 227 147.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 220.19 97 999999999 137.45 220.19 percent of total billed charges "TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE" 48526063_1 CDM 0636 RC A9512 HCPCS inpatient 227 147.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 156.63 69 999999999 137.45 220.19 percent of total billed charges "TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE" 48526063_1 CDM 0636 RC A9512 HCPCS inpatient 227 147.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 177.06 78 999999999 137.45 220.19 percent of total billed charges "TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE" 48526063_1 CDM 0636 RC A9512 HCPCS inpatient 227 147.55 SIHO - ALL PLANS SIHO - ALL PLANS 204.3 90 999999999 137.45 220.19 percent of total billed charges "TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE" 48526063_1 CDM 0636 RC A9512 HCPCS inpatient 227 147.55 UMR - ALL PLANS UMR - ALL PLANS 158.9 70 999999999 137.45 220.19 percent of total billed charges "TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE" 48526063_1 CDM 0636 RC A9512 HCPCS inpatient 227 147.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 137.45 60.55 999999999 137.45 220.19 percent of total billed charges "TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE" 48526063_1 CDM 0636 RC A9512 HCPCS inpatient 227 147.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 137.45 220.19 "TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE" 48526063_1 CDM 0636 RC A9512 HCPCS inpatient 227 147.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 137.45 220.19 "TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE" 48526063_1 CDM 0636 RC A9512 HCPCS inpatient 227 147.55 ANTHEM HMO ANTHEM HMO 999999999 137.45 220.19 "TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE" 48526063_1 CDM 0636 RC A9512 HCPCS inpatient 227 147.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 153.45 67.6 999999999 137.45 220.19 percent of total billed charges "TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE" 48526063_1 CDM 0636 RC A9512 HCPCS inpatient 227 147.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 137.45 220.19 "TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE" 48526063_1 CDM 0636 RC A9512 HCPCS inpatient 227 147.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 137.45 220.19 "IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999 MICROCURIES" 48526066_1 CDM 0343 RC A9516 HCPCS inpatient 361 234.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 234.65 65 999999999 218.59 350.17 percent of total billed charges "IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999 MICROCURIES" 48526066_1 CDM 0343 RC A9516 HCPCS inpatient 361 234.65 AETNA AETNA 285.19 79 999999999 218.59 350.17 percent of total billed charges "IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999 MICROCURIES" 48526066_1 CDM 0343 RC A9516 HCPCS inpatient 361 234.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 350.17 97 999999999 218.59 350.17 percent of total billed charges "IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999 MICROCURIES" 48526066_1 CDM 0343 RC A9516 HCPCS inpatient 361 234.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 249.09 69 999999999 218.59 350.17 percent of total billed charges "IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999 MICROCURIES" 48526066_1 CDM 0343 RC A9516 HCPCS inpatient 361 234.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 281.58 78 999999999 218.59 350.17 percent of total billed charges "IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999 MICROCURIES" 48526066_1 CDM 0343 RC A9516 HCPCS inpatient 361 234.65 SIHO - ALL PLANS SIHO - ALL PLANS 324.9 90 999999999 218.59 350.17 percent of total billed charges "IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999 MICROCURIES" 48526066_1 CDM 0343 RC A9516 HCPCS inpatient 361 234.65 UMR - ALL PLANS UMR - ALL PLANS 252.7 70 999999999 218.59 350.17 percent of total billed charges "IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999 MICROCURIES" 48526066_1 CDM 0343 RC A9516 HCPCS inpatient 361 234.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 218.59 60.55 999999999 218.59 350.17 percent of total billed charges "IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999 MICROCURIES" 48526066_1 CDM 0343 RC A9516 HCPCS inpatient 361 234.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 218.59 350.17 "IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999 MICROCURIES" 48526066_1 CDM 0343 RC A9516 HCPCS inpatient 361 234.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 218.59 350.17 "IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999 MICROCURIES" 48526066_1 CDM 0343 RC A9516 HCPCS inpatient 361 234.65 ANTHEM HMO ANTHEM HMO 999999999 218.59 350.17 "IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999 MICROCURIES" 48526066_1 CDM 0343 RC A9516 HCPCS inpatient 361 234.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 244.04 67.6 999999999 218.59 350.17 percent of total billed charges "IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999 MICROCURIES" 48526066_1 CDM 0343 RC A9516 HCPCS inpatient 361 234.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 218.59 350.17 "IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999 MICROCURIES" 48526066_1 CDM 0343 RC A9516 HCPCS inpatient 361 234.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 218.59 350.17 "IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER MILLICURIE" 48526069_1 CDM 0636 RC A9528 HCPCS inpatient 292 189.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 189.8 65 999999999 176.81 283.24 percent of total billed charges "IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER MILLICURIE" 48526069_1 CDM 0636 RC A9528 HCPCS inpatient 292 189.8 AETNA AETNA 230.68 79 999999999 176.81 283.24 percent of total billed charges "IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER MILLICURIE" 48526069_1 CDM 0636 RC A9528 HCPCS inpatient 292 189.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 283.24 97 999999999 176.81 283.24 percent of total billed charges "IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER MILLICURIE" 48526069_1 CDM 0636 RC A9528 HCPCS inpatient 292 189.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 201.48 69 999999999 176.81 283.24 percent of total billed charges "IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER MILLICURIE" 48526069_1 CDM 0636 RC A9528 HCPCS inpatient 292 189.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 227.76 78 999999999 176.81 283.24 percent of total billed charges "IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER MILLICURIE" 48526069_1 CDM 0636 RC A9528 HCPCS inpatient 292 189.8 SIHO - ALL PLANS SIHO - ALL PLANS 262.8 90 999999999 176.81 283.24 percent of total billed charges "IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER MILLICURIE" 48526069_1 CDM 0636 RC A9528 HCPCS inpatient 292 189.8 UMR - ALL PLANS UMR - ALL PLANS 204.4 70 999999999 176.81 283.24 percent of total billed charges "IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER MILLICURIE" 48526069_1 CDM 0636 RC A9528 HCPCS inpatient 292 189.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 176.81 60.55 999999999 176.81 283.24 percent of total billed charges "IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER MILLICURIE" 48526069_1 CDM 0636 RC A9528 HCPCS inpatient 292 189.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 176.81 283.24 "IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER MILLICURIE" 48526069_1 CDM 0636 RC A9528 HCPCS inpatient 292 189.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 176.81 283.24 "IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER MILLICURIE" 48526069_1 CDM 0636 RC A9528 HCPCS inpatient 292 189.8 ANTHEM HMO ANTHEM HMO 999999999 176.81 283.24 "IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER MILLICURIE" 48526069_1 CDM 0636 RC A9528 HCPCS inpatient 292 189.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 197.39 67.6 999999999 176.81 283.24 percent of total billed charges "IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER MILLICURIE" 48526069_1 CDM 0636 RC A9528 HCPCS inpatient 292 189.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 176.81 283.24 "IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER MILLICURIE" 48526069_1 CDM 0636 RC A9528 HCPCS inpatient 292 189.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 176.81 283.24 "TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526075_1 CDM 0343 RC A9537 HCPCS inpatient 265 172.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 172.25 65 999999999 160.46 257.05 percent of total billed charges "TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526075_1 CDM 0343 RC A9537 HCPCS inpatient 265 172.25 AETNA AETNA 209.35 79 999999999 160.46 257.05 percent of total billed charges "TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526075_1 CDM 0343 RC A9537 HCPCS inpatient 265 172.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 257.05 97 999999999 160.46 257.05 percent of total billed charges "TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526075_1 CDM 0343 RC A9537 HCPCS inpatient 265 172.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 182.85 69 999999999 160.46 257.05 percent of total billed charges "TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526075_1 CDM 0343 RC A9537 HCPCS inpatient 265 172.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 206.7 78 999999999 160.46 257.05 percent of total billed charges "TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526075_1 CDM 0343 RC A9537 HCPCS inpatient 265 172.25 SIHO - ALL PLANS SIHO - ALL PLANS 238.5 90 999999999 160.46 257.05 percent of total billed charges "TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526075_1 CDM 0343 RC A9537 HCPCS inpatient 265 172.25 UMR - ALL PLANS UMR - ALL PLANS 185.5 70 999999999 160.46 257.05 percent of total billed charges "TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526075_1 CDM 0343 RC A9537 HCPCS inpatient 265 172.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 160.46 60.55 999999999 160.46 257.05 percent of total billed charges "TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526075_1 CDM 0343 RC A9537 HCPCS inpatient 265 172.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 160.46 257.05 "TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526075_1 CDM 0343 RC A9537 HCPCS inpatient 265 172.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 160.46 257.05 "TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526075_1 CDM 0343 RC A9537 HCPCS inpatient 265 172.25 ANTHEM HMO ANTHEM HMO 999999999 160.46 257.05 "TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526075_1 CDM 0343 RC A9537 HCPCS inpatient 265 172.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 179.14 67.6 999999999 160.46 257.05 percent of total billed charges "TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526075_1 CDM 0343 RC A9537 HCPCS inpatient 265 172.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 160.46 257.05 "TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526075_1 CDM 0343 RC A9537 HCPCS inpatient 265 172.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 160.46 257.05 "TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES" 48526077_1 CDM 0340 RC A9538 HCPCS inpatient 497 323.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 323.05 65 999999999 300.93 482.09 percent of total billed charges "TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES" 48526077_1 CDM 0340 RC A9538 HCPCS inpatient 497 323.05 AETNA AETNA 392.63 79 999999999 300.93 482.09 percent of total billed charges "TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES" 48526077_1 CDM 0340 RC A9538 HCPCS inpatient 497 323.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 482.09 97 999999999 300.93 482.09 percent of total billed charges "TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES" 48526077_1 CDM 0340 RC A9538 HCPCS inpatient 497 323.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 342.93 69 999999999 300.93 482.09 percent of total billed charges "TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES" 48526077_1 CDM 0340 RC A9538 HCPCS inpatient 497 323.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 387.66 78 999999999 300.93 482.09 percent of total billed charges "TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES" 48526077_1 CDM 0340 RC A9538 HCPCS inpatient 497 323.05 SIHO - ALL PLANS SIHO - ALL PLANS 447.3 90 999999999 300.93 482.09 percent of total billed charges "TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES" 48526077_1 CDM 0340 RC A9538 HCPCS inpatient 497 323.05 UMR - ALL PLANS UMR - ALL PLANS 347.9 70 999999999 300.93 482.09 percent of total billed charges "TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES" 48526077_1 CDM 0340 RC A9538 HCPCS inpatient 497 323.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 300.93 60.55 999999999 300.93 482.09 percent of total billed charges "TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES" 48526077_1 CDM 0340 RC A9538 HCPCS inpatient 497 323.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 300.93 482.09 "TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES" 48526077_1 CDM 0340 RC A9538 HCPCS inpatient 497 323.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 300.93 482.09 "TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES" 48526077_1 CDM 0340 RC A9538 HCPCS inpatient 497 323.05 ANTHEM HMO ANTHEM HMO 999999999 300.93 482.09 "TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES" 48526077_1 CDM 0340 RC A9538 HCPCS inpatient 497 323.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 335.97 67.6 999999999 300.93 482.09 percent of total billed charges "TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES" 48526077_1 CDM 0340 RC A9538 HCPCS inpatient 497 323.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 300.93 482.09 "TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES" 48526077_1 CDM 0340 RC A9538 HCPCS inpatient 497 323.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 300.93 482.09 "TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES" 48526079_1 CDM 0343 RC A9540 HCPCS inpatient 260 169 SELF PAY DISCOUNT SELF PAY DISCOUNT 169 65 999999999 157.43 252.2 percent of total billed charges "TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES" 48526079_1 CDM 0343 RC A9540 HCPCS inpatient 260 169 AETNA AETNA 205.4 79 999999999 157.43 252.2 percent of total billed charges "TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES" 48526079_1 CDM 0343 RC A9540 HCPCS inpatient 260 169 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 252.2 97 999999999 157.43 252.2 percent of total billed charges "TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES" 48526079_1 CDM 0343 RC A9540 HCPCS inpatient 260 169 ENCORE - ALL PLANS ENCORE - ALL PLANS 179.4 69 999999999 157.43 252.2 percent of total billed charges "TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES" 48526079_1 CDM 0343 RC A9540 HCPCS inpatient 260 169 HUMANA - ALL PLANS HUMANA - ALL PLANS 202.8 78 999999999 157.43 252.2 percent of total billed charges "TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES" 48526079_1 CDM 0343 RC A9540 HCPCS inpatient 260 169 SIHO - ALL PLANS SIHO - ALL PLANS 234 90 999999999 157.43 252.2 percent of total billed charges "TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES" 48526079_1 CDM 0343 RC A9540 HCPCS inpatient 260 169 UMR - ALL PLANS UMR - ALL PLANS 182 70 999999999 157.43 252.2 percent of total billed charges "TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES" 48526079_1 CDM 0343 RC A9540 HCPCS inpatient 260 169 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 157.43 60.55 999999999 157.43 252.2 percent of total billed charges "TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES" 48526079_1 CDM 0343 RC A9540 HCPCS inpatient 260 169 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 157.43 252.2 "TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES" 48526079_1 CDM 0343 RC A9540 HCPCS inpatient 260 169 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 157.43 252.2 "TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES" 48526079_1 CDM 0343 RC A9540 HCPCS inpatient 260 169 ANTHEM HMO ANTHEM HMO 999999999 157.43 252.2 "TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES" 48526079_1 CDM 0343 RC A9540 HCPCS inpatient 260 169 CIGNA - ALL PLANS CIGNA - ALL PLANS 175.76 67.6 999999999 157.43 252.2 percent of total billed charges "TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES" 48526079_1 CDM 0343 RC A9540 HCPCS inpatient 260 169 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 157.43 252.2 "TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES" 48526079_1 CDM 0343 RC A9540 HCPCS inpatient 260 169 UHC - ALL PLANS UHC - ALL PLANS 999999999 157.43 252.2 "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526081_1 CDM 0343 RC A9541 HCPCS inpatient 341 221.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 221.65 65 999999999 206.48 330.77 percent of total billed charges "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526081_1 CDM 0343 RC A9541 HCPCS inpatient 341 221.65 AETNA AETNA 269.39 79 999999999 206.48 330.77 percent of total billed charges "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526081_1 CDM 0343 RC A9541 HCPCS inpatient 341 221.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 330.77 97 999999999 206.48 330.77 percent of total billed charges "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526081_1 CDM 0343 RC A9541 HCPCS inpatient 341 221.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 235.29 69 999999999 206.48 330.77 percent of total billed charges "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526081_1 CDM 0343 RC A9541 HCPCS inpatient 341 221.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 265.98 78 999999999 206.48 330.77 percent of total billed charges "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526081_1 CDM 0343 RC A9541 HCPCS inpatient 341 221.65 SIHO - ALL PLANS SIHO - ALL PLANS 306.9 90 999999999 206.48 330.77 percent of total billed charges "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526081_1 CDM 0343 RC A9541 HCPCS inpatient 341 221.65 UMR - ALL PLANS UMR - ALL PLANS 238.7 70 999999999 206.48 330.77 percent of total billed charges "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526081_1 CDM 0343 RC A9541 HCPCS inpatient 341 221.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 206.48 60.55 999999999 206.48 330.77 percent of total billed charges "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526081_1 CDM 0343 RC A9541 HCPCS inpatient 341 221.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 206.48 330.77 "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526081_1 CDM 0343 RC A9541 HCPCS inpatient 341 221.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 206.48 330.77 "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526081_1 CDM 0343 RC A9541 HCPCS inpatient 341 221.65 ANTHEM HMO ANTHEM HMO 999999999 206.48 330.77 "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526081_1 CDM 0343 RC A9541 HCPCS inpatient 341 221.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 230.52 67.6 999999999 206.48 330.77 percent of total billed charges "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526081_1 CDM 0343 RC A9541 HCPCS inpatient 341 221.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 206.48 330.77 "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526081_1 CDM 0343 RC A9541 HCPCS inpatient 341 221.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 206.48 330.77 "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526083_1 CDM 0343 RC A9541 HCPCS inpatient 1628 1058.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1058.2 65 999999999 985.75 1579.16 percent of total billed charges "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526083_1 CDM 0343 RC A9541 HCPCS inpatient 1628 1058.2 AETNA AETNA 1286.12 79 999999999 985.75 1579.16 percent of total billed charges "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526083_1 CDM 0343 RC A9541 HCPCS inpatient 1628 1058.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1579.16 97 999999999 985.75 1579.16 percent of total billed charges "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526083_1 CDM 0343 RC A9541 HCPCS inpatient 1628 1058.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1123.32 69 999999999 985.75 1579.16 percent of total billed charges "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526083_1 CDM 0343 RC A9541 HCPCS inpatient 1628 1058.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1269.84 78 999999999 985.75 1579.16 percent of total billed charges "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526083_1 CDM 0343 RC A9541 HCPCS inpatient 1628 1058.2 SIHO - ALL PLANS SIHO - ALL PLANS 1465.2 90 999999999 985.75 1579.16 percent of total billed charges "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526083_1 CDM 0343 RC A9541 HCPCS inpatient 1628 1058.2 UMR - ALL PLANS UMR - ALL PLANS 1139.6 70 999999999 985.75 1579.16 percent of total billed charges "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526083_1 CDM 0343 RC A9541 HCPCS inpatient 1628 1058.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 985.75 60.55 999999999 985.75 1579.16 percent of total billed charges "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526083_1 CDM 0343 RC A9541 HCPCS inpatient 1628 1058.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 985.75 1579.16 "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526083_1 CDM 0343 RC A9541 HCPCS inpatient 1628 1058.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 985.75 1579.16 "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526083_1 CDM 0343 RC A9541 HCPCS inpatient 1628 1058.2 ANTHEM HMO ANTHEM HMO 999999999 985.75 1579.16 "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526083_1 CDM 0343 RC A9541 HCPCS inpatient 1628 1058.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1100.53 67.6 999999999 985.75 1579.16 percent of total billed charges "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526083_1 CDM 0343 RC A9541 HCPCS inpatient 1628 1058.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 985.75 1579.16 "TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES" 48526083_1 CDM 0343 RC A9541 HCPCS inpatient 1628 1058.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 985.75 1579.16 "FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES" 48526085_1 CDM 0343 RC A9552 HCPCS inpatient 2675 1738.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1738.75 65 999999999 1619.71 2594.75 percent of total billed charges "FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES" 48526085_1 CDM 0343 RC A9552 HCPCS inpatient 2675 1738.75 AETNA AETNA 2113.25 79 999999999 1619.71 2594.75 percent of total billed charges "FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES" 48526085_1 CDM 0343 RC A9552 HCPCS inpatient 2675 1738.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2594.75 97 999999999 1619.71 2594.75 percent of total billed charges "FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES" 48526085_1 CDM 0343 RC A9552 HCPCS inpatient 2675 1738.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1845.75 69 999999999 1619.71 2594.75 percent of total billed charges "FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES" 48526085_1 CDM 0343 RC A9552 HCPCS inpatient 2675 1738.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 2086.5 78 999999999 1619.71 2594.75 percent of total billed charges "FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES" 48526085_1 CDM 0343 RC A9552 HCPCS inpatient 2675 1738.75 SIHO - ALL PLANS SIHO - ALL PLANS 2407.5 90 999999999 1619.71 2594.75 percent of total billed charges "FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES" 48526085_1 CDM 0343 RC A9552 HCPCS inpatient 2675 1738.75 UMR - ALL PLANS UMR - ALL PLANS 1872.5 70 999999999 1619.71 2594.75 percent of total billed charges "FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES" 48526085_1 CDM 0343 RC A9552 HCPCS inpatient 2675 1738.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1619.71 60.55 999999999 1619.71 2594.75 percent of total billed charges "FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES" 48526085_1 CDM 0343 RC A9552 HCPCS inpatient 2675 1738.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1619.71 2594.75 "FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES" 48526085_1 CDM 0343 RC A9552 HCPCS inpatient 2675 1738.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1619.71 2594.75 "FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES" 48526085_1 CDM 0343 RC A9552 HCPCS inpatient 2675 1738.75 ANTHEM HMO ANTHEM HMO 999999999 1619.71 2594.75 "FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES" 48526085_1 CDM 0343 RC A9552 HCPCS inpatient 2675 1738.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1808.3 67.6 999999999 1619.71 2594.75 percent of total billed charges "FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES" 48526085_1 CDM 0343 RC A9552 HCPCS inpatient 2675 1738.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1619.71 2594.75 "FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES" 48526085_1 CDM 0343 RC A9552 HCPCS inpatient 2675 1738.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1619.71 2594.75 "GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE" 48526087_1 CDM 0636 RC A9556 HCPCS inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges "GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE" 48526087_1 CDM 0636 RC A9556 HCPCS inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges "GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE" 48526087_1 CDM 0636 RC A9556 HCPCS inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges "GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE" 48526087_1 CDM 0636 RC A9556 HCPCS inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges "GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE" 48526087_1 CDM 0636 RC A9556 HCPCS inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges "GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE" 48526087_1 CDM 0636 RC A9556 HCPCS inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges "GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE" 48526087_1 CDM 0636 RC A9556 HCPCS inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges "GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE" 48526087_1 CDM 0636 RC A9556 HCPCS inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges "GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE" 48526087_1 CDM 0636 RC A9556 HCPCS inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 "GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE" 48526087_1 CDM 0636 RC A9556 HCPCS inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 "GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE" 48526087_1 CDM 0636 RC A9556 HCPCS inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 "GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE" 48526087_1 CDM 0636 RC A9556 HCPCS inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges "GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE" 48526087_1 CDM 0636 RC A9556 HCPCS inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 "GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE" 48526087_1 CDM 0636 RC A9556 HCPCS inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 "XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES" 48526089_1 CDM 0343 RC A9558 HCPCS inpatient 397 258.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 258.05 65 999999999 240.38 385.09 percent of total billed charges "XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES" 48526089_1 CDM 0343 RC A9558 HCPCS inpatient 397 258.05 AETNA AETNA 313.63 79 999999999 240.38 385.09 percent of total billed charges "XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES" 48526089_1 CDM 0343 RC A9558 HCPCS inpatient 397 258.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 385.09 97 999999999 240.38 385.09 percent of total billed charges "XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES" 48526089_1 CDM 0343 RC A9558 HCPCS inpatient 397 258.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 273.93 69 999999999 240.38 385.09 percent of total billed charges "XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES" 48526089_1 CDM 0343 RC A9558 HCPCS inpatient 397 258.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 309.66 78 999999999 240.38 385.09 percent of total billed charges "XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES" 48526089_1 CDM 0343 RC A9558 HCPCS inpatient 397 258.05 SIHO - ALL PLANS SIHO - ALL PLANS 357.3 90 999999999 240.38 385.09 percent of total billed charges "XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES" 48526089_1 CDM 0343 RC A9558 HCPCS inpatient 397 258.05 UMR - ALL PLANS UMR - ALL PLANS 277.9 70 999999999 240.38 385.09 percent of total billed charges "XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES" 48526089_1 CDM 0343 RC A9558 HCPCS inpatient 397 258.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 240.38 60.55 999999999 240.38 385.09 percent of total billed charges "XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES" 48526089_1 CDM 0343 RC A9558 HCPCS inpatient 397 258.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 240.38 385.09 "XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES" 48526089_1 CDM 0343 RC A9558 HCPCS inpatient 397 258.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 240.38 385.09 "XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES" 48526089_1 CDM 0343 RC A9558 HCPCS inpatient 397 258.05 ANTHEM HMO ANTHEM HMO 999999999 240.38 385.09 "XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES" 48526089_1 CDM 0343 RC A9558 HCPCS inpatient 397 258.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 268.37 67.6 999999999 240.38 385.09 percent of total billed charges "XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES" 48526089_1 CDM 0343 RC A9558 HCPCS inpatient 397 258.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 240.38 385.09 "XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES" 48526089_1 CDM 0343 RC A9558 HCPCS inpatient 397 258.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 240.38 385.09 "INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE" 48526091_1 CDM 0343 RC A9570 HCPCS inpatient 7024 4565.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 4565.6 65 999999999 4253.03 6813.28 percent of total billed charges "INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE" 48526091_1 CDM 0343 RC A9570 HCPCS inpatient 7024 4565.6 AETNA AETNA 5548.96 79 999999999 4253.03 6813.28 percent of total billed charges "INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE" 48526091_1 CDM 0343 RC A9570 HCPCS inpatient 7024 4565.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6813.28 97 999999999 4253.03 6813.28 percent of total billed charges "INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE" 48526091_1 CDM 0343 RC A9570 HCPCS inpatient 7024 4565.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 4846.56 69 999999999 4253.03 6813.28 percent of total billed charges "INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE" 48526091_1 CDM 0343 RC A9570 HCPCS inpatient 7024 4565.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 5478.72 78 999999999 4253.03 6813.28 percent of total billed charges "INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE" 48526091_1 CDM 0343 RC A9570 HCPCS inpatient 7024 4565.6 SIHO - ALL PLANS SIHO - ALL PLANS 6321.6 90 999999999 4253.03 6813.28 percent of total billed charges "INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE" 48526091_1 CDM 0343 RC A9570 HCPCS inpatient 7024 4565.6 UMR - ALL PLANS UMR - ALL PLANS 4916.8 70 999999999 4253.03 6813.28 percent of total billed charges "INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE" 48526091_1 CDM 0343 RC A9570 HCPCS inpatient 7024 4565.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4253.03 60.55 999999999 4253.03 6813.28 percent of total billed charges "INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE" 48526091_1 CDM 0343 RC A9570 HCPCS inpatient 7024 4565.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4253.03 6813.28 "INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE" 48526091_1 CDM 0343 RC A9570 HCPCS inpatient 7024 4565.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4253.03 6813.28 "INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE" 48526091_1 CDM 0343 RC A9570 HCPCS inpatient 7024 4565.6 ANTHEM HMO ANTHEM HMO 999999999 4253.03 6813.28 "INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE" 48526091_1 CDM 0343 RC A9570 HCPCS inpatient 7024 4565.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 4748.22 67.6 999999999 4253.03 6813.28 percent of total billed charges "INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE" 48526091_1 CDM 0343 RC A9570 HCPCS inpatient 7024 4565.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4253.03 6813.28 "INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE" 48526091_1 CDM 0343 RC A9570 HCPCS inpatient 7024 4565.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 4253.03 6813.28 "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526093_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526093_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526093_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526093_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526093_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526093_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526093_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526093_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526093_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526093_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526093_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526093_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526093_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526093_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526095_1 CDM 0636 RC A9579 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526095_1 CDM 0636 RC A9579 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526095_1 CDM 0636 RC A9579 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526095_1 CDM 0636 RC A9579 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526095_1 CDM 0636 RC A9579 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526095_1 CDM 0636 RC A9579 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526095_1 CDM 0636 RC A9579 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526095_1 CDM 0636 RC A9579 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526095_1 CDM 0636 RC A9579 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526095_1 CDM 0636 RC A9579 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526095_1 CDM 0636 RC A9579 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526095_1 CDM 0636 RC A9579 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526095_1 CDM 0636 RC A9579 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526095_1 CDM 0636 RC A9579 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526098_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526098_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526098_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526098_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526098_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526098_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526098_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526098_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526098_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526098_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526098_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526098_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526098_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML" 48526098_1 CDM 0636 RC A9579 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "INJECTION, GADOXETATE DISODIUM, 1 ML" 48526100_1 CDM 0255 RC A9581 HCPCS inpatient 84 54.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 54.6 65 999999999 50.86 81.48 percent of total billed charges "INJECTION, GADOXETATE DISODIUM, 1 ML" 48526100_1 CDM 0255 RC A9581 HCPCS inpatient 84 54.6 AETNA AETNA 66.36 79 999999999 50.86 81.48 percent of total billed charges "INJECTION, GADOXETATE DISODIUM, 1 ML" 48526100_1 CDM 0255 RC A9581 HCPCS inpatient 84 54.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 81.48 97 999999999 50.86 81.48 percent of total billed charges "INJECTION, GADOXETATE DISODIUM, 1 ML" 48526100_1 CDM 0255 RC A9581 HCPCS inpatient 84 54.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.96 69 999999999 50.86 81.48 percent of total billed charges "INJECTION, GADOXETATE DISODIUM, 1 ML" 48526100_1 CDM 0255 RC A9581 HCPCS inpatient 84 54.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 65.52 78 999999999 50.86 81.48 percent of total billed charges "INJECTION, GADOXETATE DISODIUM, 1 ML" 48526100_1 CDM 0255 RC A9581 HCPCS inpatient 84 54.6 SIHO - ALL PLANS SIHO - ALL PLANS 75.6 90 999999999 50.86 81.48 percent of total billed charges "INJECTION, GADOXETATE DISODIUM, 1 ML" 48526100_1 CDM 0255 RC A9581 HCPCS inpatient 84 54.6 UMR - ALL PLANS UMR - ALL PLANS 58.8 70 999999999 50.86 81.48 percent of total billed charges "INJECTION, GADOXETATE DISODIUM, 1 ML" 48526100_1 CDM 0255 RC A9581 HCPCS inpatient 84 54.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.86 60.55 999999999 50.86 81.48 percent of total billed charges "INJECTION, GADOXETATE DISODIUM, 1 ML" 48526100_1 CDM 0255 RC A9581 HCPCS inpatient 84 54.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.86 81.48 "INJECTION, GADOXETATE DISODIUM, 1 ML" 48526100_1 CDM 0255 RC A9581 HCPCS inpatient 84 54.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.86 81.48 "INJECTION, GADOXETATE DISODIUM, 1 ML" 48526100_1 CDM 0255 RC A9581 HCPCS inpatient 84 54.6 ANTHEM HMO ANTHEM HMO 999999999 50.86 81.48 "INJECTION, GADOXETATE DISODIUM, 1 ML" 48526100_1 CDM 0255 RC A9581 HCPCS inpatient 84 54.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.78 67.6 999999999 50.86 81.48 percent of total billed charges "INJECTION, GADOXETATE DISODIUM, 1 ML" 48526100_1 CDM 0255 RC A9581 HCPCS inpatient 84 54.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.86 81.48 "INJECTION, GADOXETATE DISODIUM, 1 ML" 48526100_1 CDM 0255 RC A9581 HCPCS inpatient 84 54.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.86 81.48 "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 48526102_1 CDM 0636 RC J1030 HCPCS inpatient 59 38.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 38.35 65 999999999 35.72 57.23 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 48526102_1 CDM 0636 RC J1030 HCPCS inpatient 59 38.35 AETNA AETNA 46.61 79 999999999 35.72 57.23 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 48526102_1 CDM 0636 RC J1030 HCPCS inpatient 59 38.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 57.23 97 999999999 35.72 57.23 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 48526102_1 CDM 0636 RC J1030 HCPCS inpatient 59 38.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.71 69 999999999 35.72 57.23 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 48526102_1 CDM 0636 RC J1030 HCPCS inpatient 59 38.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.02 78 999999999 35.72 57.23 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 48526102_1 CDM 0636 RC J1030 HCPCS inpatient 59 38.35 SIHO - ALL PLANS SIHO - ALL PLANS 53.1 90 999999999 35.72 57.23 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 48526102_1 CDM 0636 RC J1030 HCPCS inpatient 59 38.35 UMR - ALL PLANS UMR - ALL PLANS 41.3 70 999999999 35.72 57.23 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 48526102_1 CDM 0636 RC J1030 HCPCS inpatient 59 38.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.72 60.55 999999999 35.72 57.23 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 48526102_1 CDM 0636 RC J1030 HCPCS inpatient 59 38.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.72 57.23 "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 48526102_1 CDM 0636 RC J1030 HCPCS inpatient 59 38.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.72 57.23 "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 48526102_1 CDM 0636 RC J1030 HCPCS inpatient 59 38.35 ANTHEM HMO ANTHEM HMO 999999999 35.72 57.23 "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 48526102_1 CDM 0636 RC J1030 HCPCS inpatient 59 38.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.88 67.6 999999999 35.72 57.23 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 48526102_1 CDM 0636 RC J1030 HCPCS inpatient 59 38.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.72 57.23 "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 48526102_1 CDM 0636 RC J1030 HCPCS inpatient 59 38.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.72 57.23 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48526104_1 CDM 0636 RC J1610 HCPCS inpatient 201 130.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 130.65 65 999999999 121.71 194.97 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48526104_1 CDM 0636 RC J1610 HCPCS inpatient 201 130.65 AETNA AETNA 158.79 79 999999999 121.71 194.97 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48526104_1 CDM 0636 RC J1610 HCPCS inpatient 201 130.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 194.97 97 999999999 121.71 194.97 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48526104_1 CDM 0636 RC J1610 HCPCS inpatient 201 130.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 138.69 69 999999999 121.71 194.97 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48526104_1 CDM 0636 RC J1610 HCPCS inpatient 201 130.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 156.78 78 999999999 121.71 194.97 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48526104_1 CDM 0636 RC J1610 HCPCS inpatient 201 130.65 SIHO - ALL PLANS SIHO - ALL PLANS 180.9 90 999999999 121.71 194.97 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48526104_1 CDM 0636 RC J1610 HCPCS inpatient 201 130.65 UMR - ALL PLANS UMR - ALL PLANS 140.7 70 999999999 121.71 194.97 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48526104_1 CDM 0636 RC J1610 HCPCS inpatient 201 130.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 121.71 60.55 999999999 121.71 194.97 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48526104_1 CDM 0636 RC J1610 HCPCS inpatient 201 130.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 121.71 194.97 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48526104_1 CDM 0636 RC J1610 HCPCS inpatient 201 130.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 121.71 194.97 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48526104_1 CDM 0636 RC J1610 HCPCS inpatient 201 130.65 ANTHEM HMO ANTHEM HMO 999999999 121.71 194.97 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48526104_1 CDM 0636 RC J1610 HCPCS inpatient 201 130.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 135.88 67.6 999999999 121.71 194.97 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48526104_1 CDM 0636 RC J1610 HCPCS inpatient 201 130.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 121.71 194.97 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48526104_1 CDM 0636 RC J1610 HCPCS inpatient 201 130.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 121.71 194.97 "INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS" 48526106_1 CDM 0636 RC J1642 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges "INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS" 48526106_1 CDM 0636 RC J1642 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges "INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS" 48526106_1 CDM 0636 RC J1642 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges "INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS" 48526106_1 CDM 0636 RC J1642 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges "INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS" 48526106_1 CDM 0636 RC J1642 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges "INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS" 48526106_1 CDM 0636 RC J1642 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges "INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS" 48526106_1 CDM 0636 RC J1642 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges "INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS" 48526106_1 CDM 0636 RC J1642 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges "INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS" 48526106_1 CDM 0636 RC J1642 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 "INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS" 48526106_1 CDM 0636 RC J1642 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 "INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS" 48526106_1 CDM 0636 RC J1642 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 "INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS" 48526106_1 CDM 0636 RC J1642 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges "INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS" 48526106_1 CDM 0636 RC J1642 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 "INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS" 48526106_1 CDM 0636 RC J1642 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 "INJECTION, FUROSEMIDE, UP TO 20 MG" 48526108_1 CDM 0636 RC J1940 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges "INJECTION, FUROSEMIDE, UP TO 20 MG" 48526108_1 CDM 0636 RC J1940 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges "INJECTION, FUROSEMIDE, UP TO 20 MG" 48526108_1 CDM 0636 RC J1940 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges "INJECTION, FUROSEMIDE, UP TO 20 MG" 48526108_1 CDM 0636 RC J1940 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges "INJECTION, FUROSEMIDE, UP TO 20 MG" 48526108_1 CDM 0636 RC J1940 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges "INJECTION, FUROSEMIDE, UP TO 20 MG" 48526108_1 CDM 0636 RC J1940 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges "INJECTION, FUROSEMIDE, UP TO 20 MG" 48526108_1 CDM 0636 RC J1940 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges "INJECTION, FUROSEMIDE, UP TO 20 MG" 48526108_1 CDM 0636 RC J1940 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges "INJECTION, FUROSEMIDE, UP TO 20 MG" 48526108_1 CDM 0636 RC J1940 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 "INJECTION, FUROSEMIDE, UP TO 20 MG" 48526108_1 CDM 0636 RC J1940 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 "INJECTION, FUROSEMIDE, UP TO 20 MG" 48526108_1 CDM 0636 RC J1940 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 "INJECTION, FUROSEMIDE, UP TO 20 MG" 48526108_1 CDM 0636 RC J1940 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges "INJECTION, FUROSEMIDE, UP TO 20 MG" 48526108_1 CDM 0636 RC J1940 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 "INJECTION, FUROSEMIDE, UP TO 20 MG" 48526108_1 CDM 0636 RC J1940 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 "HIGH OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE CONCENTRATION, PER ML" 48526111_1 CDM 0636 RC Q9958 HCPCS inpatient 11 7.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.15 65 999999999 6.66 10.67 percent of total billed charges "HIGH OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE CONCENTRATION, PER ML" 48526111_1 CDM 0636 RC Q9958 HCPCS inpatient 11 7.15 AETNA AETNA 8.69 79 999999999 6.66 10.67 percent of total billed charges "HIGH OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE CONCENTRATION, PER ML" 48526111_1 CDM 0636 RC Q9958 HCPCS inpatient 11 7.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10.67 97 999999999 6.66 10.67 percent of total billed charges "HIGH OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE CONCENTRATION, PER ML" 48526111_1 CDM 0636 RC Q9958 HCPCS inpatient 11 7.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.59 69 999999999 6.66 10.67 percent of total billed charges "HIGH OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE CONCENTRATION, PER ML" 48526111_1 CDM 0636 RC Q9958 HCPCS inpatient 11 7.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 8.58 78 999999999 6.66 10.67 percent of total billed charges "HIGH OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE CONCENTRATION, PER ML" 48526111_1 CDM 0636 RC Q9958 HCPCS inpatient 11 7.15 SIHO - ALL PLANS SIHO - ALL PLANS 9.9 90 999999999 6.66 10.67 percent of total billed charges "HIGH OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE CONCENTRATION, PER ML" 48526111_1 CDM 0636 RC Q9958 HCPCS inpatient 11 7.15 UMR - ALL PLANS UMR - ALL PLANS 7.7 70 999999999 6.66 10.67 percent of total billed charges "HIGH OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE CONCENTRATION, PER ML" 48526111_1 CDM 0636 RC Q9958 HCPCS inpatient 11 7.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.66 60.55 999999999 6.66 10.67 percent of total billed charges "HIGH OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE CONCENTRATION, PER ML" 48526111_1 CDM 0636 RC Q9958 HCPCS inpatient 11 7.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.66 10.67 "HIGH OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE CONCENTRATION, PER ML" 48526111_1 CDM 0636 RC Q9958 HCPCS inpatient 11 7.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.66 10.67 "HIGH OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE CONCENTRATION, PER ML" 48526111_1 CDM 0636 RC Q9958 HCPCS inpatient 11 7.15 ANTHEM HMO ANTHEM HMO 999999999 6.66 10.67 "HIGH OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE CONCENTRATION, PER ML" 48526111_1 CDM 0636 RC Q9958 HCPCS inpatient 11 7.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 7.44 67.6 999999999 6.66 10.67 percent of total billed charges "HIGH OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE CONCENTRATION, PER ML" 48526111_1 CDM 0636 RC Q9958 HCPCS inpatient 11 7.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.66 10.67 "HIGH OSMOLAR CONTRAST MATERIAL, UP TO 149 MG/ML IODINE CONCENTRATION, PER ML" 48526111_1 CDM 0636 RC Q9958 HCPCS inpatient 11 7.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.66 10.67 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526116_1 CDM 0636 RC Q9967 HCPCS inpatient 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526116_1 CDM 0636 RC Q9967 HCPCS inpatient 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526116_1 CDM 0636 RC Q9967 HCPCS inpatient 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526116_1 CDM 0636 RC Q9967 HCPCS inpatient 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526116_1 CDM 0636 RC Q9967 HCPCS inpatient 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526116_1 CDM 0636 RC Q9967 HCPCS inpatient 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526116_1 CDM 0636 RC Q9967 HCPCS inpatient 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526116_1 CDM 0636 RC Q9967 HCPCS inpatient 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526116_1 CDM 0636 RC Q9967 HCPCS inpatient 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526116_1 CDM 0636 RC Q9967 HCPCS inpatient 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526116_1 CDM 0636 RC Q9967 HCPCS inpatient 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526116_1 CDM 0636 RC Q9967 HCPCS inpatient 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526116_1 CDM 0636 RC Q9967 HCPCS inpatient 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526116_1 CDM 0636 RC Q9967 HCPCS inpatient 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526121_1 CDM 0636 RC Q9967 HCPCS inpatient 17 11.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.05 65 999999999 10.29 16.49 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526121_1 CDM 0636 RC Q9967 HCPCS inpatient 17 11.05 AETNA AETNA 13.43 79 999999999 10.29 16.49 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526121_1 CDM 0636 RC Q9967 HCPCS inpatient 17 11.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16.49 97 999999999 10.29 16.49 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526121_1 CDM 0636 RC Q9967 HCPCS inpatient 17 11.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.73 69 999999999 10.29 16.49 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526121_1 CDM 0636 RC Q9967 HCPCS inpatient 17 11.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.26 78 999999999 10.29 16.49 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526121_1 CDM 0636 RC Q9967 HCPCS inpatient 17 11.05 SIHO - ALL PLANS SIHO - ALL PLANS 15.3 90 999999999 10.29 16.49 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526121_1 CDM 0636 RC Q9967 HCPCS inpatient 17 11.05 UMR - ALL PLANS UMR - ALL PLANS 11.9 70 999999999 10.29 16.49 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526121_1 CDM 0636 RC Q9967 HCPCS inpatient 17 11.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.29 60.55 999999999 10.29 16.49 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526121_1 CDM 0636 RC Q9967 HCPCS inpatient 17 11.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.29 16.49 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526121_1 CDM 0636 RC Q9967 HCPCS inpatient 17 11.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.29 16.49 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526121_1 CDM 0636 RC Q9967 HCPCS inpatient 17 11.05 ANTHEM HMO ANTHEM HMO 999999999 10.29 16.49 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526121_1 CDM 0636 RC Q9967 HCPCS inpatient 17 11.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.49 67.6 999999999 10.29 16.49 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526121_1 CDM 0636 RC Q9967 HCPCS inpatient 17 11.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.29 16.49 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526121_1 CDM 0636 RC Q9967 HCPCS inpatient 17 11.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.29 16.49 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526125_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.75 65 999999999 9.08 14.55 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526125_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 AETNA AETNA 11.85 79 999999999 9.08 14.55 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526125_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14.55 97 999999999 9.08 14.55 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526125_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.35 69 999999999 9.08 14.55 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526125_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.7 78 999999999 9.08 14.55 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526125_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 SIHO - ALL PLANS SIHO - ALL PLANS 13.5 90 999999999 9.08 14.55 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526125_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 UMR - ALL PLANS UMR - ALL PLANS 10.5 70 999999999 9.08 14.55 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526125_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.08 60.55 999999999 9.08 14.55 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526125_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.08 14.55 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526125_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.08 14.55 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526125_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 ANTHEM HMO ANTHEM HMO 999999999 9.08 14.55 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526125_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.14 67.6 999999999 9.08 14.55 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526125_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.08 14.55 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526125_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.08 14.55 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526130_1 CDM 0636 RC Q9967 HCPCS inpatient 18 11.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.7 65 999999999 10.9 17.46 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526130_1 CDM 0636 RC Q9967 HCPCS inpatient 18 11.7 AETNA AETNA 14.22 79 999999999 10.9 17.46 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526130_1 CDM 0636 RC Q9967 HCPCS inpatient 18 11.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.46 97 999999999 10.9 17.46 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526130_1 CDM 0636 RC Q9967 HCPCS inpatient 18 11.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.42 69 999999999 10.9 17.46 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526130_1 CDM 0636 RC Q9967 HCPCS inpatient 18 11.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.04 78 999999999 10.9 17.46 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526130_1 CDM 0636 RC Q9967 HCPCS inpatient 18 11.7 SIHO - ALL PLANS SIHO - ALL PLANS 16.2 90 999999999 10.9 17.46 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526130_1 CDM 0636 RC Q9967 HCPCS inpatient 18 11.7 UMR - ALL PLANS UMR - ALL PLANS 12.6 70 999999999 10.9 17.46 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526130_1 CDM 0636 RC Q9967 HCPCS inpatient 18 11.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.9 60.55 999999999 10.9 17.46 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526130_1 CDM 0636 RC Q9967 HCPCS inpatient 18 11.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.9 17.46 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526130_1 CDM 0636 RC Q9967 HCPCS inpatient 18 11.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.9 17.46 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526130_1 CDM 0636 RC Q9967 HCPCS inpatient 18 11.7 ANTHEM HMO ANTHEM HMO 999999999 10.9 17.46 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526130_1 CDM 0636 RC Q9967 HCPCS inpatient 18 11.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.17 67.6 999999999 10.9 17.46 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526130_1 CDM 0636 RC Q9967 HCPCS inpatient 18 11.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.9 17.46 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526130_1 CDM 0636 RC Q9967 HCPCS inpatient 18 11.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.9 17.46 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526134_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.75 65 999999999 9.08 14.55 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526134_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 AETNA AETNA 11.85 79 999999999 9.08 14.55 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526134_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14.55 97 999999999 9.08 14.55 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526134_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.35 69 999999999 9.08 14.55 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526134_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.7 78 999999999 9.08 14.55 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526134_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 SIHO - ALL PLANS SIHO - ALL PLANS 13.5 90 999999999 9.08 14.55 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526134_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 UMR - ALL PLANS UMR - ALL PLANS 10.5 70 999999999 9.08 14.55 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526134_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.08 60.55 999999999 9.08 14.55 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526134_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.08 14.55 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526134_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.08 14.55 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526134_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 ANTHEM HMO ANTHEM HMO 999999999 9.08 14.55 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526134_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.14 67.6 999999999 9.08 14.55 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526134_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.08 14.55 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526134_1 CDM 0636 RC Q9967 HCPCS inpatient 15 9.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.08 14.55 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526140_1 CDM 0255 RC Q9967 HCPCS inpatient 14 9.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.1 65 999999999 8.48 13.58 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526140_1 CDM 0255 RC Q9967 HCPCS inpatient 14 9.1 AETNA AETNA 11.06 79 999999999 8.48 13.58 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526140_1 CDM 0255 RC Q9967 HCPCS inpatient 14 9.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13.58 97 999999999 8.48 13.58 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526140_1 CDM 0255 RC Q9967 HCPCS inpatient 14 9.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.66 69 999999999 8.48 13.58 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526140_1 CDM 0255 RC Q9967 HCPCS inpatient 14 9.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.92 78 999999999 8.48 13.58 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526140_1 CDM 0255 RC Q9967 HCPCS inpatient 14 9.1 SIHO - ALL PLANS SIHO - ALL PLANS 12.6 90 999999999 8.48 13.58 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526140_1 CDM 0255 RC Q9967 HCPCS inpatient 14 9.1 UMR - ALL PLANS UMR - ALL PLANS 9.8 70 999999999 8.48 13.58 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526140_1 CDM 0255 RC Q9967 HCPCS inpatient 14 9.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.48 60.55 999999999 8.48 13.58 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526140_1 CDM 0255 RC Q9967 HCPCS inpatient 14 9.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.48 13.58 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526140_1 CDM 0255 RC Q9967 HCPCS inpatient 14 9.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.48 13.58 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526140_1 CDM 0255 RC Q9967 HCPCS inpatient 14 9.1 ANTHEM HMO ANTHEM HMO 999999999 8.48 13.58 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526140_1 CDM 0255 RC Q9967 HCPCS inpatient 14 9.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.46 67.6 999999999 8.48 13.58 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526140_1 CDM 0255 RC Q9967 HCPCS inpatient 14 9.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.48 13.58 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48526140_1 CDM 0255 RC Q9967 HCPCS inpatient 14 9.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.48 13.58 JOH 1% LIDOCAINE 20ML NOT BUFF 48526148_1 CDM 0255 RC inpatient 49 31.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.85 65 999999999 29.67 47.53 percent of total billed charges JOH 1% LIDOCAINE 20ML NOT BUFF 48526148_1 CDM 0255 RC inpatient 49 31.85 AETNA AETNA 38.71 79 999999999 29.67 47.53 percent of total billed charges JOH 1% LIDOCAINE 20ML NOT BUFF 48526148_1 CDM 0255 RC inpatient 49 31.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 47.53 97 999999999 29.67 47.53 percent of total billed charges JOH 1% LIDOCAINE 20ML NOT BUFF 48526148_1 CDM 0255 RC inpatient 49 31.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.81 69 999999999 29.67 47.53 percent of total billed charges JOH 1% LIDOCAINE 20ML NOT BUFF 48526148_1 CDM 0255 RC inpatient 49 31.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 38.22 78 999999999 29.67 47.53 percent of total billed charges JOH 1% LIDOCAINE 20ML NOT BUFF 48526148_1 CDM 0255 RC inpatient 49 31.85 SIHO - ALL PLANS SIHO - ALL PLANS 44.1 90 999999999 29.67 47.53 percent of total billed charges JOH 1% LIDOCAINE 20ML NOT BUFF 48526148_1 CDM 0255 RC inpatient 49 31.85 UMR - ALL PLANS UMR - ALL PLANS 34.3 70 999999999 29.67 47.53 percent of total billed charges JOH 1% LIDOCAINE 20ML NOT BUFF 48526148_1 CDM 0255 RC inpatient 49 31.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.67 60.55 999999999 29.67 47.53 percent of total billed charges JOH 1% LIDOCAINE 20ML NOT BUFF 48526148_1 CDM 0255 RC inpatient 49 31.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.67 47.53 JOH 1% LIDOCAINE 20ML NOT BUFF 48526148_1 CDM 0255 RC inpatient 49 31.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.67 47.53 JOH 1% LIDOCAINE 20ML NOT BUFF 48526148_1 CDM 0255 RC inpatient 49 31.85 ANTHEM HMO ANTHEM HMO 999999999 29.67 47.53 JOH 1% LIDOCAINE 20ML NOT BUFF 48526148_1 CDM 0255 RC inpatient 49 31.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.12 67.6 999999999 29.67 47.53 percent of total billed charges JOH 1% LIDOCAINE 20ML NOT BUFF 48526148_1 CDM 0255 RC inpatient 49 31.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.67 47.53 JOH 1% LIDOCAINE 20ML NOT BUFF 48526148_1 CDM 0255 RC inpatient 49 31.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.67 47.53 JOH TECH 99M LAB RBC PER MCI 48526241_1 CDM 0255 RC inpatient 861 559.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 559.65 65 999999999 521.34 835.17 percent of total billed charges JOH TECH 99M LAB RBC PER MCI 48526241_1 CDM 0255 RC inpatient 861 559.65 AETNA AETNA 680.19 79 999999999 521.34 835.17 percent of total billed charges JOH TECH 99M LAB RBC PER MCI 48526241_1 CDM 0255 RC inpatient 861 559.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 835.17 97 999999999 521.34 835.17 percent of total billed charges JOH TECH 99M LAB RBC PER MCI 48526241_1 CDM 0255 RC inpatient 861 559.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 594.09 69 999999999 521.34 835.17 percent of total billed charges JOH TECH 99M LAB RBC PER MCI 48526241_1 CDM 0255 RC inpatient 861 559.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 671.58 78 999999999 521.34 835.17 percent of total billed charges JOH TECH 99M LAB RBC PER MCI 48526241_1 CDM 0255 RC inpatient 861 559.65 SIHO - ALL PLANS SIHO - ALL PLANS 774.9 90 999999999 521.34 835.17 percent of total billed charges JOH TECH 99M LAB RBC PER MCI 48526241_1 CDM 0255 RC inpatient 861 559.65 UMR - ALL PLANS UMR - ALL PLANS 602.7 70 999999999 521.34 835.17 percent of total billed charges JOH TECH 99M LAB RBC PER MCI 48526241_1 CDM 0255 RC inpatient 861 559.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 521.34 60.55 999999999 521.34 835.17 percent of total billed charges JOH TECH 99M LAB RBC PER MCI 48526241_1 CDM 0255 RC inpatient 861 559.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 521.34 835.17 JOH TECH 99M LAB RBC PER MCI 48526241_1 CDM 0255 RC inpatient 861 559.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 521.34 835.17 JOH TECH 99M LAB RBC PER MCI 48526241_1 CDM 0255 RC inpatient 861 559.65 ANTHEM HMO ANTHEM HMO 999999999 521.34 835.17 JOH TECH 99M LAB RBC PER MCI 48526241_1 CDM 0255 RC inpatient 861 559.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 582.04 67.6 999999999 521.34 835.17 percent of total billed charges JOH TECH 99M LAB RBC PER MCI 48526241_1 CDM 0255 RC inpatient 861 559.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 521.34 835.17 JOH TECH 99M LAB RBC PER MCI 48526241_1 CDM 0255 RC inpatient 861 559.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 521.34 835.17 "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526246_1 CDM 0636 RC A9562 HCPCS inpatient 1231 800.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 800.15 65 999999999 745.37 1194.07 percent of total billed charges "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526246_1 CDM 0636 RC A9562 HCPCS inpatient 1231 800.15 AETNA AETNA 972.49 79 999999999 745.37 1194.07 percent of total billed charges "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526246_1 CDM 0636 RC A9562 HCPCS inpatient 1231 800.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1194.07 97 999999999 745.37 1194.07 percent of total billed charges "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526246_1 CDM 0636 RC A9562 HCPCS inpatient 1231 800.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 849.39 69 999999999 745.37 1194.07 percent of total billed charges "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526246_1 CDM 0636 RC A9562 HCPCS inpatient 1231 800.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 960.18 78 999999999 745.37 1194.07 percent of total billed charges "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526246_1 CDM 0636 RC A9562 HCPCS inpatient 1231 800.15 SIHO - ALL PLANS SIHO - ALL PLANS 1107.9 90 999999999 745.37 1194.07 percent of total billed charges "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526246_1 CDM 0636 RC A9562 HCPCS inpatient 1231 800.15 UMR - ALL PLANS UMR - ALL PLANS 861.7 70 999999999 745.37 1194.07 percent of total billed charges "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526246_1 CDM 0636 RC A9562 HCPCS inpatient 1231 800.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 745.37 60.55 999999999 745.37 1194.07 percent of total billed charges "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526246_1 CDM 0636 RC A9562 HCPCS inpatient 1231 800.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 745.37 1194.07 "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526246_1 CDM 0636 RC A9562 HCPCS inpatient 1231 800.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 745.37 1194.07 "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526246_1 CDM 0636 RC A9562 HCPCS inpatient 1231 800.15 ANTHEM HMO ANTHEM HMO 999999999 745.37 1194.07 "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526246_1 CDM 0636 RC A9562 HCPCS inpatient 1231 800.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 832.16 67.6 999999999 745.37 1194.07 percent of total billed charges "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526246_1 CDM 0636 RC A9562 HCPCS inpatient 1231 800.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 745.37 1194.07 "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 48526246_1 CDM 0636 RC A9562 HCPCS inpatient 1231 800.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 745.37 1194.07 RADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAY 48526251_1 CDM 0341 RC C9898 HCPCS inpatient 8 5.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.2 65 999999999 4.84 7.76 percent of total billed charges RADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAY 48526251_1 CDM 0341 RC C9898 HCPCS inpatient 8 5.2 AETNA AETNA 6.32 79 999999999 4.84 7.76 percent of total billed charges RADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAY 48526251_1 CDM 0341 RC C9898 HCPCS inpatient 8 5.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7.76 97 999999999 4.84 7.76 percent of total billed charges RADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAY 48526251_1 CDM 0341 RC C9898 HCPCS inpatient 8 5.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.52 69 999999999 4.84 7.76 percent of total billed charges RADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAY 48526251_1 CDM 0341 RC C9898 HCPCS inpatient 8 5.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.24 78 999999999 4.84 7.76 percent of total billed charges RADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAY 48526251_1 CDM 0341 RC C9898 HCPCS inpatient 8 5.2 SIHO - ALL PLANS SIHO - ALL PLANS 7.2 90 999999999 4.84 7.76 percent of total billed charges RADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAY 48526251_1 CDM 0341 RC C9898 HCPCS inpatient 8 5.2 UMR - ALL PLANS UMR - ALL PLANS 5.6 70 999999999 4.84 7.76 percent of total billed charges RADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAY 48526251_1 CDM 0341 RC C9898 HCPCS inpatient 8 5.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.84 60.55 999999999 4.84 7.76 percent of total billed charges RADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAY 48526251_1 CDM 0341 RC C9898 HCPCS inpatient 8 5.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.84 7.76 RADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAY 48526251_1 CDM 0341 RC C9898 HCPCS inpatient 8 5.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.84 7.76 RADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAY 48526251_1 CDM 0341 RC C9898 HCPCS inpatient 8 5.2 ANTHEM HMO ANTHEM HMO 999999999 4.84 7.76 RADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAY 48526251_1 CDM 0341 RC C9898 HCPCS inpatient 8 5.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.41 67.6 999999999 4.84 7.76 percent of total billed charges RADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAY 48526251_1 CDM 0341 RC C9898 HCPCS inpatient 8 5.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.84 7.76 RADIOLABELED PRODUCT PROVIDED DURING A HOSPITAL INPATIENT STAY 48526251_1 CDM 0341 RC C9898 HCPCS inpatient 8 5.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.84 7.76 Ultrasound scan of abdominal aorta 48526257_1 CDM 0921 RC 76706 HCPCS inpatient 926 601.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 601.9 65 999999999 560.69 898.22 percent of total billed charges Ultrasound scan of abdominal aorta 48526257_1 CDM 0921 RC 76706 HCPCS inpatient 926 601.9 AETNA AETNA 731.54 79 999999999 560.69 898.22 percent of total billed charges Ultrasound scan of abdominal aorta 48526257_1 CDM 0921 RC 76706 HCPCS inpatient 926 601.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 898.22 97 999999999 560.69 898.22 percent of total billed charges Ultrasound scan of abdominal aorta 48526257_1 CDM 0921 RC 76706 HCPCS inpatient 926 601.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 638.94 69 999999999 560.69 898.22 percent of total billed charges Ultrasound scan of abdominal aorta 48526257_1 CDM 0921 RC 76706 HCPCS inpatient 926 601.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 722.28 78 999999999 560.69 898.22 percent of total billed charges Ultrasound scan of abdominal aorta 48526257_1 CDM 0921 RC 76706 HCPCS inpatient 926 601.9 SIHO - ALL PLANS SIHO - ALL PLANS 833.4 90 999999999 560.69 898.22 percent of total billed charges Ultrasound scan of abdominal aorta 48526257_1 CDM 0921 RC 76706 HCPCS inpatient 926 601.9 UMR - ALL PLANS UMR - ALL PLANS 648.2 70 999999999 560.69 898.22 percent of total billed charges Ultrasound scan of abdominal aorta 48526257_1 CDM 0921 RC 76706 HCPCS inpatient 926 601.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 560.69 60.55 999999999 560.69 898.22 percent of total billed charges Ultrasound scan of abdominal aorta 48526257_1 CDM 0921 RC 76706 HCPCS inpatient 926 601.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 560.69 898.22 Ultrasound scan of abdominal aorta 48526257_1 CDM 0921 RC 76706 HCPCS inpatient 926 601.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 560.69 898.22 Ultrasound scan of abdominal aorta 48526257_1 CDM 0921 RC 76706 HCPCS inpatient 926 601.9 ANTHEM HMO ANTHEM HMO 999999999 560.69 898.22 Ultrasound scan of abdominal aorta 48526257_1 CDM 0921 RC 76706 HCPCS inpatient 926 601.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 625.98 67.6 999999999 560.69 898.22 percent of total billed charges Ultrasound scan of abdominal aorta 48526257_1 CDM 0921 RC 76706 HCPCS inpatient 926 601.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 560.69 898.22 Ultrasound scan of abdominal aorta 48526257_1 CDM 0921 RC 76706 HCPCS inpatient 926 601.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 560.69 898.22 "TC-99M FROM NON-HIGHLY ENRICHED URANIUM SOURCE, FULL COST RECOVERY ADD-ON, PER STUDY DOSE" 48526261_1 CDM 0343 RC Q9969 HCPCS inpatient 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges "TC-99M FROM NON-HIGHLY ENRICHED URANIUM SOURCE, FULL COST RECOVERY ADD-ON, PER STUDY DOSE" 48526261_1 CDM 0343 RC Q9969 HCPCS inpatient 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges "TC-99M FROM NON-HIGHLY ENRICHED URANIUM SOURCE, FULL COST RECOVERY ADD-ON, PER STUDY DOSE" 48526261_1 CDM 0343 RC Q9969 HCPCS inpatient 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges "TC-99M FROM NON-HIGHLY ENRICHED URANIUM SOURCE, FULL COST RECOVERY ADD-ON, PER STUDY DOSE" 48526261_1 CDM 0343 RC Q9969 HCPCS inpatient 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges "TC-99M FROM NON-HIGHLY ENRICHED URANIUM SOURCE, FULL COST RECOVERY ADD-ON, PER STUDY DOSE" 48526261_1 CDM 0343 RC Q9969 HCPCS inpatient 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges "TC-99M FROM NON-HIGHLY ENRICHED URANIUM SOURCE, FULL COST RECOVERY ADD-ON, PER STUDY DOSE" 48526261_1 CDM 0343 RC Q9969 HCPCS inpatient 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges "TC-99M FROM NON-HIGHLY ENRICHED URANIUM SOURCE, FULL COST RECOVERY ADD-ON, PER STUDY DOSE" 48526261_1 CDM 0343 RC Q9969 HCPCS inpatient 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges "TC-99M FROM NON-HIGHLY ENRICHED URANIUM SOURCE, FULL COST RECOVERY ADD-ON, PER STUDY DOSE" 48526261_1 CDM 0343 RC Q9969 HCPCS inpatient 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges "TC-99M FROM NON-HIGHLY ENRICHED URANIUM SOURCE, FULL COST RECOVERY ADD-ON, PER STUDY DOSE" 48526261_1 CDM 0343 RC Q9969 HCPCS inpatient 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 "TC-99M FROM NON-HIGHLY ENRICHED URANIUM SOURCE, FULL COST RECOVERY ADD-ON, PER STUDY DOSE" 48526261_1 CDM 0343 RC Q9969 HCPCS inpatient 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 "TC-99M FROM NON-HIGHLY ENRICHED URANIUM SOURCE, FULL COST RECOVERY ADD-ON, PER STUDY DOSE" 48526261_1 CDM 0343 RC Q9969 HCPCS inpatient 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 "TC-99M FROM NON-HIGHLY ENRICHED URANIUM SOURCE, FULL COST RECOVERY ADD-ON, PER STUDY DOSE" 48526261_1 CDM 0343 RC Q9969 HCPCS inpatient 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges "TC-99M FROM NON-HIGHLY ENRICHED URANIUM SOURCE, FULL COST RECOVERY ADD-ON, PER STUDY DOSE" 48526261_1 CDM 0343 RC Q9969 HCPCS inpatient 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 "TC-99M FROM NON-HIGHLY ENRICHED URANIUM SOURCE, FULL COST RECOVERY ADD-ON, PER STUDY DOSE" 48526261_1 CDM 0343 RC Q9969 HCPCS inpatient 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 JOH 1% LIDOCAINE W/ EPI 2OML Per Bottle 48526269_1 CDM 0255 RC inpatient 66 42.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.9 65 999999999 39.96 64.02 percent of total billed charges JOH 1% LIDOCAINE W/ EPI 2OML Per Bottle 48526269_1 CDM 0255 RC inpatient 66 42.9 AETNA AETNA 52.14 79 999999999 39.96 64.02 percent of total billed charges JOH 1% LIDOCAINE W/ EPI 2OML Per Bottle 48526269_1 CDM 0255 RC inpatient 66 42.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.02 97 999999999 39.96 64.02 percent of total billed charges JOH 1% LIDOCAINE W/ EPI 2OML Per Bottle 48526269_1 CDM 0255 RC inpatient 66 42.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.54 69 999999999 39.96 64.02 percent of total billed charges JOH 1% LIDOCAINE W/ EPI 2OML Per Bottle 48526269_1 CDM 0255 RC inpatient 66 42.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.48 78 999999999 39.96 64.02 percent of total billed charges JOH 1% LIDOCAINE W/ EPI 2OML Per Bottle 48526269_1 CDM 0255 RC inpatient 66 42.9 SIHO - ALL PLANS SIHO - ALL PLANS 59.4 90 999999999 39.96 64.02 percent of total billed charges JOH 1% LIDOCAINE W/ EPI 2OML Per Bottle 48526269_1 CDM 0255 RC inpatient 66 42.9 UMR - ALL PLANS UMR - ALL PLANS 46.2 70 999999999 39.96 64.02 percent of total billed charges JOH 1% LIDOCAINE W/ EPI 2OML Per Bottle 48526269_1 CDM 0255 RC inpatient 66 42.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.96 60.55 999999999 39.96 64.02 percent of total billed charges JOH 1% LIDOCAINE W/ EPI 2OML Per Bottle 48526269_1 CDM 0255 RC inpatient 66 42.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.96 64.02 JOH 1% LIDOCAINE W/ EPI 2OML Per Bottle 48526269_1 CDM 0255 RC inpatient 66 42.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.96 64.02 JOH 1% LIDOCAINE W/ EPI 2OML Per Bottle 48526269_1 CDM 0255 RC inpatient 66 42.9 ANTHEM HMO ANTHEM HMO 999999999 39.96 64.02 JOH 1% LIDOCAINE W/ EPI 2OML Per Bottle 48526269_1 CDM 0255 RC inpatient 66 42.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.62 67.6 999999999 39.96 64.02 percent of total billed charges JOH 1% LIDOCAINE W/ EPI 2OML Per Bottle 48526269_1 CDM 0255 RC inpatient 66 42.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.96 64.02 JOH 1% LIDOCAINE W/ EPI 2OML Per Bottle 48526269_1 CDM 0255 RC inpatient 66 42.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.96 64.02 JOH 2% LIDOCAINE WITH EPI 20ML 48526272_1 CDM 0255 RC inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges JOH 2% LIDOCAINE WITH EPI 20ML 48526272_1 CDM 0255 RC inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges JOH 2% LIDOCAINE WITH EPI 20ML 48526272_1 CDM 0255 RC inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges JOH 2% LIDOCAINE WITH EPI 20ML 48526272_1 CDM 0255 RC inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges JOH 2% LIDOCAINE WITH EPI 20ML 48526272_1 CDM 0255 RC inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges JOH 2% LIDOCAINE WITH EPI 20ML 48526272_1 CDM 0255 RC inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges JOH 2% LIDOCAINE WITH EPI 20ML 48526272_1 CDM 0255 RC inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges JOH 2% LIDOCAINE WITH EPI 20ML 48526272_1 CDM 0255 RC inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges JOH 2% LIDOCAINE WITH EPI 20ML 48526272_1 CDM 0255 RC inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 JOH 2% LIDOCAINE WITH EPI 20ML 48526272_1 CDM 0255 RC inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 JOH 2% LIDOCAINE WITH EPI 20ML 48526272_1 CDM 0255 RC inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 JOH 2% LIDOCAINE WITH EPI 20ML 48526272_1 CDM 0255 RC inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges JOH 2% LIDOCAINE WITH EPI 20ML 48526272_1 CDM 0255 RC inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 JOH 2% LIDOCAINE WITH EPI 20ML 48526272_1 CDM 0255 RC inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 "JOH CT CORONAL, SAG, RECON" 48526278_1 CDM 0350 RC inpatient 1368 889.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 889.2 65 999999999 828.32 1326.96 percent of total billed charges "JOH CT CORONAL, SAG, RECON" 48526278_1 CDM 0350 RC inpatient 1368 889.2 AETNA AETNA 1080.72 79 999999999 828.32 1326.96 percent of total billed charges "JOH CT CORONAL, SAG, RECON" 48526278_1 CDM 0350 RC inpatient 1368 889.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1326.96 97 999999999 828.32 1326.96 percent of total billed charges "JOH CT CORONAL, SAG, RECON" 48526278_1 CDM 0350 RC inpatient 1368 889.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 943.92 69 999999999 828.32 1326.96 percent of total billed charges "JOH CT CORONAL, SAG, RECON" 48526278_1 CDM 0350 RC inpatient 1368 889.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1067.04 78 999999999 828.32 1326.96 percent of total billed charges "JOH CT CORONAL, SAG, RECON" 48526278_1 CDM 0350 RC inpatient 1368 889.2 SIHO - ALL PLANS SIHO - ALL PLANS 1231.2 90 999999999 828.32 1326.96 percent of total billed charges "JOH CT CORONAL, SAG, RECON" 48526278_1 CDM 0350 RC inpatient 1368 889.2 UMR - ALL PLANS UMR - ALL PLANS 957.6 70 999999999 828.32 1326.96 percent of total billed charges "JOH CT CORONAL, SAG, RECON" 48526278_1 CDM 0350 RC inpatient 1368 889.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 828.32 60.55 999999999 828.32 1326.96 percent of total billed charges "JOH CT CORONAL, SAG, RECON" 48526278_1 CDM 0350 RC inpatient 1368 889.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 828.32 1326.96 "JOH CT CORONAL, SAG, RECON" 48526278_1 CDM 0350 RC inpatient 1368 889.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 828.32 1326.96 "JOH CT CORONAL, SAG, RECON" 48526278_1 CDM 0350 RC inpatient 1368 889.2 ANTHEM HMO ANTHEM HMO 999999999 828.32 1326.96 "JOH CT CORONAL, SAG, RECON" 48526278_1 CDM 0350 RC inpatient 1368 889.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 924.77 67.6 999999999 828.32 1326.96 percent of total billed charges "JOH CT CORONAL, SAG, RECON" 48526278_1 CDM 0350 RC inpatient 1368 889.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 828.32 1326.96 "JOH CT CORONAL, SAG, RECON" 48526278_1 CDM 0350 RC inpatient 1368 889.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 828.32 1326.96 JOH ENALAPRILAT INC TO RAD 48526282_1 CDM 0636 RC inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges JOH ENALAPRILAT INC TO RAD 48526282_1 CDM 0636 RC inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges JOH ENALAPRILAT INC TO RAD 48526282_1 CDM 0636 RC inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges JOH ENALAPRILAT INC TO RAD 48526282_1 CDM 0636 RC inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges JOH ENALAPRILAT INC TO RAD 48526282_1 CDM 0636 RC inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges JOH ENALAPRILAT INC TO RAD 48526282_1 CDM 0636 RC inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges JOH ENALAPRILAT INC TO RAD 48526282_1 CDM 0636 RC inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges JOH ENALAPRILAT INC TO RAD 48526282_1 CDM 0636 RC inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges JOH ENALAPRILAT INC TO RAD 48526282_1 CDM 0636 RC inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 JOH ENALAPRILAT INC TO RAD 48526282_1 CDM 0636 RC inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 JOH ENALAPRILAT INC TO RAD 48526282_1 CDM 0636 RC inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 JOH ENALAPRILAT INC TO RAD 48526282_1 CDM 0636 RC inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges JOH ENALAPRILAT INC TO RAD 48526282_1 CDM 0636 RC inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 JOH ENALAPRILAT INC TO RAD 48526282_1 CDM 0636 RC inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 SPECIALTY SERVICES - TREATMENT ROOM 48526284_1 CDM 0761 RC inpatient 1506 978.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 978.9 65 999999999 911.88 1460.82 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48526284_1 CDM 0761 RC inpatient 1506 978.9 AETNA AETNA 1189.74 79 999999999 911.88 1460.82 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48526284_1 CDM 0761 RC inpatient 1506 978.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1460.82 97 999999999 911.88 1460.82 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48526284_1 CDM 0761 RC inpatient 1506 978.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1039.14 69 999999999 911.88 1460.82 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48526284_1 CDM 0761 RC inpatient 1506 978.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1174.68 78 999999999 911.88 1460.82 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48526284_1 CDM 0761 RC inpatient 1506 978.9 SIHO - ALL PLANS SIHO - ALL PLANS 1355.4 90 999999999 911.88 1460.82 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48526284_1 CDM 0761 RC inpatient 1506 978.9 UMR - ALL PLANS UMR - ALL PLANS 1054.2 70 999999999 911.88 1460.82 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48526284_1 CDM 0761 RC inpatient 1506 978.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 911.88 60.55 999999999 911.88 1460.82 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48526284_1 CDM 0761 RC inpatient 1506 978.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 911.88 1460.82 SPECIALTY SERVICES - TREATMENT ROOM 48526284_1 CDM 0761 RC inpatient 1506 978.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 911.88 1460.82 SPECIALTY SERVICES - TREATMENT ROOM 48526284_1 CDM 0761 RC inpatient 1506 978.9 ANTHEM HMO ANTHEM HMO 999999999 911.88 1460.82 SPECIALTY SERVICES - TREATMENT ROOM 48526284_1 CDM 0761 RC inpatient 1506 978.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1018.06 67.6 999999999 911.88 1460.82 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48526284_1 CDM 0761 RC inpatient 1506 978.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 911.88 1460.82 SPECIALTY SERVICES - TREATMENT ROOM 48526284_1 CDM 0761 RC inpatient 1506 978.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 911.88 1460.82 JOH MARCAINE 0.5 MG PER BOTTLE 48526290_1 CDM 0255 RC inpatient 49 31.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.85 65 999999999 29.67 47.53 percent of total billed charges JOH MARCAINE 0.5 MG PER BOTTLE 48526290_1 CDM 0255 RC inpatient 49 31.85 AETNA AETNA 38.71 79 999999999 29.67 47.53 percent of total billed charges JOH MARCAINE 0.5 MG PER BOTTLE 48526290_1 CDM 0255 RC inpatient 49 31.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 47.53 97 999999999 29.67 47.53 percent of total billed charges JOH MARCAINE 0.5 MG PER BOTTLE 48526290_1 CDM 0255 RC inpatient 49 31.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.81 69 999999999 29.67 47.53 percent of total billed charges JOH MARCAINE 0.5 MG PER BOTTLE 48526290_1 CDM 0255 RC inpatient 49 31.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 38.22 78 999999999 29.67 47.53 percent of total billed charges JOH MARCAINE 0.5 MG PER BOTTLE 48526290_1 CDM 0255 RC inpatient 49 31.85 SIHO - ALL PLANS SIHO - ALL PLANS 44.1 90 999999999 29.67 47.53 percent of total billed charges JOH MARCAINE 0.5 MG PER BOTTLE 48526290_1 CDM 0255 RC inpatient 49 31.85 UMR - ALL PLANS UMR - ALL PLANS 34.3 70 999999999 29.67 47.53 percent of total billed charges JOH MARCAINE 0.5 MG PER BOTTLE 48526290_1 CDM 0255 RC inpatient 49 31.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.67 60.55 999999999 29.67 47.53 percent of total billed charges JOH MARCAINE 0.5 MG PER BOTTLE 48526290_1 CDM 0255 RC inpatient 49 31.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.67 47.53 JOH MARCAINE 0.5 MG PER BOTTLE 48526290_1 CDM 0255 RC inpatient 49 31.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.67 47.53 JOH MARCAINE 0.5 MG PER BOTTLE 48526290_1 CDM 0255 RC inpatient 49 31.85 ANTHEM HMO ANTHEM HMO 999999999 29.67 47.53 JOH MARCAINE 0.5 MG PER BOTTLE 48526290_1 CDM 0255 RC inpatient 49 31.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.12 67.6 999999999 29.67 47.53 percent of total billed charges JOH MARCAINE 0.5 MG PER BOTTLE 48526290_1 CDM 0255 RC inpatient 49 31.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.67 47.53 JOH MARCAINE 0.5 MG PER BOTTLE 48526290_1 CDM 0255 RC inpatient 49 31.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.67 47.53 SPECIALTY SERVICES - TREATMENT ROOM 48526300_1 CDM 0761 RC inpatient 286 185.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.9 65 999999999 173.17 277.42 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48526300_1 CDM 0761 RC inpatient 286 185.9 AETNA AETNA 225.94 79 999999999 173.17 277.42 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48526300_1 CDM 0761 RC inpatient 286 185.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 277.42 97 999999999 173.17 277.42 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48526300_1 CDM 0761 RC inpatient 286 185.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 197.34 69 999999999 173.17 277.42 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48526300_1 CDM 0761 RC inpatient 286 185.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 223.08 78 999999999 173.17 277.42 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48526300_1 CDM 0761 RC inpatient 286 185.9 SIHO - ALL PLANS SIHO - ALL PLANS 257.4 90 999999999 173.17 277.42 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48526300_1 CDM 0761 RC inpatient 286 185.9 UMR - ALL PLANS UMR - ALL PLANS 200.2 70 999999999 173.17 277.42 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48526300_1 CDM 0761 RC inpatient 286 185.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 173.17 60.55 999999999 173.17 277.42 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48526300_1 CDM 0761 RC inpatient 286 185.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 173.17 277.42 SPECIALTY SERVICES - TREATMENT ROOM 48526300_1 CDM 0761 RC inpatient 286 185.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 173.17 277.42 SPECIALTY SERVICES - TREATMENT ROOM 48526300_1 CDM 0761 RC inpatient 286 185.9 ANTHEM HMO ANTHEM HMO 999999999 173.17 277.42 SPECIALTY SERVICES - TREATMENT ROOM 48526300_1 CDM 0761 RC inpatient 286 185.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 193.34 67.6 999999999 173.17 277.42 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48526300_1 CDM 0761 RC inpatient 286 185.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 173.17 277.42 SPECIALTY SERVICES - TREATMENT ROOM 48526300_1 CDM 0761 RC inpatient 286 185.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 173.17 277.42 JOH US BIOPHYS PROFILE/FETALS 48526302_1 CDM 0402 RC inpatient 1289 837.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 837.85 65 999999999 780.49 1250.33 percent of total billed charges JOH US BIOPHYS PROFILE/FETALS 48526302_1 CDM 0402 RC inpatient 1289 837.85 AETNA AETNA 1018.31 79 999999999 780.49 1250.33 percent of total billed charges JOH US BIOPHYS PROFILE/FETALS 48526302_1 CDM 0402 RC inpatient 1289 837.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1250.33 97 999999999 780.49 1250.33 percent of total billed charges JOH US BIOPHYS PROFILE/FETALS 48526302_1 CDM 0402 RC inpatient 1289 837.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 889.41 69 999999999 780.49 1250.33 percent of total billed charges JOH US BIOPHYS PROFILE/FETALS 48526302_1 CDM 0402 RC inpatient 1289 837.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1005.42 78 999999999 780.49 1250.33 percent of total billed charges JOH US BIOPHYS PROFILE/FETALS 48526302_1 CDM 0402 RC inpatient 1289 837.85 SIHO - ALL PLANS SIHO - ALL PLANS 1160.1 90 999999999 780.49 1250.33 percent of total billed charges JOH US BIOPHYS PROFILE/FETALS 48526302_1 CDM 0402 RC inpatient 1289 837.85 UMR - ALL PLANS UMR - ALL PLANS 902.3 70 999999999 780.49 1250.33 percent of total billed charges JOH US BIOPHYS PROFILE/FETALS 48526302_1 CDM 0402 RC inpatient 1289 837.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 780.49 60.55 999999999 780.49 1250.33 percent of total billed charges JOH US BIOPHYS PROFILE/FETALS 48526302_1 CDM 0402 RC inpatient 1289 837.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 780.49 1250.33 JOH US BIOPHYS PROFILE/FETALS 48526302_1 CDM 0402 RC inpatient 1289 837.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 780.49 1250.33 JOH US BIOPHYS PROFILE/FETALS 48526302_1 CDM 0402 RC inpatient 1289 837.85 ANTHEM HMO ANTHEM HMO 999999999 780.49 1250.33 JOH US BIOPHYS PROFILE/FETALS 48526302_1 CDM 0402 RC inpatient 1289 837.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 871.36 67.6 999999999 780.49 1250.33 percent of total billed charges JOH US BIOPHYS PROFILE/FETALS 48526302_1 CDM 0402 RC inpatient 1289 837.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 780.49 1250.33 JOH US BIOPHYS PROFILE/FETALS 48526302_1 CDM 0402 RC inpatient 1289 837.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 780.49 1250.33 "Biopsy of breast and placement of locating device using ultrasound, each additional growth" 48526304_1 CDM 0361 RC 19084 HCPCS inpatient 194 126.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 126.1 65 999999999 117.47 188.18 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, each additional growth" 48526304_1 CDM 0361 RC 19084 HCPCS inpatient 194 126.1 AETNA AETNA 153.26 79 999999999 117.47 188.18 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, each additional growth" 48526304_1 CDM 0361 RC 19084 HCPCS inpatient 194 126.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 188.18 97 999999999 117.47 188.18 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, each additional growth" 48526304_1 CDM 0361 RC 19084 HCPCS inpatient 194 126.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.86 69 999999999 117.47 188.18 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, each additional growth" 48526304_1 CDM 0361 RC 19084 HCPCS inpatient 194 126.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 151.32 78 999999999 117.47 188.18 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, each additional growth" 48526304_1 CDM 0361 RC 19084 HCPCS inpatient 194 126.1 SIHO - ALL PLANS SIHO - ALL PLANS 174.6 90 999999999 117.47 188.18 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, each additional growth" 48526304_1 CDM 0361 RC 19084 HCPCS inpatient 194 126.1 UMR - ALL PLANS UMR - ALL PLANS 135.8 70 999999999 117.47 188.18 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, each additional growth" 48526304_1 CDM 0361 RC 19084 HCPCS inpatient 194 126.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 117.47 60.55 999999999 117.47 188.18 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, each additional growth" 48526304_1 CDM 0361 RC 19084 HCPCS inpatient 194 126.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 117.47 188.18 "Biopsy of breast and placement of locating device using ultrasound, each additional growth" 48526304_1 CDM 0361 RC 19084 HCPCS inpatient 194 126.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 117.47 188.18 "Biopsy of breast and placement of locating device using ultrasound, each additional growth" 48526304_1 CDM 0361 RC 19084 HCPCS inpatient 194 126.1 ANTHEM HMO ANTHEM HMO 999999999 117.47 188.18 "Biopsy of breast and placement of locating device using ultrasound, each additional growth" 48526304_1 CDM 0361 RC 19084 HCPCS inpatient 194 126.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 131.14 67.6 999999999 117.47 188.18 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, each additional growth" 48526304_1 CDM 0361 RC 19084 HCPCS inpatient 194 126.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 117.47 188.18 "Biopsy of breast and placement of locating device using ultrasound, each additional growth" 48526304_1 CDM 0361 RC 19084 HCPCS inpatient 194 126.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 117.47 188.18 "Placement of locating device in breast using imaging guidance, each additional growth" 48526306_1 CDM 0361 RC 19282 HCPCS inpatient 695 451.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 451.75 65 999999999 420.82 674.15 percent of total billed charges "Placement of locating device in breast using imaging guidance, each additional growth" 48526306_1 CDM 0361 RC 19282 HCPCS inpatient 695 451.75 AETNA AETNA 549.05 79 999999999 420.82 674.15 percent of total billed charges "Placement of locating device in breast using imaging guidance, each additional growth" 48526306_1 CDM 0361 RC 19282 HCPCS inpatient 695 451.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 674.15 97 999999999 420.82 674.15 percent of total billed charges "Placement of locating device in breast using imaging guidance, each additional growth" 48526306_1 CDM 0361 RC 19282 HCPCS inpatient 695 451.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 479.55 69 999999999 420.82 674.15 percent of total billed charges "Placement of locating device in breast using imaging guidance, each additional growth" 48526306_1 CDM 0361 RC 19282 HCPCS inpatient 695 451.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 542.1 78 999999999 420.82 674.15 percent of total billed charges "Placement of locating device in breast using imaging guidance, each additional growth" 48526306_1 CDM 0361 RC 19282 HCPCS inpatient 695 451.75 SIHO - ALL PLANS SIHO - ALL PLANS 625.5 90 999999999 420.82 674.15 percent of total billed charges "Placement of locating device in breast using imaging guidance, each additional growth" 48526306_1 CDM 0361 RC 19282 HCPCS inpatient 695 451.75 UMR - ALL PLANS UMR - ALL PLANS 486.5 70 999999999 420.82 674.15 percent of total billed charges "Placement of locating device in breast using imaging guidance, each additional growth" 48526306_1 CDM 0361 RC 19282 HCPCS inpatient 695 451.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 420.82 60.55 999999999 420.82 674.15 percent of total billed charges "Placement of locating device in breast using imaging guidance, each additional growth" 48526306_1 CDM 0361 RC 19282 HCPCS inpatient 695 451.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 420.82 674.15 "Placement of locating device in breast using imaging guidance, each additional growth" 48526306_1 CDM 0361 RC 19282 HCPCS inpatient 695 451.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 420.82 674.15 "Placement of locating device in breast using imaging guidance, each additional growth" 48526306_1 CDM 0361 RC 19282 HCPCS inpatient 695 451.75 ANTHEM HMO ANTHEM HMO 999999999 420.82 674.15 "Placement of locating device in breast using imaging guidance, each additional growth" 48526306_1 CDM 0361 RC 19282 HCPCS inpatient 695 451.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 469.82 67.6 999999999 420.82 674.15 percent of total billed charges "Placement of locating device in breast using imaging guidance, each additional growth" 48526306_1 CDM 0361 RC 19282 HCPCS inpatient 695 451.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 420.82 674.15 "Placement of locating device in breast using imaging guidance, each additional growth" 48526306_1 CDM 0361 RC 19282 HCPCS inpatient 695 451.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 420.82 674.15 Adjustment of stomach reduction device using an endoscope 48526308_1 CDM 0361 RC 43771 HCPCS inpatient 565 367.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 367.25 65 999999999 342.11 548.05 percent of total billed charges Adjustment of stomach reduction device using an endoscope 48526308_1 CDM 0361 RC 43771 HCPCS inpatient 565 367.25 AETNA AETNA 446.35 79 999999999 342.11 548.05 percent of total billed charges Adjustment of stomach reduction device using an endoscope 48526308_1 CDM 0361 RC 43771 HCPCS inpatient 565 367.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 548.05 97 999999999 342.11 548.05 percent of total billed charges Adjustment of stomach reduction device using an endoscope 48526308_1 CDM 0361 RC 43771 HCPCS inpatient 565 367.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 389.85 69 999999999 342.11 548.05 percent of total billed charges Adjustment of stomach reduction device using an endoscope 48526308_1 CDM 0361 RC 43771 HCPCS inpatient 565 367.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 440.7 78 999999999 342.11 548.05 percent of total billed charges Adjustment of stomach reduction device using an endoscope 48526308_1 CDM 0361 RC 43771 HCPCS inpatient 565 367.25 SIHO - ALL PLANS SIHO - ALL PLANS 508.5 90 999999999 342.11 548.05 percent of total billed charges Adjustment of stomach reduction device using an endoscope 48526308_1 CDM 0361 RC 43771 HCPCS inpatient 565 367.25 UMR - ALL PLANS UMR - ALL PLANS 395.5 70 999999999 342.11 548.05 percent of total billed charges Adjustment of stomach reduction device using an endoscope 48526308_1 CDM 0361 RC 43771 HCPCS inpatient 565 367.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 342.11 60.55 999999999 342.11 548.05 percent of total billed charges Adjustment of stomach reduction device using an endoscope 48526308_1 CDM 0361 RC 43771 HCPCS inpatient 565 367.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 342.11 548.05 Adjustment of stomach reduction device using an endoscope 48526308_1 CDM 0361 RC 43771 HCPCS inpatient 565 367.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 342.11 548.05 Adjustment of stomach reduction device using an endoscope 48526308_1 CDM 0361 RC 43771 HCPCS inpatient 565 367.25 ANTHEM HMO ANTHEM HMO 999999999 342.11 548.05 Adjustment of stomach reduction device using an endoscope 48526308_1 CDM 0361 RC 43771 HCPCS inpatient 565 367.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 381.94 67.6 999999999 342.11 548.05 percent of total billed charges Adjustment of stomach reduction device using an endoscope 48526308_1 CDM 0361 RC 43771 HCPCS inpatient 565 367.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 342.11 548.05 Adjustment of stomach reduction device using an endoscope 48526308_1 CDM 0361 RC 43771 HCPCS inpatient 565 367.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 342.11 548.05 "Biopsy of breast and placement of locating device using X-ray with needle, each additional growth" 48526310_1 CDM 0361 RC 19082 HCPCS inpatient 194 126.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 126.1 65 999999999 117.47 188.18 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, each additional growth" 48526310_1 CDM 0361 RC 19082 HCPCS inpatient 194 126.1 AETNA AETNA 153.26 79 999999999 117.47 188.18 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, each additional growth" 48526310_1 CDM 0361 RC 19082 HCPCS inpatient 194 126.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 188.18 97 999999999 117.47 188.18 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, each additional growth" 48526310_1 CDM 0361 RC 19082 HCPCS inpatient 194 126.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.86 69 999999999 117.47 188.18 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, each additional growth" 48526310_1 CDM 0361 RC 19082 HCPCS inpatient 194 126.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 151.32 78 999999999 117.47 188.18 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, each additional growth" 48526310_1 CDM 0361 RC 19082 HCPCS inpatient 194 126.1 SIHO - ALL PLANS SIHO - ALL PLANS 174.6 90 999999999 117.47 188.18 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, each additional growth" 48526310_1 CDM 0361 RC 19082 HCPCS inpatient 194 126.1 UMR - ALL PLANS UMR - ALL PLANS 135.8 70 999999999 117.47 188.18 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, each additional growth" 48526310_1 CDM 0361 RC 19082 HCPCS inpatient 194 126.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 117.47 60.55 999999999 117.47 188.18 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, each additional growth" 48526310_1 CDM 0361 RC 19082 HCPCS inpatient 194 126.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 117.47 188.18 "Biopsy of breast and placement of locating device using X-ray with needle, each additional growth" 48526310_1 CDM 0361 RC 19082 HCPCS inpatient 194 126.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 117.47 188.18 "Biopsy of breast and placement of locating device using X-ray with needle, each additional growth" 48526310_1 CDM 0361 RC 19082 HCPCS inpatient 194 126.1 ANTHEM HMO ANTHEM HMO 999999999 117.47 188.18 "Biopsy of breast and placement of locating device using X-ray with needle, each additional growth" 48526310_1 CDM 0361 RC 19082 HCPCS inpatient 194 126.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 131.14 67.6 999999999 117.47 188.18 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, each additional growth" 48526310_1 CDM 0361 RC 19082 HCPCS inpatient 194 126.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 117.47 188.18 "Biopsy of breast and placement of locating device using X-ray with needle, each additional growth" 48526310_1 CDM 0361 RC 19082 HCPCS inpatient 194 126.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 117.47 188.18 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526464_1 CDM 0301 RC 82952 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526464_1 CDM 0301 RC 82952 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526464_1 CDM 0301 RC 82952 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526464_1 CDM 0301 RC 82952 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526464_1 CDM 0301 RC 82952 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526464_1 CDM 0301 RC 82952 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526464_1 CDM 0301 RC 82952 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526464_1 CDM 0301 RC 82952 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526464_1 CDM 0301 RC 82952 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526464_1 CDM 0301 RC 82952 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526464_1 CDM 0301 RC 82952 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526464_1 CDM 0301 RC 82952 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526464_1 CDM 0301 RC 82952 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526464_1 CDM 0301 RC 82952 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 "Blood glucose (sugar) tolerance test, 3 specimens" 48526469_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48526469_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48526469_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48526469_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48526469_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48526469_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48526469_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48526469_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48526469_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, 3 specimens" 48526469_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, 3 specimens" 48526469_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, 3 specimens" 48526469_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48526469_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, 3 specimens" 48526469_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, 3 specimens" 48526470_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48526470_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48526470_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48526470_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48526470_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48526470_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48526470_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48526470_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48526470_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, 3 specimens" 48526470_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, 3 specimens" 48526470_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, 3 specimens" 48526470_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48526470_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, 3 specimens" 48526470_1 CDM 0301 RC 82951 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526475_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526475_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526475_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526475_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526475_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526475_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526475_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526475_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526475_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526475_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526475_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526475_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526475_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526475_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526476_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526476_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526476_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526476_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526476_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526476_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526476_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526476_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526476_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526476_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526476_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526476_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526476_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526476_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526477_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526477_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526477_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526477_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526477_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526477_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526477_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526477_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526477_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526477_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526477_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526477_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526477_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526477_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526482_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526482_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526482_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526482_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526482_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526482_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526482_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526482_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526482_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526482_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526482_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526482_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526482_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526482_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526483_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526483_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526483_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526483_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526483_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526483_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526483_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526483_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526483_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526483_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526483_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526483_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526483_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526483_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526484_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526484_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526484_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526484_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526484_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526484_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526484_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526484_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526484_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526484_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526484_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526484_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526484_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526484_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526485_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526485_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526485_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526485_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526485_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526485_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526485_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526485_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526485_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526485_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526485_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526485_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526485_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48526485_1 CDM 0301 RC 82952 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 LAMOTRIGINE 100 MG TABLET 48540133_1 CDM 0250 RC 68084-0319-01 NDC inpatient 1 UN 1.17 0.76 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.76 65 999999999 0.71 1.13 percent of total billed charges LAMOTRIGINE 100 MG TABLET 48540133_1 CDM 0250 RC 68084-0319-01 NDC inpatient 1 UN 1.17 0.76 AETNA AETNA 0.92 79 999999999 0.71 1.13 percent of total billed charges LAMOTRIGINE 100 MG TABLET 48540133_1 CDM 0250 RC 68084-0319-01 NDC inpatient 1 UN 1.17 0.76 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.13 97 999999999 0.71 1.13 percent of total billed charges LAMOTRIGINE 100 MG TABLET 48540133_1 CDM 0250 RC 68084-0319-01 NDC inpatient 1 UN 1.17 0.76 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.81 69 999999999 0.71 1.13 percent of total billed charges LAMOTRIGINE 100 MG TABLET 48540133_1 CDM 0250 RC 68084-0319-01 NDC inpatient 1 UN 1.17 0.76 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.91 78 999999999 0.71 1.13 percent of total billed charges LAMOTRIGINE 100 MG TABLET 48540133_1 CDM 0250 RC 68084-0319-01 NDC inpatient 1 UN 1.17 0.76 SIHO - ALL PLANS SIHO - ALL PLANS 1.05 90 999999999 0.71 1.13 percent of total billed charges LAMOTRIGINE 100 MG TABLET 48540133_1 CDM 0250 RC 68084-0319-01 NDC inpatient 1 UN 1.17 0.76 UMR - ALL PLANS UMR - ALL PLANS 0.82 70 999999999 0.71 1.13 percent of total billed charges LAMOTRIGINE 100 MG TABLET 48540133_1 CDM 0250 RC 68084-0319-01 NDC inpatient 1 UN 1.17 0.76 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.71 60.55 999999999 0.71 1.13 percent of total billed charges LAMOTRIGINE 100 MG TABLET 48540133_1 CDM 0250 RC 68084-0319-01 NDC inpatient 1 UN 1.17 0.76 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.71 1.13 LAMOTRIGINE 100 MG TABLET 48540133_1 CDM 0250 RC 68084-0319-01 NDC inpatient 1 UN 1.17 0.76 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.71 1.13 LAMOTRIGINE 100 MG TABLET 48540133_1 CDM 0250 RC 68084-0319-01 NDC inpatient 1 UN 1.17 0.76 ANTHEM HMO ANTHEM HMO 999999999 0.71 1.13 LAMOTRIGINE 100 MG TABLET 48540133_1 CDM 0250 RC 68084-0319-01 NDC inpatient 1 UN 1.17 0.76 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.79 67.6 999999999 0.71 1.13 percent of total billed charges LAMOTRIGINE 100 MG TABLET 48540133_1 CDM 0250 RC 68084-0319-01 NDC inpatient 1 UN 1.17 0.76 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.71 1.13 LAMOTRIGINE 100 MG TABLET 48540133_1 CDM 0250 RC 68084-0319-01 NDC inpatient 1 UN 1.17 0.76 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.71 1.13 68084-0783-01 - gabapentin 100 mg Cap [JOHN] 48540144_1 CDM 0250 RC 68084-0783-01 NDC inpatient 1 UN 1.86 1.21 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.21 65 999999999 1.13 1.8 percent of total billed charges 68084-0783-01 - gabapentin 100 mg Cap [JOHN] 48540144_1 CDM 0250 RC 68084-0783-01 NDC inpatient 1 UN 1.86 1.21 AETNA AETNA 1.47 79 999999999 1.13 1.8 percent of total billed charges 68084-0783-01 - gabapentin 100 mg Cap [JOHN] 48540144_1 CDM 0250 RC 68084-0783-01 NDC inpatient 1 UN 1.86 1.21 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.8 97 999999999 1.13 1.8 percent of total billed charges 68084-0783-01 - gabapentin 100 mg Cap [JOHN] 48540144_1 CDM 0250 RC 68084-0783-01 NDC inpatient 1 UN 1.86 1.21 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.28 69 999999999 1.13 1.8 percent of total billed charges 68084-0783-01 - gabapentin 100 mg Cap [JOHN] 48540144_1 CDM 0250 RC 68084-0783-01 NDC inpatient 1 UN 1.86 1.21 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.45 78 999999999 1.13 1.8 percent of total billed charges 68084-0783-01 - gabapentin 100 mg Cap [JOHN] 48540144_1 CDM 0250 RC 68084-0783-01 NDC inpatient 1 UN 1.86 1.21 SIHO - ALL PLANS SIHO - ALL PLANS 1.67 90 999999999 1.13 1.8 percent of total billed charges 68084-0783-01 - gabapentin 100 mg Cap [JOHN] 48540144_1 CDM 0250 RC 68084-0783-01 NDC inpatient 1 UN 1.86 1.21 UMR - ALL PLANS UMR - ALL PLANS 1.3 70 999999999 1.13 1.8 percent of total billed charges 68084-0783-01 - gabapentin 100 mg Cap [JOHN] 48540144_1 CDM 0250 RC 68084-0783-01 NDC inpatient 1 UN 1.86 1.21 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.13 60.55 999999999 1.13 1.8 percent of total billed charges 68084-0783-01 - gabapentin 100 mg Cap [JOHN] 48540144_1 CDM 0250 RC 68084-0783-01 NDC inpatient 1 UN 1.86 1.21 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.13 1.8 68084-0783-01 - gabapentin 100 mg Cap [JOHN] 48540144_1 CDM 0250 RC 68084-0783-01 NDC inpatient 1 UN 1.86 1.21 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.13 1.8 68084-0783-01 - gabapentin 100 mg Cap [JOHN] 48540144_1 CDM 0250 RC 68084-0783-01 NDC inpatient 1 UN 1.86 1.21 ANTHEM HMO ANTHEM HMO 999999999 1.13 1.8 68084-0783-01 - gabapentin 100 mg Cap [JOHN] 48540144_1 CDM 0250 RC 68084-0783-01 NDC inpatient 1 UN 1.86 1.21 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.26 67.6 999999999 1.13 1.8 percent of total billed charges 68084-0783-01 - gabapentin 100 mg Cap [JOHN] 48540144_1 CDM 0250 RC 68084-0783-01 NDC inpatient 1 UN 1.86 1.21 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.13 1.8 68084-0783-01 - gabapentin 100 mg Cap [JOHN] 48540144_1 CDM 0250 RC 68084-0783-01 NDC inpatient 1 UN 1.86 1.21 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.13 1.8 "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48540287_1 CDM 0250 RC 76204-0800-24 NDC J7614 HCPCS inpatient 1 UN 8.01 5.21 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.21 65 999999999 4.85 7.77 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48540287_1 CDM 0250 RC 76204-0800-24 NDC J7614 HCPCS inpatient 1 UN 8.01 5.21 AETNA AETNA 6.33 79 999999999 4.85 7.77 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48540287_1 CDM 0250 RC 76204-0800-24 NDC J7614 HCPCS inpatient 1 UN 8.01 5.21 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7.77 97 999999999 4.85 7.77 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48540287_1 CDM 0250 RC 76204-0800-24 NDC J7614 HCPCS inpatient 1 UN 8.01 5.21 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.53 69 999999999 4.85 7.77 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48540287_1 CDM 0250 RC 76204-0800-24 NDC J7614 HCPCS inpatient 1 UN 8.01 5.21 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.25 78 999999999 4.85 7.77 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48540287_1 CDM 0250 RC 76204-0800-24 NDC J7614 HCPCS inpatient 1 UN 8.01 5.21 SIHO - ALL PLANS SIHO - ALL PLANS 7.21 90 999999999 4.85 7.77 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48540287_1 CDM 0250 RC 76204-0800-24 NDC J7614 HCPCS inpatient 1 UN 8.01 5.21 UMR - ALL PLANS UMR - ALL PLANS 5.61 70 999999999 4.85 7.77 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48540287_1 CDM 0250 RC 76204-0800-24 NDC J7614 HCPCS inpatient 1 UN 8.01 5.21 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.85 60.55 999999999 4.85 7.77 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48540287_1 CDM 0250 RC 76204-0800-24 NDC J7614 HCPCS inpatient 1 UN 8.01 5.21 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.85 7.77 "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48540287_1 CDM 0250 RC 76204-0800-24 NDC J7614 HCPCS inpatient 1 UN 8.01 5.21 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.85 7.77 "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48540287_1 CDM 0250 RC 76204-0800-24 NDC J7614 HCPCS inpatient 1 UN 8.01 5.21 ANTHEM HMO ANTHEM HMO 999999999 4.85 7.77 "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48540287_1 CDM 0250 RC 76204-0800-24 NDC J7614 HCPCS inpatient 1 UN 8.01 5.21 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.41 67.6 999999999 4.85 7.77 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48540287_1 CDM 0250 RC 76204-0800-24 NDC J7614 HCPCS inpatient 1 UN 8.01 5.21 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.85 7.77 "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 48540287_1 CDM 0250 RC 76204-0800-24 NDC J7614 HCPCS inpatient 1 UN 8.01 5.21 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.85 7.77 "INJECTION, VANCOMYCIN HCL, 500 MG" 48559948_1 CDM 0250 RC 67457-0340-01 NDC J3370 HCPCS inpatient 2 UN 29.8 19.37 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.37 65 999999999 18.04 28.91 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 48559948_1 CDM 0250 RC 67457-0340-01 NDC J3370 HCPCS inpatient 2 UN 29.8 19.37 AETNA AETNA 23.54 79 999999999 18.04 28.91 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 48559948_1 CDM 0250 RC 67457-0340-01 NDC J3370 HCPCS inpatient 2 UN 29.8 19.37 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 28.91 97 999999999 18.04 28.91 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 48559948_1 CDM 0250 RC 67457-0340-01 NDC J3370 HCPCS inpatient 2 UN 29.8 19.37 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.56 69 999999999 18.04 28.91 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 48559948_1 CDM 0250 RC 67457-0340-01 NDC J3370 HCPCS inpatient 2 UN 29.8 19.37 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.24 78 999999999 18.04 28.91 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 48559948_1 CDM 0250 RC 67457-0340-01 NDC J3370 HCPCS inpatient 2 UN 29.8 19.37 SIHO - ALL PLANS SIHO - ALL PLANS 26.82 90 999999999 18.04 28.91 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 48559948_1 CDM 0250 RC 67457-0340-01 NDC J3370 HCPCS inpatient 2 UN 29.8 19.37 UMR - ALL PLANS UMR - ALL PLANS 20.86 70 999999999 18.04 28.91 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 48559948_1 CDM 0250 RC 67457-0340-01 NDC J3370 HCPCS inpatient 2 UN 29.8 19.37 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.04 60.55 999999999 18.04 28.91 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 48559948_1 CDM 0250 RC 67457-0340-01 NDC J3370 HCPCS inpatient 2 UN 29.8 19.37 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.04 28.91 "INJECTION, VANCOMYCIN HCL, 500 MG" 48559948_1 CDM 0250 RC 67457-0340-01 NDC J3370 HCPCS inpatient 2 UN 29.8 19.37 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.04 28.91 "INJECTION, VANCOMYCIN HCL, 500 MG" 48559948_1 CDM 0250 RC 67457-0340-01 NDC J3370 HCPCS inpatient 2 UN 29.8 19.37 ANTHEM HMO ANTHEM HMO 999999999 18.04 28.91 "INJECTION, VANCOMYCIN HCL, 500 MG" 48559948_1 CDM 0250 RC 67457-0340-01 NDC J3370 HCPCS inpatient 2 UN 29.8 19.37 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.14 67.6 999999999 18.04 28.91 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 48559948_1 CDM 0250 RC 67457-0340-01 NDC J3370 HCPCS inpatient 2 UN 29.8 19.37 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.04 28.91 "INJECTION, VANCOMYCIN HCL, 500 MG" 48559948_1 CDM 0250 RC 67457-0340-01 NDC J3370 HCPCS inpatient 2 UN 29.8 19.37 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.04 28.91 JOH MA CAD Screen 48560604_1 CDM 0403 RC inpatient 45 29.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 29.25 65 999999999 27.25 43.65 percent of total billed charges JOH MA CAD Screen 48560604_1 CDM 0403 RC inpatient 45 29.25 AETNA AETNA 35.55 79 999999999 27.25 43.65 percent of total billed charges JOH MA CAD Screen 48560604_1 CDM 0403 RC inpatient 45 29.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 43.65 97 999999999 27.25 43.65 percent of total billed charges JOH MA CAD Screen 48560604_1 CDM 0403 RC inpatient 45 29.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 31.05 69 999999999 27.25 43.65 percent of total billed charges JOH MA CAD Screen 48560604_1 CDM 0403 RC inpatient 45 29.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 35.1 78 999999999 27.25 43.65 percent of total billed charges JOH MA CAD Screen 48560604_1 CDM 0403 RC inpatient 45 29.25 SIHO - ALL PLANS SIHO - ALL PLANS 40.5 90 999999999 27.25 43.65 percent of total billed charges JOH MA CAD Screen 48560604_1 CDM 0403 RC inpatient 45 29.25 UMR - ALL PLANS UMR - ALL PLANS 31.5 70 999999999 27.25 43.65 percent of total billed charges JOH MA CAD Screen 48560604_1 CDM 0403 RC inpatient 45 29.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27.25 60.55 999999999 27.25 43.65 percent of total billed charges JOH MA CAD Screen 48560604_1 CDM 0403 RC inpatient 45 29.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 27.25 43.65 JOH MA CAD Screen 48560604_1 CDM 0403 RC inpatient 45 29.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 27.25 43.65 JOH MA CAD Screen 48560604_1 CDM 0403 RC inpatient 45 29.25 ANTHEM HMO ANTHEM HMO 999999999 27.25 43.65 JOH MA CAD Screen 48560604_1 CDM 0403 RC inpatient 45 29.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 30.42 67.6 999999999 27.25 43.65 percent of total billed charges JOH MA CAD Screen 48560604_1 CDM 0403 RC inpatient 45 29.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 27.25 43.65 JOH MA CAD Screen 48560604_1 CDM 0403 RC inpatient 45 29.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 27.25 43.65 JOH MA CAD Diag 48560605_1 CDM 0401 RC inpatient 49 31.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.85 65 999999999 29.67 47.53 percent of total billed charges JOH MA CAD Diag 48560605_1 CDM 0401 RC inpatient 49 31.85 AETNA AETNA 38.71 79 999999999 29.67 47.53 percent of total billed charges JOH MA CAD Diag 48560605_1 CDM 0401 RC inpatient 49 31.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 47.53 97 999999999 29.67 47.53 percent of total billed charges JOH MA CAD Diag 48560605_1 CDM 0401 RC inpatient 49 31.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.81 69 999999999 29.67 47.53 percent of total billed charges JOH MA CAD Diag 48560605_1 CDM 0401 RC inpatient 49 31.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 38.22 78 999999999 29.67 47.53 percent of total billed charges JOH MA CAD Diag 48560605_1 CDM 0401 RC inpatient 49 31.85 SIHO - ALL PLANS SIHO - ALL PLANS 44.1 90 999999999 29.67 47.53 percent of total billed charges JOH MA CAD Diag 48560605_1 CDM 0401 RC inpatient 49 31.85 UMR - ALL PLANS UMR - ALL PLANS 34.3 70 999999999 29.67 47.53 percent of total billed charges JOH MA CAD Diag 48560605_1 CDM 0401 RC inpatient 49 31.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.67 60.55 999999999 29.67 47.53 percent of total billed charges JOH MA CAD Diag 48560605_1 CDM 0401 RC inpatient 49 31.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.67 47.53 JOH MA CAD Diag 48560605_1 CDM 0401 RC inpatient 49 31.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.67 47.53 JOH MA CAD Diag 48560605_1 CDM 0401 RC inpatient 49 31.85 ANTHEM HMO ANTHEM HMO 999999999 29.67 47.53 JOH MA CAD Diag 48560605_1 CDM 0401 RC inpatient 49 31.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.12 67.6 999999999 29.67 47.53 percent of total billed charges JOH MA CAD Diag 48560605_1 CDM 0401 RC inpatient 49 31.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.67 47.53 JOH MA CAD Diag 48560605_1 CDM 0401 RC inpatient 49 31.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.67 47.53 "Biopsy of breast and placement of locating device using ultrasound, first growth" 48560606_1 CDM 0361 RC 19083 HCPCS inpatient 1653 1074.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1074.45 65 999999999 1000.89 1603.41 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 48560606_1 CDM 0361 RC 19083 HCPCS inpatient 1653 1074.45 AETNA AETNA 1305.87 79 999999999 1000.89 1603.41 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 48560606_1 CDM 0361 RC 19083 HCPCS inpatient 1653 1074.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1603.41 97 999999999 1000.89 1603.41 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 48560606_1 CDM 0361 RC 19083 HCPCS inpatient 1653 1074.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1140.57 69 999999999 1000.89 1603.41 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 48560606_1 CDM 0361 RC 19083 HCPCS inpatient 1653 1074.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1289.34 78 999999999 1000.89 1603.41 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 48560606_1 CDM 0361 RC 19083 HCPCS inpatient 1653 1074.45 SIHO - ALL PLANS SIHO - ALL PLANS 1487.7 90 999999999 1000.89 1603.41 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 48560606_1 CDM 0361 RC 19083 HCPCS inpatient 1653 1074.45 UMR - ALL PLANS UMR - ALL PLANS 1157.1 70 999999999 1000.89 1603.41 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 48560606_1 CDM 0361 RC 19083 HCPCS inpatient 1653 1074.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1000.89 60.55 999999999 1000.89 1603.41 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 48560606_1 CDM 0361 RC 19083 HCPCS inpatient 1653 1074.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1000.89 1603.41 "Biopsy of breast and placement of locating device using ultrasound, first growth" 48560606_1 CDM 0361 RC 19083 HCPCS inpatient 1653 1074.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1000.89 1603.41 "Biopsy of breast and placement of locating device using ultrasound, first growth" 48560606_1 CDM 0361 RC 19083 HCPCS inpatient 1653 1074.45 ANTHEM HMO ANTHEM HMO 999999999 1000.89 1603.41 "Biopsy of breast and placement of locating device using ultrasound, first growth" 48560606_1 CDM 0361 RC 19083 HCPCS inpatient 1653 1074.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1117.43 67.6 999999999 1000.89 1603.41 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 48560606_1 CDM 0361 RC 19083 HCPCS inpatient 1653 1074.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1000.89 1603.41 "Biopsy of breast and placement of locating device using ultrasound, first growth" 48560606_1 CDM 0361 RC 19083 HCPCS inpatient 1653 1074.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1000.89 1603.41 "Aspiration of cyst of breast, first cyst" 48560607_1 CDM 0361 RC 19000 HCPCS inpatient 986 640.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 640.9 65 999999999 597.02 956.42 percent of total billed charges "Aspiration of cyst of breast, first cyst" 48560607_1 CDM 0361 RC 19000 HCPCS inpatient 986 640.9 AETNA AETNA 778.94 79 999999999 597.02 956.42 percent of total billed charges "Aspiration of cyst of breast, first cyst" 48560607_1 CDM 0361 RC 19000 HCPCS inpatient 986 640.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 956.42 97 999999999 597.02 956.42 percent of total billed charges "Aspiration of cyst of breast, first cyst" 48560607_1 CDM 0361 RC 19000 HCPCS inpatient 986 640.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 680.34 69 999999999 597.02 956.42 percent of total billed charges "Aspiration of cyst of breast, first cyst" 48560607_1 CDM 0361 RC 19000 HCPCS inpatient 986 640.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 769.08 78 999999999 597.02 956.42 percent of total billed charges "Aspiration of cyst of breast, first cyst" 48560607_1 CDM 0361 RC 19000 HCPCS inpatient 986 640.9 SIHO - ALL PLANS SIHO - ALL PLANS 887.4 90 999999999 597.02 956.42 percent of total billed charges "Aspiration of cyst of breast, first cyst" 48560607_1 CDM 0361 RC 19000 HCPCS inpatient 986 640.9 UMR - ALL PLANS UMR - ALL PLANS 690.2 70 999999999 597.02 956.42 percent of total billed charges "Aspiration of cyst of breast, first cyst" 48560607_1 CDM 0361 RC 19000 HCPCS inpatient 986 640.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 597.02 60.55 999999999 597.02 956.42 percent of total billed charges "Aspiration of cyst of breast, first cyst" 48560607_1 CDM 0361 RC 19000 HCPCS inpatient 986 640.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 597.02 956.42 "Aspiration of cyst of breast, first cyst" 48560607_1 CDM 0361 RC 19000 HCPCS inpatient 986 640.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 597.02 956.42 "Aspiration of cyst of breast, first cyst" 48560607_1 CDM 0361 RC 19000 HCPCS inpatient 986 640.9 ANTHEM HMO ANTHEM HMO 999999999 597.02 956.42 "Aspiration of cyst of breast, first cyst" 48560607_1 CDM 0361 RC 19000 HCPCS inpatient 986 640.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 666.54 67.6 999999999 597.02 956.42 percent of total billed charges "Aspiration of cyst of breast, first cyst" 48560607_1 CDM 0361 RC 19000 HCPCS inpatient 986 640.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 597.02 956.42 "Aspiration of cyst of breast, first cyst" 48560607_1 CDM 0361 RC 19000 HCPCS inpatient 986 640.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 597.02 956.42 Injection of contrast for imaging of lower spinal canal 48560608_1 CDM 0361 RC 62284 HCPCS inpatient 667 433.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 433.55 65 999999999 403.87 646.99 percent of total billed charges Injection of contrast for imaging of lower spinal canal 48560608_1 CDM 0361 RC 62284 HCPCS inpatient 667 433.55 AETNA AETNA 526.93 79 999999999 403.87 646.99 percent of total billed charges Injection of contrast for imaging of lower spinal canal 48560608_1 CDM 0361 RC 62284 HCPCS inpatient 667 433.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 646.99 97 999999999 403.87 646.99 percent of total billed charges Injection of contrast for imaging of lower spinal canal 48560608_1 CDM 0361 RC 62284 HCPCS inpatient 667 433.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 460.23 69 999999999 403.87 646.99 percent of total billed charges Injection of contrast for imaging of lower spinal canal 48560608_1 CDM 0361 RC 62284 HCPCS inpatient 667 433.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 520.26 78 999999999 403.87 646.99 percent of total billed charges Injection of contrast for imaging of lower spinal canal 48560608_1 CDM 0361 RC 62284 HCPCS inpatient 667 433.55 SIHO - ALL PLANS SIHO - ALL PLANS 600.3 90 999999999 403.87 646.99 percent of total billed charges Injection of contrast for imaging of lower spinal canal 48560608_1 CDM 0361 RC 62284 HCPCS inpatient 667 433.55 UMR - ALL PLANS UMR - ALL PLANS 466.9 70 999999999 403.87 646.99 percent of total billed charges Injection of contrast for imaging of lower spinal canal 48560608_1 CDM 0361 RC 62284 HCPCS inpatient 667 433.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 403.87 60.55 999999999 403.87 646.99 percent of total billed charges Injection of contrast for imaging of lower spinal canal 48560608_1 CDM 0361 RC 62284 HCPCS inpatient 667 433.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 403.87 646.99 Injection of contrast for imaging of lower spinal canal 48560608_1 CDM 0361 RC 62284 HCPCS inpatient 667 433.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 403.87 646.99 Injection of contrast for imaging of lower spinal canal 48560608_1 CDM 0361 RC 62284 HCPCS inpatient 667 433.55 ANTHEM HMO ANTHEM HMO 999999999 403.87 646.99 Injection of contrast for imaging of lower spinal canal 48560608_1 CDM 0361 RC 62284 HCPCS inpatient 667 433.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 450.89 67.6 999999999 403.87 646.99 percent of total billed charges Injection of contrast for imaging of lower spinal canal 48560608_1 CDM 0361 RC 62284 HCPCS inpatient 667 433.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 403.87 646.99 Injection of contrast for imaging of lower spinal canal 48560608_1 CDM 0361 RC 62284 HCPCS inpatient 667 433.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 403.87 646.99 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48560609_1 CDM 0361 RC 62270 HCPCS inpatient 807 524.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 524.55 65 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48560609_1 CDM 0361 RC 62270 HCPCS inpatient 807 524.55 AETNA AETNA 637.53 79 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48560609_1 CDM 0361 RC 62270 HCPCS inpatient 807 524.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 782.79 97 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48560609_1 CDM 0361 RC 62270 HCPCS inpatient 807 524.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 556.83 69 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48560609_1 CDM 0361 RC 62270 HCPCS inpatient 807 524.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 629.46 78 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48560609_1 CDM 0361 RC 62270 HCPCS inpatient 807 524.55 SIHO - ALL PLANS SIHO - ALL PLANS 726.3 90 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48560609_1 CDM 0361 RC 62270 HCPCS inpatient 807 524.55 UMR - ALL PLANS UMR - ALL PLANS 564.9 70 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48560609_1 CDM 0361 RC 62270 HCPCS inpatient 807 524.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 488.64 60.55 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48560609_1 CDM 0361 RC 62270 HCPCS inpatient 807 524.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 488.64 782.79 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48560609_1 CDM 0361 RC 62270 HCPCS inpatient 807 524.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 488.64 782.79 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48560609_1 CDM 0361 RC 62270 HCPCS inpatient 807 524.55 ANTHEM HMO ANTHEM HMO 999999999 488.64 782.79 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48560609_1 CDM 0361 RC 62270 HCPCS inpatient 807 524.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 545.53 67.6 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48560609_1 CDM 0361 RC 62270 HCPCS inpatient 807 524.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 488.64 782.79 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48560609_1 CDM 0361 RC 62270 HCPCS inpatient 807 524.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 488.64 782.79 Limited ultrasound scan of joint or other extremity structure except blood vessels 48560610_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 518.7 65 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48560610_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 AETNA AETNA 630.42 79 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48560610_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 774.06 97 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48560610_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 550.62 69 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48560610_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 622.44 78 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48560610_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 SIHO - ALL PLANS SIHO - ALL PLANS 718.2 90 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48560610_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 UMR - ALL PLANS UMR - ALL PLANS 558.6 70 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48560610_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 483.19 60.55 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48560610_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 483.19 774.06 Limited ultrasound scan of joint or other extremity structure except blood vessels 48560610_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 483.19 774.06 Limited ultrasound scan of joint or other extremity structure except blood vessels 48560610_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 ANTHEM HMO ANTHEM HMO 999999999 483.19 774.06 Limited ultrasound scan of joint or other extremity structure except blood vessels 48560610_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 539.45 67.6 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48560610_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 483.19 774.06 Limited ultrasound scan of joint or other extremity structure except blood vessels 48560610_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 483.19 774.06 Limited ultrasound scan of joint or other extremity structure except blood vessels 48560611_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 518.7 65 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48560611_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 AETNA AETNA 630.42 79 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48560611_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 774.06 97 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48560611_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 550.62 69 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48560611_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 622.44 78 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48560611_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 SIHO - ALL PLANS SIHO - ALL PLANS 718.2 90 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48560611_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 UMR - ALL PLANS UMR - ALL PLANS 558.6 70 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48560611_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 483.19 60.55 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48560611_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 483.19 774.06 Limited ultrasound scan of joint or other extremity structure except blood vessels 48560611_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 483.19 774.06 Limited ultrasound scan of joint or other extremity structure except blood vessels 48560611_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 ANTHEM HMO ANTHEM HMO 999999999 483.19 774.06 Limited ultrasound scan of joint or other extremity structure except blood vessels 48560611_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 539.45 67.6 999999999 483.19 774.06 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 48560611_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 483.19 774.06 Limited ultrasound scan of joint or other extremity structure except blood vessels 48560611_1 CDM 0402 RC 76882 HCPCS inpatient 798 518.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 483.19 774.06 "Aspiration of abscess, blood, or cyst" 48560612_1 CDM 0361 RC 10160 HCPCS inpatient 470 305.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 305.5 65 999999999 284.59 455.9 percent of total billed charges "Aspiration of abscess, blood, or cyst" 48560612_1 CDM 0361 RC 10160 HCPCS inpatient 470 305.5 AETNA AETNA 371.3 79 999999999 284.59 455.9 percent of total billed charges "Aspiration of abscess, blood, or cyst" 48560612_1 CDM 0361 RC 10160 HCPCS inpatient 470 305.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 455.9 97 999999999 284.59 455.9 percent of total billed charges "Aspiration of abscess, blood, or cyst" 48560612_1 CDM 0361 RC 10160 HCPCS inpatient 470 305.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 324.3 69 999999999 284.59 455.9 percent of total billed charges "Aspiration of abscess, blood, or cyst" 48560612_1 CDM 0361 RC 10160 HCPCS inpatient 470 305.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 366.6 78 999999999 284.59 455.9 percent of total billed charges "Aspiration of abscess, blood, or cyst" 48560612_1 CDM 0361 RC 10160 HCPCS inpatient 470 305.5 SIHO - ALL PLANS SIHO - ALL PLANS 423 90 999999999 284.59 455.9 percent of total billed charges "Aspiration of abscess, blood, or cyst" 48560612_1 CDM 0361 RC 10160 HCPCS inpatient 470 305.5 UMR - ALL PLANS UMR - ALL PLANS 329 70 999999999 284.59 455.9 percent of total billed charges "Aspiration of abscess, blood, or cyst" 48560612_1 CDM 0361 RC 10160 HCPCS inpatient 470 305.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 284.59 60.55 999999999 284.59 455.9 percent of total billed charges "Aspiration of abscess, blood, or cyst" 48560612_1 CDM 0361 RC 10160 HCPCS inpatient 470 305.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 284.59 455.9 "Aspiration of abscess, blood, or cyst" 48560612_1 CDM 0361 RC 10160 HCPCS inpatient 470 305.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 284.59 455.9 "Aspiration of abscess, blood, or cyst" 48560612_1 CDM 0361 RC 10160 HCPCS inpatient 470 305.5 ANTHEM HMO ANTHEM HMO 999999999 284.59 455.9 "Aspiration of abscess, blood, or cyst" 48560612_1 CDM 0361 RC 10160 HCPCS inpatient 470 305.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 317.72 67.6 999999999 284.59 455.9 percent of total billed charges "Aspiration of abscess, blood, or cyst" 48560612_1 CDM 0361 RC 10160 HCPCS inpatient 470 305.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 284.59 455.9 "Aspiration of abscess, blood, or cyst" 48560612_1 CDM 0361 RC 10160 HCPCS inpatient 470 305.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 284.59 455.9 Drainage of blood or fluid accumulation 48560613_1 CDM 0361 RC 10140 HCPCS inpatient 2620 1703 SELF PAY DISCOUNT SELF PAY DISCOUNT 1703 65 999999999 1586.41 2541.4 percent of total billed charges Drainage of blood or fluid accumulation 48560613_1 CDM 0361 RC 10140 HCPCS inpatient 2620 1703 AETNA AETNA 2069.8 79 999999999 1586.41 2541.4 percent of total billed charges Drainage of blood or fluid accumulation 48560613_1 CDM 0361 RC 10140 HCPCS inpatient 2620 1703 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2541.4 97 999999999 1586.41 2541.4 percent of total billed charges Drainage of blood or fluid accumulation 48560613_1 CDM 0361 RC 10140 HCPCS inpatient 2620 1703 ENCORE - ALL PLANS ENCORE - ALL PLANS 1807.8 69 999999999 1586.41 2541.4 percent of total billed charges Drainage of blood or fluid accumulation 48560613_1 CDM 0361 RC 10140 HCPCS inpatient 2620 1703 HUMANA - ALL PLANS HUMANA - ALL PLANS 2043.6 78 999999999 1586.41 2541.4 percent of total billed charges Drainage of blood or fluid accumulation 48560613_1 CDM 0361 RC 10140 HCPCS inpatient 2620 1703 SIHO - ALL PLANS SIHO - ALL PLANS 2358 90 999999999 1586.41 2541.4 percent of total billed charges Drainage of blood or fluid accumulation 48560613_1 CDM 0361 RC 10140 HCPCS inpatient 2620 1703 UMR - ALL PLANS UMR - ALL PLANS 1834 70 999999999 1586.41 2541.4 percent of total billed charges Drainage of blood or fluid accumulation 48560613_1 CDM 0361 RC 10140 HCPCS inpatient 2620 1703 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1586.41 60.55 999999999 1586.41 2541.4 percent of total billed charges Drainage of blood or fluid accumulation 48560613_1 CDM 0361 RC 10140 HCPCS inpatient 2620 1703 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1586.41 2541.4 Drainage of blood or fluid accumulation 48560613_1 CDM 0361 RC 10140 HCPCS inpatient 2620 1703 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1586.41 2541.4 Drainage of blood or fluid accumulation 48560613_1 CDM 0361 RC 10140 HCPCS inpatient 2620 1703 ANTHEM HMO ANTHEM HMO 999999999 1586.41 2541.4 Drainage of blood or fluid accumulation 48560613_1 CDM 0361 RC 10140 HCPCS inpatient 2620 1703 CIGNA - ALL PLANS CIGNA - ALL PLANS 1771.12 67.6 999999999 1586.41 2541.4 percent of total billed charges Drainage of blood or fluid accumulation 48560613_1 CDM 0361 RC 10140 HCPCS inpatient 2620 1703 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1586.41 2541.4 Drainage of blood or fluid accumulation 48560613_1 CDM 0361 RC 10140 HCPCS inpatient 2620 1703 UHC - ALL PLANS UHC - ALL PLANS 999999999 1586.41 2541.4 Vaginal ultrasound of pregnant uterus 48560614_1 CDM 0402 RC 76817 HCPCS inpatient 694 451.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 451.1 65 999999999 420.22 673.18 percent of total billed charges Vaginal ultrasound of pregnant uterus 48560614_1 CDM 0402 RC 76817 HCPCS inpatient 694 451.1 AETNA AETNA 548.26 79 999999999 420.22 673.18 percent of total billed charges Vaginal ultrasound of pregnant uterus 48560614_1 CDM 0402 RC 76817 HCPCS inpatient 694 451.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 673.18 97 999999999 420.22 673.18 percent of total billed charges Vaginal ultrasound of pregnant uterus 48560614_1 CDM 0402 RC 76817 HCPCS inpatient 694 451.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 478.86 69 999999999 420.22 673.18 percent of total billed charges Vaginal ultrasound of pregnant uterus 48560614_1 CDM 0402 RC 76817 HCPCS inpatient 694 451.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 541.32 78 999999999 420.22 673.18 percent of total billed charges Vaginal ultrasound of pregnant uterus 48560614_1 CDM 0402 RC 76817 HCPCS inpatient 694 451.1 SIHO - ALL PLANS SIHO - ALL PLANS 624.6 90 999999999 420.22 673.18 percent of total billed charges Vaginal ultrasound of pregnant uterus 48560614_1 CDM 0402 RC 76817 HCPCS inpatient 694 451.1 UMR - ALL PLANS UMR - ALL PLANS 485.8 70 999999999 420.22 673.18 percent of total billed charges Vaginal ultrasound of pregnant uterus 48560614_1 CDM 0402 RC 76817 HCPCS inpatient 694 451.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 420.22 60.55 999999999 420.22 673.18 percent of total billed charges Vaginal ultrasound of pregnant uterus 48560614_1 CDM 0402 RC 76817 HCPCS inpatient 694 451.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 420.22 673.18 Vaginal ultrasound of pregnant uterus 48560614_1 CDM 0402 RC 76817 HCPCS inpatient 694 451.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 420.22 673.18 Vaginal ultrasound of pregnant uterus 48560614_1 CDM 0402 RC 76817 HCPCS inpatient 694 451.1 ANTHEM HMO ANTHEM HMO 999999999 420.22 673.18 Vaginal ultrasound of pregnant uterus 48560614_1 CDM 0402 RC 76817 HCPCS inpatient 694 451.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 469.14 67.6 999999999 420.22 673.18 percent of total billed charges Vaginal ultrasound of pregnant uterus 48560614_1 CDM 0402 RC 76817 HCPCS inpatient 694 451.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 420.22 673.18 Vaginal ultrasound of pregnant uterus 48560614_1 CDM 0402 RC 76817 HCPCS inpatient 694 451.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 420.22 673.18 Insertion of tube and introduction of contrast for X-ray of uterus and fallopian tubes 48560615_1 CDM 0361 RC 58340 HCPCS inpatient 561 364.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 364.65 65 999999999 339.69 544.17 percent of total billed charges Insertion of tube and introduction of contrast for X-ray of uterus and fallopian tubes 48560615_1 CDM 0361 RC 58340 HCPCS inpatient 561 364.65 AETNA AETNA 443.19 79 999999999 339.69 544.17 percent of total billed charges Insertion of tube and introduction of contrast for X-ray of uterus and fallopian tubes 48560615_1 CDM 0361 RC 58340 HCPCS inpatient 561 364.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 544.17 97 999999999 339.69 544.17 percent of total billed charges Insertion of tube and introduction of contrast for X-ray of uterus and fallopian tubes 48560615_1 CDM 0361 RC 58340 HCPCS inpatient 561 364.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 387.09 69 999999999 339.69 544.17 percent of total billed charges Insertion of tube and introduction of contrast for X-ray of uterus and fallopian tubes 48560615_1 CDM 0361 RC 58340 HCPCS inpatient 561 364.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 437.58 78 999999999 339.69 544.17 percent of total billed charges Insertion of tube and introduction of contrast for X-ray of uterus and fallopian tubes 48560615_1 CDM 0361 RC 58340 HCPCS inpatient 561 364.65 SIHO - ALL PLANS SIHO - ALL PLANS 504.9 90 999999999 339.69 544.17 percent of total billed charges Insertion of tube and introduction of contrast for X-ray of uterus and fallopian tubes 48560615_1 CDM 0361 RC 58340 HCPCS inpatient 561 364.65 UMR - ALL PLANS UMR - ALL PLANS 392.7 70 999999999 339.69 544.17 percent of total billed charges Insertion of tube and introduction of contrast for X-ray of uterus and fallopian tubes 48560615_1 CDM 0361 RC 58340 HCPCS inpatient 561 364.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 339.69 60.55 999999999 339.69 544.17 percent of total billed charges Insertion of tube and introduction of contrast for X-ray of uterus and fallopian tubes 48560615_1 CDM 0361 RC 58340 HCPCS inpatient 561 364.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 339.69 544.17 Insertion of tube and introduction of contrast for X-ray of uterus and fallopian tubes 48560615_1 CDM 0361 RC 58340 HCPCS inpatient 561 364.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 339.69 544.17 Insertion of tube and introduction of contrast for X-ray of uterus and fallopian tubes 48560615_1 CDM 0361 RC 58340 HCPCS inpatient 561 364.65 ANTHEM HMO ANTHEM HMO 999999999 339.69 544.17 Insertion of tube and introduction of contrast for X-ray of uterus and fallopian tubes 48560615_1 CDM 0361 RC 58340 HCPCS inpatient 561 364.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 379.24 67.6 999999999 339.69 544.17 percent of total billed charges Insertion of tube and introduction of contrast for X-ray of uterus and fallopian tubes 48560615_1 CDM 0361 RC 58340 HCPCS inpatient 561 364.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 339.69 544.17 Insertion of tube and introduction of contrast for X-ray of uterus and fallopian tubes 48560615_1 CDM 0361 RC 58340 HCPCS inpatient 561 364.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 339.69 544.17 Injection of abnormal muscle drainage tract for X-ray study 48560616_1 CDM 0361 RC 20501 HCPCS inpatient 564 366.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 366.6 65 999999999 341.5 547.08 percent of total billed charges Injection of abnormal muscle drainage tract for X-ray study 48560616_1 CDM 0361 RC 20501 HCPCS inpatient 564 366.6 AETNA AETNA 445.56 79 999999999 341.5 547.08 percent of total billed charges Injection of abnormal muscle drainage tract for X-ray study 48560616_1 CDM 0361 RC 20501 HCPCS inpatient 564 366.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 547.08 97 999999999 341.5 547.08 percent of total billed charges Injection of abnormal muscle drainage tract for X-ray study 48560616_1 CDM 0361 RC 20501 HCPCS inpatient 564 366.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 389.16 69 999999999 341.5 547.08 percent of total billed charges Injection of abnormal muscle drainage tract for X-ray study 48560616_1 CDM 0361 RC 20501 HCPCS inpatient 564 366.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 439.92 78 999999999 341.5 547.08 percent of total billed charges Injection of abnormal muscle drainage tract for X-ray study 48560616_1 CDM 0361 RC 20501 HCPCS inpatient 564 366.6 SIHO - ALL PLANS SIHO - ALL PLANS 507.6 90 999999999 341.5 547.08 percent of total billed charges Injection of abnormal muscle drainage tract for X-ray study 48560616_1 CDM 0361 RC 20501 HCPCS inpatient 564 366.6 UMR - ALL PLANS UMR - ALL PLANS 394.8 70 999999999 341.5 547.08 percent of total billed charges Injection of abnormal muscle drainage tract for X-ray study 48560616_1 CDM 0361 RC 20501 HCPCS inpatient 564 366.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 341.5 60.55 999999999 341.5 547.08 percent of total billed charges Injection of abnormal muscle drainage tract for X-ray study 48560616_1 CDM 0361 RC 20501 HCPCS inpatient 564 366.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 341.5 547.08 Injection of abnormal muscle drainage tract for X-ray study 48560616_1 CDM 0361 RC 20501 HCPCS inpatient 564 366.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 341.5 547.08 Injection of abnormal muscle drainage tract for X-ray study 48560616_1 CDM 0361 RC 20501 HCPCS inpatient 564 366.6 ANTHEM HMO ANTHEM HMO 999999999 341.5 547.08 Injection of abnormal muscle drainage tract for X-ray study 48560616_1 CDM 0361 RC 20501 HCPCS inpatient 564 366.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 381.26 67.6 999999999 341.5 547.08 percent of total billed charges Injection of abnormal muscle drainage tract for X-ray study 48560616_1 CDM 0361 RC 20501 HCPCS inpatient 564 366.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 341.5 547.08 Injection of abnormal muscle drainage tract for X-ray study 48560616_1 CDM 0361 RC 20501 HCPCS inpatient 564 366.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 341.5 547.08 Injection of contrast for imaging of saliva glands 48560617_1 CDM 0361 RC 42550 HCPCS inpatient 616 400.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 400.4 65 999999999 372.99 597.52 percent of total billed charges Injection of contrast for imaging of saliva glands 48560617_1 CDM 0361 RC 42550 HCPCS inpatient 616 400.4 AETNA AETNA 486.64 79 999999999 372.99 597.52 percent of total billed charges Injection of contrast for imaging of saliva glands 48560617_1 CDM 0361 RC 42550 HCPCS inpatient 616 400.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 597.52 97 999999999 372.99 597.52 percent of total billed charges Injection of contrast for imaging of saliva glands 48560617_1 CDM 0361 RC 42550 HCPCS inpatient 616 400.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 425.04 69 999999999 372.99 597.52 percent of total billed charges Injection of contrast for imaging of saliva glands 48560617_1 CDM 0361 RC 42550 HCPCS inpatient 616 400.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 480.48 78 999999999 372.99 597.52 percent of total billed charges Injection of contrast for imaging of saliva glands 48560617_1 CDM 0361 RC 42550 HCPCS inpatient 616 400.4 SIHO - ALL PLANS SIHO - ALL PLANS 554.4 90 999999999 372.99 597.52 percent of total billed charges Injection of contrast for imaging of saliva glands 48560617_1 CDM 0361 RC 42550 HCPCS inpatient 616 400.4 UMR - ALL PLANS UMR - ALL PLANS 431.2 70 999999999 372.99 597.52 percent of total billed charges Injection of contrast for imaging of saliva glands 48560617_1 CDM 0361 RC 42550 HCPCS inpatient 616 400.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 372.99 60.55 999999999 372.99 597.52 percent of total billed charges Injection of contrast for imaging of saliva glands 48560617_1 CDM 0361 RC 42550 HCPCS inpatient 616 400.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 372.99 597.52 Injection of contrast for imaging of saliva glands 48560617_1 CDM 0361 RC 42550 HCPCS inpatient 616 400.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 372.99 597.52 Injection of contrast for imaging of saliva glands 48560617_1 CDM 0361 RC 42550 HCPCS inpatient 616 400.4 ANTHEM HMO ANTHEM HMO 999999999 372.99 597.52 Injection of contrast for imaging of saliva glands 48560617_1 CDM 0361 RC 42550 HCPCS inpatient 616 400.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 416.42 67.6 999999999 372.99 597.52 percent of total billed charges Injection of contrast for imaging of saliva glands 48560617_1 CDM 0361 RC 42550 HCPCS inpatient 616 400.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 372.99 597.52 Injection of contrast for imaging of saliva glands 48560617_1 CDM 0361 RC 42550 HCPCS inpatient 616 400.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 372.99 597.52 Removal of sample of amniotic fluid surrounding fetus for diagnosis 48560618_1 CDM 0361 RC 59000 HCPCS inpatient 1165 757.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 757.25 65 999999999 705.41 1130.05 percent of total billed charges Removal of sample of amniotic fluid surrounding fetus for diagnosis 48560618_1 CDM 0361 RC 59000 HCPCS inpatient 1165 757.25 AETNA AETNA 920.35 79 999999999 705.41 1130.05 percent of total billed charges Removal of sample of amniotic fluid surrounding fetus for diagnosis 48560618_1 CDM 0361 RC 59000 HCPCS inpatient 1165 757.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1130.05 97 999999999 705.41 1130.05 percent of total billed charges Removal of sample of amniotic fluid surrounding fetus for diagnosis 48560618_1 CDM 0361 RC 59000 HCPCS inpatient 1165 757.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 803.85 69 999999999 705.41 1130.05 percent of total billed charges Removal of sample of amniotic fluid surrounding fetus for diagnosis 48560618_1 CDM 0361 RC 59000 HCPCS inpatient 1165 757.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 908.7 78 999999999 705.41 1130.05 percent of total billed charges Removal of sample of amniotic fluid surrounding fetus for diagnosis 48560618_1 CDM 0361 RC 59000 HCPCS inpatient 1165 757.25 SIHO - ALL PLANS SIHO - ALL PLANS 1048.5 90 999999999 705.41 1130.05 percent of total billed charges Removal of sample of amniotic fluid surrounding fetus for diagnosis 48560618_1 CDM 0361 RC 59000 HCPCS inpatient 1165 757.25 UMR - ALL PLANS UMR - ALL PLANS 815.5 70 999999999 705.41 1130.05 percent of total billed charges Removal of sample of amniotic fluid surrounding fetus for diagnosis 48560618_1 CDM 0361 RC 59000 HCPCS inpatient 1165 757.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 705.41 60.55 999999999 705.41 1130.05 percent of total billed charges Removal of sample of amniotic fluid surrounding fetus for diagnosis 48560618_1 CDM 0361 RC 59000 HCPCS inpatient 1165 757.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 705.41 1130.05 Removal of sample of amniotic fluid surrounding fetus for diagnosis 48560618_1 CDM 0361 RC 59000 HCPCS inpatient 1165 757.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 705.41 1130.05 Removal of sample of amniotic fluid surrounding fetus for diagnosis 48560618_1 CDM 0361 RC 59000 HCPCS inpatient 1165 757.25 ANTHEM HMO ANTHEM HMO 999999999 705.41 1130.05 Removal of sample of amniotic fluid surrounding fetus for diagnosis 48560618_1 CDM 0361 RC 59000 HCPCS inpatient 1165 757.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 787.54 67.6 999999999 705.41 1130.05 percent of total billed charges Removal of sample of amniotic fluid surrounding fetus for diagnosis 48560618_1 CDM 0361 RC 59000 HCPCS inpatient 1165 757.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 705.41 1130.05 Removal of sample of amniotic fluid surrounding fetus for diagnosis 48560618_1 CDM 0361 RC 59000 HCPCS inpatient 1165 757.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 705.41 1130.05 Drainage of fluid from abdominal cavity using imaging guidance 48560619_1 CDM 0361 RC 49083 HCPCS inpatient 812 527.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 527.8 65 999999999 491.67 787.64 percent of total billed charges Drainage of fluid from abdominal cavity using imaging guidance 48560619_1 CDM 0361 RC 49083 HCPCS inpatient 812 527.8 AETNA AETNA 641.48 79 999999999 491.67 787.64 percent of total billed charges Drainage of fluid from abdominal cavity using imaging guidance 48560619_1 CDM 0361 RC 49083 HCPCS inpatient 812 527.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 787.64 97 999999999 491.67 787.64 percent of total billed charges Drainage of fluid from abdominal cavity using imaging guidance 48560619_1 CDM 0361 RC 49083 HCPCS inpatient 812 527.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 560.28 69 999999999 491.67 787.64 percent of total billed charges Drainage of fluid from abdominal cavity using imaging guidance 48560619_1 CDM 0361 RC 49083 HCPCS inpatient 812 527.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 633.36 78 999999999 491.67 787.64 percent of total billed charges Drainage of fluid from abdominal cavity using imaging guidance 48560619_1 CDM 0361 RC 49083 HCPCS inpatient 812 527.8 SIHO - ALL PLANS SIHO - ALL PLANS 730.8 90 999999999 491.67 787.64 percent of total billed charges Drainage of fluid from abdominal cavity using imaging guidance 48560619_1 CDM 0361 RC 49083 HCPCS inpatient 812 527.8 UMR - ALL PLANS UMR - ALL PLANS 568.4 70 999999999 491.67 787.64 percent of total billed charges Drainage of fluid from abdominal cavity using imaging guidance 48560619_1 CDM 0361 RC 49083 HCPCS inpatient 812 527.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 491.67 60.55 999999999 491.67 787.64 percent of total billed charges Drainage of fluid from abdominal cavity using imaging guidance 48560619_1 CDM 0361 RC 49083 HCPCS inpatient 812 527.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 491.67 787.64 Drainage of fluid from abdominal cavity using imaging guidance 48560619_1 CDM 0361 RC 49083 HCPCS inpatient 812 527.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 491.67 787.64 Drainage of fluid from abdominal cavity using imaging guidance 48560619_1 CDM 0361 RC 49083 HCPCS inpatient 812 527.8 ANTHEM HMO ANTHEM HMO 999999999 491.67 787.64 Drainage of fluid from abdominal cavity using imaging guidance 48560619_1 CDM 0361 RC 49083 HCPCS inpatient 812 527.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 548.91 67.6 999999999 491.67 787.64 percent of total billed charges Drainage of fluid from abdominal cavity using imaging guidance 48560619_1 CDM 0361 RC 49083 HCPCS inpatient 812 527.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 491.67 787.64 Drainage of fluid from abdominal cavity using imaging guidance 48560619_1 CDM 0361 RC 49083 HCPCS inpatient 812 527.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 491.67 787.64 Drainage of abscess behind abdominal cavity 48560620_1 CDM 0361 RC 49060 HCPCS inpatient 449 291.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 291.85 65 999999999 271.87 435.53 percent of total billed charges Drainage of abscess behind abdominal cavity 48560620_1 CDM 0361 RC 49060 HCPCS inpatient 449 291.85 AETNA AETNA 354.71 79 999999999 271.87 435.53 percent of total billed charges Drainage of abscess behind abdominal cavity 48560620_1 CDM 0361 RC 49060 HCPCS inpatient 449 291.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 435.53 97 999999999 271.87 435.53 percent of total billed charges Drainage of abscess behind abdominal cavity 48560620_1 CDM 0361 RC 49060 HCPCS inpatient 449 291.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 309.81 69 999999999 271.87 435.53 percent of total billed charges Drainage of abscess behind abdominal cavity 48560620_1 CDM 0361 RC 49060 HCPCS inpatient 449 291.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 350.22 78 999999999 271.87 435.53 percent of total billed charges Drainage of abscess behind abdominal cavity 48560620_1 CDM 0361 RC 49060 HCPCS inpatient 449 291.85 SIHO - ALL PLANS SIHO - ALL PLANS 404.1 90 999999999 271.87 435.53 percent of total billed charges Drainage of abscess behind abdominal cavity 48560620_1 CDM 0361 RC 49060 HCPCS inpatient 449 291.85 UMR - ALL PLANS UMR - ALL PLANS 314.3 70 999999999 271.87 435.53 percent of total billed charges Drainage of abscess behind abdominal cavity 48560620_1 CDM 0361 RC 49060 HCPCS inpatient 449 291.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 271.87 60.55 999999999 271.87 435.53 percent of total billed charges Drainage of abscess behind abdominal cavity 48560620_1 CDM 0361 RC 49060 HCPCS inpatient 449 291.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 271.87 435.53 Drainage of abscess behind abdominal cavity 48560620_1 CDM 0361 RC 49060 HCPCS inpatient 449 291.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 271.87 435.53 Drainage of abscess behind abdominal cavity 48560620_1 CDM 0361 RC 49060 HCPCS inpatient 449 291.85 ANTHEM HMO ANTHEM HMO 999999999 271.87 435.53 Drainage of abscess behind abdominal cavity 48560620_1 CDM 0361 RC 49060 HCPCS inpatient 449 291.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 303.52 67.6 999999999 271.87 435.53 percent of total billed charges Drainage of abscess behind abdominal cavity 48560620_1 CDM 0361 RC 49060 HCPCS inpatient 449 291.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 271.87 435.53 Drainage of abscess behind abdominal cavity 48560620_1 CDM 0361 RC 49060 HCPCS inpatient 449 291.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 271.87 435.53 Needle biopsy of growth of abdominal cavity 48560621_1 CDM 0361 RC 49180 HCPCS inpatient 2015 1309.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1309.75 65 999999999 1220.08 1954.55 percent of total billed charges Needle biopsy of growth of abdominal cavity 48560621_1 CDM 0361 RC 49180 HCPCS inpatient 2015 1309.75 AETNA AETNA 1591.85 79 999999999 1220.08 1954.55 percent of total billed charges Needle biopsy of growth of abdominal cavity 48560621_1 CDM 0361 RC 49180 HCPCS inpatient 2015 1309.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1954.55 97 999999999 1220.08 1954.55 percent of total billed charges Needle biopsy of growth of abdominal cavity 48560621_1 CDM 0361 RC 49180 HCPCS inpatient 2015 1309.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1390.35 69 999999999 1220.08 1954.55 percent of total billed charges Needle biopsy of growth of abdominal cavity 48560621_1 CDM 0361 RC 49180 HCPCS inpatient 2015 1309.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1571.7 78 999999999 1220.08 1954.55 percent of total billed charges Needle biopsy of growth of abdominal cavity 48560621_1 CDM 0361 RC 49180 HCPCS inpatient 2015 1309.75 SIHO - ALL PLANS SIHO - ALL PLANS 1813.5 90 999999999 1220.08 1954.55 percent of total billed charges Needle biopsy of growth of abdominal cavity 48560621_1 CDM 0361 RC 49180 HCPCS inpatient 2015 1309.75 UMR - ALL PLANS UMR - ALL PLANS 1410.5 70 999999999 1220.08 1954.55 percent of total billed charges Needle biopsy of growth of abdominal cavity 48560621_1 CDM 0361 RC 49180 HCPCS inpatient 2015 1309.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1220.08 60.55 999999999 1220.08 1954.55 percent of total billed charges Needle biopsy of growth of abdominal cavity 48560621_1 CDM 0361 RC 49180 HCPCS inpatient 2015 1309.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1220.08 1954.55 Needle biopsy of growth of abdominal cavity 48560621_1 CDM 0361 RC 49180 HCPCS inpatient 2015 1309.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1220.08 1954.55 Needle biopsy of growth of abdominal cavity 48560621_1 CDM 0361 RC 49180 HCPCS inpatient 2015 1309.75 ANTHEM HMO ANTHEM HMO 999999999 1220.08 1954.55 Needle biopsy of growth of abdominal cavity 48560621_1 CDM 0361 RC 49180 HCPCS inpatient 2015 1309.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1362.14 67.6 999999999 1220.08 1954.55 percent of total billed charges Needle biopsy of growth of abdominal cavity 48560621_1 CDM 0361 RC 49180 HCPCS inpatient 2015 1309.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1220.08 1954.55 Needle biopsy of growth of abdominal cavity 48560621_1 CDM 0361 RC 49180 HCPCS inpatient 2015 1309.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1220.08 1954.55 "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 48560622_1 CDM 0611 RC 70543 HCPCS inpatient 4583 2978.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 2978.95 65 999999999 2775.01 4445.51 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 48560622_1 CDM 0611 RC 70543 HCPCS inpatient 4583 2978.95 AETNA AETNA 3620.57 79 999999999 2775.01 4445.51 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 48560622_1 CDM 0611 RC 70543 HCPCS inpatient 4583 2978.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4445.51 97 999999999 2775.01 4445.51 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 48560622_1 CDM 0611 RC 70543 HCPCS inpatient 4583 2978.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 3162.27 69 999999999 2775.01 4445.51 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 48560622_1 CDM 0611 RC 70543 HCPCS inpatient 4583 2978.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 3574.74 78 999999999 2775.01 4445.51 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 48560622_1 CDM 0611 RC 70543 HCPCS inpatient 4583 2978.95 SIHO - ALL PLANS SIHO - ALL PLANS 4124.7 90 999999999 2775.01 4445.51 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 48560622_1 CDM 0611 RC 70543 HCPCS inpatient 4583 2978.95 UMR - ALL PLANS UMR - ALL PLANS 3208.1 70 999999999 2775.01 4445.51 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 48560622_1 CDM 0611 RC 70543 HCPCS inpatient 4583 2978.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2775.01 60.55 999999999 2775.01 4445.51 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 48560622_1 CDM 0611 RC 70543 HCPCS inpatient 4583 2978.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2775.01 4445.51 "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 48560622_1 CDM 0611 RC 70543 HCPCS inpatient 4583 2978.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2775.01 4445.51 "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 48560622_1 CDM 0611 RC 70543 HCPCS inpatient 4583 2978.95 ANTHEM HMO ANTHEM HMO 999999999 2775.01 4445.51 "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 48560622_1 CDM 0611 RC 70543 HCPCS inpatient 4583 2978.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 3098.11 67.6 999999999 2775.01 4445.51 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 48560622_1 CDM 0611 RC 70543 HCPCS inpatient 4583 2978.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2775.01 4445.51 "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 48560622_1 CDM 0611 RC 70543 HCPCS inpatient 4583 2978.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 2775.01 4445.51 MRI scan of brain without contrast 48560623_1 CDM 0611 RC 70551 HCPCS inpatient 4425 2876.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 2876.25 65 999999999 2679.34 4292.25 percent of total billed charges MRI scan of brain without contrast 48560623_1 CDM 0611 RC 70551 HCPCS inpatient 4425 2876.25 AETNA AETNA 3495.75 79 999999999 2679.34 4292.25 percent of total billed charges MRI scan of brain without contrast 48560623_1 CDM 0611 RC 70551 HCPCS inpatient 4425 2876.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4292.25 97 999999999 2679.34 4292.25 percent of total billed charges MRI scan of brain without contrast 48560623_1 CDM 0611 RC 70551 HCPCS inpatient 4425 2876.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 3053.25 69 999999999 2679.34 4292.25 percent of total billed charges MRI scan of brain without contrast 48560623_1 CDM 0611 RC 70551 HCPCS inpatient 4425 2876.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 3451.5 78 999999999 2679.34 4292.25 percent of total billed charges MRI scan of brain without contrast 48560623_1 CDM 0611 RC 70551 HCPCS inpatient 4425 2876.25 SIHO - ALL PLANS SIHO - ALL PLANS 3982.5 90 999999999 2679.34 4292.25 percent of total billed charges MRI scan of brain without contrast 48560623_1 CDM 0611 RC 70551 HCPCS inpatient 4425 2876.25 UMR - ALL PLANS UMR - ALL PLANS 3097.5 70 999999999 2679.34 4292.25 percent of total billed charges MRI scan of brain without contrast 48560623_1 CDM 0611 RC 70551 HCPCS inpatient 4425 2876.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2679.34 60.55 999999999 2679.34 4292.25 percent of total billed charges MRI scan of brain without contrast 48560623_1 CDM 0611 RC 70551 HCPCS inpatient 4425 2876.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2679.34 4292.25 MRI scan of brain without contrast 48560623_1 CDM 0611 RC 70551 HCPCS inpatient 4425 2876.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2679.34 4292.25 MRI scan of brain without contrast 48560623_1 CDM 0611 RC 70551 HCPCS inpatient 4425 2876.25 ANTHEM HMO ANTHEM HMO 999999999 2679.34 4292.25 MRI scan of brain without contrast 48560623_1 CDM 0611 RC 70551 HCPCS inpatient 4425 2876.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 2991.3 67.6 999999999 2679.34 4292.25 percent of total billed charges MRI scan of brain without contrast 48560623_1 CDM 0611 RC 70551 HCPCS inpatient 4425 2876.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2679.34 4292.25 MRI scan of brain without contrast 48560623_1 CDM 0611 RC 70551 HCPCS inpatient 4425 2876.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 2679.34 4292.25 Needle biopsy of liver through skin 48560624_1 CDM 0361 RC 47000 HCPCS inpatient 2015 1309.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1309.75 65 999999999 1220.08 1954.55 percent of total billed charges Needle biopsy of liver through skin 48560624_1 CDM 0361 RC 47000 HCPCS inpatient 2015 1309.75 AETNA AETNA 1591.85 79 999999999 1220.08 1954.55 percent of total billed charges Needle biopsy of liver through skin 48560624_1 CDM 0361 RC 47000 HCPCS inpatient 2015 1309.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1954.55 97 999999999 1220.08 1954.55 percent of total billed charges Needle biopsy of liver through skin 48560624_1 CDM 0361 RC 47000 HCPCS inpatient 2015 1309.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1390.35 69 999999999 1220.08 1954.55 percent of total billed charges Needle biopsy of liver through skin 48560624_1 CDM 0361 RC 47000 HCPCS inpatient 2015 1309.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1571.7 78 999999999 1220.08 1954.55 percent of total billed charges Needle biopsy of liver through skin 48560624_1 CDM 0361 RC 47000 HCPCS inpatient 2015 1309.75 SIHO - ALL PLANS SIHO - ALL PLANS 1813.5 90 999999999 1220.08 1954.55 percent of total billed charges Needle biopsy of liver through skin 48560624_1 CDM 0361 RC 47000 HCPCS inpatient 2015 1309.75 UMR - ALL PLANS UMR - ALL PLANS 1410.5 70 999999999 1220.08 1954.55 percent of total billed charges Needle biopsy of liver through skin 48560624_1 CDM 0361 RC 47000 HCPCS inpatient 2015 1309.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1220.08 60.55 999999999 1220.08 1954.55 percent of total billed charges Needle biopsy of liver through skin 48560624_1 CDM 0361 RC 47000 HCPCS inpatient 2015 1309.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1220.08 1954.55 Needle biopsy of liver through skin 48560624_1 CDM 0361 RC 47000 HCPCS inpatient 2015 1309.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1220.08 1954.55 Needle biopsy of liver through skin 48560624_1 CDM 0361 RC 47000 HCPCS inpatient 2015 1309.75 ANTHEM HMO ANTHEM HMO 999999999 1220.08 1954.55 Needle biopsy of liver through skin 48560624_1 CDM 0361 RC 47000 HCPCS inpatient 2015 1309.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1362.14 67.6 999999999 1220.08 1954.55 percent of total billed charges Needle biopsy of liver through skin 48560624_1 CDM 0361 RC 47000 HCPCS inpatient 2015 1309.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1220.08 1954.55 Needle biopsy of liver through skin 48560624_1 CDM 0361 RC 47000 HCPCS inpatient 2015 1309.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1220.08 1954.55 "Fine needle aspiration biopsy using ultrasound guidance, first growth" 48560625_1 CDM 0361 RC 10005 HCPCS inpatient 1133 736.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 736.45 65 999999999 686.03 1099.01 percent of total billed charges "Fine needle aspiration biopsy using ultrasound guidance, first growth" 48560625_1 CDM 0361 RC 10005 HCPCS inpatient 1133 736.45 AETNA AETNA 895.07 79 999999999 686.03 1099.01 percent of total billed charges "Fine needle aspiration biopsy using ultrasound guidance, first growth" 48560625_1 CDM 0361 RC 10005 HCPCS inpatient 1133 736.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1099.01 97 999999999 686.03 1099.01 percent of total billed charges "Fine needle aspiration biopsy using ultrasound guidance, first growth" 48560625_1 CDM 0361 RC 10005 HCPCS inpatient 1133 736.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 781.77 69 999999999 686.03 1099.01 percent of total billed charges "Fine needle aspiration biopsy using ultrasound guidance, first growth" 48560625_1 CDM 0361 RC 10005 HCPCS inpatient 1133 736.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 883.74 78 999999999 686.03 1099.01 percent of total billed charges "Fine needle aspiration biopsy using ultrasound guidance, first growth" 48560625_1 CDM 0361 RC 10005 HCPCS inpatient 1133 736.45 SIHO - ALL PLANS SIHO - ALL PLANS 1019.7 90 999999999 686.03 1099.01 percent of total billed charges "Fine needle aspiration biopsy using ultrasound guidance, first growth" 48560625_1 CDM 0361 RC 10005 HCPCS inpatient 1133 736.45 UMR - ALL PLANS UMR - ALL PLANS 793.1 70 999999999 686.03 1099.01 percent of total billed charges "Fine needle aspiration biopsy using ultrasound guidance, first growth" 48560625_1 CDM 0361 RC 10005 HCPCS inpatient 1133 736.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 686.03 60.55 999999999 686.03 1099.01 percent of total billed charges "Fine needle aspiration biopsy using ultrasound guidance, first growth" 48560625_1 CDM 0361 RC 10005 HCPCS inpatient 1133 736.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 686.03 1099.01 "Fine needle aspiration biopsy using ultrasound guidance, first growth" 48560625_1 CDM 0361 RC 10005 HCPCS inpatient 1133 736.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 686.03 1099.01 "Fine needle aspiration biopsy using ultrasound guidance, first growth" 48560625_1 CDM 0361 RC 10005 HCPCS inpatient 1133 736.45 ANTHEM HMO ANTHEM HMO 999999999 686.03 1099.01 "Fine needle aspiration biopsy using ultrasound guidance, first growth" 48560625_1 CDM 0361 RC 10005 HCPCS inpatient 1133 736.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 765.91 67.6 999999999 686.03 1099.01 percent of total billed charges "Fine needle aspiration biopsy using ultrasound guidance, first growth" 48560625_1 CDM 0361 RC 10005 HCPCS inpatient 1133 736.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 686.03 1099.01 "Fine needle aspiration biopsy using ultrasound guidance, first growth" 48560625_1 CDM 0361 RC 10005 HCPCS inpatient 1133 736.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 686.03 1099.01 "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560626_1 CDM 0361 RC 32408 HCPCS inpatient 1658 1077.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1077.7 65 999999999 1003.92 1608.26 percent of total billed charges "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560626_1 CDM 0361 RC 32408 HCPCS inpatient 1658 1077.7 AETNA AETNA 1309.82 79 999999999 1003.92 1608.26 percent of total billed charges "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560626_1 CDM 0361 RC 32408 HCPCS inpatient 1658 1077.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1608.26 97 999999999 1003.92 1608.26 percent of total billed charges "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560626_1 CDM 0361 RC 32408 HCPCS inpatient 1658 1077.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1144.02 69 999999999 1003.92 1608.26 percent of total billed charges "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560626_1 CDM 0361 RC 32408 HCPCS inpatient 1658 1077.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1293.24 78 999999999 1003.92 1608.26 percent of total billed charges "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560626_1 CDM 0361 RC 32408 HCPCS inpatient 1658 1077.7 SIHO - ALL PLANS SIHO - ALL PLANS 1492.2 90 999999999 1003.92 1608.26 percent of total billed charges "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560626_1 CDM 0361 RC 32408 HCPCS inpatient 1658 1077.7 UMR - ALL PLANS UMR - ALL PLANS 1160.6 70 999999999 1003.92 1608.26 percent of total billed charges "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560626_1 CDM 0361 RC 32408 HCPCS inpatient 1658 1077.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1003.92 60.55 999999999 1003.92 1608.26 percent of total billed charges "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560626_1 CDM 0361 RC 32408 HCPCS inpatient 1658 1077.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1003.92 1608.26 "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560626_1 CDM 0361 RC 32408 HCPCS inpatient 1658 1077.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1003.92 1608.26 "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560626_1 CDM 0361 RC 32408 HCPCS inpatient 1658 1077.7 ANTHEM HMO ANTHEM HMO 999999999 1003.92 1608.26 "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560626_1 CDM 0361 RC 32408 HCPCS inpatient 1658 1077.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1120.81 67.6 999999999 1003.92 1608.26 percent of total billed charges "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560626_1 CDM 0361 RC 32408 HCPCS inpatient 1658 1077.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1003.92 1608.26 "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560626_1 CDM 0361 RC 32408 HCPCS inpatient 1658 1077.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 1003.92 1608.26 "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560627_1 CDM 0361 RC 32408 HCPCS inpatient 1507 979.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 979.55 65 999999999 912.49 1461.79 percent of total billed charges "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560627_1 CDM 0361 RC 32408 HCPCS inpatient 1507 979.55 AETNA AETNA 1190.53 79 999999999 912.49 1461.79 percent of total billed charges "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560627_1 CDM 0361 RC 32408 HCPCS inpatient 1507 979.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1461.79 97 999999999 912.49 1461.79 percent of total billed charges "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560627_1 CDM 0361 RC 32408 HCPCS inpatient 1507 979.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1039.83 69 999999999 912.49 1461.79 percent of total billed charges "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560627_1 CDM 0361 RC 32408 HCPCS inpatient 1507 979.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1175.46 78 999999999 912.49 1461.79 percent of total billed charges "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560627_1 CDM 0361 RC 32408 HCPCS inpatient 1507 979.55 SIHO - ALL PLANS SIHO - ALL PLANS 1356.3 90 999999999 912.49 1461.79 percent of total billed charges "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560627_1 CDM 0361 RC 32408 HCPCS inpatient 1507 979.55 UMR - ALL PLANS UMR - ALL PLANS 1054.9 70 999999999 912.49 1461.79 percent of total billed charges "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560627_1 CDM 0361 RC 32408 HCPCS inpatient 1507 979.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 912.49 60.55 999999999 912.49 1461.79 percent of total billed charges "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560627_1 CDM 0361 RC 32408 HCPCS inpatient 1507 979.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 912.49 1461.79 "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560627_1 CDM 0361 RC 32408 HCPCS inpatient 1507 979.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 912.49 1461.79 "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560627_1 CDM 0361 RC 32408 HCPCS inpatient 1507 979.55 ANTHEM HMO ANTHEM HMO 999999999 912.49 1461.79 "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560627_1 CDM 0361 RC 32408 HCPCS inpatient 1507 979.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1018.73 67.6 999999999 912.49 1461.79 percent of total billed charges "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560627_1 CDM 0361 RC 32408 HCPCS inpatient 1507 979.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 912.49 1461.79 "Core needle biopsy of lung or center cavity of chest (mediastinum), accessed through skin" 48560627_1 CDM 0361 RC 32408 HCPCS inpatient 1507 979.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 912.49 1461.79 Needle biopsy of lining of lung 48560628_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 979.55 65 999999999 912.49 1461.79 percent of total billed charges Needle biopsy of lining of lung 48560628_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 AETNA AETNA 1190.53 79 999999999 912.49 1461.79 percent of total billed charges Needle biopsy of lining of lung 48560628_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1461.79 97 999999999 912.49 1461.79 percent of total billed charges Needle biopsy of lining of lung 48560628_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1039.83 69 999999999 912.49 1461.79 percent of total billed charges Needle biopsy of lining of lung 48560628_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1175.46 78 999999999 912.49 1461.79 percent of total billed charges Needle biopsy of lining of lung 48560628_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 SIHO - ALL PLANS SIHO - ALL PLANS 1356.3 90 999999999 912.49 1461.79 percent of total billed charges Needle biopsy of lining of lung 48560628_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 UMR - ALL PLANS UMR - ALL PLANS 1054.9 70 999999999 912.49 1461.79 percent of total billed charges Needle biopsy of lining of lung 48560628_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 912.49 60.55 999999999 912.49 1461.79 percent of total billed charges Needle biopsy of lining of lung 48560628_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 912.49 1461.79 Needle biopsy of lining of lung 48560628_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 912.49 1461.79 Needle biopsy of lining of lung 48560628_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 ANTHEM HMO ANTHEM HMO 999999999 912.49 1461.79 Needle biopsy of lining of lung 48560628_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1018.73 67.6 999999999 912.49 1461.79 percent of total billed charges Needle biopsy of lining of lung 48560628_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 912.49 1461.79 Needle biopsy of lining of lung 48560628_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 912.49 1461.79 Needle biopsy of lining of lung 48560629_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 979.55 65 999999999 912.49 1461.79 percent of total billed charges Needle biopsy of lining of lung 48560629_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 AETNA AETNA 1190.53 79 999999999 912.49 1461.79 percent of total billed charges Needle biopsy of lining of lung 48560629_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1461.79 97 999999999 912.49 1461.79 percent of total billed charges Needle biopsy of lining of lung 48560629_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1039.83 69 999999999 912.49 1461.79 percent of total billed charges Needle biopsy of lining of lung 48560629_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1175.46 78 999999999 912.49 1461.79 percent of total billed charges Needle biopsy of lining of lung 48560629_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 SIHO - ALL PLANS SIHO - ALL PLANS 1356.3 90 999999999 912.49 1461.79 percent of total billed charges Needle biopsy of lining of lung 48560629_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 UMR - ALL PLANS UMR - ALL PLANS 1054.9 70 999999999 912.49 1461.79 percent of total billed charges Needle biopsy of lining of lung 48560629_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 912.49 60.55 999999999 912.49 1461.79 percent of total billed charges Needle biopsy of lining of lung 48560629_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 912.49 1461.79 Needle biopsy of lining of lung 48560629_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 912.49 1461.79 Needle biopsy of lining of lung 48560629_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 ANTHEM HMO ANTHEM HMO 999999999 912.49 1461.79 Needle biopsy of lining of lung 48560629_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1018.73 67.6 999999999 912.49 1461.79 percent of total billed charges Needle biopsy of lining of lung 48560629_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 912.49 1461.79 Needle biopsy of lining of lung 48560629_1 CDM 0361 RC 32400 HCPCS inpatient 1507 979.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 912.49 1461.79 Aspiration of fluid from chest cavity using imaging guidance 48560630_1 CDM 0361 RC 32555 HCPCS inpatient 1809 1175.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1175.85 65 999999999 1095.35 1754.73 percent of total billed charges Aspiration of fluid from chest cavity using imaging guidance 48560630_1 CDM 0361 RC 32555 HCPCS inpatient 1809 1175.85 AETNA AETNA 1429.11 79 999999999 1095.35 1754.73 percent of total billed charges Aspiration of fluid from chest cavity using imaging guidance 48560630_1 CDM 0361 RC 32555 HCPCS inpatient 1809 1175.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1754.73 97 999999999 1095.35 1754.73 percent of total billed charges Aspiration of fluid from chest cavity using imaging guidance 48560630_1 CDM 0361 RC 32555 HCPCS inpatient 1809 1175.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1248.21 69 999999999 1095.35 1754.73 percent of total billed charges Aspiration of fluid from chest cavity using imaging guidance 48560630_1 CDM 0361 RC 32555 HCPCS inpatient 1809 1175.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1411.02 78 999999999 1095.35 1754.73 percent of total billed charges Aspiration of fluid from chest cavity using imaging guidance 48560630_1 CDM 0361 RC 32555 HCPCS inpatient 1809 1175.85 SIHO - ALL PLANS SIHO - ALL PLANS 1628.1 90 999999999 1095.35 1754.73 percent of total billed charges Aspiration of fluid from chest cavity using imaging guidance 48560630_1 CDM 0361 RC 32555 HCPCS inpatient 1809 1175.85 UMR - ALL PLANS UMR - ALL PLANS 1266.3 70 999999999 1095.35 1754.73 percent of total billed charges Aspiration of fluid from chest cavity using imaging guidance 48560630_1 CDM 0361 RC 32555 HCPCS inpatient 1809 1175.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1095.35 60.55 999999999 1095.35 1754.73 percent of total billed charges Aspiration of fluid from chest cavity using imaging guidance 48560630_1 CDM 0361 RC 32555 HCPCS inpatient 1809 1175.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1095.35 1754.73 Aspiration of fluid from chest cavity using imaging guidance 48560630_1 CDM 0361 RC 32555 HCPCS inpatient 1809 1175.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1095.35 1754.73 Aspiration of fluid from chest cavity using imaging guidance 48560630_1 CDM 0361 RC 32555 HCPCS inpatient 1809 1175.85 ANTHEM HMO ANTHEM HMO 999999999 1095.35 1754.73 Aspiration of fluid from chest cavity using imaging guidance 48560630_1 CDM 0361 RC 32555 HCPCS inpatient 1809 1175.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1222.88 67.6 999999999 1095.35 1754.73 percent of total billed charges Aspiration of fluid from chest cavity using imaging guidance 48560630_1 CDM 0361 RC 32555 HCPCS inpatient 1809 1175.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1095.35 1754.73 Aspiration of fluid from chest cavity using imaging guidance 48560630_1 CDM 0361 RC 32555 HCPCS inpatient 1809 1175.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1095.35 1754.73 Needle biopsy or removal of surface lymph nodes 48560631_1 CDM 0361 RC 38505 HCPCS inpatient 1475 958.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 958.75 65 999999999 893.11 1430.75 percent of total billed charges Needle biopsy or removal of surface lymph nodes 48560631_1 CDM 0361 RC 38505 HCPCS inpatient 1475 958.75 AETNA AETNA 1165.25 79 999999999 893.11 1430.75 percent of total billed charges Needle biopsy or removal of surface lymph nodes 48560631_1 CDM 0361 RC 38505 HCPCS inpatient 1475 958.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1430.75 97 999999999 893.11 1430.75 percent of total billed charges Needle biopsy or removal of surface lymph nodes 48560631_1 CDM 0361 RC 38505 HCPCS inpatient 1475 958.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1017.75 69 999999999 893.11 1430.75 percent of total billed charges Needle biopsy or removal of surface lymph nodes 48560631_1 CDM 0361 RC 38505 HCPCS inpatient 1475 958.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1150.5 78 999999999 893.11 1430.75 percent of total billed charges Needle biopsy or removal of surface lymph nodes 48560631_1 CDM 0361 RC 38505 HCPCS inpatient 1475 958.75 SIHO - ALL PLANS SIHO - ALL PLANS 1327.5 90 999999999 893.11 1430.75 percent of total billed charges Needle biopsy or removal of surface lymph nodes 48560631_1 CDM 0361 RC 38505 HCPCS inpatient 1475 958.75 UMR - ALL PLANS UMR - ALL PLANS 1032.5 70 999999999 893.11 1430.75 percent of total billed charges Needle biopsy or removal of surface lymph nodes 48560631_1 CDM 0361 RC 38505 HCPCS inpatient 1475 958.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 893.11 60.55 999999999 893.11 1430.75 percent of total billed charges Needle biopsy or removal of surface lymph nodes 48560631_1 CDM 0361 RC 38505 HCPCS inpatient 1475 958.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 893.11 1430.75 Needle biopsy or removal of surface lymph nodes 48560631_1 CDM 0361 RC 38505 HCPCS inpatient 1475 958.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 893.11 1430.75 Needle biopsy or removal of surface lymph nodes 48560631_1 CDM 0361 RC 38505 HCPCS inpatient 1475 958.75 ANTHEM HMO ANTHEM HMO 999999999 893.11 1430.75 Needle biopsy or removal of surface lymph nodes 48560631_1 CDM 0361 RC 38505 HCPCS inpatient 1475 958.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 997.1 67.6 999999999 893.11 1430.75 percent of total billed charges Needle biopsy or removal of surface lymph nodes 48560631_1 CDM 0361 RC 38505 HCPCS inpatient 1475 958.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 893.11 1430.75 Needle biopsy or removal of surface lymph nodes 48560631_1 CDM 0361 RC 38505 HCPCS inpatient 1475 958.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 893.11 1430.75 Drainage of abscess of kidney 48560632_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 291.85 65 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560632_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 AETNA AETNA 354.71 79 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560632_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 435.53 97 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560632_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 309.81 69 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560632_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 350.22 78 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560632_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 SIHO - ALL PLANS SIHO - ALL PLANS 404.1 90 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560632_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 UMR - ALL PLANS UMR - ALL PLANS 314.3 70 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560632_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 271.87 60.55 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560632_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 271.87 435.53 Drainage of abscess of kidney 48560632_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 271.87 435.53 Drainage of abscess of kidney 48560632_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 ANTHEM HMO ANTHEM HMO 999999999 271.87 435.53 Drainage of abscess of kidney 48560632_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 303.52 67.6 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560632_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 271.87 435.53 Drainage of abscess of kidney 48560632_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 271.87 435.53 Drainage of abscess of kidney 48560633_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 291.85 65 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560633_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 AETNA AETNA 354.71 79 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560633_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 435.53 97 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560633_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 309.81 69 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560633_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 350.22 78 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560633_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 SIHO - ALL PLANS SIHO - ALL PLANS 404.1 90 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560633_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 UMR - ALL PLANS UMR - ALL PLANS 314.3 70 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560633_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 271.87 60.55 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560633_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 271.87 435.53 Drainage of abscess of kidney 48560633_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 271.87 435.53 Drainage of abscess of kidney 48560633_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 ANTHEM HMO ANTHEM HMO 999999999 271.87 435.53 Drainage of abscess of kidney 48560633_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 303.52 67.6 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560633_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 271.87 435.53 Drainage of abscess of kidney 48560633_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 271.87 435.53 Drainage of abscess of kidney 48560634_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 291.85 65 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560634_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 AETNA AETNA 354.71 79 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560634_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 435.53 97 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560634_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 309.81 69 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560634_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 350.22 78 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560634_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 SIHO - ALL PLANS SIHO - ALL PLANS 404.1 90 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560634_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 UMR - ALL PLANS UMR - ALL PLANS 314.3 70 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560634_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 271.87 60.55 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560634_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 271.87 435.53 Drainage of abscess of kidney 48560634_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 271.87 435.53 Drainage of abscess of kidney 48560634_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 ANTHEM HMO ANTHEM HMO 999999999 271.87 435.53 Drainage of abscess of kidney 48560634_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 303.52 67.6 999999999 271.87 435.53 percent of total billed charges Drainage of abscess of kidney 48560634_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 271.87 435.53 Drainage of abscess of kidney 48560634_1 CDM 0320 RC 50020 HCPCS inpatient 449 291.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 271.87 435.53 Needle biopsy of kidney 48560635_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 580.45 65 999999999 540.71 866.21 percent of total billed charges Needle biopsy of kidney 48560635_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 AETNA AETNA 705.47 79 999999999 540.71 866.21 percent of total billed charges Needle biopsy of kidney 48560635_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 866.21 97 999999999 540.71 866.21 percent of total billed charges Needle biopsy of kidney 48560635_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 616.17 69 999999999 540.71 866.21 percent of total billed charges Needle biopsy of kidney 48560635_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 696.54 78 999999999 540.71 866.21 percent of total billed charges Needle biopsy of kidney 48560635_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 SIHO - ALL PLANS SIHO - ALL PLANS 803.7 90 999999999 540.71 866.21 percent of total billed charges Needle biopsy of kidney 48560635_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 UMR - ALL PLANS UMR - ALL PLANS 625.1 70 999999999 540.71 866.21 percent of total billed charges Needle biopsy of kidney 48560635_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 540.71 60.55 999999999 540.71 866.21 percent of total billed charges Needle biopsy of kidney 48560635_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 540.71 866.21 Needle biopsy of kidney 48560635_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 540.71 866.21 Needle biopsy of kidney 48560635_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 ANTHEM HMO ANTHEM HMO 999999999 540.71 866.21 Needle biopsy of kidney 48560635_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 603.67 67.6 999999999 540.71 866.21 percent of total billed charges Needle biopsy of kidney 48560635_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 540.71 866.21 Needle biopsy of kidney 48560635_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 540.71 866.21 Needle biopsy of kidney 48560641_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 580.45 65 999999999 540.71 866.21 percent of total billed charges Needle biopsy of kidney 48560641_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 AETNA AETNA 705.47 79 999999999 540.71 866.21 percent of total billed charges Needle biopsy of kidney 48560641_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 866.21 97 999999999 540.71 866.21 percent of total billed charges Needle biopsy of kidney 48560641_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 616.17 69 999999999 540.71 866.21 percent of total billed charges Needle biopsy of kidney 48560641_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 696.54 78 999999999 540.71 866.21 percent of total billed charges Needle biopsy of kidney 48560641_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 SIHO - ALL PLANS SIHO - ALL PLANS 803.7 90 999999999 540.71 866.21 percent of total billed charges Needle biopsy of kidney 48560641_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 UMR - ALL PLANS UMR - ALL PLANS 625.1 70 999999999 540.71 866.21 percent of total billed charges Needle biopsy of kidney 48560641_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 540.71 60.55 999999999 540.71 866.21 percent of total billed charges Needle biopsy of kidney 48560641_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 540.71 866.21 Needle biopsy of kidney 48560641_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 540.71 866.21 Needle biopsy of kidney 48560641_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 ANTHEM HMO ANTHEM HMO 999999999 540.71 866.21 Needle biopsy of kidney 48560641_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 603.67 67.6 999999999 540.71 866.21 percent of total billed charges Needle biopsy of kidney 48560641_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 540.71 866.21 Needle biopsy of kidney 48560641_1 CDM 0361 RC 50200 HCPCS inpatient 893 580.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 540.71 866.21 Needle biopsy of kidney 48560642_1 CDM 0361 RC 50200 HCPCS inpatient 1742 1132.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1132.3 65 999999999 1054.78 1689.74 percent of total billed charges Needle biopsy of kidney 48560642_1 CDM 0361 RC 50200 HCPCS inpatient 1742 1132.3 AETNA AETNA 1376.18 79 999999999 1054.78 1689.74 percent of total billed charges Needle biopsy of kidney 48560642_1 CDM 0361 RC 50200 HCPCS inpatient 1742 1132.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1689.74 97 999999999 1054.78 1689.74 percent of total billed charges Needle biopsy of kidney 48560642_1 CDM 0361 RC 50200 HCPCS inpatient 1742 1132.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1201.98 69 999999999 1054.78 1689.74 percent of total billed charges Needle biopsy of kidney 48560642_1 CDM 0361 RC 50200 HCPCS inpatient 1742 1132.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1358.76 78 999999999 1054.78 1689.74 percent of total billed charges Needle biopsy of kidney 48560642_1 CDM 0361 RC 50200 HCPCS inpatient 1742 1132.3 SIHO - ALL PLANS SIHO - ALL PLANS 1567.8 90 999999999 1054.78 1689.74 percent of total billed charges Needle biopsy of kidney 48560642_1 CDM 0361 RC 50200 HCPCS inpatient 1742 1132.3 UMR - ALL PLANS UMR - ALL PLANS 1219.4 70 999999999 1054.78 1689.74 percent of total billed charges Needle biopsy of kidney 48560642_1 CDM 0361 RC 50200 HCPCS inpatient 1742 1132.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1054.78 60.55 999999999 1054.78 1689.74 percent of total billed charges Needle biopsy of kidney 48560642_1 CDM 0361 RC 50200 HCPCS inpatient 1742 1132.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1054.78 1689.74 Needle biopsy of kidney 48560642_1 CDM 0361 RC 50200 HCPCS inpatient 1742 1132.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1054.78 1689.74 Needle biopsy of kidney 48560642_1 CDM 0361 RC 50200 HCPCS inpatient 1742 1132.3 ANTHEM HMO ANTHEM HMO 999999999 1054.78 1689.74 Needle biopsy of kidney 48560642_1 CDM 0361 RC 50200 HCPCS inpatient 1742 1132.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1177.59 67.6 999999999 1054.78 1689.74 percent of total billed charges Needle biopsy of kidney 48560642_1 CDM 0361 RC 50200 HCPCS inpatient 1742 1132.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1054.78 1689.74 Needle biopsy of kidney 48560642_1 CDM 0361 RC 50200 HCPCS inpatient 1742 1132.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1054.78 1689.74 Injection of bladder and ureter for imaging 48560643_1 CDM 0320 RC 50690 HCPCS inpatient 510 331.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 331.5 65 999999999 308.81 494.7 percent of total billed charges Injection of bladder and ureter for imaging 48560643_1 CDM 0320 RC 50690 HCPCS inpatient 510 331.5 AETNA AETNA 402.9 79 999999999 308.81 494.7 percent of total billed charges Injection of bladder and ureter for imaging 48560643_1 CDM 0320 RC 50690 HCPCS inpatient 510 331.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 494.7 97 999999999 308.81 494.7 percent of total billed charges Injection of bladder and ureter for imaging 48560643_1 CDM 0320 RC 50690 HCPCS inpatient 510 331.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 351.9 69 999999999 308.81 494.7 percent of total billed charges Injection of bladder and ureter for imaging 48560643_1 CDM 0320 RC 50690 HCPCS inpatient 510 331.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 397.8 78 999999999 308.81 494.7 percent of total billed charges Injection of bladder and ureter for imaging 48560643_1 CDM 0320 RC 50690 HCPCS inpatient 510 331.5 SIHO - ALL PLANS SIHO - ALL PLANS 459 90 999999999 308.81 494.7 percent of total billed charges Injection of bladder and ureter for imaging 48560643_1 CDM 0320 RC 50690 HCPCS inpatient 510 331.5 UMR - ALL PLANS UMR - ALL PLANS 357 70 999999999 308.81 494.7 percent of total billed charges Injection of bladder and ureter for imaging 48560643_1 CDM 0320 RC 50690 HCPCS inpatient 510 331.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 308.81 60.55 999999999 308.81 494.7 percent of total billed charges Injection of bladder and ureter for imaging 48560643_1 CDM 0320 RC 50690 HCPCS inpatient 510 331.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 308.81 494.7 Injection of bladder and ureter for imaging 48560643_1 CDM 0320 RC 50690 HCPCS inpatient 510 331.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 308.81 494.7 Injection of bladder and ureter for imaging 48560643_1 CDM 0320 RC 50690 HCPCS inpatient 510 331.5 ANTHEM HMO ANTHEM HMO 999999999 308.81 494.7 Injection of bladder and ureter for imaging 48560643_1 CDM 0320 RC 50690 HCPCS inpatient 510 331.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 344.76 67.6 999999999 308.81 494.7 percent of total billed charges Injection of bladder and ureter for imaging 48560643_1 CDM 0320 RC 50690 HCPCS inpatient 510 331.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 308.81 494.7 Injection of bladder and ureter for imaging 48560643_1 CDM 0320 RC 50690 HCPCS inpatient 510 331.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 308.81 494.7 Injection procedure for imaging of bladder during voiding 48560644_1 CDM 0361 RC 51600 HCPCS inpatient 438 284.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 284.7 65 999999999 265.21 424.86 percent of total billed charges Injection procedure for imaging of bladder during voiding 48560644_1 CDM 0361 RC 51600 HCPCS inpatient 438 284.7 AETNA AETNA 346.02 79 999999999 265.21 424.86 percent of total billed charges Injection procedure for imaging of bladder during voiding 48560644_1 CDM 0361 RC 51600 HCPCS inpatient 438 284.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 424.86 97 999999999 265.21 424.86 percent of total billed charges Injection procedure for imaging of bladder during voiding 48560644_1 CDM 0361 RC 51600 HCPCS inpatient 438 284.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 302.22 69 999999999 265.21 424.86 percent of total billed charges Injection procedure for imaging of bladder during voiding 48560644_1 CDM 0361 RC 51600 HCPCS inpatient 438 284.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 341.64 78 999999999 265.21 424.86 percent of total billed charges Injection procedure for imaging of bladder during voiding 48560644_1 CDM 0361 RC 51600 HCPCS inpatient 438 284.7 SIHO - ALL PLANS SIHO - ALL PLANS 394.2 90 999999999 265.21 424.86 percent of total billed charges Injection procedure for imaging of bladder during voiding 48560644_1 CDM 0361 RC 51600 HCPCS inpatient 438 284.7 UMR - ALL PLANS UMR - ALL PLANS 306.6 70 999999999 265.21 424.86 percent of total billed charges Injection procedure for imaging of bladder during voiding 48560644_1 CDM 0361 RC 51600 HCPCS inpatient 438 284.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 265.21 60.55 999999999 265.21 424.86 percent of total billed charges Injection procedure for imaging of bladder during voiding 48560644_1 CDM 0361 RC 51600 HCPCS inpatient 438 284.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 265.21 424.86 Injection procedure for imaging of bladder during voiding 48560644_1 CDM 0361 RC 51600 HCPCS inpatient 438 284.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 265.21 424.86 Injection procedure for imaging of bladder during voiding 48560644_1 CDM 0361 RC 51600 HCPCS inpatient 438 284.7 ANTHEM HMO ANTHEM HMO 999999999 265.21 424.86 Injection procedure for imaging of bladder during voiding 48560644_1 CDM 0361 RC 51600 HCPCS inpatient 438 284.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 296.09 67.6 999999999 265.21 424.86 percent of total billed charges Injection procedure for imaging of bladder during voiding 48560644_1 CDM 0361 RC 51600 HCPCS inpatient 438 284.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 265.21 424.86 Injection procedure for imaging of bladder during voiding 48560644_1 CDM 0361 RC 51600 HCPCS inpatient 438 284.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 265.21 424.86 Injection procedure through bladder and urethra for X-ray imaging 48560645_1 CDM 0320 RC 51610 HCPCS inpatient 498 323.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 323.7 65 999999999 301.54 483.06 percent of total billed charges Injection procedure through bladder and urethra for X-ray imaging 48560645_1 CDM 0320 RC 51610 HCPCS inpatient 498 323.7 AETNA AETNA 393.42 79 999999999 301.54 483.06 percent of total billed charges Injection procedure through bladder and urethra for X-ray imaging 48560645_1 CDM 0320 RC 51610 HCPCS inpatient 498 323.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 483.06 97 999999999 301.54 483.06 percent of total billed charges Injection procedure through bladder and urethra for X-ray imaging 48560645_1 CDM 0320 RC 51610 HCPCS inpatient 498 323.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 343.62 69 999999999 301.54 483.06 percent of total billed charges Injection procedure through bladder and urethra for X-ray imaging 48560645_1 CDM 0320 RC 51610 HCPCS inpatient 498 323.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 388.44 78 999999999 301.54 483.06 percent of total billed charges Injection procedure through bladder and urethra for X-ray imaging 48560645_1 CDM 0320 RC 51610 HCPCS inpatient 498 323.7 SIHO - ALL PLANS SIHO - ALL PLANS 448.2 90 999999999 301.54 483.06 percent of total billed charges Injection procedure through bladder and urethra for X-ray imaging 48560645_1 CDM 0320 RC 51610 HCPCS inpatient 498 323.7 UMR - ALL PLANS UMR - ALL PLANS 348.6 70 999999999 301.54 483.06 percent of total billed charges Injection procedure through bladder and urethra for X-ray imaging 48560645_1 CDM 0320 RC 51610 HCPCS inpatient 498 323.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 301.54 60.55 999999999 301.54 483.06 percent of total billed charges Injection procedure through bladder and urethra for X-ray imaging 48560645_1 CDM 0320 RC 51610 HCPCS inpatient 498 323.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 301.54 483.06 Injection procedure through bladder and urethra for X-ray imaging 48560645_1 CDM 0320 RC 51610 HCPCS inpatient 498 323.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 301.54 483.06 Injection procedure through bladder and urethra for X-ray imaging 48560645_1 CDM 0320 RC 51610 HCPCS inpatient 498 323.7 ANTHEM HMO ANTHEM HMO 999999999 301.54 483.06 Injection procedure through bladder and urethra for X-ray imaging 48560645_1 CDM 0320 RC 51610 HCPCS inpatient 498 323.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 336.65 67.6 999999999 301.54 483.06 percent of total billed charges Injection procedure through bladder and urethra for X-ray imaging 48560645_1 CDM 0320 RC 51610 HCPCS inpatient 498 323.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 301.54 483.06 Injection procedure through bladder and urethra for X-ray imaging 48560645_1 CDM 0320 RC 51610 HCPCS inpatient 498 323.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 301.54 483.06 Complete ultrasound of abdomen and pelvis artery and vein blood flow 48560646_1 CDM 0402 RC 93975 HCPCS inpatient 926 601.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 601.9 65 999999999 560.69 898.22 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 48560646_1 CDM 0402 RC 93975 HCPCS inpatient 926 601.9 AETNA AETNA 731.54 79 999999999 560.69 898.22 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 48560646_1 CDM 0402 RC 93975 HCPCS inpatient 926 601.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 898.22 97 999999999 560.69 898.22 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 48560646_1 CDM 0402 RC 93975 HCPCS inpatient 926 601.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 638.94 69 999999999 560.69 898.22 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 48560646_1 CDM 0402 RC 93975 HCPCS inpatient 926 601.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 722.28 78 999999999 560.69 898.22 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 48560646_1 CDM 0402 RC 93975 HCPCS inpatient 926 601.9 SIHO - ALL PLANS SIHO - ALL PLANS 833.4 90 999999999 560.69 898.22 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 48560646_1 CDM 0402 RC 93975 HCPCS inpatient 926 601.9 UMR - ALL PLANS UMR - ALL PLANS 648.2 70 999999999 560.69 898.22 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 48560646_1 CDM 0402 RC 93975 HCPCS inpatient 926 601.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 560.69 60.55 999999999 560.69 898.22 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 48560646_1 CDM 0402 RC 93975 HCPCS inpatient 926 601.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 560.69 898.22 Complete ultrasound of abdomen and pelvis artery and vein blood flow 48560646_1 CDM 0402 RC 93975 HCPCS inpatient 926 601.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 560.69 898.22 Complete ultrasound of abdomen and pelvis artery and vein blood flow 48560646_1 CDM 0402 RC 93975 HCPCS inpatient 926 601.9 ANTHEM HMO ANTHEM HMO 999999999 560.69 898.22 Complete ultrasound of abdomen and pelvis artery and vein blood flow 48560646_1 CDM 0402 RC 93975 HCPCS inpatient 926 601.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 625.98 67.6 999999999 560.69 898.22 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 48560646_1 CDM 0402 RC 93975 HCPCS inpatient 926 601.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 560.69 898.22 Complete ultrasound of abdomen and pelvis artery and vein blood flow 48560646_1 CDM 0402 RC 93975 HCPCS inpatient 926 601.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 560.69 898.22 X-RAY CONTROL CATH INSERT 48560647_1 CDM 0320 RC 74475 HCPCS inpatient 561 364.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 364.65 65 999999999 339.69 544.17 percent of total billed charges X-RAY CONTROL CATH INSERT 48560647_1 CDM 0320 RC 74475 HCPCS inpatient 561 364.65 AETNA AETNA 443.19 79 999999999 339.69 544.17 percent of total billed charges X-RAY CONTROL CATH INSERT 48560647_1 CDM 0320 RC 74475 HCPCS inpatient 561 364.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 387.09 69 999999999 339.69 544.17 percent of total billed charges X-RAY CONTROL CATH INSERT 48560647_1 CDM 0320 RC 74475 HCPCS inpatient 561 364.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 544.17 97 999999999 339.69 544.17 percent of total billed charges X-RAY CONTROL CATH INSERT 48560647_1 CDM 0320 RC 74475 HCPCS inpatient 561 364.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 437.58 78 999999999 339.69 544.17 percent of total billed charges X-RAY CONTROL CATH INSERT 48560647_1 CDM 0320 RC 74475 HCPCS inpatient 561 364.65 SIHO - ALL PLANS SIHO - ALL PLANS 504.9 90 999999999 339.69 544.17 percent of total billed charges X-RAY CONTROL CATH INSERT 48560647_1 CDM 0320 RC 74475 HCPCS inpatient 561 364.65 UMR - ALL PLANS UMR - ALL PLANS 392.7 70 999999999 339.69 544.17 percent of total billed charges X-RAY CONTROL CATH INSERT 48560647_1 CDM 0320 RC 74475 HCPCS inpatient 561 364.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 339.69 60.55 999999999 339.69 544.17 percent of total billed charges X-RAY CONTROL CATH INSERT 48560647_1 CDM 0320 RC 74475 HCPCS inpatient 561 364.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 339.69 544.17 X-RAY CONTROL CATH INSERT 48560647_1 CDM 0320 RC 74475 HCPCS inpatient 561 364.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 339.69 544.17 X-RAY CONTROL CATH INSERT 48560647_1 CDM 0320 RC 74475 HCPCS inpatient 561 364.65 ANTHEM HMO ANTHEM HMO 999999999 339.69 544.17 X-RAY CONTROL CATH INSERT 48560647_1 CDM 0320 RC 74475 HCPCS inpatient 561 364.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 379.24 67.6 999999999 339.69 544.17 percent of total billed charges X-RAY CONTROL CATH INSERT 48560647_1 CDM 0320 RC 74475 HCPCS inpatient 561 364.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 339.69 544.17 X-RAY CONTROL CATH INSERT 48560647_1 CDM 0320 RC 74475 HCPCS inpatient 561 364.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 339.69 544.17 Needle biopsy of pancreas 48560648_1 CDM 0361 RC 48102 HCPCS inpatient 1510 981.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 981.5 65 999999999 914.31 1464.7 percent of total billed charges Needle biopsy of pancreas 48560648_1 CDM 0361 RC 48102 HCPCS inpatient 1510 981.5 AETNA AETNA 1192.9 79 999999999 914.31 1464.7 percent of total billed charges Needle biopsy of pancreas 48560648_1 CDM 0361 RC 48102 HCPCS inpatient 1510 981.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1041.9 69 999999999 914.31 1464.7 percent of total billed charges Needle biopsy of pancreas 48560648_1 CDM 0361 RC 48102 HCPCS inpatient 1510 981.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1464.7 97 999999999 914.31 1464.7 percent of total billed charges Needle biopsy of pancreas 48560648_1 CDM 0361 RC 48102 HCPCS inpatient 1510 981.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1177.8 78 999999999 914.31 1464.7 percent of total billed charges Needle biopsy of pancreas 48560648_1 CDM 0361 RC 48102 HCPCS inpatient 1510 981.5 SIHO - ALL PLANS SIHO - ALL PLANS 1359 90 999999999 914.31 1464.7 percent of total billed charges Needle biopsy of pancreas 48560648_1 CDM 0361 RC 48102 HCPCS inpatient 1510 981.5 UMR - ALL PLANS UMR - ALL PLANS 1057 70 999999999 914.31 1464.7 percent of total billed charges Needle biopsy of pancreas 48560648_1 CDM 0361 RC 48102 HCPCS inpatient 1510 981.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 914.31 60.55 999999999 914.31 1464.7 percent of total billed charges Needle biopsy of pancreas 48560648_1 CDM 0361 RC 48102 HCPCS inpatient 1510 981.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 914.31 1464.7 Needle biopsy of pancreas 48560648_1 CDM 0361 RC 48102 HCPCS inpatient 1510 981.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 914.31 1464.7 Needle biopsy of pancreas 48560648_1 CDM 0361 RC 48102 HCPCS inpatient 1510 981.5 ANTHEM HMO ANTHEM HMO 999999999 914.31 1464.7 Needle biopsy of pancreas 48560648_1 CDM 0361 RC 48102 HCPCS inpatient 1510 981.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1020.76 67.6 999999999 914.31 1464.7 percent of total billed charges Needle biopsy of pancreas 48560648_1 CDM 0361 RC 48102 HCPCS inpatient 1510 981.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 914.31 1464.7 Needle biopsy of pancreas 48560648_1 CDM 0361 RC 48102 HCPCS inpatient 1510 981.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 914.31 1464.7 Injection of bile duct for X-ray through already existing skin access using imaging guidance with review by radiologist 48560649_1 CDM 0361 RC 47531 HCPCS inpatient 566 367.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 367.9 65 999999999 342.71 549.02 percent of total billed charges Injection of bile duct for X-ray through already existing skin access using imaging guidance with review by radiologist 48560649_1 CDM 0361 RC 47531 HCPCS inpatient 566 367.9 AETNA AETNA 447.14 79 999999999 342.71 549.02 percent of total billed charges Injection of bile duct for X-ray through already existing skin access using imaging guidance with review by radiologist 48560649_1 CDM 0361 RC 47531 HCPCS inpatient 566 367.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 390.54 69 999999999 342.71 549.02 percent of total billed charges Injection of bile duct for X-ray through already existing skin access using imaging guidance with review by radiologist 48560649_1 CDM 0361 RC 47531 HCPCS inpatient 566 367.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 549.02 97 999999999 342.71 549.02 percent of total billed charges Injection of bile duct for X-ray through already existing skin access using imaging guidance with review by radiologist 48560649_1 CDM 0361 RC 47531 HCPCS inpatient 566 367.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 441.48 78 999999999 342.71 549.02 percent of total billed charges Injection of bile duct for X-ray through already existing skin access using imaging guidance with review by radiologist 48560649_1 CDM 0361 RC 47531 HCPCS inpatient 566 367.9 SIHO - ALL PLANS SIHO - ALL PLANS 509.4 90 999999999 342.71 549.02 percent of total billed charges Injection of bile duct for X-ray through already existing skin access using imaging guidance with review by radiologist 48560649_1 CDM 0361 RC 47531 HCPCS inpatient 566 367.9 UMR - ALL PLANS UMR - ALL PLANS 396.2 70 999999999 342.71 549.02 percent of total billed charges Injection of bile duct for X-ray through already existing skin access using imaging guidance with review by radiologist 48560649_1 CDM 0361 RC 47531 HCPCS inpatient 566 367.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 342.71 60.55 999999999 342.71 549.02 percent of total billed charges Injection of bile duct for X-ray through already existing skin access using imaging guidance with review by radiologist 48560649_1 CDM 0361 RC 47531 HCPCS inpatient 566 367.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 342.71 549.02 Injection of bile duct for X-ray through already existing skin access using imaging guidance with review by radiologist 48560649_1 CDM 0361 RC 47531 HCPCS inpatient 566 367.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 342.71 549.02 Injection of bile duct for X-ray through already existing skin access using imaging guidance with review by radiologist 48560649_1 CDM 0361 RC 47531 HCPCS inpatient 566 367.9 ANTHEM HMO ANTHEM HMO 999999999 342.71 549.02 Injection of bile duct for X-ray through already existing skin access using imaging guidance with review by radiologist 48560649_1 CDM 0361 RC 47531 HCPCS inpatient 566 367.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 382.62 67.6 999999999 342.71 549.02 percent of total billed charges Injection of bile duct for X-ray through already existing skin access using imaging guidance with review by radiologist 48560649_1 CDM 0361 RC 47531 HCPCS inpatient 566 367.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 342.71 549.02 Injection of bile duct for X-ray through already existing skin access using imaging guidance with review by radiologist 48560649_1 CDM 0361 RC 47531 HCPCS inpatient 566 367.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 342.71 549.02 Injection of contrast for imaging of elbow joint 48560651_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 SELF PAY DISCOUNT SELF PAY DISCOUNT 351 65 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of elbow joint 48560651_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 AETNA AETNA 426.6 79 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of elbow joint 48560651_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 ENCORE - ALL PLANS ENCORE - ALL PLANS 372.6 69 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of elbow joint 48560651_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 523.8 97 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of elbow joint 48560651_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 HUMANA - ALL PLANS HUMANA - ALL PLANS 421.2 78 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of elbow joint 48560651_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 SIHO - ALL PLANS SIHO - ALL PLANS 486 90 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of elbow joint 48560651_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 UMR - ALL PLANS UMR - ALL PLANS 378 70 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of elbow joint 48560651_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 326.97 60.55 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of elbow joint 48560651_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 326.97 523.8 Injection of contrast for imaging of elbow joint 48560651_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 326.97 523.8 Injection of contrast for imaging of elbow joint 48560651_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 ANTHEM HMO ANTHEM HMO 999999999 326.97 523.8 Injection of contrast for imaging of elbow joint 48560651_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 CIGNA - ALL PLANS CIGNA - ALL PLANS 365.04 67.6 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of elbow joint 48560651_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 326.97 523.8 Injection of contrast for imaging of elbow joint 48560651_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 UHC - ALL PLANS UHC - ALL PLANS 999999999 326.97 523.8 Injection of contrast for imaging of elbow joint 48560664_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 SELF PAY DISCOUNT SELF PAY DISCOUNT 351 65 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of elbow joint 48560664_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 AETNA AETNA 426.6 79 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of elbow joint 48560664_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 ENCORE - ALL PLANS ENCORE - ALL PLANS 372.6 69 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of elbow joint 48560664_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 523.8 97 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of elbow joint 48560664_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 HUMANA - ALL PLANS HUMANA - ALL PLANS 421.2 78 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of elbow joint 48560664_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 SIHO - ALL PLANS SIHO - ALL PLANS 486 90 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of elbow joint 48560664_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 UMR - ALL PLANS UMR - ALL PLANS 378 70 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of elbow joint 48560664_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 326.97 60.55 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of elbow joint 48560664_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 326.97 523.8 Injection of contrast for imaging of elbow joint 48560664_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 326.97 523.8 Injection of contrast for imaging of elbow joint 48560664_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 ANTHEM HMO ANTHEM HMO 999999999 326.97 523.8 Injection of contrast for imaging of elbow joint 48560664_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 CIGNA - ALL PLANS CIGNA - ALL PLANS 365.04 67.6 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of elbow joint 48560664_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 326.97 523.8 Injection of contrast for imaging of elbow joint 48560664_1 CDM 0361 RC 24220 HCPCS inpatient 540 351 UHC - ALL PLANS UHC - ALL PLANS 999999999 326.97 523.8 Injection of contrast for imaging of elbow joint 48560665_1 CDM 0361 RC 24220 HCPCS inpatient 1078 700.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 700.7 65 999999999 652.73 1045.66 percent of total billed charges Injection of contrast for imaging of elbow joint 48560665_1 CDM 0361 RC 24220 HCPCS inpatient 1078 700.7 AETNA AETNA 851.62 79 999999999 652.73 1045.66 percent of total billed charges Injection of contrast for imaging of elbow joint 48560665_1 CDM 0361 RC 24220 HCPCS inpatient 1078 700.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 743.82 69 999999999 652.73 1045.66 percent of total billed charges Injection of contrast for imaging of elbow joint 48560665_1 CDM 0361 RC 24220 HCPCS inpatient 1078 700.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1045.66 97 999999999 652.73 1045.66 percent of total billed charges Injection of contrast for imaging of elbow joint 48560665_1 CDM 0361 RC 24220 HCPCS inpatient 1078 700.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 840.84 78 999999999 652.73 1045.66 percent of total billed charges Injection of contrast for imaging of elbow joint 48560665_1 CDM 0361 RC 24220 HCPCS inpatient 1078 700.7 SIHO - ALL PLANS SIHO - ALL PLANS 970.2 90 999999999 652.73 1045.66 percent of total billed charges Injection of contrast for imaging of elbow joint 48560665_1 CDM 0361 RC 24220 HCPCS inpatient 1078 700.7 UMR - ALL PLANS UMR - ALL PLANS 754.6 70 999999999 652.73 1045.66 percent of total billed charges Injection of contrast for imaging of elbow joint 48560665_1 CDM 0361 RC 24220 HCPCS inpatient 1078 700.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 652.73 60.55 999999999 652.73 1045.66 percent of total billed charges Injection of contrast for imaging of elbow joint 48560665_1 CDM 0361 RC 24220 HCPCS inpatient 1078 700.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 652.73 1045.66 Injection of contrast for imaging of elbow joint 48560665_1 CDM 0361 RC 24220 HCPCS inpatient 1078 700.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 652.73 1045.66 Injection of contrast for imaging of elbow joint 48560665_1 CDM 0361 RC 24220 HCPCS inpatient 1078 700.7 ANTHEM HMO ANTHEM HMO 999999999 652.73 1045.66 Injection of contrast for imaging of elbow joint 48560665_1 CDM 0361 RC 24220 HCPCS inpatient 1078 700.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 728.73 67.6 999999999 652.73 1045.66 percent of total billed charges Injection of contrast for imaging of elbow joint 48560665_1 CDM 0361 RC 24220 HCPCS inpatient 1078 700.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 652.73 1045.66 Injection of contrast for imaging of elbow joint 48560665_1 CDM 0361 RC 24220 HCPCS inpatient 1078 700.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 652.73 1045.66 INJECTION FOR KNEE X-RAY 48560671_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 SELF PAY DISCOUNT SELF PAY DISCOUNT 351 65 999999999 326.97 523.8 percent of total billed charges INJECTION FOR KNEE X-RAY 48560671_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 AETNA AETNA 426.6 79 999999999 326.97 523.8 percent of total billed charges INJECTION FOR KNEE X-RAY 48560671_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 ENCORE - ALL PLANS ENCORE - ALL PLANS 372.6 69 999999999 326.97 523.8 percent of total billed charges INJECTION FOR KNEE X-RAY 48560671_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 523.8 97 999999999 326.97 523.8 percent of total billed charges INJECTION FOR KNEE X-RAY 48560671_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 HUMANA - ALL PLANS HUMANA - ALL PLANS 421.2 78 999999999 326.97 523.8 percent of total billed charges INJECTION FOR KNEE X-RAY 48560671_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 SIHO - ALL PLANS SIHO - ALL PLANS 486 90 999999999 326.97 523.8 percent of total billed charges INJECTION FOR KNEE X-RAY 48560671_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 UMR - ALL PLANS UMR - ALL PLANS 378 70 999999999 326.97 523.8 percent of total billed charges INJECTION FOR KNEE X-RAY 48560671_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 326.97 60.55 999999999 326.97 523.8 percent of total billed charges INJECTION FOR KNEE X-RAY 48560671_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 326.97 523.8 INJECTION FOR KNEE X-RAY 48560671_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 326.97 523.8 INJECTION FOR KNEE X-RAY 48560671_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 ANTHEM HMO ANTHEM HMO 999999999 326.97 523.8 INJECTION FOR KNEE X-RAY 48560671_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 CIGNA - ALL PLANS CIGNA - ALL PLANS 365.04 67.6 999999999 326.97 523.8 percent of total billed charges INJECTION FOR KNEE X-RAY 48560671_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 326.97 523.8 INJECTION FOR KNEE X-RAY 48560671_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 UHC - ALL PLANS UHC - ALL PLANS 999999999 326.97 523.8 INJECTION FOR KNEE X-RAY 48560672_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 SELF PAY DISCOUNT SELF PAY DISCOUNT 351 65 999999999 326.97 523.8 percent of total billed charges INJECTION FOR KNEE X-RAY 48560672_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 AETNA AETNA 426.6 79 999999999 326.97 523.8 percent of total billed charges INJECTION FOR KNEE X-RAY 48560672_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 ENCORE - ALL PLANS ENCORE - ALL PLANS 372.6 69 999999999 326.97 523.8 percent of total billed charges INJECTION FOR KNEE X-RAY 48560672_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 523.8 97 999999999 326.97 523.8 percent of total billed charges INJECTION FOR KNEE X-RAY 48560672_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 HUMANA - ALL PLANS HUMANA - ALL PLANS 421.2 78 999999999 326.97 523.8 percent of total billed charges INJECTION FOR KNEE X-RAY 48560672_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 SIHO - ALL PLANS SIHO - ALL PLANS 486 90 999999999 326.97 523.8 percent of total billed charges INJECTION FOR KNEE X-RAY 48560672_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 UMR - ALL PLANS UMR - ALL PLANS 378 70 999999999 326.97 523.8 percent of total billed charges INJECTION FOR KNEE X-RAY 48560672_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 326.97 60.55 999999999 326.97 523.8 percent of total billed charges INJECTION FOR KNEE X-RAY 48560672_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 326.97 523.8 INJECTION FOR KNEE X-RAY 48560672_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 326.97 523.8 INJECTION FOR KNEE X-RAY 48560672_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 ANTHEM HMO ANTHEM HMO 999999999 326.97 523.8 INJECTION FOR KNEE X-RAY 48560672_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 CIGNA - ALL PLANS CIGNA - ALL PLANS 365.04 67.6 999999999 326.97 523.8 percent of total billed charges INJECTION FOR KNEE X-RAY 48560672_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 326.97 523.8 INJECTION FOR KNEE X-RAY 48560672_1 CDM 0361 RC 27370 HCPCS inpatient 540 351 UHC - ALL PLANS UHC - ALL PLANS 999999999 326.97 523.8 Injection for X-ray imaging of ankle 48560673_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 SELF PAY DISCOUNT SELF PAY DISCOUNT 351 65 999999999 326.97 523.8 percent of total billed charges Injection for X-ray imaging of ankle 48560673_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 AETNA AETNA 426.6 79 999999999 326.97 523.8 percent of total billed charges Injection for X-ray imaging of ankle 48560673_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 ENCORE - ALL PLANS ENCORE - ALL PLANS 372.6 69 999999999 326.97 523.8 percent of total billed charges Injection for X-ray imaging of ankle 48560673_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 523.8 97 999999999 326.97 523.8 percent of total billed charges Injection for X-ray imaging of ankle 48560673_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 HUMANA - ALL PLANS HUMANA - ALL PLANS 421.2 78 999999999 326.97 523.8 percent of total billed charges Injection for X-ray imaging of ankle 48560673_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 SIHO - ALL PLANS SIHO - ALL PLANS 486 90 999999999 326.97 523.8 percent of total billed charges Injection for X-ray imaging of ankle 48560673_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 UMR - ALL PLANS UMR - ALL PLANS 378 70 999999999 326.97 523.8 percent of total billed charges Injection for X-ray imaging of ankle 48560673_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 326.97 60.55 999999999 326.97 523.8 percent of total billed charges Injection for X-ray imaging of ankle 48560673_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 326.97 523.8 Injection for X-ray imaging of ankle 48560673_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 326.97 523.8 Injection for X-ray imaging of ankle 48560673_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 ANTHEM HMO ANTHEM HMO 999999999 326.97 523.8 Injection for X-ray imaging of ankle 48560673_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 CIGNA - ALL PLANS CIGNA - ALL PLANS 365.04 67.6 999999999 326.97 523.8 percent of total billed charges Injection for X-ray imaging of ankle 48560673_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 326.97 523.8 Injection for X-ray imaging of ankle 48560673_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 UHC - ALL PLANS UHC - ALL PLANS 999999999 326.97 523.8 Injection for X-ray imaging of ankle 48560674_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 SELF PAY DISCOUNT SELF PAY DISCOUNT 351 65 999999999 326.97 523.8 percent of total billed charges Injection for X-ray imaging of ankle 48560674_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 AETNA AETNA 426.6 79 999999999 326.97 523.8 percent of total billed charges Injection for X-ray imaging of ankle 48560674_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 ENCORE - ALL PLANS ENCORE - ALL PLANS 372.6 69 999999999 326.97 523.8 percent of total billed charges Injection for X-ray imaging of ankle 48560674_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 523.8 97 999999999 326.97 523.8 percent of total billed charges Injection for X-ray imaging of ankle 48560674_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 HUMANA - ALL PLANS HUMANA - ALL PLANS 421.2 78 999999999 326.97 523.8 percent of total billed charges Injection for X-ray imaging of ankle 48560674_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 SIHO - ALL PLANS SIHO - ALL PLANS 486 90 999999999 326.97 523.8 percent of total billed charges Injection for X-ray imaging of ankle 48560674_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 UMR - ALL PLANS UMR - ALL PLANS 378 70 999999999 326.97 523.8 percent of total billed charges Injection for X-ray imaging of ankle 48560674_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 326.97 60.55 999999999 326.97 523.8 percent of total billed charges Injection for X-ray imaging of ankle 48560674_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 326.97 523.8 Injection for X-ray imaging of ankle 48560674_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 326.97 523.8 Injection for X-ray imaging of ankle 48560674_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 ANTHEM HMO ANTHEM HMO 999999999 326.97 523.8 Injection for X-ray imaging of ankle 48560674_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 CIGNA - ALL PLANS CIGNA - ALL PLANS 365.04 67.6 999999999 326.97 523.8 percent of total billed charges Injection for X-ray imaging of ankle 48560674_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 326.97 523.8 Injection for X-ray imaging of ankle 48560674_1 CDM 0361 RC 27648 HCPCS inpatient 540 351 UHC - ALL PLANS UHC - ALL PLANS 999999999 326.97 523.8 Injection of contrast for imaging of wrist 48560675_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 SELF PAY DISCOUNT SELF PAY DISCOUNT 351 65 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of wrist 48560675_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 AETNA AETNA 426.6 79 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of wrist 48560675_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 ENCORE - ALL PLANS ENCORE - ALL PLANS 372.6 69 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of wrist 48560675_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 523.8 97 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of wrist 48560675_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 HUMANA - ALL PLANS HUMANA - ALL PLANS 421.2 78 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of wrist 48560675_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 SIHO - ALL PLANS SIHO - ALL PLANS 486 90 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of wrist 48560675_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 UMR - ALL PLANS UMR - ALL PLANS 378 70 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of wrist 48560675_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 326.97 60.55 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of wrist 48560675_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 326.97 523.8 Injection of contrast for imaging of wrist 48560675_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 326.97 523.8 Injection of contrast for imaging of wrist 48560675_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 ANTHEM HMO ANTHEM HMO 999999999 326.97 523.8 Injection of contrast for imaging of wrist 48560675_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 CIGNA - ALL PLANS CIGNA - ALL PLANS 365.04 67.6 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of wrist 48560675_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 326.97 523.8 Injection of contrast for imaging of wrist 48560675_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 UHC - ALL PLANS UHC - ALL PLANS 999999999 326.97 523.8 Injection of contrast for imaging of wrist 48560676_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 SELF PAY DISCOUNT SELF PAY DISCOUNT 351 65 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of wrist 48560676_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 AETNA AETNA 426.6 79 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of wrist 48560676_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 ENCORE - ALL PLANS ENCORE - ALL PLANS 372.6 69 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of wrist 48560676_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 523.8 97 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of wrist 48560676_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 HUMANA - ALL PLANS HUMANA - ALL PLANS 421.2 78 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of wrist 48560676_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 SIHO - ALL PLANS SIHO - ALL PLANS 486 90 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of wrist 48560676_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 UMR - ALL PLANS UMR - ALL PLANS 378 70 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of wrist 48560676_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 326.97 60.55 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of wrist 48560676_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 326.97 523.8 Injection of contrast for imaging of wrist 48560676_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 326.97 523.8 Injection of contrast for imaging of wrist 48560676_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 ANTHEM HMO ANTHEM HMO 999999999 326.97 523.8 Injection of contrast for imaging of wrist 48560676_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 CIGNA - ALL PLANS CIGNA - ALL PLANS 365.04 67.6 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of wrist 48560676_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 326.97 523.8 Injection of contrast for imaging of wrist 48560676_1 CDM 0361 RC 25246 HCPCS inpatient 540 351 UHC - ALL PLANS UHC - ALL PLANS 999999999 326.97 523.8 Biopsy of bone using needle or trocar 48560677_1 CDM 0361 RC 20220 HCPCS inpatient 2041 1326.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1326.65 65 999999999 1235.83 1979.77 percent of total billed charges Biopsy of bone using needle or trocar 48560677_1 CDM 0361 RC 20220 HCPCS inpatient 2041 1326.65 AETNA AETNA 1612.39 79 999999999 1235.83 1979.77 percent of total billed charges Biopsy of bone using needle or trocar 48560677_1 CDM 0361 RC 20220 HCPCS inpatient 2041 1326.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1408.29 69 999999999 1235.83 1979.77 percent of total billed charges Biopsy of bone using needle or trocar 48560677_1 CDM 0361 RC 20220 HCPCS inpatient 2041 1326.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1979.77 97 999999999 1235.83 1979.77 percent of total billed charges Biopsy of bone using needle or trocar 48560677_1 CDM 0361 RC 20220 HCPCS inpatient 2041 1326.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1591.98 78 999999999 1235.83 1979.77 percent of total billed charges Biopsy of bone using needle or trocar 48560677_1 CDM 0361 RC 20220 HCPCS inpatient 2041 1326.65 SIHO - ALL PLANS SIHO - ALL PLANS 1836.9 90 999999999 1235.83 1979.77 percent of total billed charges Biopsy of bone using needle or trocar 48560677_1 CDM 0361 RC 20220 HCPCS inpatient 2041 1326.65 UMR - ALL PLANS UMR - ALL PLANS 1428.7 70 999999999 1235.83 1979.77 percent of total billed charges Biopsy of bone using needle or trocar 48560677_1 CDM 0361 RC 20220 HCPCS inpatient 2041 1326.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1235.83 60.55 999999999 1235.83 1979.77 percent of total billed charges Biopsy of bone using needle or trocar 48560677_1 CDM 0361 RC 20220 HCPCS inpatient 2041 1326.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1235.83 1979.77 Biopsy of bone using needle or trocar 48560677_1 CDM 0361 RC 20220 HCPCS inpatient 2041 1326.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1235.83 1979.77 Biopsy of bone using needle or trocar 48560677_1 CDM 0361 RC 20220 HCPCS inpatient 2041 1326.65 ANTHEM HMO ANTHEM HMO 999999999 1235.83 1979.77 Biopsy of bone using needle or trocar 48560677_1 CDM 0361 RC 20220 HCPCS inpatient 2041 1326.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1379.72 67.6 999999999 1235.83 1979.77 percent of total billed charges Biopsy of bone using needle or trocar 48560677_1 CDM 0361 RC 20220 HCPCS inpatient 2041 1326.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1235.83 1979.77 Biopsy of bone using needle or trocar 48560677_1 CDM 0361 RC 20220 HCPCS inpatient 2041 1326.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1235.83 1979.77 CT scan of soft tissue of neck without contrast 48560678_1 CDM 0351 RC 70490 HCPCS inpatient 2545 1654.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1654.25 65 999999999 1541 2468.65 percent of total billed charges CT scan of soft tissue of neck without contrast 48560678_1 CDM 0351 RC 70490 HCPCS inpatient 2545 1654.25 AETNA AETNA 2010.55 79 999999999 1541 2468.65 percent of total billed charges CT scan of soft tissue of neck without contrast 48560678_1 CDM 0351 RC 70490 HCPCS inpatient 2545 1654.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1756.05 69 999999999 1541 2468.65 percent of total billed charges CT scan of soft tissue of neck without contrast 48560678_1 CDM 0351 RC 70490 HCPCS inpatient 2545 1654.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2468.65 97 999999999 1541 2468.65 percent of total billed charges CT scan of soft tissue of neck without contrast 48560678_1 CDM 0351 RC 70490 HCPCS inpatient 2545 1654.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1985.1 78 999999999 1541 2468.65 percent of total billed charges CT scan of soft tissue of neck without contrast 48560678_1 CDM 0351 RC 70490 HCPCS inpatient 2545 1654.25 SIHO - ALL PLANS SIHO - ALL PLANS 2290.5 90 999999999 1541 2468.65 percent of total billed charges CT scan of soft tissue of neck without contrast 48560678_1 CDM 0351 RC 70490 HCPCS inpatient 2545 1654.25 UMR - ALL PLANS UMR - ALL PLANS 1781.5 70 999999999 1541 2468.65 percent of total billed charges CT scan of soft tissue of neck without contrast 48560678_1 CDM 0351 RC 70490 HCPCS inpatient 2545 1654.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1541 60.55 999999999 1541 2468.65 percent of total billed charges CT scan of soft tissue of neck without contrast 48560678_1 CDM 0351 RC 70490 HCPCS inpatient 2545 1654.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1541 2468.65 CT scan of soft tissue of neck without contrast 48560678_1 CDM 0351 RC 70490 HCPCS inpatient 2545 1654.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1541 2468.65 CT scan of soft tissue of neck without contrast 48560678_1 CDM 0351 RC 70490 HCPCS inpatient 2545 1654.25 ANTHEM HMO ANTHEM HMO 999999999 1541 2468.65 CT scan of soft tissue of neck without contrast 48560678_1 CDM 0351 RC 70490 HCPCS inpatient 2545 1654.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1720.42 67.6 999999999 1541 2468.65 percent of total billed charges CT scan of soft tissue of neck without contrast 48560678_1 CDM 0351 RC 70490 HCPCS inpatient 2545 1654.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1541 2468.65 CT scan of soft tissue of neck without contrast 48560678_1 CDM 0351 RC 70490 HCPCS inpatient 2545 1654.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1541 2468.65 Drainage of deep abscess or blood accumulation of pelvis or hip near joint 48560679_1 CDM 0361 RC 26990 HCPCS inpatient 3041 1976.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1976.65 65 999999999 1841.33 2949.77 percent of total billed charges Drainage of deep abscess or blood accumulation of pelvis or hip near joint 48560679_1 CDM 0361 RC 26990 HCPCS inpatient 3041 1976.65 AETNA AETNA 2402.39 79 999999999 1841.33 2949.77 percent of total billed charges Drainage of deep abscess or blood accumulation of pelvis or hip near joint 48560679_1 CDM 0361 RC 26990 HCPCS inpatient 3041 1976.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2098.29 69 999999999 1841.33 2949.77 percent of total billed charges Drainage of deep abscess or blood accumulation of pelvis or hip near joint 48560679_1 CDM 0361 RC 26990 HCPCS inpatient 3041 1976.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2949.77 97 999999999 1841.33 2949.77 percent of total billed charges Drainage of deep abscess or blood accumulation of pelvis or hip near joint 48560679_1 CDM 0361 RC 26990 HCPCS inpatient 3041 1976.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2371.98 78 999999999 1841.33 2949.77 percent of total billed charges Drainage of deep abscess or blood accumulation of pelvis or hip near joint 48560679_1 CDM 0361 RC 26990 HCPCS inpatient 3041 1976.65 SIHO - ALL PLANS SIHO - ALL PLANS 2736.9 90 999999999 1841.33 2949.77 percent of total billed charges Drainage of deep abscess or blood accumulation of pelvis or hip near joint 48560679_1 CDM 0361 RC 26990 HCPCS inpatient 3041 1976.65 UMR - ALL PLANS UMR - ALL PLANS 2128.7 70 999999999 1841.33 2949.77 percent of total billed charges Drainage of deep abscess or blood accumulation of pelvis or hip near joint 48560679_1 CDM 0361 RC 26990 HCPCS inpatient 3041 1976.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1841.33 60.55 999999999 1841.33 2949.77 percent of total billed charges Drainage of deep abscess or blood accumulation of pelvis or hip near joint 48560679_1 CDM 0361 RC 26990 HCPCS inpatient 3041 1976.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1841.33 2949.77 Drainage of deep abscess or blood accumulation of pelvis or hip near joint 48560679_1 CDM 0361 RC 26990 HCPCS inpatient 3041 1976.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1841.33 2949.77 Drainage of deep abscess or blood accumulation of pelvis or hip near joint 48560679_1 CDM 0361 RC 26990 HCPCS inpatient 3041 1976.65 ANTHEM HMO ANTHEM HMO 999999999 1841.33 2949.77 Drainage of deep abscess or blood accumulation of pelvis or hip near joint 48560679_1 CDM 0361 RC 26990 HCPCS inpatient 3041 1976.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2055.72 67.6 999999999 1841.33 2949.77 percent of total billed charges Drainage of deep abscess or blood accumulation of pelvis or hip near joint 48560679_1 CDM 0361 RC 26990 HCPCS inpatient 3041 1976.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1841.33 2949.77 Drainage of deep abscess or blood accumulation of pelvis or hip near joint 48560679_1 CDM 0361 RC 26990 HCPCS inpatient 3041 1976.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1841.33 2949.77 Nuclear medicine study of bone and/or joint whole body 48560680_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1184.3 65 999999999 1103.22 1767.34 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 48560680_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 AETNA AETNA 1439.38 79 999999999 1103.22 1767.34 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 48560680_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1257.18 69 999999999 1103.22 1767.34 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 48560680_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1767.34 97 999999999 1103.22 1767.34 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 48560680_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1421.16 78 999999999 1103.22 1767.34 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 48560680_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 SIHO - ALL PLANS SIHO - ALL PLANS 1639.8 90 999999999 1103.22 1767.34 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 48560680_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 UMR - ALL PLANS UMR - ALL PLANS 1275.4 70 999999999 1103.22 1767.34 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 48560680_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1103.22 60.55 999999999 1103.22 1767.34 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 48560680_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1103.22 1767.34 Nuclear medicine study of bone and/or joint whole body 48560680_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1103.22 1767.34 Nuclear medicine study of bone and/or joint whole body 48560680_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 ANTHEM HMO ANTHEM HMO 999999999 1103.22 1767.34 Nuclear medicine study of bone and/or joint whole body 48560680_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1231.67 67.6 999999999 1103.22 1767.34 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 48560680_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1103.22 1767.34 Nuclear medicine study of bone and/or joint whole body 48560680_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1103.22 1767.34 "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 48560681_1 CDM 0402 RC 76830 HCPCS inpatient 584 379.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 379.6 65 999999999 353.61 566.48 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 48560681_1 CDM 0402 RC 76830 HCPCS inpatient 584 379.6 AETNA AETNA 461.36 79 999999999 353.61 566.48 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 48560681_1 CDM 0402 RC 76830 HCPCS inpatient 584 379.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 402.96 69 999999999 353.61 566.48 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 48560681_1 CDM 0402 RC 76830 HCPCS inpatient 584 379.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 566.48 97 999999999 353.61 566.48 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 48560681_1 CDM 0402 RC 76830 HCPCS inpatient 584 379.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 455.52 78 999999999 353.61 566.48 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 48560681_1 CDM 0402 RC 76830 HCPCS inpatient 584 379.6 SIHO - ALL PLANS SIHO - ALL PLANS 525.6 90 999999999 353.61 566.48 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 48560681_1 CDM 0402 RC 76830 HCPCS inpatient 584 379.6 UMR - ALL PLANS UMR - ALL PLANS 408.8 70 999999999 353.61 566.48 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 48560681_1 CDM 0402 RC 76830 HCPCS inpatient 584 379.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 353.61 60.55 999999999 353.61 566.48 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 48560681_1 CDM 0402 RC 76830 HCPCS inpatient 584 379.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 353.61 566.48 "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 48560681_1 CDM 0402 RC 76830 HCPCS inpatient 584 379.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 353.61 566.48 "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 48560681_1 CDM 0402 RC 76830 HCPCS inpatient 584 379.6 ANTHEM HMO ANTHEM HMO 999999999 353.61 566.48 "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 48560681_1 CDM 0402 RC 76830 HCPCS inpatient 584 379.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 394.78 67.6 999999999 353.61 566.48 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 48560681_1 CDM 0402 RC 76830 HCPCS inpatient 584 379.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 353.61 566.48 "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 48560681_1 CDM 0402 RC 76830 HCPCS inpatient 584 379.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 353.61 566.48 CT scan of abdomen without contrast 48560682_1 CDM 0352 RC 74150 HCPCS inpatient 2491 1619.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1619.15 65 999999999 1508.3 2416.27 percent of total billed charges CT scan of abdomen without contrast 48560682_1 CDM 0352 RC 74150 HCPCS inpatient 2491 1619.15 AETNA AETNA 1967.89 79 999999999 1508.3 2416.27 percent of total billed charges CT scan of abdomen without contrast 48560682_1 CDM 0352 RC 74150 HCPCS inpatient 2491 1619.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1718.79 69 999999999 1508.3 2416.27 percent of total billed charges CT scan of abdomen without contrast 48560682_1 CDM 0352 RC 74150 HCPCS inpatient 2491 1619.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2416.27 97 999999999 1508.3 2416.27 percent of total billed charges CT scan of abdomen without contrast 48560682_1 CDM 0352 RC 74150 HCPCS inpatient 2491 1619.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1942.98 78 999999999 1508.3 2416.27 percent of total billed charges CT scan of abdomen without contrast 48560682_1 CDM 0352 RC 74150 HCPCS inpatient 2491 1619.15 SIHO - ALL PLANS SIHO - ALL PLANS 2241.9 90 999999999 1508.3 2416.27 percent of total billed charges CT scan of abdomen without contrast 48560682_1 CDM 0352 RC 74150 HCPCS inpatient 2491 1619.15 UMR - ALL PLANS UMR - ALL PLANS 1743.7 70 999999999 1508.3 2416.27 percent of total billed charges CT scan of abdomen without contrast 48560682_1 CDM 0352 RC 74150 HCPCS inpatient 2491 1619.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1508.3 60.55 999999999 1508.3 2416.27 percent of total billed charges CT scan of abdomen without contrast 48560682_1 CDM 0352 RC 74150 HCPCS inpatient 2491 1619.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1508.3 2416.27 CT scan of abdomen without contrast 48560682_1 CDM 0352 RC 74150 HCPCS inpatient 2491 1619.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1508.3 2416.27 CT scan of abdomen without contrast 48560682_1 CDM 0352 RC 74150 HCPCS inpatient 2491 1619.15 ANTHEM HMO ANTHEM HMO 999999999 1508.3 2416.27 CT scan of abdomen without contrast 48560682_1 CDM 0352 RC 74150 HCPCS inpatient 2491 1619.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1683.92 67.6 999999999 1508.3 2416.27 percent of total billed charges CT scan of abdomen without contrast 48560682_1 CDM 0352 RC 74150 HCPCS inpatient 2491 1619.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1508.3 2416.27 CT scan of abdomen without contrast 48560682_1 CDM 0352 RC 74150 HCPCS inpatient 2491 1619.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1508.3 2416.27 CT scan of blood vessels of neck with contrast 48560683_1 CDM 0351 RC 70498 HCPCS inpatient 3248 2111.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 2111.2 65 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of neck with contrast 48560683_1 CDM 0351 RC 70498 HCPCS inpatient 3248 2111.2 AETNA AETNA 2565.92 79 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of neck with contrast 48560683_1 CDM 0351 RC 70498 HCPCS inpatient 3248 2111.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 2241.12 69 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of neck with contrast 48560683_1 CDM 0351 RC 70498 HCPCS inpatient 3248 2111.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3150.56 97 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of neck with contrast 48560683_1 CDM 0351 RC 70498 HCPCS inpatient 3248 2111.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 2533.44 78 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of neck with contrast 48560683_1 CDM 0351 RC 70498 HCPCS inpatient 3248 2111.2 SIHO - ALL PLANS SIHO - ALL PLANS 2923.2 90 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of neck with contrast 48560683_1 CDM 0351 RC 70498 HCPCS inpatient 3248 2111.2 UMR - ALL PLANS UMR - ALL PLANS 2273.6 70 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of neck with contrast 48560683_1 CDM 0351 RC 70498 HCPCS inpatient 3248 2111.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1966.66 60.55 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of neck with contrast 48560683_1 CDM 0351 RC 70498 HCPCS inpatient 3248 2111.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1966.66 3150.56 CT scan of blood vessels of neck with contrast 48560683_1 CDM 0351 RC 70498 HCPCS inpatient 3248 2111.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1966.66 3150.56 CT scan of blood vessels of neck with contrast 48560683_1 CDM 0351 RC 70498 HCPCS inpatient 3248 2111.2 ANTHEM HMO ANTHEM HMO 999999999 1966.66 3150.56 CT scan of blood vessels of neck with contrast 48560683_1 CDM 0351 RC 70498 HCPCS inpatient 3248 2111.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 2195.65 67.6 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of neck with contrast 48560683_1 CDM 0351 RC 70498 HCPCS inpatient 3248 2111.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1966.66 3150.56 CT scan of blood vessels of neck with contrast 48560683_1 CDM 0351 RC 70498 HCPCS inpatient 3248 2111.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1966.66 3150.56 CT scan of abdomen with contrast 48560684_1 CDM 0352 RC 74160 HCPCS inpatient 2176 1414.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1414.4 65 999999999 1317.57 2110.72 percent of total billed charges CT scan of abdomen with contrast 48560684_1 CDM 0352 RC 74160 HCPCS inpatient 2176 1414.4 AETNA AETNA 1719.04 79 999999999 1317.57 2110.72 percent of total billed charges CT scan of abdomen with contrast 48560684_1 CDM 0352 RC 74160 HCPCS inpatient 2176 1414.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1501.44 69 999999999 1317.57 2110.72 percent of total billed charges CT scan of abdomen with contrast 48560684_1 CDM 0352 RC 74160 HCPCS inpatient 2176 1414.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2110.72 97 999999999 1317.57 2110.72 percent of total billed charges CT scan of abdomen with contrast 48560684_1 CDM 0352 RC 74160 HCPCS inpatient 2176 1414.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1697.28 78 999999999 1317.57 2110.72 percent of total billed charges CT scan of abdomen with contrast 48560684_1 CDM 0352 RC 74160 HCPCS inpatient 2176 1414.4 SIHO - ALL PLANS SIHO - ALL PLANS 1958.4 90 999999999 1317.57 2110.72 percent of total billed charges CT scan of abdomen with contrast 48560684_1 CDM 0352 RC 74160 HCPCS inpatient 2176 1414.4 UMR - ALL PLANS UMR - ALL PLANS 1523.2 70 999999999 1317.57 2110.72 percent of total billed charges CT scan of abdomen with contrast 48560684_1 CDM 0352 RC 74160 HCPCS inpatient 2176 1414.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1317.57 60.55 999999999 1317.57 2110.72 percent of total billed charges CT scan of abdomen with contrast 48560684_1 CDM 0352 RC 74160 HCPCS inpatient 2176 1414.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1317.57 2110.72 CT scan of abdomen with contrast 48560684_1 CDM 0352 RC 74160 HCPCS inpatient 2176 1414.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1317.57 2110.72 CT scan of abdomen with contrast 48560684_1 CDM 0352 RC 74160 HCPCS inpatient 2176 1414.4 ANTHEM HMO ANTHEM HMO 999999999 1317.57 2110.72 CT scan of abdomen with contrast 48560684_1 CDM 0352 RC 74160 HCPCS inpatient 2176 1414.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1470.98 67.6 999999999 1317.57 2110.72 percent of total billed charges CT scan of abdomen with contrast 48560684_1 CDM 0352 RC 74160 HCPCS inpatient 2176 1414.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1317.57 2110.72 CT scan of abdomen with contrast 48560684_1 CDM 0352 RC 74160 HCPCS inpatient 2176 1414.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1317.57 2110.72 CT scan of blood vessels of abdomen with contrast 48560685_1 CDM 0352 RC 74175 HCPCS inpatient 3248 2111.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 2111.2 65 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of abdomen with contrast 48560685_1 CDM 0352 RC 74175 HCPCS inpatient 3248 2111.2 AETNA AETNA 2565.92 79 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of abdomen with contrast 48560685_1 CDM 0352 RC 74175 HCPCS inpatient 3248 2111.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 2241.12 69 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of abdomen with contrast 48560685_1 CDM 0352 RC 74175 HCPCS inpatient 3248 2111.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3150.56 97 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of abdomen with contrast 48560685_1 CDM 0352 RC 74175 HCPCS inpatient 3248 2111.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 2533.44 78 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of abdomen with contrast 48560685_1 CDM 0352 RC 74175 HCPCS inpatient 3248 2111.2 SIHO - ALL PLANS SIHO - ALL PLANS 2923.2 90 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of abdomen with contrast 48560685_1 CDM 0352 RC 74175 HCPCS inpatient 3248 2111.2 UMR - ALL PLANS UMR - ALL PLANS 2273.6 70 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of abdomen with contrast 48560685_1 CDM 0352 RC 74175 HCPCS inpatient 3248 2111.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1966.66 60.55 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of abdomen with contrast 48560685_1 CDM 0352 RC 74175 HCPCS inpatient 3248 2111.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1966.66 3150.56 CT scan of blood vessels of abdomen with contrast 48560685_1 CDM 0352 RC 74175 HCPCS inpatient 3248 2111.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1966.66 3150.56 CT scan of blood vessels of abdomen with contrast 48560685_1 CDM 0352 RC 74175 HCPCS inpatient 3248 2111.2 ANTHEM HMO ANTHEM HMO 999999999 1966.66 3150.56 CT scan of blood vessels of abdomen with contrast 48560685_1 CDM 0352 RC 74175 HCPCS inpatient 3248 2111.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 2195.65 67.6 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of abdomen with contrast 48560685_1 CDM 0352 RC 74175 HCPCS inpatient 3248 2111.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1966.66 3150.56 CT scan of blood vessels of abdomen with contrast 48560685_1 CDM 0352 RC 74175 HCPCS inpatient 3248 2111.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1966.66 3150.56 CT scan of abdomen and pelvis before and after contrast 48560688_1 CDM 0352 RC 74178 HCPCS inpatient 2176 1414.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1414.4 65 999999999 1317.57 2110.72 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 48560688_1 CDM 0352 RC 74178 HCPCS inpatient 2176 1414.4 AETNA AETNA 1719.04 79 999999999 1317.57 2110.72 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 48560688_1 CDM 0352 RC 74178 HCPCS inpatient 2176 1414.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1501.44 69 999999999 1317.57 2110.72 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 48560688_1 CDM 0352 RC 74178 HCPCS inpatient 2176 1414.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2110.72 97 999999999 1317.57 2110.72 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 48560688_1 CDM 0352 RC 74178 HCPCS inpatient 2176 1414.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1697.28 78 999999999 1317.57 2110.72 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 48560688_1 CDM 0352 RC 74178 HCPCS inpatient 2176 1414.4 SIHO - ALL PLANS SIHO - ALL PLANS 1958.4 90 999999999 1317.57 2110.72 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 48560688_1 CDM 0352 RC 74178 HCPCS inpatient 2176 1414.4 UMR - ALL PLANS UMR - ALL PLANS 1523.2 70 999999999 1317.57 2110.72 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 48560688_1 CDM 0352 RC 74178 HCPCS inpatient 2176 1414.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1317.57 60.55 999999999 1317.57 2110.72 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 48560688_1 CDM 0352 RC 74178 HCPCS inpatient 2176 1414.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1317.57 2110.72 CT scan of abdomen and pelvis before and after contrast 48560688_1 CDM 0352 RC 74178 HCPCS inpatient 2176 1414.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1317.57 2110.72 CT scan of abdomen and pelvis before and after contrast 48560688_1 CDM 0352 RC 74178 HCPCS inpatient 2176 1414.4 ANTHEM HMO ANTHEM HMO 999999999 1317.57 2110.72 CT scan of abdomen and pelvis before and after contrast 48560688_1 CDM 0352 RC 74178 HCPCS inpatient 2176 1414.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1470.98 67.6 999999999 1317.57 2110.72 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 48560688_1 CDM 0352 RC 74178 HCPCS inpatient 2176 1414.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1317.57 2110.72 CT scan of abdomen and pelvis before and after contrast 48560688_1 CDM 0352 RC 74178 HCPCS inpatient 2176 1414.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1317.57 2110.72 CT scan of abdomen and pelvis without contrast 48560689_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 SELF PAY DISCOUNT SELF PAY DISCOUNT 3003 65 999999999 2797.41 4481.4 percent of total billed charges CT scan of abdomen and pelvis without contrast 48560689_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 AETNA AETNA 3649.8 79 999999999 2797.41 4481.4 percent of total billed charges CT scan of abdomen and pelvis without contrast 48560689_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 ENCORE - ALL PLANS ENCORE - ALL PLANS 3187.8 69 999999999 2797.41 4481.4 percent of total billed charges CT scan of abdomen and pelvis without contrast 48560689_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4481.4 97 999999999 2797.41 4481.4 percent of total billed charges CT scan of abdomen and pelvis without contrast 48560689_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 HUMANA - ALL PLANS HUMANA - ALL PLANS 3603.6 78 999999999 2797.41 4481.4 percent of total billed charges CT scan of abdomen and pelvis without contrast 48560689_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 SIHO - ALL PLANS SIHO - ALL PLANS 4158 90 999999999 2797.41 4481.4 percent of total billed charges CT scan of abdomen and pelvis without contrast 48560689_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 UMR - ALL PLANS UMR - ALL PLANS 3234 70 999999999 2797.41 4481.4 percent of total billed charges CT scan of abdomen and pelvis without contrast 48560689_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2797.41 60.55 999999999 2797.41 4481.4 percent of total billed charges CT scan of abdomen and pelvis without contrast 48560689_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2797.41 4481.4 CT scan of abdomen and pelvis without contrast 48560689_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2797.41 4481.4 CT scan of abdomen and pelvis without contrast 48560689_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 ANTHEM HMO ANTHEM HMO 999999999 2797.41 4481.4 CT scan of abdomen and pelvis without contrast 48560689_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 CIGNA - ALL PLANS CIGNA - ALL PLANS 3123.12 67.6 999999999 2797.41 4481.4 percent of total billed charges CT scan of abdomen and pelvis without contrast 48560689_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2797.41 4481.4 CT scan of abdomen and pelvis without contrast 48560689_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 UHC - ALL PLANS UHC - ALL PLANS 999999999 2797.41 4481.4 CT scan of abdomen and pelvis with contrast 48560693_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 SELF PAY DISCOUNT SELF PAY DISCOUNT 2626 65 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 48560693_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 AETNA AETNA 3191.6 79 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 48560693_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 ENCORE - ALL PLANS ENCORE - ALL PLANS 2787.6 69 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 48560693_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3918.8 97 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 48560693_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 HUMANA - ALL PLANS HUMANA - ALL PLANS 3151.2 78 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 48560693_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 SIHO - ALL PLANS SIHO - ALL PLANS 3636 90 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 48560693_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 UMR - ALL PLANS UMR - ALL PLANS 2828 70 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 48560693_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2446.22 60.55 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 48560693_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2446.22 3918.8 CT scan of abdomen and pelvis with contrast 48560693_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2446.22 3918.8 CT scan of abdomen and pelvis with contrast 48560693_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 ANTHEM HMO ANTHEM HMO 999999999 2446.22 3918.8 CT scan of abdomen and pelvis with contrast 48560693_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 CIGNA - ALL PLANS CIGNA - ALL PLANS 2731.04 67.6 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 48560693_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2446.22 3918.8 CT scan of abdomen and pelvis with contrast 48560693_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 UHC - ALL PLANS UHC - ALL PLANS 999999999 2446.22 3918.8 Needle biopsy of thyroid through skin 48560694_1 CDM 0361 RC 60100 HCPCS inpatient 915 594.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 594.75 65 999999999 554.03 887.55 percent of total billed charges Needle biopsy of thyroid through skin 48560694_1 CDM 0361 RC 60100 HCPCS inpatient 915 594.75 AETNA AETNA 722.85 79 999999999 554.03 887.55 percent of total billed charges Needle biopsy of thyroid through skin 48560694_1 CDM 0361 RC 60100 HCPCS inpatient 915 594.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 631.35 69 999999999 554.03 887.55 percent of total billed charges Needle biopsy of thyroid through skin 48560694_1 CDM 0361 RC 60100 HCPCS inpatient 915 594.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 887.55 97 999999999 554.03 887.55 percent of total billed charges Needle biopsy of thyroid through skin 48560694_1 CDM 0361 RC 60100 HCPCS inpatient 915 594.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 713.7 78 999999999 554.03 887.55 percent of total billed charges Needle biopsy of thyroid through skin 48560694_1 CDM 0361 RC 60100 HCPCS inpatient 915 594.75 SIHO - ALL PLANS SIHO - ALL PLANS 823.5 90 999999999 554.03 887.55 percent of total billed charges Needle biopsy of thyroid through skin 48560694_1 CDM 0361 RC 60100 HCPCS inpatient 915 594.75 UMR - ALL PLANS UMR - ALL PLANS 640.5 70 999999999 554.03 887.55 percent of total billed charges Needle biopsy of thyroid through skin 48560694_1 CDM 0361 RC 60100 HCPCS inpatient 915 594.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 554.03 60.55 999999999 554.03 887.55 percent of total billed charges Needle biopsy of thyroid through skin 48560694_1 CDM 0361 RC 60100 HCPCS inpatient 915 594.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 554.03 887.55 Needle biopsy of thyroid through skin 48560694_1 CDM 0361 RC 60100 HCPCS inpatient 915 594.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 554.03 887.55 Needle biopsy of thyroid through skin 48560694_1 CDM 0361 RC 60100 HCPCS inpatient 915 594.75 ANTHEM HMO ANTHEM HMO 999999999 554.03 887.55 Needle biopsy of thyroid through skin 48560694_1 CDM 0361 RC 60100 HCPCS inpatient 915 594.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 618.54 67.6 999999999 554.03 887.55 percent of total billed charges Needle biopsy of thyroid through skin 48560694_1 CDM 0361 RC 60100 HCPCS inpatient 915 594.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 554.03 887.55 Needle biopsy of thyroid through skin 48560694_1 CDM 0361 RC 60100 HCPCS inpatient 915 594.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 554.03 887.55 Injection of contrast for imaging of hip under anesthesia 48560695_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 SELF PAY DISCOUNT SELF PAY DISCOUNT 351 65 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip under anesthesia 48560695_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 AETNA AETNA 426.6 79 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip under anesthesia 48560695_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 ENCORE - ALL PLANS ENCORE - ALL PLANS 372.6 69 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip under anesthesia 48560695_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 523.8 97 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip under anesthesia 48560695_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 HUMANA - ALL PLANS HUMANA - ALL PLANS 421.2 78 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip under anesthesia 48560695_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 SIHO - ALL PLANS SIHO - ALL PLANS 486 90 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip under anesthesia 48560695_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 UMR - ALL PLANS UMR - ALL PLANS 378 70 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip under anesthesia 48560695_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 326.97 60.55 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip under anesthesia 48560695_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 326.97 523.8 Injection of contrast for imaging of hip under anesthesia 48560695_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 326.97 523.8 Injection of contrast for imaging of hip under anesthesia 48560695_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 ANTHEM HMO ANTHEM HMO 999999999 326.97 523.8 Injection of contrast for imaging of hip under anesthesia 48560695_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 CIGNA - ALL PLANS CIGNA - ALL PLANS 365.04 67.6 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip under anesthesia 48560695_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 326.97 523.8 Injection of contrast for imaging of hip under anesthesia 48560695_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 UHC - ALL PLANS UHC - ALL PLANS 999999999 326.97 523.8 Injection of contrast for imaging of hip under anesthesia 48560724_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 SELF PAY DISCOUNT SELF PAY DISCOUNT 351 65 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip under anesthesia 48560724_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 AETNA AETNA 426.6 79 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip under anesthesia 48560724_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 ENCORE - ALL PLANS ENCORE - ALL PLANS 372.6 69 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip under anesthesia 48560724_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 523.8 97 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip under anesthesia 48560724_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 HUMANA - ALL PLANS HUMANA - ALL PLANS 421.2 78 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip under anesthesia 48560724_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 SIHO - ALL PLANS SIHO - ALL PLANS 486 90 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip under anesthesia 48560724_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 UMR - ALL PLANS UMR - ALL PLANS 378 70 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip under anesthesia 48560724_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 326.97 60.55 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip under anesthesia 48560724_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 326.97 523.8 Injection of contrast for imaging of hip under anesthesia 48560724_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 326.97 523.8 Injection of contrast for imaging of hip under anesthesia 48560724_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 ANTHEM HMO ANTHEM HMO 999999999 326.97 523.8 Injection of contrast for imaging of hip under anesthesia 48560724_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 CIGNA - ALL PLANS CIGNA - ALL PLANS 365.04 67.6 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip under anesthesia 48560724_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 326.97 523.8 Injection of contrast for imaging of hip under anesthesia 48560724_1 CDM 0361 RC 27095 HCPCS inpatient 540 351 UHC - ALL PLANS UHC - ALL PLANS 999999999 326.97 523.8 Injection of contrast for imaging of hip joint 48560725_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 SELF PAY DISCOUNT SELF PAY DISCOUNT 351 65 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip joint 48560725_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 AETNA AETNA 426.6 79 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip joint 48560725_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 ENCORE - ALL PLANS ENCORE - ALL PLANS 372.6 69 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip joint 48560725_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 523.8 97 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip joint 48560725_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 HUMANA - ALL PLANS HUMANA - ALL PLANS 421.2 78 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip joint 48560725_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 SIHO - ALL PLANS SIHO - ALL PLANS 486 90 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip joint 48560725_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 UMR - ALL PLANS UMR - ALL PLANS 378 70 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip joint 48560725_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 326.97 60.55 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip joint 48560725_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 326.97 523.8 Injection of contrast for imaging of hip joint 48560725_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 326.97 523.8 Injection of contrast for imaging of hip joint 48560725_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 ANTHEM HMO ANTHEM HMO 999999999 326.97 523.8 Injection of contrast for imaging of hip joint 48560725_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 CIGNA - ALL PLANS CIGNA - ALL PLANS 365.04 67.6 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip joint 48560725_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 326.97 523.8 Injection of contrast for imaging of hip joint 48560725_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 UHC - ALL PLANS UHC - ALL PLANS 999999999 326.97 523.8 Injection of contrast for imaging of hip joint 48560726_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 SELF PAY DISCOUNT SELF PAY DISCOUNT 351 65 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip joint 48560726_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 AETNA AETNA 426.6 79 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip joint 48560726_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 ENCORE - ALL PLANS ENCORE - ALL PLANS 372.6 69 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip joint 48560726_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 523.8 97 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip joint 48560726_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 HUMANA - ALL PLANS HUMANA - ALL PLANS 421.2 78 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip joint 48560726_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 SIHO - ALL PLANS SIHO - ALL PLANS 486 90 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip joint 48560726_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 UMR - ALL PLANS UMR - ALL PLANS 378 70 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip joint 48560726_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 326.97 60.55 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip joint 48560726_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 326.97 523.8 Injection of contrast for imaging of hip joint 48560726_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 326.97 523.8 Injection of contrast for imaging of hip joint 48560726_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 ANTHEM HMO ANTHEM HMO 999999999 326.97 523.8 Injection of contrast for imaging of hip joint 48560726_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 CIGNA - ALL PLANS CIGNA - ALL PLANS 365.04 67.6 999999999 326.97 523.8 percent of total billed charges Injection of contrast for imaging of hip joint 48560726_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 326.97 523.8 Injection of contrast for imaging of hip joint 48560726_1 CDM 0361 RC 27093 HCPCS inpatient 540 351 UHC - ALL PLANS UHC - ALL PLANS 999999999 326.97 523.8 Nuclear medicine study of bone and/or joint whole body 48560761_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1184.3 65 999999999 1103.22 1767.34 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 48560761_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 AETNA AETNA 1439.38 79 999999999 1103.22 1767.34 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 48560761_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1257.18 69 999999999 1103.22 1767.34 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 48560761_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1767.34 97 999999999 1103.22 1767.34 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 48560761_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1421.16 78 999999999 1103.22 1767.34 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 48560761_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 SIHO - ALL PLANS SIHO - ALL PLANS 1639.8 90 999999999 1103.22 1767.34 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 48560761_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 UMR - ALL PLANS UMR - ALL PLANS 1275.4 70 999999999 1103.22 1767.34 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 48560761_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1103.22 60.55 999999999 1103.22 1767.34 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 48560761_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1103.22 1767.34 Nuclear medicine study of bone and/or joint whole body 48560761_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1103.22 1767.34 Nuclear medicine study of bone and/or joint whole body 48560761_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 ANTHEM HMO ANTHEM HMO 999999999 1103.22 1767.34 Nuclear medicine study of bone and/or joint whole body 48560761_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1231.67 67.6 999999999 1103.22 1767.34 percent of total billed charges Nuclear medicine study of bone and/or joint whole body 48560761_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1103.22 1767.34 Nuclear medicine study of bone and/or joint whole body 48560761_1 CDM 0341 RC 78306 HCPCS inpatient 1822 1184.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1103.22 1767.34 Aspiration and/or injection of fluid from medium joint 48560762_1 CDM 0361 RC 20605 HCPCS inpatient 723 469.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 469.95 65 999999999 437.78 701.31 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48560762_1 CDM 0361 RC 20605 HCPCS inpatient 723 469.95 AETNA AETNA 571.17 79 999999999 437.78 701.31 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48560762_1 CDM 0361 RC 20605 HCPCS inpatient 723 469.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 498.87 69 999999999 437.78 701.31 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48560762_1 CDM 0361 RC 20605 HCPCS inpatient 723 469.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 701.31 97 999999999 437.78 701.31 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48560762_1 CDM 0361 RC 20605 HCPCS inpatient 723 469.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 563.94 78 999999999 437.78 701.31 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48560762_1 CDM 0361 RC 20605 HCPCS inpatient 723 469.95 SIHO - ALL PLANS SIHO - ALL PLANS 650.7 90 999999999 437.78 701.31 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48560762_1 CDM 0361 RC 20605 HCPCS inpatient 723 469.95 UMR - ALL PLANS UMR - ALL PLANS 506.1 70 999999999 437.78 701.31 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48560762_1 CDM 0361 RC 20605 HCPCS inpatient 723 469.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 437.78 60.55 999999999 437.78 701.31 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48560762_1 CDM 0361 RC 20605 HCPCS inpatient 723 469.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 437.78 701.31 Aspiration and/or injection of fluid from medium joint 48560762_1 CDM 0361 RC 20605 HCPCS inpatient 723 469.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 437.78 701.31 Aspiration and/or injection of fluid from medium joint 48560762_1 CDM 0361 RC 20605 HCPCS inpatient 723 469.95 ANTHEM HMO ANTHEM HMO 999999999 437.78 701.31 Aspiration and/or injection of fluid from medium joint 48560762_1 CDM 0361 RC 20605 HCPCS inpatient 723 469.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 488.75 67.6 999999999 437.78 701.31 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48560762_1 CDM 0361 RC 20605 HCPCS inpatient 723 469.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 437.78 701.31 Aspiration and/or injection of fluid from medium joint 48560762_1 CDM 0361 RC 20605 HCPCS inpatient 723 469.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 437.78 701.31 Aspiration and/or injection of fluid from large joint 48560797_1 CDM 0361 RC 20610 HCPCS inpatient 1118 726.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 726.7 65 999999999 676.95 1084.46 percent of total billed charges Aspiration and/or injection of fluid from large joint 48560797_1 CDM 0361 RC 20610 HCPCS inpatient 1118 726.7 AETNA AETNA 883.22 79 999999999 676.95 1084.46 percent of total billed charges Aspiration and/or injection of fluid from large joint 48560797_1 CDM 0361 RC 20610 HCPCS inpatient 1118 726.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 771.42 69 999999999 676.95 1084.46 percent of total billed charges Aspiration and/or injection of fluid from large joint 48560797_1 CDM 0361 RC 20610 HCPCS inpatient 1118 726.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1084.46 97 999999999 676.95 1084.46 percent of total billed charges Aspiration and/or injection of fluid from large joint 48560797_1 CDM 0361 RC 20610 HCPCS inpatient 1118 726.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 872.04 78 999999999 676.95 1084.46 percent of total billed charges Aspiration and/or injection of fluid from large joint 48560797_1 CDM 0361 RC 20610 HCPCS inpatient 1118 726.7 SIHO - ALL PLANS SIHO - ALL PLANS 1006.2 90 999999999 676.95 1084.46 percent of total billed charges Aspiration and/or injection of fluid from large joint 48560797_1 CDM 0361 RC 20610 HCPCS inpatient 1118 726.7 UMR - ALL PLANS UMR - ALL PLANS 782.6 70 999999999 676.95 1084.46 percent of total billed charges Aspiration and/or injection of fluid from large joint 48560797_1 CDM 0361 RC 20610 HCPCS inpatient 1118 726.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 676.95 60.55 999999999 676.95 1084.46 percent of total billed charges Aspiration and/or injection of fluid from large joint 48560797_1 CDM 0361 RC 20610 HCPCS inpatient 1118 726.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 676.95 1084.46 Aspiration and/or injection of fluid from large joint 48560797_1 CDM 0361 RC 20610 HCPCS inpatient 1118 726.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 676.95 1084.46 Aspiration and/or injection of fluid from large joint 48560797_1 CDM 0361 RC 20610 HCPCS inpatient 1118 726.7 ANTHEM HMO ANTHEM HMO 999999999 676.95 1084.46 Aspiration and/or injection of fluid from large joint 48560797_1 CDM 0361 RC 20610 HCPCS inpatient 1118 726.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 755.77 67.6 999999999 676.95 1084.46 percent of total billed charges Aspiration and/or injection of fluid from large joint 48560797_1 CDM 0361 RC 20610 HCPCS inpatient 1118 726.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 676.95 1084.46 Aspiration and/or injection of fluid from large joint 48560797_1 CDM 0361 RC 20610 HCPCS inpatient 1118 726.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 676.95 1084.46 Aspiration and/or injection of fluid from small joint 48560798_1 CDM 0361 RC 20600 HCPCS inpatient 675 438.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 438.75 65 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 48560798_1 CDM 0361 RC 20600 HCPCS inpatient 675 438.75 AETNA AETNA 533.25 79 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 48560798_1 CDM 0361 RC 20600 HCPCS inpatient 675 438.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 465.75 69 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 48560798_1 CDM 0361 RC 20600 HCPCS inpatient 675 438.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 654.75 97 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 48560798_1 CDM 0361 RC 20600 HCPCS inpatient 675 438.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 526.5 78 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 48560798_1 CDM 0361 RC 20600 HCPCS inpatient 675 438.75 SIHO - ALL PLANS SIHO - ALL PLANS 607.5 90 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 48560798_1 CDM 0361 RC 20600 HCPCS inpatient 675 438.75 UMR - ALL PLANS UMR - ALL PLANS 472.5 70 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 48560798_1 CDM 0361 RC 20600 HCPCS inpatient 675 438.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 408.71 60.55 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 48560798_1 CDM 0361 RC 20600 HCPCS inpatient 675 438.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 408.71 654.75 Aspiration and/or injection of fluid from small joint 48560798_1 CDM 0361 RC 20600 HCPCS inpatient 675 438.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 408.71 654.75 Aspiration and/or injection of fluid from small joint 48560798_1 CDM 0361 RC 20600 HCPCS inpatient 675 438.75 ANTHEM HMO ANTHEM HMO 999999999 408.71 654.75 Aspiration and/or injection of fluid from small joint 48560798_1 CDM 0361 RC 20600 HCPCS inpatient 675 438.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 456.3 67.6 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 48560798_1 CDM 0361 RC 20600 HCPCS inpatient 675 438.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 408.71 654.75 Aspiration and/or injection of fluid from small joint 48560798_1 CDM 0361 RC 20600 HCPCS inpatient 675 438.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 408.71 654.75 Injection of radioactive material for X-ray identification of lymph node 48560799_1 CDM 0361 RC 38792 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Injection of radioactive material for X-ray identification of lymph node 48560799_1 CDM 0361 RC 38792 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Injection of radioactive material for X-ray identification of lymph node 48560799_1 CDM 0361 RC 38792 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Injection of radioactive material for X-ray identification of lymph node 48560799_1 CDM 0361 RC 38792 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Injection of radioactive material for X-ray identification of lymph node 48560799_1 CDM 0361 RC 38792 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Injection of radioactive material for X-ray identification of lymph node 48560799_1 CDM 0361 RC 38792 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Injection of radioactive material for X-ray identification of lymph node 48560799_1 CDM 0361 RC 38792 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Injection of radioactive material for X-ray identification of lymph node 48560799_1 CDM 0361 RC 38792 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Injection of radioactive material for X-ray identification of lymph node 48560799_1 CDM 0361 RC 38792 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Injection of radioactive material for X-ray identification of lymph node 48560799_1 CDM 0361 RC 38792 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Injection of radioactive material for X-ray identification of lymph node 48560799_1 CDM 0361 RC 38792 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Injection of radioactive material for X-ray identification of lymph node 48560799_1 CDM 0361 RC 38792 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges Injection of radioactive material for X-ray identification of lymph node 48560799_1 CDM 0361 RC 38792 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Injection of radioactive material for X-ray identification of lymph node 48560799_1 CDM 0361 RC 38792 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Complicated or multiple drainage of skin abscess 48567620_1 CDM 0450 RC 10061 HCPCS inpatient 587 381.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 381.55 65 999999999 355.43 569.39 percent of total billed charges Complicated or multiple drainage of skin abscess 48567620_1 CDM 0450 RC 10061 HCPCS inpatient 587 381.55 AETNA AETNA 463.73 79 999999999 355.43 569.39 percent of total billed charges Complicated or multiple drainage of skin abscess 48567620_1 CDM 0450 RC 10061 HCPCS inpatient 587 381.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 405.03 69 999999999 355.43 569.39 percent of total billed charges Complicated or multiple drainage of skin abscess 48567620_1 CDM 0450 RC 10061 HCPCS inpatient 587 381.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 569.39 97 999999999 355.43 569.39 percent of total billed charges Complicated or multiple drainage of skin abscess 48567620_1 CDM 0450 RC 10061 HCPCS inpatient 587 381.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 457.86 78 999999999 355.43 569.39 percent of total billed charges Complicated or multiple drainage of skin abscess 48567620_1 CDM 0450 RC 10061 HCPCS inpatient 587 381.55 SIHO - ALL PLANS SIHO - ALL PLANS 528.3 90 999999999 355.43 569.39 percent of total billed charges Complicated or multiple drainage of skin abscess 48567620_1 CDM 0450 RC 10061 HCPCS inpatient 587 381.55 UMR - ALL PLANS UMR - ALL PLANS 410.9 70 999999999 355.43 569.39 percent of total billed charges Complicated or multiple drainage of skin abscess 48567620_1 CDM 0450 RC 10061 HCPCS inpatient 587 381.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 355.43 60.55 999999999 355.43 569.39 percent of total billed charges Complicated or multiple drainage of skin abscess 48567620_1 CDM 0450 RC 10061 HCPCS inpatient 587 381.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 355.43 569.39 Complicated or multiple drainage of skin abscess 48567620_1 CDM 0450 RC 10061 HCPCS inpatient 587 381.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 355.43 569.39 Complicated or multiple drainage of skin abscess 48567620_1 CDM 0450 RC 10061 HCPCS inpatient 587 381.55 ANTHEM HMO ANTHEM HMO 999999999 355.43 569.39 Complicated or multiple drainage of skin abscess 48567620_1 CDM 0450 RC 10061 HCPCS inpatient 587 381.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 396.81 67.6 999999999 355.43 569.39 percent of total billed charges Complicated or multiple drainage of skin abscess 48567620_1 CDM 0450 RC 10061 HCPCS inpatient 587 381.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 355.43 569.39 Complicated or multiple drainage of skin abscess 48567620_1 CDM 0450 RC 10061 HCPCS inpatient 587 381.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 355.43 569.39 Simple drainage of cyst of tailbone 48567621_1 CDM 0450 RC 10080 HCPCS inpatient 957 622.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 622.05 65 999999999 579.46 928.29 percent of total billed charges Simple drainage of cyst of tailbone 48567621_1 CDM 0450 RC 10080 HCPCS inpatient 957 622.05 AETNA AETNA 756.03 79 999999999 579.46 928.29 percent of total billed charges Simple drainage of cyst of tailbone 48567621_1 CDM 0450 RC 10080 HCPCS inpatient 957 622.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 660.33 69 999999999 579.46 928.29 percent of total billed charges Simple drainage of cyst of tailbone 48567621_1 CDM 0450 RC 10080 HCPCS inpatient 957 622.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 928.29 97 999999999 579.46 928.29 percent of total billed charges Simple drainage of cyst of tailbone 48567621_1 CDM 0450 RC 10080 HCPCS inpatient 957 622.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 746.46 78 999999999 579.46 928.29 percent of total billed charges Simple drainage of cyst of tailbone 48567621_1 CDM 0450 RC 10080 HCPCS inpatient 957 622.05 SIHO - ALL PLANS SIHO - ALL PLANS 861.3 90 999999999 579.46 928.29 percent of total billed charges Simple drainage of cyst of tailbone 48567621_1 CDM 0450 RC 10080 HCPCS inpatient 957 622.05 UMR - ALL PLANS UMR - ALL PLANS 669.9 70 999999999 579.46 928.29 percent of total billed charges Simple drainage of cyst of tailbone 48567621_1 CDM 0450 RC 10080 HCPCS inpatient 957 622.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 579.46 60.55 999999999 579.46 928.29 percent of total billed charges Simple drainage of cyst of tailbone 48567621_1 CDM 0450 RC 10080 HCPCS inpatient 957 622.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 579.46 928.29 Simple drainage of cyst of tailbone 48567621_1 CDM 0450 RC 10080 HCPCS inpatient 957 622.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 579.46 928.29 Simple drainage of cyst of tailbone 48567621_1 CDM 0450 RC 10080 HCPCS inpatient 957 622.05 ANTHEM HMO ANTHEM HMO 999999999 579.46 928.29 Simple drainage of cyst of tailbone 48567621_1 CDM 0450 RC 10080 HCPCS inpatient 957 622.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 646.93 67.6 999999999 579.46 928.29 percent of total billed charges Simple drainage of cyst of tailbone 48567621_1 CDM 0450 RC 10080 HCPCS inpatient 957 622.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 579.46 928.29 Simple drainage of cyst of tailbone 48567621_1 CDM 0450 RC 10080 HCPCS inpatient 957 622.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 579.46 928.29 "Removal of foreign body from tissue, accessed beneath the skin, simple" 48567623_1 CDM 0450 RC 10120 HCPCS inpatient 747 485.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 485.55 65 999999999 452.31 724.59 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48567623_1 CDM 0450 RC 10120 HCPCS inpatient 747 485.55 AETNA AETNA 590.13 79 999999999 452.31 724.59 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48567623_1 CDM 0450 RC 10120 HCPCS inpatient 747 485.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 515.43 69 999999999 452.31 724.59 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48567623_1 CDM 0450 RC 10120 HCPCS inpatient 747 485.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 724.59 97 999999999 452.31 724.59 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48567623_1 CDM 0450 RC 10120 HCPCS inpatient 747 485.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 582.66 78 999999999 452.31 724.59 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48567623_1 CDM 0450 RC 10120 HCPCS inpatient 747 485.55 SIHO - ALL PLANS SIHO - ALL PLANS 672.3 90 999999999 452.31 724.59 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48567623_1 CDM 0450 RC 10120 HCPCS inpatient 747 485.55 UMR - ALL PLANS UMR - ALL PLANS 522.9 70 999999999 452.31 724.59 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48567623_1 CDM 0450 RC 10120 HCPCS inpatient 747 485.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 452.31 60.55 999999999 452.31 724.59 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48567623_1 CDM 0450 RC 10120 HCPCS inpatient 747 485.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 452.31 724.59 "Removal of foreign body from tissue, accessed beneath the skin, simple" 48567623_1 CDM 0450 RC 10120 HCPCS inpatient 747 485.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 452.31 724.59 "Removal of foreign body from tissue, accessed beneath the skin, simple" 48567623_1 CDM 0450 RC 10120 HCPCS inpatient 747 485.55 ANTHEM HMO ANTHEM HMO 999999999 452.31 724.59 "Removal of foreign body from tissue, accessed beneath the skin, simple" 48567623_1 CDM 0450 RC 10120 HCPCS inpatient 747 485.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 504.97 67.6 999999999 452.31 724.59 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48567623_1 CDM 0450 RC 10120 HCPCS inpatient 747 485.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 452.31 724.59 "Removal of foreign body from tissue, accessed beneath the skin, simple" 48567623_1 CDM 0450 RC 10120 HCPCS inpatient 747 485.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 452.31 724.59 "Removal of foreign body from tissue, accessed beneath the skin, complex" 48567626_1 CDM 0450 RC 10121 HCPCS inpatient 1476 959.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 959.4 65 999999999 893.72 1431.72 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, complex" 48567626_1 CDM 0450 RC 10121 HCPCS inpatient 1476 959.4 AETNA AETNA 1166.04 79 999999999 893.72 1431.72 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, complex" 48567626_1 CDM 0450 RC 10121 HCPCS inpatient 1476 959.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1018.44 69 999999999 893.72 1431.72 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, complex" 48567626_1 CDM 0450 RC 10121 HCPCS inpatient 1476 959.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1431.72 97 999999999 893.72 1431.72 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, complex" 48567626_1 CDM 0450 RC 10121 HCPCS inpatient 1476 959.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1151.28 78 999999999 893.72 1431.72 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, complex" 48567626_1 CDM 0450 RC 10121 HCPCS inpatient 1476 959.4 SIHO - ALL PLANS SIHO - ALL PLANS 1328.4 90 999999999 893.72 1431.72 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, complex" 48567626_1 CDM 0450 RC 10121 HCPCS inpatient 1476 959.4 UMR - ALL PLANS UMR - ALL PLANS 1033.2 70 999999999 893.72 1431.72 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, complex" 48567626_1 CDM 0450 RC 10121 HCPCS inpatient 1476 959.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 893.72 60.55 999999999 893.72 1431.72 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, complex" 48567626_1 CDM 0450 RC 10121 HCPCS inpatient 1476 959.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 893.72 1431.72 "Removal of foreign body from tissue, accessed beneath the skin, complex" 48567626_1 CDM 0450 RC 10121 HCPCS inpatient 1476 959.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 893.72 1431.72 "Removal of foreign body from tissue, accessed beneath the skin, complex" 48567626_1 CDM 0450 RC 10121 HCPCS inpatient 1476 959.4 ANTHEM HMO ANTHEM HMO 999999999 893.72 1431.72 "Removal of foreign body from tissue, accessed beneath the skin, complex" 48567626_1 CDM 0450 RC 10121 HCPCS inpatient 1476 959.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 997.78 67.6 999999999 893.72 1431.72 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, complex" 48567626_1 CDM 0450 RC 10121 HCPCS inpatient 1476 959.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 893.72 1431.72 "Removal of foreign body from tissue, accessed beneath the skin, complex" 48567626_1 CDM 0450 RC 10121 HCPCS inpatient 1476 959.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 893.72 1431.72 "Aspiration of abscess, blood, or cyst" 48567628_1 CDM 0450 RC 10160 HCPCS inpatient 471 306.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 306.15 65 999999999 285.19 456.87 percent of total billed charges "Aspiration of abscess, blood, or cyst" 48567628_1 CDM 0450 RC 10160 HCPCS inpatient 471 306.15 AETNA AETNA 372.09 79 999999999 285.19 456.87 percent of total billed charges "Aspiration of abscess, blood, or cyst" 48567628_1 CDM 0450 RC 10160 HCPCS inpatient 471 306.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 324.99 69 999999999 285.19 456.87 percent of total billed charges "Aspiration of abscess, blood, or cyst" 48567628_1 CDM 0450 RC 10160 HCPCS inpatient 471 306.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 456.87 97 999999999 285.19 456.87 percent of total billed charges "Aspiration of abscess, blood, or cyst" 48567628_1 CDM 0450 RC 10160 HCPCS inpatient 471 306.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 367.38 78 999999999 285.19 456.87 percent of total billed charges "Aspiration of abscess, blood, or cyst" 48567628_1 CDM 0450 RC 10160 HCPCS inpatient 471 306.15 SIHO - ALL PLANS SIHO - ALL PLANS 423.9 90 999999999 285.19 456.87 percent of total billed charges "Aspiration of abscess, blood, or cyst" 48567628_1 CDM 0450 RC 10160 HCPCS inpatient 471 306.15 UMR - ALL PLANS UMR - ALL PLANS 329.7 70 999999999 285.19 456.87 percent of total billed charges "Aspiration of abscess, blood, or cyst" 48567628_1 CDM 0450 RC 10160 HCPCS inpatient 471 306.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 285.19 60.55 999999999 285.19 456.87 percent of total billed charges "Aspiration of abscess, blood, or cyst" 48567628_1 CDM 0450 RC 10160 HCPCS inpatient 471 306.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 285.19 456.87 "Aspiration of abscess, blood, or cyst" 48567628_1 CDM 0450 RC 10160 HCPCS inpatient 471 306.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 285.19 456.87 "Aspiration of abscess, blood, or cyst" 48567628_1 CDM 0450 RC 10160 HCPCS inpatient 471 306.15 ANTHEM HMO ANTHEM HMO 999999999 285.19 456.87 "Aspiration of abscess, blood, or cyst" 48567628_1 CDM 0450 RC 10160 HCPCS inpatient 471 306.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 318.4 67.6 999999999 285.19 456.87 percent of total billed charges "Aspiration of abscess, blood, or cyst" 48567628_1 CDM 0450 RC 10160 HCPCS inpatient 471 306.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 285.19 456.87 "Aspiration of abscess, blood, or cyst" 48567628_1 CDM 0450 RC 10160 HCPCS inpatient 471 306.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 285.19 456.87 BIOPSY SKIN LESION 48567634_1 CDM 0450 RC 11100 HCPCS inpatient 692 449.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 449.8 65 999999999 419.01 671.24 percent of total billed charges BIOPSY SKIN LESION 48567634_1 CDM 0450 RC 11100 HCPCS inpatient 692 449.8 AETNA AETNA 546.68 79 999999999 419.01 671.24 percent of total billed charges BIOPSY SKIN LESION 48567634_1 CDM 0450 RC 11100 HCPCS inpatient 692 449.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 477.48 69 999999999 419.01 671.24 percent of total billed charges BIOPSY SKIN LESION 48567634_1 CDM 0450 RC 11100 HCPCS inpatient 692 449.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 671.24 97 999999999 419.01 671.24 percent of total billed charges BIOPSY SKIN LESION 48567634_1 CDM 0450 RC 11100 HCPCS inpatient 692 449.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 539.76 78 999999999 419.01 671.24 percent of total billed charges BIOPSY SKIN LESION 48567634_1 CDM 0450 RC 11100 HCPCS inpatient 692 449.8 SIHO - ALL PLANS SIHO - ALL PLANS 622.8 90 999999999 419.01 671.24 percent of total billed charges BIOPSY SKIN LESION 48567634_1 CDM 0450 RC 11100 HCPCS inpatient 692 449.8 UMR - ALL PLANS UMR - ALL PLANS 484.4 70 999999999 419.01 671.24 percent of total billed charges BIOPSY SKIN LESION 48567634_1 CDM 0450 RC 11100 HCPCS inpatient 692 449.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 419.01 60.55 999999999 419.01 671.24 percent of total billed charges BIOPSY SKIN LESION 48567634_1 CDM 0450 RC 11100 HCPCS inpatient 692 449.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 419.01 671.24 BIOPSY SKIN LESION 48567634_1 CDM 0450 RC 11100 HCPCS inpatient 692 449.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 419.01 671.24 BIOPSY SKIN LESION 48567634_1 CDM 0450 RC 11100 HCPCS inpatient 692 449.8 ANTHEM HMO ANTHEM HMO 999999999 419.01 671.24 BIOPSY SKIN LESION 48567634_1 CDM 0450 RC 11100 HCPCS inpatient 692 449.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 467.79 67.6 999999999 419.01 671.24 percent of total billed charges BIOPSY SKIN LESION 48567634_1 CDM 0450 RC 11100 HCPCS inpatient 692 449.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 419.01 671.24 BIOPSY SKIN LESION 48567634_1 CDM 0450 RC 11100 HCPCS inpatient 692 449.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 419.01 671.24 BIOPSY SKIN ADD-ON 48567639_1 CDM 0450 RC 11101 HCPCS inpatient 258 167.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.7 65 999999999 156.22 250.26 percent of total billed charges BIOPSY SKIN ADD-ON 48567639_1 CDM 0450 RC 11101 HCPCS inpatient 258 167.7 AETNA AETNA 203.82 79 999999999 156.22 250.26 percent of total billed charges BIOPSY SKIN ADD-ON 48567639_1 CDM 0450 RC 11101 HCPCS inpatient 258 167.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 178.02 69 999999999 156.22 250.26 percent of total billed charges BIOPSY SKIN ADD-ON 48567639_1 CDM 0450 RC 11101 HCPCS inpatient 258 167.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 250.26 97 999999999 156.22 250.26 percent of total billed charges BIOPSY SKIN ADD-ON 48567639_1 CDM 0450 RC 11101 HCPCS inpatient 258 167.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 201.24 78 999999999 156.22 250.26 percent of total billed charges BIOPSY SKIN ADD-ON 48567639_1 CDM 0450 RC 11101 HCPCS inpatient 258 167.7 SIHO - ALL PLANS SIHO - ALL PLANS 232.2 90 999999999 156.22 250.26 percent of total billed charges BIOPSY SKIN ADD-ON 48567639_1 CDM 0450 RC 11101 HCPCS inpatient 258 167.7 UMR - ALL PLANS UMR - ALL PLANS 180.6 70 999999999 156.22 250.26 percent of total billed charges BIOPSY SKIN ADD-ON 48567639_1 CDM 0450 RC 11101 HCPCS inpatient 258 167.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 156.22 60.55 999999999 156.22 250.26 percent of total billed charges BIOPSY SKIN ADD-ON 48567639_1 CDM 0450 RC 11101 HCPCS inpatient 258 167.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 156.22 250.26 BIOPSY SKIN ADD-ON 48567639_1 CDM 0450 RC 11101 HCPCS inpatient 258 167.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 156.22 250.26 BIOPSY SKIN ADD-ON 48567639_1 CDM 0450 RC 11101 HCPCS inpatient 258 167.7 ANTHEM HMO ANTHEM HMO 999999999 156.22 250.26 BIOPSY SKIN ADD-ON 48567639_1 CDM 0450 RC 11101 HCPCS inpatient 258 167.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 174.41 67.6 999999999 156.22 250.26 percent of total billed charges BIOPSY SKIN ADD-ON 48567639_1 CDM 0450 RC 11101 HCPCS inpatient 258 167.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 156.22 250.26 BIOPSY SKIN ADD-ON 48567639_1 CDM 0450 RC 11101 HCPCS inpatient 258 167.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 156.22 250.26 "Removal of skin tag, 1-15 skin tags" 48567640_1 CDM 0450 RC 11200 HCPCS inpatient 414 269.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 269.1 65 999999999 250.68 401.58 percent of total billed charges "Removal of skin tag, 1-15 skin tags" 48567640_1 CDM 0450 RC 11200 HCPCS inpatient 414 269.1 AETNA AETNA 327.06 79 999999999 250.68 401.58 percent of total billed charges "Removal of skin tag, 1-15 skin tags" 48567640_1 CDM 0450 RC 11200 HCPCS inpatient 414 269.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 285.66 69 999999999 250.68 401.58 percent of total billed charges "Removal of skin tag, 1-15 skin tags" 48567640_1 CDM 0450 RC 11200 HCPCS inpatient 414 269.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 401.58 97 999999999 250.68 401.58 percent of total billed charges "Removal of skin tag, 1-15 skin tags" 48567640_1 CDM 0450 RC 11200 HCPCS inpatient 414 269.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 322.92 78 999999999 250.68 401.58 percent of total billed charges "Removal of skin tag, 1-15 skin tags" 48567640_1 CDM 0450 RC 11200 HCPCS inpatient 414 269.1 SIHO - ALL PLANS SIHO - ALL PLANS 372.6 90 999999999 250.68 401.58 percent of total billed charges "Removal of skin tag, 1-15 skin tags" 48567640_1 CDM 0450 RC 11200 HCPCS inpatient 414 269.1 UMR - ALL PLANS UMR - ALL PLANS 289.8 70 999999999 250.68 401.58 percent of total billed charges "Removal of skin tag, 1-15 skin tags" 48567640_1 CDM 0450 RC 11200 HCPCS inpatient 414 269.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 250.68 60.55 999999999 250.68 401.58 percent of total billed charges "Removal of skin tag, 1-15 skin tags" 48567640_1 CDM 0450 RC 11200 HCPCS inpatient 414 269.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 250.68 401.58 "Removal of skin tag, 1-15 skin tags" 48567640_1 CDM 0450 RC 11200 HCPCS inpatient 414 269.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 250.68 401.58 "Removal of skin tag, 1-15 skin tags" 48567640_1 CDM 0450 RC 11200 HCPCS inpatient 414 269.1 ANTHEM HMO ANTHEM HMO 999999999 250.68 401.58 "Removal of skin tag, 1-15 skin tags" 48567640_1 CDM 0450 RC 11200 HCPCS inpatient 414 269.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 279.86 67.6 999999999 250.68 401.58 percent of total billed charges "Removal of skin tag, 1-15 skin tags" 48567640_1 CDM 0450 RC 11200 HCPCS inpatient 414 269.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 250.68 401.58 "Removal of skin tag, 1-15 skin tags" 48567640_1 CDM 0450 RC 11200 HCPCS inpatient 414 269.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 250.68 401.58 "Simple separation of fingernail or toenail from nail bed, first nail" 48567655_1 CDM 0450 RC 11730 HCPCS inpatient 241 156.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 156.65 65 999999999 145.93 233.77 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48567655_1 CDM 0450 RC 11730 HCPCS inpatient 241 156.65 AETNA AETNA 190.39 79 999999999 145.93 233.77 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48567655_1 CDM 0450 RC 11730 HCPCS inpatient 241 156.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 166.29 69 999999999 145.93 233.77 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48567655_1 CDM 0450 RC 11730 HCPCS inpatient 241 156.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 233.77 97 999999999 145.93 233.77 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48567655_1 CDM 0450 RC 11730 HCPCS inpatient 241 156.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.98 78 999999999 145.93 233.77 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48567655_1 CDM 0450 RC 11730 HCPCS inpatient 241 156.65 SIHO - ALL PLANS SIHO - ALL PLANS 216.9 90 999999999 145.93 233.77 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48567655_1 CDM 0450 RC 11730 HCPCS inpatient 241 156.65 UMR - ALL PLANS UMR - ALL PLANS 168.7 70 999999999 145.93 233.77 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48567655_1 CDM 0450 RC 11730 HCPCS inpatient 241 156.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.93 60.55 999999999 145.93 233.77 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48567655_1 CDM 0450 RC 11730 HCPCS inpatient 241 156.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.93 233.77 "Simple separation of fingernail or toenail from nail bed, first nail" 48567655_1 CDM 0450 RC 11730 HCPCS inpatient 241 156.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.93 233.77 "Simple separation of fingernail or toenail from nail bed, first nail" 48567655_1 CDM 0450 RC 11730 HCPCS inpatient 241 156.65 ANTHEM HMO ANTHEM HMO 999999999 145.93 233.77 "Simple separation of fingernail or toenail from nail bed, first nail" 48567655_1 CDM 0450 RC 11730 HCPCS inpatient 241 156.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.92 67.6 999999999 145.93 233.77 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48567655_1 CDM 0450 RC 11730 HCPCS inpatient 241 156.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.93 233.77 "Simple separation of fingernail or toenail from nail bed, first nail" 48567655_1 CDM 0450 RC 11730 HCPCS inpatient 241 156.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.93 233.77 Removal of blood accumulation under fingernail or toenail 48567656_1 CDM 0450 RC 11740 HCPCS inpatient 198 128.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.7 65 999999999 119.89 192.06 percent of total billed charges Removal of blood accumulation under fingernail or toenail 48567656_1 CDM 0450 RC 11740 HCPCS inpatient 198 128.7 AETNA AETNA 156.42 79 999999999 119.89 192.06 percent of total billed charges Removal of blood accumulation under fingernail or toenail 48567656_1 CDM 0450 RC 11740 HCPCS inpatient 198 128.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 136.62 69 999999999 119.89 192.06 percent of total billed charges Removal of blood accumulation under fingernail or toenail 48567656_1 CDM 0450 RC 11740 HCPCS inpatient 198 128.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 192.06 97 999999999 119.89 192.06 percent of total billed charges Removal of blood accumulation under fingernail or toenail 48567656_1 CDM 0450 RC 11740 HCPCS inpatient 198 128.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 154.44 78 999999999 119.89 192.06 percent of total billed charges Removal of blood accumulation under fingernail or toenail 48567656_1 CDM 0450 RC 11740 HCPCS inpatient 198 128.7 SIHO - ALL PLANS SIHO - ALL PLANS 178.2 90 999999999 119.89 192.06 percent of total billed charges Removal of blood accumulation under fingernail or toenail 48567656_1 CDM 0450 RC 11740 HCPCS inpatient 198 128.7 UMR - ALL PLANS UMR - ALL PLANS 138.6 70 999999999 119.89 192.06 percent of total billed charges Removal of blood accumulation under fingernail or toenail 48567656_1 CDM 0450 RC 11740 HCPCS inpatient 198 128.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.89 60.55 999999999 119.89 192.06 percent of total billed charges Removal of blood accumulation under fingernail or toenail 48567656_1 CDM 0450 RC 11740 HCPCS inpatient 198 128.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.89 192.06 Removal of blood accumulation under fingernail or toenail 48567656_1 CDM 0450 RC 11740 HCPCS inpatient 198 128.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.89 192.06 Removal of blood accumulation under fingernail or toenail 48567656_1 CDM 0450 RC 11740 HCPCS inpatient 198 128.7 ANTHEM HMO ANTHEM HMO 999999999 119.89 192.06 Removal of blood accumulation under fingernail or toenail 48567656_1 CDM 0450 RC 11740 HCPCS inpatient 198 128.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.85 67.6 999999999 119.89 192.06 percent of total billed charges Removal of blood accumulation under fingernail or toenail 48567656_1 CDM 0450 RC 11740 HCPCS inpatient 198 128.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.89 192.06 Removal of blood accumulation under fingernail or toenail 48567656_1 CDM 0450 RC 11740 HCPCS inpatient 198 128.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.89 192.06 Permanent removal fingernail or toenail 48567657_1 CDM 0450 RC 11750 HCPCS inpatient 1003 651.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 651.95 65 999999999 607.32 972.91 percent of total billed charges Permanent removal fingernail or toenail 48567657_1 CDM 0450 RC 11750 HCPCS inpatient 1003 651.95 AETNA AETNA 792.37 79 999999999 607.32 972.91 percent of total billed charges Permanent removal fingernail or toenail 48567657_1 CDM 0450 RC 11750 HCPCS inpatient 1003 651.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 692.07 69 999999999 607.32 972.91 percent of total billed charges Permanent removal fingernail or toenail 48567657_1 CDM 0450 RC 11750 HCPCS inpatient 1003 651.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 972.91 97 999999999 607.32 972.91 percent of total billed charges Permanent removal fingernail or toenail 48567657_1 CDM 0450 RC 11750 HCPCS inpatient 1003 651.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 782.34 78 999999999 607.32 972.91 percent of total billed charges Permanent removal fingernail or toenail 48567657_1 CDM 0450 RC 11750 HCPCS inpatient 1003 651.95 SIHO - ALL PLANS SIHO - ALL PLANS 902.7 90 999999999 607.32 972.91 percent of total billed charges Permanent removal fingernail or toenail 48567657_1 CDM 0450 RC 11750 HCPCS inpatient 1003 651.95 UMR - ALL PLANS UMR - ALL PLANS 702.1 70 999999999 607.32 972.91 percent of total billed charges Permanent removal fingernail or toenail 48567657_1 CDM 0450 RC 11750 HCPCS inpatient 1003 651.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 607.32 60.55 999999999 607.32 972.91 percent of total billed charges Permanent removal fingernail or toenail 48567657_1 CDM 0450 RC 11750 HCPCS inpatient 1003 651.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 607.32 972.91 Permanent removal fingernail or toenail 48567657_1 CDM 0450 RC 11750 HCPCS inpatient 1003 651.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 607.32 972.91 Permanent removal fingernail or toenail 48567657_1 CDM 0450 RC 11750 HCPCS inpatient 1003 651.95 ANTHEM HMO ANTHEM HMO 999999999 607.32 972.91 Permanent removal fingernail or toenail 48567657_1 CDM 0450 RC 11750 HCPCS inpatient 1003 651.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 678.03 67.6 999999999 607.32 972.91 percent of total billed charges Permanent removal fingernail or toenail 48567657_1 CDM 0450 RC 11750 HCPCS inpatient 1003 651.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 607.32 972.91 Permanent removal fingernail or toenail 48567657_1 CDM 0450 RC 11750 HCPCS inpatient 1003 651.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 607.32 972.91 Repair of fingernail or toenail bed 48567659_1 CDM 0450 RC 11760 HCPCS inpatient 571 371.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 371.15 65 999999999 345.74 553.87 percent of total billed charges Repair of fingernail or toenail bed 48567659_1 CDM 0450 RC 11760 HCPCS inpatient 571 371.15 AETNA AETNA 451.09 79 999999999 345.74 553.87 percent of total billed charges Repair of fingernail or toenail bed 48567659_1 CDM 0450 RC 11760 HCPCS inpatient 571 371.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 393.99 69 999999999 345.74 553.87 percent of total billed charges Repair of fingernail or toenail bed 48567659_1 CDM 0450 RC 11760 HCPCS inpatient 571 371.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 553.87 97 999999999 345.74 553.87 percent of total billed charges Repair of fingernail or toenail bed 48567659_1 CDM 0450 RC 11760 HCPCS inpatient 571 371.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 445.38 78 999999999 345.74 553.87 percent of total billed charges Repair of fingernail or toenail bed 48567659_1 CDM 0450 RC 11760 HCPCS inpatient 571 371.15 SIHO - ALL PLANS SIHO - ALL PLANS 513.9 90 999999999 345.74 553.87 percent of total billed charges Repair of fingernail or toenail bed 48567659_1 CDM 0450 RC 11760 HCPCS inpatient 571 371.15 UMR - ALL PLANS UMR - ALL PLANS 399.7 70 999999999 345.74 553.87 percent of total billed charges Repair of fingernail or toenail bed 48567659_1 CDM 0450 RC 11760 HCPCS inpatient 571 371.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 345.74 60.55 999999999 345.74 553.87 percent of total billed charges Repair of fingernail or toenail bed 48567659_1 CDM 0450 RC 11760 HCPCS inpatient 571 371.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 345.74 553.87 Repair of fingernail or toenail bed 48567659_1 CDM 0450 RC 11760 HCPCS inpatient 571 371.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 345.74 553.87 Repair of fingernail or toenail bed 48567659_1 CDM 0450 RC 11760 HCPCS inpatient 571 371.15 ANTHEM HMO ANTHEM HMO 999999999 345.74 553.87 Repair of fingernail or toenail bed 48567659_1 CDM 0450 RC 11760 HCPCS inpatient 571 371.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 386 67.6 999999999 345.74 553.87 percent of total billed charges Repair of fingernail or toenail bed 48567659_1 CDM 0450 RC 11760 HCPCS inpatient 571 371.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 345.74 553.87 Repair of fingernail or toenail bed 48567659_1 CDM 0450 RC 11760 HCPCS inpatient 571 371.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 345.74 553.87 Removal of skin of fingernail or toenail 48567660_1 CDM 0450 RC 11765 HCPCS inpatient 414 269.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 269.1 65 999999999 250.68 401.58 percent of total billed charges Removal of skin of fingernail or toenail 48567660_1 CDM 0450 RC 11765 HCPCS inpatient 414 269.1 AETNA AETNA 327.06 79 999999999 250.68 401.58 percent of total billed charges Removal of skin of fingernail or toenail 48567660_1 CDM 0450 RC 11765 HCPCS inpatient 414 269.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 285.66 69 999999999 250.68 401.58 percent of total billed charges Removal of skin of fingernail or toenail 48567660_1 CDM 0450 RC 11765 HCPCS inpatient 414 269.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 401.58 97 999999999 250.68 401.58 percent of total billed charges Removal of skin of fingernail or toenail 48567660_1 CDM 0450 RC 11765 HCPCS inpatient 414 269.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 322.92 78 999999999 250.68 401.58 percent of total billed charges Removal of skin of fingernail or toenail 48567660_1 CDM 0450 RC 11765 HCPCS inpatient 414 269.1 SIHO - ALL PLANS SIHO - ALL PLANS 372.6 90 999999999 250.68 401.58 percent of total billed charges Removal of skin of fingernail or toenail 48567660_1 CDM 0450 RC 11765 HCPCS inpatient 414 269.1 UMR - ALL PLANS UMR - ALL PLANS 289.8 70 999999999 250.68 401.58 percent of total billed charges Removal of skin of fingernail or toenail 48567660_1 CDM 0450 RC 11765 HCPCS inpatient 414 269.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 250.68 60.55 999999999 250.68 401.58 percent of total billed charges Removal of skin of fingernail or toenail 48567660_1 CDM 0450 RC 11765 HCPCS inpatient 414 269.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 250.68 401.58 Removal of skin of fingernail or toenail 48567660_1 CDM 0450 RC 11765 HCPCS inpatient 414 269.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 250.68 401.58 Removal of skin of fingernail or toenail 48567660_1 CDM 0450 RC 11765 HCPCS inpatient 414 269.1 ANTHEM HMO ANTHEM HMO 999999999 250.68 401.58 Removal of skin of fingernail or toenail 48567660_1 CDM 0450 RC 11765 HCPCS inpatient 414 269.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 279.86 67.6 999999999 250.68 401.58 percent of total billed charges Removal of skin of fingernail or toenail 48567660_1 CDM 0450 RC 11765 HCPCS inpatient 414 269.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 250.68 401.58 Removal of skin of fingernail or toenail 48567660_1 CDM 0450 RC 11765 HCPCS inpatient 414 269.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 250.68 401.58 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48567661_1 CDM 0450 RC 12001 HCPCS inpatient 715 464.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 464.75 65 999999999 432.93 693.55 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48567661_1 CDM 0450 RC 12001 HCPCS inpatient 715 464.75 AETNA AETNA 564.85 79 999999999 432.93 693.55 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48567661_1 CDM 0450 RC 12001 HCPCS inpatient 715 464.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 493.35 69 999999999 432.93 693.55 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48567661_1 CDM 0450 RC 12001 HCPCS inpatient 715 464.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 693.55 97 999999999 432.93 693.55 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48567661_1 CDM 0450 RC 12001 HCPCS inpatient 715 464.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 557.7 78 999999999 432.93 693.55 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48567661_1 CDM 0450 RC 12001 HCPCS inpatient 715 464.75 SIHO - ALL PLANS SIHO - ALL PLANS 643.5 90 999999999 432.93 693.55 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48567661_1 CDM 0450 RC 12001 HCPCS inpatient 715 464.75 UMR - ALL PLANS UMR - ALL PLANS 500.5 70 999999999 432.93 693.55 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48567661_1 CDM 0450 RC 12001 HCPCS inpatient 715 464.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 432.93 60.55 999999999 432.93 693.55 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48567661_1 CDM 0450 RC 12001 HCPCS inpatient 715 464.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 432.93 693.55 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48567661_1 CDM 0450 RC 12001 HCPCS inpatient 715 464.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 432.93 693.55 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48567661_1 CDM 0450 RC 12001 HCPCS inpatient 715 464.75 ANTHEM HMO ANTHEM HMO 999999999 432.93 693.55 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48567661_1 CDM 0450 RC 12001 HCPCS inpatient 715 464.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 483.34 67.6 999999999 432.93 693.55 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48567661_1 CDM 0450 RC 12001 HCPCS inpatient 715 464.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 432.93 693.55 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48567661_1 CDM 0450 RC 12001 HCPCS inpatient 715 464.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 432.93 693.55 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567662_1 CDM 0450 RC 12002 HCPCS inpatient 817 531.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 531.05 65 999999999 494.69 792.49 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567662_1 CDM 0450 RC 12002 HCPCS inpatient 817 531.05 AETNA AETNA 645.43 79 999999999 494.69 792.49 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567662_1 CDM 0450 RC 12002 HCPCS inpatient 817 531.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 563.73 69 999999999 494.69 792.49 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567662_1 CDM 0450 RC 12002 HCPCS inpatient 817 531.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 792.49 97 999999999 494.69 792.49 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567662_1 CDM 0450 RC 12002 HCPCS inpatient 817 531.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 637.26 78 999999999 494.69 792.49 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567662_1 CDM 0450 RC 12002 HCPCS inpatient 817 531.05 SIHO - ALL PLANS SIHO - ALL PLANS 735.3 90 999999999 494.69 792.49 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567662_1 CDM 0450 RC 12002 HCPCS inpatient 817 531.05 UMR - ALL PLANS UMR - ALL PLANS 571.9 70 999999999 494.69 792.49 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567662_1 CDM 0450 RC 12002 HCPCS inpatient 817 531.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 494.69 60.55 999999999 494.69 792.49 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567662_1 CDM 0450 RC 12002 HCPCS inpatient 817 531.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 494.69 792.49 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567662_1 CDM 0450 RC 12002 HCPCS inpatient 817 531.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 494.69 792.49 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567662_1 CDM 0450 RC 12002 HCPCS inpatient 817 531.05 ANTHEM HMO ANTHEM HMO 999999999 494.69 792.49 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567662_1 CDM 0450 RC 12002 HCPCS inpatient 817 531.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 552.29 67.6 999999999 494.69 792.49 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567662_1 CDM 0450 RC 12002 HCPCS inpatient 817 531.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 494.69 792.49 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567662_1 CDM 0450 RC 12002 HCPCS inpatient 817 531.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 494.69 792.49 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567663_1 CDM 0450 RC 12004 HCPCS inpatient 601 390.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 390.65 65 999999999 363.91 582.97 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567663_1 CDM 0450 RC 12004 HCPCS inpatient 601 390.65 AETNA AETNA 474.79 79 999999999 363.91 582.97 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567663_1 CDM 0450 RC 12004 HCPCS inpatient 601 390.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 414.69 69 999999999 363.91 582.97 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567663_1 CDM 0450 RC 12004 HCPCS inpatient 601 390.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 582.97 97 999999999 363.91 582.97 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567663_1 CDM 0450 RC 12004 HCPCS inpatient 601 390.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 468.78 78 999999999 363.91 582.97 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567663_1 CDM 0450 RC 12004 HCPCS inpatient 601 390.65 SIHO - ALL PLANS SIHO - ALL PLANS 540.9 90 999999999 363.91 582.97 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567663_1 CDM 0450 RC 12004 HCPCS inpatient 601 390.65 UMR - ALL PLANS UMR - ALL PLANS 420.7 70 999999999 363.91 582.97 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567663_1 CDM 0450 RC 12004 HCPCS inpatient 601 390.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 363.91 60.55 999999999 363.91 582.97 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567663_1 CDM 0450 RC 12004 HCPCS inpatient 601 390.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 363.91 582.97 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567663_1 CDM 0450 RC 12004 HCPCS inpatient 601 390.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 363.91 582.97 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567663_1 CDM 0450 RC 12004 HCPCS inpatient 601 390.65 ANTHEM HMO ANTHEM HMO 999999999 363.91 582.97 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567663_1 CDM 0450 RC 12004 HCPCS inpatient 601 390.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 406.28 67.6 999999999 363.91 582.97 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567663_1 CDM 0450 RC 12004 HCPCS inpatient 601 390.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 363.91 582.97 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567663_1 CDM 0450 RC 12004 HCPCS inpatient 601 390.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 363.91 582.97 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48567664_1 CDM 0450 RC 12005 HCPCS inpatient 559 363.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 363.35 65 999999999 338.47 542.23 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48567664_1 CDM 0450 RC 12005 HCPCS inpatient 559 363.35 AETNA AETNA 441.61 79 999999999 338.47 542.23 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48567664_1 CDM 0450 RC 12005 HCPCS inpatient 559 363.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 385.71 69 999999999 338.47 542.23 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48567664_1 CDM 0450 RC 12005 HCPCS inpatient 559 363.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 542.23 97 999999999 338.47 542.23 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48567664_1 CDM 0450 RC 12005 HCPCS inpatient 559 363.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 436.02 78 999999999 338.47 542.23 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48567664_1 CDM 0450 RC 12005 HCPCS inpatient 559 363.35 SIHO - ALL PLANS SIHO - ALL PLANS 503.1 90 999999999 338.47 542.23 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48567664_1 CDM 0450 RC 12005 HCPCS inpatient 559 363.35 UMR - ALL PLANS UMR - ALL PLANS 391.3 70 999999999 338.47 542.23 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48567664_1 CDM 0450 RC 12005 HCPCS inpatient 559 363.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 338.47 60.55 999999999 338.47 542.23 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48567664_1 CDM 0450 RC 12005 HCPCS inpatient 559 363.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 338.47 542.23 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48567664_1 CDM 0450 RC 12005 HCPCS inpatient 559 363.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 338.47 542.23 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48567664_1 CDM 0450 RC 12005 HCPCS inpatient 559 363.35 ANTHEM HMO ANTHEM HMO 999999999 338.47 542.23 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48567664_1 CDM 0450 RC 12005 HCPCS inpatient 559 363.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 377.88 67.6 999999999 338.47 542.23 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48567664_1 CDM 0450 RC 12005 HCPCS inpatient 559 363.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 338.47 542.23 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48567664_1 CDM 0450 RC 12005 HCPCS inpatient 559 363.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 338.47 542.23 "Simple repair of surface wound to scalp, neck, underarms, trunk, arms, or legs, more than 30.0 cm" 48567667_1 CDM 0450 RC 12007 HCPCS inpatient 582 378.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 378.3 65 999999999 352.4 564.54 percent of total billed charges "Simple repair of surface wound to scalp, neck, underarms, trunk, arms, or legs, more than 30.0 cm" 48567667_1 CDM 0450 RC 12007 HCPCS inpatient 582 378.3 AETNA AETNA 459.78 79 999999999 352.4 564.54 percent of total billed charges "Simple repair of surface wound to scalp, neck, underarms, trunk, arms, or legs, more than 30.0 cm" 48567667_1 CDM 0450 RC 12007 HCPCS inpatient 582 378.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 401.58 69 999999999 352.4 564.54 percent of total billed charges "Simple repair of surface wound to scalp, neck, underarms, trunk, arms, or legs, more than 30.0 cm" 48567667_1 CDM 0450 RC 12007 HCPCS inpatient 582 378.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 564.54 97 999999999 352.4 564.54 percent of total billed charges "Simple repair of surface wound to scalp, neck, underarms, trunk, arms, or legs, more than 30.0 cm" 48567667_1 CDM 0450 RC 12007 HCPCS inpatient 582 378.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 453.96 78 999999999 352.4 564.54 percent of total billed charges "Simple repair of surface wound to scalp, neck, underarms, trunk, arms, or legs, more than 30.0 cm" 48567667_1 CDM 0450 RC 12007 HCPCS inpatient 582 378.3 SIHO - ALL PLANS SIHO - ALL PLANS 523.8 90 999999999 352.4 564.54 percent of total billed charges "Simple repair of surface wound to scalp, neck, underarms, trunk, arms, or legs, more than 30.0 cm" 48567667_1 CDM 0450 RC 12007 HCPCS inpatient 582 378.3 UMR - ALL PLANS UMR - ALL PLANS 407.4 70 999999999 352.4 564.54 percent of total billed charges "Simple repair of surface wound to scalp, neck, underarms, trunk, arms, or legs, more than 30.0 cm" 48567667_1 CDM 0450 RC 12007 HCPCS inpatient 582 378.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 352.4 60.55 999999999 352.4 564.54 percent of total billed charges "Simple repair of surface wound to scalp, neck, underarms, trunk, arms, or legs, more than 30.0 cm" 48567667_1 CDM 0450 RC 12007 HCPCS inpatient 582 378.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 352.4 564.54 "Simple repair of surface wound to scalp, neck, underarms, trunk, arms, or legs, more than 30.0 cm" 48567667_1 CDM 0450 RC 12007 HCPCS inpatient 582 378.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 352.4 564.54 "Simple repair of surface wound to scalp, neck, underarms, trunk, arms, or legs, more than 30.0 cm" 48567667_1 CDM 0450 RC 12007 HCPCS inpatient 582 378.3 ANTHEM HMO ANTHEM HMO 999999999 352.4 564.54 "Simple repair of surface wound to scalp, neck, underarms, trunk, arms, or legs, more than 30.0 cm" 48567667_1 CDM 0450 RC 12007 HCPCS inpatient 582 378.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 393.43 67.6 999999999 352.4 564.54 percent of total billed charges "Simple repair of surface wound to scalp, neck, underarms, trunk, arms, or legs, more than 30.0 cm" 48567667_1 CDM 0450 RC 12007 HCPCS inpatient 582 378.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 352.4 564.54 "Simple repair of surface wound to scalp, neck, underarms, trunk, arms, or legs, more than 30.0 cm" 48567667_1 CDM 0450 RC 12007 HCPCS inpatient 582 378.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 352.4 564.54 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48567671_1 CDM 0450 RC 12011 HCPCS inpatient 638 414.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 414.7 65 999999999 386.31 618.86 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48567671_1 CDM 0450 RC 12011 HCPCS inpatient 638 414.7 AETNA AETNA 504.02 79 999999999 386.31 618.86 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48567671_1 CDM 0450 RC 12011 HCPCS inpatient 638 414.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 440.22 69 999999999 386.31 618.86 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48567671_1 CDM 0450 RC 12011 HCPCS inpatient 638 414.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 618.86 97 999999999 386.31 618.86 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48567671_1 CDM 0450 RC 12011 HCPCS inpatient 638 414.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 497.64 78 999999999 386.31 618.86 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48567671_1 CDM 0450 RC 12011 HCPCS inpatient 638 414.7 SIHO - ALL PLANS SIHO - ALL PLANS 574.2 90 999999999 386.31 618.86 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48567671_1 CDM 0450 RC 12011 HCPCS inpatient 638 414.7 UMR - ALL PLANS UMR - ALL PLANS 446.6 70 999999999 386.31 618.86 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48567671_1 CDM 0450 RC 12011 HCPCS inpatient 638 414.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 386.31 60.55 999999999 386.31 618.86 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48567671_1 CDM 0450 RC 12011 HCPCS inpatient 638 414.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 386.31 618.86 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48567671_1 CDM 0450 RC 12011 HCPCS inpatient 638 414.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 386.31 618.86 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48567671_1 CDM 0450 RC 12011 HCPCS inpatient 638 414.7 ANTHEM HMO ANTHEM HMO 999999999 386.31 618.86 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48567671_1 CDM 0450 RC 12011 HCPCS inpatient 638 414.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 431.29 67.6 999999999 386.31 618.86 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48567671_1 CDM 0450 RC 12011 HCPCS inpatient 638 414.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 386.31 618.86 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48567671_1 CDM 0450 RC 12011 HCPCS inpatient 638 414.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 386.31 618.86 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48567673_1 CDM 0450 RC 12013 HCPCS inpatient 643 417.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 417.95 65 999999999 389.34 623.71 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48567673_1 CDM 0450 RC 12013 HCPCS inpatient 643 417.95 AETNA AETNA 507.97 79 999999999 389.34 623.71 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48567673_1 CDM 0450 RC 12013 HCPCS inpatient 643 417.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 443.67 69 999999999 389.34 623.71 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48567673_1 CDM 0450 RC 12013 HCPCS inpatient 643 417.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 623.71 97 999999999 389.34 623.71 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48567673_1 CDM 0450 RC 12013 HCPCS inpatient 643 417.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 501.54 78 999999999 389.34 623.71 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48567673_1 CDM 0450 RC 12013 HCPCS inpatient 643 417.95 SIHO - ALL PLANS SIHO - ALL PLANS 578.7 90 999999999 389.34 623.71 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48567673_1 CDM 0450 RC 12013 HCPCS inpatient 643 417.95 UMR - ALL PLANS UMR - ALL PLANS 450.1 70 999999999 389.34 623.71 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48567673_1 CDM 0450 RC 12013 HCPCS inpatient 643 417.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 389.34 60.55 999999999 389.34 623.71 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48567673_1 CDM 0450 RC 12013 HCPCS inpatient 643 417.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 389.34 623.71 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48567673_1 CDM 0450 RC 12013 HCPCS inpatient 643 417.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 389.34 623.71 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48567673_1 CDM 0450 RC 12013 HCPCS inpatient 643 417.95 ANTHEM HMO ANTHEM HMO 999999999 389.34 623.71 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48567673_1 CDM 0450 RC 12013 HCPCS inpatient 643 417.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 434.67 67.6 999999999 389.34 623.71 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48567673_1 CDM 0450 RC 12013 HCPCS inpatient 643 417.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 389.34 623.71 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48567673_1 CDM 0450 RC 12013 HCPCS inpatient 643 417.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 389.34 623.71 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 48567674_1 CDM 0450 RC 12014 HCPCS inpatient 671 436.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 436.15 65 999999999 406.29 650.87 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 48567674_1 CDM 0450 RC 12014 HCPCS inpatient 671 436.15 AETNA AETNA 530.09 79 999999999 406.29 650.87 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 48567674_1 CDM 0450 RC 12014 HCPCS inpatient 671 436.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 462.99 69 999999999 406.29 650.87 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 48567674_1 CDM 0450 RC 12014 HCPCS inpatient 671 436.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 650.87 97 999999999 406.29 650.87 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 48567674_1 CDM 0450 RC 12014 HCPCS inpatient 671 436.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 523.38 78 999999999 406.29 650.87 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 48567674_1 CDM 0450 RC 12014 HCPCS inpatient 671 436.15 SIHO - ALL PLANS SIHO - ALL PLANS 603.9 90 999999999 406.29 650.87 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 48567674_1 CDM 0450 RC 12014 HCPCS inpatient 671 436.15 UMR - ALL PLANS UMR - ALL PLANS 469.7 70 999999999 406.29 650.87 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 48567674_1 CDM 0450 RC 12014 HCPCS inpatient 671 436.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 406.29 60.55 999999999 406.29 650.87 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 48567674_1 CDM 0450 RC 12014 HCPCS inpatient 671 436.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 406.29 650.87 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 48567674_1 CDM 0450 RC 12014 HCPCS inpatient 671 436.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 406.29 650.87 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 48567674_1 CDM 0450 RC 12014 HCPCS inpatient 671 436.15 ANTHEM HMO ANTHEM HMO 999999999 406.29 650.87 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 48567674_1 CDM 0450 RC 12014 HCPCS inpatient 671 436.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 453.6 67.6 999999999 406.29 650.87 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 48567674_1 CDM 0450 RC 12014 HCPCS inpatient 671 436.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 406.29 650.87 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 5.1-7.5 cm" 48567674_1 CDM 0450 RC 12014 HCPCS inpatient 671 436.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 406.29 650.87 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 48567675_1 CDM 0450 RC 12015 HCPCS inpatient 678 440.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.7 65 999999999 410.53 657.66 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 48567675_1 CDM 0450 RC 12015 HCPCS inpatient 678 440.7 AETNA AETNA 535.62 79 999999999 410.53 657.66 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 48567675_1 CDM 0450 RC 12015 HCPCS inpatient 678 440.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.82 69 999999999 410.53 657.66 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 48567675_1 CDM 0450 RC 12015 HCPCS inpatient 678 440.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 657.66 97 999999999 410.53 657.66 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 48567675_1 CDM 0450 RC 12015 HCPCS inpatient 678 440.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.84 78 999999999 410.53 657.66 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 48567675_1 CDM 0450 RC 12015 HCPCS inpatient 678 440.7 SIHO - ALL PLANS SIHO - ALL PLANS 610.2 90 999999999 410.53 657.66 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 48567675_1 CDM 0450 RC 12015 HCPCS inpatient 678 440.7 UMR - ALL PLANS UMR - ALL PLANS 474.6 70 999999999 410.53 657.66 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 48567675_1 CDM 0450 RC 12015 HCPCS inpatient 678 440.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 410.53 60.55 999999999 410.53 657.66 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 48567675_1 CDM 0450 RC 12015 HCPCS inpatient 678 440.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 410.53 657.66 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 48567675_1 CDM 0450 RC 12015 HCPCS inpatient 678 440.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 410.53 657.66 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 48567675_1 CDM 0450 RC 12015 HCPCS inpatient 678 440.7 ANTHEM HMO ANTHEM HMO 999999999 410.53 657.66 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 48567675_1 CDM 0450 RC 12015 HCPCS inpatient 678 440.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 458.33 67.6 999999999 410.53 657.66 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 48567675_1 CDM 0450 RC 12015 HCPCS inpatient 678 440.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 410.53 657.66 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 7.6-12.5 cm" 48567675_1 CDM 0450 RC 12015 HCPCS inpatient 678 440.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 410.53 657.66 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, more than 30.0 cm" 48567681_1 CDM 0450 RC 12018 HCPCS inpatient 651 423.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 423.15 65 999999999 394.18 631.47 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, more than 30.0 cm" 48567681_1 CDM 0450 RC 12018 HCPCS inpatient 651 423.15 AETNA AETNA 514.29 79 999999999 394.18 631.47 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, more than 30.0 cm" 48567681_1 CDM 0450 RC 12018 HCPCS inpatient 651 423.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 449.19 69 999999999 394.18 631.47 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, more than 30.0 cm" 48567681_1 CDM 0450 RC 12018 HCPCS inpatient 651 423.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 631.47 97 999999999 394.18 631.47 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, more than 30.0 cm" 48567681_1 CDM 0450 RC 12018 HCPCS inpatient 651 423.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 507.78 78 999999999 394.18 631.47 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, more than 30.0 cm" 48567681_1 CDM 0450 RC 12018 HCPCS inpatient 651 423.15 SIHO - ALL PLANS SIHO - ALL PLANS 585.9 90 999999999 394.18 631.47 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, more than 30.0 cm" 48567681_1 CDM 0450 RC 12018 HCPCS inpatient 651 423.15 UMR - ALL PLANS UMR - ALL PLANS 455.7 70 999999999 394.18 631.47 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, more than 30.0 cm" 48567681_1 CDM 0450 RC 12018 HCPCS inpatient 651 423.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 394.18 60.55 999999999 394.18 631.47 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, more than 30.0 cm" 48567681_1 CDM 0450 RC 12018 HCPCS inpatient 651 423.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 394.18 631.47 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, more than 30.0 cm" 48567681_1 CDM 0450 RC 12018 HCPCS inpatient 651 423.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 394.18 631.47 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, more than 30.0 cm" 48567681_1 CDM 0450 RC 12018 HCPCS inpatient 651 423.15 ANTHEM HMO ANTHEM HMO 999999999 394.18 631.47 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, more than 30.0 cm" 48567681_1 CDM 0450 RC 12018 HCPCS inpatient 651 423.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 440.08 67.6 999999999 394.18 631.47 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, more than 30.0 cm" 48567681_1 CDM 0450 RC 12018 HCPCS inpatient 651 423.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 394.18 631.47 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, more than 30.0 cm" 48567681_1 CDM 0450 RC 12018 HCPCS inpatient 651 423.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 394.18 631.47 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.5 cm or less" 48567687_1 CDM 0450 RC 12031 HCPCS inpatient 595 386.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 386.75 65 999999999 360.27 577.15 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.5 cm or less" 48567687_1 CDM 0450 RC 12031 HCPCS inpatient 595 386.75 AETNA AETNA 470.05 79 999999999 360.27 577.15 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.5 cm or less" 48567687_1 CDM 0450 RC 12031 HCPCS inpatient 595 386.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 410.55 69 999999999 360.27 577.15 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.5 cm or less" 48567687_1 CDM 0450 RC 12031 HCPCS inpatient 595 386.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 577.15 97 999999999 360.27 577.15 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.5 cm or less" 48567687_1 CDM 0450 RC 12031 HCPCS inpatient 595 386.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 464.1 78 999999999 360.27 577.15 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.5 cm or less" 48567687_1 CDM 0450 RC 12031 HCPCS inpatient 595 386.75 SIHO - ALL PLANS SIHO - ALL PLANS 535.5 90 999999999 360.27 577.15 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.5 cm or less" 48567687_1 CDM 0450 RC 12031 HCPCS inpatient 595 386.75 UMR - ALL PLANS UMR - ALL PLANS 416.5 70 999999999 360.27 577.15 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.5 cm or less" 48567687_1 CDM 0450 RC 12031 HCPCS inpatient 595 386.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 360.27 60.55 999999999 360.27 577.15 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.5 cm or less" 48567687_1 CDM 0450 RC 12031 HCPCS inpatient 595 386.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 360.27 577.15 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.5 cm or less" 48567687_1 CDM 0450 RC 12031 HCPCS inpatient 595 386.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 360.27 577.15 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.5 cm or less" 48567687_1 CDM 0450 RC 12031 HCPCS inpatient 595 386.75 ANTHEM HMO ANTHEM HMO 999999999 360.27 577.15 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.5 cm or less" 48567687_1 CDM 0450 RC 12031 HCPCS inpatient 595 386.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 402.22 67.6 999999999 360.27 577.15 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.5 cm or less" 48567687_1 CDM 0450 RC 12031 HCPCS inpatient 595 386.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 360.27 577.15 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.5 cm or less" 48567687_1 CDM 0450 RC 12031 HCPCS inpatient 595 386.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 360.27 577.15 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567689_1 CDM 0450 RC 12032 HCPCS inpatient 662 430.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 430.3 65 999999999 400.84 642.14 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567689_1 CDM 0450 RC 12032 HCPCS inpatient 662 430.3 AETNA AETNA 522.98 79 999999999 400.84 642.14 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567689_1 CDM 0450 RC 12032 HCPCS inpatient 662 430.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 456.78 69 999999999 400.84 642.14 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567689_1 CDM 0450 RC 12032 HCPCS inpatient 662 430.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 642.14 97 999999999 400.84 642.14 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567689_1 CDM 0450 RC 12032 HCPCS inpatient 662 430.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 516.36 78 999999999 400.84 642.14 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567689_1 CDM 0450 RC 12032 HCPCS inpatient 662 430.3 SIHO - ALL PLANS SIHO - ALL PLANS 595.8 90 999999999 400.84 642.14 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567689_1 CDM 0450 RC 12032 HCPCS inpatient 662 430.3 UMR - ALL PLANS UMR - ALL PLANS 463.4 70 999999999 400.84 642.14 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567689_1 CDM 0450 RC 12032 HCPCS inpatient 662 430.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 400.84 60.55 999999999 400.84 642.14 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567689_1 CDM 0450 RC 12032 HCPCS inpatient 662 430.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 400.84 642.14 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567689_1 CDM 0450 RC 12032 HCPCS inpatient 662 430.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 400.84 642.14 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567689_1 CDM 0450 RC 12032 HCPCS inpatient 662 430.3 ANTHEM HMO ANTHEM HMO 999999999 400.84 642.14 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567689_1 CDM 0450 RC 12032 HCPCS inpatient 662 430.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 447.51 67.6 999999999 400.84 642.14 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567689_1 CDM 0450 RC 12032 HCPCS inpatient 662 430.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 400.84 642.14 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48567689_1 CDM 0450 RC 12032 HCPCS inpatient 662 430.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 400.84 642.14 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567690_1 CDM 0450 RC 12034 HCPCS inpatient 673 437.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 437.45 65 999999999 407.5 652.81 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567690_1 CDM 0450 RC 12034 HCPCS inpatient 673 437.45 AETNA AETNA 531.67 79 999999999 407.5 652.81 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567690_1 CDM 0450 RC 12034 HCPCS inpatient 673 437.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 464.37 69 999999999 407.5 652.81 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567690_1 CDM 0450 RC 12034 HCPCS inpatient 673 437.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 652.81 97 999999999 407.5 652.81 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567690_1 CDM 0450 RC 12034 HCPCS inpatient 673 437.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 524.94 78 999999999 407.5 652.81 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567690_1 CDM 0450 RC 12034 HCPCS inpatient 673 437.45 SIHO - ALL PLANS SIHO - ALL PLANS 605.7 90 999999999 407.5 652.81 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567690_1 CDM 0450 RC 12034 HCPCS inpatient 673 437.45 UMR - ALL PLANS UMR - ALL PLANS 471.1 70 999999999 407.5 652.81 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567690_1 CDM 0450 RC 12034 HCPCS inpatient 673 437.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 407.5 60.55 999999999 407.5 652.81 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567690_1 CDM 0450 RC 12034 HCPCS inpatient 673 437.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 407.5 652.81 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567690_1 CDM 0450 RC 12034 HCPCS inpatient 673 437.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 407.5 652.81 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567690_1 CDM 0450 RC 12034 HCPCS inpatient 673 437.45 ANTHEM HMO ANTHEM HMO 999999999 407.5 652.81 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567690_1 CDM 0450 RC 12034 HCPCS inpatient 673 437.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 454.95 67.6 999999999 407.5 652.81 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567690_1 CDM 0450 RC 12034 HCPCS inpatient 673 437.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 407.5 652.81 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48567690_1 CDM 0450 RC 12034 HCPCS inpatient 673 437.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 407.5 652.81 "Cell examination of body fluid, simple filter method" 48567943_1 CDM 0312 RC 88106 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Cell examination of body fluid, simple filter method" 48567943_1 CDM 0312 RC 88106 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Cell examination of body fluid, simple filter method" 48567943_1 CDM 0312 RC 88106 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Cell examination of body fluid, simple filter method" 48567943_1 CDM 0312 RC 88106 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Cell examination of body fluid, simple filter method" 48567943_1 CDM 0312 RC 88106 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Cell examination of body fluid, simple filter method" 48567943_1 CDM 0312 RC 88106 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Cell examination of body fluid, simple filter method" 48567943_1 CDM 0312 RC 88106 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Cell examination of body fluid, simple filter method" 48567943_1 CDM 0312 RC 88106 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Cell examination of body fluid, simple filter method" 48567943_1 CDM 0312 RC 88106 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Cell examination of body fluid, simple filter method" 48567943_1 CDM 0312 RC 88106 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Cell examination of body fluid, simple filter method" 48567943_1 CDM 0312 RC 88106 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Cell examination of body fluid, simple filter method" 48567943_1 CDM 0312 RC 88106 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Cell examination of body fluid, simple filter method" 48567943_1 CDM 0312 RC 88106 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Cell examination of body fluid, simple filter method" 48567943_1 CDM 0312 RC 88106 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571387_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571387_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571387_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571387_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571387_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571387_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571387_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571387_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571387_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571387_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571387_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571387_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571387_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571387_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 Pap test 48571389_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges Pap test 48571389_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges Pap test 48571389_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges Pap test 48571389_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges Pap test 48571389_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges Pap test 48571389_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges Pap test 48571389_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges Pap test 48571389_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges Pap test 48571389_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 Pap test 48571389_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 Pap test 48571389_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 Pap test 48571389_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges Pap test 48571389_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 Pap test 48571389_1 CDM 0311 RC 88141 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571393_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571393_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571393_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571393_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571393_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571393_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571393_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571393_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571393_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571393_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571393_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571393_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571393_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48571393_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 Blood typing for Rh (D) antigen 48572707_1 CDM 0302 RC 86901 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges Blood typing for Rh (D) antigen 48572707_1 CDM 0302 RC 86901 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges Blood typing for Rh (D) antigen 48572707_1 CDM 0302 RC 86901 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges Blood typing for Rh (D) antigen 48572707_1 CDM 0302 RC 86901 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges Blood typing for Rh (D) antigen 48572707_1 CDM 0302 RC 86901 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges Blood typing for Rh (D) antigen 48572707_1 CDM 0302 RC 86901 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges Blood typing for Rh (D) antigen 48572707_1 CDM 0302 RC 86901 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges Blood typing for Rh (D) antigen 48572707_1 CDM 0302 RC 86901 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges Blood typing for Rh (D) antigen 48572707_1 CDM 0302 RC 86901 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 Blood typing for Rh (D) antigen 48572707_1 CDM 0302 RC 86901 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 Blood typing for Rh (D) antigen 48572707_1 CDM 0302 RC 86901 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 Blood typing for Rh (D) antigen 48572707_1 CDM 0302 RC 86901 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges Blood typing for Rh (D) antigen 48572707_1 CDM 0302 RC 86901 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 Blood typing for Rh (D) antigen 48572707_1 CDM 0302 RC 86901 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 "Urinalysis, manual test" 48574246_1 CDM 0300 RC 81002 HCPCS inpatient 78 50.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.7 65 999999999 47.23 75.66 percent of total billed charges "Urinalysis, manual test" 48574246_1 CDM 0300 RC 81002 HCPCS inpatient 78 50.7 AETNA AETNA 61.62 79 999999999 47.23 75.66 percent of total billed charges "Urinalysis, manual test" 48574246_1 CDM 0300 RC 81002 HCPCS inpatient 78 50.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.82 69 999999999 47.23 75.66 percent of total billed charges "Urinalysis, manual test" 48574246_1 CDM 0300 RC 81002 HCPCS inpatient 78 50.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 75.66 97 999999999 47.23 75.66 percent of total billed charges "Urinalysis, manual test" 48574246_1 CDM 0300 RC 81002 HCPCS inpatient 78 50.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.84 78 999999999 47.23 75.66 percent of total billed charges "Urinalysis, manual test" 48574246_1 CDM 0300 RC 81002 HCPCS inpatient 78 50.7 SIHO - ALL PLANS SIHO - ALL PLANS 70.2 90 999999999 47.23 75.66 percent of total billed charges "Urinalysis, manual test" 48574246_1 CDM 0300 RC 81002 HCPCS inpatient 78 50.7 UMR - ALL PLANS UMR - ALL PLANS 54.6 70 999999999 47.23 75.66 percent of total billed charges "Urinalysis, manual test" 48574246_1 CDM 0300 RC 81002 HCPCS inpatient 78 50.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.23 60.55 999999999 47.23 75.66 percent of total billed charges "Urinalysis, manual test" 48574246_1 CDM 0300 RC 81002 HCPCS inpatient 78 50.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.23 75.66 "Urinalysis, manual test" 48574246_1 CDM 0300 RC 81002 HCPCS inpatient 78 50.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.23 75.66 "Urinalysis, manual test" 48574246_1 CDM 0300 RC 81002 HCPCS inpatient 78 50.7 ANTHEM HMO ANTHEM HMO 999999999 47.23 75.66 "Urinalysis, manual test" 48574246_1 CDM 0300 RC 81002 HCPCS inpatient 78 50.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.73 67.6 999999999 47.23 75.66 percent of total billed charges "Urinalysis, manual test" 48574246_1 CDM 0300 RC 81002 HCPCS inpatient 78 50.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.23 75.66 "Urinalysis, manual test" 48574246_1 CDM 0300 RC 81002 HCPCS inpatient 78 50.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.23 75.66 Insertion of needle into vein for collection of blood sample 48574247_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 29.9 65 999999999 27.85 44.62 percent of total billed charges Insertion of needle into vein for collection of blood sample 48574247_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 AETNA AETNA 36.34 79 999999999 27.85 44.62 percent of total billed charges Insertion of needle into vein for collection of blood sample 48574247_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 31.74 69 999999999 27.85 44.62 percent of total billed charges Insertion of needle into vein for collection of blood sample 48574247_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 44.62 97 999999999 27.85 44.62 percent of total billed charges Insertion of needle into vein for collection of blood sample 48574247_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 35.88 78 999999999 27.85 44.62 percent of total billed charges Insertion of needle into vein for collection of blood sample 48574247_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 SIHO - ALL PLANS SIHO - ALL PLANS 41.4 90 999999999 27.85 44.62 percent of total billed charges Insertion of needle into vein for collection of blood sample 48574247_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 UMR - ALL PLANS UMR - ALL PLANS 32.2 70 999999999 27.85 44.62 percent of total billed charges Insertion of needle into vein for collection of blood sample 48574247_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27.85 60.55 999999999 27.85 44.62 percent of total billed charges Insertion of needle into vein for collection of blood sample 48574247_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 27.85 44.62 Insertion of needle into vein for collection of blood sample 48574247_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 27.85 44.62 Insertion of needle into vein for collection of blood sample 48574247_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 ANTHEM HMO ANTHEM HMO 999999999 27.85 44.62 Insertion of needle into vein for collection of blood sample 48574247_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 31.1 67.6 999999999 27.85 44.62 percent of total billed charges Insertion of needle into vein for collection of blood sample 48574247_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 27.85 44.62 Insertion of needle into vein for collection of blood sample 48574247_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 27.85 44.62 "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 48574248_1 CDM 0516 RC J0780 HCPCS inpatient 51 33.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 33.15 65 999999999 30.88 49.47 percent of total billed charges "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 48574248_1 CDM 0516 RC J0780 HCPCS inpatient 51 33.15 AETNA AETNA 40.29 79 999999999 30.88 49.47 percent of total billed charges "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 48574248_1 CDM 0516 RC J0780 HCPCS inpatient 51 33.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 35.19 69 999999999 30.88 49.47 percent of total billed charges "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 48574248_1 CDM 0516 RC J0780 HCPCS inpatient 51 33.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 49.47 97 999999999 30.88 49.47 percent of total billed charges "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 48574248_1 CDM 0516 RC J0780 HCPCS inpatient 51 33.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 39.78 78 999999999 30.88 49.47 percent of total billed charges "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 48574248_1 CDM 0516 RC J0780 HCPCS inpatient 51 33.15 SIHO - ALL PLANS SIHO - ALL PLANS 45.9 90 999999999 30.88 49.47 percent of total billed charges "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 48574248_1 CDM 0516 RC J0780 HCPCS inpatient 51 33.15 UMR - ALL PLANS UMR - ALL PLANS 35.7 70 999999999 30.88 49.47 percent of total billed charges "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 48574248_1 CDM 0516 RC J0780 HCPCS inpatient 51 33.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.88 60.55 999999999 30.88 49.47 percent of total billed charges "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 48574248_1 CDM 0516 RC J0780 HCPCS inpatient 51 33.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.88 49.47 "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 48574248_1 CDM 0516 RC J0780 HCPCS inpatient 51 33.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.88 49.47 "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 48574248_1 CDM 0516 RC J0780 HCPCS inpatient 51 33.15 ANTHEM HMO ANTHEM HMO 999999999 30.88 49.47 "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 48574248_1 CDM 0516 RC J0780 HCPCS inpatient 51 33.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 34.48 67.6 999999999 30.88 49.47 percent of total billed charges "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 48574248_1 CDM 0516 RC J0780 HCPCS inpatient 51 33.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.88 49.47 "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 48574248_1 CDM 0516 RC J0780 HCPCS inpatient 51 33.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.88 49.47 Simple or single drainage of skin abscess 48574249_1 CDM 0516 RC 10060 HCPCS inpatient 549 356.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 356.85 65 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 48574249_1 CDM 0516 RC 10060 HCPCS inpatient 549 356.85 AETNA AETNA 433.71 79 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 48574249_1 CDM 0516 RC 10060 HCPCS inpatient 549 356.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 378.81 69 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 48574249_1 CDM 0516 RC 10060 HCPCS inpatient 549 356.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 532.53 97 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 48574249_1 CDM 0516 RC 10060 HCPCS inpatient 549 356.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 428.22 78 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 48574249_1 CDM 0516 RC 10060 HCPCS inpatient 549 356.85 SIHO - ALL PLANS SIHO - ALL PLANS 494.1 90 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 48574249_1 CDM 0516 RC 10060 HCPCS inpatient 549 356.85 UMR - ALL PLANS UMR - ALL PLANS 384.3 70 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 48574249_1 CDM 0516 RC 10060 HCPCS inpatient 549 356.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 332.42 60.55 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 48574249_1 CDM 0516 RC 10060 HCPCS inpatient 549 356.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 332.42 532.53 Simple or single drainage of skin abscess 48574249_1 CDM 0516 RC 10060 HCPCS inpatient 549 356.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 332.42 532.53 Simple or single drainage of skin abscess 48574249_1 CDM 0516 RC 10060 HCPCS inpatient 549 356.85 ANTHEM HMO ANTHEM HMO 999999999 332.42 532.53 Simple or single drainage of skin abscess 48574249_1 CDM 0516 RC 10060 HCPCS inpatient 549 356.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 371.12 67.6 999999999 332.42 532.53 percent of total billed charges Simple or single drainage of skin abscess 48574249_1 CDM 0516 RC 10060 HCPCS inpatient 549 356.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 332.42 532.53 Simple or single drainage of skin abscess 48574249_1 CDM 0516 RC 10060 HCPCS inpatient 549 356.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 332.42 532.53 "Removal of foreign body from tissue, accessed beneath the skin, simple" 48574250_1 CDM 0516 RC 10120 HCPCS inpatient 692 449.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 449.8 65 999999999 419.01 671.24 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48574250_1 CDM 0516 RC 10120 HCPCS inpatient 692 449.8 AETNA AETNA 546.68 79 999999999 419.01 671.24 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48574250_1 CDM 0516 RC 10120 HCPCS inpatient 692 449.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 477.48 69 999999999 419.01 671.24 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48574250_1 CDM 0516 RC 10120 HCPCS inpatient 692 449.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 671.24 97 999999999 419.01 671.24 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48574250_1 CDM 0516 RC 10120 HCPCS inpatient 692 449.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 539.76 78 999999999 419.01 671.24 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48574250_1 CDM 0516 RC 10120 HCPCS inpatient 692 449.8 SIHO - ALL PLANS SIHO - ALL PLANS 622.8 90 999999999 419.01 671.24 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48574250_1 CDM 0516 RC 10120 HCPCS inpatient 692 449.8 UMR - ALL PLANS UMR - ALL PLANS 484.4 70 999999999 419.01 671.24 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48574250_1 CDM 0516 RC 10120 HCPCS inpatient 692 449.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 419.01 60.55 999999999 419.01 671.24 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48574250_1 CDM 0516 RC 10120 HCPCS inpatient 692 449.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 419.01 671.24 "Removal of foreign body from tissue, accessed beneath the skin, simple" 48574250_1 CDM 0516 RC 10120 HCPCS inpatient 692 449.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 419.01 671.24 "Removal of foreign body from tissue, accessed beneath the skin, simple" 48574250_1 CDM 0516 RC 10120 HCPCS inpatient 692 449.8 ANTHEM HMO ANTHEM HMO 999999999 419.01 671.24 "Removal of foreign body from tissue, accessed beneath the skin, simple" 48574250_1 CDM 0516 RC 10120 HCPCS inpatient 692 449.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 467.79 67.6 999999999 419.01 671.24 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 48574250_1 CDM 0516 RC 10120 HCPCS inpatient 692 449.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 419.01 671.24 "Removal of foreign body from tissue, accessed beneath the skin, simple" 48574250_1 CDM 0516 RC 10120 HCPCS inpatient 692 449.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 419.01 671.24 Removal of foreign body in muscle or tendon 48574251_1 CDM 0516 RC 20520 HCPCS inpatient 1002 651.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 651.3 65 999999999 606.71 971.94 percent of total billed charges Removal of foreign body in muscle or tendon 48574251_1 CDM 0516 RC 20520 HCPCS inpatient 1002 651.3 AETNA AETNA 791.58 79 999999999 606.71 971.94 percent of total billed charges Removal of foreign body in muscle or tendon 48574251_1 CDM 0516 RC 20520 HCPCS inpatient 1002 651.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 691.38 69 999999999 606.71 971.94 percent of total billed charges Removal of foreign body in muscle or tendon 48574251_1 CDM 0516 RC 20520 HCPCS inpatient 1002 651.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 971.94 97 999999999 606.71 971.94 percent of total billed charges Removal of foreign body in muscle or tendon 48574251_1 CDM 0516 RC 20520 HCPCS inpatient 1002 651.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 781.56 78 999999999 606.71 971.94 percent of total billed charges Removal of foreign body in muscle or tendon 48574251_1 CDM 0516 RC 20520 HCPCS inpatient 1002 651.3 SIHO - ALL PLANS SIHO - ALL PLANS 901.8 90 999999999 606.71 971.94 percent of total billed charges Removal of foreign body in muscle or tendon 48574251_1 CDM 0516 RC 20520 HCPCS inpatient 1002 651.3 UMR - ALL PLANS UMR - ALL PLANS 701.4 70 999999999 606.71 971.94 percent of total billed charges Removal of foreign body in muscle or tendon 48574251_1 CDM 0516 RC 20520 HCPCS inpatient 1002 651.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 606.71 60.55 999999999 606.71 971.94 percent of total billed charges Removal of foreign body in muscle or tendon 48574251_1 CDM 0516 RC 20520 HCPCS inpatient 1002 651.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 606.71 971.94 Removal of foreign body in muscle or tendon 48574251_1 CDM 0516 RC 20520 HCPCS inpatient 1002 651.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 606.71 971.94 Removal of foreign body in muscle or tendon 48574251_1 CDM 0516 RC 20520 HCPCS inpatient 1002 651.3 ANTHEM HMO ANTHEM HMO 999999999 606.71 971.94 Removal of foreign body in muscle or tendon 48574251_1 CDM 0516 RC 20520 HCPCS inpatient 1002 651.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 677.35 67.6 999999999 606.71 971.94 percent of total billed charges Removal of foreign body in muscle or tendon 48574251_1 CDM 0516 RC 20520 HCPCS inpatient 1002 651.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 606.71 971.94 Removal of foreign body in muscle or tendon 48574251_1 CDM 0516 RC 20520 HCPCS inpatient 1002 651.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 606.71 971.94 "Simple separation of fingernail or toenail from nail bed, first nail" 48574252_1 CDM 0516 RC 11730 HCPCS inpatient 258 167.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.7 65 999999999 156.22 250.26 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48574252_1 CDM 0516 RC 11730 HCPCS inpatient 258 167.7 AETNA AETNA 203.82 79 999999999 156.22 250.26 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48574252_1 CDM 0516 RC 11730 HCPCS inpatient 258 167.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 178.02 69 999999999 156.22 250.26 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48574252_1 CDM 0516 RC 11730 HCPCS inpatient 258 167.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 250.26 97 999999999 156.22 250.26 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48574252_1 CDM 0516 RC 11730 HCPCS inpatient 258 167.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 201.24 78 999999999 156.22 250.26 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48574252_1 CDM 0516 RC 11730 HCPCS inpatient 258 167.7 SIHO - ALL PLANS SIHO - ALL PLANS 232.2 90 999999999 156.22 250.26 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48574252_1 CDM 0516 RC 11730 HCPCS inpatient 258 167.7 UMR - ALL PLANS UMR - ALL PLANS 180.6 70 999999999 156.22 250.26 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48574252_1 CDM 0516 RC 11730 HCPCS inpatient 258 167.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 156.22 60.55 999999999 156.22 250.26 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48574252_1 CDM 0516 RC 11730 HCPCS inpatient 258 167.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 156.22 250.26 "Simple separation of fingernail or toenail from nail bed, first nail" 48574252_1 CDM 0516 RC 11730 HCPCS inpatient 258 167.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 156.22 250.26 "Simple separation of fingernail or toenail from nail bed, first nail" 48574252_1 CDM 0516 RC 11730 HCPCS inpatient 258 167.7 ANTHEM HMO ANTHEM HMO 999999999 156.22 250.26 "Simple separation of fingernail or toenail from nail bed, first nail" 48574252_1 CDM 0516 RC 11730 HCPCS inpatient 258 167.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 174.41 67.6 999999999 156.22 250.26 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 48574252_1 CDM 0516 RC 11730 HCPCS inpatient 258 167.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 156.22 250.26 "Simple separation of fingernail or toenail from nail bed, first nail" 48574252_1 CDM 0516 RC 11730 HCPCS inpatient 258 167.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 156.22 250.26 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48574253_1 CDM 0516 RC 12001 HCPCS inpatient 715 464.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 464.75 65 999999999 432.93 693.55 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48574253_1 CDM 0516 RC 12001 HCPCS inpatient 715 464.75 AETNA AETNA 564.85 79 999999999 432.93 693.55 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48574253_1 CDM 0516 RC 12001 HCPCS inpatient 715 464.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 493.35 69 999999999 432.93 693.55 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48574253_1 CDM 0516 RC 12001 HCPCS inpatient 715 464.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 693.55 97 999999999 432.93 693.55 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48574253_1 CDM 0516 RC 12001 HCPCS inpatient 715 464.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 557.7 78 999999999 432.93 693.55 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48574253_1 CDM 0516 RC 12001 HCPCS inpatient 715 464.75 SIHO - ALL PLANS SIHO - ALL PLANS 643.5 90 999999999 432.93 693.55 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48574253_1 CDM 0516 RC 12001 HCPCS inpatient 715 464.75 UMR - ALL PLANS UMR - ALL PLANS 500.5 70 999999999 432.93 693.55 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48574253_1 CDM 0516 RC 12001 HCPCS inpatient 715 464.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 432.93 60.55 999999999 432.93 693.55 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48574253_1 CDM 0516 RC 12001 HCPCS inpatient 715 464.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 432.93 693.55 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48574253_1 CDM 0516 RC 12001 HCPCS inpatient 715 464.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 432.93 693.55 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48574253_1 CDM 0516 RC 12001 HCPCS inpatient 715 464.75 ANTHEM HMO ANTHEM HMO 999999999 432.93 693.55 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48574253_1 CDM 0516 RC 12001 HCPCS inpatient 715 464.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 483.34 67.6 999999999 432.93 693.55 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48574253_1 CDM 0516 RC 12001 HCPCS inpatient 715 464.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 432.93 693.55 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 48574253_1 CDM 0516 RC 12001 HCPCS inpatient 715 464.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 432.93 693.55 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574254_1 CDM 0516 RC 12002 HCPCS inpatient 817 531.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 531.05 65 999999999 494.69 792.49 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574254_1 CDM 0516 RC 12002 HCPCS inpatient 817 531.05 AETNA AETNA 645.43 79 999999999 494.69 792.49 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574254_1 CDM 0516 RC 12002 HCPCS inpatient 817 531.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 563.73 69 999999999 494.69 792.49 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574254_1 CDM 0516 RC 12002 HCPCS inpatient 817 531.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 792.49 97 999999999 494.69 792.49 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574254_1 CDM 0516 RC 12002 HCPCS inpatient 817 531.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 637.26 78 999999999 494.69 792.49 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574254_1 CDM 0516 RC 12002 HCPCS inpatient 817 531.05 SIHO - ALL PLANS SIHO - ALL PLANS 735.3 90 999999999 494.69 792.49 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574254_1 CDM 0516 RC 12002 HCPCS inpatient 817 531.05 UMR - ALL PLANS UMR - ALL PLANS 571.9 70 999999999 494.69 792.49 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574254_1 CDM 0516 RC 12002 HCPCS inpatient 817 531.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 494.69 60.55 999999999 494.69 792.49 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574254_1 CDM 0516 RC 12002 HCPCS inpatient 817 531.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 494.69 792.49 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574254_1 CDM 0516 RC 12002 HCPCS inpatient 817 531.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 494.69 792.49 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574254_1 CDM 0516 RC 12002 HCPCS inpatient 817 531.05 ANTHEM HMO ANTHEM HMO 999999999 494.69 792.49 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574254_1 CDM 0516 RC 12002 HCPCS inpatient 817 531.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 552.29 67.6 999999999 494.69 792.49 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574254_1 CDM 0516 RC 12002 HCPCS inpatient 817 531.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 494.69 792.49 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574254_1 CDM 0516 RC 12002 HCPCS inpatient 817 531.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 494.69 792.49 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48574255_1 CDM 0516 RC 12004 HCPCS inpatient 546 354.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 354.9 65 999999999 330.6 529.62 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48574255_1 CDM 0516 RC 12004 HCPCS inpatient 546 354.9 AETNA AETNA 431.34 79 999999999 330.6 529.62 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48574255_1 CDM 0516 RC 12004 HCPCS inpatient 546 354.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 376.74 69 999999999 330.6 529.62 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48574255_1 CDM 0516 RC 12004 HCPCS inpatient 546 354.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 529.62 97 999999999 330.6 529.62 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48574255_1 CDM 0516 RC 12004 HCPCS inpatient 546 354.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 425.88 78 999999999 330.6 529.62 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48574255_1 CDM 0516 RC 12004 HCPCS inpatient 546 354.9 SIHO - ALL PLANS SIHO - ALL PLANS 491.4 90 999999999 330.6 529.62 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48574255_1 CDM 0516 RC 12004 HCPCS inpatient 546 354.9 UMR - ALL PLANS UMR - ALL PLANS 382.2 70 999999999 330.6 529.62 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48574255_1 CDM 0516 RC 12004 HCPCS inpatient 546 354.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 330.6 60.55 999999999 330.6 529.62 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48574255_1 CDM 0516 RC 12004 HCPCS inpatient 546 354.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 330.6 529.62 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48574255_1 CDM 0516 RC 12004 HCPCS inpatient 546 354.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 330.6 529.62 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48574255_1 CDM 0516 RC 12004 HCPCS inpatient 546 354.9 ANTHEM HMO ANTHEM HMO 999999999 330.6 529.62 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48574255_1 CDM 0516 RC 12004 HCPCS inpatient 546 354.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 369.1 67.6 999999999 330.6 529.62 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48574255_1 CDM 0516 RC 12004 HCPCS inpatient 546 354.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 330.6 529.62 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 7.6-12.5 cm" 48574255_1 CDM 0516 RC 12004 HCPCS inpatient 546 354.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 330.6 529.62 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48574256_1 CDM 0516 RC 12011 HCPCS inpatient 638 414.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 414.7 65 999999999 386.31 618.86 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48574256_1 CDM 0516 RC 12011 HCPCS inpatient 638 414.7 AETNA AETNA 504.02 79 999999999 386.31 618.86 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48574256_1 CDM 0516 RC 12011 HCPCS inpatient 638 414.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 440.22 69 999999999 386.31 618.86 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48574256_1 CDM 0516 RC 12011 HCPCS inpatient 638 414.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 618.86 97 999999999 386.31 618.86 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48574256_1 CDM 0516 RC 12011 HCPCS inpatient 638 414.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 497.64 78 999999999 386.31 618.86 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48574256_1 CDM 0516 RC 12011 HCPCS inpatient 638 414.7 SIHO - ALL PLANS SIHO - ALL PLANS 574.2 90 999999999 386.31 618.86 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48574256_1 CDM 0516 RC 12011 HCPCS inpatient 638 414.7 UMR - ALL PLANS UMR - ALL PLANS 446.6 70 999999999 386.31 618.86 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48574256_1 CDM 0516 RC 12011 HCPCS inpatient 638 414.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 386.31 60.55 999999999 386.31 618.86 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48574256_1 CDM 0516 RC 12011 HCPCS inpatient 638 414.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 386.31 618.86 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48574256_1 CDM 0516 RC 12011 HCPCS inpatient 638 414.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 386.31 618.86 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48574256_1 CDM 0516 RC 12011 HCPCS inpatient 638 414.7 ANTHEM HMO ANTHEM HMO 999999999 386.31 618.86 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48574256_1 CDM 0516 RC 12011 HCPCS inpatient 638 414.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 431.29 67.6 999999999 386.31 618.86 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48574256_1 CDM 0516 RC 12011 HCPCS inpatient 638 414.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 386.31 618.86 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 2.5 cm or less" 48574256_1 CDM 0516 RC 12011 HCPCS inpatient 638 414.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 386.31 618.86 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 48574257_1 CDM 0516 RC 12016 HCPCS inpatient 629 408.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 408.85 65 999999999 380.86 610.13 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 48574257_1 CDM 0516 RC 12016 HCPCS inpatient 629 408.85 AETNA AETNA 496.91 79 999999999 380.86 610.13 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 48574257_1 CDM 0516 RC 12016 HCPCS inpatient 629 408.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 434.01 69 999999999 380.86 610.13 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 48574257_1 CDM 0516 RC 12016 HCPCS inpatient 629 408.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 610.13 97 999999999 380.86 610.13 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 48574257_1 CDM 0516 RC 12016 HCPCS inpatient 629 408.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 490.62 78 999999999 380.86 610.13 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 48574257_1 CDM 0516 RC 12016 HCPCS inpatient 629 408.85 SIHO - ALL PLANS SIHO - ALL PLANS 566.1 90 999999999 380.86 610.13 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 48574257_1 CDM 0516 RC 12016 HCPCS inpatient 629 408.85 UMR - ALL PLANS UMR - ALL PLANS 440.3 70 999999999 380.86 610.13 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 48574257_1 CDM 0516 RC 12016 HCPCS inpatient 629 408.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 380.86 60.55 999999999 380.86 610.13 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 48574257_1 CDM 0516 RC 12016 HCPCS inpatient 629 408.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 380.86 610.13 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 48574257_1 CDM 0516 RC 12016 HCPCS inpatient 629 408.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 380.86 610.13 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 48574257_1 CDM 0516 RC 12016 HCPCS inpatient 629 408.85 ANTHEM HMO ANTHEM HMO 999999999 380.86 610.13 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 48574257_1 CDM 0516 RC 12016 HCPCS inpatient 629 408.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 425.2 67.6 999999999 380.86 610.13 percent of total billed charges "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 48574257_1 CDM 0516 RC 12016 HCPCS inpatient 629 408.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 380.86 610.13 "Simple repair of surface wound of face, ears, eyelids, nose, lips, or mouth, 12.6-20.0 cm" 48574257_1 CDM 0516 RC 12016 HCPCS inpatient 629 408.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 380.86 610.13 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574258_1 CDM 0516 RC 12032 HCPCS inpatient 602 391.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 391.3 65 999999999 364.51 583.94 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574258_1 CDM 0516 RC 12032 HCPCS inpatient 602 391.3 AETNA AETNA 475.58 79 999999999 364.51 583.94 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574258_1 CDM 0516 RC 12032 HCPCS inpatient 602 391.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 415.38 69 999999999 364.51 583.94 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574258_1 CDM 0516 RC 12032 HCPCS inpatient 602 391.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 583.94 97 999999999 364.51 583.94 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574258_1 CDM 0516 RC 12032 HCPCS inpatient 602 391.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 469.56 78 999999999 364.51 583.94 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574258_1 CDM 0516 RC 12032 HCPCS inpatient 602 391.3 SIHO - ALL PLANS SIHO - ALL PLANS 541.8 90 999999999 364.51 583.94 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574258_1 CDM 0516 RC 12032 HCPCS inpatient 602 391.3 UMR - ALL PLANS UMR - ALL PLANS 421.4 70 999999999 364.51 583.94 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574258_1 CDM 0516 RC 12032 HCPCS inpatient 602 391.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 364.51 60.55 999999999 364.51 583.94 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574258_1 CDM 0516 RC 12032 HCPCS inpatient 602 391.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 364.51 583.94 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574258_1 CDM 0516 RC 12032 HCPCS inpatient 602 391.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 364.51 583.94 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574258_1 CDM 0516 RC 12032 HCPCS inpatient 602 391.3 ANTHEM HMO ANTHEM HMO 999999999 364.51 583.94 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574258_1 CDM 0516 RC 12032 HCPCS inpatient 602 391.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 406.95 67.6 999999999 364.51 583.94 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574258_1 CDM 0516 RC 12032 HCPCS inpatient 602 391.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 364.51 583.94 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 2.6-7.5 cm" 48574258_1 CDM 0516 RC 12032 HCPCS inpatient 602 391.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 364.51 583.94 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48574259_1 CDM 0516 RC 12035 HCPCS inpatient 627 407.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 407.55 65 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48574259_1 CDM 0516 RC 12035 HCPCS inpatient 627 407.55 AETNA AETNA 495.33 79 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48574259_1 CDM 0516 RC 12035 HCPCS inpatient 627 407.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 432.63 69 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48574259_1 CDM 0516 RC 12035 HCPCS inpatient 627 407.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 608.19 97 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48574259_1 CDM 0516 RC 12035 HCPCS inpatient 627 407.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 489.06 78 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48574259_1 CDM 0516 RC 12035 HCPCS inpatient 627 407.55 SIHO - ALL PLANS SIHO - ALL PLANS 564.3 90 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48574259_1 CDM 0516 RC 12035 HCPCS inpatient 627 407.55 UMR - ALL PLANS UMR - ALL PLANS 438.9 70 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48574259_1 CDM 0516 RC 12035 HCPCS inpatient 627 407.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 379.65 60.55 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48574259_1 CDM 0516 RC 12035 HCPCS inpatient 627 407.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 379.65 608.19 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48574259_1 CDM 0516 RC 12035 HCPCS inpatient 627 407.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 379.65 608.19 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48574259_1 CDM 0516 RC 12035 HCPCS inpatient 627 407.55 ANTHEM HMO ANTHEM HMO 999999999 379.65 608.19 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48574259_1 CDM 0516 RC 12035 HCPCS inpatient 627 407.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 423.85 67.6 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48574259_1 CDM 0516 RC 12035 HCPCS inpatient 627 407.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 379.65 608.19 "Intermediate repair of wound of scalp, underarms, trunk, arms, or legs, 12.6-20.0 cm" 48574259_1 CDM 0516 RC 12035 HCPCS inpatient 627 407.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 379.65 608.19 "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 48574260_1 CDM 0516 RC 12042 HCPCS inpatient 611 397.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 397.15 65 999999999 369.96 592.67 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 48574260_1 CDM 0516 RC 12042 HCPCS inpatient 611 397.15 AETNA AETNA 482.69 79 999999999 369.96 592.67 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 48574260_1 CDM 0516 RC 12042 HCPCS inpatient 611 397.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 421.59 69 999999999 369.96 592.67 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 48574260_1 CDM 0516 RC 12042 HCPCS inpatient 611 397.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 592.67 97 999999999 369.96 592.67 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 48574260_1 CDM 0516 RC 12042 HCPCS inpatient 611 397.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 476.58 78 999999999 369.96 592.67 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 48574260_1 CDM 0516 RC 12042 HCPCS inpatient 611 397.15 SIHO - ALL PLANS SIHO - ALL PLANS 549.9 90 999999999 369.96 592.67 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 48574260_1 CDM 0516 RC 12042 HCPCS inpatient 611 397.15 UMR - ALL PLANS UMR - ALL PLANS 427.7 70 999999999 369.96 592.67 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 48574260_1 CDM 0516 RC 12042 HCPCS inpatient 611 397.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 369.96 60.55 999999999 369.96 592.67 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 48574260_1 CDM 0516 RC 12042 HCPCS inpatient 611 397.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 369.96 592.67 "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 48574260_1 CDM 0516 RC 12042 HCPCS inpatient 611 397.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 369.96 592.67 "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 48574260_1 CDM 0516 RC 12042 HCPCS inpatient 611 397.15 ANTHEM HMO ANTHEM HMO 999999999 369.96 592.67 "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 48574260_1 CDM 0516 RC 12042 HCPCS inpatient 611 397.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 413.04 67.6 999999999 369.96 592.67 percent of total billed charges "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 48574260_1 CDM 0516 RC 12042 HCPCS inpatient 611 397.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 369.96 592.67 "Intermediate repair of wound of neck, hands, feet, or genitals, 2.6-7.5 cm" 48574260_1 CDM 0516 RC 12042 HCPCS inpatient 611 397.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 369.96 592.67 Aspiration and/or injection of fluid from small joint 48574261_1 CDM 0516 RC 20600 HCPCS inpatient 675 438.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 438.75 65 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 48574261_1 CDM 0516 RC 20600 HCPCS inpatient 675 438.75 AETNA AETNA 533.25 79 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 48574261_1 CDM 0516 RC 20600 HCPCS inpatient 675 438.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 465.75 69 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 48574261_1 CDM 0516 RC 20600 HCPCS inpatient 675 438.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 654.75 97 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 48574261_1 CDM 0516 RC 20600 HCPCS inpatient 675 438.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 526.5 78 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 48574261_1 CDM 0516 RC 20600 HCPCS inpatient 675 438.75 SIHO - ALL PLANS SIHO - ALL PLANS 607.5 90 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 48574261_1 CDM 0516 RC 20600 HCPCS inpatient 675 438.75 UMR - ALL PLANS UMR - ALL PLANS 472.5 70 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 48574261_1 CDM 0516 RC 20600 HCPCS inpatient 675 438.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 408.71 60.55 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 48574261_1 CDM 0516 RC 20600 HCPCS inpatient 675 438.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 408.71 654.75 Aspiration and/or injection of fluid from small joint 48574261_1 CDM 0516 RC 20600 HCPCS inpatient 675 438.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 408.71 654.75 Aspiration and/or injection of fluid from small joint 48574261_1 CDM 0516 RC 20600 HCPCS inpatient 675 438.75 ANTHEM HMO ANTHEM HMO 999999999 408.71 654.75 Aspiration and/or injection of fluid from small joint 48574261_1 CDM 0516 RC 20600 HCPCS inpatient 675 438.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 456.3 67.6 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from small joint 48574261_1 CDM 0516 RC 20600 HCPCS inpatient 675 438.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 408.71 654.75 Aspiration and/or injection of fluid from small joint 48574261_1 CDM 0516 RC 20600 HCPCS inpatient 675 438.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 408.71 654.75 Aspiration and/or injection of fluid from medium joint 48574262_1 CDM 0516 RC 20605 HCPCS inpatient 724 470.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 470.6 65 999999999 438.38 702.28 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48574262_1 CDM 0516 RC 20605 HCPCS inpatient 724 470.6 AETNA AETNA 571.96 79 999999999 438.38 702.28 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48574262_1 CDM 0516 RC 20605 HCPCS inpatient 724 470.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 499.56 69 999999999 438.38 702.28 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48574262_1 CDM 0516 RC 20605 HCPCS inpatient 724 470.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 702.28 97 999999999 438.38 702.28 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48574262_1 CDM 0516 RC 20605 HCPCS inpatient 724 470.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 564.72 78 999999999 438.38 702.28 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48574262_1 CDM 0516 RC 20605 HCPCS inpatient 724 470.6 SIHO - ALL PLANS SIHO - ALL PLANS 651.6 90 999999999 438.38 702.28 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48574262_1 CDM 0516 RC 20605 HCPCS inpatient 724 470.6 UMR - ALL PLANS UMR - ALL PLANS 506.8 70 999999999 438.38 702.28 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48574262_1 CDM 0516 RC 20605 HCPCS inpatient 724 470.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 438.38 60.55 999999999 438.38 702.28 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48574262_1 CDM 0516 RC 20605 HCPCS inpatient 724 470.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 438.38 702.28 Aspiration and/or injection of fluid from medium joint 48574262_1 CDM 0516 RC 20605 HCPCS inpatient 724 470.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 438.38 702.28 Aspiration and/or injection of fluid from medium joint 48574262_1 CDM 0516 RC 20605 HCPCS inpatient 724 470.6 ANTHEM HMO ANTHEM HMO 999999999 438.38 702.28 Aspiration and/or injection of fluid from medium joint 48574262_1 CDM 0516 RC 20605 HCPCS inpatient 724 470.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 489.42 67.6 999999999 438.38 702.28 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48574262_1 CDM 0516 RC 20605 HCPCS inpatient 724 470.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 438.38 702.28 Aspiration and/or injection of fluid from medium joint 48574262_1 CDM 0516 RC 20605 HCPCS inpatient 724 470.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 438.38 702.28 Aspiration and/or injection of fluid from large joint 48574263_1 CDM 0516 RC 20610 HCPCS inpatient 1030 669.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 669.5 65 999999999 623.67 999.1 percent of total billed charges Aspiration and/or injection of fluid from large joint 48574263_1 CDM 0516 RC 20610 HCPCS inpatient 1030 669.5 AETNA AETNA 813.7 79 999999999 623.67 999.1 percent of total billed charges Aspiration and/or injection of fluid from large joint 48574263_1 CDM 0516 RC 20610 HCPCS inpatient 1030 669.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 710.7 69 999999999 623.67 999.1 percent of total billed charges Aspiration and/or injection of fluid from large joint 48574263_1 CDM 0516 RC 20610 HCPCS inpatient 1030 669.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 999.1 97 999999999 623.67 999.1 percent of total billed charges Aspiration and/or injection of fluid from large joint 48574263_1 CDM 0516 RC 20610 HCPCS inpatient 1030 669.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 803.4 78 999999999 623.67 999.1 percent of total billed charges Aspiration and/or injection of fluid from large joint 48574263_1 CDM 0516 RC 20610 HCPCS inpatient 1030 669.5 SIHO - ALL PLANS SIHO - ALL PLANS 927 90 999999999 623.67 999.1 percent of total billed charges Aspiration and/or injection of fluid from large joint 48574263_1 CDM 0516 RC 20610 HCPCS inpatient 1030 669.5 UMR - ALL PLANS UMR - ALL PLANS 721 70 999999999 623.67 999.1 percent of total billed charges Aspiration and/or injection of fluid from large joint 48574263_1 CDM 0516 RC 20610 HCPCS inpatient 1030 669.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 623.67 60.55 999999999 623.67 999.1 percent of total billed charges Aspiration and/or injection of fluid from large joint 48574263_1 CDM 0516 RC 20610 HCPCS inpatient 1030 669.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 623.67 999.1 Aspiration and/or injection of fluid from large joint 48574263_1 CDM 0516 RC 20610 HCPCS inpatient 1030 669.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 623.67 999.1 Aspiration and/or injection of fluid from large joint 48574263_1 CDM 0516 RC 20610 HCPCS inpatient 1030 669.5 ANTHEM HMO ANTHEM HMO 999999999 623.67 999.1 Aspiration and/or injection of fluid from large joint 48574263_1 CDM 0516 RC 20610 HCPCS inpatient 1030 669.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 696.28 67.6 999999999 623.67 999.1 percent of total billed charges Aspiration and/or injection of fluid from large joint 48574263_1 CDM 0516 RC 20610 HCPCS inpatient 1030 669.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 623.67 999.1 Aspiration and/or injection of fluid from large joint 48574263_1 CDM 0516 RC 20610 HCPCS inpatient 1030 669.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 623.67 999.1 Application of lower and upper arm splint 48574264_1 CDM 0516 RC 29105 HCPCS inpatient 490 318.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 318.5 65 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 48574264_1 CDM 0516 RC 29105 HCPCS inpatient 490 318.5 AETNA AETNA 387.1 79 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 48574264_1 CDM 0516 RC 29105 HCPCS inpatient 490 318.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 338.1 69 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 48574264_1 CDM 0516 RC 29105 HCPCS inpatient 490 318.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 475.3 97 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 48574264_1 CDM 0516 RC 29105 HCPCS inpatient 490 318.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 382.2 78 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 48574264_1 CDM 0516 RC 29105 HCPCS inpatient 490 318.5 SIHO - ALL PLANS SIHO - ALL PLANS 441 90 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 48574264_1 CDM 0516 RC 29105 HCPCS inpatient 490 318.5 UMR - ALL PLANS UMR - ALL PLANS 343 70 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 48574264_1 CDM 0516 RC 29105 HCPCS inpatient 490 318.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 296.7 60.55 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 48574264_1 CDM 0516 RC 29105 HCPCS inpatient 490 318.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 296.7 475.3 Application of lower and upper arm splint 48574264_1 CDM 0516 RC 29105 HCPCS inpatient 490 318.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 296.7 475.3 Application of lower and upper arm splint 48574264_1 CDM 0516 RC 29105 HCPCS inpatient 490 318.5 ANTHEM HMO ANTHEM HMO 999999999 296.7 475.3 Application of lower and upper arm splint 48574264_1 CDM 0516 RC 29105 HCPCS inpatient 490 318.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 331.24 67.6 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 48574264_1 CDM 0516 RC 29105 HCPCS inpatient 490 318.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 296.7 475.3 Application of lower and upper arm splint 48574264_1 CDM 0516 RC 29105 HCPCS inpatient 490 318.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 296.7 475.3 Removal of foreign body in cornea 48574265_1 CDM 0516 RC 65220 HCPCS inpatient 456 296.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 296.4 65 999999999 276.11 442.32 percent of total billed charges Removal of foreign body in cornea 48574265_1 CDM 0516 RC 65220 HCPCS inpatient 456 296.4 AETNA AETNA 360.24 79 999999999 276.11 442.32 percent of total billed charges Removal of foreign body in cornea 48574265_1 CDM 0516 RC 65220 HCPCS inpatient 456 296.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 314.64 69 999999999 276.11 442.32 percent of total billed charges Removal of foreign body in cornea 48574265_1 CDM 0516 RC 65220 HCPCS inpatient 456 296.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 442.32 97 999999999 276.11 442.32 percent of total billed charges Removal of foreign body in cornea 48574265_1 CDM 0516 RC 65220 HCPCS inpatient 456 296.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 355.68 78 999999999 276.11 442.32 percent of total billed charges Removal of foreign body in cornea 48574265_1 CDM 0516 RC 65220 HCPCS inpatient 456 296.4 SIHO - ALL PLANS SIHO - ALL PLANS 410.4 90 999999999 276.11 442.32 percent of total billed charges Removal of foreign body in cornea 48574265_1 CDM 0516 RC 65220 HCPCS inpatient 456 296.4 UMR - ALL PLANS UMR - ALL PLANS 319.2 70 999999999 276.11 442.32 percent of total billed charges Removal of foreign body in cornea 48574265_1 CDM 0516 RC 65220 HCPCS inpatient 456 296.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 276.11 60.55 999999999 276.11 442.32 percent of total billed charges Removal of foreign body in cornea 48574265_1 CDM 0516 RC 65220 HCPCS inpatient 456 296.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 276.11 442.32 Removal of foreign body in cornea 48574265_1 CDM 0516 RC 65220 HCPCS inpatient 456 296.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 276.11 442.32 Removal of foreign body in cornea 48574265_1 CDM 0516 RC 65220 HCPCS inpatient 456 296.4 ANTHEM HMO ANTHEM HMO 999999999 276.11 442.32 Removal of foreign body in cornea 48574265_1 CDM 0516 RC 65220 HCPCS inpatient 456 296.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 308.26 67.6 999999999 276.11 442.32 percent of total billed charges Removal of foreign body in cornea 48574265_1 CDM 0516 RC 65220 HCPCS inpatient 456 296.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 276.11 442.32 Removal of foreign body in cornea 48574265_1 CDM 0516 RC 65220 HCPCS inpatient 456 296.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 276.11 442.32 Removal of foreign body in ear canal 48574266_1 CDM 0516 RC 69200 HCPCS inpatient 456 296.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 296.4 65 999999999 276.11 442.32 percent of total billed charges Removal of foreign body in ear canal 48574266_1 CDM 0516 RC 69200 HCPCS inpatient 456 296.4 AETNA AETNA 360.24 79 999999999 276.11 442.32 percent of total billed charges Removal of foreign body in ear canal 48574266_1 CDM 0516 RC 69200 HCPCS inpatient 456 296.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 314.64 69 999999999 276.11 442.32 percent of total billed charges Removal of foreign body in ear canal 48574266_1 CDM 0516 RC 69200 HCPCS inpatient 456 296.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 442.32 97 999999999 276.11 442.32 percent of total billed charges Removal of foreign body in ear canal 48574266_1 CDM 0516 RC 69200 HCPCS inpatient 456 296.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 355.68 78 999999999 276.11 442.32 percent of total billed charges Removal of foreign body in ear canal 48574266_1 CDM 0516 RC 69200 HCPCS inpatient 456 296.4 SIHO - ALL PLANS SIHO - ALL PLANS 410.4 90 999999999 276.11 442.32 percent of total billed charges Removal of foreign body in ear canal 48574266_1 CDM 0516 RC 69200 HCPCS inpatient 456 296.4 UMR - ALL PLANS UMR - ALL PLANS 319.2 70 999999999 276.11 442.32 percent of total billed charges Removal of foreign body in ear canal 48574266_1 CDM 0516 RC 69200 HCPCS inpatient 456 296.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 276.11 60.55 999999999 276.11 442.32 percent of total billed charges Removal of foreign body in ear canal 48574266_1 CDM 0516 RC 69200 HCPCS inpatient 456 296.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 276.11 442.32 Removal of foreign body in ear canal 48574266_1 CDM 0516 RC 69200 HCPCS inpatient 456 296.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 276.11 442.32 Removal of foreign body in ear canal 48574266_1 CDM 0516 RC 69200 HCPCS inpatient 456 296.4 ANTHEM HMO ANTHEM HMO 999999999 276.11 442.32 Removal of foreign body in ear canal 48574266_1 CDM 0516 RC 69200 HCPCS inpatient 456 296.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 308.26 67.6 999999999 276.11 442.32 percent of total billed charges Removal of foreign body in ear canal 48574266_1 CDM 0516 RC 69200 HCPCS inpatient 456 296.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 276.11 442.32 Removal of foreign body in ear canal 48574266_1 CDM 0516 RC 69200 HCPCS inpatient 456 296.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 276.11 442.32 Removal of impacted ear wax 48574267_1 CDM 0516 RC 69210 HCPCS inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges Removal of impacted ear wax 48574267_1 CDM 0516 RC 69210 HCPCS inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges Removal of impacted ear wax 48574267_1 CDM 0516 RC 69210 HCPCS inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges Removal of impacted ear wax 48574267_1 CDM 0516 RC 69210 HCPCS inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges Removal of impacted ear wax 48574267_1 CDM 0516 RC 69210 HCPCS inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges Removal of impacted ear wax 48574267_1 CDM 0516 RC 69210 HCPCS inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges Removal of impacted ear wax 48574267_1 CDM 0516 RC 69210 HCPCS inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges Removal of impacted ear wax 48574267_1 CDM 0516 RC 69210 HCPCS inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges Removal of impacted ear wax 48574267_1 CDM 0516 RC 69210 HCPCS inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 Removal of impacted ear wax 48574267_1 CDM 0516 RC 69210 HCPCS inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 Removal of impacted ear wax 48574267_1 CDM 0516 RC 69210 HCPCS inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 Removal of impacted ear wax 48574267_1 CDM 0516 RC 69210 HCPCS inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges Removal of impacted ear wax 48574267_1 CDM 0516 RC 69210 HCPCS inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 Removal of impacted ear wax 48574267_1 CDM 0516 RC 69210 HCPCS inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 Injection of drug or substance under skin or into muscle 48574268_1 CDM 0516 RC 96372 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges Injection of drug or substance under skin or into muscle 48574268_1 CDM 0516 RC 96372 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges Injection of drug or substance under skin or into muscle 48574268_1 CDM 0516 RC 96372 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges Injection of drug or substance under skin or into muscle 48574268_1 CDM 0516 RC 96372 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges Injection of drug or substance under skin or into muscle 48574268_1 CDM 0516 RC 96372 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges Injection of drug or substance under skin or into muscle 48574268_1 CDM 0516 RC 96372 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges Injection of drug or substance under skin or into muscle 48574268_1 CDM 0516 RC 96372 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges Injection of drug or substance under skin or into muscle 48574268_1 CDM 0516 RC 96372 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges Injection of drug or substance under skin or into muscle 48574268_1 CDM 0516 RC 96372 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 Injection of drug or substance under skin or into muscle 48574268_1 CDM 0516 RC 96372 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 Injection of drug or substance under skin or into muscle 48574268_1 CDM 0516 RC 96372 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 Injection of drug or substance under skin or into muscle 48574268_1 CDM 0516 RC 96372 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges Injection of drug or substance under skin or into muscle 48574268_1 CDM 0516 RC 96372 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 Injection of drug or substance under skin or into muscle 48574268_1 CDM 0516 RC 96372 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574269_1 CDM 0516 RC 93005 HCPCS inpatient 338 219.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 219.7 65 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574269_1 CDM 0516 RC 93005 HCPCS inpatient 338 219.7 AETNA AETNA 267.02 79 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574269_1 CDM 0516 RC 93005 HCPCS inpatient 338 219.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 233.22 69 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574269_1 CDM 0516 RC 93005 HCPCS inpatient 338 219.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 327.86 97 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574269_1 CDM 0516 RC 93005 HCPCS inpatient 338 219.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 263.64 78 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574269_1 CDM 0516 RC 93005 HCPCS inpatient 338 219.7 SIHO - ALL PLANS SIHO - ALL PLANS 304.2 90 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574269_1 CDM 0516 RC 93005 HCPCS inpatient 338 219.7 UMR - ALL PLANS UMR - ALL PLANS 236.6 70 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574269_1 CDM 0516 RC 93005 HCPCS inpatient 338 219.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 204.66 60.55 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574269_1 CDM 0516 RC 93005 HCPCS inpatient 338 219.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 204.66 327.86 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574269_1 CDM 0516 RC 93005 HCPCS inpatient 338 219.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 204.66 327.86 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574269_1 CDM 0516 RC 93005 HCPCS inpatient 338 219.7 ANTHEM HMO ANTHEM HMO 999999999 204.66 327.86 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574269_1 CDM 0516 RC 93005 HCPCS inpatient 338 219.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 228.49 67.6 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574269_1 CDM 0516 RC 93005 HCPCS inpatient 338 219.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 204.66 327.86 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574269_1 CDM 0516 RC 93005 HCPCS inpatient 338 219.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 204.66 327.86 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574270_1 CDM 0516 RC G0463 HCPCS inpatient 266 172.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 172.9 65 999999999 161.06 258.02 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574270_1 CDM 0516 RC G0463 HCPCS inpatient 266 172.9 AETNA AETNA 210.14 79 999999999 161.06 258.02 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574270_1 CDM 0516 RC G0463 HCPCS inpatient 266 172.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 183.54 69 999999999 161.06 258.02 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574270_1 CDM 0516 RC G0463 HCPCS inpatient 266 172.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 258.02 97 999999999 161.06 258.02 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574270_1 CDM 0516 RC G0463 HCPCS inpatient 266 172.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 207.48 78 999999999 161.06 258.02 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574270_1 CDM 0516 RC G0463 HCPCS inpatient 266 172.9 SIHO - ALL PLANS SIHO - ALL PLANS 239.4 90 999999999 161.06 258.02 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574270_1 CDM 0516 RC G0463 HCPCS inpatient 266 172.9 UMR - ALL PLANS UMR - ALL PLANS 186.2 70 999999999 161.06 258.02 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574270_1 CDM 0516 RC G0463 HCPCS inpatient 266 172.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 161.06 60.55 999999999 161.06 258.02 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574270_1 CDM 0516 RC G0463 HCPCS inpatient 266 172.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 161.06 258.02 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574270_1 CDM 0516 RC G0463 HCPCS inpatient 266 172.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 161.06 258.02 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574270_1 CDM 0516 RC G0463 HCPCS inpatient 266 172.9 ANTHEM HMO ANTHEM HMO 999999999 161.06 258.02 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574270_1 CDM 0516 RC G0463 HCPCS inpatient 266 172.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 179.82 67.6 999999999 161.06 258.02 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574270_1 CDM 0516 RC G0463 HCPCS inpatient 266 172.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 161.06 258.02 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574270_1 CDM 0516 RC G0463 HCPCS inpatient 266 172.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 161.06 258.02 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574271_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 192.4 65 999999999 179.23 287.12 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574271_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 AETNA AETNA 233.84 79 999999999 179.23 287.12 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574271_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 204.24 69 999999999 179.23 287.12 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574271_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 287.12 97 999999999 179.23 287.12 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574271_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 230.88 78 999999999 179.23 287.12 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574271_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 SIHO - ALL PLANS SIHO - ALL PLANS 266.4 90 999999999 179.23 287.12 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574271_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 UMR - ALL PLANS UMR - ALL PLANS 207.2 70 999999999 179.23 287.12 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574271_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 179.23 60.55 999999999 179.23 287.12 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574271_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 179.23 287.12 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574271_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 179.23 287.12 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574271_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 ANTHEM HMO ANTHEM HMO 999999999 179.23 287.12 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574271_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 200.1 67.6 999999999 179.23 287.12 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574271_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 179.23 287.12 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574271_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 179.23 287.12 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574272_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 252.85 65 999999999 235.54 377.33 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574272_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 AETNA AETNA 307.31 79 999999999 235.54 377.33 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574272_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 268.41 69 999999999 235.54 377.33 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574272_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 377.33 97 999999999 235.54 377.33 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574272_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 303.42 78 999999999 235.54 377.33 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574272_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 SIHO - ALL PLANS SIHO - ALL PLANS 350.1 90 999999999 235.54 377.33 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574272_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 UMR - ALL PLANS UMR - ALL PLANS 272.3 70 999999999 235.54 377.33 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574272_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 235.54 60.55 999999999 235.54 377.33 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574272_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 235.54 377.33 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574272_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 235.54 377.33 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574272_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 ANTHEM HMO ANTHEM HMO 999999999 235.54 377.33 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574272_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 262.96 67.6 999999999 235.54 377.33 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574272_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 235.54 377.33 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574272_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 235.54 377.33 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574273_1 CDM 0516 RC G0463 HCPCS inpatient 486 315.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 315.9 65 999999999 294.27 471.42 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574273_1 CDM 0516 RC G0463 HCPCS inpatient 486 315.9 AETNA AETNA 383.94 79 999999999 294.27 471.42 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574273_1 CDM 0516 RC G0463 HCPCS inpatient 486 315.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 335.34 69 999999999 294.27 471.42 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574273_1 CDM 0516 RC G0463 HCPCS inpatient 486 315.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 471.42 97 999999999 294.27 471.42 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574273_1 CDM 0516 RC G0463 HCPCS inpatient 486 315.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 379.08 78 999999999 294.27 471.42 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574273_1 CDM 0516 RC G0463 HCPCS inpatient 486 315.9 SIHO - ALL PLANS SIHO - ALL PLANS 437.4 90 999999999 294.27 471.42 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574273_1 CDM 0516 RC G0463 HCPCS inpatient 486 315.9 UMR - ALL PLANS UMR - ALL PLANS 340.2 70 999999999 294.27 471.42 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574273_1 CDM 0516 RC G0463 HCPCS inpatient 486 315.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 294.27 60.55 999999999 294.27 471.42 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574273_1 CDM 0516 RC G0463 HCPCS inpatient 486 315.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 294.27 471.42 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574273_1 CDM 0516 RC G0463 HCPCS inpatient 486 315.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 294.27 471.42 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574273_1 CDM 0516 RC G0463 HCPCS inpatient 486 315.9 ANTHEM HMO ANTHEM HMO 999999999 294.27 471.42 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574273_1 CDM 0516 RC G0463 HCPCS inpatient 486 315.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 328.54 67.6 999999999 294.27 471.42 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574273_1 CDM 0516 RC G0463 HCPCS inpatient 486 315.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 294.27 471.42 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574273_1 CDM 0516 RC G0463 HCPCS inpatient 486 315.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 294.27 471.42 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574274_1 CDM 0516 RC G0463 HCPCS inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574274_1 CDM 0516 RC G0463 HCPCS inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574274_1 CDM 0516 RC G0463 HCPCS inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574274_1 CDM 0516 RC G0463 HCPCS inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574274_1 CDM 0516 RC G0463 HCPCS inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574274_1 CDM 0516 RC G0463 HCPCS inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574274_1 CDM 0516 RC G0463 HCPCS inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574274_1 CDM 0516 RC G0463 HCPCS inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574274_1 CDM 0516 RC G0463 HCPCS inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574274_1 CDM 0516 RC G0463 HCPCS inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574274_1 CDM 0516 RC G0463 HCPCS inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574274_1 CDM 0516 RC G0463 HCPCS inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574274_1 CDM 0516 RC G0463 HCPCS inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574274_1 CDM 0516 RC G0463 HCPCS inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574275_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 192.4 65 999999999 179.23 287.12 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574275_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 AETNA AETNA 233.84 79 999999999 179.23 287.12 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574275_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 287.12 97 999999999 179.23 287.12 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574275_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 204.24 69 999999999 179.23 287.12 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574275_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 230.88 78 999999999 179.23 287.12 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574275_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 SIHO - ALL PLANS SIHO - ALL PLANS 266.4 90 999999999 179.23 287.12 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574275_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 UMR - ALL PLANS UMR - ALL PLANS 207.2 70 999999999 179.23 287.12 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574275_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 179.23 60.55 999999999 179.23 287.12 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574275_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 179.23 287.12 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574275_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 179.23 287.12 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574275_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 ANTHEM HMO ANTHEM HMO 999999999 179.23 287.12 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574275_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 200.1 67.6 999999999 179.23 287.12 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574275_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 179.23 287.12 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574275_1 CDM 0516 RC G0463 HCPCS inpatient 296 192.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 179.23 287.12 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574276_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 252.85 65 999999999 235.54 377.33 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574276_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 AETNA AETNA 307.31 79 999999999 235.54 377.33 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574276_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 377.33 97 999999999 235.54 377.33 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574276_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 268.41 69 999999999 235.54 377.33 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574276_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 303.42 78 999999999 235.54 377.33 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574276_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 SIHO - ALL PLANS SIHO - ALL PLANS 350.1 90 999999999 235.54 377.33 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574276_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 UMR - ALL PLANS UMR - ALL PLANS 272.3 70 999999999 235.54 377.33 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574276_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 235.54 60.55 999999999 235.54 377.33 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574276_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 235.54 377.33 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574276_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 235.54 377.33 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574276_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 ANTHEM HMO ANTHEM HMO 999999999 235.54 377.33 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574276_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 262.96 67.6 999999999 235.54 377.33 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574276_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 235.54 377.33 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574276_1 CDM 0516 RC G0463 HCPCS inpatient 389 252.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 235.54 377.33 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574277_1 CDM 0516 RC G0463 HCPCS inpatient 424 275.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 275.6 65 999999999 256.73 411.28 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574277_1 CDM 0516 RC G0463 HCPCS inpatient 424 275.6 AETNA AETNA 334.96 79 999999999 256.73 411.28 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574277_1 CDM 0516 RC G0463 HCPCS inpatient 424 275.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 411.28 97 999999999 256.73 411.28 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574277_1 CDM 0516 RC G0463 HCPCS inpatient 424 275.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 292.56 69 999999999 256.73 411.28 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574277_1 CDM 0516 RC G0463 HCPCS inpatient 424 275.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 330.72 78 999999999 256.73 411.28 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574277_1 CDM 0516 RC G0463 HCPCS inpatient 424 275.6 SIHO - ALL PLANS SIHO - ALL PLANS 381.6 90 999999999 256.73 411.28 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574277_1 CDM 0516 RC G0463 HCPCS inpatient 424 275.6 UMR - ALL PLANS UMR - ALL PLANS 296.8 70 999999999 256.73 411.28 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574277_1 CDM 0516 RC G0463 HCPCS inpatient 424 275.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 256.73 60.55 999999999 256.73 411.28 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574277_1 CDM 0516 RC G0463 HCPCS inpatient 424 275.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 256.73 411.28 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574277_1 CDM 0516 RC G0463 HCPCS inpatient 424 275.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 256.73 411.28 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574277_1 CDM 0516 RC G0463 HCPCS inpatient 424 275.6 ANTHEM HMO ANTHEM HMO 999999999 256.73 411.28 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574277_1 CDM 0516 RC G0463 HCPCS inpatient 424 275.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 286.62 67.6 999999999 256.73 411.28 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574277_1 CDM 0516 RC G0463 HCPCS inpatient 424 275.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 256.73 411.28 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574277_1 CDM 0516 RC G0463 HCPCS inpatient 424 275.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 256.73 411.28 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574278_1 CDM 0516 RC G0463 HCPCS inpatient 520 338 SELF PAY DISCOUNT SELF PAY DISCOUNT 338 65 999999999 314.86 504.4 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574278_1 CDM 0516 RC G0463 HCPCS inpatient 520 338 AETNA AETNA 410.8 79 999999999 314.86 504.4 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574278_1 CDM 0516 RC G0463 HCPCS inpatient 520 338 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 504.4 97 999999999 314.86 504.4 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574278_1 CDM 0516 RC G0463 HCPCS inpatient 520 338 ENCORE - ALL PLANS ENCORE - ALL PLANS 358.8 69 999999999 314.86 504.4 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574278_1 CDM 0516 RC G0463 HCPCS inpatient 520 338 HUMANA - ALL PLANS HUMANA - ALL PLANS 405.6 78 999999999 314.86 504.4 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574278_1 CDM 0516 RC G0463 HCPCS inpatient 520 338 SIHO - ALL PLANS SIHO - ALL PLANS 468 90 999999999 314.86 504.4 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574278_1 CDM 0516 RC G0463 HCPCS inpatient 520 338 UMR - ALL PLANS UMR - ALL PLANS 364 70 999999999 314.86 504.4 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574278_1 CDM 0516 RC G0463 HCPCS inpatient 520 338 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 314.86 60.55 999999999 314.86 504.4 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574278_1 CDM 0516 RC G0463 HCPCS inpatient 520 338 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 314.86 504.4 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574278_1 CDM 0516 RC G0463 HCPCS inpatient 520 338 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 314.86 504.4 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574278_1 CDM 0516 RC G0463 HCPCS inpatient 520 338 ANTHEM HMO ANTHEM HMO 999999999 314.86 504.4 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574278_1 CDM 0516 RC G0463 HCPCS inpatient 520 338 CIGNA - ALL PLANS CIGNA - ALL PLANS 351.52 67.6 999999999 314.86 504.4 percent of total billed charges HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574278_1 CDM 0516 RC G0463 HCPCS inpatient 520 338 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 314.86 504.4 HOSPITAL OUTPATIENT CLINIC VISIT FOR ASSESSMENT AND MANAGEMENT OF A PATIENT 48574278_1 CDM 0516 RC G0463 HCPCS inpatient 520 338 UHC - ALL PLANS UHC - ALL PLANS 999999999 314.86 504.4 Injection into tendon or ligament 48574279_1 CDM 0516 RC 20550 HCPCS inpatient 675 438.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 438.75 65 999999999 408.71 654.75 percent of total billed charges Injection into tendon or ligament 48574279_1 CDM 0516 RC 20550 HCPCS inpatient 675 438.75 AETNA AETNA 533.25 79 999999999 408.71 654.75 percent of total billed charges Injection into tendon or ligament 48574279_1 CDM 0516 RC 20550 HCPCS inpatient 675 438.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 654.75 97 999999999 408.71 654.75 percent of total billed charges Injection into tendon or ligament 48574279_1 CDM 0516 RC 20550 HCPCS inpatient 675 438.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 465.75 69 999999999 408.71 654.75 percent of total billed charges Injection into tendon or ligament 48574279_1 CDM 0516 RC 20550 HCPCS inpatient 675 438.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 526.5 78 999999999 408.71 654.75 percent of total billed charges Injection into tendon or ligament 48574279_1 CDM 0516 RC 20550 HCPCS inpatient 675 438.75 SIHO - ALL PLANS SIHO - ALL PLANS 607.5 90 999999999 408.71 654.75 percent of total billed charges Injection into tendon or ligament 48574279_1 CDM 0516 RC 20550 HCPCS inpatient 675 438.75 UMR - ALL PLANS UMR - ALL PLANS 472.5 70 999999999 408.71 654.75 percent of total billed charges Injection into tendon or ligament 48574279_1 CDM 0516 RC 20550 HCPCS inpatient 675 438.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 408.71 60.55 999999999 408.71 654.75 percent of total billed charges Injection into tendon or ligament 48574279_1 CDM 0516 RC 20550 HCPCS inpatient 675 438.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 408.71 654.75 Injection into tendon or ligament 48574279_1 CDM 0516 RC 20550 HCPCS inpatient 675 438.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 408.71 654.75 Injection into tendon or ligament 48574279_1 CDM 0516 RC 20550 HCPCS inpatient 675 438.75 ANTHEM HMO ANTHEM HMO 999999999 408.71 654.75 Injection into tendon or ligament 48574279_1 CDM 0516 RC 20550 HCPCS inpatient 675 438.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 456.3 67.6 999999999 408.71 654.75 percent of total billed charges Injection into tendon or ligament 48574279_1 CDM 0516 RC 20550 HCPCS inpatient 675 438.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 408.71 654.75 Injection into tendon or ligament 48574279_1 CDM 0516 RC 20550 HCPCS inpatient 675 438.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 408.71 654.75 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574280_1 CDM 0516 RC 93005 HCPCS inpatient 316 205.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 205.4 65 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574280_1 CDM 0516 RC 93005 HCPCS inpatient 316 205.4 AETNA AETNA 249.64 79 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574280_1 CDM 0516 RC 93005 HCPCS inpatient 316 205.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 306.52 97 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574280_1 CDM 0516 RC 93005 HCPCS inpatient 316 205.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 218.04 69 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574280_1 CDM 0516 RC 93005 HCPCS inpatient 316 205.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 246.48 78 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574280_1 CDM 0516 RC 93005 HCPCS inpatient 316 205.4 SIHO - ALL PLANS SIHO - ALL PLANS 284.4 90 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574280_1 CDM 0516 RC 93005 HCPCS inpatient 316 205.4 UMR - ALL PLANS UMR - ALL PLANS 221.2 70 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574280_1 CDM 0516 RC 93005 HCPCS inpatient 316 205.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 191.34 60.55 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574280_1 CDM 0516 RC 93005 HCPCS inpatient 316 205.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574280_1 CDM 0516 RC 93005 HCPCS inpatient 316 205.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574280_1 CDM 0516 RC 93005 HCPCS inpatient 316 205.4 ANTHEM HMO ANTHEM HMO 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574280_1 CDM 0516 RC 93005 HCPCS inpatient 316 205.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 213.62 67.6 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574280_1 CDM 0516 RC 93005 HCPCS inpatient 316 205.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48574280_1 CDM 0516 RC 93005 HCPCS inpatient 316 205.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 191.34 306.52 "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48574281_1 CDM 0636 RC 90715 HCPCS inpatient 117 76.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 76.05 65 999999999 70.84 113.49 percent of total billed charges "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48574281_1 CDM 0636 RC 90715 HCPCS inpatient 117 76.05 AETNA AETNA 92.43 79 999999999 70.84 113.49 percent of total billed charges "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48574281_1 CDM 0636 RC 90715 HCPCS inpatient 117 76.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 113.49 97 999999999 70.84 113.49 percent of total billed charges "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48574281_1 CDM 0636 RC 90715 HCPCS inpatient 117 76.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.73 69 999999999 70.84 113.49 percent of total billed charges "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48574281_1 CDM 0636 RC 90715 HCPCS inpatient 117 76.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 91.26 78 999999999 70.84 113.49 percent of total billed charges "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48574281_1 CDM 0636 RC 90715 HCPCS inpatient 117 76.05 SIHO - ALL PLANS SIHO - ALL PLANS 105.3 90 999999999 70.84 113.49 percent of total billed charges "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48574281_1 CDM 0636 RC 90715 HCPCS inpatient 117 76.05 UMR - ALL PLANS UMR - ALL PLANS 81.9 70 999999999 70.84 113.49 percent of total billed charges "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48574281_1 CDM 0636 RC 90715 HCPCS inpatient 117 76.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 70.84 60.55 999999999 70.84 113.49 percent of total billed charges "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48574281_1 CDM 0636 RC 90715 HCPCS inpatient 117 76.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 70.84 113.49 "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48574281_1 CDM 0636 RC 90715 HCPCS inpatient 117 76.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 70.84 113.49 "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48574281_1 CDM 0636 RC 90715 HCPCS inpatient 117 76.05 ANTHEM HMO ANTHEM HMO 999999999 70.84 113.49 "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48574281_1 CDM 0636 RC 90715 HCPCS inpatient 117 76.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 79.09 67.6 999999999 70.84 113.49 percent of total billed charges "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48574281_1 CDM 0636 RC 90715 HCPCS inpatient 117 76.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 70.84 113.49 "Diphtheria, tetanus, and acellular pertussis vaccine (7 years or older)" 48574281_1 CDM 0636 RC 90715 HCPCS inpatient 117 76.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 70.84 113.49 "INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG" 48574282_1 CDM 0636 RC J1040 HCPCS inpatient 123 79.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.95 65 999999999 74.48 119.31 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG" 48574282_1 CDM 0636 RC J1040 HCPCS inpatient 123 79.95 AETNA AETNA 97.17 79 999999999 74.48 119.31 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG" 48574282_1 CDM 0636 RC J1040 HCPCS inpatient 123 79.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 119.31 97 999999999 74.48 119.31 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG" 48574282_1 CDM 0636 RC J1040 HCPCS inpatient 123 79.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.87 69 999999999 74.48 119.31 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG" 48574282_1 CDM 0636 RC J1040 HCPCS inpatient 123 79.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.94 78 999999999 74.48 119.31 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG" 48574282_1 CDM 0636 RC J1040 HCPCS inpatient 123 79.95 SIHO - ALL PLANS SIHO - ALL PLANS 110.7 90 999999999 74.48 119.31 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG" 48574282_1 CDM 0636 RC J1040 HCPCS inpatient 123 79.95 UMR - ALL PLANS UMR - ALL PLANS 86.1 70 999999999 74.48 119.31 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG" 48574282_1 CDM 0636 RC J1040 HCPCS inpatient 123 79.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 74.48 60.55 999999999 74.48 119.31 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG" 48574282_1 CDM 0636 RC J1040 HCPCS inpatient 123 79.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 74.48 119.31 "INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG" 48574282_1 CDM 0636 RC J1040 HCPCS inpatient 123 79.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 74.48 119.31 "INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG" 48574282_1 CDM 0636 RC J1040 HCPCS inpatient 123 79.95 ANTHEM HMO ANTHEM HMO 999999999 74.48 119.31 "INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG" 48574282_1 CDM 0636 RC J1040 HCPCS inpatient 123 79.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.15 67.6 999999999 74.48 119.31 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG" 48574282_1 CDM 0636 RC J1040 HCPCS inpatient 123 79.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 74.48 119.31 "INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG" 48574282_1 CDM 0636 RC J1040 HCPCS inpatient 123 79.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 74.48 119.31 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48574283_1 CDM 0516 RC J1100 HCPCS inpatient 139 90.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 90.35 65 999999999 84.16 134.83 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48574283_1 CDM 0516 RC J1100 HCPCS inpatient 139 90.35 AETNA AETNA 109.81 79 999999999 84.16 134.83 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48574283_1 CDM 0516 RC J1100 HCPCS inpatient 139 90.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 134.83 97 999999999 84.16 134.83 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48574283_1 CDM 0516 RC J1100 HCPCS inpatient 139 90.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.91 69 999999999 84.16 134.83 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48574283_1 CDM 0516 RC J1100 HCPCS inpatient 139 90.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 108.42 78 999999999 84.16 134.83 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48574283_1 CDM 0516 RC J1100 HCPCS inpatient 139 90.35 SIHO - ALL PLANS SIHO - ALL PLANS 125.1 90 999999999 84.16 134.83 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48574283_1 CDM 0516 RC J1100 HCPCS inpatient 139 90.35 UMR - ALL PLANS UMR - ALL PLANS 97.3 70 999999999 84.16 134.83 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48574283_1 CDM 0516 RC J1100 HCPCS inpatient 139 90.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 84.16 60.55 999999999 84.16 134.83 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48574283_1 CDM 0516 RC J1100 HCPCS inpatient 139 90.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 84.16 134.83 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48574283_1 CDM 0516 RC J1100 HCPCS inpatient 139 90.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 84.16 134.83 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48574283_1 CDM 0516 RC J1100 HCPCS inpatient 139 90.35 ANTHEM HMO ANTHEM HMO 999999999 84.16 134.83 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48574283_1 CDM 0516 RC J1100 HCPCS inpatient 139 90.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.96 67.6 999999999 84.16 134.83 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48574283_1 CDM 0516 RC J1100 HCPCS inpatient 139 90.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 84.16 134.83 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 48574283_1 CDM 0516 RC J1100 HCPCS inpatient 139 90.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 84.16 134.83 "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 48575138_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 93.6 65 999999999 87.19 139.68 percent of total billed charges "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 48575138_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 AETNA AETNA 113.76 79 999999999 87.19 139.68 percent of total billed charges "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 48575138_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 139.68 97 999999999 87.19 139.68 percent of total billed charges "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 48575138_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 99.36 69 999999999 87.19 139.68 percent of total billed charges "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 48575138_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 112.32 78 999999999 87.19 139.68 percent of total billed charges "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 48575138_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 SIHO - ALL PLANS SIHO - ALL PLANS 129.6 90 999999999 87.19 139.68 percent of total billed charges "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 48575138_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 UMR - ALL PLANS UMR - ALL PLANS 100.8 70 999999999 87.19 139.68 percent of total billed charges "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 48575138_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.19 60.55 999999999 87.19 139.68 percent of total billed charges "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 48575138_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.19 139.68 "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 48575138_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.19 139.68 "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 48575138_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 ANTHEM HMO ANTHEM HMO 999999999 87.19 139.68 "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 48575138_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 97.34 67.6 999999999 87.19 139.68 percent of total billed charges "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 48575138_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.19 139.68 "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 48575138_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.19 139.68 Fluoroscopic guidance for needle placement 48577851_1 CDM 0322 RC 77002 HCPCS inpatient 1622.5 1054.63 SELF PAY DISCOUNT SELF PAY DISCOUNT 1054.63 65 999999999 982.42 1573.83 percent of total billed charges Fluoroscopic guidance for needle placement 48577851_1 CDM 0322 RC 77002 HCPCS inpatient 1622.5 1054.63 AETNA AETNA 1281.78 79 999999999 982.42 1573.83 percent of total billed charges Fluoroscopic guidance for needle placement 48577851_1 CDM 0322 RC 77002 HCPCS inpatient 1622.5 1054.63 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1573.83 97 999999999 982.42 1573.83 percent of total billed charges Fluoroscopic guidance for needle placement 48577851_1 CDM 0322 RC 77002 HCPCS inpatient 1622.5 1054.63 ENCORE - ALL PLANS ENCORE - ALL PLANS 1119.53 69 999999999 982.42 1573.83 percent of total billed charges Fluoroscopic guidance for needle placement 48577851_1 CDM 0322 RC 77002 HCPCS inpatient 1622.5 1054.63 HUMANA - ALL PLANS HUMANA - ALL PLANS 1265.55 78 999999999 982.42 1573.83 percent of total billed charges Fluoroscopic guidance for needle placement 48577851_1 CDM 0322 RC 77002 HCPCS inpatient 1622.5 1054.63 SIHO - ALL PLANS SIHO - ALL PLANS 1460.25 90 999999999 982.42 1573.83 percent of total billed charges Fluoroscopic guidance for needle placement 48577851_1 CDM 0322 RC 77002 HCPCS inpatient 1622.5 1054.63 UMR - ALL PLANS UMR - ALL PLANS 1135.75 70 999999999 982.42 1573.83 percent of total billed charges Fluoroscopic guidance for needle placement 48577851_1 CDM 0322 RC 77002 HCPCS inpatient 1622.5 1054.63 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 982.42 60.55 999999999 982.42 1573.83 percent of total billed charges Fluoroscopic guidance for needle placement 48577851_1 CDM 0322 RC 77002 HCPCS inpatient 1622.5 1054.63 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 982.42 1573.83 Fluoroscopic guidance for needle placement 48577851_1 CDM 0322 RC 77002 HCPCS inpatient 1622.5 1054.63 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 982.42 1573.83 Fluoroscopic guidance for needle placement 48577851_1 CDM 0322 RC 77002 HCPCS inpatient 1622.5 1054.63 ANTHEM HMO ANTHEM HMO 999999999 982.42 1573.83 Fluoroscopic guidance for needle placement 48577851_1 CDM 0322 RC 77002 HCPCS inpatient 1622.5 1054.63 CIGNA - ALL PLANS CIGNA - ALL PLANS 1096.81 67.6 999999999 982.42 1573.83 percent of total billed charges Fluoroscopic guidance for needle placement 48577851_1 CDM 0322 RC 77002 HCPCS inpatient 1622.5 1054.63 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 982.42 1573.83 Fluoroscopic guidance for needle placement 48577851_1 CDM 0322 RC 77002 HCPCS inpatient 1622.5 1054.63 UHC - ALL PLANS UHC - ALL PLANS 999999999 982.42 1573.83 Review by radiologist of CT guidance for needle placement 48577881_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.2 65 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577881_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 AETNA AETNA 1333.52 79 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577881_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1637.36 97 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577881_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1164.72 69 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577881_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1316.64 78 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577881_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 SIHO - ALL PLANS SIHO - ALL PLANS 1519.2 90 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577881_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 UMR - ALL PLANS UMR - ALL PLANS 1181.6 70 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577881_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.08 60.55 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577881_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 48577881_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 48577881_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 ANTHEM HMO ANTHEM HMO 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 48577881_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.09 67.6 999999999 1022.08 1637.36 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577881_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 48577881_1 CDM 0350 RC 77012 HCPCS inpatient 1688 1097.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.08 1637.36 Review by radiologist of CT guidance for needle placement 48577887_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.85 65 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577887_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 AETNA AETNA 1334.31 79 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577887_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1638.33 97 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577887_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1165.41 69 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577887_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1317.42 78 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577887_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 SIHO - ALL PLANS SIHO - ALL PLANS 1520.1 90 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577887_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UMR - ALL PLANS UMR - ALL PLANS 1182.3 70 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577887_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.69 60.55 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577887_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48577887_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48577887_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM HMO ANTHEM HMO 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48577887_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48577887_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.76 67.6 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577887_1 CDM 0320 RC 77012 HCPCS inpatient 1689 1097.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48577902_1 CDM 0350 RC 77012 HCPCS inpatient 1689 1097.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.85 65 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577902_1 CDM 0350 RC 77012 HCPCS inpatient 1689 1097.85 AETNA AETNA 1334.31 79 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577902_1 CDM 0350 RC 77012 HCPCS inpatient 1689 1097.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1638.33 97 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577902_1 CDM 0350 RC 77012 HCPCS inpatient 1689 1097.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1165.41 69 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577902_1 CDM 0350 RC 77012 HCPCS inpatient 1689 1097.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1317.42 78 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577902_1 CDM 0350 RC 77012 HCPCS inpatient 1689 1097.85 SIHO - ALL PLANS SIHO - ALL PLANS 1520.1 90 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577902_1 CDM 0350 RC 77012 HCPCS inpatient 1689 1097.85 UMR - ALL PLANS UMR - ALL PLANS 1182.3 70 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577902_1 CDM 0350 RC 77012 HCPCS inpatient 1689 1097.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.69 60.55 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577902_1 CDM 0350 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48577902_1 CDM 0350 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48577902_1 CDM 0350 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM HMO ANTHEM HMO 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48577902_1 CDM 0350 RC 77012 HCPCS inpatient 1689 1097.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.69 1638.33 Review by radiologist of CT guidance for needle placement 48577902_1 CDM 0350 RC 77012 HCPCS inpatient 1689 1097.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.76 67.6 999999999 1022.69 1638.33 percent of total billed charges Review by radiologist of CT guidance for needle placement 48577902_1 CDM 0350 RC 77012 HCPCS inpatient 1689 1097.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.69 1638.33 Limited or follow-up CT scan 48577911_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 735.15 65 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 48577911_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 AETNA AETNA 893.49 79 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 48577911_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1097.07 97 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 48577911_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 780.39 69 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 48577911_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 882.18 78 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 48577911_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 SIHO - ALL PLANS SIHO - ALL PLANS 1017.9 90 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 48577911_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 UMR - ALL PLANS UMR - ALL PLANS 791.7 70 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 48577911_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 684.82 60.55 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 48577911_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 684.82 1097.07 Limited or follow-up CT scan 48577911_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 684.82 1097.07 Limited or follow-up CT scan 48577911_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 ANTHEM HMO ANTHEM HMO 999999999 684.82 1097.07 Limited or follow-up CT scan 48577911_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 684.82 1097.07 Limited or follow-up CT scan 48577911_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 764.56 67.6 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 48577911_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 684.82 1097.07 Limited or follow-up CT scan 48577914_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 735.15 65 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 48577914_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 AETNA AETNA 893.49 79 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 48577914_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1097.07 97 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 48577914_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 780.39 69 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 48577914_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 882.18 78 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 48577914_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 SIHO - ALL PLANS SIHO - ALL PLANS 1017.9 90 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 48577914_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 UMR - ALL PLANS UMR - ALL PLANS 791.7 70 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 48577914_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 684.82 60.55 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 48577914_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 684.82 1097.07 Limited or follow-up CT scan 48577914_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 684.82 1097.07 Limited or follow-up CT scan 48577914_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 ANTHEM HMO ANTHEM HMO 999999999 684.82 1097.07 Limited or follow-up CT scan 48577914_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 684.82 1097.07 Limited or follow-up CT scan 48577914_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 764.56 67.6 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 48577914_1 CDM 0320 RC 76380 HCPCS inpatient 1131 735.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 684.82 1097.07 "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 48577947_1 CDM 0361 RC 19081 HCPCS inpatient 16172 10511.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 10511.8 65 999999999 9792.15 15686.84 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 48577947_1 CDM 0361 RC 19081 HCPCS inpatient 16172 10511.8 AETNA AETNA 12775.88 79 999999999 9792.15 15686.84 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 48577947_1 CDM 0361 RC 19081 HCPCS inpatient 16172 10511.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15686.84 97 999999999 9792.15 15686.84 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 48577947_1 CDM 0361 RC 19081 HCPCS inpatient 16172 10511.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 11158.68 69 999999999 9792.15 15686.84 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 48577947_1 CDM 0361 RC 19081 HCPCS inpatient 16172 10511.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 12614.16 78 999999999 9792.15 15686.84 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 48577947_1 CDM 0361 RC 19081 HCPCS inpatient 16172 10511.8 SIHO - ALL PLANS SIHO - ALL PLANS 14554.8 90 999999999 9792.15 15686.84 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 48577947_1 CDM 0361 RC 19081 HCPCS inpatient 16172 10511.8 UMR - ALL PLANS UMR - ALL PLANS 11320.4 70 999999999 9792.15 15686.84 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 48577947_1 CDM 0361 RC 19081 HCPCS inpatient 16172 10511.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9792.15 60.55 999999999 9792.15 15686.84 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 48577947_1 CDM 0361 RC 19081 HCPCS inpatient 16172 10511.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9792.15 15686.84 "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 48577947_1 CDM 0361 RC 19081 HCPCS inpatient 16172 10511.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9792.15 15686.84 "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 48577947_1 CDM 0361 RC 19081 HCPCS inpatient 16172 10511.8 ANTHEM HMO ANTHEM HMO 999999999 9792.15 15686.84 "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 48577947_1 CDM 0361 RC 19081 HCPCS inpatient 16172 10511.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9792.15 15686.84 "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 48577947_1 CDM 0361 RC 19081 HCPCS inpatient 16172 10511.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 10932.27 67.6 999999999 9792.15 15686.84 percent of total billed charges "Biopsy of breast and placement of locating device using X-ray with needle, first growth" 48577947_1 CDM 0361 RC 19081 HCPCS inpatient 16172 10511.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 9792.15 15686.84 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 48577953_1 CDM 0341 RC 78803 HCPCS inpatient 1970 1280.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1280.5 65 999999999 1192.84 1910.9 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 48577953_1 CDM 0341 RC 78803 HCPCS inpatient 1970 1280.5 AETNA AETNA 1556.3 79 999999999 1192.84 1910.9 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 48577953_1 CDM 0341 RC 78803 HCPCS inpatient 1970 1280.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1910.9 97 999999999 1192.84 1910.9 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 48577953_1 CDM 0341 RC 78803 HCPCS inpatient 1970 1280.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1359.3 69 999999999 1192.84 1910.9 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 48577953_1 CDM 0341 RC 78803 HCPCS inpatient 1970 1280.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1536.6 78 999999999 1192.84 1910.9 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 48577953_1 CDM 0341 RC 78803 HCPCS inpatient 1970 1280.5 SIHO - ALL PLANS SIHO - ALL PLANS 1773 90 999999999 1192.84 1910.9 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 48577953_1 CDM 0341 RC 78803 HCPCS inpatient 1970 1280.5 UMR - ALL PLANS UMR - ALL PLANS 1379 70 999999999 1192.84 1910.9 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 48577953_1 CDM 0341 RC 78803 HCPCS inpatient 1970 1280.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1192.84 60.55 999999999 1192.84 1910.9 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 48577953_1 CDM 0341 RC 78803 HCPCS inpatient 1970 1280.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1192.84 1910.9 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 48577953_1 CDM 0341 RC 78803 HCPCS inpatient 1970 1280.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1192.84 1910.9 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 48577953_1 CDM 0341 RC 78803 HCPCS inpatient 1970 1280.5 ANTHEM HMO ANTHEM HMO 999999999 1192.84 1910.9 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 48577953_1 CDM 0341 RC 78803 HCPCS inpatient 1970 1280.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1192.84 1910.9 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 48577953_1 CDM 0341 RC 78803 HCPCS inpatient 1970 1280.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1331.72 67.6 999999999 1192.84 1910.9 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 48577953_1 CDM 0341 RC 78803 HCPCS inpatient 1970 1280.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1192.84 1910.9 Ultrasonic guidance for needle placement 48577959_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577959_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577959_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577959_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577959_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577959_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577959_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577959_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577959_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577959_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577959_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577959_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577959_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577959_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577962_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577962_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577962_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577962_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577962_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577962_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577962_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577962_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577962_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577962_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577962_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577962_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577962_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577962_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577965_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577965_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577965_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577965_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577965_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577965_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577965_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577965_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577965_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577965_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577965_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577965_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577965_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577965_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577968_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577968_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577968_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577968_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577968_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577968_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577968_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577968_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577968_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577968_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577968_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577968_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577968_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577968_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577971_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577971_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577971_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577971_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577971_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577971_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577971_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577971_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577971_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577971_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577971_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577971_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577971_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 48577971_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 48577989_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 627.25 65 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48577989_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 AETNA AETNA 762.35 79 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48577989_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 936.05 97 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48577989_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 665.85 69 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48577989_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 752.7 78 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48577989_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SIHO - ALL PLANS SIHO - ALL PLANS 868.5 90 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48577989_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UMR - ALL PLANS UMR - ALL PLANS 675.5 70 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48577989_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 584.31 60.55 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48577989_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48577989_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48577989_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM HMO ANTHEM HMO 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48577989_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48577989_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 652.34 67.6 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48577989_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48577992_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 627.25 65 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48577992_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 AETNA AETNA 762.35 79 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48577992_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 936.05 97 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48577992_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 665.85 69 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48577992_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 752.7 78 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48577992_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SIHO - ALL PLANS SIHO - ALL PLANS 868.5 90 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48577992_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UMR - ALL PLANS UMR - ALL PLANS 675.5 70 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48577992_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 584.31 60.55 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48577992_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48577992_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48577992_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM HMO ANTHEM HMO 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48577992_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48577992_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 652.34 67.6 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48577992_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48578001_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 627.25 65 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48578001_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 AETNA AETNA 762.35 79 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48578001_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 936.05 97 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48578001_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 665.85 69 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48578001_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 752.7 78 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48578001_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SIHO - ALL PLANS SIHO - ALL PLANS 868.5 90 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48578001_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UMR - ALL PLANS UMR - ALL PLANS 675.5 70 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48578001_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 584.31 60.55 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48578001_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48578001_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48578001_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM HMO ANTHEM HMO 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48578001_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48578001_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 652.34 67.6 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48578001_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48578004_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 627.25 65 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48578004_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 AETNA AETNA 762.35 79 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48578004_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 936.05 97 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48578004_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 665.85 69 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48578004_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 752.7 78 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48578004_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SIHO - ALL PLANS SIHO - ALL PLANS 868.5 90 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48578004_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UMR - ALL PLANS UMR - ALL PLANS 675.5 70 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48578004_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 584.31 60.55 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48578004_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48578004_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48578004_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM HMO ANTHEM HMO 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48578004_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 48578004_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 652.34 67.6 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 48578004_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 584.31 936.05 Review by radiologist of hip joint image 48578010_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 696.8 65 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 48578010_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 AETNA AETNA 846.88 79 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 48578010_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1039.84 97 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 48578010_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 739.68 69 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 48578010_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 836.16 78 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 48578010_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 SIHO - ALL PLANS SIHO - ALL PLANS 964.8 90 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 48578010_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 UMR - ALL PLANS UMR - ALL PLANS 750.4 70 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 48578010_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 649.1 60.55 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 48578010_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 649.1 1039.84 Review by radiologist of hip joint image 48578010_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 649.1 1039.84 Review by radiologist of hip joint image 48578010_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 ANTHEM HMO ANTHEM HMO 999999999 649.1 1039.84 Review by radiologist of hip joint image 48578010_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 649.1 1039.84 Review by radiologist of hip joint image 48578010_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 724.67 67.6 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 48578010_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 649.1 1039.84 Review by radiologist of hip joint image 48578013_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 696.8 65 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 48578013_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 AETNA AETNA 846.88 79 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 48578013_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1039.84 97 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 48578013_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 739.68 69 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 48578013_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 836.16 78 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 48578013_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 SIHO - ALL PLANS SIHO - ALL PLANS 964.8 90 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 48578013_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 UMR - ALL PLANS UMR - ALL PLANS 750.4 70 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 48578013_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 649.1 60.55 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 48578013_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 649.1 1039.84 Review by radiologist of hip joint image 48578013_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 649.1 1039.84 Review by radiologist of hip joint image 48578013_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 ANTHEM HMO ANTHEM HMO 999999999 649.1 1039.84 Review by radiologist of hip joint image 48578013_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 649.1 1039.84 Review by radiologist of hip joint image 48578013_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 724.67 67.6 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 48578013_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 649.1 1039.84 Fluoroscopic guidance for needle placement 48578037_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1107.6 65 999999999 1031.77 1652.88 percent of total billed charges Fluoroscopic guidance for needle placement 48578037_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 AETNA AETNA 1346.16 79 999999999 1031.77 1652.88 percent of total billed charges Fluoroscopic guidance for needle placement 48578037_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1652.88 97 999999999 1031.77 1652.88 percent of total billed charges Fluoroscopic guidance for needle placement 48578037_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1175.76 69 999999999 1031.77 1652.88 percent of total billed charges Fluoroscopic guidance for needle placement 48578037_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1329.12 78 999999999 1031.77 1652.88 percent of total billed charges Fluoroscopic guidance for needle placement 48578037_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 SIHO - ALL PLANS SIHO - ALL PLANS 1533.6 90 999999999 1031.77 1652.88 percent of total billed charges Fluoroscopic guidance for needle placement 48578037_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 UMR - ALL PLANS UMR - ALL PLANS 1192.8 70 999999999 1031.77 1652.88 percent of total billed charges Fluoroscopic guidance for needle placement 48578037_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1031.77 60.55 999999999 1031.77 1652.88 percent of total billed charges Fluoroscopic guidance for needle placement 48578037_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1031.77 1652.88 Fluoroscopic guidance for needle placement 48578037_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1031.77 1652.88 Fluoroscopic guidance for needle placement 48578037_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 ANTHEM HMO ANTHEM HMO 999999999 1031.77 1652.88 Fluoroscopic guidance for needle placement 48578037_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1031.77 1652.88 Fluoroscopic guidance for needle placement 48578037_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1151.9 67.6 999999999 1031.77 1652.88 percent of total billed charges Fluoroscopic guidance for needle placement 48578037_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1031.77 1652.88 Fluoroscopic guidance for needle placement 48578043_1 CDM 0322 RC 77002 HCPCS inpatient 1849 1201.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1201.85 65 999999999 1119.57 1793.53 percent of total billed charges Fluoroscopic guidance for needle placement 48578043_1 CDM 0322 RC 77002 HCPCS inpatient 1849 1201.85 AETNA AETNA 1460.71 79 999999999 1119.57 1793.53 percent of total billed charges Fluoroscopic guidance for needle placement 48578043_1 CDM 0322 RC 77002 HCPCS inpatient 1849 1201.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1793.53 97 999999999 1119.57 1793.53 percent of total billed charges Fluoroscopic guidance for needle placement 48578043_1 CDM 0322 RC 77002 HCPCS inpatient 1849 1201.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1275.81 69 999999999 1119.57 1793.53 percent of total billed charges Fluoroscopic guidance for needle placement 48578043_1 CDM 0322 RC 77002 HCPCS inpatient 1849 1201.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1442.22 78 999999999 1119.57 1793.53 percent of total billed charges Fluoroscopic guidance for needle placement 48578043_1 CDM 0322 RC 77002 HCPCS inpatient 1849 1201.85 SIHO - ALL PLANS SIHO - ALL PLANS 1664.1 90 999999999 1119.57 1793.53 percent of total billed charges Fluoroscopic guidance for needle placement 48578043_1 CDM 0322 RC 77002 HCPCS inpatient 1849 1201.85 UMR - ALL PLANS UMR - ALL PLANS 1294.3 70 999999999 1119.57 1793.53 percent of total billed charges Fluoroscopic guidance for needle placement 48578043_1 CDM 0322 RC 77002 HCPCS inpatient 1849 1201.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1119.57 60.55 999999999 1119.57 1793.53 percent of total billed charges Fluoroscopic guidance for needle placement 48578043_1 CDM 0322 RC 77002 HCPCS inpatient 1849 1201.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1119.57 1793.53 Fluoroscopic guidance for needle placement 48578043_1 CDM 0322 RC 77002 HCPCS inpatient 1849 1201.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1119.57 1793.53 Fluoroscopic guidance for needle placement 48578043_1 CDM 0322 RC 77002 HCPCS inpatient 1849 1201.85 ANTHEM HMO ANTHEM HMO 999999999 1119.57 1793.53 Fluoroscopic guidance for needle placement 48578043_1 CDM 0322 RC 77002 HCPCS inpatient 1849 1201.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1119.57 1793.53 Fluoroscopic guidance for needle placement 48578043_1 CDM 0322 RC 77002 HCPCS inpatient 1849 1201.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1249.92 67.6 999999999 1119.57 1793.53 percent of total billed charges Fluoroscopic guidance for needle placement 48578043_1 CDM 0322 RC 77002 HCPCS inpatient 1849 1201.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1119.57 1793.53 Fluoroscopic guidance for needle placement 48578046_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1107.6 65 999999999 1031.77 1652.88 percent of total billed charges Fluoroscopic guidance for needle placement 48578046_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 AETNA AETNA 1346.16 79 999999999 1031.77 1652.88 percent of total billed charges Fluoroscopic guidance for needle placement 48578046_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1652.88 97 999999999 1031.77 1652.88 percent of total billed charges Fluoroscopic guidance for needle placement 48578046_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1175.76 69 999999999 1031.77 1652.88 percent of total billed charges Fluoroscopic guidance for needle placement 48578046_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1329.12 78 999999999 1031.77 1652.88 percent of total billed charges Fluoroscopic guidance for needle placement 48578046_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 SIHO - ALL PLANS SIHO - ALL PLANS 1533.6 90 999999999 1031.77 1652.88 percent of total billed charges Fluoroscopic guidance for needle placement 48578046_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 UMR - ALL PLANS UMR - ALL PLANS 1192.8 70 999999999 1031.77 1652.88 percent of total billed charges Fluoroscopic guidance for needle placement 48578046_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1031.77 60.55 999999999 1031.77 1652.88 percent of total billed charges Fluoroscopic guidance for needle placement 48578046_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1031.77 1652.88 Fluoroscopic guidance for needle placement 48578046_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1031.77 1652.88 Fluoroscopic guidance for needle placement 48578046_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 ANTHEM HMO ANTHEM HMO 999999999 1031.77 1652.88 Fluoroscopic guidance for needle placement 48578046_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1031.77 1652.88 Fluoroscopic guidance for needle placement 48578046_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1151.9 67.6 999999999 1031.77 1652.88 percent of total billed charges Fluoroscopic guidance for needle placement 48578046_1 CDM 0322 RC 77002 HCPCS inpatient 1704 1107.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1031.77 1652.88 00409-7077-26 - potassium chloride 40 mEq/100 mL IV Sol [JOHN] 48578058_1 CDM 0250 RC 00409-7077-26 NDC inpatient 1 UN 62.4 40.56 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.56 65 999999999 37.78 60.53 percent of total billed charges 00409-7077-26 - potassium chloride 40 mEq/100 mL IV Sol [JOHN] 48578058_1 CDM 0250 RC 00409-7077-26 NDC inpatient 1 UN 62.4 40.56 AETNA AETNA 49.3 79 999999999 37.78 60.53 percent of total billed charges 00409-7077-26 - potassium chloride 40 mEq/100 mL IV Sol [JOHN] 48578058_1 CDM 0250 RC 00409-7077-26 NDC inpatient 1 UN 62.4 40.56 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 60.53 97 999999999 37.78 60.53 percent of total billed charges 00409-7077-26 - potassium chloride 40 mEq/100 mL IV Sol [JOHN] 48578058_1 CDM 0250 RC 00409-7077-26 NDC inpatient 1 UN 62.4 40.56 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.06 69 999999999 37.78 60.53 percent of total billed charges 00409-7077-26 - potassium chloride 40 mEq/100 mL IV Sol [JOHN] 48578058_1 CDM 0250 RC 00409-7077-26 NDC inpatient 1 UN 62.4 40.56 HUMANA - ALL PLANS HUMANA - ALL PLANS 48.67 78 999999999 37.78 60.53 percent of total billed charges 00409-7077-26 - potassium chloride 40 mEq/100 mL IV Sol [JOHN] 48578058_1 CDM 0250 RC 00409-7077-26 NDC inpatient 1 UN 62.4 40.56 SIHO - ALL PLANS SIHO - ALL PLANS 56.16 90 999999999 37.78 60.53 percent of total billed charges 00409-7077-26 - potassium chloride 40 mEq/100 mL IV Sol [JOHN] 48578058_1 CDM 0250 RC 00409-7077-26 NDC inpatient 1 UN 62.4 40.56 UMR - ALL PLANS UMR - ALL PLANS 43.68 70 999999999 37.78 60.53 percent of total billed charges 00409-7077-26 - potassium chloride 40 mEq/100 mL IV Sol [JOHN] 48578058_1 CDM 0250 RC 00409-7077-26 NDC inpatient 1 UN 62.4 40.56 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 37.78 60.55 999999999 37.78 60.53 percent of total billed charges 00409-7077-26 - potassium chloride 40 mEq/100 mL IV Sol [JOHN] 48578058_1 CDM 0250 RC 00409-7077-26 NDC inpatient 1 UN 62.4 40.56 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 37.78 60.53 00409-7077-26 - potassium chloride 40 mEq/100 mL IV Sol [JOHN] 48578058_1 CDM 0250 RC 00409-7077-26 NDC inpatient 1 UN 62.4 40.56 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 37.78 60.53 00409-7077-26 - potassium chloride 40 mEq/100 mL IV Sol [JOHN] 48578058_1 CDM 0250 RC 00409-7077-26 NDC inpatient 1 UN 62.4 40.56 ANTHEM HMO ANTHEM HMO 999999999 37.78 60.53 00409-7077-26 - potassium chloride 40 mEq/100 mL IV Sol [JOHN] 48578058_1 CDM 0250 RC 00409-7077-26 NDC inpatient 1 UN 62.4 40.56 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 37.78 60.53 00409-7077-26 - potassium chloride 40 mEq/100 mL IV Sol [JOHN] 48578058_1 CDM 0250 RC 00409-7077-26 NDC inpatient 1 UN 62.4 40.56 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.18 67.6 999999999 37.78 60.53 percent of total billed charges 00409-7077-26 - potassium chloride 40 mEq/100 mL IV Sol [JOHN] 48578058_1 CDM 0250 RC 00409-7077-26 NDC inpatient 1 UN 62.4 40.56 UHC - ALL PLANS UHC - ALL PLANS 999999999 37.78 60.53 Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578068_1 CDM 0320 RC 50430 HCPCS inpatient 913 593.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 593.45 65 999999999 552.82 885.61 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578068_1 CDM 0320 RC 50430 HCPCS inpatient 913 593.45 AETNA AETNA 721.27 79 999999999 552.82 885.61 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578068_1 CDM 0320 RC 50430 HCPCS inpatient 913 593.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 885.61 97 999999999 552.82 885.61 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578068_1 CDM 0320 RC 50430 HCPCS inpatient 913 593.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 629.97 69 999999999 552.82 885.61 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578068_1 CDM 0320 RC 50430 HCPCS inpatient 913 593.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 712.14 78 999999999 552.82 885.61 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578068_1 CDM 0320 RC 50430 HCPCS inpatient 913 593.45 SIHO - ALL PLANS SIHO - ALL PLANS 821.7 90 999999999 552.82 885.61 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578068_1 CDM 0320 RC 50430 HCPCS inpatient 913 593.45 UMR - ALL PLANS UMR - ALL PLANS 639.1 70 999999999 552.82 885.61 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578068_1 CDM 0320 RC 50430 HCPCS inpatient 913 593.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 552.82 60.55 999999999 552.82 885.61 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578068_1 CDM 0320 RC 50430 HCPCS inpatient 913 593.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 552.82 885.61 Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578068_1 CDM 0320 RC 50430 HCPCS inpatient 913 593.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 552.82 885.61 Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578068_1 CDM 0320 RC 50430 HCPCS inpatient 913 593.45 ANTHEM HMO ANTHEM HMO 999999999 552.82 885.61 Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578068_1 CDM 0320 RC 50430 HCPCS inpatient 913 593.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 552.82 885.61 Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578068_1 CDM 0320 RC 50430 HCPCS inpatient 913 593.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 617.19 67.6 999999999 552.82 885.61 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578068_1 CDM 0320 RC 50430 HCPCS inpatient 913 593.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 552.82 885.61 Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578071_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 287.3 65 999999999 267.63 428.74 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578071_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 AETNA AETNA 349.18 79 999999999 267.63 428.74 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578071_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 428.74 97 999999999 267.63 428.74 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578071_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 304.98 69 999999999 267.63 428.74 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578071_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 344.76 78 999999999 267.63 428.74 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578071_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 SIHO - ALL PLANS SIHO - ALL PLANS 397.8 90 999999999 267.63 428.74 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578071_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 UMR - ALL PLANS UMR - ALL PLANS 309.4 70 999999999 267.63 428.74 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578071_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 267.63 60.55 999999999 267.63 428.74 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578071_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 267.63 428.74 Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578071_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 267.63 428.74 Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578071_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 ANTHEM HMO ANTHEM HMO 999999999 267.63 428.74 Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578071_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 267.63 428.74 Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578071_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 298.79 67.6 999999999 267.63 428.74 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578071_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 267.63 428.74 Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578074_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 287.3 65 999999999 267.63 428.74 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578074_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 AETNA AETNA 349.18 79 999999999 267.63 428.74 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578074_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 428.74 97 999999999 267.63 428.74 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578074_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 304.98 69 999999999 267.63 428.74 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578074_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 344.76 78 999999999 267.63 428.74 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578074_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 SIHO - ALL PLANS SIHO - ALL PLANS 397.8 90 999999999 267.63 428.74 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578074_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 UMR - ALL PLANS UMR - ALL PLANS 309.4 70 999999999 267.63 428.74 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578074_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 267.63 60.55 999999999 267.63 428.74 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578074_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 267.63 428.74 Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578074_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 267.63 428.74 Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578074_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 ANTHEM HMO ANTHEM HMO 999999999 267.63 428.74 Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578074_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 267.63 428.74 Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578074_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 298.79 67.6 999999999 267.63 428.74 percent of total billed charges Injection procedure for imaging of kidney and ureter through new skin access using imaging guidance with review by radiologist 48578074_1 CDM 0361 RC 50430 HCPCS inpatient 442 287.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 267.63 428.74 "Red blood cell antibody detection test, direct" 48578737_1 CDM 0301 RC 86880 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48578737_1 CDM 0301 RC 86880 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48578737_1 CDM 0301 RC 86880 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48578737_1 CDM 0301 RC 86880 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48578737_1 CDM 0301 RC 86880 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48578737_1 CDM 0301 RC 86880 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48578737_1 CDM 0301 RC 86880 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48578737_1 CDM 0301 RC 86880 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48578737_1 CDM 0301 RC 86880 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Red blood cell antibody detection test, direct" 48578737_1 CDM 0301 RC 86880 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Red blood cell antibody detection test, direct" 48578737_1 CDM 0301 RC 86880 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Red blood cell antibody detection test, direct" 48578737_1 CDM 0301 RC 86880 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Red blood cell antibody detection test, direct" 48578737_1 CDM 0301 RC 86880 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Red blood cell antibody detection test, direct" 48578737_1 CDM 0301 RC 86880 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 RIVASTIGMINE 4.6 MG/24HR PATCH 48578763_1 CDM 0250 RC 00781-7304-31 NDC inpatient 1 UN 18.05 11.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.73 65 999999999 10.93 17.51 percent of total billed charges RIVASTIGMINE 4.6 MG/24HR PATCH 48578763_1 CDM 0250 RC 00781-7304-31 NDC inpatient 1 UN 18.05 11.73 AETNA AETNA 14.26 79 999999999 10.93 17.51 percent of total billed charges RIVASTIGMINE 4.6 MG/24HR PATCH 48578763_1 CDM 0250 RC 00781-7304-31 NDC inpatient 1 UN 18.05 11.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.51 97 999999999 10.93 17.51 percent of total billed charges RIVASTIGMINE 4.6 MG/24HR PATCH 48578763_1 CDM 0250 RC 00781-7304-31 NDC inpatient 1 UN 18.05 11.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.45 69 999999999 10.93 17.51 percent of total billed charges RIVASTIGMINE 4.6 MG/24HR PATCH 48578763_1 CDM 0250 RC 00781-7304-31 NDC inpatient 1 UN 18.05 11.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.08 78 999999999 10.93 17.51 percent of total billed charges RIVASTIGMINE 4.6 MG/24HR PATCH 48578763_1 CDM 0250 RC 00781-7304-31 NDC inpatient 1 UN 18.05 11.73 SIHO - ALL PLANS SIHO - ALL PLANS 16.25 90 999999999 10.93 17.51 percent of total billed charges RIVASTIGMINE 4.6 MG/24HR PATCH 48578763_1 CDM 0250 RC 00781-7304-31 NDC inpatient 1 UN 18.05 11.73 UMR - ALL PLANS UMR - ALL PLANS 12.64 70 999999999 10.93 17.51 percent of total billed charges RIVASTIGMINE 4.6 MG/24HR PATCH 48578763_1 CDM 0250 RC 00781-7304-31 NDC inpatient 1 UN 18.05 11.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.93 60.55 999999999 10.93 17.51 percent of total billed charges RIVASTIGMINE 4.6 MG/24HR PATCH 48578763_1 CDM 0250 RC 00781-7304-31 NDC inpatient 1 UN 18.05 11.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.93 17.51 RIVASTIGMINE 4.6 MG/24HR PATCH 48578763_1 CDM 0250 RC 00781-7304-31 NDC inpatient 1 UN 18.05 11.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.93 17.51 RIVASTIGMINE 4.6 MG/24HR PATCH 48578763_1 CDM 0250 RC 00781-7304-31 NDC inpatient 1 UN 18.05 11.73 ANTHEM HMO ANTHEM HMO 999999999 10.93 17.51 RIVASTIGMINE 4.6 MG/24HR PATCH 48578763_1 CDM 0250 RC 00781-7304-31 NDC inpatient 1 UN 18.05 11.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.93 17.51 RIVASTIGMINE 4.6 MG/24HR PATCH 48578763_1 CDM 0250 RC 00781-7304-31 NDC inpatient 1 UN 18.05 11.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.2 67.6 999999999 10.93 17.51 percent of total billed charges RIVASTIGMINE 4.6 MG/24HR PATCH 48578763_1 CDM 0250 RC 00781-7304-31 NDC inpatient 1 UN 18.05 11.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.93 17.51 DILTIAZEM 12HR ER 90 MG CAP 48578778_1 CDM 0250 RC 00378-6090-01 NDC inpatient 1 UN 11.47 7.46 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.46 65 999999999 6.95 11.13 percent of total billed charges DILTIAZEM 12HR ER 90 MG CAP 48578778_1 CDM 0250 RC 00378-6090-01 NDC inpatient 1 UN 11.47 7.46 AETNA AETNA 9.06 79 999999999 6.95 11.13 percent of total billed charges DILTIAZEM 12HR ER 90 MG CAP 48578778_1 CDM 0250 RC 00378-6090-01 NDC inpatient 1 UN 11.47 7.46 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11.13 97 999999999 6.95 11.13 percent of total billed charges DILTIAZEM 12HR ER 90 MG CAP 48578778_1 CDM 0250 RC 00378-6090-01 NDC inpatient 1 UN 11.47 7.46 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.91 69 999999999 6.95 11.13 percent of total billed charges DILTIAZEM 12HR ER 90 MG CAP 48578778_1 CDM 0250 RC 00378-6090-01 NDC inpatient 1 UN 11.47 7.46 HUMANA - ALL PLANS HUMANA - ALL PLANS 8.95 78 999999999 6.95 11.13 percent of total billed charges DILTIAZEM 12HR ER 90 MG CAP 48578778_1 CDM 0250 RC 00378-6090-01 NDC inpatient 1 UN 11.47 7.46 SIHO - ALL PLANS SIHO - ALL PLANS 10.32 90 999999999 6.95 11.13 percent of total billed charges DILTIAZEM 12HR ER 90 MG CAP 48578778_1 CDM 0250 RC 00378-6090-01 NDC inpatient 1 UN 11.47 7.46 UMR - ALL PLANS UMR - ALL PLANS 8.03 70 999999999 6.95 11.13 percent of total billed charges DILTIAZEM 12HR ER 90 MG CAP 48578778_1 CDM 0250 RC 00378-6090-01 NDC inpatient 1 UN 11.47 7.46 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.95 60.55 999999999 6.95 11.13 percent of total billed charges DILTIAZEM 12HR ER 90 MG CAP 48578778_1 CDM 0250 RC 00378-6090-01 NDC inpatient 1 UN 11.47 7.46 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.95 11.13 DILTIAZEM 12HR ER 90 MG CAP 48578778_1 CDM 0250 RC 00378-6090-01 NDC inpatient 1 UN 11.47 7.46 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.95 11.13 DILTIAZEM 12HR ER 90 MG CAP 48578778_1 CDM 0250 RC 00378-6090-01 NDC inpatient 1 UN 11.47 7.46 ANTHEM HMO ANTHEM HMO 999999999 6.95 11.13 DILTIAZEM 12HR ER 90 MG CAP 48578778_1 CDM 0250 RC 00378-6090-01 NDC inpatient 1 UN 11.47 7.46 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.95 11.13 DILTIAZEM 12HR ER 90 MG CAP 48578778_1 CDM 0250 RC 00378-6090-01 NDC inpatient 1 UN 11.47 7.46 CIGNA - ALL PLANS CIGNA - ALL PLANS 7.75 67.6 999999999 6.95 11.13 percent of total billed charges DILTIAZEM 12HR ER 90 MG CAP 48578778_1 CDM 0250 RC 00378-6090-01 NDC inpatient 1 UN 11.47 7.46 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.95 11.13 Nasal smear for eosinophils (allergy related white blood cells) 48579132_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 83.85 65 999999999 78.11 125.13 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579132_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 AETNA AETNA 101.91 79 999999999 78.11 125.13 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579132_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 125.13 97 999999999 78.11 125.13 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579132_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.01 69 999999999 78.11 125.13 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579132_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 100.62 78 999999999 78.11 125.13 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579132_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 SIHO - ALL PLANS SIHO - ALL PLANS 116.1 90 999999999 78.11 125.13 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579132_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 UMR - ALL PLANS UMR - ALL PLANS 90.3 70 999999999 78.11 125.13 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579132_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.11 60.55 999999999 78.11 125.13 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579132_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.11 125.13 Nasal smear for eosinophils (allergy related white blood cells) 48579132_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.11 125.13 Nasal smear for eosinophils (allergy related white blood cells) 48579132_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 ANTHEM HMO ANTHEM HMO 999999999 78.11 125.13 Nasal smear for eosinophils (allergy related white blood cells) 48579132_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.11 125.13 Nasal smear for eosinophils (allergy related white blood cells) 48579132_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.2 67.6 999999999 78.11 125.13 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579132_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.11 125.13 Nasal smear for eosinophils (allergy related white blood cells) 48579134_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 83.85 65 999999999 78.11 125.13 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579134_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 AETNA AETNA 101.91 79 999999999 78.11 125.13 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579134_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 125.13 97 999999999 78.11 125.13 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579134_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.01 69 999999999 78.11 125.13 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579134_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 100.62 78 999999999 78.11 125.13 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579134_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 SIHO - ALL PLANS SIHO - ALL PLANS 116.1 90 999999999 78.11 125.13 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579134_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 UMR - ALL PLANS UMR - ALL PLANS 90.3 70 999999999 78.11 125.13 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579134_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.11 60.55 999999999 78.11 125.13 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579134_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.11 125.13 Nasal smear for eosinophils (allergy related white blood cells) 48579134_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.11 125.13 Nasal smear for eosinophils (allergy related white blood cells) 48579134_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 ANTHEM HMO ANTHEM HMO 999999999 78.11 125.13 Nasal smear for eosinophils (allergy related white blood cells) 48579134_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.11 125.13 Nasal smear for eosinophils (allergy related white blood cells) 48579134_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.2 67.6 999999999 78.11 125.13 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579134_1 CDM 0309 RC 89190 HCPCS inpatient 129 83.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.11 125.13 Nasal smear for eosinophils (allergy related white blood cells) 48579138_1 CDM 0305 RC 89190 HCPCS inpatient 121 78.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 78.65 65 999999999 73.27 117.37 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579138_1 CDM 0305 RC 89190 HCPCS inpatient 121 78.65 AETNA AETNA 95.59 79 999999999 73.27 117.37 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579138_1 CDM 0305 RC 89190 HCPCS inpatient 121 78.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 117.37 97 999999999 73.27 117.37 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579138_1 CDM 0305 RC 89190 HCPCS inpatient 121 78.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 83.49 69 999999999 73.27 117.37 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579138_1 CDM 0305 RC 89190 HCPCS inpatient 121 78.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 94.38 78 999999999 73.27 117.37 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579138_1 CDM 0305 RC 89190 HCPCS inpatient 121 78.65 SIHO - ALL PLANS SIHO - ALL PLANS 108.9 90 999999999 73.27 117.37 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579138_1 CDM 0305 RC 89190 HCPCS inpatient 121 78.65 UMR - ALL PLANS UMR - ALL PLANS 84.7 70 999999999 73.27 117.37 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579138_1 CDM 0305 RC 89190 HCPCS inpatient 121 78.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.27 60.55 999999999 73.27 117.37 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579138_1 CDM 0305 RC 89190 HCPCS inpatient 121 78.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.27 117.37 Nasal smear for eosinophils (allergy related white blood cells) 48579138_1 CDM 0305 RC 89190 HCPCS inpatient 121 78.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.27 117.37 Nasal smear for eosinophils (allergy related white blood cells) 48579138_1 CDM 0305 RC 89190 HCPCS inpatient 121 78.65 ANTHEM HMO ANTHEM HMO 999999999 73.27 117.37 Nasal smear for eosinophils (allergy related white blood cells) 48579138_1 CDM 0305 RC 89190 HCPCS inpatient 121 78.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.27 117.37 Nasal smear for eosinophils (allergy related white blood cells) 48579138_1 CDM 0305 RC 89190 HCPCS inpatient 121 78.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.8 67.6 999999999 73.27 117.37 percent of total billed charges Nasal smear for eosinophils (allergy related white blood cells) 48579138_1 CDM 0305 RC 89190 HCPCS inpatient 121 78.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.27 117.37 "Insulin measurement, total" 48579682_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 48579682_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 48579682_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 48579682_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 48579682_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 48579682_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 48579682_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 48579682_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 48579682_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 "Insulin measurement, total" 48579682_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 "Insulin measurement, total" 48579682_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 "Insulin measurement, total" 48579682_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 "Insulin measurement, total" 48579682_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 48579682_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 Sleep study in sleep lab (6 years or older) 48580348_1 CDM 0740 RC 95810 HCPCS inpatient 6936 4508.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 4508.4 65 999999999 4199.75 6727.92 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580348_1 CDM 0740 RC 95810 HCPCS inpatient 6936 4508.4 AETNA AETNA 5479.44 79 999999999 4199.75 6727.92 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580348_1 CDM 0740 RC 95810 HCPCS inpatient 6936 4508.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6727.92 97 999999999 4199.75 6727.92 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580348_1 CDM 0740 RC 95810 HCPCS inpatient 6936 4508.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 4785.84 69 999999999 4199.75 6727.92 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580348_1 CDM 0740 RC 95810 HCPCS inpatient 6936 4508.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 5410.08 78 999999999 4199.75 6727.92 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580348_1 CDM 0740 RC 95810 HCPCS inpatient 6936 4508.4 SIHO - ALL PLANS SIHO - ALL PLANS 6242.4 90 999999999 4199.75 6727.92 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580348_1 CDM 0740 RC 95810 HCPCS inpatient 6936 4508.4 UMR - ALL PLANS UMR - ALL PLANS 4855.2 70 999999999 4199.75 6727.92 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580348_1 CDM 0740 RC 95810 HCPCS inpatient 6936 4508.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4199.75 60.55 999999999 4199.75 6727.92 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580348_1 CDM 0740 RC 95810 HCPCS inpatient 6936 4508.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4199.75 6727.92 Sleep study in sleep lab (6 years or older) 48580348_1 CDM 0740 RC 95810 HCPCS inpatient 6936 4508.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4199.75 6727.92 Sleep study in sleep lab (6 years or older) 48580348_1 CDM 0740 RC 95810 HCPCS inpatient 6936 4508.4 ANTHEM HMO ANTHEM HMO 999999999 4199.75 6727.92 Sleep study in sleep lab (6 years or older) 48580348_1 CDM 0740 RC 95810 HCPCS inpatient 6936 4508.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4199.75 6727.92 Sleep study in sleep lab (6 years or older) 48580348_1 CDM 0740 RC 95810 HCPCS inpatient 6936 4508.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 4688.74 67.6 999999999 4199.75 6727.92 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580348_1 CDM 0740 RC 95810 HCPCS inpatient 6936 4508.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 4199.75 6727.92 Sleep study in sleep lab (6 years or older) 48580354_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1690.65 65 999999999 1574.91 2522.97 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580354_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 AETNA AETNA 2054.79 79 999999999 1574.91 2522.97 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580354_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2522.97 97 999999999 1574.91 2522.97 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580354_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1794.69 69 999999999 1574.91 2522.97 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580354_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2028.78 78 999999999 1574.91 2522.97 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580354_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 SIHO - ALL PLANS SIHO - ALL PLANS 2340.9 90 999999999 1574.91 2522.97 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580354_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 UMR - ALL PLANS UMR - ALL PLANS 1820.7 70 999999999 1574.91 2522.97 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580354_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1574.91 60.55 999999999 1574.91 2522.97 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580354_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1574.91 2522.97 Sleep study in sleep lab (6 years or older) 48580354_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1574.91 2522.97 Sleep study in sleep lab (6 years or older) 48580354_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 ANTHEM HMO ANTHEM HMO 999999999 1574.91 2522.97 Sleep study in sleep lab (6 years or older) 48580354_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1574.91 2522.97 Sleep study in sleep lab (6 years or older) 48580354_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1758.28 67.6 999999999 1574.91 2522.97 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580354_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1574.91 2522.97 Sleep study in sleep lab (6 years or older) 48580355_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1690.65 65 999999999 1574.91 2522.97 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580355_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 AETNA AETNA 2054.79 79 999999999 1574.91 2522.97 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580355_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2522.97 97 999999999 1574.91 2522.97 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580355_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1794.69 69 999999999 1574.91 2522.97 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580355_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2028.78 78 999999999 1574.91 2522.97 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580355_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 SIHO - ALL PLANS SIHO - ALL PLANS 2340.9 90 999999999 1574.91 2522.97 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580355_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 UMR - ALL PLANS UMR - ALL PLANS 1820.7 70 999999999 1574.91 2522.97 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580355_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1574.91 60.55 999999999 1574.91 2522.97 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580355_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1574.91 2522.97 Sleep study in sleep lab (6 years or older) 48580355_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1574.91 2522.97 Sleep study in sleep lab (6 years or older) 48580355_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 ANTHEM HMO ANTHEM HMO 999999999 1574.91 2522.97 Sleep study in sleep lab (6 years or older) 48580355_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1574.91 2522.97 Sleep study in sleep lab (6 years or older) 48580355_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1758.28 67.6 999999999 1574.91 2522.97 percent of total billed charges Sleep study in sleep lab (6 years or older) 48580355_1 CDM 0740 RC 95810 HCPCS inpatient 2601 1690.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1574.91 2522.97 "Sleep study, multiple trials" 48580356_1 CDM 0740 RC 95805 HCPCS inpatient 4707 3059.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 3059.55 65 999999999 2850.09 4565.79 percent of total billed charges "Sleep study, multiple trials" 48580356_1 CDM 0740 RC 95805 HCPCS inpatient 4707 3059.55 AETNA AETNA 3718.53 79 999999999 2850.09 4565.79 percent of total billed charges "Sleep study, multiple trials" 48580356_1 CDM 0740 RC 95805 HCPCS inpatient 4707 3059.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4565.79 97 999999999 2850.09 4565.79 percent of total billed charges "Sleep study, multiple trials" 48580356_1 CDM 0740 RC 95805 HCPCS inpatient 4707 3059.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 3247.83 69 999999999 2850.09 4565.79 percent of total billed charges "Sleep study, multiple trials" 48580356_1 CDM 0740 RC 95805 HCPCS inpatient 4707 3059.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 3671.46 78 999999999 2850.09 4565.79 percent of total billed charges "Sleep study, multiple trials" 48580356_1 CDM 0740 RC 95805 HCPCS inpatient 4707 3059.55 SIHO - ALL PLANS SIHO - ALL PLANS 4236.3 90 999999999 2850.09 4565.79 percent of total billed charges "Sleep study, multiple trials" 48580356_1 CDM 0740 RC 95805 HCPCS inpatient 4707 3059.55 UMR - ALL PLANS UMR - ALL PLANS 3294.9 70 999999999 2850.09 4565.79 percent of total billed charges "Sleep study, multiple trials" 48580356_1 CDM 0740 RC 95805 HCPCS inpatient 4707 3059.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2850.09 60.55 999999999 2850.09 4565.79 percent of total billed charges "Sleep study, multiple trials" 48580356_1 CDM 0740 RC 95805 HCPCS inpatient 4707 3059.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2850.09 4565.79 "Sleep study, multiple trials" 48580356_1 CDM 0740 RC 95805 HCPCS inpatient 4707 3059.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2850.09 4565.79 "Sleep study, multiple trials" 48580356_1 CDM 0740 RC 95805 HCPCS inpatient 4707 3059.55 ANTHEM HMO ANTHEM HMO 999999999 2850.09 4565.79 "Sleep study, multiple trials" 48580356_1 CDM 0740 RC 95805 HCPCS inpatient 4707 3059.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2850.09 4565.79 "Sleep study, multiple trials" 48580356_1 CDM 0740 RC 95805 HCPCS inpatient 4707 3059.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 3181.93 67.6 999999999 2850.09 4565.79 percent of total billed charges "Sleep study, multiple trials" 48580356_1 CDM 0740 RC 95805 HCPCS inpatient 4707 3059.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 2850.09 4565.79 "Sleep study, multiple trials" 48580357_1 CDM 0740 RC 95805 HCPCS inpatient 5178 3365.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 3365.7 65 999999999 3135.28 5022.66 percent of total billed charges "Sleep study, multiple trials" 48580357_1 CDM 0740 RC 95805 HCPCS inpatient 5178 3365.7 AETNA AETNA 4090.62 79 999999999 3135.28 5022.66 percent of total billed charges "Sleep study, multiple trials" 48580357_1 CDM 0740 RC 95805 HCPCS inpatient 5178 3365.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5022.66 97 999999999 3135.28 5022.66 percent of total billed charges "Sleep study, multiple trials" 48580357_1 CDM 0740 RC 95805 HCPCS inpatient 5178 3365.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 3572.82 69 999999999 3135.28 5022.66 percent of total billed charges "Sleep study, multiple trials" 48580357_1 CDM 0740 RC 95805 HCPCS inpatient 5178 3365.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 4038.84 78 999999999 3135.28 5022.66 percent of total billed charges "Sleep study, multiple trials" 48580357_1 CDM 0740 RC 95805 HCPCS inpatient 5178 3365.7 SIHO - ALL PLANS SIHO - ALL PLANS 4660.2 90 999999999 3135.28 5022.66 percent of total billed charges "Sleep study, multiple trials" 48580357_1 CDM 0740 RC 95805 HCPCS inpatient 5178 3365.7 UMR - ALL PLANS UMR - ALL PLANS 3624.6 70 999999999 3135.28 5022.66 percent of total billed charges "Sleep study, multiple trials" 48580357_1 CDM 0740 RC 95805 HCPCS inpatient 5178 3365.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3135.28 60.55 999999999 3135.28 5022.66 percent of total billed charges "Sleep study, multiple trials" 48580357_1 CDM 0740 RC 95805 HCPCS inpatient 5178 3365.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3135.28 5022.66 "Sleep study, multiple trials" 48580357_1 CDM 0740 RC 95805 HCPCS inpatient 5178 3365.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3135.28 5022.66 "Sleep study, multiple trials" 48580357_1 CDM 0740 RC 95805 HCPCS inpatient 5178 3365.7 ANTHEM HMO ANTHEM HMO 999999999 3135.28 5022.66 "Sleep study, multiple trials" 48580357_1 CDM 0740 RC 95805 HCPCS inpatient 5178 3365.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3135.28 5022.66 "Sleep study, multiple trials" 48580357_1 CDM 0740 RC 95805 HCPCS inpatient 5178 3365.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 3500.33 67.6 999999999 3135.28 5022.66 percent of total billed charges "Sleep study, multiple trials" 48580357_1 CDM 0740 RC 95805 HCPCS inpatient 5178 3365.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 3135.28 5022.66 Sleep study in sleep lab with continuous airway pressure (6 years or older) 48580358_1 CDM 0740 RC 95811 HCPCS inpatient 7838 5094.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 5094.7 65 999999999 4745.91 7602.86 percent of total billed charges Sleep study in sleep lab with continuous airway pressure (6 years or older) 48580358_1 CDM 0740 RC 95811 HCPCS inpatient 7838 5094.7 AETNA AETNA 6192.02 79 999999999 4745.91 7602.86 percent of total billed charges Sleep study in sleep lab with continuous airway pressure (6 years or older) 48580358_1 CDM 0740 RC 95811 HCPCS inpatient 7838 5094.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7602.86 97 999999999 4745.91 7602.86 percent of total billed charges Sleep study in sleep lab with continuous airway pressure (6 years or older) 48580358_1 CDM 0740 RC 95811 HCPCS inpatient 7838 5094.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 5408.22 69 999999999 4745.91 7602.86 percent of total billed charges Sleep study in sleep lab with continuous airway pressure (6 years or older) 48580358_1 CDM 0740 RC 95811 HCPCS inpatient 7838 5094.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 6113.64 78 999999999 4745.91 7602.86 percent of total billed charges Sleep study in sleep lab with continuous airway pressure (6 years or older) 48580358_1 CDM 0740 RC 95811 HCPCS inpatient 7838 5094.7 SIHO - ALL PLANS SIHO - ALL PLANS 7054.2 90 999999999 4745.91 7602.86 percent of total billed charges Sleep study in sleep lab with continuous airway pressure (6 years or older) 48580358_1 CDM 0740 RC 95811 HCPCS inpatient 7838 5094.7 UMR - ALL PLANS UMR - ALL PLANS 5486.6 70 999999999 4745.91 7602.86 percent of total billed charges Sleep study in sleep lab with continuous airway pressure (6 years or older) 48580358_1 CDM 0740 RC 95811 HCPCS inpatient 7838 5094.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4745.91 60.55 999999999 4745.91 7602.86 percent of total billed charges Sleep study in sleep lab with continuous airway pressure (6 years or older) 48580358_1 CDM 0740 RC 95811 HCPCS inpatient 7838 5094.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4745.91 7602.86 Sleep study in sleep lab with continuous airway pressure (6 years or older) 48580358_1 CDM 0740 RC 95811 HCPCS inpatient 7838 5094.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4745.91 7602.86 Sleep study in sleep lab with continuous airway pressure (6 years or older) 48580358_1 CDM 0740 RC 95811 HCPCS inpatient 7838 5094.7 ANTHEM HMO ANTHEM HMO 999999999 4745.91 7602.86 Sleep study in sleep lab with continuous airway pressure (6 years or older) 48580358_1 CDM 0740 RC 95811 HCPCS inpatient 7838 5094.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4745.91 7602.86 Sleep study in sleep lab with continuous airway pressure (6 years or older) 48580358_1 CDM 0740 RC 95811 HCPCS inpatient 7838 5094.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 5298.49 67.6 999999999 4745.91 7602.86 percent of total billed charges Sleep study in sleep lab with continuous airway pressure (6 years or older) 48580358_1 CDM 0740 RC 95811 HCPCS inpatient 7838 5094.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 4745.91 7602.86 "HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION" 48580360_1 CDM 0740 RC G0399 HCPCS inpatient 1060 689 SELF PAY DISCOUNT SELF PAY DISCOUNT 689 65 999999999 641.83 1028.2 percent of total billed charges "HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION" 48580360_1 CDM 0740 RC G0399 HCPCS inpatient 1060 689 AETNA AETNA 837.4 79 999999999 641.83 1028.2 percent of total billed charges "HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION" 48580360_1 CDM 0740 RC G0399 HCPCS inpatient 1060 689 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1028.2 97 999999999 641.83 1028.2 percent of total billed charges "HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION" 48580360_1 CDM 0740 RC G0399 HCPCS inpatient 1060 689 ENCORE - ALL PLANS ENCORE - ALL PLANS 731.4 69 999999999 641.83 1028.2 percent of total billed charges "HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION" 48580360_1 CDM 0740 RC G0399 HCPCS inpatient 1060 689 HUMANA - ALL PLANS HUMANA - ALL PLANS 826.8 78 999999999 641.83 1028.2 percent of total billed charges "HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION" 48580360_1 CDM 0740 RC G0399 HCPCS inpatient 1060 689 SIHO - ALL PLANS SIHO - ALL PLANS 954 90 999999999 641.83 1028.2 percent of total billed charges "HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION" 48580360_1 CDM 0740 RC G0399 HCPCS inpatient 1060 689 UMR - ALL PLANS UMR - ALL PLANS 742 70 999999999 641.83 1028.2 percent of total billed charges "HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION" 48580360_1 CDM 0740 RC G0399 HCPCS inpatient 1060 689 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 641.83 60.55 999999999 641.83 1028.2 percent of total billed charges "HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION" 48580360_1 CDM 0740 RC G0399 HCPCS inpatient 1060 689 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 641.83 1028.2 "HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION" 48580360_1 CDM 0740 RC G0399 HCPCS inpatient 1060 689 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 641.83 1028.2 "HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION" 48580360_1 CDM 0740 RC G0399 HCPCS inpatient 1060 689 ANTHEM HMO ANTHEM HMO 999999999 641.83 1028.2 "HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION" 48580360_1 CDM 0740 RC G0399 HCPCS inpatient 1060 689 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 641.83 1028.2 "HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION" 48580360_1 CDM 0740 RC G0399 HCPCS inpatient 1060 689 CIGNA - ALL PLANS CIGNA - ALL PLANS 716.56 67.6 999999999 641.83 1028.2 percent of total billed charges "HOME SLEEP TEST (HST) WITH TYPE III PORTABLE MONITOR, UNATTENDED; MINIMUM OF 4 CHANNELS: 2 RESPIRATORY MOVEMENT/AIRFLOW, 1 ECG/HEART RATE AND 1 OXYGEN SATURATION" 48580360_1 CDM 0740 RC G0399 HCPCS inpatient 1060 689 UHC - ALL PLANS UHC - ALL PLANS 999999999 641.83 1028.2 "Sleep study including heart rate, breathing, and sleep time" 48580361_1 CDM 0740 RC 95800 HCPCS inpatient 964 626.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 626.6 65 999999999 583.7 935.08 percent of total billed charges "Sleep study including heart rate, breathing, and sleep time" 48580361_1 CDM 0740 RC 95800 HCPCS inpatient 964 626.6 AETNA AETNA 761.56 79 999999999 583.7 935.08 percent of total billed charges "Sleep study including heart rate, breathing, and sleep time" 48580361_1 CDM 0740 RC 95800 HCPCS inpatient 964 626.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 935.08 97 999999999 583.7 935.08 percent of total billed charges "Sleep study including heart rate, breathing, and sleep time" 48580361_1 CDM 0740 RC 95800 HCPCS inpatient 964 626.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 665.16 69 999999999 583.7 935.08 percent of total billed charges "Sleep study including heart rate, breathing, and sleep time" 48580361_1 CDM 0740 RC 95800 HCPCS inpatient 964 626.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 751.92 78 999999999 583.7 935.08 percent of total billed charges "Sleep study including heart rate, breathing, and sleep time" 48580361_1 CDM 0740 RC 95800 HCPCS inpatient 964 626.6 SIHO - ALL PLANS SIHO - ALL PLANS 867.6 90 999999999 583.7 935.08 percent of total billed charges "Sleep study including heart rate, breathing, and sleep time" 48580361_1 CDM 0740 RC 95800 HCPCS inpatient 964 626.6 UMR - ALL PLANS UMR - ALL PLANS 674.8 70 999999999 583.7 935.08 percent of total billed charges "Sleep study including heart rate, breathing, and sleep time" 48580361_1 CDM 0740 RC 95800 HCPCS inpatient 964 626.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 583.7 60.55 999999999 583.7 935.08 percent of total billed charges "Sleep study including heart rate, breathing, and sleep time" 48580361_1 CDM 0740 RC 95800 HCPCS inpatient 964 626.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 583.7 935.08 "Sleep study including heart rate, breathing, and sleep time" 48580361_1 CDM 0740 RC 95800 HCPCS inpatient 964 626.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 583.7 935.08 "Sleep study including heart rate, breathing, and sleep time" 48580361_1 CDM 0740 RC 95800 HCPCS inpatient 964 626.6 ANTHEM HMO ANTHEM HMO 999999999 583.7 935.08 "Sleep study including heart rate, breathing, and sleep time" 48580361_1 CDM 0740 RC 95800 HCPCS inpatient 964 626.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 583.7 935.08 "Sleep study including heart rate, breathing, and sleep time" 48580361_1 CDM 0740 RC 95800 HCPCS inpatient 964 626.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 651.66 67.6 999999999 583.7 935.08 percent of total billed charges "Sleep study including heart rate, breathing, and sleep time" 48580361_1 CDM 0740 RC 95800 HCPCS inpatient 964 626.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 583.7 935.08 "Removal of foreign body of foot tissue, accessed beneath the skin" 48580549_1 CDM 0450 RC 28190 HCPCS inpatient 2600 1690 SELF PAY DISCOUNT SELF PAY DISCOUNT 1690 65 999999999 1574.3 2522 percent of total billed charges "Removal of foreign body of foot tissue, accessed beneath the skin" 48580549_1 CDM 0450 RC 28190 HCPCS inpatient 2600 1690 AETNA AETNA 2054 79 999999999 1574.3 2522 percent of total billed charges "Removal of foreign body of foot tissue, accessed beneath the skin" 48580549_1 CDM 0450 RC 28190 HCPCS inpatient 2600 1690 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2522 97 999999999 1574.3 2522 percent of total billed charges "Removal of foreign body of foot tissue, accessed beneath the skin" 48580549_1 CDM 0450 RC 28190 HCPCS inpatient 2600 1690 ENCORE - ALL PLANS ENCORE - ALL PLANS 1794 69 999999999 1574.3 2522 percent of total billed charges "Removal of foreign body of foot tissue, accessed beneath the skin" 48580549_1 CDM 0450 RC 28190 HCPCS inpatient 2600 1690 HUMANA - ALL PLANS HUMANA - ALL PLANS 2028 78 999999999 1574.3 2522 percent of total billed charges "Removal of foreign body of foot tissue, accessed beneath the skin" 48580549_1 CDM 0450 RC 28190 HCPCS inpatient 2600 1690 SIHO - ALL PLANS SIHO - ALL PLANS 2340 90 999999999 1574.3 2522 percent of total billed charges "Removal of foreign body of foot tissue, accessed beneath the skin" 48580549_1 CDM 0450 RC 28190 HCPCS inpatient 2600 1690 UMR - ALL PLANS UMR - ALL PLANS 1820 70 999999999 1574.3 2522 percent of total billed charges "Removal of foreign body of foot tissue, accessed beneath the skin" 48580549_1 CDM 0450 RC 28190 HCPCS inpatient 2600 1690 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1574.3 60.55 999999999 1574.3 2522 percent of total billed charges "Removal of foreign body of foot tissue, accessed beneath the skin" 48580549_1 CDM 0450 RC 28190 HCPCS inpatient 2600 1690 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1574.3 2522 "Removal of foreign body of foot tissue, accessed beneath the skin" 48580549_1 CDM 0450 RC 28190 HCPCS inpatient 2600 1690 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1574.3 2522 "Removal of foreign body of foot tissue, accessed beneath the skin" 48580549_1 CDM 0450 RC 28190 HCPCS inpatient 2600 1690 ANTHEM HMO ANTHEM HMO 999999999 1574.3 2522 "Removal of foreign body of foot tissue, accessed beneath the skin" 48580549_1 CDM 0450 RC 28190 HCPCS inpatient 2600 1690 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1574.3 2522 "Removal of foreign body of foot tissue, accessed beneath the skin" 48580549_1 CDM 0450 RC 28190 HCPCS inpatient 2600 1690 CIGNA - ALL PLANS CIGNA - ALL PLANS 1757.6 67.6 999999999 1574.3 2522 percent of total billed charges "Removal of foreign body of foot tissue, accessed beneath the skin" 48580549_1 CDM 0450 RC 28190 HCPCS inpatient 2600 1690 UHC - ALL PLANS UHC - ALL PLANS 999999999 1574.3 2522 99999-9999-79 - Amiodarone Premix Additive [JOHN] 48580702_1 CDM 0259 RC 99999-9999-79 NDC inpatient 1 UN 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges 99999-9999-79 - Amiodarone Premix Additive [JOHN] 48580702_1 CDM 0259 RC 99999-9999-79 NDC inpatient 1 UN 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges 99999-9999-79 - Amiodarone Premix Additive [JOHN] 48580702_1 CDM 0259 RC 99999-9999-79 NDC inpatient 1 UN 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges 99999-9999-79 - Amiodarone Premix Additive [JOHN] 48580702_1 CDM 0259 RC 99999-9999-79 NDC inpatient 1 UN 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges 99999-9999-79 - Amiodarone Premix Additive [JOHN] 48580702_1 CDM 0259 RC 99999-9999-79 NDC inpatient 1 UN 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges 99999-9999-79 - Amiodarone Premix Additive [JOHN] 48580702_1 CDM 0259 RC 99999-9999-79 NDC inpatient 1 UN 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges 99999-9999-79 - Amiodarone Premix Additive [JOHN] 48580702_1 CDM 0259 RC 99999-9999-79 NDC inpatient 1 UN 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges 99999-9999-79 - Amiodarone Premix Additive [JOHN] 48580702_1 CDM 0259 RC 99999-9999-79 NDC inpatient 1 UN 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges 99999-9999-79 - Amiodarone Premix Additive [JOHN] 48580702_1 CDM 0259 RC 99999-9999-79 NDC inpatient 1 UN 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 99999-9999-79 - Amiodarone Premix Additive [JOHN] 48580702_1 CDM 0259 RC 99999-9999-79 NDC inpatient 1 UN 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 99999-9999-79 - Amiodarone Premix Additive [JOHN] 48580702_1 CDM 0259 RC 99999-9999-79 NDC inpatient 1 UN 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 99999-9999-79 - Amiodarone Premix Additive [JOHN] 48580702_1 CDM 0259 RC 99999-9999-79 NDC inpatient 1 UN 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 99999-9999-79 - Amiodarone Premix Additive [JOHN] 48580702_1 CDM 0259 RC 99999-9999-79 NDC inpatient 1 UN 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges 99999-9999-79 - Amiodarone Premix Additive [JOHN] 48580702_1 CDM 0259 RC 99999-9999-79 NDC inpatient 1 UN 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 99999-9999-75 - Morphine Premix Additive [JOHN] 48580708_1 CDM 0259 RC 99999-9999-75 NDC inpatient 1 UN 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges 99999-9999-75 - Morphine Premix Additive [JOHN] 48580708_1 CDM 0259 RC 99999-9999-75 NDC inpatient 1 UN 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges 99999-9999-75 - Morphine Premix Additive [JOHN] 48580708_1 CDM 0259 RC 99999-9999-75 NDC inpatient 1 UN 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges 99999-9999-75 - Morphine Premix Additive [JOHN] 48580708_1 CDM 0259 RC 99999-9999-75 NDC inpatient 1 UN 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges 99999-9999-75 - Morphine Premix Additive [JOHN] 48580708_1 CDM 0259 RC 99999-9999-75 NDC inpatient 1 UN 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges 99999-9999-75 - Morphine Premix Additive [JOHN] 48580708_1 CDM 0259 RC 99999-9999-75 NDC inpatient 1 UN 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges 99999-9999-75 - Morphine Premix Additive [JOHN] 48580708_1 CDM 0259 RC 99999-9999-75 NDC inpatient 1 UN 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges 99999-9999-75 - Morphine Premix Additive [JOHN] 48580708_1 CDM 0259 RC 99999-9999-75 NDC inpatient 1 UN 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges 99999-9999-75 - Morphine Premix Additive [JOHN] 48580708_1 CDM 0259 RC 99999-9999-75 NDC inpatient 1 UN 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 99999-9999-75 - Morphine Premix Additive [JOHN] 48580708_1 CDM 0259 RC 99999-9999-75 NDC inpatient 1 UN 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 99999-9999-75 - Morphine Premix Additive [JOHN] 48580708_1 CDM 0259 RC 99999-9999-75 NDC inpatient 1 UN 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 99999-9999-75 - Morphine Premix Additive [JOHN] 48580708_1 CDM 0259 RC 99999-9999-75 NDC inpatient 1 UN 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 99999-9999-75 - Morphine Premix Additive [JOHN] 48580708_1 CDM 0259 RC 99999-9999-75 NDC inpatient 1 UN 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges 99999-9999-75 - Morphine Premix Additive [JOHN] 48580708_1 CDM 0259 RC 99999-9999-75 NDC inpatient 1 UN 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 99999-9999-74 - Norepinephrine Premix Additve [JOHN] 48580709_1 CDM 0259 RC 99999-9999-74 NDC inpatient 1 UN 6.25 4.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.06 65 999999999 3.78 6.06 percent of total billed charges 99999-9999-74 - Norepinephrine Premix Additve [JOHN] 48580709_1 CDM 0259 RC 99999-9999-74 NDC inpatient 1 UN 6.25 4.06 AETNA AETNA 4.94 79 999999999 3.78 6.06 percent of total billed charges 99999-9999-74 - Norepinephrine Premix Additve [JOHN] 48580709_1 CDM 0259 RC 99999-9999-74 NDC inpatient 1 UN 6.25 4.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.06 97 999999999 3.78 6.06 percent of total billed charges 99999-9999-74 - Norepinephrine Premix Additve [JOHN] 48580709_1 CDM 0259 RC 99999-9999-74 NDC inpatient 1 UN 6.25 4.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.31 69 999999999 3.78 6.06 percent of total billed charges 99999-9999-74 - Norepinephrine Premix Additve [JOHN] 48580709_1 CDM 0259 RC 99999-9999-74 NDC inpatient 1 UN 6.25 4.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.88 78 999999999 3.78 6.06 percent of total billed charges 99999-9999-74 - Norepinephrine Premix Additve [JOHN] 48580709_1 CDM 0259 RC 99999-9999-74 NDC inpatient 1 UN 6.25 4.06 SIHO - ALL PLANS SIHO - ALL PLANS 5.63 90 999999999 3.78 6.06 percent of total billed charges 99999-9999-74 - Norepinephrine Premix Additve [JOHN] 48580709_1 CDM 0259 RC 99999-9999-74 NDC inpatient 1 UN 6.25 4.06 UMR - ALL PLANS UMR - ALL PLANS 4.38 70 999999999 3.78 6.06 percent of total billed charges 99999-9999-74 - Norepinephrine Premix Additve [JOHN] 48580709_1 CDM 0259 RC 99999-9999-74 NDC inpatient 1 UN 6.25 4.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.78 60.55 999999999 3.78 6.06 percent of total billed charges 99999-9999-74 - Norepinephrine Premix Additve [JOHN] 48580709_1 CDM 0259 RC 99999-9999-74 NDC inpatient 1 UN 6.25 4.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.78 6.06 99999-9999-74 - Norepinephrine Premix Additve [JOHN] 48580709_1 CDM 0259 RC 99999-9999-74 NDC inpatient 1 UN 6.25 4.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.78 6.06 99999-9999-74 - Norepinephrine Premix Additve [JOHN] 48580709_1 CDM 0259 RC 99999-9999-74 NDC inpatient 1 UN 6.25 4.06 ANTHEM HMO ANTHEM HMO 999999999 3.78 6.06 99999-9999-74 - Norepinephrine Premix Additve [JOHN] 48580709_1 CDM 0259 RC 99999-9999-74 NDC inpatient 1 UN 6.25 4.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.78 6.06 99999-9999-74 - Norepinephrine Premix Additve [JOHN] 48580709_1 CDM 0259 RC 99999-9999-74 NDC inpatient 1 UN 6.25 4.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.23 67.6 999999999 3.78 6.06 percent of total billed charges 99999-9999-74 - Norepinephrine Premix Additve [JOHN] 48580709_1 CDM 0259 RC 99999-9999-74 NDC inpatient 1 UN 6.25 4.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.78 6.06 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48580710_1 CDM 0259 RC 99999-9999-73 NDC J2590 HCPCS inpatient 3 UN 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48580710_1 CDM 0259 RC 99999-9999-73 NDC J2590 HCPCS inpatient 3 UN 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48580710_1 CDM 0259 RC 99999-9999-73 NDC J2590 HCPCS inpatient 3 UN 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48580710_1 CDM 0259 RC 99999-9999-73 NDC J2590 HCPCS inpatient 3 UN 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48580710_1 CDM 0259 RC 99999-9999-73 NDC J2590 HCPCS inpatient 3 UN 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48580710_1 CDM 0259 RC 99999-9999-73 NDC J2590 HCPCS inpatient 3 UN 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48580710_1 CDM 0259 RC 99999-9999-73 NDC J2590 HCPCS inpatient 3 UN 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48580710_1 CDM 0259 RC 99999-9999-73 NDC J2590 HCPCS inpatient 3 UN 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48580710_1 CDM 0259 RC 99999-9999-73 NDC J2590 HCPCS inpatient 3 UN 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48580710_1 CDM 0259 RC 99999-9999-73 NDC J2590 HCPCS inpatient 3 UN 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48580710_1 CDM 0259 RC 99999-9999-73 NDC J2590 HCPCS inpatient 3 UN 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48580710_1 CDM 0259 RC 99999-9999-73 NDC J2590 HCPCS inpatient 3 UN 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48580710_1 CDM 0259 RC 99999-9999-73 NDC J2590 HCPCS inpatient 3 UN 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 48580710_1 CDM 0259 RC 99999-9999-73 NDC J2590 HCPCS inpatient 3 UN 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 99999-9999-72 - Magnesium Sulfate Premix Additive [JOHN] 48580744_1 CDM 0259 RC 99999-9999-72 NDC inpatient 1 UN 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges 99999-9999-72 - Magnesium Sulfate Premix Additive [JOHN] 48580744_1 CDM 0259 RC 99999-9999-72 NDC inpatient 1 UN 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges 99999-9999-72 - Magnesium Sulfate Premix Additive [JOHN] 48580744_1 CDM 0259 RC 99999-9999-72 NDC inpatient 1 UN 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges 99999-9999-72 - Magnesium Sulfate Premix Additive [JOHN] 48580744_1 CDM 0259 RC 99999-9999-72 NDC inpatient 1 UN 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges 99999-9999-72 - Magnesium Sulfate Premix Additive [JOHN] 48580744_1 CDM 0259 RC 99999-9999-72 NDC inpatient 1 UN 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges 99999-9999-72 - Magnesium Sulfate Premix Additive [JOHN] 48580744_1 CDM 0259 RC 99999-9999-72 NDC inpatient 1 UN 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges 99999-9999-72 - Magnesium Sulfate Premix Additive [JOHN] 48580744_1 CDM 0259 RC 99999-9999-72 NDC inpatient 1 UN 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges 99999-9999-72 - Magnesium Sulfate Premix Additive [JOHN] 48580744_1 CDM 0259 RC 99999-9999-72 NDC inpatient 1 UN 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges 99999-9999-72 - Magnesium Sulfate Premix Additive [JOHN] 48580744_1 CDM 0259 RC 99999-9999-72 NDC inpatient 1 UN 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 99999-9999-72 - Magnesium Sulfate Premix Additive [JOHN] 48580744_1 CDM 0259 RC 99999-9999-72 NDC inpatient 1 UN 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 99999-9999-72 - Magnesium Sulfate Premix Additive [JOHN] 48580744_1 CDM 0259 RC 99999-9999-72 NDC inpatient 1 UN 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 99999-9999-72 - Magnesium Sulfate Premix Additive [JOHN] 48580744_1 CDM 0259 RC 99999-9999-72 NDC inpatient 1 UN 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 99999-9999-72 - Magnesium Sulfate Premix Additive [JOHN] 48580744_1 CDM 0259 RC 99999-9999-72 NDC inpatient 1 UN 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges 99999-9999-72 - Magnesium Sulfate Premix Additive [JOHN] 48580744_1 CDM 0259 RC 99999-9999-72 NDC inpatient 1 UN 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 99999-9999-70 - Nitroglycerin Premix Additive [JOHN] 48580747_1 CDM 0259 RC 99999-9999-70 NDC inpatient 1 UN 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges 99999-9999-70 - Nitroglycerin Premix Additive [JOHN] 48580747_1 CDM 0259 RC 99999-9999-70 NDC inpatient 1 UN 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges 99999-9999-70 - Nitroglycerin Premix Additive [JOHN] 48580747_1 CDM 0259 RC 99999-9999-70 NDC inpatient 1 UN 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges 99999-9999-70 - Nitroglycerin Premix Additive [JOHN] 48580747_1 CDM 0259 RC 99999-9999-70 NDC inpatient 1 UN 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges 99999-9999-70 - Nitroglycerin Premix Additive [JOHN] 48580747_1 CDM 0259 RC 99999-9999-70 NDC inpatient 1 UN 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges 99999-9999-70 - Nitroglycerin Premix Additive [JOHN] 48580747_1 CDM 0259 RC 99999-9999-70 NDC inpatient 1 UN 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges 99999-9999-70 - Nitroglycerin Premix Additive [JOHN] 48580747_1 CDM 0259 RC 99999-9999-70 NDC inpatient 1 UN 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges 99999-9999-70 - Nitroglycerin Premix Additive [JOHN] 48580747_1 CDM 0259 RC 99999-9999-70 NDC inpatient 1 UN 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges 99999-9999-70 - Nitroglycerin Premix Additive [JOHN] 48580747_1 CDM 0259 RC 99999-9999-70 NDC inpatient 1 UN 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 99999-9999-70 - Nitroglycerin Premix Additive [JOHN] 48580747_1 CDM 0259 RC 99999-9999-70 NDC inpatient 1 UN 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 99999-9999-70 - Nitroglycerin Premix Additive [JOHN] 48580747_1 CDM 0259 RC 99999-9999-70 NDC inpatient 1 UN 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 99999-9999-70 - Nitroglycerin Premix Additive [JOHN] 48580747_1 CDM 0259 RC 99999-9999-70 NDC inpatient 1 UN 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 99999-9999-70 - Nitroglycerin Premix Additive [JOHN] 48580747_1 CDM 0259 RC 99999-9999-70 NDC inpatient 1 UN 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges 99999-9999-70 - Nitroglycerin Premix Additive [JOHN] 48580747_1 CDM 0259 RC 99999-9999-70 NDC inpatient 1 UN 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 Body fluid pH level 48594098_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594098_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594098_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594098_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594098_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594098_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594098_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594098_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594098_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 Body fluid pH level 48594098_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 Body fluid pH level 48594098_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 Body fluid pH level 48594098_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 Body fluid pH level 48594098_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594098_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 Body fluid pH level 48594099_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594099_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594099_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594099_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594099_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594099_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594099_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594099_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594099_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 Body fluid pH level 48594099_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 Body fluid pH level 48594099_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 Body fluid pH level 48594099_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 Body fluid pH level 48594099_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594099_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 Body fluid pH level 48594100_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594100_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594100_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594100_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594100_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594100_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594100_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594100_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594100_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 Body fluid pH level 48594100_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 Body fluid pH level 48594100_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 Body fluid pH level 48594100_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 Body fluid pH level 48594100_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594100_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 Body fluid pH level 48594101_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594101_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594101_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594101_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594101_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594101_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594101_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594101_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594101_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 Body fluid pH level 48594101_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 Body fluid pH level 48594101_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 Body fluid pH level 48594101_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 Body fluid pH level 48594101_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges Body fluid pH level 48594101_1 CDM 0301 RC 83986 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 Amylase (enzyme) level 48594109_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 48594109_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 48594109_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 48594109_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 48594109_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 48594109_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 48594109_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 48594109_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 48594109_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 Amylase (enzyme) level 48594109_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 Amylase (enzyme) level 48594109_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 Amylase (enzyme) level 48594109_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 Amylase (enzyme) level 48594109_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 48594109_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 "Nephelometry, test method using light" 48594110_1 CDM 0301 RC 83883 HCPCS inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges "Nephelometry, test method using light" 48594110_1 CDM 0301 RC 83883 HCPCS inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges "Nephelometry, test method using light" 48594110_1 CDM 0301 RC 83883 HCPCS inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges "Nephelometry, test method using light" 48594110_1 CDM 0301 RC 83883 HCPCS inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges "Nephelometry, test method using light" 48594110_1 CDM 0301 RC 83883 HCPCS inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges "Nephelometry, test method using light" 48594110_1 CDM 0301 RC 83883 HCPCS inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges "Nephelometry, test method using light" 48594110_1 CDM 0301 RC 83883 HCPCS inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges "Nephelometry, test method using light" 48594110_1 CDM 0301 RC 83883 HCPCS inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges "Nephelometry, test method using light" 48594110_1 CDM 0301 RC 83883 HCPCS inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 "Nephelometry, test method using light" 48594110_1 CDM 0301 RC 83883 HCPCS inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 "Nephelometry, test method using light" 48594110_1 CDM 0301 RC 83883 HCPCS inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 "Nephelometry, test method using light" 48594110_1 CDM 0301 RC 83883 HCPCS inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 "Nephelometry, test method using light" 48594110_1 CDM 0301 RC 83883 HCPCS inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges "Nephelometry, test method using light" 48594110_1 CDM 0301 RC 83883 HCPCS inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 Albumin (protein) level 48594112_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594112_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594112_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594112_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594112_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594112_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594112_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594112_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594112_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Albumin (protein) level 48594112_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Albumin (protein) level 48594112_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Albumin (protein) level 48594112_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Albumin (protein) level 48594112_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594112_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Albumin (protein) level 48594113_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594113_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594113_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594113_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594113_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594113_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594113_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594113_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594113_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Albumin (protein) level 48594113_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Albumin (protein) level 48594113_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Albumin (protein) level 48594113_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Albumin (protein) level 48594113_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594113_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Albumin (protein) level 48594114_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594114_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594114_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594114_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594114_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594114_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594114_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594114_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594114_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Albumin (protein) level 48594114_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Albumin (protein) level 48594114_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Albumin (protein) level 48594114_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Albumin (protein) level 48594114_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 48594114_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Total protein level, body fluid" 48594115_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 104.65 65 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48594115_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 AETNA AETNA 127.19 79 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48594115_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 156.17 97 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48594115_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 111.09 69 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48594115_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 125.58 78 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48594115_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 SIHO - ALL PLANS SIHO - ALL PLANS 144.9 90 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48594115_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 UMR - ALL PLANS UMR - ALL PLANS 112.7 70 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48594115_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 97.49 60.55 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48594115_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 97.49 156.17 "Total protein level, body fluid" 48594115_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 97.49 156.17 "Total protein level, body fluid" 48594115_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 ANTHEM HMO ANTHEM HMO 999999999 97.49 156.17 "Total protein level, body fluid" 48594115_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 97.49 156.17 "Total protein level, body fluid" 48594115_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.84 67.6 999999999 97.49 156.17 percent of total billed charges "Total protein level, body fluid" 48594115_1 CDM 0301 RC 84157 HCPCS inpatient 161 104.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 97.49 156.17 Glucose (sugar) level on body fluid 48594116_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48594116_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48594116_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48594116_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48594116_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48594116_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48594116_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48594116_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48594116_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 Glucose (sugar) level on body fluid 48594116_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 Glucose (sugar) level on body fluid 48594116_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 Glucose (sugar) level on body fluid 48594116_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 Glucose (sugar) level on body fluid 48594116_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48594116_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 Glucose (sugar) level on body fluid 48594117_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48594117_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48594117_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48594117_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48594117_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48594117_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48594117_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48594117_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48594117_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 Glucose (sugar) level on body fluid 48594117_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 Glucose (sugar) level on body fluid 48594117_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 Glucose (sugar) level on body fluid 48594117_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 Glucose (sugar) level on body fluid 48594117_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 48594117_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 Lactate dehydrogenase (enzyme) level 48594119_1 CDM 0300 RC 83615 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges Lactate dehydrogenase (enzyme) level 48594119_1 CDM 0300 RC 83615 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges Lactate dehydrogenase (enzyme) level 48594119_1 CDM 0300 RC 83615 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges Lactate dehydrogenase (enzyme) level 48594119_1 CDM 0300 RC 83615 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges Lactate dehydrogenase (enzyme) level 48594119_1 CDM 0300 RC 83615 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges Lactate dehydrogenase (enzyme) level 48594119_1 CDM 0300 RC 83615 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges Lactate dehydrogenase (enzyme) level 48594119_1 CDM 0300 RC 83615 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges Lactate dehydrogenase (enzyme) level 48594119_1 CDM 0300 RC 83615 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges Lactate dehydrogenase (enzyme) level 48594119_1 CDM 0300 RC 83615 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 Lactate dehydrogenase (enzyme) level 48594119_1 CDM 0300 RC 83615 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 Lactate dehydrogenase (enzyme) level 48594119_1 CDM 0300 RC 83615 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 Lactate dehydrogenase (enzyme) level 48594119_1 CDM 0300 RC 83615 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 Lactate dehydrogenase (enzyme) level 48594119_1 CDM 0300 RC 83615 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges Lactate dehydrogenase (enzyme) level 48594119_1 CDM 0300 RC 83615 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 Lactate dehydrogenase (enzyme) level 48594120_1 CDM 0300 RC 83615 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges Lactate dehydrogenase (enzyme) level 48594120_1 CDM 0300 RC 83615 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges Lactate dehydrogenase (enzyme) level 48594120_1 CDM 0300 RC 83615 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges Lactate dehydrogenase (enzyme) level 48594120_1 CDM 0300 RC 83615 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges Lactate dehydrogenase (enzyme) level 48594120_1 CDM 0300 RC 83615 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges Lactate dehydrogenase (enzyme) level 48594120_1 CDM 0300 RC 83615 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges Lactate dehydrogenase (enzyme) level 48594120_1 CDM 0300 RC 83615 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges Lactate dehydrogenase (enzyme) level 48594120_1 CDM 0300 RC 83615 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges Lactate dehydrogenase (enzyme) level 48594120_1 CDM 0300 RC 83615 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 Lactate dehydrogenase (enzyme) level 48594120_1 CDM 0300 RC 83615 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 Lactate dehydrogenase (enzyme) level 48594120_1 CDM 0300 RC 83615 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 Lactate dehydrogenase (enzyme) level 48594120_1 CDM 0300 RC 83615 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 Lactate dehydrogenase (enzyme) level 48594120_1 CDM 0300 RC 83615 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges Lactate dehydrogenase (enzyme) level 48594120_1 CDM 0300 RC 83615 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 Body fluid cell count with cell identification 48594125_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 183.95 65 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594125_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 AETNA AETNA 223.57 79 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594125_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 274.51 97 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594125_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 195.27 69 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594125_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 220.74 78 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594125_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 SIHO - ALL PLANS SIHO - ALL PLANS 254.7 90 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594125_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 UMR - ALL PLANS UMR - ALL PLANS 198.1 70 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594125_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 171.36 60.55 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594125_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 171.36 274.51 Body fluid cell count with cell identification 48594125_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 171.36 274.51 Body fluid cell count with cell identification 48594125_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 ANTHEM HMO ANTHEM HMO 999999999 171.36 274.51 Body fluid cell count with cell identification 48594125_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 171.36 274.51 Body fluid cell count with cell identification 48594125_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 191.31 67.6 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594125_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 171.36 274.51 Body fluid cell count with cell identification 48594126_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 183.95 65 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594126_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 AETNA AETNA 223.57 79 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594126_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 274.51 97 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594126_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 195.27 69 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594126_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 220.74 78 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594126_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 SIHO - ALL PLANS SIHO - ALL PLANS 254.7 90 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594126_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 UMR - ALL PLANS UMR - ALL PLANS 198.1 70 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594126_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 171.36 60.55 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594126_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 171.36 274.51 Body fluid cell count with cell identification 48594126_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 171.36 274.51 Body fluid cell count with cell identification 48594126_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 ANTHEM HMO ANTHEM HMO 999999999 171.36 274.51 Body fluid cell count with cell identification 48594126_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 171.36 274.51 Body fluid cell count with cell identification 48594126_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 191.31 67.6 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594126_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 171.36 274.51 Body fluid cell count with cell identification 48594127_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 183.95 65 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594127_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 AETNA AETNA 223.57 79 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594127_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 274.51 97 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594127_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 195.27 69 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594127_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 220.74 78 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594127_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 SIHO - ALL PLANS SIHO - ALL PLANS 254.7 90 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594127_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 UMR - ALL PLANS UMR - ALL PLANS 198.1 70 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594127_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 171.36 60.55 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594127_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 171.36 274.51 Body fluid cell count with cell identification 48594127_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 171.36 274.51 Body fluid cell count with cell identification 48594127_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 ANTHEM HMO ANTHEM HMO 999999999 171.36 274.51 Body fluid cell count with cell identification 48594127_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 171.36 274.51 Body fluid cell count with cell identification 48594127_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 191.31 67.6 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48594127_1 CDM 0301 RC 89051 HCPCS inpatient 283 183.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 171.36 274.51 Thermolabile (heat sensitive) hemoglobin level 48594128_1 CDM 0301 RC 83065 HCPCS inpatient 238 154.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.7 65 999999999 144.11 230.86 percent of total billed charges Thermolabile (heat sensitive) hemoglobin level 48594128_1 CDM 0301 RC 83065 HCPCS inpatient 238 154.7 AETNA AETNA 188.02 79 999999999 144.11 230.86 percent of total billed charges Thermolabile (heat sensitive) hemoglobin level 48594128_1 CDM 0301 RC 83065 HCPCS inpatient 238 154.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 230.86 97 999999999 144.11 230.86 percent of total billed charges Thermolabile (heat sensitive) hemoglobin level 48594128_1 CDM 0301 RC 83065 HCPCS inpatient 238 154.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.22 69 999999999 144.11 230.86 percent of total billed charges Thermolabile (heat sensitive) hemoglobin level 48594128_1 CDM 0301 RC 83065 HCPCS inpatient 238 154.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 185.64 78 999999999 144.11 230.86 percent of total billed charges Thermolabile (heat sensitive) hemoglobin level 48594128_1 CDM 0301 RC 83065 HCPCS inpatient 238 154.7 SIHO - ALL PLANS SIHO - ALL PLANS 214.2 90 999999999 144.11 230.86 percent of total billed charges Thermolabile (heat sensitive) hemoglobin level 48594128_1 CDM 0301 RC 83065 HCPCS inpatient 238 154.7 UMR - ALL PLANS UMR - ALL PLANS 166.6 70 999999999 144.11 230.86 percent of total billed charges Thermolabile (heat sensitive) hemoglobin level 48594128_1 CDM 0301 RC 83065 HCPCS inpatient 238 154.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.11 60.55 999999999 144.11 230.86 percent of total billed charges Thermolabile (heat sensitive) hemoglobin level 48594128_1 CDM 0301 RC 83065 HCPCS inpatient 238 154.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.11 230.86 Thermolabile (heat sensitive) hemoglobin level 48594128_1 CDM 0301 RC 83065 HCPCS inpatient 238 154.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.11 230.86 Thermolabile (heat sensitive) hemoglobin level 48594128_1 CDM 0301 RC 83065 HCPCS inpatient 238 154.7 ANTHEM HMO ANTHEM HMO 999999999 144.11 230.86 Thermolabile (heat sensitive) hemoglobin level 48594128_1 CDM 0301 RC 83065 HCPCS inpatient 238 154.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.11 230.86 Thermolabile (heat sensitive) hemoglobin level 48594128_1 CDM 0301 RC 83065 HCPCS inpatient 238 154.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.89 67.6 999999999 144.11 230.86 percent of total billed charges Thermolabile (heat sensitive) hemoglobin level 48594128_1 CDM 0301 RC 83065 HCPCS inpatient 238 154.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.11 230.86 JOH 2% LIDOCAINE 20ML 48604456_1 CDM 0255 RC inpatient 58 37.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.7 65 999999999 35.12 56.26 percent of total billed charges JOH 2% LIDOCAINE 20ML 48604456_1 CDM 0255 RC inpatient 58 37.7 AETNA AETNA 45.82 79 999999999 35.12 56.26 percent of total billed charges JOH 2% LIDOCAINE 20ML 48604456_1 CDM 0255 RC inpatient 58 37.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.26 97 999999999 35.12 56.26 percent of total billed charges JOH 2% LIDOCAINE 20ML 48604456_1 CDM 0255 RC inpatient 58 37.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.02 69 999999999 35.12 56.26 percent of total billed charges JOH 2% LIDOCAINE 20ML 48604456_1 CDM 0255 RC inpatient 58 37.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.24 78 999999999 35.12 56.26 percent of total billed charges JOH 2% LIDOCAINE 20ML 48604456_1 CDM 0255 RC inpatient 58 37.7 SIHO - ALL PLANS SIHO - ALL PLANS 52.2 90 999999999 35.12 56.26 percent of total billed charges JOH 2% LIDOCAINE 20ML 48604456_1 CDM 0255 RC inpatient 58 37.7 UMR - ALL PLANS UMR - ALL PLANS 40.6 70 999999999 35.12 56.26 percent of total billed charges JOH 2% LIDOCAINE 20ML 48604456_1 CDM 0255 RC inpatient 58 37.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.12 60.55 999999999 35.12 56.26 percent of total billed charges JOH 2% LIDOCAINE 20ML 48604456_1 CDM 0255 RC inpatient 58 37.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.12 56.26 JOH 2% LIDOCAINE 20ML 48604456_1 CDM 0255 RC inpatient 58 37.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.12 56.26 JOH 2% LIDOCAINE 20ML 48604456_1 CDM 0255 RC inpatient 58 37.7 ANTHEM HMO ANTHEM HMO 999999999 35.12 56.26 JOH 2% LIDOCAINE 20ML 48604456_1 CDM 0255 RC inpatient 58 37.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.12 56.26 JOH 2% LIDOCAINE 20ML 48604456_1 CDM 0255 RC inpatient 58 37.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.21 67.6 999999999 35.12 56.26 percent of total billed charges JOH 2% LIDOCAINE 20ML 48604456_1 CDM 0255 RC inpatient 58 37.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.12 56.26 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48604464_1 CDM 0636 RC Q9967 HCPCS inpatient 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48604464_1 CDM 0636 RC Q9967 HCPCS inpatient 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48604464_1 CDM 0636 RC Q9967 HCPCS inpatient 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48604464_1 CDM 0636 RC Q9967 HCPCS inpatient 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48604464_1 CDM 0636 RC Q9967 HCPCS inpatient 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48604464_1 CDM 0636 RC Q9967 HCPCS inpatient 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48604464_1 CDM 0636 RC Q9967 HCPCS inpatient 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48604464_1 CDM 0636 RC Q9967 HCPCS inpatient 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48604464_1 CDM 0636 RC Q9967 HCPCS inpatient 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48604464_1 CDM 0636 RC Q9967 HCPCS inpatient 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48604464_1 CDM 0636 RC Q9967 HCPCS inpatient 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48604464_1 CDM 0636 RC Q9967 HCPCS inpatient 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48604464_1 CDM 0636 RC Q9967 HCPCS inpatient 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48604464_1 CDM 0636 RC Q9967 HCPCS inpatient 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 ROOM & BOARD - PRIVATE (ONE BED) - MEDICAL/SURGICAL/GYN 48604682_1 CDM 0111 RC inpatient 1618 1051.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1051.7 65 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - MEDICAL/SURGICAL/GYN 48604682_1 CDM 0111 RC inpatient 1618 1051.7 AETNA AETNA 1278.22 79 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - MEDICAL/SURGICAL/GYN 48604682_1 CDM 0111 RC inpatient 1618 1051.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1569.46 97 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - MEDICAL/SURGICAL/GYN 48604682_1 CDM 0111 RC inpatient 1618 1051.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1116.42 69 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - MEDICAL/SURGICAL/GYN 48604682_1 CDM 0111 RC inpatient 1618 1051.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1262.04 78 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - MEDICAL/SURGICAL/GYN 48604682_1 CDM 0111 RC inpatient 1618 1051.7 SIHO - ALL PLANS SIHO - ALL PLANS 1456.2 90 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - MEDICAL/SURGICAL/GYN 48604682_1 CDM 0111 RC inpatient 1618 1051.7 UMR - ALL PLANS UMR - ALL PLANS 1132.6 70 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - MEDICAL/SURGICAL/GYN 48604682_1 CDM 0111 RC inpatient 1618 1051.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 979.7 60.55 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - MEDICAL/SURGICAL/GYN 48604682_1 CDM 0111 RC inpatient 1618 1051.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 979.7 1569.46 ROOM & BOARD - PRIVATE (ONE BED) - MEDICAL/SURGICAL/GYN 48604682_1 CDM 0111 RC inpatient 1618 1051.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 979.7 1569.46 ROOM & BOARD - PRIVATE (ONE BED) - MEDICAL/SURGICAL/GYN 48604682_1 CDM 0111 RC inpatient 1618 1051.7 ANTHEM HMO ANTHEM HMO 999999999 979.7 1569.46 ROOM & BOARD - PRIVATE (ONE BED) - MEDICAL/SURGICAL/GYN 48604682_1 CDM 0111 RC inpatient 1618 1051.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 979.7 1569.46 ROOM & BOARD - PRIVATE (ONE BED) - MEDICAL/SURGICAL/GYN 48604682_1 CDM 0111 RC inpatient 1618 1051.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1093.77 67.6 999999999 979.7 1569.46 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - MEDICAL/SURGICAL/GYN 48604682_1 CDM 0111 RC inpatient 1618 1051.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 979.7 1569.46 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604683_1 CDM 0762 RC G0378 HCPCS inpatient 212.93 138.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 138.4 65 999999999 128.93 206.54 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604683_1 CDM 0762 RC G0378 HCPCS inpatient 212.93 138.4 AETNA AETNA 168.21 79 999999999 128.93 206.54 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604683_1 CDM 0762 RC G0378 HCPCS inpatient 212.93 138.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 206.54 97 999999999 128.93 206.54 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604683_1 CDM 0762 RC G0378 HCPCS inpatient 212.93 138.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 146.92 69 999999999 128.93 206.54 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604683_1 CDM 0762 RC G0378 HCPCS inpatient 212.93 138.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 166.09 78 999999999 128.93 206.54 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604683_1 CDM 0762 RC G0378 HCPCS inpatient 212.93 138.4 SIHO - ALL PLANS SIHO - ALL PLANS 191.64 90 999999999 128.93 206.54 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604683_1 CDM 0762 RC G0378 HCPCS inpatient 212.93 138.4 UMR - ALL PLANS UMR - ALL PLANS 149.05 70 999999999 128.93 206.54 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604683_1 CDM 0762 RC G0378 HCPCS inpatient 212.93 138.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 128.93 60.55 999999999 128.93 206.54 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604683_1 CDM 0762 RC G0378 HCPCS inpatient 212.93 138.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 128.93 206.54 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604683_1 CDM 0762 RC G0378 HCPCS inpatient 212.93 138.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 128.93 206.54 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604683_1 CDM 0762 RC G0378 HCPCS inpatient 212.93 138.4 ANTHEM HMO ANTHEM HMO 999999999 128.93 206.54 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604683_1 CDM 0762 RC G0378 HCPCS inpatient 212.93 138.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 128.93 206.54 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604683_1 CDM 0762 RC G0378 HCPCS inpatient 212.93 138.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 143.94 67.6 999999999 128.93 206.54 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604683_1 CDM 0762 RC G0378 HCPCS inpatient 212.93 138.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 128.93 206.54 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604684_1 CDM 0762 RC G0378 HCPCS inpatient 75.72 49.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.22 65 999999999 45.85 73.45 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604684_1 CDM 0762 RC G0378 HCPCS inpatient 75.72 49.22 AETNA AETNA 59.82 79 999999999 45.85 73.45 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604684_1 CDM 0762 RC G0378 HCPCS inpatient 75.72 49.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.45 97 999999999 45.85 73.45 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604684_1 CDM 0762 RC G0378 HCPCS inpatient 75.72 49.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.25 69 999999999 45.85 73.45 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604684_1 CDM 0762 RC G0378 HCPCS inpatient 75.72 49.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.06 78 999999999 45.85 73.45 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604684_1 CDM 0762 RC G0378 HCPCS inpatient 75.72 49.22 SIHO - ALL PLANS SIHO - ALL PLANS 68.15 90 999999999 45.85 73.45 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604684_1 CDM 0762 RC G0378 HCPCS inpatient 75.72 49.22 UMR - ALL PLANS UMR - ALL PLANS 53 70 999999999 45.85 73.45 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604684_1 CDM 0762 RC G0378 HCPCS inpatient 75.72 49.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.85 60.55 999999999 45.85 73.45 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604684_1 CDM 0762 RC G0378 HCPCS inpatient 75.72 49.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.85 73.45 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604684_1 CDM 0762 RC G0378 HCPCS inpatient 75.72 49.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.85 73.45 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604684_1 CDM 0762 RC G0378 HCPCS inpatient 75.72 49.22 ANTHEM HMO ANTHEM HMO 999999999 45.85 73.45 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604684_1 CDM 0762 RC G0378 HCPCS inpatient 75.72 49.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.85 73.45 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604684_1 CDM 0762 RC G0378 HCPCS inpatient 75.72 49.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.19 67.6 999999999 45.85 73.45 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604684_1 CDM 0762 RC G0378 HCPCS inpatient 75.72 49.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.85 73.45 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604685_1 CDM 0762 RC G0378 HCPCS inpatient 98.94 64.31 SELF PAY DISCOUNT SELF PAY DISCOUNT 64.31 65 999999999 59.91 95.97 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604685_1 CDM 0762 RC G0378 HCPCS inpatient 98.94 64.31 AETNA AETNA 78.16 79 999999999 59.91 95.97 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604685_1 CDM 0762 RC G0378 HCPCS inpatient 98.94 64.31 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.97 97 999999999 59.91 95.97 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604685_1 CDM 0762 RC G0378 HCPCS inpatient 98.94 64.31 ENCORE - ALL PLANS ENCORE - ALL PLANS 68.27 69 999999999 59.91 95.97 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604685_1 CDM 0762 RC G0378 HCPCS inpatient 98.94 64.31 HUMANA - ALL PLANS HUMANA - ALL PLANS 77.17 78 999999999 59.91 95.97 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604685_1 CDM 0762 RC G0378 HCPCS inpatient 98.94 64.31 SIHO - ALL PLANS SIHO - ALL PLANS 89.05 90 999999999 59.91 95.97 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604685_1 CDM 0762 RC G0378 HCPCS inpatient 98.94 64.31 UMR - ALL PLANS UMR - ALL PLANS 69.26 70 999999999 59.91 95.97 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604685_1 CDM 0762 RC G0378 HCPCS inpatient 98.94 64.31 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.91 60.55 999999999 59.91 95.97 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604685_1 CDM 0762 RC G0378 HCPCS inpatient 98.94 64.31 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.91 95.97 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604685_1 CDM 0762 RC G0378 HCPCS inpatient 98.94 64.31 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.91 95.97 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604685_1 CDM 0762 RC G0378 HCPCS inpatient 98.94 64.31 ANTHEM HMO ANTHEM HMO 999999999 59.91 95.97 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604685_1 CDM 0762 RC G0378 HCPCS inpatient 98.94 64.31 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.91 95.97 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604685_1 CDM 0762 RC G0378 HCPCS inpatient 98.94 64.31 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.88 67.6 999999999 59.91 95.97 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604685_1 CDM 0762 RC G0378 HCPCS inpatient 98.94 64.31 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.91 95.97 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604687_1 CDM 0762 RC G0378 HCPCS inpatient 72.58 47.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.18 65 999999999 43.95 70.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604687_1 CDM 0762 RC G0378 HCPCS inpatient 72.58 47.18 AETNA AETNA 57.34 79 999999999 43.95 70.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604687_1 CDM 0762 RC G0378 HCPCS inpatient 72.58 47.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.4 97 999999999 43.95 70.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604687_1 CDM 0762 RC G0378 HCPCS inpatient 72.58 47.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.08 69 999999999 43.95 70.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604687_1 CDM 0762 RC G0378 HCPCS inpatient 72.58 47.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.61 78 999999999 43.95 70.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604687_1 CDM 0762 RC G0378 HCPCS inpatient 72.58 47.18 SIHO - ALL PLANS SIHO - ALL PLANS 65.32 90 999999999 43.95 70.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604687_1 CDM 0762 RC G0378 HCPCS inpatient 72.58 47.18 UMR - ALL PLANS UMR - ALL PLANS 50.81 70 999999999 43.95 70.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604687_1 CDM 0762 RC G0378 HCPCS inpatient 72.58 47.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.95 60.55 999999999 43.95 70.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604687_1 CDM 0762 RC G0378 HCPCS inpatient 72.58 47.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.95 70.4 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604687_1 CDM 0762 RC G0378 HCPCS inpatient 72.58 47.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.95 70.4 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604687_1 CDM 0762 RC G0378 HCPCS inpatient 72.58 47.18 ANTHEM HMO ANTHEM HMO 999999999 43.95 70.4 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604687_1 CDM 0762 RC G0378 HCPCS inpatient 72.58 47.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.95 70.4 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604687_1 CDM 0762 RC G0378 HCPCS inpatient 72.58 47.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.06 67.6 999999999 43.95 70.4 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604687_1 CDM 0762 RC G0378 HCPCS inpatient 72.58 47.18 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.95 70.4 NURSERY - NEWBORN - LEVEL III 48604689_1 CDM 0173 RC inpatient 1625 1056.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1056.25 65 999999999 983.94 1576.25 percent of total billed charges NURSERY - NEWBORN - LEVEL III 48604689_1 CDM 0173 RC inpatient 1625 1056.25 AETNA AETNA 1283.75 79 999999999 983.94 1576.25 percent of total billed charges NURSERY - NEWBORN - LEVEL III 48604689_1 CDM 0173 RC inpatient 1625 1056.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1576.25 97 999999999 983.94 1576.25 percent of total billed charges NURSERY - NEWBORN - LEVEL III 48604689_1 CDM 0173 RC inpatient 1625 1056.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1121.25 69 999999999 983.94 1576.25 percent of total billed charges NURSERY - NEWBORN - LEVEL III 48604689_1 CDM 0173 RC inpatient 1625 1056.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1267.5 78 999999999 983.94 1576.25 percent of total billed charges NURSERY - NEWBORN - LEVEL III 48604689_1 CDM 0173 RC inpatient 1625 1056.25 SIHO - ALL PLANS SIHO - ALL PLANS 1462.5 90 999999999 983.94 1576.25 percent of total billed charges NURSERY - NEWBORN - LEVEL III 48604689_1 CDM 0173 RC inpatient 1625 1056.25 UMR - ALL PLANS UMR - ALL PLANS 1137.5 70 999999999 983.94 1576.25 percent of total billed charges NURSERY - NEWBORN - LEVEL III 48604689_1 CDM 0173 RC inpatient 1625 1056.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 983.94 60.55 999999999 983.94 1576.25 percent of total billed charges NURSERY - NEWBORN - LEVEL III 48604689_1 CDM 0173 RC inpatient 1625 1056.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 983.94 1576.25 NURSERY - NEWBORN - LEVEL III 48604689_1 CDM 0173 RC inpatient 1625 1056.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 983.94 1576.25 NURSERY - NEWBORN - LEVEL III 48604689_1 CDM 0173 RC inpatient 1625 1056.25 ANTHEM HMO ANTHEM HMO 999999999 983.94 1576.25 NURSERY - NEWBORN - LEVEL III 48604689_1 CDM 0173 RC inpatient 1625 1056.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 983.94 1576.25 NURSERY - NEWBORN - LEVEL III 48604689_1 CDM 0173 RC inpatient 1625 1056.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1098.5 67.6 999999999 983.94 1576.25 percent of total billed charges NURSERY - NEWBORN - LEVEL III 48604689_1 CDM 0173 RC inpatient 1625 1056.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 983.94 1576.25 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604694_1 CDM 0762 RC G0378 HCPCS inpatient 97.72 63.52 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.52 65 999999999 59.17 94.79 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604694_1 CDM 0762 RC G0378 HCPCS inpatient 97.72 63.52 AETNA AETNA 77.2 79 999999999 59.17 94.79 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604694_1 CDM 0762 RC G0378 HCPCS inpatient 97.72 63.52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 94.79 97 999999999 59.17 94.79 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604694_1 CDM 0762 RC G0378 HCPCS inpatient 97.72 63.52 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.43 69 999999999 59.17 94.79 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604694_1 CDM 0762 RC G0378 HCPCS inpatient 97.72 63.52 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.22 78 999999999 59.17 94.79 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604694_1 CDM 0762 RC G0378 HCPCS inpatient 97.72 63.52 SIHO - ALL PLANS SIHO - ALL PLANS 87.95 90 999999999 59.17 94.79 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604694_1 CDM 0762 RC G0378 HCPCS inpatient 97.72 63.52 UMR - ALL PLANS UMR - ALL PLANS 68.4 70 999999999 59.17 94.79 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604694_1 CDM 0762 RC G0378 HCPCS inpatient 97.72 63.52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.17 60.55 999999999 59.17 94.79 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604694_1 CDM 0762 RC G0378 HCPCS inpatient 97.72 63.52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.17 94.79 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604694_1 CDM 0762 RC G0378 HCPCS inpatient 97.72 63.52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.17 94.79 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604694_1 CDM 0762 RC G0378 HCPCS inpatient 97.72 63.52 ANTHEM HMO ANTHEM HMO 999999999 59.17 94.79 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604694_1 CDM 0762 RC G0378 HCPCS inpatient 97.72 63.52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.17 94.79 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604694_1 CDM 0762 RC G0378 HCPCS inpatient 97.72 63.52 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.06 67.6 999999999 59.17 94.79 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604694_1 CDM 0762 RC G0378 HCPCS inpatient 97.72 63.52 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.17 94.79 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604696_1 CDM 0762 RC G0378 HCPCS inpatient 132.64 86.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.22 65 999999999 80.31 128.66 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604696_1 CDM 0762 RC G0378 HCPCS inpatient 132.64 86.22 AETNA AETNA 104.79 79 999999999 80.31 128.66 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604696_1 CDM 0762 RC G0378 HCPCS inpatient 132.64 86.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 128.66 97 999999999 80.31 128.66 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604696_1 CDM 0762 RC G0378 HCPCS inpatient 132.64 86.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.52 69 999999999 80.31 128.66 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604696_1 CDM 0762 RC G0378 HCPCS inpatient 132.64 86.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.46 78 999999999 80.31 128.66 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604696_1 CDM 0762 RC G0378 HCPCS inpatient 132.64 86.22 SIHO - ALL PLANS SIHO - ALL PLANS 119.38 90 999999999 80.31 128.66 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604696_1 CDM 0762 RC G0378 HCPCS inpatient 132.64 86.22 UMR - ALL PLANS UMR - ALL PLANS 92.85 70 999999999 80.31 128.66 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604696_1 CDM 0762 RC G0378 HCPCS inpatient 132.64 86.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.31 60.55 999999999 80.31 128.66 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604696_1 CDM 0762 RC G0378 HCPCS inpatient 132.64 86.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.31 128.66 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604696_1 CDM 0762 RC G0378 HCPCS inpatient 132.64 86.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.31 128.66 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604696_1 CDM 0762 RC G0378 HCPCS inpatient 132.64 86.22 ANTHEM HMO ANTHEM HMO 999999999 80.31 128.66 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604696_1 CDM 0762 RC G0378 HCPCS inpatient 132.64 86.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.31 128.66 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604696_1 CDM 0762 RC G0378 HCPCS inpatient 132.64 86.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.66 67.6 999999999 80.31 128.66 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604696_1 CDM 0762 RC G0378 HCPCS inpatient 132.64 86.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.31 128.66 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604697_1 CDM 0762 RC G0378 HCPCS inpatient 89.29 58.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.04 65 999999999 54.07 86.61 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604697_1 CDM 0762 RC G0378 HCPCS inpatient 89.29 58.04 AETNA AETNA 70.54 79 999999999 54.07 86.61 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604697_1 CDM 0762 RC G0378 HCPCS inpatient 89.29 58.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 86.61 97 999999999 54.07 86.61 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604697_1 CDM 0762 RC G0378 HCPCS inpatient 89.29 58.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 61.61 69 999999999 54.07 86.61 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604697_1 CDM 0762 RC G0378 HCPCS inpatient 89.29 58.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 69.65 78 999999999 54.07 86.61 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604697_1 CDM 0762 RC G0378 HCPCS inpatient 89.29 58.04 SIHO - ALL PLANS SIHO - ALL PLANS 80.36 90 999999999 54.07 86.61 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604697_1 CDM 0762 RC G0378 HCPCS inpatient 89.29 58.04 UMR - ALL PLANS UMR - ALL PLANS 62.5 70 999999999 54.07 86.61 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604697_1 CDM 0762 RC G0378 HCPCS inpatient 89.29 58.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.07 60.55 999999999 54.07 86.61 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604697_1 CDM 0762 RC G0378 HCPCS inpatient 89.29 58.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.07 86.61 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604697_1 CDM 0762 RC G0378 HCPCS inpatient 89.29 58.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.07 86.61 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604697_1 CDM 0762 RC G0378 HCPCS inpatient 89.29 58.04 ANTHEM HMO ANTHEM HMO 999999999 54.07 86.61 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604697_1 CDM 0762 RC G0378 HCPCS inpatient 89.29 58.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.07 86.61 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604697_1 CDM 0762 RC G0378 HCPCS inpatient 89.29 58.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.36 67.6 999999999 54.07 86.61 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604697_1 CDM 0762 RC G0378 HCPCS inpatient 89.29 58.04 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.07 86.61 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604698_1 CDM 0762 RC G0378 HCPCS inpatient 119.81 77.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.88 65 999999999 72.55 116.22 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604698_1 CDM 0762 RC G0378 HCPCS inpatient 119.81 77.88 AETNA AETNA 94.65 79 999999999 72.55 116.22 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604698_1 CDM 0762 RC G0378 HCPCS inpatient 119.81 77.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.22 97 999999999 72.55 116.22 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604698_1 CDM 0762 RC G0378 HCPCS inpatient 119.81 77.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.67 69 999999999 72.55 116.22 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604698_1 CDM 0762 RC G0378 HCPCS inpatient 119.81 77.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.45 78 999999999 72.55 116.22 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604698_1 CDM 0762 RC G0378 HCPCS inpatient 119.81 77.88 SIHO - ALL PLANS SIHO - ALL PLANS 107.83 90 999999999 72.55 116.22 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604698_1 CDM 0762 RC G0378 HCPCS inpatient 119.81 77.88 UMR - ALL PLANS UMR - ALL PLANS 83.87 70 999999999 72.55 116.22 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604698_1 CDM 0762 RC G0378 HCPCS inpatient 119.81 77.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.55 60.55 999999999 72.55 116.22 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604698_1 CDM 0762 RC G0378 HCPCS inpatient 119.81 77.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.55 116.22 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604698_1 CDM 0762 RC G0378 HCPCS inpatient 119.81 77.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.55 116.22 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604698_1 CDM 0762 RC G0378 HCPCS inpatient 119.81 77.88 ANTHEM HMO ANTHEM HMO 999999999 72.55 116.22 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604698_1 CDM 0762 RC G0378 HCPCS inpatient 119.81 77.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.55 116.22 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604698_1 CDM 0762 RC G0378 HCPCS inpatient 119.81 77.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.99 67.6 999999999 72.55 116.22 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604698_1 CDM 0762 RC G0378 HCPCS inpatient 119.81 77.88 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.55 116.22 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604699_1 CDM 0762 RC G0378 HCPCS inpatient 92.63 60.21 SELF PAY DISCOUNT SELF PAY DISCOUNT 60.21 65 999999999 56.09 89.85 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604699_1 CDM 0762 RC G0378 HCPCS inpatient 92.63 60.21 AETNA AETNA 73.18 79 999999999 56.09 89.85 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604699_1 CDM 0762 RC G0378 HCPCS inpatient 92.63 60.21 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.85 97 999999999 56.09 89.85 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604699_1 CDM 0762 RC G0378 HCPCS inpatient 92.63 60.21 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.91 69 999999999 56.09 89.85 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604699_1 CDM 0762 RC G0378 HCPCS inpatient 92.63 60.21 HUMANA - ALL PLANS HUMANA - ALL PLANS 72.25 78 999999999 56.09 89.85 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604699_1 CDM 0762 RC G0378 HCPCS inpatient 92.63 60.21 SIHO - ALL PLANS SIHO - ALL PLANS 83.37 90 999999999 56.09 89.85 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604699_1 CDM 0762 RC G0378 HCPCS inpatient 92.63 60.21 UMR - ALL PLANS UMR - ALL PLANS 64.84 70 999999999 56.09 89.85 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604699_1 CDM 0762 RC G0378 HCPCS inpatient 92.63 60.21 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.09 60.55 999999999 56.09 89.85 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604699_1 CDM 0762 RC G0378 HCPCS inpatient 92.63 60.21 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.09 89.85 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604699_1 CDM 0762 RC G0378 HCPCS inpatient 92.63 60.21 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.09 89.85 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604699_1 CDM 0762 RC G0378 HCPCS inpatient 92.63 60.21 ANTHEM HMO ANTHEM HMO 999999999 56.09 89.85 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604699_1 CDM 0762 RC G0378 HCPCS inpatient 92.63 60.21 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.09 89.85 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604699_1 CDM 0762 RC G0378 HCPCS inpatient 92.63 60.21 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.62 67.6 999999999 56.09 89.85 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 48604699_1 CDM 0762 RC G0378 HCPCS inpatient 92.63 60.21 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.09 89.85 39822-1001-07 - tranexamic acid 100 mg/mL Sol [JOHN] 48604839_1 CDM 0250 RC 39822-1001-07 NDC inpatient 1 UN 83.03 53.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.97 65 999999999 50.27 80.54 percent of total billed charges 39822-1001-07 - tranexamic acid 100 mg/mL Sol [JOHN] 48604839_1 CDM 0250 RC 39822-1001-07 NDC inpatient 1 UN 83.03 53.97 AETNA AETNA 65.59 79 999999999 50.27 80.54 percent of total billed charges 39822-1001-07 - tranexamic acid 100 mg/mL Sol [JOHN] 48604839_1 CDM 0250 RC 39822-1001-07 NDC inpatient 1 UN 83.03 53.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.54 97 999999999 50.27 80.54 percent of total billed charges 39822-1001-07 - tranexamic acid 100 mg/mL Sol [JOHN] 48604839_1 CDM 0250 RC 39822-1001-07 NDC inpatient 1 UN 83.03 53.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.29 69 999999999 50.27 80.54 percent of total billed charges 39822-1001-07 - tranexamic acid 100 mg/mL Sol [JOHN] 48604839_1 CDM 0250 RC 39822-1001-07 NDC inpatient 1 UN 83.03 53.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.76 78 999999999 50.27 80.54 percent of total billed charges 39822-1001-07 - tranexamic acid 100 mg/mL Sol [JOHN] 48604839_1 CDM 0250 RC 39822-1001-07 NDC inpatient 1 UN 83.03 53.97 SIHO - ALL PLANS SIHO - ALL PLANS 74.73 90 999999999 50.27 80.54 percent of total billed charges 39822-1001-07 - tranexamic acid 100 mg/mL Sol [JOHN] 48604839_1 CDM 0250 RC 39822-1001-07 NDC inpatient 1 UN 83.03 53.97 UMR - ALL PLANS UMR - ALL PLANS 58.12 70 999999999 50.27 80.54 percent of total billed charges 39822-1001-07 - tranexamic acid 100 mg/mL Sol [JOHN] 48604839_1 CDM 0250 RC 39822-1001-07 NDC inpatient 1 UN 83.03 53.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.27 60.55 999999999 50.27 80.54 percent of total billed charges 39822-1001-07 - tranexamic acid 100 mg/mL Sol [JOHN] 48604839_1 CDM 0250 RC 39822-1001-07 NDC inpatient 1 UN 83.03 53.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.27 80.54 39822-1001-07 - tranexamic acid 100 mg/mL Sol [JOHN] 48604839_1 CDM 0250 RC 39822-1001-07 NDC inpatient 1 UN 83.03 53.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.27 80.54 39822-1001-07 - tranexamic acid 100 mg/mL Sol [JOHN] 48604839_1 CDM 0250 RC 39822-1001-07 NDC inpatient 1 UN 83.03 53.97 ANTHEM HMO ANTHEM HMO 999999999 50.27 80.54 39822-1001-07 - tranexamic acid 100 mg/mL Sol [JOHN] 48604839_1 CDM 0250 RC 39822-1001-07 NDC inpatient 1 UN 83.03 53.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.27 80.54 39822-1001-07 - tranexamic acid 100 mg/mL Sol [JOHN] 48604839_1 CDM 0250 RC 39822-1001-07 NDC inpatient 1 UN 83.03 53.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.13 67.6 999999999 50.27 80.54 percent of total billed charges 39822-1001-07 - tranexamic acid 100 mg/mL Sol [JOHN] 48604839_1 CDM 0250 RC 39822-1001-07 NDC inpatient 1 UN 83.03 53.97 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.27 80.54 OR IV HYDRATION THER ADD HOUR 48606174_1 CDM 0260 RC inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges OR IV HYDRATION THER ADD HOUR 48606174_1 CDM 0260 RC inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges OR IV HYDRATION THER ADD HOUR 48606174_1 CDM 0260 RC inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges OR IV HYDRATION THER ADD HOUR 48606174_1 CDM 0260 RC inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges OR IV HYDRATION THER ADD HOUR 48606174_1 CDM 0260 RC inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges OR IV HYDRATION THER ADD HOUR 48606174_1 CDM 0260 RC inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges OR IV HYDRATION THER ADD HOUR 48606174_1 CDM 0260 RC inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges OR IV HYDRATION THER ADD HOUR 48606174_1 CDM 0260 RC inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges OR IV HYDRATION THER ADD HOUR 48606174_1 CDM 0260 RC inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 OR IV HYDRATION THER ADD HOUR 48606174_1 CDM 0260 RC inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 OR IV HYDRATION THER ADD HOUR 48606174_1 CDM 0260 RC inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 OR IV HYDRATION THER ADD HOUR 48606174_1 CDM 0260 RC inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 OR IV HYDRATION THER ADD HOUR 48606174_1 CDM 0260 RC inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges OR IV HYDRATION THER ADD HOUR 48606174_1 CDM 0260 RC inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 OR NON CHEMO INF INITIAL HOUR 48606175_1 CDM 0260 RC inpatient 505 328.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 328.25 65 999999999 305.78 489.85 percent of total billed charges OR NON CHEMO INF INITIAL HOUR 48606175_1 CDM 0260 RC inpatient 505 328.25 AETNA AETNA 398.95 79 999999999 305.78 489.85 percent of total billed charges OR NON CHEMO INF INITIAL HOUR 48606175_1 CDM 0260 RC inpatient 505 328.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 489.85 97 999999999 305.78 489.85 percent of total billed charges OR NON CHEMO INF INITIAL HOUR 48606175_1 CDM 0260 RC inpatient 505 328.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 348.45 69 999999999 305.78 489.85 percent of total billed charges OR NON CHEMO INF INITIAL HOUR 48606175_1 CDM 0260 RC inpatient 505 328.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 393.9 78 999999999 305.78 489.85 percent of total billed charges OR NON CHEMO INF INITIAL HOUR 48606175_1 CDM 0260 RC inpatient 505 328.25 SIHO - ALL PLANS SIHO - ALL PLANS 454.5 90 999999999 305.78 489.85 percent of total billed charges OR NON CHEMO INF INITIAL HOUR 48606175_1 CDM 0260 RC inpatient 505 328.25 UMR - ALL PLANS UMR - ALL PLANS 353.5 70 999999999 305.78 489.85 percent of total billed charges OR NON CHEMO INF INITIAL HOUR 48606175_1 CDM 0260 RC inpatient 505 328.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 305.78 60.55 999999999 305.78 489.85 percent of total billed charges OR NON CHEMO INF INITIAL HOUR 48606175_1 CDM 0260 RC inpatient 505 328.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 305.78 489.85 OR NON CHEMO INF INITIAL HOUR 48606175_1 CDM 0260 RC inpatient 505 328.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 305.78 489.85 OR NON CHEMO INF INITIAL HOUR 48606175_1 CDM 0260 RC inpatient 505 328.25 ANTHEM HMO ANTHEM HMO 999999999 305.78 489.85 OR NON CHEMO INF INITIAL HOUR 48606175_1 CDM 0260 RC inpatient 505 328.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 305.78 489.85 OR NON CHEMO INF INITIAL HOUR 48606175_1 CDM 0260 RC inpatient 505 328.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 341.38 67.6 999999999 305.78 489.85 percent of total billed charges OR NON CHEMO INF INITIAL HOUR 48606175_1 CDM 0260 RC inpatient 505 328.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 305.78 489.85 OR NON CHEMO INF EA ADD HOUR 48606176_1 CDM 0260 RC inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges OR NON CHEMO INF EA ADD HOUR 48606176_1 CDM 0260 RC inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges OR NON CHEMO INF EA ADD HOUR 48606176_1 CDM 0260 RC inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges OR NON CHEMO INF EA ADD HOUR 48606176_1 CDM 0260 RC inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges OR NON CHEMO INF EA ADD HOUR 48606176_1 CDM 0260 RC inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges OR NON CHEMO INF EA ADD HOUR 48606176_1 CDM 0260 RC inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges OR NON CHEMO INF EA ADD HOUR 48606176_1 CDM 0260 RC inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges OR NON CHEMO INF EA ADD HOUR 48606176_1 CDM 0260 RC inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges OR NON CHEMO INF EA ADD HOUR 48606176_1 CDM 0260 RC inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 OR NON CHEMO INF EA ADD HOUR 48606176_1 CDM 0260 RC inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 OR NON CHEMO INF EA ADD HOUR 48606176_1 CDM 0260 RC inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 OR NON CHEMO INF EA ADD HOUR 48606176_1 CDM 0260 RC inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 OR NON CHEMO INF EA ADD HOUR 48606176_1 CDM 0260 RC inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges OR NON CHEMO INF EA ADD HOUR 48606176_1 CDM 0260 RC inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 OR TAKE HOME WOUND SUPPLY 48606177_1 CDM 0270 RC inpatient 34 22.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.1 65 999999999 20.59 32.98 percent of total billed charges OR TAKE HOME WOUND SUPPLY 48606177_1 CDM 0270 RC inpatient 34 22.1 AETNA AETNA 26.86 79 999999999 20.59 32.98 percent of total billed charges OR TAKE HOME WOUND SUPPLY 48606177_1 CDM 0270 RC inpatient 34 22.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.98 97 999999999 20.59 32.98 percent of total billed charges OR TAKE HOME WOUND SUPPLY 48606177_1 CDM 0270 RC inpatient 34 22.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 23.46 69 999999999 20.59 32.98 percent of total billed charges OR TAKE HOME WOUND SUPPLY 48606177_1 CDM 0270 RC inpatient 34 22.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 26.52 78 999999999 20.59 32.98 percent of total billed charges OR TAKE HOME WOUND SUPPLY 48606177_1 CDM 0270 RC inpatient 34 22.1 SIHO - ALL PLANS SIHO - ALL PLANS 30.6 90 999999999 20.59 32.98 percent of total billed charges OR TAKE HOME WOUND SUPPLY 48606177_1 CDM 0270 RC inpatient 34 22.1 UMR - ALL PLANS UMR - ALL PLANS 23.8 70 999999999 20.59 32.98 percent of total billed charges OR TAKE HOME WOUND SUPPLY 48606177_1 CDM 0270 RC inpatient 34 22.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.59 60.55 999999999 20.59 32.98 percent of total billed charges OR TAKE HOME WOUND SUPPLY 48606177_1 CDM 0270 RC inpatient 34 22.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.59 32.98 OR TAKE HOME WOUND SUPPLY 48606177_1 CDM 0270 RC inpatient 34 22.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.59 32.98 OR TAKE HOME WOUND SUPPLY 48606177_1 CDM 0270 RC inpatient 34 22.1 ANTHEM HMO ANTHEM HMO 999999999 20.59 32.98 OR TAKE HOME WOUND SUPPLY 48606177_1 CDM 0270 RC inpatient 34 22.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.59 32.98 OR TAKE HOME WOUND SUPPLY 48606177_1 CDM 0270 RC inpatient 34 22.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.98 67.6 999999999 20.59 32.98 percent of total billed charges OR TAKE HOME WOUND SUPPLY 48606177_1 CDM 0270 RC inpatient 34 22.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.59 32.98 OR IVAS VERTEBRAL AUGMTN SYST 48606178_1 CDM 0272 RC inpatient 5385 3500.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 3500.25 65 999999999 3260.62 5223.45 percent of total billed charges OR IVAS VERTEBRAL AUGMTN SYST 48606178_1 CDM 0272 RC inpatient 5385 3500.25 AETNA AETNA 4254.15 79 999999999 3260.62 5223.45 percent of total billed charges OR IVAS VERTEBRAL AUGMTN SYST 48606178_1 CDM 0272 RC inpatient 5385 3500.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5223.45 97 999999999 3260.62 5223.45 percent of total billed charges OR IVAS VERTEBRAL AUGMTN SYST 48606178_1 CDM 0272 RC inpatient 5385 3500.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 3715.65 69 999999999 3260.62 5223.45 percent of total billed charges OR IVAS VERTEBRAL AUGMTN SYST 48606178_1 CDM 0272 RC inpatient 5385 3500.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 4200.3 78 999999999 3260.62 5223.45 percent of total billed charges OR IVAS VERTEBRAL AUGMTN SYST 48606178_1 CDM 0272 RC inpatient 5385 3500.25 SIHO - ALL PLANS SIHO - ALL PLANS 4846.5 90 999999999 3260.62 5223.45 percent of total billed charges OR IVAS VERTEBRAL AUGMTN SYST 48606178_1 CDM 0272 RC inpatient 5385 3500.25 UMR - ALL PLANS UMR - ALL PLANS 3769.5 70 999999999 3260.62 5223.45 percent of total billed charges OR IVAS VERTEBRAL AUGMTN SYST 48606178_1 CDM 0272 RC inpatient 5385 3500.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3260.62 60.55 999999999 3260.62 5223.45 percent of total billed charges OR IVAS VERTEBRAL AUGMTN SYST 48606178_1 CDM 0272 RC inpatient 5385 3500.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3260.62 5223.45 OR IVAS VERTEBRAL AUGMTN SYST 48606178_1 CDM 0272 RC inpatient 5385 3500.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3260.62 5223.45 OR IVAS VERTEBRAL AUGMTN SYST 48606178_1 CDM 0272 RC inpatient 5385 3500.25 ANTHEM HMO ANTHEM HMO 999999999 3260.62 5223.45 OR IVAS VERTEBRAL AUGMTN SYST 48606178_1 CDM 0272 RC inpatient 5385 3500.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3260.62 5223.45 OR IVAS VERTEBRAL AUGMTN SYST 48606178_1 CDM 0272 RC inpatient 5385 3500.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 3640.26 67.6 999999999 3260.62 5223.45 percent of total billed charges OR IVAS VERTEBRAL AUGMTN SYST 48606178_1 CDM 0272 RC inpatient 5385 3500.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 3260.62 5223.45 OR LIGASURE HANDPIECE BLUNT 48606179_1 CDM 0272 RC inpatient 2428 1578.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1578.2 65 999999999 1470.15 2355.16 percent of total billed charges OR LIGASURE HANDPIECE BLUNT 48606179_1 CDM 0272 RC inpatient 2428 1578.2 AETNA AETNA 1918.12 79 999999999 1470.15 2355.16 percent of total billed charges OR LIGASURE HANDPIECE BLUNT 48606179_1 CDM 0272 RC inpatient 2428 1578.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2355.16 97 999999999 1470.15 2355.16 percent of total billed charges OR LIGASURE HANDPIECE BLUNT 48606179_1 CDM 0272 RC inpatient 2428 1578.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1675.32 69 999999999 1470.15 2355.16 percent of total billed charges OR LIGASURE HANDPIECE BLUNT 48606179_1 CDM 0272 RC inpatient 2428 1578.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1893.84 78 999999999 1470.15 2355.16 percent of total billed charges OR LIGASURE HANDPIECE BLUNT 48606179_1 CDM 0272 RC inpatient 2428 1578.2 SIHO - ALL PLANS SIHO - ALL PLANS 2185.2 90 999999999 1470.15 2355.16 percent of total billed charges OR LIGASURE HANDPIECE BLUNT 48606179_1 CDM 0272 RC inpatient 2428 1578.2 UMR - ALL PLANS UMR - ALL PLANS 1699.6 70 999999999 1470.15 2355.16 percent of total billed charges OR LIGASURE HANDPIECE BLUNT 48606179_1 CDM 0272 RC inpatient 2428 1578.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1470.15 60.55 999999999 1470.15 2355.16 percent of total billed charges OR LIGASURE HANDPIECE BLUNT 48606179_1 CDM 0272 RC inpatient 2428 1578.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1470.15 2355.16 OR LIGASURE HANDPIECE BLUNT 48606179_1 CDM 0272 RC inpatient 2428 1578.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1470.15 2355.16 OR LIGASURE HANDPIECE BLUNT 48606179_1 CDM 0272 RC inpatient 2428 1578.2 ANTHEM HMO ANTHEM HMO 999999999 1470.15 2355.16 OR LIGASURE HANDPIECE BLUNT 48606179_1 CDM 0272 RC inpatient 2428 1578.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1470.15 2355.16 OR LIGASURE HANDPIECE BLUNT 48606179_1 CDM 0272 RC inpatient 2428 1578.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1641.33 67.6 999999999 1470.15 2355.16 percent of total billed charges OR LIGASURE HANDPIECE BLUNT 48606179_1 CDM 0272 RC inpatient 2428 1578.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1470.15 2355.16 OR ARTHREX TIGHTROPES 48606284_1 CDM 0278 RC inpatient 2225 1446.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1446.25 65 999999999 1347.24 2158.25 percent of total billed charges OR ARTHREX TIGHTROPES 48606284_1 CDM 0278 RC inpatient 2225 1446.25 AETNA AETNA 1757.75 79 999999999 1347.24 2158.25 percent of total billed charges OR ARTHREX TIGHTROPES 48606284_1 CDM 0278 RC inpatient 2225 1446.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2158.25 97 999999999 1347.24 2158.25 percent of total billed charges OR ARTHREX TIGHTROPES 48606284_1 CDM 0278 RC inpatient 2225 1446.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1535.25 69 999999999 1347.24 2158.25 percent of total billed charges OR ARTHREX TIGHTROPES 48606284_1 CDM 0278 RC inpatient 2225 1446.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1735.5 78 999999999 1347.24 2158.25 percent of total billed charges OR ARTHREX TIGHTROPES 48606284_1 CDM 0278 RC inpatient 2225 1446.25 SIHO - ALL PLANS SIHO - ALL PLANS 2002.5 90 999999999 1347.24 2158.25 percent of total billed charges OR ARTHREX TIGHTROPES 48606284_1 CDM 0278 RC inpatient 2225 1446.25 UMR - ALL PLANS UMR - ALL PLANS 1557.5 70 999999999 1347.24 2158.25 percent of total billed charges OR ARTHREX TIGHTROPES 48606284_1 CDM 0278 RC inpatient 2225 1446.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1347.24 60.55 999999999 1347.24 2158.25 percent of total billed charges OR ARTHREX TIGHTROPES 48606284_1 CDM 0278 RC inpatient 2225 1446.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1347.24 2158.25 OR ARTHREX TIGHTROPES 48606284_1 CDM 0278 RC inpatient 2225 1446.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1347.24 2158.25 OR ARTHREX TIGHTROPES 48606284_1 CDM 0278 RC inpatient 2225 1446.25 ANTHEM HMO ANTHEM HMO 999999999 1347.24 2158.25 OR ARTHREX TIGHTROPES 48606284_1 CDM 0278 RC inpatient 2225 1446.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1347.24 2158.25 OR ARTHREX TIGHTROPES 48606284_1 CDM 0278 RC inpatient 2225 1446.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1504.1 67.6 999999999 1347.24 2158.25 percent of total billed charges OR ARTHREX TIGHTROPES 48606284_1 CDM 0278 RC inpatient 2225 1446.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1347.24 2158.25 "Coagulation time measurement, activated" 48606285_1 CDM 0300 RC 85347 HCPCS inpatient 104 67.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 67.6 65 999999999 62.97 100.88 percent of total billed charges "Coagulation time measurement, activated" 48606285_1 CDM 0300 RC 85347 HCPCS inpatient 104 67.6 AETNA AETNA 82.16 79 999999999 62.97 100.88 percent of total billed charges "Coagulation time measurement, activated" 48606285_1 CDM 0300 RC 85347 HCPCS inpatient 104 67.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 100.88 97 999999999 62.97 100.88 percent of total billed charges "Coagulation time measurement, activated" 48606285_1 CDM 0300 RC 85347 HCPCS inpatient 104 67.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.76 69 999999999 62.97 100.88 percent of total billed charges "Coagulation time measurement, activated" 48606285_1 CDM 0300 RC 85347 HCPCS inpatient 104 67.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.12 78 999999999 62.97 100.88 percent of total billed charges "Coagulation time measurement, activated" 48606285_1 CDM 0300 RC 85347 HCPCS inpatient 104 67.6 SIHO - ALL PLANS SIHO - ALL PLANS 93.6 90 999999999 62.97 100.88 percent of total billed charges "Coagulation time measurement, activated" 48606285_1 CDM 0300 RC 85347 HCPCS inpatient 104 67.6 UMR - ALL PLANS UMR - ALL PLANS 72.8 70 999999999 62.97 100.88 percent of total billed charges "Coagulation time measurement, activated" 48606285_1 CDM 0300 RC 85347 HCPCS inpatient 104 67.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.97 60.55 999999999 62.97 100.88 percent of total billed charges "Coagulation time measurement, activated" 48606285_1 CDM 0300 RC 85347 HCPCS inpatient 104 67.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.97 100.88 "Coagulation time measurement, activated" 48606285_1 CDM 0300 RC 85347 HCPCS inpatient 104 67.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.97 100.88 "Coagulation time measurement, activated" 48606285_1 CDM 0300 RC 85347 HCPCS inpatient 104 67.6 ANTHEM HMO ANTHEM HMO 999999999 62.97 100.88 "Coagulation time measurement, activated" 48606285_1 CDM 0300 RC 85347 HCPCS inpatient 104 67.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.97 100.88 "Coagulation time measurement, activated" 48606285_1 CDM 0300 RC 85347 HCPCS inpatient 104 67.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.3 67.6 999999999 62.97 100.88 percent of total billed charges "Coagulation time measurement, activated" 48606285_1 CDM 0300 RC 85347 HCPCS inpatient 104 67.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.97 100.88 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606286_1 CDM 0360 RC inpatient 578 375.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 375.7 65 999999999 349.98 560.66 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606286_1 CDM 0360 RC inpatient 578 375.7 AETNA AETNA 456.62 79 999999999 349.98 560.66 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606286_1 CDM 0360 RC inpatient 578 375.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 560.66 97 999999999 349.98 560.66 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606286_1 CDM 0360 RC inpatient 578 375.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 398.82 69 999999999 349.98 560.66 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606286_1 CDM 0360 RC inpatient 578 375.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 450.84 78 999999999 349.98 560.66 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606286_1 CDM 0360 RC inpatient 578 375.7 SIHO - ALL PLANS SIHO - ALL PLANS 520.2 90 999999999 349.98 560.66 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606286_1 CDM 0360 RC inpatient 578 375.7 UMR - ALL PLANS UMR - ALL PLANS 404.6 70 999999999 349.98 560.66 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606286_1 CDM 0360 RC inpatient 578 375.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 349.98 60.55 999999999 349.98 560.66 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606286_1 CDM 0360 RC inpatient 578 375.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 349.98 560.66 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606286_1 CDM 0360 RC inpatient 578 375.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 349.98 560.66 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606286_1 CDM 0360 RC inpatient 578 375.7 ANTHEM HMO ANTHEM HMO 999999999 349.98 560.66 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606286_1 CDM 0360 RC inpatient 578 375.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 349.98 560.66 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606286_1 CDM 0360 RC inpatient 578 375.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 390.73 67.6 999999999 349.98 560.66 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606286_1 CDM 0360 RC inpatient 578 375.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 349.98 560.66 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606287_1 CDM 0360 RC inpatient 442 287.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 287.3 65 999999999 267.63 428.74 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606287_1 CDM 0360 RC inpatient 442 287.3 AETNA AETNA 349.18 79 999999999 267.63 428.74 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606287_1 CDM 0360 RC inpatient 442 287.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 428.74 97 999999999 267.63 428.74 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606287_1 CDM 0360 RC inpatient 442 287.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 304.98 69 999999999 267.63 428.74 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606287_1 CDM 0360 RC inpatient 442 287.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 344.76 78 999999999 267.63 428.74 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606287_1 CDM 0360 RC inpatient 442 287.3 SIHO - ALL PLANS SIHO - ALL PLANS 397.8 90 999999999 267.63 428.74 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606287_1 CDM 0360 RC inpatient 442 287.3 UMR - ALL PLANS UMR - ALL PLANS 309.4 70 999999999 267.63 428.74 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606287_1 CDM 0360 RC inpatient 442 287.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 267.63 60.55 999999999 267.63 428.74 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606287_1 CDM 0360 RC inpatient 442 287.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 267.63 428.74 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606287_1 CDM 0360 RC inpatient 442 287.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 267.63 428.74 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606287_1 CDM 0360 RC inpatient 442 287.3 ANTHEM HMO ANTHEM HMO 999999999 267.63 428.74 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606287_1 CDM 0360 RC inpatient 442 287.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 267.63 428.74 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606287_1 CDM 0360 RC inpatient 442 287.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 298.79 67.6 999999999 267.63 428.74 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606287_1 CDM 0360 RC inpatient 442 287.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 267.63 428.74 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606288_1 CDM 0360 RC inpatient 2434 1582.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1582.1 65 999999999 1473.79 2360.98 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606288_1 CDM 0360 RC inpatient 2434 1582.1 AETNA AETNA 1922.86 79 999999999 1473.79 2360.98 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606288_1 CDM 0360 RC inpatient 2434 1582.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2360.98 97 999999999 1473.79 2360.98 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606288_1 CDM 0360 RC inpatient 2434 1582.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 1679.46 69 999999999 1473.79 2360.98 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606288_1 CDM 0360 RC inpatient 2434 1582.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1898.52 78 999999999 1473.79 2360.98 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606288_1 CDM 0360 RC inpatient 2434 1582.1 SIHO - ALL PLANS SIHO - ALL PLANS 2190.6 90 999999999 1473.79 2360.98 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606288_1 CDM 0360 RC inpatient 2434 1582.1 UMR - ALL PLANS UMR - ALL PLANS 1703.8 70 999999999 1473.79 2360.98 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606288_1 CDM 0360 RC inpatient 2434 1582.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1473.79 60.55 999999999 1473.79 2360.98 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606288_1 CDM 0360 RC inpatient 2434 1582.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1473.79 2360.98 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606288_1 CDM 0360 RC inpatient 2434 1582.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1473.79 2360.98 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606288_1 CDM 0360 RC inpatient 2434 1582.1 ANTHEM HMO ANTHEM HMO 999999999 1473.79 2360.98 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606288_1 CDM 0360 RC inpatient 2434 1582.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1473.79 2360.98 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606288_1 CDM 0360 RC inpatient 2434 1582.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1645.38 67.6 999999999 1473.79 2360.98 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606288_1 CDM 0360 RC inpatient 2434 1582.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1473.79 2360.98 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606289_1 CDM 0360 RC inpatient 1708 1110.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1110.2 65 999999999 1034.19 1656.76 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606289_1 CDM 0360 RC inpatient 1708 1110.2 AETNA AETNA 1349.32 79 999999999 1034.19 1656.76 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606289_1 CDM 0360 RC inpatient 1708 1110.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1656.76 97 999999999 1034.19 1656.76 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606289_1 CDM 0360 RC inpatient 1708 1110.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1178.52 69 999999999 1034.19 1656.76 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606289_1 CDM 0360 RC inpatient 1708 1110.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1332.24 78 999999999 1034.19 1656.76 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606289_1 CDM 0360 RC inpatient 1708 1110.2 SIHO - ALL PLANS SIHO - ALL PLANS 1537.2 90 999999999 1034.19 1656.76 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606289_1 CDM 0360 RC inpatient 1708 1110.2 UMR - ALL PLANS UMR - ALL PLANS 1195.6 70 999999999 1034.19 1656.76 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606289_1 CDM 0360 RC inpatient 1708 1110.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1034.19 60.55 999999999 1034.19 1656.76 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606289_1 CDM 0360 RC inpatient 1708 1110.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1034.19 1656.76 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606289_1 CDM 0360 RC inpatient 1708 1110.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1034.19 1656.76 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606289_1 CDM 0360 RC inpatient 1708 1110.2 ANTHEM HMO ANTHEM HMO 999999999 1034.19 1656.76 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606289_1 CDM 0360 RC inpatient 1708 1110.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1034.19 1656.76 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606289_1 CDM 0360 RC inpatient 1708 1110.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1154.61 67.6 999999999 1034.19 1656.76 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606289_1 CDM 0360 RC inpatient 1708 1110.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1034.19 1656.76 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606290_1 CDM 0360 RC inpatient 2302 1496.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1496.3 65 999999999 1393.86 2232.94 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606290_1 CDM 0360 RC inpatient 2302 1496.3 AETNA AETNA 1818.58 79 999999999 1393.86 2232.94 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606290_1 CDM 0360 RC inpatient 2302 1496.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2232.94 97 999999999 1393.86 2232.94 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606290_1 CDM 0360 RC inpatient 2302 1496.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1588.38 69 999999999 1393.86 2232.94 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606290_1 CDM 0360 RC inpatient 2302 1496.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1795.56 78 999999999 1393.86 2232.94 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606290_1 CDM 0360 RC inpatient 2302 1496.3 SIHO - ALL PLANS SIHO - ALL PLANS 2071.8 90 999999999 1393.86 2232.94 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606290_1 CDM 0360 RC inpatient 2302 1496.3 UMR - ALL PLANS UMR - ALL PLANS 1611.4 70 999999999 1393.86 2232.94 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606290_1 CDM 0360 RC inpatient 2302 1496.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1393.86 60.55 999999999 1393.86 2232.94 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606290_1 CDM 0360 RC inpatient 2302 1496.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1393.86 2232.94 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606290_1 CDM 0360 RC inpatient 2302 1496.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1393.86 2232.94 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606290_1 CDM 0360 RC inpatient 2302 1496.3 ANTHEM HMO ANTHEM HMO 999999999 1393.86 2232.94 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606290_1 CDM 0360 RC inpatient 2302 1496.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1393.86 2232.94 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606290_1 CDM 0360 RC inpatient 2302 1496.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1556.15 67.6 999999999 1393.86 2232.94 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606290_1 CDM 0360 RC inpatient 2302 1496.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1393.86 2232.94 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606291_1 CDM 0360 RC inpatient 515 334.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 334.75 65 999999999 311.83 499.55 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606291_1 CDM 0360 RC inpatient 515 334.75 AETNA AETNA 406.85 79 999999999 311.83 499.55 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606291_1 CDM 0360 RC inpatient 515 334.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 499.55 97 999999999 311.83 499.55 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606291_1 CDM 0360 RC inpatient 515 334.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 355.35 69 999999999 311.83 499.55 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606291_1 CDM 0360 RC inpatient 515 334.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 401.7 78 999999999 311.83 499.55 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606291_1 CDM 0360 RC inpatient 515 334.75 SIHO - ALL PLANS SIHO - ALL PLANS 463.5 90 999999999 311.83 499.55 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606291_1 CDM 0360 RC inpatient 515 334.75 UMR - ALL PLANS UMR - ALL PLANS 360.5 70 999999999 311.83 499.55 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606291_1 CDM 0360 RC inpatient 515 334.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 311.83 60.55 999999999 311.83 499.55 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606291_1 CDM 0360 RC inpatient 515 334.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 311.83 499.55 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606291_1 CDM 0360 RC inpatient 515 334.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 311.83 499.55 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606291_1 CDM 0360 RC inpatient 515 334.75 ANTHEM HMO ANTHEM HMO 999999999 311.83 499.55 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606291_1 CDM 0360 RC inpatient 515 334.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 311.83 499.55 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606291_1 CDM 0360 RC inpatient 515 334.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 348.14 67.6 999999999 311.83 499.55 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606291_1 CDM 0360 RC inpatient 515 334.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 311.83 499.55 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606308_1 CDM 0360 RC inpatient 204 132.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.6 65 999999999 123.52 197.88 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606308_1 CDM 0360 RC inpatient 204 132.6 AETNA AETNA 161.16 79 999999999 123.52 197.88 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606308_1 CDM 0360 RC inpatient 204 132.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.88 97 999999999 123.52 197.88 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606308_1 CDM 0360 RC inpatient 204 132.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.76 69 999999999 123.52 197.88 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606308_1 CDM 0360 RC inpatient 204 132.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.12 78 999999999 123.52 197.88 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606308_1 CDM 0360 RC inpatient 204 132.6 SIHO - ALL PLANS SIHO - ALL PLANS 183.6 90 999999999 123.52 197.88 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606308_1 CDM 0360 RC inpatient 204 132.6 UMR - ALL PLANS UMR - ALL PLANS 142.8 70 999999999 123.52 197.88 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606308_1 CDM 0360 RC inpatient 204 132.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.52 60.55 999999999 123.52 197.88 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606308_1 CDM 0360 RC inpatient 204 132.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.52 197.88 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606308_1 CDM 0360 RC inpatient 204 132.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.52 197.88 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606308_1 CDM 0360 RC inpatient 204 132.6 ANTHEM HMO ANTHEM HMO 999999999 123.52 197.88 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606308_1 CDM 0360 RC inpatient 204 132.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.52 197.88 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606308_1 CDM 0360 RC inpatient 204 132.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.9 67.6 999999999 123.52 197.88 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606308_1 CDM 0360 RC inpatient 204 132.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.52 197.88 Electronic analysis of neurostimulator generator with simple cranial nerve stimulator programming 48606309_1 CDM 0360 RC 95976 HCPCS inpatient 374 243.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 243.1 65 999999999 226.46 362.78 percent of total billed charges Electronic analysis of neurostimulator generator with simple cranial nerve stimulator programming 48606309_1 CDM 0360 RC 95976 HCPCS inpatient 374 243.1 AETNA AETNA 295.46 79 999999999 226.46 362.78 percent of total billed charges Electronic analysis of neurostimulator generator with simple cranial nerve stimulator programming 48606309_1 CDM 0360 RC 95976 HCPCS inpatient 374 243.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 362.78 97 999999999 226.46 362.78 percent of total billed charges Electronic analysis of neurostimulator generator with simple cranial nerve stimulator programming 48606309_1 CDM 0360 RC 95976 HCPCS inpatient 374 243.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 258.06 69 999999999 226.46 362.78 percent of total billed charges Electronic analysis of neurostimulator generator with simple cranial nerve stimulator programming 48606309_1 CDM 0360 RC 95976 HCPCS inpatient 374 243.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 291.72 78 999999999 226.46 362.78 percent of total billed charges Electronic analysis of neurostimulator generator with simple cranial nerve stimulator programming 48606309_1 CDM 0360 RC 95976 HCPCS inpatient 374 243.1 SIHO - ALL PLANS SIHO - ALL PLANS 336.6 90 999999999 226.46 362.78 percent of total billed charges Electronic analysis of neurostimulator generator with simple cranial nerve stimulator programming 48606309_1 CDM 0360 RC 95976 HCPCS inpatient 374 243.1 UMR - ALL PLANS UMR - ALL PLANS 261.8 70 999999999 226.46 362.78 percent of total billed charges Electronic analysis of neurostimulator generator with simple cranial nerve stimulator programming 48606309_1 CDM 0360 RC 95976 HCPCS inpatient 374 243.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 226.46 60.55 999999999 226.46 362.78 percent of total billed charges Electronic analysis of neurostimulator generator with simple cranial nerve stimulator programming 48606309_1 CDM 0360 RC 95976 HCPCS inpatient 374 243.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 226.46 362.78 Electronic analysis of neurostimulator generator with simple cranial nerve stimulator programming 48606309_1 CDM 0360 RC 95976 HCPCS inpatient 374 243.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 226.46 362.78 Electronic analysis of neurostimulator generator with simple cranial nerve stimulator programming 48606309_1 CDM 0360 RC 95976 HCPCS inpatient 374 243.1 ANTHEM HMO ANTHEM HMO 999999999 226.46 362.78 Electronic analysis of neurostimulator generator with simple cranial nerve stimulator programming 48606309_1 CDM 0360 RC 95976 HCPCS inpatient 374 243.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 226.46 362.78 Electronic analysis of neurostimulator generator with simple cranial nerve stimulator programming 48606309_1 CDM 0360 RC 95976 HCPCS inpatient 374 243.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 252.82 67.6 999999999 226.46 362.78 percent of total billed charges Electronic analysis of neurostimulator generator with simple cranial nerve stimulator programming 48606309_1 CDM 0360 RC 95976 HCPCS inpatient 374 243.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 226.46 362.78 CRANIAL NEUROSTIM COMPLEX 48606310_1 CDM 0360 RC 95975 HCPCS inpatient 374 243.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 243.1 65 999999999 226.46 362.78 percent of total billed charges CRANIAL NEUROSTIM COMPLEX 48606310_1 CDM 0360 RC 95975 HCPCS inpatient 374 243.1 AETNA AETNA 295.46 79 999999999 226.46 362.78 percent of total billed charges CRANIAL NEUROSTIM COMPLEX 48606310_1 CDM 0360 RC 95975 HCPCS inpatient 374 243.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 362.78 97 999999999 226.46 362.78 percent of total billed charges CRANIAL NEUROSTIM COMPLEX 48606310_1 CDM 0360 RC 95975 HCPCS inpatient 374 243.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 258.06 69 999999999 226.46 362.78 percent of total billed charges CRANIAL NEUROSTIM COMPLEX 48606310_1 CDM 0360 RC 95975 HCPCS inpatient 374 243.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 291.72 78 999999999 226.46 362.78 percent of total billed charges CRANIAL NEUROSTIM COMPLEX 48606310_1 CDM 0360 RC 95975 HCPCS inpatient 374 243.1 SIHO - ALL PLANS SIHO - ALL PLANS 336.6 90 999999999 226.46 362.78 percent of total billed charges CRANIAL NEUROSTIM COMPLEX 48606310_1 CDM 0360 RC 95975 HCPCS inpatient 374 243.1 UMR - ALL PLANS UMR - ALL PLANS 261.8 70 999999999 226.46 362.78 percent of total billed charges CRANIAL NEUROSTIM COMPLEX 48606310_1 CDM 0360 RC 95975 HCPCS inpatient 374 243.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 226.46 60.55 999999999 226.46 362.78 percent of total billed charges CRANIAL NEUROSTIM COMPLEX 48606310_1 CDM 0360 RC 95975 HCPCS inpatient 374 243.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 226.46 362.78 CRANIAL NEUROSTIM COMPLEX 48606310_1 CDM 0360 RC 95975 HCPCS inpatient 374 243.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 226.46 362.78 CRANIAL NEUROSTIM COMPLEX 48606310_1 CDM 0360 RC 95975 HCPCS inpatient 374 243.1 ANTHEM HMO ANTHEM HMO 999999999 226.46 362.78 CRANIAL NEUROSTIM COMPLEX 48606310_1 CDM 0360 RC 95975 HCPCS inpatient 374 243.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 226.46 362.78 CRANIAL NEUROSTIM COMPLEX 48606310_1 CDM 0360 RC 95975 HCPCS inpatient 374 243.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 252.82 67.6 999999999 226.46 362.78 percent of total billed charges CRANIAL NEUROSTIM COMPLEX 48606310_1 CDM 0360 RC 95975 HCPCS inpatient 374 243.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 226.46 362.78 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606316_1 CDM 0360 RC inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606316_1 CDM 0360 RC inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606316_1 CDM 0360 RC inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606316_1 CDM 0360 RC inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606316_1 CDM 0360 RC inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606316_1 CDM 0360 RC inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606316_1 CDM 0360 RC inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606316_1 CDM 0360 RC inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606316_1 CDM 0360 RC inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606316_1 CDM 0360 RC inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606316_1 CDM 0360 RC inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606316_1 CDM 0360 RC inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606316_1 CDM 0360 RC inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606316_1 CDM 0360 RC inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606317_1 CDM 0360 RC inpatient 763 495.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 495.95 65 999999999 462 740.11 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606317_1 CDM 0360 RC inpatient 763 495.95 AETNA AETNA 602.77 79 999999999 462 740.11 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606317_1 CDM 0360 RC inpatient 763 495.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 740.11 97 999999999 462 740.11 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606317_1 CDM 0360 RC inpatient 763 495.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 526.47 69 999999999 462 740.11 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606317_1 CDM 0360 RC inpatient 763 495.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 595.14 78 999999999 462 740.11 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606317_1 CDM 0360 RC inpatient 763 495.95 SIHO - ALL PLANS SIHO - ALL PLANS 686.7 90 999999999 462 740.11 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606317_1 CDM 0360 RC inpatient 763 495.95 UMR - ALL PLANS UMR - ALL PLANS 534.1 70 999999999 462 740.11 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606317_1 CDM 0360 RC inpatient 763 495.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 462 60.55 999999999 462 740.11 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606317_1 CDM 0360 RC inpatient 763 495.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 462 740.11 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606317_1 CDM 0360 RC inpatient 763 495.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 462 740.11 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606317_1 CDM 0360 RC inpatient 763 495.95 ANTHEM HMO ANTHEM HMO 999999999 462 740.11 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606317_1 CDM 0360 RC inpatient 763 495.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 462 740.11 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606317_1 CDM 0360 RC inpatient 763 495.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 515.79 67.6 999999999 462 740.11 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 48606317_1 CDM 0360 RC inpatient 763 495.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 462 740.11 OPERATING ROOM SERVICES - MINOR SURGERY 48606480_1 CDM 0361 RC inpatient 1390 903.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 903.5 65 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606480_1 CDM 0361 RC inpatient 1390 903.5 AETNA AETNA 1098.1 79 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606480_1 CDM 0361 RC inpatient 1390 903.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1348.3 97 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606480_1 CDM 0361 RC inpatient 1390 903.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 959.1 69 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606480_1 CDM 0361 RC inpatient 1390 903.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1084.2 78 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606480_1 CDM 0361 RC inpatient 1390 903.5 SIHO - ALL PLANS SIHO - ALL PLANS 1251 90 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606480_1 CDM 0361 RC inpatient 1390 903.5 UMR - ALL PLANS UMR - ALL PLANS 973 70 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606480_1 CDM 0361 RC inpatient 1390 903.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 841.65 60.55 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606480_1 CDM 0361 RC inpatient 1390 903.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606480_1 CDM 0361 RC inpatient 1390 903.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606480_1 CDM 0361 RC inpatient 1390 903.5 ANTHEM HMO ANTHEM HMO 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606480_1 CDM 0361 RC inpatient 1390 903.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606480_1 CDM 0361 RC inpatient 1390 903.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 939.64 67.6 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606480_1 CDM 0361 RC inpatient 1390 903.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606481_1 CDM 0361 RC inpatient 1390 903.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 903.5 65 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606481_1 CDM 0361 RC inpatient 1390 903.5 AETNA AETNA 1098.1 79 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606481_1 CDM 0361 RC inpatient 1390 903.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1348.3 97 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606481_1 CDM 0361 RC inpatient 1390 903.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 959.1 69 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606481_1 CDM 0361 RC inpatient 1390 903.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1084.2 78 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606481_1 CDM 0361 RC inpatient 1390 903.5 SIHO - ALL PLANS SIHO - ALL PLANS 1251 90 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606481_1 CDM 0361 RC inpatient 1390 903.5 UMR - ALL PLANS UMR - ALL PLANS 973 70 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606481_1 CDM 0361 RC inpatient 1390 903.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 841.65 60.55 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606481_1 CDM 0361 RC inpatient 1390 903.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606481_1 CDM 0361 RC inpatient 1390 903.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606481_1 CDM 0361 RC inpatient 1390 903.5 ANTHEM HMO ANTHEM HMO 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606481_1 CDM 0361 RC inpatient 1390 903.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606481_1 CDM 0361 RC inpatient 1390 903.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 939.64 67.6 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606481_1 CDM 0361 RC inpatient 1390 903.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606482_1 CDM 0361 RC inpatient 1390 903.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 903.5 65 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606482_1 CDM 0361 RC inpatient 1390 903.5 AETNA AETNA 1098.1 79 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606482_1 CDM 0361 RC inpatient 1390 903.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1348.3 97 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606482_1 CDM 0361 RC inpatient 1390 903.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 959.1 69 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606482_1 CDM 0361 RC inpatient 1390 903.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1084.2 78 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606482_1 CDM 0361 RC inpatient 1390 903.5 SIHO - ALL PLANS SIHO - ALL PLANS 1251 90 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606482_1 CDM 0361 RC inpatient 1390 903.5 UMR - ALL PLANS UMR - ALL PLANS 973 70 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606482_1 CDM 0361 RC inpatient 1390 903.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 841.65 60.55 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606482_1 CDM 0361 RC inpatient 1390 903.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606482_1 CDM 0361 RC inpatient 1390 903.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606482_1 CDM 0361 RC inpatient 1390 903.5 ANTHEM HMO ANTHEM HMO 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606482_1 CDM 0361 RC inpatient 1390 903.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606482_1 CDM 0361 RC inpatient 1390 903.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 939.64 67.6 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606482_1 CDM 0361 RC inpatient 1390 903.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606483_1 CDM 0361 RC inpatient 1390 903.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 903.5 65 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606483_1 CDM 0361 RC inpatient 1390 903.5 AETNA AETNA 1098.1 79 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606483_1 CDM 0361 RC inpatient 1390 903.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1348.3 97 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606483_1 CDM 0361 RC inpatient 1390 903.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 959.1 69 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606483_1 CDM 0361 RC inpatient 1390 903.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1084.2 78 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606483_1 CDM 0361 RC inpatient 1390 903.5 SIHO - ALL PLANS SIHO - ALL PLANS 1251 90 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606483_1 CDM 0361 RC inpatient 1390 903.5 UMR - ALL PLANS UMR - ALL PLANS 973 70 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606483_1 CDM 0361 RC inpatient 1390 903.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 841.65 60.55 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606483_1 CDM 0361 RC inpatient 1390 903.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606483_1 CDM 0361 RC inpatient 1390 903.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606483_1 CDM 0361 RC inpatient 1390 903.5 ANTHEM HMO ANTHEM HMO 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606483_1 CDM 0361 RC inpatient 1390 903.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 841.65 1348.3 OPERATING ROOM SERVICES - MINOR SURGERY 48606483_1 CDM 0361 RC inpatient 1390 903.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 939.64 67.6 999999999 841.65 1348.3 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48606483_1 CDM 0361 RC inpatient 1390 903.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 841.65 1348.3 "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48606484_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 365.3 65 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48606484_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 AETNA AETNA 443.98 79 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48606484_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 545.14 97 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48606484_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 387.78 69 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48606484_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 438.36 78 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48606484_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 SIHO - ALL PLANS SIHO - ALL PLANS 505.8 90 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48606484_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 UMR - ALL PLANS UMR - ALL PLANS 393.4 70 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48606484_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 340.29 60.55 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48606484_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 340.29 545.14 "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48606484_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 340.29 545.14 "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48606484_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 ANTHEM HMO ANTHEM HMO 999999999 340.29 545.14 "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48606484_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 340.29 545.14 "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48606484_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 379.91 67.6 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48606484_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 340.29 545.14 Electronic analysis of implanted neurostimulator generator with complex spinal cord or peripheral nerve stimulator programming 48606485_1 CDM 0920 RC 95972 HCPCS inpatient 470 305.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 305.5 65 999999999 284.59 455.9 percent of total billed charges Electronic analysis of implanted neurostimulator generator with complex spinal cord or peripheral nerve stimulator programming 48606485_1 CDM 0920 RC 95972 HCPCS inpatient 470 305.5 AETNA AETNA 371.3 79 999999999 284.59 455.9 percent of total billed charges Electronic analysis of implanted neurostimulator generator with complex spinal cord or peripheral nerve stimulator programming 48606485_1 CDM 0920 RC 95972 HCPCS inpatient 470 305.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 455.9 97 999999999 284.59 455.9 percent of total billed charges Electronic analysis of implanted neurostimulator generator with complex spinal cord or peripheral nerve stimulator programming 48606485_1 CDM 0920 RC 95972 HCPCS inpatient 470 305.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 324.3 69 999999999 284.59 455.9 percent of total billed charges Electronic analysis of implanted neurostimulator generator with complex spinal cord or peripheral nerve stimulator programming 48606485_1 CDM 0920 RC 95972 HCPCS inpatient 470 305.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 366.6 78 999999999 284.59 455.9 percent of total billed charges Electronic analysis of implanted neurostimulator generator with complex spinal cord or peripheral nerve stimulator programming 48606485_1 CDM 0920 RC 95972 HCPCS inpatient 470 305.5 SIHO - ALL PLANS SIHO - ALL PLANS 423 90 999999999 284.59 455.9 percent of total billed charges Electronic analysis of implanted neurostimulator generator with complex spinal cord or peripheral nerve stimulator programming 48606485_1 CDM 0920 RC 95972 HCPCS inpatient 470 305.5 UMR - ALL PLANS UMR - ALL PLANS 329 70 999999999 284.59 455.9 percent of total billed charges Electronic analysis of implanted neurostimulator generator with complex spinal cord or peripheral nerve stimulator programming 48606485_1 CDM 0920 RC 95972 HCPCS inpatient 470 305.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 284.59 60.55 999999999 284.59 455.9 percent of total billed charges Electronic analysis of implanted neurostimulator generator with complex spinal cord or peripheral nerve stimulator programming 48606485_1 CDM 0920 RC 95972 HCPCS inpatient 470 305.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 284.59 455.9 Electronic analysis of implanted neurostimulator generator with complex spinal cord or peripheral nerve stimulator programming 48606485_1 CDM 0920 RC 95972 HCPCS inpatient 470 305.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 284.59 455.9 Electronic analysis of implanted neurostimulator generator with complex spinal cord or peripheral nerve stimulator programming 48606485_1 CDM 0920 RC 95972 HCPCS inpatient 470 305.5 ANTHEM HMO ANTHEM HMO 999999999 284.59 455.9 Electronic analysis of implanted neurostimulator generator with complex spinal cord or peripheral nerve stimulator programming 48606485_1 CDM 0920 RC 95972 HCPCS inpatient 470 305.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 284.59 455.9 Electronic analysis of implanted neurostimulator generator with complex spinal cord or peripheral nerve stimulator programming 48606485_1 CDM 0920 RC 95972 HCPCS inpatient 470 305.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 317.72 67.6 999999999 284.59 455.9 percent of total billed charges Electronic analysis of implanted neurostimulator generator with complex spinal cord or peripheral nerve stimulator programming 48606485_1 CDM 0920 RC 95972 HCPCS inpatient 470 305.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 284.59 455.9 OR INTER STIM PROG ADD 30 MIN 48606486_1 CDM 0920 RC inpatient 412 267.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 267.8 65 999999999 249.47 399.64 percent of total billed charges OR INTER STIM PROG ADD 30 MIN 48606486_1 CDM 0920 RC inpatient 412 267.8 AETNA AETNA 325.48 79 999999999 249.47 399.64 percent of total billed charges OR INTER STIM PROG ADD 30 MIN 48606486_1 CDM 0920 RC inpatient 412 267.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 399.64 97 999999999 249.47 399.64 percent of total billed charges OR INTER STIM PROG ADD 30 MIN 48606486_1 CDM 0920 RC inpatient 412 267.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 284.28 69 999999999 249.47 399.64 percent of total billed charges OR INTER STIM PROG ADD 30 MIN 48606486_1 CDM 0920 RC inpatient 412 267.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 321.36 78 999999999 249.47 399.64 percent of total billed charges OR INTER STIM PROG ADD 30 MIN 48606486_1 CDM 0920 RC inpatient 412 267.8 SIHO - ALL PLANS SIHO - ALL PLANS 370.8 90 999999999 249.47 399.64 percent of total billed charges OR INTER STIM PROG ADD 30 MIN 48606486_1 CDM 0920 RC inpatient 412 267.8 UMR - ALL PLANS UMR - ALL PLANS 288.4 70 999999999 249.47 399.64 percent of total billed charges OR INTER STIM PROG ADD 30 MIN 48606486_1 CDM 0920 RC inpatient 412 267.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 249.47 60.55 999999999 249.47 399.64 percent of total billed charges OR INTER STIM PROG ADD 30 MIN 48606486_1 CDM 0920 RC inpatient 412 267.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 249.47 399.64 OR INTER STIM PROG ADD 30 MIN 48606486_1 CDM 0920 RC inpatient 412 267.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 249.47 399.64 OR INTER STIM PROG ADD 30 MIN 48606486_1 CDM 0920 RC inpatient 412 267.8 ANTHEM HMO ANTHEM HMO 999999999 249.47 399.64 OR INTER STIM PROG ADD 30 MIN 48606486_1 CDM 0920 RC inpatient 412 267.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 249.47 399.64 OR INTER STIM PROG ADD 30 MIN 48606486_1 CDM 0920 RC inpatient 412 267.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 278.51 67.6 999999999 249.47 399.64 percent of total billed charges OR INTER STIM PROG ADD 30 MIN 48606486_1 CDM 0920 RC inpatient 412 267.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 249.47 399.64 "Continuous monitoring of nervous system during operation, each 15 minutes" 48606487_1 CDM 0920 RC 95940 HCPCS inpatient 69 44.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.85 65 999999999 41.78 66.93 percent of total billed charges "Continuous monitoring of nervous system during operation, each 15 minutes" 48606487_1 CDM 0920 RC 95940 HCPCS inpatient 69 44.85 AETNA AETNA 54.51 79 999999999 41.78 66.93 percent of total billed charges "Continuous monitoring of nervous system during operation, each 15 minutes" 48606487_1 CDM 0920 RC 95940 HCPCS inpatient 69 44.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 66.93 97 999999999 41.78 66.93 percent of total billed charges "Continuous monitoring of nervous system during operation, each 15 minutes" 48606487_1 CDM 0920 RC 95940 HCPCS inpatient 69 44.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 47.61 69 999999999 41.78 66.93 percent of total billed charges "Continuous monitoring of nervous system during operation, each 15 minutes" 48606487_1 CDM 0920 RC 95940 HCPCS inpatient 69 44.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.82 78 999999999 41.78 66.93 percent of total billed charges "Continuous monitoring of nervous system during operation, each 15 minutes" 48606487_1 CDM 0920 RC 95940 HCPCS inpatient 69 44.85 SIHO - ALL PLANS SIHO - ALL PLANS 62.1 90 999999999 41.78 66.93 percent of total billed charges "Continuous monitoring of nervous system during operation, each 15 minutes" 48606487_1 CDM 0920 RC 95940 HCPCS inpatient 69 44.85 UMR - ALL PLANS UMR - ALL PLANS 48.3 70 999999999 41.78 66.93 percent of total billed charges "Continuous monitoring of nervous system during operation, each 15 minutes" 48606487_1 CDM 0920 RC 95940 HCPCS inpatient 69 44.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.78 60.55 999999999 41.78 66.93 percent of total billed charges "Continuous monitoring of nervous system during operation, each 15 minutes" 48606487_1 CDM 0920 RC 95940 HCPCS inpatient 69 44.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.78 66.93 "Continuous monitoring of nervous system during operation, each 15 minutes" 48606487_1 CDM 0920 RC 95940 HCPCS inpatient 69 44.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.78 66.93 "Continuous monitoring of nervous system during operation, each 15 minutes" 48606487_1 CDM 0920 RC 95940 HCPCS inpatient 69 44.85 ANTHEM HMO ANTHEM HMO 999999999 41.78 66.93 "Continuous monitoring of nervous system during operation, each 15 minutes" 48606487_1 CDM 0920 RC 95940 HCPCS inpatient 69 44.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.78 66.93 "Continuous monitoring of nervous system during operation, each 15 minutes" 48606487_1 CDM 0920 RC 95940 HCPCS inpatient 69 44.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 46.64 67.6 999999999 41.78 66.93 percent of total billed charges "Continuous monitoring of nervous system during operation, each 15 minutes" 48606487_1 CDM 0920 RC 95940 HCPCS inpatient 69 44.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.78 66.93 Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 48606493_1 CDM 0510 RC 64425 HCPCS inpatient 634 412.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 412.1 65 999999999 383.89 614.98 percent of total billed charges Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 48606493_1 CDM 0510 RC 64425 HCPCS inpatient 634 412.1 AETNA AETNA 500.86 79 999999999 383.89 614.98 percent of total billed charges Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 48606493_1 CDM 0510 RC 64425 HCPCS inpatient 634 412.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 614.98 97 999999999 383.89 614.98 percent of total billed charges Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 48606493_1 CDM 0510 RC 64425 HCPCS inpatient 634 412.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 437.46 69 999999999 383.89 614.98 percent of total billed charges Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 48606493_1 CDM 0510 RC 64425 HCPCS inpatient 634 412.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 494.52 78 999999999 383.89 614.98 percent of total billed charges Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 48606493_1 CDM 0510 RC 64425 HCPCS inpatient 634 412.1 SIHO - ALL PLANS SIHO - ALL PLANS 570.6 90 999999999 383.89 614.98 percent of total billed charges Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 48606493_1 CDM 0510 RC 64425 HCPCS inpatient 634 412.1 UMR - ALL PLANS UMR - ALL PLANS 443.8 70 999999999 383.89 614.98 percent of total billed charges Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 48606493_1 CDM 0510 RC 64425 HCPCS inpatient 634 412.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 383.89 60.55 999999999 383.89 614.98 percent of total billed charges Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 48606493_1 CDM 0510 RC 64425 HCPCS inpatient 634 412.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 383.89 614.98 Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 48606493_1 CDM 0510 RC 64425 HCPCS inpatient 634 412.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 383.89 614.98 Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 48606493_1 CDM 0510 RC 64425 HCPCS inpatient 634 412.1 ANTHEM HMO ANTHEM HMO 999999999 383.89 614.98 Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 48606493_1 CDM 0510 RC 64425 HCPCS inpatient 634 412.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 383.89 614.98 Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 48606493_1 CDM 0510 RC 64425 HCPCS inpatient 634 412.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 428.58 67.6 999999999 383.89 614.98 percent of total billed charges Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 48606493_1 CDM 0510 RC 64425 HCPCS inpatient 634 412.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 383.89 614.98 Injection of anesthetic agent and/or steroid into other nerve or branch 48606494_1 CDM 0370 RC 64450 HCPCS inpatient 634 412.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 412.1 65 999999999 383.89 614.98 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48606494_1 CDM 0370 RC 64450 HCPCS inpatient 634 412.1 AETNA AETNA 500.86 79 999999999 383.89 614.98 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48606494_1 CDM 0370 RC 64450 HCPCS inpatient 634 412.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 614.98 97 999999999 383.89 614.98 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48606494_1 CDM 0370 RC 64450 HCPCS inpatient 634 412.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 437.46 69 999999999 383.89 614.98 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48606494_1 CDM 0370 RC 64450 HCPCS inpatient 634 412.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 494.52 78 999999999 383.89 614.98 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48606494_1 CDM 0370 RC 64450 HCPCS inpatient 634 412.1 SIHO - ALL PLANS SIHO - ALL PLANS 570.6 90 999999999 383.89 614.98 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48606494_1 CDM 0370 RC 64450 HCPCS inpatient 634 412.1 UMR - ALL PLANS UMR - ALL PLANS 443.8 70 999999999 383.89 614.98 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48606494_1 CDM 0370 RC 64450 HCPCS inpatient 634 412.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 383.89 60.55 999999999 383.89 614.98 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48606494_1 CDM 0370 RC 64450 HCPCS inpatient 634 412.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 383.89 614.98 Injection of anesthetic agent and/or steroid into other nerve or branch 48606494_1 CDM 0370 RC 64450 HCPCS inpatient 634 412.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 383.89 614.98 Injection of anesthetic agent and/or steroid into other nerve or branch 48606494_1 CDM 0370 RC 64450 HCPCS inpatient 634 412.1 ANTHEM HMO ANTHEM HMO 999999999 383.89 614.98 Injection of anesthetic agent and/or steroid into other nerve or branch 48606494_1 CDM 0370 RC 64450 HCPCS inpatient 634 412.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 383.89 614.98 Injection of anesthetic agent and/or steroid into other nerve or branch 48606494_1 CDM 0370 RC 64450 HCPCS inpatient 634 412.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 428.58 67.6 999999999 383.89 614.98 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48606494_1 CDM 0370 RC 64450 HCPCS inpatient 634 412.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 383.89 614.98 ANS EPIDURAL 48606495_1 CDM 0370 RC inpatient 550 357.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 357.5 65 999999999 333.03 533.5 percent of total billed charges ANS EPIDURAL 48606495_1 CDM 0370 RC inpatient 550 357.5 AETNA AETNA 434.5 79 999999999 333.03 533.5 percent of total billed charges ANS EPIDURAL 48606495_1 CDM 0370 RC inpatient 550 357.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 533.5 97 999999999 333.03 533.5 percent of total billed charges ANS EPIDURAL 48606495_1 CDM 0370 RC inpatient 550 357.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 379.5 69 999999999 333.03 533.5 percent of total billed charges ANS EPIDURAL 48606495_1 CDM 0370 RC inpatient 550 357.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 429 78 999999999 333.03 533.5 percent of total billed charges ANS EPIDURAL 48606495_1 CDM 0370 RC inpatient 550 357.5 SIHO - ALL PLANS SIHO - ALL PLANS 495 90 999999999 333.03 533.5 percent of total billed charges ANS EPIDURAL 48606495_1 CDM 0370 RC inpatient 550 357.5 UMR - ALL PLANS UMR - ALL PLANS 385 70 999999999 333.03 533.5 percent of total billed charges ANS EPIDURAL 48606495_1 CDM 0370 RC inpatient 550 357.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 333.03 60.55 999999999 333.03 533.5 percent of total billed charges ANS EPIDURAL 48606495_1 CDM 0370 RC inpatient 550 357.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 333.03 533.5 ANS EPIDURAL 48606495_1 CDM 0370 RC inpatient 550 357.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 333.03 533.5 ANS EPIDURAL 48606495_1 CDM 0370 RC inpatient 550 357.5 ANTHEM HMO ANTHEM HMO 999999999 333.03 533.5 ANS EPIDURAL 48606495_1 CDM 0370 RC inpatient 550 357.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 333.03 533.5 ANS EPIDURAL 48606495_1 CDM 0370 RC inpatient 550 357.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 371.8 67.6 999999999 333.03 533.5 percent of total billed charges ANS EPIDURAL 48606495_1 CDM 0370 RC inpatient 550 357.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 333.03 533.5 ANS MAC ANESTHESIA 48606496_1 CDM 0370 RC inpatient 562 365.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 365.3 65 999999999 340.29 545.14 percent of total billed charges ANS MAC ANESTHESIA 48606496_1 CDM 0370 RC inpatient 562 365.3 AETNA AETNA 443.98 79 999999999 340.29 545.14 percent of total billed charges ANS MAC ANESTHESIA 48606496_1 CDM 0370 RC inpatient 562 365.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 545.14 97 999999999 340.29 545.14 percent of total billed charges ANS MAC ANESTHESIA 48606496_1 CDM 0370 RC inpatient 562 365.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 387.78 69 999999999 340.29 545.14 percent of total billed charges ANS MAC ANESTHESIA 48606496_1 CDM 0370 RC inpatient 562 365.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 438.36 78 999999999 340.29 545.14 percent of total billed charges ANS MAC ANESTHESIA 48606496_1 CDM 0370 RC inpatient 562 365.3 SIHO - ALL PLANS SIHO - ALL PLANS 505.8 90 999999999 340.29 545.14 percent of total billed charges ANS MAC ANESTHESIA 48606496_1 CDM 0370 RC inpatient 562 365.3 UMR - ALL PLANS UMR - ALL PLANS 393.4 70 999999999 340.29 545.14 percent of total billed charges ANS MAC ANESTHESIA 48606496_1 CDM 0370 RC inpatient 562 365.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 340.29 60.55 999999999 340.29 545.14 percent of total billed charges ANS MAC ANESTHESIA 48606496_1 CDM 0370 RC inpatient 562 365.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 340.29 545.14 ANS MAC ANESTHESIA 48606496_1 CDM 0370 RC inpatient 562 365.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 340.29 545.14 ANS MAC ANESTHESIA 48606496_1 CDM 0370 RC inpatient 562 365.3 ANTHEM HMO ANTHEM HMO 999999999 340.29 545.14 ANS MAC ANESTHESIA 48606496_1 CDM 0370 RC inpatient 562 365.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 340.29 545.14 ANS MAC ANESTHESIA 48606496_1 CDM 0370 RC inpatient 562 365.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 379.91 67.6 999999999 340.29 545.14 percent of total billed charges ANS MAC ANESTHESIA 48606496_1 CDM 0370 RC inpatient 562 365.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 340.29 545.14 ANS SPINAL BLOCK 48606497_1 CDM 0370 RC inpatient 611 397.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 397.15 65 999999999 369.96 592.67 percent of total billed charges ANS SPINAL BLOCK 48606497_1 CDM 0370 RC inpatient 611 397.15 AETNA AETNA 482.69 79 999999999 369.96 592.67 percent of total billed charges ANS SPINAL BLOCK 48606497_1 CDM 0370 RC inpatient 611 397.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 592.67 97 999999999 369.96 592.67 percent of total billed charges ANS SPINAL BLOCK 48606497_1 CDM 0370 RC inpatient 611 397.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 421.59 69 999999999 369.96 592.67 percent of total billed charges ANS SPINAL BLOCK 48606497_1 CDM 0370 RC inpatient 611 397.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 476.58 78 999999999 369.96 592.67 percent of total billed charges ANS SPINAL BLOCK 48606497_1 CDM 0370 RC inpatient 611 397.15 SIHO - ALL PLANS SIHO - ALL PLANS 549.9 90 999999999 369.96 592.67 percent of total billed charges ANS SPINAL BLOCK 48606497_1 CDM 0370 RC inpatient 611 397.15 UMR - ALL PLANS UMR - ALL PLANS 427.7 70 999999999 369.96 592.67 percent of total billed charges ANS SPINAL BLOCK 48606497_1 CDM 0370 RC inpatient 611 397.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 369.96 60.55 999999999 369.96 592.67 percent of total billed charges ANS SPINAL BLOCK 48606497_1 CDM 0370 RC inpatient 611 397.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 369.96 592.67 ANS SPINAL BLOCK 48606497_1 CDM 0370 RC inpatient 611 397.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 369.96 592.67 ANS SPINAL BLOCK 48606497_1 CDM 0370 RC inpatient 611 397.15 ANTHEM HMO ANTHEM HMO 999999999 369.96 592.67 ANS SPINAL BLOCK 48606497_1 CDM 0370 RC inpatient 611 397.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 369.96 592.67 ANS SPINAL BLOCK 48606497_1 CDM 0370 RC inpatient 611 397.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 413.04 67.6 999999999 369.96 592.67 percent of total billed charges ANS SPINAL BLOCK 48606497_1 CDM 0370 RC inpatient 611 397.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 369.96 592.67 Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 48606646_1 CDM 0370 RC 64417 HCPCS inpatient 1257 817.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 817.05 65 999999999 761.11 1219.29 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 48606646_1 CDM 0370 RC 64417 HCPCS inpatient 1257 817.05 AETNA AETNA 993.03 79 999999999 761.11 1219.29 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 48606646_1 CDM 0370 RC 64417 HCPCS inpatient 1257 817.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1219.29 97 999999999 761.11 1219.29 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 48606646_1 CDM 0370 RC 64417 HCPCS inpatient 1257 817.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 867.33 69 999999999 761.11 1219.29 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 48606646_1 CDM 0370 RC 64417 HCPCS inpatient 1257 817.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 980.46 78 999999999 761.11 1219.29 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 48606646_1 CDM 0370 RC 64417 HCPCS inpatient 1257 817.05 SIHO - ALL PLANS SIHO - ALL PLANS 1131.3 90 999999999 761.11 1219.29 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 48606646_1 CDM 0370 RC 64417 HCPCS inpatient 1257 817.05 UMR - ALL PLANS UMR - ALL PLANS 879.9 70 999999999 761.11 1219.29 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 48606646_1 CDM 0370 RC 64417 HCPCS inpatient 1257 817.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 761.11 60.55 999999999 761.11 1219.29 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 48606646_1 CDM 0370 RC 64417 HCPCS inpatient 1257 817.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 761.11 1219.29 Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 48606646_1 CDM 0370 RC 64417 HCPCS inpatient 1257 817.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 761.11 1219.29 Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 48606646_1 CDM 0370 RC 64417 HCPCS inpatient 1257 817.05 ANTHEM HMO ANTHEM HMO 999999999 761.11 1219.29 Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 48606646_1 CDM 0370 RC 64417 HCPCS inpatient 1257 817.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 761.11 1219.29 Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 48606646_1 CDM 0370 RC 64417 HCPCS inpatient 1257 817.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 849.73 67.6 999999999 761.11 1219.29 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 48606646_1 CDM 0370 RC 64417 HCPCS inpatient 1257 817.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 761.11 1219.29 Injection of blood or blood clot into spinal canal 48606652_1 CDM 0370 RC 62273 HCPCS inpatient 543 352.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 352.95 65 999999999 328.79 526.71 percent of total billed charges Injection of blood or blood clot into spinal canal 48606652_1 CDM 0370 RC 62273 HCPCS inpatient 543 352.95 AETNA AETNA 428.97 79 999999999 328.79 526.71 percent of total billed charges Injection of blood or blood clot into spinal canal 48606652_1 CDM 0370 RC 62273 HCPCS inpatient 543 352.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 526.71 97 999999999 328.79 526.71 percent of total billed charges Injection of blood or blood clot into spinal canal 48606652_1 CDM 0370 RC 62273 HCPCS inpatient 543 352.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 374.67 69 999999999 328.79 526.71 percent of total billed charges Injection of blood or blood clot into spinal canal 48606652_1 CDM 0370 RC 62273 HCPCS inpatient 543 352.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 423.54 78 999999999 328.79 526.71 percent of total billed charges Injection of blood or blood clot into spinal canal 48606652_1 CDM 0370 RC 62273 HCPCS inpatient 543 352.95 SIHO - ALL PLANS SIHO - ALL PLANS 488.7 90 999999999 328.79 526.71 percent of total billed charges Injection of blood or blood clot into spinal canal 48606652_1 CDM 0370 RC 62273 HCPCS inpatient 543 352.95 UMR - ALL PLANS UMR - ALL PLANS 380.1 70 999999999 328.79 526.71 percent of total billed charges Injection of blood or blood clot into spinal canal 48606652_1 CDM 0370 RC 62273 HCPCS inpatient 543 352.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 328.79 60.55 999999999 328.79 526.71 percent of total billed charges Injection of blood or blood clot into spinal canal 48606652_1 CDM 0370 RC 62273 HCPCS inpatient 543 352.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 328.79 526.71 Injection of blood or blood clot into spinal canal 48606652_1 CDM 0370 RC 62273 HCPCS inpatient 543 352.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 328.79 526.71 Injection of blood or blood clot into spinal canal 48606652_1 CDM 0370 RC 62273 HCPCS inpatient 543 352.95 ANTHEM HMO ANTHEM HMO 999999999 328.79 526.71 Injection of blood or blood clot into spinal canal 48606652_1 CDM 0370 RC 62273 HCPCS inpatient 543 352.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 328.79 526.71 Injection of blood or blood clot into spinal canal 48606652_1 CDM 0370 RC 62273 HCPCS inpatient 543 352.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 367.07 67.6 999999999 328.79 526.71 percent of total billed charges Injection of blood or blood clot into spinal canal 48606652_1 CDM 0370 RC 62273 HCPCS inpatient 543 352.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 328.79 526.71 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48606653_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 241.8 65 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48606653_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 AETNA AETNA 293.88 79 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48606653_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 360.84 97 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48606653_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 256.68 69 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48606653_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 290.16 78 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48606653_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 SIHO - ALL PLANS SIHO - ALL PLANS 334.8 90 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48606653_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 UMR - ALL PLANS UMR - ALL PLANS 260.4 70 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48606653_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 225.25 60.55 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48606653_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 225.25 360.84 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48606653_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 225.25 360.84 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48606653_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 ANTHEM HMO ANTHEM HMO 999999999 225.25 360.84 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48606653_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 225.25 360.84 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48606653_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 251.47 67.6 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48606653_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 225.25 360.84 Transfusion of blood or blood products 48606654_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 807.3 65 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48606654_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 AETNA AETNA 981.18 79 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48606654_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1204.74 97 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48606654_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 856.98 69 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48606654_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 968.76 78 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48606654_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 SIHO - ALL PLANS SIHO - ALL PLANS 1117.8 90 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48606654_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 UMR - ALL PLANS UMR - ALL PLANS 869.4 70 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48606654_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 752.03 60.55 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48606654_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 752.03 1204.74 Transfusion of blood or blood products 48606654_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 752.03 1204.74 Transfusion of blood or blood products 48606654_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM HMO ANTHEM HMO 999999999 752.03 1204.74 Transfusion of blood or blood products 48606654_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 752.03 1204.74 Transfusion of blood or blood products 48606654_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 839.59 67.6 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48606654_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 752.03 1204.74 Ultrasonic guidance for blood vessel access 48606857_1 CDM 0761 RC 76937 HCPCS inpatient 559 363.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 363.35 65 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 48606857_1 CDM 0761 RC 76937 HCPCS inpatient 559 363.35 AETNA AETNA 441.61 79 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 48606857_1 CDM 0761 RC 76937 HCPCS inpatient 559 363.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 542.23 97 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 48606857_1 CDM 0761 RC 76937 HCPCS inpatient 559 363.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 385.71 69 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 48606857_1 CDM 0761 RC 76937 HCPCS inpatient 559 363.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 436.02 78 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 48606857_1 CDM 0761 RC 76937 HCPCS inpatient 559 363.35 SIHO - ALL PLANS SIHO - ALL PLANS 503.1 90 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 48606857_1 CDM 0761 RC 76937 HCPCS inpatient 559 363.35 UMR - ALL PLANS UMR - ALL PLANS 391.3 70 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 48606857_1 CDM 0761 RC 76937 HCPCS inpatient 559 363.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 338.47 60.55 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 48606857_1 CDM 0761 RC 76937 HCPCS inpatient 559 363.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 338.47 542.23 Ultrasonic guidance for blood vessel access 48606857_1 CDM 0761 RC 76937 HCPCS inpatient 559 363.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 338.47 542.23 Ultrasonic guidance for blood vessel access 48606857_1 CDM 0761 RC 76937 HCPCS inpatient 559 363.35 ANTHEM HMO ANTHEM HMO 999999999 338.47 542.23 Ultrasonic guidance for blood vessel access 48606857_1 CDM 0761 RC 76937 HCPCS inpatient 559 363.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 338.47 542.23 Ultrasonic guidance for blood vessel access 48606857_1 CDM 0761 RC 76937 HCPCS inpatient 559 363.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 377.88 67.6 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 48606857_1 CDM 0761 RC 76937 HCPCS inpatient 559 363.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 338.47 542.23 SPECIALTY SERVICES - TREATMENT ROOM 48606858_1 CDM 0761 RC inpatient 286 185.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.9 65 999999999 173.17 277.42 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48606858_1 CDM 0761 RC inpatient 286 185.9 AETNA AETNA 225.94 79 999999999 173.17 277.42 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48606858_1 CDM 0761 RC inpatient 286 185.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 277.42 97 999999999 173.17 277.42 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48606858_1 CDM 0761 RC inpatient 286 185.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 197.34 69 999999999 173.17 277.42 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48606858_1 CDM 0761 RC inpatient 286 185.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 223.08 78 999999999 173.17 277.42 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48606858_1 CDM 0761 RC inpatient 286 185.9 SIHO - ALL PLANS SIHO - ALL PLANS 257.4 90 999999999 173.17 277.42 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48606858_1 CDM 0761 RC inpatient 286 185.9 UMR - ALL PLANS UMR - ALL PLANS 200.2 70 999999999 173.17 277.42 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48606858_1 CDM 0761 RC inpatient 286 185.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 173.17 60.55 999999999 173.17 277.42 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48606858_1 CDM 0761 RC inpatient 286 185.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 173.17 277.42 SPECIALTY SERVICES - TREATMENT ROOM 48606858_1 CDM 0761 RC inpatient 286 185.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 173.17 277.42 SPECIALTY SERVICES - TREATMENT ROOM 48606858_1 CDM 0761 RC inpatient 286 185.9 ANTHEM HMO ANTHEM HMO 999999999 173.17 277.42 SPECIALTY SERVICES - TREATMENT ROOM 48606858_1 CDM 0761 RC inpatient 286 185.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 173.17 277.42 SPECIALTY SERVICES - TREATMENT ROOM 48606858_1 CDM 0761 RC inpatient 286 185.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 193.34 67.6 999999999 173.17 277.42 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48606858_1 CDM 0761 RC inpatient 286 185.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 173.17 277.42 INSERT CATHETER BILE DUCT 48606859_1 CDM 0361 RC 47510 HCPCS inpatient 2545 1654.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1654.25 65 999999999 1541 2468.65 percent of total billed charges INSERT CATHETER BILE DUCT 48606859_1 CDM 0361 RC 47510 HCPCS inpatient 2545 1654.25 AETNA AETNA 2010.55 79 999999999 1541 2468.65 percent of total billed charges INSERT CATHETER BILE DUCT 48606859_1 CDM 0361 RC 47510 HCPCS inpatient 2545 1654.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2468.65 97 999999999 1541 2468.65 percent of total billed charges INSERT CATHETER BILE DUCT 48606859_1 CDM 0361 RC 47510 HCPCS inpatient 2545 1654.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1756.05 69 999999999 1541 2468.65 percent of total billed charges INSERT CATHETER BILE DUCT 48606859_1 CDM 0361 RC 47510 HCPCS inpatient 2545 1654.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1985.1 78 999999999 1541 2468.65 percent of total billed charges INSERT CATHETER BILE DUCT 48606859_1 CDM 0361 RC 47510 HCPCS inpatient 2545 1654.25 SIHO - ALL PLANS SIHO - ALL PLANS 2290.5 90 999999999 1541 2468.65 percent of total billed charges INSERT CATHETER BILE DUCT 48606859_1 CDM 0361 RC 47510 HCPCS inpatient 2545 1654.25 UMR - ALL PLANS UMR - ALL PLANS 1781.5 70 999999999 1541 2468.65 percent of total billed charges INSERT CATHETER BILE DUCT 48606859_1 CDM 0361 RC 47510 HCPCS inpatient 2545 1654.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1541 60.55 999999999 1541 2468.65 percent of total billed charges INSERT CATHETER BILE DUCT 48606859_1 CDM 0361 RC 47510 HCPCS inpatient 2545 1654.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1541 2468.65 INSERT CATHETER BILE DUCT 48606859_1 CDM 0361 RC 47510 HCPCS inpatient 2545 1654.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1541 2468.65 INSERT CATHETER BILE DUCT 48606859_1 CDM 0361 RC 47510 HCPCS inpatient 2545 1654.25 ANTHEM HMO ANTHEM HMO 999999999 1541 2468.65 INSERT CATHETER BILE DUCT 48606859_1 CDM 0361 RC 47510 HCPCS inpatient 2545 1654.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1541 2468.65 INSERT CATHETER BILE DUCT 48606859_1 CDM 0361 RC 47510 HCPCS inpatient 2545 1654.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1720.42 67.6 999999999 1541 2468.65 percent of total billed charges INSERT CATHETER BILE DUCT 48606859_1 CDM 0361 RC 47510 HCPCS inpatient 2545 1654.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1541 2468.65 Placement of tube of kidney using imaging guidance with review by radiologist 48606860_1 CDM 0361 RC 50432 HCPCS inpatient 4518 2936.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 2936.7 65 999999999 2735.65 4382.46 percent of total billed charges Placement of tube of kidney using imaging guidance with review by radiologist 48606860_1 CDM 0361 RC 50432 HCPCS inpatient 4518 2936.7 AETNA AETNA 3569.22 79 999999999 2735.65 4382.46 percent of total billed charges Placement of tube of kidney using imaging guidance with review by radiologist 48606860_1 CDM 0361 RC 50432 HCPCS inpatient 4518 2936.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4382.46 97 999999999 2735.65 4382.46 percent of total billed charges Placement of tube of kidney using imaging guidance with review by radiologist 48606860_1 CDM 0361 RC 50432 HCPCS inpatient 4518 2936.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 3117.42 69 999999999 2735.65 4382.46 percent of total billed charges Placement of tube of kidney using imaging guidance with review by radiologist 48606860_1 CDM 0361 RC 50432 HCPCS inpatient 4518 2936.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 3524.04 78 999999999 2735.65 4382.46 percent of total billed charges Placement of tube of kidney using imaging guidance with review by radiologist 48606860_1 CDM 0361 RC 50432 HCPCS inpatient 4518 2936.7 SIHO - ALL PLANS SIHO - ALL PLANS 4066.2 90 999999999 2735.65 4382.46 percent of total billed charges Placement of tube of kidney using imaging guidance with review by radiologist 48606860_1 CDM 0361 RC 50432 HCPCS inpatient 4518 2936.7 UMR - ALL PLANS UMR - ALL PLANS 3162.6 70 999999999 2735.65 4382.46 percent of total billed charges Placement of tube of kidney using imaging guidance with review by radiologist 48606860_1 CDM 0361 RC 50432 HCPCS inpatient 4518 2936.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2735.65 60.55 999999999 2735.65 4382.46 percent of total billed charges Placement of tube of kidney using imaging guidance with review by radiologist 48606860_1 CDM 0361 RC 50432 HCPCS inpatient 4518 2936.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2735.65 4382.46 Placement of tube of kidney using imaging guidance with review by radiologist 48606860_1 CDM 0361 RC 50432 HCPCS inpatient 4518 2936.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2735.65 4382.46 Placement of tube of kidney using imaging guidance with review by radiologist 48606860_1 CDM 0361 RC 50432 HCPCS inpatient 4518 2936.7 ANTHEM HMO ANTHEM HMO 999999999 2735.65 4382.46 Placement of tube of kidney using imaging guidance with review by radiologist 48606860_1 CDM 0361 RC 50432 HCPCS inpatient 4518 2936.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2735.65 4382.46 Placement of tube of kidney using imaging guidance with review by radiologist 48606860_1 CDM 0361 RC 50432 HCPCS inpatient 4518 2936.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 3054.17 67.6 999999999 2735.65 4382.46 percent of total billed charges Placement of tube of kidney using imaging guidance with review by radiologist 48606860_1 CDM 0361 RC 50432 HCPCS inpatient 4518 2936.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 2735.65 4382.46 Placement of tube of kidney using imaging guidance with review by radiologist 48606861_1 CDM 0361 RC 50432 HCPCS inpatient 2856 1856.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1856.4 65 999999999 1729.31 2770.32 percent of total billed charges Placement of tube of kidney using imaging guidance with review by radiologist 48606861_1 CDM 0361 RC 50432 HCPCS inpatient 2856 1856.4 AETNA AETNA 2256.24 79 999999999 1729.31 2770.32 percent of total billed charges Placement of tube of kidney using imaging guidance with review by radiologist 48606861_1 CDM 0361 RC 50432 HCPCS inpatient 2856 1856.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2770.32 97 999999999 1729.31 2770.32 percent of total billed charges Placement of tube of kidney using imaging guidance with review by radiologist 48606861_1 CDM 0361 RC 50432 HCPCS inpatient 2856 1856.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1970.64 69 999999999 1729.31 2770.32 percent of total billed charges Placement of tube of kidney using imaging guidance with review by radiologist 48606861_1 CDM 0361 RC 50432 HCPCS inpatient 2856 1856.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 2227.68 78 999999999 1729.31 2770.32 percent of total billed charges Placement of tube of kidney using imaging guidance with review by radiologist 48606861_1 CDM 0361 RC 50432 HCPCS inpatient 2856 1856.4 SIHO - ALL PLANS SIHO - ALL PLANS 2570.4 90 999999999 1729.31 2770.32 percent of total billed charges Placement of tube of kidney using imaging guidance with review by radiologist 48606861_1 CDM 0361 RC 50432 HCPCS inpatient 2856 1856.4 UMR - ALL PLANS UMR - ALL PLANS 1999.2 70 999999999 1729.31 2770.32 percent of total billed charges Placement of tube of kidney using imaging guidance with review by radiologist 48606861_1 CDM 0361 RC 50432 HCPCS inpatient 2856 1856.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1729.31 60.55 999999999 1729.31 2770.32 percent of total billed charges Placement of tube of kidney using imaging guidance with review by radiologist 48606861_1 CDM 0361 RC 50432 HCPCS inpatient 2856 1856.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1729.31 2770.32 Placement of tube of kidney using imaging guidance with review by radiologist 48606861_1 CDM 0361 RC 50432 HCPCS inpatient 2856 1856.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1729.31 2770.32 Placement of tube of kidney using imaging guidance with review by radiologist 48606861_1 CDM 0361 RC 50432 HCPCS inpatient 2856 1856.4 ANTHEM HMO ANTHEM HMO 999999999 1729.31 2770.32 Placement of tube of kidney using imaging guidance with review by radiologist 48606861_1 CDM 0361 RC 50432 HCPCS inpatient 2856 1856.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1729.31 2770.32 Placement of tube of kidney using imaging guidance with review by radiologist 48606861_1 CDM 0361 RC 50432 HCPCS inpatient 2856 1856.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1930.66 67.6 999999999 1729.31 2770.32 percent of total billed charges Placement of tube of kidney using imaging guidance with review by radiologist 48606861_1 CDM 0361 RC 50432 HCPCS inpatient 2856 1856.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1729.31 2770.32 Removal of central venous tube with port or pump 48606862_1 CDM 0361 RC 36590 HCPCS inpatient 2302 1496.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1496.3 65 999999999 1393.86 2232.94 percent of total billed charges Removal of central venous tube with port or pump 48606862_1 CDM 0361 RC 36590 HCPCS inpatient 2302 1496.3 AETNA AETNA 1818.58 79 999999999 1393.86 2232.94 percent of total billed charges Removal of central venous tube with port or pump 48606862_1 CDM 0361 RC 36590 HCPCS inpatient 2302 1496.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2232.94 97 999999999 1393.86 2232.94 percent of total billed charges Removal of central venous tube with port or pump 48606862_1 CDM 0361 RC 36590 HCPCS inpatient 2302 1496.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1588.38 69 999999999 1393.86 2232.94 percent of total billed charges Removal of central venous tube with port or pump 48606862_1 CDM 0361 RC 36590 HCPCS inpatient 2302 1496.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1795.56 78 999999999 1393.86 2232.94 percent of total billed charges Removal of central venous tube with port or pump 48606862_1 CDM 0361 RC 36590 HCPCS inpatient 2302 1496.3 SIHO - ALL PLANS SIHO - ALL PLANS 2071.8 90 999999999 1393.86 2232.94 percent of total billed charges Removal of central venous tube with port or pump 48606862_1 CDM 0361 RC 36590 HCPCS inpatient 2302 1496.3 UMR - ALL PLANS UMR - ALL PLANS 1611.4 70 999999999 1393.86 2232.94 percent of total billed charges Removal of central venous tube with port or pump 48606862_1 CDM 0361 RC 36590 HCPCS inpatient 2302 1496.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1393.86 60.55 999999999 1393.86 2232.94 percent of total billed charges Removal of central venous tube with port or pump 48606862_1 CDM 0361 RC 36590 HCPCS inpatient 2302 1496.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1393.86 2232.94 Removal of central venous tube with port or pump 48606862_1 CDM 0361 RC 36590 HCPCS inpatient 2302 1496.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1393.86 2232.94 Removal of central venous tube with port or pump 48606862_1 CDM 0361 RC 36590 HCPCS inpatient 2302 1496.3 ANTHEM HMO ANTHEM HMO 999999999 1393.86 2232.94 Removal of central venous tube with port or pump 48606862_1 CDM 0361 RC 36590 HCPCS inpatient 2302 1496.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1393.86 2232.94 Removal of central venous tube with port or pump 48606862_1 CDM 0361 RC 36590 HCPCS inpatient 2302 1496.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1556.15 67.6 999999999 1393.86 2232.94 percent of total billed charges Removal of central venous tube with port or pump 48606862_1 CDM 0361 RC 36590 HCPCS inpatient 2302 1496.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1393.86 2232.94 Insertion of central venous tube with port (5 years or older) 48606863_1 CDM 0361 RC 36561 HCPCS inpatient 8975 5833.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 5833.75 65 999999999 5434.36 8705.75 percent of total billed charges Insertion of central venous tube with port (5 years or older) 48606863_1 CDM 0361 RC 36561 HCPCS inpatient 8975 5833.75 AETNA AETNA 7090.25 79 999999999 5434.36 8705.75 percent of total billed charges Insertion of central venous tube with port (5 years or older) 48606863_1 CDM 0361 RC 36561 HCPCS inpatient 8975 5833.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8705.75 97 999999999 5434.36 8705.75 percent of total billed charges Insertion of central venous tube with port (5 years or older) 48606863_1 CDM 0361 RC 36561 HCPCS inpatient 8975 5833.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 6192.75 69 999999999 5434.36 8705.75 percent of total billed charges Insertion of central venous tube with port (5 years or older) 48606863_1 CDM 0361 RC 36561 HCPCS inpatient 8975 5833.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 7000.5 78 999999999 5434.36 8705.75 percent of total billed charges Insertion of central venous tube with port (5 years or older) 48606863_1 CDM 0361 RC 36561 HCPCS inpatient 8975 5833.75 SIHO - ALL PLANS SIHO - ALL PLANS 8077.5 90 999999999 5434.36 8705.75 percent of total billed charges Insertion of central venous tube with port (5 years or older) 48606863_1 CDM 0361 RC 36561 HCPCS inpatient 8975 5833.75 UMR - ALL PLANS UMR - ALL PLANS 6282.5 70 999999999 5434.36 8705.75 percent of total billed charges Insertion of central venous tube with port (5 years or older) 48606863_1 CDM 0361 RC 36561 HCPCS inpatient 8975 5833.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5434.36 60.55 999999999 5434.36 8705.75 percent of total billed charges Insertion of central venous tube with port (5 years or older) 48606863_1 CDM 0361 RC 36561 HCPCS inpatient 8975 5833.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5434.36 8705.75 Insertion of central venous tube with port (5 years or older) 48606863_1 CDM 0361 RC 36561 HCPCS inpatient 8975 5833.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5434.36 8705.75 Insertion of central venous tube with port (5 years or older) 48606863_1 CDM 0361 RC 36561 HCPCS inpatient 8975 5833.75 ANTHEM HMO ANTHEM HMO 999999999 5434.36 8705.75 Insertion of central venous tube with port (5 years or older) 48606863_1 CDM 0361 RC 36561 HCPCS inpatient 8975 5833.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5434.36 8705.75 Insertion of central venous tube with port (5 years or older) 48606863_1 CDM 0361 RC 36561 HCPCS inpatient 8975 5833.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 6067.1 67.6 999999999 5434.36 8705.75 percent of total billed charges Insertion of central venous tube with port (5 years or older) 48606863_1 CDM 0361 RC 36561 HCPCS inpatient 8975 5833.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 5434.36 8705.75 Insertion of tube into vena cava 48606864_1 CDM 0361 RC 36010 HCPCS inpatient 1629 1058.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1058.85 65 999999999 986.36 1580.13 percent of total billed charges Insertion of tube into vena cava 48606864_1 CDM 0361 RC 36010 HCPCS inpatient 1629 1058.85 AETNA AETNA 1286.91 79 999999999 986.36 1580.13 percent of total billed charges Insertion of tube into vena cava 48606864_1 CDM 0361 RC 36010 HCPCS inpatient 1629 1058.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1580.13 97 999999999 986.36 1580.13 percent of total billed charges Insertion of tube into vena cava 48606864_1 CDM 0361 RC 36010 HCPCS inpatient 1629 1058.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1124.01 69 999999999 986.36 1580.13 percent of total billed charges Insertion of tube into vena cava 48606864_1 CDM 0361 RC 36010 HCPCS inpatient 1629 1058.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1270.62 78 999999999 986.36 1580.13 percent of total billed charges Insertion of tube into vena cava 48606864_1 CDM 0361 RC 36010 HCPCS inpatient 1629 1058.85 SIHO - ALL PLANS SIHO - ALL PLANS 1466.1 90 999999999 986.36 1580.13 percent of total billed charges Insertion of tube into vena cava 48606864_1 CDM 0361 RC 36010 HCPCS inpatient 1629 1058.85 UMR - ALL PLANS UMR - ALL PLANS 1140.3 70 999999999 986.36 1580.13 percent of total billed charges Insertion of tube into vena cava 48606864_1 CDM 0361 RC 36010 HCPCS inpatient 1629 1058.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 986.36 60.55 999999999 986.36 1580.13 percent of total billed charges Insertion of tube into vena cava 48606864_1 CDM 0361 RC 36010 HCPCS inpatient 1629 1058.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 986.36 1580.13 Insertion of tube into vena cava 48606864_1 CDM 0361 RC 36010 HCPCS inpatient 1629 1058.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 986.36 1580.13 Insertion of tube into vena cava 48606864_1 CDM 0361 RC 36010 HCPCS inpatient 1629 1058.85 ANTHEM HMO ANTHEM HMO 999999999 986.36 1580.13 Insertion of tube into vena cava 48606864_1 CDM 0361 RC 36010 HCPCS inpatient 1629 1058.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 986.36 1580.13 Insertion of tube into vena cava 48606864_1 CDM 0361 RC 36010 HCPCS inpatient 1629 1058.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1101.2 67.6 999999999 986.36 1580.13 percent of total billed charges Insertion of tube into vena cava 48606864_1 CDM 0361 RC 36010 HCPCS inpatient 1629 1058.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 986.36 1580.13 Biopsy of bone marrow 48606865_1 CDM 0361 RC 38221 HCPCS inpatient 533 346.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 346.45 65 999999999 322.73 517.01 percent of total billed charges Biopsy of bone marrow 48606865_1 CDM 0361 RC 38221 HCPCS inpatient 533 346.45 AETNA AETNA 421.07 79 999999999 322.73 517.01 percent of total billed charges Biopsy of bone marrow 48606865_1 CDM 0361 RC 38221 HCPCS inpatient 533 346.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 517.01 97 999999999 322.73 517.01 percent of total billed charges Biopsy of bone marrow 48606865_1 CDM 0361 RC 38221 HCPCS inpatient 533 346.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 367.77 69 999999999 322.73 517.01 percent of total billed charges Biopsy of bone marrow 48606865_1 CDM 0361 RC 38221 HCPCS inpatient 533 346.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 415.74 78 999999999 322.73 517.01 percent of total billed charges Biopsy of bone marrow 48606865_1 CDM 0361 RC 38221 HCPCS inpatient 533 346.45 SIHO - ALL PLANS SIHO - ALL PLANS 479.7 90 999999999 322.73 517.01 percent of total billed charges Biopsy of bone marrow 48606865_1 CDM 0361 RC 38221 HCPCS inpatient 533 346.45 UMR - ALL PLANS UMR - ALL PLANS 373.1 70 999999999 322.73 517.01 percent of total billed charges Biopsy of bone marrow 48606865_1 CDM 0361 RC 38221 HCPCS inpatient 533 346.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 322.73 60.55 999999999 322.73 517.01 percent of total billed charges Biopsy of bone marrow 48606865_1 CDM 0361 RC 38221 HCPCS inpatient 533 346.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 322.73 517.01 Biopsy of bone marrow 48606865_1 CDM 0361 RC 38221 HCPCS inpatient 533 346.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 322.73 517.01 Biopsy of bone marrow 48606865_1 CDM 0361 RC 38221 HCPCS inpatient 533 346.45 ANTHEM HMO ANTHEM HMO 999999999 322.73 517.01 Biopsy of bone marrow 48606865_1 CDM 0361 RC 38221 HCPCS inpatient 533 346.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 322.73 517.01 Biopsy of bone marrow 48606865_1 CDM 0361 RC 38221 HCPCS inpatient 533 346.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 360.31 67.6 999999999 322.73 517.01 percent of total billed charges Biopsy of bone marrow 48606865_1 CDM 0361 RC 38221 HCPCS inpatient 533 346.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 322.73 517.01 Removal of fluid from between lung and chest cavity 48606866_1 CDM 0361 RC 32551 HCPCS inpatient 1643 1067.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1067.95 65 999999999 994.84 1593.71 percent of total billed charges Removal of fluid from between lung and chest cavity 48606866_1 CDM 0361 RC 32551 HCPCS inpatient 1643 1067.95 AETNA AETNA 1297.97 79 999999999 994.84 1593.71 percent of total billed charges Removal of fluid from between lung and chest cavity 48606866_1 CDM 0361 RC 32551 HCPCS inpatient 1643 1067.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1593.71 97 999999999 994.84 1593.71 percent of total billed charges Removal of fluid from between lung and chest cavity 48606866_1 CDM 0361 RC 32551 HCPCS inpatient 1643 1067.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1133.67 69 999999999 994.84 1593.71 percent of total billed charges Removal of fluid from between lung and chest cavity 48606866_1 CDM 0361 RC 32551 HCPCS inpatient 1643 1067.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1281.54 78 999999999 994.84 1593.71 percent of total billed charges Removal of fluid from between lung and chest cavity 48606866_1 CDM 0361 RC 32551 HCPCS inpatient 1643 1067.95 SIHO - ALL PLANS SIHO - ALL PLANS 1478.7 90 999999999 994.84 1593.71 percent of total billed charges Removal of fluid from between lung and chest cavity 48606866_1 CDM 0361 RC 32551 HCPCS inpatient 1643 1067.95 UMR - ALL PLANS UMR - ALL PLANS 1150.1 70 999999999 994.84 1593.71 percent of total billed charges Removal of fluid from between lung and chest cavity 48606866_1 CDM 0361 RC 32551 HCPCS inpatient 1643 1067.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 994.84 60.55 999999999 994.84 1593.71 percent of total billed charges Removal of fluid from between lung and chest cavity 48606866_1 CDM 0361 RC 32551 HCPCS inpatient 1643 1067.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 994.84 1593.71 Removal of fluid from between lung and chest cavity 48606866_1 CDM 0361 RC 32551 HCPCS inpatient 1643 1067.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 994.84 1593.71 Removal of fluid from between lung and chest cavity 48606866_1 CDM 0361 RC 32551 HCPCS inpatient 1643 1067.95 ANTHEM HMO ANTHEM HMO 999999999 994.84 1593.71 Removal of fluid from between lung and chest cavity 48606866_1 CDM 0361 RC 32551 HCPCS inpatient 1643 1067.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 994.84 1593.71 Removal of fluid from between lung and chest cavity 48606866_1 CDM 0361 RC 32551 HCPCS inpatient 1643 1067.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1110.67 67.6 999999999 994.84 1593.71 percent of total billed charges Removal of fluid from between lung and chest cavity 48606866_1 CDM 0361 RC 32551 HCPCS inpatient 1643 1067.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 994.84 1593.71 Insertion of tube for infusion (5 years or older) 48606867_1 CDM 0361 RC 36569 HCPCS inpatient 4430 2879.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 2879.5 65 999999999 2682.37 4297.1 percent of total billed charges Insertion of tube for infusion (5 years or older) 48606867_1 CDM 0361 RC 36569 HCPCS inpatient 4430 2879.5 AETNA AETNA 3499.7 79 999999999 2682.37 4297.1 percent of total billed charges Insertion of tube for infusion (5 years or older) 48606867_1 CDM 0361 RC 36569 HCPCS inpatient 4430 2879.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4297.1 97 999999999 2682.37 4297.1 percent of total billed charges Insertion of tube for infusion (5 years or older) 48606867_1 CDM 0361 RC 36569 HCPCS inpatient 4430 2879.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 3056.7 69 999999999 2682.37 4297.1 percent of total billed charges Insertion of tube for infusion (5 years or older) 48606867_1 CDM 0361 RC 36569 HCPCS inpatient 4430 2879.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 3455.4 78 999999999 2682.37 4297.1 percent of total billed charges Insertion of tube for infusion (5 years or older) 48606867_1 CDM 0361 RC 36569 HCPCS inpatient 4430 2879.5 SIHO - ALL PLANS SIHO - ALL PLANS 3987 90 999999999 2682.37 4297.1 percent of total billed charges Insertion of tube for infusion (5 years or older) 48606867_1 CDM 0361 RC 36569 HCPCS inpatient 4430 2879.5 UMR - ALL PLANS UMR - ALL PLANS 3101 70 999999999 2682.37 4297.1 percent of total billed charges Insertion of tube for infusion (5 years or older) 48606867_1 CDM 0361 RC 36569 HCPCS inpatient 4430 2879.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2682.37 60.55 999999999 2682.37 4297.1 percent of total billed charges Insertion of tube for infusion (5 years or older) 48606867_1 CDM 0361 RC 36569 HCPCS inpatient 4430 2879.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2682.37 4297.1 Insertion of tube for infusion (5 years or older) 48606867_1 CDM 0361 RC 36569 HCPCS inpatient 4430 2879.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2682.37 4297.1 Insertion of tube for infusion (5 years or older) 48606867_1 CDM 0361 RC 36569 HCPCS inpatient 4430 2879.5 ANTHEM HMO ANTHEM HMO 999999999 2682.37 4297.1 Insertion of tube for infusion (5 years or older) 48606867_1 CDM 0361 RC 36569 HCPCS inpatient 4430 2879.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2682.37 4297.1 Insertion of tube for infusion (5 years or older) 48606867_1 CDM 0361 RC 36569 HCPCS inpatient 4430 2879.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 2994.68 67.6 999999999 2682.37 4297.1 percent of total billed charges Insertion of tube for infusion (5 years or older) 48606867_1 CDM 0361 RC 36569 HCPCS inpatient 4430 2879.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 2682.37 4297.1 Insertion of tunneled central venous tube for infusion (5 years or older) 48606868_1 CDM 0361 RC 36558 HCPCS inpatient 7374 4793.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 4793.1 65 999999999 4464.96 7152.78 percent of total billed charges Insertion of tunneled central venous tube for infusion (5 years or older) 48606868_1 CDM 0361 RC 36558 HCPCS inpatient 7374 4793.1 AETNA AETNA 5825.46 79 999999999 4464.96 7152.78 percent of total billed charges Insertion of tunneled central venous tube for infusion (5 years or older) 48606868_1 CDM 0361 RC 36558 HCPCS inpatient 7374 4793.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7152.78 97 999999999 4464.96 7152.78 percent of total billed charges Insertion of tunneled central venous tube for infusion (5 years or older) 48606868_1 CDM 0361 RC 36558 HCPCS inpatient 7374 4793.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 5088.06 69 999999999 4464.96 7152.78 percent of total billed charges Insertion of tunneled central venous tube for infusion (5 years or older) 48606868_1 CDM 0361 RC 36558 HCPCS inpatient 7374 4793.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 5751.72 78 999999999 4464.96 7152.78 percent of total billed charges Insertion of tunneled central venous tube for infusion (5 years or older) 48606868_1 CDM 0361 RC 36558 HCPCS inpatient 7374 4793.1 SIHO - ALL PLANS SIHO - ALL PLANS 6636.6 90 999999999 4464.96 7152.78 percent of total billed charges Insertion of tunneled central venous tube for infusion (5 years or older) 48606868_1 CDM 0361 RC 36558 HCPCS inpatient 7374 4793.1 UMR - ALL PLANS UMR - ALL PLANS 5161.8 70 999999999 4464.96 7152.78 percent of total billed charges Insertion of tunneled central venous tube for infusion (5 years or older) 48606868_1 CDM 0361 RC 36558 HCPCS inpatient 7374 4793.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4464.96 60.55 999999999 4464.96 7152.78 percent of total billed charges Insertion of tunneled central venous tube for infusion (5 years or older) 48606868_1 CDM 0361 RC 36558 HCPCS inpatient 7374 4793.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4464.96 7152.78 Insertion of tunneled central venous tube for infusion (5 years or older) 48606868_1 CDM 0361 RC 36558 HCPCS inpatient 7374 4793.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4464.96 7152.78 Insertion of tunneled central venous tube for infusion (5 years or older) 48606868_1 CDM 0361 RC 36558 HCPCS inpatient 7374 4793.1 ANTHEM HMO ANTHEM HMO 999999999 4464.96 7152.78 Insertion of tunneled central venous tube for infusion (5 years or older) 48606868_1 CDM 0361 RC 36558 HCPCS inpatient 7374 4793.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4464.96 7152.78 Insertion of tunneled central venous tube for infusion (5 years or older) 48606868_1 CDM 0361 RC 36558 HCPCS inpatient 7374 4793.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 4984.82 67.6 999999999 4464.96 7152.78 percent of total billed charges Insertion of tunneled central venous tube for infusion (5 years or older) 48606868_1 CDM 0361 RC 36558 HCPCS inpatient 7374 4793.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 4464.96 7152.78 Insertion of vena cava filter with review by radiologist 48606869_1 CDM 0361 RC 37191 HCPCS inpatient 12964 8426.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 8426.6 65 999999999 7849.7 12575.08 percent of total billed charges Insertion of vena cava filter with review by radiologist 48606869_1 CDM 0361 RC 37191 HCPCS inpatient 12964 8426.6 AETNA AETNA 10241.56 79 999999999 7849.7 12575.08 percent of total billed charges Insertion of vena cava filter with review by radiologist 48606869_1 CDM 0361 RC 37191 HCPCS inpatient 12964 8426.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12575.08 97 999999999 7849.7 12575.08 percent of total billed charges Insertion of vena cava filter with review by radiologist 48606869_1 CDM 0361 RC 37191 HCPCS inpatient 12964 8426.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 8945.16 69 999999999 7849.7 12575.08 percent of total billed charges Insertion of vena cava filter with review by radiologist 48606869_1 CDM 0361 RC 37191 HCPCS inpatient 12964 8426.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 10111.92 78 999999999 7849.7 12575.08 percent of total billed charges Insertion of vena cava filter with review by radiologist 48606869_1 CDM 0361 RC 37191 HCPCS inpatient 12964 8426.6 SIHO - ALL PLANS SIHO - ALL PLANS 11667.6 90 999999999 7849.7 12575.08 percent of total billed charges Insertion of vena cava filter with review by radiologist 48606869_1 CDM 0361 RC 37191 HCPCS inpatient 12964 8426.6 UMR - ALL PLANS UMR - ALL PLANS 9074.8 70 999999999 7849.7 12575.08 percent of total billed charges Insertion of vena cava filter with review by radiologist 48606869_1 CDM 0361 RC 37191 HCPCS inpatient 12964 8426.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7849.7 60.55 999999999 7849.7 12575.08 percent of total billed charges Insertion of vena cava filter with review by radiologist 48606869_1 CDM 0361 RC 37191 HCPCS inpatient 12964 8426.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7849.7 12575.08 Insertion of vena cava filter with review by radiologist 48606869_1 CDM 0361 RC 37191 HCPCS inpatient 12964 8426.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7849.7 12575.08 Insertion of vena cava filter with review by radiologist 48606869_1 CDM 0361 RC 37191 HCPCS inpatient 12964 8426.6 ANTHEM HMO ANTHEM HMO 999999999 7849.7 12575.08 Insertion of vena cava filter with review by radiologist 48606869_1 CDM 0361 RC 37191 HCPCS inpatient 12964 8426.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7849.7 12575.08 Insertion of vena cava filter with review by radiologist 48606869_1 CDM 0361 RC 37191 HCPCS inpatient 12964 8426.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 8763.66 67.6 999999999 7849.7 12575.08 percent of total billed charges Insertion of vena cava filter with review by radiologist 48606869_1 CDM 0361 RC 37191 HCPCS inpatient 12964 8426.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 7849.7 12575.08 Review by radiologist of abdominal aorta and both leg arteries image 48606870_1 CDM 0323 RC 75630 HCPCS inpatient 8757 5692.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 5692.05 65 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of abdominal aorta and both leg arteries image 48606870_1 CDM 0323 RC 75630 HCPCS inpatient 8757 5692.05 AETNA AETNA 6918.03 79 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of abdominal aorta and both leg arteries image 48606870_1 CDM 0323 RC 75630 HCPCS inpatient 8757 5692.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8494.29 97 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of abdominal aorta and both leg arteries image 48606870_1 CDM 0323 RC 75630 HCPCS inpatient 8757 5692.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 6042.33 69 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of abdominal aorta and both leg arteries image 48606870_1 CDM 0323 RC 75630 HCPCS inpatient 8757 5692.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 6830.46 78 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of abdominal aorta and both leg arteries image 48606870_1 CDM 0323 RC 75630 HCPCS inpatient 8757 5692.05 SIHO - ALL PLANS SIHO - ALL PLANS 7881.3 90 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of abdominal aorta and both leg arteries image 48606870_1 CDM 0323 RC 75630 HCPCS inpatient 8757 5692.05 UMR - ALL PLANS UMR - ALL PLANS 6129.9 70 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of abdominal aorta and both leg arteries image 48606870_1 CDM 0323 RC 75630 HCPCS inpatient 8757 5692.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5302.36 60.55 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of abdominal aorta and both leg arteries image 48606870_1 CDM 0323 RC 75630 HCPCS inpatient 8757 5692.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5302.36 8494.29 Review by radiologist of abdominal aorta and both leg arteries image 48606870_1 CDM 0323 RC 75630 HCPCS inpatient 8757 5692.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5302.36 8494.29 Review by radiologist of abdominal aorta and both leg arteries image 48606870_1 CDM 0323 RC 75630 HCPCS inpatient 8757 5692.05 ANTHEM HMO ANTHEM HMO 999999999 5302.36 8494.29 Review by radiologist of abdominal aorta and both leg arteries image 48606870_1 CDM 0323 RC 75630 HCPCS inpatient 8757 5692.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5302.36 8494.29 Review by radiologist of abdominal aorta and both leg arteries image 48606870_1 CDM 0323 RC 75630 HCPCS inpatient 8757 5692.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 5919.73 67.6 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of abdominal aorta and both leg arteries image 48606870_1 CDM 0323 RC 75630 HCPCS inpatient 8757 5692.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 5302.36 8494.29 Review by radiologist of abdominal aorta image 48606871_1 CDM 0323 RC 75625 HCPCS inpatient 8757 5692.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 5692.05 65 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of abdominal aorta image 48606871_1 CDM 0323 RC 75625 HCPCS inpatient 8757 5692.05 AETNA AETNA 6918.03 79 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of abdominal aorta image 48606871_1 CDM 0323 RC 75625 HCPCS inpatient 8757 5692.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8494.29 97 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of abdominal aorta image 48606871_1 CDM 0323 RC 75625 HCPCS inpatient 8757 5692.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 6042.33 69 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of abdominal aorta image 48606871_1 CDM 0323 RC 75625 HCPCS inpatient 8757 5692.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 6830.46 78 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of abdominal aorta image 48606871_1 CDM 0323 RC 75625 HCPCS inpatient 8757 5692.05 SIHO - ALL PLANS SIHO - ALL PLANS 7881.3 90 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of abdominal aorta image 48606871_1 CDM 0323 RC 75625 HCPCS inpatient 8757 5692.05 UMR - ALL PLANS UMR - ALL PLANS 6129.9 70 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of abdominal aorta image 48606871_1 CDM 0323 RC 75625 HCPCS inpatient 8757 5692.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5302.36 60.55 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of abdominal aorta image 48606871_1 CDM 0323 RC 75625 HCPCS inpatient 8757 5692.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5302.36 8494.29 Review by radiologist of abdominal aorta image 48606871_1 CDM 0323 RC 75625 HCPCS inpatient 8757 5692.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5302.36 8494.29 Review by radiologist of abdominal aorta image 48606871_1 CDM 0323 RC 75625 HCPCS inpatient 8757 5692.05 ANTHEM HMO ANTHEM HMO 999999999 5302.36 8494.29 Review by radiologist of abdominal aorta image 48606871_1 CDM 0323 RC 75625 HCPCS inpatient 8757 5692.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5302.36 8494.29 Review by radiologist of abdominal aorta image 48606871_1 CDM 0323 RC 75625 HCPCS inpatient 8757 5692.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 5919.73 67.6 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of abdominal aorta image 48606871_1 CDM 0323 RC 75625 HCPCS inpatient 8757 5692.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 5302.36 8494.29 IRPV ANGIOGRAPHY RENAL BILAT 48606872_1 CDM 0323 RC 75724 HCPCS inpatient 8757 5692.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 5692.05 65 999999999 5302.36 8494.29 percent of total billed charges IRPV ANGIOGRAPHY RENAL BILAT 48606872_1 CDM 0323 RC 75724 HCPCS inpatient 8757 5692.05 AETNA AETNA 6918.03 79 999999999 5302.36 8494.29 percent of total billed charges IRPV ANGIOGRAPHY RENAL BILAT 48606872_1 CDM 0323 RC 75724 HCPCS inpatient 8757 5692.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8494.29 97 999999999 5302.36 8494.29 percent of total billed charges IRPV ANGIOGRAPHY RENAL BILAT 48606872_1 CDM 0323 RC 75724 HCPCS inpatient 8757 5692.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 6042.33 69 999999999 5302.36 8494.29 percent of total billed charges IRPV ANGIOGRAPHY RENAL BILAT 48606872_1 CDM 0323 RC 75724 HCPCS inpatient 8757 5692.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 6830.46 78 999999999 5302.36 8494.29 percent of total billed charges IRPV ANGIOGRAPHY RENAL BILAT 48606872_1 CDM 0323 RC 75724 HCPCS inpatient 8757 5692.05 SIHO - ALL PLANS SIHO - ALL PLANS 7881.3 90 999999999 5302.36 8494.29 percent of total billed charges IRPV ANGIOGRAPHY RENAL BILAT 48606872_1 CDM 0323 RC 75724 HCPCS inpatient 8757 5692.05 UMR - ALL PLANS UMR - ALL PLANS 6129.9 70 999999999 5302.36 8494.29 percent of total billed charges IRPV ANGIOGRAPHY RENAL BILAT 48606872_1 CDM 0323 RC 75724 HCPCS inpatient 8757 5692.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5302.36 60.55 999999999 5302.36 8494.29 percent of total billed charges IRPV ANGIOGRAPHY RENAL BILAT 48606872_1 CDM 0323 RC 75724 HCPCS inpatient 8757 5692.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5302.36 8494.29 IRPV ANGIOGRAPHY RENAL BILAT 48606872_1 CDM 0323 RC 75724 HCPCS inpatient 8757 5692.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5302.36 8494.29 IRPV ANGIOGRAPHY RENAL BILAT 48606872_1 CDM 0323 RC 75724 HCPCS inpatient 8757 5692.05 ANTHEM HMO ANTHEM HMO 999999999 5302.36 8494.29 IRPV ANGIOGRAPHY RENAL BILAT 48606872_1 CDM 0323 RC 75724 HCPCS inpatient 8757 5692.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5302.36 8494.29 IRPV ANGIOGRAPHY RENAL BILAT 48606872_1 CDM 0323 RC 75724 HCPCS inpatient 8757 5692.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 5919.73 67.6 999999999 5302.36 8494.29 percent of total billed charges IRPV ANGIOGRAPHY RENAL BILAT 48606872_1 CDM 0323 RC 75724 HCPCS inpatient 8757 5692.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 5302.36 8494.29 IRPV ANGIOGRAPHY RENAL UNIL LT 48606873_1 CDM 0323 RC 75722 HCPCS inpatient 8757 5692.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 5692.05 65 999999999 5302.36 8494.29 percent of total billed charges IRPV ANGIOGRAPHY RENAL UNIL LT 48606873_1 CDM 0323 RC 75722 HCPCS inpatient 8757 5692.05 AETNA AETNA 6918.03 79 999999999 5302.36 8494.29 percent of total billed charges IRPV ANGIOGRAPHY RENAL UNIL LT 48606873_1 CDM 0323 RC 75722 HCPCS inpatient 8757 5692.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8494.29 97 999999999 5302.36 8494.29 percent of total billed charges IRPV ANGIOGRAPHY RENAL UNIL LT 48606873_1 CDM 0323 RC 75722 HCPCS inpatient 8757 5692.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 6042.33 69 999999999 5302.36 8494.29 percent of total billed charges IRPV ANGIOGRAPHY RENAL UNIL LT 48606873_1 CDM 0323 RC 75722 HCPCS inpatient 8757 5692.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 6830.46 78 999999999 5302.36 8494.29 percent of total billed charges IRPV ANGIOGRAPHY RENAL UNIL LT 48606873_1 CDM 0323 RC 75722 HCPCS inpatient 8757 5692.05 SIHO - ALL PLANS SIHO - ALL PLANS 7881.3 90 999999999 5302.36 8494.29 percent of total billed charges IRPV ANGIOGRAPHY RENAL UNIL LT 48606873_1 CDM 0323 RC 75722 HCPCS inpatient 8757 5692.05 UMR - ALL PLANS UMR - ALL PLANS 6129.9 70 999999999 5302.36 8494.29 percent of total billed charges IRPV ANGIOGRAPHY RENAL UNIL LT 48606873_1 CDM 0323 RC 75722 HCPCS inpatient 8757 5692.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5302.36 60.55 999999999 5302.36 8494.29 percent of total billed charges IRPV ANGIOGRAPHY RENAL UNIL LT 48606873_1 CDM 0323 RC 75722 HCPCS inpatient 8757 5692.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5302.36 8494.29 IRPV ANGIOGRAPHY RENAL UNIL LT 48606873_1 CDM 0323 RC 75722 HCPCS inpatient 8757 5692.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5302.36 8494.29 IRPV ANGIOGRAPHY RENAL UNIL LT 48606873_1 CDM 0323 RC 75722 HCPCS inpatient 8757 5692.05 ANTHEM HMO ANTHEM HMO 999999999 5302.36 8494.29 IRPV ANGIOGRAPHY RENAL UNIL LT 48606873_1 CDM 0323 RC 75722 HCPCS inpatient 8757 5692.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5302.36 8494.29 IRPV ANGIOGRAPHY RENAL UNIL LT 48606873_1 CDM 0323 RC 75722 HCPCS inpatient 8757 5692.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 5919.73 67.6 999999999 5302.36 8494.29 percent of total billed charges IRPV ANGIOGRAPHY RENAL UNIL LT 48606873_1 CDM 0323 RC 75722 HCPCS inpatient 8757 5692.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 5302.36 8494.29 Review by radiologist of both arms or legs arteries image 48606874_1 CDM 0323 RC 75716 HCPCS inpatient 8757 5692.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 5692.05 65 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of both arms or legs arteries image 48606874_1 CDM 0323 RC 75716 HCPCS inpatient 8757 5692.05 AETNA AETNA 6918.03 79 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of both arms or legs arteries image 48606874_1 CDM 0323 RC 75716 HCPCS inpatient 8757 5692.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8494.29 97 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of both arms or legs arteries image 48606874_1 CDM 0323 RC 75716 HCPCS inpatient 8757 5692.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 6042.33 69 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of both arms or legs arteries image 48606874_1 CDM 0323 RC 75716 HCPCS inpatient 8757 5692.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 6830.46 78 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of both arms or legs arteries image 48606874_1 CDM 0323 RC 75716 HCPCS inpatient 8757 5692.05 SIHO - ALL PLANS SIHO - ALL PLANS 7881.3 90 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of both arms or legs arteries image 48606874_1 CDM 0323 RC 75716 HCPCS inpatient 8757 5692.05 UMR - ALL PLANS UMR - ALL PLANS 6129.9 70 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of both arms or legs arteries image 48606874_1 CDM 0323 RC 75716 HCPCS inpatient 8757 5692.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5302.36 60.55 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of both arms or legs arteries image 48606874_1 CDM 0323 RC 75716 HCPCS inpatient 8757 5692.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5302.36 8494.29 Review by radiologist of both arms or legs arteries image 48606874_1 CDM 0323 RC 75716 HCPCS inpatient 8757 5692.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5302.36 8494.29 Review by radiologist of both arms or legs arteries image 48606874_1 CDM 0323 RC 75716 HCPCS inpatient 8757 5692.05 ANTHEM HMO ANTHEM HMO 999999999 5302.36 8494.29 Review by radiologist of both arms or legs arteries image 48606874_1 CDM 0323 RC 75716 HCPCS inpatient 8757 5692.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5302.36 8494.29 Review by radiologist of both arms or legs arteries image 48606874_1 CDM 0323 RC 75716 HCPCS inpatient 8757 5692.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 5919.73 67.6 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of both arms or legs arteries image 48606874_1 CDM 0323 RC 75716 HCPCS inpatient 8757 5692.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 5302.36 8494.29 Review by radiologist of arm or leg artery image 48606875_1 CDM 0323 RC 75710 HCPCS inpatient 8757 5692.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 5692.05 65 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of arm or leg artery image 48606875_1 CDM 0323 RC 75710 HCPCS inpatient 8757 5692.05 AETNA AETNA 6918.03 79 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of arm or leg artery image 48606875_1 CDM 0323 RC 75710 HCPCS inpatient 8757 5692.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8494.29 97 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of arm or leg artery image 48606875_1 CDM 0323 RC 75710 HCPCS inpatient 8757 5692.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 6042.33 69 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of arm or leg artery image 48606875_1 CDM 0323 RC 75710 HCPCS inpatient 8757 5692.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 6830.46 78 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of arm or leg artery image 48606875_1 CDM 0323 RC 75710 HCPCS inpatient 8757 5692.05 SIHO - ALL PLANS SIHO - ALL PLANS 7881.3 90 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of arm or leg artery image 48606875_1 CDM 0323 RC 75710 HCPCS inpatient 8757 5692.05 UMR - ALL PLANS UMR - ALL PLANS 6129.9 70 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of arm or leg artery image 48606875_1 CDM 0323 RC 75710 HCPCS inpatient 8757 5692.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5302.36 60.55 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of arm or leg artery image 48606875_1 CDM 0323 RC 75710 HCPCS inpatient 8757 5692.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5302.36 8494.29 Review by radiologist of arm or leg artery image 48606875_1 CDM 0323 RC 75710 HCPCS inpatient 8757 5692.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5302.36 8494.29 Review by radiologist of arm or leg artery image 48606875_1 CDM 0323 RC 75710 HCPCS inpatient 8757 5692.05 ANTHEM HMO ANTHEM HMO 999999999 5302.36 8494.29 Review by radiologist of arm or leg artery image 48606875_1 CDM 0323 RC 75710 HCPCS inpatient 8757 5692.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5302.36 8494.29 Review by radiologist of arm or leg artery image 48606875_1 CDM 0323 RC 75710 HCPCS inpatient 8757 5692.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 5919.73 67.6 999999999 5302.36 8494.29 percent of total billed charges Review by radiologist of arm or leg artery image 48606875_1 CDM 0323 RC 75710 HCPCS inpatient 8757 5692.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 5302.36 8494.29 X-RAY CONTROL CATH INSERT 48606876_1 CDM 0320 RC 74475 HCPCS inpatient 5028 3268.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 3268.2 65 999999999 3044.45 4877.16 percent of total billed charges X-RAY CONTROL CATH INSERT 48606876_1 CDM 0320 RC 74475 HCPCS inpatient 5028 3268.2 AETNA AETNA 3972.12 79 999999999 3044.45 4877.16 percent of total billed charges X-RAY CONTROL CATH INSERT 48606876_1 CDM 0320 RC 74475 HCPCS inpatient 5028 3268.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4877.16 97 999999999 3044.45 4877.16 percent of total billed charges X-RAY CONTROL CATH INSERT 48606876_1 CDM 0320 RC 74475 HCPCS inpatient 5028 3268.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 3469.32 69 999999999 3044.45 4877.16 percent of total billed charges X-RAY CONTROL CATH INSERT 48606876_1 CDM 0320 RC 74475 HCPCS inpatient 5028 3268.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 3921.84 78 999999999 3044.45 4877.16 percent of total billed charges X-RAY CONTROL CATH INSERT 48606876_1 CDM 0320 RC 74475 HCPCS inpatient 5028 3268.2 SIHO - ALL PLANS SIHO - ALL PLANS 4525.2 90 999999999 3044.45 4877.16 percent of total billed charges X-RAY CONTROL CATH INSERT 48606876_1 CDM 0320 RC 74475 HCPCS inpatient 5028 3268.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3044.45 60.55 999999999 3044.45 4877.16 percent of total billed charges X-RAY CONTROL CATH INSERT 48606876_1 CDM 0320 RC 74475 HCPCS inpatient 5028 3268.2 UMR - ALL PLANS UMR - ALL PLANS 3519.6 70 999999999 3044.45 4877.16 percent of total billed charges X-RAY CONTROL CATH INSERT 48606876_1 CDM 0320 RC 74475 HCPCS inpatient 5028 3268.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3044.45 4877.16 X-RAY CONTROL CATH INSERT 48606876_1 CDM 0320 RC 74475 HCPCS inpatient 5028 3268.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3044.45 4877.16 X-RAY CONTROL CATH INSERT 48606876_1 CDM 0320 RC 74475 HCPCS inpatient 5028 3268.2 ANTHEM HMO ANTHEM HMO 999999999 3044.45 4877.16 X-RAY CONTROL CATH INSERT 48606876_1 CDM 0320 RC 74475 HCPCS inpatient 5028 3268.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3044.45 4877.16 X-RAY CONTROL CATH INSERT 48606876_1 CDM 0320 RC 74475 HCPCS inpatient 5028 3268.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 3398.93 67.6 999999999 3044.45 4877.16 percent of total billed charges X-RAY CONTROL CATH INSERT 48606876_1 CDM 0320 RC 74475 HCPCS inpatient 5028 3268.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 3044.45 4877.16 Fluoroscopic guidance for insertion or removal of central vein access device 48606877_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 250.9 65 999999999 233.72 374.42 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 48606877_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 AETNA AETNA 304.94 79 999999999 233.72 374.42 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 48606877_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 374.42 97 999999999 233.72 374.42 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 48606877_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 266.34 69 999999999 233.72 374.42 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 48606877_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.08 78 999999999 233.72 374.42 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 48606877_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 SIHO - ALL PLANS SIHO - ALL PLANS 347.4 90 999999999 233.72 374.42 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 48606877_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 233.72 60.55 999999999 233.72 374.42 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 48606877_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 UMR - ALL PLANS UMR - ALL PLANS 270.2 70 999999999 233.72 374.42 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 48606877_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 233.72 374.42 Fluoroscopic guidance for insertion or removal of central vein access device 48606877_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 233.72 374.42 Fluoroscopic guidance for insertion or removal of central vein access device 48606877_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 ANTHEM HMO ANTHEM HMO 999999999 233.72 374.42 Fluoroscopic guidance for insertion or removal of central vein access device 48606877_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 233.72 374.42 Fluoroscopic guidance for insertion or removal of central vein access device 48606877_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 260.94 67.6 999999999 233.72 374.42 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 48606877_1 CDM 0320 RC 77001 HCPCS inpatient 386 250.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 233.72 374.42 Review by radiologist of 1 arm or leg vein of 1 arm or leg image 48606878_1 CDM 0320 RC 75820 HCPCS inpatient 3065 1992.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1992.25 65 999999999 1855.86 2973.05 percent of total billed charges Review by radiologist of 1 arm or leg vein of 1 arm or leg image 48606878_1 CDM 0320 RC 75820 HCPCS inpatient 3065 1992.25 AETNA AETNA 2421.35 79 999999999 1855.86 2973.05 percent of total billed charges Review by radiologist of 1 arm or leg vein of 1 arm or leg image 48606878_1 CDM 0320 RC 75820 HCPCS inpatient 3065 1992.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2973.05 97 999999999 1855.86 2973.05 percent of total billed charges Review by radiologist of 1 arm or leg vein of 1 arm or leg image 48606878_1 CDM 0320 RC 75820 HCPCS inpatient 3065 1992.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 2114.85 69 999999999 1855.86 2973.05 percent of total billed charges Review by radiologist of 1 arm or leg vein of 1 arm or leg image 48606878_1 CDM 0320 RC 75820 HCPCS inpatient 3065 1992.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 2390.7 78 999999999 1855.86 2973.05 percent of total billed charges Review by radiologist of 1 arm or leg vein of 1 arm or leg image 48606878_1 CDM 0320 RC 75820 HCPCS inpatient 3065 1992.25 SIHO - ALL PLANS SIHO - ALL PLANS 2758.5 90 999999999 1855.86 2973.05 percent of total billed charges Review by radiologist of 1 arm or leg vein of 1 arm or leg image 48606878_1 CDM 0320 RC 75820 HCPCS inpatient 3065 1992.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1855.86 60.55 999999999 1855.86 2973.05 percent of total billed charges Review by radiologist of 1 arm or leg vein of 1 arm or leg image 48606878_1 CDM 0320 RC 75820 HCPCS inpatient 3065 1992.25 UMR - ALL PLANS UMR - ALL PLANS 2145.5 70 999999999 1855.86 2973.05 percent of total billed charges Review by radiologist of 1 arm or leg vein of 1 arm or leg image 48606878_1 CDM 0320 RC 75820 HCPCS inpatient 3065 1992.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1855.86 2973.05 Review by radiologist of 1 arm or leg vein of 1 arm or leg image 48606878_1 CDM 0320 RC 75820 HCPCS inpatient 3065 1992.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1855.86 2973.05 Review by radiologist of 1 arm or leg vein of 1 arm or leg image 48606878_1 CDM 0320 RC 75820 HCPCS inpatient 3065 1992.25 ANTHEM HMO ANTHEM HMO 999999999 1855.86 2973.05 Review by radiologist of 1 arm or leg vein of 1 arm or leg image 48606878_1 CDM 0320 RC 75820 HCPCS inpatient 3065 1992.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1855.86 2973.05 Review by radiologist of 1 arm or leg vein of 1 arm or leg image 48606878_1 CDM 0320 RC 75820 HCPCS inpatient 3065 1992.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 2071.94 67.6 999999999 1855.86 2973.05 percent of total billed charges Review by radiologist of 1 arm or leg vein of 1 arm or leg image 48606878_1 CDM 0320 RC 75820 HCPCS inpatient 3065 1992.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1855.86 2973.05 "Insertion of tube in right and left heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606879_1 CDM 0481 RC 93461 HCPCS inpatient 22390 14553.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 14553.5 65 999999999 13557.15 21718.3 percent of total billed charges "Insertion of tube in right and left heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606879_1 CDM 0481 RC 93461 HCPCS inpatient 22390 14553.5 AETNA AETNA 17688.1 79 999999999 13557.15 21718.3 percent of total billed charges "Insertion of tube in right and left heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606879_1 CDM 0481 RC 93461 HCPCS inpatient 22390 14553.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21718.3 97 999999999 13557.15 21718.3 percent of total billed charges "Insertion of tube in right and left heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606879_1 CDM 0481 RC 93461 HCPCS inpatient 22390 14553.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 15449.1 69 999999999 13557.15 21718.3 percent of total billed charges "Insertion of tube in right and left heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606879_1 CDM 0481 RC 93461 HCPCS inpatient 22390 14553.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 17464.2 78 999999999 13557.15 21718.3 percent of total billed charges "Insertion of tube in right and left heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606879_1 CDM 0481 RC 93461 HCPCS inpatient 22390 14553.5 SIHO - ALL PLANS SIHO - ALL PLANS 20151 90 999999999 13557.15 21718.3 percent of total billed charges "Insertion of tube in right and left heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606879_1 CDM 0481 RC 93461 HCPCS inpatient 22390 14553.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13557.15 60.55 999999999 13557.15 21718.3 percent of total billed charges "Insertion of tube in right and left heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606879_1 CDM 0481 RC 93461 HCPCS inpatient 22390 14553.5 UMR - ALL PLANS UMR - ALL PLANS 15673 70 999999999 13557.15 21718.3 percent of total billed charges "Insertion of tube in right and left heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606879_1 CDM 0481 RC 93461 HCPCS inpatient 22390 14553.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13557.15 21718.3 "Insertion of tube in right and left heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606879_1 CDM 0481 RC 93461 HCPCS inpatient 22390 14553.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13557.15 21718.3 "Insertion of tube in right and left heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606879_1 CDM 0481 RC 93461 HCPCS inpatient 22390 14553.5 ANTHEM HMO ANTHEM HMO 999999999 13557.15 21718.3 "Insertion of tube in right and left heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606879_1 CDM 0481 RC 93461 HCPCS inpatient 22390 14553.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13557.15 21718.3 "Insertion of tube in right and left heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606879_1 CDM 0481 RC 93461 HCPCS inpatient 22390 14553.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 15135.64 67.6 999999999 13557.15 21718.3 percent of total billed charges "Insertion of tube in right and left heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606879_1 CDM 0481 RC 93461 HCPCS inpatient 22390 14553.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 13557.15 21718.3 Insertion of tube in right and left heart chambers and coronary artery for diagnosis with review by radiologist 48606880_1 CDM 0481 RC 93460 HCPCS inpatient 22390 14553.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 14553.5 65 999999999 13557.15 21718.3 percent of total billed charges Insertion of tube in right and left heart chambers and coronary artery for diagnosis with review by radiologist 48606880_1 CDM 0481 RC 93460 HCPCS inpatient 22390 14553.5 AETNA AETNA 17688.1 79 999999999 13557.15 21718.3 percent of total billed charges Insertion of tube in right and left heart chambers and coronary artery for diagnosis with review by radiologist 48606880_1 CDM 0481 RC 93460 HCPCS inpatient 22390 14553.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21718.3 97 999999999 13557.15 21718.3 percent of total billed charges Insertion of tube in right and left heart chambers and coronary artery for diagnosis with review by radiologist 48606880_1 CDM 0481 RC 93460 HCPCS inpatient 22390 14553.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 15449.1 69 999999999 13557.15 21718.3 percent of total billed charges Insertion of tube in right and left heart chambers and coronary artery for diagnosis with review by radiologist 48606880_1 CDM 0481 RC 93460 HCPCS inpatient 22390 14553.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 17464.2 78 999999999 13557.15 21718.3 percent of total billed charges Insertion of tube in right and left heart chambers and coronary artery for diagnosis with review by radiologist 48606880_1 CDM 0481 RC 93460 HCPCS inpatient 22390 14553.5 SIHO - ALL PLANS SIHO - ALL PLANS 20151 90 999999999 13557.15 21718.3 percent of total billed charges Insertion of tube in right and left heart chambers and coronary artery for diagnosis with review by radiologist 48606880_1 CDM 0481 RC 93460 HCPCS inpatient 22390 14553.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13557.15 60.55 999999999 13557.15 21718.3 percent of total billed charges Insertion of tube in right and left heart chambers and coronary artery for diagnosis with review by radiologist 48606880_1 CDM 0481 RC 93460 HCPCS inpatient 22390 14553.5 UMR - ALL PLANS UMR - ALL PLANS 15673 70 999999999 13557.15 21718.3 percent of total billed charges Insertion of tube in right and left heart chambers and coronary artery for diagnosis with review by radiologist 48606880_1 CDM 0481 RC 93460 HCPCS inpatient 22390 14553.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13557.15 21718.3 Insertion of tube in right and left heart chambers and coronary artery for diagnosis with review by radiologist 48606880_1 CDM 0481 RC 93460 HCPCS inpatient 22390 14553.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13557.15 21718.3 Insertion of tube in right and left heart chambers and coronary artery for diagnosis with review by radiologist 48606880_1 CDM 0481 RC 93460 HCPCS inpatient 22390 14553.5 ANTHEM HMO ANTHEM HMO 999999999 13557.15 21718.3 Insertion of tube in right and left heart chambers and coronary artery for diagnosis with review by radiologist 48606880_1 CDM 0481 RC 93460 HCPCS inpatient 22390 14553.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13557.15 21718.3 Insertion of tube in right and left heart chambers and coronary artery for diagnosis with review by radiologist 48606880_1 CDM 0481 RC 93460 HCPCS inpatient 22390 14553.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 15135.64 67.6 999999999 13557.15 21718.3 percent of total billed charges Insertion of tube in right and left heart chambers and coronary artery for diagnosis with review by radiologist 48606880_1 CDM 0481 RC 93460 HCPCS inpatient 22390 14553.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 13557.15 21718.3 "Insertion of tube in left lower heart chamber, coronary artery and bypass graft for diagnosis with review by radiologist" 48606881_1 CDM 0481 RC 93459 HCPCS inpatient 22390 14553.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 14553.5 65 999999999 13557.15 21718.3 percent of total billed charges "Insertion of tube in left lower heart chamber, coronary artery and bypass graft for diagnosis with review by radiologist" 48606881_1 CDM 0481 RC 93459 HCPCS inpatient 22390 14553.5 AETNA AETNA 17688.1 79 999999999 13557.15 21718.3 percent of total billed charges "Insertion of tube in left lower heart chamber, coronary artery and bypass graft for diagnosis with review by radiologist" 48606881_1 CDM 0481 RC 93459 HCPCS inpatient 22390 14553.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21718.3 97 999999999 13557.15 21718.3 percent of total billed charges "Insertion of tube in left lower heart chamber, coronary artery and bypass graft for diagnosis with review by radiologist" 48606881_1 CDM 0481 RC 93459 HCPCS inpatient 22390 14553.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 15449.1 69 999999999 13557.15 21718.3 percent of total billed charges "Insertion of tube in left lower heart chamber, coronary artery and bypass graft for diagnosis with review by radiologist" 48606881_1 CDM 0481 RC 93459 HCPCS inpatient 22390 14553.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 17464.2 78 999999999 13557.15 21718.3 percent of total billed charges "Insertion of tube in left lower heart chamber, coronary artery and bypass graft for diagnosis with review by radiologist" 48606881_1 CDM 0481 RC 93459 HCPCS inpatient 22390 14553.5 SIHO - ALL PLANS SIHO - ALL PLANS 20151 90 999999999 13557.15 21718.3 percent of total billed charges "Insertion of tube in left lower heart chamber, coronary artery and bypass graft for diagnosis with review by radiologist" 48606881_1 CDM 0481 RC 93459 HCPCS inpatient 22390 14553.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13557.15 60.55 999999999 13557.15 21718.3 percent of total billed charges "Insertion of tube in left lower heart chamber, coronary artery and bypass graft for diagnosis with review by radiologist" 48606881_1 CDM 0481 RC 93459 HCPCS inpatient 22390 14553.5 UMR - ALL PLANS UMR - ALL PLANS 15673 70 999999999 13557.15 21718.3 percent of total billed charges "Insertion of tube in left lower heart chamber, coronary artery and bypass graft for diagnosis with review by radiologist" 48606881_1 CDM 0481 RC 93459 HCPCS inpatient 22390 14553.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13557.15 21718.3 "Insertion of tube in left lower heart chamber, coronary artery and bypass graft for diagnosis with review by radiologist" 48606881_1 CDM 0481 RC 93459 HCPCS inpatient 22390 14553.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13557.15 21718.3 "Insertion of tube in left lower heart chamber, coronary artery and bypass graft for diagnosis with review by radiologist" 48606881_1 CDM 0481 RC 93459 HCPCS inpatient 22390 14553.5 ANTHEM HMO ANTHEM HMO 999999999 13557.15 21718.3 "Insertion of tube in left lower heart chamber, coronary artery and bypass graft for diagnosis with review by radiologist" 48606881_1 CDM 0481 RC 93459 HCPCS inpatient 22390 14553.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13557.15 21718.3 "Insertion of tube in left lower heart chamber, coronary artery and bypass graft for diagnosis with review by radiologist" 48606881_1 CDM 0481 RC 93459 HCPCS inpatient 22390 14553.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 15135.64 67.6 999999999 13557.15 21718.3 percent of total billed charges "Insertion of tube in left lower heart chamber, coronary artery and bypass graft for diagnosis with review by radiologist" 48606881_1 CDM 0481 RC 93459 HCPCS inpatient 22390 14553.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 13557.15 21718.3 Insertion of tube in left lower heart chamber and coronary artery for diagnosis with review by radiologist 48606882_1 CDM 0481 RC 93458 HCPCS inpatient 22390 14553.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 14553.5 65 999999999 13557.15 21718.3 percent of total billed charges Insertion of tube in left lower heart chamber and coronary artery for diagnosis with review by radiologist 48606882_1 CDM 0481 RC 93458 HCPCS inpatient 22390 14553.5 AETNA AETNA 17688.1 79 999999999 13557.15 21718.3 percent of total billed charges Insertion of tube in left lower heart chamber and coronary artery for diagnosis with review by radiologist 48606882_1 CDM 0481 RC 93458 HCPCS inpatient 22390 14553.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21718.3 97 999999999 13557.15 21718.3 percent of total billed charges Insertion of tube in left lower heart chamber and coronary artery for diagnosis with review by radiologist 48606882_1 CDM 0481 RC 93458 HCPCS inpatient 22390 14553.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 15449.1 69 999999999 13557.15 21718.3 percent of total billed charges Insertion of tube in left lower heart chamber and coronary artery for diagnosis with review by radiologist 48606882_1 CDM 0481 RC 93458 HCPCS inpatient 22390 14553.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 17464.2 78 999999999 13557.15 21718.3 percent of total billed charges Insertion of tube in left lower heart chamber and coronary artery for diagnosis with review by radiologist 48606882_1 CDM 0481 RC 93458 HCPCS inpatient 22390 14553.5 SIHO - ALL PLANS SIHO - ALL PLANS 20151 90 999999999 13557.15 21718.3 percent of total billed charges Insertion of tube in left lower heart chamber and coronary artery for diagnosis with review by radiologist 48606882_1 CDM 0481 RC 93458 HCPCS inpatient 22390 14553.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13557.15 60.55 999999999 13557.15 21718.3 percent of total billed charges Insertion of tube in left lower heart chamber and coronary artery for diagnosis with review by radiologist 48606882_1 CDM 0481 RC 93458 HCPCS inpatient 22390 14553.5 UMR - ALL PLANS UMR - ALL PLANS 15673 70 999999999 13557.15 21718.3 percent of total billed charges Insertion of tube in left lower heart chamber and coronary artery for diagnosis with review by radiologist 48606882_1 CDM 0481 RC 93458 HCPCS inpatient 22390 14553.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13557.15 21718.3 Insertion of tube in left lower heart chamber and coronary artery for diagnosis with review by radiologist 48606882_1 CDM 0481 RC 93458 HCPCS inpatient 22390 14553.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13557.15 21718.3 Insertion of tube in left lower heart chamber and coronary artery for diagnosis with review by radiologist 48606882_1 CDM 0481 RC 93458 HCPCS inpatient 22390 14553.5 ANTHEM HMO ANTHEM HMO 999999999 13557.15 21718.3 Insertion of tube in left lower heart chamber and coronary artery for diagnosis with review by radiologist 48606882_1 CDM 0481 RC 93458 HCPCS inpatient 22390 14553.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13557.15 21718.3 Insertion of tube in left lower heart chamber and coronary artery for diagnosis with review by radiologist 48606882_1 CDM 0481 RC 93458 HCPCS inpatient 22390 14553.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 15135.64 67.6 999999999 13557.15 21718.3 percent of total billed charges Insertion of tube in left lower heart chamber and coronary artery for diagnosis with review by radiologist 48606882_1 CDM 0481 RC 93458 HCPCS inpatient 22390 14553.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 13557.15 21718.3 "Insertion of tube in right heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606883_1 CDM 0481 RC 93457 HCPCS inpatient 29460 19149 SELF PAY DISCOUNT SELF PAY DISCOUNT 19149 65 999999999 17838.03 28576.2 percent of total billed charges "Insertion of tube in right heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606883_1 CDM 0481 RC 93457 HCPCS inpatient 29460 19149 AETNA AETNA 23273.4 79 999999999 17838.03 28576.2 percent of total billed charges "Insertion of tube in right heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606883_1 CDM 0481 RC 93457 HCPCS inpatient 29460 19149 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 28576.2 97 999999999 17838.03 28576.2 percent of total billed charges "Insertion of tube in right heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606883_1 CDM 0481 RC 93457 HCPCS inpatient 29460 19149 ENCORE - ALL PLANS ENCORE - ALL PLANS 20327.4 69 999999999 17838.03 28576.2 percent of total billed charges "Insertion of tube in right heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606883_1 CDM 0481 RC 93457 HCPCS inpatient 29460 19149 HUMANA - ALL PLANS HUMANA - ALL PLANS 22978.8 78 999999999 17838.03 28576.2 percent of total billed charges "Insertion of tube in right heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606883_1 CDM 0481 RC 93457 HCPCS inpatient 29460 19149 SIHO - ALL PLANS SIHO - ALL PLANS 26514 90 999999999 17838.03 28576.2 percent of total billed charges "Insertion of tube in right heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606883_1 CDM 0481 RC 93457 HCPCS inpatient 29460 19149 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17838.03 60.55 999999999 17838.03 28576.2 percent of total billed charges "Insertion of tube in right heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606883_1 CDM 0481 RC 93457 HCPCS inpatient 29460 19149 UMR - ALL PLANS UMR - ALL PLANS 20622 70 999999999 17838.03 28576.2 percent of total billed charges "Insertion of tube in right heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606883_1 CDM 0481 RC 93457 HCPCS inpatient 29460 19149 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 17838.03 28576.2 "Insertion of tube in right heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606883_1 CDM 0481 RC 93457 HCPCS inpatient 29460 19149 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 17838.03 28576.2 "Insertion of tube in right heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606883_1 CDM 0481 RC 93457 HCPCS inpatient 29460 19149 ANTHEM HMO ANTHEM HMO 999999999 17838.03 28576.2 "Insertion of tube in right heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606883_1 CDM 0481 RC 93457 HCPCS inpatient 29460 19149 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 17838.03 28576.2 "Insertion of tube in right heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606883_1 CDM 0481 RC 93457 HCPCS inpatient 29460 19149 CIGNA - ALL PLANS CIGNA - ALL PLANS 19914.96 67.6 999999999 17838.03 28576.2 percent of total billed charges "Insertion of tube in right heart chambers, coronary artery, and bypass graft for diagnosis with review by radiologist" 48606883_1 CDM 0481 RC 93457 HCPCS inpatient 29460 19149 UHC - ALL PLANS UHC - ALL PLANS 999999999 17838.03 28576.2 Insertion of tube in right heart chambers and coronary artery for diagnosis with review by radiologist 48606884_1 CDM 0481 RC 93456 HCPCS inpatient 27337 17769.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 17769.05 65 999999999 16552.55 26516.89 percent of total billed charges Insertion of tube in right heart chambers and coronary artery for diagnosis with review by radiologist 48606884_1 CDM 0481 RC 93456 HCPCS inpatient 27337 17769.05 AETNA AETNA 21596.23 79 999999999 16552.55 26516.89 percent of total billed charges Insertion of tube in right heart chambers and coronary artery for diagnosis with review by radiologist 48606884_1 CDM 0481 RC 93456 HCPCS inpatient 27337 17769.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26516.89 97 999999999 16552.55 26516.89 percent of total billed charges Insertion of tube in right heart chambers and coronary artery for diagnosis with review by radiologist 48606884_1 CDM 0481 RC 93456 HCPCS inpatient 27337 17769.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 18862.53 69 999999999 16552.55 26516.89 percent of total billed charges Insertion of tube in right heart chambers and coronary artery for diagnosis with review by radiologist 48606884_1 CDM 0481 RC 93456 HCPCS inpatient 27337 17769.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 21322.86 78 999999999 16552.55 26516.89 percent of total billed charges Insertion of tube in right heart chambers and coronary artery for diagnosis with review by radiologist 48606884_1 CDM 0481 RC 93456 HCPCS inpatient 27337 17769.05 SIHO - ALL PLANS SIHO - ALL PLANS 24603.3 90 999999999 16552.55 26516.89 percent of total billed charges Insertion of tube in right heart chambers and coronary artery for diagnosis with review by radiologist 48606884_1 CDM 0481 RC 93456 HCPCS inpatient 27337 17769.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16552.55 60.55 999999999 16552.55 26516.89 percent of total billed charges Insertion of tube in right heart chambers and coronary artery for diagnosis with review by radiologist 48606884_1 CDM 0481 RC 93456 HCPCS inpatient 27337 17769.05 UMR - ALL PLANS UMR - ALL PLANS 19135.9 70 999999999 16552.55 26516.89 percent of total billed charges Insertion of tube in right heart chambers and coronary artery for diagnosis with review by radiologist 48606884_1 CDM 0481 RC 93456 HCPCS inpatient 27337 17769.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16552.55 26516.89 Insertion of tube in right heart chambers and coronary artery for diagnosis with review by radiologist 48606884_1 CDM 0481 RC 93456 HCPCS inpatient 27337 17769.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16552.55 26516.89 Insertion of tube in right heart chambers and coronary artery for diagnosis with review by radiologist 48606884_1 CDM 0481 RC 93456 HCPCS inpatient 27337 17769.05 ANTHEM HMO ANTHEM HMO 999999999 16552.55 26516.89 Insertion of tube in right heart chambers and coronary artery for diagnosis with review by radiologist 48606884_1 CDM 0481 RC 93456 HCPCS inpatient 27337 17769.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16552.55 26516.89 Insertion of tube in right heart chambers and coronary artery for diagnosis with review by radiologist 48606884_1 CDM 0481 RC 93456 HCPCS inpatient 27337 17769.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 18479.81 67.6 999999999 16552.55 26516.89 percent of total billed charges Insertion of tube in right heart chambers and coronary artery for diagnosis with review by radiologist 48606884_1 CDM 0481 RC 93456 HCPCS inpatient 27337 17769.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 16552.55 26516.89 ANS ANESTH LEVEL I 1st 1/2 HR 48607035_1 CDM 0370 RC inpatient 679 441.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 441.35 65 999999999 411.13 658.63 percent of total billed charges ANS ANESTH LEVEL I 1st 1/2 HR 48607035_1 CDM 0370 RC inpatient 679 441.35 AETNA AETNA 536.41 79 999999999 411.13 658.63 percent of total billed charges ANS ANESTH LEVEL I 1st 1/2 HR 48607035_1 CDM 0370 RC inpatient 679 441.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 658.63 97 999999999 411.13 658.63 percent of total billed charges ANS ANESTH LEVEL I 1st 1/2 HR 48607035_1 CDM 0370 RC inpatient 679 441.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 468.51 69 999999999 411.13 658.63 percent of total billed charges ANS ANESTH LEVEL I 1st 1/2 HR 48607035_1 CDM 0370 RC inpatient 679 441.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 529.62 78 999999999 411.13 658.63 percent of total billed charges ANS ANESTH LEVEL I 1st 1/2 HR 48607035_1 CDM 0370 RC inpatient 679 441.35 SIHO - ALL PLANS SIHO - ALL PLANS 611.1 90 999999999 411.13 658.63 percent of total billed charges ANS ANESTH LEVEL I 1st 1/2 HR 48607035_1 CDM 0370 RC inpatient 679 441.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 411.13 60.55 999999999 411.13 658.63 percent of total billed charges ANS ANESTH LEVEL I 1st 1/2 HR 48607035_1 CDM 0370 RC inpatient 679 441.35 UMR - ALL PLANS UMR - ALL PLANS 475.3 70 999999999 411.13 658.63 percent of total billed charges ANS ANESTH LEVEL I 1st 1/2 HR 48607035_1 CDM 0370 RC inpatient 679 441.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 411.13 658.63 ANS ANESTH LEVEL I 1st 1/2 HR 48607035_1 CDM 0370 RC inpatient 679 441.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 411.13 658.63 ANS ANESTH LEVEL I 1st 1/2 HR 48607035_1 CDM 0370 RC inpatient 679 441.35 ANTHEM HMO ANTHEM HMO 999999999 411.13 658.63 ANS ANESTH LEVEL I 1st 1/2 HR 48607035_1 CDM 0370 RC inpatient 679 441.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 411.13 658.63 ANS ANESTH LEVEL I 1st 1/2 HR 48607035_1 CDM 0370 RC inpatient 679 441.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 459 67.6 999999999 411.13 658.63 percent of total billed charges ANS ANESTH LEVEL I 1st 1/2 HR 48607035_1 CDM 0370 RC inpatient 679 441.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 411.13 658.63 ANS ANESTH LEVEL I ADD UNIT 48607036_1 CDM 0370 RC inpatient 236 153.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 153.4 65 999999999 142.9 228.92 percent of total billed charges ANS ANESTH LEVEL I ADD UNIT 48607036_1 CDM 0370 RC inpatient 236 153.4 AETNA AETNA 186.44 79 999999999 142.9 228.92 percent of total billed charges ANS ANESTH LEVEL I ADD UNIT 48607036_1 CDM 0370 RC inpatient 236 153.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 228.92 97 999999999 142.9 228.92 percent of total billed charges ANS ANESTH LEVEL I ADD UNIT 48607036_1 CDM 0370 RC inpatient 236 153.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 162.84 69 999999999 142.9 228.92 percent of total billed charges ANS ANESTH LEVEL I ADD UNIT 48607036_1 CDM 0370 RC inpatient 236 153.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 184.08 78 999999999 142.9 228.92 percent of total billed charges ANS ANESTH LEVEL I ADD UNIT 48607036_1 CDM 0370 RC inpatient 236 153.4 SIHO - ALL PLANS SIHO - ALL PLANS 212.4 90 999999999 142.9 228.92 percent of total billed charges ANS ANESTH LEVEL I ADD UNIT 48607036_1 CDM 0370 RC inpatient 236 153.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 142.9 60.55 999999999 142.9 228.92 percent of total billed charges ANS ANESTH LEVEL I ADD UNIT 48607036_1 CDM 0370 RC inpatient 236 153.4 UMR - ALL PLANS UMR - ALL PLANS 165.2 70 999999999 142.9 228.92 percent of total billed charges ANS ANESTH LEVEL I ADD UNIT 48607036_1 CDM 0370 RC inpatient 236 153.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 142.9 228.92 ANS ANESTH LEVEL I ADD UNIT 48607036_1 CDM 0370 RC inpatient 236 153.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 142.9 228.92 ANS ANESTH LEVEL I ADD UNIT 48607036_1 CDM 0370 RC inpatient 236 153.4 ANTHEM HMO ANTHEM HMO 999999999 142.9 228.92 ANS ANESTH LEVEL I ADD UNIT 48607036_1 CDM 0370 RC inpatient 236 153.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 142.9 228.92 ANS ANESTH LEVEL I ADD UNIT 48607036_1 CDM 0370 RC inpatient 236 153.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 159.54 67.6 999999999 142.9 228.92 percent of total billed charges ANS ANESTH LEVEL I ADD UNIT 48607036_1 CDM 0370 RC inpatient 236 153.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 142.9 228.92 ANS ANESTH LVL II 1st 1/2HR 48607037_1 CDM 0370 RC inpatient 774 503.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 503.1 65 999999999 468.66 750.78 percent of total billed charges ANS ANESTH LVL II 1st 1/2HR 48607037_1 CDM 0370 RC inpatient 774 503.1 AETNA AETNA 611.46 79 999999999 468.66 750.78 percent of total billed charges ANS ANESTH LVL II 1st 1/2HR 48607037_1 CDM 0370 RC inpatient 774 503.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 750.78 97 999999999 468.66 750.78 percent of total billed charges ANS ANESTH LVL II 1st 1/2HR 48607037_1 CDM 0370 RC inpatient 774 503.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 534.06 69 999999999 468.66 750.78 percent of total billed charges ANS ANESTH LVL II 1st 1/2HR 48607037_1 CDM 0370 RC inpatient 774 503.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 603.72 78 999999999 468.66 750.78 percent of total billed charges ANS ANESTH LVL II 1st 1/2HR 48607037_1 CDM 0370 RC inpatient 774 503.1 SIHO - ALL PLANS SIHO - ALL PLANS 696.6 90 999999999 468.66 750.78 percent of total billed charges ANS ANESTH LVL II 1st 1/2HR 48607037_1 CDM 0370 RC inpatient 774 503.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 468.66 60.55 999999999 468.66 750.78 percent of total billed charges ANS ANESTH LVL II 1st 1/2HR 48607037_1 CDM 0370 RC inpatient 774 503.1 UMR - ALL PLANS UMR - ALL PLANS 541.8 70 999999999 468.66 750.78 percent of total billed charges ANS ANESTH LVL II 1st 1/2HR 48607037_1 CDM 0370 RC inpatient 774 503.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 468.66 750.78 ANS ANESTH LVL II 1st 1/2HR 48607037_1 CDM 0370 RC inpatient 774 503.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 468.66 750.78 ANS ANESTH LVL II 1st 1/2HR 48607037_1 CDM 0370 RC inpatient 774 503.1 ANTHEM HMO ANTHEM HMO 999999999 468.66 750.78 ANS ANESTH LVL II 1st 1/2HR 48607037_1 CDM 0370 RC inpatient 774 503.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 468.66 750.78 ANS ANESTH LVL II 1st 1/2HR 48607037_1 CDM 0370 RC inpatient 774 503.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 523.22 67.6 999999999 468.66 750.78 percent of total billed charges ANS ANESTH LVL II 1st 1/2HR 48607037_1 CDM 0370 RC inpatient 774 503.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 468.66 750.78 ANS ANESTHES LEVEL II ADD UNIT 48607038_1 CDM 0370 RC inpatient 225 146.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 146.25 65 999999999 136.24 218.25 percent of total billed charges ANS ANESTHES LEVEL II ADD UNIT 48607038_1 CDM 0370 RC inpatient 225 146.25 AETNA AETNA 177.75 79 999999999 136.24 218.25 percent of total billed charges ANS ANESTHES LEVEL II ADD UNIT 48607038_1 CDM 0370 RC inpatient 225 146.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 218.25 97 999999999 136.24 218.25 percent of total billed charges ANS ANESTHES LEVEL II ADD UNIT 48607038_1 CDM 0370 RC inpatient 225 146.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 155.25 69 999999999 136.24 218.25 percent of total billed charges ANS ANESTHES LEVEL II ADD UNIT 48607038_1 CDM 0370 RC inpatient 225 146.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 175.5 78 999999999 136.24 218.25 percent of total billed charges ANS ANESTHES LEVEL II ADD UNIT 48607038_1 CDM 0370 RC inpatient 225 146.25 SIHO - ALL PLANS SIHO - ALL PLANS 202.5 90 999999999 136.24 218.25 percent of total billed charges ANS ANESTHES LEVEL II ADD UNIT 48607038_1 CDM 0370 RC inpatient 225 146.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 136.24 60.55 999999999 136.24 218.25 percent of total billed charges ANS ANESTHES LEVEL II ADD UNIT 48607038_1 CDM 0370 RC inpatient 225 146.25 UMR - ALL PLANS UMR - ALL PLANS 157.5 70 999999999 136.24 218.25 percent of total billed charges ANS ANESTHES LEVEL II ADD UNIT 48607038_1 CDM 0370 RC inpatient 225 146.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 136.24 218.25 ANS ANESTHES LEVEL II ADD UNIT 48607038_1 CDM 0370 RC inpatient 225 146.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 136.24 218.25 ANS ANESTHES LEVEL II ADD UNIT 48607038_1 CDM 0370 RC inpatient 225 146.25 ANTHEM HMO ANTHEM HMO 999999999 136.24 218.25 ANS ANESTHES LEVEL II ADD UNIT 48607038_1 CDM 0370 RC inpatient 225 146.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 136.24 218.25 ANS ANESTHES LEVEL II ADD UNIT 48607038_1 CDM 0370 RC inpatient 225 146.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 152.1 67.6 999999999 136.24 218.25 percent of total billed charges ANS ANESTHES LEVEL II ADD UNIT 48607038_1 CDM 0370 RC inpatient 225 146.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 136.24 218.25 ANS ANESTHS LVL III 1st 1/2 HR 48607039_1 CDM 0370 RC inpatient 814 529.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 529.1 65 999999999 492.88 789.58 percent of total billed charges ANS ANESTHS LVL III 1st 1/2 HR 48607039_1 CDM 0370 RC inpatient 814 529.1 AETNA AETNA 643.06 79 999999999 492.88 789.58 percent of total billed charges ANS ANESTHS LVL III 1st 1/2 HR 48607039_1 CDM 0370 RC inpatient 814 529.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 789.58 97 999999999 492.88 789.58 percent of total billed charges ANS ANESTHS LVL III 1st 1/2 HR 48607039_1 CDM 0370 RC inpatient 814 529.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 561.66 69 999999999 492.88 789.58 percent of total billed charges ANS ANESTHS LVL III 1st 1/2 HR 48607039_1 CDM 0370 RC inpatient 814 529.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 634.92 78 999999999 492.88 789.58 percent of total billed charges ANS ANESTHS LVL III 1st 1/2 HR 48607039_1 CDM 0370 RC inpatient 814 529.1 SIHO - ALL PLANS SIHO - ALL PLANS 732.6 90 999999999 492.88 789.58 percent of total billed charges ANS ANESTHS LVL III 1st 1/2 HR 48607039_1 CDM 0370 RC inpatient 814 529.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 492.88 60.55 999999999 492.88 789.58 percent of total billed charges ANS ANESTHS LVL III 1st 1/2 HR 48607039_1 CDM 0370 RC inpatient 814 529.1 UMR - ALL PLANS UMR - ALL PLANS 569.8 70 999999999 492.88 789.58 percent of total billed charges ANS ANESTHS LVL III 1st 1/2 HR 48607039_1 CDM 0370 RC inpatient 814 529.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 492.88 789.58 ANS ANESTHS LVL III 1st 1/2 HR 48607039_1 CDM 0370 RC inpatient 814 529.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 492.88 789.58 ANS ANESTHS LVL III 1st 1/2 HR 48607039_1 CDM 0370 RC inpatient 814 529.1 ANTHEM HMO ANTHEM HMO 999999999 492.88 789.58 ANS ANESTHS LVL III 1st 1/2 HR 48607039_1 CDM 0370 RC inpatient 814 529.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 492.88 789.58 ANS ANESTHS LVL III 1st 1/2 HR 48607039_1 CDM 0370 RC inpatient 814 529.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 550.26 67.6 999999999 492.88 789.58 percent of total billed charges ANS ANESTHS LVL III 1st 1/2 HR 48607039_1 CDM 0370 RC inpatient 814 529.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 492.88 789.58 ANS ANESTHS LEVEL III ADD UNIT 48607040_1 CDM 0370 RC inpatient 286 185.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.9 65 999999999 173.17 277.42 percent of total billed charges ANS ANESTHS LEVEL III ADD UNIT 48607040_1 CDM 0370 RC inpatient 286 185.9 AETNA AETNA 225.94 79 999999999 173.17 277.42 percent of total billed charges ANS ANESTHS LEVEL III ADD UNIT 48607040_1 CDM 0370 RC inpatient 286 185.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 277.42 97 999999999 173.17 277.42 percent of total billed charges ANS ANESTHS LEVEL III ADD UNIT 48607040_1 CDM 0370 RC inpatient 286 185.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 197.34 69 999999999 173.17 277.42 percent of total billed charges ANS ANESTHS LEVEL III ADD UNIT 48607040_1 CDM 0370 RC inpatient 286 185.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 223.08 78 999999999 173.17 277.42 percent of total billed charges ANS ANESTHS LEVEL III ADD UNIT 48607040_1 CDM 0370 RC inpatient 286 185.9 SIHO - ALL PLANS SIHO - ALL PLANS 257.4 90 999999999 173.17 277.42 percent of total billed charges ANS ANESTHS LEVEL III ADD UNIT 48607040_1 CDM 0370 RC inpatient 286 185.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 173.17 60.55 999999999 173.17 277.42 percent of total billed charges ANS ANESTHS LEVEL III ADD UNIT 48607040_1 CDM 0370 RC inpatient 286 185.9 UMR - ALL PLANS UMR - ALL PLANS 200.2 70 999999999 173.17 277.42 percent of total billed charges ANS ANESTHS LEVEL III ADD UNIT 48607040_1 CDM 0370 RC inpatient 286 185.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 173.17 277.42 ANS ANESTHS LEVEL III ADD UNIT 48607040_1 CDM 0370 RC inpatient 286 185.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 173.17 277.42 ANS ANESTHS LEVEL III ADD UNIT 48607040_1 CDM 0370 RC inpatient 286 185.9 ANTHEM HMO ANTHEM HMO 999999999 173.17 277.42 ANS ANESTHS LEVEL III ADD UNIT 48607040_1 CDM 0370 RC inpatient 286 185.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 173.17 277.42 ANS ANESTHS LEVEL III ADD UNIT 48607040_1 CDM 0370 RC inpatient 286 185.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 193.34 67.6 999999999 173.17 277.42 percent of total billed charges ANS ANESTHS LEVEL III ADD UNIT 48607040_1 CDM 0370 RC inpatient 286 185.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 173.17 277.42 ANS ANESTHS LVL IV 1ST 1/2 HR 48607041_1 CDM 0370 RC inpatient 870 565.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 565.5 65 999999999 526.79 843.9 percent of total billed charges ANS ANESTHS LVL IV 1ST 1/2 HR 48607041_1 CDM 0370 RC inpatient 870 565.5 AETNA AETNA 687.3 79 999999999 526.79 843.9 percent of total billed charges ANS ANESTHS LVL IV 1ST 1/2 HR 48607041_1 CDM 0370 RC inpatient 870 565.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 843.9 97 999999999 526.79 843.9 percent of total billed charges ANS ANESTHS LVL IV 1ST 1/2 HR 48607041_1 CDM 0370 RC inpatient 870 565.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 600.3 69 999999999 526.79 843.9 percent of total billed charges ANS ANESTHS LVL IV 1ST 1/2 HR 48607041_1 CDM 0370 RC inpatient 870 565.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 678.6 78 999999999 526.79 843.9 percent of total billed charges ANS ANESTHS LVL IV 1ST 1/2 HR 48607041_1 CDM 0370 RC inpatient 870 565.5 SIHO - ALL PLANS SIHO - ALL PLANS 783 90 999999999 526.79 843.9 percent of total billed charges ANS ANESTHS LVL IV 1ST 1/2 HR 48607041_1 CDM 0370 RC inpatient 870 565.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 526.79 60.55 999999999 526.79 843.9 percent of total billed charges ANS ANESTHS LVL IV 1ST 1/2 HR 48607041_1 CDM 0370 RC inpatient 870 565.5 UMR - ALL PLANS UMR - ALL PLANS 609 70 999999999 526.79 843.9 percent of total billed charges ANS ANESTHS LVL IV 1ST 1/2 HR 48607041_1 CDM 0370 RC inpatient 870 565.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 526.79 843.9 ANS ANESTHS LVL IV 1ST 1/2 HR 48607041_1 CDM 0370 RC inpatient 870 565.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 526.79 843.9 ANS ANESTHS LVL IV 1ST 1/2 HR 48607041_1 CDM 0370 RC inpatient 870 565.5 ANTHEM HMO ANTHEM HMO 999999999 526.79 843.9 ANS ANESTHS LVL IV 1ST 1/2 HR 48607041_1 CDM 0370 RC inpatient 870 565.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 526.79 843.9 ANS ANESTHS LVL IV 1ST 1/2 HR 48607041_1 CDM 0370 RC inpatient 870 565.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 588.12 67.6 999999999 526.79 843.9 percent of total billed charges ANS ANESTHS LVL IV 1ST 1/2 HR 48607041_1 CDM 0370 RC inpatient 870 565.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 526.79 843.9 ANS ANESTH LVL IV ADD UNIT 48607042_1 CDM 0370 RC inpatient 286 185.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.9 65 999999999 173.17 277.42 percent of total billed charges ANS ANESTH LVL IV ADD UNIT 48607042_1 CDM 0370 RC inpatient 286 185.9 AETNA AETNA 225.94 79 999999999 173.17 277.42 percent of total billed charges ANS ANESTH LVL IV ADD UNIT 48607042_1 CDM 0370 RC inpatient 286 185.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 277.42 97 999999999 173.17 277.42 percent of total billed charges ANS ANESTH LVL IV ADD UNIT 48607042_1 CDM 0370 RC inpatient 286 185.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 197.34 69 999999999 173.17 277.42 percent of total billed charges ANS ANESTH LVL IV ADD UNIT 48607042_1 CDM 0370 RC inpatient 286 185.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 223.08 78 999999999 173.17 277.42 percent of total billed charges ANS ANESTH LVL IV ADD UNIT 48607042_1 CDM 0370 RC inpatient 286 185.9 SIHO - ALL PLANS SIHO - ALL PLANS 257.4 90 999999999 173.17 277.42 percent of total billed charges ANS ANESTH LVL IV ADD UNIT 48607042_1 CDM 0370 RC inpatient 286 185.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 173.17 60.55 999999999 173.17 277.42 percent of total billed charges ANS ANESTH LVL IV ADD UNIT 48607042_1 CDM 0370 RC inpatient 286 185.9 UMR - ALL PLANS UMR - ALL PLANS 200.2 70 999999999 173.17 277.42 percent of total billed charges ANS ANESTH LVL IV ADD UNIT 48607042_1 CDM 0370 RC inpatient 286 185.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 173.17 277.42 ANS ANESTH LVL IV ADD UNIT 48607042_1 CDM 0370 RC inpatient 286 185.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 173.17 277.42 ANS ANESTH LVL IV ADD UNIT 48607042_1 CDM 0370 RC inpatient 286 185.9 ANTHEM HMO ANTHEM HMO 999999999 173.17 277.42 ANS ANESTH LVL IV ADD UNIT 48607042_1 CDM 0370 RC inpatient 286 185.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 173.17 277.42 ANS ANESTH LVL IV ADD UNIT 48607042_1 CDM 0370 RC inpatient 286 185.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 193.34 67.6 999999999 173.17 277.42 percent of total billed charges ANS ANESTH LVL IV ADD UNIT 48607042_1 CDM 0370 RC inpatient 286 185.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 173.17 277.42 Other procedure on nervous system 48607043_1 CDM 0370 RC 64999 HCPCS inpatient 646 419.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 419.9 65 999999999 391.15 626.62 percent of total billed charges Other procedure on nervous system 48607043_1 CDM 0370 RC 64999 HCPCS inpatient 646 419.9 AETNA AETNA 510.34 79 999999999 391.15 626.62 percent of total billed charges Other procedure on nervous system 48607043_1 CDM 0370 RC 64999 HCPCS inpatient 646 419.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 445.74 69 999999999 391.15 626.62 percent of total billed charges Other procedure on nervous system 48607043_1 CDM 0370 RC 64999 HCPCS inpatient 646 419.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 626.62 97 999999999 391.15 626.62 percent of total billed charges Other procedure on nervous system 48607043_1 CDM 0370 RC 64999 HCPCS inpatient 646 419.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 503.88 78 999999999 391.15 626.62 percent of total billed charges Other procedure on nervous system 48607043_1 CDM 0370 RC 64999 HCPCS inpatient 646 419.9 SIHO - ALL PLANS SIHO - ALL PLANS 581.4 90 999999999 391.15 626.62 percent of total billed charges Other procedure on nervous system 48607043_1 CDM 0370 RC 64999 HCPCS inpatient 646 419.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 391.15 60.55 999999999 391.15 626.62 percent of total billed charges Other procedure on nervous system 48607043_1 CDM 0370 RC 64999 HCPCS inpatient 646 419.9 UMR - ALL PLANS UMR - ALL PLANS 452.2 70 999999999 391.15 626.62 percent of total billed charges Other procedure on nervous system 48607043_1 CDM 0370 RC 64999 HCPCS inpatient 646 419.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 391.15 626.62 Other procedure on nervous system 48607043_1 CDM 0370 RC 64999 HCPCS inpatient 646 419.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 391.15 626.62 Other procedure on nervous system 48607043_1 CDM 0370 RC 64999 HCPCS inpatient 646 419.9 ANTHEM HMO ANTHEM HMO 999999999 391.15 626.62 Other procedure on nervous system 48607043_1 CDM 0370 RC 64999 HCPCS inpatient 646 419.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 391.15 626.62 Other procedure on nervous system 48607043_1 CDM 0370 RC 64999 HCPCS inpatient 646 419.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 436.7 67.6 999999999 391.15 626.62 percent of total billed charges Other procedure on nervous system 48607043_1 CDM 0370 RC 64999 HCPCS inpatient 646 419.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 391.15 626.62 Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607044_1 CDM 0370 RC 64415 HCPCS inpatient 1131 735.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 735.15 65 999999999 684.82 1097.07 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607044_1 CDM 0370 RC 64415 HCPCS inpatient 1131 735.15 AETNA AETNA 893.49 79 999999999 684.82 1097.07 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607044_1 CDM 0370 RC 64415 HCPCS inpatient 1131 735.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 780.39 69 999999999 684.82 1097.07 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607044_1 CDM 0370 RC 64415 HCPCS inpatient 1131 735.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1097.07 97 999999999 684.82 1097.07 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607044_1 CDM 0370 RC 64415 HCPCS inpatient 1131 735.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 882.18 78 999999999 684.82 1097.07 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607044_1 CDM 0370 RC 64415 HCPCS inpatient 1131 735.15 SIHO - ALL PLANS SIHO - ALL PLANS 1017.9 90 999999999 684.82 1097.07 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607044_1 CDM 0370 RC 64415 HCPCS inpatient 1131 735.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 684.82 60.55 999999999 684.82 1097.07 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607044_1 CDM 0370 RC 64415 HCPCS inpatient 1131 735.15 UMR - ALL PLANS UMR - ALL PLANS 791.7 70 999999999 684.82 1097.07 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607044_1 CDM 0370 RC 64415 HCPCS inpatient 1131 735.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 684.82 1097.07 Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607044_1 CDM 0370 RC 64415 HCPCS inpatient 1131 735.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 684.82 1097.07 Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607044_1 CDM 0370 RC 64415 HCPCS inpatient 1131 735.15 ANTHEM HMO ANTHEM HMO 999999999 684.82 1097.07 Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607044_1 CDM 0370 RC 64415 HCPCS inpatient 1131 735.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 684.82 1097.07 Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607044_1 CDM 0370 RC 64415 HCPCS inpatient 1131 735.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 764.56 67.6 999999999 684.82 1097.07 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607044_1 CDM 0370 RC 64415 HCPCS inpatient 1131 735.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 684.82 1097.07 Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607045_1 CDM 0370 RC 64415 HCPCS inpatient 961 624.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 624.65 65 999999999 581.89 932.17 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607045_1 CDM 0370 RC 64415 HCPCS inpatient 961 624.65 AETNA AETNA 759.19 79 999999999 581.89 932.17 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607045_1 CDM 0370 RC 64415 HCPCS inpatient 961 624.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 663.09 69 999999999 581.89 932.17 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607045_1 CDM 0370 RC 64415 HCPCS inpatient 961 624.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 932.17 97 999999999 581.89 932.17 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607045_1 CDM 0370 RC 64415 HCPCS inpatient 961 624.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 749.58 78 999999999 581.89 932.17 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607045_1 CDM 0370 RC 64415 HCPCS inpatient 961 624.65 SIHO - ALL PLANS SIHO - ALL PLANS 864.9 90 999999999 581.89 932.17 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607045_1 CDM 0370 RC 64415 HCPCS inpatient 961 624.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 581.89 60.55 999999999 581.89 932.17 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607045_1 CDM 0370 RC 64415 HCPCS inpatient 961 624.65 UMR - ALL PLANS UMR - ALL PLANS 672.7 70 999999999 581.89 932.17 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607045_1 CDM 0370 RC 64415 HCPCS inpatient 961 624.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 581.89 932.17 Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607045_1 CDM 0370 RC 64415 HCPCS inpatient 961 624.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 581.89 932.17 Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607045_1 CDM 0370 RC 64415 HCPCS inpatient 961 624.65 ANTHEM HMO ANTHEM HMO 999999999 581.89 932.17 Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607045_1 CDM 0370 RC 64415 HCPCS inpatient 961 624.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 581.89 932.17 Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607045_1 CDM 0370 RC 64415 HCPCS inpatient 961 624.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 649.64 67.6 999999999 581.89 932.17 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 48607045_1 CDM 0370 RC 64415 HCPCS inpatient 961 624.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 581.89 932.17 Injection of anesthetic agent and/or steroid into lower back and leg nerve (sciatic nerve) 48607046_1 CDM 0370 RC 64445 HCPCS inpatient 713 463.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 463.45 65 999999999 431.72 691.61 percent of total billed charges Injection of anesthetic agent and/or steroid into lower back and leg nerve (sciatic nerve) 48607046_1 CDM 0370 RC 64445 HCPCS inpatient 713 463.45 AETNA AETNA 563.27 79 999999999 431.72 691.61 percent of total billed charges Injection of anesthetic agent and/or steroid into lower back and leg nerve (sciatic nerve) 48607046_1 CDM 0370 RC 64445 HCPCS inpatient 713 463.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 491.97 69 999999999 431.72 691.61 percent of total billed charges Injection of anesthetic agent and/or steroid into lower back and leg nerve (sciatic nerve) 48607046_1 CDM 0370 RC 64445 HCPCS inpatient 713 463.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 691.61 97 999999999 431.72 691.61 percent of total billed charges Injection of anesthetic agent and/or steroid into lower back and leg nerve (sciatic nerve) 48607046_1 CDM 0370 RC 64445 HCPCS inpatient 713 463.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 556.14 78 999999999 431.72 691.61 percent of total billed charges Injection of anesthetic agent and/or steroid into lower back and leg nerve (sciatic nerve) 48607046_1 CDM 0370 RC 64445 HCPCS inpatient 713 463.45 SIHO - ALL PLANS SIHO - ALL PLANS 641.7 90 999999999 431.72 691.61 percent of total billed charges Injection of anesthetic agent and/or steroid into lower back and leg nerve (sciatic nerve) 48607046_1 CDM 0370 RC 64445 HCPCS inpatient 713 463.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 431.72 60.55 999999999 431.72 691.61 percent of total billed charges Injection of anesthetic agent and/or steroid into lower back and leg nerve (sciatic nerve) 48607046_1 CDM 0370 RC 64445 HCPCS inpatient 713 463.45 UMR - ALL PLANS UMR - ALL PLANS 499.1 70 999999999 431.72 691.61 percent of total billed charges Injection of anesthetic agent and/or steroid into lower back and leg nerve (sciatic nerve) 48607046_1 CDM 0370 RC 64445 HCPCS inpatient 713 463.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 431.72 691.61 Injection of anesthetic agent and/or steroid into lower back and leg nerve (sciatic nerve) 48607046_1 CDM 0370 RC 64445 HCPCS inpatient 713 463.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 431.72 691.61 Injection of anesthetic agent and/or steroid into lower back and leg nerve (sciatic nerve) 48607046_1 CDM 0370 RC 64445 HCPCS inpatient 713 463.45 ANTHEM HMO ANTHEM HMO 999999999 431.72 691.61 Injection of anesthetic agent and/or steroid into lower back and leg nerve (sciatic nerve) 48607046_1 CDM 0370 RC 64445 HCPCS inpatient 713 463.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 431.72 691.61 Injection of anesthetic agent and/or steroid into lower back and leg nerve (sciatic nerve) 48607046_1 CDM 0370 RC 64445 HCPCS inpatient 713 463.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 481.99 67.6 999999999 431.72 691.61 percent of total billed charges Injection of anesthetic agent and/or steroid into lower back and leg nerve (sciatic nerve) 48607046_1 CDM 0370 RC 64445 HCPCS inpatient 713 463.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 431.72 691.61 Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 48607047_1 CDM 0370 RC 64447 HCPCS inpatient 826 536.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 536.9 65 999999999 500.14 801.22 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 48607047_1 CDM 0370 RC 64447 HCPCS inpatient 826 536.9 AETNA AETNA 652.54 79 999999999 500.14 801.22 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 48607047_1 CDM 0370 RC 64447 HCPCS inpatient 826 536.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 569.94 69 999999999 500.14 801.22 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 48607047_1 CDM 0370 RC 64447 HCPCS inpatient 826 536.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 801.22 97 999999999 500.14 801.22 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 48607047_1 CDM 0370 RC 64447 HCPCS inpatient 826 536.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 644.28 78 999999999 500.14 801.22 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 48607047_1 CDM 0370 RC 64447 HCPCS inpatient 826 536.9 SIHO - ALL PLANS SIHO - ALL PLANS 743.4 90 999999999 500.14 801.22 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 48607047_1 CDM 0370 RC 64447 HCPCS inpatient 826 536.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 500.14 60.55 999999999 500.14 801.22 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 48607047_1 CDM 0370 RC 64447 HCPCS inpatient 826 536.9 UMR - ALL PLANS UMR - ALL PLANS 578.2 70 999999999 500.14 801.22 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 48607047_1 CDM 0370 RC 64447 HCPCS inpatient 826 536.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 500.14 801.22 Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 48607047_1 CDM 0370 RC 64447 HCPCS inpatient 826 536.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 500.14 801.22 Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 48607047_1 CDM 0370 RC 64447 HCPCS inpatient 826 536.9 ANTHEM HMO ANTHEM HMO 999999999 500.14 801.22 Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 48607047_1 CDM 0370 RC 64447 HCPCS inpatient 826 536.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 500.14 801.22 Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 48607047_1 CDM 0370 RC 64447 HCPCS inpatient 826 536.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 558.38 67.6 999999999 500.14 801.22 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 48607047_1 CDM 0370 RC 64447 HCPCS inpatient 826 536.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 500.14 801.22 "PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE, POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G., ANGIOSEAL PLUG, VASCULAR PLUG)" 48607048_1 CDM 0481 RC G0269 HCPCS inpatient 453 294.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 294.45 65 999999999 274.29 439.41 percent of total billed charges "PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE, POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G., ANGIOSEAL PLUG, VASCULAR PLUG)" 48607048_1 CDM 0481 RC G0269 HCPCS inpatient 453 294.45 AETNA AETNA 357.87 79 999999999 274.29 439.41 percent of total billed charges "PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE, POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G., ANGIOSEAL PLUG, VASCULAR PLUG)" 48607048_1 CDM 0481 RC G0269 HCPCS inpatient 453 294.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 312.57 69 999999999 274.29 439.41 percent of total billed charges "PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE, POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G., ANGIOSEAL PLUG, VASCULAR PLUG)" 48607048_1 CDM 0481 RC G0269 HCPCS inpatient 453 294.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 439.41 97 999999999 274.29 439.41 percent of total billed charges "PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE, POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G., ANGIOSEAL PLUG, VASCULAR PLUG)" 48607048_1 CDM 0481 RC G0269 HCPCS inpatient 453 294.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 353.34 78 999999999 274.29 439.41 percent of total billed charges "PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE, POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G., ANGIOSEAL PLUG, VASCULAR PLUG)" 48607048_1 CDM 0481 RC G0269 HCPCS inpatient 453 294.45 SIHO - ALL PLANS SIHO - ALL PLANS 407.7 90 999999999 274.29 439.41 percent of total billed charges "PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE, POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G., ANGIOSEAL PLUG, VASCULAR PLUG)" 48607048_1 CDM 0481 RC G0269 HCPCS inpatient 453 294.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 274.29 60.55 999999999 274.29 439.41 percent of total billed charges "PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE, POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G., ANGIOSEAL PLUG, VASCULAR PLUG)" 48607048_1 CDM 0481 RC G0269 HCPCS inpatient 453 294.45 UMR - ALL PLANS UMR - ALL PLANS 317.1 70 999999999 274.29 439.41 percent of total billed charges "PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE, POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G., ANGIOSEAL PLUG, VASCULAR PLUG)" 48607048_1 CDM 0481 RC G0269 HCPCS inpatient 453 294.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 274.29 439.41 "PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE, POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G., ANGIOSEAL PLUG, VASCULAR PLUG)" 48607048_1 CDM 0481 RC G0269 HCPCS inpatient 453 294.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 274.29 439.41 "PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE, POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G., ANGIOSEAL PLUG, VASCULAR PLUG)" 48607048_1 CDM 0481 RC G0269 HCPCS inpatient 453 294.45 ANTHEM HMO ANTHEM HMO 999999999 274.29 439.41 "PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE, POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G., ANGIOSEAL PLUG, VASCULAR PLUG)" 48607048_1 CDM 0481 RC G0269 HCPCS inpatient 453 294.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 274.29 439.41 "PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE, POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G., ANGIOSEAL PLUG, VASCULAR PLUG)" 48607048_1 CDM 0481 RC G0269 HCPCS inpatient 453 294.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 306.23 67.6 999999999 274.29 439.41 percent of total billed charges "PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER A VENOUS OR ARTERIAL ACCESS SITE, POST SURGICAL OR INTERVENTIONAL PROCEDURE (E.G., ANGIOSEAL PLUG, VASCULAR PLUG)" 48607048_1 CDM 0481 RC G0269 HCPCS inpatient 453 294.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 274.29 439.41 Insertion of blood flow assist device in aorta through skin 48607049_1 CDM 0481 RC 33967 HCPCS inpatient 1829 1188.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1188.85 65 999999999 1107.46 1774.13 percent of total billed charges Insertion of blood flow assist device in aorta through skin 48607049_1 CDM 0481 RC 33967 HCPCS inpatient 1829 1188.85 AETNA AETNA 1444.91 79 999999999 1107.46 1774.13 percent of total billed charges Insertion of blood flow assist device in aorta through skin 48607049_1 CDM 0481 RC 33967 HCPCS inpatient 1829 1188.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1262.01 69 999999999 1107.46 1774.13 percent of total billed charges Insertion of blood flow assist device in aorta through skin 48607049_1 CDM 0481 RC 33967 HCPCS inpatient 1829 1188.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1774.13 97 999999999 1107.46 1774.13 percent of total billed charges Insertion of blood flow assist device in aorta through skin 48607049_1 CDM 0481 RC 33967 HCPCS inpatient 1829 1188.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1426.62 78 999999999 1107.46 1774.13 percent of total billed charges Insertion of blood flow assist device in aorta through skin 48607049_1 CDM 0481 RC 33967 HCPCS inpatient 1829 1188.85 SIHO - ALL PLANS SIHO - ALL PLANS 1646.1 90 999999999 1107.46 1774.13 percent of total billed charges Insertion of blood flow assist device in aorta through skin 48607049_1 CDM 0481 RC 33967 HCPCS inpatient 1829 1188.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1107.46 60.55 999999999 1107.46 1774.13 percent of total billed charges Insertion of blood flow assist device in aorta through skin 48607049_1 CDM 0481 RC 33967 HCPCS inpatient 1829 1188.85 UMR - ALL PLANS UMR - ALL PLANS 1280.3 70 999999999 1107.46 1774.13 percent of total billed charges Insertion of blood flow assist device in aorta through skin 48607049_1 CDM 0481 RC 33967 HCPCS inpatient 1829 1188.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1107.46 1774.13 Insertion of blood flow assist device in aorta through skin 48607049_1 CDM 0481 RC 33967 HCPCS inpatient 1829 1188.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1107.46 1774.13 Insertion of blood flow assist device in aorta through skin 48607049_1 CDM 0481 RC 33967 HCPCS inpatient 1829 1188.85 ANTHEM HMO ANTHEM HMO 999999999 1107.46 1774.13 Insertion of blood flow assist device in aorta through skin 48607049_1 CDM 0481 RC 33967 HCPCS inpatient 1829 1188.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1107.46 1774.13 Insertion of blood flow assist device in aorta through skin 48607049_1 CDM 0481 RC 33967 HCPCS inpatient 1829 1188.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1236.4 67.6 999999999 1107.46 1774.13 percent of total billed charges Insertion of blood flow assist device in aorta through skin 48607049_1 CDM 0481 RC 33967 HCPCS inpatient 1829 1188.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1107.46 1774.13 External shock to heart to regulate heart beat 48607050_1 CDM 0481 RC 92960 HCPCS inpatient 1269 824.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 824.85 65 999999999 768.38 1230.93 percent of total billed charges External shock to heart to regulate heart beat 48607050_1 CDM 0481 RC 92960 HCPCS inpatient 1269 824.85 AETNA AETNA 1002.51 79 999999999 768.38 1230.93 percent of total billed charges External shock to heart to regulate heart beat 48607050_1 CDM 0481 RC 92960 HCPCS inpatient 1269 824.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 875.61 69 999999999 768.38 1230.93 percent of total billed charges External shock to heart to regulate heart beat 48607050_1 CDM 0481 RC 92960 HCPCS inpatient 1269 824.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1230.93 97 999999999 768.38 1230.93 percent of total billed charges External shock to heart to regulate heart beat 48607050_1 CDM 0481 RC 92960 HCPCS inpatient 1269 824.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 989.82 78 999999999 768.38 1230.93 percent of total billed charges External shock to heart to regulate heart beat 48607050_1 CDM 0481 RC 92960 HCPCS inpatient 1269 824.85 SIHO - ALL PLANS SIHO - ALL PLANS 1142.1 90 999999999 768.38 1230.93 percent of total billed charges External shock to heart to regulate heart beat 48607050_1 CDM 0481 RC 92960 HCPCS inpatient 1269 824.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 768.38 60.55 999999999 768.38 1230.93 percent of total billed charges External shock to heart to regulate heart beat 48607050_1 CDM 0481 RC 92960 HCPCS inpatient 1269 824.85 UMR - ALL PLANS UMR - ALL PLANS 888.3 70 999999999 768.38 1230.93 percent of total billed charges External shock to heart to regulate heart beat 48607050_1 CDM 0481 RC 92960 HCPCS inpatient 1269 824.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 768.38 1230.93 External shock to heart to regulate heart beat 48607050_1 CDM 0481 RC 92960 HCPCS inpatient 1269 824.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 768.38 1230.93 External shock to heart to regulate heart beat 48607050_1 CDM 0481 RC 92960 HCPCS inpatient 1269 824.85 ANTHEM HMO ANTHEM HMO 999999999 768.38 1230.93 External shock to heart to regulate heart beat 48607050_1 CDM 0481 RC 92960 HCPCS inpatient 1269 824.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 768.38 1230.93 External shock to heart to regulate heart beat 48607050_1 CDM 0481 RC 92960 HCPCS inpatient 1269 824.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 857.84 67.6 999999999 768.38 1230.93 percent of total billed charges External shock to heart to regulate heart beat 48607050_1 CDM 0481 RC 92960 HCPCS inpatient 1269 824.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 768.38 1230.93 "Ultrasound evaluation of heart blood vessel or graft with review by radiologist, initial vessel" 48607051_1 CDM 0481 RC 92978 HCPCS inpatient 2356 1531.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1531.4 65 999999999 1426.56 2285.32 percent of total billed charges "Ultrasound evaluation of heart blood vessel or graft with review by radiologist, initial vessel" 48607051_1 CDM 0481 RC 92978 HCPCS inpatient 2356 1531.4 AETNA AETNA 1861.24 79 999999999 1426.56 2285.32 percent of total billed charges "Ultrasound evaluation of heart blood vessel or graft with review by radiologist, initial vessel" 48607051_1 CDM 0481 RC 92978 HCPCS inpatient 2356 1531.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1625.64 69 999999999 1426.56 2285.32 percent of total billed charges "Ultrasound evaluation of heart blood vessel or graft with review by radiologist, initial vessel" 48607051_1 CDM 0481 RC 92978 HCPCS inpatient 2356 1531.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2285.32 97 999999999 1426.56 2285.32 percent of total billed charges "Ultrasound evaluation of heart blood vessel or graft with review by radiologist, initial vessel" 48607051_1 CDM 0481 RC 92978 HCPCS inpatient 2356 1531.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1837.68 78 999999999 1426.56 2285.32 percent of total billed charges "Ultrasound evaluation of heart blood vessel or graft with review by radiologist, initial vessel" 48607051_1 CDM 0481 RC 92978 HCPCS inpatient 2356 1531.4 SIHO - ALL PLANS SIHO - ALL PLANS 2120.4 90 999999999 1426.56 2285.32 percent of total billed charges "Ultrasound evaluation of heart blood vessel or graft with review by radiologist, initial vessel" 48607051_1 CDM 0481 RC 92978 HCPCS inpatient 2356 1531.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1426.56 60.55 999999999 1426.56 2285.32 percent of total billed charges "Ultrasound evaluation of heart blood vessel or graft with review by radiologist, initial vessel" 48607051_1 CDM 0481 RC 92978 HCPCS inpatient 2356 1531.4 UMR - ALL PLANS UMR - ALL PLANS 1649.2 70 999999999 1426.56 2285.32 percent of total billed charges "Ultrasound evaluation of heart blood vessel or graft with review by radiologist, initial vessel" 48607051_1 CDM 0481 RC 92978 HCPCS inpatient 2356 1531.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1426.56 2285.32 "Ultrasound evaluation of heart blood vessel or graft with review by radiologist, initial vessel" 48607051_1 CDM 0481 RC 92978 HCPCS inpatient 2356 1531.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1426.56 2285.32 "Ultrasound evaluation of heart blood vessel or graft with review by radiologist, initial vessel" 48607051_1 CDM 0481 RC 92978 HCPCS inpatient 2356 1531.4 ANTHEM HMO ANTHEM HMO 999999999 1426.56 2285.32 "Ultrasound evaluation of heart blood vessel or graft with review by radiologist, initial vessel" 48607051_1 CDM 0481 RC 92978 HCPCS inpatient 2356 1531.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1426.56 2285.32 "Ultrasound evaluation of heart blood vessel or graft with review by radiologist, initial vessel" 48607051_1 CDM 0481 RC 92978 HCPCS inpatient 2356 1531.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1592.66 67.6 999999999 1426.56 2285.32 percent of total billed charges "Ultrasound evaluation of heart blood vessel or graft with review by radiologist, initial vessel" 48607051_1 CDM 0481 RC 92978 HCPCS inpatient 2356 1531.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1426.56 2285.32 "Balloon dilation of pulmonary artery, single vessel" 48607052_1 CDM 0481 RC 92997 HCPCS inpatient 17245 11209.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 11209.25 65 999999999 10441.85 16727.65 percent of total billed charges "Balloon dilation of pulmonary artery, single vessel" 48607052_1 CDM 0481 RC 92997 HCPCS inpatient 17245 11209.25 AETNA AETNA 13623.55 79 999999999 10441.85 16727.65 percent of total billed charges "Balloon dilation of pulmonary artery, single vessel" 48607052_1 CDM 0481 RC 92997 HCPCS inpatient 17245 11209.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 11899.05 69 999999999 10441.85 16727.65 percent of total billed charges "Balloon dilation of pulmonary artery, single vessel" 48607052_1 CDM 0481 RC 92997 HCPCS inpatient 17245 11209.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16727.65 97 999999999 10441.85 16727.65 percent of total billed charges "Balloon dilation of pulmonary artery, single vessel" 48607052_1 CDM 0481 RC 92997 HCPCS inpatient 17245 11209.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 13451.1 78 999999999 10441.85 16727.65 percent of total billed charges "Balloon dilation of pulmonary artery, single vessel" 48607052_1 CDM 0481 RC 92997 HCPCS inpatient 17245 11209.25 SIHO - ALL PLANS SIHO - ALL PLANS 15520.5 90 999999999 10441.85 16727.65 percent of total billed charges "Balloon dilation of pulmonary artery, single vessel" 48607052_1 CDM 0481 RC 92997 HCPCS inpatient 17245 11209.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10441.85 60.55 999999999 10441.85 16727.65 percent of total billed charges "Balloon dilation of pulmonary artery, single vessel" 48607052_1 CDM 0481 RC 92997 HCPCS inpatient 17245 11209.25 UMR - ALL PLANS UMR - ALL PLANS 12071.5 70 999999999 10441.85 16727.65 percent of total billed charges "Balloon dilation of pulmonary artery, single vessel" 48607052_1 CDM 0481 RC 92997 HCPCS inpatient 17245 11209.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10441.85 16727.65 "Balloon dilation of pulmonary artery, single vessel" 48607052_1 CDM 0481 RC 92997 HCPCS inpatient 17245 11209.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10441.85 16727.65 "Balloon dilation of pulmonary artery, single vessel" 48607052_1 CDM 0481 RC 92997 HCPCS inpatient 17245 11209.25 ANTHEM HMO ANTHEM HMO 999999999 10441.85 16727.65 "Balloon dilation of pulmonary artery, single vessel" 48607052_1 CDM 0481 RC 92997 HCPCS inpatient 17245 11209.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10441.85 16727.65 "Balloon dilation of pulmonary artery, single vessel" 48607052_1 CDM 0481 RC 92997 HCPCS inpatient 17245 11209.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 11657.62 67.6 999999999 10441.85 16727.65 percent of total billed charges "Balloon dilation of pulmonary artery, single vessel" 48607052_1 CDM 0481 RC 92997 HCPCS inpatient 17245 11209.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 10441.85 16727.65 Balloon dilation of single coronary artery or branch 48607053_1 CDM 0481 RC 92920 HCPCS inpatient 17245 11209.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 11209.25 65 999999999 10441.85 16727.65 percent of total billed charges Balloon dilation of single coronary artery or branch 48607053_1 CDM 0481 RC 92920 HCPCS inpatient 17245 11209.25 AETNA AETNA 13623.55 79 999999999 10441.85 16727.65 percent of total billed charges Balloon dilation of single coronary artery or branch 48607053_1 CDM 0481 RC 92920 HCPCS inpatient 17245 11209.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 11899.05 69 999999999 10441.85 16727.65 percent of total billed charges Balloon dilation of single coronary artery or branch 48607053_1 CDM 0481 RC 92920 HCPCS inpatient 17245 11209.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16727.65 97 999999999 10441.85 16727.65 percent of total billed charges Balloon dilation of single coronary artery or branch 48607053_1 CDM 0481 RC 92920 HCPCS inpatient 17245 11209.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 13451.1 78 999999999 10441.85 16727.65 percent of total billed charges Balloon dilation of single coronary artery or branch 48607053_1 CDM 0481 RC 92920 HCPCS inpatient 17245 11209.25 SIHO - ALL PLANS SIHO - ALL PLANS 15520.5 90 999999999 10441.85 16727.65 percent of total billed charges Balloon dilation of single coronary artery or branch 48607053_1 CDM 0481 RC 92920 HCPCS inpatient 17245 11209.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10441.85 60.55 999999999 10441.85 16727.65 percent of total billed charges Balloon dilation of single coronary artery or branch 48607053_1 CDM 0481 RC 92920 HCPCS inpatient 17245 11209.25 UMR - ALL PLANS UMR - ALL PLANS 12071.5 70 999999999 10441.85 16727.65 percent of total billed charges Balloon dilation of single coronary artery or branch 48607053_1 CDM 0481 RC 92920 HCPCS inpatient 17245 11209.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10441.85 16727.65 Balloon dilation of single coronary artery or branch 48607053_1 CDM 0481 RC 92920 HCPCS inpatient 17245 11209.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10441.85 16727.65 Balloon dilation of single coronary artery or branch 48607053_1 CDM 0481 RC 92920 HCPCS inpatient 17245 11209.25 ANTHEM HMO ANTHEM HMO 999999999 10441.85 16727.65 Balloon dilation of single coronary artery or branch 48607053_1 CDM 0481 RC 92920 HCPCS inpatient 17245 11209.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10441.85 16727.65 Balloon dilation of single coronary artery or branch 48607053_1 CDM 0481 RC 92920 HCPCS inpatient 17245 11209.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 11657.62 67.6 999999999 10441.85 16727.65 percent of total billed charges Balloon dilation of single coronary artery or branch 48607053_1 CDM 0481 RC 92920 HCPCS inpatient 17245 11209.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 10441.85 16727.65 CCL CARDIAC PROCEDURE 48607054_1 CDM 0481 RC inpatient 10530 6844.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 6844.5 65 999999999 6375.92 10214.1 percent of total billed charges CCL CARDIAC PROCEDURE 48607054_1 CDM 0481 RC inpatient 10530 6844.5 AETNA AETNA 8318.7 79 999999999 6375.92 10214.1 percent of total billed charges CCL CARDIAC PROCEDURE 48607054_1 CDM 0481 RC inpatient 10530 6844.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 7265.7 69 999999999 6375.92 10214.1 percent of total billed charges CCL CARDIAC PROCEDURE 48607054_1 CDM 0481 RC inpatient 10530 6844.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10214.1 97 999999999 6375.92 10214.1 percent of total billed charges CCL CARDIAC PROCEDURE 48607054_1 CDM 0481 RC inpatient 10530 6844.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 8213.4 78 999999999 6375.92 10214.1 percent of total billed charges CCL CARDIAC PROCEDURE 48607054_1 CDM 0481 RC inpatient 10530 6844.5 SIHO - ALL PLANS SIHO - ALL PLANS 9477 90 999999999 6375.92 10214.1 percent of total billed charges CCL CARDIAC PROCEDURE 48607054_1 CDM 0481 RC inpatient 10530 6844.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6375.92 60.55 999999999 6375.92 10214.1 percent of total billed charges CCL CARDIAC PROCEDURE 48607054_1 CDM 0481 RC inpatient 10530 6844.5 UMR - ALL PLANS UMR - ALL PLANS 7371 70 999999999 6375.92 10214.1 percent of total billed charges CCL CARDIAC PROCEDURE 48607054_1 CDM 0481 RC inpatient 10530 6844.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6375.92 10214.1 CCL CARDIAC PROCEDURE 48607054_1 CDM 0481 RC inpatient 10530 6844.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6375.92 10214.1 CCL CARDIAC PROCEDURE 48607054_1 CDM 0481 RC inpatient 10530 6844.5 ANTHEM HMO ANTHEM HMO 999999999 6375.92 10214.1 CCL CARDIAC PROCEDURE 48607054_1 CDM 0481 RC inpatient 10530 6844.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6375.92 10214.1 CCL CARDIAC PROCEDURE 48607054_1 CDM 0481 RC inpatient 10530 6844.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 7118.28 67.6 999999999 6375.92 10214.1 percent of total billed charges CCL CARDIAC PROCEDURE 48607054_1 CDM 0481 RC inpatient 10530 6844.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 6375.92 10214.1 Injection for imaging of right heart chambers with review by radiologist 48607055_1 CDM 0481 RC 93566 HCPCS inpatient 1237 804.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 804.05 65 999999999 749 1199.89 percent of total billed charges Injection for imaging of right heart chambers with review by radiologist 48607055_1 CDM 0481 RC 93566 HCPCS inpatient 1237 804.05 AETNA AETNA 977.23 79 999999999 749 1199.89 percent of total billed charges Injection for imaging of right heart chambers with review by radiologist 48607055_1 CDM 0481 RC 93566 HCPCS inpatient 1237 804.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 853.53 69 999999999 749 1199.89 percent of total billed charges Injection for imaging of right heart chambers with review by radiologist 48607055_1 CDM 0481 RC 93566 HCPCS inpatient 1237 804.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1199.89 97 999999999 749 1199.89 percent of total billed charges Injection for imaging of right heart chambers with review by radiologist 48607055_1 CDM 0481 RC 93566 HCPCS inpatient 1237 804.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 964.86 78 999999999 749 1199.89 percent of total billed charges Injection for imaging of right heart chambers with review by radiologist 48607055_1 CDM 0481 RC 93566 HCPCS inpatient 1237 804.05 SIHO - ALL PLANS SIHO - ALL PLANS 1113.3 90 999999999 749 1199.89 percent of total billed charges Injection for imaging of right heart chambers with review by radiologist 48607055_1 CDM 0481 RC 93566 HCPCS inpatient 1237 804.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 749 60.55 999999999 749 1199.89 percent of total billed charges Injection for imaging of right heart chambers with review by radiologist 48607055_1 CDM 0481 RC 93566 HCPCS inpatient 1237 804.05 UMR - ALL PLANS UMR - ALL PLANS 865.9 70 999999999 749 1199.89 percent of total billed charges Injection for imaging of right heart chambers with review by radiologist 48607055_1 CDM 0481 RC 93566 HCPCS inpatient 1237 804.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 749 1199.89 Injection for imaging of right heart chambers with review by radiologist 48607055_1 CDM 0481 RC 93566 HCPCS inpatient 1237 804.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 749 1199.89 Injection for imaging of right heart chambers with review by radiologist 48607055_1 CDM 0481 RC 93566 HCPCS inpatient 1237 804.05 ANTHEM HMO ANTHEM HMO 999999999 749 1199.89 Injection for imaging of right heart chambers with review by radiologist 48607055_1 CDM 0481 RC 93566 HCPCS inpatient 1237 804.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 749 1199.89 Injection for imaging of right heart chambers with review by radiologist 48607055_1 CDM 0481 RC 93566 HCPCS inpatient 1237 804.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 836.21 67.6 999999999 749 1199.89 percent of total billed charges Injection for imaging of right heart chambers with review by radiologist 48607055_1 CDM 0481 RC 93566 HCPCS inpatient 1237 804.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 749 1199.89 Injection for imaging of aorta above heart valve with review by radiologist 48607056_1 CDM 0481 RC 93567 HCPCS inpatient 1237 804.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 804.05 65 999999999 749 1199.89 percent of total billed charges Injection for imaging of aorta above heart valve with review by radiologist 48607056_1 CDM 0481 RC 93567 HCPCS inpatient 1237 804.05 AETNA AETNA 977.23 79 999999999 749 1199.89 percent of total billed charges Injection for imaging of aorta above heart valve with review by radiologist 48607056_1 CDM 0481 RC 93567 HCPCS inpatient 1237 804.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 853.53 69 999999999 749 1199.89 percent of total billed charges Injection for imaging of aorta above heart valve with review by radiologist 48607056_1 CDM 0481 RC 93567 HCPCS inpatient 1237 804.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1199.89 97 999999999 749 1199.89 percent of total billed charges Injection for imaging of aorta above heart valve with review by radiologist 48607056_1 CDM 0481 RC 93567 HCPCS inpatient 1237 804.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 964.86 78 999999999 749 1199.89 percent of total billed charges Injection for imaging of aorta above heart valve with review by radiologist 48607056_1 CDM 0481 RC 93567 HCPCS inpatient 1237 804.05 SIHO - ALL PLANS SIHO - ALL PLANS 1113.3 90 999999999 749 1199.89 percent of total billed charges Injection for imaging of aorta above heart valve with review by radiologist 48607056_1 CDM 0481 RC 93567 HCPCS inpatient 1237 804.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 749 60.55 999999999 749 1199.89 percent of total billed charges Injection for imaging of aorta above heart valve with review by radiologist 48607056_1 CDM 0481 RC 93567 HCPCS inpatient 1237 804.05 UMR - ALL PLANS UMR - ALL PLANS 865.9 70 999999999 749 1199.89 percent of total billed charges Injection for imaging of aorta above heart valve with review by radiologist 48607056_1 CDM 0481 RC 93567 HCPCS inpatient 1237 804.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 749 1199.89 Injection for imaging of aorta above heart valve with review by radiologist 48607056_1 CDM 0481 RC 93567 HCPCS inpatient 1237 804.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 749 1199.89 Injection for imaging of aorta above heart valve with review by radiologist 48607056_1 CDM 0481 RC 93567 HCPCS inpatient 1237 804.05 ANTHEM HMO ANTHEM HMO 999999999 749 1199.89 Injection for imaging of aorta above heart valve with review by radiologist 48607056_1 CDM 0481 RC 93567 HCPCS inpatient 1237 804.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 749 1199.89 Injection for imaging of aorta above heart valve with review by radiologist 48607056_1 CDM 0481 RC 93567 HCPCS inpatient 1237 804.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 836.21 67.6 999999999 749 1199.89 percent of total billed charges Injection for imaging of aorta above heart valve with review by radiologist 48607056_1 CDM 0481 RC 93567 HCPCS inpatient 1237 804.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 749 1199.89 "TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT" 48607057_1 CDM 0481 RC C8925 HCPCS inpatient 2197 1428.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1428.05 65 999999999 1330.28 2131.09 percent of total billed charges "TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT" 48607057_1 CDM 0481 RC C8925 HCPCS inpatient 2197 1428.05 AETNA AETNA 1735.63 79 999999999 1330.28 2131.09 percent of total billed charges "TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT" 48607057_1 CDM 0481 RC C8925 HCPCS inpatient 2197 1428.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1515.93 69 999999999 1330.28 2131.09 percent of total billed charges "TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT" 48607057_1 CDM 0481 RC C8925 HCPCS inpatient 2197 1428.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2131.09 97 999999999 1330.28 2131.09 percent of total billed charges "TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT" 48607057_1 CDM 0481 RC C8925 HCPCS inpatient 2197 1428.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1713.66 78 999999999 1330.28 2131.09 percent of total billed charges "TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT" 48607057_1 CDM 0481 RC C8925 HCPCS inpatient 2197 1428.05 SIHO - ALL PLANS SIHO - ALL PLANS 1977.3 90 999999999 1330.28 2131.09 percent of total billed charges "TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT" 48607057_1 CDM 0481 RC C8925 HCPCS inpatient 2197 1428.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1330.28 60.55 999999999 1330.28 2131.09 percent of total billed charges "TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT" 48607057_1 CDM 0481 RC C8925 HCPCS inpatient 2197 1428.05 UMR - ALL PLANS UMR - ALL PLANS 1537.9 70 999999999 1330.28 2131.09 percent of total billed charges "TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT" 48607057_1 CDM 0481 RC C8925 HCPCS inpatient 2197 1428.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1330.28 2131.09 "TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT" 48607057_1 CDM 0481 RC C8925 HCPCS inpatient 2197 1428.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1330.28 2131.09 "TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT" 48607057_1 CDM 0481 RC C8925 HCPCS inpatient 2197 1428.05 ANTHEM HMO ANTHEM HMO 999999999 1330.28 2131.09 "TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT" 48607057_1 CDM 0481 RC C8925 HCPCS inpatient 2197 1428.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1330.28 2131.09 "TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT" 48607057_1 CDM 0481 RC C8925 HCPCS inpatient 2197 1428.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1485.17 67.6 999999999 1330.28 2131.09 percent of total billed charges "TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL TIME WITH IMAGE DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT" 48607057_1 CDM 0481 RC C8925 HCPCS inpatient 2197 1428.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1330.28 2131.09 "Insertion of stents with balloon dilation of coronary artery or branch, single artery or branch" 48607058_1 CDM 0481 RC 92928 HCPCS inpatient 22390 14553.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 14553.5 65 999999999 13557.15 21718.3 percent of total billed charges "Insertion of stents with balloon dilation of coronary artery or branch, single artery or branch" 48607058_1 CDM 0481 RC 92928 HCPCS inpatient 22390 14553.5 AETNA AETNA 17688.1 79 999999999 13557.15 21718.3 percent of total billed charges "Insertion of stents with balloon dilation of coronary artery or branch, single artery or branch" 48607058_1 CDM 0481 RC 92928 HCPCS inpatient 22390 14553.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 15449.1 69 999999999 13557.15 21718.3 percent of total billed charges "Insertion of stents with balloon dilation of coronary artery or branch, single artery or branch" 48607058_1 CDM 0481 RC 92928 HCPCS inpatient 22390 14553.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21718.3 97 999999999 13557.15 21718.3 percent of total billed charges "Insertion of stents with balloon dilation of coronary artery or branch, single artery or branch" 48607058_1 CDM 0481 RC 92928 HCPCS inpatient 22390 14553.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 17464.2 78 999999999 13557.15 21718.3 percent of total billed charges "Insertion of stents with balloon dilation of coronary artery or branch, single artery or branch" 48607058_1 CDM 0481 RC 92928 HCPCS inpatient 22390 14553.5 SIHO - ALL PLANS SIHO - ALL PLANS 20151 90 999999999 13557.15 21718.3 percent of total billed charges "Insertion of stents with balloon dilation of coronary artery or branch, single artery or branch" 48607058_1 CDM 0481 RC 92928 HCPCS inpatient 22390 14553.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13557.15 60.55 999999999 13557.15 21718.3 percent of total billed charges "Insertion of stents with balloon dilation of coronary artery or branch, single artery or branch" 48607058_1 CDM 0481 RC 92928 HCPCS inpatient 22390 14553.5 UMR - ALL PLANS UMR - ALL PLANS 15673 70 999999999 13557.15 21718.3 percent of total billed charges "Insertion of stents with balloon dilation of coronary artery or branch, single artery or branch" 48607058_1 CDM 0481 RC 92928 HCPCS inpatient 22390 14553.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13557.15 21718.3 "Insertion of stents with balloon dilation of coronary artery or branch, single artery or branch" 48607058_1 CDM 0481 RC 92928 HCPCS inpatient 22390 14553.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13557.15 21718.3 "Insertion of stents with balloon dilation of coronary artery or branch, single artery or branch" 48607058_1 CDM 0481 RC 92928 HCPCS inpatient 22390 14553.5 ANTHEM HMO ANTHEM HMO 999999999 13557.15 21718.3 "Insertion of stents with balloon dilation of coronary artery or branch, single artery or branch" 48607058_1 CDM 0481 RC 92928 HCPCS inpatient 22390 14553.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13557.15 21718.3 "Insertion of stents with balloon dilation of coronary artery or branch, single artery or branch" 48607058_1 CDM 0481 RC 92928 HCPCS inpatient 22390 14553.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 15135.64 67.6 999999999 13557.15 21718.3 percent of total billed charges "Insertion of stents with balloon dilation of coronary artery or branch, single artery or branch" 48607058_1 CDM 0481 RC 92928 HCPCS inpatient 22390 14553.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 13557.15 21718.3 "Insertion of stents with balloon dilation of coronary artery or branch, each additional artery or branch" 48607059_1 CDM 0481 RC 92929 HCPCS inpatient 22390 14553.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 14553.5 65 999999999 13557.15 21718.3 percent of total billed charges "Insertion of stents with balloon dilation of coronary artery or branch, each additional artery or branch" 48607059_1 CDM 0481 RC 92929 HCPCS inpatient 22390 14553.5 AETNA AETNA 17688.1 79 999999999 13557.15 21718.3 percent of total billed charges "Insertion of stents with balloon dilation of coronary artery or branch, each additional artery or branch" 48607059_1 CDM 0481 RC 92929 HCPCS inpatient 22390 14553.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 15449.1 69 999999999 13557.15 21718.3 percent of total billed charges "Insertion of stents with balloon dilation of coronary artery or branch, each additional artery or branch" 48607059_1 CDM 0481 RC 92929 HCPCS inpatient 22390 14553.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21718.3 97 999999999 13557.15 21718.3 percent of total billed charges "Insertion of stents with balloon dilation of coronary artery or branch, each additional artery or branch" 48607059_1 CDM 0481 RC 92929 HCPCS inpatient 22390 14553.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 17464.2 78 999999999 13557.15 21718.3 percent of total billed charges "Insertion of stents with balloon dilation of coronary artery or branch, each additional artery or branch" 48607059_1 CDM 0481 RC 92929 HCPCS inpatient 22390 14553.5 SIHO - ALL PLANS SIHO - ALL PLANS 20151 90 999999999 13557.15 21718.3 percent of total billed charges "Insertion of stents with balloon dilation of coronary artery or branch, each additional artery or branch" 48607059_1 CDM 0481 RC 92929 HCPCS inpatient 22390 14553.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13557.15 60.55 999999999 13557.15 21718.3 percent of total billed charges "Insertion of stents with balloon dilation of coronary artery or branch, each additional artery or branch" 48607059_1 CDM 0481 RC 92929 HCPCS inpatient 22390 14553.5 UMR - ALL PLANS UMR - ALL PLANS 15673 70 999999999 13557.15 21718.3 percent of total billed charges "Insertion of stents with balloon dilation of coronary artery or branch, each additional artery or branch" 48607059_1 CDM 0481 RC 92929 HCPCS inpatient 22390 14553.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13557.15 21718.3 "Insertion of stents with balloon dilation of coronary artery or branch, each additional artery or branch" 48607059_1 CDM 0481 RC 92929 HCPCS inpatient 22390 14553.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13557.15 21718.3 "Insertion of stents with balloon dilation of coronary artery or branch, each additional artery or branch" 48607059_1 CDM 0481 RC 92929 HCPCS inpatient 22390 14553.5 ANTHEM HMO ANTHEM HMO 999999999 13557.15 21718.3 "Insertion of stents with balloon dilation of coronary artery or branch, each additional artery or branch" 48607059_1 CDM 0481 RC 92929 HCPCS inpatient 22390 14553.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13557.15 21718.3 "Insertion of stents with balloon dilation of coronary artery or branch, each additional artery or branch" 48607059_1 CDM 0481 RC 92929 HCPCS inpatient 22390 14553.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 15135.64 67.6 999999999 13557.15 21718.3 percent of total billed charges "Insertion of stents with balloon dilation of coronary artery or branch, each additional artery or branch" 48607059_1 CDM 0481 RC 92929 HCPCS inpatient 22390 14553.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 13557.15 21718.3 Insertion of tube in right heart chambers for measurement 48607060_1 CDM 0481 RC 93451 HCPCS inpatient 11107 7219.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 7219.55 65 999999999 6725.29 10773.79 percent of total billed charges Insertion of tube in right heart chambers for measurement 48607060_1 CDM 0481 RC 93451 HCPCS inpatient 11107 7219.55 AETNA AETNA 8774.53 79 999999999 6725.29 10773.79 percent of total billed charges Insertion of tube in right heart chambers for measurement 48607060_1 CDM 0481 RC 93451 HCPCS inpatient 11107 7219.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 7663.83 69 999999999 6725.29 10773.79 percent of total billed charges Insertion of tube in right heart chambers for measurement 48607060_1 CDM 0481 RC 93451 HCPCS inpatient 11107 7219.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10773.79 97 999999999 6725.29 10773.79 percent of total billed charges Insertion of tube in right heart chambers for measurement 48607060_1 CDM 0481 RC 93451 HCPCS inpatient 11107 7219.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 8663.46 78 999999999 6725.29 10773.79 percent of total billed charges Insertion of tube in right heart chambers for measurement 48607060_1 CDM 0481 RC 93451 HCPCS inpatient 11107 7219.55 SIHO - ALL PLANS SIHO - ALL PLANS 9996.3 90 999999999 6725.29 10773.79 percent of total billed charges Insertion of tube in right heart chambers for measurement 48607060_1 CDM 0481 RC 93451 HCPCS inpatient 11107 7219.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6725.29 60.55 999999999 6725.29 10773.79 percent of total billed charges Insertion of tube in right heart chambers for measurement 48607060_1 CDM 0481 RC 93451 HCPCS inpatient 11107 7219.55 UMR - ALL PLANS UMR - ALL PLANS 7774.9 70 999999999 6725.29 10773.79 percent of total billed charges Insertion of tube in right heart chambers for measurement 48607060_1 CDM 0481 RC 93451 HCPCS inpatient 11107 7219.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6725.29 10773.79 Insertion of tube in right heart chambers for measurement 48607060_1 CDM 0481 RC 93451 HCPCS inpatient 11107 7219.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6725.29 10773.79 Insertion of tube in right heart chambers for measurement 48607060_1 CDM 0481 RC 93451 HCPCS inpatient 11107 7219.55 ANTHEM HMO ANTHEM HMO 999999999 6725.29 10773.79 Insertion of tube in right heart chambers for measurement 48607060_1 CDM 0481 RC 93451 HCPCS inpatient 11107 7219.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6725.29 10773.79 Insertion of tube in right heart chambers for measurement 48607060_1 CDM 0481 RC 93451 HCPCS inpatient 11107 7219.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 7508.33 67.6 999999999 6725.29 10773.79 percent of total billed charges Insertion of tube in right heart chambers for measurement 48607060_1 CDM 0481 RC 93451 HCPCS inpatient 11107 7219.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 6725.29 10773.79 Insertion of tube in left heart chambers for diagnosis with review by radiologist 48607061_1 CDM 0481 RC 93452 HCPCS inpatient 15401 10010.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 10010.65 65 999999999 9325.31 14938.97 percent of total billed charges Insertion of tube in left heart chambers for diagnosis with review by radiologist 48607061_1 CDM 0481 RC 93452 HCPCS inpatient 15401 10010.65 AETNA AETNA 12166.79 79 999999999 9325.31 14938.97 percent of total billed charges Insertion of tube in left heart chambers for diagnosis with review by radiologist 48607061_1 CDM 0481 RC 93452 HCPCS inpatient 15401 10010.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 10626.69 69 999999999 9325.31 14938.97 percent of total billed charges Insertion of tube in left heart chambers for diagnosis with review by radiologist 48607061_1 CDM 0481 RC 93452 HCPCS inpatient 15401 10010.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14938.97 97 999999999 9325.31 14938.97 percent of total billed charges Insertion of tube in left heart chambers for diagnosis with review by radiologist 48607061_1 CDM 0481 RC 93452 HCPCS inpatient 15401 10010.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 12012.78 78 999999999 9325.31 14938.97 percent of total billed charges Insertion of tube in left heart chambers for diagnosis with review by radiologist 48607061_1 CDM 0481 RC 93452 HCPCS inpatient 15401 10010.65 SIHO - ALL PLANS SIHO - ALL PLANS 13860.9 90 999999999 9325.31 14938.97 percent of total billed charges Insertion of tube in left heart chambers for diagnosis with review by radiologist 48607061_1 CDM 0481 RC 93452 HCPCS inpatient 15401 10010.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9325.31 60.55 999999999 9325.31 14938.97 percent of total billed charges Insertion of tube in left heart chambers for diagnosis with review by radiologist 48607061_1 CDM 0481 RC 93452 HCPCS inpatient 15401 10010.65 UMR - ALL PLANS UMR - ALL PLANS 10780.7 70 999999999 9325.31 14938.97 percent of total billed charges Insertion of tube in left heart chambers for diagnosis with review by radiologist 48607061_1 CDM 0481 RC 93452 HCPCS inpatient 15401 10010.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9325.31 14938.97 Insertion of tube in left heart chambers for diagnosis with review by radiologist 48607061_1 CDM 0481 RC 93452 HCPCS inpatient 15401 10010.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9325.31 14938.97 Insertion of tube in left heart chambers for diagnosis with review by radiologist 48607061_1 CDM 0481 RC 93452 HCPCS inpatient 15401 10010.65 ANTHEM HMO ANTHEM HMO 999999999 9325.31 14938.97 Insertion of tube in left heart chambers for diagnosis with review by radiologist 48607061_1 CDM 0481 RC 93452 HCPCS inpatient 15401 10010.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9325.31 14938.97 Insertion of tube in left heart chambers for diagnosis with review by radiologist 48607061_1 CDM 0481 RC 93452 HCPCS inpatient 15401 10010.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 10411.08 67.6 999999999 9325.31 14938.97 percent of total billed charges Insertion of tube in left heart chambers for diagnosis with review by radiologist 48607061_1 CDM 0481 RC 93452 HCPCS inpatient 15401 10010.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 9325.31 14938.97 Insertion of tube in right and left heart chambers for diagnosis with review by radiologist 48607062_1 CDM 0481 RC 93453 HCPCS inpatient 15401 10010.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 10010.65 65 999999999 9325.31 14938.97 percent of total billed charges Insertion of tube in right and left heart chambers for diagnosis with review by radiologist 48607062_1 CDM 0481 RC 93453 HCPCS inpatient 15401 10010.65 AETNA AETNA 12166.79 79 999999999 9325.31 14938.97 percent of total billed charges Insertion of tube in right and left heart chambers for diagnosis with review by radiologist 48607062_1 CDM 0481 RC 93453 HCPCS inpatient 15401 10010.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 10626.69 69 999999999 9325.31 14938.97 percent of total billed charges Insertion of tube in right and left heart chambers for diagnosis with review by radiologist 48607062_1 CDM 0481 RC 93453 HCPCS inpatient 15401 10010.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14938.97 97 999999999 9325.31 14938.97 percent of total billed charges Insertion of tube in right and left heart chambers for diagnosis with review by radiologist 48607062_1 CDM 0481 RC 93453 HCPCS inpatient 15401 10010.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 12012.78 78 999999999 9325.31 14938.97 percent of total billed charges Insertion of tube in right and left heart chambers for diagnosis with review by radiologist 48607062_1 CDM 0481 RC 93453 HCPCS inpatient 15401 10010.65 SIHO - ALL PLANS SIHO - ALL PLANS 13860.9 90 999999999 9325.31 14938.97 percent of total billed charges Insertion of tube in right and left heart chambers for diagnosis with review by radiologist 48607062_1 CDM 0481 RC 93453 HCPCS inpatient 15401 10010.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9325.31 60.55 999999999 9325.31 14938.97 percent of total billed charges Insertion of tube in right and left heart chambers for diagnosis with review by radiologist 48607062_1 CDM 0481 RC 93453 HCPCS inpatient 15401 10010.65 UMR - ALL PLANS UMR - ALL PLANS 10780.7 70 999999999 9325.31 14938.97 percent of total billed charges Insertion of tube in right and left heart chambers for diagnosis with review by radiologist 48607062_1 CDM 0481 RC 93453 HCPCS inpatient 15401 10010.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9325.31 14938.97 Insertion of tube in right and left heart chambers for diagnosis with review by radiologist 48607062_1 CDM 0481 RC 93453 HCPCS inpatient 15401 10010.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9325.31 14938.97 Insertion of tube in right and left heart chambers for diagnosis with review by radiologist 48607062_1 CDM 0481 RC 93453 HCPCS inpatient 15401 10010.65 ANTHEM HMO ANTHEM HMO 999999999 9325.31 14938.97 Insertion of tube in right and left heart chambers for diagnosis with review by radiologist 48607062_1 CDM 0481 RC 93453 HCPCS inpatient 15401 10010.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9325.31 14938.97 Insertion of tube in right and left heart chambers for diagnosis with review by radiologist 48607062_1 CDM 0481 RC 93453 HCPCS inpatient 15401 10010.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 10411.08 67.6 999999999 9325.31 14938.97 percent of total billed charges Insertion of tube in right and left heart chambers for diagnosis with review by radiologist 48607062_1 CDM 0481 RC 93453 HCPCS inpatient 15401 10010.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 9325.31 14938.97 Insertion of tube in coronary artery for diagnosis with review by radiologist 48607063_1 CDM 0481 RC 93454 HCPCS inpatient 16238 10554.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 10554.7 65 999999999 9832.11 15750.86 percent of total billed charges Insertion of tube in coronary artery for diagnosis with review by radiologist 48607063_1 CDM 0481 RC 93454 HCPCS inpatient 16238 10554.7 AETNA AETNA 12828.02 79 999999999 9832.11 15750.86 percent of total billed charges Insertion of tube in coronary artery for diagnosis with review by radiologist 48607063_1 CDM 0481 RC 93454 HCPCS inpatient 16238 10554.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 11204.22 69 999999999 9832.11 15750.86 percent of total billed charges Insertion of tube in coronary artery for diagnosis with review by radiologist 48607063_1 CDM 0481 RC 93454 HCPCS inpatient 16238 10554.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15750.86 97 999999999 9832.11 15750.86 percent of total billed charges Insertion of tube in coronary artery for diagnosis with review by radiologist 48607063_1 CDM 0481 RC 93454 HCPCS inpatient 16238 10554.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 12665.64 78 999999999 9832.11 15750.86 percent of total billed charges Insertion of tube in coronary artery for diagnosis with review by radiologist 48607063_1 CDM 0481 RC 93454 HCPCS inpatient 16238 10554.7 SIHO - ALL PLANS SIHO - ALL PLANS 14614.2 90 999999999 9832.11 15750.86 percent of total billed charges Insertion of tube in coronary artery for diagnosis with review by radiologist 48607063_1 CDM 0481 RC 93454 HCPCS inpatient 16238 10554.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9832.11 60.55 999999999 9832.11 15750.86 percent of total billed charges Insertion of tube in coronary artery for diagnosis with review by radiologist 48607063_1 CDM 0481 RC 93454 HCPCS inpatient 16238 10554.7 UMR - ALL PLANS UMR - ALL PLANS 11366.6 70 999999999 9832.11 15750.86 percent of total billed charges Insertion of tube in coronary artery for diagnosis with review by radiologist 48607063_1 CDM 0481 RC 93454 HCPCS inpatient 16238 10554.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9832.11 15750.86 Insertion of tube in coronary artery for diagnosis with review by radiologist 48607063_1 CDM 0481 RC 93454 HCPCS inpatient 16238 10554.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9832.11 15750.86 Insertion of tube in coronary artery for diagnosis with review by radiologist 48607063_1 CDM 0481 RC 93454 HCPCS inpatient 16238 10554.7 ANTHEM HMO ANTHEM HMO 999999999 9832.11 15750.86 Insertion of tube in coronary artery for diagnosis with review by radiologist 48607063_1 CDM 0481 RC 93454 HCPCS inpatient 16238 10554.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9832.11 15750.86 Insertion of tube in coronary artery for diagnosis with review by radiologist 48607063_1 CDM 0481 RC 93454 HCPCS inpatient 16238 10554.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 10976.89 67.6 999999999 9832.11 15750.86 percent of total billed charges Insertion of tube in coronary artery for diagnosis with review by radiologist 48607063_1 CDM 0481 RC 93454 HCPCS inpatient 16238 10554.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 9832.11 15750.86 Insertion of tube in bypass graft for diagnosis with review by radiologist 48607064_1 CDM 0481 RC 93455 HCPCS inpatient 18358 11932.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 11932.7 65 999999999 11115.77 17807.26 percent of total billed charges Insertion of tube in bypass graft for diagnosis with review by radiologist 48607064_1 CDM 0481 RC 93455 HCPCS inpatient 18358 11932.7 AETNA AETNA 14502.82 79 999999999 11115.77 17807.26 percent of total billed charges Insertion of tube in bypass graft for diagnosis with review by radiologist 48607064_1 CDM 0481 RC 93455 HCPCS inpatient 18358 11932.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 12667.02 69 999999999 11115.77 17807.26 percent of total billed charges Insertion of tube in bypass graft for diagnosis with review by radiologist 48607064_1 CDM 0481 RC 93455 HCPCS inpatient 18358 11932.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17807.26 97 999999999 11115.77 17807.26 percent of total billed charges Insertion of tube in bypass graft for diagnosis with review by radiologist 48607064_1 CDM 0481 RC 93455 HCPCS inpatient 18358 11932.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 14319.24 78 999999999 11115.77 17807.26 percent of total billed charges Insertion of tube in bypass graft for diagnosis with review by radiologist 48607064_1 CDM 0481 RC 93455 HCPCS inpatient 18358 11932.7 SIHO - ALL PLANS SIHO - ALL PLANS 16522.2 90 999999999 11115.77 17807.26 percent of total billed charges Insertion of tube in bypass graft for diagnosis with review by radiologist 48607064_1 CDM 0481 RC 93455 HCPCS inpatient 18358 11932.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11115.77 60.55 999999999 11115.77 17807.26 percent of total billed charges Insertion of tube in bypass graft for diagnosis with review by radiologist 48607064_1 CDM 0481 RC 93455 HCPCS inpatient 18358 11932.7 UMR - ALL PLANS UMR - ALL PLANS 12850.6 70 999999999 11115.77 17807.26 percent of total billed charges Insertion of tube in bypass graft for diagnosis with review by radiologist 48607064_1 CDM 0481 RC 93455 HCPCS inpatient 18358 11932.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11115.77 17807.26 Insertion of tube in bypass graft for diagnosis with review by radiologist 48607064_1 CDM 0481 RC 93455 HCPCS inpatient 18358 11932.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11115.77 17807.26 Insertion of tube in bypass graft for diagnosis with review by radiologist 48607064_1 CDM 0481 RC 93455 HCPCS inpatient 18358 11932.7 ANTHEM HMO ANTHEM HMO 999999999 11115.77 17807.26 Insertion of tube in bypass graft for diagnosis with review by radiologist 48607064_1 CDM 0481 RC 93455 HCPCS inpatient 18358 11932.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11115.77 17807.26 Insertion of tube in bypass graft for diagnosis with review by radiologist 48607064_1 CDM 0481 RC 93455 HCPCS inpatient 18358 11932.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 12410.01 67.6 999999999 11115.77 17807.26 percent of total billed charges Insertion of tube in bypass graft for diagnosis with review by radiologist 48607064_1 CDM 0481 RC 93455 HCPCS inpatient 18358 11932.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 11115.77 17807.26 "Established patient office or other outpatient visit, 10-19 minutes" 48609722_1 CDM 0510 RC 99212 HCPCS inpatient 307 199.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 199.55 65 999999999 185.89 297.79 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 48609722_1 CDM 0510 RC 99212 HCPCS inpatient 307 199.55 AETNA AETNA 242.53 79 999999999 185.89 297.79 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 48609722_1 CDM 0510 RC 99212 HCPCS inpatient 307 199.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 211.83 69 999999999 185.89 297.79 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 48609722_1 CDM 0510 RC 99212 HCPCS inpatient 307 199.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 297.79 97 999999999 185.89 297.79 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 48609722_1 CDM 0510 RC 99212 HCPCS inpatient 307 199.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 239.46 78 999999999 185.89 297.79 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 48609722_1 CDM 0510 RC 99212 HCPCS inpatient 307 199.55 SIHO - ALL PLANS SIHO - ALL PLANS 276.3 90 999999999 185.89 297.79 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 48609722_1 CDM 0510 RC 99212 HCPCS inpatient 307 199.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 185.89 60.55 999999999 185.89 297.79 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 48609722_1 CDM 0510 RC 99212 HCPCS inpatient 307 199.55 UMR - ALL PLANS UMR - ALL PLANS 214.9 70 999999999 185.89 297.79 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 48609722_1 CDM 0510 RC 99212 HCPCS inpatient 307 199.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 185.89 297.79 "Established patient office or other outpatient visit, 10-19 minutes" 48609722_1 CDM 0510 RC 99212 HCPCS inpatient 307 199.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 185.89 297.79 "Established patient office or other outpatient visit, 10-19 minutes" 48609722_1 CDM 0510 RC 99212 HCPCS inpatient 307 199.55 ANTHEM HMO ANTHEM HMO 999999999 185.89 297.79 "Established patient office or other outpatient visit, 10-19 minutes" 48609722_1 CDM 0510 RC 99212 HCPCS inpatient 307 199.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 185.89 297.79 "Established patient office or other outpatient visit, 10-19 minutes" 48609722_1 CDM 0510 RC 99212 HCPCS inpatient 307 199.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 207.53 67.6 999999999 185.89 297.79 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 48609722_1 CDM 0510 RC 99212 HCPCS inpatient 307 199.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 185.89 297.79 Aspiration and/or injection of fluid from large joint 48609736_1 CDM 0510 RC 20610 HCPCS inpatient 986 640.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 640.9 65 999999999 597.02 956.42 percent of total billed charges Aspiration and/or injection of fluid from large joint 48609736_1 CDM 0510 RC 20610 HCPCS inpatient 986 640.9 AETNA AETNA 778.94 79 999999999 597.02 956.42 percent of total billed charges Aspiration and/or injection of fluid from large joint 48609736_1 CDM 0510 RC 20610 HCPCS inpatient 986 640.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 680.34 69 999999999 597.02 956.42 percent of total billed charges Aspiration and/or injection of fluid from large joint 48609736_1 CDM 0510 RC 20610 HCPCS inpatient 986 640.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 956.42 97 999999999 597.02 956.42 percent of total billed charges Aspiration and/or injection of fluid from large joint 48609736_1 CDM 0510 RC 20610 HCPCS inpatient 986 640.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 769.08 78 999999999 597.02 956.42 percent of total billed charges Aspiration and/or injection of fluid from large joint 48609736_1 CDM 0510 RC 20610 HCPCS inpatient 986 640.9 SIHO - ALL PLANS SIHO - ALL PLANS 887.4 90 999999999 597.02 956.42 percent of total billed charges Aspiration and/or injection of fluid from large joint 48609736_1 CDM 0510 RC 20610 HCPCS inpatient 986 640.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 597.02 60.55 999999999 597.02 956.42 percent of total billed charges Aspiration and/or injection of fluid from large joint 48609736_1 CDM 0510 RC 20610 HCPCS inpatient 986 640.9 UMR - ALL PLANS UMR - ALL PLANS 690.2 70 999999999 597.02 956.42 percent of total billed charges Aspiration and/or injection of fluid from large joint 48609736_1 CDM 0510 RC 20610 HCPCS inpatient 986 640.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 597.02 956.42 Aspiration and/or injection of fluid from large joint 48609736_1 CDM 0510 RC 20610 HCPCS inpatient 986 640.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 597.02 956.42 Aspiration and/or injection of fluid from large joint 48609736_1 CDM 0510 RC 20610 HCPCS inpatient 986 640.9 ANTHEM HMO ANTHEM HMO 999999999 597.02 956.42 Aspiration and/or injection of fluid from large joint 48609736_1 CDM 0510 RC 20610 HCPCS inpatient 986 640.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 597.02 956.42 Aspiration and/or injection of fluid from large joint 48609736_1 CDM 0510 RC 20610 HCPCS inpatient 986 640.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 666.54 67.6 999999999 597.02 956.42 percent of total billed charges Aspiration and/or injection of fluid from large joint 48609736_1 CDM 0510 RC 20610 HCPCS inpatient 986 640.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 597.02 956.42 "Semen evaluation volume, sperm count, motility and analysis" 48609831_1 CDM 0309 RC 89320 HCPCS inpatient 243 157.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 157.95 65 999999999 147.14 235.71 percent of total billed charges "Semen evaluation volume, sperm count, motility and analysis" 48609831_1 CDM 0309 RC 89320 HCPCS inpatient 243 157.95 AETNA AETNA 191.97 79 999999999 147.14 235.71 percent of total billed charges "Semen evaluation volume, sperm count, motility and analysis" 48609831_1 CDM 0309 RC 89320 HCPCS inpatient 243 157.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 167.67 69 999999999 147.14 235.71 percent of total billed charges "Semen evaluation volume, sperm count, motility and analysis" 48609831_1 CDM 0309 RC 89320 HCPCS inpatient 243 157.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 235.71 97 999999999 147.14 235.71 percent of total billed charges "Semen evaluation volume, sperm count, motility and analysis" 48609831_1 CDM 0309 RC 89320 HCPCS inpatient 243 157.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 189.54 78 999999999 147.14 235.71 percent of total billed charges "Semen evaluation volume, sperm count, motility and analysis" 48609831_1 CDM 0309 RC 89320 HCPCS inpatient 243 157.95 SIHO - ALL PLANS SIHO - ALL PLANS 218.7 90 999999999 147.14 235.71 percent of total billed charges "Semen evaluation volume, sperm count, motility and analysis" 48609831_1 CDM 0309 RC 89320 HCPCS inpatient 243 157.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.14 60.55 999999999 147.14 235.71 percent of total billed charges "Semen evaluation volume, sperm count, motility and analysis" 48609831_1 CDM 0309 RC 89320 HCPCS inpatient 243 157.95 UMR - ALL PLANS UMR - ALL PLANS 170.1 70 999999999 147.14 235.71 percent of total billed charges "Semen evaluation volume, sperm count, motility and analysis" 48609831_1 CDM 0309 RC 89320 HCPCS inpatient 243 157.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.14 235.71 "Semen evaluation volume, sperm count, motility and analysis" 48609831_1 CDM 0309 RC 89320 HCPCS inpatient 243 157.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.14 235.71 "Semen evaluation volume, sperm count, motility and analysis" 48609831_1 CDM 0309 RC 89320 HCPCS inpatient 243 157.95 ANTHEM HMO ANTHEM HMO 999999999 147.14 235.71 "Semen evaluation volume, sperm count, motility and analysis" 48609831_1 CDM 0309 RC 89320 HCPCS inpatient 243 157.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.14 235.71 "Semen evaluation volume, sperm count, motility and analysis" 48609831_1 CDM 0309 RC 89320 HCPCS inpatient 243 157.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.27 67.6 999999999 147.14 235.71 percent of total billed charges "Semen evaluation volume, sperm count, motility and analysis" 48609831_1 CDM 0309 RC 89320 HCPCS inpatient 243 157.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.14 235.71 Blood glucose (sugar) level after receiving dose of glucose 48609865_1 CDM 0301 RC 82950 HCPCS inpatient 165 107.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.25 65 999999999 99.91 160.05 percent of total billed charges Blood glucose (sugar) level after receiving dose of glucose 48609865_1 CDM 0301 RC 82950 HCPCS inpatient 165 107.25 AETNA AETNA 130.35 79 999999999 99.91 160.05 percent of total billed charges Blood glucose (sugar) level after receiving dose of glucose 48609865_1 CDM 0301 RC 82950 HCPCS inpatient 165 107.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.85 69 999999999 99.91 160.05 percent of total billed charges Blood glucose (sugar) level after receiving dose of glucose 48609865_1 CDM 0301 RC 82950 HCPCS inpatient 165 107.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 160.05 97 999999999 99.91 160.05 percent of total billed charges Blood glucose (sugar) level after receiving dose of glucose 48609865_1 CDM 0301 RC 82950 HCPCS inpatient 165 107.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.7 78 999999999 99.91 160.05 percent of total billed charges Blood glucose (sugar) level after receiving dose of glucose 48609865_1 CDM 0301 RC 82950 HCPCS inpatient 165 107.25 SIHO - ALL PLANS SIHO - ALL PLANS 148.5 90 999999999 99.91 160.05 percent of total billed charges Blood glucose (sugar) level after receiving dose of glucose 48609865_1 CDM 0301 RC 82950 HCPCS inpatient 165 107.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.91 60.55 999999999 99.91 160.05 percent of total billed charges Blood glucose (sugar) level after receiving dose of glucose 48609865_1 CDM 0301 RC 82950 HCPCS inpatient 165 107.25 UMR - ALL PLANS UMR - ALL PLANS 115.5 70 999999999 99.91 160.05 percent of total billed charges Blood glucose (sugar) level after receiving dose of glucose 48609865_1 CDM 0301 RC 82950 HCPCS inpatient 165 107.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.91 160.05 Blood glucose (sugar) level after receiving dose of glucose 48609865_1 CDM 0301 RC 82950 HCPCS inpatient 165 107.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.91 160.05 Blood glucose (sugar) level after receiving dose of glucose 48609865_1 CDM 0301 RC 82950 HCPCS inpatient 165 107.25 ANTHEM HMO ANTHEM HMO 999999999 99.91 160.05 Blood glucose (sugar) level after receiving dose of glucose 48609865_1 CDM 0301 RC 82950 HCPCS inpatient 165 107.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.91 160.05 Blood glucose (sugar) level after receiving dose of glucose 48609865_1 CDM 0301 RC 82950 HCPCS inpatient 165 107.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.54 67.6 999999999 99.91 160.05 percent of total billed charges Blood glucose (sugar) level after receiving dose of glucose 48609865_1 CDM 0301 RC 82950 HCPCS inpatient 165 107.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.91 160.05 Ammonia level 48609874_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 165.1 65 999999999 153.8 246.38 percent of total billed charges Ammonia level 48609874_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 AETNA AETNA 200.66 79 999999999 153.8 246.38 percent of total billed charges Ammonia level 48609874_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 175.26 69 999999999 153.8 246.38 percent of total billed charges Ammonia level 48609874_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 246.38 97 999999999 153.8 246.38 percent of total billed charges Ammonia level 48609874_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 198.12 78 999999999 153.8 246.38 percent of total billed charges Ammonia level 48609874_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 SIHO - ALL PLANS SIHO - ALL PLANS 228.6 90 999999999 153.8 246.38 percent of total billed charges Ammonia level 48609874_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 153.8 60.55 999999999 153.8 246.38 percent of total billed charges Ammonia level 48609874_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 UMR - ALL PLANS UMR - ALL PLANS 177.8 70 999999999 153.8 246.38 percent of total billed charges Ammonia level 48609874_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 153.8 246.38 Ammonia level 48609874_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 153.8 246.38 Ammonia level 48609874_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 ANTHEM HMO ANTHEM HMO 999999999 153.8 246.38 Ammonia level 48609874_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 153.8 246.38 Ammonia level 48609874_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 171.7 67.6 999999999 153.8 246.38 percent of total billed charges Ammonia level 48609874_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 153.8 246.38 Magnesium level 48610192_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges Magnesium level 48610192_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges Magnesium level 48610192_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges Magnesium level 48610192_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges Magnesium level 48610192_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges Magnesium level 48610192_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges Magnesium level 48610192_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges Magnesium level 48610192_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges Magnesium level 48610192_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 Magnesium level 48610192_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 Magnesium level 48610192_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 Magnesium level 48610192_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 Magnesium level 48610192_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges Magnesium level 48610192_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 "INJECTION, FLUOROURACIL, 500 MG" 48610339_1 CDM 0636 RC 63323-0117-19 NDC J9190 HCPCS inpatient 1 UN 38.6 25.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 25.09 65 999999999 23.37 37.44 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 48610339_1 CDM 0636 RC 63323-0117-19 NDC J9190 HCPCS inpatient 1 UN 38.6 25.09 AETNA AETNA 30.49 79 999999999 23.37 37.44 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 48610339_1 CDM 0636 RC 63323-0117-19 NDC J9190 HCPCS inpatient 1 UN 38.6 25.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.63 69 999999999 23.37 37.44 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 48610339_1 CDM 0636 RC 63323-0117-19 NDC J9190 HCPCS inpatient 1 UN 38.6 25.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37.44 97 999999999 23.37 37.44 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 48610339_1 CDM 0636 RC 63323-0117-19 NDC J9190 HCPCS inpatient 1 UN 38.6 25.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 30.11 78 999999999 23.37 37.44 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 48610339_1 CDM 0636 RC 63323-0117-19 NDC J9190 HCPCS inpatient 1 UN 38.6 25.09 SIHO - ALL PLANS SIHO - ALL PLANS 34.74 90 999999999 23.37 37.44 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 48610339_1 CDM 0636 RC 63323-0117-19 NDC J9190 HCPCS inpatient 1 UN 38.6 25.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.37 60.55 999999999 23.37 37.44 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 48610339_1 CDM 0636 RC 63323-0117-19 NDC J9190 HCPCS inpatient 1 UN 38.6 25.09 UMR - ALL PLANS UMR - ALL PLANS 27.02 70 999999999 23.37 37.44 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 48610339_1 CDM 0636 RC 63323-0117-19 NDC J9190 HCPCS inpatient 1 UN 38.6 25.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.37 37.44 "INJECTION, FLUOROURACIL, 500 MG" 48610339_1 CDM 0636 RC 63323-0117-19 NDC J9190 HCPCS inpatient 1 UN 38.6 25.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.37 37.44 "INJECTION, FLUOROURACIL, 500 MG" 48610339_1 CDM 0636 RC 63323-0117-19 NDC J9190 HCPCS inpatient 1 UN 38.6 25.09 ANTHEM HMO ANTHEM HMO 999999999 23.37 37.44 "INJECTION, FLUOROURACIL, 500 MG" 48610339_1 CDM 0636 RC 63323-0117-19 NDC J9190 HCPCS inpatient 1 UN 38.6 25.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.37 37.44 "INJECTION, FLUOROURACIL, 500 MG" 48610339_1 CDM 0636 RC 63323-0117-19 NDC J9190 HCPCS inpatient 1 UN 38.6 25.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 26.09 67.6 999999999 23.37 37.44 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 48610339_1 CDM 0636 RC 63323-0117-19 NDC J9190 HCPCS inpatient 1 UN 38.6 25.09 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.37 37.44 Emergency department visit for problem that may not require health care professional 48614788_1 CDM 0451 RC 99281 HCPCS inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges Emergency department visit for problem that may not require health care professional 48614788_1 CDM 0451 RC 99281 HCPCS inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges Emergency department visit for problem that may not require health care professional 48614788_1 CDM 0451 RC 99281 HCPCS inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges Emergency department visit for problem that may not require health care professional 48614788_1 CDM 0451 RC 99281 HCPCS inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges Emergency department visit for problem that may not require health care professional 48614788_1 CDM 0451 RC 99281 HCPCS inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges Emergency department visit for problem that may not require health care professional 48614788_1 CDM 0451 RC 99281 HCPCS inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges Emergency department visit for problem that may not require health care professional 48614788_1 CDM 0451 RC 99281 HCPCS inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges Emergency department visit for problem that may not require health care professional 48614788_1 CDM 0451 RC 99281 HCPCS inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges Emergency department visit for problem that may not require health care professional 48614788_1 CDM 0451 RC 99281 HCPCS inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 Emergency department visit for problem that may not require health care professional 48614788_1 CDM 0451 RC 99281 HCPCS inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 Emergency department visit for problem that may not require health care professional 48614788_1 CDM 0451 RC 99281 HCPCS inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 Emergency department visit for problem that may not require health care professional 48614788_1 CDM 0451 RC 99281 HCPCS inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 Emergency department visit for problem that may not require health care professional 48614788_1 CDM 0451 RC 99281 HCPCS inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges Emergency department visit for problem that may not require health care professional 48614788_1 CDM 0451 RC 99281 HCPCS inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 "Processing and storage of blood unit or component, predeposited" 48633410_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 237.25 65 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48633410_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 AETNA AETNA 288.35 79 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48633410_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 251.85 69 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48633410_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 354.05 97 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48633410_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 284.7 78 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48633410_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 SIHO - ALL PLANS SIHO - ALL PLANS 328.5 90 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48633410_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 221.01 60.55 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48633410_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 UMR - ALL PLANS UMR - ALL PLANS 255.5 70 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48633410_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 221.01 354.05 "Processing and storage of blood unit or component, predeposited" 48633410_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 221.01 354.05 "Processing and storage of blood unit or component, predeposited" 48633410_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ANTHEM HMO ANTHEM HMO 999999999 221.01 354.05 "Processing and storage of blood unit or component, predeposited" 48633410_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 221.01 354.05 "Processing and storage of blood unit or component, predeposited" 48633410_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 246.74 67.6 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48633410_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 221.01 354.05 "Processing and storage of blood unit or component, predeposited" 48633411_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 237.25 65 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48633411_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 AETNA AETNA 288.35 79 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48633411_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 251.85 69 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48633411_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 354.05 97 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48633411_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 284.7 78 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48633411_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 SIHO - ALL PLANS SIHO - ALL PLANS 328.5 90 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48633411_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 221.01 60.55 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48633411_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 UMR - ALL PLANS UMR - ALL PLANS 255.5 70 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48633411_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 221.01 354.05 "Processing and storage of blood unit or component, predeposited" 48633411_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 221.01 354.05 "Processing and storage of blood unit or component, predeposited" 48633411_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ANTHEM HMO ANTHEM HMO 999999999 221.01 354.05 "Processing and storage of blood unit or component, predeposited" 48633411_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 221.01 354.05 "Processing and storage of blood unit or component, predeposited" 48633411_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 246.74 67.6 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48633411_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 221.01 354.05 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48654221_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48654221_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48654221_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48654221_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48654221_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48654221_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48654221_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48654221_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48654221_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48654221_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48654221_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48654221_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48654221_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48654221_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 61553-0148-48 - fentaNYL-ropivacaine 2 mcg/mL-0.2%-NaCl 0.9% Sol[JOHN] 48655991_1 CDM 0250 RC 61553-0148-48 NDC inpatient 1 UN 214.42 139.37 SELF PAY DISCOUNT SELF PAY DISCOUNT 139.37 65 999999999 129.83 207.99 percent of total billed charges 61553-0148-48 - fentaNYL-ropivacaine 2 mcg/mL-0.2%-NaCl 0.9% Sol[JOHN] 48655991_1 CDM 0250 RC 61553-0148-48 NDC inpatient 1 UN 214.42 139.37 AETNA AETNA 169.39 79 999999999 129.83 207.99 percent of total billed charges 61553-0148-48 - fentaNYL-ropivacaine 2 mcg/mL-0.2%-NaCl 0.9% Sol[JOHN] 48655991_1 CDM 0250 RC 61553-0148-48 NDC inpatient 1 UN 214.42 139.37 ENCORE - ALL PLANS ENCORE - ALL PLANS 147.95 69 999999999 129.83 207.99 percent of total billed charges 61553-0148-48 - fentaNYL-ropivacaine 2 mcg/mL-0.2%-NaCl 0.9% Sol[JOHN] 48655991_1 CDM 0250 RC 61553-0148-48 NDC inpatient 1 UN 214.42 139.37 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 207.99 97 999999999 129.83 207.99 percent of total billed charges 61553-0148-48 - fentaNYL-ropivacaine 2 mcg/mL-0.2%-NaCl 0.9% Sol[JOHN] 48655991_1 CDM 0250 RC 61553-0148-48 NDC inpatient 1 UN 214.42 139.37 HUMANA - ALL PLANS HUMANA - ALL PLANS 167.25 78 999999999 129.83 207.99 percent of total billed charges 61553-0148-48 - fentaNYL-ropivacaine 2 mcg/mL-0.2%-NaCl 0.9% Sol[JOHN] 48655991_1 CDM 0250 RC 61553-0148-48 NDC inpatient 1 UN 214.42 139.37 SIHO - ALL PLANS SIHO - ALL PLANS 192.98 90 999999999 129.83 207.99 percent of total billed charges 61553-0148-48 - fentaNYL-ropivacaine 2 mcg/mL-0.2%-NaCl 0.9% Sol[JOHN] 48655991_1 CDM 0250 RC 61553-0148-48 NDC inpatient 1 UN 214.42 139.37 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 129.83 60.55 999999999 129.83 207.99 percent of total billed charges 61553-0148-48 - fentaNYL-ropivacaine 2 mcg/mL-0.2%-NaCl 0.9% Sol[JOHN] 48655991_1 CDM 0250 RC 61553-0148-48 NDC inpatient 1 UN 214.42 139.37 UMR - ALL PLANS UMR - ALL PLANS 150.09 70 999999999 129.83 207.99 percent of total billed charges 61553-0148-48 - fentaNYL-ropivacaine 2 mcg/mL-0.2%-NaCl 0.9% Sol[JOHN] 48655991_1 CDM 0250 RC 61553-0148-48 NDC inpatient 1 UN 214.42 139.37 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 129.83 207.99 61553-0148-48 - fentaNYL-ropivacaine 2 mcg/mL-0.2%-NaCl 0.9% Sol[JOHN] 48655991_1 CDM 0250 RC 61553-0148-48 NDC inpatient 1 UN 214.42 139.37 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 129.83 207.99 61553-0148-48 - fentaNYL-ropivacaine 2 mcg/mL-0.2%-NaCl 0.9% Sol[JOHN] 48655991_1 CDM 0250 RC 61553-0148-48 NDC inpatient 1 UN 214.42 139.37 ANTHEM HMO ANTHEM HMO 999999999 129.83 207.99 61553-0148-48 - fentaNYL-ropivacaine 2 mcg/mL-0.2%-NaCl 0.9% Sol[JOHN] 48655991_1 CDM 0250 RC 61553-0148-48 NDC inpatient 1 UN 214.42 139.37 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 129.83 207.99 61553-0148-48 - fentaNYL-ropivacaine 2 mcg/mL-0.2%-NaCl 0.9% Sol[JOHN] 48655991_1 CDM 0250 RC 61553-0148-48 NDC inpatient 1 UN 214.42 139.37 CIGNA - ALL PLANS CIGNA - ALL PLANS 144.95 67.6 999999999 129.83 207.99 percent of total billed charges 61553-0148-48 - fentaNYL-ropivacaine 2 mcg/mL-0.2%-NaCl 0.9% Sol[JOHN] 48655991_1 CDM 0250 RC 61553-0148-48 NDC inpatient 1 UN 214.42 139.37 UHC - ALL PLANS UHC - ALL PLANS 999999999 129.83 207.99 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656058_1 CDM 0250 RC 00338-0551-18 NDC J7060 HCPCS inpatient 1 UN 64.12 41.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.68 65 999999999 38.82 62.2 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656058_1 CDM 0250 RC 00338-0551-18 NDC J7060 HCPCS inpatient 1 UN 64.12 41.68 AETNA AETNA 50.65 79 999999999 38.82 62.2 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656058_1 CDM 0250 RC 00338-0551-18 NDC J7060 HCPCS inpatient 1 UN 64.12 41.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.24 69 999999999 38.82 62.2 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656058_1 CDM 0250 RC 00338-0551-18 NDC J7060 HCPCS inpatient 1 UN 64.12 41.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 62.2 97 999999999 38.82 62.2 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656058_1 CDM 0250 RC 00338-0551-18 NDC J7060 HCPCS inpatient 1 UN 64.12 41.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 50.01 78 999999999 38.82 62.2 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656058_1 CDM 0250 RC 00338-0551-18 NDC J7060 HCPCS inpatient 1 UN 64.12 41.68 SIHO - ALL PLANS SIHO - ALL PLANS 57.71 90 999999999 38.82 62.2 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656058_1 CDM 0250 RC 00338-0551-18 NDC J7060 HCPCS inpatient 1 UN 64.12 41.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.82 60.55 999999999 38.82 62.2 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656058_1 CDM 0250 RC 00338-0551-18 NDC J7060 HCPCS inpatient 1 UN 64.12 41.68 UMR - ALL PLANS UMR - ALL PLANS 44.88 70 999999999 38.82 62.2 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656058_1 CDM 0250 RC 00338-0551-18 NDC J7060 HCPCS inpatient 1 UN 64.12 41.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.82 62.2 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656058_1 CDM 0250 RC 00338-0551-18 NDC J7060 HCPCS inpatient 1 UN 64.12 41.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.82 62.2 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656058_1 CDM 0250 RC 00338-0551-18 NDC J7060 HCPCS inpatient 1 UN 64.12 41.68 ANTHEM HMO ANTHEM HMO 999999999 38.82 62.2 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656058_1 CDM 0250 RC 00338-0551-18 NDC J7060 HCPCS inpatient 1 UN 64.12 41.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.82 62.2 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656058_1 CDM 0250 RC 00338-0551-18 NDC J7060 HCPCS inpatient 1 UN 64.12 41.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.35 67.6 999999999 38.82 62.2 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656058_1 CDM 0250 RC 00338-0551-18 NDC J7060 HCPCS inpatient 1 UN 64.12 41.68 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.82 62.2 "INJECTION, FENTANYL CITRATE, 0.1 MG" 48656088_1 CDM 0250 RC 61553-0112-52 NDC J3010 HCPCS inpatient 10 UN 135.69 88.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.2 65 999999999 82.16 131.62 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48656088_1 CDM 0250 RC 61553-0112-52 NDC J3010 HCPCS inpatient 10 UN 135.69 88.2 AETNA AETNA 107.2 79 999999999 82.16 131.62 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48656088_1 CDM 0250 RC 61553-0112-52 NDC J3010 HCPCS inpatient 10 UN 135.69 88.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.63 69 999999999 82.16 131.62 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48656088_1 CDM 0250 RC 61553-0112-52 NDC J3010 HCPCS inpatient 10 UN 135.69 88.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.62 97 999999999 82.16 131.62 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48656088_1 CDM 0250 RC 61553-0112-52 NDC J3010 HCPCS inpatient 10 UN 135.69 88.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 105.84 78 999999999 82.16 131.62 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48656088_1 CDM 0250 RC 61553-0112-52 NDC J3010 HCPCS inpatient 10 UN 135.69 88.2 SIHO - ALL PLANS SIHO - ALL PLANS 122.12 90 999999999 82.16 131.62 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48656088_1 CDM 0250 RC 61553-0112-52 NDC J3010 HCPCS inpatient 10 UN 135.69 88.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.16 60.55 999999999 82.16 131.62 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48656088_1 CDM 0250 RC 61553-0112-52 NDC J3010 HCPCS inpatient 10 UN 135.69 88.2 UMR - ALL PLANS UMR - ALL PLANS 94.98 70 999999999 82.16 131.62 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48656088_1 CDM 0250 RC 61553-0112-52 NDC J3010 HCPCS inpatient 10 UN 135.69 88.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.16 131.62 "INJECTION, FENTANYL CITRATE, 0.1 MG" 48656088_1 CDM 0250 RC 61553-0112-52 NDC J3010 HCPCS inpatient 10 UN 135.69 88.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.16 131.62 "INJECTION, FENTANYL CITRATE, 0.1 MG" 48656088_1 CDM 0250 RC 61553-0112-52 NDC J3010 HCPCS inpatient 10 UN 135.69 88.2 ANTHEM HMO ANTHEM HMO 999999999 82.16 131.62 "INJECTION, FENTANYL CITRATE, 0.1 MG" 48656088_1 CDM 0250 RC 61553-0112-52 NDC J3010 HCPCS inpatient 10 UN 135.69 88.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.16 131.62 "INJECTION, FENTANYL CITRATE, 0.1 MG" 48656088_1 CDM 0250 RC 61553-0112-52 NDC J3010 HCPCS inpatient 10 UN 135.69 88.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.73 67.6 999999999 82.16 131.62 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 48656088_1 CDM 0250 RC 61553-0112-52 NDC J3010 HCPCS inpatient 10 UN 135.69 88.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.16 131.62 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656089_1 CDM 0250 RC 00338-0551-11 NDC J7060 HCPCS inpatient 1 UN 63.72 41.42 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.42 65 999999999 38.58 61.81 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656089_1 CDM 0250 RC 00338-0551-11 NDC J7060 HCPCS inpatient 1 UN 63.72 41.42 AETNA AETNA 50.34 79 999999999 38.58 61.81 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656089_1 CDM 0250 RC 00338-0551-11 NDC J7060 HCPCS inpatient 1 UN 63.72 41.42 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.97 69 999999999 38.58 61.81 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656089_1 CDM 0250 RC 00338-0551-11 NDC J7060 HCPCS inpatient 1 UN 63.72 41.42 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.81 97 999999999 38.58 61.81 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656089_1 CDM 0250 RC 00338-0551-11 NDC J7060 HCPCS inpatient 1 UN 63.72 41.42 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.7 78 999999999 38.58 61.81 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656089_1 CDM 0250 RC 00338-0551-11 NDC J7060 HCPCS inpatient 1 UN 63.72 41.42 SIHO - ALL PLANS SIHO - ALL PLANS 57.35 90 999999999 38.58 61.81 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656089_1 CDM 0250 RC 00338-0551-11 NDC J7060 HCPCS inpatient 1 UN 63.72 41.42 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.58 60.55 999999999 38.58 61.81 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656089_1 CDM 0250 RC 00338-0551-11 NDC J7060 HCPCS inpatient 1 UN 63.72 41.42 UMR - ALL PLANS UMR - ALL PLANS 44.6 70 999999999 38.58 61.81 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656089_1 CDM 0250 RC 00338-0551-11 NDC J7060 HCPCS inpatient 1 UN 63.72 41.42 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.58 61.81 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656089_1 CDM 0250 RC 00338-0551-11 NDC J7060 HCPCS inpatient 1 UN 63.72 41.42 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.58 61.81 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656089_1 CDM 0250 RC 00338-0551-11 NDC J7060 HCPCS inpatient 1 UN 63.72 41.42 ANTHEM HMO ANTHEM HMO 999999999 38.58 61.81 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656089_1 CDM 0250 RC 00338-0551-11 NDC J7060 HCPCS inpatient 1 UN 63.72 41.42 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.58 61.81 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656089_1 CDM 0250 RC 00338-0551-11 NDC J7060 HCPCS inpatient 1 UN 63.72 41.42 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.07 67.6 999999999 38.58 61.81 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656089_1 CDM 0250 RC 00338-0551-11 NDC J7060 HCPCS inpatient 1 UN 63.72 41.42 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.58 61.81 "INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML = 1 UNIT)" 48656091_1 CDM 0250 RC 00338-0553-18 NDC J7040 HCPCS inpatient 1 UN 63.39 41.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.2 65 999999999 38.38 61.49 percent of total billed charges "INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML = 1 UNIT)" 48656091_1 CDM 0250 RC 00338-0553-18 NDC J7040 HCPCS inpatient 1 UN 63.39 41.2 AETNA AETNA 50.08 79 999999999 38.38 61.49 percent of total billed charges "INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML = 1 UNIT)" 48656091_1 CDM 0250 RC 00338-0553-18 NDC J7040 HCPCS inpatient 1 UN 63.39 41.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.74 69 999999999 38.38 61.49 percent of total billed charges "INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML = 1 UNIT)" 48656091_1 CDM 0250 RC 00338-0553-18 NDC J7040 HCPCS inpatient 1 UN 63.39 41.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.49 97 999999999 38.38 61.49 percent of total billed charges "INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML = 1 UNIT)" 48656091_1 CDM 0250 RC 00338-0553-18 NDC J7040 HCPCS inpatient 1 UN 63.39 41.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.44 78 999999999 38.38 61.49 percent of total billed charges "INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML = 1 UNIT)" 48656091_1 CDM 0250 RC 00338-0553-18 NDC J7040 HCPCS inpatient 1 UN 63.39 41.2 SIHO - ALL PLANS SIHO - ALL PLANS 57.05 90 999999999 38.38 61.49 percent of total billed charges "INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML = 1 UNIT)" 48656091_1 CDM 0250 RC 00338-0553-18 NDC J7040 HCPCS inpatient 1 UN 63.39 41.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.38 60.55 999999999 38.38 61.49 percent of total billed charges "INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML = 1 UNIT)" 48656091_1 CDM 0250 RC 00338-0553-18 NDC J7040 HCPCS inpatient 1 UN 63.39 41.2 UMR - ALL PLANS UMR - ALL PLANS 44.37 70 999999999 38.38 61.49 percent of total billed charges "INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML = 1 UNIT)" 48656091_1 CDM 0250 RC 00338-0553-18 NDC J7040 HCPCS inpatient 1 UN 63.39 41.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.38 61.49 "INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML = 1 UNIT)" 48656091_1 CDM 0250 RC 00338-0553-18 NDC J7040 HCPCS inpatient 1 UN 63.39 41.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.38 61.49 "INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML = 1 UNIT)" 48656091_1 CDM 0250 RC 00338-0553-18 NDC J7040 HCPCS inpatient 1 UN 63.39 41.2 ANTHEM HMO ANTHEM HMO 999999999 38.38 61.49 "INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML = 1 UNIT)" 48656091_1 CDM 0250 RC 00338-0553-18 NDC J7040 HCPCS inpatient 1 UN 63.39 41.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.38 61.49 "INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML = 1 UNIT)" 48656091_1 CDM 0250 RC 00338-0553-18 NDC J7040 HCPCS inpatient 1 UN 63.39 41.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.85 67.6 999999999 38.38 61.49 percent of total billed charges "INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML = 1 UNIT)" 48656091_1 CDM 0250 RC 00338-0553-18 NDC J7040 HCPCS inpatient 1 UN 63.39 41.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.38 61.49 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656133_1 CDM 0258 RC 00409-7100-02 NDC J7060 HCPCS inpatient 1 UN 63.94 41.56 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.56 65 999999999 38.72 62.02 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656133_1 CDM 0258 RC 00409-7100-02 NDC J7060 HCPCS inpatient 1 UN 63.94 41.56 AETNA AETNA 50.51 79 999999999 38.72 62.02 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656133_1 CDM 0258 RC 00409-7100-02 NDC J7060 HCPCS inpatient 1 UN 63.94 41.56 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.12 69 999999999 38.72 62.02 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656133_1 CDM 0258 RC 00409-7100-02 NDC J7060 HCPCS inpatient 1 UN 63.94 41.56 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 62.02 97 999999999 38.72 62.02 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656133_1 CDM 0258 RC 00409-7100-02 NDC J7060 HCPCS inpatient 1 UN 63.94 41.56 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.87 78 999999999 38.72 62.02 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656133_1 CDM 0258 RC 00409-7100-02 NDC J7060 HCPCS inpatient 1 UN 63.94 41.56 SIHO - ALL PLANS SIHO - ALL PLANS 57.55 90 999999999 38.72 62.02 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656133_1 CDM 0258 RC 00409-7100-02 NDC J7060 HCPCS inpatient 1 UN 63.94 41.56 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.72 60.55 999999999 38.72 62.02 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656133_1 CDM 0258 RC 00409-7100-02 NDC J7060 HCPCS inpatient 1 UN 63.94 41.56 UMR - ALL PLANS UMR - ALL PLANS 44.76 70 999999999 38.72 62.02 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656133_1 CDM 0258 RC 00409-7100-02 NDC J7060 HCPCS inpatient 1 UN 63.94 41.56 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.72 62.02 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656133_1 CDM 0258 RC 00409-7100-02 NDC J7060 HCPCS inpatient 1 UN 63.94 41.56 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.72 62.02 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656133_1 CDM 0258 RC 00409-7100-02 NDC J7060 HCPCS inpatient 1 UN 63.94 41.56 ANTHEM HMO ANTHEM HMO 999999999 38.72 62.02 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656133_1 CDM 0258 RC 00409-7100-02 NDC J7060 HCPCS inpatient 1 UN 63.94 41.56 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.72 62.02 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656133_1 CDM 0258 RC 00409-7100-02 NDC J7060 HCPCS inpatient 1 UN 63.94 41.56 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.22 67.6 999999999 38.72 62.02 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656133_1 CDM 0258 RC 00409-7100-02 NDC J7060 HCPCS inpatient 1 UN 63.94 41.56 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.72 62.02 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656134_1 CDM 0250 RC 00409-7100-67 NDC J7060 HCPCS inpatient 1 UN 55.46 36.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 36.05 65 999999999 33.58 53.8 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656134_1 CDM 0250 RC 00409-7100-67 NDC J7060 HCPCS inpatient 1 UN 55.46 36.05 AETNA AETNA 43.81 79 999999999 33.58 53.8 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656134_1 CDM 0250 RC 00409-7100-67 NDC J7060 HCPCS inpatient 1 UN 55.46 36.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 38.27 69 999999999 33.58 53.8 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656134_1 CDM 0250 RC 00409-7100-67 NDC J7060 HCPCS inpatient 1 UN 55.46 36.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 53.8 97 999999999 33.58 53.8 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656134_1 CDM 0250 RC 00409-7100-67 NDC J7060 HCPCS inpatient 1 UN 55.46 36.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 43.26 78 999999999 33.58 53.8 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656134_1 CDM 0250 RC 00409-7100-67 NDC J7060 HCPCS inpatient 1 UN 55.46 36.05 SIHO - ALL PLANS SIHO - ALL PLANS 49.91 90 999999999 33.58 53.8 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656134_1 CDM 0250 RC 00409-7100-67 NDC J7060 HCPCS inpatient 1 UN 55.46 36.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33.58 60.55 999999999 33.58 53.8 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656134_1 CDM 0250 RC 00409-7100-67 NDC J7060 HCPCS inpatient 1 UN 55.46 36.05 UMR - ALL PLANS UMR - ALL PLANS 38.82 70 999999999 33.58 53.8 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656134_1 CDM 0250 RC 00409-7100-67 NDC J7060 HCPCS inpatient 1 UN 55.46 36.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 33.58 53.8 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656134_1 CDM 0250 RC 00409-7100-67 NDC J7060 HCPCS inpatient 1 UN 55.46 36.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 33.58 53.8 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656134_1 CDM 0250 RC 00409-7100-67 NDC J7060 HCPCS inpatient 1 UN 55.46 36.05 ANTHEM HMO ANTHEM HMO 999999999 33.58 53.8 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656134_1 CDM 0250 RC 00409-7100-67 NDC J7060 HCPCS inpatient 1 UN 55.46 36.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 33.58 53.8 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656134_1 CDM 0250 RC 00409-7100-67 NDC J7060 HCPCS inpatient 1 UN 55.46 36.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 37.49 67.6 999999999 33.58 53.8 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 48656134_1 CDM 0250 RC 00409-7100-67 NDC J7060 HCPCS inpatient 1 UN 55.46 36.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 33.58 53.8 Bacterial culture for aerobic isolates 48662951_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.05 65 999999999 58.73 94.09 percent of total billed charges Bacterial culture for aerobic isolates 48662951_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 AETNA AETNA 76.63 79 999999999 58.73 94.09 percent of total billed charges Bacterial culture for aerobic isolates 48662951_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.93 69 999999999 58.73 94.09 percent of total billed charges Bacterial culture for aerobic isolates 48662951_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 94.09 97 999999999 58.73 94.09 percent of total billed charges Bacterial culture for aerobic isolates 48662951_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 75.66 78 999999999 58.73 94.09 percent of total billed charges Bacterial culture for aerobic isolates 48662951_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 SIHO - ALL PLANS SIHO - ALL PLANS 87.3 90 999999999 58.73 94.09 percent of total billed charges Bacterial culture for aerobic isolates 48662951_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.73 60.55 999999999 58.73 94.09 percent of total billed charges Bacterial culture for aerobic isolates 48662951_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 UMR - ALL PLANS UMR - ALL PLANS 67.9 70 999999999 58.73 94.09 percent of total billed charges Bacterial culture for aerobic isolates 48662951_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.73 94.09 Bacterial culture for aerobic isolates 48662951_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.73 94.09 Bacterial culture for aerobic isolates 48662951_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 ANTHEM HMO ANTHEM HMO 999999999 58.73 94.09 Bacterial culture for aerobic isolates 48662951_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.73 94.09 Bacterial culture for aerobic isolates 48662951_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 65.57 67.6 999999999 58.73 94.09 percent of total billed charges Bacterial culture for aerobic isolates 48662951_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.73 94.09 Bacterial culture for anaerobic isolates 48663835_1 CDM 0306 RC 87076 HCPCS inpatient 276 179.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 179.4 65 999999999 167.12 267.72 percent of total billed charges Bacterial culture for anaerobic isolates 48663835_1 CDM 0306 RC 87076 HCPCS inpatient 276 179.4 AETNA AETNA 218.04 79 999999999 167.12 267.72 percent of total billed charges Bacterial culture for anaerobic isolates 48663835_1 CDM 0306 RC 87076 HCPCS inpatient 276 179.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 190.44 69 999999999 167.12 267.72 percent of total billed charges Bacterial culture for anaerobic isolates 48663835_1 CDM 0306 RC 87076 HCPCS inpatient 276 179.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 267.72 97 999999999 167.12 267.72 percent of total billed charges Bacterial culture for anaerobic isolates 48663835_1 CDM 0306 RC 87076 HCPCS inpatient 276 179.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 215.28 78 999999999 167.12 267.72 percent of total billed charges Bacterial culture for anaerobic isolates 48663835_1 CDM 0306 RC 87076 HCPCS inpatient 276 179.4 SIHO - ALL PLANS SIHO - ALL PLANS 248.4 90 999999999 167.12 267.72 percent of total billed charges Bacterial culture for anaerobic isolates 48663835_1 CDM 0306 RC 87076 HCPCS inpatient 276 179.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 167.12 60.55 999999999 167.12 267.72 percent of total billed charges Bacterial culture for anaerobic isolates 48663835_1 CDM 0306 RC 87076 HCPCS inpatient 276 179.4 UMR - ALL PLANS UMR - ALL PLANS 193.2 70 999999999 167.12 267.72 percent of total billed charges Bacterial culture for anaerobic isolates 48663835_1 CDM 0306 RC 87076 HCPCS inpatient 276 179.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 167.12 267.72 Bacterial culture for anaerobic isolates 48663835_1 CDM 0306 RC 87076 HCPCS inpatient 276 179.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 167.12 267.72 Bacterial culture for anaerobic isolates 48663835_1 CDM 0306 RC 87076 HCPCS inpatient 276 179.4 ANTHEM HMO ANTHEM HMO 999999999 167.12 267.72 Bacterial culture for anaerobic isolates 48663835_1 CDM 0306 RC 87076 HCPCS inpatient 276 179.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 167.12 267.72 Bacterial culture for anaerobic isolates 48663835_1 CDM 0306 RC 87076 HCPCS inpatient 276 179.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 186.58 67.6 999999999 167.12 267.72 percent of total billed charges Bacterial culture for anaerobic isolates 48663835_1 CDM 0306 RC 87076 HCPCS inpatient 276 179.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 167.12 267.72 "Bacterial culture, any source, except blood, anaerobic" 48663836_1 CDM 0306 RC 87075 HCPCS inpatient 231 150.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 150.15 65 999999999 139.87 224.07 percent of total billed charges "Bacterial culture, any source, except blood, anaerobic" 48663836_1 CDM 0306 RC 87075 HCPCS inpatient 231 150.15 AETNA AETNA 182.49 79 999999999 139.87 224.07 percent of total billed charges "Bacterial culture, any source, except blood, anaerobic" 48663836_1 CDM 0306 RC 87075 HCPCS inpatient 231 150.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 159.39 69 999999999 139.87 224.07 percent of total billed charges "Bacterial culture, any source, except blood, anaerobic" 48663836_1 CDM 0306 RC 87075 HCPCS inpatient 231 150.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 224.07 97 999999999 139.87 224.07 percent of total billed charges "Bacterial culture, any source, except blood, anaerobic" 48663836_1 CDM 0306 RC 87075 HCPCS inpatient 231 150.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 180.18 78 999999999 139.87 224.07 percent of total billed charges "Bacterial culture, any source, except blood, anaerobic" 48663836_1 CDM 0306 RC 87075 HCPCS inpatient 231 150.15 SIHO - ALL PLANS SIHO - ALL PLANS 207.9 90 999999999 139.87 224.07 percent of total billed charges "Bacterial culture, any source, except blood, anaerobic" 48663836_1 CDM 0306 RC 87075 HCPCS inpatient 231 150.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 139.87 60.55 999999999 139.87 224.07 percent of total billed charges "Bacterial culture, any source, except blood, anaerobic" 48663836_1 CDM 0306 RC 87075 HCPCS inpatient 231 150.15 UMR - ALL PLANS UMR - ALL PLANS 161.7 70 999999999 139.87 224.07 percent of total billed charges "Bacterial culture, any source, except blood, anaerobic" 48663836_1 CDM 0306 RC 87075 HCPCS inpatient 231 150.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 139.87 224.07 "Bacterial culture, any source, except blood, anaerobic" 48663836_1 CDM 0306 RC 87075 HCPCS inpatient 231 150.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 139.87 224.07 "Bacterial culture, any source, except blood, anaerobic" 48663836_1 CDM 0306 RC 87075 HCPCS inpatient 231 150.15 ANTHEM HMO ANTHEM HMO 999999999 139.87 224.07 "Bacterial culture, any source, except blood, anaerobic" 48663836_1 CDM 0306 RC 87075 HCPCS inpatient 231 150.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 139.87 224.07 "Bacterial culture, any source, except blood, anaerobic" 48663836_1 CDM 0306 RC 87075 HCPCS inpatient 231 150.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 156.16 67.6 999999999 139.87 224.07 percent of total billed charges "Bacterial culture, any source, except blood, anaerobic" 48663836_1 CDM 0306 RC 87075 HCPCS inpatient 231 150.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 139.87 224.07 "INJECTION, LEVETIRACETAM, 10 MG" 48665866_1 CDM 0250 RC 00143-9574-10 NDC J1953 HCPCS inpatient 1 UN 32.44 21.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.09 65 999999999 19.64 31.47 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 48665866_1 CDM 0250 RC 00143-9574-10 NDC J1953 HCPCS inpatient 1 UN 32.44 21.09 AETNA AETNA 25.63 79 999999999 19.64 31.47 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 48665866_1 CDM 0250 RC 00143-9574-10 NDC J1953 HCPCS inpatient 1 UN 32.44 21.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.38 69 999999999 19.64 31.47 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 48665866_1 CDM 0250 RC 00143-9574-10 NDC J1953 HCPCS inpatient 1 UN 32.44 21.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31.47 97 999999999 19.64 31.47 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 48665866_1 CDM 0250 RC 00143-9574-10 NDC J1953 HCPCS inpatient 1 UN 32.44 21.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.3 78 999999999 19.64 31.47 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 48665866_1 CDM 0250 RC 00143-9574-10 NDC J1953 HCPCS inpatient 1 UN 32.44 21.09 SIHO - ALL PLANS SIHO - ALL PLANS 29.2 90 999999999 19.64 31.47 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 48665866_1 CDM 0250 RC 00143-9574-10 NDC J1953 HCPCS inpatient 1 UN 32.44 21.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.64 60.55 999999999 19.64 31.47 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 48665866_1 CDM 0250 RC 00143-9574-10 NDC J1953 HCPCS inpatient 1 UN 32.44 21.09 UMR - ALL PLANS UMR - ALL PLANS 22.71 70 999999999 19.64 31.47 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 48665866_1 CDM 0250 RC 00143-9574-10 NDC J1953 HCPCS inpatient 1 UN 32.44 21.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.64 31.47 "INJECTION, LEVETIRACETAM, 10 MG" 48665866_1 CDM 0250 RC 00143-9574-10 NDC J1953 HCPCS inpatient 1 UN 32.44 21.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.64 31.47 "INJECTION, LEVETIRACETAM, 10 MG" 48665866_1 CDM 0250 RC 00143-9574-10 NDC J1953 HCPCS inpatient 1 UN 32.44 21.09 ANTHEM HMO ANTHEM HMO 999999999 19.64 31.47 "INJECTION, LEVETIRACETAM, 10 MG" 48665866_1 CDM 0250 RC 00143-9574-10 NDC J1953 HCPCS inpatient 1 UN 32.44 21.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.64 31.47 "INJECTION, LEVETIRACETAM, 10 MG" 48665866_1 CDM 0250 RC 00143-9574-10 NDC J1953 HCPCS inpatient 1 UN 32.44 21.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.93 67.6 999999999 19.64 31.47 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 48665866_1 CDM 0250 RC 00143-9574-10 NDC J1953 HCPCS inpatient 1 UN 32.44 21.09 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.64 31.47 Bacterial culture for aerobic isolates 48666062_1 CDM 0306 RC 87077 HCPCS inpatient 106 68.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.9 65 999999999 64.18 102.82 percent of total billed charges Bacterial culture for aerobic isolates 48666062_1 CDM 0306 RC 87077 HCPCS inpatient 106 68.9 AETNA AETNA 83.74 79 999999999 64.18 102.82 percent of total billed charges Bacterial culture for aerobic isolates 48666062_1 CDM 0306 RC 87077 HCPCS inpatient 106 68.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.14 69 999999999 64.18 102.82 percent of total billed charges Bacterial culture for aerobic isolates 48666062_1 CDM 0306 RC 87077 HCPCS inpatient 106 68.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 102.82 97 999999999 64.18 102.82 percent of total billed charges Bacterial culture for aerobic isolates 48666062_1 CDM 0306 RC 87077 HCPCS inpatient 106 68.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 82.68 78 999999999 64.18 102.82 percent of total billed charges Bacterial culture for aerobic isolates 48666062_1 CDM 0306 RC 87077 HCPCS inpatient 106 68.9 SIHO - ALL PLANS SIHO - ALL PLANS 95.4 90 999999999 64.18 102.82 percent of total billed charges Bacterial culture for aerobic isolates 48666062_1 CDM 0306 RC 87077 HCPCS inpatient 106 68.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.18 60.55 999999999 64.18 102.82 percent of total billed charges Bacterial culture for aerobic isolates 48666062_1 CDM 0306 RC 87077 HCPCS inpatient 106 68.9 UMR - ALL PLANS UMR - ALL PLANS 74.2 70 999999999 64.18 102.82 percent of total billed charges Bacterial culture for aerobic isolates 48666062_1 CDM 0306 RC 87077 HCPCS inpatient 106 68.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.18 102.82 Bacterial culture for aerobic isolates 48666062_1 CDM 0306 RC 87077 HCPCS inpatient 106 68.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.18 102.82 Bacterial culture for aerobic isolates 48666062_1 CDM 0306 RC 87077 HCPCS inpatient 106 68.9 ANTHEM HMO ANTHEM HMO 999999999 64.18 102.82 Bacterial culture for aerobic isolates 48666062_1 CDM 0306 RC 87077 HCPCS inpatient 106 68.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.18 102.82 Bacterial culture for aerobic isolates 48666062_1 CDM 0306 RC 87077 HCPCS inpatient 106 68.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 71.66 67.6 999999999 64.18 102.82 percent of total billed charges Bacterial culture for aerobic isolates 48666062_1 CDM 0306 RC 87077 HCPCS inpatient 106 68.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.18 102.82 Concentration of specimen for infectious agents 48666066_1 CDM 0306 RC 87015 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Concentration of specimen for infectious agents 48666066_1 CDM 0306 RC 87015 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Concentration of specimen for infectious agents 48666066_1 CDM 0306 RC 87015 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Concentration of specimen for infectious agents 48666066_1 CDM 0306 RC 87015 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Concentration of specimen for infectious agents 48666066_1 CDM 0306 RC 87015 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Concentration of specimen for infectious agents 48666066_1 CDM 0306 RC 87015 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Concentration of specimen for infectious agents 48666066_1 CDM 0306 RC 87015 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Concentration of specimen for infectious agents 48666066_1 CDM 0306 RC 87015 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Concentration of specimen for infectious agents 48666066_1 CDM 0306 RC 87015 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Concentration of specimen for infectious agents 48666066_1 CDM 0306 RC 87015 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Concentration of specimen for infectious agents 48666066_1 CDM 0306 RC 87015 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Concentration of specimen for infectious agents 48666066_1 CDM 0306 RC 87015 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Concentration of specimen for infectious agents 48666066_1 CDM 0306 RC 87015 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Concentration of specimen for infectious agents 48666066_1 CDM 0306 RC 87015 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Stool culture, additional pathogens" 48666067_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.6 65 999999999 38.75 62.08 percent of total billed charges "Stool culture, additional pathogens" 48666067_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 AETNA AETNA 50.56 79 999999999 38.75 62.08 percent of total billed charges "Stool culture, additional pathogens" 48666067_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.16 69 999999999 38.75 62.08 percent of total billed charges "Stool culture, additional pathogens" 48666067_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 62.08 97 999999999 38.75 62.08 percent of total billed charges "Stool culture, additional pathogens" 48666067_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.92 78 999999999 38.75 62.08 percent of total billed charges "Stool culture, additional pathogens" 48666067_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 SIHO - ALL PLANS SIHO - ALL PLANS 57.6 90 999999999 38.75 62.08 percent of total billed charges "Stool culture, additional pathogens" 48666067_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.75 60.55 999999999 38.75 62.08 percent of total billed charges "Stool culture, additional pathogens" 48666067_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 UMR - ALL PLANS UMR - ALL PLANS 44.8 70 999999999 38.75 62.08 percent of total billed charges "Stool culture, additional pathogens" 48666067_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.75 62.08 "Stool culture, additional pathogens" 48666067_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.75 62.08 "Stool culture, additional pathogens" 48666067_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 ANTHEM HMO ANTHEM HMO 999999999 38.75 62.08 "Stool culture, additional pathogens" 48666067_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.75 62.08 "Stool culture, additional pathogens" 48666067_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.26 67.6 999999999 38.75 62.08 percent of total billed charges "Stool culture, additional pathogens" 48666067_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.75 62.08 "Stool culture, additional pathogens" 48666068_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.6 65 999999999 38.75 62.08 percent of total billed charges "Stool culture, additional pathogens" 48666068_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 AETNA AETNA 50.56 79 999999999 38.75 62.08 percent of total billed charges "Stool culture, additional pathogens" 48666068_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.16 69 999999999 38.75 62.08 percent of total billed charges "Stool culture, additional pathogens" 48666068_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 62.08 97 999999999 38.75 62.08 percent of total billed charges "Stool culture, additional pathogens" 48666068_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.92 78 999999999 38.75 62.08 percent of total billed charges "Stool culture, additional pathogens" 48666068_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 SIHO - ALL PLANS SIHO - ALL PLANS 57.6 90 999999999 38.75 62.08 percent of total billed charges "Stool culture, additional pathogens" 48666068_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.75 60.55 999999999 38.75 62.08 percent of total billed charges "Stool culture, additional pathogens" 48666068_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 UMR - ALL PLANS UMR - ALL PLANS 44.8 70 999999999 38.75 62.08 percent of total billed charges "Stool culture, additional pathogens" 48666068_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.75 62.08 "Stool culture, additional pathogens" 48666068_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.75 62.08 "Stool culture, additional pathogens" 48666068_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 ANTHEM HMO ANTHEM HMO 999999999 38.75 62.08 "Stool culture, additional pathogens" 48666068_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.75 62.08 "Stool culture, additional pathogens" 48666068_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.26 67.6 999999999 38.75 62.08 percent of total billed charges "Stool culture, additional pathogens" 48666068_1 CDM 0306 RC 87046 HCPCS inpatient 64 41.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.75 62.08 68094-0171-62 - sucralfate 1 g/10 mL Oral Susp [JOHN] 48667853_1 CDM 0250 RC 68094-0171-62 NDC inpatient 1 UN 40.5 26.33 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.33 65 999999999 24.52 39.29 percent of total billed charges 68094-0171-62 - sucralfate 1 g/10 mL Oral Susp [JOHN] 48667853_1 CDM 0250 RC 68094-0171-62 NDC inpatient 1 UN 40.5 26.33 AETNA AETNA 32 79 999999999 24.52 39.29 percent of total billed charges 68094-0171-62 - sucralfate 1 g/10 mL Oral Susp [JOHN] 48667853_1 CDM 0250 RC 68094-0171-62 NDC inpatient 1 UN 40.5 26.33 ENCORE - ALL PLANS ENCORE - ALL PLANS 27.95 69 999999999 24.52 39.29 percent of total billed charges 68094-0171-62 - sucralfate 1 g/10 mL Oral Susp [JOHN] 48667853_1 CDM 0250 RC 68094-0171-62 NDC inpatient 1 UN 40.5 26.33 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39.29 97 999999999 24.52 39.29 percent of total billed charges 68094-0171-62 - sucralfate 1 g/10 mL Oral Susp [JOHN] 48667853_1 CDM 0250 RC 68094-0171-62 NDC inpatient 1 UN 40.5 26.33 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.59 78 999999999 24.52 39.29 percent of total billed charges 68094-0171-62 - sucralfate 1 g/10 mL Oral Susp [JOHN] 48667853_1 CDM 0250 RC 68094-0171-62 NDC inpatient 1 UN 40.5 26.33 SIHO - ALL PLANS SIHO - ALL PLANS 36.45 90 999999999 24.52 39.29 percent of total billed charges 68094-0171-62 - sucralfate 1 g/10 mL Oral Susp [JOHN] 48667853_1 CDM 0250 RC 68094-0171-62 NDC inpatient 1 UN 40.5 26.33 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.52 60.55 999999999 24.52 39.29 percent of total billed charges 68094-0171-62 - sucralfate 1 g/10 mL Oral Susp [JOHN] 48667853_1 CDM 0250 RC 68094-0171-62 NDC inpatient 1 UN 40.5 26.33 UMR - ALL PLANS UMR - ALL PLANS 28.35 70 999999999 24.52 39.29 percent of total billed charges 68094-0171-62 - sucralfate 1 g/10 mL Oral Susp [JOHN] 48667853_1 CDM 0250 RC 68094-0171-62 NDC inpatient 1 UN 40.5 26.33 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.52 39.29 68094-0171-62 - sucralfate 1 g/10 mL Oral Susp [JOHN] 48667853_1 CDM 0250 RC 68094-0171-62 NDC inpatient 1 UN 40.5 26.33 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.52 39.29 68094-0171-62 - sucralfate 1 g/10 mL Oral Susp [JOHN] 48667853_1 CDM 0250 RC 68094-0171-62 NDC inpatient 1 UN 40.5 26.33 ANTHEM HMO ANTHEM HMO 999999999 24.52 39.29 68094-0171-62 - sucralfate 1 g/10 mL Oral Susp [JOHN] 48667853_1 CDM 0250 RC 68094-0171-62 NDC inpatient 1 UN 40.5 26.33 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.52 39.29 68094-0171-62 - sucralfate 1 g/10 mL Oral Susp [JOHN] 48667853_1 CDM 0250 RC 68094-0171-62 NDC inpatient 1 UN 40.5 26.33 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.38 67.6 999999999 24.52 39.29 percent of total billed charges 68094-0171-62 - sucralfate 1 g/10 mL Oral Susp [JOHN] 48667853_1 CDM 0250 RC 68094-0171-62 NDC inpatient 1 UN 40.5 26.33 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.52 39.29 "Blood glucose (sugar) tolerance test, 3 specimens" 48667887_1 CDM 0301 RC 82951 HCPCS inpatient 154 100.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.1 65 999999999 93.25 149.38 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48667887_1 CDM 0301 RC 82951 HCPCS inpatient 154 100.1 AETNA AETNA 121.66 79 999999999 93.25 149.38 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48667887_1 CDM 0301 RC 82951 HCPCS inpatient 154 100.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.26 69 999999999 93.25 149.38 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48667887_1 CDM 0301 RC 82951 HCPCS inpatient 154 100.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 149.38 97 999999999 93.25 149.38 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48667887_1 CDM 0301 RC 82951 HCPCS inpatient 154 100.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.12 78 999999999 93.25 149.38 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48667887_1 CDM 0301 RC 82951 HCPCS inpatient 154 100.1 SIHO - ALL PLANS SIHO - ALL PLANS 138.6 90 999999999 93.25 149.38 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48667887_1 CDM 0301 RC 82951 HCPCS inpatient 154 100.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.25 60.55 999999999 93.25 149.38 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48667887_1 CDM 0301 RC 82951 HCPCS inpatient 154 100.1 UMR - ALL PLANS UMR - ALL PLANS 107.8 70 999999999 93.25 149.38 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48667887_1 CDM 0301 RC 82951 HCPCS inpatient 154 100.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.25 149.38 "Blood glucose (sugar) tolerance test, 3 specimens" 48667887_1 CDM 0301 RC 82951 HCPCS inpatient 154 100.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.25 149.38 "Blood glucose (sugar) tolerance test, 3 specimens" 48667887_1 CDM 0301 RC 82951 HCPCS inpatient 154 100.1 ANTHEM HMO ANTHEM HMO 999999999 93.25 149.38 "Blood glucose (sugar) tolerance test, 3 specimens" 48667887_1 CDM 0301 RC 82951 HCPCS inpatient 154 100.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.25 149.38 "Blood glucose (sugar) tolerance test, 3 specimens" 48667887_1 CDM 0301 RC 82951 HCPCS inpatient 154 100.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.1 67.6 999999999 93.25 149.38 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 48667887_1 CDM 0301 RC 82951 HCPCS inpatient 154 100.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.25 149.38 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667888_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.25 65 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667888_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 AETNA AETNA 114.55 79 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667888_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.05 69 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667888_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 140.65 97 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667888_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.1 78 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667888_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 SIHO - ALL PLANS SIHO - ALL PLANS 130.5 90 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667888_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.8 60.55 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667888_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 UMR - ALL PLANS UMR - ALL PLANS 101.5 70 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667888_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.8 140.65 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667888_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.8 140.65 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667888_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 ANTHEM HMO ANTHEM HMO 999999999 87.8 140.65 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667888_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.8 140.65 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667888_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.02 67.6 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667888_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.8 140.65 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667889_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.25 65 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667889_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 AETNA AETNA 114.55 79 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667889_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.05 69 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667889_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 140.65 97 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667889_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.1 78 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667889_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 SIHO - ALL PLANS SIHO - ALL PLANS 130.5 90 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667889_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.8 60.55 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667889_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 UMR - ALL PLANS UMR - ALL PLANS 101.5 70 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667889_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.8 140.65 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667889_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.8 140.65 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667889_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 ANTHEM HMO ANTHEM HMO 999999999 87.8 140.65 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667889_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.8 140.65 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667889_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.02 67.6 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667889_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.8 140.65 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667890_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.25 65 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667890_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 AETNA AETNA 114.55 79 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667890_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.05 69 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667890_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 140.65 97 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667890_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.1 78 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667890_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 SIHO - ALL PLANS SIHO - ALL PLANS 130.5 90 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667890_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.8 60.55 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667890_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 UMR - ALL PLANS UMR - ALL PLANS 101.5 70 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667890_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.8 140.65 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667890_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.8 140.65 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667890_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 ANTHEM HMO ANTHEM HMO 999999999 87.8 140.65 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667890_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.8 140.65 "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667890_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.02 67.6 999999999 87.8 140.65 percent of total billed charges "Blood glucose (sugar) tolerance test, each additional beyond 3 specimens" 48667890_1 CDM 0301 RC 82952 HCPCS inpatient 145 94.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.8 140.65 Creatinine level to test for kidney function or muscle injury 48667891_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 48667891_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 48667891_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 48667891_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 48667891_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 48667891_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 48667891_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 48667891_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 48667891_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 Creatinine level to test for kidney function or muscle injury 48667891_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 Creatinine level to test for kidney function or muscle injury 48667891_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 Creatinine level to test for kidney function or muscle injury 48667891_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 Creatinine level to test for kidney function or muscle injury 48667891_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 48667891_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 "Total protein level, urine" 48667893_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 48667893_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 48667893_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 48667893_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 48667893_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 48667893_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 48667893_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 48667893_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 48667893_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 "Total protein level, urine" 48667893_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 "Total protein level, urine" 48667893_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 "Total protein level, urine" 48667893_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 "Total protein level, urine" 48667893_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 48667893_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 Urine volume measurement 48667894_1 CDM 0301 RC 81050 HCPCS inpatient 51 33.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 33.15 65 999999999 30.88 49.47 percent of total billed charges Urine volume measurement 48667894_1 CDM 0301 RC 81050 HCPCS inpatient 51 33.15 AETNA AETNA 40.29 79 999999999 30.88 49.47 percent of total billed charges Urine volume measurement 48667894_1 CDM 0301 RC 81050 HCPCS inpatient 51 33.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 35.19 69 999999999 30.88 49.47 percent of total billed charges Urine volume measurement 48667894_1 CDM 0301 RC 81050 HCPCS inpatient 51 33.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 49.47 97 999999999 30.88 49.47 percent of total billed charges Urine volume measurement 48667894_1 CDM 0301 RC 81050 HCPCS inpatient 51 33.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 39.78 78 999999999 30.88 49.47 percent of total billed charges Urine volume measurement 48667894_1 CDM 0301 RC 81050 HCPCS inpatient 51 33.15 SIHO - ALL PLANS SIHO - ALL PLANS 45.9 90 999999999 30.88 49.47 percent of total billed charges Urine volume measurement 48667894_1 CDM 0301 RC 81050 HCPCS inpatient 51 33.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.88 60.55 999999999 30.88 49.47 percent of total billed charges Urine volume measurement 48667894_1 CDM 0301 RC 81050 HCPCS inpatient 51 33.15 UMR - ALL PLANS UMR - ALL PLANS 35.7 70 999999999 30.88 49.47 percent of total billed charges Urine volume measurement 48667894_1 CDM 0301 RC 81050 HCPCS inpatient 51 33.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.88 49.47 Urine volume measurement 48667894_1 CDM 0301 RC 81050 HCPCS inpatient 51 33.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.88 49.47 Urine volume measurement 48667894_1 CDM 0301 RC 81050 HCPCS inpatient 51 33.15 ANTHEM HMO ANTHEM HMO 999999999 30.88 49.47 Urine volume measurement 48667894_1 CDM 0301 RC 81050 HCPCS inpatient 51 33.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.88 49.47 Urine volume measurement 48667894_1 CDM 0301 RC 81050 HCPCS inpatient 51 33.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 34.48 67.6 999999999 30.88 49.47 percent of total billed charges Urine volume measurement 48667894_1 CDM 0301 RC 81050 HCPCS inpatient 51 33.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.88 49.47 Urine chloride level 48667895_1 CDM 0301 RC 82436 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges Urine chloride level 48667895_1 CDM 0301 RC 82436 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges Urine chloride level 48667895_1 CDM 0301 RC 82436 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges Urine chloride level 48667895_1 CDM 0301 RC 82436 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges Urine chloride level 48667895_1 CDM 0301 RC 82436 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges Urine chloride level 48667895_1 CDM 0301 RC 82436 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges Urine chloride level 48667895_1 CDM 0301 RC 82436 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges Urine chloride level 48667895_1 CDM 0301 RC 82436 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges Urine chloride level 48667895_1 CDM 0301 RC 82436 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 Urine chloride level 48667895_1 CDM 0301 RC 82436 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 Urine chloride level 48667895_1 CDM 0301 RC 82436 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 Urine chloride level 48667895_1 CDM 0301 RC 82436 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 Urine chloride level 48667895_1 CDM 0301 RC 82436 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges Urine chloride level 48667895_1 CDM 0301 RC 82436 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 Blood glucose (sugar) level 48667896_1 CDM 0301 RC 82947 HCPCS inpatient 98 63.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.7 65 999999999 59.34 95.06 percent of total billed charges Blood glucose (sugar) level 48667896_1 CDM 0301 RC 82947 HCPCS inpatient 98 63.7 AETNA AETNA 77.42 79 999999999 59.34 95.06 percent of total billed charges Blood glucose (sugar) level 48667896_1 CDM 0301 RC 82947 HCPCS inpatient 98 63.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.62 69 999999999 59.34 95.06 percent of total billed charges Blood glucose (sugar) level 48667896_1 CDM 0301 RC 82947 HCPCS inpatient 98 63.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.06 97 999999999 59.34 95.06 percent of total billed charges Blood glucose (sugar) level 48667896_1 CDM 0301 RC 82947 HCPCS inpatient 98 63.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.44 78 999999999 59.34 95.06 percent of total billed charges Blood glucose (sugar) level 48667896_1 CDM 0301 RC 82947 HCPCS inpatient 98 63.7 SIHO - ALL PLANS SIHO - ALL PLANS 88.2 90 999999999 59.34 95.06 percent of total billed charges Blood glucose (sugar) level 48667896_1 CDM 0301 RC 82947 HCPCS inpatient 98 63.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.34 60.55 999999999 59.34 95.06 percent of total billed charges Blood glucose (sugar) level 48667896_1 CDM 0301 RC 82947 HCPCS inpatient 98 63.7 UMR - ALL PLANS UMR - ALL PLANS 68.6 70 999999999 59.34 95.06 percent of total billed charges Blood glucose (sugar) level 48667896_1 CDM 0301 RC 82947 HCPCS inpatient 98 63.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.34 95.06 Blood glucose (sugar) level 48667896_1 CDM 0301 RC 82947 HCPCS inpatient 98 63.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.34 95.06 Blood glucose (sugar) level 48667896_1 CDM 0301 RC 82947 HCPCS inpatient 98 63.7 ANTHEM HMO ANTHEM HMO 999999999 59.34 95.06 Blood glucose (sugar) level 48667896_1 CDM 0301 RC 82947 HCPCS inpatient 98 63.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.34 95.06 Blood glucose (sugar) level 48667896_1 CDM 0301 RC 82947 HCPCS inpatient 98 63.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.25 67.6 999999999 59.34 95.06 percent of total billed charges Blood glucose (sugar) level 48667896_1 CDM 0301 RC 82947 HCPCS inpatient 98 63.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.34 95.06 Magnesium level 48667897_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges Magnesium level 48667897_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges Magnesium level 48667897_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges Magnesium level 48667897_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges Magnesium level 48667897_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges Magnesium level 48667897_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges Magnesium level 48667897_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges Magnesium level 48667897_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges Magnesium level 48667897_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 Magnesium level 48667897_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 Magnesium level 48667897_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 Magnesium level 48667897_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 Magnesium level 48667897_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges Magnesium level 48667897_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 Urine phosphate level 48667898_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.4 65 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 48667898_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 AETNA AETNA 123.24 79 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 48667898_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.64 69 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 48667898_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 151.32 97 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 48667898_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.68 78 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 48667898_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 SIHO - ALL PLANS SIHO - ALL PLANS 140.4 90 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 48667898_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.46 60.55 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 48667898_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 UMR - ALL PLANS UMR - ALL PLANS 109.2 70 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 48667898_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.46 151.32 Urine phosphate level 48667898_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.46 151.32 Urine phosphate level 48667898_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 ANTHEM HMO ANTHEM HMO 999999999 94.46 151.32 Urine phosphate level 48667898_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.46 151.32 Urine phosphate level 48667898_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.46 67.6 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 48667898_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.46 151.32 Urine potassium level 48667899_1 CDM 0301 RC 84133 HCPCS inpatient 138 89.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.7 65 999999999 83.56 133.86 percent of total billed charges Urine potassium level 48667899_1 CDM 0301 RC 84133 HCPCS inpatient 138 89.7 AETNA AETNA 109.02 79 999999999 83.56 133.86 percent of total billed charges Urine potassium level 48667899_1 CDM 0301 RC 84133 HCPCS inpatient 138 89.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.22 69 999999999 83.56 133.86 percent of total billed charges Urine potassium level 48667899_1 CDM 0301 RC 84133 HCPCS inpatient 138 89.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 133.86 97 999999999 83.56 133.86 percent of total billed charges Urine potassium level 48667899_1 CDM 0301 RC 84133 HCPCS inpatient 138 89.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 107.64 78 999999999 83.56 133.86 percent of total billed charges Urine potassium level 48667899_1 CDM 0301 RC 84133 HCPCS inpatient 138 89.7 SIHO - ALL PLANS SIHO - ALL PLANS 124.2 90 999999999 83.56 133.86 percent of total billed charges Urine potassium level 48667899_1 CDM 0301 RC 84133 HCPCS inpatient 138 89.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 83.56 60.55 999999999 83.56 133.86 percent of total billed charges Urine potassium level 48667899_1 CDM 0301 RC 84133 HCPCS inpatient 138 89.7 UMR - ALL PLANS UMR - ALL PLANS 96.6 70 999999999 83.56 133.86 percent of total billed charges Urine potassium level 48667899_1 CDM 0301 RC 84133 HCPCS inpatient 138 89.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 83.56 133.86 Urine potassium level 48667899_1 CDM 0301 RC 84133 HCPCS inpatient 138 89.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 83.56 133.86 Urine potassium level 48667899_1 CDM 0301 RC 84133 HCPCS inpatient 138 89.7 ANTHEM HMO ANTHEM HMO 999999999 83.56 133.86 Urine potassium level 48667899_1 CDM 0301 RC 84133 HCPCS inpatient 138 89.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 83.56 133.86 Urine potassium level 48667899_1 CDM 0301 RC 84133 HCPCS inpatient 138 89.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.29 67.6 999999999 83.56 133.86 percent of total billed charges Urine potassium level 48667899_1 CDM 0301 RC 84133 HCPCS inpatient 138 89.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 83.56 133.86 "Total protein level, urine" 48667900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 48667900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 48667900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 48667900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 48667900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 48667900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 48667900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 48667900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 48667900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 "Total protein level, urine" 48667900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 "Total protein level, urine" 48667900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 "Total protein level, urine" 48667900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 "Total protein level, urine" 48667900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 48667900_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 Urine sodium level 48667901_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges Urine sodium level 48667901_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges Urine sodium level 48667901_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges Urine sodium level 48667901_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges Urine sodium level 48667901_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges Urine sodium level 48667901_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges Urine sodium level 48667901_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges Urine sodium level 48667901_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges Urine sodium level 48667901_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 Urine sodium level 48667901_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 Urine sodium level 48667901_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 Urine sodium level 48667901_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 Urine sodium level 48667901_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges Urine sodium level 48667901_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 "Urea nitrogen level to assess kidney function, urine" 48667902_1 CDM 0301 RC 84540 HCPCS inpatient 130 84.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 84.5 65 999999999 78.72 126.1 percent of total billed charges "Urea nitrogen level to assess kidney function, urine" 48667902_1 CDM 0301 RC 84540 HCPCS inpatient 130 84.5 AETNA AETNA 102.7 79 999999999 78.72 126.1 percent of total billed charges "Urea nitrogen level to assess kidney function, urine" 48667902_1 CDM 0301 RC 84540 HCPCS inpatient 130 84.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.7 69 999999999 78.72 126.1 percent of total billed charges "Urea nitrogen level to assess kidney function, urine" 48667902_1 CDM 0301 RC 84540 HCPCS inpatient 130 84.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 126.1 97 999999999 78.72 126.1 percent of total billed charges "Urea nitrogen level to assess kidney function, urine" 48667902_1 CDM 0301 RC 84540 HCPCS inpatient 130 84.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 101.4 78 999999999 78.72 126.1 percent of total billed charges "Urea nitrogen level to assess kidney function, urine" 48667902_1 CDM 0301 RC 84540 HCPCS inpatient 130 84.5 SIHO - ALL PLANS SIHO - ALL PLANS 117 90 999999999 78.72 126.1 percent of total billed charges "Urea nitrogen level to assess kidney function, urine" 48667902_1 CDM 0301 RC 84540 HCPCS inpatient 130 84.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.72 60.55 999999999 78.72 126.1 percent of total billed charges "Urea nitrogen level to assess kidney function, urine" 48667902_1 CDM 0301 RC 84540 HCPCS inpatient 130 84.5 UMR - ALL PLANS UMR - ALL PLANS 91 70 999999999 78.72 126.1 percent of total billed charges "Urea nitrogen level to assess kidney function, urine" 48667902_1 CDM 0301 RC 84540 HCPCS inpatient 130 84.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.72 126.1 "Urea nitrogen level to assess kidney function, urine" 48667902_1 CDM 0301 RC 84540 HCPCS inpatient 130 84.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.72 126.1 "Urea nitrogen level to assess kidney function, urine" 48667902_1 CDM 0301 RC 84540 HCPCS inpatient 130 84.5 ANTHEM HMO ANTHEM HMO 999999999 78.72 126.1 "Urea nitrogen level to assess kidney function, urine" 48667902_1 CDM 0301 RC 84540 HCPCS inpatient 130 84.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.72 126.1 "Urea nitrogen level to assess kidney function, urine" 48667902_1 CDM 0301 RC 84540 HCPCS inpatient 130 84.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.88 67.6 999999999 78.72 126.1 percent of total billed charges "Urea nitrogen level to assess kidney function, urine" 48667902_1 CDM 0301 RC 84540 HCPCS inpatient 130 84.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.72 126.1 Uric acid level 48667903_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges Uric acid level 48667903_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges Uric acid level 48667903_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges Uric acid level 48667903_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges Uric acid level 48667903_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges Uric acid level 48667903_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges Uric acid level 48667903_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges Uric acid level 48667903_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges Uric acid level 48667903_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 Uric acid level 48667903_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 Uric acid level 48667903_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 Uric acid level 48667903_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 Uric acid level 48667903_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges Uric acid level 48667903_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Urine calcium level 48667904_1 CDM 0301 RC 82340 HCPCS inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges Urine calcium level 48667904_1 CDM 0301 RC 82340 HCPCS inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges Urine calcium level 48667904_1 CDM 0301 RC 82340 HCPCS inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges Urine calcium level 48667904_1 CDM 0301 RC 82340 HCPCS inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges Urine calcium level 48667904_1 CDM 0301 RC 82340 HCPCS inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges Urine calcium level 48667904_1 CDM 0301 RC 82340 HCPCS inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges Urine calcium level 48667904_1 CDM 0301 RC 82340 HCPCS inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges Urine calcium level 48667904_1 CDM 0301 RC 82340 HCPCS inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges Urine calcium level 48667904_1 CDM 0301 RC 82340 HCPCS inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 Urine calcium level 48667904_1 CDM 0301 RC 82340 HCPCS inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 Urine calcium level 48667904_1 CDM 0301 RC 82340 HCPCS inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 Urine calcium level 48667904_1 CDM 0301 RC 82340 HCPCS inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 Urine calcium level 48667904_1 CDM 0301 RC 82340 HCPCS inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges Urine calcium level 48667904_1 CDM 0301 RC 82340 HCPCS inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667905_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 SELF PAY DISCOUNT SELF PAY DISCOUNT 143 65 999999999 133.21 213.4 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667905_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 AETNA AETNA 173.8 79 999999999 133.21 213.4 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667905_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.8 69 999999999 133.21 213.4 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667905_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 213.4 97 999999999 133.21 213.4 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667905_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 HUMANA - ALL PLANS HUMANA - ALL PLANS 171.6 78 999999999 133.21 213.4 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667905_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 SIHO - ALL PLANS SIHO - ALL PLANS 198 90 999999999 133.21 213.4 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667905_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 133.21 60.55 999999999 133.21 213.4 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667905_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 UMR - ALL PLANS UMR - ALL PLANS 154 70 999999999 133.21 213.4 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667905_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 133.21 213.4 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667905_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 133.21 213.4 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667905_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 ANTHEM HMO ANTHEM HMO 999999999 133.21 213.4 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667905_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 133.21 213.4 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667905_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.72 67.6 999999999 133.21 213.4 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667905_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 UHC - ALL PLANS UHC - ALL PLANS 999999999 133.21 213.4 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667906_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 SELF PAY DISCOUNT SELF PAY DISCOUNT 143 65 999999999 133.21 213.4 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667906_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 AETNA AETNA 173.8 79 999999999 133.21 213.4 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667906_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.8 69 999999999 133.21 213.4 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667906_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 213.4 97 999999999 133.21 213.4 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667906_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 HUMANA - ALL PLANS HUMANA - ALL PLANS 171.6 78 999999999 133.21 213.4 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667906_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 SIHO - ALL PLANS SIHO - ALL PLANS 198 90 999999999 133.21 213.4 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667906_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 133.21 60.55 999999999 133.21 213.4 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667906_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 UMR - ALL PLANS UMR - ALL PLANS 154 70 999999999 133.21 213.4 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667906_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 133.21 213.4 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667906_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 133.21 213.4 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667906_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 ANTHEM HMO ANTHEM HMO 999999999 133.21 213.4 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667906_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 133.21 213.4 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667906_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.72 67.6 999999999 133.21 213.4 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 48667906_1 CDM 0306 RC 87493 HCPCS inpatient 220 143 UHC - ALL PLANS UHC - ALL PLANS 999999999 133.21 213.4 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48667907_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48667907_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48667907_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48667907_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48667907_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48667907_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48667907_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48667907_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48667907_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48667907_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48667907_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48667907_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48667907_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48667907_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48667908_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48667908_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48667908_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48667908_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48667908_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48667908_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48667908_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48667908_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48667908_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48667908_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48667908_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48667908_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48667908_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48667908_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 Tramadol level 48667990_1 CDM 0301 RC 80373 HCPCS inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges Tramadol level 48667990_1 CDM 0301 RC 80373 HCPCS inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges Tramadol level 48667990_1 CDM 0301 RC 80373 HCPCS inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges Tramadol level 48667990_1 CDM 0301 RC 80373 HCPCS inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges Tramadol level 48667990_1 CDM 0301 RC 80373 HCPCS inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges Tramadol level 48667990_1 CDM 0301 RC 80373 HCPCS inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges Tramadol level 48667990_1 CDM 0301 RC 80373 HCPCS inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges Tramadol level 48667990_1 CDM 0301 RC 80373 HCPCS inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges Tramadol level 48667990_1 CDM 0301 RC 80373 HCPCS inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 Tramadol level 48667990_1 CDM 0301 RC 80373 HCPCS inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 Tramadol level 48667990_1 CDM 0301 RC 80373 HCPCS inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 Tramadol level 48667990_1 CDM 0301 RC 80373 HCPCS inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 Tramadol level 48667990_1 CDM 0301 RC 80373 HCPCS inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges Tramadol level 48667990_1 CDM 0301 RC 80373 HCPCS inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 Test to measure expiratory airflow and volume 48676030_1 CDM 0410 RC 94010 HCPCS inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges Test to measure expiratory airflow and volume 48676030_1 CDM 0410 RC 94010 HCPCS inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges Test to measure expiratory airflow and volume 48676030_1 CDM 0410 RC 94010 HCPCS inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges Test to measure expiratory airflow and volume 48676030_1 CDM 0410 RC 94010 HCPCS inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges Test to measure expiratory airflow and volume 48676030_1 CDM 0410 RC 94010 HCPCS inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges Test to measure expiratory airflow and volume 48676030_1 CDM 0410 RC 94010 HCPCS inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges Test to measure expiratory airflow and volume 48676030_1 CDM 0410 RC 94010 HCPCS inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges Test to measure expiratory airflow and volume 48676030_1 CDM 0410 RC 94010 HCPCS inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges Test to measure expiratory airflow and volume 48676030_1 CDM 0410 RC 94010 HCPCS inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 Test to measure expiratory airflow and volume 48676030_1 CDM 0410 RC 94010 HCPCS inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 Test to measure expiratory airflow and volume 48676030_1 CDM 0410 RC 94010 HCPCS inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 Test to measure expiratory airflow and volume 48676030_1 CDM 0410 RC 94010 HCPCS inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 Test to measure expiratory airflow and volume 48676030_1 CDM 0410 RC 94010 HCPCS inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges Test to measure expiratory airflow and volume 48676030_1 CDM 0410 RC 94010 HCPCS inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 Test to measure expiratory airflow and volume changes before and after medication administration 48676031_1 CDM 0410 RC 94060 HCPCS inpatient 1202 781.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 781.3 65 999999999 727.81 1165.94 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 48676031_1 CDM 0410 RC 94060 HCPCS inpatient 1202 781.3 AETNA AETNA 949.58 79 999999999 727.81 1165.94 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 48676031_1 CDM 0410 RC 94060 HCPCS inpatient 1202 781.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 829.38 69 999999999 727.81 1165.94 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 48676031_1 CDM 0410 RC 94060 HCPCS inpatient 1202 781.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1165.94 97 999999999 727.81 1165.94 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 48676031_1 CDM 0410 RC 94060 HCPCS inpatient 1202 781.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 937.56 78 999999999 727.81 1165.94 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 48676031_1 CDM 0410 RC 94060 HCPCS inpatient 1202 781.3 SIHO - ALL PLANS SIHO - ALL PLANS 1081.8 90 999999999 727.81 1165.94 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 48676031_1 CDM 0410 RC 94060 HCPCS inpatient 1202 781.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 727.81 60.55 999999999 727.81 1165.94 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 48676031_1 CDM 0410 RC 94060 HCPCS inpatient 1202 781.3 UMR - ALL PLANS UMR - ALL PLANS 841.4 70 999999999 727.81 1165.94 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 48676031_1 CDM 0410 RC 94060 HCPCS inpatient 1202 781.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 727.81 1165.94 Test to measure expiratory airflow and volume changes before and after medication administration 48676031_1 CDM 0410 RC 94060 HCPCS inpatient 1202 781.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 727.81 1165.94 Test to measure expiratory airflow and volume changes before and after medication administration 48676031_1 CDM 0410 RC 94060 HCPCS inpatient 1202 781.3 ANTHEM HMO ANTHEM HMO 999999999 727.81 1165.94 Test to measure expiratory airflow and volume changes before and after medication administration 48676031_1 CDM 0410 RC 94060 HCPCS inpatient 1202 781.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 727.81 1165.94 Test to measure expiratory airflow and volume changes before and after medication administration 48676031_1 CDM 0410 RC 94060 HCPCS inpatient 1202 781.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 812.55 67.6 999999999 727.81 1165.94 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 48676031_1 CDM 0410 RC 94060 HCPCS inpatient 1202 781.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 727.81 1165.94 Test to measure expiratory airflow and volume changes before and after medication administration 48676035_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 286.65 65 999999999 267.03 427.77 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 48676035_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 AETNA AETNA 348.39 79 999999999 267.03 427.77 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 48676035_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 304.29 69 999999999 267.03 427.77 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 48676035_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 427.77 97 999999999 267.03 427.77 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 48676035_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 343.98 78 999999999 267.03 427.77 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 48676035_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 SIHO - ALL PLANS SIHO - ALL PLANS 396.9 90 999999999 267.03 427.77 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 48676035_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 267.03 60.55 999999999 267.03 427.77 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 48676035_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 UMR - ALL PLANS UMR - ALL PLANS 308.7 70 999999999 267.03 427.77 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 48676035_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 267.03 427.77 Test to measure expiratory airflow and volume changes before and after medication administration 48676035_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 267.03 427.77 Test to measure expiratory airflow and volume changes before and after medication administration 48676035_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 ANTHEM HMO ANTHEM HMO 999999999 267.03 427.77 Test to measure expiratory airflow and volume changes before and after medication administration 48676035_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 267.03 427.77 Test to measure expiratory airflow and volume changes before and after medication administration 48676035_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 298.12 67.6 999999999 267.03 427.77 percent of total billed charges Test to measure expiratory airflow and volume changes before and after medication administration 48676035_1 CDM 0410 RC 94060 HCPCS inpatient 441 286.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 267.03 427.77 Test for allergy using drugs 48676038_1 CDM 0410 RC 95070 HCPCS inpatient 953 619.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 619.45 65 999999999 577.04 924.41 percent of total billed charges Test for allergy using drugs 48676038_1 CDM 0410 RC 95070 HCPCS inpatient 953 619.45 AETNA AETNA 752.87 79 999999999 577.04 924.41 percent of total billed charges Test for allergy using drugs 48676038_1 CDM 0410 RC 95070 HCPCS inpatient 953 619.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 657.57 69 999999999 577.04 924.41 percent of total billed charges Test for allergy using drugs 48676038_1 CDM 0410 RC 95070 HCPCS inpatient 953 619.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 924.41 97 999999999 577.04 924.41 percent of total billed charges Test for allergy using drugs 48676038_1 CDM 0410 RC 95070 HCPCS inpatient 953 619.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 743.34 78 999999999 577.04 924.41 percent of total billed charges Test for allergy using drugs 48676038_1 CDM 0410 RC 95070 HCPCS inpatient 953 619.45 SIHO - ALL PLANS SIHO - ALL PLANS 857.7 90 999999999 577.04 924.41 percent of total billed charges Test for allergy using drugs 48676038_1 CDM 0410 RC 95070 HCPCS inpatient 953 619.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 577.04 60.55 999999999 577.04 924.41 percent of total billed charges Test for allergy using drugs 48676038_1 CDM 0410 RC 95070 HCPCS inpatient 953 619.45 UMR - ALL PLANS UMR - ALL PLANS 667.1 70 999999999 577.04 924.41 percent of total billed charges Test for allergy using drugs 48676038_1 CDM 0410 RC 95070 HCPCS inpatient 953 619.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 577.04 924.41 Test for allergy using drugs 48676038_1 CDM 0410 RC 95070 HCPCS inpatient 953 619.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 577.04 924.41 Test for allergy using drugs 48676038_1 CDM 0410 RC 95070 HCPCS inpatient 953 619.45 ANTHEM HMO ANTHEM HMO 999999999 577.04 924.41 Test for allergy using drugs 48676038_1 CDM 0410 RC 95070 HCPCS inpatient 953 619.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 577.04 924.41 Test for allergy using drugs 48676038_1 CDM 0410 RC 95070 HCPCS inpatient 953 619.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 644.23 67.6 999999999 577.04 924.41 percent of total billed charges Test for allergy using drugs 48676038_1 CDM 0410 RC 95070 HCPCS inpatient 953 619.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 577.04 924.41 Test to measure largest amount of air breathed in an out 48676051_1 CDM 0410 RC 94200 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges Test to measure largest amount of air breathed in an out 48676051_1 CDM 0410 RC 94200 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges Test to measure largest amount of air breathed in an out 48676051_1 CDM 0410 RC 94200 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges Test to measure largest amount of air breathed in an out 48676051_1 CDM 0410 RC 94200 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges Test to measure largest amount of air breathed in an out 48676051_1 CDM 0410 RC 94200 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges Test to measure largest amount of air breathed in an out 48676051_1 CDM 0410 RC 94200 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges Test to measure largest amount of air breathed in an out 48676051_1 CDM 0410 RC 94200 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges Test to measure largest amount of air breathed in an out 48676051_1 CDM 0410 RC 94200 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges Test to measure largest amount of air breathed in an out 48676051_1 CDM 0410 RC 94200 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 Test to measure largest amount of air breathed in an out 48676051_1 CDM 0410 RC 94200 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 Test to measure largest amount of air breathed in an out 48676051_1 CDM 0410 RC 94200 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 Test to measure largest amount of air breathed in an out 48676051_1 CDM 0410 RC 94200 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 Test to measure largest amount of air breathed in an out 48676051_1 CDM 0410 RC 94200 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges Test to measure largest amount of air breathed in an out 48676051_1 CDM 0410 RC 94200 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 Test to measure the level of nitric oxide gas 48676060_1 CDM 0460 RC 95012 HCPCS inpatient 196 127.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 127.4 65 999999999 118.68 190.12 percent of total billed charges Test to measure the level of nitric oxide gas 48676060_1 CDM 0460 RC 95012 HCPCS inpatient 196 127.4 AETNA AETNA 154.84 79 999999999 118.68 190.12 percent of total billed charges Test to measure the level of nitric oxide gas 48676060_1 CDM 0460 RC 95012 HCPCS inpatient 196 127.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 135.24 69 999999999 118.68 190.12 percent of total billed charges Test to measure the level of nitric oxide gas 48676060_1 CDM 0460 RC 95012 HCPCS inpatient 196 127.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 190.12 97 999999999 118.68 190.12 percent of total billed charges Test to measure the level of nitric oxide gas 48676060_1 CDM 0460 RC 95012 HCPCS inpatient 196 127.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 152.88 78 999999999 118.68 190.12 percent of total billed charges Test to measure the level of nitric oxide gas 48676060_1 CDM 0460 RC 95012 HCPCS inpatient 196 127.4 SIHO - ALL PLANS SIHO - ALL PLANS 176.4 90 999999999 118.68 190.12 percent of total billed charges Test to measure the level of nitric oxide gas 48676060_1 CDM 0460 RC 95012 HCPCS inpatient 196 127.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 118.68 60.55 999999999 118.68 190.12 percent of total billed charges Test to measure the level of nitric oxide gas 48676060_1 CDM 0460 RC 95012 HCPCS inpatient 196 127.4 UMR - ALL PLANS UMR - ALL PLANS 137.2 70 999999999 118.68 190.12 percent of total billed charges Test to measure the level of nitric oxide gas 48676060_1 CDM 0460 RC 95012 HCPCS inpatient 196 127.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 118.68 190.12 Test to measure the level of nitric oxide gas 48676060_1 CDM 0460 RC 95012 HCPCS inpatient 196 127.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 118.68 190.12 Test to measure the level of nitric oxide gas 48676060_1 CDM 0460 RC 95012 HCPCS inpatient 196 127.4 ANTHEM HMO ANTHEM HMO 999999999 118.68 190.12 Test to measure the level of nitric oxide gas 48676060_1 CDM 0460 RC 95012 HCPCS inpatient 196 127.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 118.68 190.12 Test to measure the level of nitric oxide gas 48676060_1 CDM 0460 RC 95012 HCPCS inpatient 196 127.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 132.5 67.6 999999999 118.68 190.12 percent of total billed charges Test to measure the level of nitric oxide gas 48676060_1 CDM 0460 RC 95012 HCPCS inpatient 196 127.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 118.68 190.12 Test to determine lung volumes using sensors 48676064_1 CDM 0460 RC 94726 HCPCS inpatient 282 183.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 183.3 65 999999999 170.75 273.54 percent of total billed charges Test to determine lung volumes using sensors 48676064_1 CDM 0460 RC 94726 HCPCS inpatient 282 183.3 AETNA AETNA 222.78 79 999999999 170.75 273.54 percent of total billed charges Test to determine lung volumes using sensors 48676064_1 CDM 0460 RC 94726 HCPCS inpatient 282 183.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 194.58 69 999999999 170.75 273.54 percent of total billed charges Test to determine lung volumes using sensors 48676064_1 CDM 0460 RC 94726 HCPCS inpatient 282 183.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 273.54 97 999999999 170.75 273.54 percent of total billed charges Test to determine lung volumes using sensors 48676064_1 CDM 0460 RC 94726 HCPCS inpatient 282 183.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 219.96 78 999999999 170.75 273.54 percent of total billed charges Test to determine lung volumes using sensors 48676064_1 CDM 0460 RC 94726 HCPCS inpatient 282 183.3 SIHO - ALL PLANS SIHO - ALL PLANS 253.8 90 999999999 170.75 273.54 percent of total billed charges Test to determine lung volumes using sensors 48676064_1 CDM 0460 RC 94726 HCPCS inpatient 282 183.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 170.75 60.55 999999999 170.75 273.54 percent of total billed charges Test to determine lung volumes using sensors 48676064_1 CDM 0460 RC 94726 HCPCS inpatient 282 183.3 UMR - ALL PLANS UMR - ALL PLANS 197.4 70 999999999 170.75 273.54 percent of total billed charges Test to determine lung volumes using sensors 48676064_1 CDM 0460 RC 94726 HCPCS inpatient 282 183.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 170.75 273.54 Test to determine lung volumes using sensors 48676064_1 CDM 0460 RC 94726 HCPCS inpatient 282 183.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 170.75 273.54 Test to determine lung volumes using sensors 48676064_1 CDM 0460 RC 94726 HCPCS inpatient 282 183.3 ANTHEM HMO ANTHEM HMO 999999999 170.75 273.54 Test to determine lung volumes using sensors 48676064_1 CDM 0460 RC 94726 HCPCS inpatient 282 183.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 170.75 273.54 Test to determine lung volumes using sensors 48676064_1 CDM 0460 RC 94726 HCPCS inpatient 282 183.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 190.63 67.6 999999999 170.75 273.54 percent of total billed charges Test to determine lung volumes using sensors 48676064_1 CDM 0460 RC 94726 HCPCS inpatient 282 183.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 170.75 273.54 Test to examine how well the lungs exchange gases 48676068_1 CDM 0460 RC 94729 HCPCS inpatient 379 246.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 246.35 65 999999999 229.48 367.63 percent of total billed charges Test to examine how well the lungs exchange gases 48676068_1 CDM 0460 RC 94729 HCPCS inpatient 379 246.35 AETNA AETNA 299.41 79 999999999 229.48 367.63 percent of total billed charges Test to examine how well the lungs exchange gases 48676068_1 CDM 0460 RC 94729 HCPCS inpatient 379 246.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 261.51 69 999999999 229.48 367.63 percent of total billed charges Test to examine how well the lungs exchange gases 48676068_1 CDM 0460 RC 94729 HCPCS inpatient 379 246.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 367.63 97 999999999 229.48 367.63 percent of total billed charges Test to examine how well the lungs exchange gases 48676068_1 CDM 0460 RC 94729 HCPCS inpatient 379 246.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 295.62 78 999999999 229.48 367.63 percent of total billed charges Test to examine how well the lungs exchange gases 48676068_1 CDM 0460 RC 94729 HCPCS inpatient 379 246.35 SIHO - ALL PLANS SIHO - ALL PLANS 341.1 90 999999999 229.48 367.63 percent of total billed charges Test to examine how well the lungs exchange gases 48676068_1 CDM 0460 RC 94729 HCPCS inpatient 379 246.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 229.48 60.55 999999999 229.48 367.63 percent of total billed charges Test to examine how well the lungs exchange gases 48676068_1 CDM 0460 RC 94729 HCPCS inpatient 379 246.35 UMR - ALL PLANS UMR - ALL PLANS 265.3 70 999999999 229.48 367.63 percent of total billed charges Test to examine how well the lungs exchange gases 48676068_1 CDM 0460 RC 94729 HCPCS inpatient 379 246.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 229.48 367.63 Test to examine how well the lungs exchange gases 48676068_1 CDM 0460 RC 94729 HCPCS inpatient 379 246.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 229.48 367.63 Test to examine how well the lungs exchange gases 48676068_1 CDM 0460 RC 94729 HCPCS inpatient 379 246.35 ANTHEM HMO ANTHEM HMO 999999999 229.48 367.63 Test to examine how well the lungs exchange gases 48676068_1 CDM 0460 RC 94729 HCPCS inpatient 379 246.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 229.48 367.63 Test to examine how well the lungs exchange gases 48676068_1 CDM 0460 RC 94729 HCPCS inpatient 379 246.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 256.2 67.6 999999999 229.48 367.63 percent of total billed charges Test to examine how well the lungs exchange gases 48676068_1 CDM 0460 RC 94729 HCPCS inpatient 379 246.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 229.48 367.63 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676072_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 219.7 65 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676072_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 AETNA AETNA 267.02 79 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676072_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 233.22 69 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676072_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 327.86 97 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676072_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 263.64 78 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676072_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 SIHO - ALL PLANS SIHO - ALL PLANS 304.2 90 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676072_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 UMR - ALL PLANS UMR - ALL PLANS 236.6 70 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676072_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 204.66 60.55 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676072_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 204.66 327.86 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676072_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 204.66 327.86 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676072_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 ANTHEM HMO ANTHEM HMO 999999999 204.66 327.86 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676072_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 204.66 327.86 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676072_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 228.49 67.6 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676072_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 204.66 327.86 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676073_1 CDM 0740 RC 93005 HCPCS inpatient 316 205.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 205.4 65 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676073_1 CDM 0740 RC 93005 HCPCS inpatient 316 205.4 AETNA AETNA 249.64 79 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676073_1 CDM 0740 RC 93005 HCPCS inpatient 316 205.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 218.04 69 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676073_1 CDM 0740 RC 93005 HCPCS inpatient 316 205.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 306.52 97 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676073_1 CDM 0740 RC 93005 HCPCS inpatient 316 205.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 246.48 78 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676073_1 CDM 0740 RC 93005 HCPCS inpatient 316 205.4 SIHO - ALL PLANS SIHO - ALL PLANS 284.4 90 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676073_1 CDM 0740 RC 93005 HCPCS inpatient 316 205.4 UMR - ALL PLANS UMR - ALL PLANS 221.2 70 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676073_1 CDM 0740 RC 93005 HCPCS inpatient 316 205.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 191.34 60.55 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676073_1 CDM 0740 RC 93005 HCPCS inpatient 316 205.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676073_1 CDM 0740 RC 93005 HCPCS inpatient 316 205.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676073_1 CDM 0740 RC 93005 HCPCS inpatient 316 205.4 ANTHEM HMO ANTHEM HMO 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676073_1 CDM 0740 RC 93005 HCPCS inpatient 316 205.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676073_1 CDM 0740 RC 93005 HCPCS inpatient 316 205.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 213.62 67.6 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676073_1 CDM 0740 RC 93005 HCPCS inpatient 316 205.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 191.34 306.52 "Measurement of brain wave activity (EEG), awake and asleep" 48676094_1 CDM 0740 RC 95819 HCPCS inpatient 904 587.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 587.6 65 999999999 547.37 876.88 percent of total billed charges "Measurement of brain wave activity (EEG), awake and asleep" 48676094_1 CDM 0740 RC 95819 HCPCS inpatient 904 587.6 AETNA AETNA 714.16 79 999999999 547.37 876.88 percent of total billed charges "Measurement of brain wave activity (EEG), awake and asleep" 48676094_1 CDM 0740 RC 95819 HCPCS inpatient 904 587.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 623.76 69 999999999 547.37 876.88 percent of total billed charges "Measurement of brain wave activity (EEG), awake and asleep" 48676094_1 CDM 0740 RC 95819 HCPCS inpatient 904 587.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 876.88 97 999999999 547.37 876.88 percent of total billed charges "Measurement of brain wave activity (EEG), awake and asleep" 48676094_1 CDM 0740 RC 95819 HCPCS inpatient 904 587.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 705.12 78 999999999 547.37 876.88 percent of total billed charges "Measurement of brain wave activity (EEG), awake and asleep" 48676094_1 CDM 0740 RC 95819 HCPCS inpatient 904 587.6 SIHO - ALL PLANS SIHO - ALL PLANS 813.6 90 999999999 547.37 876.88 percent of total billed charges "Measurement of brain wave activity (EEG), awake and asleep" 48676094_1 CDM 0740 RC 95819 HCPCS inpatient 904 587.6 UMR - ALL PLANS UMR - ALL PLANS 632.8 70 999999999 547.37 876.88 percent of total billed charges "Measurement of brain wave activity (EEG), awake and asleep" 48676094_1 CDM 0740 RC 95819 HCPCS inpatient 904 587.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 547.37 60.55 999999999 547.37 876.88 percent of total billed charges "Measurement of brain wave activity (EEG), awake and asleep" 48676094_1 CDM 0740 RC 95819 HCPCS inpatient 904 587.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 547.37 876.88 "Measurement of brain wave activity (EEG), awake and asleep" 48676094_1 CDM 0740 RC 95819 HCPCS inpatient 904 587.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 547.37 876.88 "Measurement of brain wave activity (EEG), awake and asleep" 48676094_1 CDM 0740 RC 95819 HCPCS inpatient 904 587.6 ANTHEM HMO ANTHEM HMO 999999999 547.37 876.88 "Measurement of brain wave activity (EEG), awake and asleep" 48676094_1 CDM 0740 RC 95819 HCPCS inpatient 904 587.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 547.37 876.88 "Measurement of brain wave activity (EEG), awake and asleep" 48676094_1 CDM 0740 RC 95819 HCPCS inpatient 904 587.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 611.1 67.6 999999999 547.37 876.88 percent of total billed charges "Measurement of brain wave activity (EEG), awake and asleep" 48676094_1 CDM 0740 RC 95819 HCPCS inpatient 904 587.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 547.37 876.88 "Measurement of brain wave activity (EEG), awake and drowsy" 48676095_1 CDM 0740 RC 95816 HCPCS inpatient 904 587.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 587.6 65 999999999 547.37 876.88 percent of total billed charges "Measurement of brain wave activity (EEG), awake and drowsy" 48676095_1 CDM 0740 RC 95816 HCPCS inpatient 904 587.6 AETNA AETNA 714.16 79 999999999 547.37 876.88 percent of total billed charges "Measurement of brain wave activity (EEG), awake and drowsy" 48676095_1 CDM 0740 RC 95816 HCPCS inpatient 904 587.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 623.76 69 999999999 547.37 876.88 percent of total billed charges "Measurement of brain wave activity (EEG), awake and drowsy" 48676095_1 CDM 0740 RC 95816 HCPCS inpatient 904 587.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 876.88 97 999999999 547.37 876.88 percent of total billed charges "Measurement of brain wave activity (EEG), awake and drowsy" 48676095_1 CDM 0740 RC 95816 HCPCS inpatient 904 587.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 705.12 78 999999999 547.37 876.88 percent of total billed charges "Measurement of brain wave activity (EEG), awake and drowsy" 48676095_1 CDM 0740 RC 95816 HCPCS inpatient 904 587.6 SIHO - ALL PLANS SIHO - ALL PLANS 813.6 90 999999999 547.37 876.88 percent of total billed charges "Measurement of brain wave activity (EEG), awake and drowsy" 48676095_1 CDM 0740 RC 95816 HCPCS inpatient 904 587.6 UMR - ALL PLANS UMR - ALL PLANS 632.8 70 999999999 547.37 876.88 percent of total billed charges "Measurement of brain wave activity (EEG), awake and drowsy" 48676095_1 CDM 0740 RC 95816 HCPCS inpatient 904 587.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 547.37 60.55 999999999 547.37 876.88 percent of total billed charges "Measurement of brain wave activity (EEG), awake and drowsy" 48676095_1 CDM 0740 RC 95816 HCPCS inpatient 904 587.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 547.37 876.88 "Measurement of brain wave activity (EEG), awake and drowsy" 48676095_1 CDM 0740 RC 95816 HCPCS inpatient 904 587.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 547.37 876.88 "Measurement of brain wave activity (EEG), awake and drowsy" 48676095_1 CDM 0740 RC 95816 HCPCS inpatient 904 587.6 ANTHEM HMO ANTHEM HMO 999999999 547.37 876.88 "Measurement of brain wave activity (EEG), awake and drowsy" 48676095_1 CDM 0740 RC 95816 HCPCS inpatient 904 587.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 547.37 876.88 "Measurement of brain wave activity (EEG), awake and drowsy" 48676095_1 CDM 0740 RC 95816 HCPCS inpatient 904 587.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 611.1 67.6 999999999 547.37 876.88 percent of total billed charges "Measurement of brain wave activity (EEG), awake and drowsy" 48676095_1 CDM 0740 RC 95816 HCPCS inpatient 904 587.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 547.37 876.88 "Measurement of brain wave activity (EEG), in coma or asleep" 48676097_1 CDM 0740 RC 95822 HCPCS inpatient 881 572.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 572.65 65 999999999 533.45 854.57 percent of total billed charges "Measurement of brain wave activity (EEG), in coma or asleep" 48676097_1 CDM 0740 RC 95822 HCPCS inpatient 881 572.65 AETNA AETNA 695.99 79 999999999 533.45 854.57 percent of total billed charges "Measurement of brain wave activity (EEG), in coma or asleep" 48676097_1 CDM 0740 RC 95822 HCPCS inpatient 881 572.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 607.89 69 999999999 533.45 854.57 percent of total billed charges "Measurement of brain wave activity (EEG), in coma or asleep" 48676097_1 CDM 0740 RC 95822 HCPCS inpatient 881 572.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 854.57 97 999999999 533.45 854.57 percent of total billed charges "Measurement of brain wave activity (EEG), in coma or asleep" 48676097_1 CDM 0740 RC 95822 HCPCS inpatient 881 572.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 687.18 78 999999999 533.45 854.57 percent of total billed charges "Measurement of brain wave activity (EEG), in coma or asleep" 48676097_1 CDM 0740 RC 95822 HCPCS inpatient 881 572.65 SIHO - ALL PLANS SIHO - ALL PLANS 792.9 90 999999999 533.45 854.57 percent of total billed charges "Measurement of brain wave activity (EEG), in coma or asleep" 48676097_1 CDM 0740 RC 95822 HCPCS inpatient 881 572.65 UMR - ALL PLANS UMR - ALL PLANS 616.7 70 999999999 533.45 854.57 percent of total billed charges "Measurement of brain wave activity (EEG), in coma or asleep" 48676097_1 CDM 0740 RC 95822 HCPCS inpatient 881 572.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 533.45 60.55 999999999 533.45 854.57 percent of total billed charges "Measurement of brain wave activity (EEG), in coma or asleep" 48676097_1 CDM 0740 RC 95822 HCPCS inpatient 881 572.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 533.45 854.57 "Measurement of brain wave activity (EEG), in coma or asleep" 48676097_1 CDM 0740 RC 95822 HCPCS inpatient 881 572.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 533.45 854.57 "Measurement of brain wave activity (EEG), in coma or asleep" 48676097_1 CDM 0740 RC 95822 HCPCS inpatient 881 572.65 ANTHEM HMO ANTHEM HMO 999999999 533.45 854.57 "Measurement of brain wave activity (EEG), in coma or asleep" 48676097_1 CDM 0740 RC 95822 HCPCS inpatient 881 572.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 533.45 854.57 "Measurement of brain wave activity (EEG), in coma or asleep" 48676097_1 CDM 0740 RC 95822 HCPCS inpatient 881 572.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 595.56 67.6 999999999 533.45 854.57 percent of total billed charges "Measurement of brain wave activity (EEG), in coma or asleep" 48676097_1 CDM 0740 RC 95822 HCPCS inpatient 881 572.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 533.45 854.57 "Measurement of brain wave activity (EEG), 61-119 minutes" 48676098_1 CDM 0740 RC 95813 HCPCS inpatient 1227 797.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 797.55 65 999999999 742.95 1190.19 percent of total billed charges "Measurement of brain wave activity (EEG), 61-119 minutes" 48676098_1 CDM 0740 RC 95813 HCPCS inpatient 1227 797.55 AETNA AETNA 969.33 79 999999999 742.95 1190.19 percent of total billed charges "Measurement of brain wave activity (EEG), 61-119 minutes" 48676098_1 CDM 0740 RC 95813 HCPCS inpatient 1227 797.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 846.63 69 999999999 742.95 1190.19 percent of total billed charges "Measurement of brain wave activity (EEG), 61-119 minutes" 48676098_1 CDM 0740 RC 95813 HCPCS inpatient 1227 797.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1190.19 97 999999999 742.95 1190.19 percent of total billed charges "Measurement of brain wave activity (EEG), 61-119 minutes" 48676098_1 CDM 0740 RC 95813 HCPCS inpatient 1227 797.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 957.06 78 999999999 742.95 1190.19 percent of total billed charges "Measurement of brain wave activity (EEG), 61-119 minutes" 48676098_1 CDM 0740 RC 95813 HCPCS inpatient 1227 797.55 SIHO - ALL PLANS SIHO - ALL PLANS 1104.3 90 999999999 742.95 1190.19 percent of total billed charges "Measurement of brain wave activity (EEG), 61-119 minutes" 48676098_1 CDM 0740 RC 95813 HCPCS inpatient 1227 797.55 UMR - ALL PLANS UMR - ALL PLANS 858.9 70 999999999 742.95 1190.19 percent of total billed charges "Measurement of brain wave activity (EEG), 61-119 minutes" 48676098_1 CDM 0740 RC 95813 HCPCS inpatient 1227 797.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 742.95 60.55 999999999 742.95 1190.19 percent of total billed charges "Measurement of brain wave activity (EEG), 61-119 minutes" 48676098_1 CDM 0740 RC 95813 HCPCS inpatient 1227 797.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 742.95 1190.19 "Measurement of brain wave activity (EEG), 61-119 minutes" 48676098_1 CDM 0740 RC 95813 HCPCS inpatient 1227 797.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 742.95 1190.19 "Measurement of brain wave activity (EEG), 61-119 minutes" 48676098_1 CDM 0740 RC 95813 HCPCS inpatient 1227 797.55 ANTHEM HMO ANTHEM HMO 999999999 742.95 1190.19 "Measurement of brain wave activity (EEG), 61-119 minutes" 48676098_1 CDM 0740 RC 95813 HCPCS inpatient 1227 797.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 742.95 1190.19 "Measurement of brain wave activity (EEG), 61-119 minutes" 48676098_1 CDM 0740 RC 95813 HCPCS inpatient 1227 797.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 829.45 67.6 999999999 742.95 1190.19 percent of total billed charges "Measurement of brain wave activity (EEG), 61-119 minutes" 48676098_1 CDM 0740 RC 95813 HCPCS inpatient 1227 797.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 742.95 1190.19 Measurement of brain wave activity (EEG) to evaluate brain death 48676099_1 CDM 0740 RC 95824 HCPCS inpatient 757 492.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 492.05 65 999999999 458.36 734.29 percent of total billed charges Measurement of brain wave activity (EEG) to evaluate brain death 48676099_1 CDM 0740 RC 95824 HCPCS inpatient 757 492.05 AETNA AETNA 598.03 79 999999999 458.36 734.29 percent of total billed charges Measurement of brain wave activity (EEG) to evaluate brain death 48676099_1 CDM 0740 RC 95824 HCPCS inpatient 757 492.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 522.33 69 999999999 458.36 734.29 percent of total billed charges Measurement of brain wave activity (EEG) to evaluate brain death 48676099_1 CDM 0740 RC 95824 HCPCS inpatient 757 492.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 734.29 97 999999999 458.36 734.29 percent of total billed charges Measurement of brain wave activity (EEG) to evaluate brain death 48676099_1 CDM 0740 RC 95824 HCPCS inpatient 757 492.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 590.46 78 999999999 458.36 734.29 percent of total billed charges Measurement of brain wave activity (EEG) to evaluate brain death 48676099_1 CDM 0740 RC 95824 HCPCS inpatient 757 492.05 SIHO - ALL PLANS SIHO - ALL PLANS 681.3 90 999999999 458.36 734.29 percent of total billed charges Measurement of brain wave activity (EEG) to evaluate brain death 48676099_1 CDM 0740 RC 95824 HCPCS inpatient 757 492.05 UMR - ALL PLANS UMR - ALL PLANS 529.9 70 999999999 458.36 734.29 percent of total billed charges Measurement of brain wave activity (EEG) to evaluate brain death 48676099_1 CDM 0740 RC 95824 HCPCS inpatient 757 492.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 458.36 60.55 999999999 458.36 734.29 percent of total billed charges Measurement of brain wave activity (EEG) to evaluate brain death 48676099_1 CDM 0740 RC 95824 HCPCS inpatient 757 492.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 458.36 734.29 Measurement of brain wave activity (EEG) to evaluate brain death 48676099_1 CDM 0740 RC 95824 HCPCS inpatient 757 492.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 458.36 734.29 Measurement of brain wave activity (EEG) to evaluate brain death 48676099_1 CDM 0740 RC 95824 HCPCS inpatient 757 492.05 ANTHEM HMO ANTHEM HMO 999999999 458.36 734.29 Measurement of brain wave activity (EEG) to evaluate brain death 48676099_1 CDM 0740 RC 95824 HCPCS inpatient 757 492.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 458.36 734.29 Measurement of brain wave activity (EEG) to evaluate brain death 48676099_1 CDM 0740 RC 95824 HCPCS inpatient 757 492.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 511.73 67.6 999999999 458.36 734.29 percent of total billed charges Measurement of brain wave activity (EEG) to evaluate brain death 48676099_1 CDM 0740 RC 95824 HCPCS inpatient 757 492.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 458.36 734.29 Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676102_1 CDM 0730 RC 93042 HCPCS inpatient 40 26 SELF PAY DISCOUNT SELF PAY DISCOUNT 26 65 999999999 24.22 38.8 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676102_1 CDM 0730 RC 93042 HCPCS inpatient 40 26 AETNA AETNA 31.6 79 999999999 24.22 38.8 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676102_1 CDM 0730 RC 93042 HCPCS inpatient 40 26 ENCORE - ALL PLANS ENCORE - ALL PLANS 27.6 69 999999999 24.22 38.8 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676102_1 CDM 0730 RC 93042 HCPCS inpatient 40 26 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 38.8 97 999999999 24.22 38.8 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676102_1 CDM 0730 RC 93042 HCPCS inpatient 40 26 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.2 78 999999999 24.22 38.8 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676102_1 CDM 0730 RC 93042 HCPCS inpatient 40 26 SIHO - ALL PLANS SIHO - ALL PLANS 36 90 999999999 24.22 38.8 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676102_1 CDM 0730 RC 93042 HCPCS inpatient 40 26 UMR - ALL PLANS UMR - ALL PLANS 28 70 999999999 24.22 38.8 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676102_1 CDM 0730 RC 93042 HCPCS inpatient 40 26 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.22 60.55 999999999 24.22 38.8 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676102_1 CDM 0730 RC 93042 HCPCS inpatient 40 26 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.22 38.8 Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676102_1 CDM 0730 RC 93042 HCPCS inpatient 40 26 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.22 38.8 Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676102_1 CDM 0730 RC 93042 HCPCS inpatient 40 26 ANTHEM HMO ANTHEM HMO 999999999 24.22 38.8 Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676102_1 CDM 0730 RC 93042 HCPCS inpatient 40 26 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.22 38.8 Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676102_1 CDM 0730 RC 93042 HCPCS inpatient 40 26 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.04 67.6 999999999 24.22 38.8 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676102_1 CDM 0730 RC 93042 HCPCS inpatient 40 26 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.22 38.8 Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676104_1 CDM 0730 RC 93042 HCPCS inpatient 43 27.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 27.95 65 999999999 26.04 41.71 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676104_1 CDM 0730 RC 93042 HCPCS inpatient 43 27.95 AETNA AETNA 33.97 79 999999999 26.04 41.71 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676104_1 CDM 0730 RC 93042 HCPCS inpatient 43 27.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 29.67 69 999999999 26.04 41.71 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676104_1 CDM 0730 RC 93042 HCPCS inpatient 43 27.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 41.71 97 999999999 26.04 41.71 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676104_1 CDM 0730 RC 93042 HCPCS inpatient 43 27.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 33.54 78 999999999 26.04 41.71 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676104_1 CDM 0730 RC 93042 HCPCS inpatient 43 27.95 SIHO - ALL PLANS SIHO - ALL PLANS 38.7 90 999999999 26.04 41.71 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676104_1 CDM 0730 RC 93042 HCPCS inpatient 43 27.95 UMR - ALL PLANS UMR - ALL PLANS 30.1 70 999999999 26.04 41.71 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676104_1 CDM 0730 RC 93042 HCPCS inpatient 43 27.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26.04 60.55 999999999 26.04 41.71 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676104_1 CDM 0730 RC 93042 HCPCS inpatient 43 27.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26.04 41.71 Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676104_1 CDM 0730 RC 93042 HCPCS inpatient 43 27.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26.04 41.71 Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676104_1 CDM 0730 RC 93042 HCPCS inpatient 43 27.95 ANTHEM HMO ANTHEM HMO 999999999 26.04 41.71 Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676104_1 CDM 0730 RC 93042 HCPCS inpatient 43 27.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26.04 41.71 Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676104_1 CDM 0730 RC 93042 HCPCS inpatient 43 27.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 29.07 67.6 999999999 26.04 41.71 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads with review by physician only 48676104_1 CDM 0730 RC 93042 HCPCS inpatient 43 27.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 26.04 41.71 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676107_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 241.8 65 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676107_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 AETNA AETNA 293.88 79 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676107_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 256.68 69 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676107_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 360.84 97 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676107_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 290.16 78 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676107_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 SIHO - ALL PLANS SIHO - ALL PLANS 334.8 90 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676107_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 UMR - ALL PLANS UMR - ALL PLANS 260.4 70 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676107_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 225.25 60.55 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676107_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 225.25 360.84 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676107_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 225.25 360.84 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676107_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 ANTHEM HMO ANTHEM HMO 999999999 225.25 360.84 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676107_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 225.25 360.84 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676107_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 251.47 67.6 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48676107_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 225.25 360.84 "Established patient office or other outpatient visit, 20-29 minutes" 48676110_1 CDM 0510 RC 99213 HCPCS inpatient 388 252.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 252.2 65 999999999 234.93 376.36 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48676110_1 CDM 0510 RC 99213 HCPCS inpatient 388 252.2 AETNA AETNA 306.52 79 999999999 234.93 376.36 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48676110_1 CDM 0510 RC 99213 HCPCS inpatient 388 252.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.72 69 999999999 234.93 376.36 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48676110_1 CDM 0510 RC 99213 HCPCS inpatient 388 252.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 376.36 97 999999999 234.93 376.36 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48676110_1 CDM 0510 RC 99213 HCPCS inpatient 388 252.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 302.64 78 999999999 234.93 376.36 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48676110_1 CDM 0510 RC 99213 HCPCS inpatient 388 252.2 SIHO - ALL PLANS SIHO - ALL PLANS 349.2 90 999999999 234.93 376.36 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48676110_1 CDM 0510 RC 99213 HCPCS inpatient 388 252.2 UMR - ALL PLANS UMR - ALL PLANS 271.6 70 999999999 234.93 376.36 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48676110_1 CDM 0510 RC 99213 HCPCS inpatient 388 252.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.93 60.55 999999999 234.93 376.36 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48676110_1 CDM 0510 RC 99213 HCPCS inpatient 388 252.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.93 376.36 "Established patient office or other outpatient visit, 20-29 minutes" 48676110_1 CDM 0510 RC 99213 HCPCS inpatient 388 252.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.93 376.36 "Established patient office or other outpatient visit, 20-29 minutes" 48676110_1 CDM 0510 RC 99213 HCPCS inpatient 388 252.2 ANTHEM HMO ANTHEM HMO 999999999 234.93 376.36 "Established patient office or other outpatient visit, 20-29 minutes" 48676110_1 CDM 0510 RC 99213 HCPCS inpatient 388 252.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.93 376.36 "Established patient office or other outpatient visit, 20-29 minutes" 48676110_1 CDM 0510 RC 99213 HCPCS inpatient 388 252.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 262.29 67.6 999999999 234.93 376.36 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48676110_1 CDM 0510 RC 99213 HCPCS inpatient 388 252.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.93 376.36 "Established patient office or other outpatient visit, 30-39 minutes" 48676112_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 295.1 65 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48676112_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 AETNA AETNA 358.66 79 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48676112_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 313.26 69 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48676112_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 440.38 97 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48676112_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 354.12 78 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48676112_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 SIHO - ALL PLANS SIHO - ALL PLANS 408.6 90 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48676112_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 UMR - ALL PLANS UMR - ALL PLANS 317.8 70 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48676112_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 274.9 60.55 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48676112_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 274.9 440.38 "Established patient office or other outpatient visit, 30-39 minutes" 48676112_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 274.9 440.38 "Established patient office or other outpatient visit, 30-39 minutes" 48676112_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 ANTHEM HMO ANTHEM HMO 999999999 274.9 440.38 "Established patient office or other outpatient visit, 30-39 minutes" 48676112_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 274.9 440.38 "Established patient office or other outpatient visit, 30-39 minutes" 48676112_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 306.9 67.6 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48676112_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 274.9 440.38 REV - IHS-MOA CLINIC VISIT 48676115_1 CDM 0510 RC inpatient 520 338 SELF PAY DISCOUNT SELF PAY DISCOUNT 338 65 999999999 314.86 504.4 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48676115_1 CDM 0510 RC inpatient 520 338 AETNA AETNA 410.8 79 999999999 314.86 504.4 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48676115_1 CDM 0510 RC inpatient 520 338 ENCORE - ALL PLANS ENCORE - ALL PLANS 358.8 69 999999999 314.86 504.4 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48676115_1 CDM 0510 RC inpatient 520 338 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 504.4 97 999999999 314.86 504.4 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48676115_1 CDM 0510 RC inpatient 520 338 HUMANA - ALL PLANS HUMANA - ALL PLANS 405.6 78 999999999 314.86 504.4 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48676115_1 CDM 0510 RC inpatient 520 338 SIHO - ALL PLANS SIHO - ALL PLANS 468 90 999999999 314.86 504.4 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48676115_1 CDM 0510 RC inpatient 520 338 UMR - ALL PLANS UMR - ALL PLANS 364 70 999999999 314.86 504.4 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48676115_1 CDM 0510 RC inpatient 520 338 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 314.86 60.55 999999999 314.86 504.4 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48676115_1 CDM 0510 RC inpatient 520 338 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 314.86 504.4 REV - IHS-MOA CLINIC VISIT 48676115_1 CDM 0510 RC inpatient 520 338 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 314.86 504.4 REV - IHS-MOA CLINIC VISIT 48676115_1 CDM 0510 RC inpatient 520 338 ANTHEM HMO ANTHEM HMO 999999999 314.86 504.4 REV - IHS-MOA CLINIC VISIT 48676115_1 CDM 0510 RC inpatient 520 338 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 314.86 504.4 REV - IHS-MOA CLINIC VISIT 48676115_1 CDM 0510 RC inpatient 520 338 CIGNA - ALL PLANS CIGNA - ALL PLANS 351.52 67.6 999999999 314.86 504.4 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48676115_1 CDM 0510 RC inpatient 520 338 UHC - ALL PLANS UHC - ALL PLANS 999999999 314.86 504.4 Bacterial culture for aerobic isolates 48678680_1 CDM 0306 RC 87077 HCPCS inpatient 108 70.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.2 65 999999999 65.39 104.76 percent of total billed charges Bacterial culture for aerobic isolates 48678680_1 CDM 0306 RC 87077 HCPCS inpatient 108 70.2 AETNA AETNA 85.32 79 999999999 65.39 104.76 percent of total billed charges Bacterial culture for aerobic isolates 48678680_1 CDM 0306 RC 87077 HCPCS inpatient 108 70.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 74.52 69 999999999 65.39 104.76 percent of total billed charges Bacterial culture for aerobic isolates 48678680_1 CDM 0306 RC 87077 HCPCS inpatient 108 70.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 104.76 97 999999999 65.39 104.76 percent of total billed charges Bacterial culture for aerobic isolates 48678680_1 CDM 0306 RC 87077 HCPCS inpatient 108 70.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 84.24 78 999999999 65.39 104.76 percent of total billed charges Bacterial culture for aerobic isolates 48678680_1 CDM 0306 RC 87077 HCPCS inpatient 108 70.2 SIHO - ALL PLANS SIHO - ALL PLANS 97.2 90 999999999 65.39 104.76 percent of total billed charges Bacterial culture for aerobic isolates 48678680_1 CDM 0306 RC 87077 HCPCS inpatient 108 70.2 UMR - ALL PLANS UMR - ALL PLANS 75.6 70 999999999 65.39 104.76 percent of total billed charges Bacterial culture for aerobic isolates 48678680_1 CDM 0306 RC 87077 HCPCS inpatient 108 70.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 65.39 60.55 999999999 65.39 104.76 percent of total billed charges Bacterial culture for aerobic isolates 48678680_1 CDM 0306 RC 87077 HCPCS inpatient 108 70.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 65.39 104.76 Bacterial culture for aerobic isolates 48678680_1 CDM 0306 RC 87077 HCPCS inpatient 108 70.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 65.39 104.76 Bacterial culture for aerobic isolates 48678680_1 CDM 0306 RC 87077 HCPCS inpatient 108 70.2 ANTHEM HMO ANTHEM HMO 999999999 65.39 104.76 Bacterial culture for aerobic isolates 48678680_1 CDM 0306 RC 87077 HCPCS inpatient 108 70.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 65.39 104.76 Bacterial culture for aerobic isolates 48678680_1 CDM 0306 RC 87077 HCPCS inpatient 108 70.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.01 67.6 999999999 65.39 104.76 percent of total billed charges Bacterial culture for aerobic isolates 48678680_1 CDM 0306 RC 87077 HCPCS inpatient 108 70.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 65.39 104.76 Complicated or multiple drainage of skin abscess 48685323_1 CDM 0510 RC 10061 HCPCS inpatient 587 381.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 381.55 65 999999999 355.43 569.39 percent of total billed charges Complicated or multiple drainage of skin abscess 48685323_1 CDM 0510 RC 10061 HCPCS inpatient 587 381.55 AETNA AETNA 463.73 79 999999999 355.43 569.39 percent of total billed charges Complicated or multiple drainage of skin abscess 48685323_1 CDM 0510 RC 10061 HCPCS inpatient 587 381.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 405.03 69 999999999 355.43 569.39 percent of total billed charges Complicated or multiple drainage of skin abscess 48685323_1 CDM 0510 RC 10061 HCPCS inpatient 587 381.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 569.39 97 999999999 355.43 569.39 percent of total billed charges Complicated or multiple drainage of skin abscess 48685323_1 CDM 0510 RC 10061 HCPCS inpatient 587 381.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 457.86 78 999999999 355.43 569.39 percent of total billed charges Complicated or multiple drainage of skin abscess 48685323_1 CDM 0510 RC 10061 HCPCS inpatient 587 381.55 SIHO - ALL PLANS SIHO - ALL PLANS 528.3 90 999999999 355.43 569.39 percent of total billed charges Complicated or multiple drainage of skin abscess 48685323_1 CDM 0510 RC 10061 HCPCS inpatient 587 381.55 UMR - ALL PLANS UMR - ALL PLANS 410.9 70 999999999 355.43 569.39 percent of total billed charges Complicated or multiple drainage of skin abscess 48685323_1 CDM 0510 RC 10061 HCPCS inpatient 587 381.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 355.43 60.55 999999999 355.43 569.39 percent of total billed charges Complicated or multiple drainage of skin abscess 48685323_1 CDM 0510 RC 10061 HCPCS inpatient 587 381.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 355.43 569.39 Complicated or multiple drainage of skin abscess 48685323_1 CDM 0510 RC 10061 HCPCS inpatient 587 381.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 355.43 569.39 Complicated or multiple drainage of skin abscess 48685323_1 CDM 0510 RC 10061 HCPCS inpatient 587 381.55 ANTHEM HMO ANTHEM HMO 999999999 355.43 569.39 Complicated or multiple drainage of skin abscess 48685323_1 CDM 0510 RC 10061 HCPCS inpatient 587 381.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 355.43 569.39 Complicated or multiple drainage of skin abscess 48685323_1 CDM 0510 RC 10061 HCPCS inpatient 587 381.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 396.81 67.6 999999999 355.43 569.39 percent of total billed charges Complicated or multiple drainage of skin abscess 48685323_1 CDM 0510 RC 10061 HCPCS inpatient 587 381.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 355.43 569.39 Placement of strapping to elbow or wrist 48685324_1 CDM 0510 RC 29260 HCPCS inpatient 404 262.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 262.6 65 999999999 244.62 391.88 percent of total billed charges Placement of strapping to elbow or wrist 48685324_1 CDM 0510 RC 29260 HCPCS inpatient 404 262.6 AETNA AETNA 319.16 79 999999999 244.62 391.88 percent of total billed charges Placement of strapping to elbow or wrist 48685324_1 CDM 0510 RC 29260 HCPCS inpatient 404 262.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 278.76 69 999999999 244.62 391.88 percent of total billed charges Placement of strapping to elbow or wrist 48685324_1 CDM 0510 RC 29260 HCPCS inpatient 404 262.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 391.88 97 999999999 244.62 391.88 percent of total billed charges Placement of strapping to elbow or wrist 48685324_1 CDM 0510 RC 29260 HCPCS inpatient 404 262.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 315.12 78 999999999 244.62 391.88 percent of total billed charges Placement of strapping to elbow or wrist 48685324_1 CDM 0510 RC 29260 HCPCS inpatient 404 262.6 SIHO - ALL PLANS SIHO - ALL PLANS 363.6 90 999999999 244.62 391.88 percent of total billed charges Placement of strapping to elbow or wrist 48685324_1 CDM 0510 RC 29260 HCPCS inpatient 404 262.6 UMR - ALL PLANS UMR - ALL PLANS 282.8 70 999999999 244.62 391.88 percent of total billed charges Placement of strapping to elbow or wrist 48685324_1 CDM 0510 RC 29260 HCPCS inpatient 404 262.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 244.62 60.55 999999999 244.62 391.88 percent of total billed charges Placement of strapping to elbow or wrist 48685324_1 CDM 0510 RC 29260 HCPCS inpatient 404 262.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 244.62 391.88 Placement of strapping to elbow or wrist 48685324_1 CDM 0510 RC 29260 HCPCS inpatient 404 262.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 244.62 391.88 Placement of strapping to elbow or wrist 48685324_1 CDM 0510 RC 29260 HCPCS inpatient 404 262.6 ANTHEM HMO ANTHEM HMO 999999999 244.62 391.88 Placement of strapping to elbow or wrist 48685324_1 CDM 0510 RC 29260 HCPCS inpatient 404 262.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 244.62 391.88 Placement of strapping to elbow or wrist 48685324_1 CDM 0510 RC 29260 HCPCS inpatient 404 262.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 273.1 67.6 999999999 244.62 391.88 percent of total billed charges Placement of strapping to elbow or wrist 48685324_1 CDM 0510 RC 29260 HCPCS inpatient 404 262.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 244.62 391.88 Application of nonmoveable finger splint 48685325_1 CDM 0510 RC 29130 HCPCS inpatient 404 262.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 262.6 65 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 48685325_1 CDM 0510 RC 29130 HCPCS inpatient 404 262.6 AETNA AETNA 319.16 79 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 48685325_1 CDM 0510 RC 29130 HCPCS inpatient 404 262.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 278.76 69 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 48685325_1 CDM 0510 RC 29130 HCPCS inpatient 404 262.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 391.88 97 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 48685325_1 CDM 0510 RC 29130 HCPCS inpatient 404 262.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 315.12 78 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 48685325_1 CDM 0510 RC 29130 HCPCS inpatient 404 262.6 SIHO - ALL PLANS SIHO - ALL PLANS 363.6 90 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 48685325_1 CDM 0510 RC 29130 HCPCS inpatient 404 262.6 UMR - ALL PLANS UMR - ALL PLANS 282.8 70 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 48685325_1 CDM 0510 RC 29130 HCPCS inpatient 404 262.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 244.62 60.55 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 48685325_1 CDM 0510 RC 29130 HCPCS inpatient 404 262.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 244.62 391.88 Application of nonmoveable finger splint 48685325_1 CDM 0510 RC 29130 HCPCS inpatient 404 262.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 244.62 391.88 Application of nonmoveable finger splint 48685325_1 CDM 0510 RC 29130 HCPCS inpatient 404 262.6 ANTHEM HMO ANTHEM HMO 999999999 244.62 391.88 Application of nonmoveable finger splint 48685325_1 CDM 0510 RC 29130 HCPCS inpatient 404 262.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 244.62 391.88 Application of nonmoveable finger splint 48685325_1 CDM 0510 RC 29130 HCPCS inpatient 404 262.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 273.1 67.6 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 48685325_1 CDM 0510 RC 29130 HCPCS inpatient 404 262.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 244.62 391.88 Application of short leg splint from calf to foot 48685326_1 CDM 0510 RC 29515 HCPCS inpatient 261 169.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 169.65 65 999999999 158.04 253.17 percent of total billed charges Application of short leg splint from calf to foot 48685326_1 CDM 0510 RC 29515 HCPCS inpatient 261 169.65 AETNA AETNA 206.19 79 999999999 158.04 253.17 percent of total billed charges Application of short leg splint from calf to foot 48685326_1 CDM 0510 RC 29515 HCPCS inpatient 261 169.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.09 69 999999999 158.04 253.17 percent of total billed charges Application of short leg splint from calf to foot 48685326_1 CDM 0510 RC 29515 HCPCS inpatient 261 169.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 253.17 97 999999999 158.04 253.17 percent of total billed charges Application of short leg splint from calf to foot 48685326_1 CDM 0510 RC 29515 HCPCS inpatient 261 169.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 203.58 78 999999999 158.04 253.17 percent of total billed charges Application of short leg splint from calf to foot 48685326_1 CDM 0510 RC 29515 HCPCS inpatient 261 169.65 SIHO - ALL PLANS SIHO - ALL PLANS 234.9 90 999999999 158.04 253.17 percent of total billed charges Application of short leg splint from calf to foot 48685326_1 CDM 0510 RC 29515 HCPCS inpatient 261 169.65 UMR - ALL PLANS UMR - ALL PLANS 182.7 70 999999999 158.04 253.17 percent of total billed charges Application of short leg splint from calf to foot 48685326_1 CDM 0510 RC 29515 HCPCS inpatient 261 169.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.04 60.55 999999999 158.04 253.17 percent of total billed charges Application of short leg splint from calf to foot 48685326_1 CDM 0510 RC 29515 HCPCS inpatient 261 169.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.04 253.17 Application of short leg splint from calf to foot 48685326_1 CDM 0510 RC 29515 HCPCS inpatient 261 169.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.04 253.17 Application of short leg splint from calf to foot 48685326_1 CDM 0510 RC 29515 HCPCS inpatient 261 169.65 ANTHEM HMO ANTHEM HMO 999999999 158.04 253.17 Application of short leg splint from calf to foot 48685326_1 CDM 0510 RC 29515 HCPCS inpatient 261 169.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.04 253.17 Application of short leg splint from calf to foot 48685326_1 CDM 0510 RC 29515 HCPCS inpatient 261 169.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 176.44 67.6 999999999 158.04 253.17 percent of total billed charges Application of short leg splint from calf to foot 48685326_1 CDM 0510 RC 29515 HCPCS inpatient 261 169.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.04 253.17 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48685327_1 CDM 0510 RC 12052 HCPCS inpatient 627 407.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 407.55 65 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48685327_1 CDM 0510 RC 12052 HCPCS inpatient 627 407.55 AETNA AETNA 495.33 79 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48685327_1 CDM 0510 RC 12052 HCPCS inpatient 627 407.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 432.63 69 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48685327_1 CDM 0510 RC 12052 HCPCS inpatient 627 407.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 608.19 97 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48685327_1 CDM 0510 RC 12052 HCPCS inpatient 627 407.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 489.06 78 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48685327_1 CDM 0510 RC 12052 HCPCS inpatient 627 407.55 SIHO - ALL PLANS SIHO - ALL PLANS 564.3 90 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48685327_1 CDM 0510 RC 12052 HCPCS inpatient 627 407.55 UMR - ALL PLANS UMR - ALL PLANS 438.9 70 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48685327_1 CDM 0510 RC 12052 HCPCS inpatient 627 407.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 379.65 60.55 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48685327_1 CDM 0510 RC 12052 HCPCS inpatient 627 407.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 379.65 608.19 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48685327_1 CDM 0510 RC 12052 HCPCS inpatient 627 407.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 379.65 608.19 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48685327_1 CDM 0510 RC 12052 HCPCS inpatient 627 407.55 ANTHEM HMO ANTHEM HMO 999999999 379.65 608.19 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48685327_1 CDM 0510 RC 12052 HCPCS inpatient 627 407.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 379.65 608.19 "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48685327_1 CDM 0510 RC 12052 HCPCS inpatient 627 407.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 423.85 67.6 999999999 379.65 608.19 percent of total billed charges "Intermediate repair of wound of face, ears, eyelids, nose, lips, or mouth, 2.6-5.0 cm" 48685327_1 CDM 0510 RC 12052 HCPCS inpatient 627 407.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 379.65 608.19 VAIS-Conscious Sedation 1st 30 Min Charge 48688666_1 CDM 0370 RC inpatient 562 365.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 365.3 65 999999999 340.29 545.14 percent of total billed charges VAIS-Conscious Sedation 1st 30 Min Charge 48688666_1 CDM 0370 RC inpatient 562 365.3 AETNA AETNA 443.98 79 999999999 340.29 545.14 percent of total billed charges VAIS-Conscious Sedation 1st 30 Min Charge 48688666_1 CDM 0370 RC inpatient 562 365.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 387.78 69 999999999 340.29 545.14 percent of total billed charges VAIS-Conscious Sedation 1st 30 Min Charge 48688666_1 CDM 0370 RC inpatient 562 365.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 545.14 97 999999999 340.29 545.14 percent of total billed charges VAIS-Conscious Sedation 1st 30 Min Charge 48688666_1 CDM 0370 RC inpatient 562 365.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 438.36 78 999999999 340.29 545.14 percent of total billed charges VAIS-Conscious Sedation 1st 30 Min Charge 48688666_1 CDM 0370 RC inpatient 562 365.3 SIHO - ALL PLANS SIHO - ALL PLANS 505.8 90 999999999 340.29 545.14 percent of total billed charges VAIS-Conscious Sedation 1st 30 Min Charge 48688666_1 CDM 0370 RC inpatient 562 365.3 UMR - ALL PLANS UMR - ALL PLANS 393.4 70 999999999 340.29 545.14 percent of total billed charges VAIS-Conscious Sedation 1st 30 Min Charge 48688666_1 CDM 0370 RC inpatient 562 365.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 340.29 60.55 999999999 340.29 545.14 percent of total billed charges VAIS-Conscious Sedation 1st 30 Min Charge 48688666_1 CDM 0370 RC inpatient 562 365.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 340.29 545.14 VAIS-Conscious Sedation 1st 30 Min Charge 48688666_1 CDM 0370 RC inpatient 562 365.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 340.29 545.14 VAIS-Conscious Sedation 1st 30 Min Charge 48688666_1 CDM 0370 RC inpatient 562 365.3 ANTHEM HMO ANTHEM HMO 999999999 340.29 545.14 VAIS-Conscious Sedation 1st 30 Min Charge 48688666_1 CDM 0370 RC inpatient 562 365.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 340.29 545.14 VAIS-Conscious Sedation 1st 30 Min Charge 48688666_1 CDM 0370 RC inpatient 562 365.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 379.91 67.6 999999999 340.29 545.14 percent of total billed charges VAIS-Conscious Sedation 1st 30 Min Charge 48688666_1 CDM 0370 RC inpatient 562 365.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 340.29 545.14 VAIS- Conscious Sedation Add 15 Min Charge 48688669_1 CDM 0370 RC inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges VAIS- Conscious Sedation Add 15 Min Charge 48688669_1 CDM 0370 RC inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges VAIS- Conscious Sedation Add 15 Min Charge 48688669_1 CDM 0370 RC inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges VAIS- Conscious Sedation Add 15 Min Charge 48688669_1 CDM 0370 RC inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges VAIS- Conscious Sedation Add 15 Min Charge 48688669_1 CDM 0370 RC inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges VAIS- Conscious Sedation Add 15 Min Charge 48688669_1 CDM 0370 RC inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges VAIS- Conscious Sedation Add 15 Min Charge 48688669_1 CDM 0370 RC inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges VAIS- Conscious Sedation Add 15 Min Charge 48688669_1 CDM 0370 RC inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges VAIS- Conscious Sedation Add 15 Min Charge 48688669_1 CDM 0370 RC inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 VAIS- Conscious Sedation Add 15 Min Charge 48688669_1 CDM 0370 RC inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 VAIS- Conscious Sedation Add 15 Min Charge 48688669_1 CDM 0370 RC inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 VAIS- Conscious Sedation Add 15 Min Charge 48688669_1 CDM 0370 RC inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 VAIS- Conscious Sedation Add 15 Min Charge 48688669_1 CDM 0370 RC inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges VAIS- Conscious Sedation Add 15 Min Charge 48688669_1 CDM 0370 RC inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 EMERGENCY HEMODIALYSIS CHARGE 48688678_1 CDM 0801 RC inpatient 1446 939.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 939.9 65 999999999 875.55 1402.62 percent of total billed charges EMERGENCY HEMODIALYSIS CHARGE 48688678_1 CDM 0801 RC inpatient 1446 939.9 AETNA AETNA 1142.34 79 999999999 875.55 1402.62 percent of total billed charges EMERGENCY HEMODIALYSIS CHARGE 48688678_1 CDM 0801 RC inpatient 1446 939.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 997.74 69 999999999 875.55 1402.62 percent of total billed charges EMERGENCY HEMODIALYSIS CHARGE 48688678_1 CDM 0801 RC inpatient 1446 939.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1402.62 97 999999999 875.55 1402.62 percent of total billed charges EMERGENCY HEMODIALYSIS CHARGE 48688678_1 CDM 0801 RC inpatient 1446 939.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1127.88 78 999999999 875.55 1402.62 percent of total billed charges EMERGENCY HEMODIALYSIS CHARGE 48688678_1 CDM 0801 RC inpatient 1446 939.9 SIHO - ALL PLANS SIHO - ALL PLANS 1301.4 90 999999999 875.55 1402.62 percent of total billed charges EMERGENCY HEMODIALYSIS CHARGE 48688678_1 CDM 0801 RC inpatient 1446 939.9 UMR - ALL PLANS UMR - ALL PLANS 1012.2 70 999999999 875.55 1402.62 percent of total billed charges EMERGENCY HEMODIALYSIS CHARGE 48688678_1 CDM 0801 RC inpatient 1446 939.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 875.55 60.55 999999999 875.55 1402.62 percent of total billed charges EMERGENCY HEMODIALYSIS CHARGE 48688678_1 CDM 0801 RC inpatient 1446 939.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 875.55 1402.62 EMERGENCY HEMODIALYSIS CHARGE 48688678_1 CDM 0801 RC inpatient 1446 939.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 875.55 1402.62 EMERGENCY HEMODIALYSIS CHARGE 48688678_1 CDM 0801 RC inpatient 1446 939.9 ANTHEM HMO ANTHEM HMO 999999999 875.55 1402.62 EMERGENCY HEMODIALYSIS CHARGE 48688678_1 CDM 0801 RC inpatient 1446 939.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 875.55 1402.62 EMERGENCY HEMODIALYSIS CHARGE 48688678_1 CDM 0801 RC inpatient 1446 939.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 977.5 67.6 999999999 875.55 1402.62 percent of total billed charges EMERGENCY HEMODIALYSIS CHARGE 48688678_1 CDM 0801 RC inpatient 1446 939.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 875.55 1402.62 FEEDING PUMP B9002RR CHARGE 48688685_1 CDM 0271 RC inpatient 166 107.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.9 65 999999999 100.51 161.02 percent of total billed charges FEEDING PUMP B9002RR CHARGE 48688685_1 CDM 0271 RC inpatient 166 107.9 AETNA AETNA 131.14 79 999999999 100.51 161.02 percent of total billed charges FEEDING PUMP B9002RR CHARGE 48688685_1 CDM 0271 RC inpatient 166 107.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 114.54 69 999999999 100.51 161.02 percent of total billed charges FEEDING PUMP B9002RR CHARGE 48688685_1 CDM 0271 RC inpatient 166 107.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.02 97 999999999 100.51 161.02 percent of total billed charges FEEDING PUMP B9002RR CHARGE 48688685_1 CDM 0271 RC inpatient 166 107.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 129.48 78 999999999 100.51 161.02 percent of total billed charges FEEDING PUMP B9002RR CHARGE 48688685_1 CDM 0271 RC inpatient 166 107.9 SIHO - ALL PLANS SIHO - ALL PLANS 149.4 90 999999999 100.51 161.02 percent of total billed charges FEEDING PUMP B9002RR CHARGE 48688685_1 CDM 0271 RC inpatient 166 107.9 UMR - ALL PLANS UMR - ALL PLANS 116.2 70 999999999 100.51 161.02 percent of total billed charges FEEDING PUMP B9002RR CHARGE 48688685_1 CDM 0271 RC inpatient 166 107.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 100.51 60.55 999999999 100.51 161.02 percent of total billed charges FEEDING PUMP B9002RR CHARGE 48688685_1 CDM 0271 RC inpatient 166 107.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 100.51 161.02 FEEDING PUMP B9002RR CHARGE 48688685_1 CDM 0271 RC inpatient 166 107.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 100.51 161.02 FEEDING PUMP B9002RR CHARGE 48688685_1 CDM 0271 RC inpatient 166 107.9 ANTHEM HMO ANTHEM HMO 999999999 100.51 161.02 FEEDING PUMP B9002RR CHARGE 48688685_1 CDM 0271 RC inpatient 166 107.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 100.51 161.02 FEEDING PUMP B9002RR CHARGE 48688685_1 CDM 0271 RC inpatient 166 107.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.22 67.6 999999999 100.51 161.02 percent of total billed charges FEEDING PUMP B9002RR CHARGE 48688685_1 CDM 0271 RC inpatient 166 107.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 100.51 161.02 HEMODIALYSIS 1/1 CHARGE 48688689_1 CDM 0801 RC inpatient 1187 771.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 771.55 65 999999999 718.73 1151.39 percent of total billed charges HEMODIALYSIS 1/1 CHARGE 48688689_1 CDM 0801 RC inpatient 1187 771.55 AETNA AETNA 937.73 79 999999999 718.73 1151.39 percent of total billed charges HEMODIALYSIS 1/1 CHARGE 48688689_1 CDM 0801 RC inpatient 1187 771.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 819.03 69 999999999 718.73 1151.39 percent of total billed charges HEMODIALYSIS 1/1 CHARGE 48688689_1 CDM 0801 RC inpatient 1187 771.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1151.39 97 999999999 718.73 1151.39 percent of total billed charges HEMODIALYSIS 1/1 CHARGE 48688689_1 CDM 0801 RC inpatient 1187 771.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 925.86 78 999999999 718.73 1151.39 percent of total billed charges HEMODIALYSIS 1/1 CHARGE 48688689_1 CDM 0801 RC inpatient 1187 771.55 SIHO - ALL PLANS SIHO - ALL PLANS 1068.3 90 999999999 718.73 1151.39 percent of total billed charges HEMODIALYSIS 1/1 CHARGE 48688689_1 CDM 0801 RC inpatient 1187 771.55 UMR - ALL PLANS UMR - ALL PLANS 830.9 70 999999999 718.73 1151.39 percent of total billed charges HEMODIALYSIS 1/1 CHARGE 48688689_1 CDM 0801 RC inpatient 1187 771.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 718.73 60.55 999999999 718.73 1151.39 percent of total billed charges HEMODIALYSIS 1/1 CHARGE 48688689_1 CDM 0801 RC inpatient 1187 771.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 718.73 1151.39 HEMODIALYSIS 1/1 CHARGE 48688689_1 CDM 0801 RC inpatient 1187 771.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 718.73 1151.39 HEMODIALYSIS 1/1 CHARGE 48688689_1 CDM 0801 RC inpatient 1187 771.55 ANTHEM HMO ANTHEM HMO 999999999 718.73 1151.39 HEMODIALYSIS 1/1 CHARGE 48688689_1 CDM 0801 RC inpatient 1187 771.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 718.73 1151.39 HEMODIALYSIS 1/1 CHARGE 48688689_1 CDM 0801 RC inpatient 1187 771.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 802.41 67.6 999999999 718.73 1151.39 percent of total billed charges HEMODIALYSIS 1/1 CHARGE 48688689_1 CDM 0801 RC inpatient 1187 771.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 718.73 1151.39 HEMODIALYSIS 2/1 CHARGE 48688690_1 CDM 0801 RC inpatient 1027 667.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 667.55 65 999999999 621.85 996.19 percent of total billed charges HEMODIALYSIS 2/1 CHARGE 48688690_1 CDM 0801 RC inpatient 1027 667.55 AETNA AETNA 811.33 79 999999999 621.85 996.19 percent of total billed charges HEMODIALYSIS 2/1 CHARGE 48688690_1 CDM 0801 RC inpatient 1027 667.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 708.63 69 999999999 621.85 996.19 percent of total billed charges HEMODIALYSIS 2/1 CHARGE 48688690_1 CDM 0801 RC inpatient 1027 667.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 996.19 97 999999999 621.85 996.19 percent of total billed charges HEMODIALYSIS 2/1 CHARGE 48688690_1 CDM 0801 RC inpatient 1027 667.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 801.06 78 999999999 621.85 996.19 percent of total billed charges HEMODIALYSIS 2/1 CHARGE 48688690_1 CDM 0801 RC inpatient 1027 667.55 SIHO - ALL PLANS SIHO - ALL PLANS 924.3 90 999999999 621.85 996.19 percent of total billed charges HEMODIALYSIS 2/1 CHARGE 48688690_1 CDM 0801 RC inpatient 1027 667.55 UMR - ALL PLANS UMR - ALL PLANS 718.9 70 999999999 621.85 996.19 percent of total billed charges HEMODIALYSIS 2/1 CHARGE 48688690_1 CDM 0801 RC inpatient 1027 667.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 621.85 60.55 999999999 621.85 996.19 percent of total billed charges HEMODIALYSIS 2/1 CHARGE 48688690_1 CDM 0801 RC inpatient 1027 667.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 621.85 996.19 HEMODIALYSIS 2/1 CHARGE 48688690_1 CDM 0801 RC inpatient 1027 667.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 621.85 996.19 HEMODIALYSIS 2/1 CHARGE 48688690_1 CDM 0801 RC inpatient 1027 667.55 ANTHEM HMO ANTHEM HMO 999999999 621.85 996.19 HEMODIALYSIS 2/1 CHARGE 48688690_1 CDM 0801 RC inpatient 1027 667.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 621.85 996.19 HEMODIALYSIS 2/1 CHARGE 48688690_1 CDM 0801 RC inpatient 1027 667.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 694.25 67.6 999999999 621.85 996.19 percent of total billed charges HEMODIALYSIS 2/1 CHARGE 48688690_1 CDM 0801 RC inpatient 1027 667.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 621.85 996.19 HEMODIALYSIS 2/1 AFTER HRS CHARGE 48688693_1 CDM 0801 RC inpatient 1446 939.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 939.9 65 999999999 875.55 1402.62 percent of total billed charges HEMODIALYSIS 2/1 AFTER HRS CHARGE 48688693_1 CDM 0801 RC inpatient 1446 939.9 AETNA AETNA 1142.34 79 999999999 875.55 1402.62 percent of total billed charges HEMODIALYSIS 2/1 AFTER HRS CHARGE 48688693_1 CDM 0801 RC inpatient 1446 939.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 997.74 69 999999999 875.55 1402.62 percent of total billed charges HEMODIALYSIS 2/1 AFTER HRS CHARGE 48688693_1 CDM 0801 RC inpatient 1446 939.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1402.62 97 999999999 875.55 1402.62 percent of total billed charges HEMODIALYSIS 2/1 AFTER HRS CHARGE 48688693_1 CDM 0801 RC inpatient 1446 939.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1127.88 78 999999999 875.55 1402.62 percent of total billed charges HEMODIALYSIS 2/1 AFTER HRS CHARGE 48688693_1 CDM 0801 RC inpatient 1446 939.9 SIHO - ALL PLANS SIHO - ALL PLANS 1301.4 90 999999999 875.55 1402.62 percent of total billed charges HEMODIALYSIS 2/1 AFTER HRS CHARGE 48688693_1 CDM 0801 RC inpatient 1446 939.9 UMR - ALL PLANS UMR - ALL PLANS 1012.2 70 999999999 875.55 1402.62 percent of total billed charges HEMODIALYSIS 2/1 AFTER HRS CHARGE 48688693_1 CDM 0801 RC inpatient 1446 939.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 875.55 60.55 999999999 875.55 1402.62 percent of total billed charges HEMODIALYSIS 2/1 AFTER HRS CHARGE 48688693_1 CDM 0801 RC inpatient 1446 939.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 875.55 1402.62 HEMODIALYSIS 2/1 AFTER HRS CHARGE 48688693_1 CDM 0801 RC inpatient 1446 939.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 875.55 1402.62 HEMODIALYSIS 2/1 AFTER HRS CHARGE 48688693_1 CDM 0801 RC inpatient 1446 939.9 ANTHEM HMO ANTHEM HMO 999999999 875.55 1402.62 HEMODIALYSIS 2/1 AFTER HRS CHARGE 48688693_1 CDM 0801 RC inpatient 1446 939.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 875.55 1402.62 HEMODIALYSIS 2/1 AFTER HRS CHARGE 48688693_1 CDM 0801 RC inpatient 1446 939.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 977.5 67.6 999999999 875.55 1402.62 percent of total billed charges HEMODIALYSIS 2/1 AFTER HRS CHARGE 48688693_1 CDM 0801 RC inpatient 1446 939.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 875.55 1402.62 HEMODIALYSIS ADDITIONL HRS CHARGE 48688698_1 CDM 0801 RC inpatient 193 125.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 125.45 65 999999999 116.86 187.21 percent of total billed charges HEMODIALYSIS ADDITIONL HRS CHARGE 48688698_1 CDM 0801 RC inpatient 193 125.45 AETNA AETNA 152.47 79 999999999 116.86 187.21 percent of total billed charges HEMODIALYSIS ADDITIONL HRS CHARGE 48688698_1 CDM 0801 RC inpatient 193 125.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.17 69 999999999 116.86 187.21 percent of total billed charges HEMODIALYSIS ADDITIONL HRS CHARGE 48688698_1 CDM 0801 RC inpatient 193 125.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 187.21 97 999999999 116.86 187.21 percent of total billed charges HEMODIALYSIS ADDITIONL HRS CHARGE 48688698_1 CDM 0801 RC inpatient 193 125.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 150.54 78 999999999 116.86 187.21 percent of total billed charges HEMODIALYSIS ADDITIONL HRS CHARGE 48688698_1 CDM 0801 RC inpatient 193 125.45 SIHO - ALL PLANS SIHO - ALL PLANS 173.7 90 999999999 116.86 187.21 percent of total billed charges HEMODIALYSIS ADDITIONL HRS CHARGE 48688698_1 CDM 0801 RC inpatient 193 125.45 UMR - ALL PLANS UMR - ALL PLANS 135.1 70 999999999 116.86 187.21 percent of total billed charges HEMODIALYSIS ADDITIONL HRS CHARGE 48688698_1 CDM 0801 RC inpatient 193 125.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.86 60.55 999999999 116.86 187.21 percent of total billed charges HEMODIALYSIS ADDITIONL HRS CHARGE 48688698_1 CDM 0801 RC inpatient 193 125.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.86 187.21 HEMODIALYSIS ADDITIONL HRS CHARGE 48688698_1 CDM 0801 RC inpatient 193 125.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.86 187.21 HEMODIALYSIS ADDITIONL HRS CHARGE 48688698_1 CDM 0801 RC inpatient 193 125.45 ANTHEM HMO ANTHEM HMO 999999999 116.86 187.21 HEMODIALYSIS ADDITIONL HRS CHARGE 48688698_1 CDM 0801 RC inpatient 193 125.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.86 187.21 HEMODIALYSIS ADDITIONL HRS CHARGE 48688698_1 CDM 0801 RC inpatient 193 125.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 130.47 67.6 999999999 116.86 187.21 percent of total billed charges HEMODIALYSIS ADDITIONL HRS CHARGE 48688698_1 CDM 0801 RC inpatient 193 125.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.86 187.21 HEMODIALYSIS INCOMPLETE CHARGE 48688703_1 CDM 0801 RC inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges HEMODIALYSIS INCOMPLETE CHARGE 48688703_1 CDM 0801 RC inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges HEMODIALYSIS INCOMPLETE CHARGE 48688703_1 CDM 0801 RC inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges HEMODIALYSIS INCOMPLETE CHARGE 48688703_1 CDM 0801 RC inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges HEMODIALYSIS INCOMPLETE CHARGE 48688703_1 CDM 0801 RC inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges HEMODIALYSIS INCOMPLETE CHARGE 48688703_1 CDM 0801 RC inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges HEMODIALYSIS INCOMPLETE CHARGE 48688703_1 CDM 0801 RC inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges HEMODIALYSIS INCOMPLETE CHARGE 48688703_1 CDM 0801 RC inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges HEMODIALYSIS INCOMPLETE CHARGE 48688703_1 CDM 0801 RC inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 HEMODIALYSIS INCOMPLETE CHARGE 48688703_1 CDM 0801 RC inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 HEMODIALYSIS INCOMPLETE CHARGE 48688703_1 CDM 0801 RC inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 HEMODIALYSIS INCOMPLETE CHARGE 48688703_1 CDM 0801 RC inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 HEMODIALYSIS INCOMPLETE CHARGE 48688703_1 CDM 0801 RC inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges HEMODIALYSIS INCOMPLETE CHARGE 48688703_1 CDM 0801 RC inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 HEMODIALYSIS-UNSCHEDULED CHARGE 48688714_1 CDM 0801 RC inpatient 1452 943.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 943.8 65 999999999 879.19 1408.44 percent of total billed charges HEMODIALYSIS-UNSCHEDULED CHARGE 48688714_1 CDM 0801 RC inpatient 1452 943.8 AETNA AETNA 1147.08 79 999999999 879.19 1408.44 percent of total billed charges HEMODIALYSIS-UNSCHEDULED CHARGE 48688714_1 CDM 0801 RC inpatient 1452 943.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1001.88 69 999999999 879.19 1408.44 percent of total billed charges HEMODIALYSIS-UNSCHEDULED CHARGE 48688714_1 CDM 0801 RC inpatient 1452 943.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1408.44 97 999999999 879.19 1408.44 percent of total billed charges HEMODIALYSIS-UNSCHEDULED CHARGE 48688714_1 CDM 0801 RC inpatient 1452 943.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1132.56 78 999999999 879.19 1408.44 percent of total billed charges HEMODIALYSIS-UNSCHEDULED CHARGE 48688714_1 CDM 0801 RC inpatient 1452 943.8 SIHO - ALL PLANS SIHO - ALL PLANS 1306.8 90 999999999 879.19 1408.44 percent of total billed charges HEMODIALYSIS-UNSCHEDULED CHARGE 48688714_1 CDM 0801 RC inpatient 1452 943.8 UMR - ALL PLANS UMR - ALL PLANS 1016.4 70 999999999 879.19 1408.44 percent of total billed charges HEMODIALYSIS-UNSCHEDULED CHARGE 48688714_1 CDM 0801 RC inpatient 1452 943.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 879.19 60.55 999999999 879.19 1408.44 percent of total billed charges HEMODIALYSIS-UNSCHEDULED CHARGE 48688714_1 CDM 0801 RC inpatient 1452 943.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 879.19 1408.44 HEMODIALYSIS-UNSCHEDULED CHARGE 48688714_1 CDM 0801 RC inpatient 1452 943.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 879.19 1408.44 HEMODIALYSIS-UNSCHEDULED CHARGE 48688714_1 CDM 0801 RC inpatient 1452 943.8 ANTHEM HMO ANTHEM HMO 999999999 879.19 1408.44 HEMODIALYSIS-UNSCHEDULED CHARGE 48688714_1 CDM 0801 RC inpatient 1452 943.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 879.19 1408.44 HEMODIALYSIS-UNSCHEDULED CHARGE 48688714_1 CDM 0801 RC inpatient 1452 943.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 981.55 67.6 999999999 879.19 1408.44 percent of total billed charges HEMODIALYSIS-UNSCHEDULED CHARGE 48688714_1 CDM 0801 RC inpatient 1452 943.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 879.19 1408.44 "Infusion into a vein for hydration, each additional hour" 48688716_1 CDM 0761 RC 96361 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 48688716_1 CDM 0761 RC 96361 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 48688716_1 CDM 0761 RC 96361 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 48688716_1 CDM 0761 RC 96361 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 48688716_1 CDM 0761 RC 96361 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 48688716_1 CDM 0761 RC 96361 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 48688716_1 CDM 0761 RC 96361 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 48688716_1 CDM 0761 RC 96361 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 48688716_1 CDM 0761 RC 96361 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Infusion into a vein for hydration, each additional hour" 48688716_1 CDM 0761 RC 96361 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Infusion into a vein for hydration, each additional hour" 48688716_1 CDM 0761 RC 96361 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Infusion into a vein for hydration, each additional hour" 48688716_1 CDM 0761 RC 96361 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Infusion into a vein for hydration, each additional hour" 48688716_1 CDM 0761 RC 96361 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 48688716_1 CDM 0761 RC 96361 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Infusion into a vein for hydration, 31-60 minutes" 48688719_1 CDM 0761 RC 96360 HCPCS inpatient 236 153.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 153.4 65 999999999 142.9 228.92 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 48688719_1 CDM 0761 RC 96360 HCPCS inpatient 236 153.4 AETNA AETNA 186.44 79 999999999 142.9 228.92 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 48688719_1 CDM 0761 RC 96360 HCPCS inpatient 236 153.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 162.84 69 999999999 142.9 228.92 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 48688719_1 CDM 0761 RC 96360 HCPCS inpatient 236 153.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 228.92 97 999999999 142.9 228.92 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 48688719_1 CDM 0761 RC 96360 HCPCS inpatient 236 153.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 184.08 78 999999999 142.9 228.92 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 48688719_1 CDM 0761 RC 96360 HCPCS inpatient 236 153.4 SIHO - ALL PLANS SIHO - ALL PLANS 212.4 90 999999999 142.9 228.92 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 48688719_1 CDM 0761 RC 96360 HCPCS inpatient 236 153.4 UMR - ALL PLANS UMR - ALL PLANS 165.2 70 999999999 142.9 228.92 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 48688719_1 CDM 0761 RC 96360 HCPCS inpatient 236 153.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 142.9 60.55 999999999 142.9 228.92 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 48688719_1 CDM 0761 RC 96360 HCPCS inpatient 236 153.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 142.9 228.92 "Infusion into a vein for hydration, 31-60 minutes" 48688719_1 CDM 0761 RC 96360 HCPCS inpatient 236 153.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 142.9 228.92 "Infusion into a vein for hydration, 31-60 minutes" 48688719_1 CDM 0761 RC 96360 HCPCS inpatient 236 153.4 ANTHEM HMO ANTHEM HMO 999999999 142.9 228.92 "Infusion into a vein for hydration, 31-60 minutes" 48688719_1 CDM 0761 RC 96360 HCPCS inpatient 236 153.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 142.9 228.92 "Infusion into a vein for hydration, 31-60 minutes" 48688719_1 CDM 0761 RC 96360 HCPCS inpatient 236 153.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 159.54 67.6 999999999 142.9 228.92 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 48688719_1 CDM 0761 RC 96360 HCPCS inpatient 236 153.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 142.9 228.92 "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48688730_1 CDM 0761 RC 96368 HCPCS inpatient 96 62.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.4 65 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48688730_1 CDM 0761 RC 96368 HCPCS inpatient 96 62.4 AETNA AETNA 75.84 79 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48688730_1 CDM 0761 RC 96368 HCPCS inpatient 96 62.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.24 69 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48688730_1 CDM 0761 RC 96368 HCPCS inpatient 96 62.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.12 97 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48688730_1 CDM 0761 RC 96368 HCPCS inpatient 96 62.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.88 78 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48688730_1 CDM 0761 RC 96368 HCPCS inpatient 96 62.4 SIHO - ALL PLANS SIHO - ALL PLANS 86.4 90 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48688730_1 CDM 0761 RC 96368 HCPCS inpatient 96 62.4 UMR - ALL PLANS UMR - ALL PLANS 67.2 70 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48688730_1 CDM 0761 RC 96368 HCPCS inpatient 96 62.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.13 60.55 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48688730_1 CDM 0761 RC 96368 HCPCS inpatient 96 62.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.13 93.12 "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48688730_1 CDM 0761 RC 96368 HCPCS inpatient 96 62.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.13 93.12 "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48688730_1 CDM 0761 RC 96368 HCPCS inpatient 96 62.4 ANTHEM HMO ANTHEM HMO 999999999 58.13 93.12 "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48688730_1 CDM 0761 RC 96368 HCPCS inpatient 96 62.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.13 93.12 "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48688730_1 CDM 0761 RC 96368 HCPCS inpatient 96 62.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.9 67.6 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48688730_1 CDM 0761 RC 96368 HCPCS inpatient 96 62.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.13 93.12 "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48688736_1 CDM 0263 RC 96366 HCPCS inpatient 74 48.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.1 65 999999999 44.81 71.78 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48688736_1 CDM 0263 RC 96366 HCPCS inpatient 74 48.1 AETNA AETNA 58.46 79 999999999 44.81 71.78 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48688736_1 CDM 0263 RC 96366 HCPCS inpatient 74 48.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.06 69 999999999 44.81 71.78 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48688736_1 CDM 0263 RC 96366 HCPCS inpatient 74 48.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 71.78 97 999999999 44.81 71.78 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48688736_1 CDM 0263 RC 96366 HCPCS inpatient 74 48.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 57.72 78 999999999 44.81 71.78 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48688736_1 CDM 0263 RC 96366 HCPCS inpatient 74 48.1 SIHO - ALL PLANS SIHO - ALL PLANS 66.6 90 999999999 44.81 71.78 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48688736_1 CDM 0263 RC 96366 HCPCS inpatient 74 48.1 UMR - ALL PLANS UMR - ALL PLANS 51.8 70 999999999 44.81 71.78 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48688736_1 CDM 0263 RC 96366 HCPCS inpatient 74 48.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.81 60.55 999999999 44.81 71.78 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48688736_1 CDM 0263 RC 96366 HCPCS inpatient 74 48.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.81 71.78 "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48688736_1 CDM 0263 RC 96366 HCPCS inpatient 74 48.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.81 71.78 "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48688736_1 CDM 0263 RC 96366 HCPCS inpatient 74 48.1 ANTHEM HMO ANTHEM HMO 999999999 44.81 71.78 "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48688736_1 CDM 0263 RC 96366 HCPCS inpatient 74 48.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.81 71.78 "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48688736_1 CDM 0263 RC 96366 HCPCS inpatient 74 48.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.02 67.6 999999999 44.81 71.78 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48688736_1 CDM 0263 RC 96366 HCPCS inpatient 74 48.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.81 71.78 "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48688740_1 CDM 0761 RC 96365 HCPCS inpatient 472 306.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 306.8 65 999999999 285.8 457.84 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48688740_1 CDM 0761 RC 96365 HCPCS inpatient 472 306.8 AETNA AETNA 372.88 79 999999999 285.8 457.84 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48688740_1 CDM 0761 RC 96365 HCPCS inpatient 472 306.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 325.68 69 999999999 285.8 457.84 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48688740_1 CDM 0761 RC 96365 HCPCS inpatient 472 306.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 457.84 97 999999999 285.8 457.84 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48688740_1 CDM 0761 RC 96365 HCPCS inpatient 472 306.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 368.16 78 999999999 285.8 457.84 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48688740_1 CDM 0761 RC 96365 HCPCS inpatient 472 306.8 SIHO - ALL PLANS SIHO - ALL PLANS 424.8 90 999999999 285.8 457.84 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48688740_1 CDM 0761 RC 96365 HCPCS inpatient 472 306.8 UMR - ALL PLANS UMR - ALL PLANS 330.4 70 999999999 285.8 457.84 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48688740_1 CDM 0761 RC 96365 HCPCS inpatient 472 306.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 285.8 60.55 999999999 285.8 457.84 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48688740_1 CDM 0761 RC 96365 HCPCS inpatient 472 306.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 285.8 457.84 "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48688740_1 CDM 0761 RC 96365 HCPCS inpatient 472 306.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 285.8 457.84 "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48688740_1 CDM 0761 RC 96365 HCPCS inpatient 472 306.8 ANTHEM HMO ANTHEM HMO 999999999 285.8 457.84 "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48688740_1 CDM 0761 RC 96365 HCPCS inpatient 472 306.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 285.8 457.84 "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48688740_1 CDM 0761 RC 96365 HCPCS inpatient 472 306.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 319.07 67.6 999999999 285.8 457.84 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48688740_1 CDM 0761 RC 96365 HCPCS inpatient 472 306.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 285.8 457.84 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48688745_1 CDM 0761 RC 96367 HCPCS inpatient 96 62.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.4 65 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48688745_1 CDM 0761 RC 96367 HCPCS inpatient 96 62.4 AETNA AETNA 75.84 79 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48688745_1 CDM 0761 RC 96367 HCPCS inpatient 96 62.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.24 69 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48688745_1 CDM 0761 RC 96367 HCPCS inpatient 96 62.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.12 97 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48688745_1 CDM 0761 RC 96367 HCPCS inpatient 96 62.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.88 78 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48688745_1 CDM 0761 RC 96367 HCPCS inpatient 96 62.4 SIHO - ALL PLANS SIHO - ALL PLANS 86.4 90 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48688745_1 CDM 0761 RC 96367 HCPCS inpatient 96 62.4 UMR - ALL PLANS UMR - ALL PLANS 67.2 70 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48688745_1 CDM 0761 RC 96367 HCPCS inpatient 96 62.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.13 60.55 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48688745_1 CDM 0761 RC 96367 HCPCS inpatient 96 62.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.13 93.12 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48688745_1 CDM 0761 RC 96367 HCPCS inpatient 96 62.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.13 93.12 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48688745_1 CDM 0761 RC 96367 HCPCS inpatient 96 62.4 ANTHEM HMO ANTHEM HMO 999999999 58.13 93.12 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48688745_1 CDM 0761 RC 96367 HCPCS inpatient 96 62.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.13 93.12 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48688745_1 CDM 0761 RC 96367 HCPCS inpatient 96 62.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.9 67.6 999999999 58.13 93.12 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48688745_1 CDM 0761 RC 96367 HCPCS inpatient 96 62.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.13 93.12 Injection of drug or substance under skin or into muscle 48688749_1 CDM 0761 RC 96372 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges Injection of drug or substance under skin or into muscle 48688749_1 CDM 0761 RC 96372 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges Injection of drug or substance under skin or into muscle 48688749_1 CDM 0761 RC 96372 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges Injection of drug or substance under skin or into muscle 48688749_1 CDM 0761 RC 96372 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges Injection of drug or substance under skin or into muscle 48688749_1 CDM 0761 RC 96372 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges Injection of drug or substance under skin or into muscle 48688749_1 CDM 0761 RC 96372 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges Injection of drug or substance under skin or into muscle 48688749_1 CDM 0761 RC 96372 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges Injection of drug or substance under skin or into muscle 48688749_1 CDM 0761 RC 96372 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges Injection of drug or substance under skin or into muscle 48688749_1 CDM 0761 RC 96372 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 Injection of drug or substance under skin or into muscle 48688749_1 CDM 0761 RC 96372 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 Injection of drug or substance under skin or into muscle 48688749_1 CDM 0761 RC 96372 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 Injection of drug or substance under skin or into muscle 48688749_1 CDM 0761 RC 96372 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 Injection of drug or substance under skin or into muscle 48688749_1 CDM 0761 RC 96372 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges Injection of drug or substance under skin or into muscle 48688749_1 CDM 0761 RC 96372 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 Injection of drug or substance into artery 48688752_1 CDM 0761 RC 96373 HCPCS inpatient 173 112.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 112.45 65 999999999 104.75 167.81 percent of total billed charges Injection of drug or substance into artery 48688752_1 CDM 0761 RC 96373 HCPCS inpatient 173 112.45 AETNA AETNA 136.67 79 999999999 104.75 167.81 percent of total billed charges Injection of drug or substance into artery 48688752_1 CDM 0761 RC 96373 HCPCS inpatient 173 112.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 119.37 69 999999999 104.75 167.81 percent of total billed charges Injection of drug or substance into artery 48688752_1 CDM 0761 RC 96373 HCPCS inpatient 173 112.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 167.81 97 999999999 104.75 167.81 percent of total billed charges Injection of drug or substance into artery 48688752_1 CDM 0761 RC 96373 HCPCS inpatient 173 112.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.94 78 999999999 104.75 167.81 percent of total billed charges Injection of drug or substance into artery 48688752_1 CDM 0761 RC 96373 HCPCS inpatient 173 112.45 SIHO - ALL PLANS SIHO - ALL PLANS 155.7 90 999999999 104.75 167.81 percent of total billed charges Injection of drug or substance into artery 48688752_1 CDM 0761 RC 96373 HCPCS inpatient 173 112.45 UMR - ALL PLANS UMR - ALL PLANS 121.1 70 999999999 104.75 167.81 percent of total billed charges Injection of drug or substance into artery 48688752_1 CDM 0761 RC 96373 HCPCS inpatient 173 112.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.75 60.55 999999999 104.75 167.81 percent of total billed charges Injection of drug or substance into artery 48688752_1 CDM 0761 RC 96373 HCPCS inpatient 173 112.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.75 167.81 Injection of drug or substance into artery 48688752_1 CDM 0761 RC 96373 HCPCS inpatient 173 112.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.75 167.81 Injection of drug or substance into artery 48688752_1 CDM 0761 RC 96373 HCPCS inpatient 173 112.45 ANTHEM HMO ANTHEM HMO 999999999 104.75 167.81 Injection of drug or substance into artery 48688752_1 CDM 0761 RC 96373 HCPCS inpatient 173 112.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.75 167.81 Injection of drug or substance into artery 48688752_1 CDM 0761 RC 96373 HCPCS inpatient 173 112.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.95 67.6 999999999 104.75 167.81 percent of total billed charges Injection of drug or substance into artery 48688752_1 CDM 0761 RC 96373 HCPCS inpatient 173 112.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.75 167.81 Injection of drug or substance into vein 48688756_1 CDM 0761 RC 96374 HCPCS inpatient 268 174.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 174.2 65 999999999 162.27 259.96 percent of total billed charges Injection of drug or substance into vein 48688756_1 CDM 0761 RC 96374 HCPCS inpatient 268 174.2 AETNA AETNA 211.72 79 999999999 162.27 259.96 percent of total billed charges Injection of drug or substance into vein 48688756_1 CDM 0761 RC 96374 HCPCS inpatient 268 174.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.92 69 999999999 162.27 259.96 percent of total billed charges Injection of drug or substance into vein 48688756_1 CDM 0761 RC 96374 HCPCS inpatient 268 174.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 259.96 97 999999999 162.27 259.96 percent of total billed charges Injection of drug or substance into vein 48688756_1 CDM 0761 RC 96374 HCPCS inpatient 268 174.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 209.04 78 999999999 162.27 259.96 percent of total billed charges Injection of drug or substance into vein 48688756_1 CDM 0761 RC 96374 HCPCS inpatient 268 174.2 SIHO - ALL PLANS SIHO - ALL PLANS 241.2 90 999999999 162.27 259.96 percent of total billed charges Injection of drug or substance into vein 48688756_1 CDM 0761 RC 96374 HCPCS inpatient 268 174.2 UMR - ALL PLANS UMR - ALL PLANS 187.6 70 999999999 162.27 259.96 percent of total billed charges Injection of drug or substance into vein 48688756_1 CDM 0761 RC 96374 HCPCS inpatient 268 174.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 162.27 60.55 999999999 162.27 259.96 percent of total billed charges Injection of drug or substance into vein 48688756_1 CDM 0761 RC 96374 HCPCS inpatient 268 174.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 162.27 259.96 Injection of drug or substance into vein 48688756_1 CDM 0761 RC 96374 HCPCS inpatient 268 174.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 162.27 259.96 Injection of drug or substance into vein 48688756_1 CDM 0761 RC 96374 HCPCS inpatient 268 174.2 ANTHEM HMO ANTHEM HMO 999999999 162.27 259.96 Injection of drug or substance into vein 48688756_1 CDM 0761 RC 96374 HCPCS inpatient 268 174.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 162.27 259.96 Injection of drug or substance into vein 48688756_1 CDM 0761 RC 96374 HCPCS inpatient 268 174.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 181.17 67.6 999999999 162.27 259.96 percent of total billed charges Injection of drug or substance into vein 48688756_1 CDM 0761 RC 96374 HCPCS inpatient 268 174.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 162.27 259.96 Injection of additional new drug or substance into vein 48688757_1 CDM 0761 RC 96375 HCPCS inpatient 173 112.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 112.45 65 999999999 104.75 167.81 percent of total billed charges Injection of additional new drug or substance into vein 48688757_1 CDM 0761 RC 96375 HCPCS inpatient 173 112.45 AETNA AETNA 136.67 79 999999999 104.75 167.81 percent of total billed charges Injection of additional new drug or substance into vein 48688757_1 CDM 0761 RC 96375 HCPCS inpatient 173 112.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 119.37 69 999999999 104.75 167.81 percent of total billed charges Injection of additional new drug or substance into vein 48688757_1 CDM 0761 RC 96375 HCPCS inpatient 173 112.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 167.81 97 999999999 104.75 167.81 percent of total billed charges Injection of additional new drug or substance into vein 48688757_1 CDM 0761 RC 96375 HCPCS inpatient 173 112.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.94 78 999999999 104.75 167.81 percent of total billed charges Injection of additional new drug or substance into vein 48688757_1 CDM 0761 RC 96375 HCPCS inpatient 173 112.45 SIHO - ALL PLANS SIHO - ALL PLANS 155.7 90 999999999 104.75 167.81 percent of total billed charges Injection of additional new drug or substance into vein 48688757_1 CDM 0761 RC 96375 HCPCS inpatient 173 112.45 UMR - ALL PLANS UMR - ALL PLANS 121.1 70 999999999 104.75 167.81 percent of total billed charges Injection of additional new drug or substance into vein 48688757_1 CDM 0761 RC 96375 HCPCS inpatient 173 112.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.75 60.55 999999999 104.75 167.81 percent of total billed charges Injection of additional new drug or substance into vein 48688757_1 CDM 0761 RC 96375 HCPCS inpatient 173 112.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.75 167.81 Injection of additional new drug or substance into vein 48688757_1 CDM 0761 RC 96375 HCPCS inpatient 173 112.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.75 167.81 Injection of additional new drug or substance into vein 48688757_1 CDM 0761 RC 96375 HCPCS inpatient 173 112.45 ANTHEM HMO ANTHEM HMO 999999999 104.75 167.81 Injection of additional new drug or substance into vein 48688757_1 CDM 0761 RC 96375 HCPCS inpatient 173 112.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.75 167.81 Injection of additional new drug or substance into vein 48688757_1 CDM 0761 RC 96375 HCPCS inpatient 173 112.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.95 67.6 999999999 104.75 167.81 percent of total billed charges Injection of additional new drug or substance into vein 48688757_1 CDM 0761 RC 96375 HCPCS inpatient 173 112.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.75 167.81 PERITONEAL DIALYSIS-CCPD-AFTR HRS CHARGE 48688766_1 CDM 0804 RC inpatient 1326 861.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 861.9 65 999999999 802.89 1286.22 percent of total billed charges PERITONEAL DIALYSIS-CCPD-AFTR HRS CHARGE 48688766_1 CDM 0804 RC inpatient 1326 861.9 AETNA AETNA 1047.54 79 999999999 802.89 1286.22 percent of total billed charges PERITONEAL DIALYSIS-CCPD-AFTR HRS CHARGE 48688766_1 CDM 0804 RC inpatient 1326 861.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 914.94 69 999999999 802.89 1286.22 percent of total billed charges PERITONEAL DIALYSIS-CCPD-AFTR HRS CHARGE 48688766_1 CDM 0804 RC inpatient 1326 861.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1286.22 97 999999999 802.89 1286.22 percent of total billed charges PERITONEAL DIALYSIS-CCPD-AFTR HRS CHARGE 48688766_1 CDM 0804 RC inpatient 1326 861.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1034.28 78 999999999 802.89 1286.22 percent of total billed charges PERITONEAL DIALYSIS-CCPD-AFTR HRS CHARGE 48688766_1 CDM 0804 RC inpatient 1326 861.9 SIHO - ALL PLANS SIHO - ALL PLANS 1193.4 90 999999999 802.89 1286.22 percent of total billed charges PERITONEAL DIALYSIS-CCPD-AFTR HRS CHARGE 48688766_1 CDM 0804 RC inpatient 1326 861.9 UMR - ALL PLANS UMR - ALL PLANS 928.2 70 999999999 802.89 1286.22 percent of total billed charges PERITONEAL DIALYSIS-CCPD-AFTR HRS CHARGE 48688766_1 CDM 0804 RC inpatient 1326 861.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 802.89 60.55 999999999 802.89 1286.22 percent of total billed charges PERITONEAL DIALYSIS-CCPD-AFTR HRS CHARGE 48688766_1 CDM 0804 RC inpatient 1326 861.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 802.89 1286.22 PERITONEAL DIALYSIS-CCPD-AFTR HRS CHARGE 48688766_1 CDM 0804 RC inpatient 1326 861.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 802.89 1286.22 PERITONEAL DIALYSIS-CCPD-AFTR HRS CHARGE 48688766_1 CDM 0804 RC inpatient 1326 861.9 ANTHEM HMO ANTHEM HMO 999999999 802.89 1286.22 PERITONEAL DIALYSIS-CCPD-AFTR HRS CHARGE 48688766_1 CDM 0804 RC inpatient 1326 861.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 802.89 1286.22 PERITONEAL DIALYSIS-CCPD-AFTR HRS CHARGE 48688766_1 CDM 0804 RC inpatient 1326 861.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 896.38 67.6 999999999 802.89 1286.22 percent of total billed charges PERITONEAL DIALYSIS-CCPD-AFTR HRS CHARGE 48688766_1 CDM 0804 RC inpatient 1326 861.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 802.89 1286.22 PERITONEAL DIALYSIS-CAPD CHARGE 48688769_1 CDM 0803 RC inpatient 351 228.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 228.15 65 999999999 212.53 340.47 percent of total billed charges PERITONEAL DIALYSIS-CAPD CHARGE 48688769_1 CDM 0803 RC inpatient 351 228.15 AETNA AETNA 277.29 79 999999999 212.53 340.47 percent of total billed charges PERITONEAL DIALYSIS-CAPD CHARGE 48688769_1 CDM 0803 RC inpatient 351 228.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 242.19 69 999999999 212.53 340.47 percent of total billed charges PERITONEAL DIALYSIS-CAPD CHARGE 48688769_1 CDM 0803 RC inpatient 351 228.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 340.47 97 999999999 212.53 340.47 percent of total billed charges PERITONEAL DIALYSIS-CAPD CHARGE 48688769_1 CDM 0803 RC inpatient 351 228.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 273.78 78 999999999 212.53 340.47 percent of total billed charges PERITONEAL DIALYSIS-CAPD CHARGE 48688769_1 CDM 0803 RC inpatient 351 228.15 SIHO - ALL PLANS SIHO - ALL PLANS 315.9 90 999999999 212.53 340.47 percent of total billed charges PERITONEAL DIALYSIS-CAPD CHARGE 48688769_1 CDM 0803 RC inpatient 351 228.15 UMR - ALL PLANS UMR - ALL PLANS 245.7 70 999999999 212.53 340.47 percent of total billed charges PERITONEAL DIALYSIS-CAPD CHARGE 48688769_1 CDM 0803 RC inpatient 351 228.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 212.53 60.55 999999999 212.53 340.47 percent of total billed charges PERITONEAL DIALYSIS-CAPD CHARGE 48688769_1 CDM 0803 RC inpatient 351 228.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 212.53 340.47 PERITONEAL DIALYSIS-CAPD CHARGE 48688769_1 CDM 0803 RC inpatient 351 228.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 212.53 340.47 PERITONEAL DIALYSIS-CAPD CHARGE 48688769_1 CDM 0803 RC inpatient 351 228.15 ANTHEM HMO ANTHEM HMO 999999999 212.53 340.47 PERITONEAL DIALYSIS-CAPD CHARGE 48688769_1 CDM 0803 RC inpatient 351 228.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 212.53 340.47 PERITONEAL DIALYSIS-CAPD CHARGE 48688769_1 CDM 0803 RC inpatient 351 228.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 237.28 67.6 999999999 212.53 340.47 percent of total billed charges PERITONEAL DIALYSIS-CAPD CHARGE 48688769_1 CDM 0803 RC inpatient 351 228.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 212.53 340.47 PERITONEAL DIALYSIS-CCPD CHARGE 48688770_1 CDM 0804 RC inpatient 899 584.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 584.35 65 999999999 544.34 872.03 percent of total billed charges PERITONEAL DIALYSIS-CCPD CHARGE 48688770_1 CDM 0804 RC inpatient 899 584.35 AETNA AETNA 710.21 79 999999999 544.34 872.03 percent of total billed charges PERITONEAL DIALYSIS-CCPD CHARGE 48688770_1 CDM 0804 RC inpatient 899 584.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 620.31 69 999999999 544.34 872.03 percent of total billed charges PERITONEAL DIALYSIS-CCPD CHARGE 48688770_1 CDM 0804 RC inpatient 899 584.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 872.03 97 999999999 544.34 872.03 percent of total billed charges PERITONEAL DIALYSIS-CCPD CHARGE 48688770_1 CDM 0804 RC inpatient 899 584.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 701.22 78 999999999 544.34 872.03 percent of total billed charges PERITONEAL DIALYSIS-CCPD CHARGE 48688770_1 CDM 0804 RC inpatient 899 584.35 SIHO - ALL PLANS SIHO - ALL PLANS 809.1 90 999999999 544.34 872.03 percent of total billed charges PERITONEAL DIALYSIS-CCPD CHARGE 48688770_1 CDM 0804 RC inpatient 899 584.35 UMR - ALL PLANS UMR - ALL PLANS 629.3 70 999999999 544.34 872.03 percent of total billed charges PERITONEAL DIALYSIS-CCPD CHARGE 48688770_1 CDM 0804 RC inpatient 899 584.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 544.34 60.55 999999999 544.34 872.03 percent of total billed charges PERITONEAL DIALYSIS-CCPD CHARGE 48688770_1 CDM 0804 RC inpatient 899 584.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 544.34 872.03 PERITONEAL DIALYSIS-CCPD CHARGE 48688770_1 CDM 0804 RC inpatient 899 584.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 544.34 872.03 PERITONEAL DIALYSIS-CCPD CHARGE 48688770_1 CDM 0804 RC inpatient 899 584.35 ANTHEM HMO ANTHEM HMO 999999999 544.34 872.03 PERITONEAL DIALYSIS-CCPD CHARGE 48688770_1 CDM 0804 RC inpatient 899 584.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 544.34 872.03 PERITONEAL DIALYSIS-CCPD CHARGE 48688770_1 CDM 0804 RC inpatient 899 584.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 607.72 67.6 999999999 544.34 872.03 percent of total billed charges PERITONEAL DIALYSIS-CCPD CHARGE 48688770_1 CDM 0804 RC inpatient 899 584.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 544.34 872.03 Removal of tunneled central venous tube 48688775_1 CDM 0761 RC 36589 HCPCS inpatient 1883 1223.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1223.95 65 999999999 1140.16 1826.51 percent of total billed charges Removal of tunneled central venous tube 48688775_1 CDM 0761 RC 36589 HCPCS inpatient 1883 1223.95 AETNA AETNA 1487.57 79 999999999 1140.16 1826.51 percent of total billed charges Removal of tunneled central venous tube 48688775_1 CDM 0761 RC 36589 HCPCS inpatient 1883 1223.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1299.27 69 999999999 1140.16 1826.51 percent of total billed charges Removal of tunneled central venous tube 48688775_1 CDM 0761 RC 36589 HCPCS inpatient 1883 1223.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1826.51 97 999999999 1140.16 1826.51 percent of total billed charges Removal of tunneled central venous tube 48688775_1 CDM 0761 RC 36589 HCPCS inpatient 1883 1223.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1468.74 78 999999999 1140.16 1826.51 percent of total billed charges Removal of tunneled central venous tube 48688775_1 CDM 0761 RC 36589 HCPCS inpatient 1883 1223.95 SIHO - ALL PLANS SIHO - ALL PLANS 1694.7 90 999999999 1140.16 1826.51 percent of total billed charges Removal of tunneled central venous tube 48688775_1 CDM 0761 RC 36589 HCPCS inpatient 1883 1223.95 UMR - ALL PLANS UMR - ALL PLANS 1318.1 70 999999999 1140.16 1826.51 percent of total billed charges Removal of tunneled central venous tube 48688775_1 CDM 0761 RC 36589 HCPCS inpatient 1883 1223.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1140.16 60.55 999999999 1140.16 1826.51 percent of total billed charges Removal of tunneled central venous tube 48688775_1 CDM 0761 RC 36589 HCPCS inpatient 1883 1223.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1140.16 1826.51 Removal of tunneled central venous tube 48688775_1 CDM 0761 RC 36589 HCPCS inpatient 1883 1223.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1140.16 1826.51 Removal of tunneled central venous tube 48688775_1 CDM 0761 RC 36589 HCPCS inpatient 1883 1223.95 ANTHEM HMO ANTHEM HMO 999999999 1140.16 1826.51 Removal of tunneled central venous tube 48688775_1 CDM 0761 RC 36589 HCPCS inpatient 1883 1223.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1140.16 1826.51 Removal of tunneled central venous tube 48688775_1 CDM 0761 RC 36589 HCPCS inpatient 1883 1223.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1272.91 67.6 999999999 1140.16 1826.51 percent of total billed charges Removal of tunneled central venous tube 48688775_1 CDM 0761 RC 36589 HCPCS inpatient 1883 1223.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1140.16 1826.51 Insertion of tube for infusion (5 years or older) 48689131_1 CDM 0761 RC 36569 HCPCS inpatient 4430 2879.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 2879.5 65 999999999 2682.37 4297.1 percent of total billed charges Insertion of tube for infusion (5 years or older) 48689131_1 CDM 0761 RC 36569 HCPCS inpatient 4430 2879.5 AETNA AETNA 3499.7 79 999999999 2682.37 4297.1 percent of total billed charges Insertion of tube for infusion (5 years or older) 48689131_1 CDM 0761 RC 36569 HCPCS inpatient 4430 2879.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 3056.7 69 999999999 2682.37 4297.1 percent of total billed charges Insertion of tube for infusion (5 years or older) 48689131_1 CDM 0761 RC 36569 HCPCS inpatient 4430 2879.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4297.1 97 999999999 2682.37 4297.1 percent of total billed charges Insertion of tube for infusion (5 years or older) 48689131_1 CDM 0761 RC 36569 HCPCS inpatient 4430 2879.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 3455.4 78 999999999 2682.37 4297.1 percent of total billed charges Insertion of tube for infusion (5 years or older) 48689131_1 CDM 0761 RC 36569 HCPCS inpatient 4430 2879.5 SIHO - ALL PLANS SIHO - ALL PLANS 3987 90 999999999 2682.37 4297.1 percent of total billed charges Insertion of tube for infusion (5 years or older) 48689131_1 CDM 0761 RC 36569 HCPCS inpatient 4430 2879.5 UMR - ALL PLANS UMR - ALL PLANS 3101 70 999999999 2682.37 4297.1 percent of total billed charges Insertion of tube for infusion (5 years or older) 48689131_1 CDM 0761 RC 36569 HCPCS inpatient 4430 2879.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2682.37 60.55 999999999 2682.37 4297.1 percent of total billed charges Insertion of tube for infusion (5 years or older) 48689131_1 CDM 0761 RC 36569 HCPCS inpatient 4430 2879.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2682.37 4297.1 Insertion of tube for infusion (5 years or older) 48689131_1 CDM 0761 RC 36569 HCPCS inpatient 4430 2879.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2682.37 4297.1 Insertion of tube for infusion (5 years or older) 48689131_1 CDM 0761 RC 36569 HCPCS inpatient 4430 2879.5 ANTHEM HMO ANTHEM HMO 999999999 2682.37 4297.1 Insertion of tube for infusion (5 years or older) 48689131_1 CDM 0761 RC 36569 HCPCS inpatient 4430 2879.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2682.37 4297.1 Insertion of tube for infusion (5 years or older) 48689131_1 CDM 0761 RC 36569 HCPCS inpatient 4430 2879.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 2994.68 67.6 999999999 2682.37 4297.1 percent of total billed charges Insertion of tube for infusion (5 years or older) 48689131_1 CDM 0761 RC 36569 HCPCS inpatient 4430 2879.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 2682.37 4297.1 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48689132_1 CDM 0761 RC 99211 HCPCS inpatient 215 139.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 139.75 65 999999999 130.18 208.55 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48689132_1 CDM 0761 RC 99211 HCPCS inpatient 215 139.75 AETNA AETNA 169.85 79 999999999 130.18 208.55 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48689132_1 CDM 0761 RC 99211 HCPCS inpatient 215 139.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 148.35 69 999999999 130.18 208.55 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48689132_1 CDM 0761 RC 99211 HCPCS inpatient 215 139.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 208.55 97 999999999 130.18 208.55 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48689132_1 CDM 0761 RC 99211 HCPCS inpatient 215 139.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 167.7 78 999999999 130.18 208.55 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48689132_1 CDM 0761 RC 99211 HCPCS inpatient 215 139.75 SIHO - ALL PLANS SIHO - ALL PLANS 193.5 90 999999999 130.18 208.55 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48689132_1 CDM 0761 RC 99211 HCPCS inpatient 215 139.75 UMR - ALL PLANS UMR - ALL PLANS 150.5 70 999999999 130.18 208.55 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48689132_1 CDM 0761 RC 99211 HCPCS inpatient 215 139.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 130.18 60.55 999999999 130.18 208.55 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48689132_1 CDM 0761 RC 99211 HCPCS inpatient 215 139.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 130.18 208.55 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48689132_1 CDM 0761 RC 99211 HCPCS inpatient 215 139.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 130.18 208.55 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48689132_1 CDM 0761 RC 99211 HCPCS inpatient 215 139.75 ANTHEM HMO ANTHEM HMO 999999999 130.18 208.55 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48689132_1 CDM 0761 RC 99211 HCPCS inpatient 215 139.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 130.18 208.55 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48689132_1 CDM 0761 RC 99211 HCPCS inpatient 215 139.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 145.34 67.6 999999999 130.18 208.55 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48689132_1 CDM 0761 RC 99211 HCPCS inpatient 215 139.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 130.18 208.55 Insertion of tube for infusion (5 years or older) 48689133_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 2692.3 65 999999999 2507.98 4017.74 percent of total billed charges Insertion of tube for infusion (5 years or older) 48689133_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 AETNA AETNA 3272.18 79 999999999 2507.98 4017.74 percent of total billed charges Insertion of tube for infusion (5 years or older) 48689133_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 2857.98 69 999999999 2507.98 4017.74 percent of total billed charges Insertion of tube for infusion (5 years or older) 48689133_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4017.74 97 999999999 2507.98 4017.74 percent of total billed charges Insertion of tube for infusion (5 years or older) 48689133_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 3230.76 78 999999999 2507.98 4017.74 percent of total billed charges Insertion of tube for infusion (5 years or older) 48689133_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 SIHO - ALL PLANS SIHO - ALL PLANS 3727.8 90 999999999 2507.98 4017.74 percent of total billed charges Insertion of tube for infusion (5 years or older) 48689133_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 UMR - ALL PLANS UMR - ALL PLANS 2899.4 70 999999999 2507.98 4017.74 percent of total billed charges Insertion of tube for infusion (5 years or older) 48689133_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2507.98 60.55 999999999 2507.98 4017.74 percent of total billed charges Insertion of tube for infusion (5 years or older) 48689133_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2507.98 4017.74 Insertion of tube for infusion (5 years or older) 48689133_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2507.98 4017.74 Insertion of tube for infusion (5 years or older) 48689133_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 ANTHEM HMO ANTHEM HMO 999999999 2507.98 4017.74 Insertion of tube for infusion (5 years or older) 48689133_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2507.98 4017.74 Insertion of tube for infusion (5 years or older) 48689133_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 2799.99 67.6 999999999 2507.98 4017.74 percent of total billed charges Insertion of tube for infusion (5 years or older) 48689133_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 2507.98 4017.74 Replacement of peripherally inserted central venous tube (PICC) with review by radiologist 48689134_1 CDM 0761 RC 36584 HCPCS inpatient 2152 1398.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1398.8 65 999999999 1303.04 2087.44 percent of total billed charges Replacement of peripherally inserted central venous tube (PICC) with review by radiologist 48689134_1 CDM 0761 RC 36584 HCPCS inpatient 2152 1398.8 AETNA AETNA 1700.08 79 999999999 1303.04 2087.44 percent of total billed charges Replacement of peripherally inserted central venous tube (PICC) with review by radiologist 48689134_1 CDM 0761 RC 36584 HCPCS inpatient 2152 1398.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1484.88 69 999999999 1303.04 2087.44 percent of total billed charges Replacement of peripherally inserted central venous tube (PICC) with review by radiologist 48689134_1 CDM 0761 RC 36584 HCPCS inpatient 2152 1398.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2087.44 97 999999999 1303.04 2087.44 percent of total billed charges Replacement of peripherally inserted central venous tube (PICC) with review by radiologist 48689134_1 CDM 0761 RC 36584 HCPCS inpatient 2152 1398.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1678.56 78 999999999 1303.04 2087.44 percent of total billed charges Replacement of peripherally inserted central venous tube (PICC) with review by radiologist 48689134_1 CDM 0761 RC 36584 HCPCS inpatient 2152 1398.8 SIHO - ALL PLANS SIHO - ALL PLANS 1936.8 90 999999999 1303.04 2087.44 percent of total billed charges Replacement of peripherally inserted central venous tube (PICC) with review by radiologist 48689134_1 CDM 0761 RC 36584 HCPCS inpatient 2152 1398.8 UMR - ALL PLANS UMR - ALL PLANS 1506.4 70 999999999 1303.04 2087.44 percent of total billed charges Replacement of peripherally inserted central venous tube (PICC) with review by radiologist 48689134_1 CDM 0761 RC 36584 HCPCS inpatient 2152 1398.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1303.04 60.55 999999999 1303.04 2087.44 percent of total billed charges Replacement of peripherally inserted central venous tube (PICC) with review by radiologist 48689134_1 CDM 0761 RC 36584 HCPCS inpatient 2152 1398.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1303.04 2087.44 Replacement of peripherally inserted central venous tube (PICC) with review by radiologist 48689134_1 CDM 0761 RC 36584 HCPCS inpatient 2152 1398.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1303.04 2087.44 Replacement of peripherally inserted central venous tube (PICC) with review by radiologist 48689134_1 CDM 0761 RC 36584 HCPCS inpatient 2152 1398.8 ANTHEM HMO ANTHEM HMO 999999999 1303.04 2087.44 Replacement of peripherally inserted central venous tube (PICC) with review by radiologist 48689134_1 CDM 0761 RC 36584 HCPCS inpatient 2152 1398.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1303.04 2087.44 Replacement of peripherally inserted central venous tube (PICC) with review by radiologist 48689134_1 CDM 0761 RC 36584 HCPCS inpatient 2152 1398.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1454.75 67.6 999999999 1303.04 2087.44 percent of total billed charges Replacement of peripherally inserted central venous tube (PICC) with review by radiologist 48689134_1 CDM 0761 RC 36584 HCPCS inpatient 2152 1398.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1303.04 2087.44 TELEMETRY SET UP PACK CHARGE 48689139_1 CDM 0272 RC inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges TELEMETRY SET UP PACK CHARGE 48689139_1 CDM 0272 RC inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges TELEMETRY SET UP PACK CHARGE 48689139_1 CDM 0272 RC inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges TELEMETRY SET UP PACK CHARGE 48689139_1 CDM 0272 RC inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges TELEMETRY SET UP PACK CHARGE 48689139_1 CDM 0272 RC inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges TELEMETRY SET UP PACK CHARGE 48689139_1 CDM 0272 RC inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges TELEMETRY SET UP PACK CHARGE 48689139_1 CDM 0272 RC inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges TELEMETRY SET UP PACK CHARGE 48689139_1 CDM 0272 RC inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges TELEMETRY SET UP PACK CHARGE 48689139_1 CDM 0272 RC inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 TELEMETRY SET UP PACK CHARGE 48689139_1 CDM 0272 RC inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 TELEMETRY SET UP PACK CHARGE 48689139_1 CDM 0272 RC inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 TELEMETRY SET UP PACK CHARGE 48689139_1 CDM 0272 RC inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 TELEMETRY SET UP PACK CHARGE 48689139_1 CDM 0272 RC inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges TELEMETRY SET UP PACK CHARGE 48689139_1 CDM 0272 RC inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 TRACTION SETUP FEE CHARGE 48689158_1 CDM 0271 RC inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges TRACTION SETUP FEE CHARGE 48689158_1 CDM 0271 RC inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges TRACTION SETUP FEE CHARGE 48689158_1 CDM 0271 RC inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges TRACTION SETUP FEE CHARGE 48689158_1 CDM 0271 RC inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges TRACTION SETUP FEE CHARGE 48689158_1 CDM 0271 RC inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges TRACTION SETUP FEE CHARGE 48689158_1 CDM 0271 RC inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges TRACTION SETUP FEE CHARGE 48689158_1 CDM 0271 RC inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges TRACTION SETUP FEE CHARGE 48689158_1 CDM 0271 RC inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges TRACTION SETUP FEE CHARGE 48689158_1 CDM 0271 RC inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 TRACTION SETUP FEE CHARGE 48689158_1 CDM 0271 RC inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 TRACTION SETUP FEE CHARGE 48689158_1 CDM 0271 RC inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 TRACTION SETUP FEE CHARGE 48689158_1 CDM 0271 RC inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 TRACTION SETUP FEE CHARGE 48689158_1 CDM 0271 RC inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges TRACTION SETUP FEE CHARGE 48689158_1 CDM 0271 RC inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 Ultrasonic guidance for blood vessel access 48689159_1 CDM 0272 RC 76937 HCPCS inpatient 523 339.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 339.95 65 999999999 316.68 507.31 percent of total billed charges Ultrasonic guidance for blood vessel access 48689159_1 CDM 0272 RC 76937 HCPCS inpatient 523 339.95 AETNA AETNA 413.17 79 999999999 316.68 507.31 percent of total billed charges Ultrasonic guidance for blood vessel access 48689159_1 CDM 0272 RC 76937 HCPCS inpatient 523 339.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 360.87 69 999999999 316.68 507.31 percent of total billed charges Ultrasonic guidance for blood vessel access 48689159_1 CDM 0272 RC 76937 HCPCS inpatient 523 339.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 507.31 97 999999999 316.68 507.31 percent of total billed charges Ultrasonic guidance for blood vessel access 48689159_1 CDM 0272 RC 76937 HCPCS inpatient 523 339.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 407.94 78 999999999 316.68 507.31 percent of total billed charges Ultrasonic guidance for blood vessel access 48689159_1 CDM 0272 RC 76937 HCPCS inpatient 523 339.95 SIHO - ALL PLANS SIHO - ALL PLANS 470.7 90 999999999 316.68 507.31 percent of total billed charges Ultrasonic guidance for blood vessel access 48689159_1 CDM 0272 RC 76937 HCPCS inpatient 523 339.95 UMR - ALL PLANS UMR - ALL PLANS 366.1 70 999999999 316.68 507.31 percent of total billed charges Ultrasonic guidance for blood vessel access 48689159_1 CDM 0272 RC 76937 HCPCS inpatient 523 339.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 316.68 60.55 999999999 316.68 507.31 percent of total billed charges Ultrasonic guidance for blood vessel access 48689159_1 CDM 0272 RC 76937 HCPCS inpatient 523 339.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 316.68 507.31 Ultrasonic guidance for blood vessel access 48689159_1 CDM 0272 RC 76937 HCPCS inpatient 523 339.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 316.68 507.31 Ultrasonic guidance for blood vessel access 48689159_1 CDM 0272 RC 76937 HCPCS inpatient 523 339.95 ANTHEM HMO ANTHEM HMO 999999999 316.68 507.31 Ultrasonic guidance for blood vessel access 48689159_1 CDM 0272 RC 76937 HCPCS inpatient 523 339.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 316.68 507.31 Ultrasonic guidance for blood vessel access 48689159_1 CDM 0272 RC 76937 HCPCS inpatient 523 339.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 353.55 67.6 999999999 316.68 507.31 percent of total billed charges Ultrasonic guidance for blood vessel access 48689159_1 CDM 0272 RC 76937 HCPCS inpatient 523 339.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 316.68 507.31 Drawing of blood for a medical problem 48689160_1 CDM 0402 RC 99195 HCPCS inpatient 203 131.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 131.95 65 999999999 122.92 196.91 percent of total billed charges Drawing of blood for a medical problem 48689160_1 CDM 0402 RC 99195 HCPCS inpatient 203 131.95 AETNA AETNA 160.37 79 999999999 122.92 196.91 percent of total billed charges Drawing of blood for a medical problem 48689160_1 CDM 0402 RC 99195 HCPCS inpatient 203 131.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.07 69 999999999 122.92 196.91 percent of total billed charges Drawing of blood for a medical problem 48689160_1 CDM 0402 RC 99195 HCPCS inpatient 203 131.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 196.91 97 999999999 122.92 196.91 percent of total billed charges Drawing of blood for a medical problem 48689160_1 CDM 0402 RC 99195 HCPCS inpatient 203 131.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 158.34 78 999999999 122.92 196.91 percent of total billed charges Drawing of blood for a medical problem 48689160_1 CDM 0402 RC 99195 HCPCS inpatient 203 131.95 SIHO - ALL PLANS SIHO - ALL PLANS 182.7 90 999999999 122.92 196.91 percent of total billed charges Drawing of blood for a medical problem 48689160_1 CDM 0402 RC 99195 HCPCS inpatient 203 131.95 UMR - ALL PLANS UMR - ALL PLANS 142.1 70 999999999 122.92 196.91 percent of total billed charges Drawing of blood for a medical problem 48689160_1 CDM 0402 RC 99195 HCPCS inpatient 203 131.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 122.92 60.55 999999999 122.92 196.91 percent of total billed charges Drawing of blood for a medical problem 48689160_1 CDM 0402 RC 99195 HCPCS inpatient 203 131.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 122.92 196.91 Drawing of blood for a medical problem 48689160_1 CDM 0402 RC 99195 HCPCS inpatient 203 131.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 122.92 196.91 Drawing of blood for a medical problem 48689160_1 CDM 0402 RC 99195 HCPCS inpatient 203 131.95 ANTHEM HMO ANTHEM HMO 999999999 122.92 196.91 Drawing of blood for a medical problem 48689160_1 CDM 0402 RC 99195 HCPCS inpatient 203 131.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 122.92 196.91 Drawing of blood for a medical problem 48689160_1 CDM 0402 RC 99195 HCPCS inpatient 203 131.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.23 67.6 999999999 122.92 196.91 percent of total billed charges Drawing of blood for a medical problem 48689160_1 CDM 0402 RC 99195 HCPCS inpatient 203 131.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 122.92 196.91 Blood group typing (ABO) 48695280_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges Blood group typing (ABO) 48695280_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges Blood group typing (ABO) 48695280_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges Blood group typing (ABO) 48695280_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges Blood group typing (ABO) 48695280_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges Blood group typing (ABO) 48695280_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges Blood group typing (ABO) 48695280_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges Blood group typing (ABO) 48695280_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges Blood group typing (ABO) 48695280_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 Blood group typing (ABO) 48695280_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 Blood group typing (ABO) 48695280_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 Blood group typing (ABO) 48695280_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 Blood group typing (ABO) 48695280_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges Blood group typing (ABO) 48695280_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 Blood gases measurement 48696835_1 CDM 0301 RC 82803 HCPCS inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges Blood gases measurement 48696835_1 CDM 0301 RC 82803 HCPCS inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges Blood gases measurement 48696835_1 CDM 0301 RC 82803 HCPCS inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges Blood gases measurement 48696835_1 CDM 0301 RC 82803 HCPCS inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges Blood gases measurement 48696835_1 CDM 0301 RC 82803 HCPCS inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges Blood gases measurement 48696835_1 CDM 0301 RC 82803 HCPCS inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges Blood gases measurement 48696835_1 CDM 0301 RC 82803 HCPCS inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges Blood gases measurement 48696835_1 CDM 0301 RC 82803 HCPCS inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges Blood gases measurement 48696835_1 CDM 0301 RC 82803 HCPCS inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 Blood gases measurement 48696835_1 CDM 0301 RC 82803 HCPCS inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 Blood gases measurement 48696835_1 CDM 0301 RC 82803 HCPCS inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 Blood gases measurement 48696835_1 CDM 0301 RC 82803 HCPCS inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 Blood gases measurement 48696835_1 CDM 0301 RC 82803 HCPCS inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges Blood gases measurement 48696835_1 CDM 0301 RC 82803 HCPCS inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 Body fluid cell count with cell identification 48697335_1 CDM 0305 RC 89051 HCPCS inpatient 283 183.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 183.95 65 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48697335_1 CDM 0305 RC 89051 HCPCS inpatient 283 183.95 AETNA AETNA 223.57 79 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48697335_1 CDM 0305 RC 89051 HCPCS inpatient 283 183.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 195.27 69 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48697335_1 CDM 0305 RC 89051 HCPCS inpatient 283 183.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 274.51 97 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48697335_1 CDM 0305 RC 89051 HCPCS inpatient 283 183.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 220.74 78 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48697335_1 CDM 0305 RC 89051 HCPCS inpatient 283 183.95 SIHO - ALL PLANS SIHO - ALL PLANS 254.7 90 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48697335_1 CDM 0305 RC 89051 HCPCS inpatient 283 183.95 UMR - ALL PLANS UMR - ALL PLANS 198.1 70 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48697335_1 CDM 0305 RC 89051 HCPCS inpatient 283 183.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 171.36 60.55 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48697335_1 CDM 0305 RC 89051 HCPCS inpatient 283 183.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 171.36 274.51 Body fluid cell count with cell identification 48697335_1 CDM 0305 RC 89051 HCPCS inpatient 283 183.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 171.36 274.51 Body fluid cell count with cell identification 48697335_1 CDM 0305 RC 89051 HCPCS inpatient 283 183.95 ANTHEM HMO ANTHEM HMO 999999999 171.36 274.51 Body fluid cell count with cell identification 48697335_1 CDM 0305 RC 89051 HCPCS inpatient 283 183.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 171.36 274.51 Body fluid cell count with cell identification 48697335_1 CDM 0305 RC 89051 HCPCS inpatient 283 183.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 191.31 67.6 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 48697335_1 CDM 0305 RC 89051 HCPCS inpatient 283 183.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 171.36 274.51 Measurement of alcohol level in breath specimen 48698311_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges Measurement of alcohol level in breath specimen 48698311_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges Measurement of alcohol level in breath specimen 48698311_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges Measurement of alcohol level in breath specimen 48698311_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges Measurement of alcohol level in breath specimen 48698311_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges Measurement of alcohol level in breath specimen 48698311_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges Measurement of alcohol level in breath specimen 48698311_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges Measurement of alcohol level in breath specimen 48698311_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges Measurement of alcohol level in breath specimen 48698311_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 Measurement of alcohol level in breath specimen 48698311_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 Measurement of alcohol level in breath specimen 48698311_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 Measurement of alcohol level in breath specimen 48698311_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 Measurement of alcohol level in breath specimen 48698311_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges Measurement of alcohol level in breath specimen 48698311_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 Measurement of alcohol level in breath specimen 48698378_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges Measurement of alcohol level in breath specimen 48698378_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges Measurement of alcohol level in breath specimen 48698378_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges Measurement of alcohol level in breath specimen 48698378_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges Measurement of alcohol level in breath specimen 48698378_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges Measurement of alcohol level in breath specimen 48698378_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges Measurement of alcohol level in breath specimen 48698378_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges Measurement of alcohol level in breath specimen 48698378_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges Measurement of alcohol level in breath specimen 48698378_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 Measurement of alcohol level in breath specimen 48698378_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 Measurement of alcohol level in breath specimen 48698378_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 Measurement of alcohol level in breath specimen 48698378_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 Measurement of alcohol level in breath specimen 48698378_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges Measurement of alcohol level in breath specimen 48698378_1 CDM 0301 RC 82075 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48698614_1 CDM 0305 RC 82274 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48698614_1 CDM 0305 RC 82274 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48698614_1 CDM 0305 RC 82274 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48698614_1 CDM 0305 RC 82274 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48698614_1 CDM 0305 RC 82274 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48698614_1 CDM 0305 RC 82274 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48698614_1 CDM 0305 RC 82274 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48698614_1 CDM 0305 RC 82274 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48698614_1 CDM 0305 RC 82274 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48698614_1 CDM 0305 RC 82274 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48698614_1 CDM 0305 RC 82274 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48698614_1 CDM 0305 RC 82274 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48698614_1 CDM 0305 RC 82274 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 48698614_1 CDM 0305 RC 82274 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 LEVETIRACETAM 100 MG/ML SOLN 48705476_1 CDM 0250 RC 31722-0574-47 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LEVETIRACETAM 100 MG/ML SOLN 48705476_1 CDM 0250 RC 31722-0574-47 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LEVETIRACETAM 100 MG/ML SOLN 48705476_1 CDM 0250 RC 31722-0574-47 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LEVETIRACETAM 100 MG/ML SOLN 48705476_1 CDM 0250 RC 31722-0574-47 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LEVETIRACETAM 100 MG/ML SOLN 48705476_1 CDM 0250 RC 31722-0574-47 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LEVETIRACETAM 100 MG/ML SOLN 48705476_1 CDM 0250 RC 31722-0574-47 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LEVETIRACETAM 100 MG/ML SOLN 48705476_1 CDM 0250 RC 31722-0574-47 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LEVETIRACETAM 100 MG/ML SOLN 48705476_1 CDM 0250 RC 31722-0574-47 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LEVETIRACETAM 100 MG/ML SOLN 48705476_1 CDM 0250 RC 31722-0574-47 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LEVETIRACETAM 100 MG/ML SOLN 48705476_1 CDM 0250 RC 31722-0574-47 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LEVETIRACETAM 100 MG/ML SOLN 48705476_1 CDM 0250 RC 31722-0574-47 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LEVETIRACETAM 100 MG/ML SOLN 48705476_1 CDM 0250 RC 31722-0574-47 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LEVETIRACETAM 100 MG/ML SOLN 48705476_1 CDM 0250 RC 31722-0574-47 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges LEVETIRACETAM 100 MG/ML SOLN 48705476_1 CDM 0250 RC 31722-0574-47 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "IMPLANTABLE/INSERTABLE DEVICE, NOT OTHERWISE CLASSIFIED" 48707302_1 CDM 0278 RC C1889 HCPCS inpatient 2560.42 1664.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 1664.27 65 999999999 1550.33 2483.61 percent of total billed charges "IMPLANTABLE/INSERTABLE DEVICE, NOT OTHERWISE CLASSIFIED" 48707302_1 CDM 0278 RC C1889 HCPCS inpatient 2560.42 1664.27 AETNA AETNA 2022.73 79 999999999 1550.33 2483.61 percent of total billed charges "IMPLANTABLE/INSERTABLE DEVICE, NOT OTHERWISE CLASSIFIED" 48707302_1 CDM 0278 RC C1889 HCPCS inpatient 2560.42 1664.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 1766.69 69 999999999 1550.33 2483.61 percent of total billed charges "IMPLANTABLE/INSERTABLE DEVICE, NOT OTHERWISE CLASSIFIED" 48707302_1 CDM 0278 RC C1889 HCPCS inpatient 2560.42 1664.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2483.61 97 999999999 1550.33 2483.61 percent of total billed charges "IMPLANTABLE/INSERTABLE DEVICE, NOT OTHERWISE CLASSIFIED" 48707302_1 CDM 0278 RC C1889 HCPCS inpatient 2560.42 1664.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 1997.13 78 999999999 1550.33 2483.61 percent of total billed charges "IMPLANTABLE/INSERTABLE DEVICE, NOT OTHERWISE CLASSIFIED" 48707302_1 CDM 0278 RC C1889 HCPCS inpatient 2560.42 1664.27 SIHO - ALL PLANS SIHO - ALL PLANS 2304.38 90 999999999 1550.33 2483.61 percent of total billed charges "IMPLANTABLE/INSERTABLE DEVICE, NOT OTHERWISE CLASSIFIED" 48707302_1 CDM 0278 RC C1889 HCPCS inpatient 2560.42 1664.27 UMR - ALL PLANS UMR - ALL PLANS 1792.29 70 999999999 1550.33 2483.61 percent of total billed charges "IMPLANTABLE/INSERTABLE DEVICE, NOT OTHERWISE CLASSIFIED" 48707302_1 CDM 0278 RC C1889 HCPCS inpatient 2560.42 1664.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1550.33 60.55 999999999 1550.33 2483.61 percent of total billed charges "IMPLANTABLE/INSERTABLE DEVICE, NOT OTHERWISE CLASSIFIED" 48707302_1 CDM 0278 RC C1889 HCPCS inpatient 2560.42 1664.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1550.33 2483.61 "IMPLANTABLE/INSERTABLE DEVICE, NOT OTHERWISE CLASSIFIED" 48707302_1 CDM 0278 RC C1889 HCPCS inpatient 2560.42 1664.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1550.33 2483.61 "IMPLANTABLE/INSERTABLE DEVICE, NOT OTHERWISE CLASSIFIED" 48707302_1 CDM 0278 RC C1889 HCPCS inpatient 2560.42 1664.27 ANTHEM HMO ANTHEM HMO 999999999 1550.33 2483.61 "IMPLANTABLE/INSERTABLE DEVICE, NOT OTHERWISE CLASSIFIED" 48707302_1 CDM 0278 RC C1889 HCPCS inpatient 2560.42 1664.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1550.33 2483.61 "IMPLANTABLE/INSERTABLE DEVICE, NOT OTHERWISE CLASSIFIED" 48707302_1 CDM 0278 RC C1889 HCPCS inpatient 2560.42 1664.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 1730.84 67.6 999999999 1550.33 2483.61 percent of total billed charges "IMPLANTABLE/INSERTABLE DEVICE, NOT OTHERWISE CLASSIFIED" 48707302_1 CDM 0278 RC C1889 HCPCS inpatient 2560.42 1664.27 UHC - ALL PLANS UHC - ALL PLANS 999999999 1550.33 2483.61 NASAL MASK -- A -- 48708608_1 CDM 0270 RC inpatient 126 81.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.9 65 999999999 76.29 122.22 percent of total billed charges NASAL MASK -- A -- 48708608_1 CDM 0270 RC inpatient 126 81.9 AETNA AETNA 99.54 79 999999999 76.29 122.22 percent of total billed charges NASAL MASK -- A -- 48708608_1 CDM 0270 RC inpatient 126 81.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.94 69 999999999 76.29 122.22 percent of total billed charges NASAL MASK -- A -- 48708608_1 CDM 0270 RC inpatient 126 81.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 122.22 97 999999999 76.29 122.22 percent of total billed charges NASAL MASK -- A -- 48708608_1 CDM 0270 RC inpatient 126 81.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 98.28 78 999999999 76.29 122.22 percent of total billed charges NASAL MASK -- A -- 48708608_1 CDM 0270 RC inpatient 126 81.9 SIHO - ALL PLANS SIHO - ALL PLANS 113.4 90 999999999 76.29 122.22 percent of total billed charges NASAL MASK -- A -- 48708608_1 CDM 0270 RC inpatient 126 81.9 UMR - ALL PLANS UMR - ALL PLANS 88.2 70 999999999 76.29 122.22 percent of total billed charges NASAL MASK -- A -- 48708608_1 CDM 0270 RC inpatient 126 81.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.29 60.55 999999999 76.29 122.22 percent of total billed charges NASAL MASK -- A -- 48708608_1 CDM 0270 RC inpatient 126 81.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.29 122.22 NASAL MASK -- A -- 48708608_1 CDM 0270 RC inpatient 126 81.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.29 122.22 NASAL MASK -- A -- 48708608_1 CDM 0270 RC inpatient 126 81.9 ANTHEM HMO ANTHEM HMO 999999999 76.29 122.22 NASAL MASK -- A -- 48708608_1 CDM 0270 RC inpatient 126 81.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.29 122.22 NASAL MASK -- A -- 48708608_1 CDM 0270 RC inpatient 126 81.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.18 67.6 999999999 76.29 122.22 percent of total billed charges NASAL MASK -- A -- 48708608_1 CDM 0270 RC inpatient 126 81.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.29 122.22 MASK SMALL FULL FACE CPAP 48709196_1 CDM 0271 RC inpatient 378 245.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 245.7 65 999999999 228.88 366.66 percent of total billed charges MASK SMALL FULL FACE CPAP 48709196_1 CDM 0271 RC inpatient 378 245.7 AETNA AETNA 298.62 79 999999999 228.88 366.66 percent of total billed charges MASK SMALL FULL FACE CPAP 48709196_1 CDM 0271 RC inpatient 378 245.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 260.82 69 999999999 228.88 366.66 percent of total billed charges MASK SMALL FULL FACE CPAP 48709196_1 CDM 0271 RC inpatient 378 245.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 366.66 97 999999999 228.88 366.66 percent of total billed charges MASK SMALL FULL FACE CPAP 48709196_1 CDM 0271 RC inpatient 378 245.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 294.84 78 999999999 228.88 366.66 percent of total billed charges MASK SMALL FULL FACE CPAP 48709196_1 CDM 0271 RC inpatient 378 245.7 SIHO - ALL PLANS SIHO - ALL PLANS 340.2 90 999999999 228.88 366.66 percent of total billed charges MASK SMALL FULL FACE CPAP 48709196_1 CDM 0271 RC inpatient 378 245.7 UMR - ALL PLANS UMR - ALL PLANS 264.6 70 999999999 228.88 366.66 percent of total billed charges MASK SMALL FULL FACE CPAP 48709196_1 CDM 0271 RC inpatient 378 245.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 228.88 60.55 999999999 228.88 366.66 percent of total billed charges MASK SMALL FULL FACE CPAP 48709196_1 CDM 0271 RC inpatient 378 245.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 228.88 366.66 MASK SMALL FULL FACE CPAP 48709196_1 CDM 0271 RC inpatient 378 245.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 228.88 366.66 MASK SMALL FULL FACE CPAP 48709196_1 CDM 0271 RC inpatient 378 245.7 ANTHEM HMO ANTHEM HMO 999999999 228.88 366.66 MASK SMALL FULL FACE CPAP 48709196_1 CDM 0271 RC inpatient 378 245.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 228.88 366.66 MASK SMALL FULL FACE CPAP 48709196_1 CDM 0271 RC inpatient 378 245.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 255.53 67.6 999999999 228.88 366.66 percent of total billed charges MASK SMALL FULL FACE CPAP 48709196_1 CDM 0271 RC inpatient 378 245.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 228.88 366.66 MASK MEDIUM FULL FACE CPAP 48709197_1 CDM 0279 RC inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges MASK MEDIUM FULL FACE CPAP 48709197_1 CDM 0279 RC inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges MASK MEDIUM FULL FACE CPAP 48709197_1 CDM 0279 RC inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges MASK MEDIUM FULL FACE CPAP 48709197_1 CDM 0279 RC inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges MASK MEDIUM FULL FACE CPAP 48709197_1 CDM 0279 RC inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges MASK MEDIUM FULL FACE CPAP 48709197_1 CDM 0279 RC inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges MASK MEDIUM FULL FACE CPAP 48709197_1 CDM 0279 RC inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges MASK MEDIUM FULL FACE CPAP 48709197_1 CDM 0279 RC inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges MASK MEDIUM FULL FACE CPAP 48709197_1 CDM 0279 RC inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 MASK MEDIUM FULL FACE CPAP 48709197_1 CDM 0279 RC inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 MASK MEDIUM FULL FACE CPAP 48709197_1 CDM 0279 RC inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 MASK MEDIUM FULL FACE CPAP 48709197_1 CDM 0279 RC inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 MASK MEDIUM FULL FACE CPAP 48709197_1 CDM 0279 RC inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges MASK MEDIUM FULL FACE CPAP 48709197_1 CDM 0279 RC inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 MASK LARGE FULL FACE CPAP 48709198_1 CDM 0271 RC inpatient 378 245.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 245.7 65 999999999 228.88 366.66 percent of total billed charges MASK LARGE FULL FACE CPAP 48709198_1 CDM 0271 RC inpatient 378 245.7 AETNA AETNA 298.62 79 999999999 228.88 366.66 percent of total billed charges MASK LARGE FULL FACE CPAP 48709198_1 CDM 0271 RC inpatient 378 245.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 260.82 69 999999999 228.88 366.66 percent of total billed charges MASK LARGE FULL FACE CPAP 48709198_1 CDM 0271 RC inpatient 378 245.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 366.66 97 999999999 228.88 366.66 percent of total billed charges MASK LARGE FULL FACE CPAP 48709198_1 CDM 0271 RC inpatient 378 245.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 294.84 78 999999999 228.88 366.66 percent of total billed charges MASK LARGE FULL FACE CPAP 48709198_1 CDM 0271 RC inpatient 378 245.7 SIHO - ALL PLANS SIHO - ALL PLANS 340.2 90 999999999 228.88 366.66 percent of total billed charges MASK LARGE FULL FACE CPAP 48709198_1 CDM 0271 RC inpatient 378 245.7 UMR - ALL PLANS UMR - ALL PLANS 264.6 70 999999999 228.88 366.66 percent of total billed charges MASK LARGE FULL FACE CPAP 48709198_1 CDM 0271 RC inpatient 378 245.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 228.88 60.55 999999999 228.88 366.66 percent of total billed charges MASK LARGE FULL FACE CPAP 48709198_1 CDM 0271 RC inpatient 378 245.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 228.88 366.66 MASK LARGE FULL FACE CPAP 48709198_1 CDM 0271 RC inpatient 378 245.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 228.88 366.66 MASK LARGE FULL FACE CPAP 48709198_1 CDM 0271 RC inpatient 378 245.7 ANTHEM HMO ANTHEM HMO 999999999 228.88 366.66 MASK LARGE FULL FACE CPAP 48709198_1 CDM 0271 RC inpatient 378 245.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 228.88 366.66 MASK LARGE FULL FACE CPAP 48709198_1 CDM 0271 RC inpatient 378 245.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 255.53 67.6 999999999 228.88 366.66 percent of total billed charges MASK LARGE FULL FACE CPAP 48709198_1 CDM 0271 RC inpatient 378 245.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 228.88 366.66 DRILL BIT 1/16 ZIMMER 2318-15 6/PK 48709239_1 CDM 0270 RC inpatient 359 233.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 233.35 65 999999999 217.37 348.23 percent of total billed charges DRILL BIT 1/16 ZIMMER 2318-15 6/PK 48709239_1 CDM 0270 RC inpatient 359 233.35 AETNA AETNA 283.61 79 999999999 217.37 348.23 percent of total billed charges DRILL BIT 1/16 ZIMMER 2318-15 6/PK 48709239_1 CDM 0270 RC inpatient 359 233.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 247.71 69 999999999 217.37 348.23 percent of total billed charges DRILL BIT 1/16 ZIMMER 2318-15 6/PK 48709239_1 CDM 0270 RC inpatient 359 233.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 348.23 97 999999999 217.37 348.23 percent of total billed charges DRILL BIT 1/16 ZIMMER 2318-15 6/PK 48709239_1 CDM 0270 RC inpatient 359 233.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 280.02 78 999999999 217.37 348.23 percent of total billed charges DRILL BIT 1/16 ZIMMER 2318-15 6/PK 48709239_1 CDM 0270 RC inpatient 359 233.35 SIHO - ALL PLANS SIHO - ALL PLANS 323.1 90 999999999 217.37 348.23 percent of total billed charges DRILL BIT 1/16 ZIMMER 2318-15 6/PK 48709239_1 CDM 0270 RC inpatient 359 233.35 UMR - ALL PLANS UMR - ALL PLANS 251.3 70 999999999 217.37 348.23 percent of total billed charges DRILL BIT 1/16 ZIMMER 2318-15 6/PK 48709239_1 CDM 0270 RC inpatient 359 233.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 217.37 60.55 999999999 217.37 348.23 percent of total billed charges DRILL BIT 1/16 ZIMMER 2318-15 6/PK 48709239_1 CDM 0270 RC inpatient 359 233.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 217.37 348.23 DRILL BIT 1/16 ZIMMER 2318-15 6/PK 48709239_1 CDM 0270 RC inpatient 359 233.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 217.37 348.23 DRILL BIT 1/16 ZIMMER 2318-15 6/PK 48709239_1 CDM 0270 RC inpatient 359 233.35 ANTHEM HMO ANTHEM HMO 999999999 217.37 348.23 DRILL BIT 1/16 ZIMMER 2318-15 6/PK 48709239_1 CDM 0270 RC inpatient 359 233.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 217.37 348.23 DRILL BIT 1/16 ZIMMER 2318-15 6/PK 48709239_1 CDM 0270 RC inpatient 359 233.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 242.68 67.6 999999999 217.37 348.23 percent of total billed charges DRILL BIT 1/16 ZIMMER 2318-15 6/PK 48709239_1 CDM 0270 RC inpatient 359 233.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 217.37 348.23 LACT RINGERS 500ML 2B2323Q 48709711_1 CDM 0258 RC inpatient 13 8.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.45 65 999999999 7.87 12.61 percent of total billed charges LACT RINGERS 500ML 2B2323Q 48709711_1 CDM 0258 RC inpatient 13 8.45 AETNA AETNA 10.27 79 999999999 7.87 12.61 percent of total billed charges LACT RINGERS 500ML 2B2323Q 48709711_1 CDM 0258 RC inpatient 13 8.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.97 69 999999999 7.87 12.61 percent of total billed charges LACT RINGERS 500ML 2B2323Q 48709711_1 CDM 0258 RC inpatient 13 8.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.61 97 999999999 7.87 12.61 percent of total billed charges LACT RINGERS 500ML 2B2323Q 48709711_1 CDM 0258 RC inpatient 13 8.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.14 78 999999999 7.87 12.61 percent of total billed charges LACT RINGERS 500ML 2B2323Q 48709711_1 CDM 0258 RC inpatient 13 8.45 SIHO - ALL PLANS SIHO - ALL PLANS 11.7 90 999999999 7.87 12.61 percent of total billed charges LACT RINGERS 500ML 2B2323Q 48709711_1 CDM 0258 RC inpatient 13 8.45 UMR - ALL PLANS UMR - ALL PLANS 9.1 70 999999999 7.87 12.61 percent of total billed charges LACT RINGERS 500ML 2B2323Q 48709711_1 CDM 0258 RC inpatient 13 8.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.87 60.55 999999999 7.87 12.61 percent of total billed charges LACT RINGERS 500ML 2B2323Q 48709711_1 CDM 0258 RC inpatient 13 8.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.87 12.61 LACT RINGERS 500ML 2B2323Q 48709711_1 CDM 0258 RC inpatient 13 8.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.87 12.61 LACT RINGERS 500ML 2B2323Q 48709711_1 CDM 0258 RC inpatient 13 8.45 ANTHEM HMO ANTHEM HMO 999999999 7.87 12.61 LACT RINGERS 500ML 2B2323Q 48709711_1 CDM 0258 RC inpatient 13 8.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.87 12.61 LACT RINGERS 500ML 2B2323Q 48709711_1 CDM 0258 RC inpatient 13 8.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.79 67.6 999999999 7.87 12.61 percent of total billed charges LACT RINGERS 500ML 2B2323Q 48709711_1 CDM 0258 RC inpatient 13 8.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.87 12.61 DRILL BIT 2.0MM ZIMMER 02-2318-020-06 6/PK 48709772_1 CDM 0278 RC inpatient 359 233.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 233.35 65 999999999 217.37 348.23 percent of total billed charges DRILL BIT 2.0MM ZIMMER 02-2318-020-06 6/PK 48709772_1 CDM 0278 RC inpatient 359 233.35 AETNA AETNA 283.61 79 999999999 217.37 348.23 percent of total billed charges DRILL BIT 2.0MM ZIMMER 02-2318-020-06 6/PK 48709772_1 CDM 0278 RC inpatient 359 233.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 247.71 69 999999999 217.37 348.23 percent of total billed charges DRILL BIT 2.0MM ZIMMER 02-2318-020-06 6/PK 48709772_1 CDM 0278 RC inpatient 359 233.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 348.23 97 999999999 217.37 348.23 percent of total billed charges DRILL BIT 2.0MM ZIMMER 02-2318-020-06 6/PK 48709772_1 CDM 0278 RC inpatient 359 233.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 280.02 78 999999999 217.37 348.23 percent of total billed charges DRILL BIT 2.0MM ZIMMER 02-2318-020-06 6/PK 48709772_1 CDM 0278 RC inpatient 359 233.35 SIHO - ALL PLANS SIHO - ALL PLANS 323.1 90 999999999 217.37 348.23 percent of total billed charges DRILL BIT 2.0MM ZIMMER 02-2318-020-06 6/PK 48709772_1 CDM 0278 RC inpatient 359 233.35 UMR - ALL PLANS UMR - ALL PLANS 251.3 70 999999999 217.37 348.23 percent of total billed charges DRILL BIT 2.0MM ZIMMER 02-2318-020-06 6/PK 48709772_1 CDM 0278 RC inpatient 359 233.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 217.37 60.55 999999999 217.37 348.23 percent of total billed charges DRILL BIT 2.0MM ZIMMER 02-2318-020-06 6/PK 48709772_1 CDM 0278 RC inpatient 359 233.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 217.37 348.23 DRILL BIT 2.0MM ZIMMER 02-2318-020-06 6/PK 48709772_1 CDM 0278 RC inpatient 359 233.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 217.37 348.23 DRILL BIT 2.0MM ZIMMER 02-2318-020-06 6/PK 48709772_1 CDM 0278 RC inpatient 359 233.35 ANTHEM HMO ANTHEM HMO 999999999 217.37 348.23 DRILL BIT 2.0MM ZIMMER 02-2318-020-06 6/PK 48709772_1 CDM 0278 RC inpatient 359 233.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 217.37 348.23 DRILL BIT 2.0MM ZIMMER 02-2318-020-06 6/PK 48709772_1 CDM 0278 RC inpatient 359 233.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 242.68 67.6 999999999 217.37 348.23 percent of total billed charges DRILL BIT 2.0MM ZIMMER 02-2318-020-06 6/PK 48709772_1 CDM 0278 RC inpatient 359 233.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 217.37 348.23 PAD GROUNDING 406-650-205 48710731_1 CDM 0272 RC inpatient 118 76.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 76.7 65 999999999 71.45 114.46 percent of total billed charges PAD GROUNDING 406-650-205 48710731_1 CDM 0272 RC inpatient 118 76.7 AETNA AETNA 93.22 79 999999999 71.45 114.46 percent of total billed charges PAD GROUNDING 406-650-205 48710731_1 CDM 0272 RC inpatient 118 76.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 81.42 69 999999999 71.45 114.46 percent of total billed charges PAD GROUNDING 406-650-205 48710731_1 CDM 0272 RC inpatient 118 76.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 114.46 97 999999999 71.45 114.46 percent of total billed charges PAD GROUNDING 406-650-205 48710731_1 CDM 0272 RC inpatient 118 76.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.04 78 999999999 71.45 114.46 percent of total billed charges PAD GROUNDING 406-650-205 48710731_1 CDM 0272 RC inpatient 118 76.7 SIHO - ALL PLANS SIHO - ALL PLANS 106.2 90 999999999 71.45 114.46 percent of total billed charges PAD GROUNDING 406-650-205 48710731_1 CDM 0272 RC inpatient 118 76.7 UMR - ALL PLANS UMR - ALL PLANS 82.6 70 999999999 71.45 114.46 percent of total billed charges PAD GROUNDING 406-650-205 48710731_1 CDM 0272 RC inpatient 118 76.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 71.45 60.55 999999999 71.45 114.46 percent of total billed charges PAD GROUNDING 406-650-205 48710731_1 CDM 0272 RC inpatient 118 76.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 71.45 114.46 PAD GROUNDING 406-650-205 48710731_1 CDM 0272 RC inpatient 118 76.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 71.45 114.46 PAD GROUNDING 406-650-205 48710731_1 CDM 0272 RC inpatient 118 76.7 ANTHEM HMO ANTHEM HMO 999999999 71.45 114.46 PAD GROUNDING 406-650-205 48710731_1 CDM 0272 RC inpatient 118 76.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 71.45 114.46 PAD GROUNDING 406-650-205 48710731_1 CDM 0272 RC inpatient 118 76.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 79.77 67.6 999999999 71.45 114.46 percent of total billed charges PAD GROUNDING 406-650-205 48710731_1 CDM 0272 RC inpatient 118 76.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 71.45 114.46 "CLOSURE KIT 100CM CPK55-11 (includes CF7-7-100, CFP, MIS-7F11)" 48710984_1 CDM 0272 RC inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges "CLOSURE KIT 100CM CPK55-11 (includes CF7-7-100, CFP, MIS-7F11)" 48710984_1 CDM 0272 RC inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges "CLOSURE KIT 100CM CPK55-11 (includes CF7-7-100, CFP, MIS-7F11)" 48710984_1 CDM 0272 RC inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges "CLOSURE KIT 100CM CPK55-11 (includes CF7-7-100, CFP, MIS-7F11)" 48710984_1 CDM 0272 RC inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges "CLOSURE KIT 100CM CPK55-11 (includes CF7-7-100, CFP, MIS-7F11)" 48710984_1 CDM 0272 RC inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges "CLOSURE KIT 100CM CPK55-11 (includes CF7-7-100, CFP, MIS-7F11)" 48710984_1 CDM 0272 RC inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges "CLOSURE KIT 100CM CPK55-11 (includes CF7-7-100, CFP, MIS-7F11)" 48710984_1 CDM 0272 RC inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges "CLOSURE KIT 100CM CPK55-11 (includes CF7-7-100, CFP, MIS-7F11)" 48710984_1 CDM 0272 RC inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges "CLOSURE KIT 100CM CPK55-11 (includes CF7-7-100, CFP, MIS-7F11)" 48710984_1 CDM 0272 RC inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 "CLOSURE KIT 100CM CPK55-11 (includes CF7-7-100, CFP, MIS-7F11)" 48710984_1 CDM 0272 RC inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 "CLOSURE KIT 100CM CPK55-11 (includes CF7-7-100, CFP, MIS-7F11)" 48710984_1 CDM 0272 RC inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 "CLOSURE KIT 100CM CPK55-11 (includes CF7-7-100, CFP, MIS-7F11)" 48710984_1 CDM 0272 RC inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 "CLOSURE KIT 100CM CPK55-11 (includes CF7-7-100, CFP, MIS-7F11)" 48710984_1 CDM 0272 RC inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges "CLOSURE KIT 100CM CPK55-11 (includes CF7-7-100, CFP, MIS-7F11)" 48710984_1 CDM 0272 RC inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 MICRO INTRO SHEATH SET MIS-7F11 48710985_1 CDM 0272 RC inpatient 24 15.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 15.6 65 999999999 14.53 23.28 percent of total billed charges MICRO INTRO SHEATH SET MIS-7F11 48710985_1 CDM 0272 RC inpatient 24 15.6 AETNA AETNA 18.96 79 999999999 14.53 23.28 percent of total billed charges MICRO INTRO SHEATH SET MIS-7F11 48710985_1 CDM 0272 RC inpatient 24 15.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 16.56 69 999999999 14.53 23.28 percent of total billed charges MICRO INTRO SHEATH SET MIS-7F11 48710985_1 CDM 0272 RC inpatient 24 15.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23.28 97 999999999 14.53 23.28 percent of total billed charges MICRO INTRO SHEATH SET MIS-7F11 48710985_1 CDM 0272 RC inpatient 24 15.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 18.72 78 999999999 14.53 23.28 percent of total billed charges MICRO INTRO SHEATH SET MIS-7F11 48710985_1 CDM 0272 RC inpatient 24 15.6 SIHO - ALL PLANS SIHO - ALL PLANS 21.6 90 999999999 14.53 23.28 percent of total billed charges MICRO INTRO SHEATH SET MIS-7F11 48710985_1 CDM 0272 RC inpatient 24 15.6 UMR - ALL PLANS UMR - ALL PLANS 16.8 70 999999999 14.53 23.28 percent of total billed charges MICRO INTRO SHEATH SET MIS-7F11 48710985_1 CDM 0272 RC inpatient 24 15.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.53 60.55 999999999 14.53 23.28 percent of total billed charges MICRO INTRO SHEATH SET MIS-7F11 48710985_1 CDM 0272 RC inpatient 24 15.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.53 23.28 MICRO INTRO SHEATH SET MIS-7F11 48710985_1 CDM 0272 RC inpatient 24 15.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.53 23.28 MICRO INTRO SHEATH SET MIS-7F11 48710985_1 CDM 0272 RC inpatient 24 15.6 ANTHEM HMO ANTHEM HMO 999999999 14.53 23.28 MICRO INTRO SHEATH SET MIS-7F11 48710985_1 CDM 0272 RC inpatient 24 15.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.53 23.28 MICRO INTRO SHEATH SET MIS-7F11 48710985_1 CDM 0272 RC inpatient 24 15.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.22 67.6 999999999 14.53 23.28 percent of total billed charges MICRO INTRO SHEATH SET MIS-7F11 48710985_1 CDM 0272 RC inpatient 24 15.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.53 23.28 SUTURE O CHROMIC 864H 48711105_1 CDM 0272 RC inpatient 32 20.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.8 65 999999999 19.38 31.04 percent of total billed charges SUTURE O CHROMIC 864H 48711105_1 CDM 0272 RC inpatient 32 20.8 AETNA AETNA 25.28 79 999999999 19.38 31.04 percent of total billed charges SUTURE O CHROMIC 864H 48711105_1 CDM 0272 RC inpatient 32 20.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.08 69 999999999 19.38 31.04 percent of total billed charges SUTURE O CHROMIC 864H 48711105_1 CDM 0272 RC inpatient 32 20.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31.04 97 999999999 19.38 31.04 percent of total billed charges SUTURE O CHROMIC 864H 48711105_1 CDM 0272 RC inpatient 32 20.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.96 78 999999999 19.38 31.04 percent of total billed charges SUTURE O CHROMIC 864H 48711105_1 CDM 0272 RC inpatient 32 20.8 SIHO - ALL PLANS SIHO - ALL PLANS 28.8 90 999999999 19.38 31.04 percent of total billed charges SUTURE O CHROMIC 864H 48711105_1 CDM 0272 RC inpatient 32 20.8 UMR - ALL PLANS UMR - ALL PLANS 22.4 70 999999999 19.38 31.04 percent of total billed charges SUTURE O CHROMIC 864H 48711105_1 CDM 0272 RC inpatient 32 20.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.38 60.55 999999999 19.38 31.04 percent of total billed charges SUTURE O CHROMIC 864H 48711105_1 CDM 0272 RC inpatient 32 20.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.38 31.04 SUTURE O CHROMIC 864H 48711105_1 CDM 0272 RC inpatient 32 20.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.38 31.04 SUTURE O CHROMIC 864H 48711105_1 CDM 0272 RC inpatient 32 20.8 ANTHEM HMO ANTHEM HMO 999999999 19.38 31.04 SUTURE O CHROMIC 864H 48711105_1 CDM 0272 RC inpatient 32 20.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.38 31.04 SUTURE O CHROMIC 864H 48711105_1 CDM 0272 RC inpatient 32 20.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.63 67.6 999999999 19.38 31.04 percent of total billed charges SUTURE O CHROMIC 864H 48711105_1 CDM 0272 RC inpatient 32 20.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.38 31.04 SUCTION DEVICE BLACK HOLE 000H 48711135_1 CDM 0272 RC inpatient 158 102.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.7 65 999999999 95.67 153.26 percent of total billed charges SUCTION DEVICE BLACK HOLE 000H 48711135_1 CDM 0272 RC inpatient 158 102.7 AETNA AETNA 124.82 79 999999999 95.67 153.26 percent of total billed charges SUCTION DEVICE BLACK HOLE 000H 48711135_1 CDM 0272 RC inpatient 158 102.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 109.02 69 999999999 95.67 153.26 percent of total billed charges SUCTION DEVICE BLACK HOLE 000H 48711135_1 CDM 0272 RC inpatient 158 102.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 153.26 97 999999999 95.67 153.26 percent of total billed charges SUCTION DEVICE BLACK HOLE 000H 48711135_1 CDM 0272 RC inpatient 158 102.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 123.24 78 999999999 95.67 153.26 percent of total billed charges SUCTION DEVICE BLACK HOLE 000H 48711135_1 CDM 0272 RC inpatient 158 102.7 SIHO - ALL PLANS SIHO - ALL PLANS 142.2 90 999999999 95.67 153.26 percent of total billed charges SUCTION DEVICE BLACK HOLE 000H 48711135_1 CDM 0272 RC inpatient 158 102.7 UMR - ALL PLANS UMR - ALL PLANS 110.6 70 999999999 95.67 153.26 percent of total billed charges SUCTION DEVICE BLACK HOLE 000H 48711135_1 CDM 0272 RC inpatient 158 102.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.67 60.55 999999999 95.67 153.26 percent of total billed charges SUCTION DEVICE BLACK HOLE 000H 48711135_1 CDM 0272 RC inpatient 158 102.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.67 153.26 SUCTION DEVICE BLACK HOLE 000H 48711135_1 CDM 0272 RC inpatient 158 102.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.67 153.26 SUCTION DEVICE BLACK HOLE 000H 48711135_1 CDM 0272 RC inpatient 158 102.7 ANTHEM HMO ANTHEM HMO 999999999 95.67 153.26 SUCTION DEVICE BLACK HOLE 000H 48711135_1 CDM 0272 RC inpatient 158 102.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.67 153.26 SUCTION DEVICE BLACK HOLE 000H 48711135_1 CDM 0272 RC inpatient 158 102.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.81 67.6 999999999 95.67 153.26 percent of total billed charges SUCTION DEVICE BLACK HOLE 000H 48711135_1 CDM 0272 RC inpatient 158 102.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.67 153.26 "CATH SHEATH PACK 3CM CPK83-11 (includes CF7-3-60, CFP, MIS-7F11)" 48711163_1 CDM 0272 RC inpatient 1139 740.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 740.35 65 999999999 689.66 1104.83 percent of total billed charges "CATH SHEATH PACK 3CM CPK83-11 (includes CF7-3-60, CFP, MIS-7F11)" 48711163_1 CDM 0272 RC inpatient 1139 740.35 AETNA AETNA 899.81 79 999999999 689.66 1104.83 percent of total billed charges "CATH SHEATH PACK 3CM CPK83-11 (includes CF7-3-60, CFP, MIS-7F11)" 48711163_1 CDM 0272 RC inpatient 1139 740.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 785.91 69 999999999 689.66 1104.83 percent of total billed charges "CATH SHEATH PACK 3CM CPK83-11 (includes CF7-3-60, CFP, MIS-7F11)" 48711163_1 CDM 0272 RC inpatient 1139 740.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1104.83 97 999999999 689.66 1104.83 percent of total billed charges "CATH SHEATH PACK 3CM CPK83-11 (includes CF7-3-60, CFP, MIS-7F11)" 48711163_1 CDM 0272 RC inpatient 1139 740.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 888.42 78 999999999 689.66 1104.83 percent of total billed charges "CATH SHEATH PACK 3CM CPK83-11 (includes CF7-3-60, CFP, MIS-7F11)" 48711163_1 CDM 0272 RC inpatient 1139 740.35 SIHO - ALL PLANS SIHO - ALL PLANS 1025.1 90 999999999 689.66 1104.83 percent of total billed charges "CATH SHEATH PACK 3CM CPK83-11 (includes CF7-3-60, CFP, MIS-7F11)" 48711163_1 CDM 0272 RC inpatient 1139 740.35 UMR - ALL PLANS UMR - ALL PLANS 797.3 70 999999999 689.66 1104.83 percent of total billed charges "CATH SHEATH PACK 3CM CPK83-11 (includes CF7-3-60, CFP, MIS-7F11)" 48711163_1 CDM 0272 RC inpatient 1139 740.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 689.66 60.55 999999999 689.66 1104.83 percent of total billed charges "CATH SHEATH PACK 3CM CPK83-11 (includes CF7-3-60, CFP, MIS-7F11)" 48711163_1 CDM 0272 RC inpatient 1139 740.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 689.66 1104.83 "CATH SHEATH PACK 3CM CPK83-11 (includes CF7-3-60, CFP, MIS-7F11)" 48711163_1 CDM 0272 RC inpatient 1139 740.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 689.66 1104.83 "CATH SHEATH PACK 3CM CPK83-11 (includes CF7-3-60, CFP, MIS-7F11)" 48711163_1 CDM 0272 RC inpatient 1139 740.35 ANTHEM HMO ANTHEM HMO 999999999 689.66 1104.83 "CATH SHEATH PACK 3CM CPK83-11 (includes CF7-3-60, CFP, MIS-7F11)" 48711163_1 CDM 0272 RC inpatient 1139 740.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 689.66 1104.83 "CATH SHEATH PACK 3CM CPK83-11 (includes CF7-3-60, CFP, MIS-7F11)" 48711163_1 CDM 0272 RC inpatient 1139 740.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 769.96 67.6 999999999 689.66 1104.83 percent of total billed charges "CATH SHEATH PACK 3CM CPK83-11 (includes CF7-3-60, CFP, MIS-7F11)" 48711163_1 CDM 0272 RC inpatient 1139 740.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 689.66 1104.83 SHOULDER IMMOBILIZER 79-84100 48711597_1 CDM 0270 RC inpatient 35 22.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.75 65 999999999 21.19 33.95 percent of total billed charges SHOULDER IMMOBILIZER 79-84100 48711597_1 CDM 0270 RC inpatient 35 22.75 AETNA AETNA 27.65 79 999999999 21.19 33.95 percent of total billed charges SHOULDER IMMOBILIZER 79-84100 48711597_1 CDM 0270 RC inpatient 35 22.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.15 69 999999999 21.19 33.95 percent of total billed charges SHOULDER IMMOBILIZER 79-84100 48711597_1 CDM 0270 RC inpatient 35 22.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33.95 97 999999999 21.19 33.95 percent of total billed charges SHOULDER IMMOBILIZER 79-84100 48711597_1 CDM 0270 RC inpatient 35 22.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.3 78 999999999 21.19 33.95 percent of total billed charges SHOULDER IMMOBILIZER 79-84100 48711597_1 CDM 0270 RC inpatient 35 22.75 SIHO - ALL PLANS SIHO - ALL PLANS 31.5 90 999999999 21.19 33.95 percent of total billed charges SHOULDER IMMOBILIZER 79-84100 48711597_1 CDM 0270 RC inpatient 35 22.75 UMR - ALL PLANS UMR - ALL PLANS 24.5 70 999999999 21.19 33.95 percent of total billed charges SHOULDER IMMOBILIZER 79-84100 48711597_1 CDM 0270 RC inpatient 35 22.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.19 60.55 999999999 21.19 33.95 percent of total billed charges SHOULDER IMMOBILIZER 79-84100 48711597_1 CDM 0270 RC inpatient 35 22.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.19 33.95 SHOULDER IMMOBILIZER 79-84100 48711597_1 CDM 0270 RC inpatient 35 22.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.19 33.95 SHOULDER IMMOBILIZER 79-84100 48711597_1 CDM 0270 RC inpatient 35 22.75 ANTHEM HMO ANTHEM HMO 999999999 21.19 33.95 SHOULDER IMMOBILIZER 79-84100 48711597_1 CDM 0270 RC inpatient 35 22.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.19 33.95 SHOULDER IMMOBILIZER 79-84100 48711597_1 CDM 0270 RC inpatient 35 22.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 23.66 67.6 999999999 21.19 33.95 percent of total billed charges SHOULDER IMMOBILIZER 79-84100 48711597_1 CDM 0270 RC inpatient 35 22.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.19 33.95 "IODOFORM STRIP GUAZE 1/4""" 48711621_1 CDM 0272 RC inpatient 12 7.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.8 65 999999999 7.27 11.64 percent of total billed charges "IODOFORM STRIP GUAZE 1/4""" 48711621_1 CDM 0272 RC inpatient 12 7.8 AETNA AETNA 9.48 79 999999999 7.27 11.64 percent of total billed charges "IODOFORM STRIP GUAZE 1/4""" 48711621_1 CDM 0272 RC inpatient 12 7.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.28 69 999999999 7.27 11.64 percent of total billed charges "IODOFORM STRIP GUAZE 1/4""" 48711621_1 CDM 0272 RC inpatient 12 7.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11.64 97 999999999 7.27 11.64 percent of total billed charges "IODOFORM STRIP GUAZE 1/4""" 48711621_1 CDM 0272 RC inpatient 12 7.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.36 78 999999999 7.27 11.64 percent of total billed charges "IODOFORM STRIP GUAZE 1/4""" 48711621_1 CDM 0272 RC inpatient 12 7.8 SIHO - ALL PLANS SIHO - ALL PLANS 10.8 90 999999999 7.27 11.64 percent of total billed charges "IODOFORM STRIP GUAZE 1/4""" 48711621_1 CDM 0272 RC inpatient 12 7.8 UMR - ALL PLANS UMR - ALL PLANS 8.4 70 999999999 7.27 11.64 percent of total billed charges "IODOFORM STRIP GUAZE 1/4""" 48711621_1 CDM 0272 RC inpatient 12 7.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.27 60.55 999999999 7.27 11.64 percent of total billed charges "IODOFORM STRIP GUAZE 1/4""" 48711621_1 CDM 0272 RC inpatient 12 7.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.27 11.64 "IODOFORM STRIP GUAZE 1/4""" 48711621_1 CDM 0272 RC inpatient 12 7.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.27 11.64 "IODOFORM STRIP GUAZE 1/4""" 48711621_1 CDM 0272 RC inpatient 12 7.8 ANTHEM HMO ANTHEM HMO 999999999 7.27 11.64 "IODOFORM STRIP GUAZE 1/4""" 48711621_1 CDM 0272 RC inpatient 12 7.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.27 11.64 "IODOFORM STRIP GUAZE 1/4""" 48711621_1 CDM 0272 RC inpatient 12 7.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.11 67.6 999999999 7.27 11.64 percent of total billed charges "IODOFORM STRIP GUAZE 1/4""" 48711621_1 CDM 0272 RC inpatient 12 7.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.27 11.64 CATH RED RUBBER 20FR 48711646_1 CDM 0272 RC inpatient 7 4.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.55 65 999999999 4.24 6.79 percent of total billed charges CATH RED RUBBER 20FR 48711646_1 CDM 0272 RC inpatient 7 4.55 AETNA AETNA 5.53 79 999999999 4.24 6.79 percent of total billed charges CATH RED RUBBER 20FR 48711646_1 CDM 0272 RC inpatient 7 4.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.83 69 999999999 4.24 6.79 percent of total billed charges CATH RED RUBBER 20FR 48711646_1 CDM 0272 RC inpatient 7 4.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.79 97 999999999 4.24 6.79 percent of total billed charges CATH RED RUBBER 20FR 48711646_1 CDM 0272 RC inpatient 7 4.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 5.46 78 999999999 4.24 6.79 percent of total billed charges CATH RED RUBBER 20FR 48711646_1 CDM 0272 RC inpatient 7 4.55 SIHO - ALL PLANS SIHO - ALL PLANS 6.3 90 999999999 4.24 6.79 percent of total billed charges CATH RED RUBBER 20FR 48711646_1 CDM 0272 RC inpatient 7 4.55 UMR - ALL PLANS UMR - ALL PLANS 4.9 70 999999999 4.24 6.79 percent of total billed charges CATH RED RUBBER 20FR 48711646_1 CDM 0272 RC inpatient 7 4.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.24 60.55 999999999 4.24 6.79 percent of total billed charges CATH RED RUBBER 20FR 48711646_1 CDM 0272 RC inpatient 7 4.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.24 6.79 CATH RED RUBBER 20FR 48711646_1 CDM 0272 RC inpatient 7 4.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.24 6.79 CATH RED RUBBER 20FR 48711646_1 CDM 0272 RC inpatient 7 4.55 ANTHEM HMO ANTHEM HMO 999999999 4.24 6.79 CATH RED RUBBER 20FR 48711646_1 CDM 0272 RC inpatient 7 4.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.24 6.79 CATH RED RUBBER 20FR 48711646_1 CDM 0272 RC inpatient 7 4.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.73 67.6 999999999 4.24 6.79 percent of total billed charges CATH RED RUBBER 20FR 48711646_1 CDM 0272 RC inpatient 7 4.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.24 6.79 SIDEKICK NEEDLE INJ #890-304 48711726_1 CDM 0270 RC inpatient 261 169.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 169.65 65 999999999 158.04 253.17 percent of total billed charges SIDEKICK NEEDLE INJ #890-304 48711726_1 CDM 0270 RC inpatient 261 169.65 AETNA AETNA 206.19 79 999999999 158.04 253.17 percent of total billed charges SIDEKICK NEEDLE INJ #890-304 48711726_1 CDM 0270 RC inpatient 261 169.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.09 69 999999999 158.04 253.17 percent of total billed charges SIDEKICK NEEDLE INJ #890-304 48711726_1 CDM 0270 RC inpatient 261 169.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 253.17 97 999999999 158.04 253.17 percent of total billed charges SIDEKICK NEEDLE INJ #890-304 48711726_1 CDM 0270 RC inpatient 261 169.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 203.58 78 999999999 158.04 253.17 percent of total billed charges SIDEKICK NEEDLE INJ #890-304 48711726_1 CDM 0270 RC inpatient 261 169.65 SIHO - ALL PLANS SIHO - ALL PLANS 234.9 90 999999999 158.04 253.17 percent of total billed charges SIDEKICK NEEDLE INJ #890-304 48711726_1 CDM 0270 RC inpatient 261 169.65 UMR - ALL PLANS UMR - ALL PLANS 182.7 70 999999999 158.04 253.17 percent of total billed charges SIDEKICK NEEDLE INJ #890-304 48711726_1 CDM 0270 RC inpatient 261 169.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.04 60.55 999999999 158.04 253.17 percent of total billed charges SIDEKICK NEEDLE INJ #890-304 48711726_1 CDM 0270 RC inpatient 261 169.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.04 253.17 SIDEKICK NEEDLE INJ #890-304 48711726_1 CDM 0270 RC inpatient 261 169.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.04 253.17 SIDEKICK NEEDLE INJ #890-304 48711726_1 CDM 0270 RC inpatient 261 169.65 ANTHEM HMO ANTHEM HMO 999999999 158.04 253.17 SIDEKICK NEEDLE INJ #890-304 48711726_1 CDM 0270 RC inpatient 261 169.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.04 253.17 SIDEKICK NEEDLE INJ #890-304 48711726_1 CDM 0270 RC inpatient 261 169.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 176.44 67.6 999999999 158.04 253.17 percent of total billed charges SIDEKICK NEEDLE INJ #890-304 48711726_1 CDM 0270 RC inpatient 261 169.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.04 253.17 "REPAIR DEVICE, URINARY, INCONTINENCE, WITHOUT SLING GRAFT" 48711727_1 CDM 0278 RC C2631 HCPCS inpatient 1936 1258.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1258.4 65 999999999 1172.25 1877.92 percent of total billed charges "REPAIR DEVICE, URINARY, INCONTINENCE, WITHOUT SLING GRAFT" 48711727_1 CDM 0278 RC C2631 HCPCS inpatient 1936 1258.4 AETNA AETNA 1529.44 79 999999999 1172.25 1877.92 percent of total billed charges "REPAIR DEVICE, URINARY, INCONTINENCE, WITHOUT SLING GRAFT" 48711727_1 CDM 0278 RC C2631 HCPCS inpatient 1936 1258.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1335.84 69 999999999 1172.25 1877.92 percent of total billed charges "REPAIR DEVICE, URINARY, INCONTINENCE, WITHOUT SLING GRAFT" 48711727_1 CDM 0278 RC C2631 HCPCS inpatient 1936 1258.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1877.92 97 999999999 1172.25 1877.92 percent of total billed charges "REPAIR DEVICE, URINARY, INCONTINENCE, WITHOUT SLING GRAFT" 48711727_1 CDM 0278 RC C2631 HCPCS inpatient 1936 1258.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1510.08 78 999999999 1172.25 1877.92 percent of total billed charges "REPAIR DEVICE, URINARY, INCONTINENCE, WITHOUT SLING GRAFT" 48711727_1 CDM 0278 RC C2631 HCPCS inpatient 1936 1258.4 SIHO - ALL PLANS SIHO - ALL PLANS 1742.4 90 999999999 1172.25 1877.92 percent of total billed charges "REPAIR DEVICE, URINARY, INCONTINENCE, WITHOUT SLING GRAFT" 48711727_1 CDM 0278 RC C2631 HCPCS inpatient 1936 1258.4 UMR - ALL PLANS UMR - ALL PLANS 1355.2 70 999999999 1172.25 1877.92 percent of total billed charges "REPAIR DEVICE, URINARY, INCONTINENCE, WITHOUT SLING GRAFT" 48711727_1 CDM 0278 RC C2631 HCPCS inpatient 1936 1258.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1172.25 60.55 999999999 1172.25 1877.92 percent of total billed charges "REPAIR DEVICE, URINARY, INCONTINENCE, WITHOUT SLING GRAFT" 48711727_1 CDM 0278 RC C2631 HCPCS inpatient 1936 1258.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1172.25 1877.92 "REPAIR DEVICE, URINARY, INCONTINENCE, WITHOUT SLING GRAFT" 48711727_1 CDM 0278 RC C2631 HCPCS inpatient 1936 1258.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1172.25 1877.92 "REPAIR DEVICE, URINARY, INCONTINENCE, WITHOUT SLING GRAFT" 48711727_1 CDM 0278 RC C2631 HCPCS inpatient 1936 1258.4 ANTHEM HMO ANTHEM HMO 999999999 1172.25 1877.92 "REPAIR DEVICE, URINARY, INCONTINENCE, WITHOUT SLING GRAFT" 48711727_1 CDM 0278 RC C2631 HCPCS inpatient 1936 1258.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1172.25 1877.92 "REPAIR DEVICE, URINARY, INCONTINENCE, WITHOUT SLING GRAFT" 48711727_1 CDM 0278 RC C2631 HCPCS inpatient 1936 1258.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1308.74 67.6 999999999 1172.25 1877.92 percent of total billed charges "REPAIR DEVICE, URINARY, INCONTINENCE, WITHOUT SLING GRAFT" 48711727_1 CDM 0278 RC C2631 HCPCS inpatient 1936 1258.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1172.25 1877.92 COLLAR PHILIDELPHIA LG PHP-T3L 48711730_1 CDM 0274 RC inpatient 69 44.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.85 65 999999999 41.78 66.93 percent of total billed charges COLLAR PHILIDELPHIA LG PHP-T3L 48711730_1 CDM 0274 RC inpatient 69 44.85 AETNA AETNA 54.51 79 999999999 41.78 66.93 percent of total billed charges COLLAR PHILIDELPHIA LG PHP-T3L 48711730_1 CDM 0274 RC inpatient 69 44.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 47.61 69 999999999 41.78 66.93 percent of total billed charges COLLAR PHILIDELPHIA LG PHP-T3L 48711730_1 CDM 0274 RC inpatient 69 44.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 66.93 97 999999999 41.78 66.93 percent of total billed charges COLLAR PHILIDELPHIA LG PHP-T3L 48711730_1 CDM 0274 RC inpatient 69 44.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.82 78 999999999 41.78 66.93 percent of total billed charges COLLAR PHILIDELPHIA LG PHP-T3L 48711730_1 CDM 0274 RC inpatient 69 44.85 SIHO - ALL PLANS SIHO - ALL PLANS 62.1 90 999999999 41.78 66.93 percent of total billed charges COLLAR PHILIDELPHIA LG PHP-T3L 48711730_1 CDM 0274 RC inpatient 69 44.85 UMR - ALL PLANS UMR - ALL PLANS 48.3 70 999999999 41.78 66.93 percent of total billed charges COLLAR PHILIDELPHIA LG PHP-T3L 48711730_1 CDM 0274 RC inpatient 69 44.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.78 60.55 999999999 41.78 66.93 percent of total billed charges COLLAR PHILIDELPHIA LG PHP-T3L 48711730_1 CDM 0274 RC inpatient 69 44.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.78 66.93 COLLAR PHILIDELPHIA LG PHP-T3L 48711730_1 CDM 0274 RC inpatient 69 44.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.78 66.93 COLLAR PHILIDELPHIA LG PHP-T3L 48711730_1 CDM 0274 RC inpatient 69 44.85 ANTHEM HMO ANTHEM HMO 999999999 41.78 66.93 COLLAR PHILIDELPHIA LG PHP-T3L 48711730_1 CDM 0274 RC inpatient 69 44.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.78 66.93 COLLAR PHILIDELPHIA LG PHP-T3L 48711730_1 CDM 0274 RC inpatient 69 44.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 46.64 67.6 999999999 41.78 66.93 percent of total billed charges COLLAR PHILIDELPHIA LG PHP-T3L 48711730_1 CDM 0274 RC inpatient 69 44.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.78 66.93 COLLAR PHIL. CERVICAL PEDS 48711733_1 CDM 0274 RC inpatient 93 60.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 60.45 65 999999999 56.31 90.21 percent of total billed charges COLLAR PHIL. CERVICAL PEDS 48711733_1 CDM 0274 RC inpatient 93 60.45 AETNA AETNA 73.47 79 999999999 56.31 90.21 percent of total billed charges COLLAR PHIL. CERVICAL PEDS 48711733_1 CDM 0274 RC inpatient 93 60.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.17 69 999999999 56.31 90.21 percent of total billed charges COLLAR PHIL. CERVICAL PEDS 48711733_1 CDM 0274 RC inpatient 93 60.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 90.21 97 999999999 56.31 90.21 percent of total billed charges COLLAR PHIL. CERVICAL PEDS 48711733_1 CDM 0274 RC inpatient 93 60.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 72.54 78 999999999 56.31 90.21 percent of total billed charges COLLAR PHIL. CERVICAL PEDS 48711733_1 CDM 0274 RC inpatient 93 60.45 SIHO - ALL PLANS SIHO - ALL PLANS 83.7 90 999999999 56.31 90.21 percent of total billed charges COLLAR PHIL. CERVICAL PEDS 48711733_1 CDM 0274 RC inpatient 93 60.45 UMR - ALL PLANS UMR - ALL PLANS 65.1 70 999999999 56.31 90.21 percent of total billed charges COLLAR PHIL. CERVICAL PEDS 48711733_1 CDM 0274 RC inpatient 93 60.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.31 60.55 999999999 56.31 90.21 percent of total billed charges COLLAR PHIL. CERVICAL PEDS 48711733_1 CDM 0274 RC inpatient 93 60.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.31 90.21 COLLAR PHIL. CERVICAL PEDS 48711733_1 CDM 0274 RC inpatient 93 60.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.31 90.21 COLLAR PHIL. CERVICAL PEDS 48711733_1 CDM 0274 RC inpatient 93 60.45 ANTHEM HMO ANTHEM HMO 999999999 56.31 90.21 COLLAR PHIL. CERVICAL PEDS 48711733_1 CDM 0274 RC inpatient 93 60.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.31 90.21 COLLAR PHIL. CERVICAL PEDS 48711733_1 CDM 0274 RC inpatient 93 60.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.87 67.6 999999999 56.31 90.21 percent of total billed charges COLLAR PHIL. CERVICAL PEDS 48711733_1 CDM 0274 RC inpatient 93 60.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.31 90.21 PILLOW ABDUCTION MED HIP 79-90175 48711734_1 CDM 0271 RC inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges PILLOW ABDUCTION MED HIP 79-90175 48711734_1 CDM 0271 RC inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges PILLOW ABDUCTION MED HIP 79-90175 48711734_1 CDM 0271 RC inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges PILLOW ABDUCTION MED HIP 79-90175 48711734_1 CDM 0271 RC inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges PILLOW ABDUCTION MED HIP 79-90175 48711734_1 CDM 0271 RC inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges PILLOW ABDUCTION MED HIP 79-90175 48711734_1 CDM 0271 RC inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges PILLOW ABDUCTION MED HIP 79-90175 48711734_1 CDM 0271 RC inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges PILLOW ABDUCTION MED HIP 79-90175 48711734_1 CDM 0271 RC inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges PILLOW ABDUCTION MED HIP 79-90175 48711734_1 CDM 0271 RC inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 PILLOW ABDUCTION MED HIP 79-90175 48711734_1 CDM 0271 RC inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 PILLOW ABDUCTION MED HIP 79-90175 48711734_1 CDM 0271 RC inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 PILLOW ABDUCTION MED HIP 79-90175 48711734_1 CDM 0271 RC inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 PILLOW ABDUCTION MED HIP 79-90175 48711734_1 CDM 0271 RC inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges PILLOW ABDUCTION MED HIP 79-90175 48711734_1 CDM 0271 RC inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 PILLOW ABDUCTION SHOULDER MED. 48711735_1 CDM 0271 RC inpatient 414 269.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 269.1 65 999999999 250.68 401.58 percent of total billed charges PILLOW ABDUCTION SHOULDER MED. 48711735_1 CDM 0271 RC inpatient 414 269.1 AETNA AETNA 327.06 79 999999999 250.68 401.58 percent of total billed charges PILLOW ABDUCTION SHOULDER MED. 48711735_1 CDM 0271 RC inpatient 414 269.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 285.66 69 999999999 250.68 401.58 percent of total billed charges PILLOW ABDUCTION SHOULDER MED. 48711735_1 CDM 0271 RC inpatient 414 269.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 401.58 97 999999999 250.68 401.58 percent of total billed charges PILLOW ABDUCTION SHOULDER MED. 48711735_1 CDM 0271 RC inpatient 414 269.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 322.92 78 999999999 250.68 401.58 percent of total billed charges PILLOW ABDUCTION SHOULDER MED. 48711735_1 CDM 0271 RC inpatient 414 269.1 SIHO - ALL PLANS SIHO - ALL PLANS 372.6 90 999999999 250.68 401.58 percent of total billed charges PILLOW ABDUCTION SHOULDER MED. 48711735_1 CDM 0271 RC inpatient 414 269.1 UMR - ALL PLANS UMR - ALL PLANS 289.8 70 999999999 250.68 401.58 percent of total billed charges PILLOW ABDUCTION SHOULDER MED. 48711735_1 CDM 0271 RC inpatient 414 269.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 250.68 60.55 999999999 250.68 401.58 percent of total billed charges PILLOW ABDUCTION SHOULDER MED. 48711735_1 CDM 0271 RC inpatient 414 269.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 250.68 401.58 PILLOW ABDUCTION SHOULDER MED. 48711735_1 CDM 0271 RC inpatient 414 269.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 250.68 401.58 PILLOW ABDUCTION SHOULDER MED. 48711735_1 CDM 0271 RC inpatient 414 269.1 ANTHEM HMO ANTHEM HMO 999999999 250.68 401.58 PILLOW ABDUCTION SHOULDER MED. 48711735_1 CDM 0271 RC inpatient 414 269.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 250.68 401.58 PILLOW ABDUCTION SHOULDER MED. 48711735_1 CDM 0271 RC inpatient 414 269.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 279.86 67.6 999999999 250.68 401.58 percent of total billed charges PILLOW ABDUCTION SHOULDER MED. 48711735_1 CDM 0271 RC inpatient 414 269.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 250.68 401.58 PILLOW ABDUCTION SHOULDER LG. 48711737_1 CDM 0271 RC inpatient 327 212.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 212.55 65 999999999 198 317.19 percent of total billed charges PILLOW ABDUCTION SHOULDER LG. 48711737_1 CDM 0271 RC inpatient 327 212.55 AETNA AETNA 258.33 79 999999999 198 317.19 percent of total billed charges PILLOW ABDUCTION SHOULDER LG. 48711737_1 CDM 0271 RC inpatient 327 212.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 225.63 69 999999999 198 317.19 percent of total billed charges PILLOW ABDUCTION SHOULDER LG. 48711737_1 CDM 0271 RC inpatient 327 212.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 317.19 97 999999999 198 317.19 percent of total billed charges PILLOW ABDUCTION SHOULDER LG. 48711737_1 CDM 0271 RC inpatient 327 212.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.06 78 999999999 198 317.19 percent of total billed charges PILLOW ABDUCTION SHOULDER LG. 48711737_1 CDM 0271 RC inpatient 327 212.55 SIHO - ALL PLANS SIHO - ALL PLANS 294.3 90 999999999 198 317.19 percent of total billed charges PILLOW ABDUCTION SHOULDER LG. 48711737_1 CDM 0271 RC inpatient 327 212.55 UMR - ALL PLANS UMR - ALL PLANS 228.9 70 999999999 198 317.19 percent of total billed charges PILLOW ABDUCTION SHOULDER LG. 48711737_1 CDM 0271 RC inpatient 327 212.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198 60.55 999999999 198 317.19 percent of total billed charges PILLOW ABDUCTION SHOULDER LG. 48711737_1 CDM 0271 RC inpatient 327 212.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198 317.19 PILLOW ABDUCTION SHOULDER LG. 48711737_1 CDM 0271 RC inpatient 327 212.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198 317.19 PILLOW ABDUCTION SHOULDER LG. 48711737_1 CDM 0271 RC inpatient 327 212.55 ANTHEM HMO ANTHEM HMO 999999999 198 317.19 PILLOW ABDUCTION SHOULDER LG. 48711737_1 CDM 0271 RC inpatient 327 212.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198 317.19 PILLOW ABDUCTION SHOULDER LG. 48711737_1 CDM 0271 RC inpatient 327 212.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.05 67.6 999999999 198 317.19 percent of total billed charges PILLOW ABDUCTION SHOULDER LG. 48711737_1 CDM 0271 RC inpatient 327 212.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 198 317.19 AIRWAY KING KLTSD422 SIZE 2 GREEN 48711749_1 CDM 0272 RC inpatient 223 144.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 144.95 65 999999999 135.03 216.31 percent of total billed charges AIRWAY KING KLTSD422 SIZE 2 GREEN 48711749_1 CDM 0272 RC inpatient 223 144.95 AETNA AETNA 176.17 79 999999999 135.03 216.31 percent of total billed charges AIRWAY KING KLTSD422 SIZE 2 GREEN 48711749_1 CDM 0272 RC inpatient 223 144.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 153.87 69 999999999 135.03 216.31 percent of total billed charges AIRWAY KING KLTSD422 SIZE 2 GREEN 48711749_1 CDM 0272 RC inpatient 223 144.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 216.31 97 999999999 135.03 216.31 percent of total billed charges AIRWAY KING KLTSD422 SIZE 2 GREEN 48711749_1 CDM 0272 RC inpatient 223 144.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 173.94 78 999999999 135.03 216.31 percent of total billed charges AIRWAY KING KLTSD422 SIZE 2 GREEN 48711749_1 CDM 0272 RC inpatient 223 144.95 SIHO - ALL PLANS SIHO - ALL PLANS 200.7 90 999999999 135.03 216.31 percent of total billed charges AIRWAY KING KLTSD422 SIZE 2 GREEN 48711749_1 CDM 0272 RC inpatient 223 144.95 UMR - ALL PLANS UMR - ALL PLANS 156.1 70 999999999 135.03 216.31 percent of total billed charges AIRWAY KING KLTSD422 SIZE 2 GREEN 48711749_1 CDM 0272 RC inpatient 223 144.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 135.03 60.55 999999999 135.03 216.31 percent of total billed charges AIRWAY KING KLTSD422 SIZE 2 GREEN 48711749_1 CDM 0272 RC inpatient 223 144.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 135.03 216.31 AIRWAY KING KLTSD422 SIZE 2 GREEN 48711749_1 CDM 0272 RC inpatient 223 144.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 135.03 216.31 AIRWAY KING KLTSD422 SIZE 2 GREEN 48711749_1 CDM 0272 RC inpatient 223 144.95 ANTHEM HMO ANTHEM HMO 999999999 135.03 216.31 AIRWAY KING KLTSD422 SIZE 2 GREEN 48711749_1 CDM 0272 RC inpatient 223 144.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 135.03 216.31 AIRWAY KING KLTSD422 SIZE 2 GREEN 48711749_1 CDM 0272 RC inpatient 223 144.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 150.75 67.6 999999999 135.03 216.31 percent of total billed charges AIRWAY KING KLTSD422 SIZE 2 GREEN 48711749_1 CDM 0272 RC inpatient 223 144.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 135.03 216.31 AIRWAY KING KLTSD45225 SZ 2.5 48711750_1 CDM 0272 RC inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges AIRWAY KING KLTSD45225 SZ 2.5 48711750_1 CDM 0272 RC inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges AIRWAY KING KLTSD45225 SZ 2.5 48711750_1 CDM 0272 RC inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges AIRWAY KING KLTSD45225 SZ 2.5 48711750_1 CDM 0272 RC inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges AIRWAY KING KLTSD45225 SZ 2.5 48711750_1 CDM 0272 RC inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges AIRWAY KING KLTSD45225 SZ 2.5 48711750_1 CDM 0272 RC inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges AIRWAY KING KLTSD45225 SZ 2.5 48711750_1 CDM 0272 RC inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges AIRWAY KING KLTSD45225 SZ 2.5 48711750_1 CDM 0272 RC inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges AIRWAY KING KLTSD45225 SZ 2.5 48711750_1 CDM 0272 RC inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 AIRWAY KING KLTSD45225 SZ 2.5 48711750_1 CDM 0272 RC inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 AIRWAY KING KLTSD45225 SZ 2.5 48711750_1 CDM 0272 RC inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 AIRWAY KING KLTSD45225 SZ 2.5 48711750_1 CDM 0272 RC inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 AIRWAY KING KLTSD45225 SZ 2.5 48711750_1 CDM 0272 RC inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges AIRWAY KING KLTSD45225 SZ 2.5 48711750_1 CDM 0272 RC inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 AIRWAY KING KLTSD403 SZ 3 YELLOW 48711751_1 CDM 0272 RC inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges AIRWAY KING KLTSD403 SZ 3 YELLOW 48711751_1 CDM 0272 RC inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges AIRWAY KING KLTSD403 SZ 3 YELLOW 48711751_1 CDM 0272 RC inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges AIRWAY KING KLTSD403 SZ 3 YELLOW 48711751_1 CDM 0272 RC inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges AIRWAY KING KLTSD403 SZ 3 YELLOW 48711751_1 CDM 0272 RC inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges AIRWAY KING KLTSD403 SZ 3 YELLOW 48711751_1 CDM 0272 RC inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges AIRWAY KING KLTSD403 SZ 3 YELLOW 48711751_1 CDM 0272 RC inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges AIRWAY KING KLTSD403 SZ 3 YELLOW 48711751_1 CDM 0272 RC inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges AIRWAY KING KLTSD403 SZ 3 YELLOW 48711751_1 CDM 0272 RC inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 AIRWAY KING KLTSD403 SZ 3 YELLOW 48711751_1 CDM 0272 RC inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 AIRWAY KING KLTSD403 SZ 3 YELLOW 48711751_1 CDM 0272 RC inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 AIRWAY KING KLTSD403 SZ 3 YELLOW 48711751_1 CDM 0272 RC inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 AIRWAY KING KLTSD403 SZ 3 YELLOW 48711751_1 CDM 0272 RC inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges AIRWAY KING KLTSD403 SZ 3 YELLOW 48711751_1 CDM 0272 RC inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 AIRWAY KING LTSD TUBE SIZE 4 W/SUCTION PORT RED MFG# KLTSD424 48711752_1 CDM 0272 RC inpatient 96 62.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.4 65 999999999 58.13 93.12 percent of total billed charges AIRWAY KING LTSD TUBE SIZE 4 W/SUCTION PORT RED MFG# KLTSD424 48711752_1 CDM 0272 RC inpatient 96 62.4 AETNA AETNA 75.84 79 999999999 58.13 93.12 percent of total billed charges AIRWAY KING LTSD TUBE SIZE 4 W/SUCTION PORT RED MFG# KLTSD424 48711752_1 CDM 0272 RC inpatient 96 62.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.24 69 999999999 58.13 93.12 percent of total billed charges AIRWAY KING LTSD TUBE SIZE 4 W/SUCTION PORT RED MFG# KLTSD424 48711752_1 CDM 0272 RC inpatient 96 62.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.12 97 999999999 58.13 93.12 percent of total billed charges AIRWAY KING LTSD TUBE SIZE 4 W/SUCTION PORT RED MFG# KLTSD424 48711752_1 CDM 0272 RC inpatient 96 62.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.88 78 999999999 58.13 93.12 percent of total billed charges AIRWAY KING LTSD TUBE SIZE 4 W/SUCTION PORT RED MFG# KLTSD424 48711752_1 CDM 0272 RC inpatient 96 62.4 SIHO - ALL PLANS SIHO - ALL PLANS 86.4 90 999999999 58.13 93.12 percent of total billed charges AIRWAY KING LTSD TUBE SIZE 4 W/SUCTION PORT RED MFG# KLTSD424 48711752_1 CDM 0272 RC inpatient 96 62.4 UMR - ALL PLANS UMR - ALL PLANS 67.2 70 999999999 58.13 93.12 percent of total billed charges AIRWAY KING LTSD TUBE SIZE 4 W/SUCTION PORT RED MFG# KLTSD424 48711752_1 CDM 0272 RC inpatient 96 62.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.13 60.55 999999999 58.13 93.12 percent of total billed charges AIRWAY KING LTSD TUBE SIZE 4 W/SUCTION PORT RED MFG# KLTSD424 48711752_1 CDM 0272 RC inpatient 96 62.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.13 93.12 AIRWAY KING LTSD TUBE SIZE 4 W/SUCTION PORT RED MFG# KLTSD424 48711752_1 CDM 0272 RC inpatient 96 62.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.13 93.12 AIRWAY KING LTSD TUBE SIZE 4 W/SUCTION PORT RED MFG# KLTSD424 48711752_1 CDM 0272 RC inpatient 96 62.4 ANTHEM HMO ANTHEM HMO 999999999 58.13 93.12 AIRWAY KING LTSD TUBE SIZE 4 W/SUCTION PORT RED MFG# KLTSD424 48711752_1 CDM 0272 RC inpatient 96 62.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.13 93.12 AIRWAY KING LTSD TUBE SIZE 4 W/SUCTION PORT RED MFG# KLTSD424 48711752_1 CDM 0272 RC inpatient 96 62.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.9 67.6 999999999 58.13 93.12 percent of total billed charges AIRWAY KING LTSD TUBE SIZE 4 W/SUCTION PORT RED MFG# KLTSD424 48711752_1 CDM 0272 RC inpatient 96 62.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.13 93.12 AIRWAY KING KLTSD405 SZ 5 PURPLE 48711753_1 CDM 0272 RC inpatient 156 101.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.4 65 999999999 94.46 151.32 percent of total billed charges AIRWAY KING KLTSD405 SZ 5 PURPLE 48711753_1 CDM 0272 RC inpatient 156 101.4 AETNA AETNA 123.24 79 999999999 94.46 151.32 percent of total billed charges AIRWAY KING KLTSD405 SZ 5 PURPLE 48711753_1 CDM 0272 RC inpatient 156 101.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.64 69 999999999 94.46 151.32 percent of total billed charges AIRWAY KING KLTSD405 SZ 5 PURPLE 48711753_1 CDM 0272 RC inpatient 156 101.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 151.32 97 999999999 94.46 151.32 percent of total billed charges AIRWAY KING KLTSD405 SZ 5 PURPLE 48711753_1 CDM 0272 RC inpatient 156 101.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.68 78 999999999 94.46 151.32 percent of total billed charges AIRWAY KING KLTSD405 SZ 5 PURPLE 48711753_1 CDM 0272 RC inpatient 156 101.4 SIHO - ALL PLANS SIHO - ALL PLANS 140.4 90 999999999 94.46 151.32 percent of total billed charges AIRWAY KING KLTSD405 SZ 5 PURPLE 48711753_1 CDM 0272 RC inpatient 156 101.4 UMR - ALL PLANS UMR - ALL PLANS 109.2 70 999999999 94.46 151.32 percent of total billed charges AIRWAY KING KLTSD405 SZ 5 PURPLE 48711753_1 CDM 0272 RC inpatient 156 101.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.46 60.55 999999999 94.46 151.32 percent of total billed charges AIRWAY KING KLTSD405 SZ 5 PURPLE 48711753_1 CDM 0272 RC inpatient 156 101.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.46 151.32 AIRWAY KING KLTSD405 SZ 5 PURPLE 48711753_1 CDM 0272 RC inpatient 156 101.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.46 151.32 AIRWAY KING KLTSD405 SZ 5 PURPLE 48711753_1 CDM 0272 RC inpatient 156 101.4 ANTHEM HMO ANTHEM HMO 999999999 94.46 151.32 AIRWAY KING KLTSD405 SZ 5 PURPLE 48711753_1 CDM 0272 RC inpatient 156 101.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.46 151.32 AIRWAY KING KLTSD405 SZ 5 PURPLE 48711753_1 CDM 0272 RC inpatient 156 101.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.46 67.6 999999999 94.46 151.32 percent of total billed charges AIRWAY KING KLTSD405 SZ 5 PURPLE 48711753_1 CDM 0272 RC inpatient 156 101.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.46 151.32 BACK/HIP/RIB CRYO CUFF W/COOLE 48711755_1 CDM 0271 RC inpatient 456 296.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 296.4 65 999999999 276.11 442.32 percent of total billed charges BACK/HIP/RIB CRYO CUFF W/COOLE 48711755_1 CDM 0271 RC inpatient 456 296.4 AETNA AETNA 360.24 79 999999999 276.11 442.32 percent of total billed charges BACK/HIP/RIB CRYO CUFF W/COOLE 48711755_1 CDM 0271 RC inpatient 456 296.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 314.64 69 999999999 276.11 442.32 percent of total billed charges BACK/HIP/RIB CRYO CUFF W/COOLE 48711755_1 CDM 0271 RC inpatient 456 296.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 442.32 97 999999999 276.11 442.32 percent of total billed charges BACK/HIP/RIB CRYO CUFF W/COOLE 48711755_1 CDM 0271 RC inpatient 456 296.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 355.68 78 999999999 276.11 442.32 percent of total billed charges BACK/HIP/RIB CRYO CUFF W/COOLE 48711755_1 CDM 0271 RC inpatient 456 296.4 SIHO - ALL PLANS SIHO - ALL PLANS 410.4 90 999999999 276.11 442.32 percent of total billed charges BACK/HIP/RIB CRYO CUFF W/COOLE 48711755_1 CDM 0271 RC inpatient 456 296.4 UMR - ALL PLANS UMR - ALL PLANS 319.2 70 999999999 276.11 442.32 percent of total billed charges BACK/HIP/RIB CRYO CUFF W/COOLE 48711755_1 CDM 0271 RC inpatient 456 296.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 276.11 60.55 999999999 276.11 442.32 percent of total billed charges BACK/HIP/RIB CRYO CUFF W/COOLE 48711755_1 CDM 0271 RC inpatient 456 296.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 276.11 442.32 BACK/HIP/RIB CRYO CUFF W/COOLE 48711755_1 CDM 0271 RC inpatient 456 296.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 276.11 442.32 BACK/HIP/RIB CRYO CUFF W/COOLE 48711755_1 CDM 0271 RC inpatient 456 296.4 ANTHEM HMO ANTHEM HMO 999999999 276.11 442.32 BACK/HIP/RIB CRYO CUFF W/COOLE 48711755_1 CDM 0271 RC inpatient 456 296.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 276.11 442.32 BACK/HIP/RIB CRYO CUFF W/COOLE 48711755_1 CDM 0271 RC inpatient 456 296.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 308.26 67.6 999999999 276.11 442.32 percent of total billed charges BACK/HIP/RIB CRYO CUFF W/COOLE 48711755_1 CDM 0271 RC inpatient 456 296.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 276.11 442.32 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711756_1 CDM 0278 RC C1713 HCPCS inpatient 454 295.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 295.1 65 999999999 274.9 440.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711756_1 CDM 0278 RC C1713 HCPCS inpatient 454 295.1 AETNA AETNA 358.66 79 999999999 274.9 440.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711756_1 CDM 0278 RC C1713 HCPCS inpatient 454 295.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 313.26 69 999999999 274.9 440.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711756_1 CDM 0278 RC C1713 HCPCS inpatient 454 295.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 440.38 97 999999999 274.9 440.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711756_1 CDM 0278 RC C1713 HCPCS inpatient 454 295.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 354.12 78 999999999 274.9 440.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711756_1 CDM 0278 RC C1713 HCPCS inpatient 454 295.1 SIHO - ALL PLANS SIHO - ALL PLANS 408.6 90 999999999 274.9 440.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711756_1 CDM 0278 RC C1713 HCPCS inpatient 454 295.1 UMR - ALL PLANS UMR - ALL PLANS 317.8 70 999999999 274.9 440.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711756_1 CDM 0278 RC C1713 HCPCS inpatient 454 295.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 274.9 60.55 999999999 274.9 440.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711756_1 CDM 0278 RC C1713 HCPCS inpatient 454 295.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 274.9 440.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711756_1 CDM 0278 RC C1713 HCPCS inpatient 454 295.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 274.9 440.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711756_1 CDM 0278 RC C1713 HCPCS inpatient 454 295.1 ANTHEM HMO ANTHEM HMO 999999999 274.9 440.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711756_1 CDM 0278 RC C1713 HCPCS inpatient 454 295.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 274.9 440.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711756_1 CDM 0278 RC C1713 HCPCS inpatient 454 295.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 306.9 67.6 999999999 274.9 440.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711756_1 CDM 0278 RC C1713 HCPCS inpatient 454 295.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 274.9 440.38 FLEXISEAL FECAL SYSTEM 418000 48711768_1 CDM 0272 RC inpatient 911 592.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 592.15 65 999999999 551.61 883.67 percent of total billed charges FLEXISEAL FECAL SYSTEM 418000 48711768_1 CDM 0272 RC inpatient 911 592.15 AETNA AETNA 719.69 79 999999999 551.61 883.67 percent of total billed charges FLEXISEAL FECAL SYSTEM 418000 48711768_1 CDM 0272 RC inpatient 911 592.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 628.59 69 999999999 551.61 883.67 percent of total billed charges FLEXISEAL FECAL SYSTEM 418000 48711768_1 CDM 0272 RC inpatient 911 592.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 883.67 97 999999999 551.61 883.67 percent of total billed charges FLEXISEAL FECAL SYSTEM 418000 48711768_1 CDM 0272 RC inpatient 911 592.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 710.58 78 999999999 551.61 883.67 percent of total billed charges FLEXISEAL FECAL SYSTEM 418000 48711768_1 CDM 0272 RC inpatient 911 592.15 SIHO - ALL PLANS SIHO - ALL PLANS 819.9 90 999999999 551.61 883.67 percent of total billed charges FLEXISEAL FECAL SYSTEM 418000 48711768_1 CDM 0272 RC inpatient 911 592.15 UMR - ALL PLANS UMR - ALL PLANS 637.7 70 999999999 551.61 883.67 percent of total billed charges FLEXISEAL FECAL SYSTEM 418000 48711768_1 CDM 0272 RC inpatient 911 592.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 551.61 60.55 999999999 551.61 883.67 percent of total billed charges FLEXISEAL FECAL SYSTEM 418000 48711768_1 CDM 0272 RC inpatient 911 592.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 551.61 883.67 FLEXISEAL FECAL SYSTEM 418000 48711768_1 CDM 0272 RC inpatient 911 592.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 551.61 883.67 FLEXISEAL FECAL SYSTEM 418000 48711768_1 CDM 0272 RC inpatient 911 592.15 ANTHEM HMO ANTHEM HMO 999999999 551.61 883.67 FLEXISEAL FECAL SYSTEM 418000 48711768_1 CDM 0272 RC inpatient 911 592.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 551.61 883.67 FLEXISEAL FECAL SYSTEM 418000 48711768_1 CDM 0272 RC inpatient 911 592.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 615.84 67.6 999999999 551.61 883.67 percent of total billed charges FLEXISEAL FECAL SYSTEM 418000 48711768_1 CDM 0272 RC inpatient 911 592.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 551.61 883.67 "BANDAGE ESMARK 4""X9FT DYNJ05916" 48711781_1 CDM 0272 RC inpatient 30 19.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.5 65 999999999 18.17 29.1 percent of total billed charges "BANDAGE ESMARK 4""X9FT DYNJ05916" 48711781_1 CDM 0272 RC inpatient 30 19.5 AETNA AETNA 23.7 79 999999999 18.17 29.1 percent of total billed charges "BANDAGE ESMARK 4""X9FT DYNJ05916" 48711781_1 CDM 0272 RC inpatient 30 19.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.7 69 999999999 18.17 29.1 percent of total billed charges "BANDAGE ESMARK 4""X9FT DYNJ05916" 48711781_1 CDM 0272 RC inpatient 30 19.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.1 97 999999999 18.17 29.1 percent of total billed charges "BANDAGE ESMARK 4""X9FT DYNJ05916" 48711781_1 CDM 0272 RC inpatient 30 19.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.4 78 999999999 18.17 29.1 percent of total billed charges "BANDAGE ESMARK 4""X9FT DYNJ05916" 48711781_1 CDM 0272 RC inpatient 30 19.5 SIHO - ALL PLANS SIHO - ALL PLANS 27 90 999999999 18.17 29.1 percent of total billed charges "BANDAGE ESMARK 4""X9FT DYNJ05916" 48711781_1 CDM 0272 RC inpatient 30 19.5 UMR - ALL PLANS UMR - ALL PLANS 21 70 999999999 18.17 29.1 percent of total billed charges "BANDAGE ESMARK 4""X9FT DYNJ05916" 48711781_1 CDM 0272 RC inpatient 30 19.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.17 60.55 999999999 18.17 29.1 percent of total billed charges "BANDAGE ESMARK 4""X9FT DYNJ05916" 48711781_1 CDM 0272 RC inpatient 30 19.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.17 29.1 "BANDAGE ESMARK 4""X9FT DYNJ05916" 48711781_1 CDM 0272 RC inpatient 30 19.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.17 29.1 "BANDAGE ESMARK 4""X9FT DYNJ05916" 48711781_1 CDM 0272 RC inpatient 30 19.5 ANTHEM HMO ANTHEM HMO 999999999 18.17 29.1 "BANDAGE ESMARK 4""X9FT DYNJ05916" 48711781_1 CDM 0272 RC inpatient 30 19.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.17 29.1 "BANDAGE ESMARK 4""X9FT DYNJ05916" 48711781_1 CDM 0272 RC inpatient 30 19.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.28 67.6 999999999 18.17 29.1 percent of total billed charges "BANDAGE ESMARK 4""X9FT DYNJ05916" 48711781_1 CDM 0272 RC inpatient 30 19.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.17 29.1 BARRIER ADHESION INTERCEED 3X4 48711782_1 CDM 0272 RC inpatient 1546 1004.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1004.9 65 999999999 936.1 1499.62 percent of total billed charges BARRIER ADHESION INTERCEED 3X4 48711782_1 CDM 0272 RC inpatient 1546 1004.9 AETNA AETNA 1221.34 79 999999999 936.1 1499.62 percent of total billed charges BARRIER ADHESION INTERCEED 3X4 48711782_1 CDM 0272 RC inpatient 1546 1004.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1066.74 69 999999999 936.1 1499.62 percent of total billed charges BARRIER ADHESION INTERCEED 3X4 48711782_1 CDM 0272 RC inpatient 1546 1004.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1499.62 97 999999999 936.1 1499.62 percent of total billed charges BARRIER ADHESION INTERCEED 3X4 48711782_1 CDM 0272 RC inpatient 1546 1004.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1205.88 78 999999999 936.1 1499.62 percent of total billed charges BARRIER ADHESION INTERCEED 3X4 48711782_1 CDM 0272 RC inpatient 1546 1004.9 SIHO - ALL PLANS SIHO - ALL PLANS 1391.4 90 999999999 936.1 1499.62 percent of total billed charges BARRIER ADHESION INTERCEED 3X4 48711782_1 CDM 0272 RC inpatient 1546 1004.9 UMR - ALL PLANS UMR - ALL PLANS 1082.2 70 999999999 936.1 1499.62 percent of total billed charges BARRIER ADHESION INTERCEED 3X4 48711782_1 CDM 0272 RC inpatient 1546 1004.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 936.1 60.55 999999999 936.1 1499.62 percent of total billed charges BARRIER ADHESION INTERCEED 3X4 48711782_1 CDM 0272 RC inpatient 1546 1004.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 936.1 1499.62 BARRIER ADHESION INTERCEED 3X4 48711782_1 CDM 0272 RC inpatient 1546 1004.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 936.1 1499.62 BARRIER ADHESION INTERCEED 3X4 48711782_1 CDM 0272 RC inpatient 1546 1004.9 ANTHEM HMO ANTHEM HMO 999999999 936.1 1499.62 BARRIER ADHESION INTERCEED 3X4 48711782_1 CDM 0272 RC inpatient 1546 1004.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 936.1 1499.62 BARRIER ADHESION INTERCEED 3X4 48711782_1 CDM 0272 RC inpatient 1546 1004.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1045.1 67.6 999999999 936.1 1499.62 percent of total billed charges BARRIER ADHESION INTERCEED 3X4 48711782_1 CDM 0272 RC inpatient 1546 1004.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 936.1 1499.62 ELECTRODE PED ONESTEP ZOLL 8900-000220-01 48711785_1 CDM 0272 RC inpatient 454 295.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 295.1 65 999999999 274.9 440.38 percent of total billed charges ELECTRODE PED ONESTEP ZOLL 8900-000220-01 48711785_1 CDM 0272 RC inpatient 454 295.1 AETNA AETNA 358.66 79 999999999 274.9 440.38 percent of total billed charges ELECTRODE PED ONESTEP ZOLL 8900-000220-01 48711785_1 CDM 0272 RC inpatient 454 295.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 313.26 69 999999999 274.9 440.38 percent of total billed charges ELECTRODE PED ONESTEP ZOLL 8900-000220-01 48711785_1 CDM 0272 RC inpatient 454 295.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 440.38 97 999999999 274.9 440.38 percent of total billed charges ELECTRODE PED ONESTEP ZOLL 8900-000220-01 48711785_1 CDM 0272 RC inpatient 454 295.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 354.12 78 999999999 274.9 440.38 percent of total billed charges ELECTRODE PED ONESTEP ZOLL 8900-000220-01 48711785_1 CDM 0272 RC inpatient 454 295.1 SIHO - ALL PLANS SIHO - ALL PLANS 408.6 90 999999999 274.9 440.38 percent of total billed charges ELECTRODE PED ONESTEP ZOLL 8900-000220-01 48711785_1 CDM 0272 RC inpatient 454 295.1 UMR - ALL PLANS UMR - ALL PLANS 317.8 70 999999999 274.9 440.38 percent of total billed charges ELECTRODE PED ONESTEP ZOLL 8900-000220-01 48711785_1 CDM 0272 RC inpatient 454 295.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 274.9 60.55 999999999 274.9 440.38 percent of total billed charges ELECTRODE PED ONESTEP ZOLL 8900-000220-01 48711785_1 CDM 0272 RC inpatient 454 295.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 274.9 440.38 ELECTRODE PED ONESTEP ZOLL 8900-000220-01 48711785_1 CDM 0272 RC inpatient 454 295.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 274.9 440.38 ELECTRODE PED ONESTEP ZOLL 8900-000220-01 48711785_1 CDM 0272 RC inpatient 454 295.1 ANTHEM HMO ANTHEM HMO 999999999 274.9 440.38 ELECTRODE PED ONESTEP ZOLL 8900-000220-01 48711785_1 CDM 0272 RC inpatient 454 295.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 274.9 440.38 ELECTRODE PED ONESTEP ZOLL 8900-000220-01 48711785_1 CDM 0272 RC inpatient 454 295.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 306.9 67.6 999999999 274.9 440.38 percent of total billed charges ELECTRODE PED ONESTEP ZOLL 8900-000220-01 48711785_1 CDM 0272 RC inpatient 454 295.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 274.9 440.38 KIT TRANSDUCER MONITORING 48711786_1 CDM 0272 RC inpatient 134 87.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 87.1 65 999999999 81.14 129.98 percent of total billed charges KIT TRANSDUCER MONITORING 48711786_1 CDM 0272 RC inpatient 134 87.1 AETNA AETNA 105.86 79 999999999 81.14 129.98 percent of total billed charges KIT TRANSDUCER MONITORING 48711786_1 CDM 0272 RC inpatient 134 87.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 92.46 69 999999999 81.14 129.98 percent of total billed charges KIT TRANSDUCER MONITORING 48711786_1 CDM 0272 RC inpatient 134 87.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.98 97 999999999 81.14 129.98 percent of total billed charges KIT TRANSDUCER MONITORING 48711786_1 CDM 0272 RC inpatient 134 87.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 104.52 78 999999999 81.14 129.98 percent of total billed charges KIT TRANSDUCER MONITORING 48711786_1 CDM 0272 RC inpatient 134 87.1 SIHO - ALL PLANS SIHO - ALL PLANS 120.6 90 999999999 81.14 129.98 percent of total billed charges KIT TRANSDUCER MONITORING 48711786_1 CDM 0272 RC inpatient 134 87.1 UMR - ALL PLANS UMR - ALL PLANS 93.8 70 999999999 81.14 129.98 percent of total billed charges KIT TRANSDUCER MONITORING 48711786_1 CDM 0272 RC inpatient 134 87.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 81.14 60.55 999999999 81.14 129.98 percent of total billed charges KIT TRANSDUCER MONITORING 48711786_1 CDM 0272 RC inpatient 134 87.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 81.14 129.98 KIT TRANSDUCER MONITORING 48711786_1 CDM 0272 RC inpatient 134 87.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 81.14 129.98 KIT TRANSDUCER MONITORING 48711786_1 CDM 0272 RC inpatient 134 87.1 ANTHEM HMO ANTHEM HMO 999999999 81.14 129.98 KIT TRANSDUCER MONITORING 48711786_1 CDM 0272 RC inpatient 134 87.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 81.14 129.98 KIT TRANSDUCER MONITORING 48711786_1 CDM 0272 RC inpatient 134 87.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 90.58 67.6 999999999 81.14 129.98 percent of total billed charges KIT TRANSDUCER MONITORING 48711786_1 CDM 0272 RC inpatient 134 87.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 81.14 129.98 ELECTRODE ONESTEP ADULT ZOLL 48711787_1 CDM 0272 RC inpatient 467 303.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 303.55 65 999999999 282.77 452.99 percent of total billed charges ELECTRODE ONESTEP ADULT ZOLL 48711787_1 CDM 0272 RC inpatient 467 303.55 AETNA AETNA 368.93 79 999999999 282.77 452.99 percent of total billed charges ELECTRODE ONESTEP ADULT ZOLL 48711787_1 CDM 0272 RC inpatient 467 303.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 322.23 69 999999999 282.77 452.99 percent of total billed charges ELECTRODE ONESTEP ADULT ZOLL 48711787_1 CDM 0272 RC inpatient 467 303.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 452.99 97 999999999 282.77 452.99 percent of total billed charges ELECTRODE ONESTEP ADULT ZOLL 48711787_1 CDM 0272 RC inpatient 467 303.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 364.26 78 999999999 282.77 452.99 percent of total billed charges ELECTRODE ONESTEP ADULT ZOLL 48711787_1 CDM 0272 RC inpatient 467 303.55 SIHO - ALL PLANS SIHO - ALL PLANS 420.3 90 999999999 282.77 452.99 percent of total billed charges ELECTRODE ONESTEP ADULT ZOLL 48711787_1 CDM 0272 RC inpatient 467 303.55 UMR - ALL PLANS UMR - ALL PLANS 326.9 70 999999999 282.77 452.99 percent of total billed charges ELECTRODE ONESTEP ADULT ZOLL 48711787_1 CDM 0272 RC inpatient 467 303.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 282.77 60.55 999999999 282.77 452.99 percent of total billed charges ELECTRODE ONESTEP ADULT ZOLL 48711787_1 CDM 0272 RC inpatient 467 303.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 282.77 452.99 ELECTRODE ONESTEP ADULT ZOLL 48711787_1 CDM 0272 RC inpatient 467 303.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 282.77 452.99 ELECTRODE ONESTEP ADULT ZOLL 48711787_1 CDM 0272 RC inpatient 467 303.55 ANTHEM HMO ANTHEM HMO 999999999 282.77 452.99 ELECTRODE ONESTEP ADULT ZOLL 48711787_1 CDM 0272 RC inpatient 467 303.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 282.77 452.99 ELECTRODE ONESTEP ADULT ZOLL 48711787_1 CDM 0272 RC inpatient 467 303.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 315.69 67.6 999999999 282.77 452.99 percent of total billed charges ELECTRODE ONESTEP ADULT ZOLL 48711787_1 CDM 0272 RC inpatient 467 303.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 282.77 452.99 FORCEP ALLIGATOR JAW BIOPSY FB-210U.A 48711790_1 CDM 0272 RC inpatient 69 44.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.85 65 999999999 41.78 66.93 percent of total billed charges FORCEP ALLIGATOR JAW BIOPSY FB-210U.A 48711790_1 CDM 0272 RC inpatient 69 44.85 AETNA AETNA 54.51 79 999999999 41.78 66.93 percent of total billed charges FORCEP ALLIGATOR JAW BIOPSY FB-210U.A 48711790_1 CDM 0272 RC inpatient 69 44.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 47.61 69 999999999 41.78 66.93 percent of total billed charges FORCEP ALLIGATOR JAW BIOPSY FB-210U.A 48711790_1 CDM 0272 RC inpatient 69 44.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 66.93 97 999999999 41.78 66.93 percent of total billed charges FORCEP ALLIGATOR JAW BIOPSY FB-210U.A 48711790_1 CDM 0272 RC inpatient 69 44.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.82 78 999999999 41.78 66.93 percent of total billed charges FORCEP ALLIGATOR JAW BIOPSY FB-210U.A 48711790_1 CDM 0272 RC inpatient 69 44.85 SIHO - ALL PLANS SIHO - ALL PLANS 62.1 90 999999999 41.78 66.93 percent of total billed charges FORCEP ALLIGATOR JAW BIOPSY FB-210U.A 48711790_1 CDM 0272 RC inpatient 69 44.85 UMR - ALL PLANS UMR - ALL PLANS 48.3 70 999999999 41.78 66.93 percent of total billed charges FORCEP ALLIGATOR JAW BIOPSY FB-210U.A 48711790_1 CDM 0272 RC inpatient 69 44.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.78 60.55 999999999 41.78 66.93 percent of total billed charges FORCEP ALLIGATOR JAW BIOPSY FB-210U.A 48711790_1 CDM 0272 RC inpatient 69 44.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.78 66.93 FORCEP ALLIGATOR JAW BIOPSY FB-210U.A 48711790_1 CDM 0272 RC inpatient 69 44.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.78 66.93 FORCEP ALLIGATOR JAW BIOPSY FB-210U.A 48711790_1 CDM 0272 RC inpatient 69 44.85 ANTHEM HMO ANTHEM HMO 999999999 41.78 66.93 FORCEP ALLIGATOR JAW BIOPSY FB-210U.A 48711790_1 CDM 0272 RC inpatient 69 44.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.78 66.93 FORCEP ALLIGATOR JAW BIOPSY FB-210U.A 48711790_1 CDM 0272 RC inpatient 69 44.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 46.64 67.6 999999999 41.78 66.93 percent of total billed charges FORCEP ALLIGATOR JAW BIOPSY FB-210U.A 48711790_1 CDM 0272 RC inpatient 69 44.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.78 66.93 BIPOLAR CORD DISP 301538 48711791_1 CDM 0272 RC inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges BIPOLAR CORD DISP 301538 48711791_1 CDM 0272 RC inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges BIPOLAR CORD DISP 301538 48711791_1 CDM 0272 RC inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges BIPOLAR CORD DISP 301538 48711791_1 CDM 0272 RC inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges BIPOLAR CORD DISP 301538 48711791_1 CDM 0272 RC inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges BIPOLAR CORD DISP 301538 48711791_1 CDM 0272 RC inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges BIPOLAR CORD DISP 301538 48711791_1 CDM 0272 RC inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges BIPOLAR CORD DISP 301538 48711791_1 CDM 0272 RC inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges BIPOLAR CORD DISP 301538 48711791_1 CDM 0272 RC inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 BIPOLAR CORD DISP 301538 48711791_1 CDM 0272 RC inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 BIPOLAR CORD DISP 301538 48711791_1 CDM 0272 RC inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 BIPOLAR CORD DISP 301538 48711791_1 CDM 0272 RC inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 BIPOLAR CORD DISP 301538 48711791_1 CDM 0272 RC inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges BIPOLAR CORD DISP 301538 48711791_1 CDM 0272 RC inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 AQUAMANTYS 6.0 BIPOLAR SEALER 48711792_1 CDM 0272 RC inpatient 2958 1922.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1922.7 65 999999999 1791.07 2869.26 percent of total billed charges AQUAMANTYS 6.0 BIPOLAR SEALER 48711792_1 CDM 0272 RC inpatient 2958 1922.7 AETNA AETNA 2336.82 79 999999999 1791.07 2869.26 percent of total billed charges AQUAMANTYS 6.0 BIPOLAR SEALER 48711792_1 CDM 0272 RC inpatient 2958 1922.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 2041.02 69 999999999 1791.07 2869.26 percent of total billed charges AQUAMANTYS 6.0 BIPOLAR SEALER 48711792_1 CDM 0272 RC inpatient 2958 1922.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2869.26 97 999999999 1791.07 2869.26 percent of total billed charges AQUAMANTYS 6.0 BIPOLAR SEALER 48711792_1 CDM 0272 RC inpatient 2958 1922.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 2307.24 78 999999999 1791.07 2869.26 percent of total billed charges AQUAMANTYS 6.0 BIPOLAR SEALER 48711792_1 CDM 0272 RC inpatient 2958 1922.7 SIHO - ALL PLANS SIHO - ALL PLANS 2662.2 90 999999999 1791.07 2869.26 percent of total billed charges AQUAMANTYS 6.0 BIPOLAR SEALER 48711792_1 CDM 0272 RC inpatient 2958 1922.7 UMR - ALL PLANS UMR - ALL PLANS 2070.6 70 999999999 1791.07 2869.26 percent of total billed charges AQUAMANTYS 6.0 BIPOLAR SEALER 48711792_1 CDM 0272 RC inpatient 2958 1922.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1791.07 60.55 999999999 1791.07 2869.26 percent of total billed charges AQUAMANTYS 6.0 BIPOLAR SEALER 48711792_1 CDM 0272 RC inpatient 2958 1922.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1791.07 2869.26 AQUAMANTYS 6.0 BIPOLAR SEALER 48711792_1 CDM 0272 RC inpatient 2958 1922.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1791.07 2869.26 AQUAMANTYS 6.0 BIPOLAR SEALER 48711792_1 CDM 0272 RC inpatient 2958 1922.7 ANTHEM HMO ANTHEM HMO 999999999 1791.07 2869.26 AQUAMANTYS 6.0 BIPOLAR SEALER 48711792_1 CDM 0272 RC inpatient 2958 1922.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1791.07 2869.26 AQUAMANTYS 6.0 BIPOLAR SEALER 48711792_1 CDM 0272 RC inpatient 2958 1922.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1999.61 67.6 999999999 1791.07 2869.26 percent of total billed charges AQUAMANTYS 6.0 BIPOLAR SEALER 48711792_1 CDM 0272 RC inpatient 2958 1922.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 1791.07 2869.26 AQUAMANTYS EVS BIPOLAR SEALER 48711793_1 CDM 0272 RC inpatient 3723 2419.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 2419.95 65 999999999 2254.28 3611.31 percent of total billed charges AQUAMANTYS EVS BIPOLAR SEALER 48711793_1 CDM 0272 RC inpatient 3723 2419.95 AETNA AETNA 2941.17 79 999999999 2254.28 3611.31 percent of total billed charges AQUAMANTYS EVS BIPOLAR SEALER 48711793_1 CDM 0272 RC inpatient 3723 2419.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 2568.87 69 999999999 2254.28 3611.31 percent of total billed charges AQUAMANTYS EVS BIPOLAR SEALER 48711793_1 CDM 0272 RC inpatient 3723 2419.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3611.31 97 999999999 2254.28 3611.31 percent of total billed charges AQUAMANTYS EVS BIPOLAR SEALER 48711793_1 CDM 0272 RC inpatient 3723 2419.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 2903.94 78 999999999 2254.28 3611.31 percent of total billed charges AQUAMANTYS EVS BIPOLAR SEALER 48711793_1 CDM 0272 RC inpatient 3723 2419.95 SIHO - ALL PLANS SIHO - ALL PLANS 3350.7 90 999999999 2254.28 3611.31 percent of total billed charges AQUAMANTYS EVS BIPOLAR SEALER 48711793_1 CDM 0272 RC inpatient 3723 2419.95 UMR - ALL PLANS UMR - ALL PLANS 2606.1 70 999999999 2254.28 3611.31 percent of total billed charges AQUAMANTYS EVS BIPOLAR SEALER 48711793_1 CDM 0272 RC inpatient 3723 2419.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2254.28 60.55 999999999 2254.28 3611.31 percent of total billed charges AQUAMANTYS EVS BIPOLAR SEALER 48711793_1 CDM 0272 RC inpatient 3723 2419.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2254.28 3611.31 AQUAMANTYS EVS BIPOLAR SEALER 48711793_1 CDM 0272 RC inpatient 3723 2419.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2254.28 3611.31 AQUAMANTYS EVS BIPOLAR SEALER 48711793_1 CDM 0272 RC inpatient 3723 2419.95 ANTHEM HMO ANTHEM HMO 999999999 2254.28 3611.31 AQUAMANTYS EVS BIPOLAR SEALER 48711793_1 CDM 0272 RC inpatient 3723 2419.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2254.28 3611.31 AQUAMANTYS EVS BIPOLAR SEALER 48711793_1 CDM 0272 RC inpatient 3723 2419.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 2516.75 67.6 999999999 2254.28 3611.31 percent of total billed charges AQUAMANTYS EVS BIPOLAR SEALER 48711793_1 CDM 0272 RC inpatient 3723 2419.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 2254.28 3611.31 MICROAIRE SAG SAW BLADE ZS-032 48711795_1 CDM 0272 RC inpatient 122 79.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.3 65 999999999 73.87 118.34 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-032 48711795_1 CDM 0272 RC inpatient 122 79.3 AETNA AETNA 96.38 79 999999999 73.87 118.34 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-032 48711795_1 CDM 0272 RC inpatient 122 79.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.18 69 999999999 73.87 118.34 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-032 48711795_1 CDM 0272 RC inpatient 122 79.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 118.34 97 999999999 73.87 118.34 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-032 48711795_1 CDM 0272 RC inpatient 122 79.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.16 78 999999999 73.87 118.34 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-032 48711795_1 CDM 0272 RC inpatient 122 79.3 SIHO - ALL PLANS SIHO - ALL PLANS 109.8 90 999999999 73.87 118.34 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-032 48711795_1 CDM 0272 RC inpatient 122 79.3 UMR - ALL PLANS UMR - ALL PLANS 85.4 70 999999999 73.87 118.34 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-032 48711795_1 CDM 0272 RC inpatient 122 79.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.87 60.55 999999999 73.87 118.34 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-032 48711795_1 CDM 0272 RC inpatient 122 79.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.87 118.34 MICROAIRE SAG SAW BLADE ZS-032 48711795_1 CDM 0272 RC inpatient 122 79.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.87 118.34 MICROAIRE SAG SAW BLADE ZS-032 48711795_1 CDM 0272 RC inpatient 122 79.3 ANTHEM HMO ANTHEM HMO 999999999 73.87 118.34 MICROAIRE SAG SAW BLADE ZS-032 48711795_1 CDM 0272 RC inpatient 122 79.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.87 118.34 MICROAIRE SAG SAW BLADE ZS-032 48711795_1 CDM 0272 RC inpatient 122 79.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 82.47 67.6 999999999 73.87 118.34 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-032 48711795_1 CDM 0272 RC inpatient 122 79.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.87 118.34 MICROAIRE SAG SAW BLADE ZS-038 48711796_1 CDM 0272 RC inpatient 132 85.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.8 65 999999999 79.93 128.04 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-038 48711796_1 CDM 0272 RC inpatient 132 85.8 AETNA AETNA 104.28 79 999999999 79.93 128.04 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-038 48711796_1 CDM 0272 RC inpatient 132 85.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.08 69 999999999 79.93 128.04 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-038 48711796_1 CDM 0272 RC inpatient 132 85.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 128.04 97 999999999 79.93 128.04 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-038 48711796_1 CDM 0272 RC inpatient 132 85.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.96 78 999999999 79.93 128.04 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-038 48711796_1 CDM 0272 RC inpatient 132 85.8 SIHO - ALL PLANS SIHO - ALL PLANS 118.8 90 999999999 79.93 128.04 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-038 48711796_1 CDM 0272 RC inpatient 132 85.8 UMR - ALL PLANS UMR - ALL PLANS 92.4 70 999999999 79.93 128.04 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-038 48711796_1 CDM 0272 RC inpatient 132 85.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.93 60.55 999999999 79.93 128.04 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-038 48711796_1 CDM 0272 RC inpatient 132 85.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.93 128.04 MICROAIRE SAG SAW BLADE ZS-038 48711796_1 CDM 0272 RC inpatient 132 85.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.93 128.04 MICROAIRE SAG SAW BLADE ZS-038 48711796_1 CDM 0272 RC inpatient 132 85.8 ANTHEM HMO ANTHEM HMO 999999999 79.93 128.04 MICROAIRE SAG SAW BLADE ZS-038 48711796_1 CDM 0272 RC inpatient 132 85.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.93 128.04 MICROAIRE SAG SAW BLADE ZS-038 48711796_1 CDM 0272 RC inpatient 132 85.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.23 67.6 999999999 79.93 128.04 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-038 48711796_1 CDM 0272 RC inpatient 132 85.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.93 128.04 BLADE STRYKER SAGITTAL WIDE ME 48711797_1 CDM 0272 RC inpatient 199 129.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 129.35 65 999999999 120.49 193.03 percent of total billed charges BLADE STRYKER SAGITTAL WIDE ME 48711797_1 CDM 0272 RC inpatient 199 129.35 AETNA AETNA 157.21 79 999999999 120.49 193.03 percent of total billed charges BLADE STRYKER SAGITTAL WIDE ME 48711797_1 CDM 0272 RC inpatient 199 129.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 137.31 69 999999999 120.49 193.03 percent of total billed charges BLADE STRYKER SAGITTAL WIDE ME 48711797_1 CDM 0272 RC inpatient 199 129.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 193.03 97 999999999 120.49 193.03 percent of total billed charges BLADE STRYKER SAGITTAL WIDE ME 48711797_1 CDM 0272 RC inpatient 199 129.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 155.22 78 999999999 120.49 193.03 percent of total billed charges BLADE STRYKER SAGITTAL WIDE ME 48711797_1 CDM 0272 RC inpatient 199 129.35 SIHO - ALL PLANS SIHO - ALL PLANS 179.1 90 999999999 120.49 193.03 percent of total billed charges BLADE STRYKER SAGITTAL WIDE ME 48711797_1 CDM 0272 RC inpatient 199 129.35 UMR - ALL PLANS UMR - ALL PLANS 139.3 70 999999999 120.49 193.03 percent of total billed charges BLADE STRYKER SAGITTAL WIDE ME 48711797_1 CDM 0272 RC inpatient 199 129.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 120.49 60.55 999999999 120.49 193.03 percent of total billed charges BLADE STRYKER SAGITTAL WIDE ME 48711797_1 CDM 0272 RC inpatient 199 129.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 120.49 193.03 BLADE STRYKER SAGITTAL WIDE ME 48711797_1 CDM 0272 RC inpatient 199 129.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 120.49 193.03 BLADE STRYKER SAGITTAL WIDE ME 48711797_1 CDM 0272 RC inpatient 199 129.35 ANTHEM HMO ANTHEM HMO 999999999 120.49 193.03 BLADE STRYKER SAGITTAL WIDE ME 48711797_1 CDM 0272 RC inpatient 199 129.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 120.49 193.03 BLADE STRYKER SAGITTAL WIDE ME 48711797_1 CDM 0272 RC inpatient 199 129.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 134.52 67.6 999999999 120.49 193.03 percent of total billed charges BLADE STRYKER SAGITTAL WIDE ME 48711797_1 CDM 0272 RC inpatient 199 129.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 120.49 193.03 BLADE STRYKER SAGITTAL MED LG 48711798_1 CDM 0272 RC inpatient 176 114.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 114.4 65 999999999 106.57 170.72 percent of total billed charges BLADE STRYKER SAGITTAL MED LG 48711798_1 CDM 0272 RC inpatient 176 114.4 AETNA AETNA 139.04 79 999999999 106.57 170.72 percent of total billed charges BLADE STRYKER SAGITTAL MED LG 48711798_1 CDM 0272 RC inpatient 176 114.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 121.44 69 999999999 106.57 170.72 percent of total billed charges BLADE STRYKER SAGITTAL MED LG 48711798_1 CDM 0272 RC inpatient 176 114.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 170.72 97 999999999 106.57 170.72 percent of total billed charges BLADE STRYKER SAGITTAL MED LG 48711798_1 CDM 0272 RC inpatient 176 114.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 137.28 78 999999999 106.57 170.72 percent of total billed charges BLADE STRYKER SAGITTAL MED LG 48711798_1 CDM 0272 RC inpatient 176 114.4 SIHO - ALL PLANS SIHO - ALL PLANS 158.4 90 999999999 106.57 170.72 percent of total billed charges BLADE STRYKER SAGITTAL MED LG 48711798_1 CDM 0272 RC inpatient 176 114.4 UMR - ALL PLANS UMR - ALL PLANS 123.2 70 999999999 106.57 170.72 percent of total billed charges BLADE STRYKER SAGITTAL MED LG 48711798_1 CDM 0272 RC inpatient 176 114.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 106.57 60.55 999999999 106.57 170.72 percent of total billed charges BLADE STRYKER SAGITTAL MED LG 48711798_1 CDM 0272 RC inpatient 176 114.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 106.57 170.72 BLADE STRYKER SAGITTAL MED LG 48711798_1 CDM 0272 RC inpatient 176 114.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 106.57 170.72 BLADE STRYKER SAGITTAL MED LG 48711798_1 CDM 0272 RC inpatient 176 114.4 ANTHEM HMO ANTHEM HMO 999999999 106.57 170.72 BLADE STRYKER SAGITTAL MED LG 48711798_1 CDM 0272 RC inpatient 176 114.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 106.57 170.72 BLADE STRYKER SAGITTAL MED LG 48711798_1 CDM 0272 RC inpatient 176 114.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.98 67.6 999999999 106.57 170.72 percent of total billed charges BLADE STRYKER SAGITTAL MED LG 48711798_1 CDM 0272 RC inpatient 176 114.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 106.57 170.72 SAG SAW BLADE #4125-127-90 48711799_1 CDM 0272 RC inpatient 272 176.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 176.8 65 999999999 164.7 263.84 percent of total billed charges SAG SAW BLADE #4125-127-90 48711799_1 CDM 0272 RC inpatient 272 176.8 AETNA AETNA 214.88 79 999999999 164.7 263.84 percent of total billed charges SAG SAW BLADE #4125-127-90 48711799_1 CDM 0272 RC inpatient 272 176.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 187.68 69 999999999 164.7 263.84 percent of total billed charges SAG SAW BLADE #4125-127-90 48711799_1 CDM 0272 RC inpatient 272 176.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 263.84 97 999999999 164.7 263.84 percent of total billed charges SAG SAW BLADE #4125-127-90 48711799_1 CDM 0272 RC inpatient 272 176.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 212.16 78 999999999 164.7 263.84 percent of total billed charges SAG SAW BLADE #4125-127-90 48711799_1 CDM 0272 RC inpatient 272 176.8 SIHO - ALL PLANS SIHO - ALL PLANS 244.8 90 999999999 164.7 263.84 percent of total billed charges SAG SAW BLADE #4125-127-90 48711799_1 CDM 0272 RC inpatient 272 176.8 UMR - ALL PLANS UMR - ALL PLANS 190.4 70 999999999 164.7 263.84 percent of total billed charges SAG SAW BLADE #4125-127-90 48711799_1 CDM 0272 RC inpatient 272 176.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 164.7 60.55 999999999 164.7 263.84 percent of total billed charges SAG SAW BLADE #4125-127-90 48711799_1 CDM 0272 RC inpatient 272 176.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 164.7 263.84 SAG SAW BLADE #4125-127-90 48711799_1 CDM 0272 RC inpatient 272 176.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 164.7 263.84 SAG SAW BLADE #4125-127-90 48711799_1 CDM 0272 RC inpatient 272 176.8 ANTHEM HMO ANTHEM HMO 999999999 164.7 263.84 SAG SAW BLADE #4125-127-90 48711799_1 CDM 0272 RC inpatient 272 176.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 164.7 263.84 SAG SAW BLADE #4125-127-90 48711799_1 CDM 0272 RC inpatient 272 176.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 183.87 67.6 999999999 164.7 263.84 percent of total billed charges SAG SAW BLADE #4125-127-90 48711799_1 CDM 0272 RC inpatient 272 176.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 164.7 263.84 BLADE STRYKER SAGITTAL XLONG 48711800_1 CDM 0272 RC inpatient 245 159.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 159.25 65 999999999 148.35 237.65 percent of total billed charges BLADE STRYKER SAGITTAL XLONG 48711800_1 CDM 0272 RC inpatient 245 159.25 AETNA AETNA 193.55 79 999999999 148.35 237.65 percent of total billed charges BLADE STRYKER SAGITTAL XLONG 48711800_1 CDM 0272 RC inpatient 245 159.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 169.05 69 999999999 148.35 237.65 percent of total billed charges BLADE STRYKER SAGITTAL XLONG 48711800_1 CDM 0272 RC inpatient 245 159.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 237.65 97 999999999 148.35 237.65 percent of total billed charges BLADE STRYKER SAGITTAL XLONG 48711800_1 CDM 0272 RC inpatient 245 159.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 191.1 78 999999999 148.35 237.65 percent of total billed charges BLADE STRYKER SAGITTAL XLONG 48711800_1 CDM 0272 RC inpatient 245 159.25 SIHO - ALL PLANS SIHO - ALL PLANS 220.5 90 999999999 148.35 237.65 percent of total billed charges BLADE STRYKER SAGITTAL XLONG 48711800_1 CDM 0272 RC inpatient 245 159.25 UMR - ALL PLANS UMR - ALL PLANS 171.5 70 999999999 148.35 237.65 percent of total billed charges BLADE STRYKER SAGITTAL XLONG 48711800_1 CDM 0272 RC inpatient 245 159.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 148.35 60.55 999999999 148.35 237.65 percent of total billed charges BLADE STRYKER SAGITTAL XLONG 48711800_1 CDM 0272 RC inpatient 245 159.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 148.35 237.65 BLADE STRYKER SAGITTAL XLONG 48711800_1 CDM 0272 RC inpatient 245 159.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 148.35 237.65 BLADE STRYKER SAGITTAL XLONG 48711800_1 CDM 0272 RC inpatient 245 159.25 ANTHEM HMO ANTHEM HMO 999999999 148.35 237.65 BLADE STRYKER SAGITTAL XLONG 48711800_1 CDM 0272 RC inpatient 245 159.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 148.35 237.65 BLADE STRYKER SAGITTAL XLONG 48711800_1 CDM 0272 RC inpatient 245 159.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 165.62 67.6 999999999 148.35 237.65 percent of total billed charges BLADE STRYKER SAGITTAL XLONG 48711800_1 CDM 0272 RC inpatient 245 159.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 148.35 237.65 BLADE OTOLOGY SPEAR TIP 377120 48711801_1 CDM 0272 RC inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges BLADE OTOLOGY SPEAR TIP 377120 48711801_1 CDM 0272 RC inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges BLADE OTOLOGY SPEAR TIP 377120 48711801_1 CDM 0272 RC inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges BLADE OTOLOGY SPEAR TIP 377120 48711801_1 CDM 0272 RC inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges BLADE OTOLOGY SPEAR TIP 377120 48711801_1 CDM 0272 RC inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges BLADE OTOLOGY SPEAR TIP 377120 48711801_1 CDM 0272 RC inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges BLADE OTOLOGY SPEAR TIP 377120 48711801_1 CDM 0272 RC inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges BLADE OTOLOGY SPEAR TIP 377120 48711801_1 CDM 0272 RC inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges BLADE OTOLOGY SPEAR TIP 377120 48711801_1 CDM 0272 RC inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 BLADE OTOLOGY SPEAR TIP 377120 48711801_1 CDM 0272 RC inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 BLADE OTOLOGY SPEAR TIP 377120 48711801_1 CDM 0272 RC inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 BLADE OTOLOGY SPEAR TIP 377120 48711801_1 CDM 0272 RC inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 BLADE OTOLOGY SPEAR TIP 377120 48711801_1 CDM 0272 RC inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges BLADE OTOLOGY SPEAR TIP 377120 48711801_1 CDM 0272 RC inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 (order from Esutire.com) BONE CEMENT 6191-1-010 48711802_1 CDM 0272 RC inpatient 590 383.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 383.5 65 999999999 357.25 572.3 percent of total billed charges (order from Esutire.com) BONE CEMENT 6191-1-010 48711802_1 CDM 0272 RC inpatient 590 383.5 AETNA AETNA 466.1 79 999999999 357.25 572.3 percent of total billed charges (order from Esutire.com) BONE CEMENT 6191-1-010 48711802_1 CDM 0272 RC inpatient 590 383.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 407.1 69 999999999 357.25 572.3 percent of total billed charges (order from Esutire.com) BONE CEMENT 6191-1-010 48711802_1 CDM 0272 RC inpatient 590 383.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 572.3 97 999999999 357.25 572.3 percent of total billed charges (order from Esutire.com) BONE CEMENT 6191-1-010 48711802_1 CDM 0272 RC inpatient 590 383.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 460.2 78 999999999 357.25 572.3 percent of total billed charges (order from Esutire.com) BONE CEMENT 6191-1-010 48711802_1 CDM 0272 RC inpatient 590 383.5 SIHO - ALL PLANS SIHO - ALL PLANS 531 90 999999999 357.25 572.3 percent of total billed charges (order from Esutire.com) BONE CEMENT 6191-1-010 48711802_1 CDM 0272 RC inpatient 590 383.5 UMR - ALL PLANS UMR - ALL PLANS 413 70 999999999 357.25 572.3 percent of total billed charges (order from Esutire.com) BONE CEMENT 6191-1-010 48711802_1 CDM 0272 RC inpatient 590 383.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 357.25 60.55 999999999 357.25 572.3 percent of total billed charges (order from Esutire.com) BONE CEMENT 6191-1-010 48711802_1 CDM 0272 RC inpatient 590 383.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 357.25 572.3 (order from Esutire.com) BONE CEMENT 6191-1-010 48711802_1 CDM 0272 RC inpatient 590 383.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 357.25 572.3 (order from Esutire.com) BONE CEMENT 6191-1-010 48711802_1 CDM 0272 RC inpatient 590 383.5 ANTHEM HMO ANTHEM HMO 999999999 357.25 572.3 (order from Esutire.com) BONE CEMENT 6191-1-010 48711802_1 CDM 0272 RC inpatient 590 383.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 357.25 572.3 (order from Esutire.com) BONE CEMENT 6191-1-010 48711802_1 CDM 0272 RC inpatient 590 383.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 398.84 67.6 999999999 357.25 572.3 percent of total billed charges (order from Esutire.com) BONE CEMENT 6191-1-010 48711802_1 CDM 0272 RC inpatient 590 383.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 357.25 572.3 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711803_1 CDM 0278 RC C1713 HCPCS inpatient 2390 1553.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1553.5 65 999999999 1447.15 2318.3 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711803_1 CDM 0278 RC C1713 HCPCS inpatient 2390 1553.5 AETNA AETNA 1888.1 79 999999999 1447.15 2318.3 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711803_1 CDM 0278 RC C1713 HCPCS inpatient 2390 1553.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1649.1 69 999999999 1447.15 2318.3 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711803_1 CDM 0278 RC C1713 HCPCS inpatient 2390 1553.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2318.3 97 999999999 1447.15 2318.3 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711803_1 CDM 0278 RC C1713 HCPCS inpatient 2390 1553.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1864.2 78 999999999 1447.15 2318.3 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711803_1 CDM 0278 RC C1713 HCPCS inpatient 2390 1553.5 SIHO - ALL PLANS SIHO - ALL PLANS 2151 90 999999999 1447.15 2318.3 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711803_1 CDM 0278 RC C1713 HCPCS inpatient 2390 1553.5 UMR - ALL PLANS UMR - ALL PLANS 1673 70 999999999 1447.15 2318.3 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711803_1 CDM 0278 RC C1713 HCPCS inpatient 2390 1553.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1447.15 60.55 999999999 1447.15 2318.3 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711803_1 CDM 0278 RC C1713 HCPCS inpatient 2390 1553.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1447.15 2318.3 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711803_1 CDM 0278 RC C1713 HCPCS inpatient 2390 1553.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1447.15 2318.3 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711803_1 CDM 0278 RC C1713 HCPCS inpatient 2390 1553.5 ANTHEM HMO ANTHEM HMO 999999999 1447.15 2318.3 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711803_1 CDM 0278 RC C1713 HCPCS inpatient 2390 1553.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1447.15 2318.3 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711803_1 CDM 0278 RC C1713 HCPCS inpatient 2390 1553.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1615.64 67.6 999999999 1447.15 2318.3 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711803_1 CDM 0278 RC C1713 HCPCS inpatient 2390 1553.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1447.15 2318.3 BLAKE DRAIN KIT 10MM FULL/FLUT 48711808_1 CDM 0272 RC inpatient 448 291.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 291.2 65 999999999 271.26 434.56 percent of total billed charges BLAKE DRAIN KIT 10MM FULL/FLUT 48711808_1 CDM 0272 RC inpatient 448 291.2 AETNA AETNA 353.92 79 999999999 271.26 434.56 percent of total billed charges BLAKE DRAIN KIT 10MM FULL/FLUT 48711808_1 CDM 0272 RC inpatient 448 291.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 309.12 69 999999999 271.26 434.56 percent of total billed charges BLAKE DRAIN KIT 10MM FULL/FLUT 48711808_1 CDM 0272 RC inpatient 448 291.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 434.56 97 999999999 271.26 434.56 percent of total billed charges BLAKE DRAIN KIT 10MM FULL/FLUT 48711808_1 CDM 0272 RC inpatient 448 291.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 349.44 78 999999999 271.26 434.56 percent of total billed charges BLAKE DRAIN KIT 10MM FULL/FLUT 48711808_1 CDM 0272 RC inpatient 448 291.2 SIHO - ALL PLANS SIHO - ALL PLANS 403.2 90 999999999 271.26 434.56 percent of total billed charges BLAKE DRAIN KIT 10MM FULL/FLUT 48711808_1 CDM 0272 RC inpatient 448 291.2 UMR - ALL PLANS UMR - ALL PLANS 313.6 70 999999999 271.26 434.56 percent of total billed charges BLAKE DRAIN KIT 10MM FULL/FLUT 48711808_1 CDM 0272 RC inpatient 448 291.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 271.26 60.55 999999999 271.26 434.56 percent of total billed charges BLAKE DRAIN KIT 10MM FULL/FLUT 48711808_1 CDM 0272 RC inpatient 448 291.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 271.26 434.56 BLAKE DRAIN KIT 10MM FULL/FLUT 48711808_1 CDM 0272 RC inpatient 448 291.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 271.26 434.56 BLAKE DRAIN KIT 10MM FULL/FLUT 48711808_1 CDM 0272 RC inpatient 448 291.2 ANTHEM HMO ANTHEM HMO 999999999 271.26 434.56 BLAKE DRAIN KIT 10MM FULL/FLUT 48711808_1 CDM 0272 RC inpatient 448 291.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 271.26 434.56 BLAKE DRAIN KIT 10MM FULL/FLUT 48711808_1 CDM 0272 RC inpatient 448 291.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 302.85 67.6 999999999 271.26 434.56 percent of total billed charges BLAKE DRAIN KIT 10MM FULL/FLUT 48711808_1 CDM 0272 RC inpatient 448 291.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 271.26 434.56 BLAKE DRAIN FLUTE RD 19FR 2231 48711809_1 CDM 0272 RC inpatient 418 271.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 271.7 65 999999999 253.1 405.46 percent of total billed charges BLAKE DRAIN FLUTE RD 19FR 2231 48711809_1 CDM 0272 RC inpatient 418 271.7 AETNA AETNA 330.22 79 999999999 253.1 405.46 percent of total billed charges BLAKE DRAIN FLUTE RD 19FR 2231 48711809_1 CDM 0272 RC inpatient 418 271.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 288.42 69 999999999 253.1 405.46 percent of total billed charges BLAKE DRAIN FLUTE RD 19FR 2231 48711809_1 CDM 0272 RC inpatient 418 271.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 405.46 97 999999999 253.1 405.46 percent of total billed charges BLAKE DRAIN FLUTE RD 19FR 2231 48711809_1 CDM 0272 RC inpatient 418 271.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 326.04 78 999999999 253.1 405.46 percent of total billed charges BLAKE DRAIN FLUTE RD 19FR 2231 48711809_1 CDM 0272 RC inpatient 418 271.7 SIHO - ALL PLANS SIHO - ALL PLANS 376.2 90 999999999 253.1 405.46 percent of total billed charges BLAKE DRAIN FLUTE RD 19FR 2231 48711809_1 CDM 0272 RC inpatient 418 271.7 UMR - ALL PLANS UMR - ALL PLANS 292.6 70 999999999 253.1 405.46 percent of total billed charges BLAKE DRAIN FLUTE RD 19FR 2231 48711809_1 CDM 0272 RC inpatient 418 271.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 253.1 60.55 999999999 253.1 405.46 percent of total billed charges BLAKE DRAIN FLUTE RD 19FR 2231 48711809_1 CDM 0272 RC inpatient 418 271.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 253.1 405.46 BLAKE DRAIN FLUTE RD 19FR 2231 48711809_1 CDM 0272 RC inpatient 418 271.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 253.1 405.46 BLAKE DRAIN FLUTE RD 19FR 2231 48711809_1 CDM 0272 RC inpatient 418 271.7 ANTHEM HMO ANTHEM HMO 999999999 253.1 405.46 BLAKE DRAIN FLUTE RD 19FR 2231 48711809_1 CDM 0272 RC inpatient 418 271.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 253.1 405.46 BLAKE DRAIN FLUTE RD 19FR 2231 48711809_1 CDM 0272 RC inpatient 418 271.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 282.57 67.6 999999999 253.1 405.46 percent of total billed charges BLAKE DRAIN FLUTE RD 19FR 2231 48711809_1 CDM 0272 RC inpatient 418 271.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 253.1 405.46 BREAST PUMP KIT #67186S 48711814_1 CDM 0270 RC inpatient 104 67.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 67.6 65 999999999 62.97 100.88 percent of total billed charges BREAST PUMP KIT #67186S 48711814_1 CDM 0270 RC inpatient 104 67.6 AETNA AETNA 82.16 79 999999999 62.97 100.88 percent of total billed charges BREAST PUMP KIT #67186S 48711814_1 CDM 0270 RC inpatient 104 67.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.76 69 999999999 62.97 100.88 percent of total billed charges BREAST PUMP KIT #67186S 48711814_1 CDM 0270 RC inpatient 104 67.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 100.88 97 999999999 62.97 100.88 percent of total billed charges BREAST PUMP KIT #67186S 48711814_1 CDM 0270 RC inpatient 104 67.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.12 78 999999999 62.97 100.88 percent of total billed charges BREAST PUMP KIT #67186S 48711814_1 CDM 0270 RC inpatient 104 67.6 SIHO - ALL PLANS SIHO - ALL PLANS 93.6 90 999999999 62.97 100.88 percent of total billed charges BREAST PUMP KIT #67186S 48711814_1 CDM 0270 RC inpatient 104 67.6 UMR - ALL PLANS UMR - ALL PLANS 72.8 70 999999999 62.97 100.88 percent of total billed charges BREAST PUMP KIT #67186S 48711814_1 CDM 0270 RC inpatient 104 67.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.97 60.55 999999999 62.97 100.88 percent of total billed charges BREAST PUMP KIT #67186S 48711814_1 CDM 0270 RC inpatient 104 67.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.97 100.88 BREAST PUMP KIT #67186S 48711814_1 CDM 0270 RC inpatient 104 67.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.97 100.88 BREAST PUMP KIT #67186S 48711814_1 CDM 0270 RC inpatient 104 67.6 ANTHEM HMO ANTHEM HMO 999999999 62.97 100.88 BREAST PUMP KIT #67186S 48711814_1 CDM 0270 RC inpatient 104 67.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.97 100.88 BREAST PUMP KIT #67186S 48711814_1 CDM 0270 RC inpatient 104 67.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.3 67.6 999999999 62.97 100.88 percent of total billed charges BREAST PUMP KIT #67186S 48711814_1 CDM 0270 RC inpatient 104 67.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.97 100.88 DOUBLE BREAST PUMP KIT 67355S 48711815_1 CDM 0272 RC inpatient 185 120.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 120.25 65 999999999 112.02 179.45 percent of total billed charges DOUBLE BREAST PUMP KIT 67355S 48711815_1 CDM 0272 RC inpatient 185 120.25 AETNA AETNA 146.15 79 999999999 112.02 179.45 percent of total billed charges DOUBLE BREAST PUMP KIT 67355S 48711815_1 CDM 0272 RC inpatient 185 120.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 127.65 69 999999999 112.02 179.45 percent of total billed charges DOUBLE BREAST PUMP KIT 67355S 48711815_1 CDM 0272 RC inpatient 185 120.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 179.45 97 999999999 112.02 179.45 percent of total billed charges DOUBLE BREAST PUMP KIT 67355S 48711815_1 CDM 0272 RC inpatient 185 120.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 144.3 78 999999999 112.02 179.45 percent of total billed charges DOUBLE BREAST PUMP KIT 67355S 48711815_1 CDM 0272 RC inpatient 185 120.25 SIHO - ALL PLANS SIHO - ALL PLANS 166.5 90 999999999 112.02 179.45 percent of total billed charges DOUBLE BREAST PUMP KIT 67355S 48711815_1 CDM 0272 RC inpatient 185 120.25 UMR - ALL PLANS UMR - ALL PLANS 129.5 70 999999999 112.02 179.45 percent of total billed charges DOUBLE BREAST PUMP KIT 67355S 48711815_1 CDM 0272 RC inpatient 185 120.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 112.02 60.55 999999999 112.02 179.45 percent of total billed charges DOUBLE BREAST PUMP KIT 67355S 48711815_1 CDM 0272 RC inpatient 185 120.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 112.02 179.45 DOUBLE BREAST PUMP KIT 67355S 48711815_1 CDM 0272 RC inpatient 185 120.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 112.02 179.45 DOUBLE BREAST PUMP KIT 67355S 48711815_1 CDM 0272 RC inpatient 185 120.25 ANTHEM HMO ANTHEM HMO 999999999 112.02 179.45 DOUBLE BREAST PUMP KIT 67355S 48711815_1 CDM 0272 RC inpatient 185 120.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 112.02 179.45 DOUBLE BREAST PUMP KIT 67355S 48711815_1 CDM 0272 RC inpatient 185 120.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 125.06 67.6 999999999 112.02 179.45 percent of total billed charges DOUBLE BREAST PUMP KIT 67355S 48711815_1 CDM 0272 RC inpatient 185 120.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 112.02 179.45 BRUSH CYSTOLOGY 48711822_1 CDM 0272 RC inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges BRUSH CYSTOLOGY 48711822_1 CDM 0272 RC inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges BRUSH CYSTOLOGY 48711822_1 CDM 0272 RC inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges BRUSH CYSTOLOGY 48711822_1 CDM 0272 RC inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges BRUSH CYSTOLOGY 48711822_1 CDM 0272 RC inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges BRUSH CYSTOLOGY 48711822_1 CDM 0272 RC inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges BRUSH CYSTOLOGY 48711822_1 CDM 0272 RC inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges BRUSH CYSTOLOGY 48711822_1 CDM 0272 RC inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges BRUSH CYSTOLOGY 48711822_1 CDM 0272 RC inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 BRUSH CYSTOLOGY 48711822_1 CDM 0272 RC inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 BRUSH CYSTOLOGY 48711822_1 CDM 0272 RC inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 BRUSH CYSTOLOGY 48711822_1 CDM 0272 RC inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 BRUSH CYSTOLOGY 48711822_1 CDM 0272 RC inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges BRUSH CYSTOLOGY 48711822_1 CDM 0272 RC inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 BRONCHOSCOPE ADAPTER 625191 48711823_1 CDM 0272 RC inpatient 33 21.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.45 65 999999999 19.98 32.01 percent of total billed charges BRONCHOSCOPE ADAPTER 625191 48711823_1 CDM 0272 RC inpatient 33 21.45 AETNA AETNA 26.07 79 999999999 19.98 32.01 percent of total billed charges BRONCHOSCOPE ADAPTER 625191 48711823_1 CDM 0272 RC inpatient 33 21.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.77 69 999999999 19.98 32.01 percent of total billed charges BRONCHOSCOPE ADAPTER 625191 48711823_1 CDM 0272 RC inpatient 33 21.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.01 97 999999999 19.98 32.01 percent of total billed charges BRONCHOSCOPE ADAPTER 625191 48711823_1 CDM 0272 RC inpatient 33 21.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.74 78 999999999 19.98 32.01 percent of total billed charges BRONCHOSCOPE ADAPTER 625191 48711823_1 CDM 0272 RC inpatient 33 21.45 SIHO - ALL PLANS SIHO - ALL PLANS 29.7 90 999999999 19.98 32.01 percent of total billed charges BRONCHOSCOPE ADAPTER 625191 48711823_1 CDM 0272 RC inpatient 33 21.45 UMR - ALL PLANS UMR - ALL PLANS 23.1 70 999999999 19.98 32.01 percent of total billed charges BRONCHOSCOPE ADAPTER 625191 48711823_1 CDM 0272 RC inpatient 33 21.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.98 60.55 999999999 19.98 32.01 percent of total billed charges BRONCHOSCOPE ADAPTER 625191 48711823_1 CDM 0272 RC inpatient 33 21.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.98 32.01 BRONCHOSCOPE ADAPTER 625191 48711823_1 CDM 0272 RC inpatient 33 21.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.98 32.01 BRONCHOSCOPE ADAPTER 625191 48711823_1 CDM 0272 RC inpatient 33 21.45 ANTHEM HMO ANTHEM HMO 999999999 19.98 32.01 BRONCHOSCOPE ADAPTER 625191 48711823_1 CDM 0272 RC inpatient 33 21.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.98 32.01 BRONCHOSCOPE ADAPTER 625191 48711823_1 CDM 0272 RC inpatient 33 21.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.31 67.6 999999999 19.98 32.01 percent of total billed charges BRONCHOSCOPE ADAPTER 625191 48711823_1 CDM 0272 RC inpatient 33 21.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.98 32.01 DISCONTINUED BY MEGAN PALMER BRUSH MICROBIOLOGY DISPOSABLE 48711825_1 CDM 0272 RC inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges DISCONTINUED BY MEGAN PALMER BRUSH MICROBIOLOGY DISPOSABLE 48711825_1 CDM 0272 RC inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges DISCONTINUED BY MEGAN PALMER BRUSH MICROBIOLOGY DISPOSABLE 48711825_1 CDM 0272 RC inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges DISCONTINUED BY MEGAN PALMER BRUSH MICROBIOLOGY DISPOSABLE 48711825_1 CDM 0272 RC inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges DISCONTINUED BY MEGAN PALMER BRUSH MICROBIOLOGY DISPOSABLE 48711825_1 CDM 0272 RC inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges DISCONTINUED BY MEGAN PALMER BRUSH MICROBIOLOGY DISPOSABLE 48711825_1 CDM 0272 RC inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges DISCONTINUED BY MEGAN PALMER BRUSH MICROBIOLOGY DISPOSABLE 48711825_1 CDM 0272 RC inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges DISCONTINUED BY MEGAN PALMER BRUSH MICROBIOLOGY DISPOSABLE 48711825_1 CDM 0272 RC inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges DISCONTINUED BY MEGAN PALMER BRUSH MICROBIOLOGY DISPOSABLE 48711825_1 CDM 0272 RC inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 DISCONTINUED BY MEGAN PALMER BRUSH MICROBIOLOGY DISPOSABLE 48711825_1 CDM 0272 RC inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 DISCONTINUED BY MEGAN PALMER BRUSH MICROBIOLOGY DISPOSABLE 48711825_1 CDM 0272 RC inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 DISCONTINUED BY MEGAN PALMER BRUSH MICROBIOLOGY DISPOSABLE 48711825_1 CDM 0272 RC inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 DISCONTINUED BY MEGAN PALMER BRUSH MICROBIOLOGY DISPOSABLE 48711825_1 CDM 0272 RC inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges DISCONTINUED BY MEGAN PALMER BRUSH MICROBIOLOGY DISPOSABLE 48711825_1 CDM 0272 RC inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 BUTTON FEEDING TUBE 18FR X3.4C 48711829_1 CDM 0272 RC inpatient 2172 1411.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1411.8 65 999999999 1315.15 2106.84 percent of total billed charges BUTTON FEEDING TUBE 18FR X3.4C 48711829_1 CDM 0272 RC inpatient 2172 1411.8 AETNA AETNA 1715.88 79 999999999 1315.15 2106.84 percent of total billed charges BUTTON FEEDING TUBE 18FR X3.4C 48711829_1 CDM 0272 RC inpatient 2172 1411.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1498.68 69 999999999 1315.15 2106.84 percent of total billed charges BUTTON FEEDING TUBE 18FR X3.4C 48711829_1 CDM 0272 RC inpatient 2172 1411.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2106.84 97 999999999 1315.15 2106.84 percent of total billed charges BUTTON FEEDING TUBE 18FR X3.4C 48711829_1 CDM 0272 RC inpatient 2172 1411.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1694.16 78 999999999 1315.15 2106.84 percent of total billed charges BUTTON FEEDING TUBE 18FR X3.4C 48711829_1 CDM 0272 RC inpatient 2172 1411.8 SIHO - ALL PLANS SIHO - ALL PLANS 1954.8 90 999999999 1315.15 2106.84 percent of total billed charges BUTTON FEEDING TUBE 18FR X3.4C 48711829_1 CDM 0272 RC inpatient 2172 1411.8 UMR - ALL PLANS UMR - ALL PLANS 1520.4 70 999999999 1315.15 2106.84 percent of total billed charges BUTTON FEEDING TUBE 18FR X3.4C 48711829_1 CDM 0272 RC inpatient 2172 1411.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1315.15 60.55 999999999 1315.15 2106.84 percent of total billed charges BUTTON FEEDING TUBE 18FR X3.4C 48711829_1 CDM 0272 RC inpatient 2172 1411.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1315.15 2106.84 BUTTON FEEDING TUBE 18FR X3.4C 48711829_1 CDM 0272 RC inpatient 2172 1411.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1315.15 2106.84 BUTTON FEEDING TUBE 18FR X3.4C 48711829_1 CDM 0272 RC inpatient 2172 1411.8 ANTHEM HMO ANTHEM HMO 999999999 1315.15 2106.84 BUTTON FEEDING TUBE 18FR X3.4C 48711829_1 CDM 0272 RC inpatient 2172 1411.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1315.15 2106.84 BUTTON FEEDING TUBE 18FR X3.4C 48711829_1 CDM 0272 RC inpatient 2172 1411.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1468.27 67.6 999999999 1315.15 2106.84 percent of total billed charges BUTTON FEEDING TUBE 18FR X3.4C 48711829_1 CDM 0272 RC inpatient 2172 1411.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1315.15 2106.84 CUTTER 5.5 AGG MENISCUS 48711830_1 CDM 0272 RC inpatient 395 256.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 256.75 65 999999999 239.17 383.15 percent of total billed charges CUTTER 5.5 AGG MENISCUS 48711830_1 CDM 0272 RC inpatient 395 256.75 AETNA AETNA 312.05 79 999999999 239.17 383.15 percent of total billed charges CUTTER 5.5 AGG MENISCUS 48711830_1 CDM 0272 RC inpatient 395 256.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 272.55 69 999999999 239.17 383.15 percent of total billed charges CUTTER 5.5 AGG MENISCUS 48711830_1 CDM 0272 RC inpatient 395 256.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 383.15 97 999999999 239.17 383.15 percent of total billed charges CUTTER 5.5 AGG MENISCUS 48711830_1 CDM 0272 RC inpatient 395 256.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 308.1 78 999999999 239.17 383.15 percent of total billed charges CUTTER 5.5 AGG MENISCUS 48711830_1 CDM 0272 RC inpatient 395 256.75 SIHO - ALL PLANS SIHO - ALL PLANS 355.5 90 999999999 239.17 383.15 percent of total billed charges CUTTER 5.5 AGG MENISCUS 48711830_1 CDM 0272 RC inpatient 395 256.75 UMR - ALL PLANS UMR - ALL PLANS 276.5 70 999999999 239.17 383.15 percent of total billed charges CUTTER 5.5 AGG MENISCUS 48711830_1 CDM 0272 RC inpatient 395 256.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 239.17 60.55 999999999 239.17 383.15 percent of total billed charges CUTTER 5.5 AGG MENISCUS 48711830_1 CDM 0272 RC inpatient 395 256.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 239.17 383.15 CUTTER 5.5 AGG MENISCUS 48711830_1 CDM 0272 RC inpatient 395 256.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 239.17 383.15 CUTTER 5.5 AGG MENISCUS 48711830_1 CDM 0272 RC inpatient 395 256.75 ANTHEM HMO ANTHEM HMO 999999999 239.17 383.15 CUTTER 5.5 AGG MENISCUS 48711830_1 CDM 0272 RC inpatient 395 256.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 239.17 383.15 CUTTER 5.5 AGG MENISCUS 48711830_1 CDM 0272 RC inpatient 395 256.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 267.02 67.6 999999999 239.17 383.15 percent of total billed charges CUTTER 5.5 AGG MENISCUS 48711830_1 CDM 0272 RC inpatient 395 256.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 239.17 383.15 5.0 BARREL BUR 6 FL 0375951100 48711831_1 CDM 0272 RC inpatient 374 243.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 243.1 65 999999999 226.46 362.78 percent of total billed charges 5.0 BARREL BUR 6 FL 0375951100 48711831_1 CDM 0272 RC inpatient 374 243.1 AETNA AETNA 295.46 79 999999999 226.46 362.78 percent of total billed charges 5.0 BARREL BUR 6 FL 0375951100 48711831_1 CDM 0272 RC inpatient 374 243.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 258.06 69 999999999 226.46 362.78 percent of total billed charges 5.0 BARREL BUR 6 FL 0375951100 48711831_1 CDM 0272 RC inpatient 374 243.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 362.78 97 999999999 226.46 362.78 percent of total billed charges 5.0 BARREL BUR 6 FL 0375951100 48711831_1 CDM 0272 RC inpatient 374 243.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 291.72 78 999999999 226.46 362.78 percent of total billed charges 5.0 BARREL BUR 6 FL 0375951100 48711831_1 CDM 0272 RC inpatient 374 243.1 SIHO - ALL PLANS SIHO - ALL PLANS 336.6 90 999999999 226.46 362.78 percent of total billed charges 5.0 BARREL BUR 6 FL 0375951100 48711831_1 CDM 0272 RC inpatient 374 243.1 UMR - ALL PLANS UMR - ALL PLANS 261.8 70 999999999 226.46 362.78 percent of total billed charges 5.0 BARREL BUR 6 FL 0375951100 48711831_1 CDM 0272 RC inpatient 374 243.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 226.46 60.55 999999999 226.46 362.78 percent of total billed charges 5.0 BARREL BUR 6 FL 0375951100 48711831_1 CDM 0272 RC inpatient 374 243.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 226.46 362.78 5.0 BARREL BUR 6 FL 0375951100 48711831_1 CDM 0272 RC inpatient 374 243.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 226.46 362.78 5.0 BARREL BUR 6 FL 0375951100 48711831_1 CDM 0272 RC inpatient 374 243.1 ANTHEM HMO ANTHEM HMO 999999999 226.46 362.78 5.0 BARREL BUR 6 FL 0375951100 48711831_1 CDM 0272 RC inpatient 374 243.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 226.46 362.78 5.0 BARREL BUR 6 FL 0375951100 48711831_1 CDM 0272 RC inpatient 374 243.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 252.82 67.6 999999999 226.46 362.78 percent of total billed charges 5.0 BARREL BUR 6 FL 0375951100 48711831_1 CDM 0272 RC inpatient 374 243.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 226.46 362.78 HYPERTHERMIA BLANKET LITE 876 48711833_1 CDM 0271 RC inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges HYPERTHERMIA BLANKET LITE 876 48711833_1 CDM 0271 RC inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges HYPERTHERMIA BLANKET LITE 876 48711833_1 CDM 0271 RC inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges HYPERTHERMIA BLANKET LITE 876 48711833_1 CDM 0271 RC inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges HYPERTHERMIA BLANKET LITE 876 48711833_1 CDM 0271 RC inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges HYPERTHERMIA BLANKET LITE 876 48711833_1 CDM 0271 RC inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges HYPERTHERMIA BLANKET LITE 876 48711833_1 CDM 0271 RC inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges HYPERTHERMIA BLANKET LITE 876 48711833_1 CDM 0271 RC inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges HYPERTHERMIA BLANKET LITE 876 48711833_1 CDM 0271 RC inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 HYPERTHERMIA BLANKET LITE 876 48711833_1 CDM 0271 RC inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 HYPERTHERMIA BLANKET LITE 876 48711833_1 CDM 0271 RC inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 HYPERTHERMIA BLANKET LITE 876 48711833_1 CDM 0271 RC inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 HYPERTHERMIA BLANKET LITE 876 48711833_1 CDM 0271 RC inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges HYPERTHERMIA BLANKET LITE 876 48711833_1 CDM 0271 RC inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 CADAVER KIT BODY BAG 903 48711836_1 CDM 0271 RC inpatient 55 35.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 35.75 65 999999999 33.3 53.35 percent of total billed charges CADAVER KIT BODY BAG 903 48711836_1 CDM 0271 RC inpatient 55 35.75 AETNA AETNA 43.45 79 999999999 33.3 53.35 percent of total billed charges CADAVER KIT BODY BAG 903 48711836_1 CDM 0271 RC inpatient 55 35.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 37.95 69 999999999 33.3 53.35 percent of total billed charges CADAVER KIT BODY BAG 903 48711836_1 CDM 0271 RC inpatient 55 35.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 53.35 97 999999999 33.3 53.35 percent of total billed charges CADAVER KIT BODY BAG 903 48711836_1 CDM 0271 RC inpatient 55 35.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 42.9 78 999999999 33.3 53.35 percent of total billed charges CADAVER KIT BODY BAG 903 48711836_1 CDM 0271 RC inpatient 55 35.75 SIHO - ALL PLANS SIHO - ALL PLANS 49.5 90 999999999 33.3 53.35 percent of total billed charges CADAVER KIT BODY BAG 903 48711836_1 CDM 0271 RC inpatient 55 35.75 UMR - ALL PLANS UMR - ALL PLANS 38.5 70 999999999 33.3 53.35 percent of total billed charges CADAVER KIT BODY BAG 903 48711836_1 CDM 0271 RC inpatient 55 35.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33.3 60.55 999999999 33.3 53.35 percent of total billed charges CADAVER KIT BODY BAG 903 48711836_1 CDM 0271 RC inpatient 55 35.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 33.3 53.35 CADAVER KIT BODY BAG 903 48711836_1 CDM 0271 RC inpatient 55 35.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 33.3 53.35 CADAVER KIT BODY BAG 903 48711836_1 CDM 0271 RC inpatient 55 35.75 ANTHEM HMO ANTHEM HMO 999999999 33.3 53.35 CADAVER KIT BODY BAG 903 48711836_1 CDM 0271 RC inpatient 55 35.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 33.3 53.35 CADAVER KIT BODY BAG 903 48711836_1 CDM 0271 RC inpatient 55 35.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 37.18 67.6 999999999 33.3 53.35 percent of total billed charges CADAVER KIT BODY BAG 903 48711836_1 CDM 0271 RC inpatient 55 35.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 33.3 53.35 CADAVER BAG BARI NON70548WM 48711837_1 CDM 0271 RC inpatient 257 167.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.05 65 999999999 155.61 249.29 percent of total billed charges CADAVER BAG BARI NON70548WM 48711837_1 CDM 0271 RC inpatient 257 167.05 AETNA AETNA 203.03 79 999999999 155.61 249.29 percent of total billed charges CADAVER BAG BARI NON70548WM 48711837_1 CDM 0271 RC inpatient 257 167.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 177.33 69 999999999 155.61 249.29 percent of total billed charges CADAVER BAG BARI NON70548WM 48711837_1 CDM 0271 RC inpatient 257 167.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 249.29 97 999999999 155.61 249.29 percent of total billed charges CADAVER BAG BARI NON70548WM 48711837_1 CDM 0271 RC inpatient 257 167.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 200.46 78 999999999 155.61 249.29 percent of total billed charges CADAVER BAG BARI NON70548WM 48711837_1 CDM 0271 RC inpatient 257 167.05 SIHO - ALL PLANS SIHO - ALL PLANS 231.3 90 999999999 155.61 249.29 percent of total billed charges CADAVER BAG BARI NON70548WM 48711837_1 CDM 0271 RC inpatient 257 167.05 UMR - ALL PLANS UMR - ALL PLANS 179.9 70 999999999 155.61 249.29 percent of total billed charges CADAVER BAG BARI NON70548WM 48711837_1 CDM 0271 RC inpatient 257 167.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.61 60.55 999999999 155.61 249.29 percent of total billed charges CADAVER BAG BARI NON70548WM 48711837_1 CDM 0271 RC inpatient 257 167.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.61 249.29 CADAVER BAG BARI NON70548WM 48711837_1 CDM 0271 RC inpatient 257 167.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.61 249.29 CADAVER BAG BARI NON70548WM 48711837_1 CDM 0271 RC inpatient 257 167.05 ANTHEM HMO ANTHEM HMO 999999999 155.61 249.29 CADAVER BAG BARI NON70548WM 48711837_1 CDM 0271 RC inpatient 257 167.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.61 249.29 CADAVER BAG BARI NON70548WM 48711837_1 CDM 0271 RC inpatient 257 167.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.73 67.6 999999999 155.61 249.29 percent of total billed charges CADAVER BAG BARI NON70548WM 48711837_1 CDM 0271 RC inpatient 257 167.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.61 249.29 CVC DRESSING KIT DT19900A 48711838_1 CDM 0272 RC inpatient 61 39.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.65 65 999999999 36.94 59.17 percent of total billed charges CVC DRESSING KIT DT19900A 48711838_1 CDM 0272 RC inpatient 61 39.65 AETNA AETNA 48.19 79 999999999 36.94 59.17 percent of total billed charges CVC DRESSING KIT DT19900A 48711838_1 CDM 0272 RC inpatient 61 39.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.09 69 999999999 36.94 59.17 percent of total billed charges CVC DRESSING KIT DT19900A 48711838_1 CDM 0272 RC inpatient 61 39.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59.17 97 999999999 36.94 59.17 percent of total billed charges CVC DRESSING KIT DT19900A 48711838_1 CDM 0272 RC inpatient 61 39.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.58 78 999999999 36.94 59.17 percent of total billed charges CVC DRESSING KIT DT19900A 48711838_1 CDM 0272 RC inpatient 61 39.65 SIHO - ALL PLANS SIHO - ALL PLANS 54.9 90 999999999 36.94 59.17 percent of total billed charges CVC DRESSING KIT DT19900A 48711838_1 CDM 0272 RC inpatient 61 39.65 UMR - ALL PLANS UMR - ALL PLANS 42.7 70 999999999 36.94 59.17 percent of total billed charges CVC DRESSING KIT DT19900A 48711838_1 CDM 0272 RC inpatient 61 39.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.94 60.55 999999999 36.94 59.17 percent of total billed charges CVC DRESSING KIT DT19900A 48711838_1 CDM 0272 RC inpatient 61 39.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.94 59.17 CVC DRESSING KIT DT19900A 48711838_1 CDM 0272 RC inpatient 61 39.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.94 59.17 CVC DRESSING KIT DT19900A 48711838_1 CDM 0272 RC inpatient 61 39.65 ANTHEM HMO ANTHEM HMO 999999999 36.94 59.17 CVC DRESSING KIT DT19900A 48711838_1 CDM 0272 RC inpatient 61 39.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.94 59.17 CVC DRESSING KIT DT19900A 48711838_1 CDM 0272 RC inpatient 61 39.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.24 67.6 999999999 36.94 59.17 percent of total billed charges CVC DRESSING KIT DT19900A 48711838_1 CDM 0272 RC inpatient 61 39.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.94 59.17 CATH COUNCIL 22F 40522L 48711844_1 CDM 0274 RC inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges CATH COUNCIL 22F 40522L 48711844_1 CDM 0274 RC inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges CATH COUNCIL 22F 40522L 48711844_1 CDM 0274 RC inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges CATH COUNCIL 22F 40522L 48711844_1 CDM 0274 RC inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges CATH COUNCIL 22F 40522L 48711844_1 CDM 0274 RC inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges CATH COUNCIL 22F 40522L 48711844_1 CDM 0274 RC inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges CATH COUNCIL 22F 40522L 48711844_1 CDM 0274 RC inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges CATH COUNCIL 22F 40522L 48711844_1 CDM 0274 RC inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges CATH COUNCIL 22F 40522L 48711844_1 CDM 0274 RC inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 CATH COUNCIL 22F 40522L 48711844_1 CDM 0274 RC inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 CATH COUNCIL 22F 40522L 48711844_1 CDM 0274 RC inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 CATH COUNCIL 22F 40522L 48711844_1 CDM 0274 RC inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 CATH COUNCIL 22F 40522L 48711844_1 CDM 0274 RC inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges CATH COUNCIL 22F 40522L 48711844_1 CDM 0274 RC inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 CATH COUNCIL FOLEY 16F 5C 48711845_1 CDM 0274 RC inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges CATH COUNCIL FOLEY 16F 5C 48711845_1 CDM 0274 RC inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges CATH COUNCIL FOLEY 16F 5C 48711845_1 CDM 0274 RC inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges CATH COUNCIL FOLEY 16F 5C 48711845_1 CDM 0274 RC inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges CATH COUNCIL FOLEY 16F 5C 48711845_1 CDM 0274 RC inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges CATH COUNCIL FOLEY 16F 5C 48711845_1 CDM 0274 RC inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges CATH COUNCIL FOLEY 16F 5C 48711845_1 CDM 0274 RC inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges CATH COUNCIL FOLEY 16F 5C 48711845_1 CDM 0274 RC inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges CATH COUNCIL FOLEY 16F 5C 48711845_1 CDM 0274 RC inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 CATH COUNCIL FOLEY 16F 5C 48711845_1 CDM 0274 RC inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 CATH COUNCIL FOLEY 16F 5C 48711845_1 CDM 0274 RC inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 CATH COUNCIL FOLEY 16F 5C 48711845_1 CDM 0274 RC inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 CATH COUNCIL FOLEY 16F 5C 48711845_1 CDM 0274 RC inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges CATH COUNCIL FOLEY 16F 5C 48711845_1 CDM 0274 RC inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 CATH COUNCIL FOLEY 20FR 5CC 0196L20 48711846_1 CDM 0274 RC inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges CATH COUNCIL FOLEY 20FR 5CC 0196L20 48711846_1 CDM 0274 RC inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges CATH COUNCIL FOLEY 20FR 5CC 0196L20 48711846_1 CDM 0274 RC inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges CATH COUNCIL FOLEY 20FR 5CC 0196L20 48711846_1 CDM 0274 RC inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges CATH COUNCIL FOLEY 20FR 5CC 0196L20 48711846_1 CDM 0274 RC inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges CATH COUNCIL FOLEY 20FR 5CC 0196L20 48711846_1 CDM 0274 RC inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges CATH COUNCIL FOLEY 20FR 5CC 0196L20 48711846_1 CDM 0274 RC inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges CATH COUNCIL FOLEY 20FR 5CC 0196L20 48711846_1 CDM 0274 RC inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges CATH COUNCIL FOLEY 20FR 5CC 0196L20 48711846_1 CDM 0274 RC inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 CATH COUNCIL FOLEY 20FR 5CC 0196L20 48711846_1 CDM 0274 RC inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 CATH COUNCIL FOLEY 20FR 5CC 0196L20 48711846_1 CDM 0274 RC inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 CATH COUNCIL FOLEY 20FR 5CC 0196L20 48711846_1 CDM 0274 RC inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 CATH COUNCIL FOLEY 20FR 5CC 0196L20 48711846_1 CDM 0274 RC inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges CATH COUNCIL FOLEY 20FR 5CC 0196L20 48711846_1 CDM 0274 RC inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 ROUND CUTTING BUR 5.0M ZB-130 48711847_1 CDM 0272 RC inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges ROUND CUTTING BUR 5.0M ZB-130 48711847_1 CDM 0272 RC inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges ROUND CUTTING BUR 5.0M ZB-130 48711847_1 CDM 0272 RC inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges ROUND CUTTING BUR 5.0M ZB-130 48711847_1 CDM 0272 RC inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges ROUND CUTTING BUR 5.0M ZB-130 48711847_1 CDM 0272 RC inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges ROUND CUTTING BUR 5.0M ZB-130 48711847_1 CDM 0272 RC inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges ROUND CUTTING BUR 5.0M ZB-130 48711847_1 CDM 0272 RC inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges ROUND CUTTING BUR 5.0M ZB-130 48711847_1 CDM 0272 RC inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges ROUND CUTTING BUR 5.0M ZB-130 48711847_1 CDM 0272 RC inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 ROUND CUTTING BUR 5.0M ZB-130 48711847_1 CDM 0272 RC inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 ROUND CUTTING BUR 5.0M ZB-130 48711847_1 CDM 0272 RC inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 ROUND CUTTING BUR 5.0M ZB-130 48711847_1 CDM 0272 RC inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 ROUND CUTTING BUR 5.0M ZB-130 48711847_1 CDM 0272 RC inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges ROUND CUTTING BUR 5.0M ZB-130 48711847_1 CDM 0272 RC inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711848_1 CDM 0278 RC C1713 HCPCS inpatient 196 127.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 127.4 65 999999999 118.68 190.12 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711848_1 CDM 0278 RC C1713 HCPCS inpatient 196 127.4 AETNA AETNA 154.84 79 999999999 118.68 190.12 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711848_1 CDM 0278 RC C1713 HCPCS inpatient 196 127.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 135.24 69 999999999 118.68 190.12 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711848_1 CDM 0278 RC C1713 HCPCS inpatient 196 127.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 190.12 97 999999999 118.68 190.12 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711848_1 CDM 0278 RC C1713 HCPCS inpatient 196 127.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 152.88 78 999999999 118.68 190.12 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711848_1 CDM 0278 RC C1713 HCPCS inpatient 196 127.4 SIHO - ALL PLANS SIHO - ALL PLANS 176.4 90 999999999 118.68 190.12 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711848_1 CDM 0278 RC C1713 HCPCS inpatient 196 127.4 UMR - ALL PLANS UMR - ALL PLANS 137.2 70 999999999 118.68 190.12 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711848_1 CDM 0278 RC C1713 HCPCS inpatient 196 127.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 118.68 60.55 999999999 118.68 190.12 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711848_1 CDM 0278 RC C1713 HCPCS inpatient 196 127.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 118.68 190.12 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711848_1 CDM 0278 RC C1713 HCPCS inpatient 196 127.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 118.68 190.12 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711848_1 CDM 0278 RC C1713 HCPCS inpatient 196 127.4 ANTHEM HMO ANTHEM HMO 999999999 118.68 190.12 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711848_1 CDM 0278 RC C1713 HCPCS inpatient 196 127.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 118.68 190.12 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711848_1 CDM 0278 RC C1713 HCPCS inpatient 196 127.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 132.5 67.6 999999999 118.68 190.12 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48711848_1 CDM 0278 RC C1713 HCPCS inpatient 196 127.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 118.68 190.12 LONG OVAL CUT BUR 4.0M ZB-236 48711850_1 CDM 0272 RC inpatient 170 110.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.5 65 999999999 102.94 164.9 percent of total billed charges LONG OVAL CUT BUR 4.0M ZB-236 48711850_1 CDM 0272 RC inpatient 170 110.5 AETNA AETNA 134.3 79 999999999 102.94 164.9 percent of total billed charges LONG OVAL CUT BUR 4.0M ZB-236 48711850_1 CDM 0272 RC inpatient 170 110.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.3 69 999999999 102.94 164.9 percent of total billed charges LONG OVAL CUT BUR 4.0M ZB-236 48711850_1 CDM 0272 RC inpatient 170 110.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.9 97 999999999 102.94 164.9 percent of total billed charges LONG OVAL CUT BUR 4.0M ZB-236 48711850_1 CDM 0272 RC inpatient 170 110.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.6 78 999999999 102.94 164.9 percent of total billed charges LONG OVAL CUT BUR 4.0M ZB-236 48711850_1 CDM 0272 RC inpatient 170 110.5 SIHO - ALL PLANS SIHO - ALL PLANS 153 90 999999999 102.94 164.9 percent of total billed charges LONG OVAL CUT BUR 4.0M ZB-236 48711850_1 CDM 0272 RC inpatient 170 110.5 UMR - ALL PLANS UMR - ALL PLANS 119 70 999999999 102.94 164.9 percent of total billed charges LONG OVAL CUT BUR 4.0M ZB-236 48711850_1 CDM 0272 RC inpatient 170 110.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.94 60.55 999999999 102.94 164.9 percent of total billed charges LONG OVAL CUT BUR 4.0M ZB-236 48711850_1 CDM 0272 RC inpatient 170 110.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.94 164.9 LONG OVAL CUT BUR 4.0M ZB-236 48711850_1 CDM 0272 RC inpatient 170 110.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.94 164.9 LONG OVAL CUT BUR 4.0M ZB-236 48711850_1 CDM 0272 RC inpatient 170 110.5 ANTHEM HMO ANTHEM HMO 999999999 102.94 164.9 LONG OVAL CUT BUR 4.0M ZB-236 48711850_1 CDM 0272 RC inpatient 170 110.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.94 164.9 LONG OVAL CUT BUR 4.0M ZB-236 48711850_1 CDM 0272 RC inpatient 170 110.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.92 67.6 999999999 102.94 164.9 percent of total billed charges LONG OVAL CUT BUR 4.0M ZB-236 48711850_1 CDM 0272 RC inpatient 170 110.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.94 164.9 LINDEMANN CARBIDE 1.5M ZB-200 48711851_1 CDM 0272 RC inpatient 231 150.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 150.15 65 999999999 139.87 224.07 percent of total billed charges LINDEMANN CARBIDE 1.5M ZB-200 48711851_1 CDM 0272 RC inpatient 231 150.15 AETNA AETNA 182.49 79 999999999 139.87 224.07 percent of total billed charges LINDEMANN CARBIDE 1.5M ZB-200 48711851_1 CDM 0272 RC inpatient 231 150.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 159.39 69 999999999 139.87 224.07 percent of total billed charges LINDEMANN CARBIDE 1.5M ZB-200 48711851_1 CDM 0272 RC inpatient 231 150.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 224.07 97 999999999 139.87 224.07 percent of total billed charges LINDEMANN CARBIDE 1.5M ZB-200 48711851_1 CDM 0272 RC inpatient 231 150.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 180.18 78 999999999 139.87 224.07 percent of total billed charges LINDEMANN CARBIDE 1.5M ZB-200 48711851_1 CDM 0272 RC inpatient 231 150.15 SIHO - ALL PLANS SIHO - ALL PLANS 207.9 90 999999999 139.87 224.07 percent of total billed charges LINDEMANN CARBIDE 1.5M ZB-200 48711851_1 CDM 0272 RC inpatient 231 150.15 UMR - ALL PLANS UMR - ALL PLANS 161.7 70 999999999 139.87 224.07 percent of total billed charges LINDEMANN CARBIDE 1.5M ZB-200 48711851_1 CDM 0272 RC inpatient 231 150.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 139.87 60.55 999999999 139.87 224.07 percent of total billed charges LINDEMANN CARBIDE 1.5M ZB-200 48711851_1 CDM 0272 RC inpatient 231 150.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 139.87 224.07 LINDEMANN CARBIDE 1.5M ZB-200 48711851_1 CDM 0272 RC inpatient 231 150.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 139.87 224.07 LINDEMANN CARBIDE 1.5M ZB-200 48711851_1 CDM 0272 RC inpatient 231 150.15 ANTHEM HMO ANTHEM HMO 999999999 139.87 224.07 LINDEMANN CARBIDE 1.5M ZB-200 48711851_1 CDM 0272 RC inpatient 231 150.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 139.87 224.07 LINDEMANN CARBIDE 1.5M ZB-200 48711851_1 CDM 0272 RC inpatient 231 150.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 156.16 67.6 999999999 139.87 224.07 percent of total billed charges LINDEMANN CARBIDE 1.5M ZB-200 48711851_1 CDM 0272 RC inpatient 231 150.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 139.87 224.07 NEURO BUR 3.0MM 5820-107-530 48711852_1 CDM 0272 RC inpatient 938 609.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 609.7 65 999999999 567.96 909.86 percent of total billed charges NEURO BUR 3.0MM 5820-107-530 48711852_1 CDM 0272 RC inpatient 938 609.7 AETNA AETNA 741.02 79 999999999 567.96 909.86 percent of total billed charges NEURO BUR 3.0MM 5820-107-530 48711852_1 CDM 0272 RC inpatient 938 609.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 647.22 69 999999999 567.96 909.86 percent of total billed charges NEURO BUR 3.0MM 5820-107-530 48711852_1 CDM 0272 RC inpatient 938 609.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 909.86 97 999999999 567.96 909.86 percent of total billed charges NEURO BUR 3.0MM 5820-107-530 48711852_1 CDM 0272 RC inpatient 938 609.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 731.64 78 999999999 567.96 909.86 percent of total billed charges NEURO BUR 3.0MM 5820-107-530 48711852_1 CDM 0272 RC inpatient 938 609.7 SIHO - ALL PLANS SIHO - ALL PLANS 844.2 90 999999999 567.96 909.86 percent of total billed charges NEURO BUR 3.0MM 5820-107-530 48711852_1 CDM 0272 RC inpatient 938 609.7 UMR - ALL PLANS UMR - ALL PLANS 656.6 70 999999999 567.96 909.86 percent of total billed charges NEURO BUR 3.0MM 5820-107-530 48711852_1 CDM 0272 RC inpatient 938 609.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 567.96 60.55 999999999 567.96 909.86 percent of total billed charges NEURO BUR 3.0MM 5820-107-530 48711852_1 CDM 0272 RC inpatient 938 609.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 567.96 909.86 NEURO BUR 3.0MM 5820-107-530 48711852_1 CDM 0272 RC inpatient 938 609.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 567.96 909.86 NEURO BUR 3.0MM 5820-107-530 48711852_1 CDM 0272 RC inpatient 938 609.7 ANTHEM HMO ANTHEM HMO 999999999 567.96 909.86 NEURO BUR 3.0MM 5820-107-530 48711852_1 CDM 0272 RC inpatient 938 609.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 567.96 909.86 NEURO BUR 3.0MM 5820-107-530 48711852_1 CDM 0272 RC inpatient 938 609.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 634.09 67.6 999999999 567.96 909.86 percent of total billed charges NEURO BUR 3.0MM 5820-107-530 48711852_1 CDM 0272 RC inpatient 938 609.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 567.96 909.86 LONG DIAMOND BUR 1.0MM L10D 48711853_1 CDM 0272 RC inpatient 334 217.1 AETNA AETNA 263.86 79 999999999 202.24 323.98 percent of total billed charges LONG DIAMOND BUR 1.0MM L10D 48711853_1 CDM 0272 RC inpatient 334 217.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 217.1 65 999999999 202.24 323.98 percent of total billed charges LONG DIAMOND BUR 1.0MM L10D 48711853_1 CDM 0272 RC inpatient 334 217.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 230.46 69 999999999 202.24 323.98 percent of total billed charges LONG DIAMOND BUR 1.0MM L10D 48711853_1 CDM 0272 RC inpatient 334 217.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 323.98 97 999999999 202.24 323.98 percent of total billed charges LONG DIAMOND BUR 1.0MM L10D 48711853_1 CDM 0272 RC inpatient 334 217.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 260.52 78 999999999 202.24 323.98 percent of total billed charges LONG DIAMOND BUR 1.0MM L10D 48711853_1 CDM 0272 RC inpatient 334 217.1 SIHO - ALL PLANS SIHO - ALL PLANS 300.6 90 999999999 202.24 323.98 percent of total billed charges LONG DIAMOND BUR 1.0MM L10D 48711853_1 CDM 0272 RC inpatient 334 217.1 UMR - ALL PLANS UMR - ALL PLANS 233.8 70 999999999 202.24 323.98 percent of total billed charges LONG DIAMOND BUR 1.0MM L10D 48711853_1 CDM 0272 RC inpatient 334 217.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 202.24 60.55 999999999 202.24 323.98 percent of total billed charges LONG DIAMOND BUR 1.0MM L10D 48711853_1 CDM 0272 RC inpatient 334 217.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 202.24 323.98 LONG DIAMOND BUR 1.0MM L10D 48711853_1 CDM 0272 RC inpatient 334 217.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 202.24 323.98 LONG DIAMOND BUR 1.0MM L10D 48711853_1 CDM 0272 RC inpatient 334 217.1 ANTHEM HMO ANTHEM HMO 999999999 202.24 323.98 LONG DIAMOND BUR 1.0MM L10D 48711853_1 CDM 0272 RC inpatient 334 217.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 202.24 323.98 LONG DIAMOND BUR 1.0MM L10D 48711853_1 CDM 0272 RC inpatient 334 217.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 225.78 67.6 999999999 202.24 323.98 percent of total billed charges LONG DIAMOND BUR 1.0MM L10D 48711853_1 CDM 0272 RC inpatient 334 217.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 202.24 323.98 LONG CARBIDE BUR 1MM 5092-220 48711854_1 CDM 0278 RC inpatient 172 111.8 AETNA AETNA 135.88 79 999999999 104.15 166.84 percent of total billed charges LONG CARBIDE BUR 1MM 5092-220 48711854_1 CDM 0278 RC inpatient 172 111.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.8 65 999999999 104.15 166.84 percent of total billed charges LONG CARBIDE BUR 1MM 5092-220 48711854_1 CDM 0278 RC inpatient 172 111.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 118.68 69 999999999 104.15 166.84 percent of total billed charges LONG CARBIDE BUR 1MM 5092-220 48711854_1 CDM 0278 RC inpatient 172 111.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 166.84 97 999999999 104.15 166.84 percent of total billed charges LONG CARBIDE BUR 1MM 5092-220 48711854_1 CDM 0278 RC inpatient 172 111.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.16 78 999999999 104.15 166.84 percent of total billed charges LONG CARBIDE BUR 1MM 5092-220 48711854_1 CDM 0278 RC inpatient 172 111.8 SIHO - ALL PLANS SIHO - ALL PLANS 154.8 90 999999999 104.15 166.84 percent of total billed charges LONG CARBIDE BUR 1MM 5092-220 48711854_1 CDM 0278 RC inpatient 172 111.8 UMR - ALL PLANS UMR - ALL PLANS 120.4 70 999999999 104.15 166.84 percent of total billed charges LONG CARBIDE BUR 1MM 5092-220 48711854_1 CDM 0278 RC inpatient 172 111.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.15 60.55 999999999 104.15 166.84 percent of total billed charges LONG CARBIDE BUR 1MM 5092-220 48711854_1 CDM 0278 RC inpatient 172 111.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.15 166.84 LONG CARBIDE BUR 1MM 5092-220 48711854_1 CDM 0278 RC inpatient 172 111.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.15 166.84 LONG CARBIDE BUR 1MM 5092-220 48711854_1 CDM 0278 RC inpatient 172 111.8 ANTHEM HMO ANTHEM HMO 999999999 104.15 166.84 LONG CARBIDE BUR 1MM 5092-220 48711854_1 CDM 0278 RC inpatient 172 111.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.15 166.84 LONG CARBIDE BUR 1MM 5092-220 48711854_1 CDM 0278 RC inpatient 172 111.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.27 67.6 999999999 104.15 166.84 percent of total billed charges LONG CARBIDE BUR 1MM 5092-220 48711854_1 CDM 0278 RC inpatient 172 111.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.15 166.84 LONG CARBIDE BUR 2MM 5092-224 48711855_1 CDM 0278 RC inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges LONG CARBIDE BUR 2MM 5092-224 48711855_1 CDM 0278 RC inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges LONG CARBIDE BUR 2MM 5092-224 48711855_1 CDM 0278 RC inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges LONG CARBIDE BUR 2MM 5092-224 48711855_1 CDM 0278 RC inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges LONG CARBIDE BUR 2MM 5092-224 48711855_1 CDM 0278 RC inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges LONG CARBIDE BUR 2MM 5092-224 48711855_1 CDM 0278 RC inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges LONG CARBIDE BUR 2MM 5092-224 48711855_1 CDM 0278 RC inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges LONG CARBIDE BUR 2MM 5092-224 48711855_1 CDM 0278 RC inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges LONG CARBIDE BUR 2MM 5092-224 48711855_1 CDM 0278 RC inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 LONG CARBIDE BUR 2MM 5092-224 48711855_1 CDM 0278 RC inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 LONG CARBIDE BUR 2MM 5092-224 48711855_1 CDM 0278 RC inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 LONG CARBIDE BUR 2MM 5092-224 48711855_1 CDM 0278 RC inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 LONG CARBIDE BUR 2MM 5092-224 48711855_1 CDM 0278 RC inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges LONG CARBIDE BUR 2MM 5092-224 48711855_1 CDM 0278 RC inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 LONG CARBIDE BUR 3MM 5092-226 48711856_1 CDM 0278 RC inpatient 98 63.7 AETNA AETNA 77.42 79 999999999 59.34 95.06 percent of total billed charges LONG CARBIDE BUR 3MM 5092-226 48711856_1 CDM 0278 RC inpatient 98 63.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.7 65 999999999 59.34 95.06 percent of total billed charges LONG CARBIDE BUR 3MM 5092-226 48711856_1 CDM 0278 RC inpatient 98 63.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.62 69 999999999 59.34 95.06 percent of total billed charges LONG CARBIDE BUR 3MM 5092-226 48711856_1 CDM 0278 RC inpatient 98 63.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.06 97 999999999 59.34 95.06 percent of total billed charges LONG CARBIDE BUR 3MM 5092-226 48711856_1 CDM 0278 RC inpatient 98 63.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.44 78 999999999 59.34 95.06 percent of total billed charges LONG CARBIDE BUR 3MM 5092-226 48711856_1 CDM 0278 RC inpatient 98 63.7 SIHO - ALL PLANS SIHO - ALL PLANS 88.2 90 999999999 59.34 95.06 percent of total billed charges LONG CARBIDE BUR 3MM 5092-226 48711856_1 CDM 0278 RC inpatient 98 63.7 UMR - ALL PLANS UMR - ALL PLANS 68.6 70 999999999 59.34 95.06 percent of total billed charges LONG CARBIDE BUR 3MM 5092-226 48711856_1 CDM 0278 RC inpatient 98 63.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.34 60.55 999999999 59.34 95.06 percent of total billed charges LONG CARBIDE BUR 3MM 5092-226 48711856_1 CDM 0278 RC inpatient 98 63.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.34 95.06 LONG CARBIDE BUR 3MM 5092-226 48711856_1 CDM 0278 RC inpatient 98 63.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.34 95.06 LONG CARBIDE BUR 3MM 5092-226 48711856_1 CDM 0278 RC inpatient 98 63.7 ANTHEM HMO ANTHEM HMO 999999999 59.34 95.06 LONG CARBIDE BUR 3MM 5092-226 48711856_1 CDM 0278 RC inpatient 98 63.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.34 95.06 LONG CARBIDE BUR 3MM 5092-226 48711856_1 CDM 0278 RC inpatient 98 63.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.25 67.6 999999999 59.34 95.06 percent of total billed charges LONG CARBIDE BUR 3MM 5092-226 48711856_1 CDM 0278 RC inpatient 98 63.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.34 95.06 LONG CARBIDE BUR 4MM 5092-228 48711857_1 CDM 0272 RC inpatient 98 63.7 AETNA AETNA 77.42 79 999999999 59.34 95.06 percent of total billed charges LONG CARBIDE BUR 4MM 5092-228 48711857_1 CDM 0272 RC inpatient 98 63.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.7 65 999999999 59.34 95.06 percent of total billed charges LONG CARBIDE BUR 4MM 5092-228 48711857_1 CDM 0272 RC inpatient 98 63.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.62 69 999999999 59.34 95.06 percent of total billed charges LONG CARBIDE BUR 4MM 5092-228 48711857_1 CDM 0272 RC inpatient 98 63.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.06 97 999999999 59.34 95.06 percent of total billed charges LONG CARBIDE BUR 4MM 5092-228 48711857_1 CDM 0272 RC inpatient 98 63.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.44 78 999999999 59.34 95.06 percent of total billed charges LONG CARBIDE BUR 4MM 5092-228 48711857_1 CDM 0272 RC inpatient 98 63.7 SIHO - ALL PLANS SIHO - ALL PLANS 88.2 90 999999999 59.34 95.06 percent of total billed charges LONG CARBIDE BUR 4MM 5092-228 48711857_1 CDM 0272 RC inpatient 98 63.7 UMR - ALL PLANS UMR - ALL PLANS 68.6 70 999999999 59.34 95.06 percent of total billed charges LONG CARBIDE BUR 4MM 5092-228 48711857_1 CDM 0272 RC inpatient 98 63.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.34 60.55 999999999 59.34 95.06 percent of total billed charges LONG CARBIDE BUR 4MM 5092-228 48711857_1 CDM 0272 RC inpatient 98 63.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.34 95.06 LONG CARBIDE BUR 4MM 5092-228 48711857_1 CDM 0272 RC inpatient 98 63.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.34 95.06 LONG CARBIDE BUR 4MM 5092-228 48711857_1 CDM 0272 RC inpatient 98 63.7 ANTHEM HMO ANTHEM HMO 999999999 59.34 95.06 LONG CARBIDE BUR 4MM 5092-228 48711857_1 CDM 0272 RC inpatient 98 63.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.34 95.06 LONG CARBIDE BUR 4MM 5092-228 48711857_1 CDM 0272 RC inpatient 98 63.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.25 67.6 999999999 59.34 95.06 percent of total billed charges LONG CARBIDE BUR 4MM 5092-228 48711857_1 CDM 0272 RC inpatient 98 63.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.34 95.06 LONG DIAMOND BUR 2MM 5092-260 48711858_1 CDM 0272 RC inpatient 205 133.25 AETNA AETNA 161.95 79 999999999 124.13 198.85 percent of total billed charges LONG DIAMOND BUR 2MM 5092-260 48711858_1 CDM 0272 RC inpatient 205 133.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.25 65 999999999 124.13 198.85 percent of total billed charges LONG DIAMOND BUR 2MM 5092-260 48711858_1 CDM 0272 RC inpatient 205 133.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 141.45 69 999999999 124.13 198.85 percent of total billed charges LONG DIAMOND BUR 2MM 5092-260 48711858_1 CDM 0272 RC inpatient 205 133.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 198.85 97 999999999 124.13 198.85 percent of total billed charges LONG DIAMOND BUR 2MM 5092-260 48711858_1 CDM 0272 RC inpatient 205 133.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.9 78 999999999 124.13 198.85 percent of total billed charges LONG DIAMOND BUR 2MM 5092-260 48711858_1 CDM 0272 RC inpatient 205 133.25 SIHO - ALL PLANS SIHO - ALL PLANS 184.5 90 999999999 124.13 198.85 percent of total billed charges LONG DIAMOND BUR 2MM 5092-260 48711858_1 CDM 0272 RC inpatient 205 133.25 UMR - ALL PLANS UMR - ALL PLANS 143.5 70 999999999 124.13 198.85 percent of total billed charges LONG DIAMOND BUR 2MM 5092-260 48711858_1 CDM 0272 RC inpatient 205 133.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.13 60.55 999999999 124.13 198.85 percent of total billed charges LONG DIAMOND BUR 2MM 5092-260 48711858_1 CDM 0272 RC inpatient 205 133.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.13 198.85 LONG DIAMOND BUR 2MM 5092-260 48711858_1 CDM 0272 RC inpatient 205 133.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.13 198.85 LONG DIAMOND BUR 2MM 5092-260 48711858_1 CDM 0272 RC inpatient 205 133.25 ANTHEM HMO ANTHEM HMO 999999999 124.13 198.85 LONG DIAMOND BUR 2MM 5092-260 48711858_1 CDM 0272 RC inpatient 205 133.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.13 198.85 LONG DIAMOND BUR 2MM 5092-260 48711858_1 CDM 0272 RC inpatient 205 133.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 138.58 67.6 999999999 124.13 198.85 percent of total billed charges LONG DIAMOND BUR 2MM 5092-260 48711858_1 CDM 0272 RC inpatient 205 133.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.13 198.85 HANDPIECE SUPERSECT PK 784515 48711859_1 CDM 0272 RC inpatient 3166 2057.9 AETNA AETNA 2501.14 79 999999999 1917.01 3071.02 percent of total billed charges HANDPIECE SUPERSECT PK 784515 48711859_1 CDM 0272 RC inpatient 3166 2057.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 2057.9 65 999999999 1917.01 3071.02 percent of total billed charges HANDPIECE SUPERSECT PK 784515 48711859_1 CDM 0272 RC inpatient 3166 2057.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 2184.54 69 999999999 1917.01 3071.02 percent of total billed charges HANDPIECE SUPERSECT PK 784515 48711859_1 CDM 0272 RC inpatient 3166 2057.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3071.02 97 999999999 1917.01 3071.02 percent of total billed charges HANDPIECE SUPERSECT PK 784515 48711859_1 CDM 0272 RC inpatient 3166 2057.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 2469.48 78 999999999 1917.01 3071.02 percent of total billed charges HANDPIECE SUPERSECT PK 784515 48711859_1 CDM 0272 RC inpatient 3166 2057.9 SIHO - ALL PLANS SIHO - ALL PLANS 2849.4 90 999999999 1917.01 3071.02 percent of total billed charges HANDPIECE SUPERSECT PK 784515 48711859_1 CDM 0272 RC inpatient 3166 2057.9 UMR - ALL PLANS UMR - ALL PLANS 2216.2 70 999999999 1917.01 3071.02 percent of total billed charges HANDPIECE SUPERSECT PK 784515 48711859_1 CDM 0272 RC inpatient 3166 2057.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1917.01 60.55 999999999 1917.01 3071.02 percent of total billed charges HANDPIECE SUPERSECT PK 784515 48711859_1 CDM 0272 RC inpatient 3166 2057.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1917.01 3071.02 HANDPIECE SUPERSECT PK 784515 48711859_1 CDM 0272 RC inpatient 3166 2057.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1917.01 3071.02 HANDPIECE SUPERSECT PK 784515 48711859_1 CDM 0272 RC inpatient 3166 2057.9 ANTHEM HMO ANTHEM HMO 999999999 1917.01 3071.02 HANDPIECE SUPERSECT PK 784515 48711859_1 CDM 0272 RC inpatient 3166 2057.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1917.01 3071.02 HANDPIECE SUPERSECT PK 784515 48711859_1 CDM 0272 RC inpatient 3166 2057.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 2140.22 67.6 999999999 1917.01 3071.02 percent of total billed charges HANDPIECE SUPERSECT PK 784515 48711859_1 CDM 0272 RC inpatient 3166 2057.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1917.01 3071.02 CATH FOLEY COUDE 16FR 20516C 48711862_1 CDM 0274 RC inpatient 93 60.45 AETNA AETNA 73.47 79 999999999 56.31 90.21 percent of total billed charges CATH FOLEY COUDE 16FR 20516C 48711862_1 CDM 0274 RC inpatient 93 60.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 60.45 65 999999999 56.31 90.21 percent of total billed charges CATH FOLEY COUDE 16FR 20516C 48711862_1 CDM 0274 RC inpatient 93 60.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.17 69 999999999 56.31 90.21 percent of total billed charges CATH FOLEY COUDE 16FR 20516C 48711862_1 CDM 0274 RC inpatient 93 60.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 90.21 97 999999999 56.31 90.21 percent of total billed charges CATH FOLEY COUDE 16FR 20516C 48711862_1 CDM 0274 RC inpatient 93 60.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 72.54 78 999999999 56.31 90.21 percent of total billed charges CATH FOLEY COUDE 16FR 20516C 48711862_1 CDM 0274 RC inpatient 93 60.45 SIHO - ALL PLANS SIHO - ALL PLANS 83.7 90 999999999 56.31 90.21 percent of total billed charges CATH FOLEY COUDE 16FR 20516C 48711862_1 CDM 0274 RC inpatient 93 60.45 UMR - ALL PLANS UMR - ALL PLANS 65.1 70 999999999 56.31 90.21 percent of total billed charges CATH FOLEY COUDE 16FR 20516C 48711862_1 CDM 0274 RC inpatient 93 60.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.31 60.55 999999999 56.31 90.21 percent of total billed charges CATH FOLEY COUDE 16FR 20516C 48711862_1 CDM 0274 RC inpatient 93 60.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.31 90.21 CATH FOLEY COUDE 16FR 20516C 48711862_1 CDM 0274 RC inpatient 93 60.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.31 90.21 CATH FOLEY COUDE 16FR 20516C 48711862_1 CDM 0274 RC inpatient 93 60.45 ANTHEM HMO ANTHEM HMO 999999999 56.31 90.21 CATH FOLEY COUDE 16FR 20516C 48711862_1 CDM 0274 RC inpatient 93 60.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.31 90.21 CATH FOLEY COUDE 16FR 20516C 48711862_1 CDM 0274 RC inpatient 93 60.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.87 67.6 999999999 56.31 90.21 percent of total billed charges CATH FOLEY COUDE 16FR 20516C 48711862_1 CDM 0274 RC inpatient 93 60.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.31 90.21 CATH FOLEY COUDE 18F 5C 2O518C 48711863_1 CDM 0274 RC inpatient 93 60.45 AETNA AETNA 73.47 79 999999999 56.31 90.21 percent of total billed charges CATH FOLEY COUDE 18F 5C 2O518C 48711863_1 CDM 0274 RC inpatient 93 60.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 60.45 65 999999999 56.31 90.21 percent of total billed charges CATH FOLEY COUDE 18F 5C 2O518C 48711863_1 CDM 0274 RC inpatient 93 60.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.17 69 999999999 56.31 90.21 percent of total billed charges CATH FOLEY COUDE 18F 5C 2O518C 48711863_1 CDM 0274 RC inpatient 93 60.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 90.21 97 999999999 56.31 90.21 percent of total billed charges CATH FOLEY COUDE 18F 5C 2O518C 48711863_1 CDM 0274 RC inpatient 93 60.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 72.54 78 999999999 56.31 90.21 percent of total billed charges CATH FOLEY COUDE 18F 5C 2O518C 48711863_1 CDM 0274 RC inpatient 93 60.45 SIHO - ALL PLANS SIHO - ALL PLANS 83.7 90 999999999 56.31 90.21 percent of total billed charges CATH FOLEY COUDE 18F 5C 2O518C 48711863_1 CDM 0274 RC inpatient 93 60.45 UMR - ALL PLANS UMR - ALL PLANS 65.1 70 999999999 56.31 90.21 percent of total billed charges CATH FOLEY COUDE 18F 5C 2O518C 48711863_1 CDM 0274 RC inpatient 93 60.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.31 60.55 999999999 56.31 90.21 percent of total billed charges CATH FOLEY COUDE 18F 5C 2O518C 48711863_1 CDM 0274 RC inpatient 93 60.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.31 90.21 CATH FOLEY COUDE 18F 5C 2O518C 48711863_1 CDM 0274 RC inpatient 93 60.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.31 90.21 CATH FOLEY COUDE 18F 5C 2O518C 48711863_1 CDM 0274 RC inpatient 93 60.45 ANTHEM HMO ANTHEM HMO 999999999 56.31 90.21 CATH FOLEY COUDE 18F 5C 2O518C 48711863_1 CDM 0274 RC inpatient 93 60.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.31 90.21 CATH FOLEY COUDE 18F 5C 2O518C 48711863_1 CDM 0274 RC inpatient 93 60.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.87 67.6 999999999 56.31 90.21 percent of total billed charges CATH FOLEY COUDE 18F 5C 2O518C 48711863_1 CDM 0274 RC inpatient 93 60.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.31 90.21 CATH FOLEY 3-W 18FR 30CC DYND11573 48711864_1 CDM 0274 RC inpatient 40 26 AETNA AETNA 31.6 79 999999999 24.22 38.8 percent of total billed charges CATH FOLEY 3-W 18FR 30CC DYND11573 48711864_1 CDM 0274 RC inpatient 40 26 SELF PAY DISCOUNT SELF PAY DISCOUNT 26 65 999999999 24.22 38.8 percent of total billed charges CATH FOLEY 3-W 18FR 30CC DYND11573 48711864_1 CDM 0274 RC inpatient 40 26 ENCORE - ALL PLANS ENCORE - ALL PLANS 27.6 69 999999999 24.22 38.8 percent of total billed charges CATH FOLEY 3-W 18FR 30CC DYND11573 48711864_1 CDM 0274 RC inpatient 40 26 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 38.8 97 999999999 24.22 38.8 percent of total billed charges CATH FOLEY 3-W 18FR 30CC DYND11573 48711864_1 CDM 0274 RC inpatient 40 26 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.2 78 999999999 24.22 38.8 percent of total billed charges CATH FOLEY 3-W 18FR 30CC DYND11573 48711864_1 CDM 0274 RC inpatient 40 26 SIHO - ALL PLANS SIHO - ALL PLANS 36 90 999999999 24.22 38.8 percent of total billed charges CATH FOLEY 3-W 18FR 30CC DYND11573 48711864_1 CDM 0274 RC inpatient 40 26 UMR - ALL PLANS UMR - ALL PLANS 28 70 999999999 24.22 38.8 percent of total billed charges CATH FOLEY 3-W 18FR 30CC DYND11573 48711864_1 CDM 0274 RC inpatient 40 26 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.22 60.55 999999999 24.22 38.8 percent of total billed charges CATH FOLEY 3-W 18FR 30CC DYND11573 48711864_1 CDM 0274 RC inpatient 40 26 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.22 38.8 CATH FOLEY 3-W 18FR 30CC DYND11573 48711864_1 CDM 0274 RC inpatient 40 26 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.22 38.8 CATH FOLEY 3-W 18FR 30CC DYND11573 48711864_1 CDM 0274 RC inpatient 40 26 ANTHEM HMO ANTHEM HMO 999999999 24.22 38.8 CATH FOLEY 3-W 18FR 30CC DYND11573 48711864_1 CDM 0274 RC inpatient 40 26 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.22 38.8 CATH FOLEY 3-W 18FR 30CC DYND11573 48711864_1 CDM 0274 RC inpatient 40 26 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.04 67.6 999999999 24.22 38.8 percent of total billed charges CATH FOLEY 3-W 18FR 30CC DYND11573 48711864_1 CDM 0274 RC inpatient 40 26 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.22 38.8 CATH 3-WAY 30CC 22FR 8887665225 48711865_1 CDM 0272 RC inpatient 155 100.75 AETNA AETNA 122.45 79 999999999 93.85 150.35 percent of total billed charges CATH 3-WAY 30CC 22FR 8887665225 48711865_1 CDM 0272 RC inpatient 155 100.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.75 65 999999999 93.85 150.35 percent of total billed charges CATH 3-WAY 30CC 22FR 8887665225 48711865_1 CDM 0272 RC inpatient 155 100.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.95 69 999999999 93.85 150.35 percent of total billed charges CATH 3-WAY 30CC 22FR 8887665225 48711865_1 CDM 0272 RC inpatient 155 100.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 150.35 97 999999999 93.85 150.35 percent of total billed charges CATH 3-WAY 30CC 22FR 8887665225 48711865_1 CDM 0272 RC inpatient 155 100.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.9 78 999999999 93.85 150.35 percent of total billed charges CATH 3-WAY 30CC 22FR 8887665225 48711865_1 CDM 0272 RC inpatient 155 100.75 SIHO - ALL PLANS SIHO - ALL PLANS 139.5 90 999999999 93.85 150.35 percent of total billed charges CATH 3-WAY 30CC 22FR 8887665225 48711865_1 CDM 0272 RC inpatient 155 100.75 UMR - ALL PLANS UMR - ALL PLANS 108.5 70 999999999 93.85 150.35 percent of total billed charges CATH 3-WAY 30CC 22FR 8887665225 48711865_1 CDM 0272 RC inpatient 155 100.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.85 60.55 999999999 93.85 150.35 percent of total billed charges CATH 3-WAY 30CC 22FR 8887665225 48711865_1 CDM 0272 RC inpatient 155 100.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.85 150.35 CATH 3-WAY 30CC 22FR 8887665225 48711865_1 CDM 0272 RC inpatient 155 100.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.85 150.35 CATH 3-WAY 30CC 22FR 8887665225 48711865_1 CDM 0272 RC inpatient 155 100.75 ANTHEM HMO ANTHEM HMO 999999999 93.85 150.35 CATH 3-WAY 30CC 22FR 8887665225 48711865_1 CDM 0272 RC inpatient 155 100.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.85 150.35 CATH 3-WAY 30CC 22FR 8887665225 48711865_1 CDM 0272 RC inpatient 155 100.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.78 67.6 999999999 93.85 150.35 percent of total billed charges CATH 3-WAY 30CC 22FR 8887665225 48711865_1 CDM 0272 RC inpatient 155 100.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.85 150.35 CATH FOLEY 3-W 24FR 30CC 48711866_1 CDM 0274 RC inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges CATH FOLEY 3-W 24FR 30CC 48711866_1 CDM 0274 RC inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges CATH FOLEY 3-W 24FR 30CC 48711866_1 CDM 0274 RC inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges CATH FOLEY 3-W 24FR 30CC 48711866_1 CDM 0274 RC inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges CATH FOLEY 3-W 24FR 30CC 48711866_1 CDM 0274 RC inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges CATH FOLEY 3-W 24FR 30CC 48711866_1 CDM 0274 RC inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges CATH FOLEY 3-W 24FR 30CC 48711866_1 CDM 0274 RC inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges CATH FOLEY 3-W 24FR 30CC 48711866_1 CDM 0274 RC inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges CATH FOLEY 3-W 24FR 30CC 48711866_1 CDM 0274 RC inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 CATH FOLEY 3-W 24FR 30CC 48711866_1 CDM 0274 RC inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 CATH FOLEY 3-W 24FR 30CC 48711866_1 CDM 0274 RC inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 CATH FOLEY 3-W 24FR 30CC 48711866_1 CDM 0274 RC inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 CATH FOLEY 3-W 24FR 30CC 48711866_1 CDM 0274 RC inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges CATH FOLEY 3-W 24FR 30CC 48711866_1 CDM 0274 RC inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 CEMENT PALACOS R&G 00111314001 48711868_1 CDM 0278 RC inpatient 1727 1122.55 AETNA AETNA 1364.33 79 999999999 1045.7 1675.19 percent of total billed charges CEMENT PALACOS R&G 00111314001 48711868_1 CDM 0278 RC inpatient 1727 1122.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1122.55 65 999999999 1045.7 1675.19 percent of total billed charges CEMENT PALACOS R&G 00111314001 48711868_1 CDM 0278 RC inpatient 1727 1122.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1191.63 69 999999999 1045.7 1675.19 percent of total billed charges CEMENT PALACOS R&G 00111314001 48711868_1 CDM 0278 RC inpatient 1727 1122.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1675.19 97 999999999 1045.7 1675.19 percent of total billed charges CEMENT PALACOS R&G 00111314001 48711868_1 CDM 0278 RC inpatient 1727 1122.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1347.06 78 999999999 1045.7 1675.19 percent of total billed charges CEMENT PALACOS R&G 00111314001 48711868_1 CDM 0278 RC inpatient 1727 1122.55 SIHO - ALL PLANS SIHO - ALL PLANS 1554.3 90 999999999 1045.7 1675.19 percent of total billed charges CEMENT PALACOS R&G 00111314001 48711868_1 CDM 0278 RC inpatient 1727 1122.55 UMR - ALL PLANS UMR - ALL PLANS 1208.9 70 999999999 1045.7 1675.19 percent of total billed charges CEMENT PALACOS R&G 00111314001 48711868_1 CDM 0278 RC inpatient 1727 1122.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1045.7 60.55 999999999 1045.7 1675.19 percent of total billed charges CEMENT PALACOS R&G 00111314001 48711868_1 CDM 0278 RC inpatient 1727 1122.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1045.7 1675.19 CEMENT PALACOS R&G 00111314001 48711868_1 CDM 0278 RC inpatient 1727 1122.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1045.7 1675.19 CEMENT PALACOS R&G 00111314001 48711868_1 CDM 0278 RC inpatient 1727 1122.55 ANTHEM HMO ANTHEM HMO 999999999 1045.7 1675.19 CEMENT PALACOS R&G 00111314001 48711868_1 CDM 0278 RC inpatient 1727 1122.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1045.7 1675.19 CEMENT PALACOS R&G 00111314001 48711868_1 CDM 0278 RC inpatient 1727 1122.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1167.45 67.6 999999999 1045.7 1675.19 percent of total billed charges CEMENT PALACOS R&G 00111314001 48711868_1 CDM 0278 RC inpatient 1727 1122.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1045.7 1675.19 CATH FOLEY 3-WAY 30CC 20FR 48711869_1 CDM 0272 RC inpatient 222 144.3 AETNA AETNA 175.38 79 999999999 134.42 215.34 percent of total billed charges CATH FOLEY 3-WAY 30CC 20FR 48711869_1 CDM 0272 RC inpatient 222 144.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 144.3 65 999999999 134.42 215.34 percent of total billed charges CATH FOLEY 3-WAY 30CC 20FR 48711869_1 CDM 0272 RC inpatient 222 144.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 153.18 69 999999999 134.42 215.34 percent of total billed charges CATH FOLEY 3-WAY 30CC 20FR 48711869_1 CDM 0272 RC inpatient 222 144.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 215.34 97 999999999 134.42 215.34 percent of total billed charges CATH FOLEY 3-WAY 30CC 20FR 48711869_1 CDM 0272 RC inpatient 222 144.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 173.16 78 999999999 134.42 215.34 percent of total billed charges CATH FOLEY 3-WAY 30CC 20FR 48711869_1 CDM 0272 RC inpatient 222 144.3 SIHO - ALL PLANS SIHO - ALL PLANS 199.8 90 999999999 134.42 215.34 percent of total billed charges CATH FOLEY 3-WAY 30CC 20FR 48711869_1 CDM 0272 RC inpatient 222 144.3 UMR - ALL PLANS UMR - ALL PLANS 155.4 70 999999999 134.42 215.34 percent of total billed charges CATH FOLEY 3-WAY 30CC 20FR 48711869_1 CDM 0272 RC inpatient 222 144.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 134.42 60.55 999999999 134.42 215.34 percent of total billed charges CATH FOLEY 3-WAY 30CC 20FR 48711869_1 CDM 0272 RC inpatient 222 144.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 134.42 215.34 CATH FOLEY 3-WAY 30CC 20FR 48711869_1 CDM 0272 RC inpatient 222 144.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 134.42 215.34 CATH FOLEY 3-WAY 30CC 20FR 48711869_1 CDM 0272 RC inpatient 222 144.3 ANTHEM HMO ANTHEM HMO 999999999 134.42 215.34 CATH FOLEY 3-WAY 30CC 20FR 48711869_1 CDM 0272 RC inpatient 222 144.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 134.42 215.34 CATH FOLEY 3-WAY 30CC 20FR 48711869_1 CDM 0272 RC inpatient 222 144.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 150.07 67.6 999999999 134.42 215.34 percent of total billed charges CATH FOLEY 3-WAY 30CC 20FR 48711869_1 CDM 0272 RC inpatient 222 144.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 134.42 215.34 MALECOT CATHETER 18FR 48711870_1 CDM 0272 RC inpatient 125 81.25 AETNA AETNA 98.75 79 999999999 75.69 121.25 percent of total billed charges MALECOT CATHETER 18FR 48711870_1 CDM 0272 RC inpatient 125 81.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.25 65 999999999 75.69 121.25 percent of total billed charges MALECOT CATHETER 18FR 48711870_1 CDM 0272 RC inpatient 125 81.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.25 69 999999999 75.69 121.25 percent of total billed charges MALECOT CATHETER 18FR 48711870_1 CDM 0272 RC inpatient 125 81.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 121.25 97 999999999 75.69 121.25 percent of total billed charges MALECOT CATHETER 18FR 48711870_1 CDM 0272 RC inpatient 125 81.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.5 78 999999999 75.69 121.25 percent of total billed charges MALECOT CATHETER 18FR 48711870_1 CDM 0272 RC inpatient 125 81.25 SIHO - ALL PLANS SIHO - ALL PLANS 112.5 90 999999999 75.69 121.25 percent of total billed charges MALECOT CATHETER 18FR 48711870_1 CDM 0272 RC inpatient 125 81.25 UMR - ALL PLANS UMR - ALL PLANS 87.5 70 999999999 75.69 121.25 percent of total billed charges MALECOT CATHETER 18FR 48711870_1 CDM 0272 RC inpatient 125 81.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.69 60.55 999999999 75.69 121.25 percent of total billed charges MALECOT CATHETER 18FR 48711870_1 CDM 0272 RC inpatient 125 81.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.69 121.25 MALECOT CATHETER 18FR 48711870_1 CDM 0272 RC inpatient 125 81.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.69 121.25 MALECOT CATHETER 18FR 48711870_1 CDM 0272 RC inpatient 125 81.25 ANTHEM HMO ANTHEM HMO 999999999 75.69 121.25 MALECOT CATHETER 18FR 48711870_1 CDM 0272 RC inpatient 125 81.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.69 121.25 MALECOT CATHETER 18FR 48711870_1 CDM 0272 RC inpatient 125 81.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.5 67.6 999999999 75.69 121.25 percent of total billed charges MALECOT CATHETER 18FR 48711870_1 CDM 0272 RC inpatient 125 81.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.69 121.25 MALECOT CATHETER 24FR 48711871_1 CDM 0272 RC inpatient 125 81.25 AETNA AETNA 98.75 79 999999999 75.69 121.25 percent of total billed charges MALECOT CATHETER 24FR 48711871_1 CDM 0272 RC inpatient 125 81.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.25 65 999999999 75.69 121.25 percent of total billed charges MALECOT CATHETER 24FR 48711871_1 CDM 0272 RC inpatient 125 81.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.25 69 999999999 75.69 121.25 percent of total billed charges MALECOT CATHETER 24FR 48711871_1 CDM 0272 RC inpatient 125 81.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 121.25 97 999999999 75.69 121.25 percent of total billed charges MALECOT CATHETER 24FR 48711871_1 CDM 0272 RC inpatient 125 81.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.5 78 999999999 75.69 121.25 percent of total billed charges MALECOT CATHETER 24FR 48711871_1 CDM 0272 RC inpatient 125 81.25 SIHO - ALL PLANS SIHO - ALL PLANS 112.5 90 999999999 75.69 121.25 percent of total billed charges MALECOT CATHETER 24FR 48711871_1 CDM 0272 RC inpatient 125 81.25 UMR - ALL PLANS UMR - ALL PLANS 87.5 70 999999999 75.69 121.25 percent of total billed charges MALECOT CATHETER 24FR 48711871_1 CDM 0272 RC inpatient 125 81.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.69 60.55 999999999 75.69 121.25 percent of total billed charges MALECOT CATHETER 24FR 48711871_1 CDM 0272 RC inpatient 125 81.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.69 121.25 MALECOT CATHETER 24FR 48711871_1 CDM 0272 RC inpatient 125 81.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.69 121.25 MALECOT CATHETER 24FR 48711871_1 CDM 0272 RC inpatient 125 81.25 ANTHEM HMO ANTHEM HMO 999999999 75.69 121.25 MALECOT CATHETER 24FR 48711871_1 CDM 0272 RC inpatient 125 81.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.69 121.25 MALECOT CATHETER 24FR 48711871_1 CDM 0272 RC inpatient 125 81.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.5 67.6 999999999 75.69 121.25 percent of total billed charges MALECOT CATHETER 24FR 48711871_1 CDM 0272 RC inpatient 125 81.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.69 121.25 CATHETER EPUSTAXIS BIVONA 48711875_1 CDM 0272 RC inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges CATHETER EPUSTAXIS BIVONA 48711875_1 CDM 0272 RC inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges CATHETER EPUSTAXIS BIVONA 48711875_1 CDM 0272 RC inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges CATHETER EPUSTAXIS BIVONA 48711875_1 CDM 0272 RC inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges CATHETER EPUSTAXIS BIVONA 48711875_1 CDM 0272 RC inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges CATHETER EPUSTAXIS BIVONA 48711875_1 CDM 0272 RC inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges CATHETER EPUSTAXIS BIVONA 48711875_1 CDM 0272 RC inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges CATHETER EPUSTAXIS BIVONA 48711875_1 CDM 0272 RC inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges CATHETER EPUSTAXIS BIVONA 48711875_1 CDM 0272 RC inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 CATHETER EPUSTAXIS BIVONA 48711875_1 CDM 0272 RC inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 CATHETER EPUSTAXIS BIVONA 48711875_1 CDM 0272 RC inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 CATHETER EPUSTAXIS BIVONA 48711875_1 CDM 0272 RC inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 CATHETER EPUSTAXIS BIVONA 48711875_1 CDM 0272 RC inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges CATHETER EPUSTAXIS BIVONA 48711875_1 CDM 0272 RC inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 CATHETER OPEN END 5FR 020015 48711876_1 CDM 0272 RC inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges CATHETER OPEN END 5FR 020015 48711876_1 CDM 0272 RC inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges CATHETER OPEN END 5FR 020015 48711876_1 CDM 0272 RC inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges CATHETER OPEN END 5FR 020015 48711876_1 CDM 0272 RC inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges CATHETER OPEN END 5FR 020015 48711876_1 CDM 0272 RC inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges CATHETER OPEN END 5FR 020015 48711876_1 CDM 0272 RC inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges CATHETER OPEN END 5FR 020015 48711876_1 CDM 0272 RC inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges CATHETER OPEN END 5FR 020015 48711876_1 CDM 0272 RC inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges CATHETER OPEN END 5FR 020015 48711876_1 CDM 0272 RC inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 CATHETER OPEN END 5FR 020015 48711876_1 CDM 0272 RC inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 CATHETER OPEN END 5FR 020015 48711876_1 CDM 0272 RC inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 CATHETER OPEN END 5FR 020015 48711876_1 CDM 0272 RC inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 CATHETER OPEN END 5FR 020015 48711876_1 CDM 0272 RC inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges CATHETER OPEN END 5FR 020015 48711876_1 CDM 0272 RC inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 TROCAR SLEEVE 12MM 48711879_1 CDM 0272 RC inpatient 134 87.1 AETNA AETNA 105.86 79 999999999 81.14 129.98 percent of total billed charges TROCAR SLEEVE 12MM 48711879_1 CDM 0272 RC inpatient 134 87.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 87.1 65 999999999 81.14 129.98 percent of total billed charges TROCAR SLEEVE 12MM 48711879_1 CDM 0272 RC inpatient 134 87.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 92.46 69 999999999 81.14 129.98 percent of total billed charges TROCAR SLEEVE 12MM 48711879_1 CDM 0272 RC inpatient 134 87.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.98 97 999999999 81.14 129.98 percent of total billed charges TROCAR SLEEVE 12MM 48711879_1 CDM 0272 RC inpatient 134 87.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 104.52 78 999999999 81.14 129.98 percent of total billed charges TROCAR SLEEVE 12MM 48711879_1 CDM 0272 RC inpatient 134 87.1 SIHO - ALL PLANS SIHO - ALL PLANS 120.6 90 999999999 81.14 129.98 percent of total billed charges TROCAR SLEEVE 12MM 48711879_1 CDM 0272 RC inpatient 134 87.1 UMR - ALL PLANS UMR - ALL PLANS 93.8 70 999999999 81.14 129.98 percent of total billed charges TROCAR SLEEVE 12MM 48711879_1 CDM 0272 RC inpatient 134 87.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 81.14 60.55 999999999 81.14 129.98 percent of total billed charges TROCAR SLEEVE 12MM 48711879_1 CDM 0272 RC inpatient 134 87.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 81.14 129.98 TROCAR SLEEVE 12MM 48711879_1 CDM 0272 RC inpatient 134 87.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 81.14 129.98 TROCAR SLEEVE 12MM 48711879_1 CDM 0272 RC inpatient 134 87.1 ANTHEM HMO ANTHEM HMO 999999999 81.14 129.98 TROCAR SLEEVE 12MM 48711879_1 CDM 0272 RC inpatient 134 87.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 81.14 129.98 TROCAR SLEEVE 12MM 48711879_1 CDM 0272 RC inpatient 134 87.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 90.58 67.6 999999999 81.14 129.98 percent of total billed charges TROCAR SLEEVE 12MM 48711879_1 CDM 0272 RC inpatient 134 87.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 81.14 129.98 TROCAR SLEEVE 12MM 179303 48711881_1 CDM 0272 RC inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges TROCAR SLEEVE 12MM 179303 48711881_1 CDM 0272 RC inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges TROCAR SLEEVE 12MM 179303 48711881_1 CDM 0272 RC inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges TROCAR SLEEVE 12MM 179303 48711881_1 CDM 0272 RC inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges TROCAR SLEEVE 12MM 179303 48711881_1 CDM 0272 RC inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges TROCAR SLEEVE 12MM 179303 48711881_1 CDM 0272 RC inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges TROCAR SLEEVE 12MM 179303 48711881_1 CDM 0272 RC inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges TROCAR SLEEVE 12MM 179303 48711881_1 CDM 0272 RC inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges TROCAR SLEEVE 12MM 179303 48711881_1 CDM 0272 RC inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 TROCAR SLEEVE 12MM 179303 48711881_1 CDM 0272 RC inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 TROCAR SLEEVE 12MM 179303 48711881_1 CDM 0272 RC inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 TROCAR SLEEVE 12MM 179303 48711881_1 CDM 0272 RC inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 TROCAR SLEEVE 12MM 179303 48711881_1 CDM 0272 RC inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges TROCAR SLEEVE 12MM 179303 48711881_1 CDM 0272 RC inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 SLEEVE UNIVERSAL 5X100MM UNVCA5STF 48711882_1 CDM 0272 RC inpatient 99 64.35 AETNA AETNA 78.21 79 999999999 59.94 96.03 percent of total billed charges SLEEVE UNIVERSAL 5X100MM UNVCA5STF 48711882_1 CDM 0272 RC inpatient 99 64.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 64.35 65 999999999 59.94 96.03 percent of total billed charges SLEEVE UNIVERSAL 5X100MM UNVCA5STF 48711882_1 CDM 0272 RC inpatient 99 64.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 96.03 97 999999999 59.94 96.03 percent of total billed charges SLEEVE UNIVERSAL 5X100MM UNVCA5STF 48711882_1 CDM 0272 RC inpatient 99 64.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 68.31 69 999999999 59.94 96.03 percent of total billed charges SLEEVE UNIVERSAL 5X100MM UNVCA5STF 48711882_1 CDM 0272 RC inpatient 99 64.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 77.22 78 999999999 59.94 96.03 percent of total billed charges SLEEVE UNIVERSAL 5X100MM UNVCA5STF 48711882_1 CDM 0272 RC inpatient 99 64.35 SIHO - ALL PLANS SIHO - ALL PLANS 89.1 90 999999999 59.94 96.03 percent of total billed charges SLEEVE UNIVERSAL 5X100MM UNVCA5STF 48711882_1 CDM 0272 RC inpatient 99 64.35 UMR - ALL PLANS UMR - ALL PLANS 69.3 70 999999999 59.94 96.03 percent of total billed charges SLEEVE UNIVERSAL 5X100MM UNVCA5STF 48711882_1 CDM 0272 RC inpatient 99 64.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.94 60.55 999999999 59.94 96.03 percent of total billed charges SLEEVE UNIVERSAL 5X100MM UNVCA5STF 48711882_1 CDM 0272 RC inpatient 99 64.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.94 96.03 SLEEVE UNIVERSAL 5X100MM UNVCA5STF 48711882_1 CDM 0272 RC inpatient 99 64.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.94 96.03 SLEEVE UNIVERSAL 5X100MM UNVCA5STF 48711882_1 CDM 0272 RC inpatient 99 64.35 ANTHEM HMO ANTHEM HMO 999999999 59.94 96.03 SLEEVE UNIVERSAL 5X100MM UNVCA5STF 48711882_1 CDM 0272 RC inpatient 99 64.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.94 96.03 SLEEVE UNIVERSAL 5X100MM UNVCA5STF 48711882_1 CDM 0272 RC inpatient 99 64.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.92 67.6 999999999 59.94 96.03 percent of total billed charges SLEEVE UNIVERSAL 5X100MM UNVCA5STF 48711882_1 CDM 0272 RC inpatient 99 64.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.94 96.03 TROCAR BLADELESS 5X100MM ONB5STF 48711883_1 CDM 0272 RC inpatient 227 147.55 AETNA AETNA 179.33 79 999999999 137.45 220.19 percent of total billed charges TROCAR BLADELESS 5X100MM ONB5STF 48711883_1 CDM 0272 RC inpatient 227 147.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 147.55 65 999999999 137.45 220.19 percent of total billed charges TROCAR BLADELESS 5X100MM ONB5STF 48711883_1 CDM 0272 RC inpatient 227 147.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 220.19 97 999999999 137.45 220.19 percent of total billed charges TROCAR BLADELESS 5X100MM ONB5STF 48711883_1 CDM 0272 RC inpatient 227 147.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 156.63 69 999999999 137.45 220.19 percent of total billed charges TROCAR BLADELESS 5X100MM ONB5STF 48711883_1 CDM 0272 RC inpatient 227 147.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 177.06 78 999999999 137.45 220.19 percent of total billed charges TROCAR BLADELESS 5X100MM ONB5STF 48711883_1 CDM 0272 RC inpatient 227 147.55 SIHO - ALL PLANS SIHO - ALL PLANS 204.3 90 999999999 137.45 220.19 percent of total billed charges TROCAR BLADELESS 5X100MM ONB5STF 48711883_1 CDM 0272 RC inpatient 227 147.55 UMR - ALL PLANS UMR - ALL PLANS 158.9 70 999999999 137.45 220.19 percent of total billed charges TROCAR BLADELESS 5X100MM ONB5STF 48711883_1 CDM 0272 RC inpatient 227 147.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 137.45 60.55 999999999 137.45 220.19 percent of total billed charges TROCAR BLADELESS 5X100MM ONB5STF 48711883_1 CDM 0272 RC inpatient 227 147.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 137.45 220.19 TROCAR BLADELESS 5X100MM ONB5STF 48711883_1 CDM 0272 RC inpatient 227 147.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 137.45 220.19 TROCAR BLADELESS 5X100MM ONB5STF 48711883_1 CDM 0272 RC inpatient 227 147.55 ANTHEM HMO ANTHEM HMO 999999999 137.45 220.19 TROCAR BLADELESS 5X100MM ONB5STF 48711883_1 CDM 0272 RC inpatient 227 147.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 137.45 220.19 TROCAR BLADELESS 5X100MM ONB5STF 48711883_1 CDM 0272 RC inpatient 227 147.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 153.45 67.6 999999999 137.45 220.19 percent of total billed charges TROCAR BLADELESS 5X100MM ONB5STF 48711883_1 CDM 0272 RC inpatient 227 147.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 137.45 220.19 SLEEVE UNIVERSAL 12X100MM 48711884_1 CDM 0272 RC inpatient 107 69.55 AETNA AETNA 84.53 79 999999999 64.79 103.79 percent of total billed charges SLEEVE UNIVERSAL 12X100MM 48711884_1 CDM 0272 RC inpatient 107 69.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 69.55 65 999999999 64.79 103.79 percent of total billed charges SLEEVE UNIVERSAL 12X100MM 48711884_1 CDM 0272 RC inpatient 107 69.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 103.79 97 999999999 64.79 103.79 percent of total billed charges SLEEVE UNIVERSAL 12X100MM 48711884_1 CDM 0272 RC inpatient 107 69.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.83 69 999999999 64.79 103.79 percent of total billed charges SLEEVE UNIVERSAL 12X100MM 48711884_1 CDM 0272 RC inpatient 107 69.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 83.46 78 999999999 64.79 103.79 percent of total billed charges SLEEVE UNIVERSAL 12X100MM 48711884_1 CDM 0272 RC inpatient 107 69.55 SIHO - ALL PLANS SIHO - ALL PLANS 96.3 90 999999999 64.79 103.79 percent of total billed charges SLEEVE UNIVERSAL 12X100MM 48711884_1 CDM 0272 RC inpatient 107 69.55 UMR - ALL PLANS UMR - ALL PLANS 74.9 70 999999999 64.79 103.79 percent of total billed charges SLEEVE UNIVERSAL 12X100MM 48711884_1 CDM 0272 RC inpatient 107 69.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.79 60.55 999999999 64.79 103.79 percent of total billed charges SLEEVE UNIVERSAL 12X100MM 48711884_1 CDM 0272 RC inpatient 107 69.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.79 103.79 SLEEVE UNIVERSAL 12X100MM 48711884_1 CDM 0272 RC inpatient 107 69.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.79 103.79 SLEEVE UNIVERSAL 12X100MM 48711884_1 CDM 0272 RC inpatient 107 69.55 ANTHEM HMO ANTHEM HMO 999999999 64.79 103.79 SLEEVE UNIVERSAL 12X100MM 48711884_1 CDM 0272 RC inpatient 107 69.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.79 103.79 SLEEVE UNIVERSAL 12X100MM 48711884_1 CDM 0272 RC inpatient 107 69.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 72.33 67.6 999999999 64.79 103.79 percent of total billed charges SLEEVE UNIVERSAL 12X100MM 48711884_1 CDM 0272 RC inpatient 107 69.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.79 103.79 TROCAR DILATING TIP 12MM 48711886_1 CDM 0272 RC inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges TROCAR DILATING TIP 12MM 48711886_1 CDM 0272 RC inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges TROCAR DILATING TIP 12MM 48711886_1 CDM 0272 RC inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges TROCAR DILATING TIP 12MM 48711886_1 CDM 0272 RC inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges TROCAR DILATING TIP 12MM 48711886_1 CDM 0272 RC inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges TROCAR DILATING TIP 12MM 48711886_1 CDM 0272 RC inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges TROCAR DILATING TIP 12MM 48711886_1 CDM 0272 RC inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges TROCAR DILATING TIP 12MM 48711886_1 CDM 0272 RC inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges TROCAR DILATING TIP 12MM 48711886_1 CDM 0272 RC inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 TROCAR DILATING TIP 12MM 48711886_1 CDM 0272 RC inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 TROCAR DILATING TIP 12MM 48711886_1 CDM 0272 RC inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 TROCAR DILATING TIP 12MM 48711886_1 CDM 0272 RC inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 TROCAR DILATING TIP 12MM 48711886_1 CDM 0272 RC inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges TROCAR DILATING TIP 12MM 48711886_1 CDM 0272 RC inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 TROCAR BLADELESS 12X100MM - ONB12STF 48711887_1 CDM 0272 RC inpatient 276 179.4 AETNA AETNA 218.04 79 999999999 167.12 267.72 percent of total billed charges TROCAR BLADELESS 12X100MM - ONB12STF 48711887_1 CDM 0272 RC inpatient 276 179.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 179.4 65 999999999 167.12 267.72 percent of total billed charges TROCAR BLADELESS 12X100MM - ONB12STF 48711887_1 CDM 0272 RC inpatient 276 179.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 267.72 97 999999999 167.12 267.72 percent of total billed charges TROCAR BLADELESS 12X100MM - ONB12STF 48711887_1 CDM 0272 RC inpatient 276 179.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 190.44 69 999999999 167.12 267.72 percent of total billed charges TROCAR BLADELESS 12X100MM - ONB12STF 48711887_1 CDM 0272 RC inpatient 276 179.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 215.28 78 999999999 167.12 267.72 percent of total billed charges TROCAR BLADELESS 12X100MM - ONB12STF 48711887_1 CDM 0272 RC inpatient 276 179.4 SIHO - ALL PLANS SIHO - ALL PLANS 248.4 90 999999999 167.12 267.72 percent of total billed charges TROCAR BLADELESS 12X100MM - ONB12STF 48711887_1 CDM 0272 RC inpatient 276 179.4 UMR - ALL PLANS UMR - ALL PLANS 193.2 70 999999999 167.12 267.72 percent of total billed charges TROCAR BLADELESS 12X100MM - ONB12STF 48711887_1 CDM 0272 RC inpatient 276 179.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 167.12 60.55 999999999 167.12 267.72 percent of total billed charges TROCAR BLADELESS 12X100MM - ONB12STF 48711887_1 CDM 0272 RC inpatient 276 179.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 167.12 267.72 TROCAR BLADELESS 12X100MM - ONB12STF 48711887_1 CDM 0272 RC inpatient 276 179.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 167.12 267.72 TROCAR BLADELESS 12X100MM - ONB12STF 48711887_1 CDM 0272 RC inpatient 276 179.4 ANTHEM HMO ANTHEM HMO 999999999 167.12 267.72 TROCAR BLADELESS 12X100MM - ONB12STF 48711887_1 CDM 0272 RC inpatient 276 179.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 167.12 267.72 TROCAR BLADELESS 12X100MM - ONB12STF 48711887_1 CDM 0272 RC inpatient 276 179.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 186.58 67.6 999999999 167.12 267.72 percent of total billed charges TROCAR BLADELESS 12X100MM - ONB12STF 48711887_1 CDM 0272 RC inpatient 276 179.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 167.12 267.72 TROCAR DILATING 12X150MM 48711888_1 CDM 0272 RC inpatient 286 185.9 AETNA AETNA 225.94 79 999999999 173.17 277.42 percent of total billed charges TROCAR DILATING 12X150MM 48711888_1 CDM 0272 RC inpatient 286 185.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.9 65 999999999 173.17 277.42 percent of total billed charges TROCAR DILATING 12X150MM 48711888_1 CDM 0272 RC inpatient 286 185.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 277.42 97 999999999 173.17 277.42 percent of total billed charges TROCAR DILATING 12X150MM 48711888_1 CDM 0272 RC inpatient 286 185.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 197.34 69 999999999 173.17 277.42 percent of total billed charges TROCAR DILATING 12X150MM 48711888_1 CDM 0272 RC inpatient 286 185.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 223.08 78 999999999 173.17 277.42 percent of total billed charges TROCAR DILATING 12X150MM 48711888_1 CDM 0272 RC inpatient 286 185.9 SIHO - ALL PLANS SIHO - ALL PLANS 257.4 90 999999999 173.17 277.42 percent of total billed charges TROCAR DILATING 12X150MM 48711888_1 CDM 0272 RC inpatient 286 185.9 UMR - ALL PLANS UMR - ALL PLANS 200.2 70 999999999 173.17 277.42 percent of total billed charges TROCAR DILATING 12X150MM 48711888_1 CDM 0272 RC inpatient 286 185.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 173.17 60.55 999999999 173.17 277.42 percent of total billed charges TROCAR DILATING 12X150MM 48711888_1 CDM 0272 RC inpatient 286 185.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 173.17 277.42 TROCAR DILATING 12X150MM 48711888_1 CDM 0272 RC inpatient 286 185.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 173.17 277.42 TROCAR DILATING 12X150MM 48711888_1 CDM 0272 RC inpatient 286 185.9 ANTHEM HMO ANTHEM HMO 999999999 173.17 277.42 TROCAR DILATING 12X150MM 48711888_1 CDM 0272 RC inpatient 286 185.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 173.17 277.42 TROCAR DILATING 12X150MM 48711888_1 CDM 0272 RC inpatient 286 185.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 193.34 67.6 999999999 173.17 277.42 percent of total billed charges TROCAR DILATING 12X150MM 48711888_1 CDM 0272 RC inpatient 286 185.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 173.17 277.42 CLIP APPLIER FOR OPEN CASES 48711889_1 CDM 0272 RC inpatient 444 288.6 AETNA AETNA 350.76 79 999999999 268.84 430.68 percent of total billed charges CLIP APPLIER FOR OPEN CASES 48711889_1 CDM 0272 RC inpatient 444 288.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 288.6 65 999999999 268.84 430.68 percent of total billed charges CLIP APPLIER FOR OPEN CASES 48711889_1 CDM 0272 RC inpatient 444 288.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 430.68 97 999999999 268.84 430.68 percent of total billed charges CLIP APPLIER FOR OPEN CASES 48711889_1 CDM 0272 RC inpatient 444 288.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 306.36 69 999999999 268.84 430.68 percent of total billed charges CLIP APPLIER FOR OPEN CASES 48711889_1 CDM 0272 RC inpatient 444 288.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 346.32 78 999999999 268.84 430.68 percent of total billed charges CLIP APPLIER FOR OPEN CASES 48711889_1 CDM 0272 RC inpatient 444 288.6 SIHO - ALL PLANS SIHO - ALL PLANS 399.6 90 999999999 268.84 430.68 percent of total billed charges CLIP APPLIER FOR OPEN CASES 48711889_1 CDM 0272 RC inpatient 444 288.6 UMR - ALL PLANS UMR - ALL PLANS 310.8 70 999999999 268.84 430.68 percent of total billed charges CLIP APPLIER FOR OPEN CASES 48711889_1 CDM 0272 RC inpatient 444 288.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 268.84 60.55 999999999 268.84 430.68 percent of total billed charges CLIP APPLIER FOR OPEN CASES 48711889_1 CDM 0272 RC inpatient 444 288.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 268.84 430.68 CLIP APPLIER FOR OPEN CASES 48711889_1 CDM 0272 RC inpatient 444 288.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 268.84 430.68 CLIP APPLIER FOR OPEN CASES 48711889_1 CDM 0272 RC inpatient 444 288.6 ANTHEM HMO ANTHEM HMO 999999999 268.84 430.68 CLIP APPLIER FOR OPEN CASES 48711889_1 CDM 0272 RC inpatient 444 288.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 268.84 430.68 CLIP APPLIER FOR OPEN CASES 48711889_1 CDM 0272 RC inpatient 444 288.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 300.14 67.6 999999999 268.84 430.68 percent of total billed charges CLIP APPLIER FOR OPEN CASES 48711889_1 CDM 0272 RC inpatient 444 288.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 268.84 430.68 5MM BLUNT TIP DISSECTORS 48711890_1 CDM 0272 RC inpatient 154 100.1 AETNA AETNA 121.66 79 999999999 93.25 149.38 percent of total billed charges 5MM BLUNT TIP DISSECTORS 48711890_1 CDM 0272 RC inpatient 154 100.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.1 65 999999999 93.25 149.38 percent of total billed charges 5MM BLUNT TIP DISSECTORS 48711890_1 CDM 0272 RC inpatient 154 100.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 149.38 97 999999999 93.25 149.38 percent of total billed charges 5MM BLUNT TIP DISSECTORS 48711890_1 CDM 0272 RC inpatient 154 100.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.26 69 999999999 93.25 149.38 percent of total billed charges 5MM BLUNT TIP DISSECTORS 48711890_1 CDM 0272 RC inpatient 154 100.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.12 78 999999999 93.25 149.38 percent of total billed charges 5MM BLUNT TIP DISSECTORS 48711890_1 CDM 0272 RC inpatient 154 100.1 SIHO - ALL PLANS SIHO - ALL PLANS 138.6 90 999999999 93.25 149.38 percent of total billed charges 5MM BLUNT TIP DISSECTORS 48711890_1 CDM 0272 RC inpatient 154 100.1 UMR - ALL PLANS UMR - ALL PLANS 107.8 70 999999999 93.25 149.38 percent of total billed charges 5MM BLUNT TIP DISSECTORS 48711890_1 CDM 0272 RC inpatient 154 100.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.25 60.55 999999999 93.25 149.38 percent of total billed charges 5MM BLUNT TIP DISSECTORS 48711890_1 CDM 0272 RC inpatient 154 100.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.25 149.38 5MM BLUNT TIP DISSECTORS 48711890_1 CDM 0272 RC inpatient 154 100.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.25 149.38 5MM BLUNT TIP DISSECTORS 48711890_1 CDM 0272 RC inpatient 154 100.1 ANTHEM HMO ANTHEM HMO 999999999 93.25 149.38 5MM BLUNT TIP DISSECTORS 48711890_1 CDM 0272 RC inpatient 154 100.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.25 149.38 5MM BLUNT TIP DISSECTORS 48711890_1 CDM 0272 RC inpatient 154 100.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.1 67.6 999999999 93.25 149.38 percent of total billed charges 5MM BLUNT TIP DISSECTORS 48711890_1 CDM 0272 RC inpatient 154 100.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.25 149.38 DEFIB PAD RADIOLUCENT ADULT 48711894_1 CDM 0272 RC inpatient 769 499.85 AETNA AETNA 607.51 79 999999999 465.63 745.93 percent of total billed charges DEFIB PAD RADIOLUCENT ADULT 48711894_1 CDM 0272 RC inpatient 769 499.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 499.85 65 999999999 465.63 745.93 percent of total billed charges DEFIB PAD RADIOLUCENT ADULT 48711894_1 CDM 0272 RC inpatient 769 499.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 745.93 97 999999999 465.63 745.93 percent of total billed charges DEFIB PAD RADIOLUCENT ADULT 48711894_1 CDM 0272 RC inpatient 769 499.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 530.61 69 999999999 465.63 745.93 percent of total billed charges DEFIB PAD RADIOLUCENT ADULT 48711894_1 CDM 0272 RC inpatient 769 499.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 599.82 78 999999999 465.63 745.93 percent of total billed charges DEFIB PAD RADIOLUCENT ADULT 48711894_1 CDM 0272 RC inpatient 769 499.85 SIHO - ALL PLANS SIHO - ALL PLANS 692.1 90 999999999 465.63 745.93 percent of total billed charges DEFIB PAD RADIOLUCENT ADULT 48711894_1 CDM 0272 RC inpatient 769 499.85 UMR - ALL PLANS UMR - ALL PLANS 538.3 70 999999999 465.63 745.93 percent of total billed charges DEFIB PAD RADIOLUCENT ADULT 48711894_1 CDM 0272 RC inpatient 769 499.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 465.63 60.55 999999999 465.63 745.93 percent of total billed charges DEFIB PAD RADIOLUCENT ADULT 48711894_1 CDM 0272 RC inpatient 769 499.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 465.63 745.93 DEFIB PAD RADIOLUCENT ADULT 48711894_1 CDM 0272 RC inpatient 769 499.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 465.63 745.93 DEFIB PAD RADIOLUCENT ADULT 48711894_1 CDM 0272 RC inpatient 769 499.85 ANTHEM HMO ANTHEM HMO 999999999 465.63 745.93 DEFIB PAD RADIOLUCENT ADULT 48711894_1 CDM 0272 RC inpatient 769 499.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 465.63 745.93 DEFIB PAD RADIOLUCENT ADULT 48711894_1 CDM 0272 RC inpatient 769 499.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 519.84 67.6 999999999 465.63 745.93 percent of total billed charges DEFIB PAD RADIOLUCENT ADULT 48711894_1 CDM 0272 RC inpatient 769 499.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 465.63 745.93 ARTERIAL CATH KIT AK04020 48711895_1 CDM 0272 RC inpatient 159 103.35 AETNA AETNA 125.61 79 999999999 96.27 154.23 percent of total billed charges ARTERIAL CATH KIT AK04020 48711895_1 CDM 0272 RC inpatient 159 103.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 103.35 65 999999999 96.27 154.23 percent of total billed charges ARTERIAL CATH KIT AK04020 48711895_1 CDM 0272 RC inpatient 159 103.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 154.23 97 999999999 96.27 154.23 percent of total billed charges ARTERIAL CATH KIT AK04020 48711895_1 CDM 0272 RC inpatient 159 103.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 109.71 69 999999999 96.27 154.23 percent of total billed charges ARTERIAL CATH KIT AK04020 48711895_1 CDM 0272 RC inpatient 159 103.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 124.02 78 999999999 96.27 154.23 percent of total billed charges ARTERIAL CATH KIT AK04020 48711895_1 CDM 0272 RC inpatient 159 103.35 SIHO - ALL PLANS SIHO - ALL PLANS 143.1 90 999999999 96.27 154.23 percent of total billed charges ARTERIAL CATH KIT AK04020 48711895_1 CDM 0272 RC inpatient 159 103.35 UMR - ALL PLANS UMR - ALL PLANS 111.3 70 999999999 96.27 154.23 percent of total billed charges ARTERIAL CATH KIT AK04020 48711895_1 CDM 0272 RC inpatient 159 103.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 96.27 60.55 999999999 96.27 154.23 percent of total billed charges ARTERIAL CATH KIT AK04020 48711895_1 CDM 0272 RC inpatient 159 103.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 96.27 154.23 ARTERIAL CATH KIT AK04020 48711895_1 CDM 0272 RC inpatient 159 103.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 96.27 154.23 ARTERIAL CATH KIT AK04020 48711895_1 CDM 0272 RC inpatient 159 103.35 ANTHEM HMO ANTHEM HMO 999999999 96.27 154.23 ARTERIAL CATH KIT AK04020 48711895_1 CDM 0272 RC inpatient 159 103.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 96.27 154.23 ARTERIAL CATH KIT AK04020 48711895_1 CDM 0272 RC inpatient 159 103.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 107.48 67.6 999999999 96.27 154.23 percent of total billed charges ARTERIAL CATH KIT AK04020 48711895_1 CDM 0272 RC inpatient 159 103.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 96.27 154.23 TRAY FOLEY 16FR DYND11523 48711898_1 CDM 0272 RC inpatient 44 28.6 AETNA AETNA 34.76 79 999999999 26.64 42.68 percent of total billed charges TRAY FOLEY 16FR DYND11523 48711898_1 CDM 0272 RC inpatient 44 28.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 28.6 65 999999999 26.64 42.68 percent of total billed charges TRAY FOLEY 16FR DYND11523 48711898_1 CDM 0272 RC inpatient 44 28.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 42.68 97 999999999 26.64 42.68 percent of total billed charges TRAY FOLEY 16FR DYND11523 48711898_1 CDM 0272 RC inpatient 44 28.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 30.36 69 999999999 26.64 42.68 percent of total billed charges TRAY FOLEY 16FR DYND11523 48711898_1 CDM 0272 RC inpatient 44 28.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 34.32 78 999999999 26.64 42.68 percent of total billed charges TRAY FOLEY 16FR DYND11523 48711898_1 CDM 0272 RC inpatient 44 28.6 SIHO - ALL PLANS SIHO - ALL PLANS 39.6 90 999999999 26.64 42.68 percent of total billed charges TRAY FOLEY 16FR DYND11523 48711898_1 CDM 0272 RC inpatient 44 28.6 UMR - ALL PLANS UMR - ALL PLANS 30.8 70 999999999 26.64 42.68 percent of total billed charges TRAY FOLEY 16FR DYND11523 48711898_1 CDM 0272 RC inpatient 44 28.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26.64 60.55 999999999 26.64 42.68 percent of total billed charges TRAY FOLEY 16FR DYND11523 48711898_1 CDM 0272 RC inpatient 44 28.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26.64 42.68 TRAY FOLEY 16FR DYND11523 48711898_1 CDM 0272 RC inpatient 44 28.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26.64 42.68 TRAY FOLEY 16FR DYND11523 48711898_1 CDM 0272 RC inpatient 44 28.6 ANTHEM HMO ANTHEM HMO 999999999 26.64 42.68 TRAY FOLEY 16FR DYND11523 48711898_1 CDM 0272 RC inpatient 44 28.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26.64 42.68 TRAY FOLEY 16FR DYND11523 48711898_1 CDM 0272 RC inpatient 44 28.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 29.74 67.6 999999999 26.64 42.68 percent of total billed charges TRAY FOLEY 16FR DYND11523 48711898_1 CDM 0272 RC inpatient 44 28.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 26.64 42.68 CATHETER THORACIC TROCAR 12FR 8888561027 48711901_1 CDM 0272 RC inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges CATHETER THORACIC TROCAR 12FR 8888561027 48711901_1 CDM 0272 RC inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges CATHETER THORACIC TROCAR 12FR 8888561027 48711901_1 CDM 0272 RC inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges CATHETER THORACIC TROCAR 12FR 8888561027 48711901_1 CDM 0272 RC inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges CATHETER THORACIC TROCAR 12FR 8888561027 48711901_1 CDM 0272 RC inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges CATHETER THORACIC TROCAR 12FR 8888561027 48711901_1 CDM 0272 RC inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges CATHETER THORACIC TROCAR 12FR 8888561027 48711901_1 CDM 0272 RC inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges CATHETER THORACIC TROCAR 12FR 8888561027 48711901_1 CDM 0272 RC inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges CATHETER THORACIC TROCAR 12FR 8888561027 48711901_1 CDM 0272 RC inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 CATHETER THORACIC TROCAR 12FR 8888561027 48711901_1 CDM 0272 RC inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 CATHETER THORACIC TROCAR 12FR 8888561027 48711901_1 CDM 0272 RC inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 CATHETER THORACIC TROCAR 12FR 8888561027 48711901_1 CDM 0272 RC inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 CATHETER THORACIC TROCAR 12FR 8888561027 48711901_1 CDM 0272 RC inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges CATHETER THORACIC TROCAR 12FR 8888561027 48711901_1 CDM 0272 RC inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 CATHETER TROCAR 20FR 8888561043 48711902_1 CDM 0272 RC inpatient 108 70.2 AETNA AETNA 85.32 79 999999999 65.39 104.76 percent of total billed charges CATHETER TROCAR 20FR 8888561043 48711902_1 CDM 0272 RC inpatient 108 70.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.2 65 999999999 65.39 104.76 percent of total billed charges CATHETER TROCAR 20FR 8888561043 48711902_1 CDM 0272 RC inpatient 108 70.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 104.76 97 999999999 65.39 104.76 percent of total billed charges CATHETER TROCAR 20FR 8888561043 48711902_1 CDM 0272 RC inpatient 108 70.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 74.52 69 999999999 65.39 104.76 percent of total billed charges CATHETER TROCAR 20FR 8888561043 48711902_1 CDM 0272 RC inpatient 108 70.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 84.24 78 999999999 65.39 104.76 percent of total billed charges CATHETER TROCAR 20FR 8888561043 48711902_1 CDM 0272 RC inpatient 108 70.2 SIHO - ALL PLANS SIHO - ALL PLANS 97.2 90 999999999 65.39 104.76 percent of total billed charges CATHETER TROCAR 20FR 8888561043 48711902_1 CDM 0272 RC inpatient 108 70.2 UMR - ALL PLANS UMR - ALL PLANS 75.6 70 999999999 65.39 104.76 percent of total billed charges CATHETER TROCAR 20FR 8888561043 48711902_1 CDM 0272 RC inpatient 108 70.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 65.39 60.55 999999999 65.39 104.76 percent of total billed charges CATHETER TROCAR 20FR 8888561043 48711902_1 CDM 0272 RC inpatient 108 70.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 65.39 104.76 CATHETER TROCAR 20FR 8888561043 48711902_1 CDM 0272 RC inpatient 108 70.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 65.39 104.76 CATHETER TROCAR 20FR 8888561043 48711902_1 CDM 0272 RC inpatient 108 70.2 ANTHEM HMO ANTHEM HMO 999999999 65.39 104.76 CATHETER TROCAR 20FR 8888561043 48711902_1 CDM 0272 RC inpatient 108 70.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 65.39 104.76 CATHETER TROCAR 20FR 8888561043 48711902_1 CDM 0272 RC inpatient 108 70.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.01 67.6 999999999 65.39 104.76 percent of total billed charges CATHETER TROCAR 20FR 8888561043 48711902_1 CDM 0272 RC inpatient 108 70.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 65.39 104.76 CATHETER TROCAR 24FR 8888561050 48711903_1 CDM 0272 RC inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges CATHETER TROCAR 24FR 8888561050 48711903_1 CDM 0272 RC inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges CATHETER TROCAR 24FR 8888561050 48711903_1 CDM 0272 RC inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges CATHETER TROCAR 24FR 8888561050 48711903_1 CDM 0272 RC inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges CATHETER TROCAR 24FR 8888561050 48711903_1 CDM 0272 RC inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges CATHETER TROCAR 24FR 8888561050 48711903_1 CDM 0272 RC inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges CATHETER TROCAR 24FR 8888561050 48711903_1 CDM 0272 RC inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges CATHETER TROCAR 24FR 8888561050 48711903_1 CDM 0272 RC inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges CATHETER TROCAR 24FR 8888561050 48711903_1 CDM 0272 RC inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 CATHETER TROCAR 24FR 8888561050 48711903_1 CDM 0272 RC inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 CATHETER TROCAR 24FR 8888561050 48711903_1 CDM 0272 RC inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 CATHETER TROCAR 24FR 8888561050 48711903_1 CDM 0272 RC inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 CATHETER TROCAR 24FR 8888561050 48711903_1 CDM 0272 RC inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges CATHETER TROCAR 24FR 8888561050 48711903_1 CDM 0272 RC inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 CATH TROCAR 28FR 8888561068 48711904_1 CDM 0272 RC inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges CATH TROCAR 28FR 8888561068 48711904_1 CDM 0272 RC inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges CATH TROCAR 28FR 8888561068 48711904_1 CDM 0272 RC inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges CATH TROCAR 28FR 8888561068 48711904_1 CDM 0272 RC inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges CATH TROCAR 28FR 8888561068 48711904_1 CDM 0272 RC inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges CATH TROCAR 28FR 8888561068 48711904_1 CDM 0272 RC inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges CATH TROCAR 28FR 8888561068 48711904_1 CDM 0272 RC inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges CATH TROCAR 28FR 8888561068 48711904_1 CDM 0272 RC inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges CATH TROCAR 28FR 8888561068 48711904_1 CDM 0272 RC inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 CATH TROCAR 28FR 8888561068 48711904_1 CDM 0272 RC inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 CATH TROCAR 28FR 8888561068 48711904_1 CDM 0272 RC inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 CATH TROCAR 28FR 8888561068 48711904_1 CDM 0272 RC inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 CATH TROCAR 28FR 8888561068 48711904_1 CDM 0272 RC inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges CATH TROCAR 28FR 8888561068 48711904_1 CDM 0272 RC inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 CATHETER TROCAR 32FR 8888561076 48711905_1 CDM 0272 RC inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges CATHETER TROCAR 32FR 8888561076 48711905_1 CDM 0272 RC inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges CATHETER TROCAR 32FR 8888561076 48711905_1 CDM 0272 RC inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges CATHETER TROCAR 32FR 8888561076 48711905_1 CDM 0272 RC inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges CATHETER TROCAR 32FR 8888561076 48711905_1 CDM 0272 RC inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges CATHETER TROCAR 32FR 8888561076 48711905_1 CDM 0272 RC inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges CATHETER TROCAR 32FR 8888561076 48711905_1 CDM 0272 RC inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges CATHETER TROCAR 32FR 8888561076 48711905_1 CDM 0272 RC inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges CATHETER TROCAR 32FR 8888561076 48711905_1 CDM 0272 RC inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 CATHETER TROCAR 32FR 8888561076 48711905_1 CDM 0272 RC inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 CATHETER TROCAR 32FR 8888561076 48711905_1 CDM 0272 RC inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 CATHETER TROCAR 32FR 8888561076 48711905_1 CDM 0272 RC inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 CATHETER TROCAR 32FR 8888561076 48711905_1 CDM 0272 RC inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges CATHETER TROCAR 32FR 8888561076 48711905_1 CDM 0272 RC inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 BIOPSY FORCEPS 3FR PIRANHA 48711909_1 CDM 0272 RC inpatient 1897 1233.05 AETNA AETNA 1498.63 79 999999999 1148.63 1840.09 percent of total billed charges BIOPSY FORCEPS 3FR PIRANHA 48711909_1 CDM 0272 RC inpatient 1897 1233.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1233.05 65 999999999 1148.63 1840.09 percent of total billed charges BIOPSY FORCEPS 3FR PIRANHA 48711909_1 CDM 0272 RC inpatient 1897 1233.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1840.09 97 999999999 1148.63 1840.09 percent of total billed charges BIOPSY FORCEPS 3FR PIRANHA 48711909_1 CDM 0272 RC inpatient 1897 1233.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1308.93 69 999999999 1148.63 1840.09 percent of total billed charges BIOPSY FORCEPS 3FR PIRANHA 48711909_1 CDM 0272 RC inpatient 1897 1233.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1479.66 78 999999999 1148.63 1840.09 percent of total billed charges BIOPSY FORCEPS 3FR PIRANHA 48711909_1 CDM 0272 RC inpatient 1897 1233.05 SIHO - ALL PLANS SIHO - ALL PLANS 1707.3 90 999999999 1148.63 1840.09 percent of total billed charges BIOPSY FORCEPS 3FR PIRANHA 48711909_1 CDM 0272 RC inpatient 1897 1233.05 UMR - ALL PLANS UMR - ALL PLANS 1327.9 70 999999999 1148.63 1840.09 percent of total billed charges BIOPSY FORCEPS 3FR PIRANHA 48711909_1 CDM 0272 RC inpatient 1897 1233.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1148.63 60.55 999999999 1148.63 1840.09 percent of total billed charges BIOPSY FORCEPS 3FR PIRANHA 48711909_1 CDM 0272 RC inpatient 1897 1233.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1148.63 1840.09 BIOPSY FORCEPS 3FR PIRANHA 48711909_1 CDM 0272 RC inpatient 1897 1233.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1148.63 1840.09 BIOPSY FORCEPS 3FR PIRANHA 48711909_1 CDM 0272 RC inpatient 1897 1233.05 ANTHEM HMO ANTHEM HMO 999999999 1148.63 1840.09 BIOPSY FORCEPS 3FR PIRANHA 48711909_1 CDM 0272 RC inpatient 1897 1233.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1148.63 1840.09 BIOPSY FORCEPS 3FR PIRANHA 48711909_1 CDM 0272 RC inpatient 1897 1233.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1282.37 67.6 999999999 1148.63 1840.09 percent of total billed charges BIOPSY FORCEPS 3FR PIRANHA 48711909_1 CDM 0272 RC inpatient 1897 1233.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1148.63 1840.09 CATHETER-OPERATIVE 2001-010 48711911_1 CDM 0272 RC inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges CATHETER-OPERATIVE 2001-010 48711911_1 CDM 0272 RC inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges CATHETER-OPERATIVE 2001-010 48711911_1 CDM 0272 RC inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges CATHETER-OPERATIVE 2001-010 48711911_1 CDM 0272 RC inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges CATHETER-OPERATIVE 2001-010 48711911_1 CDM 0272 RC inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges CATHETER-OPERATIVE 2001-010 48711911_1 CDM 0272 RC inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges CATHETER-OPERATIVE 2001-010 48711911_1 CDM 0272 RC inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges CATHETER-OPERATIVE 2001-010 48711911_1 CDM 0272 RC inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges CATHETER-OPERATIVE 2001-010 48711911_1 CDM 0272 RC inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 CATHETER-OPERATIVE 2001-010 48711911_1 CDM 0272 RC inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 CATHETER-OPERATIVE 2001-010 48711911_1 CDM 0272 RC inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 CATHETER-OPERATIVE 2001-010 48711911_1 CDM 0272 RC inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 CATHETER-OPERATIVE 2001-010 48711911_1 CDM 0272 RC inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges CATHETER-OPERATIVE 2001-010 48711911_1 CDM 0272 RC inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 ACTIDOSE AQUA 25 GRAM CHARCOAL 48711917_1 CDM 0272 RC inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges ACTIDOSE AQUA 25 GRAM CHARCOAL 48711917_1 CDM 0272 RC inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges ACTIDOSE AQUA 25 GRAM CHARCOAL 48711917_1 CDM 0272 RC inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges ACTIDOSE AQUA 25 GRAM CHARCOAL 48711917_1 CDM 0272 RC inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges ACTIDOSE AQUA 25 GRAM CHARCOAL 48711917_1 CDM 0272 RC inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges ACTIDOSE AQUA 25 GRAM CHARCOAL 48711917_1 CDM 0272 RC inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges ACTIDOSE AQUA 25 GRAM CHARCOAL 48711917_1 CDM 0272 RC inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges ACTIDOSE AQUA 25 GRAM CHARCOAL 48711917_1 CDM 0272 RC inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges ACTIDOSE AQUA 25 GRAM CHARCOAL 48711917_1 CDM 0272 RC inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 ACTIDOSE AQUA 25 GRAM CHARCOAL 48711917_1 CDM 0272 RC inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 ACTIDOSE AQUA 25 GRAM CHARCOAL 48711917_1 CDM 0272 RC inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 ACTIDOSE AQUA 25 GRAM CHARCOAL 48711917_1 CDM 0272 RC inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 ACTIDOSE AQUA 25 GRAM CHARCOAL 48711917_1 CDM 0272 RC inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges ACTIDOSE AQUA 25 GRAM CHARCOAL 48711917_1 CDM 0272 RC inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 ACKERMANN BONE BIO ST ABC-200 48711918_1 CDM 0621 RC inpatient 2422 1574.3 AETNA AETNA 1913.38 79 999999999 1466.52 2349.34 percent of total billed charges ACKERMANN BONE BIO ST ABC-200 48711918_1 CDM 0621 RC inpatient 2422 1574.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1574.3 65 999999999 1466.52 2349.34 percent of total billed charges ACKERMANN BONE BIO ST ABC-200 48711918_1 CDM 0621 RC inpatient 2422 1574.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2349.34 97 999999999 1466.52 2349.34 percent of total billed charges ACKERMANN BONE BIO ST ABC-200 48711918_1 CDM 0621 RC inpatient 2422 1574.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1671.18 69 999999999 1466.52 2349.34 percent of total billed charges ACKERMANN BONE BIO ST ABC-200 48711918_1 CDM 0621 RC inpatient 2422 1574.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1889.16 78 999999999 1466.52 2349.34 percent of total billed charges ACKERMANN BONE BIO ST ABC-200 48711918_1 CDM 0621 RC inpatient 2422 1574.3 SIHO - ALL PLANS SIHO - ALL PLANS 2179.8 90 999999999 1466.52 2349.34 percent of total billed charges ACKERMANN BONE BIO ST ABC-200 48711918_1 CDM 0621 RC inpatient 2422 1574.3 UMR - ALL PLANS UMR - ALL PLANS 1695.4 70 999999999 1466.52 2349.34 percent of total billed charges ACKERMANN BONE BIO ST ABC-200 48711918_1 CDM 0621 RC inpatient 2422 1574.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1466.52 60.55 999999999 1466.52 2349.34 percent of total billed charges ACKERMANN BONE BIO ST ABC-200 48711918_1 CDM 0621 RC inpatient 2422 1574.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1466.52 2349.34 ACKERMANN BONE BIO ST ABC-200 48711918_1 CDM 0621 RC inpatient 2422 1574.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1466.52 2349.34 ACKERMANN BONE BIO ST ABC-200 48711918_1 CDM 0621 RC inpatient 2422 1574.3 ANTHEM HMO ANTHEM HMO 999999999 1466.52 2349.34 ACKERMANN BONE BIO ST ABC-200 48711918_1 CDM 0621 RC inpatient 2422 1574.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1466.52 2349.34 ACKERMANN BONE BIO ST ABC-200 48711918_1 CDM 0621 RC inpatient 2422 1574.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1637.27 67.6 999999999 1466.52 2349.34 percent of total billed charges ACKERMANN BONE BIO ST ABC-200 48711918_1 CDM 0621 RC inpatient 2422 1574.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1466.52 2349.34 CHOLANGIOGRAPHY INDUCTOR 48711920_1 CDM 0272 RC inpatient 397 258.05 AETNA AETNA 313.63 79 999999999 240.38 385.09 percent of total billed charges CHOLANGIOGRAPHY INDUCTOR 48711920_1 CDM 0272 RC inpatient 397 258.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 258.05 65 999999999 240.38 385.09 percent of total billed charges CHOLANGIOGRAPHY INDUCTOR 48711920_1 CDM 0272 RC inpatient 397 258.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 385.09 97 999999999 240.38 385.09 percent of total billed charges CHOLANGIOGRAPHY INDUCTOR 48711920_1 CDM 0272 RC inpatient 397 258.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 273.93 69 999999999 240.38 385.09 percent of total billed charges CHOLANGIOGRAPHY INDUCTOR 48711920_1 CDM 0272 RC inpatient 397 258.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 309.66 78 999999999 240.38 385.09 percent of total billed charges CHOLANGIOGRAPHY INDUCTOR 48711920_1 CDM 0272 RC inpatient 397 258.05 SIHO - ALL PLANS SIHO - ALL PLANS 357.3 90 999999999 240.38 385.09 percent of total billed charges CHOLANGIOGRAPHY INDUCTOR 48711920_1 CDM 0272 RC inpatient 397 258.05 UMR - ALL PLANS UMR - ALL PLANS 277.9 70 999999999 240.38 385.09 percent of total billed charges CHOLANGIOGRAPHY INDUCTOR 48711920_1 CDM 0272 RC inpatient 397 258.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 240.38 60.55 999999999 240.38 385.09 percent of total billed charges CHOLANGIOGRAPHY INDUCTOR 48711920_1 CDM 0272 RC inpatient 397 258.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 240.38 385.09 CHOLANGIOGRAPHY INDUCTOR 48711920_1 CDM 0272 RC inpatient 397 258.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 240.38 385.09 CHOLANGIOGRAPHY INDUCTOR 48711920_1 CDM 0272 RC inpatient 397 258.05 ANTHEM HMO ANTHEM HMO 999999999 240.38 385.09 CHOLANGIOGRAPHY INDUCTOR 48711920_1 CDM 0272 RC inpatient 397 258.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 240.38 385.09 CHOLANGIOGRAPHY INDUCTOR 48711920_1 CDM 0272 RC inpatient 397 258.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 268.37 67.6 999999999 240.38 385.09 percent of total billed charges CHOLANGIOGRAPHY INDUCTOR 48711920_1 CDM 0272 RC inpatient 397 258.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 240.38 385.09 UPPER BODY BAIR HUGGER 48711922_1 CDM 0270 RC inpatient 32 20.8 AETNA AETNA 25.28 79 999999999 19.38 31.04 percent of total billed charges UPPER BODY BAIR HUGGER 48711922_1 CDM 0270 RC inpatient 32 20.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.8 65 999999999 19.38 31.04 percent of total billed charges UPPER BODY BAIR HUGGER 48711922_1 CDM 0270 RC inpatient 32 20.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31.04 97 999999999 19.38 31.04 percent of total billed charges UPPER BODY BAIR HUGGER 48711922_1 CDM 0270 RC inpatient 32 20.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.08 69 999999999 19.38 31.04 percent of total billed charges UPPER BODY BAIR HUGGER 48711922_1 CDM 0270 RC inpatient 32 20.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.96 78 999999999 19.38 31.04 percent of total billed charges UPPER BODY BAIR HUGGER 48711922_1 CDM 0270 RC inpatient 32 20.8 SIHO - ALL PLANS SIHO - ALL PLANS 28.8 90 999999999 19.38 31.04 percent of total billed charges UPPER BODY BAIR HUGGER 48711922_1 CDM 0270 RC inpatient 32 20.8 UMR - ALL PLANS UMR - ALL PLANS 22.4 70 999999999 19.38 31.04 percent of total billed charges UPPER BODY BAIR HUGGER 48711922_1 CDM 0270 RC inpatient 32 20.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.38 60.55 999999999 19.38 31.04 percent of total billed charges UPPER BODY BAIR HUGGER 48711922_1 CDM 0270 RC inpatient 32 20.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.38 31.04 UPPER BODY BAIR HUGGER 48711922_1 CDM 0270 RC inpatient 32 20.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.38 31.04 UPPER BODY BAIR HUGGER 48711922_1 CDM 0270 RC inpatient 32 20.8 ANTHEM HMO ANTHEM HMO 999999999 19.38 31.04 UPPER BODY BAIR HUGGER 48711922_1 CDM 0270 RC inpatient 32 20.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.38 31.04 UPPER BODY BAIR HUGGER 48711922_1 CDM 0270 RC inpatient 32 20.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.63 67.6 999999999 19.38 31.04 percent of total billed charges UPPER BODY BAIR HUGGER 48711922_1 CDM 0270 RC inpatient 32 20.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.38 31.04 COPE LOOP NEPHROSTOMY (OE) 48711928_1 CDM 0272 RC inpatient 1090 708.5 AETNA AETNA 861.1 79 999999999 660 1057.3 percent of total billed charges COPE LOOP NEPHROSTOMY (OE) 48711928_1 CDM 0272 RC inpatient 1090 708.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 708.5 65 999999999 660 1057.3 percent of total billed charges COPE LOOP NEPHROSTOMY (OE) 48711928_1 CDM 0272 RC inpatient 1090 708.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1057.3 97 999999999 660 1057.3 percent of total billed charges COPE LOOP NEPHROSTOMY (OE) 48711928_1 CDM 0272 RC inpatient 1090 708.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 752.1 69 999999999 660 1057.3 percent of total billed charges COPE LOOP NEPHROSTOMY (OE) 48711928_1 CDM 0272 RC inpatient 1090 708.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 850.2 78 999999999 660 1057.3 percent of total billed charges COPE LOOP NEPHROSTOMY (OE) 48711928_1 CDM 0272 RC inpatient 1090 708.5 SIHO - ALL PLANS SIHO - ALL PLANS 981 90 999999999 660 1057.3 percent of total billed charges COPE LOOP NEPHROSTOMY (OE) 48711928_1 CDM 0272 RC inpatient 1090 708.5 UMR - ALL PLANS UMR - ALL PLANS 763 70 999999999 660 1057.3 percent of total billed charges COPE LOOP NEPHROSTOMY (OE) 48711928_1 CDM 0272 RC inpatient 1090 708.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 660 60.55 999999999 660 1057.3 percent of total billed charges COPE LOOP NEPHROSTOMY (OE) 48711928_1 CDM 0272 RC inpatient 1090 708.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 660 1057.3 COPE LOOP NEPHROSTOMY (OE) 48711928_1 CDM 0272 RC inpatient 1090 708.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 660 1057.3 COPE LOOP NEPHROSTOMY (OE) 48711928_1 CDM 0272 RC inpatient 1090 708.5 ANTHEM HMO ANTHEM HMO 999999999 660 1057.3 COPE LOOP NEPHROSTOMY (OE) 48711928_1 CDM 0272 RC inpatient 1090 708.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 660 1057.3 COPE LOOP NEPHROSTOMY (OE) 48711928_1 CDM 0272 RC inpatient 1090 708.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 736.84 67.6 999999999 660 1057.3 percent of total billed charges COPE LOOP NEPHROSTOMY (OE) 48711928_1 CDM 0272 RC inpatient 1090 708.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 660 1057.3 CUP M MYTIVAC W/TUBING 10007LP 48711929_1 CDM 0272 RC inpatient 213 138.45 AETNA AETNA 168.27 79 999999999 128.97 206.61 percent of total billed charges CUP M MYTIVAC W/TUBING 10007LP 48711929_1 CDM 0272 RC inpatient 213 138.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 138.45 65 999999999 128.97 206.61 percent of total billed charges CUP M MYTIVAC W/TUBING 10007LP 48711929_1 CDM 0272 RC inpatient 213 138.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 206.61 97 999999999 128.97 206.61 percent of total billed charges CUP M MYTIVAC W/TUBING 10007LP 48711929_1 CDM 0272 RC inpatient 213 138.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 146.97 69 999999999 128.97 206.61 percent of total billed charges CUP M MYTIVAC W/TUBING 10007LP 48711929_1 CDM 0272 RC inpatient 213 138.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 166.14 78 999999999 128.97 206.61 percent of total billed charges CUP M MYTIVAC W/TUBING 10007LP 48711929_1 CDM 0272 RC inpatient 213 138.45 SIHO - ALL PLANS SIHO - ALL PLANS 191.7 90 999999999 128.97 206.61 percent of total billed charges CUP M MYTIVAC W/TUBING 10007LP 48711929_1 CDM 0272 RC inpatient 213 138.45 UMR - ALL PLANS UMR - ALL PLANS 149.1 70 999999999 128.97 206.61 percent of total billed charges CUP M MYTIVAC W/TUBING 10007LP 48711929_1 CDM 0272 RC inpatient 213 138.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 128.97 60.55 999999999 128.97 206.61 percent of total billed charges CUP M MYTIVAC W/TUBING 10007LP 48711929_1 CDM 0272 RC inpatient 213 138.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 128.97 206.61 CUP M MYTIVAC W/TUBING 10007LP 48711929_1 CDM 0272 RC inpatient 213 138.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 128.97 206.61 CUP M MYTIVAC W/TUBING 10007LP 48711929_1 CDM 0272 RC inpatient 213 138.45 ANTHEM HMO ANTHEM HMO 999999999 128.97 206.61 CUP M MYTIVAC W/TUBING 10007LP 48711929_1 CDM 0272 RC inpatient 213 138.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 128.97 206.61 CUP M MYTIVAC W/TUBING 10007LP 48711929_1 CDM 0272 RC inpatient 213 138.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 143.99 67.6 999999999 128.97 206.61 percent of total billed charges CUP M MYTIVAC W/TUBING 10007LP 48711929_1 CDM 0272 RC inpatient 213 138.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 128.97 206.61 SPARC SLING 72403656 48711930_1 CDM 0278 RC inpatient 2922 1899.3 AETNA AETNA 2308.38 79 999999999 1769.27 2834.34 percent of total billed charges SPARC SLING 72403656 48711930_1 CDM 0278 RC inpatient 2922 1899.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1899.3 65 999999999 1769.27 2834.34 percent of total billed charges SPARC SLING 72403656 48711930_1 CDM 0278 RC inpatient 2922 1899.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2834.34 97 999999999 1769.27 2834.34 percent of total billed charges SPARC SLING 72403656 48711930_1 CDM 0278 RC inpatient 2922 1899.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 2016.18 69 999999999 1769.27 2834.34 percent of total billed charges SPARC SLING 72403656 48711930_1 CDM 0278 RC inpatient 2922 1899.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 2279.16 78 999999999 1769.27 2834.34 percent of total billed charges SPARC SLING 72403656 48711930_1 CDM 0278 RC inpatient 2922 1899.3 SIHO - ALL PLANS SIHO - ALL PLANS 2629.8 90 999999999 1769.27 2834.34 percent of total billed charges SPARC SLING 72403656 48711930_1 CDM 0278 RC inpatient 2922 1899.3 UMR - ALL PLANS UMR - ALL PLANS 2045.4 70 999999999 1769.27 2834.34 percent of total billed charges SPARC SLING 72403656 48711930_1 CDM 0278 RC inpatient 2922 1899.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1769.27 60.55 999999999 1769.27 2834.34 percent of total billed charges SPARC SLING 72403656 48711930_1 CDM 0278 RC inpatient 2922 1899.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1769.27 2834.34 SPARC SLING 72403656 48711930_1 CDM 0278 RC inpatient 2922 1899.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1769.27 2834.34 SPARC SLING 72403656 48711930_1 CDM 0278 RC inpatient 2922 1899.3 ANTHEM HMO ANTHEM HMO 999999999 1769.27 2834.34 SPARC SLING 72403656 48711930_1 CDM 0278 RC inpatient 2922 1899.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1769.27 2834.34 SPARC SLING 72403656 48711930_1 CDM 0278 RC inpatient 2922 1899.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1975.27 67.6 999999999 1769.27 2834.34 percent of total billed charges SPARC SLING 72403656 48711930_1 CDM 0278 RC inpatient 2922 1899.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1769.27 2834.34 CRUTCH ADULT TALL MDSV80534 48711931_1 CDM 0271 RC inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges CRUTCH ADULT TALL MDSV80534 48711931_1 CDM 0271 RC inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges CRUTCH ADULT TALL MDSV80534 48711931_1 CDM 0271 RC inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges CRUTCH ADULT TALL MDSV80534 48711931_1 CDM 0271 RC inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges CRUTCH ADULT TALL MDSV80534 48711931_1 CDM 0271 RC inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges CRUTCH ADULT TALL MDSV80534 48711931_1 CDM 0271 RC inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges CRUTCH ADULT TALL MDSV80534 48711931_1 CDM 0271 RC inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges CRUTCH ADULT TALL MDSV80534 48711931_1 CDM 0271 RC inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges CRUTCH ADULT TALL MDSV80534 48711931_1 CDM 0271 RC inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 CRUTCH ADULT TALL MDSV80534 48711931_1 CDM 0271 RC inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 CRUTCH ADULT TALL MDSV80534 48711931_1 CDM 0271 RC inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 CRUTCH ADULT TALL MDSV80534 48711931_1 CDM 0271 RC inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 CRUTCH ADULT TALL MDSV80534 48711931_1 CDM 0271 RC inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges CRUTCH ADULT TALL MDSV80534 48711931_1 CDM 0271 RC inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 CRUTCH MED ADULT MDS51514-10 48711932_1 CDM 0271 RC inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges CRUTCH MED ADULT MDS51514-10 48711932_1 CDM 0271 RC inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges CRUTCH MED ADULT MDS51514-10 48711932_1 CDM 0271 RC inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges CRUTCH MED ADULT MDS51514-10 48711932_1 CDM 0271 RC inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges CRUTCH MED ADULT MDS51514-10 48711932_1 CDM 0271 RC inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges CRUTCH MED ADULT MDS51514-10 48711932_1 CDM 0271 RC inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges CRUTCH MED ADULT MDS51514-10 48711932_1 CDM 0271 RC inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges CRUTCH MED ADULT MDS51514-10 48711932_1 CDM 0271 RC inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges CRUTCH MED ADULT MDS51514-10 48711932_1 CDM 0271 RC inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 CRUTCH MED ADULT MDS51514-10 48711932_1 CDM 0271 RC inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 CRUTCH MED ADULT MDS51514-10 48711932_1 CDM 0271 RC inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 CRUTCH MED ADULT MDS51514-10 48711932_1 CDM 0271 RC inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 CRUTCH MED ADULT MDS51514-10 48711932_1 CDM 0271 RC inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges CRUTCH MED ADULT MDS51514-10 48711932_1 CDM 0271 RC inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 CTU14.0-30-ST CONNECT TB (OE) G02278 48711933_1 CDM 0272 RC inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges CTU14.0-30-ST CONNECT TB (OE) G02278 48711933_1 CDM 0272 RC inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges CTU14.0-30-ST CONNECT TB (OE) G02278 48711933_1 CDM 0272 RC inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges CTU14.0-30-ST CONNECT TB (OE) G02278 48711933_1 CDM 0272 RC inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges CTU14.0-30-ST CONNECT TB (OE) G02278 48711933_1 CDM 0272 RC inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges CTU14.0-30-ST CONNECT TB (OE) G02278 48711933_1 CDM 0272 RC inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges CTU14.0-30-ST CONNECT TB (OE) G02278 48711933_1 CDM 0272 RC inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges CTU14.0-30-ST CONNECT TB (OE) G02278 48711933_1 CDM 0272 RC inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges CTU14.0-30-ST CONNECT TB (OE) G02278 48711933_1 CDM 0272 RC inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 CTU14.0-30-ST CONNECT TB (OE) G02278 48711933_1 CDM 0272 RC inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 CTU14.0-30-ST CONNECT TB (OE) G02278 48711933_1 CDM 0272 RC inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 CTU14.0-30-ST CONNECT TB (OE) G02278 48711933_1 CDM 0272 RC inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 CTU14.0-30-ST CONNECT TB (OE) G02278 48711933_1 CDM 0272 RC inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges CTU14.0-30-ST CONNECT TB (OE) G02278 48711933_1 CDM 0272 RC inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 CRUTCH YOUTH MDSV80536 48711934_1 CDM 0271 RC inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges CRUTCH YOUTH MDSV80536 48711934_1 CDM 0271 RC inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges CRUTCH YOUTH MDSV80536 48711934_1 CDM 0271 RC inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges CRUTCH YOUTH MDSV80536 48711934_1 CDM 0271 RC inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges CRUTCH YOUTH MDSV80536 48711934_1 CDM 0271 RC inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges CRUTCH YOUTH MDSV80536 48711934_1 CDM 0271 RC inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges CRUTCH YOUTH MDSV80536 48711934_1 CDM 0271 RC inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges CRUTCH YOUTH MDSV80536 48711934_1 CDM 0271 RC inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges CRUTCH YOUTH MDSV80536 48711934_1 CDM 0271 RC inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 CRUTCH YOUTH MDSV80536 48711934_1 CDM 0271 RC inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 CRUTCH YOUTH MDSV80536 48711934_1 CDM 0271 RC inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 CRUTCH YOUTH MDSV80536 48711934_1 CDM 0271 RC inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 CRUTCH YOUTH MDSV80536 48711934_1 CDM 0271 RC inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges CRUTCH YOUTH MDSV80536 48711934_1 CDM 0271 RC inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 CUTTING HEAD DERMATOME DC3295 48711935_1 CDM 0272 RC inpatient 341 221.65 AETNA AETNA 269.39 79 999999999 206.48 330.77 percent of total billed charges CUTTING HEAD DERMATOME DC3295 48711935_1 CDM 0272 RC inpatient 341 221.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 221.65 65 999999999 206.48 330.77 percent of total billed charges CUTTING HEAD DERMATOME DC3295 48711935_1 CDM 0272 RC inpatient 341 221.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 330.77 97 999999999 206.48 330.77 percent of total billed charges CUTTING HEAD DERMATOME DC3295 48711935_1 CDM 0272 RC inpatient 341 221.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 235.29 69 999999999 206.48 330.77 percent of total billed charges CUTTING HEAD DERMATOME DC3295 48711935_1 CDM 0272 RC inpatient 341 221.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 265.98 78 999999999 206.48 330.77 percent of total billed charges CUTTING HEAD DERMATOME DC3295 48711935_1 CDM 0272 RC inpatient 341 221.65 SIHO - ALL PLANS SIHO - ALL PLANS 306.9 90 999999999 206.48 330.77 percent of total billed charges CUTTING HEAD DERMATOME DC3295 48711935_1 CDM 0272 RC inpatient 341 221.65 UMR - ALL PLANS UMR - ALL PLANS 238.7 70 999999999 206.48 330.77 percent of total billed charges CUTTING HEAD DERMATOME DC3295 48711935_1 CDM 0272 RC inpatient 341 221.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 206.48 60.55 999999999 206.48 330.77 percent of total billed charges CUTTING HEAD DERMATOME DC3295 48711935_1 CDM 0272 RC inpatient 341 221.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 206.48 330.77 CUTTING HEAD DERMATOME DC3295 48711935_1 CDM 0272 RC inpatient 341 221.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 206.48 330.77 CUTTING HEAD DERMATOME DC3295 48711935_1 CDM 0272 RC inpatient 341 221.65 ANTHEM HMO ANTHEM HMO 999999999 206.48 330.77 CUTTING HEAD DERMATOME DC3295 48711935_1 CDM 0272 RC inpatient 341 221.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 206.48 330.77 CUTTING HEAD DERMATOME DC3295 48711935_1 CDM 0272 RC inpatient 341 221.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 230.52 67.6 999999999 206.48 330.77 percent of total billed charges CUTTING HEAD DERMATOME DC3295 48711935_1 CDM 0272 RC inpatient 341 221.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 206.48 330.77 CURVTEK CARTRIDGE MED 7MM 48711936_1 CDM 0278 RC inpatient 4860 3159 AETNA AETNA 3839.4 79 999999999 2942.73 4714.2 percent of total billed charges CURVTEK CARTRIDGE MED 7MM 48711936_1 CDM 0278 RC inpatient 4860 3159 SELF PAY DISCOUNT SELF PAY DISCOUNT 3159 65 999999999 2942.73 4714.2 percent of total billed charges CURVTEK CARTRIDGE MED 7MM 48711936_1 CDM 0278 RC inpatient 4860 3159 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4714.2 97 999999999 2942.73 4714.2 percent of total billed charges CURVTEK CARTRIDGE MED 7MM 48711936_1 CDM 0278 RC inpatient 4860 3159 ENCORE - ALL PLANS ENCORE - ALL PLANS 3353.4 69 999999999 2942.73 4714.2 percent of total billed charges CURVTEK CARTRIDGE MED 7MM 48711936_1 CDM 0278 RC inpatient 4860 3159 HUMANA - ALL PLANS HUMANA - ALL PLANS 3790.8 78 999999999 2942.73 4714.2 percent of total billed charges CURVTEK CARTRIDGE MED 7MM 48711936_1 CDM 0278 RC inpatient 4860 3159 SIHO - ALL PLANS SIHO - ALL PLANS 4374 90 999999999 2942.73 4714.2 percent of total billed charges CURVTEK CARTRIDGE MED 7MM 48711936_1 CDM 0278 RC inpatient 4860 3159 UMR - ALL PLANS UMR - ALL PLANS 3402 70 999999999 2942.73 4714.2 percent of total billed charges CURVTEK CARTRIDGE MED 7MM 48711936_1 CDM 0278 RC inpatient 4860 3159 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2942.73 60.55 999999999 2942.73 4714.2 percent of total billed charges CURVTEK CARTRIDGE MED 7MM 48711936_1 CDM 0278 RC inpatient 4860 3159 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2942.73 4714.2 CURVTEK CARTRIDGE MED 7MM 48711936_1 CDM 0278 RC inpatient 4860 3159 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2942.73 4714.2 CURVTEK CARTRIDGE MED 7MM 48711936_1 CDM 0278 RC inpatient 4860 3159 ANTHEM HMO ANTHEM HMO 999999999 2942.73 4714.2 CURVTEK CARTRIDGE MED 7MM 48711936_1 CDM 0278 RC inpatient 4860 3159 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2942.73 4714.2 CURVTEK CARTRIDGE MED 7MM 48711936_1 CDM 0278 RC inpatient 4860 3159 CIGNA - ALL PLANS CIGNA - ALL PLANS 3285.36 67.6 999999999 2942.73 4714.2 percent of total billed charges CURVTEK CARTRIDGE MED 7MM 48711936_1 CDM 0278 RC inpatient 4860 3159 UHC - ALL PLANS UHC - ALL PLANS 999999999 2942.73 4714.2 CURVTEK CARTRIDGE LG 12MM 48711937_1 CDM 0278 RC inpatient 4650 3022.5 AETNA AETNA 3673.5 79 999999999 2815.58 4510.5 percent of total billed charges CURVTEK CARTRIDGE LG 12MM 48711937_1 CDM 0278 RC inpatient 4650 3022.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 3022.5 65 999999999 2815.58 4510.5 percent of total billed charges CURVTEK CARTRIDGE LG 12MM 48711937_1 CDM 0278 RC inpatient 4650 3022.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4510.5 97 999999999 2815.58 4510.5 percent of total billed charges CURVTEK CARTRIDGE LG 12MM 48711937_1 CDM 0278 RC inpatient 4650 3022.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 3208.5 69 999999999 2815.58 4510.5 percent of total billed charges CURVTEK CARTRIDGE LG 12MM 48711937_1 CDM 0278 RC inpatient 4650 3022.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 3627 78 999999999 2815.58 4510.5 percent of total billed charges CURVTEK CARTRIDGE LG 12MM 48711937_1 CDM 0278 RC inpatient 4650 3022.5 SIHO - ALL PLANS SIHO - ALL PLANS 4185 90 999999999 2815.58 4510.5 percent of total billed charges CURVTEK CARTRIDGE LG 12MM 48711937_1 CDM 0278 RC inpatient 4650 3022.5 UMR - ALL PLANS UMR - ALL PLANS 3255 70 999999999 2815.58 4510.5 percent of total billed charges CURVTEK CARTRIDGE LG 12MM 48711937_1 CDM 0278 RC inpatient 4650 3022.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2815.58 60.55 999999999 2815.58 4510.5 percent of total billed charges CURVTEK CARTRIDGE LG 12MM 48711937_1 CDM 0278 RC inpatient 4650 3022.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2815.58 4510.5 CURVTEK CARTRIDGE LG 12MM 48711937_1 CDM 0278 RC inpatient 4650 3022.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2815.58 4510.5 CURVTEK CARTRIDGE LG 12MM 48711937_1 CDM 0278 RC inpatient 4650 3022.5 ANTHEM HMO ANTHEM HMO 999999999 2815.58 4510.5 CURVTEK CARTRIDGE LG 12MM 48711937_1 CDM 0278 RC inpatient 4650 3022.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2815.58 4510.5 CURVTEK CARTRIDGE LG 12MM 48711937_1 CDM 0278 RC inpatient 4650 3022.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 3143.4 67.6 999999999 2815.58 4510.5 percent of total billed charges CURVTEK CARTRIDGE LG 12MM 48711937_1 CDM 0278 RC inpatient 4650 3022.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 2815.58 4510.5 CUTTING LOOP 24FR 802-131 48711938_1 CDM 0272 RC inpatient 411 267.15 AETNA AETNA 324.69 79 999999999 248.86 398.67 percent of total billed charges CUTTING LOOP 24FR 802-131 48711938_1 CDM 0272 RC inpatient 411 267.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 267.15 65 999999999 248.86 398.67 percent of total billed charges CUTTING LOOP 24FR 802-131 48711938_1 CDM 0272 RC inpatient 411 267.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 398.67 97 999999999 248.86 398.67 percent of total billed charges CUTTING LOOP 24FR 802-131 48711938_1 CDM 0272 RC inpatient 411 267.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 283.59 69 999999999 248.86 398.67 percent of total billed charges CUTTING LOOP 24FR 802-131 48711938_1 CDM 0272 RC inpatient 411 267.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 320.58 78 999999999 248.86 398.67 percent of total billed charges CUTTING LOOP 24FR 802-131 48711938_1 CDM 0272 RC inpatient 411 267.15 SIHO - ALL PLANS SIHO - ALL PLANS 369.9 90 999999999 248.86 398.67 percent of total billed charges CUTTING LOOP 24FR 802-131 48711938_1 CDM 0272 RC inpatient 411 267.15 UMR - ALL PLANS UMR - ALL PLANS 287.7 70 999999999 248.86 398.67 percent of total billed charges CUTTING LOOP 24FR 802-131 48711938_1 CDM 0272 RC inpatient 411 267.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 248.86 60.55 999999999 248.86 398.67 percent of total billed charges CUTTING LOOP 24FR 802-131 48711938_1 CDM 0272 RC inpatient 411 267.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 248.86 398.67 CUTTING LOOP 24FR 802-131 48711938_1 CDM 0272 RC inpatient 411 267.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 248.86 398.67 CUTTING LOOP 24FR 802-131 48711938_1 CDM 0272 RC inpatient 411 267.15 ANTHEM HMO ANTHEM HMO 999999999 248.86 398.67 CUTTING LOOP 24FR 802-131 48711938_1 CDM 0272 RC inpatient 411 267.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 248.86 398.67 CUTTING LOOP 24FR 802-131 48711938_1 CDM 0272 RC inpatient 411 267.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 277.84 67.6 999999999 248.86 398.67 percent of total billed charges CUTTING LOOP 24FR 802-131 48711938_1 CDM 0272 RC inpatient 411 267.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 248.86 398.67 CUTTER 5.0 AGG MENIS 375554000 48711940_1 CDM 0272 RC inpatient 395 256.75 AETNA AETNA 312.05 79 999999999 239.17 383.15 percent of total billed charges CUTTER 5.0 AGG MENIS 375554000 48711940_1 CDM 0272 RC inpatient 395 256.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 256.75 65 999999999 239.17 383.15 percent of total billed charges CUTTER 5.0 AGG MENIS 375554000 48711940_1 CDM 0272 RC inpatient 395 256.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 383.15 97 999999999 239.17 383.15 percent of total billed charges CUTTER 5.0 AGG MENIS 375554000 48711940_1 CDM 0272 RC inpatient 395 256.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 272.55 69 999999999 239.17 383.15 percent of total billed charges CUTTER 5.0 AGG MENIS 375554000 48711940_1 CDM 0272 RC inpatient 395 256.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 308.1 78 999999999 239.17 383.15 percent of total billed charges CUTTER 5.0 AGG MENIS 375554000 48711940_1 CDM 0272 RC inpatient 395 256.75 SIHO - ALL PLANS SIHO - ALL PLANS 355.5 90 999999999 239.17 383.15 percent of total billed charges CUTTER 5.0 AGG MENIS 375554000 48711940_1 CDM 0272 RC inpatient 395 256.75 UMR - ALL PLANS UMR - ALL PLANS 276.5 70 999999999 239.17 383.15 percent of total billed charges CUTTER 5.0 AGG MENIS 375554000 48711940_1 CDM 0272 RC inpatient 395 256.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 239.17 60.55 999999999 239.17 383.15 percent of total billed charges CUTTER 5.0 AGG MENIS 375554000 48711940_1 CDM 0272 RC inpatient 395 256.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 239.17 383.15 CUTTER 5.0 AGG MENIS 375554000 48711940_1 CDM 0272 RC inpatient 395 256.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 239.17 383.15 CUTTER 5.0 AGG MENIS 375554000 48711940_1 CDM 0272 RC inpatient 395 256.75 ANTHEM HMO ANTHEM HMO 999999999 239.17 383.15 CUTTER 5.0 AGG MENIS 375554000 48711940_1 CDM 0272 RC inpatient 395 256.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 239.17 383.15 CUTTER 5.0 AGG MENIS 375554000 48711940_1 CDM 0272 RC inpatient 395 256.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 267.02 67.6 999999999 239.17 383.15 percent of total billed charges CUTTER 5.0 AGG MENIS 375554000 48711940_1 CDM 0272 RC inpatient 395 256.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 239.17 383.15 CUTTER 4.0 AGG MEN 375-544-000 48711941_1 CDM 0272 RC inpatient 327 212.55 AETNA AETNA 258.33 79 999999999 198 317.19 percent of total billed charges CUTTER 4.0 AGG MEN 375-544-000 48711941_1 CDM 0272 RC inpatient 327 212.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 212.55 65 999999999 198 317.19 percent of total billed charges CUTTER 4.0 AGG MEN 375-544-000 48711941_1 CDM 0272 RC inpatient 327 212.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 317.19 97 999999999 198 317.19 percent of total billed charges CUTTER 4.0 AGG MEN 375-544-000 48711941_1 CDM 0272 RC inpatient 327 212.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 225.63 69 999999999 198 317.19 percent of total billed charges CUTTER 4.0 AGG MEN 375-544-000 48711941_1 CDM 0272 RC inpatient 327 212.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.06 78 999999999 198 317.19 percent of total billed charges CUTTER 4.0 AGG MEN 375-544-000 48711941_1 CDM 0272 RC inpatient 327 212.55 SIHO - ALL PLANS SIHO - ALL PLANS 294.3 90 999999999 198 317.19 percent of total billed charges CUTTER 4.0 AGG MEN 375-544-000 48711941_1 CDM 0272 RC inpatient 327 212.55 UMR - ALL PLANS UMR - ALL PLANS 228.9 70 999999999 198 317.19 percent of total billed charges CUTTER 4.0 AGG MEN 375-544-000 48711941_1 CDM 0272 RC inpatient 327 212.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198 60.55 999999999 198 317.19 percent of total billed charges CUTTER 4.0 AGG MEN 375-544-000 48711941_1 CDM 0272 RC inpatient 327 212.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198 317.19 CUTTER 4.0 AGG MEN 375-544-000 48711941_1 CDM 0272 RC inpatient 327 212.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198 317.19 CUTTER 4.0 AGG MEN 375-544-000 48711941_1 CDM 0272 RC inpatient 327 212.55 ANTHEM HMO ANTHEM HMO 999999999 198 317.19 CUTTER 4.0 AGG MEN 375-544-000 48711941_1 CDM 0272 RC inpatient 327 212.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198 317.19 CUTTER 4.0 AGG MEN 375-544-000 48711941_1 CDM 0272 RC inpatient 327 212.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.05 67.6 999999999 198 317.19 percent of total billed charges CUTTER 4.0 AGG MEN 375-544-000 48711941_1 CDM 0272 RC inpatient 327 212.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 198 317.19 SHAVER BLADE 4.0 RESECTOR 48711942_1 CDM 0272 RC inpatient 395 256.75 AETNA AETNA 312.05 79 999999999 239.17 383.15 percent of total billed charges SHAVER BLADE 4.0 RESECTOR 48711942_1 CDM 0272 RC inpatient 395 256.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 256.75 65 999999999 239.17 383.15 percent of total billed charges SHAVER BLADE 4.0 RESECTOR 48711942_1 CDM 0272 RC inpatient 395 256.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 383.15 97 999999999 239.17 383.15 percent of total billed charges SHAVER BLADE 4.0 RESECTOR 48711942_1 CDM 0272 RC inpatient 395 256.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 272.55 69 999999999 239.17 383.15 percent of total billed charges SHAVER BLADE 4.0 RESECTOR 48711942_1 CDM 0272 RC inpatient 395 256.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 308.1 78 999999999 239.17 383.15 percent of total billed charges SHAVER BLADE 4.0 RESECTOR 48711942_1 CDM 0272 RC inpatient 395 256.75 SIHO - ALL PLANS SIHO - ALL PLANS 355.5 90 999999999 239.17 383.15 percent of total billed charges SHAVER BLADE 4.0 RESECTOR 48711942_1 CDM 0272 RC inpatient 395 256.75 UMR - ALL PLANS UMR - ALL PLANS 276.5 70 999999999 239.17 383.15 percent of total billed charges SHAVER BLADE 4.0 RESECTOR 48711942_1 CDM 0272 RC inpatient 395 256.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 239.17 60.55 999999999 239.17 383.15 percent of total billed charges SHAVER BLADE 4.0 RESECTOR 48711942_1 CDM 0272 RC inpatient 395 256.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 239.17 383.15 SHAVER BLADE 4.0 RESECTOR 48711942_1 CDM 0272 RC inpatient 395 256.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 239.17 383.15 SHAVER BLADE 4.0 RESECTOR 48711942_1 CDM 0272 RC inpatient 395 256.75 ANTHEM HMO ANTHEM HMO 999999999 239.17 383.15 SHAVER BLADE 4.0 RESECTOR 48711942_1 CDM 0272 RC inpatient 395 256.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 239.17 383.15 SHAVER BLADE 4.0 RESECTOR 48711942_1 CDM 0272 RC inpatient 395 256.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 267.02 67.6 999999999 239.17 383.15 percent of total billed charges SHAVER BLADE 4.0 RESECTOR 48711942_1 CDM 0272 RC inpatient 395 256.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 239.17 383.15 DAC FOR ELECTROSURGICAL 48711943_1 CDM 0272 RC inpatient 134 87.1 AETNA AETNA 105.86 79 999999999 81.14 129.98 percent of total billed charges DAC FOR ELECTROSURGICAL 48711943_1 CDM 0272 RC inpatient 134 87.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 87.1 65 999999999 81.14 129.98 percent of total billed charges DAC FOR ELECTROSURGICAL 48711943_1 CDM 0272 RC inpatient 134 87.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.98 97 999999999 81.14 129.98 percent of total billed charges DAC FOR ELECTROSURGICAL 48711943_1 CDM 0272 RC inpatient 134 87.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 92.46 69 999999999 81.14 129.98 percent of total billed charges DAC FOR ELECTROSURGICAL 48711943_1 CDM 0272 RC inpatient 134 87.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 104.52 78 999999999 81.14 129.98 percent of total billed charges DAC FOR ELECTROSURGICAL 48711943_1 CDM 0272 RC inpatient 134 87.1 SIHO - ALL PLANS SIHO - ALL PLANS 120.6 90 999999999 81.14 129.98 percent of total billed charges DAC FOR ELECTROSURGICAL 48711943_1 CDM 0272 RC inpatient 134 87.1 UMR - ALL PLANS UMR - ALL PLANS 93.8 70 999999999 81.14 129.98 percent of total billed charges DAC FOR ELECTROSURGICAL 48711943_1 CDM 0272 RC inpatient 134 87.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 81.14 60.55 999999999 81.14 129.98 percent of total billed charges DAC FOR ELECTROSURGICAL 48711943_1 CDM 0272 RC inpatient 134 87.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 81.14 129.98 DAC FOR ELECTROSURGICAL 48711943_1 CDM 0272 RC inpatient 134 87.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 81.14 129.98 DAC FOR ELECTROSURGICAL 48711943_1 CDM 0272 RC inpatient 134 87.1 ANTHEM HMO ANTHEM HMO 999999999 81.14 129.98 DAC FOR ELECTROSURGICAL 48711943_1 CDM 0272 RC inpatient 134 87.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 81.14 129.98 DAC FOR ELECTROSURGICAL 48711943_1 CDM 0272 RC inpatient 134 87.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 90.58 67.6 999999999 81.14 129.98 percent of total billed charges DAC FOR ELECTROSURGICAL 48711943_1 CDM 0272 RC inpatient 134 87.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 81.14 129.98 SKIN AFFIX SURG ADHESIVE MSC091040 48711944_1 CDM 0272 RC inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges SKIN AFFIX SURG ADHESIVE MSC091040 48711944_1 CDM 0272 RC inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges SKIN AFFIX SURG ADHESIVE MSC091040 48711944_1 CDM 0272 RC inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges SKIN AFFIX SURG ADHESIVE MSC091040 48711944_1 CDM 0272 RC inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges SKIN AFFIX SURG ADHESIVE MSC091040 48711944_1 CDM 0272 RC inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges SKIN AFFIX SURG ADHESIVE MSC091040 48711944_1 CDM 0272 RC inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges SKIN AFFIX SURG ADHESIVE MSC091040 48711944_1 CDM 0272 RC inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges SKIN AFFIX SURG ADHESIVE MSC091040 48711944_1 CDM 0272 RC inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges SKIN AFFIX SURG ADHESIVE MSC091040 48711944_1 CDM 0272 RC inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 SKIN AFFIX SURG ADHESIVE MSC091040 48711944_1 CDM 0272 RC inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 SKIN AFFIX SURG ADHESIVE MSC091040 48711944_1 CDM 0272 RC inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 SKIN AFFIX SURG ADHESIVE MSC091040 48711944_1 CDM 0272 RC inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 SKIN AFFIX SURG ADHESIVE MSC091040 48711944_1 CDM 0272 RC inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges SKIN AFFIX SURG ADHESIVE MSC091040 48711944_1 CDM 0272 RC inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 DILATOR ESOPH BALLOON 15-18MM 48711945_1 CDM 0272 RC inpatient 1253 814.45 AETNA AETNA 989.87 79 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 15-18MM 48711945_1 CDM 0272 RC inpatient 1253 814.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 814.45 65 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 15-18MM 48711945_1 CDM 0272 RC inpatient 1253 814.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1215.41 97 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 15-18MM 48711945_1 CDM 0272 RC inpatient 1253 814.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 864.57 69 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 15-18MM 48711945_1 CDM 0272 RC inpatient 1253 814.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 977.34 78 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 15-18MM 48711945_1 CDM 0272 RC inpatient 1253 814.45 SIHO - ALL PLANS SIHO - ALL PLANS 1127.7 90 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 15-18MM 48711945_1 CDM 0272 RC inpatient 1253 814.45 UMR - ALL PLANS UMR - ALL PLANS 877.1 70 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 15-18MM 48711945_1 CDM 0272 RC inpatient 1253 814.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 758.69 60.55 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 15-18MM 48711945_1 CDM 0272 RC inpatient 1253 814.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 758.69 1215.41 DILATOR ESOPH BALLOON 15-18MM 48711945_1 CDM 0272 RC inpatient 1253 814.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 758.69 1215.41 DILATOR ESOPH BALLOON 15-18MM 48711945_1 CDM 0272 RC inpatient 1253 814.45 ANTHEM HMO ANTHEM HMO 999999999 758.69 1215.41 DILATOR ESOPH BALLOON 15-18MM 48711945_1 CDM 0272 RC inpatient 1253 814.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 758.69 1215.41 DILATOR ESOPH BALLOON 15-18MM 48711945_1 CDM 0272 RC inpatient 1253 814.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 847.03 67.6 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 15-18MM 48711945_1 CDM 0272 RC inpatient 1253 814.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 758.69 1215.41 DILATOR ESOPH BALLOON 12-15MM 48711946_1 CDM 0272 RC inpatient 1253 814.45 AETNA AETNA 989.87 79 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 12-15MM 48711946_1 CDM 0272 RC inpatient 1253 814.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 814.45 65 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 12-15MM 48711946_1 CDM 0272 RC inpatient 1253 814.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1215.41 97 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 12-15MM 48711946_1 CDM 0272 RC inpatient 1253 814.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 864.57 69 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 12-15MM 48711946_1 CDM 0272 RC inpatient 1253 814.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 977.34 78 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 12-15MM 48711946_1 CDM 0272 RC inpatient 1253 814.45 SIHO - ALL PLANS SIHO - ALL PLANS 1127.7 90 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 12-15MM 48711946_1 CDM 0272 RC inpatient 1253 814.45 UMR - ALL PLANS UMR - ALL PLANS 877.1 70 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 12-15MM 48711946_1 CDM 0272 RC inpatient 1253 814.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 758.69 60.55 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 12-15MM 48711946_1 CDM 0272 RC inpatient 1253 814.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 758.69 1215.41 DILATOR ESOPH BALLOON 12-15MM 48711946_1 CDM 0272 RC inpatient 1253 814.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 758.69 1215.41 DILATOR ESOPH BALLOON 12-15MM 48711946_1 CDM 0272 RC inpatient 1253 814.45 ANTHEM HMO ANTHEM HMO 999999999 758.69 1215.41 DILATOR ESOPH BALLOON 12-15MM 48711946_1 CDM 0272 RC inpatient 1253 814.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 758.69 1215.41 DILATOR ESOPH BALLOON 12-15MM 48711946_1 CDM 0272 RC inpatient 1253 814.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 847.03 67.6 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 12-15MM 48711946_1 CDM 0272 RC inpatient 1253 814.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 758.69 1215.41 DILATOR ESOPH BALLOON 10-12MM 48711947_1 CDM 0272 RC inpatient 1097 713.05 AETNA AETNA 866.63 79 999999999 664.23 1064.09 percent of total billed charges DILATOR ESOPH BALLOON 10-12MM 48711947_1 CDM 0272 RC inpatient 1097 713.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 713.05 65 999999999 664.23 1064.09 percent of total billed charges DILATOR ESOPH BALLOON 10-12MM 48711947_1 CDM 0272 RC inpatient 1097 713.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1064.09 97 999999999 664.23 1064.09 percent of total billed charges DILATOR ESOPH BALLOON 10-12MM 48711947_1 CDM 0272 RC inpatient 1097 713.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 756.93 69 999999999 664.23 1064.09 percent of total billed charges DILATOR ESOPH BALLOON 10-12MM 48711947_1 CDM 0272 RC inpatient 1097 713.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 855.66 78 999999999 664.23 1064.09 percent of total billed charges DILATOR ESOPH BALLOON 10-12MM 48711947_1 CDM 0272 RC inpatient 1097 713.05 SIHO - ALL PLANS SIHO - ALL PLANS 987.3 90 999999999 664.23 1064.09 percent of total billed charges DILATOR ESOPH BALLOON 10-12MM 48711947_1 CDM 0272 RC inpatient 1097 713.05 UMR - ALL PLANS UMR - ALL PLANS 767.9 70 999999999 664.23 1064.09 percent of total billed charges DILATOR ESOPH BALLOON 10-12MM 48711947_1 CDM 0272 RC inpatient 1097 713.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 664.23 60.55 999999999 664.23 1064.09 percent of total billed charges DILATOR ESOPH BALLOON 10-12MM 48711947_1 CDM 0272 RC inpatient 1097 713.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 664.23 1064.09 DILATOR ESOPH BALLOON 10-12MM 48711947_1 CDM 0272 RC inpatient 1097 713.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 664.23 1064.09 DILATOR ESOPH BALLOON 10-12MM 48711947_1 CDM 0272 RC inpatient 1097 713.05 ANTHEM HMO ANTHEM HMO 999999999 664.23 1064.09 DILATOR ESOPH BALLOON 10-12MM 48711947_1 CDM 0272 RC inpatient 1097 713.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 664.23 1064.09 DILATOR ESOPH BALLOON 10-12MM 48711947_1 CDM 0272 RC inpatient 1097 713.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 741.57 67.6 999999999 664.23 1064.09 percent of total billed charges DILATOR ESOPH BALLOON 10-12MM 48711947_1 CDM 0272 RC inpatient 1097 713.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 664.23 1064.09 DERMA CARRIER II SZ 11/2X1 48711948_1 CDM 0272 RC inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges DERMA CARRIER II SZ 11/2X1 48711948_1 CDM 0272 RC inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges DERMA CARRIER II SZ 11/2X1 48711948_1 CDM 0272 RC inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges DERMA CARRIER II SZ 11/2X1 48711948_1 CDM 0272 RC inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges DERMA CARRIER II SZ 11/2X1 48711948_1 CDM 0272 RC inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges DERMA CARRIER II SZ 11/2X1 48711948_1 CDM 0272 RC inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges DERMA CARRIER II SZ 11/2X1 48711948_1 CDM 0272 RC inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges DERMA CARRIER II SZ 11/2X1 48711948_1 CDM 0272 RC inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges DERMA CARRIER II SZ 11/2X1 48711948_1 CDM 0272 RC inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 DERMA CARRIER II SZ 11/2X1 48711948_1 CDM 0272 RC inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 DERMA CARRIER II SZ 11/2X1 48711948_1 CDM 0272 RC inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 DERMA CARRIER II SZ 11/2X1 48711948_1 CDM 0272 RC inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 DERMA CARRIER II SZ 11/2X1 48711948_1 CDM 0272 RC inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges DERMA CARRIER II SZ 11/2X1 48711948_1 CDM 0272 RC inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 DISPOSA TOP W/BT AND FILTER 003853-902 48711951_1 CDM 0272 RC inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges DISPOSA TOP W/BT AND FILTER 003853-902 48711951_1 CDM 0272 RC inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges DISPOSA TOP W/BT AND FILTER 003853-902 48711951_1 CDM 0272 RC inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges DISPOSA TOP W/BT AND FILTER 003853-902 48711951_1 CDM 0272 RC inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges DISPOSA TOP W/BT AND FILTER 003853-902 48711951_1 CDM 0272 RC inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges DISPOSA TOP W/BT AND FILTER 003853-902 48711951_1 CDM 0272 RC inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges DISPOSA TOP W/BT AND FILTER 003853-902 48711951_1 CDM 0272 RC inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges DISPOSA TOP W/BT AND FILTER 003853-902 48711951_1 CDM 0272 RC inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges DISPOSA TOP W/BT AND FILTER 003853-902 48711951_1 CDM 0272 RC inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 DISPOSA TOP W/BT AND FILTER 003853-902 48711951_1 CDM 0272 RC inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 DISPOSA TOP W/BT AND FILTER 003853-902 48711951_1 CDM 0272 RC inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 DISPOSA TOP W/BT AND FILTER 003853-902 48711951_1 CDM 0272 RC inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 DISPOSA TOP W/BT AND FILTER 003853-902 48711951_1 CDM 0272 RC inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges DISPOSA TOP W/BT AND FILTER 003853-902 48711951_1 CDM 0272 RC inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 "AQUACEL 3.5"" X 12""" 48711956_1 CDM 0272 RC inpatient 258 167.7 AETNA AETNA 203.82 79 999999999 156.22 250.26 percent of total billed charges "AQUACEL 3.5"" X 12""" 48711956_1 CDM 0272 RC inpatient 258 167.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.7 65 999999999 156.22 250.26 percent of total billed charges "AQUACEL 3.5"" X 12""" 48711956_1 CDM 0272 RC inpatient 258 167.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 250.26 97 999999999 156.22 250.26 percent of total billed charges "AQUACEL 3.5"" X 12""" 48711956_1 CDM 0272 RC inpatient 258 167.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 178.02 69 999999999 156.22 250.26 percent of total billed charges "AQUACEL 3.5"" X 12""" 48711956_1 CDM 0272 RC inpatient 258 167.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 201.24 78 999999999 156.22 250.26 percent of total billed charges "AQUACEL 3.5"" X 12""" 48711956_1 CDM 0272 RC inpatient 258 167.7 SIHO - ALL PLANS SIHO - ALL PLANS 232.2 90 999999999 156.22 250.26 percent of total billed charges "AQUACEL 3.5"" X 12""" 48711956_1 CDM 0272 RC inpatient 258 167.7 UMR - ALL PLANS UMR - ALL PLANS 180.6 70 999999999 156.22 250.26 percent of total billed charges "AQUACEL 3.5"" X 12""" 48711956_1 CDM 0272 RC inpatient 258 167.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 156.22 60.55 999999999 156.22 250.26 percent of total billed charges "AQUACEL 3.5"" X 12""" 48711956_1 CDM 0272 RC inpatient 258 167.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 156.22 250.26 "AQUACEL 3.5"" X 12""" 48711956_1 CDM 0272 RC inpatient 258 167.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 156.22 250.26 "AQUACEL 3.5"" X 12""" 48711956_1 CDM 0272 RC inpatient 258 167.7 ANTHEM HMO ANTHEM HMO 999999999 156.22 250.26 "AQUACEL 3.5"" X 12""" 48711956_1 CDM 0272 RC inpatient 258 167.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 156.22 250.26 "AQUACEL 3.5"" X 12""" 48711956_1 CDM 0272 RC inpatient 258 167.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 174.41 67.6 999999999 156.22 250.26 percent of total billed charges "AQUACEL 3.5"" X 12""" 48711956_1 CDM 0272 RC inpatient 258 167.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 156.22 250.26 DRESSING NASAL SLIM-LINE 8CM 440413 48711958_1 CDM 0272 RC inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges DRESSING NASAL SLIM-LINE 8CM 440413 48711958_1 CDM 0272 RC inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges DRESSING NASAL SLIM-LINE 8CM 440413 48711958_1 CDM 0272 RC inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges DRESSING NASAL SLIM-LINE 8CM 440413 48711958_1 CDM 0272 RC inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges DRESSING NASAL SLIM-LINE 8CM 440413 48711958_1 CDM 0272 RC inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges DRESSING NASAL SLIM-LINE 8CM 440413 48711958_1 CDM 0272 RC inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges DRESSING NASAL SLIM-LINE 8CM 440413 48711958_1 CDM 0272 RC inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges DRESSING NASAL SLIM-LINE 8CM 440413 48711958_1 CDM 0272 RC inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges DRESSING NASAL SLIM-LINE 8CM 440413 48711958_1 CDM 0272 RC inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 DRESSING NASAL SLIM-LINE 8CM 440413 48711958_1 CDM 0272 RC inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 DRESSING NASAL SLIM-LINE 8CM 440413 48711958_1 CDM 0272 RC inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 DRESSING NASAL SLIM-LINE 8CM 440413 48711958_1 CDM 0272 RC inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 DRESSING NASAL SLIM-LINE 8CM 440413 48711958_1 CDM 0272 RC inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges DRESSING NASAL SLIM-LINE 8CM 440413 48711958_1 CDM 0272 RC inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 INFLATION DEVICE BID30 48711959_1 CDM 0272 RC inpatient 618 401.7 AETNA AETNA 488.22 79 999999999 374.2 599.46 percent of total billed charges INFLATION DEVICE BID30 48711959_1 CDM 0272 RC inpatient 618 401.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 401.7 65 999999999 374.2 599.46 percent of total billed charges INFLATION DEVICE BID30 48711959_1 CDM 0272 RC inpatient 618 401.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 599.46 97 999999999 374.2 599.46 percent of total billed charges INFLATION DEVICE BID30 48711959_1 CDM 0272 RC inpatient 618 401.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 426.42 69 999999999 374.2 599.46 percent of total billed charges INFLATION DEVICE BID30 48711959_1 CDM 0272 RC inpatient 618 401.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 482.04 78 999999999 374.2 599.46 percent of total billed charges INFLATION DEVICE BID30 48711959_1 CDM 0272 RC inpatient 618 401.7 SIHO - ALL PLANS SIHO - ALL PLANS 556.2 90 999999999 374.2 599.46 percent of total billed charges INFLATION DEVICE BID30 48711959_1 CDM 0272 RC inpatient 618 401.7 UMR - ALL PLANS UMR - ALL PLANS 432.6 70 999999999 374.2 599.46 percent of total billed charges INFLATION DEVICE BID30 48711959_1 CDM 0272 RC inpatient 618 401.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 374.2 60.55 999999999 374.2 599.46 percent of total billed charges INFLATION DEVICE BID30 48711959_1 CDM 0272 RC inpatient 618 401.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 374.2 599.46 INFLATION DEVICE BID30 48711959_1 CDM 0272 RC inpatient 618 401.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 374.2 599.46 INFLATION DEVICE BID30 48711959_1 CDM 0272 RC inpatient 618 401.7 ANTHEM HMO ANTHEM HMO 999999999 374.2 599.46 INFLATION DEVICE BID30 48711959_1 CDM 0272 RC inpatient 618 401.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 374.2 599.46 INFLATION DEVICE BID30 48711959_1 CDM 0272 RC inpatient 618 401.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 417.77 67.6 999999999 374.2 599.46 percent of total billed charges INFLATION DEVICE BID30 48711959_1 CDM 0272 RC inpatient 618 401.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 374.2 599.46 MEPILEX BORDER SACRUM 282400 48711966_1 CDM 0270 RC inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges MEPILEX BORDER SACRUM 282400 48711966_1 CDM 0270 RC inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges MEPILEX BORDER SACRUM 282400 48711966_1 CDM 0270 RC inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges MEPILEX BORDER SACRUM 282400 48711966_1 CDM 0270 RC inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges MEPILEX BORDER SACRUM 282400 48711966_1 CDM 0270 RC inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges MEPILEX BORDER SACRUM 282400 48711966_1 CDM 0270 RC inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges MEPILEX BORDER SACRUM 282400 48711966_1 CDM 0270 RC inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges MEPILEX BORDER SACRUM 282400 48711966_1 CDM 0270 RC inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges MEPILEX BORDER SACRUM 282400 48711966_1 CDM 0270 RC inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 MEPILEX BORDER SACRUM 282400 48711966_1 CDM 0270 RC inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 MEPILEX BORDER SACRUM 282400 48711966_1 CDM 0270 RC inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 MEPILEX BORDER SACRUM 282400 48711966_1 CDM 0270 RC inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 MEPILEX BORDER SACRUM 282400 48711966_1 CDM 0270 RC inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges MEPILEX BORDER SACRUM 282400 48711966_1 CDM 0270 RC inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 RAPID RHINO NASAL 5.5 RR550 48711977_1 CDM 0272 RC inpatient 239 155.35 AETNA AETNA 188.81 79 999999999 144.71 231.83 percent of total billed charges RAPID RHINO NASAL 5.5 RR550 48711977_1 CDM 0272 RC inpatient 239 155.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 155.35 65 999999999 144.71 231.83 percent of total billed charges RAPID RHINO NASAL 5.5 RR550 48711977_1 CDM 0272 RC inpatient 239 155.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 231.83 97 999999999 144.71 231.83 percent of total billed charges RAPID RHINO NASAL 5.5 RR550 48711977_1 CDM 0272 RC inpatient 239 155.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.91 69 999999999 144.71 231.83 percent of total billed charges RAPID RHINO NASAL 5.5 RR550 48711977_1 CDM 0272 RC inpatient 239 155.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 186.42 78 999999999 144.71 231.83 percent of total billed charges RAPID RHINO NASAL 5.5 RR550 48711977_1 CDM 0272 RC inpatient 239 155.35 SIHO - ALL PLANS SIHO - ALL PLANS 215.1 90 999999999 144.71 231.83 percent of total billed charges RAPID RHINO NASAL 5.5 RR550 48711977_1 CDM 0272 RC inpatient 239 155.35 UMR - ALL PLANS UMR - ALL PLANS 167.3 70 999999999 144.71 231.83 percent of total billed charges RAPID RHINO NASAL 5.5 RR550 48711977_1 CDM 0272 RC inpatient 239 155.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.71 60.55 999999999 144.71 231.83 percent of total billed charges RAPID RHINO NASAL 5.5 RR550 48711977_1 CDM 0272 RC inpatient 239 155.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.71 231.83 RAPID RHINO NASAL 5.5 RR550 48711977_1 CDM 0272 RC inpatient 239 155.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.71 231.83 RAPID RHINO NASAL 5.5 RR550 48711977_1 CDM 0272 RC inpatient 239 155.35 ANTHEM HMO ANTHEM HMO 999999999 144.71 231.83 RAPID RHINO NASAL 5.5 RR550 48711977_1 CDM 0272 RC inpatient 239 155.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.71 231.83 RAPID RHINO NASAL 5.5 RR550 48711977_1 CDM 0272 RC inpatient 239 155.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 161.56 67.6 999999999 144.71 231.83 percent of total billed charges RAPID RHINO NASAL 5.5 RR550 48711977_1 CDM 0272 RC inpatient 239 155.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.71 231.83 RAPID RHINO NASAL 7.5 RR750 48711978_1 CDM 0272 RC inpatient 247 160.55 AETNA AETNA 195.13 79 999999999 149.56 239.59 percent of total billed charges RAPID RHINO NASAL 7.5 RR750 48711978_1 CDM 0272 RC inpatient 247 160.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 160.55 65 999999999 149.56 239.59 percent of total billed charges RAPID RHINO NASAL 7.5 RR750 48711978_1 CDM 0272 RC inpatient 247 160.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 239.59 97 999999999 149.56 239.59 percent of total billed charges RAPID RHINO NASAL 7.5 RR750 48711978_1 CDM 0272 RC inpatient 247 160.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 170.43 69 999999999 149.56 239.59 percent of total billed charges RAPID RHINO NASAL 7.5 RR750 48711978_1 CDM 0272 RC inpatient 247 160.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 192.66 78 999999999 149.56 239.59 percent of total billed charges RAPID RHINO NASAL 7.5 RR750 48711978_1 CDM 0272 RC inpatient 247 160.55 SIHO - ALL PLANS SIHO - ALL PLANS 222.3 90 999999999 149.56 239.59 percent of total billed charges RAPID RHINO NASAL 7.5 RR750 48711978_1 CDM 0272 RC inpatient 247 160.55 UMR - ALL PLANS UMR - ALL PLANS 172.9 70 999999999 149.56 239.59 percent of total billed charges RAPID RHINO NASAL 7.5 RR750 48711978_1 CDM 0272 RC inpatient 247 160.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 149.56 60.55 999999999 149.56 239.59 percent of total billed charges RAPID RHINO NASAL 7.5 RR750 48711978_1 CDM 0272 RC inpatient 247 160.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 149.56 239.59 RAPID RHINO NASAL 7.5 RR750 48711978_1 CDM 0272 RC inpatient 247 160.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 149.56 239.59 RAPID RHINO NASAL 7.5 RR750 48711978_1 CDM 0272 RC inpatient 247 160.55 ANTHEM HMO ANTHEM HMO 999999999 149.56 239.59 RAPID RHINO NASAL 7.5 RR750 48711978_1 CDM 0272 RC inpatient 247 160.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 149.56 239.59 RAPID RHINO NASAL 7.5 RR750 48711978_1 CDM 0272 RC inpatient 247 160.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 166.97 67.6 999999999 149.56 239.59 percent of total billed charges RAPID RHINO NASAL 7.5 RR750 48711978_1 CDM 0272 RC inpatient 247 160.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 149.56 239.59 CHLORAPREP HI-LITE ORANGE 930815 48711979_1 CDM 0272 RC inpatient 45 29.25 AETNA AETNA 35.55 79 999999999 27.25 43.65 percent of total billed charges CHLORAPREP HI-LITE ORANGE 930815 48711979_1 CDM 0272 RC inpatient 45 29.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 29.25 65 999999999 27.25 43.65 percent of total billed charges CHLORAPREP HI-LITE ORANGE 930815 48711979_1 CDM 0272 RC inpatient 45 29.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 43.65 97 999999999 27.25 43.65 percent of total billed charges CHLORAPREP HI-LITE ORANGE 930815 48711979_1 CDM 0272 RC inpatient 45 29.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 31.05 69 999999999 27.25 43.65 percent of total billed charges CHLORAPREP HI-LITE ORANGE 930815 48711979_1 CDM 0272 RC inpatient 45 29.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 35.1 78 999999999 27.25 43.65 percent of total billed charges CHLORAPREP HI-LITE ORANGE 930815 48711979_1 CDM 0272 RC inpatient 45 29.25 SIHO - ALL PLANS SIHO - ALL PLANS 40.5 90 999999999 27.25 43.65 percent of total billed charges CHLORAPREP HI-LITE ORANGE 930815 48711979_1 CDM 0272 RC inpatient 45 29.25 UMR - ALL PLANS UMR - ALL PLANS 31.5 70 999999999 27.25 43.65 percent of total billed charges CHLORAPREP HI-LITE ORANGE 930815 48711979_1 CDM 0272 RC inpatient 45 29.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27.25 60.55 999999999 27.25 43.65 percent of total billed charges CHLORAPREP HI-LITE ORANGE 930815 48711979_1 CDM 0272 RC inpatient 45 29.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 27.25 43.65 CHLORAPREP HI-LITE ORANGE 930815 48711979_1 CDM 0272 RC inpatient 45 29.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 27.25 43.65 CHLORAPREP HI-LITE ORANGE 930815 48711979_1 CDM 0272 RC inpatient 45 29.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 27.25 43.65 CHLORAPREP HI-LITE ORANGE 930815 48711979_1 CDM 0272 RC inpatient 45 29.25 ANTHEM HMO ANTHEM HMO 999999999 27.25 43.65 CHLORAPREP HI-LITE ORANGE 930815 48711979_1 CDM 0272 RC inpatient 45 29.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 30.42 67.6 999999999 27.25 43.65 percent of total billed charges CHLORAPREP HI-LITE ORANGE 930815 48711979_1 CDM 0272 RC inpatient 45 29.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 27.25 43.65 ELECTROSURG BALL ELECTRODE 5MM DBL-511 48711980_1 CDM 0272 RC inpatient 98 63.7 AETNA AETNA 77.42 79 999999999 59.34 95.06 percent of total billed charges ELECTROSURG BALL ELECTRODE 5MM DBL-511 48711980_1 CDM 0272 RC inpatient 98 63.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.7 65 999999999 59.34 95.06 percent of total billed charges ELECTROSURG BALL ELECTRODE 5MM DBL-511 48711980_1 CDM 0272 RC inpatient 98 63.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.06 97 999999999 59.34 95.06 percent of total billed charges ELECTROSURG BALL ELECTRODE 5MM DBL-511 48711980_1 CDM 0272 RC inpatient 98 63.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.62 69 999999999 59.34 95.06 percent of total billed charges ELECTROSURG BALL ELECTRODE 5MM DBL-511 48711980_1 CDM 0272 RC inpatient 98 63.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.44 78 999999999 59.34 95.06 percent of total billed charges ELECTROSURG BALL ELECTRODE 5MM DBL-511 48711980_1 CDM 0272 RC inpatient 98 63.7 SIHO - ALL PLANS SIHO - ALL PLANS 88.2 90 999999999 59.34 95.06 percent of total billed charges ELECTROSURG BALL ELECTRODE 5MM DBL-511 48711980_1 CDM 0272 RC inpatient 98 63.7 UMR - ALL PLANS UMR - ALL PLANS 68.6 70 999999999 59.34 95.06 percent of total billed charges ELECTROSURG BALL ELECTRODE 5MM DBL-511 48711980_1 CDM 0272 RC inpatient 98 63.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.34 60.55 999999999 59.34 95.06 percent of total billed charges ELECTROSURG BALL ELECTRODE 5MM DBL-511 48711980_1 CDM 0272 RC inpatient 98 63.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.34 95.06 ELECTROSURG BALL ELECTRODE 5MM DBL-511 48711980_1 CDM 0272 RC inpatient 98 63.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.34 95.06 ELECTROSURG BALL ELECTRODE 5MM DBL-511 48711980_1 CDM 0272 RC inpatient 98 63.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.34 95.06 ELECTROSURG BALL ELECTRODE 5MM DBL-511 48711980_1 CDM 0272 RC inpatient 98 63.7 ANTHEM HMO ANTHEM HMO 999999999 59.34 95.06 ELECTROSURG BALL ELECTRODE 5MM DBL-511 48711980_1 CDM 0272 RC inpatient 98 63.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.25 67.6 999999999 59.34 95.06 percent of total billed charges ELECTROSURG BALL ELECTRODE 5MM DBL-511 48711980_1 CDM 0272 RC inpatient 98 63.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.34 95.06 ELECTRODE LOOP 10MM YELLOW DLP-S11 48711981_1 CDM 0272 RC inpatient 148 96.2 AETNA AETNA 116.92 79 999999999 89.61 143.56 percent of total billed charges ELECTRODE LOOP 10MM YELLOW DLP-S11 48711981_1 CDM 0272 RC inpatient 148 96.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 96.2 65 999999999 89.61 143.56 percent of total billed charges ELECTRODE LOOP 10MM YELLOW DLP-S11 48711981_1 CDM 0272 RC inpatient 148 96.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 143.56 97 999999999 89.61 143.56 percent of total billed charges ELECTRODE LOOP 10MM YELLOW DLP-S11 48711981_1 CDM 0272 RC inpatient 148 96.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 102.12 69 999999999 89.61 143.56 percent of total billed charges ELECTRODE LOOP 10MM YELLOW DLP-S11 48711981_1 CDM 0272 RC inpatient 148 96.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 115.44 78 999999999 89.61 143.56 percent of total billed charges ELECTRODE LOOP 10MM YELLOW DLP-S11 48711981_1 CDM 0272 RC inpatient 148 96.2 SIHO - ALL PLANS SIHO - ALL PLANS 133.2 90 999999999 89.61 143.56 percent of total billed charges ELECTRODE LOOP 10MM YELLOW DLP-S11 48711981_1 CDM 0272 RC inpatient 148 96.2 UMR - ALL PLANS UMR - ALL PLANS 103.6 70 999999999 89.61 143.56 percent of total billed charges ELECTRODE LOOP 10MM YELLOW DLP-S11 48711981_1 CDM 0272 RC inpatient 148 96.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 89.61 60.55 999999999 89.61 143.56 percent of total billed charges ELECTRODE LOOP 10MM YELLOW DLP-S11 48711981_1 CDM 0272 RC inpatient 148 96.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 89.61 143.56 ELECTRODE LOOP 10MM YELLOW DLP-S11 48711981_1 CDM 0272 RC inpatient 148 96.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 89.61 143.56 ELECTRODE LOOP 10MM YELLOW DLP-S11 48711981_1 CDM 0272 RC inpatient 148 96.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 89.61 143.56 ELECTRODE LOOP 10MM YELLOW DLP-S11 48711981_1 CDM 0272 RC inpatient 148 96.2 ANTHEM HMO ANTHEM HMO 999999999 89.61 143.56 ELECTRODE LOOP 10MM YELLOW DLP-S11 48711981_1 CDM 0272 RC inpatient 148 96.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 100.05 67.6 999999999 89.61 143.56 percent of total billed charges ELECTRODE LOOP 10MM YELLOW DLP-S11 48711981_1 CDM 0272 RC inpatient 148 96.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 89.61 143.56 ELECTRODE KNIFE 24FR 48711982_1 CDM 0272 RC inpatient 659 428.35 AETNA AETNA 520.61 79 999999999 399.02 639.23 percent of total billed charges ELECTRODE KNIFE 24FR 48711982_1 CDM 0272 RC inpatient 659 428.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 428.35 65 999999999 399.02 639.23 percent of total billed charges ELECTRODE KNIFE 24FR 48711982_1 CDM 0272 RC inpatient 659 428.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 639.23 97 999999999 399.02 639.23 percent of total billed charges ELECTRODE KNIFE 24FR 48711982_1 CDM 0272 RC inpatient 659 428.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 454.71 69 999999999 399.02 639.23 percent of total billed charges ELECTRODE KNIFE 24FR 48711982_1 CDM 0272 RC inpatient 659 428.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 514.02 78 999999999 399.02 639.23 percent of total billed charges ELECTRODE KNIFE 24FR 48711982_1 CDM 0272 RC inpatient 659 428.35 SIHO - ALL PLANS SIHO - ALL PLANS 593.1 90 999999999 399.02 639.23 percent of total billed charges ELECTRODE KNIFE 24FR 48711982_1 CDM 0272 RC inpatient 659 428.35 UMR - ALL PLANS UMR - ALL PLANS 461.3 70 999999999 399.02 639.23 percent of total billed charges ELECTRODE KNIFE 24FR 48711982_1 CDM 0272 RC inpatient 659 428.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 399.02 60.55 999999999 399.02 639.23 percent of total billed charges ELECTRODE KNIFE 24FR 48711982_1 CDM 0272 RC inpatient 659 428.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 399.02 639.23 ELECTRODE KNIFE 24FR 48711982_1 CDM 0272 RC inpatient 659 428.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 399.02 639.23 ELECTRODE KNIFE 24FR 48711982_1 CDM 0272 RC inpatient 659 428.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 399.02 639.23 ELECTRODE KNIFE 24FR 48711982_1 CDM 0272 RC inpatient 659 428.35 ANTHEM HMO ANTHEM HMO 999999999 399.02 639.23 ELECTRODE KNIFE 24FR 48711982_1 CDM 0272 RC inpatient 659 428.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 445.48 67.6 999999999 399.02 639.23 percent of total billed charges ELECTRODE KNIFE 24FR 48711982_1 CDM 0272 RC inpatient 659 428.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 399.02 639.23 ELECTRODE ROLLER BALL RB 48711983_1 CDM 0272 RC inpatient 659 428.35 AETNA AETNA 520.61 79 999999999 399.02 639.23 percent of total billed charges ELECTRODE ROLLER BALL RB 48711983_1 CDM 0272 RC inpatient 659 428.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 428.35 65 999999999 399.02 639.23 percent of total billed charges ELECTRODE ROLLER BALL RB 48711983_1 CDM 0272 RC inpatient 659 428.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 639.23 97 999999999 399.02 639.23 percent of total billed charges ELECTRODE ROLLER BALL RB 48711983_1 CDM 0272 RC inpatient 659 428.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 454.71 69 999999999 399.02 639.23 percent of total billed charges ELECTRODE ROLLER BALL RB 48711983_1 CDM 0272 RC inpatient 659 428.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 514.02 78 999999999 399.02 639.23 percent of total billed charges ELECTRODE ROLLER BALL RB 48711983_1 CDM 0272 RC inpatient 659 428.35 SIHO - ALL PLANS SIHO - ALL PLANS 593.1 90 999999999 399.02 639.23 percent of total billed charges ELECTRODE ROLLER BALL RB 48711983_1 CDM 0272 RC inpatient 659 428.35 UMR - ALL PLANS UMR - ALL PLANS 461.3 70 999999999 399.02 639.23 percent of total billed charges ELECTRODE ROLLER BALL RB 48711983_1 CDM 0272 RC inpatient 659 428.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 399.02 60.55 999999999 399.02 639.23 percent of total billed charges ELECTRODE ROLLER BALL RB 48711983_1 CDM 0272 RC inpatient 659 428.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 399.02 639.23 ELECTRODE ROLLER BALL RB 48711983_1 CDM 0272 RC inpatient 659 428.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 399.02 639.23 ELECTRODE ROLLER BALL RB 48711983_1 CDM 0272 RC inpatient 659 428.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 399.02 639.23 ELECTRODE ROLLER BALL RB 48711983_1 CDM 0272 RC inpatient 659 428.35 ANTHEM HMO ANTHEM HMO 999999999 399.02 639.23 ELECTRODE ROLLER BALL RB 48711983_1 CDM 0272 RC inpatient 659 428.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 445.48 67.6 999999999 399.02 639.23 percent of total billed charges ELECTRODE ROLLER BALL RB 48711983_1 CDM 0272 RC inpatient 659 428.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 399.02 639.23 ELECTRODE BALL 48711984_1 CDM 0272 RC inpatient 1094 711.1 AETNA AETNA 864.26 79 999999999 662.42 1061.18 percent of total billed charges ELECTRODE BALL 48711984_1 CDM 0272 RC inpatient 1094 711.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 711.1 65 999999999 662.42 1061.18 percent of total billed charges ELECTRODE BALL 48711984_1 CDM 0272 RC inpatient 1094 711.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1061.18 97 999999999 662.42 1061.18 percent of total billed charges ELECTRODE BALL 48711984_1 CDM 0272 RC inpatient 1094 711.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 754.86 69 999999999 662.42 1061.18 percent of total billed charges ELECTRODE BALL 48711984_1 CDM 0272 RC inpatient 1094 711.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 853.32 78 999999999 662.42 1061.18 percent of total billed charges ELECTRODE BALL 48711984_1 CDM 0272 RC inpatient 1094 711.1 SIHO - ALL PLANS SIHO - ALL PLANS 984.6 90 999999999 662.42 1061.18 percent of total billed charges ELECTRODE BALL 48711984_1 CDM 0272 RC inpatient 1094 711.1 UMR - ALL PLANS UMR - ALL PLANS 765.8 70 999999999 662.42 1061.18 percent of total billed charges ELECTRODE BALL 48711984_1 CDM 0272 RC inpatient 1094 711.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 662.42 60.55 999999999 662.42 1061.18 percent of total billed charges ELECTRODE BALL 48711984_1 CDM 0272 RC inpatient 1094 711.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 662.42 1061.18 ELECTRODE BALL 48711984_1 CDM 0272 RC inpatient 1094 711.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 662.42 1061.18 ELECTRODE BALL 48711984_1 CDM 0272 RC inpatient 1094 711.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 662.42 1061.18 ELECTRODE BALL 48711984_1 CDM 0272 RC inpatient 1094 711.1 ANTHEM HMO ANTHEM HMO 999999999 662.42 1061.18 ELECTRODE BALL 48711984_1 CDM 0272 RC inpatient 1094 711.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 739.54 67.6 999999999 662.42 1061.18 percent of total billed charges ELECTRODE BALL 48711984_1 CDM 0272 RC inpatient 1094 711.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 662.42 1061.18 ELECTRODE LOOP 20MM WHITE DLP-W11 48711985_1 CDM 0272 RC inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges ELECTRODE LOOP 20MM WHITE DLP-W11 48711985_1 CDM 0272 RC inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges ELECTRODE LOOP 20MM WHITE DLP-W11 48711985_1 CDM 0272 RC inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges ELECTRODE LOOP 20MM WHITE DLP-W11 48711985_1 CDM 0272 RC inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges ELECTRODE LOOP 20MM WHITE DLP-W11 48711985_1 CDM 0272 RC inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges ELECTRODE LOOP 20MM WHITE DLP-W11 48711985_1 CDM 0272 RC inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges ELECTRODE LOOP 20MM WHITE DLP-W11 48711985_1 CDM 0272 RC inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges ELECTRODE LOOP 20MM WHITE DLP-W11 48711985_1 CDM 0272 RC inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges ELECTRODE LOOP 20MM WHITE DLP-W11 48711985_1 CDM 0272 RC inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 ELECTRODE LOOP 20MM WHITE DLP-W11 48711985_1 CDM 0272 RC inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 ELECTRODE LOOP 20MM WHITE DLP-W11 48711985_1 CDM 0272 RC inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 ELECTRODE LOOP 20MM WHITE DLP-W11 48711985_1 CDM 0272 RC inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 ELECTRODE LOOP 20MM WHITE DLP-W11 48711985_1 CDM 0272 RC inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges ELECTRODE LOOP 20MM WHITE DLP-W11 48711985_1 CDM 0272 RC inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 ELECTRODE LOOP 15MM GREEN DLP-M11 48711986_1 CDM 0272 RC inpatient 98 63.7 AETNA AETNA 77.42 79 999999999 59.34 95.06 percent of total billed charges ELECTRODE LOOP 15MM GREEN DLP-M11 48711986_1 CDM 0272 RC inpatient 98 63.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.7 65 999999999 59.34 95.06 percent of total billed charges ELECTRODE LOOP 15MM GREEN DLP-M11 48711986_1 CDM 0272 RC inpatient 98 63.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.06 97 999999999 59.34 95.06 percent of total billed charges ELECTRODE LOOP 15MM GREEN DLP-M11 48711986_1 CDM 0272 RC inpatient 98 63.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.62 69 999999999 59.34 95.06 percent of total billed charges ELECTRODE LOOP 15MM GREEN DLP-M11 48711986_1 CDM 0272 RC inpatient 98 63.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.44 78 999999999 59.34 95.06 percent of total billed charges ELECTRODE LOOP 15MM GREEN DLP-M11 48711986_1 CDM 0272 RC inpatient 98 63.7 SIHO - ALL PLANS SIHO - ALL PLANS 88.2 90 999999999 59.34 95.06 percent of total billed charges ELECTRODE LOOP 15MM GREEN DLP-M11 48711986_1 CDM 0272 RC inpatient 98 63.7 UMR - ALL PLANS UMR - ALL PLANS 68.6 70 999999999 59.34 95.06 percent of total billed charges ELECTRODE LOOP 15MM GREEN DLP-M11 48711986_1 CDM 0272 RC inpatient 98 63.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.34 60.55 999999999 59.34 95.06 percent of total billed charges ELECTRODE LOOP 15MM GREEN DLP-M11 48711986_1 CDM 0272 RC inpatient 98 63.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.34 95.06 ELECTRODE LOOP 15MM GREEN DLP-M11 48711986_1 CDM 0272 RC inpatient 98 63.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.34 95.06 ELECTRODE LOOP 15MM GREEN DLP-M11 48711986_1 CDM 0272 RC inpatient 98 63.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.34 95.06 ELECTRODE LOOP 15MM GREEN DLP-M11 48711986_1 CDM 0272 RC inpatient 98 63.7 ANTHEM HMO ANTHEM HMO 999999999 59.34 95.06 ELECTRODE LOOP 15MM GREEN DLP-M11 48711986_1 CDM 0272 RC inpatient 98 63.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.25 67.6 999999999 59.34 95.06 percent of total billed charges ELECTRODE LOOP 15MM GREEN DLP-M11 48711986_1 CDM 0272 RC inpatient 98 63.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.34 95.06 ENDO CHOLANGIOCATH 5MM 48711989_1 CDM 0272 RC inpatient 340 221 AETNA AETNA 268.6 79 999999999 205.87 329.8 percent of total billed charges ENDO CHOLANGIOCATH 5MM 48711989_1 CDM 0272 RC inpatient 340 221 SELF PAY DISCOUNT SELF PAY DISCOUNT 221 65 999999999 205.87 329.8 percent of total billed charges ENDO CHOLANGIOCATH 5MM 48711989_1 CDM 0272 RC inpatient 340 221 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 329.8 97 999999999 205.87 329.8 percent of total billed charges ENDO CHOLANGIOCATH 5MM 48711989_1 CDM 0272 RC inpatient 340 221 ENCORE - ALL PLANS ENCORE - ALL PLANS 234.6 69 999999999 205.87 329.8 percent of total billed charges ENDO CHOLANGIOCATH 5MM 48711989_1 CDM 0272 RC inpatient 340 221 HUMANA - ALL PLANS HUMANA - ALL PLANS 265.2 78 999999999 205.87 329.8 percent of total billed charges ENDO CHOLANGIOCATH 5MM 48711989_1 CDM 0272 RC inpatient 340 221 SIHO - ALL PLANS SIHO - ALL PLANS 306 90 999999999 205.87 329.8 percent of total billed charges ENDO CHOLANGIOCATH 5MM 48711989_1 CDM 0272 RC inpatient 340 221 UMR - ALL PLANS UMR - ALL PLANS 238 70 999999999 205.87 329.8 percent of total billed charges ENDO CHOLANGIOCATH 5MM 48711989_1 CDM 0272 RC inpatient 340 221 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.87 60.55 999999999 205.87 329.8 percent of total billed charges ENDO CHOLANGIOCATH 5MM 48711989_1 CDM 0272 RC inpatient 340 221 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.87 329.8 ENDO CHOLANGIOCATH 5MM 48711989_1 CDM 0272 RC inpatient 340 221 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.87 329.8 ENDO CHOLANGIOCATH 5MM 48711989_1 CDM 0272 RC inpatient 340 221 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.87 329.8 ENDO CHOLANGIOCATH 5MM 48711989_1 CDM 0272 RC inpatient 340 221 ANTHEM HMO ANTHEM HMO 999999999 205.87 329.8 ENDO CHOLANGIOCATH 5MM 48711989_1 CDM 0272 RC inpatient 340 221 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.84 67.6 999999999 205.87 329.8 percent of total billed charges ENDO CHOLANGIOCATH 5MM 48711989_1 CDM 0272 RC inpatient 340 221 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.87 329.8 ENDOBAG 25030 48711990_1 CDM 0272 RC inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges ENDOBAG 25030 48711990_1 CDM 0272 RC inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges ENDOBAG 25030 48711990_1 CDM 0272 RC inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges ENDOBAG 25030 48711990_1 CDM 0272 RC inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges ENDOBAG 25030 48711990_1 CDM 0272 RC inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges ENDOBAG 25030 48711990_1 CDM 0272 RC inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges ENDOBAG 25030 48711990_1 CDM 0272 RC inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges ENDOBAG 25030 48711990_1 CDM 0272 RC inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges ENDOBAG 25030 48711990_1 CDM 0272 RC inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 ENDOBAG 25030 48711990_1 CDM 0272 RC inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 ENDOBAG 25030 48711990_1 CDM 0272 RC inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 ENDOBAG 25030 48711990_1 CDM 0272 RC inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 ENDOBAG 25030 48711990_1 CDM 0272 RC inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges ENDOBAG 25030 48711990_1 CDM 0272 RC inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 TRAY INCISION DRAINAGE ID1850 48711991_1 CDM 0272 RC inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges TRAY INCISION DRAINAGE ID1850 48711991_1 CDM 0272 RC inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges TRAY INCISION DRAINAGE ID1850 48711991_1 CDM 0272 RC inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges TRAY INCISION DRAINAGE ID1850 48711991_1 CDM 0272 RC inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges TRAY INCISION DRAINAGE ID1850 48711991_1 CDM 0272 RC inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges TRAY INCISION DRAINAGE ID1850 48711991_1 CDM 0272 RC inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges TRAY INCISION DRAINAGE ID1850 48711991_1 CDM 0272 RC inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges TRAY INCISION DRAINAGE ID1850 48711991_1 CDM 0272 RC inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges TRAY INCISION DRAINAGE ID1850 48711991_1 CDM 0272 RC inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 TRAY INCISION DRAINAGE ID1850 48711991_1 CDM 0272 RC inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 TRAY INCISION DRAINAGE ID1850 48711991_1 CDM 0272 RC inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 TRAY INCISION DRAINAGE ID1850 48711991_1 CDM 0272 RC inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 TRAY INCISION DRAINAGE ID1850 48711991_1 CDM 0272 RC inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges TRAY INCISION DRAINAGE ID1850 48711991_1 CDM 0272 RC inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 ENDO CATCH BAG CD001 48711992_1 CDM 0272 RC inpatient 203 131.95 AETNA AETNA 160.37 79 999999999 122.92 196.91 percent of total billed charges ENDO CATCH BAG CD001 48711992_1 CDM 0272 RC inpatient 203 131.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 131.95 65 999999999 122.92 196.91 percent of total billed charges ENDO CATCH BAG CD001 48711992_1 CDM 0272 RC inpatient 203 131.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 196.91 97 999999999 122.92 196.91 percent of total billed charges ENDO CATCH BAG CD001 48711992_1 CDM 0272 RC inpatient 203 131.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.07 69 999999999 122.92 196.91 percent of total billed charges ENDO CATCH BAG CD001 48711992_1 CDM 0272 RC inpatient 203 131.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 158.34 78 999999999 122.92 196.91 percent of total billed charges ENDO CATCH BAG CD001 48711992_1 CDM 0272 RC inpatient 203 131.95 SIHO - ALL PLANS SIHO - ALL PLANS 182.7 90 999999999 122.92 196.91 percent of total billed charges ENDO CATCH BAG CD001 48711992_1 CDM 0272 RC inpatient 203 131.95 UMR - ALL PLANS UMR - ALL PLANS 142.1 70 999999999 122.92 196.91 percent of total billed charges ENDO CATCH BAG CD001 48711992_1 CDM 0272 RC inpatient 203 131.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 122.92 60.55 999999999 122.92 196.91 percent of total billed charges ENDO CATCH BAG CD001 48711992_1 CDM 0272 RC inpatient 203 131.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 122.92 196.91 ENDO CATCH BAG CD001 48711992_1 CDM 0272 RC inpatient 203 131.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 122.92 196.91 ENDO CATCH BAG CD001 48711992_1 CDM 0272 RC inpatient 203 131.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 122.92 196.91 ENDO CATCH BAG CD001 48711992_1 CDM 0272 RC inpatient 203 131.95 ANTHEM HMO ANTHEM HMO 999999999 122.92 196.91 ENDO CATCH BAG CD001 48711992_1 CDM 0272 RC inpatient 203 131.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.23 67.6 999999999 122.92 196.91 percent of total billed charges ENDO CATCH BAG CD001 48711992_1 CDM 0272 RC inpatient 203 131.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 122.92 196.91 ENDO CLIP APLIER 5MM 176630 48711993_1 CDM 0272 RC inpatient 1061 689.65 AETNA AETNA 838.19 79 999999999 642.44 1029.17 percent of total billed charges ENDO CLIP APLIER 5MM 176630 48711993_1 CDM 0272 RC inpatient 1061 689.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 689.65 65 999999999 642.44 1029.17 percent of total billed charges ENDO CLIP APLIER 5MM 176630 48711993_1 CDM 0272 RC inpatient 1061 689.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1029.17 97 999999999 642.44 1029.17 percent of total billed charges ENDO CLIP APLIER 5MM 176630 48711993_1 CDM 0272 RC inpatient 1061 689.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 732.09 69 999999999 642.44 1029.17 percent of total billed charges ENDO CLIP APLIER 5MM 176630 48711993_1 CDM 0272 RC inpatient 1061 689.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 827.58 78 999999999 642.44 1029.17 percent of total billed charges ENDO CLIP APLIER 5MM 176630 48711993_1 CDM 0272 RC inpatient 1061 689.65 SIHO - ALL PLANS SIHO - ALL PLANS 954.9 90 999999999 642.44 1029.17 percent of total billed charges ENDO CLIP APLIER 5MM 176630 48711993_1 CDM 0272 RC inpatient 1061 689.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 642.44 60.55 999999999 642.44 1029.17 percent of total billed charges ENDO CLIP APLIER 5MM 176630 48711993_1 CDM 0272 RC inpatient 1061 689.65 UMR - ALL PLANS UMR - ALL PLANS 742.7 70 999999999 642.44 1029.17 percent of total billed charges ENDO CLIP APLIER 5MM 176630 48711993_1 CDM 0272 RC inpatient 1061 689.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 642.44 1029.17 ENDO CLIP APLIER 5MM 176630 48711993_1 CDM 0272 RC inpatient 1061 689.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 642.44 1029.17 ENDO CLIP APLIER 5MM 176630 48711993_1 CDM 0272 RC inpatient 1061 689.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 642.44 1029.17 ENDO CLIP APLIER 5MM 176630 48711993_1 CDM 0272 RC inpatient 1061 689.65 ANTHEM HMO ANTHEM HMO 999999999 642.44 1029.17 ENDO CLIP APLIER 5MM 176630 48711993_1 CDM 0272 RC inpatient 1061 689.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 717.24 67.6 999999999 642.44 1029.17 percent of total billed charges ENDO CLIP APLIER 5MM 176630 48711993_1 CDM 0272 RC inpatient 1061 689.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 642.44 1029.17 LASER FLEX TRACH TUBE 4.5MM 48712009_1 CDM 0274 RC inpatient 327 212.55 AETNA AETNA 258.33 79 999999999 198 317.19 percent of total billed charges LASER FLEX TRACH TUBE 4.5MM 48712009_1 CDM 0274 RC inpatient 327 212.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 212.55 65 999999999 198 317.19 percent of total billed charges LASER FLEX TRACH TUBE 4.5MM 48712009_1 CDM 0274 RC inpatient 327 212.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 317.19 97 999999999 198 317.19 percent of total billed charges LASER FLEX TRACH TUBE 4.5MM 48712009_1 CDM 0274 RC inpatient 327 212.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 225.63 69 999999999 198 317.19 percent of total billed charges LASER FLEX TRACH TUBE 4.5MM 48712009_1 CDM 0274 RC inpatient 327 212.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.06 78 999999999 198 317.19 percent of total billed charges LASER FLEX TRACH TUBE 4.5MM 48712009_1 CDM 0274 RC inpatient 327 212.55 SIHO - ALL PLANS SIHO - ALL PLANS 294.3 90 999999999 198 317.19 percent of total billed charges LASER FLEX TRACH TUBE 4.5MM 48712009_1 CDM 0274 RC inpatient 327 212.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198 60.55 999999999 198 317.19 percent of total billed charges LASER FLEX TRACH TUBE 4.5MM 48712009_1 CDM 0274 RC inpatient 327 212.55 UMR - ALL PLANS UMR - ALL PLANS 228.9 70 999999999 198 317.19 percent of total billed charges LASER FLEX TRACH TUBE 4.5MM 48712009_1 CDM 0274 RC inpatient 327 212.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198 317.19 LASER FLEX TRACH TUBE 4.5MM 48712009_1 CDM 0274 RC inpatient 327 212.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198 317.19 LASER FLEX TRACH TUBE 4.5MM 48712009_1 CDM 0274 RC inpatient 327 212.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198 317.19 LASER FLEX TRACH TUBE 4.5MM 48712009_1 CDM 0274 RC inpatient 327 212.55 ANTHEM HMO ANTHEM HMO 999999999 198 317.19 LASER FLEX TRACH TUBE 4.5MM 48712009_1 CDM 0274 RC inpatient 327 212.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.05 67.6 999999999 198 317.19 percent of total billed charges LASER FLEX TRACH TUBE 4.5MM 48712009_1 CDM 0274 RC inpatient 327 212.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 198 317.19 LASER FLEX TRACH TUBE 5.0MM 48712010_1 CDM 0274 RC inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges LASER FLEX TRACH TUBE 5.0MM 48712010_1 CDM 0274 RC inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges LASER FLEX TRACH TUBE 5.0MM 48712010_1 CDM 0274 RC inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges LASER FLEX TRACH TUBE 5.0MM 48712010_1 CDM 0274 RC inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges LASER FLEX TRACH TUBE 5.0MM 48712010_1 CDM 0274 RC inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges LASER FLEX TRACH TUBE 5.0MM 48712010_1 CDM 0274 RC inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges LASER FLEX TRACH TUBE 5.0MM 48712010_1 CDM 0274 RC inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges LASER FLEX TRACH TUBE 5.0MM 48712010_1 CDM 0274 RC inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges LASER FLEX TRACH TUBE 5.0MM 48712010_1 CDM 0274 RC inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 LASER FLEX TRACH TUBE 5.0MM 48712010_1 CDM 0274 RC inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 LASER FLEX TRACH TUBE 5.0MM 48712010_1 CDM 0274 RC inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 LASER FLEX TRACH TUBE 5.0MM 48712010_1 CDM 0274 RC inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 LASER FLEX TRACH TUBE 5.0MM 48712010_1 CDM 0274 RC inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges LASER FLEX TRACH TUBE 5.0MM 48712010_1 CDM 0274 RC inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 LASER FLEX TRACH TUBE 6MM T 86398 48712011_1 CDM 0274 RC inpatient 268 174.2 AETNA AETNA 211.72 79 999999999 162.27 259.96 percent of total billed charges LASER FLEX TRACH TUBE 6MM T 86398 48712011_1 CDM 0274 RC inpatient 268 174.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 174.2 65 999999999 162.27 259.96 percent of total billed charges LASER FLEX TRACH TUBE 6MM T 86398 48712011_1 CDM 0274 RC inpatient 268 174.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 259.96 97 999999999 162.27 259.96 percent of total billed charges LASER FLEX TRACH TUBE 6MM T 86398 48712011_1 CDM 0274 RC inpatient 268 174.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.92 69 999999999 162.27 259.96 percent of total billed charges LASER FLEX TRACH TUBE 6MM T 86398 48712011_1 CDM 0274 RC inpatient 268 174.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 209.04 78 999999999 162.27 259.96 percent of total billed charges LASER FLEX TRACH TUBE 6MM T 86398 48712011_1 CDM 0274 RC inpatient 268 174.2 SIHO - ALL PLANS SIHO - ALL PLANS 241.2 90 999999999 162.27 259.96 percent of total billed charges LASER FLEX TRACH TUBE 6MM T 86398 48712011_1 CDM 0274 RC inpatient 268 174.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 162.27 60.55 999999999 162.27 259.96 percent of total billed charges LASER FLEX TRACH TUBE 6MM T 86398 48712011_1 CDM 0274 RC inpatient 268 174.2 UMR - ALL PLANS UMR - ALL PLANS 187.6 70 999999999 162.27 259.96 percent of total billed charges LASER FLEX TRACH TUBE 6MM T 86398 48712011_1 CDM 0274 RC inpatient 268 174.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 162.27 259.96 LASER FLEX TRACH TUBE 6MM T 86398 48712011_1 CDM 0274 RC inpatient 268 174.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 162.27 259.96 LASER FLEX TRACH TUBE 6MM T 86398 48712011_1 CDM 0274 RC inpatient 268 174.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 162.27 259.96 LASER FLEX TRACH TUBE 6MM T 86398 48712011_1 CDM 0274 RC inpatient 268 174.2 ANTHEM HMO ANTHEM HMO 999999999 162.27 259.96 LASER FLEX TRACH TUBE 6MM T 86398 48712011_1 CDM 0274 RC inpatient 268 174.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 181.17 67.6 999999999 162.27 259.96 percent of total billed charges LASER FLEX TRACH TUBE 6MM T 86398 48712011_1 CDM 0274 RC inpatient 268 174.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 162.27 259.96 ELLIK EVACUTOR DISP #000451 48712012_1 CDM 0272 RC inpatient 139 90.35 AETNA AETNA 109.81 79 999999999 84.16 134.83 percent of total billed charges ELLIK EVACUTOR DISP #000451 48712012_1 CDM 0272 RC inpatient 139 90.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 90.35 65 999999999 84.16 134.83 percent of total billed charges ELLIK EVACUTOR DISP #000451 48712012_1 CDM 0272 RC inpatient 139 90.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 134.83 97 999999999 84.16 134.83 percent of total billed charges ELLIK EVACUTOR DISP #000451 48712012_1 CDM 0272 RC inpatient 139 90.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.91 69 999999999 84.16 134.83 percent of total billed charges ELLIK EVACUTOR DISP #000451 48712012_1 CDM 0272 RC inpatient 139 90.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 108.42 78 999999999 84.16 134.83 percent of total billed charges ELLIK EVACUTOR DISP #000451 48712012_1 CDM 0272 RC inpatient 139 90.35 SIHO - ALL PLANS SIHO - ALL PLANS 125.1 90 999999999 84.16 134.83 percent of total billed charges ELLIK EVACUTOR DISP #000451 48712012_1 CDM 0272 RC inpatient 139 90.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 84.16 60.55 999999999 84.16 134.83 percent of total billed charges ELLIK EVACUTOR DISP #000451 48712012_1 CDM 0272 RC inpatient 139 90.35 UMR - ALL PLANS UMR - ALL PLANS 97.3 70 999999999 84.16 134.83 percent of total billed charges ELLIK EVACUTOR DISP #000451 48712012_1 CDM 0272 RC inpatient 139 90.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 84.16 134.83 ELLIK EVACUTOR DISP #000451 48712012_1 CDM 0272 RC inpatient 139 90.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 84.16 134.83 ELLIK EVACUTOR DISP #000451 48712012_1 CDM 0272 RC inpatient 139 90.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 84.16 134.83 ELLIK EVACUTOR DISP #000451 48712012_1 CDM 0272 RC inpatient 139 90.35 ANTHEM HMO ANTHEM HMO 999999999 84.16 134.83 ELLIK EVACUTOR DISP #000451 48712012_1 CDM 0272 RC inpatient 139 90.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.96 67.6 999999999 84.16 134.83 percent of total billed charges ELLIK EVACUTOR DISP #000451 48712012_1 CDM 0272 RC inpatient 139 90.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 84.16 134.83 GASTROSTOMY TUBE 14FR STRAIGHT M00582050 48712013_1 CDM 0272 RC inpatient 192 124.8 AETNA AETNA 151.68 79 999999999 116.26 186.24 percent of total billed charges GASTROSTOMY TUBE 14FR STRAIGHT M00582050 48712013_1 CDM 0272 RC inpatient 192 124.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 124.8 65 999999999 116.26 186.24 percent of total billed charges GASTROSTOMY TUBE 14FR STRAIGHT M00582050 48712013_1 CDM 0272 RC inpatient 192 124.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 186.24 97 999999999 116.26 186.24 percent of total billed charges GASTROSTOMY TUBE 14FR STRAIGHT M00582050 48712013_1 CDM 0272 RC inpatient 192 124.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 132.48 69 999999999 116.26 186.24 percent of total billed charges GASTROSTOMY TUBE 14FR STRAIGHT M00582050 48712013_1 CDM 0272 RC inpatient 192 124.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 149.76 78 999999999 116.26 186.24 percent of total billed charges GASTROSTOMY TUBE 14FR STRAIGHT M00582050 48712013_1 CDM 0272 RC inpatient 192 124.8 SIHO - ALL PLANS SIHO - ALL PLANS 172.8 90 999999999 116.26 186.24 percent of total billed charges GASTROSTOMY TUBE 14FR STRAIGHT M00582050 48712013_1 CDM 0272 RC inpatient 192 124.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.26 60.55 999999999 116.26 186.24 percent of total billed charges GASTROSTOMY TUBE 14FR STRAIGHT M00582050 48712013_1 CDM 0272 RC inpatient 192 124.8 UMR - ALL PLANS UMR - ALL PLANS 134.4 70 999999999 116.26 186.24 percent of total billed charges GASTROSTOMY TUBE 14FR STRAIGHT M00582050 48712013_1 CDM 0272 RC inpatient 192 124.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.26 186.24 GASTROSTOMY TUBE 14FR STRAIGHT M00582050 48712013_1 CDM 0272 RC inpatient 192 124.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.26 186.24 GASTROSTOMY TUBE 14FR STRAIGHT M00582050 48712013_1 CDM 0272 RC inpatient 192 124.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.26 186.24 GASTROSTOMY TUBE 14FR STRAIGHT M00582050 48712013_1 CDM 0272 RC inpatient 192 124.8 ANTHEM HMO ANTHEM HMO 999999999 116.26 186.24 GASTROSTOMY TUBE 14FR STRAIGHT M00582050 48712013_1 CDM 0272 RC inpatient 192 124.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 129.79 67.6 999999999 116.26 186.24 percent of total billed charges GASTROSTOMY TUBE 14FR STRAIGHT M00582050 48712013_1 CDM 0272 RC inpatient 192 124.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.26 186.24 GASTROSTOMY TUBE 18FR STRAIGHT M00582070 48712014_1 CDM 0270 RC inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges GASTROSTOMY TUBE 18FR STRAIGHT M00582070 48712014_1 CDM 0270 RC inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges GASTROSTOMY TUBE 18FR STRAIGHT M00582070 48712014_1 CDM 0270 RC inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges GASTROSTOMY TUBE 18FR STRAIGHT M00582070 48712014_1 CDM 0270 RC inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges GASTROSTOMY TUBE 18FR STRAIGHT M00582070 48712014_1 CDM 0270 RC inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges GASTROSTOMY TUBE 18FR STRAIGHT M00582070 48712014_1 CDM 0270 RC inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges GASTROSTOMY TUBE 18FR STRAIGHT M00582070 48712014_1 CDM 0270 RC inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges GASTROSTOMY TUBE 18FR STRAIGHT M00582070 48712014_1 CDM 0270 RC inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges GASTROSTOMY TUBE 18FR STRAIGHT M00582070 48712014_1 CDM 0270 RC inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 GASTROSTOMY TUBE 18FR STRAIGHT M00582070 48712014_1 CDM 0270 RC inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 GASTROSTOMY TUBE 18FR STRAIGHT M00582070 48712014_1 CDM 0270 RC inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 GASTROSTOMY TUBE 18FR STRAIGHT M00582070 48712014_1 CDM 0270 RC inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 GASTROSTOMY TUBE 18FR STRAIGHT M00582070 48712014_1 CDM 0270 RC inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges GASTROSTOMY TUBE 18FR STRAIGHT M00582070 48712014_1 CDM 0270 RC inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 TUBE GASTROSTOMY 24FR M00582090 48712015_1 CDM 0272 RC inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges TUBE GASTROSTOMY 24FR M00582090 48712015_1 CDM 0272 RC inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges TUBE GASTROSTOMY 24FR M00582090 48712015_1 CDM 0272 RC inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges TUBE GASTROSTOMY 24FR M00582090 48712015_1 CDM 0272 RC inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges TUBE GASTROSTOMY 24FR M00582090 48712015_1 CDM 0272 RC inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges TUBE GASTROSTOMY 24FR M00582090 48712015_1 CDM 0272 RC inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges TUBE GASTROSTOMY 24FR M00582090 48712015_1 CDM 0272 RC inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges TUBE GASTROSTOMY 24FR M00582090 48712015_1 CDM 0272 RC inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges TUBE GASTROSTOMY 24FR M00582090 48712015_1 CDM 0272 RC inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 TUBE GASTROSTOMY 24FR M00582090 48712015_1 CDM 0272 RC inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 TUBE GASTROSTOMY 24FR M00582090 48712015_1 CDM 0272 RC inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 TUBE GASTROSTOMY 24FR M00582090 48712015_1 CDM 0272 RC inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 TUBE GASTROSTOMY 24FR M00582090 48712015_1 CDM 0272 RC inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges TUBE GASTROSTOMY 24FR M00582090 48712015_1 CDM 0272 RC inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 GASTROSTOMY TUBE 20FR 48712016_1 CDM 0272 RC inpatient 192 124.8 AETNA AETNA 151.68 79 999999999 116.26 186.24 percent of total billed charges GASTROSTOMY TUBE 20FR 48712016_1 CDM 0272 RC inpatient 192 124.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 124.8 65 999999999 116.26 186.24 percent of total billed charges GASTROSTOMY TUBE 20FR 48712016_1 CDM 0272 RC inpatient 192 124.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 186.24 97 999999999 116.26 186.24 percent of total billed charges GASTROSTOMY TUBE 20FR 48712016_1 CDM 0272 RC inpatient 192 124.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 132.48 69 999999999 116.26 186.24 percent of total billed charges GASTROSTOMY TUBE 20FR 48712016_1 CDM 0272 RC inpatient 192 124.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 149.76 78 999999999 116.26 186.24 percent of total billed charges GASTROSTOMY TUBE 20FR 48712016_1 CDM 0272 RC inpatient 192 124.8 SIHO - ALL PLANS SIHO - ALL PLANS 172.8 90 999999999 116.26 186.24 percent of total billed charges GASTROSTOMY TUBE 20FR 48712016_1 CDM 0272 RC inpatient 192 124.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.26 60.55 999999999 116.26 186.24 percent of total billed charges GASTROSTOMY TUBE 20FR 48712016_1 CDM 0272 RC inpatient 192 124.8 UMR - ALL PLANS UMR - ALL PLANS 134.4 70 999999999 116.26 186.24 percent of total billed charges GASTROSTOMY TUBE 20FR 48712016_1 CDM 0272 RC inpatient 192 124.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.26 186.24 GASTROSTOMY TUBE 20FR 48712016_1 CDM 0272 RC inpatient 192 124.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.26 186.24 GASTROSTOMY TUBE 20FR 48712016_1 CDM 0272 RC inpatient 192 124.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.26 186.24 GASTROSTOMY TUBE 20FR 48712016_1 CDM 0272 RC inpatient 192 124.8 ANTHEM HMO ANTHEM HMO 999999999 116.26 186.24 GASTROSTOMY TUBE 20FR 48712016_1 CDM 0272 RC inpatient 192 124.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 129.79 67.6 999999999 116.26 186.24 percent of total billed charges GASTROSTOMY TUBE 20FR 48712016_1 CDM 0272 RC inpatient 192 124.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.26 186.24 "BANDAGE ESMARK 6""" 48712018_1 CDM 0272 RC inpatient 16 10.4 AETNA AETNA 12.64 79 999999999 9.69 15.52 percent of total billed charges "BANDAGE ESMARK 6""" 48712018_1 CDM 0272 RC inpatient 16 10.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.4 65 999999999 9.69 15.52 percent of total billed charges "BANDAGE ESMARK 6""" 48712018_1 CDM 0272 RC inpatient 16 10.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15.52 97 999999999 9.69 15.52 percent of total billed charges "BANDAGE ESMARK 6""" 48712018_1 CDM 0272 RC inpatient 16 10.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.04 69 999999999 9.69 15.52 percent of total billed charges "BANDAGE ESMARK 6""" 48712018_1 CDM 0272 RC inpatient 16 10.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.48 78 999999999 9.69 15.52 percent of total billed charges "BANDAGE ESMARK 6""" 48712018_1 CDM 0272 RC inpatient 16 10.4 SIHO - ALL PLANS SIHO - ALL PLANS 14.4 90 999999999 9.69 15.52 percent of total billed charges "BANDAGE ESMARK 6""" 48712018_1 CDM 0272 RC inpatient 16 10.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.69 60.55 999999999 9.69 15.52 percent of total billed charges "BANDAGE ESMARK 6""" 48712018_1 CDM 0272 RC inpatient 16 10.4 UMR - ALL PLANS UMR - ALL PLANS 11.2 70 999999999 9.69 15.52 percent of total billed charges "BANDAGE ESMARK 6""" 48712018_1 CDM 0272 RC inpatient 16 10.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.69 15.52 "BANDAGE ESMARK 6""" 48712018_1 CDM 0272 RC inpatient 16 10.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.69 15.52 "BANDAGE ESMARK 6""" 48712018_1 CDM 0272 RC inpatient 16 10.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.69 15.52 "BANDAGE ESMARK 6""" 48712018_1 CDM 0272 RC inpatient 16 10.4 ANTHEM HMO ANTHEM HMO 999999999 9.69 15.52 "BANDAGE ESMARK 6""" 48712018_1 CDM 0272 RC inpatient 16 10.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.82 67.6 999999999 9.69 15.52 percent of total billed charges "BANDAGE ESMARK 6""" 48712018_1 CDM 0272 RC inpatient 16 10.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.69 15.52 FOGARTY BIL BALLOON 5F 410405FP 48712019_1 CDM 0270 RC inpatient 535 347.75 AETNA AETNA 422.65 79 999999999 323.94 518.95 percent of total billed charges FOGARTY BIL BALLOON 5F 410405FP 48712019_1 CDM 0270 RC inpatient 535 347.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 347.75 65 999999999 323.94 518.95 percent of total billed charges FOGARTY BIL BALLOON 5F 410405FP 48712019_1 CDM 0270 RC inpatient 535 347.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 518.95 97 999999999 323.94 518.95 percent of total billed charges FOGARTY BIL BALLOON 5F 410405FP 48712019_1 CDM 0270 RC inpatient 535 347.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 369.15 69 999999999 323.94 518.95 percent of total billed charges FOGARTY BIL BALLOON 5F 410405FP 48712019_1 CDM 0270 RC inpatient 535 347.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 417.3 78 999999999 323.94 518.95 percent of total billed charges FOGARTY BIL BALLOON 5F 410405FP 48712019_1 CDM 0270 RC inpatient 535 347.75 SIHO - ALL PLANS SIHO - ALL PLANS 481.5 90 999999999 323.94 518.95 percent of total billed charges FOGARTY BIL BALLOON 5F 410405FP 48712019_1 CDM 0270 RC inpatient 535 347.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 323.94 60.55 999999999 323.94 518.95 percent of total billed charges FOGARTY BIL BALLOON 5F 410405FP 48712019_1 CDM 0270 RC inpatient 535 347.75 UMR - ALL PLANS UMR - ALL PLANS 374.5 70 999999999 323.94 518.95 percent of total billed charges FOGARTY BIL BALLOON 5F 410405FP 48712019_1 CDM 0270 RC inpatient 535 347.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 323.94 518.95 FOGARTY BIL BALLOON 5F 410405FP 48712019_1 CDM 0270 RC inpatient 535 347.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 323.94 518.95 FOGARTY BIL BALLOON 5F 410405FP 48712019_1 CDM 0270 RC inpatient 535 347.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 323.94 518.95 FOGARTY BIL BALLOON 5F 410405FP 48712019_1 CDM 0270 RC inpatient 535 347.75 ANTHEM HMO ANTHEM HMO 999999999 323.94 518.95 FOGARTY BIL BALLOON 5F 410405FP 48712019_1 CDM 0270 RC inpatient 535 347.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 361.66 67.6 999999999 323.94 518.95 percent of total billed charges FOGARTY BIL BALLOON 5F 410405FP 48712019_1 CDM 0270 RC inpatient 535 347.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 323.94 518.95 FOGARTY ARTER EMBOL 3FR. 80CM 48712020_1 CDM 0270 RC inpatient 245 159.25 AETNA AETNA 193.55 79 999999999 148.35 237.65 percent of total billed charges FOGARTY ARTER EMBOL 3FR. 80CM 48712020_1 CDM 0270 RC inpatient 245 159.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 159.25 65 999999999 148.35 237.65 percent of total billed charges FOGARTY ARTER EMBOL 3FR. 80CM 48712020_1 CDM 0270 RC inpatient 245 159.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 237.65 97 999999999 148.35 237.65 percent of total billed charges FOGARTY ARTER EMBOL 3FR. 80CM 48712020_1 CDM 0270 RC inpatient 245 159.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 169.05 69 999999999 148.35 237.65 percent of total billed charges FOGARTY ARTER EMBOL 3FR. 80CM 48712020_1 CDM 0270 RC inpatient 245 159.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 191.1 78 999999999 148.35 237.65 percent of total billed charges FOGARTY ARTER EMBOL 3FR. 80CM 48712020_1 CDM 0270 RC inpatient 245 159.25 SIHO - ALL PLANS SIHO - ALL PLANS 220.5 90 999999999 148.35 237.65 percent of total billed charges FOGARTY ARTER EMBOL 3FR. 80CM 48712020_1 CDM 0270 RC inpatient 245 159.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 148.35 60.55 999999999 148.35 237.65 percent of total billed charges FOGARTY ARTER EMBOL 3FR. 80CM 48712020_1 CDM 0270 RC inpatient 245 159.25 UMR - ALL PLANS UMR - ALL PLANS 171.5 70 999999999 148.35 237.65 percent of total billed charges FOGARTY ARTER EMBOL 3FR. 80CM 48712020_1 CDM 0270 RC inpatient 245 159.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 148.35 237.65 FOGARTY ARTER EMBOL 3FR. 80CM 48712020_1 CDM 0270 RC inpatient 245 159.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 148.35 237.65 FOGARTY ARTER EMBOL 3FR. 80CM 48712020_1 CDM 0270 RC inpatient 245 159.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 148.35 237.65 FOGARTY ARTER EMBOL 3FR. 80CM 48712020_1 CDM 0270 RC inpatient 245 159.25 ANTHEM HMO ANTHEM HMO 999999999 148.35 237.65 FOGARTY ARTER EMBOL 3FR. 80CM 48712020_1 CDM 0270 RC inpatient 245 159.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 165.62 67.6 999999999 148.35 237.65 percent of total billed charges FOGARTY ARTER EMBOL 3FR. 80CM 48712020_1 CDM 0270 RC inpatient 245 159.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 148.35 237.65 CHOLANGIOGRAPHY CATHETER 4FR. 48712021_1 CDM 0272 RC inpatient 264 171.6 AETNA AETNA 208.56 79 999999999 159.85 256.08 percent of total billed charges CHOLANGIOGRAPHY CATHETER 4FR. 48712021_1 CDM 0272 RC inpatient 264 171.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 171.6 65 999999999 159.85 256.08 percent of total billed charges CHOLANGIOGRAPHY CATHETER 4FR. 48712021_1 CDM 0272 RC inpatient 264 171.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 256.08 97 999999999 159.85 256.08 percent of total billed charges CHOLANGIOGRAPHY CATHETER 4FR. 48712021_1 CDM 0272 RC inpatient 264 171.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 182.16 69 999999999 159.85 256.08 percent of total billed charges CHOLANGIOGRAPHY CATHETER 4FR. 48712021_1 CDM 0272 RC inpatient 264 171.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 205.92 78 999999999 159.85 256.08 percent of total billed charges CHOLANGIOGRAPHY CATHETER 4FR. 48712021_1 CDM 0272 RC inpatient 264 171.6 SIHO - ALL PLANS SIHO - ALL PLANS 237.6 90 999999999 159.85 256.08 percent of total billed charges CHOLANGIOGRAPHY CATHETER 4FR. 48712021_1 CDM 0272 RC inpatient 264 171.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 159.85 60.55 999999999 159.85 256.08 percent of total billed charges CHOLANGIOGRAPHY CATHETER 4FR. 48712021_1 CDM 0272 RC inpatient 264 171.6 UMR - ALL PLANS UMR - ALL PLANS 184.8 70 999999999 159.85 256.08 percent of total billed charges CHOLANGIOGRAPHY CATHETER 4FR. 48712021_1 CDM 0272 RC inpatient 264 171.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 159.85 256.08 CHOLANGIOGRAPHY CATHETER 4FR. 48712021_1 CDM 0272 RC inpatient 264 171.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 159.85 256.08 CHOLANGIOGRAPHY CATHETER 4FR. 48712021_1 CDM 0272 RC inpatient 264 171.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 159.85 256.08 CHOLANGIOGRAPHY CATHETER 4FR. 48712021_1 CDM 0272 RC inpatient 264 171.6 ANTHEM HMO ANTHEM HMO 999999999 159.85 256.08 CHOLANGIOGRAPHY CATHETER 4FR. 48712021_1 CDM 0272 RC inpatient 264 171.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 178.46 67.6 999999999 159.85 256.08 percent of total billed charges CHOLANGIOGRAPHY CATHETER 4FR. 48712021_1 CDM 0272 RC inpatient 264 171.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 159.85 256.08 TUBING FILTER INSUFF 0620050100 48712022_1 CDM 0272 RC inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges TUBING FILTER INSUFF 0620050100 48712022_1 CDM 0272 RC inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges TUBING FILTER INSUFF 0620050100 48712022_1 CDM 0272 RC inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges TUBING FILTER INSUFF 0620050100 48712022_1 CDM 0272 RC inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges TUBING FILTER INSUFF 0620050100 48712022_1 CDM 0272 RC inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges TUBING FILTER INSUFF 0620050100 48712022_1 CDM 0272 RC inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges TUBING FILTER INSUFF 0620050100 48712022_1 CDM 0272 RC inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges TUBING FILTER INSUFF 0620050100 48712022_1 CDM 0272 RC inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges TUBING FILTER INSUFF 0620050100 48712022_1 CDM 0272 RC inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 TUBING FILTER INSUFF 0620050100 48712022_1 CDM 0272 RC inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 TUBING FILTER INSUFF 0620050100 48712022_1 CDM 0272 RC inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 TUBING FILTER INSUFF 0620050100 48712022_1 CDM 0272 RC inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 TUBING FILTER INSUFF 0620050100 48712022_1 CDM 0272 RC inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges TUBING FILTER INSUFF 0620050100 48712022_1 CDM 0272 RC inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 FOGARTY BILI/BALL/PRO 5FR.23CM 48712023_1 CDM 0272 RC inpatient 598 388.7 AETNA AETNA 472.42 79 999999999 362.09 580.06 percent of total billed charges FOGARTY BILI/BALL/PRO 5FR.23CM 48712023_1 CDM 0272 RC inpatient 598 388.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 388.7 65 999999999 362.09 580.06 percent of total billed charges FOGARTY BILI/BALL/PRO 5FR.23CM 48712023_1 CDM 0272 RC inpatient 598 388.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 580.06 97 999999999 362.09 580.06 percent of total billed charges FOGARTY BILI/BALL/PRO 5FR.23CM 48712023_1 CDM 0272 RC inpatient 598 388.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 412.62 69 999999999 362.09 580.06 percent of total billed charges FOGARTY BILI/BALL/PRO 5FR.23CM 48712023_1 CDM 0272 RC inpatient 598 388.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 466.44 78 999999999 362.09 580.06 percent of total billed charges FOGARTY BILI/BALL/PRO 5FR.23CM 48712023_1 CDM 0272 RC inpatient 598 388.7 SIHO - ALL PLANS SIHO - ALL PLANS 538.2 90 999999999 362.09 580.06 percent of total billed charges FOGARTY BILI/BALL/PRO 5FR.23CM 48712023_1 CDM 0272 RC inpatient 598 388.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 362.09 60.55 999999999 362.09 580.06 percent of total billed charges FOGARTY BILI/BALL/PRO 5FR.23CM 48712023_1 CDM 0272 RC inpatient 598 388.7 UMR - ALL PLANS UMR - ALL PLANS 418.6 70 999999999 362.09 580.06 percent of total billed charges FOGARTY BILI/BALL/PRO 5FR.23CM 48712023_1 CDM 0272 RC inpatient 598 388.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 362.09 580.06 FOGARTY BILI/BALL/PRO 5FR.23CM 48712023_1 CDM 0272 RC inpatient 598 388.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 362.09 580.06 FOGARTY BILI/BALL/PRO 5FR.23CM 48712023_1 CDM 0272 RC inpatient 598 388.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 362.09 580.06 FOGARTY BILI/BALL/PRO 5FR.23CM 48712023_1 CDM 0272 RC inpatient 598 388.7 ANTHEM HMO ANTHEM HMO 999999999 362.09 580.06 FOGARTY BILI/BALL/PRO 5FR.23CM 48712023_1 CDM 0272 RC inpatient 598 388.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 404.25 67.6 999999999 362.09 580.06 percent of total billed charges FOGARTY BILI/BALL/PRO 5FR.23CM 48712023_1 CDM 0272 RC inpatient 598 388.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 362.09 580.06 FEMORAL IRRIGATION SUCTION TIP 48712025_1 CDM 0272 RC inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges FEMORAL IRRIGATION SUCTION TIP 48712025_1 CDM 0272 RC inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges FEMORAL IRRIGATION SUCTION TIP 48712025_1 CDM 0272 RC inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges FEMORAL IRRIGATION SUCTION TIP 48712025_1 CDM 0272 RC inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges FEMORAL IRRIGATION SUCTION TIP 48712025_1 CDM 0272 RC inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges FEMORAL IRRIGATION SUCTION TIP 48712025_1 CDM 0272 RC inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges FEMORAL IRRIGATION SUCTION TIP 48712025_1 CDM 0272 RC inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges FEMORAL IRRIGATION SUCTION TIP 48712025_1 CDM 0272 RC inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges FEMORAL IRRIGATION SUCTION TIP 48712025_1 CDM 0272 RC inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 FEMORAL IRRIGATION SUCTION TIP 48712025_1 CDM 0272 RC inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 FEMORAL IRRIGATION SUCTION TIP 48712025_1 CDM 0272 RC inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 FEMORAL IRRIGATION SUCTION TIP 48712025_1 CDM 0272 RC inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 FEMORAL IRRIGATION SUCTION TIP 48712025_1 CDM 0272 RC inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges FEMORAL IRRIGATION SUCTION TIP 48712025_1 CDM 0272 RC inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 FROVA INTUB INTRODUCER G12591 48712026_1 CDM 0272 RC inpatient 630 409.5 AETNA AETNA 497.7 79 999999999 381.47 611.1 percent of total billed charges FROVA INTUB INTRODUCER G12591 48712026_1 CDM 0272 RC inpatient 630 409.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 409.5 65 999999999 381.47 611.1 percent of total billed charges FROVA INTUB INTRODUCER G12591 48712026_1 CDM 0272 RC inpatient 630 409.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 611.1 97 999999999 381.47 611.1 percent of total billed charges FROVA INTUB INTRODUCER G12591 48712026_1 CDM 0272 RC inpatient 630 409.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 434.7 69 999999999 381.47 611.1 percent of total billed charges FROVA INTUB INTRODUCER G12591 48712026_1 CDM 0272 RC inpatient 630 409.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 491.4 78 999999999 381.47 611.1 percent of total billed charges FROVA INTUB INTRODUCER G12591 48712026_1 CDM 0272 RC inpatient 630 409.5 SIHO - ALL PLANS SIHO - ALL PLANS 567 90 999999999 381.47 611.1 percent of total billed charges FROVA INTUB INTRODUCER G12591 48712026_1 CDM 0272 RC inpatient 630 409.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 381.47 60.55 999999999 381.47 611.1 percent of total billed charges FROVA INTUB INTRODUCER G12591 48712026_1 CDM 0272 RC inpatient 630 409.5 UMR - ALL PLANS UMR - ALL PLANS 441 70 999999999 381.47 611.1 percent of total billed charges FROVA INTUB INTRODUCER G12591 48712026_1 CDM 0272 RC inpatient 630 409.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 381.47 611.1 FROVA INTUB INTRODUCER G12591 48712026_1 CDM 0272 RC inpatient 630 409.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 381.47 611.1 FROVA INTUB INTRODUCER G12591 48712026_1 CDM 0272 RC inpatient 630 409.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 381.47 611.1 FROVA INTUB INTRODUCER G12591 48712026_1 CDM 0272 RC inpatient 630 409.5 ANTHEM HMO ANTHEM HMO 999999999 381.47 611.1 FROVA INTUB INTRODUCER G12591 48712026_1 CDM 0272 RC inpatient 630 409.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 425.88 67.6 999999999 381.47 611.1 percent of total billed charges FROVA INTUB INTRODUCER G12591 48712026_1 CDM 0272 RC inpatient 630 409.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 381.47 611.1 MANIFOLD FOR DORNOCH UL-CL500 48712027_1 CDM 0272 RC inpatient 121 78.65 AETNA AETNA 95.59 79 999999999 73.27 117.37 percent of total billed charges MANIFOLD FOR DORNOCH UL-CL500 48712027_1 CDM 0272 RC inpatient 121 78.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 78.65 65 999999999 73.27 117.37 percent of total billed charges MANIFOLD FOR DORNOCH UL-CL500 48712027_1 CDM 0272 RC inpatient 121 78.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 117.37 97 999999999 73.27 117.37 percent of total billed charges MANIFOLD FOR DORNOCH UL-CL500 48712027_1 CDM 0272 RC inpatient 121 78.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 83.49 69 999999999 73.27 117.37 percent of total billed charges MANIFOLD FOR DORNOCH UL-CL500 48712027_1 CDM 0272 RC inpatient 121 78.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 94.38 78 999999999 73.27 117.37 percent of total billed charges MANIFOLD FOR DORNOCH UL-CL500 48712027_1 CDM 0272 RC inpatient 121 78.65 SIHO - ALL PLANS SIHO - ALL PLANS 108.9 90 999999999 73.27 117.37 percent of total billed charges MANIFOLD FOR DORNOCH UL-CL500 48712027_1 CDM 0272 RC inpatient 121 78.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.27 60.55 999999999 73.27 117.37 percent of total billed charges MANIFOLD FOR DORNOCH UL-CL500 48712027_1 CDM 0272 RC inpatient 121 78.65 UMR - ALL PLANS UMR - ALL PLANS 84.7 70 999999999 73.27 117.37 percent of total billed charges MANIFOLD FOR DORNOCH UL-CL500 48712027_1 CDM 0272 RC inpatient 121 78.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.27 117.37 MANIFOLD FOR DORNOCH UL-CL500 48712027_1 CDM 0272 RC inpatient 121 78.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.27 117.37 MANIFOLD FOR DORNOCH UL-CL500 48712027_1 CDM 0272 RC inpatient 121 78.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.27 117.37 MANIFOLD FOR DORNOCH UL-CL500 48712027_1 CDM 0272 RC inpatient 121 78.65 ANTHEM HMO ANTHEM HMO 999999999 73.27 117.37 MANIFOLD FOR DORNOCH UL-CL500 48712027_1 CDM 0272 RC inpatient 121 78.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.8 67.6 999999999 73.27 117.37 percent of total billed charges MANIFOLD FOR DORNOCH UL-CL500 48712027_1 CDM 0272 RC inpatient 121 78.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.27 117.37 DISC CONT BY MFG GELFOAM SZ 100 48712033_1 CDM 0272 RC inpatient 118 76.7 AETNA AETNA 93.22 79 999999999 71.45 114.46 percent of total billed charges DISC CONT BY MFG GELFOAM SZ 100 48712033_1 CDM 0272 RC inpatient 118 76.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 76.7 65 999999999 71.45 114.46 percent of total billed charges DISC CONT BY MFG GELFOAM SZ 100 48712033_1 CDM 0272 RC inpatient 118 76.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 114.46 97 999999999 71.45 114.46 percent of total billed charges DISC CONT BY MFG GELFOAM SZ 100 48712033_1 CDM 0272 RC inpatient 118 76.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 81.42 69 999999999 71.45 114.46 percent of total billed charges DISC CONT BY MFG GELFOAM SZ 100 48712033_1 CDM 0272 RC inpatient 118 76.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.04 78 999999999 71.45 114.46 percent of total billed charges DISC CONT BY MFG GELFOAM SZ 100 48712033_1 CDM 0272 RC inpatient 118 76.7 SIHO - ALL PLANS SIHO - ALL PLANS 106.2 90 999999999 71.45 114.46 percent of total billed charges DISC CONT BY MFG GELFOAM SZ 100 48712033_1 CDM 0272 RC inpatient 118 76.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 71.45 60.55 999999999 71.45 114.46 percent of total billed charges DISC CONT BY MFG GELFOAM SZ 100 48712033_1 CDM 0272 RC inpatient 118 76.7 UMR - ALL PLANS UMR - ALL PLANS 82.6 70 999999999 71.45 114.46 percent of total billed charges DISC CONT BY MFG GELFOAM SZ 100 48712033_1 CDM 0272 RC inpatient 118 76.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 71.45 114.46 DISC CONT BY MFG GELFOAM SZ 100 48712033_1 CDM 0272 RC inpatient 118 76.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 71.45 114.46 DISC CONT BY MFG GELFOAM SZ 100 48712033_1 CDM 0272 RC inpatient 118 76.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 71.45 114.46 DISC CONT BY MFG GELFOAM SZ 100 48712033_1 CDM 0272 RC inpatient 118 76.7 ANTHEM HMO ANTHEM HMO 999999999 71.45 114.46 DISC CONT BY MFG GELFOAM SZ 100 48712033_1 CDM 0272 RC inpatient 118 76.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 79.77 67.6 999999999 71.45 114.46 percent of total billed charges DISC CONT BY MFG GELFOAM SZ 100 48712033_1 CDM 0272 RC inpatient 118 76.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 71.45 114.46 GELFOAM 12-7MM #31503 48712034_1 CDM 0272 RC inpatient 66 42.9 AETNA AETNA 52.14 79 999999999 39.96 64.02 percent of total billed charges GELFOAM 12-7MM #31503 48712034_1 CDM 0272 RC inpatient 66 42.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.9 65 999999999 39.96 64.02 percent of total billed charges GELFOAM 12-7MM #31503 48712034_1 CDM 0272 RC inpatient 66 42.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.02 97 999999999 39.96 64.02 percent of total billed charges GELFOAM 12-7MM #31503 48712034_1 CDM 0272 RC inpatient 66 42.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.54 69 999999999 39.96 64.02 percent of total billed charges GELFOAM 12-7MM #31503 48712034_1 CDM 0272 RC inpatient 66 42.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.48 78 999999999 39.96 64.02 percent of total billed charges GELFOAM 12-7MM #31503 48712034_1 CDM 0272 RC inpatient 66 42.9 SIHO - ALL PLANS SIHO - ALL PLANS 59.4 90 999999999 39.96 64.02 percent of total billed charges GELFOAM 12-7MM #31503 48712034_1 CDM 0272 RC inpatient 66 42.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.96 60.55 999999999 39.96 64.02 percent of total billed charges GELFOAM 12-7MM #31503 48712034_1 CDM 0272 RC inpatient 66 42.9 UMR - ALL PLANS UMR - ALL PLANS 46.2 70 999999999 39.96 64.02 percent of total billed charges GELFOAM 12-7MM #31503 48712034_1 CDM 0272 RC inpatient 66 42.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.96 64.02 GELFOAM 12-7MM #31503 48712034_1 CDM 0272 RC inpatient 66 42.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.96 64.02 GELFOAM 12-7MM #31503 48712034_1 CDM 0272 RC inpatient 66 42.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.96 64.02 GELFOAM 12-7MM #31503 48712034_1 CDM 0272 RC inpatient 66 42.9 ANTHEM HMO ANTHEM HMO 999999999 39.96 64.02 GELFOAM 12-7MM #31503 48712034_1 CDM 0272 RC inpatient 66 42.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.62 67.6 999999999 39.96 64.02 percent of total billed charges GELFOAM 12-7MM #31503 48712034_1 CDM 0272 RC inpatient 66 42.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.96 64.02 "TRAY, TEMP-URINE METER 16FR A119216M" 48712035_1 CDM 0272 RC inpatient 144 93.6 AETNA AETNA 113.76 79 999999999 87.19 139.68 percent of total billed charges "TRAY, TEMP-URINE METER 16FR A119216M" 48712035_1 CDM 0272 RC inpatient 144 93.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 93.6 65 999999999 87.19 139.68 percent of total billed charges "TRAY, TEMP-URINE METER 16FR A119216M" 48712035_1 CDM 0272 RC inpatient 144 93.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 139.68 97 999999999 87.19 139.68 percent of total billed charges "TRAY, TEMP-URINE METER 16FR A119216M" 48712035_1 CDM 0272 RC inpatient 144 93.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 99.36 69 999999999 87.19 139.68 percent of total billed charges "TRAY, TEMP-URINE METER 16FR A119216M" 48712035_1 CDM 0272 RC inpatient 144 93.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 112.32 78 999999999 87.19 139.68 percent of total billed charges "TRAY, TEMP-URINE METER 16FR A119216M" 48712035_1 CDM 0272 RC inpatient 144 93.6 SIHO - ALL PLANS SIHO - ALL PLANS 129.6 90 999999999 87.19 139.68 percent of total billed charges "TRAY, TEMP-URINE METER 16FR A119216M" 48712035_1 CDM 0272 RC inpatient 144 93.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.19 60.55 999999999 87.19 139.68 percent of total billed charges "TRAY, TEMP-URINE METER 16FR A119216M" 48712035_1 CDM 0272 RC inpatient 144 93.6 UMR - ALL PLANS UMR - ALL PLANS 100.8 70 999999999 87.19 139.68 percent of total billed charges "TRAY, TEMP-URINE METER 16FR A119216M" 48712035_1 CDM 0272 RC inpatient 144 93.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.19 139.68 "TRAY, TEMP-URINE METER 16FR A119216M" 48712035_1 CDM 0272 RC inpatient 144 93.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.19 139.68 "TRAY, TEMP-URINE METER 16FR A119216M" 48712035_1 CDM 0272 RC inpatient 144 93.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.19 139.68 "TRAY, TEMP-URINE METER 16FR A119216M" 48712035_1 CDM 0272 RC inpatient 144 93.6 ANTHEM HMO ANTHEM HMO 999999999 87.19 139.68 "TRAY, TEMP-URINE METER 16FR A119216M" 48712035_1 CDM 0272 RC inpatient 144 93.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 97.34 67.6 999999999 87.19 139.68 percent of total billed charges "TRAY, TEMP-URINE METER 16FR A119216M" 48712035_1 CDM 0272 RC inpatient 144 93.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.19 139.68 HAND-SWITCHING PENCIL ESRK3000 48712039_1 CDM 0272 RC inpatient 24 15.6 AETNA AETNA 18.96 79 999999999 14.53 23.28 percent of total billed charges HAND-SWITCHING PENCIL ESRK3000 48712039_1 CDM 0272 RC inpatient 24 15.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 15.6 65 999999999 14.53 23.28 percent of total billed charges HAND-SWITCHING PENCIL ESRK3000 48712039_1 CDM 0272 RC inpatient 24 15.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23.28 97 999999999 14.53 23.28 percent of total billed charges HAND-SWITCHING PENCIL ESRK3000 48712039_1 CDM 0272 RC inpatient 24 15.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 16.56 69 999999999 14.53 23.28 percent of total billed charges HAND-SWITCHING PENCIL ESRK3000 48712039_1 CDM 0272 RC inpatient 24 15.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 18.72 78 999999999 14.53 23.28 percent of total billed charges HAND-SWITCHING PENCIL ESRK3000 48712039_1 CDM 0272 RC inpatient 24 15.6 SIHO - ALL PLANS SIHO - ALL PLANS 21.6 90 999999999 14.53 23.28 percent of total billed charges HAND-SWITCHING PENCIL ESRK3000 48712039_1 CDM 0272 RC inpatient 24 15.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.53 60.55 999999999 14.53 23.28 percent of total billed charges HAND-SWITCHING PENCIL ESRK3000 48712039_1 CDM 0272 RC inpatient 24 15.6 UMR - ALL PLANS UMR - ALL PLANS 16.8 70 999999999 14.53 23.28 percent of total billed charges HAND-SWITCHING PENCIL ESRK3000 48712039_1 CDM 0272 RC inpatient 24 15.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.53 23.28 HAND-SWITCHING PENCIL ESRK3000 48712039_1 CDM 0272 RC inpatient 24 15.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.53 23.28 HAND-SWITCHING PENCIL ESRK3000 48712039_1 CDM 0272 RC inpatient 24 15.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.53 23.28 HAND-SWITCHING PENCIL ESRK3000 48712039_1 CDM 0272 RC inpatient 24 15.6 ANTHEM HMO ANTHEM HMO 999999999 14.53 23.28 HAND-SWITCHING PENCIL ESRK3000 48712039_1 CDM 0272 RC inpatient 24 15.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.22 67.6 999999999 14.53 23.28 percent of total billed charges HAND-SWITCHING PENCIL ESRK3000 48712039_1 CDM 0272 RC inpatient 24 15.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.53 23.28 DHS 135 STAND 12 HOLE 281.110 48712040_1 CDM 0278 RC inpatient 2043 1327.95 AETNA AETNA 1613.97 79 999999999 1237.04 1981.71 percent of total billed charges DHS 135 STAND 12 HOLE 281.110 48712040_1 CDM 0278 RC inpatient 2043 1327.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1327.95 65 999999999 1237.04 1981.71 percent of total billed charges DHS 135 STAND 12 HOLE 281.110 48712040_1 CDM 0278 RC inpatient 2043 1327.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1981.71 97 999999999 1237.04 1981.71 percent of total billed charges DHS 135 STAND 12 HOLE 281.110 48712040_1 CDM 0278 RC inpatient 2043 1327.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1409.67 69 999999999 1237.04 1981.71 percent of total billed charges DHS 135 STAND 12 HOLE 281.110 48712040_1 CDM 0278 RC inpatient 2043 1327.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1593.54 78 999999999 1237.04 1981.71 percent of total billed charges DHS 135 STAND 12 HOLE 281.110 48712040_1 CDM 0278 RC inpatient 2043 1327.95 SIHO - ALL PLANS SIHO - ALL PLANS 1838.7 90 999999999 1237.04 1981.71 percent of total billed charges DHS 135 STAND 12 HOLE 281.110 48712040_1 CDM 0278 RC inpatient 2043 1327.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1237.04 60.55 999999999 1237.04 1981.71 percent of total billed charges DHS 135 STAND 12 HOLE 281.110 48712040_1 CDM 0278 RC inpatient 2043 1327.95 UMR - ALL PLANS UMR - ALL PLANS 1430.1 70 999999999 1237.04 1981.71 percent of total billed charges DHS 135 STAND 12 HOLE 281.110 48712040_1 CDM 0278 RC inpatient 2043 1327.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1237.04 1981.71 DHS 135 STAND 12 HOLE 281.110 48712040_1 CDM 0278 RC inpatient 2043 1327.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1237.04 1981.71 DHS 135 STAND 12 HOLE 281.110 48712040_1 CDM 0278 RC inpatient 2043 1327.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1237.04 1981.71 DHS 135 STAND 12 HOLE 281.110 48712040_1 CDM 0278 RC inpatient 2043 1327.95 ANTHEM HMO ANTHEM HMO 999999999 1237.04 1981.71 DHS 135 STAND 12 HOLE 281.110 48712040_1 CDM 0278 RC inpatient 2043 1327.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1381.07 67.6 999999999 1237.04 1981.71 percent of total billed charges DHS 135 STAND 12 HOLE 281.110 48712040_1 CDM 0278 RC inpatient 2043 1327.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1237.04 1981.71 ALUMI-HAND LG #760 48712041_1 CDM 0272 RC inpatient 198 128.7 AETNA AETNA 156.42 79 999999999 119.89 192.06 percent of total billed charges ALUMI-HAND LG #760 48712041_1 CDM 0272 RC inpatient 198 128.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.7 65 999999999 119.89 192.06 percent of total billed charges ALUMI-HAND LG #760 48712041_1 CDM 0272 RC inpatient 198 128.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 192.06 97 999999999 119.89 192.06 percent of total billed charges ALUMI-HAND LG #760 48712041_1 CDM 0272 RC inpatient 198 128.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 136.62 69 999999999 119.89 192.06 percent of total billed charges ALUMI-HAND LG #760 48712041_1 CDM 0272 RC inpatient 198 128.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 154.44 78 999999999 119.89 192.06 percent of total billed charges ALUMI-HAND LG #760 48712041_1 CDM 0272 RC inpatient 198 128.7 SIHO - ALL PLANS SIHO - ALL PLANS 178.2 90 999999999 119.89 192.06 percent of total billed charges ALUMI-HAND LG #760 48712041_1 CDM 0272 RC inpatient 198 128.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.89 60.55 999999999 119.89 192.06 percent of total billed charges ALUMI-HAND LG #760 48712041_1 CDM 0272 RC inpatient 198 128.7 UMR - ALL PLANS UMR - ALL PLANS 138.6 70 999999999 119.89 192.06 percent of total billed charges ALUMI-HAND LG #760 48712041_1 CDM 0272 RC inpatient 198 128.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.89 192.06 ALUMI-HAND LG #760 48712041_1 CDM 0272 RC inpatient 198 128.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.89 192.06 ALUMI-HAND LG #760 48712041_1 CDM 0272 RC inpatient 198 128.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.89 192.06 ALUMI-HAND LG #760 48712041_1 CDM 0272 RC inpatient 198 128.7 ANTHEM HMO ANTHEM HMO 999999999 119.89 192.06 ALUMI-HAND LG #760 48712041_1 CDM 0272 RC inpatient 198 128.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.85 67.6 999999999 119.89 192.06 percent of total billed charges ALUMI-HAND LG #760 48712041_1 CDM 0272 RC inpatient 198 128.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.89 192.06 ENDO HELICAL RETRIEVAL BASKET 48712043_1 CDM 0272 RC inpatient 1025 666.25 AETNA AETNA 809.75 79 999999999 620.64 994.25 percent of total billed charges ENDO HELICAL RETRIEVAL BASKET 48712043_1 CDM 0272 RC inpatient 1025 666.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 666.25 65 999999999 620.64 994.25 percent of total billed charges ENDO HELICAL RETRIEVAL BASKET 48712043_1 CDM 0272 RC inpatient 1025 666.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 994.25 97 999999999 620.64 994.25 percent of total billed charges ENDO HELICAL RETRIEVAL BASKET 48712043_1 CDM 0272 RC inpatient 1025 666.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 707.25 69 999999999 620.64 994.25 percent of total billed charges ENDO HELICAL RETRIEVAL BASKET 48712043_1 CDM 0272 RC inpatient 1025 666.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 799.5 78 999999999 620.64 994.25 percent of total billed charges ENDO HELICAL RETRIEVAL BASKET 48712043_1 CDM 0272 RC inpatient 1025 666.25 SIHO - ALL PLANS SIHO - ALL PLANS 922.5 90 999999999 620.64 994.25 percent of total billed charges ENDO HELICAL RETRIEVAL BASKET 48712043_1 CDM 0272 RC inpatient 1025 666.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 620.64 60.55 999999999 620.64 994.25 percent of total billed charges ENDO HELICAL RETRIEVAL BASKET 48712043_1 CDM 0272 RC inpatient 1025 666.25 UMR - ALL PLANS UMR - ALL PLANS 717.5 70 999999999 620.64 994.25 percent of total billed charges ENDO HELICAL RETRIEVAL BASKET 48712043_1 CDM 0272 RC inpatient 1025 666.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 620.64 994.25 ENDO HELICAL RETRIEVAL BASKET 48712043_1 CDM 0272 RC inpatient 1025 666.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 620.64 994.25 ENDO HELICAL RETRIEVAL BASKET 48712043_1 CDM 0272 RC inpatient 1025 666.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 620.64 994.25 ENDO HELICAL RETRIEVAL BASKET 48712043_1 CDM 0272 RC inpatient 1025 666.25 ANTHEM HMO ANTHEM HMO 999999999 620.64 994.25 ENDO HELICAL RETRIEVAL BASKET 48712043_1 CDM 0272 RC inpatient 1025 666.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 692.9 67.6 999999999 620.64 994.25 percent of total billed charges ENDO HELICAL RETRIEVAL BASKET 48712043_1 CDM 0272 RC inpatient 1025 666.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 620.64 994.25 ROTATABLE ROTH RETRIEVAL 2.5MM BX00711050 48712044_1 CDM 0270 RC inpatient 650 422.5 AETNA AETNA 513.5 79 999999999 393.58 630.5 percent of total billed charges ROTATABLE ROTH RETRIEVAL 2.5MM BX00711050 48712044_1 CDM 0270 RC inpatient 650 422.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 422.5 65 999999999 393.58 630.5 percent of total billed charges ROTATABLE ROTH RETRIEVAL 2.5MM BX00711050 48712044_1 CDM 0270 RC inpatient 650 422.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 630.5 97 999999999 393.58 630.5 percent of total billed charges ROTATABLE ROTH RETRIEVAL 2.5MM BX00711050 48712044_1 CDM 0270 RC inpatient 650 422.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 448.5 69 999999999 393.58 630.5 percent of total billed charges ROTATABLE ROTH RETRIEVAL 2.5MM BX00711050 48712044_1 CDM 0270 RC inpatient 650 422.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 507 78 999999999 393.58 630.5 percent of total billed charges ROTATABLE ROTH RETRIEVAL 2.5MM BX00711050 48712044_1 CDM 0270 RC inpatient 650 422.5 SIHO - ALL PLANS SIHO - ALL PLANS 585 90 999999999 393.58 630.5 percent of total billed charges ROTATABLE ROTH RETRIEVAL 2.5MM BX00711050 48712044_1 CDM 0270 RC inpatient 650 422.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 393.58 60.55 999999999 393.58 630.5 percent of total billed charges ROTATABLE ROTH RETRIEVAL 2.5MM BX00711050 48712044_1 CDM 0270 RC inpatient 650 422.5 UMR - ALL PLANS UMR - ALL PLANS 455 70 999999999 393.58 630.5 percent of total billed charges ROTATABLE ROTH RETRIEVAL 2.5MM BX00711050 48712044_1 CDM 0270 RC inpatient 650 422.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 393.58 630.5 ROTATABLE ROTH RETRIEVAL 2.5MM BX00711050 48712044_1 CDM 0270 RC inpatient 650 422.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 393.58 630.5 ROTATABLE ROTH RETRIEVAL 2.5MM BX00711050 48712044_1 CDM 0270 RC inpatient 650 422.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 393.58 630.5 ROTATABLE ROTH RETRIEVAL 2.5MM BX00711050 48712044_1 CDM 0270 RC inpatient 650 422.5 ANTHEM HMO ANTHEM HMO 999999999 393.58 630.5 ROTATABLE ROTH RETRIEVAL 2.5MM BX00711050 48712044_1 CDM 0270 RC inpatient 650 422.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 439.4 67.6 999999999 393.58 630.5 percent of total billed charges ROTATABLE ROTH RETRIEVAL 2.5MM BX00711050 48712044_1 CDM 0270 RC inpatient 650 422.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 393.58 630.5 ****BLANKET PER MEGAN HEMOVAC SNYDER 400ML MED 48712045_1 CDM 0272 RC inpatient 122 79.3 AETNA AETNA 96.38 79 999999999 73.87 118.34 percent of total billed charges ****BLANKET PER MEGAN HEMOVAC SNYDER 400ML MED 48712045_1 CDM 0272 RC inpatient 122 79.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.3 65 999999999 73.87 118.34 percent of total billed charges ****BLANKET PER MEGAN HEMOVAC SNYDER 400ML MED 48712045_1 CDM 0272 RC inpatient 122 79.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 118.34 97 999999999 73.87 118.34 percent of total billed charges ****BLANKET PER MEGAN HEMOVAC SNYDER 400ML MED 48712045_1 CDM 0272 RC inpatient 122 79.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.18 69 999999999 73.87 118.34 percent of total billed charges ****BLANKET PER MEGAN HEMOVAC SNYDER 400ML MED 48712045_1 CDM 0272 RC inpatient 122 79.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.16 78 999999999 73.87 118.34 percent of total billed charges ****BLANKET PER MEGAN HEMOVAC SNYDER 400ML MED 48712045_1 CDM 0272 RC inpatient 122 79.3 SIHO - ALL PLANS SIHO - ALL PLANS 109.8 90 999999999 73.87 118.34 percent of total billed charges ****BLANKET PER MEGAN HEMOVAC SNYDER 400ML MED 48712045_1 CDM 0272 RC inpatient 122 79.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.87 60.55 999999999 73.87 118.34 percent of total billed charges ****BLANKET PER MEGAN HEMOVAC SNYDER 400ML MED 48712045_1 CDM 0272 RC inpatient 122 79.3 UMR - ALL PLANS UMR - ALL PLANS 85.4 70 999999999 73.87 118.34 percent of total billed charges ****BLANKET PER MEGAN HEMOVAC SNYDER 400ML MED 48712045_1 CDM 0272 RC inpatient 122 79.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.87 118.34 ****BLANKET PER MEGAN HEMOVAC SNYDER 400ML MED 48712045_1 CDM 0272 RC inpatient 122 79.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.87 118.34 ****BLANKET PER MEGAN HEMOVAC SNYDER 400ML MED 48712045_1 CDM 0272 RC inpatient 122 79.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.87 118.34 ****BLANKET PER MEGAN HEMOVAC SNYDER 400ML MED 48712045_1 CDM 0272 RC inpatient 122 79.3 ANTHEM HMO ANTHEM HMO 999999999 73.87 118.34 ****BLANKET PER MEGAN HEMOVAC SNYDER 400ML MED 48712045_1 CDM 0272 RC inpatient 122 79.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 82.47 67.6 999999999 73.87 118.34 percent of total billed charges ****BLANKET PER MEGAN HEMOVAC SNYDER 400ML MED 48712045_1 CDM 0272 RC inpatient 122 79.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.87 118.34 STRYKER T7 PLUS HOOD W/PEELAWAY SHIELD 48712048_1 CDM 0272 RC inpatient 258 167.7 AETNA AETNA 203.82 79 999999999 156.22 250.26 percent of total billed charges STRYKER T7 PLUS HOOD W/PEELAWAY SHIELD 48712048_1 CDM 0272 RC inpatient 258 167.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.7 65 999999999 156.22 250.26 percent of total billed charges STRYKER T7 PLUS HOOD W/PEELAWAY SHIELD 48712048_1 CDM 0272 RC inpatient 258 167.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 250.26 97 999999999 156.22 250.26 percent of total billed charges STRYKER T7 PLUS HOOD W/PEELAWAY SHIELD 48712048_1 CDM 0272 RC inpatient 258 167.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 178.02 69 999999999 156.22 250.26 percent of total billed charges STRYKER T7 PLUS HOOD W/PEELAWAY SHIELD 48712048_1 CDM 0272 RC inpatient 258 167.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 201.24 78 999999999 156.22 250.26 percent of total billed charges STRYKER T7 PLUS HOOD W/PEELAWAY SHIELD 48712048_1 CDM 0272 RC inpatient 258 167.7 SIHO - ALL PLANS SIHO - ALL PLANS 232.2 90 999999999 156.22 250.26 percent of total billed charges STRYKER T7 PLUS HOOD W/PEELAWAY SHIELD 48712048_1 CDM 0272 RC inpatient 258 167.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 156.22 60.55 999999999 156.22 250.26 percent of total billed charges STRYKER T7 PLUS HOOD W/PEELAWAY SHIELD 48712048_1 CDM 0272 RC inpatient 258 167.7 UMR - ALL PLANS UMR - ALL PLANS 180.6 70 999999999 156.22 250.26 percent of total billed charges STRYKER T7 PLUS HOOD W/PEELAWAY SHIELD 48712048_1 CDM 0272 RC inpatient 258 167.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 156.22 250.26 STRYKER T7 PLUS HOOD W/PEELAWAY SHIELD 48712048_1 CDM 0272 RC inpatient 258 167.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 156.22 250.26 STRYKER T7 PLUS HOOD W/PEELAWAY SHIELD 48712048_1 CDM 0272 RC inpatient 258 167.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 156.22 250.26 STRYKER T7 PLUS HOOD W/PEELAWAY SHIELD 48712048_1 CDM 0272 RC inpatient 258 167.7 ANTHEM HMO ANTHEM HMO 999999999 156.22 250.26 STRYKER T7 PLUS HOOD W/PEELAWAY SHIELD 48712048_1 CDM 0272 RC inpatient 258 167.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 174.41 67.6 999999999 156.22 250.26 percent of total billed charges STRYKER T7 PLUS HOOD W/PEELAWAY SHIELD 48712048_1 CDM 0272 RC inpatient 258 167.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 156.22 250.26 FLOWTRON FOOT 48712049_1 CDM 0271 RC inpatient 132 85.8 AETNA AETNA 104.28 79 999999999 79.93 128.04 percent of total billed charges FLOWTRON FOOT 48712049_1 CDM 0271 RC inpatient 132 85.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.8 65 999999999 79.93 128.04 percent of total billed charges FLOWTRON FOOT 48712049_1 CDM 0271 RC inpatient 132 85.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 128.04 97 999999999 79.93 128.04 percent of total billed charges FLOWTRON FOOT 48712049_1 CDM 0271 RC inpatient 132 85.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.08 69 999999999 79.93 128.04 percent of total billed charges FLOWTRON FOOT 48712049_1 CDM 0271 RC inpatient 132 85.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.96 78 999999999 79.93 128.04 percent of total billed charges FLOWTRON FOOT 48712049_1 CDM 0271 RC inpatient 132 85.8 SIHO - ALL PLANS SIHO - ALL PLANS 118.8 90 999999999 79.93 128.04 percent of total billed charges FLOWTRON FOOT 48712049_1 CDM 0271 RC inpatient 132 85.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.93 60.55 999999999 79.93 128.04 percent of total billed charges FLOWTRON FOOT 48712049_1 CDM 0271 RC inpatient 132 85.8 UMR - ALL PLANS UMR - ALL PLANS 92.4 70 999999999 79.93 128.04 percent of total billed charges FLOWTRON FOOT 48712049_1 CDM 0271 RC inpatient 132 85.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.93 128.04 FLOWTRON FOOT 48712049_1 CDM 0271 RC inpatient 132 85.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.93 128.04 FLOWTRON FOOT 48712049_1 CDM 0271 RC inpatient 132 85.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.93 128.04 FLOWTRON FOOT 48712049_1 CDM 0271 RC inpatient 132 85.8 ANTHEM HMO ANTHEM HMO 999999999 79.93 128.04 FLOWTRON FOOT 48712049_1 CDM 0271 RC inpatient 132 85.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.23 67.6 999999999 79.93 128.04 percent of total billed charges FLOWTRON FOOT 48712049_1 CDM 0271 RC inpatient 132 85.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.93 128.04 THIGH HI LG-REG MDS160864 48712058_1 CDM 0271 RC inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-REG MDS160864 48712058_1 CDM 0271 RC inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-REG MDS160864 48712058_1 CDM 0271 RC inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-REG MDS160864 48712058_1 CDM 0271 RC inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-REG MDS160864 48712058_1 CDM 0271 RC inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-REG MDS160864 48712058_1 CDM 0271 RC inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-REG MDS160864 48712058_1 CDM 0271 RC inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-REG MDS160864 48712058_1 CDM 0271 RC inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-REG MDS160864 48712058_1 CDM 0271 RC inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 THIGH HI LG-REG MDS160864 48712058_1 CDM 0271 RC inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 THIGH HI LG-REG MDS160864 48712058_1 CDM 0271 RC inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 THIGH HI LG-REG MDS160864 48712058_1 CDM 0271 RC inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 THIGH HI LG-REG MDS160864 48712058_1 CDM 0271 RC inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-REG MDS160864 48712058_1 CDM 0271 RC inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 THIGH HI LG-LONG #3856LF 48712059_1 CDM 0271 RC inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-LONG #3856LF 48712059_1 CDM 0271 RC inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-LONG #3856LF 48712059_1 CDM 0271 RC inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-LONG #3856LF 48712059_1 CDM 0271 RC inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-LONG #3856LF 48712059_1 CDM 0271 RC inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-LONG #3856LF 48712059_1 CDM 0271 RC inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-LONG #3856LF 48712059_1 CDM 0271 RC inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-LONG #3856LF 48712059_1 CDM 0271 RC inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-LONG #3856LF 48712059_1 CDM 0271 RC inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 THIGH HI LG-LONG #3856LF 48712059_1 CDM 0271 RC inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 THIGH HI LG-LONG #3856LF 48712059_1 CDM 0271 RC inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 THIGH HI LG-LONG #3856LF 48712059_1 CDM 0271 RC inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 THIGH HI LG-LONG #3856LF 48712059_1 CDM 0271 RC inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-LONG #3856LF 48712059_1 CDM 0271 RC inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 THIGH HI M-LONG 3549LF 48712060_1 CDM 0271 RC inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges THIGH HI M-LONG 3549LF 48712060_1 CDM 0271 RC inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges THIGH HI M-LONG 3549LF 48712060_1 CDM 0271 RC inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges THIGH HI M-LONG 3549LF 48712060_1 CDM 0271 RC inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges THIGH HI M-LONG 3549LF 48712060_1 CDM 0271 RC inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges THIGH HI M-LONG 3549LF 48712060_1 CDM 0271 RC inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges THIGH HI M-LONG 3549LF 48712060_1 CDM 0271 RC inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges THIGH HI M-LONG 3549LF 48712060_1 CDM 0271 RC inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges THIGH HI M-LONG 3549LF 48712060_1 CDM 0271 RC inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 THIGH HI M-LONG 3549LF 48712060_1 CDM 0271 RC inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 THIGH HI M-LONG 3549LF 48712060_1 CDM 0271 RC inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 THIGH HI M-LONG 3549LF 48712060_1 CDM 0271 RC inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 THIGH HI M-LONG 3549LF 48712060_1 CDM 0271 RC inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges THIGH HI M-LONG 3549LF 48712060_1 CDM 0271 RC inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 THIGH HI MED-REG #3416LF 48712061_1 CDM 0271 RC inpatient 54 35.1 AETNA AETNA 42.66 79 999999999 32.7 52.38 percent of total billed charges THIGH HI MED-REG #3416LF 48712061_1 CDM 0271 RC inpatient 54 35.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 35.1 65 999999999 32.7 52.38 percent of total billed charges THIGH HI MED-REG #3416LF 48712061_1 CDM 0271 RC inpatient 54 35.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 52.38 97 999999999 32.7 52.38 percent of total billed charges THIGH HI MED-REG #3416LF 48712061_1 CDM 0271 RC inpatient 54 35.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 37.26 69 999999999 32.7 52.38 percent of total billed charges THIGH HI MED-REG #3416LF 48712061_1 CDM 0271 RC inpatient 54 35.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 42.12 78 999999999 32.7 52.38 percent of total billed charges THIGH HI MED-REG #3416LF 48712061_1 CDM 0271 RC inpatient 54 35.1 SIHO - ALL PLANS SIHO - ALL PLANS 48.6 90 999999999 32.7 52.38 percent of total billed charges THIGH HI MED-REG #3416LF 48712061_1 CDM 0271 RC inpatient 54 35.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.7 60.55 999999999 32.7 52.38 percent of total billed charges THIGH HI MED-REG #3416LF 48712061_1 CDM 0271 RC inpatient 54 35.1 UMR - ALL PLANS UMR - ALL PLANS 37.8 70 999999999 32.7 52.38 percent of total billed charges THIGH HI MED-REG #3416LF 48712061_1 CDM 0271 RC inpatient 54 35.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.7 52.38 THIGH HI MED-REG #3416LF 48712061_1 CDM 0271 RC inpatient 54 35.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.7 52.38 THIGH HI MED-REG #3416LF 48712061_1 CDM 0271 RC inpatient 54 35.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.7 52.38 THIGH HI MED-REG #3416LF 48712061_1 CDM 0271 RC inpatient 54 35.1 ANTHEM HMO ANTHEM HMO 999999999 32.7 52.38 THIGH HI MED-REG #3416LF 48712061_1 CDM 0271 RC inpatient 54 35.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 36.5 67.6 999999999 32.7 52.38 percent of total billed charges THIGH HI MED-REG #3416LF 48712061_1 CDM 0271 RC inpatient 54 35.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.7 52.38 THIGH HI MED-SHORT #3310LF 48712062_1 CDM 0271 RC inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges THIGH HI MED-SHORT #3310LF 48712062_1 CDM 0271 RC inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges THIGH HI MED-SHORT #3310LF 48712062_1 CDM 0271 RC inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges THIGH HI MED-SHORT #3310LF 48712062_1 CDM 0271 RC inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges THIGH HI MED-SHORT #3310LF 48712062_1 CDM 0271 RC inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges THIGH HI MED-SHORT #3310LF 48712062_1 CDM 0271 RC inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges THIGH HI MED-SHORT #3310LF 48712062_1 CDM 0271 RC inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges THIGH HI MED-SHORT #3310LF 48712062_1 CDM 0271 RC inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges THIGH HI MED-SHORT #3310LF 48712062_1 CDM 0271 RC inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 THIGH HI MED-SHORT #3310LF 48712062_1 CDM 0271 RC inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 THIGH HI MED-SHORT #3310LF 48712062_1 CDM 0271 RC inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 THIGH HI MED-SHORT #3310LF 48712062_1 CDM 0271 RC inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 THIGH HI MED-SHORT #3310LF 48712062_1 CDM 0271 RC inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges THIGH HI MED-SHORT #3310LF 48712062_1 CDM 0271 RC inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 THIGH HI SM-REG #3130LF 48712063_1 CDM 0271 RC inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges THIGH HI SM-REG #3130LF 48712063_1 CDM 0271 RC inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges THIGH HI SM-REG #3130LF 48712063_1 CDM 0271 RC inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges THIGH HI SM-REG #3130LF 48712063_1 CDM 0271 RC inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges THIGH HI SM-REG #3130LF 48712063_1 CDM 0271 RC inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges THIGH HI SM-REG #3130LF 48712063_1 CDM 0271 RC inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges THIGH HI SM-REG #3130LF 48712063_1 CDM 0271 RC inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges THIGH HI SM-REG #3130LF 48712063_1 CDM 0271 RC inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges THIGH HI SM-REG #3130LF 48712063_1 CDM 0271 RC inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 THIGH HI SM-REG #3130LF 48712063_1 CDM 0271 RC inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 THIGH HI SM-REG #3130LF 48712063_1 CDM 0271 RC inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 THIGH HI SM-REG #3130LF 48712063_1 CDM 0271 RC inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 THIGH HI SM-REG #3130LF 48712063_1 CDM 0271 RC inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges THIGH HI SM-REG #3130LF 48712063_1 CDM 0271 RC inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 THIGH HI SM-SHORT #3071LF 48712064_1 CDM 0271 RC inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges THIGH HI SM-SHORT #3071LF 48712064_1 CDM 0271 RC inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges THIGH HI SM-SHORT #3071LF 48712064_1 CDM 0271 RC inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges THIGH HI SM-SHORT #3071LF 48712064_1 CDM 0271 RC inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges THIGH HI SM-SHORT #3071LF 48712064_1 CDM 0271 RC inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges THIGH HI SM-SHORT #3071LF 48712064_1 CDM 0271 RC inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges THIGH HI SM-SHORT #3071LF 48712064_1 CDM 0271 RC inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges THIGH HI SM-SHORT #3071LF 48712064_1 CDM 0271 RC inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges THIGH HI SM-SHORT #3071LF 48712064_1 CDM 0271 RC inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 THIGH HI SM-SHORT #3071LF 48712064_1 CDM 0271 RC inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 THIGH HI SM-SHORT #3071LF 48712064_1 CDM 0271 RC inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 THIGH HI SM-SHORT #3071LF 48712064_1 CDM 0271 RC inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 THIGH HI SM-SHORT #3071LF 48712064_1 CDM 0271 RC inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges THIGH HI SM-SHORT #3071LF 48712064_1 CDM 0271 RC inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 THIGH HI LG-SHORT #3634LF DO NOT USE THIS NUMBER - USE 4000882 48712065_1 CDM 0271 RC inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-SHORT #3634LF DO NOT USE THIS NUMBER - USE 4000882 48712065_1 CDM 0271 RC inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-SHORT #3634LF DO NOT USE THIS NUMBER - USE 4000882 48712065_1 CDM 0271 RC inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-SHORT #3634LF DO NOT USE THIS NUMBER - USE 4000882 48712065_1 CDM 0271 RC inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-SHORT #3634LF DO NOT USE THIS NUMBER - USE 4000882 48712065_1 CDM 0271 RC inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-SHORT #3634LF DO NOT USE THIS NUMBER - USE 4000882 48712065_1 CDM 0271 RC inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-SHORT #3634LF DO NOT USE THIS NUMBER - USE 4000882 48712065_1 CDM 0271 RC inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-SHORT #3634LF DO NOT USE THIS NUMBER - USE 4000882 48712065_1 CDM 0271 RC inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-SHORT #3634LF DO NOT USE THIS NUMBER - USE 4000882 48712065_1 CDM 0271 RC inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 THIGH HI LG-SHORT #3634LF DO NOT USE THIS NUMBER - USE 4000882 48712065_1 CDM 0271 RC inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 THIGH HI LG-SHORT #3634LF DO NOT USE THIS NUMBER - USE 4000882 48712065_1 CDM 0271 RC inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 THIGH HI LG-SHORT #3634LF DO NOT USE THIS NUMBER - USE 4000882 48712065_1 CDM 0271 RC inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 THIGH HI LG-SHORT #3634LF DO NOT USE THIS NUMBER - USE 4000882 48712065_1 CDM 0271 RC inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges THIGH HI LG-SHORT #3634LF DO NOT USE THIS NUMBER - USE 4000882 48712065_1 CDM 0271 RC inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 THIGH HI XL-REG 111462 48712066_1 CDM 0271 RC inpatient 30 19.5 AETNA AETNA 23.7 79 999999999 18.17 29.1 percent of total billed charges THIGH HI XL-REG 111462 48712066_1 CDM 0271 RC inpatient 30 19.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.5 65 999999999 18.17 29.1 percent of total billed charges THIGH HI XL-REG 111462 48712066_1 CDM 0271 RC inpatient 30 19.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.1 97 999999999 18.17 29.1 percent of total billed charges THIGH HI XL-REG 111462 48712066_1 CDM 0271 RC inpatient 30 19.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.7 69 999999999 18.17 29.1 percent of total billed charges THIGH HI XL-REG 111462 48712066_1 CDM 0271 RC inpatient 30 19.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.4 78 999999999 18.17 29.1 percent of total billed charges THIGH HI XL-REG 111462 48712066_1 CDM 0271 RC inpatient 30 19.5 SIHO - ALL PLANS SIHO - ALL PLANS 27 90 999999999 18.17 29.1 percent of total billed charges THIGH HI XL-REG 111462 48712066_1 CDM 0271 RC inpatient 30 19.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.17 60.55 999999999 18.17 29.1 percent of total billed charges THIGH HI XL-REG 111462 48712066_1 CDM 0271 RC inpatient 30 19.5 UMR - ALL PLANS UMR - ALL PLANS 21 70 999999999 18.17 29.1 percent of total billed charges THIGH HI XL-REG 111462 48712066_1 CDM 0271 RC inpatient 30 19.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.17 29.1 THIGH HI XL-REG 111462 48712066_1 CDM 0271 RC inpatient 30 19.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.17 29.1 THIGH HI XL-REG 111462 48712066_1 CDM 0271 RC inpatient 30 19.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.17 29.1 THIGH HI XL-REG 111462 48712066_1 CDM 0271 RC inpatient 30 19.5 ANTHEM HMO ANTHEM HMO 999999999 18.17 29.1 THIGH HI XL-REG 111462 48712066_1 CDM 0271 RC inpatient 30 19.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.28 67.6 999999999 18.17 29.1 percent of total billed charges THIGH HI XL-REG 111462 48712066_1 CDM 0271 RC inpatient 30 19.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.17 29.1 THIGH HI XL-LONG 111488 48712067_1 CDM 0272 RC inpatient 138 89.7 AETNA AETNA 109.02 79 999999999 83.56 133.86 percent of total billed charges THIGH HI XL-LONG 111488 48712067_1 CDM 0272 RC inpatient 138 89.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.7 65 999999999 83.56 133.86 percent of total billed charges THIGH HI XL-LONG 111488 48712067_1 CDM 0272 RC inpatient 138 89.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 133.86 97 999999999 83.56 133.86 percent of total billed charges THIGH HI XL-LONG 111488 48712067_1 CDM 0272 RC inpatient 138 89.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.22 69 999999999 83.56 133.86 percent of total billed charges THIGH HI XL-LONG 111488 48712067_1 CDM 0272 RC inpatient 138 89.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 107.64 78 999999999 83.56 133.86 percent of total billed charges THIGH HI XL-LONG 111488 48712067_1 CDM 0272 RC inpatient 138 89.7 SIHO - ALL PLANS SIHO - ALL PLANS 124.2 90 999999999 83.56 133.86 percent of total billed charges THIGH HI XL-LONG 111488 48712067_1 CDM 0272 RC inpatient 138 89.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 83.56 60.55 999999999 83.56 133.86 percent of total billed charges THIGH HI XL-LONG 111488 48712067_1 CDM 0272 RC inpatient 138 89.7 UMR - ALL PLANS UMR - ALL PLANS 96.6 70 999999999 83.56 133.86 percent of total billed charges THIGH HI XL-LONG 111488 48712067_1 CDM 0272 RC inpatient 138 89.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 83.56 133.86 THIGH HI XL-LONG 111488 48712067_1 CDM 0272 RC inpatient 138 89.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 83.56 133.86 THIGH HI XL-LONG 111488 48712067_1 CDM 0272 RC inpatient 138 89.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 83.56 133.86 THIGH HI XL-LONG 111488 48712067_1 CDM 0272 RC inpatient 138 89.7 ANTHEM HMO ANTHEM HMO 999999999 83.56 133.86 THIGH HI XL-LONG 111488 48712067_1 CDM 0272 RC inpatient 138 89.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.29 67.6 999999999 83.56 133.86 percent of total billed charges THIGH HI XL-LONG 111488 48712067_1 CDM 0272 RC inpatient 138 89.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 83.56 133.86 ANTENNA 37092 (INNER STEM) 48712070_1 CDM 0278 RC inpatient 553 359.45 AETNA AETNA 436.87 79 999999999 334.84 536.41 percent of total billed charges ANTENNA 37092 (INNER STEM) 48712070_1 CDM 0278 RC inpatient 553 359.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 359.45 65 999999999 334.84 536.41 percent of total billed charges ANTENNA 37092 (INNER STEM) 48712070_1 CDM 0278 RC inpatient 553 359.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 536.41 97 999999999 334.84 536.41 percent of total billed charges ANTENNA 37092 (INNER STEM) 48712070_1 CDM 0278 RC inpatient 553 359.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 381.57 69 999999999 334.84 536.41 percent of total billed charges ANTENNA 37092 (INNER STEM) 48712070_1 CDM 0278 RC inpatient 553 359.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 431.34 78 999999999 334.84 536.41 percent of total billed charges ANTENNA 37092 (INNER STEM) 48712070_1 CDM 0278 RC inpatient 553 359.45 SIHO - ALL PLANS SIHO - ALL PLANS 497.7 90 999999999 334.84 536.41 percent of total billed charges ANTENNA 37092 (INNER STEM) 48712070_1 CDM 0278 RC inpatient 553 359.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 334.84 60.55 999999999 334.84 536.41 percent of total billed charges ANTENNA 37092 (INNER STEM) 48712070_1 CDM 0278 RC inpatient 553 359.45 UMR - ALL PLANS UMR - ALL PLANS 387.1 70 999999999 334.84 536.41 percent of total billed charges ANTENNA 37092 (INNER STEM) 48712070_1 CDM 0278 RC inpatient 553 359.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 334.84 536.41 ANTENNA 37092 (INNER STEM) 48712070_1 CDM 0278 RC inpatient 553 359.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 334.84 536.41 ANTENNA 37092 (INNER STEM) 48712070_1 CDM 0278 RC inpatient 553 359.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 334.84 536.41 ANTENNA 37092 (INNER STEM) 48712070_1 CDM 0278 RC inpatient 553 359.45 ANTHEM HMO ANTHEM HMO 999999999 334.84 536.41 ANTENNA 37092 (INNER STEM) 48712070_1 CDM 0278 RC inpatient 553 359.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 373.83 67.6 999999999 334.84 536.41 percent of total billed charges ANTENNA 37092 (INNER STEM) 48712070_1 CDM 0278 RC inpatient 553 359.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 334.84 536.41 LAP CHOLE KIT OOZ2504 WIPPERMA 48712071_1 CDM 0272 RC inpatient 1163 755.95 AETNA AETNA 918.77 79 999999999 704.2 1128.11 percent of total billed charges LAP CHOLE KIT OOZ2504 WIPPERMA 48712071_1 CDM 0272 RC inpatient 1163 755.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 755.95 65 999999999 704.2 1128.11 percent of total billed charges LAP CHOLE KIT OOZ2504 WIPPERMA 48712071_1 CDM 0272 RC inpatient 1163 755.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1128.11 97 999999999 704.2 1128.11 percent of total billed charges LAP CHOLE KIT OOZ2504 WIPPERMA 48712071_1 CDM 0272 RC inpatient 1163 755.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 802.47 69 999999999 704.2 1128.11 percent of total billed charges LAP CHOLE KIT OOZ2504 WIPPERMA 48712071_1 CDM 0272 RC inpatient 1163 755.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 907.14 78 999999999 704.2 1128.11 percent of total billed charges LAP CHOLE KIT OOZ2504 WIPPERMA 48712071_1 CDM 0272 RC inpatient 1163 755.95 SIHO - ALL PLANS SIHO - ALL PLANS 1046.7 90 999999999 704.2 1128.11 percent of total billed charges LAP CHOLE KIT OOZ2504 WIPPERMA 48712071_1 CDM 0272 RC inpatient 1163 755.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 704.2 60.55 999999999 704.2 1128.11 percent of total billed charges LAP CHOLE KIT OOZ2504 WIPPERMA 48712071_1 CDM 0272 RC inpatient 1163 755.95 UMR - ALL PLANS UMR - ALL PLANS 814.1 70 999999999 704.2 1128.11 percent of total billed charges LAP CHOLE KIT OOZ2504 WIPPERMA 48712071_1 CDM 0272 RC inpatient 1163 755.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 704.2 1128.11 LAP CHOLE KIT OOZ2504 WIPPERMA 48712071_1 CDM 0272 RC inpatient 1163 755.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 704.2 1128.11 LAP CHOLE KIT OOZ2504 WIPPERMA 48712071_1 CDM 0272 RC inpatient 1163 755.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 704.2 1128.11 LAP CHOLE KIT OOZ2504 WIPPERMA 48712071_1 CDM 0272 RC inpatient 1163 755.95 ANTHEM HMO ANTHEM HMO 999999999 704.2 1128.11 LAP CHOLE KIT OOZ2504 WIPPERMA 48712071_1 CDM 0272 RC inpatient 1163 755.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 786.19 67.6 999999999 704.2 1128.11 percent of total billed charges LAP CHOLE KIT OOZ2504 WIPPERMA 48712071_1 CDM 0272 RC inpatient 1163 755.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 704.2 1128.11 LAP CHOLE KIT K0724 WIPPERMANN 48712072_1 CDM 0272 RC inpatient 791 514.15 AETNA AETNA 624.89 79 999999999 478.95 767.27 percent of total billed charges LAP CHOLE KIT K0724 WIPPERMANN 48712072_1 CDM 0272 RC inpatient 791 514.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 514.15 65 999999999 478.95 767.27 percent of total billed charges LAP CHOLE KIT K0724 WIPPERMANN 48712072_1 CDM 0272 RC inpatient 791 514.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 767.27 97 999999999 478.95 767.27 percent of total billed charges LAP CHOLE KIT K0724 WIPPERMANN 48712072_1 CDM 0272 RC inpatient 791 514.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 545.79 69 999999999 478.95 767.27 percent of total billed charges LAP CHOLE KIT K0724 WIPPERMANN 48712072_1 CDM 0272 RC inpatient 791 514.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 616.98 78 999999999 478.95 767.27 percent of total billed charges LAP CHOLE KIT K0724 WIPPERMANN 48712072_1 CDM 0272 RC inpatient 791 514.15 SIHO - ALL PLANS SIHO - ALL PLANS 711.9 90 999999999 478.95 767.27 percent of total billed charges LAP CHOLE KIT K0724 WIPPERMANN 48712072_1 CDM 0272 RC inpatient 791 514.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 478.95 60.55 999999999 478.95 767.27 percent of total billed charges LAP CHOLE KIT K0724 WIPPERMANN 48712072_1 CDM 0272 RC inpatient 791 514.15 UMR - ALL PLANS UMR - ALL PLANS 553.7 70 999999999 478.95 767.27 percent of total billed charges LAP CHOLE KIT K0724 WIPPERMANN 48712072_1 CDM 0272 RC inpatient 791 514.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 478.95 767.27 LAP CHOLE KIT K0724 WIPPERMANN 48712072_1 CDM 0272 RC inpatient 791 514.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 478.95 767.27 LAP CHOLE KIT K0724 WIPPERMANN 48712072_1 CDM 0272 RC inpatient 791 514.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 478.95 767.27 LAP CHOLE KIT K0724 WIPPERMANN 48712072_1 CDM 0272 RC inpatient 791 514.15 ANTHEM HMO ANTHEM HMO 999999999 478.95 767.27 LAP CHOLE KIT K0724 WIPPERMANN 48712072_1 CDM 0272 RC inpatient 791 514.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 534.72 67.6 999999999 478.95 767.27 percent of total billed charges LAP CHOLE KIT K0724 WIPPERMANN 48712072_1 CDM 0272 RC inpatient 791 514.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 478.95 767.27 LAP CHOLE KIT 00Z2596 VORNEHM 10884521735552 48712074_1 CDM 0272 RC inpatient 670 435.5 AETNA AETNA 529.3 79 999999999 405.69 649.9 percent of total billed charges LAP CHOLE KIT 00Z2596 VORNEHM 10884521735552 48712074_1 CDM 0272 RC inpatient 670 435.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 435.5 65 999999999 405.69 649.9 percent of total billed charges LAP CHOLE KIT 00Z2596 VORNEHM 10884521735552 48712074_1 CDM 0272 RC inpatient 670 435.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 649.9 97 999999999 405.69 649.9 percent of total billed charges LAP CHOLE KIT 00Z2596 VORNEHM 10884521735552 48712074_1 CDM 0272 RC inpatient 670 435.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 462.3 69 999999999 405.69 649.9 percent of total billed charges LAP CHOLE KIT 00Z2596 VORNEHM 10884521735552 48712074_1 CDM 0272 RC inpatient 670 435.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 522.6 78 999999999 405.69 649.9 percent of total billed charges LAP CHOLE KIT 00Z2596 VORNEHM 10884521735552 48712074_1 CDM 0272 RC inpatient 670 435.5 SIHO - ALL PLANS SIHO - ALL PLANS 603 90 999999999 405.69 649.9 percent of total billed charges LAP CHOLE KIT 00Z2596 VORNEHM 10884521735552 48712074_1 CDM 0272 RC inpatient 670 435.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 405.69 60.55 999999999 405.69 649.9 percent of total billed charges LAP CHOLE KIT 00Z2596 VORNEHM 10884521735552 48712074_1 CDM 0272 RC inpatient 670 435.5 UMR - ALL PLANS UMR - ALL PLANS 469 70 999999999 405.69 649.9 percent of total billed charges LAP CHOLE KIT 00Z2596 VORNEHM 10884521735552 48712074_1 CDM 0272 RC inpatient 670 435.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 405.69 649.9 LAP CHOLE KIT 00Z2596 VORNEHM 10884521735552 48712074_1 CDM 0272 RC inpatient 670 435.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 405.69 649.9 LAP CHOLE KIT 00Z2596 VORNEHM 10884521735552 48712074_1 CDM 0272 RC inpatient 670 435.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 405.69 649.9 LAP CHOLE KIT 00Z2596 VORNEHM 10884521735552 48712074_1 CDM 0272 RC inpatient 670 435.5 ANTHEM HMO ANTHEM HMO 999999999 405.69 649.9 LAP CHOLE KIT 00Z2596 VORNEHM 10884521735552 48712074_1 CDM 0272 RC inpatient 670 435.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 452.92 67.6 999999999 405.69 649.9 percent of total billed charges LAP CHOLE KIT 00Z2596 VORNEHM 10884521735552 48712074_1 CDM 0272 RC inpatient 670 435.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 405.69 649.9 MESH (IMPLANTABLE) 48712075_1 CDM 0278 RC C1781 HCPCS inpatient 3173 2062.45 AETNA AETNA 2506.67 79 999999999 1921.25 3077.81 percent of total billed charges MESH (IMPLANTABLE) 48712075_1 CDM 0278 RC C1781 HCPCS inpatient 3173 2062.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 2062.45 65 999999999 1921.25 3077.81 percent of total billed charges MESH (IMPLANTABLE) 48712075_1 CDM 0278 RC C1781 HCPCS inpatient 3173 2062.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3077.81 97 999999999 1921.25 3077.81 percent of total billed charges MESH (IMPLANTABLE) 48712075_1 CDM 0278 RC C1781 HCPCS inpatient 3173 2062.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 2189.37 69 999999999 1921.25 3077.81 percent of total billed charges MESH (IMPLANTABLE) 48712075_1 CDM 0278 RC C1781 HCPCS inpatient 3173 2062.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 2474.94 78 999999999 1921.25 3077.81 percent of total billed charges MESH (IMPLANTABLE) 48712075_1 CDM 0278 RC C1781 HCPCS inpatient 3173 2062.45 SIHO - ALL PLANS SIHO - ALL PLANS 2855.7 90 999999999 1921.25 3077.81 percent of total billed charges MESH (IMPLANTABLE) 48712075_1 CDM 0278 RC C1781 HCPCS inpatient 3173 2062.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1921.25 60.55 999999999 1921.25 3077.81 percent of total billed charges MESH (IMPLANTABLE) 48712075_1 CDM 0278 RC C1781 HCPCS inpatient 3173 2062.45 UMR - ALL PLANS UMR - ALL PLANS 2221.1 70 999999999 1921.25 3077.81 percent of total billed charges MESH (IMPLANTABLE) 48712075_1 CDM 0278 RC C1781 HCPCS inpatient 3173 2062.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1921.25 3077.81 MESH (IMPLANTABLE) 48712075_1 CDM 0278 RC C1781 HCPCS inpatient 3173 2062.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1921.25 3077.81 MESH (IMPLANTABLE) 48712075_1 CDM 0278 RC C1781 HCPCS inpatient 3173 2062.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1921.25 3077.81 MESH (IMPLANTABLE) 48712075_1 CDM 0278 RC C1781 HCPCS inpatient 3173 2062.45 ANTHEM HMO ANTHEM HMO 999999999 1921.25 3077.81 MESH (IMPLANTABLE) 48712075_1 CDM 0278 RC C1781 HCPCS inpatient 3173 2062.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 2144.95 67.6 999999999 1921.25 3077.81 percent of total billed charges MESH (IMPLANTABLE) 48712075_1 CDM 0278 RC C1781 HCPCS inpatient 3173 2062.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1921.25 3077.81 LAP CHOLE KIT BOYER 00Z2505 48712076_1 CDM 0272 RC inpatient 1824 1185.6 AETNA AETNA 1440.96 79 999999999 1104.43 1769.28 percent of total billed charges LAP CHOLE KIT BOYER 00Z2505 48712076_1 CDM 0272 RC inpatient 1824 1185.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1185.6 65 999999999 1104.43 1769.28 percent of total billed charges LAP CHOLE KIT BOYER 00Z2505 48712076_1 CDM 0272 RC inpatient 1824 1185.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1769.28 97 999999999 1104.43 1769.28 percent of total billed charges LAP CHOLE KIT BOYER 00Z2505 48712076_1 CDM 0272 RC inpatient 1824 1185.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1258.56 69 999999999 1104.43 1769.28 percent of total billed charges LAP CHOLE KIT BOYER 00Z2505 48712076_1 CDM 0272 RC inpatient 1824 1185.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1422.72 78 999999999 1104.43 1769.28 percent of total billed charges LAP CHOLE KIT BOYER 00Z2505 48712076_1 CDM 0272 RC inpatient 1824 1185.6 SIHO - ALL PLANS SIHO - ALL PLANS 1641.6 90 999999999 1104.43 1769.28 percent of total billed charges LAP CHOLE KIT BOYER 00Z2505 48712076_1 CDM 0272 RC inpatient 1824 1185.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1104.43 60.55 999999999 1104.43 1769.28 percent of total billed charges LAP CHOLE KIT BOYER 00Z2505 48712076_1 CDM 0272 RC inpatient 1824 1185.6 UMR - ALL PLANS UMR - ALL PLANS 1276.8 70 999999999 1104.43 1769.28 percent of total billed charges LAP CHOLE KIT BOYER 00Z2505 48712076_1 CDM 0272 RC inpatient 1824 1185.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1104.43 1769.28 LAP CHOLE KIT BOYER 00Z2505 48712076_1 CDM 0272 RC inpatient 1824 1185.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1104.43 1769.28 LAP CHOLE KIT BOYER 00Z2505 48712076_1 CDM 0272 RC inpatient 1824 1185.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1104.43 1769.28 LAP CHOLE KIT BOYER 00Z2505 48712076_1 CDM 0272 RC inpatient 1824 1185.6 ANTHEM HMO ANTHEM HMO 999999999 1104.43 1769.28 LAP CHOLE KIT BOYER 00Z2505 48712076_1 CDM 0272 RC inpatient 1824 1185.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1233.02 67.6 999999999 1104.43 1769.28 percent of total billed charges LAP CHOLE KIT BOYER 00Z2505 48712076_1 CDM 0272 RC inpatient 1824 1185.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1104.43 1769.28 LAP CHOLE KIT K0722 BOYER 48712077_1 CDM 0272 RC inpatient 1356 881.4 AETNA AETNA 1071.24 79 999999999 821.06 1315.32 percent of total billed charges LAP CHOLE KIT K0722 BOYER 48712077_1 CDM 0272 RC inpatient 1356 881.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 881.4 65 999999999 821.06 1315.32 percent of total billed charges LAP CHOLE KIT K0722 BOYER 48712077_1 CDM 0272 RC inpatient 1356 881.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1315.32 97 999999999 821.06 1315.32 percent of total billed charges LAP CHOLE KIT K0722 BOYER 48712077_1 CDM 0272 RC inpatient 1356 881.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 935.64 69 999999999 821.06 1315.32 percent of total billed charges LAP CHOLE KIT K0722 BOYER 48712077_1 CDM 0272 RC inpatient 1356 881.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1057.68 78 999999999 821.06 1315.32 percent of total billed charges LAP CHOLE KIT K0722 BOYER 48712077_1 CDM 0272 RC inpatient 1356 881.4 SIHO - ALL PLANS SIHO - ALL PLANS 1220.4 90 999999999 821.06 1315.32 percent of total billed charges LAP CHOLE KIT K0722 BOYER 48712077_1 CDM 0272 RC inpatient 1356 881.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 821.06 60.55 999999999 821.06 1315.32 percent of total billed charges LAP CHOLE KIT K0722 BOYER 48712077_1 CDM 0272 RC inpatient 1356 881.4 UMR - ALL PLANS UMR - ALL PLANS 949.2 70 999999999 821.06 1315.32 percent of total billed charges LAP CHOLE KIT K0722 BOYER 48712077_1 CDM 0272 RC inpatient 1356 881.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 821.06 1315.32 LAP CHOLE KIT K0722 BOYER 48712077_1 CDM 0272 RC inpatient 1356 881.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 821.06 1315.32 LAP CHOLE KIT K0722 BOYER 48712077_1 CDM 0272 RC inpatient 1356 881.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 821.06 1315.32 LAP CHOLE KIT K0722 BOYER 48712077_1 CDM 0272 RC inpatient 1356 881.4 ANTHEM HMO ANTHEM HMO 999999999 821.06 1315.32 LAP CHOLE KIT K0722 BOYER 48712077_1 CDM 0272 RC inpatient 1356 881.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 916.66 67.6 999999999 821.06 1315.32 percent of total billed charges LAP CHOLE KIT K0722 BOYER 48712077_1 CDM 0272 RC inpatient 1356 881.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 821.06 1315.32 GEL PORT C8XX2 48712079_1 CDM 0272 RC inpatient 3172 2061.8 AETNA AETNA 2505.88 79 999999999 1920.65 3076.84 percent of total billed charges GEL PORT C8XX2 48712079_1 CDM 0272 RC inpatient 3172 2061.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 2061.8 65 999999999 1920.65 3076.84 percent of total billed charges GEL PORT C8XX2 48712079_1 CDM 0272 RC inpatient 3172 2061.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3076.84 97 999999999 1920.65 3076.84 percent of total billed charges GEL PORT C8XX2 48712079_1 CDM 0272 RC inpatient 3172 2061.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 2188.68 69 999999999 1920.65 3076.84 percent of total billed charges GEL PORT C8XX2 48712079_1 CDM 0272 RC inpatient 3172 2061.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 2474.16 78 999999999 1920.65 3076.84 percent of total billed charges GEL PORT C8XX2 48712079_1 CDM 0272 RC inpatient 3172 2061.8 SIHO - ALL PLANS SIHO - ALL PLANS 2854.8 90 999999999 1920.65 3076.84 percent of total billed charges GEL PORT C8XX2 48712079_1 CDM 0272 RC inpatient 3172 2061.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1920.65 60.55 999999999 1920.65 3076.84 percent of total billed charges GEL PORT C8XX2 48712079_1 CDM 0272 RC inpatient 3172 2061.8 UMR - ALL PLANS UMR - ALL PLANS 2220.4 70 999999999 1920.65 3076.84 percent of total billed charges GEL PORT C8XX2 48712079_1 CDM 0272 RC inpatient 3172 2061.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1920.65 3076.84 GEL PORT C8XX2 48712079_1 CDM 0272 RC inpatient 3172 2061.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1920.65 3076.84 GEL PORT C8XX2 48712079_1 CDM 0272 RC inpatient 3172 2061.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1920.65 3076.84 GEL PORT C8XX2 48712079_1 CDM 0272 RC inpatient 3172 2061.8 ANTHEM HMO ANTHEM HMO 999999999 1920.65 3076.84 GEL PORT C8XX2 48712079_1 CDM 0272 RC inpatient 3172 2061.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 2144.27 67.6 999999999 1920.65 3076.84 percent of total billed charges GEL PORT C8XX2 48712079_1 CDM 0272 RC inpatient 3172 2061.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1920.65 3076.84 "INTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, STEERABLE, OTHER THAN PEEL-AWAY" 48712080_1 CDM 0621 RC C1766 HCPCS inpatient 156 101.4 AETNA AETNA 123.24 79 999999999 94.46 151.32 percent of total billed charges "INTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, STEERABLE, OTHER THAN PEEL-AWAY" 48712080_1 CDM 0621 RC C1766 HCPCS inpatient 156 101.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.4 65 999999999 94.46 151.32 percent of total billed charges "INTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, STEERABLE, OTHER THAN PEEL-AWAY" 48712080_1 CDM 0621 RC C1766 HCPCS inpatient 156 101.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 151.32 97 999999999 94.46 151.32 percent of total billed charges "INTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, STEERABLE, OTHER THAN PEEL-AWAY" 48712080_1 CDM 0621 RC C1766 HCPCS inpatient 156 101.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.64 69 999999999 94.46 151.32 percent of total billed charges "INTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, STEERABLE, OTHER THAN PEEL-AWAY" 48712080_1 CDM 0621 RC C1766 HCPCS inpatient 156 101.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.68 78 999999999 94.46 151.32 percent of total billed charges "INTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, STEERABLE, OTHER THAN PEEL-AWAY" 48712080_1 CDM 0621 RC C1766 HCPCS inpatient 156 101.4 SIHO - ALL PLANS SIHO - ALL PLANS 140.4 90 999999999 94.46 151.32 percent of total billed charges "INTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, STEERABLE, OTHER THAN PEEL-AWAY" 48712080_1 CDM 0621 RC C1766 HCPCS inpatient 156 101.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.46 60.55 999999999 94.46 151.32 percent of total billed charges "INTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, STEERABLE, OTHER THAN PEEL-AWAY" 48712080_1 CDM 0621 RC C1766 HCPCS inpatient 156 101.4 UMR - ALL PLANS UMR - ALL PLANS 109.2 70 999999999 94.46 151.32 percent of total billed charges "INTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, STEERABLE, OTHER THAN PEEL-AWAY" 48712080_1 CDM 0621 RC C1766 HCPCS inpatient 156 101.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.46 151.32 "INTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, STEERABLE, OTHER THAN PEEL-AWAY" 48712080_1 CDM 0621 RC C1766 HCPCS inpatient 156 101.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.46 151.32 "INTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, STEERABLE, OTHER THAN PEEL-AWAY" 48712080_1 CDM 0621 RC C1766 HCPCS inpatient 156 101.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.46 151.32 "INTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, STEERABLE, OTHER THAN PEEL-AWAY" 48712080_1 CDM 0621 RC C1766 HCPCS inpatient 156 101.4 ANTHEM HMO ANTHEM HMO 999999999 94.46 151.32 "INTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, STEERABLE, OTHER THAN PEEL-AWAY" 48712080_1 CDM 0621 RC C1766 HCPCS inpatient 156 101.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.46 67.6 999999999 94.46 151.32 percent of total billed charges "INTRODUCER/SHEATH, GUIDING, INTRACARDIAC ELECTROPHYSIOLOGICAL, STEERABLE, OTHER THAN PEEL-AWAY" 48712080_1 CDM 0621 RC C1766 HCPCS inpatient 156 101.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.46 151.32 HUMI UTERINE MANIPULATOR INJ LTL-6003 48712082_1 CDM 0272 RC inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges HUMI UTERINE MANIPULATOR INJ LTL-6003 48712082_1 CDM 0272 RC inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges HUMI UTERINE MANIPULATOR INJ LTL-6003 48712082_1 CDM 0272 RC inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges HUMI UTERINE MANIPULATOR INJ LTL-6003 48712082_1 CDM 0272 RC inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges HUMI UTERINE MANIPULATOR INJ LTL-6003 48712082_1 CDM 0272 RC inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges HUMI UTERINE MANIPULATOR INJ LTL-6003 48712082_1 CDM 0272 RC inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges HUMI UTERINE MANIPULATOR INJ LTL-6003 48712082_1 CDM 0272 RC inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges HUMI UTERINE MANIPULATOR INJ LTL-6003 48712082_1 CDM 0272 RC inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges HUMI UTERINE MANIPULATOR INJ LTL-6003 48712082_1 CDM 0272 RC inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 HUMI UTERINE MANIPULATOR INJ LTL-6003 48712082_1 CDM 0272 RC inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 HUMI UTERINE MANIPULATOR INJ LTL-6003 48712082_1 CDM 0272 RC inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 HUMI UTERINE MANIPULATOR INJ LTL-6003 48712082_1 CDM 0272 RC inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 HUMI UTERINE MANIPULATOR INJ LTL-6003 48712082_1 CDM 0272 RC inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges HUMI UTERINE MANIPULATOR INJ LTL-6003 48712082_1 CDM 0272 RC inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 SONICISION HANDPIECE SCDA39 48712086_1 CDM 0272 RC inpatient 2402 1561.3 AETNA AETNA 1897.58 79 999999999 1454.41 2329.94 percent of total billed charges SONICISION HANDPIECE SCDA39 48712086_1 CDM 0272 RC inpatient 2402 1561.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1561.3 65 999999999 1454.41 2329.94 percent of total billed charges SONICISION HANDPIECE SCDA39 48712086_1 CDM 0272 RC inpatient 2402 1561.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2329.94 97 999999999 1454.41 2329.94 percent of total billed charges SONICISION HANDPIECE SCDA39 48712086_1 CDM 0272 RC inpatient 2402 1561.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1657.38 69 999999999 1454.41 2329.94 percent of total billed charges SONICISION HANDPIECE SCDA39 48712086_1 CDM 0272 RC inpatient 2402 1561.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1873.56 78 999999999 1454.41 2329.94 percent of total billed charges SONICISION HANDPIECE SCDA39 48712086_1 CDM 0272 RC inpatient 2402 1561.3 SIHO - ALL PLANS SIHO - ALL PLANS 2161.8 90 999999999 1454.41 2329.94 percent of total billed charges SONICISION HANDPIECE SCDA39 48712086_1 CDM 0272 RC inpatient 2402 1561.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1454.41 60.55 999999999 1454.41 2329.94 percent of total billed charges SONICISION HANDPIECE SCDA39 48712086_1 CDM 0272 RC inpatient 2402 1561.3 UMR - ALL PLANS UMR - ALL PLANS 1681.4 70 999999999 1454.41 2329.94 percent of total billed charges SONICISION HANDPIECE SCDA39 48712086_1 CDM 0272 RC inpatient 2402 1561.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1454.41 2329.94 SONICISION HANDPIECE SCDA39 48712086_1 CDM 0272 RC inpatient 2402 1561.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1454.41 2329.94 SONICISION HANDPIECE SCDA39 48712086_1 CDM 0272 RC inpatient 2402 1561.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1454.41 2329.94 SONICISION HANDPIECE SCDA39 48712086_1 CDM 0272 RC inpatient 2402 1561.3 ANTHEM HMO ANTHEM HMO 999999999 1454.41 2329.94 SONICISION HANDPIECE SCDA39 48712086_1 CDM 0272 RC inpatient 2402 1561.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1623.75 67.6 999999999 1454.41 2329.94 percent of total billed charges SONICISION HANDPIECE SCDA39 48712086_1 CDM 0272 RC inpatient 2402 1561.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1454.41 2329.94 CATH HICKMAN HOHN 7FR FEED TB 48712089_1 CDM 0272 RC inpatient 1025 666.25 AETNA AETNA 809.75 79 999999999 620.64 994.25 percent of total billed charges CATH HICKMAN HOHN 7FR FEED TB 48712089_1 CDM 0272 RC inpatient 1025 666.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 666.25 65 999999999 620.64 994.25 percent of total billed charges CATH HICKMAN HOHN 7FR FEED TB 48712089_1 CDM 0272 RC inpatient 1025 666.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 994.25 97 999999999 620.64 994.25 percent of total billed charges CATH HICKMAN HOHN 7FR FEED TB 48712089_1 CDM 0272 RC inpatient 1025 666.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 707.25 69 999999999 620.64 994.25 percent of total billed charges CATH HICKMAN HOHN 7FR FEED TB 48712089_1 CDM 0272 RC inpatient 1025 666.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 799.5 78 999999999 620.64 994.25 percent of total billed charges CATH HICKMAN HOHN 7FR FEED TB 48712089_1 CDM 0272 RC inpatient 1025 666.25 SIHO - ALL PLANS SIHO - ALL PLANS 922.5 90 999999999 620.64 994.25 percent of total billed charges CATH HICKMAN HOHN 7FR FEED TB 48712089_1 CDM 0272 RC inpatient 1025 666.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 620.64 60.55 999999999 620.64 994.25 percent of total billed charges CATH HICKMAN HOHN 7FR FEED TB 48712089_1 CDM 0272 RC inpatient 1025 666.25 UMR - ALL PLANS UMR - ALL PLANS 717.5 70 999999999 620.64 994.25 percent of total billed charges CATH HICKMAN HOHN 7FR FEED TB 48712089_1 CDM 0272 RC inpatient 1025 666.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 620.64 994.25 CATH HICKMAN HOHN 7FR FEED TB 48712089_1 CDM 0272 RC inpatient 1025 666.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 620.64 994.25 CATH HICKMAN HOHN 7FR FEED TB 48712089_1 CDM 0272 RC inpatient 1025 666.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 620.64 994.25 CATH HICKMAN HOHN 7FR FEED TB 48712089_1 CDM 0272 RC inpatient 1025 666.25 ANTHEM HMO ANTHEM HMO 999999999 620.64 994.25 CATH HICKMAN HOHN 7FR FEED TB 48712089_1 CDM 0272 RC inpatient 1025 666.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 692.9 67.6 999999999 620.64 994.25 percent of total billed charges CATH HICKMAN HOHN 7FR FEED TB 48712089_1 CDM 0272 RC inpatient 1025 666.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 620.64 994.25 TRAY CATH TRIPLE LUMEN 12FR 48712090_1 CDM 0272 RC inpatient 905 588.25 AETNA AETNA 714.95 79 999999999 547.98 877.85 percent of total billed charges TRAY CATH TRIPLE LUMEN 12FR 48712090_1 CDM 0272 RC inpatient 905 588.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 588.25 65 999999999 547.98 877.85 percent of total billed charges TRAY CATH TRIPLE LUMEN 12FR 48712090_1 CDM 0272 RC inpatient 905 588.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 877.85 97 999999999 547.98 877.85 percent of total billed charges TRAY CATH TRIPLE LUMEN 12FR 48712090_1 CDM 0272 RC inpatient 905 588.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 624.45 69 999999999 547.98 877.85 percent of total billed charges TRAY CATH TRIPLE LUMEN 12FR 48712090_1 CDM 0272 RC inpatient 905 588.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 705.9 78 999999999 547.98 877.85 percent of total billed charges TRAY CATH TRIPLE LUMEN 12FR 48712090_1 CDM 0272 RC inpatient 905 588.25 SIHO - ALL PLANS SIHO - ALL PLANS 814.5 90 999999999 547.98 877.85 percent of total billed charges TRAY CATH TRIPLE LUMEN 12FR 48712090_1 CDM 0272 RC inpatient 905 588.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 547.98 60.55 999999999 547.98 877.85 percent of total billed charges TRAY CATH TRIPLE LUMEN 12FR 48712090_1 CDM 0272 RC inpatient 905 588.25 UMR - ALL PLANS UMR - ALL PLANS 633.5 70 999999999 547.98 877.85 percent of total billed charges TRAY CATH TRIPLE LUMEN 12FR 48712090_1 CDM 0272 RC inpatient 905 588.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 547.98 877.85 TRAY CATH TRIPLE LUMEN 12FR 48712090_1 CDM 0272 RC inpatient 905 588.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 547.98 877.85 TRAY CATH TRIPLE LUMEN 12FR 48712090_1 CDM 0272 RC inpatient 905 588.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 547.98 877.85 TRAY CATH TRIPLE LUMEN 12FR 48712090_1 CDM 0272 RC inpatient 905 588.25 ANTHEM HMO ANTHEM HMO 999999999 547.98 877.85 TRAY CATH TRIPLE LUMEN 12FR 48712090_1 CDM 0272 RC inpatient 905 588.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 611.78 67.6 999999999 547.98 877.85 percent of total billed charges TRAY CATH TRIPLE LUMEN 12FR 48712090_1 CDM 0272 RC inpatient 905 588.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 547.98 877.85 TWO LUMEN CATH KIT CDC-47702-XP1A 48712091_1 CDM 0272 RC inpatient 728 473.2 AETNA AETNA 575.12 79 999999999 440.8 706.16 percent of total billed charges TWO LUMEN CATH KIT CDC-47702-XP1A 48712091_1 CDM 0272 RC inpatient 728 473.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 473.2 65 999999999 440.8 706.16 percent of total billed charges TWO LUMEN CATH KIT CDC-47702-XP1A 48712091_1 CDM 0272 RC inpatient 728 473.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 706.16 97 999999999 440.8 706.16 percent of total billed charges TWO LUMEN CATH KIT CDC-47702-XP1A 48712091_1 CDM 0272 RC inpatient 728 473.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 502.32 69 999999999 440.8 706.16 percent of total billed charges TWO LUMEN CATH KIT CDC-47702-XP1A 48712091_1 CDM 0272 RC inpatient 728 473.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 567.84 78 999999999 440.8 706.16 percent of total billed charges TWO LUMEN CATH KIT CDC-47702-XP1A 48712091_1 CDM 0272 RC inpatient 728 473.2 SIHO - ALL PLANS SIHO - ALL PLANS 655.2 90 999999999 440.8 706.16 percent of total billed charges TWO LUMEN CATH KIT CDC-47702-XP1A 48712091_1 CDM 0272 RC inpatient 728 473.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 440.8 60.55 999999999 440.8 706.16 percent of total billed charges TWO LUMEN CATH KIT CDC-47702-XP1A 48712091_1 CDM 0272 RC inpatient 728 473.2 UMR - ALL PLANS UMR - ALL PLANS 509.6 70 999999999 440.8 706.16 percent of total billed charges TWO LUMEN CATH KIT CDC-47702-XP1A 48712091_1 CDM 0272 RC inpatient 728 473.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 440.8 706.16 TWO LUMEN CATH KIT CDC-47702-XP1A 48712091_1 CDM 0272 RC inpatient 728 473.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 440.8 706.16 TWO LUMEN CATH KIT CDC-47702-XP1A 48712091_1 CDM 0272 RC inpatient 728 473.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 440.8 706.16 TWO LUMEN CATH KIT CDC-47702-XP1A 48712091_1 CDM 0272 RC inpatient 728 473.2 ANTHEM HMO ANTHEM HMO 999999999 440.8 706.16 TWO LUMEN CATH KIT CDC-47702-XP1A 48712091_1 CDM 0272 RC inpatient 728 473.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 492.13 67.6 999999999 440.8 706.16 percent of total billed charges TWO LUMEN CATH KIT CDC-47702-XP1A 48712091_1 CDM 0272 RC inpatient 728 473.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 440.8 706.16 TRAY THREE LUMEN CDC45703XP1A 48712092_1 CDM 0272 RC inpatient 804 522.6 AETNA AETNA 635.16 79 999999999 486.82 779.88 percent of total billed charges TRAY THREE LUMEN CDC45703XP1A 48712092_1 CDM 0272 RC inpatient 804 522.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 522.6 65 999999999 486.82 779.88 percent of total billed charges TRAY THREE LUMEN CDC45703XP1A 48712092_1 CDM 0272 RC inpatient 804 522.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 779.88 97 999999999 486.82 779.88 percent of total billed charges TRAY THREE LUMEN CDC45703XP1A 48712092_1 CDM 0272 RC inpatient 804 522.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 554.76 69 999999999 486.82 779.88 percent of total billed charges TRAY THREE LUMEN CDC45703XP1A 48712092_1 CDM 0272 RC inpatient 804 522.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 627.12 78 999999999 486.82 779.88 percent of total billed charges TRAY THREE LUMEN CDC45703XP1A 48712092_1 CDM 0272 RC inpatient 804 522.6 SIHO - ALL PLANS SIHO - ALL PLANS 723.6 90 999999999 486.82 779.88 percent of total billed charges TRAY THREE LUMEN CDC45703XP1A 48712092_1 CDM 0272 RC inpatient 804 522.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 486.82 60.55 999999999 486.82 779.88 percent of total billed charges TRAY THREE LUMEN CDC45703XP1A 48712092_1 CDM 0272 RC inpatient 804 522.6 UMR - ALL PLANS UMR - ALL PLANS 562.8 70 999999999 486.82 779.88 percent of total billed charges TRAY THREE LUMEN CDC45703XP1A 48712092_1 CDM 0272 RC inpatient 804 522.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 486.82 779.88 TRAY THREE LUMEN CDC45703XP1A 48712092_1 CDM 0272 RC inpatient 804 522.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 486.82 779.88 TRAY THREE LUMEN CDC45703XP1A 48712092_1 CDM 0272 RC inpatient 804 522.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 486.82 779.88 TRAY THREE LUMEN CDC45703XP1A 48712092_1 CDM 0272 RC inpatient 804 522.6 ANTHEM HMO ANTHEM HMO 999999999 486.82 779.88 TRAY THREE LUMEN CDC45703XP1A 48712092_1 CDM 0272 RC inpatient 804 522.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 543.5 67.6 999999999 486.82 779.88 percent of total billed charges TRAY THREE LUMEN CDC45703XP1A 48712092_1 CDM 0272 RC inpatient 804 522.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 486.82 779.88 TUR IRRGATION Y-TYPE 2C4041 48712098_1 CDM 0272 RC inpatient 89 57.85 AETNA AETNA 70.31 79 999999999 53.89 86.33 percent of total billed charges TUR IRRGATION Y-TYPE 2C4041 48712098_1 CDM 0272 RC inpatient 89 57.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.85 65 999999999 53.89 86.33 percent of total billed charges TUR IRRGATION Y-TYPE 2C4041 48712098_1 CDM 0272 RC inpatient 89 57.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 86.33 97 999999999 53.89 86.33 percent of total billed charges TUR IRRGATION Y-TYPE 2C4041 48712098_1 CDM 0272 RC inpatient 89 57.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 61.41 69 999999999 53.89 86.33 percent of total billed charges TUR IRRGATION Y-TYPE 2C4041 48712098_1 CDM 0272 RC inpatient 89 57.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 69.42 78 999999999 53.89 86.33 percent of total billed charges TUR IRRGATION Y-TYPE 2C4041 48712098_1 CDM 0272 RC inpatient 89 57.85 SIHO - ALL PLANS SIHO - ALL PLANS 80.1 90 999999999 53.89 86.33 percent of total billed charges TUR IRRGATION Y-TYPE 2C4041 48712098_1 CDM 0272 RC inpatient 89 57.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.89 60.55 999999999 53.89 86.33 percent of total billed charges TUR IRRGATION Y-TYPE 2C4041 48712098_1 CDM 0272 RC inpatient 89 57.85 UMR - ALL PLANS UMR - ALL PLANS 62.3 70 999999999 53.89 86.33 percent of total billed charges TUR IRRGATION Y-TYPE 2C4041 48712098_1 CDM 0272 RC inpatient 89 57.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.89 86.33 TUR IRRGATION Y-TYPE 2C4041 48712098_1 CDM 0272 RC inpatient 89 57.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.89 86.33 TUR IRRGATION Y-TYPE 2C4041 48712098_1 CDM 0272 RC inpatient 89 57.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.89 86.33 TUR IRRGATION Y-TYPE 2C4041 48712098_1 CDM 0272 RC inpatient 89 57.85 ANTHEM HMO ANTHEM HMO 999999999 53.89 86.33 TUR IRRGATION Y-TYPE 2C4041 48712098_1 CDM 0272 RC inpatient 89 57.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.16 67.6 999999999 53.89 86.33 percent of total billed charges TUR IRRGATION Y-TYPE 2C4041 48712098_1 CDM 0272 RC inpatient 89 57.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.89 86.33 RETRO INTUBATION SET #G10554 48712101_1 CDM 0270 RC inpatient 867 563.55 AETNA AETNA 684.93 79 999999999 524.97 840.99 percent of total billed charges RETRO INTUBATION SET #G10554 48712101_1 CDM 0270 RC inpatient 867 563.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 563.55 65 999999999 524.97 840.99 percent of total billed charges RETRO INTUBATION SET #G10554 48712101_1 CDM 0270 RC inpatient 867 563.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 840.99 97 999999999 524.97 840.99 percent of total billed charges RETRO INTUBATION SET #G10554 48712101_1 CDM 0270 RC inpatient 867 563.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 598.23 69 999999999 524.97 840.99 percent of total billed charges RETRO INTUBATION SET #G10554 48712101_1 CDM 0270 RC inpatient 867 563.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 676.26 78 999999999 524.97 840.99 percent of total billed charges RETRO INTUBATION SET #G10554 48712101_1 CDM 0270 RC inpatient 867 563.55 SIHO - ALL PLANS SIHO - ALL PLANS 780.3 90 999999999 524.97 840.99 percent of total billed charges RETRO INTUBATION SET #G10554 48712101_1 CDM 0270 RC inpatient 867 563.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 524.97 60.55 999999999 524.97 840.99 percent of total billed charges RETRO INTUBATION SET #G10554 48712101_1 CDM 0270 RC inpatient 867 563.55 UMR - ALL PLANS UMR - ALL PLANS 606.9 70 999999999 524.97 840.99 percent of total billed charges RETRO INTUBATION SET #G10554 48712101_1 CDM 0270 RC inpatient 867 563.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 524.97 840.99 RETRO INTUBATION SET #G10554 48712101_1 CDM 0270 RC inpatient 867 563.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 524.97 840.99 RETRO INTUBATION SET #G10554 48712101_1 CDM 0270 RC inpatient 867 563.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 524.97 840.99 RETRO INTUBATION SET #G10554 48712101_1 CDM 0270 RC inpatient 867 563.55 ANTHEM HMO ANTHEM HMO 999999999 524.97 840.99 RETRO INTUBATION SET #G10554 48712101_1 CDM 0270 RC inpatient 867 563.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 586.09 67.6 999999999 524.97 840.99 percent of total billed charges RETRO INTUBATION SET #G10554 48712101_1 CDM 0270 RC inpatient 867 563.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 524.97 840.99 SOD CHL IRR 0.9% 500ML 2F7123 48712102_1 CDM 0272 RC inpatient 19 12.35 AETNA AETNA 15.01 79 999999999 11.5 18.43 percent of total billed charges SOD CHL IRR 0.9% 500ML 2F7123 48712102_1 CDM 0272 RC inpatient 19 12.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.35 65 999999999 11.5 18.43 percent of total billed charges SOD CHL IRR 0.9% 500ML 2F7123 48712102_1 CDM 0272 RC inpatient 19 12.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 18.43 97 999999999 11.5 18.43 percent of total billed charges SOD CHL IRR 0.9% 500ML 2F7123 48712102_1 CDM 0272 RC inpatient 19 12.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.11 69 999999999 11.5 18.43 percent of total billed charges SOD CHL IRR 0.9% 500ML 2F7123 48712102_1 CDM 0272 RC inpatient 19 12.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.82 78 999999999 11.5 18.43 percent of total billed charges SOD CHL IRR 0.9% 500ML 2F7123 48712102_1 CDM 0272 RC inpatient 19 12.35 SIHO - ALL PLANS SIHO - ALL PLANS 17.1 90 999999999 11.5 18.43 percent of total billed charges SOD CHL IRR 0.9% 500ML 2F7123 48712102_1 CDM 0272 RC inpatient 19 12.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.5 60.55 999999999 11.5 18.43 percent of total billed charges SOD CHL IRR 0.9% 500ML 2F7123 48712102_1 CDM 0272 RC inpatient 19 12.35 UMR - ALL PLANS UMR - ALL PLANS 13.3 70 999999999 11.5 18.43 percent of total billed charges SOD CHL IRR 0.9% 500ML 2F7123 48712102_1 CDM 0272 RC inpatient 19 12.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.5 18.43 SOD CHL IRR 0.9% 500ML 2F7123 48712102_1 CDM 0272 RC inpatient 19 12.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.5 18.43 SOD CHL IRR 0.9% 500ML 2F7123 48712102_1 CDM 0272 RC inpatient 19 12.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.5 18.43 SOD CHL IRR 0.9% 500ML 2F7123 48712102_1 CDM 0272 RC inpatient 19 12.35 ANTHEM HMO ANTHEM HMO 999999999 11.5 18.43 SOD CHL IRR 0.9% 500ML 2F7123 48712102_1 CDM 0272 RC inpatient 19 12.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.84 67.6 999999999 11.5 18.43 percent of total billed charges SOD CHL IRR 0.9% 500ML 2F7123 48712102_1 CDM 0272 RC inpatient 19 12.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.5 18.43 SOD CHL IRR 0.9 1000ML 2F7124 48712103_1 CDM 0272 RC inpatient 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges SOD CHL IRR 0.9 1000ML 2F7124 48712103_1 CDM 0272 RC inpatient 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges SOD CHL IRR 0.9 1000ML 2F7124 48712103_1 CDM 0272 RC inpatient 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges SOD CHL IRR 0.9 1000ML 2F7124 48712103_1 CDM 0272 RC inpatient 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges SOD CHL IRR 0.9 1000ML 2F7124 48712103_1 CDM 0272 RC inpatient 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges SOD CHL IRR 0.9 1000ML 2F7124 48712103_1 CDM 0272 RC inpatient 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges SOD CHL IRR 0.9 1000ML 2F7124 48712103_1 CDM 0272 RC inpatient 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges SOD CHL IRR 0.9 1000ML 2F7124 48712103_1 CDM 0272 RC inpatient 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges SOD CHL IRR 0.9 1000ML 2F7124 48712103_1 CDM 0272 RC inpatient 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 SOD CHL IRR 0.9 1000ML 2F7124 48712103_1 CDM 0272 RC inpatient 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 SOD CHL IRR 0.9 1000ML 2F7124 48712103_1 CDM 0272 RC inpatient 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 SOD CHL IRR 0.9 1000ML 2F7124 48712103_1 CDM 0272 RC inpatient 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 SOD CHL IRR 0.9 1000ML 2F7124 48712103_1 CDM 0272 RC inpatient 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges SOD CHL IRR 0.9 1000ML 2F7124 48712103_1 CDM 0272 RC inpatient 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 ST WATER IRR 1000ML BT 2F7114 48712104_1 CDM 0272 RC inpatient 22 14.3 AETNA AETNA 17.38 79 999999999 13.32 21.34 percent of total billed charges ST WATER IRR 1000ML BT 2F7114 48712104_1 CDM 0272 RC inpatient 22 14.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.3 65 999999999 13.32 21.34 percent of total billed charges ST WATER IRR 1000ML BT 2F7114 48712104_1 CDM 0272 RC inpatient 22 14.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21.34 97 999999999 13.32 21.34 percent of total billed charges ST WATER IRR 1000ML BT 2F7114 48712104_1 CDM 0272 RC inpatient 22 14.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.18 69 999999999 13.32 21.34 percent of total billed charges ST WATER IRR 1000ML BT 2F7114 48712104_1 CDM 0272 RC inpatient 22 14.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.16 78 999999999 13.32 21.34 percent of total billed charges ST WATER IRR 1000ML BT 2F7114 48712104_1 CDM 0272 RC inpatient 22 14.3 SIHO - ALL PLANS SIHO - ALL PLANS 19.8 90 999999999 13.32 21.34 percent of total billed charges ST WATER IRR 1000ML BT 2F7114 48712104_1 CDM 0272 RC inpatient 22 14.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.32 60.55 999999999 13.32 21.34 percent of total billed charges ST WATER IRR 1000ML BT 2F7114 48712104_1 CDM 0272 RC inpatient 22 14.3 UMR - ALL PLANS UMR - ALL PLANS 15.4 70 999999999 13.32 21.34 percent of total billed charges ST WATER IRR 1000ML BT 2F7114 48712104_1 CDM 0272 RC inpatient 22 14.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.32 21.34 ST WATER IRR 1000ML BT 2F7114 48712104_1 CDM 0272 RC inpatient 22 14.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.32 21.34 ST WATER IRR 1000ML BT 2F7114 48712104_1 CDM 0272 RC inpatient 22 14.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.32 21.34 ST WATER IRR 1000ML BT 2F7114 48712104_1 CDM 0272 RC inpatient 22 14.3 ANTHEM HMO ANTHEM HMO 999999999 13.32 21.34 ST WATER IRR 1000ML BT 2F7114 48712104_1 CDM 0272 RC inpatient 22 14.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.87 67.6 999999999 13.32 21.34 percent of total billed charges ST WATER IRR 1000ML BT 2F7114 48712104_1 CDM 0272 RC inpatient 22 14.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.32 21.34 ST WATER IRR 500ML POUR 2F7113 48712105_1 CDM 0272 RC inpatient 18 11.7 AETNA AETNA 14.22 79 999999999 10.9 17.46 percent of total billed charges ST WATER IRR 500ML POUR 2F7113 48712105_1 CDM 0272 RC inpatient 18 11.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.7 65 999999999 10.9 17.46 percent of total billed charges ST WATER IRR 500ML POUR 2F7113 48712105_1 CDM 0272 RC inpatient 18 11.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.46 97 999999999 10.9 17.46 percent of total billed charges ST WATER IRR 500ML POUR 2F7113 48712105_1 CDM 0272 RC inpatient 18 11.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.42 69 999999999 10.9 17.46 percent of total billed charges ST WATER IRR 500ML POUR 2F7113 48712105_1 CDM 0272 RC inpatient 18 11.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.04 78 999999999 10.9 17.46 percent of total billed charges ST WATER IRR 500ML POUR 2F7113 48712105_1 CDM 0272 RC inpatient 18 11.7 SIHO - ALL PLANS SIHO - ALL PLANS 16.2 90 999999999 10.9 17.46 percent of total billed charges ST WATER IRR 500ML POUR 2F7113 48712105_1 CDM 0272 RC inpatient 18 11.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.9 60.55 999999999 10.9 17.46 percent of total billed charges ST WATER IRR 500ML POUR 2F7113 48712105_1 CDM 0272 RC inpatient 18 11.7 UMR - ALL PLANS UMR - ALL PLANS 12.6 70 999999999 10.9 17.46 percent of total billed charges ST WATER IRR 500ML POUR 2F7113 48712105_1 CDM 0272 RC inpatient 18 11.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.9 17.46 ST WATER IRR 500ML POUR 2F7113 48712105_1 CDM 0272 RC inpatient 18 11.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.9 17.46 ST WATER IRR 500ML POUR 2F7113 48712105_1 CDM 0272 RC inpatient 18 11.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.9 17.46 ST WATER IRR 500ML POUR 2F7113 48712105_1 CDM 0272 RC inpatient 18 11.7 ANTHEM HMO ANTHEM HMO 999999999 10.9 17.46 ST WATER IRR 500ML POUR 2F7113 48712105_1 CDM 0272 RC inpatient 18 11.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.17 67.6 999999999 10.9 17.46 percent of total billed charges ST WATER IRR 500ML POUR 2F7113 48712105_1 CDM 0272 RC inpatient 18 11.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.9 17.46 STERILE WATER IRR 1000 BAG 2B7114X 48712106_1 CDM 0272 RC inpatient 30 19.5 AETNA AETNA 23.7 79 999999999 18.17 29.1 percent of total billed charges STERILE WATER IRR 1000 BAG 2B7114X 48712106_1 CDM 0272 RC inpatient 30 19.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.5 65 999999999 18.17 29.1 percent of total billed charges STERILE WATER IRR 1000 BAG 2B7114X 48712106_1 CDM 0272 RC inpatient 30 19.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.1 97 999999999 18.17 29.1 percent of total billed charges STERILE WATER IRR 1000 BAG 2B7114X 48712106_1 CDM 0272 RC inpatient 30 19.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.7 69 999999999 18.17 29.1 percent of total billed charges STERILE WATER IRR 1000 BAG 2B7114X 48712106_1 CDM 0272 RC inpatient 30 19.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.4 78 999999999 18.17 29.1 percent of total billed charges STERILE WATER IRR 1000 BAG 2B7114X 48712106_1 CDM 0272 RC inpatient 30 19.5 SIHO - ALL PLANS SIHO - ALL PLANS 27 90 999999999 18.17 29.1 percent of total billed charges STERILE WATER IRR 1000 BAG 2B7114X 48712106_1 CDM 0272 RC inpatient 30 19.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.17 60.55 999999999 18.17 29.1 percent of total billed charges STERILE WATER IRR 1000 BAG 2B7114X 48712106_1 CDM 0272 RC inpatient 30 19.5 UMR - ALL PLANS UMR - ALL PLANS 21 70 999999999 18.17 29.1 percent of total billed charges STERILE WATER IRR 1000 BAG 2B7114X 48712106_1 CDM 0272 RC inpatient 30 19.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.17 29.1 STERILE WATER IRR 1000 BAG 2B7114X 48712106_1 CDM 0272 RC inpatient 30 19.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.17 29.1 STERILE WATER IRR 1000 BAG 2B7114X 48712106_1 CDM 0272 RC inpatient 30 19.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.17 29.1 STERILE WATER IRR 1000 BAG 2B7114X 48712106_1 CDM 0272 RC inpatient 30 19.5 ANTHEM HMO ANTHEM HMO 999999999 18.17 29.1 STERILE WATER IRR 1000 BAG 2B7114X 48712106_1 CDM 0272 RC inpatient 30 19.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.28 67.6 999999999 18.17 29.1 percent of total billed charges STERILE WATER IRR 1000 BAG 2B7114X 48712106_1 CDM 0272 RC inpatient 30 19.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.17 29.1 SYSTEM ORAL CLEANSE & SUCTION 48712107_1 CDM 0270 RC inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges SYSTEM ORAL CLEANSE & SUCTION 48712107_1 CDM 0270 RC inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges SYSTEM ORAL CLEANSE & SUCTION 48712107_1 CDM 0270 RC inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges SYSTEM ORAL CLEANSE & SUCTION 48712107_1 CDM 0270 RC inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges SYSTEM ORAL CLEANSE & SUCTION 48712107_1 CDM 0270 RC inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges SYSTEM ORAL CLEANSE & SUCTION 48712107_1 CDM 0270 RC inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges SYSTEM ORAL CLEANSE & SUCTION 48712107_1 CDM 0270 RC inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges SYSTEM ORAL CLEANSE & SUCTION 48712107_1 CDM 0270 RC inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges SYSTEM ORAL CLEANSE & SUCTION 48712107_1 CDM 0270 RC inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 SYSTEM ORAL CLEANSE & SUCTION 48712107_1 CDM 0270 RC inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 SYSTEM ORAL CLEANSE & SUCTION 48712107_1 CDM 0270 RC inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 SYSTEM ORAL CLEANSE & SUCTION 48712107_1 CDM 0270 RC inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 SYSTEM ORAL CLEANSE & SUCTION 48712107_1 CDM 0270 RC inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges SYSTEM ORAL CLEANSE & SUCTION 48712107_1 CDM 0270 RC inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 STERILE WATER FOR IRRIG 3000ML 2B7117 48712109_1 CDM 0272 RC inpatient 69 44.85 AETNA AETNA 54.51 79 999999999 41.78 66.93 percent of total billed charges STERILE WATER FOR IRRIG 3000ML 2B7117 48712109_1 CDM 0272 RC inpatient 69 44.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.85 65 999999999 41.78 66.93 percent of total billed charges STERILE WATER FOR IRRIG 3000ML 2B7117 48712109_1 CDM 0272 RC inpatient 69 44.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 66.93 97 999999999 41.78 66.93 percent of total billed charges STERILE WATER FOR IRRIG 3000ML 2B7117 48712109_1 CDM 0272 RC inpatient 69 44.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 47.61 69 999999999 41.78 66.93 percent of total billed charges STERILE WATER FOR IRRIG 3000ML 2B7117 48712109_1 CDM 0272 RC inpatient 69 44.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.82 78 999999999 41.78 66.93 percent of total billed charges STERILE WATER FOR IRRIG 3000ML 2B7117 48712109_1 CDM 0272 RC inpatient 69 44.85 SIHO - ALL PLANS SIHO - ALL PLANS 62.1 90 999999999 41.78 66.93 percent of total billed charges STERILE WATER FOR IRRIG 3000ML 2B7117 48712109_1 CDM 0272 RC inpatient 69 44.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.78 60.55 999999999 41.78 66.93 percent of total billed charges STERILE WATER FOR IRRIG 3000ML 2B7117 48712109_1 CDM 0272 RC inpatient 69 44.85 UMR - ALL PLANS UMR - ALL PLANS 48.3 70 999999999 41.78 66.93 percent of total billed charges STERILE WATER FOR IRRIG 3000ML 2B7117 48712109_1 CDM 0272 RC inpatient 69 44.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.78 66.93 STERILE WATER FOR IRRIG 3000ML 2B7117 48712109_1 CDM 0272 RC inpatient 69 44.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.78 66.93 STERILE WATER FOR IRRIG 3000ML 2B7117 48712109_1 CDM 0272 RC inpatient 69 44.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.78 66.93 STERILE WATER FOR IRRIG 3000ML 2B7117 48712109_1 CDM 0272 RC inpatient 69 44.85 ANTHEM HMO ANTHEM HMO 999999999 41.78 66.93 STERILE WATER FOR IRRIG 3000ML 2B7117 48712109_1 CDM 0272 RC inpatient 69 44.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 46.64 67.6 999999999 41.78 66.93 percent of total billed charges STERILE WATER FOR IRRIG 3000ML 2B7117 48712109_1 CDM 0272 RC inpatient 69 44.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.78 66.93 LACT RINGERS 3000ML IRR 2B7487 48712111_1 CDM 0272 RC inpatient 62 40.3 AETNA AETNA 48.98 79 999999999 37.54 60.14 percent of total billed charges LACT RINGERS 3000ML IRR 2B7487 48712111_1 CDM 0272 RC inpatient 62 40.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.3 65 999999999 37.54 60.14 percent of total billed charges LACT RINGERS 3000ML IRR 2B7487 48712111_1 CDM 0272 RC inpatient 62 40.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 60.14 97 999999999 37.54 60.14 percent of total billed charges LACT RINGERS 3000ML IRR 2B7487 48712111_1 CDM 0272 RC inpatient 62 40.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.78 69 999999999 37.54 60.14 percent of total billed charges LACT RINGERS 3000ML IRR 2B7487 48712111_1 CDM 0272 RC inpatient 62 40.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 48.36 78 999999999 37.54 60.14 percent of total billed charges LACT RINGERS 3000ML IRR 2B7487 48712111_1 CDM 0272 RC inpatient 62 40.3 SIHO - ALL PLANS SIHO - ALL PLANS 55.8 90 999999999 37.54 60.14 percent of total billed charges LACT RINGERS 3000ML IRR 2B7487 48712111_1 CDM 0272 RC inpatient 62 40.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 37.54 60.55 999999999 37.54 60.14 percent of total billed charges LACT RINGERS 3000ML IRR 2B7487 48712111_1 CDM 0272 RC inpatient 62 40.3 UMR - ALL PLANS UMR - ALL PLANS 43.4 70 999999999 37.54 60.14 percent of total billed charges LACT RINGERS 3000ML IRR 2B7487 48712111_1 CDM 0272 RC inpatient 62 40.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 37.54 60.14 LACT RINGERS 3000ML IRR 2B7487 48712111_1 CDM 0272 RC inpatient 62 40.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 37.54 60.14 LACT RINGERS 3000ML IRR 2B7487 48712111_1 CDM 0272 RC inpatient 62 40.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 37.54 60.14 LACT RINGERS 3000ML IRR 2B7487 48712111_1 CDM 0272 RC inpatient 62 40.3 ANTHEM HMO ANTHEM HMO 999999999 37.54 60.14 LACT RINGERS 3000ML IRR 2B7487 48712111_1 CDM 0272 RC inpatient 62 40.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.91 67.6 999999999 37.54 60.14 percent of total billed charges LACT RINGERS 3000ML IRR 2B7487 48712111_1 CDM 0272 RC inpatient 62 40.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 37.54 60.14 PARACENTESIS TRAY 48712112_1 CDM 0272 RC inpatient 431 280.15 AETNA AETNA 340.49 79 999999999 260.97 418.07 percent of total billed charges PARACENTESIS TRAY 48712112_1 CDM 0272 RC inpatient 431 280.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 280.15 65 999999999 260.97 418.07 percent of total billed charges PARACENTESIS TRAY 48712112_1 CDM 0272 RC inpatient 431 280.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 418.07 97 999999999 260.97 418.07 percent of total billed charges PARACENTESIS TRAY 48712112_1 CDM 0272 RC inpatient 431 280.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 297.39 69 999999999 260.97 418.07 percent of total billed charges PARACENTESIS TRAY 48712112_1 CDM 0272 RC inpatient 431 280.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 336.18 78 999999999 260.97 418.07 percent of total billed charges PARACENTESIS TRAY 48712112_1 CDM 0272 RC inpatient 431 280.15 SIHO - ALL PLANS SIHO - ALL PLANS 387.9 90 999999999 260.97 418.07 percent of total billed charges PARACENTESIS TRAY 48712112_1 CDM 0272 RC inpatient 431 280.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 260.97 60.55 999999999 260.97 418.07 percent of total billed charges PARACENTESIS TRAY 48712112_1 CDM 0272 RC inpatient 431 280.15 UMR - ALL PLANS UMR - ALL PLANS 301.7 70 999999999 260.97 418.07 percent of total billed charges PARACENTESIS TRAY 48712112_1 CDM 0272 RC inpatient 431 280.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 260.97 418.07 PARACENTESIS TRAY 48712112_1 CDM 0272 RC inpatient 431 280.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 260.97 418.07 PARACENTESIS TRAY 48712112_1 CDM 0272 RC inpatient 431 280.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 260.97 418.07 PARACENTESIS TRAY 48712112_1 CDM 0272 RC inpatient 431 280.15 ANTHEM HMO ANTHEM HMO 999999999 260.97 418.07 PARACENTESIS TRAY 48712112_1 CDM 0272 RC inpatient 431 280.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 291.36 67.6 999999999 260.97 418.07 percent of total billed charges PARACENTESIS TRAY 48712112_1 CDM 0272 RC inpatient 431 280.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 260.97 418.07 SODIUM CHLORIDE 0.9% 3000ML 2B7127 48712113_1 CDM 0272 RC inpatient 61 39.65 AETNA AETNA 48.19 79 999999999 36.94 59.17 percent of total billed charges SODIUM CHLORIDE 0.9% 3000ML 2B7127 48712113_1 CDM 0272 RC inpatient 61 39.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.65 65 999999999 36.94 59.17 percent of total billed charges SODIUM CHLORIDE 0.9% 3000ML 2B7127 48712113_1 CDM 0272 RC inpatient 61 39.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59.17 97 999999999 36.94 59.17 percent of total billed charges SODIUM CHLORIDE 0.9% 3000ML 2B7127 48712113_1 CDM 0272 RC inpatient 61 39.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.09 69 999999999 36.94 59.17 percent of total billed charges SODIUM CHLORIDE 0.9% 3000ML 2B7127 48712113_1 CDM 0272 RC inpatient 61 39.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.58 78 999999999 36.94 59.17 percent of total billed charges SODIUM CHLORIDE 0.9% 3000ML 2B7127 48712113_1 CDM 0272 RC inpatient 61 39.65 SIHO - ALL PLANS SIHO - ALL PLANS 54.9 90 999999999 36.94 59.17 percent of total billed charges SODIUM CHLORIDE 0.9% 3000ML 2B7127 48712113_1 CDM 0272 RC inpatient 61 39.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.94 60.55 999999999 36.94 59.17 percent of total billed charges SODIUM CHLORIDE 0.9% 3000ML 2B7127 48712113_1 CDM 0272 RC inpatient 61 39.65 UMR - ALL PLANS UMR - ALL PLANS 42.7 70 999999999 36.94 59.17 percent of total billed charges SODIUM CHLORIDE 0.9% 3000ML 2B7127 48712113_1 CDM 0272 RC inpatient 61 39.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.94 59.17 SODIUM CHLORIDE 0.9% 3000ML 2B7127 48712113_1 CDM 0272 RC inpatient 61 39.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.94 59.17 SODIUM CHLORIDE 0.9% 3000ML 2B7127 48712113_1 CDM 0272 RC inpatient 61 39.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.94 59.17 SODIUM CHLORIDE 0.9% 3000ML 2B7127 48712113_1 CDM 0272 RC inpatient 61 39.65 ANTHEM HMO ANTHEM HMO 999999999 36.94 59.17 SODIUM CHLORIDE 0.9% 3000ML 2B7127 48712113_1 CDM 0272 RC inpatient 61 39.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.24 67.6 999999999 36.94 59.17 percent of total billed charges SODIUM CHLORIDE 0.9% 3000ML 2B7127 48712113_1 CDM 0272 RC inpatient 61 39.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.94 59.17 INSPIRATORY MUSCLE TRAINER 26-22-7500EA 48712115_1 CDM 0272 RC inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges INSPIRATORY MUSCLE TRAINER 26-22-7500EA 48712115_1 CDM 0272 RC inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges INSPIRATORY MUSCLE TRAINER 26-22-7500EA 48712115_1 CDM 0272 RC inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges INSPIRATORY MUSCLE TRAINER 26-22-7500EA 48712115_1 CDM 0272 RC inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges INSPIRATORY MUSCLE TRAINER 26-22-7500EA 48712115_1 CDM 0272 RC inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges INSPIRATORY MUSCLE TRAINER 26-22-7500EA 48712115_1 CDM 0272 RC inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges INSPIRATORY MUSCLE TRAINER 26-22-7500EA 48712115_1 CDM 0272 RC inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges INSPIRATORY MUSCLE TRAINER 26-22-7500EA 48712115_1 CDM 0272 RC inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges INSPIRATORY MUSCLE TRAINER 26-22-7500EA 48712115_1 CDM 0272 RC inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 INSPIRATORY MUSCLE TRAINER 26-22-7500EA 48712115_1 CDM 0272 RC inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 INSPIRATORY MUSCLE TRAINER 26-22-7500EA 48712115_1 CDM 0272 RC inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 INSPIRATORY MUSCLE TRAINER 26-22-7500EA 48712115_1 CDM 0272 RC inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 INSPIRATORY MUSCLE TRAINER 26-22-7500EA 48712115_1 CDM 0272 RC inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges INSPIRATORY MUSCLE TRAINER 26-22-7500EA 48712115_1 CDM 0272 RC inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 IRRIGATION SET CYSTO DYND19140 48712116_1 CDM 0272 RC inpatient 35 22.75 AETNA AETNA 27.65 79 999999999 21.19 33.95 percent of total billed charges IRRIGATION SET CYSTO DYND19140 48712116_1 CDM 0272 RC inpatient 35 22.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.75 65 999999999 21.19 33.95 percent of total billed charges IRRIGATION SET CYSTO DYND19140 48712116_1 CDM 0272 RC inpatient 35 22.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33.95 97 999999999 21.19 33.95 percent of total billed charges IRRIGATION SET CYSTO DYND19140 48712116_1 CDM 0272 RC inpatient 35 22.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.15 69 999999999 21.19 33.95 percent of total billed charges IRRIGATION SET CYSTO DYND19140 48712116_1 CDM 0272 RC inpatient 35 22.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.3 78 999999999 21.19 33.95 percent of total billed charges IRRIGATION SET CYSTO DYND19140 48712116_1 CDM 0272 RC inpatient 35 22.75 SIHO - ALL PLANS SIHO - ALL PLANS 31.5 90 999999999 21.19 33.95 percent of total billed charges IRRIGATION SET CYSTO DYND19140 48712116_1 CDM 0272 RC inpatient 35 22.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.19 60.55 999999999 21.19 33.95 percent of total billed charges IRRIGATION SET CYSTO DYND19140 48712116_1 CDM 0272 RC inpatient 35 22.75 UMR - ALL PLANS UMR - ALL PLANS 24.5 70 999999999 21.19 33.95 percent of total billed charges IRRIGATION SET CYSTO DYND19140 48712116_1 CDM 0272 RC inpatient 35 22.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.19 33.95 IRRIGATION SET CYSTO DYND19140 48712116_1 CDM 0272 RC inpatient 35 22.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.19 33.95 IRRIGATION SET CYSTO DYND19140 48712116_1 CDM 0272 RC inpatient 35 22.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.19 33.95 IRRIGATION SET CYSTO DYND19140 48712116_1 CDM 0272 RC inpatient 35 22.75 ANTHEM HMO ANTHEM HMO 999999999 21.19 33.95 IRRIGATION SET CYSTO DYND19140 48712116_1 CDM 0272 RC inpatient 35 22.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 23.66 67.6 999999999 21.19 33.95 percent of total billed charges IRRIGATION SET CYSTO DYND19140 48712116_1 CDM 0272 RC inpatient 35 22.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.19 33.95 SHOWERHEAD TIP IRRG 4in 0210-014-000 48712117_1 CDM 0274 RC inpatient 71 46.15 AETNA AETNA 56.09 79 999999999 42.99 68.87 percent of total billed charges SHOWERHEAD TIP IRRG 4in 0210-014-000 48712117_1 CDM 0274 RC inpatient 71 46.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.15 65 999999999 42.99 68.87 percent of total billed charges SHOWERHEAD TIP IRRG 4in 0210-014-000 48712117_1 CDM 0274 RC inpatient 71 46.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 68.87 97 999999999 42.99 68.87 percent of total billed charges SHOWERHEAD TIP IRRG 4in 0210-014-000 48712117_1 CDM 0274 RC inpatient 71 46.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.99 69 999999999 42.99 68.87 percent of total billed charges SHOWERHEAD TIP IRRG 4in 0210-014-000 48712117_1 CDM 0274 RC inpatient 71 46.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 55.38 78 999999999 42.99 68.87 percent of total billed charges SHOWERHEAD TIP IRRG 4in 0210-014-000 48712117_1 CDM 0274 RC inpatient 71 46.15 SIHO - ALL PLANS SIHO - ALL PLANS 63.9 90 999999999 42.99 68.87 percent of total billed charges SHOWERHEAD TIP IRRG 4in 0210-014-000 48712117_1 CDM 0274 RC inpatient 71 46.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.99 60.55 999999999 42.99 68.87 percent of total billed charges SHOWERHEAD TIP IRRG 4in 0210-014-000 48712117_1 CDM 0274 RC inpatient 71 46.15 UMR - ALL PLANS UMR - ALL PLANS 49.7 70 999999999 42.99 68.87 percent of total billed charges SHOWERHEAD TIP IRRG 4in 0210-014-000 48712117_1 CDM 0274 RC inpatient 71 46.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.99 68.87 SHOWERHEAD TIP IRRG 4in 0210-014-000 48712117_1 CDM 0274 RC inpatient 71 46.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.99 68.87 SHOWERHEAD TIP IRRG 4in 0210-014-000 48712117_1 CDM 0274 RC inpatient 71 46.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.99 68.87 SHOWERHEAD TIP IRRG 4in 0210-014-000 48712117_1 CDM 0274 RC inpatient 71 46.15 ANTHEM HMO ANTHEM HMO 999999999 42.99 68.87 SHOWERHEAD TIP IRRG 4in 0210-014-000 48712117_1 CDM 0274 RC inpatient 71 46.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 48 67.6 999999999 42.99 68.87 percent of total billed charges SHOWERHEAD TIP IRRG 4in 0210-014-000 48712117_1 CDM 0274 RC inpatient 71 46.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.99 68.87 SILVASORB HYDRO 1.5 MSC9301EP 48712122_1 CDM 0272 RC inpatient 125 81.25 AETNA AETNA 98.75 79 999999999 75.69 121.25 percent of total billed charges SILVASORB HYDRO 1.5 MSC9301EP 48712122_1 CDM 0272 RC inpatient 125 81.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.25 65 999999999 75.69 121.25 percent of total billed charges SILVASORB HYDRO 1.5 MSC9301EP 48712122_1 CDM 0272 RC inpatient 125 81.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 121.25 97 999999999 75.69 121.25 percent of total billed charges SILVASORB HYDRO 1.5 MSC9301EP 48712122_1 CDM 0272 RC inpatient 125 81.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.25 69 999999999 75.69 121.25 percent of total billed charges SILVASORB HYDRO 1.5 MSC9301EP 48712122_1 CDM 0272 RC inpatient 125 81.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.5 78 999999999 75.69 121.25 percent of total billed charges SILVASORB HYDRO 1.5 MSC9301EP 48712122_1 CDM 0272 RC inpatient 125 81.25 SIHO - ALL PLANS SIHO - ALL PLANS 112.5 90 999999999 75.69 121.25 percent of total billed charges SILVASORB HYDRO 1.5 MSC9301EP 48712122_1 CDM 0272 RC inpatient 125 81.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.69 60.55 999999999 75.69 121.25 percent of total billed charges SILVASORB HYDRO 1.5 MSC9301EP 48712122_1 CDM 0272 RC inpatient 125 81.25 UMR - ALL PLANS UMR - ALL PLANS 87.5 70 999999999 75.69 121.25 percent of total billed charges SILVASORB HYDRO 1.5 MSC9301EP 48712122_1 CDM 0272 RC inpatient 125 81.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.69 121.25 SILVASORB HYDRO 1.5 MSC9301EP 48712122_1 CDM 0272 RC inpatient 125 81.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.69 121.25 SILVASORB HYDRO 1.5 MSC9301EP 48712122_1 CDM 0272 RC inpatient 125 81.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.69 121.25 SILVASORB HYDRO 1.5 MSC9301EP 48712122_1 CDM 0272 RC inpatient 125 81.25 ANTHEM HMO ANTHEM HMO 999999999 75.69 121.25 SILVASORB HYDRO 1.5 MSC9301EP 48712122_1 CDM 0272 RC inpatient 125 81.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.5 67.6 999999999 75.69 121.25 percent of total billed charges SILVASORB HYDRO 1.5 MSC9301EP 48712122_1 CDM 0272 RC inpatient 125 81.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.69 121.25 BRACE KNEE POST OP 08814 48712123_1 CDM 0271 RC inpatient 602 391.3 AETNA AETNA 475.58 79 999999999 364.51 583.94 percent of total billed charges BRACE KNEE POST OP 08814 48712123_1 CDM 0271 RC inpatient 602 391.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 391.3 65 999999999 364.51 583.94 percent of total billed charges BRACE KNEE POST OP 08814 48712123_1 CDM 0271 RC inpatient 602 391.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 583.94 97 999999999 364.51 583.94 percent of total billed charges BRACE KNEE POST OP 08814 48712123_1 CDM 0271 RC inpatient 602 391.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 415.38 69 999999999 364.51 583.94 percent of total billed charges BRACE KNEE POST OP 08814 48712123_1 CDM 0271 RC inpatient 602 391.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 469.56 78 999999999 364.51 583.94 percent of total billed charges BRACE KNEE POST OP 08814 48712123_1 CDM 0271 RC inpatient 602 391.3 SIHO - ALL PLANS SIHO - ALL PLANS 541.8 90 999999999 364.51 583.94 percent of total billed charges BRACE KNEE POST OP 08814 48712123_1 CDM 0271 RC inpatient 602 391.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 364.51 60.55 999999999 364.51 583.94 percent of total billed charges BRACE KNEE POST OP 08814 48712123_1 CDM 0271 RC inpatient 602 391.3 UMR - ALL PLANS UMR - ALL PLANS 421.4 70 999999999 364.51 583.94 percent of total billed charges BRACE KNEE POST OP 08814 48712123_1 CDM 0271 RC inpatient 602 391.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 364.51 583.94 BRACE KNEE POST OP 08814 48712123_1 CDM 0271 RC inpatient 602 391.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 364.51 583.94 BRACE KNEE POST OP 08814 48712123_1 CDM 0271 RC inpatient 602 391.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 364.51 583.94 BRACE KNEE POST OP 08814 48712123_1 CDM 0271 RC inpatient 602 391.3 ANTHEM HMO ANTHEM HMO 999999999 364.51 583.94 BRACE KNEE POST OP 08814 48712123_1 CDM 0271 RC inpatient 602 391.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 406.95 67.6 999999999 364.51 583.94 percent of total billed charges BRACE KNEE POST OP 08814 48712123_1 CDM 0271 RC inpatient 602 391.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 364.51 583.94 KNEE POSITIONING KIT FP-KNEEPOS 48712125_1 CDM 0272 RC inpatient 165 107.25 AETNA AETNA 130.35 79 999999999 99.91 160.05 percent of total billed charges KNEE POSITIONING KIT FP-KNEEPOS 48712125_1 CDM 0272 RC inpatient 165 107.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.25 65 999999999 99.91 160.05 percent of total billed charges KNEE POSITIONING KIT FP-KNEEPOS 48712125_1 CDM 0272 RC inpatient 165 107.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 160.05 97 999999999 99.91 160.05 percent of total billed charges KNEE POSITIONING KIT FP-KNEEPOS 48712125_1 CDM 0272 RC inpatient 165 107.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.85 69 999999999 99.91 160.05 percent of total billed charges KNEE POSITIONING KIT FP-KNEEPOS 48712125_1 CDM 0272 RC inpatient 165 107.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.7 78 999999999 99.91 160.05 percent of total billed charges KNEE POSITIONING KIT FP-KNEEPOS 48712125_1 CDM 0272 RC inpatient 165 107.25 SIHO - ALL PLANS SIHO - ALL PLANS 148.5 90 999999999 99.91 160.05 percent of total billed charges KNEE POSITIONING KIT FP-KNEEPOS 48712125_1 CDM 0272 RC inpatient 165 107.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.91 60.55 999999999 99.91 160.05 percent of total billed charges KNEE POSITIONING KIT FP-KNEEPOS 48712125_1 CDM 0272 RC inpatient 165 107.25 UMR - ALL PLANS UMR - ALL PLANS 115.5 70 999999999 99.91 160.05 percent of total billed charges KNEE POSITIONING KIT FP-KNEEPOS 48712125_1 CDM 0272 RC inpatient 165 107.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.91 160.05 KNEE POSITIONING KIT FP-KNEEPOS 48712125_1 CDM 0272 RC inpatient 165 107.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.91 160.05 KNEE POSITIONING KIT FP-KNEEPOS 48712125_1 CDM 0272 RC inpatient 165 107.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.91 160.05 KNEE POSITIONING KIT FP-KNEEPOS 48712125_1 CDM 0272 RC inpatient 165 107.25 ANTHEM HMO ANTHEM HMO 999999999 99.91 160.05 KNEE POSITIONING KIT FP-KNEEPOS 48712125_1 CDM 0272 RC inpatient 165 107.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.54 67.6 999999999 99.91 160.05 percent of total billed charges KNEE POSITIONING KIT FP-KNEEPOS 48712125_1 CDM 0272 RC inpatient 165 107.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.91 160.05 CANNULA CURETTE W/60CC SYR 48712126_1 CDM 0272 RC inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges CANNULA CURETTE W/60CC SYR 48712126_1 CDM 0272 RC inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges CANNULA CURETTE W/60CC SYR 48712126_1 CDM 0272 RC inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges CANNULA CURETTE W/60CC SYR 48712126_1 CDM 0272 RC inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges CANNULA CURETTE W/60CC SYR 48712126_1 CDM 0272 RC inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges CANNULA CURETTE W/60CC SYR 48712126_1 CDM 0272 RC inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges CANNULA CURETTE W/60CC SYR 48712126_1 CDM 0272 RC inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges CANNULA CURETTE W/60CC SYR 48712126_1 CDM 0272 RC inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges CANNULA CURETTE W/60CC SYR 48712126_1 CDM 0272 RC inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 CANNULA CURETTE W/60CC SYR 48712126_1 CDM 0272 RC inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 CANNULA CURETTE W/60CC SYR 48712126_1 CDM 0272 RC inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 CANNULA CURETTE W/60CC SYR 48712126_1 CDM 0272 RC inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 CANNULA CURETTE W/60CC SYR 48712126_1 CDM 0272 RC inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges CANNULA CURETTE W/60CC SYR 48712126_1 CDM 0272 RC inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 "KNEE IMMOBILIZER 12"" 1120917" 48712127_1 CDM 0271 RC inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges "KNEE IMMOBILIZER 12"" 1120917" 48712127_1 CDM 0271 RC inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges "KNEE IMMOBILIZER 12"" 1120917" 48712127_1 CDM 0271 RC inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges "KNEE IMMOBILIZER 12"" 1120917" 48712127_1 CDM 0271 RC inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges "KNEE IMMOBILIZER 12"" 1120917" 48712127_1 CDM 0271 RC inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges "KNEE IMMOBILIZER 12"" 1120917" 48712127_1 CDM 0271 RC inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges "KNEE IMMOBILIZER 12"" 1120917" 48712127_1 CDM 0271 RC inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges "KNEE IMMOBILIZER 12"" 1120917" 48712127_1 CDM 0271 RC inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges "KNEE IMMOBILIZER 12"" 1120917" 48712127_1 CDM 0271 RC inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 "KNEE IMMOBILIZER 12"" 1120917" 48712127_1 CDM 0271 RC inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 "KNEE IMMOBILIZER 12"" 1120917" 48712127_1 CDM 0271 RC inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 "KNEE IMMOBILIZER 12"" 1120917" 48712127_1 CDM 0271 RC inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 "KNEE IMMOBILIZER 12"" 1120917" 48712127_1 CDM 0271 RC inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges "KNEE IMMOBILIZER 12"" 1120917" 48712127_1 CDM 0271 RC inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 KNEE IMMOBILIZER 16in 48712128_1 CDM 0271 RC inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges KNEE IMMOBILIZER 16in 48712128_1 CDM 0271 RC inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges KNEE IMMOBILIZER 16in 48712128_1 CDM 0271 RC inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges KNEE IMMOBILIZER 16in 48712128_1 CDM 0271 RC inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges KNEE IMMOBILIZER 16in 48712128_1 CDM 0271 RC inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges KNEE IMMOBILIZER 16in 48712128_1 CDM 0271 RC inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges KNEE IMMOBILIZER 16in 48712128_1 CDM 0271 RC inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges KNEE IMMOBILIZER 16in 48712128_1 CDM 0271 RC inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges KNEE IMMOBILIZER 16in 48712128_1 CDM 0271 RC inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 KNEE IMMOBILIZER 16in 48712128_1 CDM 0271 RC inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 KNEE IMMOBILIZER 16in 48712128_1 CDM 0271 RC inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 KNEE IMMOBILIZER 16in 48712128_1 CDM 0271 RC inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 KNEE IMMOBILIZER 16in 48712128_1 CDM 0271 RC inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges KNEE IMMOBILIZER 16in 48712128_1 CDM 0271 RC inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 KNEE IMMOBILIZER 14in 48712129_1 CDM 0271 RC inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges KNEE IMMOBILIZER 14in 48712129_1 CDM 0271 RC inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges KNEE IMMOBILIZER 14in 48712129_1 CDM 0271 RC inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges KNEE IMMOBILIZER 14in 48712129_1 CDM 0271 RC inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges KNEE IMMOBILIZER 14in 48712129_1 CDM 0271 RC inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges KNEE IMMOBILIZER 14in 48712129_1 CDM 0271 RC inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges KNEE IMMOBILIZER 14in 48712129_1 CDM 0271 RC inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges KNEE IMMOBILIZER 14in 48712129_1 CDM 0271 RC inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges KNEE IMMOBILIZER 14in 48712129_1 CDM 0271 RC inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 KNEE IMMOBILIZER 14in 48712129_1 CDM 0271 RC inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 KNEE IMMOBILIZER 14in 48712129_1 CDM 0271 RC inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 KNEE IMMOBILIZER 14in 48712129_1 CDM 0271 RC inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 KNEE IMMOBILIZER 14in 48712129_1 CDM 0271 RC inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges KNEE IMMOBILIZER 14in 48712129_1 CDM 0271 RC inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 "KNEE IMMBOLIZER 19"" 1190917" 48712131_1 CDM 0270 RC inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges "KNEE IMMBOLIZER 19"" 1190917" 48712131_1 CDM 0270 RC inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges "KNEE IMMBOLIZER 19"" 1190917" 48712131_1 CDM 0270 RC inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges "KNEE IMMBOLIZER 19"" 1190917" 48712131_1 CDM 0270 RC inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges "KNEE IMMBOLIZER 19"" 1190917" 48712131_1 CDM 0270 RC inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges "KNEE IMMBOLIZER 19"" 1190917" 48712131_1 CDM 0270 RC inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges "KNEE IMMBOLIZER 19"" 1190917" 48712131_1 CDM 0270 RC inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges "KNEE IMMBOLIZER 19"" 1190917" 48712131_1 CDM 0270 RC inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges "KNEE IMMBOLIZER 19"" 1190917" 48712131_1 CDM 0270 RC inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 "KNEE IMMBOLIZER 19"" 1190917" 48712131_1 CDM 0270 RC inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 "KNEE IMMBOLIZER 19"" 1190917" 48712131_1 CDM 0270 RC inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 "KNEE IMMBOLIZER 19"" 1190917" 48712131_1 CDM 0270 RC inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 "KNEE IMMBOLIZER 19"" 1190917" 48712131_1 CDM 0270 RC inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges "KNEE IMMBOLIZER 19"" 1190917" 48712131_1 CDM 0270 RC inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 SPLINT KNEE BASIC 24IN 79-96024 48712132_1 CDM 0274 RC inpatient 93 60.45 AETNA AETNA 73.47 79 999999999 56.31 90.21 percent of total billed charges SPLINT KNEE BASIC 24IN 79-96024 48712132_1 CDM 0274 RC inpatient 93 60.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 60.45 65 999999999 56.31 90.21 percent of total billed charges SPLINT KNEE BASIC 24IN 79-96024 48712132_1 CDM 0274 RC inpatient 93 60.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 90.21 97 999999999 56.31 90.21 percent of total billed charges SPLINT KNEE BASIC 24IN 79-96024 48712132_1 CDM 0274 RC inpatient 93 60.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.17 69 999999999 56.31 90.21 percent of total billed charges SPLINT KNEE BASIC 24IN 79-96024 48712132_1 CDM 0274 RC inpatient 93 60.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 72.54 78 999999999 56.31 90.21 percent of total billed charges SPLINT KNEE BASIC 24IN 79-96024 48712132_1 CDM 0274 RC inpatient 93 60.45 SIHO - ALL PLANS SIHO - ALL PLANS 83.7 90 999999999 56.31 90.21 percent of total billed charges SPLINT KNEE BASIC 24IN 79-96024 48712132_1 CDM 0274 RC inpatient 93 60.45 UMR - ALL PLANS UMR - ALL PLANS 65.1 70 999999999 56.31 90.21 percent of total billed charges SPLINT KNEE BASIC 24IN 79-96024 48712132_1 CDM 0274 RC inpatient 93 60.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.31 60.55 999999999 56.31 90.21 percent of total billed charges SPLINT KNEE BASIC 24IN 79-96024 48712132_1 CDM 0274 RC inpatient 93 60.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.31 90.21 SPLINT KNEE BASIC 24IN 79-96024 48712132_1 CDM 0274 RC inpatient 93 60.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.31 90.21 SPLINT KNEE BASIC 24IN 79-96024 48712132_1 CDM 0274 RC inpatient 93 60.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.31 90.21 SPLINT KNEE BASIC 24IN 79-96024 48712132_1 CDM 0274 RC inpatient 93 60.45 ANTHEM HMO ANTHEM HMO 999999999 56.31 90.21 SPLINT KNEE BASIC 24IN 79-96024 48712132_1 CDM 0274 RC inpatient 93 60.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.87 67.6 999999999 56.31 90.21 percent of total billed charges SPLINT KNEE BASIC 24IN 79-96024 48712132_1 CDM 0274 RC inpatient 93 60.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.31 90.21 LAVAGE CHARCOAL E/R 48712136_1 CDM 0270 RC inpatient 390 253.5 AETNA AETNA 308.1 79 999999999 236.15 378.3 percent of total billed charges LAVAGE CHARCOAL E/R 48712136_1 CDM 0270 RC inpatient 390 253.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 253.5 65 999999999 236.15 378.3 percent of total billed charges LAVAGE CHARCOAL E/R 48712136_1 CDM 0270 RC inpatient 390 253.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 378.3 97 999999999 236.15 378.3 percent of total billed charges LAVAGE CHARCOAL E/R 48712136_1 CDM 0270 RC inpatient 390 253.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 269.1 69 999999999 236.15 378.3 percent of total billed charges LAVAGE CHARCOAL E/R 48712136_1 CDM 0270 RC inpatient 390 253.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 304.2 78 999999999 236.15 378.3 percent of total billed charges LAVAGE CHARCOAL E/R 48712136_1 CDM 0270 RC inpatient 390 253.5 SIHO - ALL PLANS SIHO - ALL PLANS 351 90 999999999 236.15 378.3 percent of total billed charges LAVAGE CHARCOAL E/R 48712136_1 CDM 0270 RC inpatient 390 253.5 UMR - ALL PLANS UMR - ALL PLANS 273 70 999999999 236.15 378.3 percent of total billed charges LAVAGE CHARCOAL E/R 48712136_1 CDM 0270 RC inpatient 390 253.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 236.15 60.55 999999999 236.15 378.3 percent of total billed charges LAVAGE CHARCOAL E/R 48712136_1 CDM 0270 RC inpatient 390 253.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 236.15 378.3 LAVAGE CHARCOAL E/R 48712136_1 CDM 0270 RC inpatient 390 253.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 236.15 378.3 LAVAGE CHARCOAL E/R 48712136_1 CDM 0270 RC inpatient 390 253.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 236.15 378.3 LAVAGE CHARCOAL E/R 48712136_1 CDM 0270 RC inpatient 390 253.5 ANTHEM HMO ANTHEM HMO 999999999 236.15 378.3 LAVAGE CHARCOAL E/R 48712136_1 CDM 0270 RC inpatient 390 253.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 263.64 67.6 999999999 236.15 378.3 percent of total billed charges LAVAGE CHARCOAL E/R 48712136_1 CDM 0270 RC inpatient 390 253.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 236.15 378.3 RESUSCITATOR PEDS 87-AF2142MB2 48712139_1 CDM 0274 RC inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges RESUSCITATOR PEDS 87-AF2142MB2 48712139_1 CDM 0274 RC inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges RESUSCITATOR PEDS 87-AF2142MB2 48712139_1 CDM 0274 RC inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges RESUSCITATOR PEDS 87-AF2142MB2 48712139_1 CDM 0274 RC inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges RESUSCITATOR PEDS 87-AF2142MB2 48712139_1 CDM 0274 RC inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges RESUSCITATOR PEDS 87-AF2142MB2 48712139_1 CDM 0274 RC inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges RESUSCITATOR PEDS 87-AF2142MB2 48712139_1 CDM 0274 RC inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges RESUSCITATOR PEDS 87-AF2142MB2 48712139_1 CDM 0274 RC inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges RESUSCITATOR PEDS 87-AF2142MB2 48712139_1 CDM 0274 RC inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 RESUSCITATOR PEDS 87-AF2142MB2 48712139_1 CDM 0274 RC inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 RESUSCITATOR PEDS 87-AF2142MB2 48712139_1 CDM 0274 RC inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 RESUSCITATOR PEDS 87-AF2142MB2 48712139_1 CDM 0274 RC inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 RESUSCITATOR PEDS 87-AF2142MB2 48712139_1 CDM 0274 RC inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges RESUSCITATOR PEDS 87-AF2142MB2 48712139_1 CDM 0274 RC inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 MOUTH TO MASK ONE WAY #7100 48712143_1 CDM 0274 RC inpatient 96 62.4 AETNA AETNA 75.84 79 999999999 58.13 93.12 percent of total billed charges MOUTH TO MASK ONE WAY #7100 48712143_1 CDM 0274 RC inpatient 96 62.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.4 65 999999999 58.13 93.12 percent of total billed charges MOUTH TO MASK ONE WAY #7100 48712143_1 CDM 0274 RC inpatient 96 62.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.12 97 999999999 58.13 93.12 percent of total billed charges MOUTH TO MASK ONE WAY #7100 48712143_1 CDM 0274 RC inpatient 96 62.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.24 69 999999999 58.13 93.12 percent of total billed charges MOUTH TO MASK ONE WAY #7100 48712143_1 CDM 0274 RC inpatient 96 62.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.88 78 999999999 58.13 93.12 percent of total billed charges MOUTH TO MASK ONE WAY #7100 48712143_1 CDM 0274 RC inpatient 96 62.4 SIHO - ALL PLANS SIHO - ALL PLANS 86.4 90 999999999 58.13 93.12 percent of total billed charges MOUTH TO MASK ONE WAY #7100 48712143_1 CDM 0274 RC inpatient 96 62.4 UMR - ALL PLANS UMR - ALL PLANS 67.2 70 999999999 58.13 93.12 percent of total billed charges MOUTH TO MASK ONE WAY #7100 48712143_1 CDM 0274 RC inpatient 96 62.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.13 60.55 999999999 58.13 93.12 percent of total billed charges MOUTH TO MASK ONE WAY #7100 48712143_1 CDM 0274 RC inpatient 96 62.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.13 93.12 MOUTH TO MASK ONE WAY #7100 48712143_1 CDM 0274 RC inpatient 96 62.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.13 93.12 MOUTH TO MASK ONE WAY #7100 48712143_1 CDM 0274 RC inpatient 96 62.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.13 93.12 MOUTH TO MASK ONE WAY #7100 48712143_1 CDM 0274 RC inpatient 96 62.4 ANTHEM HMO ANTHEM HMO 999999999 58.13 93.12 MOUTH TO MASK ONE WAY #7100 48712143_1 CDM 0274 RC inpatient 96 62.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.9 67.6 999999999 58.13 93.12 percent of total billed charges MOUTH TO MASK ONE WAY #7100 48712143_1 CDM 0274 RC inpatient 96 62.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.13 93.12 "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712146_1 CDM 0278 RC C1767 HCPCS inpatient 30951 20118.15 AETNA AETNA 24451.29 79 999999999 18740.83 30022.47 percent of total billed charges "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712146_1 CDM 0278 RC C1767 HCPCS inpatient 30951 20118.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 20118.15 65 999999999 18740.83 30022.47 percent of total billed charges "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712146_1 CDM 0278 RC C1767 HCPCS inpatient 30951 20118.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30022.47 97 999999999 18740.83 30022.47 percent of total billed charges "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712146_1 CDM 0278 RC C1767 HCPCS inpatient 30951 20118.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 21356.19 69 999999999 18740.83 30022.47 percent of total billed charges "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712146_1 CDM 0278 RC C1767 HCPCS inpatient 30951 20118.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 24141.78 78 999999999 18740.83 30022.47 percent of total billed charges "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712146_1 CDM 0278 RC C1767 HCPCS inpatient 30951 20118.15 SIHO - ALL PLANS SIHO - ALL PLANS 27855.9 90 999999999 18740.83 30022.47 percent of total billed charges "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712146_1 CDM 0278 RC C1767 HCPCS inpatient 30951 20118.15 UMR - ALL PLANS UMR - ALL PLANS 21665.7 70 999999999 18740.83 30022.47 percent of total billed charges "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712146_1 CDM 0278 RC C1767 HCPCS inpatient 30951 20118.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18740.83 60.55 999999999 18740.83 30022.47 percent of total billed charges "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712146_1 CDM 0278 RC C1767 HCPCS inpatient 30951 20118.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18740.83 30022.47 "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712146_1 CDM 0278 RC C1767 HCPCS inpatient 30951 20118.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18740.83 30022.47 "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712146_1 CDM 0278 RC C1767 HCPCS inpatient 30951 20118.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18740.83 30022.47 "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712146_1 CDM 0278 RC C1767 HCPCS inpatient 30951 20118.15 ANTHEM HMO ANTHEM HMO 999999999 18740.83 30022.47 "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712146_1 CDM 0278 RC C1767 HCPCS inpatient 30951 20118.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 20922.88 67.6 999999999 18740.83 30022.47 percent of total billed charges "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712146_1 CDM 0278 RC C1767 HCPCS inpatient 30951 20118.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 18740.83 30022.47 ******* BLANKET PER MEGAN P. 07/20/2023********* 365 MICRON LASER FIBER 48712147_1 CDM 0272 RC inpatient 2117 1376.05 AETNA AETNA 1672.43 79 999999999 1281.84 2053.49 percent of total billed charges ******* BLANKET PER MEGAN P. 07/20/2023********* 365 MICRON LASER FIBER 48712147_1 CDM 0272 RC inpatient 2117 1376.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1376.05 65 999999999 1281.84 2053.49 percent of total billed charges ******* BLANKET PER MEGAN P. 07/20/2023********* 365 MICRON LASER FIBER 48712147_1 CDM 0272 RC inpatient 2117 1376.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2053.49 97 999999999 1281.84 2053.49 percent of total billed charges ******* BLANKET PER MEGAN P. 07/20/2023********* 365 MICRON LASER FIBER 48712147_1 CDM 0272 RC inpatient 2117 1376.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1460.73 69 999999999 1281.84 2053.49 percent of total billed charges ******* BLANKET PER MEGAN P. 07/20/2023********* 365 MICRON LASER FIBER 48712147_1 CDM 0272 RC inpatient 2117 1376.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1651.26 78 999999999 1281.84 2053.49 percent of total billed charges ******* BLANKET PER MEGAN P. 07/20/2023********* 365 MICRON LASER FIBER 48712147_1 CDM 0272 RC inpatient 2117 1376.05 SIHO - ALL PLANS SIHO - ALL PLANS 1905.3 90 999999999 1281.84 2053.49 percent of total billed charges ******* BLANKET PER MEGAN P. 07/20/2023********* 365 MICRON LASER FIBER 48712147_1 CDM 0272 RC inpatient 2117 1376.05 UMR - ALL PLANS UMR - ALL PLANS 1481.9 70 999999999 1281.84 2053.49 percent of total billed charges ******* BLANKET PER MEGAN P. 07/20/2023********* 365 MICRON LASER FIBER 48712147_1 CDM 0272 RC inpatient 2117 1376.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1281.84 60.55 999999999 1281.84 2053.49 percent of total billed charges ******* BLANKET PER MEGAN P. 07/20/2023********* 365 MICRON LASER FIBER 48712147_1 CDM 0272 RC inpatient 2117 1376.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1281.84 2053.49 ******* BLANKET PER MEGAN P. 07/20/2023********* 365 MICRON LASER FIBER 48712147_1 CDM 0272 RC inpatient 2117 1376.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1281.84 2053.49 ******* BLANKET PER MEGAN P. 07/20/2023********* 365 MICRON LASER FIBER 48712147_1 CDM 0272 RC inpatient 2117 1376.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1281.84 2053.49 ******* BLANKET PER MEGAN P. 07/20/2023********* 365 MICRON LASER FIBER 48712147_1 CDM 0272 RC inpatient 2117 1376.05 ANTHEM HMO ANTHEM HMO 999999999 1281.84 2053.49 ******* BLANKET PER MEGAN P. 07/20/2023********* 365 MICRON LASER FIBER 48712147_1 CDM 0272 RC inpatient 2117 1376.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1431.09 67.6 999999999 1281.84 2053.49 percent of total billed charges ******* BLANKET PER MEGAN P. 07/20/2023********* 365 MICRON LASER FIBER 48712147_1 CDM 0272 RC inpatient 2117 1376.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1281.84 2053.49 NOVASURE ADVANCED NS2013KITUS 48712148_1 CDM 0272 RC inpatient 4331 2815.15 AETNA AETNA 3421.49 79 999999999 2622.42 4201.07 percent of total billed charges NOVASURE ADVANCED NS2013KITUS 48712148_1 CDM 0272 RC inpatient 4331 2815.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 2815.15 65 999999999 2622.42 4201.07 percent of total billed charges NOVASURE ADVANCED NS2013KITUS 48712148_1 CDM 0272 RC inpatient 4331 2815.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4201.07 97 999999999 2622.42 4201.07 percent of total billed charges NOVASURE ADVANCED NS2013KITUS 48712148_1 CDM 0272 RC inpatient 4331 2815.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 2988.39 69 999999999 2622.42 4201.07 percent of total billed charges NOVASURE ADVANCED NS2013KITUS 48712148_1 CDM 0272 RC inpatient 4331 2815.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 3378.18 78 999999999 2622.42 4201.07 percent of total billed charges NOVASURE ADVANCED NS2013KITUS 48712148_1 CDM 0272 RC inpatient 4331 2815.15 SIHO - ALL PLANS SIHO - ALL PLANS 3897.9 90 999999999 2622.42 4201.07 percent of total billed charges NOVASURE ADVANCED NS2013KITUS 48712148_1 CDM 0272 RC inpatient 4331 2815.15 UMR - ALL PLANS UMR - ALL PLANS 3031.7 70 999999999 2622.42 4201.07 percent of total billed charges NOVASURE ADVANCED NS2013KITUS 48712148_1 CDM 0272 RC inpatient 4331 2815.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2622.42 60.55 999999999 2622.42 4201.07 percent of total billed charges NOVASURE ADVANCED NS2013KITUS 48712148_1 CDM 0272 RC inpatient 4331 2815.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2622.42 4201.07 NOVASURE ADVANCED NS2013KITUS 48712148_1 CDM 0272 RC inpatient 4331 2815.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2622.42 4201.07 NOVASURE ADVANCED NS2013KITUS 48712148_1 CDM 0272 RC inpatient 4331 2815.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2622.42 4201.07 NOVASURE ADVANCED NS2013KITUS 48712148_1 CDM 0272 RC inpatient 4331 2815.15 ANTHEM HMO ANTHEM HMO 999999999 2622.42 4201.07 NOVASURE ADVANCED NS2013KITUS 48712148_1 CDM 0272 RC inpatient 4331 2815.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 2927.76 67.6 999999999 2622.42 4201.07 percent of total billed charges NOVASURE ADVANCED NS2013KITUS 48712148_1 CDM 0272 RC inpatient 4331 2815.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 2622.42 4201.07 ***BLANKET PER MEGAN PALMER 9-18-23 272 MICRON LASER FIBER 48712149_1 CDM 0272 RC inpatient 2049 1331.85 AETNA AETNA 1618.71 79 999999999 1240.67 1987.53 percent of total billed charges ***BLANKET PER MEGAN PALMER 9-18-23 272 MICRON LASER FIBER 48712149_1 CDM 0272 RC inpatient 2049 1331.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1331.85 65 999999999 1240.67 1987.53 percent of total billed charges ***BLANKET PER MEGAN PALMER 9-18-23 272 MICRON LASER FIBER 48712149_1 CDM 0272 RC inpatient 2049 1331.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1987.53 97 999999999 1240.67 1987.53 percent of total billed charges ***BLANKET PER MEGAN PALMER 9-18-23 272 MICRON LASER FIBER 48712149_1 CDM 0272 RC inpatient 2049 1331.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1413.81 69 999999999 1240.67 1987.53 percent of total billed charges ***BLANKET PER MEGAN PALMER 9-18-23 272 MICRON LASER FIBER 48712149_1 CDM 0272 RC inpatient 2049 1331.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1598.22 78 999999999 1240.67 1987.53 percent of total billed charges ***BLANKET PER MEGAN PALMER 9-18-23 272 MICRON LASER FIBER 48712149_1 CDM 0272 RC inpatient 2049 1331.85 UMR - ALL PLANS UMR - ALL PLANS 1434.3 70 999999999 1240.67 1987.53 percent of total billed charges ***BLANKET PER MEGAN PALMER 9-18-23 272 MICRON LASER FIBER 48712149_1 CDM 0272 RC inpatient 2049 1331.85 SIHO - ALL PLANS SIHO - ALL PLANS 1844.1 90 999999999 1240.67 1987.53 percent of total billed charges ***BLANKET PER MEGAN PALMER 9-18-23 272 MICRON LASER FIBER 48712149_1 CDM 0272 RC inpatient 2049 1331.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1240.67 60.55 999999999 1240.67 1987.53 percent of total billed charges ***BLANKET PER MEGAN PALMER 9-18-23 272 MICRON LASER FIBER 48712149_1 CDM 0272 RC inpatient 2049 1331.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1240.67 1987.53 ***BLANKET PER MEGAN PALMER 9-18-23 272 MICRON LASER FIBER 48712149_1 CDM 0272 RC inpatient 2049 1331.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1240.67 1987.53 ***BLANKET PER MEGAN PALMER 9-18-23 272 MICRON LASER FIBER 48712149_1 CDM 0272 RC inpatient 2049 1331.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1240.67 1987.53 ***BLANKET PER MEGAN PALMER 9-18-23 272 MICRON LASER FIBER 48712149_1 CDM 0272 RC inpatient 2049 1331.85 ANTHEM HMO ANTHEM HMO 999999999 1240.67 1987.53 ***BLANKET PER MEGAN PALMER 9-18-23 272 MICRON LASER FIBER 48712149_1 CDM 0272 RC inpatient 2049 1331.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1385.12 67.6 999999999 1240.67 1987.53 percent of total billed charges ***BLANKET PER MEGAN PALMER 9-18-23 272 MICRON LASER FIBER 48712149_1 CDM 0272 RC inpatient 2049 1331.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1240.67 1987.53 MATERNITY SUPPLIES J290 48712151_1 CDM 0271 RC inpatient 71 46.15 AETNA AETNA 56.09 79 999999999 42.99 68.87 percent of total billed charges MATERNITY SUPPLIES J290 48712151_1 CDM 0271 RC inpatient 71 46.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.15 65 999999999 42.99 68.87 percent of total billed charges MATERNITY SUPPLIES J290 48712151_1 CDM 0271 RC inpatient 71 46.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 68.87 97 999999999 42.99 68.87 percent of total billed charges MATERNITY SUPPLIES J290 48712151_1 CDM 0271 RC inpatient 71 46.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.99 69 999999999 42.99 68.87 percent of total billed charges MATERNITY SUPPLIES J290 48712151_1 CDM 0271 RC inpatient 71 46.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 55.38 78 999999999 42.99 68.87 percent of total billed charges MATERNITY SUPPLIES J290 48712151_1 CDM 0271 RC inpatient 71 46.15 UMR - ALL PLANS UMR - ALL PLANS 49.7 70 999999999 42.99 68.87 percent of total billed charges MATERNITY SUPPLIES J290 48712151_1 CDM 0271 RC inpatient 71 46.15 SIHO - ALL PLANS SIHO - ALL PLANS 63.9 90 999999999 42.99 68.87 percent of total billed charges MATERNITY SUPPLIES J290 48712151_1 CDM 0271 RC inpatient 71 46.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.99 60.55 999999999 42.99 68.87 percent of total billed charges MATERNITY SUPPLIES J290 48712151_1 CDM 0271 RC inpatient 71 46.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.99 68.87 MATERNITY SUPPLIES J290 48712151_1 CDM 0271 RC inpatient 71 46.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.99 68.87 MATERNITY SUPPLIES J290 48712151_1 CDM 0271 RC inpatient 71 46.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.99 68.87 MATERNITY SUPPLIES J290 48712151_1 CDM 0271 RC inpatient 71 46.15 ANTHEM HMO ANTHEM HMO 999999999 42.99 68.87 MATERNITY SUPPLIES J290 48712151_1 CDM 0271 RC inpatient 71 46.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 48 67.6 999999999 42.99 68.87 percent of total billed charges MATERNITY SUPPLIES J290 48712151_1 CDM 0271 RC inpatient 71 46.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.99 68.87 MESH (IMPLANTABLE) 48712152_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 AETNA AETNA 721.27 79 999999999 552.82 885.61 percent of total billed charges MESH (IMPLANTABLE) 48712152_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 593.45 65 999999999 552.82 885.61 percent of total billed charges MESH (IMPLANTABLE) 48712152_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 885.61 97 999999999 552.82 885.61 percent of total billed charges MESH (IMPLANTABLE) 48712152_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 629.97 69 999999999 552.82 885.61 percent of total billed charges MESH (IMPLANTABLE) 48712152_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 712.14 78 999999999 552.82 885.61 percent of total billed charges MESH (IMPLANTABLE) 48712152_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 UMR - ALL PLANS UMR - ALL PLANS 639.1 70 999999999 552.82 885.61 percent of total billed charges MESH (IMPLANTABLE) 48712152_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 SIHO - ALL PLANS SIHO - ALL PLANS 821.7 90 999999999 552.82 885.61 percent of total billed charges MESH (IMPLANTABLE) 48712152_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 552.82 60.55 999999999 552.82 885.61 percent of total billed charges MESH (IMPLANTABLE) 48712152_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 552.82 885.61 MESH (IMPLANTABLE) 48712152_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 552.82 885.61 MESH (IMPLANTABLE) 48712152_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 552.82 885.61 MESH (IMPLANTABLE) 48712152_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 ANTHEM HMO ANTHEM HMO 999999999 552.82 885.61 MESH (IMPLANTABLE) 48712152_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 617.19 67.6 999999999 552.82 885.61 percent of total billed charges MESH (IMPLANTABLE) 48712152_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 552.82 885.61 MESH (IMPLANTABLE) 48712153_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 AETNA AETNA 721.27 79 999999999 552.82 885.61 percent of total billed charges MESH (IMPLANTABLE) 48712153_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 593.45 65 999999999 552.82 885.61 percent of total billed charges MESH (IMPLANTABLE) 48712153_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 885.61 97 999999999 552.82 885.61 percent of total billed charges MESH (IMPLANTABLE) 48712153_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 629.97 69 999999999 552.82 885.61 percent of total billed charges MESH (IMPLANTABLE) 48712153_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 712.14 78 999999999 552.82 885.61 percent of total billed charges MESH (IMPLANTABLE) 48712153_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 UMR - ALL PLANS UMR - ALL PLANS 639.1 70 999999999 552.82 885.61 percent of total billed charges MESH (IMPLANTABLE) 48712153_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 SIHO - ALL PLANS SIHO - ALL PLANS 821.7 90 999999999 552.82 885.61 percent of total billed charges MESH (IMPLANTABLE) 48712153_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 552.82 60.55 999999999 552.82 885.61 percent of total billed charges MESH (IMPLANTABLE) 48712153_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 552.82 885.61 MESH (IMPLANTABLE) 48712153_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 552.82 885.61 MESH (IMPLANTABLE) 48712153_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 552.82 885.61 MESH (IMPLANTABLE) 48712153_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 ANTHEM HMO ANTHEM HMO 999999999 552.82 885.61 MESH (IMPLANTABLE) 48712153_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 617.19 67.6 999999999 552.82 885.61 percent of total billed charges MESH (IMPLANTABLE) 48712153_1 CDM 0278 RC C1781 HCPCS inpatient 913 593.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 552.82 885.61 MESH (IMPLANTABLE) 48712154_1 CDM 0278 RC C1781 HCPCS inpatient 849 551.85 AETNA AETNA 670.71 79 999999999 514.07 823.53 percent of total billed charges MESH (IMPLANTABLE) 48712154_1 CDM 0278 RC C1781 HCPCS inpatient 849 551.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 551.85 65 999999999 514.07 823.53 percent of total billed charges MESH (IMPLANTABLE) 48712154_1 CDM 0278 RC C1781 HCPCS inpatient 849 551.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 823.53 97 999999999 514.07 823.53 percent of total billed charges MESH (IMPLANTABLE) 48712154_1 CDM 0278 RC C1781 HCPCS inpatient 849 551.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 585.81 69 999999999 514.07 823.53 percent of total billed charges MESH (IMPLANTABLE) 48712154_1 CDM 0278 RC C1781 HCPCS inpatient 849 551.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 662.22 78 999999999 514.07 823.53 percent of total billed charges MESH (IMPLANTABLE) 48712154_1 CDM 0278 RC C1781 HCPCS inpatient 849 551.85 UMR - ALL PLANS UMR - ALL PLANS 594.3 70 999999999 514.07 823.53 percent of total billed charges MESH (IMPLANTABLE) 48712154_1 CDM 0278 RC C1781 HCPCS inpatient 849 551.85 SIHO - ALL PLANS SIHO - ALL PLANS 764.1 90 999999999 514.07 823.53 percent of total billed charges MESH (IMPLANTABLE) 48712154_1 CDM 0278 RC C1781 HCPCS inpatient 849 551.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 514.07 60.55 999999999 514.07 823.53 percent of total billed charges MESH (IMPLANTABLE) 48712154_1 CDM 0278 RC C1781 HCPCS inpatient 849 551.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 514.07 823.53 MESH (IMPLANTABLE) 48712154_1 CDM 0278 RC C1781 HCPCS inpatient 849 551.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 514.07 823.53 MESH (IMPLANTABLE) 48712154_1 CDM 0278 RC C1781 HCPCS inpatient 849 551.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 514.07 823.53 MESH (IMPLANTABLE) 48712154_1 CDM 0278 RC C1781 HCPCS inpatient 849 551.85 ANTHEM HMO ANTHEM HMO 999999999 514.07 823.53 MESH (IMPLANTABLE) 48712154_1 CDM 0278 RC C1781 HCPCS inpatient 849 551.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 573.92 67.6 999999999 514.07 823.53 percent of total billed charges MESH (IMPLANTABLE) 48712154_1 CDM 0278 RC C1781 HCPCS inpatient 849 551.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 514.07 823.53 MESH (IMPLANTABLE) 48712156_1 CDM 0278 RC C1781 HCPCS inpatient 264 171.6 AETNA AETNA 208.56 79 999999999 159.85 256.08 percent of total billed charges MESH (IMPLANTABLE) 48712156_1 CDM 0278 RC C1781 HCPCS inpatient 264 171.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 171.6 65 999999999 159.85 256.08 percent of total billed charges MESH (IMPLANTABLE) 48712156_1 CDM 0278 RC C1781 HCPCS inpatient 264 171.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 256.08 97 999999999 159.85 256.08 percent of total billed charges MESH (IMPLANTABLE) 48712156_1 CDM 0278 RC C1781 HCPCS inpatient 264 171.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 182.16 69 999999999 159.85 256.08 percent of total billed charges MESH (IMPLANTABLE) 48712156_1 CDM 0278 RC C1781 HCPCS inpatient 264 171.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 205.92 78 999999999 159.85 256.08 percent of total billed charges MESH (IMPLANTABLE) 48712156_1 CDM 0278 RC C1781 HCPCS inpatient 264 171.6 UMR - ALL PLANS UMR - ALL PLANS 184.8 70 999999999 159.85 256.08 percent of total billed charges MESH (IMPLANTABLE) 48712156_1 CDM 0278 RC C1781 HCPCS inpatient 264 171.6 SIHO - ALL PLANS SIHO - ALL PLANS 237.6 90 999999999 159.85 256.08 percent of total billed charges MESH (IMPLANTABLE) 48712156_1 CDM 0278 RC C1781 HCPCS inpatient 264 171.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 159.85 60.55 999999999 159.85 256.08 percent of total billed charges MESH (IMPLANTABLE) 48712156_1 CDM 0278 RC C1781 HCPCS inpatient 264 171.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 159.85 256.08 MESH (IMPLANTABLE) 48712156_1 CDM 0278 RC C1781 HCPCS inpatient 264 171.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 159.85 256.08 MESH (IMPLANTABLE) 48712156_1 CDM 0278 RC C1781 HCPCS inpatient 264 171.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 159.85 256.08 MESH (IMPLANTABLE) 48712156_1 CDM 0278 RC C1781 HCPCS inpatient 264 171.6 ANTHEM HMO ANTHEM HMO 999999999 159.85 256.08 MESH (IMPLANTABLE) 48712156_1 CDM 0278 RC C1781 HCPCS inpatient 264 171.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 178.46 67.6 999999999 159.85 256.08 percent of total billed charges MESH (IMPLANTABLE) 48712156_1 CDM 0278 RC C1781 HCPCS inpatient 264 171.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 159.85 256.08 MESH (IMPLANTABLE) 48712157_1 CDM 0278 RC C1781 HCPCS inpatient 359 233.35 AETNA AETNA 283.61 79 999999999 217.37 348.23 percent of total billed charges MESH (IMPLANTABLE) 48712157_1 CDM 0278 RC C1781 HCPCS inpatient 359 233.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 233.35 65 999999999 217.37 348.23 percent of total billed charges MESH (IMPLANTABLE) 48712157_1 CDM 0278 RC C1781 HCPCS inpatient 359 233.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 348.23 97 999999999 217.37 348.23 percent of total billed charges MESH (IMPLANTABLE) 48712157_1 CDM 0278 RC C1781 HCPCS inpatient 359 233.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 247.71 69 999999999 217.37 348.23 percent of total billed charges MESH (IMPLANTABLE) 48712157_1 CDM 0278 RC C1781 HCPCS inpatient 359 233.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 280.02 78 999999999 217.37 348.23 percent of total billed charges MESH (IMPLANTABLE) 48712157_1 CDM 0278 RC C1781 HCPCS inpatient 359 233.35 UMR - ALL PLANS UMR - ALL PLANS 251.3 70 999999999 217.37 348.23 percent of total billed charges MESH (IMPLANTABLE) 48712157_1 CDM 0278 RC C1781 HCPCS inpatient 359 233.35 SIHO - ALL PLANS SIHO - ALL PLANS 323.1 90 999999999 217.37 348.23 percent of total billed charges MESH (IMPLANTABLE) 48712157_1 CDM 0278 RC C1781 HCPCS inpatient 359 233.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 217.37 60.55 999999999 217.37 348.23 percent of total billed charges MESH (IMPLANTABLE) 48712157_1 CDM 0278 RC C1781 HCPCS inpatient 359 233.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 217.37 348.23 MESH (IMPLANTABLE) 48712157_1 CDM 0278 RC C1781 HCPCS inpatient 359 233.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 217.37 348.23 MESH (IMPLANTABLE) 48712157_1 CDM 0278 RC C1781 HCPCS inpatient 359 233.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 217.37 348.23 MESH (IMPLANTABLE) 48712157_1 CDM 0278 RC C1781 HCPCS inpatient 359 233.35 ANTHEM HMO ANTHEM HMO 999999999 217.37 348.23 MESH (IMPLANTABLE) 48712157_1 CDM 0278 RC C1781 HCPCS inpatient 359 233.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 242.68 67.6 999999999 217.37 348.23 percent of total billed charges MESH (IMPLANTABLE) 48712157_1 CDM 0278 RC C1781 HCPCS inpatient 359 233.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 217.37 348.23 MESH (IMPLANTABLE) 48712158_1 CDM 0278 RC C1781 HCPCS inpatient 3554 2310.1 AETNA AETNA 2807.66 79 999999999 2151.95 3447.38 percent of total billed charges MESH (IMPLANTABLE) 48712158_1 CDM 0278 RC C1781 HCPCS inpatient 3554 2310.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 2310.1 65 999999999 2151.95 3447.38 percent of total billed charges MESH (IMPLANTABLE) 48712158_1 CDM 0278 RC C1781 HCPCS inpatient 3554 2310.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3447.38 97 999999999 2151.95 3447.38 percent of total billed charges MESH (IMPLANTABLE) 48712158_1 CDM 0278 RC C1781 HCPCS inpatient 3554 2310.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 2452.26 69 999999999 2151.95 3447.38 percent of total billed charges MESH (IMPLANTABLE) 48712158_1 CDM 0278 RC C1781 HCPCS inpatient 3554 2310.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 2772.12 78 999999999 2151.95 3447.38 percent of total billed charges MESH (IMPLANTABLE) 48712158_1 CDM 0278 RC C1781 HCPCS inpatient 3554 2310.1 UMR - ALL PLANS UMR - ALL PLANS 2487.8 70 999999999 2151.95 3447.38 percent of total billed charges MESH (IMPLANTABLE) 48712158_1 CDM 0278 RC C1781 HCPCS inpatient 3554 2310.1 SIHO - ALL PLANS SIHO - ALL PLANS 3198.6 90 999999999 2151.95 3447.38 percent of total billed charges MESH (IMPLANTABLE) 48712158_1 CDM 0278 RC C1781 HCPCS inpatient 3554 2310.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2151.95 60.55 999999999 2151.95 3447.38 percent of total billed charges MESH (IMPLANTABLE) 48712158_1 CDM 0278 RC C1781 HCPCS inpatient 3554 2310.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2151.95 3447.38 MESH (IMPLANTABLE) 48712158_1 CDM 0278 RC C1781 HCPCS inpatient 3554 2310.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2151.95 3447.38 MESH (IMPLANTABLE) 48712158_1 CDM 0278 RC C1781 HCPCS inpatient 3554 2310.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2151.95 3447.38 MESH (IMPLANTABLE) 48712158_1 CDM 0278 RC C1781 HCPCS inpatient 3554 2310.1 ANTHEM HMO ANTHEM HMO 999999999 2151.95 3447.38 MESH (IMPLANTABLE) 48712158_1 CDM 0278 RC C1781 HCPCS inpatient 3554 2310.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 2402.5 67.6 999999999 2151.95 3447.38 percent of total billed charges MESH (IMPLANTABLE) 48712158_1 CDM 0278 RC C1781 HCPCS inpatient 3554 2310.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 2151.95 3447.38 PERIETEX MESH D/FACING PC02H3 48712159_1 CDM 0271 RC inpatient 3082 2003.3 AETNA AETNA 2434.78 79 999999999 1866.15 2989.54 percent of total billed charges PERIETEX MESH D/FACING PC02H3 48712159_1 CDM 0271 RC inpatient 3082 2003.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 2003.3 65 999999999 1866.15 2989.54 percent of total billed charges PERIETEX MESH D/FACING PC02H3 48712159_1 CDM 0271 RC inpatient 3082 2003.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2989.54 97 999999999 1866.15 2989.54 percent of total billed charges PERIETEX MESH D/FACING PC02H3 48712159_1 CDM 0271 RC inpatient 3082 2003.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 2126.58 69 999999999 1866.15 2989.54 percent of total billed charges PERIETEX MESH D/FACING PC02H3 48712159_1 CDM 0271 RC inpatient 3082 2003.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 2403.96 78 999999999 1866.15 2989.54 percent of total billed charges PERIETEX MESH D/FACING PC02H3 48712159_1 CDM 0271 RC inpatient 3082 2003.3 UMR - ALL PLANS UMR - ALL PLANS 2157.4 70 999999999 1866.15 2989.54 percent of total billed charges PERIETEX MESH D/FACING PC02H3 48712159_1 CDM 0271 RC inpatient 3082 2003.3 SIHO - ALL PLANS SIHO - ALL PLANS 2773.8 90 999999999 1866.15 2989.54 percent of total billed charges PERIETEX MESH D/FACING PC02H3 48712159_1 CDM 0271 RC inpatient 3082 2003.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1866.15 60.55 999999999 1866.15 2989.54 percent of total billed charges PERIETEX MESH D/FACING PC02H3 48712159_1 CDM 0271 RC inpatient 3082 2003.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1866.15 2989.54 PERIETEX MESH D/FACING PC02H3 48712159_1 CDM 0271 RC inpatient 3082 2003.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1866.15 2989.54 PERIETEX MESH D/FACING PC02H3 48712159_1 CDM 0271 RC inpatient 3082 2003.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1866.15 2989.54 PERIETEX MESH D/FACING PC02H3 48712159_1 CDM 0271 RC inpatient 3082 2003.3 ANTHEM HMO ANTHEM HMO 999999999 1866.15 2989.54 PERIETEX MESH D/FACING PC02H3 48712159_1 CDM 0271 RC inpatient 3082 2003.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 2083.43 67.6 999999999 1866.15 2989.54 percent of total billed charges PERIETEX MESH D/FACING PC02H3 48712159_1 CDM 0271 RC inpatient 3082 2003.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1866.15 2989.54 STRYKER CEMENT MIXING KIT 48712160_1 CDM 0272 RC inpatient 710 461.5 AETNA AETNA 560.9 79 999999999 429.91 688.7 percent of total billed charges STRYKER CEMENT MIXING KIT 48712160_1 CDM 0272 RC inpatient 710 461.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 461.5 65 999999999 429.91 688.7 percent of total billed charges STRYKER CEMENT MIXING KIT 48712160_1 CDM 0272 RC inpatient 710 461.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 688.7 97 999999999 429.91 688.7 percent of total billed charges STRYKER CEMENT MIXING KIT 48712160_1 CDM 0272 RC inpatient 710 461.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 489.9 69 999999999 429.91 688.7 percent of total billed charges STRYKER CEMENT MIXING KIT 48712160_1 CDM 0272 RC inpatient 710 461.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 553.8 78 999999999 429.91 688.7 percent of total billed charges STRYKER CEMENT MIXING KIT 48712160_1 CDM 0272 RC inpatient 710 461.5 UMR - ALL PLANS UMR - ALL PLANS 497 70 999999999 429.91 688.7 percent of total billed charges STRYKER CEMENT MIXING KIT 48712160_1 CDM 0272 RC inpatient 710 461.5 SIHO - ALL PLANS SIHO - ALL PLANS 639 90 999999999 429.91 688.7 percent of total billed charges STRYKER CEMENT MIXING KIT 48712160_1 CDM 0272 RC inpatient 710 461.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 429.91 60.55 999999999 429.91 688.7 percent of total billed charges STRYKER CEMENT MIXING KIT 48712160_1 CDM 0272 RC inpatient 710 461.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 429.91 688.7 STRYKER CEMENT MIXING KIT 48712160_1 CDM 0272 RC inpatient 710 461.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 429.91 688.7 STRYKER CEMENT MIXING KIT 48712160_1 CDM 0272 RC inpatient 710 461.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 429.91 688.7 STRYKER CEMENT MIXING KIT 48712160_1 CDM 0272 RC inpatient 710 461.5 ANTHEM HMO ANTHEM HMO 999999999 429.91 688.7 STRYKER CEMENT MIXING KIT 48712160_1 CDM 0272 RC inpatient 710 461.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 479.96 67.6 999999999 429.91 688.7 percent of total billed charges STRYKER CEMENT MIXING KIT 48712160_1 CDM 0272 RC inpatient 710 461.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 429.91 688.7 MIXEVAC III BONE CEMENT MIXER 48712161_1 CDM 0272 RC inpatient 368 239.2 AETNA AETNA 290.72 79 999999999 222.82 356.96 percent of total billed charges MIXEVAC III BONE CEMENT MIXER 48712161_1 CDM 0272 RC inpatient 368 239.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 239.2 65 999999999 222.82 356.96 percent of total billed charges MIXEVAC III BONE CEMENT MIXER 48712161_1 CDM 0272 RC inpatient 368 239.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 356.96 97 999999999 222.82 356.96 percent of total billed charges MIXEVAC III BONE CEMENT MIXER 48712161_1 CDM 0272 RC inpatient 368 239.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.92 69 999999999 222.82 356.96 percent of total billed charges MIXEVAC III BONE CEMENT MIXER 48712161_1 CDM 0272 RC inpatient 368 239.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 287.04 78 999999999 222.82 356.96 percent of total billed charges MIXEVAC III BONE CEMENT MIXER 48712161_1 CDM 0272 RC inpatient 368 239.2 UMR - ALL PLANS UMR - ALL PLANS 257.6 70 999999999 222.82 356.96 percent of total billed charges MIXEVAC III BONE CEMENT MIXER 48712161_1 CDM 0272 RC inpatient 368 239.2 SIHO - ALL PLANS SIHO - ALL PLANS 331.2 90 999999999 222.82 356.96 percent of total billed charges MIXEVAC III BONE CEMENT MIXER 48712161_1 CDM 0272 RC inpatient 368 239.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.82 60.55 999999999 222.82 356.96 percent of total billed charges MIXEVAC III BONE CEMENT MIXER 48712161_1 CDM 0272 RC inpatient 368 239.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.82 356.96 MIXEVAC III BONE CEMENT MIXER 48712161_1 CDM 0272 RC inpatient 368 239.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.82 356.96 MIXEVAC III BONE CEMENT MIXER 48712161_1 CDM 0272 RC inpatient 368 239.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.82 356.96 MIXEVAC III BONE CEMENT MIXER 48712161_1 CDM 0272 RC inpatient 368 239.2 ANTHEM HMO ANTHEM HMO 999999999 222.82 356.96 MIXEVAC III BONE CEMENT MIXER 48712161_1 CDM 0272 RC inpatient 368 239.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.77 67.6 999999999 222.82 356.96 percent of total billed charges MIXEVAC III BONE CEMENT MIXER 48712161_1 CDM 0272 RC inpatient 368 239.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.82 356.96 QUICK PRES/MONITOR SET 0295-002-000 48712163_1 CDM 0272 RC inpatient 648 421.2 AETNA AETNA 511.92 79 999999999 392.36 628.56 percent of total billed charges QUICK PRES/MONITOR SET 0295-002-000 48712163_1 CDM 0272 RC inpatient 648 421.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 421.2 65 999999999 392.36 628.56 percent of total billed charges QUICK PRES/MONITOR SET 0295-002-000 48712163_1 CDM 0272 RC inpatient 648 421.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 628.56 97 999999999 392.36 628.56 percent of total billed charges QUICK PRES/MONITOR SET 0295-002-000 48712163_1 CDM 0272 RC inpatient 648 421.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 447.12 69 999999999 392.36 628.56 percent of total billed charges QUICK PRES/MONITOR SET 0295-002-000 48712163_1 CDM 0272 RC inpatient 648 421.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 505.44 78 999999999 392.36 628.56 percent of total billed charges QUICK PRES/MONITOR SET 0295-002-000 48712163_1 CDM 0272 RC inpatient 648 421.2 UMR - ALL PLANS UMR - ALL PLANS 453.6 70 999999999 392.36 628.56 percent of total billed charges QUICK PRES/MONITOR SET 0295-002-000 48712163_1 CDM 0272 RC inpatient 648 421.2 SIHO - ALL PLANS SIHO - ALL PLANS 583.2 90 999999999 392.36 628.56 percent of total billed charges QUICK PRES/MONITOR SET 0295-002-000 48712163_1 CDM 0272 RC inpatient 648 421.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 392.36 60.55 999999999 392.36 628.56 percent of total billed charges QUICK PRES/MONITOR SET 0295-002-000 48712163_1 CDM 0272 RC inpatient 648 421.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 392.36 628.56 QUICK PRES/MONITOR SET 0295-002-000 48712163_1 CDM 0272 RC inpatient 648 421.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 392.36 628.56 QUICK PRES/MONITOR SET 0295-002-000 48712163_1 CDM 0272 RC inpatient 648 421.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 392.36 628.56 QUICK PRES/MONITOR SET 0295-002-000 48712163_1 CDM 0272 RC inpatient 648 421.2 ANTHEM HMO ANTHEM HMO 999999999 392.36 628.56 QUICK PRES/MONITOR SET 0295-002-000 48712163_1 CDM 0272 RC inpatient 648 421.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 438.05 67.6 999999999 392.36 628.56 percent of total billed charges QUICK PRES/MONITOR SET 0295-002-000 48712163_1 CDM 0272 RC inpatient 648 421.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 392.36 628.56 MORGAN THERAPEUTIC LENS MFG# MT2000 48712165_1 CDM 0272 RC inpatient 286 185.9 AETNA AETNA 225.94 79 999999999 173.17 277.42 percent of total billed charges MORGAN THERAPEUTIC LENS MFG# MT2000 48712165_1 CDM 0272 RC inpatient 286 185.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.9 65 999999999 173.17 277.42 percent of total billed charges MORGAN THERAPEUTIC LENS MFG# MT2000 48712165_1 CDM 0272 RC inpatient 286 185.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 277.42 97 999999999 173.17 277.42 percent of total billed charges MORGAN THERAPEUTIC LENS MFG# MT2000 48712165_1 CDM 0272 RC inpatient 286 185.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 197.34 69 999999999 173.17 277.42 percent of total billed charges MORGAN THERAPEUTIC LENS MFG# MT2000 48712165_1 CDM 0272 RC inpatient 286 185.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 223.08 78 999999999 173.17 277.42 percent of total billed charges MORGAN THERAPEUTIC LENS MFG# MT2000 48712165_1 CDM 0272 RC inpatient 286 185.9 UMR - ALL PLANS UMR - ALL PLANS 200.2 70 999999999 173.17 277.42 percent of total billed charges MORGAN THERAPEUTIC LENS MFG# MT2000 48712165_1 CDM 0272 RC inpatient 286 185.9 SIHO - ALL PLANS SIHO - ALL PLANS 257.4 90 999999999 173.17 277.42 percent of total billed charges MORGAN THERAPEUTIC LENS MFG# MT2000 48712165_1 CDM 0272 RC inpatient 286 185.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 173.17 60.55 999999999 173.17 277.42 percent of total billed charges MORGAN THERAPEUTIC LENS MFG# MT2000 48712165_1 CDM 0272 RC inpatient 286 185.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 173.17 277.42 MORGAN THERAPEUTIC LENS MFG# MT2000 48712165_1 CDM 0272 RC inpatient 286 185.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 173.17 277.42 MORGAN THERAPEUTIC LENS MFG# MT2000 48712165_1 CDM 0272 RC inpatient 286 185.9 ANTHEM HMO ANTHEM HMO 999999999 173.17 277.42 MORGAN THERAPEUTIC LENS MFG# MT2000 48712165_1 CDM 0272 RC inpatient 286 185.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 173.17 277.42 MORGAN THERAPEUTIC LENS MFG# MT2000 48712165_1 CDM 0272 RC inpatient 286 185.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 193.34 67.6 999999999 173.17 277.42 percent of total billed charges MORGAN THERAPEUTIC LENS MFG# MT2000 48712165_1 CDM 0272 RC inpatient 286 185.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 173.17 277.42 OPEP AEROBIKA 58-62510 (OE) FLUTTER VALVE 48712166_1 CDM 0272 RC inpatient 302 196.3 AETNA AETNA 238.58 79 999999999 182.86 292.94 percent of total billed charges OPEP AEROBIKA 58-62510 (OE) FLUTTER VALVE 48712166_1 CDM 0272 RC inpatient 302 196.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 196.3 65 999999999 182.86 292.94 percent of total billed charges OPEP AEROBIKA 58-62510 (OE) FLUTTER VALVE 48712166_1 CDM 0272 RC inpatient 302 196.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 292.94 97 999999999 182.86 292.94 percent of total billed charges OPEP AEROBIKA 58-62510 (OE) FLUTTER VALVE 48712166_1 CDM 0272 RC inpatient 302 196.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 208.38 69 999999999 182.86 292.94 percent of total billed charges OPEP AEROBIKA 58-62510 (OE) FLUTTER VALVE 48712166_1 CDM 0272 RC inpatient 302 196.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 235.56 78 999999999 182.86 292.94 percent of total billed charges OPEP AEROBIKA 58-62510 (OE) FLUTTER VALVE 48712166_1 CDM 0272 RC inpatient 302 196.3 UMR - ALL PLANS UMR - ALL PLANS 211.4 70 999999999 182.86 292.94 percent of total billed charges OPEP AEROBIKA 58-62510 (OE) FLUTTER VALVE 48712166_1 CDM 0272 RC inpatient 302 196.3 SIHO - ALL PLANS SIHO - ALL PLANS 271.8 90 999999999 182.86 292.94 percent of total billed charges OPEP AEROBIKA 58-62510 (OE) FLUTTER VALVE 48712166_1 CDM 0272 RC inpatient 302 196.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.86 60.55 999999999 182.86 292.94 percent of total billed charges OPEP AEROBIKA 58-62510 (OE) FLUTTER VALVE 48712166_1 CDM 0272 RC inpatient 302 196.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.86 292.94 OPEP AEROBIKA 58-62510 (OE) FLUTTER VALVE 48712166_1 CDM 0272 RC inpatient 302 196.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.86 292.94 OPEP AEROBIKA 58-62510 (OE) FLUTTER VALVE 48712166_1 CDM 0272 RC inpatient 302 196.3 ANTHEM HMO ANTHEM HMO 999999999 182.86 292.94 OPEP AEROBIKA 58-62510 (OE) FLUTTER VALVE 48712166_1 CDM 0272 RC inpatient 302 196.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.86 292.94 OPEP AEROBIKA 58-62510 (OE) FLUTTER VALVE 48712166_1 CDM 0272 RC inpatient 302 196.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 204.15 67.6 999999999 182.86 292.94 percent of total billed charges OPEP AEROBIKA 58-62510 (OE) FLUTTER VALVE 48712166_1 CDM 0272 RC inpatient 302 196.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.86 292.94 RF CANNULA 100MM CURVED TIP 5M 48712168_1 CDM 0272 RC inpatient 369 239.85 AETNA AETNA 291.51 79 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100MM CURVED TIP 5M 48712168_1 CDM 0272 RC inpatient 369 239.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 239.85 65 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100MM CURVED TIP 5M 48712168_1 CDM 0272 RC inpatient 369 239.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 357.93 97 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100MM CURVED TIP 5M 48712168_1 CDM 0272 RC inpatient 369 239.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 254.61 69 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100MM CURVED TIP 5M 48712168_1 CDM 0272 RC inpatient 369 239.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 287.82 78 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100MM CURVED TIP 5M 48712168_1 CDM 0272 RC inpatient 369 239.85 UMR - ALL PLANS UMR - ALL PLANS 258.3 70 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100MM CURVED TIP 5M 48712168_1 CDM 0272 RC inpatient 369 239.85 SIHO - ALL PLANS SIHO - ALL PLANS 332.1 90 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100MM CURVED TIP 5M 48712168_1 CDM 0272 RC inpatient 369 239.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 223.43 60.55 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100MM CURVED TIP 5M 48712168_1 CDM 0272 RC inpatient 369 239.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 223.43 357.93 RF CANNULA 100MM CURVED TIP 5M 48712168_1 CDM 0272 RC inpatient 369 239.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 223.43 357.93 RF CANNULA 100MM CURVED TIP 5M 48712168_1 CDM 0272 RC inpatient 369 239.85 ANTHEM HMO ANTHEM HMO 999999999 223.43 357.93 RF CANNULA 100MM CURVED TIP 5M 48712168_1 CDM 0272 RC inpatient 369 239.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 223.43 357.93 RF CANNULA 100MM CURVED TIP 5M 48712168_1 CDM 0272 RC inpatient 369 239.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 249.44 67.6 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100MM CURVED TIP 5M 48712168_1 CDM 0272 RC inpatient 369 239.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 223.43 357.93 RF CANNULA 150M CURVED TIP 10M 48712169_1 CDM 0272 RC inpatient 369 239.85 AETNA AETNA 291.51 79 999999999 223.43 357.93 percent of total billed charges RF CANNULA 150M CURVED TIP 10M 48712169_1 CDM 0272 RC inpatient 369 239.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 239.85 65 999999999 223.43 357.93 percent of total billed charges RF CANNULA 150M CURVED TIP 10M 48712169_1 CDM 0272 RC inpatient 369 239.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 357.93 97 999999999 223.43 357.93 percent of total billed charges RF CANNULA 150M CURVED TIP 10M 48712169_1 CDM 0272 RC inpatient 369 239.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 254.61 69 999999999 223.43 357.93 percent of total billed charges RF CANNULA 150M CURVED TIP 10M 48712169_1 CDM 0272 RC inpatient 369 239.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 287.82 78 999999999 223.43 357.93 percent of total billed charges RF CANNULA 150M CURVED TIP 10M 48712169_1 CDM 0272 RC inpatient 369 239.85 UMR - ALL PLANS UMR - ALL PLANS 258.3 70 999999999 223.43 357.93 percent of total billed charges RF CANNULA 150M CURVED TIP 10M 48712169_1 CDM 0272 RC inpatient 369 239.85 SIHO - ALL PLANS SIHO - ALL PLANS 332.1 90 999999999 223.43 357.93 percent of total billed charges RF CANNULA 150M CURVED TIP 10M 48712169_1 CDM 0272 RC inpatient 369 239.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 223.43 60.55 999999999 223.43 357.93 percent of total billed charges RF CANNULA 150M CURVED TIP 10M 48712169_1 CDM 0272 RC inpatient 369 239.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 223.43 357.93 RF CANNULA 150M CURVED TIP 10M 48712169_1 CDM 0272 RC inpatient 369 239.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 223.43 357.93 RF CANNULA 150M CURVED TIP 10M 48712169_1 CDM 0272 RC inpatient 369 239.85 ANTHEM HMO ANTHEM HMO 999999999 223.43 357.93 RF CANNULA 150M CURVED TIP 10M 48712169_1 CDM 0272 RC inpatient 369 239.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 223.43 357.93 RF CANNULA 150M CURVED TIP 10M 48712169_1 CDM 0272 RC inpatient 369 239.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 249.44 67.6 999999999 223.43 357.93 percent of total billed charges RF CANNULA 150M CURVED TIP 10M 48712169_1 CDM 0272 RC inpatient 369 239.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 223.43 357.93 RF CANNULA 100MM CURVED 20 GA 48712170_1 CDM 0272 RC inpatient 369 239.85 AETNA AETNA 291.51 79 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100MM CURVED 20 GA 48712170_1 CDM 0272 RC inpatient 369 239.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 239.85 65 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100MM CURVED 20 GA 48712170_1 CDM 0272 RC inpatient 369 239.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 357.93 97 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100MM CURVED 20 GA 48712170_1 CDM 0272 RC inpatient 369 239.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 254.61 69 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100MM CURVED 20 GA 48712170_1 CDM 0272 RC inpatient 369 239.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 287.82 78 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100MM CURVED 20 GA 48712170_1 CDM 0272 RC inpatient 369 239.85 UMR - ALL PLANS UMR - ALL PLANS 258.3 70 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100MM CURVED 20 GA 48712170_1 CDM 0272 RC inpatient 369 239.85 SIHO - ALL PLANS SIHO - ALL PLANS 332.1 90 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100MM CURVED 20 GA 48712170_1 CDM 0272 RC inpatient 369 239.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 223.43 60.55 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100MM CURVED 20 GA 48712170_1 CDM 0272 RC inpatient 369 239.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 223.43 357.93 RF CANNULA 100MM CURVED 20 GA 48712170_1 CDM 0272 RC inpatient 369 239.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 223.43 357.93 RF CANNULA 100MM CURVED 20 GA 48712170_1 CDM 0272 RC inpatient 369 239.85 ANTHEM HMO ANTHEM HMO 999999999 223.43 357.93 RF CANNULA 100MM CURVED 20 GA 48712170_1 CDM 0272 RC inpatient 369 239.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 223.43 357.93 RF CANNULA 100MM CURVED 20 GA 48712170_1 CDM 0272 RC inpatient 369 239.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 249.44 67.6 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100MM CURVED 20 GA 48712170_1 CDM 0272 RC inpatient 369 239.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 223.43 357.93 RF CANNULA 100M ACTIVE TIP 10M 406-840-125 48712171_1 CDM 0272 RC inpatient 369 239.85 AETNA AETNA 291.51 79 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100M ACTIVE TIP 10M 406-840-125 48712171_1 CDM 0272 RC inpatient 369 239.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 239.85 65 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100M ACTIVE TIP 10M 406-840-125 48712171_1 CDM 0272 RC inpatient 369 239.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 357.93 97 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100M ACTIVE TIP 10M 406-840-125 48712171_1 CDM 0272 RC inpatient 369 239.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 254.61 69 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100M ACTIVE TIP 10M 406-840-125 48712171_1 CDM 0272 RC inpatient 369 239.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 287.82 78 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100M ACTIVE TIP 10M 406-840-125 48712171_1 CDM 0272 RC inpatient 369 239.85 UMR - ALL PLANS UMR - ALL PLANS 258.3 70 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100M ACTIVE TIP 10M 406-840-125 48712171_1 CDM 0272 RC inpatient 369 239.85 SIHO - ALL PLANS SIHO - ALL PLANS 332.1 90 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100M ACTIVE TIP 10M 406-840-125 48712171_1 CDM 0272 RC inpatient 369 239.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 223.43 60.55 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100M ACTIVE TIP 10M 406-840-125 48712171_1 CDM 0272 RC inpatient 369 239.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 223.43 357.93 RF CANNULA 100M ACTIVE TIP 10M 406-840-125 48712171_1 CDM 0272 RC inpatient 369 239.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 223.43 357.93 RF CANNULA 100M ACTIVE TIP 10M 406-840-125 48712171_1 CDM 0272 RC inpatient 369 239.85 ANTHEM HMO ANTHEM HMO 999999999 223.43 357.93 RF CANNULA 100M ACTIVE TIP 10M 406-840-125 48712171_1 CDM 0272 RC inpatient 369 239.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 223.43 357.93 RF CANNULA 100M ACTIVE TIP 10M 406-840-125 48712171_1 CDM 0272 RC inpatient 369 239.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 249.44 67.6 999999999 223.43 357.93 percent of total billed charges RF CANNULA 100M ACTIVE TIP 10M 406-840-125 48712171_1 CDM 0272 RC inpatient 369 239.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 223.43 357.93 CANNULA ARTHROSCOPY 8.5X75MM 48712172_1 CDM 0272 RC inpatient 236 153.4 AETNA AETNA 186.44 79 999999999 142.9 228.92 percent of total billed charges CANNULA ARTHROSCOPY 8.5X75MM 48712172_1 CDM 0272 RC inpatient 236 153.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 153.4 65 999999999 142.9 228.92 percent of total billed charges CANNULA ARTHROSCOPY 8.5X75MM 48712172_1 CDM 0272 RC inpatient 236 153.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 228.92 97 999999999 142.9 228.92 percent of total billed charges CANNULA ARTHROSCOPY 8.5X75MM 48712172_1 CDM 0272 RC inpatient 236 153.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 162.84 69 999999999 142.9 228.92 percent of total billed charges CANNULA ARTHROSCOPY 8.5X75MM 48712172_1 CDM 0272 RC inpatient 236 153.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 184.08 78 999999999 142.9 228.92 percent of total billed charges CANNULA ARTHROSCOPY 8.5X75MM 48712172_1 CDM 0272 RC inpatient 236 153.4 UMR - ALL PLANS UMR - ALL PLANS 165.2 70 999999999 142.9 228.92 percent of total billed charges CANNULA ARTHROSCOPY 8.5X75MM 48712172_1 CDM 0272 RC inpatient 236 153.4 SIHO - ALL PLANS SIHO - ALL PLANS 212.4 90 999999999 142.9 228.92 percent of total billed charges CANNULA ARTHROSCOPY 8.5X75MM 48712172_1 CDM 0272 RC inpatient 236 153.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 142.9 60.55 999999999 142.9 228.92 percent of total billed charges CANNULA ARTHROSCOPY 8.5X75MM 48712172_1 CDM 0272 RC inpatient 236 153.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 142.9 228.92 CANNULA ARTHROSCOPY 8.5X75MM 48712172_1 CDM 0272 RC inpatient 236 153.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 142.9 228.92 CANNULA ARTHROSCOPY 8.5X75MM 48712172_1 CDM 0272 RC inpatient 236 153.4 ANTHEM HMO ANTHEM HMO 999999999 142.9 228.92 CANNULA ARTHROSCOPY 8.5X75MM 48712172_1 CDM 0272 RC inpatient 236 153.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 142.9 228.92 CANNULA ARTHROSCOPY 8.5X75MM 48712172_1 CDM 0272 RC inpatient 236 153.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 159.54 67.6 999999999 142.9 228.92 percent of total billed charges CANNULA ARTHROSCOPY 8.5X75MM 48712172_1 CDM 0272 RC inpatient 236 153.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 142.9 228.92 CANNULA ARTHROSCOPY 7.0X75MM 214116 48712173_1 CDM 0272 RC inpatient 267 173.55 AETNA AETNA 210.93 79 999999999 161.67 258.99 percent of total billed charges CANNULA ARTHROSCOPY 7.0X75MM 214116 48712173_1 CDM 0272 RC inpatient 267 173.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 173.55 65 999999999 161.67 258.99 percent of total billed charges CANNULA ARTHROSCOPY 7.0X75MM 214116 48712173_1 CDM 0272 RC inpatient 267 173.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 258.99 97 999999999 161.67 258.99 percent of total billed charges CANNULA ARTHROSCOPY 7.0X75MM 214116 48712173_1 CDM 0272 RC inpatient 267 173.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.23 69 999999999 161.67 258.99 percent of total billed charges CANNULA ARTHROSCOPY 7.0X75MM 214116 48712173_1 CDM 0272 RC inpatient 267 173.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 208.26 78 999999999 161.67 258.99 percent of total billed charges CANNULA ARTHROSCOPY 7.0X75MM 214116 48712173_1 CDM 0272 RC inpatient 267 173.55 UMR - ALL PLANS UMR - ALL PLANS 186.9 70 999999999 161.67 258.99 percent of total billed charges CANNULA ARTHROSCOPY 7.0X75MM 214116 48712173_1 CDM 0272 RC inpatient 267 173.55 SIHO - ALL PLANS SIHO - ALL PLANS 240.3 90 999999999 161.67 258.99 percent of total billed charges CANNULA ARTHROSCOPY 7.0X75MM 214116 48712173_1 CDM 0272 RC inpatient 267 173.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 161.67 60.55 999999999 161.67 258.99 percent of total billed charges CANNULA ARTHROSCOPY 7.0X75MM 214116 48712173_1 CDM 0272 RC inpatient 267 173.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 161.67 258.99 CANNULA ARTHROSCOPY 7.0X75MM 214116 48712173_1 CDM 0272 RC inpatient 267 173.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 161.67 258.99 CANNULA ARTHROSCOPY 7.0X75MM 214116 48712173_1 CDM 0272 RC inpatient 267 173.55 ANTHEM HMO ANTHEM HMO 999999999 161.67 258.99 CANNULA ARTHROSCOPY 7.0X75MM 214116 48712173_1 CDM 0272 RC inpatient 267 173.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 161.67 258.99 CANNULA ARTHROSCOPY 7.0X75MM 214116 48712173_1 CDM 0272 RC inpatient 267 173.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 180.49 67.6 999999999 161.67 258.99 percent of total billed charges CANNULA ARTHROSCOPY 7.0X75MM 214116 48712173_1 CDM 0272 RC inpatient 267 173.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 161.67 258.99 PACK UNIVERSAL I ECLIPSE DYNJP1050 48712176_1 CDM 0272 RC inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges PACK UNIVERSAL I ECLIPSE DYNJP1050 48712176_1 CDM 0272 RC inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges PACK UNIVERSAL I ECLIPSE DYNJP1050 48712176_1 CDM 0272 RC inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges PACK UNIVERSAL I ECLIPSE DYNJP1050 48712176_1 CDM 0272 RC inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges PACK UNIVERSAL I ECLIPSE DYNJP1050 48712176_1 CDM 0272 RC inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges PACK UNIVERSAL I ECLIPSE DYNJP1050 48712176_1 CDM 0272 RC inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges PACK UNIVERSAL I ECLIPSE DYNJP1050 48712176_1 CDM 0272 RC inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges PACK UNIVERSAL I ECLIPSE DYNJP1050 48712176_1 CDM 0272 RC inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges PACK UNIVERSAL I ECLIPSE DYNJP1050 48712176_1 CDM 0272 RC inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 PACK UNIVERSAL I ECLIPSE DYNJP1050 48712176_1 CDM 0272 RC inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 PACK UNIVERSAL I ECLIPSE DYNJP1050 48712176_1 CDM 0272 RC inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 PACK UNIVERSAL I ECLIPSE DYNJP1050 48712176_1 CDM 0272 RC inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 PACK UNIVERSAL I ECLIPSE DYNJP1050 48712176_1 CDM 0272 RC inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges PACK UNIVERSAL I ECLIPSE DYNJP1050 48712176_1 CDM 0272 RC inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 CT CLOSURE SYSTEM XL CTXL 48712177_1 CDM 0272 RC inpatient 1043 677.95 AETNA AETNA 823.97 79 999999999 631.54 1011.71 percent of total billed charges CT CLOSURE SYSTEM XL CTXL 48712177_1 CDM 0272 RC inpatient 1043 677.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 677.95 65 999999999 631.54 1011.71 percent of total billed charges CT CLOSURE SYSTEM XL CTXL 48712177_1 CDM 0272 RC inpatient 1043 677.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1011.71 97 999999999 631.54 1011.71 percent of total billed charges CT CLOSURE SYSTEM XL CTXL 48712177_1 CDM 0272 RC inpatient 1043 677.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 719.67 69 999999999 631.54 1011.71 percent of total billed charges CT CLOSURE SYSTEM XL CTXL 48712177_1 CDM 0272 RC inpatient 1043 677.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 813.54 78 999999999 631.54 1011.71 percent of total billed charges CT CLOSURE SYSTEM XL CTXL 48712177_1 CDM 0272 RC inpatient 1043 677.95 UMR - ALL PLANS UMR - ALL PLANS 730.1 70 999999999 631.54 1011.71 percent of total billed charges CT CLOSURE SYSTEM XL CTXL 48712177_1 CDM 0272 RC inpatient 1043 677.95 SIHO - ALL PLANS SIHO - ALL PLANS 938.7 90 999999999 631.54 1011.71 percent of total billed charges CT CLOSURE SYSTEM XL CTXL 48712177_1 CDM 0272 RC inpatient 1043 677.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 631.54 60.55 999999999 631.54 1011.71 percent of total billed charges CT CLOSURE SYSTEM XL CTXL 48712177_1 CDM 0272 RC inpatient 1043 677.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 631.54 1011.71 CT CLOSURE SYSTEM XL CTXL 48712177_1 CDM 0272 RC inpatient 1043 677.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 631.54 1011.71 CT CLOSURE SYSTEM XL CTXL 48712177_1 CDM 0272 RC inpatient 1043 677.95 ANTHEM HMO ANTHEM HMO 999999999 631.54 1011.71 CT CLOSURE SYSTEM XL CTXL 48712177_1 CDM 0272 RC inpatient 1043 677.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 631.54 1011.71 CT CLOSURE SYSTEM XL CTXL 48712177_1 CDM 0272 RC inpatient 1043 677.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 705.07 67.6 999999999 631.54 1011.71 percent of total billed charges CT CLOSURE SYSTEM XL CTXL 48712177_1 CDM 0272 RC inpatient 1043 677.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 631.54 1011.71 TRAY NOSE BLEED MNS990 48712178_1 CDM 0272 RC inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges TRAY NOSE BLEED MNS990 48712178_1 CDM 0272 RC inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges TRAY NOSE BLEED MNS990 48712178_1 CDM 0272 RC inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges TRAY NOSE BLEED MNS990 48712178_1 CDM 0272 RC inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges TRAY NOSE BLEED MNS990 48712178_1 CDM 0272 RC inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges TRAY NOSE BLEED MNS990 48712178_1 CDM 0272 RC inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges TRAY NOSE BLEED MNS990 48712178_1 CDM 0272 RC inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges TRAY NOSE BLEED MNS990 48712178_1 CDM 0272 RC inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges TRAY NOSE BLEED MNS990 48712178_1 CDM 0272 RC inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 TRAY NOSE BLEED MNS990 48712178_1 CDM 0272 RC inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 TRAY NOSE BLEED MNS990 48712178_1 CDM 0272 RC inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 TRAY NOSE BLEED MNS990 48712178_1 CDM 0272 RC inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 TRAY NOSE BLEED MNS990 48712178_1 CDM 0272 RC inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges TRAY NOSE BLEED MNS990 48712178_1 CDM 0272 RC inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 NEEDLE ANCHOR 1842-10DC #10 48712192_1 CDM 0272 RC inpatient 33 21.45 AETNA AETNA 26.07 79 999999999 19.98 32.01 percent of total billed charges NEEDLE ANCHOR 1842-10DC #10 48712192_1 CDM 0272 RC inpatient 33 21.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.45 65 999999999 19.98 32.01 percent of total billed charges NEEDLE ANCHOR 1842-10DC #10 48712192_1 CDM 0272 RC inpatient 33 21.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.01 97 999999999 19.98 32.01 percent of total billed charges NEEDLE ANCHOR 1842-10DC #10 48712192_1 CDM 0272 RC inpatient 33 21.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.77 69 999999999 19.98 32.01 percent of total billed charges NEEDLE ANCHOR 1842-10DC #10 48712192_1 CDM 0272 RC inpatient 33 21.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.74 78 999999999 19.98 32.01 percent of total billed charges NEEDLE ANCHOR 1842-10DC #10 48712192_1 CDM 0272 RC inpatient 33 21.45 UMR - ALL PLANS UMR - ALL PLANS 23.1 70 999999999 19.98 32.01 percent of total billed charges NEEDLE ANCHOR 1842-10DC #10 48712192_1 CDM 0272 RC inpatient 33 21.45 SIHO - ALL PLANS SIHO - ALL PLANS 29.7 90 999999999 19.98 32.01 percent of total billed charges NEEDLE ANCHOR 1842-10DC #10 48712192_1 CDM 0272 RC inpatient 33 21.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.98 60.55 999999999 19.98 32.01 percent of total billed charges NEEDLE ANCHOR 1842-10DC #10 48712192_1 CDM 0272 RC inpatient 33 21.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.98 32.01 NEEDLE ANCHOR 1842-10DC #10 48712192_1 CDM 0272 RC inpatient 33 21.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.98 32.01 NEEDLE ANCHOR 1842-10DC #10 48712192_1 CDM 0272 RC inpatient 33 21.45 ANTHEM HMO ANTHEM HMO 999999999 19.98 32.01 NEEDLE ANCHOR 1842-10DC #10 48712192_1 CDM 0272 RC inpatient 33 21.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.98 32.01 NEEDLE ANCHOR 1842-10DC #10 48712192_1 CDM 0272 RC inpatient 33 21.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.31 67.6 999999999 19.98 32.01 percent of total billed charges NEEDLE ANCHOR 1842-10DC #10 48712192_1 CDM 0272 RC inpatient 33 21.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.98 32.01 "NEEDLE, STERILE, ANY SIZE, EACH" 48712194_1 CDM 0621 RC A4215 HCPCS inpatient 183 118.95 AETNA AETNA 144.57 79 999999999 110.81 177.51 percent of total billed charges "NEEDLE, STERILE, ANY SIZE, EACH" 48712194_1 CDM 0621 RC A4215 HCPCS inpatient 183 118.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.95 65 999999999 110.81 177.51 percent of total billed charges "NEEDLE, STERILE, ANY SIZE, EACH" 48712194_1 CDM 0621 RC A4215 HCPCS inpatient 183 118.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.51 97 999999999 110.81 177.51 percent of total billed charges "NEEDLE, STERILE, ANY SIZE, EACH" 48712194_1 CDM 0621 RC A4215 HCPCS inpatient 183 118.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.27 69 999999999 110.81 177.51 percent of total billed charges "NEEDLE, STERILE, ANY SIZE, EACH" 48712194_1 CDM 0621 RC A4215 HCPCS inpatient 183 118.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 142.74 78 999999999 110.81 177.51 percent of total billed charges "NEEDLE, STERILE, ANY SIZE, EACH" 48712194_1 CDM 0621 RC A4215 HCPCS inpatient 183 118.95 UMR - ALL PLANS UMR - ALL PLANS 128.1 70 999999999 110.81 177.51 percent of total billed charges "NEEDLE, STERILE, ANY SIZE, EACH" 48712194_1 CDM 0621 RC A4215 HCPCS inpatient 183 118.95 SIHO - ALL PLANS SIHO - ALL PLANS 164.7 90 999999999 110.81 177.51 percent of total billed charges "NEEDLE, STERILE, ANY SIZE, EACH" 48712194_1 CDM 0621 RC A4215 HCPCS inpatient 183 118.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.81 60.55 999999999 110.81 177.51 percent of total billed charges "NEEDLE, STERILE, ANY SIZE, EACH" 48712194_1 CDM 0621 RC A4215 HCPCS inpatient 183 118.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.81 177.51 "NEEDLE, STERILE, ANY SIZE, EACH" 48712194_1 CDM 0621 RC A4215 HCPCS inpatient 183 118.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.81 177.51 "NEEDLE, STERILE, ANY SIZE, EACH" 48712194_1 CDM 0621 RC A4215 HCPCS inpatient 183 118.95 ANTHEM HMO ANTHEM HMO 999999999 110.81 177.51 "NEEDLE, STERILE, ANY SIZE, EACH" 48712194_1 CDM 0621 RC A4215 HCPCS inpatient 183 118.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.81 177.51 "NEEDLE, STERILE, ANY SIZE, EACH" 48712194_1 CDM 0621 RC A4215 HCPCS inpatient 183 118.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.71 67.6 999999999 110.81 177.51 percent of total billed charges "NEEDLE, STERILE, ANY SIZE, EACH" 48712194_1 CDM 0621 RC A4215 HCPCS inpatient 183 118.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.81 177.51 INTRAOSSEOUS INF NEEDLE 18GA 48712195_1 CDM 0272 RC inpatient 221 143.65 AETNA AETNA 174.59 79 999999999 133.82 214.37 percent of total billed charges INTRAOSSEOUS INF NEEDLE 18GA 48712195_1 CDM 0272 RC inpatient 221 143.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 143.65 65 999999999 133.82 214.37 percent of total billed charges INTRAOSSEOUS INF NEEDLE 18GA 48712195_1 CDM 0272 RC inpatient 221 143.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 214.37 97 999999999 133.82 214.37 percent of total billed charges INTRAOSSEOUS INF NEEDLE 18GA 48712195_1 CDM 0272 RC inpatient 221 143.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 152.49 69 999999999 133.82 214.37 percent of total billed charges INTRAOSSEOUS INF NEEDLE 18GA 48712195_1 CDM 0272 RC inpatient 221 143.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 172.38 78 999999999 133.82 214.37 percent of total billed charges INTRAOSSEOUS INF NEEDLE 18GA 48712195_1 CDM 0272 RC inpatient 221 143.65 UMR - ALL PLANS UMR - ALL PLANS 154.7 70 999999999 133.82 214.37 percent of total billed charges INTRAOSSEOUS INF NEEDLE 18GA 48712195_1 CDM 0272 RC inpatient 221 143.65 SIHO - ALL PLANS SIHO - ALL PLANS 198.9 90 999999999 133.82 214.37 percent of total billed charges INTRAOSSEOUS INF NEEDLE 18GA 48712195_1 CDM 0272 RC inpatient 221 143.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 133.82 60.55 999999999 133.82 214.37 percent of total billed charges INTRAOSSEOUS INF NEEDLE 18GA 48712195_1 CDM 0272 RC inpatient 221 143.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 133.82 214.37 INTRAOSSEOUS INF NEEDLE 18GA 48712195_1 CDM 0272 RC inpatient 221 143.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 133.82 214.37 INTRAOSSEOUS INF NEEDLE 18GA 48712195_1 CDM 0272 RC inpatient 221 143.65 ANTHEM HMO ANTHEM HMO 999999999 133.82 214.37 INTRAOSSEOUS INF NEEDLE 18GA 48712195_1 CDM 0272 RC inpatient 221 143.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 133.82 214.37 INTRAOSSEOUS INF NEEDLE 18GA 48712195_1 CDM 0272 RC inpatient 221 143.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 149.4 67.6 999999999 133.82 214.37 percent of total billed charges INTRAOSSEOUS INF NEEDLE 18GA 48712195_1 CDM 0272 RC inpatient 221 143.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 133.82 214.37 EZ-IO AD 15G INTRAOSSEOUS 9001-VC-005 5/BOX 48712196_1 CDM 0272 RC inpatient 770 500.5 AETNA AETNA 608.3 79 999999999 466.24 746.9 percent of total billed charges EZ-IO AD 15G INTRAOSSEOUS 9001-VC-005 5/BOX 48712196_1 CDM 0272 RC inpatient 770 500.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 500.5 65 999999999 466.24 746.9 percent of total billed charges EZ-IO AD 15G INTRAOSSEOUS 9001-VC-005 5/BOX 48712196_1 CDM 0272 RC inpatient 770 500.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 746.9 97 999999999 466.24 746.9 percent of total billed charges EZ-IO AD 15G INTRAOSSEOUS 9001-VC-005 5/BOX 48712196_1 CDM 0272 RC inpatient 770 500.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 531.3 69 999999999 466.24 746.9 percent of total billed charges EZ-IO AD 15G INTRAOSSEOUS 9001-VC-005 5/BOX 48712196_1 CDM 0272 RC inpatient 770 500.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 600.6 78 999999999 466.24 746.9 percent of total billed charges EZ-IO AD 15G INTRAOSSEOUS 9001-VC-005 5/BOX 48712196_1 CDM 0272 RC inpatient 770 500.5 UMR - ALL PLANS UMR - ALL PLANS 539 70 999999999 466.24 746.9 percent of total billed charges EZ-IO AD 15G INTRAOSSEOUS 9001-VC-005 5/BOX 48712196_1 CDM 0272 RC inpatient 770 500.5 SIHO - ALL PLANS SIHO - ALL PLANS 693 90 999999999 466.24 746.9 percent of total billed charges EZ-IO AD 15G INTRAOSSEOUS 9001-VC-005 5/BOX 48712196_1 CDM 0272 RC inpatient 770 500.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 466.24 60.55 999999999 466.24 746.9 percent of total billed charges EZ-IO AD 15G INTRAOSSEOUS 9001-VC-005 5/BOX 48712196_1 CDM 0272 RC inpatient 770 500.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 466.24 746.9 EZ-IO AD 15G INTRAOSSEOUS 9001-VC-005 5/BOX 48712196_1 CDM 0272 RC inpatient 770 500.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 466.24 746.9 EZ-IO AD 15G INTRAOSSEOUS 9001-VC-005 5/BOX 48712196_1 CDM 0272 RC inpatient 770 500.5 ANTHEM HMO ANTHEM HMO 999999999 466.24 746.9 EZ-IO AD 15G INTRAOSSEOUS 9001-VC-005 5/BOX 48712196_1 CDM 0272 RC inpatient 770 500.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 466.24 746.9 EZ-IO AD 15G INTRAOSSEOUS 9001-VC-005 5/BOX 48712196_1 CDM 0272 RC inpatient 770 500.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 520.52 67.6 999999999 466.24 746.9 percent of total billed charges EZ-IO AD 15G INTRAOSSEOUS 9001-VC-005 5/BOX 48712196_1 CDM 0272 RC inpatient 770 500.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 466.24 746.9 EZ-IO PD 15G INTRAOSSEOUS 9018 48712197_1 CDM 0272 RC inpatient 801 520.65 AETNA AETNA 632.79 79 999999999 485.01 776.97 percent of total billed charges EZ-IO PD 15G INTRAOSSEOUS 9018 48712197_1 CDM 0272 RC inpatient 801 520.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 520.65 65 999999999 485.01 776.97 percent of total billed charges EZ-IO PD 15G INTRAOSSEOUS 9018 48712197_1 CDM 0272 RC inpatient 801 520.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 776.97 97 999999999 485.01 776.97 percent of total billed charges EZ-IO PD 15G INTRAOSSEOUS 9018 48712197_1 CDM 0272 RC inpatient 801 520.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 552.69 69 999999999 485.01 776.97 percent of total billed charges EZ-IO PD 15G INTRAOSSEOUS 9018 48712197_1 CDM 0272 RC inpatient 801 520.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 624.78 78 999999999 485.01 776.97 percent of total billed charges EZ-IO PD 15G INTRAOSSEOUS 9018 48712197_1 CDM 0272 RC inpatient 801 520.65 UMR - ALL PLANS UMR - ALL PLANS 560.7 70 999999999 485.01 776.97 percent of total billed charges EZ-IO PD 15G INTRAOSSEOUS 9018 48712197_1 CDM 0272 RC inpatient 801 520.65 SIHO - ALL PLANS SIHO - ALL PLANS 720.9 90 999999999 485.01 776.97 percent of total billed charges EZ-IO PD 15G INTRAOSSEOUS 9018 48712197_1 CDM 0272 RC inpatient 801 520.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 485.01 60.55 999999999 485.01 776.97 percent of total billed charges EZ-IO PD 15G INTRAOSSEOUS 9018 48712197_1 CDM 0272 RC inpatient 801 520.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 485.01 776.97 EZ-IO PD 15G INTRAOSSEOUS 9018 48712197_1 CDM 0272 RC inpatient 801 520.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 485.01 776.97 EZ-IO PD 15G INTRAOSSEOUS 9018 48712197_1 CDM 0272 RC inpatient 801 520.65 ANTHEM HMO ANTHEM HMO 999999999 485.01 776.97 EZ-IO PD 15G INTRAOSSEOUS 9018 48712197_1 CDM 0272 RC inpatient 801 520.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 485.01 776.97 EZ-IO PD 15G INTRAOSSEOUS 9018 48712197_1 CDM 0272 RC inpatient 801 520.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 541.48 67.6 999999999 485.01 776.97 percent of total billed charges EZ-IO PD 15G INTRAOSSEOUS 9018 48712197_1 CDM 0272 RC inpatient 801 520.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 485.01 776.97 NEEDLE INTRAOSSEOUS 15G 9079 48712198_1 CDM 0272 RC inpatient 816 530.4 AETNA AETNA 644.64 79 999999999 494.09 791.52 percent of total billed charges NEEDLE INTRAOSSEOUS 15G 9079 48712198_1 CDM 0272 RC inpatient 816 530.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 530.4 65 999999999 494.09 791.52 percent of total billed charges NEEDLE INTRAOSSEOUS 15G 9079 48712198_1 CDM 0272 RC inpatient 816 530.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 791.52 97 999999999 494.09 791.52 percent of total billed charges NEEDLE INTRAOSSEOUS 15G 9079 48712198_1 CDM 0272 RC inpatient 816 530.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 563.04 69 999999999 494.09 791.52 percent of total billed charges NEEDLE INTRAOSSEOUS 15G 9079 48712198_1 CDM 0272 RC inpatient 816 530.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 636.48 78 999999999 494.09 791.52 percent of total billed charges NEEDLE INTRAOSSEOUS 15G 9079 48712198_1 CDM 0272 RC inpatient 816 530.4 UMR - ALL PLANS UMR - ALL PLANS 571.2 70 999999999 494.09 791.52 percent of total billed charges NEEDLE INTRAOSSEOUS 15G 9079 48712198_1 CDM 0272 RC inpatient 816 530.4 SIHO - ALL PLANS SIHO - ALL PLANS 734.4 90 999999999 494.09 791.52 percent of total billed charges NEEDLE INTRAOSSEOUS 15G 9079 48712198_1 CDM 0272 RC inpatient 816 530.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 494.09 60.55 999999999 494.09 791.52 percent of total billed charges NEEDLE INTRAOSSEOUS 15G 9079 48712198_1 CDM 0272 RC inpatient 816 530.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 494.09 791.52 NEEDLE INTRAOSSEOUS 15G 9079 48712198_1 CDM 0272 RC inpatient 816 530.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 494.09 791.52 NEEDLE INTRAOSSEOUS 15G 9079 48712198_1 CDM 0272 RC inpatient 816 530.4 ANTHEM HMO ANTHEM HMO 999999999 494.09 791.52 NEEDLE INTRAOSSEOUS 15G 9079 48712198_1 CDM 0272 RC inpatient 816 530.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 494.09 791.52 NEEDLE INTRAOSSEOUS 15G 9079 48712198_1 CDM 0272 RC inpatient 816 530.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 551.62 67.6 999999999 494.09 791.52 percent of total billed charges NEEDLE INTRAOSSEOUS 15G 9079 48712198_1 CDM 0272 RC inpatient 816 530.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 494.09 791.52 "NEEDLE, STERILE, ANY SIZE, EACH" 48712199_1 CDM 0621 RC A4215 HCPCS inpatient 266 172.9 AETNA AETNA 210.14 79 999999999 161.06 258.02 percent of total billed charges "NEEDLE, STERILE, ANY SIZE, EACH" 48712199_1 CDM 0621 RC A4215 HCPCS inpatient 266 172.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 172.9 65 999999999 161.06 258.02 percent of total billed charges "NEEDLE, STERILE, ANY SIZE, EACH" 48712199_1 CDM 0621 RC A4215 HCPCS inpatient 266 172.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 258.02 97 999999999 161.06 258.02 percent of total billed charges "NEEDLE, STERILE, ANY SIZE, EACH" 48712199_1 CDM 0621 RC A4215 HCPCS inpatient 266 172.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 183.54 69 999999999 161.06 258.02 percent of total billed charges "NEEDLE, STERILE, ANY SIZE, EACH" 48712199_1 CDM 0621 RC A4215 HCPCS inpatient 266 172.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 207.48 78 999999999 161.06 258.02 percent of total billed charges "NEEDLE, STERILE, ANY SIZE, EACH" 48712199_1 CDM 0621 RC A4215 HCPCS inpatient 266 172.9 UMR - ALL PLANS UMR - ALL PLANS 186.2 70 999999999 161.06 258.02 percent of total billed charges "NEEDLE, STERILE, ANY SIZE, EACH" 48712199_1 CDM 0621 RC A4215 HCPCS inpatient 266 172.9 SIHO - ALL PLANS SIHO - ALL PLANS 239.4 90 999999999 161.06 258.02 percent of total billed charges "NEEDLE, STERILE, ANY SIZE, EACH" 48712199_1 CDM 0621 RC A4215 HCPCS inpatient 266 172.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 161.06 60.55 999999999 161.06 258.02 percent of total billed charges "NEEDLE, STERILE, ANY SIZE, EACH" 48712199_1 CDM 0621 RC A4215 HCPCS inpatient 266 172.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 161.06 258.02 "NEEDLE, STERILE, ANY SIZE, EACH" 48712199_1 CDM 0621 RC A4215 HCPCS inpatient 266 172.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 161.06 258.02 "NEEDLE, STERILE, ANY SIZE, EACH" 48712199_1 CDM 0621 RC A4215 HCPCS inpatient 266 172.9 ANTHEM HMO ANTHEM HMO 999999999 161.06 258.02 "NEEDLE, STERILE, ANY SIZE, EACH" 48712199_1 CDM 0621 RC A4215 HCPCS inpatient 266 172.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 161.06 258.02 "NEEDLE, STERILE, ANY SIZE, EACH" 48712199_1 CDM 0621 RC A4215 HCPCS inpatient 266 172.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 179.82 67.6 999999999 161.06 258.02 percent of total billed charges "NEEDLE, STERILE, ANY SIZE, EACH" 48712199_1 CDM 0621 RC A4215 HCPCS inpatient 266 172.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 161.06 258.02 NEEDLE BIOPSY TR-CUT 14G 48712200_1 CDM 0272 RC inpatient 192 124.8 AETNA AETNA 151.68 79 999999999 116.26 186.24 percent of total billed charges NEEDLE BIOPSY TR-CUT 14G 48712200_1 CDM 0272 RC inpatient 192 124.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 124.8 65 999999999 116.26 186.24 percent of total billed charges NEEDLE BIOPSY TR-CUT 14G 48712200_1 CDM 0272 RC inpatient 192 124.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 186.24 97 999999999 116.26 186.24 percent of total billed charges NEEDLE BIOPSY TR-CUT 14G 48712200_1 CDM 0272 RC inpatient 192 124.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 132.48 69 999999999 116.26 186.24 percent of total billed charges NEEDLE BIOPSY TR-CUT 14G 48712200_1 CDM 0272 RC inpatient 192 124.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 149.76 78 999999999 116.26 186.24 percent of total billed charges NEEDLE BIOPSY TR-CUT 14G 48712200_1 CDM 0272 RC inpatient 192 124.8 UMR - ALL PLANS UMR - ALL PLANS 134.4 70 999999999 116.26 186.24 percent of total billed charges NEEDLE BIOPSY TR-CUT 14G 48712200_1 CDM 0272 RC inpatient 192 124.8 SIHO - ALL PLANS SIHO - ALL PLANS 172.8 90 999999999 116.26 186.24 percent of total billed charges NEEDLE BIOPSY TR-CUT 14G 48712200_1 CDM 0272 RC inpatient 192 124.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.26 60.55 999999999 116.26 186.24 percent of total billed charges NEEDLE BIOPSY TR-CUT 14G 48712200_1 CDM 0272 RC inpatient 192 124.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.26 186.24 NEEDLE BIOPSY TR-CUT 14G 48712200_1 CDM 0272 RC inpatient 192 124.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.26 186.24 NEEDLE BIOPSY TR-CUT 14G 48712200_1 CDM 0272 RC inpatient 192 124.8 ANTHEM HMO ANTHEM HMO 999999999 116.26 186.24 NEEDLE BIOPSY TR-CUT 14G 48712200_1 CDM 0272 RC inpatient 192 124.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.26 186.24 NEEDLE BIOPSY TR-CUT 14G 48712200_1 CDM 0272 RC inpatient 192 124.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 129.79 67.6 999999999 116.26 186.24 percent of total billed charges NEEDLE BIOPSY TR-CUT 14G 48712200_1 CDM 0272 RC inpatient 192 124.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.26 186.24 DGBS-200 IUH-122193 21-25 (OE) 48712204_1 CDM 0621 RC inpatient 317 206.05 AETNA AETNA 250.43 79 999999999 191.94 307.49 percent of total billed charges DGBS-200 IUH-122193 21-25 (OE) 48712204_1 CDM 0621 RC inpatient 317 206.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 206.05 65 999999999 191.94 307.49 percent of total billed charges DGBS-200 IUH-122193 21-25 (OE) 48712204_1 CDM 0621 RC inpatient 317 206.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 307.49 97 999999999 191.94 307.49 percent of total billed charges DGBS-200 IUH-122193 21-25 (OE) 48712204_1 CDM 0621 RC inpatient 317 206.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 218.73 69 999999999 191.94 307.49 percent of total billed charges DGBS-200 IUH-122193 21-25 (OE) 48712204_1 CDM 0621 RC inpatient 317 206.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 247.26 78 999999999 191.94 307.49 percent of total billed charges DGBS-200 IUH-122193 21-25 (OE) 48712204_1 CDM 0621 RC inpatient 317 206.05 UMR - ALL PLANS UMR - ALL PLANS 221.9 70 999999999 191.94 307.49 percent of total billed charges DGBS-200 IUH-122193 21-25 (OE) 48712204_1 CDM 0621 RC inpatient 317 206.05 SIHO - ALL PLANS SIHO - ALL PLANS 285.3 90 999999999 191.94 307.49 percent of total billed charges DGBS-200 IUH-122193 21-25 (OE) 48712204_1 CDM 0621 RC inpatient 317 206.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 191.94 60.55 999999999 191.94 307.49 percent of total billed charges DGBS-200 IUH-122193 21-25 (OE) 48712204_1 CDM 0621 RC inpatient 317 206.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 191.94 307.49 DGBS-200 IUH-122193 21-25 (OE) 48712204_1 CDM 0621 RC inpatient 317 206.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 191.94 307.49 DGBS-200 IUH-122193 21-25 (OE) 48712204_1 CDM 0621 RC inpatient 317 206.05 ANTHEM HMO ANTHEM HMO 999999999 191.94 307.49 DGBS-200 IUH-122193 21-25 (OE) 48712204_1 CDM 0621 RC inpatient 317 206.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 191.94 307.49 DGBS-200 IUH-122193 21-25 (OE) 48712204_1 CDM 0621 RC inpatient 317 206.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 214.29 67.6 999999999 191.94 307.49 percent of total billed charges DGBS-200 IUH-122193 21-25 (OE) 48712204_1 CDM 0621 RC inpatient 317 206.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 191.94 307.49 NEEDLE BIOPSY TURNER 041261 OE 48712206_1 CDM 0272 RC inpatient 170 110.5 AETNA AETNA 134.3 79 999999999 102.94 164.9 percent of total billed charges NEEDLE BIOPSY TURNER 041261 OE 48712206_1 CDM 0272 RC inpatient 170 110.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.5 65 999999999 102.94 164.9 percent of total billed charges NEEDLE BIOPSY TURNER 041261 OE 48712206_1 CDM 0272 RC inpatient 170 110.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.9 97 999999999 102.94 164.9 percent of total billed charges NEEDLE BIOPSY TURNER 041261 OE 48712206_1 CDM 0272 RC inpatient 170 110.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.3 69 999999999 102.94 164.9 percent of total billed charges NEEDLE BIOPSY TURNER 041261 OE 48712206_1 CDM 0272 RC inpatient 170 110.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.6 78 999999999 102.94 164.9 percent of total billed charges NEEDLE BIOPSY TURNER 041261 OE 48712206_1 CDM 0272 RC inpatient 170 110.5 UMR - ALL PLANS UMR - ALL PLANS 119 70 999999999 102.94 164.9 percent of total billed charges NEEDLE BIOPSY TURNER 041261 OE 48712206_1 CDM 0272 RC inpatient 170 110.5 SIHO - ALL PLANS SIHO - ALL PLANS 153 90 999999999 102.94 164.9 percent of total billed charges NEEDLE BIOPSY TURNER 041261 OE 48712206_1 CDM 0272 RC inpatient 170 110.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.94 60.55 999999999 102.94 164.9 percent of total billed charges NEEDLE BIOPSY TURNER 041261 OE 48712206_1 CDM 0272 RC inpatient 170 110.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.94 164.9 NEEDLE BIOPSY TURNER 041261 OE 48712206_1 CDM 0272 RC inpatient 170 110.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.94 164.9 NEEDLE BIOPSY TURNER 041261 OE 48712206_1 CDM 0272 RC inpatient 170 110.5 ANTHEM HMO ANTHEM HMO 999999999 102.94 164.9 NEEDLE BIOPSY TURNER 041261 OE 48712206_1 CDM 0272 RC inpatient 170 110.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.94 164.9 NEEDLE BIOPSY TURNER 041261 OE 48712206_1 CDM 0272 RC inpatient 170 110.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.92 67.6 999999999 102.94 164.9 percent of total billed charges NEEDLE BIOPSY TURNER 041261 OE 48712206_1 CDM 0272 RC inpatient 170 110.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.94 164.9 EPIDURAL NEEDLE 16GA 100-1416 48712207_1 CDM 0272 RC inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges EPIDURAL NEEDLE 16GA 100-1416 48712207_1 CDM 0272 RC inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges EPIDURAL NEEDLE 16GA 100-1416 48712207_1 CDM 0272 RC inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges EPIDURAL NEEDLE 16GA 100-1416 48712207_1 CDM 0272 RC inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges EPIDURAL NEEDLE 16GA 100-1416 48712207_1 CDM 0272 RC inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges EPIDURAL NEEDLE 16GA 100-1416 48712207_1 CDM 0272 RC inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges EPIDURAL NEEDLE 16GA 100-1416 48712207_1 CDM 0272 RC inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges EPIDURAL NEEDLE 16GA 100-1416 48712207_1 CDM 0272 RC inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges EPIDURAL NEEDLE 16GA 100-1416 48712207_1 CDM 0272 RC inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 EPIDURAL NEEDLE 16GA 100-1416 48712207_1 CDM 0272 RC inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 EPIDURAL NEEDLE 16GA 100-1416 48712207_1 CDM 0272 RC inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 EPIDURAL NEEDLE 16GA 100-1416 48712207_1 CDM 0272 RC inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 EPIDURAL NEEDLE 16GA 100-1416 48712207_1 CDM 0272 RC inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges EPIDURAL NEEDLE 16GA 100-1416 48712207_1 CDM 0272 RC inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 BREVI KATH 155-2393 48712208_1 CDM 0272 RC inpatient 420 273 AETNA AETNA 331.8 79 999999999 254.31 407.4 percent of total billed charges BREVI KATH 155-2393 48712208_1 CDM 0272 RC inpatient 420 273 SELF PAY DISCOUNT SELF PAY DISCOUNT 273 65 999999999 254.31 407.4 percent of total billed charges BREVI KATH 155-2393 48712208_1 CDM 0272 RC inpatient 420 273 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 407.4 97 999999999 254.31 407.4 percent of total billed charges BREVI KATH 155-2393 48712208_1 CDM 0272 RC inpatient 420 273 ENCORE - ALL PLANS ENCORE - ALL PLANS 289.8 69 999999999 254.31 407.4 percent of total billed charges BREVI KATH 155-2393 48712208_1 CDM 0272 RC inpatient 420 273 HUMANA - ALL PLANS HUMANA - ALL PLANS 327.6 78 999999999 254.31 407.4 percent of total billed charges BREVI KATH 155-2393 48712208_1 CDM 0272 RC inpatient 420 273 UMR - ALL PLANS UMR - ALL PLANS 294 70 999999999 254.31 407.4 percent of total billed charges BREVI KATH 155-2393 48712208_1 CDM 0272 RC inpatient 420 273 SIHO - ALL PLANS SIHO - ALL PLANS 378 90 999999999 254.31 407.4 percent of total billed charges BREVI KATH 155-2393 48712208_1 CDM 0272 RC inpatient 420 273 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 254.31 60.55 999999999 254.31 407.4 percent of total billed charges BREVI KATH 155-2393 48712208_1 CDM 0272 RC inpatient 420 273 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 254.31 407.4 BREVI KATH 155-2393 48712208_1 CDM 0272 RC inpatient 420 273 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 254.31 407.4 BREVI KATH 155-2393 48712208_1 CDM 0272 RC inpatient 420 273 ANTHEM HMO ANTHEM HMO 999999999 254.31 407.4 BREVI KATH 155-2393 48712208_1 CDM 0272 RC inpatient 420 273 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 254.31 407.4 BREVI KATH 155-2393 48712208_1 CDM 0272 RC inpatient 420 273 CIGNA - ALL PLANS CIGNA - ALL PLANS 283.92 67.6 999999999 254.31 407.4 percent of total billed charges BREVI KATH 155-2393 48712208_1 CDM 0272 RC inpatient 420 273 UHC - ALL PLANS UHC - ALL PLANS 999999999 254.31 407.4 YUEH CENTESIS CATH NDLE 5.0 G09489 48712210_1 CDM 0272 RC inpatient 125 81.25 AETNA AETNA 98.75 79 999999999 75.69 121.25 percent of total billed charges YUEH CENTESIS CATH NDLE 5.0 G09489 48712210_1 CDM 0272 RC inpatient 125 81.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.25 65 999999999 75.69 121.25 percent of total billed charges YUEH CENTESIS CATH NDLE 5.0 G09489 48712210_1 CDM 0272 RC inpatient 125 81.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 121.25 97 999999999 75.69 121.25 percent of total billed charges YUEH CENTESIS CATH NDLE 5.0 G09489 48712210_1 CDM 0272 RC inpatient 125 81.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.5 78 999999999 75.69 121.25 percent of total billed charges YUEH CENTESIS CATH NDLE 5.0 G09489 48712210_1 CDM 0272 RC inpatient 125 81.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.25 69 999999999 75.69 121.25 percent of total billed charges YUEH CENTESIS CATH NDLE 5.0 G09489 48712210_1 CDM 0272 RC inpatient 125 81.25 UMR - ALL PLANS UMR - ALL PLANS 87.5 70 999999999 75.69 121.25 percent of total billed charges YUEH CENTESIS CATH NDLE 5.0 G09489 48712210_1 CDM 0272 RC inpatient 125 81.25 SIHO - ALL PLANS SIHO - ALL PLANS 112.5 90 999999999 75.69 121.25 percent of total billed charges YUEH CENTESIS CATH NDLE 5.0 G09489 48712210_1 CDM 0272 RC inpatient 125 81.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.69 60.55 999999999 75.69 121.25 percent of total billed charges YUEH CENTESIS CATH NDLE 5.0 G09489 48712210_1 CDM 0272 RC inpatient 125 81.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.69 121.25 YUEH CENTESIS CATH NDLE 5.0 G09489 48712210_1 CDM 0272 RC inpatient 125 81.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.69 121.25 YUEH CENTESIS CATH NDLE 5.0 G09489 48712210_1 CDM 0272 RC inpatient 125 81.25 ANTHEM HMO ANTHEM HMO 999999999 75.69 121.25 YUEH CENTESIS CATH NDLE 5.0 G09489 48712210_1 CDM 0272 RC inpatient 125 81.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.69 121.25 YUEH CENTESIS CATH NDLE 5.0 G09489 48712210_1 CDM 0272 RC inpatient 125 81.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.5 67.6 999999999 75.69 121.25 percent of total billed charges YUEH CENTESIS CATH NDLE 5.0 G09489 48712210_1 CDM 0272 RC inpatient 125 81.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.69 121.25 YUEH CENT CATH NDLE 10.0 (OE) 48712211_1 CDM 0272 RC inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges YUEH CENT CATH NDLE 10.0 (OE) 48712211_1 CDM 0272 RC inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges YUEH CENT CATH NDLE 10.0 (OE) 48712211_1 CDM 0272 RC inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges YUEH CENT CATH NDLE 10.0 (OE) 48712211_1 CDM 0272 RC inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges YUEH CENT CATH NDLE 10.0 (OE) 48712211_1 CDM 0272 RC inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges YUEH CENT CATH NDLE 10.0 (OE) 48712211_1 CDM 0272 RC inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges YUEH CENT CATH NDLE 10.0 (OE) 48712211_1 CDM 0272 RC inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges YUEH CENT CATH NDLE 10.0 (OE) 48712211_1 CDM 0272 RC inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges YUEH CENT CATH NDLE 10.0 (OE) 48712211_1 CDM 0272 RC inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 YUEH CENT CATH NDLE 10.0 (OE) 48712211_1 CDM 0272 RC inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 YUEH CENT CATH NDLE 10.0 (OE) 48712211_1 CDM 0272 RC inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 YUEH CENT CATH NDLE 10.0 (OE) 48712211_1 CDM 0272 RC inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 YUEH CENT CATH NDLE 10.0 (OE) 48712211_1 CDM 0272 RC inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges YUEH CENT CATH NDLE 10.0 (OE) 48712211_1 CDM 0272 RC inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 BIOPINCE FULL CORE BIOPSY 18GA 48712213_1 CDM 0272 RC inpatient 339 220.35 AETNA AETNA 267.81 79 999999999 205.26 328.83 percent of total billed charges BIOPINCE FULL CORE BIOPSY 18GA 48712213_1 CDM 0272 RC inpatient 339 220.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 220.35 65 999999999 205.26 328.83 percent of total billed charges BIOPINCE FULL CORE BIOPSY 18GA 48712213_1 CDM 0272 RC inpatient 339 220.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 328.83 97 999999999 205.26 328.83 percent of total billed charges BIOPINCE FULL CORE BIOPSY 18GA 48712213_1 CDM 0272 RC inpatient 339 220.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 264.42 78 999999999 205.26 328.83 percent of total billed charges BIOPINCE FULL CORE BIOPSY 18GA 48712213_1 CDM 0272 RC inpatient 339 220.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 233.91 69 999999999 205.26 328.83 percent of total billed charges BIOPINCE FULL CORE BIOPSY 18GA 48712213_1 CDM 0272 RC inpatient 339 220.35 UMR - ALL PLANS UMR - ALL PLANS 237.3 70 999999999 205.26 328.83 percent of total billed charges BIOPINCE FULL CORE BIOPSY 18GA 48712213_1 CDM 0272 RC inpatient 339 220.35 SIHO - ALL PLANS SIHO - ALL PLANS 305.1 90 999999999 205.26 328.83 percent of total billed charges BIOPINCE FULL CORE BIOPSY 18GA 48712213_1 CDM 0272 RC inpatient 339 220.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.26 60.55 999999999 205.26 328.83 percent of total billed charges BIOPINCE FULL CORE BIOPSY 18GA 48712213_1 CDM 0272 RC inpatient 339 220.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.26 328.83 BIOPINCE FULL CORE BIOPSY 18GA 48712213_1 CDM 0272 RC inpatient 339 220.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.26 328.83 BIOPINCE FULL CORE BIOPSY 18GA 48712213_1 CDM 0272 RC inpatient 339 220.35 ANTHEM HMO ANTHEM HMO 999999999 205.26 328.83 BIOPINCE FULL CORE BIOPSY 18GA 48712213_1 CDM 0272 RC inpatient 339 220.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.26 328.83 BIOPINCE FULL CORE BIOPSY 18GA 48712213_1 CDM 0272 RC inpatient 339 220.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.16 67.6 999999999 205.26 328.83 percent of total billed charges BIOPINCE FULL CORE BIOPSY 18GA 48712213_1 CDM 0272 RC inpatient 339 220.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.26 328.83 LIGACLIP MEDIUM 29.2CM MCM20 48712217_1 CDM 0272 RC inpatient 1078 700.7 AETNA AETNA 851.62 79 999999999 652.73 1045.66 percent of total billed charges LIGACLIP MEDIUM 29.2CM MCM20 48712217_1 CDM 0272 RC inpatient 1078 700.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 700.7 65 999999999 652.73 1045.66 percent of total billed charges LIGACLIP MEDIUM 29.2CM MCM20 48712217_1 CDM 0272 RC inpatient 1078 700.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1045.66 97 999999999 652.73 1045.66 percent of total billed charges LIGACLIP MEDIUM 29.2CM MCM20 48712217_1 CDM 0272 RC inpatient 1078 700.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 840.84 78 999999999 652.73 1045.66 percent of total billed charges LIGACLIP MEDIUM 29.2CM MCM20 48712217_1 CDM 0272 RC inpatient 1078 700.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 743.82 69 999999999 652.73 1045.66 percent of total billed charges LIGACLIP MEDIUM 29.2CM MCM20 48712217_1 CDM 0272 RC inpatient 1078 700.7 UMR - ALL PLANS UMR - ALL PLANS 754.6 70 999999999 652.73 1045.66 percent of total billed charges LIGACLIP MEDIUM 29.2CM MCM20 48712217_1 CDM 0272 RC inpatient 1078 700.7 SIHO - ALL PLANS SIHO - ALL PLANS 970.2 90 999999999 652.73 1045.66 percent of total billed charges LIGACLIP MEDIUM 29.2CM MCM20 48712217_1 CDM 0272 RC inpatient 1078 700.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 652.73 60.55 999999999 652.73 1045.66 percent of total billed charges LIGACLIP MEDIUM 29.2CM MCM20 48712217_1 CDM 0272 RC inpatient 1078 700.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 652.73 1045.66 LIGACLIP MEDIUM 29.2CM MCM20 48712217_1 CDM 0272 RC inpatient 1078 700.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 652.73 1045.66 LIGACLIP MEDIUM 29.2CM MCM20 48712217_1 CDM 0272 RC inpatient 1078 700.7 ANTHEM HMO ANTHEM HMO 999999999 652.73 1045.66 LIGACLIP MEDIUM 29.2CM MCM20 48712217_1 CDM 0272 RC inpatient 1078 700.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 652.73 1045.66 LIGACLIP MEDIUM 29.2CM MCM20 48712217_1 CDM 0272 RC inpatient 1078 700.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 728.73 67.6 999999999 652.73 1045.66 percent of total billed charges LIGACLIP MEDIUM 29.2CM MCM20 48712217_1 CDM 0272 RC inpatient 1078 700.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 652.73 1045.66 IODOFORM STRIP 1/2 NON256125 48712221_1 CDM 0272 RC inpatient 11 7.15 AETNA AETNA 8.69 79 999999999 6.66 10.67 percent of total billed charges IODOFORM STRIP 1/2 NON256125 48712221_1 CDM 0272 RC inpatient 11 7.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.15 65 999999999 6.66 10.67 percent of total billed charges IODOFORM STRIP 1/2 NON256125 48712221_1 CDM 0272 RC inpatient 11 7.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10.67 97 999999999 6.66 10.67 percent of total billed charges IODOFORM STRIP 1/2 NON256125 48712221_1 CDM 0272 RC inpatient 11 7.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 8.58 78 999999999 6.66 10.67 percent of total billed charges IODOFORM STRIP 1/2 NON256125 48712221_1 CDM 0272 RC inpatient 11 7.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.59 69 999999999 6.66 10.67 percent of total billed charges IODOFORM STRIP 1/2 NON256125 48712221_1 CDM 0272 RC inpatient 11 7.15 UMR - ALL PLANS UMR - ALL PLANS 7.7 70 999999999 6.66 10.67 percent of total billed charges IODOFORM STRIP 1/2 NON256125 48712221_1 CDM 0272 RC inpatient 11 7.15 SIHO - ALL PLANS SIHO - ALL PLANS 9.9 90 999999999 6.66 10.67 percent of total billed charges IODOFORM STRIP 1/2 NON256125 48712221_1 CDM 0272 RC inpatient 11 7.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.66 60.55 999999999 6.66 10.67 percent of total billed charges IODOFORM STRIP 1/2 NON256125 48712221_1 CDM 0272 RC inpatient 11 7.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.66 10.67 IODOFORM STRIP 1/2 NON256125 48712221_1 CDM 0272 RC inpatient 11 7.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.66 10.67 IODOFORM STRIP 1/2 NON256125 48712221_1 CDM 0272 RC inpatient 11 7.15 ANTHEM HMO ANTHEM HMO 999999999 6.66 10.67 IODOFORM STRIP 1/2 NON256125 48712221_1 CDM 0272 RC inpatient 11 7.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.66 10.67 IODOFORM STRIP 1/2 NON256125 48712221_1 CDM 0272 RC inpatient 11 7.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 7.44 67.6 999999999 6.66 10.67 percent of total billed charges IODOFORM STRIP 1/2 NON256125 48712221_1 CDM 0272 RC inpatient 11 7.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.66 10.67 IODOFORM STRIP 1 5YD NON256015 48712222_1 CDM 0272 RC inpatient 12 7.8 AETNA AETNA 9.48 79 999999999 7.27 11.64 percent of total billed charges IODOFORM STRIP 1 5YD NON256015 48712222_1 CDM 0272 RC inpatient 12 7.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.8 65 999999999 7.27 11.64 percent of total billed charges IODOFORM STRIP 1 5YD NON256015 48712222_1 CDM 0272 RC inpatient 12 7.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11.64 97 999999999 7.27 11.64 percent of total billed charges IODOFORM STRIP 1 5YD NON256015 48712222_1 CDM 0272 RC inpatient 12 7.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.36 78 999999999 7.27 11.64 percent of total billed charges IODOFORM STRIP 1 5YD NON256015 48712222_1 CDM 0272 RC inpatient 12 7.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.28 69 999999999 7.27 11.64 percent of total billed charges IODOFORM STRIP 1 5YD NON256015 48712222_1 CDM 0272 RC inpatient 12 7.8 UMR - ALL PLANS UMR - ALL PLANS 8.4 70 999999999 7.27 11.64 percent of total billed charges IODOFORM STRIP 1 5YD NON256015 48712222_1 CDM 0272 RC inpatient 12 7.8 SIHO - ALL PLANS SIHO - ALL PLANS 10.8 90 999999999 7.27 11.64 percent of total billed charges IODOFORM STRIP 1 5YD NON256015 48712222_1 CDM 0272 RC inpatient 12 7.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.27 60.55 999999999 7.27 11.64 percent of total billed charges IODOFORM STRIP 1 5YD NON256015 48712222_1 CDM 0272 RC inpatient 12 7.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.27 11.64 IODOFORM STRIP 1 5YD NON256015 48712222_1 CDM 0272 RC inpatient 12 7.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.27 11.64 IODOFORM STRIP 1 5YD NON256015 48712222_1 CDM 0272 RC inpatient 12 7.8 ANTHEM HMO ANTHEM HMO 999999999 7.27 11.64 IODOFORM STRIP 1 5YD NON256015 48712222_1 CDM 0272 RC inpatient 12 7.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.27 11.64 IODOFORM STRIP 1 5YD NON256015 48712222_1 CDM 0272 RC inpatient 12 7.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.11 67.6 999999999 7.27 11.64 percent of total billed charges IODOFORM STRIP 1 5YD NON256015 48712222_1 CDM 0272 RC inpatient 12 7.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.27 11.64 NEEDLE COAXIAL 18-15 BP MEDIM 48712223_1 CDM 0272 RC inpatient 118 76.7 AETNA AETNA 93.22 79 999999999 71.45 114.46 percent of total billed charges NEEDLE COAXIAL 18-15 BP MEDIM 48712223_1 CDM 0272 RC inpatient 118 76.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 76.7 65 999999999 71.45 114.46 percent of total billed charges NEEDLE COAXIAL 18-15 BP MEDIM 48712223_1 CDM 0272 RC inpatient 118 76.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 114.46 97 999999999 71.45 114.46 percent of total billed charges NEEDLE COAXIAL 18-15 BP MEDIM 48712223_1 CDM 0272 RC inpatient 118 76.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.04 78 999999999 71.45 114.46 percent of total billed charges NEEDLE COAXIAL 18-15 BP MEDIM 48712223_1 CDM 0272 RC inpatient 118 76.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 81.42 69 999999999 71.45 114.46 percent of total billed charges NEEDLE COAXIAL 18-15 BP MEDIM 48712223_1 CDM 0272 RC inpatient 118 76.7 UMR - ALL PLANS UMR - ALL PLANS 82.6 70 999999999 71.45 114.46 percent of total billed charges NEEDLE COAXIAL 18-15 BP MEDIM 48712223_1 CDM 0272 RC inpatient 118 76.7 SIHO - ALL PLANS SIHO - ALL PLANS 106.2 90 999999999 71.45 114.46 percent of total billed charges NEEDLE COAXIAL 18-15 BP MEDIM 48712223_1 CDM 0272 RC inpatient 118 76.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 71.45 60.55 999999999 71.45 114.46 percent of total billed charges NEEDLE COAXIAL 18-15 BP MEDIM 48712223_1 CDM 0272 RC inpatient 118 76.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 71.45 114.46 NEEDLE COAXIAL 18-15 BP MEDIM 48712223_1 CDM 0272 RC inpatient 118 76.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 71.45 114.46 NEEDLE COAXIAL 18-15 BP MEDIM 48712223_1 CDM 0272 RC inpatient 118 76.7 ANTHEM HMO ANTHEM HMO 999999999 71.45 114.46 NEEDLE COAXIAL 18-15 BP MEDIM 48712223_1 CDM 0272 RC inpatient 118 76.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 71.45 114.46 NEEDLE COAXIAL 18-15 BP MEDIM 48712223_1 CDM 0272 RC inpatient 118 76.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 79.77 67.6 999999999 71.45 114.46 percent of total billed charges NEEDLE COAXIAL 18-15 BP MEDIM 48712223_1 CDM 0272 RC inpatient 118 76.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 71.45 114.46 "IODOFORM PK STRIP 2"" NON256025" 48712224_1 CDM 0272 RC inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges "IODOFORM PK STRIP 2"" NON256025" 48712224_1 CDM 0272 RC inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges "IODOFORM PK STRIP 2"" NON256025" 48712224_1 CDM 0272 RC inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges "IODOFORM PK STRIP 2"" NON256025" 48712224_1 CDM 0272 RC inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges "IODOFORM PK STRIP 2"" NON256025" 48712224_1 CDM 0272 RC inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges "IODOFORM PK STRIP 2"" NON256025" 48712224_1 CDM 0272 RC inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges "IODOFORM PK STRIP 2"" NON256025" 48712224_1 CDM 0272 RC inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges "IODOFORM PK STRIP 2"" NON256025" 48712224_1 CDM 0272 RC inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges "IODOFORM PK STRIP 2"" NON256025" 48712224_1 CDM 0272 RC inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 "IODOFORM PK STRIP 2"" NON256025" 48712224_1 CDM 0272 RC inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 "IODOFORM PK STRIP 2"" NON256025" 48712224_1 CDM 0272 RC inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 "IODOFORM PK STRIP 2"" NON256025" 48712224_1 CDM 0272 RC inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 "IODOFORM PK STRIP 2"" NON256025" 48712224_1 CDM 0272 RC inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges "IODOFORM PK STRIP 2"" NON256025" 48712224_1 CDM 0272 RC inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 OXIMIZER P-224 48712247_1 CDM 0272 RC inpatient 104 67.6 AETNA AETNA 82.16 79 999999999 62.97 100.88 percent of total billed charges OXIMIZER P-224 48712247_1 CDM 0272 RC inpatient 104 67.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 67.6 65 999999999 62.97 100.88 percent of total billed charges OXIMIZER P-224 48712247_1 CDM 0272 RC inpatient 104 67.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 100.88 97 999999999 62.97 100.88 percent of total billed charges OXIMIZER P-224 48712247_1 CDM 0272 RC inpatient 104 67.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.12 78 999999999 62.97 100.88 percent of total billed charges OXIMIZER P-224 48712247_1 CDM 0272 RC inpatient 104 67.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.76 69 999999999 62.97 100.88 percent of total billed charges OXIMIZER P-224 48712247_1 CDM 0272 RC inpatient 104 67.6 UMR - ALL PLANS UMR - ALL PLANS 72.8 70 999999999 62.97 100.88 percent of total billed charges OXIMIZER P-224 48712247_1 CDM 0272 RC inpatient 104 67.6 SIHO - ALL PLANS SIHO - ALL PLANS 93.6 90 999999999 62.97 100.88 percent of total billed charges OXIMIZER P-224 48712247_1 CDM 0272 RC inpatient 104 67.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.97 60.55 999999999 62.97 100.88 percent of total billed charges OXIMIZER P-224 48712247_1 CDM 0272 RC inpatient 104 67.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.97 100.88 OXIMIZER P-224 48712247_1 CDM 0272 RC inpatient 104 67.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.97 100.88 OXIMIZER P-224 48712247_1 CDM 0272 RC inpatient 104 67.6 ANTHEM HMO ANTHEM HMO 999999999 62.97 100.88 OXIMIZER P-224 48712247_1 CDM 0272 RC inpatient 104 67.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.97 100.88 OXIMIZER P-224 48712247_1 CDM 0272 RC inpatient 104 67.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.3 67.6 999999999 62.97 100.88 percent of total billed charges OXIMIZER P-224 48712247_1 CDM 0272 RC inpatient 104 67.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.97 100.88 PEG KIT PULL G TUBE 48712248_1 CDM 0272 RC inpatient 414 269.1 AETNA AETNA 327.06 79 999999999 250.68 401.58 percent of total billed charges PEG KIT PULL G TUBE 48712248_1 CDM 0272 RC inpatient 414 269.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 269.1 65 999999999 250.68 401.58 percent of total billed charges PEG KIT PULL G TUBE 48712248_1 CDM 0272 RC inpatient 414 269.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 401.58 97 999999999 250.68 401.58 percent of total billed charges PEG KIT PULL G TUBE 48712248_1 CDM 0272 RC inpatient 414 269.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 322.92 78 999999999 250.68 401.58 percent of total billed charges PEG KIT PULL G TUBE 48712248_1 CDM 0272 RC inpatient 414 269.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 285.66 69 999999999 250.68 401.58 percent of total billed charges PEG KIT PULL G TUBE 48712248_1 CDM 0272 RC inpatient 414 269.1 UMR - ALL PLANS UMR - ALL PLANS 289.8 70 999999999 250.68 401.58 percent of total billed charges PEG KIT PULL G TUBE 48712248_1 CDM 0272 RC inpatient 414 269.1 SIHO - ALL PLANS SIHO - ALL PLANS 372.6 90 999999999 250.68 401.58 percent of total billed charges PEG KIT PULL G TUBE 48712248_1 CDM 0272 RC inpatient 414 269.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 250.68 60.55 999999999 250.68 401.58 percent of total billed charges PEG KIT PULL G TUBE 48712248_1 CDM 0272 RC inpatient 414 269.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 250.68 401.58 PEG KIT PULL G TUBE 48712248_1 CDM 0272 RC inpatient 414 269.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 250.68 401.58 PEG KIT PULL G TUBE 48712248_1 CDM 0272 RC inpatient 414 269.1 ANTHEM HMO ANTHEM HMO 999999999 250.68 401.58 PEG KIT PULL G TUBE 48712248_1 CDM 0272 RC inpatient 414 269.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 250.68 401.58 PEG KIT PULL G TUBE 48712248_1 CDM 0272 RC inpatient 414 269.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 279.86 67.6 999999999 250.68 401.58 percent of total billed charges PEG KIT PULL G TUBE 48712248_1 CDM 0272 RC inpatient 414 269.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 250.68 401.58 "PACING KIT SWAN-GANZ THERMODILUTION PACEPORT CATHETER, VENTRICULAR PACKING, TORQUE 931F75" 48712249_1 CDM 0270 RC inpatient 762 495.3 AETNA AETNA 601.98 79 999999999 461.39 739.14 percent of total billed charges "PACING KIT SWAN-GANZ THERMODILUTION PACEPORT CATHETER, VENTRICULAR PACKING, TORQUE 931F75" 48712249_1 CDM 0270 RC inpatient 762 495.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 495.3 65 999999999 461.39 739.14 percent of total billed charges "PACING KIT SWAN-GANZ THERMODILUTION PACEPORT CATHETER, VENTRICULAR PACKING, TORQUE 931F75" 48712249_1 CDM 0270 RC inpatient 762 495.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 739.14 97 999999999 461.39 739.14 percent of total billed charges "PACING KIT SWAN-GANZ THERMODILUTION PACEPORT CATHETER, VENTRICULAR PACKING, TORQUE 931F75" 48712249_1 CDM 0270 RC inpatient 762 495.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 594.36 78 999999999 461.39 739.14 percent of total billed charges "PACING KIT SWAN-GANZ THERMODILUTION PACEPORT CATHETER, VENTRICULAR PACKING, TORQUE 931F75" 48712249_1 CDM 0270 RC inpatient 762 495.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 525.78 69 999999999 461.39 739.14 percent of total billed charges "PACING KIT SWAN-GANZ THERMODILUTION PACEPORT CATHETER, VENTRICULAR PACKING, TORQUE 931F75" 48712249_1 CDM 0270 RC inpatient 762 495.3 UMR - ALL PLANS UMR - ALL PLANS 533.4 70 999999999 461.39 739.14 percent of total billed charges "PACING KIT SWAN-GANZ THERMODILUTION PACEPORT CATHETER, VENTRICULAR PACKING, TORQUE 931F75" 48712249_1 CDM 0270 RC inpatient 762 495.3 SIHO - ALL PLANS SIHO - ALL PLANS 685.8 90 999999999 461.39 739.14 percent of total billed charges "PACING KIT SWAN-GANZ THERMODILUTION PACEPORT CATHETER, VENTRICULAR PACKING, TORQUE 931F75" 48712249_1 CDM 0270 RC inpatient 762 495.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 461.39 60.55 999999999 461.39 739.14 percent of total billed charges "PACING KIT SWAN-GANZ THERMODILUTION PACEPORT CATHETER, VENTRICULAR PACKING, TORQUE 931F75" 48712249_1 CDM 0270 RC inpatient 762 495.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 461.39 739.14 "PACING KIT SWAN-GANZ THERMODILUTION PACEPORT CATHETER, VENTRICULAR PACKING, TORQUE 931F75" 48712249_1 CDM 0270 RC inpatient 762 495.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 461.39 739.14 "PACING KIT SWAN-GANZ THERMODILUTION PACEPORT CATHETER, VENTRICULAR PACKING, TORQUE 931F75" 48712249_1 CDM 0270 RC inpatient 762 495.3 ANTHEM HMO ANTHEM HMO 999999999 461.39 739.14 "PACING KIT SWAN-GANZ THERMODILUTION PACEPORT CATHETER, VENTRICULAR PACKING, TORQUE 931F75" 48712249_1 CDM 0270 RC inpatient 762 495.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 461.39 739.14 "PACING KIT SWAN-GANZ THERMODILUTION PACEPORT CATHETER, VENTRICULAR PACKING, TORQUE 931F75" 48712249_1 CDM 0270 RC inpatient 762 495.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 515.11 67.6 999999999 461.39 739.14 percent of total billed charges "PACING KIT SWAN-GANZ THERMODILUTION PACEPORT CATHETER, VENTRICULAR PACKING, TORQUE 931F75" 48712249_1 CDM 0270 RC inpatient 762 495.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 461.39 739.14 SHEATH INTR/TRAY 8.5FR AK-09803-CDC 48712250_1 CDM 0272 RC inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges SHEATH INTR/TRAY 8.5FR AK-09803-CDC 48712250_1 CDM 0272 RC inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges SHEATH INTR/TRAY 8.5FR AK-09803-CDC 48712250_1 CDM 0272 RC inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges SHEATH INTR/TRAY 8.5FR AK-09803-CDC 48712250_1 CDM 0272 RC inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges SHEATH INTR/TRAY 8.5FR AK-09803-CDC 48712250_1 CDM 0272 RC inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges SHEATH INTR/TRAY 8.5FR AK-09803-CDC 48712250_1 CDM 0272 RC inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges SHEATH INTR/TRAY 8.5FR AK-09803-CDC 48712250_1 CDM 0272 RC inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges SHEATH INTR/TRAY 8.5FR AK-09803-CDC 48712250_1 CDM 0272 RC inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges SHEATH INTR/TRAY 8.5FR AK-09803-CDC 48712250_1 CDM 0272 RC inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 SHEATH INTR/TRAY 8.5FR AK-09803-CDC 48712250_1 CDM 0272 RC inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 SHEATH INTR/TRAY 8.5FR AK-09803-CDC 48712250_1 CDM 0272 RC inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 SHEATH INTR/TRAY 8.5FR AK-09803-CDC 48712250_1 CDM 0272 RC inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 SHEATH INTR/TRAY 8.5FR AK-09803-CDC 48712250_1 CDM 0272 RC inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges SHEATH INTR/TRAY 8.5FR AK-09803-CDC 48712250_1 CDM 0272 RC inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 PACK MAJOR ORTHO DYNJP8340 48712253_1 CDM 0272 RC inpatient 195 126.75 AETNA AETNA 154.05 79 999999999 118.07 189.15 percent of total billed charges PACK MAJOR ORTHO DYNJP8340 48712253_1 CDM 0272 RC inpatient 195 126.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 126.75 65 999999999 118.07 189.15 percent of total billed charges PACK MAJOR ORTHO DYNJP8340 48712253_1 CDM 0272 RC inpatient 195 126.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 189.15 97 999999999 118.07 189.15 percent of total billed charges PACK MAJOR ORTHO DYNJP8340 48712253_1 CDM 0272 RC inpatient 195 126.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 152.1 78 999999999 118.07 189.15 percent of total billed charges PACK MAJOR ORTHO DYNJP8340 48712253_1 CDM 0272 RC inpatient 195 126.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 134.55 69 999999999 118.07 189.15 percent of total billed charges PACK MAJOR ORTHO DYNJP8340 48712253_1 CDM 0272 RC inpatient 195 126.75 UMR - ALL PLANS UMR - ALL PLANS 136.5 70 999999999 118.07 189.15 percent of total billed charges PACK MAJOR ORTHO DYNJP8340 48712253_1 CDM 0272 RC inpatient 195 126.75 SIHO - ALL PLANS SIHO - ALL PLANS 175.5 90 999999999 118.07 189.15 percent of total billed charges PACK MAJOR ORTHO DYNJP8340 48712253_1 CDM 0272 RC inpatient 195 126.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 118.07 60.55 999999999 118.07 189.15 percent of total billed charges PACK MAJOR ORTHO DYNJP8340 48712253_1 CDM 0272 RC inpatient 195 126.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 118.07 189.15 PACK MAJOR ORTHO DYNJP8340 48712253_1 CDM 0272 RC inpatient 195 126.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 118.07 189.15 PACK MAJOR ORTHO DYNJP8340 48712253_1 CDM 0272 RC inpatient 195 126.75 ANTHEM HMO ANTHEM HMO 999999999 118.07 189.15 PACK MAJOR ORTHO DYNJP8340 48712253_1 CDM 0272 RC inpatient 195 126.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 118.07 189.15 PACK MAJOR ORTHO DYNJP8340 48712253_1 CDM 0272 RC inpatient 195 126.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 131.82 67.6 999999999 118.07 189.15 percent of total billed charges PACK MAJOR ORTHO DYNJP8340 48712253_1 CDM 0272 RC inpatient 195 126.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 118.07 189.15 ENDO PACK (CDS) DYNDA3058 48712254_1 CDM 0272 RC inpatient 108 70.2 AETNA AETNA 85.32 79 999999999 65.39 104.76 percent of total billed charges ENDO PACK (CDS) DYNDA3058 48712254_1 CDM 0272 RC inpatient 108 70.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.2 65 999999999 65.39 104.76 percent of total billed charges ENDO PACK (CDS) DYNDA3058 48712254_1 CDM 0272 RC inpatient 108 70.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 104.76 97 999999999 65.39 104.76 percent of total billed charges ENDO PACK (CDS) DYNDA3058 48712254_1 CDM 0272 RC inpatient 108 70.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 84.24 78 999999999 65.39 104.76 percent of total billed charges ENDO PACK (CDS) DYNDA3058 48712254_1 CDM 0272 RC inpatient 108 70.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 74.52 69 999999999 65.39 104.76 percent of total billed charges ENDO PACK (CDS) DYNDA3058 48712254_1 CDM 0272 RC inpatient 108 70.2 UMR - ALL PLANS UMR - ALL PLANS 75.6 70 999999999 65.39 104.76 percent of total billed charges ENDO PACK (CDS) DYNDA3058 48712254_1 CDM 0272 RC inpatient 108 70.2 SIHO - ALL PLANS SIHO - ALL PLANS 97.2 90 999999999 65.39 104.76 percent of total billed charges ENDO PACK (CDS) DYNDA3058 48712254_1 CDM 0272 RC inpatient 108 70.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 65.39 60.55 999999999 65.39 104.76 percent of total billed charges ENDO PACK (CDS) DYNDA3058 48712254_1 CDM 0272 RC inpatient 108 70.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 65.39 104.76 ENDO PACK (CDS) DYNDA3058 48712254_1 CDM 0272 RC inpatient 108 70.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 65.39 104.76 ENDO PACK (CDS) DYNDA3058 48712254_1 CDM 0272 RC inpatient 108 70.2 ANTHEM HMO ANTHEM HMO 999999999 65.39 104.76 ENDO PACK (CDS) DYNDA3058 48712254_1 CDM 0272 RC inpatient 108 70.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 65.39 104.76 ENDO PACK (CDS) DYNDA3058 48712254_1 CDM 0272 RC inpatient 108 70.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.01 67.6 999999999 65.39 104.76 percent of total billed charges ENDO PACK (CDS) DYNDA3058 48712254_1 CDM 0272 RC inpatient 108 70.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 65.39 104.76 OB DELIVERY PACK (CDS) DYNJ84730 48712255_1 CDM 0272 RC inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges OB DELIVERY PACK (CDS) DYNJ84730 48712255_1 CDM 0272 RC inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges OB DELIVERY PACK (CDS) DYNJ84730 48712255_1 CDM 0272 RC inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges OB DELIVERY PACK (CDS) DYNJ84730 48712255_1 CDM 0272 RC inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges OB DELIVERY PACK (CDS) DYNJ84730 48712255_1 CDM 0272 RC inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges OB DELIVERY PACK (CDS) DYNJ84730 48712255_1 CDM 0272 RC inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges OB DELIVERY PACK (CDS) DYNJ84730 48712255_1 CDM 0272 RC inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges OB DELIVERY PACK (CDS) DYNJ84730 48712255_1 CDM 0272 RC inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges OB DELIVERY PACK (CDS) DYNJ84730 48712255_1 CDM 0272 RC inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 OB DELIVERY PACK (CDS) DYNJ84730 48712255_1 CDM 0272 RC inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 OB DELIVERY PACK (CDS) DYNJ84730 48712255_1 CDM 0272 RC inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 OB DELIVERY PACK (CDS) DYNJ84730 48712255_1 CDM 0272 RC inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 OB DELIVERY PACK (CDS) DYNJ84730 48712255_1 CDM 0272 RC inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges OB DELIVERY PACK (CDS) DYNJ84730 48712255_1 CDM 0272 RC inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 PACK ORTHO/MINOR #DYNJP8060 48712256_1 CDM 0272 RC inpatient 227 147.55 AETNA AETNA 179.33 79 999999999 137.45 220.19 percent of total billed charges PACK ORTHO/MINOR #DYNJP8060 48712256_1 CDM 0272 RC inpatient 227 147.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 147.55 65 999999999 137.45 220.19 percent of total billed charges PACK ORTHO/MINOR #DYNJP8060 48712256_1 CDM 0272 RC inpatient 227 147.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 220.19 97 999999999 137.45 220.19 percent of total billed charges PACK ORTHO/MINOR #DYNJP8060 48712256_1 CDM 0272 RC inpatient 227 147.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 177.06 78 999999999 137.45 220.19 percent of total billed charges PACK ORTHO/MINOR #DYNJP8060 48712256_1 CDM 0272 RC inpatient 227 147.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 156.63 69 999999999 137.45 220.19 percent of total billed charges PACK ORTHO/MINOR #DYNJP8060 48712256_1 CDM 0272 RC inpatient 227 147.55 UMR - ALL PLANS UMR - ALL PLANS 158.9 70 999999999 137.45 220.19 percent of total billed charges PACK ORTHO/MINOR #DYNJP8060 48712256_1 CDM 0272 RC inpatient 227 147.55 SIHO - ALL PLANS SIHO - ALL PLANS 204.3 90 999999999 137.45 220.19 percent of total billed charges PACK ORTHO/MINOR #DYNJP8060 48712256_1 CDM 0272 RC inpatient 227 147.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 137.45 60.55 999999999 137.45 220.19 percent of total billed charges PACK ORTHO/MINOR #DYNJP8060 48712256_1 CDM 0272 RC inpatient 227 147.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 137.45 220.19 PACK ORTHO/MINOR #DYNJP8060 48712256_1 CDM 0272 RC inpatient 227 147.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 137.45 220.19 PACK ORTHO/MINOR #DYNJP8060 48712256_1 CDM 0272 RC inpatient 227 147.55 ANTHEM HMO ANTHEM HMO 999999999 137.45 220.19 PACK ORTHO/MINOR #DYNJP8060 48712256_1 CDM 0272 RC inpatient 227 147.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 137.45 220.19 PACK ORTHO/MINOR #DYNJP8060 48712256_1 CDM 0272 RC inpatient 227 147.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 153.45 67.6 999999999 137.45 220.19 percent of total billed charges PACK ORTHO/MINOR #DYNJP8060 48712256_1 CDM 0272 RC inpatient 227 147.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 137.45 220.19 PECU GUIDE 48712258_1 CDM 0270 RC inpatient 94 61.1 AETNA AETNA 74.26 79 999999999 56.92 91.18 percent of total billed charges PECU GUIDE 48712258_1 CDM 0270 RC inpatient 94 61.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.1 65 999999999 56.92 91.18 percent of total billed charges PECU GUIDE 48712258_1 CDM 0270 RC inpatient 94 61.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.18 97 999999999 56.92 91.18 percent of total billed charges PECU GUIDE 48712258_1 CDM 0270 RC inpatient 94 61.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.32 78 999999999 56.92 91.18 percent of total billed charges PECU GUIDE 48712258_1 CDM 0270 RC inpatient 94 61.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.86 69 999999999 56.92 91.18 percent of total billed charges PECU GUIDE 48712258_1 CDM 0270 RC inpatient 94 61.1 UMR - ALL PLANS UMR - ALL PLANS 65.8 70 999999999 56.92 91.18 percent of total billed charges PECU GUIDE 48712258_1 CDM 0270 RC inpatient 94 61.1 SIHO - ALL PLANS SIHO - ALL PLANS 84.6 90 999999999 56.92 91.18 percent of total billed charges PECU GUIDE 48712258_1 CDM 0270 RC inpatient 94 61.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.92 60.55 999999999 56.92 91.18 percent of total billed charges PECU GUIDE 48712258_1 CDM 0270 RC inpatient 94 61.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.92 91.18 PECU GUIDE 48712258_1 CDM 0270 RC inpatient 94 61.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.92 91.18 PECU GUIDE 48712258_1 CDM 0270 RC inpatient 94 61.1 ANTHEM HMO ANTHEM HMO 999999999 56.92 91.18 PECU GUIDE 48712258_1 CDM 0270 RC inpatient 94 61.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.92 91.18 PECU GUIDE 48712258_1 CDM 0270 RC inpatient 94 61.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.54 67.6 999999999 56.92 91.18 percent of total billed charges PECU GUIDE 48712258_1 CDM 0270 RC inpatient 94 61.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.92 91.18 IOBAN ISOLATION DRAPE #6619 48712259_1 CDM 0271 RC inpatient 138 89.7 AETNA AETNA 109.02 79 999999999 83.56 133.86 percent of total billed charges IOBAN ISOLATION DRAPE #6619 48712259_1 CDM 0271 RC inpatient 138 89.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.7 65 999999999 83.56 133.86 percent of total billed charges IOBAN ISOLATION DRAPE #6619 48712259_1 CDM 0271 RC inpatient 138 89.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 133.86 97 999999999 83.56 133.86 percent of total billed charges IOBAN ISOLATION DRAPE #6619 48712259_1 CDM 0271 RC inpatient 138 89.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 107.64 78 999999999 83.56 133.86 percent of total billed charges IOBAN ISOLATION DRAPE #6619 48712259_1 CDM 0271 RC inpatient 138 89.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.22 69 999999999 83.56 133.86 percent of total billed charges IOBAN ISOLATION DRAPE #6619 48712259_1 CDM 0271 RC inpatient 138 89.7 UMR - ALL PLANS UMR - ALL PLANS 96.6 70 999999999 83.56 133.86 percent of total billed charges IOBAN ISOLATION DRAPE #6619 48712259_1 CDM 0271 RC inpatient 138 89.7 SIHO - ALL PLANS SIHO - ALL PLANS 124.2 90 999999999 83.56 133.86 percent of total billed charges IOBAN ISOLATION DRAPE #6619 48712259_1 CDM 0271 RC inpatient 138 89.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 83.56 60.55 999999999 83.56 133.86 percent of total billed charges IOBAN ISOLATION DRAPE #6619 48712259_1 CDM 0271 RC inpatient 138 89.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 83.56 133.86 IOBAN ISOLATION DRAPE #6619 48712259_1 CDM 0271 RC inpatient 138 89.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 83.56 133.86 IOBAN ISOLATION DRAPE #6619 48712259_1 CDM 0271 RC inpatient 138 89.7 ANTHEM HMO ANTHEM HMO 999999999 83.56 133.86 IOBAN ISOLATION DRAPE #6619 48712259_1 CDM 0271 RC inpatient 138 89.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 83.56 133.86 IOBAN ISOLATION DRAPE #6619 48712259_1 CDM 0271 RC inpatient 138 89.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.29 67.6 999999999 83.56 133.86 percent of total billed charges IOBAN ISOLATION DRAPE #6619 48712259_1 CDM 0271 RC inpatient 138 89.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 83.56 133.86 PAIN BUSTER PUMP PM012 48712263_1 CDM 0272 RC inpatient 684 444.6 AETNA AETNA 540.36 79 999999999 414.16 663.48 percent of total billed charges PAIN BUSTER PUMP PM012 48712263_1 CDM 0272 RC inpatient 684 444.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 444.6 65 999999999 414.16 663.48 percent of total billed charges PAIN BUSTER PUMP PM012 48712263_1 CDM 0272 RC inpatient 684 444.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 663.48 97 999999999 414.16 663.48 percent of total billed charges PAIN BUSTER PUMP PM012 48712263_1 CDM 0272 RC inpatient 684 444.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 533.52 78 999999999 414.16 663.48 percent of total billed charges PAIN BUSTER PUMP PM012 48712263_1 CDM 0272 RC inpatient 684 444.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 471.96 69 999999999 414.16 663.48 percent of total billed charges PAIN BUSTER PUMP PM012 48712263_1 CDM 0272 RC inpatient 684 444.6 UMR - ALL PLANS UMR - ALL PLANS 478.8 70 999999999 414.16 663.48 percent of total billed charges PAIN BUSTER PUMP PM012 48712263_1 CDM 0272 RC inpatient 684 444.6 SIHO - ALL PLANS SIHO - ALL PLANS 615.6 90 999999999 414.16 663.48 percent of total billed charges PAIN BUSTER PUMP PM012 48712263_1 CDM 0272 RC inpatient 684 444.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 414.16 60.55 999999999 414.16 663.48 percent of total billed charges PAIN BUSTER PUMP PM012 48712263_1 CDM 0272 RC inpatient 684 444.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 414.16 663.48 PAIN BUSTER PUMP PM012 48712263_1 CDM 0272 RC inpatient 684 444.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 414.16 663.48 PAIN BUSTER PUMP PM012 48712263_1 CDM 0272 RC inpatient 684 444.6 ANTHEM HMO ANTHEM HMO 999999999 414.16 663.48 PAIN BUSTER PUMP PM012 48712263_1 CDM 0272 RC inpatient 684 444.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 414.16 663.48 PAIN BUSTER PUMP PM012 48712263_1 CDM 0272 RC inpatient 684 444.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 462.38 67.6 999999999 414.16 663.48 percent of total billed charges PAIN BUSTER PUMP PM012 48712263_1 CDM 0272 RC inpatient 684 444.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 414.16 663.48 "INFUSION PUMP, NON-PROGRAMMABLE, TEMPORARY (IMPLANTABLE)" 48712264_1 CDM 0272 RC C2626 HCPCS inpatient 1057 687.05 AETNA AETNA 835.03 79 999999999 640.01 1025.29 percent of total billed charges "INFUSION PUMP, NON-PROGRAMMABLE, TEMPORARY (IMPLANTABLE)" 48712264_1 CDM 0272 RC C2626 HCPCS inpatient 1057 687.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 687.05 65 999999999 640.01 1025.29 percent of total billed charges "INFUSION PUMP, NON-PROGRAMMABLE, TEMPORARY (IMPLANTABLE)" 48712264_1 CDM 0272 RC C2626 HCPCS inpatient 1057 687.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1025.29 97 999999999 640.01 1025.29 percent of total billed charges "INFUSION PUMP, NON-PROGRAMMABLE, TEMPORARY (IMPLANTABLE)" 48712264_1 CDM 0272 RC C2626 HCPCS inpatient 1057 687.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 824.46 78 999999999 640.01 1025.29 percent of total billed charges "INFUSION PUMP, NON-PROGRAMMABLE, TEMPORARY (IMPLANTABLE)" 48712264_1 CDM 0272 RC C2626 HCPCS inpatient 1057 687.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 729.33 69 999999999 640.01 1025.29 percent of total billed charges "INFUSION PUMP, NON-PROGRAMMABLE, TEMPORARY (IMPLANTABLE)" 48712264_1 CDM 0272 RC C2626 HCPCS inpatient 1057 687.05 UMR - ALL PLANS UMR - ALL PLANS 739.9 70 999999999 640.01 1025.29 percent of total billed charges "INFUSION PUMP, NON-PROGRAMMABLE, TEMPORARY (IMPLANTABLE)" 48712264_1 CDM 0272 RC C2626 HCPCS inpatient 1057 687.05 SIHO - ALL PLANS SIHO - ALL PLANS 951.3 90 999999999 640.01 1025.29 percent of total billed charges "INFUSION PUMP, NON-PROGRAMMABLE, TEMPORARY (IMPLANTABLE)" 48712264_1 CDM 0272 RC C2626 HCPCS inpatient 1057 687.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 640.01 60.55 999999999 640.01 1025.29 percent of total billed charges "INFUSION PUMP, NON-PROGRAMMABLE, TEMPORARY (IMPLANTABLE)" 48712264_1 CDM 0272 RC C2626 HCPCS inpatient 1057 687.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 640.01 1025.29 "INFUSION PUMP, NON-PROGRAMMABLE, TEMPORARY (IMPLANTABLE)" 48712264_1 CDM 0272 RC C2626 HCPCS inpatient 1057 687.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 640.01 1025.29 "INFUSION PUMP, NON-PROGRAMMABLE, TEMPORARY (IMPLANTABLE)" 48712264_1 CDM 0272 RC C2626 HCPCS inpatient 1057 687.05 ANTHEM HMO ANTHEM HMO 999999999 640.01 1025.29 "INFUSION PUMP, NON-PROGRAMMABLE, TEMPORARY (IMPLANTABLE)" 48712264_1 CDM 0272 RC C2626 HCPCS inpatient 1057 687.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 640.01 1025.29 "INFUSION PUMP, NON-PROGRAMMABLE, TEMPORARY (IMPLANTABLE)" 48712264_1 CDM 0272 RC C2626 HCPCS inpatient 1057 687.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 714.53 67.6 999999999 640.01 1025.29 percent of total billed charges "INFUSION PUMP, NON-PROGRAMMABLE, TEMPORARY (IMPLANTABLE)" 48712264_1 CDM 0272 RC C2626 HCPCS inpatient 1057 687.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 640.01 1025.29 CATH MIDLINE POWERGLIDE 18 X 8 48712269_1 CDM 0272 RC inpatient 740 481 AETNA AETNA 584.6 79 999999999 448.07 717.8 percent of total billed charges CATH MIDLINE POWERGLIDE 18 X 8 48712269_1 CDM 0272 RC inpatient 740 481 SELF PAY DISCOUNT SELF PAY DISCOUNT 481 65 999999999 448.07 717.8 percent of total billed charges CATH MIDLINE POWERGLIDE 18 X 8 48712269_1 CDM 0272 RC inpatient 740 481 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 717.8 97 999999999 448.07 717.8 percent of total billed charges CATH MIDLINE POWERGLIDE 18 X 8 48712269_1 CDM 0272 RC inpatient 740 481 HUMANA - ALL PLANS HUMANA - ALL PLANS 577.2 78 999999999 448.07 717.8 percent of total billed charges CATH MIDLINE POWERGLIDE 18 X 8 48712269_1 CDM 0272 RC inpatient 740 481 ENCORE - ALL PLANS ENCORE - ALL PLANS 510.6 69 999999999 448.07 717.8 percent of total billed charges CATH MIDLINE POWERGLIDE 18 X 8 48712269_1 CDM 0272 RC inpatient 740 481 UMR - ALL PLANS UMR - ALL PLANS 518 70 999999999 448.07 717.8 percent of total billed charges CATH MIDLINE POWERGLIDE 18 X 8 48712269_1 CDM 0272 RC inpatient 740 481 SIHO - ALL PLANS SIHO - ALL PLANS 666 90 999999999 448.07 717.8 percent of total billed charges CATH MIDLINE POWERGLIDE 18 X 8 48712269_1 CDM 0272 RC inpatient 740 481 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 448.07 60.55 999999999 448.07 717.8 percent of total billed charges CATH MIDLINE POWERGLIDE 18 X 8 48712269_1 CDM 0272 RC inpatient 740 481 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 448.07 717.8 CATH MIDLINE POWERGLIDE 18 X 8 48712269_1 CDM 0272 RC inpatient 740 481 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 448.07 717.8 CATH MIDLINE POWERGLIDE 18 X 8 48712269_1 CDM 0272 RC inpatient 740 481 ANTHEM HMO ANTHEM HMO 999999999 448.07 717.8 CATH MIDLINE POWERGLIDE 18 X 8 48712269_1 CDM 0272 RC inpatient 740 481 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 448.07 717.8 CATH MIDLINE POWERGLIDE 18 X 8 48712269_1 CDM 0272 RC inpatient 740 481 CIGNA - ALL PLANS CIGNA - ALL PLANS 500.24 67.6 999999999 448.07 717.8 percent of total billed charges CATH MIDLINE POWERGLIDE 18 X 8 48712269_1 CDM 0272 RC inpatient 740 481 UHC - ALL PLANS UHC - ALL PLANS 999999999 448.07 717.8 LG WOUND PROTECTOR - ALEXIS O G6313 48712270_1 CDM 0272 RC inpatient 394 256.1 AETNA AETNA 311.26 79 999999999 238.57 382.18 percent of total billed charges LG WOUND PROTECTOR - ALEXIS O G6313 48712270_1 CDM 0272 RC inpatient 394 256.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 256.1 65 999999999 238.57 382.18 percent of total billed charges LG WOUND PROTECTOR - ALEXIS O G6313 48712270_1 CDM 0272 RC inpatient 394 256.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 382.18 97 999999999 238.57 382.18 percent of total billed charges LG WOUND PROTECTOR - ALEXIS O G6313 48712270_1 CDM 0272 RC inpatient 394 256.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 307.32 78 999999999 238.57 382.18 percent of total billed charges LG WOUND PROTECTOR - ALEXIS O G6313 48712270_1 CDM 0272 RC inpatient 394 256.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 271.86 69 999999999 238.57 382.18 percent of total billed charges LG WOUND PROTECTOR - ALEXIS O G6313 48712270_1 CDM 0272 RC inpatient 394 256.1 UMR - ALL PLANS UMR - ALL PLANS 275.8 70 999999999 238.57 382.18 percent of total billed charges LG WOUND PROTECTOR - ALEXIS O G6313 48712270_1 CDM 0272 RC inpatient 394 256.1 SIHO - ALL PLANS SIHO - ALL PLANS 354.6 90 999999999 238.57 382.18 percent of total billed charges LG WOUND PROTECTOR - ALEXIS O G6313 48712270_1 CDM 0272 RC inpatient 394 256.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 238.57 60.55 999999999 238.57 382.18 percent of total billed charges LG WOUND PROTECTOR - ALEXIS O G6313 48712270_1 CDM 0272 RC inpatient 394 256.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 238.57 382.18 LG WOUND PROTECTOR - ALEXIS O G6313 48712270_1 CDM 0272 RC inpatient 394 256.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 238.57 382.18 LG WOUND PROTECTOR - ALEXIS O G6313 48712270_1 CDM 0272 RC inpatient 394 256.1 ANTHEM HMO ANTHEM HMO 999999999 238.57 382.18 LG WOUND PROTECTOR - ALEXIS O G6313 48712270_1 CDM 0272 RC inpatient 394 256.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 238.57 382.18 LG WOUND PROTECTOR - ALEXIS O G6313 48712270_1 CDM 0272 RC inpatient 394 256.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 266.34 67.6 999999999 238.57 382.18 percent of total billed charges LG WOUND PROTECTOR - ALEXIS O G6313 48712270_1 CDM 0272 RC inpatient 394 256.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 238.57 382.18 ORTHO PACK LF DYNJ16098F 48712271_1 CDM 0272 RC inpatient 188 122.2 AETNA AETNA 148.52 79 999999999 113.83 182.36 percent of total billed charges ORTHO PACK LF DYNJ16098F 48712271_1 CDM 0272 RC inpatient 188 122.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.2 65 999999999 113.83 182.36 percent of total billed charges ORTHO PACK LF DYNJ16098F 48712271_1 CDM 0272 RC inpatient 188 122.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 182.36 97 999999999 113.83 182.36 percent of total billed charges ORTHO PACK LF DYNJ16098F 48712271_1 CDM 0272 RC inpatient 188 122.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 146.64 78 999999999 113.83 182.36 percent of total billed charges ORTHO PACK LF DYNJ16098F 48712271_1 CDM 0272 RC inpatient 188 122.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.72 69 999999999 113.83 182.36 percent of total billed charges ORTHO PACK LF DYNJ16098F 48712271_1 CDM 0272 RC inpatient 188 122.2 UMR - ALL PLANS UMR - ALL PLANS 131.6 70 999999999 113.83 182.36 percent of total billed charges ORTHO PACK LF DYNJ16098F 48712271_1 CDM 0272 RC inpatient 188 122.2 SIHO - ALL PLANS SIHO - ALL PLANS 169.2 90 999999999 113.83 182.36 percent of total billed charges ORTHO PACK LF DYNJ16098F 48712271_1 CDM 0272 RC inpatient 188 122.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.83 60.55 999999999 113.83 182.36 percent of total billed charges ORTHO PACK LF DYNJ16098F 48712271_1 CDM 0272 RC inpatient 188 122.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.83 182.36 ORTHO PACK LF DYNJ16098F 48712271_1 CDM 0272 RC inpatient 188 122.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.83 182.36 ORTHO PACK LF DYNJ16098F 48712271_1 CDM 0272 RC inpatient 188 122.2 ANTHEM HMO ANTHEM HMO 999999999 113.83 182.36 ORTHO PACK LF DYNJ16098F 48712271_1 CDM 0272 RC inpatient 188 122.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.83 182.36 ORTHO PACK LF DYNJ16098F 48712271_1 CDM 0272 RC inpatient 188 122.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.09 67.6 999999999 113.83 182.36 percent of total billed charges ORTHO PACK LF DYNJ16098F 48712271_1 CDM 0272 RC inpatient 188 122.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.83 182.36 LAPAROSCOPY GENERAL PACK (CDS) DYNJ909605 48712272_1 CDM 0272 RC inpatient 1695 1101.75 AETNA AETNA 1339.05 79 999999999 1026.32 1644.15 percent of total billed charges LAPAROSCOPY GENERAL PACK (CDS) DYNJ909605 48712272_1 CDM 0272 RC inpatient 1695 1101.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1101.75 65 999999999 1026.32 1644.15 percent of total billed charges LAPAROSCOPY GENERAL PACK (CDS) DYNJ909605 48712272_1 CDM 0272 RC inpatient 1695 1101.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1644.15 97 999999999 1026.32 1644.15 percent of total billed charges LAPAROSCOPY GENERAL PACK (CDS) DYNJ909605 48712272_1 CDM 0272 RC inpatient 1695 1101.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1322.1 78 999999999 1026.32 1644.15 percent of total billed charges LAPAROSCOPY GENERAL PACK (CDS) DYNJ909605 48712272_1 CDM 0272 RC inpatient 1695 1101.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1169.55 69 999999999 1026.32 1644.15 percent of total billed charges LAPAROSCOPY GENERAL PACK (CDS) DYNJ909605 48712272_1 CDM 0272 RC inpatient 1695 1101.75 UMR - ALL PLANS UMR - ALL PLANS 1186.5 70 999999999 1026.32 1644.15 percent of total billed charges LAPAROSCOPY GENERAL PACK (CDS) DYNJ909605 48712272_1 CDM 0272 RC inpatient 1695 1101.75 SIHO - ALL PLANS SIHO - ALL PLANS 1525.5 90 999999999 1026.32 1644.15 percent of total billed charges LAPAROSCOPY GENERAL PACK (CDS) DYNJ909605 48712272_1 CDM 0272 RC inpatient 1695 1101.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1026.32 60.55 999999999 1026.32 1644.15 percent of total billed charges LAPAROSCOPY GENERAL PACK (CDS) DYNJ909605 48712272_1 CDM 0272 RC inpatient 1695 1101.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1026.32 1644.15 LAPAROSCOPY GENERAL PACK (CDS) DYNJ909605 48712272_1 CDM 0272 RC inpatient 1695 1101.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1026.32 1644.15 LAPAROSCOPY GENERAL PACK (CDS) DYNJ909605 48712272_1 CDM 0272 RC inpatient 1695 1101.75 ANTHEM HMO ANTHEM HMO 999999999 1026.32 1644.15 LAPAROSCOPY GENERAL PACK (CDS) DYNJ909605 48712272_1 CDM 0272 RC inpatient 1695 1101.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1026.32 1644.15 LAPAROSCOPY GENERAL PACK (CDS) DYNJ909605 48712272_1 CDM 0272 RC inpatient 1695 1101.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1145.82 67.6 999999999 1026.32 1644.15 percent of total billed charges LAPAROSCOPY GENERAL PACK (CDS) DYNJ909605 48712272_1 CDM 0272 RC inpatient 1695 1101.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1026.32 1644.15 LAPAROTOMY MAJOR PACK (CDS) DYNJ909606 48712273_1 CDM 0272 RC inpatient 679 441.35 AETNA AETNA 536.41 79 999999999 411.13 658.63 percent of total billed charges LAPAROTOMY MAJOR PACK (CDS) DYNJ909606 48712273_1 CDM 0272 RC inpatient 679 441.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 441.35 65 999999999 411.13 658.63 percent of total billed charges LAPAROTOMY MAJOR PACK (CDS) DYNJ909606 48712273_1 CDM 0272 RC inpatient 679 441.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 658.63 97 999999999 411.13 658.63 percent of total billed charges LAPAROTOMY MAJOR PACK (CDS) DYNJ909606 48712273_1 CDM 0272 RC inpatient 679 441.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 529.62 78 999999999 411.13 658.63 percent of total billed charges LAPAROTOMY MAJOR PACK (CDS) DYNJ909606 48712273_1 CDM 0272 RC inpatient 679 441.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 468.51 69 999999999 411.13 658.63 percent of total billed charges LAPAROTOMY MAJOR PACK (CDS) DYNJ909606 48712273_1 CDM 0272 RC inpatient 679 441.35 UMR - ALL PLANS UMR - ALL PLANS 475.3 70 999999999 411.13 658.63 percent of total billed charges LAPAROTOMY MAJOR PACK (CDS) DYNJ909606 48712273_1 CDM 0272 RC inpatient 679 441.35 SIHO - ALL PLANS SIHO - ALL PLANS 611.1 90 999999999 411.13 658.63 percent of total billed charges LAPAROTOMY MAJOR PACK (CDS) DYNJ909606 48712273_1 CDM 0272 RC inpatient 679 441.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 411.13 60.55 999999999 411.13 658.63 percent of total billed charges LAPAROTOMY MAJOR PACK (CDS) DYNJ909606 48712273_1 CDM 0272 RC inpatient 679 441.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 411.13 658.63 LAPAROTOMY MAJOR PACK (CDS) DYNJ909606 48712273_1 CDM 0272 RC inpatient 679 441.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 411.13 658.63 LAPAROTOMY MAJOR PACK (CDS) DYNJ909606 48712273_1 CDM 0272 RC inpatient 679 441.35 ANTHEM HMO ANTHEM HMO 999999999 411.13 658.63 LAPAROTOMY MAJOR PACK (CDS) DYNJ909606 48712273_1 CDM 0272 RC inpatient 679 441.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 411.13 658.63 LAPAROTOMY MAJOR PACK (CDS) DYNJ909606 48712273_1 CDM 0272 RC inpatient 679 441.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 459 67.6 999999999 411.13 658.63 percent of total billed charges LAPAROTOMY MAJOR PACK (CDS) DYNJ909606 48712273_1 CDM 0272 RC inpatient 679 441.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 411.13 658.63 LITHOTOMY MINOR PACK (CDS) DYNJ909607 48712274_1 CDM 0272 RC inpatient 355 230.75 AETNA AETNA 280.45 79 999999999 214.95 344.35 percent of total billed charges LITHOTOMY MINOR PACK (CDS) DYNJ909607 48712274_1 CDM 0272 RC inpatient 355 230.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 230.75 65 999999999 214.95 344.35 percent of total billed charges LITHOTOMY MINOR PACK (CDS) DYNJ909607 48712274_1 CDM 0272 RC inpatient 355 230.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 344.35 97 999999999 214.95 344.35 percent of total billed charges LITHOTOMY MINOR PACK (CDS) DYNJ909607 48712274_1 CDM 0272 RC inpatient 355 230.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 276.9 78 999999999 214.95 344.35 percent of total billed charges LITHOTOMY MINOR PACK (CDS) DYNJ909607 48712274_1 CDM 0272 RC inpatient 355 230.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 244.95 69 999999999 214.95 344.35 percent of total billed charges LITHOTOMY MINOR PACK (CDS) DYNJ909607 48712274_1 CDM 0272 RC inpatient 355 230.75 UMR - ALL PLANS UMR - ALL PLANS 248.5 70 999999999 214.95 344.35 percent of total billed charges LITHOTOMY MINOR PACK (CDS) DYNJ909607 48712274_1 CDM 0272 RC inpatient 355 230.75 SIHO - ALL PLANS SIHO - ALL PLANS 319.5 90 999999999 214.95 344.35 percent of total billed charges LITHOTOMY MINOR PACK (CDS) DYNJ909607 48712274_1 CDM 0272 RC inpatient 355 230.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 214.95 60.55 999999999 214.95 344.35 percent of total billed charges LITHOTOMY MINOR PACK (CDS) DYNJ909607 48712274_1 CDM 0272 RC inpatient 355 230.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 214.95 344.35 LITHOTOMY MINOR PACK (CDS) DYNJ909607 48712274_1 CDM 0272 RC inpatient 355 230.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 214.95 344.35 LITHOTOMY MINOR PACK (CDS) DYNJ909607 48712274_1 CDM 0272 RC inpatient 355 230.75 ANTHEM HMO ANTHEM HMO 999999999 214.95 344.35 LITHOTOMY MINOR PACK (CDS) DYNJ909607 48712274_1 CDM 0272 RC inpatient 355 230.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 214.95 344.35 LITHOTOMY MINOR PACK (CDS) DYNJ909607 48712274_1 CDM 0272 RC inpatient 355 230.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 239.98 67.6 999999999 214.95 344.35 percent of total billed charges LITHOTOMY MINOR PACK (CDS) DYNJ909607 48712274_1 CDM 0272 RC inpatient 355 230.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 214.95 344.35 MINOR PROCEDURE PACK (CDS) 48712275_1 CDM 0272 RC inpatient 456 296.4 AETNA AETNA 360.24 79 999999999 276.11 442.32 percent of total billed charges MINOR PROCEDURE PACK (CDS) 48712275_1 CDM 0272 RC inpatient 456 296.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 296.4 65 999999999 276.11 442.32 percent of total billed charges MINOR PROCEDURE PACK (CDS) 48712275_1 CDM 0272 RC inpatient 456 296.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 442.32 97 999999999 276.11 442.32 percent of total billed charges MINOR PROCEDURE PACK (CDS) 48712275_1 CDM 0272 RC inpatient 456 296.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 355.68 78 999999999 276.11 442.32 percent of total billed charges MINOR PROCEDURE PACK (CDS) 48712275_1 CDM 0272 RC inpatient 456 296.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 314.64 69 999999999 276.11 442.32 percent of total billed charges MINOR PROCEDURE PACK (CDS) 48712275_1 CDM 0272 RC inpatient 456 296.4 UMR - ALL PLANS UMR - ALL PLANS 319.2 70 999999999 276.11 442.32 percent of total billed charges MINOR PROCEDURE PACK (CDS) 48712275_1 CDM 0272 RC inpatient 456 296.4 SIHO - ALL PLANS SIHO - ALL PLANS 410.4 90 999999999 276.11 442.32 percent of total billed charges MINOR PROCEDURE PACK (CDS) 48712275_1 CDM 0272 RC inpatient 456 296.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 276.11 60.55 999999999 276.11 442.32 percent of total billed charges MINOR PROCEDURE PACK (CDS) 48712275_1 CDM 0272 RC inpatient 456 296.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 276.11 442.32 MINOR PROCEDURE PACK (CDS) 48712275_1 CDM 0272 RC inpatient 456 296.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 276.11 442.32 MINOR PROCEDURE PACK (CDS) 48712275_1 CDM 0272 RC inpatient 456 296.4 ANTHEM HMO ANTHEM HMO 999999999 276.11 442.32 MINOR PROCEDURE PACK (CDS) 48712275_1 CDM 0272 RC inpatient 456 296.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 276.11 442.32 MINOR PROCEDURE PACK (CDS) 48712275_1 CDM 0272 RC inpatient 456 296.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 308.26 67.6 999999999 276.11 442.32 percent of total billed charges MINOR PROCEDURE PACK (CDS) 48712275_1 CDM 0272 RC inpatient 456 296.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 276.11 442.32 C-SECTION PACK (CDS) DYNJ909609 48712276_1 CDM 0272 RC inpatient 680 442 AETNA AETNA 537.2 79 999999999 411.74 659.6 percent of total billed charges C-SECTION PACK (CDS) DYNJ909609 48712276_1 CDM 0272 RC inpatient 680 442 SELF PAY DISCOUNT SELF PAY DISCOUNT 442 65 999999999 411.74 659.6 percent of total billed charges C-SECTION PACK (CDS) DYNJ909609 48712276_1 CDM 0272 RC inpatient 680 442 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 659.6 97 999999999 411.74 659.6 percent of total billed charges C-SECTION PACK (CDS) DYNJ909609 48712276_1 CDM 0272 RC inpatient 680 442 HUMANA - ALL PLANS HUMANA - ALL PLANS 530.4 78 999999999 411.74 659.6 percent of total billed charges C-SECTION PACK (CDS) DYNJ909609 48712276_1 CDM 0272 RC inpatient 680 442 ENCORE - ALL PLANS ENCORE - ALL PLANS 469.2 69 999999999 411.74 659.6 percent of total billed charges C-SECTION PACK (CDS) DYNJ909609 48712276_1 CDM 0272 RC inpatient 680 442 UMR - ALL PLANS UMR - ALL PLANS 476 70 999999999 411.74 659.6 percent of total billed charges C-SECTION PACK (CDS) DYNJ909609 48712276_1 CDM 0272 RC inpatient 680 442 SIHO - ALL PLANS SIHO - ALL PLANS 612 90 999999999 411.74 659.6 percent of total billed charges C-SECTION PACK (CDS) DYNJ909609 48712276_1 CDM 0272 RC inpatient 680 442 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 411.74 60.55 999999999 411.74 659.6 percent of total billed charges C-SECTION PACK (CDS) DYNJ909609 48712276_1 CDM 0272 RC inpatient 680 442 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 411.74 659.6 C-SECTION PACK (CDS) DYNJ909609 48712276_1 CDM 0272 RC inpatient 680 442 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 411.74 659.6 C-SECTION PACK (CDS) DYNJ909609 48712276_1 CDM 0272 RC inpatient 680 442 ANTHEM HMO ANTHEM HMO 999999999 411.74 659.6 C-SECTION PACK (CDS) DYNJ909609 48712276_1 CDM 0272 RC inpatient 680 442 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 411.74 659.6 C-SECTION PACK (CDS) DYNJ909609 48712276_1 CDM 0272 RC inpatient 680 442 CIGNA - ALL PLANS CIGNA - ALL PLANS 459.68 67.6 999999999 411.74 659.6 percent of total billed charges C-SECTION PACK (CDS) DYNJ909609 48712276_1 CDM 0272 RC inpatient 680 442 UHC - ALL PLANS UHC - ALL PLANS 999999999 411.74 659.6 ARTHROSCOPY PACK (CDS) DYNJ909610A 48712277_1 CDM 0272 RC inpatient 1504 977.6 AETNA AETNA 1188.16 79 999999999 910.67 1458.88 percent of total billed charges ARTHROSCOPY PACK (CDS) DYNJ909610A 48712277_1 CDM 0272 RC inpatient 1504 977.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 977.6 65 999999999 910.67 1458.88 percent of total billed charges ARTHROSCOPY PACK (CDS) DYNJ909610A 48712277_1 CDM 0272 RC inpatient 1504 977.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1458.88 97 999999999 910.67 1458.88 percent of total billed charges ARTHROSCOPY PACK (CDS) DYNJ909610A 48712277_1 CDM 0272 RC inpatient 1504 977.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1173.12 78 999999999 910.67 1458.88 percent of total billed charges ARTHROSCOPY PACK (CDS) DYNJ909610A 48712277_1 CDM 0272 RC inpatient 1504 977.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1037.76 69 999999999 910.67 1458.88 percent of total billed charges ARTHROSCOPY PACK (CDS) DYNJ909610A 48712277_1 CDM 0272 RC inpatient 1504 977.6 UMR - ALL PLANS UMR - ALL PLANS 1052.8 70 999999999 910.67 1458.88 percent of total billed charges ARTHROSCOPY PACK (CDS) DYNJ909610A 48712277_1 CDM 0272 RC inpatient 1504 977.6 SIHO - ALL PLANS SIHO - ALL PLANS 1353.6 90 999999999 910.67 1458.88 percent of total billed charges ARTHROSCOPY PACK (CDS) DYNJ909610A 48712277_1 CDM 0272 RC inpatient 1504 977.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 910.67 60.55 999999999 910.67 1458.88 percent of total billed charges ARTHROSCOPY PACK (CDS) DYNJ909610A 48712277_1 CDM 0272 RC inpatient 1504 977.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 910.67 1458.88 ARTHROSCOPY PACK (CDS) DYNJ909610A 48712277_1 CDM 0272 RC inpatient 1504 977.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 910.67 1458.88 ARTHROSCOPY PACK (CDS) DYNJ909610A 48712277_1 CDM 0272 RC inpatient 1504 977.6 ANTHEM HMO ANTHEM HMO 999999999 910.67 1458.88 ARTHROSCOPY PACK (CDS) DYNJ909610A 48712277_1 CDM 0272 RC inpatient 1504 977.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 910.67 1458.88 ARTHROSCOPY PACK (CDS) DYNJ909610A 48712277_1 CDM 0272 RC inpatient 1504 977.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1016.7 67.6 999999999 910.67 1458.88 percent of total billed charges ARTHROSCOPY PACK (CDS) DYNJ909610A 48712277_1 CDM 0272 RC inpatient 1504 977.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 910.67 1458.88 ORTHO PACK (CDS) DYNJ909611 48712278_1 CDM 0272 RC inpatient 404 262.6 AETNA AETNA 319.16 79 999999999 244.62 391.88 percent of total billed charges ORTHO PACK (CDS) DYNJ909611 48712278_1 CDM 0272 RC inpatient 404 262.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 262.6 65 999999999 244.62 391.88 percent of total billed charges ORTHO PACK (CDS) DYNJ909611 48712278_1 CDM 0272 RC inpatient 404 262.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 391.88 97 999999999 244.62 391.88 percent of total billed charges ORTHO PACK (CDS) DYNJ909611 48712278_1 CDM 0272 RC inpatient 404 262.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 315.12 78 999999999 244.62 391.88 percent of total billed charges ORTHO PACK (CDS) DYNJ909611 48712278_1 CDM 0272 RC inpatient 404 262.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 278.76 69 999999999 244.62 391.88 percent of total billed charges ORTHO PACK (CDS) DYNJ909611 48712278_1 CDM 0272 RC inpatient 404 262.6 UMR - ALL PLANS UMR - ALL PLANS 282.8 70 999999999 244.62 391.88 percent of total billed charges ORTHO PACK (CDS) DYNJ909611 48712278_1 CDM 0272 RC inpatient 404 262.6 SIHO - ALL PLANS SIHO - ALL PLANS 363.6 90 999999999 244.62 391.88 percent of total billed charges ORTHO PACK (CDS) DYNJ909611 48712278_1 CDM 0272 RC inpatient 404 262.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 244.62 60.55 999999999 244.62 391.88 percent of total billed charges ORTHO PACK (CDS) DYNJ909611 48712278_1 CDM 0272 RC inpatient 404 262.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 244.62 391.88 ORTHO PACK (CDS) DYNJ909611 48712278_1 CDM 0272 RC inpatient 404 262.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 244.62 391.88 ORTHO PACK (CDS) DYNJ909611 48712278_1 CDM 0272 RC inpatient 404 262.6 ANTHEM HMO ANTHEM HMO 999999999 244.62 391.88 ORTHO PACK (CDS) DYNJ909611 48712278_1 CDM 0272 RC inpatient 404 262.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 244.62 391.88 ORTHO PACK (CDS) DYNJ909611 48712278_1 CDM 0272 RC inpatient 404 262.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 273.1 67.6 999999999 244.62 391.88 percent of total billed charges ORTHO PACK (CDS) DYNJ909611 48712278_1 CDM 0272 RC inpatient 404 262.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 244.62 391.88 LAPAROSCOPY PERI GYN PACK (CDS) DYNJ909612 48712279_1 CDM 0272 RC inpatient 1033 671.45 AETNA AETNA 816.07 79 999999999 625.48 1002.01 percent of total billed charges LAPAROSCOPY PERI GYN PACK (CDS) DYNJ909612 48712279_1 CDM 0272 RC inpatient 1033 671.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 671.45 65 999999999 625.48 1002.01 percent of total billed charges LAPAROSCOPY PERI GYN PACK (CDS) DYNJ909612 48712279_1 CDM 0272 RC inpatient 1033 671.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1002.01 97 999999999 625.48 1002.01 percent of total billed charges LAPAROSCOPY PERI GYN PACK (CDS) DYNJ909612 48712279_1 CDM 0272 RC inpatient 1033 671.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 805.74 78 999999999 625.48 1002.01 percent of total billed charges LAPAROSCOPY PERI GYN PACK (CDS) DYNJ909612 48712279_1 CDM 0272 RC inpatient 1033 671.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 712.77 69 999999999 625.48 1002.01 percent of total billed charges LAPAROSCOPY PERI GYN PACK (CDS) DYNJ909612 48712279_1 CDM 0272 RC inpatient 1033 671.45 UMR - ALL PLANS UMR - ALL PLANS 723.1 70 999999999 625.48 1002.01 percent of total billed charges LAPAROSCOPY PERI GYN PACK (CDS) DYNJ909612 48712279_1 CDM 0272 RC inpatient 1033 671.45 SIHO - ALL PLANS SIHO - ALL PLANS 929.7 90 999999999 625.48 1002.01 percent of total billed charges LAPAROSCOPY PERI GYN PACK (CDS) DYNJ909612 48712279_1 CDM 0272 RC inpatient 1033 671.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 625.48 60.55 999999999 625.48 1002.01 percent of total billed charges LAPAROSCOPY PERI GYN PACK (CDS) DYNJ909612 48712279_1 CDM 0272 RC inpatient 1033 671.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 625.48 1002.01 LAPAROSCOPY PERI GYN PACK (CDS) DYNJ909612 48712279_1 CDM 0272 RC inpatient 1033 671.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 625.48 1002.01 LAPAROSCOPY PERI GYN PACK (CDS) DYNJ909612 48712279_1 CDM 0272 RC inpatient 1033 671.45 ANTHEM HMO ANTHEM HMO 999999999 625.48 1002.01 LAPAROSCOPY PERI GYN PACK (CDS) DYNJ909612 48712279_1 CDM 0272 RC inpatient 1033 671.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 625.48 1002.01 LAPAROSCOPY PERI GYN PACK (CDS) DYNJ909612 48712279_1 CDM 0272 RC inpatient 1033 671.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 698.31 67.6 999999999 625.48 1002.01 percent of total billed charges LAPAROSCOPY PERI GYN PACK (CDS) DYNJ909612 48712279_1 CDM 0272 RC inpatient 1033 671.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 625.48 1002.01 VAG HYSTERECTOMY PACK (CDS) DYNJ909613 48712280_1 CDM 0272 RC inpatient 687 446.55 AETNA AETNA 542.73 79 999999999 415.98 666.39 percent of total billed charges VAG HYSTERECTOMY PACK (CDS) DYNJ909613 48712280_1 CDM 0272 RC inpatient 687 446.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 446.55 65 999999999 415.98 666.39 percent of total billed charges VAG HYSTERECTOMY PACK (CDS) DYNJ909613 48712280_1 CDM 0272 RC inpatient 687 446.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 666.39 97 999999999 415.98 666.39 percent of total billed charges VAG HYSTERECTOMY PACK (CDS) DYNJ909613 48712280_1 CDM 0272 RC inpatient 687 446.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 535.86 78 999999999 415.98 666.39 percent of total billed charges VAG HYSTERECTOMY PACK (CDS) DYNJ909613 48712280_1 CDM 0272 RC inpatient 687 446.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 474.03 69 999999999 415.98 666.39 percent of total billed charges VAG HYSTERECTOMY PACK (CDS) DYNJ909613 48712280_1 CDM 0272 RC inpatient 687 446.55 UMR - ALL PLANS UMR - ALL PLANS 480.9 70 999999999 415.98 666.39 percent of total billed charges VAG HYSTERECTOMY PACK (CDS) DYNJ909613 48712280_1 CDM 0272 RC inpatient 687 446.55 SIHO - ALL PLANS SIHO - ALL PLANS 618.3 90 999999999 415.98 666.39 percent of total billed charges VAG HYSTERECTOMY PACK (CDS) DYNJ909613 48712280_1 CDM 0272 RC inpatient 687 446.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 415.98 60.55 999999999 415.98 666.39 percent of total billed charges VAG HYSTERECTOMY PACK (CDS) DYNJ909613 48712280_1 CDM 0272 RC inpatient 687 446.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 415.98 666.39 VAG HYSTERECTOMY PACK (CDS) DYNJ909613 48712280_1 CDM 0272 RC inpatient 687 446.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 415.98 666.39 VAG HYSTERECTOMY PACK (CDS) DYNJ909613 48712280_1 CDM 0272 RC inpatient 687 446.55 ANTHEM HMO ANTHEM HMO 999999999 415.98 666.39 VAG HYSTERECTOMY PACK (CDS) DYNJ909613 48712280_1 CDM 0272 RC inpatient 687 446.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 415.98 666.39 VAG HYSTERECTOMY PACK (CDS) DYNJ909613 48712280_1 CDM 0272 RC inpatient 687 446.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 464.41 67.6 999999999 415.98 666.39 percent of total billed charges VAG HYSTERECTOMY PACK (CDS) DYNJ909613 48712280_1 CDM 0272 RC inpatient 687 446.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 415.98 666.39 CYSTO PACK (CDS) DYNJ909614 48712281_1 CDM 0272 RC inpatient 571 371.15 AETNA AETNA 451.09 79 999999999 345.74 553.87 percent of total billed charges CYSTO PACK (CDS) DYNJ909614 48712281_1 CDM 0272 RC inpatient 571 371.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 371.15 65 999999999 345.74 553.87 percent of total billed charges CYSTO PACK (CDS) DYNJ909614 48712281_1 CDM 0272 RC inpatient 571 371.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 553.87 97 999999999 345.74 553.87 percent of total billed charges CYSTO PACK (CDS) DYNJ909614 48712281_1 CDM 0272 RC inpatient 571 371.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 445.38 78 999999999 345.74 553.87 percent of total billed charges CYSTO PACK (CDS) DYNJ909614 48712281_1 CDM 0272 RC inpatient 571 371.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 393.99 69 999999999 345.74 553.87 percent of total billed charges CYSTO PACK (CDS) DYNJ909614 48712281_1 CDM 0272 RC inpatient 571 371.15 UMR - ALL PLANS UMR - ALL PLANS 399.7 70 999999999 345.74 553.87 percent of total billed charges CYSTO PACK (CDS) DYNJ909614 48712281_1 CDM 0272 RC inpatient 571 371.15 SIHO - ALL PLANS SIHO - ALL PLANS 513.9 90 999999999 345.74 553.87 percent of total billed charges CYSTO PACK (CDS) DYNJ909614 48712281_1 CDM 0272 RC inpatient 571 371.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 345.74 60.55 999999999 345.74 553.87 percent of total billed charges CYSTO PACK (CDS) DYNJ909614 48712281_1 CDM 0272 RC inpatient 571 371.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 345.74 553.87 CYSTO PACK (CDS) DYNJ909614 48712281_1 CDM 0272 RC inpatient 571 371.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 345.74 553.87 CYSTO PACK (CDS) DYNJ909614 48712281_1 CDM 0272 RC inpatient 571 371.15 ANTHEM HMO ANTHEM HMO 999999999 345.74 553.87 CYSTO PACK (CDS) DYNJ909614 48712281_1 CDM 0272 RC inpatient 571 371.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 345.74 553.87 CYSTO PACK (CDS) DYNJ909614 48712281_1 CDM 0272 RC inpatient 571 371.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 386 67.6 999999999 345.74 553.87 percent of total billed charges CYSTO PACK (CDS) DYNJ909614 48712281_1 CDM 0272 RC inpatient 571 371.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 345.74 553.87 PERIVAC FLUID ASPIRATION KIT 48712282_1 CDM 0270 RC inpatient 1025 666.25 AETNA AETNA 809.75 79 999999999 620.64 994.25 percent of total billed charges PERIVAC FLUID ASPIRATION KIT 48712282_1 CDM 0270 RC inpatient 1025 666.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 666.25 65 999999999 620.64 994.25 percent of total billed charges PERIVAC FLUID ASPIRATION KIT 48712282_1 CDM 0270 RC inpatient 1025 666.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 994.25 97 999999999 620.64 994.25 percent of total billed charges PERIVAC FLUID ASPIRATION KIT 48712282_1 CDM 0270 RC inpatient 1025 666.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 799.5 78 999999999 620.64 994.25 percent of total billed charges PERIVAC FLUID ASPIRATION KIT 48712282_1 CDM 0270 RC inpatient 1025 666.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 707.25 69 999999999 620.64 994.25 percent of total billed charges PERIVAC FLUID ASPIRATION KIT 48712282_1 CDM 0270 RC inpatient 1025 666.25 UMR - ALL PLANS UMR - ALL PLANS 717.5 70 999999999 620.64 994.25 percent of total billed charges PERIVAC FLUID ASPIRATION KIT 48712282_1 CDM 0270 RC inpatient 1025 666.25 SIHO - ALL PLANS SIHO - ALL PLANS 922.5 90 999999999 620.64 994.25 percent of total billed charges PERIVAC FLUID ASPIRATION KIT 48712282_1 CDM 0270 RC inpatient 1025 666.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 620.64 60.55 999999999 620.64 994.25 percent of total billed charges PERIVAC FLUID ASPIRATION KIT 48712282_1 CDM 0270 RC inpatient 1025 666.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 620.64 994.25 PERIVAC FLUID ASPIRATION KIT 48712282_1 CDM 0270 RC inpatient 1025 666.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 620.64 994.25 PERIVAC FLUID ASPIRATION KIT 48712282_1 CDM 0270 RC inpatient 1025 666.25 ANTHEM HMO ANTHEM HMO 999999999 620.64 994.25 PERIVAC FLUID ASPIRATION KIT 48712282_1 CDM 0270 RC inpatient 1025 666.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 620.64 994.25 PERIVAC FLUID ASPIRATION KIT 48712282_1 CDM 0270 RC inpatient 1025 666.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 692.9 67.6 999999999 620.64 994.25 percent of total billed charges PERIVAC FLUID ASPIRATION KIT 48712282_1 CDM 0270 RC inpatient 1025 666.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 620.64 994.25 PNEUMOTHORAX 8 FR KIT AK-01500 48712286_1 CDM 0272 RC inpatient 754 490.1 AETNA AETNA 595.66 79 999999999 456.55 731.38 percent of total billed charges PNEUMOTHORAX 8 FR KIT AK-01500 48712286_1 CDM 0272 RC inpatient 754 490.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 490.1 65 999999999 456.55 731.38 percent of total billed charges PNEUMOTHORAX 8 FR KIT AK-01500 48712286_1 CDM 0272 RC inpatient 754 490.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 731.38 97 999999999 456.55 731.38 percent of total billed charges PNEUMOTHORAX 8 FR KIT AK-01500 48712286_1 CDM 0272 RC inpatient 754 490.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 588.12 78 999999999 456.55 731.38 percent of total billed charges PNEUMOTHORAX 8 FR KIT AK-01500 48712286_1 CDM 0272 RC inpatient 754 490.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 520.26 69 999999999 456.55 731.38 percent of total billed charges PNEUMOTHORAX 8 FR KIT AK-01500 48712286_1 CDM 0272 RC inpatient 754 490.1 UMR - ALL PLANS UMR - ALL PLANS 527.8 70 999999999 456.55 731.38 percent of total billed charges PNEUMOTHORAX 8 FR KIT AK-01500 48712286_1 CDM 0272 RC inpatient 754 490.1 SIHO - ALL PLANS SIHO - ALL PLANS 678.6 90 999999999 456.55 731.38 percent of total billed charges PNEUMOTHORAX 8 FR KIT AK-01500 48712286_1 CDM 0272 RC inpatient 754 490.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 456.55 60.55 999999999 456.55 731.38 percent of total billed charges PNEUMOTHORAX 8 FR KIT AK-01500 48712286_1 CDM 0272 RC inpatient 754 490.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 456.55 731.38 PNEUMOTHORAX 8 FR KIT AK-01500 48712286_1 CDM 0272 RC inpatient 754 490.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 456.55 731.38 PNEUMOTHORAX 8 FR KIT AK-01500 48712286_1 CDM 0272 RC inpatient 754 490.1 ANTHEM HMO ANTHEM HMO 999999999 456.55 731.38 PNEUMOTHORAX 8 FR KIT AK-01500 48712286_1 CDM 0272 RC inpatient 754 490.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 456.55 731.38 PNEUMOTHORAX 8 FR KIT AK-01500 48712286_1 CDM 0272 RC inpatient 754 490.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 509.7 67.6 999999999 456.55 731.38 percent of total billed charges PNEUMOTHORAX 8 FR KIT AK-01500 48712286_1 CDM 0272 RC inpatient 754 490.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 456.55 731.38 PNEU VIEW XE 9660-XE 48712287_1 CDM 0272 RC inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges PNEU VIEW XE 9660-XE 48712287_1 CDM 0272 RC inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges PNEU VIEW XE 9660-XE 48712287_1 CDM 0272 RC inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges PNEU VIEW XE 9660-XE 48712287_1 CDM 0272 RC inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges PNEU VIEW XE 9660-XE 48712287_1 CDM 0272 RC inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges PNEU VIEW XE 9660-XE 48712287_1 CDM 0272 RC inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges PNEU VIEW XE 9660-XE 48712287_1 CDM 0272 RC inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges PNEU VIEW XE 9660-XE 48712287_1 CDM 0272 RC inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges PNEU VIEW XE 9660-XE 48712287_1 CDM 0272 RC inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 PNEU VIEW XE 9660-XE 48712287_1 CDM 0272 RC inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 PNEU VIEW XE 9660-XE 48712287_1 CDM 0272 RC inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 PNEU VIEW XE 9660-XE 48712287_1 CDM 0272 RC inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 PNEU VIEW XE 9660-XE 48712287_1 CDM 0272 RC inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges PNEU VIEW XE 9660-XE 48712287_1 CDM 0272 RC inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 SM FRA DPC PL 6HOLE 3.5 423.56 48712288_1 CDM 0278 RC inpatient 983 638.95 AETNA AETNA 776.57 79 999999999 595.21 953.51 percent of total billed charges SM FRA DPC PL 6HOLE 3.5 423.56 48712288_1 CDM 0278 RC inpatient 983 638.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 638.95 65 999999999 595.21 953.51 percent of total billed charges SM FRA DPC PL 6HOLE 3.5 423.56 48712288_1 CDM 0278 RC inpatient 983 638.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 953.51 97 999999999 595.21 953.51 percent of total billed charges SM FRA DPC PL 6HOLE 3.5 423.56 48712288_1 CDM 0278 RC inpatient 983 638.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 766.74 78 999999999 595.21 953.51 percent of total billed charges SM FRA DPC PL 6HOLE 3.5 423.56 48712288_1 CDM 0278 RC inpatient 983 638.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 678.27 69 999999999 595.21 953.51 percent of total billed charges SM FRA DPC PL 6HOLE 3.5 423.56 48712288_1 CDM 0278 RC inpatient 983 638.95 UMR - ALL PLANS UMR - ALL PLANS 688.1 70 999999999 595.21 953.51 percent of total billed charges SM FRA DPC PL 6HOLE 3.5 423.56 48712288_1 CDM 0278 RC inpatient 983 638.95 SIHO - ALL PLANS SIHO - ALL PLANS 884.7 90 999999999 595.21 953.51 percent of total billed charges SM FRA DPC PL 6HOLE 3.5 423.56 48712288_1 CDM 0278 RC inpatient 983 638.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 595.21 60.55 999999999 595.21 953.51 percent of total billed charges SM FRA DPC PL 6HOLE 3.5 423.56 48712288_1 CDM 0278 RC inpatient 983 638.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 595.21 953.51 SM FRA DPC PL 6HOLE 3.5 423.56 48712288_1 CDM 0278 RC inpatient 983 638.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 595.21 953.51 SM FRA DPC PL 6HOLE 3.5 423.56 48712288_1 CDM 0278 RC inpatient 983 638.95 ANTHEM HMO ANTHEM HMO 999999999 595.21 953.51 SM FRA DPC PL 6HOLE 3.5 423.56 48712288_1 CDM 0278 RC inpatient 983 638.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 595.21 953.51 SM FRA DPC PL 6HOLE 3.5 423.56 48712288_1 CDM 0278 RC inpatient 983 638.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 664.51 67.6 999999999 595.21 953.51 percent of total billed charges SM FRA DPC PL 6HOLE 3.5 423.56 48712288_1 CDM 0278 RC inpatient 983 638.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 595.21 953.51 PLATE DIS RAD LT/LONG 242.492 48712289_1 CDM 0278 RC inpatient 4820 3133 AETNA AETNA 3807.8 79 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD LT/LONG 242.492 48712289_1 CDM 0278 RC inpatient 4820 3133 SELF PAY DISCOUNT SELF PAY DISCOUNT 3133 65 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD LT/LONG 242.492 48712289_1 CDM 0278 RC inpatient 4820 3133 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4675.4 97 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD LT/LONG 242.492 48712289_1 CDM 0278 RC inpatient 4820 3133 HUMANA - ALL PLANS HUMANA - ALL PLANS 3759.6 78 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD LT/LONG 242.492 48712289_1 CDM 0278 RC inpatient 4820 3133 ENCORE - ALL PLANS ENCORE - ALL PLANS 3325.8 69 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD LT/LONG 242.492 48712289_1 CDM 0278 RC inpatient 4820 3133 UMR - ALL PLANS UMR - ALL PLANS 3374 70 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD LT/LONG 242.492 48712289_1 CDM 0278 RC inpatient 4820 3133 SIHO - ALL PLANS SIHO - ALL PLANS 4338 90 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD LT/LONG 242.492 48712289_1 CDM 0278 RC inpatient 4820 3133 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2918.51 60.55 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD LT/LONG 242.492 48712289_1 CDM 0278 RC inpatient 4820 3133 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2918.51 4675.4 PLATE DIS RAD LT/LONG 242.492 48712289_1 CDM 0278 RC inpatient 4820 3133 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2918.51 4675.4 PLATE DIS RAD LT/LONG 242.492 48712289_1 CDM 0278 RC inpatient 4820 3133 ANTHEM HMO ANTHEM HMO 999999999 2918.51 4675.4 PLATE DIS RAD LT/LONG 242.492 48712289_1 CDM 0278 RC inpatient 4820 3133 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2918.51 4675.4 PLATE DIS RAD LT/LONG 242.492 48712289_1 CDM 0278 RC inpatient 4820 3133 CIGNA - ALL PLANS CIGNA - ALL PLANS 3258.32 67.6 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD LT/LONG 242.492 48712289_1 CDM 0278 RC inpatient 4820 3133 UHC - ALL PLANS UHC - ALL PLANS 999999999 2918.51 4675.4 PLATE DIS RAD RT/SHORT 242.493 48712290_1 CDM 0278 RC inpatient 4549 2956.85 AETNA AETNA 3593.71 79 999999999 2754.42 4412.53 percent of total billed charges PLATE DIS RAD RT/SHORT 242.493 48712290_1 CDM 0278 RC inpatient 4549 2956.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 2956.85 65 999999999 2754.42 4412.53 percent of total billed charges PLATE DIS RAD RT/SHORT 242.493 48712290_1 CDM 0278 RC inpatient 4549 2956.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4412.53 97 999999999 2754.42 4412.53 percent of total billed charges PLATE DIS RAD RT/SHORT 242.493 48712290_1 CDM 0278 RC inpatient 4549 2956.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 3548.22 78 999999999 2754.42 4412.53 percent of total billed charges PLATE DIS RAD RT/SHORT 242.493 48712290_1 CDM 0278 RC inpatient 4549 2956.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 3138.81 69 999999999 2754.42 4412.53 percent of total billed charges PLATE DIS RAD RT/SHORT 242.493 48712290_1 CDM 0278 RC inpatient 4549 2956.85 UMR - ALL PLANS UMR - ALL PLANS 3184.3 70 999999999 2754.42 4412.53 percent of total billed charges PLATE DIS RAD RT/SHORT 242.493 48712290_1 CDM 0278 RC inpatient 4549 2956.85 SIHO - ALL PLANS SIHO - ALL PLANS 4094.1 90 999999999 2754.42 4412.53 percent of total billed charges PLATE DIS RAD RT/SHORT 242.493 48712290_1 CDM 0278 RC inpatient 4549 2956.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2754.42 60.55 999999999 2754.42 4412.53 percent of total billed charges PLATE DIS RAD RT/SHORT 242.493 48712290_1 CDM 0278 RC inpatient 4549 2956.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2754.42 4412.53 PLATE DIS RAD RT/SHORT 242.493 48712290_1 CDM 0278 RC inpatient 4549 2956.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2754.42 4412.53 PLATE DIS RAD RT/SHORT 242.493 48712290_1 CDM 0278 RC inpatient 4549 2956.85 ANTHEM HMO ANTHEM HMO 999999999 2754.42 4412.53 PLATE DIS RAD RT/SHORT 242.493 48712290_1 CDM 0278 RC inpatient 4549 2956.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2754.42 4412.53 PLATE DIS RAD RT/SHORT 242.493 48712290_1 CDM 0278 RC inpatient 4549 2956.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 3075.12 67.6 999999999 2754.42 4412.53 percent of total billed charges PLATE DIS RAD RT/SHORT 242.493 48712290_1 CDM 0278 RC inpatient 4549 2956.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 2754.42 4412.53 PLATE DIS RAD RT/LONG 242.494 48712291_1 CDM 0278 RC inpatient 4820 3133 AETNA AETNA 3807.8 79 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD RT/LONG 242.494 48712291_1 CDM 0278 RC inpatient 4820 3133 SELF PAY DISCOUNT SELF PAY DISCOUNT 3133 65 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD RT/LONG 242.494 48712291_1 CDM 0278 RC inpatient 4820 3133 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4675.4 97 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD RT/LONG 242.494 48712291_1 CDM 0278 RC inpatient 4820 3133 HUMANA - ALL PLANS HUMANA - ALL PLANS 3759.6 78 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD RT/LONG 242.494 48712291_1 CDM 0278 RC inpatient 4820 3133 ENCORE - ALL PLANS ENCORE - ALL PLANS 3325.8 69 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD RT/LONG 242.494 48712291_1 CDM 0278 RC inpatient 4820 3133 UMR - ALL PLANS UMR - ALL PLANS 3374 70 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD RT/LONG 242.494 48712291_1 CDM 0278 RC inpatient 4820 3133 SIHO - ALL PLANS SIHO - ALL PLANS 4338 90 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD RT/LONG 242.494 48712291_1 CDM 0278 RC inpatient 4820 3133 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2918.51 60.55 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD RT/LONG 242.494 48712291_1 CDM 0278 RC inpatient 4820 3133 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2918.51 4675.4 PLATE DIS RAD RT/LONG 242.494 48712291_1 CDM 0278 RC inpatient 4820 3133 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2918.51 4675.4 PLATE DIS RAD RT/LONG 242.494 48712291_1 CDM 0278 RC inpatient 4820 3133 ANTHEM HMO ANTHEM HMO 999999999 2918.51 4675.4 PLATE DIS RAD RT/LONG 242.494 48712291_1 CDM 0278 RC inpatient 4820 3133 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2918.51 4675.4 PLATE DIS RAD RT/LONG 242.494 48712291_1 CDM 0278 RC inpatient 4820 3133 CIGNA - ALL PLANS CIGNA - ALL PLANS 3258.32 67.6 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD RT/LONG 242.494 48712291_1 CDM 0278 RC inpatient 4820 3133 UHC - ALL PLANS UHC - ALL PLANS 999999999 2918.51 4675.4 PLATE-T DIS RA 3HH/3HS 242.477 48712292_1 CDM 0278 RC inpatient 2913 1893.45 AETNA AETNA 2301.27 79 999999999 1763.82 2825.61 percent of total billed charges PLATE-T DIS RA 3HH/3HS 242.477 48712292_1 CDM 0278 RC inpatient 2913 1893.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1893.45 65 999999999 1763.82 2825.61 percent of total billed charges PLATE-T DIS RA 3HH/3HS 242.477 48712292_1 CDM 0278 RC inpatient 2913 1893.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2825.61 97 999999999 1763.82 2825.61 percent of total billed charges PLATE-T DIS RA 3HH/3HS 242.477 48712292_1 CDM 0278 RC inpatient 2913 1893.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 2272.14 78 999999999 1763.82 2825.61 percent of total billed charges PLATE-T DIS RA 3HH/3HS 242.477 48712292_1 CDM 0278 RC inpatient 2913 1893.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 2009.97 69 999999999 1763.82 2825.61 percent of total billed charges PLATE-T DIS RA 3HH/3HS 242.477 48712292_1 CDM 0278 RC inpatient 2913 1893.45 UMR - ALL PLANS UMR - ALL PLANS 2039.1 70 999999999 1763.82 2825.61 percent of total billed charges PLATE-T DIS RA 3HH/3HS 242.477 48712292_1 CDM 0278 RC inpatient 2913 1893.45 SIHO - ALL PLANS SIHO - ALL PLANS 2621.7 90 999999999 1763.82 2825.61 percent of total billed charges PLATE-T DIS RA 3HH/3HS 242.477 48712292_1 CDM 0278 RC inpatient 2913 1893.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1763.82 60.55 999999999 1763.82 2825.61 percent of total billed charges PLATE-T DIS RA 3HH/3HS 242.477 48712292_1 CDM 0278 RC inpatient 2913 1893.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1763.82 2825.61 PLATE-T DIS RA 3HH/3HS 242.477 48712292_1 CDM 0278 RC inpatient 2913 1893.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1763.82 2825.61 PLATE-T DIS RA 3HH/3HS 242.477 48712292_1 CDM 0278 RC inpatient 2913 1893.45 ANTHEM HMO ANTHEM HMO 999999999 1763.82 2825.61 PLATE-T DIS RA 3HH/3HS 242.477 48712292_1 CDM 0278 RC inpatient 2913 1893.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1763.82 2825.61 PLATE-T DIS RA 3HH/3HS 242.477 48712292_1 CDM 0278 RC inpatient 2913 1893.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1969.19 67.6 999999999 1763.82 2825.61 percent of total billed charges PLATE-T DIS RA 3HH/3HS 242.477 48712292_1 CDM 0278 RC inpatient 2913 1893.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1763.82 2825.61 PLATE-T DIS RA 3HH/4HS 242.478 48712293_1 CDM 0278 RC inpatient 3043 1977.95 AETNA AETNA 2403.97 79 999999999 1842.54 2951.71 percent of total billed charges PLATE-T DIS RA 3HH/4HS 242.478 48712293_1 CDM 0278 RC inpatient 3043 1977.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1977.95 65 999999999 1842.54 2951.71 percent of total billed charges PLATE-T DIS RA 3HH/4HS 242.478 48712293_1 CDM 0278 RC inpatient 3043 1977.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2951.71 97 999999999 1842.54 2951.71 percent of total billed charges PLATE-T DIS RA 3HH/4HS 242.478 48712293_1 CDM 0278 RC inpatient 3043 1977.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 2373.54 78 999999999 1842.54 2951.71 percent of total billed charges PLATE-T DIS RA 3HH/4HS 242.478 48712293_1 CDM 0278 RC inpatient 3043 1977.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 2099.67 69 999999999 1842.54 2951.71 percent of total billed charges PLATE-T DIS RA 3HH/4HS 242.478 48712293_1 CDM 0278 RC inpatient 3043 1977.95 UMR - ALL PLANS UMR - ALL PLANS 2130.1 70 999999999 1842.54 2951.71 percent of total billed charges PLATE-T DIS RA 3HH/4HS 242.478 48712293_1 CDM 0278 RC inpatient 3043 1977.95 SIHO - ALL PLANS SIHO - ALL PLANS 2738.7 90 999999999 1842.54 2951.71 percent of total billed charges PLATE-T DIS RA 3HH/4HS 242.478 48712293_1 CDM 0278 RC inpatient 3043 1977.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1842.54 60.55 999999999 1842.54 2951.71 percent of total billed charges PLATE-T DIS RA 3HH/4HS 242.478 48712293_1 CDM 0278 RC inpatient 3043 1977.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1842.54 2951.71 PLATE-T DIS RA 3HH/4HS 242.478 48712293_1 CDM 0278 RC inpatient 3043 1977.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1842.54 2951.71 PLATE-T DIS RA 3HH/4HS 242.478 48712293_1 CDM 0278 RC inpatient 3043 1977.95 ANTHEM HMO ANTHEM HMO 999999999 1842.54 2951.71 PLATE-T DIS RA 3HH/4HS 242.478 48712293_1 CDM 0278 RC inpatient 3043 1977.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1842.54 2951.71 PLATE-T DIS RA 3HH/4HS 242.478 48712293_1 CDM 0278 RC inpatient 3043 1977.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 2057.07 67.6 999999999 1842.54 2951.71 percent of total billed charges PLATE-T DIS RA 3HH/4HS 242.478 48712293_1 CDM 0278 RC inpatient 3043 1977.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1842.54 2951.71 PLATE DIS RAD STR/SHT 242.479 48712294_1 CDM 0278 RC inpatient 2856 1856.4 AETNA AETNA 2256.24 79 999999999 1729.31 2770.32 percent of total billed charges PLATE DIS RAD STR/SHT 242.479 48712294_1 CDM 0278 RC inpatient 2856 1856.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1856.4 65 999999999 1729.31 2770.32 percent of total billed charges PLATE DIS RAD STR/SHT 242.479 48712294_1 CDM 0278 RC inpatient 2856 1856.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2770.32 97 999999999 1729.31 2770.32 percent of total billed charges PLATE DIS RAD STR/SHT 242.479 48712294_1 CDM 0278 RC inpatient 2856 1856.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 2227.68 78 999999999 1729.31 2770.32 percent of total billed charges PLATE DIS RAD STR/SHT 242.479 48712294_1 CDM 0278 RC inpatient 2856 1856.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1970.64 69 999999999 1729.31 2770.32 percent of total billed charges PLATE DIS RAD STR/SHT 242.479 48712294_1 CDM 0278 RC inpatient 2856 1856.4 UMR - ALL PLANS UMR - ALL PLANS 1999.2 70 999999999 1729.31 2770.32 percent of total billed charges PLATE DIS RAD STR/SHT 242.479 48712294_1 CDM 0278 RC inpatient 2856 1856.4 SIHO - ALL PLANS SIHO - ALL PLANS 2570.4 90 999999999 1729.31 2770.32 percent of total billed charges PLATE DIS RAD STR/SHT 242.479 48712294_1 CDM 0278 RC inpatient 2856 1856.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1729.31 60.55 999999999 1729.31 2770.32 percent of total billed charges PLATE DIS RAD STR/SHT 242.479 48712294_1 CDM 0278 RC inpatient 2856 1856.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1729.31 2770.32 PLATE DIS RAD STR/SHT 242.479 48712294_1 CDM 0278 RC inpatient 2856 1856.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1729.31 2770.32 PLATE DIS RAD STR/SHT 242.479 48712294_1 CDM 0278 RC inpatient 2856 1856.4 ANTHEM HMO ANTHEM HMO 999999999 1729.31 2770.32 PLATE DIS RAD STR/SHT 242.479 48712294_1 CDM 0278 RC inpatient 2856 1856.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1729.31 2770.32 PLATE DIS RAD STR/SHT 242.479 48712294_1 CDM 0278 RC inpatient 2856 1856.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1930.66 67.6 999999999 1729.31 2770.32 percent of total billed charges PLATE DIS RAD STR/SHT 242.479 48712294_1 CDM 0278 RC inpatient 2856 1856.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1729.31 2770.32 PLATE DIS RAD STR/LONG 242.490 48712295_1 CDM 0278 RC inpatient 2913 1893.45 AETNA AETNA 2301.27 79 999999999 1763.82 2825.61 percent of total billed charges PLATE DIS RAD STR/LONG 242.490 48712295_1 CDM 0278 RC inpatient 2913 1893.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1893.45 65 999999999 1763.82 2825.61 percent of total billed charges PLATE DIS RAD STR/LONG 242.490 48712295_1 CDM 0278 RC inpatient 2913 1893.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2825.61 97 999999999 1763.82 2825.61 percent of total billed charges PLATE DIS RAD STR/LONG 242.490 48712295_1 CDM 0278 RC inpatient 2913 1893.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 2272.14 78 999999999 1763.82 2825.61 percent of total billed charges PLATE DIS RAD STR/LONG 242.490 48712295_1 CDM 0278 RC inpatient 2913 1893.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 2009.97 69 999999999 1763.82 2825.61 percent of total billed charges PLATE DIS RAD STR/LONG 242.490 48712295_1 CDM 0278 RC inpatient 2913 1893.45 UMR - ALL PLANS UMR - ALL PLANS 2039.1 70 999999999 1763.82 2825.61 percent of total billed charges PLATE DIS RAD STR/LONG 242.490 48712295_1 CDM 0278 RC inpatient 2913 1893.45 SIHO - ALL PLANS SIHO - ALL PLANS 2621.7 90 999999999 1763.82 2825.61 percent of total billed charges PLATE DIS RAD STR/LONG 242.490 48712295_1 CDM 0278 RC inpatient 2913 1893.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1763.82 60.55 999999999 1763.82 2825.61 percent of total billed charges PLATE DIS RAD STR/LONG 242.490 48712295_1 CDM 0278 RC inpatient 2913 1893.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1763.82 2825.61 PLATE DIS RAD STR/LONG 242.490 48712295_1 CDM 0278 RC inpatient 2913 1893.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1763.82 2825.61 PLATE DIS RAD STR/LONG 242.490 48712295_1 CDM 0278 RC inpatient 2913 1893.45 ANTHEM HMO ANTHEM HMO 999999999 1763.82 2825.61 PLATE DIS RAD STR/LONG 242.490 48712295_1 CDM 0278 RC inpatient 2913 1893.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1763.82 2825.61 PLATE DIS RAD STR/LONG 242.490 48712295_1 CDM 0278 RC inpatient 2913 1893.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1969.19 67.6 999999999 1763.82 2825.61 percent of total billed charges PLATE DIS RAD STR/LONG 242.490 48712295_1 CDM 0278 RC inpatient 2913 1893.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1763.82 2825.61 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712296_1 CDM 0278 RC C1713 HCPCS inpatient 1018 661.7 AETNA AETNA 804.22 79 999999999 616.4 987.46 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712296_1 CDM 0278 RC C1713 HCPCS inpatient 1018 661.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 661.7 65 999999999 616.4 987.46 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712296_1 CDM 0278 RC C1713 HCPCS inpatient 1018 661.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 987.46 97 999999999 616.4 987.46 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712296_1 CDM 0278 RC C1713 HCPCS inpatient 1018 661.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 794.04 78 999999999 616.4 987.46 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712296_1 CDM 0278 RC C1713 HCPCS inpatient 1018 661.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 702.42 69 999999999 616.4 987.46 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712296_1 CDM 0278 RC C1713 HCPCS inpatient 1018 661.7 UMR - ALL PLANS UMR - ALL PLANS 712.6 70 999999999 616.4 987.46 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712296_1 CDM 0278 RC C1713 HCPCS inpatient 1018 661.7 SIHO - ALL PLANS SIHO - ALL PLANS 916.2 90 999999999 616.4 987.46 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712296_1 CDM 0278 RC C1713 HCPCS inpatient 1018 661.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 616.4 60.55 999999999 616.4 987.46 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712296_1 CDM 0278 RC C1713 HCPCS inpatient 1018 661.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 616.4 987.46 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712296_1 CDM 0278 RC C1713 HCPCS inpatient 1018 661.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 616.4 987.46 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712296_1 CDM 0278 RC C1713 HCPCS inpatient 1018 661.7 ANTHEM HMO ANTHEM HMO 999999999 616.4 987.46 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712296_1 CDM 0278 RC C1713 HCPCS inpatient 1018 661.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 616.4 987.46 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712296_1 CDM 0278 RC C1713 HCPCS inpatient 1018 661.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 688.17 67.6 999999999 616.4 987.46 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712296_1 CDM 0278 RC C1713 HCPCS inpatient 1018 661.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 616.4 987.46 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712297_1 CDM 0278 RC C1713 HCPCS inpatient 3014 1959.1 AETNA AETNA 2381.06 79 999999999 1824.98 2923.58 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712297_1 CDM 0278 RC C1713 HCPCS inpatient 3014 1959.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1959.1 65 999999999 1824.98 2923.58 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712297_1 CDM 0278 RC C1713 HCPCS inpatient 3014 1959.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2923.58 97 999999999 1824.98 2923.58 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712297_1 CDM 0278 RC C1713 HCPCS inpatient 3014 1959.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 2350.92 78 999999999 1824.98 2923.58 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712297_1 CDM 0278 RC C1713 HCPCS inpatient 3014 1959.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 2079.66 69 999999999 1824.98 2923.58 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712297_1 CDM 0278 RC C1713 HCPCS inpatient 3014 1959.1 UMR - ALL PLANS UMR - ALL PLANS 2109.8 70 999999999 1824.98 2923.58 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712297_1 CDM 0278 RC C1713 HCPCS inpatient 3014 1959.1 SIHO - ALL PLANS SIHO - ALL PLANS 2712.6 90 999999999 1824.98 2923.58 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712297_1 CDM 0278 RC C1713 HCPCS inpatient 3014 1959.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1824.98 60.55 999999999 1824.98 2923.58 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712297_1 CDM 0278 RC C1713 HCPCS inpatient 3014 1959.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1824.98 2923.58 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712297_1 CDM 0278 RC C1713 HCPCS inpatient 3014 1959.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1824.98 2923.58 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712297_1 CDM 0278 RC C1713 HCPCS inpatient 3014 1959.1 ANTHEM HMO ANTHEM HMO 999999999 1824.98 2923.58 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712297_1 CDM 0278 RC C1713 HCPCS inpatient 3014 1959.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1824.98 2923.58 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712297_1 CDM 0278 RC C1713 HCPCS inpatient 3014 1959.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 2037.46 67.6 999999999 1824.98 2923.58 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712297_1 CDM 0278 RC C1713 HCPCS inpatient 3014 1959.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1824.98 2923.58 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712298_1 CDM 0278 RC C1713 HCPCS inpatient 3061 1989.65 AETNA AETNA 2418.19 79 999999999 1853.44 2969.17 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712298_1 CDM 0278 RC C1713 HCPCS inpatient 3061 1989.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1989.65 65 999999999 1853.44 2969.17 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712298_1 CDM 0278 RC C1713 HCPCS inpatient 3061 1989.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2969.17 97 999999999 1853.44 2969.17 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712298_1 CDM 0278 RC C1713 HCPCS inpatient 3061 1989.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2387.58 78 999999999 1853.44 2969.17 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712298_1 CDM 0278 RC C1713 HCPCS inpatient 3061 1989.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2112.09 69 999999999 1853.44 2969.17 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712298_1 CDM 0278 RC C1713 HCPCS inpatient 3061 1989.65 UMR - ALL PLANS UMR - ALL PLANS 2142.7 70 999999999 1853.44 2969.17 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712298_1 CDM 0278 RC C1713 HCPCS inpatient 3061 1989.65 SIHO - ALL PLANS SIHO - ALL PLANS 2754.9 90 999999999 1853.44 2969.17 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712298_1 CDM 0278 RC C1713 HCPCS inpatient 3061 1989.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1853.44 60.55 999999999 1853.44 2969.17 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712298_1 CDM 0278 RC C1713 HCPCS inpatient 3061 1989.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1853.44 2969.17 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712298_1 CDM 0278 RC C1713 HCPCS inpatient 3061 1989.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1853.44 2969.17 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712298_1 CDM 0278 RC C1713 HCPCS inpatient 3061 1989.65 ANTHEM HMO ANTHEM HMO 999999999 1853.44 2969.17 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712298_1 CDM 0278 RC C1713 HCPCS inpatient 3061 1989.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1853.44 2969.17 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712298_1 CDM 0278 RC C1713 HCPCS inpatient 3061 1989.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2069.24 67.6 999999999 1853.44 2969.17 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712298_1 CDM 0278 RC C1713 HCPCS inpatient 3061 1989.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1853.44 2969.17 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712299_1 CDM 0278 RC C1713 HCPCS inpatient 2845 1849.25 AETNA AETNA 2247.55 79 999999999 1722.65 2759.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712299_1 CDM 0278 RC C1713 HCPCS inpatient 2845 1849.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1849.25 65 999999999 1722.65 2759.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712299_1 CDM 0278 RC C1713 HCPCS inpatient 2845 1849.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2759.65 97 999999999 1722.65 2759.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712299_1 CDM 0278 RC C1713 HCPCS inpatient 2845 1849.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 2219.1 78 999999999 1722.65 2759.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712299_1 CDM 0278 RC C1713 HCPCS inpatient 2845 1849.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1963.05 69 999999999 1722.65 2759.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712299_1 CDM 0278 RC C1713 HCPCS inpatient 2845 1849.25 UMR - ALL PLANS UMR - ALL PLANS 1991.5 70 999999999 1722.65 2759.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712299_1 CDM 0278 RC C1713 HCPCS inpatient 2845 1849.25 SIHO - ALL PLANS SIHO - ALL PLANS 2560.5 90 999999999 1722.65 2759.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712299_1 CDM 0278 RC C1713 HCPCS inpatient 2845 1849.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1722.65 60.55 999999999 1722.65 2759.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712299_1 CDM 0278 RC C1713 HCPCS inpatient 2845 1849.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1722.65 2759.65 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712299_1 CDM 0278 RC C1713 HCPCS inpatient 2845 1849.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1722.65 2759.65 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712299_1 CDM 0278 RC C1713 HCPCS inpatient 2845 1849.25 ANTHEM HMO ANTHEM HMO 999999999 1722.65 2759.65 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712299_1 CDM 0278 RC C1713 HCPCS inpatient 2845 1849.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1722.65 2759.65 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712299_1 CDM 0278 RC C1713 HCPCS inpatient 2845 1849.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1923.22 67.6 999999999 1722.65 2759.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712299_1 CDM 0278 RC C1713 HCPCS inpatient 2845 1849.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1722.65 2759.65 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712300_1 CDM 0278 RC C1713 HCPCS inpatient 3167 2058.55 AETNA AETNA 2501.93 79 999999999 1917.62 3071.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712300_1 CDM 0278 RC C1713 HCPCS inpatient 3167 2058.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 2058.55 65 999999999 1917.62 3071.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712300_1 CDM 0278 RC C1713 HCPCS inpatient 3167 2058.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3071.99 97 999999999 1917.62 3071.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712300_1 CDM 0278 RC C1713 HCPCS inpatient 3167 2058.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 2470.26 78 999999999 1917.62 3071.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712300_1 CDM 0278 RC C1713 HCPCS inpatient 3167 2058.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 2185.23 69 999999999 1917.62 3071.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712300_1 CDM 0278 RC C1713 HCPCS inpatient 3167 2058.55 UMR - ALL PLANS UMR - ALL PLANS 2216.9 70 999999999 1917.62 3071.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712300_1 CDM 0278 RC C1713 HCPCS inpatient 3167 2058.55 SIHO - ALL PLANS SIHO - ALL PLANS 2850.3 90 999999999 1917.62 3071.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712300_1 CDM 0278 RC C1713 HCPCS inpatient 3167 2058.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1917.62 60.55 999999999 1917.62 3071.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712300_1 CDM 0278 RC C1713 HCPCS inpatient 3167 2058.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1917.62 3071.99 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712300_1 CDM 0278 RC C1713 HCPCS inpatient 3167 2058.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1917.62 3071.99 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712300_1 CDM 0278 RC C1713 HCPCS inpatient 3167 2058.55 ANTHEM HMO ANTHEM HMO 999999999 1917.62 3071.99 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712300_1 CDM 0278 RC C1713 HCPCS inpatient 3167 2058.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1917.62 3071.99 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712300_1 CDM 0278 RC C1713 HCPCS inpatient 3167 2058.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 2140.89 67.6 999999999 1917.62 3071.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712300_1 CDM 0278 RC C1713 HCPCS inpatient 3167 2058.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1917.62 3071.99 PLATE L+90 DEG 3HH/3HS 242.504 48712301_1 CDM 0278 RC inpatient 2819 1832.35 AETNA AETNA 2227.01 79 999999999 1706.9 2734.43 percent of total billed charges PLATE L+90 DEG 3HH/3HS 242.504 48712301_1 CDM 0278 RC inpatient 2819 1832.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1832.35 65 999999999 1706.9 2734.43 percent of total billed charges PLATE L+90 DEG 3HH/3HS 242.504 48712301_1 CDM 0278 RC inpatient 2819 1832.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2734.43 97 999999999 1706.9 2734.43 percent of total billed charges PLATE L+90 DEG 3HH/3HS 242.504 48712301_1 CDM 0278 RC inpatient 2819 1832.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 2198.82 78 999999999 1706.9 2734.43 percent of total billed charges PLATE L+90 DEG 3HH/3HS 242.504 48712301_1 CDM 0278 RC inpatient 2819 1832.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1945.11 69 999999999 1706.9 2734.43 percent of total billed charges PLATE L+90 DEG 3HH/3HS 242.504 48712301_1 CDM 0278 RC inpatient 2819 1832.35 UMR - ALL PLANS UMR - ALL PLANS 1973.3 70 999999999 1706.9 2734.43 percent of total billed charges PLATE L+90 DEG 3HH/3HS 242.504 48712301_1 CDM 0278 RC inpatient 2819 1832.35 SIHO - ALL PLANS SIHO - ALL PLANS 2537.1 90 999999999 1706.9 2734.43 percent of total billed charges PLATE L+90 DEG 3HH/3HS 242.504 48712301_1 CDM 0278 RC inpatient 2819 1832.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1706.9 60.55 999999999 1706.9 2734.43 percent of total billed charges PLATE L+90 DEG 3HH/3HS 242.504 48712301_1 CDM 0278 RC inpatient 2819 1832.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1706.9 2734.43 PLATE L+90 DEG 3HH/3HS 242.504 48712301_1 CDM 0278 RC inpatient 2819 1832.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1706.9 2734.43 PLATE L+90 DEG 3HH/3HS 242.504 48712301_1 CDM 0278 RC inpatient 2819 1832.35 ANTHEM HMO ANTHEM HMO 999999999 1706.9 2734.43 PLATE L+90 DEG 3HH/3HS 242.504 48712301_1 CDM 0278 RC inpatient 2819 1832.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1706.9 2734.43 PLATE L+90 DEG 3HH/3HS 242.504 48712301_1 CDM 0278 RC inpatient 2819 1832.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1905.64 67.6 999999999 1706.9 2734.43 percent of total billed charges PLATE L+90 DEG 3HH/3HS 242.504 48712301_1 CDM 0278 RC inpatient 2819 1832.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1706.9 2734.43 PLATE L+90 DEG 3HH/4HS 242.505 48712302_1 CDM 0278 RC inpatient 2967 1928.55 AETNA AETNA 2343.93 79 999999999 1796.52 2877.99 percent of total billed charges PLATE L+90 DEG 3HH/4HS 242.505 48712302_1 CDM 0278 RC inpatient 2967 1928.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1928.55 65 999999999 1796.52 2877.99 percent of total billed charges PLATE L+90 DEG 3HH/4HS 242.505 48712302_1 CDM 0278 RC inpatient 2967 1928.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2877.99 97 999999999 1796.52 2877.99 percent of total billed charges PLATE L+90 DEG 3HH/4HS 242.505 48712302_1 CDM 0278 RC inpatient 2967 1928.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 2314.26 78 999999999 1796.52 2877.99 percent of total billed charges PLATE L+90 DEG 3HH/4HS 242.505 48712302_1 CDM 0278 RC inpatient 2967 1928.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 2047.23 69 999999999 1796.52 2877.99 percent of total billed charges PLATE L+90 DEG 3HH/4HS 242.505 48712302_1 CDM 0278 RC inpatient 2967 1928.55 UMR - ALL PLANS UMR - ALL PLANS 2076.9 70 999999999 1796.52 2877.99 percent of total billed charges PLATE L+90 DEG 3HH/4HS 242.505 48712302_1 CDM 0278 RC inpatient 2967 1928.55 SIHO - ALL PLANS SIHO - ALL PLANS 2670.3 90 999999999 1796.52 2877.99 percent of total billed charges PLATE L+90 DEG 3HH/4HS 242.505 48712302_1 CDM 0278 RC inpatient 2967 1928.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1796.52 60.55 999999999 1796.52 2877.99 percent of total billed charges PLATE L+90 DEG 3HH/4HS 242.505 48712302_1 CDM 0278 RC inpatient 2967 1928.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1796.52 2877.99 PLATE L+90 DEG 3HH/4HS 242.505 48712302_1 CDM 0278 RC inpatient 2967 1928.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1796.52 2877.99 PLATE L+90 DEG 3HH/4HS 242.505 48712302_1 CDM 0278 RC inpatient 2967 1928.55 ANTHEM HMO ANTHEM HMO 999999999 1796.52 2877.99 PLATE L+90 DEG 3HH/4HS 242.505 48712302_1 CDM 0278 RC inpatient 2967 1928.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1796.52 2877.99 PLATE L+90 DEG 3HH/4HS 242.505 48712302_1 CDM 0278 RC inpatient 2967 1928.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 2005.69 67.6 999999999 1796.52 2877.99 percent of total billed charges PLATE L+90 DEG 3HH/4HS 242.505 48712302_1 CDM 0278 RC inpatient 2967 1928.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1796.52 2877.99 PLATE L-90 DEG 3HH/3HS 242.506 48712303_1 CDM 0278 RC inpatient 2819 1832.35 AETNA AETNA 2227.01 79 999999999 1706.9 2734.43 percent of total billed charges PLATE L-90 DEG 3HH/3HS 242.506 48712303_1 CDM 0278 RC inpatient 2819 1832.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1832.35 65 999999999 1706.9 2734.43 percent of total billed charges PLATE L-90 DEG 3HH/3HS 242.506 48712303_1 CDM 0278 RC inpatient 2819 1832.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2734.43 97 999999999 1706.9 2734.43 percent of total billed charges PLATE L-90 DEG 3HH/3HS 242.506 48712303_1 CDM 0278 RC inpatient 2819 1832.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 2198.82 78 999999999 1706.9 2734.43 percent of total billed charges PLATE L-90 DEG 3HH/3HS 242.506 48712303_1 CDM 0278 RC inpatient 2819 1832.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1945.11 69 999999999 1706.9 2734.43 percent of total billed charges PLATE L-90 DEG 3HH/3HS 242.506 48712303_1 CDM 0278 RC inpatient 2819 1832.35 UMR - ALL PLANS UMR - ALL PLANS 1973.3 70 999999999 1706.9 2734.43 percent of total billed charges PLATE L-90 DEG 3HH/3HS 242.506 48712303_1 CDM 0278 RC inpatient 2819 1832.35 SIHO - ALL PLANS SIHO - ALL PLANS 2537.1 90 999999999 1706.9 2734.43 percent of total billed charges PLATE L-90 DEG 3HH/3HS 242.506 48712303_1 CDM 0278 RC inpatient 2819 1832.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1706.9 60.55 999999999 1706.9 2734.43 percent of total billed charges PLATE L-90 DEG 3HH/3HS 242.506 48712303_1 CDM 0278 RC inpatient 2819 1832.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1706.9 2734.43 PLATE L-90 DEG 3HH/3HS 242.506 48712303_1 CDM 0278 RC inpatient 2819 1832.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1706.9 2734.43 PLATE L-90 DEG 3HH/3HS 242.506 48712303_1 CDM 0278 RC inpatient 2819 1832.35 ANTHEM HMO ANTHEM HMO 999999999 1706.9 2734.43 PLATE L-90 DEG 3HH/3HS 242.506 48712303_1 CDM 0278 RC inpatient 2819 1832.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1706.9 2734.43 PLATE L-90 DEG 3HH/3HS 242.506 48712303_1 CDM 0278 RC inpatient 2819 1832.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1905.64 67.6 999999999 1706.9 2734.43 percent of total billed charges PLATE L-90 DEG 3HH/3HS 242.506 48712303_1 CDM 0278 RC inpatient 2819 1832.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1706.9 2734.43 PLATE L-90 DEG 3HH/4HS 242.507 48712304_1 CDM 0278 RC inpatient 2967 1928.55 AETNA AETNA 2343.93 79 999999999 1796.52 2877.99 percent of total billed charges PLATE L-90 DEG 3HH/4HS 242.507 48712304_1 CDM 0278 RC inpatient 2967 1928.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1928.55 65 999999999 1796.52 2877.99 percent of total billed charges PLATE L-90 DEG 3HH/4HS 242.507 48712304_1 CDM 0278 RC inpatient 2967 1928.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2877.99 97 999999999 1796.52 2877.99 percent of total billed charges PLATE L-90 DEG 3HH/4HS 242.507 48712304_1 CDM 0278 RC inpatient 2967 1928.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 2314.26 78 999999999 1796.52 2877.99 percent of total billed charges PLATE L-90 DEG 3HH/4HS 242.507 48712304_1 CDM 0278 RC inpatient 2967 1928.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 2047.23 69 999999999 1796.52 2877.99 percent of total billed charges PLATE L-90 DEG 3HH/4HS 242.507 48712304_1 CDM 0278 RC inpatient 2967 1928.55 UMR - ALL PLANS UMR - ALL PLANS 2076.9 70 999999999 1796.52 2877.99 percent of total billed charges PLATE L-90 DEG 3HH/4HS 242.507 48712304_1 CDM 0278 RC inpatient 2967 1928.55 SIHO - ALL PLANS SIHO - ALL PLANS 2670.3 90 999999999 1796.52 2877.99 percent of total billed charges PLATE L-90 DEG 3HH/4HS 242.507 48712304_1 CDM 0278 RC inpatient 2967 1928.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1796.52 60.55 999999999 1796.52 2877.99 percent of total billed charges PLATE L-90 DEG 3HH/4HS 242.507 48712304_1 CDM 0278 RC inpatient 2967 1928.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1796.52 2877.99 PLATE L-90 DEG 3HH/4HS 242.507 48712304_1 CDM 0278 RC inpatient 2967 1928.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1796.52 2877.99 PLATE L-90 DEG 3HH/4HS 242.507 48712304_1 CDM 0278 RC inpatient 2967 1928.55 ANTHEM HMO ANTHEM HMO 999999999 1796.52 2877.99 PLATE L-90 DEG 3HH/4HS 242.507 48712304_1 CDM 0278 RC inpatient 2967 1928.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1796.52 2877.99 PLATE L-90 DEG 3HH/4HS 242.507 48712304_1 CDM 0278 RC inpatient 2967 1928.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 2005.69 67.6 999999999 1796.52 2877.99 percent of total billed charges PLATE L-90 DEG 3HH/4HS 242.507 48712304_1 CDM 0278 RC inpatient 2967 1928.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1796.52 2877.99 PLATE L+20 DEG 3HH/3HS 242.508 48712305_1 CDM 0278 RC inpatient 2786 1810.9 AETNA AETNA 2200.94 79 999999999 1686.92 2702.42 percent of total billed charges PLATE L+20 DEG 3HH/3HS 242.508 48712305_1 CDM 0278 RC inpatient 2786 1810.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1810.9 65 999999999 1686.92 2702.42 percent of total billed charges PLATE L+20 DEG 3HH/3HS 242.508 48712305_1 CDM 0278 RC inpatient 2786 1810.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2702.42 97 999999999 1686.92 2702.42 percent of total billed charges PLATE L+20 DEG 3HH/3HS 242.508 48712305_1 CDM 0278 RC inpatient 2786 1810.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 2173.08 78 999999999 1686.92 2702.42 percent of total billed charges PLATE L+20 DEG 3HH/3HS 242.508 48712305_1 CDM 0278 RC inpatient 2786 1810.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1922.34 69 999999999 1686.92 2702.42 percent of total billed charges PLATE L+20 DEG 3HH/3HS 242.508 48712305_1 CDM 0278 RC inpatient 2786 1810.9 UMR - ALL PLANS UMR - ALL PLANS 1950.2 70 999999999 1686.92 2702.42 percent of total billed charges PLATE L+20 DEG 3HH/3HS 242.508 48712305_1 CDM 0278 RC inpatient 2786 1810.9 SIHO - ALL PLANS SIHO - ALL PLANS 2507.4 90 999999999 1686.92 2702.42 percent of total billed charges PLATE L+20 DEG 3HH/3HS 242.508 48712305_1 CDM 0278 RC inpatient 2786 1810.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1686.92 60.55 999999999 1686.92 2702.42 percent of total billed charges PLATE L+20 DEG 3HH/3HS 242.508 48712305_1 CDM 0278 RC inpatient 2786 1810.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1686.92 2702.42 PLATE L+20 DEG 3HH/3HS 242.508 48712305_1 CDM 0278 RC inpatient 2786 1810.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1686.92 2702.42 PLATE L+20 DEG 3HH/3HS 242.508 48712305_1 CDM 0278 RC inpatient 2786 1810.9 ANTHEM HMO ANTHEM HMO 999999999 1686.92 2702.42 PLATE L+20 DEG 3HH/3HS 242.508 48712305_1 CDM 0278 RC inpatient 2786 1810.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1686.92 2702.42 PLATE L+20 DEG 3HH/3HS 242.508 48712305_1 CDM 0278 RC inpatient 2786 1810.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1883.34 67.6 999999999 1686.92 2702.42 percent of total billed charges PLATE L+20 DEG 3HH/3HS 242.508 48712305_1 CDM 0278 RC inpatient 2786 1810.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1686.92 2702.42 PLATE L+20 DEG 3HH/4HS 242.509 48712306_1 CDM 0278 RC inpatient 3061 1989.65 AETNA AETNA 2418.19 79 999999999 1853.44 2969.17 percent of total billed charges PLATE L+20 DEG 3HH/4HS 242.509 48712306_1 CDM 0278 RC inpatient 3061 1989.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1989.65 65 999999999 1853.44 2969.17 percent of total billed charges PLATE L+20 DEG 3HH/4HS 242.509 48712306_1 CDM 0278 RC inpatient 3061 1989.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2969.17 97 999999999 1853.44 2969.17 percent of total billed charges PLATE L+20 DEG 3HH/4HS 242.509 48712306_1 CDM 0278 RC inpatient 3061 1989.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2387.58 78 999999999 1853.44 2969.17 percent of total billed charges PLATE L+20 DEG 3HH/4HS 242.509 48712306_1 CDM 0278 RC inpatient 3061 1989.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2112.09 69 999999999 1853.44 2969.17 percent of total billed charges PLATE L+20 DEG 3HH/4HS 242.509 48712306_1 CDM 0278 RC inpatient 3061 1989.65 UMR - ALL PLANS UMR - ALL PLANS 2142.7 70 999999999 1853.44 2969.17 percent of total billed charges PLATE L+20 DEG 3HH/4HS 242.509 48712306_1 CDM 0278 RC inpatient 3061 1989.65 SIHO - ALL PLANS SIHO - ALL PLANS 2754.9 90 999999999 1853.44 2969.17 percent of total billed charges PLATE L+20 DEG 3HH/4HS 242.509 48712306_1 CDM 0278 RC inpatient 3061 1989.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1853.44 60.55 999999999 1853.44 2969.17 percent of total billed charges PLATE L+20 DEG 3HH/4HS 242.509 48712306_1 CDM 0278 RC inpatient 3061 1989.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1853.44 2969.17 PLATE L+20 DEG 3HH/4HS 242.509 48712306_1 CDM 0278 RC inpatient 3061 1989.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1853.44 2969.17 PLATE L+20 DEG 3HH/4HS 242.509 48712306_1 CDM 0278 RC inpatient 3061 1989.65 ANTHEM HMO ANTHEM HMO 999999999 1853.44 2969.17 PLATE L+20 DEG 3HH/4HS 242.509 48712306_1 CDM 0278 RC inpatient 3061 1989.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1853.44 2969.17 PLATE L+20 DEG 3HH/4HS 242.509 48712306_1 CDM 0278 RC inpatient 3061 1989.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2069.24 67.6 999999999 1853.44 2969.17 percent of total billed charges PLATE L+20 DEG 3HH/4HS 242.509 48712306_1 CDM 0278 RC inpatient 3061 1989.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1853.44 2969.17 PLATE L-20 DEG 3HH/3HS 242.511 48712307_1 CDM 0278 RC inpatient 2819 1832.35 AETNA AETNA 2227.01 79 999999999 1706.9 2734.43 percent of total billed charges PLATE L-20 DEG 3HH/3HS 242.511 48712307_1 CDM 0278 RC inpatient 2819 1832.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1832.35 65 999999999 1706.9 2734.43 percent of total billed charges PLATE L-20 DEG 3HH/3HS 242.511 48712307_1 CDM 0278 RC inpatient 2819 1832.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2734.43 97 999999999 1706.9 2734.43 percent of total billed charges PLATE L-20 DEG 3HH/3HS 242.511 48712307_1 CDM 0278 RC inpatient 2819 1832.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 2198.82 78 999999999 1706.9 2734.43 percent of total billed charges PLATE L-20 DEG 3HH/3HS 242.511 48712307_1 CDM 0278 RC inpatient 2819 1832.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1945.11 69 999999999 1706.9 2734.43 percent of total billed charges PLATE L-20 DEG 3HH/3HS 242.511 48712307_1 CDM 0278 RC inpatient 2819 1832.35 UMR - ALL PLANS UMR - ALL PLANS 1973.3 70 999999999 1706.9 2734.43 percent of total billed charges PLATE L-20 DEG 3HH/3HS 242.511 48712307_1 CDM 0278 RC inpatient 2819 1832.35 SIHO - ALL PLANS SIHO - ALL PLANS 2537.1 90 999999999 1706.9 2734.43 percent of total billed charges PLATE L-20 DEG 3HH/3HS 242.511 48712307_1 CDM 0278 RC inpatient 2819 1832.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1706.9 60.55 999999999 1706.9 2734.43 percent of total billed charges PLATE L-20 DEG 3HH/3HS 242.511 48712307_1 CDM 0278 RC inpatient 2819 1832.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1706.9 2734.43 PLATE L-20 DEG 3HH/3HS 242.511 48712307_1 CDM 0278 RC inpatient 2819 1832.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1706.9 2734.43 PLATE L-20 DEG 3HH/3HS 242.511 48712307_1 CDM 0278 RC inpatient 2819 1832.35 ANTHEM HMO ANTHEM HMO 999999999 1706.9 2734.43 PLATE L-20 DEG 3HH/3HS 242.511 48712307_1 CDM 0278 RC inpatient 2819 1832.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1706.9 2734.43 PLATE L-20 DEG 3HH/3HS 242.511 48712307_1 CDM 0278 RC inpatient 2819 1832.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1905.64 67.6 999999999 1706.9 2734.43 percent of total billed charges PLATE L-20 DEG 3HH/3HS 242.511 48712307_1 CDM 0278 RC inpatient 2819 1832.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1706.9 2734.43 PLATE L-20 DEG 3HH/4HS 242.512 48712308_1 CDM 0278 RC inpatient 2967 1928.55 AETNA AETNA 2343.93 79 999999999 1796.52 2877.99 percent of total billed charges PLATE L-20 DEG 3HH/4HS 242.512 48712308_1 CDM 0278 RC inpatient 2967 1928.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1928.55 65 999999999 1796.52 2877.99 percent of total billed charges PLATE L-20 DEG 3HH/4HS 242.512 48712308_1 CDM 0278 RC inpatient 2967 1928.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2877.99 97 999999999 1796.52 2877.99 percent of total billed charges PLATE L-20 DEG 3HH/4HS 242.512 48712308_1 CDM 0278 RC inpatient 2967 1928.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 2314.26 78 999999999 1796.52 2877.99 percent of total billed charges PLATE L-20 DEG 3HH/4HS 242.512 48712308_1 CDM 0278 RC inpatient 2967 1928.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 2047.23 69 999999999 1796.52 2877.99 percent of total billed charges PLATE L-20 DEG 3HH/4HS 242.512 48712308_1 CDM 0278 RC inpatient 2967 1928.55 UMR - ALL PLANS UMR - ALL PLANS 2076.9 70 999999999 1796.52 2877.99 percent of total billed charges PLATE L-20 DEG 3HH/4HS 242.512 48712308_1 CDM 0278 RC inpatient 2967 1928.55 SIHO - ALL PLANS SIHO - ALL PLANS 2670.3 90 999999999 1796.52 2877.99 percent of total billed charges PLATE L-20 DEG 3HH/4HS 242.512 48712308_1 CDM 0278 RC inpatient 2967 1928.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1796.52 60.55 999999999 1796.52 2877.99 percent of total billed charges PLATE L-20 DEG 3HH/4HS 242.512 48712308_1 CDM 0278 RC inpatient 2967 1928.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1796.52 2877.99 PLATE L-20 DEG 3HH/4HS 242.512 48712308_1 CDM 0278 RC inpatient 2967 1928.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1796.52 2877.99 PLATE L-20 DEG 3HH/4HS 242.512 48712308_1 CDM 0278 RC inpatient 2967 1928.55 ANTHEM HMO ANTHEM HMO 999999999 1796.52 2877.99 PLATE L-20 DEG 3HH/4HS 242.512 48712308_1 CDM 0278 RC inpatient 2967 1928.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1796.52 2877.99 PLATE L-20 DEG 3HH/4HS 242.512 48712308_1 CDM 0278 RC inpatient 2967 1928.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 2005.69 67.6 999999999 1796.52 2877.99 percent of total billed charges PLATE L-20 DEG 3HH/4HS 242.512 48712308_1 CDM 0278 RC inpatient 2967 1928.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1796.52 2877.99 2.4 LCK SCREW ST/SD 6M 212.806 48712309_1 CDM 0278 RC inpatient 727 472.55 AETNA AETNA 574.33 79 999999999 440.2 705.19 percent of total billed charges 2.4 LCK SCREW ST/SD 6M 212.806 48712309_1 CDM 0278 RC inpatient 727 472.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 472.55 65 999999999 440.2 705.19 percent of total billed charges 2.4 LCK SCREW ST/SD 6M 212.806 48712309_1 CDM 0278 RC inpatient 727 472.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 705.19 97 999999999 440.2 705.19 percent of total billed charges 2.4 LCK SCREW ST/SD 6M 212.806 48712309_1 CDM 0278 RC inpatient 727 472.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 567.06 78 999999999 440.2 705.19 percent of total billed charges 2.4 LCK SCREW ST/SD 6M 212.806 48712309_1 CDM 0278 RC inpatient 727 472.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 501.63 69 999999999 440.2 705.19 percent of total billed charges 2.4 LCK SCREW ST/SD 6M 212.806 48712309_1 CDM 0278 RC inpatient 727 472.55 UMR - ALL PLANS UMR - ALL PLANS 508.9 70 999999999 440.2 705.19 percent of total billed charges 2.4 LCK SCREW ST/SD 6M 212.806 48712309_1 CDM 0278 RC inpatient 727 472.55 SIHO - ALL PLANS SIHO - ALL PLANS 654.3 90 999999999 440.2 705.19 percent of total billed charges 2.4 LCK SCREW ST/SD 6M 212.806 48712309_1 CDM 0278 RC inpatient 727 472.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 440.2 60.55 999999999 440.2 705.19 percent of total billed charges 2.4 LCK SCREW ST/SD 6M 212.806 48712309_1 CDM 0278 RC inpatient 727 472.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 440.2 705.19 2.4 LCK SCREW ST/SD 6M 212.806 48712309_1 CDM 0278 RC inpatient 727 472.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 440.2 705.19 2.4 LCK SCREW ST/SD 6M 212.806 48712309_1 CDM 0278 RC inpatient 727 472.55 ANTHEM HMO ANTHEM HMO 999999999 440.2 705.19 2.4 LCK SCREW ST/SD 6M 212.806 48712309_1 CDM 0278 RC inpatient 727 472.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 440.2 705.19 2.4 LCK SCREW ST/SD 6M 212.806 48712309_1 CDM 0278 RC inpatient 727 472.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 491.45 67.6 999999999 440.2 705.19 percent of total billed charges 2.4 LCK SCREW ST/SD 6M 212.806 48712309_1 CDM 0278 RC inpatient 727 472.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 440.2 705.19 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712310_1 CDM 0278 RC C1713 HCPCS inpatient 779 506.35 AETNA AETNA 615.41 79 999999999 471.68 755.63 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712310_1 CDM 0278 RC C1713 HCPCS inpatient 779 506.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 506.35 65 999999999 471.68 755.63 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712310_1 CDM 0278 RC C1713 HCPCS inpatient 779 506.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 755.63 97 999999999 471.68 755.63 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712310_1 CDM 0278 RC C1713 HCPCS inpatient 779 506.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 607.62 78 999999999 471.68 755.63 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712310_1 CDM 0278 RC C1713 HCPCS inpatient 779 506.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 537.51 69 999999999 471.68 755.63 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712310_1 CDM 0278 RC C1713 HCPCS inpatient 779 506.35 UMR - ALL PLANS UMR - ALL PLANS 545.3 70 999999999 471.68 755.63 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712310_1 CDM 0278 RC C1713 HCPCS inpatient 779 506.35 SIHO - ALL PLANS SIHO - ALL PLANS 701.1 90 999999999 471.68 755.63 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712310_1 CDM 0278 RC C1713 HCPCS inpatient 779 506.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 471.68 60.55 999999999 471.68 755.63 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712310_1 CDM 0278 RC C1713 HCPCS inpatient 779 506.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 471.68 755.63 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712310_1 CDM 0278 RC C1713 HCPCS inpatient 779 506.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 471.68 755.63 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712310_1 CDM 0278 RC C1713 HCPCS inpatient 779 506.35 ANTHEM HMO ANTHEM HMO 999999999 471.68 755.63 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712310_1 CDM 0278 RC C1713 HCPCS inpatient 779 506.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 471.68 755.63 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712310_1 CDM 0278 RC C1713 HCPCS inpatient 779 506.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 526.6 67.6 999999999 471.68 755.63 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712310_1 CDM 0278 RC C1713 HCPCS inpatient 779 506.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 471.68 755.63 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712311_1 CDM 0278 RC C1713 HCPCS inpatient 723 469.95 AETNA AETNA 571.17 79 999999999 437.78 701.31 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712311_1 CDM 0278 RC C1713 HCPCS inpatient 723 469.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 469.95 65 999999999 437.78 701.31 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712311_1 CDM 0278 RC C1713 HCPCS inpatient 723 469.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 701.31 97 999999999 437.78 701.31 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712311_1 CDM 0278 RC C1713 HCPCS inpatient 723 469.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 563.94 78 999999999 437.78 701.31 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712311_1 CDM 0278 RC C1713 HCPCS inpatient 723 469.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 498.87 69 999999999 437.78 701.31 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712311_1 CDM 0278 RC C1713 HCPCS inpatient 723 469.95 UMR - ALL PLANS UMR - ALL PLANS 506.1 70 999999999 437.78 701.31 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712311_1 CDM 0278 RC C1713 HCPCS inpatient 723 469.95 SIHO - ALL PLANS SIHO - ALL PLANS 650.7 90 999999999 437.78 701.31 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712311_1 CDM 0278 RC C1713 HCPCS inpatient 723 469.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 437.78 60.55 999999999 437.78 701.31 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712311_1 CDM 0278 RC C1713 HCPCS inpatient 723 469.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 437.78 701.31 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712311_1 CDM 0278 RC C1713 HCPCS inpatient 723 469.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 437.78 701.31 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712311_1 CDM 0278 RC C1713 HCPCS inpatient 723 469.95 ANTHEM HMO ANTHEM HMO 999999999 437.78 701.31 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712311_1 CDM 0278 RC C1713 HCPCS inpatient 723 469.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 437.78 701.31 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712311_1 CDM 0278 RC C1713 HCPCS inpatient 723 469.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 488.75 67.6 999999999 437.78 701.31 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712311_1 CDM 0278 RC C1713 HCPCS inpatient 723 469.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 437.78 701.31 SM FRA 8HOLE DPC PL 3.5 423.58 48712312_1 CDM 0278 RC inpatient 1080 702 AETNA AETNA 853.2 79 999999999 653.94 1047.6 percent of total billed charges SM FRA 8HOLE DPC PL 3.5 423.58 48712312_1 CDM 0278 RC inpatient 1080 702 SELF PAY DISCOUNT SELF PAY DISCOUNT 702 65 999999999 653.94 1047.6 percent of total billed charges SM FRA 8HOLE DPC PL 3.5 423.58 48712312_1 CDM 0278 RC inpatient 1080 702 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1047.6 97 999999999 653.94 1047.6 percent of total billed charges SM FRA 8HOLE DPC PL 3.5 423.58 48712312_1 CDM 0278 RC inpatient 1080 702 HUMANA - ALL PLANS HUMANA - ALL PLANS 842.4 78 999999999 653.94 1047.6 percent of total billed charges SM FRA 8HOLE DPC PL 3.5 423.58 48712312_1 CDM 0278 RC inpatient 1080 702 ENCORE - ALL PLANS ENCORE - ALL PLANS 745.2 69 999999999 653.94 1047.6 percent of total billed charges SM FRA 8HOLE DPC PL 3.5 423.58 48712312_1 CDM 0278 RC inpatient 1080 702 UMR - ALL PLANS UMR - ALL PLANS 756 70 999999999 653.94 1047.6 percent of total billed charges SM FRA 8HOLE DPC PL 3.5 423.58 48712312_1 CDM 0278 RC inpatient 1080 702 SIHO - ALL PLANS SIHO - ALL PLANS 972 90 999999999 653.94 1047.6 percent of total billed charges SM FRA 8HOLE DPC PL 3.5 423.58 48712312_1 CDM 0278 RC inpatient 1080 702 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 653.94 60.55 999999999 653.94 1047.6 percent of total billed charges SM FRA 8HOLE DPC PL 3.5 423.58 48712312_1 CDM 0278 RC inpatient 1080 702 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 653.94 1047.6 SM FRA 8HOLE DPC PL 3.5 423.58 48712312_1 CDM 0278 RC inpatient 1080 702 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 653.94 1047.6 SM FRA 8HOLE DPC PL 3.5 423.58 48712312_1 CDM 0278 RC inpatient 1080 702 ANTHEM HMO ANTHEM HMO 999999999 653.94 1047.6 SM FRA 8HOLE DPC PL 3.5 423.58 48712312_1 CDM 0278 RC inpatient 1080 702 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 653.94 1047.6 SM FRA 8HOLE DPC PL 3.5 423.58 48712312_1 CDM 0278 RC inpatient 1080 702 CIGNA - ALL PLANS CIGNA - ALL PLANS 730.08 67.6 999999999 653.94 1047.6 percent of total billed charges SM FRA 8HOLE DPC PL 3.5 423.58 48712312_1 CDM 0278 RC inpatient 1080 702 UHC - ALL PLANS UHC - ALL PLANS 999999999 653.94 1047.6 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712313_1 CDM 0278 RC C1713 HCPCS inpatient 873 567.45 AETNA AETNA 689.67 79 999999999 528.6 846.81 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712313_1 CDM 0278 RC C1713 HCPCS inpatient 873 567.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 567.45 65 999999999 528.6 846.81 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712313_1 CDM 0278 RC C1713 HCPCS inpatient 873 567.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 846.81 97 999999999 528.6 846.81 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712313_1 CDM 0278 RC C1713 HCPCS inpatient 873 567.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 680.94 78 999999999 528.6 846.81 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712313_1 CDM 0278 RC C1713 HCPCS inpatient 873 567.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 602.37 69 999999999 528.6 846.81 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712313_1 CDM 0278 RC C1713 HCPCS inpatient 873 567.45 UMR - ALL PLANS UMR - ALL PLANS 611.1 70 999999999 528.6 846.81 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712313_1 CDM 0278 RC C1713 HCPCS inpatient 873 567.45 SIHO - ALL PLANS SIHO - ALL PLANS 785.7 90 999999999 528.6 846.81 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712313_1 CDM 0278 RC C1713 HCPCS inpatient 873 567.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 528.6 60.55 999999999 528.6 846.81 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712313_1 CDM 0278 RC C1713 HCPCS inpatient 873 567.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 528.6 846.81 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712313_1 CDM 0278 RC C1713 HCPCS inpatient 873 567.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 528.6 846.81 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712313_1 CDM 0278 RC C1713 HCPCS inpatient 873 567.45 ANTHEM HMO ANTHEM HMO 999999999 528.6 846.81 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712313_1 CDM 0278 RC C1713 HCPCS inpatient 873 567.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 528.6 846.81 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712313_1 CDM 0278 RC C1713 HCPCS inpatient 873 567.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 590.15 67.6 999999999 528.6 846.81 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712313_1 CDM 0278 RC C1713 HCPCS inpatient 873 567.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 528.6 846.81 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712314_1 CDM 0278 RC C1713 HCPCS inpatient 785 510.25 AETNA AETNA 620.15 79 999999999 475.32 761.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712314_1 CDM 0278 RC C1713 HCPCS inpatient 785 510.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 510.25 65 999999999 475.32 761.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712314_1 CDM 0278 RC C1713 HCPCS inpatient 785 510.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 761.45 97 999999999 475.32 761.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712314_1 CDM 0278 RC C1713 HCPCS inpatient 785 510.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 612.3 78 999999999 475.32 761.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712314_1 CDM 0278 RC C1713 HCPCS inpatient 785 510.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 541.65 69 999999999 475.32 761.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712314_1 CDM 0278 RC C1713 HCPCS inpatient 785 510.25 UMR - ALL PLANS UMR - ALL PLANS 549.5 70 999999999 475.32 761.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712314_1 CDM 0278 RC C1713 HCPCS inpatient 785 510.25 SIHO - ALL PLANS SIHO - ALL PLANS 706.5 90 999999999 475.32 761.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712314_1 CDM 0278 RC C1713 HCPCS inpatient 785 510.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 475.32 60.55 999999999 475.32 761.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712314_1 CDM 0278 RC C1713 HCPCS inpatient 785 510.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 475.32 761.45 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712314_1 CDM 0278 RC C1713 HCPCS inpatient 785 510.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 475.32 761.45 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712314_1 CDM 0278 RC C1713 HCPCS inpatient 785 510.25 ANTHEM HMO ANTHEM HMO 999999999 475.32 761.45 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712314_1 CDM 0278 RC C1713 HCPCS inpatient 785 510.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 475.32 761.45 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712314_1 CDM 0278 RC C1713 HCPCS inpatient 785 510.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 530.66 67.6 999999999 475.32 761.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712314_1 CDM 0278 RC C1713 HCPCS inpatient 785 510.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 475.32 761.45 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712315_1 CDM 0278 RC C1713 HCPCS inpatient 762 495.3 AETNA AETNA 601.98 79 999999999 461.39 739.14 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712315_1 CDM 0278 RC C1713 HCPCS inpatient 762 495.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 495.3 65 999999999 461.39 739.14 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712315_1 CDM 0278 RC C1713 HCPCS inpatient 762 495.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 739.14 97 999999999 461.39 739.14 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712315_1 CDM 0278 RC C1713 HCPCS inpatient 762 495.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 594.36 78 999999999 461.39 739.14 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712315_1 CDM 0278 RC C1713 HCPCS inpatient 762 495.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 525.78 69 999999999 461.39 739.14 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712315_1 CDM 0278 RC C1713 HCPCS inpatient 762 495.3 UMR - ALL PLANS UMR - ALL PLANS 533.4 70 999999999 461.39 739.14 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712315_1 CDM 0278 RC C1713 HCPCS inpatient 762 495.3 SIHO - ALL PLANS SIHO - ALL PLANS 685.8 90 999999999 461.39 739.14 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712315_1 CDM 0278 RC C1713 HCPCS inpatient 762 495.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 461.39 60.55 999999999 461.39 739.14 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712315_1 CDM 0278 RC C1713 HCPCS inpatient 762 495.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 461.39 739.14 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712315_1 CDM 0278 RC C1713 HCPCS inpatient 762 495.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 461.39 739.14 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712315_1 CDM 0278 RC C1713 HCPCS inpatient 762 495.3 ANTHEM HMO ANTHEM HMO 999999999 461.39 739.14 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712315_1 CDM 0278 RC C1713 HCPCS inpatient 762 495.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 461.39 739.14 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712315_1 CDM 0278 RC C1713 HCPCS inpatient 762 495.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 515.11 67.6 999999999 461.39 739.14 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712315_1 CDM 0278 RC C1713 HCPCS inpatient 762 495.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 461.39 739.14 2.4 LK SCREW ST/SD 28M 212.828 48712316_1 CDM 0278 RC inpatient 785 510.25 AETNA AETNA 620.15 79 999999999 475.32 761.45 percent of total billed charges 2.4 LK SCREW ST/SD 28M 212.828 48712316_1 CDM 0278 RC inpatient 785 510.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 510.25 65 999999999 475.32 761.45 percent of total billed charges 2.4 LK SCREW ST/SD 28M 212.828 48712316_1 CDM 0278 RC inpatient 785 510.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 761.45 97 999999999 475.32 761.45 percent of total billed charges 2.4 LK SCREW ST/SD 28M 212.828 48712316_1 CDM 0278 RC inpatient 785 510.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 612.3 78 999999999 475.32 761.45 percent of total billed charges 2.4 LK SCREW ST/SD 28M 212.828 48712316_1 CDM 0278 RC inpatient 785 510.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 541.65 69 999999999 475.32 761.45 percent of total billed charges 2.4 LK SCREW ST/SD 28M 212.828 48712316_1 CDM 0278 RC inpatient 785 510.25 UMR - ALL PLANS UMR - ALL PLANS 549.5 70 999999999 475.32 761.45 percent of total billed charges 2.4 LK SCREW ST/SD 28M 212.828 48712316_1 CDM 0278 RC inpatient 785 510.25 SIHO - ALL PLANS SIHO - ALL PLANS 706.5 90 999999999 475.32 761.45 percent of total billed charges 2.4 LK SCREW ST/SD 28M 212.828 48712316_1 CDM 0278 RC inpatient 785 510.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 475.32 60.55 999999999 475.32 761.45 percent of total billed charges 2.4 LK SCREW ST/SD 28M 212.828 48712316_1 CDM 0278 RC inpatient 785 510.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 475.32 761.45 2.4 LK SCREW ST/SD 28M 212.828 48712316_1 CDM 0278 RC inpatient 785 510.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 475.32 761.45 2.4 LK SCREW ST/SD 28M 212.828 48712316_1 CDM 0278 RC inpatient 785 510.25 ANTHEM HMO ANTHEM HMO 999999999 475.32 761.45 2.4 LK SCREW ST/SD 28M 212.828 48712316_1 CDM 0278 RC inpatient 785 510.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 475.32 761.45 2.4 LK SCREW ST/SD 28M 212.828 48712316_1 CDM 0278 RC inpatient 785 510.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 530.66 67.6 999999999 475.32 761.45 percent of total billed charges 2.4 LK SCREW ST/SD 28M 212.828 48712316_1 CDM 0278 RC inpatient 785 510.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 475.32 761.45 SM FRA 9HOLE DPC PL 3.5 423.59 48712317_1 CDM 0278 RC inpatient 994 646.1 AETNA AETNA 785.26 79 999999999 601.87 964.18 percent of total billed charges SM FRA 9HOLE DPC PL 3.5 423.59 48712317_1 CDM 0278 RC inpatient 994 646.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 646.1 65 999999999 601.87 964.18 percent of total billed charges SM FRA 9HOLE DPC PL 3.5 423.59 48712317_1 CDM 0278 RC inpatient 994 646.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 964.18 97 999999999 601.87 964.18 percent of total billed charges SM FRA 9HOLE DPC PL 3.5 423.59 48712317_1 CDM 0278 RC inpatient 994 646.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 775.32 78 999999999 601.87 964.18 percent of total billed charges SM FRA 9HOLE DPC PL 3.5 423.59 48712317_1 CDM 0278 RC inpatient 994 646.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 685.86 69 999999999 601.87 964.18 percent of total billed charges SM FRA 9HOLE DPC PL 3.5 423.59 48712317_1 CDM 0278 RC inpatient 994 646.1 UMR - ALL PLANS UMR - ALL PLANS 695.8 70 999999999 601.87 964.18 percent of total billed charges SM FRA 9HOLE DPC PL 3.5 423.59 48712317_1 CDM 0278 RC inpatient 994 646.1 SIHO - ALL PLANS SIHO - ALL PLANS 894.6 90 999999999 601.87 964.18 percent of total billed charges SM FRA 9HOLE DPC PL 3.5 423.59 48712317_1 CDM 0278 RC inpatient 994 646.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 601.87 60.55 999999999 601.87 964.18 percent of total billed charges SM FRA 9HOLE DPC PL 3.5 423.59 48712317_1 CDM 0278 RC inpatient 994 646.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 601.87 964.18 SM FRA 9HOLE DPC PL 3.5 423.59 48712317_1 CDM 0278 RC inpatient 994 646.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 601.87 964.18 SM FRA 9HOLE DPC PL 3.5 423.59 48712317_1 CDM 0278 RC inpatient 994 646.1 ANTHEM HMO ANTHEM HMO 999999999 601.87 964.18 SM FRA 9HOLE DPC PL 3.5 423.59 48712317_1 CDM 0278 RC inpatient 994 646.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 601.87 964.18 SM FRA 9HOLE DPC PL 3.5 423.59 48712317_1 CDM 0278 RC inpatient 994 646.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 671.94 67.6 999999999 601.87 964.18 percent of total billed charges SM FRA 9HOLE DPC PL 3.5 423.59 48712317_1 CDM 0278 RC inpatient 994 646.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 601.87 964.18 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712318_1 CDM 0278 RC C1713 HCPCS inpatient 446 289.9 AETNA AETNA 352.34 79 999999999 270.05 432.62 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712318_1 CDM 0278 RC C1713 HCPCS inpatient 446 289.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 289.9 65 999999999 270.05 432.62 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712318_1 CDM 0278 RC C1713 HCPCS inpatient 446 289.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 432.62 97 999999999 270.05 432.62 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712318_1 CDM 0278 RC C1713 HCPCS inpatient 446 289.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 347.88 78 999999999 270.05 432.62 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712318_1 CDM 0278 RC C1713 HCPCS inpatient 446 289.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 307.74 69 999999999 270.05 432.62 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712318_1 CDM 0278 RC C1713 HCPCS inpatient 446 289.9 UMR - ALL PLANS UMR - ALL PLANS 312.2 70 999999999 270.05 432.62 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712318_1 CDM 0278 RC C1713 HCPCS inpatient 446 289.9 SIHO - ALL PLANS SIHO - ALL PLANS 401.4 90 999999999 270.05 432.62 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712318_1 CDM 0278 RC C1713 HCPCS inpatient 446 289.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.05 60.55 999999999 270.05 432.62 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712318_1 CDM 0278 RC C1713 HCPCS inpatient 446 289.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.05 432.62 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712318_1 CDM 0278 RC C1713 HCPCS inpatient 446 289.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.05 432.62 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712318_1 CDM 0278 RC C1713 HCPCS inpatient 446 289.9 ANTHEM HMO ANTHEM HMO 999999999 270.05 432.62 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712318_1 CDM 0278 RC C1713 HCPCS inpatient 446 289.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.05 432.62 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712318_1 CDM 0278 RC C1713 HCPCS inpatient 446 289.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 301.5 67.6 999999999 270.05 432.62 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712318_1 CDM 0278 RC C1713 HCPCS inpatient 446 289.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.05 432.62 SM FRA 10H DPC PL 3.5 423.60 48712319_1 CDM 0278 RC inpatient 628 408.2 AETNA AETNA 496.12 79 999999999 380.25 609.16 percent of total billed charges SM FRA 10H DPC PL 3.5 423.60 48712319_1 CDM 0278 RC inpatient 628 408.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 408.2 65 999999999 380.25 609.16 percent of total billed charges SM FRA 10H DPC PL 3.5 423.60 48712319_1 CDM 0278 RC inpatient 628 408.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 609.16 97 999999999 380.25 609.16 percent of total billed charges SM FRA 10H DPC PL 3.5 423.60 48712319_1 CDM 0278 RC inpatient 628 408.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 489.84 78 999999999 380.25 609.16 percent of total billed charges SM FRA 10H DPC PL 3.5 423.60 48712319_1 CDM 0278 RC inpatient 628 408.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 433.32 69 999999999 380.25 609.16 percent of total billed charges SM FRA 10H DPC PL 3.5 423.60 48712319_1 CDM 0278 RC inpatient 628 408.2 UMR - ALL PLANS UMR - ALL PLANS 439.6 70 999999999 380.25 609.16 percent of total billed charges SM FRA 10H DPC PL 3.5 423.60 48712319_1 CDM 0278 RC inpatient 628 408.2 SIHO - ALL PLANS SIHO - ALL PLANS 565.2 90 999999999 380.25 609.16 percent of total billed charges SM FRA 10H DPC PL 3.5 423.60 48712319_1 CDM 0278 RC inpatient 628 408.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 380.25 60.55 999999999 380.25 609.16 percent of total billed charges SM FRA 10H DPC PL 3.5 423.60 48712319_1 CDM 0278 RC inpatient 628 408.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 380.25 609.16 SM FRA 10H DPC PL 3.5 423.60 48712319_1 CDM 0278 RC inpatient 628 408.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 380.25 609.16 SM FRA 10H DPC PL 3.5 423.60 48712319_1 CDM 0278 RC inpatient 628 408.2 ANTHEM HMO ANTHEM HMO 999999999 380.25 609.16 SM FRA 10H DPC PL 3.5 423.60 48712319_1 CDM 0278 RC inpatient 628 408.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 380.25 609.16 SM FRA 10H DPC PL 3.5 423.60 48712319_1 CDM 0278 RC inpatient 628 408.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 424.53 67.6 999999999 380.25 609.16 percent of total billed charges SM FRA 10H DPC PL 3.5 423.60 48712319_1 CDM 0278 RC inpatient 628 408.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 380.25 609.16 2.4 LK SCREW ST/SD 30M 212.830 48712320_1 CDM 0278 RC inpatient 847 550.55 AETNA AETNA 669.13 79 999999999 512.86 821.59 percent of total billed charges 2.4 LK SCREW ST/SD 30M 212.830 48712320_1 CDM 0278 RC inpatient 847 550.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 550.55 65 999999999 512.86 821.59 percent of total billed charges 2.4 LK SCREW ST/SD 30M 212.830 48712320_1 CDM 0278 RC inpatient 847 550.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 821.59 97 999999999 512.86 821.59 percent of total billed charges 2.4 LK SCREW ST/SD 30M 212.830 48712320_1 CDM 0278 RC inpatient 847 550.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 660.66 78 999999999 512.86 821.59 percent of total billed charges 2.4 LK SCREW ST/SD 30M 212.830 48712320_1 CDM 0278 RC inpatient 847 550.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 584.43 69 999999999 512.86 821.59 percent of total billed charges 2.4 LK SCREW ST/SD 30M 212.830 48712320_1 CDM 0278 RC inpatient 847 550.55 UMR - ALL PLANS UMR - ALL PLANS 592.9 70 999999999 512.86 821.59 percent of total billed charges 2.4 LK SCREW ST/SD 30M 212.830 48712320_1 CDM 0278 RC inpatient 847 550.55 SIHO - ALL PLANS SIHO - ALL PLANS 762.3 90 999999999 512.86 821.59 percent of total billed charges 2.4 LK SCREW ST/SD 30M 212.830 48712320_1 CDM 0278 RC inpatient 847 550.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 512.86 60.55 999999999 512.86 821.59 percent of total billed charges 2.4 LK SCREW ST/SD 30M 212.830 48712320_1 CDM 0278 RC inpatient 847 550.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 512.86 821.59 2.4 LK SCREW ST/SD 30M 212.830 48712320_1 CDM 0278 RC inpatient 847 550.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 512.86 821.59 2.4 LK SCREW ST/SD 30M 212.830 48712320_1 CDM 0278 RC inpatient 847 550.55 ANTHEM HMO ANTHEM HMO 999999999 512.86 821.59 2.4 LK SCREW ST/SD 30M 212.830 48712320_1 CDM 0278 RC inpatient 847 550.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 512.86 821.59 2.4 LK SCREW ST/SD 30M 212.830 48712320_1 CDM 0278 RC inpatient 847 550.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 572.57 67.6 999999999 512.86 821.59 percent of total billed charges 2.4 LK SCREW ST/SD 30M 212.830 48712320_1 CDM 0278 RC inpatient 847 550.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 512.86 821.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712321_1 CDM 0278 RC C1713 HCPCS inpatient 377 245.05 AETNA AETNA 297.83 79 999999999 228.27 365.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712321_1 CDM 0278 RC C1713 HCPCS inpatient 377 245.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 245.05 65 999999999 228.27 365.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712321_1 CDM 0278 RC C1713 HCPCS inpatient 377 245.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 365.69 97 999999999 228.27 365.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712321_1 CDM 0278 RC C1713 HCPCS inpatient 377 245.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 294.06 78 999999999 228.27 365.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712321_1 CDM 0278 RC C1713 HCPCS inpatient 377 245.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 260.13 69 999999999 228.27 365.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712321_1 CDM 0278 RC C1713 HCPCS inpatient 377 245.05 UMR - ALL PLANS UMR - ALL PLANS 263.9 70 999999999 228.27 365.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712321_1 CDM 0278 RC C1713 HCPCS inpatient 377 245.05 SIHO - ALL PLANS SIHO - ALL PLANS 339.3 90 999999999 228.27 365.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712321_1 CDM 0278 RC C1713 HCPCS inpatient 377 245.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 228.27 60.55 999999999 228.27 365.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712321_1 CDM 0278 RC C1713 HCPCS inpatient 377 245.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 228.27 365.69 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712321_1 CDM 0278 RC C1713 HCPCS inpatient 377 245.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 228.27 365.69 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712321_1 CDM 0278 RC C1713 HCPCS inpatient 377 245.05 ANTHEM HMO ANTHEM HMO 999999999 228.27 365.69 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712321_1 CDM 0278 RC C1713 HCPCS inpatient 377 245.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 228.27 365.69 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712321_1 CDM 0278 RC C1713 HCPCS inpatient 377 245.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 254.85 67.6 999999999 228.27 365.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712321_1 CDM 0278 RC C1713 HCPCS inpatient 377 245.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 228.27 365.69 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712322_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 AETNA AETNA 331.8 79 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712322_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 SELF PAY DISCOUNT SELF PAY DISCOUNT 273 65 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712322_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 407.4 97 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712322_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 HUMANA - ALL PLANS HUMANA - ALL PLANS 327.6 78 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712322_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 ENCORE - ALL PLANS ENCORE - ALL PLANS 289.8 69 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712322_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 UMR - ALL PLANS UMR - ALL PLANS 294 70 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712322_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 SIHO - ALL PLANS SIHO - ALL PLANS 378 90 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712322_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 254.31 60.55 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712322_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 254.31 407.4 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712322_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 254.31 407.4 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712322_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 ANTHEM HMO ANTHEM HMO 999999999 254.31 407.4 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712322_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 254.31 407.4 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712322_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 CIGNA - ALL PLANS CIGNA - ALL PLANS 283.92 67.6 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712322_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 UHC - ALL PLANS UHC - ALL PLANS 999999999 254.31 407.4 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712323_1 CDM 0278 RC C1713 HCPCS inpatient 460 299 AETNA AETNA 363.4 79 999999999 278.53 446.2 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712323_1 CDM 0278 RC C1713 HCPCS inpatient 460 299 SELF PAY DISCOUNT SELF PAY DISCOUNT 299 65 999999999 278.53 446.2 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712323_1 CDM 0278 RC C1713 HCPCS inpatient 460 299 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 446.2 97 999999999 278.53 446.2 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712323_1 CDM 0278 RC C1713 HCPCS inpatient 460 299 HUMANA - ALL PLANS HUMANA - ALL PLANS 358.8 78 999999999 278.53 446.2 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712323_1 CDM 0278 RC C1713 HCPCS inpatient 460 299 ENCORE - ALL PLANS ENCORE - ALL PLANS 317.4 69 999999999 278.53 446.2 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712323_1 CDM 0278 RC C1713 HCPCS inpatient 460 299 UMR - ALL PLANS UMR - ALL PLANS 322 70 999999999 278.53 446.2 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712323_1 CDM 0278 RC C1713 HCPCS inpatient 460 299 SIHO - ALL PLANS SIHO - ALL PLANS 414 90 999999999 278.53 446.2 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712323_1 CDM 0278 RC C1713 HCPCS inpatient 460 299 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 278.53 60.55 999999999 278.53 446.2 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712323_1 CDM 0278 RC C1713 HCPCS inpatient 460 299 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 278.53 446.2 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712323_1 CDM 0278 RC C1713 HCPCS inpatient 460 299 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 278.53 446.2 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712323_1 CDM 0278 RC C1713 HCPCS inpatient 460 299 ANTHEM HMO ANTHEM HMO 999999999 278.53 446.2 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712323_1 CDM 0278 RC C1713 HCPCS inpatient 460 299 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 278.53 446.2 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712323_1 CDM 0278 RC C1713 HCPCS inpatient 460 299 CIGNA - ALL PLANS CIGNA - ALL PLANS 310.96 67.6 999999999 278.53 446.2 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712323_1 CDM 0278 RC C1713 HCPCS inpatient 460 299 UHC - ALL PLANS UHC - ALL PLANS 999999999 278.53 446.2 2.4 CTX SCREW S/T 12M 201.762 48712324_1 CDM 0278 RC inpatient 407 264.55 AETNA AETNA 321.53 79 999999999 246.44 394.79 percent of total billed charges 2.4 CTX SCREW S/T 12M 201.762 48712324_1 CDM 0278 RC inpatient 407 264.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 264.55 65 999999999 246.44 394.79 percent of total billed charges 2.4 CTX SCREW S/T 12M 201.762 48712324_1 CDM 0278 RC inpatient 407 264.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 394.79 97 999999999 246.44 394.79 percent of total billed charges 2.4 CTX SCREW S/T 12M 201.762 48712324_1 CDM 0278 RC inpatient 407 264.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 317.46 78 999999999 246.44 394.79 percent of total billed charges 2.4 CTX SCREW S/T 12M 201.762 48712324_1 CDM 0278 RC inpatient 407 264.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 280.83 69 999999999 246.44 394.79 percent of total billed charges 2.4 CTX SCREW S/T 12M 201.762 48712324_1 CDM 0278 RC inpatient 407 264.55 UMR - ALL PLANS UMR - ALL PLANS 284.9 70 999999999 246.44 394.79 percent of total billed charges 2.4 CTX SCREW S/T 12M 201.762 48712324_1 CDM 0278 RC inpatient 407 264.55 SIHO - ALL PLANS SIHO - ALL PLANS 366.3 90 999999999 246.44 394.79 percent of total billed charges 2.4 CTX SCREW S/T 12M 201.762 48712324_1 CDM 0278 RC inpatient 407 264.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 246.44 60.55 999999999 246.44 394.79 percent of total billed charges 2.4 CTX SCREW S/T 12M 201.762 48712324_1 CDM 0278 RC inpatient 407 264.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 246.44 394.79 2.4 CTX SCREW S/T 12M 201.762 48712324_1 CDM 0278 RC inpatient 407 264.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 246.44 394.79 2.4 CTX SCREW S/T 12M 201.762 48712324_1 CDM 0278 RC inpatient 407 264.55 ANTHEM HMO ANTHEM HMO 999999999 246.44 394.79 2.4 CTX SCREW S/T 12M 201.762 48712324_1 CDM 0278 RC inpatient 407 264.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 246.44 394.79 2.4 CTX SCREW S/T 12M 201.762 48712324_1 CDM 0278 RC inpatient 407 264.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 275.13 67.6 999999999 246.44 394.79 percent of total billed charges 2.4 CTX SCREW S/T 12M 201.762 48712324_1 CDM 0278 RC inpatient 407 264.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 246.44 394.79 2.4 CTX SCREW S/T 14MM 201.764 48712325_1 CDM 0278 RC inpatient 395 256.75 AETNA AETNA 312.05 79 999999999 239.17 383.15 percent of total billed charges 2.4 CTX SCREW S/T 14MM 201.764 48712325_1 CDM 0278 RC inpatient 395 256.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 256.75 65 999999999 239.17 383.15 percent of total billed charges 2.4 CTX SCREW S/T 14MM 201.764 48712325_1 CDM 0278 RC inpatient 395 256.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 383.15 97 999999999 239.17 383.15 percent of total billed charges 2.4 CTX SCREW S/T 14MM 201.764 48712325_1 CDM 0278 RC inpatient 395 256.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 308.1 78 999999999 239.17 383.15 percent of total billed charges 2.4 CTX SCREW S/T 14MM 201.764 48712325_1 CDM 0278 RC inpatient 395 256.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 272.55 69 999999999 239.17 383.15 percent of total billed charges 2.4 CTX SCREW S/T 14MM 201.764 48712325_1 CDM 0278 RC inpatient 395 256.75 UMR - ALL PLANS UMR - ALL PLANS 276.5 70 999999999 239.17 383.15 percent of total billed charges 2.4 CTX SCREW S/T 14MM 201.764 48712325_1 CDM 0278 RC inpatient 395 256.75 SIHO - ALL PLANS SIHO - ALL PLANS 355.5 90 999999999 239.17 383.15 percent of total billed charges 2.4 CTX SCREW S/T 14MM 201.764 48712325_1 CDM 0278 RC inpatient 395 256.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 239.17 60.55 999999999 239.17 383.15 percent of total billed charges 2.4 CTX SCREW S/T 14MM 201.764 48712325_1 CDM 0278 RC inpatient 395 256.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 239.17 383.15 2.4 CTX SCREW S/T 14MM 201.764 48712325_1 CDM 0278 RC inpatient 395 256.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 239.17 383.15 2.4 CTX SCREW S/T 14MM 201.764 48712325_1 CDM 0278 RC inpatient 395 256.75 ANTHEM HMO ANTHEM HMO 999999999 239.17 383.15 2.4 CTX SCREW S/T 14MM 201.764 48712325_1 CDM 0278 RC inpatient 395 256.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 239.17 383.15 2.4 CTX SCREW S/T 14MM 201.764 48712325_1 CDM 0278 RC inpatient 395 256.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 267.02 67.6 999999999 239.17 383.15 percent of total billed charges 2.4 CTX SCREW S/T 14MM 201.764 48712325_1 CDM 0278 RC inpatient 395 256.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 239.17 383.15 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712326_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 AETNA AETNA 321.53 79 999999999 246.44 394.79 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712326_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 264.55 65 999999999 246.44 394.79 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712326_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 394.79 97 999999999 246.44 394.79 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712326_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 317.46 78 999999999 246.44 394.79 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712326_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 280.83 69 999999999 246.44 394.79 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712326_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 UMR - ALL PLANS UMR - ALL PLANS 284.9 70 999999999 246.44 394.79 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712326_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 SIHO - ALL PLANS SIHO - ALL PLANS 366.3 90 999999999 246.44 394.79 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712326_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 246.44 60.55 999999999 246.44 394.79 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712326_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 246.44 394.79 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712326_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 246.44 394.79 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712326_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 ANTHEM HMO ANTHEM HMO 999999999 246.44 394.79 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712326_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 246.44 394.79 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712326_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 275.13 67.6 999999999 246.44 394.79 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712326_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 246.44 394.79 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712327_1 CDM 0278 RC C1713 HCPCS inpatient 411 267.15 AETNA AETNA 324.69 79 999999999 248.86 398.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712327_1 CDM 0278 RC C1713 HCPCS inpatient 411 267.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 267.15 65 999999999 248.86 398.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712327_1 CDM 0278 RC C1713 HCPCS inpatient 411 267.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 398.67 97 999999999 248.86 398.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712327_1 CDM 0278 RC C1713 HCPCS inpatient 411 267.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 320.58 78 999999999 248.86 398.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712327_1 CDM 0278 RC C1713 HCPCS inpatient 411 267.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 283.59 69 999999999 248.86 398.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712327_1 CDM 0278 RC C1713 HCPCS inpatient 411 267.15 UMR - ALL PLANS UMR - ALL PLANS 287.7 70 999999999 248.86 398.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712327_1 CDM 0278 RC C1713 HCPCS inpatient 411 267.15 SIHO - ALL PLANS SIHO - ALL PLANS 369.9 90 999999999 248.86 398.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712327_1 CDM 0278 RC C1713 HCPCS inpatient 411 267.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 248.86 60.55 999999999 248.86 398.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712327_1 CDM 0278 RC C1713 HCPCS inpatient 411 267.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 248.86 398.67 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712327_1 CDM 0278 RC C1713 HCPCS inpatient 411 267.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 248.86 398.67 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712327_1 CDM 0278 RC C1713 HCPCS inpatient 411 267.15 ANTHEM HMO ANTHEM HMO 999999999 248.86 398.67 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712327_1 CDM 0278 RC C1713 HCPCS inpatient 411 267.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 248.86 398.67 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712327_1 CDM 0278 RC C1713 HCPCS inpatient 411 267.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 277.84 67.6 999999999 248.86 398.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712327_1 CDM 0278 RC C1713 HCPCS inpatient 411 267.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 248.86 398.67 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712328_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 AETNA AETNA 331.8 79 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712328_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 SELF PAY DISCOUNT SELF PAY DISCOUNT 273 65 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712328_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 407.4 97 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712328_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 HUMANA - ALL PLANS HUMANA - ALL PLANS 327.6 78 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712328_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 ENCORE - ALL PLANS ENCORE - ALL PLANS 289.8 69 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712328_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 UMR - ALL PLANS UMR - ALL PLANS 294 70 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712328_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 SIHO - ALL PLANS SIHO - ALL PLANS 378 90 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712328_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 254.31 60.55 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712328_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 254.31 407.4 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712328_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 254.31 407.4 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712328_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 ANTHEM HMO ANTHEM HMO 999999999 254.31 407.4 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712328_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 254.31 407.4 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712328_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 CIGNA - ALL PLANS CIGNA - ALL PLANS 283.92 67.6 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712328_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 UHC - ALL PLANS UHC - ALL PLANS 999999999 254.31 407.4 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712329_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 AETNA AETNA 331.8 79 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712329_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 SELF PAY DISCOUNT SELF PAY DISCOUNT 273 65 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712329_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 407.4 97 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712329_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 HUMANA - ALL PLANS HUMANA - ALL PLANS 327.6 78 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712329_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 ENCORE - ALL PLANS ENCORE - ALL PLANS 289.8 69 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712329_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 UMR - ALL PLANS UMR - ALL PLANS 294 70 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712329_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 SIHO - ALL PLANS SIHO - ALL PLANS 378 90 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712329_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 254.31 60.55 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712329_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 254.31 407.4 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712329_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 254.31 407.4 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712329_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 ANTHEM HMO ANTHEM HMO 999999999 254.31 407.4 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712329_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 254.31 407.4 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712329_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 CIGNA - ALL PLANS CIGNA - ALL PLANS 283.92 67.6 999999999 254.31 407.4 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712329_1 CDM 0278 RC C1713 HCPCS inpatient 420 273 UHC - ALL PLANS UHC - ALL PLANS 999999999 254.31 407.4 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712330_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 AETNA AETNA 321.53 79 999999999 246.44 394.79 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712330_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 264.55 65 999999999 246.44 394.79 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712330_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 394.79 97 999999999 246.44 394.79 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712330_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 317.46 78 999999999 246.44 394.79 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712330_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 280.83 69 999999999 246.44 394.79 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712330_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 UMR - ALL PLANS UMR - ALL PLANS 284.9 70 999999999 246.44 394.79 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712330_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 SIHO - ALL PLANS SIHO - ALL PLANS 366.3 90 999999999 246.44 394.79 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712330_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 246.44 60.55 999999999 246.44 394.79 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712330_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 246.44 394.79 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712330_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 246.44 394.79 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712330_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 ANTHEM HMO ANTHEM HMO 999999999 246.44 394.79 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712330_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 246.44 394.79 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712330_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 275.13 67.6 999999999 246.44 394.79 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712330_1 CDM 0278 RC C1713 HCPCS inpatient 407 264.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 246.44 394.79 2.4 CTX SCREW S/T 30MM 201.780 48712331_1 CDM 0278 RC inpatient 395 256.75 AETNA AETNA 312.05 79 999999999 239.17 383.15 percent of total billed charges 2.4 CTX SCREW S/T 30MM 201.780 48712331_1 CDM 0278 RC inpatient 395 256.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 256.75 65 999999999 239.17 383.15 percent of total billed charges 2.4 CTX SCREW S/T 30MM 201.780 48712331_1 CDM 0278 RC inpatient 395 256.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 383.15 97 999999999 239.17 383.15 percent of total billed charges 2.4 CTX SCREW S/T 30MM 201.780 48712331_1 CDM 0278 RC inpatient 395 256.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 308.1 78 999999999 239.17 383.15 percent of total billed charges 2.4 CTX SCREW S/T 30MM 201.780 48712331_1 CDM 0278 RC inpatient 395 256.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 272.55 69 999999999 239.17 383.15 percent of total billed charges 2.4 CTX SCREW S/T 30MM 201.780 48712331_1 CDM 0278 RC inpatient 395 256.75 UMR - ALL PLANS UMR - ALL PLANS 276.5 70 999999999 239.17 383.15 percent of total billed charges 2.4 CTX SCREW S/T 30MM 201.780 48712331_1 CDM 0278 RC inpatient 395 256.75 SIHO - ALL PLANS SIHO - ALL PLANS 355.5 90 999999999 239.17 383.15 percent of total billed charges 2.4 CTX SCREW S/T 30MM 201.780 48712331_1 CDM 0278 RC inpatient 395 256.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 239.17 60.55 999999999 239.17 383.15 percent of total billed charges 2.4 CTX SCREW S/T 30MM 201.780 48712331_1 CDM 0278 RC inpatient 395 256.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 239.17 383.15 2.4 CTX SCREW S/T 30MM 201.780 48712331_1 CDM 0278 RC inpatient 395 256.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 239.17 383.15 2.4 CTX SCREW S/T 30MM 201.780 48712331_1 CDM 0278 RC inpatient 395 256.75 ANTHEM HMO ANTHEM HMO 999999999 239.17 383.15 2.4 CTX SCREW S/T 30MM 201.780 48712331_1 CDM 0278 RC inpatient 395 256.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 239.17 383.15 2.4 CTX SCREW S/T 30MM 201.780 48712331_1 CDM 0278 RC inpatient 395 256.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 267.02 67.6 999999999 239.17 383.15 percent of total billed charges 2.4 CTX SCREW S/T 30MM 201.780 48712331_1 CDM 0278 RC inpatient 395 256.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 239.17 383.15 2.7 CTX SCREW S/T 10MM 202.870 48712332_1 CDM 0278 RC inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 10MM 202.870 48712332_1 CDM 0278 RC inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 10MM 202.870 48712332_1 CDM 0278 RC inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 10MM 202.870 48712332_1 CDM 0278 RC inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 10MM 202.870 48712332_1 CDM 0278 RC inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 10MM 202.870 48712332_1 CDM 0278 RC inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 10MM 202.870 48712332_1 CDM 0278 RC inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 10MM 202.870 48712332_1 CDM 0278 RC inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 10MM 202.870 48712332_1 CDM 0278 RC inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 2.7 CTX SCREW S/T 10MM 202.870 48712332_1 CDM 0278 RC inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 2.7 CTX SCREW S/T 10MM 202.870 48712332_1 CDM 0278 RC inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 2.7 CTX SCREW S/T 10MM 202.870 48712332_1 CDM 0278 RC inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 2.7 CTX SCREW S/T 10MM 202.870 48712332_1 CDM 0278 RC inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 10MM 202.870 48712332_1 CDM 0278 RC inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 2.7 CTX SCREW S/T 12MM 202.872 48712333_1 CDM 0278 RC inpatient 321 208.65 AETNA AETNA 253.59 79 999999999 194.37 311.37 percent of total billed charges 2.7 CTX SCREW S/T 12MM 202.872 48712333_1 CDM 0278 RC inpatient 321 208.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 208.65 65 999999999 194.37 311.37 percent of total billed charges 2.7 CTX SCREW S/T 12MM 202.872 48712333_1 CDM 0278 RC inpatient 321 208.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 311.37 97 999999999 194.37 311.37 percent of total billed charges 2.7 CTX SCREW S/T 12MM 202.872 48712333_1 CDM 0278 RC inpatient 321 208.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 250.38 78 999999999 194.37 311.37 percent of total billed charges 2.7 CTX SCREW S/T 12MM 202.872 48712333_1 CDM 0278 RC inpatient 321 208.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 221.49 69 999999999 194.37 311.37 percent of total billed charges 2.7 CTX SCREW S/T 12MM 202.872 48712333_1 CDM 0278 RC inpatient 321 208.65 UMR - ALL PLANS UMR - ALL PLANS 224.7 70 999999999 194.37 311.37 percent of total billed charges 2.7 CTX SCREW S/T 12MM 202.872 48712333_1 CDM 0278 RC inpatient 321 208.65 SIHO - ALL PLANS SIHO - ALL PLANS 288.9 90 999999999 194.37 311.37 percent of total billed charges 2.7 CTX SCREW S/T 12MM 202.872 48712333_1 CDM 0278 RC inpatient 321 208.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 194.37 60.55 999999999 194.37 311.37 percent of total billed charges 2.7 CTX SCREW S/T 12MM 202.872 48712333_1 CDM 0278 RC inpatient 321 208.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 194.37 311.37 2.7 CTX SCREW S/T 12MM 202.872 48712333_1 CDM 0278 RC inpatient 321 208.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 194.37 311.37 2.7 CTX SCREW S/T 12MM 202.872 48712333_1 CDM 0278 RC inpatient 321 208.65 ANTHEM HMO ANTHEM HMO 999999999 194.37 311.37 2.7 CTX SCREW S/T 12MM 202.872 48712333_1 CDM 0278 RC inpatient 321 208.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 194.37 311.37 2.7 CTX SCREW S/T 12MM 202.872 48712333_1 CDM 0278 RC inpatient 321 208.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 217 67.6 999999999 194.37 311.37 percent of total billed charges 2.7 CTX SCREW S/T 12MM 202.872 48712333_1 CDM 0278 RC inpatient 321 208.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 194.37 311.37 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712334_1 CDM 0278 RC C1713 HCPCS inpatient 285 185.25 AETNA AETNA 225.15 79 999999999 172.57 276.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712334_1 CDM 0278 RC C1713 HCPCS inpatient 285 185.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.25 65 999999999 172.57 276.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712334_1 CDM 0278 RC C1713 HCPCS inpatient 285 185.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 276.45 97 999999999 172.57 276.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712334_1 CDM 0278 RC C1713 HCPCS inpatient 285 185.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 222.3 78 999999999 172.57 276.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712334_1 CDM 0278 RC C1713 HCPCS inpatient 285 185.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 196.65 69 999999999 172.57 276.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712334_1 CDM 0278 RC C1713 HCPCS inpatient 285 185.25 UMR - ALL PLANS UMR - ALL PLANS 199.5 70 999999999 172.57 276.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712334_1 CDM 0278 RC C1713 HCPCS inpatient 285 185.25 SIHO - ALL PLANS SIHO - ALL PLANS 256.5 90 999999999 172.57 276.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712334_1 CDM 0278 RC C1713 HCPCS inpatient 285 185.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 172.57 60.55 999999999 172.57 276.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712334_1 CDM 0278 RC C1713 HCPCS inpatient 285 185.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 172.57 276.45 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712334_1 CDM 0278 RC C1713 HCPCS inpatient 285 185.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 172.57 276.45 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712334_1 CDM 0278 RC C1713 HCPCS inpatient 285 185.25 ANTHEM HMO ANTHEM HMO 999999999 172.57 276.45 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712334_1 CDM 0278 RC C1713 HCPCS inpatient 285 185.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 172.57 276.45 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712334_1 CDM 0278 RC C1713 HCPCS inpatient 285 185.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 192.66 67.6 999999999 172.57 276.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712334_1 CDM 0278 RC C1713 HCPCS inpatient 285 185.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 172.57 276.45 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712335_1 CDM 0278 RC C1713 HCPCS inpatient 321 208.65 AETNA AETNA 253.59 79 999999999 194.37 311.37 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712335_1 CDM 0278 RC C1713 HCPCS inpatient 321 208.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 208.65 65 999999999 194.37 311.37 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712335_1 CDM 0278 RC C1713 HCPCS inpatient 321 208.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 311.37 97 999999999 194.37 311.37 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712335_1 CDM 0278 RC C1713 HCPCS inpatient 321 208.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 250.38 78 999999999 194.37 311.37 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712335_1 CDM 0278 RC C1713 HCPCS inpatient 321 208.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 221.49 69 999999999 194.37 311.37 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712335_1 CDM 0278 RC C1713 HCPCS inpatient 321 208.65 UMR - ALL PLANS UMR - ALL PLANS 224.7 70 999999999 194.37 311.37 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712335_1 CDM 0278 RC C1713 HCPCS inpatient 321 208.65 SIHO - ALL PLANS SIHO - ALL PLANS 288.9 90 999999999 194.37 311.37 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712335_1 CDM 0278 RC C1713 HCPCS inpatient 321 208.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 194.37 60.55 999999999 194.37 311.37 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712335_1 CDM 0278 RC C1713 HCPCS inpatient 321 208.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 194.37 311.37 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712335_1 CDM 0278 RC C1713 HCPCS inpatient 321 208.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 194.37 311.37 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712335_1 CDM 0278 RC C1713 HCPCS inpatient 321 208.65 ANTHEM HMO ANTHEM HMO 999999999 194.37 311.37 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712335_1 CDM 0278 RC C1713 HCPCS inpatient 321 208.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 194.37 311.37 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712335_1 CDM 0278 RC C1713 HCPCS inpatient 321 208.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 217 67.6 999999999 194.37 311.37 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712335_1 CDM 0278 RC C1713 HCPCS inpatient 321 208.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 194.37 311.37 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712336_1 CDM 0278 RC C1713 HCPCS inpatient 278 180.7 AETNA AETNA 219.62 79 999999999 168.33 269.66 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712336_1 CDM 0278 RC C1713 HCPCS inpatient 278 180.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 180.7 65 999999999 168.33 269.66 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712336_1 CDM 0278 RC C1713 HCPCS inpatient 278 180.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 269.66 97 999999999 168.33 269.66 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712336_1 CDM 0278 RC C1713 HCPCS inpatient 278 180.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 216.84 78 999999999 168.33 269.66 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712336_1 CDM 0278 RC C1713 HCPCS inpatient 278 180.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 191.82 69 999999999 168.33 269.66 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712336_1 CDM 0278 RC C1713 HCPCS inpatient 278 180.7 UMR - ALL PLANS UMR - ALL PLANS 194.6 70 999999999 168.33 269.66 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712336_1 CDM 0278 RC C1713 HCPCS inpatient 278 180.7 SIHO - ALL PLANS SIHO - ALL PLANS 250.2 90 999999999 168.33 269.66 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712336_1 CDM 0278 RC C1713 HCPCS inpatient 278 180.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.33 60.55 999999999 168.33 269.66 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712336_1 CDM 0278 RC C1713 HCPCS inpatient 278 180.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.33 269.66 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712336_1 CDM 0278 RC C1713 HCPCS inpatient 278 180.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.33 269.66 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712336_1 CDM 0278 RC C1713 HCPCS inpatient 278 180.7 ANTHEM HMO ANTHEM HMO 999999999 168.33 269.66 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712336_1 CDM 0278 RC C1713 HCPCS inpatient 278 180.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.33 269.66 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712336_1 CDM 0278 RC C1713 HCPCS inpatient 278 180.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 187.93 67.6 999999999 168.33 269.66 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712336_1 CDM 0278 RC C1713 HCPCS inpatient 278 180.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.33 269.66 2.7 CTX SCREW S/T 22MM 202.882 48712337_1 CDM 0278 RC inpatient 277 180.05 AETNA AETNA 218.83 79 999999999 167.72 268.69 percent of total billed charges 2.7 CTX SCREW S/T 22MM 202.882 48712337_1 CDM 0278 RC inpatient 277 180.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 180.05 65 999999999 167.72 268.69 percent of total billed charges 2.7 CTX SCREW S/T 22MM 202.882 48712337_1 CDM 0278 RC inpatient 277 180.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 268.69 97 999999999 167.72 268.69 percent of total billed charges 2.7 CTX SCREW S/T 22MM 202.882 48712337_1 CDM 0278 RC inpatient 277 180.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 216.06 78 999999999 167.72 268.69 percent of total billed charges 2.7 CTX SCREW S/T 22MM 202.882 48712337_1 CDM 0278 RC inpatient 277 180.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 191.13 69 999999999 167.72 268.69 percent of total billed charges 2.7 CTX SCREW S/T 22MM 202.882 48712337_1 CDM 0278 RC inpatient 277 180.05 UMR - ALL PLANS UMR - ALL PLANS 193.9 70 999999999 167.72 268.69 percent of total billed charges 2.7 CTX SCREW S/T 22MM 202.882 48712337_1 CDM 0278 RC inpatient 277 180.05 SIHO - ALL PLANS SIHO - ALL PLANS 249.3 90 999999999 167.72 268.69 percent of total billed charges 2.7 CTX SCREW S/T 22MM 202.882 48712337_1 CDM 0278 RC inpatient 277 180.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 167.72 60.55 999999999 167.72 268.69 percent of total billed charges 2.7 CTX SCREW S/T 22MM 202.882 48712337_1 CDM 0278 RC inpatient 277 180.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 167.72 268.69 2.7 CTX SCREW S/T 22MM 202.882 48712337_1 CDM 0278 RC inpatient 277 180.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 167.72 268.69 2.7 CTX SCREW S/T 22MM 202.882 48712337_1 CDM 0278 RC inpatient 277 180.05 ANTHEM HMO ANTHEM HMO 999999999 167.72 268.69 2.7 CTX SCREW S/T 22MM 202.882 48712337_1 CDM 0278 RC inpatient 277 180.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 167.72 268.69 2.7 CTX SCREW S/T 22MM 202.882 48712337_1 CDM 0278 RC inpatient 277 180.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 187.25 67.6 999999999 167.72 268.69 percent of total billed charges 2.7 CTX SCREW S/T 22MM 202.882 48712337_1 CDM 0278 RC inpatient 277 180.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 167.72 268.69 2.7 CTX SCREW S/T 24MM 202.884 48712338_1 CDM 0278 RC inpatient 277 180.05 AETNA AETNA 218.83 79 999999999 167.72 268.69 percent of total billed charges 2.7 CTX SCREW S/T 24MM 202.884 48712338_1 CDM 0278 RC inpatient 277 180.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 180.05 65 999999999 167.72 268.69 percent of total billed charges 2.7 CTX SCREW S/T 24MM 202.884 48712338_1 CDM 0278 RC inpatient 277 180.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 268.69 97 999999999 167.72 268.69 percent of total billed charges 2.7 CTX SCREW S/T 24MM 202.884 48712338_1 CDM 0278 RC inpatient 277 180.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 216.06 78 999999999 167.72 268.69 percent of total billed charges 2.7 CTX SCREW S/T 24MM 202.884 48712338_1 CDM 0278 RC inpatient 277 180.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 191.13 69 999999999 167.72 268.69 percent of total billed charges 2.7 CTX SCREW S/T 24MM 202.884 48712338_1 CDM 0278 RC inpatient 277 180.05 UMR - ALL PLANS UMR - ALL PLANS 193.9 70 999999999 167.72 268.69 percent of total billed charges 2.7 CTX SCREW S/T 24MM 202.884 48712338_1 CDM 0278 RC inpatient 277 180.05 SIHO - ALL PLANS SIHO - ALL PLANS 249.3 90 999999999 167.72 268.69 percent of total billed charges 2.7 CTX SCREW S/T 24MM 202.884 48712338_1 CDM 0278 RC inpatient 277 180.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 167.72 60.55 999999999 167.72 268.69 percent of total billed charges 2.7 CTX SCREW S/T 24MM 202.884 48712338_1 CDM 0278 RC inpatient 277 180.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 167.72 268.69 2.7 CTX SCREW S/T 24MM 202.884 48712338_1 CDM 0278 RC inpatient 277 180.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 167.72 268.69 2.7 CTX SCREW S/T 24MM 202.884 48712338_1 CDM 0278 RC inpatient 277 180.05 ANTHEM HMO ANTHEM HMO 999999999 167.72 268.69 2.7 CTX SCREW S/T 24MM 202.884 48712338_1 CDM 0278 RC inpatient 277 180.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 167.72 268.69 2.7 CTX SCREW S/T 24MM 202.884 48712338_1 CDM 0278 RC inpatient 277 180.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 187.25 67.6 999999999 167.72 268.69 percent of total billed charges 2.7 CTX SCREW S/T 24MM 202.884 48712338_1 CDM 0278 RC inpatient 277 180.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 167.72 268.69 2.7 CTX SCREW S/T 26MM 202.886 48712339_1 CDM 0278 RC inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 26MM 202.886 48712339_1 CDM 0278 RC inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 26MM 202.886 48712339_1 CDM 0278 RC inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 26MM 202.886 48712339_1 CDM 0278 RC inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 26MM 202.886 48712339_1 CDM 0278 RC inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 26MM 202.886 48712339_1 CDM 0278 RC inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 26MM 202.886 48712339_1 CDM 0278 RC inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 26MM 202.886 48712339_1 CDM 0278 RC inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 26MM 202.886 48712339_1 CDM 0278 RC inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 2.7 CTX SCREW S/T 26MM 202.886 48712339_1 CDM 0278 RC inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 2.7 CTX SCREW S/T 26MM 202.886 48712339_1 CDM 0278 RC inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 2.7 CTX SCREW S/T 26MM 202.886 48712339_1 CDM 0278 RC inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 2.7 CTX SCREW S/T 26MM 202.886 48712339_1 CDM 0278 RC inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 26MM 202.886 48712339_1 CDM 0278 RC inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 2.7 CTX SCREW S/T 28MM 202.888 48712340_1 CDM 0278 RC inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 28MM 202.888 48712340_1 CDM 0278 RC inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 28MM 202.888 48712340_1 CDM 0278 RC inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 28MM 202.888 48712340_1 CDM 0278 RC inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 28MM 202.888 48712340_1 CDM 0278 RC inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 28MM 202.888 48712340_1 CDM 0278 RC inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 28MM 202.888 48712340_1 CDM 0278 RC inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 28MM 202.888 48712340_1 CDM 0278 RC inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 28MM 202.888 48712340_1 CDM 0278 RC inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 2.7 CTX SCREW S/T 28MM 202.888 48712340_1 CDM 0278 RC inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 2.7 CTX SCREW S/T 28MM 202.888 48712340_1 CDM 0278 RC inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 2.7 CTX SCREW S/T 28MM 202.888 48712340_1 CDM 0278 RC inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 2.7 CTX SCREW S/T 28MM 202.888 48712340_1 CDM 0278 RC inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 28MM 202.888 48712340_1 CDM 0278 RC inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 2.7 CTX SCREW S/T 30MM 202.890 48712341_1 CDM 0278 RC inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 30MM 202.890 48712341_1 CDM 0278 RC inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 30MM 202.890 48712341_1 CDM 0278 RC inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 30MM 202.890 48712341_1 CDM 0278 RC inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 30MM 202.890 48712341_1 CDM 0278 RC inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 30MM 202.890 48712341_1 CDM 0278 RC inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 30MM 202.890 48712341_1 CDM 0278 RC inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 30MM 202.890 48712341_1 CDM 0278 RC inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 30MM 202.890 48712341_1 CDM 0278 RC inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 2.7 CTX SCREW S/T 30MM 202.890 48712341_1 CDM 0278 RC inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 2.7 CTX SCREW S/T 30MM 202.890 48712341_1 CDM 0278 RC inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 2.7 CTX SCREW S/T 30MM 202.890 48712341_1 CDM 0278 RC inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 2.7 CTX SCREW S/T 30MM 202.890 48712341_1 CDM 0278 RC inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges 2.7 CTX SCREW S/T 30MM 202.890 48712341_1 CDM 0278 RC inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 SM FRAG 1/3 TUB 2HOLE 441.32 48712342_1 CDM 0278 RC inpatient 231 150.15 AETNA AETNA 182.49 79 999999999 139.87 224.07 percent of total billed charges SM FRAG 1/3 TUB 2HOLE 441.32 48712342_1 CDM 0278 RC inpatient 231 150.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 150.15 65 999999999 139.87 224.07 percent of total billed charges SM FRAG 1/3 TUB 2HOLE 441.32 48712342_1 CDM 0278 RC inpatient 231 150.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 224.07 97 999999999 139.87 224.07 percent of total billed charges SM FRAG 1/3 TUB 2HOLE 441.32 48712342_1 CDM 0278 RC inpatient 231 150.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 180.18 78 999999999 139.87 224.07 percent of total billed charges SM FRAG 1/3 TUB 2HOLE 441.32 48712342_1 CDM 0278 RC inpatient 231 150.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 159.39 69 999999999 139.87 224.07 percent of total billed charges SM FRAG 1/3 TUB 2HOLE 441.32 48712342_1 CDM 0278 RC inpatient 231 150.15 UMR - ALL PLANS UMR - ALL PLANS 161.7 70 999999999 139.87 224.07 percent of total billed charges SM FRAG 1/3 TUB 2HOLE 441.32 48712342_1 CDM 0278 RC inpatient 231 150.15 SIHO - ALL PLANS SIHO - ALL PLANS 207.9 90 999999999 139.87 224.07 percent of total billed charges SM FRAG 1/3 TUB 2HOLE 441.32 48712342_1 CDM 0278 RC inpatient 231 150.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 139.87 60.55 999999999 139.87 224.07 percent of total billed charges SM FRAG 1/3 TUB 2HOLE 441.32 48712342_1 CDM 0278 RC inpatient 231 150.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 139.87 224.07 SM FRAG 1/3 TUB 2HOLE 441.32 48712342_1 CDM 0278 RC inpatient 231 150.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 139.87 224.07 SM FRAG 1/3 TUB 2HOLE 441.32 48712342_1 CDM 0278 RC inpatient 231 150.15 ANTHEM HMO ANTHEM HMO 999999999 139.87 224.07 SM FRAG 1/3 TUB 2HOLE 441.32 48712342_1 CDM 0278 RC inpatient 231 150.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 139.87 224.07 SM FRAG 1/3 TUB 2HOLE 441.32 48712342_1 CDM 0278 RC inpatient 231 150.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 156.16 67.6 999999999 139.87 224.07 percent of total billed charges SM FRAG 1/3 TUB 2HOLE 441.32 48712342_1 CDM 0278 RC inpatient 231 150.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 139.87 224.07 DRILL BIT 1.8MM 310.509 48712343_1 CDM 0272 RC inpatient 986 640.9 AETNA AETNA 778.94 79 999999999 597.02 956.42 percent of total billed charges DRILL BIT 1.8MM 310.509 48712343_1 CDM 0272 RC inpatient 986 640.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 640.9 65 999999999 597.02 956.42 percent of total billed charges DRILL BIT 1.8MM 310.509 48712343_1 CDM 0272 RC inpatient 986 640.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 956.42 97 999999999 597.02 956.42 percent of total billed charges DRILL BIT 1.8MM 310.509 48712343_1 CDM 0272 RC inpatient 986 640.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 769.08 78 999999999 597.02 956.42 percent of total billed charges DRILL BIT 1.8MM 310.509 48712343_1 CDM 0272 RC inpatient 986 640.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 680.34 69 999999999 597.02 956.42 percent of total billed charges DRILL BIT 1.8MM 310.509 48712343_1 CDM 0272 RC inpatient 986 640.9 UMR - ALL PLANS UMR - ALL PLANS 690.2 70 999999999 597.02 956.42 percent of total billed charges DRILL BIT 1.8MM 310.509 48712343_1 CDM 0272 RC inpatient 986 640.9 SIHO - ALL PLANS SIHO - ALL PLANS 887.4 90 999999999 597.02 956.42 percent of total billed charges DRILL BIT 1.8MM 310.509 48712343_1 CDM 0272 RC inpatient 986 640.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 597.02 60.55 999999999 597.02 956.42 percent of total billed charges DRILL BIT 1.8MM 310.509 48712343_1 CDM 0272 RC inpatient 986 640.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 597.02 956.42 DRILL BIT 1.8MM 310.509 48712343_1 CDM 0272 RC inpatient 986 640.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 597.02 956.42 DRILL BIT 1.8MM 310.509 48712343_1 CDM 0272 RC inpatient 986 640.9 ANTHEM HMO ANTHEM HMO 999999999 597.02 956.42 DRILL BIT 1.8MM 310.509 48712343_1 CDM 0272 RC inpatient 986 640.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 597.02 956.42 DRILL BIT 1.8MM 310.509 48712343_1 CDM 0272 RC inpatient 986 640.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 666.54 67.6 999999999 597.02 956.42 percent of total billed charges DRILL BIT 1.8MM 310.509 48712343_1 CDM 0272 RC inpatient 986 640.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 597.02 956.42 K-WIRE INSERT 1.25MM 324.084 48712344_1 CDM 0278 RC inpatient 1169 759.85 AETNA AETNA 923.51 79 999999999 707.83 1133.93 percent of total billed charges K-WIRE INSERT 1.25MM 324.084 48712344_1 CDM 0278 RC inpatient 1169 759.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 759.85 65 999999999 707.83 1133.93 percent of total billed charges K-WIRE INSERT 1.25MM 324.084 48712344_1 CDM 0278 RC inpatient 1169 759.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1133.93 97 999999999 707.83 1133.93 percent of total billed charges K-WIRE INSERT 1.25MM 324.084 48712344_1 CDM 0278 RC inpatient 1169 759.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 911.82 78 999999999 707.83 1133.93 percent of total billed charges K-WIRE INSERT 1.25MM 324.084 48712344_1 CDM 0278 RC inpatient 1169 759.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 806.61 69 999999999 707.83 1133.93 percent of total billed charges K-WIRE INSERT 1.25MM 324.084 48712344_1 CDM 0278 RC inpatient 1169 759.85 UMR - ALL PLANS UMR - ALL PLANS 818.3 70 999999999 707.83 1133.93 percent of total billed charges K-WIRE INSERT 1.25MM 324.084 48712344_1 CDM 0278 RC inpatient 1169 759.85 SIHO - ALL PLANS SIHO - ALL PLANS 1052.1 90 999999999 707.83 1133.93 percent of total billed charges K-WIRE INSERT 1.25MM 324.084 48712344_1 CDM 0278 RC inpatient 1169 759.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 707.83 60.55 999999999 707.83 1133.93 percent of total billed charges K-WIRE INSERT 1.25MM 324.084 48712344_1 CDM 0278 RC inpatient 1169 759.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 707.83 1133.93 K-WIRE INSERT 1.25MM 324.084 48712344_1 CDM 0278 RC inpatient 1169 759.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 707.83 1133.93 K-WIRE INSERT 1.25MM 324.084 48712344_1 CDM 0278 RC inpatient 1169 759.85 ANTHEM HMO ANTHEM HMO 999999999 707.83 1133.93 K-WIRE INSERT 1.25MM 324.084 48712344_1 CDM 0278 RC inpatient 1169 759.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 707.83 1133.93 K-WIRE INSERT 1.25MM 324.084 48712344_1 CDM 0278 RC inpatient 1169 759.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 790.24 67.6 999999999 707.83 1133.93 percent of total billed charges K-WIRE INSERT 1.25MM 324.084 48712344_1 CDM 0278 RC inpatient 1169 759.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 707.83 1133.93 DRILL BIT 2.4MM 100MM 310.530 48712345_1 CDM 0272 RC inpatient 759 493.35 AETNA AETNA 599.61 79 999999999 459.57 736.23 percent of total billed charges DRILL BIT 2.4MM 100MM 310.530 48712345_1 CDM 0272 RC inpatient 759 493.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 493.35 65 999999999 459.57 736.23 percent of total billed charges DRILL BIT 2.4MM 100MM 310.530 48712345_1 CDM 0272 RC inpatient 759 493.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 736.23 97 999999999 459.57 736.23 percent of total billed charges DRILL BIT 2.4MM 100MM 310.530 48712345_1 CDM 0272 RC inpatient 759 493.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 592.02 78 999999999 459.57 736.23 percent of total billed charges DRILL BIT 2.4MM 100MM 310.530 48712345_1 CDM 0272 RC inpatient 759 493.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 523.71 69 999999999 459.57 736.23 percent of total billed charges DRILL BIT 2.4MM 100MM 310.530 48712345_1 CDM 0272 RC inpatient 759 493.35 UMR - ALL PLANS UMR - ALL PLANS 531.3 70 999999999 459.57 736.23 percent of total billed charges DRILL BIT 2.4MM 100MM 310.530 48712345_1 CDM 0272 RC inpatient 759 493.35 SIHO - ALL PLANS SIHO - ALL PLANS 683.1 90 999999999 459.57 736.23 percent of total billed charges DRILL BIT 2.4MM 100MM 310.530 48712345_1 CDM 0272 RC inpatient 759 493.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 459.57 60.55 999999999 459.57 736.23 percent of total billed charges DRILL BIT 2.4MM 100MM 310.530 48712345_1 CDM 0272 RC inpatient 759 493.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 459.57 736.23 DRILL BIT 2.4MM 100MM 310.530 48712345_1 CDM 0272 RC inpatient 759 493.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 459.57 736.23 DRILL BIT 2.4MM 100MM 310.530 48712345_1 CDM 0272 RC inpatient 759 493.35 ANTHEM HMO ANTHEM HMO 999999999 459.57 736.23 DRILL BIT 2.4MM 100MM 310.530 48712345_1 CDM 0272 RC inpatient 759 493.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 459.57 736.23 DRILL BIT 2.4MM 100MM 310.530 48712345_1 CDM 0272 RC inpatient 759 493.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 513.08 67.6 999999999 459.57 736.23 percent of total billed charges DRILL BIT 2.4MM 100MM 310.530 48712345_1 CDM 0272 RC inpatient 759 493.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 459.57 736.23 DRILL BIT 2.7MM 100MM 310.26 48712346_1 CDM 0272 RC inpatient 553 359.45 AETNA AETNA 436.87 79 999999999 334.84 536.41 percent of total billed charges DRILL BIT 2.7MM 100MM 310.26 48712346_1 CDM 0272 RC inpatient 553 359.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 359.45 65 999999999 334.84 536.41 percent of total billed charges DRILL BIT 2.7MM 100MM 310.26 48712346_1 CDM 0272 RC inpatient 553 359.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 536.41 97 999999999 334.84 536.41 percent of total billed charges DRILL BIT 2.7MM 100MM 310.26 48712346_1 CDM 0272 RC inpatient 553 359.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 431.34 78 999999999 334.84 536.41 percent of total billed charges DRILL BIT 2.7MM 100MM 310.26 48712346_1 CDM 0272 RC inpatient 553 359.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 381.57 69 999999999 334.84 536.41 percent of total billed charges DRILL BIT 2.7MM 100MM 310.26 48712346_1 CDM 0272 RC inpatient 553 359.45 UMR - ALL PLANS UMR - ALL PLANS 387.1 70 999999999 334.84 536.41 percent of total billed charges DRILL BIT 2.7MM 100MM 310.26 48712346_1 CDM 0272 RC inpatient 553 359.45 SIHO - ALL PLANS SIHO - ALL PLANS 497.7 90 999999999 334.84 536.41 percent of total billed charges DRILL BIT 2.7MM 100MM 310.26 48712346_1 CDM 0272 RC inpatient 553 359.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 334.84 60.55 999999999 334.84 536.41 percent of total billed charges DRILL BIT 2.7MM 100MM 310.26 48712346_1 CDM 0272 RC inpatient 553 359.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 334.84 536.41 DRILL BIT 2.7MM 100MM 310.26 48712346_1 CDM 0272 RC inpatient 553 359.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 334.84 536.41 DRILL BIT 2.7MM 100MM 310.26 48712346_1 CDM 0272 RC inpatient 553 359.45 ANTHEM HMO ANTHEM HMO 999999999 334.84 536.41 DRILL BIT 2.7MM 100MM 310.26 48712346_1 CDM 0272 RC inpatient 553 359.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 334.84 536.41 DRILL BIT 2.7MM 100MM 310.26 48712346_1 CDM 0272 RC inpatient 553 359.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 373.83 67.6 999999999 334.84 536.41 percent of total billed charges DRILL BIT 2.7MM 100MM 310.26 48712346_1 CDM 0272 RC inpatient 553 359.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 334.84 536.41 SM FRAG 1/3 TUB 4HOLE 441.34 48712347_1 CDM 0278 RC inpatient 356 231.4 AETNA AETNA 281.24 79 999999999 215.56 345.32 percent of total billed charges SM FRAG 1/3 TUB 4HOLE 441.34 48712347_1 CDM 0278 RC inpatient 356 231.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 231.4 65 999999999 215.56 345.32 percent of total billed charges SM FRAG 1/3 TUB 4HOLE 441.34 48712347_1 CDM 0278 RC inpatient 356 231.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 345.32 97 999999999 215.56 345.32 percent of total billed charges SM FRAG 1/3 TUB 4HOLE 441.34 48712347_1 CDM 0278 RC inpatient 356 231.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 277.68 78 999999999 215.56 345.32 percent of total billed charges SM FRAG 1/3 TUB 4HOLE 441.34 48712347_1 CDM 0278 RC inpatient 356 231.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 245.64 69 999999999 215.56 345.32 percent of total billed charges SM FRAG 1/3 TUB 4HOLE 441.34 48712347_1 CDM 0278 RC inpatient 356 231.4 UMR - ALL PLANS UMR - ALL PLANS 249.2 70 999999999 215.56 345.32 percent of total billed charges SM FRAG 1/3 TUB 4HOLE 441.34 48712347_1 CDM 0278 RC inpatient 356 231.4 SIHO - ALL PLANS SIHO - ALL PLANS 320.4 90 999999999 215.56 345.32 percent of total billed charges SM FRAG 1/3 TUB 4HOLE 441.34 48712347_1 CDM 0278 RC inpatient 356 231.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 215.56 60.55 999999999 215.56 345.32 percent of total billed charges SM FRAG 1/3 TUB 4HOLE 441.34 48712347_1 CDM 0278 RC inpatient 356 231.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 215.56 345.32 SM FRAG 1/3 TUB 4HOLE 441.34 48712347_1 CDM 0278 RC inpatient 356 231.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 215.56 345.32 SM FRAG 1/3 TUB 4HOLE 441.34 48712347_1 CDM 0278 RC inpatient 356 231.4 ANTHEM HMO ANTHEM HMO 999999999 215.56 345.32 SM FRAG 1/3 TUB 4HOLE 441.34 48712347_1 CDM 0278 RC inpatient 356 231.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 215.56 345.32 SM FRAG 1/3 TUB 4HOLE 441.34 48712347_1 CDM 0278 RC inpatient 356 231.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 240.66 67.6 999999999 215.56 345.32 percent of total billed charges SM FRAG 1/3 TUB 4HOLE 441.34 48712347_1 CDM 0278 RC inpatient 356 231.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 215.56 345.32 SM FRAG 1/3 TUB 5HOLE 441.35 48712348_1 CDM 0278 RC inpatient 589 382.85 AETNA AETNA 465.31 79 999999999 356.64 571.33 percent of total billed charges SM FRAG 1/3 TUB 5HOLE 441.35 48712348_1 CDM 0278 RC inpatient 589 382.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 382.85 65 999999999 356.64 571.33 percent of total billed charges SM FRAG 1/3 TUB 5HOLE 441.35 48712348_1 CDM 0278 RC inpatient 589 382.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 571.33 97 999999999 356.64 571.33 percent of total billed charges SM FRAG 1/3 TUB 5HOLE 441.35 48712348_1 CDM 0278 RC inpatient 589 382.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 459.42 78 999999999 356.64 571.33 percent of total billed charges SM FRAG 1/3 TUB 5HOLE 441.35 48712348_1 CDM 0278 RC inpatient 589 382.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 406.41 69 999999999 356.64 571.33 percent of total billed charges SM FRAG 1/3 TUB 5HOLE 441.35 48712348_1 CDM 0278 RC inpatient 589 382.85 UMR - ALL PLANS UMR - ALL PLANS 412.3 70 999999999 356.64 571.33 percent of total billed charges SM FRAG 1/3 TUB 5HOLE 441.35 48712348_1 CDM 0278 RC inpatient 589 382.85 SIHO - ALL PLANS SIHO - ALL PLANS 530.1 90 999999999 356.64 571.33 percent of total billed charges SM FRAG 1/3 TUB 5HOLE 441.35 48712348_1 CDM 0278 RC inpatient 589 382.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 356.64 60.55 999999999 356.64 571.33 percent of total billed charges SM FRAG 1/3 TUB 5HOLE 441.35 48712348_1 CDM 0278 RC inpatient 589 382.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 356.64 571.33 SM FRAG 1/3 TUB 5HOLE 441.35 48712348_1 CDM 0278 RC inpatient 589 382.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 356.64 571.33 SM FRAG 1/3 TUB 5HOLE 441.35 48712348_1 CDM 0278 RC inpatient 589 382.85 ANTHEM HMO ANTHEM HMO 999999999 356.64 571.33 SM FRAG 1/3 TUB 5HOLE 441.35 48712348_1 CDM 0278 RC inpatient 589 382.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 356.64 571.33 SM FRAG 1/3 TUB 5HOLE 441.35 48712348_1 CDM 0278 RC inpatient 589 382.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 398.16 67.6 999999999 356.64 571.33 percent of total billed charges SM FRAG 1/3 TUB 5HOLE 441.35 48712348_1 CDM 0278 RC inpatient 589 382.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 356.64 571.33 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712349_1 CDM 0278 RC C1713 HCPCS inpatient 4887 3176.55 AETNA AETNA 3860.73 79 999999999 2959.08 4740.39 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712349_1 CDM 0278 RC C1713 HCPCS inpatient 4887 3176.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 3176.55 65 999999999 2959.08 4740.39 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712349_1 CDM 0278 RC C1713 HCPCS inpatient 4887 3176.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4740.39 97 999999999 2959.08 4740.39 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712349_1 CDM 0278 RC C1713 HCPCS inpatient 4887 3176.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 3811.86 78 999999999 2959.08 4740.39 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712349_1 CDM 0278 RC C1713 HCPCS inpatient 4887 3176.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 3372.03 69 999999999 2959.08 4740.39 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712349_1 CDM 0278 RC C1713 HCPCS inpatient 4887 3176.55 UMR - ALL PLANS UMR - ALL PLANS 3420.9 70 999999999 2959.08 4740.39 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712349_1 CDM 0278 RC C1713 HCPCS inpatient 4887 3176.55 SIHO - ALL PLANS SIHO - ALL PLANS 4398.3 90 999999999 2959.08 4740.39 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712349_1 CDM 0278 RC C1713 HCPCS inpatient 4887 3176.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2959.08 60.55 999999999 2959.08 4740.39 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712349_1 CDM 0278 RC C1713 HCPCS inpatient 4887 3176.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2959.08 4740.39 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712349_1 CDM 0278 RC C1713 HCPCS inpatient 4887 3176.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2959.08 4740.39 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712349_1 CDM 0278 RC C1713 HCPCS inpatient 4887 3176.55 ANTHEM HMO ANTHEM HMO 999999999 2959.08 4740.39 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712349_1 CDM 0278 RC C1713 HCPCS inpatient 4887 3176.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2959.08 4740.39 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712349_1 CDM 0278 RC C1713 HCPCS inpatient 4887 3176.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 3303.61 67.6 999999999 2959.08 4740.39 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712349_1 CDM 0278 RC C1713 HCPCS inpatient 4887 3176.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 2959.08 4740.39 PLATE DISTAL RAD RT LG 242.459 48712350_1 CDM 0278 RC inpatient 5147 3345.55 AETNA AETNA 4066.13 79 999999999 3116.51 4992.59 percent of total billed charges PLATE DISTAL RAD RT LG 242.459 48712350_1 CDM 0278 RC inpatient 5147 3345.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 3345.55 65 999999999 3116.51 4992.59 percent of total billed charges PLATE DISTAL RAD RT LG 242.459 48712350_1 CDM 0278 RC inpatient 5147 3345.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4992.59 97 999999999 3116.51 4992.59 percent of total billed charges PLATE DISTAL RAD RT LG 242.459 48712350_1 CDM 0278 RC inpatient 5147 3345.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 4014.66 78 999999999 3116.51 4992.59 percent of total billed charges PLATE DISTAL RAD RT LG 242.459 48712350_1 CDM 0278 RC inpatient 5147 3345.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 3551.43 69 999999999 3116.51 4992.59 percent of total billed charges PLATE DISTAL RAD RT LG 242.459 48712350_1 CDM 0278 RC inpatient 5147 3345.55 UMR - ALL PLANS UMR - ALL PLANS 3602.9 70 999999999 3116.51 4992.59 percent of total billed charges PLATE DISTAL RAD RT LG 242.459 48712350_1 CDM 0278 RC inpatient 5147 3345.55 SIHO - ALL PLANS SIHO - ALL PLANS 4632.3 90 999999999 3116.51 4992.59 percent of total billed charges PLATE DISTAL RAD RT LG 242.459 48712350_1 CDM 0278 RC inpatient 5147 3345.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3116.51 60.55 999999999 3116.51 4992.59 percent of total billed charges PLATE DISTAL RAD RT LG 242.459 48712350_1 CDM 0278 RC inpatient 5147 3345.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3116.51 4992.59 PLATE DISTAL RAD RT LG 242.459 48712350_1 CDM 0278 RC inpatient 5147 3345.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3116.51 4992.59 PLATE DISTAL RAD RT LG 242.459 48712350_1 CDM 0278 RC inpatient 5147 3345.55 ANTHEM HMO ANTHEM HMO 999999999 3116.51 4992.59 PLATE DISTAL RAD RT LG 242.459 48712350_1 CDM 0278 RC inpatient 5147 3345.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3116.51 4992.59 PLATE DISTAL RAD RT LG 242.459 48712350_1 CDM 0278 RC inpatient 5147 3345.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 3479.37 67.6 999999999 3116.51 4992.59 percent of total billed charges PLATE DISTAL RAD RT LG 242.459 48712350_1 CDM 0278 RC inpatient 5147 3345.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 3116.51 4992.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712351_1 CDM 0278 RC C1713 HCPCS inpatient 4606 2993.9 AETNA AETNA 3638.74 79 999999999 2788.93 4467.82 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712351_1 CDM 0278 RC C1713 HCPCS inpatient 4606 2993.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 2993.9 65 999999999 2788.93 4467.82 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712351_1 CDM 0278 RC C1713 HCPCS inpatient 4606 2993.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4467.82 97 999999999 2788.93 4467.82 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712351_1 CDM 0278 RC C1713 HCPCS inpatient 4606 2993.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 3592.68 78 999999999 2788.93 4467.82 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712351_1 CDM 0278 RC C1713 HCPCS inpatient 4606 2993.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 3178.14 69 999999999 2788.93 4467.82 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712351_1 CDM 0278 RC C1713 HCPCS inpatient 4606 2993.9 UMR - ALL PLANS UMR - ALL PLANS 3224.2 70 999999999 2788.93 4467.82 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712351_1 CDM 0278 RC C1713 HCPCS inpatient 4606 2993.9 SIHO - ALL PLANS SIHO - ALL PLANS 4145.4 90 999999999 2788.93 4467.82 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712351_1 CDM 0278 RC C1713 HCPCS inpatient 4606 2993.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2788.93 60.55 999999999 2788.93 4467.82 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712351_1 CDM 0278 RC C1713 HCPCS inpatient 4606 2993.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2788.93 4467.82 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712351_1 CDM 0278 RC C1713 HCPCS inpatient 4606 2993.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2788.93 4467.82 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712351_1 CDM 0278 RC C1713 HCPCS inpatient 4606 2993.9 ANTHEM HMO ANTHEM HMO 999999999 2788.93 4467.82 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712351_1 CDM 0278 RC C1713 HCPCS inpatient 4606 2993.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2788.93 4467.82 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712351_1 CDM 0278 RC C1713 HCPCS inpatient 4606 2993.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 3113.66 67.6 999999999 2788.93 4467.82 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712351_1 CDM 0278 RC C1713 HCPCS inpatient 4606 2993.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 2788.93 4467.82 PLATE DIS RAD LFT LG 242.462 48712352_1 CDM 0278 RC inpatient 4820 3133 AETNA AETNA 3807.8 79 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD LFT LG 242.462 48712352_1 CDM 0278 RC inpatient 4820 3133 SELF PAY DISCOUNT SELF PAY DISCOUNT 3133 65 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD LFT LG 242.462 48712352_1 CDM 0278 RC inpatient 4820 3133 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4675.4 97 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD LFT LG 242.462 48712352_1 CDM 0278 RC inpatient 4820 3133 HUMANA - ALL PLANS HUMANA - ALL PLANS 3759.6 78 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD LFT LG 242.462 48712352_1 CDM 0278 RC inpatient 4820 3133 ENCORE - ALL PLANS ENCORE - ALL PLANS 3325.8 69 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD LFT LG 242.462 48712352_1 CDM 0278 RC inpatient 4820 3133 UMR - ALL PLANS UMR - ALL PLANS 3374 70 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD LFT LG 242.462 48712352_1 CDM 0278 RC inpatient 4820 3133 SIHO - ALL PLANS SIHO - ALL PLANS 4338 90 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD LFT LG 242.462 48712352_1 CDM 0278 RC inpatient 4820 3133 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2918.51 60.55 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD LFT LG 242.462 48712352_1 CDM 0278 RC inpatient 4820 3133 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2918.51 4675.4 PLATE DIS RAD LFT LG 242.462 48712352_1 CDM 0278 RC inpatient 4820 3133 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2918.51 4675.4 PLATE DIS RAD LFT LG 242.462 48712352_1 CDM 0278 RC inpatient 4820 3133 ANTHEM HMO ANTHEM HMO 999999999 2918.51 4675.4 PLATE DIS RAD LFT LG 242.462 48712352_1 CDM 0278 RC inpatient 4820 3133 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2918.51 4675.4 PLATE DIS RAD LFT LG 242.462 48712352_1 CDM 0278 RC inpatient 4820 3133 CIGNA - ALL PLANS CIGNA - ALL PLANS 3258.32 67.6 999999999 2918.51 4675.4 percent of total billed charges PLATE DIS RAD LFT LG 242.462 48712352_1 CDM 0278 RC inpatient 4820 3133 UHC - ALL PLANS UHC - ALL PLANS 999999999 2918.51 4675.4 PLATE DIS RAD 4H RT LG 242.465 48712353_1 CDM 0278 RC inpatient 5147 3345.55 AETNA AETNA 4066.13 79 999999999 3116.51 4992.59 percent of total billed charges PLATE DIS RAD 4H RT LG 242.465 48712353_1 CDM 0278 RC inpatient 5147 3345.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 3345.55 65 999999999 3116.51 4992.59 percent of total billed charges PLATE DIS RAD 4H RT LG 242.465 48712353_1 CDM 0278 RC inpatient 5147 3345.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4992.59 97 999999999 3116.51 4992.59 percent of total billed charges PLATE DIS RAD 4H RT LG 242.465 48712353_1 CDM 0278 RC inpatient 5147 3345.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 4014.66 78 999999999 3116.51 4992.59 percent of total billed charges PLATE DIS RAD 4H RT LG 242.465 48712353_1 CDM 0278 RC inpatient 5147 3345.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 3551.43 69 999999999 3116.51 4992.59 percent of total billed charges PLATE DIS RAD 4H RT LG 242.465 48712353_1 CDM 0278 RC inpatient 5147 3345.55 UMR - ALL PLANS UMR - ALL PLANS 3602.9 70 999999999 3116.51 4992.59 percent of total billed charges PLATE DIS RAD 4H RT LG 242.465 48712353_1 CDM 0278 RC inpatient 5147 3345.55 SIHO - ALL PLANS SIHO - ALL PLANS 4632.3 90 999999999 3116.51 4992.59 percent of total billed charges PLATE DIS RAD 4H RT LG 242.465 48712353_1 CDM 0278 RC inpatient 5147 3345.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3116.51 60.55 999999999 3116.51 4992.59 percent of total billed charges PLATE DIS RAD 4H RT LG 242.465 48712353_1 CDM 0278 RC inpatient 5147 3345.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3116.51 4992.59 PLATE DIS RAD 4H RT LG 242.465 48712353_1 CDM 0278 RC inpatient 5147 3345.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3116.51 4992.59 PLATE DIS RAD 4H RT LG 242.465 48712353_1 CDM 0278 RC inpatient 5147 3345.55 ANTHEM HMO ANTHEM HMO 999999999 3116.51 4992.59 PLATE DIS RAD 4H RT LG 242.465 48712353_1 CDM 0278 RC inpatient 5147 3345.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3116.51 4992.59 PLATE DIS RAD 4H RT LG 242.465 48712353_1 CDM 0278 RC inpatient 5147 3345.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 3479.37 67.6 999999999 3116.51 4992.59 percent of total billed charges PLATE DIS RAD 4H RT LG 242.465 48712353_1 CDM 0278 RC inpatient 5147 3345.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 3116.51 4992.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712354_1 CDM 0278 RC C1713 HCPCS inpatient 4577 2975.05 AETNA AETNA 3615.83 79 999999999 2771.37 4439.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712354_1 CDM 0278 RC C1713 HCPCS inpatient 4577 2975.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 2975.05 65 999999999 2771.37 4439.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712354_1 CDM 0278 RC C1713 HCPCS inpatient 4577 2975.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4439.69 97 999999999 2771.37 4439.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712354_1 CDM 0278 RC C1713 HCPCS inpatient 4577 2975.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 3570.06 78 999999999 2771.37 4439.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712354_1 CDM 0278 RC C1713 HCPCS inpatient 4577 2975.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 3158.13 69 999999999 2771.37 4439.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712354_1 CDM 0278 RC C1713 HCPCS inpatient 4577 2975.05 UMR - ALL PLANS UMR - ALL PLANS 3203.9 70 999999999 2771.37 4439.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712354_1 CDM 0278 RC C1713 HCPCS inpatient 4577 2975.05 SIHO - ALL PLANS SIHO - ALL PLANS 4119.3 90 999999999 2771.37 4439.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712354_1 CDM 0278 RC C1713 HCPCS inpatient 4577 2975.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2771.37 60.55 999999999 2771.37 4439.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712354_1 CDM 0278 RC C1713 HCPCS inpatient 4577 2975.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2771.37 4439.69 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712354_1 CDM 0278 RC C1713 HCPCS inpatient 4577 2975.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2771.37 4439.69 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712354_1 CDM 0278 RC C1713 HCPCS inpatient 4577 2975.05 ANTHEM HMO ANTHEM HMO 999999999 2771.37 4439.69 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712354_1 CDM 0278 RC C1713 HCPCS inpatient 4577 2975.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2771.37 4439.69 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712354_1 CDM 0278 RC C1713 HCPCS inpatient 4577 2975.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 3094.05 67.6 999999999 2771.37 4439.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712354_1 CDM 0278 RC C1713 HCPCS inpatient 4577 2975.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 2771.37 4439.69 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712355_1 CDM 0278 RC C1713 HCPCS inpatient 572 371.8 AETNA AETNA 451.88 79 999999999 346.35 554.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712355_1 CDM 0278 RC C1713 HCPCS inpatient 572 371.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 371.8 65 999999999 346.35 554.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712355_1 CDM 0278 RC C1713 HCPCS inpatient 572 371.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 554.84 97 999999999 346.35 554.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712355_1 CDM 0278 RC C1713 HCPCS inpatient 572 371.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 446.16 78 999999999 346.35 554.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712355_1 CDM 0278 RC C1713 HCPCS inpatient 572 371.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 394.68 69 999999999 346.35 554.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712355_1 CDM 0278 RC C1713 HCPCS inpatient 572 371.8 UMR - ALL PLANS UMR - ALL PLANS 400.4 70 999999999 346.35 554.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712355_1 CDM 0278 RC C1713 HCPCS inpatient 572 371.8 SIHO - ALL PLANS SIHO - ALL PLANS 514.8 90 999999999 346.35 554.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712355_1 CDM 0278 RC C1713 HCPCS inpatient 572 371.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 346.35 60.55 999999999 346.35 554.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712355_1 CDM 0278 RC C1713 HCPCS inpatient 572 371.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 346.35 554.84 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712355_1 CDM 0278 RC C1713 HCPCS inpatient 572 371.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 346.35 554.84 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712355_1 CDM 0278 RC C1713 HCPCS inpatient 572 371.8 ANTHEM HMO ANTHEM HMO 999999999 346.35 554.84 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712355_1 CDM 0278 RC C1713 HCPCS inpatient 572 371.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 346.35 554.84 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712355_1 CDM 0278 RC C1713 HCPCS inpatient 572 371.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 386.67 67.6 999999999 346.35 554.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712355_1 CDM 0278 RC C1713 HCPCS inpatient 572 371.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 346.35 554.84 PLATE DIS RAD 4H LT LG 242.468 48712356_1 CDM 0278 RC inpatient 5147 3345.55 AETNA AETNA 4066.13 79 999999999 3116.51 4992.59 percent of total billed charges PLATE DIS RAD 4H LT LG 242.468 48712356_1 CDM 0278 RC inpatient 5147 3345.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 3345.55 65 999999999 3116.51 4992.59 percent of total billed charges PLATE DIS RAD 4H LT LG 242.468 48712356_1 CDM 0278 RC inpatient 5147 3345.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4992.59 97 999999999 3116.51 4992.59 percent of total billed charges PLATE DIS RAD 4H LT LG 242.468 48712356_1 CDM 0278 RC inpatient 5147 3345.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 4014.66 78 999999999 3116.51 4992.59 percent of total billed charges PLATE DIS RAD 4H LT LG 242.468 48712356_1 CDM 0278 RC inpatient 5147 3345.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 3551.43 69 999999999 3116.51 4992.59 percent of total billed charges PLATE DIS RAD 4H LT LG 242.468 48712356_1 CDM 0278 RC inpatient 5147 3345.55 UMR - ALL PLANS UMR - ALL PLANS 3602.9 70 999999999 3116.51 4992.59 percent of total billed charges PLATE DIS RAD 4H LT LG 242.468 48712356_1 CDM 0278 RC inpatient 5147 3345.55 SIHO - ALL PLANS SIHO - ALL PLANS 4632.3 90 999999999 3116.51 4992.59 percent of total billed charges PLATE DIS RAD 4H LT LG 242.468 48712356_1 CDM 0278 RC inpatient 5147 3345.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3116.51 60.55 999999999 3116.51 4992.59 percent of total billed charges PLATE DIS RAD 4H LT LG 242.468 48712356_1 CDM 0278 RC inpatient 5147 3345.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3116.51 4992.59 PLATE DIS RAD 4H LT LG 242.468 48712356_1 CDM 0278 RC inpatient 5147 3345.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3116.51 4992.59 PLATE DIS RAD 4H LT LG 242.468 48712356_1 CDM 0278 RC inpatient 5147 3345.55 ANTHEM HMO ANTHEM HMO 999999999 3116.51 4992.59 PLATE DIS RAD 4H LT LG 242.468 48712356_1 CDM 0278 RC inpatient 5147 3345.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3116.51 4992.59 PLATE DIS RAD 4H LT LG 242.468 48712356_1 CDM 0278 RC inpatient 5147 3345.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 3479.37 67.6 999999999 3116.51 4992.59 percent of total billed charges PLATE DIS RAD 4H LT LG 242.468 48712356_1 CDM 0278 RC inpatient 5147 3345.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 3116.51 4992.59 PLATE DR 9HH/3HS RT 02.110.330 48712357_1 CDM 0278 RC inpatient 4753 3089.45 AETNA AETNA 3754.87 79 999999999 2877.94 4610.41 percent of total billed charges PLATE DR 9HH/3HS RT 02.110.330 48712357_1 CDM 0278 RC inpatient 4753 3089.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 3089.45 65 999999999 2877.94 4610.41 percent of total billed charges PLATE DR 9HH/3HS RT 02.110.330 48712357_1 CDM 0278 RC inpatient 4753 3089.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4610.41 97 999999999 2877.94 4610.41 percent of total billed charges PLATE DR 9HH/3HS RT 02.110.330 48712357_1 CDM 0278 RC inpatient 4753 3089.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 3707.34 78 999999999 2877.94 4610.41 percent of total billed charges PLATE DR 9HH/3HS RT 02.110.330 48712357_1 CDM 0278 RC inpatient 4753 3089.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 3279.57 69 999999999 2877.94 4610.41 percent of total billed charges PLATE DR 9HH/3HS RT 02.110.330 48712357_1 CDM 0278 RC inpatient 4753 3089.45 UMR - ALL PLANS UMR - ALL PLANS 3327.1 70 999999999 2877.94 4610.41 percent of total billed charges PLATE DR 9HH/3HS RT 02.110.330 48712357_1 CDM 0278 RC inpatient 4753 3089.45 SIHO - ALL PLANS SIHO - ALL PLANS 4277.7 90 999999999 2877.94 4610.41 percent of total billed charges PLATE DR 9HH/3HS RT 02.110.330 48712357_1 CDM 0278 RC inpatient 4753 3089.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2877.94 60.55 999999999 2877.94 4610.41 percent of total billed charges PLATE DR 9HH/3HS RT 02.110.330 48712357_1 CDM 0278 RC inpatient 4753 3089.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2877.94 4610.41 PLATE DR 9HH/3HS RT 02.110.330 48712357_1 CDM 0278 RC inpatient 4753 3089.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2877.94 4610.41 PLATE DR 9HH/3HS RT 02.110.330 48712357_1 CDM 0278 RC inpatient 4753 3089.45 ANTHEM HMO ANTHEM HMO 999999999 2877.94 4610.41 PLATE DR 9HH/3HS RT 02.110.330 48712357_1 CDM 0278 RC inpatient 4753 3089.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2877.94 4610.41 PLATE DR 9HH/3HS RT 02.110.330 48712357_1 CDM 0278 RC inpatient 4753 3089.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 3213.03 67.6 999999999 2877.94 4610.41 percent of total billed charges PLATE DR 9HH/3HS RT 02.110.330 48712357_1 CDM 0278 RC inpatient 4753 3089.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 2877.94 4610.41 PLATE DR 9HH/3HS LT 02.110.331 48712358_1 CDM 0278 RC inpatient 5115 3324.75 AETNA AETNA 4040.85 79 999999999 3097.13 4961.55 percent of total billed charges PLATE DR 9HH/3HS LT 02.110.331 48712358_1 CDM 0278 RC inpatient 5115 3324.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 3324.75 65 999999999 3097.13 4961.55 percent of total billed charges PLATE DR 9HH/3HS LT 02.110.331 48712358_1 CDM 0278 RC inpatient 5115 3324.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4961.55 97 999999999 3097.13 4961.55 percent of total billed charges PLATE DR 9HH/3HS LT 02.110.331 48712358_1 CDM 0278 RC inpatient 5115 3324.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 3989.7 78 999999999 3097.13 4961.55 percent of total billed charges PLATE DR 9HH/3HS LT 02.110.331 48712358_1 CDM 0278 RC inpatient 5115 3324.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 3529.35 69 999999999 3097.13 4961.55 percent of total billed charges PLATE DR 9HH/3HS LT 02.110.331 48712358_1 CDM 0278 RC inpatient 5115 3324.75 UMR - ALL PLANS UMR - ALL PLANS 3580.5 70 999999999 3097.13 4961.55 percent of total billed charges PLATE DR 9HH/3HS LT 02.110.331 48712358_1 CDM 0278 RC inpatient 5115 3324.75 SIHO - ALL PLANS SIHO - ALL PLANS 4603.5 90 999999999 3097.13 4961.55 percent of total billed charges PLATE DR 9HH/3HS LT 02.110.331 48712358_1 CDM 0278 RC inpatient 5115 3324.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3097.13 60.55 999999999 3097.13 4961.55 percent of total billed charges PLATE DR 9HH/3HS LT 02.110.331 48712358_1 CDM 0278 RC inpatient 5115 3324.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3097.13 4961.55 PLATE DR 9HH/3HS LT 02.110.331 48712358_1 CDM 0278 RC inpatient 5115 3324.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3097.13 4961.55 PLATE DR 9HH/3HS LT 02.110.331 48712358_1 CDM 0278 RC inpatient 5115 3324.75 ANTHEM HMO ANTHEM HMO 999999999 3097.13 4961.55 PLATE DR 9HH/3HS LT 02.110.331 48712358_1 CDM 0278 RC inpatient 5115 3324.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3097.13 4961.55 PLATE DR 9HH/3HS LT 02.110.331 48712358_1 CDM 0278 RC inpatient 5115 3324.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 3457.74 67.6 999999999 3097.13 4961.55 percent of total billed charges PLATE DR 9HH/3HS LT 02.110.331 48712358_1 CDM 0278 RC inpatient 5115 3324.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 3097.13 4961.55 PLATE DR 9HH/4HS RT 02.110.340 48712359_1 CDM 0278 RC inpatient 5276 3429.4 AETNA AETNA 4168.04 79 999999999 3194.62 5117.72 percent of total billed charges PLATE DR 9HH/4HS RT 02.110.340 48712359_1 CDM 0278 RC inpatient 5276 3429.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 3429.4 65 999999999 3194.62 5117.72 percent of total billed charges PLATE DR 9HH/4HS RT 02.110.340 48712359_1 CDM 0278 RC inpatient 5276 3429.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5117.72 97 999999999 3194.62 5117.72 percent of total billed charges PLATE DR 9HH/4HS RT 02.110.340 48712359_1 CDM 0278 RC inpatient 5276 3429.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 4115.28 78 999999999 3194.62 5117.72 percent of total billed charges PLATE DR 9HH/4HS RT 02.110.340 48712359_1 CDM 0278 RC inpatient 5276 3429.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 3640.44 69 999999999 3194.62 5117.72 percent of total billed charges PLATE DR 9HH/4HS RT 02.110.340 48712359_1 CDM 0278 RC inpatient 5276 3429.4 UMR - ALL PLANS UMR - ALL PLANS 3693.2 70 999999999 3194.62 5117.72 percent of total billed charges PLATE DR 9HH/4HS RT 02.110.340 48712359_1 CDM 0278 RC inpatient 5276 3429.4 SIHO - ALL PLANS SIHO - ALL PLANS 4748.4 90 999999999 3194.62 5117.72 percent of total billed charges PLATE DR 9HH/4HS RT 02.110.340 48712359_1 CDM 0278 RC inpatient 5276 3429.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3194.62 60.55 999999999 3194.62 5117.72 percent of total billed charges PLATE DR 9HH/4HS RT 02.110.340 48712359_1 CDM 0278 RC inpatient 5276 3429.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3194.62 5117.72 PLATE DR 9HH/4HS RT 02.110.340 48712359_1 CDM 0278 RC inpatient 5276 3429.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3194.62 5117.72 PLATE DR 9HH/4HS RT 02.110.340 48712359_1 CDM 0278 RC inpatient 5276 3429.4 ANTHEM HMO ANTHEM HMO 999999999 3194.62 5117.72 PLATE DR 9HH/4HS RT 02.110.340 48712359_1 CDM 0278 RC inpatient 5276 3429.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3194.62 5117.72 PLATE DR 9HH/4HS RT 02.110.340 48712359_1 CDM 0278 RC inpatient 5276 3429.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 3566.58 67.6 999999999 3194.62 5117.72 percent of total billed charges PLATE DR 9HH/4HS RT 02.110.340 48712359_1 CDM 0278 RC inpatient 5276 3429.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 3194.62 5117.72 PLATE DR 9HH/4HS LT 02.110.341 48712360_1 CDM 0278 RC inpatient 5276 3429.4 AETNA AETNA 4168.04 79 999999999 3194.62 5117.72 percent of total billed charges PLATE DR 9HH/4HS LT 02.110.341 48712360_1 CDM 0278 RC inpatient 5276 3429.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 3429.4 65 999999999 3194.62 5117.72 percent of total billed charges PLATE DR 9HH/4HS LT 02.110.341 48712360_1 CDM 0278 RC inpatient 5276 3429.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5117.72 97 999999999 3194.62 5117.72 percent of total billed charges PLATE DR 9HH/4HS LT 02.110.341 48712360_1 CDM 0278 RC inpatient 5276 3429.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 4115.28 78 999999999 3194.62 5117.72 percent of total billed charges PLATE DR 9HH/4HS LT 02.110.341 48712360_1 CDM 0278 RC inpatient 5276 3429.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 3640.44 69 999999999 3194.62 5117.72 percent of total billed charges PLATE DR 9HH/4HS LT 02.110.341 48712360_1 CDM 0278 RC inpatient 5276 3429.4 UMR - ALL PLANS UMR - ALL PLANS 3693.2 70 999999999 3194.62 5117.72 percent of total billed charges PLATE DR 9HH/4HS LT 02.110.341 48712360_1 CDM 0278 RC inpatient 5276 3429.4 SIHO - ALL PLANS SIHO - ALL PLANS 4748.4 90 999999999 3194.62 5117.72 percent of total billed charges PLATE DR 9HH/4HS LT 02.110.341 48712360_1 CDM 0278 RC inpatient 5276 3429.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3194.62 60.55 999999999 3194.62 5117.72 percent of total billed charges PLATE DR 9HH/4HS LT 02.110.341 48712360_1 CDM 0278 RC inpatient 5276 3429.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3194.62 5117.72 PLATE DR 9HH/4HS LT 02.110.341 48712360_1 CDM 0278 RC inpatient 5276 3429.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3194.62 5117.72 PLATE DR 9HH/4HS LT 02.110.341 48712360_1 CDM 0278 RC inpatient 5276 3429.4 ANTHEM HMO ANTHEM HMO 999999999 3194.62 5117.72 PLATE DR 9HH/4HS LT 02.110.341 48712360_1 CDM 0278 RC inpatient 5276 3429.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3194.62 5117.72 PLATE DR 9HH/4HS LT 02.110.341 48712360_1 CDM 0278 RC inpatient 5276 3429.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 3566.58 67.6 999999999 3194.62 5117.72 percent of total billed charges PLATE DR 9HH/4HS LT 02.110.341 48712360_1 CDM 0278 RC inpatient 5276 3429.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 3194.62 5117.72 PLATE DR 9HH/5HS RT 02.110.350 48712361_1 CDM 0278 RC inpatient 5427 3527.55 AETNA AETNA 4287.33 79 999999999 3286.05 5264.19 percent of total billed charges PLATE DR 9HH/5HS RT 02.110.350 48712361_1 CDM 0278 RC inpatient 5427 3527.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 3527.55 65 999999999 3286.05 5264.19 percent of total billed charges PLATE DR 9HH/5HS RT 02.110.350 48712361_1 CDM 0278 RC inpatient 5427 3527.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5264.19 97 999999999 3286.05 5264.19 percent of total billed charges PLATE DR 9HH/5HS RT 02.110.350 48712361_1 CDM 0278 RC inpatient 5427 3527.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 4233.06 78 999999999 3286.05 5264.19 percent of total billed charges PLATE DR 9HH/5HS RT 02.110.350 48712361_1 CDM 0278 RC inpatient 5427 3527.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 3744.63 69 999999999 3286.05 5264.19 percent of total billed charges PLATE DR 9HH/5HS RT 02.110.350 48712361_1 CDM 0278 RC inpatient 5427 3527.55 UMR - ALL PLANS UMR - ALL PLANS 3798.9 70 999999999 3286.05 5264.19 percent of total billed charges PLATE DR 9HH/5HS RT 02.110.350 48712361_1 CDM 0278 RC inpatient 5427 3527.55 SIHO - ALL PLANS SIHO - ALL PLANS 4884.3 90 999999999 3286.05 5264.19 percent of total billed charges PLATE DR 9HH/5HS RT 02.110.350 48712361_1 CDM 0278 RC inpatient 5427 3527.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3286.05 60.55 999999999 3286.05 5264.19 percent of total billed charges PLATE DR 9HH/5HS RT 02.110.350 48712361_1 CDM 0278 RC inpatient 5427 3527.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3286.05 5264.19 PLATE DR 9HH/5HS RT 02.110.350 48712361_1 CDM 0278 RC inpatient 5427 3527.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3286.05 5264.19 PLATE DR 9HH/5HS RT 02.110.350 48712361_1 CDM 0278 RC inpatient 5427 3527.55 ANTHEM HMO ANTHEM HMO 999999999 3286.05 5264.19 PLATE DR 9HH/5HS RT 02.110.350 48712361_1 CDM 0278 RC inpatient 5427 3527.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3286.05 5264.19 PLATE DR 9HH/5HS RT 02.110.350 48712361_1 CDM 0278 RC inpatient 5427 3527.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 3668.65 67.6 999999999 3286.05 5264.19 percent of total billed charges PLATE DR 9HH/5HS RT 02.110.350 48712361_1 CDM 0278 RC inpatient 5427 3527.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 3286.05 5264.19 PLATE DR 9HH/5HS LT 02.110.351 48712362_1 CDM 0278 RC inpatient 5427 3527.55 AETNA AETNA 4287.33 79 999999999 3286.05 5264.19 percent of total billed charges PLATE DR 9HH/5HS LT 02.110.351 48712362_1 CDM 0278 RC inpatient 5427 3527.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 3527.55 65 999999999 3286.05 5264.19 percent of total billed charges PLATE DR 9HH/5HS LT 02.110.351 48712362_1 CDM 0278 RC inpatient 5427 3527.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5264.19 97 999999999 3286.05 5264.19 percent of total billed charges PLATE DR 9HH/5HS LT 02.110.351 48712362_1 CDM 0278 RC inpatient 5427 3527.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 4233.06 78 999999999 3286.05 5264.19 percent of total billed charges PLATE DR 9HH/5HS LT 02.110.351 48712362_1 CDM 0278 RC inpatient 5427 3527.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 3744.63 69 999999999 3286.05 5264.19 percent of total billed charges PLATE DR 9HH/5HS LT 02.110.351 48712362_1 CDM 0278 RC inpatient 5427 3527.55 UMR - ALL PLANS UMR - ALL PLANS 3798.9 70 999999999 3286.05 5264.19 percent of total billed charges PLATE DR 9HH/5HS LT 02.110.351 48712362_1 CDM 0278 RC inpatient 5427 3527.55 SIHO - ALL PLANS SIHO - ALL PLANS 4884.3 90 999999999 3286.05 5264.19 percent of total billed charges PLATE DR 9HH/5HS LT 02.110.351 48712362_1 CDM 0278 RC inpatient 5427 3527.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3286.05 60.55 999999999 3286.05 5264.19 percent of total billed charges PLATE DR 9HH/5HS LT 02.110.351 48712362_1 CDM 0278 RC inpatient 5427 3527.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3286.05 5264.19 PLATE DR 9HH/5HS LT 02.110.351 48712362_1 CDM 0278 RC inpatient 5427 3527.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3286.05 5264.19 PLATE DR 9HH/5HS LT 02.110.351 48712362_1 CDM 0278 RC inpatient 5427 3527.55 ANTHEM HMO ANTHEM HMO 999999999 3286.05 5264.19 PLATE DR 9HH/5HS LT 02.110.351 48712362_1 CDM 0278 RC inpatient 5427 3527.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3286.05 5264.19 PLATE DR 9HH/5HS LT 02.110.351 48712362_1 CDM 0278 RC inpatient 5427 3527.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 3668.65 67.6 999999999 3286.05 5264.19 percent of total billed charges PLATE DR 9HH/5HS LT 02.110.351 48712362_1 CDM 0278 RC inpatient 5427 3527.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 3286.05 5264.19 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712363_1 CDM 0278 RC C1713 HCPCS inpatient 555 360.75 AETNA AETNA 438.45 79 999999999 336.05 538.35 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712363_1 CDM 0278 RC C1713 HCPCS inpatient 555 360.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 360.75 65 999999999 336.05 538.35 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712363_1 CDM 0278 RC C1713 HCPCS inpatient 555 360.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 538.35 97 999999999 336.05 538.35 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712363_1 CDM 0278 RC C1713 HCPCS inpatient 555 360.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 432.9 78 999999999 336.05 538.35 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712363_1 CDM 0278 RC C1713 HCPCS inpatient 555 360.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 382.95 69 999999999 336.05 538.35 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712363_1 CDM 0278 RC C1713 HCPCS inpatient 555 360.75 UMR - ALL PLANS UMR - ALL PLANS 388.5 70 999999999 336.05 538.35 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712363_1 CDM 0278 RC C1713 HCPCS inpatient 555 360.75 SIHO - ALL PLANS SIHO - ALL PLANS 499.5 90 999999999 336.05 538.35 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712363_1 CDM 0278 RC C1713 HCPCS inpatient 555 360.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 336.05 60.55 999999999 336.05 538.35 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712363_1 CDM 0278 RC C1713 HCPCS inpatient 555 360.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 336.05 538.35 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712363_1 CDM 0278 RC C1713 HCPCS inpatient 555 360.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 336.05 538.35 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712363_1 CDM 0278 RC C1713 HCPCS inpatient 555 360.75 ANTHEM HMO ANTHEM HMO 999999999 336.05 538.35 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712363_1 CDM 0278 RC C1713 HCPCS inpatient 555 360.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 336.05 538.35 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712363_1 CDM 0278 RC C1713 HCPCS inpatient 555 360.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 375.18 67.6 999999999 336.05 538.35 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712363_1 CDM 0278 RC C1713 HCPCS inpatient 555 360.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 336.05 538.35 PLATE DR 8HH/3HS RT 02.110.430 48712364_1 CDM 0278 RC inpatient 4927 3202.55 AETNA AETNA 3892.33 79 999999999 2983.3 4779.19 percent of total billed charges PLATE DR 8HH/3HS RT 02.110.430 48712364_1 CDM 0278 RC inpatient 4927 3202.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 3202.55 65 999999999 2983.3 4779.19 percent of total billed charges PLATE DR 8HH/3HS RT 02.110.430 48712364_1 CDM 0278 RC inpatient 4927 3202.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4779.19 97 999999999 2983.3 4779.19 percent of total billed charges PLATE DR 8HH/3HS RT 02.110.430 48712364_1 CDM 0278 RC inpatient 4927 3202.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 3843.06 78 999999999 2983.3 4779.19 percent of total billed charges PLATE DR 8HH/3HS RT 02.110.430 48712364_1 CDM 0278 RC inpatient 4927 3202.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 3399.63 69 999999999 2983.3 4779.19 percent of total billed charges PLATE DR 8HH/3HS RT 02.110.430 48712364_1 CDM 0278 RC inpatient 4927 3202.55 UMR - ALL PLANS UMR - ALL PLANS 3448.9 70 999999999 2983.3 4779.19 percent of total billed charges PLATE DR 8HH/3HS RT 02.110.430 48712364_1 CDM 0278 RC inpatient 4927 3202.55 SIHO - ALL PLANS SIHO - ALL PLANS 4434.3 90 999999999 2983.3 4779.19 percent of total billed charges PLATE DR 8HH/3HS RT 02.110.430 48712364_1 CDM 0278 RC inpatient 4927 3202.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2983.3 60.55 999999999 2983.3 4779.19 percent of total billed charges PLATE DR 8HH/3HS RT 02.110.430 48712364_1 CDM 0278 RC inpatient 4927 3202.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2983.3 4779.19 PLATE DR 8HH/3HS RT 02.110.430 48712364_1 CDM 0278 RC inpatient 4927 3202.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2983.3 4779.19 PLATE DR 8HH/3HS RT 02.110.430 48712364_1 CDM 0278 RC inpatient 4927 3202.55 ANTHEM HMO ANTHEM HMO 999999999 2983.3 4779.19 PLATE DR 8HH/3HS RT 02.110.430 48712364_1 CDM 0278 RC inpatient 4927 3202.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2983.3 4779.19 PLATE DR 8HH/3HS RT 02.110.430 48712364_1 CDM 0278 RC inpatient 4927 3202.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 3330.65 67.6 999999999 2983.3 4779.19 percent of total billed charges PLATE DR 8HH/3HS RT 02.110.430 48712364_1 CDM 0278 RC inpatient 4927 3202.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 2983.3 4779.19 PLATE DR 8HH/3HS LT 02.110.431 48712365_1 CDM 0278 RC inpatient 4753 3089.45 AETNA AETNA 3754.87 79 999999999 2877.94 4610.41 percent of total billed charges PLATE DR 8HH/3HS LT 02.110.431 48712365_1 CDM 0278 RC inpatient 4753 3089.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 3089.45 65 999999999 2877.94 4610.41 percent of total billed charges PLATE DR 8HH/3HS LT 02.110.431 48712365_1 CDM 0278 RC inpatient 4753 3089.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4610.41 97 999999999 2877.94 4610.41 percent of total billed charges PLATE DR 8HH/3HS LT 02.110.431 48712365_1 CDM 0278 RC inpatient 4753 3089.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 3707.34 78 999999999 2877.94 4610.41 percent of total billed charges PLATE DR 8HH/3HS LT 02.110.431 48712365_1 CDM 0278 RC inpatient 4753 3089.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 3279.57 69 999999999 2877.94 4610.41 percent of total billed charges PLATE DR 8HH/3HS LT 02.110.431 48712365_1 CDM 0278 RC inpatient 4753 3089.45 UMR - ALL PLANS UMR - ALL PLANS 3327.1 70 999999999 2877.94 4610.41 percent of total billed charges PLATE DR 8HH/3HS LT 02.110.431 48712365_1 CDM 0278 RC inpatient 4753 3089.45 SIHO - ALL PLANS SIHO - ALL PLANS 4277.7 90 999999999 2877.94 4610.41 percent of total billed charges PLATE DR 8HH/3HS LT 02.110.431 48712365_1 CDM 0278 RC inpatient 4753 3089.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2877.94 60.55 999999999 2877.94 4610.41 percent of total billed charges PLATE DR 8HH/3HS LT 02.110.431 48712365_1 CDM 0278 RC inpatient 4753 3089.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2877.94 4610.41 PLATE DR 8HH/3HS LT 02.110.431 48712365_1 CDM 0278 RC inpatient 4753 3089.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2877.94 4610.41 PLATE DR 8HH/3HS LT 02.110.431 48712365_1 CDM 0278 RC inpatient 4753 3089.45 ANTHEM HMO ANTHEM HMO 999999999 2877.94 4610.41 PLATE DR 8HH/3HS LT 02.110.431 48712365_1 CDM 0278 RC inpatient 4753 3089.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2877.94 4610.41 PLATE DR 8HH/3HS LT 02.110.431 48712365_1 CDM 0278 RC inpatient 4753 3089.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 3213.03 67.6 999999999 2877.94 4610.41 percent of total billed charges PLATE DR 8HH/3HS LT 02.110.431 48712365_1 CDM 0278 RC inpatient 4753 3089.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 2877.94 4610.41 PLATE DR 8HH/4HS RT 02.110.440 48712366_1 CDM 0278 RC inpatient 4905 3188.25 AETNA AETNA 3874.95 79 999999999 2969.98 4757.85 percent of total billed charges PLATE DR 8HH/4HS RT 02.110.440 48712366_1 CDM 0278 RC inpatient 4905 3188.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 3188.25 65 999999999 2969.98 4757.85 percent of total billed charges PLATE DR 8HH/4HS RT 02.110.440 48712366_1 CDM 0278 RC inpatient 4905 3188.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4757.85 97 999999999 2969.98 4757.85 percent of total billed charges PLATE DR 8HH/4HS RT 02.110.440 48712366_1 CDM 0278 RC inpatient 4905 3188.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 3825.9 78 999999999 2969.98 4757.85 percent of total billed charges PLATE DR 8HH/4HS RT 02.110.440 48712366_1 CDM 0278 RC inpatient 4905 3188.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 3384.45 69 999999999 2969.98 4757.85 percent of total billed charges PLATE DR 8HH/4HS RT 02.110.440 48712366_1 CDM 0278 RC inpatient 4905 3188.25 UMR - ALL PLANS UMR - ALL PLANS 3433.5 70 999999999 2969.98 4757.85 percent of total billed charges PLATE DR 8HH/4HS RT 02.110.440 48712366_1 CDM 0278 RC inpatient 4905 3188.25 SIHO - ALL PLANS SIHO - ALL PLANS 4414.5 90 999999999 2969.98 4757.85 percent of total billed charges PLATE DR 8HH/4HS RT 02.110.440 48712366_1 CDM 0278 RC inpatient 4905 3188.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2969.98 60.55 999999999 2969.98 4757.85 percent of total billed charges PLATE DR 8HH/4HS RT 02.110.440 48712366_1 CDM 0278 RC inpatient 4905 3188.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2969.98 4757.85 PLATE DR 8HH/4HS RT 02.110.440 48712366_1 CDM 0278 RC inpatient 4905 3188.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2969.98 4757.85 PLATE DR 8HH/4HS RT 02.110.440 48712366_1 CDM 0278 RC inpatient 4905 3188.25 ANTHEM HMO ANTHEM HMO 999999999 2969.98 4757.85 PLATE DR 8HH/4HS RT 02.110.440 48712366_1 CDM 0278 RC inpatient 4905 3188.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2969.98 4757.85 PLATE DR 8HH/4HS RT 02.110.440 48712366_1 CDM 0278 RC inpatient 4905 3188.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 3315.78 67.6 999999999 2969.98 4757.85 percent of total billed charges PLATE DR 8HH/4HS RT 02.110.440 48712366_1 CDM 0278 RC inpatient 4905 3188.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 2969.98 4757.85 PLATE DR 8HH/4HS LT 02.110.441 48712367_1 CDM 0278 RC inpatient 4905 3188.25 AETNA AETNA 3874.95 79 999999999 2969.98 4757.85 percent of total billed charges PLATE DR 8HH/4HS LT 02.110.441 48712367_1 CDM 0278 RC inpatient 4905 3188.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 3188.25 65 999999999 2969.98 4757.85 percent of total billed charges PLATE DR 8HH/4HS LT 02.110.441 48712367_1 CDM 0278 RC inpatient 4905 3188.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4757.85 97 999999999 2969.98 4757.85 percent of total billed charges PLATE DR 8HH/4HS LT 02.110.441 48712367_1 CDM 0278 RC inpatient 4905 3188.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 3825.9 78 999999999 2969.98 4757.85 percent of total billed charges PLATE DR 8HH/4HS LT 02.110.441 48712367_1 CDM 0278 RC inpatient 4905 3188.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 3384.45 69 999999999 2969.98 4757.85 percent of total billed charges PLATE DR 8HH/4HS LT 02.110.441 48712367_1 CDM 0278 RC inpatient 4905 3188.25 UMR - ALL PLANS UMR - ALL PLANS 3433.5 70 999999999 2969.98 4757.85 percent of total billed charges PLATE DR 8HH/4HS LT 02.110.441 48712367_1 CDM 0278 RC inpatient 4905 3188.25 SIHO - ALL PLANS SIHO - ALL PLANS 4414.5 90 999999999 2969.98 4757.85 percent of total billed charges PLATE DR 8HH/4HS LT 02.110.441 48712367_1 CDM 0278 RC inpatient 4905 3188.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2969.98 60.55 999999999 2969.98 4757.85 percent of total billed charges PLATE DR 8HH/4HS LT 02.110.441 48712367_1 CDM 0278 RC inpatient 4905 3188.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2969.98 4757.85 PLATE DR 8HH/4HS LT 02.110.441 48712367_1 CDM 0278 RC inpatient 4905 3188.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2969.98 4757.85 PLATE DR 8HH/4HS LT 02.110.441 48712367_1 CDM 0278 RC inpatient 4905 3188.25 ANTHEM HMO ANTHEM HMO 999999999 2969.98 4757.85 PLATE DR 8HH/4HS LT 02.110.441 48712367_1 CDM 0278 RC inpatient 4905 3188.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2969.98 4757.85 PLATE DR 8HH/4HS LT 02.110.441 48712367_1 CDM 0278 RC inpatient 4905 3188.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 3315.78 67.6 999999999 2969.98 4757.85 percent of total billed charges PLATE DR 8HH/4HS LT 02.110.441 48712367_1 CDM 0278 RC inpatient 4905 3188.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 2969.98 4757.85 PLATE DR 8HH/5HS RT 02.110.450 48712368_1 CDM 0278 RC inpatient 5046 3279.9 AETNA AETNA 3986.34 79 999999999 3055.35 4894.62 percent of total billed charges PLATE DR 8HH/5HS RT 02.110.450 48712368_1 CDM 0278 RC inpatient 5046 3279.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 3279.9 65 999999999 3055.35 4894.62 percent of total billed charges PLATE DR 8HH/5HS RT 02.110.450 48712368_1 CDM 0278 RC inpatient 5046 3279.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4894.62 97 999999999 3055.35 4894.62 percent of total billed charges PLATE DR 8HH/5HS RT 02.110.450 48712368_1 CDM 0278 RC inpatient 5046 3279.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 3935.88 78 999999999 3055.35 4894.62 percent of total billed charges PLATE DR 8HH/5HS RT 02.110.450 48712368_1 CDM 0278 RC inpatient 5046 3279.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 3481.74 69 999999999 3055.35 4894.62 percent of total billed charges PLATE DR 8HH/5HS RT 02.110.450 48712368_1 CDM 0278 RC inpatient 5046 3279.9 UMR - ALL PLANS UMR - ALL PLANS 3532.2 70 999999999 3055.35 4894.62 percent of total billed charges PLATE DR 8HH/5HS RT 02.110.450 48712368_1 CDM 0278 RC inpatient 5046 3279.9 SIHO - ALL PLANS SIHO - ALL PLANS 4541.4 90 999999999 3055.35 4894.62 percent of total billed charges PLATE DR 8HH/5HS RT 02.110.450 48712368_1 CDM 0278 RC inpatient 5046 3279.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3055.35 60.55 999999999 3055.35 4894.62 percent of total billed charges PLATE DR 8HH/5HS RT 02.110.450 48712368_1 CDM 0278 RC inpatient 5046 3279.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3055.35 4894.62 PLATE DR 8HH/5HS RT 02.110.450 48712368_1 CDM 0278 RC inpatient 5046 3279.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3055.35 4894.62 PLATE DR 8HH/5HS RT 02.110.450 48712368_1 CDM 0278 RC inpatient 5046 3279.9 ANTHEM HMO ANTHEM HMO 999999999 3055.35 4894.62 PLATE DR 8HH/5HS RT 02.110.450 48712368_1 CDM 0278 RC inpatient 5046 3279.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3055.35 4894.62 PLATE DR 8HH/5HS RT 02.110.450 48712368_1 CDM 0278 RC inpatient 5046 3279.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 3411.1 67.6 999999999 3055.35 4894.62 percent of total billed charges PLATE DR 8HH/5HS RT 02.110.450 48712368_1 CDM 0278 RC inpatient 5046 3279.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 3055.35 4894.62 PLATE DR 8HH/5HS LT 02.110.451 48712369_1 CDM 0278 RC inpatient 5046 3279.9 AETNA AETNA 3986.34 79 999999999 3055.35 4894.62 percent of total billed charges PLATE DR 8HH/5HS LT 02.110.451 48712369_1 CDM 0278 RC inpatient 5046 3279.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 3279.9 65 999999999 3055.35 4894.62 percent of total billed charges PLATE DR 8HH/5HS LT 02.110.451 48712369_1 CDM 0278 RC inpatient 5046 3279.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4894.62 97 999999999 3055.35 4894.62 percent of total billed charges PLATE DR 8HH/5HS LT 02.110.451 48712369_1 CDM 0278 RC inpatient 5046 3279.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 3935.88 78 999999999 3055.35 4894.62 percent of total billed charges PLATE DR 8HH/5HS LT 02.110.451 48712369_1 CDM 0278 RC inpatient 5046 3279.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 3481.74 69 999999999 3055.35 4894.62 percent of total billed charges PLATE DR 8HH/5HS LT 02.110.451 48712369_1 CDM 0278 RC inpatient 5046 3279.9 UMR - ALL PLANS UMR - ALL PLANS 3532.2 70 999999999 3055.35 4894.62 percent of total billed charges PLATE DR 8HH/5HS LT 02.110.451 48712369_1 CDM 0278 RC inpatient 5046 3279.9 SIHO - ALL PLANS SIHO - ALL PLANS 4541.4 90 999999999 3055.35 4894.62 percent of total billed charges PLATE DR 8HH/5HS LT 02.110.451 48712369_1 CDM 0278 RC inpatient 5046 3279.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3055.35 60.55 999999999 3055.35 4894.62 percent of total billed charges PLATE DR 8HH/5HS LT 02.110.451 48712369_1 CDM 0278 RC inpatient 5046 3279.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3055.35 4894.62 PLATE DR 8HH/5HS LT 02.110.451 48712369_1 CDM 0278 RC inpatient 5046 3279.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3055.35 4894.62 PLATE DR 8HH/5HS LT 02.110.451 48712369_1 CDM 0278 RC inpatient 5046 3279.9 ANTHEM HMO ANTHEM HMO 999999999 3055.35 4894.62 PLATE DR 8HH/5HS LT 02.110.451 48712369_1 CDM 0278 RC inpatient 5046 3279.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3055.35 4894.62 PLATE DR 8HH/5HS LT 02.110.451 48712369_1 CDM 0278 RC inpatient 5046 3279.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 3411.1 67.6 999999999 3055.35 4894.62 percent of total billed charges PLATE DR 8HH/5HS LT 02.110.451 48712369_1 CDM 0278 RC inpatient 5046 3279.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 3055.35 4894.62 PLATE DIS RAD LT/SHORT 242.491 48712370_1 CDM 0278 RC inpatient 4695 3051.75 AETNA AETNA 3709.05 79 999999999 2842.82 4554.15 percent of total billed charges PLATE DIS RAD LT/SHORT 242.491 48712370_1 CDM 0278 RC inpatient 4695 3051.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 3051.75 65 999999999 2842.82 4554.15 percent of total billed charges PLATE DIS RAD LT/SHORT 242.491 48712370_1 CDM 0278 RC inpatient 4695 3051.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4554.15 97 999999999 2842.82 4554.15 percent of total billed charges PLATE DIS RAD LT/SHORT 242.491 48712370_1 CDM 0278 RC inpatient 4695 3051.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 3662.1 78 999999999 2842.82 4554.15 percent of total billed charges PLATE DIS RAD LT/SHORT 242.491 48712370_1 CDM 0278 RC inpatient 4695 3051.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 3239.55 69 999999999 2842.82 4554.15 percent of total billed charges PLATE DIS RAD LT/SHORT 242.491 48712370_1 CDM 0278 RC inpatient 4695 3051.75 UMR - ALL PLANS UMR - ALL PLANS 3286.5 70 999999999 2842.82 4554.15 percent of total billed charges PLATE DIS RAD LT/SHORT 242.491 48712370_1 CDM 0278 RC inpatient 4695 3051.75 SIHO - ALL PLANS SIHO - ALL PLANS 4225.5 90 999999999 2842.82 4554.15 percent of total billed charges PLATE DIS RAD LT/SHORT 242.491 48712370_1 CDM 0278 RC inpatient 4695 3051.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2842.82 60.55 999999999 2842.82 4554.15 percent of total billed charges PLATE DIS RAD LT/SHORT 242.491 48712370_1 CDM 0278 RC inpatient 4695 3051.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2842.82 4554.15 PLATE DIS RAD LT/SHORT 242.491 48712370_1 CDM 0278 RC inpatient 4695 3051.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2842.82 4554.15 PLATE DIS RAD LT/SHORT 242.491 48712370_1 CDM 0278 RC inpatient 4695 3051.75 ANTHEM HMO ANTHEM HMO 999999999 2842.82 4554.15 PLATE DIS RAD LT/SHORT 242.491 48712370_1 CDM 0278 RC inpatient 4695 3051.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2842.82 4554.15 PLATE DIS RAD LT/SHORT 242.491 48712370_1 CDM 0278 RC inpatient 4695 3051.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 3173.82 67.6 999999999 2842.82 4554.15 percent of total billed charges PLATE DIS RAD LT/SHORT 242.491 48712370_1 CDM 0278 RC inpatient 4695 3051.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 2842.82 4554.15 SM FRAG 1/3 TUB 8HOLE 441.38 48712371_1 CDM 0278 RC inpatient 633 411.45 AETNA AETNA 500.07 79 999999999 383.28 614.01 percent of total billed charges SM FRAG 1/3 TUB 8HOLE 441.38 48712371_1 CDM 0278 RC inpatient 633 411.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 411.45 65 999999999 383.28 614.01 percent of total billed charges SM FRAG 1/3 TUB 8HOLE 441.38 48712371_1 CDM 0278 RC inpatient 633 411.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 614.01 97 999999999 383.28 614.01 percent of total billed charges SM FRAG 1/3 TUB 8HOLE 441.38 48712371_1 CDM 0278 RC inpatient 633 411.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 493.74 78 999999999 383.28 614.01 percent of total billed charges SM FRAG 1/3 TUB 8HOLE 441.38 48712371_1 CDM 0278 RC inpatient 633 411.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 436.77 69 999999999 383.28 614.01 percent of total billed charges SM FRAG 1/3 TUB 8HOLE 441.38 48712371_1 CDM 0278 RC inpatient 633 411.45 UMR - ALL PLANS UMR - ALL PLANS 443.1 70 999999999 383.28 614.01 percent of total billed charges SM FRAG 1/3 TUB 8HOLE 441.38 48712371_1 CDM 0278 RC inpatient 633 411.45 SIHO - ALL PLANS SIHO - ALL PLANS 569.7 90 999999999 383.28 614.01 percent of total billed charges SM FRAG 1/3 TUB 8HOLE 441.38 48712371_1 CDM 0278 RC inpatient 633 411.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 383.28 60.55 999999999 383.28 614.01 percent of total billed charges SM FRAG 1/3 TUB 8HOLE 441.38 48712371_1 CDM 0278 RC inpatient 633 411.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 383.28 614.01 SM FRAG 1/3 TUB 8HOLE 441.38 48712371_1 CDM 0278 RC inpatient 633 411.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 383.28 614.01 SM FRAG 1/3 TUB 8HOLE 441.38 48712371_1 CDM 0278 RC inpatient 633 411.45 ANTHEM HMO ANTHEM HMO 999999999 383.28 614.01 SM FRAG 1/3 TUB 8HOLE 441.38 48712371_1 CDM 0278 RC inpatient 633 411.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 383.28 614.01 SM FRAG 1/3 TUB 8HOLE 441.38 48712371_1 CDM 0278 RC inpatient 633 411.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 427.91 67.6 999999999 383.28 614.01 percent of total billed charges SM FRAG 1/3 TUB 8HOLE 441.38 48712371_1 CDM 0278 RC inpatient 633 411.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 383.28 614.01 SM FRAG T-PLATE 3HOLE 441.13 48712372_1 CDM 0278 RC inpatient 690 448.5 AETNA AETNA 545.1 79 999999999 417.8 669.3 percent of total billed charges SM FRAG T-PLATE 3HOLE 441.13 48712372_1 CDM 0278 RC inpatient 690 448.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 448.5 65 999999999 417.8 669.3 percent of total billed charges SM FRAG T-PLATE 3HOLE 441.13 48712372_1 CDM 0278 RC inpatient 690 448.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 669.3 97 999999999 417.8 669.3 percent of total billed charges SM FRAG T-PLATE 3HOLE 441.13 48712372_1 CDM 0278 RC inpatient 690 448.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 538.2 78 999999999 417.8 669.3 percent of total billed charges SM FRAG T-PLATE 3HOLE 441.13 48712372_1 CDM 0278 RC inpatient 690 448.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 476.1 69 999999999 417.8 669.3 percent of total billed charges SM FRAG T-PLATE 3HOLE 441.13 48712372_1 CDM 0278 RC inpatient 690 448.5 UMR - ALL PLANS UMR - ALL PLANS 483 70 999999999 417.8 669.3 percent of total billed charges SM FRAG T-PLATE 3HOLE 441.13 48712372_1 CDM 0278 RC inpatient 690 448.5 SIHO - ALL PLANS SIHO - ALL PLANS 621 90 999999999 417.8 669.3 percent of total billed charges SM FRAG T-PLATE 3HOLE 441.13 48712372_1 CDM 0278 RC inpatient 690 448.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 417.8 60.55 999999999 417.8 669.3 percent of total billed charges SM FRAG T-PLATE 3HOLE 441.13 48712372_1 CDM 0278 RC inpatient 690 448.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 417.8 669.3 SM FRAG T-PLATE 3HOLE 441.13 48712372_1 CDM 0278 RC inpatient 690 448.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 417.8 669.3 SM FRAG T-PLATE 3HOLE 441.13 48712372_1 CDM 0278 RC inpatient 690 448.5 ANTHEM HMO ANTHEM HMO 999999999 417.8 669.3 SM FRAG T-PLATE 3HOLE 441.13 48712372_1 CDM 0278 RC inpatient 690 448.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 417.8 669.3 SM FRAG T-PLATE 3HOLE 441.13 48712372_1 CDM 0278 RC inpatient 690 448.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 466.44 67.6 999999999 417.8 669.3 percent of total billed charges SM FRAG T-PLATE 3HOLE 441.13 48712372_1 CDM 0278 RC inpatient 690 448.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 417.8 669.3 SM FRAG T-PLATE 5HOLE 441.15 48712373_1 CDM 0278 RC inpatient 864 561.6 AETNA AETNA 682.56 79 999999999 523.15 838.08 percent of total billed charges SM FRAG T-PLATE 5HOLE 441.15 48712373_1 CDM 0278 RC inpatient 864 561.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 561.6 65 999999999 523.15 838.08 percent of total billed charges SM FRAG T-PLATE 5HOLE 441.15 48712373_1 CDM 0278 RC inpatient 864 561.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 838.08 97 999999999 523.15 838.08 percent of total billed charges SM FRAG T-PLATE 5HOLE 441.15 48712373_1 CDM 0278 RC inpatient 864 561.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 673.92 78 999999999 523.15 838.08 percent of total billed charges SM FRAG T-PLATE 5HOLE 441.15 48712373_1 CDM 0278 RC inpatient 864 561.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 596.16 69 999999999 523.15 838.08 percent of total billed charges SM FRAG T-PLATE 5HOLE 441.15 48712373_1 CDM 0278 RC inpatient 864 561.6 UMR - ALL PLANS UMR - ALL PLANS 604.8 70 999999999 523.15 838.08 percent of total billed charges SM FRAG T-PLATE 5HOLE 441.15 48712373_1 CDM 0278 RC inpatient 864 561.6 SIHO - ALL PLANS SIHO - ALL PLANS 777.6 90 999999999 523.15 838.08 percent of total billed charges SM FRAG T-PLATE 5HOLE 441.15 48712373_1 CDM 0278 RC inpatient 864 561.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 523.15 60.55 999999999 523.15 838.08 percent of total billed charges SM FRAG T-PLATE 5HOLE 441.15 48712373_1 CDM 0278 RC inpatient 864 561.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 523.15 838.08 SM FRAG T-PLATE 5HOLE 441.15 48712373_1 CDM 0278 RC inpatient 864 561.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 523.15 838.08 SM FRAG T-PLATE 5HOLE 441.15 48712373_1 CDM 0278 RC inpatient 864 561.6 ANTHEM HMO ANTHEM HMO 999999999 523.15 838.08 SM FRAG T-PLATE 5HOLE 441.15 48712373_1 CDM 0278 RC inpatient 864 561.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 523.15 838.08 SM FRAG T-PLATE 5HOLE 441.15 48712373_1 CDM 0278 RC inpatient 864 561.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 523.15 838.08 SM FRAG T-PLATE 5HOLE 441.15 48712373_1 CDM 0278 RC inpatient 864 561.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 584.06 67.6 999999999 523.15 838.08 percent of total billed charges SM FRA T PLATE 3 HOLE 441.23 48712374_1 CDM 0278 RC inpatient 982 638.3 AETNA AETNA 775.78 79 999999999 594.6 952.54 percent of total billed charges SM FRA T PLATE 3 HOLE 441.23 48712374_1 CDM 0278 RC inpatient 982 638.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 638.3 65 999999999 594.6 952.54 percent of total billed charges SM FRA T PLATE 3 HOLE 441.23 48712374_1 CDM 0278 RC inpatient 982 638.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 952.54 97 999999999 594.6 952.54 percent of total billed charges SM FRA T PLATE 3 HOLE 441.23 48712374_1 CDM 0278 RC inpatient 982 638.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.96 78 999999999 594.6 952.54 percent of total billed charges SM FRA T PLATE 3 HOLE 441.23 48712374_1 CDM 0278 RC inpatient 982 638.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 677.58 69 999999999 594.6 952.54 percent of total billed charges SM FRA T PLATE 3 HOLE 441.23 48712374_1 CDM 0278 RC inpatient 982 638.3 UMR - ALL PLANS UMR - ALL PLANS 687.4 70 999999999 594.6 952.54 percent of total billed charges SM FRA T PLATE 3 HOLE 441.23 48712374_1 CDM 0278 RC inpatient 982 638.3 SIHO - ALL PLANS SIHO - ALL PLANS 883.8 90 999999999 594.6 952.54 percent of total billed charges SM FRA T PLATE 3 HOLE 441.23 48712374_1 CDM 0278 RC inpatient 982 638.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594.6 60.55 999999999 594.6 952.54 percent of total billed charges SM FRA T PLATE 3 HOLE 441.23 48712374_1 CDM 0278 RC inpatient 982 638.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594.6 952.54 SM FRA T PLATE 3 HOLE 441.23 48712374_1 CDM 0278 RC inpatient 982 638.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594.6 952.54 SM FRA T PLATE 3 HOLE 441.23 48712374_1 CDM 0278 RC inpatient 982 638.3 ANTHEM HMO ANTHEM HMO 999999999 594.6 952.54 SM FRA T PLATE 3 HOLE 441.23 48712374_1 CDM 0278 RC inpatient 982 638.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594.6 952.54 SM FRA T PLATE 3 HOLE 441.23 48712374_1 CDM 0278 RC inpatient 982 638.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 594.6 952.54 SM FRA T PLATE 3 HOLE 441.23 48712374_1 CDM 0278 RC inpatient 982 638.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.83 67.6 999999999 594.6 952.54 percent of total billed charges SM FRA T PLATE 4HOLE 441.24 48712375_1 CDM 0278 RC inpatient 844 548.6 AETNA AETNA 666.76 79 999999999 511.04 818.68 percent of total billed charges SM FRA T PLATE 4HOLE 441.24 48712375_1 CDM 0278 RC inpatient 844 548.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 548.6 65 999999999 511.04 818.68 percent of total billed charges SM FRA T PLATE 4HOLE 441.24 48712375_1 CDM 0278 RC inpatient 844 548.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 818.68 97 999999999 511.04 818.68 percent of total billed charges SM FRA T PLATE 4HOLE 441.24 48712375_1 CDM 0278 RC inpatient 844 548.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 658.32 78 999999999 511.04 818.68 percent of total billed charges SM FRA T PLATE 4HOLE 441.24 48712375_1 CDM 0278 RC inpatient 844 548.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 582.36 69 999999999 511.04 818.68 percent of total billed charges SM FRA T PLATE 4HOLE 441.24 48712375_1 CDM 0278 RC inpatient 844 548.6 UMR - ALL PLANS UMR - ALL PLANS 590.8 70 999999999 511.04 818.68 percent of total billed charges SM FRA T PLATE 4HOLE 441.24 48712375_1 CDM 0278 RC inpatient 844 548.6 SIHO - ALL PLANS SIHO - ALL PLANS 759.6 90 999999999 511.04 818.68 percent of total billed charges SM FRA T PLATE 4HOLE 441.24 48712375_1 CDM 0278 RC inpatient 844 548.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 511.04 60.55 999999999 511.04 818.68 percent of total billed charges SM FRA T PLATE 4HOLE 441.24 48712375_1 CDM 0278 RC inpatient 844 548.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 511.04 818.68 SM FRA T PLATE 4HOLE 441.24 48712375_1 CDM 0278 RC inpatient 844 548.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 511.04 818.68 SM FRA T PLATE 4HOLE 441.24 48712375_1 CDM 0278 RC inpatient 844 548.6 ANTHEM HMO ANTHEM HMO 999999999 511.04 818.68 SM FRA T PLATE 4HOLE 441.24 48712375_1 CDM 0278 RC inpatient 844 548.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 511.04 818.68 SM FRA T PLATE 4HOLE 441.24 48712375_1 CDM 0278 RC inpatient 844 548.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 511.04 818.68 SM FRA T PLATE 4HOLE 441.24 48712375_1 CDM 0278 RC inpatient 844 548.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 570.54 67.6 999999999 511.04 818.68 percent of total billed charges SM FRA T PLATE 5HOLE 441.25 48712376_1 CDM 0278 RC inpatient 1080 702 AETNA AETNA 853.2 79 999999999 653.94 1047.6 percent of total billed charges SM FRA T PLATE 5HOLE 441.25 48712376_1 CDM 0278 RC inpatient 1080 702 SELF PAY DISCOUNT SELF PAY DISCOUNT 702 65 999999999 653.94 1047.6 percent of total billed charges SM FRA T PLATE 5HOLE 441.25 48712376_1 CDM 0278 RC inpatient 1080 702 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1047.6 97 999999999 653.94 1047.6 percent of total billed charges SM FRA T PLATE 5HOLE 441.25 48712376_1 CDM 0278 RC inpatient 1080 702 HUMANA - ALL PLANS HUMANA - ALL PLANS 842.4 78 999999999 653.94 1047.6 percent of total billed charges SM FRA T PLATE 5HOLE 441.25 48712376_1 CDM 0278 RC inpatient 1080 702 ENCORE - ALL PLANS ENCORE - ALL PLANS 745.2 69 999999999 653.94 1047.6 percent of total billed charges SM FRA T PLATE 5HOLE 441.25 48712376_1 CDM 0278 RC inpatient 1080 702 UMR - ALL PLANS UMR - ALL PLANS 756 70 999999999 653.94 1047.6 percent of total billed charges SM FRA T PLATE 5HOLE 441.25 48712376_1 CDM 0278 RC inpatient 1080 702 SIHO - ALL PLANS SIHO - ALL PLANS 972 90 999999999 653.94 1047.6 percent of total billed charges SM FRA T PLATE 5HOLE 441.25 48712376_1 CDM 0278 RC inpatient 1080 702 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 653.94 60.55 999999999 653.94 1047.6 percent of total billed charges SM FRA T PLATE 5HOLE 441.25 48712376_1 CDM 0278 RC inpatient 1080 702 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 653.94 1047.6 SM FRA T PLATE 5HOLE 441.25 48712376_1 CDM 0278 RC inpatient 1080 702 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 653.94 1047.6 SM FRA T PLATE 5HOLE 441.25 48712376_1 CDM 0278 RC inpatient 1080 702 ANTHEM HMO ANTHEM HMO 999999999 653.94 1047.6 SM FRA T PLATE 5HOLE 441.25 48712376_1 CDM 0278 RC inpatient 1080 702 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 653.94 1047.6 SM FRA T PLATE 5HOLE 441.25 48712376_1 CDM 0278 RC inpatient 1080 702 UHC - ALL PLANS UHC - ALL PLANS 999999999 653.94 1047.6 SM FRA T PLATE 5HOLE 441.25 48712376_1 CDM 0278 RC inpatient 1080 702 CIGNA - ALL PLANS CIGNA - ALL PLANS 730.08 67.6 999999999 653.94 1047.6 percent of total billed charges SM FRA CLOVERLEAF 3 PL 441.83 48712377_1 CDM 0278 RC inpatient 908 590.2 AETNA AETNA 717.32 79 999999999 549.79 880.76 percent of total billed charges SM FRA CLOVERLEAF 3 PL 441.83 48712377_1 CDM 0278 RC inpatient 908 590.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 590.2 65 999999999 549.79 880.76 percent of total billed charges SM FRA CLOVERLEAF 3 PL 441.83 48712377_1 CDM 0278 RC inpatient 908 590.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 880.76 97 999999999 549.79 880.76 percent of total billed charges SM FRA CLOVERLEAF 3 PL 441.83 48712377_1 CDM 0278 RC inpatient 908 590.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 708.24 78 999999999 549.79 880.76 percent of total billed charges SM FRA CLOVERLEAF 3 PL 441.83 48712377_1 CDM 0278 RC inpatient 908 590.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 626.52 69 999999999 549.79 880.76 percent of total billed charges SM FRA CLOVERLEAF 3 PL 441.83 48712377_1 CDM 0278 RC inpatient 908 590.2 UMR - ALL PLANS UMR - ALL PLANS 635.6 70 999999999 549.79 880.76 percent of total billed charges SM FRA CLOVERLEAF 3 PL 441.83 48712377_1 CDM 0278 RC inpatient 908 590.2 SIHO - ALL PLANS SIHO - ALL PLANS 817.2 90 999999999 549.79 880.76 percent of total billed charges SM FRA CLOVERLEAF 3 PL 441.83 48712377_1 CDM 0278 RC inpatient 908 590.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 549.79 60.55 999999999 549.79 880.76 percent of total billed charges SM FRA CLOVERLEAF 3 PL 441.83 48712377_1 CDM 0278 RC inpatient 908 590.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 549.79 880.76 SM FRA CLOVERLEAF 3 PL 441.83 48712377_1 CDM 0278 RC inpatient 908 590.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 549.79 880.76 SM FRA CLOVERLEAF 3 PL 441.83 48712377_1 CDM 0278 RC inpatient 908 590.2 ANTHEM HMO ANTHEM HMO 999999999 549.79 880.76 SM FRA CLOVERLEAF 3 PL 441.83 48712377_1 CDM 0278 RC inpatient 908 590.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 549.79 880.76 SM FRA CLOVERLEAF 3 PL 441.83 48712377_1 CDM 0278 RC inpatient 908 590.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 549.79 880.76 SM FRA CLOVERLEAF 3 PL 441.83 48712377_1 CDM 0278 RC inpatient 908 590.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 613.81 67.6 999999999 549.79 880.76 percent of total billed charges SM FRA CLOV LEAF PL 5HO 441.84 48712378_1 CDM 0278 RC inpatient 1187 771.55 AETNA AETNA 937.73 79 999999999 718.73 1151.39 percent of total billed charges SM FRA CLOV LEAF PL 5HO 441.84 48712378_1 CDM 0278 RC inpatient 1187 771.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 771.55 65 999999999 718.73 1151.39 percent of total billed charges SM FRA CLOV LEAF PL 5HO 441.84 48712378_1 CDM 0278 RC inpatient 1187 771.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1151.39 97 999999999 718.73 1151.39 percent of total billed charges SM FRA CLOV LEAF PL 5HO 441.84 48712378_1 CDM 0278 RC inpatient 1187 771.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 925.86 78 999999999 718.73 1151.39 percent of total billed charges SM FRA CLOV LEAF PL 5HO 441.84 48712378_1 CDM 0278 RC inpatient 1187 771.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 819.03 69 999999999 718.73 1151.39 percent of total billed charges SM FRA CLOV LEAF PL 5HO 441.84 48712378_1 CDM 0278 RC inpatient 1187 771.55 UMR - ALL PLANS UMR - ALL PLANS 830.9 70 999999999 718.73 1151.39 percent of total billed charges SM FRA CLOV LEAF PL 5HO 441.84 48712378_1 CDM 0278 RC inpatient 1187 771.55 SIHO - ALL PLANS SIHO - ALL PLANS 1068.3 90 999999999 718.73 1151.39 percent of total billed charges SM FRA CLOV LEAF PL 5HO 441.84 48712378_1 CDM 0278 RC inpatient 1187 771.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 718.73 60.55 999999999 718.73 1151.39 percent of total billed charges SM FRA CLOV LEAF PL 5HO 441.84 48712378_1 CDM 0278 RC inpatient 1187 771.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 718.73 1151.39 SM FRA CLOV LEAF PL 5HO 441.84 48712378_1 CDM 0278 RC inpatient 1187 771.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 718.73 1151.39 SM FRA CLOV LEAF PL 5HO 441.84 48712378_1 CDM 0278 RC inpatient 1187 771.55 ANTHEM HMO ANTHEM HMO 999999999 718.73 1151.39 SM FRA CLOV LEAF PL 5HO 441.84 48712378_1 CDM 0278 RC inpatient 1187 771.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 718.73 1151.39 SM FRA CLOV LEAF PL 5HO 441.84 48712378_1 CDM 0278 RC inpatient 1187 771.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 718.73 1151.39 SM FRA CLOV LEAF PL 5HO 441.84 48712378_1 CDM 0278 RC inpatient 1187 771.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 802.41 67.6 999999999 718.73 1151.39 percent of total billed charges DHS 135 STAND 4 HOLE 281.140 48712379_1 CDM 0278 RC inpatient 2893 1880.45 AETNA AETNA 2285.47 79 999999999 1751.71 2806.21 percent of total billed charges DHS 135 STAND 4 HOLE 281.140 48712379_1 CDM 0278 RC inpatient 2893 1880.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1880.45 65 999999999 1751.71 2806.21 percent of total billed charges DHS 135 STAND 4 HOLE 281.140 48712379_1 CDM 0278 RC inpatient 2893 1880.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2806.21 97 999999999 1751.71 2806.21 percent of total billed charges DHS 135 STAND 4 HOLE 281.140 48712379_1 CDM 0278 RC inpatient 2893 1880.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 2256.54 78 999999999 1751.71 2806.21 percent of total billed charges DHS 135 STAND 4 HOLE 281.140 48712379_1 CDM 0278 RC inpatient 2893 1880.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1996.17 69 999999999 1751.71 2806.21 percent of total billed charges DHS 135 STAND 4 HOLE 281.140 48712379_1 CDM 0278 RC inpatient 2893 1880.45 UMR - ALL PLANS UMR - ALL PLANS 2025.1 70 999999999 1751.71 2806.21 percent of total billed charges DHS 135 STAND 4 HOLE 281.140 48712379_1 CDM 0278 RC inpatient 2893 1880.45 SIHO - ALL PLANS SIHO - ALL PLANS 2603.7 90 999999999 1751.71 2806.21 percent of total billed charges DHS 135 STAND 4 HOLE 281.140 48712379_1 CDM 0278 RC inpatient 2893 1880.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1751.71 60.55 999999999 1751.71 2806.21 percent of total billed charges DHS 135 STAND 4 HOLE 281.140 48712379_1 CDM 0278 RC inpatient 2893 1880.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1751.71 2806.21 DHS 135 STAND 4 HOLE 281.140 48712379_1 CDM 0278 RC inpatient 2893 1880.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1751.71 2806.21 DHS 135 STAND 4 HOLE 281.140 48712379_1 CDM 0278 RC inpatient 2893 1880.45 ANTHEM HMO ANTHEM HMO 999999999 1751.71 2806.21 DHS 135 STAND 4 HOLE 281.140 48712379_1 CDM 0278 RC inpatient 2893 1880.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1751.71 2806.21 DHS 135 STAND 4 HOLE 281.140 48712379_1 CDM 0278 RC inpatient 2893 1880.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1751.71 2806.21 DHS 135 STAND 4 HOLE 281.140 48712379_1 CDM 0278 RC inpatient 2893 1880.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1955.67 67.6 999999999 1751.71 2806.21 percent of total billed charges DHS 135 STANDARD 5 HOLE 281.15 48712380_1 CDM 0278 RC inpatient 2019 1312.35 AETNA AETNA 1595.01 79 999999999 1222.5 1958.43 percent of total billed charges DHS 135 STANDARD 5 HOLE 281.15 48712380_1 CDM 0278 RC inpatient 2019 1312.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1312.35 65 999999999 1222.5 1958.43 percent of total billed charges DHS 135 STANDARD 5 HOLE 281.15 48712380_1 CDM 0278 RC inpatient 2019 1312.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1958.43 97 999999999 1222.5 1958.43 percent of total billed charges DHS 135 STANDARD 5 HOLE 281.15 48712380_1 CDM 0278 RC inpatient 2019 1312.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1574.82 78 999999999 1222.5 1958.43 percent of total billed charges DHS 135 STANDARD 5 HOLE 281.15 48712380_1 CDM 0278 RC inpatient 2019 1312.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1393.11 69 999999999 1222.5 1958.43 percent of total billed charges DHS 135 STANDARD 5 HOLE 281.15 48712380_1 CDM 0278 RC inpatient 2019 1312.35 UMR - ALL PLANS UMR - ALL PLANS 1413.3 70 999999999 1222.5 1958.43 percent of total billed charges DHS 135 STANDARD 5 HOLE 281.15 48712380_1 CDM 0278 RC inpatient 2019 1312.35 SIHO - ALL PLANS SIHO - ALL PLANS 1817.1 90 999999999 1222.5 1958.43 percent of total billed charges DHS 135 STANDARD 5 HOLE 281.15 48712380_1 CDM 0278 RC inpatient 2019 1312.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1222.5 60.55 999999999 1222.5 1958.43 percent of total billed charges DHS 135 STANDARD 5 HOLE 281.15 48712380_1 CDM 0278 RC inpatient 2019 1312.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1222.5 1958.43 DHS 135 STANDARD 5 HOLE 281.15 48712380_1 CDM 0278 RC inpatient 2019 1312.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1222.5 1958.43 DHS 135 STANDARD 5 HOLE 281.15 48712380_1 CDM 0278 RC inpatient 2019 1312.35 ANTHEM HMO ANTHEM HMO 999999999 1222.5 1958.43 DHS 135 STANDARD 5 HOLE 281.15 48712380_1 CDM 0278 RC inpatient 2019 1312.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1222.5 1958.43 DHS 135 STANDARD 5 HOLE 281.15 48712380_1 CDM 0278 RC inpatient 2019 1312.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1222.5 1958.43 DHS 135 STANDARD 5 HOLE 281.15 48712380_1 CDM 0278 RC inpatient 2019 1312.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1364.84 67.6 999999999 1222.5 1958.43 percent of total billed charges DHS 135 STANDARD 6 HOLE 281.16 48712381_1 CDM 0278 RC inpatient 2769 1799.85 AETNA AETNA 2187.51 79 999999999 1676.63 2685.93 percent of total billed charges DHS 135 STANDARD 6 HOLE 281.16 48712381_1 CDM 0278 RC inpatient 2769 1799.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1799.85 65 999999999 1676.63 2685.93 percent of total billed charges DHS 135 STANDARD 6 HOLE 281.16 48712381_1 CDM 0278 RC inpatient 2769 1799.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2685.93 97 999999999 1676.63 2685.93 percent of total billed charges DHS 135 STANDARD 6 HOLE 281.16 48712381_1 CDM 0278 RC inpatient 2769 1799.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 2159.82 78 999999999 1676.63 2685.93 percent of total billed charges DHS 135 STANDARD 6 HOLE 281.16 48712381_1 CDM 0278 RC inpatient 2769 1799.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1910.61 69 999999999 1676.63 2685.93 percent of total billed charges DHS 135 STANDARD 6 HOLE 281.16 48712381_1 CDM 0278 RC inpatient 2769 1799.85 UMR - ALL PLANS UMR - ALL PLANS 1938.3 70 999999999 1676.63 2685.93 percent of total billed charges DHS 135 STANDARD 6 HOLE 281.16 48712381_1 CDM 0278 RC inpatient 2769 1799.85 SIHO - ALL PLANS SIHO - ALL PLANS 2492.1 90 999999999 1676.63 2685.93 percent of total billed charges DHS 135 STANDARD 6 HOLE 281.16 48712381_1 CDM 0278 RC inpatient 2769 1799.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1676.63 60.55 999999999 1676.63 2685.93 percent of total billed charges DHS 135 STANDARD 6 HOLE 281.16 48712381_1 CDM 0278 RC inpatient 2769 1799.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1676.63 2685.93 DHS 135 STANDARD 6 HOLE 281.16 48712381_1 CDM 0278 RC inpatient 2769 1799.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1676.63 2685.93 DHS 135 STANDARD 6 HOLE 281.16 48712381_1 CDM 0278 RC inpatient 2769 1799.85 ANTHEM HMO ANTHEM HMO 999999999 1676.63 2685.93 DHS 135 STANDARD 6 HOLE 281.16 48712381_1 CDM 0278 RC inpatient 2769 1799.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1676.63 2685.93 DHS 135 STANDARD 6 HOLE 281.16 48712381_1 CDM 0278 RC inpatient 2769 1799.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1676.63 2685.93 DHS 135 STANDARD 6 HOLE 281.16 48712381_1 CDM 0278 RC inpatient 2769 1799.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1871.84 67.6 999999999 1676.63 2685.93 percent of total billed charges DHS 150 STANDARD 4 HOLE 281.44 48712382_1 CDM 0278 RC inpatient 2539 1650.35 AETNA AETNA 2005.81 79 999999999 1537.36 2462.83 percent of total billed charges DHS 150 STANDARD 4 HOLE 281.44 48712382_1 CDM 0278 RC inpatient 2539 1650.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1650.35 65 999999999 1537.36 2462.83 percent of total billed charges DHS 150 STANDARD 4 HOLE 281.44 48712382_1 CDM 0278 RC inpatient 2539 1650.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2462.83 97 999999999 1537.36 2462.83 percent of total billed charges DHS 150 STANDARD 4 HOLE 281.44 48712382_1 CDM 0278 RC inpatient 2539 1650.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1980.42 78 999999999 1537.36 2462.83 percent of total billed charges DHS 150 STANDARD 4 HOLE 281.44 48712382_1 CDM 0278 RC inpatient 2539 1650.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1751.91 69 999999999 1537.36 2462.83 percent of total billed charges DHS 150 STANDARD 4 HOLE 281.44 48712382_1 CDM 0278 RC inpatient 2539 1650.35 UMR - ALL PLANS UMR - ALL PLANS 1777.3 70 999999999 1537.36 2462.83 percent of total billed charges DHS 150 STANDARD 4 HOLE 281.44 48712382_1 CDM 0278 RC inpatient 2539 1650.35 SIHO - ALL PLANS SIHO - ALL PLANS 2285.1 90 999999999 1537.36 2462.83 percent of total billed charges DHS 150 STANDARD 4 HOLE 281.44 48712382_1 CDM 0278 RC inpatient 2539 1650.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1537.36 60.55 999999999 1537.36 2462.83 percent of total billed charges DHS 150 STANDARD 4 HOLE 281.44 48712382_1 CDM 0278 RC inpatient 2539 1650.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1537.36 2462.83 DHS 150 STANDARD 4 HOLE 281.44 48712382_1 CDM 0278 RC inpatient 2539 1650.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1537.36 2462.83 DHS 150 STANDARD 4 HOLE 281.44 48712382_1 CDM 0278 RC inpatient 2539 1650.35 ANTHEM HMO ANTHEM HMO 999999999 1537.36 2462.83 DHS 150 STANDARD 4 HOLE 281.44 48712382_1 CDM 0278 RC inpatient 2539 1650.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1537.36 2462.83 DHS 150 STANDARD 4 HOLE 281.44 48712382_1 CDM 0278 RC inpatient 2539 1650.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1537.36 2462.83 DHS 150 STANDARD 4 HOLE 281.44 48712382_1 CDM 0278 RC inpatient 2539 1650.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1716.36 67.6 999999999 1537.36 2462.83 percent of total billed charges DHS 150 STANDARD 5 HOLE 281.45 48712383_1 CDM 0278 RC inpatient 1472 956.8 AETNA AETNA 1162.88 79 999999999 891.3 1427.84 percent of total billed charges DHS 150 STANDARD 5 HOLE 281.45 48712383_1 CDM 0278 RC inpatient 1472 956.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 956.8 65 999999999 891.3 1427.84 percent of total billed charges DHS 150 STANDARD 5 HOLE 281.45 48712383_1 CDM 0278 RC inpatient 1472 956.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1427.84 97 999999999 891.3 1427.84 percent of total billed charges DHS 150 STANDARD 5 HOLE 281.45 48712383_1 CDM 0278 RC inpatient 1472 956.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1148.16 78 999999999 891.3 1427.84 percent of total billed charges DHS 150 STANDARD 5 HOLE 281.45 48712383_1 CDM 0278 RC inpatient 1472 956.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1015.68 69 999999999 891.3 1427.84 percent of total billed charges DHS 150 STANDARD 5 HOLE 281.45 48712383_1 CDM 0278 RC inpatient 1472 956.8 UMR - ALL PLANS UMR - ALL PLANS 1030.4 70 999999999 891.3 1427.84 percent of total billed charges DHS 150 STANDARD 5 HOLE 281.45 48712383_1 CDM 0278 RC inpatient 1472 956.8 SIHO - ALL PLANS SIHO - ALL PLANS 1324.8 90 999999999 891.3 1427.84 percent of total billed charges DHS 150 STANDARD 5 HOLE 281.45 48712383_1 CDM 0278 RC inpatient 1472 956.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 891.3 60.55 999999999 891.3 1427.84 percent of total billed charges DHS 150 STANDARD 5 HOLE 281.45 48712383_1 CDM 0278 RC inpatient 1472 956.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 891.3 1427.84 DHS 150 STANDARD 5 HOLE 281.45 48712383_1 CDM 0278 RC inpatient 1472 956.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 891.3 1427.84 DHS 150 STANDARD 5 HOLE 281.45 48712383_1 CDM 0278 RC inpatient 1472 956.8 ANTHEM HMO ANTHEM HMO 999999999 891.3 1427.84 DHS 150 STANDARD 5 HOLE 281.45 48712383_1 CDM 0278 RC inpatient 1472 956.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 891.3 1427.84 DHS 150 STANDARD 5 HOLE 281.45 48712383_1 CDM 0278 RC inpatient 1472 956.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 891.3 1427.84 DHS 150 STANDARD 5 HOLE 281.45 48712383_1 CDM 0278 RC inpatient 1472 956.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 995.07 67.6 999999999 891.3 1427.84 percent of total billed charges DHS 150 STANDARD 6 HOLE 281.46 48712384_1 CDM 0278 RC inpatient 1565 1017.25 AETNA AETNA 1236.35 79 999999999 947.61 1518.05 percent of total billed charges DHS 150 STANDARD 6 HOLE 281.46 48712384_1 CDM 0278 RC inpatient 1565 1017.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1017.25 65 999999999 947.61 1518.05 percent of total billed charges DHS 150 STANDARD 6 HOLE 281.46 48712384_1 CDM 0278 RC inpatient 1565 1017.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1518.05 97 999999999 947.61 1518.05 percent of total billed charges DHS 150 STANDARD 6 HOLE 281.46 48712384_1 CDM 0278 RC inpatient 1565 1017.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1220.7 78 999999999 947.61 1518.05 percent of total billed charges DHS 150 STANDARD 6 HOLE 281.46 48712384_1 CDM 0278 RC inpatient 1565 1017.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1079.85 69 999999999 947.61 1518.05 percent of total billed charges DHS 150 STANDARD 6 HOLE 281.46 48712384_1 CDM 0278 RC inpatient 1565 1017.25 UMR - ALL PLANS UMR - ALL PLANS 1095.5 70 999999999 947.61 1518.05 percent of total billed charges DHS 150 STANDARD 6 HOLE 281.46 48712384_1 CDM 0278 RC inpatient 1565 1017.25 SIHO - ALL PLANS SIHO - ALL PLANS 1408.5 90 999999999 947.61 1518.05 percent of total billed charges DHS 150 STANDARD 6 HOLE 281.46 48712384_1 CDM 0278 RC inpatient 1565 1017.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 947.61 60.55 999999999 947.61 1518.05 percent of total billed charges DHS 150 STANDARD 6 HOLE 281.46 48712384_1 CDM 0278 RC inpatient 1565 1017.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 947.61 1518.05 DHS 150 STANDARD 6 HOLE 281.46 48712384_1 CDM 0278 RC inpatient 1565 1017.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 947.61 1518.05 DHS 150 STANDARD 6 HOLE 281.46 48712384_1 CDM 0278 RC inpatient 1565 1017.25 ANTHEM HMO ANTHEM HMO 999999999 947.61 1518.05 DHS 150 STANDARD 6 HOLE 281.46 48712384_1 CDM 0278 RC inpatient 1565 1017.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 947.61 1518.05 DHS 150 STANDARD 6 HOLE 281.46 48712384_1 CDM 0278 RC inpatient 1565 1017.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 947.61 1518.05 DHS 150 STANDARD 6 HOLE 281.46 48712384_1 CDM 0278 RC inpatient 1565 1017.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1057.94 67.6 999999999 947.61 1518.05 percent of total billed charges SM. FRAG 12 H DPC PLATE 423.62 48712385_1 CDM 0278 RC inpatient 1286 835.9 AETNA AETNA 1015.94 79 999999999 778.67 1247.42 percent of total billed charges SM. FRAG 12 H DPC PLATE 423.62 48712385_1 CDM 0278 RC inpatient 1286 835.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 835.9 65 999999999 778.67 1247.42 percent of total billed charges SM. FRAG 12 H DPC PLATE 423.62 48712385_1 CDM 0278 RC inpatient 1286 835.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1247.42 97 999999999 778.67 1247.42 percent of total billed charges SM. FRAG 12 H DPC PLATE 423.62 48712385_1 CDM 0278 RC inpatient 1286 835.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1003.08 78 999999999 778.67 1247.42 percent of total billed charges SM. FRAG 12 H DPC PLATE 423.62 48712385_1 CDM 0278 RC inpatient 1286 835.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 887.34 69 999999999 778.67 1247.42 percent of total billed charges SM. FRAG 12 H DPC PLATE 423.62 48712385_1 CDM 0278 RC inpatient 1286 835.9 UMR - ALL PLANS UMR - ALL PLANS 900.2 70 999999999 778.67 1247.42 percent of total billed charges SM. FRAG 12 H DPC PLATE 423.62 48712385_1 CDM 0278 RC inpatient 1286 835.9 SIHO - ALL PLANS SIHO - ALL PLANS 1157.4 90 999999999 778.67 1247.42 percent of total billed charges SM. FRAG 12 H DPC PLATE 423.62 48712385_1 CDM 0278 RC inpatient 1286 835.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 778.67 60.55 999999999 778.67 1247.42 percent of total billed charges SM. FRAG 12 H DPC PLATE 423.62 48712385_1 CDM 0278 RC inpatient 1286 835.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 778.67 1247.42 SM. FRAG 12 H DPC PLATE 423.62 48712385_1 CDM 0278 RC inpatient 1286 835.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 778.67 1247.42 SM. FRAG 12 H DPC PLATE 423.62 48712385_1 CDM 0278 RC inpatient 1286 835.9 ANTHEM HMO ANTHEM HMO 999999999 778.67 1247.42 SM. FRAG 12 H DPC PLATE 423.62 48712385_1 CDM 0278 RC inpatient 1286 835.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 778.67 1247.42 SM. FRAG 12 H DPC PLATE 423.62 48712385_1 CDM 0278 RC inpatient 1286 835.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 778.67 1247.42 SM. FRAG 12 H DPC PLATE 423.62 48712385_1 CDM 0278 RC inpatient 1286 835.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 869.34 67.6 999999999 778.67 1247.42 percent of total billed charges DHS 135 STD 10 HOLE 281.100 48712386_1 CDM 0278 RC inpatient 2043 1327.95 AETNA AETNA 1613.97 79 999999999 1237.04 1981.71 percent of total billed charges DHS 135 STD 10 HOLE 281.100 48712386_1 CDM 0278 RC inpatient 2043 1327.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1327.95 65 999999999 1237.04 1981.71 percent of total billed charges DHS 135 STD 10 HOLE 281.100 48712386_1 CDM 0278 RC inpatient 2043 1327.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1981.71 97 999999999 1237.04 1981.71 percent of total billed charges DHS 135 STD 10 HOLE 281.100 48712386_1 CDM 0278 RC inpatient 2043 1327.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1593.54 78 999999999 1237.04 1981.71 percent of total billed charges DHS 135 STD 10 HOLE 281.100 48712386_1 CDM 0278 RC inpatient 2043 1327.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1409.67 69 999999999 1237.04 1981.71 percent of total billed charges DHS 135 STD 10 HOLE 281.100 48712386_1 CDM 0278 RC inpatient 2043 1327.95 UMR - ALL PLANS UMR - ALL PLANS 1430.1 70 999999999 1237.04 1981.71 percent of total billed charges DHS 135 STD 10 HOLE 281.100 48712386_1 CDM 0278 RC inpatient 2043 1327.95 SIHO - ALL PLANS SIHO - ALL PLANS 1838.7 90 999999999 1237.04 1981.71 percent of total billed charges DHS 135 STD 10 HOLE 281.100 48712386_1 CDM 0278 RC inpatient 2043 1327.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1237.04 60.55 999999999 1237.04 1981.71 percent of total billed charges DHS 135 STD 10 HOLE 281.100 48712386_1 CDM 0278 RC inpatient 2043 1327.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1237.04 1981.71 DHS 135 STD 10 HOLE 281.100 48712386_1 CDM 0278 RC inpatient 2043 1327.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1237.04 1981.71 DHS 135 STD 10 HOLE 281.100 48712386_1 CDM 0278 RC inpatient 2043 1327.95 ANTHEM HMO ANTHEM HMO 999999999 1237.04 1981.71 DHS 135 STD 10 HOLE 281.100 48712386_1 CDM 0278 RC inpatient 2043 1327.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1237.04 1981.71 DHS 135 STD 10 HOLE 281.100 48712386_1 CDM 0278 RC inpatient 2043 1327.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1237.04 1981.71 DHS 135 STD 10 HOLE 281.100 48712386_1 CDM 0278 RC inpatient 2043 1327.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1381.07 67.6 999999999 1237.04 1981.71 percent of total billed charges DHS 135 STANDARD 8 HOLE 281.18 48712387_1 CDM 0278 RC inpatient 2335 1517.75 AETNA AETNA 1844.65 79 999999999 1413.84 2264.95 percent of total billed charges DHS 135 STANDARD 8 HOLE 281.18 48712387_1 CDM 0278 RC inpatient 2335 1517.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1517.75 65 999999999 1413.84 2264.95 percent of total billed charges DHS 135 STANDARD 8 HOLE 281.18 48712387_1 CDM 0278 RC inpatient 2335 1517.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2264.95 97 999999999 1413.84 2264.95 percent of total billed charges DHS 135 STANDARD 8 HOLE 281.18 48712387_1 CDM 0278 RC inpatient 2335 1517.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1821.3 78 999999999 1413.84 2264.95 percent of total billed charges DHS 135 STANDARD 8 HOLE 281.18 48712387_1 CDM 0278 RC inpatient 2335 1517.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1611.15 69 999999999 1413.84 2264.95 percent of total billed charges DHS 135 STANDARD 8 HOLE 281.18 48712387_1 CDM 0278 RC inpatient 2335 1517.75 UMR - ALL PLANS UMR - ALL PLANS 1634.5 70 999999999 1413.84 2264.95 percent of total billed charges DHS 135 STANDARD 8 HOLE 281.18 48712387_1 CDM 0278 RC inpatient 2335 1517.75 SIHO - ALL PLANS SIHO - ALL PLANS 2101.5 90 999999999 1413.84 2264.95 percent of total billed charges DHS 135 STANDARD 8 HOLE 281.18 48712387_1 CDM 0278 RC inpatient 2335 1517.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1413.84 60.55 999999999 1413.84 2264.95 percent of total billed charges DHS 135 STANDARD 8 HOLE 281.18 48712387_1 CDM 0278 RC inpatient 2335 1517.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1413.84 2264.95 DHS 135 STANDARD 8 HOLE 281.18 48712387_1 CDM 0278 RC inpatient 2335 1517.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1413.84 2264.95 DHS 135 STANDARD 8 HOLE 281.18 48712387_1 CDM 0278 RC inpatient 2335 1517.75 ANTHEM HMO ANTHEM HMO 999999999 1413.84 2264.95 DHS 135 STANDARD 8 HOLE 281.18 48712387_1 CDM 0278 RC inpatient 2335 1517.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1413.84 2264.95 DHS 135 STANDARD 8 HOLE 281.18 48712387_1 CDM 0278 RC inpatient 2335 1517.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1413.84 2264.95 DHS 135 STANDARD 8 HOLE 281.18 48712387_1 CDM 0278 RC inpatient 2335 1517.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1578.46 67.6 999999999 1413.84 2264.95 percent of total billed charges 4.5M BROAD DCP 9HOLE 226.59 48712388_1 CDM 0278 RC inpatient 1293 840.45 AETNA AETNA 1021.47 79 999999999 782.91 1254.21 percent of total billed charges 4.5M BROAD DCP 9HOLE 226.59 48712388_1 CDM 0278 RC inpatient 1293 840.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 840.45 65 999999999 782.91 1254.21 percent of total billed charges 4.5M BROAD DCP 9HOLE 226.59 48712388_1 CDM 0278 RC inpatient 1293 840.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1254.21 97 999999999 782.91 1254.21 percent of total billed charges 4.5M BROAD DCP 9HOLE 226.59 48712388_1 CDM 0278 RC inpatient 1293 840.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1008.54 78 999999999 782.91 1254.21 percent of total billed charges 4.5M BROAD DCP 9HOLE 226.59 48712388_1 CDM 0278 RC inpatient 1293 840.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 892.17 69 999999999 782.91 1254.21 percent of total billed charges 4.5M BROAD DCP 9HOLE 226.59 48712388_1 CDM 0278 RC inpatient 1293 840.45 UMR - ALL PLANS UMR - ALL PLANS 905.1 70 999999999 782.91 1254.21 percent of total billed charges 4.5M BROAD DCP 9HOLE 226.59 48712388_1 CDM 0278 RC inpatient 1293 840.45 SIHO - ALL PLANS SIHO - ALL PLANS 1163.7 90 999999999 782.91 1254.21 percent of total billed charges 4.5M BROAD DCP 9HOLE 226.59 48712388_1 CDM 0278 RC inpatient 1293 840.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 782.91 60.55 999999999 782.91 1254.21 percent of total billed charges 4.5M BROAD DCP 9HOLE 226.59 48712388_1 CDM 0278 RC inpatient 1293 840.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 782.91 1254.21 4.5M BROAD DCP 9HOLE 226.59 48712388_1 CDM 0278 RC inpatient 1293 840.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 782.91 1254.21 4.5M BROAD DCP 9HOLE 226.59 48712388_1 CDM 0278 RC inpatient 1293 840.45 ANTHEM HMO ANTHEM HMO 999999999 782.91 1254.21 4.5M BROAD DCP 9HOLE 226.59 48712388_1 CDM 0278 RC inpatient 1293 840.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 782.91 1254.21 4.5M BROAD DCP 9HOLE 226.59 48712388_1 CDM 0278 RC inpatient 1293 840.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 782.91 1254.21 4.5M BROAD DCP 9HOLE 226.59 48712388_1 CDM 0278 RC inpatient 1293 840.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 874.07 67.6 999999999 782.91 1254.21 percent of total billed charges DCP PLATE SEMI TUB 5HOLE 22205 48712389_1 CDM 0278 RC inpatient 160 104 AETNA AETNA 126.4 79 999999999 96.88 155.2 percent of total billed charges DCP PLATE SEMI TUB 5HOLE 22205 48712389_1 CDM 0278 RC inpatient 160 104 SELF PAY DISCOUNT SELF PAY DISCOUNT 104 65 999999999 96.88 155.2 percent of total billed charges DCP PLATE SEMI TUB 5HOLE 22205 48712389_1 CDM 0278 RC inpatient 160 104 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 155.2 97 999999999 96.88 155.2 percent of total billed charges DCP PLATE SEMI TUB 5HOLE 22205 48712389_1 CDM 0278 RC inpatient 160 104 HUMANA - ALL PLANS HUMANA - ALL PLANS 124.8 78 999999999 96.88 155.2 percent of total billed charges DCP PLATE SEMI TUB 5HOLE 22205 48712389_1 CDM 0278 RC inpatient 160 104 ENCORE - ALL PLANS ENCORE - ALL PLANS 110.4 69 999999999 96.88 155.2 percent of total billed charges DCP PLATE SEMI TUB 5HOLE 22205 48712389_1 CDM 0278 RC inpatient 160 104 UMR - ALL PLANS UMR - ALL PLANS 112 70 999999999 96.88 155.2 percent of total billed charges DCP PLATE SEMI TUB 5HOLE 22205 48712389_1 CDM 0278 RC inpatient 160 104 SIHO - ALL PLANS SIHO - ALL PLANS 144 90 999999999 96.88 155.2 percent of total billed charges DCP PLATE SEMI TUB 5HOLE 22205 48712389_1 CDM 0278 RC inpatient 160 104 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 96.88 60.55 999999999 96.88 155.2 percent of total billed charges DCP PLATE SEMI TUB 5HOLE 22205 48712389_1 CDM 0278 RC inpatient 160 104 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 96.88 155.2 DCP PLATE SEMI TUB 5HOLE 22205 48712389_1 CDM 0278 RC inpatient 160 104 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 96.88 155.2 DCP PLATE SEMI TUB 5HOLE 22205 48712389_1 CDM 0278 RC inpatient 160 104 ANTHEM HMO ANTHEM HMO 999999999 96.88 155.2 DCP PLATE SEMI TUB 5HOLE 22205 48712389_1 CDM 0278 RC inpatient 160 104 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 96.88 155.2 DCP PLATE SEMI TUB 5HOLE 22205 48712389_1 CDM 0278 RC inpatient 160 104 UHC - ALL PLANS UHC - ALL PLANS 999999999 96.88 155.2 DCP PLATE SEMI TUB 5HOLE 22205 48712389_1 CDM 0278 RC inpatient 160 104 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.16 67.6 999999999 96.88 155.2 percent of total billed charges DCP PLATE SEMI TUB 4HOLE 22204 48712390_1 CDM 0278 RC inpatient 173 112.45 AETNA AETNA 136.67 79 999999999 104.75 167.81 percent of total billed charges DCP PLATE SEMI TUB 4HOLE 22204 48712390_1 CDM 0278 RC inpatient 173 112.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 112.45 65 999999999 104.75 167.81 percent of total billed charges DCP PLATE SEMI TUB 4HOLE 22204 48712390_1 CDM 0278 RC inpatient 173 112.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 167.81 97 999999999 104.75 167.81 percent of total billed charges DCP PLATE SEMI TUB 4HOLE 22204 48712390_1 CDM 0278 RC inpatient 173 112.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.94 78 999999999 104.75 167.81 percent of total billed charges DCP PLATE SEMI TUB 4HOLE 22204 48712390_1 CDM 0278 RC inpatient 173 112.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 119.37 69 999999999 104.75 167.81 percent of total billed charges DCP PLATE SEMI TUB 4HOLE 22204 48712390_1 CDM 0278 RC inpatient 173 112.45 UMR - ALL PLANS UMR - ALL PLANS 121.1 70 999999999 104.75 167.81 percent of total billed charges DCP PLATE SEMI TUB 4HOLE 22204 48712390_1 CDM 0278 RC inpatient 173 112.45 SIHO - ALL PLANS SIHO - ALL PLANS 155.7 90 999999999 104.75 167.81 percent of total billed charges DCP PLATE SEMI TUB 4HOLE 22204 48712390_1 CDM 0278 RC inpatient 173 112.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.75 60.55 999999999 104.75 167.81 percent of total billed charges DCP PLATE SEMI TUB 4HOLE 22204 48712390_1 CDM 0278 RC inpatient 173 112.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.75 167.81 DCP PLATE SEMI TUB 4HOLE 22204 48712390_1 CDM 0278 RC inpatient 173 112.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.75 167.81 DCP PLATE SEMI TUB 4HOLE 22204 48712390_1 CDM 0278 RC inpatient 173 112.45 ANTHEM HMO ANTHEM HMO 999999999 104.75 167.81 DCP PLATE SEMI TUB 4HOLE 22204 48712390_1 CDM 0278 RC inpatient 173 112.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.75 167.81 DCP PLATE SEMI TUB 4HOLE 22204 48712390_1 CDM 0278 RC inpatient 173 112.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.75 167.81 DCP PLATE SEMI TUB 4HOLE 22204 48712390_1 CDM 0278 RC inpatient 173 112.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.95 67.6 999999999 104.75 167.81 percent of total billed charges DCP PLATE SEMI TUB 6HOLE 22206 48712391_1 CDM 0278 RC inpatient 167 108.55 AETNA AETNA 131.93 79 999999999 101.12 161.99 percent of total billed charges DCP PLATE SEMI TUB 6HOLE 22206 48712391_1 CDM 0278 RC inpatient 167 108.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 108.55 65 999999999 101.12 161.99 percent of total billed charges DCP PLATE SEMI TUB 6HOLE 22206 48712391_1 CDM 0278 RC inpatient 167 108.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.99 97 999999999 101.12 161.99 percent of total billed charges DCP PLATE SEMI TUB 6HOLE 22206 48712391_1 CDM 0278 RC inpatient 167 108.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 130.26 78 999999999 101.12 161.99 percent of total billed charges DCP PLATE SEMI TUB 6HOLE 22206 48712391_1 CDM 0278 RC inpatient 167 108.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.23 69 999999999 101.12 161.99 percent of total billed charges DCP PLATE SEMI TUB 6HOLE 22206 48712391_1 CDM 0278 RC inpatient 167 108.55 UMR - ALL PLANS UMR - ALL PLANS 116.9 70 999999999 101.12 161.99 percent of total billed charges DCP PLATE SEMI TUB 6HOLE 22206 48712391_1 CDM 0278 RC inpatient 167 108.55 SIHO - ALL PLANS SIHO - ALL PLANS 150.3 90 999999999 101.12 161.99 percent of total billed charges DCP PLATE SEMI TUB 6HOLE 22206 48712391_1 CDM 0278 RC inpatient 167 108.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.12 60.55 999999999 101.12 161.99 percent of total billed charges DCP PLATE SEMI TUB 6HOLE 22206 48712391_1 CDM 0278 RC inpatient 167 108.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.12 161.99 DCP PLATE SEMI TUB 6HOLE 22206 48712391_1 CDM 0278 RC inpatient 167 108.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.12 161.99 DCP PLATE SEMI TUB 6HOLE 22206 48712391_1 CDM 0278 RC inpatient 167 108.55 ANTHEM HMO ANTHEM HMO 999999999 101.12 161.99 DCP PLATE SEMI TUB 6HOLE 22206 48712391_1 CDM 0278 RC inpatient 167 108.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.12 161.99 DCP PLATE SEMI TUB 6HOLE 22206 48712391_1 CDM 0278 RC inpatient 167 108.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.12 161.99 DCP PLATE SEMI TUB 6HOLE 22206 48712391_1 CDM 0278 RC inpatient 167 108.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.89 67.6 999999999 101.12 161.99 percent of total billed charges 4.5M BROAD DCP 6 HOLE 226.06 48712392_1 CDM 0278 RC inpatient 588 382.2 AETNA AETNA 464.52 79 999999999 356.03 570.36 percent of total billed charges 4.5M BROAD DCP 6 HOLE 226.06 48712392_1 CDM 0278 RC inpatient 588 382.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 382.2 65 999999999 356.03 570.36 percent of total billed charges 4.5M BROAD DCP 6 HOLE 226.06 48712392_1 CDM 0278 RC inpatient 588 382.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 570.36 97 999999999 356.03 570.36 percent of total billed charges 4.5M BROAD DCP 6 HOLE 226.06 48712392_1 CDM 0278 RC inpatient 588 382.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 458.64 78 999999999 356.03 570.36 percent of total billed charges 4.5M BROAD DCP 6 HOLE 226.06 48712392_1 CDM 0278 RC inpatient 588 382.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 405.72 69 999999999 356.03 570.36 percent of total billed charges 4.5M BROAD DCP 6 HOLE 226.06 48712392_1 CDM 0278 RC inpatient 588 382.2 UMR - ALL PLANS UMR - ALL PLANS 411.6 70 999999999 356.03 570.36 percent of total billed charges 4.5M BROAD DCP 6 HOLE 226.06 48712392_1 CDM 0278 RC inpatient 588 382.2 SIHO - ALL PLANS SIHO - ALL PLANS 529.2 90 999999999 356.03 570.36 percent of total billed charges 4.5M BROAD DCP 6 HOLE 226.06 48712392_1 CDM 0278 RC inpatient 588 382.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 356.03 60.55 999999999 356.03 570.36 percent of total billed charges 4.5M BROAD DCP 6 HOLE 226.06 48712392_1 CDM 0278 RC inpatient 588 382.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 356.03 570.36 4.5M BROAD DCP 6 HOLE 226.06 48712392_1 CDM 0278 RC inpatient 588 382.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 356.03 570.36 4.5M BROAD DCP 6 HOLE 226.06 48712392_1 CDM 0278 RC inpatient 588 382.2 ANTHEM HMO ANTHEM HMO 999999999 356.03 570.36 4.5M BROAD DCP 6 HOLE 226.06 48712392_1 CDM 0278 RC inpatient 588 382.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 356.03 570.36 4.5M BROAD DCP 6 HOLE 226.06 48712392_1 CDM 0278 RC inpatient 588 382.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 356.03 570.36 4.5M BROAD DCP 6 HOLE 226.06 48712392_1 CDM 0278 RC inpatient 588 382.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 397.49 67.6 999999999 356.03 570.36 percent of total billed charges 95 CONDYLAR 7H 124/50MM 237.70 48712393_1 CDM 0278 RC inpatient 908 590.2 AETNA AETNA 717.32 79 999999999 549.79 880.76 percent of total billed charges 95 CONDYLAR 7H 124/50MM 237.70 48712393_1 CDM 0278 RC inpatient 908 590.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 590.2 65 999999999 549.79 880.76 percent of total billed charges 95 CONDYLAR 7H 124/50MM 237.70 48712393_1 CDM 0278 RC inpatient 908 590.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 880.76 97 999999999 549.79 880.76 percent of total billed charges 95 CONDYLAR 7H 124/50MM 237.70 48712393_1 CDM 0278 RC inpatient 908 590.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 708.24 78 999999999 549.79 880.76 percent of total billed charges 95 CONDYLAR 7H 124/50MM 237.70 48712393_1 CDM 0278 RC inpatient 908 590.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 626.52 69 999999999 549.79 880.76 percent of total billed charges 95 CONDYLAR 7H 124/50MM 237.70 48712393_1 CDM 0278 RC inpatient 908 590.2 UMR - ALL PLANS UMR - ALL PLANS 635.6 70 999999999 549.79 880.76 percent of total billed charges 95 CONDYLAR 7H 124/50MM 237.70 48712393_1 CDM 0278 RC inpatient 908 590.2 SIHO - ALL PLANS SIHO - ALL PLANS 817.2 90 999999999 549.79 880.76 percent of total billed charges 95 CONDYLAR 7H 124/50MM 237.70 48712393_1 CDM 0278 RC inpatient 908 590.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 549.79 60.55 999999999 549.79 880.76 percent of total billed charges 95 CONDYLAR 7H 124/50MM 237.70 48712393_1 CDM 0278 RC inpatient 908 590.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 549.79 880.76 95 CONDYLAR 7H 124/50MM 237.70 48712393_1 CDM 0278 RC inpatient 908 590.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 549.79 880.76 95 CONDYLAR 7H 124/50MM 237.70 48712393_1 CDM 0278 RC inpatient 908 590.2 ANTHEM HMO ANTHEM HMO 999999999 549.79 880.76 95 CONDYLAR 7H 124/50MM 237.70 48712393_1 CDM 0278 RC inpatient 908 590.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 549.79 880.76 95 CONDYLAR 7H 124/50MM 237.70 48712393_1 CDM 0278 RC inpatient 908 590.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 549.79 880.76 95 CONDYLAR 7H 124/50MM 237.70 48712393_1 CDM 0278 RC inpatient 908 590.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 613.81 67.6 999999999 549.79 880.76 percent of total billed charges 95 CONDYLAR 9H 156/60MM 237.92 48712394_1 CDM 0278 RC inpatient 957 622.05 AETNA AETNA 756.03 79 999999999 579.46 928.29 percent of total billed charges 95 CONDYLAR 9H 156/60MM 237.92 48712394_1 CDM 0278 RC inpatient 957 622.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 622.05 65 999999999 579.46 928.29 percent of total billed charges 95 CONDYLAR 9H 156/60MM 237.92 48712394_1 CDM 0278 RC inpatient 957 622.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 928.29 97 999999999 579.46 928.29 percent of total billed charges 95 CONDYLAR 9H 156/60MM 237.92 48712394_1 CDM 0278 RC inpatient 957 622.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 746.46 78 999999999 579.46 928.29 percent of total billed charges 95 CONDYLAR 9H 156/60MM 237.92 48712394_1 CDM 0278 RC inpatient 957 622.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 660.33 69 999999999 579.46 928.29 percent of total billed charges 95 CONDYLAR 9H 156/60MM 237.92 48712394_1 CDM 0278 RC inpatient 957 622.05 UMR - ALL PLANS UMR - ALL PLANS 669.9 70 999999999 579.46 928.29 percent of total billed charges 95 CONDYLAR 9H 156/60MM 237.92 48712394_1 CDM 0278 RC inpatient 957 622.05 SIHO - ALL PLANS SIHO - ALL PLANS 861.3 90 999999999 579.46 928.29 percent of total billed charges 95 CONDYLAR 9H 156/60MM 237.92 48712394_1 CDM 0278 RC inpatient 957 622.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 579.46 60.55 999999999 579.46 928.29 percent of total billed charges 95 CONDYLAR 9H 156/60MM 237.92 48712394_1 CDM 0278 RC inpatient 957 622.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 579.46 928.29 95 CONDYLAR 9H 156/60MM 237.92 48712394_1 CDM 0278 RC inpatient 957 622.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 579.46 928.29 95 CONDYLAR 9H 156/60MM 237.92 48712394_1 CDM 0278 RC inpatient 957 622.05 ANTHEM HMO ANTHEM HMO 999999999 579.46 928.29 95 CONDYLAR 9H 156/60MM 237.92 48712394_1 CDM 0278 RC inpatient 957 622.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 579.46 928.29 95 CONDYLAR 9H 156/60MM 237.92 48712394_1 CDM 0278 RC inpatient 957 622.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 579.46 928.29 95 CONDYLAR 9H 156/60MM 237.92 48712394_1 CDM 0278 RC inpatient 957 622.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 646.93 67.6 999999999 579.46 928.29 percent of total billed charges 4.5M BROAD DCP 14 HOLE 226.64 48712395_1 CDM 0278 RC inpatient 703 456.95 AETNA AETNA 555.37 79 999999999 425.67 681.91 percent of total billed charges 4.5M BROAD DCP 14 HOLE 226.64 48712395_1 CDM 0278 RC inpatient 703 456.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 456.95 65 999999999 425.67 681.91 percent of total billed charges 4.5M BROAD DCP 14 HOLE 226.64 48712395_1 CDM 0278 RC inpatient 703 456.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 681.91 97 999999999 425.67 681.91 percent of total billed charges 4.5M BROAD DCP 14 HOLE 226.64 48712395_1 CDM 0278 RC inpatient 703 456.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 548.34 78 999999999 425.67 681.91 percent of total billed charges 4.5M BROAD DCP 14 HOLE 226.64 48712395_1 CDM 0278 RC inpatient 703 456.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 485.07 69 999999999 425.67 681.91 percent of total billed charges 4.5M BROAD DCP 14 HOLE 226.64 48712395_1 CDM 0278 RC inpatient 703 456.95 UMR - ALL PLANS UMR - ALL PLANS 492.1 70 999999999 425.67 681.91 percent of total billed charges 4.5M BROAD DCP 14 HOLE 226.64 48712395_1 CDM 0278 RC inpatient 703 456.95 SIHO - ALL PLANS SIHO - ALL PLANS 632.7 90 999999999 425.67 681.91 percent of total billed charges 4.5M BROAD DCP 14 HOLE 226.64 48712395_1 CDM 0278 RC inpatient 703 456.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 425.67 60.55 999999999 425.67 681.91 percent of total billed charges 4.5M BROAD DCP 14 HOLE 226.64 48712395_1 CDM 0278 RC inpatient 703 456.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 425.67 681.91 4.5M BROAD DCP 14 HOLE 226.64 48712395_1 CDM 0278 RC inpatient 703 456.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 425.67 681.91 4.5M BROAD DCP 14 HOLE 226.64 48712395_1 CDM 0278 RC inpatient 703 456.95 ANTHEM HMO ANTHEM HMO 999999999 425.67 681.91 4.5M BROAD DCP 14 HOLE 226.64 48712395_1 CDM 0278 RC inpatient 703 456.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 425.67 681.91 4.5M BROAD DCP 14 HOLE 226.64 48712395_1 CDM 0278 RC inpatient 703 456.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 425.67 681.91 4.5M BROAD DCP 14 HOLE 226.64 48712395_1 CDM 0278 RC inpatient 703 456.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 475.23 67.6 999999999 425.67 681.91 percent of total billed charges 4.5M NAR DCP 5 HOLE 224.05 48712396_1 CDM 0278 RC inpatient 327 212.55 AETNA AETNA 258.33 79 999999999 198 317.19 percent of total billed charges 4.5M NAR DCP 5 HOLE 224.05 48712396_1 CDM 0278 RC inpatient 327 212.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 212.55 65 999999999 198 317.19 percent of total billed charges 4.5M NAR DCP 5 HOLE 224.05 48712396_1 CDM 0278 RC inpatient 327 212.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 317.19 97 999999999 198 317.19 percent of total billed charges 4.5M NAR DCP 5 HOLE 224.05 48712396_1 CDM 0278 RC inpatient 327 212.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.06 78 999999999 198 317.19 percent of total billed charges 4.5M NAR DCP 5 HOLE 224.05 48712396_1 CDM 0278 RC inpatient 327 212.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 225.63 69 999999999 198 317.19 percent of total billed charges 4.5M NAR DCP 5 HOLE 224.05 48712396_1 CDM 0278 RC inpatient 327 212.55 UMR - ALL PLANS UMR - ALL PLANS 228.9 70 999999999 198 317.19 percent of total billed charges 4.5M NAR DCP 5 HOLE 224.05 48712396_1 CDM 0278 RC inpatient 327 212.55 SIHO - ALL PLANS SIHO - ALL PLANS 294.3 90 999999999 198 317.19 percent of total billed charges 4.5M NAR DCP 5 HOLE 224.05 48712396_1 CDM 0278 RC inpatient 327 212.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198 60.55 999999999 198 317.19 percent of total billed charges 4.5M NAR DCP 5 HOLE 224.05 48712396_1 CDM 0278 RC inpatient 327 212.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198 317.19 4.5M NAR DCP 5 HOLE 224.05 48712396_1 CDM 0278 RC inpatient 327 212.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198 317.19 4.5M NAR DCP 5 HOLE 224.05 48712396_1 CDM 0278 RC inpatient 327 212.55 ANTHEM HMO ANTHEM HMO 999999999 198 317.19 4.5M NAR DCP 5 HOLE 224.05 48712396_1 CDM 0278 RC inpatient 327 212.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198 317.19 4.5M NAR DCP 5 HOLE 224.05 48712396_1 CDM 0278 RC inpatient 327 212.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 198 317.19 4.5M NAR DCP 5 HOLE 224.05 48712396_1 CDM 0278 RC inpatient 327 212.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.05 67.6 999999999 198 317.19 percent of total billed charges 4.5M BROAD DCP 7HOLE 226.57 48712397_1 CDM 0278 RC inpatient 374 243.1 AETNA AETNA 295.46 79 999999999 226.46 362.78 percent of total billed charges 4.5M BROAD DCP 7HOLE 226.57 48712397_1 CDM 0278 RC inpatient 374 243.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 243.1 65 999999999 226.46 362.78 percent of total billed charges 4.5M BROAD DCP 7HOLE 226.57 48712397_1 CDM 0278 RC inpatient 374 243.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 362.78 97 999999999 226.46 362.78 percent of total billed charges 4.5M BROAD DCP 7HOLE 226.57 48712397_1 CDM 0278 RC inpatient 374 243.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 291.72 78 999999999 226.46 362.78 percent of total billed charges 4.5M BROAD DCP 7HOLE 226.57 48712397_1 CDM 0278 RC inpatient 374 243.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 258.06 69 999999999 226.46 362.78 percent of total billed charges 4.5M BROAD DCP 7HOLE 226.57 48712397_1 CDM 0278 RC inpatient 374 243.1 UMR - ALL PLANS UMR - ALL PLANS 261.8 70 999999999 226.46 362.78 percent of total billed charges 4.5M BROAD DCP 7HOLE 226.57 48712397_1 CDM 0278 RC inpatient 374 243.1 SIHO - ALL PLANS SIHO - ALL PLANS 336.6 90 999999999 226.46 362.78 percent of total billed charges 4.5M BROAD DCP 7HOLE 226.57 48712397_1 CDM 0278 RC inpatient 374 243.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 226.46 60.55 999999999 226.46 362.78 percent of total billed charges 4.5M BROAD DCP 7HOLE 226.57 48712397_1 CDM 0278 RC inpatient 374 243.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 226.46 362.78 4.5M BROAD DCP 7HOLE 226.57 48712397_1 CDM 0278 RC inpatient 374 243.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 226.46 362.78 4.5M BROAD DCP 7HOLE 226.57 48712397_1 CDM 0278 RC inpatient 374 243.1 ANTHEM HMO ANTHEM HMO 999999999 226.46 362.78 4.5M BROAD DCP 7HOLE 226.57 48712397_1 CDM 0278 RC inpatient 374 243.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 226.46 362.78 4.5M BROAD DCP 7HOLE 226.57 48712397_1 CDM 0278 RC inpatient 374 243.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 226.46 362.78 4.5M BROAD DCP 7HOLE 226.57 48712397_1 CDM 0278 RC inpatient 374 243.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 252.82 67.6 999999999 226.46 362.78 percent of total billed charges 4.5M NAR DCP 8HOLE 224.58 48712398_1 CDM 0278 RC inpatient 647 420.55 AETNA AETNA 511.13 79 999999999 391.76 627.59 percent of total billed charges 4.5M NAR DCP 8HOLE 224.58 48712398_1 CDM 0278 RC inpatient 647 420.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 420.55 65 999999999 391.76 627.59 percent of total billed charges 4.5M NAR DCP 8HOLE 224.58 48712398_1 CDM 0278 RC inpatient 647 420.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 627.59 97 999999999 391.76 627.59 percent of total billed charges 4.5M NAR DCP 8HOLE 224.58 48712398_1 CDM 0278 RC inpatient 647 420.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 504.66 78 999999999 391.76 627.59 percent of total billed charges 4.5M NAR DCP 8HOLE 224.58 48712398_1 CDM 0278 RC inpatient 647 420.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 446.43 69 999999999 391.76 627.59 percent of total billed charges 4.5M NAR DCP 8HOLE 224.58 48712398_1 CDM 0278 RC inpatient 647 420.55 UMR - ALL PLANS UMR - ALL PLANS 452.9 70 999999999 391.76 627.59 percent of total billed charges 4.5M NAR DCP 8HOLE 224.58 48712398_1 CDM 0278 RC inpatient 647 420.55 SIHO - ALL PLANS SIHO - ALL PLANS 582.3 90 999999999 391.76 627.59 percent of total billed charges 4.5M NAR DCP 8HOLE 224.58 48712398_1 CDM 0278 RC inpatient 647 420.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 391.76 60.55 999999999 391.76 627.59 percent of total billed charges 4.5M NAR DCP 8HOLE 224.58 48712398_1 CDM 0278 RC inpatient 647 420.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 391.76 627.59 4.5M NAR DCP 8HOLE 224.58 48712398_1 CDM 0278 RC inpatient 647 420.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 391.76 627.59 4.5M NAR DCP 8HOLE 224.58 48712398_1 CDM 0278 RC inpatient 647 420.55 ANTHEM HMO ANTHEM HMO 999999999 391.76 627.59 4.5M NAR DCP 8HOLE 224.58 48712398_1 CDM 0278 RC inpatient 647 420.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 391.76 627.59 4.5M NAR DCP 8HOLE 224.58 48712398_1 CDM 0278 RC inpatient 647 420.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 391.76 627.59 4.5M NAR DCP 8HOLE 224.58 48712398_1 CDM 0278 RC inpatient 647 420.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 437.37 67.6 999999999 391.76 627.59 percent of total billed charges 4.5M NAR DCP 9HOLE 224.59 48712399_1 CDM 0278 RC inpatient 647 420.55 AETNA AETNA 511.13 79 999999999 391.76 627.59 percent of total billed charges 4.5M NAR DCP 9HOLE 224.59 48712399_1 CDM 0278 RC inpatient 647 420.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 420.55 65 999999999 391.76 627.59 percent of total billed charges 4.5M NAR DCP 9HOLE 224.59 48712399_1 CDM 0278 RC inpatient 647 420.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 627.59 97 999999999 391.76 627.59 percent of total billed charges 4.5M NAR DCP 9HOLE 224.59 48712399_1 CDM 0278 RC inpatient 647 420.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 504.66 78 999999999 391.76 627.59 percent of total billed charges 4.5M NAR DCP 9HOLE 224.59 48712399_1 CDM 0278 RC inpatient 647 420.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 446.43 69 999999999 391.76 627.59 percent of total billed charges 4.5M NAR DCP 9HOLE 224.59 48712399_1 CDM 0278 RC inpatient 647 420.55 UMR - ALL PLANS UMR - ALL PLANS 452.9 70 999999999 391.76 627.59 percent of total billed charges 4.5M NAR DCP 9HOLE 224.59 48712399_1 CDM 0278 RC inpatient 647 420.55 SIHO - ALL PLANS SIHO - ALL PLANS 582.3 90 999999999 391.76 627.59 percent of total billed charges 4.5M NAR DCP 9HOLE 224.59 48712399_1 CDM 0278 RC inpatient 647 420.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 391.76 60.55 999999999 391.76 627.59 percent of total billed charges 4.5M NAR DCP 9HOLE 224.59 48712399_1 CDM 0278 RC inpatient 647 420.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 391.76 627.59 4.5M NAR DCP 9HOLE 224.59 48712399_1 CDM 0278 RC inpatient 647 420.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 391.76 627.59 4.5M NAR DCP 9HOLE 224.59 48712399_1 CDM 0278 RC inpatient 647 420.55 ANTHEM HMO ANTHEM HMO 999999999 391.76 627.59 4.5M NAR DCP 9HOLE 224.59 48712399_1 CDM 0278 RC inpatient 647 420.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 391.76 627.59 4.5M NAR DCP 9HOLE 224.59 48712399_1 CDM 0278 RC inpatient 647 420.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 391.76 627.59 4.5M NAR DCP 9HOLE 224.59 48712399_1 CDM 0278 RC inpatient 647 420.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 437.37 67.6 999999999 391.76 627.59 percent of total billed charges 4.5MM NAR DCP 7HOLE 224.57 48712400_1 CDM 0278 RC inpatient 615 399.75 AETNA AETNA 485.85 79 999999999 372.38 596.55 percent of total billed charges 4.5MM NAR DCP 7HOLE 224.57 48712400_1 CDM 0278 RC inpatient 615 399.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 399.75 65 999999999 372.38 596.55 percent of total billed charges 4.5MM NAR DCP 7HOLE 224.57 48712400_1 CDM 0278 RC inpatient 615 399.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 596.55 97 999999999 372.38 596.55 percent of total billed charges 4.5MM NAR DCP 7HOLE 224.57 48712400_1 CDM 0278 RC inpatient 615 399.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 479.7 78 999999999 372.38 596.55 percent of total billed charges 4.5MM NAR DCP 7HOLE 224.57 48712400_1 CDM 0278 RC inpatient 615 399.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 424.35 69 999999999 372.38 596.55 percent of total billed charges 4.5MM NAR DCP 7HOLE 224.57 48712400_1 CDM 0278 RC inpatient 615 399.75 UMR - ALL PLANS UMR - ALL PLANS 430.5 70 999999999 372.38 596.55 percent of total billed charges 4.5MM NAR DCP 7HOLE 224.57 48712400_1 CDM 0278 RC inpatient 615 399.75 SIHO - ALL PLANS SIHO - ALL PLANS 553.5 90 999999999 372.38 596.55 percent of total billed charges 4.5MM NAR DCP 7HOLE 224.57 48712400_1 CDM 0278 RC inpatient 615 399.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 372.38 60.55 999999999 372.38 596.55 percent of total billed charges 4.5MM NAR DCP 7HOLE 224.57 48712400_1 CDM 0278 RC inpatient 615 399.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 372.38 596.55 4.5MM NAR DCP 7HOLE 224.57 48712400_1 CDM 0278 RC inpatient 615 399.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 372.38 596.55 4.5MM NAR DCP 7HOLE 224.57 48712400_1 CDM 0278 RC inpatient 615 399.75 ANTHEM HMO ANTHEM HMO 999999999 372.38 596.55 4.5MM NAR DCP 7HOLE 224.57 48712400_1 CDM 0278 RC inpatient 615 399.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 372.38 596.55 4.5MM NAR DCP 7HOLE 224.57 48712400_1 CDM 0278 RC inpatient 615 399.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 372.38 596.55 4.5MM NAR DCP 7HOLE 224.57 48712400_1 CDM 0278 RC inpatient 615 399.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 415.74 67.6 999999999 372.38 596.55 percent of total billed charges DCP SPOON PLATE 5HOLE 240.05 48712401_1 CDM 0278 RC inpatient 894 581.1 AETNA AETNA 706.26 79 999999999 541.32 867.18 percent of total billed charges DCP SPOON PLATE 5HOLE 240.05 48712401_1 CDM 0278 RC inpatient 894 581.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 581.1 65 999999999 541.32 867.18 percent of total billed charges DCP SPOON PLATE 5HOLE 240.05 48712401_1 CDM 0278 RC inpatient 894 581.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 867.18 97 999999999 541.32 867.18 percent of total billed charges DCP SPOON PLATE 5HOLE 240.05 48712401_1 CDM 0278 RC inpatient 894 581.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 697.32 78 999999999 541.32 867.18 percent of total billed charges DCP SPOON PLATE 5HOLE 240.05 48712401_1 CDM 0278 RC inpatient 894 581.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 616.86 69 999999999 541.32 867.18 percent of total billed charges DCP SPOON PLATE 5HOLE 240.05 48712401_1 CDM 0278 RC inpatient 894 581.1 UMR - ALL PLANS UMR - ALL PLANS 625.8 70 999999999 541.32 867.18 percent of total billed charges DCP SPOON PLATE 5HOLE 240.05 48712401_1 CDM 0278 RC inpatient 894 581.1 SIHO - ALL PLANS SIHO - ALL PLANS 804.6 90 999999999 541.32 867.18 percent of total billed charges DCP SPOON PLATE 5HOLE 240.05 48712401_1 CDM 0278 RC inpatient 894 581.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 541.32 60.55 999999999 541.32 867.18 percent of total billed charges DCP SPOON PLATE 5HOLE 240.05 48712401_1 CDM 0278 RC inpatient 894 581.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 541.32 867.18 DCP SPOON PLATE 5HOLE 240.05 48712401_1 CDM 0278 RC inpatient 894 581.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 541.32 867.18 DCP SPOON PLATE 5HOLE 240.05 48712401_1 CDM 0278 RC inpatient 894 581.1 ANTHEM HMO ANTHEM HMO 999999999 541.32 867.18 DCP SPOON PLATE 5HOLE 240.05 48712401_1 CDM 0278 RC inpatient 894 581.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 541.32 867.18 DCP SPOON PLATE 5HOLE 240.05 48712401_1 CDM 0278 RC inpatient 894 581.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 541.32 867.18 DCP SPOON PLATE 5HOLE 240.05 48712401_1 CDM 0278 RC inpatient 894 581.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 604.34 67.6 999999999 541.32 867.18 percent of total billed charges DCP T PLATE 4HOLE 240.14 48712402_1 CDM 0278 RC inpatient 1874 1218.1 AETNA AETNA 1480.46 79 999999999 1134.71 1817.78 percent of total billed charges DCP T PLATE 4HOLE 240.14 48712402_1 CDM 0278 RC inpatient 1874 1218.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1218.1 65 999999999 1134.71 1817.78 percent of total billed charges DCP T PLATE 4HOLE 240.14 48712402_1 CDM 0278 RC inpatient 1874 1218.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1817.78 97 999999999 1134.71 1817.78 percent of total billed charges DCP T PLATE 4HOLE 240.14 48712402_1 CDM 0278 RC inpatient 1874 1218.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1461.72 78 999999999 1134.71 1817.78 percent of total billed charges DCP T PLATE 4HOLE 240.14 48712402_1 CDM 0278 RC inpatient 1874 1218.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 1293.06 69 999999999 1134.71 1817.78 percent of total billed charges DCP T PLATE 4HOLE 240.14 48712402_1 CDM 0278 RC inpatient 1874 1218.1 UMR - ALL PLANS UMR - ALL PLANS 1311.8 70 999999999 1134.71 1817.78 percent of total billed charges DCP T PLATE 4HOLE 240.14 48712402_1 CDM 0278 RC inpatient 1874 1218.1 SIHO - ALL PLANS SIHO - ALL PLANS 1686.6 90 999999999 1134.71 1817.78 percent of total billed charges DCP T PLATE 4HOLE 240.14 48712402_1 CDM 0278 RC inpatient 1874 1218.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1134.71 60.55 999999999 1134.71 1817.78 percent of total billed charges DCP T PLATE 4HOLE 240.14 48712402_1 CDM 0278 RC inpatient 1874 1218.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1134.71 1817.78 DCP T PLATE 4HOLE 240.14 48712402_1 CDM 0278 RC inpatient 1874 1218.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1134.71 1817.78 DCP T PLATE 4HOLE 240.14 48712402_1 CDM 0278 RC inpatient 1874 1218.1 ANTHEM HMO ANTHEM HMO 999999999 1134.71 1817.78 DCP T PLATE 4HOLE 240.14 48712402_1 CDM 0278 RC inpatient 1874 1218.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1134.71 1817.78 DCP T PLATE 4HOLE 240.14 48712402_1 CDM 0278 RC inpatient 1874 1218.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1134.71 1817.78 DCP T PLATE 4HOLE 240.14 48712402_1 CDM 0278 RC inpatient 1874 1218.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1266.82 67.6 999999999 1134.71 1817.78 percent of total billed charges DCP LEFT BUTTRESS 4HOLE 240.44 48712403_1 CDM 0278 RC inpatient 844 548.6 AETNA AETNA 666.76 79 999999999 511.04 818.68 percent of total billed charges DCP LEFT BUTTRESS 4HOLE 240.44 48712403_1 CDM 0278 RC inpatient 844 548.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 548.6 65 999999999 511.04 818.68 percent of total billed charges DCP LEFT BUTTRESS 4HOLE 240.44 48712403_1 CDM 0278 RC inpatient 844 548.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 818.68 97 999999999 511.04 818.68 percent of total billed charges DCP LEFT BUTTRESS 4HOLE 240.44 48712403_1 CDM 0278 RC inpatient 844 548.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 658.32 78 999999999 511.04 818.68 percent of total billed charges DCP LEFT BUTTRESS 4HOLE 240.44 48712403_1 CDM 0278 RC inpatient 844 548.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 582.36 69 999999999 511.04 818.68 percent of total billed charges DCP LEFT BUTTRESS 4HOLE 240.44 48712403_1 CDM 0278 RC inpatient 844 548.6 UMR - ALL PLANS UMR - ALL PLANS 590.8 70 999999999 511.04 818.68 percent of total billed charges DCP LEFT BUTTRESS 4HOLE 240.44 48712403_1 CDM 0278 RC inpatient 844 548.6 SIHO - ALL PLANS SIHO - ALL PLANS 759.6 90 999999999 511.04 818.68 percent of total billed charges DCP LEFT BUTTRESS 4HOLE 240.44 48712403_1 CDM 0278 RC inpatient 844 548.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 511.04 60.55 999999999 511.04 818.68 percent of total billed charges DCP LEFT BUTTRESS 4HOLE 240.44 48712403_1 CDM 0278 RC inpatient 844 548.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 511.04 818.68 DCP LEFT BUTTRESS 4HOLE 240.44 48712403_1 CDM 0278 RC inpatient 844 548.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 511.04 818.68 DCP LEFT BUTTRESS 4HOLE 240.44 48712403_1 CDM 0278 RC inpatient 844 548.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 511.04 818.68 DCP LEFT BUTTRESS 4HOLE 240.44 48712403_1 CDM 0278 RC inpatient 844 548.6 ANTHEM HMO ANTHEM HMO 999999999 511.04 818.68 DCP LEFT BUTTRESS 4HOLE 240.44 48712403_1 CDM 0278 RC inpatient 844 548.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 511.04 818.68 DCP LEFT BUTTRESS 4HOLE 240.44 48712403_1 CDM 0278 RC inpatient 844 548.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 570.54 67.6 999999999 511.04 818.68 percent of total billed charges DCP RIGHT BUTTRESS 4HOLE 24054 48712404_1 CDM 0278 RC inpatient 858 557.7 AETNA AETNA 677.82 79 999999999 519.52 832.26 percent of total billed charges DCP RIGHT BUTTRESS 4HOLE 24054 48712404_1 CDM 0278 RC inpatient 858 557.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 557.7 65 999999999 519.52 832.26 percent of total billed charges DCP RIGHT BUTTRESS 4HOLE 24054 48712404_1 CDM 0278 RC inpatient 858 557.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 832.26 97 999999999 519.52 832.26 percent of total billed charges DCP RIGHT BUTTRESS 4HOLE 24054 48712404_1 CDM 0278 RC inpatient 858 557.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 669.24 78 999999999 519.52 832.26 percent of total billed charges DCP RIGHT BUTTRESS 4HOLE 24054 48712404_1 CDM 0278 RC inpatient 858 557.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 592.02 69 999999999 519.52 832.26 percent of total billed charges DCP RIGHT BUTTRESS 4HOLE 24054 48712404_1 CDM 0278 RC inpatient 858 557.7 UMR - ALL PLANS UMR - ALL PLANS 600.6 70 999999999 519.52 832.26 percent of total billed charges DCP RIGHT BUTTRESS 4HOLE 24054 48712404_1 CDM 0278 RC inpatient 858 557.7 SIHO - ALL PLANS SIHO - ALL PLANS 772.2 90 999999999 519.52 832.26 percent of total billed charges DCP RIGHT BUTTRESS 4HOLE 24054 48712404_1 CDM 0278 RC inpatient 858 557.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 519.52 60.55 999999999 519.52 832.26 percent of total billed charges DCP RIGHT BUTTRESS 4HOLE 24054 48712404_1 CDM 0278 RC inpatient 858 557.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 519.52 832.26 DCP RIGHT BUTTRESS 4HOLE 24054 48712404_1 CDM 0278 RC inpatient 858 557.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 519.52 832.26 DCP RIGHT BUTTRESS 4HOLE 24054 48712404_1 CDM 0278 RC inpatient 858 557.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 519.52 832.26 DCP RIGHT BUTTRESS 4HOLE 24054 48712404_1 CDM 0278 RC inpatient 858 557.7 ANTHEM HMO ANTHEM HMO 999999999 519.52 832.26 DCP RIGHT BUTTRESS 4HOLE 24054 48712404_1 CDM 0278 RC inpatient 858 557.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 519.52 832.26 DCP RIGHT BUTTRESS 4HOLE 24054 48712404_1 CDM 0278 RC inpatient 858 557.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 580.01 67.6 999999999 519.52 832.26 percent of total billed charges DCP T PLATE 6HOLE 240.16 48712405_1 CDM 0278 RC inpatient 728 473.2 AETNA AETNA 575.12 79 999999999 440.8 706.16 percent of total billed charges DCP T PLATE 6HOLE 240.16 48712405_1 CDM 0278 RC inpatient 728 473.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 473.2 65 999999999 440.8 706.16 percent of total billed charges DCP T PLATE 6HOLE 240.16 48712405_1 CDM 0278 RC inpatient 728 473.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 706.16 97 999999999 440.8 706.16 percent of total billed charges DCP T PLATE 6HOLE 240.16 48712405_1 CDM 0278 RC inpatient 728 473.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 567.84 78 999999999 440.8 706.16 percent of total billed charges DCP T PLATE 6HOLE 240.16 48712405_1 CDM 0278 RC inpatient 728 473.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 502.32 69 999999999 440.8 706.16 percent of total billed charges DCP T PLATE 6HOLE 240.16 48712405_1 CDM 0278 RC inpatient 728 473.2 UMR - ALL PLANS UMR - ALL PLANS 509.6 70 999999999 440.8 706.16 percent of total billed charges DCP T PLATE 6HOLE 240.16 48712405_1 CDM 0278 RC inpatient 728 473.2 SIHO - ALL PLANS SIHO - ALL PLANS 655.2 90 999999999 440.8 706.16 percent of total billed charges DCP T PLATE 6HOLE 240.16 48712405_1 CDM 0278 RC inpatient 728 473.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 440.8 60.55 999999999 440.8 706.16 percent of total billed charges DCP T PLATE 6HOLE 240.16 48712405_1 CDM 0278 RC inpatient 728 473.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 440.8 706.16 DCP T PLATE 6HOLE 240.16 48712405_1 CDM 0278 RC inpatient 728 473.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 440.8 706.16 DCP T PLATE 6HOLE 240.16 48712405_1 CDM 0278 RC inpatient 728 473.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 440.8 706.16 DCP T PLATE 6HOLE 240.16 48712405_1 CDM 0278 RC inpatient 728 473.2 ANTHEM HMO ANTHEM HMO 999999999 440.8 706.16 DCP T PLATE 6HOLE 240.16 48712405_1 CDM 0278 RC inpatient 728 473.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 440.8 706.16 DCP T PLATE 6HOLE 240.16 48712405_1 CDM 0278 RC inpatient 728 473.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 492.13 67.6 999999999 440.8 706.16 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712406_1 CDM 0278 RC C1713 HCPCS inpatient 1916 1245.4 AETNA AETNA 1513.64 79 999999999 1160.14 1858.52 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712406_1 CDM 0278 RC C1713 HCPCS inpatient 1916 1245.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1245.4 65 999999999 1160.14 1858.52 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712406_1 CDM 0278 RC C1713 HCPCS inpatient 1916 1245.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1858.52 97 999999999 1160.14 1858.52 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712406_1 CDM 0278 RC C1713 HCPCS inpatient 1916 1245.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1494.48 78 999999999 1160.14 1858.52 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712406_1 CDM 0278 RC C1713 HCPCS inpatient 1916 1245.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1322.04 69 999999999 1160.14 1858.52 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712406_1 CDM 0278 RC C1713 HCPCS inpatient 1916 1245.4 UMR - ALL PLANS UMR - ALL PLANS 1341.2 70 999999999 1160.14 1858.52 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712406_1 CDM 0278 RC C1713 HCPCS inpatient 1916 1245.4 SIHO - ALL PLANS SIHO - ALL PLANS 1724.4 90 999999999 1160.14 1858.52 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712406_1 CDM 0278 RC C1713 HCPCS inpatient 1916 1245.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1160.14 60.55 999999999 1160.14 1858.52 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712406_1 CDM 0278 RC C1713 HCPCS inpatient 1916 1245.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1160.14 1858.52 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712406_1 CDM 0278 RC C1713 HCPCS inpatient 1916 1245.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1160.14 1858.52 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712406_1 CDM 0278 RC C1713 HCPCS inpatient 1916 1245.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1160.14 1858.52 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712406_1 CDM 0278 RC C1713 HCPCS inpatient 1916 1245.4 ANTHEM HMO ANTHEM HMO 999999999 1160.14 1858.52 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712406_1 CDM 0278 RC C1713 HCPCS inpatient 1916 1245.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1160.14 1858.52 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712406_1 CDM 0278 RC C1713 HCPCS inpatient 1916 1245.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1295.22 67.6 999999999 1160.14 1858.52 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712407_1 CDM 0278 RC C1713 HCPCS inpatient 1795 1166.75 AETNA AETNA 1418.05 79 999999999 1086.87 1741.15 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712407_1 CDM 0278 RC C1713 HCPCS inpatient 1795 1166.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1166.75 65 999999999 1086.87 1741.15 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712407_1 CDM 0278 RC C1713 HCPCS inpatient 1795 1166.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1741.15 97 999999999 1086.87 1741.15 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712407_1 CDM 0278 RC C1713 HCPCS inpatient 1795 1166.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1400.1 78 999999999 1086.87 1741.15 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712407_1 CDM 0278 RC C1713 HCPCS inpatient 1795 1166.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1238.55 69 999999999 1086.87 1741.15 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712407_1 CDM 0278 RC C1713 HCPCS inpatient 1795 1166.75 UMR - ALL PLANS UMR - ALL PLANS 1256.5 70 999999999 1086.87 1741.15 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712407_1 CDM 0278 RC C1713 HCPCS inpatient 1795 1166.75 SIHO - ALL PLANS SIHO - ALL PLANS 1615.5 90 999999999 1086.87 1741.15 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712407_1 CDM 0278 RC C1713 HCPCS inpatient 1795 1166.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1086.87 60.55 999999999 1086.87 1741.15 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712407_1 CDM 0278 RC C1713 HCPCS inpatient 1795 1166.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1086.87 1741.15 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712407_1 CDM 0278 RC C1713 HCPCS inpatient 1795 1166.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1086.87 1741.15 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712407_1 CDM 0278 RC C1713 HCPCS inpatient 1795 1166.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1086.87 1741.15 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712407_1 CDM 0278 RC C1713 HCPCS inpatient 1795 1166.75 ANTHEM HMO ANTHEM HMO 999999999 1086.87 1741.15 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712407_1 CDM 0278 RC C1713 HCPCS inpatient 1795 1166.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1086.87 1741.15 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712407_1 CDM 0278 RC C1713 HCPCS inpatient 1795 1166.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1213.42 67.6 999999999 1086.87 1741.15 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712408_1 CDM 0278 RC C1713 HCPCS inpatient 1925 1251.25 AETNA AETNA 1520.75 79 999999999 1165.59 1867.25 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712408_1 CDM 0278 RC C1713 HCPCS inpatient 1925 1251.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1251.25 65 999999999 1165.59 1867.25 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712408_1 CDM 0278 RC C1713 HCPCS inpatient 1925 1251.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1867.25 97 999999999 1165.59 1867.25 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712408_1 CDM 0278 RC C1713 HCPCS inpatient 1925 1251.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1501.5 78 999999999 1165.59 1867.25 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712408_1 CDM 0278 RC C1713 HCPCS inpatient 1925 1251.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1328.25 69 999999999 1165.59 1867.25 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712408_1 CDM 0278 RC C1713 HCPCS inpatient 1925 1251.25 UMR - ALL PLANS UMR - ALL PLANS 1347.5 70 999999999 1165.59 1867.25 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712408_1 CDM 0278 RC C1713 HCPCS inpatient 1925 1251.25 SIHO - ALL PLANS SIHO - ALL PLANS 1732.5 90 999999999 1165.59 1867.25 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712408_1 CDM 0278 RC C1713 HCPCS inpatient 1925 1251.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1165.59 60.55 999999999 1165.59 1867.25 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712408_1 CDM 0278 RC C1713 HCPCS inpatient 1925 1251.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1165.59 1867.25 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712408_1 CDM 0278 RC C1713 HCPCS inpatient 1925 1251.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1165.59 1867.25 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712408_1 CDM 0278 RC C1713 HCPCS inpatient 1925 1251.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1165.59 1867.25 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712408_1 CDM 0278 RC C1713 HCPCS inpatient 1925 1251.25 ANTHEM HMO ANTHEM HMO 999999999 1165.59 1867.25 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712408_1 CDM 0278 RC C1713 HCPCS inpatient 1925 1251.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1165.59 1867.25 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712408_1 CDM 0278 RC C1713 HCPCS inpatient 1925 1251.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1301.3 67.6 999999999 1165.59 1867.25 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712409_1 CDM 0278 RC C1713 HCPCS inpatient 2055 1335.75 AETNA AETNA 1623.45 79 999999999 1244.3 1993.35 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712409_1 CDM 0278 RC C1713 HCPCS inpatient 2055 1335.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1335.75 65 999999999 1244.3 1993.35 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712409_1 CDM 0278 RC C1713 HCPCS inpatient 2055 1335.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1993.35 97 999999999 1244.3 1993.35 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712409_1 CDM 0278 RC C1713 HCPCS inpatient 2055 1335.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1602.9 78 999999999 1244.3 1993.35 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712409_1 CDM 0278 RC C1713 HCPCS inpatient 2055 1335.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1417.95 69 999999999 1244.3 1993.35 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712409_1 CDM 0278 RC C1713 HCPCS inpatient 2055 1335.75 UMR - ALL PLANS UMR - ALL PLANS 1438.5 70 999999999 1244.3 1993.35 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712409_1 CDM 0278 RC C1713 HCPCS inpatient 2055 1335.75 SIHO - ALL PLANS SIHO - ALL PLANS 1849.5 90 999999999 1244.3 1993.35 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712409_1 CDM 0278 RC C1713 HCPCS inpatient 2055 1335.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1244.3 60.55 999999999 1244.3 1993.35 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712409_1 CDM 0278 RC C1713 HCPCS inpatient 2055 1335.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1244.3 1993.35 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712409_1 CDM 0278 RC C1713 HCPCS inpatient 2055 1335.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1244.3 1993.35 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712409_1 CDM 0278 RC C1713 HCPCS inpatient 2055 1335.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1244.3 1993.35 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712409_1 CDM 0278 RC C1713 HCPCS inpatient 2055 1335.75 ANTHEM HMO ANTHEM HMO 999999999 1244.3 1993.35 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712409_1 CDM 0278 RC C1713 HCPCS inpatient 2055 1335.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1244.3 1993.35 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712409_1 CDM 0278 RC C1713 HCPCS inpatient 2055 1335.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1389.18 67.6 999999999 1244.3 1993.35 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712410_1 CDM 0278 RC C1713 HCPCS inpatient 1503 976.95 AETNA AETNA 1187.37 79 999999999 910.07 1457.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712410_1 CDM 0278 RC C1713 HCPCS inpatient 1503 976.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 976.95 65 999999999 910.07 1457.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712410_1 CDM 0278 RC C1713 HCPCS inpatient 1503 976.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1457.91 97 999999999 910.07 1457.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712410_1 CDM 0278 RC C1713 HCPCS inpatient 1503 976.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1172.34 78 999999999 910.07 1457.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712410_1 CDM 0278 RC C1713 HCPCS inpatient 1503 976.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1037.07 69 999999999 910.07 1457.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712410_1 CDM 0278 RC C1713 HCPCS inpatient 1503 976.95 UMR - ALL PLANS UMR - ALL PLANS 1052.1 70 999999999 910.07 1457.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712410_1 CDM 0278 RC C1713 HCPCS inpatient 1503 976.95 SIHO - ALL PLANS SIHO - ALL PLANS 1352.7 90 999999999 910.07 1457.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712410_1 CDM 0278 RC C1713 HCPCS inpatient 1503 976.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 910.07 60.55 999999999 910.07 1457.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712410_1 CDM 0278 RC C1713 HCPCS inpatient 1503 976.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 910.07 1457.91 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712410_1 CDM 0278 RC C1713 HCPCS inpatient 1503 976.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 910.07 1457.91 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712410_1 CDM 0278 RC C1713 HCPCS inpatient 1503 976.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 910.07 1457.91 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712410_1 CDM 0278 RC C1713 HCPCS inpatient 1503 976.95 ANTHEM HMO ANTHEM HMO 999999999 910.07 1457.91 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712410_1 CDM 0278 RC C1713 HCPCS inpatient 1503 976.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 910.07 1457.91 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712410_1 CDM 0278 RC C1713 HCPCS inpatient 1503 976.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1016.03 67.6 999999999 910.07 1457.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712411_1 CDM 0278 RC C1713 HCPCS inpatient 1713 1113.45 AETNA AETNA 1353.27 79 999999999 1037.22 1661.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712411_1 CDM 0278 RC C1713 HCPCS inpatient 1713 1113.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1113.45 65 999999999 1037.22 1661.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712411_1 CDM 0278 RC C1713 HCPCS inpatient 1713 1113.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1661.61 97 999999999 1037.22 1661.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712411_1 CDM 0278 RC C1713 HCPCS inpatient 1713 1113.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1336.14 78 999999999 1037.22 1661.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712411_1 CDM 0278 RC C1713 HCPCS inpatient 1713 1113.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1181.97 69 999999999 1037.22 1661.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712411_1 CDM 0278 RC C1713 HCPCS inpatient 1713 1113.45 UMR - ALL PLANS UMR - ALL PLANS 1199.1 70 999999999 1037.22 1661.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712411_1 CDM 0278 RC C1713 HCPCS inpatient 1713 1113.45 SIHO - ALL PLANS SIHO - ALL PLANS 1541.7 90 999999999 1037.22 1661.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712411_1 CDM 0278 RC C1713 HCPCS inpatient 1713 1113.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1037.22 60.55 999999999 1037.22 1661.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712411_1 CDM 0278 RC C1713 HCPCS inpatient 1713 1113.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1037.22 1661.61 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712411_1 CDM 0278 RC C1713 HCPCS inpatient 1713 1113.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1037.22 1661.61 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712411_1 CDM 0278 RC C1713 HCPCS inpatient 1713 1113.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1037.22 1661.61 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712411_1 CDM 0278 RC C1713 HCPCS inpatient 1713 1113.45 ANTHEM HMO ANTHEM HMO 999999999 1037.22 1661.61 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712411_1 CDM 0278 RC C1713 HCPCS inpatient 1713 1113.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1037.22 1661.61 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712411_1 CDM 0278 RC C1713 HCPCS inpatient 1713 1113.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1157.99 67.6 999999999 1037.22 1661.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712412_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 AETNA AETNA 1456.76 79 999999999 1116.54 1788.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712412_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1198.6 65 999999999 1116.54 1788.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712412_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1788.68 97 999999999 1116.54 1788.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712412_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1438.32 78 999999999 1116.54 1788.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712412_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1272.36 69 999999999 1116.54 1788.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712412_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 UMR - ALL PLANS UMR - ALL PLANS 1290.8 70 999999999 1116.54 1788.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712412_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 SIHO - ALL PLANS SIHO - ALL PLANS 1659.6 90 999999999 1116.54 1788.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712412_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1116.54 60.55 999999999 1116.54 1788.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712412_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1116.54 1788.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712412_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1116.54 1788.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712412_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1116.54 1788.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712412_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 ANTHEM HMO ANTHEM HMO 999999999 1116.54 1788.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712412_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1116.54 1788.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712412_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1246.54 67.6 999999999 1116.54 1788.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712413_1 CDM 0278 RC C1713 HCPCS inpatient 1981 1287.65 AETNA AETNA 1564.99 79 999999999 1199.5 1921.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712413_1 CDM 0278 RC C1713 HCPCS inpatient 1981 1287.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1287.65 65 999999999 1199.5 1921.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712413_1 CDM 0278 RC C1713 HCPCS inpatient 1981 1287.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1921.57 97 999999999 1199.5 1921.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712413_1 CDM 0278 RC C1713 HCPCS inpatient 1981 1287.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1545.18 78 999999999 1199.5 1921.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712413_1 CDM 0278 RC C1713 HCPCS inpatient 1981 1287.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1366.89 69 999999999 1199.5 1921.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712413_1 CDM 0278 RC C1713 HCPCS inpatient 1981 1287.65 UMR - ALL PLANS UMR - ALL PLANS 1386.7 70 999999999 1199.5 1921.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712413_1 CDM 0278 RC C1713 HCPCS inpatient 1981 1287.65 SIHO - ALL PLANS SIHO - ALL PLANS 1782.9 90 999999999 1199.5 1921.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712413_1 CDM 0278 RC C1713 HCPCS inpatient 1981 1287.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1199.5 60.55 999999999 1199.5 1921.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712413_1 CDM 0278 RC C1713 HCPCS inpatient 1981 1287.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1199.5 1921.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712413_1 CDM 0278 RC C1713 HCPCS inpatient 1981 1287.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1199.5 1921.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712413_1 CDM 0278 RC C1713 HCPCS inpatient 1981 1287.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1199.5 1921.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712413_1 CDM 0278 RC C1713 HCPCS inpatient 1981 1287.65 ANTHEM HMO ANTHEM HMO 999999999 1199.5 1921.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712413_1 CDM 0278 RC C1713 HCPCS inpatient 1981 1287.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1199.5 1921.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712413_1 CDM 0278 RC C1713 HCPCS inpatient 1981 1287.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1339.16 67.6 999999999 1199.5 1921.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712414_1 CDM 0278 RC C1713 HCPCS inpatient 2117 1376.05 AETNA AETNA 1672.43 79 999999999 1281.84 2053.49 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712414_1 CDM 0278 RC C1713 HCPCS inpatient 2117 1376.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1376.05 65 999999999 1281.84 2053.49 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712414_1 CDM 0278 RC C1713 HCPCS inpatient 2117 1376.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2053.49 97 999999999 1281.84 2053.49 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712414_1 CDM 0278 RC C1713 HCPCS inpatient 2117 1376.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1651.26 78 999999999 1281.84 2053.49 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712414_1 CDM 0278 RC C1713 HCPCS inpatient 2117 1376.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1460.73 69 999999999 1281.84 2053.49 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712414_1 CDM 0278 RC C1713 HCPCS inpatient 2117 1376.05 UMR - ALL PLANS UMR - ALL PLANS 1481.9 70 999999999 1281.84 2053.49 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712414_1 CDM 0278 RC C1713 HCPCS inpatient 2117 1376.05 SIHO - ALL PLANS SIHO - ALL PLANS 1905.3 90 999999999 1281.84 2053.49 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712414_1 CDM 0278 RC C1713 HCPCS inpatient 2117 1376.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1281.84 60.55 999999999 1281.84 2053.49 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712414_1 CDM 0278 RC C1713 HCPCS inpatient 2117 1376.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1281.84 2053.49 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712414_1 CDM 0278 RC C1713 HCPCS inpatient 2117 1376.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1281.84 2053.49 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712414_1 CDM 0278 RC C1713 HCPCS inpatient 2117 1376.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1281.84 2053.49 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712414_1 CDM 0278 RC C1713 HCPCS inpatient 2117 1376.05 ANTHEM HMO ANTHEM HMO 999999999 1281.84 2053.49 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712414_1 CDM 0278 RC C1713 HCPCS inpatient 2117 1376.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1281.84 2053.49 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712414_1 CDM 0278 RC C1713 HCPCS inpatient 2117 1376.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1431.09 67.6 999999999 1281.84 2053.49 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712415_1 CDM 0278 RC C1713 HCPCS inpatient 2954 1920.1 AETNA AETNA 2333.66 79 999999999 1788.65 2865.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712415_1 CDM 0278 RC C1713 HCPCS inpatient 2954 1920.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1920.1 65 999999999 1788.65 2865.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712415_1 CDM 0278 RC C1713 HCPCS inpatient 2954 1920.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2865.38 97 999999999 1788.65 2865.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712415_1 CDM 0278 RC C1713 HCPCS inpatient 2954 1920.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 2304.12 78 999999999 1788.65 2865.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712415_1 CDM 0278 RC C1713 HCPCS inpatient 2954 1920.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 2038.26 69 999999999 1788.65 2865.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712415_1 CDM 0278 RC C1713 HCPCS inpatient 2954 1920.1 UMR - ALL PLANS UMR - ALL PLANS 2067.8 70 999999999 1788.65 2865.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712415_1 CDM 0278 RC C1713 HCPCS inpatient 2954 1920.1 SIHO - ALL PLANS SIHO - ALL PLANS 2658.6 90 999999999 1788.65 2865.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712415_1 CDM 0278 RC C1713 HCPCS inpatient 2954 1920.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1788.65 60.55 999999999 1788.65 2865.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712415_1 CDM 0278 RC C1713 HCPCS inpatient 2954 1920.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1788.65 2865.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712415_1 CDM 0278 RC C1713 HCPCS inpatient 2954 1920.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1788.65 2865.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712415_1 CDM 0278 RC C1713 HCPCS inpatient 2954 1920.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1788.65 2865.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712415_1 CDM 0278 RC C1713 HCPCS inpatient 2954 1920.1 ANTHEM HMO ANTHEM HMO 999999999 1788.65 2865.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712415_1 CDM 0278 RC C1713 HCPCS inpatient 2954 1920.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1788.65 2865.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712415_1 CDM 0278 RC C1713 HCPCS inpatient 2954 1920.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1996.9 67.6 999999999 1788.65 2865.38 percent of total billed charges 4.5M NAR DCP 10HOLE 224.60 48712416_1 CDM 0278 RC inpatient 304 197.6 AETNA AETNA 240.16 79 999999999 184.07 294.88 percent of total billed charges 4.5M NAR DCP 10HOLE 224.60 48712416_1 CDM 0278 RC inpatient 304 197.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 197.6 65 999999999 184.07 294.88 percent of total billed charges 4.5M NAR DCP 10HOLE 224.60 48712416_1 CDM 0278 RC inpatient 304 197.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 294.88 97 999999999 184.07 294.88 percent of total billed charges 4.5M NAR DCP 10HOLE 224.60 48712416_1 CDM 0278 RC inpatient 304 197.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 237.12 78 999999999 184.07 294.88 percent of total billed charges 4.5M NAR DCP 10HOLE 224.60 48712416_1 CDM 0278 RC inpatient 304 197.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 209.76 69 999999999 184.07 294.88 percent of total billed charges 4.5M NAR DCP 10HOLE 224.60 48712416_1 CDM 0278 RC inpatient 304 197.6 UMR - ALL PLANS UMR - ALL PLANS 212.8 70 999999999 184.07 294.88 percent of total billed charges 4.5M NAR DCP 10HOLE 224.60 48712416_1 CDM 0278 RC inpatient 304 197.6 SIHO - ALL PLANS SIHO - ALL PLANS 273.6 90 999999999 184.07 294.88 percent of total billed charges 4.5M NAR DCP 10HOLE 224.60 48712416_1 CDM 0278 RC inpatient 304 197.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 184.07 60.55 999999999 184.07 294.88 percent of total billed charges 4.5M NAR DCP 10HOLE 224.60 48712416_1 CDM 0278 RC inpatient 304 197.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 184.07 294.88 4.5M NAR DCP 10HOLE 224.60 48712416_1 CDM 0278 RC inpatient 304 197.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 184.07 294.88 4.5M NAR DCP 10HOLE 224.60 48712416_1 CDM 0278 RC inpatient 304 197.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 184.07 294.88 4.5M NAR DCP 10HOLE 224.60 48712416_1 CDM 0278 RC inpatient 304 197.6 ANTHEM HMO ANTHEM HMO 999999999 184.07 294.88 4.5M NAR DCP 10HOLE 224.60 48712416_1 CDM 0278 RC inpatient 304 197.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 184.07 294.88 4.5M NAR DCP 10HOLE 224.60 48712416_1 CDM 0278 RC inpatient 304 197.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 205.5 67.6 999999999 184.07 294.88 percent of total billed charges CLIP APPLIER 10MM 176657 48712417_1 CDM 0272 RC inpatient 654 425.1 AETNA AETNA 516.66 79 999999999 396 634.38 percent of total billed charges CLIP APPLIER 10MM 176657 48712417_1 CDM 0272 RC inpatient 654 425.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 425.1 65 999999999 396 634.38 percent of total billed charges CLIP APPLIER 10MM 176657 48712417_1 CDM 0272 RC inpatient 654 425.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 634.38 97 999999999 396 634.38 percent of total billed charges CLIP APPLIER 10MM 176657 48712417_1 CDM 0272 RC inpatient 654 425.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 510.12 78 999999999 396 634.38 percent of total billed charges CLIP APPLIER 10MM 176657 48712417_1 CDM 0272 RC inpatient 654 425.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 451.26 69 999999999 396 634.38 percent of total billed charges CLIP APPLIER 10MM 176657 48712417_1 CDM 0272 RC inpatient 654 425.1 UMR - ALL PLANS UMR - ALL PLANS 457.8 70 999999999 396 634.38 percent of total billed charges CLIP APPLIER 10MM 176657 48712417_1 CDM 0272 RC inpatient 654 425.1 SIHO - ALL PLANS SIHO - ALL PLANS 588.6 90 999999999 396 634.38 percent of total billed charges CLIP APPLIER 10MM 176657 48712417_1 CDM 0272 RC inpatient 654 425.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 396 60.55 999999999 396 634.38 percent of total billed charges CLIP APPLIER 10MM 176657 48712417_1 CDM 0272 RC inpatient 654 425.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 396 634.38 CLIP APPLIER 10MM 176657 48712417_1 CDM 0272 RC inpatient 654 425.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 396 634.38 CLIP APPLIER 10MM 176657 48712417_1 CDM 0272 RC inpatient 654 425.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 396 634.38 CLIP APPLIER 10MM 176657 48712417_1 CDM 0272 RC inpatient 654 425.1 ANTHEM HMO ANTHEM HMO 999999999 396 634.38 CLIP APPLIER 10MM 176657 48712417_1 CDM 0272 RC inpatient 654 425.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 396 634.38 CLIP APPLIER 10MM 176657 48712417_1 CDM 0272 RC inpatient 654 425.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 442.1 67.6 999999999 396 634.38 percent of total billed charges TUBING SMART CAPNOLINE+ 010625 48712418_1 CDM 0270 RC inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges TUBING SMART CAPNOLINE+ 010625 48712418_1 CDM 0270 RC inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges TUBING SMART CAPNOLINE+ 010625 48712418_1 CDM 0270 RC inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges TUBING SMART CAPNOLINE+ 010625 48712418_1 CDM 0270 RC inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges TUBING SMART CAPNOLINE+ 010625 48712418_1 CDM 0270 RC inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges TUBING SMART CAPNOLINE+ 010625 48712418_1 CDM 0270 RC inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges TUBING SMART CAPNOLINE+ 010625 48712418_1 CDM 0270 RC inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges TUBING SMART CAPNOLINE+ 010625 48712418_1 CDM 0270 RC inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges TUBING SMART CAPNOLINE+ 010625 48712418_1 CDM 0270 RC inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 TUBING SMART CAPNOLINE+ 010625 48712418_1 CDM 0270 RC inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 TUBING SMART CAPNOLINE+ 010625 48712418_1 CDM 0270 RC inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 TUBING SMART CAPNOLINE+ 010625 48712418_1 CDM 0270 RC inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 TUBING SMART CAPNOLINE+ 010625 48712418_1 CDM 0270 RC inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 TUBING SMART CAPNOLINE+ 010625 48712418_1 CDM 0270 RC inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges TUBING SMART CAPNOLINE FEMALE MVAOL100U 48712419_1 CDM 0270 RC inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges TUBING SMART CAPNOLINE FEMALE MVAOL100U 48712419_1 CDM 0270 RC inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges TUBING SMART CAPNOLINE FEMALE MVAOL100U 48712419_1 CDM 0270 RC inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges TUBING SMART CAPNOLINE FEMALE MVAOL100U 48712419_1 CDM 0270 RC inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges TUBING SMART CAPNOLINE FEMALE MVAOL100U 48712419_1 CDM 0270 RC inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges TUBING SMART CAPNOLINE FEMALE MVAOL100U 48712419_1 CDM 0270 RC inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges TUBING SMART CAPNOLINE FEMALE MVAOL100U 48712419_1 CDM 0270 RC inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges TUBING SMART CAPNOLINE FEMALE MVAOL100U 48712419_1 CDM 0270 RC inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges TUBING SMART CAPNOLINE FEMALE MVAOL100U 48712419_1 CDM 0270 RC inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 TUBING SMART CAPNOLINE FEMALE MVAOL100U 48712419_1 CDM 0270 RC inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 TUBING SMART CAPNOLINE FEMALE MVAOL100U 48712419_1 CDM 0270 RC inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 TUBING SMART CAPNOLINE FEMALE MVAOL100U 48712419_1 CDM 0270 RC inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 TUBING SMART CAPNOLINE FEMALE MVAOL100U 48712419_1 CDM 0270 RC inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 TUBING SMART CAPNOLINE FEMALE MVAOL100U 48712419_1 CDM 0270 RC inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges "HUMAN PLASMA FIBRIN SEALANT, VAPOR-HEATED, SOLVENT-DETERGENT (ARTISS), 2 ML" 48712420_1 CDM 0270 RC C9250 HCPCS inpatient 4963 3225.95 AETNA AETNA 3920.77 79 999999999 3005.1 4814.11 percent of total billed charges "HUMAN PLASMA FIBRIN SEALANT, VAPOR-HEATED, SOLVENT-DETERGENT (ARTISS), 2 ML" 48712420_1 CDM 0270 RC C9250 HCPCS inpatient 4963 3225.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 3225.95 65 999999999 3005.1 4814.11 percent of total billed charges "HUMAN PLASMA FIBRIN SEALANT, VAPOR-HEATED, SOLVENT-DETERGENT (ARTISS), 2 ML" 48712420_1 CDM 0270 RC C9250 HCPCS inpatient 4963 3225.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4814.11 97 999999999 3005.1 4814.11 percent of total billed charges "HUMAN PLASMA FIBRIN SEALANT, VAPOR-HEATED, SOLVENT-DETERGENT (ARTISS), 2 ML" 48712420_1 CDM 0270 RC C9250 HCPCS inpatient 4963 3225.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 3871.14 78 999999999 3005.1 4814.11 percent of total billed charges "HUMAN PLASMA FIBRIN SEALANT, VAPOR-HEATED, SOLVENT-DETERGENT (ARTISS), 2 ML" 48712420_1 CDM 0270 RC C9250 HCPCS inpatient 4963 3225.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 3424.47 69 999999999 3005.1 4814.11 percent of total billed charges "HUMAN PLASMA FIBRIN SEALANT, VAPOR-HEATED, SOLVENT-DETERGENT (ARTISS), 2 ML" 48712420_1 CDM 0270 RC C9250 HCPCS inpatient 4963 3225.95 UMR - ALL PLANS UMR - ALL PLANS 3474.1 70 999999999 3005.1 4814.11 percent of total billed charges "HUMAN PLASMA FIBRIN SEALANT, VAPOR-HEATED, SOLVENT-DETERGENT (ARTISS), 2 ML" 48712420_1 CDM 0270 RC C9250 HCPCS inpatient 4963 3225.95 SIHO - ALL PLANS SIHO - ALL PLANS 4466.7 90 999999999 3005.1 4814.11 percent of total billed charges "HUMAN PLASMA FIBRIN SEALANT, VAPOR-HEATED, SOLVENT-DETERGENT (ARTISS), 2 ML" 48712420_1 CDM 0270 RC C9250 HCPCS inpatient 4963 3225.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3005.1 60.55 999999999 3005.1 4814.11 percent of total billed charges "HUMAN PLASMA FIBRIN SEALANT, VAPOR-HEATED, SOLVENT-DETERGENT (ARTISS), 2 ML" 48712420_1 CDM 0270 RC C9250 HCPCS inpatient 4963 3225.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3005.1 4814.11 "HUMAN PLASMA FIBRIN SEALANT, VAPOR-HEATED, SOLVENT-DETERGENT (ARTISS), 2 ML" 48712420_1 CDM 0270 RC C9250 HCPCS inpatient 4963 3225.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3005.1 4814.11 "HUMAN PLASMA FIBRIN SEALANT, VAPOR-HEATED, SOLVENT-DETERGENT (ARTISS), 2 ML" 48712420_1 CDM 0270 RC C9250 HCPCS inpatient 4963 3225.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3005.1 4814.11 "HUMAN PLASMA FIBRIN SEALANT, VAPOR-HEATED, SOLVENT-DETERGENT (ARTISS), 2 ML" 48712420_1 CDM 0270 RC C9250 HCPCS inpatient 4963 3225.95 ANTHEM HMO ANTHEM HMO 999999999 3005.1 4814.11 "HUMAN PLASMA FIBRIN SEALANT, VAPOR-HEATED, SOLVENT-DETERGENT (ARTISS), 2 ML" 48712420_1 CDM 0270 RC C9250 HCPCS inpatient 4963 3225.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 3005.1 4814.11 "HUMAN PLASMA FIBRIN SEALANT, VAPOR-HEATED, SOLVENT-DETERGENT (ARTISS), 2 ML" 48712420_1 CDM 0270 RC C9250 HCPCS inpatient 4963 3225.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 3354.99 67.6 999999999 3005.1 4814.11 percent of total billed charges X-SM FIXATION STAPLE W/SPIKE 48712421_1 CDM 0278 RC inpatient 596 387.4 AETNA AETNA 470.84 79 999999999 360.88 578.12 percent of total billed charges X-SM FIXATION STAPLE W/SPIKE 48712421_1 CDM 0278 RC inpatient 596 387.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 387.4 65 999999999 360.88 578.12 percent of total billed charges X-SM FIXATION STAPLE W/SPIKE 48712421_1 CDM 0278 RC inpatient 596 387.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 578.12 97 999999999 360.88 578.12 percent of total billed charges X-SM FIXATION STAPLE W/SPIKE 48712421_1 CDM 0278 RC inpatient 596 387.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 464.88 78 999999999 360.88 578.12 percent of total billed charges X-SM FIXATION STAPLE W/SPIKE 48712421_1 CDM 0278 RC inpatient 596 387.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 411.24 69 999999999 360.88 578.12 percent of total billed charges X-SM FIXATION STAPLE W/SPIKE 48712421_1 CDM 0278 RC inpatient 596 387.4 UMR - ALL PLANS UMR - ALL PLANS 417.2 70 999999999 360.88 578.12 percent of total billed charges X-SM FIXATION STAPLE W/SPIKE 48712421_1 CDM 0278 RC inpatient 596 387.4 SIHO - ALL PLANS SIHO - ALL PLANS 536.4 90 999999999 360.88 578.12 percent of total billed charges X-SM FIXATION STAPLE W/SPIKE 48712421_1 CDM 0278 RC inpatient 596 387.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 360.88 60.55 999999999 360.88 578.12 percent of total billed charges X-SM FIXATION STAPLE W/SPIKE 48712421_1 CDM 0278 RC inpatient 596 387.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 360.88 578.12 X-SM FIXATION STAPLE W/SPIKE 48712421_1 CDM 0278 RC inpatient 596 387.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 360.88 578.12 X-SM FIXATION STAPLE W/SPIKE 48712421_1 CDM 0278 RC inpatient 596 387.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 360.88 578.12 X-SM FIXATION STAPLE W/SPIKE 48712421_1 CDM 0278 RC inpatient 596 387.4 ANTHEM HMO ANTHEM HMO 999999999 360.88 578.12 X-SM FIXATION STAPLE W/SPIKE 48712421_1 CDM 0278 RC inpatient 596 387.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 360.88 578.12 X-SM FIXATION STAPLE W/SPIKE 48712421_1 CDM 0278 RC inpatient 596 387.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 402.9 67.6 999999999 360.88 578.12 percent of total billed charges SCREW CAN 7.3 32M/85M 209.885 48712422_1 CDM 0278 RC inpatient 1708 1110.2 AETNA AETNA 1349.32 79 999999999 1034.19 1656.76 percent of total billed charges SCREW CAN 7.3 32M/85M 209.885 48712422_1 CDM 0278 RC inpatient 1708 1110.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1110.2 65 999999999 1034.19 1656.76 percent of total billed charges SCREW CAN 7.3 32M/85M 209.885 48712422_1 CDM 0278 RC inpatient 1708 1110.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1656.76 97 999999999 1034.19 1656.76 percent of total billed charges SCREW CAN 7.3 32M/85M 209.885 48712422_1 CDM 0278 RC inpatient 1708 1110.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1332.24 78 999999999 1034.19 1656.76 percent of total billed charges SCREW CAN 7.3 32M/85M 209.885 48712422_1 CDM 0278 RC inpatient 1708 1110.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1178.52 69 999999999 1034.19 1656.76 percent of total billed charges SCREW CAN 7.3 32M/85M 209.885 48712422_1 CDM 0278 RC inpatient 1708 1110.2 UMR - ALL PLANS UMR - ALL PLANS 1195.6 70 999999999 1034.19 1656.76 percent of total billed charges SCREW CAN 7.3 32M/85M 209.885 48712422_1 CDM 0278 RC inpatient 1708 1110.2 SIHO - ALL PLANS SIHO - ALL PLANS 1537.2 90 999999999 1034.19 1656.76 percent of total billed charges SCREW CAN 7.3 32M/85M 209.885 48712422_1 CDM 0278 RC inpatient 1708 1110.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1034.19 60.55 999999999 1034.19 1656.76 percent of total billed charges SCREW CAN 7.3 32M/85M 209.885 48712422_1 CDM 0278 RC inpatient 1708 1110.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1034.19 1656.76 SCREW CAN 7.3 32M/85M 209.885 48712422_1 CDM 0278 RC inpatient 1708 1110.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1034.19 1656.76 SCREW CAN 7.3 32M/85M 209.885 48712422_1 CDM 0278 RC inpatient 1708 1110.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1034.19 1656.76 SCREW CAN 7.3 32M/85M 209.885 48712422_1 CDM 0278 RC inpatient 1708 1110.2 ANTHEM HMO ANTHEM HMO 999999999 1034.19 1656.76 SCREW CAN 7.3 32M/85M 209.885 48712422_1 CDM 0278 RC inpatient 1708 1110.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1034.19 1656.76 SCREW CAN 7.3 32M/85M 209.885 48712422_1 CDM 0278 RC inpatient 1708 1110.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1154.61 67.6 999999999 1034.19 1656.76 percent of total billed charges SM CC FIXATION STAPLE W/SPIKE 48712423_1 CDM 0278 RC inpatient 596 387.4 AETNA AETNA 470.84 79 999999999 360.88 578.12 percent of total billed charges SM CC FIXATION STAPLE W/SPIKE 48712423_1 CDM 0278 RC inpatient 596 387.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 387.4 65 999999999 360.88 578.12 percent of total billed charges SM CC FIXATION STAPLE W/SPIKE 48712423_1 CDM 0278 RC inpatient 596 387.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 578.12 97 999999999 360.88 578.12 percent of total billed charges SM CC FIXATION STAPLE W/SPIKE 48712423_1 CDM 0278 RC inpatient 596 387.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 464.88 78 999999999 360.88 578.12 percent of total billed charges SM CC FIXATION STAPLE W/SPIKE 48712423_1 CDM 0278 RC inpatient 596 387.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 411.24 69 999999999 360.88 578.12 percent of total billed charges SM CC FIXATION STAPLE W/SPIKE 48712423_1 CDM 0278 RC inpatient 596 387.4 UMR - ALL PLANS UMR - ALL PLANS 417.2 70 999999999 360.88 578.12 percent of total billed charges SM CC FIXATION STAPLE W/SPIKE 48712423_1 CDM 0278 RC inpatient 596 387.4 SIHO - ALL PLANS SIHO - ALL PLANS 536.4 90 999999999 360.88 578.12 percent of total billed charges SM CC FIXATION STAPLE W/SPIKE 48712423_1 CDM 0278 RC inpatient 596 387.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 360.88 60.55 999999999 360.88 578.12 percent of total billed charges SM CC FIXATION STAPLE W/SPIKE 48712423_1 CDM 0278 RC inpatient 596 387.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 360.88 578.12 SM CC FIXATION STAPLE W/SPIKE 48712423_1 CDM 0278 RC inpatient 596 387.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 360.88 578.12 SM CC FIXATION STAPLE W/SPIKE 48712423_1 CDM 0278 RC inpatient 596 387.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 360.88 578.12 SM CC FIXATION STAPLE W/SPIKE 48712423_1 CDM 0278 RC inpatient 596 387.4 ANTHEM HMO ANTHEM HMO 999999999 360.88 578.12 SM CC FIXATION STAPLE W/SPIKE 48712423_1 CDM 0278 RC inpatient 596 387.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 360.88 578.12 SM CC FIXATION STAPLE W/SPIKE 48712423_1 CDM 0278 RC inpatient 596 387.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 402.9 67.6 999999999 360.88 578.12 percent of total billed charges MED CC FIXAT-STAPLE W/SPIKE 48712424_1 CDM 0278 RC inpatient 596 387.4 AETNA AETNA 470.84 79 999999999 360.88 578.12 percent of total billed charges MED CC FIXAT-STAPLE W/SPIKE 48712424_1 CDM 0278 RC inpatient 596 387.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 387.4 65 999999999 360.88 578.12 percent of total billed charges MED CC FIXAT-STAPLE W/SPIKE 48712424_1 CDM 0278 RC inpatient 596 387.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 578.12 97 999999999 360.88 578.12 percent of total billed charges MED CC FIXAT-STAPLE W/SPIKE 48712424_1 CDM 0278 RC inpatient 596 387.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 464.88 78 999999999 360.88 578.12 percent of total billed charges MED CC FIXAT-STAPLE W/SPIKE 48712424_1 CDM 0278 RC inpatient 596 387.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 411.24 69 999999999 360.88 578.12 percent of total billed charges MED CC FIXAT-STAPLE W/SPIKE 48712424_1 CDM 0278 RC inpatient 596 387.4 UMR - ALL PLANS UMR - ALL PLANS 417.2 70 999999999 360.88 578.12 percent of total billed charges MED CC FIXAT-STAPLE W/SPIKE 48712424_1 CDM 0278 RC inpatient 596 387.4 SIHO - ALL PLANS SIHO - ALL PLANS 536.4 90 999999999 360.88 578.12 percent of total billed charges MED CC FIXAT-STAPLE W/SPIKE 48712424_1 CDM 0278 RC inpatient 596 387.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 360.88 60.55 999999999 360.88 578.12 percent of total billed charges MED CC FIXAT-STAPLE W/SPIKE 48712424_1 CDM 0278 RC inpatient 596 387.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 360.88 578.12 MED CC FIXAT-STAPLE W/SPIKE 48712424_1 CDM 0278 RC inpatient 596 387.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 360.88 578.12 MED CC FIXAT-STAPLE W/SPIKE 48712424_1 CDM 0278 RC inpatient 596 387.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 360.88 578.12 MED CC FIXAT-STAPLE W/SPIKE 48712424_1 CDM 0278 RC inpatient 596 387.4 ANTHEM HMO ANTHEM HMO 999999999 360.88 578.12 MED CC FIXAT-STAPLE W/SPIKE 48712424_1 CDM 0278 RC inpatient 596 387.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 360.88 578.12 MED CC FIXAT-STAPLE W/SPIKE 48712424_1 CDM 0278 RC inpatient 596 387.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 402.9 67.6 999999999 360.88 578.12 percent of total billed charges MED CC FIXAT-STAPLE W/O SPIKE 48712425_1 CDM 0278 RC inpatient 596 387.4 AETNA AETNA 470.84 79 999999999 360.88 578.12 percent of total billed charges MED CC FIXAT-STAPLE W/O SPIKE 48712425_1 CDM 0278 RC inpatient 596 387.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 387.4 65 999999999 360.88 578.12 percent of total billed charges MED CC FIXAT-STAPLE W/O SPIKE 48712425_1 CDM 0278 RC inpatient 596 387.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 578.12 97 999999999 360.88 578.12 percent of total billed charges MED CC FIXAT-STAPLE W/O SPIKE 48712425_1 CDM 0278 RC inpatient 596 387.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 464.88 78 999999999 360.88 578.12 percent of total billed charges MED CC FIXAT-STAPLE W/O SPIKE 48712425_1 CDM 0278 RC inpatient 596 387.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 411.24 69 999999999 360.88 578.12 percent of total billed charges MED CC FIXAT-STAPLE W/O SPIKE 48712425_1 CDM 0278 RC inpatient 596 387.4 UMR - ALL PLANS UMR - ALL PLANS 417.2 70 999999999 360.88 578.12 percent of total billed charges MED CC FIXAT-STAPLE W/O SPIKE 48712425_1 CDM 0278 RC inpatient 596 387.4 SIHO - ALL PLANS SIHO - ALL PLANS 536.4 90 999999999 360.88 578.12 percent of total billed charges MED CC FIXAT-STAPLE W/O SPIKE 48712425_1 CDM 0278 RC inpatient 596 387.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 360.88 60.55 999999999 360.88 578.12 percent of total billed charges MED CC FIXAT-STAPLE W/O SPIKE 48712425_1 CDM 0278 RC inpatient 596 387.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 360.88 578.12 MED CC FIXAT-STAPLE W/O SPIKE 48712425_1 CDM 0278 RC inpatient 596 387.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 360.88 578.12 MED CC FIXAT-STAPLE W/O SPIKE 48712425_1 CDM 0278 RC inpatient 596 387.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 360.88 578.12 MED CC FIXAT-STAPLE W/O SPIKE 48712425_1 CDM 0278 RC inpatient 596 387.4 ANTHEM HMO ANTHEM HMO 999999999 360.88 578.12 MED CC FIXAT-STAPLE W/O SPIKE 48712425_1 CDM 0278 RC inpatient 596 387.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 360.88 578.12 MED CC FIXAT-STAPLE W/O SPIKE 48712425_1 CDM 0278 RC inpatient 596 387.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 402.9 67.6 999999999 360.88 578.12 percent of total billed charges OSTEOTOMY STAPLE 14MM 12.8675 48712426_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 14MM 12.8675 48712426_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 14MM 12.8675 48712426_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 14MM 12.8675 48712426_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 14MM 12.8675 48712426_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 14MM 12.8675 48712426_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 14MM 12.8675 48712426_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 14MM 12.8675 48712426_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 14MM 12.8675 48712426_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 OSTEOTOMY STAPLE 14MM 12.8675 48712426_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 OSTEOTOMY STAPLE 14MM 12.8675 48712426_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 OSTEOTOMY STAPLE 14MM 12.8675 48712426_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 OSTEOTOMY STAPLE 14MM 12.8675 48712426_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 OSTEOTOMY STAPLE 14MM 12.8675 48712426_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 10MM 12.8674 48712427_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 10MM 12.8674 48712427_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 10MM 12.8674 48712427_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 10MM 12.8674 48712427_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 10MM 12.8674 48712427_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 10MM 12.8674 48712427_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 10MM 12.8674 48712427_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 10MM 12.8674 48712427_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 10MM 12.8674 48712427_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 OSTEOTOMY STAPLE 10MM 12.8674 48712427_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 OSTEOTOMY STAPLE 10MM 12.8674 48712427_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 OSTEOTOMY STAPLE 10MM 12.8674 48712427_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 OSTEOTOMY STAPLE 10MM 12.8674 48712427_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 OSTEOTOMY STAPLE 10MM 12.8674 48712427_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 5MM 12.8673 48712428_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 5MM 12.8673 48712428_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 5MM 12.8673 48712428_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 5MM 12.8673 48712428_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 5MM 12.8673 48712428_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 5MM 12.8673 48712428_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 5MM 12.8673 48712428_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 5MM 12.8673 48712428_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges OSTEOTOMY STAPLE 5MM 12.8673 48712428_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 OSTEOTOMY STAPLE 5MM 12.8673 48712428_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 OSTEOTOMY STAPLE 5MM 12.8673 48712428_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 OSTEOTOMY STAPLE 5MM 12.8673 48712428_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 OSTEOTOMY STAPLE 5MM 12.8673 48712428_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 OSTEOTOMY STAPLE 5MM 12.8673 48712428_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges LG CC FIXATION STAPLE W/SPIKE 48712429_1 CDM 0278 RC inpatient 596 387.4 AETNA AETNA 470.84 79 999999999 360.88 578.12 percent of total billed charges LG CC FIXATION STAPLE W/SPIKE 48712429_1 CDM 0278 RC inpatient 596 387.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 387.4 65 999999999 360.88 578.12 percent of total billed charges LG CC FIXATION STAPLE W/SPIKE 48712429_1 CDM 0278 RC inpatient 596 387.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 578.12 97 999999999 360.88 578.12 percent of total billed charges LG CC FIXATION STAPLE W/SPIKE 48712429_1 CDM 0278 RC inpatient 596 387.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 464.88 78 999999999 360.88 578.12 percent of total billed charges LG CC FIXATION STAPLE W/SPIKE 48712429_1 CDM 0278 RC inpatient 596 387.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 411.24 69 999999999 360.88 578.12 percent of total billed charges LG CC FIXATION STAPLE W/SPIKE 48712429_1 CDM 0278 RC inpatient 596 387.4 UMR - ALL PLANS UMR - ALL PLANS 417.2 70 999999999 360.88 578.12 percent of total billed charges LG CC FIXATION STAPLE W/SPIKE 48712429_1 CDM 0278 RC inpatient 596 387.4 SIHO - ALL PLANS SIHO - ALL PLANS 536.4 90 999999999 360.88 578.12 percent of total billed charges LG CC FIXATION STAPLE W/SPIKE 48712429_1 CDM 0278 RC inpatient 596 387.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 360.88 60.55 999999999 360.88 578.12 percent of total billed charges LG CC FIXATION STAPLE W/SPIKE 48712429_1 CDM 0278 RC inpatient 596 387.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 360.88 578.12 LG CC FIXATION STAPLE W/SPIKE 48712429_1 CDM 0278 RC inpatient 596 387.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 360.88 578.12 LG CC FIXATION STAPLE W/SPIKE 48712429_1 CDM 0278 RC inpatient 596 387.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 360.88 578.12 LG CC FIXATION STAPLE W/SPIKE 48712429_1 CDM 0278 RC inpatient 596 387.4 ANTHEM HMO ANTHEM HMO 999999999 360.88 578.12 LG CC FIXATION STAPLE W/SPIKE 48712429_1 CDM 0278 RC inpatient 596 387.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 360.88 578.12 LG CC FIXATION STAPLE W/SPIKE 48712429_1 CDM 0278 RC inpatient 596 387.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 402.9 67.6 999999999 360.88 578.12 percent of total billed charges LG SCREW COUNTERSINK 310.99 48712430_1 CDM 0278 RC inpatient 1038 674.7 AETNA AETNA 820.02 79 999999999 628.51 1006.86 percent of total billed charges LG SCREW COUNTERSINK 310.99 48712430_1 CDM 0278 RC inpatient 1038 674.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 674.7 65 999999999 628.51 1006.86 percent of total billed charges LG SCREW COUNTERSINK 310.99 48712430_1 CDM 0278 RC inpatient 1038 674.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1006.86 97 999999999 628.51 1006.86 percent of total billed charges LG SCREW COUNTERSINK 310.99 48712430_1 CDM 0278 RC inpatient 1038 674.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 809.64 78 999999999 628.51 1006.86 percent of total billed charges LG SCREW COUNTERSINK 310.99 48712430_1 CDM 0278 RC inpatient 1038 674.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 716.22 69 999999999 628.51 1006.86 percent of total billed charges LG SCREW COUNTERSINK 310.99 48712430_1 CDM 0278 RC inpatient 1038 674.7 UMR - ALL PLANS UMR - ALL PLANS 726.6 70 999999999 628.51 1006.86 percent of total billed charges LG SCREW COUNTERSINK 310.99 48712430_1 CDM 0278 RC inpatient 1038 674.7 SIHO - ALL PLANS SIHO - ALL PLANS 934.2 90 999999999 628.51 1006.86 percent of total billed charges LG SCREW COUNTERSINK 310.99 48712430_1 CDM 0278 RC inpatient 1038 674.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 628.51 60.55 999999999 628.51 1006.86 percent of total billed charges LG SCREW COUNTERSINK 310.99 48712430_1 CDM 0278 RC inpatient 1038 674.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 628.51 1006.86 LG SCREW COUNTERSINK 310.99 48712430_1 CDM 0278 RC inpatient 1038 674.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 628.51 1006.86 LG SCREW COUNTERSINK 310.99 48712430_1 CDM 0278 RC inpatient 1038 674.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 628.51 1006.86 LG SCREW COUNTERSINK 310.99 48712430_1 CDM 0278 RC inpatient 1038 674.7 ANTHEM HMO ANTHEM HMO 999999999 628.51 1006.86 LG SCREW COUNTERSINK 310.99 48712430_1 CDM 0278 RC inpatient 1038 674.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 628.51 1006.86 LG SCREW COUNTERSINK 310.99 48712430_1 CDM 0278 RC inpatient 1038 674.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 701.69 67.6 999999999 628.51 1006.86 percent of total billed charges ULT12.0-38-25-P-6S-MCL CATH 48712431_1 CDM 0272 RC inpatient 613 398.45 AETNA AETNA 484.27 79 999999999 371.17 594.61 percent of total billed charges ULT12.0-38-25-P-6S-MCL CATH 48712431_1 CDM 0272 RC inpatient 613 398.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 398.45 65 999999999 371.17 594.61 percent of total billed charges ULT12.0-38-25-P-6S-MCL CATH 48712431_1 CDM 0272 RC inpatient 613 398.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 594.61 97 999999999 371.17 594.61 percent of total billed charges ULT12.0-38-25-P-6S-MCL CATH 48712431_1 CDM 0272 RC inpatient 613 398.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 478.14 78 999999999 371.17 594.61 percent of total billed charges ULT12.0-38-25-P-6S-MCL CATH 48712431_1 CDM 0272 RC inpatient 613 398.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 422.97 69 999999999 371.17 594.61 percent of total billed charges ULT12.0-38-25-P-6S-MCL CATH 48712431_1 CDM 0272 RC inpatient 613 398.45 UMR - ALL PLANS UMR - ALL PLANS 429.1 70 999999999 371.17 594.61 percent of total billed charges ULT12.0-38-25-P-6S-MCL CATH 48712431_1 CDM 0272 RC inpatient 613 398.45 SIHO - ALL PLANS SIHO - ALL PLANS 551.7 90 999999999 371.17 594.61 percent of total billed charges ULT12.0-38-25-P-6S-MCL CATH 48712431_1 CDM 0272 RC inpatient 613 398.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 371.17 60.55 999999999 371.17 594.61 percent of total billed charges ULT12.0-38-25-P-6S-MCL CATH 48712431_1 CDM 0272 RC inpatient 613 398.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 371.17 594.61 ULT12.0-38-25-P-6S-MCL CATH 48712431_1 CDM 0272 RC inpatient 613 398.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 371.17 594.61 ULT12.0-38-25-P-6S-MCL CATH 48712431_1 CDM 0272 RC inpatient 613 398.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 371.17 594.61 ULT12.0-38-25-P-6S-MCL CATH 48712431_1 CDM 0272 RC inpatient 613 398.45 ANTHEM HMO ANTHEM HMO 999999999 371.17 594.61 ULT12.0-38-25-P-6S-MCL CATH 48712431_1 CDM 0272 RC inpatient 613 398.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 371.17 594.61 ULT12.0-38-25-P-6S-MCL CATH 48712431_1 CDM 0272 RC inpatient 613 398.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 414.39 67.6 999999999 371.17 594.61 percent of total billed charges "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712432_1 CDM 0278 RC C1778 HCPCS inpatient 11772 7651.8 AETNA AETNA 9299.88 79 999999999 7127.95 11418.84 percent of total billed charges "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712432_1 CDM 0278 RC C1778 HCPCS inpatient 11772 7651.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 7651.8 65 999999999 7127.95 11418.84 percent of total billed charges "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712432_1 CDM 0278 RC C1778 HCPCS inpatient 11772 7651.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11418.84 97 999999999 7127.95 11418.84 percent of total billed charges "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712432_1 CDM 0278 RC C1778 HCPCS inpatient 11772 7651.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 9182.16 78 999999999 7127.95 11418.84 percent of total billed charges "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712432_1 CDM 0278 RC C1778 HCPCS inpatient 11772 7651.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 8122.68 69 999999999 7127.95 11418.84 percent of total billed charges "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712432_1 CDM 0278 RC C1778 HCPCS inpatient 11772 7651.8 UMR - ALL PLANS UMR - ALL PLANS 8240.4 70 999999999 7127.95 11418.84 percent of total billed charges "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712432_1 CDM 0278 RC C1778 HCPCS inpatient 11772 7651.8 SIHO - ALL PLANS SIHO - ALL PLANS 10594.8 90 999999999 7127.95 11418.84 percent of total billed charges "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712432_1 CDM 0278 RC C1778 HCPCS inpatient 11772 7651.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7127.95 60.55 999999999 7127.95 11418.84 percent of total billed charges "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712432_1 CDM 0278 RC C1778 HCPCS inpatient 11772 7651.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7127.95 11418.84 "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712432_1 CDM 0278 RC C1778 HCPCS inpatient 11772 7651.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7127.95 11418.84 "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712432_1 CDM 0278 RC C1778 HCPCS inpatient 11772 7651.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7127.95 11418.84 "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712432_1 CDM 0278 RC C1778 HCPCS inpatient 11772 7651.8 ANTHEM HMO ANTHEM HMO 999999999 7127.95 11418.84 "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712432_1 CDM 0278 RC C1778 HCPCS inpatient 11772 7651.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 7127.95 11418.84 "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712432_1 CDM 0278 RC C1778 HCPCS inpatient 11772 7651.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 7957.87 67.6 999999999 7127.95 11418.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712433_1 CDM 0278 RC C1713 HCPCS inpatient 213 138.45 AETNA AETNA 168.27 79 999999999 128.97 206.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712433_1 CDM 0278 RC C1713 HCPCS inpatient 213 138.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 138.45 65 999999999 128.97 206.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712433_1 CDM 0278 RC C1713 HCPCS inpatient 213 138.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 206.61 97 999999999 128.97 206.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712433_1 CDM 0278 RC C1713 HCPCS inpatient 213 138.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 166.14 78 999999999 128.97 206.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712433_1 CDM 0278 RC C1713 HCPCS inpatient 213 138.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 146.97 69 999999999 128.97 206.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712433_1 CDM 0278 RC C1713 HCPCS inpatient 213 138.45 UMR - ALL PLANS UMR - ALL PLANS 149.1 70 999999999 128.97 206.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712433_1 CDM 0278 RC C1713 HCPCS inpatient 213 138.45 SIHO - ALL PLANS SIHO - ALL PLANS 191.7 90 999999999 128.97 206.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712433_1 CDM 0278 RC C1713 HCPCS inpatient 213 138.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 128.97 60.55 999999999 128.97 206.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712433_1 CDM 0278 RC C1713 HCPCS inpatient 213 138.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 128.97 206.61 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712433_1 CDM 0278 RC C1713 HCPCS inpatient 213 138.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 128.97 206.61 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712433_1 CDM 0278 RC C1713 HCPCS inpatient 213 138.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 128.97 206.61 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712433_1 CDM 0278 RC C1713 HCPCS inpatient 213 138.45 ANTHEM HMO ANTHEM HMO 999999999 128.97 206.61 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712433_1 CDM 0278 RC C1713 HCPCS inpatient 213 138.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 128.97 206.61 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712433_1 CDM 0278 RC C1713 HCPCS inpatient 213 138.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 143.99 67.6 999999999 128.97 206.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712434_1 CDM 0278 RC C1713 HCPCS inpatient 1309 850.85 AETNA AETNA 1034.11 79 999999999 792.6 1269.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712434_1 CDM 0278 RC C1713 HCPCS inpatient 1309 850.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 850.85 65 999999999 792.6 1269.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712434_1 CDM 0278 RC C1713 HCPCS inpatient 1309 850.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1269.73 97 999999999 792.6 1269.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712434_1 CDM 0278 RC C1713 HCPCS inpatient 1309 850.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1021.02 78 999999999 792.6 1269.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712434_1 CDM 0278 RC C1713 HCPCS inpatient 1309 850.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 903.21 69 999999999 792.6 1269.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712434_1 CDM 0278 RC C1713 HCPCS inpatient 1309 850.85 UMR - ALL PLANS UMR - ALL PLANS 916.3 70 999999999 792.6 1269.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712434_1 CDM 0278 RC C1713 HCPCS inpatient 1309 850.85 SIHO - ALL PLANS SIHO - ALL PLANS 1178.1 90 999999999 792.6 1269.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712434_1 CDM 0278 RC C1713 HCPCS inpatient 1309 850.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 792.6 60.55 999999999 792.6 1269.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712434_1 CDM 0278 RC C1713 HCPCS inpatient 1309 850.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 792.6 1269.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712434_1 CDM 0278 RC C1713 HCPCS inpatient 1309 850.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 792.6 1269.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712434_1 CDM 0278 RC C1713 HCPCS inpatient 1309 850.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 792.6 1269.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712434_1 CDM 0278 RC C1713 HCPCS inpatient 1309 850.85 ANTHEM HMO ANTHEM HMO 999999999 792.6 1269.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712434_1 CDM 0278 RC C1713 HCPCS inpatient 1309 850.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 792.6 1269.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712434_1 CDM 0278 RC C1713 HCPCS inpatient 1309 850.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 884.88 67.6 999999999 792.6 1269.73 percent of total billed charges KIT LEAD INTRODUCER 3550-18 48712435_1 CDM 0272 RC inpatient 1739 1130.35 AETNA AETNA 1373.81 79 999999999 1052.96 1686.83 percent of total billed charges KIT LEAD INTRODUCER 3550-18 48712435_1 CDM 0272 RC inpatient 1739 1130.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1130.35 65 999999999 1052.96 1686.83 percent of total billed charges KIT LEAD INTRODUCER 3550-18 48712435_1 CDM 0272 RC inpatient 1739 1130.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1686.83 97 999999999 1052.96 1686.83 percent of total billed charges KIT LEAD INTRODUCER 3550-18 48712435_1 CDM 0272 RC inpatient 1739 1130.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1356.42 78 999999999 1052.96 1686.83 percent of total billed charges KIT LEAD INTRODUCER 3550-18 48712435_1 CDM 0272 RC inpatient 1739 1130.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1199.91 69 999999999 1052.96 1686.83 percent of total billed charges KIT LEAD INTRODUCER 3550-18 48712435_1 CDM 0272 RC inpatient 1739 1130.35 UMR - ALL PLANS UMR - ALL PLANS 1217.3 70 999999999 1052.96 1686.83 percent of total billed charges KIT LEAD INTRODUCER 3550-18 48712435_1 CDM 0272 RC inpatient 1739 1130.35 SIHO - ALL PLANS SIHO - ALL PLANS 1565.1 90 999999999 1052.96 1686.83 percent of total billed charges KIT LEAD INTRODUCER 3550-18 48712435_1 CDM 0272 RC inpatient 1739 1130.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1052.96 60.55 999999999 1052.96 1686.83 percent of total billed charges KIT LEAD INTRODUCER 3550-18 48712435_1 CDM 0272 RC inpatient 1739 1130.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1052.96 1686.83 KIT LEAD INTRODUCER 3550-18 48712435_1 CDM 0272 RC inpatient 1739 1130.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1052.96 1686.83 KIT LEAD INTRODUCER 3550-18 48712435_1 CDM 0272 RC inpatient 1739 1130.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1052.96 1686.83 KIT LEAD INTRODUCER 3550-18 48712435_1 CDM 0272 RC inpatient 1739 1130.35 ANTHEM HMO ANTHEM HMO 999999999 1052.96 1686.83 KIT LEAD INTRODUCER 3550-18 48712435_1 CDM 0272 RC inpatient 1739 1130.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1052.96 1686.83 KIT LEAD INTRODUCER 3550-18 48712435_1 CDM 0272 RC inpatient 1739 1130.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1175.56 67.6 999999999 1052.96 1686.83 percent of total billed charges WIRE GUIDE STR W/MOVABLE CORE 620-130 48712436_1 CDM 0272 RC inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges WIRE GUIDE STR W/MOVABLE CORE 620-130 48712436_1 CDM 0272 RC inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges WIRE GUIDE STR W/MOVABLE CORE 620-130 48712436_1 CDM 0272 RC inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges WIRE GUIDE STR W/MOVABLE CORE 620-130 48712436_1 CDM 0272 RC inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges WIRE GUIDE STR W/MOVABLE CORE 620-130 48712436_1 CDM 0272 RC inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges WIRE GUIDE STR W/MOVABLE CORE 620-130 48712436_1 CDM 0272 RC inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges WIRE GUIDE STR W/MOVABLE CORE 620-130 48712436_1 CDM 0272 RC inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges WIRE GUIDE STR W/MOVABLE CORE 620-130 48712436_1 CDM 0272 RC inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges WIRE GUIDE STR W/MOVABLE CORE 620-130 48712436_1 CDM 0272 RC inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 WIRE GUIDE STR W/MOVABLE CORE 620-130 48712436_1 CDM 0272 RC inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 WIRE GUIDE STR W/MOVABLE CORE 620-130 48712436_1 CDM 0272 RC inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 WIRE GUIDE STR W/MOVABLE CORE 620-130 48712436_1 CDM 0272 RC inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 WIRE GUIDE STR W/MOVABLE CORE 620-130 48712436_1 CDM 0272 RC inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 WIRE GUIDE STR W/MOVABLE CORE 620-130 48712436_1 CDM 0272 RC inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges ****BLANKET PER MEGAN ROTATABLE OVAL 20MM SNARE 6183 48712437_1 CDM 0272 RC inpatient 125 81.25 AETNA AETNA 98.75 79 999999999 75.69 121.25 percent of total billed charges ****BLANKET PER MEGAN ROTATABLE OVAL 20MM SNARE 6183 48712437_1 CDM 0272 RC inpatient 125 81.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.25 65 999999999 75.69 121.25 percent of total billed charges ****BLANKET PER MEGAN ROTATABLE OVAL 20MM SNARE 6183 48712437_1 CDM 0272 RC inpatient 125 81.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 121.25 97 999999999 75.69 121.25 percent of total billed charges ****BLANKET PER MEGAN ROTATABLE OVAL 20MM SNARE 6183 48712437_1 CDM 0272 RC inpatient 125 81.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.5 78 999999999 75.69 121.25 percent of total billed charges ****BLANKET PER MEGAN ROTATABLE OVAL 20MM SNARE 6183 48712437_1 CDM 0272 RC inpatient 125 81.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.25 69 999999999 75.69 121.25 percent of total billed charges ****BLANKET PER MEGAN ROTATABLE OVAL 20MM SNARE 6183 48712437_1 CDM 0272 RC inpatient 125 81.25 UMR - ALL PLANS UMR - ALL PLANS 87.5 70 999999999 75.69 121.25 percent of total billed charges ****BLANKET PER MEGAN ROTATABLE OVAL 20MM SNARE 6183 48712437_1 CDM 0272 RC inpatient 125 81.25 SIHO - ALL PLANS SIHO - ALL PLANS 112.5 90 999999999 75.69 121.25 percent of total billed charges ****BLANKET PER MEGAN ROTATABLE OVAL 20MM SNARE 6183 48712437_1 CDM 0272 RC inpatient 125 81.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.69 60.55 999999999 75.69 121.25 percent of total billed charges ****BLANKET PER MEGAN ROTATABLE OVAL 20MM SNARE 6183 48712437_1 CDM 0272 RC inpatient 125 81.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.69 121.25 ****BLANKET PER MEGAN ROTATABLE OVAL 20MM SNARE 6183 48712437_1 CDM 0272 RC inpatient 125 81.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.69 121.25 ****BLANKET PER MEGAN ROTATABLE OVAL 20MM SNARE 6183 48712437_1 CDM 0272 RC inpatient 125 81.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.69 121.25 ****BLANKET PER MEGAN ROTATABLE OVAL 20MM SNARE 6183 48712437_1 CDM 0272 RC inpatient 125 81.25 ANTHEM HMO ANTHEM HMO 999999999 75.69 121.25 ****BLANKET PER MEGAN ROTATABLE OVAL 20MM SNARE 6183 48712437_1 CDM 0272 RC inpatient 125 81.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.69 121.25 ****BLANKET PER MEGAN ROTATABLE OVAL 20MM SNARE 6183 48712437_1 CDM 0272 RC inpatient 125 81.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.5 67.6 999999999 75.69 121.25 percent of total billed charges TUNNELER 402 48712439_1 CDM 0272 RC inpatient 2763 1795.95 AETNA AETNA 2182.77 79 999999999 1673 2680.11 percent of total billed charges TUNNELER 402 48712439_1 CDM 0272 RC inpatient 2763 1795.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1795.95 65 999999999 1673 2680.11 percent of total billed charges TUNNELER 402 48712439_1 CDM 0272 RC inpatient 2763 1795.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2680.11 97 999999999 1673 2680.11 percent of total billed charges TUNNELER 402 48712439_1 CDM 0272 RC inpatient 2763 1795.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 2155.14 78 999999999 1673 2680.11 percent of total billed charges TUNNELER 402 48712439_1 CDM 0272 RC inpatient 2763 1795.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1906.47 69 999999999 1673 2680.11 percent of total billed charges TUNNELER 402 48712439_1 CDM 0272 RC inpatient 2763 1795.95 UMR - ALL PLANS UMR - ALL PLANS 1934.1 70 999999999 1673 2680.11 percent of total billed charges TUNNELER 402 48712439_1 CDM 0272 RC inpatient 2763 1795.95 SIHO - ALL PLANS SIHO - ALL PLANS 2486.7 90 999999999 1673 2680.11 percent of total billed charges TUNNELER 402 48712439_1 CDM 0272 RC inpatient 2763 1795.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1673 60.55 999999999 1673 2680.11 percent of total billed charges TUNNELER 402 48712439_1 CDM 0272 RC inpatient 2763 1795.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1673 2680.11 TUNNELER 402 48712439_1 CDM 0272 RC inpatient 2763 1795.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1673 2680.11 TUNNELER 402 48712439_1 CDM 0272 RC inpatient 2763 1795.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1673 2680.11 TUNNELER 402 48712439_1 CDM 0272 RC inpatient 2763 1795.95 ANTHEM HMO ANTHEM HMO 999999999 1673 2680.11 TUNNELER 402 48712439_1 CDM 0272 RC inpatient 2763 1795.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1673 2680.11 TUNNELER 402 48712439_1 CDM 0272 RC inpatient 2763 1795.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1867.79 67.6 999999999 1673 2680.11 percent of total billed charges "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712440_1 CDM 0278 RC C1778 HCPCS inpatient 19393 12605.45 AETNA AETNA 15320.47 79 999999999 11742.46 18811.21 percent of total billed charges "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712440_1 CDM 0278 RC C1778 HCPCS inpatient 19393 12605.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 12605.45 65 999999999 11742.46 18811.21 percent of total billed charges "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712440_1 CDM 0278 RC C1778 HCPCS inpatient 19393 12605.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 18811.21 97 999999999 11742.46 18811.21 percent of total billed charges "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712440_1 CDM 0278 RC C1778 HCPCS inpatient 19393 12605.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 15126.54 78 999999999 11742.46 18811.21 percent of total billed charges "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712440_1 CDM 0278 RC C1778 HCPCS inpatient 19393 12605.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 13381.17 69 999999999 11742.46 18811.21 percent of total billed charges "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712440_1 CDM 0278 RC C1778 HCPCS inpatient 19393 12605.45 UMR - ALL PLANS UMR - ALL PLANS 13575.1 70 999999999 11742.46 18811.21 percent of total billed charges "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712440_1 CDM 0278 RC C1778 HCPCS inpatient 19393 12605.45 SIHO - ALL PLANS SIHO - ALL PLANS 17453.7 90 999999999 11742.46 18811.21 percent of total billed charges "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712440_1 CDM 0278 RC C1778 HCPCS inpatient 19393 12605.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11742.46 60.55 999999999 11742.46 18811.21 percent of total billed charges "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712440_1 CDM 0278 RC C1778 HCPCS inpatient 19393 12605.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11742.46 18811.21 "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712440_1 CDM 0278 RC C1778 HCPCS inpatient 19393 12605.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11742.46 18811.21 "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712440_1 CDM 0278 RC C1778 HCPCS inpatient 19393 12605.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11742.46 18811.21 "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712440_1 CDM 0278 RC C1778 HCPCS inpatient 19393 12605.45 ANTHEM HMO ANTHEM HMO 999999999 11742.46 18811.21 "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712440_1 CDM 0278 RC C1778 HCPCS inpatient 19393 12605.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 11742.46 18811.21 "LEAD, NEUROSTIMULATOR (IMPLANTABLE)" 48712440_1 CDM 0278 RC C1778 HCPCS inpatient 19393 12605.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 13109.67 67.6 999999999 11742.46 18811.21 percent of total billed charges "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712441_1 CDM 0278 RC C1767 HCPCS inpatient 60032 39020.8 AETNA AETNA 47425.28 79 999999999 36349.38 58231.04 percent of total billed charges "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712441_1 CDM 0278 RC C1767 HCPCS inpatient 60032 39020.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 39020.8 65 999999999 36349.38 58231.04 percent of total billed charges "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712441_1 CDM 0278 RC C1767 HCPCS inpatient 60032 39020.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58231.04 97 999999999 36349.38 58231.04 percent of total billed charges "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712441_1 CDM 0278 RC C1767 HCPCS inpatient 60032 39020.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 46824.96 78 999999999 36349.38 58231.04 percent of total billed charges "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712441_1 CDM 0278 RC C1767 HCPCS inpatient 60032 39020.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 41422.08 69 999999999 36349.38 58231.04 percent of total billed charges "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712441_1 CDM 0278 RC C1767 HCPCS inpatient 60032 39020.8 UMR - ALL PLANS UMR - ALL PLANS 42022.4 70 999999999 36349.38 58231.04 percent of total billed charges "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712441_1 CDM 0278 RC C1767 HCPCS inpatient 60032 39020.8 SIHO - ALL PLANS SIHO - ALL PLANS 54028.8 90 999999999 36349.38 58231.04 percent of total billed charges "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712441_1 CDM 0278 RC C1767 HCPCS inpatient 60032 39020.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36349.38 60.55 999999999 36349.38 58231.04 percent of total billed charges "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712441_1 CDM 0278 RC C1767 HCPCS inpatient 60032 39020.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36349.38 58231.04 "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712441_1 CDM 0278 RC C1767 HCPCS inpatient 60032 39020.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36349.38 58231.04 "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712441_1 CDM 0278 RC C1767 HCPCS inpatient 60032 39020.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36349.38 58231.04 "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712441_1 CDM 0278 RC C1767 HCPCS inpatient 60032 39020.8 ANTHEM HMO ANTHEM HMO 999999999 36349.38 58231.04 "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712441_1 CDM 0278 RC C1767 HCPCS inpatient 60032 39020.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 36349.38 58231.04 "GENERATOR, NEUROSTIMULATOR (IMPLANTABLE), NON-RECHARGEABLE" 48712441_1 CDM 0278 RC C1767 HCPCS inpatient 60032 39020.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 40581.63 67.6 999999999 36349.38 58231.04 percent of total billed charges PLEUR-EV CHEST DRAIN 110008LF 48712442_1 CDM 0272 RC inpatient 283 183.95 AETNA AETNA 223.57 79 999999999 171.36 274.51 percent of total billed charges PLEUR-EV CHEST DRAIN 110008LF 48712442_1 CDM 0272 RC inpatient 283 183.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 183.95 65 999999999 171.36 274.51 percent of total billed charges PLEUR-EV CHEST DRAIN 110008LF 48712442_1 CDM 0272 RC inpatient 283 183.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 274.51 97 999999999 171.36 274.51 percent of total billed charges PLEUR-EV CHEST DRAIN 110008LF 48712442_1 CDM 0272 RC inpatient 283 183.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 220.74 78 999999999 171.36 274.51 percent of total billed charges PLEUR-EV CHEST DRAIN 110008LF 48712442_1 CDM 0272 RC inpatient 283 183.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 195.27 69 999999999 171.36 274.51 percent of total billed charges PLEUR-EV CHEST DRAIN 110008LF 48712442_1 CDM 0272 RC inpatient 283 183.95 UMR - ALL PLANS UMR - ALL PLANS 198.1 70 999999999 171.36 274.51 percent of total billed charges PLEUR-EV CHEST DRAIN 110008LF 48712442_1 CDM 0272 RC inpatient 283 183.95 SIHO - ALL PLANS SIHO - ALL PLANS 254.7 90 999999999 171.36 274.51 percent of total billed charges PLEUR-EV CHEST DRAIN 110008LF 48712442_1 CDM 0272 RC inpatient 283 183.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 171.36 60.55 999999999 171.36 274.51 percent of total billed charges PLEUR-EV CHEST DRAIN 110008LF 48712442_1 CDM 0272 RC inpatient 283 183.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 171.36 274.51 PLEUR-EV CHEST DRAIN 110008LF 48712442_1 CDM 0272 RC inpatient 283 183.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 171.36 274.51 PLEUR-EV CHEST DRAIN 110008LF 48712442_1 CDM 0272 RC inpatient 283 183.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 171.36 274.51 PLEUR-EV CHEST DRAIN 110008LF 48712442_1 CDM 0272 RC inpatient 283 183.95 ANTHEM HMO ANTHEM HMO 999999999 171.36 274.51 PLEUR-EV CHEST DRAIN 110008LF 48712442_1 CDM 0272 RC inpatient 283 183.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 171.36 274.51 PLEUR-EV CHEST DRAIN 110008LF 48712442_1 CDM 0272 RC inpatient 283 183.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 191.31 67.6 999999999 171.36 274.51 percent of total billed charges CHEST DRAIN VALVE WITHOUT TUBING 48712443_1 CDM 0272 RC inpatient 182 118.3 AETNA AETNA 143.78 79 999999999 110.2 176.54 percent of total billed charges CHEST DRAIN VALVE WITHOUT TUBING 48712443_1 CDM 0272 RC inpatient 182 118.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.3 65 999999999 110.2 176.54 percent of total billed charges CHEST DRAIN VALVE WITHOUT TUBING 48712443_1 CDM 0272 RC inpatient 182 118.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 176.54 97 999999999 110.2 176.54 percent of total billed charges CHEST DRAIN VALVE WITHOUT TUBING 48712443_1 CDM 0272 RC inpatient 182 118.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.96 78 999999999 110.2 176.54 percent of total billed charges CHEST DRAIN VALVE WITHOUT TUBING 48712443_1 CDM 0272 RC inpatient 182 118.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 125.58 69 999999999 110.2 176.54 percent of total billed charges CHEST DRAIN VALVE WITHOUT TUBING 48712443_1 CDM 0272 RC inpatient 182 118.3 UMR - ALL PLANS UMR - ALL PLANS 127.4 70 999999999 110.2 176.54 percent of total billed charges CHEST DRAIN VALVE WITHOUT TUBING 48712443_1 CDM 0272 RC inpatient 182 118.3 SIHO - ALL PLANS SIHO - ALL PLANS 163.8 90 999999999 110.2 176.54 percent of total billed charges CHEST DRAIN VALVE WITHOUT TUBING 48712443_1 CDM 0272 RC inpatient 182 118.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.2 60.55 999999999 110.2 176.54 percent of total billed charges CHEST DRAIN VALVE WITHOUT TUBING 48712443_1 CDM 0272 RC inpatient 182 118.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.2 176.54 CHEST DRAIN VALVE WITHOUT TUBING 48712443_1 CDM 0272 RC inpatient 182 118.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.2 176.54 CHEST DRAIN VALVE WITHOUT TUBING 48712443_1 CDM 0272 RC inpatient 182 118.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.2 176.54 CHEST DRAIN VALVE WITHOUT TUBING 48712443_1 CDM 0272 RC inpatient 182 118.3 ANTHEM HMO ANTHEM HMO 999999999 110.2 176.54 CHEST DRAIN VALVE WITHOUT TUBING 48712443_1 CDM 0272 RC inpatient 182 118.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.2 176.54 CHEST DRAIN VALVE WITHOUT TUBING 48712443_1 CDM 0272 RC inpatient 182 118.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.03 67.6 999999999 110.2 176.54 percent of total billed charges QUICK ANCHOR 5.0X15M AR1920SNF 48712445_1 CDM 0278 RC inpatient 849 551.85 AETNA AETNA 670.71 79 999999999 514.07 823.53 percent of total billed charges QUICK ANCHOR 5.0X15M AR1920SNF 48712445_1 CDM 0278 RC inpatient 849 551.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 551.85 65 999999999 514.07 823.53 percent of total billed charges QUICK ANCHOR 5.0X15M AR1920SNF 48712445_1 CDM 0278 RC inpatient 849 551.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 823.53 97 999999999 514.07 823.53 percent of total billed charges QUICK ANCHOR 5.0X15M AR1920SNF 48712445_1 CDM 0278 RC inpatient 849 551.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 662.22 78 999999999 514.07 823.53 percent of total billed charges QUICK ANCHOR 5.0X15M AR1920SNF 48712445_1 CDM 0278 RC inpatient 849 551.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 585.81 69 999999999 514.07 823.53 percent of total billed charges QUICK ANCHOR 5.0X15M AR1920SNF 48712445_1 CDM 0278 RC inpatient 849 551.85 UMR - ALL PLANS UMR - ALL PLANS 594.3 70 999999999 514.07 823.53 percent of total billed charges QUICK ANCHOR 5.0X15M AR1920SNF 48712445_1 CDM 0278 RC inpatient 849 551.85 SIHO - ALL PLANS SIHO - ALL PLANS 764.1 90 999999999 514.07 823.53 percent of total billed charges QUICK ANCHOR 5.0X15M AR1920SNF 48712445_1 CDM 0278 RC inpatient 849 551.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 514.07 60.55 999999999 514.07 823.53 percent of total billed charges QUICK ANCHOR 5.0X15M AR1920SNF 48712445_1 CDM 0278 RC inpatient 849 551.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 514.07 823.53 QUICK ANCHOR 5.0X15M AR1920SNF 48712445_1 CDM 0278 RC inpatient 849 551.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 514.07 823.53 QUICK ANCHOR 5.0X15M AR1920SNF 48712445_1 CDM 0278 RC inpatient 849 551.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 514.07 823.53 QUICK ANCHOR 5.0X15M AR1920SNF 48712445_1 CDM 0278 RC inpatient 849 551.85 ANTHEM HMO ANTHEM HMO 999999999 514.07 823.53 QUICK ANCHOR 5.0X15M AR1920SNF 48712445_1 CDM 0278 RC inpatient 849 551.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 514.07 823.53 QUICK ANCHOR 5.0X15M AR1920SNF 48712445_1 CDM 0278 RC inpatient 849 551.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 573.92 67.6 999999999 514.07 823.53 percent of total billed charges QUICK ANCHOR 3.5 X 10 AR1915FT 48712446_1 CDM 0272 RC inpatient 1668 1084.2 AETNA AETNA 1317.72 79 999999999 1009.97 1617.96 percent of total billed charges QUICK ANCHOR 3.5 X 10 AR1915FT 48712446_1 CDM 0272 RC inpatient 1668 1084.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1084.2 65 999999999 1009.97 1617.96 percent of total billed charges QUICK ANCHOR 3.5 X 10 AR1915FT 48712446_1 CDM 0272 RC inpatient 1668 1084.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1617.96 97 999999999 1009.97 1617.96 percent of total billed charges QUICK ANCHOR 3.5 X 10 AR1915FT 48712446_1 CDM 0272 RC inpatient 1668 1084.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1301.04 78 999999999 1009.97 1617.96 percent of total billed charges QUICK ANCHOR 3.5 X 10 AR1915FT 48712446_1 CDM 0272 RC inpatient 1668 1084.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1150.92 69 999999999 1009.97 1617.96 percent of total billed charges QUICK ANCHOR 3.5 X 10 AR1915FT 48712446_1 CDM 0272 RC inpatient 1668 1084.2 UMR - ALL PLANS UMR - ALL PLANS 1167.6 70 999999999 1009.97 1617.96 percent of total billed charges QUICK ANCHOR 3.5 X 10 AR1915FT 48712446_1 CDM 0272 RC inpatient 1668 1084.2 SIHO - ALL PLANS SIHO - ALL PLANS 1501.2 90 999999999 1009.97 1617.96 percent of total billed charges QUICK ANCHOR 3.5 X 10 AR1915FT 48712446_1 CDM 0272 RC inpatient 1668 1084.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1009.97 60.55 999999999 1009.97 1617.96 percent of total billed charges QUICK ANCHOR 3.5 X 10 AR1915FT 48712446_1 CDM 0272 RC inpatient 1668 1084.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1009.97 1617.96 QUICK ANCHOR 3.5 X 10 AR1915FT 48712446_1 CDM 0272 RC inpatient 1668 1084.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1009.97 1617.96 QUICK ANCHOR 3.5 X 10 AR1915FT 48712446_1 CDM 0272 RC inpatient 1668 1084.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1009.97 1617.96 QUICK ANCHOR 3.5 X 10 AR1915FT 48712446_1 CDM 0272 RC inpatient 1668 1084.2 ANTHEM HMO ANTHEM HMO 999999999 1009.97 1617.96 QUICK ANCHOR 3.5 X 10 AR1915FT 48712446_1 CDM 0272 RC inpatient 1668 1084.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1009.97 1617.96 QUICK ANCHOR 3.5 X 10 AR1915FT 48712446_1 CDM 0272 RC inpatient 1668 1084.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1127.57 67.6 999999999 1009.97 1617.96 percent of total billed charges CELON BIPOLAR ELECTRODE 48712447_1 CDM 0272 RC inpatient 791 514.15 AETNA AETNA 624.89 79 999999999 478.95 767.27 percent of total billed charges CELON BIPOLAR ELECTRODE 48712447_1 CDM 0272 RC inpatient 791 514.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 514.15 65 999999999 478.95 767.27 percent of total billed charges CELON BIPOLAR ELECTRODE 48712447_1 CDM 0272 RC inpatient 791 514.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 767.27 97 999999999 478.95 767.27 percent of total billed charges CELON BIPOLAR ELECTRODE 48712447_1 CDM 0272 RC inpatient 791 514.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 616.98 78 999999999 478.95 767.27 percent of total billed charges CELON BIPOLAR ELECTRODE 48712447_1 CDM 0272 RC inpatient 791 514.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 545.79 69 999999999 478.95 767.27 percent of total billed charges CELON BIPOLAR ELECTRODE 48712447_1 CDM 0272 RC inpatient 791 514.15 UMR - ALL PLANS UMR - ALL PLANS 553.7 70 999999999 478.95 767.27 percent of total billed charges CELON BIPOLAR ELECTRODE 48712447_1 CDM 0272 RC inpatient 791 514.15 SIHO - ALL PLANS SIHO - ALL PLANS 711.9 90 999999999 478.95 767.27 percent of total billed charges CELON BIPOLAR ELECTRODE 48712447_1 CDM 0272 RC inpatient 791 514.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 478.95 60.55 999999999 478.95 767.27 percent of total billed charges CELON BIPOLAR ELECTRODE 48712447_1 CDM 0272 RC inpatient 791 514.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 478.95 767.27 CELON BIPOLAR ELECTRODE 48712447_1 CDM 0272 RC inpatient 791 514.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 478.95 767.27 CELON BIPOLAR ELECTRODE 48712447_1 CDM 0272 RC inpatient 791 514.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 478.95 767.27 CELON BIPOLAR ELECTRODE 48712447_1 CDM 0272 RC inpatient 791 514.15 ANTHEM HMO ANTHEM HMO 999999999 478.95 767.27 CELON BIPOLAR ELECTRODE 48712447_1 CDM 0272 RC inpatient 791 514.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 478.95 767.27 CELON BIPOLAR ELECTRODE 48712447_1 CDM 0272 RC inpatient 791 514.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 534.72 67.6 999999999 478.95 767.27 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48712448_1 CDM 0636 RC Q9967 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48712448_1 CDM 0636 RC Q9967 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48712448_1 CDM 0636 RC Q9967 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48712448_1 CDM 0636 RC Q9967 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48712448_1 CDM 0636 RC Q9967 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48712448_1 CDM 0636 RC Q9967 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48712448_1 CDM 0636 RC Q9967 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48712448_1 CDM 0636 RC Q9967 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48712448_1 CDM 0636 RC Q9967 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48712448_1 CDM 0636 RC Q9967 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48712448_1 CDM 0636 RC Q9967 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48712448_1 CDM 0636 RC Q9967 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48712448_1 CDM 0636 RC Q9967 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 48712448_1 CDM 0636 RC Q9967 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges POSEY PEEK-A-BOO MITTENS #2811 48712451_1 CDM 0271 RC inpatient 125 81.25 AETNA AETNA 98.75 79 999999999 75.69 121.25 percent of total billed charges POSEY PEEK-A-BOO MITTENS #2811 48712451_1 CDM 0271 RC inpatient 125 81.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.25 65 999999999 75.69 121.25 percent of total billed charges POSEY PEEK-A-BOO MITTENS #2811 48712451_1 CDM 0271 RC inpatient 125 81.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 121.25 97 999999999 75.69 121.25 percent of total billed charges POSEY PEEK-A-BOO MITTENS #2811 48712451_1 CDM 0271 RC inpatient 125 81.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.5 78 999999999 75.69 121.25 percent of total billed charges POSEY PEEK-A-BOO MITTENS #2811 48712451_1 CDM 0271 RC inpatient 125 81.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.25 69 999999999 75.69 121.25 percent of total billed charges POSEY PEEK-A-BOO MITTENS #2811 48712451_1 CDM 0271 RC inpatient 125 81.25 UMR - ALL PLANS UMR - ALL PLANS 87.5 70 999999999 75.69 121.25 percent of total billed charges POSEY PEEK-A-BOO MITTENS #2811 48712451_1 CDM 0271 RC inpatient 125 81.25 SIHO - ALL PLANS SIHO - ALL PLANS 112.5 90 999999999 75.69 121.25 percent of total billed charges POSEY PEEK-A-BOO MITTENS #2811 48712451_1 CDM 0271 RC inpatient 125 81.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.69 60.55 999999999 75.69 121.25 percent of total billed charges POSEY PEEK-A-BOO MITTENS #2811 48712451_1 CDM 0271 RC inpatient 125 81.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.69 121.25 POSEY PEEK-A-BOO MITTENS #2811 48712451_1 CDM 0271 RC inpatient 125 81.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.69 121.25 POSEY PEEK-A-BOO MITTENS #2811 48712451_1 CDM 0271 RC inpatient 125 81.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.69 121.25 POSEY PEEK-A-BOO MITTENS #2811 48712451_1 CDM 0271 RC inpatient 125 81.25 ANTHEM HMO ANTHEM HMO 999999999 75.69 121.25 POSEY PEEK-A-BOO MITTENS #2811 48712451_1 CDM 0271 RC inpatient 125 81.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.69 121.25 POSEY PEEK-A-BOO MITTENS #2811 48712451_1 CDM 0271 RC inpatient 125 81.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.5 67.6 999999999 75.69 121.25 percent of total billed charges RESUSCITATOR INFANT VN3100MB 48712453_1 CDM 0271 RC inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges RESUSCITATOR INFANT VN3100MB 48712453_1 CDM 0271 RC inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges RESUSCITATOR INFANT VN3100MB 48712453_1 CDM 0271 RC inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges RESUSCITATOR INFANT VN3100MB 48712453_1 CDM 0271 RC inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges RESUSCITATOR INFANT VN3100MB 48712453_1 CDM 0271 RC inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges RESUSCITATOR INFANT VN3100MB 48712453_1 CDM 0271 RC inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges RESUSCITATOR INFANT VN3100MB 48712453_1 CDM 0271 RC inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges RESUSCITATOR INFANT VN3100MB 48712453_1 CDM 0271 RC inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges RESUSCITATOR INFANT VN3100MB 48712453_1 CDM 0271 RC inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 RESUSCITATOR INFANT VN3100MB 48712453_1 CDM 0271 RC inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 RESUSCITATOR INFANT VN3100MB 48712453_1 CDM 0271 RC inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 RESUSCITATOR INFANT VN3100MB 48712453_1 CDM 0271 RC inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 RESUSCITATOR INFANT VN3100MB 48712453_1 CDM 0271 RC inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 RESUSCITATOR INFANT VN3100MB 48712453_1 CDM 0271 RC inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges "RIB BELT ELASTIC 6""" 48712454_1 CDM 0270 RC inpatient 41 26.65 AETNA AETNA 32.39 79 999999999 24.83 39.77 percent of total billed charges "RIB BELT ELASTIC 6""" 48712454_1 CDM 0270 RC inpatient 41 26.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.65 65 999999999 24.83 39.77 percent of total billed charges "RIB BELT ELASTIC 6""" 48712454_1 CDM 0270 RC inpatient 41 26.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39.77 97 999999999 24.83 39.77 percent of total billed charges "RIB BELT ELASTIC 6""" 48712454_1 CDM 0270 RC inpatient 41 26.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.98 78 999999999 24.83 39.77 percent of total billed charges "RIB BELT ELASTIC 6""" 48712454_1 CDM 0270 RC inpatient 41 26.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.29 69 999999999 24.83 39.77 percent of total billed charges "RIB BELT ELASTIC 6""" 48712454_1 CDM 0270 RC inpatient 41 26.65 UMR - ALL PLANS UMR - ALL PLANS 28.7 70 999999999 24.83 39.77 percent of total billed charges "RIB BELT ELASTIC 6""" 48712454_1 CDM 0270 RC inpatient 41 26.65 SIHO - ALL PLANS SIHO - ALL PLANS 36.9 90 999999999 24.83 39.77 percent of total billed charges "RIB BELT ELASTIC 6""" 48712454_1 CDM 0270 RC inpatient 41 26.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.83 60.55 999999999 24.83 39.77 percent of total billed charges "RIB BELT ELASTIC 6""" 48712454_1 CDM 0270 RC inpatient 41 26.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.83 39.77 "RIB BELT ELASTIC 6""" 48712454_1 CDM 0270 RC inpatient 41 26.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.83 39.77 "RIB BELT ELASTIC 6""" 48712454_1 CDM 0270 RC inpatient 41 26.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.83 39.77 "RIB BELT ELASTIC 6""" 48712454_1 CDM 0270 RC inpatient 41 26.65 ANTHEM HMO ANTHEM HMO 999999999 24.83 39.77 "RIB BELT ELASTIC 6""" 48712454_1 CDM 0270 RC inpatient 41 26.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.83 39.77 "RIB BELT ELASTIC 6""" 48712454_1 CDM 0270 RC inpatient 41 26.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.72 67.6 999999999 24.83 39.77 percent of total billed charges SCISSOR RENEW II ENDOCUT 3142 48712459_1 CDM 0272 RC inpatient 161 104.65 AETNA AETNA 127.19 79 999999999 97.49 156.17 percent of total billed charges SCISSOR RENEW II ENDOCUT 3142 48712459_1 CDM 0272 RC inpatient 161 104.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 104.65 65 999999999 97.49 156.17 percent of total billed charges SCISSOR RENEW II ENDOCUT 3142 48712459_1 CDM 0272 RC inpatient 161 104.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 156.17 97 999999999 97.49 156.17 percent of total billed charges SCISSOR RENEW II ENDOCUT 3142 48712459_1 CDM 0272 RC inpatient 161 104.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 125.58 78 999999999 97.49 156.17 percent of total billed charges SCISSOR RENEW II ENDOCUT 3142 48712459_1 CDM 0272 RC inpatient 161 104.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 111.09 69 999999999 97.49 156.17 percent of total billed charges SCISSOR RENEW II ENDOCUT 3142 48712459_1 CDM 0272 RC inpatient 161 104.65 UMR - ALL PLANS UMR - ALL PLANS 112.7 70 999999999 97.49 156.17 percent of total billed charges SCISSOR RENEW II ENDOCUT 3142 48712459_1 CDM 0272 RC inpatient 161 104.65 SIHO - ALL PLANS SIHO - ALL PLANS 144.9 90 999999999 97.49 156.17 percent of total billed charges SCISSOR RENEW II ENDOCUT 3142 48712459_1 CDM 0272 RC inpatient 161 104.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 97.49 60.55 999999999 97.49 156.17 percent of total billed charges SCISSOR RENEW II ENDOCUT 3142 48712459_1 CDM 0272 RC inpatient 161 104.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 97.49 156.17 SCISSOR RENEW II ENDOCUT 3142 48712459_1 CDM 0272 RC inpatient 161 104.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 97.49 156.17 SCISSOR RENEW II ENDOCUT 3142 48712459_1 CDM 0272 RC inpatient 161 104.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 97.49 156.17 SCISSOR RENEW II ENDOCUT 3142 48712459_1 CDM 0272 RC inpatient 161 104.65 ANTHEM HMO ANTHEM HMO 999999999 97.49 156.17 SCISSOR RENEW II ENDOCUT 3142 48712459_1 CDM 0272 RC inpatient 161 104.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 97.49 156.17 SCISSOR RENEW II ENDOCUT 3142 48712459_1 CDM 0272 RC inpatient 161 104.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.84 67.6 999999999 97.49 156.17 percent of total billed charges 6.5 CANCELL 32MM/75MM 217.075 48712460_1 CDM 0278 RC inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32MM/75MM 217.075 48712460_1 CDM 0278 RC inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32MM/75MM 217.075 48712460_1 CDM 0278 RC inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32MM/75MM 217.075 48712460_1 CDM 0278 RC inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32MM/75MM 217.075 48712460_1 CDM 0278 RC inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32MM/75MM 217.075 48712460_1 CDM 0278 RC inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32MM/75MM 217.075 48712460_1 CDM 0278 RC inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32MM/75MM 217.075 48712460_1 CDM 0278 RC inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32MM/75MM 217.075 48712460_1 CDM 0278 RC inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 6.5 CANCELL 32MM/75MM 217.075 48712460_1 CDM 0278 RC inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 6.5 CANCELL 32MM/75MM 217.075 48712460_1 CDM 0278 RC inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 6.5 CANCELL 32MM/75MM 217.075 48712460_1 CDM 0278 RC inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 6.5 CANCELL 32MM/75MM 217.075 48712460_1 CDM 0278 RC inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 6.5 CANCELL 32MM/75MM 217.075 48712460_1 CDM 0278 RC inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32/50MM 217.050 48712461_1 CDM 0278 RC inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges 6.5 CANCELL 32/50MM 217.050 48712461_1 CDM 0278 RC inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges 6.5 CANCELL 32/50MM 217.050 48712461_1 CDM 0278 RC inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges 6.5 CANCELL 32/50MM 217.050 48712461_1 CDM 0278 RC inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges 6.5 CANCELL 32/50MM 217.050 48712461_1 CDM 0278 RC inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges 6.5 CANCELL 32/50MM 217.050 48712461_1 CDM 0278 RC inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges 6.5 CANCELL 32/50MM 217.050 48712461_1 CDM 0278 RC inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges 6.5 CANCELL 32/50MM 217.050 48712461_1 CDM 0278 RC inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges 6.5 CANCELL 32/50MM 217.050 48712461_1 CDM 0278 RC inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 6.5 CANCELL 32/50MM 217.050 48712461_1 CDM 0278 RC inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 6.5 CANCELL 32/50MM 217.050 48712461_1 CDM 0278 RC inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 6.5 CANCELL 32/50MM 217.050 48712461_1 CDM 0278 RC inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 6.5 CANCELL 32/50MM 217.050 48712461_1 CDM 0278 RC inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 6.5 CANCELL 32/50MM 217.050 48712461_1 CDM 0278 RC inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges 6.5 CANCELL 32/60MM 217.060 48712462_1 CDM 0278 RC inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32/60MM 217.060 48712462_1 CDM 0278 RC inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32/60MM 217.060 48712462_1 CDM 0278 RC inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32/60MM 217.060 48712462_1 CDM 0278 RC inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32/60MM 217.060 48712462_1 CDM 0278 RC inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32/60MM 217.060 48712462_1 CDM 0278 RC inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32/60MM 217.060 48712462_1 CDM 0278 RC inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32/60MM 217.060 48712462_1 CDM 0278 RC inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32/60MM 217.060 48712462_1 CDM 0278 RC inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 6.5 CANCELL 32/60MM 217.060 48712462_1 CDM 0278 RC inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 6.5 CANCELL 32/60MM 217.060 48712462_1 CDM 0278 RC inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 6.5 CANCELL 32/60MM 217.060 48712462_1 CDM 0278 RC inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 6.5 CANCELL 32/60MM 217.060 48712462_1 CDM 0278 RC inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 6.5 CANCELL 32/60MM 217.060 48712462_1 CDM 0278 RC inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32/65M 217.065 48712463_1 CDM 0278 RC inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32/65M 217.065 48712463_1 CDM 0278 RC inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32/65M 217.065 48712463_1 CDM 0278 RC inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32/65M 217.065 48712463_1 CDM 0278 RC inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32/65M 217.065 48712463_1 CDM 0278 RC inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32/65M 217.065 48712463_1 CDM 0278 RC inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32/65M 217.065 48712463_1 CDM 0278 RC inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32/65M 217.065 48712463_1 CDM 0278 RC inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELL 32/65M 217.065 48712463_1 CDM 0278 RC inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 6.5 CANCELL 32/65M 217.065 48712463_1 CDM 0278 RC inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 6.5 CANCELL 32/65M 217.065 48712463_1 CDM 0278 RC inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 6.5 CANCELL 32/65M 217.065 48712463_1 CDM 0278 RC inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 6.5 CANCELL 32/65M 217.065 48712463_1 CDM 0278 RC inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 6.5 CANCELL 32/65M 217.065 48712463_1 CDM 0278 RC inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges 6.5 CANCELLOUS 32M/80M 217.080 48712464_1 CDM 0278 RC inpatient 240 156 AETNA AETNA 189.6 79 999999999 145.32 232.8 percent of total billed charges 6.5 CANCELLOUS 32M/80M 217.080 48712464_1 CDM 0278 RC inpatient 240 156 SELF PAY DISCOUNT SELF PAY DISCOUNT 156 65 999999999 145.32 232.8 percent of total billed charges 6.5 CANCELLOUS 32M/80M 217.080 48712464_1 CDM 0278 RC inpatient 240 156 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 232.8 97 999999999 145.32 232.8 percent of total billed charges 6.5 CANCELLOUS 32M/80M 217.080 48712464_1 CDM 0278 RC inpatient 240 156 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.2 78 999999999 145.32 232.8 percent of total billed charges 6.5 CANCELLOUS 32M/80M 217.080 48712464_1 CDM 0278 RC inpatient 240 156 ENCORE - ALL PLANS ENCORE - ALL PLANS 165.6 69 999999999 145.32 232.8 percent of total billed charges 6.5 CANCELLOUS 32M/80M 217.080 48712464_1 CDM 0278 RC inpatient 240 156 UMR - ALL PLANS UMR - ALL PLANS 168 70 999999999 145.32 232.8 percent of total billed charges 6.5 CANCELLOUS 32M/80M 217.080 48712464_1 CDM 0278 RC inpatient 240 156 SIHO - ALL PLANS SIHO - ALL PLANS 216 90 999999999 145.32 232.8 percent of total billed charges 6.5 CANCELLOUS 32M/80M 217.080 48712464_1 CDM 0278 RC inpatient 240 156 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.32 60.55 999999999 145.32 232.8 percent of total billed charges 6.5 CANCELLOUS 32M/80M 217.080 48712464_1 CDM 0278 RC inpatient 240 156 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.32 232.8 6.5 CANCELLOUS 32M/80M 217.080 48712464_1 CDM 0278 RC inpatient 240 156 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.32 232.8 6.5 CANCELLOUS 32M/80M 217.080 48712464_1 CDM 0278 RC inpatient 240 156 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.32 232.8 6.5 CANCELLOUS 32M/80M 217.080 48712464_1 CDM 0278 RC inpatient 240 156 ANTHEM HMO ANTHEM HMO 999999999 145.32 232.8 6.5 CANCELLOUS 32M/80M 217.080 48712464_1 CDM 0278 RC inpatient 240 156 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.32 232.8 6.5 CANCELLOUS 32M/80M 217.080 48712464_1 CDM 0278 RC inpatient 240 156 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.24 67.6 999999999 145.32 232.8 percent of total billed charges 6.5 CANCELLOUS 32M/95M 217.095 48712465_1 CDM 0278 RC inpatient 267 173.55 AETNA AETNA 210.93 79 999999999 161.67 258.99 percent of total billed charges 6.5 CANCELLOUS 32M/95M 217.095 48712465_1 CDM 0278 RC inpatient 267 173.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 173.55 65 999999999 161.67 258.99 percent of total billed charges 6.5 CANCELLOUS 32M/95M 217.095 48712465_1 CDM 0278 RC inpatient 267 173.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 258.99 97 999999999 161.67 258.99 percent of total billed charges 6.5 CANCELLOUS 32M/95M 217.095 48712465_1 CDM 0278 RC inpatient 267 173.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 208.26 78 999999999 161.67 258.99 percent of total billed charges 6.5 CANCELLOUS 32M/95M 217.095 48712465_1 CDM 0278 RC inpatient 267 173.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.23 69 999999999 161.67 258.99 percent of total billed charges 6.5 CANCELLOUS 32M/95M 217.095 48712465_1 CDM 0278 RC inpatient 267 173.55 UMR - ALL PLANS UMR - ALL PLANS 186.9 70 999999999 161.67 258.99 percent of total billed charges 6.5 CANCELLOUS 32M/95M 217.095 48712465_1 CDM 0278 RC inpatient 267 173.55 SIHO - ALL PLANS SIHO - ALL PLANS 240.3 90 999999999 161.67 258.99 percent of total billed charges 6.5 CANCELLOUS 32M/95M 217.095 48712465_1 CDM 0278 RC inpatient 267 173.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 161.67 60.55 999999999 161.67 258.99 percent of total billed charges 6.5 CANCELLOUS 32M/95M 217.095 48712465_1 CDM 0278 RC inpatient 267 173.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 161.67 258.99 6.5 CANCELLOUS 32M/95M 217.095 48712465_1 CDM 0278 RC inpatient 267 173.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 161.67 258.99 6.5 CANCELLOUS 32M/95M 217.095 48712465_1 CDM 0278 RC inpatient 267 173.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 161.67 258.99 6.5 CANCELLOUS 32M/95M 217.095 48712465_1 CDM 0278 RC inpatient 267 173.55 ANTHEM HMO ANTHEM HMO 999999999 161.67 258.99 6.5 CANCELLOUS 32M/95M 217.095 48712465_1 CDM 0278 RC inpatient 267 173.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 161.67 258.99 6.5 CANCELLOUS 32M/95M 217.095 48712465_1 CDM 0278 RC inpatient 267 173.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 180.49 67.6 999999999 161.67 258.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712466_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712466_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712466_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712466_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712466_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712466_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712466_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712466_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712466_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712466_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712466_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712466_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712466_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712466_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges SCREW CORTES 2.7 26MM 202.826 48712467_1 CDM 0278 RC inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges SCREW CORTES 2.7 26MM 202.826 48712467_1 CDM 0278 RC inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges SCREW CORTES 2.7 26MM 202.826 48712467_1 CDM 0278 RC inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges SCREW CORTES 2.7 26MM 202.826 48712467_1 CDM 0278 RC inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges SCREW CORTES 2.7 26MM 202.826 48712467_1 CDM 0278 RC inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges SCREW CORTES 2.7 26MM 202.826 48712467_1 CDM 0278 RC inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges SCREW CORTES 2.7 26MM 202.826 48712467_1 CDM 0278 RC inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges SCREW CORTES 2.7 26MM 202.826 48712467_1 CDM 0278 RC inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges SCREW CORTES 2.7 26MM 202.826 48712467_1 CDM 0278 RC inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 SCREW CORTES 2.7 26MM 202.826 48712467_1 CDM 0278 RC inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 SCREW CORTES 2.7 26MM 202.826 48712467_1 CDM 0278 RC inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 SCREW CORTES 2.7 26MM 202.826 48712467_1 CDM 0278 RC inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 SCREW CORTES 2.7 26MM 202.826 48712467_1 CDM 0278 RC inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 SCREW CORTES 2.7 26MM 202.826 48712467_1 CDM 0278 RC inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712468_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 AETNA AETNA 130.35 79 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712468_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.25 65 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712468_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 160.05 97 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712468_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.7 78 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712468_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.85 69 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712468_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 UMR - ALL PLANS UMR - ALL PLANS 115.5 70 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712468_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 SIHO - ALL PLANS SIHO - ALL PLANS 148.5 90 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712468_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.91 60.55 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712468_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712468_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712468_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712468_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM HMO ANTHEM HMO 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712468_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712468_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.54 67.6 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712469_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 AETNA AETNA 135.09 79 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712469_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.15 65 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712469_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 165.87 97 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712469_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 133.38 78 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712469_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.99 69 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712469_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UMR - ALL PLANS UMR - ALL PLANS 119.7 70 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712469_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 SIHO - ALL PLANS SIHO - ALL PLANS 153.9 90 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712469_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 103.54 60.55 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712469_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712469_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712469_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712469_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM HMO ANTHEM HMO 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712469_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712469_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 115.6 67.6 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712470_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 AETNA AETNA 130.35 79 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712470_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.25 65 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712470_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 160.05 97 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712470_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.7 78 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712470_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.85 69 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712470_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 UMR - ALL PLANS UMR - ALL PLANS 115.5 70 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712470_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 SIHO - ALL PLANS SIHO - ALL PLANS 148.5 90 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712470_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.91 60.55 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712470_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712470_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712470_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712470_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM HMO ANTHEM HMO 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712470_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712470_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.54 67.6 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712472_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 AETNA AETNA 135.09 79 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712472_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.15 65 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712472_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 165.87 97 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712472_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 133.38 78 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712472_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.99 69 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712472_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UMR - ALL PLANS UMR - ALL PLANS 119.7 70 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712472_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 SIHO - ALL PLANS SIHO - ALL PLANS 153.9 90 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712472_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 103.54 60.55 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712472_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712472_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712472_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712472_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM HMO ANTHEM HMO 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712472_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712472_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 115.6 67.6 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712473_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712473_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712473_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712473_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712473_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712473_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712473_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712473_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712473_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712473_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712473_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712473_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712473_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712473_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712474_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 AETNA AETNA 156.42 79 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712474_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.7 65 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712474_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 192.06 97 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712474_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 154.44 78 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712474_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 136.62 69 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712474_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 UMR - ALL PLANS UMR - ALL PLANS 138.6 70 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712474_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 SIHO - ALL PLANS SIHO - ALL PLANS 178.2 90 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712474_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.89 60.55 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712474_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712474_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712474_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712474_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM HMO ANTHEM HMO 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712474_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712474_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.85 67.6 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712475_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 AETNA AETNA 124.03 79 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712475_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.05 65 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712475_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 152.29 97 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712475_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 122.46 78 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712475_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 108.33 69 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712475_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 UMR - ALL PLANS UMR - ALL PLANS 109.9 70 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712475_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 SIHO - ALL PLANS SIHO - ALL PLANS 141.3 90 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712475_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.06 60.55 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712475_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712475_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712475_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712475_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ANTHEM HMO ANTHEM HMO 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712475_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712475_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.13 67.6 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712476_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712476_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712476_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712476_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712476_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712476_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712476_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712476_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712476_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712476_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712476_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712476_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712476_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712476_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712477_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712477_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712477_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712477_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712477_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712477_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712477_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712477_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712477_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712477_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712477_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712477_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712477_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712477_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712478_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712478_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712478_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712478_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712478_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712478_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712478_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712478_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712478_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712478_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712478_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712478_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712478_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712478_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712479_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712479_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712479_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712479_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712479_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712479_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712479_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712479_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712479_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712479_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712479_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712479_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712479_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712479_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712480_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712480_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712480_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712480_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712480_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712480_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712480_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712480_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712480_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712480_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712480_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712480_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712480_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712480_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712481_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 AETNA AETNA 192.76 79 999999999 147.74 236.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712481_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 158.6 65 999999999 147.74 236.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712481_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 236.68 97 999999999 147.74 236.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712481_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 190.32 78 999999999 147.74 236.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712481_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 168.36 69 999999999 147.74 236.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712481_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 UMR - ALL PLANS UMR - ALL PLANS 170.8 70 999999999 147.74 236.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712481_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 SIHO - ALL PLANS SIHO - ALL PLANS 219.6 90 999999999 147.74 236.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712481_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.74 60.55 999999999 147.74 236.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712481_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.74 236.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712481_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.74 236.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712481_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.74 236.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712481_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 ANTHEM HMO ANTHEM HMO 999999999 147.74 236.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712481_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.74 236.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712481_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.94 67.6 999999999 147.74 236.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712482_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712482_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712482_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712482_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712482_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712482_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712482_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712482_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712482_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712482_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712482_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712482_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712482_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712482_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712483_1 CDM 0278 RC C1713 HCPCS inpatient 264 171.6 AETNA AETNA 208.56 79 999999999 159.85 256.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712483_1 CDM 0278 RC C1713 HCPCS inpatient 264 171.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 171.6 65 999999999 159.85 256.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712483_1 CDM 0278 RC C1713 HCPCS inpatient 264 171.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 256.08 97 999999999 159.85 256.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712483_1 CDM 0278 RC C1713 HCPCS inpatient 264 171.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 205.92 78 999999999 159.85 256.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712483_1 CDM 0278 RC C1713 HCPCS inpatient 264 171.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 182.16 69 999999999 159.85 256.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712483_1 CDM 0278 RC C1713 HCPCS inpatient 264 171.6 UMR - ALL PLANS UMR - ALL PLANS 184.8 70 999999999 159.85 256.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712483_1 CDM 0278 RC C1713 HCPCS inpatient 264 171.6 SIHO - ALL PLANS SIHO - ALL PLANS 237.6 90 999999999 159.85 256.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712483_1 CDM 0278 RC C1713 HCPCS inpatient 264 171.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 159.85 60.55 999999999 159.85 256.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712483_1 CDM 0278 RC C1713 HCPCS inpatient 264 171.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 159.85 256.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712483_1 CDM 0278 RC C1713 HCPCS inpatient 264 171.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 159.85 256.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712483_1 CDM 0278 RC C1713 HCPCS inpatient 264 171.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 159.85 256.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712483_1 CDM 0278 RC C1713 HCPCS inpatient 264 171.6 ANTHEM HMO ANTHEM HMO 999999999 159.85 256.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712483_1 CDM 0278 RC C1713 HCPCS inpatient 264 171.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 159.85 256.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712483_1 CDM 0278 RC C1713 HCPCS inpatient 264 171.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 178.46 67.6 999999999 159.85 256.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712484_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 AETNA AETNA 192.76 79 999999999 147.74 236.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712484_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 158.6 65 999999999 147.74 236.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712484_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 236.68 97 999999999 147.74 236.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712484_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 190.32 78 999999999 147.74 236.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712484_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 168.36 69 999999999 147.74 236.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712484_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 UMR - ALL PLANS UMR - ALL PLANS 170.8 70 999999999 147.74 236.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712484_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 SIHO - ALL PLANS SIHO - ALL PLANS 219.6 90 999999999 147.74 236.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712484_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.74 60.55 999999999 147.74 236.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712484_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.74 236.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712484_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.74 236.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712484_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.74 236.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712484_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 ANTHEM HMO ANTHEM HMO 999999999 147.74 236.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712484_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.94 67.6 999999999 147.74 236.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712484_1 CDM 0278 RC C1713 HCPCS inpatient 244 158.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.74 236.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712485_1 CDM 0278 RC C1713 HCPCS inpatient 295 191.75 AETNA AETNA 233.05 79 999999999 178.62 286.15 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712485_1 CDM 0278 RC C1713 HCPCS inpatient 295 191.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 191.75 65 999999999 178.62 286.15 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712485_1 CDM 0278 RC C1713 HCPCS inpatient 295 191.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 286.15 97 999999999 178.62 286.15 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712485_1 CDM 0278 RC C1713 HCPCS inpatient 295 191.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 230.1 78 999999999 178.62 286.15 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712485_1 CDM 0278 RC C1713 HCPCS inpatient 295 191.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 203.55 69 999999999 178.62 286.15 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712485_1 CDM 0278 RC C1713 HCPCS inpatient 295 191.75 UMR - ALL PLANS UMR - ALL PLANS 206.5 70 999999999 178.62 286.15 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712485_1 CDM 0278 RC C1713 HCPCS inpatient 295 191.75 SIHO - ALL PLANS SIHO - ALL PLANS 265.5 90 999999999 178.62 286.15 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712485_1 CDM 0278 RC C1713 HCPCS inpatient 295 191.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 178.62 60.55 999999999 178.62 286.15 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712485_1 CDM 0278 RC C1713 HCPCS inpatient 295 191.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 178.62 286.15 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712485_1 CDM 0278 RC C1713 HCPCS inpatient 295 191.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 178.62 286.15 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712485_1 CDM 0278 RC C1713 HCPCS inpatient 295 191.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 178.62 286.15 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712485_1 CDM 0278 RC C1713 HCPCS inpatient 295 191.75 ANTHEM HMO ANTHEM HMO 999999999 178.62 286.15 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712485_1 CDM 0278 RC C1713 HCPCS inpatient 295 191.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 199.42 67.6 999999999 178.62 286.15 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712485_1 CDM 0278 RC C1713 HCPCS inpatient 295 191.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 178.62 286.15 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712486_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712486_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712486_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712486_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712486_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712486_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712486_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712486_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712486_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712486_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712486_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712486_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712486_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712486_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712487_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712487_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712487_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712487_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712487_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712487_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712487_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712487_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712487_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712487_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712487_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712487_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712487_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712487_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712488_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712488_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712488_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712488_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712488_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712488_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712488_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712488_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712488_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712488_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712488_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712488_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712488_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712488_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712489_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712489_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712489_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712489_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712489_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712489_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712489_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712489_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712489_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712489_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712489_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712489_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712489_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712489_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712490_1 CDM 0278 RC C1713 HCPCS inpatient 154 100.1 AETNA AETNA 121.66 79 999999999 93.25 149.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712490_1 CDM 0278 RC C1713 HCPCS inpatient 154 100.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.1 65 999999999 93.25 149.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712490_1 CDM 0278 RC C1713 HCPCS inpatient 154 100.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 149.38 97 999999999 93.25 149.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712490_1 CDM 0278 RC C1713 HCPCS inpatient 154 100.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.12 78 999999999 93.25 149.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712490_1 CDM 0278 RC C1713 HCPCS inpatient 154 100.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.26 69 999999999 93.25 149.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712490_1 CDM 0278 RC C1713 HCPCS inpatient 154 100.1 UMR - ALL PLANS UMR - ALL PLANS 107.8 70 999999999 93.25 149.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712490_1 CDM 0278 RC C1713 HCPCS inpatient 154 100.1 SIHO - ALL PLANS SIHO - ALL PLANS 138.6 90 999999999 93.25 149.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712490_1 CDM 0278 RC C1713 HCPCS inpatient 154 100.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.25 60.55 999999999 93.25 149.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712490_1 CDM 0278 RC C1713 HCPCS inpatient 154 100.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.25 149.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712490_1 CDM 0278 RC C1713 HCPCS inpatient 154 100.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.25 149.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712490_1 CDM 0278 RC C1713 HCPCS inpatient 154 100.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.25 149.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712490_1 CDM 0278 RC C1713 HCPCS inpatient 154 100.1 ANTHEM HMO ANTHEM HMO 999999999 93.25 149.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712490_1 CDM 0278 RC C1713 HCPCS inpatient 154 100.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.1 67.6 999999999 93.25 149.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712490_1 CDM 0278 RC C1713 HCPCS inpatient 154 100.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.25 149.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712491_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712491_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712491_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712491_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712491_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712491_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712491_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712491_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712491_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712491_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712491_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712491_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712491_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712491_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712492_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712492_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712492_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712492_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712492_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712492_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712492_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712492_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712492_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712492_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712492_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712492_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712492_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712492_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712493_1 CDM 0278 RC C1713 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712493_1 CDM 0278 RC C1713 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712493_1 CDM 0278 RC C1713 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712493_1 CDM 0278 RC C1713 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712493_1 CDM 0278 RC C1713 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712493_1 CDM 0278 RC C1713 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712493_1 CDM 0278 RC C1713 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712493_1 CDM 0278 RC C1713 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712493_1 CDM 0278 RC C1713 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712493_1 CDM 0278 RC C1713 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712493_1 CDM 0278 RC C1713 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712493_1 CDM 0278 RC C1713 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712493_1 CDM 0278 RC C1713 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712493_1 CDM 0278 RC C1713 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712494_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 AETNA AETNA 135.09 79 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712494_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.15 65 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712494_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 165.87 97 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712494_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 133.38 78 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712494_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.99 69 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712494_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UMR - ALL PLANS UMR - ALL PLANS 119.7 70 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712494_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 SIHO - ALL PLANS SIHO - ALL PLANS 153.9 90 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712494_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 103.54 60.55 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712494_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712494_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712494_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712494_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM HMO ANTHEM HMO 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712494_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 115.6 67.6 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712494_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712495_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 AETNA AETNA 135.09 79 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712495_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.15 65 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712495_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 165.87 97 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712495_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 133.38 78 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712495_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.99 69 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712495_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UMR - ALL PLANS UMR - ALL PLANS 119.7 70 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712495_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 SIHO - ALL PLANS SIHO - ALL PLANS 153.9 90 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712495_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 103.54 60.55 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712495_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712495_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712495_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712495_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM HMO ANTHEM HMO 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712495_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 115.6 67.6 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712495_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712496_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 AETNA AETNA 135.09 79 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712496_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.15 65 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712496_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 165.87 97 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712496_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 133.38 78 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712496_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.99 69 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712496_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UMR - ALL PLANS UMR - ALL PLANS 119.7 70 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712496_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 SIHO - ALL PLANS SIHO - ALL PLANS 153.9 90 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712496_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 103.54 60.55 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712496_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712496_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712496_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712496_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM HMO ANTHEM HMO 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712496_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 115.6 67.6 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712496_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712497_1 CDM 0278 RC C1713 HCPCS inpatient 185 120.25 AETNA AETNA 146.15 79 999999999 112.02 179.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712497_1 CDM 0278 RC C1713 HCPCS inpatient 185 120.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 120.25 65 999999999 112.02 179.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712497_1 CDM 0278 RC C1713 HCPCS inpatient 185 120.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 179.45 97 999999999 112.02 179.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712497_1 CDM 0278 RC C1713 HCPCS inpatient 185 120.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 144.3 78 999999999 112.02 179.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712497_1 CDM 0278 RC C1713 HCPCS inpatient 185 120.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 127.65 69 999999999 112.02 179.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712497_1 CDM 0278 RC C1713 HCPCS inpatient 185 120.25 UMR - ALL PLANS UMR - ALL PLANS 129.5 70 999999999 112.02 179.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712497_1 CDM 0278 RC C1713 HCPCS inpatient 185 120.25 SIHO - ALL PLANS SIHO - ALL PLANS 166.5 90 999999999 112.02 179.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712497_1 CDM 0278 RC C1713 HCPCS inpatient 185 120.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 112.02 60.55 999999999 112.02 179.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712497_1 CDM 0278 RC C1713 HCPCS inpatient 185 120.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 112.02 179.45 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712497_1 CDM 0278 RC C1713 HCPCS inpatient 185 120.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 112.02 179.45 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712497_1 CDM 0278 RC C1713 HCPCS inpatient 185 120.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 112.02 179.45 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712497_1 CDM 0278 RC C1713 HCPCS inpatient 185 120.25 ANTHEM HMO ANTHEM HMO 999999999 112.02 179.45 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712497_1 CDM 0278 RC C1713 HCPCS inpatient 185 120.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 125.06 67.6 999999999 112.02 179.45 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712497_1 CDM 0278 RC C1713 HCPCS inpatient 185 120.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 112.02 179.45 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712498_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 AETNA AETNA 135.09 79 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712498_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.15 65 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712498_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 165.87 97 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712498_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 133.38 78 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712498_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.99 69 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712498_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UMR - ALL PLANS UMR - ALL PLANS 119.7 70 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712498_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 SIHO - ALL PLANS SIHO - ALL PLANS 153.9 90 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712498_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 103.54 60.55 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712498_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712498_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712498_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712498_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM HMO ANTHEM HMO 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712498_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 115.6 67.6 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712498_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712499_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 AETNA AETNA 156.42 79 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712499_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.7 65 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712499_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 192.06 97 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712499_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 154.44 78 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712499_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 136.62 69 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712499_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 UMR - ALL PLANS UMR - ALL PLANS 138.6 70 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712499_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 SIHO - ALL PLANS SIHO - ALL PLANS 178.2 90 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712499_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.89 60.55 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712499_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712499_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712499_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712499_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM HMO ANTHEM HMO 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712499_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.85 67.6 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712499_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712500_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 AETNA AETNA 156.42 79 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712500_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.7 65 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712500_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 192.06 97 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712500_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 154.44 78 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712500_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 136.62 69 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712500_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 UMR - ALL PLANS UMR - ALL PLANS 138.6 70 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712500_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 SIHO - ALL PLANS SIHO - ALL PLANS 178.2 90 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712500_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.89 60.55 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712500_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712500_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712500_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712500_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM HMO ANTHEM HMO 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712500_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.85 67.6 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712500_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712501_1 CDM 0278 RC C1713 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712501_1 CDM 0278 RC C1713 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712501_1 CDM 0278 RC C1713 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712501_1 CDM 0278 RC C1713 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712501_1 CDM 0278 RC C1713 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712501_1 CDM 0278 RC C1713 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712501_1 CDM 0278 RC C1713 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712501_1 CDM 0278 RC C1713 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712501_1 CDM 0278 RC C1713 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712501_1 CDM 0278 RC C1713 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712501_1 CDM 0278 RC C1713 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712501_1 CDM 0278 RC C1713 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712501_1 CDM 0278 RC C1713 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712501_1 CDM 0278 RC C1713 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712502_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 AETNA AETNA 156.42 79 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712502_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.7 65 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712502_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 192.06 97 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712502_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 154.44 78 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712502_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 136.62 69 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712502_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 UMR - ALL PLANS UMR - ALL PLANS 138.6 70 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712502_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 SIHO - ALL PLANS SIHO - ALL PLANS 178.2 90 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712502_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.89 60.55 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712502_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712502_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712502_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712502_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM HMO ANTHEM HMO 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712502_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.85 67.6 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712502_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712503_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 AETNA AETNA 156.42 79 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712503_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.7 65 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712503_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 192.06 97 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712503_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 154.44 78 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712503_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 136.62 69 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712503_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 UMR - ALL PLANS UMR - ALL PLANS 138.6 70 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712503_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 SIHO - ALL PLANS SIHO - ALL PLANS 178.2 90 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712503_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.89 60.55 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712503_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712503_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712503_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712503_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 ANTHEM HMO ANTHEM HMO 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712503_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.85 67.6 999999999 119.89 192.06 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712503_1 CDM 0278 RC C1713 HCPCS inpatient 198 128.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.89 192.06 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712504_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 AETNA AETNA 135.09 79 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712504_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.15 65 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712504_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 165.87 97 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712504_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 133.38 78 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712504_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.99 69 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712504_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UMR - ALL PLANS UMR - ALL PLANS 119.7 70 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712504_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 SIHO - ALL PLANS SIHO - ALL PLANS 153.9 90 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712504_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 103.54 60.55 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712504_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712504_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712504_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712504_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM HMO ANTHEM HMO 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712504_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 115.6 67.6 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712504_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 103.54 165.87 4.5 CORTEX SCREW 48M 214.048 48712506_1 CDM 0278 RC inpatient 126 81.9 AETNA AETNA 99.54 79 999999999 76.29 122.22 percent of total billed charges 4.5 CORTEX SCREW 48M 214.048 48712506_1 CDM 0278 RC inpatient 126 81.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.9 65 999999999 76.29 122.22 percent of total billed charges 4.5 CORTEX SCREW 48M 214.048 48712506_1 CDM 0278 RC inpatient 126 81.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 122.22 97 999999999 76.29 122.22 percent of total billed charges 4.5 CORTEX SCREW 48M 214.048 48712506_1 CDM 0278 RC inpatient 126 81.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 98.28 78 999999999 76.29 122.22 percent of total billed charges 4.5 CORTEX SCREW 48M 214.048 48712506_1 CDM 0278 RC inpatient 126 81.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.94 69 999999999 76.29 122.22 percent of total billed charges 4.5 CORTEX SCREW 48M 214.048 48712506_1 CDM 0278 RC inpatient 126 81.9 UMR - ALL PLANS UMR - ALL PLANS 88.2 70 999999999 76.29 122.22 percent of total billed charges 4.5 CORTEX SCREW 48M 214.048 48712506_1 CDM 0278 RC inpatient 126 81.9 SIHO - ALL PLANS SIHO - ALL PLANS 113.4 90 999999999 76.29 122.22 percent of total billed charges 4.5 CORTEX SCREW 48M 214.048 48712506_1 CDM 0278 RC inpatient 126 81.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.29 60.55 999999999 76.29 122.22 percent of total billed charges 4.5 CORTEX SCREW 48M 214.048 48712506_1 CDM 0278 RC inpatient 126 81.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.29 122.22 4.5 CORTEX SCREW 48M 214.048 48712506_1 CDM 0278 RC inpatient 126 81.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.29 122.22 4.5 CORTEX SCREW 48M 214.048 48712506_1 CDM 0278 RC inpatient 126 81.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.29 122.22 4.5 CORTEX SCREW 48M 214.048 48712506_1 CDM 0278 RC inpatient 126 81.9 ANTHEM HMO ANTHEM HMO 999999999 76.29 122.22 4.5 CORTEX SCREW 48M 214.048 48712506_1 CDM 0278 RC inpatient 126 81.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.18 67.6 999999999 76.29 122.22 percent of total billed charges 4.5 CORTEX SCREW 48M 214.048 48712506_1 CDM 0278 RC inpatient 126 81.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.29 122.22 4.5 CORTEX SCREW 50M 214-050 48712507_1 CDM 0278 RC inpatient 58 37.7 AETNA AETNA 45.82 79 999999999 35.12 56.26 percent of total billed charges 4.5 CORTEX SCREW 50M 214-050 48712507_1 CDM 0278 RC inpatient 58 37.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.7 65 999999999 35.12 56.26 percent of total billed charges 4.5 CORTEX SCREW 50M 214-050 48712507_1 CDM 0278 RC inpatient 58 37.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.26 97 999999999 35.12 56.26 percent of total billed charges 4.5 CORTEX SCREW 50M 214-050 48712507_1 CDM 0278 RC inpatient 58 37.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.24 78 999999999 35.12 56.26 percent of total billed charges 4.5 CORTEX SCREW 50M 214-050 48712507_1 CDM 0278 RC inpatient 58 37.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.02 69 999999999 35.12 56.26 percent of total billed charges 4.5 CORTEX SCREW 50M 214-050 48712507_1 CDM 0278 RC inpatient 58 37.7 UMR - ALL PLANS UMR - ALL PLANS 40.6 70 999999999 35.12 56.26 percent of total billed charges 4.5 CORTEX SCREW 50M 214-050 48712507_1 CDM 0278 RC inpatient 58 37.7 SIHO - ALL PLANS SIHO - ALL PLANS 52.2 90 999999999 35.12 56.26 percent of total billed charges 4.5 CORTEX SCREW 50M 214-050 48712507_1 CDM 0278 RC inpatient 58 37.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.12 60.55 999999999 35.12 56.26 percent of total billed charges 4.5 CORTEX SCREW 50M 214-050 48712507_1 CDM 0278 RC inpatient 58 37.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.12 56.26 4.5 CORTEX SCREW 50M 214-050 48712507_1 CDM 0278 RC inpatient 58 37.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.12 56.26 4.5 CORTEX SCREW 50M 214-050 48712507_1 CDM 0278 RC inpatient 58 37.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.12 56.26 4.5 CORTEX SCREW 50M 214-050 48712507_1 CDM 0278 RC inpatient 58 37.7 ANTHEM HMO ANTHEM HMO 999999999 35.12 56.26 4.5 CORTEX SCREW 50M 214-050 48712507_1 CDM 0278 RC inpatient 58 37.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.21 67.6 999999999 35.12 56.26 percent of total billed charges 4.5 CORTEX SCREW 50M 214-050 48712507_1 CDM 0278 RC inpatient 58 37.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.12 56.26 4.5 CORTEX SCREW 30M 214.030 48712509_1 CDM 0278 RC inpatient 55 35.75 AETNA AETNA 43.45 79 999999999 33.3 53.35 percent of total billed charges 4.5 CORTEX SCREW 30M 214.030 48712509_1 CDM 0278 RC inpatient 55 35.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 35.75 65 999999999 33.3 53.35 percent of total billed charges 4.5 CORTEX SCREW 30M 214.030 48712509_1 CDM 0278 RC inpatient 55 35.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 53.35 97 999999999 33.3 53.35 percent of total billed charges 4.5 CORTEX SCREW 30M 214.030 48712509_1 CDM 0278 RC inpatient 55 35.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 42.9 78 999999999 33.3 53.35 percent of total billed charges 4.5 CORTEX SCREW 30M 214.030 48712509_1 CDM 0278 RC inpatient 55 35.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 37.95 69 999999999 33.3 53.35 percent of total billed charges 4.5 CORTEX SCREW 30M 214.030 48712509_1 CDM 0278 RC inpatient 55 35.75 UMR - ALL PLANS UMR - ALL PLANS 38.5 70 999999999 33.3 53.35 percent of total billed charges 4.5 CORTEX SCREW 30M 214.030 48712509_1 CDM 0278 RC inpatient 55 35.75 SIHO - ALL PLANS SIHO - ALL PLANS 49.5 90 999999999 33.3 53.35 percent of total billed charges 4.5 CORTEX SCREW 30M 214.030 48712509_1 CDM 0278 RC inpatient 55 35.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33.3 60.55 999999999 33.3 53.35 percent of total billed charges 4.5 CORTEX SCREW 30M 214.030 48712509_1 CDM 0278 RC inpatient 55 35.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 33.3 53.35 4.5 CORTEX SCREW 30M 214.030 48712509_1 CDM 0278 RC inpatient 55 35.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 33.3 53.35 4.5 CORTEX SCREW 30M 214.030 48712509_1 CDM 0278 RC inpatient 55 35.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 33.3 53.35 4.5 CORTEX SCREW 30M 214.030 48712509_1 CDM 0278 RC inpatient 55 35.75 ANTHEM HMO ANTHEM HMO 999999999 33.3 53.35 4.5 CORTEX SCREW 30M 214.030 48712509_1 CDM 0278 RC inpatient 55 35.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 37.18 67.6 999999999 33.3 53.35 percent of total billed charges 4.5 CORTEX SCREW 30M 214.030 48712509_1 CDM 0278 RC inpatient 55 35.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 33.3 53.35 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712512_1 CDM 0278 RC C1713 HCPCS inpatient 66 42.9 AETNA AETNA 52.14 79 999999999 39.96 64.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712512_1 CDM 0278 RC C1713 HCPCS inpatient 66 42.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.9 65 999999999 39.96 64.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712512_1 CDM 0278 RC C1713 HCPCS inpatient 66 42.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.02 97 999999999 39.96 64.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712512_1 CDM 0278 RC C1713 HCPCS inpatient 66 42.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.48 78 999999999 39.96 64.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712512_1 CDM 0278 RC C1713 HCPCS inpatient 66 42.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.54 69 999999999 39.96 64.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712512_1 CDM 0278 RC C1713 HCPCS inpatient 66 42.9 UMR - ALL PLANS UMR - ALL PLANS 46.2 70 999999999 39.96 64.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712512_1 CDM 0278 RC C1713 HCPCS inpatient 66 42.9 SIHO - ALL PLANS SIHO - ALL PLANS 59.4 90 999999999 39.96 64.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712512_1 CDM 0278 RC C1713 HCPCS inpatient 66 42.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.96 60.55 999999999 39.96 64.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712512_1 CDM 0278 RC C1713 HCPCS inpatient 66 42.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.96 64.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712512_1 CDM 0278 RC C1713 HCPCS inpatient 66 42.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.96 64.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712512_1 CDM 0278 RC C1713 HCPCS inpatient 66 42.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.96 64.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712512_1 CDM 0278 RC C1713 HCPCS inpatient 66 42.9 ANTHEM HMO ANTHEM HMO 999999999 39.96 64.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712512_1 CDM 0278 RC C1713 HCPCS inpatient 66 42.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.62 67.6 999999999 39.96 64.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712512_1 CDM 0278 RC C1713 HCPCS inpatient 66 42.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.96 64.02 4.5 CORTEX SCREW 42M 214-042 48712513_1 CDM 0278 RC inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges 4.5 CORTEX SCREW 42M 214-042 48712513_1 CDM 0278 RC inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges 4.5 CORTEX SCREW 42M 214-042 48712513_1 CDM 0278 RC inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges 4.5 CORTEX SCREW 42M 214-042 48712513_1 CDM 0278 RC inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges 4.5 CORTEX SCREW 42M 214-042 48712513_1 CDM 0278 RC inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges 4.5 CORTEX SCREW 42M 214-042 48712513_1 CDM 0278 RC inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges 4.5 CORTEX SCREW 42M 214-042 48712513_1 CDM 0278 RC inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges 4.5 CORTEX SCREW 42M 214-042 48712513_1 CDM 0278 RC inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges 4.5 CORTEX SCREW 42M 214-042 48712513_1 CDM 0278 RC inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 4.5 CORTEX SCREW 42M 214-042 48712513_1 CDM 0278 RC inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 4.5 CORTEX SCREW 42M 214-042 48712513_1 CDM 0278 RC inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 4.5 CORTEX SCREW 42M 214-042 48712513_1 CDM 0278 RC inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 4.5 CORTEX SCREW 42M 214-042 48712513_1 CDM 0278 RC inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges 4.5 CORTEX SCREW 42M 214-042 48712513_1 CDM 0278 RC inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 4.5 CORTEX SCREW 32M 214.032 48712515_1 CDM 0278 RC inpatient 51 33.15 AETNA AETNA 40.29 79 999999999 30.88 49.47 percent of total billed charges 4.5 CORTEX SCREW 32M 214.032 48712515_1 CDM 0278 RC inpatient 51 33.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 33.15 65 999999999 30.88 49.47 percent of total billed charges 4.5 CORTEX SCREW 32M 214.032 48712515_1 CDM 0278 RC inpatient 51 33.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 49.47 97 999999999 30.88 49.47 percent of total billed charges 4.5 CORTEX SCREW 32M 214.032 48712515_1 CDM 0278 RC inpatient 51 33.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 39.78 78 999999999 30.88 49.47 percent of total billed charges 4.5 CORTEX SCREW 32M 214.032 48712515_1 CDM 0278 RC inpatient 51 33.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 35.19 69 999999999 30.88 49.47 percent of total billed charges 4.5 CORTEX SCREW 32M 214.032 48712515_1 CDM 0278 RC inpatient 51 33.15 UMR - ALL PLANS UMR - ALL PLANS 35.7 70 999999999 30.88 49.47 percent of total billed charges 4.5 CORTEX SCREW 32M 214.032 48712515_1 CDM 0278 RC inpatient 51 33.15 SIHO - ALL PLANS SIHO - ALL PLANS 45.9 90 999999999 30.88 49.47 percent of total billed charges 4.5 CORTEX SCREW 32M 214.032 48712515_1 CDM 0278 RC inpatient 51 33.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.88 60.55 999999999 30.88 49.47 percent of total billed charges 4.5 CORTEX SCREW 32M 214.032 48712515_1 CDM 0278 RC inpatient 51 33.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.88 49.47 4.5 CORTEX SCREW 32M 214.032 48712515_1 CDM 0278 RC inpatient 51 33.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.88 49.47 4.5 CORTEX SCREW 32M 214.032 48712515_1 CDM 0278 RC inpatient 51 33.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.88 49.47 4.5 CORTEX SCREW 32M 214.032 48712515_1 CDM 0278 RC inpatient 51 33.15 ANTHEM HMO ANTHEM HMO 999999999 30.88 49.47 4.5 CORTEX SCREW 32M 214.032 48712515_1 CDM 0278 RC inpatient 51 33.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 34.48 67.6 999999999 30.88 49.47 percent of total billed charges 4.5 CORTEX SCREW 32M 214.032 48712515_1 CDM 0278 RC inpatient 51 33.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.88 49.47 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712517_1 CDM 0278 RC C1713 HCPCS inpatient 108 70.2 AETNA AETNA 85.32 79 999999999 65.39 104.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712517_1 CDM 0278 RC C1713 HCPCS inpatient 108 70.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.2 65 999999999 65.39 104.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712517_1 CDM 0278 RC C1713 HCPCS inpatient 108 70.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 104.76 97 999999999 65.39 104.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712517_1 CDM 0278 RC C1713 HCPCS inpatient 108 70.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 84.24 78 999999999 65.39 104.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712517_1 CDM 0278 RC C1713 HCPCS inpatient 108 70.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 74.52 69 999999999 65.39 104.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712517_1 CDM 0278 RC C1713 HCPCS inpatient 108 70.2 UMR - ALL PLANS UMR - ALL PLANS 75.6 70 999999999 65.39 104.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712517_1 CDM 0278 RC C1713 HCPCS inpatient 108 70.2 SIHO - ALL PLANS SIHO - ALL PLANS 97.2 90 999999999 65.39 104.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712517_1 CDM 0278 RC C1713 HCPCS inpatient 108 70.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 65.39 60.55 999999999 65.39 104.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712517_1 CDM 0278 RC C1713 HCPCS inpatient 108 70.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 65.39 104.76 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712517_1 CDM 0278 RC C1713 HCPCS inpatient 108 70.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 65.39 104.76 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712517_1 CDM 0278 RC C1713 HCPCS inpatient 108 70.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 65.39 104.76 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712517_1 CDM 0278 RC C1713 HCPCS inpatient 108 70.2 ANTHEM HMO ANTHEM HMO 999999999 65.39 104.76 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712517_1 CDM 0278 RC C1713 HCPCS inpatient 108 70.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.01 67.6 999999999 65.39 104.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712517_1 CDM 0278 RC C1713 HCPCS inpatient 108 70.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 65.39 104.76 4.5 CORTEX SCREW 44M 214-044 48712518_1 CDM 0278 RC inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges 4.5 CORTEX SCREW 44M 214-044 48712518_1 CDM 0278 RC inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges 4.5 CORTEX SCREW 44M 214-044 48712518_1 CDM 0278 RC inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges 4.5 CORTEX SCREW 44M 214-044 48712518_1 CDM 0278 RC inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges 4.5 CORTEX SCREW 44M 214-044 48712518_1 CDM 0278 RC inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges 4.5 CORTEX SCREW 44M 214-044 48712518_1 CDM 0278 RC inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges 4.5 CORTEX SCREW 44M 214-044 48712518_1 CDM 0278 RC inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges 4.5 CORTEX SCREW 44M 214-044 48712518_1 CDM 0278 RC inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges 4.5 CORTEX SCREW 44M 214-044 48712518_1 CDM 0278 RC inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 4.5 CORTEX SCREW 44M 214-044 48712518_1 CDM 0278 RC inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 4.5 CORTEX SCREW 44M 214-044 48712518_1 CDM 0278 RC inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 4.5 CORTEX SCREW 44M 214-044 48712518_1 CDM 0278 RC inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 4.5 CORTEX SCREW 44M 214-044 48712518_1 CDM 0278 RC inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges 4.5 CORTEX SCREW 44M 214-044 48712518_1 CDM 0278 RC inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 4.5 CORTEX SCREW 24MM 214.024 48712520_1 CDM 0278 RC inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges 4.5 CORTEX SCREW 24MM 214.024 48712520_1 CDM 0278 RC inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges 4.5 CORTEX SCREW 24MM 214.024 48712520_1 CDM 0278 RC inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges 4.5 CORTEX SCREW 24MM 214.024 48712520_1 CDM 0278 RC inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges 4.5 CORTEX SCREW 24MM 214.024 48712520_1 CDM 0278 RC inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges 4.5 CORTEX SCREW 24MM 214.024 48712520_1 CDM 0278 RC inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges 4.5 CORTEX SCREW 24MM 214.024 48712520_1 CDM 0278 RC inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges 4.5 CORTEX SCREW 24MM 214.024 48712520_1 CDM 0278 RC inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges 4.5 CORTEX SCREW 24MM 214.024 48712520_1 CDM 0278 RC inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 4.5 CORTEX SCREW 24MM 214.024 48712520_1 CDM 0278 RC inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 4.5 CORTEX SCREW 24MM 214.024 48712520_1 CDM 0278 RC inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 4.5 CORTEX SCREW 24MM 214.024 48712520_1 CDM 0278 RC inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 4.5 CORTEX SCREW 24MM 214.024 48712520_1 CDM 0278 RC inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges 4.5 CORTEX SCREW 24MM 214.024 48712520_1 CDM 0278 RC inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 SM FRAG 3.5 CORTEX 22M 404.022 48712521_1 CDM 0278 RC inpatient 116 75.4 AETNA AETNA 91.64 79 999999999 70.24 112.52 percent of total billed charges SM FRAG 3.5 CORTEX 22M 404.022 48712521_1 CDM 0278 RC inpatient 116 75.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 75.4 65 999999999 70.24 112.52 percent of total billed charges SM FRAG 3.5 CORTEX 22M 404.022 48712521_1 CDM 0278 RC inpatient 116 75.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 112.52 97 999999999 70.24 112.52 percent of total billed charges SM FRAG 3.5 CORTEX 22M 404.022 48712521_1 CDM 0278 RC inpatient 116 75.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 90.48 78 999999999 70.24 112.52 percent of total billed charges SM FRAG 3.5 CORTEX 22M 404.022 48712521_1 CDM 0278 RC inpatient 116 75.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.04 69 999999999 70.24 112.52 percent of total billed charges SM FRAG 3.5 CORTEX 22M 404.022 48712521_1 CDM 0278 RC inpatient 116 75.4 UMR - ALL PLANS UMR - ALL PLANS 81.2 70 999999999 70.24 112.52 percent of total billed charges SM FRAG 3.5 CORTEX 22M 404.022 48712521_1 CDM 0278 RC inpatient 116 75.4 SIHO - ALL PLANS SIHO - ALL PLANS 104.4 90 999999999 70.24 112.52 percent of total billed charges SM FRAG 3.5 CORTEX 22M 404.022 48712521_1 CDM 0278 RC inpatient 116 75.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 70.24 60.55 999999999 70.24 112.52 percent of total billed charges SM FRAG 3.5 CORTEX 22M 404.022 48712521_1 CDM 0278 RC inpatient 116 75.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 70.24 112.52 SM FRAG 3.5 CORTEX 22M 404.022 48712521_1 CDM 0278 RC inpatient 116 75.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 70.24 112.52 SM FRAG 3.5 CORTEX 22M 404.022 48712521_1 CDM 0278 RC inpatient 116 75.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 70.24 112.52 SM FRAG 3.5 CORTEX 22M 404.022 48712521_1 CDM 0278 RC inpatient 116 75.4 ANTHEM HMO ANTHEM HMO 999999999 70.24 112.52 SM FRAG 3.5 CORTEX 22M 404.022 48712521_1 CDM 0278 RC inpatient 116 75.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 78.42 67.6 999999999 70.24 112.52 percent of total billed charges SM FRAG 3.5 CORTEX 22M 404.022 48712521_1 CDM 0278 RC inpatient 116 75.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 70.24 112.52 SM FRAG 3.5 CORTEX 10M 404.810 48712522_1 CDM 0278 RC inpatient 176 114.4 AETNA AETNA 139.04 79 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 10M 404.810 48712522_1 CDM 0278 RC inpatient 176 114.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 114.4 65 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 10M 404.810 48712522_1 CDM 0278 RC inpatient 176 114.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 170.72 97 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 10M 404.810 48712522_1 CDM 0278 RC inpatient 176 114.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 137.28 78 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 10M 404.810 48712522_1 CDM 0278 RC inpatient 176 114.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 121.44 69 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 10M 404.810 48712522_1 CDM 0278 RC inpatient 176 114.4 UMR - ALL PLANS UMR - ALL PLANS 123.2 70 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 10M 404.810 48712522_1 CDM 0278 RC inpatient 176 114.4 SIHO - ALL PLANS SIHO - ALL PLANS 158.4 90 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 10M 404.810 48712522_1 CDM 0278 RC inpatient 176 114.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 106.57 60.55 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 10M 404.810 48712522_1 CDM 0278 RC inpatient 176 114.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 10M 404.810 48712522_1 CDM 0278 RC inpatient 176 114.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 10M 404.810 48712522_1 CDM 0278 RC inpatient 176 114.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 10M 404.810 48712522_1 CDM 0278 RC inpatient 176 114.4 ANTHEM HMO ANTHEM HMO 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 10M 404.810 48712522_1 CDM 0278 RC inpatient 176 114.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.98 67.6 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 10M 404.810 48712522_1 CDM 0278 RC inpatient 176 114.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 106.57 170.72 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712523_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 AETNA AETNA 124.03 79 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712523_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.05 65 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712523_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 152.29 97 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712523_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 122.46 78 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712523_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 108.33 69 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712523_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 UMR - ALL PLANS UMR - ALL PLANS 109.9 70 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712523_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 SIHO - ALL PLANS SIHO - ALL PLANS 141.3 90 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712523_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.06 60.55 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712523_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712523_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712523_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712523_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ANTHEM HMO ANTHEM HMO 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712523_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.13 67.6 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712523_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712524_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 AETNA AETNA 124.03 79 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712524_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.05 65 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712524_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 152.29 97 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712524_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 122.46 78 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712524_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 108.33 69 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712524_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 UMR - ALL PLANS UMR - ALL PLANS 109.9 70 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712524_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 SIHO - ALL PLANS SIHO - ALL PLANS 141.3 90 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712524_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.06 60.55 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712524_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712524_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712524_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712524_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ANTHEM HMO ANTHEM HMO 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712524_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.13 67.6 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712524_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712525_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 AETNA AETNA 135.09 79 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712525_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.15 65 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712525_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 165.87 97 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712525_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 133.38 78 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712525_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.99 69 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712525_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UMR - ALL PLANS UMR - ALL PLANS 119.7 70 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712525_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 SIHO - ALL PLANS SIHO - ALL PLANS 153.9 90 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712525_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 103.54 60.55 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712525_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712525_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712525_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712525_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 ANTHEM HMO ANTHEM HMO 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712525_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 115.6 67.6 999999999 103.54 165.87 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712525_1 CDM 0278 RC C1713 HCPCS inpatient 171 111.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 103.54 165.87 SM FRAG 3.5 CORTEX 18M 404.818 48712526_1 CDM 0278 RC inpatient 176 114.4 AETNA AETNA 139.04 79 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 18M 404.818 48712526_1 CDM 0278 RC inpatient 176 114.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 114.4 65 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 18M 404.818 48712526_1 CDM 0278 RC inpatient 176 114.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 170.72 97 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 18M 404.818 48712526_1 CDM 0278 RC inpatient 176 114.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 137.28 78 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 18M 404.818 48712526_1 CDM 0278 RC inpatient 176 114.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 121.44 69 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 18M 404.818 48712526_1 CDM 0278 RC inpatient 176 114.4 UMR - ALL PLANS UMR - ALL PLANS 123.2 70 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 18M 404.818 48712526_1 CDM 0278 RC inpatient 176 114.4 SIHO - ALL PLANS SIHO - ALL PLANS 158.4 90 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 18M 404.818 48712526_1 CDM 0278 RC inpatient 176 114.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 106.57 60.55 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 18M 404.818 48712526_1 CDM 0278 RC inpatient 176 114.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 18M 404.818 48712526_1 CDM 0278 RC inpatient 176 114.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 18M 404.818 48712526_1 CDM 0278 RC inpatient 176 114.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 18M 404.818 48712526_1 CDM 0278 RC inpatient 176 114.4 ANTHEM HMO ANTHEM HMO 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 18M 404.818 48712526_1 CDM 0278 RC inpatient 176 114.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.98 67.6 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 18M 404.818 48712526_1 CDM 0278 RC inpatient 176 114.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 20M 404.820 48712527_1 CDM 0278 RC inpatient 171 111.15 AETNA AETNA 135.09 79 999999999 103.54 165.87 percent of total billed charges SM FRAG 3.5 CORTEX 20M 404.820 48712527_1 CDM 0278 RC inpatient 171 111.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.15 65 999999999 103.54 165.87 percent of total billed charges SM FRAG 3.5 CORTEX 20M 404.820 48712527_1 CDM 0278 RC inpatient 171 111.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 165.87 97 999999999 103.54 165.87 percent of total billed charges SM FRAG 3.5 CORTEX 20M 404.820 48712527_1 CDM 0278 RC inpatient 171 111.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 133.38 78 999999999 103.54 165.87 percent of total billed charges SM FRAG 3.5 CORTEX 20M 404.820 48712527_1 CDM 0278 RC inpatient 171 111.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.99 69 999999999 103.54 165.87 percent of total billed charges SM FRAG 3.5 CORTEX 20M 404.820 48712527_1 CDM 0278 RC inpatient 171 111.15 UMR - ALL PLANS UMR - ALL PLANS 119.7 70 999999999 103.54 165.87 percent of total billed charges SM FRAG 3.5 CORTEX 20M 404.820 48712527_1 CDM 0278 RC inpatient 171 111.15 SIHO - ALL PLANS SIHO - ALL PLANS 153.9 90 999999999 103.54 165.87 percent of total billed charges SM FRAG 3.5 CORTEX 20M 404.820 48712527_1 CDM 0278 RC inpatient 171 111.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 103.54 60.55 999999999 103.54 165.87 percent of total billed charges SM FRAG 3.5 CORTEX 20M 404.820 48712527_1 CDM 0278 RC inpatient 171 111.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 103.54 165.87 SM FRAG 3.5 CORTEX 20M 404.820 48712527_1 CDM 0278 RC inpatient 171 111.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 103.54 165.87 SM FRAG 3.5 CORTEX 20M 404.820 48712527_1 CDM 0278 RC inpatient 171 111.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 103.54 165.87 SM FRAG 3.5 CORTEX 20M 404.820 48712527_1 CDM 0278 RC inpatient 171 111.15 ANTHEM HMO ANTHEM HMO 999999999 103.54 165.87 SM FRAG 3.5 CORTEX 20M 404.820 48712527_1 CDM 0278 RC inpatient 171 111.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 115.6 67.6 999999999 103.54 165.87 percent of total billed charges SM FRAG 3.5 CORTEX 20M 404.820 48712527_1 CDM 0278 RC inpatient 171 111.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 103.54 165.87 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712528_1 CDM 0278 RC C1713 HCPCS inpatient 176 114.4 AETNA AETNA 139.04 79 999999999 106.57 170.72 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712528_1 CDM 0278 RC C1713 HCPCS inpatient 176 114.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 114.4 65 999999999 106.57 170.72 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712528_1 CDM 0278 RC C1713 HCPCS inpatient 176 114.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 170.72 97 999999999 106.57 170.72 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712528_1 CDM 0278 RC C1713 HCPCS inpatient 176 114.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 137.28 78 999999999 106.57 170.72 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712528_1 CDM 0278 RC C1713 HCPCS inpatient 176 114.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 121.44 69 999999999 106.57 170.72 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712528_1 CDM 0278 RC C1713 HCPCS inpatient 176 114.4 UMR - ALL PLANS UMR - ALL PLANS 123.2 70 999999999 106.57 170.72 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712528_1 CDM 0278 RC C1713 HCPCS inpatient 176 114.4 SIHO - ALL PLANS SIHO - ALL PLANS 158.4 90 999999999 106.57 170.72 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712528_1 CDM 0278 RC C1713 HCPCS inpatient 176 114.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 106.57 60.55 999999999 106.57 170.72 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712528_1 CDM 0278 RC C1713 HCPCS inpatient 176 114.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 106.57 170.72 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712528_1 CDM 0278 RC C1713 HCPCS inpatient 176 114.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 106.57 170.72 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712528_1 CDM 0278 RC C1713 HCPCS inpatient 176 114.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 106.57 170.72 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712528_1 CDM 0278 RC C1713 HCPCS inpatient 176 114.4 ANTHEM HMO ANTHEM HMO 999999999 106.57 170.72 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712528_1 CDM 0278 RC C1713 HCPCS inpatient 176 114.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.98 67.6 999999999 106.57 170.72 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712528_1 CDM 0278 RC C1713 HCPCS inpatient 176 114.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 24M 404.824 48712529_1 CDM 0278 RC inpatient 176 114.4 AETNA AETNA 139.04 79 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 24M 404.824 48712529_1 CDM 0278 RC inpatient 176 114.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 114.4 65 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 24M 404.824 48712529_1 CDM 0278 RC inpatient 176 114.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 170.72 97 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 24M 404.824 48712529_1 CDM 0278 RC inpatient 176 114.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 137.28 78 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 24M 404.824 48712529_1 CDM 0278 RC inpatient 176 114.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 121.44 69 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 24M 404.824 48712529_1 CDM 0278 RC inpatient 176 114.4 UMR - ALL PLANS UMR - ALL PLANS 123.2 70 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 24M 404.824 48712529_1 CDM 0278 RC inpatient 176 114.4 SIHO - ALL PLANS SIHO - ALL PLANS 158.4 90 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 24M 404.824 48712529_1 CDM 0278 RC inpatient 176 114.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 106.57 60.55 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 24M 404.824 48712529_1 CDM 0278 RC inpatient 176 114.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 24M 404.824 48712529_1 CDM 0278 RC inpatient 176 114.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 24M 404.824 48712529_1 CDM 0278 RC inpatient 176 114.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 24M 404.824 48712529_1 CDM 0278 RC inpatient 176 114.4 ANTHEM HMO ANTHEM HMO 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 24M 404.824 48712529_1 CDM 0278 RC inpatient 176 114.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.98 67.6 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 24M 404.824 48712529_1 CDM 0278 RC inpatient 176 114.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 26M 404.826 48712530_1 CDM 0278 RC inpatient 188 122.2 AETNA AETNA 148.52 79 999999999 113.83 182.36 percent of total billed charges SM FRAG 3.5 CORTEX 26M 404.826 48712530_1 CDM 0278 RC inpatient 188 122.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.2 65 999999999 113.83 182.36 percent of total billed charges SM FRAG 3.5 CORTEX 26M 404.826 48712530_1 CDM 0278 RC inpatient 188 122.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 182.36 97 999999999 113.83 182.36 percent of total billed charges SM FRAG 3.5 CORTEX 26M 404.826 48712530_1 CDM 0278 RC inpatient 188 122.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 146.64 78 999999999 113.83 182.36 percent of total billed charges SM FRAG 3.5 CORTEX 26M 404.826 48712530_1 CDM 0278 RC inpatient 188 122.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.72 69 999999999 113.83 182.36 percent of total billed charges SM FRAG 3.5 CORTEX 26M 404.826 48712530_1 CDM 0278 RC inpatient 188 122.2 UMR - ALL PLANS UMR - ALL PLANS 131.6 70 999999999 113.83 182.36 percent of total billed charges SM FRAG 3.5 CORTEX 26M 404.826 48712530_1 CDM 0278 RC inpatient 188 122.2 SIHO - ALL PLANS SIHO - ALL PLANS 169.2 90 999999999 113.83 182.36 percent of total billed charges SM FRAG 3.5 CORTEX 26M 404.826 48712530_1 CDM 0278 RC inpatient 188 122.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.83 60.55 999999999 113.83 182.36 percent of total billed charges SM FRAG 3.5 CORTEX 26M 404.826 48712530_1 CDM 0278 RC inpatient 188 122.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.83 182.36 SM FRAG 3.5 CORTEX 26M 404.826 48712530_1 CDM 0278 RC inpatient 188 122.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.83 182.36 SM FRAG 3.5 CORTEX 26M 404.826 48712530_1 CDM 0278 RC inpatient 188 122.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.83 182.36 SM FRAG 3.5 CORTEX 26M 404.826 48712530_1 CDM 0278 RC inpatient 188 122.2 ANTHEM HMO ANTHEM HMO 999999999 113.83 182.36 SM FRAG 3.5 CORTEX 26M 404.826 48712530_1 CDM 0278 RC inpatient 188 122.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.09 67.6 999999999 113.83 182.36 percent of total billed charges SM FRAG 3.5 CORTEX 26M 404.826 48712530_1 CDM 0278 RC inpatient 188 122.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.83 182.36 SM FRAG 3.5 CORTEX 28M 404.828 48712531_1 CDM 0278 RC inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges SM FRAG 3.5 CORTEX 28M 404.828 48712531_1 CDM 0278 RC inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges SM FRAG 3.5 CORTEX 28M 404.828 48712531_1 CDM 0278 RC inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges SM FRAG 3.5 CORTEX 28M 404.828 48712531_1 CDM 0278 RC inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges SM FRAG 3.5 CORTEX 28M 404.828 48712531_1 CDM 0278 RC inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges SM FRAG 3.5 CORTEX 28M 404.828 48712531_1 CDM 0278 RC inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges SM FRAG 3.5 CORTEX 28M 404.828 48712531_1 CDM 0278 RC inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges SM FRAG 3.5 CORTEX 28M 404.828 48712531_1 CDM 0278 RC inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges SM FRAG 3.5 CORTEX 28M 404.828 48712531_1 CDM 0278 RC inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 SM FRAG 3.5 CORTEX 28M 404.828 48712531_1 CDM 0278 RC inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 SM FRAG 3.5 CORTEX 28M 404.828 48712531_1 CDM 0278 RC inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 SM FRAG 3.5 CORTEX 28M 404.828 48712531_1 CDM 0278 RC inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 SM FRAG 3.5 CORTEX 28M 404.828 48712531_1 CDM 0278 RC inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges SM FRAG 3.5 CORTEX 28M 404.828 48712531_1 CDM 0278 RC inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 SM FRAG 3.5 CORTEX 30M 404.830 48712532_1 CDM 0278 RC inpatient 157 102.05 AETNA AETNA 124.03 79 999999999 95.06 152.29 percent of total billed charges SM FRAG 3.5 CORTEX 30M 404.830 48712532_1 CDM 0278 RC inpatient 157 102.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.05 65 999999999 95.06 152.29 percent of total billed charges SM FRAG 3.5 CORTEX 30M 404.830 48712532_1 CDM 0278 RC inpatient 157 102.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 152.29 97 999999999 95.06 152.29 percent of total billed charges SM FRAG 3.5 CORTEX 30M 404.830 48712532_1 CDM 0278 RC inpatient 157 102.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 122.46 78 999999999 95.06 152.29 percent of total billed charges SM FRAG 3.5 CORTEX 30M 404.830 48712532_1 CDM 0278 RC inpatient 157 102.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 108.33 69 999999999 95.06 152.29 percent of total billed charges SM FRAG 3.5 CORTEX 30M 404.830 48712532_1 CDM 0278 RC inpatient 157 102.05 UMR - ALL PLANS UMR - ALL PLANS 109.9 70 999999999 95.06 152.29 percent of total billed charges SM FRAG 3.5 CORTEX 30M 404.830 48712532_1 CDM 0278 RC inpatient 157 102.05 SIHO - ALL PLANS SIHO - ALL PLANS 141.3 90 999999999 95.06 152.29 percent of total billed charges SM FRAG 3.5 CORTEX 30M 404.830 48712532_1 CDM 0278 RC inpatient 157 102.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.06 60.55 999999999 95.06 152.29 percent of total billed charges SM FRAG 3.5 CORTEX 30M 404.830 48712532_1 CDM 0278 RC inpatient 157 102.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.06 152.29 SM FRAG 3.5 CORTEX 30M 404.830 48712532_1 CDM 0278 RC inpatient 157 102.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.06 152.29 SM FRAG 3.5 CORTEX 30M 404.830 48712532_1 CDM 0278 RC inpatient 157 102.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.06 152.29 SM FRAG 3.5 CORTEX 30M 404.830 48712532_1 CDM 0278 RC inpatient 157 102.05 ANTHEM HMO ANTHEM HMO 999999999 95.06 152.29 SM FRAG 3.5 CORTEX 30M 404.830 48712532_1 CDM 0278 RC inpatient 157 102.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.13 67.6 999999999 95.06 152.29 percent of total billed charges SM FRAG 3.5 CORTEX 30M 404.830 48712532_1 CDM 0278 RC inpatient 157 102.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.06 152.29 SM FRAG 3.5 CORTEX 32M 404.832 48712533_1 CDM 0278 RC inpatient 165 107.25 AETNA AETNA 130.35 79 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 32M 404.832 48712533_1 CDM 0278 RC inpatient 165 107.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.25 65 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 32M 404.832 48712533_1 CDM 0278 RC inpatient 165 107.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 160.05 97 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 32M 404.832 48712533_1 CDM 0278 RC inpatient 165 107.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.7 78 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 32M 404.832 48712533_1 CDM 0278 RC inpatient 165 107.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.85 69 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 32M 404.832 48712533_1 CDM 0278 RC inpatient 165 107.25 UMR - ALL PLANS UMR - ALL PLANS 115.5 70 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 32M 404.832 48712533_1 CDM 0278 RC inpatient 165 107.25 SIHO - ALL PLANS SIHO - ALL PLANS 148.5 90 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 32M 404.832 48712533_1 CDM 0278 RC inpatient 165 107.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.91 60.55 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 32M 404.832 48712533_1 CDM 0278 RC inpatient 165 107.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.91 160.05 SM FRAG 3.5 CORTEX 32M 404.832 48712533_1 CDM 0278 RC inpatient 165 107.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.91 160.05 SM FRAG 3.5 CORTEX 32M 404.832 48712533_1 CDM 0278 RC inpatient 165 107.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.91 160.05 SM FRAG 3.5 CORTEX 32M 404.832 48712533_1 CDM 0278 RC inpatient 165 107.25 ANTHEM HMO ANTHEM HMO 999999999 99.91 160.05 SM FRAG 3.5 CORTEX 32M 404.832 48712533_1 CDM 0278 RC inpatient 165 107.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.54 67.6 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 32M 404.832 48712533_1 CDM 0278 RC inpatient 165 107.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.91 160.05 SM FRAG 3.5 CORTEX 34M 404.834 48712534_1 CDM 0278 RC inpatient 165 107.25 AETNA AETNA 130.35 79 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 34M 404.834 48712534_1 CDM 0278 RC inpatient 165 107.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.25 65 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 34M 404.834 48712534_1 CDM 0278 RC inpatient 165 107.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 160.05 97 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 34M 404.834 48712534_1 CDM 0278 RC inpatient 165 107.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.7 78 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 34M 404.834 48712534_1 CDM 0278 RC inpatient 165 107.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.85 69 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 34M 404.834 48712534_1 CDM 0278 RC inpatient 165 107.25 UMR - ALL PLANS UMR - ALL PLANS 115.5 70 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 34M 404.834 48712534_1 CDM 0278 RC inpatient 165 107.25 SIHO - ALL PLANS SIHO - ALL PLANS 148.5 90 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 34M 404.834 48712534_1 CDM 0278 RC inpatient 165 107.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.91 60.55 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 34M 404.834 48712534_1 CDM 0278 RC inpatient 165 107.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.91 160.05 SM FRAG 3.5 CORTEX 34M 404.834 48712534_1 CDM 0278 RC inpatient 165 107.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.91 160.05 SM FRAG 3.5 CORTEX 34M 404.834 48712534_1 CDM 0278 RC inpatient 165 107.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.91 160.05 SM FRAG 3.5 CORTEX 34M 404.834 48712534_1 CDM 0278 RC inpatient 165 107.25 ANTHEM HMO ANTHEM HMO 999999999 99.91 160.05 SM FRAG 3.5 CORTEX 34M 404.834 48712534_1 CDM 0278 RC inpatient 165 107.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.54 67.6 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 34M 404.834 48712534_1 CDM 0278 RC inpatient 165 107.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.91 160.05 SM FRAG 3.5 CORTEX 36M 404.836 48712535_1 CDM 0278 RC inpatient 188 122.2 AETNA AETNA 148.52 79 999999999 113.83 182.36 percent of total billed charges SM FRAG 3.5 CORTEX 36M 404.836 48712535_1 CDM 0278 RC inpatient 188 122.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.2 65 999999999 113.83 182.36 percent of total billed charges SM FRAG 3.5 CORTEX 36M 404.836 48712535_1 CDM 0278 RC inpatient 188 122.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 182.36 97 999999999 113.83 182.36 percent of total billed charges SM FRAG 3.5 CORTEX 36M 404.836 48712535_1 CDM 0278 RC inpatient 188 122.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 146.64 78 999999999 113.83 182.36 percent of total billed charges SM FRAG 3.5 CORTEX 36M 404.836 48712535_1 CDM 0278 RC inpatient 188 122.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.72 69 999999999 113.83 182.36 percent of total billed charges SM FRAG 3.5 CORTEX 36M 404.836 48712535_1 CDM 0278 RC inpatient 188 122.2 UMR - ALL PLANS UMR - ALL PLANS 131.6 70 999999999 113.83 182.36 percent of total billed charges SM FRAG 3.5 CORTEX 36M 404.836 48712535_1 CDM 0278 RC inpatient 188 122.2 SIHO - ALL PLANS SIHO - ALL PLANS 169.2 90 999999999 113.83 182.36 percent of total billed charges SM FRAG 3.5 CORTEX 36M 404.836 48712535_1 CDM 0278 RC inpatient 188 122.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.83 60.55 999999999 113.83 182.36 percent of total billed charges SM FRAG 3.5 CORTEX 36M 404.836 48712535_1 CDM 0278 RC inpatient 188 122.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.83 182.36 SM FRAG 3.5 CORTEX 36M 404.836 48712535_1 CDM 0278 RC inpatient 188 122.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.83 182.36 SM FRAG 3.5 CORTEX 36M 404.836 48712535_1 CDM 0278 RC inpatient 188 122.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.83 182.36 SM FRAG 3.5 CORTEX 36M 404.836 48712535_1 CDM 0278 RC inpatient 188 122.2 ANTHEM HMO ANTHEM HMO 999999999 113.83 182.36 SM FRAG 3.5 CORTEX 36M 404.836 48712535_1 CDM 0278 RC inpatient 188 122.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.09 67.6 999999999 113.83 182.36 percent of total billed charges SM FRAG 3.5 CORTEX 36M 404.836 48712535_1 CDM 0278 RC inpatient 188 122.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.83 182.36 SM FRAG 3.5 CORTEX 38M 404.838 48712536_1 CDM 0278 RC inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges SM FRAG 3.5 CORTEX 38M 404.838 48712536_1 CDM 0278 RC inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges SM FRAG 3.5 CORTEX 38M 404.838 48712536_1 CDM 0278 RC inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges SM FRAG 3.5 CORTEX 38M 404.838 48712536_1 CDM 0278 RC inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges SM FRAG 3.5 CORTEX 38M 404.838 48712536_1 CDM 0278 RC inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges SM FRAG 3.5 CORTEX 38M 404.838 48712536_1 CDM 0278 RC inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges SM FRAG 3.5 CORTEX 38M 404.838 48712536_1 CDM 0278 RC inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges SM FRAG 3.5 CORTEX 38M 404.838 48712536_1 CDM 0278 RC inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges SM FRAG 3.5 CORTEX 38M 404.838 48712536_1 CDM 0278 RC inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 SM FRAG 3.5 CORTEX 38M 404.838 48712536_1 CDM 0278 RC inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 SM FRAG 3.5 CORTEX 38M 404.838 48712536_1 CDM 0278 RC inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 SM FRAG 3.5 CORTEX 38M 404.838 48712536_1 CDM 0278 RC inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 SM FRAG 3.5 CORTEX 38M 404.838 48712536_1 CDM 0278 RC inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges SM FRAG 3.5 CORTEX 38M 404.838 48712536_1 CDM 0278 RC inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 SM FRAG 3.5 CORTEX 40M 404.840 48712537_1 CDM 0278 RC inpatient 165 107.25 AETNA AETNA 130.35 79 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 40M 404.840 48712537_1 CDM 0278 RC inpatient 165 107.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.25 65 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 40M 404.840 48712537_1 CDM 0278 RC inpatient 165 107.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 160.05 97 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 40M 404.840 48712537_1 CDM 0278 RC inpatient 165 107.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.7 78 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 40M 404.840 48712537_1 CDM 0278 RC inpatient 165 107.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.85 69 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 40M 404.840 48712537_1 CDM 0278 RC inpatient 165 107.25 UMR - ALL PLANS UMR - ALL PLANS 115.5 70 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 40M 404.840 48712537_1 CDM 0278 RC inpatient 165 107.25 SIHO - ALL PLANS SIHO - ALL PLANS 148.5 90 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 40M 404.840 48712537_1 CDM 0278 RC inpatient 165 107.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.91 60.55 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 40M 404.840 48712537_1 CDM 0278 RC inpatient 165 107.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.91 160.05 SM FRAG 3.5 CORTEX 40M 404.840 48712537_1 CDM 0278 RC inpatient 165 107.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.91 160.05 SM FRAG 3.5 CORTEX 40M 404.840 48712537_1 CDM 0278 RC inpatient 165 107.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.91 160.05 SM FRAG 3.5 CORTEX 40M 404.840 48712537_1 CDM 0278 RC inpatient 165 107.25 ANTHEM HMO ANTHEM HMO 999999999 99.91 160.05 SM FRAG 3.5 CORTEX 40M 404.840 48712537_1 CDM 0278 RC inpatient 165 107.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.54 67.6 999999999 99.91 160.05 percent of total billed charges SM FRAG 3.5 CORTEX 40M 404.840 48712537_1 CDM 0278 RC inpatient 165 107.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.91 160.05 SM FRAG 3.5 CORTEX 45M 404.845 48712538_1 CDM 0278 RC inpatient 176 114.4 AETNA AETNA 139.04 79 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 45M 404.845 48712538_1 CDM 0278 RC inpatient 176 114.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 114.4 65 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 45M 404.845 48712538_1 CDM 0278 RC inpatient 176 114.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 170.72 97 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 45M 404.845 48712538_1 CDM 0278 RC inpatient 176 114.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 137.28 78 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 45M 404.845 48712538_1 CDM 0278 RC inpatient 176 114.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 121.44 69 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 45M 404.845 48712538_1 CDM 0278 RC inpatient 176 114.4 UMR - ALL PLANS UMR - ALL PLANS 123.2 70 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 45M 404.845 48712538_1 CDM 0278 RC inpatient 176 114.4 SIHO - ALL PLANS SIHO - ALL PLANS 158.4 90 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 45M 404.845 48712538_1 CDM 0278 RC inpatient 176 114.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 106.57 60.55 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 45M 404.845 48712538_1 CDM 0278 RC inpatient 176 114.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 45M 404.845 48712538_1 CDM 0278 RC inpatient 176 114.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 45M 404.845 48712538_1 CDM 0278 RC inpatient 176 114.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 45M 404.845 48712538_1 CDM 0278 RC inpatient 176 114.4 ANTHEM HMO ANTHEM HMO 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 45M 404.845 48712538_1 CDM 0278 RC inpatient 176 114.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.98 67.6 999999999 106.57 170.72 percent of total billed charges SM FRAG 3.5 CORTEX 45M 404.845 48712538_1 CDM 0278 RC inpatient 176 114.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 106.57 170.72 SM FRAG 3.5 CORTEX 50M 404.850 48712539_1 CDM 0278 RC inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges SM FRAG 3.5 CORTEX 50M 404.850 48712539_1 CDM 0278 RC inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges SM FRAG 3.5 CORTEX 50M 404.850 48712539_1 CDM 0278 RC inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges SM FRAG 3.5 CORTEX 50M 404.850 48712539_1 CDM 0278 RC inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges SM FRAG 3.5 CORTEX 50M 404.850 48712539_1 CDM 0278 RC inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges SM FRAG 3.5 CORTEX 50M 404.850 48712539_1 CDM 0278 RC inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges SM FRAG 3.5 CORTEX 50M 404.850 48712539_1 CDM 0278 RC inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges SM FRAG 3.5 CORTEX 50M 404.850 48712539_1 CDM 0278 RC inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges SM FRAG 3.5 CORTEX 50M 404.850 48712539_1 CDM 0278 RC inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 SM FRAG 3.5 CORTEX 50M 404.850 48712539_1 CDM 0278 RC inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 SM FRAG 3.5 CORTEX 50M 404.850 48712539_1 CDM 0278 RC inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 SM FRAG 3.5 CORTEX 50M 404.850 48712539_1 CDM 0278 RC inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 SM FRAG 3.5 CORTEX 50M 404.850 48712539_1 CDM 0278 RC inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges SM FRAG 3.5 CORTEX 50M 404.850 48712539_1 CDM 0278 RC inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 SM FRAG SHAFT SCREW 16M 404216 48712540_1 CDM 0278 RC inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 16M 404216 48712540_1 CDM 0278 RC inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 16M 404216 48712540_1 CDM 0278 RC inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 16M 404216 48712540_1 CDM 0278 RC inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 16M 404216 48712540_1 CDM 0278 RC inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 16M 404216 48712540_1 CDM 0278 RC inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 16M 404216 48712540_1 CDM 0278 RC inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 16M 404216 48712540_1 CDM 0278 RC inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 16M 404216 48712540_1 CDM 0278 RC inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 SM FRAG SHAFT SCREW 16M 404216 48712540_1 CDM 0278 RC inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 SM FRAG SHAFT SCREW 16M 404216 48712540_1 CDM 0278 RC inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 SM FRAG SHAFT SCREW 16M 404216 48712540_1 CDM 0278 RC inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 SM FRAG SHAFT SCREW 16M 404216 48712540_1 CDM 0278 RC inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 16M 404216 48712540_1 CDM 0278 RC inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 SM FRAG SHAFT SCREW 18M 404218 48712541_1 CDM 0278 RC inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 18M 404218 48712541_1 CDM 0278 RC inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 18M 404218 48712541_1 CDM 0278 RC inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 18M 404218 48712541_1 CDM 0278 RC inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 18M 404218 48712541_1 CDM 0278 RC inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 18M 404218 48712541_1 CDM 0278 RC inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 18M 404218 48712541_1 CDM 0278 RC inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 18M 404218 48712541_1 CDM 0278 RC inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 18M 404218 48712541_1 CDM 0278 RC inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 SM FRAG SHAFT SCREW 18M 404218 48712541_1 CDM 0278 RC inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 SM FRAG SHAFT SCREW 18M 404218 48712541_1 CDM 0278 RC inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 SM FRAG SHAFT SCREW 18M 404218 48712541_1 CDM 0278 RC inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 SM FRAG SHAFT SCREW 18M 404218 48712541_1 CDM 0278 RC inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 18M 404218 48712541_1 CDM 0278 RC inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 SM FRAG SHAFT SCREW 20M 404220 48712542_1 CDM 0278 RC inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 20M 404220 48712542_1 CDM 0278 RC inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 20M 404220 48712542_1 CDM 0278 RC inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 20M 404220 48712542_1 CDM 0278 RC inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 20M 404220 48712542_1 CDM 0278 RC inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 20M 404220 48712542_1 CDM 0278 RC inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 20M 404220 48712542_1 CDM 0278 RC inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 20M 404220 48712542_1 CDM 0278 RC inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 20M 404220 48712542_1 CDM 0278 RC inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 SM FRAG SHAFT SCREW 20M 404220 48712542_1 CDM 0278 RC inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 SM FRAG SHAFT SCREW 20M 404220 48712542_1 CDM 0278 RC inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 SM FRAG SHAFT SCREW 20M 404220 48712542_1 CDM 0278 RC inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 SM FRAG SHAFT SCREW 20M 404220 48712542_1 CDM 0278 RC inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 20M 404220 48712542_1 CDM 0278 RC inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 SM FRAG SHAFT SCREW 22M 404222 48712543_1 CDM 0278 RC inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges SM FRAG SHAFT SCREW 22M 404222 48712543_1 CDM 0278 RC inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges SM FRAG SHAFT SCREW 22M 404222 48712543_1 CDM 0278 RC inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges SM FRAG SHAFT SCREW 22M 404222 48712543_1 CDM 0278 RC inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges SM FRAG SHAFT SCREW 22M 404222 48712543_1 CDM 0278 RC inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges SM FRAG SHAFT SCREW 22M 404222 48712543_1 CDM 0278 RC inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges SM FRAG SHAFT SCREW 22M 404222 48712543_1 CDM 0278 RC inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges SM FRAG SHAFT SCREW 22M 404222 48712543_1 CDM 0278 RC inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges SM FRAG SHAFT SCREW 22M 404222 48712543_1 CDM 0278 RC inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 SM FRAG SHAFT SCREW 22M 404222 48712543_1 CDM 0278 RC inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 SM FRAG SHAFT SCREW 22M 404222 48712543_1 CDM 0278 RC inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 SM FRAG SHAFT SCREW 22M 404222 48712543_1 CDM 0278 RC inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 SM FRAG SHAFT SCREW 22M 404222 48712543_1 CDM 0278 RC inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges SM FRAG SHAFT SCREW 22M 404222 48712543_1 CDM 0278 RC inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 SM FRAG SHAFT SCREW 24M 404224 48712544_1 CDM 0278 RC inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 24M 404224 48712544_1 CDM 0278 RC inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 24M 404224 48712544_1 CDM 0278 RC inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 24M 404224 48712544_1 CDM 0278 RC inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 24M 404224 48712544_1 CDM 0278 RC inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 24M 404224 48712544_1 CDM 0278 RC inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 24M 404224 48712544_1 CDM 0278 RC inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 24M 404224 48712544_1 CDM 0278 RC inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 24M 404224 48712544_1 CDM 0278 RC inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 SM FRAG SHAFT SCREW 24M 404224 48712544_1 CDM 0278 RC inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 SM FRAG SHAFT SCREW 24M 404224 48712544_1 CDM 0278 RC inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 SM FRAG SHAFT SCREW 24M 404224 48712544_1 CDM 0278 RC inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 SM FRAG SHAFT SCREW 24M 404224 48712544_1 CDM 0278 RC inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 24M 404224 48712544_1 CDM 0278 RC inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 SCREW DHS LAG 100MM 280.000 48712545_1 CDM 0278 RC inpatient 2070 1345.5 AETNA AETNA 1635.3 79 999999999 1253.39 2007.9 percent of total billed charges SCREW DHS LAG 100MM 280.000 48712545_1 CDM 0278 RC inpatient 2070 1345.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1345.5 65 999999999 1253.39 2007.9 percent of total billed charges SCREW DHS LAG 100MM 280.000 48712545_1 CDM 0278 RC inpatient 2070 1345.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2007.9 97 999999999 1253.39 2007.9 percent of total billed charges SCREW DHS LAG 100MM 280.000 48712545_1 CDM 0278 RC inpatient 2070 1345.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1614.6 78 999999999 1253.39 2007.9 percent of total billed charges SCREW DHS LAG 100MM 280.000 48712545_1 CDM 0278 RC inpatient 2070 1345.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1428.3 69 999999999 1253.39 2007.9 percent of total billed charges SCREW DHS LAG 100MM 280.000 48712545_1 CDM 0278 RC inpatient 2070 1345.5 UMR - ALL PLANS UMR - ALL PLANS 1449 70 999999999 1253.39 2007.9 percent of total billed charges SCREW DHS LAG 100MM 280.000 48712545_1 CDM 0278 RC inpatient 2070 1345.5 SIHO - ALL PLANS SIHO - ALL PLANS 1863 90 999999999 1253.39 2007.9 percent of total billed charges SCREW DHS LAG 100MM 280.000 48712545_1 CDM 0278 RC inpatient 2070 1345.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1253.39 60.55 999999999 1253.39 2007.9 percent of total billed charges SCREW DHS LAG 100MM 280.000 48712545_1 CDM 0278 RC inpatient 2070 1345.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1253.39 2007.9 SCREW DHS LAG 100MM 280.000 48712545_1 CDM 0278 RC inpatient 2070 1345.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1253.39 2007.9 SCREW DHS LAG 100MM 280.000 48712545_1 CDM 0278 RC inpatient 2070 1345.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1253.39 2007.9 SCREW DHS LAG 100MM 280.000 48712545_1 CDM 0278 RC inpatient 2070 1345.5 ANTHEM HMO ANTHEM HMO 999999999 1253.39 2007.9 SCREW DHS LAG 100MM 280.000 48712545_1 CDM 0278 RC inpatient 2070 1345.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1399.32 67.6 999999999 1253.39 2007.9 percent of total billed charges SCREW DHS LAG 100MM 280.000 48712545_1 CDM 0278 RC inpatient 2070 1345.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1253.39 2007.9 SCREW DHS LAG 105MM 280.050 48712546_1 CDM 0278 RC inpatient 1970 1280.5 AETNA AETNA 1556.3 79 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 105MM 280.050 48712546_1 CDM 0278 RC inpatient 1970 1280.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1280.5 65 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 105MM 280.050 48712546_1 CDM 0278 RC inpatient 1970 1280.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1910.9 97 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 105MM 280.050 48712546_1 CDM 0278 RC inpatient 1970 1280.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1536.6 78 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 105MM 280.050 48712546_1 CDM 0278 RC inpatient 1970 1280.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1359.3 69 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 105MM 280.050 48712546_1 CDM 0278 RC inpatient 1970 1280.5 UMR - ALL PLANS UMR - ALL PLANS 1379 70 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 105MM 280.050 48712546_1 CDM 0278 RC inpatient 1970 1280.5 SIHO - ALL PLANS SIHO - ALL PLANS 1773 90 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 105MM 280.050 48712546_1 CDM 0278 RC inpatient 1970 1280.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1192.84 60.55 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 105MM 280.050 48712546_1 CDM 0278 RC inpatient 1970 1280.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1192.84 1910.9 SCREW DHS LAG 105MM 280.050 48712546_1 CDM 0278 RC inpatient 1970 1280.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1192.84 1910.9 SCREW DHS LAG 105MM 280.050 48712546_1 CDM 0278 RC inpatient 1970 1280.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1192.84 1910.9 SCREW DHS LAG 105MM 280.050 48712546_1 CDM 0278 RC inpatient 1970 1280.5 ANTHEM HMO ANTHEM HMO 999999999 1192.84 1910.9 SCREW DHS LAG 105MM 280.050 48712546_1 CDM 0278 RC inpatient 1970 1280.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1331.72 67.6 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 105MM 280.050 48712546_1 CDM 0278 RC inpatient 1970 1280.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1192.84 1910.9 SCREW DHS LAG 110MM 280.100 48712547_1 CDM 0278 RC inpatient 1970 1280.5 AETNA AETNA 1556.3 79 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 110MM 280.100 48712547_1 CDM 0278 RC inpatient 1970 1280.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1280.5 65 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 110MM 280.100 48712547_1 CDM 0278 RC inpatient 1970 1280.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1910.9 97 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 110MM 280.100 48712547_1 CDM 0278 RC inpatient 1970 1280.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1536.6 78 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 110MM 280.100 48712547_1 CDM 0278 RC inpatient 1970 1280.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1359.3 69 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 110MM 280.100 48712547_1 CDM 0278 RC inpatient 1970 1280.5 UMR - ALL PLANS UMR - ALL PLANS 1379 70 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 110MM 280.100 48712547_1 CDM 0278 RC inpatient 1970 1280.5 SIHO - ALL PLANS SIHO - ALL PLANS 1773 90 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 110MM 280.100 48712547_1 CDM 0278 RC inpatient 1970 1280.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1192.84 60.55 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 110MM 280.100 48712547_1 CDM 0278 RC inpatient 1970 1280.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1192.84 1910.9 SCREW DHS LAG 110MM 280.100 48712547_1 CDM 0278 RC inpatient 1970 1280.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1192.84 1910.9 SCREW DHS LAG 110MM 280.100 48712547_1 CDM 0278 RC inpatient 1970 1280.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1192.84 1910.9 SCREW DHS LAG 110MM 280.100 48712547_1 CDM 0278 RC inpatient 1970 1280.5 ANTHEM HMO ANTHEM HMO 999999999 1192.84 1910.9 SCREW DHS LAG 110MM 280.100 48712547_1 CDM 0278 RC inpatient 1970 1280.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1331.72 67.6 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 110MM 280.100 48712547_1 CDM 0278 RC inpatient 1970 1280.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1192.84 1910.9 SCREW DHS LAG 115MM 280.15 48712548_1 CDM 0278 RC inpatient 1099 714.35 AETNA AETNA 868.21 79 999999999 665.44 1066.03 percent of total billed charges SCREW DHS LAG 115MM 280.15 48712548_1 CDM 0278 RC inpatient 1099 714.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 714.35 65 999999999 665.44 1066.03 percent of total billed charges SCREW DHS LAG 115MM 280.15 48712548_1 CDM 0278 RC inpatient 1099 714.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1066.03 97 999999999 665.44 1066.03 percent of total billed charges SCREW DHS LAG 115MM 280.15 48712548_1 CDM 0278 RC inpatient 1099 714.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 857.22 78 999999999 665.44 1066.03 percent of total billed charges SCREW DHS LAG 115MM 280.15 48712548_1 CDM 0278 RC inpatient 1099 714.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 758.31 69 999999999 665.44 1066.03 percent of total billed charges SCREW DHS LAG 115MM 280.15 48712548_1 CDM 0278 RC inpatient 1099 714.35 UMR - ALL PLANS UMR - ALL PLANS 769.3 70 999999999 665.44 1066.03 percent of total billed charges SCREW DHS LAG 115MM 280.15 48712548_1 CDM 0278 RC inpatient 1099 714.35 SIHO - ALL PLANS SIHO - ALL PLANS 989.1 90 999999999 665.44 1066.03 percent of total billed charges SCREW DHS LAG 115MM 280.15 48712548_1 CDM 0278 RC inpatient 1099 714.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 665.44 60.55 999999999 665.44 1066.03 percent of total billed charges SCREW DHS LAG 115MM 280.15 48712548_1 CDM 0278 RC inpatient 1099 714.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 665.44 1066.03 SCREW DHS LAG 115MM 280.15 48712548_1 CDM 0278 RC inpatient 1099 714.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 665.44 1066.03 SCREW DHS LAG 115MM 280.15 48712548_1 CDM 0278 RC inpatient 1099 714.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 665.44 1066.03 SCREW DHS LAG 115MM 280.15 48712548_1 CDM 0278 RC inpatient 1099 714.35 ANTHEM HMO ANTHEM HMO 999999999 665.44 1066.03 SCREW DHS LAG 115MM 280.15 48712548_1 CDM 0278 RC inpatient 1099 714.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 742.92 67.6 999999999 665.44 1066.03 percent of total billed charges SCREW DHS LAG 115MM 280.15 48712548_1 CDM 0278 RC inpatient 1099 714.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 665.44 1066.03 SCREW DHS LAG 65MM 280.65 48712549_1 CDM 0278 RC inpatient 1068 694.2 AETNA AETNA 843.72 79 999999999 646.67 1035.96 percent of total billed charges SCREW DHS LAG 65MM 280.65 48712549_1 CDM 0278 RC inpatient 1068 694.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 694.2 65 999999999 646.67 1035.96 percent of total billed charges SCREW DHS LAG 65MM 280.65 48712549_1 CDM 0278 RC inpatient 1068 694.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1035.96 97 999999999 646.67 1035.96 percent of total billed charges SCREW DHS LAG 65MM 280.65 48712549_1 CDM 0278 RC inpatient 1068 694.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 833.04 78 999999999 646.67 1035.96 percent of total billed charges SCREW DHS LAG 65MM 280.65 48712549_1 CDM 0278 RC inpatient 1068 694.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 736.92 69 999999999 646.67 1035.96 percent of total billed charges SCREW DHS LAG 65MM 280.65 48712549_1 CDM 0278 RC inpatient 1068 694.2 UMR - ALL PLANS UMR - ALL PLANS 747.6 70 999999999 646.67 1035.96 percent of total billed charges SCREW DHS LAG 65MM 280.65 48712549_1 CDM 0278 RC inpatient 1068 694.2 SIHO - ALL PLANS SIHO - ALL PLANS 961.2 90 999999999 646.67 1035.96 percent of total billed charges SCREW DHS LAG 65MM 280.65 48712549_1 CDM 0278 RC inpatient 1068 694.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 646.67 60.55 999999999 646.67 1035.96 percent of total billed charges SCREW DHS LAG 65MM 280.65 48712549_1 CDM 0278 RC inpatient 1068 694.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 646.67 1035.96 SCREW DHS LAG 65MM 280.65 48712549_1 CDM 0278 RC inpatient 1068 694.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 646.67 1035.96 SCREW DHS LAG 65MM 280.65 48712549_1 CDM 0278 RC inpatient 1068 694.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 646.67 1035.96 SCREW DHS LAG 65MM 280.65 48712549_1 CDM 0278 RC inpatient 1068 694.2 ANTHEM HMO ANTHEM HMO 999999999 646.67 1035.96 SCREW DHS LAG 65MM 280.65 48712549_1 CDM 0278 RC inpatient 1068 694.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 721.97 67.6 999999999 646.67 1035.96 percent of total billed charges SCREW DHS LAG 65MM 280.65 48712549_1 CDM 0278 RC inpatient 1068 694.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 646.67 1035.96 SCREW DHS LAG 70MM 280.70 48712550_1 CDM 0278 RC inpatient 1757 1142.05 AETNA AETNA 1388.03 79 999999999 1063.86 1704.29 percent of total billed charges SCREW DHS LAG 70MM 280.70 48712550_1 CDM 0278 RC inpatient 1757 1142.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1142.05 65 999999999 1063.86 1704.29 percent of total billed charges SCREW DHS LAG 70MM 280.70 48712550_1 CDM 0278 RC inpatient 1757 1142.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1704.29 97 999999999 1063.86 1704.29 percent of total billed charges SCREW DHS LAG 70MM 280.70 48712550_1 CDM 0278 RC inpatient 1757 1142.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1370.46 78 999999999 1063.86 1704.29 percent of total billed charges SCREW DHS LAG 70MM 280.70 48712550_1 CDM 0278 RC inpatient 1757 1142.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1212.33 69 999999999 1063.86 1704.29 percent of total billed charges SCREW DHS LAG 70MM 280.70 48712550_1 CDM 0278 RC inpatient 1757 1142.05 UMR - ALL PLANS UMR - ALL PLANS 1229.9 70 999999999 1063.86 1704.29 percent of total billed charges SCREW DHS LAG 70MM 280.70 48712550_1 CDM 0278 RC inpatient 1757 1142.05 SIHO - ALL PLANS SIHO - ALL PLANS 1581.3 90 999999999 1063.86 1704.29 percent of total billed charges SCREW DHS LAG 70MM 280.70 48712550_1 CDM 0278 RC inpatient 1757 1142.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1063.86 60.55 999999999 1063.86 1704.29 percent of total billed charges SCREW DHS LAG 70MM 280.70 48712550_1 CDM 0278 RC inpatient 1757 1142.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1063.86 1704.29 SCREW DHS LAG 70MM 280.70 48712550_1 CDM 0278 RC inpatient 1757 1142.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1063.86 1704.29 SCREW DHS LAG 70MM 280.70 48712550_1 CDM 0278 RC inpatient 1757 1142.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1063.86 1704.29 SCREW DHS LAG 70MM 280.70 48712550_1 CDM 0278 RC inpatient 1757 1142.05 ANTHEM HMO ANTHEM HMO 999999999 1063.86 1704.29 SCREW DHS LAG 70MM 280.70 48712550_1 CDM 0278 RC inpatient 1757 1142.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1187.73 67.6 999999999 1063.86 1704.29 percent of total billed charges SCREW DHS LAG 70MM 280.70 48712550_1 CDM 0278 RC inpatient 1757 1142.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1063.86 1704.29 SCREW DHS LAG 75MM 280.75 48712551_1 CDM 0278 RC inpatient 1757 1142.05 AETNA AETNA 1388.03 79 999999999 1063.86 1704.29 percent of total billed charges SCREW DHS LAG 75MM 280.75 48712551_1 CDM 0278 RC inpatient 1757 1142.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1142.05 65 999999999 1063.86 1704.29 percent of total billed charges SCREW DHS LAG 75MM 280.75 48712551_1 CDM 0278 RC inpatient 1757 1142.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1704.29 97 999999999 1063.86 1704.29 percent of total billed charges SCREW DHS LAG 75MM 280.75 48712551_1 CDM 0278 RC inpatient 1757 1142.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1370.46 78 999999999 1063.86 1704.29 percent of total billed charges SCREW DHS LAG 75MM 280.75 48712551_1 CDM 0278 RC inpatient 1757 1142.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1212.33 69 999999999 1063.86 1704.29 percent of total billed charges SCREW DHS LAG 75MM 280.75 48712551_1 CDM 0278 RC inpatient 1757 1142.05 UMR - ALL PLANS UMR - ALL PLANS 1229.9 70 999999999 1063.86 1704.29 percent of total billed charges SCREW DHS LAG 75MM 280.75 48712551_1 CDM 0278 RC inpatient 1757 1142.05 SIHO - ALL PLANS SIHO - ALL PLANS 1581.3 90 999999999 1063.86 1704.29 percent of total billed charges SCREW DHS LAG 75MM 280.75 48712551_1 CDM 0278 RC inpatient 1757 1142.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1063.86 60.55 999999999 1063.86 1704.29 percent of total billed charges SCREW DHS LAG 75MM 280.75 48712551_1 CDM 0278 RC inpatient 1757 1142.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1063.86 1704.29 SCREW DHS LAG 75MM 280.75 48712551_1 CDM 0278 RC inpatient 1757 1142.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1063.86 1704.29 SCREW DHS LAG 75MM 280.75 48712551_1 CDM 0278 RC inpatient 1757 1142.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1063.86 1704.29 SCREW DHS LAG 75MM 280.75 48712551_1 CDM 0278 RC inpatient 1757 1142.05 ANTHEM HMO ANTHEM HMO 999999999 1063.86 1704.29 SCREW DHS LAG 75MM 280.75 48712551_1 CDM 0278 RC inpatient 1757 1142.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1187.73 67.6 999999999 1063.86 1704.29 percent of total billed charges SCREW DHS LAG 75MM 280.75 48712551_1 CDM 0278 RC inpatient 1757 1142.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1063.86 1704.29 SCREW DHS LAG 80MM 280.80 48712552_1 CDM 0278 RC inpatient 2070 1345.5 AETNA AETNA 1635.3 79 999999999 1253.39 2007.9 percent of total billed charges SCREW DHS LAG 80MM 280.80 48712552_1 CDM 0278 RC inpatient 2070 1345.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1345.5 65 999999999 1253.39 2007.9 percent of total billed charges SCREW DHS LAG 80MM 280.80 48712552_1 CDM 0278 RC inpatient 2070 1345.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2007.9 97 999999999 1253.39 2007.9 percent of total billed charges SCREW DHS LAG 80MM 280.80 48712552_1 CDM 0278 RC inpatient 2070 1345.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1614.6 78 999999999 1253.39 2007.9 percent of total billed charges SCREW DHS LAG 80MM 280.80 48712552_1 CDM 0278 RC inpatient 2070 1345.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1428.3 69 999999999 1253.39 2007.9 percent of total billed charges SCREW DHS LAG 80MM 280.80 48712552_1 CDM 0278 RC inpatient 2070 1345.5 UMR - ALL PLANS UMR - ALL PLANS 1449 70 999999999 1253.39 2007.9 percent of total billed charges SCREW DHS LAG 80MM 280.80 48712552_1 CDM 0278 RC inpatient 2070 1345.5 SIHO - ALL PLANS SIHO - ALL PLANS 1863 90 999999999 1253.39 2007.9 percent of total billed charges SCREW DHS LAG 80MM 280.80 48712552_1 CDM 0278 RC inpatient 2070 1345.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1253.39 60.55 999999999 1253.39 2007.9 percent of total billed charges SCREW DHS LAG 80MM 280.80 48712552_1 CDM 0278 RC inpatient 2070 1345.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1253.39 2007.9 SCREW DHS LAG 80MM 280.80 48712552_1 CDM 0278 RC inpatient 2070 1345.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1253.39 2007.9 SCREW DHS LAG 80MM 280.80 48712552_1 CDM 0278 RC inpatient 2070 1345.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1253.39 2007.9 SCREW DHS LAG 80MM 280.80 48712552_1 CDM 0278 RC inpatient 2070 1345.5 ANTHEM HMO ANTHEM HMO 999999999 1253.39 2007.9 SCREW DHS LAG 80MM 280.80 48712552_1 CDM 0278 RC inpatient 2070 1345.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1399.32 67.6 999999999 1253.39 2007.9 percent of total billed charges SCREW DHS LAG 80MM 280.80 48712552_1 CDM 0278 RC inpatient 2070 1345.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1253.39 2007.9 SCREW DHS LAG 85MM 280.850 48712553_1 CDM 0278 RC inpatient 2130 1384.5 AETNA AETNA 1682.7 79 999999999 1289.72 2066.1 percent of total billed charges SCREW DHS LAG 85MM 280.850 48712553_1 CDM 0278 RC inpatient 2130 1384.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1384.5 65 999999999 1289.72 2066.1 percent of total billed charges SCREW DHS LAG 85MM 280.850 48712553_1 CDM 0278 RC inpatient 2130 1384.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2066.1 97 999999999 1289.72 2066.1 percent of total billed charges SCREW DHS LAG 85MM 280.850 48712553_1 CDM 0278 RC inpatient 2130 1384.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1661.4 78 999999999 1289.72 2066.1 percent of total billed charges SCREW DHS LAG 85MM 280.850 48712553_1 CDM 0278 RC inpatient 2130 1384.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1469.7 69 999999999 1289.72 2066.1 percent of total billed charges SCREW DHS LAG 85MM 280.850 48712553_1 CDM 0278 RC inpatient 2130 1384.5 UMR - ALL PLANS UMR - ALL PLANS 1491 70 999999999 1289.72 2066.1 percent of total billed charges SCREW DHS LAG 85MM 280.850 48712553_1 CDM 0278 RC inpatient 2130 1384.5 SIHO - ALL PLANS SIHO - ALL PLANS 1917 90 999999999 1289.72 2066.1 percent of total billed charges SCREW DHS LAG 85MM 280.850 48712553_1 CDM 0278 RC inpatient 2130 1384.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1289.72 60.55 999999999 1289.72 2066.1 percent of total billed charges SCREW DHS LAG 85MM 280.850 48712553_1 CDM 0278 RC inpatient 2130 1384.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1289.72 2066.1 SCREW DHS LAG 85MM 280.850 48712553_1 CDM 0278 RC inpatient 2130 1384.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1289.72 2066.1 SCREW DHS LAG 85MM 280.850 48712553_1 CDM 0278 RC inpatient 2130 1384.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1289.72 2066.1 SCREW DHS LAG 85MM 280.850 48712553_1 CDM 0278 RC inpatient 2130 1384.5 ANTHEM HMO ANTHEM HMO 999999999 1289.72 2066.1 SCREW DHS LAG 85MM 280.850 48712553_1 CDM 0278 RC inpatient 2130 1384.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1439.88 67.6 999999999 1289.72 2066.1 percent of total billed charges SCREW DHS LAG 85MM 280.850 48712553_1 CDM 0278 RC inpatient 2130 1384.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1289.72 2066.1 SCREW DHS LAG 90MM 280.900 48712554_1 CDM 0278 RC inpatient 2273 1477.45 AETNA AETNA 1795.67 79 999999999 1376.3 2204.81 percent of total billed charges SCREW DHS LAG 90MM 280.900 48712554_1 CDM 0278 RC inpatient 2273 1477.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1477.45 65 999999999 1376.3 2204.81 percent of total billed charges SCREW DHS LAG 90MM 280.900 48712554_1 CDM 0278 RC inpatient 2273 1477.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2204.81 97 999999999 1376.3 2204.81 percent of total billed charges SCREW DHS LAG 90MM 280.900 48712554_1 CDM 0278 RC inpatient 2273 1477.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1772.94 78 999999999 1376.3 2204.81 percent of total billed charges SCREW DHS LAG 90MM 280.900 48712554_1 CDM 0278 RC inpatient 2273 1477.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1568.37 69 999999999 1376.3 2204.81 percent of total billed charges SCREW DHS LAG 90MM 280.900 48712554_1 CDM 0278 RC inpatient 2273 1477.45 UMR - ALL PLANS UMR - ALL PLANS 1591.1 70 999999999 1376.3 2204.81 percent of total billed charges SCREW DHS LAG 90MM 280.900 48712554_1 CDM 0278 RC inpatient 2273 1477.45 SIHO - ALL PLANS SIHO - ALL PLANS 2045.7 90 999999999 1376.3 2204.81 percent of total billed charges SCREW DHS LAG 90MM 280.900 48712554_1 CDM 0278 RC inpatient 2273 1477.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1376.3 60.55 999999999 1376.3 2204.81 percent of total billed charges SCREW DHS LAG 90MM 280.900 48712554_1 CDM 0278 RC inpatient 2273 1477.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1376.3 2204.81 SCREW DHS LAG 90MM 280.900 48712554_1 CDM 0278 RC inpatient 2273 1477.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1376.3 2204.81 SCREW DHS LAG 90MM 280.900 48712554_1 CDM 0278 RC inpatient 2273 1477.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1376.3 2204.81 SCREW DHS LAG 90MM 280.900 48712554_1 CDM 0278 RC inpatient 2273 1477.45 ANTHEM HMO ANTHEM HMO 999999999 1376.3 2204.81 SCREW DHS LAG 90MM 280.900 48712554_1 CDM 0278 RC inpatient 2273 1477.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1536.55 67.6 999999999 1376.3 2204.81 percent of total billed charges SCREW DHS LAG 90MM 280.900 48712554_1 CDM 0278 RC inpatient 2273 1477.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1376.3 2204.81 SCREW DHS LAG 95MM 280.950 48712555_1 CDM 0278 RC inpatient 1970 1280.5 AETNA AETNA 1556.3 79 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 95MM 280.950 48712555_1 CDM 0278 RC inpatient 1970 1280.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1280.5 65 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 95MM 280.950 48712555_1 CDM 0278 RC inpatient 1970 1280.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1910.9 97 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 95MM 280.950 48712555_1 CDM 0278 RC inpatient 1970 1280.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1536.6 78 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 95MM 280.950 48712555_1 CDM 0278 RC inpatient 1970 1280.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1359.3 69 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 95MM 280.950 48712555_1 CDM 0278 RC inpatient 1970 1280.5 UMR - ALL PLANS UMR - ALL PLANS 1379 70 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 95MM 280.950 48712555_1 CDM 0278 RC inpatient 1970 1280.5 SIHO - ALL PLANS SIHO - ALL PLANS 1773 90 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 95MM 280.950 48712555_1 CDM 0278 RC inpatient 1970 1280.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1192.84 60.55 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 95MM 280.950 48712555_1 CDM 0278 RC inpatient 1970 1280.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1192.84 1910.9 SCREW DHS LAG 95MM 280.950 48712555_1 CDM 0278 RC inpatient 1970 1280.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1192.84 1910.9 SCREW DHS LAG 95MM 280.950 48712555_1 CDM 0278 RC inpatient 1970 1280.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1192.84 1910.9 SCREW DHS LAG 95MM 280.950 48712555_1 CDM 0278 RC inpatient 1970 1280.5 ANTHEM HMO ANTHEM HMO 999999999 1192.84 1910.9 SCREW DHS LAG 95MM 280.950 48712555_1 CDM 0278 RC inpatient 1970 1280.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1331.72 67.6 999999999 1192.84 1910.9 percent of total billed charges SCREW DHS LAG 95MM 280.950 48712555_1 CDM 0278 RC inpatient 1970 1280.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1192.84 1910.9 SM FRAG SHAFT SCREW 26M 404226 48712556_1 CDM 0278 RC inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 26M 404226 48712556_1 CDM 0278 RC inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 26M 404226 48712556_1 CDM 0278 RC inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 26M 404226 48712556_1 CDM 0278 RC inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 26M 404226 48712556_1 CDM 0278 RC inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 26M 404226 48712556_1 CDM 0278 RC inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 26M 404226 48712556_1 CDM 0278 RC inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 26M 404226 48712556_1 CDM 0278 RC inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 26M 404226 48712556_1 CDM 0278 RC inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 SM FRAG SHAFT SCREW 26M 404226 48712556_1 CDM 0278 RC inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 SM FRAG SHAFT SCREW 26M 404226 48712556_1 CDM 0278 RC inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 SM FRAG SHAFT SCREW 26M 404226 48712556_1 CDM 0278 RC inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 SM FRAG SHAFT SCREW 26M 404226 48712556_1 CDM 0278 RC inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 26M 404226 48712556_1 CDM 0278 RC inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 SM FRAG SHAFT SCREW 28M 404228 48712557_1 CDM 0278 RC inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 28M 404228 48712557_1 CDM 0278 RC inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 28M 404228 48712557_1 CDM 0278 RC inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 28M 404228 48712557_1 CDM 0278 RC inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 28M 404228 48712557_1 CDM 0278 RC inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 28M 404228 48712557_1 CDM 0278 RC inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 28M 404228 48712557_1 CDM 0278 RC inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 28M 404228 48712557_1 CDM 0278 RC inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 28M 404228 48712557_1 CDM 0278 RC inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 SM FRAG SHAFT SCREW 28M 404228 48712557_1 CDM 0278 RC inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 SM FRAG SHAFT SCREW 28M 404228 48712557_1 CDM 0278 RC inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 SM FRAG SHAFT SCREW 28M 404228 48712557_1 CDM 0278 RC inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 SM FRAG SHAFT SCREW 28M 404228 48712557_1 CDM 0278 RC inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 28M 404228 48712557_1 CDM 0278 RC inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 SM FRAG SHAFT SCREW 30M 404230 48712558_1 CDM 0278 RC inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 30M 404230 48712558_1 CDM 0278 RC inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 30M 404230 48712558_1 CDM 0278 RC inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 30M 404230 48712558_1 CDM 0278 RC inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 30M 404230 48712558_1 CDM 0278 RC inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 30M 404230 48712558_1 CDM 0278 RC inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 30M 404230 48712558_1 CDM 0278 RC inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 30M 404230 48712558_1 CDM 0278 RC inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 30M 404230 48712558_1 CDM 0278 RC inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 SM FRAG SHAFT SCREW 30M 404230 48712558_1 CDM 0278 RC inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 SM FRAG SHAFT SCREW 30M 404230 48712558_1 CDM 0278 RC inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 SM FRAG SHAFT SCREW 30M 404230 48712558_1 CDM 0278 RC inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 SM FRAG SHAFT SCREW 30M 404230 48712558_1 CDM 0278 RC inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 30M 404230 48712558_1 CDM 0278 RC inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 SM FRAG SHAFT SCREW 32M 404232 48712559_1 CDM 0278 RC inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 32M 404232 48712559_1 CDM 0278 RC inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 32M 404232 48712559_1 CDM 0278 RC inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 32M 404232 48712559_1 CDM 0278 RC inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 32M 404232 48712559_1 CDM 0278 RC inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 32M 404232 48712559_1 CDM 0278 RC inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 32M 404232 48712559_1 CDM 0278 RC inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 32M 404232 48712559_1 CDM 0278 RC inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 32M 404232 48712559_1 CDM 0278 RC inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 SM FRAG SHAFT SCREW 32M 404232 48712559_1 CDM 0278 RC inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 SM FRAG SHAFT SCREW 32M 404232 48712559_1 CDM 0278 RC inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 SM FRAG SHAFT SCREW 32M 404232 48712559_1 CDM 0278 RC inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 SM FRAG SHAFT SCREW 32M 404232 48712559_1 CDM 0278 RC inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 32M 404232 48712559_1 CDM 0278 RC inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 SM FRAG SHAFT SCREW 34M 404234 48712560_1 CDM 0278 RC inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 34M 404234 48712560_1 CDM 0278 RC inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 34M 404234 48712560_1 CDM 0278 RC inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 34M 404234 48712560_1 CDM 0278 RC inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 34M 404234 48712560_1 CDM 0278 RC inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 34M 404234 48712560_1 CDM 0278 RC inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 34M 404234 48712560_1 CDM 0278 RC inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 34M 404234 48712560_1 CDM 0278 RC inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 34M 404234 48712560_1 CDM 0278 RC inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 SM FRAG SHAFT SCREW 34M 404234 48712560_1 CDM 0278 RC inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 SM FRAG SHAFT SCREW 34M 404234 48712560_1 CDM 0278 RC inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 SM FRAG SHAFT SCREW 34M 404234 48712560_1 CDM 0278 RC inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 SM FRAG SHAFT SCREW 34M 404234 48712560_1 CDM 0278 RC inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges SM FRAG SHAFT SCREW 34M 404234 48712560_1 CDM 0278 RC inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 SM FRAG SHAFT SCREW 36M 404236 48712561_1 CDM 0278 RC inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 36M 404236 48712561_1 CDM 0278 RC inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 36M 404236 48712561_1 CDM 0278 RC inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 36M 404236 48712561_1 CDM 0278 RC inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 36M 404236 48712561_1 CDM 0278 RC inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 36M 404236 48712561_1 CDM 0278 RC inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 36M 404236 48712561_1 CDM 0278 RC inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 36M 404236 48712561_1 CDM 0278 RC inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 36M 404236 48712561_1 CDM 0278 RC inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 SM FRAG SHAFT SCREW 36M 404236 48712561_1 CDM 0278 RC inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 SM FRAG SHAFT SCREW 36M 404236 48712561_1 CDM 0278 RC inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 SM FRAG SHAFT SCREW 36M 404236 48712561_1 CDM 0278 RC inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 SM FRAG SHAFT SCREW 36M 404236 48712561_1 CDM 0278 RC inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 36M 404236 48712561_1 CDM 0278 RC inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 SM FRAG SHAFT SCREW 38M 404238 48712562_1 CDM 0278 RC inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 38M 404238 48712562_1 CDM 0278 RC inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 38M 404238 48712562_1 CDM 0278 RC inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 38M 404238 48712562_1 CDM 0278 RC inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 38M 404238 48712562_1 CDM 0278 RC inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 38M 404238 48712562_1 CDM 0278 RC inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 38M 404238 48712562_1 CDM 0278 RC inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 38M 404238 48712562_1 CDM 0278 RC inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 38M 404238 48712562_1 CDM 0278 RC inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 SM FRAG SHAFT SCREW 38M 404238 48712562_1 CDM 0278 RC inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 SM FRAG SHAFT SCREW 38M 404238 48712562_1 CDM 0278 RC inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 SM FRAG SHAFT SCREW 38M 404238 48712562_1 CDM 0278 RC inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 SM FRAG SHAFT SCREW 38M 404238 48712562_1 CDM 0278 RC inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges SM FRAG SHAFT SCREW 38M 404238 48712562_1 CDM 0278 RC inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 ***DO NOT UES UNLESS ORDERED BY IMP***4.0 CAN SM FRAG PT 10M 407.010 48712563_1 CDM 0278 RC inpatient 138 89.7 AETNA AETNA 109.02 79 999999999 83.56 133.86 percent of total billed charges ***DO NOT UES UNLESS ORDERED BY IMP***4.0 CAN SM FRAG PT 10M 407.010 48712563_1 CDM 0278 RC inpatient 138 89.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.7 65 999999999 83.56 133.86 percent of total billed charges ***DO NOT UES UNLESS ORDERED BY IMP***4.0 CAN SM FRAG PT 10M 407.010 48712563_1 CDM 0278 RC inpatient 138 89.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 133.86 97 999999999 83.56 133.86 percent of total billed charges ***DO NOT UES UNLESS ORDERED BY IMP***4.0 CAN SM FRAG PT 10M 407.010 48712563_1 CDM 0278 RC inpatient 138 89.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 107.64 78 999999999 83.56 133.86 percent of total billed charges ***DO NOT UES UNLESS ORDERED BY IMP***4.0 CAN SM FRAG PT 10M 407.010 48712563_1 CDM 0278 RC inpatient 138 89.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.22 69 999999999 83.56 133.86 percent of total billed charges ***DO NOT UES UNLESS ORDERED BY IMP***4.0 CAN SM FRAG PT 10M 407.010 48712563_1 CDM 0278 RC inpatient 138 89.7 UMR - ALL PLANS UMR - ALL PLANS 96.6 70 999999999 83.56 133.86 percent of total billed charges ***DO NOT UES UNLESS ORDERED BY IMP***4.0 CAN SM FRAG PT 10M 407.010 48712563_1 CDM 0278 RC inpatient 138 89.7 SIHO - ALL PLANS SIHO - ALL PLANS 124.2 90 999999999 83.56 133.86 percent of total billed charges ***DO NOT UES UNLESS ORDERED BY IMP***4.0 CAN SM FRAG PT 10M 407.010 48712563_1 CDM 0278 RC inpatient 138 89.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 83.56 60.55 999999999 83.56 133.86 percent of total billed charges ***DO NOT UES UNLESS ORDERED BY IMP***4.0 CAN SM FRAG PT 10M 407.010 48712563_1 CDM 0278 RC inpatient 138 89.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 83.56 133.86 ***DO NOT UES UNLESS ORDERED BY IMP***4.0 CAN SM FRAG PT 10M 407.010 48712563_1 CDM 0278 RC inpatient 138 89.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 83.56 133.86 ***DO NOT UES UNLESS ORDERED BY IMP***4.0 CAN SM FRAG PT 10M 407.010 48712563_1 CDM 0278 RC inpatient 138 89.7 ANTHEM HMO ANTHEM HMO 999999999 83.56 133.86 ***DO NOT UES UNLESS ORDERED BY IMP***4.0 CAN SM FRAG PT 10M 407.010 48712563_1 CDM 0278 RC inpatient 138 89.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 83.56 133.86 ***DO NOT UES UNLESS ORDERED BY IMP***4.0 CAN SM FRAG PT 10M 407.010 48712563_1 CDM 0278 RC inpatient 138 89.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.29 67.6 999999999 83.56 133.86 percent of total billed charges ***DO NOT UES UNLESS ORDERED BY IMP***4.0 CAN SM FRAG PT 10M 407.010 48712563_1 CDM 0278 RC inpatient 138 89.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 83.56 133.86 4.0 CAN SM FRAG PT 12M 407.012 48712564_1 CDM 0278 RC inpatient 104 67.6 AETNA AETNA 82.16 79 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 12M 407.012 48712564_1 CDM 0278 RC inpatient 104 67.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 67.6 65 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 12M 407.012 48712564_1 CDM 0278 RC inpatient 104 67.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 100.88 97 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 12M 407.012 48712564_1 CDM 0278 RC inpatient 104 67.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.12 78 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 12M 407.012 48712564_1 CDM 0278 RC inpatient 104 67.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.76 69 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 12M 407.012 48712564_1 CDM 0278 RC inpatient 104 67.6 UMR - ALL PLANS UMR - ALL PLANS 72.8 70 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 12M 407.012 48712564_1 CDM 0278 RC inpatient 104 67.6 SIHO - ALL PLANS SIHO - ALL PLANS 93.6 90 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 12M 407.012 48712564_1 CDM 0278 RC inpatient 104 67.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.97 60.55 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 12M 407.012 48712564_1 CDM 0278 RC inpatient 104 67.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.97 100.88 4.0 CAN SM FRAG PT 12M 407.012 48712564_1 CDM 0278 RC inpatient 104 67.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.97 100.88 4.0 CAN SM FRAG PT 12M 407.012 48712564_1 CDM 0278 RC inpatient 104 67.6 ANTHEM HMO ANTHEM HMO 999999999 62.97 100.88 4.0 CAN SM FRAG PT 12M 407.012 48712564_1 CDM 0278 RC inpatient 104 67.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.97 100.88 4.0 CAN SM FRAG PT 12M 407.012 48712564_1 CDM 0278 RC inpatient 104 67.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.3 67.6 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 12M 407.012 48712564_1 CDM 0278 RC inpatient 104 67.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.97 100.88 4.0 CAN SM FRAG PT 14M 407.014 48712565_1 CDM 0278 RC inpatient 104 67.6 AETNA AETNA 82.16 79 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 14M 407.014 48712565_1 CDM 0278 RC inpatient 104 67.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 67.6 65 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 14M 407.014 48712565_1 CDM 0278 RC inpatient 104 67.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 100.88 97 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 14M 407.014 48712565_1 CDM 0278 RC inpatient 104 67.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.12 78 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 14M 407.014 48712565_1 CDM 0278 RC inpatient 104 67.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.76 69 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 14M 407.014 48712565_1 CDM 0278 RC inpatient 104 67.6 UMR - ALL PLANS UMR - ALL PLANS 72.8 70 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 14M 407.014 48712565_1 CDM 0278 RC inpatient 104 67.6 SIHO - ALL PLANS SIHO - ALL PLANS 93.6 90 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 14M 407.014 48712565_1 CDM 0278 RC inpatient 104 67.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.97 60.55 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 14M 407.014 48712565_1 CDM 0278 RC inpatient 104 67.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.97 100.88 4.0 CAN SM FRAG PT 14M 407.014 48712565_1 CDM 0278 RC inpatient 104 67.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.97 100.88 4.0 CAN SM FRAG PT 14M 407.014 48712565_1 CDM 0278 RC inpatient 104 67.6 ANTHEM HMO ANTHEM HMO 999999999 62.97 100.88 4.0 CAN SM FRAG PT 14M 407.014 48712565_1 CDM 0278 RC inpatient 104 67.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.97 100.88 4.0 CAN SM FRAG PT 14M 407.014 48712565_1 CDM 0278 RC inpatient 104 67.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.3 67.6 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 14M 407.014 48712565_1 CDM 0278 RC inpatient 104 67.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.97 100.88 4.0 CAN SM FRAG PT 16M 407.016 48712566_1 CDM 0278 RC inpatient 104 67.6 AETNA AETNA 82.16 79 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 16M 407.016 48712566_1 CDM 0278 RC inpatient 104 67.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 67.6 65 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 16M 407.016 48712566_1 CDM 0278 RC inpatient 104 67.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 100.88 97 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 16M 407.016 48712566_1 CDM 0278 RC inpatient 104 67.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.12 78 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 16M 407.016 48712566_1 CDM 0278 RC inpatient 104 67.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.76 69 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 16M 407.016 48712566_1 CDM 0278 RC inpatient 104 67.6 UMR - ALL PLANS UMR - ALL PLANS 72.8 70 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 16M 407.016 48712566_1 CDM 0278 RC inpatient 104 67.6 SIHO - ALL PLANS SIHO - ALL PLANS 93.6 90 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 16M 407.016 48712566_1 CDM 0278 RC inpatient 104 67.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.97 60.55 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 16M 407.016 48712566_1 CDM 0278 RC inpatient 104 67.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.97 100.88 4.0 CAN SM FRAG PT 16M 407.016 48712566_1 CDM 0278 RC inpatient 104 67.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.97 100.88 4.0 CAN SM FRAG PT 16M 407.016 48712566_1 CDM 0278 RC inpatient 104 67.6 ANTHEM HMO ANTHEM HMO 999999999 62.97 100.88 4.0 CAN SM FRAG PT 16M 407.016 48712566_1 CDM 0278 RC inpatient 104 67.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.97 100.88 4.0 CAN SM FRAG PT 16M 407.016 48712566_1 CDM 0278 RC inpatient 104 67.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.3 67.6 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 16M 407.016 48712566_1 CDM 0278 RC inpatient 104 67.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.97 100.88 4.0 CAN SM FRAG PT 18M 407.018 48712567_1 CDM 0278 RC inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges 4.0 CAN SM FRAG PT 18M 407.018 48712567_1 CDM 0278 RC inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges 4.0 CAN SM FRAG PT 18M 407.018 48712567_1 CDM 0278 RC inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges 4.0 CAN SM FRAG PT 18M 407.018 48712567_1 CDM 0278 RC inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges 4.0 CAN SM FRAG PT 18M 407.018 48712567_1 CDM 0278 RC inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges 4.0 CAN SM FRAG PT 18M 407.018 48712567_1 CDM 0278 RC inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges 4.0 CAN SM FRAG PT 18M 407.018 48712567_1 CDM 0278 RC inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges 4.0 CAN SM FRAG PT 18M 407.018 48712567_1 CDM 0278 RC inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges 4.0 CAN SM FRAG PT 18M 407.018 48712567_1 CDM 0278 RC inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 4.0 CAN SM FRAG PT 18M 407.018 48712567_1 CDM 0278 RC inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 4.0 CAN SM FRAG PT 18M 407.018 48712567_1 CDM 0278 RC inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 4.0 CAN SM FRAG PT 18M 407.018 48712567_1 CDM 0278 RC inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 4.0 CAN SM FRAG PT 18M 407.018 48712567_1 CDM 0278 RC inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges 4.0 CAN SM FRAG PT 18M 407.018 48712567_1 CDM 0278 RC inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 6.5 CANCELOUS 16M/110M 216.110 48712568_1 CDM 0278 RC inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges 6.5 CANCELOUS 16M/110M 216.110 48712568_1 CDM 0278 RC inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges 6.5 CANCELOUS 16M/110M 216.110 48712568_1 CDM 0278 RC inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges 6.5 CANCELOUS 16M/110M 216.110 48712568_1 CDM 0278 RC inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges 6.5 CANCELOUS 16M/110M 216.110 48712568_1 CDM 0278 RC inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges 6.5 CANCELOUS 16M/110M 216.110 48712568_1 CDM 0278 RC inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges 6.5 CANCELOUS 16M/110M 216.110 48712568_1 CDM 0278 RC inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges 6.5 CANCELOUS 16M/110M 216.110 48712568_1 CDM 0278 RC inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges 6.5 CANCELOUS 16M/110M 216.110 48712568_1 CDM 0278 RC inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 6.5 CANCELOUS 16M/110M 216.110 48712568_1 CDM 0278 RC inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 6.5 CANCELOUS 16M/110M 216.110 48712568_1 CDM 0278 RC inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 6.5 CANCELOUS 16M/110M 216.110 48712568_1 CDM 0278 RC inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 6.5 CANCELOUS 16M/110M 216.110 48712568_1 CDM 0278 RC inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges 6.5 CANCELOUS 16M/110M 216.110 48712568_1 CDM 0278 RC inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 4.0 CAN SM FRAG PT 20M 407.020 48712569_1 CDM 0278 RC inpatient 104 67.6 AETNA AETNA 82.16 79 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 20M 407.020 48712569_1 CDM 0278 RC inpatient 104 67.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 67.6 65 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 20M 407.020 48712569_1 CDM 0278 RC inpatient 104 67.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 100.88 97 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 20M 407.020 48712569_1 CDM 0278 RC inpatient 104 67.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.12 78 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 20M 407.020 48712569_1 CDM 0278 RC inpatient 104 67.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.76 69 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 20M 407.020 48712569_1 CDM 0278 RC inpatient 104 67.6 UMR - ALL PLANS UMR - ALL PLANS 72.8 70 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 20M 407.020 48712569_1 CDM 0278 RC inpatient 104 67.6 SIHO - ALL PLANS SIHO - ALL PLANS 93.6 90 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 20M 407.020 48712569_1 CDM 0278 RC inpatient 104 67.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.97 60.55 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 20M 407.020 48712569_1 CDM 0278 RC inpatient 104 67.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.97 100.88 4.0 CAN SM FRAG PT 20M 407.020 48712569_1 CDM 0278 RC inpatient 104 67.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.97 100.88 4.0 CAN SM FRAG PT 20M 407.020 48712569_1 CDM 0278 RC inpatient 104 67.6 ANTHEM HMO ANTHEM HMO 999999999 62.97 100.88 4.0 CAN SM FRAG PT 20M 407.020 48712569_1 CDM 0278 RC inpatient 104 67.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.97 100.88 4.0 CAN SM FRAG PT 20M 407.020 48712569_1 CDM 0278 RC inpatient 104 67.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.3 67.6 999999999 62.97 100.88 percent of total billed charges 4.0 CAN SM FRAG PT 20M 407.020 48712569_1 CDM 0278 RC inpatient 104 67.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.97 100.88 4.O CAN SM FRAG PT 22M 407.022 48712570_1 CDM 0278 RC inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges 4.O CAN SM FRAG PT 22M 407.022 48712570_1 CDM 0278 RC inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges 4.O CAN SM FRAG PT 22M 407.022 48712570_1 CDM 0278 RC inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges 4.O CAN SM FRAG PT 22M 407.022 48712570_1 CDM 0278 RC inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges 4.O CAN SM FRAG PT 22M 407.022 48712570_1 CDM 0278 RC inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges 4.O CAN SM FRAG PT 22M 407.022 48712570_1 CDM 0278 RC inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges 4.O CAN SM FRAG PT 22M 407.022 48712570_1 CDM 0278 RC inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges 4.O CAN SM FRAG PT 22M 407.022 48712570_1 CDM 0278 RC inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges 4.O CAN SM FRAG PT 22M 407.022 48712570_1 CDM 0278 RC inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 4.O CAN SM FRAG PT 22M 407.022 48712570_1 CDM 0278 RC inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 4.O CAN SM FRAG PT 22M 407.022 48712570_1 CDM 0278 RC inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 4.O CAN SM FRAG PT 22M 407.022 48712570_1 CDM 0278 RC inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 4.O CAN SM FRAG PT 22M 407.022 48712570_1 CDM 0278 RC inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges 4.O CAN SM FRAG PT 22M 407.022 48712570_1 CDM 0278 RC inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 4.0 CAN SM FRAG PT 24M 407.024 48712571_1 CDM 0278 RC inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges 4.0 CAN SM FRAG PT 24M 407.024 48712571_1 CDM 0278 RC inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges 4.0 CAN SM FRAG PT 24M 407.024 48712571_1 CDM 0278 RC inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges 4.0 CAN SM FRAG PT 24M 407.024 48712571_1 CDM 0278 RC inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges 4.0 CAN SM FRAG PT 24M 407.024 48712571_1 CDM 0278 RC inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges 4.0 CAN SM FRAG PT 24M 407.024 48712571_1 CDM 0278 RC inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges 4.0 CAN SM FRAG PT 24M 407.024 48712571_1 CDM 0278 RC inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges 4.0 CAN SM FRAG PT 24M 407.024 48712571_1 CDM 0278 RC inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges 4.0 CAN SM FRAG PT 24M 407.024 48712571_1 CDM 0278 RC inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 4.0 CAN SM FRAG PT 24M 407.024 48712571_1 CDM 0278 RC inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 4.0 CAN SM FRAG PT 24M 407.024 48712571_1 CDM 0278 RC inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 4.0 CAN SM FRAG PT 24M 407.024 48712571_1 CDM 0278 RC inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 4.0 CAN SM FRAG PT 24M 407.024 48712571_1 CDM 0278 RC inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges 4.0 CAN SM FRAG PT 24M 407.024 48712571_1 CDM 0278 RC inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 4.0 CAN SM FRAG PT 26M 407.026 48712572_1 CDM 0278 RC inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges 4.0 CAN SM FRAG PT 26M 407.026 48712572_1 CDM 0278 RC inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges 4.0 CAN SM FRAG PT 26M 407.026 48712572_1 CDM 0278 RC inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges 4.0 CAN SM FRAG PT 26M 407.026 48712572_1 CDM 0278 RC inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges 4.0 CAN SM FRAG PT 26M 407.026 48712572_1 CDM 0278 RC inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges 4.0 CAN SM FRAG PT 26M 407.026 48712572_1 CDM 0278 RC inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges 4.0 CAN SM FRAG PT 26M 407.026 48712572_1 CDM 0278 RC inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges 4.0 CAN SM FRAG PT 26M 407.026 48712572_1 CDM 0278 RC inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges 4.0 CAN SM FRAG PT 26M 407.026 48712572_1 CDM 0278 RC inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 4.0 CAN SM FRAG PT 26M 407.026 48712572_1 CDM 0278 RC inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 4.0 CAN SM FRAG PT 26M 407.026 48712572_1 CDM 0278 RC inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 4.0 CAN SM FRAG PT 26M 407.026 48712572_1 CDM 0278 RC inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 4.0 CAN SM FRAG PT 26M 407.026 48712572_1 CDM 0278 RC inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges 4.0 CAN SM FRAG PT 26M 407.026 48712572_1 CDM 0278 RC inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 4.0 CAN SM FRAG FT 60M 406.060 48712573_1 CDM 0278 RC inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 60M 406.060 48712573_1 CDM 0278 RC inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 60M 406.060 48712573_1 CDM 0278 RC inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 60M 406.060 48712573_1 CDM 0278 RC inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 60M 406.060 48712573_1 CDM 0278 RC inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 60M 406.060 48712573_1 CDM 0278 RC inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 60M 406.060 48712573_1 CDM 0278 RC inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 60M 406.060 48712573_1 CDM 0278 RC inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 60M 406.060 48712573_1 CDM 0278 RC inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 4.0 CAN SM FRAG FT 60M 406.060 48712573_1 CDM 0278 RC inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 4.0 CAN SM FRAG FT 60M 406.060 48712573_1 CDM 0278 RC inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 4.0 CAN SM FRAG FT 60M 406.060 48712573_1 CDM 0278 RC inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 4.0 CAN SM FRAG FT 60M 406.060 48712573_1 CDM 0278 RC inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 60M 406.060 48712573_1 CDM 0278 RC inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 4.0 CAN SM FRAG FT 55M 406.055 48712574_1 CDM 0278 RC inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 55M 406.055 48712574_1 CDM 0278 RC inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 55M 406.055 48712574_1 CDM 0278 RC inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 55M 406.055 48712574_1 CDM 0278 RC inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 55M 406.055 48712574_1 CDM 0278 RC inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 55M 406.055 48712574_1 CDM 0278 RC inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 55M 406.055 48712574_1 CDM 0278 RC inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 55M 406.055 48712574_1 CDM 0278 RC inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 55M 406.055 48712574_1 CDM 0278 RC inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 4.0 CAN SM FRAG FT 55M 406.055 48712574_1 CDM 0278 RC inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 4.0 CAN SM FRAG FT 55M 406.055 48712574_1 CDM 0278 RC inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 4.0 CAN SM FRAG FT 55M 406.055 48712574_1 CDM 0278 RC inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 4.0 CAN SM FRAG FT 55M 406.055 48712574_1 CDM 0278 RC inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 55M 406.055 48712574_1 CDM 0278 RC inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 4.0 CAN SM FRAG FT 50M 406.050 48712575_1 CDM 0278 RC inpatient 126 81.9 AETNA AETNA 99.54 79 999999999 76.29 122.22 percent of total billed charges 4.0 CAN SM FRAG FT 50M 406.050 48712575_1 CDM 0278 RC inpatient 126 81.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.9 65 999999999 76.29 122.22 percent of total billed charges 4.0 CAN SM FRAG FT 50M 406.050 48712575_1 CDM 0278 RC inpatient 126 81.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 122.22 97 999999999 76.29 122.22 percent of total billed charges 4.0 CAN SM FRAG FT 50M 406.050 48712575_1 CDM 0278 RC inpatient 126 81.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 98.28 78 999999999 76.29 122.22 percent of total billed charges 4.0 CAN SM FRAG FT 50M 406.050 48712575_1 CDM 0278 RC inpatient 126 81.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.94 69 999999999 76.29 122.22 percent of total billed charges 4.0 CAN SM FRAG FT 50M 406.050 48712575_1 CDM 0278 RC inpatient 126 81.9 UMR - ALL PLANS UMR - ALL PLANS 88.2 70 999999999 76.29 122.22 percent of total billed charges 4.0 CAN SM FRAG FT 50M 406.050 48712575_1 CDM 0278 RC inpatient 126 81.9 SIHO - ALL PLANS SIHO - ALL PLANS 113.4 90 999999999 76.29 122.22 percent of total billed charges 4.0 CAN SM FRAG FT 50M 406.050 48712575_1 CDM 0278 RC inpatient 126 81.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.29 60.55 999999999 76.29 122.22 percent of total billed charges 4.0 CAN SM FRAG FT 50M 406.050 48712575_1 CDM 0278 RC inpatient 126 81.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.29 122.22 4.0 CAN SM FRAG FT 50M 406.050 48712575_1 CDM 0278 RC inpatient 126 81.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.29 122.22 4.0 CAN SM FRAG FT 50M 406.050 48712575_1 CDM 0278 RC inpatient 126 81.9 ANTHEM HMO ANTHEM HMO 999999999 76.29 122.22 4.0 CAN SM FRAG FT 50M 406.050 48712575_1 CDM 0278 RC inpatient 126 81.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.29 122.22 4.0 CAN SM FRAG FT 50M 406.050 48712575_1 CDM 0278 RC inpatient 126 81.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.18 67.6 999999999 76.29 122.22 percent of total billed charges 4.0 CAN SM FRAG FT 50M 406.050 48712575_1 CDM 0278 RC inpatient 126 81.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.29 122.22 4.0 CAN SM FRAG FT 45M 406.045 48712576_1 CDM 0278 RC inpatient 145 94.25 AETNA AETNA 114.55 79 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 45M 406.045 48712576_1 CDM 0278 RC inpatient 145 94.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.25 65 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 45M 406.045 48712576_1 CDM 0278 RC inpatient 145 94.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 140.65 97 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 45M 406.045 48712576_1 CDM 0278 RC inpatient 145 94.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.1 78 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 45M 406.045 48712576_1 CDM 0278 RC inpatient 145 94.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.05 69 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 45M 406.045 48712576_1 CDM 0278 RC inpatient 145 94.25 UMR - ALL PLANS UMR - ALL PLANS 101.5 70 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 45M 406.045 48712576_1 CDM 0278 RC inpatient 145 94.25 SIHO - ALL PLANS SIHO - ALL PLANS 130.5 90 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 45M 406.045 48712576_1 CDM 0278 RC inpatient 145 94.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.8 60.55 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 45M 406.045 48712576_1 CDM 0278 RC inpatient 145 94.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.8 140.65 4.0 CAN SM FRAG FT 45M 406.045 48712576_1 CDM 0278 RC inpatient 145 94.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.8 140.65 4.0 CAN SM FRAG FT 45M 406.045 48712576_1 CDM 0278 RC inpatient 145 94.25 ANTHEM HMO ANTHEM HMO 999999999 87.8 140.65 4.0 CAN SM FRAG FT 45M 406.045 48712576_1 CDM 0278 RC inpatient 145 94.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.8 140.65 4.0 CAN SM FRAG FT 45M 406.045 48712576_1 CDM 0278 RC inpatient 145 94.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.02 67.6 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 45M 406.045 48712576_1 CDM 0278 RC inpatient 145 94.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.8 140.65 4.0 CAN SM FRAG FT 35M 406.035 48712578_1 CDM 0278 RC inpatient 60 39 AETNA AETNA 47.4 79 999999999 36.33 58.2 percent of total billed charges 4.0 CAN SM FRAG FT 35M 406.035 48712578_1 CDM 0278 RC inpatient 60 39 SELF PAY DISCOUNT SELF PAY DISCOUNT 39 65 999999999 36.33 58.2 percent of total billed charges 4.0 CAN SM FRAG FT 35M 406.035 48712578_1 CDM 0278 RC inpatient 60 39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.2 97 999999999 36.33 58.2 percent of total billed charges 4.0 CAN SM FRAG FT 35M 406.035 48712578_1 CDM 0278 RC inpatient 60 39 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.8 78 999999999 36.33 58.2 percent of total billed charges 4.0 CAN SM FRAG FT 35M 406.035 48712578_1 CDM 0278 RC inpatient 60 39 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.4 69 999999999 36.33 58.2 percent of total billed charges 4.0 CAN SM FRAG FT 35M 406.035 48712578_1 CDM 0278 RC inpatient 60 39 UMR - ALL PLANS UMR - ALL PLANS 42 70 999999999 36.33 58.2 percent of total billed charges 4.0 CAN SM FRAG FT 35M 406.035 48712578_1 CDM 0278 RC inpatient 60 39 SIHO - ALL PLANS SIHO - ALL PLANS 54 90 999999999 36.33 58.2 percent of total billed charges 4.0 CAN SM FRAG FT 35M 406.035 48712578_1 CDM 0278 RC inpatient 60 39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.33 60.55 999999999 36.33 58.2 percent of total billed charges 4.0 CAN SM FRAG FT 35M 406.035 48712578_1 CDM 0278 RC inpatient 60 39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.33 58.2 4.0 CAN SM FRAG FT 35M 406.035 48712578_1 CDM 0278 RC inpatient 60 39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.33 58.2 4.0 CAN SM FRAG FT 35M 406.035 48712578_1 CDM 0278 RC inpatient 60 39 ANTHEM HMO ANTHEM HMO 999999999 36.33 58.2 4.0 CAN SM FRAG FT 35M 406.035 48712578_1 CDM 0278 RC inpatient 60 39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.33 58.2 4.0 CAN SM FRAG FT 35M 406.035 48712578_1 CDM 0278 RC inpatient 60 39 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.56 67.6 999999999 36.33 58.2 percent of total billed charges 4.0 CAN SM FRAG FT 35M 406.035 48712578_1 CDM 0278 RC inpatient 60 39 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.33 58.2 4.0 CAN SM FRAG FT 30M 406.030 48712579_1 CDM 0278 RC inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 30M 406.030 48712579_1 CDM 0278 RC inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 30M 406.030 48712579_1 CDM 0278 RC inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 30M 406.030 48712579_1 CDM 0278 RC inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 30M 406.030 48712579_1 CDM 0278 RC inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 30M 406.030 48712579_1 CDM 0278 RC inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 30M 406.030 48712579_1 CDM 0278 RC inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 30M 406.030 48712579_1 CDM 0278 RC inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 30M 406.030 48712579_1 CDM 0278 RC inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 4.0 CAN SM FRAG FT 30M 406.030 48712579_1 CDM 0278 RC inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 4.0 CAN SM FRAG FT 30M 406.030 48712579_1 CDM 0278 RC inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 4.0 CAN SM FRAG FT 30M 406.030 48712579_1 CDM 0278 RC inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 4.0 CAN SM FRAG FT 30M 406.030 48712579_1 CDM 0278 RC inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 30M 406.030 48712579_1 CDM 0278 RC inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 4.0 CAN SM FRAG FT 28M 406.028 48712580_1 CDM 0278 RC inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 28M 406.028 48712580_1 CDM 0278 RC inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 28M 406.028 48712580_1 CDM 0278 RC inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 28M 406.028 48712580_1 CDM 0278 RC inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 28M 406.028 48712580_1 CDM 0278 RC inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 28M 406.028 48712580_1 CDM 0278 RC inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 28M 406.028 48712580_1 CDM 0278 RC inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 28M 406.028 48712580_1 CDM 0278 RC inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 28M 406.028 48712580_1 CDM 0278 RC inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 4.0 CAN SM FRAG FT 28M 406.028 48712580_1 CDM 0278 RC inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 4.0 CAN SM FRAG FT 28M 406.028 48712580_1 CDM 0278 RC inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 4.0 CAN SM FRAG FT 28M 406.028 48712580_1 CDM 0278 RC inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 4.0 CAN SM FRAG FT 28M 406.028 48712580_1 CDM 0278 RC inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG FT 28M 406.028 48712580_1 CDM 0278 RC inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 4.O CAN SM FRAG FT 26M 406.026 48712581_1 CDM 0278 RC inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges 4.O CAN SM FRAG FT 26M 406.026 48712581_1 CDM 0278 RC inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges 4.O CAN SM FRAG FT 26M 406.026 48712581_1 CDM 0278 RC inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges 4.O CAN SM FRAG FT 26M 406.026 48712581_1 CDM 0278 RC inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges 4.O CAN SM FRAG FT 26M 406.026 48712581_1 CDM 0278 RC inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges 4.O CAN SM FRAG FT 26M 406.026 48712581_1 CDM 0278 RC inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges 4.O CAN SM FRAG FT 26M 406.026 48712581_1 CDM 0278 RC inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges 4.O CAN SM FRAG FT 26M 406.026 48712581_1 CDM 0278 RC inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges 4.O CAN SM FRAG FT 26M 406.026 48712581_1 CDM 0278 RC inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 4.O CAN SM FRAG FT 26M 406.026 48712581_1 CDM 0278 RC inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 4.O CAN SM FRAG FT 26M 406.026 48712581_1 CDM 0278 RC inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 4.O CAN SM FRAG FT 26M 406.026 48712581_1 CDM 0278 RC inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 4.O CAN SM FRAG FT 26M 406.026 48712581_1 CDM 0278 RC inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges 4.O CAN SM FRAG FT 26M 406.026 48712581_1 CDM 0278 RC inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 4.0 CAN SM FRAG FT 24M 406.024 48712582_1 CDM 0278 RC inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 24M 406.024 48712582_1 CDM 0278 RC inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 24M 406.024 48712582_1 CDM 0278 RC inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 24M 406.024 48712582_1 CDM 0278 RC inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 24M 406.024 48712582_1 CDM 0278 RC inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 24M 406.024 48712582_1 CDM 0278 RC inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 24M 406.024 48712582_1 CDM 0278 RC inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 24M 406.024 48712582_1 CDM 0278 RC inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 24M 406.024 48712582_1 CDM 0278 RC inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 4.0 CAN SM FRAG FT 24M 406.024 48712582_1 CDM 0278 RC inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 4.0 CAN SM FRAG FT 24M 406.024 48712582_1 CDM 0278 RC inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 4.0 CAN SM FRAG FT 24M 406.024 48712582_1 CDM 0278 RC inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 4.0 CAN SM FRAG FT 24M 406.024 48712582_1 CDM 0278 RC inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 24M 406.024 48712582_1 CDM 0278 RC inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 4.0 CAN SM FRAG FT 22M 406.022 48712583_1 CDM 0278 RC inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 22M 406.022 48712583_1 CDM 0278 RC inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 22M 406.022 48712583_1 CDM 0278 RC inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 22M 406.022 48712583_1 CDM 0278 RC inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 22M 406.022 48712583_1 CDM 0278 RC inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 22M 406.022 48712583_1 CDM 0278 RC inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 22M 406.022 48712583_1 CDM 0278 RC inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 22M 406.022 48712583_1 CDM 0278 RC inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 22M 406.022 48712583_1 CDM 0278 RC inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 4.0 CAN SM FRAG FT 22M 406.022 48712583_1 CDM 0278 RC inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 4.0 CAN SM FRAG FT 22M 406.022 48712583_1 CDM 0278 RC inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 4.0 CAN SM FRAG FT 22M 406.022 48712583_1 CDM 0278 RC inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 4.0 CAN SM FRAG FT 22M 406.022 48712583_1 CDM 0278 RC inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges 4.0 CAN SM FRAG FT 22M 406.022 48712583_1 CDM 0278 RC inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 4.0 CAN SM FRAG FT 20M 406.020 48712584_1 CDM 0278 RC inpatient 145 94.25 AETNA AETNA 114.55 79 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 20M 406.020 48712584_1 CDM 0278 RC inpatient 145 94.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.25 65 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 20M 406.020 48712584_1 CDM 0278 RC inpatient 145 94.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 140.65 97 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 20M 406.020 48712584_1 CDM 0278 RC inpatient 145 94.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.1 78 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 20M 406.020 48712584_1 CDM 0278 RC inpatient 145 94.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.05 69 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 20M 406.020 48712584_1 CDM 0278 RC inpatient 145 94.25 UMR - ALL PLANS UMR - ALL PLANS 101.5 70 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 20M 406.020 48712584_1 CDM 0278 RC inpatient 145 94.25 SIHO - ALL PLANS SIHO - ALL PLANS 130.5 90 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 20M 406.020 48712584_1 CDM 0278 RC inpatient 145 94.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.8 60.55 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 20M 406.020 48712584_1 CDM 0278 RC inpatient 145 94.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.8 140.65 4.0 CAN SM FRAG FT 20M 406.020 48712584_1 CDM 0278 RC inpatient 145 94.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.8 140.65 4.0 CAN SM FRAG FT 20M 406.020 48712584_1 CDM 0278 RC inpatient 145 94.25 ANTHEM HMO ANTHEM HMO 999999999 87.8 140.65 4.0 CAN SM FRAG FT 20M 406.020 48712584_1 CDM 0278 RC inpatient 145 94.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.8 140.65 4.0 CAN SM FRAG FT 20M 406.020 48712584_1 CDM 0278 RC inpatient 145 94.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.02 67.6 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 20M 406.020 48712584_1 CDM 0278 RC inpatient 145 94.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.8 140.65 4.0 CAN SM FRAG FT 18M 406.018 48712585_1 CDM 0278 RC inpatient 141 91.65 AETNA AETNA 111.39 79 999999999 85.38 136.77 percent of total billed charges 4.0 CAN SM FRAG FT 18M 406.018 48712585_1 CDM 0278 RC inpatient 141 91.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 91.65 65 999999999 85.38 136.77 percent of total billed charges 4.0 CAN SM FRAG FT 18M 406.018 48712585_1 CDM 0278 RC inpatient 141 91.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 136.77 97 999999999 85.38 136.77 percent of total billed charges 4.0 CAN SM FRAG FT 18M 406.018 48712585_1 CDM 0278 RC inpatient 141 91.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 109.98 78 999999999 85.38 136.77 percent of total billed charges 4.0 CAN SM FRAG FT 18M 406.018 48712585_1 CDM 0278 RC inpatient 141 91.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.29 69 999999999 85.38 136.77 percent of total billed charges 4.0 CAN SM FRAG FT 18M 406.018 48712585_1 CDM 0278 RC inpatient 141 91.65 UMR - ALL PLANS UMR - ALL PLANS 98.7 70 999999999 85.38 136.77 percent of total billed charges 4.0 CAN SM FRAG FT 18M 406.018 48712585_1 CDM 0278 RC inpatient 141 91.65 SIHO - ALL PLANS SIHO - ALL PLANS 126.9 90 999999999 85.38 136.77 percent of total billed charges 4.0 CAN SM FRAG FT 18M 406.018 48712585_1 CDM 0278 RC inpatient 141 91.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.38 60.55 999999999 85.38 136.77 percent of total billed charges 4.0 CAN SM FRAG FT 18M 406.018 48712585_1 CDM 0278 RC inpatient 141 91.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.38 136.77 4.0 CAN SM FRAG FT 18M 406.018 48712585_1 CDM 0278 RC inpatient 141 91.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.38 136.77 4.0 CAN SM FRAG FT 18M 406.018 48712585_1 CDM 0278 RC inpatient 141 91.65 ANTHEM HMO ANTHEM HMO 999999999 85.38 136.77 4.0 CAN SM FRAG FT 18M 406.018 48712585_1 CDM 0278 RC inpatient 141 91.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.38 136.77 4.0 CAN SM FRAG FT 18M 406.018 48712585_1 CDM 0278 RC inpatient 141 91.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.32 67.6 999999999 85.38 136.77 percent of total billed charges 4.0 CAN SM FRAG FT 18M 406.018 48712585_1 CDM 0278 RC inpatient 141 91.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.38 136.77 4.0 CAN SM FRAG FT 10M 406.010 48712586_1 CDM 0278 RC inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges 4.0 CAN SM FRAG FT 10M 406.010 48712586_1 CDM 0278 RC inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges 4.0 CAN SM FRAG FT 10M 406.010 48712586_1 CDM 0278 RC inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges 4.0 CAN SM FRAG FT 10M 406.010 48712586_1 CDM 0278 RC inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges 4.0 CAN SM FRAG FT 10M 406.010 48712586_1 CDM 0278 RC inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges 4.0 CAN SM FRAG FT 10M 406.010 48712586_1 CDM 0278 RC inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges 4.0 CAN SM FRAG FT 10M 406.010 48712586_1 CDM 0278 RC inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges 4.0 CAN SM FRAG FT 10M 406.010 48712586_1 CDM 0278 RC inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges 4.0 CAN SM FRAG FT 10M 406.010 48712586_1 CDM 0278 RC inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 4.0 CAN SM FRAG FT 10M 406.010 48712586_1 CDM 0278 RC inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 4.0 CAN SM FRAG FT 10M 406.010 48712586_1 CDM 0278 RC inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 4.0 CAN SM FRAG FT 10M 406.010 48712586_1 CDM 0278 RC inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 4.0 CAN SM FRAG FT 10M 406.010 48712586_1 CDM 0278 RC inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges 4.0 CAN SM FRAG FT 10M 406.010 48712586_1 CDM 0278 RC inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 4.0 CAN SM FRAG FT 12M 406.012 48712587_1 CDM 0278 RC inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges 4.0 CAN SM FRAG FT 12M 406.012 48712587_1 CDM 0278 RC inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges 4.0 CAN SM FRAG FT 12M 406.012 48712587_1 CDM 0278 RC inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges 4.0 CAN SM FRAG FT 12M 406.012 48712587_1 CDM 0278 RC inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges 4.0 CAN SM FRAG FT 12M 406.012 48712587_1 CDM 0278 RC inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges 4.0 CAN SM FRAG FT 12M 406.012 48712587_1 CDM 0278 RC inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges 4.0 CAN SM FRAG FT 12M 406.012 48712587_1 CDM 0278 RC inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges 4.0 CAN SM FRAG FT 12M 406.012 48712587_1 CDM 0278 RC inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges 4.0 CAN SM FRAG FT 12M 406.012 48712587_1 CDM 0278 RC inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 4.0 CAN SM FRAG FT 12M 406.012 48712587_1 CDM 0278 RC inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 4.0 CAN SM FRAG FT 12M 406.012 48712587_1 CDM 0278 RC inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 4.0 CAN SM FRAG FT 12M 406.012 48712587_1 CDM 0278 RC inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 4.0 CAN SM FRAG FT 12M 406.012 48712587_1 CDM 0278 RC inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges 4.0 CAN SM FRAG FT 12M 406.012 48712587_1 CDM 0278 RC inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 4.0 CAN SM FRAG FT 14M 406.014 48712588_1 CDM 0278 RC inpatient 145 94.25 AETNA AETNA 114.55 79 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 14M 406.014 48712588_1 CDM 0278 RC inpatient 145 94.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.25 65 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 14M 406.014 48712588_1 CDM 0278 RC inpatient 145 94.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 140.65 97 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 14M 406.014 48712588_1 CDM 0278 RC inpatient 145 94.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.1 78 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 14M 406.014 48712588_1 CDM 0278 RC inpatient 145 94.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.05 69 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 14M 406.014 48712588_1 CDM 0278 RC inpatient 145 94.25 UMR - ALL PLANS UMR - ALL PLANS 101.5 70 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 14M 406.014 48712588_1 CDM 0278 RC inpatient 145 94.25 SIHO - ALL PLANS SIHO - ALL PLANS 130.5 90 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 14M 406.014 48712588_1 CDM 0278 RC inpatient 145 94.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.8 60.55 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 14M 406.014 48712588_1 CDM 0278 RC inpatient 145 94.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.8 140.65 4.0 CAN SM FRAG FT 14M 406.014 48712588_1 CDM 0278 RC inpatient 145 94.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.8 140.65 4.0 CAN SM FRAG FT 14M 406.014 48712588_1 CDM 0278 RC inpatient 145 94.25 ANTHEM HMO ANTHEM HMO 999999999 87.8 140.65 4.0 CAN SM FRAG FT 14M 406.014 48712588_1 CDM 0278 RC inpatient 145 94.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.8 140.65 4.0 CAN SM FRAG FT 14M 406.014 48712588_1 CDM 0278 RC inpatient 145 94.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.02 67.6 999999999 87.8 140.65 percent of total billed charges 4.0 CAN SM FRAG FT 14M 406.014 48712588_1 CDM 0278 RC inpatient 145 94.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.8 140.65 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712589_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 AETNA AETNA 114.55 79 999999999 87.8 140.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712589_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.25 65 999999999 87.8 140.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712589_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 140.65 97 999999999 87.8 140.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712589_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.1 78 999999999 87.8 140.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712589_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.05 69 999999999 87.8 140.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712589_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 UMR - ALL PLANS UMR - ALL PLANS 101.5 70 999999999 87.8 140.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712589_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 SIHO - ALL PLANS SIHO - ALL PLANS 130.5 90 999999999 87.8 140.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712589_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.8 60.55 999999999 87.8 140.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712589_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.8 140.65 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712589_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.8 140.65 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712589_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 ANTHEM HMO ANTHEM HMO 999999999 87.8 140.65 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712589_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.8 140.65 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712589_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.02 67.6 999999999 87.8 140.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712589_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.8 140.65 4.0 CAN SM FRAG PT 28M 407.028 48712590_1 CDM 0278 RC inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG PT 28M 407.028 48712590_1 CDM 0278 RC inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG PT 28M 407.028 48712590_1 CDM 0278 RC inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG PT 28M 407.028 48712590_1 CDM 0278 RC inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG PT 28M 407.028 48712590_1 CDM 0278 RC inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG PT 28M 407.028 48712590_1 CDM 0278 RC inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG PT 28M 407.028 48712590_1 CDM 0278 RC inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG PT 28M 407.028 48712590_1 CDM 0278 RC inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG PT 28M 407.028 48712590_1 CDM 0278 RC inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 4.0 CAN SM FRAG PT 28M 407.028 48712590_1 CDM 0278 RC inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 4.0 CAN SM FRAG PT 28M 407.028 48712590_1 CDM 0278 RC inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 4.0 CAN SM FRAG PT 28M 407.028 48712590_1 CDM 0278 RC inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 4.0 CAN SM FRAG PT 28M 407.028 48712590_1 CDM 0278 RC inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges 4.0 CAN SM FRAG PT 28M 407.028 48712590_1 CDM 0278 RC inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 4.0 CAN SM FRAG PT 30M 407.030 48712591_1 CDM 0278 RC inpatient 120 78 AETNA AETNA 94.8 79 999999999 72.66 116.4 percent of total billed charges 4.0 CAN SM FRAG PT 30M 407.030 48712591_1 CDM 0278 RC inpatient 120 78 SELF PAY DISCOUNT SELF PAY DISCOUNT 78 65 999999999 72.66 116.4 percent of total billed charges 4.0 CAN SM FRAG PT 30M 407.030 48712591_1 CDM 0278 RC inpatient 120 78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.4 97 999999999 72.66 116.4 percent of total billed charges 4.0 CAN SM FRAG PT 30M 407.030 48712591_1 CDM 0278 RC inpatient 120 78 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.6 78 999999999 72.66 116.4 percent of total billed charges 4.0 CAN SM FRAG PT 30M 407.030 48712591_1 CDM 0278 RC inpatient 120 78 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.8 69 999999999 72.66 116.4 percent of total billed charges 4.0 CAN SM FRAG PT 30M 407.030 48712591_1 CDM 0278 RC inpatient 120 78 UMR - ALL PLANS UMR - ALL PLANS 84 70 999999999 72.66 116.4 percent of total billed charges 4.0 CAN SM FRAG PT 30M 407.030 48712591_1 CDM 0278 RC inpatient 120 78 SIHO - ALL PLANS SIHO - ALL PLANS 108 90 999999999 72.66 116.4 percent of total billed charges 4.0 CAN SM FRAG PT 30M 407.030 48712591_1 CDM 0278 RC inpatient 120 78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.66 60.55 999999999 72.66 116.4 percent of total billed charges 4.0 CAN SM FRAG PT 30M 407.030 48712591_1 CDM 0278 RC inpatient 120 78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.66 116.4 4.0 CAN SM FRAG PT 30M 407.030 48712591_1 CDM 0278 RC inpatient 120 78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.66 116.4 4.0 CAN SM FRAG PT 30M 407.030 48712591_1 CDM 0278 RC inpatient 120 78 ANTHEM HMO ANTHEM HMO 999999999 72.66 116.4 4.0 CAN SM FRAG PT 30M 407.030 48712591_1 CDM 0278 RC inpatient 120 78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.66 116.4 4.0 CAN SM FRAG PT 30M 407.030 48712591_1 CDM 0278 RC inpatient 120 78 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.12 67.6 999999999 72.66 116.4 percent of total billed charges 4.0 CAN SM FRAG PT 30M 407.030 48712591_1 CDM 0278 RC inpatient 120 78 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.66 116.4 4.0 CAN SM FRAG PT 35M 407.035 48712592_1 CDM 0278 RC inpatient 120 78 AETNA AETNA 94.8 79 999999999 72.66 116.4 percent of total billed charges 4.0 CAN SM FRAG PT 35M 407.035 48712592_1 CDM 0278 RC inpatient 120 78 SELF PAY DISCOUNT SELF PAY DISCOUNT 78 65 999999999 72.66 116.4 percent of total billed charges 4.0 CAN SM FRAG PT 35M 407.035 48712592_1 CDM 0278 RC inpatient 120 78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.4 97 999999999 72.66 116.4 percent of total billed charges 4.0 CAN SM FRAG PT 35M 407.035 48712592_1 CDM 0278 RC inpatient 120 78 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.6 78 999999999 72.66 116.4 percent of total billed charges 4.0 CAN SM FRAG PT 35M 407.035 48712592_1 CDM 0278 RC inpatient 120 78 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.8 69 999999999 72.66 116.4 percent of total billed charges 4.0 CAN SM FRAG PT 35M 407.035 48712592_1 CDM 0278 RC inpatient 120 78 UMR - ALL PLANS UMR - ALL PLANS 84 70 999999999 72.66 116.4 percent of total billed charges 4.0 CAN SM FRAG PT 35M 407.035 48712592_1 CDM 0278 RC inpatient 120 78 SIHO - ALL PLANS SIHO - ALL PLANS 108 90 999999999 72.66 116.4 percent of total billed charges 4.0 CAN SM FRAG PT 35M 407.035 48712592_1 CDM 0278 RC inpatient 120 78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.66 60.55 999999999 72.66 116.4 percent of total billed charges 4.0 CAN SM FRAG PT 35M 407.035 48712592_1 CDM 0278 RC inpatient 120 78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.66 116.4 4.0 CAN SM FRAG PT 35M 407.035 48712592_1 CDM 0278 RC inpatient 120 78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.66 116.4 4.0 CAN SM FRAG PT 35M 407.035 48712592_1 CDM 0278 RC inpatient 120 78 ANTHEM HMO ANTHEM HMO 999999999 72.66 116.4 4.0 CAN SM FRAG PT 35M 407.035 48712592_1 CDM 0278 RC inpatient 120 78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.66 116.4 4.0 CAN SM FRAG PT 35M 407.035 48712592_1 CDM 0278 RC inpatient 120 78 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.12 67.6 999999999 72.66 116.4 percent of total billed charges 4.0 CAN SM FRAG PT 35M 407.035 48712592_1 CDM 0278 RC inpatient 120 78 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.66 116.4 4.0 CAN SM FRAG PT 40M 407.040 48712593_1 CDM 0278 RC inpatient 138 89.7 AETNA AETNA 109.02 79 999999999 83.56 133.86 percent of total billed charges 4.0 CAN SM FRAG PT 40M 407.040 48712593_1 CDM 0278 RC inpatient 138 89.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.7 65 999999999 83.56 133.86 percent of total billed charges 4.0 CAN SM FRAG PT 40M 407.040 48712593_1 CDM 0278 RC inpatient 138 89.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 133.86 97 999999999 83.56 133.86 percent of total billed charges 4.0 CAN SM FRAG PT 40M 407.040 48712593_1 CDM 0278 RC inpatient 138 89.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 107.64 78 999999999 83.56 133.86 percent of total billed charges 4.0 CAN SM FRAG PT 40M 407.040 48712593_1 CDM 0278 RC inpatient 138 89.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.22 69 999999999 83.56 133.86 percent of total billed charges 4.0 CAN SM FRAG PT 40M 407.040 48712593_1 CDM 0278 RC inpatient 138 89.7 UMR - ALL PLANS UMR - ALL PLANS 96.6 70 999999999 83.56 133.86 percent of total billed charges 4.0 CAN SM FRAG PT 40M 407.040 48712593_1 CDM 0278 RC inpatient 138 89.7 SIHO - ALL PLANS SIHO - ALL PLANS 124.2 90 999999999 83.56 133.86 percent of total billed charges 4.0 CAN SM FRAG PT 40M 407.040 48712593_1 CDM 0278 RC inpatient 138 89.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 83.56 60.55 999999999 83.56 133.86 percent of total billed charges 4.0 CAN SM FRAG PT 40M 407.040 48712593_1 CDM 0278 RC inpatient 138 89.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 83.56 133.86 4.0 CAN SM FRAG PT 40M 407.040 48712593_1 CDM 0278 RC inpatient 138 89.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 83.56 133.86 4.0 CAN SM FRAG PT 40M 407.040 48712593_1 CDM 0278 RC inpatient 138 89.7 ANTHEM HMO ANTHEM HMO 999999999 83.56 133.86 4.0 CAN SM FRAG PT 40M 407.040 48712593_1 CDM 0278 RC inpatient 138 89.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 83.56 133.86 4.0 CAN SM FRAG PT 40M 407.040 48712593_1 CDM 0278 RC inpatient 138 89.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.29 67.6 999999999 83.56 133.86 percent of total billed charges 4.0 CAN SM FRAG PT 40M 407.040 48712593_1 CDM 0278 RC inpatient 138 89.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 83.56 133.86 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712594_1 CDM 0278 RC C1713 HCPCS inpatient 138 89.7 AETNA AETNA 109.02 79 999999999 83.56 133.86 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712594_1 CDM 0278 RC C1713 HCPCS inpatient 138 89.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.7 65 999999999 83.56 133.86 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712594_1 CDM 0278 RC C1713 HCPCS inpatient 138 89.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 133.86 97 999999999 83.56 133.86 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712594_1 CDM 0278 RC C1713 HCPCS inpatient 138 89.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 107.64 78 999999999 83.56 133.86 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712594_1 CDM 0278 RC C1713 HCPCS inpatient 138 89.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.22 69 999999999 83.56 133.86 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712594_1 CDM 0278 RC C1713 HCPCS inpatient 138 89.7 UMR - ALL PLANS UMR - ALL PLANS 96.6 70 999999999 83.56 133.86 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712594_1 CDM 0278 RC C1713 HCPCS inpatient 138 89.7 SIHO - ALL PLANS SIHO - ALL PLANS 124.2 90 999999999 83.56 133.86 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712594_1 CDM 0278 RC C1713 HCPCS inpatient 138 89.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 83.56 60.55 999999999 83.56 133.86 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712594_1 CDM 0278 RC C1713 HCPCS inpatient 138 89.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 83.56 133.86 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712594_1 CDM 0278 RC C1713 HCPCS inpatient 138 89.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 83.56 133.86 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712594_1 CDM 0278 RC C1713 HCPCS inpatient 138 89.7 ANTHEM HMO ANTHEM HMO 999999999 83.56 133.86 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712594_1 CDM 0278 RC C1713 HCPCS inpatient 138 89.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 83.56 133.86 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712594_1 CDM 0278 RC C1713 HCPCS inpatient 138 89.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.29 67.6 999999999 83.56 133.86 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712594_1 CDM 0278 RC C1713 HCPCS inpatient 138 89.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 83.56 133.86 4.0 CAN SM FRAG PT 50M 407.050 48712595_1 CDM 0278 RC inpatient 138 89.7 AETNA AETNA 109.02 79 999999999 83.56 133.86 percent of total billed charges 4.0 CAN SM FRAG PT 50M 407.050 48712595_1 CDM 0278 RC inpatient 138 89.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.7 65 999999999 83.56 133.86 percent of total billed charges 4.0 CAN SM FRAG PT 50M 407.050 48712595_1 CDM 0278 RC inpatient 138 89.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 133.86 97 999999999 83.56 133.86 percent of total billed charges 4.0 CAN SM FRAG PT 50M 407.050 48712595_1 CDM 0278 RC inpatient 138 89.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 107.64 78 999999999 83.56 133.86 percent of total billed charges 4.0 CAN SM FRAG PT 50M 407.050 48712595_1 CDM 0278 RC inpatient 138 89.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.22 69 999999999 83.56 133.86 percent of total billed charges 4.0 CAN SM FRAG PT 50M 407.050 48712595_1 CDM 0278 RC inpatient 138 89.7 UMR - ALL PLANS UMR - ALL PLANS 96.6 70 999999999 83.56 133.86 percent of total billed charges 4.0 CAN SM FRAG PT 50M 407.050 48712595_1 CDM 0278 RC inpatient 138 89.7 SIHO - ALL PLANS SIHO - ALL PLANS 124.2 90 999999999 83.56 133.86 percent of total billed charges 4.0 CAN SM FRAG PT 50M 407.050 48712595_1 CDM 0278 RC inpatient 138 89.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 83.56 60.55 999999999 83.56 133.86 percent of total billed charges 4.0 CAN SM FRAG PT 50M 407.050 48712595_1 CDM 0278 RC inpatient 138 89.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 83.56 133.86 4.0 CAN SM FRAG PT 50M 407.050 48712595_1 CDM 0278 RC inpatient 138 89.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 83.56 133.86 4.0 CAN SM FRAG PT 50M 407.050 48712595_1 CDM 0278 RC inpatient 138 89.7 ANTHEM HMO ANTHEM HMO 999999999 83.56 133.86 4.0 CAN SM FRAG PT 50M 407.050 48712595_1 CDM 0278 RC inpatient 138 89.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 83.56 133.86 4.0 CAN SM FRAG PT 50M 407.050 48712595_1 CDM 0278 RC inpatient 138 89.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.29 67.6 999999999 83.56 133.86 percent of total billed charges 4.0 CAN SM FRAG PT 50M 407.050 48712595_1 CDM 0278 RC inpatient 138 89.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 83.56 133.86 4.5 CANN SCREW 22MM 214.522 48712596_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 22MM 214.522 48712596_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 22MM 214.522 48712596_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 22MM 214.522 48712596_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 22MM 214.522 48712596_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 22MM 214.522 48712596_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 22MM 214.522 48712596_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 22MM 214.522 48712596_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 22MM 214.522 48712596_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 4.5 CANN SCREW 22MM 214.522 48712596_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 22MM 214.522 48712596_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 4.5 CANN SCREW 22MM 214.522 48712596_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 22MM 214.522 48712596_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 22MM 214.522 48712596_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 4.5 CANN SCREW 24MM 214.524 48712597_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 24MM 214.524 48712597_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 24MM 214.524 48712597_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 24MM 214.524 48712597_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 24MM 214.524 48712597_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 24MM 214.524 48712597_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 24MM 214.524 48712597_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 24MM 214.524 48712597_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 24MM 214.524 48712597_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 4.5 CANN SCREW 24MM 214.524 48712597_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 24MM 214.524 48712597_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 4.5 CANN SCREW 24MM 214.524 48712597_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 24MM 214.524 48712597_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 24MM 214.524 48712597_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 4.5 CANN SCREW 26MM 214.526 48712598_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 26MM 214.526 48712598_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 26MM 214.526 48712598_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 26MM 214.526 48712598_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 26MM 214.526 48712598_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 26MM 214.526 48712598_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 26MM 214.526 48712598_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 26MM 214.526 48712598_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 26MM 214.526 48712598_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 4.5 CANN SCREW 26MM 214.526 48712598_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 26MM 214.526 48712598_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 4.5 CANN SCREW 26MM 214.526 48712598_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 26MM 214.526 48712598_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 26MM 214.526 48712598_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 4.5 CANN SCREW 28MM 214.528 48712599_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 28MM 214.528 48712599_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 28MM 214.528 48712599_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 28MM 214.528 48712599_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 28MM 214.528 48712599_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 28MM 214.528 48712599_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 28MM 214.528 48712599_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 28MM 214.528 48712599_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 28MM 214.528 48712599_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 4.5 CANN SCREW 28MM 214.528 48712599_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 28MM 214.528 48712599_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 4.5 CANN SCREW 28MM 214.528 48712599_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 28MM 214.528 48712599_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 28MM 214.528 48712599_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 4.5 CANN SCREW 30MM 214.530 48712600_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 30MM 214.530 48712600_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 30MM 214.530 48712600_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 30MM 214.530 48712600_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 30MM 214.530 48712600_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 30MM 214.530 48712600_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 30MM 214.530 48712600_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 30MM 214.530 48712600_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 30MM 214.530 48712600_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 4.5 CANN SCREW 30MM 214.530 48712600_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 30MM 214.530 48712600_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 4.5 CANN SCREW 30MM 214.530 48712600_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 30MM 214.530 48712600_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 30MM 214.530 48712600_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 4.5 CANN SCREW 32MM 214.532 48712601_1 CDM 0278 RC inpatient 1269 824.85 AETNA AETNA 1002.51 79 999999999 768.38 1230.93 percent of total billed charges 4.5 CANN SCREW 32MM 214.532 48712601_1 CDM 0278 RC inpatient 1269 824.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 824.85 65 999999999 768.38 1230.93 percent of total billed charges 4.5 CANN SCREW 32MM 214.532 48712601_1 CDM 0278 RC inpatient 1269 824.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1230.93 97 999999999 768.38 1230.93 percent of total billed charges 4.5 CANN SCREW 32MM 214.532 48712601_1 CDM 0278 RC inpatient 1269 824.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 989.82 78 999999999 768.38 1230.93 percent of total billed charges 4.5 CANN SCREW 32MM 214.532 48712601_1 CDM 0278 RC inpatient 1269 824.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 875.61 69 999999999 768.38 1230.93 percent of total billed charges 4.5 CANN SCREW 32MM 214.532 48712601_1 CDM 0278 RC inpatient 1269 824.85 UMR - ALL PLANS UMR - ALL PLANS 888.3 70 999999999 768.38 1230.93 percent of total billed charges 4.5 CANN SCREW 32MM 214.532 48712601_1 CDM 0278 RC inpatient 1269 824.85 SIHO - ALL PLANS SIHO - ALL PLANS 1142.1 90 999999999 768.38 1230.93 percent of total billed charges 4.5 CANN SCREW 32MM 214.532 48712601_1 CDM 0278 RC inpatient 1269 824.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 768.38 60.55 999999999 768.38 1230.93 percent of total billed charges 4.5 CANN SCREW 32MM 214.532 48712601_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 768.38 1230.93 4.5 CANN SCREW 32MM 214.532 48712601_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 768.38 1230.93 4.5 CANN SCREW 32MM 214.532 48712601_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM HMO ANTHEM HMO 999999999 768.38 1230.93 4.5 CANN SCREW 32MM 214.532 48712601_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 768.38 1230.93 4.5 CANN SCREW 32MM 214.532 48712601_1 CDM 0278 RC inpatient 1269 824.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 857.84 67.6 999999999 768.38 1230.93 percent of total billed charges 4.5 CANN SCREW 32MM 214.532 48712601_1 CDM 0278 RC inpatient 1269 824.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 768.38 1230.93 4.5 CANN SCREW 34MM 214.534 48712602_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 34MM 214.534 48712602_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 34MM 214.534 48712602_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 34MM 214.534 48712602_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 34MM 214.534 48712602_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 34MM 214.534 48712602_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 34MM 214.534 48712602_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 34MM 214.534 48712602_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 34MM 214.534 48712602_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 4.5 CANN SCREW 34MM 214.534 48712602_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 34MM 214.534 48712602_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 4.5 CANN SCREW 34MM 214.534 48712602_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 34MM 214.534 48712602_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 34MM 214.534 48712602_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 4.5 CANN SCREW 36MM 214.536 48712603_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 36MM 214.536 48712603_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 36MM 214.536 48712603_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 36MM 214.536 48712603_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 36MM 214.536 48712603_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 36MM 214.536 48712603_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 36MM 214.536 48712603_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 36MM 214.536 48712603_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 36MM 214.536 48712603_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 4.5 CANN SCREW 36MM 214.536 48712603_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 36MM 214.536 48712603_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 4.5 CANN SCREW 36MM 214.536 48712603_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 36MM 214.536 48712603_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 36MM 214.536 48712603_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 4.5 CANN SCREW 38MM 214.538 48712604_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 38MM 214.538 48712604_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 38MM 214.538 48712604_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 38MM 214.538 48712604_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 38MM 214.538 48712604_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 38MM 214.538 48712604_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 38MM 214.538 48712604_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 38MM 214.538 48712604_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 38MM 214.538 48712604_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 4.5 CANN SCREW 38MM 214.538 48712604_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 38MM 214.538 48712604_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 4.5 CANN SCREW 38MM 214.538 48712604_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 38MM 214.538 48712604_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 38MM 214.538 48712604_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712605_1 CDM 0278 RC C1713 HCPCS inpatient 1377 895.05 AETNA AETNA 1087.83 79 999999999 833.77 1335.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712605_1 CDM 0278 RC C1713 HCPCS inpatient 1377 895.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 895.05 65 999999999 833.77 1335.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712605_1 CDM 0278 RC C1713 HCPCS inpatient 1377 895.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1335.69 97 999999999 833.77 1335.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712605_1 CDM 0278 RC C1713 HCPCS inpatient 1377 895.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1074.06 78 999999999 833.77 1335.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712605_1 CDM 0278 RC C1713 HCPCS inpatient 1377 895.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 950.13 69 999999999 833.77 1335.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712605_1 CDM 0278 RC C1713 HCPCS inpatient 1377 895.05 UMR - ALL PLANS UMR - ALL PLANS 963.9 70 999999999 833.77 1335.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712605_1 CDM 0278 RC C1713 HCPCS inpatient 1377 895.05 SIHO - ALL PLANS SIHO - ALL PLANS 1239.3 90 999999999 833.77 1335.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712605_1 CDM 0278 RC C1713 HCPCS inpatient 1377 895.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 833.77 60.55 999999999 833.77 1335.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712605_1 CDM 0278 RC C1713 HCPCS inpatient 1377 895.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 833.77 1335.69 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712605_1 CDM 0278 RC C1713 HCPCS inpatient 1377 895.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 833.77 1335.69 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712605_1 CDM 0278 RC C1713 HCPCS inpatient 1377 895.05 ANTHEM HMO ANTHEM HMO 999999999 833.77 1335.69 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712605_1 CDM 0278 RC C1713 HCPCS inpatient 1377 895.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 833.77 1335.69 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712605_1 CDM 0278 RC C1713 HCPCS inpatient 1377 895.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 930.85 67.6 999999999 833.77 1335.69 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712605_1 CDM 0278 RC C1713 HCPCS inpatient 1377 895.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 833.77 1335.69 4.5 CANN SCREW 42MM 214.542 48712606_1 CDM 0278 RC inpatient 1319 857.35 AETNA AETNA 1042.01 79 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 42MM 214.542 48712606_1 CDM 0278 RC inpatient 1319 857.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 857.35 65 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 42MM 214.542 48712606_1 CDM 0278 RC inpatient 1319 857.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1279.43 97 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 42MM 214.542 48712606_1 CDM 0278 RC inpatient 1319 857.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1028.82 78 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 42MM 214.542 48712606_1 CDM 0278 RC inpatient 1319 857.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 910.11 69 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 42MM 214.542 48712606_1 CDM 0278 RC inpatient 1319 857.35 UMR - ALL PLANS UMR - ALL PLANS 923.3 70 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 42MM 214.542 48712606_1 CDM 0278 RC inpatient 1319 857.35 SIHO - ALL PLANS SIHO - ALL PLANS 1187.1 90 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 42MM 214.542 48712606_1 CDM 0278 RC inpatient 1319 857.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 798.65 60.55 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 42MM 214.542 48712606_1 CDM 0278 RC inpatient 1319 857.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 798.65 1279.43 4.5 CANN SCREW 42MM 214.542 48712606_1 CDM 0278 RC inpatient 1319 857.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 798.65 1279.43 4.5 CANN SCREW 42MM 214.542 48712606_1 CDM 0278 RC inpatient 1319 857.35 ANTHEM HMO ANTHEM HMO 999999999 798.65 1279.43 4.5 CANN SCREW 42MM 214.542 48712606_1 CDM 0278 RC inpatient 1319 857.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 798.65 1279.43 4.5 CANN SCREW 42MM 214.542 48712606_1 CDM 0278 RC inpatient 1319 857.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 891.64 67.6 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 42MM 214.542 48712606_1 CDM 0278 RC inpatient 1319 857.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 798.65 1279.43 4.5 CANN SCREW 46MM 214.546 48712607_1 CDM 0278 RC inpatient 1319 857.35 AETNA AETNA 1042.01 79 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 46MM 214.546 48712607_1 CDM 0278 RC inpatient 1319 857.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 857.35 65 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 46MM 214.546 48712607_1 CDM 0278 RC inpatient 1319 857.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1279.43 97 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 46MM 214.546 48712607_1 CDM 0278 RC inpatient 1319 857.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1028.82 78 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 46MM 214.546 48712607_1 CDM 0278 RC inpatient 1319 857.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 910.11 69 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 46MM 214.546 48712607_1 CDM 0278 RC inpatient 1319 857.35 UMR - ALL PLANS UMR - ALL PLANS 923.3 70 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 46MM 214.546 48712607_1 CDM 0278 RC inpatient 1319 857.35 SIHO - ALL PLANS SIHO - ALL PLANS 1187.1 90 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 46MM 214.546 48712607_1 CDM 0278 RC inpatient 1319 857.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 798.65 60.55 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 46MM 214.546 48712607_1 CDM 0278 RC inpatient 1319 857.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 798.65 1279.43 4.5 CANN SCREW 46MM 214.546 48712607_1 CDM 0278 RC inpatient 1319 857.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 798.65 1279.43 4.5 CANN SCREW 46MM 214.546 48712607_1 CDM 0278 RC inpatient 1319 857.35 ANTHEM HMO ANTHEM HMO 999999999 798.65 1279.43 4.5 CANN SCREW 46MM 214.546 48712607_1 CDM 0278 RC inpatient 1319 857.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 798.65 1279.43 4.5 CANN SCREW 46MM 214.546 48712607_1 CDM 0278 RC inpatient 1319 857.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 891.64 67.6 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 46MM 214.546 48712607_1 CDM 0278 RC inpatient 1319 857.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 798.65 1279.43 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712608_1 CDM 0278 RC C1713 HCPCS inpatient 1269 824.85 AETNA AETNA 1002.51 79 999999999 768.38 1230.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712608_1 CDM 0278 RC C1713 HCPCS inpatient 1269 824.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 824.85 65 999999999 768.38 1230.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712608_1 CDM 0278 RC C1713 HCPCS inpatient 1269 824.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1230.93 97 999999999 768.38 1230.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712608_1 CDM 0278 RC C1713 HCPCS inpatient 1269 824.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 989.82 78 999999999 768.38 1230.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712608_1 CDM 0278 RC C1713 HCPCS inpatient 1269 824.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 875.61 69 999999999 768.38 1230.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712608_1 CDM 0278 RC C1713 HCPCS inpatient 1269 824.85 UMR - ALL PLANS UMR - ALL PLANS 888.3 70 999999999 768.38 1230.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712608_1 CDM 0278 RC C1713 HCPCS inpatient 1269 824.85 SIHO - ALL PLANS SIHO - ALL PLANS 1142.1 90 999999999 768.38 1230.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712608_1 CDM 0278 RC C1713 HCPCS inpatient 1269 824.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 768.38 60.55 999999999 768.38 1230.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712608_1 CDM 0278 RC C1713 HCPCS inpatient 1269 824.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 768.38 1230.93 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712608_1 CDM 0278 RC C1713 HCPCS inpatient 1269 824.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 768.38 1230.93 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712608_1 CDM 0278 RC C1713 HCPCS inpatient 1269 824.85 ANTHEM HMO ANTHEM HMO 999999999 768.38 1230.93 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712608_1 CDM 0278 RC C1713 HCPCS inpatient 1269 824.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 768.38 1230.93 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712608_1 CDM 0278 RC C1713 HCPCS inpatient 1269 824.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 857.84 67.6 999999999 768.38 1230.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712608_1 CDM 0278 RC C1713 HCPCS inpatient 1269 824.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 768.38 1230.93 4.5 CANN SCREW 54MM 214.554 48712609_1 CDM 0278 RC inpatient 1168 759.2 AETNA AETNA 922.72 79 999999999 707.22 1132.96 percent of total billed charges 4.5 CANN SCREW 54MM 214.554 48712609_1 CDM 0278 RC inpatient 1168 759.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 759.2 65 999999999 707.22 1132.96 percent of total billed charges 4.5 CANN SCREW 54MM 214.554 48712609_1 CDM 0278 RC inpatient 1168 759.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1132.96 97 999999999 707.22 1132.96 percent of total billed charges 4.5 CANN SCREW 54MM 214.554 48712609_1 CDM 0278 RC inpatient 1168 759.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 911.04 78 999999999 707.22 1132.96 percent of total billed charges 4.5 CANN SCREW 54MM 214.554 48712609_1 CDM 0278 RC inpatient 1168 759.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 805.92 69 999999999 707.22 1132.96 percent of total billed charges 4.5 CANN SCREW 54MM 214.554 48712609_1 CDM 0278 RC inpatient 1168 759.2 UMR - ALL PLANS UMR - ALL PLANS 817.6 70 999999999 707.22 1132.96 percent of total billed charges 4.5 CANN SCREW 54MM 214.554 48712609_1 CDM 0278 RC inpatient 1168 759.2 SIHO - ALL PLANS SIHO - ALL PLANS 1051.2 90 999999999 707.22 1132.96 percent of total billed charges 4.5 CANN SCREW 54MM 214.554 48712609_1 CDM 0278 RC inpatient 1168 759.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 707.22 60.55 999999999 707.22 1132.96 percent of total billed charges 4.5 CANN SCREW 54MM 214.554 48712609_1 CDM 0278 RC inpatient 1168 759.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 707.22 1132.96 4.5 CANN SCREW 54MM 214.554 48712609_1 CDM 0278 RC inpatient 1168 759.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 707.22 1132.96 4.5 CANN SCREW 54MM 214.554 48712609_1 CDM 0278 RC inpatient 1168 759.2 ANTHEM HMO ANTHEM HMO 999999999 707.22 1132.96 4.5 CANN SCREW 54MM 214.554 48712609_1 CDM 0278 RC inpatient 1168 759.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 707.22 1132.96 4.5 CANN SCREW 54MM 214.554 48712609_1 CDM 0278 RC inpatient 1168 759.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 789.57 67.6 999999999 707.22 1132.96 percent of total billed charges 4.5 CANN SCREW 54MM 214.554 48712609_1 CDM 0278 RC inpatient 1168 759.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 707.22 1132.96 4.5 CANN SCREW 20MM 214.520 48712610_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 20MM 214.520 48712610_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 20MM 214.520 48712610_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 20MM 214.520 48712610_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 20MM 214.520 48712610_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 20MM 214.520 48712610_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 20MM 214.520 48712610_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 20MM 214.520 48712610_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 20MM 214.520 48712610_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 4.5 CANN SCREW 20MM 214.520 48712610_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 20MM 214.520 48712610_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 4.5 CANN SCREW 20MM 214.520 48712610_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 20MM 214.520 48712610_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 20MM 214.520 48712610_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 INSERTION KIT FOR 2.0 CORTICAL 48712611_1 CDM 0272 RC inpatient 553 359.45 AETNA AETNA 436.87 79 999999999 334.84 536.41 percent of total billed charges INSERTION KIT FOR 2.0 CORTICAL 48712611_1 CDM 0272 RC inpatient 553 359.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 359.45 65 999999999 334.84 536.41 percent of total billed charges INSERTION KIT FOR 2.0 CORTICAL 48712611_1 CDM 0272 RC inpatient 553 359.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 536.41 97 999999999 334.84 536.41 percent of total billed charges INSERTION KIT FOR 2.0 CORTICAL 48712611_1 CDM 0272 RC inpatient 553 359.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 431.34 78 999999999 334.84 536.41 percent of total billed charges INSERTION KIT FOR 2.0 CORTICAL 48712611_1 CDM 0272 RC inpatient 553 359.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 381.57 69 999999999 334.84 536.41 percent of total billed charges INSERTION KIT FOR 2.0 CORTICAL 48712611_1 CDM 0272 RC inpatient 553 359.45 UMR - ALL PLANS UMR - ALL PLANS 387.1 70 999999999 334.84 536.41 percent of total billed charges INSERTION KIT FOR 2.0 CORTICAL 48712611_1 CDM 0272 RC inpatient 553 359.45 SIHO - ALL PLANS SIHO - ALL PLANS 497.7 90 999999999 334.84 536.41 percent of total billed charges INSERTION KIT FOR 2.0 CORTICAL 48712611_1 CDM 0272 RC inpatient 553 359.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 334.84 60.55 999999999 334.84 536.41 percent of total billed charges INSERTION KIT FOR 2.0 CORTICAL 48712611_1 CDM 0272 RC inpatient 553 359.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 334.84 536.41 INSERTION KIT FOR 2.0 CORTICAL 48712611_1 CDM 0272 RC inpatient 553 359.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 334.84 536.41 INSERTION KIT FOR 2.0 CORTICAL 48712611_1 CDM 0272 RC inpatient 553 359.45 ANTHEM HMO ANTHEM HMO 999999999 334.84 536.41 INSERTION KIT FOR 2.0 CORTICAL 48712611_1 CDM 0272 RC inpatient 553 359.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 334.84 536.41 INSERTION KIT FOR 2.0 CORTICAL 48712611_1 CDM 0272 RC inpatient 553 359.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 373.83 67.6 999999999 334.84 536.41 percent of total billed charges INSERTION KIT FOR 2.0 CORTICAL 48712611_1 CDM 0272 RC inpatient 553 359.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 334.84 536.41 INSORB STAPLE 2030 48712612_1 CDM 0272 RC inpatient 288 187.2 AETNA AETNA 227.52 79 999999999 174.38 279.36 percent of total billed charges INSORB STAPLE 2030 48712612_1 CDM 0272 RC inpatient 288 187.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 187.2 65 999999999 174.38 279.36 percent of total billed charges INSORB STAPLE 2030 48712612_1 CDM 0272 RC inpatient 288 187.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 279.36 97 999999999 174.38 279.36 percent of total billed charges INSORB STAPLE 2030 48712612_1 CDM 0272 RC inpatient 288 187.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 224.64 78 999999999 174.38 279.36 percent of total billed charges INSORB STAPLE 2030 48712612_1 CDM 0272 RC inpatient 288 187.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 198.72 69 999999999 174.38 279.36 percent of total billed charges INSORB STAPLE 2030 48712612_1 CDM 0272 RC inpatient 288 187.2 UMR - ALL PLANS UMR - ALL PLANS 201.6 70 999999999 174.38 279.36 percent of total billed charges INSORB STAPLE 2030 48712612_1 CDM 0272 RC inpatient 288 187.2 SIHO - ALL PLANS SIHO - ALL PLANS 259.2 90 999999999 174.38 279.36 percent of total billed charges INSORB STAPLE 2030 48712612_1 CDM 0272 RC inpatient 288 187.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 174.38 60.55 999999999 174.38 279.36 percent of total billed charges INSORB STAPLE 2030 48712612_1 CDM 0272 RC inpatient 288 187.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 174.38 279.36 INSORB STAPLE 2030 48712612_1 CDM 0272 RC inpatient 288 187.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 174.38 279.36 INSORB STAPLE 2030 48712612_1 CDM 0272 RC inpatient 288 187.2 ANTHEM HMO ANTHEM HMO 999999999 174.38 279.36 INSORB STAPLE 2030 48712612_1 CDM 0272 RC inpatient 288 187.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 174.38 279.36 INSORB STAPLE 2030 48712612_1 CDM 0272 RC inpatient 288 187.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 194.69 67.6 999999999 174.38 279.36 percent of total billed charges INSORB STAPLE 2030 48712612_1 CDM 0272 RC inpatient 288 187.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 174.38 279.36 DRILL BIT LG FRAG 310.32 48712613_1 CDM 0278 RC inpatient 370 240.5 AETNA AETNA 292.3 79 999999999 224.04 358.9 percent of total billed charges DRILL BIT LG FRAG 310.32 48712613_1 CDM 0278 RC inpatient 370 240.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 240.5 65 999999999 224.04 358.9 percent of total billed charges DRILL BIT LG FRAG 310.32 48712613_1 CDM 0278 RC inpatient 370 240.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 358.9 97 999999999 224.04 358.9 percent of total billed charges DRILL BIT LG FRAG 310.32 48712613_1 CDM 0278 RC inpatient 370 240.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 288.6 78 999999999 224.04 358.9 percent of total billed charges DRILL BIT LG FRAG 310.32 48712613_1 CDM 0278 RC inpatient 370 240.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 255.3 69 999999999 224.04 358.9 percent of total billed charges DRILL BIT LG FRAG 310.32 48712613_1 CDM 0278 RC inpatient 370 240.5 UMR - ALL PLANS UMR - ALL PLANS 259 70 999999999 224.04 358.9 percent of total billed charges DRILL BIT LG FRAG 310.32 48712613_1 CDM 0278 RC inpatient 370 240.5 SIHO - ALL PLANS SIHO - ALL PLANS 333 90 999999999 224.04 358.9 percent of total billed charges DRILL BIT LG FRAG 310.32 48712613_1 CDM 0278 RC inpatient 370 240.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 224.04 60.55 999999999 224.04 358.9 percent of total billed charges DRILL BIT LG FRAG 310.32 48712613_1 CDM 0278 RC inpatient 370 240.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 224.04 358.9 DRILL BIT LG FRAG 310.32 48712613_1 CDM 0278 RC inpatient 370 240.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 224.04 358.9 DRILL BIT LG FRAG 310.32 48712613_1 CDM 0278 RC inpatient 370 240.5 ANTHEM HMO ANTHEM HMO 999999999 224.04 358.9 DRILL BIT LG FRAG 310.32 48712613_1 CDM 0278 RC inpatient 370 240.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 224.04 358.9 DRILL BIT LG FRAG 310.32 48712613_1 CDM 0278 RC inpatient 370 240.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 250.12 67.6 999999999 224.04 358.9 percent of total billed charges DRILL BIT LG FRAG 310.32 48712613_1 CDM 0278 RC inpatient 370 240.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 224.04 358.9 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712614_1 CDM 0272 RC C1713 HCPCS inpatient 2672 1736.8 AETNA AETNA 2110.88 79 999999999 1617.9 2591.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712614_1 CDM 0272 RC C1713 HCPCS inpatient 2672 1736.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1736.8 65 999999999 1617.9 2591.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712614_1 CDM 0272 RC C1713 HCPCS inpatient 2672 1736.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2591.84 97 999999999 1617.9 2591.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712614_1 CDM 0272 RC C1713 HCPCS inpatient 2672 1736.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 2084.16 78 999999999 1617.9 2591.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712614_1 CDM 0272 RC C1713 HCPCS inpatient 2672 1736.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1843.68 69 999999999 1617.9 2591.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712614_1 CDM 0272 RC C1713 HCPCS inpatient 2672 1736.8 UMR - ALL PLANS UMR - ALL PLANS 1870.4 70 999999999 1617.9 2591.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712614_1 CDM 0272 RC C1713 HCPCS inpatient 2672 1736.8 SIHO - ALL PLANS SIHO - ALL PLANS 2404.8 90 999999999 1617.9 2591.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712614_1 CDM 0272 RC C1713 HCPCS inpatient 2672 1736.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1617.9 60.55 999999999 1617.9 2591.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712614_1 CDM 0272 RC C1713 HCPCS inpatient 2672 1736.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1617.9 2591.84 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712614_1 CDM 0272 RC C1713 HCPCS inpatient 2672 1736.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1617.9 2591.84 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712614_1 CDM 0272 RC C1713 HCPCS inpatient 2672 1736.8 ANTHEM HMO ANTHEM HMO 999999999 1617.9 2591.84 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712614_1 CDM 0272 RC C1713 HCPCS inpatient 2672 1736.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1617.9 2591.84 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712614_1 CDM 0272 RC C1713 HCPCS inpatient 2672 1736.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1806.27 67.6 999999999 1617.9 2591.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712614_1 CDM 0272 RC C1713 HCPCS inpatient 2672 1736.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1617.9 2591.84 COUNTERSINK 310.78 48712615_1 CDM 0278 RC inpatient 2914 1894.1 AETNA AETNA 2302.06 79 999999999 1764.43 2826.58 percent of total billed charges COUNTERSINK 310.78 48712615_1 CDM 0278 RC inpatient 2914 1894.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1894.1 65 999999999 1764.43 2826.58 percent of total billed charges COUNTERSINK 310.78 48712615_1 CDM 0278 RC inpatient 2914 1894.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2826.58 97 999999999 1764.43 2826.58 percent of total billed charges COUNTERSINK 310.78 48712615_1 CDM 0278 RC inpatient 2914 1894.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 2272.92 78 999999999 1764.43 2826.58 percent of total billed charges COUNTERSINK 310.78 48712615_1 CDM 0278 RC inpatient 2914 1894.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 2010.66 69 999999999 1764.43 2826.58 percent of total billed charges COUNTERSINK 310.78 48712615_1 CDM 0278 RC inpatient 2914 1894.1 UMR - ALL PLANS UMR - ALL PLANS 2039.8 70 999999999 1764.43 2826.58 percent of total billed charges COUNTERSINK 310.78 48712615_1 CDM 0278 RC inpatient 2914 1894.1 SIHO - ALL PLANS SIHO - ALL PLANS 2622.6 90 999999999 1764.43 2826.58 percent of total billed charges COUNTERSINK 310.78 48712615_1 CDM 0278 RC inpatient 2914 1894.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1764.43 60.55 999999999 1764.43 2826.58 percent of total billed charges COUNTERSINK 310.78 48712615_1 CDM 0278 RC inpatient 2914 1894.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1764.43 2826.58 COUNTERSINK 310.78 48712615_1 CDM 0278 RC inpatient 2914 1894.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1764.43 2826.58 COUNTERSINK 310.78 48712615_1 CDM 0278 RC inpatient 2914 1894.1 ANTHEM HMO ANTHEM HMO 999999999 1764.43 2826.58 COUNTERSINK 310.78 48712615_1 CDM 0278 RC inpatient 2914 1894.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1764.43 2826.58 COUNTERSINK 310.78 48712615_1 CDM 0278 RC inpatient 2914 1894.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1969.86 67.6 999999999 1764.43 2826.58 percent of total billed charges COUNTERSINK 310.78 48712615_1 CDM 0278 RC inpatient 2914 1894.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1764.43 2826.58 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712616_1 CDM 0278 RC C1713 HCPCS inpatient 2911 1892.15 AETNA AETNA 2299.69 79 999999999 1762.61 2823.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712616_1 CDM 0278 RC C1713 HCPCS inpatient 2911 1892.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1892.15 65 999999999 1762.61 2823.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712616_1 CDM 0278 RC C1713 HCPCS inpatient 2911 1892.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2823.67 97 999999999 1762.61 2823.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712616_1 CDM 0278 RC C1713 HCPCS inpatient 2911 1892.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 2270.58 78 999999999 1762.61 2823.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712616_1 CDM 0278 RC C1713 HCPCS inpatient 2911 1892.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 2008.59 69 999999999 1762.61 2823.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712616_1 CDM 0278 RC C1713 HCPCS inpatient 2911 1892.15 UMR - ALL PLANS UMR - ALL PLANS 2037.7 70 999999999 1762.61 2823.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712616_1 CDM 0278 RC C1713 HCPCS inpatient 2911 1892.15 SIHO - ALL PLANS SIHO - ALL PLANS 2619.9 90 999999999 1762.61 2823.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712616_1 CDM 0278 RC C1713 HCPCS inpatient 2911 1892.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1762.61 60.55 999999999 1762.61 2823.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712616_1 CDM 0278 RC C1713 HCPCS inpatient 2911 1892.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1762.61 2823.67 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712616_1 CDM 0278 RC C1713 HCPCS inpatient 2911 1892.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1762.61 2823.67 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712616_1 CDM 0278 RC C1713 HCPCS inpatient 2911 1892.15 ANTHEM HMO ANTHEM HMO 999999999 1762.61 2823.67 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712616_1 CDM 0278 RC C1713 HCPCS inpatient 2911 1892.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1762.61 2823.67 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712616_1 CDM 0278 RC C1713 HCPCS inpatient 2911 1892.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1967.84 67.6 999999999 1762.61 2823.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712616_1 CDM 0278 RC C1713 HCPCS inpatient 2911 1892.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1762.61 2823.67 6.5 CANCELLOUS 32M/70M 217.070 48712617_1 CDM 0278 RC inpatient 130 84.5 AETNA AETNA 102.7 79 999999999 78.72 126.1 percent of total billed charges 6.5 CANCELLOUS 32M/70M 217.070 48712617_1 CDM 0278 RC inpatient 130 84.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 84.5 65 999999999 78.72 126.1 percent of total billed charges 6.5 CANCELLOUS 32M/70M 217.070 48712617_1 CDM 0278 RC inpatient 130 84.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 126.1 97 999999999 78.72 126.1 percent of total billed charges 6.5 CANCELLOUS 32M/70M 217.070 48712617_1 CDM 0278 RC inpatient 130 84.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 101.4 78 999999999 78.72 126.1 percent of total billed charges 6.5 CANCELLOUS 32M/70M 217.070 48712617_1 CDM 0278 RC inpatient 130 84.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.7 69 999999999 78.72 126.1 percent of total billed charges 6.5 CANCELLOUS 32M/70M 217.070 48712617_1 CDM 0278 RC inpatient 130 84.5 UMR - ALL PLANS UMR - ALL PLANS 91 70 999999999 78.72 126.1 percent of total billed charges 6.5 CANCELLOUS 32M/70M 217.070 48712617_1 CDM 0278 RC inpatient 130 84.5 SIHO - ALL PLANS SIHO - ALL PLANS 117 90 999999999 78.72 126.1 percent of total billed charges 6.5 CANCELLOUS 32M/70M 217.070 48712617_1 CDM 0278 RC inpatient 130 84.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.72 60.55 999999999 78.72 126.1 percent of total billed charges 6.5 CANCELLOUS 32M/70M 217.070 48712617_1 CDM 0278 RC inpatient 130 84.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.72 126.1 6.5 CANCELLOUS 32M/70M 217.070 48712617_1 CDM 0278 RC inpatient 130 84.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.72 126.1 6.5 CANCELLOUS 32M/70M 217.070 48712617_1 CDM 0278 RC inpatient 130 84.5 ANTHEM HMO ANTHEM HMO 999999999 78.72 126.1 6.5 CANCELLOUS 32M/70M 217.070 48712617_1 CDM 0278 RC inpatient 130 84.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.72 126.1 6.5 CANCELLOUS 32M/70M 217.070 48712617_1 CDM 0278 RC inpatient 130 84.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.88 67.6 999999999 78.72 126.1 percent of total billed charges 6.5 CANCELLOUS 32M/70M 217.070 48712617_1 CDM 0278 RC inpatient 130 84.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.72 126.1 4.5 CANN SCREW 44MM 214.544 48712618_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 44MM 214.544 48712618_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 44MM 214.544 48712618_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 44MM 214.544 48712618_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 44MM 214.544 48712618_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 44MM 214.544 48712618_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 44MM 214.544 48712618_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 44MM 214.544 48712618_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 44MM 214.544 48712618_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 4.5 CANN SCREW 44MM 214.544 48712618_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 44MM 214.544 48712618_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 4.5 CANN SCREW 44MM 214.544 48712618_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 44MM 214.544 48712618_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 44MM 214.544 48712618_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 4.5 CANN SCREW 48MM 214.548 48712619_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 48MM 214.548 48712619_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 48MM 214.548 48712619_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 48MM 214.548 48712619_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 48MM 214.548 48712619_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 48MM 214.548 48712619_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 48MM 214.548 48712619_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 48MM 214.548 48712619_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 48MM 214.548 48712619_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 4.5 CANN SCREW 48MM 214.548 48712619_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 48MM 214.548 48712619_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 4.5 CANN SCREW 48MM 214.548 48712619_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 48MM 214.548 48712619_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 48MM 214.548 48712619_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 4.5 CANN SCREW 52MM 214.552 48712620_1 CDM 0278 RC inpatient 717 466.05 AETNA AETNA 566.43 79 999999999 434.14 695.49 percent of total billed charges 4.5 CANN SCREW 52MM 214.552 48712620_1 CDM 0278 RC inpatient 717 466.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 466.05 65 999999999 434.14 695.49 percent of total billed charges 4.5 CANN SCREW 52MM 214.552 48712620_1 CDM 0278 RC inpatient 717 466.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 695.49 97 999999999 434.14 695.49 percent of total billed charges 4.5 CANN SCREW 52MM 214.552 48712620_1 CDM 0278 RC inpatient 717 466.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 559.26 78 999999999 434.14 695.49 percent of total billed charges 4.5 CANN SCREW 52MM 214.552 48712620_1 CDM 0278 RC inpatient 717 466.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 494.73 69 999999999 434.14 695.49 percent of total billed charges 4.5 CANN SCREW 52MM 214.552 48712620_1 CDM 0278 RC inpatient 717 466.05 UMR - ALL PLANS UMR - ALL PLANS 501.9 70 999999999 434.14 695.49 percent of total billed charges 4.5 CANN SCREW 52MM 214.552 48712620_1 CDM 0278 RC inpatient 717 466.05 SIHO - ALL PLANS SIHO - ALL PLANS 645.3 90 999999999 434.14 695.49 percent of total billed charges 4.5 CANN SCREW 52MM 214.552 48712620_1 CDM 0278 RC inpatient 717 466.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 434.14 60.55 999999999 434.14 695.49 percent of total billed charges 4.5 CANN SCREW 52MM 214.552 48712620_1 CDM 0278 RC inpatient 717 466.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 434.14 695.49 4.5 CANN SCREW 52MM 214.552 48712620_1 CDM 0278 RC inpatient 717 466.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 434.14 695.49 4.5 CANN SCREW 52MM 214.552 48712620_1 CDM 0278 RC inpatient 717 466.05 ANTHEM HMO ANTHEM HMO 999999999 434.14 695.49 4.5 CANN SCREW 52MM 214.552 48712620_1 CDM 0278 RC inpatient 717 466.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 434.14 695.49 4.5 CANN SCREW 52MM 214.552 48712620_1 CDM 0278 RC inpatient 717 466.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 484.69 67.6 999999999 434.14 695.49 percent of total billed charges 4.5 CANN SCREW 52MM 214.552 48712620_1 CDM 0278 RC inpatient 717 466.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 434.14 695.49 4.5 CANN SCREW 56MM 214.556 48712621_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 56MM 214.556 48712621_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 56MM 214.556 48712621_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 56MM 214.556 48712621_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 56MM 214.556 48712621_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 56MM 214.556 48712621_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 56MM 214.556 48712621_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 56MM 214.556 48712621_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 56MM 214.556 48712621_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 4.5 CANN SCREW 56MM 214.556 48712621_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 56MM 214.556 48712621_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 4.5 CANN SCREW 56MM 214.556 48712621_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 56MM 214.556 48712621_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 56MM 214.556 48712621_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 4.5 CANN SCREW 60MM 214.560 48712622_1 CDM 0278 RC inpatient 1319 857.35 AETNA AETNA 1042.01 79 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 60MM 214.560 48712622_1 CDM 0278 RC inpatient 1319 857.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 857.35 65 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 60MM 214.560 48712622_1 CDM 0278 RC inpatient 1319 857.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1279.43 97 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 60MM 214.560 48712622_1 CDM 0278 RC inpatient 1319 857.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1028.82 78 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 60MM 214.560 48712622_1 CDM 0278 RC inpatient 1319 857.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 910.11 69 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 60MM 214.560 48712622_1 CDM 0278 RC inpatient 1319 857.35 UMR - ALL PLANS UMR - ALL PLANS 923.3 70 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 60MM 214.560 48712622_1 CDM 0278 RC inpatient 1319 857.35 SIHO - ALL PLANS SIHO - ALL PLANS 1187.1 90 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 60MM 214.560 48712622_1 CDM 0278 RC inpatient 1319 857.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 798.65 60.55 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 60MM 214.560 48712622_1 CDM 0278 RC inpatient 1319 857.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 798.65 1279.43 4.5 CANN SCREW 60MM 214.560 48712622_1 CDM 0278 RC inpatient 1319 857.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 798.65 1279.43 4.5 CANN SCREW 60MM 214.560 48712622_1 CDM 0278 RC inpatient 1319 857.35 ANTHEM HMO ANTHEM HMO 999999999 798.65 1279.43 4.5 CANN SCREW 60MM 214.560 48712622_1 CDM 0278 RC inpatient 1319 857.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 798.65 1279.43 4.5 CANN SCREW 60MM 214.560 48712622_1 CDM 0278 RC inpatient 1319 857.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 891.64 67.6 999999999 798.65 1279.43 percent of total billed charges 4.5 CANN SCREW 60MM 214.560 48712622_1 CDM 0278 RC inpatient 1319 857.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 798.65 1279.43 4.5 CANN SCREW 64MM 214.564 48712623_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 64MM 214.564 48712623_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 64MM 214.564 48712623_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 64MM 214.564 48712623_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 64MM 214.564 48712623_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 64MM 214.564 48712623_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 64MM 214.564 48712623_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 64MM 214.564 48712623_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 64MM 214.564 48712623_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 4.5 CANN SCREW 64MM 214.564 48712623_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 64MM 214.564 48712623_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 4.5 CANN SCREW 64MM 214.564 48712623_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 64MM 214.564 48712623_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 64MM 214.564 48712623_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 4.5 CANN SCREW 68 214.568 48712624_1 CDM 0278 RC inpatient 690 448.5 AETNA AETNA 545.1 79 999999999 417.8 669.3 percent of total billed charges 4.5 CANN SCREW 68 214.568 48712624_1 CDM 0278 RC inpatient 690 448.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 448.5 65 999999999 417.8 669.3 percent of total billed charges 4.5 CANN SCREW 68 214.568 48712624_1 CDM 0278 RC inpatient 690 448.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 669.3 97 999999999 417.8 669.3 percent of total billed charges 4.5 CANN SCREW 68 214.568 48712624_1 CDM 0278 RC inpatient 690 448.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 538.2 78 999999999 417.8 669.3 percent of total billed charges 4.5 CANN SCREW 68 214.568 48712624_1 CDM 0278 RC inpatient 690 448.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 476.1 69 999999999 417.8 669.3 percent of total billed charges 4.5 CANN SCREW 68 214.568 48712624_1 CDM 0278 RC inpatient 690 448.5 UMR - ALL PLANS UMR - ALL PLANS 483 70 999999999 417.8 669.3 percent of total billed charges 4.5 CANN SCREW 68 214.568 48712624_1 CDM 0278 RC inpatient 690 448.5 SIHO - ALL PLANS SIHO - ALL PLANS 621 90 999999999 417.8 669.3 percent of total billed charges 4.5 CANN SCREW 68 214.568 48712624_1 CDM 0278 RC inpatient 690 448.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 417.8 60.55 999999999 417.8 669.3 percent of total billed charges 4.5 CANN SCREW 68 214.568 48712624_1 CDM 0278 RC inpatient 690 448.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 417.8 669.3 4.5 CANN SCREW 68 214.568 48712624_1 CDM 0278 RC inpatient 690 448.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 417.8 669.3 4.5 CANN SCREW 68 214.568 48712624_1 CDM 0278 RC inpatient 690 448.5 ANTHEM HMO ANTHEM HMO 999999999 417.8 669.3 4.5 CANN SCREW 68 214.568 48712624_1 CDM 0278 RC inpatient 690 448.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 417.8 669.3 4.5 CANN SCREW 68 214.568 48712624_1 CDM 0278 RC inpatient 690 448.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 466.44 67.6 999999999 417.8 669.3 percent of total billed charges 4.5 CANN SCREW 68 214.568 48712624_1 CDM 0278 RC inpatient 690 448.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 417.8 669.3 4.5 CANN SCREW 72M 214.572 48712625_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 72M 214.572 48712625_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 72M 214.572 48712625_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 72M 214.572 48712625_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 72M 214.572 48712625_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 72M 214.572 48712625_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 72M 214.572 48712625_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 72M 214.572 48712625_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 72M 214.572 48712625_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 4.5 CANN SCREW 72M 214.572 48712625_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 72M 214.572 48712625_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 4.5 CANN SCREW 72M 214.572 48712625_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 4.5 CANN SCREW 72M 214.572 48712625_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges 4.5 CANN SCREW 72M 214.572 48712625_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 WASHER 219.91 48712626_1 CDM 0278 RC inpatient 188 122.2 AETNA AETNA 148.52 79 999999999 113.83 182.36 percent of total billed charges WASHER 219.91 48712626_1 CDM 0278 RC inpatient 188 122.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.2 65 999999999 113.83 182.36 percent of total billed charges WASHER 219.91 48712626_1 CDM 0278 RC inpatient 188 122.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 182.36 97 999999999 113.83 182.36 percent of total billed charges WASHER 219.91 48712626_1 CDM 0278 RC inpatient 188 122.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 146.64 78 999999999 113.83 182.36 percent of total billed charges WASHER 219.91 48712626_1 CDM 0278 RC inpatient 188 122.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.72 69 999999999 113.83 182.36 percent of total billed charges WASHER 219.91 48712626_1 CDM 0278 RC inpatient 188 122.2 UMR - ALL PLANS UMR - ALL PLANS 131.6 70 999999999 113.83 182.36 percent of total billed charges WASHER 219.91 48712626_1 CDM 0278 RC inpatient 188 122.2 SIHO - ALL PLANS SIHO - ALL PLANS 169.2 90 999999999 113.83 182.36 percent of total billed charges WASHER 219.91 48712626_1 CDM 0278 RC inpatient 188 122.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.83 60.55 999999999 113.83 182.36 percent of total billed charges WASHER 219.91 48712626_1 CDM 0278 RC inpatient 188 122.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.83 182.36 WASHER 219.91 48712626_1 CDM 0278 RC inpatient 188 122.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.83 182.36 WASHER 219.91 48712626_1 CDM 0278 RC inpatient 188 122.2 ANTHEM HMO ANTHEM HMO 999999999 113.83 182.36 WASHER 219.91 48712626_1 CDM 0278 RC inpatient 188 122.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.83 182.36 WASHER 219.91 48712626_1 CDM 0278 RC inpatient 188 122.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.09 67.6 999999999 113.83 182.36 percent of total billed charges WASHER 219.91 48712626_1 CDM 0278 RC inpatient 188 122.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.83 182.36 GUIDE WIRE 48712627_1 CDM 0272 RC C1769 HCPCS inpatient 257 167.05 AETNA AETNA 203.03 79 999999999 155.61 249.29 percent of total billed charges GUIDE WIRE 48712627_1 CDM 0272 RC C1769 HCPCS inpatient 257 167.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.05 65 999999999 155.61 249.29 percent of total billed charges GUIDE WIRE 48712627_1 CDM 0272 RC C1769 HCPCS inpatient 257 167.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 249.29 97 999999999 155.61 249.29 percent of total billed charges GUIDE WIRE 48712627_1 CDM 0272 RC C1769 HCPCS inpatient 257 167.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 200.46 78 999999999 155.61 249.29 percent of total billed charges GUIDE WIRE 48712627_1 CDM 0272 RC C1769 HCPCS inpatient 257 167.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 177.33 69 999999999 155.61 249.29 percent of total billed charges GUIDE WIRE 48712627_1 CDM 0272 RC C1769 HCPCS inpatient 257 167.05 UMR - ALL PLANS UMR - ALL PLANS 179.9 70 999999999 155.61 249.29 percent of total billed charges GUIDE WIRE 48712627_1 CDM 0272 RC C1769 HCPCS inpatient 257 167.05 SIHO - ALL PLANS SIHO - ALL PLANS 231.3 90 999999999 155.61 249.29 percent of total billed charges GUIDE WIRE 48712627_1 CDM 0272 RC C1769 HCPCS inpatient 257 167.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.61 60.55 999999999 155.61 249.29 percent of total billed charges GUIDE WIRE 48712627_1 CDM 0272 RC C1769 HCPCS inpatient 257 167.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.61 249.29 GUIDE WIRE 48712627_1 CDM 0272 RC C1769 HCPCS inpatient 257 167.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.61 249.29 GUIDE WIRE 48712627_1 CDM 0272 RC C1769 HCPCS inpatient 257 167.05 ANTHEM HMO ANTHEM HMO 999999999 155.61 249.29 GUIDE WIRE 48712627_1 CDM 0272 RC C1769 HCPCS inpatient 257 167.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.61 249.29 GUIDE WIRE 48712627_1 CDM 0272 RC C1769 HCPCS inpatient 257 167.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.73 67.6 999999999 155.61 249.29 percent of total billed charges GUIDE WIRE 48712627_1 CDM 0272 RC C1769 HCPCS inpatient 257 167.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.61 249.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712628_1 CDM 0278 RC C1713 HCPCS inpatient 126 81.9 AETNA AETNA 99.54 79 999999999 76.29 122.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712628_1 CDM 0278 RC C1713 HCPCS inpatient 126 81.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.9 65 999999999 76.29 122.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712628_1 CDM 0278 RC C1713 HCPCS inpatient 126 81.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 122.22 97 999999999 76.29 122.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712628_1 CDM 0278 RC C1713 HCPCS inpatient 126 81.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 98.28 78 999999999 76.29 122.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712628_1 CDM 0278 RC C1713 HCPCS inpatient 126 81.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.94 69 999999999 76.29 122.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712628_1 CDM 0278 RC C1713 HCPCS inpatient 126 81.9 UMR - ALL PLANS UMR - ALL PLANS 88.2 70 999999999 76.29 122.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712628_1 CDM 0278 RC C1713 HCPCS inpatient 126 81.9 SIHO - ALL PLANS SIHO - ALL PLANS 113.4 90 999999999 76.29 122.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712628_1 CDM 0278 RC C1713 HCPCS inpatient 126 81.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.29 60.55 999999999 76.29 122.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712628_1 CDM 0278 RC C1713 HCPCS inpatient 126 81.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.29 122.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712628_1 CDM 0278 RC C1713 HCPCS inpatient 126 81.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.29 122.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712628_1 CDM 0278 RC C1713 HCPCS inpatient 126 81.9 ANTHEM HMO ANTHEM HMO 999999999 76.29 122.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712628_1 CDM 0278 RC C1713 HCPCS inpatient 126 81.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.29 122.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712628_1 CDM 0278 RC C1713 HCPCS inpatient 126 81.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.18 67.6 999999999 76.29 122.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712628_1 CDM 0278 RC C1713 HCPCS inpatient 126 81.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.29 122.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712629_1 CDM 0278 RC C1713 HCPCS inpatient 353 229.45 AETNA AETNA 278.87 79 999999999 213.74 342.41 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712629_1 CDM 0278 RC C1713 HCPCS inpatient 353 229.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 229.45 65 999999999 213.74 342.41 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712629_1 CDM 0278 RC C1713 HCPCS inpatient 353 229.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 342.41 97 999999999 213.74 342.41 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712629_1 CDM 0278 RC C1713 HCPCS inpatient 353 229.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 275.34 78 999999999 213.74 342.41 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712629_1 CDM 0278 RC C1713 HCPCS inpatient 353 229.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 243.57 69 999999999 213.74 342.41 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712629_1 CDM 0278 RC C1713 HCPCS inpatient 353 229.45 UMR - ALL PLANS UMR - ALL PLANS 247.1 70 999999999 213.74 342.41 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712629_1 CDM 0278 RC C1713 HCPCS inpatient 353 229.45 SIHO - ALL PLANS SIHO - ALL PLANS 317.7 90 999999999 213.74 342.41 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712629_1 CDM 0278 RC C1713 HCPCS inpatient 353 229.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 213.74 60.55 999999999 213.74 342.41 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712629_1 CDM 0278 RC C1713 HCPCS inpatient 353 229.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 213.74 342.41 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712629_1 CDM 0278 RC C1713 HCPCS inpatient 353 229.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 213.74 342.41 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712629_1 CDM 0278 RC C1713 HCPCS inpatient 353 229.45 ANTHEM HMO ANTHEM HMO 999999999 213.74 342.41 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712629_1 CDM 0278 RC C1713 HCPCS inpatient 353 229.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 213.74 342.41 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712629_1 CDM 0278 RC C1713 HCPCS inpatient 353 229.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 238.63 67.6 999999999 213.74 342.41 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712629_1 CDM 0278 RC C1713 HCPCS inpatient 353 229.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 213.74 342.41 CANNULATED DRIVER 314.464 48712630_1 CDM 0278 RC inpatient 1595 1036.75 AETNA AETNA 1260.05 79 999999999 965.77 1547.15 percent of total billed charges CANNULATED DRIVER 314.464 48712630_1 CDM 0278 RC inpatient 1595 1036.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1036.75 65 999999999 965.77 1547.15 percent of total billed charges CANNULATED DRIVER 314.464 48712630_1 CDM 0278 RC inpatient 1595 1036.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1547.15 97 999999999 965.77 1547.15 percent of total billed charges CANNULATED DRIVER 314.464 48712630_1 CDM 0278 RC inpatient 1595 1036.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1244.1 78 999999999 965.77 1547.15 percent of total billed charges CANNULATED DRIVER 314.464 48712630_1 CDM 0278 RC inpatient 1595 1036.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1100.55 69 999999999 965.77 1547.15 percent of total billed charges CANNULATED DRIVER 314.464 48712630_1 CDM 0278 RC inpatient 1595 1036.75 UMR - ALL PLANS UMR - ALL PLANS 1116.5 70 999999999 965.77 1547.15 percent of total billed charges CANNULATED DRIVER 314.464 48712630_1 CDM 0278 RC inpatient 1595 1036.75 SIHO - ALL PLANS SIHO - ALL PLANS 1435.5 90 999999999 965.77 1547.15 percent of total billed charges CANNULATED DRIVER 314.464 48712630_1 CDM 0278 RC inpatient 1595 1036.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 965.77 60.55 999999999 965.77 1547.15 percent of total billed charges CANNULATED DRIVER 314.464 48712630_1 CDM 0278 RC inpatient 1595 1036.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 965.77 1547.15 CANNULATED DRIVER 314.464 48712630_1 CDM 0278 RC inpatient 1595 1036.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 965.77 1547.15 CANNULATED DRIVER 314.464 48712630_1 CDM 0278 RC inpatient 1595 1036.75 ANTHEM HMO ANTHEM HMO 999999999 965.77 1547.15 CANNULATED DRIVER 314.464 48712630_1 CDM 0278 RC inpatient 1595 1036.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 965.77 1547.15 CANNULATED DRIVER 314.464 48712630_1 CDM 0278 RC inpatient 1595 1036.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1078.22 67.6 999999999 965.77 1547.15 percent of total billed charges CANNULATED DRIVER 314.464 48712630_1 CDM 0278 RC inpatient 1595 1036.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 965.77 1547.15 CONICAL EXTRAC DEVICE 309.501 48712631_1 CDM 0278 RC inpatient 764 496.6 AETNA AETNA 603.56 79 999999999 462.6 741.08 percent of total billed charges CONICAL EXTRAC DEVICE 309.501 48712631_1 CDM 0278 RC inpatient 764 496.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 496.6 65 999999999 462.6 741.08 percent of total billed charges CONICAL EXTRAC DEVICE 309.501 48712631_1 CDM 0278 RC inpatient 764 496.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 741.08 97 999999999 462.6 741.08 percent of total billed charges CONICAL EXTRAC DEVICE 309.501 48712631_1 CDM 0278 RC inpatient 764 496.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 595.92 78 999999999 462.6 741.08 percent of total billed charges CONICAL EXTRAC DEVICE 309.501 48712631_1 CDM 0278 RC inpatient 764 496.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 527.16 69 999999999 462.6 741.08 percent of total billed charges CONICAL EXTRAC DEVICE 309.501 48712631_1 CDM 0278 RC inpatient 764 496.6 UMR - ALL PLANS UMR - ALL PLANS 534.8 70 999999999 462.6 741.08 percent of total billed charges CONICAL EXTRAC DEVICE 309.501 48712631_1 CDM 0278 RC inpatient 764 496.6 SIHO - ALL PLANS SIHO - ALL PLANS 687.6 90 999999999 462.6 741.08 percent of total billed charges CONICAL EXTRAC DEVICE 309.501 48712631_1 CDM 0278 RC inpatient 764 496.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 462.6 60.55 999999999 462.6 741.08 percent of total billed charges CONICAL EXTRAC DEVICE 309.501 48712631_1 CDM 0278 RC inpatient 764 496.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 462.6 741.08 CONICAL EXTRAC DEVICE 309.501 48712631_1 CDM 0278 RC inpatient 764 496.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 462.6 741.08 CONICAL EXTRAC DEVICE 309.501 48712631_1 CDM 0278 RC inpatient 764 496.6 ANTHEM HMO ANTHEM HMO 999999999 462.6 741.08 CONICAL EXTRAC DEVICE 309.501 48712631_1 CDM 0278 RC inpatient 764 496.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 462.6 741.08 CONICAL EXTRAC DEVICE 309.501 48712631_1 CDM 0278 RC inpatient 764 496.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 516.46 67.6 999999999 462.6 741.08 percent of total billed charges CONICAL EXTRAC DEVICE 309.501 48712631_1 CDM 0278 RC inpatient 764 496.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 462.6 741.08 GUIDE WIRE CFLEX BL TIP 014394 48712632_1 CDM 0272 RC inpatient 350 227.5 AETNA AETNA 276.5 79 999999999 211.93 339.5 percent of total billed charges GUIDE WIRE CFLEX BL TIP 014394 48712632_1 CDM 0272 RC inpatient 350 227.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 227.5 65 999999999 211.93 339.5 percent of total billed charges GUIDE WIRE CFLEX BL TIP 014394 48712632_1 CDM 0272 RC inpatient 350 227.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 339.5 97 999999999 211.93 339.5 percent of total billed charges GUIDE WIRE CFLEX BL TIP 014394 48712632_1 CDM 0272 RC inpatient 350 227.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 273 78 999999999 211.93 339.5 percent of total billed charges GUIDE WIRE CFLEX BL TIP 014394 48712632_1 CDM 0272 RC inpatient 350 227.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 241.5 69 999999999 211.93 339.5 percent of total billed charges GUIDE WIRE CFLEX BL TIP 014394 48712632_1 CDM 0272 RC inpatient 350 227.5 UMR - ALL PLANS UMR - ALL PLANS 245 70 999999999 211.93 339.5 percent of total billed charges GUIDE WIRE CFLEX BL TIP 014394 48712632_1 CDM 0272 RC inpatient 350 227.5 SIHO - ALL PLANS SIHO - ALL PLANS 315 90 999999999 211.93 339.5 percent of total billed charges GUIDE WIRE CFLEX BL TIP 014394 48712632_1 CDM 0272 RC inpatient 350 227.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 211.93 60.55 999999999 211.93 339.5 percent of total billed charges GUIDE WIRE CFLEX BL TIP 014394 48712632_1 CDM 0272 RC inpatient 350 227.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 211.93 339.5 GUIDE WIRE CFLEX BL TIP 014394 48712632_1 CDM 0272 RC inpatient 350 227.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 211.93 339.5 GUIDE WIRE CFLEX BL TIP 014394 48712632_1 CDM 0272 RC inpatient 350 227.5 ANTHEM HMO ANTHEM HMO 999999999 211.93 339.5 GUIDE WIRE CFLEX BL TIP 014394 48712632_1 CDM 0272 RC inpatient 350 227.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 211.93 339.5 GUIDE WIRE CFLEX BL TIP 014394 48712632_1 CDM 0272 RC inpatient 350 227.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 236.6 67.6 999999999 211.93 339.5 percent of total billed charges GUIDE WIRE CFLEX BL TIP 014394 48712632_1 CDM 0272 RC inpatient 350 227.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 211.93 339.5 HOT LINE DISP TUBING L-70 48712633_1 CDM 0272 RC inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges HOT LINE DISP TUBING L-70 48712633_1 CDM 0272 RC inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges HOT LINE DISP TUBING L-70 48712633_1 CDM 0272 RC inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges HOT LINE DISP TUBING L-70 48712633_1 CDM 0272 RC inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges HOT LINE DISP TUBING L-70 48712633_1 CDM 0272 RC inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges HOT LINE DISP TUBING L-70 48712633_1 CDM 0272 RC inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges HOT LINE DISP TUBING L-70 48712633_1 CDM 0272 RC inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges HOT LINE DISP TUBING L-70 48712633_1 CDM 0272 RC inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges HOT LINE DISP TUBING L-70 48712633_1 CDM 0272 RC inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 HOT LINE DISP TUBING L-70 48712633_1 CDM 0272 RC inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 HOT LINE DISP TUBING L-70 48712633_1 CDM 0272 RC inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 HOT LINE DISP TUBING L-70 48712633_1 CDM 0272 RC inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 HOT LINE DISP TUBING L-70 48712633_1 CDM 0272 RC inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges HOT LINE DISP TUBING L-70 48712633_1 CDM 0272 RC inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 4.5 MALLEOLAR 40MM 215.040 48712634_1 CDM 0278 RC inpatient 93 60.45 AETNA AETNA 73.47 79 999999999 56.31 90.21 percent of total billed charges 4.5 MALLEOLAR 40MM 215.040 48712634_1 CDM 0278 RC inpatient 93 60.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 60.45 65 999999999 56.31 90.21 percent of total billed charges 4.5 MALLEOLAR 40MM 215.040 48712634_1 CDM 0278 RC inpatient 93 60.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 90.21 97 999999999 56.31 90.21 percent of total billed charges 4.5 MALLEOLAR 40MM 215.040 48712634_1 CDM 0278 RC inpatient 93 60.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 72.54 78 999999999 56.31 90.21 percent of total billed charges 4.5 MALLEOLAR 40MM 215.040 48712634_1 CDM 0278 RC inpatient 93 60.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.17 69 999999999 56.31 90.21 percent of total billed charges 4.5 MALLEOLAR 40MM 215.040 48712634_1 CDM 0278 RC inpatient 93 60.45 UMR - ALL PLANS UMR - ALL PLANS 65.1 70 999999999 56.31 90.21 percent of total billed charges 4.5 MALLEOLAR 40MM 215.040 48712634_1 CDM 0278 RC inpatient 93 60.45 SIHO - ALL PLANS SIHO - ALL PLANS 83.7 90 999999999 56.31 90.21 percent of total billed charges 4.5 MALLEOLAR 40MM 215.040 48712634_1 CDM 0278 RC inpatient 93 60.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.31 60.55 999999999 56.31 90.21 percent of total billed charges 4.5 MALLEOLAR 40MM 215.040 48712634_1 CDM 0278 RC inpatient 93 60.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.31 90.21 4.5 MALLEOLAR 40MM 215.040 48712634_1 CDM 0278 RC inpatient 93 60.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.31 90.21 4.5 MALLEOLAR 40MM 215.040 48712634_1 CDM 0278 RC inpatient 93 60.45 ANTHEM HMO ANTHEM HMO 999999999 56.31 90.21 4.5 MALLEOLAR 40MM 215.040 48712634_1 CDM 0278 RC inpatient 93 60.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.31 90.21 4.5 MALLEOLAR 40MM 215.040 48712634_1 CDM 0278 RC inpatient 93 60.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.87 67.6 999999999 56.31 90.21 percent of total billed charges 4.5 MALLEOLAR 40MM 215.040 48712634_1 CDM 0278 RC inpatient 93 60.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.31 90.21 SCREW MALLEOLAR 55MM 215.055 48712635_1 CDM 0278 RC inpatient 116 75.4 AETNA AETNA 91.64 79 999999999 70.24 112.52 percent of total billed charges SCREW MALLEOLAR 55MM 215.055 48712635_1 CDM 0278 RC inpatient 116 75.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 75.4 65 999999999 70.24 112.52 percent of total billed charges SCREW MALLEOLAR 55MM 215.055 48712635_1 CDM 0278 RC inpatient 116 75.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 112.52 97 999999999 70.24 112.52 percent of total billed charges SCREW MALLEOLAR 55MM 215.055 48712635_1 CDM 0278 RC inpatient 116 75.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 90.48 78 999999999 70.24 112.52 percent of total billed charges SCREW MALLEOLAR 55MM 215.055 48712635_1 CDM 0278 RC inpatient 116 75.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.04 69 999999999 70.24 112.52 percent of total billed charges SCREW MALLEOLAR 55MM 215.055 48712635_1 CDM 0278 RC inpatient 116 75.4 UMR - ALL PLANS UMR - ALL PLANS 81.2 70 999999999 70.24 112.52 percent of total billed charges SCREW MALLEOLAR 55MM 215.055 48712635_1 CDM 0278 RC inpatient 116 75.4 SIHO - ALL PLANS SIHO - ALL PLANS 104.4 90 999999999 70.24 112.52 percent of total billed charges SCREW MALLEOLAR 55MM 215.055 48712635_1 CDM 0278 RC inpatient 116 75.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 70.24 60.55 999999999 70.24 112.52 percent of total billed charges SCREW MALLEOLAR 55MM 215.055 48712635_1 CDM 0278 RC inpatient 116 75.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 70.24 112.52 SCREW MALLEOLAR 55MM 215.055 48712635_1 CDM 0278 RC inpatient 116 75.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 70.24 112.52 SCREW MALLEOLAR 55MM 215.055 48712635_1 CDM 0278 RC inpatient 116 75.4 ANTHEM HMO ANTHEM HMO 999999999 70.24 112.52 SCREW MALLEOLAR 55MM 215.055 48712635_1 CDM 0278 RC inpatient 116 75.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 70.24 112.52 SCREW MALLEOLAR 55MM 215.055 48712635_1 CDM 0278 RC inpatient 116 75.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 78.42 67.6 999999999 70.24 112.52 percent of total billed charges SCREW MALLEOLAR 55MM 215.055 48712635_1 CDM 0278 RC inpatient 116 75.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 70.24 112.52 4.5 MALLEOLAR 50MM 215-050 48712636_1 CDM 0278 RC inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges 4.5 MALLEOLAR 50MM 215-050 48712636_1 CDM 0278 RC inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges 4.5 MALLEOLAR 50MM 215-050 48712636_1 CDM 0278 RC inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges 4.5 MALLEOLAR 50MM 215-050 48712636_1 CDM 0278 RC inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges 4.5 MALLEOLAR 50MM 215-050 48712636_1 CDM 0278 RC inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges 4.5 MALLEOLAR 50MM 215-050 48712636_1 CDM 0278 RC inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges 4.5 MALLEOLAR 50MM 215-050 48712636_1 CDM 0278 RC inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges 4.5 MALLEOLAR 50MM 215-050 48712636_1 CDM 0278 RC inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges 4.5 MALLEOLAR 50MM 215-050 48712636_1 CDM 0278 RC inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 4.5 MALLEOLAR 50MM 215-050 48712636_1 CDM 0278 RC inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 4.5 MALLEOLAR 50MM 215-050 48712636_1 CDM 0278 RC inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 4.5 MALLEOLAR 50MM 215-050 48712636_1 CDM 0278 RC inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 4.5 MALLEOLAR 50MM 215-050 48712636_1 CDM 0278 RC inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges 4.5 MALLEOLAR 50MM 215-050 48712636_1 CDM 0278 RC inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712637_1 CDM 0278 RC C1713 HCPCS inpatient 302 196.3 AETNA AETNA 238.58 79 999999999 182.86 292.94 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712637_1 CDM 0278 RC C1713 HCPCS inpatient 302 196.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 196.3 65 999999999 182.86 292.94 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712637_1 CDM 0278 RC C1713 HCPCS inpatient 302 196.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 292.94 97 999999999 182.86 292.94 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712637_1 CDM 0278 RC C1713 HCPCS inpatient 302 196.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 235.56 78 999999999 182.86 292.94 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712637_1 CDM 0278 RC C1713 HCPCS inpatient 302 196.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 208.38 69 999999999 182.86 292.94 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712637_1 CDM 0278 RC C1713 HCPCS inpatient 302 196.3 UMR - ALL PLANS UMR - ALL PLANS 211.4 70 999999999 182.86 292.94 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712637_1 CDM 0278 RC C1713 HCPCS inpatient 302 196.3 SIHO - ALL PLANS SIHO - ALL PLANS 271.8 90 999999999 182.86 292.94 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712637_1 CDM 0278 RC C1713 HCPCS inpatient 302 196.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.86 60.55 999999999 182.86 292.94 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712637_1 CDM 0278 RC C1713 HCPCS inpatient 302 196.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.86 292.94 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712637_1 CDM 0278 RC C1713 HCPCS inpatient 302 196.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.86 292.94 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712637_1 CDM 0278 RC C1713 HCPCS inpatient 302 196.3 ANTHEM HMO ANTHEM HMO 999999999 182.86 292.94 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712637_1 CDM 0278 RC C1713 HCPCS inpatient 302 196.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.86 292.94 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712637_1 CDM 0278 RC C1713 HCPCS inpatient 302 196.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 204.15 67.6 999999999 182.86 292.94 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712637_1 CDM 0278 RC C1713 HCPCS inpatient 302 196.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.86 292.94 KNOWLES PIN 3in 48712638_1 CDM 0278 RC inpatient 339 220.35 AETNA AETNA 267.81 79 999999999 205.26 328.83 percent of total billed charges KNOWLES PIN 3in 48712638_1 CDM 0278 RC inpatient 339 220.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 220.35 65 999999999 205.26 328.83 percent of total billed charges KNOWLES PIN 3in 48712638_1 CDM 0278 RC inpatient 339 220.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 328.83 97 999999999 205.26 328.83 percent of total billed charges KNOWLES PIN 3in 48712638_1 CDM 0278 RC inpatient 339 220.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 264.42 78 999999999 205.26 328.83 percent of total billed charges KNOWLES PIN 3in 48712638_1 CDM 0278 RC inpatient 339 220.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 233.91 69 999999999 205.26 328.83 percent of total billed charges KNOWLES PIN 3in 48712638_1 CDM 0278 RC inpatient 339 220.35 UMR - ALL PLANS UMR - ALL PLANS 237.3 70 999999999 205.26 328.83 percent of total billed charges KNOWLES PIN 3in 48712638_1 CDM 0278 RC inpatient 339 220.35 SIHO - ALL PLANS SIHO - ALL PLANS 305.1 90 999999999 205.26 328.83 percent of total billed charges KNOWLES PIN 3in 48712638_1 CDM 0278 RC inpatient 339 220.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.26 60.55 999999999 205.26 328.83 percent of total billed charges KNOWLES PIN 3in 48712638_1 CDM 0278 RC inpatient 339 220.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.26 328.83 KNOWLES PIN 3in 48712638_1 CDM 0278 RC inpatient 339 220.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.26 328.83 KNOWLES PIN 3in 48712638_1 CDM 0278 RC inpatient 339 220.35 ANTHEM HMO ANTHEM HMO 999999999 205.26 328.83 KNOWLES PIN 3in 48712638_1 CDM 0278 RC inpatient 339 220.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.26 328.83 KNOWLES PIN 3in 48712638_1 CDM 0278 RC inpatient 339 220.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.16 67.6 999999999 205.26 328.83 percent of total billed charges KNOWLES PIN 3in 48712638_1 CDM 0278 RC inpatient 339 220.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.26 328.83 KNOWLES PIN 4in 48712639_1 CDM 0278 RC inpatient 311 202.15 AETNA AETNA 245.69 79 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 4in 48712639_1 CDM 0278 RC inpatient 311 202.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 202.15 65 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 4in 48712639_1 CDM 0278 RC inpatient 311 202.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 301.67 97 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 4in 48712639_1 CDM 0278 RC inpatient 311 202.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 242.58 78 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 4in 48712639_1 CDM 0278 RC inpatient 311 202.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 214.59 69 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 4in 48712639_1 CDM 0278 RC inpatient 311 202.15 UMR - ALL PLANS UMR - ALL PLANS 217.7 70 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 4in 48712639_1 CDM 0278 RC inpatient 311 202.15 SIHO - ALL PLANS SIHO - ALL PLANS 279.9 90 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 4in 48712639_1 CDM 0278 RC inpatient 311 202.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 188.31 60.55 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 4in 48712639_1 CDM 0278 RC inpatient 311 202.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 188.31 301.67 KNOWLES PIN 4in 48712639_1 CDM 0278 RC inpatient 311 202.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 188.31 301.67 KNOWLES PIN 4in 48712639_1 CDM 0278 RC inpatient 311 202.15 ANTHEM HMO ANTHEM HMO 999999999 188.31 301.67 KNOWLES PIN 4in 48712639_1 CDM 0278 RC inpatient 311 202.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 188.31 301.67 KNOWLES PIN 4in 48712639_1 CDM 0278 RC inpatient 311 202.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 210.24 67.6 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 4in 48712639_1 CDM 0278 RC inpatient 311 202.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 188.31 301.67 KNOWLES PIN 43/4in 48712640_1 CDM 0278 RC inpatient 311 202.15 AETNA AETNA 245.69 79 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 43/4in 48712640_1 CDM 0278 RC inpatient 311 202.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 202.15 65 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 43/4in 48712640_1 CDM 0278 RC inpatient 311 202.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 301.67 97 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 43/4in 48712640_1 CDM 0278 RC inpatient 311 202.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 242.58 78 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 43/4in 48712640_1 CDM 0278 RC inpatient 311 202.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 214.59 69 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 43/4in 48712640_1 CDM 0278 RC inpatient 311 202.15 UMR - ALL PLANS UMR - ALL PLANS 217.7 70 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 43/4in 48712640_1 CDM 0278 RC inpatient 311 202.15 SIHO - ALL PLANS SIHO - ALL PLANS 279.9 90 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 43/4in 48712640_1 CDM 0278 RC inpatient 311 202.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 188.31 60.55 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 43/4in 48712640_1 CDM 0278 RC inpatient 311 202.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 188.31 301.67 KNOWLES PIN 43/4in 48712640_1 CDM 0278 RC inpatient 311 202.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 188.31 301.67 KNOWLES PIN 43/4in 48712640_1 CDM 0278 RC inpatient 311 202.15 ANTHEM HMO ANTHEM HMO 999999999 188.31 301.67 KNOWLES PIN 43/4in 48712640_1 CDM 0278 RC inpatient 311 202.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 188.31 301.67 KNOWLES PIN 43/4in 48712640_1 CDM 0278 RC inpatient 311 202.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 210.24 67.6 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 43/4in 48712640_1 CDM 0278 RC inpatient 311 202.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 188.31 301.67 PIN KNOWLES 2 3/4 48712641_1 CDM 0278 RC inpatient 407 264.55 AETNA AETNA 321.53 79 999999999 246.44 394.79 percent of total billed charges PIN KNOWLES 2 3/4 48712641_1 CDM 0278 RC inpatient 407 264.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 264.55 65 999999999 246.44 394.79 percent of total billed charges PIN KNOWLES 2 3/4 48712641_1 CDM 0278 RC inpatient 407 264.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 394.79 97 999999999 246.44 394.79 percent of total billed charges PIN KNOWLES 2 3/4 48712641_1 CDM 0278 RC inpatient 407 264.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 317.46 78 999999999 246.44 394.79 percent of total billed charges PIN KNOWLES 2 3/4 48712641_1 CDM 0278 RC inpatient 407 264.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 280.83 69 999999999 246.44 394.79 percent of total billed charges PIN KNOWLES 2 3/4 48712641_1 CDM 0278 RC inpatient 407 264.55 UMR - ALL PLANS UMR - ALL PLANS 284.9 70 999999999 246.44 394.79 percent of total billed charges PIN KNOWLES 2 3/4 48712641_1 CDM 0278 RC inpatient 407 264.55 SIHO - ALL PLANS SIHO - ALL PLANS 366.3 90 999999999 246.44 394.79 percent of total billed charges PIN KNOWLES 2 3/4 48712641_1 CDM 0278 RC inpatient 407 264.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 246.44 60.55 999999999 246.44 394.79 percent of total billed charges PIN KNOWLES 2 3/4 48712641_1 CDM 0278 RC inpatient 407 264.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 246.44 394.79 PIN KNOWLES 2 3/4 48712641_1 CDM 0278 RC inpatient 407 264.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 246.44 394.79 PIN KNOWLES 2 3/4 48712641_1 CDM 0278 RC inpatient 407 264.55 ANTHEM HMO ANTHEM HMO 999999999 246.44 394.79 PIN KNOWLES 2 3/4 48712641_1 CDM 0278 RC inpatient 407 264.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 246.44 394.79 PIN KNOWLES 2 3/4 48712641_1 CDM 0278 RC inpatient 407 264.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 275.13 67.6 999999999 246.44 394.79 percent of total billed charges PIN KNOWLES 2 3/4 48712641_1 CDM 0278 RC inpatient 407 264.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 246.44 394.79 PIN KNOWLES 3 1/4 48712642_1 CDM 0278 RC inpatient 311 202.15 AETNA AETNA 245.69 79 999999999 188.31 301.67 percent of total billed charges PIN KNOWLES 3 1/4 48712642_1 CDM 0278 RC inpatient 311 202.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 202.15 65 999999999 188.31 301.67 percent of total billed charges PIN KNOWLES 3 1/4 48712642_1 CDM 0278 RC inpatient 311 202.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 301.67 97 999999999 188.31 301.67 percent of total billed charges PIN KNOWLES 3 1/4 48712642_1 CDM 0278 RC inpatient 311 202.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 242.58 78 999999999 188.31 301.67 percent of total billed charges PIN KNOWLES 3 1/4 48712642_1 CDM 0278 RC inpatient 311 202.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 214.59 69 999999999 188.31 301.67 percent of total billed charges PIN KNOWLES 3 1/4 48712642_1 CDM 0278 RC inpatient 311 202.15 UMR - ALL PLANS UMR - ALL PLANS 217.7 70 999999999 188.31 301.67 percent of total billed charges PIN KNOWLES 3 1/4 48712642_1 CDM 0278 RC inpatient 311 202.15 SIHO - ALL PLANS SIHO - ALL PLANS 279.9 90 999999999 188.31 301.67 percent of total billed charges PIN KNOWLES 3 1/4 48712642_1 CDM 0278 RC inpatient 311 202.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 188.31 60.55 999999999 188.31 301.67 percent of total billed charges PIN KNOWLES 3 1/4 48712642_1 CDM 0278 RC inpatient 311 202.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 188.31 301.67 PIN KNOWLES 3 1/4 48712642_1 CDM 0278 RC inpatient 311 202.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 188.31 301.67 PIN KNOWLES 3 1/4 48712642_1 CDM 0278 RC inpatient 311 202.15 ANTHEM HMO ANTHEM HMO 999999999 188.31 301.67 PIN KNOWLES 3 1/4 48712642_1 CDM 0278 RC inpatient 311 202.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 188.31 301.67 PIN KNOWLES 3 1/4 48712642_1 CDM 0278 RC inpatient 311 202.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 210.24 67.6 999999999 188.31 301.67 percent of total billed charges PIN KNOWLES 3 1/4 48712642_1 CDM 0278 RC inpatient 311 202.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 188.31 301.67 PIN KNOWLES 3 1/2 48712643_1 CDM 0278 RC inpatient 311 202.15 AETNA AETNA 245.69 79 999999999 188.31 301.67 percent of total billed charges PIN KNOWLES 3 1/2 48712643_1 CDM 0278 RC inpatient 311 202.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 202.15 65 999999999 188.31 301.67 percent of total billed charges PIN KNOWLES 3 1/2 48712643_1 CDM 0278 RC inpatient 311 202.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 301.67 97 999999999 188.31 301.67 percent of total billed charges PIN KNOWLES 3 1/2 48712643_1 CDM 0278 RC inpatient 311 202.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 242.58 78 999999999 188.31 301.67 percent of total billed charges PIN KNOWLES 3 1/2 48712643_1 CDM 0278 RC inpatient 311 202.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 214.59 69 999999999 188.31 301.67 percent of total billed charges PIN KNOWLES 3 1/2 48712643_1 CDM 0278 RC inpatient 311 202.15 UMR - ALL PLANS UMR - ALL PLANS 217.7 70 999999999 188.31 301.67 percent of total billed charges PIN KNOWLES 3 1/2 48712643_1 CDM 0278 RC inpatient 311 202.15 SIHO - ALL PLANS SIHO - ALL PLANS 279.9 90 999999999 188.31 301.67 percent of total billed charges PIN KNOWLES 3 1/2 48712643_1 CDM 0278 RC inpatient 311 202.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 188.31 60.55 999999999 188.31 301.67 percent of total billed charges PIN KNOWLES 3 1/2 48712643_1 CDM 0278 RC inpatient 311 202.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 188.31 301.67 PIN KNOWLES 3 1/2 48712643_1 CDM 0278 RC inpatient 311 202.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 188.31 301.67 PIN KNOWLES 3 1/2 48712643_1 CDM 0278 RC inpatient 311 202.15 ANTHEM HMO ANTHEM HMO 999999999 188.31 301.67 PIN KNOWLES 3 1/2 48712643_1 CDM 0278 RC inpatient 311 202.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 188.31 301.67 PIN KNOWLES 3 1/2 48712643_1 CDM 0278 RC inpatient 311 202.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 210.24 67.6 999999999 188.31 301.67 percent of total billed charges PIN KNOWLES 3 1/2 48712643_1 CDM 0278 RC inpatient 311 202.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 188.31 301.67 PIN KNOWLES 3 3/4 48712644_1 CDM 0278 RC inpatient 322 209.3 AETNA AETNA 254.38 79 999999999 194.97 312.34 percent of total billed charges PIN KNOWLES 3 3/4 48712644_1 CDM 0278 RC inpatient 322 209.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 209.3 65 999999999 194.97 312.34 percent of total billed charges PIN KNOWLES 3 3/4 48712644_1 CDM 0278 RC inpatient 322 209.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 312.34 97 999999999 194.97 312.34 percent of total billed charges PIN KNOWLES 3 3/4 48712644_1 CDM 0278 RC inpatient 322 209.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 251.16 78 999999999 194.97 312.34 percent of total billed charges PIN KNOWLES 3 3/4 48712644_1 CDM 0278 RC inpatient 322 209.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 222.18 69 999999999 194.97 312.34 percent of total billed charges PIN KNOWLES 3 3/4 48712644_1 CDM 0278 RC inpatient 322 209.3 UMR - ALL PLANS UMR - ALL PLANS 225.4 70 999999999 194.97 312.34 percent of total billed charges PIN KNOWLES 3 3/4 48712644_1 CDM 0278 RC inpatient 322 209.3 SIHO - ALL PLANS SIHO - ALL PLANS 289.8 90 999999999 194.97 312.34 percent of total billed charges PIN KNOWLES 3 3/4 48712644_1 CDM 0278 RC inpatient 322 209.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 194.97 60.55 999999999 194.97 312.34 percent of total billed charges PIN KNOWLES 3 3/4 48712644_1 CDM 0278 RC inpatient 322 209.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 194.97 312.34 PIN KNOWLES 3 3/4 48712644_1 CDM 0278 RC inpatient 322 209.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 194.97 312.34 PIN KNOWLES 3 3/4 48712644_1 CDM 0278 RC inpatient 322 209.3 ANTHEM HMO ANTHEM HMO 999999999 194.97 312.34 PIN KNOWLES 3 3/4 48712644_1 CDM 0278 RC inpatient 322 209.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 194.97 312.34 PIN KNOWLES 3 3/4 48712644_1 CDM 0278 RC inpatient 322 209.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 217.67 67.6 999999999 194.97 312.34 percent of total billed charges PIN KNOWLES 3 3/4 48712644_1 CDM 0278 RC inpatient 322 209.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 194.97 312.34 PIN KNOWLES 4 1/4 48712645_1 CDM 0278 RC inpatient 224 145.6 AETNA AETNA 176.96 79 999999999 135.63 217.28 percent of total billed charges PIN KNOWLES 4 1/4 48712645_1 CDM 0278 RC inpatient 224 145.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 145.6 65 999999999 135.63 217.28 percent of total billed charges PIN KNOWLES 4 1/4 48712645_1 CDM 0278 RC inpatient 224 145.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 217.28 97 999999999 135.63 217.28 percent of total billed charges PIN KNOWLES 4 1/4 48712645_1 CDM 0278 RC inpatient 224 145.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 174.72 78 999999999 135.63 217.28 percent of total billed charges PIN KNOWLES 4 1/4 48712645_1 CDM 0278 RC inpatient 224 145.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 154.56 69 999999999 135.63 217.28 percent of total billed charges PIN KNOWLES 4 1/4 48712645_1 CDM 0278 RC inpatient 224 145.6 UMR - ALL PLANS UMR - ALL PLANS 156.8 70 999999999 135.63 217.28 percent of total billed charges PIN KNOWLES 4 1/4 48712645_1 CDM 0278 RC inpatient 224 145.6 SIHO - ALL PLANS SIHO - ALL PLANS 201.6 90 999999999 135.63 217.28 percent of total billed charges PIN KNOWLES 4 1/4 48712645_1 CDM 0278 RC inpatient 224 145.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 135.63 60.55 999999999 135.63 217.28 percent of total billed charges PIN KNOWLES 4 1/4 48712645_1 CDM 0278 RC inpatient 224 145.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 135.63 217.28 PIN KNOWLES 4 1/4 48712645_1 CDM 0278 RC inpatient 224 145.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 135.63 217.28 PIN KNOWLES 4 1/4 48712645_1 CDM 0278 RC inpatient 224 145.6 ANTHEM HMO ANTHEM HMO 999999999 135.63 217.28 PIN KNOWLES 4 1/4 48712645_1 CDM 0278 RC inpatient 224 145.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 135.63 217.28 PIN KNOWLES 4 1/4 48712645_1 CDM 0278 RC inpatient 224 145.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 151.42 67.6 999999999 135.63 217.28 percent of total billed charges PIN KNOWLES 4 1/4 48712645_1 CDM 0278 RC inpatient 224 145.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 135.63 217.28 PIN KNOWLES 4 1/2 48712646_1 CDM 0278 RC inpatient 224 145.6 AETNA AETNA 176.96 79 999999999 135.63 217.28 percent of total billed charges PIN KNOWLES 4 1/2 48712646_1 CDM 0278 RC inpatient 224 145.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 145.6 65 999999999 135.63 217.28 percent of total billed charges PIN KNOWLES 4 1/2 48712646_1 CDM 0278 RC inpatient 224 145.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 217.28 97 999999999 135.63 217.28 percent of total billed charges PIN KNOWLES 4 1/2 48712646_1 CDM 0278 RC inpatient 224 145.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 174.72 78 999999999 135.63 217.28 percent of total billed charges PIN KNOWLES 4 1/2 48712646_1 CDM 0278 RC inpatient 224 145.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 154.56 69 999999999 135.63 217.28 percent of total billed charges PIN KNOWLES 4 1/2 48712646_1 CDM 0278 RC inpatient 224 145.6 UMR - ALL PLANS UMR - ALL PLANS 156.8 70 999999999 135.63 217.28 percent of total billed charges PIN KNOWLES 4 1/2 48712646_1 CDM 0278 RC inpatient 224 145.6 SIHO - ALL PLANS SIHO - ALL PLANS 201.6 90 999999999 135.63 217.28 percent of total billed charges PIN KNOWLES 4 1/2 48712646_1 CDM 0278 RC inpatient 224 145.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 135.63 60.55 999999999 135.63 217.28 percent of total billed charges PIN KNOWLES 4 1/2 48712646_1 CDM 0278 RC inpatient 224 145.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 135.63 217.28 PIN KNOWLES 4 1/2 48712646_1 CDM 0278 RC inpatient 224 145.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 135.63 217.28 PIN KNOWLES 4 1/2 48712646_1 CDM 0278 RC inpatient 224 145.6 ANTHEM HMO ANTHEM HMO 999999999 135.63 217.28 PIN KNOWLES 4 1/2 48712646_1 CDM 0278 RC inpatient 224 145.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 135.63 217.28 PIN KNOWLES 4 1/2 48712646_1 CDM 0278 RC inpatient 224 145.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 151.42 67.6 999999999 135.63 217.28 percent of total billed charges PIN KNOWLES 4 1/2 48712646_1 CDM 0278 RC inpatient 224 145.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 135.63 217.28 KNOWLES PIN 21/2 48712647_1 CDM 0278 RC inpatient 311 202.15 AETNA AETNA 245.69 79 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 21/2 48712647_1 CDM 0278 RC inpatient 311 202.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 202.15 65 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 21/2 48712647_1 CDM 0278 RC inpatient 311 202.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 301.67 97 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 21/2 48712647_1 CDM 0278 RC inpatient 311 202.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 242.58 78 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 21/2 48712647_1 CDM 0278 RC inpatient 311 202.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 214.59 69 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 21/2 48712647_1 CDM 0278 RC inpatient 311 202.15 UMR - ALL PLANS UMR - ALL PLANS 217.7 70 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 21/2 48712647_1 CDM 0278 RC inpatient 311 202.15 SIHO - ALL PLANS SIHO - ALL PLANS 279.9 90 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 21/2 48712647_1 CDM 0278 RC inpatient 311 202.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 188.31 60.55 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 21/2 48712647_1 CDM 0278 RC inpatient 311 202.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 188.31 301.67 KNOWLES PIN 21/2 48712647_1 CDM 0278 RC inpatient 311 202.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 188.31 301.67 KNOWLES PIN 21/2 48712647_1 CDM 0278 RC inpatient 311 202.15 ANTHEM HMO ANTHEM HMO 999999999 188.31 301.67 KNOWLES PIN 21/2 48712647_1 CDM 0278 RC inpatient 311 202.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 188.31 301.67 KNOWLES PIN 21/2 48712647_1 CDM 0278 RC inpatient 311 202.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 210.24 67.6 999999999 188.31 301.67 percent of total billed charges KNOWLES PIN 21/2 48712647_1 CDM 0278 RC inpatient 311 202.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 188.31 301.67 PASSING PIN 2.4MM TROCAR 48712649_1 CDM 0278 RC inpatient 795 516.75 AETNA AETNA 628.05 79 999999999 481.37 771.15 percent of total billed charges PASSING PIN 2.4MM TROCAR 48712649_1 CDM 0278 RC inpatient 795 516.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 516.75 65 999999999 481.37 771.15 percent of total billed charges PASSING PIN 2.4MM TROCAR 48712649_1 CDM 0278 RC inpatient 795 516.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 771.15 97 999999999 481.37 771.15 percent of total billed charges PASSING PIN 2.4MM TROCAR 48712649_1 CDM 0278 RC inpatient 795 516.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 620.1 78 999999999 481.37 771.15 percent of total billed charges PASSING PIN 2.4MM TROCAR 48712649_1 CDM 0278 RC inpatient 795 516.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 548.55 69 999999999 481.37 771.15 percent of total billed charges PASSING PIN 2.4MM TROCAR 48712649_1 CDM 0278 RC inpatient 795 516.75 UMR - ALL PLANS UMR - ALL PLANS 556.5 70 999999999 481.37 771.15 percent of total billed charges PASSING PIN 2.4MM TROCAR 48712649_1 CDM 0278 RC inpatient 795 516.75 SIHO - ALL PLANS SIHO - ALL PLANS 715.5 90 999999999 481.37 771.15 percent of total billed charges PASSING PIN 2.4MM TROCAR 48712649_1 CDM 0278 RC inpatient 795 516.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 481.37 60.55 999999999 481.37 771.15 percent of total billed charges PASSING PIN 2.4MM TROCAR 48712649_1 CDM 0278 RC inpatient 795 516.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 481.37 771.15 PASSING PIN 2.4MM TROCAR 48712649_1 CDM 0278 RC inpatient 795 516.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 481.37 771.15 PASSING PIN 2.4MM TROCAR 48712649_1 CDM 0278 RC inpatient 795 516.75 ANTHEM HMO ANTHEM HMO 999999999 481.37 771.15 PASSING PIN 2.4MM TROCAR 48712649_1 CDM 0278 RC inpatient 795 516.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 481.37 771.15 PASSING PIN 2.4MM TROCAR 48712649_1 CDM 0278 RC inpatient 795 516.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 537.42 67.6 999999999 481.37 771.15 percent of total billed charges PASSING PIN 2.4MM TROCAR 48712649_1 CDM 0278 RC inpatient 795 516.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 481.37 771.15 PIN RUSH 3/16 A 802-01-02 48712650_1 CDM 0278 RC inpatient 386 250.9 AETNA AETNA 304.94 79 999999999 233.72 374.42 percent of total billed charges PIN RUSH 3/16 A 802-01-02 48712650_1 CDM 0278 RC inpatient 386 250.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 250.9 65 999999999 233.72 374.42 percent of total billed charges PIN RUSH 3/16 A 802-01-02 48712650_1 CDM 0278 RC inpatient 386 250.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 374.42 97 999999999 233.72 374.42 percent of total billed charges PIN RUSH 3/16 A 802-01-02 48712650_1 CDM 0278 RC inpatient 386 250.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.08 78 999999999 233.72 374.42 percent of total billed charges PIN RUSH 3/16 A 802-01-02 48712650_1 CDM 0278 RC inpatient 386 250.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 266.34 69 999999999 233.72 374.42 percent of total billed charges PIN RUSH 3/16 A 802-01-02 48712650_1 CDM 0278 RC inpatient 386 250.9 UMR - ALL PLANS UMR - ALL PLANS 270.2 70 999999999 233.72 374.42 percent of total billed charges PIN RUSH 3/16 A 802-01-02 48712650_1 CDM 0278 RC inpatient 386 250.9 SIHO - ALL PLANS SIHO - ALL PLANS 347.4 90 999999999 233.72 374.42 percent of total billed charges PIN RUSH 3/16 A 802-01-02 48712650_1 CDM 0278 RC inpatient 386 250.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 233.72 60.55 999999999 233.72 374.42 percent of total billed charges PIN RUSH 3/16 A 802-01-02 48712650_1 CDM 0278 RC inpatient 386 250.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 233.72 374.42 PIN RUSH 3/16 A 802-01-02 48712650_1 CDM 0278 RC inpatient 386 250.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 233.72 374.42 PIN RUSH 3/16 A 802-01-02 48712650_1 CDM 0278 RC inpatient 386 250.9 ANTHEM HMO ANTHEM HMO 999999999 233.72 374.42 PIN RUSH 3/16 A 802-01-02 48712650_1 CDM 0278 RC inpatient 386 250.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 233.72 374.42 PIN RUSH 3/16 A 802-01-02 48712650_1 CDM 0278 RC inpatient 386 250.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 260.94 67.6 999999999 233.72 374.42 percent of total billed charges PIN RUSH 3/16 A 802-01-02 48712650_1 CDM 0278 RC inpatient 386 250.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 233.72 374.42 PIN RUSH 3/16 B 802-01-03 48712651_1 CDM 0278 RC inpatient 424 275.6 AETNA AETNA 334.96 79 999999999 256.73 411.28 percent of total billed charges PIN RUSH 3/16 B 802-01-03 48712651_1 CDM 0278 RC inpatient 424 275.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 275.6 65 999999999 256.73 411.28 percent of total billed charges PIN RUSH 3/16 B 802-01-03 48712651_1 CDM 0278 RC inpatient 424 275.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 411.28 97 999999999 256.73 411.28 percent of total billed charges PIN RUSH 3/16 B 802-01-03 48712651_1 CDM 0278 RC inpatient 424 275.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 330.72 78 999999999 256.73 411.28 percent of total billed charges PIN RUSH 3/16 B 802-01-03 48712651_1 CDM 0278 RC inpatient 424 275.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 292.56 69 999999999 256.73 411.28 percent of total billed charges PIN RUSH 3/16 B 802-01-03 48712651_1 CDM 0278 RC inpatient 424 275.6 UMR - ALL PLANS UMR - ALL PLANS 296.8 70 999999999 256.73 411.28 percent of total billed charges PIN RUSH 3/16 B 802-01-03 48712651_1 CDM 0278 RC inpatient 424 275.6 SIHO - ALL PLANS SIHO - ALL PLANS 381.6 90 999999999 256.73 411.28 percent of total billed charges PIN RUSH 3/16 B 802-01-03 48712651_1 CDM 0278 RC inpatient 424 275.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 256.73 60.55 999999999 256.73 411.28 percent of total billed charges PIN RUSH 3/16 B 802-01-03 48712651_1 CDM 0278 RC inpatient 424 275.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 256.73 411.28 PIN RUSH 3/16 B 802-01-03 48712651_1 CDM 0278 RC inpatient 424 275.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 256.73 411.28 PIN RUSH 3/16 B 802-01-03 48712651_1 CDM 0278 RC inpatient 424 275.6 ANTHEM HMO ANTHEM HMO 999999999 256.73 411.28 PIN RUSH 3/16 B 802-01-03 48712651_1 CDM 0278 RC inpatient 424 275.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 256.73 411.28 PIN RUSH 3/16 B 802-01-03 48712651_1 CDM 0278 RC inpatient 424 275.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 286.62 67.6 999999999 256.73 411.28 percent of total billed charges PIN RUSH 3/16 B 802-01-03 48712651_1 CDM 0278 RC inpatient 424 275.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 256.73 411.28 PIN RUSH 3/16 C 802-01-04 48712652_1 CDM 0278 RC inpatient 192 124.8 AETNA AETNA 151.68 79 999999999 116.26 186.24 percent of total billed charges PIN RUSH 3/16 C 802-01-04 48712652_1 CDM 0278 RC inpatient 192 124.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 124.8 65 999999999 116.26 186.24 percent of total billed charges PIN RUSH 3/16 C 802-01-04 48712652_1 CDM 0278 RC inpatient 192 124.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 186.24 97 999999999 116.26 186.24 percent of total billed charges PIN RUSH 3/16 C 802-01-04 48712652_1 CDM 0278 RC inpatient 192 124.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 149.76 78 999999999 116.26 186.24 percent of total billed charges PIN RUSH 3/16 C 802-01-04 48712652_1 CDM 0278 RC inpatient 192 124.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 132.48 69 999999999 116.26 186.24 percent of total billed charges PIN RUSH 3/16 C 802-01-04 48712652_1 CDM 0278 RC inpatient 192 124.8 UMR - ALL PLANS UMR - ALL PLANS 134.4 70 999999999 116.26 186.24 percent of total billed charges PIN RUSH 3/16 C 802-01-04 48712652_1 CDM 0278 RC inpatient 192 124.8 SIHO - ALL PLANS SIHO - ALL PLANS 172.8 90 999999999 116.26 186.24 percent of total billed charges PIN RUSH 3/16 C 802-01-04 48712652_1 CDM 0278 RC inpatient 192 124.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.26 60.55 999999999 116.26 186.24 percent of total billed charges PIN RUSH 3/16 C 802-01-04 48712652_1 CDM 0278 RC inpatient 192 124.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.26 186.24 PIN RUSH 3/16 C 802-01-04 48712652_1 CDM 0278 RC inpatient 192 124.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.26 186.24 PIN RUSH 3/16 C 802-01-04 48712652_1 CDM 0278 RC inpatient 192 124.8 ANTHEM HMO ANTHEM HMO 999999999 116.26 186.24 PIN RUSH 3/16 C 802-01-04 48712652_1 CDM 0278 RC inpatient 192 124.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.26 186.24 PIN RUSH 3/16 C 802-01-04 48712652_1 CDM 0278 RC inpatient 192 124.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 129.79 67.6 999999999 116.26 186.24 percent of total billed charges PIN RUSH 3/16 C 802-01-04 48712652_1 CDM 0278 RC inpatient 192 124.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.26 186.24 PIN RUSH 3/16 E 802-01-06 48712653_1 CDM 0278 RC inpatient 254 165.1 AETNA AETNA 200.66 79 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 E 802-01-06 48712653_1 CDM 0278 RC inpatient 254 165.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 165.1 65 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 E 802-01-06 48712653_1 CDM 0278 RC inpatient 254 165.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 246.38 97 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 E 802-01-06 48712653_1 CDM 0278 RC inpatient 254 165.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 198.12 78 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 E 802-01-06 48712653_1 CDM 0278 RC inpatient 254 165.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 175.26 69 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 E 802-01-06 48712653_1 CDM 0278 RC inpatient 254 165.1 UMR - ALL PLANS UMR - ALL PLANS 177.8 70 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 E 802-01-06 48712653_1 CDM 0278 RC inpatient 254 165.1 SIHO - ALL PLANS SIHO - ALL PLANS 228.6 90 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 E 802-01-06 48712653_1 CDM 0278 RC inpatient 254 165.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 153.8 60.55 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 E 802-01-06 48712653_1 CDM 0278 RC inpatient 254 165.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 153.8 246.38 PIN RUSH 3/16 E 802-01-06 48712653_1 CDM 0278 RC inpatient 254 165.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 153.8 246.38 PIN RUSH 3/16 E 802-01-06 48712653_1 CDM 0278 RC inpatient 254 165.1 ANTHEM HMO ANTHEM HMO 999999999 153.8 246.38 PIN RUSH 3/16 E 802-01-06 48712653_1 CDM 0278 RC inpatient 254 165.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 153.8 246.38 PIN RUSH 3/16 E 802-01-06 48712653_1 CDM 0278 RC inpatient 254 165.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 171.7 67.6 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 E 802-01-06 48712653_1 CDM 0278 RC inpatient 254 165.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 153.8 246.38 PIN RUSH 1/8 B 803-01-03 48712654_1 CDM 0278 RC inpatient 187 121.55 AETNA AETNA 147.73 79 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 B 803-01-03 48712654_1 CDM 0278 RC inpatient 187 121.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 121.55 65 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 B 803-01-03 48712654_1 CDM 0278 RC inpatient 187 121.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 181.39 97 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 B 803-01-03 48712654_1 CDM 0278 RC inpatient 187 121.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 145.86 78 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 B 803-01-03 48712654_1 CDM 0278 RC inpatient 187 121.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.03 69 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 B 803-01-03 48712654_1 CDM 0278 RC inpatient 187 121.55 UMR - ALL PLANS UMR - ALL PLANS 130.9 70 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 B 803-01-03 48712654_1 CDM 0278 RC inpatient 187 121.55 SIHO - ALL PLANS SIHO - ALL PLANS 168.3 90 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 B 803-01-03 48712654_1 CDM 0278 RC inpatient 187 121.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.23 60.55 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 B 803-01-03 48712654_1 CDM 0278 RC inpatient 187 121.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.23 181.39 PIN RUSH 1/8 B 803-01-03 48712654_1 CDM 0278 RC inpatient 187 121.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.23 181.39 PIN RUSH 1/8 B 803-01-03 48712654_1 CDM 0278 RC inpatient 187 121.55 ANTHEM HMO ANTHEM HMO 999999999 113.23 181.39 PIN RUSH 1/8 B 803-01-03 48712654_1 CDM 0278 RC inpatient 187 121.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.23 181.39 PIN RUSH 1/8 B 803-01-03 48712654_1 CDM 0278 RC inpatient 187 121.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 126.41 67.6 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 B 803-01-03 48712654_1 CDM 0278 RC inpatient 187 121.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.23 181.39 PIN RUSH 1/8 F 803-01-07 48712655_1 CDM 0278 RC inpatient 490 318.5 AETNA AETNA 387.1 79 999999999 296.7 475.3 percent of total billed charges PIN RUSH 1/8 F 803-01-07 48712655_1 CDM 0278 RC inpatient 490 318.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 318.5 65 999999999 296.7 475.3 percent of total billed charges PIN RUSH 1/8 F 803-01-07 48712655_1 CDM 0278 RC inpatient 490 318.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 475.3 97 999999999 296.7 475.3 percent of total billed charges PIN RUSH 1/8 F 803-01-07 48712655_1 CDM 0278 RC inpatient 490 318.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 382.2 78 999999999 296.7 475.3 percent of total billed charges PIN RUSH 1/8 F 803-01-07 48712655_1 CDM 0278 RC inpatient 490 318.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 338.1 69 999999999 296.7 475.3 percent of total billed charges PIN RUSH 1/8 F 803-01-07 48712655_1 CDM 0278 RC inpatient 490 318.5 UMR - ALL PLANS UMR - ALL PLANS 343 70 999999999 296.7 475.3 percent of total billed charges PIN RUSH 1/8 F 803-01-07 48712655_1 CDM 0278 RC inpatient 490 318.5 SIHO - ALL PLANS SIHO - ALL PLANS 441 90 999999999 296.7 475.3 percent of total billed charges PIN RUSH 1/8 F 803-01-07 48712655_1 CDM 0278 RC inpatient 490 318.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 296.7 60.55 999999999 296.7 475.3 percent of total billed charges PIN RUSH 1/8 F 803-01-07 48712655_1 CDM 0278 RC inpatient 490 318.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 296.7 475.3 PIN RUSH 1/8 F 803-01-07 48712655_1 CDM 0278 RC inpatient 490 318.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 296.7 475.3 PIN RUSH 1/8 F 803-01-07 48712655_1 CDM 0278 RC inpatient 490 318.5 ANTHEM HMO ANTHEM HMO 999999999 296.7 475.3 PIN RUSH 1/8 F 803-01-07 48712655_1 CDM 0278 RC inpatient 490 318.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 296.7 475.3 PIN RUSH 1/8 F 803-01-07 48712655_1 CDM 0278 RC inpatient 490 318.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 331.24 67.6 999999999 296.7 475.3 percent of total billed charges PIN RUSH 1/8 F 803-01-07 48712655_1 CDM 0278 RC inpatient 490 318.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 296.7 475.3 PIN RUSH 3/16 D 802-01-05 48712656_1 CDM 0278 RC inpatient 254 165.1 AETNA AETNA 200.66 79 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 D 802-01-05 48712656_1 CDM 0278 RC inpatient 254 165.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 165.1 65 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 D 802-01-05 48712656_1 CDM 0278 RC inpatient 254 165.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 246.38 97 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 D 802-01-05 48712656_1 CDM 0278 RC inpatient 254 165.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 198.12 78 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 D 802-01-05 48712656_1 CDM 0278 RC inpatient 254 165.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 175.26 69 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 D 802-01-05 48712656_1 CDM 0278 RC inpatient 254 165.1 UMR - ALL PLANS UMR - ALL PLANS 177.8 70 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 D 802-01-05 48712656_1 CDM 0278 RC inpatient 254 165.1 SIHO - ALL PLANS SIHO - ALL PLANS 228.6 90 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 D 802-01-05 48712656_1 CDM 0278 RC inpatient 254 165.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 153.8 60.55 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 D 802-01-05 48712656_1 CDM 0278 RC inpatient 254 165.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 153.8 246.38 PIN RUSH 3/16 D 802-01-05 48712656_1 CDM 0278 RC inpatient 254 165.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 153.8 246.38 PIN RUSH 3/16 D 802-01-05 48712656_1 CDM 0278 RC inpatient 254 165.1 ANTHEM HMO ANTHEM HMO 999999999 153.8 246.38 PIN RUSH 3/16 D 802-01-05 48712656_1 CDM 0278 RC inpatient 254 165.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 153.8 246.38 PIN RUSH 3/16 D 802-01-05 48712656_1 CDM 0278 RC inpatient 254 165.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 171.7 67.6 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 D 802-01-05 48712656_1 CDM 0278 RC inpatient 254 165.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 153.8 246.38 PIN RUSH 1/8 G 803-01-08 48712657_1 CDM 0278 RC inpatient 187 121.55 AETNA AETNA 147.73 79 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 G 803-01-08 48712657_1 CDM 0278 RC inpatient 187 121.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 121.55 65 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 G 803-01-08 48712657_1 CDM 0278 RC inpatient 187 121.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 181.39 97 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 G 803-01-08 48712657_1 CDM 0278 RC inpatient 187 121.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 145.86 78 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 G 803-01-08 48712657_1 CDM 0278 RC inpatient 187 121.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.03 69 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 G 803-01-08 48712657_1 CDM 0278 RC inpatient 187 121.55 UMR - ALL PLANS UMR - ALL PLANS 130.9 70 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 G 803-01-08 48712657_1 CDM 0278 RC inpatient 187 121.55 SIHO - ALL PLANS SIHO - ALL PLANS 168.3 90 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 G 803-01-08 48712657_1 CDM 0278 RC inpatient 187 121.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.23 60.55 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 G 803-01-08 48712657_1 CDM 0278 RC inpatient 187 121.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.23 181.39 PIN RUSH 1/8 G 803-01-08 48712657_1 CDM 0278 RC inpatient 187 121.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.23 181.39 PIN RUSH 1/8 G 803-01-08 48712657_1 CDM 0278 RC inpatient 187 121.55 ANTHEM HMO ANTHEM HMO 999999999 113.23 181.39 PIN RUSH 1/8 G 803-01-08 48712657_1 CDM 0278 RC inpatient 187 121.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.23 181.39 PIN RUSH 1/8 G 803-01-08 48712657_1 CDM 0278 RC inpatient 187 121.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 126.41 67.6 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 G 803-01-08 48712657_1 CDM 0278 RC inpatient 187 121.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.23 181.39 PIN RUSH 3/16 F 802-01-07 48712658_1 CDM 0278 RC inpatient 254 165.1 AETNA AETNA 200.66 79 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 F 802-01-07 48712658_1 CDM 0278 RC inpatient 254 165.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 165.1 65 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 F 802-01-07 48712658_1 CDM 0278 RC inpatient 254 165.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 246.38 97 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 F 802-01-07 48712658_1 CDM 0278 RC inpatient 254 165.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 198.12 78 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 F 802-01-07 48712658_1 CDM 0278 RC inpatient 254 165.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 175.26 69 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 F 802-01-07 48712658_1 CDM 0278 RC inpatient 254 165.1 UMR - ALL PLANS UMR - ALL PLANS 177.8 70 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 F 802-01-07 48712658_1 CDM 0278 RC inpatient 254 165.1 SIHO - ALL PLANS SIHO - ALL PLANS 228.6 90 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 F 802-01-07 48712658_1 CDM 0278 RC inpatient 254 165.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 153.8 60.55 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 F 802-01-07 48712658_1 CDM 0278 RC inpatient 254 165.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 153.8 246.38 PIN RUSH 3/16 F 802-01-07 48712658_1 CDM 0278 RC inpatient 254 165.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 153.8 246.38 PIN RUSH 3/16 F 802-01-07 48712658_1 CDM 0278 RC inpatient 254 165.1 ANTHEM HMO ANTHEM HMO 999999999 153.8 246.38 PIN RUSH 3/16 F 802-01-07 48712658_1 CDM 0278 RC inpatient 254 165.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 153.8 246.38 PIN RUSH 3/16 F 802-01-07 48712658_1 CDM 0278 RC inpatient 254 165.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 171.7 67.6 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 F 802-01-07 48712658_1 CDM 0278 RC inpatient 254 165.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 153.8 246.38 PIN RUSH 3/16 G 802-01-08 48712659_1 CDM 0278 RC inpatient 254 165.1 AETNA AETNA 200.66 79 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 G 802-01-08 48712659_1 CDM 0278 RC inpatient 254 165.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 165.1 65 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 G 802-01-08 48712659_1 CDM 0278 RC inpatient 254 165.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 246.38 97 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 G 802-01-08 48712659_1 CDM 0278 RC inpatient 254 165.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 198.12 78 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 G 802-01-08 48712659_1 CDM 0278 RC inpatient 254 165.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 175.26 69 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 G 802-01-08 48712659_1 CDM 0278 RC inpatient 254 165.1 UMR - ALL PLANS UMR - ALL PLANS 177.8 70 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 G 802-01-08 48712659_1 CDM 0278 RC inpatient 254 165.1 SIHO - ALL PLANS SIHO - ALL PLANS 228.6 90 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 G 802-01-08 48712659_1 CDM 0278 RC inpatient 254 165.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 153.8 60.55 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 G 802-01-08 48712659_1 CDM 0278 RC inpatient 254 165.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 153.8 246.38 PIN RUSH 3/16 G 802-01-08 48712659_1 CDM 0278 RC inpatient 254 165.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 153.8 246.38 PIN RUSH 3/16 G 802-01-08 48712659_1 CDM 0278 RC inpatient 254 165.1 ANTHEM HMO ANTHEM HMO 999999999 153.8 246.38 PIN RUSH 3/16 G 802-01-08 48712659_1 CDM 0278 RC inpatient 254 165.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 153.8 246.38 PIN RUSH 3/16 G 802-01-08 48712659_1 CDM 0278 RC inpatient 254 165.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 171.7 67.6 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 G 802-01-08 48712659_1 CDM 0278 RC inpatient 254 165.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 153.8 246.38 PIN RUSH 3/16 H 802-01-09 48712660_1 CDM 0278 RC inpatient 254 165.1 AETNA AETNA 200.66 79 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 H 802-01-09 48712660_1 CDM 0278 RC inpatient 254 165.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 165.1 65 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 H 802-01-09 48712660_1 CDM 0278 RC inpatient 254 165.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 246.38 97 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 H 802-01-09 48712660_1 CDM 0278 RC inpatient 254 165.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 198.12 78 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 H 802-01-09 48712660_1 CDM 0278 RC inpatient 254 165.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 175.26 69 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 H 802-01-09 48712660_1 CDM 0278 RC inpatient 254 165.1 UMR - ALL PLANS UMR - ALL PLANS 177.8 70 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 H 802-01-09 48712660_1 CDM 0278 RC inpatient 254 165.1 SIHO - ALL PLANS SIHO - ALL PLANS 228.6 90 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 H 802-01-09 48712660_1 CDM 0278 RC inpatient 254 165.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 153.8 60.55 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 H 802-01-09 48712660_1 CDM 0278 RC inpatient 254 165.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 153.8 246.38 PIN RUSH 3/16 H 802-01-09 48712660_1 CDM 0278 RC inpatient 254 165.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 153.8 246.38 PIN RUSH 3/16 H 802-01-09 48712660_1 CDM 0278 RC inpatient 254 165.1 ANTHEM HMO ANTHEM HMO 999999999 153.8 246.38 PIN RUSH 3/16 H 802-01-09 48712660_1 CDM 0278 RC inpatient 254 165.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 153.8 246.38 PIN RUSH 3/16 H 802-01-09 48712660_1 CDM 0278 RC inpatient 254 165.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 171.7 67.6 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 H 802-01-09 48712660_1 CDM 0278 RC inpatient 254 165.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 153.8 246.38 PIN RUSH 3/16 I 802-01-10 48712661_1 CDM 0278 RC inpatient 254 165.1 AETNA AETNA 200.66 79 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 I 802-01-10 48712661_1 CDM 0278 RC inpatient 254 165.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 165.1 65 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 I 802-01-10 48712661_1 CDM 0278 RC inpatient 254 165.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 246.38 97 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 I 802-01-10 48712661_1 CDM 0278 RC inpatient 254 165.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 198.12 78 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 I 802-01-10 48712661_1 CDM 0278 RC inpatient 254 165.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 175.26 69 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 I 802-01-10 48712661_1 CDM 0278 RC inpatient 254 165.1 UMR - ALL PLANS UMR - ALL PLANS 177.8 70 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 I 802-01-10 48712661_1 CDM 0278 RC inpatient 254 165.1 SIHO - ALL PLANS SIHO - ALL PLANS 228.6 90 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 I 802-01-10 48712661_1 CDM 0278 RC inpatient 254 165.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 153.8 60.55 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 I 802-01-10 48712661_1 CDM 0278 RC inpatient 254 165.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 153.8 246.38 PIN RUSH 3/16 I 802-01-10 48712661_1 CDM 0278 RC inpatient 254 165.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 153.8 246.38 PIN RUSH 3/16 I 802-01-10 48712661_1 CDM 0278 RC inpatient 254 165.1 ANTHEM HMO ANTHEM HMO 999999999 153.8 246.38 PIN RUSH 3/16 I 802-01-10 48712661_1 CDM 0278 RC inpatient 254 165.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 153.8 246.38 PIN RUSH 3/16 I 802-01-10 48712661_1 CDM 0278 RC inpatient 254 165.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 171.7 67.6 999999999 153.8 246.38 percent of total billed charges PIN RUSH 3/16 I 802-01-10 48712661_1 CDM 0278 RC inpatient 254 165.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 153.8 246.38 PIN RUSH 1/8 H 803-01-09 48712662_1 CDM 0278 RC inpatient 187 121.55 AETNA AETNA 147.73 79 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 H 803-01-09 48712662_1 CDM 0278 RC inpatient 187 121.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 121.55 65 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 H 803-01-09 48712662_1 CDM 0278 RC inpatient 187 121.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 181.39 97 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 H 803-01-09 48712662_1 CDM 0278 RC inpatient 187 121.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 145.86 78 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 H 803-01-09 48712662_1 CDM 0278 RC inpatient 187 121.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.03 69 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 H 803-01-09 48712662_1 CDM 0278 RC inpatient 187 121.55 UMR - ALL PLANS UMR - ALL PLANS 130.9 70 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 H 803-01-09 48712662_1 CDM 0278 RC inpatient 187 121.55 SIHO - ALL PLANS SIHO - ALL PLANS 168.3 90 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 H 803-01-09 48712662_1 CDM 0278 RC inpatient 187 121.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.23 60.55 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 H 803-01-09 48712662_1 CDM 0278 RC inpatient 187 121.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.23 181.39 PIN RUSH 1/8 H 803-01-09 48712662_1 CDM 0278 RC inpatient 187 121.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.23 181.39 PIN RUSH 1/8 H 803-01-09 48712662_1 CDM 0278 RC inpatient 187 121.55 ANTHEM HMO ANTHEM HMO 999999999 113.23 181.39 PIN RUSH 1/8 H 803-01-09 48712662_1 CDM 0278 RC inpatient 187 121.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.23 181.39 PIN RUSH 1/8 H 803-01-09 48712662_1 CDM 0278 RC inpatient 187 121.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 126.41 67.6 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 H 803-01-09 48712662_1 CDM 0278 RC inpatient 187 121.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.23 181.39 PIN RUSH 1/8 L 803-01-13 48712663_1 CDM 0278 RC inpatient 414 269.1 AETNA AETNA 327.06 79 999999999 250.68 401.58 percent of total billed charges PIN RUSH 1/8 L 803-01-13 48712663_1 CDM 0278 RC inpatient 414 269.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 269.1 65 999999999 250.68 401.58 percent of total billed charges PIN RUSH 1/8 L 803-01-13 48712663_1 CDM 0278 RC inpatient 414 269.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 401.58 97 999999999 250.68 401.58 percent of total billed charges PIN RUSH 1/8 L 803-01-13 48712663_1 CDM 0278 RC inpatient 414 269.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 322.92 78 999999999 250.68 401.58 percent of total billed charges PIN RUSH 1/8 L 803-01-13 48712663_1 CDM 0278 RC inpatient 414 269.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 285.66 69 999999999 250.68 401.58 percent of total billed charges PIN RUSH 1/8 L 803-01-13 48712663_1 CDM 0278 RC inpatient 414 269.1 UMR - ALL PLANS UMR - ALL PLANS 289.8 70 999999999 250.68 401.58 percent of total billed charges PIN RUSH 1/8 L 803-01-13 48712663_1 CDM 0278 RC inpatient 414 269.1 SIHO - ALL PLANS SIHO - ALL PLANS 372.6 90 999999999 250.68 401.58 percent of total billed charges PIN RUSH 1/8 L 803-01-13 48712663_1 CDM 0278 RC inpatient 414 269.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 250.68 60.55 999999999 250.68 401.58 percent of total billed charges PIN RUSH 1/8 L 803-01-13 48712663_1 CDM 0278 RC inpatient 414 269.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 250.68 401.58 PIN RUSH 1/8 L 803-01-13 48712663_1 CDM 0278 RC inpatient 414 269.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 250.68 401.58 PIN RUSH 1/8 L 803-01-13 48712663_1 CDM 0278 RC inpatient 414 269.1 ANTHEM HMO ANTHEM HMO 999999999 250.68 401.58 PIN RUSH 1/8 L 803-01-13 48712663_1 CDM 0278 RC inpatient 414 269.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 250.68 401.58 PIN RUSH 1/8 L 803-01-13 48712663_1 CDM 0278 RC inpatient 414 269.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 279.86 67.6 999999999 250.68 401.58 percent of total billed charges PIN RUSH 1/8 L 803-01-13 48712663_1 CDM 0278 RC inpatient 414 269.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 250.68 401.58 PIN RUSH 1/8 C 803-01-04 48712664_1 CDM 0278 RC inpatient 187 121.55 AETNA AETNA 147.73 79 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 C 803-01-04 48712664_1 CDM 0278 RC inpatient 187 121.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 121.55 65 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 C 803-01-04 48712664_1 CDM 0278 RC inpatient 187 121.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 181.39 97 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 C 803-01-04 48712664_1 CDM 0278 RC inpatient 187 121.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 145.86 78 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 C 803-01-04 48712664_1 CDM 0278 RC inpatient 187 121.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.03 69 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 C 803-01-04 48712664_1 CDM 0278 RC inpatient 187 121.55 UMR - ALL PLANS UMR - ALL PLANS 130.9 70 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 C 803-01-04 48712664_1 CDM 0278 RC inpatient 187 121.55 SIHO - ALL PLANS SIHO - ALL PLANS 168.3 90 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 C 803-01-04 48712664_1 CDM 0278 RC inpatient 187 121.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.23 60.55 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 C 803-01-04 48712664_1 CDM 0278 RC inpatient 187 121.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.23 181.39 PIN RUSH 1/8 C 803-01-04 48712664_1 CDM 0278 RC inpatient 187 121.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.23 181.39 PIN RUSH 1/8 C 803-01-04 48712664_1 CDM 0278 RC inpatient 187 121.55 ANTHEM HMO ANTHEM HMO 999999999 113.23 181.39 PIN RUSH 1/8 C 803-01-04 48712664_1 CDM 0278 RC inpatient 187 121.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.23 181.39 PIN RUSH 1/8 C 803-01-04 48712664_1 CDM 0278 RC inpatient 187 121.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 126.41 67.6 999999999 113.23 181.39 percent of total billed charges PIN RUSH 1/8 C 803-01-04 48712664_1 CDM 0278 RC inpatient 187 121.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.23 181.39 PIN RUSH 1/8 E 803-01-06 48712665_1 CDM 0278 RC inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges PIN RUSH 1/8 E 803-01-06 48712665_1 CDM 0278 RC inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges PIN RUSH 1/8 E 803-01-06 48712665_1 CDM 0278 RC inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges PIN RUSH 1/8 E 803-01-06 48712665_1 CDM 0278 RC inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges PIN RUSH 1/8 E 803-01-06 48712665_1 CDM 0278 RC inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges PIN RUSH 1/8 E 803-01-06 48712665_1 CDM 0278 RC inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges PIN RUSH 1/8 E 803-01-06 48712665_1 CDM 0278 RC inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges PIN RUSH 1/8 E 803-01-06 48712665_1 CDM 0278 RC inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges PIN RUSH 1/8 E 803-01-06 48712665_1 CDM 0278 RC inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 PIN RUSH 1/8 E 803-01-06 48712665_1 CDM 0278 RC inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 PIN RUSH 1/8 E 803-01-06 48712665_1 CDM 0278 RC inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 PIN RUSH 1/8 E 803-01-06 48712665_1 CDM 0278 RC inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 PIN RUSH 1/8 E 803-01-06 48712665_1 CDM 0278 RC inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges PIN RUSH 1/8 E 803-01-06 48712665_1 CDM 0278 RC inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 PIN RUSH 3/32 S 806-01-08 48712666_1 CDM 0278 RC inpatient 170 110.5 AETNA AETNA 134.3 79 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 S 806-01-08 48712666_1 CDM 0278 RC inpatient 170 110.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.5 65 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 S 806-01-08 48712666_1 CDM 0278 RC inpatient 170 110.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.9 97 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 S 806-01-08 48712666_1 CDM 0278 RC inpatient 170 110.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.6 78 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 S 806-01-08 48712666_1 CDM 0278 RC inpatient 170 110.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.3 69 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 S 806-01-08 48712666_1 CDM 0278 RC inpatient 170 110.5 UMR - ALL PLANS UMR - ALL PLANS 119 70 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 S 806-01-08 48712666_1 CDM 0278 RC inpatient 170 110.5 SIHO - ALL PLANS SIHO - ALL PLANS 153 90 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 S 806-01-08 48712666_1 CDM 0278 RC inpatient 170 110.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.94 60.55 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 S 806-01-08 48712666_1 CDM 0278 RC inpatient 170 110.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.94 164.9 PIN RUSH 3/32 S 806-01-08 48712666_1 CDM 0278 RC inpatient 170 110.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.94 164.9 PIN RUSH 3/32 S 806-01-08 48712666_1 CDM 0278 RC inpatient 170 110.5 ANTHEM HMO ANTHEM HMO 999999999 102.94 164.9 PIN RUSH 3/32 S 806-01-08 48712666_1 CDM 0278 RC inpatient 170 110.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.94 164.9 PIN RUSH 3/32 S 806-01-08 48712666_1 CDM 0278 RC inpatient 170 110.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.92 67.6 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 S 806-01-08 48712666_1 CDM 0278 RC inpatient 170 110.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.94 164.9 PIN RUSH 3/32 T 806-01-09 48712667_1 CDM 0278 RC inpatient 170 110.5 AETNA AETNA 134.3 79 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 T 806-01-09 48712667_1 CDM 0278 RC inpatient 170 110.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.5 65 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 T 806-01-09 48712667_1 CDM 0278 RC inpatient 170 110.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.9 97 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 T 806-01-09 48712667_1 CDM 0278 RC inpatient 170 110.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.6 78 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 T 806-01-09 48712667_1 CDM 0278 RC inpatient 170 110.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.3 69 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 T 806-01-09 48712667_1 CDM 0278 RC inpatient 170 110.5 UMR - ALL PLANS UMR - ALL PLANS 119 70 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 T 806-01-09 48712667_1 CDM 0278 RC inpatient 170 110.5 SIHO - ALL PLANS SIHO - ALL PLANS 153 90 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 T 806-01-09 48712667_1 CDM 0278 RC inpatient 170 110.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.94 60.55 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 T 806-01-09 48712667_1 CDM 0278 RC inpatient 170 110.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.94 164.9 PIN RUSH 3/32 T 806-01-09 48712667_1 CDM 0278 RC inpatient 170 110.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.94 164.9 PIN RUSH 3/32 T 806-01-09 48712667_1 CDM 0278 RC inpatient 170 110.5 ANTHEM HMO ANTHEM HMO 999999999 102.94 164.9 PIN RUSH 3/32 T 806-01-09 48712667_1 CDM 0278 RC inpatient 170 110.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.94 164.9 PIN RUSH 3/32 T 806-01-09 48712667_1 CDM 0278 RC inpatient 170 110.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.92 67.6 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 T 806-01-09 48712667_1 CDM 0278 RC inpatient 170 110.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.94 164.9 PIN RUSH 3/32 V 806-01-11 48712668_1 CDM 0278 RC inpatient 170 110.5 AETNA AETNA 134.3 79 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 V 806-01-11 48712668_1 CDM 0278 RC inpatient 170 110.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.5 65 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 V 806-01-11 48712668_1 CDM 0278 RC inpatient 170 110.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.9 97 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 V 806-01-11 48712668_1 CDM 0278 RC inpatient 170 110.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.6 78 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 V 806-01-11 48712668_1 CDM 0278 RC inpatient 170 110.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.3 69 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 V 806-01-11 48712668_1 CDM 0278 RC inpatient 170 110.5 UMR - ALL PLANS UMR - ALL PLANS 119 70 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 V 806-01-11 48712668_1 CDM 0278 RC inpatient 170 110.5 SIHO - ALL PLANS SIHO - ALL PLANS 153 90 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 V 806-01-11 48712668_1 CDM 0278 RC inpatient 170 110.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.94 60.55 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 V 806-01-11 48712668_1 CDM 0278 RC inpatient 170 110.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.94 164.9 PIN RUSH 3/32 V 806-01-11 48712668_1 CDM 0278 RC inpatient 170 110.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.94 164.9 PIN RUSH 3/32 V 806-01-11 48712668_1 CDM 0278 RC inpatient 170 110.5 ANTHEM HMO ANTHEM HMO 999999999 102.94 164.9 PIN RUSH 3/32 V 806-01-11 48712668_1 CDM 0278 RC inpatient 170 110.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.94 164.9 PIN RUSH 3/32 V 806-01-11 48712668_1 CDM 0278 RC inpatient 170 110.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.92 67.6 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 V 806-01-11 48712668_1 CDM 0278 RC inpatient 170 110.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.94 164.9 PIN RUSH 3/32 W 806-01-12 48712669_1 CDM 0278 RC inpatient 170 110.5 AETNA AETNA 134.3 79 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 W 806-01-12 48712669_1 CDM 0278 RC inpatient 170 110.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.5 65 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 W 806-01-12 48712669_1 CDM 0278 RC inpatient 170 110.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.9 97 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 W 806-01-12 48712669_1 CDM 0278 RC inpatient 170 110.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.6 78 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 W 806-01-12 48712669_1 CDM 0278 RC inpatient 170 110.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.3 69 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 W 806-01-12 48712669_1 CDM 0278 RC inpatient 170 110.5 UMR - ALL PLANS UMR - ALL PLANS 119 70 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 W 806-01-12 48712669_1 CDM 0278 RC inpatient 170 110.5 SIHO - ALL PLANS SIHO - ALL PLANS 153 90 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 W 806-01-12 48712669_1 CDM 0278 RC inpatient 170 110.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.94 60.55 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 W 806-01-12 48712669_1 CDM 0278 RC inpatient 170 110.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.94 164.9 PIN RUSH 3/32 W 806-01-12 48712669_1 CDM 0278 RC inpatient 170 110.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.94 164.9 PIN RUSH 3/32 W 806-01-12 48712669_1 CDM 0278 RC inpatient 170 110.5 ANTHEM HMO ANTHEM HMO 999999999 102.94 164.9 PIN RUSH 3/32 W 806-01-12 48712669_1 CDM 0278 RC inpatient 170 110.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.94 164.9 PIN RUSH 3/32 W 806-01-12 48712669_1 CDM 0278 RC inpatient 170 110.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.92 67.6 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 W 806-01-12 48712669_1 CDM 0278 RC inpatient 170 110.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.94 164.9 PIN RUSH 3/32 X 806-01-13 48712670_1 CDM 0278 RC inpatient 170 110.5 AETNA AETNA 134.3 79 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 X 806-01-13 48712670_1 CDM 0278 RC inpatient 170 110.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.5 65 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 X 806-01-13 48712670_1 CDM 0278 RC inpatient 170 110.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.9 97 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 X 806-01-13 48712670_1 CDM 0278 RC inpatient 170 110.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.6 78 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 X 806-01-13 48712670_1 CDM 0278 RC inpatient 170 110.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.3 69 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 X 806-01-13 48712670_1 CDM 0278 RC inpatient 170 110.5 UMR - ALL PLANS UMR - ALL PLANS 119 70 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 X 806-01-13 48712670_1 CDM 0278 RC inpatient 170 110.5 SIHO - ALL PLANS SIHO - ALL PLANS 153 90 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 X 806-01-13 48712670_1 CDM 0278 RC inpatient 170 110.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.94 60.55 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 X 806-01-13 48712670_1 CDM 0278 RC inpatient 170 110.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.94 164.9 PIN RUSH 3/32 X 806-01-13 48712670_1 CDM 0278 RC inpatient 170 110.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.94 164.9 PIN RUSH 3/32 X 806-01-13 48712670_1 CDM 0278 RC inpatient 170 110.5 ANTHEM HMO ANTHEM HMO 999999999 102.94 164.9 PIN RUSH 3/32 X 806-01-13 48712670_1 CDM 0278 RC inpatient 170 110.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.94 164.9 PIN RUSH 3/32 X 806-01-13 48712670_1 CDM 0278 RC inpatient 170 110.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.92 67.6 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 X 806-01-13 48712670_1 CDM 0278 RC inpatient 170 110.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.94 164.9 PIN RUSH 1/4 A 801-01-02 48712671_1 CDM 0278 RC inpatient 303 196.95 AETNA AETNA 239.37 79 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 A 801-01-02 48712671_1 CDM 0278 RC inpatient 303 196.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 196.95 65 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 A 801-01-02 48712671_1 CDM 0278 RC inpatient 303 196.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 293.91 97 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 A 801-01-02 48712671_1 CDM 0278 RC inpatient 303 196.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 236.34 78 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 A 801-01-02 48712671_1 CDM 0278 RC inpatient 303 196.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 209.07 69 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 A 801-01-02 48712671_1 CDM 0278 RC inpatient 303 196.95 UMR - ALL PLANS UMR - ALL PLANS 212.1 70 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 A 801-01-02 48712671_1 CDM 0278 RC inpatient 303 196.95 SIHO - ALL PLANS SIHO - ALL PLANS 272.7 90 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 A 801-01-02 48712671_1 CDM 0278 RC inpatient 303 196.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 183.47 60.55 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 A 801-01-02 48712671_1 CDM 0278 RC inpatient 303 196.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 183.47 293.91 PIN RUSH 1/4 A 801-01-02 48712671_1 CDM 0278 RC inpatient 303 196.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 183.47 293.91 PIN RUSH 1/4 A 801-01-02 48712671_1 CDM 0278 RC inpatient 303 196.95 ANTHEM HMO ANTHEM HMO 999999999 183.47 293.91 PIN RUSH 1/4 A 801-01-02 48712671_1 CDM 0278 RC inpatient 303 196.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 183.47 293.91 PIN RUSH 1/4 A 801-01-02 48712671_1 CDM 0278 RC inpatient 303 196.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 204.83 67.6 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 A 801-01-02 48712671_1 CDM 0278 RC inpatient 303 196.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 183.47 293.91 PIN RUSH 1/4 B 801-01-03 48712672_1 CDM 0278 RC inpatient 303 196.95 AETNA AETNA 239.37 79 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 B 801-01-03 48712672_1 CDM 0278 RC inpatient 303 196.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 196.95 65 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 B 801-01-03 48712672_1 CDM 0278 RC inpatient 303 196.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 293.91 97 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 B 801-01-03 48712672_1 CDM 0278 RC inpatient 303 196.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 236.34 78 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 B 801-01-03 48712672_1 CDM 0278 RC inpatient 303 196.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 209.07 69 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 B 801-01-03 48712672_1 CDM 0278 RC inpatient 303 196.95 UMR - ALL PLANS UMR - ALL PLANS 212.1 70 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 B 801-01-03 48712672_1 CDM 0278 RC inpatient 303 196.95 SIHO - ALL PLANS SIHO - ALL PLANS 272.7 90 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 B 801-01-03 48712672_1 CDM 0278 RC inpatient 303 196.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 183.47 60.55 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 B 801-01-03 48712672_1 CDM 0278 RC inpatient 303 196.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 183.47 293.91 PIN RUSH 1/4 B 801-01-03 48712672_1 CDM 0278 RC inpatient 303 196.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 183.47 293.91 PIN RUSH 1/4 B 801-01-03 48712672_1 CDM 0278 RC inpatient 303 196.95 ANTHEM HMO ANTHEM HMO 999999999 183.47 293.91 PIN RUSH 1/4 B 801-01-03 48712672_1 CDM 0278 RC inpatient 303 196.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 183.47 293.91 PIN RUSH 1/4 B 801-01-03 48712672_1 CDM 0278 RC inpatient 303 196.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 204.83 67.6 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 B 801-01-03 48712672_1 CDM 0278 RC inpatient 303 196.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 183.47 293.91 PIN RUSH 1/4 C 801-01-04 48712673_1 CDM 0278 RC inpatient 303 196.95 AETNA AETNA 239.37 79 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 C 801-01-04 48712673_1 CDM 0278 RC inpatient 303 196.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 196.95 65 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 C 801-01-04 48712673_1 CDM 0278 RC inpatient 303 196.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 293.91 97 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 C 801-01-04 48712673_1 CDM 0278 RC inpatient 303 196.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 236.34 78 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 C 801-01-04 48712673_1 CDM 0278 RC inpatient 303 196.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 209.07 69 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 C 801-01-04 48712673_1 CDM 0278 RC inpatient 303 196.95 UMR - ALL PLANS UMR - ALL PLANS 212.1 70 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 C 801-01-04 48712673_1 CDM 0278 RC inpatient 303 196.95 SIHO - ALL PLANS SIHO - ALL PLANS 272.7 90 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 C 801-01-04 48712673_1 CDM 0278 RC inpatient 303 196.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 183.47 60.55 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 C 801-01-04 48712673_1 CDM 0278 RC inpatient 303 196.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 183.47 293.91 PIN RUSH 1/4 C 801-01-04 48712673_1 CDM 0278 RC inpatient 303 196.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 183.47 293.91 PIN RUSH 1/4 C 801-01-04 48712673_1 CDM 0278 RC inpatient 303 196.95 ANTHEM HMO ANTHEM HMO 999999999 183.47 293.91 PIN RUSH 1/4 C 801-01-04 48712673_1 CDM 0278 RC inpatient 303 196.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 183.47 293.91 PIN RUSH 1/4 C 801-01-04 48712673_1 CDM 0278 RC inpatient 303 196.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 204.83 67.6 999999999 183.47 293.91 percent of total billed charges PIN RUSH 1/4 C 801-01-04 48712673_1 CDM 0278 RC inpatient 303 196.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 183.47 293.91 PIN RUSH 1/4 A 2 801-01-11 48712674_1 CDM 0278 RC inpatient 446 289.9 AETNA AETNA 352.34 79 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 A 2 801-01-11 48712674_1 CDM 0278 RC inpatient 446 289.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 289.9 65 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 A 2 801-01-11 48712674_1 CDM 0278 RC inpatient 446 289.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 432.62 97 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 A 2 801-01-11 48712674_1 CDM 0278 RC inpatient 446 289.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 347.88 78 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 A 2 801-01-11 48712674_1 CDM 0278 RC inpatient 446 289.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 307.74 69 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 A 2 801-01-11 48712674_1 CDM 0278 RC inpatient 446 289.9 UMR - ALL PLANS UMR - ALL PLANS 312.2 70 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 A 2 801-01-11 48712674_1 CDM 0278 RC inpatient 446 289.9 SIHO - ALL PLANS SIHO - ALL PLANS 401.4 90 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 A 2 801-01-11 48712674_1 CDM 0278 RC inpatient 446 289.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.05 60.55 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 A 2 801-01-11 48712674_1 CDM 0278 RC inpatient 446 289.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.05 432.62 PIN RUSH 1/4 A 2 801-01-11 48712674_1 CDM 0278 RC inpatient 446 289.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 A 2 801-01-11 48712674_1 CDM 0278 RC inpatient 446 289.9 ANTHEM HMO ANTHEM HMO 999999999 270.05 432.62 PIN RUSH 1/4 A 2 801-01-11 48712674_1 CDM 0278 RC inpatient 446 289.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 A 2 801-01-11 48712674_1 CDM 0278 RC inpatient 446 289.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 301.5 67.6 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 A 2 801-01-11 48712674_1 CDM 0278 RC inpatient 446 289.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.05 432.62 PIN RUSH 1/4 A 1 801-01-12 48712675_1 CDM 0278 RC inpatient 312 202.8 AETNA AETNA 246.48 79 999999999 188.92 302.64 percent of total billed charges PIN RUSH 1/4 A 1 801-01-12 48712675_1 CDM 0278 RC inpatient 312 202.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 202.8 65 999999999 188.92 302.64 percent of total billed charges PIN RUSH 1/4 A 1 801-01-12 48712675_1 CDM 0278 RC inpatient 312 202.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 302.64 97 999999999 188.92 302.64 percent of total billed charges PIN RUSH 1/4 A 1 801-01-12 48712675_1 CDM 0278 RC inpatient 312 202.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 243.36 78 999999999 188.92 302.64 percent of total billed charges PIN RUSH 1/4 A 1 801-01-12 48712675_1 CDM 0278 RC inpatient 312 202.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 215.28 69 999999999 188.92 302.64 percent of total billed charges PIN RUSH 1/4 A 1 801-01-12 48712675_1 CDM 0278 RC inpatient 312 202.8 UMR - ALL PLANS UMR - ALL PLANS 218.4 70 999999999 188.92 302.64 percent of total billed charges PIN RUSH 1/4 A 1 801-01-12 48712675_1 CDM 0278 RC inpatient 312 202.8 SIHO - ALL PLANS SIHO - ALL PLANS 280.8 90 999999999 188.92 302.64 percent of total billed charges PIN RUSH 1/4 A 1 801-01-12 48712675_1 CDM 0278 RC inpatient 312 202.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 188.92 60.55 999999999 188.92 302.64 percent of total billed charges PIN RUSH 1/4 A 1 801-01-12 48712675_1 CDM 0278 RC inpatient 312 202.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 188.92 302.64 PIN RUSH 1/4 A 1 801-01-12 48712675_1 CDM 0278 RC inpatient 312 202.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 188.92 302.64 PIN RUSH 1/4 A 1 801-01-12 48712675_1 CDM 0278 RC inpatient 312 202.8 ANTHEM HMO ANTHEM HMO 999999999 188.92 302.64 PIN RUSH 1/4 A 1 801-01-12 48712675_1 CDM 0278 RC inpatient 312 202.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 188.92 302.64 PIN RUSH 1/4 A 1 801-01-12 48712675_1 CDM 0278 RC inpatient 312 202.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 210.91 67.6 999999999 188.92 302.64 percent of total billed charges PIN RUSH 1/4 A 1 801-01-12 48712675_1 CDM 0278 RC inpatient 312 202.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 188.92 302.64 PIN RUSH 1/4 J 801-01-13 48712676_1 CDM 0278 RC inpatient 446 289.9 AETNA AETNA 352.34 79 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 J 801-01-13 48712676_1 CDM 0278 RC inpatient 446 289.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 289.9 65 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 J 801-01-13 48712676_1 CDM 0278 RC inpatient 446 289.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 432.62 97 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 J 801-01-13 48712676_1 CDM 0278 RC inpatient 446 289.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 347.88 78 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 J 801-01-13 48712676_1 CDM 0278 RC inpatient 446 289.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 307.74 69 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 J 801-01-13 48712676_1 CDM 0278 RC inpatient 446 289.9 UMR - ALL PLANS UMR - ALL PLANS 312.2 70 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 J 801-01-13 48712676_1 CDM 0278 RC inpatient 446 289.9 SIHO - ALL PLANS SIHO - ALL PLANS 401.4 90 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 J 801-01-13 48712676_1 CDM 0278 RC inpatient 446 289.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.05 60.55 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 J 801-01-13 48712676_1 CDM 0278 RC inpatient 446 289.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.05 432.62 PIN RUSH 1/4 J 801-01-13 48712676_1 CDM 0278 RC inpatient 446 289.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 J 801-01-13 48712676_1 CDM 0278 RC inpatient 446 289.9 ANTHEM HMO ANTHEM HMO 999999999 270.05 432.62 PIN RUSH 1/4 J 801-01-13 48712676_1 CDM 0278 RC inpatient 446 289.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 J 801-01-13 48712676_1 CDM 0278 RC inpatient 446 289.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 301.5 67.6 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 J 801-01-13 48712676_1 CDM 0278 RC inpatient 446 289.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.05 432.62 PIN RUSH 3/32 M 804-01-14 48712677_1 CDM 0278 RC inpatient 312 202.8 AETNA AETNA 246.48 79 999999999 188.92 302.64 percent of total billed charges PIN RUSH 3/32 M 804-01-14 48712677_1 CDM 0278 RC inpatient 312 202.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 202.8 65 999999999 188.92 302.64 percent of total billed charges PIN RUSH 3/32 M 804-01-14 48712677_1 CDM 0278 RC inpatient 312 202.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 302.64 97 999999999 188.92 302.64 percent of total billed charges PIN RUSH 3/32 M 804-01-14 48712677_1 CDM 0278 RC inpatient 312 202.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 243.36 78 999999999 188.92 302.64 percent of total billed charges PIN RUSH 3/32 M 804-01-14 48712677_1 CDM 0278 RC inpatient 312 202.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 215.28 69 999999999 188.92 302.64 percent of total billed charges PIN RUSH 3/32 M 804-01-14 48712677_1 CDM 0278 RC inpatient 312 202.8 UMR - ALL PLANS UMR - ALL PLANS 218.4 70 999999999 188.92 302.64 percent of total billed charges PIN RUSH 3/32 M 804-01-14 48712677_1 CDM 0278 RC inpatient 312 202.8 SIHO - ALL PLANS SIHO - ALL PLANS 280.8 90 999999999 188.92 302.64 percent of total billed charges PIN RUSH 3/32 M 804-01-14 48712677_1 CDM 0278 RC inpatient 312 202.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 188.92 60.55 999999999 188.92 302.64 percent of total billed charges PIN RUSH 3/32 M 804-01-14 48712677_1 CDM 0278 RC inpatient 312 202.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 188.92 302.64 PIN RUSH 3/32 M 804-01-14 48712677_1 CDM 0278 RC inpatient 312 202.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 188.92 302.64 PIN RUSH 3/32 M 804-01-14 48712677_1 CDM 0278 RC inpatient 312 202.8 ANTHEM HMO ANTHEM HMO 999999999 188.92 302.64 PIN RUSH 3/32 M 804-01-14 48712677_1 CDM 0278 RC inpatient 312 202.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 188.92 302.64 PIN RUSH 3/32 M 804-01-14 48712677_1 CDM 0278 RC inpatient 312 202.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 210.91 67.6 999999999 188.92 302.64 percent of total billed charges PIN RUSH 3/32 M 804-01-14 48712677_1 CDM 0278 RC inpatient 312 202.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 188.92 302.64 PIN RUSH 1/4 L 801-01-15 48712678_1 CDM 0278 RC inpatient 446 289.9 AETNA AETNA 352.34 79 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 L 801-01-15 48712678_1 CDM 0278 RC inpatient 446 289.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 289.9 65 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 L 801-01-15 48712678_1 CDM 0278 RC inpatient 446 289.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 432.62 97 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 L 801-01-15 48712678_1 CDM 0278 RC inpatient 446 289.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 347.88 78 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 L 801-01-15 48712678_1 CDM 0278 RC inpatient 446 289.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 307.74 69 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 L 801-01-15 48712678_1 CDM 0278 RC inpatient 446 289.9 UMR - ALL PLANS UMR - ALL PLANS 312.2 70 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 L 801-01-15 48712678_1 CDM 0278 RC inpatient 446 289.9 SIHO - ALL PLANS SIHO - ALL PLANS 401.4 90 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 L 801-01-15 48712678_1 CDM 0278 RC inpatient 446 289.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.05 60.55 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 L 801-01-15 48712678_1 CDM 0278 RC inpatient 446 289.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.05 432.62 PIN RUSH 1/4 L 801-01-15 48712678_1 CDM 0278 RC inpatient 446 289.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 L 801-01-15 48712678_1 CDM 0278 RC inpatient 446 289.9 ANTHEM HMO ANTHEM HMO 999999999 270.05 432.62 PIN RUSH 1/4 L 801-01-15 48712678_1 CDM 0278 RC inpatient 446 289.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 L 801-01-15 48712678_1 CDM 0278 RC inpatient 446 289.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 301.5 67.6 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 L 801-01-15 48712678_1 CDM 0278 RC inpatient 446 289.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.05 432.62 PIN RUSH 3/32 N 806-01-03 48712679_1 CDM 0278 RC inpatient 460 299 AETNA AETNA 363.4 79 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 N 806-01-03 48712679_1 CDM 0278 RC inpatient 460 299 SELF PAY DISCOUNT SELF PAY DISCOUNT 299 65 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 N 806-01-03 48712679_1 CDM 0278 RC inpatient 460 299 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 446.2 97 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 N 806-01-03 48712679_1 CDM 0278 RC inpatient 460 299 HUMANA - ALL PLANS HUMANA - ALL PLANS 358.8 78 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 N 806-01-03 48712679_1 CDM 0278 RC inpatient 460 299 ENCORE - ALL PLANS ENCORE - ALL PLANS 317.4 69 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 N 806-01-03 48712679_1 CDM 0278 RC inpatient 460 299 UMR - ALL PLANS UMR - ALL PLANS 322 70 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 N 806-01-03 48712679_1 CDM 0278 RC inpatient 460 299 SIHO - ALL PLANS SIHO - ALL PLANS 414 90 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 N 806-01-03 48712679_1 CDM 0278 RC inpatient 460 299 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 278.53 60.55 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 N 806-01-03 48712679_1 CDM 0278 RC inpatient 460 299 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 278.53 446.2 PIN RUSH 3/32 N 806-01-03 48712679_1 CDM 0278 RC inpatient 460 299 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 278.53 446.2 PIN RUSH 3/32 N 806-01-03 48712679_1 CDM 0278 RC inpatient 460 299 ANTHEM HMO ANTHEM HMO 999999999 278.53 446.2 PIN RUSH 3/32 N 806-01-03 48712679_1 CDM 0278 RC inpatient 460 299 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 278.53 446.2 PIN RUSH 3/32 N 806-01-03 48712679_1 CDM 0278 RC inpatient 460 299 CIGNA - ALL PLANS CIGNA - ALL PLANS 310.96 67.6 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 N 806-01-03 48712679_1 CDM 0278 RC inpatient 460 299 UHC - ALL PLANS UHC - ALL PLANS 999999999 278.53 446.2 PIN RUSH 3/32 R 806-01-07 48712680_1 CDM 0278 RC inpatient 460 299 AETNA AETNA 363.4 79 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 R 806-01-07 48712680_1 CDM 0278 RC inpatient 460 299 SELF PAY DISCOUNT SELF PAY DISCOUNT 299 65 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 R 806-01-07 48712680_1 CDM 0278 RC inpatient 460 299 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 446.2 97 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 R 806-01-07 48712680_1 CDM 0278 RC inpatient 460 299 HUMANA - ALL PLANS HUMANA - ALL PLANS 358.8 78 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 R 806-01-07 48712680_1 CDM 0278 RC inpatient 460 299 ENCORE - ALL PLANS ENCORE - ALL PLANS 317.4 69 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 R 806-01-07 48712680_1 CDM 0278 RC inpatient 460 299 UMR - ALL PLANS UMR - ALL PLANS 322 70 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 R 806-01-07 48712680_1 CDM 0278 RC inpatient 460 299 SIHO - ALL PLANS SIHO - ALL PLANS 414 90 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 R 806-01-07 48712680_1 CDM 0278 RC inpatient 460 299 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 278.53 60.55 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 R 806-01-07 48712680_1 CDM 0278 RC inpatient 460 299 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 278.53 446.2 PIN RUSH 3/32 R 806-01-07 48712680_1 CDM 0278 RC inpatient 460 299 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 278.53 446.2 PIN RUSH 3/32 R 806-01-07 48712680_1 CDM 0278 RC inpatient 460 299 ANTHEM HMO ANTHEM HMO 999999999 278.53 446.2 PIN RUSH 3/32 R 806-01-07 48712680_1 CDM 0278 RC inpatient 460 299 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 278.53 446.2 PIN RUSH 3/32 R 806-01-07 48712680_1 CDM 0278 RC inpatient 460 299 CIGNA - ALL PLANS CIGNA - ALL PLANS 310.96 67.6 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 R 806-01-07 48712680_1 CDM 0278 RC inpatient 460 299 UHC - ALL PLANS UHC - ALL PLANS 999999999 278.53 446.2 PIN RUSH 1/4 I 801-01-10 48712681_1 CDM 0278 RC inpatient 446 289.9 AETNA AETNA 352.34 79 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 I 801-01-10 48712681_1 CDM 0278 RC inpatient 446 289.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 289.9 65 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 I 801-01-10 48712681_1 CDM 0278 RC inpatient 446 289.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 432.62 97 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 I 801-01-10 48712681_1 CDM 0278 RC inpatient 446 289.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 347.88 78 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 I 801-01-10 48712681_1 CDM 0278 RC inpatient 446 289.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 307.74 69 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 I 801-01-10 48712681_1 CDM 0278 RC inpatient 446 289.9 UMR - ALL PLANS UMR - ALL PLANS 312.2 70 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 I 801-01-10 48712681_1 CDM 0278 RC inpatient 446 289.9 SIHO - ALL PLANS SIHO - ALL PLANS 401.4 90 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 I 801-01-10 48712681_1 CDM 0278 RC inpatient 446 289.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.05 60.55 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 I 801-01-10 48712681_1 CDM 0278 RC inpatient 446 289.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.05 432.62 PIN RUSH 1/4 I 801-01-10 48712681_1 CDM 0278 RC inpatient 446 289.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 I 801-01-10 48712681_1 CDM 0278 RC inpatient 446 289.9 ANTHEM HMO ANTHEM HMO 999999999 270.05 432.62 PIN RUSH 1/4 I 801-01-10 48712681_1 CDM 0278 RC inpatient 446 289.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 I 801-01-10 48712681_1 CDM 0278 RC inpatient 446 289.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 301.5 67.6 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 I 801-01-10 48712681_1 CDM 0278 RC inpatient 446 289.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.05 432.62 PIN RUSH 1/4 M 801-01-16 48712682_1 CDM 0278 RC inpatient 446 289.9 AETNA AETNA 352.34 79 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 M 801-01-16 48712682_1 CDM 0278 RC inpatient 446 289.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 289.9 65 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 M 801-01-16 48712682_1 CDM 0278 RC inpatient 446 289.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 432.62 97 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 M 801-01-16 48712682_1 CDM 0278 RC inpatient 446 289.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 347.88 78 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 M 801-01-16 48712682_1 CDM 0278 RC inpatient 446 289.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 307.74 69 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 M 801-01-16 48712682_1 CDM 0278 RC inpatient 446 289.9 UMR - ALL PLANS UMR - ALL PLANS 312.2 70 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 M 801-01-16 48712682_1 CDM 0278 RC inpatient 446 289.9 SIHO - ALL PLANS SIHO - ALL PLANS 401.4 90 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 M 801-01-16 48712682_1 CDM 0278 RC inpatient 446 289.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.05 60.55 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 M 801-01-16 48712682_1 CDM 0278 RC inpatient 446 289.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.05 432.62 PIN RUSH 1/4 M 801-01-16 48712682_1 CDM 0278 RC inpatient 446 289.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 M 801-01-16 48712682_1 CDM 0278 RC inpatient 446 289.9 ANTHEM HMO ANTHEM HMO 999999999 270.05 432.62 PIN RUSH 1/4 M 801-01-16 48712682_1 CDM 0278 RC inpatient 446 289.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 M 801-01-16 48712682_1 CDM 0278 RC inpatient 446 289.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 301.5 67.6 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 M 801-01-16 48712682_1 CDM 0278 RC inpatient 446 289.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.05 432.62 PIN RUSH 1/4 K 801-01-14 48712683_1 CDM 0278 RC inpatient 446 289.9 AETNA AETNA 352.34 79 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 K 801-01-14 48712683_1 CDM 0278 RC inpatient 446 289.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 289.9 65 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 K 801-01-14 48712683_1 CDM 0278 RC inpatient 446 289.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 432.62 97 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 K 801-01-14 48712683_1 CDM 0278 RC inpatient 446 289.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 347.88 78 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 K 801-01-14 48712683_1 CDM 0278 RC inpatient 446 289.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 307.74 69 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 K 801-01-14 48712683_1 CDM 0278 RC inpatient 446 289.9 UMR - ALL PLANS UMR - ALL PLANS 312.2 70 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 K 801-01-14 48712683_1 CDM 0278 RC inpatient 446 289.9 SIHO - ALL PLANS SIHO - ALL PLANS 401.4 90 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 K 801-01-14 48712683_1 CDM 0278 RC inpatient 446 289.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.05 60.55 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 K 801-01-14 48712683_1 CDM 0278 RC inpatient 446 289.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.05 432.62 PIN RUSH 1/4 K 801-01-14 48712683_1 CDM 0278 RC inpatient 446 289.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 K 801-01-14 48712683_1 CDM 0278 RC inpatient 446 289.9 ANTHEM HMO ANTHEM HMO 999999999 270.05 432.62 PIN RUSH 1/4 K 801-01-14 48712683_1 CDM 0278 RC inpatient 446 289.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 K 801-01-14 48712683_1 CDM 0278 RC inpatient 446 289.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 301.5 67.6 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 K 801-01-14 48712683_1 CDM 0278 RC inpatient 446 289.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.05 432.62 PIN RUSH 3/32 P 806-001-05 48712684_1 CDM 0278 RC inpatient 460 299 AETNA AETNA 363.4 79 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 P 806-001-05 48712684_1 CDM 0278 RC inpatient 460 299 SELF PAY DISCOUNT SELF PAY DISCOUNT 299 65 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 P 806-001-05 48712684_1 CDM 0278 RC inpatient 460 299 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 446.2 97 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 P 806-001-05 48712684_1 CDM 0278 RC inpatient 460 299 HUMANA - ALL PLANS HUMANA - ALL PLANS 358.8 78 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 P 806-001-05 48712684_1 CDM 0278 RC inpatient 460 299 ENCORE - ALL PLANS ENCORE - ALL PLANS 317.4 69 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 P 806-001-05 48712684_1 CDM 0278 RC inpatient 460 299 UMR - ALL PLANS UMR - ALL PLANS 322 70 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 P 806-001-05 48712684_1 CDM 0278 RC inpatient 460 299 SIHO - ALL PLANS SIHO - ALL PLANS 414 90 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 P 806-001-05 48712684_1 CDM 0278 RC inpatient 460 299 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 278.53 60.55 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 P 806-001-05 48712684_1 CDM 0278 RC inpatient 460 299 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 278.53 446.2 PIN RUSH 3/32 P 806-001-05 48712684_1 CDM 0278 RC inpatient 460 299 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 278.53 446.2 PIN RUSH 3/32 P 806-001-05 48712684_1 CDM 0278 RC inpatient 460 299 ANTHEM HMO ANTHEM HMO 999999999 278.53 446.2 PIN RUSH 3/32 P 806-001-05 48712684_1 CDM 0278 RC inpatient 460 299 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 278.53 446.2 PIN RUSH 3/32 P 806-001-05 48712684_1 CDM 0278 RC inpatient 460 299 CIGNA - ALL PLANS CIGNA - ALL PLANS 310.96 67.6 999999999 278.53 446.2 percent of total billed charges PIN RUSH 3/32 P 806-001-05 48712684_1 CDM 0278 RC inpatient 460 299 UHC - ALL PLANS UHC - ALL PLANS 999999999 278.53 446.2 PIN RUSH 3/32 U 806-01-10 48712685_1 CDM 0278 RC inpatient 170 110.5 AETNA AETNA 134.3 79 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 U 806-01-10 48712685_1 CDM 0278 RC inpatient 170 110.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.5 65 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 U 806-01-10 48712685_1 CDM 0278 RC inpatient 170 110.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.9 97 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 U 806-01-10 48712685_1 CDM 0278 RC inpatient 170 110.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.6 78 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 U 806-01-10 48712685_1 CDM 0278 RC inpatient 170 110.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.3 69 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 U 806-01-10 48712685_1 CDM 0278 RC inpatient 170 110.5 UMR - ALL PLANS UMR - ALL PLANS 119 70 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 U 806-01-10 48712685_1 CDM 0278 RC inpatient 170 110.5 SIHO - ALL PLANS SIHO - ALL PLANS 153 90 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 U 806-01-10 48712685_1 CDM 0278 RC inpatient 170 110.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.94 60.55 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 U 806-01-10 48712685_1 CDM 0278 RC inpatient 170 110.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.94 164.9 PIN RUSH 3/32 U 806-01-10 48712685_1 CDM 0278 RC inpatient 170 110.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.94 164.9 PIN RUSH 3/32 U 806-01-10 48712685_1 CDM 0278 RC inpatient 170 110.5 ANTHEM HMO ANTHEM HMO 999999999 102.94 164.9 PIN RUSH 3/32 U 806-01-10 48712685_1 CDM 0278 RC inpatient 170 110.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.94 164.9 PIN RUSH 3/32 U 806-01-10 48712685_1 CDM 0278 RC inpatient 170 110.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.92 67.6 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 U 806-01-10 48712685_1 CDM 0278 RC inpatient 170 110.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.94 164.9 PIN RUSH 3/32 Y 806-01-14 48712686_1 CDM 0278 RC inpatient 170 110.5 AETNA AETNA 134.3 79 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 Y 806-01-14 48712686_1 CDM 0278 RC inpatient 170 110.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.5 65 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 Y 806-01-14 48712686_1 CDM 0278 RC inpatient 170 110.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.9 97 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 Y 806-01-14 48712686_1 CDM 0278 RC inpatient 170 110.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.6 78 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 Y 806-01-14 48712686_1 CDM 0278 RC inpatient 170 110.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.3 69 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 Y 806-01-14 48712686_1 CDM 0278 RC inpatient 170 110.5 UMR - ALL PLANS UMR - ALL PLANS 119 70 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 Y 806-01-14 48712686_1 CDM 0278 RC inpatient 170 110.5 SIHO - ALL PLANS SIHO - ALL PLANS 153 90 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 Y 806-01-14 48712686_1 CDM 0278 RC inpatient 170 110.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.94 60.55 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 Y 806-01-14 48712686_1 CDM 0278 RC inpatient 170 110.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.94 164.9 PIN RUSH 3/32 Y 806-01-14 48712686_1 CDM 0278 RC inpatient 170 110.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.94 164.9 PIN RUSH 3/32 Y 806-01-14 48712686_1 CDM 0278 RC inpatient 170 110.5 ANTHEM HMO ANTHEM HMO 999999999 102.94 164.9 PIN RUSH 3/32 Y 806-01-14 48712686_1 CDM 0278 RC inpatient 170 110.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.94 164.9 PIN RUSH 3/32 Y 806-01-14 48712686_1 CDM 0278 RC inpatient 170 110.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.92 67.6 999999999 102.94 164.9 percent of total billed charges PIN RUSH 3/32 Y 806-01-14 48712686_1 CDM 0278 RC inpatient 170 110.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.94 164.9 PIN RUSH 1/4 D 801-01-05 48712687_1 CDM 0278 RC inpatient 256 166.4 AETNA AETNA 202.24 79 999999999 155.01 248.32 percent of total billed charges PIN RUSH 1/4 D 801-01-05 48712687_1 CDM 0278 RC inpatient 256 166.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 166.4 65 999999999 155.01 248.32 percent of total billed charges PIN RUSH 1/4 D 801-01-05 48712687_1 CDM 0278 RC inpatient 256 166.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 248.32 97 999999999 155.01 248.32 percent of total billed charges PIN RUSH 1/4 D 801-01-05 48712687_1 CDM 0278 RC inpatient 256 166.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 199.68 78 999999999 155.01 248.32 percent of total billed charges PIN RUSH 1/4 D 801-01-05 48712687_1 CDM 0278 RC inpatient 256 166.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 176.64 69 999999999 155.01 248.32 percent of total billed charges PIN RUSH 1/4 D 801-01-05 48712687_1 CDM 0278 RC inpatient 256 166.4 UMR - ALL PLANS UMR - ALL PLANS 179.2 70 999999999 155.01 248.32 percent of total billed charges PIN RUSH 1/4 D 801-01-05 48712687_1 CDM 0278 RC inpatient 256 166.4 SIHO - ALL PLANS SIHO - ALL PLANS 230.4 90 999999999 155.01 248.32 percent of total billed charges PIN RUSH 1/4 D 801-01-05 48712687_1 CDM 0278 RC inpatient 256 166.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.01 60.55 999999999 155.01 248.32 percent of total billed charges PIN RUSH 1/4 D 801-01-05 48712687_1 CDM 0278 RC inpatient 256 166.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.01 248.32 PIN RUSH 1/4 D 801-01-05 48712687_1 CDM 0278 RC inpatient 256 166.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.01 248.32 PIN RUSH 1/4 D 801-01-05 48712687_1 CDM 0278 RC inpatient 256 166.4 ANTHEM HMO ANTHEM HMO 999999999 155.01 248.32 PIN RUSH 1/4 D 801-01-05 48712687_1 CDM 0278 RC inpatient 256 166.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.01 248.32 PIN RUSH 1/4 D 801-01-05 48712687_1 CDM 0278 RC inpatient 256 166.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.06 67.6 999999999 155.01 248.32 percent of total billed charges PIN RUSH 1/4 D 801-01-05 48712687_1 CDM 0278 RC inpatient 256 166.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.01 248.32 STEIN PIN 9IN 3/16 1648-109T 48712688_1 CDM 0278 RC inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges STEIN PIN 9IN 3/16 1648-109T 48712688_1 CDM 0278 RC inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges STEIN PIN 9IN 3/16 1648-109T 48712688_1 CDM 0278 RC inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges STEIN PIN 9IN 3/16 1648-109T 48712688_1 CDM 0278 RC inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges STEIN PIN 9IN 3/16 1648-109T 48712688_1 CDM 0278 RC inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges STEIN PIN 9IN 3/16 1648-109T 48712688_1 CDM 0278 RC inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges STEIN PIN 9IN 3/16 1648-109T 48712688_1 CDM 0278 RC inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges STEIN PIN 9IN 3/16 1648-109T 48712688_1 CDM 0278 RC inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges STEIN PIN 9IN 3/16 1648-109T 48712688_1 CDM 0278 RC inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 STEIN PIN 9IN 3/16 1648-109T 48712688_1 CDM 0278 RC inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 STEIN PIN 9IN 3/16 1648-109T 48712688_1 CDM 0278 RC inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 STEIN PIN 9IN 3/16 1648-109T 48712688_1 CDM 0278 RC inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 STEIN PIN 9IN 3/16 1648-109T 48712688_1 CDM 0278 RC inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges STEIN PIN 9IN 3/16 1648-109T 48712688_1 CDM 0278 RC inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 PIN RUSH 1/4 F 801-01-07 48712689_1 CDM 0278 RC inpatient 446 289.9 AETNA AETNA 352.34 79 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 F 801-01-07 48712689_1 CDM 0278 RC inpatient 446 289.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 289.9 65 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 F 801-01-07 48712689_1 CDM 0278 RC inpatient 446 289.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 432.62 97 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 F 801-01-07 48712689_1 CDM 0278 RC inpatient 446 289.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 347.88 78 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 F 801-01-07 48712689_1 CDM 0278 RC inpatient 446 289.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 307.74 69 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 F 801-01-07 48712689_1 CDM 0278 RC inpatient 446 289.9 UMR - ALL PLANS UMR - ALL PLANS 312.2 70 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 F 801-01-07 48712689_1 CDM 0278 RC inpatient 446 289.9 SIHO - ALL PLANS SIHO - ALL PLANS 401.4 90 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 F 801-01-07 48712689_1 CDM 0278 RC inpatient 446 289.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.05 60.55 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 F 801-01-07 48712689_1 CDM 0278 RC inpatient 446 289.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.05 432.62 PIN RUSH 1/4 F 801-01-07 48712689_1 CDM 0278 RC inpatient 446 289.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 F 801-01-07 48712689_1 CDM 0278 RC inpatient 446 289.9 ANTHEM HMO ANTHEM HMO 999999999 270.05 432.62 PIN RUSH 1/4 F 801-01-07 48712689_1 CDM 0278 RC inpatient 446 289.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 F 801-01-07 48712689_1 CDM 0278 RC inpatient 446 289.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 301.5 67.6 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 F 801-01-07 48712689_1 CDM 0278 RC inpatient 446 289.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.05 432.62 PIN RUSH 1/4 G 801-01-08 48712690_1 CDM 0278 RC inpatient 446 289.9 AETNA AETNA 352.34 79 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 G 801-01-08 48712690_1 CDM 0278 RC inpatient 446 289.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 289.9 65 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 G 801-01-08 48712690_1 CDM 0278 RC inpatient 446 289.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 432.62 97 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 G 801-01-08 48712690_1 CDM 0278 RC inpatient 446 289.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 347.88 78 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 G 801-01-08 48712690_1 CDM 0278 RC inpatient 446 289.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 307.74 69 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 G 801-01-08 48712690_1 CDM 0278 RC inpatient 446 289.9 UMR - ALL PLANS UMR - ALL PLANS 312.2 70 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 G 801-01-08 48712690_1 CDM 0278 RC inpatient 446 289.9 SIHO - ALL PLANS SIHO - ALL PLANS 401.4 90 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 G 801-01-08 48712690_1 CDM 0278 RC inpatient 446 289.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.05 60.55 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 G 801-01-08 48712690_1 CDM 0278 RC inpatient 446 289.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.05 432.62 PIN RUSH 1/4 G 801-01-08 48712690_1 CDM 0278 RC inpatient 446 289.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 G 801-01-08 48712690_1 CDM 0278 RC inpatient 446 289.9 ANTHEM HMO ANTHEM HMO 999999999 270.05 432.62 PIN RUSH 1/4 G 801-01-08 48712690_1 CDM 0278 RC inpatient 446 289.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 G 801-01-08 48712690_1 CDM 0278 RC inpatient 446 289.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 301.5 67.6 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 G 801-01-08 48712690_1 CDM 0278 RC inpatient 446 289.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.05 432.62 PIN RUSH 1/4 H 801-01-09 48712691_1 CDM 0278 RC inpatient 446 289.9 AETNA AETNA 352.34 79 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 H 801-01-09 48712691_1 CDM 0278 RC inpatient 446 289.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 289.9 65 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 H 801-01-09 48712691_1 CDM 0278 RC inpatient 446 289.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 432.62 97 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 H 801-01-09 48712691_1 CDM 0278 RC inpatient 446 289.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 347.88 78 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 H 801-01-09 48712691_1 CDM 0278 RC inpatient 446 289.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 307.74 69 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 H 801-01-09 48712691_1 CDM 0278 RC inpatient 446 289.9 UMR - ALL PLANS UMR - ALL PLANS 312.2 70 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 H 801-01-09 48712691_1 CDM 0278 RC inpatient 446 289.9 SIHO - ALL PLANS SIHO - ALL PLANS 401.4 90 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 H 801-01-09 48712691_1 CDM 0278 RC inpatient 446 289.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.05 60.55 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 H 801-01-09 48712691_1 CDM 0278 RC inpatient 446 289.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.05 432.62 PIN RUSH 1/4 H 801-01-09 48712691_1 CDM 0278 RC inpatient 446 289.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 H 801-01-09 48712691_1 CDM 0278 RC inpatient 446 289.9 ANTHEM HMO ANTHEM HMO 999999999 270.05 432.62 PIN RUSH 1/4 H 801-01-09 48712691_1 CDM 0278 RC inpatient 446 289.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 H 801-01-09 48712691_1 CDM 0278 RC inpatient 446 289.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 301.5 67.6 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 H 801-01-09 48712691_1 CDM 0278 RC inpatient 446 289.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.05 432.62 LUBRICANT & DIFFUSER FOR MR7 48712692_1 CDM 0272 RC inpatient 201 130.65 AETNA AETNA 158.79 79 999999999 121.71 194.97 percent of total billed charges LUBRICANT & DIFFUSER FOR MR7 48712692_1 CDM 0272 RC inpatient 201 130.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 130.65 65 999999999 121.71 194.97 percent of total billed charges LUBRICANT & DIFFUSER FOR MR7 48712692_1 CDM 0272 RC inpatient 201 130.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 194.97 97 999999999 121.71 194.97 percent of total billed charges LUBRICANT & DIFFUSER FOR MR7 48712692_1 CDM 0272 RC inpatient 201 130.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 156.78 78 999999999 121.71 194.97 percent of total billed charges LUBRICANT & DIFFUSER FOR MR7 48712692_1 CDM 0272 RC inpatient 201 130.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 138.69 69 999999999 121.71 194.97 percent of total billed charges LUBRICANT & DIFFUSER FOR MR7 48712692_1 CDM 0272 RC inpatient 201 130.65 UMR - ALL PLANS UMR - ALL PLANS 140.7 70 999999999 121.71 194.97 percent of total billed charges LUBRICANT & DIFFUSER FOR MR7 48712692_1 CDM 0272 RC inpatient 201 130.65 SIHO - ALL PLANS SIHO - ALL PLANS 180.9 90 999999999 121.71 194.97 percent of total billed charges LUBRICANT & DIFFUSER FOR MR7 48712692_1 CDM 0272 RC inpatient 201 130.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 121.71 60.55 999999999 121.71 194.97 percent of total billed charges LUBRICANT & DIFFUSER FOR MR7 48712692_1 CDM 0272 RC inpatient 201 130.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 121.71 194.97 LUBRICANT & DIFFUSER FOR MR7 48712692_1 CDM 0272 RC inpatient 201 130.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 121.71 194.97 LUBRICANT & DIFFUSER FOR MR7 48712692_1 CDM 0272 RC inpatient 201 130.65 ANTHEM HMO ANTHEM HMO 999999999 121.71 194.97 LUBRICANT & DIFFUSER FOR MR7 48712692_1 CDM 0272 RC inpatient 201 130.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 121.71 194.97 LUBRICANT & DIFFUSER FOR MR7 48712692_1 CDM 0272 RC inpatient 201 130.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 135.88 67.6 999999999 121.71 194.97 percent of total billed charges LUBRICANT & DIFFUSER FOR MR7 48712692_1 CDM 0272 RC inpatient 201 130.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 121.71 194.97 RUSH PIN 3/32 O 806-01-04 48712694_1 CDM 0278 RC inpatient 250 162.5 AETNA AETNA 197.5 79 999999999 151.38 242.5 percent of total billed charges RUSH PIN 3/32 O 806-01-04 48712694_1 CDM 0278 RC inpatient 250 162.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 162.5 65 999999999 151.38 242.5 percent of total billed charges RUSH PIN 3/32 O 806-01-04 48712694_1 CDM 0278 RC inpatient 250 162.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 242.5 97 999999999 151.38 242.5 percent of total billed charges RUSH PIN 3/32 O 806-01-04 48712694_1 CDM 0278 RC inpatient 250 162.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 195 78 999999999 151.38 242.5 percent of total billed charges RUSH PIN 3/32 O 806-01-04 48712694_1 CDM 0278 RC inpatient 250 162.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 172.5 69 999999999 151.38 242.5 percent of total billed charges RUSH PIN 3/32 O 806-01-04 48712694_1 CDM 0278 RC inpatient 250 162.5 UMR - ALL PLANS UMR - ALL PLANS 175 70 999999999 151.38 242.5 percent of total billed charges RUSH PIN 3/32 O 806-01-04 48712694_1 CDM 0278 RC inpatient 250 162.5 SIHO - ALL PLANS SIHO - ALL PLANS 225 90 999999999 151.38 242.5 percent of total billed charges RUSH PIN 3/32 O 806-01-04 48712694_1 CDM 0278 RC inpatient 250 162.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.38 60.55 999999999 151.38 242.5 percent of total billed charges RUSH PIN 3/32 O 806-01-04 48712694_1 CDM 0278 RC inpatient 250 162.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.38 242.5 RUSH PIN 3/32 O 806-01-04 48712694_1 CDM 0278 RC inpatient 250 162.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.38 242.5 RUSH PIN 3/32 O 806-01-04 48712694_1 CDM 0278 RC inpatient 250 162.5 ANTHEM HMO ANTHEM HMO 999999999 151.38 242.5 RUSH PIN 3/32 O 806-01-04 48712694_1 CDM 0278 RC inpatient 250 162.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.38 242.5 RUSH PIN 3/32 O 806-01-04 48712694_1 CDM 0278 RC inpatient 250 162.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 169 67.6 999999999 151.38 242.5 percent of total billed charges RUSH PIN 3/32 O 806-01-04 48712694_1 CDM 0278 RC inpatient 250 162.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.38 242.5 RUSH PIN 3/32 Q 806-01-06 48712695_1 CDM 0278 RC inpatient 250 162.5 AETNA AETNA 197.5 79 999999999 151.38 242.5 percent of total billed charges RUSH PIN 3/32 Q 806-01-06 48712695_1 CDM 0278 RC inpatient 250 162.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 162.5 65 999999999 151.38 242.5 percent of total billed charges RUSH PIN 3/32 Q 806-01-06 48712695_1 CDM 0278 RC inpatient 250 162.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 242.5 97 999999999 151.38 242.5 percent of total billed charges RUSH PIN 3/32 Q 806-01-06 48712695_1 CDM 0278 RC inpatient 250 162.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 195 78 999999999 151.38 242.5 percent of total billed charges RUSH PIN 3/32 Q 806-01-06 48712695_1 CDM 0278 RC inpatient 250 162.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 172.5 69 999999999 151.38 242.5 percent of total billed charges RUSH PIN 3/32 Q 806-01-06 48712695_1 CDM 0278 RC inpatient 250 162.5 UMR - ALL PLANS UMR - ALL PLANS 175 70 999999999 151.38 242.5 percent of total billed charges RUSH PIN 3/32 Q 806-01-06 48712695_1 CDM 0278 RC inpatient 250 162.5 SIHO - ALL PLANS SIHO - ALL PLANS 225 90 999999999 151.38 242.5 percent of total billed charges RUSH PIN 3/32 Q 806-01-06 48712695_1 CDM 0278 RC inpatient 250 162.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.38 60.55 999999999 151.38 242.5 percent of total billed charges RUSH PIN 3/32 Q 806-01-06 48712695_1 CDM 0278 RC inpatient 250 162.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.38 242.5 RUSH PIN 3/32 Q 806-01-06 48712695_1 CDM 0278 RC inpatient 250 162.5 ANTHEM HMO ANTHEM HMO 999999999 151.38 242.5 RUSH PIN 3/32 Q 806-01-06 48712695_1 CDM 0278 RC inpatient 250 162.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.38 242.5 RUSH PIN 3/32 Q 806-01-06 48712695_1 CDM 0278 RC inpatient 250 162.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 169 67.6 999999999 151.38 242.5 percent of total billed charges RUSH PIN 3/32 Q 806-01-06 48712695_1 CDM 0278 RC inpatient 250 162.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.38 242.5 RUSH PIN 3/32 Q 806-01-06 48712695_1 CDM 0278 RC inpatient 250 162.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.38 242.5 RUSH PIN 1/8 A 803-01-02 48712696_1 CDM 0278 RC inpatient 285 185.25 AETNA AETNA 225.15 79 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 A 803-01-02 48712696_1 CDM 0278 RC inpatient 285 185.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.25 65 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 A 803-01-02 48712696_1 CDM 0278 RC inpatient 285 185.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 276.45 97 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 A 803-01-02 48712696_1 CDM 0278 RC inpatient 285 185.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 222.3 78 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 A 803-01-02 48712696_1 CDM 0278 RC inpatient 285 185.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 196.65 69 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 A 803-01-02 48712696_1 CDM 0278 RC inpatient 285 185.25 UMR - ALL PLANS UMR - ALL PLANS 199.5 70 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 A 803-01-02 48712696_1 CDM 0278 RC inpatient 285 185.25 SIHO - ALL PLANS SIHO - ALL PLANS 256.5 90 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 A 803-01-02 48712696_1 CDM 0278 RC inpatient 285 185.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 172.57 60.55 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 A 803-01-02 48712696_1 CDM 0278 RC inpatient 285 185.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 172.57 276.45 RUSH PIN 1/8 A 803-01-02 48712696_1 CDM 0278 RC inpatient 285 185.25 ANTHEM HMO ANTHEM HMO 999999999 172.57 276.45 RUSH PIN 1/8 A 803-01-02 48712696_1 CDM 0278 RC inpatient 285 185.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 172.57 276.45 RUSH PIN 1/8 A 803-01-02 48712696_1 CDM 0278 RC inpatient 285 185.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 192.66 67.6 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 A 803-01-02 48712696_1 CDM 0278 RC inpatient 285 185.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 172.57 276.45 RUSH PIN 1/8 A 803-01-02 48712696_1 CDM 0278 RC inpatient 285 185.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 172.57 276.45 RUSH PIN 1/8 D 803-01-05 48712697_1 CDM 0278 RC inpatient 285 185.25 AETNA AETNA 225.15 79 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 D 803-01-05 48712697_1 CDM 0278 RC inpatient 285 185.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.25 65 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 D 803-01-05 48712697_1 CDM 0278 RC inpatient 285 185.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 276.45 97 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 D 803-01-05 48712697_1 CDM 0278 RC inpatient 285 185.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 222.3 78 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 D 803-01-05 48712697_1 CDM 0278 RC inpatient 285 185.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 196.65 69 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 D 803-01-05 48712697_1 CDM 0278 RC inpatient 285 185.25 UMR - ALL PLANS UMR - ALL PLANS 199.5 70 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 D 803-01-05 48712697_1 CDM 0278 RC inpatient 285 185.25 SIHO - ALL PLANS SIHO - ALL PLANS 256.5 90 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 D 803-01-05 48712697_1 CDM 0278 RC inpatient 285 185.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 172.57 60.55 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 D 803-01-05 48712697_1 CDM 0278 RC inpatient 285 185.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 172.57 276.45 RUSH PIN 1/8 D 803-01-05 48712697_1 CDM 0278 RC inpatient 285 185.25 ANTHEM HMO ANTHEM HMO 999999999 172.57 276.45 RUSH PIN 1/8 D 803-01-05 48712697_1 CDM 0278 RC inpatient 285 185.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 172.57 276.45 RUSH PIN 1/8 D 803-01-05 48712697_1 CDM 0278 RC inpatient 285 185.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 192.66 67.6 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 D 803-01-05 48712697_1 CDM 0278 RC inpatient 285 185.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 172.57 276.45 RUSH PIN 1/8 D 803-01-05 48712697_1 CDM 0278 RC inpatient 285 185.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 172.57 276.45 RUSH PIN 1/8 I 803-01-10 48712698_1 CDM 0278 RC inpatient 285 185.25 AETNA AETNA 225.15 79 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 I 803-01-10 48712698_1 CDM 0278 RC inpatient 285 185.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.25 65 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 I 803-01-10 48712698_1 CDM 0278 RC inpatient 285 185.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 276.45 97 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 I 803-01-10 48712698_1 CDM 0278 RC inpatient 285 185.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 222.3 78 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 I 803-01-10 48712698_1 CDM 0278 RC inpatient 285 185.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 196.65 69 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 I 803-01-10 48712698_1 CDM 0278 RC inpatient 285 185.25 UMR - ALL PLANS UMR - ALL PLANS 199.5 70 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 I 803-01-10 48712698_1 CDM 0278 RC inpatient 285 185.25 SIHO - ALL PLANS SIHO - ALL PLANS 256.5 90 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 I 803-01-10 48712698_1 CDM 0278 RC inpatient 285 185.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 172.57 60.55 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 I 803-01-10 48712698_1 CDM 0278 RC inpatient 285 185.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 172.57 276.45 RUSH PIN 1/8 I 803-01-10 48712698_1 CDM 0278 RC inpatient 285 185.25 ANTHEM HMO ANTHEM HMO 999999999 172.57 276.45 RUSH PIN 1/8 I 803-01-10 48712698_1 CDM 0278 RC inpatient 285 185.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 172.57 276.45 RUSH PIN 1/8 I 803-01-10 48712698_1 CDM 0278 RC inpatient 285 185.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 192.66 67.6 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 I 803-01-10 48712698_1 CDM 0278 RC inpatient 285 185.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 172.57 276.45 RUSH PIN 1/8 I 803-01-10 48712698_1 CDM 0278 RC inpatient 285 185.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 172.57 276.45 RUSH PIN 1/8 J 803-01-11 48712699_1 CDM 0278 RC inpatient 285 185.25 AETNA AETNA 225.15 79 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 J 803-01-11 48712699_1 CDM 0278 RC inpatient 285 185.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.25 65 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 J 803-01-11 48712699_1 CDM 0278 RC inpatient 285 185.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 276.45 97 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 J 803-01-11 48712699_1 CDM 0278 RC inpatient 285 185.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 222.3 78 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 J 803-01-11 48712699_1 CDM 0278 RC inpatient 285 185.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 196.65 69 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 J 803-01-11 48712699_1 CDM 0278 RC inpatient 285 185.25 UMR - ALL PLANS UMR - ALL PLANS 199.5 70 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 J 803-01-11 48712699_1 CDM 0278 RC inpatient 285 185.25 SIHO - ALL PLANS SIHO - ALL PLANS 256.5 90 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 J 803-01-11 48712699_1 CDM 0278 RC inpatient 285 185.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 172.57 60.55 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 J 803-01-11 48712699_1 CDM 0278 RC inpatient 285 185.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 172.57 276.45 RUSH PIN 1/8 J 803-01-11 48712699_1 CDM 0278 RC inpatient 285 185.25 ANTHEM HMO ANTHEM HMO 999999999 172.57 276.45 RUSH PIN 1/8 J 803-01-11 48712699_1 CDM 0278 RC inpatient 285 185.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 172.57 276.45 RUSH PIN 1/8 J 803-01-11 48712699_1 CDM 0278 RC inpatient 285 185.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 192.66 67.6 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 J 803-01-11 48712699_1 CDM 0278 RC inpatient 285 185.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 172.57 276.45 RUSH PIN 1/8 J 803-01-11 48712699_1 CDM 0278 RC inpatient 285 185.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 172.57 276.45 PIN RUSH 1/4 N 801-01-17 48712700_1 CDM 0278 RC inpatient 446 289.9 AETNA AETNA 352.34 79 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 N 801-01-17 48712700_1 CDM 0278 RC inpatient 446 289.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 289.9 65 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 N 801-01-17 48712700_1 CDM 0278 RC inpatient 446 289.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 432.62 97 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 N 801-01-17 48712700_1 CDM 0278 RC inpatient 446 289.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 347.88 78 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 N 801-01-17 48712700_1 CDM 0278 RC inpatient 446 289.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 307.74 69 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 N 801-01-17 48712700_1 CDM 0278 RC inpatient 446 289.9 UMR - ALL PLANS UMR - ALL PLANS 312.2 70 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 N 801-01-17 48712700_1 CDM 0278 RC inpatient 446 289.9 SIHO - ALL PLANS SIHO - ALL PLANS 401.4 90 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 N 801-01-17 48712700_1 CDM 0278 RC inpatient 446 289.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.05 60.55 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 N 801-01-17 48712700_1 CDM 0278 RC inpatient 446 289.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.05 432.62 PIN RUSH 1/4 N 801-01-17 48712700_1 CDM 0278 RC inpatient 446 289.9 ANTHEM HMO ANTHEM HMO 999999999 270.05 432.62 PIN RUSH 1/4 N 801-01-17 48712700_1 CDM 0278 RC inpatient 446 289.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 N 801-01-17 48712700_1 CDM 0278 RC inpatient 446 289.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 301.5 67.6 999999999 270.05 432.62 percent of total billed charges PIN RUSH 1/4 N 801-01-17 48712700_1 CDM 0278 RC inpatient 446 289.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.05 432.62 PIN RUSH 1/4 N 801-01-17 48712700_1 CDM 0278 RC inpatient 446 289.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.05 432.62 CONDYLAR RUSH RODS 3/16A 250A 48712701_1 CDM 0278 RC inpatient 533 346.45 AETNA AETNA 421.07 79 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16A 250A 48712701_1 CDM 0278 RC inpatient 533 346.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 346.45 65 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16A 250A 48712701_1 CDM 0278 RC inpatient 533 346.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 517.01 97 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16A 250A 48712701_1 CDM 0278 RC inpatient 533 346.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 415.74 78 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16A 250A 48712701_1 CDM 0278 RC inpatient 533 346.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 367.77 69 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16A 250A 48712701_1 CDM 0278 RC inpatient 533 346.45 UMR - ALL PLANS UMR - ALL PLANS 373.1 70 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16A 250A 48712701_1 CDM 0278 RC inpatient 533 346.45 SIHO - ALL PLANS SIHO - ALL PLANS 479.7 90 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16A 250A 48712701_1 CDM 0278 RC inpatient 533 346.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 322.73 60.55 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16A 250A 48712701_1 CDM 0278 RC inpatient 533 346.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16A 250A 48712701_1 CDM 0278 RC inpatient 533 346.45 ANTHEM HMO ANTHEM HMO 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16A 250A 48712701_1 CDM 0278 RC inpatient 533 346.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16A 250A 48712701_1 CDM 0278 RC inpatient 533 346.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 360.31 67.6 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16A 250A 48712701_1 CDM 0278 RC inpatient 533 346.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16A 250A 48712701_1 CDM 0278 RC inpatient 533 346.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16B 250B 48712702_1 CDM 0278 RC inpatient 533 346.45 AETNA AETNA 421.07 79 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16B 250B 48712702_1 CDM 0278 RC inpatient 533 346.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 346.45 65 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16B 250B 48712702_1 CDM 0278 RC inpatient 533 346.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 517.01 97 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16B 250B 48712702_1 CDM 0278 RC inpatient 533 346.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 415.74 78 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16B 250B 48712702_1 CDM 0278 RC inpatient 533 346.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 367.77 69 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16B 250B 48712702_1 CDM 0278 RC inpatient 533 346.45 UMR - ALL PLANS UMR - ALL PLANS 373.1 70 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16B 250B 48712702_1 CDM 0278 RC inpatient 533 346.45 SIHO - ALL PLANS SIHO - ALL PLANS 479.7 90 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16B 250B 48712702_1 CDM 0278 RC inpatient 533 346.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 322.73 60.55 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16B 250B 48712702_1 CDM 0278 RC inpatient 533 346.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16B 250B 48712702_1 CDM 0278 RC inpatient 533 346.45 ANTHEM HMO ANTHEM HMO 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16B 250B 48712702_1 CDM 0278 RC inpatient 533 346.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16B 250B 48712702_1 CDM 0278 RC inpatient 533 346.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 360.31 67.6 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16B 250B 48712702_1 CDM 0278 RC inpatient 533 346.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16B 250B 48712702_1 CDM 0278 RC inpatient 533 346.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16C 250C 48712703_1 CDM 0278 RC inpatient 533 346.45 AETNA AETNA 421.07 79 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16C 250C 48712703_1 CDM 0278 RC inpatient 533 346.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 346.45 65 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16C 250C 48712703_1 CDM 0278 RC inpatient 533 346.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 517.01 97 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16C 250C 48712703_1 CDM 0278 RC inpatient 533 346.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 415.74 78 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16C 250C 48712703_1 CDM 0278 RC inpatient 533 346.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 367.77 69 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16C 250C 48712703_1 CDM 0278 RC inpatient 533 346.45 UMR - ALL PLANS UMR - ALL PLANS 373.1 70 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16C 250C 48712703_1 CDM 0278 RC inpatient 533 346.45 SIHO - ALL PLANS SIHO - ALL PLANS 479.7 90 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16C 250C 48712703_1 CDM 0278 RC inpatient 533 346.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 322.73 60.55 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16C 250C 48712703_1 CDM 0278 RC inpatient 533 346.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16C 250C 48712703_1 CDM 0278 RC inpatient 533 346.45 ANTHEM HMO ANTHEM HMO 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16C 250C 48712703_1 CDM 0278 RC inpatient 533 346.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16C 250C 48712703_1 CDM 0278 RC inpatient 533 346.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 360.31 67.6 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16C 250C 48712703_1 CDM 0278 RC inpatient 533 346.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16C 250C 48712703_1 CDM 0278 RC inpatient 533 346.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16D 250D 48712704_1 CDM 0278 RC inpatient 533 346.45 AETNA AETNA 421.07 79 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16D 250D 48712704_1 CDM 0278 RC inpatient 533 346.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 346.45 65 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16D 250D 48712704_1 CDM 0278 RC inpatient 533 346.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 517.01 97 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16D 250D 48712704_1 CDM 0278 RC inpatient 533 346.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 415.74 78 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16D 250D 48712704_1 CDM 0278 RC inpatient 533 346.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 367.77 69 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16D 250D 48712704_1 CDM 0278 RC inpatient 533 346.45 UMR - ALL PLANS UMR - ALL PLANS 373.1 70 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16D 250D 48712704_1 CDM 0278 RC inpatient 533 346.45 SIHO - ALL PLANS SIHO - ALL PLANS 479.7 90 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16D 250D 48712704_1 CDM 0278 RC inpatient 533 346.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 322.73 60.55 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16D 250D 48712704_1 CDM 0278 RC inpatient 533 346.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16D 250D 48712704_1 CDM 0278 RC inpatient 533 346.45 ANTHEM HMO ANTHEM HMO 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16D 250D 48712704_1 CDM 0278 RC inpatient 533 346.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16D 250D 48712704_1 CDM 0278 RC inpatient 533 346.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 360.31 67.6 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16D 250D 48712704_1 CDM 0278 RC inpatient 533 346.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16D 250D 48712704_1 CDM 0278 RC inpatient 533 346.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16E 250E 48712705_1 CDM 0278 RC inpatient 533 346.45 AETNA AETNA 421.07 79 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16E 250E 48712705_1 CDM 0278 RC inpatient 533 346.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 346.45 65 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16E 250E 48712705_1 CDM 0278 RC inpatient 533 346.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 517.01 97 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16E 250E 48712705_1 CDM 0278 RC inpatient 533 346.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 415.74 78 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16E 250E 48712705_1 CDM 0278 RC inpatient 533 346.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 367.77 69 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16E 250E 48712705_1 CDM 0278 RC inpatient 533 346.45 UMR - ALL PLANS UMR - ALL PLANS 373.1 70 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16E 250E 48712705_1 CDM 0278 RC inpatient 533 346.45 SIHO - ALL PLANS SIHO - ALL PLANS 479.7 90 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16E 250E 48712705_1 CDM 0278 RC inpatient 533 346.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 322.73 60.55 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16E 250E 48712705_1 CDM 0278 RC inpatient 533 346.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16E 250E 48712705_1 CDM 0278 RC inpatient 533 346.45 ANTHEM HMO ANTHEM HMO 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16E 250E 48712705_1 CDM 0278 RC inpatient 533 346.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16E 250E 48712705_1 CDM 0278 RC inpatient 533 346.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 360.31 67.6 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16E 250E 48712705_1 CDM 0278 RC inpatient 533 346.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16E 250E 48712705_1 CDM 0278 RC inpatient 533 346.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 322.73 517.01 RUSH PIN 1/8 K 803-01-12 48712706_1 CDM 0278 RC inpatient 285 185.25 AETNA AETNA 225.15 79 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 K 803-01-12 48712706_1 CDM 0278 RC inpatient 285 185.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.25 65 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 K 803-01-12 48712706_1 CDM 0278 RC inpatient 285 185.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 276.45 97 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 K 803-01-12 48712706_1 CDM 0278 RC inpatient 285 185.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 222.3 78 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 K 803-01-12 48712706_1 CDM 0278 RC inpatient 285 185.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 196.65 69 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 K 803-01-12 48712706_1 CDM 0278 RC inpatient 285 185.25 UMR - ALL PLANS UMR - ALL PLANS 199.5 70 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 K 803-01-12 48712706_1 CDM 0278 RC inpatient 285 185.25 SIHO - ALL PLANS SIHO - ALL PLANS 256.5 90 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 K 803-01-12 48712706_1 CDM 0278 RC inpatient 285 185.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 172.57 60.55 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 K 803-01-12 48712706_1 CDM 0278 RC inpatient 285 185.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 172.57 276.45 RUSH PIN 1/8 K 803-01-12 48712706_1 CDM 0278 RC inpatient 285 185.25 ANTHEM HMO ANTHEM HMO 999999999 172.57 276.45 RUSH PIN 1/8 K 803-01-12 48712706_1 CDM 0278 RC inpatient 285 185.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 172.57 276.45 RUSH PIN 1/8 K 803-01-12 48712706_1 CDM 0278 RC inpatient 285 185.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 192.66 67.6 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 K 803-01-12 48712706_1 CDM 0278 RC inpatient 285 185.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 172.57 276.45 RUSH PIN 1/8 K 803-01-12 48712706_1 CDM 0278 RC inpatient 285 185.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 172.57 276.45 CONDYLAR RUSH RODS 3/16G 250G 48712707_1 CDM 0278 RC inpatient 533 346.45 AETNA AETNA 421.07 79 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16G 250G 48712707_1 CDM 0278 RC inpatient 533 346.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 346.45 65 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16G 250G 48712707_1 CDM 0278 RC inpatient 533 346.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 517.01 97 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16G 250G 48712707_1 CDM 0278 RC inpatient 533 346.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 415.74 78 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16G 250G 48712707_1 CDM 0278 RC inpatient 533 346.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 367.77 69 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16G 250G 48712707_1 CDM 0278 RC inpatient 533 346.45 UMR - ALL PLANS UMR - ALL PLANS 373.1 70 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16G 250G 48712707_1 CDM 0278 RC inpatient 533 346.45 SIHO - ALL PLANS SIHO - ALL PLANS 479.7 90 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16G 250G 48712707_1 CDM 0278 RC inpatient 533 346.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 322.73 60.55 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16G 250G 48712707_1 CDM 0278 RC inpatient 533 346.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16G 250G 48712707_1 CDM 0278 RC inpatient 533 346.45 ANTHEM HMO ANTHEM HMO 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16G 250G 48712707_1 CDM 0278 RC inpatient 533 346.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16G 250G 48712707_1 CDM 0278 RC inpatient 533 346.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 360.31 67.6 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16G 250G 48712707_1 CDM 0278 RC inpatient 533 346.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16G 250G 48712707_1 CDM 0278 RC inpatient 533 346.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16H 250H 48712708_1 CDM 0278 RC inpatient 533 346.45 AETNA AETNA 421.07 79 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16H 250H 48712708_1 CDM 0278 RC inpatient 533 346.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 346.45 65 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16H 250H 48712708_1 CDM 0278 RC inpatient 533 346.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 517.01 97 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16H 250H 48712708_1 CDM 0278 RC inpatient 533 346.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 415.74 78 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16H 250H 48712708_1 CDM 0278 RC inpatient 533 346.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 367.77 69 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16H 250H 48712708_1 CDM 0278 RC inpatient 533 346.45 UMR - ALL PLANS UMR - ALL PLANS 373.1 70 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16H 250H 48712708_1 CDM 0278 RC inpatient 533 346.45 SIHO - ALL PLANS SIHO - ALL PLANS 479.7 90 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16H 250H 48712708_1 CDM 0278 RC inpatient 533 346.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 322.73 60.55 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16H 250H 48712708_1 CDM 0278 RC inpatient 533 346.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16H 250H 48712708_1 CDM 0278 RC inpatient 533 346.45 ANTHEM HMO ANTHEM HMO 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16H 250H 48712708_1 CDM 0278 RC inpatient 533 346.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16H 250H 48712708_1 CDM 0278 RC inpatient 533 346.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 360.31 67.6 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16H 250H 48712708_1 CDM 0278 RC inpatient 533 346.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16H 250H 48712708_1 CDM 0278 RC inpatient 533 346.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16I 250I 48712709_1 CDM 0278 RC inpatient 533 346.45 AETNA AETNA 421.07 79 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16I 250I 48712709_1 CDM 0278 RC inpatient 533 346.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 346.45 65 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16I 250I 48712709_1 CDM 0278 RC inpatient 533 346.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 517.01 97 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16I 250I 48712709_1 CDM 0278 RC inpatient 533 346.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 415.74 78 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16I 250I 48712709_1 CDM 0278 RC inpatient 533 346.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 367.77 69 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16I 250I 48712709_1 CDM 0278 RC inpatient 533 346.45 UMR - ALL PLANS UMR - ALL PLANS 373.1 70 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16I 250I 48712709_1 CDM 0278 RC inpatient 533 346.45 SIHO - ALL PLANS SIHO - ALL PLANS 479.7 90 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16I 250I 48712709_1 CDM 0278 RC inpatient 533 346.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 322.73 60.55 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16I 250I 48712709_1 CDM 0278 RC inpatient 533 346.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16I 250I 48712709_1 CDM 0278 RC inpatient 533 346.45 ANTHEM HMO ANTHEM HMO 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16I 250I 48712709_1 CDM 0278 RC inpatient 533 346.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16I 250I 48712709_1 CDM 0278 RC inpatient 533 346.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 360.31 67.6 999999999 322.73 517.01 percent of total billed charges CONDYLAR RUSH RODS 3/16I 250I 48712709_1 CDM 0278 RC inpatient 533 346.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 322.73 517.01 CONDYLAR RUSH RODS 3/16I 250I 48712709_1 CDM 0278 RC inpatient 533 346.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 322.73 517.01 RUSH PIN 1/8 M 803-01-14 48712710_1 CDM 0278 RC inpatient 285 185.25 AETNA AETNA 225.15 79 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 M 803-01-14 48712710_1 CDM 0278 RC inpatient 285 185.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.25 65 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 M 803-01-14 48712710_1 CDM 0278 RC inpatient 285 185.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 276.45 97 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 M 803-01-14 48712710_1 CDM 0278 RC inpatient 285 185.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 222.3 78 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 M 803-01-14 48712710_1 CDM 0278 RC inpatient 285 185.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 196.65 69 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 M 803-01-14 48712710_1 CDM 0278 RC inpatient 285 185.25 UMR - ALL PLANS UMR - ALL PLANS 199.5 70 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 M 803-01-14 48712710_1 CDM 0278 RC inpatient 285 185.25 SIHO - ALL PLANS SIHO - ALL PLANS 256.5 90 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 M 803-01-14 48712710_1 CDM 0278 RC inpatient 285 185.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 172.57 60.55 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 M 803-01-14 48712710_1 CDM 0278 RC inpatient 285 185.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 172.57 276.45 RUSH PIN 1/8 M 803-01-14 48712710_1 CDM 0278 RC inpatient 285 185.25 ANTHEM HMO ANTHEM HMO 999999999 172.57 276.45 RUSH PIN 1/8 M 803-01-14 48712710_1 CDM 0278 RC inpatient 285 185.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 172.57 276.45 RUSH PIN 1/8 M 803-01-14 48712710_1 CDM 0278 RC inpatient 285 185.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 192.66 67.6 999999999 172.57 276.45 percent of total billed charges RUSH PIN 1/8 M 803-01-14 48712710_1 CDM 0278 RC inpatient 285 185.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 172.57 276.45 RUSH PIN 1/8 M 803-01-14 48712710_1 CDM 0278 RC inpatient 285 185.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 172.57 276.45 RUSH PIN 1/4 E 801-01-06 48712711_1 CDM 0278 RC inpatient 446 289.9 AETNA AETNA 352.34 79 999999999 270.05 432.62 percent of total billed charges RUSH PIN 1/4 E 801-01-06 48712711_1 CDM 0278 RC inpatient 446 289.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 289.9 65 999999999 270.05 432.62 percent of total billed charges RUSH PIN 1/4 E 801-01-06 48712711_1 CDM 0278 RC inpatient 446 289.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 432.62 97 999999999 270.05 432.62 percent of total billed charges RUSH PIN 1/4 E 801-01-06 48712711_1 CDM 0278 RC inpatient 446 289.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 347.88 78 999999999 270.05 432.62 percent of total billed charges RUSH PIN 1/4 E 801-01-06 48712711_1 CDM 0278 RC inpatient 446 289.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 307.74 69 999999999 270.05 432.62 percent of total billed charges RUSH PIN 1/4 E 801-01-06 48712711_1 CDM 0278 RC inpatient 446 289.9 UMR - ALL PLANS UMR - ALL PLANS 312.2 70 999999999 270.05 432.62 percent of total billed charges RUSH PIN 1/4 E 801-01-06 48712711_1 CDM 0278 RC inpatient 446 289.9 SIHO - ALL PLANS SIHO - ALL PLANS 401.4 90 999999999 270.05 432.62 percent of total billed charges RUSH PIN 1/4 E 801-01-06 48712711_1 CDM 0278 RC inpatient 446 289.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.05 60.55 999999999 270.05 432.62 percent of total billed charges RUSH PIN 1/4 E 801-01-06 48712711_1 CDM 0278 RC inpatient 446 289.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.05 432.62 RUSH PIN 1/4 E 801-01-06 48712711_1 CDM 0278 RC inpatient 446 289.9 ANTHEM HMO ANTHEM HMO 999999999 270.05 432.62 RUSH PIN 1/4 E 801-01-06 48712711_1 CDM 0278 RC inpatient 446 289.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.05 432.62 RUSH PIN 1/4 E 801-01-06 48712711_1 CDM 0278 RC inpatient 446 289.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 301.5 67.6 999999999 270.05 432.62 percent of total billed charges RUSH PIN 1/4 E 801-01-06 48712711_1 CDM 0278 RC inpatient 446 289.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.05 432.62 RUSH PIN 1/4 E 801-01-06 48712711_1 CDM 0278 RC inpatient 446 289.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.05 432.62 MICROAIRE SAG SAW BLADE ZS-033 48712712_1 CDM 0272 RC inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-033 48712712_1 CDM 0272 RC inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-033 48712712_1 CDM 0272 RC inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-033 48712712_1 CDM 0272 RC inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-033 48712712_1 CDM 0272 RC inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-033 48712712_1 CDM 0272 RC inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-033 48712712_1 CDM 0272 RC inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-033 48712712_1 CDM 0272 RC inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-033 48712712_1 CDM 0272 RC inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 MICROAIRE SAG SAW BLADE ZS-033 48712712_1 CDM 0272 RC inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 MICROAIRE SAG SAW BLADE ZS-033 48712712_1 CDM 0272 RC inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 MICROAIRE SAG SAW BLADE ZS-033 48712712_1 CDM 0272 RC inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges MICROAIRE SAG SAW BLADE ZS-033 48712712_1 CDM 0272 RC inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 MICROAIRE SAG SAW BLADE ZS-033 48712712_1 CDM 0272 RC inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 BOOT TRACTION UNIV 00177400100 48712713_1 CDM 0272 RC inpatient 236 153.4 AETNA AETNA 186.44 79 999999999 142.9 228.92 percent of total billed charges BOOT TRACTION UNIV 00177400100 48712713_1 CDM 0272 RC inpatient 236 153.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 153.4 65 999999999 142.9 228.92 percent of total billed charges BOOT TRACTION UNIV 00177400100 48712713_1 CDM 0272 RC inpatient 236 153.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 228.92 97 999999999 142.9 228.92 percent of total billed charges BOOT TRACTION UNIV 00177400100 48712713_1 CDM 0272 RC inpatient 236 153.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 184.08 78 999999999 142.9 228.92 percent of total billed charges BOOT TRACTION UNIV 00177400100 48712713_1 CDM 0272 RC inpatient 236 153.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 162.84 69 999999999 142.9 228.92 percent of total billed charges BOOT TRACTION UNIV 00177400100 48712713_1 CDM 0272 RC inpatient 236 153.4 UMR - ALL PLANS UMR - ALL PLANS 165.2 70 999999999 142.9 228.92 percent of total billed charges BOOT TRACTION UNIV 00177400100 48712713_1 CDM 0272 RC inpatient 236 153.4 SIHO - ALL PLANS SIHO - ALL PLANS 212.4 90 999999999 142.9 228.92 percent of total billed charges BOOT TRACTION UNIV 00177400100 48712713_1 CDM 0272 RC inpatient 236 153.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 142.9 60.55 999999999 142.9 228.92 percent of total billed charges BOOT TRACTION UNIV 00177400100 48712713_1 CDM 0272 RC inpatient 236 153.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 142.9 228.92 BOOT TRACTION UNIV 00177400100 48712713_1 CDM 0272 RC inpatient 236 153.4 ANTHEM HMO ANTHEM HMO 999999999 142.9 228.92 BOOT TRACTION UNIV 00177400100 48712713_1 CDM 0272 RC inpatient 236 153.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 142.9 228.92 BOOT TRACTION UNIV 00177400100 48712713_1 CDM 0272 RC inpatient 236 153.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 159.54 67.6 999999999 142.9 228.92 percent of total billed charges BOOT TRACTION UNIV 00177400100 48712713_1 CDM 0272 RC inpatient 236 153.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 142.9 228.92 BOOT TRACTION UNIV 00177400100 48712713_1 CDM 0272 RC inpatient 236 153.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 142.9 228.92 POLAR PAD WRAPON SHOULDER XL 48712714_1 CDM 0272 RC inpatient 299 194.35 AETNA AETNA 236.21 79 999999999 181.04 290.03 percent of total billed charges POLAR PAD WRAPON SHOULDER XL 48712714_1 CDM 0272 RC inpatient 299 194.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 194.35 65 999999999 181.04 290.03 percent of total billed charges POLAR PAD WRAPON SHOULDER XL 48712714_1 CDM 0272 RC inpatient 299 194.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 290.03 97 999999999 181.04 290.03 percent of total billed charges POLAR PAD WRAPON SHOULDER XL 48712714_1 CDM 0272 RC inpatient 299 194.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 233.22 78 999999999 181.04 290.03 percent of total billed charges POLAR PAD WRAPON SHOULDER XL 48712714_1 CDM 0272 RC inpatient 299 194.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 206.31 69 999999999 181.04 290.03 percent of total billed charges POLAR PAD WRAPON SHOULDER XL 48712714_1 CDM 0272 RC inpatient 299 194.35 UMR - ALL PLANS UMR - ALL PLANS 209.3 70 999999999 181.04 290.03 percent of total billed charges POLAR PAD WRAPON SHOULDER XL 48712714_1 CDM 0272 RC inpatient 299 194.35 SIHO - ALL PLANS SIHO - ALL PLANS 269.1 90 999999999 181.04 290.03 percent of total billed charges POLAR PAD WRAPON SHOULDER XL 48712714_1 CDM 0272 RC inpatient 299 194.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 181.04 60.55 999999999 181.04 290.03 percent of total billed charges POLAR PAD WRAPON SHOULDER XL 48712714_1 CDM 0272 RC inpatient 299 194.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 181.04 290.03 POLAR PAD WRAPON SHOULDER XL 48712714_1 CDM 0272 RC inpatient 299 194.35 ANTHEM HMO ANTHEM HMO 999999999 181.04 290.03 POLAR PAD WRAPON SHOULDER XL 48712714_1 CDM 0272 RC inpatient 299 194.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 181.04 290.03 POLAR PAD WRAPON SHOULDER XL 48712714_1 CDM 0272 RC inpatient 299 194.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 202.12 67.6 999999999 181.04 290.03 percent of total billed charges POLAR PAD WRAPON SHOULDER XL 48712714_1 CDM 0272 RC inpatient 299 194.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 181.04 290.03 POLAR PAD WRAPON SHOULDER XL 48712714_1 CDM 0272 RC inpatient 299 194.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 181.04 290.03 POLAR CARE CUBE SHOULDER 10701 (PART# 10701 & 04900) 48712715_1 CDM 0272 RC inpatient 528 343.2 AETNA AETNA 417.12 79 999999999 319.7 512.16 percent of total billed charges POLAR CARE CUBE SHOULDER 10701 (PART# 10701 & 04900) 48712715_1 CDM 0272 RC inpatient 528 343.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 343.2 65 999999999 319.7 512.16 percent of total billed charges POLAR CARE CUBE SHOULDER 10701 (PART# 10701 & 04900) 48712715_1 CDM 0272 RC inpatient 528 343.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 512.16 97 999999999 319.7 512.16 percent of total billed charges POLAR CARE CUBE SHOULDER 10701 (PART# 10701 & 04900) 48712715_1 CDM 0272 RC inpatient 528 343.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 411.84 78 999999999 319.7 512.16 percent of total billed charges POLAR CARE CUBE SHOULDER 10701 (PART# 10701 & 04900) 48712715_1 CDM 0272 RC inpatient 528 343.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 364.32 69 999999999 319.7 512.16 percent of total billed charges POLAR CARE CUBE SHOULDER 10701 (PART# 10701 & 04900) 48712715_1 CDM 0272 RC inpatient 528 343.2 UMR - ALL PLANS UMR - ALL PLANS 369.6 70 999999999 319.7 512.16 percent of total billed charges POLAR CARE CUBE SHOULDER 10701 (PART# 10701 & 04900) 48712715_1 CDM 0272 RC inpatient 528 343.2 SIHO - ALL PLANS SIHO - ALL PLANS 475.2 90 999999999 319.7 512.16 percent of total billed charges POLAR CARE CUBE SHOULDER 10701 (PART# 10701 & 04900) 48712715_1 CDM 0272 RC inpatient 528 343.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 319.7 60.55 999999999 319.7 512.16 percent of total billed charges POLAR CARE CUBE SHOULDER 10701 (PART# 10701 & 04900) 48712715_1 CDM 0272 RC inpatient 528 343.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 319.7 512.16 POLAR CARE CUBE SHOULDER 10701 (PART# 10701 & 04900) 48712715_1 CDM 0272 RC inpatient 528 343.2 ANTHEM HMO ANTHEM HMO 999999999 319.7 512.16 POLAR CARE CUBE SHOULDER 10701 (PART# 10701 & 04900) 48712715_1 CDM 0272 RC inpatient 528 343.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 319.7 512.16 POLAR CARE CUBE SHOULDER 10701 (PART# 10701 & 04900) 48712715_1 CDM 0272 RC inpatient 528 343.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 356.93 67.6 999999999 319.7 512.16 percent of total billed charges POLAR CARE CUBE SHOULDER 10701 (PART# 10701 & 04900) 48712715_1 CDM 0272 RC inpatient 528 343.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 319.7 512.16 POLAR CARE CUBE SHOULDER 10701 (PART# 10701 & 04900) 48712715_1 CDM 0272 RC inpatient 528 343.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 319.7 512.16 POLAR PAD WRAPON SHOULDER REG 04900 48712716_1 CDM 0272 RC inpatient 254 165.1 AETNA AETNA 200.66 79 999999999 153.8 246.38 percent of total billed charges POLAR PAD WRAPON SHOULDER REG 04900 48712716_1 CDM 0272 RC inpatient 254 165.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 165.1 65 999999999 153.8 246.38 percent of total billed charges POLAR PAD WRAPON SHOULDER REG 04900 48712716_1 CDM 0272 RC inpatient 254 165.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 246.38 97 999999999 153.8 246.38 percent of total billed charges POLAR PAD WRAPON SHOULDER REG 04900 48712716_1 CDM 0272 RC inpatient 254 165.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 198.12 78 999999999 153.8 246.38 percent of total billed charges POLAR PAD WRAPON SHOULDER REG 04900 48712716_1 CDM 0272 RC inpatient 254 165.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 175.26 69 999999999 153.8 246.38 percent of total billed charges POLAR PAD WRAPON SHOULDER REG 04900 48712716_1 CDM 0272 RC inpatient 254 165.1 UMR - ALL PLANS UMR - ALL PLANS 177.8 70 999999999 153.8 246.38 percent of total billed charges POLAR PAD WRAPON SHOULDER REG 04900 48712716_1 CDM 0272 RC inpatient 254 165.1 SIHO - ALL PLANS SIHO - ALL PLANS 228.6 90 999999999 153.8 246.38 percent of total billed charges POLAR PAD WRAPON SHOULDER REG 04900 48712716_1 CDM 0272 RC inpatient 254 165.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 153.8 60.55 999999999 153.8 246.38 percent of total billed charges POLAR PAD WRAPON SHOULDER REG 04900 48712716_1 CDM 0272 RC inpatient 254 165.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 153.8 246.38 POLAR PAD WRAPON SHOULDER REG 04900 48712716_1 CDM 0272 RC inpatient 254 165.1 ANTHEM HMO ANTHEM HMO 999999999 153.8 246.38 POLAR PAD WRAPON SHOULDER REG 04900 48712716_1 CDM 0272 RC inpatient 254 165.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 153.8 246.38 POLAR PAD WRAPON SHOULDER REG 04900 48712716_1 CDM 0272 RC inpatient 254 165.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 171.7 67.6 999999999 153.8 246.38 percent of total billed charges POLAR PAD WRAPON SHOULDER REG 04900 48712716_1 CDM 0272 RC inpatient 254 165.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 153.8 246.38 POLAR PAD WRAPON SHOULDER REG 04900 48712716_1 CDM 0272 RC inpatient 254 165.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 153.8 246.38 POLAR CARE COMBO KNEE 10706 (PART# 10701 & 04703) 48712717_1 CDM 0272 RC inpatient 690 448.5 AETNA AETNA 545.1 79 999999999 417.8 669.3 percent of total billed charges POLAR CARE COMBO KNEE 10706 (PART# 10701 & 04703) 48712717_1 CDM 0272 RC inpatient 690 448.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 448.5 65 999999999 417.8 669.3 percent of total billed charges POLAR CARE COMBO KNEE 10706 (PART# 10701 & 04703) 48712717_1 CDM 0272 RC inpatient 690 448.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 669.3 97 999999999 417.8 669.3 percent of total billed charges POLAR CARE COMBO KNEE 10706 (PART# 10701 & 04703) 48712717_1 CDM 0272 RC inpatient 690 448.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 538.2 78 999999999 417.8 669.3 percent of total billed charges POLAR CARE COMBO KNEE 10706 (PART# 10701 & 04703) 48712717_1 CDM 0272 RC inpatient 690 448.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 476.1 69 999999999 417.8 669.3 percent of total billed charges POLAR CARE COMBO KNEE 10706 (PART# 10701 & 04703) 48712717_1 CDM 0272 RC inpatient 690 448.5 UMR - ALL PLANS UMR - ALL PLANS 483 70 999999999 417.8 669.3 percent of total billed charges POLAR CARE COMBO KNEE 10706 (PART# 10701 & 04703) 48712717_1 CDM 0272 RC inpatient 690 448.5 SIHO - ALL PLANS SIHO - ALL PLANS 621 90 999999999 417.8 669.3 percent of total billed charges POLAR CARE COMBO KNEE 10706 (PART# 10701 & 04703) 48712717_1 CDM 0272 RC inpatient 690 448.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 417.8 60.55 999999999 417.8 669.3 percent of total billed charges POLAR CARE COMBO KNEE 10706 (PART# 10701 & 04703) 48712717_1 CDM 0272 RC inpatient 690 448.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 417.8 669.3 POLAR CARE COMBO KNEE 10706 (PART# 10701 & 04703) 48712717_1 CDM 0272 RC inpatient 690 448.5 ANTHEM HMO ANTHEM HMO 999999999 417.8 669.3 POLAR CARE COMBO KNEE 10706 (PART# 10701 & 04703) 48712717_1 CDM 0272 RC inpatient 690 448.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 417.8 669.3 POLAR CARE COMBO KNEE 10706 (PART# 10701 & 04703) 48712717_1 CDM 0272 RC inpatient 690 448.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 466.44 67.6 999999999 417.8 669.3 percent of total billed charges POLAR CARE COMBO KNEE 10706 (PART# 10701 & 04703) 48712717_1 CDM 0272 RC inpatient 690 448.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 417.8 669.3 POLAR CARE COMBO KNEE 10706 (PART# 10701 & 04703) 48712717_1 CDM 0272 RC inpatient 690 448.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 417.8 669.3 GOWN BAIR PAW FLEX ADULT 81003 48712718_1 CDM 0272 RC inpatient 98 63.7 AETNA AETNA 77.42 79 999999999 59.34 95.06 percent of total billed charges GOWN BAIR PAW FLEX ADULT 81003 48712718_1 CDM 0272 RC inpatient 98 63.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.7 65 999999999 59.34 95.06 percent of total billed charges GOWN BAIR PAW FLEX ADULT 81003 48712718_1 CDM 0272 RC inpatient 98 63.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.06 97 999999999 59.34 95.06 percent of total billed charges GOWN BAIR PAW FLEX ADULT 81003 48712718_1 CDM 0272 RC inpatient 98 63.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.44 78 999999999 59.34 95.06 percent of total billed charges GOWN BAIR PAW FLEX ADULT 81003 48712718_1 CDM 0272 RC inpatient 98 63.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.62 69 999999999 59.34 95.06 percent of total billed charges GOWN BAIR PAW FLEX ADULT 81003 48712718_1 CDM 0272 RC inpatient 98 63.7 UMR - ALL PLANS UMR - ALL PLANS 68.6 70 999999999 59.34 95.06 percent of total billed charges GOWN BAIR PAW FLEX ADULT 81003 48712718_1 CDM 0272 RC inpatient 98 63.7 SIHO - ALL PLANS SIHO - ALL PLANS 88.2 90 999999999 59.34 95.06 percent of total billed charges GOWN BAIR PAW FLEX ADULT 81003 48712718_1 CDM 0272 RC inpatient 98 63.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.34 60.55 999999999 59.34 95.06 percent of total billed charges GOWN BAIR PAW FLEX ADULT 81003 48712718_1 CDM 0272 RC inpatient 98 63.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.34 95.06 GOWN BAIR PAW FLEX ADULT 81003 48712718_1 CDM 0272 RC inpatient 98 63.7 ANTHEM HMO ANTHEM HMO 999999999 59.34 95.06 GOWN BAIR PAW FLEX ADULT 81003 48712718_1 CDM 0272 RC inpatient 98 63.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.34 95.06 GOWN BAIR PAW FLEX ADULT 81003 48712718_1 CDM 0272 RC inpatient 98 63.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.25 67.6 999999999 59.34 95.06 percent of total billed charges GOWN BAIR PAW FLEX ADULT 81003 48712718_1 CDM 0272 RC inpatient 98 63.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.34 95.06 GOWN BAIR PAW FLEX ADULT 81003 48712718_1 CDM 0272 RC inpatient 98 63.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.34 95.06 SM & LG FR TIT 2.0MM 492.20 48712719_1 CDM 0278 RC inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges SM & LG FR TIT 2.0MM 492.20 48712719_1 CDM 0278 RC inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges SM & LG FR TIT 2.0MM 492.20 48712719_1 CDM 0278 RC inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges SM & LG FR TIT 2.0MM 492.20 48712719_1 CDM 0278 RC inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges SM & LG FR TIT 2.0MM 492.20 48712719_1 CDM 0278 RC inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges SM & LG FR TIT 2.0MM 492.20 48712719_1 CDM 0278 RC inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges SM & LG FR TIT 2.0MM 492.20 48712719_1 CDM 0278 RC inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges SM & LG FR TIT 2.0MM 492.20 48712719_1 CDM 0278 RC inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges SM & LG FR TIT 2.0MM 492.20 48712719_1 CDM 0278 RC inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 SM & LG FR TIT 2.0MM 492.20 48712719_1 CDM 0278 RC inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 SM & LG FR TIT 2.0MM 492.20 48712719_1 CDM 0278 RC inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 SM & LG FR TIT 2.0MM 492.20 48712719_1 CDM 0278 RC inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges SM & LG FR TIT 2.0MM 492.20 48712719_1 CDM 0278 RC inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 SM & LG FR TIT 2.0MM 492.20 48712719_1 CDM 0278 RC inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712720_1 CDM 0278 RC C1713 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712720_1 CDM 0278 RC C1713 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712720_1 CDM 0278 RC C1713 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712720_1 CDM 0278 RC C1713 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712720_1 CDM 0278 RC C1713 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712720_1 CDM 0278 RC C1713 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712720_1 CDM 0278 RC C1713 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712720_1 CDM 0278 RC C1713 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712720_1 CDM 0278 RC C1713 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712720_1 CDM 0278 RC C1713 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712720_1 CDM 0278 RC C1713 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712720_1 CDM 0278 RC C1713 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712720_1 CDM 0278 RC C1713 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712720_1 CDM 0278 RC C1713 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 STEIN PIN 9IN 3/32 B 1624-109 48712721_1 CDM 0278 RC inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges STEIN PIN 9IN 3/32 B 1624-109 48712721_1 CDM 0278 RC inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges STEIN PIN 9IN 3/32 B 1624-109 48712721_1 CDM 0278 RC inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges STEIN PIN 9IN 3/32 B 1624-109 48712721_1 CDM 0278 RC inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges STEIN PIN 9IN 3/32 B 1624-109 48712721_1 CDM 0278 RC inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges STEIN PIN 9IN 3/32 B 1624-109 48712721_1 CDM 0278 RC inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges STEIN PIN 9IN 3/32 B 1624-109 48712721_1 CDM 0278 RC inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges STEIN PIN 9IN 3/32 B 1624-109 48712721_1 CDM 0278 RC inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges STEIN PIN 9IN 3/32 B 1624-109 48712721_1 CDM 0278 RC inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 STEIN PIN 9IN 3/32 B 1624-109 48712721_1 CDM 0278 RC inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 STEIN PIN 9IN 3/32 B 1624-109 48712721_1 CDM 0278 RC inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 STEIN PIN 9IN 3/32 B 1624-109 48712721_1 CDM 0278 RC inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges STEIN PIN 9IN 3/32 B 1624-109 48712721_1 CDM 0278 RC inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 STEIN PIN 9IN 3/32 B 1624-109 48712721_1 CDM 0278 RC inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 STEIN PIN 9IN 3/16 B 1648-109X 48712722_1 CDM 0278 RC inpatient 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges STEIN PIN 9IN 3/16 B 1648-109X 48712722_1 CDM 0278 RC inpatient 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges STEIN PIN 9IN 3/16 B 1648-109X 48712722_1 CDM 0278 RC inpatient 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges STEIN PIN 9IN 3/16 B 1648-109X 48712722_1 CDM 0278 RC inpatient 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges STEIN PIN 9IN 3/16 B 1648-109X 48712722_1 CDM 0278 RC inpatient 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges STEIN PIN 9IN 3/16 B 1648-109X 48712722_1 CDM 0278 RC inpatient 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges STEIN PIN 9IN 3/16 B 1648-109X 48712722_1 CDM 0278 RC inpatient 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges STEIN PIN 9IN 3/16 B 1648-109X 48712722_1 CDM 0278 RC inpatient 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges STEIN PIN 9IN 3/16 B 1648-109X 48712722_1 CDM 0278 RC inpatient 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 STEIN PIN 9IN 3/16 B 1648-109X 48712722_1 CDM 0278 RC inpatient 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 STEIN PIN 9IN 3/16 B 1648-109X 48712722_1 CDM 0278 RC inpatient 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 STEIN PIN 9IN 3/16 B 1648-109X 48712722_1 CDM 0278 RC inpatient 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges STEIN PIN 9IN 3/16 B 1648-109X 48712722_1 CDM 0278 RC inpatient 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 STEIN PIN 9IN 3/16 B 1648-109X 48712722_1 CDM 0278 RC inpatient 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 CERCLAGE WIRE 1.25M 291.06 48712725_1 CDM 0278 RC inpatient 387 251.55 AETNA AETNA 305.73 79 999999999 234.33 375.39 percent of total billed charges CERCLAGE WIRE 1.25M 291.06 48712725_1 CDM 0278 RC inpatient 387 251.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 251.55 65 999999999 234.33 375.39 percent of total billed charges CERCLAGE WIRE 1.25M 291.06 48712725_1 CDM 0278 RC inpatient 387 251.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 375.39 97 999999999 234.33 375.39 percent of total billed charges CERCLAGE WIRE 1.25M 291.06 48712725_1 CDM 0278 RC inpatient 387 251.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.86 78 999999999 234.33 375.39 percent of total billed charges CERCLAGE WIRE 1.25M 291.06 48712725_1 CDM 0278 RC inpatient 387 251.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.03 69 999999999 234.33 375.39 percent of total billed charges CERCLAGE WIRE 1.25M 291.06 48712725_1 CDM 0278 RC inpatient 387 251.55 UMR - ALL PLANS UMR - ALL PLANS 270.9 70 999999999 234.33 375.39 percent of total billed charges CERCLAGE WIRE 1.25M 291.06 48712725_1 CDM 0278 RC inpatient 387 251.55 SIHO - ALL PLANS SIHO - ALL PLANS 348.3 90 999999999 234.33 375.39 percent of total billed charges CERCLAGE WIRE 1.25M 291.06 48712725_1 CDM 0278 RC inpatient 387 251.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.33 60.55 999999999 234.33 375.39 percent of total billed charges CERCLAGE WIRE 1.25M 291.06 48712725_1 CDM 0278 RC inpatient 387 251.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.33 375.39 CERCLAGE WIRE 1.25M 291.06 48712725_1 CDM 0278 RC inpatient 387 251.55 ANTHEM HMO ANTHEM HMO 999999999 234.33 375.39 CERCLAGE WIRE 1.25M 291.06 48712725_1 CDM 0278 RC inpatient 387 251.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.33 375.39 CERCLAGE WIRE 1.25M 291.06 48712725_1 CDM 0278 RC inpatient 387 251.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 261.61 67.6 999999999 234.33 375.39 percent of total billed charges CERCLAGE WIRE 1.25M 291.06 48712725_1 CDM 0278 RC inpatient 387 251.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.33 375.39 CERCLAGE WIRE 1.25M 291.06 48712725_1 CDM 0278 RC inpatient 387 251.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.33 375.39 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712727_1 CDM 0278 RC C1713 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712727_1 CDM 0278 RC C1713 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712727_1 CDM 0278 RC C1713 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712727_1 CDM 0278 RC C1713 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712727_1 CDM 0278 RC C1713 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712727_1 CDM 0278 RC C1713 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712727_1 CDM 0278 RC C1713 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712727_1 CDM 0278 RC C1713 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712727_1 CDM 0278 RC C1713 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712727_1 CDM 0278 RC C1713 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712727_1 CDM 0278 RC C1713 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712727_1 CDM 0278 RC C1713 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712727_1 CDM 0278 RC C1713 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712727_1 CDM 0278 RC C1713 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 SCROTAL SUPPORT LG 201255 48712728_1 CDM 0270 RC inpatient 55 35.75 AETNA AETNA 43.45 79 999999999 33.3 53.35 percent of total billed charges SCROTAL SUPPORT LG 201255 48712728_1 CDM 0270 RC inpatient 55 35.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 35.75 65 999999999 33.3 53.35 percent of total billed charges SCROTAL SUPPORT LG 201255 48712728_1 CDM 0270 RC inpatient 55 35.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 53.35 97 999999999 33.3 53.35 percent of total billed charges SCROTAL SUPPORT LG 201255 48712728_1 CDM 0270 RC inpatient 55 35.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 42.9 78 999999999 33.3 53.35 percent of total billed charges SCROTAL SUPPORT LG 201255 48712728_1 CDM 0270 RC inpatient 55 35.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 37.95 69 999999999 33.3 53.35 percent of total billed charges SCROTAL SUPPORT LG 201255 48712728_1 CDM 0270 RC inpatient 55 35.75 UMR - ALL PLANS UMR - ALL PLANS 38.5 70 999999999 33.3 53.35 percent of total billed charges SCROTAL SUPPORT LG 201255 48712728_1 CDM 0270 RC inpatient 55 35.75 SIHO - ALL PLANS SIHO - ALL PLANS 49.5 90 999999999 33.3 53.35 percent of total billed charges SCROTAL SUPPORT LG 201255 48712728_1 CDM 0270 RC inpatient 55 35.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33.3 60.55 999999999 33.3 53.35 percent of total billed charges SCROTAL SUPPORT LG 201255 48712728_1 CDM 0270 RC inpatient 55 35.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 33.3 53.35 SCROTAL SUPPORT LG 201255 48712728_1 CDM 0270 RC inpatient 55 35.75 ANTHEM HMO ANTHEM HMO 999999999 33.3 53.35 SCROTAL SUPPORT LG 201255 48712728_1 CDM 0270 RC inpatient 55 35.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 33.3 53.35 SCROTAL SUPPORT LG 201255 48712728_1 CDM 0270 RC inpatient 55 35.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 37.18 67.6 999999999 33.3 53.35 percent of total billed charges SCROTAL SUPPORT LG 201255 48712728_1 CDM 0270 RC inpatient 55 35.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 33.3 53.35 SCROTAL SUPPORT LG 201255 48712728_1 CDM 0270 RC inpatient 55 35.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 33.3 53.35 SCROTAL SUPPORT MED #201161 48712729_1 CDM 0278 RC inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges SCROTAL SUPPORT MED #201161 48712729_1 CDM 0278 RC inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges SCROTAL SUPPORT MED #201161 48712729_1 CDM 0278 RC inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges SCROTAL SUPPORT MED #201161 48712729_1 CDM 0278 RC inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges SCROTAL SUPPORT MED #201161 48712729_1 CDM 0278 RC inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges SCROTAL SUPPORT MED #201161 48712729_1 CDM 0278 RC inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges SCROTAL SUPPORT MED #201161 48712729_1 CDM 0278 RC inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges SCROTAL SUPPORT MED #201161 48712729_1 CDM 0278 RC inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges SCROTAL SUPPORT MED #201161 48712729_1 CDM 0278 RC inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 SCROTAL SUPPORT MED #201161 48712729_1 CDM 0278 RC inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 SCROTAL SUPPORT MED #201161 48712729_1 CDM 0278 RC inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 SCROTAL SUPPORT MED #201161 48712729_1 CDM 0278 RC inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges SCROTAL SUPPORT MED #201161 48712729_1 CDM 0278 RC inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 SCROTAL SUPPORT MED #201161 48712729_1 CDM 0278 RC inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 SEGURA BASKET 3.0FR 380-102 48712730_1 CDM 0272 RC inpatient 1258 817.7 AETNA AETNA 993.82 79 999999999 761.72 1220.26 percent of total billed charges SEGURA BASKET 3.0FR 380-102 48712730_1 CDM 0272 RC inpatient 1258 817.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 817.7 65 999999999 761.72 1220.26 percent of total billed charges SEGURA BASKET 3.0FR 380-102 48712730_1 CDM 0272 RC inpatient 1258 817.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1220.26 97 999999999 761.72 1220.26 percent of total billed charges SEGURA BASKET 3.0FR 380-102 48712730_1 CDM 0272 RC inpatient 1258 817.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 981.24 78 999999999 761.72 1220.26 percent of total billed charges SEGURA BASKET 3.0FR 380-102 48712730_1 CDM 0272 RC inpatient 1258 817.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 868.02 69 999999999 761.72 1220.26 percent of total billed charges SEGURA BASKET 3.0FR 380-102 48712730_1 CDM 0272 RC inpatient 1258 817.7 UMR - ALL PLANS UMR - ALL PLANS 880.6 70 999999999 761.72 1220.26 percent of total billed charges SEGURA BASKET 3.0FR 380-102 48712730_1 CDM 0272 RC inpatient 1258 817.7 SIHO - ALL PLANS SIHO - ALL PLANS 1132.2 90 999999999 761.72 1220.26 percent of total billed charges SEGURA BASKET 3.0FR 380-102 48712730_1 CDM 0272 RC inpatient 1258 817.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 761.72 60.55 999999999 761.72 1220.26 percent of total billed charges SEGURA BASKET 3.0FR 380-102 48712730_1 CDM 0272 RC inpatient 1258 817.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 761.72 1220.26 SEGURA BASKET 3.0FR 380-102 48712730_1 CDM 0272 RC inpatient 1258 817.7 ANTHEM HMO ANTHEM HMO 999999999 761.72 1220.26 SEGURA BASKET 3.0FR 380-102 48712730_1 CDM 0272 RC inpatient 1258 817.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 761.72 1220.26 SEGURA BASKET 3.0FR 380-102 48712730_1 CDM 0272 RC inpatient 1258 817.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 850.41 67.6 999999999 761.72 1220.26 percent of total billed charges SEGURA BASKET 3.0FR 380-102 48712730_1 CDM 0272 RC inpatient 1258 817.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 761.72 1220.26 SEGURA BASKET 3.0FR 380-102 48712730_1 CDM 0272 RC inpatient 1258 817.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 761.72 1220.26 OXIMAX MAXN SENSOR 48712731_1 CDM 0272 RC inpatient 113 73.45 AETNA AETNA 89.27 79 999999999 68.42 109.61 percent of total billed charges OXIMAX MAXN SENSOR 48712731_1 CDM 0272 RC inpatient 113 73.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 73.45 65 999999999 68.42 109.61 percent of total billed charges OXIMAX MAXN SENSOR 48712731_1 CDM 0272 RC inpatient 113 73.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 109.61 97 999999999 68.42 109.61 percent of total billed charges OXIMAX MAXN SENSOR 48712731_1 CDM 0272 RC inpatient 113 73.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.14 78 999999999 68.42 109.61 percent of total billed charges OXIMAX MAXN SENSOR 48712731_1 CDM 0272 RC inpatient 113 73.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.97 69 999999999 68.42 109.61 percent of total billed charges OXIMAX MAXN SENSOR 48712731_1 CDM 0272 RC inpatient 113 73.45 UMR - ALL PLANS UMR - ALL PLANS 79.1 70 999999999 68.42 109.61 percent of total billed charges OXIMAX MAXN SENSOR 48712731_1 CDM 0272 RC inpatient 113 73.45 SIHO - ALL PLANS SIHO - ALL PLANS 101.7 90 999999999 68.42 109.61 percent of total billed charges OXIMAX MAXN SENSOR 48712731_1 CDM 0272 RC inpatient 113 73.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 68.42 60.55 999999999 68.42 109.61 percent of total billed charges OXIMAX MAXN SENSOR 48712731_1 CDM 0272 RC inpatient 113 73.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 68.42 109.61 OXIMAX MAXN SENSOR 48712731_1 CDM 0272 RC inpatient 113 73.45 ANTHEM HMO ANTHEM HMO 999999999 68.42 109.61 OXIMAX MAXN SENSOR 48712731_1 CDM 0272 RC inpatient 113 73.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 68.42 109.61 OXIMAX MAXN SENSOR 48712731_1 CDM 0272 RC inpatient 113 73.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 76.39 67.6 999999999 68.42 109.61 percent of total billed charges OXIMAX MAXN SENSOR 48712731_1 CDM 0272 RC inpatient 113 73.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 68.42 109.61 OXIMAX MAXN SENSOR 48712731_1 CDM 0272 RC inpatient 113 73.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 68.42 109.61 OXIMAX ADULT OXY SENSOR MAX-A 48712732_1 CDM 0272 RC inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges OXIMAX ADULT OXY SENSOR MAX-A 48712732_1 CDM 0272 RC inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges OXIMAX ADULT OXY SENSOR MAX-A 48712732_1 CDM 0272 RC inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges OXIMAX ADULT OXY SENSOR MAX-A 48712732_1 CDM 0272 RC inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges OXIMAX ADULT OXY SENSOR MAX-A 48712732_1 CDM 0272 RC inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges OXIMAX ADULT OXY SENSOR MAX-A 48712732_1 CDM 0272 RC inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges OXIMAX ADULT OXY SENSOR MAX-A 48712732_1 CDM 0272 RC inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges OXIMAX ADULT OXY SENSOR MAX-A 48712732_1 CDM 0272 RC inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges OXIMAX ADULT OXY SENSOR MAX-A 48712732_1 CDM 0272 RC inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 OXIMAX ADULT OXY SENSOR MAX-A 48712732_1 CDM 0272 RC inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 OXIMAX ADULT OXY SENSOR MAX-A 48712732_1 CDM 0272 RC inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 OXIMAX ADULT OXY SENSOR MAX-A 48712732_1 CDM 0272 RC inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges OXIMAX ADULT OXY SENSOR MAX-A 48712732_1 CDM 0272 RC inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 OXIMAX ADULT OXY SENSOR MAX-A 48712732_1 CDM 0272 RC inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 SENSOR TIP IUP-400 48712733_1 CDM 0272 RC inpatient 207 134.55 AETNA AETNA 163.53 79 999999999 125.34 200.79 percent of total billed charges SENSOR TIP IUP-400 48712733_1 CDM 0272 RC inpatient 207 134.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 134.55 65 999999999 125.34 200.79 percent of total billed charges SENSOR TIP IUP-400 48712733_1 CDM 0272 RC inpatient 207 134.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 200.79 97 999999999 125.34 200.79 percent of total billed charges SENSOR TIP IUP-400 48712733_1 CDM 0272 RC inpatient 207 134.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 161.46 78 999999999 125.34 200.79 percent of total billed charges SENSOR TIP IUP-400 48712733_1 CDM 0272 RC inpatient 207 134.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.83 69 999999999 125.34 200.79 percent of total billed charges SENSOR TIP IUP-400 48712733_1 CDM 0272 RC inpatient 207 134.55 UMR - ALL PLANS UMR - ALL PLANS 144.9 70 999999999 125.34 200.79 percent of total billed charges SENSOR TIP IUP-400 48712733_1 CDM 0272 RC inpatient 207 134.55 SIHO - ALL PLANS SIHO - ALL PLANS 186.3 90 999999999 125.34 200.79 percent of total billed charges SENSOR TIP IUP-400 48712733_1 CDM 0272 RC inpatient 207 134.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 125.34 60.55 999999999 125.34 200.79 percent of total billed charges SENSOR TIP IUP-400 48712733_1 CDM 0272 RC inpatient 207 134.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 125.34 200.79 SENSOR TIP IUP-400 48712733_1 CDM 0272 RC inpatient 207 134.55 ANTHEM HMO ANTHEM HMO 999999999 125.34 200.79 SENSOR TIP IUP-400 48712733_1 CDM 0272 RC inpatient 207 134.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 125.34 200.79 SENSOR TIP IUP-400 48712733_1 CDM 0272 RC inpatient 207 134.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.93 67.6 999999999 125.34 200.79 percent of total billed charges SENSOR TIP IUP-400 48712733_1 CDM 0272 RC inpatient 207 134.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 125.34 200.79 SENSOR TIP IUP-400 48712733_1 CDM 0272 RC inpatient 207 134.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 125.34 200.79 SHOULDER IMMOBILIZER MED 79-84165 48712736_1 CDM 0270 RC inpatient 28 18.2 AETNA AETNA 22.12 79 999999999 16.95 27.16 percent of total billed charges SHOULDER IMMOBILIZER MED 79-84165 48712736_1 CDM 0270 RC inpatient 28 18.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 18.2 65 999999999 16.95 27.16 percent of total billed charges SHOULDER IMMOBILIZER MED 79-84165 48712736_1 CDM 0270 RC inpatient 28 18.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 27.16 97 999999999 16.95 27.16 percent of total billed charges SHOULDER IMMOBILIZER MED 79-84165 48712736_1 CDM 0270 RC inpatient 28 18.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.84 78 999999999 16.95 27.16 percent of total billed charges SHOULDER IMMOBILIZER MED 79-84165 48712736_1 CDM 0270 RC inpatient 28 18.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 19.32 69 999999999 16.95 27.16 percent of total billed charges SHOULDER IMMOBILIZER MED 79-84165 48712736_1 CDM 0270 RC inpatient 28 18.2 UMR - ALL PLANS UMR - ALL PLANS 19.6 70 999999999 16.95 27.16 percent of total billed charges SHOULDER IMMOBILIZER MED 79-84165 48712736_1 CDM 0270 RC inpatient 28 18.2 SIHO - ALL PLANS SIHO - ALL PLANS 25.2 90 999999999 16.95 27.16 percent of total billed charges SHOULDER IMMOBILIZER MED 79-84165 48712736_1 CDM 0270 RC inpatient 28 18.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.95 60.55 999999999 16.95 27.16 percent of total billed charges SHOULDER IMMOBILIZER MED 79-84165 48712736_1 CDM 0270 RC inpatient 28 18.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.95 27.16 SHOULDER IMMOBILIZER MED 79-84165 48712736_1 CDM 0270 RC inpatient 28 18.2 ANTHEM HMO ANTHEM HMO 999999999 16.95 27.16 SHOULDER IMMOBILIZER MED 79-84165 48712736_1 CDM 0270 RC inpatient 28 18.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.95 27.16 SHOULDER IMMOBILIZER MED 79-84165 48712736_1 CDM 0270 RC inpatient 28 18.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.93 67.6 999999999 16.95 27.16 percent of total billed charges SHOULDER IMMOBILIZER MED 79-84165 48712736_1 CDM 0270 RC inpatient 28 18.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.95 27.16 SHOULDER IMMOBILIZER MED 79-84165 48712736_1 CDM 0270 RC inpatient 28 18.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.95 27.16 SIGMOIDOSCOPES BULB & BLADDER 48712739_1 CDM 0271 RC inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges SIGMOIDOSCOPES BULB & BLADDER 48712739_1 CDM 0271 RC inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges SIGMOIDOSCOPES BULB & BLADDER 48712739_1 CDM 0271 RC inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges SIGMOIDOSCOPES BULB & BLADDER 48712739_1 CDM 0271 RC inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges SIGMOIDOSCOPES BULB & BLADDER 48712739_1 CDM 0271 RC inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges SIGMOIDOSCOPES BULB & BLADDER 48712739_1 CDM 0271 RC inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges SIGMOIDOSCOPES BULB & BLADDER 48712739_1 CDM 0271 RC inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges SIGMOIDOSCOPES BULB & BLADDER 48712739_1 CDM 0271 RC inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges SIGMOIDOSCOPES BULB & BLADDER 48712739_1 CDM 0271 RC inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 SIGMOIDOSCOPES BULB & BLADDER 48712739_1 CDM 0271 RC inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 SIGMOIDOSCOPES BULB & BLADDER 48712739_1 CDM 0271 RC inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 SIGMOIDOSCOPES BULB & BLADDER 48712739_1 CDM 0271 RC inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges SIGMOIDOSCOPES BULB & BLADDER 48712739_1 CDM 0271 RC inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 SIGMOIDOSCOPES BULB & BLADDER 48712739_1 CDM 0271 RC inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 STRYKER SUC IRRIG 210-100-000 48712740_1 CDM 0272 RC inpatient 195 126.75 AETNA AETNA 154.05 79 999999999 118.07 189.15 percent of total billed charges STRYKER SUC IRRIG 210-100-000 48712740_1 CDM 0272 RC inpatient 195 126.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 126.75 65 999999999 118.07 189.15 percent of total billed charges STRYKER SUC IRRIG 210-100-000 48712740_1 CDM 0272 RC inpatient 195 126.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 189.15 97 999999999 118.07 189.15 percent of total billed charges STRYKER SUC IRRIG 210-100-000 48712740_1 CDM 0272 RC inpatient 195 126.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 152.1 78 999999999 118.07 189.15 percent of total billed charges STRYKER SUC IRRIG 210-100-000 48712740_1 CDM 0272 RC inpatient 195 126.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 134.55 69 999999999 118.07 189.15 percent of total billed charges STRYKER SUC IRRIG 210-100-000 48712740_1 CDM 0272 RC inpatient 195 126.75 UMR - ALL PLANS UMR - ALL PLANS 136.5 70 999999999 118.07 189.15 percent of total billed charges STRYKER SUC IRRIG 210-100-000 48712740_1 CDM 0272 RC inpatient 195 126.75 SIHO - ALL PLANS SIHO - ALL PLANS 175.5 90 999999999 118.07 189.15 percent of total billed charges STRYKER SUC IRRIG 210-100-000 48712740_1 CDM 0272 RC inpatient 195 126.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 118.07 60.55 999999999 118.07 189.15 percent of total billed charges STRYKER SUC IRRIG 210-100-000 48712740_1 CDM 0272 RC inpatient 195 126.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 118.07 189.15 STRYKER SUC IRRIG 210-100-000 48712740_1 CDM 0272 RC inpatient 195 126.75 ANTHEM HMO ANTHEM HMO 999999999 118.07 189.15 STRYKER SUC IRRIG 210-100-000 48712740_1 CDM 0272 RC inpatient 195 126.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 118.07 189.15 STRYKER SUC IRRIG 210-100-000 48712740_1 CDM 0272 RC inpatient 195 126.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 131.82 67.6 999999999 118.07 189.15 percent of total billed charges STRYKER SUC IRRIG 210-100-000 48712740_1 CDM 0272 RC inpatient 195 126.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 118.07 189.15 STRYKER SUC IRRIG 210-100-000 48712740_1 CDM 0272 RC inpatient 195 126.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 118.07 189.15 BOOT ST FRACTURE S BLEDSOE AL032003BB- 48712744_1 CDM 0271 RC inpatient 333 216.45 AETNA AETNA 263.07 79 999999999 201.63 323.01 percent of total billed charges BOOT ST FRACTURE S BLEDSOE AL032003BB- 48712744_1 CDM 0271 RC inpatient 333 216.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 216.45 65 999999999 201.63 323.01 percent of total billed charges BOOT ST FRACTURE S BLEDSOE AL032003BB- 48712744_1 CDM 0271 RC inpatient 333 216.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 323.01 97 999999999 201.63 323.01 percent of total billed charges BOOT ST FRACTURE S BLEDSOE AL032003BB- 48712744_1 CDM 0271 RC inpatient 333 216.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 259.74 78 999999999 201.63 323.01 percent of total billed charges BOOT ST FRACTURE S BLEDSOE AL032003BB- 48712744_1 CDM 0271 RC inpatient 333 216.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 229.77 69 999999999 201.63 323.01 percent of total billed charges BOOT ST FRACTURE S BLEDSOE AL032003BB- 48712744_1 CDM 0271 RC inpatient 333 216.45 UMR - ALL PLANS UMR - ALL PLANS 233.1 70 999999999 201.63 323.01 percent of total billed charges BOOT ST FRACTURE S BLEDSOE AL032003BB- 48712744_1 CDM 0271 RC inpatient 333 216.45 SIHO - ALL PLANS SIHO - ALL PLANS 299.7 90 999999999 201.63 323.01 percent of total billed charges BOOT ST FRACTURE S BLEDSOE AL032003BB- 48712744_1 CDM 0271 RC inpatient 333 216.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 201.63 60.55 999999999 201.63 323.01 percent of total billed charges BOOT ST FRACTURE S BLEDSOE AL032003BB- 48712744_1 CDM 0271 RC inpatient 333 216.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 201.63 323.01 BOOT ST FRACTURE S BLEDSOE AL032003BB- 48712744_1 CDM 0271 RC inpatient 333 216.45 ANTHEM HMO ANTHEM HMO 999999999 201.63 323.01 BOOT ST FRACTURE S BLEDSOE AL032003BB- 48712744_1 CDM 0271 RC inpatient 333 216.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 201.63 323.01 BOOT ST FRACTURE S BLEDSOE AL032003BB- 48712744_1 CDM 0271 RC inpatient 333 216.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 225.11 67.6 999999999 201.63 323.01 percent of total billed charges BOOT ST FRACTURE S BLEDSOE AL032003BB- 48712744_1 CDM 0271 RC inpatient 333 216.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 201.63 323.01 BOOT ST FRACTURE S BLEDSOE AL032003BB- 48712744_1 CDM 0271 RC inpatient 333 216.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 201.63 323.01 BOOT ST FRACTURE M BLEDSOE 97503 48712745_1 CDM 0271 RC inpatient 353 229.45 AETNA AETNA 278.87 79 999999999 213.74 342.41 percent of total billed charges BOOT ST FRACTURE M BLEDSOE 97503 48712745_1 CDM 0271 RC inpatient 353 229.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 229.45 65 999999999 213.74 342.41 percent of total billed charges BOOT ST FRACTURE M BLEDSOE 97503 48712745_1 CDM 0271 RC inpatient 353 229.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 342.41 97 999999999 213.74 342.41 percent of total billed charges BOOT ST FRACTURE M BLEDSOE 97503 48712745_1 CDM 0271 RC inpatient 353 229.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 275.34 78 999999999 213.74 342.41 percent of total billed charges BOOT ST FRACTURE M BLEDSOE 97503 48712745_1 CDM 0271 RC inpatient 353 229.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 243.57 69 999999999 213.74 342.41 percent of total billed charges BOOT ST FRACTURE M BLEDSOE 97503 48712745_1 CDM 0271 RC inpatient 353 229.45 UMR - ALL PLANS UMR - ALL PLANS 247.1 70 999999999 213.74 342.41 percent of total billed charges BOOT ST FRACTURE M BLEDSOE 97503 48712745_1 CDM 0271 RC inpatient 353 229.45 SIHO - ALL PLANS SIHO - ALL PLANS 317.7 90 999999999 213.74 342.41 percent of total billed charges BOOT ST FRACTURE M BLEDSOE 97503 48712745_1 CDM 0271 RC inpatient 353 229.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 213.74 60.55 999999999 213.74 342.41 percent of total billed charges BOOT ST FRACTURE M BLEDSOE 97503 48712745_1 CDM 0271 RC inpatient 353 229.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 213.74 342.41 BOOT ST FRACTURE M BLEDSOE 97503 48712745_1 CDM 0271 RC inpatient 353 229.45 ANTHEM HMO ANTHEM HMO 999999999 213.74 342.41 BOOT ST FRACTURE M BLEDSOE 97503 48712745_1 CDM 0271 RC inpatient 353 229.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 213.74 342.41 BOOT ST FRACTURE M BLEDSOE 97503 48712745_1 CDM 0271 RC inpatient 353 229.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 238.63 67.6 999999999 213.74 342.41 percent of total billed charges BOOT ST FRACTURE M BLEDSOE 97503 48712745_1 CDM 0271 RC inpatient 353 229.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 213.74 342.41 BOOT ST FRACTURE M BLEDSOE 97503 48712745_1 CDM 0271 RC inpatient 353 229.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 213.74 342.41 BOOT ST X-LG BLEDSOE AL032009BB 48712746_1 CDM 0271 RC inpatient 382 248.3 AETNA AETNA 301.78 79 999999999 231.3 370.54 percent of total billed charges BOOT ST X-LG BLEDSOE AL032009BB 48712746_1 CDM 0271 RC inpatient 382 248.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 248.3 65 999999999 231.3 370.54 percent of total billed charges BOOT ST X-LG BLEDSOE AL032009BB 48712746_1 CDM 0271 RC inpatient 382 248.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 370.54 97 999999999 231.3 370.54 percent of total billed charges BOOT ST X-LG BLEDSOE AL032009BB 48712746_1 CDM 0271 RC inpatient 382 248.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 297.96 78 999999999 231.3 370.54 percent of total billed charges BOOT ST X-LG BLEDSOE AL032009BB 48712746_1 CDM 0271 RC inpatient 382 248.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 263.58 69 999999999 231.3 370.54 percent of total billed charges BOOT ST X-LG BLEDSOE AL032009BB 48712746_1 CDM 0271 RC inpatient 382 248.3 UMR - ALL PLANS UMR - ALL PLANS 267.4 70 999999999 231.3 370.54 percent of total billed charges BOOT ST X-LG BLEDSOE AL032009BB 48712746_1 CDM 0271 RC inpatient 382 248.3 SIHO - ALL PLANS SIHO - ALL PLANS 343.8 90 999999999 231.3 370.54 percent of total billed charges BOOT ST X-LG BLEDSOE AL032009BB 48712746_1 CDM 0271 RC inpatient 382 248.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 231.3 60.55 999999999 231.3 370.54 percent of total billed charges BOOT ST X-LG BLEDSOE AL032009BB 48712746_1 CDM 0271 RC inpatient 382 248.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 231.3 370.54 BOOT ST X-LG BLEDSOE AL032009BB 48712746_1 CDM 0271 RC inpatient 382 248.3 ANTHEM HMO ANTHEM HMO 999999999 231.3 370.54 BOOT ST X-LG BLEDSOE AL032009BB 48712746_1 CDM 0271 RC inpatient 382 248.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 231.3 370.54 BOOT ST X-LG BLEDSOE AL032009BB 48712746_1 CDM 0271 RC inpatient 382 248.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 258.23 67.6 999999999 231.3 370.54 percent of total billed charges BOOT ST X-LG BLEDSOE AL032009BB 48712746_1 CDM 0271 RC inpatient 382 248.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 231.3 370.54 BOOT ST X-LG BLEDSOE AL032009BB 48712746_1 CDM 0271 RC inpatient 382 248.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 231.3 370.54 SPLASH SHIELD STRYKER 210-34 48712757_1 CDM 0272 RC inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges SPLASH SHIELD STRYKER 210-34 48712757_1 CDM 0272 RC inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges SPLASH SHIELD STRYKER 210-34 48712757_1 CDM 0272 RC inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges SPLASH SHIELD STRYKER 210-34 48712757_1 CDM 0272 RC inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges SPLASH SHIELD STRYKER 210-34 48712757_1 CDM 0272 RC inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges SPLASH SHIELD STRYKER 210-34 48712757_1 CDM 0272 RC inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges SPLASH SHIELD STRYKER 210-34 48712757_1 CDM 0272 RC inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges SPLASH SHIELD STRYKER 210-34 48712757_1 CDM 0272 RC inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges SPLASH SHIELD STRYKER 210-34 48712757_1 CDM 0272 RC inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 SPLASH SHIELD STRYKER 210-34 48712757_1 CDM 0272 RC inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 SPLASH SHIELD STRYKER 210-34 48712757_1 CDM 0272 RC inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 SPLASH SHIELD STRYKER 210-34 48712757_1 CDM 0272 RC inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges SPLASH SHIELD STRYKER 210-34 48712757_1 CDM 0272 RC inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 SPLASH SHIELD STRYKER 210-34 48712757_1 CDM 0272 RC inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 SPIRAL TIP FILIFORM 3FR. 48712758_1 CDM 0272 RC inpatient 255 165.75 AETNA AETNA 201.45 79 999999999 154.4 247.35 percent of total billed charges SPIRAL TIP FILIFORM 3FR. 48712758_1 CDM 0272 RC inpatient 255 165.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 165.75 65 999999999 154.4 247.35 percent of total billed charges SPIRAL TIP FILIFORM 3FR. 48712758_1 CDM 0272 RC inpatient 255 165.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 247.35 97 999999999 154.4 247.35 percent of total billed charges SPIRAL TIP FILIFORM 3FR. 48712758_1 CDM 0272 RC inpatient 255 165.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 198.9 78 999999999 154.4 247.35 percent of total billed charges SPIRAL TIP FILIFORM 3FR. 48712758_1 CDM 0272 RC inpatient 255 165.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 175.95 69 999999999 154.4 247.35 percent of total billed charges SPIRAL TIP FILIFORM 3FR. 48712758_1 CDM 0272 RC inpatient 255 165.75 UMR - ALL PLANS UMR - ALL PLANS 178.5 70 999999999 154.4 247.35 percent of total billed charges SPIRAL TIP FILIFORM 3FR. 48712758_1 CDM 0272 RC inpatient 255 165.75 SIHO - ALL PLANS SIHO - ALL PLANS 229.5 90 999999999 154.4 247.35 percent of total billed charges SPIRAL TIP FILIFORM 3FR. 48712758_1 CDM 0272 RC inpatient 255 165.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 154.4 60.55 999999999 154.4 247.35 percent of total billed charges SPIRAL TIP FILIFORM 3FR. 48712758_1 CDM 0272 RC inpatient 255 165.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 154.4 247.35 SPIRAL TIP FILIFORM 3FR. 48712758_1 CDM 0272 RC inpatient 255 165.75 ANTHEM HMO ANTHEM HMO 999999999 154.4 247.35 SPIRAL TIP FILIFORM 3FR. 48712758_1 CDM 0272 RC inpatient 255 165.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 154.4 247.35 SPIRAL TIP FILIFORM 3FR. 48712758_1 CDM 0272 RC inpatient 255 165.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 172.38 67.6 999999999 154.4 247.35 percent of total billed charges SPIRAL TIP FILIFORM 3FR. 48712758_1 CDM 0272 RC inpatient 255 165.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 154.4 247.35 SPIRAL TIP FILIFORM 3FR. 48712758_1 CDM 0272 RC inpatient 255 165.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 154.4 247.35 FILIFORM 4FR SPIRAL TIP 022104 48712759_1 CDM 0272 RC inpatient 255 165.75 AETNA AETNA 201.45 79 999999999 154.4 247.35 percent of total billed charges FILIFORM 4FR SPIRAL TIP 022104 48712759_1 CDM 0272 RC inpatient 255 165.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 165.75 65 999999999 154.4 247.35 percent of total billed charges FILIFORM 4FR SPIRAL TIP 022104 48712759_1 CDM 0272 RC inpatient 255 165.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 247.35 97 999999999 154.4 247.35 percent of total billed charges FILIFORM 4FR SPIRAL TIP 022104 48712759_1 CDM 0272 RC inpatient 255 165.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 198.9 78 999999999 154.4 247.35 percent of total billed charges FILIFORM 4FR SPIRAL TIP 022104 48712759_1 CDM 0272 RC inpatient 255 165.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 175.95 69 999999999 154.4 247.35 percent of total billed charges FILIFORM 4FR SPIRAL TIP 022104 48712759_1 CDM 0272 RC inpatient 255 165.75 UMR - ALL PLANS UMR - ALL PLANS 178.5 70 999999999 154.4 247.35 percent of total billed charges FILIFORM 4FR SPIRAL TIP 022104 48712759_1 CDM 0272 RC inpatient 255 165.75 SIHO - ALL PLANS SIHO - ALL PLANS 229.5 90 999999999 154.4 247.35 percent of total billed charges FILIFORM 4FR SPIRAL TIP 022104 48712759_1 CDM 0272 RC inpatient 255 165.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 154.4 60.55 999999999 154.4 247.35 percent of total billed charges FILIFORM 4FR SPIRAL TIP 022104 48712759_1 CDM 0272 RC inpatient 255 165.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 154.4 247.35 FILIFORM 4FR SPIRAL TIP 022104 48712759_1 CDM 0272 RC inpatient 255 165.75 ANTHEM HMO ANTHEM HMO 999999999 154.4 247.35 FILIFORM 4FR SPIRAL TIP 022104 48712759_1 CDM 0272 RC inpatient 255 165.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 154.4 247.35 FILIFORM 4FR SPIRAL TIP 022104 48712759_1 CDM 0272 RC inpatient 255 165.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 172.38 67.6 999999999 154.4 247.35 percent of total billed charges FILIFORM 4FR SPIRAL TIP 022104 48712759_1 CDM 0272 RC inpatient 255 165.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 154.4 247.35 FILIFORM 4FR SPIRAL TIP 022104 48712759_1 CDM 0272 RC inpatient 255 165.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 154.4 247.35 SPIRAL TIP FILIFORM 6FR. 48712760_1 CDM 0272 RC inpatient 466 302.9 AETNA AETNA 368.14 79 999999999 282.16 452.02 percent of total billed charges SPIRAL TIP FILIFORM 6FR. 48712760_1 CDM 0272 RC inpatient 466 302.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 302.9 65 999999999 282.16 452.02 percent of total billed charges SPIRAL TIP FILIFORM 6FR. 48712760_1 CDM 0272 RC inpatient 466 302.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 452.02 97 999999999 282.16 452.02 percent of total billed charges SPIRAL TIP FILIFORM 6FR. 48712760_1 CDM 0272 RC inpatient 466 302.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 363.48 78 999999999 282.16 452.02 percent of total billed charges SPIRAL TIP FILIFORM 6FR. 48712760_1 CDM 0272 RC inpatient 466 302.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 321.54 69 999999999 282.16 452.02 percent of total billed charges SPIRAL TIP FILIFORM 6FR. 48712760_1 CDM 0272 RC inpatient 466 302.9 UMR - ALL PLANS UMR - ALL PLANS 326.2 70 999999999 282.16 452.02 percent of total billed charges SPIRAL TIP FILIFORM 6FR. 48712760_1 CDM 0272 RC inpatient 466 302.9 SIHO - ALL PLANS SIHO - ALL PLANS 419.4 90 999999999 282.16 452.02 percent of total billed charges SPIRAL TIP FILIFORM 6FR. 48712760_1 CDM 0272 RC inpatient 466 302.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 282.16 60.55 999999999 282.16 452.02 percent of total billed charges SPIRAL TIP FILIFORM 6FR. 48712760_1 CDM 0272 RC inpatient 466 302.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 282.16 452.02 SPIRAL TIP FILIFORM 6FR. 48712760_1 CDM 0272 RC inpatient 466 302.9 ANTHEM HMO ANTHEM HMO 999999999 282.16 452.02 SPIRAL TIP FILIFORM 6FR. 48712760_1 CDM 0272 RC inpatient 466 302.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 282.16 452.02 SPIRAL TIP FILIFORM 6FR. 48712760_1 CDM 0272 RC inpatient 466 302.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 315.02 67.6 999999999 282.16 452.02 percent of total billed charges SPIRAL TIP FILIFORM 6FR. 48712760_1 CDM 0272 RC inpatient 466 302.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 282.16 452.02 SPIRAL TIP FILIFORM 6FR. 48712760_1 CDM 0272 RC inpatient 466 302.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 282.16 452.02 FILIFORM 4FR SPIRAL TIP 022004 48712761_1 CDM 0272 RC inpatient 482 313.3 AETNA AETNA 380.78 79 999999999 291.85 467.54 percent of total billed charges FILIFORM 4FR SPIRAL TIP 022004 48712761_1 CDM 0272 RC inpatient 482 313.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 313.3 65 999999999 291.85 467.54 percent of total billed charges FILIFORM 4FR SPIRAL TIP 022004 48712761_1 CDM 0272 RC inpatient 482 313.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 467.54 97 999999999 291.85 467.54 percent of total billed charges FILIFORM 4FR SPIRAL TIP 022004 48712761_1 CDM 0272 RC inpatient 482 313.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 375.96 78 999999999 291.85 467.54 percent of total billed charges FILIFORM 4FR SPIRAL TIP 022004 48712761_1 CDM 0272 RC inpatient 482 313.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 332.58 69 999999999 291.85 467.54 percent of total billed charges FILIFORM 4FR SPIRAL TIP 022004 48712761_1 CDM 0272 RC inpatient 482 313.3 UMR - ALL PLANS UMR - ALL PLANS 337.4 70 999999999 291.85 467.54 percent of total billed charges FILIFORM 4FR SPIRAL TIP 022004 48712761_1 CDM 0272 RC inpatient 482 313.3 SIHO - ALL PLANS SIHO - ALL PLANS 433.8 90 999999999 291.85 467.54 percent of total billed charges FILIFORM 4FR SPIRAL TIP 022004 48712761_1 CDM 0272 RC inpatient 482 313.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 291.85 60.55 999999999 291.85 467.54 percent of total billed charges FILIFORM 4FR SPIRAL TIP 022004 48712761_1 CDM 0272 RC inpatient 482 313.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 291.85 467.54 FILIFORM 4FR SPIRAL TIP 022004 48712761_1 CDM 0272 RC inpatient 482 313.3 ANTHEM HMO ANTHEM HMO 999999999 291.85 467.54 FILIFORM 4FR SPIRAL TIP 022004 48712761_1 CDM 0272 RC inpatient 482 313.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 291.85 467.54 FILIFORM 4FR SPIRAL TIP 022004 48712761_1 CDM 0272 RC inpatient 482 313.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 325.83 67.6 999999999 291.85 467.54 percent of total billed charges FILIFORM 4FR SPIRAL TIP 022004 48712761_1 CDM 0272 RC inpatient 482 313.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 291.85 467.54 FILIFORM 4FR SPIRAL TIP 022004 48712761_1 CDM 0272 RC inpatient 482 313.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 291.85 467.54 ENDOS/BLUNT TIP DISS BTD05 48712765_1 CDM 0272 RC inpatient 344 223.6 AETNA AETNA 271.76 79 999999999 208.29 333.68 percent of total billed charges ENDOS/BLUNT TIP DISS BTD05 48712765_1 CDM 0272 RC inpatient 344 223.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 223.6 65 999999999 208.29 333.68 percent of total billed charges ENDOS/BLUNT TIP DISS BTD05 48712765_1 CDM 0272 RC inpatient 344 223.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 333.68 97 999999999 208.29 333.68 percent of total billed charges ENDOS/BLUNT TIP DISS BTD05 48712765_1 CDM 0272 RC inpatient 344 223.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 268.32 78 999999999 208.29 333.68 percent of total billed charges ENDOS/BLUNT TIP DISS BTD05 48712765_1 CDM 0272 RC inpatient 344 223.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 237.36 69 999999999 208.29 333.68 percent of total billed charges ENDOS/BLUNT TIP DISS BTD05 48712765_1 CDM 0272 RC inpatient 344 223.6 UMR - ALL PLANS UMR - ALL PLANS 240.8 70 999999999 208.29 333.68 percent of total billed charges ENDOS/BLUNT TIP DISS BTD05 48712765_1 CDM 0272 RC inpatient 344 223.6 SIHO - ALL PLANS SIHO - ALL PLANS 309.6 90 999999999 208.29 333.68 percent of total billed charges ENDOS/BLUNT TIP DISS BTD05 48712765_1 CDM 0272 RC inpatient 344 223.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 208.29 60.55 999999999 208.29 333.68 percent of total billed charges ENDOS/BLUNT TIP DISS BTD05 48712765_1 CDM 0272 RC inpatient 344 223.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 208.29 333.68 ENDOS/BLUNT TIP DISS BTD05 48712765_1 CDM 0272 RC inpatient 344 223.6 ANTHEM HMO ANTHEM HMO 999999999 208.29 333.68 ENDOS/BLUNT TIP DISS BTD05 48712765_1 CDM 0272 RC inpatient 344 223.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 208.29 333.68 ENDOS/BLUNT TIP DISS BTD05 48712765_1 CDM 0272 RC inpatient 344 223.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 232.54 67.6 999999999 208.29 333.68 percent of total billed charges ENDOS/BLUNT TIP DISS BTD05 48712765_1 CDM 0272 RC inpatient 344 223.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 208.29 333.68 ENDOS/BLUNT TIP DISS BTD05 48712765_1 CDM 0272 RC inpatient 344 223.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 208.29 333.68 "STEIN PIN 9"" 5/32 1640-109T" 48712766_1 CDM 0278 RC inpatient 571 371.15 AETNA AETNA 451.09 79 999999999 345.74 553.87 percent of total billed charges "STEIN PIN 9"" 5/32 1640-109T" 48712766_1 CDM 0278 RC inpatient 571 371.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 371.15 65 999999999 345.74 553.87 percent of total billed charges "STEIN PIN 9"" 5/32 1640-109T" 48712766_1 CDM 0278 RC inpatient 571 371.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 553.87 97 999999999 345.74 553.87 percent of total billed charges "STEIN PIN 9"" 5/32 1640-109T" 48712766_1 CDM 0278 RC inpatient 571 371.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 445.38 78 999999999 345.74 553.87 percent of total billed charges "STEIN PIN 9"" 5/32 1640-109T" 48712766_1 CDM 0278 RC inpatient 571 371.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 393.99 69 999999999 345.74 553.87 percent of total billed charges "STEIN PIN 9"" 5/32 1640-109T" 48712766_1 CDM 0278 RC inpatient 571 371.15 UMR - ALL PLANS UMR - ALL PLANS 399.7 70 999999999 345.74 553.87 percent of total billed charges "STEIN PIN 9"" 5/32 1640-109T" 48712766_1 CDM 0278 RC inpatient 571 371.15 SIHO - ALL PLANS SIHO - ALL PLANS 513.9 90 999999999 345.74 553.87 percent of total billed charges "STEIN PIN 9"" 5/32 1640-109T" 48712766_1 CDM 0278 RC inpatient 571 371.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 345.74 60.55 999999999 345.74 553.87 percent of total billed charges "STEIN PIN 9"" 5/32 1640-109T" 48712766_1 CDM 0278 RC inpatient 571 371.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 345.74 553.87 "STEIN PIN 9"" 5/32 1640-109T" 48712766_1 CDM 0278 RC inpatient 571 371.15 ANTHEM HMO ANTHEM HMO 999999999 345.74 553.87 "STEIN PIN 9"" 5/32 1640-109T" 48712766_1 CDM 0278 RC inpatient 571 371.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 345.74 553.87 "STEIN PIN 9"" 5/32 1640-109T" 48712766_1 CDM 0278 RC inpatient 571 371.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 386 67.6 999999999 345.74 553.87 percent of total billed charges "STEIN PIN 9"" 5/32 1640-109T" 48712766_1 CDM 0278 RC inpatient 571 371.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 345.74 553.87 "STEIN PIN 9"" 5/32 1640-109T" 48712766_1 CDM 0278 RC inpatient 571 371.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 345.74 553.87 CATHETER DUAL LUMEN ACMI 48712767_1 CDM 0272 RC inpatient 551 358.15 AETNA AETNA 435.29 79 999999999 333.63 534.47 percent of total billed charges CATHETER DUAL LUMEN ACMI 48712767_1 CDM 0272 RC inpatient 551 358.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 358.15 65 999999999 333.63 534.47 percent of total billed charges CATHETER DUAL LUMEN ACMI 48712767_1 CDM 0272 RC inpatient 551 358.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 534.47 97 999999999 333.63 534.47 percent of total billed charges CATHETER DUAL LUMEN ACMI 48712767_1 CDM 0272 RC inpatient 551 358.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 429.78 78 999999999 333.63 534.47 percent of total billed charges CATHETER DUAL LUMEN ACMI 48712767_1 CDM 0272 RC inpatient 551 358.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 380.19 69 999999999 333.63 534.47 percent of total billed charges CATHETER DUAL LUMEN ACMI 48712767_1 CDM 0272 RC inpatient 551 358.15 UMR - ALL PLANS UMR - ALL PLANS 385.7 70 999999999 333.63 534.47 percent of total billed charges CATHETER DUAL LUMEN ACMI 48712767_1 CDM 0272 RC inpatient 551 358.15 SIHO - ALL PLANS SIHO - ALL PLANS 495.9 90 999999999 333.63 534.47 percent of total billed charges CATHETER DUAL LUMEN ACMI 48712767_1 CDM 0272 RC inpatient 551 358.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 333.63 60.55 999999999 333.63 534.47 percent of total billed charges CATHETER DUAL LUMEN ACMI 48712767_1 CDM 0272 RC inpatient 551 358.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 333.63 534.47 CATHETER DUAL LUMEN ACMI 48712767_1 CDM 0272 RC inpatient 551 358.15 ANTHEM HMO ANTHEM HMO 999999999 333.63 534.47 CATHETER DUAL LUMEN ACMI 48712767_1 CDM 0272 RC inpatient 551 358.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 333.63 534.47 CATHETER DUAL LUMEN ACMI 48712767_1 CDM 0272 RC inpatient 551 358.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 372.48 67.6 999999999 333.63 534.47 percent of total billed charges CATHETER DUAL LUMEN ACMI 48712767_1 CDM 0272 RC inpatient 551 358.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 333.63 534.47 CATHETER DUAL LUMEN ACMI 48712767_1 CDM 0272 RC inpatient 551 358.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 333.63 534.47 DRILL BIT FOR DHS & DCS 338.10 48712775_1 CDM 0278 RC inpatient 3253 2114.45 AETNA AETNA 2569.87 79 999999999 1969.69 3155.41 percent of total billed charges DRILL BIT FOR DHS & DCS 338.10 48712775_1 CDM 0278 RC inpatient 3253 2114.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 2114.45 65 999999999 1969.69 3155.41 percent of total billed charges DRILL BIT FOR DHS & DCS 338.10 48712775_1 CDM 0278 RC inpatient 3253 2114.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3155.41 97 999999999 1969.69 3155.41 percent of total billed charges DRILL BIT FOR DHS & DCS 338.10 48712775_1 CDM 0278 RC inpatient 3253 2114.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 2537.34 78 999999999 1969.69 3155.41 percent of total billed charges DRILL BIT FOR DHS & DCS 338.10 48712775_1 CDM 0278 RC inpatient 3253 2114.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 2244.57 69 999999999 1969.69 3155.41 percent of total billed charges DRILL BIT FOR DHS & DCS 338.10 48712775_1 CDM 0278 RC inpatient 3253 2114.45 UMR - ALL PLANS UMR - ALL PLANS 2277.1 70 999999999 1969.69 3155.41 percent of total billed charges DRILL BIT FOR DHS & DCS 338.10 48712775_1 CDM 0278 RC inpatient 3253 2114.45 SIHO - ALL PLANS SIHO - ALL PLANS 2927.7 90 999999999 1969.69 3155.41 percent of total billed charges DRILL BIT FOR DHS & DCS 338.10 48712775_1 CDM 0278 RC inpatient 3253 2114.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1969.69 60.55 999999999 1969.69 3155.41 percent of total billed charges DRILL BIT FOR DHS & DCS 338.10 48712775_1 CDM 0278 RC inpatient 3253 2114.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1969.69 3155.41 DRILL BIT FOR DHS & DCS 338.10 48712775_1 CDM 0278 RC inpatient 3253 2114.45 ANTHEM HMO ANTHEM HMO 999999999 1969.69 3155.41 DRILL BIT FOR DHS & DCS 338.10 48712775_1 CDM 0278 RC inpatient 3253 2114.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1969.69 3155.41 DRILL BIT FOR DHS & DCS 338.10 48712775_1 CDM 0278 RC inpatient 3253 2114.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 2199.03 67.6 999999999 1969.69 3155.41 percent of total billed charges DRILL BIT FOR DHS & DCS 338.10 48712775_1 CDM 0278 RC inpatient 3253 2114.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1969.69 3155.41 DRILL BIT FOR DHS & DCS 338.10 48712775_1 CDM 0278 RC inpatient 3253 2114.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1969.69 3155.41 REAMER ONE STEP OPENING 357.394 48712776_1 CDM 0272 RC inpatient 4281 2782.65 AETNA AETNA 3381.99 79 999999999 2592.15 4152.57 percent of total billed charges REAMER ONE STEP OPENING 357.394 48712776_1 CDM 0272 RC inpatient 4281 2782.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 2782.65 65 999999999 2592.15 4152.57 percent of total billed charges REAMER ONE STEP OPENING 357.394 48712776_1 CDM 0272 RC inpatient 4281 2782.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4152.57 97 999999999 2592.15 4152.57 percent of total billed charges REAMER ONE STEP OPENING 357.394 48712776_1 CDM 0272 RC inpatient 4281 2782.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 3339.18 78 999999999 2592.15 4152.57 percent of total billed charges REAMER ONE STEP OPENING 357.394 48712776_1 CDM 0272 RC inpatient 4281 2782.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2953.89 69 999999999 2592.15 4152.57 percent of total billed charges REAMER ONE STEP OPENING 357.394 48712776_1 CDM 0272 RC inpatient 4281 2782.65 UMR - ALL PLANS UMR - ALL PLANS 2996.7 70 999999999 2592.15 4152.57 percent of total billed charges REAMER ONE STEP OPENING 357.394 48712776_1 CDM 0272 RC inpatient 4281 2782.65 SIHO - ALL PLANS SIHO - ALL PLANS 3852.9 90 999999999 2592.15 4152.57 percent of total billed charges REAMER ONE STEP OPENING 357.394 48712776_1 CDM 0272 RC inpatient 4281 2782.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2592.15 60.55 999999999 2592.15 4152.57 percent of total billed charges REAMER ONE STEP OPENING 357.394 48712776_1 CDM 0272 RC inpatient 4281 2782.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2592.15 4152.57 REAMER ONE STEP OPENING 357.394 48712776_1 CDM 0272 RC inpatient 4281 2782.65 ANTHEM HMO ANTHEM HMO 999999999 2592.15 4152.57 REAMER ONE STEP OPENING 357.394 48712776_1 CDM 0272 RC inpatient 4281 2782.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2592.15 4152.57 REAMER ONE STEP OPENING 357.394 48712776_1 CDM 0272 RC inpatient 4281 2782.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2893.96 67.6 999999999 2592.15 4152.57 percent of total billed charges REAMER ONE STEP OPENING 357.394 48712776_1 CDM 0272 RC inpatient 4281 2782.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2592.15 4152.57 REAMER ONE STEP OPENING 357.394 48712776_1 CDM 0272 RC inpatient 4281 2782.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 2592.15 4152.57 NASAL ADHESIVE SPLINT KIT S/M 48712777_1 CDM 0272 RC inpatient 321 208.65 AETNA AETNA 253.59 79 999999999 194.37 311.37 percent of total billed charges NASAL ADHESIVE SPLINT KIT S/M 48712777_1 CDM 0272 RC inpatient 321 208.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 208.65 65 999999999 194.37 311.37 percent of total billed charges NASAL ADHESIVE SPLINT KIT S/M 48712777_1 CDM 0272 RC inpatient 321 208.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 311.37 97 999999999 194.37 311.37 percent of total billed charges NASAL ADHESIVE SPLINT KIT S/M 48712777_1 CDM 0272 RC inpatient 321 208.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 250.38 78 999999999 194.37 311.37 percent of total billed charges NASAL ADHESIVE SPLINT KIT S/M 48712777_1 CDM 0272 RC inpatient 321 208.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 221.49 69 999999999 194.37 311.37 percent of total billed charges NASAL ADHESIVE SPLINT KIT S/M 48712777_1 CDM 0272 RC inpatient 321 208.65 UMR - ALL PLANS UMR - ALL PLANS 224.7 70 999999999 194.37 311.37 percent of total billed charges NASAL ADHESIVE SPLINT KIT S/M 48712777_1 CDM 0272 RC inpatient 321 208.65 SIHO - ALL PLANS SIHO - ALL PLANS 288.9 90 999999999 194.37 311.37 percent of total billed charges NASAL ADHESIVE SPLINT KIT S/M 48712777_1 CDM 0272 RC inpatient 321 208.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 194.37 60.55 999999999 194.37 311.37 percent of total billed charges NASAL ADHESIVE SPLINT KIT S/M 48712777_1 CDM 0272 RC inpatient 321 208.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 194.37 311.37 NASAL ADHESIVE SPLINT KIT S/M 48712777_1 CDM 0272 RC inpatient 321 208.65 ANTHEM HMO ANTHEM HMO 999999999 194.37 311.37 NASAL ADHESIVE SPLINT KIT S/M 48712777_1 CDM 0272 RC inpatient 321 208.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 194.37 311.37 NASAL ADHESIVE SPLINT KIT S/M 48712777_1 CDM 0272 RC inpatient 321 208.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 217 67.6 999999999 194.37 311.37 percent of total billed charges NASAL ADHESIVE SPLINT KIT S/M 48712777_1 CDM 0272 RC inpatient 321 208.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 194.37 311.37 NASAL ADHESIVE SPLINT KIT S/M 48712777_1 CDM 0272 RC inpatient 321 208.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 194.37 311.37 NASAL ADHESIVE SPLINT LARGE 10-1500-05KL 48712778_1 CDM 0271 RC inpatient 315 204.75 AETNA AETNA 248.85 79 999999999 190.73 305.55 percent of total billed charges NASAL ADHESIVE SPLINT LARGE 10-1500-05KL 48712778_1 CDM 0271 RC inpatient 315 204.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 204.75 65 999999999 190.73 305.55 percent of total billed charges NASAL ADHESIVE SPLINT LARGE 10-1500-05KL 48712778_1 CDM 0271 RC inpatient 315 204.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 305.55 97 999999999 190.73 305.55 percent of total billed charges NASAL ADHESIVE SPLINT LARGE 10-1500-05KL 48712778_1 CDM 0271 RC inpatient 315 204.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 245.7 78 999999999 190.73 305.55 percent of total billed charges NASAL ADHESIVE SPLINT LARGE 10-1500-05KL 48712778_1 CDM 0271 RC inpatient 315 204.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 217.35 69 999999999 190.73 305.55 percent of total billed charges NASAL ADHESIVE SPLINT LARGE 10-1500-05KL 48712778_1 CDM 0271 RC inpatient 315 204.75 UMR - ALL PLANS UMR - ALL PLANS 220.5 70 999999999 190.73 305.55 percent of total billed charges NASAL ADHESIVE SPLINT LARGE 10-1500-05KL 48712778_1 CDM 0271 RC inpatient 315 204.75 SIHO - ALL PLANS SIHO - ALL PLANS 283.5 90 999999999 190.73 305.55 percent of total billed charges NASAL ADHESIVE SPLINT LARGE 10-1500-05KL 48712778_1 CDM 0271 RC inpatient 315 204.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 190.73 60.55 999999999 190.73 305.55 percent of total billed charges NASAL ADHESIVE SPLINT LARGE 10-1500-05KL 48712778_1 CDM 0271 RC inpatient 315 204.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 190.73 305.55 NASAL ADHESIVE SPLINT LARGE 10-1500-05KL 48712778_1 CDM 0271 RC inpatient 315 204.75 ANTHEM HMO ANTHEM HMO 999999999 190.73 305.55 NASAL ADHESIVE SPLINT LARGE 10-1500-05KL 48712778_1 CDM 0271 RC inpatient 315 204.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 190.73 305.55 NASAL ADHESIVE SPLINT LARGE 10-1500-05KL 48712778_1 CDM 0271 RC inpatient 315 204.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 212.94 67.6 999999999 190.73 305.55 percent of total billed charges NASAL ADHESIVE SPLINT LARGE 10-1500-05KL 48712778_1 CDM 0271 RC inpatient 315 204.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 190.73 305.55 NASAL ADHESIVE SPLINT LARGE 10-1500-05KL 48712778_1 CDM 0271 RC inpatient 315 204.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 190.73 305.55 CATH CRICOTHYROTOMY KIT 48712779_1 CDM 0272 RC inpatient 2884 1874.6 AETNA AETNA 2278.36 79 999999999 1746.26 2797.48 percent of total billed charges CATH CRICOTHYROTOMY KIT 48712779_1 CDM 0272 RC inpatient 2884 1874.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1874.6 65 999999999 1746.26 2797.48 percent of total billed charges CATH CRICOTHYROTOMY KIT 48712779_1 CDM 0272 RC inpatient 2884 1874.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2797.48 97 999999999 1746.26 2797.48 percent of total billed charges CATH CRICOTHYROTOMY KIT 48712779_1 CDM 0272 RC inpatient 2884 1874.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 2249.52 78 999999999 1746.26 2797.48 percent of total billed charges CATH CRICOTHYROTOMY KIT 48712779_1 CDM 0272 RC inpatient 2884 1874.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1989.96 69 999999999 1746.26 2797.48 percent of total billed charges CATH CRICOTHYROTOMY KIT 48712779_1 CDM 0272 RC inpatient 2884 1874.6 UMR - ALL PLANS UMR - ALL PLANS 2018.8 70 999999999 1746.26 2797.48 percent of total billed charges CATH CRICOTHYROTOMY KIT 48712779_1 CDM 0272 RC inpatient 2884 1874.6 SIHO - ALL PLANS SIHO - ALL PLANS 2595.6 90 999999999 1746.26 2797.48 percent of total billed charges CATH CRICOTHYROTOMY KIT 48712779_1 CDM 0272 RC inpatient 2884 1874.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1746.26 60.55 999999999 1746.26 2797.48 percent of total billed charges CATH CRICOTHYROTOMY KIT 48712779_1 CDM 0272 RC inpatient 2884 1874.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1746.26 2797.48 CATH CRICOTHYROTOMY KIT 48712779_1 CDM 0272 RC inpatient 2884 1874.6 ANTHEM HMO ANTHEM HMO 999999999 1746.26 2797.48 CATH CRICOTHYROTOMY KIT 48712779_1 CDM 0272 RC inpatient 2884 1874.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1746.26 2797.48 CATH CRICOTHYROTOMY KIT 48712779_1 CDM 0272 RC inpatient 2884 1874.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1949.58 67.6 999999999 1746.26 2797.48 percent of total billed charges CATH CRICOTHYROTOMY KIT 48712779_1 CDM 0272 RC inpatient 2884 1874.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1746.26 2797.48 CATH CRICOTHYROTOMY KIT 48712779_1 CDM 0272 RC inpatient 2884 1874.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1746.26 2797.48 STERI-DRAPE IOBAN 6651EZ 48712781_1 CDM 0272 RC inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges STERI-DRAPE IOBAN 6651EZ 48712781_1 CDM 0272 RC inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges STERI-DRAPE IOBAN 6651EZ 48712781_1 CDM 0272 RC inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges STERI-DRAPE IOBAN 6651EZ 48712781_1 CDM 0272 RC inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges STERI-DRAPE IOBAN 6651EZ 48712781_1 CDM 0272 RC inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges STERI-DRAPE IOBAN 6651EZ 48712781_1 CDM 0272 RC inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges STERI-DRAPE IOBAN 6651EZ 48712781_1 CDM 0272 RC inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges STERI-DRAPE IOBAN 6651EZ 48712781_1 CDM 0272 RC inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges STERI-DRAPE IOBAN 6651EZ 48712781_1 CDM 0272 RC inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 STERI-DRAPE IOBAN 6651EZ 48712781_1 CDM 0272 RC inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 STERI-DRAPE IOBAN 6651EZ 48712781_1 CDM 0272 RC inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 STERI-DRAPE IOBAN 6651EZ 48712781_1 CDM 0272 RC inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges STERI-DRAPE IOBAN 6651EZ 48712781_1 CDM 0272 RC inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 STERI-DRAPE IOBAN 6651EZ 48712781_1 CDM 0272 RC inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 DRAPE WARMER STERILE 0RS-100 48712782_1 CDM 0272 RC inpatient 240 156 AETNA AETNA 189.6 79 999999999 145.32 232.8 percent of total billed charges DRAPE WARMER STERILE 0RS-100 48712782_1 CDM 0272 RC inpatient 240 156 SELF PAY DISCOUNT SELF PAY DISCOUNT 156 65 999999999 145.32 232.8 percent of total billed charges DRAPE WARMER STERILE 0RS-100 48712782_1 CDM 0272 RC inpatient 240 156 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 232.8 97 999999999 145.32 232.8 percent of total billed charges DRAPE WARMER STERILE 0RS-100 48712782_1 CDM 0272 RC inpatient 240 156 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.2 78 999999999 145.32 232.8 percent of total billed charges DRAPE WARMER STERILE 0RS-100 48712782_1 CDM 0272 RC inpatient 240 156 ENCORE - ALL PLANS ENCORE - ALL PLANS 165.6 69 999999999 145.32 232.8 percent of total billed charges DRAPE WARMER STERILE 0RS-100 48712782_1 CDM 0272 RC inpatient 240 156 UMR - ALL PLANS UMR - ALL PLANS 168 70 999999999 145.32 232.8 percent of total billed charges DRAPE WARMER STERILE 0RS-100 48712782_1 CDM 0272 RC inpatient 240 156 SIHO - ALL PLANS SIHO - ALL PLANS 216 90 999999999 145.32 232.8 percent of total billed charges DRAPE WARMER STERILE 0RS-100 48712782_1 CDM 0272 RC inpatient 240 156 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.32 60.55 999999999 145.32 232.8 percent of total billed charges DRAPE WARMER STERILE 0RS-100 48712782_1 CDM 0272 RC inpatient 240 156 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.32 232.8 DRAPE WARMER STERILE 0RS-100 48712782_1 CDM 0272 RC inpatient 240 156 ANTHEM HMO ANTHEM HMO 999999999 145.32 232.8 DRAPE WARMER STERILE 0RS-100 48712782_1 CDM 0272 RC inpatient 240 156 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.32 232.8 DRAPE WARMER STERILE 0RS-100 48712782_1 CDM 0272 RC inpatient 240 156 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.24 67.6 999999999 145.32 232.8 percent of total billed charges DRAPE WARMER STERILE 0RS-100 48712782_1 CDM 0272 RC inpatient 240 156 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.32 232.8 DRAPE WARMER STERILE 0RS-100 48712782_1 CDM 0272 RC inpatient 240 156 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.32 232.8 STIMUPLEX NEEDLE 21G X 4 in 48712788_1 CDM 0272 RC inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges STIMUPLEX NEEDLE 21G X 4 in 48712788_1 CDM 0272 RC inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges STIMUPLEX NEEDLE 21G X 4 in 48712788_1 CDM 0272 RC inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges STIMUPLEX NEEDLE 21G X 4 in 48712788_1 CDM 0272 RC inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges STIMUPLEX NEEDLE 21G X 4 in 48712788_1 CDM 0272 RC inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges STIMUPLEX NEEDLE 21G X 4 in 48712788_1 CDM 0272 RC inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges STIMUPLEX NEEDLE 21G X 4 in 48712788_1 CDM 0272 RC inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges STIMUPLEX NEEDLE 21G X 4 in 48712788_1 CDM 0272 RC inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges STIMUPLEX NEEDLE 21G X 4 in 48712788_1 CDM 0272 RC inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 STIMUPLEX NEEDLE 21G X 4 in 48712788_1 CDM 0272 RC inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 STIMUPLEX NEEDLE 21G X 4 in 48712788_1 CDM 0272 RC inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 STIMUPLEX NEEDLE 21G X 4 in 48712788_1 CDM 0272 RC inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges STIMUPLEX NEEDLE 21G X 4 in 48712788_1 CDM 0272 RC inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 STIMUPLEX NEEDLE 21G X 4 in 48712788_1 CDM 0272 RC inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 ST/WATER IRR 1500ML 2F7115 48712789_1 CDM 0272 RC inpatient 31 20.15 AETNA AETNA 24.49 79 999999999 18.77 30.07 percent of total billed charges ST/WATER IRR 1500ML 2F7115 48712789_1 CDM 0272 RC inpatient 31 20.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.15 65 999999999 18.77 30.07 percent of total billed charges ST/WATER IRR 1500ML 2F7115 48712789_1 CDM 0272 RC inpatient 31 20.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.07 97 999999999 18.77 30.07 percent of total billed charges ST/WATER IRR 1500ML 2F7115 48712789_1 CDM 0272 RC inpatient 31 20.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.18 78 999999999 18.77 30.07 percent of total billed charges ST/WATER IRR 1500ML 2F7115 48712789_1 CDM 0272 RC inpatient 31 20.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.39 69 999999999 18.77 30.07 percent of total billed charges ST/WATER IRR 1500ML 2F7115 48712789_1 CDM 0272 RC inpatient 31 20.15 UMR - ALL PLANS UMR - ALL PLANS 21.7 70 999999999 18.77 30.07 percent of total billed charges ST/WATER IRR 1500ML 2F7115 48712789_1 CDM 0272 RC inpatient 31 20.15 SIHO - ALL PLANS SIHO - ALL PLANS 27.9 90 999999999 18.77 30.07 percent of total billed charges ST/WATER IRR 1500ML 2F7115 48712789_1 CDM 0272 RC inpatient 31 20.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.77 60.55 999999999 18.77 30.07 percent of total billed charges ST/WATER IRR 1500ML 2F7115 48712789_1 CDM 0272 RC inpatient 31 20.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.77 30.07 ST/WATER IRR 1500ML 2F7115 48712789_1 CDM 0272 RC inpatient 31 20.15 ANTHEM HMO ANTHEM HMO 999999999 18.77 30.07 ST/WATER IRR 1500ML 2F7115 48712789_1 CDM 0272 RC inpatient 31 20.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.77 30.07 ST/WATER IRR 1500ML 2F7115 48712789_1 CDM 0272 RC inpatient 31 20.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.96 67.6 999999999 18.77 30.07 percent of total billed charges ST/WATER IRR 1500ML 2F7115 48712789_1 CDM 0272 RC inpatient 31 20.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.77 30.07 ST/WATER IRR 1500ML 2F7115 48712789_1 CDM 0272 RC inpatient 31 20.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.77 30.07 NEEDLE MICROSURGICAL ESE1651 48712791_1 CDM 0272 RC inpatient 218 141.7 AETNA AETNA 172.22 79 999999999 132 211.46 percent of total billed charges NEEDLE MICROSURGICAL ESE1651 48712791_1 CDM 0272 RC inpatient 218 141.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 141.7 65 999999999 132 211.46 percent of total billed charges NEEDLE MICROSURGICAL ESE1651 48712791_1 CDM 0272 RC inpatient 218 141.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 211.46 97 999999999 132 211.46 percent of total billed charges NEEDLE MICROSURGICAL ESE1651 48712791_1 CDM 0272 RC inpatient 218 141.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.04 78 999999999 132 211.46 percent of total billed charges NEEDLE MICROSURGICAL ESE1651 48712791_1 CDM 0272 RC inpatient 218 141.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 150.42 69 999999999 132 211.46 percent of total billed charges NEEDLE MICROSURGICAL ESE1651 48712791_1 CDM 0272 RC inpatient 218 141.7 UMR - ALL PLANS UMR - ALL PLANS 152.6 70 999999999 132 211.46 percent of total billed charges NEEDLE MICROSURGICAL ESE1651 48712791_1 CDM 0272 RC inpatient 218 141.7 SIHO - ALL PLANS SIHO - ALL PLANS 196.2 90 999999999 132 211.46 percent of total billed charges NEEDLE MICROSURGICAL ESE1651 48712791_1 CDM 0272 RC inpatient 218 141.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132 60.55 999999999 132 211.46 percent of total billed charges NEEDLE MICROSURGICAL ESE1651 48712791_1 CDM 0272 RC inpatient 218 141.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132 211.46 NEEDLE MICROSURGICAL ESE1651 48712791_1 CDM 0272 RC inpatient 218 141.7 ANTHEM HMO ANTHEM HMO 999999999 132 211.46 NEEDLE MICROSURGICAL ESE1651 48712791_1 CDM 0272 RC inpatient 218 141.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132 211.46 NEEDLE MICROSURGICAL ESE1651 48712791_1 CDM 0272 RC inpatient 218 141.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 147.37 67.6 999999999 132 211.46 percent of total billed charges NEEDLE MICROSURGICAL ESE1651 48712791_1 CDM 0272 RC inpatient 218 141.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132 211.46 NEEDLE MICROSURGICAL ESE1651 48712791_1 CDM 0272 RC inpatient 218 141.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 132 211.46 ***BLANKET PER MEGAN P 05/19/2023*** MENISCAL CINCH AR-4500 48712792_1 CDM 0272 RC inpatient 1769 1149.85 AETNA AETNA 1397.51 79 999999999 1071.13 1715.93 percent of total billed charges ***BLANKET PER MEGAN P 05/19/2023*** MENISCAL CINCH AR-4500 48712792_1 CDM 0272 RC inpatient 1769 1149.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1149.85 65 999999999 1071.13 1715.93 percent of total billed charges ***BLANKET PER MEGAN P 05/19/2023*** MENISCAL CINCH AR-4500 48712792_1 CDM 0272 RC inpatient 1769 1149.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1715.93 97 999999999 1071.13 1715.93 percent of total billed charges ***BLANKET PER MEGAN P 05/19/2023*** MENISCAL CINCH AR-4500 48712792_1 CDM 0272 RC inpatient 1769 1149.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1379.82 78 999999999 1071.13 1715.93 percent of total billed charges ***BLANKET PER MEGAN P 05/19/2023*** MENISCAL CINCH AR-4500 48712792_1 CDM 0272 RC inpatient 1769 1149.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1220.61 69 999999999 1071.13 1715.93 percent of total billed charges ***BLANKET PER MEGAN P 05/19/2023*** MENISCAL CINCH AR-4500 48712792_1 CDM 0272 RC inpatient 1769 1149.85 UMR - ALL PLANS UMR - ALL PLANS 1238.3 70 999999999 1071.13 1715.93 percent of total billed charges ***BLANKET PER MEGAN P 05/19/2023*** MENISCAL CINCH AR-4500 48712792_1 CDM 0272 RC inpatient 1769 1149.85 SIHO - ALL PLANS SIHO - ALL PLANS 1592.1 90 999999999 1071.13 1715.93 percent of total billed charges ***BLANKET PER MEGAN P 05/19/2023*** MENISCAL CINCH AR-4500 48712792_1 CDM 0272 RC inpatient 1769 1149.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1071.13 60.55 999999999 1071.13 1715.93 percent of total billed charges ***BLANKET PER MEGAN P 05/19/2023*** MENISCAL CINCH AR-4500 48712792_1 CDM 0272 RC inpatient 1769 1149.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1071.13 1715.93 ***BLANKET PER MEGAN P 05/19/2023*** MENISCAL CINCH AR-4500 48712792_1 CDM 0272 RC inpatient 1769 1149.85 ANTHEM HMO ANTHEM HMO 999999999 1071.13 1715.93 ***BLANKET PER MEGAN P 05/19/2023*** MENISCAL CINCH AR-4500 48712792_1 CDM 0272 RC inpatient 1769 1149.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1071.13 1715.93 ***BLANKET PER MEGAN P 05/19/2023*** MENISCAL CINCH AR-4500 48712792_1 CDM 0272 RC inpatient 1769 1149.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1195.84 67.6 999999999 1071.13 1715.93 percent of total billed charges ***BLANKET PER MEGAN P 05/19/2023*** MENISCAL CINCH AR-4500 48712792_1 CDM 0272 RC inpatient 1769 1149.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1071.13 1715.93 ***BLANKET PER MEGAN P 05/19/2023*** MENISCAL CINCH AR-4500 48712792_1 CDM 0272 RC inpatient 1769 1149.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1071.13 1715.93 KNOT PUSHER/CUTTER AR-4515 48712793_1 CDM 0272 RC inpatient 777 505.05 AETNA AETNA 613.83 79 999999999 470.47 753.69 percent of total billed charges KNOT PUSHER/CUTTER AR-4515 48712793_1 CDM 0272 RC inpatient 777 505.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 505.05 65 999999999 470.47 753.69 percent of total billed charges KNOT PUSHER/CUTTER AR-4515 48712793_1 CDM 0272 RC inpatient 777 505.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 753.69 97 999999999 470.47 753.69 percent of total billed charges KNOT PUSHER/CUTTER AR-4515 48712793_1 CDM 0272 RC inpatient 777 505.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 606.06 78 999999999 470.47 753.69 percent of total billed charges KNOT PUSHER/CUTTER AR-4515 48712793_1 CDM 0272 RC inpatient 777 505.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 536.13 69 999999999 470.47 753.69 percent of total billed charges KNOT PUSHER/CUTTER AR-4515 48712793_1 CDM 0272 RC inpatient 777 505.05 UMR - ALL PLANS UMR - ALL PLANS 543.9 70 999999999 470.47 753.69 percent of total billed charges KNOT PUSHER/CUTTER AR-4515 48712793_1 CDM 0272 RC inpatient 777 505.05 SIHO - ALL PLANS SIHO - ALL PLANS 699.3 90 999999999 470.47 753.69 percent of total billed charges KNOT PUSHER/CUTTER AR-4515 48712793_1 CDM 0272 RC inpatient 777 505.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 470.47 60.55 999999999 470.47 753.69 percent of total billed charges KNOT PUSHER/CUTTER AR-4515 48712793_1 CDM 0272 RC inpatient 777 505.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 470.47 753.69 KNOT PUSHER/CUTTER AR-4515 48712793_1 CDM 0272 RC inpatient 777 505.05 ANTHEM HMO ANTHEM HMO 999999999 470.47 753.69 KNOT PUSHER/CUTTER AR-4515 48712793_1 CDM 0272 RC inpatient 777 505.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 470.47 753.69 KNOT PUSHER/CUTTER AR-4515 48712793_1 CDM 0272 RC inpatient 777 505.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 525.25 67.6 999999999 470.47 753.69 percent of total billed charges KNOT PUSHER/CUTTER AR-4515 48712793_1 CDM 0272 RC inpatient 777 505.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 470.47 753.69 KNOT PUSHER/CUTTER AR-4515 48712793_1 CDM 0272 RC inpatient 777 505.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 470.47 753.69 LIGHT WAND BATTERY 3950 10\CSE 48712796_1 CDM 0272 RC inpatient 189 122.85 AETNA AETNA 149.31 79 999999999 114.44 183.33 percent of total billed charges LIGHT WAND BATTERY 3950 10\CSE 48712796_1 CDM 0272 RC inpatient 189 122.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.85 65 999999999 114.44 183.33 percent of total billed charges LIGHT WAND BATTERY 3950 10\CSE 48712796_1 CDM 0272 RC inpatient 189 122.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 183.33 97 999999999 114.44 183.33 percent of total billed charges LIGHT WAND BATTERY 3950 10\CSE 48712796_1 CDM 0272 RC inpatient 189 122.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 147.42 78 999999999 114.44 183.33 percent of total billed charges LIGHT WAND BATTERY 3950 10\CSE 48712796_1 CDM 0272 RC inpatient 189 122.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 130.41 69 999999999 114.44 183.33 percent of total billed charges LIGHT WAND BATTERY 3950 10\CSE 48712796_1 CDM 0272 RC inpatient 189 122.85 UMR - ALL PLANS UMR - ALL PLANS 132.3 70 999999999 114.44 183.33 percent of total billed charges LIGHT WAND BATTERY 3950 10\CSE 48712796_1 CDM 0272 RC inpatient 189 122.85 SIHO - ALL PLANS SIHO - ALL PLANS 170.1 90 999999999 114.44 183.33 percent of total billed charges LIGHT WAND BATTERY 3950 10\CSE 48712796_1 CDM 0272 RC inpatient 189 122.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 114.44 60.55 999999999 114.44 183.33 percent of total billed charges LIGHT WAND BATTERY 3950 10\CSE 48712796_1 CDM 0272 RC inpatient 189 122.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 114.44 183.33 LIGHT WAND BATTERY 3950 10\CSE 48712796_1 CDM 0272 RC inpatient 189 122.85 ANTHEM HMO ANTHEM HMO 999999999 114.44 183.33 LIGHT WAND BATTERY 3950 10\CSE 48712796_1 CDM 0272 RC inpatient 189 122.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 114.44 183.33 LIGHT WAND BATTERY 3950 10\CSE 48712796_1 CDM 0272 RC inpatient 189 122.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.76 67.6 999999999 114.44 183.33 percent of total billed charges LIGHT WAND BATTERY 3950 10\CSE 48712796_1 CDM 0272 RC inpatient 189 122.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 114.44 183.33 LIGHT WAND BATTERY 3950 10\CSE 48712796_1 CDM 0272 RC inpatient 189 122.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 114.44 183.33 LIGHTWAND STYLET 3910VS 20/BX 48712797_1 CDM 0272 RC inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges LIGHTWAND STYLET 3910VS 20/BX 48712797_1 CDM 0272 RC inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges LIGHTWAND STYLET 3910VS 20/BX 48712797_1 CDM 0272 RC inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges LIGHTWAND STYLET 3910VS 20/BX 48712797_1 CDM 0272 RC inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges LIGHTWAND STYLET 3910VS 20/BX 48712797_1 CDM 0272 RC inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges LIGHTWAND STYLET 3910VS 20/BX 48712797_1 CDM 0272 RC inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges LIGHTWAND STYLET 3910VS 20/BX 48712797_1 CDM 0272 RC inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges LIGHTWAND STYLET 3910VS 20/BX 48712797_1 CDM 0272 RC inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges LIGHTWAND STYLET 3910VS 20/BX 48712797_1 CDM 0272 RC inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 LIGHTWAND STYLET 3910VS 20/BX 48712797_1 CDM 0272 RC inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 LIGHTWAND STYLET 3910VS 20/BX 48712797_1 CDM 0272 RC inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 LIGHTWAND STYLET 3910VS 20/BX 48712797_1 CDM 0272 RC inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges LIGHTWAND STYLET 3910VS 20/BX 48712797_1 CDM 0272 RC inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 LIGHTWAND STYLET 3910VS 20/BX 48712797_1 CDM 0272 RC inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 STRYKEFLOW IRRIG 250-070-500 48712799_1 CDM 0272 RC inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges STRYKEFLOW IRRIG 250-070-500 48712799_1 CDM 0272 RC inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges STRYKEFLOW IRRIG 250-070-500 48712799_1 CDM 0272 RC inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges STRYKEFLOW IRRIG 250-070-500 48712799_1 CDM 0272 RC inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges STRYKEFLOW IRRIG 250-070-500 48712799_1 CDM 0272 RC inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges STRYKEFLOW IRRIG 250-070-500 48712799_1 CDM 0272 RC inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges STRYKEFLOW IRRIG 250-070-500 48712799_1 CDM 0272 RC inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges STRYKEFLOW IRRIG 250-070-500 48712799_1 CDM 0272 RC inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges STRYKEFLOW IRRIG 250-070-500 48712799_1 CDM 0272 RC inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 STRYKEFLOW IRRIG 250-070-500 48712799_1 CDM 0272 RC inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 STRYKEFLOW IRRIG 250-070-500 48712799_1 CDM 0272 RC inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 STRYKEFLOW IRRIG 250-070-500 48712799_1 CDM 0272 RC inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges STRYKEFLOW IRRIG 250-070-500 48712799_1 CDM 0272 RC inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 STRYKEFLOW IRRIG 250-070-500 48712799_1 CDM 0272 RC inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 SUCTION LECTRO VAC COAGULATOR E3310 48712802_1 CDM 0272 RC inpatient 98 63.7 AETNA AETNA 77.42 79 999999999 59.34 95.06 percent of total billed charges SUCTION LECTRO VAC COAGULATOR E3310 48712802_1 CDM 0272 RC inpatient 98 63.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.7 65 999999999 59.34 95.06 percent of total billed charges SUCTION LECTRO VAC COAGULATOR E3310 48712802_1 CDM 0272 RC inpatient 98 63.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.06 97 999999999 59.34 95.06 percent of total billed charges SUCTION LECTRO VAC COAGULATOR E3310 48712802_1 CDM 0272 RC inpatient 98 63.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.44 78 999999999 59.34 95.06 percent of total billed charges SUCTION LECTRO VAC COAGULATOR E3310 48712802_1 CDM 0272 RC inpatient 98 63.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.62 69 999999999 59.34 95.06 percent of total billed charges SUCTION LECTRO VAC COAGULATOR E3310 48712802_1 CDM 0272 RC inpatient 98 63.7 UMR - ALL PLANS UMR - ALL PLANS 68.6 70 999999999 59.34 95.06 percent of total billed charges SUCTION LECTRO VAC COAGULATOR E3310 48712802_1 CDM 0272 RC inpatient 98 63.7 SIHO - ALL PLANS SIHO - ALL PLANS 88.2 90 999999999 59.34 95.06 percent of total billed charges SUCTION LECTRO VAC COAGULATOR E3310 48712802_1 CDM 0272 RC inpatient 98 63.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.34 60.55 999999999 59.34 95.06 percent of total billed charges SUCTION LECTRO VAC COAGULATOR E3310 48712802_1 CDM 0272 RC inpatient 98 63.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.34 95.06 SUCTION LECTRO VAC COAGULATOR E3310 48712802_1 CDM 0272 RC inpatient 98 63.7 ANTHEM HMO ANTHEM HMO 999999999 59.34 95.06 SUCTION LECTRO VAC COAGULATOR E3310 48712802_1 CDM 0272 RC inpatient 98 63.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.34 95.06 SUCTION LECTRO VAC COAGULATOR E3310 48712802_1 CDM 0272 RC inpatient 98 63.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.25 67.6 999999999 59.34 95.06 percent of total billed charges SUCTION LECTRO VAC COAGULATOR E3310 48712802_1 CDM 0272 RC inpatient 98 63.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.34 95.06 SUCTION LECTRO VAC COAGULATOR E3310 48712802_1 CDM 0272 RC inpatient 98 63.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.34 95.06 JACKSON PRATT SUCT SU130-1305 48712803_1 CDM 0271 RC inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges JACKSON PRATT SUCT SU130-1305 48712803_1 CDM 0271 RC inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges JACKSON PRATT SUCT SU130-1305 48712803_1 CDM 0271 RC inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges JACKSON PRATT SUCT SU130-1305 48712803_1 CDM 0271 RC inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges JACKSON PRATT SUCT SU130-1305 48712803_1 CDM 0271 RC inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges JACKSON PRATT SUCT SU130-1305 48712803_1 CDM 0271 RC inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges JACKSON PRATT SUCT SU130-1305 48712803_1 CDM 0271 RC inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges JACKSON PRATT SUCT SU130-1305 48712803_1 CDM 0271 RC inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges JACKSON PRATT SUCT SU130-1305 48712803_1 CDM 0271 RC inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 JACKSON PRATT SUCT SU130-1305 48712803_1 CDM 0271 RC inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 JACKSON PRATT SUCT SU130-1305 48712803_1 CDM 0271 RC inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 JACKSON PRATT SUCT SU130-1305 48712803_1 CDM 0271 RC inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges JACKSON PRATT SUCT SU130-1305 48712803_1 CDM 0271 RC inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 JACKSON PRATT SUCT SU130-1305 48712803_1 CDM 0271 RC inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 SURGINEEDLE 14G X 120MM 172015 48712804_1 CDM 0272 RC inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges SURGINEEDLE 14G X 120MM 172015 48712804_1 CDM 0272 RC inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges SURGINEEDLE 14G X 120MM 172015 48712804_1 CDM 0272 RC inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges SURGINEEDLE 14G X 120MM 172015 48712804_1 CDM 0272 RC inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges SURGINEEDLE 14G X 120MM 172015 48712804_1 CDM 0272 RC inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges SURGINEEDLE 14G X 120MM 172015 48712804_1 CDM 0272 RC inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges SURGINEEDLE 14G X 120MM 172015 48712804_1 CDM 0272 RC inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges SURGINEEDLE 14G X 120MM 172015 48712804_1 CDM 0272 RC inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges SURGINEEDLE 14G X 120MM 172015 48712804_1 CDM 0272 RC inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 SURGINEEDLE 14G X 120MM 172015 48712804_1 CDM 0272 RC inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 SURGINEEDLE 14G X 120MM 172015 48712804_1 CDM 0272 RC inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 SURGINEEDLE 14G X 120MM 172015 48712804_1 CDM 0272 RC inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges SURGINEEDLE 14G X 120MM 172015 48712804_1 CDM 0272 RC inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 SURGINEEDLE 14G X 120MM 172015 48712804_1 CDM 0272 RC inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 SURGICAL PATTIES 1/2 X 3 801407 48712806_1 CDM 0272 RC inpatient 11 7.15 AETNA AETNA 8.69 79 999999999 6.66 10.67 percent of total billed charges SURGICAL PATTIES 1/2 X 3 801407 48712806_1 CDM 0272 RC inpatient 11 7.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.15 65 999999999 6.66 10.67 percent of total billed charges SURGICAL PATTIES 1/2 X 3 801407 48712806_1 CDM 0272 RC inpatient 11 7.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10.67 97 999999999 6.66 10.67 percent of total billed charges SURGICAL PATTIES 1/2 X 3 801407 48712806_1 CDM 0272 RC inpatient 11 7.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 8.58 78 999999999 6.66 10.67 percent of total billed charges SURGICAL PATTIES 1/2 X 3 801407 48712806_1 CDM 0272 RC inpatient 11 7.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.59 69 999999999 6.66 10.67 percent of total billed charges SURGICAL PATTIES 1/2 X 3 801407 48712806_1 CDM 0272 RC inpatient 11 7.15 UMR - ALL PLANS UMR - ALL PLANS 7.7 70 999999999 6.66 10.67 percent of total billed charges SURGICAL PATTIES 1/2 X 3 801407 48712806_1 CDM 0272 RC inpatient 11 7.15 SIHO - ALL PLANS SIHO - ALL PLANS 9.9 90 999999999 6.66 10.67 percent of total billed charges SURGICAL PATTIES 1/2 X 3 801407 48712806_1 CDM 0272 RC inpatient 11 7.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.66 60.55 999999999 6.66 10.67 percent of total billed charges SURGICAL PATTIES 1/2 X 3 801407 48712806_1 CDM 0272 RC inpatient 11 7.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.66 10.67 SURGICAL PATTIES 1/2 X 3 801407 48712806_1 CDM 0272 RC inpatient 11 7.15 ANTHEM HMO ANTHEM HMO 999999999 6.66 10.67 SURGICAL PATTIES 1/2 X 3 801407 48712806_1 CDM 0272 RC inpatient 11 7.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.66 10.67 SURGICAL PATTIES 1/2 X 3 801407 48712806_1 CDM 0272 RC inpatient 11 7.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 7.44 67.6 999999999 6.66 10.67 percent of total billed charges SURGICAL PATTIES 1/2 X 3 801407 48712806_1 CDM 0272 RC inpatient 11 7.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.66 10.67 SURGICAL PATTIES 1/2 X 3 801407 48712806_1 CDM 0272 RC inpatient 11 7.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.66 10.67 SURGINEEDLE 150MM #172016 48712807_1 CDM 0272 RC inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges SURGINEEDLE 150MM #172016 48712807_1 CDM 0272 RC inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges SURGINEEDLE 150MM #172016 48712807_1 CDM 0272 RC inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges SURGINEEDLE 150MM #172016 48712807_1 CDM 0272 RC inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges SURGINEEDLE 150MM #172016 48712807_1 CDM 0272 RC inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges SURGINEEDLE 150MM #172016 48712807_1 CDM 0272 RC inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges SURGINEEDLE 150MM #172016 48712807_1 CDM 0272 RC inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges SURGINEEDLE 150MM #172016 48712807_1 CDM 0272 RC inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges SURGINEEDLE 150MM #172016 48712807_1 CDM 0272 RC inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 SURGINEEDLE 150MM #172016 48712807_1 CDM 0272 RC inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 SURGINEEDLE 150MM #172016 48712807_1 CDM 0272 RC inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 SURGINEEDLE 150MM #172016 48712807_1 CDM 0272 RC inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges SURGINEEDLE 150MM #172016 48712807_1 CDM 0272 RC inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 SURGINEEDLE 150MM #172016 48712807_1 CDM 0272 RC inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 BRACE ANKLE AIR-STIRRUP ORT27220 48712808_1 CDM 0270 RC inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges BRACE ANKLE AIR-STIRRUP ORT27220 48712808_1 CDM 0270 RC inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges BRACE ANKLE AIR-STIRRUP ORT27220 48712808_1 CDM 0270 RC inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges BRACE ANKLE AIR-STIRRUP ORT27220 48712808_1 CDM 0270 RC inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges BRACE ANKLE AIR-STIRRUP ORT27220 48712808_1 CDM 0270 RC inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges BRACE ANKLE AIR-STIRRUP ORT27220 48712808_1 CDM 0270 RC inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges BRACE ANKLE AIR-STIRRUP ORT27220 48712808_1 CDM 0270 RC inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges BRACE ANKLE AIR-STIRRUP ORT27220 48712808_1 CDM 0270 RC inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges BRACE ANKLE AIR-STIRRUP ORT27220 48712808_1 CDM 0270 RC inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 BRACE ANKLE AIR-STIRRUP ORT27220 48712808_1 CDM 0270 RC inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 BRACE ANKLE AIR-STIRRUP ORT27220 48712808_1 CDM 0270 RC inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 BRACE ANKLE AIR-STIRRUP ORT27220 48712808_1 CDM 0270 RC inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges BRACE ANKLE AIR-STIRRUP ORT27220 48712808_1 CDM 0270 RC inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 BRACE ANKLE AIR-STIRRUP ORT27220 48712808_1 CDM 0270 RC inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 "HEMOSTAT SURGICEL 2""X14 001951" 48712809_1 CDM 0272 RC inpatient 365 237.25 AETNA AETNA 288.35 79 999999999 221.01 354.05 percent of total billed charges "HEMOSTAT SURGICEL 2""X14 001951" 48712809_1 CDM 0272 RC inpatient 365 237.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 237.25 65 999999999 221.01 354.05 percent of total billed charges "HEMOSTAT SURGICEL 2""X14 001951" 48712809_1 CDM 0272 RC inpatient 365 237.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 354.05 97 999999999 221.01 354.05 percent of total billed charges "HEMOSTAT SURGICEL 2""X14 001951" 48712809_1 CDM 0272 RC inpatient 365 237.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 284.7 78 999999999 221.01 354.05 percent of total billed charges "HEMOSTAT SURGICEL 2""X14 001951" 48712809_1 CDM 0272 RC inpatient 365 237.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 251.85 69 999999999 221.01 354.05 percent of total billed charges "HEMOSTAT SURGICEL 2""X14 001951" 48712809_1 CDM 0272 RC inpatient 365 237.25 UMR - ALL PLANS UMR - ALL PLANS 255.5 70 999999999 221.01 354.05 percent of total billed charges "HEMOSTAT SURGICEL 2""X14 001951" 48712809_1 CDM 0272 RC inpatient 365 237.25 SIHO - ALL PLANS SIHO - ALL PLANS 328.5 90 999999999 221.01 354.05 percent of total billed charges "HEMOSTAT SURGICEL 2""X14 001951" 48712809_1 CDM 0272 RC inpatient 365 237.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 221.01 60.55 999999999 221.01 354.05 percent of total billed charges "HEMOSTAT SURGICEL 2""X14 001951" 48712809_1 CDM 0272 RC inpatient 365 237.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 221.01 354.05 "HEMOSTAT SURGICEL 2""X14 001951" 48712809_1 CDM 0272 RC inpatient 365 237.25 ANTHEM HMO ANTHEM HMO 999999999 221.01 354.05 "HEMOSTAT SURGICEL 2""X14 001951" 48712809_1 CDM 0272 RC inpatient 365 237.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 221.01 354.05 "HEMOSTAT SURGICEL 2""X14 001951" 48712809_1 CDM 0272 RC inpatient 365 237.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 246.74 67.6 999999999 221.01 354.05 percent of total billed charges "HEMOSTAT SURGICEL 2""X14 001951" 48712809_1 CDM 0272 RC inpatient 365 237.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 221.01 354.05 "HEMOSTAT SURGICEL 2""X14 001951" 48712809_1 CDM 0272 RC inpatient 365 237.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 221.01 354.05 SUTURE ENDO-STITCH #173023 48712810_1 CDM 0272 RC inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges SUTURE ENDO-STITCH #173023 48712810_1 CDM 0272 RC inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges SUTURE ENDO-STITCH #173023 48712810_1 CDM 0272 RC inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges SUTURE ENDO-STITCH #173023 48712810_1 CDM 0272 RC inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges SUTURE ENDO-STITCH #173023 48712810_1 CDM 0272 RC inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges SUTURE ENDO-STITCH #173023 48712810_1 CDM 0272 RC inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges SUTURE ENDO-STITCH #173023 48712810_1 CDM 0272 RC inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges SUTURE ENDO-STITCH #173023 48712810_1 CDM 0272 RC inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges SUTURE ENDO-STITCH #173023 48712810_1 CDM 0272 RC inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 SUTURE ENDO-STITCH #173023 48712810_1 CDM 0272 RC inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 SUTURE ENDO-STITCH #173023 48712810_1 CDM 0272 RC inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 SUTURE ENDO-STITCH #173023 48712810_1 CDM 0272 RC inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges SUTURE ENDO-STITCH #173023 48712810_1 CDM 0272 RC inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 SUTURE ENDO-STITCH #173023 48712810_1 CDM 0272 RC inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 STAPLER SKIN APPOSE WIDE ULC35 8886803712 48712811_1 CDM 0272 RC inpatient 42 27.3 AETNA AETNA 33.18 79 999999999 25.43 40.74 percent of total billed charges STAPLER SKIN APPOSE WIDE ULC35 8886803712 48712811_1 CDM 0272 RC inpatient 42 27.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 27.3 65 999999999 25.43 40.74 percent of total billed charges STAPLER SKIN APPOSE WIDE ULC35 8886803712 48712811_1 CDM 0272 RC inpatient 42 27.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 40.74 97 999999999 25.43 40.74 percent of total billed charges STAPLER SKIN APPOSE WIDE ULC35 8886803712 48712811_1 CDM 0272 RC inpatient 42 27.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 32.76 78 999999999 25.43 40.74 percent of total billed charges STAPLER SKIN APPOSE WIDE ULC35 8886803712 48712811_1 CDM 0272 RC inpatient 42 27.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.98 69 999999999 25.43 40.74 percent of total billed charges STAPLER SKIN APPOSE WIDE ULC35 8886803712 48712811_1 CDM 0272 RC inpatient 42 27.3 UMR - ALL PLANS UMR - ALL PLANS 29.4 70 999999999 25.43 40.74 percent of total billed charges STAPLER SKIN APPOSE WIDE ULC35 8886803712 48712811_1 CDM 0272 RC inpatient 42 27.3 SIHO - ALL PLANS SIHO - ALL PLANS 37.8 90 999999999 25.43 40.74 percent of total billed charges STAPLER SKIN APPOSE WIDE ULC35 8886803712 48712811_1 CDM 0272 RC inpatient 42 27.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 25.43 60.55 999999999 25.43 40.74 percent of total billed charges STAPLER SKIN APPOSE WIDE ULC35 8886803712 48712811_1 CDM 0272 RC inpatient 42 27.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 25.43 40.74 STAPLER SKIN APPOSE WIDE ULC35 8886803712 48712811_1 CDM 0272 RC inpatient 42 27.3 ANTHEM HMO ANTHEM HMO 999999999 25.43 40.74 STAPLER SKIN APPOSE WIDE ULC35 8886803712 48712811_1 CDM 0272 RC inpatient 42 27.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 25.43 40.74 STAPLER SKIN APPOSE WIDE ULC35 8886803712 48712811_1 CDM 0272 RC inpatient 42 27.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 28.39 67.6 999999999 25.43 40.74 percent of total billed charges STAPLER SKIN APPOSE WIDE ULC35 8886803712 48712811_1 CDM 0272 RC inpatient 42 27.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 25.43 40.74 STAPLER SKIN APPOSE WIDE ULC35 8886803712 48712811_1 CDM 0272 RC inpatient 42 27.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 25.43 40.74 ENDO STITCH INSTRUMENT #173016 48712812_1 CDM 0272 RC inpatient 760 494 AETNA AETNA 600.4 79 999999999 460.18 737.2 percent of total billed charges ENDO STITCH INSTRUMENT #173016 48712812_1 CDM 0272 RC inpatient 760 494 SELF PAY DISCOUNT SELF PAY DISCOUNT 494 65 999999999 460.18 737.2 percent of total billed charges ENDO STITCH INSTRUMENT #173016 48712812_1 CDM 0272 RC inpatient 760 494 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 737.2 97 999999999 460.18 737.2 percent of total billed charges ENDO STITCH INSTRUMENT #173016 48712812_1 CDM 0272 RC inpatient 760 494 HUMANA - ALL PLANS HUMANA - ALL PLANS 592.8 78 999999999 460.18 737.2 percent of total billed charges ENDO STITCH INSTRUMENT #173016 48712812_1 CDM 0272 RC inpatient 760 494 ENCORE - ALL PLANS ENCORE - ALL PLANS 524.4 69 999999999 460.18 737.2 percent of total billed charges ENDO STITCH INSTRUMENT #173016 48712812_1 CDM 0272 RC inpatient 760 494 UMR - ALL PLANS UMR - ALL PLANS 532 70 999999999 460.18 737.2 percent of total billed charges ENDO STITCH INSTRUMENT #173016 48712812_1 CDM 0272 RC inpatient 760 494 SIHO - ALL PLANS SIHO - ALL PLANS 684 90 999999999 460.18 737.2 percent of total billed charges ENDO STITCH INSTRUMENT #173016 48712812_1 CDM 0272 RC inpatient 760 494 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 460.18 60.55 999999999 460.18 737.2 percent of total billed charges ENDO STITCH INSTRUMENT #173016 48712812_1 CDM 0272 RC inpatient 760 494 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 460.18 737.2 ENDO STITCH INSTRUMENT #173016 48712812_1 CDM 0272 RC inpatient 760 494 ANTHEM HMO ANTHEM HMO 999999999 460.18 737.2 ENDO STITCH INSTRUMENT #173016 48712812_1 CDM 0272 RC inpatient 760 494 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 460.18 737.2 ENDO STITCH INSTRUMENT #173016 48712812_1 CDM 0272 RC inpatient 760 494 CIGNA - ALL PLANS CIGNA - ALL PLANS 513.76 67.6 999999999 460.18 737.2 percent of total billed charges ENDO STITCH INSTRUMENT #173016 48712812_1 CDM 0272 RC inpatient 760 494 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 460.18 737.2 ENDO STITCH INSTRUMENT #173016 48712812_1 CDM 0272 RC inpatient 760 494 UHC - ALL PLANS UHC - ALL PLANS 999999999 460.18 737.2 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712814_1 CDM 0278 RC C1713 HCPCS inpatient 3072 1996.8 AETNA AETNA 2426.88 79 999999999 1860.1 2979.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712814_1 CDM 0278 RC C1713 HCPCS inpatient 3072 1996.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1996.8 65 999999999 1860.1 2979.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712814_1 CDM 0278 RC C1713 HCPCS inpatient 3072 1996.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2979.84 97 999999999 1860.1 2979.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712814_1 CDM 0278 RC C1713 HCPCS inpatient 3072 1996.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 2396.16 78 999999999 1860.1 2979.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712814_1 CDM 0278 RC C1713 HCPCS inpatient 3072 1996.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 2119.68 69 999999999 1860.1 2979.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712814_1 CDM 0278 RC C1713 HCPCS inpatient 3072 1996.8 UMR - ALL PLANS UMR - ALL PLANS 2150.4 70 999999999 1860.1 2979.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712814_1 CDM 0278 RC C1713 HCPCS inpatient 3072 1996.8 SIHO - ALL PLANS SIHO - ALL PLANS 2764.8 90 999999999 1860.1 2979.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712814_1 CDM 0278 RC C1713 HCPCS inpatient 3072 1996.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1860.1 60.55 999999999 1860.1 2979.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712814_1 CDM 0278 RC C1713 HCPCS inpatient 3072 1996.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1860.1 2979.84 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712814_1 CDM 0278 RC C1713 HCPCS inpatient 3072 1996.8 ANTHEM HMO ANTHEM HMO 999999999 1860.1 2979.84 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712814_1 CDM 0278 RC C1713 HCPCS inpatient 3072 1996.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1860.1 2979.84 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712814_1 CDM 0278 RC C1713 HCPCS inpatient 3072 1996.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 2076.67 67.6 999999999 1860.1 2979.84 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712814_1 CDM 0278 RC C1713 HCPCS inpatient 3072 1996.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1860.1 2979.84 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712814_1 CDM 0278 RC C1713 HCPCS inpatient 3072 1996.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1860.1 2979.84 JOINT DEVICE (IMPLANTABLE) 48712815_1 CDM 0278 RC C1776 HCPCS inpatient 4854 3155.1 AETNA AETNA 3834.66 79 999999999 2939.1 4708.38 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 48712815_1 CDM 0278 RC C1776 HCPCS inpatient 4854 3155.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 3155.1 65 999999999 2939.1 4708.38 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 48712815_1 CDM 0278 RC C1776 HCPCS inpatient 4854 3155.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4708.38 97 999999999 2939.1 4708.38 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 48712815_1 CDM 0278 RC C1776 HCPCS inpatient 4854 3155.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 3786.12 78 999999999 2939.1 4708.38 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 48712815_1 CDM 0278 RC C1776 HCPCS inpatient 4854 3155.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 3349.26 69 999999999 2939.1 4708.38 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 48712815_1 CDM 0278 RC C1776 HCPCS inpatient 4854 3155.1 UMR - ALL PLANS UMR - ALL PLANS 3397.8 70 999999999 2939.1 4708.38 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 48712815_1 CDM 0278 RC C1776 HCPCS inpatient 4854 3155.1 SIHO - ALL PLANS SIHO - ALL PLANS 4368.6 90 999999999 2939.1 4708.38 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 48712815_1 CDM 0278 RC C1776 HCPCS inpatient 4854 3155.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2939.1 60.55 999999999 2939.1 4708.38 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 48712815_1 CDM 0278 RC C1776 HCPCS inpatient 4854 3155.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2939.1 4708.38 JOINT DEVICE (IMPLANTABLE) 48712815_1 CDM 0278 RC C1776 HCPCS inpatient 4854 3155.1 ANTHEM HMO ANTHEM HMO 999999999 2939.1 4708.38 JOINT DEVICE (IMPLANTABLE) 48712815_1 CDM 0278 RC C1776 HCPCS inpatient 4854 3155.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2939.1 4708.38 JOINT DEVICE (IMPLANTABLE) 48712815_1 CDM 0278 RC C1776 HCPCS inpatient 4854 3155.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 3281.3 67.6 999999999 2939.1 4708.38 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 48712815_1 CDM 0278 RC C1776 HCPCS inpatient 4854 3155.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2939.1 4708.38 JOINT DEVICE (IMPLANTABLE) 48712815_1 CDM 0278 RC C1776 HCPCS inpatient 4854 3155.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 2939.1 4708.38 SUTURE ANCHOR SWIVELOCK 48712816_1 CDM 0272 RC inpatient 2483 1613.95 AETNA AETNA 1961.57 79 999999999 1503.46 2408.51 percent of total billed charges SUTURE ANCHOR SWIVELOCK 48712816_1 CDM 0272 RC inpatient 2483 1613.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1613.95 65 999999999 1503.46 2408.51 percent of total billed charges SUTURE ANCHOR SWIVELOCK 48712816_1 CDM 0272 RC inpatient 2483 1613.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2408.51 97 999999999 1503.46 2408.51 percent of total billed charges SUTURE ANCHOR SWIVELOCK 48712816_1 CDM 0272 RC inpatient 2483 1613.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1936.74 78 999999999 1503.46 2408.51 percent of total billed charges SUTURE ANCHOR SWIVELOCK 48712816_1 CDM 0272 RC inpatient 2483 1613.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1713.27 69 999999999 1503.46 2408.51 percent of total billed charges SUTURE ANCHOR SWIVELOCK 48712816_1 CDM 0272 RC inpatient 2483 1613.95 UMR - ALL PLANS UMR - ALL PLANS 1738.1 70 999999999 1503.46 2408.51 percent of total billed charges SUTURE ANCHOR SWIVELOCK 48712816_1 CDM 0272 RC inpatient 2483 1613.95 SIHO - ALL PLANS SIHO - ALL PLANS 2234.7 90 999999999 1503.46 2408.51 percent of total billed charges SUTURE ANCHOR SWIVELOCK 48712816_1 CDM 0272 RC inpatient 2483 1613.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1503.46 60.55 999999999 1503.46 2408.51 percent of total billed charges SUTURE ANCHOR SWIVELOCK 48712816_1 CDM 0272 RC inpatient 2483 1613.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1503.46 2408.51 SUTURE ANCHOR SWIVELOCK 48712816_1 CDM 0272 RC inpatient 2483 1613.95 ANTHEM HMO ANTHEM HMO 999999999 1503.46 2408.51 SUTURE ANCHOR SWIVELOCK 48712816_1 CDM 0272 RC inpatient 2483 1613.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1503.46 2408.51 SUTURE ANCHOR SWIVELOCK 48712816_1 CDM 0272 RC inpatient 2483 1613.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1678.51 67.6 999999999 1503.46 2408.51 percent of total billed charges SUTURE ANCHOR SWIVELOCK 48712816_1 CDM 0272 RC inpatient 2483 1613.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1503.46 2408.51 SUTURE ANCHOR SWIVELOCK 48712816_1 CDM 0272 RC inpatient 2483 1613.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1503.46 2408.51 DIAPER BARIATRIC XXXL ATTENDS 48712817_1 CDM 0270 RC inpatient 108 70.2 AETNA AETNA 85.32 79 999999999 65.39 104.76 percent of total billed charges DIAPER BARIATRIC XXXL ATTENDS 48712817_1 CDM 0270 RC inpatient 108 70.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.2 65 999999999 65.39 104.76 percent of total billed charges DIAPER BARIATRIC XXXL ATTENDS 48712817_1 CDM 0270 RC inpatient 108 70.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 104.76 97 999999999 65.39 104.76 percent of total billed charges DIAPER BARIATRIC XXXL ATTENDS 48712817_1 CDM 0270 RC inpatient 108 70.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 84.24 78 999999999 65.39 104.76 percent of total billed charges DIAPER BARIATRIC XXXL ATTENDS 48712817_1 CDM 0270 RC inpatient 108 70.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 74.52 69 999999999 65.39 104.76 percent of total billed charges DIAPER BARIATRIC XXXL ATTENDS 48712817_1 CDM 0270 RC inpatient 108 70.2 UMR - ALL PLANS UMR - ALL PLANS 75.6 70 999999999 65.39 104.76 percent of total billed charges DIAPER BARIATRIC XXXL ATTENDS 48712817_1 CDM 0270 RC inpatient 108 70.2 SIHO - ALL PLANS SIHO - ALL PLANS 97.2 90 999999999 65.39 104.76 percent of total billed charges DIAPER BARIATRIC XXXL ATTENDS 48712817_1 CDM 0270 RC inpatient 108 70.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 65.39 60.55 999999999 65.39 104.76 percent of total billed charges DIAPER BARIATRIC XXXL ATTENDS 48712817_1 CDM 0270 RC inpatient 108 70.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 65.39 104.76 DIAPER BARIATRIC XXXL ATTENDS 48712817_1 CDM 0270 RC inpatient 108 70.2 ANTHEM HMO ANTHEM HMO 999999999 65.39 104.76 DIAPER BARIATRIC XXXL ATTENDS 48712817_1 CDM 0270 RC inpatient 108 70.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 65.39 104.76 DIAPER BARIATRIC XXXL ATTENDS 48712817_1 CDM 0270 RC inpatient 108 70.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.01 67.6 999999999 65.39 104.76 percent of total billed charges DIAPER BARIATRIC XXXL ATTENDS 48712817_1 CDM 0270 RC inpatient 108 70.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 65.39 104.76 DIAPER BARIATRIC XXXL ATTENDS 48712817_1 CDM 0270 RC inpatient 108 70.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 65.39 104.76 SUT AUTO PREM-35W 059037 48712818_1 CDM 0272 RC inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges SUT AUTO PREM-35W 059037 48712818_1 CDM 0272 RC inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges SUT AUTO PREM-35W 059037 48712818_1 CDM 0272 RC inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges SUT AUTO PREM-35W 059037 48712818_1 CDM 0272 RC inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges SUT AUTO PREM-35W 059037 48712818_1 CDM 0272 RC inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges SUT AUTO PREM-35W 059037 48712818_1 CDM 0272 RC inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges SUT AUTO PREM-35W 059037 48712818_1 CDM 0272 RC inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges SUT AUTO PREM-35W 059037 48712818_1 CDM 0272 RC inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges SUT AUTO PREM-35W 059037 48712818_1 CDM 0272 RC inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 SUT AUTO PREM-35W 059037 48712818_1 CDM 0272 RC inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 SUT AUTO PREM-35W 059037 48712818_1 CDM 0272 RC inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 SUT AUTO PREM-35W 059037 48712818_1 CDM 0272 RC inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges SUT AUTO PREM-35W 059037 48712818_1 CDM 0272 RC inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 SUT AUTO PREM-35W 059037 48712818_1 CDM 0272 RC inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 SHAFT MODULAR AO FIT STERILE 48712820_1 CDM 0272 RC inpatient 3060 1989 AETNA AETNA 2417.4 79 999999999 1852.83 2968.2 percent of total billed charges SHAFT MODULAR AO FIT STERILE 48712820_1 CDM 0272 RC inpatient 3060 1989 SELF PAY DISCOUNT SELF PAY DISCOUNT 1989 65 999999999 1852.83 2968.2 percent of total billed charges SHAFT MODULAR AO FIT STERILE 48712820_1 CDM 0272 RC inpatient 3060 1989 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2968.2 97 999999999 1852.83 2968.2 percent of total billed charges SHAFT MODULAR AO FIT STERILE 48712820_1 CDM 0272 RC inpatient 3060 1989 HUMANA - ALL PLANS HUMANA - ALL PLANS 2386.8 78 999999999 1852.83 2968.2 percent of total billed charges SHAFT MODULAR AO FIT STERILE 48712820_1 CDM 0272 RC inpatient 3060 1989 ENCORE - ALL PLANS ENCORE - ALL PLANS 2111.4 69 999999999 1852.83 2968.2 percent of total billed charges SHAFT MODULAR AO FIT STERILE 48712820_1 CDM 0272 RC inpatient 3060 1989 UMR - ALL PLANS UMR - ALL PLANS 2142 70 999999999 1852.83 2968.2 percent of total billed charges SHAFT MODULAR AO FIT STERILE 48712820_1 CDM 0272 RC inpatient 3060 1989 SIHO - ALL PLANS SIHO - ALL PLANS 2754 90 999999999 1852.83 2968.2 percent of total billed charges SHAFT MODULAR AO FIT STERILE 48712820_1 CDM 0272 RC inpatient 3060 1989 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1852.83 60.55 999999999 1852.83 2968.2 percent of total billed charges SHAFT MODULAR AO FIT STERILE 48712820_1 CDM 0272 RC inpatient 3060 1989 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1852.83 2968.2 SHAFT MODULAR AO FIT STERILE 48712820_1 CDM 0272 RC inpatient 3060 1989 ANTHEM HMO ANTHEM HMO 999999999 1852.83 2968.2 SHAFT MODULAR AO FIT STERILE 48712820_1 CDM 0272 RC inpatient 3060 1989 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1852.83 2968.2 SHAFT MODULAR AO FIT STERILE 48712820_1 CDM 0272 RC inpatient 3060 1989 CIGNA - ALL PLANS CIGNA - ALL PLANS 2068.56 67.6 999999999 1852.83 2968.2 percent of total billed charges SHAFT MODULAR AO FIT STERILE 48712820_1 CDM 0272 RC inpatient 3060 1989 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1852.83 2968.2 SHAFT MODULAR AO FIT STERILE 48712820_1 CDM 0272 RC inpatient 3060 1989 UHC - ALL PLANS UHC - ALL PLANS 999999999 1852.83 2968.2 SUTR ETHIBOND 0 CX41D 48712821_1 CDM 0272 RC inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges SUTR ETHIBOND 0 CX41D 48712821_1 CDM 0272 RC inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges SUTR ETHIBOND 0 CX41D 48712821_1 CDM 0272 RC inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges SUTR ETHIBOND 0 CX41D 48712821_1 CDM 0272 RC inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges SUTR ETHIBOND 0 CX41D 48712821_1 CDM 0272 RC inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges SUTR ETHIBOND 0 CX41D 48712821_1 CDM 0272 RC inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges SUTR ETHIBOND 0 CX41D 48712821_1 CDM 0272 RC inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges SUTR ETHIBOND 0 CX41D 48712821_1 CDM 0272 RC inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges SUTR ETHIBOND 0 CX41D 48712821_1 CDM 0272 RC inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 SUTR ETHIBOND 0 CX41D 48712821_1 CDM 0272 RC inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 SUTR ETHIBOND 0 CX41D 48712821_1 CDM 0272 RC inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 SUTR ETHIBOND 0 CX41D 48712821_1 CDM 0272 RC inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges SUTR ETHIBOND 0 CX41D 48712821_1 CDM 0272 RC inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 SUTR ETHIBOND 0 CX41D 48712821_1 CDM 0272 RC inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 SUTURE ETHIBOND #0 CX21D 48712822_1 CDM 0272 RC inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges SUTURE ETHIBOND #0 CX21D 48712822_1 CDM 0272 RC inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges SUTURE ETHIBOND #0 CX21D 48712822_1 CDM 0272 RC inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges SUTURE ETHIBOND #0 CX21D 48712822_1 CDM 0272 RC inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges SUTURE ETHIBOND #0 CX21D 48712822_1 CDM 0272 RC inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges SUTURE ETHIBOND #0 CX21D 48712822_1 CDM 0272 RC inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges SUTURE ETHIBOND #0 CX21D 48712822_1 CDM 0272 RC inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges SUTURE ETHIBOND #0 CX21D 48712822_1 CDM 0272 RC inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges SUTURE ETHIBOND #0 CX21D 48712822_1 CDM 0272 RC inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 SUTURE ETHIBOND #0 CX21D 48712822_1 CDM 0272 RC inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 SUTURE ETHIBOND #0 CX21D 48712822_1 CDM 0272 RC inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 SUTURE ETHIBOND #0 CX21D 48712822_1 CDM 0272 RC inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges SUTURE ETHIBOND #0 CX21D 48712822_1 CDM 0272 RC inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 SUTURE ETHIBOND #0 CX21D 48712822_1 CDM 0272 RC inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 SUTURE ETHIBOND #0 CX27D 48712823_1 CDM 0272 RC inpatient 98 63.7 AETNA AETNA 77.42 79 999999999 59.34 95.06 percent of total billed charges SUTURE ETHIBOND #0 CX27D 48712823_1 CDM 0272 RC inpatient 98 63.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.7 65 999999999 59.34 95.06 percent of total billed charges SUTURE ETHIBOND #0 CX27D 48712823_1 CDM 0272 RC inpatient 98 63.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.06 97 999999999 59.34 95.06 percent of total billed charges SUTURE ETHIBOND #0 CX27D 48712823_1 CDM 0272 RC inpatient 98 63.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.44 78 999999999 59.34 95.06 percent of total billed charges SUTURE ETHIBOND #0 CX27D 48712823_1 CDM 0272 RC inpatient 98 63.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.62 69 999999999 59.34 95.06 percent of total billed charges SUTURE ETHIBOND #0 CX27D 48712823_1 CDM 0272 RC inpatient 98 63.7 UMR - ALL PLANS UMR - ALL PLANS 68.6 70 999999999 59.34 95.06 percent of total billed charges SUTURE ETHIBOND #0 CX27D 48712823_1 CDM 0272 RC inpatient 98 63.7 SIHO - ALL PLANS SIHO - ALL PLANS 88.2 90 999999999 59.34 95.06 percent of total billed charges SUTURE ETHIBOND #0 CX27D 48712823_1 CDM 0272 RC inpatient 98 63.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.34 60.55 999999999 59.34 95.06 percent of total billed charges SUTURE ETHIBOND #0 CX27D 48712823_1 CDM 0272 RC inpatient 98 63.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.34 95.06 SUTURE ETHIBOND #0 CX27D 48712823_1 CDM 0272 RC inpatient 98 63.7 ANTHEM HMO ANTHEM HMO 999999999 59.34 95.06 SUTURE ETHIBOND #0 CX27D 48712823_1 CDM 0272 RC inpatient 98 63.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.34 95.06 SUTURE ETHIBOND #0 CX27D 48712823_1 CDM 0272 RC inpatient 98 63.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.25 67.6 999999999 59.34 95.06 percent of total billed charges SUTURE ETHIBOND #0 CX27D 48712823_1 CDM 0272 RC inpatient 98 63.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.34 95.06 SUTURE ETHIBOND #0 CX27D 48712823_1 CDM 0272 RC inpatient 98 63.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.34 95.06 MESH (IMPLANTABLE) 48712824_1 CDM 0278 RC C1781 HCPCS inpatient 3504 2277.6 AETNA AETNA 2768.16 79 999999999 2121.67 3398.88 percent of total billed charges MESH (IMPLANTABLE) 48712824_1 CDM 0278 RC C1781 HCPCS inpatient 3504 2277.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 2277.6 65 999999999 2121.67 3398.88 percent of total billed charges MESH (IMPLANTABLE) 48712824_1 CDM 0278 RC C1781 HCPCS inpatient 3504 2277.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3398.88 97 999999999 2121.67 3398.88 percent of total billed charges MESH (IMPLANTABLE) 48712824_1 CDM 0278 RC C1781 HCPCS inpatient 3504 2277.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 2733.12 78 999999999 2121.67 3398.88 percent of total billed charges MESH (IMPLANTABLE) 48712824_1 CDM 0278 RC C1781 HCPCS inpatient 3504 2277.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 2417.76 69 999999999 2121.67 3398.88 percent of total billed charges MESH (IMPLANTABLE) 48712824_1 CDM 0278 RC C1781 HCPCS inpatient 3504 2277.6 UMR - ALL PLANS UMR - ALL PLANS 2452.8 70 999999999 2121.67 3398.88 percent of total billed charges MESH (IMPLANTABLE) 48712824_1 CDM 0278 RC C1781 HCPCS inpatient 3504 2277.6 SIHO - ALL PLANS SIHO - ALL PLANS 3153.6 90 999999999 2121.67 3398.88 percent of total billed charges MESH (IMPLANTABLE) 48712824_1 CDM 0278 RC C1781 HCPCS inpatient 3504 2277.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2121.67 60.55 999999999 2121.67 3398.88 percent of total billed charges MESH (IMPLANTABLE) 48712824_1 CDM 0278 RC C1781 HCPCS inpatient 3504 2277.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2121.67 3398.88 MESH (IMPLANTABLE) 48712824_1 CDM 0278 RC C1781 HCPCS inpatient 3504 2277.6 ANTHEM HMO ANTHEM HMO 999999999 2121.67 3398.88 MESH (IMPLANTABLE) 48712824_1 CDM 0278 RC C1781 HCPCS inpatient 3504 2277.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2121.67 3398.88 MESH (IMPLANTABLE) 48712824_1 CDM 0278 RC C1781 HCPCS inpatient 3504 2277.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 2368.7 67.6 999999999 2121.67 3398.88 percent of total billed charges MESH (IMPLANTABLE) 48712824_1 CDM 0278 RC C1781 HCPCS inpatient 3504 2277.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2121.67 3398.88 MESH (IMPLANTABLE) 48712824_1 CDM 0278 RC C1781 HCPCS inpatient 3504 2277.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 2121.67 3398.88 MESH (IMPLANTABLE) 48712825_1 CDM 0278 RC C1781 HCPCS inpatient 1801 1170.65 AETNA AETNA 1422.79 79 999999999 1090.51 1746.97 percent of total billed charges MESH (IMPLANTABLE) 48712825_1 CDM 0278 RC C1781 HCPCS inpatient 1801 1170.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1170.65 65 999999999 1090.51 1746.97 percent of total billed charges MESH (IMPLANTABLE) 48712825_1 CDM 0278 RC C1781 HCPCS inpatient 1801 1170.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1746.97 97 999999999 1090.51 1746.97 percent of total billed charges MESH (IMPLANTABLE) 48712825_1 CDM 0278 RC C1781 HCPCS inpatient 1801 1170.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1404.78 78 999999999 1090.51 1746.97 percent of total billed charges MESH (IMPLANTABLE) 48712825_1 CDM 0278 RC C1781 HCPCS inpatient 1801 1170.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1242.69 69 999999999 1090.51 1746.97 percent of total billed charges MESH (IMPLANTABLE) 48712825_1 CDM 0278 RC C1781 HCPCS inpatient 1801 1170.65 UMR - ALL PLANS UMR - ALL PLANS 1260.7 70 999999999 1090.51 1746.97 percent of total billed charges MESH (IMPLANTABLE) 48712825_1 CDM 0278 RC C1781 HCPCS inpatient 1801 1170.65 SIHO - ALL PLANS SIHO - ALL PLANS 1620.9 90 999999999 1090.51 1746.97 percent of total billed charges MESH (IMPLANTABLE) 48712825_1 CDM 0278 RC C1781 HCPCS inpatient 1801 1170.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1090.51 60.55 999999999 1090.51 1746.97 percent of total billed charges MESH (IMPLANTABLE) 48712825_1 CDM 0278 RC C1781 HCPCS inpatient 1801 1170.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1090.51 1746.97 MESH (IMPLANTABLE) 48712825_1 CDM 0278 RC C1781 HCPCS inpatient 1801 1170.65 ANTHEM HMO ANTHEM HMO 999999999 1090.51 1746.97 MESH (IMPLANTABLE) 48712825_1 CDM 0278 RC C1781 HCPCS inpatient 1801 1170.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1090.51 1746.97 MESH (IMPLANTABLE) 48712825_1 CDM 0278 RC C1781 HCPCS inpatient 1801 1170.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1217.48 67.6 999999999 1090.51 1746.97 percent of total billed charges MESH (IMPLANTABLE) 48712825_1 CDM 0278 RC C1781 HCPCS inpatient 1801 1170.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1090.51 1746.97 MESH (IMPLANTABLE) 48712825_1 CDM 0278 RC C1781 HCPCS inpatient 1801 1170.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1090.51 1746.97 MESH (IMPLANTABLE) 48712826_1 CDM 0278 RC C1781 HCPCS inpatient 2806 1823.9 AETNA AETNA 2216.74 79 999999999 1699.03 2721.82 percent of total billed charges MESH (IMPLANTABLE) 48712826_1 CDM 0278 RC C1781 HCPCS inpatient 2806 1823.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1823.9 65 999999999 1699.03 2721.82 percent of total billed charges MESH (IMPLANTABLE) 48712826_1 CDM 0278 RC C1781 HCPCS inpatient 2806 1823.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2721.82 97 999999999 1699.03 2721.82 percent of total billed charges MESH (IMPLANTABLE) 48712826_1 CDM 0278 RC C1781 HCPCS inpatient 2806 1823.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 2188.68 78 999999999 1699.03 2721.82 percent of total billed charges MESH (IMPLANTABLE) 48712826_1 CDM 0278 RC C1781 HCPCS inpatient 2806 1823.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1936.14 69 999999999 1699.03 2721.82 percent of total billed charges MESH (IMPLANTABLE) 48712826_1 CDM 0278 RC C1781 HCPCS inpatient 2806 1823.9 UMR - ALL PLANS UMR - ALL PLANS 1964.2 70 999999999 1699.03 2721.82 percent of total billed charges MESH (IMPLANTABLE) 48712826_1 CDM 0278 RC C1781 HCPCS inpatient 2806 1823.9 SIHO - ALL PLANS SIHO - ALL PLANS 2525.4 90 999999999 1699.03 2721.82 percent of total billed charges MESH (IMPLANTABLE) 48712826_1 CDM 0278 RC C1781 HCPCS inpatient 2806 1823.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1699.03 60.55 999999999 1699.03 2721.82 percent of total billed charges MESH (IMPLANTABLE) 48712826_1 CDM 0278 RC C1781 HCPCS inpatient 2806 1823.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1699.03 2721.82 MESH (IMPLANTABLE) 48712826_1 CDM 0278 RC C1781 HCPCS inpatient 2806 1823.9 ANTHEM HMO ANTHEM HMO 999999999 1699.03 2721.82 MESH (IMPLANTABLE) 48712826_1 CDM 0278 RC C1781 HCPCS inpatient 2806 1823.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1699.03 2721.82 MESH (IMPLANTABLE) 48712826_1 CDM 0278 RC C1781 HCPCS inpatient 2806 1823.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1896.86 67.6 999999999 1699.03 2721.82 percent of total billed charges MESH (IMPLANTABLE) 48712826_1 CDM 0278 RC C1781 HCPCS inpatient 2806 1823.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1699.03 2721.82 MESH (IMPLANTABLE) 48712826_1 CDM 0278 RC C1781 HCPCS inpatient 2806 1823.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1699.03 2721.82 MESH (IMPLANTABLE) 48712827_1 CDM 0278 RC C1781 HCPCS inpatient 4513 2933.45 AETNA AETNA 3565.27 79 999999999 2732.62 4377.61 percent of total billed charges MESH (IMPLANTABLE) 48712827_1 CDM 0278 RC C1781 HCPCS inpatient 4513 2933.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 2933.45 65 999999999 2732.62 4377.61 percent of total billed charges MESH (IMPLANTABLE) 48712827_1 CDM 0278 RC C1781 HCPCS inpatient 4513 2933.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4377.61 97 999999999 2732.62 4377.61 percent of total billed charges MESH (IMPLANTABLE) 48712827_1 CDM 0278 RC C1781 HCPCS inpatient 4513 2933.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 3520.14 78 999999999 2732.62 4377.61 percent of total billed charges MESH (IMPLANTABLE) 48712827_1 CDM 0278 RC C1781 HCPCS inpatient 4513 2933.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 3113.97 69 999999999 2732.62 4377.61 percent of total billed charges MESH (IMPLANTABLE) 48712827_1 CDM 0278 RC C1781 HCPCS inpatient 4513 2933.45 UMR - ALL PLANS UMR - ALL PLANS 3159.1 70 999999999 2732.62 4377.61 percent of total billed charges MESH (IMPLANTABLE) 48712827_1 CDM 0278 RC C1781 HCPCS inpatient 4513 2933.45 SIHO - ALL PLANS SIHO - ALL PLANS 4061.7 90 999999999 2732.62 4377.61 percent of total billed charges MESH (IMPLANTABLE) 48712827_1 CDM 0278 RC C1781 HCPCS inpatient 4513 2933.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2732.62 60.55 999999999 2732.62 4377.61 percent of total billed charges MESH (IMPLANTABLE) 48712827_1 CDM 0278 RC C1781 HCPCS inpatient 4513 2933.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2732.62 4377.61 MESH (IMPLANTABLE) 48712827_1 CDM 0278 RC C1781 HCPCS inpatient 4513 2933.45 ANTHEM HMO ANTHEM HMO 999999999 2732.62 4377.61 MESH (IMPLANTABLE) 48712827_1 CDM 0278 RC C1781 HCPCS inpatient 4513 2933.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2732.62 4377.61 MESH (IMPLANTABLE) 48712827_1 CDM 0278 RC C1781 HCPCS inpatient 4513 2933.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 3050.79 67.6 999999999 2732.62 4377.61 percent of total billed charges MESH (IMPLANTABLE) 48712827_1 CDM 0278 RC C1781 HCPCS inpatient 4513 2933.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2732.62 4377.61 MESH (IMPLANTABLE) 48712827_1 CDM 0278 RC C1781 HCPCS inpatient 4513 2933.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 2732.62 4377.61 MESH (IMPLANTABLE) 48712828_1 CDM 0278 RC C1781 HCPCS inpatient 4621 3003.65 AETNA AETNA 3650.59 79 999999999 2798.02 4482.37 percent of total billed charges MESH (IMPLANTABLE) 48712828_1 CDM 0278 RC C1781 HCPCS inpatient 4621 3003.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 3003.65 65 999999999 2798.02 4482.37 percent of total billed charges MESH (IMPLANTABLE) 48712828_1 CDM 0278 RC C1781 HCPCS inpatient 4621 3003.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4482.37 97 999999999 2798.02 4482.37 percent of total billed charges MESH (IMPLANTABLE) 48712828_1 CDM 0278 RC C1781 HCPCS inpatient 4621 3003.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 3604.38 78 999999999 2798.02 4482.37 percent of total billed charges MESH (IMPLANTABLE) 48712828_1 CDM 0278 RC C1781 HCPCS inpatient 4621 3003.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 3188.49 69 999999999 2798.02 4482.37 percent of total billed charges MESH (IMPLANTABLE) 48712828_1 CDM 0278 RC C1781 HCPCS inpatient 4621 3003.65 UMR - ALL PLANS UMR - ALL PLANS 3234.7 70 999999999 2798.02 4482.37 percent of total billed charges MESH (IMPLANTABLE) 48712828_1 CDM 0278 RC C1781 HCPCS inpatient 4621 3003.65 SIHO - ALL PLANS SIHO - ALL PLANS 4158.9 90 999999999 2798.02 4482.37 percent of total billed charges MESH (IMPLANTABLE) 48712828_1 CDM 0278 RC C1781 HCPCS inpatient 4621 3003.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2798.02 60.55 999999999 2798.02 4482.37 percent of total billed charges MESH (IMPLANTABLE) 48712828_1 CDM 0278 RC C1781 HCPCS inpatient 4621 3003.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2798.02 4482.37 MESH (IMPLANTABLE) 48712828_1 CDM 0278 RC C1781 HCPCS inpatient 4621 3003.65 ANTHEM HMO ANTHEM HMO 999999999 2798.02 4482.37 MESH (IMPLANTABLE) 48712828_1 CDM 0278 RC C1781 HCPCS inpatient 4621 3003.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2798.02 4482.37 MESH (IMPLANTABLE) 48712828_1 CDM 0278 RC C1781 HCPCS inpatient 4621 3003.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 3123.8 67.6 999999999 2798.02 4482.37 percent of total billed charges MESH (IMPLANTABLE) 48712828_1 CDM 0278 RC C1781 HCPCS inpatient 4621 3003.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2798.02 4482.37 MESH (IMPLANTABLE) 48712828_1 CDM 0278 RC C1781 HCPCS inpatient 4621 3003.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 2798.02 4482.37 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712829_1 CDM 0278 RC C1713 HCPCS inpatient 482 313.3 AETNA AETNA 380.78 79 999999999 291.85 467.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712829_1 CDM 0278 RC C1713 HCPCS inpatient 482 313.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 313.3 65 999999999 291.85 467.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712829_1 CDM 0278 RC C1713 HCPCS inpatient 482 313.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 467.54 97 999999999 291.85 467.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712829_1 CDM 0278 RC C1713 HCPCS inpatient 482 313.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 375.96 78 999999999 291.85 467.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712829_1 CDM 0278 RC C1713 HCPCS inpatient 482 313.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 332.58 69 999999999 291.85 467.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712829_1 CDM 0278 RC C1713 HCPCS inpatient 482 313.3 UMR - ALL PLANS UMR - ALL PLANS 337.4 70 999999999 291.85 467.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712829_1 CDM 0278 RC C1713 HCPCS inpatient 482 313.3 SIHO - ALL PLANS SIHO - ALL PLANS 433.8 90 999999999 291.85 467.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712829_1 CDM 0278 RC C1713 HCPCS inpatient 482 313.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 291.85 60.55 999999999 291.85 467.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712829_1 CDM 0278 RC C1713 HCPCS inpatient 482 313.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 291.85 467.54 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712829_1 CDM 0278 RC C1713 HCPCS inpatient 482 313.3 ANTHEM HMO ANTHEM HMO 999999999 291.85 467.54 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712829_1 CDM 0278 RC C1713 HCPCS inpatient 482 313.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 291.85 467.54 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712829_1 CDM 0278 RC C1713 HCPCS inpatient 482 313.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 325.83 67.6 999999999 291.85 467.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712829_1 CDM 0278 RC C1713 HCPCS inpatient 482 313.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 291.85 467.54 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712829_1 CDM 0278 RC C1713 HCPCS inpatient 482 313.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 291.85 467.54 DRILL AO SM 42X300MM STERILE 48712830_1 CDM 0272 RC inpatient 784 509.6 AETNA AETNA 619.36 79 999999999 474.71 760.48 percent of total billed charges DRILL AO SM 42X300MM STERILE 48712830_1 CDM 0272 RC inpatient 784 509.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 509.6 65 999999999 474.71 760.48 percent of total billed charges DRILL AO SM 42X300MM STERILE 48712830_1 CDM 0272 RC inpatient 784 509.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 760.48 97 999999999 474.71 760.48 percent of total billed charges DRILL AO SM 42X300MM STERILE 48712830_1 CDM 0272 RC inpatient 784 509.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 611.52 78 999999999 474.71 760.48 percent of total billed charges DRILL AO SM 42X300MM STERILE 48712830_1 CDM 0272 RC inpatient 784 509.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 540.96 69 999999999 474.71 760.48 percent of total billed charges DRILL AO SM 42X300MM STERILE 48712830_1 CDM 0272 RC inpatient 784 509.6 UMR - ALL PLANS UMR - ALL PLANS 548.8 70 999999999 474.71 760.48 percent of total billed charges DRILL AO SM 42X300MM STERILE 48712830_1 CDM 0272 RC inpatient 784 509.6 SIHO - ALL PLANS SIHO - ALL PLANS 705.6 90 999999999 474.71 760.48 percent of total billed charges DRILL AO SM 42X300MM STERILE 48712830_1 CDM 0272 RC inpatient 784 509.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 474.71 60.55 999999999 474.71 760.48 percent of total billed charges DRILL AO SM 42X300MM STERILE 48712830_1 CDM 0272 RC inpatient 784 509.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 474.71 760.48 DRILL AO SM 42X300MM STERILE 48712830_1 CDM 0272 RC inpatient 784 509.6 ANTHEM HMO ANTHEM HMO 999999999 474.71 760.48 DRILL AO SM 42X300MM STERILE 48712830_1 CDM 0272 RC inpatient 784 509.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 474.71 760.48 DRILL AO SM 42X300MM STERILE 48712830_1 CDM 0272 RC inpatient 784 509.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 529.98 67.6 999999999 474.71 760.48 percent of total billed charges DRILL AO SM 42X300MM STERILE 48712830_1 CDM 0272 RC inpatient 784 509.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 474.71 760.48 DRILL AO SM 42X300MM STERILE 48712830_1 CDM 0272 RC inpatient 784 509.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 474.71 760.48 GUIDE WIRE 48712831_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 AETNA AETNA 492.96 79 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE 48712831_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 405.6 65 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE 48712831_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 605.28 97 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE 48712831_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 486.72 78 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE 48712831_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 430.56 69 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE 48712831_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 UMR - ALL PLANS UMR - ALL PLANS 436.8 70 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE 48712831_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 SIHO - ALL PLANS SIHO - ALL PLANS 561.6 90 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE 48712831_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 377.83 60.55 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE 48712831_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 377.83 605.28 GUIDE WIRE 48712831_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 ANTHEM HMO ANTHEM HMO 999999999 377.83 605.28 GUIDE WIRE 48712831_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 377.83 605.28 GUIDE WIRE 48712831_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 421.82 67.6 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE 48712831_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 377.83 605.28 GUIDE WIRE 48712831_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 377.83 605.28 GUIDE WIRE 48712832_1 CDM 0272 RC C1769 HCPCS inpatient 777 505.05 AETNA AETNA 613.83 79 999999999 470.47 753.69 percent of total billed charges GUIDE WIRE 48712832_1 CDM 0272 RC C1769 HCPCS inpatient 777 505.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 505.05 65 999999999 470.47 753.69 percent of total billed charges GUIDE WIRE 48712832_1 CDM 0272 RC C1769 HCPCS inpatient 777 505.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 753.69 97 999999999 470.47 753.69 percent of total billed charges GUIDE WIRE 48712832_1 CDM 0272 RC C1769 HCPCS inpatient 777 505.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 606.06 78 999999999 470.47 753.69 percent of total billed charges GUIDE WIRE 48712832_1 CDM 0272 RC C1769 HCPCS inpatient 777 505.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 536.13 69 999999999 470.47 753.69 percent of total billed charges GUIDE WIRE 48712832_1 CDM 0272 RC C1769 HCPCS inpatient 777 505.05 UMR - ALL PLANS UMR - ALL PLANS 543.9 70 999999999 470.47 753.69 percent of total billed charges GUIDE WIRE 48712832_1 CDM 0272 RC C1769 HCPCS inpatient 777 505.05 SIHO - ALL PLANS SIHO - ALL PLANS 699.3 90 999999999 470.47 753.69 percent of total billed charges GUIDE WIRE 48712832_1 CDM 0272 RC C1769 HCPCS inpatient 777 505.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 470.47 60.55 999999999 470.47 753.69 percent of total billed charges GUIDE WIRE 48712832_1 CDM 0272 RC C1769 HCPCS inpatient 777 505.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 470.47 753.69 GUIDE WIRE 48712832_1 CDM 0272 RC C1769 HCPCS inpatient 777 505.05 ANTHEM HMO ANTHEM HMO 999999999 470.47 753.69 GUIDE WIRE 48712832_1 CDM 0272 RC C1769 HCPCS inpatient 777 505.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 470.47 753.69 GUIDE WIRE 48712832_1 CDM 0272 RC C1769 HCPCS inpatient 777 505.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 525.25 67.6 999999999 470.47 753.69 percent of total billed charges GUIDE WIRE 48712832_1 CDM 0272 RC C1769 HCPCS inpatient 777 505.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 470.47 753.69 GUIDE WIRE 48712832_1 CDM 0272 RC C1769 HCPCS inpatient 777 505.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 470.47 753.69 DRILL AO SM STERILE 4.2X180MM 48712833_1 CDM 0272 RC inpatient 2219 1442.35 AETNA AETNA 1753.01 79 999999999 1343.6 2152.43 percent of total billed charges DRILL AO SM STERILE 4.2X180MM 48712833_1 CDM 0272 RC inpatient 2219 1442.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1442.35 65 999999999 1343.6 2152.43 percent of total billed charges DRILL AO SM STERILE 4.2X180MM 48712833_1 CDM 0272 RC inpatient 2219 1442.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2152.43 97 999999999 1343.6 2152.43 percent of total billed charges DRILL AO SM STERILE 4.2X180MM 48712833_1 CDM 0272 RC inpatient 2219 1442.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1730.82 78 999999999 1343.6 2152.43 percent of total billed charges DRILL AO SM STERILE 4.2X180MM 48712833_1 CDM 0272 RC inpatient 2219 1442.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1531.11 69 999999999 1343.6 2152.43 percent of total billed charges DRILL AO SM STERILE 4.2X180MM 48712833_1 CDM 0272 RC inpatient 2219 1442.35 UMR - ALL PLANS UMR - ALL PLANS 1553.3 70 999999999 1343.6 2152.43 percent of total billed charges DRILL AO SM STERILE 4.2X180MM 48712833_1 CDM 0272 RC inpatient 2219 1442.35 SIHO - ALL PLANS SIHO - ALL PLANS 1997.1 90 999999999 1343.6 2152.43 percent of total billed charges DRILL AO SM STERILE 4.2X180MM 48712833_1 CDM 0272 RC inpatient 2219 1442.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1343.6 60.55 999999999 1343.6 2152.43 percent of total billed charges DRILL AO SM STERILE 4.2X180MM 48712833_1 CDM 0272 RC inpatient 2219 1442.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1343.6 2152.43 DRILL AO SM STERILE 4.2X180MM 48712833_1 CDM 0272 RC inpatient 2219 1442.35 ANTHEM HMO ANTHEM HMO 999999999 1343.6 2152.43 DRILL AO SM STERILE 4.2X180MM 48712833_1 CDM 0272 RC inpatient 2219 1442.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1343.6 2152.43 DRILL AO SM STERILE 4.2X180MM 48712833_1 CDM 0272 RC inpatient 2219 1442.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1500.04 67.6 999999999 1343.6 2152.43 percent of total billed charges DRILL AO SM STERILE 4.2X180MM 48712833_1 CDM 0272 RC inpatient 2219 1442.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1343.6 2152.43 DRILL AO SM STERILE 4.2X180MM 48712833_1 CDM 0272 RC inpatient 2219 1442.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1343.6 2152.43 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX25MM 48712834_1 CDM 0278 RC inpatient 780 507 AETNA AETNA 616.2 79 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX25MM 48712834_1 CDM 0278 RC inpatient 780 507 SELF PAY DISCOUNT SELF PAY DISCOUNT 507 65 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX25MM 48712834_1 CDM 0278 RC inpatient 780 507 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 756.6 97 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX25MM 48712834_1 CDM 0278 RC inpatient 780 507 HUMANA - ALL PLANS HUMANA - ALL PLANS 608.4 78 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX25MM 48712834_1 CDM 0278 RC inpatient 780 507 ENCORE - ALL PLANS ENCORE - ALL PLANS 538.2 69 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX25MM 48712834_1 CDM 0278 RC inpatient 780 507 UMR - ALL PLANS UMR - ALL PLANS 546 70 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX25MM 48712834_1 CDM 0278 RC inpatient 780 507 SIHO - ALL PLANS SIHO - ALL PLANS 702 90 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX25MM 48712834_1 CDM 0278 RC inpatient 780 507 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 472.29 60.55 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX25MM 48712834_1 CDM 0278 RC inpatient 780 507 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 472.29 756.6 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX25MM 48712834_1 CDM 0278 RC inpatient 780 507 ANTHEM HMO ANTHEM HMO 999999999 472.29 756.6 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX25MM 48712834_1 CDM 0278 RC inpatient 780 507 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 472.29 756.6 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX25MM 48712834_1 CDM 0278 RC inpatient 780 507 CIGNA - ALL PLANS CIGNA - ALL PLANS 527.28 67.6 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX25MM 48712834_1 CDM 0278 RC inpatient 780 507 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 472.29 756.6 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX25MM 48712834_1 CDM 0278 RC inpatient 780 507 UHC - ALL PLANS UHC - ALL PLANS 999999999 472.29 756.6 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX30MM 48712835_1 CDM 0278 RC inpatient 780 507 AETNA AETNA 616.2 79 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX30MM 48712835_1 CDM 0278 RC inpatient 780 507 SELF PAY DISCOUNT SELF PAY DISCOUNT 507 65 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX30MM 48712835_1 CDM 0278 RC inpatient 780 507 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 756.6 97 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX30MM 48712835_1 CDM 0278 RC inpatient 780 507 HUMANA - ALL PLANS HUMANA - ALL PLANS 608.4 78 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX30MM 48712835_1 CDM 0278 RC inpatient 780 507 ENCORE - ALL PLANS ENCORE - ALL PLANS 538.2 69 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX30MM 48712835_1 CDM 0278 RC inpatient 780 507 UMR - ALL PLANS UMR - ALL PLANS 546 70 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX30MM 48712835_1 CDM 0278 RC inpatient 780 507 SIHO - ALL PLANS SIHO - ALL PLANS 702 90 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX30MM 48712835_1 CDM 0278 RC inpatient 780 507 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 472.29 60.55 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX30MM 48712835_1 CDM 0278 RC inpatient 780 507 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 472.29 756.6 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX30MM 48712835_1 CDM 0278 RC inpatient 780 507 ANTHEM HMO ANTHEM HMO 999999999 472.29 756.6 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX30MM 48712835_1 CDM 0278 RC inpatient 780 507 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 472.29 756.6 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX30MM 48712835_1 CDM 0278 RC inpatient 780 507 CIGNA - ALL PLANS CIGNA - ALL PLANS 527.28 67.6 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX30MM 48712835_1 CDM 0278 RC inpatient 780 507 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 472.29 756.6 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5MMX30MM 48712835_1 CDM 0278 RC inpatient 780 507 UHC - ALL PLANS UHC - ALL PLANS 999999999 472.29 756.6 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5X32.5MM 48712836_1 CDM 0278 RC inpatient 780 507 AETNA AETNA 616.2 79 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5X32.5MM 48712836_1 CDM 0278 RC inpatient 780 507 SELF PAY DISCOUNT SELF PAY DISCOUNT 507 65 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5X32.5MM 48712836_1 CDM 0278 RC inpatient 780 507 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 756.6 97 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5X32.5MM 48712836_1 CDM 0278 RC inpatient 780 507 HUMANA - ALL PLANS HUMANA - ALL PLANS 608.4 78 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5X32.5MM 48712836_1 CDM 0278 RC inpatient 780 507 ENCORE - ALL PLANS ENCORE - ALL PLANS 538.2 69 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5X32.5MM 48712836_1 CDM 0278 RC inpatient 780 507 UMR - ALL PLANS UMR - ALL PLANS 546 70 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5X32.5MM 48712836_1 CDM 0278 RC inpatient 780 507 SIHO - ALL PLANS SIHO - ALL PLANS 702 90 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5X32.5MM 48712836_1 CDM 0278 RC inpatient 780 507 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 472.29 60.55 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5X32.5MM 48712836_1 CDM 0278 RC inpatient 780 507 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 472.29 756.6 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5X32.5MM 48712836_1 CDM 0278 RC inpatient 780 507 ANTHEM HMO ANTHEM HMO 999999999 472.29 756.6 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5X32.5MM 48712836_1 CDM 0278 RC inpatient 780 507 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 472.29 756.6 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5X32.5MM 48712836_1 CDM 0278 RC inpatient 780 507 CIGNA - ALL PLANS CIGNA - ALL PLANS 527.28 67.6 999999999 472.29 756.6 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5X32.5MM 48712836_1 CDM 0278 RC inpatient 780 507 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 472.29 756.6 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW LOCKING T2 F/T 5X32.5MM 48712836_1 CDM 0278 RC inpatient 780 507 UHC - ALL PLANS UHC - ALL PLANS 999999999 472.29 756.6 SCREW LOCKING T2 F/T 5MMX35MM 48712837_1 CDM 0278 RC inpatient 1594 1036.1 AETNA AETNA 1259.26 79 999999999 965.17 1546.18 percent of total billed charges SCREW LOCKING T2 F/T 5MMX35MM 48712837_1 CDM 0278 RC inpatient 1594 1036.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1036.1 65 999999999 965.17 1546.18 percent of total billed charges SCREW LOCKING T2 F/T 5MMX35MM 48712837_1 CDM 0278 RC inpatient 1594 1036.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1546.18 97 999999999 965.17 1546.18 percent of total billed charges SCREW LOCKING T2 F/T 5MMX35MM 48712837_1 CDM 0278 RC inpatient 1594 1036.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1243.32 78 999999999 965.17 1546.18 percent of total billed charges SCREW LOCKING T2 F/T 5MMX35MM 48712837_1 CDM 0278 RC inpatient 1594 1036.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 1099.86 69 999999999 965.17 1546.18 percent of total billed charges SCREW LOCKING T2 F/T 5MMX35MM 48712837_1 CDM 0278 RC inpatient 1594 1036.1 UMR - ALL PLANS UMR - ALL PLANS 1115.8 70 999999999 965.17 1546.18 percent of total billed charges SCREW LOCKING T2 F/T 5MMX35MM 48712837_1 CDM 0278 RC inpatient 1594 1036.1 SIHO - ALL PLANS SIHO - ALL PLANS 1434.6 90 999999999 965.17 1546.18 percent of total billed charges SCREW LOCKING T2 F/T 5MMX35MM 48712837_1 CDM 0278 RC inpatient 1594 1036.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 965.17 60.55 999999999 965.17 1546.18 percent of total billed charges SCREW LOCKING T2 F/T 5MMX35MM 48712837_1 CDM 0278 RC inpatient 1594 1036.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 965.17 1546.18 SCREW LOCKING T2 F/T 5MMX35MM 48712837_1 CDM 0278 RC inpatient 1594 1036.1 ANTHEM HMO ANTHEM HMO 999999999 965.17 1546.18 SCREW LOCKING T2 F/T 5MMX35MM 48712837_1 CDM 0278 RC inpatient 1594 1036.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 965.17 1546.18 SCREW LOCKING T2 F/T 5MMX35MM 48712837_1 CDM 0278 RC inpatient 1594 1036.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1077.54 67.6 999999999 965.17 1546.18 percent of total billed charges SCREW LOCKING T2 F/T 5MMX35MM 48712837_1 CDM 0278 RC inpatient 1594 1036.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 965.17 1546.18 SCREW LOCKING T2 F/T 5MMX35MM 48712837_1 CDM 0278 RC inpatient 1594 1036.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 965.17 1546.18 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712838_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 AETNA AETNA 1259.26 79 999999999 965.17 1546.18 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712838_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1036.1 65 999999999 965.17 1546.18 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712838_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1546.18 97 999999999 965.17 1546.18 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712838_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1243.32 78 999999999 965.17 1546.18 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712838_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 1099.86 69 999999999 965.17 1546.18 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712838_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 UMR - ALL PLANS UMR - ALL PLANS 1115.8 70 999999999 965.17 1546.18 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712838_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 SIHO - ALL PLANS SIHO - ALL PLANS 1434.6 90 999999999 965.17 1546.18 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712838_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 965.17 60.55 999999999 965.17 1546.18 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712838_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 965.17 1546.18 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712838_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 ANTHEM HMO ANTHEM HMO 999999999 965.17 1546.18 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712838_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 965.17 1546.18 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712838_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1077.54 67.6 999999999 965.17 1546.18 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712838_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 965.17 1546.18 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712838_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 965.17 1546.18 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712839_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 AETNA AETNA 1259.26 79 999999999 965.17 1546.18 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712839_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1036.1 65 999999999 965.17 1546.18 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712839_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1546.18 97 999999999 965.17 1546.18 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712839_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1243.32 78 999999999 965.17 1546.18 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712839_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 1099.86 69 999999999 965.17 1546.18 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712839_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 UMR - ALL PLANS UMR - ALL PLANS 1115.8 70 999999999 965.17 1546.18 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712839_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 SIHO - ALL PLANS SIHO - ALL PLANS 1434.6 90 999999999 965.17 1546.18 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712839_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 965.17 60.55 999999999 965.17 1546.18 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712839_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 965.17 1546.18 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712839_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 ANTHEM HMO ANTHEM HMO 999999999 965.17 1546.18 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712839_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 965.17 1546.18 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712839_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1077.54 67.6 999999999 965.17 1546.18 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712839_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 965.17 1546.18 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712839_1 CDM 0278 RC C1713 HCPCS inpatient 1594 1036.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 965.17 1546.18 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712840_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 AETNA AETNA 906.92 79 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712840_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 746.2 65 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712840_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1113.56 97 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712840_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 895.44 78 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712840_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 792.12 69 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712840_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 UMR - ALL PLANS UMR - ALL PLANS 803.6 70 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712840_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 SIHO - ALL PLANS SIHO - ALL PLANS 1033.2 90 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712840_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 695.11 60.55 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712840_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712840_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ANTHEM HMO ANTHEM HMO 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712840_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712840_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 776.05 67.6 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712840_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712840_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712841_1 CDM 0278 RC C1713 HCPCS inpatient 1083 703.95 AETNA AETNA 855.57 79 999999999 655.76 1050.51 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712841_1 CDM 0278 RC C1713 HCPCS inpatient 1083 703.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 703.95 65 999999999 655.76 1050.51 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712841_1 CDM 0278 RC C1713 HCPCS inpatient 1083 703.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1050.51 97 999999999 655.76 1050.51 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712841_1 CDM 0278 RC C1713 HCPCS inpatient 1083 703.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 844.74 78 999999999 655.76 1050.51 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712841_1 CDM 0278 RC C1713 HCPCS inpatient 1083 703.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 747.27 69 999999999 655.76 1050.51 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712841_1 CDM 0278 RC C1713 HCPCS inpatient 1083 703.95 UMR - ALL PLANS UMR - ALL PLANS 758.1 70 999999999 655.76 1050.51 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712841_1 CDM 0278 RC C1713 HCPCS inpatient 1083 703.95 SIHO - ALL PLANS SIHO - ALL PLANS 974.7 90 999999999 655.76 1050.51 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712841_1 CDM 0278 RC C1713 HCPCS inpatient 1083 703.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 655.76 60.55 999999999 655.76 1050.51 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712841_1 CDM 0278 RC C1713 HCPCS inpatient 1083 703.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 655.76 1050.51 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712841_1 CDM 0278 RC C1713 HCPCS inpatient 1083 703.95 ANTHEM HMO ANTHEM HMO 999999999 655.76 1050.51 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712841_1 CDM 0278 RC C1713 HCPCS inpatient 1083 703.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 655.76 1050.51 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712841_1 CDM 0278 RC C1713 HCPCS inpatient 1083 703.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 732.11 67.6 999999999 655.76 1050.51 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712841_1 CDM 0278 RC C1713 HCPCS inpatient 1083 703.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 655.76 1050.51 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712841_1 CDM 0278 RC C1713 HCPCS inpatient 1083 703.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 655.76 1050.51 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712842_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 AETNA AETNA 616.2 79 999999999 472.29 756.6 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712842_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 SELF PAY DISCOUNT SELF PAY DISCOUNT 507 65 999999999 472.29 756.6 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712842_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 756.6 97 999999999 472.29 756.6 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712842_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 HUMANA - ALL PLANS HUMANA - ALL PLANS 608.4 78 999999999 472.29 756.6 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712842_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 ENCORE - ALL PLANS ENCORE - ALL PLANS 538.2 69 999999999 472.29 756.6 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712842_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 UMR - ALL PLANS UMR - ALL PLANS 546 70 999999999 472.29 756.6 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712842_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 SIHO - ALL PLANS SIHO - ALL PLANS 702 90 999999999 472.29 756.6 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712842_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 472.29 60.55 999999999 472.29 756.6 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712842_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 472.29 756.6 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712842_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 ANTHEM HMO ANTHEM HMO 999999999 472.29 756.6 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712842_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 472.29 756.6 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712842_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 CIGNA - ALL PLANS CIGNA - ALL PLANS 527.28 67.6 999999999 472.29 756.6 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712842_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 472.29 756.6 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712842_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 UHC - ALL PLANS UHC - ALL PLANS 999999999 472.29 756.6 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712843_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 AETNA AETNA 906.92 79 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712843_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 746.2 65 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712843_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1113.56 97 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712843_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 895.44 78 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712843_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 792.12 69 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712843_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 UMR - ALL PLANS UMR - ALL PLANS 803.6 70 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712843_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 SIHO - ALL PLANS SIHO - ALL PLANS 1033.2 90 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712843_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 695.11 60.55 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712843_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712843_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ANTHEM HMO ANTHEM HMO 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712843_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712843_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 776.05 67.6 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712843_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712843_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712844_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 AETNA AETNA 906.92 79 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712844_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 746.2 65 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712844_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1113.56 97 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712844_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 895.44 78 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712844_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 792.12 69 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712844_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 UMR - ALL PLANS UMR - ALL PLANS 803.6 70 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712844_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 SIHO - ALL PLANS SIHO - ALL PLANS 1033.2 90 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712844_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 695.11 60.55 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712844_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712844_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ANTHEM HMO ANTHEM HMO 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712844_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712844_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 776.05 67.6 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712844_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712844_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712845_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 AETNA AETNA 906.92 79 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712845_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 746.2 65 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712845_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1113.56 97 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712845_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 895.44 78 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712845_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 792.12 69 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712845_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 UMR - ALL PLANS UMR - ALL PLANS 803.6 70 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712845_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 SIHO - ALL PLANS SIHO - ALL PLANS 1033.2 90 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712845_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 695.11 60.55 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712845_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712845_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ANTHEM HMO ANTHEM HMO 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712845_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712845_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 776.05 67.6 999999999 695.11 1113.56 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712845_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 695.11 1113.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712845_1 CDM 0278 RC C1713 HCPCS inpatient 1148 746.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 695.11 1113.56 SCREW LOCKIGN T2 F/T 5X57.5MM 48712846_1 CDM 0278 RC inpatient 780 507 AETNA AETNA 616.2 79 999999999 472.29 756.6 percent of total billed charges SCREW LOCKIGN T2 F/T 5X57.5MM 48712846_1 CDM 0278 RC inpatient 780 507 SELF PAY DISCOUNT SELF PAY DISCOUNT 507 65 999999999 472.29 756.6 percent of total billed charges SCREW LOCKIGN T2 F/T 5X57.5MM 48712846_1 CDM 0278 RC inpatient 780 507 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 756.6 97 999999999 472.29 756.6 percent of total billed charges SCREW LOCKIGN T2 F/T 5X57.5MM 48712846_1 CDM 0278 RC inpatient 780 507 HUMANA - ALL PLANS HUMANA - ALL PLANS 608.4 78 999999999 472.29 756.6 percent of total billed charges SCREW LOCKIGN T2 F/T 5X57.5MM 48712846_1 CDM 0278 RC inpatient 780 507 ENCORE - ALL PLANS ENCORE - ALL PLANS 538.2 69 999999999 472.29 756.6 percent of total billed charges SCREW LOCKIGN T2 F/T 5X57.5MM 48712846_1 CDM 0278 RC inpatient 780 507 UMR - ALL PLANS UMR - ALL PLANS 546 70 999999999 472.29 756.6 percent of total billed charges SCREW LOCKIGN T2 F/T 5X57.5MM 48712846_1 CDM 0278 RC inpatient 780 507 SIHO - ALL PLANS SIHO - ALL PLANS 702 90 999999999 472.29 756.6 percent of total billed charges SCREW LOCKIGN T2 F/T 5X57.5MM 48712846_1 CDM 0278 RC inpatient 780 507 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 472.29 60.55 999999999 472.29 756.6 percent of total billed charges SCREW LOCKIGN T2 F/T 5X57.5MM 48712846_1 CDM 0278 RC inpatient 780 507 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 472.29 756.6 SCREW LOCKIGN T2 F/T 5X57.5MM 48712846_1 CDM 0278 RC inpatient 780 507 ANTHEM HMO ANTHEM HMO 999999999 472.29 756.6 SCREW LOCKIGN T2 F/T 5X57.5MM 48712846_1 CDM 0278 RC inpatient 780 507 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 472.29 756.6 SCREW LOCKIGN T2 F/T 5X57.5MM 48712846_1 CDM 0278 RC inpatient 780 507 CIGNA - ALL PLANS CIGNA - ALL PLANS 527.28 67.6 999999999 472.29 756.6 percent of total billed charges SCREW LOCKIGN T2 F/T 5X57.5MM 48712846_1 CDM 0278 RC inpatient 780 507 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 472.29 756.6 SCREW LOCKIGN T2 F/T 5X57.5MM 48712846_1 CDM 0278 RC inpatient 780 507 UHC - ALL PLANS UHC - ALL PLANS 999999999 472.29 756.6 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712847_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 AETNA AETNA 616.2 79 999999999 472.29 756.6 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712847_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 SELF PAY DISCOUNT SELF PAY DISCOUNT 507 65 999999999 472.29 756.6 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712847_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 756.6 97 999999999 472.29 756.6 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712847_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 HUMANA - ALL PLANS HUMANA - ALL PLANS 608.4 78 999999999 472.29 756.6 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712847_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 ENCORE - ALL PLANS ENCORE - ALL PLANS 538.2 69 999999999 472.29 756.6 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712847_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 UMR - ALL PLANS UMR - ALL PLANS 546 70 999999999 472.29 756.6 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712847_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 SIHO - ALL PLANS SIHO - ALL PLANS 702 90 999999999 472.29 756.6 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712847_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 472.29 60.55 999999999 472.29 756.6 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712847_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 472.29 756.6 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712847_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 ANTHEM HMO ANTHEM HMO 999999999 472.29 756.6 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712847_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 472.29 756.6 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712847_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 CIGNA - ALL PLANS CIGNA - ALL PLANS 527.28 67.6 999999999 472.29 756.6 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712847_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 472.29 756.6 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712847_1 CDM 0278 RC C1713 HCPCS inpatient 780 507 UHC - ALL PLANS UHC - ALL PLANS 999999999 472.29 756.6 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW SET TI 8MMX17.5MM 48712848_1 CDM 0278 RC inpatient 2287 1486.55 AETNA AETNA 1806.73 79 999999999 1384.78 2218.39 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW SET TI 8MMX17.5MM 48712848_1 CDM 0278 RC inpatient 2287 1486.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1486.55 65 999999999 1384.78 2218.39 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW SET TI 8MMX17.5MM 48712848_1 CDM 0278 RC inpatient 2287 1486.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2218.39 97 999999999 1384.78 2218.39 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW SET TI 8MMX17.5MM 48712848_1 CDM 0278 RC inpatient 2287 1486.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1783.86 78 999999999 1384.78 2218.39 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW SET TI 8MMX17.5MM 48712848_1 CDM 0278 RC inpatient 2287 1486.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1578.03 69 999999999 1384.78 2218.39 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW SET TI 8MMX17.5MM 48712848_1 CDM 0278 RC inpatient 2287 1486.55 UMR - ALL PLANS UMR - ALL PLANS 1600.9 70 999999999 1384.78 2218.39 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW SET TI 8MMX17.5MM 48712848_1 CDM 0278 RC inpatient 2287 1486.55 SIHO - ALL PLANS SIHO - ALL PLANS 2058.3 90 999999999 1384.78 2218.39 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW SET TI 8MMX17.5MM 48712848_1 CDM 0278 RC inpatient 2287 1486.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1384.78 60.55 999999999 1384.78 2218.39 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW SET TI 8MMX17.5MM 48712848_1 CDM 0278 RC inpatient 2287 1486.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1384.78 2218.39 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW SET TI 8MMX17.5MM 48712848_1 CDM 0278 RC inpatient 2287 1486.55 ANTHEM HMO ANTHEM HMO 999999999 1384.78 2218.39 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW SET TI 8MMX17.5MM 48712848_1 CDM 0278 RC inpatient 2287 1486.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1384.78 2218.39 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW SET TI 8MMX17.5MM 48712848_1 CDM 0278 RC inpatient 2287 1486.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1546.01 67.6 999999999 1384.78 2218.39 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW SET TI 8MMX17.5MM 48712848_1 CDM 0278 RC inpatient 2287 1486.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1384.78 2218.39 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW SET TI 8MMX17.5MM 48712848_1 CDM 0278 RC inpatient 2287 1486.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1384.78 2218.39 SCREW TI LAG 10.5MMX80MM 48712849_1 CDM 0278 RC inpatient 2287 1486.55 AETNA AETNA 1806.73 79 999999999 1384.78 2218.39 percent of total billed charges SCREW TI LAG 10.5MMX80MM 48712849_1 CDM 0278 RC inpatient 2287 1486.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1486.55 65 999999999 1384.78 2218.39 percent of total billed charges SCREW TI LAG 10.5MMX80MM 48712849_1 CDM 0278 RC inpatient 2287 1486.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2218.39 97 999999999 1384.78 2218.39 percent of total billed charges SCREW TI LAG 10.5MMX80MM 48712849_1 CDM 0278 RC inpatient 2287 1486.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1783.86 78 999999999 1384.78 2218.39 percent of total billed charges SCREW TI LAG 10.5MMX80MM 48712849_1 CDM 0278 RC inpatient 2287 1486.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1578.03 69 999999999 1384.78 2218.39 percent of total billed charges SCREW TI LAG 10.5MMX80MM 48712849_1 CDM 0278 RC inpatient 2287 1486.55 UMR - ALL PLANS UMR - ALL PLANS 1600.9 70 999999999 1384.78 2218.39 percent of total billed charges SCREW TI LAG 10.5MMX80MM 48712849_1 CDM 0278 RC inpatient 2287 1486.55 SIHO - ALL PLANS SIHO - ALL PLANS 2058.3 90 999999999 1384.78 2218.39 percent of total billed charges SCREW TI LAG 10.5MMX80MM 48712849_1 CDM 0278 RC inpatient 2287 1486.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1384.78 60.55 999999999 1384.78 2218.39 percent of total billed charges SCREW TI LAG 10.5MMX80MM 48712849_1 CDM 0278 RC inpatient 2287 1486.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1384.78 2218.39 SCREW TI LAG 10.5MMX80MM 48712849_1 CDM 0278 RC inpatient 2287 1486.55 ANTHEM HMO ANTHEM HMO 999999999 1384.78 2218.39 SCREW TI LAG 10.5MMX80MM 48712849_1 CDM 0278 RC inpatient 2287 1486.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1384.78 2218.39 SCREW TI LAG 10.5MMX80MM 48712849_1 CDM 0278 RC inpatient 2287 1486.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1546.01 67.6 999999999 1384.78 2218.39 percent of total billed charges SCREW TI LAG 10.5MMX80MM 48712849_1 CDM 0278 RC inpatient 2287 1486.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1384.78 2218.39 SCREW TI LAG 10.5MMX80MM 48712849_1 CDM 0278 RC inpatient 2287 1486.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1384.78 2218.39 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712850_1 CDM 0278 RC C1713 HCPCS inpatient 3503 2276.95 AETNA AETNA 2767.37 79 999999999 2121.07 3397.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712850_1 CDM 0278 RC C1713 HCPCS inpatient 3503 2276.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 2276.95 65 999999999 2121.07 3397.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712850_1 CDM 0278 RC C1713 HCPCS inpatient 3503 2276.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3397.91 97 999999999 2121.07 3397.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712850_1 CDM 0278 RC C1713 HCPCS inpatient 3503 2276.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 2732.34 78 999999999 2121.07 3397.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712850_1 CDM 0278 RC C1713 HCPCS inpatient 3503 2276.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 2417.07 69 999999999 2121.07 3397.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712850_1 CDM 0278 RC C1713 HCPCS inpatient 3503 2276.95 UMR - ALL PLANS UMR - ALL PLANS 2452.1 70 999999999 2121.07 3397.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712850_1 CDM 0278 RC C1713 HCPCS inpatient 3503 2276.95 SIHO - ALL PLANS SIHO - ALL PLANS 3152.7 90 999999999 2121.07 3397.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712850_1 CDM 0278 RC C1713 HCPCS inpatient 3503 2276.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2121.07 60.55 999999999 2121.07 3397.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712850_1 CDM 0278 RC C1713 HCPCS inpatient 3503 2276.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2121.07 3397.91 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712850_1 CDM 0278 RC C1713 HCPCS inpatient 3503 2276.95 ANTHEM HMO ANTHEM HMO 999999999 2121.07 3397.91 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712850_1 CDM 0278 RC C1713 HCPCS inpatient 3503 2276.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2121.07 3397.91 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712850_1 CDM 0278 RC C1713 HCPCS inpatient 3503 2276.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 2368.03 67.6 999999999 2121.07 3397.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712850_1 CDM 0278 RC C1713 HCPCS inpatient 3503 2276.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2121.07 3397.91 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712850_1 CDM 0278 RC C1713 HCPCS inpatient 3503 2276.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 2121.07 3397.91 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712851_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 AETNA AETNA 2234.91 79 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712851_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1838.85 65 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712851_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2744.13 97 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712851_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 2206.62 78 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712851_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1952.01 69 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712851_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 UMR - ALL PLANS UMR - ALL PLANS 1980.3 70 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712851_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 SIHO - ALL PLANS SIHO - ALL PLANS 2546.1 90 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712851_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1712.96 60.55 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712851_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1712.96 2744.13 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712851_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 ANTHEM HMO ANTHEM HMO 999999999 1712.96 2744.13 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712851_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1712.96 2744.13 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712851_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1912.4 67.6 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712851_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1712.96 2744.13 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712851_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1712.96 2744.13 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712852_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 AETNA AETNA 2108.51 79 999999999 1616.08 2588.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712852_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1734.85 65 999999999 1616.08 2588.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712852_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2588.93 97 999999999 1616.08 2588.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712852_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 2081.82 78 999999999 1616.08 2588.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712852_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1841.61 69 999999999 1616.08 2588.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712852_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 UMR - ALL PLANS UMR - ALL PLANS 1868.3 70 999999999 1616.08 2588.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712852_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 SIHO - ALL PLANS SIHO - ALL PLANS 2402.1 90 999999999 1616.08 2588.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712852_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1616.08 60.55 999999999 1616.08 2588.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712852_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1616.08 2588.93 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712852_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 ANTHEM HMO ANTHEM HMO 999999999 1616.08 2588.93 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712852_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1616.08 2588.93 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712852_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1804.24 67.6 999999999 1616.08 2588.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712852_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1616.08 2588.93 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712852_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1616.08 2588.93 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712853_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 AETNA AETNA 2108.51 79 999999999 1616.08 2588.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712853_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1734.85 65 999999999 1616.08 2588.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712853_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2588.93 97 999999999 1616.08 2588.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712853_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 2081.82 78 999999999 1616.08 2588.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712853_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1841.61 69 999999999 1616.08 2588.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712853_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 UMR - ALL PLANS UMR - ALL PLANS 1868.3 70 999999999 1616.08 2588.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712853_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 SIHO - ALL PLANS SIHO - ALL PLANS 2402.1 90 999999999 1616.08 2588.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712853_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1616.08 60.55 999999999 1616.08 2588.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712853_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1616.08 2588.93 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712853_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 ANTHEM HMO ANTHEM HMO 999999999 1616.08 2588.93 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712853_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1616.08 2588.93 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712853_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1804.24 67.6 999999999 1616.08 2588.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712853_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1616.08 2588.93 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712853_1 CDM 0278 RC C1713 HCPCS inpatient 2669 1734.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1616.08 2588.93 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712854_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 AETNA AETNA 2234.91 79 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712854_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1838.85 65 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712854_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2744.13 97 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712854_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 2206.62 78 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712854_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1952.01 69 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712854_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 UMR - ALL PLANS UMR - ALL PLANS 1980.3 70 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712854_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 SIHO - ALL PLANS SIHO - ALL PLANS 2546.1 90 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712854_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1712.96 60.55 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712854_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1712.96 2744.13 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712854_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 ANTHEM HMO ANTHEM HMO 999999999 1712.96 2744.13 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712854_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1712.96 2744.13 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712854_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1912.4 67.6 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712854_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1712.96 2744.13 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712854_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1712.96 2744.13 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712855_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 AETNA AETNA 2234.91 79 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712855_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1838.85 65 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712855_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2744.13 97 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712855_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 2206.62 78 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712855_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1952.01 69 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712855_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 UMR - ALL PLANS UMR - ALL PLANS 1980.3 70 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712855_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 SIHO - ALL PLANS SIHO - ALL PLANS 2546.1 90 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712855_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1712.96 60.55 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712855_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1712.96 2744.13 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712855_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 ANTHEM HMO ANTHEM HMO 999999999 1712.96 2744.13 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712855_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1712.96 2744.13 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712855_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1912.4 67.6 999999999 1712.96 2744.13 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712855_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1712.96 2744.13 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712855_1 CDM 0278 RC C1713 HCPCS inpatient 2829 1838.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1712.96 2744.13 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW TI LAG 10.5MMX115MM 48712856_1 CDM 0278 RC inpatient 2287 1486.55 AETNA AETNA 1806.73 79 999999999 1384.78 2218.39 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW TI LAG 10.5MMX115MM 48712856_1 CDM 0278 RC inpatient 2287 1486.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1486.55 65 999999999 1384.78 2218.39 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW TI LAG 10.5MMX115MM 48712856_1 CDM 0278 RC inpatient 2287 1486.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2218.39 97 999999999 1384.78 2218.39 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW TI LAG 10.5MMX115MM 48712856_1 CDM 0278 RC inpatient 2287 1486.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1783.86 78 999999999 1384.78 2218.39 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW TI LAG 10.5MMX115MM 48712856_1 CDM 0278 RC inpatient 2287 1486.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1578.03 69 999999999 1384.78 2218.39 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW TI LAG 10.5MMX115MM 48712856_1 CDM 0278 RC inpatient 2287 1486.55 UMR - ALL PLANS UMR - ALL PLANS 1600.9 70 999999999 1384.78 2218.39 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW TI LAG 10.5MMX115MM 48712856_1 CDM 0278 RC inpatient 2287 1486.55 SIHO - ALL PLANS SIHO - ALL PLANS 2058.3 90 999999999 1384.78 2218.39 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW TI LAG 10.5MMX115MM 48712856_1 CDM 0278 RC inpatient 2287 1486.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1384.78 60.55 999999999 1384.78 2218.39 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW TI LAG 10.5MMX115MM 48712856_1 CDM 0278 RC inpatient 2287 1486.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1384.78 2218.39 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW TI LAG 10.5MMX115MM 48712856_1 CDM 0278 RC inpatient 2287 1486.55 ANTHEM HMO ANTHEM HMO 999999999 1384.78 2218.39 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW TI LAG 10.5MMX115MM 48712856_1 CDM 0278 RC inpatient 2287 1486.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1384.78 2218.39 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW TI LAG 10.5MMX115MM 48712856_1 CDM 0278 RC inpatient 2287 1486.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1546.01 67.6 999999999 1384.78 2218.39 percent of total billed charges **** BLANKET PER MEGAN P. 09/26/2023**** SCREW TI LAG 10.5MMX115MM 48712856_1 CDM 0278 RC inpatient 2287 1486.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1384.78 2218.39 **** BLANKET PER MEGAN P. 09/26/2023**** SCREW TI LAG 10.5MMX115MM 48712856_1 CDM 0278 RC inpatient 2287 1486.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1384.78 2218.39 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712857_1 CDM 0278 RC C1713 HCPCS inpatient 2287 1486.55 AETNA AETNA 1806.73 79 999999999 1384.78 2218.39 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712857_1 CDM 0278 RC C1713 HCPCS inpatient 2287 1486.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1486.55 65 999999999 1384.78 2218.39 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712857_1 CDM 0278 RC C1713 HCPCS inpatient 2287 1486.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2218.39 97 999999999 1384.78 2218.39 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712857_1 CDM 0278 RC C1713 HCPCS inpatient 2287 1486.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1783.86 78 999999999 1384.78 2218.39 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712857_1 CDM 0278 RC C1713 HCPCS inpatient 2287 1486.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1578.03 69 999999999 1384.78 2218.39 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712857_1 CDM 0278 RC C1713 HCPCS inpatient 2287 1486.55 UMR - ALL PLANS UMR - ALL PLANS 1600.9 70 999999999 1384.78 2218.39 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712857_1 CDM 0278 RC C1713 HCPCS inpatient 2287 1486.55 SIHO - ALL PLANS SIHO - ALL PLANS 2058.3 90 999999999 1384.78 2218.39 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712857_1 CDM 0278 RC C1713 HCPCS inpatient 2287 1486.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1384.78 60.55 999999999 1384.78 2218.39 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712857_1 CDM 0278 RC C1713 HCPCS inpatient 2287 1486.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1384.78 2218.39 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712857_1 CDM 0278 RC C1713 HCPCS inpatient 2287 1486.55 ANTHEM HMO ANTHEM HMO 999999999 1384.78 2218.39 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712857_1 CDM 0278 RC C1713 HCPCS inpatient 2287 1486.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1384.78 2218.39 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712857_1 CDM 0278 RC C1713 HCPCS inpatient 2287 1486.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1546.01 67.6 999999999 1384.78 2218.39 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712857_1 CDM 0278 RC C1713 HCPCS inpatient 2287 1486.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1384.78 2218.39 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48712857_1 CDM 0278 RC C1713 HCPCS inpatient 2287 1486.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1384.78 2218.39 LAG SCREW STEP DRILL 357.403 48712858_1 CDM 0272 RC inpatient 10775 7003.75 AETNA AETNA 8512.25 79 999999999 6524.26 10451.75 percent of total billed charges LAG SCREW STEP DRILL 357.403 48712858_1 CDM 0272 RC inpatient 10775 7003.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 7003.75 65 999999999 6524.26 10451.75 percent of total billed charges LAG SCREW STEP DRILL 357.403 48712858_1 CDM 0272 RC inpatient 10775 7003.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10451.75 97 999999999 6524.26 10451.75 percent of total billed charges LAG SCREW STEP DRILL 357.403 48712858_1 CDM 0272 RC inpatient 10775 7003.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 8404.5 78 999999999 6524.26 10451.75 percent of total billed charges LAG SCREW STEP DRILL 357.403 48712858_1 CDM 0272 RC inpatient 10775 7003.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 7434.75 69 999999999 6524.26 10451.75 percent of total billed charges LAG SCREW STEP DRILL 357.403 48712858_1 CDM 0272 RC inpatient 10775 7003.75 UMR - ALL PLANS UMR - ALL PLANS 7542.5 70 999999999 6524.26 10451.75 percent of total billed charges LAG SCREW STEP DRILL 357.403 48712858_1 CDM 0272 RC inpatient 10775 7003.75 SIHO - ALL PLANS SIHO - ALL PLANS 9697.5 90 999999999 6524.26 10451.75 percent of total billed charges LAG SCREW STEP DRILL 357.403 48712858_1 CDM 0272 RC inpatient 10775 7003.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6524.26 60.55 999999999 6524.26 10451.75 percent of total billed charges LAG SCREW STEP DRILL 357.403 48712858_1 CDM 0272 RC inpatient 10775 7003.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6524.26 10451.75 LAG SCREW STEP DRILL 357.403 48712858_1 CDM 0272 RC inpatient 10775 7003.75 ANTHEM HMO ANTHEM HMO 999999999 6524.26 10451.75 LAG SCREW STEP DRILL 357.403 48712858_1 CDM 0272 RC inpatient 10775 7003.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6524.26 10451.75 LAG SCREW STEP DRILL 357.403 48712858_1 CDM 0272 RC inpatient 10775 7003.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 7283.9 67.6 999999999 6524.26 10451.75 percent of total billed charges LAG SCREW STEP DRILL 357.403 48712858_1 CDM 0272 RC inpatient 10775 7003.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6524.26 10451.75 LAG SCREW STEP DRILL 357.403 48712858_1 CDM 0272 RC inpatient 10775 7003.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 6524.26 10451.75 KIT NAIL TROCANTERIC TI 48712859_1 CDM 0270 RC inpatient 4058 2637.7 AETNA AETNA 3205.82 79 999999999 2457.12 3936.26 percent of total billed charges KIT NAIL TROCANTERIC TI 48712859_1 CDM 0270 RC inpatient 4058 2637.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 2637.7 65 999999999 2457.12 3936.26 percent of total billed charges KIT NAIL TROCANTERIC TI 48712859_1 CDM 0270 RC inpatient 4058 2637.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3936.26 97 999999999 2457.12 3936.26 percent of total billed charges KIT NAIL TROCANTERIC TI 48712859_1 CDM 0270 RC inpatient 4058 2637.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 3165.24 78 999999999 2457.12 3936.26 percent of total billed charges KIT NAIL TROCANTERIC TI 48712859_1 CDM 0270 RC inpatient 4058 2637.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 2800.02 69 999999999 2457.12 3936.26 percent of total billed charges KIT NAIL TROCANTERIC TI 48712859_1 CDM 0270 RC inpatient 4058 2637.7 UMR - ALL PLANS UMR - ALL PLANS 2840.6 70 999999999 2457.12 3936.26 percent of total billed charges KIT NAIL TROCANTERIC TI 48712859_1 CDM 0270 RC inpatient 4058 2637.7 SIHO - ALL PLANS SIHO - ALL PLANS 3652.2 90 999999999 2457.12 3936.26 percent of total billed charges KIT NAIL TROCANTERIC TI 48712859_1 CDM 0270 RC inpatient 4058 2637.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2457.12 60.55 999999999 2457.12 3936.26 percent of total billed charges KIT NAIL TROCANTERIC TI 48712859_1 CDM 0270 RC inpatient 4058 2637.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2457.12 3936.26 KIT NAIL TROCANTERIC TI 48712859_1 CDM 0270 RC inpatient 4058 2637.7 ANTHEM HMO ANTHEM HMO 999999999 2457.12 3936.26 KIT NAIL TROCANTERIC TI 48712859_1 CDM 0270 RC inpatient 4058 2637.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2457.12 3936.26 KIT NAIL TROCANTERIC TI 48712859_1 CDM 0270 RC inpatient 4058 2637.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 2743.21 67.6 999999999 2457.12 3936.26 percent of total billed charges KIT NAIL TROCANTERIC TI 48712859_1 CDM 0270 RC inpatient 4058 2637.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2457.12 3936.26 KIT NAIL TROCANTERIC TI 48712859_1 CDM 0270 RC inpatient 4058 2637.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 2457.12 3936.26 SUTURE SLK 3-0 CO13D 48712860_1 CDM 0272 RC inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges SUTURE SLK 3-0 CO13D 48712860_1 CDM 0272 RC inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges SUTURE SLK 3-0 CO13D 48712860_1 CDM 0272 RC inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges SUTURE SLK 3-0 CO13D 48712860_1 CDM 0272 RC inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges SUTURE SLK 3-0 CO13D 48712860_1 CDM 0272 RC inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges SUTURE SLK 3-0 CO13D 48712860_1 CDM 0272 RC inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges SUTURE SLK 3-0 CO13D 48712860_1 CDM 0272 RC inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges SUTURE SLK 3-0 CO13D 48712860_1 CDM 0272 RC inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges SUTURE SLK 3-0 CO13D 48712860_1 CDM 0272 RC inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 SUTURE SLK 3-0 CO13D 48712860_1 CDM 0272 RC inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 SUTURE SLK 3-0 CO13D 48712860_1 CDM 0272 RC inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 SUTURE SLK 3-0 CO13D 48712860_1 CDM 0272 RC inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges SUTURE SLK 3-0 CO13D 48712860_1 CDM 0272 RC inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 SUTURE SLK 3-0 CO13D 48712860_1 CDM 0272 RC inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 LIGASURE SEALER/DIVIDER LF4418 48712861_1 CDM 0272 RC inpatient 3939 2560.35 AETNA AETNA 3111.81 79 999999999 2385.06 3820.83 percent of total billed charges LIGASURE SEALER/DIVIDER LF4418 48712861_1 CDM 0272 RC inpatient 3939 2560.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 2560.35 65 999999999 2385.06 3820.83 percent of total billed charges LIGASURE SEALER/DIVIDER LF4418 48712861_1 CDM 0272 RC inpatient 3939 2560.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3820.83 97 999999999 2385.06 3820.83 percent of total billed charges LIGASURE SEALER/DIVIDER LF4418 48712861_1 CDM 0272 RC inpatient 3939 2560.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 3072.42 78 999999999 2385.06 3820.83 percent of total billed charges LIGASURE SEALER/DIVIDER LF4418 48712861_1 CDM 0272 RC inpatient 3939 2560.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 2717.91 69 999999999 2385.06 3820.83 percent of total billed charges LIGASURE SEALER/DIVIDER LF4418 48712861_1 CDM 0272 RC inpatient 3939 2560.35 UMR - ALL PLANS UMR - ALL PLANS 2757.3 70 999999999 2385.06 3820.83 percent of total billed charges LIGASURE SEALER/DIVIDER LF4418 48712861_1 CDM 0272 RC inpatient 3939 2560.35 SIHO - ALL PLANS SIHO - ALL PLANS 3545.1 90 999999999 2385.06 3820.83 percent of total billed charges LIGASURE SEALER/DIVIDER LF4418 48712861_1 CDM 0272 RC inpatient 3939 2560.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2385.06 60.55 999999999 2385.06 3820.83 percent of total billed charges LIGASURE SEALER/DIVIDER LF4418 48712861_1 CDM 0272 RC inpatient 3939 2560.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2385.06 3820.83 LIGASURE SEALER/DIVIDER LF4418 48712861_1 CDM 0272 RC inpatient 3939 2560.35 ANTHEM HMO ANTHEM HMO 999999999 2385.06 3820.83 LIGASURE SEALER/DIVIDER LF4418 48712861_1 CDM 0272 RC inpatient 3939 2560.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2385.06 3820.83 LIGASURE SEALER/DIVIDER LF4418 48712861_1 CDM 0272 RC inpatient 3939 2560.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 2662.76 67.6 999999999 2385.06 3820.83 percent of total billed charges LIGASURE SEALER/DIVIDER LF4418 48712861_1 CDM 0272 RC inpatient 3939 2560.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2385.06 3820.83 LIGASURE SEALER/DIVIDER LF4418 48712861_1 CDM 0272 RC inpatient 3939 2560.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 2385.06 3820.83 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712862_1 CDM 0272 RC C1760 HCPCS inpatient 4512 2932.8 AETNA AETNA 3564.48 79 999999999 2732.02 4376.64 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712862_1 CDM 0272 RC C1760 HCPCS inpatient 4512 2932.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 2932.8 65 999999999 2732.02 4376.64 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712862_1 CDM 0272 RC C1760 HCPCS inpatient 4512 2932.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4376.64 97 999999999 2732.02 4376.64 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712862_1 CDM 0272 RC C1760 HCPCS inpatient 4512 2932.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 3519.36 78 999999999 2732.02 4376.64 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712862_1 CDM 0272 RC C1760 HCPCS inpatient 4512 2932.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 3113.28 69 999999999 2732.02 4376.64 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712862_1 CDM 0272 RC C1760 HCPCS inpatient 4512 2932.8 UMR - ALL PLANS UMR - ALL PLANS 3158.4 70 999999999 2732.02 4376.64 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712862_1 CDM 0272 RC C1760 HCPCS inpatient 4512 2932.8 SIHO - ALL PLANS SIHO - ALL PLANS 4060.8 90 999999999 2732.02 4376.64 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712862_1 CDM 0272 RC C1760 HCPCS inpatient 4512 2932.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2732.02 60.55 999999999 2732.02 4376.64 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712862_1 CDM 0272 RC C1760 HCPCS inpatient 4512 2932.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2732.02 4376.64 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712862_1 CDM 0272 RC C1760 HCPCS inpatient 4512 2932.8 ANTHEM HMO ANTHEM HMO 999999999 2732.02 4376.64 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712862_1 CDM 0272 RC C1760 HCPCS inpatient 4512 2932.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2732.02 4376.64 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712862_1 CDM 0272 RC C1760 HCPCS inpatient 4512 2932.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 3050.11 67.6 999999999 2732.02 4376.64 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712862_1 CDM 0272 RC C1760 HCPCS inpatient 4512 2932.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2732.02 4376.64 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712862_1 CDM 0272 RC C1760 HCPCS inpatient 4512 2932.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 2732.02 4376.64 LIGASURE MARYLAND LF1944 6/CS 48712863_1 CDM 0272 RC inpatient 3580 2327 AETNA AETNA 2828.2 79 999999999 2167.69 3472.6 percent of total billed charges LIGASURE MARYLAND LF1944 6/CS 48712863_1 CDM 0272 RC inpatient 3580 2327 SELF PAY DISCOUNT SELF PAY DISCOUNT 2327 65 999999999 2167.69 3472.6 percent of total billed charges LIGASURE MARYLAND LF1944 6/CS 48712863_1 CDM 0272 RC inpatient 3580 2327 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3472.6 97 999999999 2167.69 3472.6 percent of total billed charges LIGASURE MARYLAND LF1944 6/CS 48712863_1 CDM 0272 RC inpatient 3580 2327 HUMANA - ALL PLANS HUMANA - ALL PLANS 2792.4 78 999999999 2167.69 3472.6 percent of total billed charges LIGASURE MARYLAND LF1944 6/CS 48712863_1 CDM 0272 RC inpatient 3580 2327 ENCORE - ALL PLANS ENCORE - ALL PLANS 2470.2 69 999999999 2167.69 3472.6 percent of total billed charges LIGASURE MARYLAND LF1944 6/CS 48712863_1 CDM 0272 RC inpatient 3580 2327 UMR - ALL PLANS UMR - ALL PLANS 2506 70 999999999 2167.69 3472.6 percent of total billed charges LIGASURE MARYLAND LF1944 6/CS 48712863_1 CDM 0272 RC inpatient 3580 2327 SIHO - ALL PLANS SIHO - ALL PLANS 3222 90 999999999 2167.69 3472.6 percent of total billed charges LIGASURE MARYLAND LF1944 6/CS 48712863_1 CDM 0272 RC inpatient 3580 2327 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2167.69 60.55 999999999 2167.69 3472.6 percent of total billed charges LIGASURE MARYLAND LF1944 6/CS 48712863_1 CDM 0272 RC inpatient 3580 2327 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2167.69 3472.6 LIGASURE MARYLAND LF1944 6/CS 48712863_1 CDM 0272 RC inpatient 3580 2327 ANTHEM HMO ANTHEM HMO 999999999 2167.69 3472.6 LIGASURE MARYLAND LF1944 6/CS 48712863_1 CDM 0272 RC inpatient 3580 2327 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2167.69 3472.6 LIGASURE MARYLAND LF1944 6/CS 48712863_1 CDM 0272 RC inpatient 3580 2327 CIGNA - ALL PLANS CIGNA - ALL PLANS 2420.08 67.6 999999999 2167.69 3472.6 percent of total billed charges LIGASURE MARYLAND LF1944 6/CS 48712863_1 CDM 0272 RC inpatient 3580 2327 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2167.69 3472.6 LIGASURE MARYLAND LF1944 6/CS 48712863_1 CDM 0272 RC inpatient 3580 2327 UHC - ALL PLANS UHC - ALL PLANS 999999999 2167.69 3472.6 SUTURE LIGACLIP MED LRGE LT300 48712864_1 CDM 0270 RC inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges SUTURE LIGACLIP MED LRGE LT300 48712864_1 CDM 0270 RC inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges SUTURE LIGACLIP MED LRGE LT300 48712864_1 CDM 0270 RC inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges SUTURE LIGACLIP MED LRGE LT300 48712864_1 CDM 0270 RC inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges SUTURE LIGACLIP MED LRGE LT300 48712864_1 CDM 0270 RC inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges SUTURE LIGACLIP MED LRGE LT300 48712864_1 CDM 0270 RC inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges SUTURE LIGACLIP MED LRGE LT300 48712864_1 CDM 0270 RC inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges SUTURE LIGACLIP MED LRGE LT300 48712864_1 CDM 0270 RC inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges SUTURE LIGACLIP MED LRGE LT300 48712864_1 CDM 0270 RC inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 SUTURE LIGACLIP MED LRGE LT300 48712864_1 CDM 0270 RC inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 SUTURE LIGACLIP MED LRGE LT300 48712864_1 CDM 0270 RC inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 SUTURE LIGACLIP MED LRGE LT300 48712864_1 CDM 0270 RC inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges SUTURE LIGACLIP MED LRGE LT300 48712864_1 CDM 0270 RC inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 SUTURE LIGACLIP MED LRGE LT300 48712864_1 CDM 0270 RC inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 SUTR MONOCRYL 5-0 Y493G 12/BX 48712865_1 CDM 0272 RC inpatient 61 39.65 AETNA AETNA 48.19 79 999999999 36.94 59.17 percent of total billed charges SUTR MONOCRYL 5-0 Y493G 12/BX 48712865_1 CDM 0272 RC inpatient 61 39.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.65 65 999999999 36.94 59.17 percent of total billed charges SUTR MONOCRYL 5-0 Y493G 12/BX 48712865_1 CDM 0272 RC inpatient 61 39.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59.17 97 999999999 36.94 59.17 percent of total billed charges SUTR MONOCRYL 5-0 Y493G 12/BX 48712865_1 CDM 0272 RC inpatient 61 39.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.58 78 999999999 36.94 59.17 percent of total billed charges SUTR MONOCRYL 5-0 Y493G 12/BX 48712865_1 CDM 0272 RC inpatient 61 39.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.09 69 999999999 36.94 59.17 percent of total billed charges SUTR MONOCRYL 5-0 Y493G 12/BX 48712865_1 CDM 0272 RC inpatient 61 39.65 UMR - ALL PLANS UMR - ALL PLANS 42.7 70 999999999 36.94 59.17 percent of total billed charges SUTR MONOCRYL 5-0 Y493G 12/BX 48712865_1 CDM 0272 RC inpatient 61 39.65 SIHO - ALL PLANS SIHO - ALL PLANS 54.9 90 999999999 36.94 59.17 percent of total billed charges SUTR MONOCRYL 5-0 Y493G 12/BX 48712865_1 CDM 0272 RC inpatient 61 39.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.94 60.55 999999999 36.94 59.17 percent of total billed charges SUTR MONOCRYL 5-0 Y493G 12/BX 48712865_1 CDM 0272 RC inpatient 61 39.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.94 59.17 SUTR MONOCRYL 5-0 Y493G 12/BX 48712865_1 CDM 0272 RC inpatient 61 39.65 ANTHEM HMO ANTHEM HMO 999999999 36.94 59.17 SUTR MONOCRYL 5-0 Y493G 12/BX 48712865_1 CDM 0272 RC inpatient 61 39.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.94 59.17 SUTR MONOCRYL 5-0 Y493G 12/BX 48712865_1 CDM 0272 RC inpatient 61 39.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.24 67.6 999999999 36.94 59.17 percent of total billed charges SUTR MONOCRYL 5-0 Y493G 12/BX 48712865_1 CDM 0272 RC inpatient 61 39.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.94 59.17 SUTR MONOCRYL 5-0 Y493G 12/BX 48712865_1 CDM 0272 RC inpatient 61 39.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.94 59.17 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712866_1 CDM 0272 RC C1760 HCPCS inpatient 2919 1897.35 AETNA AETNA 2306.01 79 999999999 1767.45 2831.43 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712866_1 CDM 0272 RC C1760 HCPCS inpatient 2919 1897.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1897.35 65 999999999 1767.45 2831.43 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712866_1 CDM 0272 RC C1760 HCPCS inpatient 2919 1897.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2831.43 97 999999999 1767.45 2831.43 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712866_1 CDM 0272 RC C1760 HCPCS inpatient 2919 1897.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 2276.82 78 999999999 1767.45 2831.43 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712866_1 CDM 0272 RC C1760 HCPCS inpatient 2919 1897.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 2014.11 69 999999999 1767.45 2831.43 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712866_1 CDM 0272 RC C1760 HCPCS inpatient 2919 1897.35 UMR - ALL PLANS UMR - ALL PLANS 2043.3 70 999999999 1767.45 2831.43 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712866_1 CDM 0272 RC C1760 HCPCS inpatient 2919 1897.35 SIHO - ALL PLANS SIHO - ALL PLANS 2627.1 90 999999999 1767.45 2831.43 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712866_1 CDM 0272 RC C1760 HCPCS inpatient 2919 1897.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1767.45 60.55 999999999 1767.45 2831.43 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712866_1 CDM 0272 RC C1760 HCPCS inpatient 2919 1897.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1767.45 2831.43 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712866_1 CDM 0272 RC C1760 HCPCS inpatient 2919 1897.35 ANTHEM HMO ANTHEM HMO 999999999 1767.45 2831.43 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712866_1 CDM 0272 RC C1760 HCPCS inpatient 2919 1897.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1767.45 2831.43 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712866_1 CDM 0272 RC C1760 HCPCS inpatient 2919 1897.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1973.24 67.6 999999999 1767.45 2831.43 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712866_1 CDM 0272 RC C1760 HCPCS inpatient 2919 1897.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1767.45 2831.43 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712866_1 CDM 0272 RC C1760 HCPCS inpatient 2919 1897.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1767.45 2831.43 SUTURE RETRIEVER HEWSON 48712867_1 CDM 0272 RC inpatient 899 584.35 AETNA AETNA 710.21 79 999999999 544.34 872.03 percent of total billed charges SUTURE RETRIEVER HEWSON 48712867_1 CDM 0272 RC inpatient 899 584.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 584.35 65 999999999 544.34 872.03 percent of total billed charges SUTURE RETRIEVER HEWSON 48712867_1 CDM 0272 RC inpatient 899 584.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 872.03 97 999999999 544.34 872.03 percent of total billed charges SUTURE RETRIEVER HEWSON 48712867_1 CDM 0272 RC inpatient 899 584.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 701.22 78 999999999 544.34 872.03 percent of total billed charges SUTURE RETRIEVER HEWSON 48712867_1 CDM 0272 RC inpatient 899 584.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 620.31 69 999999999 544.34 872.03 percent of total billed charges SUTURE RETRIEVER HEWSON 48712867_1 CDM 0272 RC inpatient 899 584.35 UMR - ALL PLANS UMR - ALL PLANS 629.3 70 999999999 544.34 872.03 percent of total billed charges SUTURE RETRIEVER HEWSON 48712867_1 CDM 0272 RC inpatient 899 584.35 SIHO - ALL PLANS SIHO - ALL PLANS 809.1 90 999999999 544.34 872.03 percent of total billed charges SUTURE RETRIEVER HEWSON 48712867_1 CDM 0272 RC inpatient 899 584.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 544.34 60.55 999999999 544.34 872.03 percent of total billed charges SUTURE RETRIEVER HEWSON 48712867_1 CDM 0272 RC inpatient 899 584.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 544.34 872.03 SUTURE RETRIEVER HEWSON 48712867_1 CDM 0272 RC inpatient 899 584.35 ANTHEM HMO ANTHEM HMO 999999999 544.34 872.03 SUTURE RETRIEVER HEWSON 48712867_1 CDM 0272 RC inpatient 899 584.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 544.34 872.03 SUTURE RETRIEVER HEWSON 48712867_1 CDM 0272 RC inpatient 899 584.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 607.72 67.6 999999999 544.34 872.03 percent of total billed charges SUTURE RETRIEVER HEWSON 48712867_1 CDM 0272 RC inpatient 899 584.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 544.34 872.03 SUTURE RETRIEVER HEWSON 48712867_1 CDM 0272 RC inpatient 899 584.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 544.34 872.03 DISPOSABLE PUNCH FOR SWIVELOCK 48712868_1 CDM 0272 RC inpatient 519 337.35 AETNA AETNA 410.01 79 999999999 314.25 503.43 percent of total billed charges DISPOSABLE PUNCH FOR SWIVELOCK 48712868_1 CDM 0272 RC inpatient 519 337.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 337.35 65 999999999 314.25 503.43 percent of total billed charges DISPOSABLE PUNCH FOR SWIVELOCK 48712868_1 CDM 0272 RC inpatient 519 337.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 503.43 97 999999999 314.25 503.43 percent of total billed charges DISPOSABLE PUNCH FOR SWIVELOCK 48712868_1 CDM 0272 RC inpatient 519 337.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 404.82 78 999999999 314.25 503.43 percent of total billed charges DISPOSABLE PUNCH FOR SWIVELOCK 48712868_1 CDM 0272 RC inpatient 519 337.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 358.11 69 999999999 314.25 503.43 percent of total billed charges DISPOSABLE PUNCH FOR SWIVELOCK 48712868_1 CDM 0272 RC inpatient 519 337.35 UMR - ALL PLANS UMR - ALL PLANS 363.3 70 999999999 314.25 503.43 percent of total billed charges DISPOSABLE PUNCH FOR SWIVELOCK 48712868_1 CDM 0272 RC inpatient 519 337.35 SIHO - ALL PLANS SIHO - ALL PLANS 467.1 90 999999999 314.25 503.43 percent of total billed charges DISPOSABLE PUNCH FOR SWIVELOCK 48712868_1 CDM 0272 RC inpatient 519 337.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 314.25 60.55 999999999 314.25 503.43 percent of total billed charges DISPOSABLE PUNCH FOR SWIVELOCK 48712868_1 CDM 0272 RC inpatient 519 337.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 314.25 503.43 DISPOSABLE PUNCH FOR SWIVELOCK 48712868_1 CDM 0272 RC inpatient 519 337.35 ANTHEM HMO ANTHEM HMO 999999999 314.25 503.43 DISPOSABLE PUNCH FOR SWIVELOCK 48712868_1 CDM 0272 RC inpatient 519 337.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 314.25 503.43 DISPOSABLE PUNCH FOR SWIVELOCK 48712868_1 CDM 0272 RC inpatient 519 337.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 350.84 67.6 999999999 314.25 503.43 percent of total billed charges DISPOSABLE PUNCH FOR SWIVELOCK 48712868_1 CDM 0272 RC inpatient 519 337.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 314.25 503.43 DISPOSABLE PUNCH FOR SWIVELOCK 48712868_1 CDM 0272 RC inpatient 519 337.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 314.25 503.43 SUTURE ETHIBOND #2 MX69G 48712869_1 CDM 0272 RC inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges SUTURE ETHIBOND #2 MX69G 48712869_1 CDM 0272 RC inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges SUTURE ETHIBOND #2 MX69G 48712869_1 CDM 0272 RC inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges SUTURE ETHIBOND #2 MX69G 48712869_1 CDM 0272 RC inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges SUTURE ETHIBOND #2 MX69G 48712869_1 CDM 0272 RC inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges SUTURE ETHIBOND #2 MX69G 48712869_1 CDM 0272 RC inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges SUTURE ETHIBOND #2 MX69G 48712869_1 CDM 0272 RC inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges SUTURE ETHIBOND #2 MX69G 48712869_1 CDM 0272 RC inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges SUTURE ETHIBOND #2 MX69G 48712869_1 CDM 0272 RC inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 SUTURE ETHIBOND #2 MX69G 48712869_1 CDM 0272 RC inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 SUTURE ETHIBOND #2 MX69G 48712869_1 CDM 0272 RC inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 SUTURE ETHIBOND #2 MX69G 48712869_1 CDM 0272 RC inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges SUTURE ETHIBOND #2 MX69G 48712869_1 CDM 0272 RC inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 SUTURE ETHIBOND #2 MX69G 48712869_1 CDM 0272 RC inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 SUTURE FIBERWIRE 2-0 #AR-7221 48712870_1 CDM 0272 RC inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges SUTURE FIBERWIRE 2-0 #AR-7221 48712870_1 CDM 0272 RC inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges SUTURE FIBERWIRE 2-0 #AR-7221 48712870_1 CDM 0272 RC inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges SUTURE FIBERWIRE 2-0 #AR-7221 48712870_1 CDM 0272 RC inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges SUTURE FIBERWIRE 2-0 #AR-7221 48712870_1 CDM 0272 RC inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges SUTURE FIBERWIRE 2-0 #AR-7221 48712870_1 CDM 0272 RC inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges SUTURE FIBERWIRE 2-0 #AR-7221 48712870_1 CDM 0272 RC inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges SUTURE FIBERWIRE 2-0 #AR-7221 48712870_1 CDM 0272 RC inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges SUTURE FIBERWIRE 2-0 #AR-7221 48712870_1 CDM 0272 RC inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 SUTURE FIBERWIRE 2-0 #AR-7221 48712870_1 CDM 0272 RC inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 SUTURE FIBERWIRE 2-0 #AR-7221 48712870_1 CDM 0272 RC inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 SUTURE FIBERWIRE 2-0 #AR-7221 48712870_1 CDM 0272 RC inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges SUTURE FIBERWIRE 2-0 #AR-7221 48712870_1 CDM 0272 RC inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 SUTURE FIBERWIRE 2-0 #AR-7221 48712870_1 CDM 0272 RC inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 SUT FIBERWIRE 2-0 #AR-7220 48712871_1 CDM 0272 RC inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges SUT FIBERWIRE 2-0 #AR-7220 48712871_1 CDM 0272 RC inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges SUT FIBERWIRE 2-0 #AR-7220 48712871_1 CDM 0272 RC inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges SUT FIBERWIRE 2-0 #AR-7220 48712871_1 CDM 0272 RC inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges SUT FIBERWIRE 2-0 #AR-7220 48712871_1 CDM 0272 RC inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges SUT FIBERWIRE 2-0 #AR-7220 48712871_1 CDM 0272 RC inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges SUT FIBERWIRE 2-0 #AR-7220 48712871_1 CDM 0272 RC inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges SUT FIBERWIRE 2-0 #AR-7220 48712871_1 CDM 0272 RC inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges SUT FIBERWIRE 2-0 #AR-7220 48712871_1 CDM 0272 RC inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 SUT FIBERWIRE 2-0 #AR-7220 48712871_1 CDM 0272 RC inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 SUT FIBERWIRE 2-0 #AR-7220 48712871_1 CDM 0272 RC inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 SUT FIBERWIRE 2-0 #AR-7220 48712871_1 CDM 0272 RC inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges SUT FIBERWIRE 2-0 #AR-7220 48712871_1 CDM 0272 RC inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 SUT FIBERWIRE 2-0 #AR-7220 48712871_1 CDM 0272 RC inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 SUT FIBERWIRE 2 #AR-7200 12/BX 48712872_1 CDM 0272 RC inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges SUT FIBERWIRE 2 #AR-7200 12/BX 48712872_1 CDM 0272 RC inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges SUT FIBERWIRE 2 #AR-7200 12/BX 48712872_1 CDM 0272 RC inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges SUT FIBERWIRE 2 #AR-7200 12/BX 48712872_1 CDM 0272 RC inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges SUT FIBERWIRE 2 #AR-7200 12/BX 48712872_1 CDM 0272 RC inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges SUT FIBERWIRE 2 #AR-7200 12/BX 48712872_1 CDM 0272 RC inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges SUT FIBERWIRE 2 #AR-7200 12/BX 48712872_1 CDM 0272 RC inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges SUT FIBERWIRE 2 #AR-7200 12/BX 48712872_1 CDM 0272 RC inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges SUT FIBERWIRE 2 #AR-7200 12/BX 48712872_1 CDM 0272 RC inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 SUT FIBERWIRE 2 #AR-7200 12/BX 48712872_1 CDM 0272 RC inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 SUT FIBERWIRE 2 #AR-7200 12/BX 48712872_1 CDM 0272 RC inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 SUT FIBERWIRE 2 #AR-7200 12/BX 48712872_1 CDM 0272 RC inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges SUT FIBERWIRE 2 #AR-7200 12/BX 48712872_1 CDM 0272 RC inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 SUT FIBERWIRE 2 #AR-7200 12/BX 48712872_1 CDM 0272 RC inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712873_1 CDM 0272 RC C1760 HCPCS inpatient 2684 1744.6 AETNA AETNA 2120.36 79 999999999 1625.16 2603.48 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712873_1 CDM 0272 RC C1760 HCPCS inpatient 2684 1744.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1744.6 65 999999999 1625.16 2603.48 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712873_1 CDM 0272 RC C1760 HCPCS inpatient 2684 1744.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2603.48 97 999999999 1625.16 2603.48 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712873_1 CDM 0272 RC C1760 HCPCS inpatient 2684 1744.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 2093.52 78 999999999 1625.16 2603.48 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712873_1 CDM 0272 RC C1760 HCPCS inpatient 2684 1744.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1851.96 69 999999999 1625.16 2603.48 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712873_1 CDM 0272 RC C1760 HCPCS inpatient 2684 1744.6 UMR - ALL PLANS UMR - ALL PLANS 1878.8 70 999999999 1625.16 2603.48 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712873_1 CDM 0272 RC C1760 HCPCS inpatient 2684 1744.6 SIHO - ALL PLANS SIHO - ALL PLANS 2415.6 90 999999999 1625.16 2603.48 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712873_1 CDM 0272 RC C1760 HCPCS inpatient 2684 1744.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1625.16 60.55 999999999 1625.16 2603.48 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712873_1 CDM 0272 RC C1760 HCPCS inpatient 2684 1744.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1625.16 2603.48 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712873_1 CDM 0272 RC C1760 HCPCS inpatient 2684 1744.6 ANTHEM HMO ANTHEM HMO 999999999 1625.16 2603.48 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712873_1 CDM 0272 RC C1760 HCPCS inpatient 2684 1744.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1625.16 2603.48 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712873_1 CDM 0272 RC C1760 HCPCS inpatient 2684 1744.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1814.38 67.6 999999999 1625.16 2603.48 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712873_1 CDM 0272 RC C1760 HCPCS inpatient 2684 1744.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1625.16 2603.48 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48712873_1 CDM 0272 RC C1760 HCPCS inpatient 2684 1744.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1625.16 2603.48 TRIUNE VENTED EAR TUBE 510-121 48712874_1 CDM 0272 RC inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges TRIUNE VENTED EAR TUBE 510-121 48712874_1 CDM 0272 RC inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges TRIUNE VENTED EAR TUBE 510-121 48712874_1 CDM 0272 RC inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges TRIUNE VENTED EAR TUBE 510-121 48712874_1 CDM 0272 RC inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges TRIUNE VENTED EAR TUBE 510-121 48712874_1 CDM 0272 RC inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges TRIUNE VENTED EAR TUBE 510-121 48712874_1 CDM 0272 RC inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges TRIUNE VENTED EAR TUBE 510-121 48712874_1 CDM 0272 RC inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges TRIUNE VENTED EAR TUBE 510-121 48712874_1 CDM 0272 RC inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges TRIUNE VENTED EAR TUBE 510-121 48712874_1 CDM 0272 RC inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 TRIUNE VENTED EAR TUBE 510-121 48712874_1 CDM 0272 RC inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 TRIUNE VENTED EAR TUBE 510-121 48712874_1 CDM 0272 RC inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 TRIUNE VENTED EAR TUBE 510-121 48712874_1 CDM 0272 RC inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges TRIUNE VENTED EAR TUBE 510-121 48712874_1 CDM 0272 RC inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 TRIUNE VENTED EAR TUBE 510-121 48712874_1 CDM 0272 RC inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 NASOPORE SINUS DRESSING 4CM 48712875_1 CDM 0272 RC inpatient 339 220.35 AETNA AETNA 267.81 79 999999999 205.26 328.83 percent of total billed charges NASOPORE SINUS DRESSING 4CM 48712875_1 CDM 0272 RC inpatient 339 220.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 220.35 65 999999999 205.26 328.83 percent of total billed charges NASOPORE SINUS DRESSING 4CM 48712875_1 CDM 0272 RC inpatient 339 220.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 328.83 97 999999999 205.26 328.83 percent of total billed charges NASOPORE SINUS DRESSING 4CM 48712875_1 CDM 0272 RC inpatient 339 220.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 264.42 78 999999999 205.26 328.83 percent of total billed charges NASOPORE SINUS DRESSING 4CM 48712875_1 CDM 0272 RC inpatient 339 220.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 233.91 69 999999999 205.26 328.83 percent of total billed charges NASOPORE SINUS DRESSING 4CM 48712875_1 CDM 0272 RC inpatient 339 220.35 UMR - ALL PLANS UMR - ALL PLANS 237.3 70 999999999 205.26 328.83 percent of total billed charges NASOPORE SINUS DRESSING 4CM 48712875_1 CDM 0272 RC inpatient 339 220.35 SIHO - ALL PLANS SIHO - ALL PLANS 305.1 90 999999999 205.26 328.83 percent of total billed charges NASOPORE SINUS DRESSING 4CM 48712875_1 CDM 0272 RC inpatient 339 220.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.26 60.55 999999999 205.26 328.83 percent of total billed charges NASOPORE SINUS DRESSING 4CM 48712875_1 CDM 0272 RC inpatient 339 220.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.26 328.83 NASOPORE SINUS DRESSING 4CM 48712875_1 CDM 0272 RC inpatient 339 220.35 ANTHEM HMO ANTHEM HMO 999999999 205.26 328.83 NASOPORE SINUS DRESSING 4CM 48712875_1 CDM 0272 RC inpatient 339 220.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.26 328.83 NASOPORE SINUS DRESSING 4CM 48712875_1 CDM 0272 RC inpatient 339 220.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.16 67.6 999999999 205.26 328.83 percent of total billed charges NASOPORE SINUS DRESSING 4CM 48712875_1 CDM 0272 RC inpatient 339 220.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.26 328.83 NASOPORE SINUS DRESSING 4CM 48712875_1 CDM 0272 RC inpatient 339 220.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.26 328.83 NASOPORE SINUS DRESSING 8CM 48712876_1 CDM 0272 RC inpatient 1134 737.1 AETNA AETNA 895.86 79 999999999 686.64 1099.98 percent of total billed charges NASOPORE SINUS DRESSING 8CM 48712876_1 CDM 0272 RC inpatient 1134 737.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 737.1 65 999999999 686.64 1099.98 percent of total billed charges NASOPORE SINUS DRESSING 8CM 48712876_1 CDM 0272 RC inpatient 1134 737.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1099.98 97 999999999 686.64 1099.98 percent of total billed charges NASOPORE SINUS DRESSING 8CM 48712876_1 CDM 0272 RC inpatient 1134 737.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 884.52 78 999999999 686.64 1099.98 percent of total billed charges NASOPORE SINUS DRESSING 8CM 48712876_1 CDM 0272 RC inpatient 1134 737.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 782.46 69 999999999 686.64 1099.98 percent of total billed charges NASOPORE SINUS DRESSING 8CM 48712876_1 CDM 0272 RC inpatient 1134 737.1 UMR - ALL PLANS UMR - ALL PLANS 793.8 70 999999999 686.64 1099.98 percent of total billed charges NASOPORE SINUS DRESSING 8CM 48712876_1 CDM 0272 RC inpatient 1134 737.1 SIHO - ALL PLANS SIHO - ALL PLANS 1020.6 90 999999999 686.64 1099.98 percent of total billed charges NASOPORE SINUS DRESSING 8CM 48712876_1 CDM 0272 RC inpatient 1134 737.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 686.64 60.55 999999999 686.64 1099.98 percent of total billed charges NASOPORE SINUS DRESSING 8CM 48712876_1 CDM 0272 RC inpatient 1134 737.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 686.64 1099.98 NASOPORE SINUS DRESSING 8CM 48712876_1 CDM 0272 RC inpatient 1134 737.1 ANTHEM HMO ANTHEM HMO 999999999 686.64 1099.98 NASOPORE SINUS DRESSING 8CM 48712876_1 CDM 0272 RC inpatient 1134 737.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 686.64 1099.98 NASOPORE SINUS DRESSING 8CM 48712876_1 CDM 0272 RC inpatient 1134 737.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 766.58 67.6 999999999 686.64 1099.98 percent of total billed charges NASOPORE SINUS DRESSING 8CM 48712876_1 CDM 0272 RC inpatient 1134 737.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 686.64 1099.98 NASOPORE SINUS DRESSING 8CM 48712876_1 CDM 0272 RC inpatient 1134 737.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 686.64 1099.98 SUTURE NUROLON 4-0 TF C584D 48712877_1 CDM 0272 RC inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges SUTURE NUROLON 4-0 TF C584D 48712877_1 CDM 0272 RC inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges SUTURE NUROLON 4-0 TF C584D 48712877_1 CDM 0272 RC inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges SUTURE NUROLON 4-0 TF C584D 48712877_1 CDM 0272 RC inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges SUTURE NUROLON 4-0 TF C584D 48712877_1 CDM 0272 RC inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges SUTURE NUROLON 4-0 TF C584D 48712877_1 CDM 0272 RC inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges SUTURE NUROLON 4-0 TF C584D 48712877_1 CDM 0272 RC inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges SUTURE NUROLON 4-0 TF C584D 48712877_1 CDM 0272 RC inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges SUTURE NUROLON 4-0 TF C584D 48712877_1 CDM 0272 RC inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 SUTURE NUROLON 4-0 TF C584D 48712877_1 CDM 0272 RC inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 SUTURE NUROLON 4-0 TF C584D 48712877_1 CDM 0272 RC inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 SUTURE NUROLON 4-0 TF C584D 48712877_1 CDM 0272 RC inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges SUTURE NUROLON 4-0 TF C584D 48712877_1 CDM 0272 RC inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 SUTURE NUROLON 4-0 TF C584D 48712877_1 CDM 0272 RC inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 PASSY-MUIR SPEAKING VALVE 48712878_1 CDM 0270 RC inpatient 438 284.7 AETNA AETNA 346.02 79 999999999 265.21 424.86 percent of total billed charges PASSY-MUIR SPEAKING VALVE 48712878_1 CDM 0270 RC inpatient 438 284.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 284.7 65 999999999 265.21 424.86 percent of total billed charges PASSY-MUIR SPEAKING VALVE 48712878_1 CDM 0270 RC inpatient 438 284.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 424.86 97 999999999 265.21 424.86 percent of total billed charges PASSY-MUIR SPEAKING VALVE 48712878_1 CDM 0270 RC inpatient 438 284.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 341.64 78 999999999 265.21 424.86 percent of total billed charges PASSY-MUIR SPEAKING VALVE 48712878_1 CDM 0270 RC inpatient 438 284.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 302.22 69 999999999 265.21 424.86 percent of total billed charges PASSY-MUIR SPEAKING VALVE 48712878_1 CDM 0270 RC inpatient 438 284.7 UMR - ALL PLANS UMR - ALL PLANS 306.6 70 999999999 265.21 424.86 percent of total billed charges PASSY-MUIR SPEAKING VALVE 48712878_1 CDM 0270 RC inpatient 438 284.7 SIHO - ALL PLANS SIHO - ALL PLANS 394.2 90 999999999 265.21 424.86 percent of total billed charges PASSY-MUIR SPEAKING VALVE 48712878_1 CDM 0270 RC inpatient 438 284.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 265.21 60.55 999999999 265.21 424.86 percent of total billed charges PASSY-MUIR SPEAKING VALVE 48712878_1 CDM 0270 RC inpatient 438 284.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 265.21 424.86 PASSY-MUIR SPEAKING VALVE 48712878_1 CDM 0270 RC inpatient 438 284.7 ANTHEM HMO ANTHEM HMO 999999999 265.21 424.86 PASSY-MUIR SPEAKING VALVE 48712878_1 CDM 0270 RC inpatient 438 284.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 265.21 424.86 PASSY-MUIR SPEAKING VALVE 48712878_1 CDM 0270 RC inpatient 438 284.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 296.09 67.6 999999999 265.21 424.86 percent of total billed charges PASSY-MUIR SPEAKING VALVE 48712878_1 CDM 0270 RC inpatient 438 284.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 265.21 424.86 PASSY-MUIR SPEAKING VALVE 48712878_1 CDM 0270 RC inpatient 438 284.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 265.21 424.86 RUMI TIP BLUE 6.7M X 8C UMB678 48712879_1 CDM 0272 RC inpatient 357 232.05 AETNA AETNA 282.03 79 999999999 216.16 346.29 percent of total billed charges RUMI TIP BLUE 6.7M X 8C UMB678 48712879_1 CDM 0272 RC inpatient 357 232.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 232.05 65 999999999 216.16 346.29 percent of total billed charges RUMI TIP BLUE 6.7M X 8C UMB678 48712879_1 CDM 0272 RC inpatient 357 232.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 346.29 97 999999999 216.16 346.29 percent of total billed charges RUMI TIP BLUE 6.7M X 8C UMB678 48712879_1 CDM 0272 RC inpatient 357 232.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 278.46 78 999999999 216.16 346.29 percent of total billed charges RUMI TIP BLUE 6.7M X 8C UMB678 48712879_1 CDM 0272 RC inpatient 357 232.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 246.33 69 999999999 216.16 346.29 percent of total billed charges RUMI TIP BLUE 6.7M X 8C UMB678 48712879_1 CDM 0272 RC inpatient 357 232.05 UMR - ALL PLANS UMR - ALL PLANS 249.9 70 999999999 216.16 346.29 percent of total billed charges RUMI TIP BLUE 6.7M X 8C UMB678 48712879_1 CDM 0272 RC inpatient 357 232.05 SIHO - ALL PLANS SIHO - ALL PLANS 321.3 90 999999999 216.16 346.29 percent of total billed charges RUMI TIP BLUE 6.7M X 8C UMB678 48712879_1 CDM 0272 RC inpatient 357 232.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 216.16 60.55 999999999 216.16 346.29 percent of total billed charges RUMI TIP BLUE 6.7M X 8C UMB678 48712879_1 CDM 0272 RC inpatient 357 232.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 216.16 346.29 RUMI TIP BLUE 6.7M X 8C UMB678 48712879_1 CDM 0272 RC inpatient 357 232.05 ANTHEM HMO ANTHEM HMO 999999999 216.16 346.29 RUMI TIP BLUE 6.7M X 8C UMB678 48712879_1 CDM 0272 RC inpatient 357 232.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 216.16 346.29 RUMI TIP BLUE 6.7M X 8C UMB678 48712879_1 CDM 0272 RC inpatient 357 232.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 241.33 67.6 999999999 216.16 346.29 percent of total billed charges RUMI TIP BLUE 6.7M X 8C UMB678 48712879_1 CDM 0272 RC inpatient 357 232.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 216.16 346.29 RUMI TIP BLUE 6.7M X 8C UMB678 48712879_1 CDM 0272 RC inpatient 357 232.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 216.16 346.29 KIT SPINAL EPIDURAL COMBO 19G 48712880_1 CDM 0272 RC inpatient 243 157.95 AETNA AETNA 191.97 79 999999999 147.14 235.71 percent of total billed charges KIT SPINAL EPIDURAL COMBO 19G 48712880_1 CDM 0272 RC inpatient 243 157.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 157.95 65 999999999 147.14 235.71 percent of total billed charges KIT SPINAL EPIDURAL COMBO 19G 48712880_1 CDM 0272 RC inpatient 243 157.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 235.71 97 999999999 147.14 235.71 percent of total billed charges KIT SPINAL EPIDURAL COMBO 19G 48712880_1 CDM 0272 RC inpatient 243 157.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 189.54 78 999999999 147.14 235.71 percent of total billed charges KIT SPINAL EPIDURAL COMBO 19G 48712880_1 CDM 0272 RC inpatient 243 157.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 167.67 69 999999999 147.14 235.71 percent of total billed charges KIT SPINAL EPIDURAL COMBO 19G 48712880_1 CDM 0272 RC inpatient 243 157.95 UMR - ALL PLANS UMR - ALL PLANS 170.1 70 999999999 147.14 235.71 percent of total billed charges KIT SPINAL EPIDURAL COMBO 19G 48712880_1 CDM 0272 RC inpatient 243 157.95 SIHO - ALL PLANS SIHO - ALL PLANS 218.7 90 999999999 147.14 235.71 percent of total billed charges KIT SPINAL EPIDURAL COMBO 19G 48712880_1 CDM 0272 RC inpatient 243 157.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.14 60.55 999999999 147.14 235.71 percent of total billed charges KIT SPINAL EPIDURAL COMBO 19G 48712880_1 CDM 0272 RC inpatient 243 157.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.14 235.71 KIT SPINAL EPIDURAL COMBO 19G 48712880_1 CDM 0272 RC inpatient 243 157.95 ANTHEM HMO ANTHEM HMO 999999999 147.14 235.71 KIT SPINAL EPIDURAL COMBO 19G 48712880_1 CDM 0272 RC inpatient 243 157.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.14 235.71 KIT SPINAL EPIDURAL COMBO 19G 48712880_1 CDM 0272 RC inpatient 243 157.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.27 67.6 999999999 147.14 235.71 percent of total billed charges KIT SPINAL EPIDURAL COMBO 19G 48712880_1 CDM 0272 RC inpatient 243 157.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.14 235.71 KIT SPINAL EPIDURAL COMBO 19G 48712880_1 CDM 0272 RC inpatient 243 157.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.14 235.71 SUTURE ENDOLOOP V-COATED EJ10G 48712881_1 CDM 0272 RC inpatient 235 152.75 AETNA AETNA 185.65 79 999999999 142.29 227.95 percent of total billed charges SUTURE ENDOLOOP V-COATED EJ10G 48712881_1 CDM 0272 RC inpatient 235 152.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 152.75 65 999999999 142.29 227.95 percent of total billed charges SUTURE ENDOLOOP V-COATED EJ10G 48712881_1 CDM 0272 RC inpatient 235 152.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 227.95 97 999999999 142.29 227.95 percent of total billed charges SUTURE ENDOLOOP V-COATED EJ10G 48712881_1 CDM 0272 RC inpatient 235 152.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 183.3 78 999999999 142.29 227.95 percent of total billed charges SUTURE ENDOLOOP V-COATED EJ10G 48712881_1 CDM 0272 RC inpatient 235 152.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 162.15 69 999999999 142.29 227.95 percent of total billed charges SUTURE ENDOLOOP V-COATED EJ10G 48712881_1 CDM 0272 RC inpatient 235 152.75 UMR - ALL PLANS UMR - ALL PLANS 164.5 70 999999999 142.29 227.95 percent of total billed charges SUTURE ENDOLOOP V-COATED EJ10G 48712881_1 CDM 0272 RC inpatient 235 152.75 SIHO - ALL PLANS SIHO - ALL PLANS 211.5 90 999999999 142.29 227.95 percent of total billed charges SUTURE ENDOLOOP V-COATED EJ10G 48712881_1 CDM 0272 RC inpatient 235 152.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 142.29 60.55 999999999 142.29 227.95 percent of total billed charges SUTURE ENDOLOOP V-COATED EJ10G 48712881_1 CDM 0272 RC inpatient 235 152.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 142.29 227.95 SUTURE ENDOLOOP V-COATED EJ10G 48712881_1 CDM 0272 RC inpatient 235 152.75 ANTHEM HMO ANTHEM HMO 999999999 142.29 227.95 SUTURE ENDOLOOP V-COATED EJ10G 48712881_1 CDM 0272 RC inpatient 235 152.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 142.29 227.95 SUTURE ENDOLOOP V-COATED EJ10G 48712881_1 CDM 0272 RC inpatient 235 152.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 158.86 67.6 999999999 142.29 227.95 percent of total billed charges SUTURE ENDOLOOP V-COATED EJ10G 48712881_1 CDM 0272 RC inpatient 235 152.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 142.29 227.95 SUTURE ENDOLOOP V-COATED EJ10G 48712881_1 CDM 0272 RC inpatient 235 152.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 142.29 227.95 SUTURE VICRYL #0 JJ31G 48712882_1 CDM 0272 RC inpatient 71 46.15 AETNA AETNA 56.09 79 999999999 42.99 68.87 percent of total billed charges SUTURE VICRYL #0 JJ31G 48712882_1 CDM 0272 RC inpatient 71 46.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.15 65 999999999 42.99 68.87 percent of total billed charges SUTURE VICRYL #0 JJ31G 48712882_1 CDM 0272 RC inpatient 71 46.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 68.87 97 999999999 42.99 68.87 percent of total billed charges SUTURE VICRYL #0 JJ31G 48712882_1 CDM 0272 RC inpatient 71 46.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 55.38 78 999999999 42.99 68.87 percent of total billed charges SUTURE VICRYL #0 JJ31G 48712882_1 CDM 0272 RC inpatient 71 46.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.99 69 999999999 42.99 68.87 percent of total billed charges SUTURE VICRYL #0 JJ31G 48712882_1 CDM 0272 RC inpatient 71 46.15 UMR - ALL PLANS UMR - ALL PLANS 49.7 70 999999999 42.99 68.87 percent of total billed charges SUTURE VICRYL #0 JJ31G 48712882_1 CDM 0272 RC inpatient 71 46.15 SIHO - ALL PLANS SIHO - ALL PLANS 63.9 90 999999999 42.99 68.87 percent of total billed charges SUTURE VICRYL #0 JJ31G 48712882_1 CDM 0272 RC inpatient 71 46.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.99 60.55 999999999 42.99 68.87 percent of total billed charges SUTURE VICRYL #0 JJ31G 48712882_1 CDM 0272 RC inpatient 71 46.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.99 68.87 SUTURE VICRYL #0 JJ31G 48712882_1 CDM 0272 RC inpatient 71 46.15 ANTHEM HMO ANTHEM HMO 999999999 42.99 68.87 SUTURE VICRYL #0 JJ31G 48712882_1 CDM 0272 RC inpatient 71 46.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.99 68.87 SUTURE VICRYL #0 JJ31G 48712882_1 CDM 0272 RC inpatient 71 46.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 48 67.6 999999999 42.99 68.87 percent of total billed charges SUTURE VICRYL #0 JJ31G 48712882_1 CDM 0272 RC inpatient 71 46.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.99 68.87 SUTURE VICRYL #0 JJ31G 48712882_1 CDM 0272 RC inpatient 71 46.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.99 68.87 STIMULATOR NERVE PROBE 3217 48712883_1 CDM 0272 RC inpatient 945 614.25 AETNA AETNA 746.55 79 999999999 572.2 916.65 percent of total billed charges STIMULATOR NERVE PROBE 3217 48712883_1 CDM 0272 RC inpatient 945 614.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 614.25 65 999999999 572.2 916.65 percent of total billed charges STIMULATOR NERVE PROBE 3217 48712883_1 CDM 0272 RC inpatient 945 614.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 916.65 97 999999999 572.2 916.65 percent of total billed charges STIMULATOR NERVE PROBE 3217 48712883_1 CDM 0272 RC inpatient 945 614.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 737.1 78 999999999 572.2 916.65 percent of total billed charges STIMULATOR NERVE PROBE 3217 48712883_1 CDM 0272 RC inpatient 945 614.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 652.05 69 999999999 572.2 916.65 percent of total billed charges STIMULATOR NERVE PROBE 3217 48712883_1 CDM 0272 RC inpatient 945 614.25 UMR - ALL PLANS UMR - ALL PLANS 661.5 70 999999999 572.2 916.65 percent of total billed charges STIMULATOR NERVE PROBE 3217 48712883_1 CDM 0272 RC inpatient 945 614.25 SIHO - ALL PLANS SIHO - ALL PLANS 850.5 90 999999999 572.2 916.65 percent of total billed charges STIMULATOR NERVE PROBE 3217 48712883_1 CDM 0272 RC inpatient 945 614.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 572.2 60.55 999999999 572.2 916.65 percent of total billed charges STIMULATOR NERVE PROBE 3217 48712883_1 CDM 0272 RC inpatient 945 614.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 572.2 916.65 STIMULATOR NERVE PROBE 3217 48712883_1 CDM 0272 RC inpatient 945 614.25 ANTHEM HMO ANTHEM HMO 999999999 572.2 916.65 STIMULATOR NERVE PROBE 3217 48712883_1 CDM 0272 RC inpatient 945 614.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 572.2 916.65 STIMULATOR NERVE PROBE 3217 48712883_1 CDM 0272 RC inpatient 945 614.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 638.82 67.6 999999999 572.2 916.65 percent of total billed charges STIMULATOR NERVE PROBE 3217 48712883_1 CDM 0272 RC inpatient 945 614.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 572.2 916.65 STIMULATOR NERVE PROBE 3217 48712883_1 CDM 0272 RC inpatient 945 614.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 572.2 916.65 SUTURE VICRYL 8-0 J574G OPHTH 48712884_1 CDM 0272 RC inpatient 134 87.1 AETNA AETNA 105.86 79 999999999 81.14 129.98 percent of total billed charges SUTURE VICRYL 8-0 J574G OPHTH 48712884_1 CDM 0272 RC inpatient 134 87.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 87.1 65 999999999 81.14 129.98 percent of total billed charges SUTURE VICRYL 8-0 J574G OPHTH 48712884_1 CDM 0272 RC inpatient 134 87.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.98 97 999999999 81.14 129.98 percent of total billed charges SUTURE VICRYL 8-0 J574G OPHTH 48712884_1 CDM 0272 RC inpatient 134 87.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 104.52 78 999999999 81.14 129.98 percent of total billed charges SUTURE VICRYL 8-0 J574G OPHTH 48712884_1 CDM 0272 RC inpatient 134 87.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 92.46 69 999999999 81.14 129.98 percent of total billed charges SUTURE VICRYL 8-0 J574G OPHTH 48712884_1 CDM 0272 RC inpatient 134 87.1 UMR - ALL PLANS UMR - ALL PLANS 93.8 70 999999999 81.14 129.98 percent of total billed charges SUTURE VICRYL 8-0 J574G OPHTH 48712884_1 CDM 0272 RC inpatient 134 87.1 SIHO - ALL PLANS SIHO - ALL PLANS 120.6 90 999999999 81.14 129.98 percent of total billed charges SUTURE VICRYL 8-0 J574G OPHTH 48712884_1 CDM 0272 RC inpatient 134 87.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 81.14 60.55 999999999 81.14 129.98 percent of total billed charges SUTURE VICRYL 8-0 J574G OPHTH 48712884_1 CDM 0272 RC inpatient 134 87.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 81.14 129.98 SUTURE VICRYL 8-0 J574G OPHTH 48712884_1 CDM 0272 RC inpatient 134 87.1 ANTHEM HMO ANTHEM HMO 999999999 81.14 129.98 SUTURE VICRYL 8-0 J574G OPHTH 48712884_1 CDM 0272 RC inpatient 134 87.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 81.14 129.98 SUTURE VICRYL 8-0 J574G OPHTH 48712884_1 CDM 0272 RC inpatient 134 87.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 90.58 67.6 999999999 81.14 129.98 percent of total billed charges SUTURE VICRYL 8-0 J574G OPHTH 48712884_1 CDM 0272 RC inpatient 134 87.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 81.14 129.98 SUTURE VICRYL 8-0 J574G OPHTH 48712884_1 CDM 0272 RC inpatient 134 87.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 81.14 129.98 SUTURE VICRYL 3-0 J774D 48712885_1 CDM 0272 RC inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges SUTURE VICRYL 3-0 J774D 48712885_1 CDM 0272 RC inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges SUTURE VICRYL 3-0 J774D 48712885_1 CDM 0272 RC inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges SUTURE VICRYL 3-0 J774D 48712885_1 CDM 0272 RC inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges SUTURE VICRYL 3-0 J774D 48712885_1 CDM 0272 RC inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges SUTURE VICRYL 3-0 J774D 48712885_1 CDM 0272 RC inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges SUTURE VICRYL 3-0 J774D 48712885_1 CDM 0272 RC inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges SUTURE VICRYL 3-0 J774D 48712885_1 CDM 0272 RC inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges SUTURE VICRYL 3-0 J774D 48712885_1 CDM 0272 RC inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 SUTURE VICRYL 3-0 J774D 48712885_1 CDM 0272 RC inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 SUTURE VICRYL 3-0 J774D 48712885_1 CDM 0272 RC inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 SUTURE VICRYL 3-0 J774D 48712885_1 CDM 0272 RC inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges SUTURE VICRYL 3-0 J774D 48712885_1 CDM 0272 RC inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 SUTURE VICRYL 3-0 J774D 48712885_1 CDM 0272 RC inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 SUTURE VICRYL 0 JTN0G 48712886_1 CDM 0272 RC inpatient 646 419.9 AETNA AETNA 510.34 79 999999999 391.15 626.62 percent of total billed charges SUTURE VICRYL 0 JTN0G 48712886_1 CDM 0272 RC inpatient 646 419.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 419.9 65 999999999 391.15 626.62 percent of total billed charges SUTURE VICRYL 0 JTN0G 48712886_1 CDM 0272 RC inpatient 646 419.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 626.62 97 999999999 391.15 626.62 percent of total billed charges SUTURE VICRYL 0 JTN0G 48712886_1 CDM 0272 RC inpatient 646 419.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 503.88 78 999999999 391.15 626.62 percent of total billed charges SUTURE VICRYL 0 JTN0G 48712886_1 CDM 0272 RC inpatient 646 419.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 445.74 69 999999999 391.15 626.62 percent of total billed charges SUTURE VICRYL 0 JTN0G 48712886_1 CDM 0272 RC inpatient 646 419.9 UMR - ALL PLANS UMR - ALL PLANS 452.2 70 999999999 391.15 626.62 percent of total billed charges SUTURE VICRYL 0 JTN0G 48712886_1 CDM 0272 RC inpatient 646 419.9 SIHO - ALL PLANS SIHO - ALL PLANS 581.4 90 999999999 391.15 626.62 percent of total billed charges SUTURE VICRYL 0 JTN0G 48712886_1 CDM 0272 RC inpatient 646 419.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 391.15 60.55 999999999 391.15 626.62 percent of total billed charges SUTURE VICRYL 0 JTN0G 48712886_1 CDM 0272 RC inpatient 646 419.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 391.15 626.62 SUTURE VICRYL 0 JTN0G 48712886_1 CDM 0272 RC inpatient 646 419.9 ANTHEM HMO ANTHEM HMO 999999999 391.15 626.62 SUTURE VICRYL 0 JTN0G 48712886_1 CDM 0272 RC inpatient 646 419.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 391.15 626.62 SUTURE VICRYL 0 JTN0G 48712886_1 CDM 0272 RC inpatient 646 419.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 436.7 67.6 999999999 391.15 626.62 percent of total billed charges SUTURE VICRYL 0 JTN0G 48712886_1 CDM 0272 RC inpatient 646 419.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 391.15 626.62 SUTURE VICRYL 0 JTN0G 48712886_1 CDM 0272 RC inpatient 646 419.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 391.15 626.62 SENSOR BIS QUATRO 186-0106 48712887_1 CDM 0271 RC inpatient 97 63.05 AETNA AETNA 76.63 79 999999999 58.73 94.09 percent of total billed charges SENSOR BIS QUATRO 186-0106 48712887_1 CDM 0271 RC inpatient 97 63.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.05 65 999999999 58.73 94.09 percent of total billed charges SENSOR BIS QUATRO 186-0106 48712887_1 CDM 0271 RC inpatient 97 63.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 94.09 97 999999999 58.73 94.09 percent of total billed charges SENSOR BIS QUATRO 186-0106 48712887_1 CDM 0271 RC inpatient 97 63.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 75.66 78 999999999 58.73 94.09 percent of total billed charges SENSOR BIS QUATRO 186-0106 48712887_1 CDM 0271 RC inpatient 97 63.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.93 69 999999999 58.73 94.09 percent of total billed charges SENSOR BIS QUATRO 186-0106 48712887_1 CDM 0271 RC inpatient 97 63.05 UMR - ALL PLANS UMR - ALL PLANS 67.9 70 999999999 58.73 94.09 percent of total billed charges SENSOR BIS QUATRO 186-0106 48712887_1 CDM 0271 RC inpatient 97 63.05 SIHO - ALL PLANS SIHO - ALL PLANS 87.3 90 999999999 58.73 94.09 percent of total billed charges SENSOR BIS QUATRO 186-0106 48712887_1 CDM 0271 RC inpatient 97 63.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.73 60.55 999999999 58.73 94.09 percent of total billed charges SENSOR BIS QUATRO 186-0106 48712887_1 CDM 0271 RC inpatient 97 63.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.73 94.09 SENSOR BIS QUATRO 186-0106 48712887_1 CDM 0271 RC inpatient 97 63.05 ANTHEM HMO ANTHEM HMO 999999999 58.73 94.09 SENSOR BIS QUATRO 186-0106 48712887_1 CDM 0271 RC inpatient 97 63.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.73 94.09 SENSOR BIS QUATRO 186-0106 48712887_1 CDM 0271 RC inpatient 97 63.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 65.57 67.6 999999999 58.73 94.09 percent of total billed charges SENSOR BIS QUATRO 186-0106 48712887_1 CDM 0271 RC inpatient 97 63.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.73 94.09 SENSOR BIS QUATRO 186-0106 48712887_1 CDM 0271 RC inpatient 97 63.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.73 94.09 NERVE STIMULATOR PROBE 3188 48712888_1 CDM 0272 RC inpatient 621 403.65 AETNA AETNA 490.59 79 999999999 376.02 602.37 percent of total billed charges NERVE STIMULATOR PROBE 3188 48712888_1 CDM 0272 RC inpatient 621 403.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 403.65 65 999999999 376.02 602.37 percent of total billed charges NERVE STIMULATOR PROBE 3188 48712888_1 CDM 0272 RC inpatient 621 403.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 602.37 97 999999999 376.02 602.37 percent of total billed charges NERVE STIMULATOR PROBE 3188 48712888_1 CDM 0272 RC inpatient 621 403.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 484.38 78 999999999 376.02 602.37 percent of total billed charges NERVE STIMULATOR PROBE 3188 48712888_1 CDM 0272 RC inpatient 621 403.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 428.49 69 999999999 376.02 602.37 percent of total billed charges NERVE STIMULATOR PROBE 3188 48712888_1 CDM 0272 RC inpatient 621 403.65 UMR - ALL PLANS UMR - ALL PLANS 434.7 70 999999999 376.02 602.37 percent of total billed charges NERVE STIMULATOR PROBE 3188 48712888_1 CDM 0272 RC inpatient 621 403.65 SIHO - ALL PLANS SIHO - ALL PLANS 558.9 90 999999999 376.02 602.37 percent of total billed charges NERVE STIMULATOR PROBE 3188 48712888_1 CDM 0272 RC inpatient 621 403.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 376.02 60.55 999999999 376.02 602.37 percent of total billed charges NERVE STIMULATOR PROBE 3188 48712888_1 CDM 0272 RC inpatient 621 403.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 376.02 602.37 NERVE STIMULATOR PROBE 3188 48712888_1 CDM 0272 RC inpatient 621 403.65 ANTHEM HMO ANTHEM HMO 999999999 376.02 602.37 NERVE STIMULATOR PROBE 3188 48712888_1 CDM 0272 RC inpatient 621 403.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 376.02 602.37 NERVE STIMULATOR PROBE 3188 48712888_1 CDM 0272 RC inpatient 621 403.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 419.8 67.6 999999999 376.02 602.37 percent of total billed charges NERVE STIMULATOR PROBE 3188 48712888_1 CDM 0272 RC inpatient 621 403.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 376.02 602.37 NERVE STIMULATOR PROBE 3188 48712888_1 CDM 0272 RC inpatient 621 403.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 376.02 602.37 UNIVERSAL HEAD RESTRAINT A-90023 48712889_1 CDM 0271 RC inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges UNIVERSAL HEAD RESTRAINT A-90023 48712889_1 CDM 0271 RC inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges UNIVERSAL HEAD RESTRAINT A-90023 48712889_1 CDM 0271 RC inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges UNIVERSAL HEAD RESTRAINT A-90023 48712889_1 CDM 0271 RC inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges UNIVERSAL HEAD RESTRAINT A-90023 48712889_1 CDM 0271 RC inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges UNIVERSAL HEAD RESTRAINT A-90023 48712889_1 CDM 0271 RC inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges UNIVERSAL HEAD RESTRAINT A-90023 48712889_1 CDM 0271 RC inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges UNIVERSAL HEAD RESTRAINT A-90023 48712889_1 CDM 0271 RC inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges UNIVERSAL HEAD RESTRAINT A-90023 48712889_1 CDM 0271 RC inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 UNIVERSAL HEAD RESTRAINT A-90023 48712889_1 CDM 0271 RC inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 UNIVERSAL HEAD RESTRAINT A-90023 48712889_1 CDM 0271 RC inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 UNIVERSAL HEAD RESTRAINT A-90023 48712889_1 CDM 0271 RC inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges UNIVERSAL HEAD RESTRAINT A-90023 48712889_1 CDM 0271 RC inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 UNIVERSAL HEAD RESTRAINT A-90023 48712889_1 CDM 0271 RC inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 SHOULDER STABILIZATION KIT 7210573 48712890_1 CDM 0272 RC inpatient 495 321.75 AETNA AETNA 391.05 79 999999999 299.72 480.15 percent of total billed charges SHOULDER STABILIZATION KIT 7210573 48712890_1 CDM 0272 RC inpatient 495 321.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 321.75 65 999999999 299.72 480.15 percent of total billed charges SHOULDER STABILIZATION KIT 7210573 48712890_1 CDM 0272 RC inpatient 495 321.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 480.15 97 999999999 299.72 480.15 percent of total billed charges SHOULDER STABILIZATION KIT 7210573 48712890_1 CDM 0272 RC inpatient 495 321.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 386.1 78 999999999 299.72 480.15 percent of total billed charges SHOULDER STABILIZATION KIT 7210573 48712890_1 CDM 0272 RC inpatient 495 321.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 341.55 69 999999999 299.72 480.15 percent of total billed charges SHOULDER STABILIZATION KIT 7210573 48712890_1 CDM 0272 RC inpatient 495 321.75 UMR - ALL PLANS UMR - ALL PLANS 346.5 70 999999999 299.72 480.15 percent of total billed charges SHOULDER STABILIZATION KIT 7210573 48712890_1 CDM 0272 RC inpatient 495 321.75 SIHO - ALL PLANS SIHO - ALL PLANS 445.5 90 999999999 299.72 480.15 percent of total billed charges SHOULDER STABILIZATION KIT 7210573 48712890_1 CDM 0272 RC inpatient 495 321.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 299.72 60.55 999999999 299.72 480.15 percent of total billed charges SHOULDER STABILIZATION KIT 7210573 48712890_1 CDM 0272 RC inpatient 495 321.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 299.72 480.15 SHOULDER STABILIZATION KIT 7210573 48712890_1 CDM 0272 RC inpatient 495 321.75 ANTHEM HMO ANTHEM HMO 999999999 299.72 480.15 SHOULDER STABILIZATION KIT 7210573 48712890_1 CDM 0272 RC inpatient 495 321.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 299.72 480.15 SHOULDER STABILIZATION KIT 7210573 48712890_1 CDM 0272 RC inpatient 495 321.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 334.62 67.6 999999999 299.72 480.15 percent of total billed charges SHOULDER STABILIZATION KIT 7210573 48712890_1 CDM 0272 RC inpatient 495 321.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 299.72 480.15 SHOULDER STABILIZATION KIT 7210573 48712890_1 CDM 0272 RC inpatient 495 321.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 299.72 480.15 PROTECTOR WOUND XSMALL C8322 48712891_1 CDM 0272 RC inpatient 280 182 AETNA AETNA 221.2 79 999999999 169.54 271.6 percent of total billed charges PROTECTOR WOUND XSMALL C8322 48712891_1 CDM 0272 RC inpatient 280 182 SELF PAY DISCOUNT SELF PAY DISCOUNT 182 65 999999999 169.54 271.6 percent of total billed charges PROTECTOR WOUND XSMALL C8322 48712891_1 CDM 0272 RC inpatient 280 182 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 271.6 97 999999999 169.54 271.6 percent of total billed charges PROTECTOR WOUND XSMALL C8322 48712891_1 CDM 0272 RC inpatient 280 182 HUMANA - ALL PLANS HUMANA - ALL PLANS 218.4 78 999999999 169.54 271.6 percent of total billed charges PROTECTOR WOUND XSMALL C8322 48712891_1 CDM 0272 RC inpatient 280 182 ENCORE - ALL PLANS ENCORE - ALL PLANS 193.2 69 999999999 169.54 271.6 percent of total billed charges PROTECTOR WOUND XSMALL C8322 48712891_1 CDM 0272 RC inpatient 280 182 UMR - ALL PLANS UMR - ALL PLANS 196 70 999999999 169.54 271.6 percent of total billed charges PROTECTOR WOUND XSMALL C8322 48712891_1 CDM 0272 RC inpatient 280 182 SIHO - ALL PLANS SIHO - ALL PLANS 252 90 999999999 169.54 271.6 percent of total billed charges PROTECTOR WOUND XSMALL C8322 48712891_1 CDM 0272 RC inpatient 280 182 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 169.54 60.55 999999999 169.54 271.6 percent of total billed charges PROTECTOR WOUND XSMALL C8322 48712891_1 CDM 0272 RC inpatient 280 182 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 169.54 271.6 PROTECTOR WOUND XSMALL C8322 48712891_1 CDM 0272 RC inpatient 280 182 ANTHEM HMO ANTHEM HMO 999999999 169.54 271.6 PROTECTOR WOUND XSMALL C8322 48712891_1 CDM 0272 RC inpatient 280 182 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 169.54 271.6 PROTECTOR WOUND XSMALL C8322 48712891_1 CDM 0272 RC inpatient 280 182 CIGNA - ALL PLANS CIGNA - ALL PLANS 189.28 67.6 999999999 169.54 271.6 percent of total billed charges PROTECTOR WOUND XSMALL C8322 48712891_1 CDM 0272 RC inpatient 280 182 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 169.54 271.6 PROTECTOR WOUND XSMALL C8322 48712891_1 CDM 0272 RC inpatient 280 182 UHC - ALL PLANS UHC - ALL PLANS 999999999 169.54 271.6 PROTECTOR WOUND SMALL WPS256 48712892_1 CDM 0272 RC inpatient 154 100.1 AETNA AETNA 121.66 79 999999999 93.25 149.38 percent of total billed charges PROTECTOR WOUND SMALL WPS256 48712892_1 CDM 0272 RC inpatient 154 100.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.1 65 999999999 93.25 149.38 percent of total billed charges PROTECTOR WOUND SMALL WPS256 48712892_1 CDM 0272 RC inpatient 154 100.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 149.38 97 999999999 93.25 149.38 percent of total billed charges PROTECTOR WOUND SMALL WPS256 48712892_1 CDM 0272 RC inpatient 154 100.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.12 78 999999999 93.25 149.38 percent of total billed charges PROTECTOR WOUND SMALL WPS256 48712892_1 CDM 0272 RC inpatient 154 100.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.26 69 999999999 93.25 149.38 percent of total billed charges PROTECTOR WOUND SMALL WPS256 48712892_1 CDM 0272 RC inpatient 154 100.1 UMR - ALL PLANS UMR - ALL PLANS 107.8 70 999999999 93.25 149.38 percent of total billed charges PROTECTOR WOUND SMALL WPS256 48712892_1 CDM 0272 RC inpatient 154 100.1 SIHO - ALL PLANS SIHO - ALL PLANS 138.6 90 999999999 93.25 149.38 percent of total billed charges PROTECTOR WOUND SMALL WPS256 48712892_1 CDM 0272 RC inpatient 154 100.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.25 60.55 999999999 93.25 149.38 percent of total billed charges PROTECTOR WOUND SMALL WPS256 48712892_1 CDM 0272 RC inpatient 154 100.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.25 149.38 PROTECTOR WOUND SMALL WPS256 48712892_1 CDM 0272 RC inpatient 154 100.1 ANTHEM HMO ANTHEM HMO 999999999 93.25 149.38 PROTECTOR WOUND SMALL WPS256 48712892_1 CDM 0272 RC inpatient 154 100.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.25 149.38 PROTECTOR WOUND SMALL WPS256 48712892_1 CDM 0272 RC inpatient 154 100.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.1 67.6 999999999 93.25 149.38 percent of total billed charges PROTECTOR WOUND SMALL WPS256 48712892_1 CDM 0272 RC inpatient 154 100.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.25 149.38 PROTECTOR WOUND SMALL WPS256 48712892_1 CDM 0272 RC inpatient 154 100.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.25 149.38 SUCTION TIP LIGHTED 2658010002 48712893_1 CDM 0272 RC inpatient 684 444.6 AETNA AETNA 540.36 79 999999999 414.16 663.48 percent of total billed charges SUCTION TIP LIGHTED 2658010002 48712893_1 CDM 0272 RC inpatient 684 444.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 444.6 65 999999999 414.16 663.48 percent of total billed charges SUCTION TIP LIGHTED 2658010002 48712893_1 CDM 0272 RC inpatient 684 444.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 663.48 97 999999999 414.16 663.48 percent of total billed charges SUCTION TIP LIGHTED 2658010002 48712893_1 CDM 0272 RC inpatient 684 444.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 533.52 78 999999999 414.16 663.48 percent of total billed charges SUCTION TIP LIGHTED 2658010002 48712893_1 CDM 0272 RC inpatient 684 444.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 471.96 69 999999999 414.16 663.48 percent of total billed charges SUCTION TIP LIGHTED 2658010002 48712893_1 CDM 0272 RC inpatient 684 444.6 UMR - ALL PLANS UMR - ALL PLANS 478.8 70 999999999 414.16 663.48 percent of total billed charges SUCTION TIP LIGHTED 2658010002 48712893_1 CDM 0272 RC inpatient 684 444.6 SIHO - ALL PLANS SIHO - ALL PLANS 615.6 90 999999999 414.16 663.48 percent of total billed charges SUCTION TIP LIGHTED 2658010002 48712893_1 CDM 0272 RC inpatient 684 444.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 414.16 60.55 999999999 414.16 663.48 percent of total billed charges SUCTION TIP LIGHTED 2658010002 48712893_1 CDM 0272 RC inpatient 684 444.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 414.16 663.48 SUCTION TIP LIGHTED 2658010002 48712893_1 CDM 0272 RC inpatient 684 444.6 ANTHEM HMO ANTHEM HMO 999999999 414.16 663.48 SUCTION TIP LIGHTED 2658010002 48712893_1 CDM 0272 RC inpatient 684 444.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 414.16 663.48 SUCTION TIP LIGHTED 2658010002 48712893_1 CDM 0272 RC inpatient 684 444.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 462.38 67.6 999999999 414.16 663.48 percent of total billed charges SUCTION TIP LIGHTED 2658010002 48712893_1 CDM 0272 RC inpatient 684 444.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 414.16 663.48 SUCTION TIP LIGHTED 2658010002 48712893_1 CDM 0272 RC inpatient 684 444.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 414.16 663.48 MAMMO MARK 8GA MAM3008 (OE) 48712894_1 CDM 0270 RC inpatient 588 382.2 AETNA AETNA 464.52 79 999999999 356.03 570.36 percent of total billed charges MAMMO MARK 8GA MAM3008 (OE) 48712894_1 CDM 0270 RC inpatient 588 382.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 382.2 65 999999999 356.03 570.36 percent of total billed charges MAMMO MARK 8GA MAM3008 (OE) 48712894_1 CDM 0270 RC inpatient 588 382.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 570.36 97 999999999 356.03 570.36 percent of total billed charges MAMMO MARK 8GA MAM3008 (OE) 48712894_1 CDM 0270 RC inpatient 588 382.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 458.64 78 999999999 356.03 570.36 percent of total billed charges MAMMO MARK 8GA MAM3008 (OE) 48712894_1 CDM 0270 RC inpatient 588 382.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 405.72 69 999999999 356.03 570.36 percent of total billed charges MAMMO MARK 8GA MAM3008 (OE) 48712894_1 CDM 0270 RC inpatient 588 382.2 UMR - ALL PLANS UMR - ALL PLANS 411.6 70 999999999 356.03 570.36 percent of total billed charges MAMMO MARK 8GA MAM3008 (OE) 48712894_1 CDM 0270 RC inpatient 588 382.2 SIHO - ALL PLANS SIHO - ALL PLANS 529.2 90 999999999 356.03 570.36 percent of total billed charges MAMMO MARK 8GA MAM3008 (OE) 48712894_1 CDM 0270 RC inpatient 588 382.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 356.03 60.55 999999999 356.03 570.36 percent of total billed charges MAMMO MARK 8GA MAM3008 (OE) 48712894_1 CDM 0270 RC inpatient 588 382.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 356.03 570.36 MAMMO MARK 8GA MAM3008 (OE) 48712894_1 CDM 0270 RC inpatient 588 382.2 ANTHEM HMO ANTHEM HMO 999999999 356.03 570.36 MAMMO MARK 8GA MAM3008 (OE) 48712894_1 CDM 0270 RC inpatient 588 382.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 356.03 570.36 MAMMO MARK 8GA MAM3008 (OE) 48712894_1 CDM 0270 RC inpatient 588 382.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 397.49 67.6 999999999 356.03 570.36 percent of total billed charges MAMMO MARK 8GA MAM3008 (OE) 48712894_1 CDM 0270 RC inpatient 588 382.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 356.03 570.36 MAMMO MARK 8GA MAM3008 (OE) 48712894_1 CDM 0270 RC inpatient 588 382.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 356.03 570.36 VLOC 0 WOUND CLOSURE VLOCA008L 48712895_1 CDM 0272 RC inpatient 317 206.05 AETNA AETNA 250.43 79 999999999 191.94 307.49 percent of total billed charges VLOC 0 WOUND CLOSURE VLOCA008L 48712895_1 CDM 0272 RC inpatient 317 206.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 206.05 65 999999999 191.94 307.49 percent of total billed charges VLOC 0 WOUND CLOSURE VLOCA008L 48712895_1 CDM 0272 RC inpatient 317 206.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 307.49 97 999999999 191.94 307.49 percent of total billed charges VLOC 0 WOUND CLOSURE VLOCA008L 48712895_1 CDM 0272 RC inpatient 317 206.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 247.26 78 999999999 191.94 307.49 percent of total billed charges VLOC 0 WOUND CLOSURE VLOCA008L 48712895_1 CDM 0272 RC inpatient 317 206.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 218.73 69 999999999 191.94 307.49 percent of total billed charges VLOC 0 WOUND CLOSURE VLOCA008L 48712895_1 CDM 0272 RC inpatient 317 206.05 UMR - ALL PLANS UMR - ALL PLANS 221.9 70 999999999 191.94 307.49 percent of total billed charges VLOC 0 WOUND CLOSURE VLOCA008L 48712895_1 CDM 0272 RC inpatient 317 206.05 SIHO - ALL PLANS SIHO - ALL PLANS 285.3 90 999999999 191.94 307.49 percent of total billed charges VLOC 0 WOUND CLOSURE VLOCA008L 48712895_1 CDM 0272 RC inpatient 317 206.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 191.94 60.55 999999999 191.94 307.49 percent of total billed charges VLOC 0 WOUND CLOSURE VLOCA008L 48712895_1 CDM 0272 RC inpatient 317 206.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 191.94 307.49 VLOC 0 WOUND CLOSURE VLOCA008L 48712895_1 CDM 0272 RC inpatient 317 206.05 ANTHEM HMO ANTHEM HMO 999999999 191.94 307.49 VLOC 0 WOUND CLOSURE VLOCA008L 48712895_1 CDM 0272 RC inpatient 317 206.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 191.94 307.49 VLOC 0 WOUND CLOSURE VLOCA008L 48712895_1 CDM 0272 RC inpatient 317 206.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 214.29 67.6 999999999 191.94 307.49 percent of total billed charges VLOC 0 WOUND CLOSURE VLOCA008L 48712895_1 CDM 0272 RC inpatient 317 206.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 191.94 307.49 VLOC 0 WOUND CLOSURE VLOCA008L 48712895_1 CDM 0272 RC inpatient 317 206.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 191.94 307.49 **** BLANKETED BY MEGAN P. 10/18/2023 ***RUMI KOH EFFICIENT 2.5CM 48712896_1 CDM 0272 RC inpatient 611 397.15 AETNA AETNA 482.69 79 999999999 369.96 592.67 percent of total billed charges **** BLANKETED BY MEGAN P. 10/18/2023 ***RUMI KOH EFFICIENT 2.5CM 48712896_1 CDM 0272 RC inpatient 611 397.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 397.15 65 999999999 369.96 592.67 percent of total billed charges **** BLANKETED BY MEGAN P. 10/18/2023 ***RUMI KOH EFFICIENT 2.5CM 48712896_1 CDM 0272 RC inpatient 611 397.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 592.67 97 999999999 369.96 592.67 percent of total billed charges **** BLANKETED BY MEGAN P. 10/18/2023 ***RUMI KOH EFFICIENT 2.5CM 48712896_1 CDM 0272 RC inpatient 611 397.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 476.58 78 999999999 369.96 592.67 percent of total billed charges **** BLANKETED BY MEGAN P. 10/18/2023 ***RUMI KOH EFFICIENT 2.5CM 48712896_1 CDM 0272 RC inpatient 611 397.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 421.59 69 999999999 369.96 592.67 percent of total billed charges **** BLANKETED BY MEGAN P. 10/18/2023 ***RUMI KOH EFFICIENT 2.5CM 48712896_1 CDM 0272 RC inpatient 611 397.15 UMR - ALL PLANS UMR - ALL PLANS 427.7 70 999999999 369.96 592.67 percent of total billed charges **** BLANKETED BY MEGAN P. 10/18/2023 ***RUMI KOH EFFICIENT 2.5CM 48712896_1 CDM 0272 RC inpatient 611 397.15 SIHO - ALL PLANS SIHO - ALL PLANS 549.9 90 999999999 369.96 592.67 percent of total billed charges **** BLANKETED BY MEGAN P. 10/18/2023 ***RUMI KOH EFFICIENT 2.5CM 48712896_1 CDM 0272 RC inpatient 611 397.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 369.96 60.55 999999999 369.96 592.67 percent of total billed charges **** BLANKETED BY MEGAN P. 10/18/2023 ***RUMI KOH EFFICIENT 2.5CM 48712896_1 CDM 0272 RC inpatient 611 397.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 369.96 592.67 **** BLANKETED BY MEGAN P. 10/18/2023 ***RUMI KOH EFFICIENT 2.5CM 48712896_1 CDM 0272 RC inpatient 611 397.15 ANTHEM HMO ANTHEM HMO 999999999 369.96 592.67 **** BLANKETED BY MEGAN P. 10/18/2023 ***RUMI KOH EFFICIENT 2.5CM 48712896_1 CDM 0272 RC inpatient 611 397.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 369.96 592.67 **** BLANKETED BY MEGAN P. 10/18/2023 ***RUMI KOH EFFICIENT 2.5CM 48712896_1 CDM 0272 RC inpatient 611 397.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 413.04 67.6 999999999 369.96 592.67 percent of total billed charges **** BLANKETED BY MEGAN P. 10/18/2023 ***RUMI KOH EFFICIENT 2.5CM 48712896_1 CDM 0272 RC inpatient 611 397.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 369.96 592.67 **** BLANKETED BY MEGAN P. 10/18/2023 ***RUMI KOH EFFICIENT 2.5CM 48712896_1 CDM 0272 RC inpatient 611 397.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 369.96 592.67 RUMI KOH EFFICIENT 3.OCM 48712897_1 CDM 0272 RC inpatient 699 454.35 AETNA AETNA 552.21 79 999999999 423.24 678.03 percent of total billed charges RUMI KOH EFFICIENT 3.OCM 48712897_1 CDM 0272 RC inpatient 699 454.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 454.35 65 999999999 423.24 678.03 percent of total billed charges RUMI KOH EFFICIENT 3.OCM 48712897_1 CDM 0272 RC inpatient 699 454.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 678.03 97 999999999 423.24 678.03 percent of total billed charges RUMI KOH EFFICIENT 3.OCM 48712897_1 CDM 0272 RC inpatient 699 454.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 545.22 78 999999999 423.24 678.03 percent of total billed charges RUMI KOH EFFICIENT 3.OCM 48712897_1 CDM 0272 RC inpatient 699 454.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 482.31 69 999999999 423.24 678.03 percent of total billed charges RUMI KOH EFFICIENT 3.OCM 48712897_1 CDM 0272 RC inpatient 699 454.35 UMR - ALL PLANS UMR - ALL PLANS 489.3 70 999999999 423.24 678.03 percent of total billed charges RUMI KOH EFFICIENT 3.OCM 48712897_1 CDM 0272 RC inpatient 699 454.35 SIHO - ALL PLANS SIHO - ALL PLANS 629.1 90 999999999 423.24 678.03 percent of total billed charges RUMI KOH EFFICIENT 3.OCM 48712897_1 CDM 0272 RC inpatient 699 454.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 423.24 60.55 999999999 423.24 678.03 percent of total billed charges RUMI KOH EFFICIENT 3.OCM 48712897_1 CDM 0272 RC inpatient 699 454.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 423.24 678.03 RUMI KOH EFFICIENT 3.OCM 48712897_1 CDM 0272 RC inpatient 699 454.35 ANTHEM HMO ANTHEM HMO 999999999 423.24 678.03 RUMI KOH EFFICIENT 3.OCM 48712897_1 CDM 0272 RC inpatient 699 454.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 423.24 678.03 RUMI KOH EFFICIENT 3.OCM 48712897_1 CDM 0272 RC inpatient 699 454.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 472.52 67.6 999999999 423.24 678.03 percent of total billed charges RUMI KOH EFFICIENT 3.OCM 48712897_1 CDM 0272 RC inpatient 699 454.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 423.24 678.03 RUMI KOH EFFICIENT 3.OCM 48712897_1 CDM 0272 RC inpatient 699 454.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 423.24 678.03 RUMI KOH EFFICIENT 3.5CM 48712898_1 CDM 0272 RC inpatient 659 428.35 AETNA AETNA 520.61 79 999999999 399.02 639.23 percent of total billed charges RUMI KOH EFFICIENT 3.5CM 48712898_1 CDM 0272 RC inpatient 659 428.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 428.35 65 999999999 399.02 639.23 percent of total billed charges RUMI KOH EFFICIENT 3.5CM 48712898_1 CDM 0272 RC inpatient 659 428.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 639.23 97 999999999 399.02 639.23 percent of total billed charges RUMI KOH EFFICIENT 3.5CM 48712898_1 CDM 0272 RC inpatient 659 428.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 514.02 78 999999999 399.02 639.23 percent of total billed charges RUMI KOH EFFICIENT 3.5CM 48712898_1 CDM 0272 RC inpatient 659 428.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 454.71 69 999999999 399.02 639.23 percent of total billed charges RUMI KOH EFFICIENT 3.5CM 48712898_1 CDM 0272 RC inpatient 659 428.35 UMR - ALL PLANS UMR - ALL PLANS 461.3 70 999999999 399.02 639.23 percent of total billed charges RUMI KOH EFFICIENT 3.5CM 48712898_1 CDM 0272 RC inpatient 659 428.35 SIHO - ALL PLANS SIHO - ALL PLANS 593.1 90 999999999 399.02 639.23 percent of total billed charges RUMI KOH EFFICIENT 3.5CM 48712898_1 CDM 0272 RC inpatient 659 428.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 399.02 60.55 999999999 399.02 639.23 percent of total billed charges RUMI KOH EFFICIENT 3.5CM 48712898_1 CDM 0272 RC inpatient 659 428.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 399.02 639.23 RUMI KOH EFFICIENT 3.5CM 48712898_1 CDM 0272 RC inpatient 659 428.35 ANTHEM HMO ANTHEM HMO 999999999 399.02 639.23 RUMI KOH EFFICIENT 3.5CM 48712898_1 CDM 0272 RC inpatient 659 428.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 399.02 639.23 RUMI KOH EFFICIENT 3.5CM 48712898_1 CDM 0272 RC inpatient 659 428.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 445.48 67.6 999999999 399.02 639.23 percent of total billed charges RUMI KOH EFFICIENT 3.5CM 48712898_1 CDM 0272 RC inpatient 659 428.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 399.02 639.23 RUMI KOH EFFICIENT 3.5CM 48712898_1 CDM 0272 RC inpatient 659 428.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 399.02 639.23 RUMI TIP LAV 5.1M X 6C UML516 48712899_1 CDM 0272 RC inpatient 238 154.7 AETNA AETNA 188.02 79 999999999 144.11 230.86 percent of total billed charges RUMI TIP LAV 5.1M X 6C UML516 48712899_1 CDM 0272 RC inpatient 238 154.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.7 65 999999999 144.11 230.86 percent of total billed charges RUMI TIP LAV 5.1M X 6C UML516 48712899_1 CDM 0272 RC inpatient 238 154.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 230.86 97 999999999 144.11 230.86 percent of total billed charges RUMI TIP LAV 5.1M X 6C UML516 48712899_1 CDM 0272 RC inpatient 238 154.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 185.64 78 999999999 144.11 230.86 percent of total billed charges RUMI TIP LAV 5.1M X 6C UML516 48712899_1 CDM 0272 RC inpatient 238 154.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.22 69 999999999 144.11 230.86 percent of total billed charges RUMI TIP LAV 5.1M X 6C UML516 48712899_1 CDM 0272 RC inpatient 238 154.7 UMR - ALL PLANS UMR - ALL PLANS 166.6 70 999999999 144.11 230.86 percent of total billed charges RUMI TIP LAV 5.1M X 6C UML516 48712899_1 CDM 0272 RC inpatient 238 154.7 SIHO - ALL PLANS SIHO - ALL PLANS 214.2 90 999999999 144.11 230.86 percent of total billed charges RUMI TIP LAV 5.1M X 6C UML516 48712899_1 CDM 0272 RC inpatient 238 154.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.11 60.55 999999999 144.11 230.86 percent of total billed charges RUMI TIP LAV 5.1M X 6C UML516 48712899_1 CDM 0272 RC inpatient 238 154.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.11 230.86 RUMI TIP LAV 5.1M X 6C UML516 48712899_1 CDM 0272 RC inpatient 238 154.7 ANTHEM HMO ANTHEM HMO 999999999 144.11 230.86 RUMI TIP LAV 5.1M X 6C UML516 48712899_1 CDM 0272 RC inpatient 238 154.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.11 230.86 RUMI TIP LAV 5.1M X 6C UML516 48712899_1 CDM 0272 RC inpatient 238 154.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.89 67.6 999999999 144.11 230.86 percent of total billed charges RUMI TIP LAV 5.1M X 6C UML516 48712899_1 CDM 0272 RC inpatient 238 154.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.11 230.86 RUMI TIP LAV 5.1M X 6C UML516 48712899_1 CDM 0272 RC inpatient 238 154.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.11 230.86 RUMI TIP WHITE 6.7M X6C UMW676 48712900_1 CDM 0272 RC inpatient 250 162.5 AETNA AETNA 197.5 79 999999999 151.38 242.5 percent of total billed charges RUMI TIP WHITE 6.7M X6C UMW676 48712900_1 CDM 0272 RC inpatient 250 162.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 162.5 65 999999999 151.38 242.5 percent of total billed charges RUMI TIP WHITE 6.7M X6C UMW676 48712900_1 CDM 0272 RC inpatient 250 162.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 242.5 97 999999999 151.38 242.5 percent of total billed charges RUMI TIP WHITE 6.7M X6C UMW676 48712900_1 CDM 0272 RC inpatient 250 162.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 195 78 999999999 151.38 242.5 percent of total billed charges RUMI TIP WHITE 6.7M X6C UMW676 48712900_1 CDM 0272 RC inpatient 250 162.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 172.5 69 999999999 151.38 242.5 percent of total billed charges RUMI TIP WHITE 6.7M X6C UMW676 48712900_1 CDM 0272 RC inpatient 250 162.5 UMR - ALL PLANS UMR - ALL PLANS 175 70 999999999 151.38 242.5 percent of total billed charges RUMI TIP WHITE 6.7M X6C UMW676 48712900_1 CDM 0272 RC inpatient 250 162.5 SIHO - ALL PLANS SIHO - ALL PLANS 225 90 999999999 151.38 242.5 percent of total billed charges RUMI TIP WHITE 6.7M X6C UMW676 48712900_1 CDM 0272 RC inpatient 250 162.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.38 60.55 999999999 151.38 242.5 percent of total billed charges RUMI TIP WHITE 6.7M X6C UMW676 48712900_1 CDM 0272 RC inpatient 250 162.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.38 242.5 RUMI TIP WHITE 6.7M X6C UMW676 48712900_1 CDM 0272 RC inpatient 250 162.5 ANTHEM HMO ANTHEM HMO 999999999 151.38 242.5 RUMI TIP WHITE 6.7M X6C UMW676 48712900_1 CDM 0272 RC inpatient 250 162.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.38 242.5 RUMI TIP WHITE 6.7M X6C UMW676 48712900_1 CDM 0272 RC inpatient 250 162.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 169 67.6 999999999 151.38 242.5 percent of total billed charges RUMI TIP WHITE 6.7M X6C UMW676 48712900_1 CDM 0272 RC inpatient 250 162.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.38 242.5 RUMI TIP WHITE 6.7M X6C UMW676 48712900_1 CDM 0272 RC inpatient 250 162.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.38 242.5 RUMI TIP GREEN 6.7MX10C UMG670 48712901_1 CDM 0272 RC inpatient 311 202.15 AETNA AETNA 245.69 79 999999999 188.31 301.67 percent of total billed charges RUMI TIP GREEN 6.7MX10C UMG670 48712901_1 CDM 0272 RC inpatient 311 202.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 202.15 65 999999999 188.31 301.67 percent of total billed charges RUMI TIP GREEN 6.7MX10C UMG670 48712901_1 CDM 0272 RC inpatient 311 202.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 301.67 97 999999999 188.31 301.67 percent of total billed charges RUMI TIP GREEN 6.7MX10C UMG670 48712901_1 CDM 0272 RC inpatient 311 202.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 242.58 78 999999999 188.31 301.67 percent of total billed charges RUMI TIP GREEN 6.7MX10C UMG670 48712901_1 CDM 0272 RC inpatient 311 202.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 214.59 69 999999999 188.31 301.67 percent of total billed charges RUMI TIP GREEN 6.7MX10C UMG670 48712901_1 CDM 0272 RC inpatient 311 202.15 UMR - ALL PLANS UMR - ALL PLANS 217.7 70 999999999 188.31 301.67 percent of total billed charges RUMI TIP GREEN 6.7MX10C UMG670 48712901_1 CDM 0272 RC inpatient 311 202.15 SIHO - ALL PLANS SIHO - ALL PLANS 279.9 90 999999999 188.31 301.67 percent of total billed charges RUMI TIP GREEN 6.7MX10C UMG670 48712901_1 CDM 0272 RC inpatient 311 202.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 188.31 60.55 999999999 188.31 301.67 percent of total billed charges RUMI TIP GREEN 6.7MX10C UMG670 48712901_1 CDM 0272 RC inpatient 311 202.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 188.31 301.67 RUMI TIP GREEN 6.7MX10C UMG670 48712901_1 CDM 0272 RC inpatient 311 202.15 ANTHEM HMO ANTHEM HMO 999999999 188.31 301.67 RUMI TIP GREEN 6.7MX10C UMG670 48712901_1 CDM 0272 RC inpatient 311 202.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 188.31 301.67 RUMI TIP GREEN 6.7MX10C UMG670 48712901_1 CDM 0272 RC inpatient 311 202.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 210.24 67.6 999999999 188.31 301.67 percent of total billed charges RUMI TIP GREEN 6.7MX10C UMG670 48712901_1 CDM 0272 RC inpatient 311 202.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 188.31 301.67 RUMI TIP GREEN 6.7MX10C UMG670 48712901_1 CDM 0272 RC inpatient 311 202.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 188.31 301.67 SUTURE PROLENE BL MONO C841G 48712902_1 CDM 0272 RC inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges SUTURE PROLENE BL MONO C841G 48712902_1 CDM 0272 RC inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges SUTURE PROLENE BL MONO C841G 48712902_1 CDM 0272 RC inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges SUTURE PROLENE BL MONO C841G 48712902_1 CDM 0272 RC inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges SUTURE PROLENE BL MONO C841G 48712902_1 CDM 0272 RC inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges SUTURE PROLENE BL MONO C841G 48712902_1 CDM 0272 RC inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges SUTURE PROLENE BL MONO C841G 48712902_1 CDM 0272 RC inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges SUTURE PROLENE BL MONO C841G 48712902_1 CDM 0272 RC inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges SUTURE PROLENE BL MONO C841G 48712902_1 CDM 0272 RC inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 SUTURE PROLENE BL MONO C841G 48712902_1 CDM 0272 RC inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 SUTURE PROLENE BL MONO C841G 48712902_1 CDM 0272 RC inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 SUTURE PROLENE BL MONO C841G 48712902_1 CDM 0272 RC inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges SUTURE PROLENE BL MONO C841G 48712902_1 CDM 0272 RC inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 SUTURE PROLENE BL MONO C841G 48712902_1 CDM 0272 RC inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 MALLEABLE EXT APPLICATORS 48712903_1 CDM 0272 RC inpatient 321 208.65 AETNA AETNA 253.59 79 999999999 194.37 311.37 percent of total billed charges MALLEABLE EXT APPLICATORS 48712903_1 CDM 0272 RC inpatient 321 208.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 208.65 65 999999999 194.37 311.37 percent of total billed charges MALLEABLE EXT APPLICATORS 48712903_1 CDM 0272 RC inpatient 321 208.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 311.37 97 999999999 194.37 311.37 percent of total billed charges MALLEABLE EXT APPLICATORS 48712903_1 CDM 0272 RC inpatient 321 208.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 250.38 78 999999999 194.37 311.37 percent of total billed charges MALLEABLE EXT APPLICATORS 48712903_1 CDM 0272 RC inpatient 321 208.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 221.49 69 999999999 194.37 311.37 percent of total billed charges MALLEABLE EXT APPLICATORS 48712903_1 CDM 0272 RC inpatient 321 208.65 UMR - ALL PLANS UMR - ALL PLANS 224.7 70 999999999 194.37 311.37 percent of total billed charges MALLEABLE EXT APPLICATORS 48712903_1 CDM 0272 RC inpatient 321 208.65 SIHO - ALL PLANS SIHO - ALL PLANS 288.9 90 999999999 194.37 311.37 percent of total billed charges MALLEABLE EXT APPLICATORS 48712903_1 CDM 0272 RC inpatient 321 208.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 194.37 60.55 999999999 194.37 311.37 percent of total billed charges MALLEABLE EXT APPLICATORS 48712903_1 CDM 0272 RC inpatient 321 208.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 194.37 311.37 MALLEABLE EXT APPLICATORS 48712903_1 CDM 0272 RC inpatient 321 208.65 ANTHEM HMO ANTHEM HMO 999999999 194.37 311.37 MALLEABLE EXT APPLICATORS 48712903_1 CDM 0272 RC inpatient 321 208.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 194.37 311.37 MALLEABLE EXT APPLICATORS 48712903_1 CDM 0272 RC inpatient 321 208.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 217 67.6 999999999 194.37 311.37 percent of total billed charges MALLEABLE EXT APPLICATORS 48712903_1 CDM 0272 RC inpatient 321 208.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 194.37 311.37 MALLEABLE EXT APPLICATORS 48712903_1 CDM 0272 RC inpatient 321 208.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 194.37 311.37 ULTRASLING III SMALL 11-0449-2 48712904_1 CDM 0271 RC inpatient 347 225.55 AETNA AETNA 274.13 79 999999999 210.11 336.59 percent of total billed charges ULTRASLING III SMALL 11-0449-2 48712904_1 CDM 0271 RC inpatient 347 225.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 225.55 65 999999999 210.11 336.59 percent of total billed charges ULTRASLING III SMALL 11-0449-2 48712904_1 CDM 0271 RC inpatient 347 225.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 336.59 97 999999999 210.11 336.59 percent of total billed charges ULTRASLING III SMALL 11-0449-2 48712904_1 CDM 0271 RC inpatient 347 225.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 270.66 78 999999999 210.11 336.59 percent of total billed charges ULTRASLING III SMALL 11-0449-2 48712904_1 CDM 0271 RC inpatient 347 225.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 239.43 69 999999999 210.11 336.59 percent of total billed charges ULTRASLING III SMALL 11-0449-2 48712904_1 CDM 0271 RC inpatient 347 225.55 UMR - ALL PLANS UMR - ALL PLANS 242.9 70 999999999 210.11 336.59 percent of total billed charges ULTRASLING III SMALL 11-0449-2 48712904_1 CDM 0271 RC inpatient 347 225.55 SIHO - ALL PLANS SIHO - ALL PLANS 312.3 90 999999999 210.11 336.59 percent of total billed charges ULTRASLING III SMALL 11-0449-2 48712904_1 CDM 0271 RC inpatient 347 225.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 210.11 60.55 999999999 210.11 336.59 percent of total billed charges ULTRASLING III SMALL 11-0449-2 48712904_1 CDM 0271 RC inpatient 347 225.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 210.11 336.59 ULTRASLING III SMALL 11-0449-2 48712904_1 CDM 0271 RC inpatient 347 225.55 ANTHEM HMO ANTHEM HMO 999999999 210.11 336.59 ULTRASLING III SMALL 11-0449-2 48712904_1 CDM 0271 RC inpatient 347 225.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 210.11 336.59 ULTRASLING III SMALL 11-0449-2 48712904_1 CDM 0271 RC inpatient 347 225.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 234.57 67.6 999999999 210.11 336.59 percent of total billed charges ULTRASLING III SMALL 11-0449-2 48712904_1 CDM 0271 RC inpatient 347 225.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 210.11 336.59 ULTRASLING III SMALL 11-0449-2 48712904_1 CDM 0271 RC inpatient 347 225.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 210.11 336.59 SUTURE ETHILON 8-0 2808G MICRO 48712905_1 CDM 0272 RC inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges SUTURE ETHILON 8-0 2808G MICRO 48712905_1 CDM 0272 RC inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges SUTURE ETHILON 8-0 2808G MICRO 48712905_1 CDM 0272 RC inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges SUTURE ETHILON 8-0 2808G MICRO 48712905_1 CDM 0272 RC inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges SUTURE ETHILON 8-0 2808G MICRO 48712905_1 CDM 0272 RC inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges SUTURE ETHILON 8-0 2808G MICRO 48712905_1 CDM 0272 RC inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges SUTURE ETHILON 8-0 2808G MICRO 48712905_1 CDM 0272 RC inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges SUTURE ETHILON 8-0 2808G MICRO 48712905_1 CDM 0272 RC inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges SUTURE ETHILON 8-0 2808G MICRO 48712905_1 CDM 0272 RC inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 SUTURE ETHILON 8-0 2808G MICRO 48712905_1 CDM 0272 RC inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 SUTURE ETHILON 8-0 2808G MICRO 48712905_1 CDM 0272 RC inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 SUTURE ETHILON 8-0 2808G MICRO 48712905_1 CDM 0272 RC inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges SUTURE ETHILON 8-0 2808G MICRO 48712905_1 CDM 0272 RC inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 SUTURE ETHILON 8-0 2808G MICRO 48712905_1 CDM 0272 RC inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 ULTRASLING III XLG 11-0449-5 48712906_1 CDM 0271 RC inpatient 347 225.55 AETNA AETNA 274.13 79 999999999 210.11 336.59 percent of total billed charges ULTRASLING III XLG 11-0449-5 48712906_1 CDM 0271 RC inpatient 347 225.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 225.55 65 999999999 210.11 336.59 percent of total billed charges ULTRASLING III XLG 11-0449-5 48712906_1 CDM 0271 RC inpatient 347 225.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 336.59 97 999999999 210.11 336.59 percent of total billed charges ULTRASLING III XLG 11-0449-5 48712906_1 CDM 0271 RC inpatient 347 225.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 270.66 78 999999999 210.11 336.59 percent of total billed charges ULTRASLING III XLG 11-0449-5 48712906_1 CDM 0271 RC inpatient 347 225.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 239.43 69 999999999 210.11 336.59 percent of total billed charges ULTRASLING III XLG 11-0449-5 48712906_1 CDM 0271 RC inpatient 347 225.55 UMR - ALL PLANS UMR - ALL PLANS 242.9 70 999999999 210.11 336.59 percent of total billed charges ULTRASLING III XLG 11-0449-5 48712906_1 CDM 0271 RC inpatient 347 225.55 SIHO - ALL PLANS SIHO - ALL PLANS 312.3 90 999999999 210.11 336.59 percent of total billed charges ULTRASLING III XLG 11-0449-5 48712906_1 CDM 0271 RC inpatient 347 225.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 210.11 60.55 999999999 210.11 336.59 percent of total billed charges ULTRASLING III XLG 11-0449-5 48712906_1 CDM 0271 RC inpatient 347 225.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 210.11 336.59 ULTRASLING III XLG 11-0449-5 48712906_1 CDM 0271 RC inpatient 347 225.55 ANTHEM HMO ANTHEM HMO 999999999 210.11 336.59 ULTRASLING III XLG 11-0449-5 48712906_1 CDM 0271 RC inpatient 347 225.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 210.11 336.59 ULTRASLING III XLG 11-0449-5 48712906_1 CDM 0271 RC inpatient 347 225.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 234.57 67.6 999999999 210.11 336.59 percent of total billed charges ULTRASLING III XLG 11-0449-5 48712906_1 CDM 0271 RC inpatient 347 225.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 210.11 336.59 ULTRASLING III XLG 11-0449-5 48712906_1 CDM 0271 RC inpatient 347 225.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 210.11 336.59 SUTURE MAXON O GS-26 GREEN MONOFILAMENT LOOP 60IN GMM-341L 48712907_1 CDM 0272 RC inpatient 122 79.3 AETNA AETNA 96.38 79 999999999 73.87 118.34 percent of total billed charges SUTURE MAXON O GS-26 GREEN MONOFILAMENT LOOP 60IN GMM-341L 48712907_1 CDM 0272 RC inpatient 122 79.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.3 65 999999999 73.87 118.34 percent of total billed charges SUTURE MAXON O GS-26 GREEN MONOFILAMENT LOOP 60IN GMM-341L 48712907_1 CDM 0272 RC inpatient 122 79.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 118.34 97 999999999 73.87 118.34 percent of total billed charges SUTURE MAXON O GS-26 GREEN MONOFILAMENT LOOP 60IN GMM-341L 48712907_1 CDM 0272 RC inpatient 122 79.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.16 78 999999999 73.87 118.34 percent of total billed charges SUTURE MAXON O GS-26 GREEN MONOFILAMENT LOOP 60IN GMM-341L 48712907_1 CDM 0272 RC inpatient 122 79.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.18 69 999999999 73.87 118.34 percent of total billed charges SUTURE MAXON O GS-26 GREEN MONOFILAMENT LOOP 60IN GMM-341L 48712907_1 CDM 0272 RC inpatient 122 79.3 UMR - ALL PLANS UMR - ALL PLANS 85.4 70 999999999 73.87 118.34 percent of total billed charges SUTURE MAXON O GS-26 GREEN MONOFILAMENT LOOP 60IN GMM-341L 48712907_1 CDM 0272 RC inpatient 122 79.3 SIHO - ALL PLANS SIHO - ALL PLANS 109.8 90 999999999 73.87 118.34 percent of total billed charges SUTURE MAXON O GS-26 GREEN MONOFILAMENT LOOP 60IN GMM-341L 48712907_1 CDM 0272 RC inpatient 122 79.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.87 60.55 999999999 73.87 118.34 percent of total billed charges SUTURE MAXON O GS-26 GREEN MONOFILAMENT LOOP 60IN GMM-341L 48712907_1 CDM 0272 RC inpatient 122 79.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.87 118.34 SUTURE MAXON O GS-26 GREEN MONOFILAMENT LOOP 60IN GMM-341L 48712907_1 CDM 0272 RC inpatient 122 79.3 ANTHEM HMO ANTHEM HMO 999999999 73.87 118.34 SUTURE MAXON O GS-26 GREEN MONOFILAMENT LOOP 60IN GMM-341L 48712907_1 CDM 0272 RC inpatient 122 79.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.87 118.34 SUTURE MAXON O GS-26 GREEN MONOFILAMENT LOOP 60IN GMM-341L 48712907_1 CDM 0272 RC inpatient 122 79.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 82.47 67.6 999999999 73.87 118.34 percent of total billed charges SUTURE MAXON O GS-26 GREEN MONOFILAMENT LOOP 60IN GMM-341L 48712907_1 CDM 0272 RC inpatient 122 79.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.87 118.34 SUTURE MAXON O GS-26 GREEN MONOFILAMENT LOOP 60IN GMM-341L 48712907_1 CDM 0272 RC inpatient 122 79.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.87 118.34 SLEEVE UNIV 5MM X 100MM CB5LT 48712908_1 CDM 0272 RC inpatient 94 61.1 AETNA AETNA 74.26 79 999999999 56.92 91.18 percent of total billed charges SLEEVE UNIV 5MM X 100MM CB5LT 48712908_1 CDM 0272 RC inpatient 94 61.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.1 65 999999999 56.92 91.18 percent of total billed charges SLEEVE UNIV 5MM X 100MM CB5LT 48712908_1 CDM 0272 RC inpatient 94 61.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.18 97 999999999 56.92 91.18 percent of total billed charges SLEEVE UNIV 5MM X 100MM CB5LT 48712908_1 CDM 0272 RC inpatient 94 61.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.32 78 999999999 56.92 91.18 percent of total billed charges SLEEVE UNIV 5MM X 100MM CB5LT 48712908_1 CDM 0272 RC inpatient 94 61.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.86 69 999999999 56.92 91.18 percent of total billed charges SLEEVE UNIV 5MM X 100MM CB5LT 48712908_1 CDM 0272 RC inpatient 94 61.1 UMR - ALL PLANS UMR - ALL PLANS 65.8 70 999999999 56.92 91.18 percent of total billed charges SLEEVE UNIV 5MM X 100MM CB5LT 48712908_1 CDM 0272 RC inpatient 94 61.1 SIHO - ALL PLANS SIHO - ALL PLANS 84.6 90 999999999 56.92 91.18 percent of total billed charges SLEEVE UNIV 5MM X 100MM CB5LT 48712908_1 CDM 0272 RC inpatient 94 61.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.92 60.55 999999999 56.92 91.18 percent of total billed charges SLEEVE UNIV 5MM X 100MM CB5LT 48712908_1 CDM 0272 RC inpatient 94 61.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.92 91.18 SLEEVE UNIV 5MM X 100MM CB5LT 48712908_1 CDM 0272 RC inpatient 94 61.1 ANTHEM HMO ANTHEM HMO 999999999 56.92 91.18 SLEEVE UNIV 5MM X 100MM CB5LT 48712908_1 CDM 0272 RC inpatient 94 61.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.92 91.18 SLEEVE UNIV 5MM X 100MM CB5LT 48712908_1 CDM 0272 RC inpatient 94 61.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.54 67.6 999999999 56.92 91.18 percent of total billed charges SLEEVE UNIV 5MM X 100MM CB5LT 48712908_1 CDM 0272 RC inpatient 94 61.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.92 91.18 SLEEVE UNIV 5MM X 100MM CB5LT 48712908_1 CDM 0272 RC inpatient 94 61.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.92 91.18 SUTURE VICRYL 2-0 J726D 48712909_1 CDM 0272 RC inpatient 94 61.1 AETNA AETNA 74.26 79 999999999 56.92 91.18 percent of total billed charges SUTURE VICRYL 2-0 J726D 48712909_1 CDM 0272 RC inpatient 94 61.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.1 65 999999999 56.92 91.18 percent of total billed charges SUTURE VICRYL 2-0 J726D 48712909_1 CDM 0272 RC inpatient 94 61.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.18 97 999999999 56.92 91.18 percent of total billed charges SUTURE VICRYL 2-0 J726D 48712909_1 CDM 0272 RC inpatient 94 61.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.32 78 999999999 56.92 91.18 percent of total billed charges SUTURE VICRYL 2-0 J726D 48712909_1 CDM 0272 RC inpatient 94 61.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.86 69 999999999 56.92 91.18 percent of total billed charges SUTURE VICRYL 2-0 J726D 48712909_1 CDM 0272 RC inpatient 94 61.1 UMR - ALL PLANS UMR - ALL PLANS 65.8 70 999999999 56.92 91.18 percent of total billed charges SUTURE VICRYL 2-0 J726D 48712909_1 CDM 0272 RC inpatient 94 61.1 SIHO - ALL PLANS SIHO - ALL PLANS 84.6 90 999999999 56.92 91.18 percent of total billed charges SUTURE VICRYL 2-0 J726D 48712909_1 CDM 0272 RC inpatient 94 61.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.92 60.55 999999999 56.92 91.18 percent of total billed charges SUTURE VICRYL 2-0 J726D 48712909_1 CDM 0272 RC inpatient 94 61.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.92 91.18 SUTURE VICRYL 2-0 J726D 48712909_1 CDM 0272 RC inpatient 94 61.1 ANTHEM HMO ANTHEM HMO 999999999 56.92 91.18 SUTURE VICRYL 2-0 J726D 48712909_1 CDM 0272 RC inpatient 94 61.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.92 91.18 SUTURE VICRYL 2-0 J726D 48712909_1 CDM 0272 RC inpatient 94 61.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.54 67.6 999999999 56.92 91.18 percent of total billed charges SUTURE VICRYL 2-0 J726D 48712909_1 CDM 0272 RC inpatient 94 61.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.92 91.18 SUTURE VICRYL 2-0 J726D 48712909_1 CDM 0272 RC inpatient 94 61.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.92 91.18 SUTURE PDS II Z370T 48712910_1 CDM 0272 RC inpatient 16 10.4 AETNA AETNA 12.64 79 999999999 9.69 15.52 percent of total billed charges SUTURE PDS II Z370T 48712910_1 CDM 0272 RC inpatient 16 10.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.4 65 999999999 9.69 15.52 percent of total billed charges SUTURE PDS II Z370T 48712910_1 CDM 0272 RC inpatient 16 10.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15.52 97 999999999 9.69 15.52 percent of total billed charges SUTURE PDS II Z370T 48712910_1 CDM 0272 RC inpatient 16 10.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.48 78 999999999 9.69 15.52 percent of total billed charges SUTURE PDS II Z370T 48712910_1 CDM 0272 RC inpatient 16 10.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.04 69 999999999 9.69 15.52 percent of total billed charges SUTURE PDS II Z370T 48712910_1 CDM 0272 RC inpatient 16 10.4 UMR - ALL PLANS UMR - ALL PLANS 11.2 70 999999999 9.69 15.52 percent of total billed charges SUTURE PDS II Z370T 48712910_1 CDM 0272 RC inpatient 16 10.4 SIHO - ALL PLANS SIHO - ALL PLANS 14.4 90 999999999 9.69 15.52 percent of total billed charges SUTURE PDS II Z370T 48712910_1 CDM 0272 RC inpatient 16 10.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.69 60.55 999999999 9.69 15.52 percent of total billed charges SUTURE PDS II Z370T 48712910_1 CDM 0272 RC inpatient 16 10.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.69 15.52 SUTURE PDS II Z370T 48712910_1 CDM 0272 RC inpatient 16 10.4 ANTHEM HMO ANTHEM HMO 999999999 9.69 15.52 SUTURE PDS II Z370T 48712910_1 CDM 0272 RC inpatient 16 10.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.69 15.52 SUTURE PDS II Z370T 48712910_1 CDM 0272 RC inpatient 16 10.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.82 67.6 999999999 9.69 15.52 percent of total billed charges SUTURE PDS II Z370T 48712910_1 CDM 0272 RC inpatient 16 10.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.69 15.52 SUTURE PDS II Z370T 48712910_1 CDM 0272 RC inpatient 16 10.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.69 15.52 ORTHOCORD SUT WO NEEDLE 223113 48712911_1 CDM 0272 RC inpatient 376 244.4 AETNA AETNA 297.04 79 999999999 227.67 364.72 percent of total billed charges ORTHOCORD SUT WO NEEDLE 223113 48712911_1 CDM 0272 RC inpatient 376 244.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 244.4 65 999999999 227.67 364.72 percent of total billed charges ORTHOCORD SUT WO NEEDLE 223113 48712911_1 CDM 0272 RC inpatient 376 244.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 364.72 97 999999999 227.67 364.72 percent of total billed charges ORTHOCORD SUT WO NEEDLE 223113 48712911_1 CDM 0272 RC inpatient 376 244.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 293.28 78 999999999 227.67 364.72 percent of total billed charges ORTHOCORD SUT WO NEEDLE 223113 48712911_1 CDM 0272 RC inpatient 376 244.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 259.44 69 999999999 227.67 364.72 percent of total billed charges ORTHOCORD SUT WO NEEDLE 223113 48712911_1 CDM 0272 RC inpatient 376 244.4 UMR - ALL PLANS UMR - ALL PLANS 263.2 70 999999999 227.67 364.72 percent of total billed charges ORTHOCORD SUT WO NEEDLE 223113 48712911_1 CDM 0272 RC inpatient 376 244.4 SIHO - ALL PLANS SIHO - ALL PLANS 338.4 90 999999999 227.67 364.72 percent of total billed charges ORTHOCORD SUT WO NEEDLE 223113 48712911_1 CDM 0272 RC inpatient 376 244.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 227.67 60.55 999999999 227.67 364.72 percent of total billed charges ORTHOCORD SUT WO NEEDLE 223113 48712911_1 CDM 0272 RC inpatient 376 244.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 227.67 364.72 ORTHOCORD SUT WO NEEDLE 223113 48712911_1 CDM 0272 RC inpatient 376 244.4 ANTHEM HMO ANTHEM HMO 999999999 227.67 364.72 ORTHOCORD SUT WO NEEDLE 223113 48712911_1 CDM 0272 RC inpatient 376 244.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 227.67 364.72 ORTHOCORD SUT WO NEEDLE 223113 48712911_1 CDM 0272 RC inpatient 376 244.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 254.18 67.6 999999999 227.67 364.72 percent of total billed charges ORTHOCORD SUT WO NEEDLE 223113 48712911_1 CDM 0272 RC inpatient 376 244.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 227.67 364.72 ORTHOCORD SUT WO NEEDLE 223113 48712911_1 CDM 0272 RC inpatient 376 244.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 227.67 364.72 SUTURE ETHIBOND 5 MB66G 48712912_1 CDM 0272 RC inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges SUTURE ETHIBOND 5 MB66G 48712912_1 CDM 0272 RC inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges SUTURE ETHIBOND 5 MB66G 48712912_1 CDM 0272 RC inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges SUTURE ETHIBOND 5 MB66G 48712912_1 CDM 0272 RC inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges SUTURE ETHIBOND 5 MB66G 48712912_1 CDM 0272 RC inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges SUTURE ETHIBOND 5 MB66G 48712912_1 CDM 0272 RC inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges SUTURE ETHIBOND 5 MB66G 48712912_1 CDM 0272 RC inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges SUTURE ETHIBOND 5 MB66G 48712912_1 CDM 0272 RC inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges SUTURE ETHIBOND 5 MB66G 48712912_1 CDM 0272 RC inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 SUTURE ETHIBOND 5 MB66G 48712912_1 CDM 0272 RC inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 SUTURE ETHIBOND 5 MB66G 48712912_1 CDM 0272 RC inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 SUTURE ETHIBOND 5 MB66G 48712912_1 CDM 0272 RC inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges SUTURE ETHIBOND 5 MB66G 48712912_1 CDM 0272 RC inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 SUTURE ETHIBOND 5 MB66G 48712912_1 CDM 0272 RC inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 TA 90 3.5 GUN #TA9035S 48712913_1 CDM 0272 RC inpatient 651 423.15 AETNA AETNA 514.29 79 999999999 394.18 631.47 percent of total billed charges TA 90 3.5 GUN #TA9035S 48712913_1 CDM 0272 RC inpatient 651 423.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 423.15 65 999999999 394.18 631.47 percent of total billed charges TA 90 3.5 GUN #TA9035S 48712913_1 CDM 0272 RC inpatient 651 423.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 631.47 97 999999999 394.18 631.47 percent of total billed charges TA 90 3.5 GUN #TA9035S 48712913_1 CDM 0272 RC inpatient 651 423.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 507.78 78 999999999 394.18 631.47 percent of total billed charges TA 90 3.5 GUN #TA9035S 48712913_1 CDM 0272 RC inpatient 651 423.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 449.19 69 999999999 394.18 631.47 percent of total billed charges TA 90 3.5 GUN #TA9035S 48712913_1 CDM 0272 RC inpatient 651 423.15 UMR - ALL PLANS UMR - ALL PLANS 455.7 70 999999999 394.18 631.47 percent of total billed charges TA 90 3.5 GUN #TA9035S 48712913_1 CDM 0272 RC inpatient 651 423.15 SIHO - ALL PLANS SIHO - ALL PLANS 585.9 90 999999999 394.18 631.47 percent of total billed charges TA 90 3.5 GUN #TA9035S 48712913_1 CDM 0272 RC inpatient 651 423.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 394.18 60.55 999999999 394.18 631.47 percent of total billed charges TA 90 3.5 GUN #TA9035S 48712913_1 CDM 0272 RC inpatient 651 423.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 394.18 631.47 TA 90 3.5 GUN #TA9035S 48712913_1 CDM 0272 RC inpatient 651 423.15 ANTHEM HMO ANTHEM HMO 999999999 394.18 631.47 TA 90 3.5 GUN #TA9035S 48712913_1 CDM 0272 RC inpatient 651 423.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 394.18 631.47 TA 90 3.5 GUN #TA9035S 48712913_1 CDM 0272 RC inpatient 651 423.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 440.08 67.6 999999999 394.18 631.47 percent of total billed charges TA 90 3.5 GUN #TA9035S 48712913_1 CDM 0272 RC inpatient 651 423.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 394.18 631.47 TA 90 3.5 GUN #TA9035S 48712913_1 CDM 0272 RC inpatient 651 423.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 394.18 631.47 TA 90 3.5MM DLU #TA9035L 48712914_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges TA 90 3.5MM DLU #TA9035L 48712914_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges TA 90 3.5MM DLU #TA9035L 48712914_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges TA 90 3.5MM DLU #TA9035L 48712914_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges TA 90 3.5MM DLU #TA9035L 48712914_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges TA 90 3.5MM DLU #TA9035L 48712914_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges TA 90 3.5MM DLU #TA9035L 48712914_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges TA 90 3.5MM DLU #TA9035L 48712914_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges TA 90 3.5MM DLU #TA9035L 48712914_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 TA 90 3.5MM DLU #TA9035L 48712914_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 TA 90 3.5MM DLU #TA9035L 48712914_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 TA 90 3.5MM DLU #TA9035L 48712914_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges TA 90 3.5MM DLU #TA9035L 48712914_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 TA 90 3.5MM DLU #TA9035L 48712914_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 STAPLER TA 90 4.8 GUN TA9048S 48712915_1 CDM 0278 RC inpatient 632 410.8 AETNA AETNA 499.28 79 999999999 382.68 613.04 percent of total billed charges STAPLER TA 90 4.8 GUN TA9048S 48712915_1 CDM 0278 RC inpatient 632 410.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 410.8 65 999999999 382.68 613.04 percent of total billed charges STAPLER TA 90 4.8 GUN TA9048S 48712915_1 CDM 0278 RC inpatient 632 410.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 613.04 97 999999999 382.68 613.04 percent of total billed charges STAPLER TA 90 4.8 GUN TA9048S 48712915_1 CDM 0278 RC inpatient 632 410.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 492.96 78 999999999 382.68 613.04 percent of total billed charges STAPLER TA 90 4.8 GUN TA9048S 48712915_1 CDM 0278 RC inpatient 632 410.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 436.08 69 999999999 382.68 613.04 percent of total billed charges STAPLER TA 90 4.8 GUN TA9048S 48712915_1 CDM 0278 RC inpatient 632 410.8 UMR - ALL PLANS UMR - ALL PLANS 442.4 70 999999999 382.68 613.04 percent of total billed charges STAPLER TA 90 4.8 GUN TA9048S 48712915_1 CDM 0278 RC inpatient 632 410.8 SIHO - ALL PLANS SIHO - ALL PLANS 568.8 90 999999999 382.68 613.04 percent of total billed charges STAPLER TA 90 4.8 GUN TA9048S 48712915_1 CDM 0278 RC inpatient 632 410.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 382.68 60.55 999999999 382.68 613.04 percent of total billed charges STAPLER TA 90 4.8 GUN TA9048S 48712915_1 CDM 0278 RC inpatient 632 410.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 382.68 613.04 STAPLER TA 90 4.8 GUN TA9048S 48712915_1 CDM 0278 RC inpatient 632 410.8 ANTHEM HMO ANTHEM HMO 999999999 382.68 613.04 STAPLER TA 90 4.8 GUN TA9048S 48712915_1 CDM 0278 RC inpatient 632 410.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 382.68 613.04 STAPLER TA 90 4.8 GUN TA9048S 48712915_1 CDM 0278 RC inpatient 632 410.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 427.23 67.6 999999999 382.68 613.04 percent of total billed charges STAPLER TA 90 4.8 GUN TA9048S 48712915_1 CDM 0278 RC inpatient 632 410.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 382.68 613.04 STAPLER TA 90 4.8 GUN TA9048S 48712915_1 CDM 0278 RC inpatient 632 410.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 382.68 613.04 TA 90 4.8 DLU #TA9048L 48712916_1 CDM 0278 RC inpatient 328 213.2 AETNA AETNA 259.12 79 999999999 198.6 318.16 percent of total billed charges TA 90 4.8 DLU #TA9048L 48712916_1 CDM 0278 RC inpatient 328 213.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 213.2 65 999999999 198.6 318.16 percent of total billed charges TA 90 4.8 DLU #TA9048L 48712916_1 CDM 0278 RC inpatient 328 213.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 318.16 97 999999999 198.6 318.16 percent of total billed charges TA 90 4.8 DLU #TA9048L 48712916_1 CDM 0278 RC inpatient 328 213.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.84 78 999999999 198.6 318.16 percent of total billed charges TA 90 4.8 DLU #TA9048L 48712916_1 CDM 0278 RC inpatient 328 213.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 226.32 69 999999999 198.6 318.16 percent of total billed charges TA 90 4.8 DLU #TA9048L 48712916_1 CDM 0278 RC inpatient 328 213.2 UMR - ALL PLANS UMR - ALL PLANS 229.6 70 999999999 198.6 318.16 percent of total billed charges TA 90 4.8 DLU #TA9048L 48712916_1 CDM 0278 RC inpatient 328 213.2 SIHO - ALL PLANS SIHO - ALL PLANS 295.2 90 999999999 198.6 318.16 percent of total billed charges TA 90 4.8 DLU #TA9048L 48712916_1 CDM 0278 RC inpatient 328 213.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198.6 60.55 999999999 198.6 318.16 percent of total billed charges TA 90 4.8 DLU #TA9048L 48712916_1 CDM 0278 RC inpatient 328 213.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198.6 318.16 TA 90 4.8 DLU #TA9048L 48712916_1 CDM 0278 RC inpatient 328 213.2 ANTHEM HMO ANTHEM HMO 999999999 198.6 318.16 TA 90 4.8 DLU #TA9048L 48712916_1 CDM 0278 RC inpatient 328 213.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198.6 318.16 TA 90 4.8 DLU #TA9048L 48712916_1 CDM 0278 RC inpatient 328 213.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.73 67.6 999999999 198.6 318.16 percent of total billed charges TA 90 4.8 DLU #TA9048L 48712916_1 CDM 0278 RC inpatient 328 213.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198.6 318.16 TA 90 4.8 DLU #TA9048L 48712916_1 CDM 0278 RC inpatient 328 213.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 198.6 318.16 STAPLER TA 30 3.5 GUN #TA3035S 48712917_1 CDM 0272 RC inpatient 633 411.45 AETNA AETNA 500.07 79 999999999 383.28 614.01 percent of total billed charges STAPLER TA 30 3.5 GUN #TA3035S 48712917_1 CDM 0272 RC inpatient 633 411.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 411.45 65 999999999 383.28 614.01 percent of total billed charges STAPLER TA 30 3.5 GUN #TA3035S 48712917_1 CDM 0272 RC inpatient 633 411.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 614.01 97 999999999 383.28 614.01 percent of total billed charges STAPLER TA 30 3.5 GUN #TA3035S 48712917_1 CDM 0272 RC inpatient 633 411.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 493.74 78 999999999 383.28 614.01 percent of total billed charges STAPLER TA 30 3.5 GUN #TA3035S 48712917_1 CDM 0272 RC inpatient 633 411.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 436.77 69 999999999 383.28 614.01 percent of total billed charges STAPLER TA 30 3.5 GUN #TA3035S 48712917_1 CDM 0272 RC inpatient 633 411.45 UMR - ALL PLANS UMR - ALL PLANS 443.1 70 999999999 383.28 614.01 percent of total billed charges STAPLER TA 30 3.5 GUN #TA3035S 48712917_1 CDM 0272 RC inpatient 633 411.45 SIHO - ALL PLANS SIHO - ALL PLANS 569.7 90 999999999 383.28 614.01 percent of total billed charges STAPLER TA 30 3.5 GUN #TA3035S 48712917_1 CDM 0272 RC inpatient 633 411.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 383.28 60.55 999999999 383.28 614.01 percent of total billed charges STAPLER TA 30 3.5 GUN #TA3035S 48712917_1 CDM 0272 RC inpatient 633 411.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 383.28 614.01 STAPLER TA 30 3.5 GUN #TA3035S 48712917_1 CDM 0272 RC inpatient 633 411.45 ANTHEM HMO ANTHEM HMO 999999999 383.28 614.01 STAPLER TA 30 3.5 GUN #TA3035S 48712917_1 CDM 0272 RC inpatient 633 411.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 383.28 614.01 STAPLER TA 30 3.5 GUN #TA3035S 48712917_1 CDM 0272 RC inpatient 633 411.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 427.91 67.6 999999999 383.28 614.01 percent of total billed charges STAPLER TA 30 3.5 GUN #TA3035S 48712917_1 CDM 0272 RC inpatient 633 411.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 383.28 614.01 STAPLER TA 30 3.5 GUN #TA3035S 48712917_1 CDM 0272 RC inpatient 633 411.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 383.28 614.01 STAPLER RELOADABLE TA60 3.5 BLUE W/TITANIUM STAPLES TA6035S 3/BX 48712918_1 CDM 0272 RC inpatient 1341 871.65 AETNA AETNA 1059.39 79 999999999 811.98 1300.77 percent of total billed charges STAPLER RELOADABLE TA60 3.5 BLUE W/TITANIUM STAPLES TA6035S 3/BX 48712918_1 CDM 0272 RC inpatient 1341 871.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 871.65 65 999999999 811.98 1300.77 percent of total billed charges STAPLER RELOADABLE TA60 3.5 BLUE W/TITANIUM STAPLES TA6035S 3/BX 48712918_1 CDM 0272 RC inpatient 1341 871.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1300.77 97 999999999 811.98 1300.77 percent of total billed charges STAPLER RELOADABLE TA60 3.5 BLUE W/TITANIUM STAPLES TA6035S 3/BX 48712918_1 CDM 0272 RC inpatient 1341 871.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1045.98 78 999999999 811.98 1300.77 percent of total billed charges STAPLER RELOADABLE TA60 3.5 BLUE W/TITANIUM STAPLES TA6035S 3/BX 48712918_1 CDM 0272 RC inpatient 1341 871.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 925.29 69 999999999 811.98 1300.77 percent of total billed charges STAPLER RELOADABLE TA60 3.5 BLUE W/TITANIUM STAPLES TA6035S 3/BX 48712918_1 CDM 0272 RC inpatient 1341 871.65 UMR - ALL PLANS UMR - ALL PLANS 938.7 70 999999999 811.98 1300.77 percent of total billed charges STAPLER RELOADABLE TA60 3.5 BLUE W/TITANIUM STAPLES TA6035S 3/BX 48712918_1 CDM 0272 RC inpatient 1341 871.65 SIHO - ALL PLANS SIHO - ALL PLANS 1206.9 90 999999999 811.98 1300.77 percent of total billed charges STAPLER RELOADABLE TA60 3.5 BLUE W/TITANIUM STAPLES TA6035S 3/BX 48712918_1 CDM 0272 RC inpatient 1341 871.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 811.98 60.55 999999999 811.98 1300.77 percent of total billed charges STAPLER RELOADABLE TA60 3.5 BLUE W/TITANIUM STAPLES TA6035S 3/BX 48712918_1 CDM 0272 RC inpatient 1341 871.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 811.98 1300.77 STAPLER RELOADABLE TA60 3.5 BLUE W/TITANIUM STAPLES TA6035S 3/BX 48712918_1 CDM 0272 RC inpatient 1341 871.65 ANTHEM HMO ANTHEM HMO 999999999 811.98 1300.77 STAPLER RELOADABLE TA60 3.5 BLUE W/TITANIUM STAPLES TA6035S 3/BX 48712918_1 CDM 0272 RC inpatient 1341 871.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 811.98 1300.77 STAPLER RELOADABLE TA60 3.5 BLUE W/TITANIUM STAPLES TA6035S 3/BX 48712918_1 CDM 0272 RC inpatient 1341 871.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 906.52 67.6 999999999 811.98 1300.77 percent of total billed charges STAPLER RELOADABLE TA60 3.5 BLUE W/TITANIUM STAPLES TA6035S 3/BX 48712918_1 CDM 0272 RC inpatient 1341 871.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 811.98 1300.77 STAPLER RELOADABLE TA60 3.5 BLUE W/TITANIUM STAPLES TA6035S 3/BX 48712918_1 CDM 0272 RC inpatient 1341 871.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 811.98 1300.77 STAPLER RELOADABLE TA60 4.8 GREEN TA6048S 48712919_1 CDM 0272 RC inpatient 1322 859.3 AETNA AETNA 1044.38 79 999999999 800.47 1282.34 percent of total billed charges STAPLER RELOADABLE TA60 4.8 GREEN TA6048S 48712919_1 CDM 0272 RC inpatient 1322 859.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 859.3 65 999999999 800.47 1282.34 percent of total billed charges STAPLER RELOADABLE TA60 4.8 GREEN TA6048S 48712919_1 CDM 0272 RC inpatient 1322 859.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1282.34 97 999999999 800.47 1282.34 percent of total billed charges STAPLER RELOADABLE TA60 4.8 GREEN TA6048S 48712919_1 CDM 0272 RC inpatient 1322 859.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1031.16 78 999999999 800.47 1282.34 percent of total billed charges STAPLER RELOADABLE TA60 4.8 GREEN TA6048S 48712919_1 CDM 0272 RC inpatient 1322 859.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 912.18 69 999999999 800.47 1282.34 percent of total billed charges STAPLER RELOADABLE TA60 4.8 GREEN TA6048S 48712919_1 CDM 0272 RC inpatient 1322 859.3 UMR - ALL PLANS UMR - ALL PLANS 925.4 70 999999999 800.47 1282.34 percent of total billed charges STAPLER RELOADABLE TA60 4.8 GREEN TA6048S 48712919_1 CDM 0272 RC inpatient 1322 859.3 SIHO - ALL PLANS SIHO - ALL PLANS 1189.8 90 999999999 800.47 1282.34 percent of total billed charges STAPLER RELOADABLE TA60 4.8 GREEN TA6048S 48712919_1 CDM 0272 RC inpatient 1322 859.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 800.47 60.55 999999999 800.47 1282.34 percent of total billed charges STAPLER RELOADABLE TA60 4.8 GREEN TA6048S 48712919_1 CDM 0272 RC inpatient 1322 859.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 800.47 1282.34 STAPLER RELOADABLE TA60 4.8 GREEN TA6048S 48712919_1 CDM 0272 RC inpatient 1322 859.3 ANTHEM HMO ANTHEM HMO 999999999 800.47 1282.34 STAPLER RELOADABLE TA60 4.8 GREEN TA6048S 48712919_1 CDM 0272 RC inpatient 1322 859.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 800.47 1282.34 STAPLER RELOADABLE TA60 4.8 GREEN TA6048S 48712919_1 CDM 0272 RC inpatient 1322 859.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 893.67 67.6 999999999 800.47 1282.34 percent of total billed charges STAPLER RELOADABLE TA60 4.8 GREEN TA6048S 48712919_1 CDM 0272 RC inpatient 1322 859.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 800.47 1282.34 STAPLER RELOADABLE TA60 4.8 GREEN TA6048S 48712919_1 CDM 0272 RC inpatient 1322 859.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 800.47 1282.34 ROTIC 30- V3 GUN #017619 48712920_1 CDM 0278 RC inpatient 1388 902.2 AETNA AETNA 1096.52 79 999999999 840.43 1346.36 percent of total billed charges ROTIC 30- V3 GUN #017619 48712920_1 CDM 0278 RC inpatient 1388 902.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 902.2 65 999999999 840.43 1346.36 percent of total billed charges ROTIC 30- V3 GUN #017619 48712920_1 CDM 0278 RC inpatient 1388 902.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1346.36 97 999999999 840.43 1346.36 percent of total billed charges ROTIC 30- V3 GUN #017619 48712920_1 CDM 0278 RC inpatient 1388 902.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1082.64 78 999999999 840.43 1346.36 percent of total billed charges ROTIC 30- V3 GUN #017619 48712920_1 CDM 0278 RC inpatient 1388 902.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 957.72 69 999999999 840.43 1346.36 percent of total billed charges ROTIC 30- V3 GUN #017619 48712920_1 CDM 0278 RC inpatient 1388 902.2 UMR - ALL PLANS UMR - ALL PLANS 971.6 70 999999999 840.43 1346.36 percent of total billed charges ROTIC 30- V3 GUN #017619 48712920_1 CDM 0278 RC inpatient 1388 902.2 SIHO - ALL PLANS SIHO - ALL PLANS 1249.2 90 999999999 840.43 1346.36 percent of total billed charges ROTIC 30- V3 GUN #017619 48712920_1 CDM 0278 RC inpatient 1388 902.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 840.43 60.55 999999999 840.43 1346.36 percent of total billed charges ROTIC 30- V3 GUN #017619 48712920_1 CDM 0278 RC inpatient 1388 902.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 840.43 1346.36 ROTIC 30- V3 GUN #017619 48712920_1 CDM 0278 RC inpatient 1388 902.2 ANTHEM HMO ANTHEM HMO 999999999 840.43 1346.36 ROTIC 30- V3 GUN #017619 48712920_1 CDM 0278 RC inpatient 1388 902.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 840.43 1346.36 ROTIC 30- V3 GUN #017619 48712920_1 CDM 0278 RC inpatient 1388 902.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 938.29 67.6 999999999 840.43 1346.36 percent of total billed charges ROTIC 30- V3 GUN #017619 48712920_1 CDM 0278 RC inpatient 1388 902.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 840.43 1346.36 ROTIC 30- V3 GUN #017619 48712920_1 CDM 0278 RC inpatient 1388 902.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 840.43 1346.36 GIA 60 3.8 GUN GIA6038S 48712921_1 CDM 0272 RC inpatient 648 421.2 AETNA AETNA 511.92 79 999999999 392.36 628.56 percent of total billed charges GIA 60 3.8 GUN GIA6038S 48712921_1 CDM 0272 RC inpatient 648 421.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 421.2 65 999999999 392.36 628.56 percent of total billed charges GIA 60 3.8 GUN GIA6038S 48712921_1 CDM 0272 RC inpatient 648 421.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 628.56 97 999999999 392.36 628.56 percent of total billed charges GIA 60 3.8 GUN GIA6038S 48712921_1 CDM 0272 RC inpatient 648 421.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 505.44 78 999999999 392.36 628.56 percent of total billed charges GIA 60 3.8 GUN GIA6038S 48712921_1 CDM 0272 RC inpatient 648 421.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 447.12 69 999999999 392.36 628.56 percent of total billed charges GIA 60 3.8 GUN GIA6038S 48712921_1 CDM 0272 RC inpatient 648 421.2 UMR - ALL PLANS UMR - ALL PLANS 453.6 70 999999999 392.36 628.56 percent of total billed charges GIA 60 3.8 GUN GIA6038S 48712921_1 CDM 0272 RC inpatient 648 421.2 SIHO - ALL PLANS SIHO - ALL PLANS 583.2 90 999999999 392.36 628.56 percent of total billed charges GIA 60 3.8 GUN GIA6038S 48712921_1 CDM 0272 RC inpatient 648 421.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 392.36 60.55 999999999 392.36 628.56 percent of total billed charges GIA 60 3.8 GUN GIA6038S 48712921_1 CDM 0272 RC inpatient 648 421.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 392.36 628.56 GIA 60 3.8 GUN GIA6038S 48712921_1 CDM 0272 RC inpatient 648 421.2 ANTHEM HMO ANTHEM HMO 999999999 392.36 628.56 GIA 60 3.8 GUN GIA6038S 48712921_1 CDM 0272 RC inpatient 648 421.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 392.36 628.56 GIA 60 3.8 GUN GIA6038S 48712921_1 CDM 0272 RC inpatient 648 421.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 438.05 67.6 999999999 392.36 628.56 percent of total billed charges GIA 60 3.8 GUN GIA6038S 48712921_1 CDM 0272 RC inpatient 648 421.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 392.36 628.56 GIA 60 3.8 GUN GIA6038S 48712921_1 CDM 0272 RC inpatient 648 421.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 392.36 628.56 GIA 60 3.8 DLU GIA6038L 48712922_1 CDM 0272 RC inpatient 379 246.35 AETNA AETNA 299.41 79 999999999 229.48 367.63 percent of total billed charges GIA 60 3.8 DLU GIA6038L 48712922_1 CDM 0272 RC inpatient 379 246.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 246.35 65 999999999 229.48 367.63 percent of total billed charges GIA 60 3.8 DLU GIA6038L 48712922_1 CDM 0272 RC inpatient 379 246.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 367.63 97 999999999 229.48 367.63 percent of total billed charges GIA 60 3.8 DLU GIA6038L 48712922_1 CDM 0272 RC inpatient 379 246.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 295.62 78 999999999 229.48 367.63 percent of total billed charges GIA 60 3.8 DLU GIA6038L 48712922_1 CDM 0272 RC inpatient 379 246.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 261.51 69 999999999 229.48 367.63 percent of total billed charges GIA 60 3.8 DLU GIA6038L 48712922_1 CDM 0272 RC inpatient 379 246.35 UMR - ALL PLANS UMR - ALL PLANS 265.3 70 999999999 229.48 367.63 percent of total billed charges GIA 60 3.8 DLU GIA6038L 48712922_1 CDM 0272 RC inpatient 379 246.35 SIHO - ALL PLANS SIHO - ALL PLANS 341.1 90 999999999 229.48 367.63 percent of total billed charges GIA 60 3.8 DLU GIA6038L 48712922_1 CDM 0272 RC inpatient 379 246.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 229.48 60.55 999999999 229.48 367.63 percent of total billed charges GIA 60 3.8 DLU GIA6038L 48712922_1 CDM 0272 RC inpatient 379 246.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 229.48 367.63 GIA 60 3.8 DLU GIA6038L 48712922_1 CDM 0272 RC inpatient 379 246.35 ANTHEM HMO ANTHEM HMO 999999999 229.48 367.63 GIA 60 3.8 DLU GIA6038L 48712922_1 CDM 0272 RC inpatient 379 246.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 229.48 367.63 GIA 60 3.8 DLU GIA6038L 48712922_1 CDM 0272 RC inpatient 379 246.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 256.2 67.6 999999999 229.48 367.63 percent of total billed charges GIA 60 3.8 DLU GIA6038L 48712922_1 CDM 0272 RC inpatient 379 246.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 229.48 367.63 GIA 60 3.8 DLU GIA6038L 48712922_1 CDM 0272 RC inpatient 379 246.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 229.48 367.63 GIA 80 3.8 GUN GIA8038S 48712923_1 CDM 0272 RC inpatient 955 620.75 AETNA AETNA 754.45 79 999999999 578.25 926.35 percent of total billed charges GIA 80 3.8 GUN GIA8038S 48712923_1 CDM 0272 RC inpatient 955 620.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 620.75 65 999999999 578.25 926.35 percent of total billed charges GIA 80 3.8 GUN GIA8038S 48712923_1 CDM 0272 RC inpatient 955 620.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 926.35 97 999999999 578.25 926.35 percent of total billed charges GIA 80 3.8 GUN GIA8038S 48712923_1 CDM 0272 RC inpatient 955 620.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 744.9 78 999999999 578.25 926.35 percent of total billed charges GIA 80 3.8 GUN GIA8038S 48712923_1 CDM 0272 RC inpatient 955 620.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 658.95 69 999999999 578.25 926.35 percent of total billed charges GIA 80 3.8 GUN GIA8038S 48712923_1 CDM 0272 RC inpatient 955 620.75 UMR - ALL PLANS UMR - ALL PLANS 668.5 70 999999999 578.25 926.35 percent of total billed charges GIA 80 3.8 GUN GIA8038S 48712923_1 CDM 0272 RC inpatient 955 620.75 SIHO - ALL PLANS SIHO - ALL PLANS 859.5 90 999999999 578.25 926.35 percent of total billed charges GIA 80 3.8 GUN GIA8038S 48712923_1 CDM 0272 RC inpatient 955 620.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 578.25 60.55 999999999 578.25 926.35 percent of total billed charges GIA 80 3.8 GUN GIA8038S 48712923_1 CDM 0272 RC inpatient 955 620.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 578.25 926.35 GIA 80 3.8 GUN GIA8038S 48712923_1 CDM 0272 RC inpatient 955 620.75 ANTHEM HMO ANTHEM HMO 999999999 578.25 926.35 GIA 80 3.8 GUN GIA8038S 48712923_1 CDM 0272 RC inpatient 955 620.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 578.25 926.35 GIA 80 3.8 GUN GIA8038S 48712923_1 CDM 0272 RC inpatient 955 620.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 645.58 67.6 999999999 578.25 926.35 percent of total billed charges GIA 80 3.8 GUN GIA8038S 48712923_1 CDM 0272 RC inpatient 955 620.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 578.25 926.35 GIA 80 3.8 GUN GIA8038S 48712923_1 CDM 0272 RC inpatient 955 620.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 578.25 926.35 GIA 80 3.8 DLU GIA8038L 48712924_1 CDM 0272 RC inpatient 554 360.1 AETNA AETNA 437.66 79 999999999 335.45 537.38 percent of total billed charges GIA 80 3.8 DLU GIA8038L 48712924_1 CDM 0272 RC inpatient 554 360.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 360.1 65 999999999 335.45 537.38 percent of total billed charges GIA 80 3.8 DLU GIA8038L 48712924_1 CDM 0272 RC inpatient 554 360.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 537.38 97 999999999 335.45 537.38 percent of total billed charges GIA 80 3.8 DLU GIA8038L 48712924_1 CDM 0272 RC inpatient 554 360.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 432.12 78 999999999 335.45 537.38 percent of total billed charges GIA 80 3.8 DLU GIA8038L 48712924_1 CDM 0272 RC inpatient 554 360.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 382.26 69 999999999 335.45 537.38 percent of total billed charges GIA 80 3.8 DLU GIA8038L 48712924_1 CDM 0272 RC inpatient 554 360.1 UMR - ALL PLANS UMR - ALL PLANS 387.8 70 999999999 335.45 537.38 percent of total billed charges GIA 80 3.8 DLU GIA8038L 48712924_1 CDM 0272 RC inpatient 554 360.1 SIHO - ALL PLANS SIHO - ALL PLANS 498.6 90 999999999 335.45 537.38 percent of total billed charges GIA 80 3.8 DLU GIA8038L 48712924_1 CDM 0272 RC inpatient 554 360.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 335.45 60.55 999999999 335.45 537.38 percent of total billed charges GIA 80 3.8 DLU GIA8038L 48712924_1 CDM 0272 RC inpatient 554 360.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 335.45 537.38 GIA 80 3.8 DLU GIA8038L 48712924_1 CDM 0272 RC inpatient 554 360.1 ANTHEM HMO ANTHEM HMO 999999999 335.45 537.38 GIA 80 3.8 DLU GIA8038L 48712924_1 CDM 0272 RC inpatient 554 360.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 335.45 537.38 GIA 80 3.8 DLU GIA8038L 48712924_1 CDM 0272 RC inpatient 554 360.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 374.5 67.6 999999999 335.45 537.38 percent of total billed charges GIA 80 3.8 DLU GIA8038L 48712924_1 CDM 0272 RC inpatient 554 360.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 335.45 537.38 GIA 80 3.8 DLU GIA8038L 48712924_1 CDM 0272 RC inpatient 554 360.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 335.45 537.38 STAPLER ENDO 31mm SINGLE USE #EEA31 48712925_1 CDM 0272 RC inpatient 1933 1256.45 AETNA AETNA 1527.07 79 999999999 1170.43 1875.01 percent of total billed charges STAPLER ENDO 31mm SINGLE USE #EEA31 48712925_1 CDM 0272 RC inpatient 1933 1256.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1256.45 65 999999999 1170.43 1875.01 percent of total billed charges STAPLER ENDO 31mm SINGLE USE #EEA31 48712925_1 CDM 0272 RC inpatient 1933 1256.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1875.01 97 999999999 1170.43 1875.01 percent of total billed charges STAPLER ENDO 31mm SINGLE USE #EEA31 48712925_1 CDM 0272 RC inpatient 1933 1256.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1507.74 78 999999999 1170.43 1875.01 percent of total billed charges STAPLER ENDO 31mm SINGLE USE #EEA31 48712925_1 CDM 0272 RC inpatient 1933 1256.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1333.77 69 999999999 1170.43 1875.01 percent of total billed charges STAPLER ENDO 31mm SINGLE USE #EEA31 48712925_1 CDM 0272 RC inpatient 1933 1256.45 UMR - ALL PLANS UMR - ALL PLANS 1353.1 70 999999999 1170.43 1875.01 percent of total billed charges STAPLER ENDO 31mm SINGLE USE #EEA31 48712925_1 CDM 0272 RC inpatient 1933 1256.45 SIHO - ALL PLANS SIHO - ALL PLANS 1739.7 90 999999999 1170.43 1875.01 percent of total billed charges STAPLER ENDO 31mm SINGLE USE #EEA31 48712925_1 CDM 0272 RC inpatient 1933 1256.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1170.43 60.55 999999999 1170.43 1875.01 percent of total billed charges STAPLER ENDO 31mm SINGLE USE #EEA31 48712925_1 CDM 0272 RC inpatient 1933 1256.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1170.43 1875.01 STAPLER ENDO 31mm SINGLE USE #EEA31 48712925_1 CDM 0272 RC inpatient 1933 1256.45 ANTHEM HMO ANTHEM HMO 999999999 1170.43 1875.01 STAPLER ENDO 31mm SINGLE USE #EEA31 48712925_1 CDM 0272 RC inpatient 1933 1256.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1170.43 1875.01 STAPLER ENDO 31mm SINGLE USE #EEA31 48712925_1 CDM 0272 RC inpatient 1933 1256.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1306.71 67.6 999999999 1170.43 1875.01 percent of total billed charges STAPLER ENDO 31mm SINGLE USE #EEA31 48712925_1 CDM 0272 RC inpatient 1933 1256.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1170.43 1875.01 STAPLER ENDO 31mm SINGLE USE #EEA31 48712925_1 CDM 0272 RC inpatient 1933 1256.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1170.43 1875.01 STAPLER ENDO 28mm SINGLE USE #EEA28 48712926_1 CDM 0272 RC inpatient 1933 1256.45 AETNA AETNA 1527.07 79 999999999 1170.43 1875.01 percent of total billed charges STAPLER ENDO 28mm SINGLE USE #EEA28 48712926_1 CDM 0272 RC inpatient 1933 1256.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1256.45 65 999999999 1170.43 1875.01 percent of total billed charges STAPLER ENDO 28mm SINGLE USE #EEA28 48712926_1 CDM 0272 RC inpatient 1933 1256.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1875.01 97 999999999 1170.43 1875.01 percent of total billed charges STAPLER ENDO 28mm SINGLE USE #EEA28 48712926_1 CDM 0272 RC inpatient 1933 1256.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1507.74 78 999999999 1170.43 1875.01 percent of total billed charges STAPLER ENDO 28mm SINGLE USE #EEA28 48712926_1 CDM 0272 RC inpatient 1933 1256.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1333.77 69 999999999 1170.43 1875.01 percent of total billed charges STAPLER ENDO 28mm SINGLE USE #EEA28 48712926_1 CDM 0272 RC inpatient 1933 1256.45 UMR - ALL PLANS UMR - ALL PLANS 1353.1 70 999999999 1170.43 1875.01 percent of total billed charges STAPLER ENDO 28mm SINGLE USE #EEA28 48712926_1 CDM 0272 RC inpatient 1933 1256.45 SIHO - ALL PLANS SIHO - ALL PLANS 1739.7 90 999999999 1170.43 1875.01 percent of total billed charges STAPLER ENDO 28mm SINGLE USE #EEA28 48712926_1 CDM 0272 RC inpatient 1933 1256.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1170.43 60.55 999999999 1170.43 1875.01 percent of total billed charges STAPLER ENDO 28mm SINGLE USE #EEA28 48712926_1 CDM 0272 RC inpatient 1933 1256.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1170.43 1875.01 STAPLER ENDO 28mm SINGLE USE #EEA28 48712926_1 CDM 0272 RC inpatient 1933 1256.45 ANTHEM HMO ANTHEM HMO 999999999 1170.43 1875.01 STAPLER ENDO 28mm SINGLE USE #EEA28 48712926_1 CDM 0272 RC inpatient 1933 1256.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1170.43 1875.01 STAPLER ENDO 28mm SINGLE USE #EEA28 48712926_1 CDM 0272 RC inpatient 1933 1256.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1306.71 67.6 999999999 1170.43 1875.01 percent of total billed charges STAPLER ENDO 28mm SINGLE USE #EEA28 48712926_1 CDM 0272 RC inpatient 1933 1256.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1170.43 1875.01 STAPLER ENDO 28mm SINGLE USE #EEA28 48712926_1 CDM 0272 RC inpatient 1933 1256.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1170.43 1875.01 STAPLER ENDO 25mm SINGLE USE #EEA25 48712927_1 CDM 0272 RC inpatient 1845 1199.25 AETNA AETNA 1457.55 79 999999999 1117.15 1789.65 percent of total billed charges STAPLER ENDO 25mm SINGLE USE #EEA25 48712927_1 CDM 0272 RC inpatient 1845 1199.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1199.25 65 999999999 1117.15 1789.65 percent of total billed charges STAPLER ENDO 25mm SINGLE USE #EEA25 48712927_1 CDM 0272 RC inpatient 1845 1199.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1789.65 97 999999999 1117.15 1789.65 percent of total billed charges STAPLER ENDO 25mm SINGLE USE #EEA25 48712927_1 CDM 0272 RC inpatient 1845 1199.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1439.1 78 999999999 1117.15 1789.65 percent of total billed charges STAPLER ENDO 25mm SINGLE USE #EEA25 48712927_1 CDM 0272 RC inpatient 1845 1199.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1273.05 69 999999999 1117.15 1789.65 percent of total billed charges STAPLER ENDO 25mm SINGLE USE #EEA25 48712927_1 CDM 0272 RC inpatient 1845 1199.25 UMR - ALL PLANS UMR - ALL PLANS 1291.5 70 999999999 1117.15 1789.65 percent of total billed charges STAPLER ENDO 25mm SINGLE USE #EEA25 48712927_1 CDM 0272 RC inpatient 1845 1199.25 SIHO - ALL PLANS SIHO - ALL PLANS 1660.5 90 999999999 1117.15 1789.65 percent of total billed charges STAPLER ENDO 25mm SINGLE USE #EEA25 48712927_1 CDM 0272 RC inpatient 1845 1199.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1117.15 60.55 999999999 1117.15 1789.65 percent of total billed charges STAPLER ENDO 25mm SINGLE USE #EEA25 48712927_1 CDM 0272 RC inpatient 1845 1199.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1117.15 1789.65 STAPLER ENDO 25mm SINGLE USE #EEA25 48712927_1 CDM 0272 RC inpatient 1845 1199.25 ANTHEM HMO ANTHEM HMO 999999999 1117.15 1789.65 STAPLER ENDO 25mm SINGLE USE #EEA25 48712927_1 CDM 0272 RC inpatient 1845 1199.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1117.15 1789.65 STAPLER ENDO 25mm SINGLE USE #EEA25 48712927_1 CDM 0272 RC inpatient 1845 1199.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1247.22 67.6 999999999 1117.15 1789.65 percent of total billed charges STAPLER ENDO 25mm SINGLE USE #EEA25 48712927_1 CDM 0272 RC inpatient 1845 1199.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1117.15 1789.65 STAPLER ENDO 25mm SINGLE USE #EEA25 48712927_1 CDM 0272 RC inpatient 1845 1199.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1117.15 1789.65 STAPLER ENDO 21mm SINGLE USE #EEA21 48712928_1 CDM 0278 RC inpatient 1810 1176.5 AETNA AETNA 1429.9 79 999999999 1095.96 1755.7 percent of total billed charges STAPLER ENDO 21mm SINGLE USE #EEA21 48712928_1 CDM 0278 RC inpatient 1810 1176.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1176.5 65 999999999 1095.96 1755.7 percent of total billed charges STAPLER ENDO 21mm SINGLE USE #EEA21 48712928_1 CDM 0278 RC inpatient 1810 1176.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1755.7 97 999999999 1095.96 1755.7 percent of total billed charges STAPLER ENDO 21mm SINGLE USE #EEA21 48712928_1 CDM 0278 RC inpatient 1810 1176.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1411.8 78 999999999 1095.96 1755.7 percent of total billed charges STAPLER ENDO 21mm SINGLE USE #EEA21 48712928_1 CDM 0278 RC inpatient 1810 1176.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1248.9 69 999999999 1095.96 1755.7 percent of total billed charges STAPLER ENDO 21mm SINGLE USE #EEA21 48712928_1 CDM 0278 RC inpatient 1810 1176.5 UMR - ALL PLANS UMR - ALL PLANS 1267 70 999999999 1095.96 1755.7 percent of total billed charges STAPLER ENDO 21mm SINGLE USE #EEA21 48712928_1 CDM 0278 RC inpatient 1810 1176.5 SIHO - ALL PLANS SIHO - ALL PLANS 1629 90 999999999 1095.96 1755.7 percent of total billed charges STAPLER ENDO 21mm SINGLE USE #EEA21 48712928_1 CDM 0278 RC inpatient 1810 1176.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1095.96 60.55 999999999 1095.96 1755.7 percent of total billed charges STAPLER ENDO 21mm SINGLE USE #EEA21 48712928_1 CDM 0278 RC inpatient 1810 1176.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1095.96 1755.7 STAPLER ENDO 21mm SINGLE USE #EEA21 48712928_1 CDM 0278 RC inpatient 1810 1176.5 ANTHEM HMO ANTHEM HMO 999999999 1095.96 1755.7 STAPLER ENDO 21mm SINGLE USE #EEA21 48712928_1 CDM 0278 RC inpatient 1810 1176.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1095.96 1755.7 STAPLER ENDO 21mm SINGLE USE #EEA21 48712928_1 CDM 0278 RC inpatient 1810 1176.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1223.56 67.6 999999999 1095.96 1755.7 percent of total billed charges STAPLER ENDO 21mm SINGLE USE #EEA21 48712928_1 CDM 0278 RC inpatient 1810 1176.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1095.96 1755.7 STAPLER ENDO 21mm SINGLE USE #EEA21 48712928_1 CDM 0278 RC inpatient 1810 1176.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1095.96 1755.7 STAPLER UNIV GIA EGIAUSTND 48712929_1 CDM 0272 RC inpatient 713 463.45 AETNA AETNA 563.27 79 999999999 431.72 691.61 percent of total billed charges STAPLER UNIV GIA EGIAUSTND 48712929_1 CDM 0272 RC inpatient 713 463.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 463.45 65 999999999 431.72 691.61 percent of total billed charges STAPLER UNIV GIA EGIAUSTND 48712929_1 CDM 0272 RC inpatient 713 463.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 691.61 97 999999999 431.72 691.61 percent of total billed charges STAPLER UNIV GIA EGIAUSTND 48712929_1 CDM 0272 RC inpatient 713 463.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 556.14 78 999999999 431.72 691.61 percent of total billed charges STAPLER UNIV GIA EGIAUSTND 48712929_1 CDM 0272 RC inpatient 713 463.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 491.97 69 999999999 431.72 691.61 percent of total billed charges STAPLER UNIV GIA EGIAUSTND 48712929_1 CDM 0272 RC inpatient 713 463.45 UMR - ALL PLANS UMR - ALL PLANS 499.1 70 999999999 431.72 691.61 percent of total billed charges STAPLER UNIV GIA EGIAUSTND 48712929_1 CDM 0272 RC inpatient 713 463.45 SIHO - ALL PLANS SIHO - ALL PLANS 641.7 90 999999999 431.72 691.61 percent of total billed charges STAPLER UNIV GIA EGIAUSTND 48712929_1 CDM 0272 RC inpatient 713 463.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 431.72 60.55 999999999 431.72 691.61 percent of total billed charges STAPLER UNIV GIA EGIAUSTND 48712929_1 CDM 0272 RC inpatient 713 463.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 431.72 691.61 STAPLER UNIV GIA EGIAUSTND 48712929_1 CDM 0272 RC inpatient 713 463.45 ANTHEM HMO ANTHEM HMO 999999999 431.72 691.61 STAPLER UNIV GIA EGIAUSTND 48712929_1 CDM 0272 RC inpatient 713 463.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 431.72 691.61 STAPLER UNIV GIA EGIAUSTND 48712929_1 CDM 0272 RC inpatient 713 463.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 481.99 67.6 999999999 431.72 691.61 percent of total billed charges STAPLER UNIV GIA EGIAUSTND 48712929_1 CDM 0272 RC inpatient 713 463.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 431.72 691.61 STAPLER UNIV GIA EGIAUSTND 48712929_1 CDM 0272 RC inpatient 713 463.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 431.72 691.61 45 ROTICULATOR EGIA45AMT 48712931_1 CDM 0272 RC inpatient 1152 748.8 AETNA AETNA 910.08 79 999999999 697.54 1117.44 percent of total billed charges 45 ROTICULATOR EGIA45AMT 48712931_1 CDM 0272 RC inpatient 1152 748.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 748.8 65 999999999 697.54 1117.44 percent of total billed charges 45 ROTICULATOR EGIA45AMT 48712931_1 CDM 0272 RC inpatient 1152 748.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1117.44 97 999999999 697.54 1117.44 percent of total billed charges 45 ROTICULATOR EGIA45AMT 48712931_1 CDM 0272 RC inpatient 1152 748.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 898.56 78 999999999 697.54 1117.44 percent of total billed charges 45 ROTICULATOR EGIA45AMT 48712931_1 CDM 0272 RC inpatient 1152 748.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 794.88 69 999999999 697.54 1117.44 percent of total billed charges 45 ROTICULATOR EGIA45AMT 48712931_1 CDM 0272 RC inpatient 1152 748.8 UMR - ALL PLANS UMR - ALL PLANS 806.4 70 999999999 697.54 1117.44 percent of total billed charges 45 ROTICULATOR EGIA45AMT 48712931_1 CDM 0272 RC inpatient 1152 748.8 SIHO - ALL PLANS SIHO - ALL PLANS 1036.8 90 999999999 697.54 1117.44 percent of total billed charges 45 ROTICULATOR EGIA45AMT 48712931_1 CDM 0272 RC inpatient 1152 748.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 697.54 60.55 999999999 697.54 1117.44 percent of total billed charges 45 ROTICULATOR EGIA45AMT 48712931_1 CDM 0272 RC inpatient 1152 748.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 697.54 1117.44 45 ROTICULATOR EGIA45AMT 48712931_1 CDM 0272 RC inpatient 1152 748.8 ANTHEM HMO ANTHEM HMO 999999999 697.54 1117.44 45 ROTICULATOR EGIA45AMT 48712931_1 CDM 0272 RC inpatient 1152 748.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 697.54 1117.44 45 ROTICULATOR EGIA45AMT 48712931_1 CDM 0272 RC inpatient 1152 748.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 778.75 67.6 999999999 697.54 1117.44 percent of total billed charges 45 ROTICULATOR EGIA45AMT 48712931_1 CDM 0272 RC inpatient 1152 748.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 697.54 1117.44 45 ROTICULATOR EGIA45AMT 48712931_1 CDM 0272 RC inpatient 1152 748.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 697.54 1117.44 60 3.5 ROTICULATOR EGIA60AMT 48712932_1 CDM 0272 RC inpatient 1515 984.75 AETNA AETNA 1196.85 79 999999999 917.33 1469.55 percent of total billed charges 60 3.5 ROTICULATOR EGIA60AMT 48712932_1 CDM 0272 RC inpatient 1515 984.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 984.75 65 999999999 917.33 1469.55 percent of total billed charges 60 3.5 ROTICULATOR EGIA60AMT 48712932_1 CDM 0272 RC inpatient 1515 984.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1469.55 97 999999999 917.33 1469.55 percent of total billed charges 60 3.5 ROTICULATOR EGIA60AMT 48712932_1 CDM 0272 RC inpatient 1515 984.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1181.7 78 999999999 917.33 1469.55 percent of total billed charges 60 3.5 ROTICULATOR EGIA60AMT 48712932_1 CDM 0272 RC inpatient 1515 984.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1045.35 69 999999999 917.33 1469.55 percent of total billed charges 60 3.5 ROTICULATOR EGIA60AMT 48712932_1 CDM 0272 RC inpatient 1515 984.75 UMR - ALL PLANS UMR - ALL PLANS 1060.5 70 999999999 917.33 1469.55 percent of total billed charges 60 3.5 ROTICULATOR EGIA60AMT 48712932_1 CDM 0272 RC inpatient 1515 984.75 SIHO - ALL PLANS SIHO - ALL PLANS 1363.5 90 999999999 917.33 1469.55 percent of total billed charges 60 3.5 ROTICULATOR EGIA60AMT 48712932_1 CDM 0272 RC inpatient 1515 984.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 917.33 60.55 999999999 917.33 1469.55 percent of total billed charges 60 3.5 ROTICULATOR EGIA60AMT 48712932_1 CDM 0272 RC inpatient 1515 984.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 917.33 1469.55 60 3.5 ROTICULATOR EGIA60AMT 48712932_1 CDM 0272 RC inpatient 1515 984.75 ANTHEM HMO ANTHEM HMO 999999999 917.33 1469.55 60 3.5 ROTICULATOR EGIA60AMT 48712932_1 CDM 0272 RC inpatient 1515 984.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 917.33 1469.55 60 3.5 ROTICULATOR EGIA60AMT 48712932_1 CDM 0272 RC inpatient 1515 984.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1024.14 67.6 999999999 917.33 1469.55 percent of total billed charges 60 3.5 ROTICULATOR EGIA60AMT 48712932_1 CDM 0272 RC inpatient 1515 984.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 917.33 1469.55 60 3.5 ROTICULATOR EGIA60AMT 48712932_1 CDM 0272 RC inpatient 1515 984.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 917.33 1469.55 REINFORCED 60mm SIGTRSB60AMT 48712935_1 CDM 0272 RC inpatient 2462 1600.3 AETNA AETNA 1944.98 79 999999999 1490.74 2388.14 percent of total billed charges REINFORCED 60mm SIGTRSB60AMT 48712935_1 CDM 0272 RC inpatient 2462 1600.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1600.3 65 999999999 1490.74 2388.14 percent of total billed charges REINFORCED 60mm SIGTRSB60AMT 48712935_1 CDM 0272 RC inpatient 2462 1600.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2388.14 97 999999999 1490.74 2388.14 percent of total billed charges REINFORCED 60mm SIGTRSB60AMT 48712935_1 CDM 0272 RC inpatient 2462 1600.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1920.36 78 999999999 1490.74 2388.14 percent of total billed charges REINFORCED 60mm SIGTRSB60AMT 48712935_1 CDM 0272 RC inpatient 2462 1600.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1698.78 69 999999999 1490.74 2388.14 percent of total billed charges REINFORCED 60mm SIGTRSB60AMT 48712935_1 CDM 0272 RC inpatient 2462 1600.3 UMR - ALL PLANS UMR - ALL PLANS 1723.4 70 999999999 1490.74 2388.14 percent of total billed charges REINFORCED 60mm SIGTRSB60AMT 48712935_1 CDM 0272 RC inpatient 2462 1600.3 SIHO - ALL PLANS SIHO - ALL PLANS 2215.8 90 999999999 1490.74 2388.14 percent of total billed charges REINFORCED 60mm SIGTRSB60AMT 48712935_1 CDM 0272 RC inpatient 2462 1600.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1490.74 60.55 999999999 1490.74 2388.14 percent of total billed charges REINFORCED 60mm SIGTRSB60AMT 48712935_1 CDM 0272 RC inpatient 2462 1600.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1490.74 2388.14 REINFORCED 60mm SIGTRSB60AMT 48712935_1 CDM 0272 RC inpatient 2462 1600.3 ANTHEM HMO ANTHEM HMO 999999999 1490.74 2388.14 REINFORCED 60mm SIGTRSB60AMT 48712935_1 CDM 0272 RC inpatient 2462 1600.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1490.74 2388.14 REINFORCED 60mm SIGTRSB60AMT 48712935_1 CDM 0272 RC inpatient 2462 1600.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1664.31 67.6 999999999 1490.74 2388.14 percent of total billed charges REINFORCED 60mm SIGTRSB60AMT 48712935_1 CDM 0272 RC inpatient 2462 1600.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1490.74 2388.14 REINFORCED 60mm SIGTRSB60AMT 48712935_1 CDM 0272 RC inpatient 2462 1600.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1490.74 2388.14 ****BLANKET PER MEGAN TROCAR BLADELESS OPTICAL 15mm #ONB15STF 48712936_1 CDM 0272 RC inpatient 373 242.45 AETNA AETNA 294.67 79 999999999 225.85 361.81 percent of total billed charges ****BLANKET PER MEGAN TROCAR BLADELESS OPTICAL 15mm #ONB15STF 48712936_1 CDM 0272 RC inpatient 373 242.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 242.45 65 999999999 225.85 361.81 percent of total billed charges ****BLANKET PER MEGAN TROCAR BLADELESS OPTICAL 15mm #ONB15STF 48712936_1 CDM 0272 RC inpatient 373 242.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 361.81 97 999999999 225.85 361.81 percent of total billed charges ****BLANKET PER MEGAN TROCAR BLADELESS OPTICAL 15mm #ONB15STF 48712936_1 CDM 0272 RC inpatient 373 242.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 290.94 78 999999999 225.85 361.81 percent of total billed charges ****BLANKET PER MEGAN TROCAR BLADELESS OPTICAL 15mm #ONB15STF 48712936_1 CDM 0272 RC inpatient 373 242.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 257.37 69 999999999 225.85 361.81 percent of total billed charges ****BLANKET PER MEGAN TROCAR BLADELESS OPTICAL 15mm #ONB15STF 48712936_1 CDM 0272 RC inpatient 373 242.45 UMR - ALL PLANS UMR - ALL PLANS 261.1 70 999999999 225.85 361.81 percent of total billed charges ****BLANKET PER MEGAN TROCAR BLADELESS OPTICAL 15mm #ONB15STF 48712936_1 CDM 0272 RC inpatient 373 242.45 SIHO - ALL PLANS SIHO - ALL PLANS 335.7 90 999999999 225.85 361.81 percent of total billed charges ****BLANKET PER MEGAN TROCAR BLADELESS OPTICAL 15mm #ONB15STF 48712936_1 CDM 0272 RC inpatient 373 242.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 225.85 60.55 999999999 225.85 361.81 percent of total billed charges ****BLANKET PER MEGAN TROCAR BLADELESS OPTICAL 15mm #ONB15STF 48712936_1 CDM 0272 RC inpatient 373 242.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 225.85 361.81 ****BLANKET PER MEGAN TROCAR BLADELESS OPTICAL 15mm #ONB15STF 48712936_1 CDM 0272 RC inpatient 373 242.45 ANTHEM HMO ANTHEM HMO 999999999 225.85 361.81 ****BLANKET PER MEGAN TROCAR BLADELESS OPTICAL 15mm #ONB15STF 48712936_1 CDM 0272 RC inpatient 373 242.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 225.85 361.81 ****BLANKET PER MEGAN TROCAR BLADELESS OPTICAL 15mm #ONB15STF 48712936_1 CDM 0272 RC inpatient 373 242.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 252.15 67.6 999999999 225.85 361.81 percent of total billed charges ****BLANKET PER MEGAN TROCAR BLADELESS OPTICAL 15mm #ONB15STF 48712936_1 CDM 0272 RC inpatient 373 242.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 225.85 361.81 ****BLANKET PER MEGAN TROCAR BLADELESS OPTICAL 15mm #ONB15STF 48712936_1 CDM 0272 RC inpatient 373 242.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 225.85 361.81 DISCONTINUED BY MEGAN PALMER 45 2.5 ROTICULATOR #030454 48712937_1 CDM 0272 RC inpatient 1127 732.55 AETNA AETNA 890.33 79 999999999 682.4 1093.19 percent of total billed charges DISCONTINUED BY MEGAN PALMER 45 2.5 ROTICULATOR #030454 48712937_1 CDM 0272 RC inpatient 1127 732.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 732.55 65 999999999 682.4 1093.19 percent of total billed charges DISCONTINUED BY MEGAN PALMER 45 2.5 ROTICULATOR #030454 48712937_1 CDM 0272 RC inpatient 1127 732.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1093.19 97 999999999 682.4 1093.19 percent of total billed charges DISCONTINUED BY MEGAN PALMER 45 2.5 ROTICULATOR #030454 48712937_1 CDM 0272 RC inpatient 1127 732.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 879.06 78 999999999 682.4 1093.19 percent of total billed charges DISCONTINUED BY MEGAN PALMER 45 2.5 ROTICULATOR #030454 48712937_1 CDM 0272 RC inpatient 1127 732.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 777.63 69 999999999 682.4 1093.19 percent of total billed charges DISCONTINUED BY MEGAN PALMER 45 2.5 ROTICULATOR #030454 48712937_1 CDM 0272 RC inpatient 1127 732.55 UMR - ALL PLANS UMR - ALL PLANS 788.9 70 999999999 682.4 1093.19 percent of total billed charges DISCONTINUED BY MEGAN PALMER 45 2.5 ROTICULATOR #030454 48712937_1 CDM 0272 RC inpatient 1127 732.55 SIHO - ALL PLANS SIHO - ALL PLANS 1014.3 90 999999999 682.4 1093.19 percent of total billed charges DISCONTINUED BY MEGAN PALMER 45 2.5 ROTICULATOR #030454 48712937_1 CDM 0272 RC inpatient 1127 732.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 682.4 60.55 999999999 682.4 1093.19 percent of total billed charges DISCONTINUED BY MEGAN PALMER 45 2.5 ROTICULATOR #030454 48712937_1 CDM 0272 RC inpatient 1127 732.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 682.4 1093.19 DISCONTINUED BY MEGAN PALMER 45 2.5 ROTICULATOR #030454 48712937_1 CDM 0272 RC inpatient 1127 732.55 ANTHEM HMO ANTHEM HMO 999999999 682.4 1093.19 DISCONTINUED BY MEGAN PALMER 45 2.5 ROTICULATOR #030454 48712937_1 CDM 0272 RC inpatient 1127 732.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 682.4 1093.19 DISCONTINUED BY MEGAN PALMER 45 2.5 ROTICULATOR #030454 48712937_1 CDM 0272 RC inpatient 1127 732.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 761.85 67.6 999999999 682.4 1093.19 percent of total billed charges DISCONTINUED BY MEGAN PALMER 45 2.5 ROTICULATOR #030454 48712937_1 CDM 0272 RC inpatient 1127 732.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 682.4 1093.19 DISCONTINUED BY MEGAN PALMER 45 2.5 ROTICULATOR #030454 48712937_1 CDM 0272 RC inpatient 1127 732.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 682.4 1093.19 STAPLER XL ENDO GIA EGIAUXL 48712938_1 CDM 0272 RC inpatient 1189 772.85 AETNA AETNA 939.31 79 999999999 719.94 1153.33 percent of total billed charges STAPLER XL ENDO GIA EGIAUXL 48712938_1 CDM 0272 RC inpatient 1189 772.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 772.85 65 999999999 719.94 1153.33 percent of total billed charges STAPLER XL ENDO GIA EGIAUXL 48712938_1 CDM 0272 RC inpatient 1189 772.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1153.33 97 999999999 719.94 1153.33 percent of total billed charges STAPLER XL ENDO GIA EGIAUXL 48712938_1 CDM 0272 RC inpatient 1189 772.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 927.42 78 999999999 719.94 1153.33 percent of total billed charges STAPLER XL ENDO GIA EGIAUXL 48712938_1 CDM 0272 RC inpatient 1189 772.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 820.41 69 999999999 719.94 1153.33 percent of total billed charges STAPLER XL ENDO GIA EGIAUXL 48712938_1 CDM 0272 RC inpatient 1189 772.85 UMR - ALL PLANS UMR - ALL PLANS 832.3 70 999999999 719.94 1153.33 percent of total billed charges STAPLER XL ENDO GIA EGIAUXL 48712938_1 CDM 0272 RC inpatient 1189 772.85 SIHO - ALL PLANS SIHO - ALL PLANS 1070.1 90 999999999 719.94 1153.33 percent of total billed charges STAPLER XL ENDO GIA EGIAUXL 48712938_1 CDM 0272 RC inpatient 1189 772.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 719.94 60.55 999999999 719.94 1153.33 percent of total billed charges STAPLER XL ENDO GIA EGIAUXL 48712938_1 CDM 0272 RC inpatient 1189 772.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 719.94 1153.33 STAPLER XL ENDO GIA EGIAUXL 48712938_1 CDM 0272 RC inpatient 1189 772.85 ANTHEM HMO ANTHEM HMO 999999999 719.94 1153.33 STAPLER XL ENDO GIA EGIAUXL 48712938_1 CDM 0272 RC inpatient 1189 772.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 719.94 1153.33 STAPLER XL ENDO GIA EGIAUXL 48712938_1 CDM 0272 RC inpatient 1189 772.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 803.76 67.6 999999999 719.94 1153.33 percent of total billed charges STAPLER XL ENDO GIA EGIAUXL 48712938_1 CDM 0272 RC inpatient 1189 772.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 719.94 1153.33 STAPLER XL ENDO GIA EGIAUXL 48712938_1 CDM 0272 RC inpatient 1189 772.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 719.94 1153.33 PERI STRIPS DRY W/VERITAS 6006 48712939_1 CDM 0272 RC inpatient 1187 771.55 AETNA AETNA 937.73 79 999999999 718.73 1151.39 percent of total billed charges PERI STRIPS DRY W/VERITAS 6006 48712939_1 CDM 0272 RC inpatient 1187 771.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 771.55 65 999999999 718.73 1151.39 percent of total billed charges PERI STRIPS DRY W/VERITAS 6006 48712939_1 CDM 0272 RC inpatient 1187 771.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1151.39 97 999999999 718.73 1151.39 percent of total billed charges PERI STRIPS DRY W/VERITAS 6006 48712939_1 CDM 0272 RC inpatient 1187 771.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 925.86 78 999999999 718.73 1151.39 percent of total billed charges PERI STRIPS DRY W/VERITAS 6006 48712939_1 CDM 0272 RC inpatient 1187 771.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 819.03 69 999999999 718.73 1151.39 percent of total billed charges PERI STRIPS DRY W/VERITAS 6006 48712939_1 CDM 0272 RC inpatient 1187 771.55 UMR - ALL PLANS UMR - ALL PLANS 830.9 70 999999999 718.73 1151.39 percent of total billed charges PERI STRIPS DRY W/VERITAS 6006 48712939_1 CDM 0272 RC inpatient 1187 771.55 SIHO - ALL PLANS SIHO - ALL PLANS 1068.3 90 999999999 718.73 1151.39 percent of total billed charges PERI STRIPS DRY W/VERITAS 6006 48712939_1 CDM 0272 RC inpatient 1187 771.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 718.73 60.55 999999999 718.73 1151.39 percent of total billed charges PERI STRIPS DRY W/VERITAS 6006 48712939_1 CDM 0272 RC inpatient 1187 771.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 718.73 1151.39 PERI STRIPS DRY W/VERITAS 6006 48712939_1 CDM 0272 RC inpatient 1187 771.55 ANTHEM HMO ANTHEM HMO 999999999 718.73 1151.39 PERI STRIPS DRY W/VERITAS 6006 48712939_1 CDM 0272 RC inpatient 1187 771.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 718.73 1151.39 PERI STRIPS DRY W/VERITAS 6006 48712939_1 CDM 0272 RC inpatient 1187 771.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 802.41 67.6 999999999 718.73 1151.39 percent of total billed charges PERI STRIPS DRY W/VERITAS 6006 48712939_1 CDM 0272 RC inpatient 1187 771.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 718.73 1151.39 PERI STRIPS DRY W/VERITAS 6006 48712939_1 CDM 0272 RC inpatient 1187 771.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 718.73 1151.39 ULTRASLING III LRG 11-0449-4 48712940_1 CDM 0271 RC inpatient 347 225.55 AETNA AETNA 274.13 79 999999999 210.11 336.59 percent of total billed charges ULTRASLING III LRG 11-0449-4 48712940_1 CDM 0271 RC inpatient 347 225.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 225.55 65 999999999 210.11 336.59 percent of total billed charges ULTRASLING III LRG 11-0449-4 48712940_1 CDM 0271 RC inpatient 347 225.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 336.59 97 999999999 210.11 336.59 percent of total billed charges ULTRASLING III LRG 11-0449-4 48712940_1 CDM 0271 RC inpatient 347 225.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 270.66 78 999999999 210.11 336.59 percent of total billed charges ULTRASLING III LRG 11-0449-4 48712940_1 CDM 0271 RC inpatient 347 225.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 239.43 69 999999999 210.11 336.59 percent of total billed charges ULTRASLING III LRG 11-0449-4 48712940_1 CDM 0271 RC inpatient 347 225.55 UMR - ALL PLANS UMR - ALL PLANS 242.9 70 999999999 210.11 336.59 percent of total billed charges ULTRASLING III LRG 11-0449-4 48712940_1 CDM 0271 RC inpatient 347 225.55 SIHO - ALL PLANS SIHO - ALL PLANS 312.3 90 999999999 210.11 336.59 percent of total billed charges ULTRASLING III LRG 11-0449-4 48712940_1 CDM 0271 RC inpatient 347 225.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 210.11 60.55 999999999 210.11 336.59 percent of total billed charges ULTRASLING III LRG 11-0449-4 48712940_1 CDM 0271 RC inpatient 347 225.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 210.11 336.59 ULTRASLING III LRG 11-0449-4 48712940_1 CDM 0271 RC inpatient 347 225.55 ANTHEM HMO ANTHEM HMO 999999999 210.11 336.59 ULTRASLING III LRG 11-0449-4 48712940_1 CDM 0271 RC inpatient 347 225.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 210.11 336.59 ULTRASLING III LRG 11-0449-4 48712940_1 CDM 0271 RC inpatient 347 225.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 234.57 67.6 999999999 210.11 336.59 percent of total billed charges ULTRASLING III LRG 11-0449-4 48712940_1 CDM 0271 RC inpatient 347 225.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 210.11 336.59 ULTRASLING III LRG 11-0449-4 48712940_1 CDM 0271 RC inpatient 347 225.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 210.11 336.59 GASTRIC BALLOON SUC/CATH B2020 48712941_1 CDM 0271 RC inpatient 1025 666.25 AETNA AETNA 809.75 79 999999999 620.64 994.25 percent of total billed charges GASTRIC BALLOON SUC/CATH B2020 48712941_1 CDM 0271 RC inpatient 1025 666.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 666.25 65 999999999 620.64 994.25 percent of total billed charges GASTRIC BALLOON SUC/CATH B2020 48712941_1 CDM 0271 RC inpatient 1025 666.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 994.25 97 999999999 620.64 994.25 percent of total billed charges GASTRIC BALLOON SUC/CATH B2020 48712941_1 CDM 0271 RC inpatient 1025 666.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 799.5 78 999999999 620.64 994.25 percent of total billed charges GASTRIC BALLOON SUC/CATH B2020 48712941_1 CDM 0271 RC inpatient 1025 666.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 707.25 69 999999999 620.64 994.25 percent of total billed charges GASTRIC BALLOON SUC/CATH B2020 48712941_1 CDM 0271 RC inpatient 1025 666.25 UMR - ALL PLANS UMR - ALL PLANS 717.5 70 999999999 620.64 994.25 percent of total billed charges GASTRIC BALLOON SUC/CATH B2020 48712941_1 CDM 0271 RC inpatient 1025 666.25 SIHO - ALL PLANS SIHO - ALL PLANS 922.5 90 999999999 620.64 994.25 percent of total billed charges GASTRIC BALLOON SUC/CATH B2020 48712941_1 CDM 0271 RC inpatient 1025 666.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 620.64 60.55 999999999 620.64 994.25 percent of total billed charges GASTRIC BALLOON SUC/CATH B2020 48712941_1 CDM 0271 RC inpatient 1025 666.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 620.64 994.25 GASTRIC BALLOON SUC/CATH B2020 48712941_1 CDM 0271 RC inpatient 1025 666.25 ANTHEM HMO ANTHEM HMO 999999999 620.64 994.25 GASTRIC BALLOON SUC/CATH B2020 48712941_1 CDM 0271 RC inpatient 1025 666.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 620.64 994.25 GASTRIC BALLOON SUC/CATH B2020 48712941_1 CDM 0271 RC inpatient 1025 666.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 692.9 67.6 999999999 620.64 994.25 percent of total billed charges GASTRIC BALLOON SUC/CATH B2020 48712941_1 CDM 0271 RC inpatient 1025 666.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 620.64 994.25 GASTRIC BALLOON SUC/CATH B2020 48712941_1 CDM 0271 RC inpatient 1025 666.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 620.64 994.25 C-ARMOR/C-ARM KIT 5536 48712942_1 CDM 0272 RC inpatient 312 202.8 AETNA AETNA 246.48 79 999999999 188.92 302.64 percent of total billed charges C-ARMOR/C-ARM KIT 5536 48712942_1 CDM 0272 RC inpatient 312 202.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 202.8 65 999999999 188.92 302.64 percent of total billed charges C-ARMOR/C-ARM KIT 5536 48712942_1 CDM 0272 RC inpatient 312 202.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 302.64 97 999999999 188.92 302.64 percent of total billed charges C-ARMOR/C-ARM KIT 5536 48712942_1 CDM 0272 RC inpatient 312 202.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 243.36 78 999999999 188.92 302.64 percent of total billed charges C-ARMOR/C-ARM KIT 5536 48712942_1 CDM 0272 RC inpatient 312 202.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 215.28 69 999999999 188.92 302.64 percent of total billed charges C-ARMOR/C-ARM KIT 5536 48712942_1 CDM 0272 RC inpatient 312 202.8 UMR - ALL PLANS UMR - ALL PLANS 218.4 70 999999999 188.92 302.64 percent of total billed charges C-ARMOR/C-ARM KIT 5536 48712942_1 CDM 0272 RC inpatient 312 202.8 SIHO - ALL PLANS SIHO - ALL PLANS 280.8 90 999999999 188.92 302.64 percent of total billed charges C-ARMOR/C-ARM KIT 5536 48712942_1 CDM 0272 RC inpatient 312 202.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 188.92 60.55 999999999 188.92 302.64 percent of total billed charges C-ARMOR/C-ARM KIT 5536 48712942_1 CDM 0272 RC inpatient 312 202.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 188.92 302.64 C-ARMOR/C-ARM KIT 5536 48712942_1 CDM 0272 RC inpatient 312 202.8 ANTHEM HMO ANTHEM HMO 999999999 188.92 302.64 C-ARMOR/C-ARM KIT 5536 48712942_1 CDM 0272 RC inpatient 312 202.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 188.92 302.64 C-ARMOR/C-ARM KIT 5536 48712942_1 CDM 0272 RC inpatient 312 202.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 210.91 67.6 999999999 188.92 302.64 percent of total billed charges C-ARMOR/C-ARM KIT 5536 48712942_1 CDM 0272 RC inpatient 312 202.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 188.92 302.64 C-ARMOR/C-ARM KIT 5536 48712942_1 CDM 0272 RC inpatient 312 202.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 188.92 302.64 FILSHIE TUBAL LIGATION AVM-910 48712943_1 CDM 0272 RC inpatient 922 599.3 AETNA AETNA 728.38 79 999999999 558.27 894.34 percent of total billed charges FILSHIE TUBAL LIGATION AVM-910 48712943_1 CDM 0272 RC inpatient 922 599.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 599.3 65 999999999 558.27 894.34 percent of total billed charges FILSHIE TUBAL LIGATION AVM-910 48712943_1 CDM 0272 RC inpatient 922 599.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 894.34 97 999999999 558.27 894.34 percent of total billed charges FILSHIE TUBAL LIGATION AVM-910 48712943_1 CDM 0272 RC inpatient 922 599.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 719.16 78 999999999 558.27 894.34 percent of total billed charges FILSHIE TUBAL LIGATION AVM-910 48712943_1 CDM 0272 RC inpatient 922 599.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 636.18 69 999999999 558.27 894.34 percent of total billed charges FILSHIE TUBAL LIGATION AVM-910 48712943_1 CDM 0272 RC inpatient 922 599.3 UMR - ALL PLANS UMR - ALL PLANS 645.4 70 999999999 558.27 894.34 percent of total billed charges FILSHIE TUBAL LIGATION AVM-910 48712943_1 CDM 0272 RC inpatient 922 599.3 SIHO - ALL PLANS SIHO - ALL PLANS 829.8 90 999999999 558.27 894.34 percent of total billed charges FILSHIE TUBAL LIGATION AVM-910 48712943_1 CDM 0272 RC inpatient 922 599.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 558.27 60.55 999999999 558.27 894.34 percent of total billed charges FILSHIE TUBAL LIGATION AVM-910 48712943_1 CDM 0272 RC inpatient 922 599.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 558.27 894.34 FILSHIE TUBAL LIGATION AVM-910 48712943_1 CDM 0272 RC inpatient 922 599.3 ANTHEM HMO ANTHEM HMO 999999999 558.27 894.34 FILSHIE TUBAL LIGATION AVM-910 48712943_1 CDM 0272 RC inpatient 922 599.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 558.27 894.34 FILSHIE TUBAL LIGATION AVM-910 48712943_1 CDM 0272 RC inpatient 922 599.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 623.27 67.6 999999999 558.27 894.34 percent of total billed charges FILSHIE TUBAL LIGATION AVM-910 48712943_1 CDM 0272 RC inpatient 922 599.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 558.27 894.34 FILSHIE TUBAL LIGATION AVM-910 48712943_1 CDM 0272 RC inpatient 922 599.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 558.27 894.34 BLADE SAW 8MM WIDTH 532.045S - PHONE IN ORDER - POWER TOOLS 48712945_1 CDM 0272 RC inpatient 616 400.4 AETNA AETNA 486.64 79 999999999 372.99 597.52 percent of total billed charges BLADE SAW 8MM WIDTH 532.045S - PHONE IN ORDER - POWER TOOLS 48712945_1 CDM 0272 RC inpatient 616 400.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 400.4 65 999999999 372.99 597.52 percent of total billed charges BLADE SAW 8MM WIDTH 532.045S - PHONE IN ORDER - POWER TOOLS 48712945_1 CDM 0272 RC inpatient 616 400.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 597.52 97 999999999 372.99 597.52 percent of total billed charges BLADE SAW 8MM WIDTH 532.045S - PHONE IN ORDER - POWER TOOLS 48712945_1 CDM 0272 RC inpatient 616 400.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 480.48 78 999999999 372.99 597.52 percent of total billed charges BLADE SAW 8MM WIDTH 532.045S - PHONE IN ORDER - POWER TOOLS 48712945_1 CDM 0272 RC inpatient 616 400.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 425.04 69 999999999 372.99 597.52 percent of total billed charges BLADE SAW 8MM WIDTH 532.045S - PHONE IN ORDER - POWER TOOLS 48712945_1 CDM 0272 RC inpatient 616 400.4 UMR - ALL PLANS UMR - ALL PLANS 431.2 70 999999999 372.99 597.52 percent of total billed charges BLADE SAW 8MM WIDTH 532.045S - PHONE IN ORDER - POWER TOOLS 48712945_1 CDM 0272 RC inpatient 616 400.4 SIHO - ALL PLANS SIHO - ALL PLANS 554.4 90 999999999 372.99 597.52 percent of total billed charges BLADE SAW 8MM WIDTH 532.045S - PHONE IN ORDER - POWER TOOLS 48712945_1 CDM 0272 RC inpatient 616 400.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 372.99 60.55 999999999 372.99 597.52 percent of total billed charges BLADE SAW 8MM WIDTH 532.045S - PHONE IN ORDER - POWER TOOLS 48712945_1 CDM 0272 RC inpatient 616 400.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 372.99 597.52 BLADE SAW 8MM WIDTH 532.045S - PHONE IN ORDER - POWER TOOLS 48712945_1 CDM 0272 RC inpatient 616 400.4 ANTHEM HMO ANTHEM HMO 999999999 372.99 597.52 BLADE SAW 8MM WIDTH 532.045S - PHONE IN ORDER - POWER TOOLS 48712945_1 CDM 0272 RC inpatient 616 400.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 372.99 597.52 BLADE SAW 8MM WIDTH 532.045S - PHONE IN ORDER - POWER TOOLS 48712945_1 CDM 0272 RC inpatient 616 400.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 416.42 67.6 999999999 372.99 597.52 percent of total billed charges BLADE SAW 8MM WIDTH 532.045S - PHONE IN ORDER - POWER TOOLS 48712945_1 CDM 0272 RC inpatient 616 400.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 372.99 597.52 BLADE SAW 8MM WIDTH 532.045S - PHONE IN ORDER - POWER TOOLS 48712945_1 CDM 0272 RC inpatient 616 400.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 372.99 597.52 TEST LUNG 1L GRAY R/T 165-1020 48712946_1 CDM 0272 RC inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges TEST LUNG 1L GRAY R/T 165-1020 48712946_1 CDM 0272 RC inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges TEST LUNG 1L GRAY R/T 165-1020 48712946_1 CDM 0272 RC inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges TEST LUNG 1L GRAY R/T 165-1020 48712946_1 CDM 0272 RC inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges TEST LUNG 1L GRAY R/T 165-1020 48712946_1 CDM 0272 RC inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges TEST LUNG 1L GRAY R/T 165-1020 48712946_1 CDM 0272 RC inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges TEST LUNG 1L GRAY R/T 165-1020 48712946_1 CDM 0272 RC inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges TEST LUNG 1L GRAY R/T 165-1020 48712946_1 CDM 0272 RC inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges TEST LUNG 1L GRAY R/T 165-1020 48712946_1 CDM 0272 RC inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 TEST LUNG 1L GRAY R/T 165-1020 48712946_1 CDM 0272 RC inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 TEST LUNG 1L GRAY R/T 165-1020 48712946_1 CDM 0272 RC inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 TEST LUNG 1L GRAY R/T 165-1020 48712946_1 CDM 0272 RC inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges TEST LUNG 1L GRAY R/T 165-1020 48712946_1 CDM 0272 RC inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 TEST LUNG 1L GRAY R/T 165-1020 48712946_1 CDM 0272 RC inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 POLYPROLENE FIXATION BUTTON 48712948_1 CDM 0272 RC inpatient 538 349.7 AETNA AETNA 425.02 79 999999999 325.76 521.86 percent of total billed charges POLYPROLENE FIXATION BUTTON 48712948_1 CDM 0272 RC inpatient 538 349.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 349.7 65 999999999 325.76 521.86 percent of total billed charges POLYPROLENE FIXATION BUTTON 48712948_1 CDM 0272 RC inpatient 538 349.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 521.86 97 999999999 325.76 521.86 percent of total billed charges POLYPROLENE FIXATION BUTTON 48712948_1 CDM 0272 RC inpatient 538 349.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 419.64 78 999999999 325.76 521.86 percent of total billed charges POLYPROLENE FIXATION BUTTON 48712948_1 CDM 0272 RC inpatient 538 349.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 371.22 69 999999999 325.76 521.86 percent of total billed charges POLYPROLENE FIXATION BUTTON 48712948_1 CDM 0272 RC inpatient 538 349.7 UMR - ALL PLANS UMR - ALL PLANS 376.6 70 999999999 325.76 521.86 percent of total billed charges POLYPROLENE FIXATION BUTTON 48712948_1 CDM 0272 RC inpatient 538 349.7 SIHO - ALL PLANS SIHO - ALL PLANS 484.2 90 999999999 325.76 521.86 percent of total billed charges POLYPROLENE FIXATION BUTTON 48712948_1 CDM 0272 RC inpatient 538 349.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 325.76 60.55 999999999 325.76 521.86 percent of total billed charges POLYPROLENE FIXATION BUTTON 48712948_1 CDM 0272 RC inpatient 538 349.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 325.76 521.86 POLYPROLENE FIXATION BUTTON 48712948_1 CDM 0272 RC inpatient 538 349.7 ANTHEM HMO ANTHEM HMO 999999999 325.76 521.86 POLYPROLENE FIXATION BUTTON 48712948_1 CDM 0272 RC inpatient 538 349.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 325.76 521.86 POLYPROLENE FIXATION BUTTON 48712948_1 CDM 0272 RC inpatient 538 349.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 363.69 67.6 999999999 325.76 521.86 percent of total billed charges POLYPROLENE FIXATION BUTTON 48712948_1 CDM 0272 RC inpatient 538 349.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 325.76 521.86 POLYPROLENE FIXATION BUTTON 48712948_1 CDM 0272 RC inpatient 538 349.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 325.76 521.86 "FLOWTRON THIGH CUFF 28""" 48712949_1 CDM 0271 RC inpatient 165 107.25 AETNA AETNA 130.35 79 999999999 99.91 160.05 percent of total billed charges "FLOWTRON THIGH CUFF 28""" 48712949_1 CDM 0271 RC inpatient 165 107.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.25 65 999999999 99.91 160.05 percent of total billed charges "FLOWTRON THIGH CUFF 28""" 48712949_1 CDM 0271 RC inpatient 165 107.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 160.05 97 999999999 99.91 160.05 percent of total billed charges "FLOWTRON THIGH CUFF 28""" 48712949_1 CDM 0271 RC inpatient 165 107.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.7 78 999999999 99.91 160.05 percent of total billed charges "FLOWTRON THIGH CUFF 28""" 48712949_1 CDM 0271 RC inpatient 165 107.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.85 69 999999999 99.91 160.05 percent of total billed charges "FLOWTRON THIGH CUFF 28""" 48712949_1 CDM 0271 RC inpatient 165 107.25 UMR - ALL PLANS UMR - ALL PLANS 115.5 70 999999999 99.91 160.05 percent of total billed charges "FLOWTRON THIGH CUFF 28""" 48712949_1 CDM 0271 RC inpatient 165 107.25 SIHO - ALL PLANS SIHO - ALL PLANS 148.5 90 999999999 99.91 160.05 percent of total billed charges "FLOWTRON THIGH CUFF 28""" 48712949_1 CDM 0271 RC inpatient 165 107.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.91 60.55 999999999 99.91 160.05 percent of total billed charges "FLOWTRON THIGH CUFF 28""" 48712949_1 CDM 0271 RC inpatient 165 107.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.91 160.05 "FLOWTRON THIGH CUFF 28""" 48712949_1 CDM 0271 RC inpatient 165 107.25 ANTHEM HMO ANTHEM HMO 999999999 99.91 160.05 "FLOWTRON THIGH CUFF 28""" 48712949_1 CDM 0271 RC inpatient 165 107.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.91 160.05 "FLOWTRON THIGH CUFF 28""" 48712949_1 CDM 0271 RC inpatient 165 107.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.54 67.6 999999999 99.91 160.05 percent of total billed charges "FLOWTRON THIGH CUFF 28""" 48712949_1 CDM 0271 RC inpatient 165 107.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.91 160.05 "FLOWTRON THIGH CUFF 28""" 48712949_1 CDM 0271 RC inpatient 165 107.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.91 160.05 "FLOWTRON CALF CUFF 17"" L501-M" 48712950_1 CDM 0272 RC inpatient 96 62.4 AETNA AETNA 75.84 79 999999999 58.13 93.12 percent of total billed charges "FLOWTRON CALF CUFF 17"" L501-M" 48712950_1 CDM 0272 RC inpatient 96 62.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.4 65 999999999 58.13 93.12 percent of total billed charges "FLOWTRON CALF CUFF 17"" L501-M" 48712950_1 CDM 0272 RC inpatient 96 62.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.12 97 999999999 58.13 93.12 percent of total billed charges "FLOWTRON CALF CUFF 17"" L501-M" 48712950_1 CDM 0272 RC inpatient 96 62.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.88 78 999999999 58.13 93.12 percent of total billed charges "FLOWTRON CALF CUFF 17"" L501-M" 48712950_1 CDM 0272 RC inpatient 96 62.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.24 69 999999999 58.13 93.12 percent of total billed charges "FLOWTRON CALF CUFF 17"" L501-M" 48712950_1 CDM 0272 RC inpatient 96 62.4 UMR - ALL PLANS UMR - ALL PLANS 67.2 70 999999999 58.13 93.12 percent of total billed charges "FLOWTRON CALF CUFF 17"" L501-M" 48712950_1 CDM 0272 RC inpatient 96 62.4 SIHO - ALL PLANS SIHO - ALL PLANS 86.4 90 999999999 58.13 93.12 percent of total billed charges "FLOWTRON CALF CUFF 17"" L501-M" 48712950_1 CDM 0272 RC inpatient 96 62.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.13 60.55 999999999 58.13 93.12 percent of total billed charges "FLOWTRON CALF CUFF 17"" L501-M" 48712950_1 CDM 0272 RC inpatient 96 62.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.13 93.12 "FLOWTRON CALF CUFF 17"" L501-M" 48712950_1 CDM 0272 RC inpatient 96 62.4 ANTHEM HMO ANTHEM HMO 999999999 58.13 93.12 "FLOWTRON CALF CUFF 17"" L501-M" 48712950_1 CDM 0272 RC inpatient 96 62.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.13 93.12 "FLOWTRON CALF CUFF 17"" L501-M" 48712950_1 CDM 0272 RC inpatient 96 62.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.9 67.6 999999999 58.13 93.12 percent of total billed charges "FLOWTRON CALF CUFF 17"" L501-M" 48712950_1 CDM 0272 RC inpatient 96 62.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.13 93.12 "FLOWTRON CALF CUFF 17"" L501-M" 48712950_1 CDM 0272 RC inpatient 96 62.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.13 93.12 "FLOWTRON CALF CUFF 23"" DVT20" 48712951_1 CDM 0271 RC inpatient 99 64.35 AETNA AETNA 78.21 79 999999999 59.94 96.03 percent of total billed charges "FLOWTRON CALF CUFF 23"" DVT20" 48712951_1 CDM 0271 RC inpatient 99 64.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 64.35 65 999999999 59.94 96.03 percent of total billed charges "FLOWTRON CALF CUFF 23"" DVT20" 48712951_1 CDM 0271 RC inpatient 99 64.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 96.03 97 999999999 59.94 96.03 percent of total billed charges "FLOWTRON CALF CUFF 23"" DVT20" 48712951_1 CDM 0271 RC inpatient 99 64.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 77.22 78 999999999 59.94 96.03 percent of total billed charges "FLOWTRON CALF CUFF 23"" DVT20" 48712951_1 CDM 0271 RC inpatient 99 64.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 68.31 69 999999999 59.94 96.03 percent of total billed charges "FLOWTRON CALF CUFF 23"" DVT20" 48712951_1 CDM 0271 RC inpatient 99 64.35 UMR - ALL PLANS UMR - ALL PLANS 69.3 70 999999999 59.94 96.03 percent of total billed charges "FLOWTRON CALF CUFF 23"" DVT20" 48712951_1 CDM 0271 RC inpatient 99 64.35 SIHO - ALL PLANS SIHO - ALL PLANS 89.1 90 999999999 59.94 96.03 percent of total billed charges "FLOWTRON CALF CUFF 23"" DVT20" 48712951_1 CDM 0271 RC inpatient 99 64.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.94 60.55 999999999 59.94 96.03 percent of total billed charges "FLOWTRON CALF CUFF 23"" DVT20" 48712951_1 CDM 0271 RC inpatient 99 64.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.94 96.03 "FLOWTRON CALF CUFF 23"" DVT20" 48712951_1 CDM 0271 RC inpatient 99 64.35 ANTHEM HMO ANTHEM HMO 999999999 59.94 96.03 "FLOWTRON CALF CUFF 23"" DVT20" 48712951_1 CDM 0271 RC inpatient 99 64.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.94 96.03 "FLOWTRON CALF CUFF 23"" DVT20" 48712951_1 CDM 0271 RC inpatient 99 64.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.92 67.6 999999999 59.94 96.03 percent of total billed charges "FLOWTRON CALF CUFF 23"" DVT20" 48712951_1 CDM 0271 RC inpatient 99 64.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.94 96.03 "FLOWTRON CALF CUFF 23"" DVT20" 48712951_1 CDM 0271 RC inpatient 99 64.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.94 96.03 TROCAR DILATING 5 X 100 2D5LT 48712952_1 CDM 0272 RC inpatient 144 93.6 AETNA AETNA 113.76 79 999999999 87.19 139.68 percent of total billed charges TROCAR DILATING 5 X 100 2D5LT 48712952_1 CDM 0272 RC inpatient 144 93.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 93.6 65 999999999 87.19 139.68 percent of total billed charges TROCAR DILATING 5 X 100 2D5LT 48712952_1 CDM 0272 RC inpatient 144 93.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 139.68 97 999999999 87.19 139.68 percent of total billed charges TROCAR DILATING 5 X 100 2D5LT 48712952_1 CDM 0272 RC inpatient 144 93.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 112.32 78 999999999 87.19 139.68 percent of total billed charges TROCAR DILATING 5 X 100 2D5LT 48712952_1 CDM 0272 RC inpatient 144 93.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 99.36 69 999999999 87.19 139.68 percent of total billed charges TROCAR DILATING 5 X 100 2D5LT 48712952_1 CDM 0272 RC inpatient 144 93.6 UMR - ALL PLANS UMR - ALL PLANS 100.8 70 999999999 87.19 139.68 percent of total billed charges TROCAR DILATING 5 X 100 2D5LT 48712952_1 CDM 0272 RC inpatient 144 93.6 SIHO - ALL PLANS SIHO - ALL PLANS 129.6 90 999999999 87.19 139.68 percent of total billed charges TROCAR DILATING 5 X 100 2D5LT 48712952_1 CDM 0272 RC inpatient 144 93.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.19 60.55 999999999 87.19 139.68 percent of total billed charges TROCAR DILATING 5 X 100 2D5LT 48712952_1 CDM 0272 RC inpatient 144 93.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.19 139.68 TROCAR DILATING 5 X 100 2D5LT 48712952_1 CDM 0272 RC inpatient 144 93.6 ANTHEM HMO ANTHEM HMO 999999999 87.19 139.68 TROCAR DILATING 5 X 100 2D5LT 48712952_1 CDM 0272 RC inpatient 144 93.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.19 139.68 TROCAR DILATING 5 X 100 2D5LT 48712952_1 CDM 0272 RC inpatient 144 93.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 97.34 67.6 999999999 87.19 139.68 percent of total billed charges TROCAR DILATING 5 X 100 2D5LT 48712952_1 CDM 0272 RC inpatient 144 93.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.19 139.68 TROCAR DILATING 5 X 100 2D5LT 48712952_1 CDM 0272 RC inpatient 144 93.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.19 139.68 SLEEVE UNIV 12M X 100M 2CB12LT 48712953_1 CDM 0272 RC inpatient 689 447.85 AETNA AETNA 544.31 79 999999999 417.19 668.33 percent of total billed charges SLEEVE UNIV 12M X 100M 2CB12LT 48712953_1 CDM 0272 RC inpatient 689 447.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 447.85 65 999999999 417.19 668.33 percent of total billed charges SLEEVE UNIV 12M X 100M 2CB12LT 48712953_1 CDM 0272 RC inpatient 689 447.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 668.33 97 999999999 417.19 668.33 percent of total billed charges SLEEVE UNIV 12M X 100M 2CB12LT 48712953_1 CDM 0272 RC inpatient 689 447.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 537.42 78 999999999 417.19 668.33 percent of total billed charges SLEEVE UNIV 12M X 100M 2CB12LT 48712953_1 CDM 0272 RC inpatient 689 447.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 475.41 69 999999999 417.19 668.33 percent of total billed charges SLEEVE UNIV 12M X 100M 2CB12LT 48712953_1 CDM 0272 RC inpatient 689 447.85 UMR - ALL PLANS UMR - ALL PLANS 482.3 70 999999999 417.19 668.33 percent of total billed charges SLEEVE UNIV 12M X 100M 2CB12LT 48712953_1 CDM 0272 RC inpatient 689 447.85 SIHO - ALL PLANS SIHO - ALL PLANS 620.1 90 999999999 417.19 668.33 percent of total billed charges SLEEVE UNIV 12M X 100M 2CB12LT 48712953_1 CDM 0272 RC inpatient 689 447.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 417.19 60.55 999999999 417.19 668.33 percent of total billed charges SLEEVE UNIV 12M X 100M 2CB12LT 48712953_1 CDM 0272 RC inpatient 689 447.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 417.19 668.33 SLEEVE UNIV 12M X 100M 2CB12LT 48712953_1 CDM 0272 RC inpatient 689 447.85 ANTHEM HMO ANTHEM HMO 999999999 417.19 668.33 SLEEVE UNIV 12M X 100M 2CB12LT 48712953_1 CDM 0272 RC inpatient 689 447.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 417.19 668.33 SLEEVE UNIV 12M X 100M 2CB12LT 48712953_1 CDM 0272 RC inpatient 689 447.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 465.76 67.6 999999999 417.19 668.33 percent of total billed charges SLEEVE UNIV 12M X 100M 2CB12LT 48712953_1 CDM 0272 RC inpatient 689 447.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 417.19 668.33 SLEEVE UNIV 12M X 100M 2CB12LT 48712953_1 CDM 0272 RC inpatient 689 447.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 417.19 668.33 ENDOTRACHEAL TUBE LASER 4.OMM 48712954_1 CDM 0272 RC inpatient 996 647.4 AETNA AETNA 786.84 79 999999999 603.08 966.12 percent of total billed charges ENDOTRACHEAL TUBE LASER 4.OMM 48712954_1 CDM 0272 RC inpatient 996 647.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 647.4 65 999999999 603.08 966.12 percent of total billed charges ENDOTRACHEAL TUBE LASER 4.OMM 48712954_1 CDM 0272 RC inpatient 996 647.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 966.12 97 999999999 603.08 966.12 percent of total billed charges ENDOTRACHEAL TUBE LASER 4.OMM 48712954_1 CDM 0272 RC inpatient 996 647.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 776.88 78 999999999 603.08 966.12 percent of total billed charges ENDOTRACHEAL TUBE LASER 4.OMM 48712954_1 CDM 0272 RC inpatient 996 647.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 687.24 69 999999999 603.08 966.12 percent of total billed charges ENDOTRACHEAL TUBE LASER 4.OMM 48712954_1 CDM 0272 RC inpatient 996 647.4 UMR - ALL PLANS UMR - ALL PLANS 697.2 70 999999999 603.08 966.12 percent of total billed charges ENDOTRACHEAL TUBE LASER 4.OMM 48712954_1 CDM 0272 RC inpatient 996 647.4 SIHO - ALL PLANS SIHO - ALL PLANS 896.4 90 999999999 603.08 966.12 percent of total billed charges ENDOTRACHEAL TUBE LASER 4.OMM 48712954_1 CDM 0272 RC inpatient 996 647.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 603.08 60.55 999999999 603.08 966.12 percent of total billed charges ENDOTRACHEAL TUBE LASER 4.OMM 48712954_1 CDM 0272 RC inpatient 996 647.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 603.08 966.12 ENDOTRACHEAL TUBE LASER 4.OMM 48712954_1 CDM 0272 RC inpatient 996 647.4 ANTHEM HMO ANTHEM HMO 999999999 603.08 966.12 ENDOTRACHEAL TUBE LASER 4.OMM 48712954_1 CDM 0272 RC inpatient 996 647.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 603.08 966.12 ENDOTRACHEAL TUBE LASER 4.OMM 48712954_1 CDM 0272 RC inpatient 996 647.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 673.3 67.6 999999999 603.08 966.12 percent of total billed charges ENDOTRACHEAL TUBE LASER 4.OMM 48712954_1 CDM 0272 RC inpatient 996 647.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 603.08 966.12 ENDOTRACHEAL TUBE LASER 4.OMM 48712954_1 CDM 0272 RC inpatient 996 647.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 603.08 966.12 ENDOTRACHEAL TUBE LASER 7.0MM 48712955_1 CDM 0272 RC inpatient 818 531.7 AETNA AETNA 646.22 79 999999999 495.3 793.46 percent of total billed charges ENDOTRACHEAL TUBE LASER 7.0MM 48712955_1 CDM 0272 RC inpatient 818 531.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 531.7 65 999999999 495.3 793.46 percent of total billed charges ENDOTRACHEAL TUBE LASER 7.0MM 48712955_1 CDM 0272 RC inpatient 818 531.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 793.46 97 999999999 495.3 793.46 percent of total billed charges ENDOTRACHEAL TUBE LASER 7.0MM 48712955_1 CDM 0272 RC inpatient 818 531.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 638.04 78 999999999 495.3 793.46 percent of total billed charges ENDOTRACHEAL TUBE LASER 7.0MM 48712955_1 CDM 0272 RC inpatient 818 531.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 564.42 69 999999999 495.3 793.46 percent of total billed charges ENDOTRACHEAL TUBE LASER 7.0MM 48712955_1 CDM 0272 RC inpatient 818 531.7 UMR - ALL PLANS UMR - ALL PLANS 572.6 70 999999999 495.3 793.46 percent of total billed charges ENDOTRACHEAL TUBE LASER 7.0MM 48712955_1 CDM 0272 RC inpatient 818 531.7 SIHO - ALL PLANS SIHO - ALL PLANS 736.2 90 999999999 495.3 793.46 percent of total billed charges ENDOTRACHEAL TUBE LASER 7.0MM 48712955_1 CDM 0272 RC inpatient 818 531.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 495.3 60.55 999999999 495.3 793.46 percent of total billed charges ENDOTRACHEAL TUBE LASER 7.0MM 48712955_1 CDM 0272 RC inpatient 818 531.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 495.3 793.46 ENDOTRACHEAL TUBE LASER 7.0MM 48712955_1 CDM 0272 RC inpatient 818 531.7 ANTHEM HMO ANTHEM HMO 999999999 495.3 793.46 ENDOTRACHEAL TUBE LASER 7.0MM 48712955_1 CDM 0272 RC inpatient 818 531.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 495.3 793.46 ENDOTRACHEAL TUBE LASER 7.0MM 48712955_1 CDM 0272 RC inpatient 818 531.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 552.97 67.6 999999999 495.3 793.46 percent of total billed charges ENDOTRACHEAL TUBE LASER 7.0MM 48712955_1 CDM 0272 RC inpatient 818 531.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 495.3 793.46 ENDOTRACHEAL TUBE LASER 7.0MM 48712955_1 CDM 0272 RC inpatient 818 531.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 495.3 793.46 ** BLANKET PER MEGAN PALMER 8-3-23 ** ENDOTRACHEAL TUBE LASER 8.0MM 48712956_1 CDM 0272 RC inpatient 401 260.65 AETNA AETNA 316.79 79 999999999 242.81 388.97 percent of total billed charges ** BLANKET PER MEGAN PALMER 8-3-23 ** ENDOTRACHEAL TUBE LASER 8.0MM 48712956_1 CDM 0272 RC inpatient 401 260.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 260.65 65 999999999 242.81 388.97 percent of total billed charges ** BLANKET PER MEGAN PALMER 8-3-23 ** ENDOTRACHEAL TUBE LASER 8.0MM 48712956_1 CDM 0272 RC inpatient 401 260.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 388.97 97 999999999 242.81 388.97 percent of total billed charges ** BLANKET PER MEGAN PALMER 8-3-23 ** ENDOTRACHEAL TUBE LASER 8.0MM 48712956_1 CDM 0272 RC inpatient 401 260.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 312.78 78 999999999 242.81 388.97 percent of total billed charges ** BLANKET PER MEGAN PALMER 8-3-23 ** ENDOTRACHEAL TUBE LASER 8.0MM 48712956_1 CDM 0272 RC inpatient 401 260.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 276.69 69 999999999 242.81 388.97 percent of total billed charges ** BLANKET PER MEGAN PALMER 8-3-23 ** ENDOTRACHEAL TUBE LASER 8.0MM 48712956_1 CDM 0272 RC inpatient 401 260.65 UMR - ALL PLANS UMR - ALL PLANS 280.7 70 999999999 242.81 388.97 percent of total billed charges ** BLANKET PER MEGAN PALMER 8-3-23 ** ENDOTRACHEAL TUBE LASER 8.0MM 48712956_1 CDM 0272 RC inpatient 401 260.65 SIHO - ALL PLANS SIHO - ALL PLANS 360.9 90 999999999 242.81 388.97 percent of total billed charges ** BLANKET PER MEGAN PALMER 8-3-23 ** ENDOTRACHEAL TUBE LASER 8.0MM 48712956_1 CDM 0272 RC inpatient 401 260.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 242.81 60.55 999999999 242.81 388.97 percent of total billed charges ** BLANKET PER MEGAN PALMER 8-3-23 ** ENDOTRACHEAL TUBE LASER 8.0MM 48712956_1 CDM 0272 RC inpatient 401 260.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 242.81 388.97 ** BLANKET PER MEGAN PALMER 8-3-23 ** ENDOTRACHEAL TUBE LASER 8.0MM 48712956_1 CDM 0272 RC inpatient 401 260.65 ANTHEM HMO ANTHEM HMO 999999999 242.81 388.97 ** BLANKET PER MEGAN PALMER 8-3-23 ** ENDOTRACHEAL TUBE LASER 8.0MM 48712956_1 CDM 0272 RC inpatient 401 260.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 242.81 388.97 ** BLANKET PER MEGAN PALMER 8-3-23 ** ENDOTRACHEAL TUBE LASER 8.0MM 48712956_1 CDM 0272 RC inpatient 401 260.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 271.08 67.6 999999999 242.81 388.97 percent of total billed charges ** BLANKET PER MEGAN PALMER 8-3-23 ** ENDOTRACHEAL TUBE LASER 8.0MM 48712956_1 CDM 0272 RC inpatient 401 260.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 242.81 388.97 ** BLANKET PER MEGAN PALMER 8-3-23 ** ENDOTRACHEAL TUBE LASER 8.0MM 48712956_1 CDM 0272 RC inpatient 401 260.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 242.81 388.97 VITAPREP PLASMA SEPARATOR 48712959_1 CDM 0272 RC inpatient 239 155.35 AETNA AETNA 188.81 79 999999999 144.71 231.83 percent of total billed charges VITAPREP PLASMA SEPARATOR 48712959_1 CDM 0272 RC inpatient 239 155.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 155.35 65 999999999 144.71 231.83 percent of total billed charges VITAPREP PLASMA SEPARATOR 48712959_1 CDM 0272 RC inpatient 239 155.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 231.83 97 999999999 144.71 231.83 percent of total billed charges VITAPREP PLASMA SEPARATOR 48712959_1 CDM 0272 RC inpatient 239 155.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 186.42 78 999999999 144.71 231.83 percent of total billed charges VITAPREP PLASMA SEPARATOR 48712959_1 CDM 0272 RC inpatient 239 155.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.91 69 999999999 144.71 231.83 percent of total billed charges VITAPREP PLASMA SEPARATOR 48712959_1 CDM 0272 RC inpatient 239 155.35 UMR - ALL PLANS UMR - ALL PLANS 167.3 70 999999999 144.71 231.83 percent of total billed charges VITAPREP PLASMA SEPARATOR 48712959_1 CDM 0272 RC inpatient 239 155.35 SIHO - ALL PLANS SIHO - ALL PLANS 215.1 90 999999999 144.71 231.83 percent of total billed charges VITAPREP PLASMA SEPARATOR 48712959_1 CDM 0272 RC inpatient 239 155.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.71 60.55 999999999 144.71 231.83 percent of total billed charges VITAPREP PLASMA SEPARATOR 48712959_1 CDM 0272 RC inpatient 239 155.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.71 231.83 VITAPREP PLASMA SEPARATOR 48712959_1 CDM 0272 RC inpatient 239 155.35 ANTHEM HMO ANTHEM HMO 999999999 144.71 231.83 VITAPREP PLASMA SEPARATOR 48712959_1 CDM 0272 RC inpatient 239 155.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.71 231.83 VITAPREP PLASMA SEPARATOR 48712959_1 CDM 0272 RC inpatient 239 155.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 161.56 67.6 999999999 144.71 231.83 percent of total billed charges VITAPREP PLASMA SEPARATOR 48712959_1 CDM 0272 RC inpatient 239 155.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.71 231.83 VITAPREP PLASMA SEPARATOR 48712959_1 CDM 0272 RC inpatient 239 155.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.71 231.83 TOURNIQUET 18IN 48712960_1 CDM 0272 RC inpatient 121 78.65 AETNA AETNA 95.59 79 999999999 73.27 117.37 percent of total billed charges TOURNIQUET 18IN 48712960_1 CDM 0272 RC inpatient 121 78.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 78.65 65 999999999 73.27 117.37 percent of total billed charges TOURNIQUET 18IN 48712960_1 CDM 0272 RC inpatient 121 78.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 117.37 97 999999999 73.27 117.37 percent of total billed charges TOURNIQUET 18IN 48712960_1 CDM 0272 RC inpatient 121 78.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 94.38 78 999999999 73.27 117.37 percent of total billed charges TOURNIQUET 18IN 48712960_1 CDM 0272 RC inpatient 121 78.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 83.49 69 999999999 73.27 117.37 percent of total billed charges TOURNIQUET 18IN 48712960_1 CDM 0272 RC inpatient 121 78.65 UMR - ALL PLANS UMR - ALL PLANS 84.7 70 999999999 73.27 117.37 percent of total billed charges TOURNIQUET 18IN 48712960_1 CDM 0272 RC inpatient 121 78.65 SIHO - ALL PLANS SIHO - ALL PLANS 108.9 90 999999999 73.27 117.37 percent of total billed charges TOURNIQUET 18IN 48712960_1 CDM 0272 RC inpatient 121 78.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.27 60.55 999999999 73.27 117.37 percent of total billed charges TOURNIQUET 18IN 48712960_1 CDM 0272 RC inpatient 121 78.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.27 117.37 TOURNIQUET 18IN 48712960_1 CDM 0272 RC inpatient 121 78.65 ANTHEM HMO ANTHEM HMO 999999999 73.27 117.37 TOURNIQUET 18IN 48712960_1 CDM 0272 RC inpatient 121 78.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.27 117.37 TOURNIQUET 18IN 48712960_1 CDM 0272 RC inpatient 121 78.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.8 67.6 999999999 73.27 117.37 percent of total billed charges TOURNIQUET 18IN 48712960_1 CDM 0272 RC inpatient 121 78.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.27 117.37 TOURNIQUET 18IN 48712960_1 CDM 0272 RC inpatient 121 78.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.27 117.37 TOURNIQUET 24IN 48712961_1 CDM 0272 RC inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges TOURNIQUET 24IN 48712961_1 CDM 0272 RC inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges TOURNIQUET 24IN 48712961_1 CDM 0272 RC inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges TOURNIQUET 24IN 48712961_1 CDM 0272 RC inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges TOURNIQUET 24IN 48712961_1 CDM 0272 RC inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges TOURNIQUET 24IN 48712961_1 CDM 0272 RC inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges TOURNIQUET 24IN 48712961_1 CDM 0272 RC inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges TOURNIQUET 24IN 48712961_1 CDM 0272 RC inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges TOURNIQUET 24IN 48712961_1 CDM 0272 RC inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 TOURNIQUET 24IN 48712961_1 CDM 0272 RC inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 TOURNIQUET 24IN 48712961_1 CDM 0272 RC inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 TOURNIQUET 24IN 48712961_1 CDM 0272 RC inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges TOURNIQUET 24IN 48712961_1 CDM 0272 RC inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 TOURNIQUET 24IN 48712961_1 CDM 0272 RC inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 TOURNIQUET 34IN 48712962_1 CDM 0272 RC inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges TOURNIQUET 34IN 48712962_1 CDM 0272 RC inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges TOURNIQUET 34IN 48712962_1 CDM 0272 RC inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges TOURNIQUET 34IN 48712962_1 CDM 0272 RC inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges TOURNIQUET 34IN 48712962_1 CDM 0272 RC inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges TOURNIQUET 34IN 48712962_1 CDM 0272 RC inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges TOURNIQUET 34IN 48712962_1 CDM 0272 RC inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges TOURNIQUET 34IN 48712962_1 CDM 0272 RC inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges TOURNIQUET 34IN 48712962_1 CDM 0272 RC inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 TOURNIQUET 34IN 48712962_1 CDM 0272 RC inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 TOURNIQUET 34IN 48712962_1 CDM 0272 RC inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 TOURNIQUET 34IN 48712962_1 CDM 0272 RC inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges TOURNIQUET 34IN 48712962_1 CDM 0272 RC inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 TOURNIQUET 34IN 48712962_1 CDM 0272 RC inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 "TOURNIQUET 30""" 48712963_1 CDM 0272 RC inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges "TOURNIQUET 30""" 48712963_1 CDM 0272 RC inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges "TOURNIQUET 30""" 48712963_1 CDM 0272 RC inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges "TOURNIQUET 30""" 48712963_1 CDM 0272 RC inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges "TOURNIQUET 30""" 48712963_1 CDM 0272 RC inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges "TOURNIQUET 30""" 48712963_1 CDM 0272 RC inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges "TOURNIQUET 30""" 48712963_1 CDM 0272 RC inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges "TOURNIQUET 30""" 48712963_1 CDM 0272 RC inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges "TOURNIQUET 30""" 48712963_1 CDM 0272 RC inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 "TOURNIQUET 30""" 48712963_1 CDM 0272 RC inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 "TOURNIQUET 30""" 48712963_1 CDM 0272 RC inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 "TOURNIQUET 30""" 48712963_1 CDM 0272 RC inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges "TOURNIQUET 30""" 48712963_1 CDM 0272 RC inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 "TOURNIQUET 30""" 48712963_1 CDM 0272 RC inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 "TOURNIQUET 44""" 48712964_1 CDM 0272 RC inpatient 170 110.5 AETNA AETNA 134.3 79 999999999 102.94 164.9 percent of total billed charges "TOURNIQUET 44""" 48712964_1 CDM 0272 RC inpatient 170 110.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.5 65 999999999 102.94 164.9 percent of total billed charges "TOURNIQUET 44""" 48712964_1 CDM 0272 RC inpatient 170 110.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.9 97 999999999 102.94 164.9 percent of total billed charges "TOURNIQUET 44""" 48712964_1 CDM 0272 RC inpatient 170 110.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.6 78 999999999 102.94 164.9 percent of total billed charges "TOURNIQUET 44""" 48712964_1 CDM 0272 RC inpatient 170 110.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.3 69 999999999 102.94 164.9 percent of total billed charges "TOURNIQUET 44""" 48712964_1 CDM 0272 RC inpatient 170 110.5 UMR - ALL PLANS UMR - ALL PLANS 119 70 999999999 102.94 164.9 percent of total billed charges "TOURNIQUET 44""" 48712964_1 CDM 0272 RC inpatient 170 110.5 SIHO - ALL PLANS SIHO - ALL PLANS 153 90 999999999 102.94 164.9 percent of total billed charges "TOURNIQUET 44""" 48712964_1 CDM 0272 RC inpatient 170 110.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.94 60.55 999999999 102.94 164.9 percent of total billed charges "TOURNIQUET 44""" 48712964_1 CDM 0272 RC inpatient 170 110.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.94 164.9 "TOURNIQUET 44""" 48712964_1 CDM 0272 RC inpatient 170 110.5 ANTHEM HMO ANTHEM HMO 999999999 102.94 164.9 "TOURNIQUET 44""" 48712964_1 CDM 0272 RC inpatient 170 110.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.94 164.9 "TOURNIQUET 44""" 48712964_1 CDM 0272 RC inpatient 170 110.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.92 67.6 999999999 102.94 164.9 percent of total billed charges "TOURNIQUET 44""" 48712964_1 CDM 0272 RC inpatient 170 110.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.94 164.9 "TOURNIQUET 44""" 48712964_1 CDM 0272 RC inpatient 170 110.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.94 164.9 TONSIL PACK (CDS) DYNJ909615 48712965_1 CDM 0272 RC inpatient 470 305.5 AETNA AETNA 371.3 79 999999999 284.59 455.9 percent of total billed charges TONSIL PACK (CDS) DYNJ909615 48712965_1 CDM 0272 RC inpatient 470 305.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 305.5 65 999999999 284.59 455.9 percent of total billed charges TONSIL PACK (CDS) DYNJ909615 48712965_1 CDM 0272 RC inpatient 470 305.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 455.9 97 999999999 284.59 455.9 percent of total billed charges TONSIL PACK (CDS) DYNJ909615 48712965_1 CDM 0272 RC inpatient 470 305.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 366.6 78 999999999 284.59 455.9 percent of total billed charges TONSIL PACK (CDS) DYNJ909615 48712965_1 CDM 0272 RC inpatient 470 305.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 324.3 69 999999999 284.59 455.9 percent of total billed charges TONSIL PACK (CDS) DYNJ909615 48712965_1 CDM 0272 RC inpatient 470 305.5 UMR - ALL PLANS UMR - ALL PLANS 329 70 999999999 284.59 455.9 percent of total billed charges TONSIL PACK (CDS) DYNJ909615 48712965_1 CDM 0272 RC inpatient 470 305.5 SIHO - ALL PLANS SIHO - ALL PLANS 423 90 999999999 284.59 455.9 percent of total billed charges TONSIL PACK (CDS) DYNJ909615 48712965_1 CDM 0272 RC inpatient 470 305.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 284.59 60.55 999999999 284.59 455.9 percent of total billed charges TONSIL PACK (CDS) DYNJ909615 48712965_1 CDM 0272 RC inpatient 470 305.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 284.59 455.9 TONSIL PACK (CDS) DYNJ909615 48712965_1 CDM 0272 RC inpatient 470 305.5 ANTHEM HMO ANTHEM HMO 999999999 284.59 455.9 TONSIL PACK (CDS) DYNJ909615 48712965_1 CDM 0272 RC inpatient 470 305.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 284.59 455.9 TONSIL PACK (CDS) DYNJ909615 48712965_1 CDM 0272 RC inpatient 470 305.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 317.72 67.6 999999999 284.59 455.9 percent of total billed charges TONSIL PACK (CDS) DYNJ909615 48712965_1 CDM 0272 RC inpatient 470 305.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 284.59 455.9 TONSIL PACK (CDS) DYNJ909615 48712965_1 CDM 0272 RC inpatient 470 305.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 284.59 455.9 MAJOR BASIN PACK (CDS) DYNJ84731 48712968_1 CDM 0272 RC inpatient 199 129.35 AETNA AETNA 157.21 79 999999999 120.49 193.03 percent of total billed charges MAJOR BASIN PACK (CDS) DYNJ84731 48712968_1 CDM 0272 RC inpatient 199 129.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 129.35 65 999999999 120.49 193.03 percent of total billed charges MAJOR BASIN PACK (CDS) DYNJ84731 48712968_1 CDM 0272 RC inpatient 199 129.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 193.03 97 999999999 120.49 193.03 percent of total billed charges MAJOR BASIN PACK (CDS) DYNJ84731 48712968_1 CDM 0272 RC inpatient 199 129.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 155.22 78 999999999 120.49 193.03 percent of total billed charges MAJOR BASIN PACK (CDS) DYNJ84731 48712968_1 CDM 0272 RC inpatient 199 129.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 137.31 69 999999999 120.49 193.03 percent of total billed charges MAJOR BASIN PACK (CDS) DYNJ84731 48712968_1 CDM 0272 RC inpatient 199 129.35 UMR - ALL PLANS UMR - ALL PLANS 139.3 70 999999999 120.49 193.03 percent of total billed charges MAJOR BASIN PACK (CDS) DYNJ84731 48712968_1 CDM 0272 RC inpatient 199 129.35 SIHO - ALL PLANS SIHO - ALL PLANS 179.1 90 999999999 120.49 193.03 percent of total billed charges MAJOR BASIN PACK (CDS) DYNJ84731 48712968_1 CDM 0272 RC inpatient 199 129.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 120.49 60.55 999999999 120.49 193.03 percent of total billed charges MAJOR BASIN PACK (CDS) DYNJ84731 48712968_1 CDM 0272 RC inpatient 199 129.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 120.49 193.03 MAJOR BASIN PACK (CDS) DYNJ84731 48712968_1 CDM 0272 RC inpatient 199 129.35 ANTHEM HMO ANTHEM HMO 999999999 120.49 193.03 MAJOR BASIN PACK (CDS) DYNJ84731 48712968_1 CDM 0272 RC inpatient 199 129.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 120.49 193.03 MAJOR BASIN PACK (CDS) DYNJ84731 48712968_1 CDM 0272 RC inpatient 199 129.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 134.52 67.6 999999999 120.49 193.03 percent of total billed charges MAJOR BASIN PACK (CDS) DYNJ84731 48712968_1 CDM 0272 RC inpatient 199 129.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 120.49 193.03 MAJOR BASIN PACK (CDS) DYNJ84731 48712968_1 CDM 0272 RC inpatient 199 129.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 120.49 193.03 TRACH TUBE 6.0MM HYPERFLEX 48712978_1 CDM 0272 RC inpatient 1115 724.75 AETNA AETNA 880.85 79 999999999 675.13 1081.55 percent of total billed charges TRACH TUBE 6.0MM HYPERFLEX 48712978_1 CDM 0272 RC inpatient 1115 724.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 724.75 65 999999999 675.13 1081.55 percent of total billed charges TRACH TUBE 6.0MM HYPERFLEX 48712978_1 CDM 0272 RC inpatient 1115 724.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1081.55 97 999999999 675.13 1081.55 percent of total billed charges TRACH TUBE 6.0MM HYPERFLEX 48712978_1 CDM 0272 RC inpatient 1115 724.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 869.7 78 999999999 675.13 1081.55 percent of total billed charges TRACH TUBE 6.0MM HYPERFLEX 48712978_1 CDM 0272 RC inpatient 1115 724.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 769.35 69 999999999 675.13 1081.55 percent of total billed charges TRACH TUBE 6.0MM HYPERFLEX 48712978_1 CDM 0272 RC inpatient 1115 724.75 UMR - ALL PLANS UMR - ALL PLANS 780.5 70 999999999 675.13 1081.55 percent of total billed charges TRACH TUBE 6.0MM HYPERFLEX 48712978_1 CDM 0272 RC inpatient 1115 724.75 SIHO - ALL PLANS SIHO - ALL PLANS 1003.5 90 999999999 675.13 1081.55 percent of total billed charges TRACH TUBE 6.0MM HYPERFLEX 48712978_1 CDM 0272 RC inpatient 1115 724.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 675.13 60.55 999999999 675.13 1081.55 percent of total billed charges TRACH TUBE 6.0MM HYPERFLEX 48712978_1 CDM 0272 RC inpatient 1115 724.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 675.13 1081.55 TRACH TUBE 6.0MM HYPERFLEX 48712978_1 CDM 0272 RC inpatient 1115 724.75 ANTHEM HMO ANTHEM HMO 999999999 675.13 1081.55 TRACH TUBE 6.0MM HYPERFLEX 48712978_1 CDM 0272 RC inpatient 1115 724.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 675.13 1081.55 TRACH TUBE 6.0MM HYPERFLEX 48712978_1 CDM 0272 RC inpatient 1115 724.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 753.74 67.6 999999999 675.13 1081.55 percent of total billed charges TRACH TUBE 6.0MM HYPERFLEX 48712978_1 CDM 0272 RC inpatient 1115 724.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 675.13 1081.55 TRACH TUBE 6.0MM HYPERFLEX 48712978_1 CDM 0272 RC inpatient 1115 724.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 675.13 1081.55 TRACH TUBE 8.0MM HYPERFLEX 48712979_1 CDM 0272 RC inpatient 1182 768.3 AETNA AETNA 933.78 79 999999999 715.7 1146.54 percent of total billed charges TRACH TUBE 8.0MM HYPERFLEX 48712979_1 CDM 0272 RC inpatient 1182 768.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 768.3 65 999999999 715.7 1146.54 percent of total billed charges TRACH TUBE 8.0MM HYPERFLEX 48712979_1 CDM 0272 RC inpatient 1182 768.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1146.54 97 999999999 715.7 1146.54 percent of total billed charges TRACH TUBE 8.0MM HYPERFLEX 48712979_1 CDM 0272 RC inpatient 1182 768.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 921.96 78 999999999 715.7 1146.54 percent of total billed charges TRACH TUBE 8.0MM HYPERFLEX 48712979_1 CDM 0272 RC inpatient 1182 768.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 815.58 69 999999999 715.7 1146.54 percent of total billed charges TRACH TUBE 8.0MM HYPERFLEX 48712979_1 CDM 0272 RC inpatient 1182 768.3 UMR - ALL PLANS UMR - ALL PLANS 827.4 70 999999999 715.7 1146.54 percent of total billed charges TRACH TUBE 8.0MM HYPERFLEX 48712979_1 CDM 0272 RC inpatient 1182 768.3 SIHO - ALL PLANS SIHO - ALL PLANS 1063.8 90 999999999 715.7 1146.54 percent of total billed charges TRACH TUBE 8.0MM HYPERFLEX 48712979_1 CDM 0272 RC inpatient 1182 768.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 715.7 60.55 999999999 715.7 1146.54 percent of total billed charges TRACH TUBE 8.0MM HYPERFLEX 48712979_1 CDM 0272 RC inpatient 1182 768.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 715.7 1146.54 TRACH TUBE 8.0MM HYPERFLEX 48712979_1 CDM 0272 RC inpatient 1182 768.3 ANTHEM HMO ANTHEM HMO 999999999 715.7 1146.54 TRACH TUBE 8.0MM HYPERFLEX 48712979_1 CDM 0272 RC inpatient 1182 768.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 715.7 1146.54 TRACH TUBE 8.0MM HYPERFLEX 48712979_1 CDM 0272 RC inpatient 1182 768.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 799.03 67.6 999999999 715.7 1146.54 percent of total billed charges TRACH TUBE 8.0MM HYPERFLEX 48712979_1 CDM 0272 RC inpatient 1182 768.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 715.7 1146.54 TRACH TUBE 8.0MM HYPERFLEX 48712979_1 CDM 0272 RC inpatient 1182 768.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 715.7 1146.54 ULTRASLING III MED 11-0449-3 48712980_1 CDM 0271 RC inpatient 336 218.4 AETNA AETNA 265.44 79 999999999 203.45 325.92 percent of total billed charges ULTRASLING III MED 11-0449-3 48712980_1 CDM 0271 RC inpatient 336 218.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 218.4 65 999999999 203.45 325.92 percent of total billed charges ULTRASLING III MED 11-0449-3 48712980_1 CDM 0271 RC inpatient 336 218.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 325.92 97 999999999 203.45 325.92 percent of total billed charges ULTRASLING III MED 11-0449-3 48712980_1 CDM 0271 RC inpatient 336 218.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 262.08 78 999999999 203.45 325.92 percent of total billed charges ULTRASLING III MED 11-0449-3 48712980_1 CDM 0271 RC inpatient 336 218.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 231.84 69 999999999 203.45 325.92 percent of total billed charges ULTRASLING III MED 11-0449-3 48712980_1 CDM 0271 RC inpatient 336 218.4 UMR - ALL PLANS UMR - ALL PLANS 235.2 70 999999999 203.45 325.92 percent of total billed charges ULTRASLING III MED 11-0449-3 48712980_1 CDM 0271 RC inpatient 336 218.4 SIHO - ALL PLANS SIHO - ALL PLANS 302.4 90 999999999 203.45 325.92 percent of total billed charges ULTRASLING III MED 11-0449-3 48712980_1 CDM 0271 RC inpatient 336 218.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 203.45 60.55 999999999 203.45 325.92 percent of total billed charges ULTRASLING III MED 11-0449-3 48712980_1 CDM 0271 RC inpatient 336 218.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 203.45 325.92 ULTRASLING III MED 11-0449-3 48712980_1 CDM 0271 RC inpatient 336 218.4 ANTHEM HMO ANTHEM HMO 999999999 203.45 325.92 ULTRASLING III MED 11-0449-3 48712980_1 CDM 0271 RC inpatient 336 218.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 203.45 325.92 ULTRASLING III MED 11-0449-3 48712980_1 CDM 0271 RC inpatient 336 218.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 227.14 67.6 999999999 203.45 325.92 percent of total billed charges ULTRASLING III MED 11-0449-3 48712980_1 CDM 0271 RC inpatient 336 218.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 203.45 325.92 ULTRASLING III MED 11-0449-3 48712980_1 CDM 0271 RC inpatient 336 218.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 203.45 325.92 TRACH SZ 6 CUFFLESS 6UN75R 48712981_1 CDM 0274 RC inpatient 284 184.6 AETNA AETNA 224.36 79 999999999 171.96 275.48 percent of total billed charges TRACH SZ 6 CUFFLESS 6UN75R 48712981_1 CDM 0274 RC inpatient 284 184.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 184.6 65 999999999 171.96 275.48 percent of total billed charges TRACH SZ 6 CUFFLESS 6UN75R 48712981_1 CDM 0274 RC inpatient 284 184.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 275.48 97 999999999 171.96 275.48 percent of total billed charges TRACH SZ 6 CUFFLESS 6UN75R 48712981_1 CDM 0274 RC inpatient 284 184.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 221.52 78 999999999 171.96 275.48 percent of total billed charges TRACH SZ 6 CUFFLESS 6UN75R 48712981_1 CDM 0274 RC inpatient 284 184.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 195.96 69 999999999 171.96 275.48 percent of total billed charges TRACH SZ 6 CUFFLESS 6UN75R 48712981_1 CDM 0274 RC inpatient 284 184.6 UMR - ALL PLANS UMR - ALL PLANS 198.8 70 999999999 171.96 275.48 percent of total billed charges TRACH SZ 6 CUFFLESS 6UN75R 48712981_1 CDM 0274 RC inpatient 284 184.6 SIHO - ALL PLANS SIHO - ALL PLANS 255.6 90 999999999 171.96 275.48 percent of total billed charges TRACH SZ 6 CUFFLESS 6UN75R 48712981_1 CDM 0274 RC inpatient 284 184.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 171.96 60.55 999999999 171.96 275.48 percent of total billed charges TRACH SZ 6 CUFFLESS 6UN75R 48712981_1 CDM 0274 RC inpatient 284 184.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 171.96 275.48 TRACH SZ 6 CUFFLESS 6UN75R 48712981_1 CDM 0274 RC inpatient 284 184.6 ANTHEM HMO ANTHEM HMO 999999999 171.96 275.48 TRACH SZ 6 CUFFLESS 6UN75R 48712981_1 CDM 0274 RC inpatient 284 184.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 171.96 275.48 TRACH SZ 6 CUFFLESS 6UN75R 48712981_1 CDM 0274 RC inpatient 284 184.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 191.98 67.6 999999999 171.96 275.48 percent of total billed charges TRACH SZ 6 CUFFLESS 6UN75R 48712981_1 CDM 0274 RC inpatient 284 184.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 171.96 275.48 TRACH SZ 6 CUFFLESS 6UN75R 48712981_1 CDM 0274 RC inpatient 284 184.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 171.96 275.48 TRACH L-PRESS CUFFED 4CN65H 48712982_1 CDM 0274 RC inpatient 286 185.9 AETNA AETNA 225.94 79 999999999 173.17 277.42 percent of total billed charges TRACH L-PRESS CUFFED 4CN65H 48712982_1 CDM 0274 RC inpatient 286 185.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.9 65 999999999 173.17 277.42 percent of total billed charges TRACH L-PRESS CUFFED 4CN65H 48712982_1 CDM 0274 RC inpatient 286 185.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 277.42 97 999999999 173.17 277.42 percent of total billed charges TRACH L-PRESS CUFFED 4CN65H 48712982_1 CDM 0274 RC inpatient 286 185.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 223.08 78 999999999 173.17 277.42 percent of total billed charges TRACH L-PRESS CUFFED 4CN65H 48712982_1 CDM 0274 RC inpatient 286 185.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 197.34 69 999999999 173.17 277.42 percent of total billed charges TRACH L-PRESS CUFFED 4CN65H 48712982_1 CDM 0274 RC inpatient 286 185.9 UMR - ALL PLANS UMR - ALL PLANS 200.2 70 999999999 173.17 277.42 percent of total billed charges TRACH L-PRESS CUFFED 4CN65H 48712982_1 CDM 0274 RC inpatient 286 185.9 SIHO - ALL PLANS SIHO - ALL PLANS 257.4 90 999999999 173.17 277.42 percent of total billed charges TRACH L-PRESS CUFFED 4CN65H 48712982_1 CDM 0274 RC inpatient 286 185.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 173.17 60.55 999999999 173.17 277.42 percent of total billed charges TRACH L-PRESS CUFFED 4CN65H 48712982_1 CDM 0274 RC inpatient 286 185.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 173.17 277.42 TRACH L-PRESS CUFFED 4CN65H 48712982_1 CDM 0274 RC inpatient 286 185.9 ANTHEM HMO ANTHEM HMO 999999999 173.17 277.42 TRACH L-PRESS CUFFED 4CN65H 48712982_1 CDM 0274 RC inpatient 286 185.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 173.17 277.42 TRACH L-PRESS CUFFED 4CN65H 48712982_1 CDM 0274 RC inpatient 286 185.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 193.34 67.6 999999999 173.17 277.42 percent of total billed charges TRACH L-PRESS CUFFED 4CN65H 48712982_1 CDM 0274 RC inpatient 286 185.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 173.17 277.42 TRACH L-PRESS CUFFED 4CN65H 48712982_1 CDM 0274 RC inpatient 286 185.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 173.17 277.42 TRACH L-PRESS CUFFED MFG# 7CN80H 48712983_1 CDM 0274 RC inpatient 286 185.9 AETNA AETNA 225.94 79 999999999 173.17 277.42 percent of total billed charges TRACH L-PRESS CUFFED MFG# 7CN80H 48712983_1 CDM 0274 RC inpatient 286 185.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.9 65 999999999 173.17 277.42 percent of total billed charges TRACH L-PRESS CUFFED MFG# 7CN80H 48712983_1 CDM 0274 RC inpatient 286 185.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 277.42 97 999999999 173.17 277.42 percent of total billed charges TRACH L-PRESS CUFFED MFG# 7CN80H 48712983_1 CDM 0274 RC inpatient 286 185.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 223.08 78 999999999 173.17 277.42 percent of total billed charges TRACH L-PRESS CUFFED MFG# 7CN80H 48712983_1 CDM 0274 RC inpatient 286 185.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 197.34 69 999999999 173.17 277.42 percent of total billed charges TRACH L-PRESS CUFFED MFG# 7CN80H 48712983_1 CDM 0274 RC inpatient 286 185.9 UMR - ALL PLANS UMR - ALL PLANS 200.2 70 999999999 173.17 277.42 percent of total billed charges TRACH L-PRESS CUFFED MFG# 7CN80H 48712983_1 CDM 0274 RC inpatient 286 185.9 SIHO - ALL PLANS SIHO - ALL PLANS 257.4 90 999999999 173.17 277.42 percent of total billed charges TRACH L-PRESS CUFFED MFG# 7CN80H 48712983_1 CDM 0274 RC inpatient 286 185.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 173.17 60.55 999999999 173.17 277.42 percent of total billed charges TRACH L-PRESS CUFFED MFG# 7CN80H 48712983_1 CDM 0274 RC inpatient 286 185.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 173.17 277.42 TRACH L-PRESS CUFFED MFG# 7CN80H 48712983_1 CDM 0274 RC inpatient 286 185.9 ANTHEM HMO ANTHEM HMO 999999999 173.17 277.42 TRACH L-PRESS CUFFED MFG# 7CN80H 48712983_1 CDM 0274 RC inpatient 286 185.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 173.17 277.42 TRACH L-PRESS CUFFED MFG# 7CN80H 48712983_1 CDM 0274 RC inpatient 286 185.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 193.34 67.6 999999999 173.17 277.42 percent of total billed charges TRACH L-PRESS CUFFED MFG# 7CN80H 48712983_1 CDM 0274 RC inpatient 286 185.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 173.17 277.42 TRACH L-PRESS CUFFED MFG# 7CN80H 48712983_1 CDM 0274 RC inpatient 286 185.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 173.17 277.42 TRACH SHILEY CUFFED 6DFEN FEN #6 48712984_1 CDM 0274 RC inpatient 300 195 AETNA AETNA 237 79 999999999 181.65 291 percent of total billed charges TRACH SHILEY CUFFED 6DFEN FEN #6 48712984_1 CDM 0274 RC inpatient 300 195 SELF PAY DISCOUNT SELF PAY DISCOUNT 195 65 999999999 181.65 291 percent of total billed charges TRACH SHILEY CUFFED 6DFEN FEN #6 48712984_1 CDM 0274 RC inpatient 300 195 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291 97 999999999 181.65 291 percent of total billed charges TRACH SHILEY CUFFED 6DFEN FEN #6 48712984_1 CDM 0274 RC inpatient 300 195 HUMANA - ALL PLANS HUMANA - ALL PLANS 234 78 999999999 181.65 291 percent of total billed charges TRACH SHILEY CUFFED 6DFEN FEN #6 48712984_1 CDM 0274 RC inpatient 300 195 ENCORE - ALL PLANS ENCORE - ALL PLANS 207 69 999999999 181.65 291 percent of total billed charges TRACH SHILEY CUFFED 6DFEN FEN #6 48712984_1 CDM 0274 RC inpatient 300 195 UMR - ALL PLANS UMR - ALL PLANS 210 70 999999999 181.65 291 percent of total billed charges TRACH SHILEY CUFFED 6DFEN FEN #6 48712984_1 CDM 0274 RC inpatient 300 195 SIHO - ALL PLANS SIHO - ALL PLANS 270 90 999999999 181.65 291 percent of total billed charges TRACH SHILEY CUFFED 6DFEN FEN #6 48712984_1 CDM 0274 RC inpatient 300 195 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 181.65 60.55 999999999 181.65 291 percent of total billed charges TRACH SHILEY CUFFED 6DFEN FEN #6 48712984_1 CDM 0274 RC inpatient 300 195 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 181.65 291 TRACH SHILEY CUFFED 6DFEN FEN #6 48712984_1 CDM 0274 RC inpatient 300 195 ANTHEM HMO ANTHEM HMO 999999999 181.65 291 TRACH SHILEY CUFFED 6DFEN FEN #6 48712984_1 CDM 0274 RC inpatient 300 195 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 181.65 291 TRACH SHILEY CUFFED 6DFEN FEN #6 48712984_1 CDM 0274 RC inpatient 300 195 CIGNA - ALL PLANS CIGNA - ALL PLANS 202.8 67.6 999999999 181.65 291 percent of total billed charges TRACH SHILEY CUFFED 6DFEN FEN #6 48712984_1 CDM 0274 RC inpatient 300 195 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 181.65 291 TRACH SHILEY CUFFED 6DFEN FEN #6 48712984_1 CDM 0274 RC inpatient 300 195 UHC - ALL PLANS UHC - ALL PLANS 999999999 181.65 291 TRACH L-PRESS CUFF 8DFEN 48712985_1 CDM 0274 RC inpatient 321 208.65 AETNA AETNA 253.59 79 999999999 194.37 311.37 percent of total billed charges TRACH L-PRESS CUFF 8DFEN 48712985_1 CDM 0274 RC inpatient 321 208.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 208.65 65 999999999 194.37 311.37 percent of total billed charges TRACH L-PRESS CUFF 8DFEN 48712985_1 CDM 0274 RC inpatient 321 208.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 311.37 97 999999999 194.37 311.37 percent of total billed charges TRACH L-PRESS CUFF 8DFEN 48712985_1 CDM 0274 RC inpatient 321 208.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 250.38 78 999999999 194.37 311.37 percent of total billed charges TRACH L-PRESS CUFF 8DFEN 48712985_1 CDM 0274 RC inpatient 321 208.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 221.49 69 999999999 194.37 311.37 percent of total billed charges TRACH L-PRESS CUFF 8DFEN 48712985_1 CDM 0274 RC inpatient 321 208.65 UMR - ALL PLANS UMR - ALL PLANS 224.7 70 999999999 194.37 311.37 percent of total billed charges TRACH L-PRESS CUFF 8DFEN 48712985_1 CDM 0274 RC inpatient 321 208.65 SIHO - ALL PLANS SIHO - ALL PLANS 288.9 90 999999999 194.37 311.37 percent of total billed charges TRACH L-PRESS CUFF 8DFEN 48712985_1 CDM 0274 RC inpatient 321 208.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 194.37 60.55 999999999 194.37 311.37 percent of total billed charges TRACH L-PRESS CUFF 8DFEN 48712985_1 CDM 0274 RC inpatient 321 208.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 194.37 311.37 TRACH L-PRESS CUFF 8DFEN 48712985_1 CDM 0274 RC inpatient 321 208.65 ANTHEM HMO ANTHEM HMO 999999999 194.37 311.37 TRACH L-PRESS CUFF 8DFEN 48712985_1 CDM 0274 RC inpatient 321 208.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 194.37 311.37 TRACH L-PRESS CUFF 8DFEN 48712985_1 CDM 0274 RC inpatient 321 208.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 217 67.6 999999999 194.37 311.37 percent of total billed charges TRACH L-PRESS CUFF 8DFEN 48712985_1 CDM 0274 RC inpatient 321 208.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 194.37 311.37 TRACH L-PRESS CUFF 8DFEN 48712985_1 CDM 0274 RC inpatient 321 208.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 194.37 311.37 TRACH L-PRESS CUFFED 8CN85H 48712986_1 CDM 0274 RC inpatient 302 196.3 AETNA AETNA 238.58 79 999999999 182.86 292.94 percent of total billed charges TRACH L-PRESS CUFFED 8CN85H 48712986_1 CDM 0274 RC inpatient 302 196.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 196.3 65 999999999 182.86 292.94 percent of total billed charges TRACH L-PRESS CUFFED 8CN85H 48712986_1 CDM 0274 RC inpatient 302 196.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 292.94 97 999999999 182.86 292.94 percent of total billed charges TRACH L-PRESS CUFFED 8CN85H 48712986_1 CDM 0274 RC inpatient 302 196.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 235.56 78 999999999 182.86 292.94 percent of total billed charges TRACH L-PRESS CUFFED 8CN85H 48712986_1 CDM 0274 RC inpatient 302 196.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 208.38 69 999999999 182.86 292.94 percent of total billed charges TRACH L-PRESS CUFFED 8CN85H 48712986_1 CDM 0274 RC inpatient 302 196.3 UMR - ALL PLANS UMR - ALL PLANS 211.4 70 999999999 182.86 292.94 percent of total billed charges TRACH L-PRESS CUFFED 8CN85H 48712986_1 CDM 0274 RC inpatient 302 196.3 SIHO - ALL PLANS SIHO - ALL PLANS 271.8 90 999999999 182.86 292.94 percent of total billed charges TRACH L-PRESS CUFFED 8CN85H 48712986_1 CDM 0274 RC inpatient 302 196.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.86 60.55 999999999 182.86 292.94 percent of total billed charges TRACH L-PRESS CUFFED 8CN85H 48712986_1 CDM 0274 RC inpatient 302 196.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.86 292.94 TRACH L-PRESS CUFFED 8CN85H 48712986_1 CDM 0274 RC inpatient 302 196.3 ANTHEM HMO ANTHEM HMO 999999999 182.86 292.94 TRACH L-PRESS CUFFED 8CN85H 48712986_1 CDM 0274 RC inpatient 302 196.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.86 292.94 TRACH L-PRESS CUFFED 8CN85H 48712986_1 CDM 0274 RC inpatient 302 196.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 204.15 67.6 999999999 182.86 292.94 percent of total billed charges TRACH L-PRESS CUFFED 8CN85H 48712986_1 CDM 0274 RC inpatient 302 196.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.86 292.94 TRACH L-PRESS CUFFED 8CN85H 48712986_1 CDM 0274 RC inpatient 302 196.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.86 292.94 SMART BITE BLOCK 7FT 012529 48712987_1 CDM 0272 RC inpatient 118 76.7 AETNA AETNA 93.22 79 999999999 71.45 114.46 percent of total billed charges SMART BITE BLOCK 7FT 012529 48712987_1 CDM 0272 RC inpatient 118 76.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 76.7 65 999999999 71.45 114.46 percent of total billed charges SMART BITE BLOCK 7FT 012529 48712987_1 CDM 0272 RC inpatient 118 76.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 114.46 97 999999999 71.45 114.46 percent of total billed charges SMART BITE BLOCK 7FT 012529 48712987_1 CDM 0272 RC inpatient 118 76.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.04 78 999999999 71.45 114.46 percent of total billed charges SMART BITE BLOCK 7FT 012529 48712987_1 CDM 0272 RC inpatient 118 76.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 81.42 69 999999999 71.45 114.46 percent of total billed charges SMART BITE BLOCK 7FT 012529 48712987_1 CDM 0272 RC inpatient 118 76.7 UMR - ALL PLANS UMR - ALL PLANS 82.6 70 999999999 71.45 114.46 percent of total billed charges SMART BITE BLOCK 7FT 012529 48712987_1 CDM 0272 RC inpatient 118 76.7 SIHO - ALL PLANS SIHO - ALL PLANS 106.2 90 999999999 71.45 114.46 percent of total billed charges SMART BITE BLOCK 7FT 012529 48712987_1 CDM 0272 RC inpatient 118 76.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 71.45 60.55 999999999 71.45 114.46 percent of total billed charges SMART BITE BLOCK 7FT 012529 48712987_1 CDM 0272 RC inpatient 118 76.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 71.45 114.46 SMART BITE BLOCK 7FT 012529 48712987_1 CDM 0272 RC inpatient 118 76.7 ANTHEM HMO ANTHEM HMO 999999999 71.45 114.46 SMART BITE BLOCK 7FT 012529 48712987_1 CDM 0272 RC inpatient 118 76.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 71.45 114.46 SMART BITE BLOCK 7FT 012529 48712987_1 CDM 0272 RC inpatient 118 76.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 79.77 67.6 999999999 71.45 114.46 percent of total billed charges SMART BITE BLOCK 7FT 012529 48712987_1 CDM 0272 RC inpatient 118 76.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 71.45 114.46 SMART BITE BLOCK 7FT 012529 48712987_1 CDM 0272 RC inpatient 118 76.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 71.45 114.46 TRACH TUBE SHILEY SZ 8 DISTAL 80XLTCD 48712989_1 CDM 0272 RC inpatient 443 287.95 AETNA AETNA 349.97 79 999999999 268.24 429.71 percent of total billed charges TRACH TUBE SHILEY SZ 8 DISTAL 80XLTCD 48712989_1 CDM 0272 RC inpatient 443 287.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 287.95 65 999999999 268.24 429.71 percent of total billed charges TRACH TUBE SHILEY SZ 8 DISTAL 80XLTCD 48712989_1 CDM 0272 RC inpatient 443 287.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 429.71 97 999999999 268.24 429.71 percent of total billed charges TRACH TUBE SHILEY SZ 8 DISTAL 80XLTCD 48712989_1 CDM 0272 RC inpatient 443 287.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 345.54 78 999999999 268.24 429.71 percent of total billed charges TRACH TUBE SHILEY SZ 8 DISTAL 80XLTCD 48712989_1 CDM 0272 RC inpatient 443 287.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 305.67 69 999999999 268.24 429.71 percent of total billed charges TRACH TUBE SHILEY SZ 8 DISTAL 80XLTCD 48712989_1 CDM 0272 RC inpatient 443 287.95 UMR - ALL PLANS UMR - ALL PLANS 310.1 70 999999999 268.24 429.71 percent of total billed charges TRACH TUBE SHILEY SZ 8 DISTAL 80XLTCD 48712989_1 CDM 0272 RC inpatient 443 287.95 SIHO - ALL PLANS SIHO - ALL PLANS 398.7 90 999999999 268.24 429.71 percent of total billed charges TRACH TUBE SHILEY SZ 8 DISTAL 80XLTCD 48712989_1 CDM 0272 RC inpatient 443 287.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 268.24 60.55 999999999 268.24 429.71 percent of total billed charges TRACH TUBE SHILEY SZ 8 DISTAL 80XLTCD 48712989_1 CDM 0272 RC inpatient 443 287.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 268.24 429.71 TRACH TUBE SHILEY SZ 8 DISTAL 80XLTCD 48712989_1 CDM 0272 RC inpatient 443 287.95 ANTHEM HMO ANTHEM HMO 999999999 268.24 429.71 TRACH TUBE SHILEY SZ 8 DISTAL 80XLTCD 48712989_1 CDM 0272 RC inpatient 443 287.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 268.24 429.71 TRACH TUBE SHILEY SZ 8 DISTAL 80XLTCD 48712989_1 CDM 0272 RC inpatient 443 287.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 299.47 67.6 999999999 268.24 429.71 percent of total billed charges TRACH TUBE SHILEY SZ 8 DISTAL 80XLTCD 48712989_1 CDM 0272 RC inpatient 443 287.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 268.24 429.71 TRACH TUBE SHILEY SZ 8 DISTAL 80XLTCD 48712989_1 CDM 0272 RC inpatient 443 287.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 268.24 429.71 TRACH PORTEX 8MM 100/815/080 48712990_1 CDM 0272 RC inpatient 223 144.95 AETNA AETNA 176.17 79 999999999 135.03 216.31 percent of total billed charges TRACH PORTEX 8MM 100/815/080 48712990_1 CDM 0272 RC inpatient 223 144.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 144.95 65 999999999 135.03 216.31 percent of total billed charges TRACH PORTEX 8MM 100/815/080 48712990_1 CDM 0272 RC inpatient 223 144.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 216.31 97 999999999 135.03 216.31 percent of total billed charges TRACH PORTEX 8MM 100/815/080 48712990_1 CDM 0272 RC inpatient 223 144.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 173.94 78 999999999 135.03 216.31 percent of total billed charges TRACH PORTEX 8MM 100/815/080 48712990_1 CDM 0272 RC inpatient 223 144.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 153.87 69 999999999 135.03 216.31 percent of total billed charges TRACH PORTEX 8MM 100/815/080 48712990_1 CDM 0272 RC inpatient 223 144.95 UMR - ALL PLANS UMR - ALL PLANS 156.1 70 999999999 135.03 216.31 percent of total billed charges TRACH PORTEX 8MM 100/815/080 48712990_1 CDM 0272 RC inpatient 223 144.95 SIHO - ALL PLANS SIHO - ALL PLANS 200.7 90 999999999 135.03 216.31 percent of total billed charges TRACH PORTEX 8MM 100/815/080 48712990_1 CDM 0272 RC inpatient 223 144.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 135.03 60.55 999999999 135.03 216.31 percent of total billed charges TRACH PORTEX 8MM 100/815/080 48712990_1 CDM 0272 RC inpatient 223 144.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 135.03 216.31 TRACH PORTEX 8MM 100/815/080 48712990_1 CDM 0272 RC inpatient 223 144.95 ANTHEM HMO ANTHEM HMO 999999999 135.03 216.31 TRACH PORTEX 8MM 100/815/080 48712990_1 CDM 0272 RC inpatient 223 144.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 135.03 216.31 TRACH PORTEX 8MM 100/815/080 48712990_1 CDM 0272 RC inpatient 223 144.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 150.75 67.6 999999999 135.03 216.31 percent of total billed charges TRACH PORTEX 8MM 100/815/080 48712990_1 CDM 0272 RC inpatient 223 144.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 135.03 216.31 TRACH PORTEX 8MM 100/815/080 48712990_1 CDM 0272 RC inpatient 223 144.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 135.03 216.31 TRACH PORTEX 6MM 100/815/060 48712991_1 CDM 0272 RC inpatient 229 148.85 AETNA AETNA 180.91 79 999999999 138.66 222.13 percent of total billed charges TRACH PORTEX 6MM 100/815/060 48712991_1 CDM 0272 RC inpatient 229 148.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 148.85 65 999999999 138.66 222.13 percent of total billed charges TRACH PORTEX 6MM 100/815/060 48712991_1 CDM 0272 RC inpatient 229 148.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 222.13 97 999999999 138.66 222.13 percent of total billed charges TRACH PORTEX 6MM 100/815/060 48712991_1 CDM 0272 RC inpatient 229 148.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 178.62 78 999999999 138.66 222.13 percent of total billed charges TRACH PORTEX 6MM 100/815/060 48712991_1 CDM 0272 RC inpatient 229 148.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 158.01 69 999999999 138.66 222.13 percent of total billed charges TRACH PORTEX 6MM 100/815/060 48712991_1 CDM 0272 RC inpatient 229 148.85 UMR - ALL PLANS UMR - ALL PLANS 160.3 70 999999999 138.66 222.13 percent of total billed charges TRACH PORTEX 6MM 100/815/060 48712991_1 CDM 0272 RC inpatient 229 148.85 SIHO - ALL PLANS SIHO - ALL PLANS 206.1 90 999999999 138.66 222.13 percent of total billed charges TRACH PORTEX 6MM 100/815/060 48712991_1 CDM 0272 RC inpatient 229 148.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 138.66 60.55 999999999 138.66 222.13 percent of total billed charges TRACH PORTEX 6MM 100/815/060 48712991_1 CDM 0272 RC inpatient 229 148.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 138.66 222.13 TRACH PORTEX 6MM 100/815/060 48712991_1 CDM 0272 RC inpatient 229 148.85 ANTHEM HMO ANTHEM HMO 999999999 138.66 222.13 TRACH PORTEX 6MM 100/815/060 48712991_1 CDM 0272 RC inpatient 229 148.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 138.66 222.13 TRACH PORTEX 6MM 100/815/060 48712991_1 CDM 0272 RC inpatient 229 148.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 154.8 67.6 999999999 138.66 222.13 percent of total billed charges TRACH PORTEX 6MM 100/815/060 48712991_1 CDM 0272 RC inpatient 229 148.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 138.66 222.13 TRACH PORTEX 6MM 100/815/060 48712991_1 CDM 0272 RC inpatient 229 148.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 138.66 222.13 TRACH TB SHILEY SZ 7 48712992_1 CDM 0274 RC inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges TRACH TB SHILEY SZ 7 48712992_1 CDM 0274 RC inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges TRACH TB SHILEY SZ 7 48712992_1 CDM 0274 RC inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges TRACH TB SHILEY SZ 7 48712992_1 CDM 0274 RC inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges TRACH TB SHILEY SZ 7 48712992_1 CDM 0274 RC inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges TRACH TB SHILEY SZ 7 48712992_1 CDM 0274 RC inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges TRACH TB SHILEY SZ 7 48712992_1 CDM 0274 RC inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges TRACH TB SHILEY SZ 7 48712992_1 CDM 0274 RC inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges TRACH TB SHILEY SZ 7 48712992_1 CDM 0274 RC inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 TRACH TB SHILEY SZ 7 48712992_1 CDM 0274 RC inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 TRACH TB SHILEY SZ 7 48712992_1 CDM 0274 RC inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 TRACH TB SHILEY SZ 7 48712992_1 CDM 0274 RC inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges TRACH TB SHILEY SZ 7 48712992_1 CDM 0274 RC inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 TRACH TB SHILEY SZ 7 48712992_1 CDM 0274 RC inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 TUBING 02 SMART CAPNOLINE PED 48712993_1 CDM 0272 RC inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges TUBING 02 SMART CAPNOLINE PED 48712993_1 CDM 0272 RC inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges TUBING 02 SMART CAPNOLINE PED 48712993_1 CDM 0272 RC inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges TUBING 02 SMART CAPNOLINE PED 48712993_1 CDM 0272 RC inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges TUBING 02 SMART CAPNOLINE PED 48712993_1 CDM 0272 RC inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges TUBING 02 SMART CAPNOLINE PED 48712993_1 CDM 0272 RC inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges TUBING 02 SMART CAPNOLINE PED 48712993_1 CDM 0272 RC inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges TUBING 02 SMART CAPNOLINE PED 48712993_1 CDM 0272 RC inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges TUBING 02 SMART CAPNOLINE PED 48712993_1 CDM 0272 RC inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 TUBING 02 SMART CAPNOLINE PED 48712993_1 CDM 0272 RC inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 TUBING 02 SMART CAPNOLINE PED 48712993_1 CDM 0272 RC inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 TUBING 02 SMART CAPNOLINE PED 48712993_1 CDM 0272 RC inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges TUBING 02 SMART CAPNOLINE PED 48712993_1 CDM 0272 RC inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 TUBING 02 SMART CAPNOLINE PED 48712993_1 CDM 0272 RC inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 TUBING CAPNOLINE PED LONG TERM 48712994_1 CDM 0272 RC inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges TUBING CAPNOLINE PED LONG TERM 48712994_1 CDM 0272 RC inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges TUBING CAPNOLINE PED LONG TERM 48712994_1 CDM 0272 RC inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges TUBING CAPNOLINE PED LONG TERM 48712994_1 CDM 0272 RC inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges TUBING CAPNOLINE PED LONG TERM 48712994_1 CDM 0272 RC inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges TUBING CAPNOLINE PED LONG TERM 48712994_1 CDM 0272 RC inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges TUBING CAPNOLINE PED LONG TERM 48712994_1 CDM 0272 RC inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges TUBING CAPNOLINE PED LONG TERM 48712994_1 CDM 0272 RC inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges TUBING CAPNOLINE PED LONG TERM 48712994_1 CDM 0272 RC inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 TUBING CAPNOLINE PED LONG TERM 48712994_1 CDM 0272 RC inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 TUBING CAPNOLINE PED LONG TERM 48712994_1 CDM 0272 RC inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 TUBING CAPNOLINE PED LONG TERM 48712994_1 CDM 0272 RC inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges TUBING CAPNOLINE PED LONG TERM 48712994_1 CDM 0272 RC inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 TUBING CAPNOLINE PED LONG TERM 48712994_1 CDM 0272 RC inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 TUBING CAPNOLINE INTUBATED MVAI 48712995_1 CDM 0272 RC inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges TUBING CAPNOLINE INTUBATED MVAI 48712995_1 CDM 0272 RC inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges TUBING CAPNOLINE INTUBATED MVAI 48712995_1 CDM 0272 RC inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges TUBING CAPNOLINE INTUBATED MVAI 48712995_1 CDM 0272 RC inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges TUBING CAPNOLINE INTUBATED MVAI 48712995_1 CDM 0272 RC inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges TUBING CAPNOLINE INTUBATED MVAI 48712995_1 CDM 0272 RC inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges TUBING CAPNOLINE INTUBATED MVAI 48712995_1 CDM 0272 RC inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges TUBING CAPNOLINE INTUBATED MVAI 48712995_1 CDM 0272 RC inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges TUBING CAPNOLINE INTUBATED MVAI 48712995_1 CDM 0272 RC inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 TUBING CAPNOLINE INTUBATED MVAI 48712995_1 CDM 0272 RC inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 TUBING CAPNOLINE INTUBATED MVAI 48712995_1 CDM 0272 RC inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 TUBING CAPNOLINE INTUBATED MVAI 48712995_1 CDM 0272 RC inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges TUBING CAPNOLINE INTUBATED MVAI 48712995_1 CDM 0272 RC inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 TUBING CAPNOLINE INTUBATED MVAI 48712995_1 CDM 0272 RC inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 FLOSEAL HEMOSTATIC MATRIX 5ML 48712998_1 CDM 0272 RC inpatient 1204 782.6 AETNA AETNA 951.16 79 999999999 729.02 1167.88 percent of total billed charges FLOSEAL HEMOSTATIC MATRIX 5ML 48712998_1 CDM 0272 RC inpatient 1204 782.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 782.6 65 999999999 729.02 1167.88 percent of total billed charges FLOSEAL HEMOSTATIC MATRIX 5ML 48712998_1 CDM 0272 RC inpatient 1204 782.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1167.88 97 999999999 729.02 1167.88 percent of total billed charges FLOSEAL HEMOSTATIC MATRIX 5ML 48712998_1 CDM 0272 RC inpatient 1204 782.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 830.76 69 999999999 729.02 1167.88 percent of total billed charges FLOSEAL HEMOSTATIC MATRIX 5ML 48712998_1 CDM 0272 RC inpatient 1204 782.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 939.12 78 999999999 729.02 1167.88 percent of total billed charges FLOSEAL HEMOSTATIC MATRIX 5ML 48712998_1 CDM 0272 RC inpatient 1204 782.6 UMR - ALL PLANS UMR - ALL PLANS 842.8 70 999999999 729.02 1167.88 percent of total billed charges FLOSEAL HEMOSTATIC MATRIX 5ML 48712998_1 CDM 0272 RC inpatient 1204 782.6 SIHO - ALL PLANS SIHO - ALL PLANS 1083.6 90 999999999 729.02 1167.88 percent of total billed charges FLOSEAL HEMOSTATIC MATRIX 5ML 48712998_1 CDM 0272 RC inpatient 1204 782.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 729.02 60.55 999999999 729.02 1167.88 percent of total billed charges FLOSEAL HEMOSTATIC MATRIX 5ML 48712998_1 CDM 0272 RC inpatient 1204 782.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 729.02 1167.88 FLOSEAL HEMOSTATIC MATRIX 5ML 48712998_1 CDM 0272 RC inpatient 1204 782.6 ANTHEM HMO ANTHEM HMO 999999999 729.02 1167.88 FLOSEAL HEMOSTATIC MATRIX 5ML 48712998_1 CDM 0272 RC inpatient 1204 782.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 729.02 1167.88 FLOSEAL HEMOSTATIC MATRIX 5ML 48712998_1 CDM 0272 RC inpatient 1204 782.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 813.9 67.6 999999999 729.02 1167.88 percent of total billed charges FLOSEAL HEMOSTATIC MATRIX 5ML 48712998_1 CDM 0272 RC inpatient 1204 782.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 729.02 1167.88 FLOSEAL HEMOSTATIC MATRIX 5ML 48712998_1 CDM 0272 RC inpatient 1204 782.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 729.02 1167.88 TRAY BARRIER MAXIMUM #69747 48712999_1 CDM 0272 RC inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges TRAY BARRIER MAXIMUM #69747 48712999_1 CDM 0272 RC inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges TRAY BARRIER MAXIMUM #69747 48712999_1 CDM 0272 RC inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges TRAY BARRIER MAXIMUM #69747 48712999_1 CDM 0272 RC inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges TRAY BARRIER MAXIMUM #69747 48712999_1 CDM 0272 RC inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges TRAY BARRIER MAXIMUM #69747 48712999_1 CDM 0272 RC inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges TRAY BARRIER MAXIMUM #69747 48712999_1 CDM 0272 RC inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges TRAY BARRIER MAXIMUM #69747 48712999_1 CDM 0272 RC inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges TRAY BARRIER MAXIMUM #69747 48712999_1 CDM 0272 RC inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 TRAY BARRIER MAXIMUM #69747 48712999_1 CDM 0272 RC inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 TRAY BARRIER MAXIMUM #69747 48712999_1 CDM 0272 RC inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 TRAY BARRIER MAXIMUM #69747 48712999_1 CDM 0272 RC inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges TRAY BARRIER MAXIMUM #69747 48712999_1 CDM 0272 RC inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 TRAY BARRIER MAXIMUM #69747 48712999_1 CDM 0272 RC inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 CONTIPLEX P/NERVE BLOCK 48713000_1 CDM 0271 RC inpatient 191 124.15 AETNA AETNA 150.89 79 999999999 115.65 185.27 percent of total billed charges CONTIPLEX P/NERVE BLOCK 48713000_1 CDM 0271 RC inpatient 191 124.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 124.15 65 999999999 115.65 185.27 percent of total billed charges CONTIPLEX P/NERVE BLOCK 48713000_1 CDM 0271 RC inpatient 191 124.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 185.27 97 999999999 115.65 185.27 percent of total billed charges CONTIPLEX P/NERVE BLOCK 48713000_1 CDM 0271 RC inpatient 191 124.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 131.79 69 999999999 115.65 185.27 percent of total billed charges CONTIPLEX P/NERVE BLOCK 48713000_1 CDM 0271 RC inpatient 191 124.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 148.98 78 999999999 115.65 185.27 percent of total billed charges CONTIPLEX P/NERVE BLOCK 48713000_1 CDM 0271 RC inpatient 191 124.15 UMR - ALL PLANS UMR - ALL PLANS 133.7 70 999999999 115.65 185.27 percent of total billed charges CONTIPLEX P/NERVE BLOCK 48713000_1 CDM 0271 RC inpatient 191 124.15 SIHO - ALL PLANS SIHO - ALL PLANS 171.9 90 999999999 115.65 185.27 percent of total billed charges CONTIPLEX P/NERVE BLOCK 48713000_1 CDM 0271 RC inpatient 191 124.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 115.65 60.55 999999999 115.65 185.27 percent of total billed charges CONTIPLEX P/NERVE BLOCK 48713000_1 CDM 0271 RC inpatient 191 124.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 115.65 185.27 CONTIPLEX P/NERVE BLOCK 48713000_1 CDM 0271 RC inpatient 191 124.15 ANTHEM HMO ANTHEM HMO 999999999 115.65 185.27 CONTIPLEX P/NERVE BLOCK 48713000_1 CDM 0271 RC inpatient 191 124.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 115.65 185.27 CONTIPLEX P/NERVE BLOCK 48713000_1 CDM 0271 RC inpatient 191 124.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 129.12 67.6 999999999 115.65 185.27 percent of total billed charges CONTIPLEX P/NERVE BLOCK 48713000_1 CDM 0271 RC inpatient 191 124.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 115.65 185.27 CONTIPLEX P/NERVE BLOCK 48713000_1 CDM 0271 RC inpatient 191 124.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 115.65 185.27 TRAY LACERATION SUT17750 48713001_1 CDM 0272 RC inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges TRAY LACERATION SUT17750 48713001_1 CDM 0272 RC inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges TRAY LACERATION SUT17750 48713001_1 CDM 0272 RC inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges TRAY LACERATION SUT17750 48713001_1 CDM 0272 RC inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges TRAY LACERATION SUT17750 48713001_1 CDM 0272 RC inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges TRAY LACERATION SUT17750 48713001_1 CDM 0272 RC inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges TRAY LACERATION SUT17750 48713001_1 CDM 0272 RC inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges TRAY LACERATION SUT17750 48713001_1 CDM 0272 RC inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges TRAY LACERATION SUT17750 48713001_1 CDM 0272 RC inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 TRAY LACERATION SUT17750 48713001_1 CDM 0272 RC inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 TRAY LACERATION SUT17750 48713001_1 CDM 0272 RC inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 TRAY LACERATION SUT17750 48713001_1 CDM 0272 RC inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges TRAY LACERATION SUT17750 48713001_1 CDM 0272 RC inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 TRAY LACERATION SUT17750 48713001_1 CDM 0272 RC inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 TRAY PUNCTURE LUMBAR 48713002_1 CDM 0272 RC inpatient 514 334.1 AETNA AETNA 406.06 79 999999999 311.23 498.58 percent of total billed charges TRAY PUNCTURE LUMBAR 48713002_1 CDM 0272 RC inpatient 514 334.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 334.1 65 999999999 311.23 498.58 percent of total billed charges TRAY PUNCTURE LUMBAR 48713002_1 CDM 0272 RC inpatient 514 334.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 498.58 97 999999999 311.23 498.58 percent of total billed charges TRAY PUNCTURE LUMBAR 48713002_1 CDM 0272 RC inpatient 514 334.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 354.66 69 999999999 311.23 498.58 percent of total billed charges TRAY PUNCTURE LUMBAR 48713002_1 CDM 0272 RC inpatient 514 334.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 400.92 78 999999999 311.23 498.58 percent of total billed charges TRAY PUNCTURE LUMBAR 48713002_1 CDM 0272 RC inpatient 514 334.1 UMR - ALL PLANS UMR - ALL PLANS 359.8 70 999999999 311.23 498.58 percent of total billed charges TRAY PUNCTURE LUMBAR 48713002_1 CDM 0272 RC inpatient 514 334.1 SIHO - ALL PLANS SIHO - ALL PLANS 462.6 90 999999999 311.23 498.58 percent of total billed charges TRAY PUNCTURE LUMBAR 48713002_1 CDM 0272 RC inpatient 514 334.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 311.23 60.55 999999999 311.23 498.58 percent of total billed charges TRAY PUNCTURE LUMBAR 48713002_1 CDM 0272 RC inpatient 514 334.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 311.23 498.58 TRAY PUNCTURE LUMBAR 48713002_1 CDM 0272 RC inpatient 514 334.1 ANTHEM HMO ANTHEM HMO 999999999 311.23 498.58 TRAY PUNCTURE LUMBAR 48713002_1 CDM 0272 RC inpatient 514 334.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 311.23 498.58 TRAY PUNCTURE LUMBAR 48713002_1 CDM 0272 RC inpatient 514 334.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 347.46 67.6 999999999 311.23 498.58 percent of total billed charges TRAY PUNCTURE LUMBAR 48713002_1 CDM 0272 RC inpatient 514 334.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 311.23 498.58 TRAY PUNCTURE LUMBAR 48713002_1 CDM 0272 RC inpatient 514 334.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 311.23 498.58 TRAY BONANNO CATH 14GA 408289 48713003_1 CDM 0272 RC inpatient 441 286.65 AETNA AETNA 348.39 79 999999999 267.03 427.77 percent of total billed charges TRAY BONANNO CATH 14GA 408289 48713003_1 CDM 0272 RC inpatient 441 286.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 286.65 65 999999999 267.03 427.77 percent of total billed charges TRAY BONANNO CATH 14GA 408289 48713003_1 CDM 0272 RC inpatient 441 286.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 427.77 97 999999999 267.03 427.77 percent of total billed charges TRAY BONANNO CATH 14GA 408289 48713003_1 CDM 0272 RC inpatient 441 286.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 304.29 69 999999999 267.03 427.77 percent of total billed charges TRAY BONANNO CATH 14GA 408289 48713003_1 CDM 0272 RC inpatient 441 286.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 343.98 78 999999999 267.03 427.77 percent of total billed charges TRAY BONANNO CATH 14GA 408289 48713003_1 CDM 0272 RC inpatient 441 286.65 UMR - ALL PLANS UMR - ALL PLANS 308.7 70 999999999 267.03 427.77 percent of total billed charges TRAY BONANNO CATH 14GA 408289 48713003_1 CDM 0272 RC inpatient 441 286.65 SIHO - ALL PLANS SIHO - ALL PLANS 396.9 90 999999999 267.03 427.77 percent of total billed charges TRAY BONANNO CATH 14GA 408289 48713003_1 CDM 0272 RC inpatient 441 286.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 267.03 60.55 999999999 267.03 427.77 percent of total billed charges TRAY BONANNO CATH 14GA 408289 48713003_1 CDM 0272 RC inpatient 441 286.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 267.03 427.77 TRAY BONANNO CATH 14GA 408289 48713003_1 CDM 0272 RC inpatient 441 286.65 ANTHEM HMO ANTHEM HMO 999999999 267.03 427.77 TRAY BONANNO CATH 14GA 408289 48713003_1 CDM 0272 RC inpatient 441 286.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 267.03 427.77 TRAY BONANNO CATH 14GA 408289 48713003_1 CDM 0272 RC inpatient 441 286.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 298.12 67.6 999999999 267.03 427.77 percent of total billed charges TRAY BONANNO CATH 14GA 408289 48713003_1 CDM 0272 RC inpatient 441 286.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 267.03 427.77 TRAY BONANNO CATH 14GA 408289 48713003_1 CDM 0272 RC inpatient 441 286.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 267.03 427.77 "PENCAN SPINAL ANESTHESIA TRAY 24g X 4""" 48713004_1 CDM 0272 RC inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges "PENCAN SPINAL ANESTHESIA TRAY 24g X 4""" 48713004_1 CDM 0272 RC inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges "PENCAN SPINAL ANESTHESIA TRAY 24g X 4""" 48713004_1 CDM 0272 RC inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges "PENCAN SPINAL ANESTHESIA TRAY 24g X 4""" 48713004_1 CDM 0272 RC inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges "PENCAN SPINAL ANESTHESIA TRAY 24g X 4""" 48713004_1 CDM 0272 RC inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges "PENCAN SPINAL ANESTHESIA TRAY 24g X 4""" 48713004_1 CDM 0272 RC inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges "PENCAN SPINAL ANESTHESIA TRAY 24g X 4""" 48713004_1 CDM 0272 RC inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges "PENCAN SPINAL ANESTHESIA TRAY 24g X 4""" 48713004_1 CDM 0272 RC inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges "PENCAN SPINAL ANESTHESIA TRAY 24g X 4""" 48713004_1 CDM 0272 RC inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 "PENCAN SPINAL ANESTHESIA TRAY 24g X 4""" 48713004_1 CDM 0272 RC inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 "PENCAN SPINAL ANESTHESIA TRAY 24g X 4""" 48713004_1 CDM 0272 RC inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 "PENCAN SPINAL ANESTHESIA TRAY 24g X 4""" 48713004_1 CDM 0272 RC inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges "PENCAN SPINAL ANESTHESIA TRAY 24g X 4""" 48713004_1 CDM 0272 RC inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 "PENCAN SPINAL ANESTHESIA TRAY 24g X 4""" 48713004_1 CDM 0272 RC inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 TRAY LUMBAR PUNCTURE PED 4302C 48713005_1 CDM 0272 RC inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges TRAY LUMBAR PUNCTURE PED 4302C 48713005_1 CDM 0272 RC inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges TRAY LUMBAR PUNCTURE PED 4302C 48713005_1 CDM 0272 RC inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges TRAY LUMBAR PUNCTURE PED 4302C 48713005_1 CDM 0272 RC inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges TRAY LUMBAR PUNCTURE PED 4302C 48713005_1 CDM 0272 RC inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges TRAY LUMBAR PUNCTURE PED 4302C 48713005_1 CDM 0272 RC inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges TRAY LUMBAR PUNCTURE PED 4302C 48713005_1 CDM 0272 RC inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges TRAY LUMBAR PUNCTURE PED 4302C 48713005_1 CDM 0272 RC inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges TRAY LUMBAR PUNCTURE PED 4302C 48713005_1 CDM 0272 RC inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 TRAY LUMBAR PUNCTURE PED 4302C 48713005_1 CDM 0272 RC inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 TRAY LUMBAR PUNCTURE PED 4302C 48713005_1 CDM 0272 RC inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 TRAY LUMBAR PUNCTURE PED 4302C 48713005_1 CDM 0272 RC inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges TRAY LUMBAR PUNCTURE PED 4302C 48713005_1 CDM 0272 RC inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 TRAY LUMBAR PUNCTURE PED 4302C 48713005_1 CDM 0272 RC inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 TROCAR 12MM W/FIX CAN B12STF 48713006_1 CDM 0272 RC inpatient 258 167.7 AETNA AETNA 203.82 79 999999999 156.22 250.26 percent of total billed charges TROCAR 12MM W/FIX CAN B12STF 48713006_1 CDM 0272 RC inpatient 258 167.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.7 65 999999999 156.22 250.26 percent of total billed charges TROCAR 12MM W/FIX CAN B12STF 48713006_1 CDM 0272 RC inpatient 258 167.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 250.26 97 999999999 156.22 250.26 percent of total billed charges TROCAR 12MM W/FIX CAN B12STF 48713006_1 CDM 0272 RC inpatient 258 167.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 178.02 69 999999999 156.22 250.26 percent of total billed charges TROCAR 12MM W/FIX CAN B12STF 48713006_1 CDM 0272 RC inpatient 258 167.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 201.24 78 999999999 156.22 250.26 percent of total billed charges TROCAR 12MM W/FIX CAN B12STF 48713006_1 CDM 0272 RC inpatient 258 167.7 SIHO - ALL PLANS SIHO - ALL PLANS 232.2 90 999999999 156.22 250.26 percent of total billed charges TROCAR 12MM W/FIX CAN B12STF 48713006_1 CDM 0272 RC inpatient 258 167.7 UMR - ALL PLANS UMR - ALL PLANS 180.6 70 999999999 156.22 250.26 percent of total billed charges TROCAR 12MM W/FIX CAN B12STF 48713006_1 CDM 0272 RC inpatient 258 167.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 156.22 60.55 999999999 156.22 250.26 percent of total billed charges TROCAR 12MM W/FIX CAN B12STF 48713006_1 CDM 0272 RC inpatient 258 167.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 156.22 250.26 TROCAR 12MM W/FIX CAN B12STF 48713006_1 CDM 0272 RC inpatient 258 167.7 ANTHEM HMO ANTHEM HMO 999999999 156.22 250.26 TROCAR 12MM W/FIX CAN B12STF 48713006_1 CDM 0272 RC inpatient 258 167.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 156.22 250.26 TROCAR 12MM W/FIX CAN B12STF 48713006_1 CDM 0272 RC inpatient 258 167.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 174.41 67.6 999999999 156.22 250.26 percent of total billed charges TROCAR 12MM W/FIX CAN B12STF 48713006_1 CDM 0272 RC inpatient 258 167.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 156.22 250.26 TROCAR 12MM W/FIX CAN B12STF 48713006_1 CDM 0272 RC inpatient 258 167.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 156.22 250.26 "CATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY OR MIDLINE (OTHER THAN HEMODIALYSIS)" 48713007_1 CDM 0278 RC C1751 HCPCS inpatient 2690 1748.5 AETNA AETNA 2125.1 79 999999999 1628.8 2609.3 percent of total billed charges "CATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY OR MIDLINE (OTHER THAN HEMODIALYSIS)" 48713007_1 CDM 0278 RC C1751 HCPCS inpatient 2690 1748.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1748.5 65 999999999 1628.8 2609.3 percent of total billed charges "CATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY OR MIDLINE (OTHER THAN HEMODIALYSIS)" 48713007_1 CDM 0278 RC C1751 HCPCS inpatient 2690 1748.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2609.3 97 999999999 1628.8 2609.3 percent of total billed charges "CATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY OR MIDLINE (OTHER THAN HEMODIALYSIS)" 48713007_1 CDM 0278 RC C1751 HCPCS inpatient 2690 1748.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1856.1 69 999999999 1628.8 2609.3 percent of total billed charges "CATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY OR MIDLINE (OTHER THAN HEMODIALYSIS)" 48713007_1 CDM 0278 RC C1751 HCPCS inpatient 2690 1748.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 2098.2 78 999999999 1628.8 2609.3 percent of total billed charges "CATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY OR MIDLINE (OTHER THAN HEMODIALYSIS)" 48713007_1 CDM 0278 RC C1751 HCPCS inpatient 2690 1748.5 SIHO - ALL PLANS SIHO - ALL PLANS 2421 90 999999999 1628.8 2609.3 percent of total billed charges "CATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY OR MIDLINE (OTHER THAN HEMODIALYSIS)" 48713007_1 CDM 0278 RC C1751 HCPCS inpatient 2690 1748.5 UMR - ALL PLANS UMR - ALL PLANS 1883 70 999999999 1628.8 2609.3 percent of total billed charges "CATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY OR MIDLINE (OTHER THAN HEMODIALYSIS)" 48713007_1 CDM 0278 RC C1751 HCPCS inpatient 2690 1748.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1628.8 60.55 999999999 1628.8 2609.3 percent of total billed charges "CATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY OR MIDLINE (OTHER THAN HEMODIALYSIS)" 48713007_1 CDM 0278 RC C1751 HCPCS inpatient 2690 1748.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1628.8 2609.3 "CATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY OR MIDLINE (OTHER THAN HEMODIALYSIS)" 48713007_1 CDM 0278 RC C1751 HCPCS inpatient 2690 1748.5 ANTHEM HMO ANTHEM HMO 999999999 1628.8 2609.3 "CATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY OR MIDLINE (OTHER THAN HEMODIALYSIS)" 48713007_1 CDM 0278 RC C1751 HCPCS inpatient 2690 1748.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1628.8 2609.3 "CATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY OR MIDLINE (OTHER THAN HEMODIALYSIS)" 48713007_1 CDM 0278 RC C1751 HCPCS inpatient 2690 1748.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1818.44 67.6 999999999 1628.8 2609.3 percent of total billed charges "CATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY OR MIDLINE (OTHER THAN HEMODIALYSIS)" 48713007_1 CDM 0278 RC C1751 HCPCS inpatient 2690 1748.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1628.8 2609.3 "CATHETER, INFUSION, INSERTED PERIPHERALLY, CENTRALLY OR MIDLINE (OTHER THAN HEMODIALYSIS)" 48713007_1 CDM 0278 RC C1751 HCPCS inpatient 2690 1748.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1628.8 2609.3 TROCAR BLUNTPORT 12MM BPT12STS 48713009_1 CDM 0272 RC inpatient 381 247.65 AETNA AETNA 300.99 79 999999999 230.7 369.57 percent of total billed charges TROCAR BLUNTPORT 12MM BPT12STS 48713009_1 CDM 0272 RC inpatient 381 247.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 247.65 65 999999999 230.7 369.57 percent of total billed charges TROCAR BLUNTPORT 12MM BPT12STS 48713009_1 CDM 0272 RC inpatient 381 247.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 369.57 97 999999999 230.7 369.57 percent of total billed charges TROCAR BLUNTPORT 12MM BPT12STS 48713009_1 CDM 0272 RC inpatient 381 247.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 262.89 69 999999999 230.7 369.57 percent of total billed charges TROCAR BLUNTPORT 12MM BPT12STS 48713009_1 CDM 0272 RC inpatient 381 247.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 297.18 78 999999999 230.7 369.57 percent of total billed charges TROCAR BLUNTPORT 12MM BPT12STS 48713009_1 CDM 0272 RC inpatient 381 247.65 SIHO - ALL PLANS SIHO - ALL PLANS 342.9 90 999999999 230.7 369.57 percent of total billed charges TROCAR BLUNTPORT 12MM BPT12STS 48713009_1 CDM 0272 RC inpatient 381 247.65 UMR - ALL PLANS UMR - ALL PLANS 266.7 70 999999999 230.7 369.57 percent of total billed charges TROCAR BLUNTPORT 12MM BPT12STS 48713009_1 CDM 0272 RC inpatient 381 247.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 230.7 60.55 999999999 230.7 369.57 percent of total billed charges TROCAR BLUNTPORT 12MM BPT12STS 48713009_1 CDM 0272 RC inpatient 381 247.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 230.7 369.57 TROCAR BLUNTPORT 12MM BPT12STS 48713009_1 CDM 0272 RC inpatient 381 247.65 ANTHEM HMO ANTHEM HMO 999999999 230.7 369.57 TROCAR BLUNTPORT 12MM BPT12STS 48713009_1 CDM 0272 RC inpatient 381 247.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 230.7 369.57 TROCAR BLUNTPORT 12MM BPT12STS 48713009_1 CDM 0272 RC inpatient 381 247.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 257.56 67.6 999999999 230.7 369.57 percent of total billed charges TROCAR BLUNTPORT 12MM BPT12STS 48713009_1 CDM 0272 RC inpatient 381 247.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 230.7 369.57 TROCAR BLUNTPORT 12MM BPT12STS 48713009_1 CDM 0272 RC inpatient 381 247.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 230.7 369.57 TRAY THORACENTESIS TPT1000 48713010_1 CDM 0272 RC inpatient 210 136.5 AETNA AETNA 165.9 79 999999999 127.16 203.7 percent of total billed charges TRAY THORACENTESIS TPT1000 48713010_1 CDM 0272 RC inpatient 210 136.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 136.5 65 999999999 127.16 203.7 percent of total billed charges TRAY THORACENTESIS TPT1000 48713010_1 CDM 0272 RC inpatient 210 136.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 203.7 97 999999999 127.16 203.7 percent of total billed charges TRAY THORACENTESIS TPT1000 48713010_1 CDM 0272 RC inpatient 210 136.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 144.9 69 999999999 127.16 203.7 percent of total billed charges TRAY THORACENTESIS TPT1000 48713010_1 CDM 0272 RC inpatient 210 136.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 163.8 78 999999999 127.16 203.7 percent of total billed charges TRAY THORACENTESIS TPT1000 48713010_1 CDM 0272 RC inpatient 210 136.5 SIHO - ALL PLANS SIHO - ALL PLANS 189 90 999999999 127.16 203.7 percent of total billed charges TRAY THORACENTESIS TPT1000 48713010_1 CDM 0272 RC inpatient 210 136.5 UMR - ALL PLANS UMR - ALL PLANS 147 70 999999999 127.16 203.7 percent of total billed charges TRAY THORACENTESIS TPT1000 48713010_1 CDM 0272 RC inpatient 210 136.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.16 60.55 999999999 127.16 203.7 percent of total billed charges TRAY THORACENTESIS TPT1000 48713010_1 CDM 0272 RC inpatient 210 136.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.16 203.7 TRAY THORACENTESIS TPT1000 48713010_1 CDM 0272 RC inpatient 210 136.5 ANTHEM HMO ANTHEM HMO 999999999 127.16 203.7 TRAY THORACENTESIS TPT1000 48713010_1 CDM 0272 RC inpatient 210 136.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.16 203.7 TRAY THORACENTESIS TPT1000 48713010_1 CDM 0272 RC inpatient 210 136.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 141.96 67.6 999999999 127.16 203.7 percent of total billed charges TRAY THORACENTESIS TPT1000 48713010_1 CDM 0272 RC inpatient 210 136.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.16 203.7 TRAY THORACENTESIS TPT1000 48713010_1 CDM 0272 RC inpatient 210 136.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.16 203.7 TROCAR DTN 21-20.0 58405 48713011_1 CDM 0272 RC inpatient 138 89.7 AETNA AETNA 109.02 79 999999999 83.56 133.86 percent of total billed charges TROCAR DTN 21-20.0 58405 48713011_1 CDM 0272 RC inpatient 138 89.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.7 65 999999999 83.56 133.86 percent of total billed charges TROCAR DTN 21-20.0 58405 48713011_1 CDM 0272 RC inpatient 138 89.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 133.86 97 999999999 83.56 133.86 percent of total billed charges TROCAR DTN 21-20.0 58405 48713011_1 CDM 0272 RC inpatient 138 89.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.22 69 999999999 83.56 133.86 percent of total billed charges TROCAR DTN 21-20.0 58405 48713011_1 CDM 0272 RC inpatient 138 89.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 107.64 78 999999999 83.56 133.86 percent of total billed charges TROCAR DTN 21-20.0 58405 48713011_1 CDM 0272 RC inpatient 138 89.7 SIHO - ALL PLANS SIHO - ALL PLANS 124.2 90 999999999 83.56 133.86 percent of total billed charges TROCAR DTN 21-20.0 58405 48713011_1 CDM 0272 RC inpatient 138 89.7 UMR - ALL PLANS UMR - ALL PLANS 96.6 70 999999999 83.56 133.86 percent of total billed charges TROCAR DTN 21-20.0 58405 48713011_1 CDM 0272 RC inpatient 138 89.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 83.56 60.55 999999999 83.56 133.86 percent of total billed charges TROCAR DTN 21-20.0 58405 48713011_1 CDM 0272 RC inpatient 138 89.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 83.56 133.86 TROCAR DTN 21-20.0 58405 48713011_1 CDM 0272 RC inpatient 138 89.7 ANTHEM HMO ANTHEM HMO 999999999 83.56 133.86 TROCAR DTN 21-20.0 58405 48713011_1 CDM 0272 RC inpatient 138 89.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 83.56 133.86 TROCAR DTN 21-20.0 58405 48713011_1 CDM 0272 RC inpatient 138 89.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.29 67.6 999999999 83.56 133.86 percent of total billed charges TROCAR DTN 21-20.0 58405 48713011_1 CDM 0272 RC inpatient 138 89.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 83.56 133.86 TROCAR DTN 21-20.0 58405 48713011_1 CDM 0272 RC inpatient 138 89.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 83.56 133.86 TUBE BRONCHIAL ENDO 35FR LEFT 5-16035 48713012_1 CDM 0272 RC inpatient 409 265.85 AETNA AETNA 323.11 79 999999999 247.65 396.73 percent of total billed charges TUBE BRONCHIAL ENDO 35FR LEFT 5-16035 48713012_1 CDM 0272 RC inpatient 409 265.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 265.85 65 999999999 247.65 396.73 percent of total billed charges TUBE BRONCHIAL ENDO 35FR LEFT 5-16035 48713012_1 CDM 0272 RC inpatient 409 265.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 396.73 97 999999999 247.65 396.73 percent of total billed charges TUBE BRONCHIAL ENDO 35FR LEFT 5-16035 48713012_1 CDM 0272 RC inpatient 409 265.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 282.21 69 999999999 247.65 396.73 percent of total billed charges TUBE BRONCHIAL ENDO 35FR LEFT 5-16035 48713012_1 CDM 0272 RC inpatient 409 265.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 319.02 78 999999999 247.65 396.73 percent of total billed charges TUBE BRONCHIAL ENDO 35FR LEFT 5-16035 48713012_1 CDM 0272 RC inpatient 409 265.85 SIHO - ALL PLANS SIHO - ALL PLANS 368.1 90 999999999 247.65 396.73 percent of total billed charges TUBE BRONCHIAL ENDO 35FR LEFT 5-16035 48713012_1 CDM 0272 RC inpatient 409 265.85 UMR - ALL PLANS UMR - ALL PLANS 286.3 70 999999999 247.65 396.73 percent of total billed charges TUBE BRONCHIAL ENDO 35FR LEFT 5-16035 48713012_1 CDM 0272 RC inpatient 409 265.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 247.65 60.55 999999999 247.65 396.73 percent of total billed charges TUBE BRONCHIAL ENDO 35FR LEFT 5-16035 48713012_1 CDM 0272 RC inpatient 409 265.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 247.65 396.73 TUBE BRONCHIAL ENDO 35FR LEFT 5-16035 48713012_1 CDM 0272 RC inpatient 409 265.85 ANTHEM HMO ANTHEM HMO 999999999 247.65 396.73 TUBE BRONCHIAL ENDO 35FR LEFT 5-16035 48713012_1 CDM 0272 RC inpatient 409 265.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 247.65 396.73 TUBE BRONCHIAL ENDO 35FR LEFT 5-16035 48713012_1 CDM 0272 RC inpatient 409 265.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 276.48 67.6 999999999 247.65 396.73 percent of total billed charges TUBE BRONCHIAL ENDO 35FR LEFT 5-16035 48713012_1 CDM 0272 RC inpatient 409 265.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 247.65 396.73 TUBE BRONCHIAL ENDO 35FR LEFT 5-16035 48713012_1 CDM 0272 RC inpatient 409 265.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 247.65 396.73 TUBE BRON ENDO 39FR L 516039 48713013_1 CDM 0272 RC inpatient 409 265.85 AETNA AETNA 323.11 79 999999999 247.65 396.73 percent of total billed charges TUBE BRON ENDO 39FR L 516039 48713013_1 CDM 0272 RC inpatient 409 265.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 265.85 65 999999999 247.65 396.73 percent of total billed charges TUBE BRON ENDO 39FR L 516039 48713013_1 CDM 0272 RC inpatient 409 265.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 396.73 97 999999999 247.65 396.73 percent of total billed charges TUBE BRON ENDO 39FR L 516039 48713013_1 CDM 0272 RC inpatient 409 265.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 282.21 69 999999999 247.65 396.73 percent of total billed charges TUBE BRON ENDO 39FR L 516039 48713013_1 CDM 0272 RC inpatient 409 265.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 319.02 78 999999999 247.65 396.73 percent of total billed charges TUBE BRON ENDO 39FR L 516039 48713013_1 CDM 0272 RC inpatient 409 265.85 SIHO - ALL PLANS SIHO - ALL PLANS 368.1 90 999999999 247.65 396.73 percent of total billed charges TUBE BRON ENDO 39FR L 516039 48713013_1 CDM 0272 RC inpatient 409 265.85 UMR - ALL PLANS UMR - ALL PLANS 286.3 70 999999999 247.65 396.73 percent of total billed charges TUBE BRON ENDO 39FR L 516039 48713013_1 CDM 0272 RC inpatient 409 265.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 247.65 60.55 999999999 247.65 396.73 percent of total billed charges TUBE BRON ENDO 39FR L 516039 48713013_1 CDM 0272 RC inpatient 409 265.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 247.65 396.73 TUBE BRON ENDO 39FR L 516039 48713013_1 CDM 0272 RC inpatient 409 265.85 ANTHEM HMO ANTHEM HMO 999999999 247.65 396.73 TUBE BRON ENDO 39FR L 516039 48713013_1 CDM 0272 RC inpatient 409 265.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 247.65 396.73 TUBE BRON ENDO 39FR L 516039 48713013_1 CDM 0272 RC inpatient 409 265.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 276.48 67.6 999999999 247.65 396.73 percent of total billed charges TUBE BRON ENDO 39FR L 516039 48713013_1 CDM 0272 RC inpatient 409 265.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 247.65 396.73 TUBE BRON ENDO 39FR L 516039 48713013_1 CDM 0272 RC inpatient 409 265.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 247.65 396.73 TUBE BRONCHIAL ENDO 41FR LEFT 48713014_1 CDM 0272 RC inpatient 393 255.45 AETNA AETNA 310.47 79 999999999 237.96 381.21 percent of total billed charges TUBE BRONCHIAL ENDO 41FR LEFT 48713014_1 CDM 0272 RC inpatient 393 255.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 255.45 65 999999999 237.96 381.21 percent of total billed charges TUBE BRONCHIAL ENDO 41FR LEFT 48713014_1 CDM 0272 RC inpatient 393 255.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 381.21 97 999999999 237.96 381.21 percent of total billed charges TUBE BRONCHIAL ENDO 41FR LEFT 48713014_1 CDM 0272 RC inpatient 393 255.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 271.17 69 999999999 237.96 381.21 percent of total billed charges TUBE BRONCHIAL ENDO 41FR LEFT 48713014_1 CDM 0272 RC inpatient 393 255.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 306.54 78 999999999 237.96 381.21 percent of total billed charges TUBE BRONCHIAL ENDO 41FR LEFT 48713014_1 CDM 0272 RC inpatient 393 255.45 SIHO - ALL PLANS SIHO - ALL PLANS 353.7 90 999999999 237.96 381.21 percent of total billed charges TUBE BRONCHIAL ENDO 41FR LEFT 48713014_1 CDM 0272 RC inpatient 393 255.45 UMR - ALL PLANS UMR - ALL PLANS 275.1 70 999999999 237.96 381.21 percent of total billed charges TUBE BRONCHIAL ENDO 41FR LEFT 48713014_1 CDM 0272 RC inpatient 393 255.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 237.96 60.55 999999999 237.96 381.21 percent of total billed charges TUBE BRONCHIAL ENDO 41FR LEFT 48713014_1 CDM 0272 RC inpatient 393 255.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 237.96 381.21 TUBE BRONCHIAL ENDO 41FR LEFT 48713014_1 CDM 0272 RC inpatient 393 255.45 ANTHEM HMO ANTHEM HMO 999999999 237.96 381.21 TUBE BRONCHIAL ENDO 41FR LEFT 48713014_1 CDM 0272 RC inpatient 393 255.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 237.96 381.21 TUBE BRONCHIAL ENDO 41FR LEFT 48713014_1 CDM 0272 RC inpatient 393 255.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 265.67 67.6 999999999 237.96 381.21 percent of total billed charges TUBE BRONCHIAL ENDO 41FR LEFT 48713014_1 CDM 0272 RC inpatient 393 255.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 237.96 381.21 TUBE BRONCHIAL ENDO 41FR LEFT 48713014_1 CDM 0272 RC inpatient 393 255.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 237.96 381.21 TROCAR VISIPORT 176673P 48713015_1 CDM 0272 RC inpatient 319 207.35 AETNA AETNA 252.01 79 999999999 193.15 309.43 percent of total billed charges TROCAR VISIPORT 176673P 48713015_1 CDM 0272 RC inpatient 319 207.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 207.35 65 999999999 193.15 309.43 percent of total billed charges TROCAR VISIPORT 176673P 48713015_1 CDM 0272 RC inpatient 319 207.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 309.43 97 999999999 193.15 309.43 percent of total billed charges TROCAR VISIPORT 176673P 48713015_1 CDM 0272 RC inpatient 319 207.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 220.11 69 999999999 193.15 309.43 percent of total billed charges TROCAR VISIPORT 176673P 48713015_1 CDM 0272 RC inpatient 319 207.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 248.82 78 999999999 193.15 309.43 percent of total billed charges TROCAR VISIPORT 176673P 48713015_1 CDM 0272 RC inpatient 319 207.35 SIHO - ALL PLANS SIHO - ALL PLANS 287.1 90 999999999 193.15 309.43 percent of total billed charges TROCAR VISIPORT 176673P 48713015_1 CDM 0272 RC inpatient 319 207.35 UMR - ALL PLANS UMR - ALL PLANS 223.3 70 999999999 193.15 309.43 percent of total billed charges TROCAR VISIPORT 176673P 48713015_1 CDM 0272 RC inpatient 319 207.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 193.15 60.55 999999999 193.15 309.43 percent of total billed charges TROCAR VISIPORT 176673P 48713015_1 CDM 0272 RC inpatient 319 207.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 193.15 309.43 TROCAR VISIPORT 176673P 48713015_1 CDM 0272 RC inpatient 319 207.35 ANTHEM HMO ANTHEM HMO 999999999 193.15 309.43 TROCAR VISIPORT 176673P 48713015_1 CDM 0272 RC inpatient 319 207.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 193.15 309.43 TROCAR VISIPORT 176673P 48713015_1 CDM 0272 RC inpatient 319 207.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 215.64 67.6 999999999 193.15 309.43 percent of total billed charges TROCAR VISIPORT 176673P 48713015_1 CDM 0272 RC inpatient 319 207.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 193.15 309.43 TROCAR VISIPORT 176673P 48713015_1 CDM 0272 RC inpatient 319 207.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 193.15 309.43 TUBE BRONC ENDO 37FR LT 516037 48713016_1 CDM 0272 RC inpatient 409 265.85 AETNA AETNA 323.11 79 999999999 247.65 396.73 percent of total billed charges TUBE BRONC ENDO 37FR LT 516037 48713016_1 CDM 0272 RC inpatient 409 265.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 265.85 65 999999999 247.65 396.73 percent of total billed charges TUBE BRONC ENDO 37FR LT 516037 48713016_1 CDM 0272 RC inpatient 409 265.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 396.73 97 999999999 247.65 396.73 percent of total billed charges TUBE BRONC ENDO 37FR LT 516037 48713016_1 CDM 0272 RC inpatient 409 265.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 282.21 69 999999999 247.65 396.73 percent of total billed charges TUBE BRONC ENDO 37FR LT 516037 48713016_1 CDM 0272 RC inpatient 409 265.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 319.02 78 999999999 247.65 396.73 percent of total billed charges TUBE BRONC ENDO 37FR LT 516037 48713016_1 CDM 0272 RC inpatient 409 265.85 SIHO - ALL PLANS SIHO - ALL PLANS 368.1 90 999999999 247.65 396.73 percent of total billed charges TUBE BRONC ENDO 37FR LT 516037 48713016_1 CDM 0272 RC inpatient 409 265.85 UMR - ALL PLANS UMR - ALL PLANS 286.3 70 999999999 247.65 396.73 percent of total billed charges TUBE BRONC ENDO 37FR LT 516037 48713016_1 CDM 0272 RC inpatient 409 265.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 247.65 60.55 999999999 247.65 396.73 percent of total billed charges TUBE BRONC ENDO 37FR LT 516037 48713016_1 CDM 0272 RC inpatient 409 265.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 247.65 396.73 TUBE BRONC ENDO 37FR LT 516037 48713016_1 CDM 0272 RC inpatient 409 265.85 ANTHEM HMO ANTHEM HMO 999999999 247.65 396.73 TUBE BRONC ENDO 37FR LT 516037 48713016_1 CDM 0272 RC inpatient 409 265.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 247.65 396.73 TUBE BRONC ENDO 37FR LT 516037 48713016_1 CDM 0272 RC inpatient 409 265.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 276.48 67.6 999999999 247.65 396.73 percent of total billed charges TUBE BRONC ENDO 37FR LT 516037 48713016_1 CDM 0272 RC inpatient 409 265.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 247.65 396.73 TUBE BRONC ENDO 37FR LT 516037 48713016_1 CDM 0272 RC inpatient 409 265.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 247.65 396.73 DERMATOME BLADE 3539-252 SUR 48713019_1 CDM 0272 RC inpatient 596 387.4 AETNA AETNA 470.84 79 999999999 360.88 578.12 percent of total billed charges DERMATOME BLADE 3539-252 SUR 48713019_1 CDM 0272 RC inpatient 596 387.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 387.4 65 999999999 360.88 578.12 percent of total billed charges DERMATOME BLADE 3539-252 SUR 48713019_1 CDM 0272 RC inpatient 596 387.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 578.12 97 999999999 360.88 578.12 percent of total billed charges DERMATOME BLADE 3539-252 SUR 48713019_1 CDM 0272 RC inpatient 596 387.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 411.24 69 999999999 360.88 578.12 percent of total billed charges DERMATOME BLADE 3539-252 SUR 48713019_1 CDM 0272 RC inpatient 596 387.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 464.88 78 999999999 360.88 578.12 percent of total billed charges DERMATOME BLADE 3539-252 SUR 48713019_1 CDM 0272 RC inpatient 596 387.4 SIHO - ALL PLANS SIHO - ALL PLANS 536.4 90 999999999 360.88 578.12 percent of total billed charges DERMATOME BLADE 3539-252 SUR 48713019_1 CDM 0272 RC inpatient 596 387.4 UMR - ALL PLANS UMR - ALL PLANS 417.2 70 999999999 360.88 578.12 percent of total billed charges DERMATOME BLADE 3539-252 SUR 48713019_1 CDM 0272 RC inpatient 596 387.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 360.88 60.55 999999999 360.88 578.12 percent of total billed charges DERMATOME BLADE 3539-252 SUR 48713019_1 CDM 0272 RC inpatient 596 387.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 360.88 578.12 DERMATOME BLADE 3539-252 SUR 48713019_1 CDM 0272 RC inpatient 596 387.4 ANTHEM HMO ANTHEM HMO 999999999 360.88 578.12 DERMATOME BLADE 3539-252 SUR 48713019_1 CDM 0272 RC inpatient 596 387.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 360.88 578.12 DERMATOME BLADE 3539-252 SUR 48713019_1 CDM 0272 RC inpatient 596 387.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 402.9 67.6 999999999 360.88 578.12 percent of total billed charges DERMATOME BLADE 3539-252 SUR 48713019_1 CDM 0272 RC inpatient 596 387.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 360.88 578.12 DERMATOME BLADE 3539-252 SUR 48713019_1 CDM 0272 RC inpatient 596 387.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 360.88 578.12 T TUBE #240074 48713020_1 CDM 0272 RC inpatient 161 104.65 AETNA AETNA 127.19 79 999999999 97.49 156.17 percent of total billed charges T TUBE #240074 48713020_1 CDM 0272 RC inpatient 161 104.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 104.65 65 999999999 97.49 156.17 percent of total billed charges T TUBE #240074 48713020_1 CDM 0272 RC inpatient 161 104.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 156.17 97 999999999 97.49 156.17 percent of total billed charges T TUBE #240074 48713020_1 CDM 0272 RC inpatient 161 104.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 111.09 69 999999999 97.49 156.17 percent of total billed charges T TUBE #240074 48713020_1 CDM 0272 RC inpatient 161 104.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 125.58 78 999999999 97.49 156.17 percent of total billed charges T TUBE #240074 48713020_1 CDM 0272 RC inpatient 161 104.65 SIHO - ALL PLANS SIHO - ALL PLANS 144.9 90 999999999 97.49 156.17 percent of total billed charges T TUBE #240074 48713020_1 CDM 0272 RC inpatient 161 104.65 UMR - ALL PLANS UMR - ALL PLANS 112.7 70 999999999 97.49 156.17 percent of total billed charges T TUBE #240074 48713020_1 CDM 0272 RC inpatient 161 104.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 97.49 60.55 999999999 97.49 156.17 percent of total billed charges T TUBE #240074 48713020_1 CDM 0272 RC inpatient 161 104.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 97.49 156.17 T TUBE #240074 48713020_1 CDM 0272 RC inpatient 161 104.65 ANTHEM HMO ANTHEM HMO 999999999 97.49 156.17 T TUBE #240074 48713020_1 CDM 0272 RC inpatient 161 104.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 97.49 156.17 T TUBE #240074 48713020_1 CDM 0272 RC inpatient 161 104.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.84 67.6 999999999 97.49 156.17 percent of total billed charges T TUBE #240074 48713020_1 CDM 0272 RC inpatient 161 104.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 97.49 156.17 T TUBE #240074 48713020_1 CDM 0272 RC inpatient 161 104.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 97.49 156.17 TUBE GASTROSTOMY #100-16 48713021_1 CDM 0272 RC inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges TUBE GASTROSTOMY #100-16 48713021_1 CDM 0272 RC inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges TUBE GASTROSTOMY #100-16 48713021_1 CDM 0272 RC inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges TUBE GASTROSTOMY #100-16 48713021_1 CDM 0272 RC inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges TUBE GASTROSTOMY #100-16 48713021_1 CDM 0272 RC inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges TUBE GASTROSTOMY #100-16 48713021_1 CDM 0272 RC inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges TUBE GASTROSTOMY #100-16 48713021_1 CDM 0272 RC inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges TUBE GASTROSTOMY #100-16 48713021_1 CDM 0272 RC inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges TUBE GASTROSTOMY #100-16 48713021_1 CDM 0272 RC inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 TUBE GASTROSTOMY #100-16 48713021_1 CDM 0272 RC inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 TUBE GASTROSTOMY #100-16 48713021_1 CDM 0272 RC inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 TUBE GASTROSTOMY #100-16 48713021_1 CDM 0272 RC inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges TUBE GASTROSTOMY #100-16 48713021_1 CDM 0272 RC inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 TUBE GASTROSTOMY #100-16 48713021_1 CDM 0272 RC inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 TUBE GASTROSTOMY 0100-18 48713022_1 CDM 0272 RC inpatient 256 166.4 AETNA AETNA 202.24 79 999999999 155.01 248.32 percent of total billed charges TUBE GASTROSTOMY 0100-18 48713022_1 CDM 0272 RC inpatient 256 166.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 166.4 65 999999999 155.01 248.32 percent of total billed charges TUBE GASTROSTOMY 0100-18 48713022_1 CDM 0272 RC inpatient 256 166.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 248.32 97 999999999 155.01 248.32 percent of total billed charges TUBE GASTROSTOMY 0100-18 48713022_1 CDM 0272 RC inpatient 256 166.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 176.64 69 999999999 155.01 248.32 percent of total billed charges TUBE GASTROSTOMY 0100-18 48713022_1 CDM 0272 RC inpatient 256 166.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 199.68 78 999999999 155.01 248.32 percent of total billed charges TUBE GASTROSTOMY 0100-18 48713022_1 CDM 0272 RC inpatient 256 166.4 SIHO - ALL PLANS SIHO - ALL PLANS 230.4 90 999999999 155.01 248.32 percent of total billed charges TUBE GASTROSTOMY 0100-18 48713022_1 CDM 0272 RC inpatient 256 166.4 UMR - ALL PLANS UMR - ALL PLANS 179.2 70 999999999 155.01 248.32 percent of total billed charges TUBE GASTROSTOMY 0100-18 48713022_1 CDM 0272 RC inpatient 256 166.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.01 60.55 999999999 155.01 248.32 percent of total billed charges TUBE GASTROSTOMY 0100-18 48713022_1 CDM 0272 RC inpatient 256 166.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.01 248.32 TUBE GASTROSTOMY 0100-18 48713022_1 CDM 0272 RC inpatient 256 166.4 ANTHEM HMO ANTHEM HMO 999999999 155.01 248.32 TUBE GASTROSTOMY 0100-18 48713022_1 CDM 0272 RC inpatient 256 166.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.01 248.32 TUBE GASTROSTOMY 0100-18 48713022_1 CDM 0272 RC inpatient 256 166.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.06 67.6 999999999 155.01 248.32 percent of total billed charges TUBE GASTROSTOMY 0100-18 48713022_1 CDM 0272 RC inpatient 256 166.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.01 248.32 TUBE GASTROSTOMY 0100-18 48713022_1 CDM 0272 RC inpatient 256 166.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.01 248.32 TUBE GASTROSTOMY #100-24 48713023_1 CDM 0272 RC inpatient 265 172.25 AETNA AETNA 209.35 79 999999999 160.46 257.05 percent of total billed charges TUBE GASTROSTOMY #100-24 48713023_1 CDM 0272 RC inpatient 265 172.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 172.25 65 999999999 160.46 257.05 percent of total billed charges TUBE GASTROSTOMY #100-24 48713023_1 CDM 0272 RC inpatient 265 172.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 257.05 97 999999999 160.46 257.05 percent of total billed charges TUBE GASTROSTOMY #100-24 48713023_1 CDM 0272 RC inpatient 265 172.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 182.85 69 999999999 160.46 257.05 percent of total billed charges TUBE GASTROSTOMY #100-24 48713023_1 CDM 0272 RC inpatient 265 172.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 206.7 78 999999999 160.46 257.05 percent of total billed charges TUBE GASTROSTOMY #100-24 48713023_1 CDM 0272 RC inpatient 265 172.25 SIHO - ALL PLANS SIHO - ALL PLANS 238.5 90 999999999 160.46 257.05 percent of total billed charges TUBE GASTROSTOMY #100-24 48713023_1 CDM 0272 RC inpatient 265 172.25 UMR - ALL PLANS UMR - ALL PLANS 185.5 70 999999999 160.46 257.05 percent of total billed charges TUBE GASTROSTOMY #100-24 48713023_1 CDM 0272 RC inpatient 265 172.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 160.46 60.55 999999999 160.46 257.05 percent of total billed charges TUBE GASTROSTOMY #100-24 48713023_1 CDM 0272 RC inpatient 265 172.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 160.46 257.05 TUBE GASTROSTOMY #100-24 48713023_1 CDM 0272 RC inpatient 265 172.25 ANTHEM HMO ANTHEM HMO 999999999 160.46 257.05 TUBE GASTROSTOMY #100-24 48713023_1 CDM 0272 RC inpatient 265 172.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 160.46 257.05 TUBE GASTROSTOMY #100-24 48713023_1 CDM 0272 RC inpatient 265 172.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 179.14 67.6 999999999 160.46 257.05 percent of total billed charges TUBE GASTROSTOMY #100-24 48713023_1 CDM 0272 RC inpatient 265 172.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 160.46 257.05 TUBE GASTROSTOMY #100-24 48713023_1 CDM 0272 RC inpatient 265 172.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 160.46 257.05 PEG 20FR WIRE GUIDE #6821 48713024_1 CDM 0272 RC inpatient 466 302.9 AETNA AETNA 368.14 79 999999999 282.16 452.02 percent of total billed charges PEG 20FR WIRE GUIDE #6821 48713024_1 CDM 0272 RC inpatient 466 302.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 302.9 65 999999999 282.16 452.02 percent of total billed charges PEG 20FR WIRE GUIDE #6821 48713024_1 CDM 0272 RC inpatient 466 302.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 452.02 97 999999999 282.16 452.02 percent of total billed charges PEG 20FR WIRE GUIDE #6821 48713024_1 CDM 0272 RC inpatient 466 302.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 321.54 69 999999999 282.16 452.02 percent of total billed charges PEG 20FR WIRE GUIDE #6821 48713024_1 CDM 0272 RC inpatient 466 302.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 363.48 78 999999999 282.16 452.02 percent of total billed charges PEG 20FR WIRE GUIDE #6821 48713024_1 CDM 0272 RC inpatient 466 302.9 SIHO - ALL PLANS SIHO - ALL PLANS 419.4 90 999999999 282.16 452.02 percent of total billed charges PEG 20FR WIRE GUIDE #6821 48713024_1 CDM 0272 RC inpatient 466 302.9 UMR - ALL PLANS UMR - ALL PLANS 326.2 70 999999999 282.16 452.02 percent of total billed charges PEG 20FR WIRE GUIDE #6821 48713024_1 CDM 0272 RC inpatient 466 302.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 282.16 60.55 999999999 282.16 452.02 percent of total billed charges PEG 20FR WIRE GUIDE #6821 48713024_1 CDM 0272 RC inpatient 466 302.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 282.16 452.02 PEG 20FR WIRE GUIDE #6821 48713024_1 CDM 0272 RC inpatient 466 302.9 ANTHEM HMO ANTHEM HMO 999999999 282.16 452.02 PEG 20FR WIRE GUIDE #6821 48713024_1 CDM 0272 RC inpatient 466 302.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 282.16 452.02 PEG 20FR WIRE GUIDE #6821 48713024_1 CDM 0272 RC inpatient 466 302.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 315.02 67.6 999999999 282.16 452.02 percent of total billed charges PEG 20FR WIRE GUIDE #6821 48713024_1 CDM 0272 RC inpatient 466 302.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 282.16 452.02 PEG 20FR WIRE GUIDE #6821 48713024_1 CDM 0272 RC inpatient 466 302.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 282.16 452.02 PEAK PLASMA BLADE 3.0S 48713025_1 CDM 0272 RC inpatient 2377 1545.05 AETNA AETNA 1877.83 79 999999999 1439.27 2305.69 percent of total billed charges PEAK PLASMA BLADE 3.0S 48713025_1 CDM 0272 RC inpatient 2377 1545.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1545.05 65 999999999 1439.27 2305.69 percent of total billed charges PEAK PLASMA BLADE 3.0S 48713025_1 CDM 0272 RC inpatient 2377 1545.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2305.69 97 999999999 1439.27 2305.69 percent of total billed charges PEAK PLASMA BLADE 3.0S 48713025_1 CDM 0272 RC inpatient 2377 1545.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1640.13 69 999999999 1439.27 2305.69 percent of total billed charges PEAK PLASMA BLADE 3.0S 48713025_1 CDM 0272 RC inpatient 2377 1545.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1854.06 78 999999999 1439.27 2305.69 percent of total billed charges PEAK PLASMA BLADE 3.0S 48713025_1 CDM 0272 RC inpatient 2377 1545.05 SIHO - ALL PLANS SIHO - ALL PLANS 2139.3 90 999999999 1439.27 2305.69 percent of total billed charges PEAK PLASMA BLADE 3.0S 48713025_1 CDM 0272 RC inpatient 2377 1545.05 UMR - ALL PLANS UMR - ALL PLANS 1663.9 70 999999999 1439.27 2305.69 percent of total billed charges PEAK PLASMA BLADE 3.0S 48713025_1 CDM 0272 RC inpatient 2377 1545.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1439.27 60.55 999999999 1439.27 2305.69 percent of total billed charges PEAK PLASMA BLADE 3.0S 48713025_1 CDM 0272 RC inpatient 2377 1545.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1439.27 2305.69 PEAK PLASMA BLADE 3.0S 48713025_1 CDM 0272 RC inpatient 2377 1545.05 ANTHEM HMO ANTHEM HMO 999999999 1439.27 2305.69 PEAK PLASMA BLADE 3.0S 48713025_1 CDM 0272 RC inpatient 2377 1545.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1439.27 2305.69 PEAK PLASMA BLADE 3.0S 48713025_1 CDM 0272 RC inpatient 2377 1545.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1606.85 67.6 999999999 1439.27 2305.69 percent of total billed charges PEAK PLASMA BLADE 3.0S 48713025_1 CDM 0272 RC inpatient 2377 1545.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1439.27 2305.69 PEAK PLASMA BLADE 3.0S 48713025_1 CDM 0272 RC inpatient 2377 1545.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1439.27 2305.69 TUBE FEEDING 12FR DOBBHOFF 48713026_1 CDM 0272 RC inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges TUBE FEEDING 12FR DOBBHOFF 48713026_1 CDM 0272 RC inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges TUBE FEEDING 12FR DOBBHOFF 48713026_1 CDM 0272 RC inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges TUBE FEEDING 12FR DOBBHOFF 48713026_1 CDM 0272 RC inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges TUBE FEEDING 12FR DOBBHOFF 48713026_1 CDM 0272 RC inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges TUBE FEEDING 12FR DOBBHOFF 48713026_1 CDM 0272 RC inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges TUBE FEEDING 12FR DOBBHOFF 48713026_1 CDM 0272 RC inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges TUBE FEEDING 12FR DOBBHOFF 48713026_1 CDM 0272 RC inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges TUBE FEEDING 12FR DOBBHOFF 48713026_1 CDM 0272 RC inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 TUBE FEEDING 12FR DOBBHOFF 48713026_1 CDM 0272 RC inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 TUBE FEEDING 12FR DOBBHOFF 48713026_1 CDM 0272 RC inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 TUBE FEEDING 12FR DOBBHOFF 48713026_1 CDM 0272 RC inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges TUBE FEEDING 12FR DOBBHOFF 48713026_1 CDM 0272 RC inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 TUBE FEEDING 12FR DOBBHOFF 48713026_1 CDM 0272 RC inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 TUBE FEEDING 8FR DOBBHOFF 48713027_1 CDM 0272 RC inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges TUBE FEEDING 8FR DOBBHOFF 48713027_1 CDM 0272 RC inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges TUBE FEEDING 8FR DOBBHOFF 48713027_1 CDM 0272 RC inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges TUBE FEEDING 8FR DOBBHOFF 48713027_1 CDM 0272 RC inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges TUBE FEEDING 8FR DOBBHOFF 48713027_1 CDM 0272 RC inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges TUBE FEEDING 8FR DOBBHOFF 48713027_1 CDM 0272 RC inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges TUBE FEEDING 8FR DOBBHOFF 48713027_1 CDM 0272 RC inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges TUBE FEEDING 8FR DOBBHOFF 48713027_1 CDM 0272 RC inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges TUBE FEEDING 8FR DOBBHOFF 48713027_1 CDM 0272 RC inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 TUBE FEEDING 8FR DOBBHOFF 48713027_1 CDM 0272 RC inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 TUBE FEEDING 8FR DOBBHOFF 48713027_1 CDM 0272 RC inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 TUBE FEEDING 8FR DOBBHOFF 48713027_1 CDM 0272 RC inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges TUBE FEEDING 8FR DOBBHOFF 48713027_1 CDM 0272 RC inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 TUBE FEEDING 8FR DOBBHOFF 48713027_1 CDM 0272 RC inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 FIBERTAPE AR-7237-7 48713030_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges FIBERTAPE AR-7237-7 48713030_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges FIBERTAPE AR-7237-7 48713030_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges FIBERTAPE AR-7237-7 48713030_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges FIBERTAPE AR-7237-7 48713030_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges FIBERTAPE AR-7237-7 48713030_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges FIBERTAPE AR-7237-7 48713030_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges FIBERTAPE AR-7237-7 48713030_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges FIBERTAPE AR-7237-7 48713030_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 FIBERTAPE AR-7237-7 48713030_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 FIBERTAPE AR-7237-7 48713030_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 FIBERTAPE AR-7237-7 48713030_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges FIBERTAPE AR-7237-7 48713030_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 FIBERTAPE AR-7237-7 48713030_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713031_1 CDM 0278 RC C1713 HCPCS inpatient 3512 2282.8 AETNA AETNA 2774.48 79 999999999 2126.52 3406.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713031_1 CDM 0278 RC C1713 HCPCS inpatient 3512 2282.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 2282.8 65 999999999 2126.52 3406.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713031_1 CDM 0278 RC C1713 HCPCS inpatient 3512 2282.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3406.64 97 999999999 2126.52 3406.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713031_1 CDM 0278 RC C1713 HCPCS inpatient 3512 2282.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 2423.28 69 999999999 2126.52 3406.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713031_1 CDM 0278 RC C1713 HCPCS inpatient 3512 2282.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 2739.36 78 999999999 2126.52 3406.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713031_1 CDM 0278 RC C1713 HCPCS inpatient 3512 2282.8 SIHO - ALL PLANS SIHO - ALL PLANS 3160.8 90 999999999 2126.52 3406.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713031_1 CDM 0278 RC C1713 HCPCS inpatient 3512 2282.8 UMR - ALL PLANS UMR - ALL PLANS 2458.4 70 999999999 2126.52 3406.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713031_1 CDM 0278 RC C1713 HCPCS inpatient 3512 2282.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2126.52 60.55 999999999 2126.52 3406.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713031_1 CDM 0278 RC C1713 HCPCS inpatient 3512 2282.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2126.52 3406.64 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713031_1 CDM 0278 RC C1713 HCPCS inpatient 3512 2282.8 ANTHEM HMO ANTHEM HMO 999999999 2126.52 3406.64 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713031_1 CDM 0278 RC C1713 HCPCS inpatient 3512 2282.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2126.52 3406.64 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713031_1 CDM 0278 RC C1713 HCPCS inpatient 3512 2282.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 2374.11 67.6 999999999 2126.52 3406.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713031_1 CDM 0278 RC C1713 HCPCS inpatient 3512 2282.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2126.52 3406.64 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713031_1 CDM 0278 RC C1713 HCPCS inpatient 3512 2282.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 2126.52 3406.64 GUIDE WIRE 48713032_1 CDM 0272 RC C1769 HCPCS inpatient 93 60.45 AETNA AETNA 73.47 79 999999999 56.31 90.21 percent of total billed charges GUIDE WIRE 48713032_1 CDM 0272 RC C1769 HCPCS inpatient 93 60.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 60.45 65 999999999 56.31 90.21 percent of total billed charges GUIDE WIRE 48713032_1 CDM 0272 RC C1769 HCPCS inpatient 93 60.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 90.21 97 999999999 56.31 90.21 percent of total billed charges GUIDE WIRE 48713032_1 CDM 0272 RC C1769 HCPCS inpatient 93 60.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.17 69 999999999 56.31 90.21 percent of total billed charges GUIDE WIRE 48713032_1 CDM 0272 RC C1769 HCPCS inpatient 93 60.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 72.54 78 999999999 56.31 90.21 percent of total billed charges GUIDE WIRE 48713032_1 CDM 0272 RC C1769 HCPCS inpatient 93 60.45 SIHO - ALL PLANS SIHO - ALL PLANS 83.7 90 999999999 56.31 90.21 percent of total billed charges GUIDE WIRE 48713032_1 CDM 0272 RC C1769 HCPCS inpatient 93 60.45 UMR - ALL PLANS UMR - ALL PLANS 65.1 70 999999999 56.31 90.21 percent of total billed charges GUIDE WIRE 48713032_1 CDM 0272 RC C1769 HCPCS inpatient 93 60.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.31 60.55 999999999 56.31 90.21 percent of total billed charges GUIDE WIRE 48713032_1 CDM 0272 RC C1769 HCPCS inpatient 93 60.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.31 90.21 GUIDE WIRE 48713032_1 CDM 0272 RC C1769 HCPCS inpatient 93 60.45 ANTHEM HMO ANTHEM HMO 999999999 56.31 90.21 GUIDE WIRE 48713032_1 CDM 0272 RC C1769 HCPCS inpatient 93 60.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.31 90.21 GUIDE WIRE 48713032_1 CDM 0272 RC C1769 HCPCS inpatient 93 60.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.87 67.6 999999999 56.31 90.21 percent of total billed charges GUIDE WIRE 48713032_1 CDM 0272 RC C1769 HCPCS inpatient 93 60.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.31 90.21 GUIDE WIRE 48713032_1 CDM 0272 RC C1769 HCPCS inpatient 93 60.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.31 90.21 TUBE ANESTHESIA ADULT CUSTOM DYNJAA10023D 48713033_1 CDM 0270 RC inpatient 71 46.15 AETNA AETNA 56.09 79 999999999 42.99 68.87 percent of total billed charges TUBE ANESTHESIA ADULT CUSTOM DYNJAA10023D 48713033_1 CDM 0270 RC inpatient 71 46.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.15 65 999999999 42.99 68.87 percent of total billed charges TUBE ANESTHESIA ADULT CUSTOM DYNJAA10023D 48713033_1 CDM 0270 RC inpatient 71 46.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 68.87 97 999999999 42.99 68.87 percent of total billed charges TUBE ANESTHESIA ADULT CUSTOM DYNJAA10023D 48713033_1 CDM 0270 RC inpatient 71 46.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.99 69 999999999 42.99 68.87 percent of total billed charges TUBE ANESTHESIA ADULT CUSTOM DYNJAA10023D 48713033_1 CDM 0270 RC inpatient 71 46.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 55.38 78 999999999 42.99 68.87 percent of total billed charges TUBE ANESTHESIA ADULT CUSTOM DYNJAA10023D 48713033_1 CDM 0270 RC inpatient 71 46.15 SIHO - ALL PLANS SIHO - ALL PLANS 63.9 90 999999999 42.99 68.87 percent of total billed charges TUBE ANESTHESIA ADULT CUSTOM DYNJAA10023D 48713033_1 CDM 0270 RC inpatient 71 46.15 UMR - ALL PLANS UMR - ALL PLANS 49.7 70 999999999 42.99 68.87 percent of total billed charges TUBE ANESTHESIA ADULT CUSTOM DYNJAA10023D 48713033_1 CDM 0270 RC inpatient 71 46.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.99 60.55 999999999 42.99 68.87 percent of total billed charges TUBE ANESTHESIA ADULT CUSTOM DYNJAA10023D 48713033_1 CDM 0270 RC inpatient 71 46.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.99 68.87 TUBE ANESTHESIA ADULT CUSTOM DYNJAA10023D 48713033_1 CDM 0270 RC inpatient 71 46.15 ANTHEM HMO ANTHEM HMO 999999999 42.99 68.87 TUBE ANESTHESIA ADULT CUSTOM DYNJAA10023D 48713033_1 CDM 0270 RC inpatient 71 46.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.99 68.87 TUBE ANESTHESIA ADULT CUSTOM DYNJAA10023D 48713033_1 CDM 0270 RC inpatient 71 46.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 48 67.6 999999999 42.99 68.87 percent of total billed charges TUBE ANESTHESIA ADULT CUSTOM DYNJAA10023D 48713033_1 CDM 0270 RC inpatient 71 46.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.99 68.87 TUBE ANESTHESIA ADULT CUSTOM DYNJAA10023D 48713033_1 CDM 0270 RC inpatient 71 46.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.99 68.87 NEEDLE JAMSHIDI BONE MARROW DJ4011X 48713036_1 CDM 0272 RC inpatient 238 154.7 AETNA AETNA 188.02 79 999999999 144.11 230.86 percent of total billed charges NEEDLE JAMSHIDI BONE MARROW DJ4011X 48713036_1 CDM 0272 RC inpatient 238 154.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.7 65 999999999 144.11 230.86 percent of total billed charges NEEDLE JAMSHIDI BONE MARROW DJ4011X 48713036_1 CDM 0272 RC inpatient 238 154.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 230.86 97 999999999 144.11 230.86 percent of total billed charges NEEDLE JAMSHIDI BONE MARROW DJ4011X 48713036_1 CDM 0272 RC inpatient 238 154.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.22 69 999999999 144.11 230.86 percent of total billed charges NEEDLE JAMSHIDI BONE MARROW DJ4011X 48713036_1 CDM 0272 RC inpatient 238 154.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 185.64 78 999999999 144.11 230.86 percent of total billed charges NEEDLE JAMSHIDI BONE MARROW DJ4011X 48713036_1 CDM 0272 RC inpatient 238 154.7 SIHO - ALL PLANS SIHO - ALL PLANS 214.2 90 999999999 144.11 230.86 percent of total billed charges NEEDLE JAMSHIDI BONE MARROW DJ4011X 48713036_1 CDM 0272 RC inpatient 238 154.7 UMR - ALL PLANS UMR - ALL PLANS 166.6 70 999999999 144.11 230.86 percent of total billed charges NEEDLE JAMSHIDI BONE MARROW DJ4011X 48713036_1 CDM 0272 RC inpatient 238 154.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.11 60.55 999999999 144.11 230.86 percent of total billed charges NEEDLE JAMSHIDI BONE MARROW DJ4011X 48713036_1 CDM 0272 RC inpatient 238 154.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.11 230.86 NEEDLE JAMSHIDI BONE MARROW DJ4011X 48713036_1 CDM 0272 RC inpatient 238 154.7 ANTHEM HMO ANTHEM HMO 999999999 144.11 230.86 NEEDLE JAMSHIDI BONE MARROW DJ4011X 48713036_1 CDM 0272 RC inpatient 238 154.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.11 230.86 NEEDLE JAMSHIDI BONE MARROW DJ4011X 48713036_1 CDM 0272 RC inpatient 238 154.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.89 67.6 999999999 144.11 230.86 percent of total billed charges NEEDLE JAMSHIDI BONE MARROW DJ4011X 48713036_1 CDM 0272 RC inpatient 238 154.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.11 230.86 NEEDLE JAMSHIDI BONE MARROW DJ4011X 48713036_1 CDM 0272 RC inpatient 238 154.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.11 230.86 URETERAL SHEATH 12/14F 61238BX 48713038_1 CDM 0272 RC inpatient 665 432.25 AETNA AETNA 525.35 79 999999999 402.66 645.05 percent of total billed charges URETERAL SHEATH 12/14F 61238BX 48713038_1 CDM 0272 RC inpatient 665 432.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 432.25 65 999999999 402.66 645.05 percent of total billed charges URETERAL SHEATH 12/14F 61238BX 48713038_1 CDM 0272 RC inpatient 665 432.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 645.05 97 999999999 402.66 645.05 percent of total billed charges URETERAL SHEATH 12/14F 61238BX 48713038_1 CDM 0272 RC inpatient 665 432.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 458.85 69 999999999 402.66 645.05 percent of total billed charges URETERAL SHEATH 12/14F 61238BX 48713038_1 CDM 0272 RC inpatient 665 432.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 518.7 78 999999999 402.66 645.05 percent of total billed charges URETERAL SHEATH 12/14F 61238BX 48713038_1 CDM 0272 RC inpatient 665 432.25 SIHO - ALL PLANS SIHO - ALL PLANS 598.5 90 999999999 402.66 645.05 percent of total billed charges URETERAL SHEATH 12/14F 61238BX 48713038_1 CDM 0272 RC inpatient 665 432.25 UMR - ALL PLANS UMR - ALL PLANS 465.5 70 999999999 402.66 645.05 percent of total billed charges URETERAL SHEATH 12/14F 61238BX 48713038_1 CDM 0272 RC inpatient 665 432.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 402.66 60.55 999999999 402.66 645.05 percent of total billed charges URETERAL SHEATH 12/14F 61238BX 48713038_1 CDM 0272 RC inpatient 665 432.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 402.66 645.05 URETERAL SHEATH 12/14F 61238BX 48713038_1 CDM 0272 RC inpatient 665 432.25 ANTHEM HMO ANTHEM HMO 999999999 402.66 645.05 URETERAL SHEATH 12/14F 61238BX 48713038_1 CDM 0272 RC inpatient 665 432.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 402.66 645.05 URETERAL SHEATH 12/14F 61238BX 48713038_1 CDM 0272 RC inpatient 665 432.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 449.54 67.6 999999999 402.66 645.05 percent of total billed charges URETERAL SHEATH 12/14F 61238BX 48713038_1 CDM 0272 RC inpatient 665 432.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 402.66 645.05 URETERAL SHEATH 12/14F 61238BX 48713038_1 CDM 0272 RC inpatient 665 432.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 402.66 645.05 UNDERPADS-CHUX 10/PK 48713039_1 CDM 0271 RC inpatient 64 41.6 AETNA AETNA 50.56 79 999999999 38.75 62.08 percent of total billed charges UNDERPADS-CHUX 10/PK 48713039_1 CDM 0271 RC inpatient 64 41.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.6 65 999999999 38.75 62.08 percent of total billed charges UNDERPADS-CHUX 10/PK 48713039_1 CDM 0271 RC inpatient 64 41.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 62.08 97 999999999 38.75 62.08 percent of total billed charges UNDERPADS-CHUX 10/PK 48713039_1 CDM 0271 RC inpatient 64 41.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.16 69 999999999 38.75 62.08 percent of total billed charges UNDERPADS-CHUX 10/PK 48713039_1 CDM 0271 RC inpatient 64 41.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.92 78 999999999 38.75 62.08 percent of total billed charges UNDERPADS-CHUX 10/PK 48713039_1 CDM 0271 RC inpatient 64 41.6 SIHO - ALL PLANS SIHO - ALL PLANS 57.6 90 999999999 38.75 62.08 percent of total billed charges UNDERPADS-CHUX 10/PK 48713039_1 CDM 0271 RC inpatient 64 41.6 UMR - ALL PLANS UMR - ALL PLANS 44.8 70 999999999 38.75 62.08 percent of total billed charges UNDERPADS-CHUX 10/PK 48713039_1 CDM 0271 RC inpatient 64 41.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.75 60.55 999999999 38.75 62.08 percent of total billed charges UNDERPADS-CHUX 10/PK 48713039_1 CDM 0271 RC inpatient 64 41.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.75 62.08 UNDERPADS-CHUX 10/PK 48713039_1 CDM 0271 RC inpatient 64 41.6 ANTHEM HMO ANTHEM HMO 999999999 38.75 62.08 UNDERPADS-CHUX 10/PK 48713039_1 CDM 0271 RC inpatient 64 41.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.75 62.08 UNDERPADS-CHUX 10/PK 48713039_1 CDM 0271 RC inpatient 64 41.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.26 67.6 999999999 38.75 62.08 percent of total billed charges UNDERPADS-CHUX 10/PK 48713039_1 CDM 0271 RC inpatient 64 41.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.75 62.08 UNDERPADS-CHUX 10/PK 48713039_1 CDM 0271 RC inpatient 64 41.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.75 62.08 URETERAL DILATATION SET 48713043_1 CDM 0272 RC inpatient 942 612.3 AETNA AETNA 744.18 79 999999999 570.38 913.74 percent of total billed charges URETERAL DILATATION SET 48713043_1 CDM 0272 RC inpatient 942 612.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 612.3 65 999999999 570.38 913.74 percent of total billed charges URETERAL DILATATION SET 48713043_1 CDM 0272 RC inpatient 942 612.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 913.74 97 999999999 570.38 913.74 percent of total billed charges URETERAL DILATATION SET 48713043_1 CDM 0272 RC inpatient 942 612.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 649.98 69 999999999 570.38 913.74 percent of total billed charges URETERAL DILATATION SET 48713043_1 CDM 0272 RC inpatient 942 612.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 734.76 78 999999999 570.38 913.74 percent of total billed charges URETERAL DILATATION SET 48713043_1 CDM 0272 RC inpatient 942 612.3 SIHO - ALL PLANS SIHO - ALL PLANS 847.8 90 999999999 570.38 913.74 percent of total billed charges URETERAL DILATATION SET 48713043_1 CDM 0272 RC inpatient 942 612.3 UMR - ALL PLANS UMR - ALL PLANS 659.4 70 999999999 570.38 913.74 percent of total billed charges URETERAL DILATATION SET 48713043_1 CDM 0272 RC inpatient 942 612.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 570.38 60.55 999999999 570.38 913.74 percent of total billed charges URETERAL DILATATION SET 48713043_1 CDM 0272 RC inpatient 942 612.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 570.38 913.74 URETERAL DILATATION SET 48713043_1 CDM 0272 RC inpatient 942 612.3 ANTHEM HMO ANTHEM HMO 999999999 570.38 913.74 URETERAL DILATATION SET 48713043_1 CDM 0272 RC inpatient 942 612.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 570.38 913.74 URETERAL DILATATION SET 48713043_1 CDM 0272 RC inpatient 942 612.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 636.79 67.6 999999999 570.38 913.74 percent of total billed charges URETERAL DILATATION SET 48713043_1 CDM 0272 RC inpatient 942 612.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 570.38 913.74 URETERAL DILATATION SET 48713043_1 CDM 0272 RC inpatient 942 612.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 570.38 913.74 GLIDEWIRE STRAIGHT .035 35BX 48713044_1 CDM 0272 RC inpatient 193 125.45 AETNA AETNA 152.47 79 999999999 116.86 187.21 percent of total billed charges GLIDEWIRE STRAIGHT .035 35BX 48713044_1 CDM 0272 RC inpatient 193 125.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 125.45 65 999999999 116.86 187.21 percent of total billed charges GLIDEWIRE STRAIGHT .035 35BX 48713044_1 CDM 0272 RC inpatient 193 125.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 187.21 97 999999999 116.86 187.21 percent of total billed charges GLIDEWIRE STRAIGHT .035 35BX 48713044_1 CDM 0272 RC inpatient 193 125.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.17 69 999999999 116.86 187.21 percent of total billed charges GLIDEWIRE STRAIGHT .035 35BX 48713044_1 CDM 0272 RC inpatient 193 125.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 150.54 78 999999999 116.86 187.21 percent of total billed charges GLIDEWIRE STRAIGHT .035 35BX 48713044_1 CDM 0272 RC inpatient 193 125.45 SIHO - ALL PLANS SIHO - ALL PLANS 173.7 90 999999999 116.86 187.21 percent of total billed charges GLIDEWIRE STRAIGHT .035 35BX 48713044_1 CDM 0272 RC inpatient 193 125.45 UMR - ALL PLANS UMR - ALL PLANS 135.1 70 999999999 116.86 187.21 percent of total billed charges GLIDEWIRE STRAIGHT .035 35BX 48713044_1 CDM 0272 RC inpatient 193 125.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.86 60.55 999999999 116.86 187.21 percent of total billed charges GLIDEWIRE STRAIGHT .035 35BX 48713044_1 CDM 0272 RC inpatient 193 125.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.86 187.21 GLIDEWIRE STRAIGHT .035 35BX 48713044_1 CDM 0272 RC inpatient 193 125.45 ANTHEM HMO ANTHEM HMO 999999999 116.86 187.21 GLIDEWIRE STRAIGHT .035 35BX 48713044_1 CDM 0272 RC inpatient 193 125.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.86 187.21 GLIDEWIRE STRAIGHT .035 35BX 48713044_1 CDM 0272 RC inpatient 193 125.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 130.47 67.6 999999999 116.86 187.21 percent of total billed charges GLIDEWIRE STRAIGHT .035 35BX 48713044_1 CDM 0272 RC inpatient 193 125.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.86 187.21 GLIDEWIRE STRAIGHT .035 35BX 48713044_1 CDM 0272 RC inpatient 193 125.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.86 187.21 STEIN PIN 9IN 5/32 1640-109NS 48713046_1 CDM 0278 RC inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges STEIN PIN 9IN 5/32 1640-109NS 48713046_1 CDM 0278 RC inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges STEIN PIN 9IN 5/32 1640-109NS 48713046_1 CDM 0278 RC inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges STEIN PIN 9IN 5/32 1640-109NS 48713046_1 CDM 0278 RC inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges STEIN PIN 9IN 5/32 1640-109NS 48713046_1 CDM 0278 RC inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges STEIN PIN 9IN 5/32 1640-109NS 48713046_1 CDM 0278 RC inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges STEIN PIN 9IN 5/32 1640-109NS 48713046_1 CDM 0278 RC inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges STEIN PIN 9IN 5/32 1640-109NS 48713046_1 CDM 0278 RC inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges STEIN PIN 9IN 5/32 1640-109NS 48713046_1 CDM 0278 RC inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 STEIN PIN 9IN 5/32 1640-109NS 48713046_1 CDM 0278 RC inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 STEIN PIN 9IN 5/32 1640-109NS 48713046_1 CDM 0278 RC inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 STEIN PIN 9IN 5/32 1640-109NS 48713046_1 CDM 0278 RC inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges STEIN PIN 9IN 5/32 1640-109NS 48713046_1 CDM 0278 RC inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 STEIN PIN 9IN 5/32 1640-109NS 48713046_1 CDM 0278 RC inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 STEIN PIN 9IN 9/64 DUAL POINT 48713047_1 CDM 0278 RC inpatient 39 25.35 AETNA AETNA 30.81 79 999999999 23.61 37.83 percent of total billed charges STEIN PIN 9IN 9/64 DUAL POINT 48713047_1 CDM 0278 RC inpatient 39 25.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 25.35 65 999999999 23.61 37.83 percent of total billed charges STEIN PIN 9IN 9/64 DUAL POINT 48713047_1 CDM 0278 RC inpatient 39 25.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37.83 97 999999999 23.61 37.83 percent of total billed charges STEIN PIN 9IN 9/64 DUAL POINT 48713047_1 CDM 0278 RC inpatient 39 25.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.91 69 999999999 23.61 37.83 percent of total billed charges STEIN PIN 9IN 9/64 DUAL POINT 48713047_1 CDM 0278 RC inpatient 39 25.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 30.42 78 999999999 23.61 37.83 percent of total billed charges STEIN PIN 9IN 9/64 DUAL POINT 48713047_1 CDM 0278 RC inpatient 39 25.35 SIHO - ALL PLANS SIHO - ALL PLANS 35.1 90 999999999 23.61 37.83 percent of total billed charges STEIN PIN 9IN 9/64 DUAL POINT 48713047_1 CDM 0278 RC inpatient 39 25.35 UMR - ALL PLANS UMR - ALL PLANS 27.3 70 999999999 23.61 37.83 percent of total billed charges STEIN PIN 9IN 9/64 DUAL POINT 48713047_1 CDM 0278 RC inpatient 39 25.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.61 60.55 999999999 23.61 37.83 percent of total billed charges STEIN PIN 9IN 9/64 DUAL POINT 48713047_1 CDM 0278 RC inpatient 39 25.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.61 37.83 STEIN PIN 9IN 9/64 DUAL POINT 48713047_1 CDM 0278 RC inpatient 39 25.35 ANTHEM HMO ANTHEM HMO 999999999 23.61 37.83 STEIN PIN 9IN 9/64 DUAL POINT 48713047_1 CDM 0278 RC inpatient 39 25.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.61 37.83 STEIN PIN 9IN 9/64 DUAL POINT 48713047_1 CDM 0278 RC inpatient 39 25.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 26.36 67.6 999999999 23.61 37.83 percent of total billed charges STEIN PIN 9IN 9/64 DUAL POINT 48713047_1 CDM 0278 RC inpatient 39 25.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.61 37.83 STEIN PIN 9IN 9/64 DUAL POINT 48713047_1 CDM 0278 RC inpatient 39 25.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.61 37.83 URINE METER FOLEY 16FR A947516 48713049_1 CDM 0272 RC inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges URINE METER FOLEY 16FR A947516 48713049_1 CDM 0272 RC inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges URINE METER FOLEY 16FR A947516 48713049_1 CDM 0272 RC inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges URINE METER FOLEY 16FR A947516 48713049_1 CDM 0272 RC inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges URINE METER FOLEY 16FR A947516 48713049_1 CDM 0272 RC inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges URINE METER FOLEY 16FR A947516 48713049_1 CDM 0272 RC inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges URINE METER FOLEY 16FR A947516 48713049_1 CDM 0272 RC inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges URINE METER FOLEY 16FR A947516 48713049_1 CDM 0272 RC inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges URINE METER FOLEY 16FR A947516 48713049_1 CDM 0272 RC inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 URINE METER FOLEY 16FR A947516 48713049_1 CDM 0272 RC inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 URINE METER FOLEY 16FR A947516 48713049_1 CDM 0272 RC inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 URINE METER FOLEY 16FR A947516 48713049_1 CDM 0272 RC inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges URINE METER FOLEY 16FR A947516 48713049_1 CDM 0272 RC inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 URINE METER FOLEY 16FR A947516 48713049_1 CDM 0272 RC inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 URO DRAIN BAG W/HOSE LG2800N 48713050_1 CDM 0271 RC inpatient 69 44.85 AETNA AETNA 54.51 79 999999999 41.78 66.93 percent of total billed charges URO DRAIN BAG W/HOSE LG2800N 48713050_1 CDM 0271 RC inpatient 69 44.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.85 65 999999999 41.78 66.93 percent of total billed charges URO DRAIN BAG W/HOSE LG2800N 48713050_1 CDM 0271 RC inpatient 69 44.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 66.93 97 999999999 41.78 66.93 percent of total billed charges URO DRAIN BAG W/HOSE LG2800N 48713050_1 CDM 0271 RC inpatient 69 44.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 47.61 69 999999999 41.78 66.93 percent of total billed charges URO DRAIN BAG W/HOSE LG2800N 48713050_1 CDM 0271 RC inpatient 69 44.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.82 78 999999999 41.78 66.93 percent of total billed charges URO DRAIN BAG W/HOSE LG2800N 48713050_1 CDM 0271 RC inpatient 69 44.85 SIHO - ALL PLANS SIHO - ALL PLANS 62.1 90 999999999 41.78 66.93 percent of total billed charges URO DRAIN BAG W/HOSE LG2800N 48713050_1 CDM 0271 RC inpatient 69 44.85 UMR - ALL PLANS UMR - ALL PLANS 48.3 70 999999999 41.78 66.93 percent of total billed charges URO DRAIN BAG W/HOSE LG2800N 48713050_1 CDM 0271 RC inpatient 69 44.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.78 60.55 999999999 41.78 66.93 percent of total billed charges URO DRAIN BAG W/HOSE LG2800N 48713050_1 CDM 0271 RC inpatient 69 44.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.78 66.93 URO DRAIN BAG W/HOSE LG2800N 48713050_1 CDM 0271 RC inpatient 69 44.85 ANTHEM HMO ANTHEM HMO 999999999 41.78 66.93 URO DRAIN BAG W/HOSE LG2800N 48713050_1 CDM 0271 RC inpatient 69 44.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.78 66.93 URO DRAIN BAG W/HOSE LG2800N 48713050_1 CDM 0271 RC inpatient 69 44.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 46.64 67.6 999999999 41.78 66.93 percent of total billed charges URO DRAIN BAG W/HOSE LG2800N 48713050_1 CDM 0271 RC inpatient 69 44.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.78 66.93 URO DRAIN BAG W/HOSE LG2800N 48713050_1 CDM 0271 RC inpatient 69 44.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.78 66.93 VACURETTE DISP 8-CURVED 022108-10 48713052_1 CDM 0272 RC inpatient 46 29.9 AETNA AETNA 36.34 79 999999999 27.85 44.62 percent of total billed charges VACURETTE DISP 8-CURVED 022108-10 48713052_1 CDM 0272 RC inpatient 46 29.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 29.9 65 999999999 27.85 44.62 percent of total billed charges VACURETTE DISP 8-CURVED 022108-10 48713052_1 CDM 0272 RC inpatient 46 29.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 44.62 97 999999999 27.85 44.62 percent of total billed charges VACURETTE DISP 8-CURVED 022108-10 48713052_1 CDM 0272 RC inpatient 46 29.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 31.74 69 999999999 27.85 44.62 percent of total billed charges VACURETTE DISP 8-CURVED 022108-10 48713052_1 CDM 0272 RC inpatient 46 29.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 35.88 78 999999999 27.85 44.62 percent of total billed charges VACURETTE DISP 8-CURVED 022108-10 48713052_1 CDM 0272 RC inpatient 46 29.9 SIHO - ALL PLANS SIHO - ALL PLANS 41.4 90 999999999 27.85 44.62 percent of total billed charges VACURETTE DISP 8-CURVED 022108-10 48713052_1 CDM 0272 RC inpatient 46 29.9 UMR - ALL PLANS UMR - ALL PLANS 32.2 70 999999999 27.85 44.62 percent of total billed charges VACURETTE DISP 8-CURVED 022108-10 48713052_1 CDM 0272 RC inpatient 46 29.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27.85 60.55 999999999 27.85 44.62 percent of total billed charges VACURETTE DISP 8-CURVED 022108-10 48713052_1 CDM 0272 RC inpatient 46 29.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 27.85 44.62 VACURETTE DISP 8-CURVED 022108-10 48713052_1 CDM 0272 RC inpatient 46 29.9 ANTHEM HMO ANTHEM HMO 999999999 27.85 44.62 VACURETTE DISP 8-CURVED 022108-10 48713052_1 CDM 0272 RC inpatient 46 29.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 27.85 44.62 VACURETTE DISP 8-CURVED 022108-10 48713052_1 CDM 0272 RC inpatient 46 29.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 31.1 67.6 999999999 27.85 44.62 percent of total billed charges VACURETTE DISP 8-CURVED 022108-10 48713052_1 CDM 0272 RC inpatient 46 29.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 27.85 44.62 VACURETTE DISP 8-CURVED 022108-10 48713052_1 CDM 0272 RC inpatient 46 29.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 27.85 44.62 SINUS GUIDE CATH TIP MAXILLARY 48713054_1 CDM 0272 RC inpatient 2383 1548.95 AETNA AETNA 1882.57 79 999999999 1442.91 2311.51 percent of total billed charges SINUS GUIDE CATH TIP MAXILLARY 48713054_1 CDM 0272 RC inpatient 2383 1548.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1548.95 65 999999999 1442.91 2311.51 percent of total billed charges SINUS GUIDE CATH TIP MAXILLARY 48713054_1 CDM 0272 RC inpatient 2383 1548.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2311.51 97 999999999 1442.91 2311.51 percent of total billed charges SINUS GUIDE CATH TIP MAXILLARY 48713054_1 CDM 0272 RC inpatient 2383 1548.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1644.27 69 999999999 1442.91 2311.51 percent of total billed charges SINUS GUIDE CATH TIP MAXILLARY 48713054_1 CDM 0272 RC inpatient 2383 1548.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1858.74 78 999999999 1442.91 2311.51 percent of total billed charges SINUS GUIDE CATH TIP MAXILLARY 48713054_1 CDM 0272 RC inpatient 2383 1548.95 SIHO - ALL PLANS SIHO - ALL PLANS 2144.7 90 999999999 1442.91 2311.51 percent of total billed charges SINUS GUIDE CATH TIP MAXILLARY 48713054_1 CDM 0272 RC inpatient 2383 1548.95 UMR - ALL PLANS UMR - ALL PLANS 1668.1 70 999999999 1442.91 2311.51 percent of total billed charges SINUS GUIDE CATH TIP MAXILLARY 48713054_1 CDM 0272 RC inpatient 2383 1548.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1442.91 60.55 999999999 1442.91 2311.51 percent of total billed charges SINUS GUIDE CATH TIP MAXILLARY 48713054_1 CDM 0272 RC inpatient 2383 1548.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1442.91 2311.51 SINUS GUIDE CATH TIP MAXILLARY 48713054_1 CDM 0272 RC inpatient 2383 1548.95 ANTHEM HMO ANTHEM HMO 999999999 1442.91 2311.51 SINUS GUIDE CATH TIP MAXILLARY 48713054_1 CDM 0272 RC inpatient 2383 1548.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1442.91 2311.51 SINUS GUIDE CATH TIP MAXILLARY 48713054_1 CDM 0272 RC inpatient 2383 1548.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1610.91 67.6 999999999 1442.91 2311.51 percent of total billed charges SINUS GUIDE CATH TIP MAXILLARY 48713054_1 CDM 0272 RC inpatient 2383 1548.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1442.91 2311.51 SINUS GUIDE CATH TIP MAXILLARY 48713054_1 CDM 0272 RC inpatient 2383 1548.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1442.91 2311.51 SINUPLASTY FRONTAL BALLOON SYS 48713055_1 CDM 0272 RC inpatient 6929 4503.85 AETNA AETNA 5473.91 79 999999999 4195.51 6721.13 percent of total billed charges SINUPLASTY FRONTAL BALLOON SYS 48713055_1 CDM 0272 RC inpatient 6929 4503.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 4503.85 65 999999999 4195.51 6721.13 percent of total billed charges SINUPLASTY FRONTAL BALLOON SYS 48713055_1 CDM 0272 RC inpatient 6929 4503.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6721.13 97 999999999 4195.51 6721.13 percent of total billed charges SINUPLASTY FRONTAL BALLOON SYS 48713055_1 CDM 0272 RC inpatient 6929 4503.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 4781.01 69 999999999 4195.51 6721.13 percent of total billed charges SINUPLASTY FRONTAL BALLOON SYS 48713055_1 CDM 0272 RC inpatient 6929 4503.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 5404.62 78 999999999 4195.51 6721.13 percent of total billed charges SINUPLASTY FRONTAL BALLOON SYS 48713055_1 CDM 0272 RC inpatient 6929 4503.85 SIHO - ALL PLANS SIHO - ALL PLANS 6236.1 90 999999999 4195.51 6721.13 percent of total billed charges SINUPLASTY FRONTAL BALLOON SYS 48713055_1 CDM 0272 RC inpatient 6929 4503.85 UMR - ALL PLANS UMR - ALL PLANS 4850.3 70 999999999 4195.51 6721.13 percent of total billed charges SINUPLASTY FRONTAL BALLOON SYS 48713055_1 CDM 0272 RC inpatient 6929 4503.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4195.51 60.55 999999999 4195.51 6721.13 percent of total billed charges SINUPLASTY FRONTAL BALLOON SYS 48713055_1 CDM 0272 RC inpatient 6929 4503.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4195.51 6721.13 SINUPLASTY FRONTAL BALLOON SYS 48713055_1 CDM 0272 RC inpatient 6929 4503.85 ANTHEM HMO ANTHEM HMO 999999999 4195.51 6721.13 SINUPLASTY FRONTAL BALLOON SYS 48713055_1 CDM 0272 RC inpatient 6929 4503.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4195.51 6721.13 SINUPLASTY FRONTAL BALLOON SYS 48713055_1 CDM 0272 RC inpatient 6929 4503.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 4684 67.6 999999999 4195.51 6721.13 percent of total billed charges SINUPLASTY FRONTAL BALLOON SYS 48713055_1 CDM 0272 RC inpatient 6929 4503.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4195.51 6721.13 SINUPLASTY FRONTAL BALLOON SYS 48713055_1 CDM 0272 RC inpatient 6929 4503.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 4195.51 6721.13 NEEDLE SCHLERO INJECTION 23GA 48713058_1 CDM 0272 RC inpatient 198 128.7 AETNA AETNA 156.42 79 999999999 119.89 192.06 percent of total billed charges NEEDLE SCHLERO INJECTION 23GA 48713058_1 CDM 0272 RC inpatient 198 128.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.7 65 999999999 119.89 192.06 percent of total billed charges NEEDLE SCHLERO INJECTION 23GA 48713058_1 CDM 0272 RC inpatient 198 128.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 192.06 97 999999999 119.89 192.06 percent of total billed charges NEEDLE SCHLERO INJECTION 23GA 48713058_1 CDM 0272 RC inpatient 198 128.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 136.62 69 999999999 119.89 192.06 percent of total billed charges NEEDLE SCHLERO INJECTION 23GA 48713058_1 CDM 0272 RC inpatient 198 128.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 154.44 78 999999999 119.89 192.06 percent of total billed charges NEEDLE SCHLERO INJECTION 23GA 48713058_1 CDM 0272 RC inpatient 198 128.7 SIHO - ALL PLANS SIHO - ALL PLANS 178.2 90 999999999 119.89 192.06 percent of total billed charges NEEDLE SCHLERO INJECTION 23GA 48713058_1 CDM 0272 RC inpatient 198 128.7 UMR - ALL PLANS UMR - ALL PLANS 138.6 70 999999999 119.89 192.06 percent of total billed charges NEEDLE SCHLERO INJECTION 23GA 48713058_1 CDM 0272 RC inpatient 198 128.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.89 60.55 999999999 119.89 192.06 percent of total billed charges NEEDLE SCHLERO INJECTION 23GA 48713058_1 CDM 0272 RC inpatient 198 128.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.89 192.06 NEEDLE SCHLERO INJECTION 23GA 48713058_1 CDM 0272 RC inpatient 198 128.7 ANTHEM HMO ANTHEM HMO 999999999 119.89 192.06 NEEDLE SCHLERO INJECTION 23GA 48713058_1 CDM 0272 RC inpatient 198 128.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.89 192.06 NEEDLE SCHLERO INJECTION 23GA 48713058_1 CDM 0272 RC inpatient 198 128.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.85 67.6 999999999 119.89 192.06 percent of total billed charges NEEDLE SCHLERO INJECTION 23GA 48713058_1 CDM 0272 RC inpatient 198 128.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.89 192.06 NEEDLE SCHLERO INJECTION 23GA 48713058_1 CDM 0272 RC inpatient 198 128.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.89 192.06 "VESSEL CATHETERIZATION KIT 20GA X 5""" 48713059_1 CDM 0272 RC inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges "VESSEL CATHETERIZATION KIT 20GA X 5""" 48713059_1 CDM 0272 RC inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges "VESSEL CATHETERIZATION KIT 20GA X 5""" 48713059_1 CDM 0272 RC inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges "VESSEL CATHETERIZATION KIT 20GA X 5""" 48713059_1 CDM 0272 RC inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges "VESSEL CATHETERIZATION KIT 20GA X 5""" 48713059_1 CDM 0272 RC inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges "VESSEL CATHETERIZATION KIT 20GA X 5""" 48713059_1 CDM 0272 RC inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges "VESSEL CATHETERIZATION KIT 20GA X 5""" 48713059_1 CDM 0272 RC inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges "VESSEL CATHETERIZATION KIT 20GA X 5""" 48713059_1 CDM 0272 RC inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges "VESSEL CATHETERIZATION KIT 20GA X 5""" 48713059_1 CDM 0272 RC inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 "VESSEL CATHETERIZATION KIT 20GA X 5""" 48713059_1 CDM 0272 RC inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 "VESSEL CATHETERIZATION KIT 20GA X 5""" 48713059_1 CDM 0272 RC inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 "VESSEL CATHETERIZATION KIT 20GA X 5""" 48713059_1 CDM 0272 RC inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges "VESSEL CATHETERIZATION KIT 20GA X 5""" 48713059_1 CDM 0272 RC inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 "VESSEL CATHETERIZATION KIT 20GA X 5""" 48713059_1 CDM 0272 RC inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 MYOSURE 10-403 48713060_1 CDM 0272 RC inpatient 4682 3043.3 AETNA AETNA 3698.78 79 999999999 2834.95 4541.54 percent of total billed charges MYOSURE 10-403 48713060_1 CDM 0272 RC inpatient 4682 3043.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 3043.3 65 999999999 2834.95 4541.54 percent of total billed charges MYOSURE 10-403 48713060_1 CDM 0272 RC inpatient 4682 3043.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4541.54 97 999999999 2834.95 4541.54 percent of total billed charges MYOSURE 10-403 48713060_1 CDM 0272 RC inpatient 4682 3043.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 3230.58 69 999999999 2834.95 4541.54 percent of total billed charges MYOSURE 10-403 48713060_1 CDM 0272 RC inpatient 4682 3043.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 3651.96 78 999999999 2834.95 4541.54 percent of total billed charges MYOSURE 10-403 48713060_1 CDM 0272 RC inpatient 4682 3043.3 SIHO - ALL PLANS SIHO - ALL PLANS 4213.8 90 999999999 2834.95 4541.54 percent of total billed charges MYOSURE 10-403 48713060_1 CDM 0272 RC inpatient 4682 3043.3 UMR - ALL PLANS UMR - ALL PLANS 3277.4 70 999999999 2834.95 4541.54 percent of total billed charges MYOSURE 10-403 48713060_1 CDM 0272 RC inpatient 4682 3043.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2834.95 60.55 999999999 2834.95 4541.54 percent of total billed charges MYOSURE 10-403 48713060_1 CDM 0272 RC inpatient 4682 3043.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2834.95 4541.54 MYOSURE 10-403 48713060_1 CDM 0272 RC inpatient 4682 3043.3 ANTHEM HMO ANTHEM HMO 999999999 2834.95 4541.54 MYOSURE 10-403 48713060_1 CDM 0272 RC inpatient 4682 3043.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2834.95 4541.54 MYOSURE 10-403 48713060_1 CDM 0272 RC inpatient 4682 3043.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 3165.03 67.6 999999999 2834.95 4541.54 percent of total billed charges MYOSURE 10-403 48713060_1 CDM 0272 RC inpatient 4682 3043.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2834.95 4541.54 MYOSURE 10-403 48713060_1 CDM 0272 RC inpatient 4682 3043.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 2834.95 4541.54 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713062_1 CDM 0278 RC C1713 HCPCS inpatient 243 157.95 AETNA AETNA 191.97 79 999999999 147.14 235.71 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713062_1 CDM 0278 RC C1713 HCPCS inpatient 243 157.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 157.95 65 999999999 147.14 235.71 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713062_1 CDM 0278 RC C1713 HCPCS inpatient 243 157.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 235.71 97 999999999 147.14 235.71 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713062_1 CDM 0278 RC C1713 HCPCS inpatient 243 157.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 167.67 69 999999999 147.14 235.71 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713062_1 CDM 0278 RC C1713 HCPCS inpatient 243 157.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 189.54 78 999999999 147.14 235.71 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713062_1 CDM 0278 RC C1713 HCPCS inpatient 243 157.95 SIHO - ALL PLANS SIHO - ALL PLANS 218.7 90 999999999 147.14 235.71 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713062_1 CDM 0278 RC C1713 HCPCS inpatient 243 157.95 UMR - ALL PLANS UMR - ALL PLANS 170.1 70 999999999 147.14 235.71 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713062_1 CDM 0278 RC C1713 HCPCS inpatient 243 157.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.14 60.55 999999999 147.14 235.71 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713062_1 CDM 0278 RC C1713 HCPCS inpatient 243 157.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.14 235.71 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713062_1 CDM 0278 RC C1713 HCPCS inpatient 243 157.95 ANTHEM HMO ANTHEM HMO 999999999 147.14 235.71 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713062_1 CDM 0278 RC C1713 HCPCS inpatient 243 157.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.14 235.71 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713062_1 CDM 0278 RC C1713 HCPCS inpatient 243 157.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.27 67.6 999999999 147.14 235.71 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713062_1 CDM 0278 RC C1713 HCPCS inpatient 243 157.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.14 235.71 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713062_1 CDM 0278 RC C1713 HCPCS inpatient 243 157.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.14 235.71 "SCREW, DISTRACTION PIN 12MM" 48713063_1 CDM 0278 RC inpatient 277 180.05 AETNA AETNA 218.83 79 999999999 167.72 268.69 percent of total billed charges "SCREW, DISTRACTION PIN 12MM" 48713063_1 CDM 0278 RC inpatient 277 180.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 180.05 65 999999999 167.72 268.69 percent of total billed charges "SCREW, DISTRACTION PIN 12MM" 48713063_1 CDM 0278 RC inpatient 277 180.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 268.69 97 999999999 167.72 268.69 percent of total billed charges "SCREW, DISTRACTION PIN 12MM" 48713063_1 CDM 0278 RC inpatient 277 180.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 191.13 69 999999999 167.72 268.69 percent of total billed charges "SCREW, DISTRACTION PIN 12MM" 48713063_1 CDM 0278 RC inpatient 277 180.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 216.06 78 999999999 167.72 268.69 percent of total billed charges "SCREW, DISTRACTION PIN 12MM" 48713063_1 CDM 0278 RC inpatient 277 180.05 SIHO - ALL PLANS SIHO - ALL PLANS 249.3 90 999999999 167.72 268.69 percent of total billed charges "SCREW, DISTRACTION PIN 12MM" 48713063_1 CDM 0278 RC inpatient 277 180.05 UMR - ALL PLANS UMR - ALL PLANS 193.9 70 999999999 167.72 268.69 percent of total billed charges "SCREW, DISTRACTION PIN 12MM" 48713063_1 CDM 0278 RC inpatient 277 180.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 167.72 60.55 999999999 167.72 268.69 percent of total billed charges "SCREW, DISTRACTION PIN 12MM" 48713063_1 CDM 0278 RC inpatient 277 180.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 167.72 268.69 "SCREW, DISTRACTION PIN 12MM" 48713063_1 CDM 0278 RC inpatient 277 180.05 ANTHEM HMO ANTHEM HMO 999999999 167.72 268.69 "SCREW, DISTRACTION PIN 12MM" 48713063_1 CDM 0278 RC inpatient 277 180.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 167.72 268.69 "SCREW, DISTRACTION PIN 12MM" 48713063_1 CDM 0278 RC inpatient 277 180.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 187.25 67.6 999999999 167.72 268.69 percent of total billed charges "SCREW, DISTRACTION PIN 12MM" 48713063_1 CDM 0278 RC inpatient 277 180.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 167.72 268.69 "SCREW, DISTRACTION PIN 12MM" 48713063_1 CDM 0278 RC inpatient 277 180.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 167.72 268.69 GRASPER MINI LAP ALLIGATOR GBC250 48713064_1 CDM 0272 RC inpatient 1230 799.5 AETNA AETNA 971.7 79 999999999 744.77 1193.1 percent of total billed charges GRASPER MINI LAP ALLIGATOR GBC250 48713064_1 CDM 0272 RC inpatient 1230 799.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 799.5 65 999999999 744.77 1193.1 percent of total billed charges GRASPER MINI LAP ALLIGATOR GBC250 48713064_1 CDM 0272 RC inpatient 1230 799.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1193.1 97 999999999 744.77 1193.1 percent of total billed charges GRASPER MINI LAP ALLIGATOR GBC250 48713064_1 CDM 0272 RC inpatient 1230 799.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 848.7 69 999999999 744.77 1193.1 percent of total billed charges GRASPER MINI LAP ALLIGATOR GBC250 48713064_1 CDM 0272 RC inpatient 1230 799.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 959.4 78 999999999 744.77 1193.1 percent of total billed charges GRASPER MINI LAP ALLIGATOR GBC250 48713064_1 CDM 0272 RC inpatient 1230 799.5 SIHO - ALL PLANS SIHO - ALL PLANS 1107 90 999999999 744.77 1193.1 percent of total billed charges GRASPER MINI LAP ALLIGATOR GBC250 48713064_1 CDM 0272 RC inpatient 1230 799.5 UMR - ALL PLANS UMR - ALL PLANS 861 70 999999999 744.77 1193.1 percent of total billed charges GRASPER MINI LAP ALLIGATOR GBC250 48713064_1 CDM 0272 RC inpatient 1230 799.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 744.77 60.55 999999999 744.77 1193.1 percent of total billed charges GRASPER MINI LAP ALLIGATOR GBC250 48713064_1 CDM 0272 RC inpatient 1230 799.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 744.77 1193.1 GRASPER MINI LAP ALLIGATOR GBC250 48713064_1 CDM 0272 RC inpatient 1230 799.5 ANTHEM HMO ANTHEM HMO 999999999 744.77 1193.1 GRASPER MINI LAP ALLIGATOR GBC250 48713064_1 CDM 0272 RC inpatient 1230 799.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 744.77 1193.1 GRASPER MINI LAP ALLIGATOR GBC250 48713064_1 CDM 0272 RC inpatient 1230 799.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 831.48 67.6 999999999 744.77 1193.1 percent of total billed charges GRASPER MINI LAP ALLIGATOR GBC250 48713064_1 CDM 0272 RC inpatient 1230 799.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 744.77 1193.1 GRASPER MINI LAP ALLIGATOR GBC250 48713064_1 CDM 0272 RC inpatient 1230 799.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 744.77 1193.1 SAW BLADE 90MMX19.0MM 1.27MM 48713065_1 CDM 0272 RC inpatient 482 313.3 AETNA AETNA 380.78 79 999999999 291.85 467.54 percent of total billed charges SAW BLADE 90MMX19.0MM 1.27MM 48713065_1 CDM 0272 RC inpatient 482 313.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 313.3 65 999999999 291.85 467.54 percent of total billed charges SAW BLADE 90MMX19.0MM 1.27MM 48713065_1 CDM 0272 RC inpatient 482 313.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 467.54 97 999999999 291.85 467.54 percent of total billed charges SAW BLADE 90MMX19.0MM 1.27MM 48713065_1 CDM 0272 RC inpatient 482 313.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 332.58 69 999999999 291.85 467.54 percent of total billed charges SAW BLADE 90MMX19.0MM 1.27MM 48713065_1 CDM 0272 RC inpatient 482 313.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 375.96 78 999999999 291.85 467.54 percent of total billed charges SAW BLADE 90MMX19.0MM 1.27MM 48713065_1 CDM 0272 RC inpatient 482 313.3 SIHO - ALL PLANS SIHO - ALL PLANS 433.8 90 999999999 291.85 467.54 percent of total billed charges SAW BLADE 90MMX19.0MM 1.27MM 48713065_1 CDM 0272 RC inpatient 482 313.3 UMR - ALL PLANS UMR - ALL PLANS 337.4 70 999999999 291.85 467.54 percent of total billed charges SAW BLADE 90MMX19.0MM 1.27MM 48713065_1 CDM 0272 RC inpatient 482 313.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 291.85 60.55 999999999 291.85 467.54 percent of total billed charges SAW BLADE 90MMX19.0MM 1.27MM 48713065_1 CDM 0272 RC inpatient 482 313.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 291.85 467.54 SAW BLADE 90MMX19.0MM 1.27MM 48713065_1 CDM 0272 RC inpatient 482 313.3 ANTHEM HMO ANTHEM HMO 999999999 291.85 467.54 SAW BLADE 90MMX19.0MM 1.27MM 48713065_1 CDM 0272 RC inpatient 482 313.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 291.85 467.54 SAW BLADE 90MMX19.0MM 1.27MM 48713065_1 CDM 0272 RC inpatient 482 313.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 325.83 67.6 999999999 291.85 467.54 percent of total billed charges SAW BLADE 90MMX19.0MM 1.27MM 48713065_1 CDM 0272 RC inpatient 482 313.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 291.85 467.54 SAW BLADE 90MMX19.0MM 1.27MM 48713065_1 CDM 0272 RC inpatient 482 313.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 291.85 467.54 RECIP SAW BLADE D-SIDED 48713066_1 CDM 0272 RC inpatient 512 332.8 AETNA AETNA 404.48 79 999999999 310.02 496.64 percent of total billed charges RECIP SAW BLADE D-SIDED 48713066_1 CDM 0272 RC inpatient 512 332.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 332.8 65 999999999 310.02 496.64 percent of total billed charges RECIP SAW BLADE D-SIDED 48713066_1 CDM 0272 RC inpatient 512 332.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 496.64 97 999999999 310.02 496.64 percent of total billed charges RECIP SAW BLADE D-SIDED 48713066_1 CDM 0272 RC inpatient 512 332.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 353.28 69 999999999 310.02 496.64 percent of total billed charges RECIP SAW BLADE D-SIDED 48713066_1 CDM 0272 RC inpatient 512 332.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 399.36 78 999999999 310.02 496.64 percent of total billed charges RECIP SAW BLADE D-SIDED 48713066_1 CDM 0272 RC inpatient 512 332.8 SIHO - ALL PLANS SIHO - ALL PLANS 460.8 90 999999999 310.02 496.64 percent of total billed charges RECIP SAW BLADE D-SIDED 48713066_1 CDM 0272 RC inpatient 512 332.8 UMR - ALL PLANS UMR - ALL PLANS 358.4 70 999999999 310.02 496.64 percent of total billed charges RECIP SAW BLADE D-SIDED 48713066_1 CDM 0272 RC inpatient 512 332.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 310.02 60.55 999999999 310.02 496.64 percent of total billed charges RECIP SAW BLADE D-SIDED 48713066_1 CDM 0272 RC inpatient 512 332.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 310.02 496.64 RECIP SAW BLADE D-SIDED 48713066_1 CDM 0272 RC inpatient 512 332.8 ANTHEM HMO ANTHEM HMO 999999999 310.02 496.64 RECIP SAW BLADE D-SIDED 48713066_1 CDM 0272 RC inpatient 512 332.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 310.02 496.64 RECIP SAW BLADE D-SIDED 48713066_1 CDM 0272 RC inpatient 512 332.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 346.11 67.6 999999999 310.02 496.64 percent of total billed charges RECIP SAW BLADE D-SIDED 48713066_1 CDM 0272 RC inpatient 512 332.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 310.02 496.64 RECIP SAW BLADE D-SIDED 48713066_1 CDM 0272 RC inpatient 512 332.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 310.02 496.64 STIMUPLEX ULTRA NEEDLE 22G X 2 48713067_1 CDM 0272 RC inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges STIMUPLEX ULTRA NEEDLE 22G X 2 48713067_1 CDM 0272 RC inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges STIMUPLEX ULTRA NEEDLE 22G X 2 48713067_1 CDM 0272 RC inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges STIMUPLEX ULTRA NEEDLE 22G X 2 48713067_1 CDM 0272 RC inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges STIMUPLEX ULTRA NEEDLE 22G X 2 48713067_1 CDM 0272 RC inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges STIMUPLEX ULTRA NEEDLE 22G X 2 48713067_1 CDM 0272 RC inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges STIMUPLEX ULTRA NEEDLE 22G X 2 48713067_1 CDM 0272 RC inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges STIMUPLEX ULTRA NEEDLE 22G X 2 48713067_1 CDM 0272 RC inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges STIMUPLEX ULTRA NEEDLE 22G X 2 48713067_1 CDM 0272 RC inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 STIMUPLEX ULTRA NEEDLE 22G X 2 48713067_1 CDM 0272 RC inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 STIMUPLEX ULTRA NEEDLE 22G X 2 48713067_1 CDM 0272 RC inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 STIMUPLEX ULTRA NEEDLE 22G X 2 48713067_1 CDM 0272 RC inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges STIMUPLEX ULTRA NEEDLE 22G X 2 48713067_1 CDM 0272 RC inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 STIMUPLEX ULTRA NEEDLE 22G X 2 48713067_1 CDM 0272 RC inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 MORCELLATOR MOR-1515-6 48713068_1 CDM 0272 RC inpatient 3855 2505.75 AETNA AETNA 3045.45 79 999999999 2334.2 3739.35 percent of total billed charges MORCELLATOR MOR-1515-6 48713068_1 CDM 0272 RC inpatient 3855 2505.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 2505.75 65 999999999 2334.2 3739.35 percent of total billed charges MORCELLATOR MOR-1515-6 48713068_1 CDM 0272 RC inpatient 3855 2505.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3739.35 97 999999999 2334.2 3739.35 percent of total billed charges MORCELLATOR MOR-1515-6 48713068_1 CDM 0272 RC inpatient 3855 2505.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 2659.95 69 999999999 2334.2 3739.35 percent of total billed charges MORCELLATOR MOR-1515-6 48713068_1 CDM 0272 RC inpatient 3855 2505.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 3006.9 78 999999999 2334.2 3739.35 percent of total billed charges MORCELLATOR MOR-1515-6 48713068_1 CDM 0272 RC inpatient 3855 2505.75 SIHO - ALL PLANS SIHO - ALL PLANS 3469.5 90 999999999 2334.2 3739.35 percent of total billed charges MORCELLATOR MOR-1515-6 48713068_1 CDM 0272 RC inpatient 3855 2505.75 UMR - ALL PLANS UMR - ALL PLANS 2698.5 70 999999999 2334.2 3739.35 percent of total billed charges MORCELLATOR MOR-1515-6 48713068_1 CDM 0272 RC inpatient 3855 2505.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2334.2 60.55 999999999 2334.2 3739.35 percent of total billed charges MORCELLATOR MOR-1515-6 48713068_1 CDM 0272 RC inpatient 3855 2505.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2334.2 3739.35 MORCELLATOR MOR-1515-6 48713068_1 CDM 0272 RC inpatient 3855 2505.75 ANTHEM HMO ANTHEM HMO 999999999 2334.2 3739.35 MORCELLATOR MOR-1515-6 48713068_1 CDM 0272 RC inpatient 3855 2505.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2334.2 3739.35 MORCELLATOR MOR-1515-6 48713068_1 CDM 0272 RC inpatient 3855 2505.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 2605.98 67.6 999999999 2334.2 3739.35 percent of total billed charges MORCELLATOR MOR-1515-6 48713068_1 CDM 0272 RC inpatient 3855 2505.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2334.2 3739.35 MORCELLATOR MOR-1515-6 48713068_1 CDM 0272 RC inpatient 3855 2505.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 2334.2 3739.35 PLATE LC-DCP 2.0MM 8H 449.938 48713069_1 CDM 0278 RC inpatient 1458 947.7 AETNA AETNA 1151.82 79 999999999 882.82 1414.26 percent of total billed charges PLATE LC-DCP 2.0MM 8H 449.938 48713069_1 CDM 0278 RC inpatient 1458 947.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 947.7 65 999999999 882.82 1414.26 percent of total billed charges PLATE LC-DCP 2.0MM 8H 449.938 48713069_1 CDM 0278 RC inpatient 1458 947.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1414.26 97 999999999 882.82 1414.26 percent of total billed charges PLATE LC-DCP 2.0MM 8H 449.938 48713069_1 CDM 0278 RC inpatient 1458 947.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1006.02 69 999999999 882.82 1414.26 percent of total billed charges PLATE LC-DCP 2.0MM 8H 449.938 48713069_1 CDM 0278 RC inpatient 1458 947.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1137.24 78 999999999 882.82 1414.26 percent of total billed charges PLATE LC-DCP 2.0MM 8H 449.938 48713069_1 CDM 0278 RC inpatient 1458 947.7 SIHO - ALL PLANS SIHO - ALL PLANS 1312.2 90 999999999 882.82 1414.26 percent of total billed charges PLATE LC-DCP 2.0MM 8H 449.938 48713069_1 CDM 0278 RC inpatient 1458 947.7 UMR - ALL PLANS UMR - ALL PLANS 1020.6 70 999999999 882.82 1414.26 percent of total billed charges PLATE LC-DCP 2.0MM 8H 449.938 48713069_1 CDM 0278 RC inpatient 1458 947.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 882.82 60.55 999999999 882.82 1414.26 percent of total billed charges PLATE LC-DCP 2.0MM 8H 449.938 48713069_1 CDM 0278 RC inpatient 1458 947.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 882.82 1414.26 PLATE LC-DCP 2.0MM 8H 449.938 48713069_1 CDM 0278 RC inpatient 1458 947.7 ANTHEM HMO ANTHEM HMO 999999999 882.82 1414.26 PLATE LC-DCP 2.0MM 8H 449.938 48713069_1 CDM 0278 RC inpatient 1458 947.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 882.82 1414.26 PLATE LC-DCP 2.0MM 8H 449.938 48713069_1 CDM 0278 RC inpatient 1458 947.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 985.61 67.6 999999999 882.82 1414.26 percent of total billed charges PLATE LC-DCP 2.0MM 8H 449.938 48713069_1 CDM 0278 RC inpatient 1458 947.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 882.82 1414.26 PLATE LC-DCP 2.0MM 8H 449.938 48713069_1 CDM 0278 RC inpatient 1458 947.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 882.82 1414.26 PLATE LC-DCP 2.0MM 6H 449.936 48713070_1 CDM 0278 RC inpatient 1384 899.6 AETNA AETNA 1093.36 79 999999999 838.01 1342.48 percent of total billed charges PLATE LC-DCP 2.0MM 6H 449.936 48713070_1 CDM 0278 RC inpatient 1384 899.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 899.6 65 999999999 838.01 1342.48 percent of total billed charges PLATE LC-DCP 2.0MM 6H 449.936 48713070_1 CDM 0278 RC inpatient 1384 899.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1342.48 97 999999999 838.01 1342.48 percent of total billed charges PLATE LC-DCP 2.0MM 6H 449.936 48713070_1 CDM 0278 RC inpatient 1384 899.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 954.96 69 999999999 838.01 1342.48 percent of total billed charges PLATE LC-DCP 2.0MM 6H 449.936 48713070_1 CDM 0278 RC inpatient 1384 899.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1079.52 78 999999999 838.01 1342.48 percent of total billed charges PLATE LC-DCP 2.0MM 6H 449.936 48713070_1 CDM 0278 RC inpatient 1384 899.6 SIHO - ALL PLANS SIHO - ALL PLANS 1245.6 90 999999999 838.01 1342.48 percent of total billed charges PLATE LC-DCP 2.0MM 6H 449.936 48713070_1 CDM 0278 RC inpatient 1384 899.6 UMR - ALL PLANS UMR - ALL PLANS 968.8 70 999999999 838.01 1342.48 percent of total billed charges PLATE LC-DCP 2.0MM 6H 449.936 48713070_1 CDM 0278 RC inpatient 1384 899.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 838.01 60.55 999999999 838.01 1342.48 percent of total billed charges PLATE LC-DCP 2.0MM 6H 449.936 48713070_1 CDM 0278 RC inpatient 1384 899.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 838.01 1342.48 PLATE LC-DCP 2.0MM 6H 449.936 48713070_1 CDM 0278 RC inpatient 1384 899.6 ANTHEM HMO ANTHEM HMO 999999999 838.01 1342.48 PLATE LC-DCP 2.0MM 6H 449.936 48713070_1 CDM 0278 RC inpatient 1384 899.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 838.01 1342.48 PLATE LC-DCP 2.0MM 6H 449.936 48713070_1 CDM 0278 RC inpatient 1384 899.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 935.58 67.6 999999999 838.01 1342.48 percent of total billed charges PLATE LC-DCP 2.0MM 6H 449.936 48713070_1 CDM 0278 RC inpatient 1384 899.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 838.01 1342.48 PLATE LC-DCP 2.0MM 6H 449.936 48713070_1 CDM 0278 RC inpatient 1384 899.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 838.01 1342.48 PLATE LC-DCP 2.0MM 4H 449.931 48713071_1 CDM 0278 RC inpatient 1548 1006.2 AETNA AETNA 1222.92 79 999999999 937.31 1501.56 percent of total billed charges PLATE LC-DCP 2.0MM 4H 449.931 48713071_1 CDM 0278 RC inpatient 1548 1006.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1006.2 65 999999999 937.31 1501.56 percent of total billed charges PLATE LC-DCP 2.0MM 4H 449.931 48713071_1 CDM 0278 RC inpatient 1548 1006.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1501.56 97 999999999 937.31 1501.56 percent of total billed charges PLATE LC-DCP 2.0MM 4H 449.931 48713071_1 CDM 0278 RC inpatient 1548 1006.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1068.12 69 999999999 937.31 1501.56 percent of total billed charges PLATE LC-DCP 2.0MM 4H 449.931 48713071_1 CDM 0278 RC inpatient 1548 1006.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1207.44 78 999999999 937.31 1501.56 percent of total billed charges PLATE LC-DCP 2.0MM 4H 449.931 48713071_1 CDM 0278 RC inpatient 1548 1006.2 SIHO - ALL PLANS SIHO - ALL PLANS 1393.2 90 999999999 937.31 1501.56 percent of total billed charges PLATE LC-DCP 2.0MM 4H 449.931 48713071_1 CDM 0278 RC inpatient 1548 1006.2 UMR - ALL PLANS UMR - ALL PLANS 1083.6 70 999999999 937.31 1501.56 percent of total billed charges PLATE LC-DCP 2.0MM 4H 449.931 48713071_1 CDM 0278 RC inpatient 1548 1006.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 937.31 60.55 999999999 937.31 1501.56 percent of total billed charges PLATE LC-DCP 2.0MM 4H 449.931 48713071_1 CDM 0278 RC inpatient 1548 1006.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 937.31 1501.56 PLATE LC-DCP 2.0MM 4H 449.931 48713071_1 CDM 0278 RC inpatient 1548 1006.2 ANTHEM HMO ANTHEM HMO 999999999 937.31 1501.56 PLATE LC-DCP 2.0MM 4H 449.931 48713071_1 CDM 0278 RC inpatient 1548 1006.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 937.31 1501.56 PLATE LC-DCP 2.0MM 4H 449.931 48713071_1 CDM 0278 RC inpatient 1548 1006.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1046.45 67.6 999999999 937.31 1501.56 percent of total billed charges PLATE LC-DCP 2.0MM 4H 449.931 48713071_1 CDM 0278 RC inpatient 1548 1006.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 937.31 1501.56 PLATE LC-DCP 2.0MM 4H 449.931 48713071_1 CDM 0278 RC inpatient 1548 1006.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 937.31 1501.56 PLATE LC-DCP 2.4MM 8H 449.928 48713072_1 CDM 0278 RC inpatient 2159 1403.35 AETNA AETNA 1705.61 79 999999999 1307.27 2094.23 percent of total billed charges PLATE LC-DCP 2.4MM 8H 449.928 48713072_1 CDM 0278 RC inpatient 2159 1403.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1403.35 65 999999999 1307.27 2094.23 percent of total billed charges PLATE LC-DCP 2.4MM 8H 449.928 48713072_1 CDM 0278 RC inpatient 2159 1403.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2094.23 97 999999999 1307.27 2094.23 percent of total billed charges PLATE LC-DCP 2.4MM 8H 449.928 48713072_1 CDM 0278 RC inpatient 2159 1403.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1489.71 69 999999999 1307.27 2094.23 percent of total billed charges PLATE LC-DCP 2.4MM 8H 449.928 48713072_1 CDM 0278 RC inpatient 2159 1403.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1684.02 78 999999999 1307.27 2094.23 percent of total billed charges PLATE LC-DCP 2.4MM 8H 449.928 48713072_1 CDM 0278 RC inpatient 2159 1403.35 SIHO - ALL PLANS SIHO - ALL PLANS 1943.1 90 999999999 1307.27 2094.23 percent of total billed charges PLATE LC-DCP 2.4MM 8H 449.928 48713072_1 CDM 0278 RC inpatient 2159 1403.35 UMR - ALL PLANS UMR - ALL PLANS 1511.3 70 999999999 1307.27 2094.23 percent of total billed charges PLATE LC-DCP 2.4MM 8H 449.928 48713072_1 CDM 0278 RC inpatient 2159 1403.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1307.27 60.55 999999999 1307.27 2094.23 percent of total billed charges PLATE LC-DCP 2.4MM 8H 449.928 48713072_1 CDM 0278 RC inpatient 2159 1403.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1307.27 2094.23 PLATE LC-DCP 2.4MM 8H 449.928 48713072_1 CDM 0278 RC inpatient 2159 1403.35 ANTHEM HMO ANTHEM HMO 999999999 1307.27 2094.23 PLATE LC-DCP 2.4MM 8H 449.928 48713072_1 CDM 0278 RC inpatient 2159 1403.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1307.27 2094.23 PLATE LC-DCP 2.4MM 8H 449.928 48713072_1 CDM 0278 RC inpatient 2159 1403.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1459.48 67.6 999999999 1307.27 2094.23 percent of total billed charges PLATE LC-DCP 2.4MM 8H 449.928 48713072_1 CDM 0278 RC inpatient 2159 1403.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1307.27 2094.23 PLATE LC-DCP 2.4MM 8H 449.928 48713072_1 CDM 0278 RC inpatient 2159 1403.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1307.27 2094.23 PLATE LC-DCP 2.4MM 6H 449.926 48713073_1 CDM 0278 RC inpatient 2512 1632.8 AETNA AETNA 1984.48 79 999999999 1521.02 2436.64 percent of total billed charges PLATE LC-DCP 2.4MM 6H 449.926 48713073_1 CDM 0278 RC inpatient 2512 1632.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1632.8 65 999999999 1521.02 2436.64 percent of total billed charges PLATE LC-DCP 2.4MM 6H 449.926 48713073_1 CDM 0278 RC inpatient 2512 1632.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2436.64 97 999999999 1521.02 2436.64 percent of total billed charges PLATE LC-DCP 2.4MM 6H 449.926 48713073_1 CDM 0278 RC inpatient 2512 1632.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1733.28 69 999999999 1521.02 2436.64 percent of total billed charges PLATE LC-DCP 2.4MM 6H 449.926 48713073_1 CDM 0278 RC inpatient 2512 1632.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1959.36 78 999999999 1521.02 2436.64 percent of total billed charges PLATE LC-DCP 2.4MM 6H 449.926 48713073_1 CDM 0278 RC inpatient 2512 1632.8 SIHO - ALL PLANS SIHO - ALL PLANS 2260.8 90 999999999 1521.02 2436.64 percent of total billed charges PLATE LC-DCP 2.4MM 6H 449.926 48713073_1 CDM 0278 RC inpatient 2512 1632.8 UMR - ALL PLANS UMR - ALL PLANS 1758.4 70 999999999 1521.02 2436.64 percent of total billed charges PLATE LC-DCP 2.4MM 6H 449.926 48713073_1 CDM 0278 RC inpatient 2512 1632.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1521.02 60.55 999999999 1521.02 2436.64 percent of total billed charges PLATE LC-DCP 2.4MM 6H 449.926 48713073_1 CDM 0278 RC inpatient 2512 1632.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1521.02 2436.64 PLATE LC-DCP 2.4MM 6H 449.926 48713073_1 CDM 0278 RC inpatient 2512 1632.8 ANTHEM HMO ANTHEM HMO 999999999 1521.02 2436.64 PLATE LC-DCP 2.4MM 6H 449.926 48713073_1 CDM 0278 RC inpatient 2512 1632.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1521.02 2436.64 PLATE LC-DCP 2.4MM 6H 449.926 48713073_1 CDM 0278 RC inpatient 2512 1632.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1698.11 67.6 999999999 1521.02 2436.64 percent of total billed charges PLATE LC-DCP 2.4MM 6H 449.926 48713073_1 CDM 0278 RC inpatient 2512 1632.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1521.02 2436.64 PLATE LC-DCP 2.4MM 6H 449.926 48713073_1 CDM 0278 RC inpatient 2512 1632.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1521.02 2436.64 PLATE LC-DCP 2.4M 4H 449.924 48713074_1 CDM 0278 RC inpatient 1993 1295.45 AETNA AETNA 1574.47 79 999999999 1206.76 1933.21 percent of total billed charges PLATE LC-DCP 2.4M 4H 449.924 48713074_1 CDM 0278 RC inpatient 1993 1295.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1295.45 65 999999999 1206.76 1933.21 percent of total billed charges PLATE LC-DCP 2.4M 4H 449.924 48713074_1 CDM 0278 RC inpatient 1993 1295.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1933.21 97 999999999 1206.76 1933.21 percent of total billed charges PLATE LC-DCP 2.4M 4H 449.924 48713074_1 CDM 0278 RC inpatient 1993 1295.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1375.17 69 999999999 1206.76 1933.21 percent of total billed charges PLATE LC-DCP 2.4M 4H 449.924 48713074_1 CDM 0278 RC inpatient 1993 1295.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1554.54 78 999999999 1206.76 1933.21 percent of total billed charges PLATE LC-DCP 2.4M 4H 449.924 48713074_1 CDM 0278 RC inpatient 1993 1295.45 SIHO - ALL PLANS SIHO - ALL PLANS 1793.7 90 999999999 1206.76 1933.21 percent of total billed charges PLATE LC-DCP 2.4M 4H 449.924 48713074_1 CDM 0278 RC inpatient 1993 1295.45 UMR - ALL PLANS UMR - ALL PLANS 1395.1 70 999999999 1206.76 1933.21 percent of total billed charges PLATE LC-DCP 2.4M 4H 449.924 48713074_1 CDM 0278 RC inpatient 1993 1295.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1206.76 60.55 999999999 1206.76 1933.21 percent of total billed charges PLATE LC-DCP 2.4M 4H 449.924 48713074_1 CDM 0278 RC inpatient 1993 1295.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1206.76 1933.21 PLATE LC-DCP 2.4M 4H 449.924 48713074_1 CDM 0278 RC inpatient 1993 1295.45 ANTHEM HMO ANTHEM HMO 999999999 1206.76 1933.21 PLATE LC-DCP 2.4M 4H 449.924 48713074_1 CDM 0278 RC inpatient 1993 1295.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1206.76 1933.21 PLATE LC-DCP 2.4M 4H 449.924 48713074_1 CDM 0278 RC inpatient 1993 1295.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1347.27 67.6 999999999 1206.76 1933.21 percent of total billed charges PLATE LC-DCP 2.4M 4H 449.924 48713074_1 CDM 0278 RC inpatient 1993 1295.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1206.76 1933.21 PLATE LC-DCP 2.4M 4H 449.924 48713074_1 CDM 0278 RC inpatient 1993 1295.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1206.76 1933.21 CNDYLAR PLT 2.4M LT 8H 449.917 48713075_1 CDM 0278 RC inpatient 1310 851.5 AETNA AETNA 1034.9 79 999999999 793.21 1270.7 percent of total billed charges CNDYLAR PLT 2.4M LT 8H 449.917 48713075_1 CDM 0278 RC inpatient 1310 851.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 851.5 65 999999999 793.21 1270.7 percent of total billed charges CNDYLAR PLT 2.4M LT 8H 449.917 48713075_1 CDM 0278 RC inpatient 1310 851.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1270.7 97 999999999 793.21 1270.7 percent of total billed charges CNDYLAR PLT 2.4M LT 8H 449.917 48713075_1 CDM 0278 RC inpatient 1310 851.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 903.9 69 999999999 793.21 1270.7 percent of total billed charges CNDYLAR PLT 2.4M LT 8H 449.917 48713075_1 CDM 0278 RC inpatient 1310 851.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1021.8 78 999999999 793.21 1270.7 percent of total billed charges CNDYLAR PLT 2.4M LT 8H 449.917 48713075_1 CDM 0278 RC inpatient 1310 851.5 SIHO - ALL PLANS SIHO - ALL PLANS 1179 90 999999999 793.21 1270.7 percent of total billed charges CNDYLAR PLT 2.4M LT 8H 449.917 48713075_1 CDM 0278 RC inpatient 1310 851.5 UMR - ALL PLANS UMR - ALL PLANS 917 70 999999999 793.21 1270.7 percent of total billed charges CNDYLAR PLT 2.4M LT 8H 449.917 48713075_1 CDM 0278 RC inpatient 1310 851.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 793.21 60.55 999999999 793.21 1270.7 percent of total billed charges CNDYLAR PLT 2.4M LT 8H 449.917 48713075_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 793.21 1270.7 CNDYLAR PLT 2.4M LT 8H 449.917 48713075_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM HMO ANTHEM HMO 999999999 793.21 1270.7 CNDYLAR PLT 2.4M LT 8H 449.917 48713075_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 793.21 1270.7 CNDYLAR PLT 2.4M LT 8H 449.917 48713075_1 CDM 0278 RC inpatient 1310 851.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 885.56 67.6 999999999 793.21 1270.7 percent of total billed charges CNDYLAR PLT 2.4M LT 8H 449.917 48713075_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 793.21 1270.7 CNDYLAR PLT 2.4M LT 8H 449.917 48713075_1 CDM 0278 RC inpatient 1310 851.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 793.21 1270.7 CNDYLAR PLT 2.4M RT 8H 449.916 48713076_1 CDM 0278 RC inpatient 1310 851.5 AETNA AETNA 1034.9 79 999999999 793.21 1270.7 percent of total billed charges CNDYLAR PLT 2.4M RT 8H 449.916 48713076_1 CDM 0278 RC inpatient 1310 851.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 851.5 65 999999999 793.21 1270.7 percent of total billed charges CNDYLAR PLT 2.4M RT 8H 449.916 48713076_1 CDM 0278 RC inpatient 1310 851.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1270.7 97 999999999 793.21 1270.7 percent of total billed charges CNDYLAR PLT 2.4M RT 8H 449.916 48713076_1 CDM 0278 RC inpatient 1310 851.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 903.9 69 999999999 793.21 1270.7 percent of total billed charges CNDYLAR PLT 2.4M RT 8H 449.916 48713076_1 CDM 0278 RC inpatient 1310 851.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1021.8 78 999999999 793.21 1270.7 percent of total billed charges CNDYLAR PLT 2.4M RT 8H 449.916 48713076_1 CDM 0278 RC inpatient 1310 851.5 SIHO - ALL PLANS SIHO - ALL PLANS 1179 90 999999999 793.21 1270.7 percent of total billed charges CNDYLAR PLT 2.4M RT 8H 449.916 48713076_1 CDM 0278 RC inpatient 1310 851.5 UMR - ALL PLANS UMR - ALL PLANS 917 70 999999999 793.21 1270.7 percent of total billed charges CNDYLAR PLT 2.4M RT 8H 449.916 48713076_1 CDM 0278 RC inpatient 1310 851.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 793.21 60.55 999999999 793.21 1270.7 percent of total billed charges CNDYLAR PLT 2.4M RT 8H 449.916 48713076_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 793.21 1270.7 CNDYLAR PLT 2.4M RT 8H 449.916 48713076_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM HMO ANTHEM HMO 999999999 793.21 1270.7 CNDYLAR PLT 2.4M RT 8H 449.916 48713076_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 793.21 1270.7 CNDYLAR PLT 2.4M RT 8H 449.916 48713076_1 CDM 0278 RC inpatient 1310 851.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 885.56 67.6 999999999 793.21 1270.7 percent of total billed charges CNDYLAR PLT 2.4M RT 8H 449.916 48713076_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 793.21 1270.7 CNDYLAR PLT 2.4M RT 8H 449.916 48713076_1 CDM 0278 RC inpatient 1310 851.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 793.21 1270.7 T-PLATE 2.4MM 11H 449.914 48713077_1 CDM 0278 RC inpatient 1192 774.8 AETNA AETNA 941.68 79 999999999 721.76 1156.24 percent of total billed charges T-PLATE 2.4MM 11H 449.914 48713077_1 CDM 0278 RC inpatient 1192 774.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 774.8 65 999999999 721.76 1156.24 percent of total billed charges T-PLATE 2.4MM 11H 449.914 48713077_1 CDM 0278 RC inpatient 1192 774.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1156.24 97 999999999 721.76 1156.24 percent of total billed charges T-PLATE 2.4MM 11H 449.914 48713077_1 CDM 0278 RC inpatient 1192 774.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 822.48 69 999999999 721.76 1156.24 percent of total billed charges T-PLATE 2.4MM 11H 449.914 48713077_1 CDM 0278 RC inpatient 1192 774.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 929.76 78 999999999 721.76 1156.24 percent of total billed charges T-PLATE 2.4MM 11H 449.914 48713077_1 CDM 0278 RC inpatient 1192 774.8 SIHO - ALL PLANS SIHO - ALL PLANS 1072.8 90 999999999 721.76 1156.24 percent of total billed charges T-PLATE 2.4MM 11H 449.914 48713077_1 CDM 0278 RC inpatient 1192 774.8 UMR - ALL PLANS UMR - ALL PLANS 834.4 70 999999999 721.76 1156.24 percent of total billed charges T-PLATE 2.4MM 11H 449.914 48713077_1 CDM 0278 RC inpatient 1192 774.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 721.76 60.55 999999999 721.76 1156.24 percent of total billed charges T-PLATE 2.4MM 11H 449.914 48713077_1 CDM 0278 RC inpatient 1192 774.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 721.76 1156.24 T-PLATE 2.4MM 11H 449.914 48713077_1 CDM 0278 RC inpatient 1192 774.8 ANTHEM HMO ANTHEM HMO 999999999 721.76 1156.24 T-PLATE 2.4MM 11H 449.914 48713077_1 CDM 0278 RC inpatient 1192 774.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 721.76 1156.24 T-PLATE 2.4MM 11H 449.914 48713077_1 CDM 0278 RC inpatient 1192 774.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 805.79 67.6 999999999 721.76 1156.24 percent of total billed charges T-PLATE 2.4MM 11H 449.914 48713077_1 CDM 0278 RC inpatient 1192 774.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 721.76 1156.24 T-PLATE 2.4MM 11H 449.914 48713077_1 CDM 0278 RC inpatient 1192 774.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 721.76 1156.24 T-PLATE 2.4MM 10H 449.913 48713078_1 CDM 0278 RC inpatient 1118 726.7 AETNA AETNA 883.22 79 999999999 676.95 1084.46 percent of total billed charges T-PLATE 2.4MM 10H 449.913 48713078_1 CDM 0278 RC inpatient 1118 726.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 726.7 65 999999999 676.95 1084.46 percent of total billed charges T-PLATE 2.4MM 10H 449.913 48713078_1 CDM 0278 RC inpatient 1118 726.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1084.46 97 999999999 676.95 1084.46 percent of total billed charges T-PLATE 2.4MM 10H 449.913 48713078_1 CDM 0278 RC inpatient 1118 726.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 771.42 69 999999999 676.95 1084.46 percent of total billed charges T-PLATE 2.4MM 10H 449.913 48713078_1 CDM 0278 RC inpatient 1118 726.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 872.04 78 999999999 676.95 1084.46 percent of total billed charges T-PLATE 2.4MM 10H 449.913 48713078_1 CDM 0278 RC inpatient 1118 726.7 SIHO - ALL PLANS SIHO - ALL PLANS 1006.2 90 999999999 676.95 1084.46 percent of total billed charges T-PLATE 2.4MM 10H 449.913 48713078_1 CDM 0278 RC inpatient 1118 726.7 UMR - ALL PLANS UMR - ALL PLANS 782.6 70 999999999 676.95 1084.46 percent of total billed charges T-PLATE 2.4MM 10H 449.913 48713078_1 CDM 0278 RC inpatient 1118 726.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 676.95 60.55 999999999 676.95 1084.46 percent of total billed charges T-PLATE 2.4MM 10H 449.913 48713078_1 CDM 0278 RC inpatient 1118 726.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 676.95 1084.46 T-PLATE 2.4MM 10H 449.913 48713078_1 CDM 0278 RC inpatient 1118 726.7 ANTHEM HMO ANTHEM HMO 999999999 676.95 1084.46 T-PLATE 2.4MM 10H 449.913 48713078_1 CDM 0278 RC inpatient 1118 726.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 676.95 1084.46 T-PLATE 2.4MM 10H 449.913 48713078_1 CDM 0278 RC inpatient 1118 726.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 755.77 67.6 999999999 676.95 1084.46 percent of total billed charges T-PLATE 2.4MM 10H 449.913 48713078_1 CDM 0278 RC inpatient 1118 726.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 676.95 1084.46 T-PLATE 2.4MM 10H 449.913 48713078_1 CDM 0278 RC inpatient 1118 726.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 676.95 1084.46 PLATE ST. 2.4MM 12\H 449.912 48713079_1 CDM 0278 RC inpatient 1173 762.45 AETNA AETNA 926.67 79 999999999 710.25 1137.81 percent of total billed charges PLATE ST. 2.4MM 12\H 449.912 48713079_1 CDM 0278 RC inpatient 1173 762.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 762.45 65 999999999 710.25 1137.81 percent of total billed charges PLATE ST. 2.4MM 12\H 449.912 48713079_1 CDM 0278 RC inpatient 1173 762.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1137.81 97 999999999 710.25 1137.81 percent of total billed charges PLATE ST. 2.4MM 12\H 449.912 48713079_1 CDM 0278 RC inpatient 1173 762.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 809.37 69 999999999 710.25 1137.81 percent of total billed charges PLATE ST. 2.4MM 12\H 449.912 48713079_1 CDM 0278 RC inpatient 1173 762.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 914.94 78 999999999 710.25 1137.81 percent of total billed charges PLATE ST. 2.4MM 12\H 449.912 48713079_1 CDM 0278 RC inpatient 1173 762.45 SIHO - ALL PLANS SIHO - ALL PLANS 1055.7 90 999999999 710.25 1137.81 percent of total billed charges PLATE ST. 2.4MM 12\H 449.912 48713079_1 CDM 0278 RC inpatient 1173 762.45 UMR - ALL PLANS UMR - ALL PLANS 821.1 70 999999999 710.25 1137.81 percent of total billed charges PLATE ST. 2.4MM 12\H 449.912 48713079_1 CDM 0278 RC inpatient 1173 762.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 710.25 60.55 999999999 710.25 1137.81 percent of total billed charges PLATE ST. 2.4MM 12\H 449.912 48713079_1 CDM 0278 RC inpatient 1173 762.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 710.25 1137.81 PLATE ST. 2.4MM 12\H 449.912 48713079_1 CDM 0278 RC inpatient 1173 762.45 ANTHEM HMO ANTHEM HMO 999999999 710.25 1137.81 PLATE ST. 2.4MM 12\H 449.912 48713079_1 CDM 0278 RC inpatient 1173 762.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 710.25 1137.81 PLATE ST. 2.4MM 12\H 449.912 48713079_1 CDM 0278 RC inpatient 1173 762.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 792.95 67.6 999999999 710.25 1137.81 percent of total billed charges PLATE ST. 2.4MM 12\H 449.912 48713079_1 CDM 0278 RC inpatient 1173 762.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 710.25 1137.81 PLATE ST. 2.4MM 12\H 449.912 48713079_1 CDM 0278 RC inpatient 1173 762.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 710.25 1137.81 PLATE ST. 2.4MM 6\H 449.906 48713080_1 CDM 0278 RC inpatient 1168 759.2 AETNA AETNA 922.72 79 999999999 707.22 1132.96 percent of total billed charges PLATE ST. 2.4MM 6\H 449.906 48713080_1 CDM 0278 RC inpatient 1168 759.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 759.2 65 999999999 707.22 1132.96 percent of total billed charges PLATE ST. 2.4MM 6\H 449.906 48713080_1 CDM 0278 RC inpatient 1168 759.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1132.96 97 999999999 707.22 1132.96 percent of total billed charges PLATE ST. 2.4MM 6\H 449.906 48713080_1 CDM 0278 RC inpatient 1168 759.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 805.92 69 999999999 707.22 1132.96 percent of total billed charges PLATE ST. 2.4MM 6\H 449.906 48713080_1 CDM 0278 RC inpatient 1168 759.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 911.04 78 999999999 707.22 1132.96 percent of total billed charges PLATE ST. 2.4MM 6\H 449.906 48713080_1 CDM 0278 RC inpatient 1168 759.2 SIHO - ALL PLANS SIHO - ALL PLANS 1051.2 90 999999999 707.22 1132.96 percent of total billed charges PLATE ST. 2.4MM 6\H 449.906 48713080_1 CDM 0278 RC inpatient 1168 759.2 UMR - ALL PLANS UMR - ALL PLANS 817.6 70 999999999 707.22 1132.96 percent of total billed charges PLATE ST. 2.4MM 6\H 449.906 48713080_1 CDM 0278 RC inpatient 1168 759.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 707.22 60.55 999999999 707.22 1132.96 percent of total billed charges PLATE ST. 2.4MM 6\H 449.906 48713080_1 CDM 0278 RC inpatient 1168 759.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 707.22 1132.96 PLATE ST. 2.4MM 6\H 449.906 48713080_1 CDM 0278 RC inpatient 1168 759.2 ANTHEM HMO ANTHEM HMO 999999999 707.22 1132.96 PLATE ST. 2.4MM 6\H 449.906 48713080_1 CDM 0278 RC inpatient 1168 759.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 707.22 1132.96 PLATE ST. 2.4MM 6\H 449.906 48713080_1 CDM 0278 RC inpatient 1168 759.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 789.57 67.6 999999999 707.22 1132.96 percent of total billed charges PLATE ST. 2.4MM 6\H 449.906 48713080_1 CDM 0278 RC inpatient 1168 759.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 707.22 1132.96 PLATE ST. 2.4MM 6\H 449.906 48713080_1 CDM 0278 RC inpatient 1168 759.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 707.22 1132.96 T-PLATE 2.0MM 11H 447.233 48713081_1 CDM 0278 RC inpatient 1086 705.9 AETNA AETNA 857.94 79 999999999 657.57 1053.42 percent of total billed charges T-PLATE 2.0MM 11H 447.233 48713081_1 CDM 0278 RC inpatient 1086 705.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 705.9 65 999999999 657.57 1053.42 percent of total billed charges T-PLATE 2.0MM 11H 447.233 48713081_1 CDM 0278 RC inpatient 1086 705.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1053.42 97 999999999 657.57 1053.42 percent of total billed charges T-PLATE 2.0MM 11H 447.233 48713081_1 CDM 0278 RC inpatient 1086 705.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 749.34 69 999999999 657.57 1053.42 percent of total billed charges T-PLATE 2.0MM 11H 447.233 48713081_1 CDM 0278 RC inpatient 1086 705.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 847.08 78 999999999 657.57 1053.42 percent of total billed charges T-PLATE 2.0MM 11H 447.233 48713081_1 CDM 0278 RC inpatient 1086 705.9 SIHO - ALL PLANS SIHO - ALL PLANS 977.4 90 999999999 657.57 1053.42 percent of total billed charges T-PLATE 2.0MM 11H 447.233 48713081_1 CDM 0278 RC inpatient 1086 705.9 UMR - ALL PLANS UMR - ALL PLANS 760.2 70 999999999 657.57 1053.42 percent of total billed charges T-PLATE 2.0MM 11H 447.233 48713081_1 CDM 0278 RC inpatient 1086 705.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 657.57 60.55 999999999 657.57 1053.42 percent of total billed charges T-PLATE 2.0MM 11H 447.233 48713081_1 CDM 0278 RC inpatient 1086 705.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 657.57 1053.42 T-PLATE 2.0MM 11H 447.233 48713081_1 CDM 0278 RC inpatient 1086 705.9 ANTHEM HMO ANTHEM HMO 999999999 657.57 1053.42 T-PLATE 2.0MM 11H 447.233 48713081_1 CDM 0278 RC inpatient 1086 705.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 657.57 1053.42 T-PLATE 2.0MM 11H 447.233 48713081_1 CDM 0278 RC inpatient 1086 705.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 734.14 67.6 999999999 657.57 1053.42 percent of total billed charges T-PLATE 2.0MM 11H 447.233 48713081_1 CDM 0278 RC inpatient 1086 705.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 657.57 1053.42 T-PLATE 2.0MM 11H 447.233 48713081_1 CDM 0278 RC inpatient 1086 705.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 657.57 1053.42 T-PLATE 2.0MM 10H 447.232 48713082_1 CDM 0278 RC inpatient 994 646.1 AETNA AETNA 785.26 79 999999999 601.87 964.18 percent of total billed charges T-PLATE 2.0MM 10H 447.232 48713082_1 CDM 0278 RC inpatient 994 646.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 646.1 65 999999999 601.87 964.18 percent of total billed charges T-PLATE 2.0MM 10H 447.232 48713082_1 CDM 0278 RC inpatient 994 646.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 964.18 97 999999999 601.87 964.18 percent of total billed charges T-PLATE 2.0MM 10H 447.232 48713082_1 CDM 0278 RC inpatient 994 646.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 685.86 69 999999999 601.87 964.18 percent of total billed charges T-PLATE 2.0MM 10H 447.232 48713082_1 CDM 0278 RC inpatient 994 646.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 775.32 78 999999999 601.87 964.18 percent of total billed charges T-PLATE 2.0MM 10H 447.232 48713082_1 CDM 0278 RC inpatient 994 646.1 SIHO - ALL PLANS SIHO - ALL PLANS 894.6 90 999999999 601.87 964.18 percent of total billed charges T-PLATE 2.0MM 10H 447.232 48713082_1 CDM 0278 RC inpatient 994 646.1 UMR - ALL PLANS UMR - ALL PLANS 695.8 70 999999999 601.87 964.18 percent of total billed charges T-PLATE 2.0MM 10H 447.232 48713082_1 CDM 0278 RC inpatient 994 646.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 601.87 60.55 999999999 601.87 964.18 percent of total billed charges T-PLATE 2.0MM 10H 447.232 48713082_1 CDM 0278 RC inpatient 994 646.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 601.87 964.18 T-PLATE 2.0MM 10H 447.232 48713082_1 CDM 0278 RC inpatient 994 646.1 ANTHEM HMO ANTHEM HMO 999999999 601.87 964.18 T-PLATE 2.0MM 10H 447.232 48713082_1 CDM 0278 RC inpatient 994 646.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 601.87 964.18 T-PLATE 2.0MM 10H 447.232 48713082_1 CDM 0278 RC inpatient 994 646.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 671.94 67.6 999999999 601.87 964.18 percent of total billed charges T-PLATE 2.0MM 10H 447.232 48713082_1 CDM 0278 RC inpatient 994 646.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 601.87 964.18 T-PLATE 2.0MM 10H 447.232 48713082_1 CDM 0278 RC inpatient 994 646.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 601.87 964.18 PLATE ST. 2.0MM 12/H 447.032 48713083_1 CDM 0278 RC inpatient 1086 705.9 AETNA AETNA 857.94 79 999999999 657.57 1053.42 percent of total billed charges PLATE ST. 2.0MM 12/H 447.032 48713083_1 CDM 0278 RC inpatient 1086 705.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 705.9 65 999999999 657.57 1053.42 percent of total billed charges PLATE ST. 2.0MM 12/H 447.032 48713083_1 CDM 0278 RC inpatient 1086 705.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1053.42 97 999999999 657.57 1053.42 percent of total billed charges PLATE ST. 2.0MM 12/H 447.032 48713083_1 CDM 0278 RC inpatient 1086 705.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 749.34 69 999999999 657.57 1053.42 percent of total billed charges PLATE ST. 2.0MM 12/H 447.032 48713083_1 CDM 0278 RC inpatient 1086 705.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 847.08 78 999999999 657.57 1053.42 percent of total billed charges PLATE ST. 2.0MM 12/H 447.032 48713083_1 CDM 0278 RC inpatient 1086 705.9 SIHO - ALL PLANS SIHO - ALL PLANS 977.4 90 999999999 657.57 1053.42 percent of total billed charges PLATE ST. 2.0MM 12/H 447.032 48713083_1 CDM 0278 RC inpatient 1086 705.9 UMR - ALL PLANS UMR - ALL PLANS 760.2 70 999999999 657.57 1053.42 percent of total billed charges PLATE ST. 2.0MM 12/H 447.032 48713083_1 CDM 0278 RC inpatient 1086 705.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 657.57 60.55 999999999 657.57 1053.42 percent of total billed charges PLATE ST. 2.0MM 12/H 447.032 48713083_1 CDM 0278 RC inpatient 1086 705.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 657.57 1053.42 PLATE ST. 2.0MM 12/H 447.032 48713083_1 CDM 0278 RC inpatient 1086 705.9 ANTHEM HMO ANTHEM HMO 999999999 657.57 1053.42 PLATE ST. 2.0MM 12/H 447.032 48713083_1 CDM 0278 RC inpatient 1086 705.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 657.57 1053.42 PLATE ST. 2.0MM 12/H 447.032 48713083_1 CDM 0278 RC inpatient 1086 705.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 734.14 67.6 999999999 657.57 1053.42 percent of total billed charges PLATE ST. 2.0MM 12/H 447.032 48713083_1 CDM 0278 RC inpatient 1086 705.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 657.57 1053.42 PLATE ST. 2.0MM 12/H 447.032 48713083_1 CDM 0278 RC inpatient 1086 705.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 657.57 1053.42 PLATE ST. 2.0MM 6\HOLE 447.031 48713084_1 CDM 0278 RC inpatient 908 590.2 AETNA AETNA 717.32 79 999999999 549.79 880.76 percent of total billed charges PLATE ST. 2.0MM 6\HOLE 447.031 48713084_1 CDM 0278 RC inpatient 908 590.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 590.2 65 999999999 549.79 880.76 percent of total billed charges PLATE ST. 2.0MM 6\HOLE 447.031 48713084_1 CDM 0278 RC inpatient 908 590.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 880.76 97 999999999 549.79 880.76 percent of total billed charges PLATE ST. 2.0MM 6\HOLE 447.031 48713084_1 CDM 0278 RC inpatient 908 590.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 626.52 69 999999999 549.79 880.76 percent of total billed charges PLATE ST. 2.0MM 6\HOLE 447.031 48713084_1 CDM 0278 RC inpatient 908 590.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 708.24 78 999999999 549.79 880.76 percent of total billed charges PLATE ST. 2.0MM 6\HOLE 447.031 48713084_1 CDM 0278 RC inpatient 908 590.2 SIHO - ALL PLANS SIHO - ALL PLANS 817.2 90 999999999 549.79 880.76 percent of total billed charges PLATE ST. 2.0MM 6\HOLE 447.031 48713084_1 CDM 0278 RC inpatient 908 590.2 UMR - ALL PLANS UMR - ALL PLANS 635.6 70 999999999 549.79 880.76 percent of total billed charges PLATE ST. 2.0MM 6\HOLE 447.031 48713084_1 CDM 0278 RC inpatient 908 590.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 549.79 60.55 999999999 549.79 880.76 percent of total billed charges PLATE ST. 2.0MM 6\HOLE 447.031 48713084_1 CDM 0278 RC inpatient 908 590.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 549.79 880.76 PLATE ST. 2.0MM 6\HOLE 447.031 48713084_1 CDM 0278 RC inpatient 908 590.2 ANTHEM HMO ANTHEM HMO 999999999 549.79 880.76 PLATE ST. 2.0MM 6\HOLE 447.031 48713084_1 CDM 0278 RC inpatient 908 590.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 549.79 880.76 PLATE ST. 2.0MM 6\HOLE 447.031 48713084_1 CDM 0278 RC inpatient 908 590.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 613.81 67.6 999999999 549.79 880.76 percent of total billed charges PLATE ST. 2.0MM 6\HOLE 447.031 48713084_1 CDM 0278 RC inpatient 908 590.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 549.79 880.76 PLATE ST. 2.0MM 6\HOLE 447.031 48713084_1 CDM 0278 RC inpatient 908 590.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 549.79 880.76 TRANSDUCER COVER W\GEL 9001C0197 48713085_1 CDM 0272 RC inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges TRANSDUCER COVER W\GEL 9001C0197 48713085_1 CDM 0272 RC inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges TRANSDUCER COVER W\GEL 9001C0197 48713085_1 CDM 0272 RC inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges TRANSDUCER COVER W\GEL 9001C0197 48713085_1 CDM 0272 RC inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges TRANSDUCER COVER W\GEL 9001C0197 48713085_1 CDM 0272 RC inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges TRANSDUCER COVER W\GEL 9001C0197 48713085_1 CDM 0272 RC inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges TRANSDUCER COVER W\GEL 9001C0197 48713085_1 CDM 0272 RC inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges TRANSDUCER COVER W\GEL 9001C0197 48713085_1 CDM 0272 RC inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges TRANSDUCER COVER W\GEL 9001C0197 48713085_1 CDM 0272 RC inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 TRANSDUCER COVER W\GEL 9001C0197 48713085_1 CDM 0272 RC inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 TRANSDUCER COVER W\GEL 9001C0197 48713085_1 CDM 0272 RC inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 TRANSDUCER COVER W\GEL 9001C0197 48713085_1 CDM 0272 RC inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges TRANSDUCER COVER W\GEL 9001C0197 48713085_1 CDM 0272 RC inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 TRANSDUCER COVER W\GEL 9001C0197 48713085_1 CDM 0272 RC inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 PROBE GOLD DIRECT 7FR. 300CM 48713086_1 CDM 0272 RC inpatient 994 646.1 AETNA AETNA 785.26 79 999999999 601.87 964.18 percent of total billed charges PROBE GOLD DIRECT 7FR. 300CM 48713086_1 CDM 0272 RC inpatient 994 646.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 646.1 65 999999999 601.87 964.18 percent of total billed charges PROBE GOLD DIRECT 7FR. 300CM 48713086_1 CDM 0272 RC inpatient 994 646.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 964.18 97 999999999 601.87 964.18 percent of total billed charges PROBE GOLD DIRECT 7FR. 300CM 48713086_1 CDM 0272 RC inpatient 994 646.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 685.86 69 999999999 601.87 964.18 percent of total billed charges PROBE GOLD DIRECT 7FR. 300CM 48713086_1 CDM 0272 RC inpatient 994 646.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 775.32 78 999999999 601.87 964.18 percent of total billed charges PROBE GOLD DIRECT 7FR. 300CM 48713086_1 CDM 0272 RC inpatient 994 646.1 SIHO - ALL PLANS SIHO - ALL PLANS 894.6 90 999999999 601.87 964.18 percent of total billed charges PROBE GOLD DIRECT 7FR. 300CM 48713086_1 CDM 0272 RC inpatient 994 646.1 UMR - ALL PLANS UMR - ALL PLANS 695.8 70 999999999 601.87 964.18 percent of total billed charges PROBE GOLD DIRECT 7FR. 300CM 48713086_1 CDM 0272 RC inpatient 994 646.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 601.87 60.55 999999999 601.87 964.18 percent of total billed charges PROBE GOLD DIRECT 7FR. 300CM 48713086_1 CDM 0272 RC inpatient 994 646.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 601.87 964.18 PROBE GOLD DIRECT 7FR. 300CM 48713086_1 CDM 0272 RC inpatient 994 646.1 ANTHEM HMO ANTHEM HMO 999999999 601.87 964.18 PROBE GOLD DIRECT 7FR. 300CM 48713086_1 CDM 0272 RC inpatient 994 646.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 601.87 964.18 PROBE GOLD DIRECT 7FR. 300CM 48713086_1 CDM 0272 RC inpatient 994 646.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 671.94 67.6 999999999 601.87 964.18 percent of total billed charges PROBE GOLD DIRECT 7FR. 300CM 48713086_1 CDM 0272 RC inpatient 994 646.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 601.87 964.18 PROBE GOLD DIRECT 7FR. 300CM 48713086_1 CDM 0272 RC inpatient 994 646.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 601.87 964.18 INFLATION SYRINGE #5060-05 48713087_1 CDM 0272 RC inpatient 222 144.3 AETNA AETNA 175.38 79 999999999 134.42 215.34 percent of total billed charges INFLATION SYRINGE #5060-05 48713087_1 CDM 0272 RC inpatient 222 144.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 144.3 65 999999999 134.42 215.34 percent of total billed charges INFLATION SYRINGE #5060-05 48713087_1 CDM 0272 RC inpatient 222 144.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 215.34 97 999999999 134.42 215.34 percent of total billed charges INFLATION SYRINGE #5060-05 48713087_1 CDM 0272 RC inpatient 222 144.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 153.18 69 999999999 134.42 215.34 percent of total billed charges INFLATION SYRINGE #5060-05 48713087_1 CDM 0272 RC inpatient 222 144.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 173.16 78 999999999 134.42 215.34 percent of total billed charges INFLATION SYRINGE #5060-05 48713087_1 CDM 0272 RC inpatient 222 144.3 SIHO - ALL PLANS SIHO - ALL PLANS 199.8 90 999999999 134.42 215.34 percent of total billed charges INFLATION SYRINGE #5060-05 48713087_1 CDM 0272 RC inpatient 222 144.3 UMR - ALL PLANS UMR - ALL PLANS 155.4 70 999999999 134.42 215.34 percent of total billed charges INFLATION SYRINGE #5060-05 48713087_1 CDM 0272 RC inpatient 222 144.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 134.42 60.55 999999999 134.42 215.34 percent of total billed charges INFLATION SYRINGE #5060-05 48713087_1 CDM 0272 RC inpatient 222 144.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 134.42 215.34 INFLATION SYRINGE #5060-05 48713087_1 CDM 0272 RC inpatient 222 144.3 ANTHEM HMO ANTHEM HMO 999999999 134.42 215.34 INFLATION SYRINGE #5060-05 48713087_1 CDM 0272 RC inpatient 222 144.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 134.42 215.34 INFLATION SYRINGE #5060-05 48713087_1 CDM 0272 RC inpatient 222 144.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 150.07 67.6 999999999 134.42 215.34 percent of total billed charges INFLATION SYRINGE #5060-05 48713087_1 CDM 0272 RC inpatient 222 144.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 134.42 215.34 INFLATION SYRINGE #5060-05 48713087_1 CDM 0272 RC inpatient 222 144.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 134.42 215.34 SYRINGE GLASS 5CC LL LOSS 332155 48713088_1 CDM 0272 RC inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges SYRINGE GLASS 5CC LL LOSS 332155 48713088_1 CDM 0272 RC inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges SYRINGE GLASS 5CC LL LOSS 332155 48713088_1 CDM 0272 RC inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges SYRINGE GLASS 5CC LL LOSS 332155 48713088_1 CDM 0272 RC inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges SYRINGE GLASS 5CC LL LOSS 332155 48713088_1 CDM 0272 RC inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges SYRINGE GLASS 5CC LL LOSS 332155 48713088_1 CDM 0272 RC inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges SYRINGE GLASS 5CC LL LOSS 332155 48713088_1 CDM 0272 RC inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges SYRINGE GLASS 5CC LL LOSS 332155 48713088_1 CDM 0272 RC inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges SYRINGE GLASS 5CC LL LOSS 332155 48713088_1 CDM 0272 RC inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 SYRINGE GLASS 5CC LL LOSS 332155 48713088_1 CDM 0272 RC inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 SYRINGE GLASS 5CC LL LOSS 332155 48713088_1 CDM 0272 RC inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 SYRINGE GLASS 5CC LL LOSS 332155 48713088_1 CDM 0272 RC inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges SYRINGE GLASS 5CC LL LOSS 332155 48713088_1 CDM 0272 RC inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 SYRINGE GLASS 5CC LL LOSS 332155 48713088_1 CDM 0272 RC inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 BRONCH BIOPSY FORCEP 515181 48713089_1 CDM 0272 RC inpatient 286 185.9 AETNA AETNA 225.94 79 999999999 173.17 277.42 percent of total billed charges BRONCH BIOPSY FORCEP 515181 48713089_1 CDM 0272 RC inpatient 286 185.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.9 65 999999999 173.17 277.42 percent of total billed charges BRONCH BIOPSY FORCEP 515181 48713089_1 CDM 0272 RC inpatient 286 185.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 277.42 97 999999999 173.17 277.42 percent of total billed charges BRONCH BIOPSY FORCEP 515181 48713089_1 CDM 0272 RC inpatient 286 185.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 197.34 69 999999999 173.17 277.42 percent of total billed charges BRONCH BIOPSY FORCEP 515181 48713089_1 CDM 0272 RC inpatient 286 185.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 223.08 78 999999999 173.17 277.42 percent of total billed charges BRONCH BIOPSY FORCEP 515181 48713089_1 CDM 0272 RC inpatient 286 185.9 SIHO - ALL PLANS SIHO - ALL PLANS 257.4 90 999999999 173.17 277.42 percent of total billed charges BRONCH BIOPSY FORCEP 515181 48713089_1 CDM 0272 RC inpatient 286 185.9 UMR - ALL PLANS UMR - ALL PLANS 200.2 70 999999999 173.17 277.42 percent of total billed charges BRONCH BIOPSY FORCEP 515181 48713089_1 CDM 0272 RC inpatient 286 185.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 173.17 60.55 999999999 173.17 277.42 percent of total billed charges BRONCH BIOPSY FORCEP 515181 48713089_1 CDM 0272 RC inpatient 286 185.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 173.17 277.42 BRONCH BIOPSY FORCEP 515181 48713089_1 CDM 0272 RC inpatient 286 185.9 ANTHEM HMO ANTHEM HMO 999999999 173.17 277.42 BRONCH BIOPSY FORCEP 515181 48713089_1 CDM 0272 RC inpatient 286 185.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 173.17 277.42 BRONCH BIOPSY FORCEP 515181 48713089_1 CDM 0272 RC inpatient 286 185.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 193.34 67.6 999999999 173.17 277.42 percent of total billed charges BRONCH BIOPSY FORCEP 515181 48713089_1 CDM 0272 RC inpatient 286 185.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 173.17 277.42 BRONCH BIOPSY FORCEP 515181 48713089_1 CDM 0272 RC inpatient 286 185.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 173.17 277.42 PEG 24FR PUSH G TUBE #6825 48713090_1 CDM 0272 RC inpatient 414 269.1 AETNA AETNA 327.06 79 999999999 250.68 401.58 percent of total billed charges PEG 24FR PUSH G TUBE #6825 48713090_1 CDM 0272 RC inpatient 414 269.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 269.1 65 999999999 250.68 401.58 percent of total billed charges PEG 24FR PUSH G TUBE #6825 48713090_1 CDM 0272 RC inpatient 414 269.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 401.58 97 999999999 250.68 401.58 percent of total billed charges PEG 24FR PUSH G TUBE #6825 48713090_1 CDM 0272 RC inpatient 414 269.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 285.66 69 999999999 250.68 401.58 percent of total billed charges PEG 24FR PUSH G TUBE #6825 48713090_1 CDM 0272 RC inpatient 414 269.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 322.92 78 999999999 250.68 401.58 percent of total billed charges PEG 24FR PUSH G TUBE #6825 48713090_1 CDM 0272 RC inpatient 414 269.1 SIHO - ALL PLANS SIHO - ALL PLANS 372.6 90 999999999 250.68 401.58 percent of total billed charges PEG 24FR PUSH G TUBE #6825 48713090_1 CDM 0272 RC inpatient 414 269.1 UMR - ALL PLANS UMR - ALL PLANS 289.8 70 999999999 250.68 401.58 percent of total billed charges PEG 24FR PUSH G TUBE #6825 48713090_1 CDM 0272 RC inpatient 414 269.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 250.68 60.55 999999999 250.68 401.58 percent of total billed charges PEG 24FR PUSH G TUBE #6825 48713090_1 CDM 0272 RC inpatient 414 269.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 250.68 401.58 PEG 24FR PUSH G TUBE #6825 48713090_1 CDM 0272 RC inpatient 414 269.1 ANTHEM HMO ANTHEM HMO 999999999 250.68 401.58 PEG 24FR PUSH G TUBE #6825 48713090_1 CDM 0272 RC inpatient 414 269.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 250.68 401.58 PEG 24FR PUSH G TUBE #6825 48713090_1 CDM 0272 RC inpatient 414 269.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 279.86 67.6 999999999 250.68 401.58 percent of total billed charges PEG 24FR PUSH G TUBE #6825 48713090_1 CDM 0272 RC inpatient 414 269.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 250.68 401.58 PEG 24FR PUSH G TUBE #6825 48713090_1 CDM 0272 RC inpatient 414 269.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 250.68 401.58 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713091_1 CDM 0272 RC C1713 HCPCS inpatient 754 490.1 AETNA AETNA 595.66 79 999999999 456.55 731.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713091_1 CDM 0272 RC C1713 HCPCS inpatient 754 490.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 490.1 65 999999999 456.55 731.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713091_1 CDM 0272 RC C1713 HCPCS inpatient 754 490.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 731.38 97 999999999 456.55 731.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713091_1 CDM 0272 RC C1713 HCPCS inpatient 754 490.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 520.26 69 999999999 456.55 731.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713091_1 CDM 0272 RC C1713 HCPCS inpatient 754 490.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 588.12 78 999999999 456.55 731.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713091_1 CDM 0272 RC C1713 HCPCS inpatient 754 490.1 SIHO - ALL PLANS SIHO - ALL PLANS 678.6 90 999999999 456.55 731.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713091_1 CDM 0272 RC C1713 HCPCS inpatient 754 490.1 UMR - ALL PLANS UMR - ALL PLANS 527.8 70 999999999 456.55 731.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713091_1 CDM 0272 RC C1713 HCPCS inpatient 754 490.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 456.55 60.55 999999999 456.55 731.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713091_1 CDM 0272 RC C1713 HCPCS inpatient 754 490.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 456.55 731.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713091_1 CDM 0272 RC C1713 HCPCS inpatient 754 490.1 ANTHEM HMO ANTHEM HMO 999999999 456.55 731.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713091_1 CDM 0272 RC C1713 HCPCS inpatient 754 490.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 456.55 731.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713091_1 CDM 0272 RC C1713 HCPCS inpatient 754 490.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 509.7 67.6 999999999 456.55 731.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713091_1 CDM 0272 RC C1713 HCPCS inpatient 754 490.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 456.55 731.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713091_1 CDM 0272 RC C1713 HCPCS inpatient 754 490.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 456.55 731.38 AUTOMATIC BIOPSY SYS CA1820 48713092_1 CDM 0272 RC inpatient 518 336.7 AETNA AETNA 409.22 79 999999999 313.65 502.46 percent of total billed charges AUTOMATIC BIOPSY SYS CA1820 48713092_1 CDM 0272 RC inpatient 518 336.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 336.7 65 999999999 313.65 502.46 percent of total billed charges AUTOMATIC BIOPSY SYS CA1820 48713092_1 CDM 0272 RC inpatient 518 336.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 502.46 97 999999999 313.65 502.46 percent of total billed charges AUTOMATIC BIOPSY SYS CA1820 48713092_1 CDM 0272 RC inpatient 518 336.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 357.42 69 999999999 313.65 502.46 percent of total billed charges AUTOMATIC BIOPSY SYS CA1820 48713092_1 CDM 0272 RC inpatient 518 336.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 404.04 78 999999999 313.65 502.46 percent of total billed charges AUTOMATIC BIOPSY SYS CA1820 48713092_1 CDM 0272 RC inpatient 518 336.7 SIHO - ALL PLANS SIHO - ALL PLANS 466.2 90 999999999 313.65 502.46 percent of total billed charges AUTOMATIC BIOPSY SYS CA1820 48713092_1 CDM 0272 RC inpatient 518 336.7 UMR - ALL PLANS UMR - ALL PLANS 362.6 70 999999999 313.65 502.46 percent of total billed charges AUTOMATIC BIOPSY SYS CA1820 48713092_1 CDM 0272 RC inpatient 518 336.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 313.65 60.55 999999999 313.65 502.46 percent of total billed charges AUTOMATIC BIOPSY SYS CA1820 48713092_1 CDM 0272 RC inpatient 518 336.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 313.65 502.46 AUTOMATIC BIOPSY SYS CA1820 48713092_1 CDM 0272 RC inpatient 518 336.7 ANTHEM HMO ANTHEM HMO 999999999 313.65 502.46 AUTOMATIC BIOPSY SYS CA1820 48713092_1 CDM 0272 RC inpatient 518 336.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 313.65 502.46 AUTOMATIC BIOPSY SYS CA1820 48713092_1 CDM 0272 RC inpatient 518 336.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 350.17 67.6 999999999 313.65 502.46 percent of total billed charges AUTOMATIC BIOPSY SYS CA1820 48713092_1 CDM 0272 RC inpatient 518 336.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 313.65 502.46 AUTOMATIC BIOPSY SYS CA1820 48713092_1 CDM 0272 RC inpatient 518 336.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 313.65 502.46 PROBE GOLD DIRECT 7FR 350CM 48713093_1 CDM 0272 RC inpatient 971 631.15 AETNA AETNA 767.09 79 999999999 587.94 941.87 percent of total billed charges PROBE GOLD DIRECT 7FR 350CM 48713093_1 CDM 0272 RC inpatient 971 631.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 631.15 65 999999999 587.94 941.87 percent of total billed charges PROBE GOLD DIRECT 7FR 350CM 48713093_1 CDM 0272 RC inpatient 971 631.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 941.87 97 999999999 587.94 941.87 percent of total billed charges PROBE GOLD DIRECT 7FR 350CM 48713093_1 CDM 0272 RC inpatient 971 631.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 669.99 69 999999999 587.94 941.87 percent of total billed charges PROBE GOLD DIRECT 7FR 350CM 48713093_1 CDM 0272 RC inpatient 971 631.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 757.38 78 999999999 587.94 941.87 percent of total billed charges PROBE GOLD DIRECT 7FR 350CM 48713093_1 CDM 0272 RC inpatient 971 631.15 SIHO - ALL PLANS SIHO - ALL PLANS 873.9 90 999999999 587.94 941.87 percent of total billed charges PROBE GOLD DIRECT 7FR 350CM 48713093_1 CDM 0272 RC inpatient 971 631.15 UMR - ALL PLANS UMR - ALL PLANS 679.7 70 999999999 587.94 941.87 percent of total billed charges PROBE GOLD DIRECT 7FR 350CM 48713093_1 CDM 0272 RC inpatient 971 631.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 587.94 60.55 999999999 587.94 941.87 percent of total billed charges PROBE GOLD DIRECT 7FR 350CM 48713093_1 CDM 0272 RC inpatient 971 631.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 587.94 941.87 PROBE GOLD DIRECT 7FR 350CM 48713093_1 CDM 0272 RC inpatient 971 631.15 ANTHEM HMO ANTHEM HMO 999999999 587.94 941.87 PROBE GOLD DIRECT 7FR 350CM 48713093_1 CDM 0272 RC inpatient 971 631.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 587.94 941.87 PROBE GOLD DIRECT 7FR 350CM 48713093_1 CDM 0272 RC inpatient 971 631.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 656.4 67.6 999999999 587.94 941.87 percent of total billed charges PROBE GOLD DIRECT 7FR 350CM 48713093_1 CDM 0272 RC inpatient 971 631.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 587.94 941.87 PROBE GOLD DIRECT 7FR 350CM 48713093_1 CDM 0272 RC inpatient 971 631.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 587.94 941.87 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713094_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 AETNA AETNA 404.48 79 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713094_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 332.8 65 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713094_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 496.64 97 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713094_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 353.28 69 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713094_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 399.36 78 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713094_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 SIHO - ALL PLANS SIHO - ALL PLANS 460.8 90 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713094_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 UMR - ALL PLANS UMR - ALL PLANS 358.4 70 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713094_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 310.02 60.55 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713094_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713094_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM HMO ANTHEM HMO 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713094_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713094_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 346.11 67.6 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713094_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713094_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713095_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 AETNA AETNA 404.48 79 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713095_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 332.8 65 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713095_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 496.64 97 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713095_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 353.28 69 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713095_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 399.36 78 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713095_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 SIHO - ALL PLANS SIHO - ALL PLANS 460.8 90 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713095_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 UMR - ALL PLANS UMR - ALL PLANS 358.4 70 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713095_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 310.02 60.55 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713095_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713095_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM HMO ANTHEM HMO 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713095_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713095_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 346.11 67.6 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713095_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713095_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713096_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 AETNA AETNA 380.78 79 999999999 291.85 467.54 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713096_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 313.3 65 999999999 291.85 467.54 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713096_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 467.54 97 999999999 291.85 467.54 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713096_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 332.58 69 999999999 291.85 467.54 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713096_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 375.96 78 999999999 291.85 467.54 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713096_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 SIHO - ALL PLANS SIHO - ALL PLANS 433.8 90 999999999 291.85 467.54 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713096_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 UMR - ALL PLANS UMR - ALL PLANS 337.4 70 999999999 291.85 467.54 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713096_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 291.85 60.55 999999999 291.85 467.54 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713096_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 291.85 467.54 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713096_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 ANTHEM HMO ANTHEM HMO 999999999 291.85 467.54 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713096_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 291.85 467.54 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713096_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 325.83 67.6 999999999 291.85 467.54 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713096_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 291.85 467.54 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713096_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 291.85 467.54 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713097_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 AETNA AETNA 404.48 79 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713097_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 332.8 65 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713097_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 496.64 97 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713097_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 353.28 69 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713097_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 399.36 78 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713097_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 SIHO - ALL PLANS SIHO - ALL PLANS 460.8 90 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713097_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 UMR - ALL PLANS UMR - ALL PLANS 358.4 70 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713097_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 310.02 60.55 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713097_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713097_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM HMO ANTHEM HMO 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713097_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713097_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 346.11 67.6 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713097_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713097_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713098_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 AETNA AETNA 404.48 79 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713098_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 332.8 65 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713098_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 496.64 97 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713098_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 353.28 69 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713098_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 399.36 78 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713098_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 SIHO - ALL PLANS SIHO - ALL PLANS 460.8 90 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713098_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 UMR - ALL PLANS UMR - ALL PLANS 358.4 70 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713098_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 310.02 60.55 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713098_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713098_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM HMO ANTHEM HMO 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713098_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713098_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 346.11 67.6 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713098_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713098_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713099_1 CDM 0272 RC C2617 HCPCS inpatient 841 546.65 AETNA AETNA 664.39 79 999999999 509.23 815.77 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713099_1 CDM 0272 RC C2617 HCPCS inpatient 841 546.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 546.65 65 999999999 509.23 815.77 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713099_1 CDM 0272 RC C2617 HCPCS inpatient 841 546.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 815.77 97 999999999 509.23 815.77 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713099_1 CDM 0272 RC C2617 HCPCS inpatient 841 546.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 580.29 69 999999999 509.23 815.77 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713099_1 CDM 0272 RC C2617 HCPCS inpatient 841 546.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 655.98 78 999999999 509.23 815.77 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713099_1 CDM 0272 RC C2617 HCPCS inpatient 841 546.65 SIHO - ALL PLANS SIHO - ALL PLANS 756.9 90 999999999 509.23 815.77 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713099_1 CDM 0272 RC C2617 HCPCS inpatient 841 546.65 UMR - ALL PLANS UMR - ALL PLANS 588.7 70 999999999 509.23 815.77 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713099_1 CDM 0272 RC C2617 HCPCS inpatient 841 546.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 509.23 60.55 999999999 509.23 815.77 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713099_1 CDM 0272 RC C2617 HCPCS inpatient 841 546.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 509.23 815.77 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713099_1 CDM 0272 RC C2617 HCPCS inpatient 841 546.65 ANTHEM HMO ANTHEM HMO 999999999 509.23 815.77 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713099_1 CDM 0272 RC C2617 HCPCS inpatient 841 546.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 509.23 815.77 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713099_1 CDM 0272 RC C2617 HCPCS inpatient 841 546.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 568.52 67.6 999999999 509.23 815.77 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713099_1 CDM 0272 RC C2617 HCPCS inpatient 841 546.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 509.23 815.77 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713099_1 CDM 0272 RC C2617 HCPCS inpatient 841 546.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 509.23 815.77 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713100_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 AETNA AETNA 404.48 79 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713100_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 332.8 65 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713100_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 496.64 97 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713100_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 353.28 69 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713100_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 399.36 78 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713100_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 SIHO - ALL PLANS SIHO - ALL PLANS 460.8 90 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713100_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 UMR - ALL PLANS UMR - ALL PLANS 358.4 70 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713100_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 310.02 60.55 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713100_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713100_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM HMO ANTHEM HMO 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713100_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713100_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 346.11 67.6 999999999 310.02 496.64 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713100_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713100_1 CDM 0272 RC C2617 HCPCS inpatient 512 332.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 310.02 496.64 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713101_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 AETNA AETNA 380.78 79 999999999 291.85 467.54 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713101_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 313.3 65 999999999 291.85 467.54 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713101_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 467.54 97 999999999 291.85 467.54 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713101_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 332.58 69 999999999 291.85 467.54 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713101_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 375.96 78 999999999 291.85 467.54 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713101_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 SIHO - ALL PLANS SIHO - ALL PLANS 433.8 90 999999999 291.85 467.54 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713101_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 UMR - ALL PLANS UMR - ALL PLANS 337.4 70 999999999 291.85 467.54 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713101_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 291.85 60.55 999999999 291.85 467.54 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713101_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 291.85 467.54 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713101_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 ANTHEM HMO ANTHEM HMO 999999999 291.85 467.54 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713101_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 291.85 467.54 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713101_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 325.83 67.6 999999999 291.85 467.54 percent of total billed charges "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713101_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 291.85 467.54 "STENT, NON-CORONARY, TEMPORARY, WITHOUT DELIVERY SYSTEM" 48713101_1 CDM 0272 RC C2617 HCPCS inpatient 482 313.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 291.85 467.54 PIGTAIL CATHETER 4 FR G13771 48713102_1 CDM 0278 RC inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges PIGTAIL CATHETER 4 FR G13771 48713102_1 CDM 0278 RC inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges PIGTAIL CATHETER 4 FR G13771 48713102_1 CDM 0278 RC inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges PIGTAIL CATHETER 4 FR G13771 48713102_1 CDM 0278 RC inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges PIGTAIL CATHETER 4 FR G13771 48713102_1 CDM 0278 RC inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges PIGTAIL CATHETER 4 FR G13771 48713102_1 CDM 0278 RC inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges PIGTAIL CATHETER 4 FR G13771 48713102_1 CDM 0278 RC inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges PIGTAIL CATHETER 4 FR G13771 48713102_1 CDM 0278 RC inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges PIGTAIL CATHETER 4 FR G13771 48713102_1 CDM 0278 RC inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 PIGTAIL CATHETER 4 FR G13771 48713102_1 CDM 0278 RC inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 PIGTAIL CATHETER 4 FR G13771 48713102_1 CDM 0278 RC inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 PIGTAIL CATHETER 4 FR G13771 48713102_1 CDM 0278 RC inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges PIGTAIL CATHETER 4 FR G13771 48713102_1 CDM 0278 RC inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 PIGTAIL CATHETER 4 FR G13771 48713102_1 CDM 0278 RC inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 SAW RASPS CROSS CUT LG ZR083 48713103_1 CDM 0272 RC inpatient 286 185.9 AETNA AETNA 225.94 79 999999999 173.17 277.42 percent of total billed charges SAW RASPS CROSS CUT LG ZR083 48713103_1 CDM 0272 RC inpatient 286 185.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.9 65 999999999 173.17 277.42 percent of total billed charges SAW RASPS CROSS CUT LG ZR083 48713103_1 CDM 0272 RC inpatient 286 185.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 277.42 97 999999999 173.17 277.42 percent of total billed charges SAW RASPS CROSS CUT LG ZR083 48713103_1 CDM 0272 RC inpatient 286 185.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 197.34 69 999999999 173.17 277.42 percent of total billed charges SAW RASPS CROSS CUT LG ZR083 48713103_1 CDM 0272 RC inpatient 286 185.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 223.08 78 999999999 173.17 277.42 percent of total billed charges SAW RASPS CROSS CUT LG ZR083 48713103_1 CDM 0272 RC inpatient 286 185.9 SIHO - ALL PLANS SIHO - ALL PLANS 257.4 90 999999999 173.17 277.42 percent of total billed charges SAW RASPS CROSS CUT LG ZR083 48713103_1 CDM 0272 RC inpatient 286 185.9 UMR - ALL PLANS UMR - ALL PLANS 200.2 70 999999999 173.17 277.42 percent of total billed charges SAW RASPS CROSS CUT LG ZR083 48713103_1 CDM 0272 RC inpatient 286 185.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 173.17 60.55 999999999 173.17 277.42 percent of total billed charges SAW RASPS CROSS CUT LG ZR083 48713103_1 CDM 0272 RC inpatient 286 185.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 173.17 277.42 SAW RASPS CROSS CUT LG ZR083 48713103_1 CDM 0272 RC inpatient 286 185.9 ANTHEM HMO ANTHEM HMO 999999999 173.17 277.42 SAW RASPS CROSS CUT LG ZR083 48713103_1 CDM 0272 RC inpatient 286 185.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 173.17 277.42 SAW RASPS CROSS CUT LG ZR083 48713103_1 CDM 0272 RC inpatient 286 185.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 193.34 67.6 999999999 173.17 277.42 percent of total billed charges SAW RASPS CROSS CUT LG ZR083 48713103_1 CDM 0272 RC inpatient 286 185.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 173.17 277.42 SAW RASPS CROSS CUT LG ZR083 48713103_1 CDM 0272 RC inpatient 286 185.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 173.17 277.42 SAW RASPS STR- CUT LG ZR081 48713104_1 CDM 0272 RC inpatient 303 196.95 AETNA AETNA 239.37 79 999999999 183.47 293.91 percent of total billed charges SAW RASPS STR- CUT LG ZR081 48713104_1 CDM 0272 RC inpatient 303 196.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 196.95 65 999999999 183.47 293.91 percent of total billed charges SAW RASPS STR- CUT LG ZR081 48713104_1 CDM 0272 RC inpatient 303 196.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 293.91 97 999999999 183.47 293.91 percent of total billed charges SAW RASPS STR- CUT LG ZR081 48713104_1 CDM 0272 RC inpatient 303 196.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 209.07 69 999999999 183.47 293.91 percent of total billed charges SAW RASPS STR- CUT LG ZR081 48713104_1 CDM 0272 RC inpatient 303 196.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 236.34 78 999999999 183.47 293.91 percent of total billed charges SAW RASPS STR- CUT LG ZR081 48713104_1 CDM 0272 RC inpatient 303 196.95 SIHO - ALL PLANS SIHO - ALL PLANS 272.7 90 999999999 183.47 293.91 percent of total billed charges SAW RASPS STR- CUT LG ZR081 48713104_1 CDM 0272 RC inpatient 303 196.95 UMR - ALL PLANS UMR - ALL PLANS 212.1 70 999999999 183.47 293.91 percent of total billed charges SAW RASPS STR- CUT LG ZR081 48713104_1 CDM 0272 RC inpatient 303 196.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 183.47 60.55 999999999 183.47 293.91 percent of total billed charges SAW RASPS STR- CUT LG ZR081 48713104_1 CDM 0272 RC inpatient 303 196.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 183.47 293.91 SAW RASPS STR- CUT LG ZR081 48713104_1 CDM 0272 RC inpatient 303 196.95 ANTHEM HMO ANTHEM HMO 999999999 183.47 293.91 SAW RASPS STR- CUT LG ZR081 48713104_1 CDM 0272 RC inpatient 303 196.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 183.47 293.91 SAW RASPS STR- CUT LG ZR081 48713104_1 CDM 0272 RC inpatient 303 196.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 204.83 67.6 999999999 183.47 293.91 percent of total billed charges SAW RASPS STR- CUT LG ZR081 48713104_1 CDM 0272 RC inpatient 303 196.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 183.47 293.91 SAW RASPS STR- CUT LG ZR081 48713104_1 CDM 0272 RC inpatient 303 196.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 183.47 293.91 PTFE FELT PLEDGET 0007973 48713105_1 CDM 0272 RC inpatient 370 240.5 AETNA AETNA 292.3 79 999999999 224.04 358.9 percent of total billed charges PTFE FELT PLEDGET 0007973 48713105_1 CDM 0272 RC inpatient 370 240.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 240.5 65 999999999 224.04 358.9 percent of total billed charges PTFE FELT PLEDGET 0007973 48713105_1 CDM 0272 RC inpatient 370 240.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 358.9 97 999999999 224.04 358.9 percent of total billed charges PTFE FELT PLEDGET 0007973 48713105_1 CDM 0272 RC inpatient 370 240.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 255.3 69 999999999 224.04 358.9 percent of total billed charges PTFE FELT PLEDGET 0007973 48713105_1 CDM 0272 RC inpatient 370 240.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 288.6 78 999999999 224.04 358.9 percent of total billed charges PTFE FELT PLEDGET 0007973 48713105_1 CDM 0272 RC inpatient 370 240.5 SIHO - ALL PLANS SIHO - ALL PLANS 333 90 999999999 224.04 358.9 percent of total billed charges PTFE FELT PLEDGET 0007973 48713105_1 CDM 0272 RC inpatient 370 240.5 UMR - ALL PLANS UMR - ALL PLANS 259 70 999999999 224.04 358.9 percent of total billed charges PTFE FELT PLEDGET 0007973 48713105_1 CDM 0272 RC inpatient 370 240.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 224.04 60.55 999999999 224.04 358.9 percent of total billed charges PTFE FELT PLEDGET 0007973 48713105_1 CDM 0272 RC inpatient 370 240.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 224.04 358.9 PTFE FELT PLEDGET 0007973 48713105_1 CDM 0272 RC inpatient 370 240.5 ANTHEM HMO ANTHEM HMO 999999999 224.04 358.9 PTFE FELT PLEDGET 0007973 48713105_1 CDM 0272 RC inpatient 370 240.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 224.04 358.9 PTFE FELT PLEDGET 0007973 48713105_1 CDM 0272 RC inpatient 370 240.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 250.12 67.6 999999999 224.04 358.9 percent of total billed charges PTFE FELT PLEDGET 0007973 48713105_1 CDM 0272 RC inpatient 370 240.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 224.04 358.9 PTFE FELT PLEDGET 0007973 48713105_1 CDM 0272 RC inpatient 370 240.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 224.04 358.9 CONDYLAR PLATE 7H RT 446.64.96 48713106_1 CDM 0278 RC inpatient 1248 811.2 AETNA AETNA 985.92 79 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H RT 446.64.96 48713106_1 CDM 0278 RC inpatient 1248 811.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 811.2 65 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H RT 446.64.96 48713106_1 CDM 0278 RC inpatient 1248 811.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1210.56 97 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H RT 446.64.96 48713106_1 CDM 0278 RC inpatient 1248 811.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 861.12 69 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H RT 446.64.96 48713106_1 CDM 0278 RC inpatient 1248 811.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 973.44 78 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H RT 446.64.96 48713106_1 CDM 0278 RC inpatient 1248 811.2 SIHO - ALL PLANS SIHO - ALL PLANS 1123.2 90 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H RT 446.64.96 48713106_1 CDM 0278 RC inpatient 1248 811.2 UMR - ALL PLANS UMR - ALL PLANS 873.6 70 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H RT 446.64.96 48713106_1 CDM 0278 RC inpatient 1248 811.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 755.66 60.55 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H RT 446.64.96 48713106_1 CDM 0278 RC inpatient 1248 811.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 755.66 1210.56 CONDYLAR PLATE 7H RT 446.64.96 48713106_1 CDM 0278 RC inpatient 1248 811.2 ANTHEM HMO ANTHEM HMO 999999999 755.66 1210.56 CONDYLAR PLATE 7H RT 446.64.96 48713106_1 CDM 0278 RC inpatient 1248 811.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 755.66 1210.56 CONDYLAR PLATE 7H RT 446.64.96 48713106_1 CDM 0278 RC inpatient 1248 811.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 843.65 67.6 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H RT 446.64.96 48713106_1 CDM 0278 RC inpatient 1248 811.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 755.66 1210.56 CONDYLAR PLATE 7H RT 446.64.96 48713106_1 CDM 0278 RC inpatient 1248 811.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 755.66 1210.56 DISCONTINUED PER MEGAN PALMER AQUILEX TUBESET AQL-112 STICKER 110 48713107_1 CDM 0272 RC inpatient 670 435.5 AETNA AETNA 529.3 79 999999999 405.69 649.9 percent of total billed charges DISCONTINUED PER MEGAN PALMER AQUILEX TUBESET AQL-112 STICKER 110 48713107_1 CDM 0272 RC inpatient 670 435.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 435.5 65 999999999 405.69 649.9 percent of total billed charges DISCONTINUED PER MEGAN PALMER AQUILEX TUBESET AQL-112 STICKER 110 48713107_1 CDM 0272 RC inpatient 670 435.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 649.9 97 999999999 405.69 649.9 percent of total billed charges DISCONTINUED PER MEGAN PALMER AQUILEX TUBESET AQL-112 STICKER 110 48713107_1 CDM 0272 RC inpatient 670 435.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 462.3 69 999999999 405.69 649.9 percent of total billed charges DISCONTINUED PER MEGAN PALMER AQUILEX TUBESET AQL-112 STICKER 110 48713107_1 CDM 0272 RC inpatient 670 435.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 522.6 78 999999999 405.69 649.9 percent of total billed charges DISCONTINUED PER MEGAN PALMER AQUILEX TUBESET AQL-112 STICKER 110 48713107_1 CDM 0272 RC inpatient 670 435.5 SIHO - ALL PLANS SIHO - ALL PLANS 603 90 999999999 405.69 649.9 percent of total billed charges DISCONTINUED PER MEGAN PALMER AQUILEX TUBESET AQL-112 STICKER 110 48713107_1 CDM 0272 RC inpatient 670 435.5 UMR - ALL PLANS UMR - ALL PLANS 469 70 999999999 405.69 649.9 percent of total billed charges DISCONTINUED PER MEGAN PALMER AQUILEX TUBESET AQL-112 STICKER 110 48713107_1 CDM 0272 RC inpatient 670 435.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 405.69 60.55 999999999 405.69 649.9 percent of total billed charges DISCONTINUED PER MEGAN PALMER AQUILEX TUBESET AQL-112 STICKER 110 48713107_1 CDM 0272 RC inpatient 670 435.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 405.69 649.9 DISCONTINUED PER MEGAN PALMER AQUILEX TUBESET AQL-112 STICKER 110 48713107_1 CDM 0272 RC inpatient 670 435.5 ANTHEM HMO ANTHEM HMO 999999999 405.69 649.9 DISCONTINUED PER MEGAN PALMER AQUILEX TUBESET AQL-112 STICKER 110 48713107_1 CDM 0272 RC inpatient 670 435.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 405.69 649.9 DISCONTINUED PER MEGAN PALMER AQUILEX TUBESET AQL-112 STICKER 110 48713107_1 CDM 0272 RC inpatient 670 435.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 452.92 67.6 999999999 405.69 649.9 percent of total billed charges DISCONTINUED PER MEGAN PALMER AQUILEX TUBESET AQL-112 STICKER 110 48713107_1 CDM 0272 RC inpatient 670 435.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 405.69 649.9 DISCONTINUED PER MEGAN PALMER AQUILEX TUBESET AQL-112 STICKER 110 48713107_1 CDM 0272 RC inpatient 670 435.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 405.69 649.9 CONDYLAR PLATE 7H LT 446.63.96 48713108_1 CDM 0278 RC inpatient 1248 811.2 AETNA AETNA 985.92 79 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H LT 446.63.96 48713108_1 CDM 0278 RC inpatient 1248 811.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 811.2 65 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H LT 446.63.96 48713108_1 CDM 0278 RC inpatient 1248 811.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1210.56 97 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H LT 446.63.96 48713108_1 CDM 0278 RC inpatient 1248 811.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 861.12 69 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H LT 446.63.96 48713108_1 CDM 0278 RC inpatient 1248 811.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 973.44 78 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H LT 446.63.96 48713108_1 CDM 0278 RC inpatient 1248 811.2 SIHO - ALL PLANS SIHO - ALL PLANS 1123.2 90 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H LT 446.63.96 48713108_1 CDM 0278 RC inpatient 1248 811.2 UMR - ALL PLANS UMR - ALL PLANS 873.6 70 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H LT 446.63.96 48713108_1 CDM 0278 RC inpatient 1248 811.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 755.66 60.55 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H LT 446.63.96 48713108_1 CDM 0278 RC inpatient 1248 811.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 755.66 1210.56 CONDYLAR PLATE 7H LT 446.63.96 48713108_1 CDM 0278 RC inpatient 1248 811.2 ANTHEM HMO ANTHEM HMO 999999999 755.66 1210.56 CONDYLAR PLATE 7H LT 446.63.96 48713108_1 CDM 0278 RC inpatient 1248 811.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 755.66 1210.56 CONDYLAR PLATE 7H LT 446.63.96 48713108_1 CDM 0278 RC inpatient 1248 811.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 843.65 67.6 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H LT 446.63.96 48713108_1 CDM 0278 RC inpatient 1248 811.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 755.66 1210.56 CONDYLAR PLATE 7H LT 446.63.96 48713108_1 CDM 0278 RC inpatient 1248 811.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 755.66 1210.56 T-PLATE 1.5MM 3\H 446.233 48713109_1 CDM 0278 RC inpatient 1592 1034.8 AETNA AETNA 1257.68 79 999999999 963.96 1544.24 percent of total billed charges T-PLATE 1.5MM 3\H 446.233 48713109_1 CDM 0278 RC inpatient 1592 1034.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1034.8 65 999999999 963.96 1544.24 percent of total billed charges T-PLATE 1.5MM 3\H 446.233 48713109_1 CDM 0278 RC inpatient 1592 1034.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1544.24 97 999999999 963.96 1544.24 percent of total billed charges T-PLATE 1.5MM 3\H 446.233 48713109_1 CDM 0278 RC inpatient 1592 1034.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1098.48 69 999999999 963.96 1544.24 percent of total billed charges T-PLATE 1.5MM 3\H 446.233 48713109_1 CDM 0278 RC inpatient 1592 1034.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1241.76 78 999999999 963.96 1544.24 percent of total billed charges T-PLATE 1.5MM 3\H 446.233 48713109_1 CDM 0278 RC inpatient 1592 1034.8 SIHO - ALL PLANS SIHO - ALL PLANS 1432.8 90 999999999 963.96 1544.24 percent of total billed charges T-PLATE 1.5MM 3\H 446.233 48713109_1 CDM 0278 RC inpatient 1592 1034.8 UMR - ALL PLANS UMR - ALL PLANS 1114.4 70 999999999 963.96 1544.24 percent of total billed charges T-PLATE 1.5MM 3\H 446.233 48713109_1 CDM 0278 RC inpatient 1592 1034.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 963.96 60.55 999999999 963.96 1544.24 percent of total billed charges T-PLATE 1.5MM 3\H 446.233 48713109_1 CDM 0278 RC inpatient 1592 1034.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 963.96 1544.24 T-PLATE 1.5MM 3\H 446.233 48713109_1 CDM 0278 RC inpatient 1592 1034.8 ANTHEM HMO ANTHEM HMO 999999999 963.96 1544.24 T-PLATE 1.5MM 3\H 446.233 48713109_1 CDM 0278 RC inpatient 1592 1034.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 963.96 1544.24 T-PLATE 1.5MM 3\H 446.233 48713109_1 CDM 0278 RC inpatient 1592 1034.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1076.19 67.6 999999999 963.96 1544.24 percent of total billed charges T-PLATE 1.5MM 3\H 446.233 48713109_1 CDM 0278 RC inpatient 1592 1034.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 963.96 1544.24 T-PLATE 1.5MM 3\H 446.233 48713109_1 CDM 0278 RC inpatient 1592 1034.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 963.96 1544.24 T-PLATE 3.5 3H 50M RT 241.131 48713110_1 CDM 0278 RC inpatient 1935 1257.75 AETNA AETNA 1528.65 79 999999999 1171.64 1876.95 percent of total billed charges T-PLATE 3.5 3H 50M RT 241.131 48713110_1 CDM 0278 RC inpatient 1935 1257.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1257.75 65 999999999 1171.64 1876.95 percent of total billed charges T-PLATE 3.5 3H 50M RT 241.131 48713110_1 CDM 0278 RC inpatient 1935 1257.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1876.95 97 999999999 1171.64 1876.95 percent of total billed charges T-PLATE 3.5 3H 50M RT 241.131 48713110_1 CDM 0278 RC inpatient 1935 1257.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1335.15 69 999999999 1171.64 1876.95 percent of total billed charges T-PLATE 3.5 3H 50M RT 241.131 48713110_1 CDM 0278 RC inpatient 1935 1257.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1509.3 78 999999999 1171.64 1876.95 percent of total billed charges T-PLATE 3.5 3H 50M RT 241.131 48713110_1 CDM 0278 RC inpatient 1935 1257.75 SIHO - ALL PLANS SIHO - ALL PLANS 1741.5 90 999999999 1171.64 1876.95 percent of total billed charges T-PLATE 3.5 3H 50M RT 241.131 48713110_1 CDM 0278 RC inpatient 1935 1257.75 UMR - ALL PLANS UMR - ALL PLANS 1354.5 70 999999999 1171.64 1876.95 percent of total billed charges T-PLATE 3.5 3H 50M RT 241.131 48713110_1 CDM 0278 RC inpatient 1935 1257.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1171.64 60.55 999999999 1171.64 1876.95 percent of total billed charges T-PLATE 3.5 3H 50M RT 241.131 48713110_1 CDM 0278 RC inpatient 1935 1257.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1171.64 1876.95 T-PLATE 3.5 3H 50M RT 241.131 48713110_1 CDM 0278 RC inpatient 1935 1257.75 ANTHEM HMO ANTHEM HMO 999999999 1171.64 1876.95 T-PLATE 3.5 3H 50M RT 241.131 48713110_1 CDM 0278 RC inpatient 1935 1257.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1171.64 1876.95 T-PLATE 3.5 3H 50M RT 241.131 48713110_1 CDM 0278 RC inpatient 1935 1257.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1308.06 67.6 999999999 1171.64 1876.95 percent of total billed charges T-PLATE 3.5 3H 50M RT 241.131 48713110_1 CDM 0278 RC inpatient 1935 1257.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1171.64 1876.95 T-PLATE 3.5 3H 50M RT 241.131 48713110_1 CDM 0278 RC inpatient 1935 1257.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1171.64 1876.95 T-PLATE 3.5 5H 67M RT 241.151 48713111_1 CDM 0278 RC inpatient 2459 1598.35 AETNA AETNA 1942.61 79 999999999 1488.92 2385.23 percent of total billed charges T-PLATE 3.5 5H 67M RT 241.151 48713111_1 CDM 0278 RC inpatient 2459 1598.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1598.35 65 999999999 1488.92 2385.23 percent of total billed charges T-PLATE 3.5 5H 67M RT 241.151 48713111_1 CDM 0278 RC inpatient 2459 1598.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2385.23 97 999999999 1488.92 2385.23 percent of total billed charges T-PLATE 3.5 5H 67M RT 241.151 48713111_1 CDM 0278 RC inpatient 2459 1598.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1696.71 69 999999999 1488.92 2385.23 percent of total billed charges T-PLATE 3.5 5H 67M RT 241.151 48713111_1 CDM 0278 RC inpatient 2459 1598.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1918.02 78 999999999 1488.92 2385.23 percent of total billed charges T-PLATE 3.5 5H 67M RT 241.151 48713111_1 CDM 0278 RC inpatient 2459 1598.35 SIHO - ALL PLANS SIHO - ALL PLANS 2213.1 90 999999999 1488.92 2385.23 percent of total billed charges T-PLATE 3.5 5H 67M RT 241.151 48713111_1 CDM 0278 RC inpatient 2459 1598.35 UMR - ALL PLANS UMR - ALL PLANS 1721.3 70 999999999 1488.92 2385.23 percent of total billed charges T-PLATE 3.5 5H 67M RT 241.151 48713111_1 CDM 0278 RC inpatient 2459 1598.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1488.92 60.55 999999999 1488.92 2385.23 percent of total billed charges T-PLATE 3.5 5H 67M RT 241.151 48713111_1 CDM 0278 RC inpatient 2459 1598.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1488.92 2385.23 T-PLATE 3.5 5H 67M RT 241.151 48713111_1 CDM 0278 RC inpatient 2459 1598.35 ANTHEM HMO ANTHEM HMO 999999999 1488.92 2385.23 T-PLATE 3.5 5H 67M RT 241.151 48713111_1 CDM 0278 RC inpatient 2459 1598.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1488.92 2385.23 T-PLATE 3.5 5H 67M RT 241.151 48713111_1 CDM 0278 RC inpatient 2459 1598.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1662.28 67.6 999999999 1488.92 2385.23 percent of total billed charges T-PLATE 3.5 5H 67M RT 241.151 48713111_1 CDM 0278 RC inpatient 2459 1598.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1488.92 2385.23 T-PLATE 3.5 5H 67M RT 241.151 48713111_1 CDM 0278 RC inpatient 2459 1598.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1488.92 2385.23 T-PLATE 3.5 3H 87M RT 241.171 48713112_1 CDM 0278 RC inpatient 2873 1867.45 AETNA AETNA 2269.67 79 999999999 1739.6 2786.81 percent of total billed charges T-PLATE 3.5 3H 87M RT 241.171 48713112_1 CDM 0278 RC inpatient 2873 1867.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1867.45 65 999999999 1739.6 2786.81 percent of total billed charges T-PLATE 3.5 3H 87M RT 241.171 48713112_1 CDM 0278 RC inpatient 2873 1867.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2786.81 97 999999999 1739.6 2786.81 percent of total billed charges T-PLATE 3.5 3H 87M RT 241.171 48713112_1 CDM 0278 RC inpatient 2873 1867.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1982.37 69 999999999 1739.6 2786.81 percent of total billed charges T-PLATE 3.5 3H 87M RT 241.171 48713112_1 CDM 0278 RC inpatient 2873 1867.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 2240.94 78 999999999 1739.6 2786.81 percent of total billed charges T-PLATE 3.5 3H 87M RT 241.171 48713112_1 CDM 0278 RC inpatient 2873 1867.45 SIHO - ALL PLANS SIHO - ALL PLANS 2585.7 90 999999999 1739.6 2786.81 percent of total billed charges T-PLATE 3.5 3H 87M RT 241.171 48713112_1 CDM 0278 RC inpatient 2873 1867.45 UMR - ALL PLANS UMR - ALL PLANS 2011.1 70 999999999 1739.6 2786.81 percent of total billed charges T-PLATE 3.5 3H 87M RT 241.171 48713112_1 CDM 0278 RC inpatient 2873 1867.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1739.6 60.55 999999999 1739.6 2786.81 percent of total billed charges T-PLATE 3.5 3H 87M RT 241.171 48713112_1 CDM 0278 RC inpatient 2873 1867.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1739.6 2786.81 T-PLATE 3.5 3H 87M RT 241.171 48713112_1 CDM 0278 RC inpatient 2873 1867.45 ANTHEM HMO ANTHEM HMO 999999999 1739.6 2786.81 T-PLATE 3.5 3H 87M RT 241.171 48713112_1 CDM 0278 RC inpatient 2873 1867.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1739.6 2786.81 T-PLATE 3.5 3H 87M RT 241.171 48713112_1 CDM 0278 RC inpatient 2873 1867.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1942.15 67.6 999999999 1739.6 2786.81 percent of total billed charges T-PLATE 3.5 3H 87M RT 241.171 48713112_1 CDM 0278 RC inpatient 2873 1867.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1739.6 2786.81 T-PLATE 3.5 3H 87M RT 241.171 48713112_1 CDM 0278 RC inpatient 2873 1867.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1739.6 2786.81 T-PLATE 3.5 4H 56M RT 241.141 48713113_1 CDM 0278 RC inpatient 2011 1307.15 AETNA AETNA 1588.69 79 999999999 1217.66 1950.67 percent of total billed charges T-PLATE 3.5 4H 56M RT 241.141 48713113_1 CDM 0278 RC inpatient 2011 1307.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1307.15 65 999999999 1217.66 1950.67 percent of total billed charges T-PLATE 3.5 4H 56M RT 241.141 48713113_1 CDM 0278 RC inpatient 2011 1307.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1950.67 97 999999999 1217.66 1950.67 percent of total billed charges T-PLATE 3.5 4H 56M RT 241.141 48713113_1 CDM 0278 RC inpatient 2011 1307.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1387.59 69 999999999 1217.66 1950.67 percent of total billed charges T-PLATE 3.5 4H 56M RT 241.141 48713113_1 CDM 0278 RC inpatient 2011 1307.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1568.58 78 999999999 1217.66 1950.67 percent of total billed charges T-PLATE 3.5 4H 56M RT 241.141 48713113_1 CDM 0278 RC inpatient 2011 1307.15 SIHO - ALL PLANS SIHO - ALL PLANS 1809.9 90 999999999 1217.66 1950.67 percent of total billed charges T-PLATE 3.5 4H 56M RT 241.141 48713113_1 CDM 0278 RC inpatient 2011 1307.15 UMR - ALL PLANS UMR - ALL PLANS 1407.7 70 999999999 1217.66 1950.67 percent of total billed charges T-PLATE 3.5 4H 56M RT 241.141 48713113_1 CDM 0278 RC inpatient 2011 1307.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1217.66 60.55 999999999 1217.66 1950.67 percent of total billed charges T-PLATE 3.5 4H 56M RT 241.141 48713113_1 CDM 0278 RC inpatient 2011 1307.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1217.66 1950.67 T-PLATE 3.5 4H 56M RT 241.141 48713113_1 CDM 0278 RC inpatient 2011 1307.15 ANTHEM HMO ANTHEM HMO 999999999 1217.66 1950.67 T-PLATE 3.5 4H 56M RT 241.141 48713113_1 CDM 0278 RC inpatient 2011 1307.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1217.66 1950.67 T-PLATE 3.5 4H 56M RT 241.141 48713113_1 CDM 0278 RC inpatient 2011 1307.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1359.44 67.6 999999999 1217.66 1950.67 percent of total billed charges T-PLATE 3.5 4H 56M RT 241.141 48713113_1 CDM 0278 RC inpatient 2011 1307.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1217.66 1950.67 T-PLATE 3.5 4H 56M RT 241.141 48713113_1 CDM 0278 RC inpatient 2011 1307.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1217.66 1950.67 T-PLATE 3.5 4H 78M RT 241.161 48713114_1 CDM 0278 RC inpatient 2582 1678.3 AETNA AETNA 2039.78 79 999999999 1563.4 2504.54 percent of total billed charges T-PLATE 3.5 4H 78M RT 241.161 48713114_1 CDM 0278 RC inpatient 2582 1678.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1678.3 65 999999999 1563.4 2504.54 percent of total billed charges T-PLATE 3.5 4H 78M RT 241.161 48713114_1 CDM 0278 RC inpatient 2582 1678.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2504.54 97 999999999 1563.4 2504.54 percent of total billed charges T-PLATE 3.5 4H 78M RT 241.161 48713114_1 CDM 0278 RC inpatient 2582 1678.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1781.58 69 999999999 1563.4 2504.54 percent of total billed charges T-PLATE 3.5 4H 78M RT 241.161 48713114_1 CDM 0278 RC inpatient 2582 1678.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 2013.96 78 999999999 1563.4 2504.54 percent of total billed charges T-PLATE 3.5 4H 78M RT 241.161 48713114_1 CDM 0278 RC inpatient 2582 1678.3 SIHO - ALL PLANS SIHO - ALL PLANS 2323.8 90 999999999 1563.4 2504.54 percent of total billed charges T-PLATE 3.5 4H 78M RT 241.161 48713114_1 CDM 0278 RC inpatient 2582 1678.3 UMR - ALL PLANS UMR - ALL PLANS 1807.4 70 999999999 1563.4 2504.54 percent of total billed charges T-PLATE 3.5 4H 78M RT 241.161 48713114_1 CDM 0278 RC inpatient 2582 1678.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1563.4 60.55 999999999 1563.4 2504.54 percent of total billed charges T-PLATE 3.5 4H 78M RT 241.161 48713114_1 CDM 0278 RC inpatient 2582 1678.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1563.4 2504.54 T-PLATE 3.5 4H 78M RT 241.161 48713114_1 CDM 0278 RC inpatient 2582 1678.3 ANTHEM HMO ANTHEM HMO 999999999 1563.4 2504.54 T-PLATE 3.5 4H 78M RT 241.161 48713114_1 CDM 0278 RC inpatient 2582 1678.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1563.4 2504.54 T-PLATE 3.5 4H 78M RT 241.161 48713114_1 CDM 0278 RC inpatient 2582 1678.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1745.43 67.6 999999999 1563.4 2504.54 percent of total billed charges T-PLATE 3.5 4H 78M RT 241.161 48713114_1 CDM 0278 RC inpatient 2582 1678.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1563.4 2504.54 T-PLATE 3.5 4H 78M RT 241.161 48713114_1 CDM 0278 RC inpatient 2582 1678.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1563.4 2504.54 T-PLATE 3.5 3H 52M OR 241.031 48713115_1 CDM 0278 RC inpatient 2387 1551.55 AETNA AETNA 1885.73 79 999999999 1445.33 2315.39 percent of total billed charges T-PLATE 3.5 3H 52M OR 241.031 48713115_1 CDM 0278 RC inpatient 2387 1551.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1551.55 65 999999999 1445.33 2315.39 percent of total billed charges T-PLATE 3.5 3H 52M OR 241.031 48713115_1 CDM 0278 RC inpatient 2387 1551.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2315.39 97 999999999 1445.33 2315.39 percent of total billed charges T-PLATE 3.5 3H 52M OR 241.031 48713115_1 CDM 0278 RC inpatient 2387 1551.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1647.03 69 999999999 1445.33 2315.39 percent of total billed charges T-PLATE 3.5 3H 52M OR 241.031 48713115_1 CDM 0278 RC inpatient 2387 1551.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1861.86 78 999999999 1445.33 2315.39 percent of total billed charges T-PLATE 3.5 3H 52M OR 241.031 48713115_1 CDM 0278 RC inpatient 2387 1551.55 SIHO - ALL PLANS SIHO - ALL PLANS 2148.3 90 999999999 1445.33 2315.39 percent of total billed charges T-PLATE 3.5 3H 52M OR 241.031 48713115_1 CDM 0278 RC inpatient 2387 1551.55 UMR - ALL PLANS UMR - ALL PLANS 1670.9 70 999999999 1445.33 2315.39 percent of total billed charges T-PLATE 3.5 3H 52M OR 241.031 48713115_1 CDM 0278 RC inpatient 2387 1551.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1445.33 60.55 999999999 1445.33 2315.39 percent of total billed charges T-PLATE 3.5 3H 52M OR 241.031 48713115_1 CDM 0278 RC inpatient 2387 1551.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1445.33 2315.39 T-PLATE 3.5 3H 52M OR 241.031 48713115_1 CDM 0278 RC inpatient 2387 1551.55 ANTHEM HMO ANTHEM HMO 999999999 1445.33 2315.39 T-PLATE 3.5 3H 52M OR 241.031 48713115_1 CDM 0278 RC inpatient 2387 1551.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1445.33 2315.39 T-PLATE 3.5 3H 52M OR 241.031 48713115_1 CDM 0278 RC inpatient 2387 1551.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1613.61 67.6 999999999 1445.33 2315.39 percent of total billed charges T-PLATE 3.5 3H 52M OR 241.031 48713115_1 CDM 0278 RC inpatient 2387 1551.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1445.33 2315.39 T-PLATE 3.5 3H 52M OR 241.031 48713115_1 CDM 0278 RC inpatient 2387 1551.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1445.33 2315.39 T-PLATE 3.5 4H 63M OR 241.041 48713116_1 CDM 0278 RC inpatient 2306 1498.9 AETNA AETNA 1821.74 79 999999999 1396.28 2236.82 percent of total billed charges T-PLATE 3.5 4H 63M OR 241.041 48713116_1 CDM 0278 RC inpatient 2306 1498.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1498.9 65 999999999 1396.28 2236.82 percent of total billed charges T-PLATE 3.5 4H 63M OR 241.041 48713116_1 CDM 0278 RC inpatient 2306 1498.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2236.82 97 999999999 1396.28 2236.82 percent of total billed charges T-PLATE 3.5 4H 63M OR 241.041 48713116_1 CDM 0278 RC inpatient 2306 1498.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1591.14 69 999999999 1396.28 2236.82 percent of total billed charges T-PLATE 3.5 4H 63M OR 241.041 48713116_1 CDM 0278 RC inpatient 2306 1498.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1798.68 78 999999999 1396.28 2236.82 percent of total billed charges T-PLATE 3.5 4H 63M OR 241.041 48713116_1 CDM 0278 RC inpatient 2306 1498.9 SIHO - ALL PLANS SIHO - ALL PLANS 2075.4 90 999999999 1396.28 2236.82 percent of total billed charges T-PLATE 3.5 4H 63M OR 241.041 48713116_1 CDM 0278 RC inpatient 2306 1498.9 UMR - ALL PLANS UMR - ALL PLANS 1614.2 70 999999999 1396.28 2236.82 percent of total billed charges T-PLATE 3.5 4H 63M OR 241.041 48713116_1 CDM 0278 RC inpatient 2306 1498.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1396.28 60.55 999999999 1396.28 2236.82 percent of total billed charges T-PLATE 3.5 4H 63M OR 241.041 48713116_1 CDM 0278 RC inpatient 2306 1498.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1396.28 2236.82 T-PLATE 3.5 4H 63M OR 241.041 48713116_1 CDM 0278 RC inpatient 2306 1498.9 ANTHEM HMO ANTHEM HMO 999999999 1396.28 2236.82 T-PLATE 3.5 4H 63M OR 241.041 48713116_1 CDM 0278 RC inpatient 2306 1498.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1396.28 2236.82 T-PLATE 3.5 4H 63M OR 241.041 48713116_1 CDM 0278 RC inpatient 2306 1498.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1558.86 67.6 999999999 1396.28 2236.82 percent of total billed charges T-PLATE 3.5 4H 63M OR 241.041 48713116_1 CDM 0278 RC inpatient 2306 1498.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1396.28 2236.82 T-PLATE 3.5 4H 63M OR 241.041 48713116_1 CDM 0278 RC inpatient 2306 1498.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1396.28 2236.82 PLATE ST. 1.5MM 12\H 446.032 48713117_1 CDM 0278 RC inpatient 1038 674.7 AETNA AETNA 820.02 79 999999999 628.51 1006.86 percent of total billed charges PLATE ST. 1.5MM 12\H 446.032 48713117_1 CDM 0278 RC inpatient 1038 674.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 674.7 65 999999999 628.51 1006.86 percent of total billed charges PLATE ST. 1.5MM 12\H 446.032 48713117_1 CDM 0278 RC inpatient 1038 674.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1006.86 97 999999999 628.51 1006.86 percent of total billed charges PLATE ST. 1.5MM 12\H 446.032 48713117_1 CDM 0278 RC inpatient 1038 674.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 716.22 69 999999999 628.51 1006.86 percent of total billed charges PLATE ST. 1.5MM 12\H 446.032 48713117_1 CDM 0278 RC inpatient 1038 674.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 809.64 78 999999999 628.51 1006.86 percent of total billed charges PLATE ST. 1.5MM 12\H 446.032 48713117_1 CDM 0278 RC inpatient 1038 674.7 SIHO - ALL PLANS SIHO - ALL PLANS 934.2 90 999999999 628.51 1006.86 percent of total billed charges PLATE ST. 1.5MM 12\H 446.032 48713117_1 CDM 0278 RC inpatient 1038 674.7 UMR - ALL PLANS UMR - ALL PLANS 726.6 70 999999999 628.51 1006.86 percent of total billed charges PLATE ST. 1.5MM 12\H 446.032 48713117_1 CDM 0278 RC inpatient 1038 674.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 628.51 60.55 999999999 628.51 1006.86 percent of total billed charges PLATE ST. 1.5MM 12\H 446.032 48713117_1 CDM 0278 RC inpatient 1038 674.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 628.51 1006.86 PLATE ST. 1.5MM 12\H 446.032 48713117_1 CDM 0278 RC inpatient 1038 674.7 ANTHEM HMO ANTHEM HMO 999999999 628.51 1006.86 PLATE ST. 1.5MM 12\H 446.032 48713117_1 CDM 0278 RC inpatient 1038 674.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 628.51 1006.86 PLATE ST. 1.5MM 12\H 446.032 48713117_1 CDM 0278 RC inpatient 1038 674.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 701.69 67.6 999999999 628.51 1006.86 percent of total billed charges PLATE ST. 1.5MM 12\H 446.032 48713117_1 CDM 0278 RC inpatient 1038 674.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 628.51 1006.86 PLATE ST. 1.5MM 12\H 446.032 48713117_1 CDM 0278 RC inpatient 1038 674.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 628.51 1006.86 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713118_1 CDM 0278 RC C1713 HCPCS inpatient 1970 1280.5 AETNA AETNA 1556.3 79 999999999 1192.84 1910.9 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713118_1 CDM 0278 RC C1713 HCPCS inpatient 1970 1280.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1280.5 65 999999999 1192.84 1910.9 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713118_1 CDM 0278 RC C1713 HCPCS inpatient 1970 1280.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1910.9 97 999999999 1192.84 1910.9 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713118_1 CDM 0278 RC C1713 HCPCS inpatient 1970 1280.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1359.3 69 999999999 1192.84 1910.9 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713118_1 CDM 0278 RC C1713 HCPCS inpatient 1970 1280.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1536.6 78 999999999 1192.84 1910.9 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713118_1 CDM 0278 RC C1713 HCPCS inpatient 1970 1280.5 SIHO - ALL PLANS SIHO - ALL PLANS 1773 90 999999999 1192.84 1910.9 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713118_1 CDM 0278 RC C1713 HCPCS inpatient 1970 1280.5 UMR - ALL PLANS UMR - ALL PLANS 1379 70 999999999 1192.84 1910.9 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713118_1 CDM 0278 RC C1713 HCPCS inpatient 1970 1280.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1192.84 60.55 999999999 1192.84 1910.9 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713118_1 CDM 0278 RC C1713 HCPCS inpatient 1970 1280.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1192.84 1910.9 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713118_1 CDM 0278 RC C1713 HCPCS inpatient 1970 1280.5 ANTHEM HMO ANTHEM HMO 999999999 1192.84 1910.9 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713118_1 CDM 0278 RC C1713 HCPCS inpatient 1970 1280.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1192.84 1910.9 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713118_1 CDM 0278 RC C1713 HCPCS inpatient 1970 1280.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1331.72 67.6 999999999 1192.84 1910.9 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713118_1 CDM 0278 RC C1713 HCPCS inpatient 1970 1280.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1192.84 1910.9 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713118_1 CDM 0278 RC C1713 HCPCS inpatient 1970 1280.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1192.84 1910.9 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713119_1 CDM 0278 RC C1713 HCPCS inpatient 2139 1390.35 AETNA AETNA 1689.81 79 999999999 1295.16 2074.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713119_1 CDM 0278 RC C1713 HCPCS inpatient 2139 1390.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1390.35 65 999999999 1295.16 2074.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713119_1 CDM 0278 RC C1713 HCPCS inpatient 2139 1390.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2074.83 97 999999999 1295.16 2074.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713119_1 CDM 0278 RC C1713 HCPCS inpatient 2139 1390.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1475.91 69 999999999 1295.16 2074.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713119_1 CDM 0278 RC C1713 HCPCS inpatient 2139 1390.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1668.42 78 999999999 1295.16 2074.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713119_1 CDM 0278 RC C1713 HCPCS inpatient 2139 1390.35 SIHO - ALL PLANS SIHO - ALL PLANS 1925.1 90 999999999 1295.16 2074.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713119_1 CDM 0278 RC C1713 HCPCS inpatient 2139 1390.35 UMR - ALL PLANS UMR - ALL PLANS 1497.3 70 999999999 1295.16 2074.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713119_1 CDM 0278 RC C1713 HCPCS inpatient 2139 1390.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1295.16 60.55 999999999 1295.16 2074.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713119_1 CDM 0278 RC C1713 HCPCS inpatient 2139 1390.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1295.16 2074.83 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713119_1 CDM 0278 RC C1713 HCPCS inpatient 2139 1390.35 ANTHEM HMO ANTHEM HMO 999999999 1295.16 2074.83 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713119_1 CDM 0278 RC C1713 HCPCS inpatient 2139 1390.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1295.16 2074.83 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713119_1 CDM 0278 RC C1713 HCPCS inpatient 2139 1390.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1445.96 67.6 999999999 1295.16 2074.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713119_1 CDM 0278 RC C1713 HCPCS inpatient 2139 1390.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1295.16 2074.83 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713119_1 CDM 0278 RC C1713 HCPCS inpatient 2139 1390.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1295.16 2074.83 PLATE 3.5MM LCP 8 HOLE 223.581 48713120_1 CDM 0278 RC inpatient 2382 1548.3 AETNA AETNA 1881.78 79 999999999 1442.3 2310.54 percent of total billed charges PLATE 3.5MM LCP 8 HOLE 223.581 48713120_1 CDM 0278 RC inpatient 2382 1548.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1548.3 65 999999999 1442.3 2310.54 percent of total billed charges PLATE 3.5MM LCP 8 HOLE 223.581 48713120_1 CDM 0278 RC inpatient 2382 1548.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2310.54 97 999999999 1442.3 2310.54 percent of total billed charges PLATE 3.5MM LCP 8 HOLE 223.581 48713120_1 CDM 0278 RC inpatient 2382 1548.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1643.58 69 999999999 1442.3 2310.54 percent of total billed charges PLATE 3.5MM LCP 8 HOLE 223.581 48713120_1 CDM 0278 RC inpatient 2382 1548.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1857.96 78 999999999 1442.3 2310.54 percent of total billed charges PLATE 3.5MM LCP 8 HOLE 223.581 48713120_1 CDM 0278 RC inpatient 2382 1548.3 SIHO - ALL PLANS SIHO - ALL PLANS 2143.8 90 999999999 1442.3 2310.54 percent of total billed charges PLATE 3.5MM LCP 8 HOLE 223.581 48713120_1 CDM 0278 RC inpatient 2382 1548.3 UMR - ALL PLANS UMR - ALL PLANS 1667.4 70 999999999 1442.3 2310.54 percent of total billed charges PLATE 3.5MM LCP 8 HOLE 223.581 48713120_1 CDM 0278 RC inpatient 2382 1548.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1442.3 60.55 999999999 1442.3 2310.54 percent of total billed charges PLATE 3.5MM LCP 8 HOLE 223.581 48713120_1 CDM 0278 RC inpatient 2382 1548.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1442.3 2310.54 PLATE 3.5MM LCP 8 HOLE 223.581 48713120_1 CDM 0278 RC inpatient 2382 1548.3 ANTHEM HMO ANTHEM HMO 999999999 1442.3 2310.54 PLATE 3.5MM LCP 8 HOLE 223.581 48713120_1 CDM 0278 RC inpatient 2382 1548.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1442.3 2310.54 PLATE 3.5MM LCP 8 HOLE 223.581 48713120_1 CDM 0278 RC inpatient 2382 1548.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1610.23 67.6 999999999 1442.3 2310.54 percent of total billed charges PLATE 3.5MM LCP 8 HOLE 223.581 48713120_1 CDM 0278 RC inpatient 2382 1548.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1442.3 2310.54 PLATE 3.5MM LCP 8 HOLE 223.581 48713120_1 CDM 0278 RC inpatient 2382 1548.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1442.3 2310.54 PLATE 3.5MM LCP 9 HOLE 223.591 48713121_1 CDM 0278 RC inpatient 2399 1559.35 AETNA AETNA 1895.21 79 999999999 1452.59 2327.03 percent of total billed charges PLATE 3.5MM LCP 9 HOLE 223.591 48713121_1 CDM 0278 RC inpatient 2399 1559.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1559.35 65 999999999 1452.59 2327.03 percent of total billed charges PLATE 3.5MM LCP 9 HOLE 223.591 48713121_1 CDM 0278 RC inpatient 2399 1559.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2327.03 97 999999999 1452.59 2327.03 percent of total billed charges PLATE 3.5MM LCP 9 HOLE 223.591 48713121_1 CDM 0278 RC inpatient 2399 1559.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1655.31 69 999999999 1452.59 2327.03 percent of total billed charges PLATE 3.5MM LCP 9 HOLE 223.591 48713121_1 CDM 0278 RC inpatient 2399 1559.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1871.22 78 999999999 1452.59 2327.03 percent of total billed charges PLATE 3.5MM LCP 9 HOLE 223.591 48713121_1 CDM 0278 RC inpatient 2399 1559.35 SIHO - ALL PLANS SIHO - ALL PLANS 2159.1 90 999999999 1452.59 2327.03 percent of total billed charges PLATE 3.5MM LCP 9 HOLE 223.591 48713121_1 CDM 0278 RC inpatient 2399 1559.35 UMR - ALL PLANS UMR - ALL PLANS 1679.3 70 999999999 1452.59 2327.03 percent of total billed charges PLATE 3.5MM LCP 9 HOLE 223.591 48713121_1 CDM 0278 RC inpatient 2399 1559.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1452.59 60.55 999999999 1452.59 2327.03 percent of total billed charges PLATE 3.5MM LCP 9 HOLE 223.591 48713121_1 CDM 0278 RC inpatient 2399 1559.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1452.59 2327.03 PLATE 3.5MM LCP 9 HOLE 223.591 48713121_1 CDM 0278 RC inpatient 2399 1559.35 ANTHEM HMO ANTHEM HMO 999999999 1452.59 2327.03 PLATE 3.5MM LCP 9 HOLE 223.591 48713121_1 CDM 0278 RC inpatient 2399 1559.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1452.59 2327.03 PLATE 3.5MM LCP 9 HOLE 223.591 48713121_1 CDM 0278 RC inpatient 2399 1559.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1621.72 67.6 999999999 1452.59 2327.03 percent of total billed charges PLATE 3.5MM LCP 9 HOLE 223.591 48713121_1 CDM 0278 RC inpatient 2399 1559.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1452.59 2327.03 PLATE 3.5MM LCP 9 HOLE 223.591 48713121_1 CDM 0278 RC inpatient 2399 1559.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1452.59 2327.03 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713122_1 CDM 0278 RC C1713 HCPCS inpatient 2512 1632.8 AETNA AETNA 1984.48 79 999999999 1521.02 2436.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713122_1 CDM 0278 RC C1713 HCPCS inpatient 2512 1632.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1632.8 65 999999999 1521.02 2436.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713122_1 CDM 0278 RC C1713 HCPCS inpatient 2512 1632.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2436.64 97 999999999 1521.02 2436.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713122_1 CDM 0278 RC C1713 HCPCS inpatient 2512 1632.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1733.28 69 999999999 1521.02 2436.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713122_1 CDM 0278 RC C1713 HCPCS inpatient 2512 1632.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1959.36 78 999999999 1521.02 2436.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713122_1 CDM 0278 RC C1713 HCPCS inpatient 2512 1632.8 SIHO - ALL PLANS SIHO - ALL PLANS 2260.8 90 999999999 1521.02 2436.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713122_1 CDM 0278 RC C1713 HCPCS inpatient 2512 1632.8 UMR - ALL PLANS UMR - ALL PLANS 1758.4 70 999999999 1521.02 2436.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713122_1 CDM 0278 RC C1713 HCPCS inpatient 2512 1632.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1521.02 60.55 999999999 1521.02 2436.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713122_1 CDM 0278 RC C1713 HCPCS inpatient 2512 1632.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1521.02 2436.64 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713122_1 CDM 0278 RC C1713 HCPCS inpatient 2512 1632.8 ANTHEM HMO ANTHEM HMO 999999999 1521.02 2436.64 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713122_1 CDM 0278 RC C1713 HCPCS inpatient 2512 1632.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1521.02 2436.64 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713122_1 CDM 0278 RC C1713 HCPCS inpatient 2512 1632.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1698.11 67.6 999999999 1521.02 2436.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713122_1 CDM 0278 RC C1713 HCPCS inpatient 2512 1632.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1521.02 2436.64 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713122_1 CDM 0278 RC C1713 HCPCS inpatient 2512 1632.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1521.02 2436.64 PLATE 3.5M LCP 12 HOLE 223.621 48713123_1 CDM 0278 RC inpatient 2813 1828.45 AETNA AETNA 2222.27 79 999999999 1703.27 2728.61 percent of total billed charges PLATE 3.5M LCP 12 HOLE 223.621 48713123_1 CDM 0278 RC inpatient 2813 1828.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1828.45 65 999999999 1703.27 2728.61 percent of total billed charges PLATE 3.5M LCP 12 HOLE 223.621 48713123_1 CDM 0278 RC inpatient 2813 1828.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2728.61 97 999999999 1703.27 2728.61 percent of total billed charges PLATE 3.5M LCP 12 HOLE 223.621 48713123_1 CDM 0278 RC inpatient 2813 1828.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1940.97 69 999999999 1703.27 2728.61 percent of total billed charges PLATE 3.5M LCP 12 HOLE 223.621 48713123_1 CDM 0278 RC inpatient 2813 1828.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 2194.14 78 999999999 1703.27 2728.61 percent of total billed charges PLATE 3.5M LCP 12 HOLE 223.621 48713123_1 CDM 0278 RC inpatient 2813 1828.45 SIHO - ALL PLANS SIHO - ALL PLANS 2531.7 90 999999999 1703.27 2728.61 percent of total billed charges PLATE 3.5M LCP 12 HOLE 223.621 48713123_1 CDM 0278 RC inpatient 2813 1828.45 UMR - ALL PLANS UMR - ALL PLANS 1969.1 70 999999999 1703.27 2728.61 percent of total billed charges PLATE 3.5M LCP 12 HOLE 223.621 48713123_1 CDM 0278 RC inpatient 2813 1828.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1703.27 60.55 999999999 1703.27 2728.61 percent of total billed charges PLATE 3.5M LCP 12 HOLE 223.621 48713123_1 CDM 0278 RC inpatient 2813 1828.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1703.27 2728.61 PLATE 3.5M LCP 12 HOLE 223.621 48713123_1 CDM 0278 RC inpatient 2813 1828.45 ANTHEM HMO ANTHEM HMO 999999999 1703.27 2728.61 PLATE 3.5M LCP 12 HOLE 223.621 48713123_1 CDM 0278 RC inpatient 2813 1828.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1703.27 2728.61 PLATE 3.5M LCP 12 HOLE 223.621 48713123_1 CDM 0278 RC inpatient 2813 1828.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1901.59 67.6 999999999 1703.27 2728.61 percent of total billed charges PLATE 3.5M LCP 12 HOLE 223.621 48713123_1 CDM 0278 RC inpatient 2813 1828.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1703.27 2728.61 PLATE 3.5M LCP 12 HOLE 223.621 48713123_1 CDM 0278 RC inpatient 2813 1828.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1703.27 2728.61 PLATE 3.5M LCP 14 HOLE 223.641 48713124_1 CDM 0278 RC inpatient 3506 2278.9 AETNA AETNA 2769.74 79 999999999 2122.88 3400.82 percent of total billed charges PLATE 3.5M LCP 14 HOLE 223.641 48713124_1 CDM 0278 RC inpatient 3506 2278.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 2278.9 65 999999999 2122.88 3400.82 percent of total billed charges PLATE 3.5M LCP 14 HOLE 223.641 48713124_1 CDM 0278 RC inpatient 3506 2278.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3400.82 97 999999999 2122.88 3400.82 percent of total billed charges PLATE 3.5M LCP 14 HOLE 223.641 48713124_1 CDM 0278 RC inpatient 3506 2278.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 2419.14 69 999999999 2122.88 3400.82 percent of total billed charges PLATE 3.5M LCP 14 HOLE 223.641 48713124_1 CDM 0278 RC inpatient 3506 2278.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 2734.68 78 999999999 2122.88 3400.82 percent of total billed charges PLATE 3.5M LCP 14 HOLE 223.641 48713124_1 CDM 0278 RC inpatient 3506 2278.9 SIHO - ALL PLANS SIHO - ALL PLANS 3155.4 90 999999999 2122.88 3400.82 percent of total billed charges PLATE 3.5M LCP 14 HOLE 223.641 48713124_1 CDM 0278 RC inpatient 3506 2278.9 UMR - ALL PLANS UMR - ALL PLANS 2454.2 70 999999999 2122.88 3400.82 percent of total billed charges PLATE 3.5M LCP 14 HOLE 223.641 48713124_1 CDM 0278 RC inpatient 3506 2278.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2122.88 60.55 999999999 2122.88 3400.82 percent of total billed charges PLATE 3.5M LCP 14 HOLE 223.641 48713124_1 CDM 0278 RC inpatient 3506 2278.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2122.88 3400.82 PLATE 3.5M LCP 14 HOLE 223.641 48713124_1 CDM 0278 RC inpatient 3506 2278.9 ANTHEM HMO ANTHEM HMO 999999999 2122.88 3400.82 PLATE 3.5M LCP 14 HOLE 223.641 48713124_1 CDM 0278 RC inpatient 3506 2278.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2122.88 3400.82 PLATE 3.5M LCP 14 HOLE 223.641 48713124_1 CDM 0278 RC inpatient 3506 2278.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 2370.06 67.6 999999999 2122.88 3400.82 percent of total billed charges PLATE 3.5M LCP 14 HOLE 223.641 48713124_1 CDM 0278 RC inpatient 3506 2278.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2122.88 3400.82 PLATE 3.5M LCP 14 HOLE 223.641 48713124_1 CDM 0278 RC inpatient 3506 2278.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 2122.88 3400.82 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713125_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 AETNA AETNA 1034.9 79 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713125_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 851.5 65 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713125_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1270.7 97 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713125_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 903.9 69 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713125_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1021.8 78 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713125_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 SIHO - ALL PLANS SIHO - ALL PLANS 1179 90 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713125_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 UMR - ALL PLANS UMR - ALL PLANS 917 70 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713125_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 793.21 60.55 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713125_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 793.21 1270.7 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713125_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ANTHEM HMO ANTHEM HMO 999999999 793.21 1270.7 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713125_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 793.21 1270.7 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713125_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 885.56 67.6 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713125_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 793.21 1270.7 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713125_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 793.21 1270.7 PLATE 3.5 LCP RECON 5H 245.051 48713126_1 CDM 0278 RC inpatient 2812 1827.8 AETNA AETNA 2221.48 79 999999999 1702.67 2727.64 percent of total billed charges PLATE 3.5 LCP RECON 5H 245.051 48713126_1 CDM 0278 RC inpatient 2812 1827.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1827.8 65 999999999 1702.67 2727.64 percent of total billed charges PLATE 3.5 LCP RECON 5H 245.051 48713126_1 CDM 0278 RC inpatient 2812 1827.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2727.64 97 999999999 1702.67 2727.64 percent of total billed charges PLATE 3.5 LCP RECON 5H 245.051 48713126_1 CDM 0278 RC inpatient 2812 1827.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1940.28 69 999999999 1702.67 2727.64 percent of total billed charges PLATE 3.5 LCP RECON 5H 245.051 48713126_1 CDM 0278 RC inpatient 2812 1827.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 2193.36 78 999999999 1702.67 2727.64 percent of total billed charges PLATE 3.5 LCP RECON 5H 245.051 48713126_1 CDM 0278 RC inpatient 2812 1827.8 SIHO - ALL PLANS SIHO - ALL PLANS 2530.8 90 999999999 1702.67 2727.64 percent of total billed charges PLATE 3.5 LCP RECON 5H 245.051 48713126_1 CDM 0278 RC inpatient 2812 1827.8 UMR - ALL PLANS UMR - ALL PLANS 1968.4 70 999999999 1702.67 2727.64 percent of total billed charges PLATE 3.5 LCP RECON 5H 245.051 48713126_1 CDM 0278 RC inpatient 2812 1827.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1702.67 60.55 999999999 1702.67 2727.64 percent of total billed charges PLATE 3.5 LCP RECON 5H 245.051 48713126_1 CDM 0278 RC inpatient 2812 1827.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1702.67 2727.64 PLATE 3.5 LCP RECON 5H 245.051 48713126_1 CDM 0278 RC inpatient 2812 1827.8 ANTHEM HMO ANTHEM HMO 999999999 1702.67 2727.64 PLATE 3.5 LCP RECON 5H 245.051 48713126_1 CDM 0278 RC inpatient 2812 1827.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1702.67 2727.64 PLATE 3.5 LCP RECON 5H 245.051 48713126_1 CDM 0278 RC inpatient 2812 1827.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1900.91 67.6 999999999 1702.67 2727.64 percent of total billed charges PLATE 3.5 LCP RECON 5H 245.051 48713126_1 CDM 0278 RC inpatient 2812 1827.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1702.67 2727.64 PLATE 3.5 LCP RECON 5H 245.051 48713126_1 CDM 0278 RC inpatient 2812 1827.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1702.67 2727.64 PLATE 3.5 LCP RECON 6H 245.061 48713127_1 CDM 0278 RC inpatient 2930 1904.5 AETNA AETNA 2314.7 79 999999999 1774.12 2842.1 percent of total billed charges PLATE 3.5 LCP RECON 6H 245.061 48713127_1 CDM 0278 RC inpatient 2930 1904.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1904.5 65 999999999 1774.12 2842.1 percent of total billed charges PLATE 3.5 LCP RECON 6H 245.061 48713127_1 CDM 0278 RC inpatient 2930 1904.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2842.1 97 999999999 1774.12 2842.1 percent of total billed charges PLATE 3.5 LCP RECON 6H 245.061 48713127_1 CDM 0278 RC inpatient 2930 1904.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 2021.7 69 999999999 1774.12 2842.1 percent of total billed charges PLATE 3.5 LCP RECON 6H 245.061 48713127_1 CDM 0278 RC inpatient 2930 1904.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 2285.4 78 999999999 1774.12 2842.1 percent of total billed charges PLATE 3.5 LCP RECON 6H 245.061 48713127_1 CDM 0278 RC inpatient 2930 1904.5 SIHO - ALL PLANS SIHO - ALL PLANS 2637 90 999999999 1774.12 2842.1 percent of total billed charges PLATE 3.5 LCP RECON 6H 245.061 48713127_1 CDM 0278 RC inpatient 2930 1904.5 UMR - ALL PLANS UMR - ALL PLANS 2051 70 999999999 1774.12 2842.1 percent of total billed charges PLATE 3.5 LCP RECON 6H 245.061 48713127_1 CDM 0278 RC inpatient 2930 1904.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1774.12 60.55 999999999 1774.12 2842.1 percent of total billed charges PLATE 3.5 LCP RECON 6H 245.061 48713127_1 CDM 0278 RC inpatient 2930 1904.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1774.12 2842.1 PLATE 3.5 LCP RECON 6H 245.061 48713127_1 CDM 0278 RC inpatient 2930 1904.5 ANTHEM HMO ANTHEM HMO 999999999 1774.12 2842.1 PLATE 3.5 LCP RECON 6H 245.061 48713127_1 CDM 0278 RC inpatient 2930 1904.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1774.12 2842.1 PLATE 3.5 LCP RECON 6H 245.061 48713127_1 CDM 0278 RC inpatient 2930 1904.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1980.68 67.6 999999999 1774.12 2842.1 percent of total billed charges PLATE 3.5 LCP RECON 6H 245.061 48713127_1 CDM 0278 RC inpatient 2930 1904.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1774.12 2842.1 PLATE 3.5 LCP RECON 6H 245.061 48713127_1 CDM 0278 RC inpatient 2930 1904.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1774.12 2842.1 PLATE 3.5 LCP RECON 7H 245.071 48713128_1 CDM 0278 RC inpatient 3010 1956.5 AETNA AETNA 2377.9 79 999999999 1822.56 2919.7 percent of total billed charges PLATE 3.5 LCP RECON 7H 245.071 48713128_1 CDM 0278 RC inpatient 3010 1956.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1956.5 65 999999999 1822.56 2919.7 percent of total billed charges PLATE 3.5 LCP RECON 7H 245.071 48713128_1 CDM 0278 RC inpatient 3010 1956.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2919.7 97 999999999 1822.56 2919.7 percent of total billed charges PLATE 3.5 LCP RECON 7H 245.071 48713128_1 CDM 0278 RC inpatient 3010 1956.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 2076.9 69 999999999 1822.56 2919.7 percent of total billed charges PLATE 3.5 LCP RECON 7H 245.071 48713128_1 CDM 0278 RC inpatient 3010 1956.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 2347.8 78 999999999 1822.56 2919.7 percent of total billed charges PLATE 3.5 LCP RECON 7H 245.071 48713128_1 CDM 0278 RC inpatient 3010 1956.5 SIHO - ALL PLANS SIHO - ALL PLANS 2709 90 999999999 1822.56 2919.7 percent of total billed charges PLATE 3.5 LCP RECON 7H 245.071 48713128_1 CDM 0278 RC inpatient 3010 1956.5 UMR - ALL PLANS UMR - ALL PLANS 2107 70 999999999 1822.56 2919.7 percent of total billed charges PLATE 3.5 LCP RECON 7H 245.071 48713128_1 CDM 0278 RC inpatient 3010 1956.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1822.56 60.55 999999999 1822.56 2919.7 percent of total billed charges PLATE 3.5 LCP RECON 7H 245.071 48713128_1 CDM 0278 RC inpatient 3010 1956.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1822.56 2919.7 PLATE 3.5 LCP RECON 7H 245.071 48713128_1 CDM 0278 RC inpatient 3010 1956.5 ANTHEM HMO ANTHEM HMO 999999999 1822.56 2919.7 PLATE 3.5 LCP RECON 7H 245.071 48713128_1 CDM 0278 RC inpatient 3010 1956.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1822.56 2919.7 PLATE 3.5 LCP RECON 7H 245.071 48713128_1 CDM 0278 RC inpatient 3010 1956.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 2034.76 67.6 999999999 1822.56 2919.7 percent of total billed charges PLATE 3.5 LCP RECON 7H 245.071 48713128_1 CDM 0278 RC inpatient 3010 1956.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1822.56 2919.7 PLATE 3.5 LCP RECON 7H 245.071 48713128_1 CDM 0278 RC inpatient 3010 1956.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1822.56 2919.7 PLATE 3.5 LCP RECON 8H 245.081 48713129_1 CDM 0278 RC inpatient 3142 2042.3 AETNA AETNA 2482.18 79 999999999 1902.48 3047.74 percent of total billed charges PLATE 3.5 LCP RECON 8H 245.081 48713129_1 CDM 0278 RC inpatient 3142 2042.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 2042.3 65 999999999 1902.48 3047.74 percent of total billed charges PLATE 3.5 LCP RECON 8H 245.081 48713129_1 CDM 0278 RC inpatient 3142 2042.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3047.74 97 999999999 1902.48 3047.74 percent of total billed charges PLATE 3.5 LCP RECON 8H 245.081 48713129_1 CDM 0278 RC inpatient 3142 2042.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 2167.98 69 999999999 1902.48 3047.74 percent of total billed charges PLATE 3.5 LCP RECON 8H 245.081 48713129_1 CDM 0278 RC inpatient 3142 2042.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 2450.76 78 999999999 1902.48 3047.74 percent of total billed charges PLATE 3.5 LCP RECON 8H 245.081 48713129_1 CDM 0278 RC inpatient 3142 2042.3 SIHO - ALL PLANS SIHO - ALL PLANS 2827.8 90 999999999 1902.48 3047.74 percent of total billed charges PLATE 3.5 LCP RECON 8H 245.081 48713129_1 CDM 0278 RC inpatient 3142 2042.3 UMR - ALL PLANS UMR - ALL PLANS 2199.4 70 999999999 1902.48 3047.74 percent of total billed charges PLATE 3.5 LCP RECON 8H 245.081 48713129_1 CDM 0278 RC inpatient 3142 2042.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1902.48 60.55 999999999 1902.48 3047.74 percent of total billed charges PLATE 3.5 LCP RECON 8H 245.081 48713129_1 CDM 0278 RC inpatient 3142 2042.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1902.48 3047.74 PLATE 3.5 LCP RECON 8H 245.081 48713129_1 CDM 0278 RC inpatient 3142 2042.3 ANTHEM HMO ANTHEM HMO 999999999 1902.48 3047.74 PLATE 3.5 LCP RECON 8H 245.081 48713129_1 CDM 0278 RC inpatient 3142 2042.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1902.48 3047.74 PLATE 3.5 LCP RECON 8H 245.081 48713129_1 CDM 0278 RC inpatient 3142 2042.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 2123.99 67.6 999999999 1902.48 3047.74 percent of total billed charges PLATE 3.5 LCP RECON 8H 245.081 48713129_1 CDM 0278 RC inpatient 3142 2042.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1902.48 3047.74 PLATE 3.5 LCP RECON 8H 245.081 48713129_1 CDM 0278 RC inpatient 3142 2042.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1902.48 3047.74 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713130_1 CDM 0278 RC C1713 HCPCS inpatient 3460 2249 AETNA AETNA 2733.4 79 999999999 2095.03 3356.2 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713130_1 CDM 0278 RC C1713 HCPCS inpatient 3460 2249 SELF PAY DISCOUNT SELF PAY DISCOUNT 2249 65 999999999 2095.03 3356.2 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713130_1 CDM 0278 RC C1713 HCPCS inpatient 3460 2249 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3356.2 97 999999999 2095.03 3356.2 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713130_1 CDM 0278 RC C1713 HCPCS inpatient 3460 2249 ENCORE - ALL PLANS ENCORE - ALL PLANS 2387.4 69 999999999 2095.03 3356.2 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713130_1 CDM 0278 RC C1713 HCPCS inpatient 3460 2249 HUMANA - ALL PLANS HUMANA - ALL PLANS 2698.8 78 999999999 2095.03 3356.2 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713130_1 CDM 0278 RC C1713 HCPCS inpatient 3460 2249 SIHO - ALL PLANS SIHO - ALL PLANS 3114 90 999999999 2095.03 3356.2 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713130_1 CDM 0278 RC C1713 HCPCS inpatient 3460 2249 UMR - ALL PLANS UMR - ALL PLANS 2422 70 999999999 2095.03 3356.2 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713130_1 CDM 0278 RC C1713 HCPCS inpatient 3460 2249 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2095.03 60.55 999999999 2095.03 3356.2 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713130_1 CDM 0278 RC C1713 HCPCS inpatient 3460 2249 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2095.03 3356.2 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713130_1 CDM 0278 RC C1713 HCPCS inpatient 3460 2249 ANTHEM HMO ANTHEM HMO 999999999 2095.03 3356.2 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713130_1 CDM 0278 RC C1713 HCPCS inpatient 3460 2249 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2095.03 3356.2 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713130_1 CDM 0278 RC C1713 HCPCS inpatient 3460 2249 CIGNA - ALL PLANS CIGNA - ALL PLANS 2338.96 67.6 999999999 2095.03 3356.2 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713130_1 CDM 0278 RC C1713 HCPCS inpatient 3460 2249 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2095.03 3356.2 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713130_1 CDM 0278 RC C1713 HCPCS inpatient 3460 2249 UHC - ALL PLANS UHC - ALL PLANS 999999999 2095.03 3356.2 PLATE 3.5 LCP REC 12H 245.121 48713131_1 CDM 0278 RC inpatient 3559 2313.35 AETNA AETNA 2811.61 79 999999999 2154.97 3452.23 percent of total billed charges PLATE 3.5 LCP REC 12H 245.121 48713131_1 CDM 0278 RC inpatient 3559 2313.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 2313.35 65 999999999 2154.97 3452.23 percent of total billed charges PLATE 3.5 LCP REC 12H 245.121 48713131_1 CDM 0278 RC inpatient 3559 2313.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3452.23 97 999999999 2154.97 3452.23 percent of total billed charges PLATE 3.5 LCP REC 12H 245.121 48713131_1 CDM 0278 RC inpatient 3559 2313.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 2455.71 69 999999999 2154.97 3452.23 percent of total billed charges PLATE 3.5 LCP REC 12H 245.121 48713131_1 CDM 0278 RC inpatient 3559 2313.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 2776.02 78 999999999 2154.97 3452.23 percent of total billed charges PLATE 3.5 LCP REC 12H 245.121 48713131_1 CDM 0278 RC inpatient 3559 2313.35 SIHO - ALL PLANS SIHO - ALL PLANS 3203.1 90 999999999 2154.97 3452.23 percent of total billed charges PLATE 3.5 LCP REC 12H 245.121 48713131_1 CDM 0278 RC inpatient 3559 2313.35 UMR - ALL PLANS UMR - ALL PLANS 2491.3 70 999999999 2154.97 3452.23 percent of total billed charges PLATE 3.5 LCP REC 12H 245.121 48713131_1 CDM 0278 RC inpatient 3559 2313.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2154.97 60.55 999999999 2154.97 3452.23 percent of total billed charges PLATE 3.5 LCP REC 12H 245.121 48713131_1 CDM 0278 RC inpatient 3559 2313.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2154.97 3452.23 PLATE 3.5 LCP REC 12H 245.121 48713131_1 CDM 0278 RC inpatient 3559 2313.35 ANTHEM HMO ANTHEM HMO 999999999 2154.97 3452.23 PLATE 3.5 LCP REC 12H 245.121 48713131_1 CDM 0278 RC inpatient 3559 2313.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2154.97 3452.23 PLATE 3.5 LCP REC 12H 245.121 48713131_1 CDM 0278 RC inpatient 3559 2313.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 2405.88 67.6 999999999 2154.97 3452.23 percent of total billed charges PLATE 3.5 LCP REC 12H 245.121 48713131_1 CDM 0278 RC inpatient 3559 2313.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2154.97 3452.23 PLATE 3.5 LCP REC 12H 245.121 48713131_1 CDM 0278 RC inpatient 3559 2313.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 2154.97 3452.23 T-PLATE 3.5 3H 74M OR 241.051 48713132_1 CDM 0278 RC inpatient 2400 1560 AETNA AETNA 1896 79 999999999 1453.2 2328 percent of total billed charges T-PLATE 3.5 3H 74M OR 241.051 48713132_1 CDM 0278 RC inpatient 2400 1560 SELF PAY DISCOUNT SELF PAY DISCOUNT 1560 65 999999999 1453.2 2328 percent of total billed charges T-PLATE 3.5 3H 74M OR 241.051 48713132_1 CDM 0278 RC inpatient 2400 1560 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2328 97 999999999 1453.2 2328 percent of total billed charges T-PLATE 3.5 3H 74M OR 241.051 48713132_1 CDM 0278 RC inpatient 2400 1560 ENCORE - ALL PLANS ENCORE - ALL PLANS 1656 69 999999999 1453.2 2328 percent of total billed charges T-PLATE 3.5 3H 74M OR 241.051 48713132_1 CDM 0278 RC inpatient 2400 1560 HUMANA - ALL PLANS HUMANA - ALL PLANS 1872 78 999999999 1453.2 2328 percent of total billed charges T-PLATE 3.5 3H 74M OR 241.051 48713132_1 CDM 0278 RC inpatient 2400 1560 SIHO - ALL PLANS SIHO - ALL PLANS 2160 90 999999999 1453.2 2328 percent of total billed charges T-PLATE 3.5 3H 74M OR 241.051 48713132_1 CDM 0278 RC inpatient 2400 1560 UMR - ALL PLANS UMR - ALL PLANS 1680 70 999999999 1453.2 2328 percent of total billed charges T-PLATE 3.5 3H 74M OR 241.051 48713132_1 CDM 0278 RC inpatient 2400 1560 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1453.2 60.55 999999999 1453.2 2328 percent of total billed charges T-PLATE 3.5 3H 74M OR 241.051 48713132_1 CDM 0278 RC inpatient 2400 1560 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1453.2 2328 T-PLATE 3.5 3H 74M OR 241.051 48713132_1 CDM 0278 RC inpatient 2400 1560 ANTHEM HMO ANTHEM HMO 999999999 1453.2 2328 T-PLATE 3.5 3H 74M OR 241.051 48713132_1 CDM 0278 RC inpatient 2400 1560 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1453.2 2328 T-PLATE 3.5 3H 74M OR 241.051 48713132_1 CDM 0278 RC inpatient 2400 1560 CIGNA - ALL PLANS CIGNA - ALL PLANS 1622.4 67.6 999999999 1453.2 2328 percent of total billed charges T-PLATE 3.5 3H 74M OR 241.051 48713132_1 CDM 0278 RC inpatient 2400 1560 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1453.2 2328 T-PLATE 3.5 3H 74M OR 241.051 48713132_1 CDM 0278 RC inpatient 2400 1560 UHC - ALL PLANS UHC - ALL PLANS 999999999 1453.2 2328 T-PLATE 3.5 3H 96M OR 241.071 48713133_1 CDM 0278 RC inpatient 2832 1840.8 AETNA AETNA 2237.28 79 999999999 1714.78 2747.04 percent of total billed charges T-PLATE 3.5 3H 96M OR 241.071 48713133_1 CDM 0278 RC inpatient 2832 1840.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1840.8 65 999999999 1714.78 2747.04 percent of total billed charges T-PLATE 3.5 3H 96M OR 241.071 48713133_1 CDM 0278 RC inpatient 2832 1840.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2747.04 97 999999999 1714.78 2747.04 percent of total billed charges T-PLATE 3.5 3H 96M OR 241.071 48713133_1 CDM 0278 RC inpatient 2832 1840.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1954.08 69 999999999 1714.78 2747.04 percent of total billed charges T-PLATE 3.5 3H 96M OR 241.071 48713133_1 CDM 0278 RC inpatient 2832 1840.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 2208.96 78 999999999 1714.78 2747.04 percent of total billed charges T-PLATE 3.5 3H 96M OR 241.071 48713133_1 CDM 0278 RC inpatient 2832 1840.8 SIHO - ALL PLANS SIHO - ALL PLANS 2548.8 90 999999999 1714.78 2747.04 percent of total billed charges T-PLATE 3.5 3H 96M OR 241.071 48713133_1 CDM 0278 RC inpatient 2832 1840.8 UMR - ALL PLANS UMR - ALL PLANS 1982.4 70 999999999 1714.78 2747.04 percent of total billed charges T-PLATE 3.5 3H 96M OR 241.071 48713133_1 CDM 0278 RC inpatient 2832 1840.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1714.78 60.55 999999999 1714.78 2747.04 percent of total billed charges T-PLATE 3.5 3H 96M OR 241.071 48713133_1 CDM 0278 RC inpatient 2832 1840.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1714.78 2747.04 T-PLATE 3.5 3H 96M OR 241.071 48713133_1 CDM 0278 RC inpatient 2832 1840.8 ANTHEM HMO ANTHEM HMO 999999999 1714.78 2747.04 T-PLATE 3.5 3H 96M OR 241.071 48713133_1 CDM 0278 RC inpatient 2832 1840.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1714.78 2747.04 T-PLATE 3.5 3H 96M OR 241.071 48713133_1 CDM 0278 RC inpatient 2832 1840.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1914.43 67.6 999999999 1714.78 2747.04 percent of total billed charges T-PLATE 3.5 3H 96M OR 241.071 48713133_1 CDM 0278 RC inpatient 2832 1840.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1714.78 2747.04 T-PLATE 3.5 3H 96M OR 241.071 48713133_1 CDM 0278 RC inpatient 2832 1840.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1714.78 2747.04 T-PLATE 3.5 3H 52M OL 241.931 48713134_1 CDM 0278 RC inpatient 2393 1555.45 AETNA AETNA 1890.47 79 999999999 1448.96 2321.21 percent of total billed charges T-PLATE 3.5 3H 52M OL 241.931 48713134_1 CDM 0278 RC inpatient 2393 1555.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1555.45 65 999999999 1448.96 2321.21 percent of total billed charges T-PLATE 3.5 3H 52M OL 241.931 48713134_1 CDM 0278 RC inpatient 2393 1555.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2321.21 97 999999999 1448.96 2321.21 percent of total billed charges T-PLATE 3.5 3H 52M OL 241.931 48713134_1 CDM 0278 RC inpatient 2393 1555.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1651.17 69 999999999 1448.96 2321.21 percent of total billed charges T-PLATE 3.5 3H 52M OL 241.931 48713134_1 CDM 0278 RC inpatient 2393 1555.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1866.54 78 999999999 1448.96 2321.21 percent of total billed charges T-PLATE 3.5 3H 52M OL 241.931 48713134_1 CDM 0278 RC inpatient 2393 1555.45 SIHO - ALL PLANS SIHO - ALL PLANS 2153.7 90 999999999 1448.96 2321.21 percent of total billed charges T-PLATE 3.5 3H 52M OL 241.931 48713134_1 CDM 0278 RC inpatient 2393 1555.45 UMR - ALL PLANS UMR - ALL PLANS 1675.1 70 999999999 1448.96 2321.21 percent of total billed charges T-PLATE 3.5 3H 52M OL 241.931 48713134_1 CDM 0278 RC inpatient 2393 1555.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1448.96 60.55 999999999 1448.96 2321.21 percent of total billed charges T-PLATE 3.5 3H 52M OL 241.931 48713134_1 CDM 0278 RC inpatient 2393 1555.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1448.96 2321.21 T-PLATE 3.5 3H 52M OL 241.931 48713134_1 CDM 0278 RC inpatient 2393 1555.45 ANTHEM HMO ANTHEM HMO 999999999 1448.96 2321.21 T-PLATE 3.5 3H 52M OL 241.931 48713134_1 CDM 0278 RC inpatient 2393 1555.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1448.96 2321.21 T-PLATE 3.5 3H 52M OL 241.931 48713134_1 CDM 0278 RC inpatient 2393 1555.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1617.67 67.6 999999999 1448.96 2321.21 percent of total billed charges T-PLATE 3.5 3H 52M OL 241.931 48713134_1 CDM 0278 RC inpatient 2393 1555.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1448.96 2321.21 T-PLATE 3.5 3H 52M OL 241.931 48713134_1 CDM 0278 RC inpatient 2393 1555.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1448.96 2321.21 T-PLATE 3.5 3H 63M OL 241.941 48713135_1 CDM 0278 RC inpatient 2306 1498.9 AETNA AETNA 1821.74 79 999999999 1396.28 2236.82 percent of total billed charges T-PLATE 3.5 3H 63M OL 241.941 48713135_1 CDM 0278 RC inpatient 2306 1498.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1498.9 65 999999999 1396.28 2236.82 percent of total billed charges T-PLATE 3.5 3H 63M OL 241.941 48713135_1 CDM 0278 RC inpatient 2306 1498.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2236.82 97 999999999 1396.28 2236.82 percent of total billed charges T-PLATE 3.5 3H 63M OL 241.941 48713135_1 CDM 0278 RC inpatient 2306 1498.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1591.14 69 999999999 1396.28 2236.82 percent of total billed charges T-PLATE 3.5 3H 63M OL 241.941 48713135_1 CDM 0278 RC inpatient 2306 1498.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1798.68 78 999999999 1396.28 2236.82 percent of total billed charges T-PLATE 3.5 3H 63M OL 241.941 48713135_1 CDM 0278 RC inpatient 2306 1498.9 SIHO - ALL PLANS SIHO - ALL PLANS 2075.4 90 999999999 1396.28 2236.82 percent of total billed charges T-PLATE 3.5 3H 63M OL 241.941 48713135_1 CDM 0278 RC inpatient 2306 1498.9 UMR - ALL PLANS UMR - ALL PLANS 1614.2 70 999999999 1396.28 2236.82 percent of total billed charges T-PLATE 3.5 3H 63M OL 241.941 48713135_1 CDM 0278 RC inpatient 2306 1498.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1396.28 60.55 999999999 1396.28 2236.82 percent of total billed charges T-PLATE 3.5 3H 63M OL 241.941 48713135_1 CDM 0278 RC inpatient 2306 1498.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1396.28 2236.82 T-PLATE 3.5 3H 63M OL 241.941 48713135_1 CDM 0278 RC inpatient 2306 1498.9 ANTHEM HMO ANTHEM HMO 999999999 1396.28 2236.82 T-PLATE 3.5 3H 63M OL 241.941 48713135_1 CDM 0278 RC inpatient 2306 1498.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1396.28 2236.82 T-PLATE 3.5 3H 63M OL 241.941 48713135_1 CDM 0278 RC inpatient 2306 1498.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1558.86 67.6 999999999 1396.28 2236.82 percent of total billed charges T-PLATE 3.5 3H 63M OL 241.941 48713135_1 CDM 0278 RC inpatient 2306 1498.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1396.28 2236.82 T-PLATE 3.5 3H 63M OL 241.941 48713135_1 CDM 0278 RC inpatient 2306 1498.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1396.28 2236.82 T-PLATE 3.5 3H 74M OL 241.951 48713136_1 CDM 0278 RC inpatient 2616 1700.4 AETNA AETNA 2066.64 79 999999999 1583.99 2537.52 percent of total billed charges T-PLATE 3.5 3H 74M OL 241.951 48713136_1 CDM 0278 RC inpatient 2616 1700.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1700.4 65 999999999 1583.99 2537.52 percent of total billed charges T-PLATE 3.5 3H 74M OL 241.951 48713136_1 CDM 0278 RC inpatient 2616 1700.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2537.52 97 999999999 1583.99 2537.52 percent of total billed charges T-PLATE 3.5 3H 74M OL 241.951 48713136_1 CDM 0278 RC inpatient 2616 1700.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1805.04 69 999999999 1583.99 2537.52 percent of total billed charges T-PLATE 3.5 3H 74M OL 241.951 48713136_1 CDM 0278 RC inpatient 2616 1700.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 2040.48 78 999999999 1583.99 2537.52 percent of total billed charges T-PLATE 3.5 3H 74M OL 241.951 48713136_1 CDM 0278 RC inpatient 2616 1700.4 SIHO - ALL PLANS SIHO - ALL PLANS 2354.4 90 999999999 1583.99 2537.52 percent of total billed charges T-PLATE 3.5 3H 74M OL 241.951 48713136_1 CDM 0278 RC inpatient 2616 1700.4 UMR - ALL PLANS UMR - ALL PLANS 1831.2 70 999999999 1583.99 2537.52 percent of total billed charges T-PLATE 3.5 3H 74M OL 241.951 48713136_1 CDM 0278 RC inpatient 2616 1700.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1583.99 60.55 999999999 1583.99 2537.52 percent of total billed charges T-PLATE 3.5 3H 74M OL 241.951 48713136_1 CDM 0278 RC inpatient 2616 1700.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1583.99 2537.52 T-PLATE 3.5 3H 74M OL 241.951 48713136_1 CDM 0278 RC inpatient 2616 1700.4 ANTHEM HMO ANTHEM HMO 999999999 1583.99 2537.52 T-PLATE 3.5 3H 74M OL 241.951 48713136_1 CDM 0278 RC inpatient 2616 1700.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1583.99 2537.52 T-PLATE 3.5 3H 74M OL 241.951 48713136_1 CDM 0278 RC inpatient 2616 1700.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1768.42 67.6 999999999 1583.99 2537.52 percent of total billed charges T-PLATE 3.5 3H 74M OL 241.951 48713136_1 CDM 0278 RC inpatient 2616 1700.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1583.99 2537.52 T-PLATE 3.5 3H 74M OL 241.951 48713136_1 CDM 0278 RC inpatient 2616 1700.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1583.99 2537.52 T-PLATE 3.5 3H 96M OL 241.971 48713137_1 CDM 0278 RC inpatient 2839 1845.35 AETNA AETNA 2242.81 79 999999999 1719.01 2753.83 percent of total billed charges T-PLATE 3.5 3H 96M OL 241.971 48713137_1 CDM 0278 RC inpatient 2839 1845.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1845.35 65 999999999 1719.01 2753.83 percent of total billed charges T-PLATE 3.5 3H 96M OL 241.971 48713137_1 CDM 0278 RC inpatient 2839 1845.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2753.83 97 999999999 1719.01 2753.83 percent of total billed charges T-PLATE 3.5 3H 96M OL 241.971 48713137_1 CDM 0278 RC inpatient 2839 1845.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1958.91 69 999999999 1719.01 2753.83 percent of total billed charges T-PLATE 3.5 3H 96M OL 241.971 48713137_1 CDM 0278 RC inpatient 2839 1845.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 2214.42 78 999999999 1719.01 2753.83 percent of total billed charges T-PLATE 3.5 3H 96M OL 241.971 48713137_1 CDM 0278 RC inpatient 2839 1845.35 SIHO - ALL PLANS SIHO - ALL PLANS 2555.1 90 999999999 1719.01 2753.83 percent of total billed charges T-PLATE 3.5 3H 96M OL 241.971 48713137_1 CDM 0278 RC inpatient 2839 1845.35 UMR - ALL PLANS UMR - ALL PLANS 1987.3 70 999999999 1719.01 2753.83 percent of total billed charges T-PLATE 3.5 3H 96M OL 241.971 48713137_1 CDM 0278 RC inpatient 2839 1845.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1719.01 60.55 999999999 1719.01 2753.83 percent of total billed charges T-PLATE 3.5 3H 96M OL 241.971 48713137_1 CDM 0278 RC inpatient 2839 1845.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1719.01 2753.83 T-PLATE 3.5 3H 96M OL 241.971 48713137_1 CDM 0278 RC inpatient 2839 1845.35 ANTHEM HMO ANTHEM HMO 999999999 1719.01 2753.83 T-PLATE 3.5 3H 96M OL 241.971 48713137_1 CDM 0278 RC inpatient 2839 1845.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1719.01 2753.83 T-PLATE 3.5 3H 96M OL 241.971 48713137_1 CDM 0278 RC inpatient 2839 1845.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1919.16 67.6 999999999 1719.01 2753.83 percent of total billed charges T-PLATE 3.5 3H 96M OL 241.971 48713137_1 CDM 0278 RC inpatient 2839 1845.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1719.01 2753.83 T-PLATE 3.5 3H 96M OL 241.971 48713137_1 CDM 0278 RC inpatient 2839 1845.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1719.01 2753.83 T PLATE LCP 1/3 5H 57M 241.351 48713138_1 CDM 0278 RC inpatient 1219 792.35 AETNA AETNA 963.01 79 999999999 738.1 1182.43 percent of total billed charges T PLATE LCP 1/3 5H 57M 241.351 48713138_1 CDM 0278 RC inpatient 1219 792.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 792.35 65 999999999 738.1 1182.43 percent of total billed charges T PLATE LCP 1/3 5H 57M 241.351 48713138_1 CDM 0278 RC inpatient 1219 792.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1182.43 97 999999999 738.1 1182.43 percent of total billed charges T PLATE LCP 1/3 5H 57M 241.351 48713138_1 CDM 0278 RC inpatient 1219 792.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 841.11 69 999999999 738.1 1182.43 percent of total billed charges T PLATE LCP 1/3 5H 57M 241.351 48713138_1 CDM 0278 RC inpatient 1219 792.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 950.82 78 999999999 738.1 1182.43 percent of total billed charges T PLATE LCP 1/3 5H 57M 241.351 48713138_1 CDM 0278 RC inpatient 1219 792.35 SIHO - ALL PLANS SIHO - ALL PLANS 1097.1 90 999999999 738.1 1182.43 percent of total billed charges T PLATE LCP 1/3 5H 57M 241.351 48713138_1 CDM 0278 RC inpatient 1219 792.35 UMR - ALL PLANS UMR - ALL PLANS 853.3 70 999999999 738.1 1182.43 percent of total billed charges T PLATE LCP 1/3 5H 57M 241.351 48713138_1 CDM 0278 RC inpatient 1219 792.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 738.1 60.55 999999999 738.1 1182.43 percent of total billed charges T PLATE LCP 1/3 5H 57M 241.351 48713138_1 CDM 0278 RC inpatient 1219 792.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 738.1 1182.43 T PLATE LCP 1/3 5H 57M 241.351 48713138_1 CDM 0278 RC inpatient 1219 792.35 ANTHEM HMO ANTHEM HMO 999999999 738.1 1182.43 T PLATE LCP 1/3 5H 57M 241.351 48713138_1 CDM 0278 RC inpatient 1219 792.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 738.1 1182.43 T PLATE LCP 1/3 5H 57M 241.351 48713138_1 CDM 0278 RC inpatient 1219 792.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 824.04 67.6 999999999 738.1 1182.43 percent of total billed charges T PLATE LCP 1/3 5H 57M 241.351 48713138_1 CDM 0278 RC inpatient 1219 792.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 738.1 1182.43 T PLATE LCP 1/3 5H 57M 241.351 48713138_1 CDM 0278 RC inpatient 1219 792.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 738.1 1182.43 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713139_1 CDM 0278 RC C1713 HCPCS inpatient 1286 835.9 AETNA AETNA 1015.94 79 999999999 778.67 1247.42 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713139_1 CDM 0278 RC C1713 HCPCS inpatient 1286 835.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 835.9 65 999999999 778.67 1247.42 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713139_1 CDM 0278 RC C1713 HCPCS inpatient 1286 835.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1247.42 97 999999999 778.67 1247.42 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713139_1 CDM 0278 RC C1713 HCPCS inpatient 1286 835.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 887.34 69 999999999 778.67 1247.42 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713139_1 CDM 0278 RC C1713 HCPCS inpatient 1286 835.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1003.08 78 999999999 778.67 1247.42 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713139_1 CDM 0278 RC C1713 HCPCS inpatient 1286 835.9 SIHO - ALL PLANS SIHO - ALL PLANS 1157.4 90 999999999 778.67 1247.42 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713139_1 CDM 0278 RC C1713 HCPCS inpatient 1286 835.9 UMR - ALL PLANS UMR - ALL PLANS 900.2 70 999999999 778.67 1247.42 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713139_1 CDM 0278 RC C1713 HCPCS inpatient 1286 835.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 778.67 60.55 999999999 778.67 1247.42 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713139_1 CDM 0278 RC C1713 HCPCS inpatient 1286 835.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 778.67 1247.42 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713139_1 CDM 0278 RC C1713 HCPCS inpatient 1286 835.9 ANTHEM HMO ANTHEM HMO 999999999 778.67 1247.42 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713139_1 CDM 0278 RC C1713 HCPCS inpatient 1286 835.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 778.67 1247.42 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713139_1 CDM 0278 RC C1713 HCPCS inpatient 1286 835.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 869.34 67.6 999999999 778.67 1247.42 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713139_1 CDM 0278 RC C1713 HCPCS inpatient 1286 835.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 778.67 1247.42 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713139_1 CDM 0278 RC C1713 HCPCS inpatient 1286 835.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 778.67 1247.42 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713140_1 CDM 0278 RC C1713 HCPCS inpatient 1184 769.6 AETNA AETNA 935.36 79 999999999 716.91 1148.48 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713140_1 CDM 0278 RC C1713 HCPCS inpatient 1184 769.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 769.6 65 999999999 716.91 1148.48 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713140_1 CDM 0278 RC C1713 HCPCS inpatient 1184 769.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1148.48 97 999999999 716.91 1148.48 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713140_1 CDM 0278 RC C1713 HCPCS inpatient 1184 769.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 816.96 69 999999999 716.91 1148.48 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713140_1 CDM 0278 RC C1713 HCPCS inpatient 1184 769.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 923.52 78 999999999 716.91 1148.48 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713140_1 CDM 0278 RC C1713 HCPCS inpatient 1184 769.6 SIHO - ALL PLANS SIHO - ALL PLANS 1065.6 90 999999999 716.91 1148.48 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713140_1 CDM 0278 RC C1713 HCPCS inpatient 1184 769.6 UMR - ALL PLANS UMR - ALL PLANS 828.8 70 999999999 716.91 1148.48 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713140_1 CDM 0278 RC C1713 HCPCS inpatient 1184 769.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 716.91 60.55 999999999 716.91 1148.48 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713140_1 CDM 0278 RC C1713 HCPCS inpatient 1184 769.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 716.91 1148.48 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713140_1 CDM 0278 RC C1713 HCPCS inpatient 1184 769.6 ANTHEM HMO ANTHEM HMO 999999999 716.91 1148.48 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713140_1 CDM 0278 RC C1713 HCPCS inpatient 1184 769.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 716.91 1148.48 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713140_1 CDM 0278 RC C1713 HCPCS inpatient 1184 769.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 800.38 67.6 999999999 716.91 1148.48 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713140_1 CDM 0278 RC C1713 HCPCS inpatient 1184 769.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 716.91 1148.48 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713140_1 CDM 0278 RC C1713 HCPCS inpatient 1184 769.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 716.91 1148.48 T PLATE LCP 1/3 8H 93M 241.381 48713141_1 CDM 0278 RC inpatient 1304 847.6 AETNA AETNA 1030.16 79 999999999 789.57 1264.88 percent of total billed charges T PLATE LCP 1/3 8H 93M 241.381 48713141_1 CDM 0278 RC inpatient 1304 847.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 847.6 65 999999999 789.57 1264.88 percent of total billed charges T PLATE LCP 1/3 8H 93M 241.381 48713141_1 CDM 0278 RC inpatient 1304 847.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1264.88 97 999999999 789.57 1264.88 percent of total billed charges T PLATE LCP 1/3 8H 93M 241.381 48713141_1 CDM 0278 RC inpatient 1304 847.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 899.76 69 999999999 789.57 1264.88 percent of total billed charges T PLATE LCP 1/3 8H 93M 241.381 48713141_1 CDM 0278 RC inpatient 1304 847.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1017.12 78 999999999 789.57 1264.88 percent of total billed charges T PLATE LCP 1/3 8H 93M 241.381 48713141_1 CDM 0278 RC inpatient 1304 847.6 SIHO - ALL PLANS SIHO - ALL PLANS 1173.6 90 999999999 789.57 1264.88 percent of total billed charges T PLATE LCP 1/3 8H 93M 241.381 48713141_1 CDM 0278 RC inpatient 1304 847.6 UMR - ALL PLANS UMR - ALL PLANS 912.8 70 999999999 789.57 1264.88 percent of total billed charges T PLATE LCP 1/3 8H 93M 241.381 48713141_1 CDM 0278 RC inpatient 1304 847.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 789.57 60.55 999999999 789.57 1264.88 percent of total billed charges T PLATE LCP 1/3 8H 93M 241.381 48713141_1 CDM 0278 RC inpatient 1304 847.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 789.57 1264.88 T PLATE LCP 1/3 8H 93M 241.381 48713141_1 CDM 0278 RC inpatient 1304 847.6 ANTHEM HMO ANTHEM HMO 999999999 789.57 1264.88 T PLATE LCP 1/3 8H 93M 241.381 48713141_1 CDM 0278 RC inpatient 1304 847.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 789.57 1264.88 T PLATE LCP 1/3 8H 93M 241.381 48713141_1 CDM 0278 RC inpatient 1304 847.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 881.5 67.6 999999999 789.57 1264.88 percent of total billed charges T PLATE LCP 1/3 8H 93M 241.381 48713141_1 CDM 0278 RC inpatient 1304 847.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 789.57 1264.88 T PLATE LCP 1/3 8H 93M 241.381 48713141_1 CDM 0278 RC inpatient 1304 847.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 789.57 1264.88 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713142_1 CDM 0278 RC C1713 HCPCS inpatient 1266 822.9 AETNA AETNA 1000.14 79 999999999 766.56 1228.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713142_1 CDM 0278 RC C1713 HCPCS inpatient 1266 822.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 822.9 65 999999999 766.56 1228.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713142_1 CDM 0278 RC C1713 HCPCS inpatient 1266 822.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1228.02 97 999999999 766.56 1228.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713142_1 CDM 0278 RC C1713 HCPCS inpatient 1266 822.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 873.54 69 999999999 766.56 1228.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713142_1 CDM 0278 RC C1713 HCPCS inpatient 1266 822.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 987.48 78 999999999 766.56 1228.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713142_1 CDM 0278 RC C1713 HCPCS inpatient 1266 822.9 SIHO - ALL PLANS SIHO - ALL PLANS 1139.4 90 999999999 766.56 1228.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713142_1 CDM 0278 RC C1713 HCPCS inpatient 1266 822.9 UMR - ALL PLANS UMR - ALL PLANS 886.2 70 999999999 766.56 1228.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713142_1 CDM 0278 RC C1713 HCPCS inpatient 1266 822.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 766.56 60.55 999999999 766.56 1228.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713142_1 CDM 0278 RC C1713 HCPCS inpatient 1266 822.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 766.56 1228.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713142_1 CDM 0278 RC C1713 HCPCS inpatient 1266 822.9 ANTHEM HMO ANTHEM HMO 999999999 766.56 1228.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713142_1 CDM 0278 RC C1713 HCPCS inpatient 1266 822.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 766.56 1228.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713142_1 CDM 0278 RC C1713 HCPCS inpatient 1266 822.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 855.82 67.6 999999999 766.56 1228.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713142_1 CDM 0278 RC C1713 HCPCS inpatient 1266 822.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 766.56 1228.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713142_1 CDM 0278 RC C1713 HCPCS inpatient 1266 822.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 766.56 1228.02 CONDYLAR PLATE 7H RT 443.62.96 48713143_1 CDM 0278 RC inpatient 1248 811.2 AETNA AETNA 985.92 79 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H RT 443.62.96 48713143_1 CDM 0278 RC inpatient 1248 811.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 811.2 65 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H RT 443.62.96 48713143_1 CDM 0278 RC inpatient 1248 811.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1210.56 97 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H RT 443.62.96 48713143_1 CDM 0278 RC inpatient 1248 811.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 861.12 69 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H RT 443.62.96 48713143_1 CDM 0278 RC inpatient 1248 811.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 973.44 78 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H RT 443.62.96 48713143_1 CDM 0278 RC inpatient 1248 811.2 SIHO - ALL PLANS SIHO - ALL PLANS 1123.2 90 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H RT 443.62.96 48713143_1 CDM 0278 RC inpatient 1248 811.2 UMR - ALL PLANS UMR - ALL PLANS 873.6 70 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H RT 443.62.96 48713143_1 CDM 0278 RC inpatient 1248 811.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 755.66 60.55 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H RT 443.62.96 48713143_1 CDM 0278 RC inpatient 1248 811.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 755.66 1210.56 CONDYLAR PLATE 7H RT 443.62.96 48713143_1 CDM 0278 RC inpatient 1248 811.2 ANTHEM HMO ANTHEM HMO 999999999 755.66 1210.56 CONDYLAR PLATE 7H RT 443.62.96 48713143_1 CDM 0278 RC inpatient 1248 811.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 755.66 1210.56 CONDYLAR PLATE 7H RT 443.62.96 48713143_1 CDM 0278 RC inpatient 1248 811.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 843.65 67.6 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H RT 443.62.96 48713143_1 CDM 0278 RC inpatient 1248 811.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 755.66 1210.56 CONDYLAR PLATE 7H RT 443.62.96 48713143_1 CDM 0278 RC inpatient 1248 811.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 755.66 1210.56 T PLATE LCP 1/3 12H 241.421 48713144_1 CDM 0278 RC inpatient 1352 878.8 AETNA AETNA 1068.08 79 999999999 818.64 1311.44 percent of total billed charges T PLATE LCP 1/3 12H 241.421 48713144_1 CDM 0278 RC inpatient 1352 878.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 878.8 65 999999999 818.64 1311.44 percent of total billed charges T PLATE LCP 1/3 12H 241.421 48713144_1 CDM 0278 RC inpatient 1352 878.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1311.44 97 999999999 818.64 1311.44 percent of total billed charges T PLATE LCP 1/3 12H 241.421 48713144_1 CDM 0278 RC inpatient 1352 878.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 932.88 69 999999999 818.64 1311.44 percent of total billed charges T PLATE LCP 1/3 12H 241.421 48713144_1 CDM 0278 RC inpatient 1352 878.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1054.56 78 999999999 818.64 1311.44 percent of total billed charges T PLATE LCP 1/3 12H 241.421 48713144_1 CDM 0278 RC inpatient 1352 878.8 SIHO - ALL PLANS SIHO - ALL PLANS 1216.8 90 999999999 818.64 1311.44 percent of total billed charges T PLATE LCP 1/3 12H 241.421 48713144_1 CDM 0278 RC inpatient 1352 878.8 UMR - ALL PLANS UMR - ALL PLANS 946.4 70 999999999 818.64 1311.44 percent of total billed charges T PLATE LCP 1/3 12H 241.421 48713144_1 CDM 0278 RC inpatient 1352 878.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 818.64 60.55 999999999 818.64 1311.44 percent of total billed charges T PLATE LCP 1/3 12H 241.421 48713144_1 CDM 0278 RC inpatient 1352 878.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 818.64 1311.44 T PLATE LCP 1/3 12H 241.421 48713144_1 CDM 0278 RC inpatient 1352 878.8 ANTHEM HMO ANTHEM HMO 999999999 818.64 1311.44 T PLATE LCP 1/3 12H 241.421 48713144_1 CDM 0278 RC inpatient 1352 878.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 818.64 1311.44 T PLATE LCP 1/3 12H 241.421 48713144_1 CDM 0278 RC inpatient 1352 878.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 913.95 67.6 999999999 818.64 1311.44 percent of total billed charges T PLATE LCP 1/3 12H 241.421 48713144_1 CDM 0278 RC inpatient 1352 878.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 818.64 1311.44 T PLATE LCP 1/3 12H 241.421 48713144_1 CDM 0278 RC inpatient 1352 878.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 818.64 1311.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713145_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 AETNA AETNA 774.99 79 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713145_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 637.65 65 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713145_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 951.57 97 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713145_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 676.89 69 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713145_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.18 78 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713145_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 SIHO - ALL PLANS SIHO - ALL PLANS 882.9 90 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713145_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UMR - ALL PLANS UMR - ALL PLANS 686.7 70 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713145_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594 60.55 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713145_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713145_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM HMO ANTHEM HMO 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713145_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713145_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.16 67.6 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713145_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713145_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713146_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 AETNA AETNA 671.5 79 999999999 514.68 824.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713146_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 552.5 65 999999999 514.68 824.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713146_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 824.5 97 999999999 514.68 824.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713146_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 586.5 69 999999999 514.68 824.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713146_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 663 78 999999999 514.68 824.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713146_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 SIHO - ALL PLANS SIHO - ALL PLANS 765 90 999999999 514.68 824.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713146_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 UMR - ALL PLANS UMR - ALL PLANS 595 70 999999999 514.68 824.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713146_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 514.68 60.55 999999999 514.68 824.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713146_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 514.68 824.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713146_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 ANTHEM HMO ANTHEM HMO 999999999 514.68 824.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713146_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 514.68 824.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713146_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 574.6 67.6 999999999 514.68 824.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713146_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 514.68 824.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713146_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 514.68 824.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713147_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 AETNA AETNA 671.5 79 999999999 514.68 824.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713147_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 552.5 65 999999999 514.68 824.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713147_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 824.5 97 999999999 514.68 824.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713147_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 586.5 69 999999999 514.68 824.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713147_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 663 78 999999999 514.68 824.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713147_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 SIHO - ALL PLANS SIHO - ALL PLANS 765 90 999999999 514.68 824.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713147_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 UMR - ALL PLANS UMR - ALL PLANS 595 70 999999999 514.68 824.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713147_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 514.68 60.55 999999999 514.68 824.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713147_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 514.68 824.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713147_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 ANTHEM HMO ANTHEM HMO 999999999 514.68 824.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713147_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 514.68 824.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713147_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 574.6 67.6 999999999 514.68 824.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713147_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 514.68 824.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713147_1 CDM 0278 RC C1713 HCPCS inpatient 850 552.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 514.68 824.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713148_1 CDM 0278 RC C1713 HCPCS inpatient 815 529.75 AETNA AETNA 643.85 79 999999999 493.48 790.55 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713148_1 CDM 0278 RC C1713 HCPCS inpatient 815 529.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 529.75 65 999999999 493.48 790.55 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713148_1 CDM 0278 RC C1713 HCPCS inpatient 815 529.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 790.55 97 999999999 493.48 790.55 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713148_1 CDM 0278 RC C1713 HCPCS inpatient 815 529.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 562.35 69 999999999 493.48 790.55 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713148_1 CDM 0278 RC C1713 HCPCS inpatient 815 529.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 635.7 78 999999999 493.48 790.55 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713148_1 CDM 0278 RC C1713 HCPCS inpatient 815 529.75 SIHO - ALL PLANS SIHO - ALL PLANS 733.5 90 999999999 493.48 790.55 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713148_1 CDM 0278 RC C1713 HCPCS inpatient 815 529.75 UMR - ALL PLANS UMR - ALL PLANS 570.5 70 999999999 493.48 790.55 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713148_1 CDM 0278 RC C1713 HCPCS inpatient 815 529.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 493.48 60.55 999999999 493.48 790.55 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713148_1 CDM 0278 RC C1713 HCPCS inpatient 815 529.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 493.48 790.55 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713148_1 CDM 0278 RC C1713 HCPCS inpatient 815 529.75 ANTHEM HMO ANTHEM HMO 999999999 493.48 790.55 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713148_1 CDM 0278 RC C1713 HCPCS inpatient 815 529.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 493.48 790.55 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713148_1 CDM 0278 RC C1713 HCPCS inpatient 815 529.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 550.94 67.6 999999999 493.48 790.55 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713148_1 CDM 0278 RC C1713 HCPCS inpatient 815 529.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 493.48 790.55 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713148_1 CDM 0278 RC C1713 HCPCS inpatient 815 529.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 493.48 790.55 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713149_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 AETNA AETNA 751.29 79 999999999 575.83 922.47 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713149_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 618.15 65 999999999 575.83 922.47 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713149_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 922.47 97 999999999 575.83 922.47 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713149_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 656.19 69 999999999 575.83 922.47 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713149_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 741.78 78 999999999 575.83 922.47 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713149_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 SIHO - ALL PLANS SIHO - ALL PLANS 855.9 90 999999999 575.83 922.47 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713149_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 UMR - ALL PLANS UMR - ALL PLANS 665.7 70 999999999 575.83 922.47 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713149_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 575.83 60.55 999999999 575.83 922.47 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713149_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 575.83 922.47 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713149_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 ANTHEM HMO ANTHEM HMO 999999999 575.83 922.47 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713149_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 575.83 922.47 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713149_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 642.88 67.6 999999999 575.83 922.47 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713149_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 575.83 922.47 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713149_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 575.83 922.47 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713150_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 AETNA AETNA 751.29 79 999999999 575.83 922.47 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713150_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 618.15 65 999999999 575.83 922.47 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713150_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 922.47 97 999999999 575.83 922.47 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713150_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 656.19 69 999999999 575.83 922.47 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713150_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 741.78 78 999999999 575.83 922.47 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713150_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 SIHO - ALL PLANS SIHO - ALL PLANS 855.9 90 999999999 575.83 922.47 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713150_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 UMR - ALL PLANS UMR - ALL PLANS 665.7 70 999999999 575.83 922.47 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713150_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 575.83 60.55 999999999 575.83 922.47 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713150_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 575.83 922.47 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713150_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 ANTHEM HMO ANTHEM HMO 999999999 575.83 922.47 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713150_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 575.83 922.47 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713150_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 642.88 67.6 999999999 575.83 922.47 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713150_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 575.83 922.47 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713150_1 CDM 0278 RC C1713 HCPCS inpatient 951 618.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 575.83 922.47 CONDYLAR PLATE 7H LT 443.61.96 48713151_1 CDM 0278 RC inpatient 1248 811.2 AETNA AETNA 985.92 79 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H LT 443.61.96 48713151_1 CDM 0278 RC inpatient 1248 811.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 811.2 65 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H LT 443.61.96 48713151_1 CDM 0278 RC inpatient 1248 811.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1210.56 97 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H LT 443.61.96 48713151_1 CDM 0278 RC inpatient 1248 811.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 861.12 69 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H LT 443.61.96 48713151_1 CDM 0278 RC inpatient 1248 811.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 973.44 78 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H LT 443.61.96 48713151_1 CDM 0278 RC inpatient 1248 811.2 SIHO - ALL PLANS SIHO - ALL PLANS 1123.2 90 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H LT 443.61.96 48713151_1 CDM 0278 RC inpatient 1248 811.2 UMR - ALL PLANS UMR - ALL PLANS 873.6 70 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H LT 443.61.96 48713151_1 CDM 0278 RC inpatient 1248 811.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 755.66 60.55 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H LT 443.61.96 48713151_1 CDM 0278 RC inpatient 1248 811.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 755.66 1210.56 CONDYLAR PLATE 7H LT 443.61.96 48713151_1 CDM 0278 RC inpatient 1248 811.2 ANTHEM HMO ANTHEM HMO 999999999 755.66 1210.56 CONDYLAR PLATE 7H LT 443.61.96 48713151_1 CDM 0278 RC inpatient 1248 811.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 755.66 1210.56 CONDYLAR PLATE 7H LT 443.61.96 48713151_1 CDM 0278 RC inpatient 1248 811.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 843.65 67.6 999999999 755.66 1210.56 percent of total billed charges CONDYLAR PLATE 7H LT 443.61.96 48713151_1 CDM 0278 RC inpatient 1248 811.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 755.66 1210.56 CONDYLAR PLATE 7H LT 443.61.96 48713151_1 CDM 0278 RC inpatient 1248 811.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 755.66 1210.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713152_1 CDM 0278 RC C1713 HCPCS inpatient 847 550.55 AETNA AETNA 669.13 79 999999999 512.86 821.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713152_1 CDM 0278 RC C1713 HCPCS inpatient 847 550.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 550.55 65 999999999 512.86 821.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713152_1 CDM 0278 RC C1713 HCPCS inpatient 847 550.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 821.59 97 999999999 512.86 821.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713152_1 CDM 0278 RC C1713 HCPCS inpatient 847 550.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 584.43 69 999999999 512.86 821.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713152_1 CDM 0278 RC C1713 HCPCS inpatient 847 550.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 660.66 78 999999999 512.86 821.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713152_1 CDM 0278 RC C1713 HCPCS inpatient 847 550.55 SIHO - ALL PLANS SIHO - ALL PLANS 762.3 90 999999999 512.86 821.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713152_1 CDM 0278 RC C1713 HCPCS inpatient 847 550.55 UMR - ALL PLANS UMR - ALL PLANS 592.9 70 999999999 512.86 821.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713152_1 CDM 0278 RC C1713 HCPCS inpatient 847 550.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 512.86 60.55 999999999 512.86 821.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713152_1 CDM 0278 RC C1713 HCPCS inpatient 847 550.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 512.86 821.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713152_1 CDM 0278 RC C1713 HCPCS inpatient 847 550.55 ANTHEM HMO ANTHEM HMO 999999999 512.86 821.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713152_1 CDM 0278 RC C1713 HCPCS inpatient 847 550.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 512.86 821.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713152_1 CDM 0278 RC C1713 HCPCS inpatient 847 550.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 572.57 67.6 999999999 512.86 821.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713152_1 CDM 0278 RC C1713 HCPCS inpatient 847 550.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 512.86 821.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713152_1 CDM 0278 RC C1713 HCPCS inpatient 847 550.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 512.86 821.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713153_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 AETNA AETNA 774.99 79 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713153_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 637.65 65 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713153_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 951.57 97 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713153_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 676.89 69 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713153_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.18 78 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713153_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 SIHO - ALL PLANS SIHO - ALL PLANS 882.9 90 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713153_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UMR - ALL PLANS UMR - ALL PLANS 686.7 70 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713153_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594 60.55 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713153_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713153_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM HMO ANTHEM HMO 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713153_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713153_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.16 67.6 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713153_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713153_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713154_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 AETNA AETNA 774.99 79 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713154_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 637.65 65 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713154_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 951.57 97 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713154_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 676.89 69 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713154_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.18 78 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713154_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 SIHO - ALL PLANS SIHO - ALL PLANS 882.9 90 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713154_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UMR - ALL PLANS UMR - ALL PLANS 686.7 70 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713154_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594 60.55 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713154_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713154_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM HMO ANTHEM HMO 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713154_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713154_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.16 67.6 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713154_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713154_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713155_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 AETNA AETNA 774.99 79 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713155_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 637.65 65 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713155_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 951.57 97 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713155_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 676.89 69 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713155_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.18 78 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713155_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 SIHO - ALL PLANS SIHO - ALL PLANS 882.9 90 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713155_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UMR - ALL PLANS UMR - ALL PLANS 686.7 70 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713155_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594 60.55 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713155_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713155_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM HMO ANTHEM HMO 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713155_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713155_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.16 67.6 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713155_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713155_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713156_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 AETNA AETNA 678.61 79 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713156_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 558.35 65 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713156_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 833.23 97 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713156_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 592.71 69 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713156_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 670.02 78 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713156_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 SIHO - ALL PLANS SIHO - ALL PLANS 773.1 90 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713156_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 UMR - ALL PLANS UMR - ALL PLANS 601.3 70 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713156_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 520.12 60.55 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713156_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 520.12 833.23 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713156_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 ANTHEM HMO ANTHEM HMO 999999999 520.12 833.23 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713156_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 520.12 833.23 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713156_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 580.68 67.6 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713156_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 520.12 833.23 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713156_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 520.12 833.23 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713157_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 AETNA AETNA 774.99 79 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713157_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 637.65 65 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713157_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 951.57 97 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713157_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 676.89 69 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713157_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.18 78 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713157_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 SIHO - ALL PLANS SIHO - ALL PLANS 882.9 90 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713157_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UMR - ALL PLANS UMR - ALL PLANS 686.7 70 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713157_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594 60.55 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713157_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713157_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM HMO ANTHEM HMO 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713157_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713157_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.16 67.6 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713157_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713157_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 594 951.57 SCREW 3.5 LOCKING 34MM 212.113 48713158_1 CDM 0278 RC inpatient 981 637.65 AETNA AETNA 774.99 79 999999999 594 951.57 percent of total billed charges SCREW 3.5 LOCKING 34MM 212.113 48713158_1 CDM 0278 RC inpatient 981 637.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 637.65 65 999999999 594 951.57 percent of total billed charges SCREW 3.5 LOCKING 34MM 212.113 48713158_1 CDM 0278 RC inpatient 981 637.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 951.57 97 999999999 594 951.57 percent of total billed charges SCREW 3.5 LOCKING 34MM 212.113 48713158_1 CDM 0278 RC inpatient 981 637.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 676.89 69 999999999 594 951.57 percent of total billed charges SCREW 3.5 LOCKING 34MM 212.113 48713158_1 CDM 0278 RC inpatient 981 637.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.18 78 999999999 594 951.57 percent of total billed charges SCREW 3.5 LOCKING 34MM 212.113 48713158_1 CDM 0278 RC inpatient 981 637.65 SIHO - ALL PLANS SIHO - ALL PLANS 882.9 90 999999999 594 951.57 percent of total billed charges SCREW 3.5 LOCKING 34MM 212.113 48713158_1 CDM 0278 RC inpatient 981 637.65 UMR - ALL PLANS UMR - ALL PLANS 686.7 70 999999999 594 951.57 percent of total billed charges SCREW 3.5 LOCKING 34MM 212.113 48713158_1 CDM 0278 RC inpatient 981 637.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594 60.55 999999999 594 951.57 percent of total billed charges SCREW 3.5 LOCKING 34MM 212.113 48713158_1 CDM 0278 RC inpatient 981 637.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594 951.57 SCREW 3.5 LOCKING 34MM 212.113 48713158_1 CDM 0278 RC inpatient 981 637.65 ANTHEM HMO ANTHEM HMO 999999999 594 951.57 SCREW 3.5 LOCKING 34MM 212.113 48713158_1 CDM 0278 RC inpatient 981 637.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594 951.57 SCREW 3.5 LOCKING 34MM 212.113 48713158_1 CDM 0278 RC inpatient 981 637.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.16 67.6 999999999 594 951.57 percent of total billed charges SCREW 3.5 LOCKING 34MM 212.113 48713158_1 CDM 0278 RC inpatient 981 637.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594 951.57 SCREW 3.5 LOCKING 34MM 212.113 48713158_1 CDM 0278 RC inpatient 981 637.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 594 951.57 T-PLATE 4\HOLE 1.3 TI 421.334 48713159_1 CDM 0278 RC inpatient 994 646.1 AETNA AETNA 785.26 79 999999999 601.87 964.18 percent of total billed charges T-PLATE 4\HOLE 1.3 TI 421.334 48713159_1 CDM 0278 RC inpatient 994 646.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 646.1 65 999999999 601.87 964.18 percent of total billed charges T-PLATE 4\HOLE 1.3 TI 421.334 48713159_1 CDM 0278 RC inpatient 994 646.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 964.18 97 999999999 601.87 964.18 percent of total billed charges T-PLATE 4\HOLE 1.3 TI 421.334 48713159_1 CDM 0278 RC inpatient 994 646.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 685.86 69 999999999 601.87 964.18 percent of total billed charges T-PLATE 4\HOLE 1.3 TI 421.334 48713159_1 CDM 0278 RC inpatient 994 646.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 775.32 78 999999999 601.87 964.18 percent of total billed charges T-PLATE 4\HOLE 1.3 TI 421.334 48713159_1 CDM 0278 RC inpatient 994 646.1 SIHO - ALL PLANS SIHO - ALL PLANS 894.6 90 999999999 601.87 964.18 percent of total billed charges T-PLATE 4\HOLE 1.3 TI 421.334 48713159_1 CDM 0278 RC inpatient 994 646.1 UMR - ALL PLANS UMR - ALL PLANS 695.8 70 999999999 601.87 964.18 percent of total billed charges T-PLATE 4\HOLE 1.3 TI 421.334 48713159_1 CDM 0278 RC inpatient 994 646.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 601.87 60.55 999999999 601.87 964.18 percent of total billed charges T-PLATE 4\HOLE 1.3 TI 421.334 48713159_1 CDM 0278 RC inpatient 994 646.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 601.87 964.18 T-PLATE 4\HOLE 1.3 TI 421.334 48713159_1 CDM 0278 RC inpatient 994 646.1 ANTHEM HMO ANTHEM HMO 999999999 601.87 964.18 T-PLATE 4\HOLE 1.3 TI 421.334 48713159_1 CDM 0278 RC inpatient 994 646.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 601.87 964.18 T-PLATE 4\HOLE 1.3 TI 421.334 48713159_1 CDM 0278 RC inpatient 994 646.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 671.94 67.6 999999999 601.87 964.18 percent of total billed charges T-PLATE 4\HOLE 1.3 TI 421.334 48713159_1 CDM 0278 RC inpatient 994 646.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 601.87 964.18 T-PLATE 4\HOLE 1.3 TI 421.334 48713159_1 CDM 0278 RC inpatient 994 646.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 601.87 964.18 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713160_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 AETNA AETNA 774.99 79 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713160_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 637.65 65 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713160_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 951.57 97 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713160_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 676.89 69 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713160_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.18 78 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713160_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 SIHO - ALL PLANS SIHO - ALL PLANS 882.9 90 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713160_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UMR - ALL PLANS UMR - ALL PLANS 686.7 70 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713160_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594 60.55 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713160_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713160_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM HMO ANTHEM HMO 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713160_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713160_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.16 67.6 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713160_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713160_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713161_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 AETNA AETNA 774.99 79 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713161_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 637.65 65 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713161_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 951.57 97 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713161_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 676.89 69 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713161_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.18 78 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713161_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 SIHO - ALL PLANS SIHO - ALL PLANS 882.9 90 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713161_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UMR - ALL PLANS UMR - ALL PLANS 686.7 70 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713161_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594 60.55 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713161_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713161_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM HMO ANTHEM HMO 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713161_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713161_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.16 67.6 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713161_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713161_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713162_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 AETNA AETNA 774.99 79 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713162_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 637.65 65 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713162_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 951.57 97 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713162_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 676.89 69 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713162_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.18 78 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713162_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 SIHO - ALL PLANS SIHO - ALL PLANS 882.9 90 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713162_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UMR - ALL PLANS UMR - ALL PLANS 686.7 70 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713162_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594 60.55 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713162_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713162_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM HMO ANTHEM HMO 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713162_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713162_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.16 67.6 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713162_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713162_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713163_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 AETNA AETNA 774.99 79 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713163_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 637.65 65 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713163_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 951.57 97 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713163_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 676.89 69 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713163_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.18 78 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713163_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 SIHO - ALL PLANS SIHO - ALL PLANS 882.9 90 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713163_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UMR - ALL PLANS UMR - ALL PLANS 686.7 70 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713163_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594 60.55 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713163_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713163_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM HMO ANTHEM HMO 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713163_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713163_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.16 67.6 999999999 594 951.57 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713163_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713163_1 CDM 0278 RC C1713 HCPCS inpatient 981 637.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 594 951.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713164_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 AETNA AETNA 678.61 79 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713164_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 558.35 65 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713164_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 833.23 97 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713164_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 592.71 69 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713164_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 670.02 78 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713164_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 SIHO - ALL PLANS SIHO - ALL PLANS 773.1 90 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713164_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 UMR - ALL PLANS UMR - ALL PLANS 601.3 70 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713164_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 520.12 60.55 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713164_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 520.12 833.23 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713164_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 ANTHEM HMO ANTHEM HMO 999999999 520.12 833.23 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713164_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 520.12 833.23 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713164_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 580.68 67.6 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713164_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 520.12 833.23 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713164_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 520.12 833.23 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713165_1 CDM 0278 RC C1713 HCPCS inpatient 782 508.3 AETNA AETNA 617.78 79 999999999 473.5 758.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713165_1 CDM 0278 RC C1713 HCPCS inpatient 782 508.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 508.3 65 999999999 473.5 758.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713165_1 CDM 0278 RC C1713 HCPCS inpatient 782 508.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 758.54 97 999999999 473.5 758.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713165_1 CDM 0278 RC C1713 HCPCS inpatient 782 508.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 539.58 69 999999999 473.5 758.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713165_1 CDM 0278 RC C1713 HCPCS inpatient 782 508.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 609.96 78 999999999 473.5 758.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713165_1 CDM 0278 RC C1713 HCPCS inpatient 782 508.3 UMR - ALL PLANS UMR - ALL PLANS 547.4 70 999999999 473.5 758.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713165_1 CDM 0278 RC C1713 HCPCS inpatient 782 508.3 SIHO - ALL PLANS SIHO - ALL PLANS 703.8 90 999999999 473.5 758.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713165_1 CDM 0278 RC C1713 HCPCS inpatient 782 508.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 473.5 60.55 999999999 473.5 758.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713165_1 CDM 0278 RC C1713 HCPCS inpatient 782 508.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 473.5 758.54 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713165_1 CDM 0278 RC C1713 HCPCS inpatient 782 508.3 ANTHEM HMO ANTHEM HMO 999999999 473.5 758.54 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713165_1 CDM 0278 RC C1713 HCPCS inpatient 782 508.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 473.5 758.54 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713165_1 CDM 0278 RC C1713 HCPCS inpatient 782 508.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 528.63 67.6 999999999 473.5 758.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713165_1 CDM 0278 RC C1713 HCPCS inpatient 782 508.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 473.5 758.54 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713165_1 CDM 0278 RC C1713 HCPCS inpatient 782 508.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 473.5 758.54 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713166_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 AETNA AETNA 678.61 79 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713166_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 558.35 65 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713166_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 833.23 97 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713166_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 592.71 69 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713166_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 670.02 78 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713166_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 UMR - ALL PLANS UMR - ALL PLANS 601.3 70 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713166_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 SIHO - ALL PLANS SIHO - ALL PLANS 773.1 90 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713166_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 520.12 60.55 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713166_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 520.12 833.23 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713166_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 ANTHEM HMO ANTHEM HMO 999999999 520.12 833.23 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713166_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 520.12 833.23 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713166_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 580.68 67.6 999999999 520.12 833.23 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713166_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 520.12 833.23 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713166_1 CDM 0278 RC C1713 HCPCS inpatient 859 558.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 520.12 833.23 T-PLATE 3/HOLE 1.3 TI 421.333 48713167_1 CDM 0278 RC inpatient 950 617.5 AETNA AETNA 750.5 79 999999999 575.23 921.5 percent of total billed charges T-PLATE 3/HOLE 1.3 TI 421.333 48713167_1 CDM 0278 RC inpatient 950 617.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 617.5 65 999999999 575.23 921.5 percent of total billed charges T-PLATE 3/HOLE 1.3 TI 421.333 48713167_1 CDM 0278 RC inpatient 950 617.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 921.5 97 999999999 575.23 921.5 percent of total billed charges T-PLATE 3/HOLE 1.3 TI 421.333 48713167_1 CDM 0278 RC inpatient 950 617.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 655.5 69 999999999 575.23 921.5 percent of total billed charges T-PLATE 3/HOLE 1.3 TI 421.333 48713167_1 CDM 0278 RC inpatient 950 617.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 741 78 999999999 575.23 921.5 percent of total billed charges T-PLATE 3/HOLE 1.3 TI 421.333 48713167_1 CDM 0278 RC inpatient 950 617.5 UMR - ALL PLANS UMR - ALL PLANS 665 70 999999999 575.23 921.5 percent of total billed charges T-PLATE 3/HOLE 1.3 TI 421.333 48713167_1 CDM 0278 RC inpatient 950 617.5 SIHO - ALL PLANS SIHO - ALL PLANS 855 90 999999999 575.23 921.5 percent of total billed charges T-PLATE 3/HOLE 1.3 TI 421.333 48713167_1 CDM 0278 RC inpatient 950 617.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 575.23 60.55 999999999 575.23 921.5 percent of total billed charges T-PLATE 3/HOLE 1.3 TI 421.333 48713167_1 CDM 0278 RC inpatient 950 617.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 575.23 921.5 T-PLATE 3/HOLE 1.3 TI 421.333 48713167_1 CDM 0278 RC inpatient 950 617.5 ANTHEM HMO ANTHEM HMO 999999999 575.23 921.5 T-PLATE 3/HOLE 1.3 TI 421.333 48713167_1 CDM 0278 RC inpatient 950 617.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 575.23 921.5 T-PLATE 3/HOLE 1.3 TI 421.333 48713167_1 CDM 0278 RC inpatient 950 617.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 642.2 67.6 999999999 575.23 921.5 percent of total billed charges T-PLATE 3/HOLE 1.3 TI 421.333 48713167_1 CDM 0278 RC inpatient 950 617.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 575.23 921.5 T-PLATE 3/HOLE 1.3 TI 421.333 48713167_1 CDM 0278 RC inpatient 950 617.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 575.23 921.5 DRILL BIT 2.0MM 125MM 310.21 48713168_1 CDM 0272 RC inpatient 617 401.05 AETNA AETNA 487.43 79 999999999 373.59 598.49 percent of total billed charges DRILL BIT 2.0MM 125MM 310.21 48713168_1 CDM 0272 RC inpatient 617 401.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 401.05 65 999999999 373.59 598.49 percent of total billed charges DRILL BIT 2.0MM 125MM 310.21 48713168_1 CDM 0272 RC inpatient 617 401.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 598.49 97 999999999 373.59 598.49 percent of total billed charges DRILL BIT 2.0MM 125MM 310.21 48713168_1 CDM 0272 RC inpatient 617 401.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 425.73 69 999999999 373.59 598.49 percent of total billed charges DRILL BIT 2.0MM 125MM 310.21 48713168_1 CDM 0272 RC inpatient 617 401.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 481.26 78 999999999 373.59 598.49 percent of total billed charges DRILL BIT 2.0MM 125MM 310.21 48713168_1 CDM 0272 RC inpatient 617 401.05 UMR - ALL PLANS UMR - ALL PLANS 431.9 70 999999999 373.59 598.49 percent of total billed charges DRILL BIT 2.0MM 125MM 310.21 48713168_1 CDM 0272 RC inpatient 617 401.05 SIHO - ALL PLANS SIHO - ALL PLANS 555.3 90 999999999 373.59 598.49 percent of total billed charges DRILL BIT 2.0MM 125MM 310.21 48713168_1 CDM 0272 RC inpatient 617 401.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 373.59 60.55 999999999 373.59 598.49 percent of total billed charges DRILL BIT 2.0MM 125MM 310.21 48713168_1 CDM 0272 RC inpatient 617 401.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 373.59 598.49 DRILL BIT 2.0MM 125MM 310.21 48713168_1 CDM 0272 RC inpatient 617 401.05 ANTHEM HMO ANTHEM HMO 999999999 373.59 598.49 DRILL BIT 2.0MM 125MM 310.21 48713168_1 CDM 0272 RC inpatient 617 401.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 373.59 598.49 DRILL BIT 2.0MM 125MM 310.21 48713168_1 CDM 0272 RC inpatient 617 401.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 417.09 67.6 999999999 373.59 598.49 percent of total billed charges DRILL BIT 2.0MM 125MM 310.21 48713168_1 CDM 0272 RC inpatient 617 401.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 373.59 598.49 DRILL BIT 2.0MM 125MM 310.21 48713168_1 CDM 0272 RC inpatient 617 401.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 373.59 598.49 DRILL BIT 2.8MM/165MM 310.288 48713169_1 CDM 0272 RC inpatient 624 405.6 AETNA AETNA 492.96 79 999999999 377.83 605.28 percent of total billed charges DRILL BIT 2.8MM/165MM 310.288 48713169_1 CDM 0272 RC inpatient 624 405.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 405.6 65 999999999 377.83 605.28 percent of total billed charges DRILL BIT 2.8MM/165MM 310.288 48713169_1 CDM 0272 RC inpatient 624 405.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 605.28 97 999999999 377.83 605.28 percent of total billed charges DRILL BIT 2.8MM/165MM 310.288 48713169_1 CDM 0272 RC inpatient 624 405.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 430.56 69 999999999 377.83 605.28 percent of total billed charges DRILL BIT 2.8MM/165MM 310.288 48713169_1 CDM 0272 RC inpatient 624 405.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 486.72 78 999999999 377.83 605.28 percent of total billed charges DRILL BIT 2.8MM/165MM 310.288 48713169_1 CDM 0272 RC inpatient 624 405.6 UMR - ALL PLANS UMR - ALL PLANS 436.8 70 999999999 377.83 605.28 percent of total billed charges DRILL BIT 2.8MM/165MM 310.288 48713169_1 CDM 0272 RC inpatient 624 405.6 SIHO - ALL PLANS SIHO - ALL PLANS 561.6 90 999999999 377.83 605.28 percent of total billed charges DRILL BIT 2.8MM/165MM 310.288 48713169_1 CDM 0272 RC inpatient 624 405.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 377.83 60.55 999999999 377.83 605.28 percent of total billed charges DRILL BIT 2.8MM/165MM 310.288 48713169_1 CDM 0272 RC inpatient 624 405.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 377.83 605.28 DRILL BIT 2.8MM/165MM 310.288 48713169_1 CDM 0272 RC inpatient 624 405.6 ANTHEM HMO ANTHEM HMO 999999999 377.83 605.28 DRILL BIT 2.8MM/165MM 310.288 48713169_1 CDM 0272 RC inpatient 624 405.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 377.83 605.28 DRILL BIT 2.8MM/165MM 310.288 48713169_1 CDM 0272 RC inpatient 624 405.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 421.82 67.6 999999999 377.83 605.28 percent of total billed charges DRILL BIT 2.8MM/165MM 310.288 48713169_1 CDM 0272 RC inpatient 624 405.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 377.83 605.28 DRILL BIT 2.8MM/165MM 310.288 48713169_1 CDM 0272 RC inpatient 624 405.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 377.83 605.28 DRILL BIT 3.5MM/110MM 310.35 - 48713170_1 CDM 0272 RC inpatient 666 432.9 AETNA AETNA 526.14 79 999999999 403.26 646.02 percent of total billed charges DRILL BIT 3.5MM/110MM 310.35 - 48713170_1 CDM 0272 RC inpatient 666 432.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 432.9 65 999999999 403.26 646.02 percent of total billed charges DRILL BIT 3.5MM/110MM 310.35 - 48713170_1 CDM 0272 RC inpatient 666 432.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 646.02 97 999999999 403.26 646.02 percent of total billed charges DRILL BIT 3.5MM/110MM 310.35 - 48713170_1 CDM 0272 RC inpatient 666 432.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 459.54 69 999999999 403.26 646.02 percent of total billed charges DRILL BIT 3.5MM/110MM 310.35 - 48713170_1 CDM 0272 RC inpatient 666 432.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 519.48 78 999999999 403.26 646.02 percent of total billed charges DRILL BIT 3.5MM/110MM 310.35 - 48713170_1 CDM 0272 RC inpatient 666 432.9 UMR - ALL PLANS UMR - ALL PLANS 466.2 70 999999999 403.26 646.02 percent of total billed charges DRILL BIT 3.5MM/110MM 310.35 - 48713170_1 CDM 0272 RC inpatient 666 432.9 SIHO - ALL PLANS SIHO - ALL PLANS 599.4 90 999999999 403.26 646.02 percent of total billed charges DRILL BIT 3.5MM/110MM 310.35 - 48713170_1 CDM 0272 RC inpatient 666 432.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 403.26 60.55 999999999 403.26 646.02 percent of total billed charges DRILL BIT 3.5MM/110MM 310.35 - 48713170_1 CDM 0272 RC inpatient 666 432.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 403.26 646.02 DRILL BIT 3.5MM/110MM 310.35 - 48713170_1 CDM 0272 RC inpatient 666 432.9 ANTHEM HMO ANTHEM HMO 999999999 403.26 646.02 DRILL BIT 3.5MM/110MM 310.35 - 48713170_1 CDM 0272 RC inpatient 666 432.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 403.26 646.02 DRILL BIT 3.5MM/110MM 310.35 - 48713170_1 CDM 0272 RC inpatient 666 432.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 450.22 67.6 999999999 403.26 646.02 percent of total billed charges DRILL BIT 3.5MM/110MM 310.35 - 48713170_1 CDM 0272 RC inpatient 666 432.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 403.26 646.02 DRILL BIT 3.5MM/110MM 310.35 - 48713170_1 CDM 0272 RC inpatient 666 432.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 403.26 646.02 DRILL BIT 2.7MM/125MM 315.28 48713171_1 CDM 0272 RC inpatient 790 513.5 AETNA AETNA 624.1 79 999999999 478.35 766.3 percent of total billed charges DRILL BIT 2.7MM/125MM 315.28 48713171_1 CDM 0272 RC inpatient 790 513.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 513.5 65 999999999 478.35 766.3 percent of total billed charges DRILL BIT 2.7MM/125MM 315.28 48713171_1 CDM 0272 RC inpatient 790 513.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 766.3 97 999999999 478.35 766.3 percent of total billed charges DRILL BIT 2.7MM/125MM 315.28 48713171_1 CDM 0272 RC inpatient 790 513.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 545.1 69 999999999 478.35 766.3 percent of total billed charges DRILL BIT 2.7MM/125MM 315.28 48713171_1 CDM 0272 RC inpatient 790 513.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 616.2 78 999999999 478.35 766.3 percent of total billed charges DRILL BIT 2.7MM/125MM 315.28 48713171_1 CDM 0272 RC inpatient 790 513.5 UMR - ALL PLANS UMR - ALL PLANS 553 70 999999999 478.35 766.3 percent of total billed charges DRILL BIT 2.7MM/125MM 315.28 48713171_1 CDM 0272 RC inpatient 790 513.5 SIHO - ALL PLANS SIHO - ALL PLANS 711 90 999999999 478.35 766.3 percent of total billed charges DRILL BIT 2.7MM/125MM 315.28 48713171_1 CDM 0272 RC inpatient 790 513.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 478.35 60.55 999999999 478.35 766.3 percent of total billed charges DRILL BIT 2.7MM/125MM 315.28 48713171_1 CDM 0272 RC inpatient 790 513.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 478.35 766.3 DRILL BIT 2.7MM/125MM 315.28 48713171_1 CDM 0272 RC inpatient 790 513.5 ANTHEM HMO ANTHEM HMO 999999999 478.35 766.3 DRILL BIT 2.7MM/125MM 315.28 48713171_1 CDM 0272 RC inpatient 790 513.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 478.35 766.3 DRILL BIT 2.7MM/125MM 315.28 48713171_1 CDM 0272 RC inpatient 790 513.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 534.04 67.6 999999999 478.35 766.3 percent of total billed charges DRILL BIT 2.7MM/125MM 315.28 48713171_1 CDM 0272 RC inpatient 790 513.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 478.35 766.3 DRILL BIT 2.7MM/125MM 315.28 48713171_1 CDM 0272 RC inpatient 790 513.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 478.35 766.3 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713172_1 CDM 0278 RC C1713 HCPCS inpatient 6709 4360.85 AETNA AETNA 5300.11 79 999999999 4062.3 6507.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713172_1 CDM 0278 RC C1713 HCPCS inpatient 6709 4360.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 4360.85 65 999999999 4062.3 6507.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713172_1 CDM 0278 RC C1713 HCPCS inpatient 6709 4360.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6507.73 97 999999999 4062.3 6507.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713172_1 CDM 0278 RC C1713 HCPCS inpatient 6709 4360.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 4629.21 69 999999999 4062.3 6507.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713172_1 CDM 0278 RC C1713 HCPCS inpatient 6709 4360.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 5233.02 78 999999999 4062.3 6507.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713172_1 CDM 0278 RC C1713 HCPCS inpatient 6709 4360.85 UMR - ALL PLANS UMR - ALL PLANS 4696.3 70 999999999 4062.3 6507.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713172_1 CDM 0278 RC C1713 HCPCS inpatient 6709 4360.85 SIHO - ALL PLANS SIHO - ALL PLANS 6038.1 90 999999999 4062.3 6507.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713172_1 CDM 0278 RC C1713 HCPCS inpatient 6709 4360.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4062.3 60.55 999999999 4062.3 6507.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713172_1 CDM 0278 RC C1713 HCPCS inpatient 6709 4360.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4062.3 6507.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713172_1 CDM 0278 RC C1713 HCPCS inpatient 6709 4360.85 ANTHEM HMO ANTHEM HMO 999999999 4062.3 6507.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713172_1 CDM 0278 RC C1713 HCPCS inpatient 6709 4360.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4062.3 6507.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713172_1 CDM 0278 RC C1713 HCPCS inpatient 6709 4360.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 4535.28 67.6 999999999 4062.3 6507.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713172_1 CDM 0278 RC C1713 HCPCS inpatient 6709 4360.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4062.3 6507.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713172_1 CDM 0278 RC C1713 HCPCS inpatient 6709 4360.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 4062.3 6507.73 PLATE 3.5 HUMERUS 5H 241.903 48713173_1 CDM 0278 RC inpatient 5773 3752.45 AETNA AETNA 4560.67 79 999999999 3495.55 5599.81 percent of total billed charges PLATE 3.5 HUMERUS 5H 241.903 48713173_1 CDM 0278 RC inpatient 5773 3752.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 3752.45 65 999999999 3495.55 5599.81 percent of total billed charges PLATE 3.5 HUMERUS 5H 241.903 48713173_1 CDM 0278 RC inpatient 5773 3752.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5599.81 97 999999999 3495.55 5599.81 percent of total billed charges PLATE 3.5 HUMERUS 5H 241.903 48713173_1 CDM 0278 RC inpatient 5773 3752.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 3983.37 69 999999999 3495.55 5599.81 percent of total billed charges PLATE 3.5 HUMERUS 5H 241.903 48713173_1 CDM 0278 RC inpatient 5773 3752.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 4502.94 78 999999999 3495.55 5599.81 percent of total billed charges PLATE 3.5 HUMERUS 5H 241.903 48713173_1 CDM 0278 RC inpatient 5773 3752.45 UMR - ALL PLANS UMR - ALL PLANS 4041.1 70 999999999 3495.55 5599.81 percent of total billed charges PLATE 3.5 HUMERUS 5H 241.903 48713173_1 CDM 0278 RC inpatient 5773 3752.45 SIHO - ALL PLANS SIHO - ALL PLANS 5195.7 90 999999999 3495.55 5599.81 percent of total billed charges PLATE 3.5 HUMERUS 5H 241.903 48713173_1 CDM 0278 RC inpatient 5773 3752.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3495.55 60.55 999999999 3495.55 5599.81 percent of total billed charges PLATE 3.5 HUMERUS 5H 241.903 48713173_1 CDM 0278 RC inpatient 5773 3752.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3495.55 5599.81 PLATE 3.5 HUMERUS 5H 241.903 48713173_1 CDM 0278 RC inpatient 5773 3752.45 ANTHEM HMO ANTHEM HMO 999999999 3495.55 5599.81 PLATE 3.5 HUMERUS 5H 241.903 48713173_1 CDM 0278 RC inpatient 5773 3752.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3495.55 5599.81 PLATE 3.5 HUMERUS 5H 241.903 48713173_1 CDM 0278 RC inpatient 5773 3752.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 3902.55 67.6 999999999 3495.55 5599.81 percent of total billed charges PLATE 3.5 HUMERUS 5H 241.903 48713173_1 CDM 0278 RC inpatient 5773 3752.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3495.55 5599.81 PLATE 3.5 HUMERUS 5H 241.903 48713173_1 CDM 0278 RC inpatient 5773 3752.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 3495.55 5599.81 PLATE 12/HOLE 1.3 TI 421.312 48713174_1 CDM 0278 RC inpatient 1038 674.7 AETNA AETNA 820.02 79 999999999 628.51 1006.86 percent of total billed charges PLATE 12/HOLE 1.3 TI 421.312 48713174_1 CDM 0278 RC inpatient 1038 674.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 674.7 65 999999999 628.51 1006.86 percent of total billed charges PLATE 12/HOLE 1.3 TI 421.312 48713174_1 CDM 0278 RC inpatient 1038 674.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1006.86 97 999999999 628.51 1006.86 percent of total billed charges PLATE 12/HOLE 1.3 TI 421.312 48713174_1 CDM 0278 RC inpatient 1038 674.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 716.22 69 999999999 628.51 1006.86 percent of total billed charges PLATE 12/HOLE 1.3 TI 421.312 48713174_1 CDM 0278 RC inpatient 1038 674.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 809.64 78 999999999 628.51 1006.86 percent of total billed charges PLATE 12/HOLE 1.3 TI 421.312 48713174_1 CDM 0278 RC inpatient 1038 674.7 UMR - ALL PLANS UMR - ALL PLANS 726.6 70 999999999 628.51 1006.86 percent of total billed charges PLATE 12/HOLE 1.3 TI 421.312 48713174_1 CDM 0278 RC inpatient 1038 674.7 SIHO - ALL PLANS SIHO - ALL PLANS 934.2 90 999999999 628.51 1006.86 percent of total billed charges PLATE 12/HOLE 1.3 TI 421.312 48713174_1 CDM 0278 RC inpatient 1038 674.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 628.51 60.55 999999999 628.51 1006.86 percent of total billed charges PLATE 12/HOLE 1.3 TI 421.312 48713174_1 CDM 0278 RC inpatient 1038 674.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 628.51 1006.86 PLATE 12/HOLE 1.3 TI 421.312 48713174_1 CDM 0278 RC inpatient 1038 674.7 ANTHEM HMO ANTHEM HMO 999999999 628.51 1006.86 PLATE 12/HOLE 1.3 TI 421.312 48713174_1 CDM 0278 RC inpatient 1038 674.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 628.51 1006.86 PLATE 12/HOLE 1.3 TI 421.312 48713174_1 CDM 0278 RC inpatient 1038 674.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 701.69 67.6 999999999 628.51 1006.86 percent of total billed charges PLATE 12/HOLE 1.3 TI 421.312 48713174_1 CDM 0278 RC inpatient 1038 674.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 628.51 1006.86 PLATE 12/HOLE 1.3 TI 421.312 48713174_1 CDM 0278 RC inpatient 1038 674.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 628.51 1006.86 BUTTRESS PIN TI 1.8 401.968.96 48713175_1 CDM 0278 RC inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges BUTTRESS PIN TI 1.8 401.968.96 48713175_1 CDM 0278 RC inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges BUTTRESS PIN TI 1.8 401.968.96 48713175_1 CDM 0278 RC inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges BUTTRESS PIN TI 1.8 401.968.96 48713175_1 CDM 0278 RC inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges BUTTRESS PIN TI 1.8 401.968.96 48713175_1 CDM 0278 RC inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges BUTTRESS PIN TI 1.8 401.968.96 48713175_1 CDM 0278 RC inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges BUTTRESS PIN TI 1.8 401.968.96 48713175_1 CDM 0278 RC inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges BUTTRESS PIN TI 1.8 401.968.96 48713175_1 CDM 0278 RC inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges BUTTRESS PIN TI 1.8 401.968.96 48713175_1 CDM 0278 RC inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 BUTTRESS PIN TI 1.8 401.968.96 48713175_1 CDM 0278 RC inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 BUTTRESS PIN TI 1.8 401.968.96 48713175_1 CDM 0278 RC inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 BUTTRESS PIN TI 1.8 401.968.96 48713175_1 CDM 0278 RC inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges BUTTRESS PIN TI 1.8 401.968.96 48713175_1 CDM 0278 RC inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 BUTTRESS PIN TI 1.8 401.968.96 48713175_1 CDM 0278 RC inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 CORTEX SCREW 2.0 TI 401.832.96 48713176_1 CDM 0278 RC inpatient 276 179.4 AETNA AETNA 218.04 79 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.832.96 48713176_1 CDM 0278 RC inpatient 276 179.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 179.4 65 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.832.96 48713176_1 CDM 0278 RC inpatient 276 179.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 267.72 97 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.832.96 48713176_1 CDM 0278 RC inpatient 276 179.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 190.44 69 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.832.96 48713176_1 CDM 0278 RC inpatient 276 179.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 215.28 78 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.832.96 48713176_1 CDM 0278 RC inpatient 276 179.4 UMR - ALL PLANS UMR - ALL PLANS 193.2 70 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.832.96 48713176_1 CDM 0278 RC inpatient 276 179.4 SIHO - ALL PLANS SIHO - ALL PLANS 248.4 90 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.832.96 48713176_1 CDM 0278 RC inpatient 276 179.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 167.12 60.55 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.832.96 48713176_1 CDM 0278 RC inpatient 276 179.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.832.96 48713176_1 CDM 0278 RC inpatient 276 179.4 ANTHEM HMO ANTHEM HMO 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.832.96 48713176_1 CDM 0278 RC inpatient 276 179.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.832.96 48713176_1 CDM 0278 RC inpatient 276 179.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 186.58 67.6 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.832.96 48713176_1 CDM 0278 RC inpatient 276 179.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.832.96 48713176_1 CDM 0278 RC inpatient 276 179.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 167.12 267.72 T-PLATE 1.5MM 4\H 446.234 48713177_1 CDM 0278 RC inpatient 994 646.1 AETNA AETNA 785.26 79 999999999 601.87 964.18 percent of total billed charges T-PLATE 1.5MM 4\H 446.234 48713177_1 CDM 0278 RC inpatient 994 646.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 646.1 65 999999999 601.87 964.18 percent of total billed charges T-PLATE 1.5MM 4\H 446.234 48713177_1 CDM 0278 RC inpatient 994 646.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 964.18 97 999999999 601.87 964.18 percent of total billed charges T-PLATE 1.5MM 4\H 446.234 48713177_1 CDM 0278 RC inpatient 994 646.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 685.86 69 999999999 601.87 964.18 percent of total billed charges T-PLATE 1.5MM 4\H 446.234 48713177_1 CDM 0278 RC inpatient 994 646.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 775.32 78 999999999 601.87 964.18 percent of total billed charges T-PLATE 1.5MM 4\H 446.234 48713177_1 CDM 0278 RC inpatient 994 646.1 UMR - ALL PLANS UMR - ALL PLANS 695.8 70 999999999 601.87 964.18 percent of total billed charges T-PLATE 1.5MM 4\H 446.234 48713177_1 CDM 0278 RC inpatient 994 646.1 SIHO - ALL PLANS SIHO - ALL PLANS 894.6 90 999999999 601.87 964.18 percent of total billed charges T-PLATE 1.5MM 4\H 446.234 48713177_1 CDM 0278 RC inpatient 994 646.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 601.87 60.55 999999999 601.87 964.18 percent of total billed charges T-PLATE 1.5MM 4\H 446.234 48713177_1 CDM 0278 RC inpatient 994 646.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 601.87 964.18 T-PLATE 1.5MM 4\H 446.234 48713177_1 CDM 0278 RC inpatient 994 646.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 601.87 964.18 T-PLATE 1.5MM 4\H 446.234 48713177_1 CDM 0278 RC inpatient 994 646.1 ANTHEM HMO ANTHEM HMO 999999999 601.87 964.18 T-PLATE 1.5MM 4\H 446.234 48713177_1 CDM 0278 RC inpatient 994 646.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 671.94 67.6 999999999 601.87 964.18 percent of total billed charges T-PLATE 1.5MM 4\H 446.234 48713177_1 CDM 0278 RC inpatient 994 646.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 601.87 964.18 T-PLATE 1.5MM 4\H 446.234 48713177_1 CDM 0278 RC inpatient 994 646.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 601.87 964.18 CORTEX SCREW 2.0 TI 401.830.96 48713178_1 CDM 0278 RC inpatient 276 179.4 AETNA AETNA 218.04 79 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.830.96 48713178_1 CDM 0278 RC inpatient 276 179.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 179.4 65 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.830.96 48713178_1 CDM 0278 RC inpatient 276 179.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 267.72 97 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.830.96 48713178_1 CDM 0278 RC inpatient 276 179.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 190.44 69 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.830.96 48713178_1 CDM 0278 RC inpatient 276 179.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 215.28 78 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.830.96 48713178_1 CDM 0278 RC inpatient 276 179.4 UMR - ALL PLANS UMR - ALL PLANS 193.2 70 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.830.96 48713178_1 CDM 0278 RC inpatient 276 179.4 SIHO - ALL PLANS SIHO - ALL PLANS 248.4 90 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.830.96 48713178_1 CDM 0278 RC inpatient 276 179.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 167.12 60.55 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.830.96 48713178_1 CDM 0278 RC inpatient 276 179.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.830.96 48713178_1 CDM 0278 RC inpatient 276 179.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.830.96 48713178_1 CDM 0278 RC inpatient 276 179.4 ANTHEM HMO ANTHEM HMO 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.830.96 48713178_1 CDM 0278 RC inpatient 276 179.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 186.58 67.6 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.830.96 48713178_1 CDM 0278 RC inpatient 276 179.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.830.96 48713178_1 CDM 0278 RC inpatient 276 179.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.828.96 48713179_1 CDM 0278 RC inpatient 276 179.4 AETNA AETNA 218.04 79 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.828.96 48713179_1 CDM 0278 RC inpatient 276 179.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 179.4 65 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.828.96 48713179_1 CDM 0278 RC inpatient 276 179.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 267.72 97 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.828.96 48713179_1 CDM 0278 RC inpatient 276 179.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 190.44 69 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.828.96 48713179_1 CDM 0278 RC inpatient 276 179.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 215.28 78 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.828.96 48713179_1 CDM 0278 RC inpatient 276 179.4 UMR - ALL PLANS UMR - ALL PLANS 193.2 70 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.828.96 48713179_1 CDM 0278 RC inpatient 276 179.4 SIHO - ALL PLANS SIHO - ALL PLANS 248.4 90 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.828.96 48713179_1 CDM 0278 RC inpatient 276 179.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 167.12 60.55 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.828.96 48713179_1 CDM 0278 RC inpatient 276 179.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.828.96 48713179_1 CDM 0278 RC inpatient 276 179.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.828.96 48713179_1 CDM 0278 RC inpatient 276 179.4 ANTHEM HMO ANTHEM HMO 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.828.96 48713179_1 CDM 0278 RC inpatient 276 179.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 186.58 67.6 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.828.96 48713179_1 CDM 0278 RC inpatient 276 179.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.828.96 48713179_1 CDM 0278 RC inpatient 276 179.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.826.96 48713180_1 CDM 0278 RC inpatient 276 179.4 AETNA AETNA 218.04 79 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.826.96 48713180_1 CDM 0278 RC inpatient 276 179.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 179.4 65 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.826.96 48713180_1 CDM 0278 RC inpatient 276 179.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 267.72 97 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.826.96 48713180_1 CDM 0278 RC inpatient 276 179.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 190.44 69 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.826.96 48713180_1 CDM 0278 RC inpatient 276 179.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 215.28 78 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.826.96 48713180_1 CDM 0278 RC inpatient 276 179.4 UMR - ALL PLANS UMR - ALL PLANS 193.2 70 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.826.96 48713180_1 CDM 0278 RC inpatient 276 179.4 SIHO - ALL PLANS SIHO - ALL PLANS 248.4 90 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.826.96 48713180_1 CDM 0278 RC inpatient 276 179.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 167.12 60.55 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.826.96 48713180_1 CDM 0278 RC inpatient 276 179.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.826.96 48713180_1 CDM 0278 RC inpatient 276 179.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.826.96 48713180_1 CDM 0278 RC inpatient 276 179.4 ANTHEM HMO ANTHEM HMO 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.826.96 48713180_1 CDM 0278 RC inpatient 276 179.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 186.58 67.6 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.826.96 48713180_1 CDM 0278 RC inpatient 276 179.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.826.96 48713180_1 CDM 0278 RC inpatient 276 179.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.824.96 48713181_1 CDM 0278 RC inpatient 276 179.4 AETNA AETNA 218.04 79 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.824.96 48713181_1 CDM 0278 RC inpatient 276 179.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 179.4 65 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.824.96 48713181_1 CDM 0278 RC inpatient 276 179.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 267.72 97 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.824.96 48713181_1 CDM 0278 RC inpatient 276 179.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 190.44 69 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.824.96 48713181_1 CDM 0278 RC inpatient 276 179.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 215.28 78 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.824.96 48713181_1 CDM 0278 RC inpatient 276 179.4 UMR - ALL PLANS UMR - ALL PLANS 193.2 70 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.824.96 48713181_1 CDM 0278 RC inpatient 276 179.4 SIHO - ALL PLANS SIHO - ALL PLANS 248.4 90 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.824.96 48713181_1 CDM 0278 RC inpatient 276 179.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 167.12 60.55 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.824.96 48713181_1 CDM 0278 RC inpatient 276 179.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.824.96 48713181_1 CDM 0278 RC inpatient 276 179.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.824.96 48713181_1 CDM 0278 RC inpatient 276 179.4 ANTHEM HMO ANTHEM HMO 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.824.96 48713181_1 CDM 0278 RC inpatient 276 179.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 186.58 67.6 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.824.96 48713181_1 CDM 0278 RC inpatient 276 179.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.824.96 48713181_1 CDM 0278 RC inpatient 276 179.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.822.96 48713182_1 CDM 0278 RC inpatient 276 179.4 AETNA AETNA 218.04 79 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.822.96 48713182_1 CDM 0278 RC inpatient 276 179.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 179.4 65 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.822.96 48713182_1 CDM 0278 RC inpatient 276 179.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 267.72 97 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.822.96 48713182_1 CDM 0278 RC inpatient 276 179.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 190.44 69 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.822.96 48713182_1 CDM 0278 RC inpatient 276 179.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 215.28 78 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.822.96 48713182_1 CDM 0278 RC inpatient 276 179.4 UMR - ALL PLANS UMR - ALL PLANS 193.2 70 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.822.96 48713182_1 CDM 0278 RC inpatient 276 179.4 SIHO - ALL PLANS SIHO - ALL PLANS 248.4 90 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.822.96 48713182_1 CDM 0278 RC inpatient 276 179.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 167.12 60.55 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.822.96 48713182_1 CDM 0278 RC inpatient 276 179.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.822.96 48713182_1 CDM 0278 RC inpatient 276 179.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.822.96 48713182_1 CDM 0278 RC inpatient 276 179.4 ANTHEM HMO ANTHEM HMO 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.822.96 48713182_1 CDM 0278 RC inpatient 276 179.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 186.58 67.6 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.822.96 48713182_1 CDM 0278 RC inpatient 276 179.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.822.96 48713182_1 CDM 0278 RC inpatient 276 179.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.820.96 48713183_1 CDM 0278 RC inpatient 276 179.4 AETNA AETNA 218.04 79 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.820.96 48713183_1 CDM 0278 RC inpatient 276 179.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 179.4 65 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.820.96 48713183_1 CDM 0278 RC inpatient 276 179.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 267.72 97 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.820.96 48713183_1 CDM 0278 RC inpatient 276 179.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 190.44 69 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.820.96 48713183_1 CDM 0278 RC inpatient 276 179.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 215.28 78 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.820.96 48713183_1 CDM 0278 RC inpatient 276 179.4 UMR - ALL PLANS UMR - ALL PLANS 193.2 70 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.820.96 48713183_1 CDM 0278 RC inpatient 276 179.4 SIHO - ALL PLANS SIHO - ALL PLANS 248.4 90 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.820.96 48713183_1 CDM 0278 RC inpatient 276 179.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 167.12 60.55 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.820.96 48713183_1 CDM 0278 RC inpatient 276 179.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.820.96 48713183_1 CDM 0278 RC inpatient 276 179.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.820.96 48713183_1 CDM 0278 RC inpatient 276 179.4 ANTHEM HMO ANTHEM HMO 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.820.96 48713183_1 CDM 0278 RC inpatient 276 179.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 186.58 67.6 999999999 167.12 267.72 percent of total billed charges CORTEX SCREW 2.0 TI 401.820.96 48713183_1 CDM 0278 RC inpatient 276 179.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.820.96 48713183_1 CDM 0278 RC inpatient 276 179.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 167.12 267.72 CORTEX SCREW 2.0 TI 401.818.96 48713184_1 CDM 0278 RC inpatient 372 241.8 AETNA AETNA 293.88 79 999999999 225.25 360.84 percent of total billed charges CORTEX SCREW 2.0 TI 401.818.96 48713184_1 CDM 0278 RC inpatient 372 241.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 241.8 65 999999999 225.25 360.84 percent of total billed charges CORTEX SCREW 2.0 TI 401.818.96 48713184_1 CDM 0278 RC inpatient 372 241.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 360.84 97 999999999 225.25 360.84 percent of total billed charges CORTEX SCREW 2.0 TI 401.818.96 48713184_1 CDM 0278 RC inpatient 372 241.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 256.68 69 999999999 225.25 360.84 percent of total billed charges CORTEX SCREW 2.0 TI 401.818.96 48713184_1 CDM 0278 RC inpatient 372 241.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 290.16 78 999999999 225.25 360.84 percent of total billed charges CORTEX SCREW 2.0 TI 401.818.96 48713184_1 CDM 0278 RC inpatient 372 241.8 UMR - ALL PLANS UMR - ALL PLANS 260.4 70 999999999 225.25 360.84 percent of total billed charges CORTEX SCREW 2.0 TI 401.818.96 48713184_1 CDM 0278 RC inpatient 372 241.8 SIHO - ALL PLANS SIHO - ALL PLANS 334.8 90 999999999 225.25 360.84 percent of total billed charges CORTEX SCREW 2.0 TI 401.818.96 48713184_1 CDM 0278 RC inpatient 372 241.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 225.25 60.55 999999999 225.25 360.84 percent of total billed charges CORTEX SCREW 2.0 TI 401.818.96 48713184_1 CDM 0278 RC inpatient 372 241.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 225.25 360.84 CORTEX SCREW 2.0 TI 401.818.96 48713184_1 CDM 0278 RC inpatient 372 241.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 225.25 360.84 CORTEX SCREW 2.0 TI 401.818.96 48713184_1 CDM 0278 RC inpatient 372 241.8 ANTHEM HMO ANTHEM HMO 999999999 225.25 360.84 CORTEX SCREW 2.0 TI 401.818.96 48713184_1 CDM 0278 RC inpatient 372 241.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 251.47 67.6 999999999 225.25 360.84 percent of total billed charges CORTEX SCREW 2.0 TI 401.818.96 48713184_1 CDM 0278 RC inpatient 372 241.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 225.25 360.84 CORTEX SCREW 2.0 TI 401.818.96 48713184_1 CDM 0278 RC inpatient 372 241.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 225.25 360.84 CORTEX SCREW 2.0 TI 401.816.96 48713185_1 CDM 0278 RC inpatient 427 277.55 AETNA AETNA 337.33 79 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.816.96 48713185_1 CDM 0278 RC inpatient 427 277.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 277.55 65 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.816.96 48713185_1 CDM 0278 RC inpatient 427 277.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 414.19 97 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.816.96 48713185_1 CDM 0278 RC inpatient 427 277.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 294.63 69 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.816.96 48713185_1 CDM 0278 RC inpatient 427 277.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.06 78 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.816.96 48713185_1 CDM 0278 RC inpatient 427 277.55 UMR - ALL PLANS UMR - ALL PLANS 298.9 70 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.816.96 48713185_1 CDM 0278 RC inpatient 427 277.55 SIHO - ALL PLANS SIHO - ALL PLANS 384.3 90 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.816.96 48713185_1 CDM 0278 RC inpatient 427 277.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 258.55 60.55 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.816.96 48713185_1 CDM 0278 RC inpatient 427 277.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.816.96 48713185_1 CDM 0278 RC inpatient 427 277.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.816.96 48713185_1 CDM 0278 RC inpatient 427 277.55 ANTHEM HMO ANTHEM HMO 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.816.96 48713185_1 CDM 0278 RC inpatient 427 277.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 288.65 67.6 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.816.96 48713185_1 CDM 0278 RC inpatient 427 277.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.816.96 48713185_1 CDM 0278 RC inpatient 427 277.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.814.96 48713186_1 CDM 0278 RC inpatient 306 198.9 AETNA AETNA 241.74 79 999999999 185.28 296.82 percent of total billed charges CORTEX SCREW 2.0 TI 401.814.96 48713186_1 CDM 0278 RC inpatient 306 198.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 198.9 65 999999999 185.28 296.82 percent of total billed charges CORTEX SCREW 2.0 TI 401.814.96 48713186_1 CDM 0278 RC inpatient 306 198.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 296.82 97 999999999 185.28 296.82 percent of total billed charges CORTEX SCREW 2.0 TI 401.814.96 48713186_1 CDM 0278 RC inpatient 306 198.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 211.14 69 999999999 185.28 296.82 percent of total billed charges CORTEX SCREW 2.0 TI 401.814.96 48713186_1 CDM 0278 RC inpatient 306 198.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 238.68 78 999999999 185.28 296.82 percent of total billed charges CORTEX SCREW 2.0 TI 401.814.96 48713186_1 CDM 0278 RC inpatient 306 198.9 UMR - ALL PLANS UMR - ALL PLANS 214.2 70 999999999 185.28 296.82 percent of total billed charges CORTEX SCREW 2.0 TI 401.814.96 48713186_1 CDM 0278 RC inpatient 306 198.9 SIHO - ALL PLANS SIHO - ALL PLANS 275.4 90 999999999 185.28 296.82 percent of total billed charges CORTEX SCREW 2.0 TI 401.814.96 48713186_1 CDM 0278 RC inpatient 306 198.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 185.28 60.55 999999999 185.28 296.82 percent of total billed charges CORTEX SCREW 2.0 TI 401.814.96 48713186_1 CDM 0278 RC inpatient 306 198.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 185.28 296.82 CORTEX SCREW 2.0 TI 401.814.96 48713186_1 CDM 0278 RC inpatient 306 198.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 185.28 296.82 CORTEX SCREW 2.0 TI 401.814.96 48713186_1 CDM 0278 RC inpatient 306 198.9 ANTHEM HMO ANTHEM HMO 999999999 185.28 296.82 CORTEX SCREW 2.0 TI 401.814.96 48713186_1 CDM 0278 RC inpatient 306 198.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 206.86 67.6 999999999 185.28 296.82 percent of total billed charges CORTEX SCREW 2.0 TI 401.814.96 48713186_1 CDM 0278 RC inpatient 306 198.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 185.28 296.82 CORTEX SCREW 2.0 TI 401.814.96 48713186_1 CDM 0278 RC inpatient 306 198.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 185.28 296.82 CORTEX SCREW 2.0 TI 401.813.96 48713187_1 CDM 0278 RC inpatient 372 241.8 AETNA AETNA 293.88 79 999999999 225.25 360.84 percent of total billed charges CORTEX SCREW 2.0 TI 401.813.96 48713187_1 CDM 0278 RC inpatient 372 241.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 241.8 65 999999999 225.25 360.84 percent of total billed charges CORTEX SCREW 2.0 TI 401.813.96 48713187_1 CDM 0278 RC inpatient 372 241.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 360.84 97 999999999 225.25 360.84 percent of total billed charges CORTEX SCREW 2.0 TI 401.813.96 48713187_1 CDM 0278 RC inpatient 372 241.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 256.68 69 999999999 225.25 360.84 percent of total billed charges CORTEX SCREW 2.0 TI 401.813.96 48713187_1 CDM 0278 RC inpatient 372 241.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 290.16 78 999999999 225.25 360.84 percent of total billed charges CORTEX SCREW 2.0 TI 401.813.96 48713187_1 CDM 0278 RC inpatient 372 241.8 UMR - ALL PLANS UMR - ALL PLANS 260.4 70 999999999 225.25 360.84 percent of total billed charges CORTEX SCREW 2.0 TI 401.813.96 48713187_1 CDM 0278 RC inpatient 372 241.8 SIHO - ALL PLANS SIHO - ALL PLANS 334.8 90 999999999 225.25 360.84 percent of total billed charges CORTEX SCREW 2.0 TI 401.813.96 48713187_1 CDM 0278 RC inpatient 372 241.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 225.25 60.55 999999999 225.25 360.84 percent of total billed charges CORTEX SCREW 2.0 TI 401.813.96 48713187_1 CDM 0278 RC inpatient 372 241.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 225.25 360.84 CORTEX SCREW 2.0 TI 401.813.96 48713187_1 CDM 0278 RC inpatient 372 241.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 225.25 360.84 CORTEX SCREW 2.0 TI 401.813.96 48713187_1 CDM 0278 RC inpatient 372 241.8 ANTHEM HMO ANTHEM HMO 999999999 225.25 360.84 CORTEX SCREW 2.0 TI 401.813.96 48713187_1 CDM 0278 RC inpatient 372 241.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 251.47 67.6 999999999 225.25 360.84 percent of total billed charges CORTEX SCREW 2.0 TI 401.813.96 48713187_1 CDM 0278 RC inpatient 372 241.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 225.25 360.84 CORTEX SCREW 2.0 TI 401.813.96 48713187_1 CDM 0278 RC inpatient 372 241.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 225.25 360.84 CORTEX SCR 2.4 32MM 401.532.96 48713188_1 CDM 0278 RC inpatient 576 374.4 AETNA AETNA 455.04 79 999999999 348.77 558.72 percent of total billed charges CORTEX SCR 2.4 32MM 401.532.96 48713188_1 CDM 0278 RC inpatient 576 374.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 374.4 65 999999999 348.77 558.72 percent of total billed charges CORTEX SCR 2.4 32MM 401.532.96 48713188_1 CDM 0278 RC inpatient 576 374.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 558.72 97 999999999 348.77 558.72 percent of total billed charges CORTEX SCR 2.4 32MM 401.532.96 48713188_1 CDM 0278 RC inpatient 576 374.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 397.44 69 999999999 348.77 558.72 percent of total billed charges CORTEX SCR 2.4 32MM 401.532.96 48713188_1 CDM 0278 RC inpatient 576 374.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 449.28 78 999999999 348.77 558.72 percent of total billed charges CORTEX SCR 2.4 32MM 401.532.96 48713188_1 CDM 0278 RC inpatient 576 374.4 UMR - ALL PLANS UMR - ALL PLANS 403.2 70 999999999 348.77 558.72 percent of total billed charges CORTEX SCR 2.4 32MM 401.532.96 48713188_1 CDM 0278 RC inpatient 576 374.4 SIHO - ALL PLANS SIHO - ALL PLANS 518.4 90 999999999 348.77 558.72 percent of total billed charges CORTEX SCR 2.4 32MM 401.532.96 48713188_1 CDM 0278 RC inpatient 576 374.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 348.77 60.55 999999999 348.77 558.72 percent of total billed charges CORTEX SCR 2.4 32MM 401.532.96 48713188_1 CDM 0278 RC inpatient 576 374.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 348.77 558.72 CORTEX SCR 2.4 32MM 401.532.96 48713188_1 CDM 0278 RC inpatient 576 374.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 348.77 558.72 CORTEX SCR 2.4 32MM 401.532.96 48713188_1 CDM 0278 RC inpatient 576 374.4 ANTHEM HMO ANTHEM HMO 999999999 348.77 558.72 CORTEX SCR 2.4 32MM 401.532.96 48713188_1 CDM 0278 RC inpatient 576 374.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 389.38 67.6 999999999 348.77 558.72 percent of total billed charges CORTEX SCR 2.4 32MM 401.532.96 48713188_1 CDM 0278 RC inpatient 576 374.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 348.77 558.72 CORTEX SCR 2.4 32MM 401.532.96 48713188_1 CDM 0278 RC inpatient 576 374.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 348.77 558.72 CONTINENCE SYSTEM TVT EXACT 48713189_1 CDM 0278 RC inpatient 4244 2758.6 AETNA AETNA 3352.76 79 999999999 2569.74 4116.68 percent of total billed charges CONTINENCE SYSTEM TVT EXACT 48713189_1 CDM 0278 RC inpatient 4244 2758.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 2758.6 65 999999999 2569.74 4116.68 percent of total billed charges CONTINENCE SYSTEM TVT EXACT 48713189_1 CDM 0278 RC inpatient 4244 2758.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4116.68 97 999999999 2569.74 4116.68 percent of total billed charges CONTINENCE SYSTEM TVT EXACT 48713189_1 CDM 0278 RC inpatient 4244 2758.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 2928.36 69 999999999 2569.74 4116.68 percent of total billed charges CONTINENCE SYSTEM TVT EXACT 48713189_1 CDM 0278 RC inpatient 4244 2758.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 3310.32 78 999999999 2569.74 4116.68 percent of total billed charges CONTINENCE SYSTEM TVT EXACT 48713189_1 CDM 0278 RC inpatient 4244 2758.6 UMR - ALL PLANS UMR - ALL PLANS 2970.8 70 999999999 2569.74 4116.68 percent of total billed charges CONTINENCE SYSTEM TVT EXACT 48713189_1 CDM 0278 RC inpatient 4244 2758.6 SIHO - ALL PLANS SIHO - ALL PLANS 3819.6 90 999999999 2569.74 4116.68 percent of total billed charges CONTINENCE SYSTEM TVT EXACT 48713189_1 CDM 0278 RC inpatient 4244 2758.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2569.74 60.55 999999999 2569.74 4116.68 percent of total billed charges CONTINENCE SYSTEM TVT EXACT 48713189_1 CDM 0278 RC inpatient 4244 2758.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2569.74 4116.68 CONTINENCE SYSTEM TVT EXACT 48713189_1 CDM 0278 RC inpatient 4244 2758.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2569.74 4116.68 CONTINENCE SYSTEM TVT EXACT 48713189_1 CDM 0278 RC inpatient 4244 2758.6 ANTHEM HMO ANTHEM HMO 999999999 2569.74 4116.68 CONTINENCE SYSTEM TVT EXACT 48713189_1 CDM 0278 RC inpatient 4244 2758.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 2868.94 67.6 999999999 2569.74 4116.68 percent of total billed charges CONTINENCE SYSTEM TVT EXACT 48713189_1 CDM 0278 RC inpatient 4244 2758.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2569.74 4116.68 CONTINENCE SYSTEM TVT EXACT 48713189_1 CDM 0278 RC inpatient 4244 2758.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 2569.74 4116.68 CORTEX SCREW 2.0 TI 401.806.96 48713190_1 CDM 0278 RC inpatient 427 277.55 AETNA AETNA 337.33 79 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.806.96 48713190_1 CDM 0278 RC inpatient 427 277.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 277.55 65 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.806.96 48713190_1 CDM 0278 RC inpatient 427 277.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 414.19 97 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.806.96 48713190_1 CDM 0278 RC inpatient 427 277.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 294.63 69 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.806.96 48713190_1 CDM 0278 RC inpatient 427 277.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.06 78 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.806.96 48713190_1 CDM 0278 RC inpatient 427 277.55 UMR - ALL PLANS UMR - ALL PLANS 298.9 70 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.806.96 48713190_1 CDM 0278 RC inpatient 427 277.55 SIHO - ALL PLANS SIHO - ALL PLANS 384.3 90 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.806.96 48713190_1 CDM 0278 RC inpatient 427 277.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 258.55 60.55 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.806.96 48713190_1 CDM 0278 RC inpatient 427 277.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.806.96 48713190_1 CDM 0278 RC inpatient 427 277.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.806.96 48713190_1 CDM 0278 RC inpatient 427 277.55 ANTHEM HMO ANTHEM HMO 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.806.96 48713190_1 CDM 0278 RC inpatient 427 277.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 288.65 67.6 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.806.96 48713190_1 CDM 0278 RC inpatient 427 277.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.806.96 48713190_1 CDM 0278 RC inpatient 427 277.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.807.96 48713191_1 CDM 0278 RC inpatient 427 277.55 AETNA AETNA 337.33 79 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.807.96 48713191_1 CDM 0278 RC inpatient 427 277.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 277.55 65 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.807.96 48713191_1 CDM 0278 RC inpatient 427 277.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 414.19 97 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.807.96 48713191_1 CDM 0278 RC inpatient 427 277.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 294.63 69 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.807.96 48713191_1 CDM 0278 RC inpatient 427 277.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.06 78 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.807.96 48713191_1 CDM 0278 RC inpatient 427 277.55 UMR - ALL PLANS UMR - ALL PLANS 298.9 70 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.807.96 48713191_1 CDM 0278 RC inpatient 427 277.55 SIHO - ALL PLANS SIHO - ALL PLANS 384.3 90 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.807.96 48713191_1 CDM 0278 RC inpatient 427 277.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 258.55 60.55 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.807.96 48713191_1 CDM 0278 RC inpatient 427 277.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.807.96 48713191_1 CDM 0278 RC inpatient 427 277.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.807.96 48713191_1 CDM 0278 RC inpatient 427 277.55 ANTHEM HMO ANTHEM HMO 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.807.96 48713191_1 CDM 0278 RC inpatient 427 277.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 288.65 67.6 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.807.96 48713191_1 CDM 0278 RC inpatient 427 277.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.807.96 48713191_1 CDM 0278 RC inpatient 427 277.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.808.96 48713192_1 CDM 0278 RC inpatient 283 183.95 AETNA AETNA 223.57 79 999999999 171.36 274.51 percent of total billed charges CORTEX SCREW 2.0 TI 401.808.96 48713192_1 CDM 0278 RC inpatient 283 183.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 183.95 65 999999999 171.36 274.51 percent of total billed charges CORTEX SCREW 2.0 TI 401.808.96 48713192_1 CDM 0278 RC inpatient 283 183.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 274.51 97 999999999 171.36 274.51 percent of total billed charges CORTEX SCREW 2.0 TI 401.808.96 48713192_1 CDM 0278 RC inpatient 283 183.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 195.27 69 999999999 171.36 274.51 percent of total billed charges CORTEX SCREW 2.0 TI 401.808.96 48713192_1 CDM 0278 RC inpatient 283 183.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 220.74 78 999999999 171.36 274.51 percent of total billed charges CORTEX SCREW 2.0 TI 401.808.96 48713192_1 CDM 0278 RC inpatient 283 183.95 UMR - ALL PLANS UMR - ALL PLANS 198.1 70 999999999 171.36 274.51 percent of total billed charges CORTEX SCREW 2.0 TI 401.808.96 48713192_1 CDM 0278 RC inpatient 283 183.95 SIHO - ALL PLANS SIHO - ALL PLANS 254.7 90 999999999 171.36 274.51 percent of total billed charges CORTEX SCREW 2.0 TI 401.808.96 48713192_1 CDM 0278 RC inpatient 283 183.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 171.36 60.55 999999999 171.36 274.51 percent of total billed charges CORTEX SCREW 2.0 TI 401.808.96 48713192_1 CDM 0278 RC inpatient 283 183.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 171.36 274.51 CORTEX SCREW 2.0 TI 401.808.96 48713192_1 CDM 0278 RC inpatient 283 183.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 171.36 274.51 CORTEX SCREW 2.0 TI 401.808.96 48713192_1 CDM 0278 RC inpatient 283 183.95 ANTHEM HMO ANTHEM HMO 999999999 171.36 274.51 CORTEX SCREW 2.0 TI 401.808.96 48713192_1 CDM 0278 RC inpatient 283 183.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 191.31 67.6 999999999 171.36 274.51 percent of total billed charges CORTEX SCREW 2.0 TI 401.808.96 48713192_1 CDM 0278 RC inpatient 283 183.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 171.36 274.51 CORTEX SCREW 2.0 TI 401.808.96 48713192_1 CDM 0278 RC inpatient 283 183.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 171.36 274.51 CORTEX SCREW 2.0 TI 401.809.96 48713193_1 CDM 0278 RC inpatient 283 183.95 AETNA AETNA 223.57 79 999999999 171.36 274.51 percent of total billed charges CORTEX SCREW 2.0 TI 401.809.96 48713193_1 CDM 0278 RC inpatient 283 183.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 183.95 65 999999999 171.36 274.51 percent of total billed charges CORTEX SCREW 2.0 TI 401.809.96 48713193_1 CDM 0278 RC inpatient 283 183.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 274.51 97 999999999 171.36 274.51 percent of total billed charges CORTEX SCREW 2.0 TI 401.809.96 48713193_1 CDM 0278 RC inpatient 283 183.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 195.27 69 999999999 171.36 274.51 percent of total billed charges CORTEX SCREW 2.0 TI 401.809.96 48713193_1 CDM 0278 RC inpatient 283 183.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 220.74 78 999999999 171.36 274.51 percent of total billed charges CORTEX SCREW 2.0 TI 401.809.96 48713193_1 CDM 0278 RC inpatient 283 183.95 UMR - ALL PLANS UMR - ALL PLANS 198.1 70 999999999 171.36 274.51 percent of total billed charges CORTEX SCREW 2.0 TI 401.809.96 48713193_1 CDM 0278 RC inpatient 283 183.95 SIHO - ALL PLANS SIHO - ALL PLANS 254.7 90 999999999 171.36 274.51 percent of total billed charges CORTEX SCREW 2.0 TI 401.809.96 48713193_1 CDM 0278 RC inpatient 283 183.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 171.36 60.55 999999999 171.36 274.51 percent of total billed charges CORTEX SCREW 2.0 TI 401.809.96 48713193_1 CDM 0278 RC inpatient 283 183.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 171.36 274.51 CORTEX SCREW 2.0 TI 401.809.96 48713193_1 CDM 0278 RC inpatient 283 183.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 171.36 274.51 CORTEX SCREW 2.0 TI 401.809.96 48713193_1 CDM 0278 RC inpatient 283 183.95 ANTHEM HMO ANTHEM HMO 999999999 171.36 274.51 CORTEX SCREW 2.0 TI 401.809.96 48713193_1 CDM 0278 RC inpatient 283 183.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 191.31 67.6 999999999 171.36 274.51 percent of total billed charges CORTEX SCREW 2.0 TI 401.809.96 48713193_1 CDM 0278 RC inpatient 283 183.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 171.36 274.51 CORTEX SCREW 2.0 TI 401.809.96 48713193_1 CDM 0278 RC inpatient 283 183.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 171.36 274.51 CORTEX SCREW 2.0 TI 401.810.96 48713194_1 CDM 0278 RC inpatient 306 198.9 AETNA AETNA 241.74 79 999999999 185.28 296.82 percent of total billed charges CORTEX SCREW 2.0 TI 401.810.96 48713194_1 CDM 0278 RC inpatient 306 198.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 198.9 65 999999999 185.28 296.82 percent of total billed charges CORTEX SCREW 2.0 TI 401.810.96 48713194_1 CDM 0278 RC inpatient 306 198.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 296.82 97 999999999 185.28 296.82 percent of total billed charges CORTEX SCREW 2.0 TI 401.810.96 48713194_1 CDM 0278 RC inpatient 306 198.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 211.14 69 999999999 185.28 296.82 percent of total billed charges CORTEX SCREW 2.0 TI 401.810.96 48713194_1 CDM 0278 RC inpatient 306 198.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 238.68 78 999999999 185.28 296.82 percent of total billed charges CORTEX SCREW 2.0 TI 401.810.96 48713194_1 CDM 0278 RC inpatient 306 198.9 UMR - ALL PLANS UMR - ALL PLANS 214.2 70 999999999 185.28 296.82 percent of total billed charges CORTEX SCREW 2.0 TI 401.810.96 48713194_1 CDM 0278 RC inpatient 306 198.9 SIHO - ALL PLANS SIHO - ALL PLANS 275.4 90 999999999 185.28 296.82 percent of total billed charges CORTEX SCREW 2.0 TI 401.810.96 48713194_1 CDM 0278 RC inpatient 306 198.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 185.28 60.55 999999999 185.28 296.82 percent of total billed charges CORTEX SCREW 2.0 TI 401.810.96 48713194_1 CDM 0278 RC inpatient 306 198.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 185.28 296.82 CORTEX SCREW 2.0 TI 401.810.96 48713194_1 CDM 0278 RC inpatient 306 198.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 185.28 296.82 CORTEX SCREW 2.0 TI 401.810.96 48713194_1 CDM 0278 RC inpatient 306 198.9 ANTHEM HMO ANTHEM HMO 999999999 185.28 296.82 CORTEX SCREW 2.0 TI 401.810.96 48713194_1 CDM 0278 RC inpatient 306 198.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 206.86 67.6 999999999 185.28 296.82 percent of total billed charges CORTEX SCREW 2.0 TI 401.810.96 48713194_1 CDM 0278 RC inpatient 306 198.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 185.28 296.82 CORTEX SCREW 2.0 TI 401.810.96 48713194_1 CDM 0278 RC inpatient 306 198.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 185.28 296.82 CORTEX SCREW 2.0 TI 401.811.96 48713195_1 CDM 0278 RC inpatient 427 277.55 AETNA AETNA 337.33 79 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.811.96 48713195_1 CDM 0278 RC inpatient 427 277.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 277.55 65 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.811.96 48713195_1 CDM 0278 RC inpatient 427 277.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 414.19 97 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.811.96 48713195_1 CDM 0278 RC inpatient 427 277.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 294.63 69 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.811.96 48713195_1 CDM 0278 RC inpatient 427 277.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.06 78 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.811.96 48713195_1 CDM 0278 RC inpatient 427 277.55 UMR - ALL PLANS UMR - ALL PLANS 298.9 70 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.811.96 48713195_1 CDM 0278 RC inpatient 427 277.55 SIHO - ALL PLANS SIHO - ALL PLANS 384.3 90 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.811.96 48713195_1 CDM 0278 RC inpatient 427 277.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 258.55 60.55 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.811.96 48713195_1 CDM 0278 RC inpatient 427 277.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.811.96 48713195_1 CDM 0278 RC inpatient 427 277.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.811.96 48713195_1 CDM 0278 RC inpatient 427 277.55 ANTHEM HMO ANTHEM HMO 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.811.96 48713195_1 CDM 0278 RC inpatient 427 277.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 288.65 67.6 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.811.96 48713195_1 CDM 0278 RC inpatient 427 277.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.811.96 48713195_1 CDM 0278 RC inpatient 427 277.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.812.96 48713196_1 CDM 0278 RC inpatient 427 277.55 AETNA AETNA 337.33 79 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.812.96 48713196_1 CDM 0278 RC inpatient 427 277.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 277.55 65 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.812.96 48713196_1 CDM 0278 RC inpatient 427 277.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 414.19 97 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.812.96 48713196_1 CDM 0278 RC inpatient 427 277.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 294.63 69 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.812.96 48713196_1 CDM 0278 RC inpatient 427 277.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.06 78 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.812.96 48713196_1 CDM 0278 RC inpatient 427 277.55 UMR - ALL PLANS UMR - ALL PLANS 298.9 70 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.812.96 48713196_1 CDM 0278 RC inpatient 427 277.55 SIHO - ALL PLANS SIHO - ALL PLANS 384.3 90 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.812.96 48713196_1 CDM 0278 RC inpatient 427 277.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 258.55 60.55 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.812.96 48713196_1 CDM 0278 RC inpatient 427 277.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.812.96 48713196_1 CDM 0278 RC inpatient 427 277.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.812.96 48713196_1 CDM 0278 RC inpatient 427 277.55 ANTHEM HMO ANTHEM HMO 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.812.96 48713196_1 CDM 0278 RC inpatient 427 277.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 288.65 67.6 999999999 258.55 414.19 percent of total billed charges CORTEX SCREW 2.0 TI 401.812.96 48713196_1 CDM 0278 RC inpatient 427 277.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 258.55 414.19 CORTEX SCREW 2.0 TI 401.812.96 48713196_1 CDM 0278 RC inpatient 427 277.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 258.55 414.19 CORTEX SCR 2.4 30MM 401.530.96 48713197_1 CDM 0278 RC inpatient 391 254.15 AETNA AETNA 308.89 79 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 30MM 401.530.96 48713197_1 CDM 0278 RC inpatient 391 254.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 254.15 65 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 30MM 401.530.96 48713197_1 CDM 0278 RC inpatient 391 254.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 379.27 97 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 30MM 401.530.96 48713197_1 CDM 0278 RC inpatient 391 254.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 269.79 69 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 30MM 401.530.96 48713197_1 CDM 0278 RC inpatient 391 254.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 304.98 78 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 30MM 401.530.96 48713197_1 CDM 0278 RC inpatient 391 254.15 UMR - ALL PLANS UMR - ALL PLANS 273.7 70 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 30MM 401.530.96 48713197_1 CDM 0278 RC inpatient 391 254.15 SIHO - ALL PLANS SIHO - ALL PLANS 351.9 90 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 30MM 401.530.96 48713197_1 CDM 0278 RC inpatient 391 254.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 236.75 60.55 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 30MM 401.530.96 48713197_1 CDM 0278 RC inpatient 391 254.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 236.75 379.27 CORTEX SCR 2.4 30MM 401.530.96 48713197_1 CDM 0278 RC inpatient 391 254.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 236.75 379.27 CORTEX SCR 2.4 30MM 401.530.96 48713197_1 CDM 0278 RC inpatient 391 254.15 ANTHEM HMO ANTHEM HMO 999999999 236.75 379.27 CORTEX SCR 2.4 30MM 401.530.96 48713197_1 CDM 0278 RC inpatient 391 254.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 264.32 67.6 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 30MM 401.530.96 48713197_1 CDM 0278 RC inpatient 391 254.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 236.75 379.27 CORTEX SCR 2.4 30MM 401.530.96 48713197_1 CDM 0278 RC inpatient 391 254.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 236.75 379.27 CORTEX SCR 2.4 28MM 401.528.96 48713198_1 CDM 0278 RC inpatient 391 254.15 AETNA AETNA 308.89 79 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 28MM 401.528.96 48713198_1 CDM 0278 RC inpatient 391 254.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 254.15 65 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 28MM 401.528.96 48713198_1 CDM 0278 RC inpatient 391 254.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 379.27 97 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 28MM 401.528.96 48713198_1 CDM 0278 RC inpatient 391 254.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 269.79 69 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 28MM 401.528.96 48713198_1 CDM 0278 RC inpatient 391 254.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 304.98 78 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 28MM 401.528.96 48713198_1 CDM 0278 RC inpatient 391 254.15 UMR - ALL PLANS UMR - ALL PLANS 273.7 70 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 28MM 401.528.96 48713198_1 CDM 0278 RC inpatient 391 254.15 SIHO - ALL PLANS SIHO - ALL PLANS 351.9 90 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 28MM 401.528.96 48713198_1 CDM 0278 RC inpatient 391 254.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 236.75 60.55 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 28MM 401.528.96 48713198_1 CDM 0278 RC inpatient 391 254.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 236.75 379.27 CORTEX SCR 2.4 28MM 401.528.96 48713198_1 CDM 0278 RC inpatient 391 254.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 236.75 379.27 CORTEX SCR 2.4 28MM 401.528.96 48713198_1 CDM 0278 RC inpatient 391 254.15 ANTHEM HMO ANTHEM HMO 999999999 236.75 379.27 CORTEX SCR 2.4 28MM 401.528.96 48713198_1 CDM 0278 RC inpatient 391 254.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 264.32 67.6 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 28MM 401.528.96 48713198_1 CDM 0278 RC inpatient 391 254.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 236.75 379.27 CORTEX SCR 2.4 28MM 401.528.96 48713198_1 CDM 0278 RC inpatient 391 254.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 236.75 379.27 CORTEX SCR 2.4 26MM 401.526.96 48713199_1 CDM 0278 RC inpatient 391 254.15 AETNA AETNA 308.89 79 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 26MM 401.526.96 48713199_1 CDM 0278 RC inpatient 391 254.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 254.15 65 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 26MM 401.526.96 48713199_1 CDM 0278 RC inpatient 391 254.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 379.27 97 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 26MM 401.526.96 48713199_1 CDM 0278 RC inpatient 391 254.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 269.79 69 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 26MM 401.526.96 48713199_1 CDM 0278 RC inpatient 391 254.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 304.98 78 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 26MM 401.526.96 48713199_1 CDM 0278 RC inpatient 391 254.15 UMR - ALL PLANS UMR - ALL PLANS 273.7 70 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 26MM 401.526.96 48713199_1 CDM 0278 RC inpatient 391 254.15 SIHO - ALL PLANS SIHO - ALL PLANS 351.9 90 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 26MM 401.526.96 48713199_1 CDM 0278 RC inpatient 391 254.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 236.75 60.55 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 26MM 401.526.96 48713199_1 CDM 0278 RC inpatient 391 254.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 236.75 379.27 CORTEX SCR 2.4 26MM 401.526.96 48713199_1 CDM 0278 RC inpatient 391 254.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 236.75 379.27 CORTEX SCR 2.4 26MM 401.526.96 48713199_1 CDM 0278 RC inpatient 391 254.15 ANTHEM HMO ANTHEM HMO 999999999 236.75 379.27 CORTEX SCR 2.4 26MM 401.526.96 48713199_1 CDM 0278 RC inpatient 391 254.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 264.32 67.6 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 26MM 401.526.96 48713199_1 CDM 0278 RC inpatient 391 254.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 236.75 379.27 CORTEX SCR 2.4 26MM 401.526.96 48713199_1 CDM 0278 RC inpatient 391 254.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 236.75 379.27 CORTEX SCR 2.4 24MM 401.524.96 48713200_1 CDM 0278 RC inpatient 391 254.15 AETNA AETNA 308.89 79 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 24MM 401.524.96 48713200_1 CDM 0278 RC inpatient 391 254.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 254.15 65 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 24MM 401.524.96 48713200_1 CDM 0278 RC inpatient 391 254.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 379.27 97 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 24MM 401.524.96 48713200_1 CDM 0278 RC inpatient 391 254.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 269.79 69 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 24MM 401.524.96 48713200_1 CDM 0278 RC inpatient 391 254.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 304.98 78 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 24MM 401.524.96 48713200_1 CDM 0278 RC inpatient 391 254.15 UMR - ALL PLANS UMR - ALL PLANS 273.7 70 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 24MM 401.524.96 48713200_1 CDM 0278 RC inpatient 391 254.15 SIHO - ALL PLANS SIHO - ALL PLANS 351.9 90 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 24MM 401.524.96 48713200_1 CDM 0278 RC inpatient 391 254.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 236.75 60.55 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 24MM 401.524.96 48713200_1 CDM 0278 RC inpatient 391 254.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 236.75 379.27 CORTEX SCR 2.4 24MM 401.524.96 48713200_1 CDM 0278 RC inpatient 391 254.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 236.75 379.27 CORTEX SCR 2.4 24MM 401.524.96 48713200_1 CDM 0278 RC inpatient 391 254.15 ANTHEM HMO ANTHEM HMO 999999999 236.75 379.27 CORTEX SCR 2.4 24MM 401.524.96 48713200_1 CDM 0278 RC inpatient 391 254.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 264.32 67.6 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 24MM 401.524.96 48713200_1 CDM 0278 RC inpatient 391 254.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 236.75 379.27 CORTEX SCR 2.4 24MM 401.524.96 48713200_1 CDM 0278 RC inpatient 391 254.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 236.75 379.27 CORTEX SCR 2.4 22M 401.522.96 48713201_1 CDM 0278 RC inpatient 634 412.1 AETNA AETNA 500.86 79 999999999 383.89 614.98 percent of total billed charges CORTEX SCR 2.4 22M 401.522.96 48713201_1 CDM 0278 RC inpatient 634 412.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 412.1 65 999999999 383.89 614.98 percent of total billed charges CORTEX SCR 2.4 22M 401.522.96 48713201_1 CDM 0278 RC inpatient 634 412.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 614.98 97 999999999 383.89 614.98 percent of total billed charges CORTEX SCR 2.4 22M 401.522.96 48713201_1 CDM 0278 RC inpatient 634 412.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 437.46 69 999999999 383.89 614.98 percent of total billed charges CORTEX SCR 2.4 22M 401.522.96 48713201_1 CDM 0278 RC inpatient 634 412.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 494.52 78 999999999 383.89 614.98 percent of total billed charges CORTEX SCR 2.4 22M 401.522.96 48713201_1 CDM 0278 RC inpatient 634 412.1 UMR - ALL PLANS UMR - ALL PLANS 443.8 70 999999999 383.89 614.98 percent of total billed charges CORTEX SCR 2.4 22M 401.522.96 48713201_1 CDM 0278 RC inpatient 634 412.1 SIHO - ALL PLANS SIHO - ALL PLANS 570.6 90 999999999 383.89 614.98 percent of total billed charges CORTEX SCR 2.4 22M 401.522.96 48713201_1 CDM 0278 RC inpatient 634 412.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 383.89 60.55 999999999 383.89 614.98 percent of total billed charges CORTEX SCR 2.4 22M 401.522.96 48713201_1 CDM 0278 RC inpatient 634 412.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 383.89 614.98 CORTEX SCR 2.4 22M 401.522.96 48713201_1 CDM 0278 RC inpatient 634 412.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 383.89 614.98 CORTEX SCR 2.4 22M 401.522.96 48713201_1 CDM 0278 RC inpatient 634 412.1 ANTHEM HMO ANTHEM HMO 999999999 383.89 614.98 CORTEX SCR 2.4 22M 401.522.96 48713201_1 CDM 0278 RC inpatient 634 412.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 428.58 67.6 999999999 383.89 614.98 percent of total billed charges CORTEX SCR 2.4 22M 401.522.96 48713201_1 CDM 0278 RC inpatient 634 412.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 383.89 614.98 CORTEX SCR 2.4 22M 401.522.96 48713201_1 CDM 0278 RC inpatient 634 412.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 383.89 614.98 CORTEX SCR 2.4 20M 401.520.96 48713202_1 CDM 0278 RC inpatient 589 382.85 AETNA AETNA 465.31 79 999999999 356.64 571.33 percent of total billed charges CORTEX SCR 2.4 20M 401.520.96 48713202_1 CDM 0278 RC inpatient 589 382.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 382.85 65 999999999 356.64 571.33 percent of total billed charges CORTEX SCR 2.4 20M 401.520.96 48713202_1 CDM 0278 RC inpatient 589 382.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 571.33 97 999999999 356.64 571.33 percent of total billed charges CORTEX SCR 2.4 20M 401.520.96 48713202_1 CDM 0278 RC inpatient 589 382.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 406.41 69 999999999 356.64 571.33 percent of total billed charges CORTEX SCR 2.4 20M 401.520.96 48713202_1 CDM 0278 RC inpatient 589 382.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 459.42 78 999999999 356.64 571.33 percent of total billed charges CORTEX SCR 2.4 20M 401.520.96 48713202_1 CDM 0278 RC inpatient 589 382.85 UMR - ALL PLANS UMR - ALL PLANS 412.3 70 999999999 356.64 571.33 percent of total billed charges CORTEX SCR 2.4 20M 401.520.96 48713202_1 CDM 0278 RC inpatient 589 382.85 SIHO - ALL PLANS SIHO - ALL PLANS 530.1 90 999999999 356.64 571.33 percent of total billed charges CORTEX SCR 2.4 20M 401.520.96 48713202_1 CDM 0278 RC inpatient 589 382.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 356.64 60.55 999999999 356.64 571.33 percent of total billed charges CORTEX SCR 2.4 20M 401.520.96 48713202_1 CDM 0278 RC inpatient 589 382.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 356.64 571.33 CORTEX SCR 2.4 20M 401.520.96 48713202_1 CDM 0278 RC inpatient 589 382.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 356.64 571.33 CORTEX SCR 2.4 20M 401.520.96 48713202_1 CDM 0278 RC inpatient 589 382.85 ANTHEM HMO ANTHEM HMO 999999999 356.64 571.33 CORTEX SCR 2.4 20M 401.520.96 48713202_1 CDM 0278 RC inpatient 589 382.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 398.16 67.6 999999999 356.64 571.33 percent of total billed charges CORTEX SCR 2.4 20M 401.520.96 48713202_1 CDM 0278 RC inpatient 589 382.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 356.64 571.33 CORTEX SCR 2.4 20M 401.520.96 48713202_1 CDM 0278 RC inpatient 589 382.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 356.64 571.33 CORTEX SCR 2.4 18M 401.518.96 48713203_1 CDM 0278 RC inpatient 608 395.2 AETNA AETNA 480.32 79 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 18M 401.518.96 48713203_1 CDM 0278 RC inpatient 608 395.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 395.2 65 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 18M 401.518.96 48713203_1 CDM 0278 RC inpatient 608 395.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 589.76 97 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 18M 401.518.96 48713203_1 CDM 0278 RC inpatient 608 395.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 419.52 69 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 18M 401.518.96 48713203_1 CDM 0278 RC inpatient 608 395.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 474.24 78 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 18M 401.518.96 48713203_1 CDM 0278 RC inpatient 608 395.2 UMR - ALL PLANS UMR - ALL PLANS 425.6 70 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 18M 401.518.96 48713203_1 CDM 0278 RC inpatient 608 395.2 SIHO - ALL PLANS SIHO - ALL PLANS 547.2 90 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 18M 401.518.96 48713203_1 CDM 0278 RC inpatient 608 395.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 368.14 60.55 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 18M 401.518.96 48713203_1 CDM 0278 RC inpatient 608 395.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 368.14 589.76 CORTEX SCR 2.4 18M 401.518.96 48713203_1 CDM 0278 RC inpatient 608 395.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 368.14 589.76 CORTEX SCR 2.4 18M 401.518.96 48713203_1 CDM 0278 RC inpatient 608 395.2 ANTHEM HMO ANTHEM HMO 999999999 368.14 589.76 CORTEX SCR 2.4 18M 401.518.96 48713203_1 CDM 0278 RC inpatient 608 395.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 411.01 67.6 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 18M 401.518.96 48713203_1 CDM 0278 RC inpatient 608 395.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 368.14 589.76 CORTEX SCR 2.4 18M 401.518.96 48713203_1 CDM 0278 RC inpatient 608 395.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 368.14 589.76 CORTEX SCR 2.4 16M 401.516.96 48713204_1 CDM 0278 RC inpatient 608 395.2 AETNA AETNA 480.32 79 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 16M 401.516.96 48713204_1 CDM 0278 RC inpatient 608 395.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 395.2 65 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 16M 401.516.96 48713204_1 CDM 0278 RC inpatient 608 395.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 589.76 97 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 16M 401.516.96 48713204_1 CDM 0278 RC inpatient 608 395.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 419.52 69 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 16M 401.516.96 48713204_1 CDM 0278 RC inpatient 608 395.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 474.24 78 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 16M 401.516.96 48713204_1 CDM 0278 RC inpatient 608 395.2 UMR - ALL PLANS UMR - ALL PLANS 425.6 70 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 16M 401.516.96 48713204_1 CDM 0278 RC inpatient 608 395.2 SIHO - ALL PLANS SIHO - ALL PLANS 547.2 90 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 16M 401.516.96 48713204_1 CDM 0278 RC inpatient 608 395.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 368.14 60.55 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 16M 401.516.96 48713204_1 CDM 0278 RC inpatient 608 395.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 368.14 589.76 CORTEX SCR 2.4 16M 401.516.96 48713204_1 CDM 0278 RC inpatient 608 395.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 368.14 589.76 CORTEX SCR 2.4 16M 401.516.96 48713204_1 CDM 0278 RC inpatient 608 395.2 ANTHEM HMO ANTHEM HMO 999999999 368.14 589.76 CORTEX SCR 2.4 16M 401.516.96 48713204_1 CDM 0278 RC inpatient 608 395.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 411.01 67.6 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 16M 401.516.96 48713204_1 CDM 0278 RC inpatient 608 395.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 368.14 589.76 CORTEX SCR 2.4 16M 401.516.96 48713204_1 CDM 0278 RC inpatient 608 395.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 368.14 589.76 CORTEX SCR 2.4 14MM 401.514.96 48713205_1 CDM 0278 RC inpatient 608 395.2 AETNA AETNA 480.32 79 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 14MM 401.514.96 48713205_1 CDM 0278 RC inpatient 608 395.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 395.2 65 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 14MM 401.514.96 48713205_1 CDM 0278 RC inpatient 608 395.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 589.76 97 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 14MM 401.514.96 48713205_1 CDM 0278 RC inpatient 608 395.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 419.52 69 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 14MM 401.514.96 48713205_1 CDM 0278 RC inpatient 608 395.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 474.24 78 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 14MM 401.514.96 48713205_1 CDM 0278 RC inpatient 608 395.2 UMR - ALL PLANS UMR - ALL PLANS 425.6 70 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 14MM 401.514.96 48713205_1 CDM 0278 RC inpatient 608 395.2 SIHO - ALL PLANS SIHO - ALL PLANS 547.2 90 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 14MM 401.514.96 48713205_1 CDM 0278 RC inpatient 608 395.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 368.14 60.55 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 14MM 401.514.96 48713205_1 CDM 0278 RC inpatient 608 395.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 368.14 589.76 CORTEX SCR 2.4 14MM 401.514.96 48713205_1 CDM 0278 RC inpatient 608 395.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 368.14 589.76 CORTEX SCR 2.4 14MM 401.514.96 48713205_1 CDM 0278 RC inpatient 608 395.2 ANTHEM HMO ANTHEM HMO 999999999 368.14 589.76 CORTEX SCR 2.4 14MM 401.514.96 48713205_1 CDM 0278 RC inpatient 608 395.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 411.01 67.6 999999999 368.14 589.76 percent of total billed charges CORTEX SCR 2.4 14MM 401.514.96 48713205_1 CDM 0278 RC inpatient 608 395.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 368.14 589.76 CORTEX SCR 2.4 14MM 401.514.96 48713205_1 CDM 0278 RC inpatient 608 395.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 368.14 589.76 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713206_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 AETNA AETNA 483.48 79 999999999 370.57 593.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713206_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 397.8 65 999999999 370.57 593.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713206_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 593.64 97 999999999 370.57 593.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713206_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 422.28 69 999999999 370.57 593.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713206_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 477.36 78 999999999 370.57 593.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713206_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 UMR - ALL PLANS UMR - ALL PLANS 428.4 70 999999999 370.57 593.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713206_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 SIHO - ALL PLANS SIHO - ALL PLANS 550.8 90 999999999 370.57 593.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713206_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 370.57 60.55 999999999 370.57 593.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713206_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 370.57 593.64 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713206_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 370.57 593.64 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713206_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 ANTHEM HMO ANTHEM HMO 999999999 370.57 593.64 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713206_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 413.71 67.6 999999999 370.57 593.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713206_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 370.57 593.64 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713206_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 370.57 593.64 CORTEX SCR 2.4 11M 401.511.96 48713207_1 CDM 0278 RC inpatient 414 269.1 AETNA AETNA 327.06 79 999999999 250.68 401.58 percent of total billed charges CORTEX SCR 2.4 11M 401.511.96 48713207_1 CDM 0278 RC inpatient 414 269.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 269.1 65 999999999 250.68 401.58 percent of total billed charges CORTEX SCR 2.4 11M 401.511.96 48713207_1 CDM 0278 RC inpatient 414 269.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 401.58 97 999999999 250.68 401.58 percent of total billed charges CORTEX SCR 2.4 11M 401.511.96 48713207_1 CDM 0278 RC inpatient 414 269.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 285.66 69 999999999 250.68 401.58 percent of total billed charges CORTEX SCR 2.4 11M 401.511.96 48713207_1 CDM 0278 RC inpatient 414 269.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 322.92 78 999999999 250.68 401.58 percent of total billed charges CORTEX SCR 2.4 11M 401.511.96 48713207_1 CDM 0278 RC inpatient 414 269.1 UMR - ALL PLANS UMR - ALL PLANS 289.8 70 999999999 250.68 401.58 percent of total billed charges CORTEX SCR 2.4 11M 401.511.96 48713207_1 CDM 0278 RC inpatient 414 269.1 SIHO - ALL PLANS SIHO - ALL PLANS 372.6 90 999999999 250.68 401.58 percent of total billed charges CORTEX SCR 2.4 11M 401.511.96 48713207_1 CDM 0278 RC inpatient 414 269.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 250.68 60.55 999999999 250.68 401.58 percent of total billed charges CORTEX SCR 2.4 11M 401.511.96 48713207_1 CDM 0278 RC inpatient 414 269.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 250.68 401.58 CORTEX SCR 2.4 11M 401.511.96 48713207_1 CDM 0278 RC inpatient 414 269.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 250.68 401.58 CORTEX SCR 2.4 11M 401.511.96 48713207_1 CDM 0278 RC inpatient 414 269.1 ANTHEM HMO ANTHEM HMO 999999999 250.68 401.58 CORTEX SCR 2.4 11M 401.511.96 48713207_1 CDM 0278 RC inpatient 414 269.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 279.86 67.6 999999999 250.68 401.58 percent of total billed charges CORTEX SCR 2.4 11M 401.511.96 48713207_1 CDM 0278 RC inpatient 414 269.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 250.68 401.58 CORTEX SCR 2.4 11M 401.511.96 48713207_1 CDM 0278 RC inpatient 414 269.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 250.68 401.58 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713208_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 AETNA AETNA 483.48 79 999999999 370.57 593.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713208_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 397.8 65 999999999 370.57 593.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713208_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 593.64 97 999999999 370.57 593.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713208_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 422.28 69 999999999 370.57 593.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713208_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 477.36 78 999999999 370.57 593.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713208_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 UMR - ALL PLANS UMR - ALL PLANS 428.4 70 999999999 370.57 593.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713208_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 SIHO - ALL PLANS SIHO - ALL PLANS 550.8 90 999999999 370.57 593.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713208_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 370.57 60.55 999999999 370.57 593.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713208_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 370.57 593.64 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713208_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 370.57 593.64 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713208_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 ANTHEM HMO ANTHEM HMO 999999999 370.57 593.64 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713208_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 413.71 67.6 999999999 370.57 593.64 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713208_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 370.57 593.64 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713208_1 CDM 0278 RC C1713 HCPCS inpatient 612 397.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 370.57 593.64 CORTEX SCR 2.4 T 9M 401.509.96 48713209_1 CDM 0278 RC inpatient 391 254.15 AETNA AETNA 308.89 79 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 T 9M 401.509.96 48713209_1 CDM 0278 RC inpatient 391 254.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 254.15 65 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 T 9M 401.509.96 48713209_1 CDM 0278 RC inpatient 391 254.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 379.27 97 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 T 9M 401.509.96 48713209_1 CDM 0278 RC inpatient 391 254.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 269.79 69 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 T 9M 401.509.96 48713209_1 CDM 0278 RC inpatient 391 254.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 304.98 78 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 T 9M 401.509.96 48713209_1 CDM 0278 RC inpatient 391 254.15 UMR - ALL PLANS UMR - ALL PLANS 273.7 70 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 T 9M 401.509.96 48713209_1 CDM 0278 RC inpatient 391 254.15 SIHO - ALL PLANS SIHO - ALL PLANS 351.9 90 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 T 9M 401.509.96 48713209_1 CDM 0278 RC inpatient 391 254.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 236.75 60.55 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 T 9M 401.509.96 48713209_1 CDM 0278 RC inpatient 391 254.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 236.75 379.27 CORTEX SCR 2.4 T 9M 401.509.96 48713209_1 CDM 0278 RC inpatient 391 254.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 236.75 379.27 CORTEX SCR 2.4 T 9M 401.509.96 48713209_1 CDM 0278 RC inpatient 391 254.15 ANTHEM HMO ANTHEM HMO 999999999 236.75 379.27 CORTEX SCR 2.4 T 9M 401.509.96 48713209_1 CDM 0278 RC inpatient 391 254.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 264.32 67.6 999999999 236.75 379.27 percent of total billed charges CORTEX SCR 2.4 T 9M 401.509.96 48713209_1 CDM 0278 RC inpatient 391 254.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 236.75 379.27 CORTEX SCR 2.4 T 9M 401.509.96 48713209_1 CDM 0278 RC inpatient 391 254.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 236.75 379.27 CORTEX SCR 1.3MM TI 6M 400.686 48713210_1 CDM 0278 RC inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 6M 400.686 48713210_1 CDM 0278 RC inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 6M 400.686 48713210_1 CDM 0278 RC inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 6M 400.686 48713210_1 CDM 0278 RC inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 6M 400.686 48713210_1 CDM 0278 RC inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 6M 400.686 48713210_1 CDM 0278 RC inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 6M 400.686 48713210_1 CDM 0278 RC inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 6M 400.686 48713210_1 CDM 0278 RC inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 6M 400.686 48713210_1 CDM 0278 RC inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 6M 400.686 48713210_1 CDM 0278 RC inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 6M 400.686 48713210_1 CDM 0278 RC inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 6M 400.686 48713210_1 CDM 0278 RC inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 6M 400.686 48713210_1 CDM 0278 RC inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 6M 400.686 48713210_1 CDM 0278 RC inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 7M 400.687 48713211_1 CDM 0278 RC inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 7M 400.687 48713211_1 CDM 0278 RC inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 7M 400.687 48713211_1 CDM 0278 RC inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 7M 400.687 48713211_1 CDM 0278 RC inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 7M 400.687 48713211_1 CDM 0278 RC inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 7M 400.687 48713211_1 CDM 0278 RC inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 7M 400.687 48713211_1 CDM 0278 RC inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 7M 400.687 48713211_1 CDM 0278 RC inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 7M 400.687 48713211_1 CDM 0278 RC inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 7M 400.687 48713211_1 CDM 0278 RC inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 7M 400.687 48713211_1 CDM 0278 RC inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 7M 400.687 48713211_1 CDM 0278 RC inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 7M 400.687 48713211_1 CDM 0278 RC inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 7M 400.687 48713211_1 CDM 0278 RC inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 8M 400.688 48713212_1 CDM 0278 RC inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 8M 400.688 48713212_1 CDM 0278 RC inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 8M 400.688 48713212_1 CDM 0278 RC inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 8M 400.688 48713212_1 CDM 0278 RC inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 8M 400.688 48713212_1 CDM 0278 RC inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 8M 400.688 48713212_1 CDM 0278 RC inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 8M 400.688 48713212_1 CDM 0278 RC inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 8M 400.688 48713212_1 CDM 0278 RC inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 8M 400.688 48713212_1 CDM 0278 RC inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 8M 400.688 48713212_1 CDM 0278 RC inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 8M 400.688 48713212_1 CDM 0278 RC inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 8M 400.688 48713212_1 CDM 0278 RC inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 8M 400.688 48713212_1 CDM 0278 RC inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 8M 400.688 48713212_1 CDM 0278 RC inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 9M 400.689 48713213_1 CDM 0278 RC inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 9M 400.689 48713213_1 CDM 0278 RC inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 9M 400.689 48713213_1 CDM 0278 RC inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 9M 400.689 48713213_1 CDM 0278 RC inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 9M 400.689 48713213_1 CDM 0278 RC inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 9M 400.689 48713213_1 CDM 0278 RC inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 9M 400.689 48713213_1 CDM 0278 RC inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 9M 400.689 48713213_1 CDM 0278 RC inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 9M 400.689 48713213_1 CDM 0278 RC inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 9M 400.689 48713213_1 CDM 0278 RC inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 9M 400.689 48713213_1 CDM 0278 RC inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 9M 400.689 48713213_1 CDM 0278 RC inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3MM TI 9M 400.689 48713213_1 CDM 0278 RC inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3MM TI 9M 400.689 48713213_1 CDM 0278 RC inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 CORTEX SCR 1.3M TI 1OM 400.690 48713214_1 CDM 0278 RC inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 1OM 400.690 48713214_1 CDM 0278 RC inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 1OM 400.690 48713214_1 CDM 0278 RC inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 1OM 400.690 48713214_1 CDM 0278 RC inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 1OM 400.690 48713214_1 CDM 0278 RC inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 1OM 400.690 48713214_1 CDM 0278 RC inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 1OM 400.690 48713214_1 CDM 0278 RC inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 1OM 400.690 48713214_1 CDM 0278 RC inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 1OM 400.690 48713214_1 CDM 0278 RC inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3M TI 1OM 400.690 48713214_1 CDM 0278 RC inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 CORTEX SCR 1.3M TI 1OM 400.690 48713214_1 CDM 0278 RC inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 CORTEX SCR 1.3M TI 1OM 400.690 48713214_1 CDM 0278 RC inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 1OM 400.690 48713214_1 CDM 0278 RC inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3M TI 1OM 400.690 48713214_1 CDM 0278 RC inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713215_1 CDM 0278 RC C1713 HCPCS inpatient 582 378.3 AETNA AETNA 459.78 79 999999999 352.4 564.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713215_1 CDM 0278 RC C1713 HCPCS inpatient 582 378.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 378.3 65 999999999 352.4 564.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713215_1 CDM 0278 RC C1713 HCPCS inpatient 582 378.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 564.54 97 999999999 352.4 564.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713215_1 CDM 0278 RC C1713 HCPCS inpatient 582 378.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 401.58 69 999999999 352.4 564.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713215_1 CDM 0278 RC C1713 HCPCS inpatient 582 378.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 453.96 78 999999999 352.4 564.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713215_1 CDM 0278 RC C1713 HCPCS inpatient 582 378.3 UMR - ALL PLANS UMR - ALL PLANS 407.4 70 999999999 352.4 564.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713215_1 CDM 0278 RC C1713 HCPCS inpatient 582 378.3 SIHO - ALL PLANS SIHO - ALL PLANS 523.8 90 999999999 352.4 564.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713215_1 CDM 0278 RC C1713 HCPCS inpatient 582 378.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 352.4 60.55 999999999 352.4 564.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713215_1 CDM 0278 RC C1713 HCPCS inpatient 582 378.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 352.4 564.54 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713215_1 CDM 0278 RC C1713 HCPCS inpatient 582 378.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 352.4 564.54 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713215_1 CDM 0278 RC C1713 HCPCS inpatient 582 378.3 ANTHEM HMO ANTHEM HMO 999999999 352.4 564.54 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713215_1 CDM 0278 RC C1713 HCPCS inpatient 582 378.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 393.43 67.6 999999999 352.4 564.54 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713215_1 CDM 0278 RC C1713 HCPCS inpatient 582 378.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 352.4 564.54 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713215_1 CDM 0278 RC C1713 HCPCS inpatient 582 378.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 352.4 564.54 CORTEX SCR 1.3M TI 12M 400.692 48713216_1 CDM 0278 RC inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 12M 400.692 48713216_1 CDM 0278 RC inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 12M 400.692 48713216_1 CDM 0278 RC inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 12M 400.692 48713216_1 CDM 0278 RC inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 12M 400.692 48713216_1 CDM 0278 RC inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 12M 400.692 48713216_1 CDM 0278 RC inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 12M 400.692 48713216_1 CDM 0278 RC inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 12M 400.692 48713216_1 CDM 0278 RC inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 12M 400.692 48713216_1 CDM 0278 RC inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3M TI 12M 400.692 48713216_1 CDM 0278 RC inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 CORTEX SCR 1.3M TI 12M 400.692 48713216_1 CDM 0278 RC inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 CORTEX SCR 1.3M TI 12M 400.692 48713216_1 CDM 0278 RC inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 12M 400.692 48713216_1 CDM 0278 RC inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3M TI 12M 400.692 48713216_1 CDM 0278 RC inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 CORTEX SCR 1.3M TI 13M 400.693 48713217_1 CDM 0278 RC inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 13M 400.693 48713217_1 CDM 0278 RC inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 13M 400.693 48713217_1 CDM 0278 RC inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 13M 400.693 48713217_1 CDM 0278 RC inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 13M 400.693 48713217_1 CDM 0278 RC inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 13M 400.693 48713217_1 CDM 0278 RC inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 13M 400.693 48713217_1 CDM 0278 RC inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 13M 400.693 48713217_1 CDM 0278 RC inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 13M 400.693 48713217_1 CDM 0278 RC inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3M TI 13M 400.693 48713217_1 CDM 0278 RC inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 CORTEX SCR 1.3M TI 13M 400.693 48713217_1 CDM 0278 RC inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 CORTEX SCR 1.3M TI 13M 400.693 48713217_1 CDM 0278 RC inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 13M 400.693 48713217_1 CDM 0278 RC inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3M TI 13M 400.693 48713217_1 CDM 0278 RC inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 CORTEX SCR 1.3M TI 14M 400.694 48713218_1 CDM 0278 RC inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 14M 400.694 48713218_1 CDM 0278 RC inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 14M 400.694 48713218_1 CDM 0278 RC inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 14M 400.694 48713218_1 CDM 0278 RC inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 14M 400.694 48713218_1 CDM 0278 RC inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 14M 400.694 48713218_1 CDM 0278 RC inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 14M 400.694 48713218_1 CDM 0278 RC inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 14M 400.694 48713218_1 CDM 0278 RC inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 14M 400.694 48713218_1 CDM 0278 RC inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3M TI 14M 400.694 48713218_1 CDM 0278 RC inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 CORTEX SCR 1.3M TI 14M 400.694 48713218_1 CDM 0278 RC inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 CORTEX SCR 1.3M TI 14M 400.694 48713218_1 CDM 0278 RC inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 14M 400.694 48713218_1 CDM 0278 RC inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3M TI 14M 400.694 48713218_1 CDM 0278 RC inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 CORTEX SCR 1.3M TI 16M 400.696 48713219_1 CDM 0278 RC inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 16M 400.696 48713219_1 CDM 0278 RC inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 16M 400.696 48713219_1 CDM 0278 RC inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 16M 400.696 48713219_1 CDM 0278 RC inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 16M 400.696 48713219_1 CDM 0278 RC inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 16M 400.696 48713219_1 CDM 0278 RC inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 16M 400.696 48713219_1 CDM 0278 RC inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 16M 400.696 48713219_1 CDM 0278 RC inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 16M 400.696 48713219_1 CDM 0278 RC inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3M TI 16M 400.696 48713219_1 CDM 0278 RC inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 CORTEX SCR 1.3M TI 16M 400.696 48713219_1 CDM 0278 RC inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 CORTEX SCR 1.3M TI 16M 400.696 48713219_1 CDM 0278 RC inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 16M 400.696 48713219_1 CDM 0278 RC inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3M TI 16M 400.696 48713219_1 CDM 0278 RC inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 CORTEX SCR 1.3M TI 18M 400.698 48713220_1 CDM 0278 RC inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 18M 400.698 48713220_1 CDM 0278 RC inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 18M 400.698 48713220_1 CDM 0278 RC inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 18M 400.698 48713220_1 CDM 0278 RC inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 18M 400.698 48713220_1 CDM 0278 RC inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 18M 400.698 48713220_1 CDM 0278 RC inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 18M 400.698 48713220_1 CDM 0278 RC inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 18M 400.698 48713220_1 CDM 0278 RC inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 18M 400.698 48713220_1 CDM 0278 RC inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3M TI 18M 400.698 48713220_1 CDM 0278 RC inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 CORTEX SCR 1.3M TI 18M 400.698 48713220_1 CDM 0278 RC inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 CORTEX SCR 1.3M TI 18M 400.698 48713220_1 CDM 0278 RC inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges CORTEX SCR 1.3M TI 18M 400.698 48713220_1 CDM 0278 RC inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 CORTEX SCR 1.3M TI 18M 400.698 48713220_1 CDM 0278 RC inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 CORTEX SCREW 1.5 TI 400.806.96 48713221_1 CDM 0278 RC inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.806.96 48713221_1 CDM 0278 RC inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.806.96 48713221_1 CDM 0278 RC inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.806.96 48713221_1 CDM 0278 RC inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.806.96 48713221_1 CDM 0278 RC inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.806.96 48713221_1 CDM 0278 RC inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.806.96 48713221_1 CDM 0278 RC inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.806.96 48713221_1 CDM 0278 RC inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.806.96 48713221_1 CDM 0278 RC inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.806.96 48713221_1 CDM 0278 RC inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.806.96 48713221_1 CDM 0278 RC inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.806.96 48713221_1 CDM 0278 RC inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.806.96 48713221_1 CDM 0278 RC inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.806.96 48713221_1 CDM 0278 RC inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.807.96 48713222_1 CDM 0278 RC inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.807.96 48713222_1 CDM 0278 RC inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.807.96 48713222_1 CDM 0278 RC inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.807.96 48713222_1 CDM 0278 RC inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.807.96 48713222_1 CDM 0278 RC inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.807.96 48713222_1 CDM 0278 RC inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.807.96 48713222_1 CDM 0278 RC inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.807.96 48713222_1 CDM 0278 RC inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.807.96 48713222_1 CDM 0278 RC inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.807.96 48713222_1 CDM 0278 RC inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.807.96 48713222_1 CDM 0278 RC inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.807.96 48713222_1 CDM 0278 RC inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.807.96 48713222_1 CDM 0278 RC inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.807.96 48713222_1 CDM 0278 RC inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713223_1 CDM 0278 RC C1713 HCPCS inpatient 266 172.9 AETNA AETNA 210.14 79 999999999 161.06 258.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713223_1 CDM 0278 RC C1713 HCPCS inpatient 266 172.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 172.9 65 999999999 161.06 258.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713223_1 CDM 0278 RC C1713 HCPCS inpatient 266 172.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 258.02 97 999999999 161.06 258.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713223_1 CDM 0278 RC C1713 HCPCS inpatient 266 172.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 183.54 69 999999999 161.06 258.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713223_1 CDM 0278 RC C1713 HCPCS inpatient 266 172.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 207.48 78 999999999 161.06 258.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713223_1 CDM 0278 RC C1713 HCPCS inpatient 266 172.9 UMR - ALL PLANS UMR - ALL PLANS 186.2 70 999999999 161.06 258.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713223_1 CDM 0278 RC C1713 HCPCS inpatient 266 172.9 SIHO - ALL PLANS SIHO - ALL PLANS 239.4 90 999999999 161.06 258.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713223_1 CDM 0278 RC C1713 HCPCS inpatient 266 172.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 161.06 60.55 999999999 161.06 258.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713223_1 CDM 0278 RC C1713 HCPCS inpatient 266 172.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 161.06 258.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713223_1 CDM 0278 RC C1713 HCPCS inpatient 266 172.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 161.06 258.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713223_1 CDM 0278 RC C1713 HCPCS inpatient 266 172.9 ANTHEM HMO ANTHEM HMO 999999999 161.06 258.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713223_1 CDM 0278 RC C1713 HCPCS inpatient 266 172.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 179.82 67.6 999999999 161.06 258.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713223_1 CDM 0278 RC C1713 HCPCS inpatient 266 172.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 161.06 258.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713223_1 CDM 0278 RC C1713 HCPCS inpatient 266 172.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 161.06 258.02 CORTEX SCREW 1.5 TI 400.809.96 48713224_1 CDM 0278 RC inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges CORTEX SCREW 1.5 TI 400.809.96 48713224_1 CDM 0278 RC inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges CORTEX SCREW 1.5 TI 400.809.96 48713224_1 CDM 0278 RC inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges CORTEX SCREW 1.5 TI 400.809.96 48713224_1 CDM 0278 RC inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges CORTEX SCREW 1.5 TI 400.809.96 48713224_1 CDM 0278 RC inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges CORTEX SCREW 1.5 TI 400.809.96 48713224_1 CDM 0278 RC inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges CORTEX SCREW 1.5 TI 400.809.96 48713224_1 CDM 0278 RC inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges CORTEX SCREW 1.5 TI 400.809.96 48713224_1 CDM 0278 RC inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges CORTEX SCREW 1.5 TI 400.809.96 48713224_1 CDM 0278 RC inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 CORTEX SCREW 1.5 TI 400.809.96 48713224_1 CDM 0278 RC inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 CORTEX SCREW 1.5 TI 400.809.96 48713224_1 CDM 0278 RC inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 CORTEX SCREW 1.5 TI 400.809.96 48713224_1 CDM 0278 RC inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges CORTEX SCREW 1.5 TI 400.809.96 48713224_1 CDM 0278 RC inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 CORTEX SCREW 1.5 TI 400.809.96 48713224_1 CDM 0278 RC inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713225_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713225_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713225_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713225_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713225_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713225_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713225_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713225_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713225_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713225_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713225_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713225_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713225_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713225_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713226_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713226_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713226_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713226_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713226_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713226_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713226_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713226_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713226_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713226_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713226_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713226_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713226_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713226_1 CDM 0278 RC C1713 HCPCS inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 CORTEX SCREW 1.5 TI 400.812.96 48713227_1 CDM 0278 RC inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges CORTEX SCREW 1.5 TI 400.812.96 48713227_1 CDM 0278 RC inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges CORTEX SCREW 1.5 TI 400.812.96 48713227_1 CDM 0278 RC inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges CORTEX SCREW 1.5 TI 400.812.96 48713227_1 CDM 0278 RC inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges CORTEX SCREW 1.5 TI 400.812.96 48713227_1 CDM 0278 RC inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges CORTEX SCREW 1.5 TI 400.812.96 48713227_1 CDM 0278 RC inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges CORTEX SCREW 1.5 TI 400.812.96 48713227_1 CDM 0278 RC inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges CORTEX SCREW 1.5 TI 400.812.96 48713227_1 CDM 0278 RC inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges CORTEX SCREW 1.5 TI 400.812.96 48713227_1 CDM 0278 RC inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 CORTEX SCREW 1.5 TI 400.812.96 48713227_1 CDM 0278 RC inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 CORTEX SCREW 1.5 TI 400.812.96 48713227_1 CDM 0278 RC inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 CORTEX SCREW 1.5 TI 400.812.96 48713227_1 CDM 0278 RC inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges CORTEX SCREW 1.5 TI 400.812.96 48713227_1 CDM 0278 RC inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 CORTEX SCREW 1.5 TI 400.812.96 48713227_1 CDM 0278 RC inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 CORTEX SCREW 1.5 TI 400.813.96 48713228_1 CDM 0278 RC inpatient 339 220.35 AETNA AETNA 267.81 79 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.813.96 48713228_1 CDM 0278 RC inpatient 339 220.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 220.35 65 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.813.96 48713228_1 CDM 0278 RC inpatient 339 220.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 328.83 97 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.813.96 48713228_1 CDM 0278 RC inpatient 339 220.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 233.91 69 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.813.96 48713228_1 CDM 0278 RC inpatient 339 220.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 264.42 78 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.813.96 48713228_1 CDM 0278 RC inpatient 339 220.35 UMR - ALL PLANS UMR - ALL PLANS 237.3 70 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.813.96 48713228_1 CDM 0278 RC inpatient 339 220.35 SIHO - ALL PLANS SIHO - ALL PLANS 305.1 90 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.813.96 48713228_1 CDM 0278 RC inpatient 339 220.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.26 60.55 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.813.96 48713228_1 CDM 0278 RC inpatient 339 220.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.26 328.83 CORTEX SCREW 1.5 TI 400.813.96 48713228_1 CDM 0278 RC inpatient 339 220.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.26 328.83 CORTEX SCREW 1.5 TI 400.813.96 48713228_1 CDM 0278 RC inpatient 339 220.35 ANTHEM HMO ANTHEM HMO 999999999 205.26 328.83 CORTEX SCREW 1.5 TI 400.813.96 48713228_1 CDM 0278 RC inpatient 339 220.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.16 67.6 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.813.96 48713228_1 CDM 0278 RC inpatient 339 220.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.26 328.83 CORTEX SCREW 1.5 TI 400.813.96 48713228_1 CDM 0278 RC inpatient 339 220.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.26 328.83 CORTEX SCREW 1.5 TI 400.816.96 48713229_1 CDM 0278 RC inpatient 339 220.35 AETNA AETNA 267.81 79 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.816.96 48713229_1 CDM 0278 RC inpatient 339 220.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 220.35 65 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.816.96 48713229_1 CDM 0278 RC inpatient 339 220.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 328.83 97 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.816.96 48713229_1 CDM 0278 RC inpatient 339 220.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 233.91 69 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.816.96 48713229_1 CDM 0278 RC inpatient 339 220.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 264.42 78 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.816.96 48713229_1 CDM 0278 RC inpatient 339 220.35 UMR - ALL PLANS UMR - ALL PLANS 237.3 70 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.816.96 48713229_1 CDM 0278 RC inpatient 339 220.35 SIHO - ALL PLANS SIHO - ALL PLANS 305.1 90 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.816.96 48713229_1 CDM 0278 RC inpatient 339 220.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.26 60.55 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.816.96 48713229_1 CDM 0278 RC inpatient 339 220.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.26 328.83 CORTEX SCREW 1.5 TI 400.816.96 48713229_1 CDM 0278 RC inpatient 339 220.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.26 328.83 CORTEX SCREW 1.5 TI 400.816.96 48713229_1 CDM 0278 RC inpatient 339 220.35 ANTHEM HMO ANTHEM HMO 999999999 205.26 328.83 CORTEX SCREW 1.5 TI 400.816.96 48713229_1 CDM 0278 RC inpatient 339 220.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.16 67.6 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.816.96 48713229_1 CDM 0278 RC inpatient 339 220.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.26 328.83 CORTEX SCREW 1.5 TI 400.816.96 48713229_1 CDM 0278 RC inpatient 339 220.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.26 328.83 CORTEX SCREW 1.5 TI 400.818.96 48713230_1 CDM 0278 RC inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.818.96 48713230_1 CDM 0278 RC inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.818.96 48713230_1 CDM 0278 RC inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.818.96 48713230_1 CDM 0278 RC inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.818.96 48713230_1 CDM 0278 RC inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.818.96 48713230_1 CDM 0278 RC inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.818.96 48713230_1 CDM 0278 RC inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.818.96 48713230_1 CDM 0278 RC inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.818.96 48713230_1 CDM 0278 RC inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.818.96 48713230_1 CDM 0278 RC inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.818.96 48713230_1 CDM 0278 RC inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.818.96 48713230_1 CDM 0278 RC inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.818.96 48713230_1 CDM 0278 RC inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.818.96 48713230_1 CDM 0278 RC inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.820.96 48713231_1 CDM 0278 RC inpatient 339 220.35 AETNA AETNA 267.81 79 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.820.96 48713231_1 CDM 0278 RC inpatient 339 220.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 220.35 65 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.820.96 48713231_1 CDM 0278 RC inpatient 339 220.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 328.83 97 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.820.96 48713231_1 CDM 0278 RC inpatient 339 220.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 233.91 69 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.820.96 48713231_1 CDM 0278 RC inpatient 339 220.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 264.42 78 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.820.96 48713231_1 CDM 0278 RC inpatient 339 220.35 UMR - ALL PLANS UMR - ALL PLANS 237.3 70 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.820.96 48713231_1 CDM 0278 RC inpatient 339 220.35 SIHO - ALL PLANS SIHO - ALL PLANS 305.1 90 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.820.96 48713231_1 CDM 0278 RC inpatient 339 220.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.26 60.55 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.820.96 48713231_1 CDM 0278 RC inpatient 339 220.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.26 328.83 CORTEX SCREW 1.5 TI 400.820.96 48713231_1 CDM 0278 RC inpatient 339 220.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.26 328.83 CORTEX SCREW 1.5 TI 400.820.96 48713231_1 CDM 0278 RC inpatient 339 220.35 ANTHEM HMO ANTHEM HMO 999999999 205.26 328.83 CORTEX SCREW 1.5 TI 400.820.96 48713231_1 CDM 0278 RC inpatient 339 220.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.16 67.6 999999999 205.26 328.83 percent of total billed charges CORTEX SCREW 1.5 TI 400.820.96 48713231_1 CDM 0278 RC inpatient 339 220.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.26 328.83 CORTEX SCREW 1.5 TI 400.820.96 48713231_1 CDM 0278 RC inpatient 339 220.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.26 328.83 CORTEX SCREW 1.5 TI 400.822.96 48713232_1 CDM 0278 RC inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.822.96 48713232_1 CDM 0278 RC inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.822.96 48713232_1 CDM 0278 RC inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.822.96 48713232_1 CDM 0278 RC inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.822.96 48713232_1 CDM 0278 RC inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.822.96 48713232_1 CDM 0278 RC inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.822.96 48713232_1 CDM 0278 RC inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.822.96 48713232_1 CDM 0278 RC inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.822.96 48713232_1 CDM 0278 RC inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.822.96 48713232_1 CDM 0278 RC inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.822.96 48713232_1 CDM 0278 RC inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.822.96 48713232_1 CDM 0278 RC inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.822.96 48713232_1 CDM 0278 RC inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.822.96 48713232_1 CDM 0278 RC inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.824.96 48713233_1 CDM 0278 RC inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.824.96 48713233_1 CDM 0278 RC inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.824.96 48713233_1 CDM 0278 RC inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.824.96 48713233_1 CDM 0278 RC inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.824.96 48713233_1 CDM 0278 RC inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.824.96 48713233_1 CDM 0278 RC inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.824.96 48713233_1 CDM 0278 RC inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.824.96 48713233_1 CDM 0278 RC inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.824.96 48713233_1 CDM 0278 RC inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.824.96 48713233_1 CDM 0278 RC inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.824.96 48713233_1 CDM 0278 RC inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.824.96 48713233_1 CDM 0278 RC inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5 TI 400.824.96 48713233_1 CDM 0278 RC inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 CORTEX SCREW 1.5 TI 400.824.96 48713233_1 CDM 0278 RC inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 CORTEX SCR 2.4 T 6M 401.506.96 48713234_1 CDM 0278 RC inpatient 443 287.95 AETNA AETNA 349.97 79 999999999 268.24 429.71 percent of total billed charges CORTEX SCR 2.4 T 6M 401.506.96 48713234_1 CDM 0278 RC inpatient 443 287.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 287.95 65 999999999 268.24 429.71 percent of total billed charges CORTEX SCR 2.4 T 6M 401.506.96 48713234_1 CDM 0278 RC inpatient 443 287.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 429.71 97 999999999 268.24 429.71 percent of total billed charges CORTEX SCR 2.4 T 6M 401.506.96 48713234_1 CDM 0278 RC inpatient 443 287.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 305.67 69 999999999 268.24 429.71 percent of total billed charges CORTEX SCR 2.4 T 6M 401.506.96 48713234_1 CDM 0278 RC inpatient 443 287.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 345.54 78 999999999 268.24 429.71 percent of total billed charges CORTEX SCR 2.4 T 6M 401.506.96 48713234_1 CDM 0278 RC inpatient 443 287.95 UMR - ALL PLANS UMR - ALL PLANS 310.1 70 999999999 268.24 429.71 percent of total billed charges CORTEX SCR 2.4 T 6M 401.506.96 48713234_1 CDM 0278 RC inpatient 443 287.95 SIHO - ALL PLANS SIHO - ALL PLANS 398.7 90 999999999 268.24 429.71 percent of total billed charges CORTEX SCR 2.4 T 6M 401.506.96 48713234_1 CDM 0278 RC inpatient 443 287.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 268.24 60.55 999999999 268.24 429.71 percent of total billed charges CORTEX SCR 2.4 T 6M 401.506.96 48713234_1 CDM 0278 RC inpatient 443 287.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 268.24 429.71 CORTEX SCR 2.4 T 6M 401.506.96 48713234_1 CDM 0278 RC inpatient 443 287.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 268.24 429.71 CORTEX SCR 2.4 T 6M 401.506.96 48713234_1 CDM 0278 RC inpatient 443 287.95 ANTHEM HMO ANTHEM HMO 999999999 268.24 429.71 CORTEX SCR 2.4 T 6M 401.506.96 48713234_1 CDM 0278 RC inpatient 443 287.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 299.47 67.6 999999999 268.24 429.71 percent of total billed charges CORTEX SCR 2.4 T 6M 401.506.96 48713234_1 CDM 0278 RC inpatient 443 287.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 268.24 429.71 CORTEX SCR 2.4 T 6M 401.506.96 48713234_1 CDM 0278 RC inpatient 443 287.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 268.24 429.71 CORTEX SCR 2.4 T 7M 401.507.96 48713235_1 CDM 0278 RC inpatient 497 323.05 AETNA AETNA 392.63 79 999999999 300.93 482.09 percent of total billed charges CORTEX SCR 2.4 T 7M 401.507.96 48713235_1 CDM 0278 RC inpatient 497 323.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 323.05 65 999999999 300.93 482.09 percent of total billed charges CORTEX SCR 2.4 T 7M 401.507.96 48713235_1 CDM 0278 RC inpatient 497 323.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 482.09 97 999999999 300.93 482.09 percent of total billed charges CORTEX SCR 2.4 T 7M 401.507.96 48713235_1 CDM 0278 RC inpatient 497 323.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 342.93 69 999999999 300.93 482.09 percent of total billed charges CORTEX SCR 2.4 T 7M 401.507.96 48713235_1 CDM 0278 RC inpatient 497 323.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 387.66 78 999999999 300.93 482.09 percent of total billed charges CORTEX SCR 2.4 T 7M 401.507.96 48713235_1 CDM 0278 RC inpatient 497 323.05 UMR - ALL PLANS UMR - ALL PLANS 347.9 70 999999999 300.93 482.09 percent of total billed charges CORTEX SCR 2.4 T 7M 401.507.96 48713235_1 CDM 0278 RC inpatient 497 323.05 SIHO - ALL PLANS SIHO - ALL PLANS 447.3 90 999999999 300.93 482.09 percent of total billed charges CORTEX SCR 2.4 T 7M 401.507.96 48713235_1 CDM 0278 RC inpatient 497 323.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 300.93 60.55 999999999 300.93 482.09 percent of total billed charges CORTEX SCR 2.4 T 7M 401.507.96 48713235_1 CDM 0278 RC inpatient 497 323.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 300.93 482.09 CORTEX SCR 2.4 T 7M 401.507.96 48713235_1 CDM 0278 RC inpatient 497 323.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 300.93 482.09 CORTEX SCR 2.4 T 7M 401.507.96 48713235_1 CDM 0278 RC inpatient 497 323.05 ANTHEM HMO ANTHEM HMO 999999999 300.93 482.09 CORTEX SCR 2.4 T 7M 401.507.96 48713235_1 CDM 0278 RC inpatient 497 323.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 335.97 67.6 999999999 300.93 482.09 percent of total billed charges CORTEX SCR 2.4 T 7M 401.507.96 48713235_1 CDM 0278 RC inpatient 497 323.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 300.93 482.09 CORTEX SCR 2.4 T 7M 401.507.96 48713235_1 CDM 0278 RC inpatient 497 323.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 300.93 482.09 CORTEX SCR 2.4 T 8M 401.508.96 48713236_1 CDM 0278 RC inpatient 544 353.6 AETNA AETNA 429.76 79 999999999 329.39 527.68 percent of total billed charges CORTEX SCR 2.4 T 8M 401.508.96 48713236_1 CDM 0278 RC inpatient 544 353.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 353.6 65 999999999 329.39 527.68 percent of total billed charges CORTEX SCR 2.4 T 8M 401.508.96 48713236_1 CDM 0278 RC inpatient 544 353.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 527.68 97 999999999 329.39 527.68 percent of total billed charges CORTEX SCR 2.4 T 8M 401.508.96 48713236_1 CDM 0278 RC inpatient 544 353.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 375.36 69 999999999 329.39 527.68 percent of total billed charges CORTEX SCR 2.4 T 8M 401.508.96 48713236_1 CDM 0278 RC inpatient 544 353.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 424.32 78 999999999 329.39 527.68 percent of total billed charges CORTEX SCR 2.4 T 8M 401.508.96 48713236_1 CDM 0278 RC inpatient 544 353.6 UMR - ALL PLANS UMR - ALL PLANS 380.8 70 999999999 329.39 527.68 percent of total billed charges CORTEX SCR 2.4 T 8M 401.508.96 48713236_1 CDM 0278 RC inpatient 544 353.6 SIHO - ALL PLANS SIHO - ALL PLANS 489.6 90 999999999 329.39 527.68 percent of total billed charges CORTEX SCR 2.4 T 8M 401.508.96 48713236_1 CDM 0278 RC inpatient 544 353.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 329.39 60.55 999999999 329.39 527.68 percent of total billed charges CORTEX SCR 2.4 T 8M 401.508.96 48713236_1 CDM 0278 RC inpatient 544 353.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 329.39 527.68 CORTEX SCR 2.4 T 8M 401.508.96 48713236_1 CDM 0278 RC inpatient 544 353.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 329.39 527.68 CORTEX SCR 2.4 T 8M 401.508.96 48713236_1 CDM 0278 RC inpatient 544 353.6 ANTHEM HMO ANTHEM HMO 999999999 329.39 527.68 CORTEX SCR 2.4 T 8M 401.508.96 48713236_1 CDM 0278 RC inpatient 544 353.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 367.74 67.6 999999999 329.39 527.68 percent of total billed charges CORTEX SCR 2.4 T 8M 401.508.96 48713236_1 CDM 0278 RC inpatient 544 353.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 329.39 527.68 CORTEX SCR 2.4 T 8M 401.508.96 48713236_1 CDM 0278 RC inpatient 544 353.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 329.39 527.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713237_1 CDM 0278 RC C1713 HCPCS inpatient 225 146.25 AETNA AETNA 177.75 79 999999999 136.24 218.25 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713237_1 CDM 0278 RC C1713 HCPCS inpatient 225 146.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 146.25 65 999999999 136.24 218.25 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713237_1 CDM 0278 RC C1713 HCPCS inpatient 225 146.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 218.25 97 999999999 136.24 218.25 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713237_1 CDM 0278 RC C1713 HCPCS inpatient 225 146.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 155.25 69 999999999 136.24 218.25 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713237_1 CDM 0278 RC C1713 HCPCS inpatient 225 146.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 175.5 78 999999999 136.24 218.25 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713237_1 CDM 0278 RC C1713 HCPCS inpatient 225 146.25 UMR - ALL PLANS UMR - ALL PLANS 157.5 70 999999999 136.24 218.25 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713237_1 CDM 0278 RC C1713 HCPCS inpatient 225 146.25 SIHO - ALL PLANS SIHO - ALL PLANS 202.5 90 999999999 136.24 218.25 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713237_1 CDM 0278 RC C1713 HCPCS inpatient 225 146.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 136.24 60.55 999999999 136.24 218.25 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713237_1 CDM 0278 RC C1713 HCPCS inpatient 225 146.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 136.24 218.25 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713237_1 CDM 0278 RC C1713 HCPCS inpatient 225 146.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 136.24 218.25 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713237_1 CDM 0278 RC C1713 HCPCS inpatient 225 146.25 ANTHEM HMO ANTHEM HMO 999999999 136.24 218.25 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713237_1 CDM 0278 RC C1713 HCPCS inpatient 225 146.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 152.1 67.6 999999999 136.24 218.25 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713237_1 CDM 0278 RC C1713 HCPCS inpatient 225 146.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 136.24 218.25 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713237_1 CDM 0278 RC C1713 HCPCS inpatient 225 146.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 136.24 218.25 4.5 CORTEX SCREW DHS 214.828 48713238_1 CDM 0278 RC inpatient 132 85.8 AETNA AETNA 104.28 79 999999999 79.93 128.04 percent of total billed charges 4.5 CORTEX SCREW DHS 214.828 48713238_1 CDM 0278 RC inpatient 132 85.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.8 65 999999999 79.93 128.04 percent of total billed charges 4.5 CORTEX SCREW DHS 214.828 48713238_1 CDM 0278 RC inpatient 132 85.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 128.04 97 999999999 79.93 128.04 percent of total billed charges 4.5 CORTEX SCREW DHS 214.828 48713238_1 CDM 0278 RC inpatient 132 85.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.08 69 999999999 79.93 128.04 percent of total billed charges 4.5 CORTEX SCREW DHS 214.828 48713238_1 CDM 0278 RC inpatient 132 85.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.96 78 999999999 79.93 128.04 percent of total billed charges 4.5 CORTEX SCREW DHS 214.828 48713238_1 CDM 0278 RC inpatient 132 85.8 UMR - ALL PLANS UMR - ALL PLANS 92.4 70 999999999 79.93 128.04 percent of total billed charges 4.5 CORTEX SCREW DHS 214.828 48713238_1 CDM 0278 RC inpatient 132 85.8 SIHO - ALL PLANS SIHO - ALL PLANS 118.8 90 999999999 79.93 128.04 percent of total billed charges 4.5 CORTEX SCREW DHS 214.828 48713238_1 CDM 0278 RC inpatient 132 85.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.93 60.55 999999999 79.93 128.04 percent of total billed charges 4.5 CORTEX SCREW DHS 214.828 48713238_1 CDM 0278 RC inpatient 132 85.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.93 128.04 4.5 CORTEX SCREW DHS 214.828 48713238_1 CDM 0278 RC inpatient 132 85.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.93 128.04 4.5 CORTEX SCREW DHS 214.828 48713238_1 CDM 0278 RC inpatient 132 85.8 ANTHEM HMO ANTHEM HMO 999999999 79.93 128.04 4.5 CORTEX SCREW DHS 214.828 48713238_1 CDM 0278 RC inpatient 132 85.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.23 67.6 999999999 79.93 128.04 percent of total billed charges 4.5 CORTEX SCREW DHS 214.828 48713238_1 CDM 0278 RC inpatient 132 85.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.93 128.04 4.5 CORTEX SCREW DHS 214.828 48713238_1 CDM 0278 RC inpatient 132 85.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.93 128.04 4.5 CORTEX SCREW DHS 214.830 48713239_1 CDM 0278 RC inpatient 120 78 AETNA AETNA 94.8 79 999999999 72.66 116.4 percent of total billed charges 4.5 CORTEX SCREW DHS 214.830 48713239_1 CDM 0278 RC inpatient 120 78 SELF PAY DISCOUNT SELF PAY DISCOUNT 78 65 999999999 72.66 116.4 percent of total billed charges 4.5 CORTEX SCREW DHS 214.830 48713239_1 CDM 0278 RC inpatient 120 78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.4 97 999999999 72.66 116.4 percent of total billed charges 4.5 CORTEX SCREW DHS 214.830 48713239_1 CDM 0278 RC inpatient 120 78 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.8 69 999999999 72.66 116.4 percent of total billed charges 4.5 CORTEX SCREW DHS 214.830 48713239_1 CDM 0278 RC inpatient 120 78 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.6 78 999999999 72.66 116.4 percent of total billed charges 4.5 CORTEX SCREW DHS 214.830 48713239_1 CDM 0278 RC inpatient 120 78 UMR - ALL PLANS UMR - ALL PLANS 84 70 999999999 72.66 116.4 percent of total billed charges 4.5 CORTEX SCREW DHS 214.830 48713239_1 CDM 0278 RC inpatient 120 78 SIHO - ALL PLANS SIHO - ALL PLANS 108 90 999999999 72.66 116.4 percent of total billed charges 4.5 CORTEX SCREW DHS 214.830 48713239_1 CDM 0278 RC inpatient 120 78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.66 60.55 999999999 72.66 116.4 percent of total billed charges 4.5 CORTEX SCREW DHS 214.830 48713239_1 CDM 0278 RC inpatient 120 78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.66 116.4 4.5 CORTEX SCREW DHS 214.830 48713239_1 CDM 0278 RC inpatient 120 78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.66 116.4 4.5 CORTEX SCREW DHS 214.830 48713239_1 CDM 0278 RC inpatient 120 78 ANTHEM HMO ANTHEM HMO 999999999 72.66 116.4 4.5 CORTEX SCREW DHS 214.830 48713239_1 CDM 0278 RC inpatient 120 78 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.12 67.6 999999999 72.66 116.4 percent of total billed charges 4.5 CORTEX SCREW DHS 214.830 48713239_1 CDM 0278 RC inpatient 120 78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.66 116.4 4.5 CORTEX SCREW DHS 214.830 48713239_1 CDM 0278 RC inpatient 120 78 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.66 116.4 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713240_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 AETNA AETNA 131.14 79 999999999 100.51 161.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713240_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.9 65 999999999 100.51 161.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713240_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.02 97 999999999 100.51 161.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713240_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 114.54 69 999999999 100.51 161.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713240_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 129.48 78 999999999 100.51 161.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713240_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 UMR - ALL PLANS UMR - ALL PLANS 116.2 70 999999999 100.51 161.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713240_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 SIHO - ALL PLANS SIHO - ALL PLANS 149.4 90 999999999 100.51 161.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713240_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 100.51 60.55 999999999 100.51 161.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713240_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 100.51 161.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713240_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 100.51 161.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713240_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 ANTHEM HMO ANTHEM HMO 999999999 100.51 161.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713240_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.22 67.6 999999999 100.51 161.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713240_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 100.51 161.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713240_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 100.51 161.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713241_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 AETNA AETNA 131.14 79 999999999 100.51 161.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713241_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.9 65 999999999 100.51 161.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713241_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.02 97 999999999 100.51 161.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713241_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 114.54 69 999999999 100.51 161.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713241_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 129.48 78 999999999 100.51 161.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713241_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 UMR - ALL PLANS UMR - ALL PLANS 116.2 70 999999999 100.51 161.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713241_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 SIHO - ALL PLANS SIHO - ALL PLANS 149.4 90 999999999 100.51 161.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713241_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 100.51 60.55 999999999 100.51 161.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713241_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 100.51 161.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713241_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 100.51 161.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713241_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 ANTHEM HMO ANTHEM HMO 999999999 100.51 161.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713241_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.22 67.6 999999999 100.51 161.02 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713241_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 100.51 161.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713241_1 CDM 0278 RC C1713 HCPCS inpatient 166 107.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 100.51 161.02 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713242_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 AETNA AETNA 130.35 79 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713242_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.25 65 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713242_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 160.05 97 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713242_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.85 69 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713242_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.7 78 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713242_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 UMR - ALL PLANS UMR - ALL PLANS 115.5 70 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713242_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 SIHO - ALL PLANS SIHO - ALL PLANS 148.5 90 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713242_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.91 60.55 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713242_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713242_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713242_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM HMO ANTHEM HMO 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713242_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.54 67.6 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713242_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713242_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713243_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 AETNA AETNA 130.35 79 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713243_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.25 65 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713243_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 160.05 97 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713243_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.85 69 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713243_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.7 78 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713243_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 UMR - ALL PLANS UMR - ALL PLANS 115.5 70 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713243_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 SIHO - ALL PLANS SIHO - ALL PLANS 148.5 90 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713243_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.91 60.55 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713243_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713243_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713243_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM HMO ANTHEM HMO 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713243_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.54 67.6 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713243_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713243_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.91 160.05 4.5 CORTEX SCREW DHS 214.840 48713244_1 CDM 0278 RC inpatient 155 100.75 AETNA AETNA 122.45 79 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.840 48713244_1 CDM 0278 RC inpatient 155 100.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.75 65 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.840 48713244_1 CDM 0278 RC inpatient 155 100.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 150.35 97 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.840 48713244_1 CDM 0278 RC inpatient 155 100.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.95 69 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.840 48713244_1 CDM 0278 RC inpatient 155 100.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.9 78 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.840 48713244_1 CDM 0278 RC inpatient 155 100.75 UMR - ALL PLANS UMR - ALL PLANS 108.5 70 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.840 48713244_1 CDM 0278 RC inpatient 155 100.75 SIHO - ALL PLANS SIHO - ALL PLANS 139.5 90 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.840 48713244_1 CDM 0278 RC inpatient 155 100.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.85 60.55 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.840 48713244_1 CDM 0278 RC inpatient 155 100.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.85 150.35 4.5 CORTEX SCREW DHS 214.840 48713244_1 CDM 0278 RC inpatient 155 100.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.85 150.35 4.5 CORTEX SCREW DHS 214.840 48713244_1 CDM 0278 RC inpatient 155 100.75 ANTHEM HMO ANTHEM HMO 999999999 93.85 150.35 4.5 CORTEX SCREW DHS 214.840 48713244_1 CDM 0278 RC inpatient 155 100.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.78 67.6 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.840 48713244_1 CDM 0278 RC inpatient 155 100.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.85 150.35 4.5 CORTEX SCREW DHS 214.840 48713244_1 CDM 0278 RC inpatient 155 100.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.85 150.35 4.5 CORTEX SCREW DHS 214.842 48713245_1 CDM 0278 RC inpatient 160 104 AETNA AETNA 126.4 79 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.842 48713245_1 CDM 0278 RC inpatient 160 104 SELF PAY DISCOUNT SELF PAY DISCOUNT 104 65 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.842 48713245_1 CDM 0278 RC inpatient 160 104 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 155.2 97 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.842 48713245_1 CDM 0278 RC inpatient 160 104 ENCORE - ALL PLANS ENCORE - ALL PLANS 110.4 69 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.842 48713245_1 CDM 0278 RC inpatient 160 104 HUMANA - ALL PLANS HUMANA - ALL PLANS 124.8 78 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.842 48713245_1 CDM 0278 RC inpatient 160 104 UMR - ALL PLANS UMR - ALL PLANS 112 70 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.842 48713245_1 CDM 0278 RC inpatient 160 104 SIHO - ALL PLANS SIHO - ALL PLANS 144 90 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.842 48713245_1 CDM 0278 RC inpatient 160 104 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 96.88 60.55 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.842 48713245_1 CDM 0278 RC inpatient 160 104 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 96.88 155.2 4.5 CORTEX SCREW DHS 214.842 48713245_1 CDM 0278 RC inpatient 160 104 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 96.88 155.2 4.5 CORTEX SCREW DHS 214.842 48713245_1 CDM 0278 RC inpatient 160 104 ANTHEM HMO ANTHEM HMO 999999999 96.88 155.2 4.5 CORTEX SCREW DHS 214.842 48713245_1 CDM 0278 RC inpatient 160 104 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.16 67.6 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.842 48713245_1 CDM 0278 RC inpatient 160 104 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 96.88 155.2 4.5 CORTEX SCREW DHS 214.842 48713245_1 CDM 0278 RC inpatient 160 104 UHC - ALL PLANS UHC - ALL PLANS 999999999 96.88 155.2 4.5 CORTEX SCREW DHS 214.844 48713246_1 CDM 0278 RC inpatient 160 104 AETNA AETNA 126.4 79 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.844 48713246_1 CDM 0278 RC inpatient 160 104 SELF PAY DISCOUNT SELF PAY DISCOUNT 104 65 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.844 48713246_1 CDM 0278 RC inpatient 160 104 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 155.2 97 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.844 48713246_1 CDM 0278 RC inpatient 160 104 ENCORE - ALL PLANS ENCORE - ALL PLANS 110.4 69 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.844 48713246_1 CDM 0278 RC inpatient 160 104 HUMANA - ALL PLANS HUMANA - ALL PLANS 124.8 78 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.844 48713246_1 CDM 0278 RC inpatient 160 104 UMR - ALL PLANS UMR - ALL PLANS 112 70 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.844 48713246_1 CDM 0278 RC inpatient 160 104 SIHO - ALL PLANS SIHO - ALL PLANS 144 90 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.844 48713246_1 CDM 0278 RC inpatient 160 104 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 96.88 60.55 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.844 48713246_1 CDM 0278 RC inpatient 160 104 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 96.88 155.2 4.5 CORTEX SCREW DHS 214.844 48713246_1 CDM 0278 RC inpatient 160 104 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 96.88 155.2 4.5 CORTEX SCREW DHS 214.844 48713246_1 CDM 0278 RC inpatient 160 104 ANTHEM HMO ANTHEM HMO 999999999 96.88 155.2 4.5 CORTEX SCREW DHS 214.844 48713246_1 CDM 0278 RC inpatient 160 104 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.16 67.6 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.844 48713246_1 CDM 0278 RC inpatient 160 104 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 96.88 155.2 4.5 CORTEX SCREW DHS 214.844 48713246_1 CDM 0278 RC inpatient 160 104 UHC - ALL PLANS UHC - ALL PLANS 999999999 96.88 155.2 4.5 CORTEX SCREW DHS 214.846 48713247_1 CDM 0278 RC inpatient 155 100.75 AETNA AETNA 122.45 79 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.846 48713247_1 CDM 0278 RC inpatient 155 100.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.75 65 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.846 48713247_1 CDM 0278 RC inpatient 155 100.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 150.35 97 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.846 48713247_1 CDM 0278 RC inpatient 155 100.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.95 69 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.846 48713247_1 CDM 0278 RC inpatient 155 100.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.9 78 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.846 48713247_1 CDM 0278 RC inpatient 155 100.75 UMR - ALL PLANS UMR - ALL PLANS 108.5 70 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.846 48713247_1 CDM 0278 RC inpatient 155 100.75 SIHO - ALL PLANS SIHO - ALL PLANS 139.5 90 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.846 48713247_1 CDM 0278 RC inpatient 155 100.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.85 60.55 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.846 48713247_1 CDM 0278 RC inpatient 155 100.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.85 150.35 4.5 CORTEX SCREW DHS 214.846 48713247_1 CDM 0278 RC inpatient 155 100.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.85 150.35 4.5 CORTEX SCREW DHS 214.846 48713247_1 CDM 0278 RC inpatient 155 100.75 ANTHEM HMO ANTHEM HMO 999999999 93.85 150.35 4.5 CORTEX SCREW DHS 214.846 48713247_1 CDM 0278 RC inpatient 155 100.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.78 67.6 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.846 48713247_1 CDM 0278 RC inpatient 155 100.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.85 150.35 4.5 CORTEX SCREW DHS 214.846 48713247_1 CDM 0278 RC inpatient 155 100.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.85 150.35 4.5 CORTEX SCREW DHS 214.848 48713248_1 CDM 0278 RC inpatient 160 104 AETNA AETNA 126.4 79 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.848 48713248_1 CDM 0278 RC inpatient 160 104 SELF PAY DISCOUNT SELF PAY DISCOUNT 104 65 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.848 48713248_1 CDM 0278 RC inpatient 160 104 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 155.2 97 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.848 48713248_1 CDM 0278 RC inpatient 160 104 ENCORE - ALL PLANS ENCORE - ALL PLANS 110.4 69 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.848 48713248_1 CDM 0278 RC inpatient 160 104 HUMANA - ALL PLANS HUMANA - ALL PLANS 124.8 78 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.848 48713248_1 CDM 0278 RC inpatient 160 104 UMR - ALL PLANS UMR - ALL PLANS 112 70 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.848 48713248_1 CDM 0278 RC inpatient 160 104 SIHO - ALL PLANS SIHO - ALL PLANS 144 90 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.848 48713248_1 CDM 0278 RC inpatient 160 104 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 96.88 60.55 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.848 48713248_1 CDM 0278 RC inpatient 160 104 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 96.88 155.2 4.5 CORTEX SCREW DHS 214.848 48713248_1 CDM 0278 RC inpatient 160 104 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 96.88 155.2 4.5 CORTEX SCREW DHS 214.848 48713248_1 CDM 0278 RC inpatient 160 104 ANTHEM HMO ANTHEM HMO 999999999 96.88 155.2 4.5 CORTEX SCREW DHS 214.848 48713248_1 CDM 0278 RC inpatient 160 104 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.16 67.6 999999999 96.88 155.2 percent of total billed charges 4.5 CORTEX SCREW DHS 214.848 48713248_1 CDM 0278 RC inpatient 160 104 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 96.88 155.2 4.5 CORTEX SCREW DHS 214.848 48713248_1 CDM 0278 RC inpatient 160 104 UHC - ALL PLANS UHC - ALL PLANS 999999999 96.88 155.2 4.5 CORTEX SCREW DHS 214.850 48713249_1 CDM 0278 RC inpatient 104 67.6 AETNA AETNA 82.16 79 999999999 62.97 100.88 percent of total billed charges 4.5 CORTEX SCREW DHS 214.850 48713249_1 CDM 0278 RC inpatient 104 67.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 67.6 65 999999999 62.97 100.88 percent of total billed charges 4.5 CORTEX SCREW DHS 214.850 48713249_1 CDM 0278 RC inpatient 104 67.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 100.88 97 999999999 62.97 100.88 percent of total billed charges 4.5 CORTEX SCREW DHS 214.850 48713249_1 CDM 0278 RC inpatient 104 67.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.76 69 999999999 62.97 100.88 percent of total billed charges 4.5 CORTEX SCREW DHS 214.850 48713249_1 CDM 0278 RC inpatient 104 67.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.12 78 999999999 62.97 100.88 percent of total billed charges 4.5 CORTEX SCREW DHS 214.850 48713249_1 CDM 0278 RC inpatient 104 67.6 UMR - ALL PLANS UMR - ALL PLANS 72.8 70 999999999 62.97 100.88 percent of total billed charges 4.5 CORTEX SCREW DHS 214.850 48713249_1 CDM 0278 RC inpatient 104 67.6 SIHO - ALL PLANS SIHO - ALL PLANS 93.6 90 999999999 62.97 100.88 percent of total billed charges 4.5 CORTEX SCREW DHS 214.850 48713249_1 CDM 0278 RC inpatient 104 67.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.97 60.55 999999999 62.97 100.88 percent of total billed charges 4.5 CORTEX SCREW DHS 214.850 48713249_1 CDM 0278 RC inpatient 104 67.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.97 100.88 4.5 CORTEX SCREW DHS 214.850 48713249_1 CDM 0278 RC inpatient 104 67.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.97 100.88 4.5 CORTEX SCREW DHS 214.850 48713249_1 CDM 0278 RC inpatient 104 67.6 ANTHEM HMO ANTHEM HMO 999999999 62.97 100.88 4.5 CORTEX SCREW DHS 214.850 48713249_1 CDM 0278 RC inpatient 104 67.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.3 67.6 999999999 62.97 100.88 percent of total billed charges 4.5 CORTEX SCREW DHS 214.850 48713249_1 CDM 0278 RC inpatient 104 67.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.97 100.88 4.5 CORTEX SCREW DHS 214.850 48713249_1 CDM 0278 RC inpatient 104 67.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.97 100.88 4.5 CORTEX SCREW DHS 214.852 48713250_1 CDM 0278 RC inpatient 155 100.75 AETNA AETNA 122.45 79 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.852 48713250_1 CDM 0278 RC inpatient 155 100.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.75 65 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.852 48713250_1 CDM 0278 RC inpatient 155 100.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 150.35 97 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.852 48713250_1 CDM 0278 RC inpatient 155 100.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.95 69 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.852 48713250_1 CDM 0278 RC inpatient 155 100.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.9 78 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.852 48713250_1 CDM 0278 RC inpatient 155 100.75 UMR - ALL PLANS UMR - ALL PLANS 108.5 70 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.852 48713250_1 CDM 0278 RC inpatient 155 100.75 SIHO - ALL PLANS SIHO - ALL PLANS 139.5 90 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.852 48713250_1 CDM 0278 RC inpatient 155 100.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.85 60.55 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.852 48713250_1 CDM 0278 RC inpatient 155 100.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.85 150.35 4.5 CORTEX SCREW DHS 214.852 48713250_1 CDM 0278 RC inpatient 155 100.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.85 150.35 4.5 CORTEX SCREW DHS 214.852 48713250_1 CDM 0278 RC inpatient 155 100.75 ANTHEM HMO ANTHEM HMO 999999999 93.85 150.35 4.5 CORTEX SCREW DHS 214.852 48713250_1 CDM 0278 RC inpatient 155 100.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.78 67.6 999999999 93.85 150.35 percent of total billed charges 4.5 CORTEX SCREW DHS 214.852 48713250_1 CDM 0278 RC inpatient 155 100.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.85 150.35 4.5 CORTEX SCREW DHS 214.852 48713250_1 CDM 0278 RC inpatient 155 100.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.85 150.35 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713251_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 AETNA AETNA 130.35 79 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713251_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.25 65 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713251_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 160.05 97 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713251_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.85 69 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713251_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.7 78 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713251_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 UMR - ALL PLANS UMR - ALL PLANS 115.5 70 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713251_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 SIHO - ALL PLANS SIHO - ALL PLANS 148.5 90 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713251_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.91 60.55 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713251_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713251_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713251_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM HMO ANTHEM HMO 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713251_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.54 67.6 999999999 99.91 160.05 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713251_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.91 160.05 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713251_1 CDM 0278 RC C1713 HCPCS inpatient 165 107.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.91 160.05 4.0MM CANN SCREW 46MM 207.646 48713252_1 CDM 0278 RC inpatient 1272 826.8 AETNA AETNA 1004.88 79 999999999 770.2 1233.84 percent of total billed charges 4.0MM CANN SCREW 46MM 207.646 48713252_1 CDM 0278 RC inpatient 1272 826.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 826.8 65 999999999 770.2 1233.84 percent of total billed charges 4.0MM CANN SCREW 46MM 207.646 48713252_1 CDM 0278 RC inpatient 1272 826.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1233.84 97 999999999 770.2 1233.84 percent of total billed charges 4.0MM CANN SCREW 46MM 207.646 48713252_1 CDM 0278 RC inpatient 1272 826.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 877.68 69 999999999 770.2 1233.84 percent of total billed charges 4.0MM CANN SCREW 46MM 207.646 48713252_1 CDM 0278 RC inpatient 1272 826.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 992.16 78 999999999 770.2 1233.84 percent of total billed charges 4.0MM CANN SCREW 46MM 207.646 48713252_1 CDM 0278 RC inpatient 1272 826.8 UMR - ALL PLANS UMR - ALL PLANS 890.4 70 999999999 770.2 1233.84 percent of total billed charges 4.0MM CANN SCREW 46MM 207.646 48713252_1 CDM 0278 RC inpatient 1272 826.8 SIHO - ALL PLANS SIHO - ALL PLANS 1144.8 90 999999999 770.2 1233.84 percent of total billed charges 4.0MM CANN SCREW 46MM 207.646 48713252_1 CDM 0278 RC inpatient 1272 826.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 770.2 60.55 999999999 770.2 1233.84 percent of total billed charges 4.0MM CANN SCREW 46MM 207.646 48713252_1 CDM 0278 RC inpatient 1272 826.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 770.2 1233.84 4.0MM CANN SCREW 46MM 207.646 48713252_1 CDM 0278 RC inpatient 1272 826.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 770.2 1233.84 4.0MM CANN SCREW 46MM 207.646 48713252_1 CDM 0278 RC inpatient 1272 826.8 ANTHEM HMO ANTHEM HMO 999999999 770.2 1233.84 4.0MM CANN SCREW 46MM 207.646 48713252_1 CDM 0278 RC inpatient 1272 826.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 859.87 67.6 999999999 770.2 1233.84 percent of total billed charges 4.0MM CANN SCREW 46MM 207.646 48713252_1 CDM 0278 RC inpatient 1272 826.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 770.2 1233.84 4.0MM CANN SCREW 46MM 207.646 48713252_1 CDM 0278 RC inpatient 1272 826.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 770.2 1233.84 4.0MM CANN SCREW 40MM 207.640 48713253_1 CDM 0278 RC inpatient 1340 871 AETNA AETNA 1058.6 79 999999999 811.37 1299.8 percent of total billed charges 4.0MM CANN SCREW 40MM 207.640 48713253_1 CDM 0278 RC inpatient 1340 871 SELF PAY DISCOUNT SELF PAY DISCOUNT 871 65 999999999 811.37 1299.8 percent of total billed charges 4.0MM CANN SCREW 40MM 207.640 48713253_1 CDM 0278 RC inpatient 1340 871 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1299.8 97 999999999 811.37 1299.8 percent of total billed charges 4.0MM CANN SCREW 40MM 207.640 48713253_1 CDM 0278 RC inpatient 1340 871 ENCORE - ALL PLANS ENCORE - ALL PLANS 924.6 69 999999999 811.37 1299.8 percent of total billed charges 4.0MM CANN SCREW 40MM 207.640 48713253_1 CDM 0278 RC inpatient 1340 871 HUMANA - ALL PLANS HUMANA - ALL PLANS 1045.2 78 999999999 811.37 1299.8 percent of total billed charges 4.0MM CANN SCREW 40MM 207.640 48713253_1 CDM 0278 RC inpatient 1340 871 UMR - ALL PLANS UMR - ALL PLANS 938 70 999999999 811.37 1299.8 percent of total billed charges 4.0MM CANN SCREW 40MM 207.640 48713253_1 CDM 0278 RC inpatient 1340 871 SIHO - ALL PLANS SIHO - ALL PLANS 1206 90 999999999 811.37 1299.8 percent of total billed charges 4.0MM CANN SCREW 40MM 207.640 48713253_1 CDM 0278 RC inpatient 1340 871 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 811.37 60.55 999999999 811.37 1299.8 percent of total billed charges 4.0MM CANN SCREW 40MM 207.640 48713253_1 CDM 0278 RC inpatient 1340 871 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 811.37 1299.8 4.0MM CANN SCREW 40MM 207.640 48713253_1 CDM 0278 RC inpatient 1340 871 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 811.37 1299.8 4.0MM CANN SCREW 40MM 207.640 48713253_1 CDM 0278 RC inpatient 1340 871 ANTHEM HMO ANTHEM HMO 999999999 811.37 1299.8 4.0MM CANN SCREW 40MM 207.640 48713253_1 CDM 0278 RC inpatient 1340 871 CIGNA - ALL PLANS CIGNA - ALL PLANS 905.84 67.6 999999999 811.37 1299.8 percent of total billed charges 4.0MM CANN SCREW 40MM 207.640 48713253_1 CDM 0278 RC inpatient 1340 871 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 811.37 1299.8 4.0MM CANN SCREW 40MM 207.640 48713253_1 CDM 0278 RC inpatient 1340 871 UHC - ALL PLANS UHC - ALL PLANS 999999999 811.37 1299.8 4.0MM CANN SCREW 38MM 207.638 48713254_1 CDM 0278 RC inpatient 1467 953.55 AETNA AETNA 1158.93 79 999999999 888.27 1422.99 percent of total billed charges 4.0MM CANN SCREW 38MM 207.638 48713254_1 CDM 0278 RC inpatient 1467 953.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 953.55 65 999999999 888.27 1422.99 percent of total billed charges 4.0MM CANN SCREW 38MM 207.638 48713254_1 CDM 0278 RC inpatient 1467 953.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1422.99 97 999999999 888.27 1422.99 percent of total billed charges 4.0MM CANN SCREW 38MM 207.638 48713254_1 CDM 0278 RC inpatient 1467 953.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1012.23 69 999999999 888.27 1422.99 percent of total billed charges 4.0MM CANN SCREW 38MM 207.638 48713254_1 CDM 0278 RC inpatient 1467 953.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1144.26 78 999999999 888.27 1422.99 percent of total billed charges 4.0MM CANN SCREW 38MM 207.638 48713254_1 CDM 0278 RC inpatient 1467 953.55 UMR - ALL PLANS UMR - ALL PLANS 1026.9 70 999999999 888.27 1422.99 percent of total billed charges 4.0MM CANN SCREW 38MM 207.638 48713254_1 CDM 0278 RC inpatient 1467 953.55 SIHO - ALL PLANS SIHO - ALL PLANS 1320.3 90 999999999 888.27 1422.99 percent of total billed charges 4.0MM CANN SCREW 38MM 207.638 48713254_1 CDM 0278 RC inpatient 1467 953.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 888.27 60.55 999999999 888.27 1422.99 percent of total billed charges 4.0MM CANN SCREW 38MM 207.638 48713254_1 CDM 0278 RC inpatient 1467 953.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 888.27 1422.99 4.0MM CANN SCREW 38MM 207.638 48713254_1 CDM 0278 RC inpatient 1467 953.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 888.27 1422.99 4.0MM CANN SCREW 38MM 207.638 48713254_1 CDM 0278 RC inpatient 1467 953.55 ANTHEM HMO ANTHEM HMO 999999999 888.27 1422.99 4.0MM CANN SCREW 38MM 207.638 48713254_1 CDM 0278 RC inpatient 1467 953.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 991.69 67.6 999999999 888.27 1422.99 percent of total billed charges 4.0MM CANN SCREW 38MM 207.638 48713254_1 CDM 0278 RC inpatient 1467 953.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 888.27 1422.99 4.0MM CANN SCREW 38MM 207.638 48713254_1 CDM 0278 RC inpatient 1467 953.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 888.27 1422.99 4.0MM CANN SCREW 32MM 207.632 48713255_1 CDM 0278 RC inpatient 1310 851.5 AETNA AETNA 1034.9 79 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 32MM 207.632 48713255_1 CDM 0278 RC inpatient 1310 851.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 851.5 65 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 32MM 207.632 48713255_1 CDM 0278 RC inpatient 1310 851.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1270.7 97 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 32MM 207.632 48713255_1 CDM 0278 RC inpatient 1310 851.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 903.9 69 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 32MM 207.632 48713255_1 CDM 0278 RC inpatient 1310 851.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1021.8 78 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 32MM 207.632 48713255_1 CDM 0278 RC inpatient 1310 851.5 UMR - ALL PLANS UMR - ALL PLANS 917 70 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 32MM 207.632 48713255_1 CDM 0278 RC inpatient 1310 851.5 SIHO - ALL PLANS SIHO - ALL PLANS 1179 90 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 32MM 207.632 48713255_1 CDM 0278 RC inpatient 1310 851.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 793.21 60.55 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 32MM 207.632 48713255_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 793.21 1270.7 4.0MM CANN SCREW 32MM 207.632 48713255_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 793.21 1270.7 4.0MM CANN SCREW 32MM 207.632 48713255_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM HMO ANTHEM HMO 999999999 793.21 1270.7 4.0MM CANN SCREW 32MM 207.632 48713255_1 CDM 0278 RC inpatient 1310 851.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 885.56 67.6 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 32MM 207.632 48713255_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 793.21 1270.7 4.0MM CANN SCREW 32MM 207.632 48713255_1 CDM 0278 RC inpatient 1310 851.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 793.21 1270.7 CERCLAGE WIRE COIL 1.0M 291.05 48713256_1 CDM 0278 RC inpatient 333 216.45 AETNA AETNA 263.07 79 999999999 201.63 323.01 percent of total billed charges CERCLAGE WIRE COIL 1.0M 291.05 48713256_1 CDM 0278 RC inpatient 333 216.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 216.45 65 999999999 201.63 323.01 percent of total billed charges CERCLAGE WIRE COIL 1.0M 291.05 48713256_1 CDM 0278 RC inpatient 333 216.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 323.01 97 999999999 201.63 323.01 percent of total billed charges CERCLAGE WIRE COIL 1.0M 291.05 48713256_1 CDM 0278 RC inpatient 333 216.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 229.77 69 999999999 201.63 323.01 percent of total billed charges CERCLAGE WIRE COIL 1.0M 291.05 48713256_1 CDM 0278 RC inpatient 333 216.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 259.74 78 999999999 201.63 323.01 percent of total billed charges CERCLAGE WIRE COIL 1.0M 291.05 48713256_1 CDM 0278 RC inpatient 333 216.45 UMR - ALL PLANS UMR - ALL PLANS 233.1 70 999999999 201.63 323.01 percent of total billed charges CERCLAGE WIRE COIL 1.0M 291.05 48713256_1 CDM 0278 RC inpatient 333 216.45 SIHO - ALL PLANS SIHO - ALL PLANS 299.7 90 999999999 201.63 323.01 percent of total billed charges CERCLAGE WIRE COIL 1.0M 291.05 48713256_1 CDM 0278 RC inpatient 333 216.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 201.63 60.55 999999999 201.63 323.01 percent of total billed charges CERCLAGE WIRE COIL 1.0M 291.05 48713256_1 CDM 0278 RC inpatient 333 216.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 201.63 323.01 CERCLAGE WIRE COIL 1.0M 291.05 48713256_1 CDM 0278 RC inpatient 333 216.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 201.63 323.01 CERCLAGE WIRE COIL 1.0M 291.05 48713256_1 CDM 0278 RC inpatient 333 216.45 ANTHEM HMO ANTHEM HMO 999999999 201.63 323.01 CERCLAGE WIRE COIL 1.0M 291.05 48713256_1 CDM 0278 RC inpatient 333 216.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 225.11 67.6 999999999 201.63 323.01 percent of total billed charges CERCLAGE WIRE COIL 1.0M 291.05 48713256_1 CDM 0278 RC inpatient 333 216.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 201.63 323.01 CERCLAGE WIRE COIL 1.0M 291.05 48713256_1 CDM 0278 RC inpatient 333 216.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 201.63 323.01 STIMUPLEX ULTRA NEEDLE 20G X 4 48713257_1 CDM 0272 RC inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges STIMUPLEX ULTRA NEEDLE 20G X 4 48713257_1 CDM 0272 RC inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges STIMUPLEX ULTRA NEEDLE 20G X 4 48713257_1 CDM 0272 RC inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges STIMUPLEX ULTRA NEEDLE 20G X 4 48713257_1 CDM 0272 RC inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges STIMUPLEX ULTRA NEEDLE 20G X 4 48713257_1 CDM 0272 RC inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges STIMUPLEX ULTRA NEEDLE 20G X 4 48713257_1 CDM 0272 RC inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges STIMUPLEX ULTRA NEEDLE 20G X 4 48713257_1 CDM 0272 RC inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges STIMUPLEX ULTRA NEEDLE 20G X 4 48713257_1 CDM 0272 RC inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges STIMUPLEX ULTRA NEEDLE 20G X 4 48713257_1 CDM 0272 RC inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 STIMUPLEX ULTRA NEEDLE 20G X 4 48713257_1 CDM 0272 RC inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 STIMUPLEX ULTRA NEEDLE 20G X 4 48713257_1 CDM 0272 RC inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 STIMUPLEX ULTRA NEEDLE 20G X 4 48713257_1 CDM 0272 RC inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges STIMUPLEX ULTRA NEEDLE 20G X 4 48713257_1 CDM 0272 RC inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 STIMUPLEX ULTRA NEEDLE 20G X 4 48713257_1 CDM 0272 RC inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 4.0MM CANN SCREW 28MM 207.628 48713258_1 CDM 0278 RC inpatient 1310 851.5 AETNA AETNA 1034.9 79 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 28MM 207.628 48713258_1 CDM 0278 RC inpatient 1310 851.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 851.5 65 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 28MM 207.628 48713258_1 CDM 0278 RC inpatient 1310 851.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1270.7 97 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 28MM 207.628 48713258_1 CDM 0278 RC inpatient 1310 851.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 903.9 69 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 28MM 207.628 48713258_1 CDM 0278 RC inpatient 1310 851.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1021.8 78 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 28MM 207.628 48713258_1 CDM 0278 RC inpatient 1310 851.5 UMR - ALL PLANS UMR - ALL PLANS 917 70 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 28MM 207.628 48713258_1 CDM 0278 RC inpatient 1310 851.5 SIHO - ALL PLANS SIHO - ALL PLANS 1179 90 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 28MM 207.628 48713258_1 CDM 0278 RC inpatient 1310 851.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 793.21 60.55 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 28MM 207.628 48713258_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 793.21 1270.7 4.0MM CANN SCREW 28MM 207.628 48713258_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 793.21 1270.7 4.0MM CANN SCREW 28MM 207.628 48713258_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM HMO ANTHEM HMO 999999999 793.21 1270.7 4.0MM CANN SCREW 28MM 207.628 48713258_1 CDM 0278 RC inpatient 1310 851.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 885.56 67.6 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 28MM 207.628 48713258_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 793.21 1270.7 4.0MM CANN SCREW 28MM 207.628 48713258_1 CDM 0278 RC inpatient 1310 851.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 793.21 1270.7 4.0MM CANN SCREW 26MM 207.626 48713259_1 CDM 0278 RC inpatient 1310 851.5 AETNA AETNA 1034.9 79 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 26MM 207.626 48713259_1 CDM 0278 RC inpatient 1310 851.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 851.5 65 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 26MM 207.626 48713259_1 CDM 0278 RC inpatient 1310 851.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1270.7 97 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 26MM 207.626 48713259_1 CDM 0278 RC inpatient 1310 851.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 903.9 69 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 26MM 207.626 48713259_1 CDM 0278 RC inpatient 1310 851.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1021.8 78 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 26MM 207.626 48713259_1 CDM 0278 RC inpatient 1310 851.5 UMR - ALL PLANS UMR - ALL PLANS 917 70 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 26MM 207.626 48713259_1 CDM 0278 RC inpatient 1310 851.5 SIHO - ALL PLANS SIHO - ALL PLANS 1179 90 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 26MM 207.626 48713259_1 CDM 0278 RC inpatient 1310 851.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 793.21 60.55 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 26MM 207.626 48713259_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 793.21 1270.7 4.0MM CANN SCREW 26MM 207.626 48713259_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 793.21 1270.7 4.0MM CANN SCREW 26MM 207.626 48713259_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM HMO ANTHEM HMO 999999999 793.21 1270.7 4.0MM CANN SCREW 26MM 207.626 48713259_1 CDM 0278 RC inpatient 1310 851.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 885.56 67.6 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 26MM 207.626 48713259_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 793.21 1270.7 4.0MM CANN SCREW 26MM 207.626 48713259_1 CDM 0278 RC inpatient 1310 851.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 793.21 1270.7 4.0MM CANN SCREW 24MM 207.624 48713260_1 CDM 0278 RC inpatient 1310 851.5 AETNA AETNA 1034.9 79 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 24MM 207.624 48713260_1 CDM 0278 RC inpatient 1310 851.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 851.5 65 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 24MM 207.624 48713260_1 CDM 0278 RC inpatient 1310 851.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1270.7 97 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 24MM 207.624 48713260_1 CDM 0278 RC inpatient 1310 851.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 903.9 69 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 24MM 207.624 48713260_1 CDM 0278 RC inpatient 1310 851.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1021.8 78 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 24MM 207.624 48713260_1 CDM 0278 RC inpatient 1310 851.5 UMR - ALL PLANS UMR - ALL PLANS 917 70 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 24MM 207.624 48713260_1 CDM 0278 RC inpatient 1310 851.5 SIHO - ALL PLANS SIHO - ALL PLANS 1179 90 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 24MM 207.624 48713260_1 CDM 0278 RC inpatient 1310 851.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 793.21 60.55 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 24MM 207.624 48713260_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 793.21 1270.7 4.0MM CANN SCREW 24MM 207.624 48713260_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 793.21 1270.7 4.0MM CANN SCREW 24MM 207.624 48713260_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM HMO ANTHEM HMO 999999999 793.21 1270.7 4.0MM CANN SCREW 24MM 207.624 48713260_1 CDM 0278 RC inpatient 1310 851.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 885.56 67.6 999999999 793.21 1270.7 percent of total billed charges 4.0MM CANN SCREW 24MM 207.624 48713260_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 793.21 1270.7 4.0MM CANN SCREW 24MM 207.624 48713260_1 CDM 0278 RC inpatient 1310 851.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 793.21 1270.7 4.0MM CANN SCREW 22MM 207.622 48713261_1 CDM 0278 RC inpatient 894 581.1 AETNA AETNA 706.26 79 999999999 541.32 867.18 percent of total billed charges 4.0MM CANN SCREW 22MM 207.622 48713261_1 CDM 0278 RC inpatient 894 581.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 581.1 65 999999999 541.32 867.18 percent of total billed charges 4.0MM CANN SCREW 22MM 207.622 48713261_1 CDM 0278 RC inpatient 894 581.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 867.18 97 999999999 541.32 867.18 percent of total billed charges 4.0MM CANN SCREW 22MM 207.622 48713261_1 CDM 0278 RC inpatient 894 581.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 616.86 69 999999999 541.32 867.18 percent of total billed charges 4.0MM CANN SCREW 22MM 207.622 48713261_1 CDM 0278 RC inpatient 894 581.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 697.32 78 999999999 541.32 867.18 percent of total billed charges 4.0MM CANN SCREW 22MM 207.622 48713261_1 CDM 0278 RC inpatient 894 581.1 UMR - ALL PLANS UMR - ALL PLANS 625.8 70 999999999 541.32 867.18 percent of total billed charges 4.0MM CANN SCREW 22MM 207.622 48713261_1 CDM 0278 RC inpatient 894 581.1 SIHO - ALL PLANS SIHO - ALL PLANS 804.6 90 999999999 541.32 867.18 percent of total billed charges 4.0MM CANN SCREW 22MM 207.622 48713261_1 CDM 0278 RC inpatient 894 581.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 541.32 60.55 999999999 541.32 867.18 percent of total billed charges 4.0MM CANN SCREW 22MM 207.622 48713261_1 CDM 0278 RC inpatient 894 581.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 541.32 867.18 4.0MM CANN SCREW 22MM 207.622 48713261_1 CDM 0278 RC inpatient 894 581.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 541.32 867.18 4.0MM CANN SCREW 22MM 207.622 48713261_1 CDM 0278 RC inpatient 894 581.1 ANTHEM HMO ANTHEM HMO 999999999 541.32 867.18 4.0MM CANN SCREW 22MM 207.622 48713261_1 CDM 0278 RC inpatient 894 581.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 604.34 67.6 999999999 541.32 867.18 percent of total billed charges 4.0MM CANN SCREW 22MM 207.622 48713261_1 CDM 0278 RC inpatient 894 581.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 541.32 867.18 4.0MM CANN SCREW 22MM 207.622 48713261_1 CDM 0278 RC inpatient 894 581.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 541.32 867.18 4.0MM CANN SCREW 20MM 207.620 48713262_1 CDM 0278 RC inpatient 963 625.95 AETNA AETNA 760.77 79 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 20MM 207.620 48713262_1 CDM 0278 RC inpatient 963 625.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 625.95 65 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 20MM 207.620 48713262_1 CDM 0278 RC inpatient 963 625.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 934.11 97 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 20MM 207.620 48713262_1 CDM 0278 RC inpatient 963 625.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 664.47 69 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 20MM 207.620 48713262_1 CDM 0278 RC inpatient 963 625.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 751.14 78 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 20MM 207.620 48713262_1 CDM 0278 RC inpatient 963 625.95 UMR - ALL PLANS UMR - ALL PLANS 674.1 70 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 20MM 207.620 48713262_1 CDM 0278 RC inpatient 963 625.95 SIHO - ALL PLANS SIHO - ALL PLANS 866.7 90 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 20MM 207.620 48713262_1 CDM 0278 RC inpatient 963 625.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 583.1 60.55 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 20MM 207.620 48713262_1 CDM 0278 RC inpatient 963 625.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 583.1 934.11 4.0MM CANN SCREW 20MM 207.620 48713262_1 CDM 0278 RC inpatient 963 625.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 583.1 934.11 4.0MM CANN SCREW 20MM 207.620 48713262_1 CDM 0278 RC inpatient 963 625.95 ANTHEM HMO ANTHEM HMO 999999999 583.1 934.11 4.0MM CANN SCREW 20MM 207.620 48713262_1 CDM 0278 RC inpatient 963 625.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 650.99 67.6 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 20MM 207.620 48713262_1 CDM 0278 RC inpatient 963 625.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 583.1 934.11 4.0MM CANN SCREW 20MM 207.620 48713262_1 CDM 0278 RC inpatient 963 625.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 583.1 934.11 4.0MM CANN SCREW 18MM 207.618 48713263_1 CDM 0278 RC inpatient 963 625.95 AETNA AETNA 760.77 79 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 18MM 207.618 48713263_1 CDM 0278 RC inpatient 963 625.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 625.95 65 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 18MM 207.618 48713263_1 CDM 0278 RC inpatient 963 625.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 934.11 97 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 18MM 207.618 48713263_1 CDM 0278 RC inpatient 963 625.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 664.47 69 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 18MM 207.618 48713263_1 CDM 0278 RC inpatient 963 625.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 751.14 78 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 18MM 207.618 48713263_1 CDM 0278 RC inpatient 963 625.95 UMR - ALL PLANS UMR - ALL PLANS 674.1 70 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 18MM 207.618 48713263_1 CDM 0278 RC inpatient 963 625.95 SIHO - ALL PLANS SIHO - ALL PLANS 866.7 90 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 18MM 207.618 48713263_1 CDM 0278 RC inpatient 963 625.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 583.1 60.55 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 18MM 207.618 48713263_1 CDM 0278 RC inpatient 963 625.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 583.1 934.11 4.0MM CANN SCREW 18MM 207.618 48713263_1 CDM 0278 RC inpatient 963 625.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 583.1 934.11 4.0MM CANN SCREW 18MM 207.618 48713263_1 CDM 0278 RC inpatient 963 625.95 ANTHEM HMO ANTHEM HMO 999999999 583.1 934.11 4.0MM CANN SCREW 18MM 207.618 48713263_1 CDM 0278 RC inpatient 963 625.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 650.99 67.6 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 18MM 207.618 48713263_1 CDM 0278 RC inpatient 963 625.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 583.1 934.11 4.0MM CANN SCREW 18MM 207.618 48713263_1 CDM 0278 RC inpatient 963 625.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 583.1 934.11 RELOAD RADIAL MEDIUM TRISTAPLE 2.0 RADIAL INTELLIGENT RELOAD 237045 48713264_1 CDM 0272 RC inpatient 2581 1677.65 AETNA AETNA 2038.99 79 999999999 1562.8 2503.57 percent of total billed charges RELOAD RADIAL MEDIUM TRISTAPLE 2.0 RADIAL INTELLIGENT RELOAD 237045 48713264_1 CDM 0272 RC inpatient 2581 1677.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1677.65 65 999999999 1562.8 2503.57 percent of total billed charges RELOAD RADIAL MEDIUM TRISTAPLE 2.0 RADIAL INTELLIGENT RELOAD 237045 48713264_1 CDM 0272 RC inpatient 2581 1677.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2503.57 97 999999999 1562.8 2503.57 percent of total billed charges RELOAD RADIAL MEDIUM TRISTAPLE 2.0 RADIAL INTELLIGENT RELOAD 237045 48713264_1 CDM 0272 RC inpatient 2581 1677.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1780.89 69 999999999 1562.8 2503.57 percent of total billed charges RELOAD RADIAL MEDIUM TRISTAPLE 2.0 RADIAL INTELLIGENT RELOAD 237045 48713264_1 CDM 0272 RC inpatient 2581 1677.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2013.18 78 999999999 1562.8 2503.57 percent of total billed charges RELOAD RADIAL MEDIUM TRISTAPLE 2.0 RADIAL INTELLIGENT RELOAD 237045 48713264_1 CDM 0272 RC inpatient 2581 1677.65 UMR - ALL PLANS UMR - ALL PLANS 1806.7 70 999999999 1562.8 2503.57 percent of total billed charges RELOAD RADIAL MEDIUM TRISTAPLE 2.0 RADIAL INTELLIGENT RELOAD 237045 48713264_1 CDM 0272 RC inpatient 2581 1677.65 SIHO - ALL PLANS SIHO - ALL PLANS 2322.9 90 999999999 1562.8 2503.57 percent of total billed charges RELOAD RADIAL MEDIUM TRISTAPLE 2.0 RADIAL INTELLIGENT RELOAD 237045 48713264_1 CDM 0272 RC inpatient 2581 1677.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1562.8 60.55 999999999 1562.8 2503.57 percent of total billed charges RELOAD RADIAL MEDIUM TRISTAPLE 2.0 RADIAL INTELLIGENT RELOAD 237045 48713264_1 CDM 0272 RC inpatient 2581 1677.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1562.8 2503.57 RELOAD RADIAL MEDIUM TRISTAPLE 2.0 RADIAL INTELLIGENT RELOAD 237045 48713264_1 CDM 0272 RC inpatient 2581 1677.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1562.8 2503.57 RELOAD RADIAL MEDIUM TRISTAPLE 2.0 RADIAL INTELLIGENT RELOAD 237045 48713264_1 CDM 0272 RC inpatient 2581 1677.65 ANTHEM HMO ANTHEM HMO 999999999 1562.8 2503.57 RELOAD RADIAL MEDIUM TRISTAPLE 2.0 RADIAL INTELLIGENT RELOAD 237045 48713264_1 CDM 0272 RC inpatient 2581 1677.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1744.76 67.6 999999999 1562.8 2503.57 percent of total billed charges RELOAD RADIAL MEDIUM TRISTAPLE 2.0 RADIAL INTELLIGENT RELOAD 237045 48713264_1 CDM 0272 RC inpatient 2581 1677.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1562.8 2503.57 RELOAD RADIAL MEDIUM TRISTAPLE 2.0 RADIAL INTELLIGENT RELOAD 237045 48713264_1 CDM 0272 RC inpatient 2581 1677.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1562.8 2503.57 4.0MM CANN SCREW 16MM 207.616 48713266_1 CDM 0278 RC inpatient 963 625.95 AETNA AETNA 760.77 79 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 16MM 207.616 48713266_1 CDM 0278 RC inpatient 963 625.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 625.95 65 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 16MM 207.616 48713266_1 CDM 0278 RC inpatient 963 625.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 934.11 97 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 16MM 207.616 48713266_1 CDM 0278 RC inpatient 963 625.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 664.47 69 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 16MM 207.616 48713266_1 CDM 0278 RC inpatient 963 625.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 751.14 78 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 16MM 207.616 48713266_1 CDM 0278 RC inpatient 963 625.95 UMR - ALL PLANS UMR - ALL PLANS 674.1 70 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 16MM 207.616 48713266_1 CDM 0278 RC inpatient 963 625.95 SIHO - ALL PLANS SIHO - ALL PLANS 866.7 90 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 16MM 207.616 48713266_1 CDM 0278 RC inpatient 963 625.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 583.1 60.55 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 16MM 207.616 48713266_1 CDM 0278 RC inpatient 963 625.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 583.1 934.11 4.0MM CANN SCREW 16MM 207.616 48713266_1 CDM 0278 RC inpatient 963 625.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 583.1 934.11 4.0MM CANN SCREW 16MM 207.616 48713266_1 CDM 0278 RC inpatient 963 625.95 ANTHEM HMO ANTHEM HMO 999999999 583.1 934.11 4.0MM CANN SCREW 16MM 207.616 48713266_1 CDM 0278 RC inpatient 963 625.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 650.99 67.6 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 16MM 207.616 48713266_1 CDM 0278 RC inpatient 963 625.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 583.1 934.11 4.0MM CANN SCREW 16MM 207.616 48713266_1 CDM 0278 RC inpatient 963 625.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 583.1 934.11 SIG60AXT ARTICULATING 48713267_1 CDM 0272 RC inpatient 1956 1271.4 AETNA AETNA 1545.24 79 999999999 1184.36 1897.32 percent of total billed charges SIG60AXT ARTICULATING 48713267_1 CDM 0272 RC inpatient 1956 1271.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1271.4 65 999999999 1184.36 1897.32 percent of total billed charges SIG60AXT ARTICULATING 48713267_1 CDM 0272 RC inpatient 1956 1271.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1897.32 97 999999999 1184.36 1897.32 percent of total billed charges SIG60AXT ARTICULATING 48713267_1 CDM 0272 RC inpatient 1956 1271.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1349.64 69 999999999 1184.36 1897.32 percent of total billed charges SIG60AXT ARTICULATING 48713267_1 CDM 0272 RC inpatient 1956 1271.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1525.68 78 999999999 1184.36 1897.32 percent of total billed charges SIG60AXT ARTICULATING 48713267_1 CDM 0272 RC inpatient 1956 1271.4 UMR - ALL PLANS UMR - ALL PLANS 1369.2 70 999999999 1184.36 1897.32 percent of total billed charges SIG60AXT ARTICULATING 48713267_1 CDM 0272 RC inpatient 1956 1271.4 SIHO - ALL PLANS SIHO - ALL PLANS 1760.4 90 999999999 1184.36 1897.32 percent of total billed charges SIG60AXT ARTICULATING 48713267_1 CDM 0272 RC inpatient 1956 1271.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1184.36 60.55 999999999 1184.36 1897.32 percent of total billed charges SIG60AXT ARTICULATING 48713267_1 CDM 0272 RC inpatient 1956 1271.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1184.36 1897.32 SIG60AXT ARTICULATING 48713267_1 CDM 0272 RC inpatient 1956 1271.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1184.36 1897.32 SIG60AXT ARTICULATING 48713267_1 CDM 0272 RC inpatient 1956 1271.4 ANTHEM HMO ANTHEM HMO 999999999 1184.36 1897.32 SIG60AXT ARTICULATING 48713267_1 CDM 0272 RC inpatient 1956 1271.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1322.26 67.6 999999999 1184.36 1897.32 percent of total billed charges SIG60AXT ARTICULATING 48713267_1 CDM 0272 RC inpatient 1956 1271.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1184.36 1897.32 SIG60AXT ARTICULATING 48713267_1 CDM 0272 RC inpatient 1956 1271.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1184.36 1897.32 BLACK REINFORCED 48713268_1 CDM 0272 RC inpatient 3012 1957.8 AETNA AETNA 2379.48 79 999999999 1823.77 2921.64 percent of total billed charges BLACK REINFORCED 48713268_1 CDM 0272 RC inpatient 3012 1957.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1957.8 65 999999999 1823.77 2921.64 percent of total billed charges BLACK REINFORCED 48713268_1 CDM 0272 RC inpatient 3012 1957.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2921.64 97 999999999 1823.77 2921.64 percent of total billed charges BLACK REINFORCED 48713268_1 CDM 0272 RC inpatient 3012 1957.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 2078.28 69 999999999 1823.77 2921.64 percent of total billed charges BLACK REINFORCED 48713268_1 CDM 0272 RC inpatient 3012 1957.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 2349.36 78 999999999 1823.77 2921.64 percent of total billed charges BLACK REINFORCED 48713268_1 CDM 0272 RC inpatient 3012 1957.8 UMR - ALL PLANS UMR - ALL PLANS 2108.4 70 999999999 1823.77 2921.64 percent of total billed charges BLACK REINFORCED 48713268_1 CDM 0272 RC inpatient 3012 1957.8 SIHO - ALL PLANS SIHO - ALL PLANS 2710.8 90 999999999 1823.77 2921.64 percent of total billed charges BLACK REINFORCED 48713268_1 CDM 0272 RC inpatient 3012 1957.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1823.77 60.55 999999999 1823.77 2921.64 percent of total billed charges BLACK REINFORCED 48713268_1 CDM 0272 RC inpatient 3012 1957.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1823.77 2921.64 BLACK REINFORCED 48713268_1 CDM 0272 RC inpatient 3012 1957.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1823.77 2921.64 BLACK REINFORCED 48713268_1 CDM 0272 RC inpatient 3012 1957.8 ANTHEM HMO ANTHEM HMO 999999999 1823.77 2921.64 BLACK REINFORCED 48713268_1 CDM 0272 RC inpatient 3012 1957.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 2036.11 67.6 999999999 1823.77 2921.64 percent of total billed charges BLACK REINFORCED 48713268_1 CDM 0272 RC inpatient 3012 1957.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1823.77 2921.64 BLACK REINFORCED 48713268_1 CDM 0272 RC inpatient 3012 1957.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1823.77 2921.64 EGIA 60AR EGIA60AVM 48713269_1 CDM 0272 RC inpatient 1490 968.5 AETNA AETNA 1177.1 79 999999999 902.2 1445.3 percent of total billed charges EGIA 60AR EGIA60AVM 48713269_1 CDM 0272 RC inpatient 1490 968.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 968.5 65 999999999 902.2 1445.3 percent of total billed charges EGIA 60AR EGIA60AVM 48713269_1 CDM 0272 RC inpatient 1490 968.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1445.3 97 999999999 902.2 1445.3 percent of total billed charges EGIA 60AR EGIA60AVM 48713269_1 CDM 0272 RC inpatient 1490 968.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1028.1 69 999999999 902.2 1445.3 percent of total billed charges EGIA 60AR EGIA60AVM 48713269_1 CDM 0272 RC inpatient 1490 968.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1162.2 78 999999999 902.2 1445.3 percent of total billed charges EGIA 60AR EGIA60AVM 48713269_1 CDM 0272 RC inpatient 1490 968.5 UMR - ALL PLANS UMR - ALL PLANS 1043 70 999999999 902.2 1445.3 percent of total billed charges EGIA 60AR EGIA60AVM 48713269_1 CDM 0272 RC inpatient 1490 968.5 SIHO - ALL PLANS SIHO - ALL PLANS 1341 90 999999999 902.2 1445.3 percent of total billed charges EGIA 60AR EGIA60AVM 48713269_1 CDM 0272 RC inpatient 1490 968.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 902.2 60.55 999999999 902.2 1445.3 percent of total billed charges EGIA 60AR EGIA60AVM 48713269_1 CDM 0272 RC inpatient 1490 968.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 902.2 1445.3 EGIA 60AR EGIA60AVM 48713269_1 CDM 0272 RC inpatient 1490 968.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 902.2 1445.3 EGIA 60AR EGIA60AVM 48713269_1 CDM 0272 RC inpatient 1490 968.5 ANTHEM HMO ANTHEM HMO 999999999 902.2 1445.3 EGIA 60AR EGIA60AVM 48713269_1 CDM 0272 RC inpatient 1490 968.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1007.24 67.6 999999999 902.2 1445.3 percent of total billed charges EGIA 60AR EGIA60AVM 48713269_1 CDM 0272 RC inpatient 1490 968.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 902.2 1445.3 EGIA 60AR EGIA60AVM 48713269_1 CDM 0272 RC inpatient 1490 968.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 902.2 1445.3 EGIA 60AR EGIA60AMT 48713270_1 CDM 0272 RC inpatient 1557 1012.05 AETNA AETNA 1230.03 79 999999999 942.76 1510.29 percent of total billed charges EGIA 60AR EGIA60AMT 48713270_1 CDM 0272 RC inpatient 1557 1012.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1012.05 65 999999999 942.76 1510.29 percent of total billed charges EGIA 60AR EGIA60AMT 48713270_1 CDM 0272 RC inpatient 1557 1012.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1510.29 97 999999999 942.76 1510.29 percent of total billed charges EGIA 60AR EGIA60AMT 48713270_1 CDM 0272 RC inpatient 1557 1012.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1074.33 69 999999999 942.76 1510.29 percent of total billed charges EGIA 60AR EGIA60AMT 48713270_1 CDM 0272 RC inpatient 1557 1012.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1214.46 78 999999999 942.76 1510.29 percent of total billed charges EGIA 60AR EGIA60AMT 48713270_1 CDM 0272 RC inpatient 1557 1012.05 UMR - ALL PLANS UMR - ALL PLANS 1089.9 70 999999999 942.76 1510.29 percent of total billed charges EGIA 60AR EGIA60AMT 48713270_1 CDM 0272 RC inpatient 1557 1012.05 SIHO - ALL PLANS SIHO - ALL PLANS 1401.3 90 999999999 942.76 1510.29 percent of total billed charges EGIA 60AR EGIA60AMT 48713270_1 CDM 0272 RC inpatient 1557 1012.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 942.76 60.55 999999999 942.76 1510.29 percent of total billed charges EGIA 60AR EGIA60AMT 48713270_1 CDM 0272 RC inpatient 1557 1012.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 942.76 1510.29 EGIA 60AR EGIA60AMT 48713270_1 CDM 0272 RC inpatient 1557 1012.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 942.76 1510.29 EGIA 60AR EGIA60AMT 48713270_1 CDM 0272 RC inpatient 1557 1012.05 ANTHEM HMO ANTHEM HMO 999999999 942.76 1510.29 EGIA 60AR EGIA60AMT 48713270_1 CDM 0272 RC inpatient 1557 1012.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1052.53 67.6 999999999 942.76 1510.29 percent of total billed charges EGIA 60AR EGIA60AMT 48713270_1 CDM 0272 RC inpatient 1557 1012.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 942.76 1510.29 EGIA 60AR EGIA60AMT 48713270_1 CDM 0272 RC inpatient 1557 1012.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 942.76 1510.29 EGIA 45AR EGIA45AVM 48713271_1 CDM 0272 RC inpatient 1140 741 AETNA AETNA 900.6 79 999999999 690.27 1105.8 percent of total billed charges EGIA 45AR EGIA45AVM 48713271_1 CDM 0272 RC inpatient 1140 741 SELF PAY DISCOUNT SELF PAY DISCOUNT 741 65 999999999 690.27 1105.8 percent of total billed charges EGIA 45AR EGIA45AVM 48713271_1 CDM 0272 RC inpatient 1140 741 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1105.8 97 999999999 690.27 1105.8 percent of total billed charges EGIA 45AR EGIA45AVM 48713271_1 CDM 0272 RC inpatient 1140 741 ENCORE - ALL PLANS ENCORE - ALL PLANS 786.6 69 999999999 690.27 1105.8 percent of total billed charges EGIA 45AR EGIA45AVM 48713271_1 CDM 0272 RC inpatient 1140 741 HUMANA - ALL PLANS HUMANA - ALL PLANS 889.2 78 999999999 690.27 1105.8 percent of total billed charges EGIA 45AR EGIA45AVM 48713271_1 CDM 0272 RC inpatient 1140 741 UMR - ALL PLANS UMR - ALL PLANS 798 70 999999999 690.27 1105.8 percent of total billed charges EGIA 45AR EGIA45AVM 48713271_1 CDM 0272 RC inpatient 1140 741 SIHO - ALL PLANS SIHO - ALL PLANS 1026 90 999999999 690.27 1105.8 percent of total billed charges EGIA 45AR EGIA45AVM 48713271_1 CDM 0272 RC inpatient 1140 741 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 690.27 60.55 999999999 690.27 1105.8 percent of total billed charges EGIA 45AR EGIA45AVM 48713271_1 CDM 0272 RC inpatient 1140 741 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 690.27 1105.8 EGIA 45AR EGIA45AVM 48713271_1 CDM 0272 RC inpatient 1140 741 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 690.27 1105.8 EGIA 45AR EGIA45AVM 48713271_1 CDM 0272 RC inpatient 1140 741 ANTHEM HMO ANTHEM HMO 999999999 690.27 1105.8 EGIA 45AR EGIA45AVM 48713271_1 CDM 0272 RC inpatient 1140 741 CIGNA - ALL PLANS CIGNA - ALL PLANS 770.64 67.6 999999999 690.27 1105.8 percent of total billed charges EGIA 45AR EGIA45AVM 48713271_1 CDM 0272 RC inpatient 1140 741 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 690.27 1105.8 EGIA 45AR EGIA45AVM 48713271_1 CDM 0272 RC inpatient 1140 741 UHC - ALL PLANS UHC - ALL PLANS 999999999 690.27 1105.8 4.0MM CANN SCREW 14MM 207.614 48713272_1 CDM 0278 RC inpatient 963 625.95 AETNA AETNA 760.77 79 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 14MM 207.614 48713272_1 CDM 0278 RC inpatient 963 625.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 625.95 65 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 14MM 207.614 48713272_1 CDM 0278 RC inpatient 963 625.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 934.11 97 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 14MM 207.614 48713272_1 CDM 0278 RC inpatient 963 625.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 664.47 69 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 14MM 207.614 48713272_1 CDM 0278 RC inpatient 963 625.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 751.14 78 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 14MM 207.614 48713272_1 CDM 0278 RC inpatient 963 625.95 UMR - ALL PLANS UMR - ALL PLANS 674.1 70 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 14MM 207.614 48713272_1 CDM 0278 RC inpatient 963 625.95 SIHO - ALL PLANS SIHO - ALL PLANS 866.7 90 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 14MM 207.614 48713272_1 CDM 0278 RC inpatient 963 625.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 583.1 60.55 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 14MM 207.614 48713272_1 CDM 0278 RC inpatient 963 625.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 583.1 934.11 4.0MM CANN SCREW 14MM 207.614 48713272_1 CDM 0278 RC inpatient 963 625.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 583.1 934.11 4.0MM CANN SCREW 14MM 207.614 48713272_1 CDM 0278 RC inpatient 963 625.95 ANTHEM HMO ANTHEM HMO 999999999 583.1 934.11 4.0MM CANN SCREW 14MM 207.614 48713272_1 CDM 0278 RC inpatient 963 625.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 650.99 67.6 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 14MM 207.614 48713272_1 CDM 0278 RC inpatient 963 625.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 583.1 934.11 4.0MM CANN SCREW 14MM 207.614 48713272_1 CDM 0278 RC inpatient 963 625.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 583.1 934.11 4.0MM CANN SCREW 12MM 207.612 48713273_1 CDM 0278 RC inpatient 963 625.95 AETNA AETNA 760.77 79 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 12MM 207.612 48713273_1 CDM 0278 RC inpatient 963 625.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 625.95 65 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 12MM 207.612 48713273_1 CDM 0278 RC inpatient 963 625.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 934.11 97 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 12MM 207.612 48713273_1 CDM 0278 RC inpatient 963 625.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 664.47 69 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 12MM 207.612 48713273_1 CDM 0278 RC inpatient 963 625.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 751.14 78 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 12MM 207.612 48713273_1 CDM 0278 RC inpatient 963 625.95 UMR - ALL PLANS UMR - ALL PLANS 674.1 70 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 12MM 207.612 48713273_1 CDM 0278 RC inpatient 963 625.95 SIHO - ALL PLANS SIHO - ALL PLANS 866.7 90 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 12MM 207.612 48713273_1 CDM 0278 RC inpatient 963 625.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 583.1 60.55 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 12MM 207.612 48713273_1 CDM 0278 RC inpatient 963 625.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 583.1 934.11 4.0MM CANN SCREW 12MM 207.612 48713273_1 CDM 0278 RC inpatient 963 625.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 583.1 934.11 4.0MM CANN SCREW 12MM 207.612 48713273_1 CDM 0278 RC inpatient 963 625.95 ANTHEM HMO ANTHEM HMO 999999999 583.1 934.11 4.0MM CANN SCREW 12MM 207.612 48713273_1 CDM 0278 RC inpatient 963 625.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 650.99 67.6 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 12MM 207.612 48713273_1 CDM 0278 RC inpatient 963 625.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 583.1 934.11 4.0MM CANN SCREW 12MM 207.612 48713273_1 CDM 0278 RC inpatient 963 625.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 583.1 934.11 4.0MM CANN SCREW 10MM 207.610 48713274_1 CDM 0278 RC inpatient 963 625.95 AETNA AETNA 760.77 79 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 10MM 207.610 48713274_1 CDM 0278 RC inpatient 963 625.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 625.95 65 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 10MM 207.610 48713274_1 CDM 0278 RC inpatient 963 625.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 934.11 97 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 10MM 207.610 48713274_1 CDM 0278 RC inpatient 963 625.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 664.47 69 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 10MM 207.610 48713274_1 CDM 0278 RC inpatient 963 625.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 751.14 78 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 10MM 207.610 48713274_1 CDM 0278 RC inpatient 963 625.95 UMR - ALL PLANS UMR - ALL PLANS 674.1 70 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 10MM 207.610 48713274_1 CDM 0278 RC inpatient 963 625.95 SIHO - ALL PLANS SIHO - ALL PLANS 866.7 90 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 10MM 207.610 48713274_1 CDM 0278 RC inpatient 963 625.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 583.1 60.55 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 10MM 207.610 48713274_1 CDM 0278 RC inpatient 963 625.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 583.1 934.11 4.0MM CANN SCREW 10MM 207.610 48713274_1 CDM 0278 RC inpatient 963 625.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 583.1 934.11 4.0MM CANN SCREW 10MM 207.610 48713274_1 CDM 0278 RC inpatient 963 625.95 ANTHEM HMO ANTHEM HMO 999999999 583.1 934.11 4.0MM CANN SCREW 10MM 207.610 48713274_1 CDM 0278 RC inpatient 963 625.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 650.99 67.6 999999999 583.1 934.11 percent of total billed charges 4.0MM CANN SCREW 10MM 207.610 48713274_1 CDM 0278 RC inpatient 963 625.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 583.1 934.11 4.0MM CANN SCREW 10MM 207.610 48713274_1 CDM 0278 RC inpatient 963 625.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 583.1 934.11 3.0MM CANN SCREW 19MM 202.719 48713275_1 CDM 0278 RC inpatient 1269 824.85 AETNA AETNA 1002.51 79 999999999 768.38 1230.93 percent of total billed charges 3.0MM CANN SCREW 19MM 202.719 48713275_1 CDM 0278 RC inpatient 1269 824.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 824.85 65 999999999 768.38 1230.93 percent of total billed charges 3.0MM CANN SCREW 19MM 202.719 48713275_1 CDM 0278 RC inpatient 1269 824.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1230.93 97 999999999 768.38 1230.93 percent of total billed charges 3.0MM CANN SCREW 19MM 202.719 48713275_1 CDM 0278 RC inpatient 1269 824.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 875.61 69 999999999 768.38 1230.93 percent of total billed charges 3.0MM CANN SCREW 19MM 202.719 48713275_1 CDM 0278 RC inpatient 1269 824.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 989.82 78 999999999 768.38 1230.93 percent of total billed charges 3.0MM CANN SCREW 19MM 202.719 48713275_1 CDM 0278 RC inpatient 1269 824.85 UMR - ALL PLANS UMR - ALL PLANS 888.3 70 999999999 768.38 1230.93 percent of total billed charges 3.0MM CANN SCREW 19MM 202.719 48713275_1 CDM 0278 RC inpatient 1269 824.85 SIHO - ALL PLANS SIHO - ALL PLANS 1142.1 90 999999999 768.38 1230.93 percent of total billed charges 3.0MM CANN SCREW 19MM 202.719 48713275_1 CDM 0278 RC inpatient 1269 824.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 768.38 60.55 999999999 768.38 1230.93 percent of total billed charges 3.0MM CANN SCREW 19MM 202.719 48713275_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 768.38 1230.93 3.0MM CANN SCREW 19MM 202.719 48713275_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 768.38 1230.93 3.0MM CANN SCREW 19MM 202.719 48713275_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM HMO ANTHEM HMO 999999999 768.38 1230.93 3.0MM CANN SCREW 19MM 202.719 48713275_1 CDM 0278 RC inpatient 1269 824.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 857.84 67.6 999999999 768.38 1230.93 percent of total billed charges 3.0MM CANN SCREW 19MM 202.719 48713275_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 768.38 1230.93 3.0MM CANN SCREW 19MM 202.719 48713275_1 CDM 0278 RC inpatient 1269 824.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 768.38 1230.93 3.0MM CANN SCREW 16MM 202.716 48713276_1 CDM 0278 RC inpatient 1307 849.55 AETNA AETNA 1032.53 79 999999999 791.39 1267.79 percent of total billed charges 3.0MM CANN SCREW 16MM 202.716 48713276_1 CDM 0278 RC inpatient 1307 849.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 849.55 65 999999999 791.39 1267.79 percent of total billed charges 3.0MM CANN SCREW 16MM 202.716 48713276_1 CDM 0278 RC inpatient 1307 849.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1267.79 97 999999999 791.39 1267.79 percent of total billed charges 3.0MM CANN SCREW 16MM 202.716 48713276_1 CDM 0278 RC inpatient 1307 849.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 901.83 69 999999999 791.39 1267.79 percent of total billed charges 3.0MM CANN SCREW 16MM 202.716 48713276_1 CDM 0278 RC inpatient 1307 849.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1019.46 78 999999999 791.39 1267.79 percent of total billed charges 3.0MM CANN SCREW 16MM 202.716 48713276_1 CDM 0278 RC inpatient 1307 849.55 UMR - ALL PLANS UMR - ALL PLANS 914.9 70 999999999 791.39 1267.79 percent of total billed charges 3.0MM CANN SCREW 16MM 202.716 48713276_1 CDM 0278 RC inpatient 1307 849.55 SIHO - ALL PLANS SIHO - ALL PLANS 1176.3 90 999999999 791.39 1267.79 percent of total billed charges 3.0MM CANN SCREW 16MM 202.716 48713276_1 CDM 0278 RC inpatient 1307 849.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 791.39 60.55 999999999 791.39 1267.79 percent of total billed charges 3.0MM CANN SCREW 16MM 202.716 48713276_1 CDM 0278 RC inpatient 1307 849.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 791.39 1267.79 3.0MM CANN SCREW 16MM 202.716 48713276_1 CDM 0278 RC inpatient 1307 849.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 791.39 1267.79 3.0MM CANN SCREW 16MM 202.716 48713276_1 CDM 0278 RC inpatient 1307 849.55 ANTHEM HMO ANTHEM HMO 999999999 791.39 1267.79 3.0MM CANN SCREW 16MM 202.716 48713276_1 CDM 0278 RC inpatient 1307 849.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 883.53 67.6 999999999 791.39 1267.79 percent of total billed charges 3.0MM CANN SCREW 16MM 202.716 48713276_1 CDM 0278 RC inpatient 1307 849.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 791.39 1267.79 3.0MM CANN SCREW 16MM 202.716 48713276_1 CDM 0278 RC inpatient 1307 849.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 791.39 1267.79 3.0MM CANN SCREW 40MM 202.640 48713277_1 CDM 0278 RC inpatient 918 596.7 AETNA AETNA 725.22 79 999999999 555.85 890.46 percent of total billed charges 3.0MM CANN SCREW 40MM 202.640 48713277_1 CDM 0278 RC inpatient 918 596.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 596.7 65 999999999 555.85 890.46 percent of total billed charges 3.0MM CANN SCREW 40MM 202.640 48713277_1 CDM 0278 RC inpatient 918 596.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 890.46 97 999999999 555.85 890.46 percent of total billed charges 3.0MM CANN SCREW 40MM 202.640 48713277_1 CDM 0278 RC inpatient 918 596.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 633.42 69 999999999 555.85 890.46 percent of total billed charges 3.0MM CANN SCREW 40MM 202.640 48713277_1 CDM 0278 RC inpatient 918 596.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 716.04 78 999999999 555.85 890.46 percent of total billed charges 3.0MM CANN SCREW 40MM 202.640 48713277_1 CDM 0278 RC inpatient 918 596.7 UMR - ALL PLANS UMR - ALL PLANS 642.6 70 999999999 555.85 890.46 percent of total billed charges 3.0MM CANN SCREW 40MM 202.640 48713277_1 CDM 0278 RC inpatient 918 596.7 SIHO - ALL PLANS SIHO - ALL PLANS 826.2 90 999999999 555.85 890.46 percent of total billed charges 3.0MM CANN SCREW 40MM 202.640 48713277_1 CDM 0278 RC inpatient 918 596.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 555.85 60.55 999999999 555.85 890.46 percent of total billed charges 3.0MM CANN SCREW 40MM 202.640 48713277_1 CDM 0278 RC inpatient 918 596.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 555.85 890.46 3.0MM CANN SCREW 40MM 202.640 48713277_1 CDM 0278 RC inpatient 918 596.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 555.85 890.46 3.0MM CANN SCREW 40MM 202.640 48713277_1 CDM 0278 RC inpatient 918 596.7 ANTHEM HMO ANTHEM HMO 999999999 555.85 890.46 3.0MM CANN SCREW 40MM 202.640 48713277_1 CDM 0278 RC inpatient 918 596.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 620.57 67.6 999999999 555.85 890.46 percent of total billed charges 3.0MM CANN SCREW 40MM 202.640 48713277_1 CDM 0278 RC inpatient 918 596.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 555.85 890.46 3.0MM CANN SCREW 40MM 202.640 48713277_1 CDM 0278 RC inpatient 918 596.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 555.85 890.46 3.0MM CANN SCREW 38MM 202.638 48713278_1 CDM 0278 RC inpatient 970 630.5 AETNA AETNA 766.3 79 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 38MM 202.638 48713278_1 CDM 0278 RC inpatient 970 630.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 630.5 65 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 38MM 202.638 48713278_1 CDM 0278 RC inpatient 970 630.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 940.9 97 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 38MM 202.638 48713278_1 CDM 0278 RC inpatient 970 630.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 669.3 69 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 38MM 202.638 48713278_1 CDM 0278 RC inpatient 970 630.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 756.6 78 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 38MM 202.638 48713278_1 CDM 0278 RC inpatient 970 630.5 UMR - ALL PLANS UMR - ALL PLANS 679 70 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 38MM 202.638 48713278_1 CDM 0278 RC inpatient 970 630.5 SIHO - ALL PLANS SIHO - ALL PLANS 873 90 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 38MM 202.638 48713278_1 CDM 0278 RC inpatient 970 630.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 587.34 60.55 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 38MM 202.638 48713278_1 CDM 0278 RC inpatient 970 630.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 587.34 940.9 3.0MM CANN SCREW 38MM 202.638 48713278_1 CDM 0278 RC inpatient 970 630.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 587.34 940.9 3.0MM CANN SCREW 38MM 202.638 48713278_1 CDM 0278 RC inpatient 970 630.5 ANTHEM HMO ANTHEM HMO 999999999 587.34 940.9 3.0MM CANN SCREW 38MM 202.638 48713278_1 CDM 0278 RC inpatient 970 630.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 655.72 67.6 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 38MM 202.638 48713278_1 CDM 0278 RC inpatient 970 630.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 587.34 940.9 3.0MM CANN SCREW 38MM 202.638 48713278_1 CDM 0278 RC inpatient 970 630.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 587.34 940.9 3.0MM CANN SCREW 36MM 202.636 48713279_1 CDM 0278 RC inpatient 918 596.7 AETNA AETNA 725.22 79 999999999 555.85 890.46 percent of total billed charges 3.0MM CANN SCREW 36MM 202.636 48713279_1 CDM 0278 RC inpatient 918 596.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 596.7 65 999999999 555.85 890.46 percent of total billed charges 3.0MM CANN SCREW 36MM 202.636 48713279_1 CDM 0278 RC inpatient 918 596.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 890.46 97 999999999 555.85 890.46 percent of total billed charges 3.0MM CANN SCREW 36MM 202.636 48713279_1 CDM 0278 RC inpatient 918 596.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 633.42 69 999999999 555.85 890.46 percent of total billed charges 3.0MM CANN SCREW 36MM 202.636 48713279_1 CDM 0278 RC inpatient 918 596.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 716.04 78 999999999 555.85 890.46 percent of total billed charges 3.0MM CANN SCREW 36MM 202.636 48713279_1 CDM 0278 RC inpatient 918 596.7 UMR - ALL PLANS UMR - ALL PLANS 642.6 70 999999999 555.85 890.46 percent of total billed charges 3.0MM CANN SCREW 36MM 202.636 48713279_1 CDM 0278 RC inpatient 918 596.7 SIHO - ALL PLANS SIHO - ALL PLANS 826.2 90 999999999 555.85 890.46 percent of total billed charges 3.0MM CANN SCREW 36MM 202.636 48713279_1 CDM 0278 RC inpatient 918 596.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 555.85 60.55 999999999 555.85 890.46 percent of total billed charges 3.0MM CANN SCREW 36MM 202.636 48713279_1 CDM 0278 RC inpatient 918 596.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 555.85 890.46 3.0MM CANN SCREW 36MM 202.636 48713279_1 CDM 0278 RC inpatient 918 596.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 555.85 890.46 3.0MM CANN SCREW 36MM 202.636 48713279_1 CDM 0278 RC inpatient 918 596.7 ANTHEM HMO ANTHEM HMO 999999999 555.85 890.46 3.0MM CANN SCREW 36MM 202.636 48713279_1 CDM 0278 RC inpatient 918 596.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 620.57 67.6 999999999 555.85 890.46 percent of total billed charges 3.0MM CANN SCREW 36MM 202.636 48713279_1 CDM 0278 RC inpatient 918 596.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 555.85 890.46 3.0MM CANN SCREW 36MM 202.636 48713279_1 CDM 0278 RC inpatient 918 596.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 555.85 890.46 3.0MM CANN SCREW 34MM 202.634 48713280_1 CDM 0278 RC inpatient 1288 837.2 AETNA AETNA 1017.52 79 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 34MM 202.634 48713280_1 CDM 0278 RC inpatient 1288 837.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 837.2 65 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 34MM 202.634 48713280_1 CDM 0278 RC inpatient 1288 837.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1249.36 97 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 34MM 202.634 48713280_1 CDM 0278 RC inpatient 1288 837.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 888.72 69 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 34MM 202.634 48713280_1 CDM 0278 RC inpatient 1288 837.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1004.64 78 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 34MM 202.634 48713280_1 CDM 0278 RC inpatient 1288 837.2 UMR - ALL PLANS UMR - ALL PLANS 901.6 70 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 34MM 202.634 48713280_1 CDM 0278 RC inpatient 1288 837.2 SIHO - ALL PLANS SIHO - ALL PLANS 1159.2 90 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 34MM 202.634 48713280_1 CDM 0278 RC inpatient 1288 837.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 779.88 60.55 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 34MM 202.634 48713280_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 779.88 1249.36 3.0MM CANN SCREW 34MM 202.634 48713280_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 779.88 1249.36 3.0MM CANN SCREW 34MM 202.634 48713280_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM HMO ANTHEM HMO 999999999 779.88 1249.36 3.0MM CANN SCREW 34MM 202.634 48713280_1 CDM 0278 RC inpatient 1288 837.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 870.69 67.6 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 34MM 202.634 48713280_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 779.88 1249.36 3.0MM CANN SCREW 34MM 202.634 48713280_1 CDM 0278 RC inpatient 1288 837.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 779.88 1249.36 3.0MM CANN SCREW 32MM 202.632 48713281_1 CDM 0278 RC inpatient 1354 880.1 AETNA AETNA 1069.66 79 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 32MM 202.632 48713281_1 CDM 0278 RC inpatient 1354 880.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 880.1 65 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 32MM 202.632 48713281_1 CDM 0278 RC inpatient 1354 880.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1313.38 97 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 32MM 202.632 48713281_1 CDM 0278 RC inpatient 1354 880.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 934.26 69 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 32MM 202.632 48713281_1 CDM 0278 RC inpatient 1354 880.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1056.12 78 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 32MM 202.632 48713281_1 CDM 0278 RC inpatient 1354 880.1 UMR - ALL PLANS UMR - ALL PLANS 947.8 70 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 32MM 202.632 48713281_1 CDM 0278 RC inpatient 1354 880.1 SIHO - ALL PLANS SIHO - ALL PLANS 1218.6 90 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 32MM 202.632 48713281_1 CDM 0278 RC inpatient 1354 880.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 819.85 60.55 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 32MM 202.632 48713281_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 819.85 1313.38 3.0MM CANN SCREW 32MM 202.632 48713281_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 819.85 1313.38 3.0MM CANN SCREW 32MM 202.632 48713281_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM HMO ANTHEM HMO 999999999 819.85 1313.38 3.0MM CANN SCREW 32MM 202.632 48713281_1 CDM 0278 RC inpatient 1354 880.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 915.3 67.6 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 32MM 202.632 48713281_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 819.85 1313.38 3.0MM CANN SCREW 32MM 202.632 48713281_1 CDM 0278 RC inpatient 1354 880.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 819.85 1313.38 3.0MM CANN SCREW 30MM 202.630 48713282_1 CDM 0278 RC inpatient 970 630.5 AETNA AETNA 766.3 79 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 30MM 202.630 48713282_1 CDM 0278 RC inpatient 970 630.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 630.5 65 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 30MM 202.630 48713282_1 CDM 0278 RC inpatient 970 630.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 940.9 97 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 30MM 202.630 48713282_1 CDM 0278 RC inpatient 970 630.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 669.3 69 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 30MM 202.630 48713282_1 CDM 0278 RC inpatient 970 630.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 756.6 78 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 30MM 202.630 48713282_1 CDM 0278 RC inpatient 970 630.5 UMR - ALL PLANS UMR - ALL PLANS 679 70 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 30MM 202.630 48713282_1 CDM 0278 RC inpatient 970 630.5 SIHO - ALL PLANS SIHO - ALL PLANS 873 90 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 30MM 202.630 48713282_1 CDM 0278 RC inpatient 970 630.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 587.34 60.55 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 30MM 202.630 48713282_1 CDM 0278 RC inpatient 970 630.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 587.34 940.9 3.0MM CANN SCREW 30MM 202.630 48713282_1 CDM 0278 RC inpatient 970 630.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 587.34 940.9 3.0MM CANN SCREW 30MM 202.630 48713282_1 CDM 0278 RC inpatient 970 630.5 ANTHEM HMO ANTHEM HMO 999999999 587.34 940.9 3.0MM CANN SCREW 30MM 202.630 48713282_1 CDM 0278 RC inpatient 970 630.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 655.72 67.6 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 30MM 202.630 48713282_1 CDM 0278 RC inpatient 970 630.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 587.34 940.9 3.0MM CANN SCREW 30MM 202.630 48713282_1 CDM 0278 RC inpatient 970 630.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 587.34 940.9 3.0MM CANN SCREW 29MM 202.629 48713283_1 CDM 0278 RC inpatient 970 630.5 AETNA AETNA 766.3 79 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 29MM 202.629 48713283_1 CDM 0278 RC inpatient 970 630.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 630.5 65 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 29MM 202.629 48713283_1 CDM 0278 RC inpatient 970 630.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 940.9 97 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 29MM 202.629 48713283_1 CDM 0278 RC inpatient 970 630.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 669.3 69 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 29MM 202.629 48713283_1 CDM 0278 RC inpatient 970 630.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 756.6 78 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 29MM 202.629 48713283_1 CDM 0278 RC inpatient 970 630.5 UMR - ALL PLANS UMR - ALL PLANS 679 70 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 29MM 202.629 48713283_1 CDM 0278 RC inpatient 970 630.5 SIHO - ALL PLANS SIHO - ALL PLANS 873 90 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 29MM 202.629 48713283_1 CDM 0278 RC inpatient 970 630.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 587.34 60.55 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 29MM 202.629 48713283_1 CDM 0278 RC inpatient 970 630.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 587.34 940.9 3.0MM CANN SCREW 29MM 202.629 48713283_1 CDM 0278 RC inpatient 970 630.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 587.34 940.9 3.0MM CANN SCREW 29MM 202.629 48713283_1 CDM 0278 RC inpatient 970 630.5 ANTHEM HMO ANTHEM HMO 999999999 587.34 940.9 3.0MM CANN SCREW 29MM 202.629 48713283_1 CDM 0278 RC inpatient 970 630.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 655.72 67.6 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 29MM 202.629 48713283_1 CDM 0278 RC inpatient 970 630.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 587.34 940.9 3.0MM CANN SCREW 29MM 202.629 48713283_1 CDM 0278 RC inpatient 970 630.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 587.34 940.9 3.0MM CANN SCREW 28MM 202.628 48713284_1 CDM 0278 RC inpatient 1288 837.2 AETNA AETNA 1017.52 79 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 28MM 202.628 48713284_1 CDM 0278 RC inpatient 1288 837.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 837.2 65 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 28MM 202.628 48713284_1 CDM 0278 RC inpatient 1288 837.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1249.36 97 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 28MM 202.628 48713284_1 CDM 0278 RC inpatient 1288 837.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 888.72 69 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 28MM 202.628 48713284_1 CDM 0278 RC inpatient 1288 837.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1004.64 78 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 28MM 202.628 48713284_1 CDM 0278 RC inpatient 1288 837.2 UMR - ALL PLANS UMR - ALL PLANS 901.6 70 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 28MM 202.628 48713284_1 CDM 0278 RC inpatient 1288 837.2 SIHO - ALL PLANS SIHO - ALL PLANS 1159.2 90 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 28MM 202.628 48713284_1 CDM 0278 RC inpatient 1288 837.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 779.88 60.55 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 28MM 202.628 48713284_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 779.88 1249.36 3.0MM CANN SCREW 28MM 202.628 48713284_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 779.88 1249.36 3.0MM CANN SCREW 28MM 202.628 48713284_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM HMO ANTHEM HMO 999999999 779.88 1249.36 3.0MM CANN SCREW 28MM 202.628 48713284_1 CDM 0278 RC inpatient 1288 837.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 870.69 67.6 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 28MM 202.628 48713284_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 779.88 1249.36 3.0MM CANN SCREW 28MM 202.628 48713284_1 CDM 0278 RC inpatient 1288 837.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 779.88 1249.36 3.0MM CANN SCREW 27MM 202.627 48713285_1 CDM 0278 RC inpatient 970 630.5 AETNA AETNA 766.3 79 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 27MM 202.627 48713285_1 CDM 0278 RC inpatient 970 630.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 630.5 65 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 27MM 202.627 48713285_1 CDM 0278 RC inpatient 970 630.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 940.9 97 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 27MM 202.627 48713285_1 CDM 0278 RC inpatient 970 630.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 669.3 69 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 27MM 202.627 48713285_1 CDM 0278 RC inpatient 970 630.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 756.6 78 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 27MM 202.627 48713285_1 CDM 0278 RC inpatient 970 630.5 UMR - ALL PLANS UMR - ALL PLANS 679 70 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 27MM 202.627 48713285_1 CDM 0278 RC inpatient 970 630.5 SIHO - ALL PLANS SIHO - ALL PLANS 873 90 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 27MM 202.627 48713285_1 CDM 0278 RC inpatient 970 630.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 587.34 60.55 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 27MM 202.627 48713285_1 CDM 0278 RC inpatient 970 630.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 587.34 940.9 3.0MM CANN SCREW 27MM 202.627 48713285_1 CDM 0278 RC inpatient 970 630.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 587.34 940.9 3.0MM CANN SCREW 27MM 202.627 48713285_1 CDM 0278 RC inpatient 970 630.5 ANTHEM HMO ANTHEM HMO 999999999 587.34 940.9 3.0MM CANN SCREW 27MM 202.627 48713285_1 CDM 0278 RC inpatient 970 630.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 655.72 67.6 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 27MM 202.627 48713285_1 CDM 0278 RC inpatient 970 630.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 587.34 940.9 3.0MM CANN SCREW 27MM 202.627 48713285_1 CDM 0278 RC inpatient 970 630.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 587.34 940.9 3.0MM CANN SCREW 26MM 202.626 48713286_1 CDM 0278 RC inpatient 1288 837.2 AETNA AETNA 1017.52 79 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 26MM 202.626 48713286_1 CDM 0278 RC inpatient 1288 837.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 837.2 65 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 26MM 202.626 48713286_1 CDM 0278 RC inpatient 1288 837.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1249.36 97 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 26MM 202.626 48713286_1 CDM 0278 RC inpatient 1288 837.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 888.72 69 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 26MM 202.626 48713286_1 CDM 0278 RC inpatient 1288 837.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1004.64 78 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 26MM 202.626 48713286_1 CDM 0278 RC inpatient 1288 837.2 UMR - ALL PLANS UMR - ALL PLANS 901.6 70 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 26MM 202.626 48713286_1 CDM 0278 RC inpatient 1288 837.2 SIHO - ALL PLANS SIHO - ALL PLANS 1159.2 90 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 26MM 202.626 48713286_1 CDM 0278 RC inpatient 1288 837.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 779.88 60.55 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 26MM 202.626 48713286_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 779.88 1249.36 3.0MM CANN SCREW 26MM 202.626 48713286_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 779.88 1249.36 3.0MM CANN SCREW 26MM 202.626 48713286_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM HMO ANTHEM HMO 999999999 779.88 1249.36 3.0MM CANN SCREW 26MM 202.626 48713286_1 CDM 0278 RC inpatient 1288 837.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 870.69 67.6 999999999 779.88 1249.36 percent of total billed charges 3.0MM CANN SCREW 26MM 202.626 48713286_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 779.88 1249.36 3.0MM CANN SCREW 26MM 202.626 48713286_1 CDM 0278 RC inpatient 1288 837.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 779.88 1249.36 3.0MM CANN SCREW 25MM 202.625 48713287_1 CDM 0278 RC inpatient 1354 880.1 AETNA AETNA 1069.66 79 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 25MM 202.625 48713287_1 CDM 0278 RC inpatient 1354 880.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 880.1 65 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 25MM 202.625 48713287_1 CDM 0278 RC inpatient 1354 880.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1313.38 97 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 25MM 202.625 48713287_1 CDM 0278 RC inpatient 1354 880.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 934.26 69 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 25MM 202.625 48713287_1 CDM 0278 RC inpatient 1354 880.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1056.12 78 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 25MM 202.625 48713287_1 CDM 0278 RC inpatient 1354 880.1 UMR - ALL PLANS UMR - ALL PLANS 947.8 70 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 25MM 202.625 48713287_1 CDM 0278 RC inpatient 1354 880.1 SIHO - ALL PLANS SIHO - ALL PLANS 1218.6 90 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 25MM 202.625 48713287_1 CDM 0278 RC inpatient 1354 880.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 819.85 60.55 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 25MM 202.625 48713287_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 819.85 1313.38 3.0MM CANN SCREW 25MM 202.625 48713287_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 819.85 1313.38 3.0MM CANN SCREW 25MM 202.625 48713287_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM HMO ANTHEM HMO 999999999 819.85 1313.38 3.0MM CANN SCREW 25MM 202.625 48713287_1 CDM 0278 RC inpatient 1354 880.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 915.3 67.6 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 25MM 202.625 48713287_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 819.85 1313.38 3.0MM CANN SCREW 25MM 202.625 48713287_1 CDM 0278 RC inpatient 1354 880.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 819.85 1313.38 3.0MM CANN SCREW 24MM 202.624 48713288_1 CDM 0278 RC inpatient 1326 861.9 AETNA AETNA 1047.54 79 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 24MM 202.624 48713288_1 CDM 0278 RC inpatient 1326 861.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 861.9 65 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 24MM 202.624 48713288_1 CDM 0278 RC inpatient 1326 861.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1286.22 97 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 24MM 202.624 48713288_1 CDM 0278 RC inpatient 1326 861.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 914.94 69 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 24MM 202.624 48713288_1 CDM 0278 RC inpatient 1326 861.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1034.28 78 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 24MM 202.624 48713288_1 CDM 0278 RC inpatient 1326 861.9 UMR - ALL PLANS UMR - ALL PLANS 928.2 70 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 24MM 202.624 48713288_1 CDM 0278 RC inpatient 1326 861.9 SIHO - ALL PLANS SIHO - ALL PLANS 1193.4 90 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 24MM 202.624 48713288_1 CDM 0278 RC inpatient 1326 861.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 802.89 60.55 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 24MM 202.624 48713288_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 802.89 1286.22 3.0MM CANN SCREW 24MM 202.624 48713288_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 802.89 1286.22 3.0MM CANN SCREW 24MM 202.624 48713288_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM HMO ANTHEM HMO 999999999 802.89 1286.22 3.0MM CANN SCREW 24MM 202.624 48713288_1 CDM 0278 RC inpatient 1326 861.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 896.38 67.6 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 24MM 202.624 48713288_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 802.89 1286.22 3.0MM CANN SCREW 24MM 202.624 48713288_1 CDM 0278 RC inpatient 1326 861.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 802.89 1286.22 3.0MM CANN SCREW 23MM 202.623 48713289_1 CDM 0278 RC inpatient 1326 861.9 AETNA AETNA 1047.54 79 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 23MM 202.623 48713289_1 CDM 0278 RC inpatient 1326 861.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 861.9 65 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 23MM 202.623 48713289_1 CDM 0278 RC inpatient 1326 861.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1286.22 97 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 23MM 202.623 48713289_1 CDM 0278 RC inpatient 1326 861.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 914.94 69 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 23MM 202.623 48713289_1 CDM 0278 RC inpatient 1326 861.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1034.28 78 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 23MM 202.623 48713289_1 CDM 0278 RC inpatient 1326 861.9 UMR - ALL PLANS UMR - ALL PLANS 928.2 70 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 23MM 202.623 48713289_1 CDM 0278 RC inpatient 1326 861.9 SIHO - ALL PLANS SIHO - ALL PLANS 1193.4 90 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 23MM 202.623 48713289_1 CDM 0278 RC inpatient 1326 861.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 802.89 60.55 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 23MM 202.623 48713289_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 802.89 1286.22 3.0MM CANN SCREW 23MM 202.623 48713289_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 802.89 1286.22 3.0MM CANN SCREW 23MM 202.623 48713289_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM HMO ANTHEM HMO 999999999 802.89 1286.22 3.0MM CANN SCREW 23MM 202.623 48713289_1 CDM 0278 RC inpatient 1326 861.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 896.38 67.6 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 23MM 202.623 48713289_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 802.89 1286.22 3.0MM CANN SCREW 23MM 202.623 48713289_1 CDM 0278 RC inpatient 1326 861.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 802.89 1286.22 3.0MM CANN SCREW 22MM 202.622 48713290_1 CDM 0278 RC inpatient 1354 880.1 AETNA AETNA 1069.66 79 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 22MM 202.622 48713290_1 CDM 0278 RC inpatient 1354 880.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 880.1 65 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 22MM 202.622 48713290_1 CDM 0278 RC inpatient 1354 880.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1313.38 97 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 22MM 202.622 48713290_1 CDM 0278 RC inpatient 1354 880.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 934.26 69 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 22MM 202.622 48713290_1 CDM 0278 RC inpatient 1354 880.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1056.12 78 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 22MM 202.622 48713290_1 CDM 0278 RC inpatient 1354 880.1 UMR - ALL PLANS UMR - ALL PLANS 947.8 70 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 22MM 202.622 48713290_1 CDM 0278 RC inpatient 1354 880.1 SIHO - ALL PLANS SIHO - ALL PLANS 1218.6 90 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 22MM 202.622 48713290_1 CDM 0278 RC inpatient 1354 880.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 819.85 60.55 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 22MM 202.622 48713290_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 819.85 1313.38 3.0MM CANN SCREW 22MM 202.622 48713290_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 819.85 1313.38 3.0MM CANN SCREW 22MM 202.622 48713290_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM HMO ANTHEM HMO 999999999 819.85 1313.38 3.0MM CANN SCREW 22MM 202.622 48713290_1 CDM 0278 RC inpatient 1354 880.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 915.3 67.6 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 22MM 202.622 48713290_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 819.85 1313.38 3.0MM CANN SCREW 22MM 202.622 48713290_1 CDM 0278 RC inpatient 1354 880.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 819.85 1313.38 3.0MM CANN SCREW 21MM 202.621 48713291_1 CDM 0278 RC inpatient 1326 861.9 AETNA AETNA 1047.54 79 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 21MM 202.621 48713291_1 CDM 0278 RC inpatient 1326 861.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 861.9 65 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 21MM 202.621 48713291_1 CDM 0278 RC inpatient 1326 861.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1286.22 97 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 21MM 202.621 48713291_1 CDM 0278 RC inpatient 1326 861.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 914.94 69 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 21MM 202.621 48713291_1 CDM 0278 RC inpatient 1326 861.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1034.28 78 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 21MM 202.621 48713291_1 CDM 0278 RC inpatient 1326 861.9 UMR - ALL PLANS UMR - ALL PLANS 928.2 70 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 21MM 202.621 48713291_1 CDM 0278 RC inpatient 1326 861.9 SIHO - ALL PLANS SIHO - ALL PLANS 1193.4 90 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 21MM 202.621 48713291_1 CDM 0278 RC inpatient 1326 861.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 802.89 60.55 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 21MM 202.621 48713291_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 802.89 1286.22 3.0MM CANN SCREW 21MM 202.621 48713291_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 802.89 1286.22 3.0MM CANN SCREW 21MM 202.621 48713291_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM HMO ANTHEM HMO 999999999 802.89 1286.22 3.0MM CANN SCREW 21MM 202.621 48713291_1 CDM 0278 RC inpatient 1326 861.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 896.38 67.6 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 21MM 202.621 48713291_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 802.89 1286.22 3.0MM CANN SCREW 21MM 202.621 48713291_1 CDM 0278 RC inpatient 1326 861.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 802.89 1286.22 3.0MM CANN SCREW 20MM 202.620 48713292_1 CDM 0278 RC inpatient 1354 880.1 AETNA AETNA 1069.66 79 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 20MM 202.620 48713292_1 CDM 0278 RC inpatient 1354 880.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 880.1 65 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 20MM 202.620 48713292_1 CDM 0278 RC inpatient 1354 880.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1313.38 97 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 20MM 202.620 48713292_1 CDM 0278 RC inpatient 1354 880.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1056.12 78 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 20MM 202.620 48713292_1 CDM 0278 RC inpatient 1354 880.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 934.26 69 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 20MM 202.620 48713292_1 CDM 0278 RC inpatient 1354 880.1 UMR - ALL PLANS UMR - ALL PLANS 947.8 70 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 20MM 202.620 48713292_1 CDM 0278 RC inpatient 1354 880.1 SIHO - ALL PLANS SIHO - ALL PLANS 1218.6 90 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 20MM 202.620 48713292_1 CDM 0278 RC inpatient 1354 880.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 819.85 60.55 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 20MM 202.620 48713292_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 819.85 1313.38 3.0MM CANN SCREW 20MM 202.620 48713292_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 819.85 1313.38 3.0MM CANN SCREW 20MM 202.620 48713292_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM HMO ANTHEM HMO 999999999 819.85 1313.38 3.0MM CANN SCREW 20MM 202.620 48713292_1 CDM 0278 RC inpatient 1354 880.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 915.3 67.6 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 20MM 202.620 48713292_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 819.85 1313.38 3.0MM CANN SCREW 20MM 202.620 48713292_1 CDM 0278 RC inpatient 1354 880.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 819.85 1313.38 3.0MM CANN SCREW 19MM 202.619 48713293_1 CDM 0278 RC inpatient 1307 849.55 AETNA AETNA 1032.53 79 999999999 791.39 1267.79 percent of total billed charges 3.0MM CANN SCREW 19MM 202.619 48713293_1 CDM 0278 RC inpatient 1307 849.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 849.55 65 999999999 791.39 1267.79 percent of total billed charges 3.0MM CANN SCREW 19MM 202.619 48713293_1 CDM 0278 RC inpatient 1307 849.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1267.79 97 999999999 791.39 1267.79 percent of total billed charges 3.0MM CANN SCREW 19MM 202.619 48713293_1 CDM 0278 RC inpatient 1307 849.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1019.46 78 999999999 791.39 1267.79 percent of total billed charges 3.0MM CANN SCREW 19MM 202.619 48713293_1 CDM 0278 RC inpatient 1307 849.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 901.83 69 999999999 791.39 1267.79 percent of total billed charges 3.0MM CANN SCREW 19MM 202.619 48713293_1 CDM 0278 RC inpatient 1307 849.55 UMR - ALL PLANS UMR - ALL PLANS 914.9 70 999999999 791.39 1267.79 percent of total billed charges 3.0MM CANN SCREW 19MM 202.619 48713293_1 CDM 0278 RC inpatient 1307 849.55 SIHO - ALL PLANS SIHO - ALL PLANS 1176.3 90 999999999 791.39 1267.79 percent of total billed charges 3.0MM CANN SCREW 19MM 202.619 48713293_1 CDM 0278 RC inpatient 1307 849.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 791.39 60.55 999999999 791.39 1267.79 percent of total billed charges 3.0MM CANN SCREW 19MM 202.619 48713293_1 CDM 0278 RC inpatient 1307 849.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 791.39 1267.79 3.0MM CANN SCREW 19MM 202.619 48713293_1 CDM 0278 RC inpatient 1307 849.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 791.39 1267.79 3.0MM CANN SCREW 19MM 202.619 48713293_1 CDM 0278 RC inpatient 1307 849.55 ANTHEM HMO ANTHEM HMO 999999999 791.39 1267.79 3.0MM CANN SCREW 19MM 202.619 48713293_1 CDM 0278 RC inpatient 1307 849.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 883.53 67.6 999999999 791.39 1267.79 percent of total billed charges 3.0MM CANN SCREW 19MM 202.619 48713293_1 CDM 0278 RC inpatient 1307 849.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 791.39 1267.79 3.0MM CANN SCREW 19MM 202.619 48713293_1 CDM 0278 RC inpatient 1307 849.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 791.39 1267.79 3.0MM CANN SCREW 18MM 202.618 48713294_1 CDM 0278 RC inpatient 1569 1019.85 AETNA AETNA 1239.51 79 999999999 950.03 1521.93 percent of total billed charges 3.0MM CANN SCREW 18MM 202.618 48713294_1 CDM 0278 RC inpatient 1569 1019.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1019.85 65 999999999 950.03 1521.93 percent of total billed charges 3.0MM CANN SCREW 18MM 202.618 48713294_1 CDM 0278 RC inpatient 1569 1019.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1521.93 97 999999999 950.03 1521.93 percent of total billed charges 3.0MM CANN SCREW 18MM 202.618 48713294_1 CDM 0278 RC inpatient 1569 1019.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1223.82 78 999999999 950.03 1521.93 percent of total billed charges 3.0MM CANN SCREW 18MM 202.618 48713294_1 CDM 0278 RC inpatient 1569 1019.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1082.61 69 999999999 950.03 1521.93 percent of total billed charges 3.0MM CANN SCREW 18MM 202.618 48713294_1 CDM 0278 RC inpatient 1569 1019.85 UMR - ALL PLANS UMR - ALL PLANS 1098.3 70 999999999 950.03 1521.93 percent of total billed charges 3.0MM CANN SCREW 18MM 202.618 48713294_1 CDM 0278 RC inpatient 1569 1019.85 SIHO - ALL PLANS SIHO - ALL PLANS 1412.1 90 999999999 950.03 1521.93 percent of total billed charges 3.0MM CANN SCREW 18MM 202.618 48713294_1 CDM 0278 RC inpatient 1569 1019.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 950.03 60.55 999999999 950.03 1521.93 percent of total billed charges 3.0MM CANN SCREW 18MM 202.618 48713294_1 CDM 0278 RC inpatient 1569 1019.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 950.03 1521.93 3.0MM CANN SCREW 18MM 202.618 48713294_1 CDM 0278 RC inpatient 1569 1019.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 950.03 1521.93 3.0MM CANN SCREW 18MM 202.618 48713294_1 CDM 0278 RC inpatient 1569 1019.85 ANTHEM HMO ANTHEM HMO 999999999 950.03 1521.93 3.0MM CANN SCREW 18MM 202.618 48713294_1 CDM 0278 RC inpatient 1569 1019.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1060.64 67.6 999999999 950.03 1521.93 percent of total billed charges 3.0MM CANN SCREW 18MM 202.618 48713294_1 CDM 0278 RC inpatient 1569 1019.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 950.03 1521.93 3.0MM CANN SCREW 18MM 202.618 48713294_1 CDM 0278 RC inpatient 1569 1019.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 950.03 1521.93 3.0MM CANN SCREW 17MM 202.617 48713295_1 CDM 0278 RC inpatient 1326 861.9 AETNA AETNA 1047.54 79 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 17MM 202.617 48713295_1 CDM 0278 RC inpatient 1326 861.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 861.9 65 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 17MM 202.617 48713295_1 CDM 0278 RC inpatient 1326 861.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1286.22 97 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 17MM 202.617 48713295_1 CDM 0278 RC inpatient 1326 861.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1034.28 78 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 17MM 202.617 48713295_1 CDM 0278 RC inpatient 1326 861.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 914.94 69 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 17MM 202.617 48713295_1 CDM 0278 RC inpatient 1326 861.9 UMR - ALL PLANS UMR - ALL PLANS 928.2 70 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 17MM 202.617 48713295_1 CDM 0278 RC inpatient 1326 861.9 SIHO - ALL PLANS SIHO - ALL PLANS 1193.4 90 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 17MM 202.617 48713295_1 CDM 0278 RC inpatient 1326 861.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 802.89 60.55 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 17MM 202.617 48713295_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 802.89 1286.22 3.0MM CANN SCREW 17MM 202.617 48713295_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 802.89 1286.22 3.0MM CANN SCREW 17MM 202.617 48713295_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM HMO ANTHEM HMO 999999999 802.89 1286.22 3.0MM CANN SCREW 17MM 202.617 48713295_1 CDM 0278 RC inpatient 1326 861.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 896.38 67.6 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 17MM 202.617 48713295_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 802.89 1286.22 3.0MM CANN SCREW 17MM 202.617 48713295_1 CDM 0278 RC inpatient 1326 861.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 802.89 1286.22 3.0MM CANN SCREW 16MM 202.616 48713296_1 CDM 0278 RC inpatient 1354 880.1 AETNA AETNA 1069.66 79 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 16MM 202.616 48713296_1 CDM 0278 RC inpatient 1354 880.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 880.1 65 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 16MM 202.616 48713296_1 CDM 0278 RC inpatient 1354 880.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1313.38 97 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 16MM 202.616 48713296_1 CDM 0278 RC inpatient 1354 880.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1056.12 78 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 16MM 202.616 48713296_1 CDM 0278 RC inpatient 1354 880.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 934.26 69 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 16MM 202.616 48713296_1 CDM 0278 RC inpatient 1354 880.1 UMR - ALL PLANS UMR - ALL PLANS 947.8 70 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 16MM 202.616 48713296_1 CDM 0278 RC inpatient 1354 880.1 SIHO - ALL PLANS SIHO - ALL PLANS 1218.6 90 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 16MM 202.616 48713296_1 CDM 0278 RC inpatient 1354 880.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 819.85 60.55 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 16MM 202.616 48713296_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 819.85 1313.38 3.0MM CANN SCREW 16MM 202.616 48713296_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 819.85 1313.38 3.0MM CANN SCREW 16MM 202.616 48713296_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM HMO ANTHEM HMO 999999999 819.85 1313.38 3.0MM CANN SCREW 16MM 202.616 48713296_1 CDM 0278 RC inpatient 1354 880.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 915.3 67.6 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 16MM 202.616 48713296_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 819.85 1313.38 3.0MM CANN SCREW 16MM 202.616 48713296_1 CDM 0278 RC inpatient 1354 880.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 819.85 1313.38 4.5 CANN SET C-SINK 310.85 48713297_1 CDM 0278 RC inpatient 1801 1170.65 AETNA AETNA 1422.79 79 999999999 1090.51 1746.97 percent of total billed charges 4.5 CANN SET C-SINK 310.85 48713297_1 CDM 0278 RC inpatient 1801 1170.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1170.65 65 999999999 1090.51 1746.97 percent of total billed charges 4.5 CANN SET C-SINK 310.85 48713297_1 CDM 0278 RC inpatient 1801 1170.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1746.97 97 999999999 1090.51 1746.97 percent of total billed charges 4.5 CANN SET C-SINK 310.85 48713297_1 CDM 0278 RC inpatient 1801 1170.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1404.78 78 999999999 1090.51 1746.97 percent of total billed charges 4.5 CANN SET C-SINK 310.85 48713297_1 CDM 0278 RC inpatient 1801 1170.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1242.69 69 999999999 1090.51 1746.97 percent of total billed charges 4.5 CANN SET C-SINK 310.85 48713297_1 CDM 0278 RC inpatient 1801 1170.65 UMR - ALL PLANS UMR - ALL PLANS 1260.7 70 999999999 1090.51 1746.97 percent of total billed charges 4.5 CANN SET C-SINK 310.85 48713297_1 CDM 0278 RC inpatient 1801 1170.65 SIHO - ALL PLANS SIHO - ALL PLANS 1620.9 90 999999999 1090.51 1746.97 percent of total billed charges 4.5 CANN SET C-SINK 310.85 48713297_1 CDM 0278 RC inpatient 1801 1170.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1090.51 60.55 999999999 1090.51 1746.97 percent of total billed charges 4.5 CANN SET C-SINK 310.85 48713297_1 CDM 0278 RC inpatient 1801 1170.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1090.51 1746.97 4.5 CANN SET C-SINK 310.85 48713297_1 CDM 0278 RC inpatient 1801 1170.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1090.51 1746.97 4.5 CANN SET C-SINK 310.85 48713297_1 CDM 0278 RC inpatient 1801 1170.65 ANTHEM HMO ANTHEM HMO 999999999 1090.51 1746.97 4.5 CANN SET C-SINK 310.85 48713297_1 CDM 0278 RC inpatient 1801 1170.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1217.48 67.6 999999999 1090.51 1746.97 percent of total billed charges 4.5 CANN SET C-SINK 310.85 48713297_1 CDM 0278 RC inpatient 1801 1170.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1090.51 1746.97 4.5 CANN SET C-SINK 310.85 48713297_1 CDM 0278 RC inpatient 1801 1170.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1090.51 1746.97 SCREW CAN 7.3 16M/30M 208.830 48713298_1 CDM 0278 RC inpatient 1099 714.35 AETNA AETNA 868.21 79 999999999 665.44 1066.03 percent of total billed charges SCREW CAN 7.3 16M/30M 208.830 48713298_1 CDM 0278 RC inpatient 1099 714.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 714.35 65 999999999 665.44 1066.03 percent of total billed charges SCREW CAN 7.3 16M/30M 208.830 48713298_1 CDM 0278 RC inpatient 1099 714.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1066.03 97 999999999 665.44 1066.03 percent of total billed charges SCREW CAN 7.3 16M/30M 208.830 48713298_1 CDM 0278 RC inpatient 1099 714.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 857.22 78 999999999 665.44 1066.03 percent of total billed charges SCREW CAN 7.3 16M/30M 208.830 48713298_1 CDM 0278 RC inpatient 1099 714.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 758.31 69 999999999 665.44 1066.03 percent of total billed charges SCREW CAN 7.3 16M/30M 208.830 48713298_1 CDM 0278 RC inpatient 1099 714.35 UMR - ALL PLANS UMR - ALL PLANS 769.3 70 999999999 665.44 1066.03 percent of total billed charges SCREW CAN 7.3 16M/30M 208.830 48713298_1 CDM 0278 RC inpatient 1099 714.35 SIHO - ALL PLANS SIHO - ALL PLANS 989.1 90 999999999 665.44 1066.03 percent of total billed charges SCREW CAN 7.3 16M/30M 208.830 48713298_1 CDM 0278 RC inpatient 1099 714.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 665.44 60.55 999999999 665.44 1066.03 percent of total billed charges SCREW CAN 7.3 16M/30M 208.830 48713298_1 CDM 0278 RC inpatient 1099 714.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 665.44 1066.03 SCREW CAN 7.3 16M/30M 208.830 48713298_1 CDM 0278 RC inpatient 1099 714.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 665.44 1066.03 SCREW CAN 7.3 16M/30M 208.830 48713298_1 CDM 0278 RC inpatient 1099 714.35 ANTHEM HMO ANTHEM HMO 999999999 665.44 1066.03 SCREW CAN 7.3 16M/30M 208.830 48713298_1 CDM 0278 RC inpatient 1099 714.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 742.92 67.6 999999999 665.44 1066.03 percent of total billed charges SCREW CAN 7.3 16M/30M 208.830 48713298_1 CDM 0278 RC inpatient 1099 714.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 665.44 1066.03 SCREW CAN 7.3 16M/30M 208.830 48713298_1 CDM 0278 RC inpatient 1099 714.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 665.44 1066.03 DRILL BIT 310.221 48713299_1 CDM 0272 RC inpatient 2891 1879.15 AETNA AETNA 2283.89 79 999999999 1750.5 2804.27 percent of total billed charges DRILL BIT 310.221 48713299_1 CDM 0272 RC inpatient 2891 1879.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1879.15 65 999999999 1750.5 2804.27 percent of total billed charges DRILL BIT 310.221 48713299_1 CDM 0272 RC inpatient 2891 1879.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2804.27 97 999999999 1750.5 2804.27 percent of total billed charges DRILL BIT 310.221 48713299_1 CDM 0272 RC inpatient 2891 1879.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 2254.98 78 999999999 1750.5 2804.27 percent of total billed charges DRILL BIT 310.221 48713299_1 CDM 0272 RC inpatient 2891 1879.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1994.79 69 999999999 1750.5 2804.27 percent of total billed charges DRILL BIT 310.221 48713299_1 CDM 0272 RC inpatient 2891 1879.15 UMR - ALL PLANS UMR - ALL PLANS 2023.7 70 999999999 1750.5 2804.27 percent of total billed charges DRILL BIT 310.221 48713299_1 CDM 0272 RC inpatient 2891 1879.15 SIHO - ALL PLANS SIHO - ALL PLANS 2601.9 90 999999999 1750.5 2804.27 percent of total billed charges DRILL BIT 310.221 48713299_1 CDM 0272 RC inpatient 2891 1879.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1750.5 60.55 999999999 1750.5 2804.27 percent of total billed charges DRILL BIT 310.221 48713299_1 CDM 0272 RC inpatient 2891 1879.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1750.5 2804.27 DRILL BIT 310.221 48713299_1 CDM 0272 RC inpatient 2891 1879.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1750.5 2804.27 DRILL BIT 310.221 48713299_1 CDM 0272 RC inpatient 2891 1879.15 ANTHEM HMO ANTHEM HMO 999999999 1750.5 2804.27 DRILL BIT 310.221 48713299_1 CDM 0272 RC inpatient 2891 1879.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1954.32 67.6 999999999 1750.5 2804.27 percent of total billed charges DRILL BIT 310.221 48713299_1 CDM 0272 RC inpatient 2891 1879.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1750.5 2804.27 DRILL BIT 310.221 48713299_1 CDM 0272 RC inpatient 2891 1879.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1750.5 2804.27 CANNULATED COUNTERSINK 310.804 48713300_1 CDM 0278 RC inpatient 2802 1821.3 AETNA AETNA 2213.58 79 999999999 1696.61 2717.94 percent of total billed charges CANNULATED COUNTERSINK 310.804 48713300_1 CDM 0278 RC inpatient 2802 1821.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1821.3 65 999999999 1696.61 2717.94 percent of total billed charges CANNULATED COUNTERSINK 310.804 48713300_1 CDM 0278 RC inpatient 2802 1821.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2717.94 97 999999999 1696.61 2717.94 percent of total billed charges CANNULATED COUNTERSINK 310.804 48713300_1 CDM 0278 RC inpatient 2802 1821.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 2185.56 78 999999999 1696.61 2717.94 percent of total billed charges CANNULATED COUNTERSINK 310.804 48713300_1 CDM 0278 RC inpatient 2802 1821.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1933.38 69 999999999 1696.61 2717.94 percent of total billed charges CANNULATED COUNTERSINK 310.804 48713300_1 CDM 0278 RC inpatient 2802 1821.3 UMR - ALL PLANS UMR - ALL PLANS 1961.4 70 999999999 1696.61 2717.94 percent of total billed charges CANNULATED COUNTERSINK 310.804 48713300_1 CDM 0278 RC inpatient 2802 1821.3 SIHO - ALL PLANS SIHO - ALL PLANS 2521.8 90 999999999 1696.61 2717.94 percent of total billed charges CANNULATED COUNTERSINK 310.804 48713300_1 CDM 0278 RC inpatient 2802 1821.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1696.61 60.55 999999999 1696.61 2717.94 percent of total billed charges CANNULATED COUNTERSINK 310.804 48713300_1 CDM 0278 RC inpatient 2802 1821.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1696.61 2717.94 CANNULATED COUNTERSINK 310.804 48713300_1 CDM 0278 RC inpatient 2802 1821.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1696.61 2717.94 CANNULATED COUNTERSINK 310.804 48713300_1 CDM 0278 RC inpatient 2802 1821.3 ANTHEM HMO ANTHEM HMO 999999999 1696.61 2717.94 CANNULATED COUNTERSINK 310.804 48713300_1 CDM 0278 RC inpatient 2802 1821.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1894.15 67.6 999999999 1696.61 2717.94 percent of total billed charges CANNULATED COUNTERSINK 310.804 48713300_1 CDM 0278 RC inpatient 2802 1821.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1696.61 2717.94 CANNULATED COUNTERSINK 310.804 48713300_1 CDM 0278 RC inpatient 2802 1821.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1696.61 2717.94 CORTEX SCREW 1.5MM 400.814.96 48713301_1 CDM 0278 RC inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5MM 400.814.96 48713301_1 CDM 0278 RC inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5MM 400.814.96 48713301_1 CDM 0278 RC inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5MM 400.814.96 48713301_1 CDM 0278 RC inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5MM 400.814.96 48713301_1 CDM 0278 RC inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5MM 400.814.96 48713301_1 CDM 0278 RC inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5MM 400.814.96 48713301_1 CDM 0278 RC inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5MM 400.814.96 48713301_1 CDM 0278 RC inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5MM 400.814.96 48713301_1 CDM 0278 RC inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 CORTEX SCREW 1.5MM 400.814.96 48713301_1 CDM 0278 RC inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 CORTEX SCREW 1.5MM 400.814.96 48713301_1 CDM 0278 RC inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 CORTEX SCREW 1.5MM 400.814.96 48713301_1 CDM 0278 RC inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges CORTEX SCREW 1.5MM 400.814.96 48713301_1 CDM 0278 RC inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 CORTEX SCREW 1.5MM 400.814.96 48713301_1 CDM 0278 RC inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 T-PLATE 6\HOLE 1.3 TI 421.306 48713302_1 CDM 0278 RC inpatient 820 533 AETNA AETNA 647.8 79 999999999 496.51 795.4 percent of total billed charges T-PLATE 6\HOLE 1.3 TI 421.306 48713302_1 CDM 0278 RC inpatient 820 533 SELF PAY DISCOUNT SELF PAY DISCOUNT 533 65 999999999 496.51 795.4 percent of total billed charges T-PLATE 6\HOLE 1.3 TI 421.306 48713302_1 CDM 0278 RC inpatient 820 533 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 795.4 97 999999999 496.51 795.4 percent of total billed charges T-PLATE 6\HOLE 1.3 TI 421.306 48713302_1 CDM 0278 RC inpatient 820 533 HUMANA - ALL PLANS HUMANA - ALL PLANS 639.6 78 999999999 496.51 795.4 percent of total billed charges T-PLATE 6\HOLE 1.3 TI 421.306 48713302_1 CDM 0278 RC inpatient 820 533 ENCORE - ALL PLANS ENCORE - ALL PLANS 565.8 69 999999999 496.51 795.4 percent of total billed charges T-PLATE 6\HOLE 1.3 TI 421.306 48713302_1 CDM 0278 RC inpatient 820 533 UMR - ALL PLANS UMR - ALL PLANS 574 70 999999999 496.51 795.4 percent of total billed charges T-PLATE 6\HOLE 1.3 TI 421.306 48713302_1 CDM 0278 RC inpatient 820 533 SIHO - ALL PLANS SIHO - ALL PLANS 738 90 999999999 496.51 795.4 percent of total billed charges T-PLATE 6\HOLE 1.3 TI 421.306 48713302_1 CDM 0278 RC inpatient 820 533 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 496.51 60.55 999999999 496.51 795.4 percent of total billed charges T-PLATE 6\HOLE 1.3 TI 421.306 48713302_1 CDM 0278 RC inpatient 820 533 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 496.51 795.4 T-PLATE 6\HOLE 1.3 TI 421.306 48713302_1 CDM 0278 RC inpatient 820 533 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 496.51 795.4 T-PLATE 6\HOLE 1.3 TI 421.306 48713302_1 CDM 0278 RC inpatient 820 533 ANTHEM HMO ANTHEM HMO 999999999 496.51 795.4 T-PLATE 6\HOLE 1.3 TI 421.306 48713302_1 CDM 0278 RC inpatient 820 533 CIGNA - ALL PLANS CIGNA - ALL PLANS 554.32 67.6 999999999 496.51 795.4 percent of total billed charges T-PLATE 6\HOLE 1.3 TI 421.306 48713302_1 CDM 0278 RC inpatient 820 533 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 496.51 795.4 T-PLATE 6\HOLE 1.3 TI 421.306 48713302_1 CDM 0278 RC inpatient 820 533 UHC - ALL PLANS UHC - ALL PLANS 999999999 496.51 795.4 H-PLATE/RT 1.3 TI EXT-421.320 48713303_1 CDM 0278 RC inpatient 994 646.1 AETNA AETNA 785.26 79 999999999 601.87 964.18 percent of total billed charges H-PLATE/RT 1.3 TI EXT-421.320 48713303_1 CDM 0278 RC inpatient 994 646.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 646.1 65 999999999 601.87 964.18 percent of total billed charges H-PLATE/RT 1.3 TI EXT-421.320 48713303_1 CDM 0278 RC inpatient 994 646.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 964.18 97 999999999 601.87 964.18 percent of total billed charges H-PLATE/RT 1.3 TI EXT-421.320 48713303_1 CDM 0278 RC inpatient 994 646.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 775.32 78 999999999 601.87 964.18 percent of total billed charges H-PLATE/RT 1.3 TI EXT-421.320 48713303_1 CDM 0278 RC inpatient 994 646.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 685.86 69 999999999 601.87 964.18 percent of total billed charges H-PLATE/RT 1.3 TI EXT-421.320 48713303_1 CDM 0278 RC inpatient 994 646.1 UMR - ALL PLANS UMR - ALL PLANS 695.8 70 999999999 601.87 964.18 percent of total billed charges H-PLATE/RT 1.3 TI EXT-421.320 48713303_1 CDM 0278 RC inpatient 994 646.1 SIHO - ALL PLANS SIHO - ALL PLANS 894.6 90 999999999 601.87 964.18 percent of total billed charges H-PLATE/RT 1.3 TI EXT-421.320 48713303_1 CDM 0278 RC inpatient 994 646.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 601.87 60.55 999999999 601.87 964.18 percent of total billed charges H-PLATE/RT 1.3 TI EXT-421.320 48713303_1 CDM 0278 RC inpatient 994 646.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 601.87 964.18 H-PLATE/RT 1.3 TI EXT-421.320 48713303_1 CDM 0278 RC inpatient 994 646.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 601.87 964.18 H-PLATE/RT 1.3 TI EXT-421.320 48713303_1 CDM 0278 RC inpatient 994 646.1 ANTHEM HMO ANTHEM HMO 999999999 601.87 964.18 H-PLATE/RT 1.3 TI EXT-421.320 48713303_1 CDM 0278 RC inpatient 994 646.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 671.94 67.6 999999999 601.87 964.18 percent of total billed charges H-PLATE/RT 1.3 TI EXT-421.320 48713303_1 CDM 0278 RC inpatient 994 646.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 601.87 964.18 H-PLATE/RT 1.3 TI EXT-421.320 48713303_1 CDM 0278 RC inpatient 994 646.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 601.87 964.18 H-PLATE/LT 1.3 TI EXT-421.321 48713304_1 CDM 0278 RC inpatient 994 646.1 AETNA AETNA 785.26 79 999999999 601.87 964.18 percent of total billed charges H-PLATE/LT 1.3 TI EXT-421.321 48713304_1 CDM 0278 RC inpatient 994 646.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 646.1 65 999999999 601.87 964.18 percent of total billed charges H-PLATE/LT 1.3 TI EXT-421.321 48713304_1 CDM 0278 RC inpatient 994 646.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 964.18 97 999999999 601.87 964.18 percent of total billed charges H-PLATE/LT 1.3 TI EXT-421.321 48713304_1 CDM 0278 RC inpatient 994 646.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 775.32 78 999999999 601.87 964.18 percent of total billed charges H-PLATE/LT 1.3 TI EXT-421.321 48713304_1 CDM 0278 RC inpatient 994 646.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 685.86 69 999999999 601.87 964.18 percent of total billed charges H-PLATE/LT 1.3 TI EXT-421.321 48713304_1 CDM 0278 RC inpatient 994 646.1 UMR - ALL PLANS UMR - ALL PLANS 695.8 70 999999999 601.87 964.18 percent of total billed charges H-PLATE/LT 1.3 TI EXT-421.321 48713304_1 CDM 0278 RC inpatient 994 646.1 SIHO - ALL PLANS SIHO - ALL PLANS 894.6 90 999999999 601.87 964.18 percent of total billed charges H-PLATE/LT 1.3 TI EXT-421.321 48713304_1 CDM 0278 RC inpatient 994 646.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 601.87 60.55 999999999 601.87 964.18 percent of total billed charges H-PLATE/LT 1.3 TI EXT-421.321 48713304_1 CDM 0278 RC inpatient 994 646.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 601.87 964.18 H-PLATE/LT 1.3 TI EXT-421.321 48713304_1 CDM 0278 RC inpatient 994 646.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 601.87 964.18 H-PLATE/LT 1.3 TI EXT-421.321 48713304_1 CDM 0278 RC inpatient 994 646.1 ANTHEM HMO ANTHEM HMO 999999999 601.87 964.18 H-PLATE/LT 1.3 TI EXT-421.321 48713304_1 CDM 0278 RC inpatient 994 646.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 671.94 67.6 999999999 601.87 964.18 percent of total billed charges H-PLATE/LT 1.3 TI EXT-421.321 48713304_1 CDM 0278 RC inpatient 994 646.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 601.87 964.18 H-PLATE/LT 1.3 TI EXT-421.321 48713304_1 CDM 0278 RC inpatient 994 646.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 601.87 964.18 Y-PLATE 3 HOLE HEAD 421.335 48713305_1 CDM 0278 RC inpatient 950 617.5 AETNA AETNA 750.5 79 999999999 575.23 921.5 percent of total billed charges Y-PLATE 3 HOLE HEAD 421.335 48713305_1 CDM 0278 RC inpatient 950 617.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 617.5 65 999999999 575.23 921.5 percent of total billed charges Y-PLATE 3 HOLE HEAD 421.335 48713305_1 CDM 0278 RC inpatient 950 617.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 921.5 97 999999999 575.23 921.5 percent of total billed charges Y-PLATE 3 HOLE HEAD 421.335 48713305_1 CDM 0278 RC inpatient 950 617.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 741 78 999999999 575.23 921.5 percent of total billed charges Y-PLATE 3 HOLE HEAD 421.335 48713305_1 CDM 0278 RC inpatient 950 617.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 655.5 69 999999999 575.23 921.5 percent of total billed charges Y-PLATE 3 HOLE HEAD 421.335 48713305_1 CDM 0278 RC inpatient 950 617.5 UMR - ALL PLANS UMR - ALL PLANS 665 70 999999999 575.23 921.5 percent of total billed charges Y-PLATE 3 HOLE HEAD 421.335 48713305_1 CDM 0278 RC inpatient 950 617.5 SIHO - ALL PLANS SIHO - ALL PLANS 855 90 999999999 575.23 921.5 percent of total billed charges Y-PLATE 3 HOLE HEAD 421.335 48713305_1 CDM 0278 RC inpatient 950 617.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 575.23 60.55 999999999 575.23 921.5 percent of total billed charges Y-PLATE 3 HOLE HEAD 421.335 48713305_1 CDM 0278 RC inpatient 950 617.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 575.23 921.5 Y-PLATE 3 HOLE HEAD 421.335 48713305_1 CDM 0278 RC inpatient 950 617.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 575.23 921.5 Y-PLATE 3 HOLE HEAD 421.335 48713305_1 CDM 0278 RC inpatient 950 617.5 ANTHEM HMO ANTHEM HMO 999999999 575.23 921.5 Y-PLATE 3 HOLE HEAD 421.335 48713305_1 CDM 0278 RC inpatient 950 617.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 642.2 67.6 999999999 575.23 921.5 percent of total billed charges Y-PLATE 3 HOLE HEAD 421.335 48713305_1 CDM 0278 RC inpatient 950 617.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 575.23 921.5 Y-PLATE 3 HOLE HEAD 421.335 48713305_1 CDM 0278 RC inpatient 950 617.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 575.23 921.5 SCREW CAN 7.3 16M/35M 208.835 48713306_1 CDM 0278 RC inpatient 1652 1073.8 AETNA AETNA 1305.08 79 999999999 1000.29 1602.44 percent of total billed charges SCREW CAN 7.3 16M/35M 208.835 48713306_1 CDM 0278 RC inpatient 1652 1073.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1073.8 65 999999999 1000.29 1602.44 percent of total billed charges SCREW CAN 7.3 16M/35M 208.835 48713306_1 CDM 0278 RC inpatient 1652 1073.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1602.44 97 999999999 1000.29 1602.44 percent of total billed charges SCREW CAN 7.3 16M/35M 208.835 48713306_1 CDM 0278 RC inpatient 1652 1073.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1288.56 78 999999999 1000.29 1602.44 percent of total billed charges SCREW CAN 7.3 16M/35M 208.835 48713306_1 CDM 0278 RC inpatient 1652 1073.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1139.88 69 999999999 1000.29 1602.44 percent of total billed charges SCREW CAN 7.3 16M/35M 208.835 48713306_1 CDM 0278 RC inpatient 1652 1073.8 UMR - ALL PLANS UMR - ALL PLANS 1156.4 70 999999999 1000.29 1602.44 percent of total billed charges SCREW CAN 7.3 16M/35M 208.835 48713306_1 CDM 0278 RC inpatient 1652 1073.8 SIHO - ALL PLANS SIHO - ALL PLANS 1486.8 90 999999999 1000.29 1602.44 percent of total billed charges SCREW CAN 7.3 16M/35M 208.835 48713306_1 CDM 0278 RC inpatient 1652 1073.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1000.29 60.55 999999999 1000.29 1602.44 percent of total billed charges SCREW CAN 7.3 16M/35M 208.835 48713306_1 CDM 0278 RC inpatient 1652 1073.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1000.29 1602.44 SCREW CAN 7.3 16M/35M 208.835 48713306_1 CDM 0278 RC inpatient 1652 1073.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1000.29 1602.44 SCREW CAN 7.3 16M/35M 208.835 48713306_1 CDM 0278 RC inpatient 1652 1073.8 ANTHEM HMO ANTHEM HMO 999999999 1000.29 1602.44 SCREW CAN 7.3 16M/35M 208.835 48713306_1 CDM 0278 RC inpatient 1652 1073.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1116.75 67.6 999999999 1000.29 1602.44 percent of total billed charges SCREW CAN 7.3 16M/35M 208.835 48713306_1 CDM 0278 RC inpatient 1652 1073.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1000.29 1602.44 SCREW CAN 7.3 16M/35M 208.835 48713306_1 CDM 0278 RC inpatient 1652 1073.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1000.29 1602.44 H-PLATE/RT EXT-1.5MM 446.482 48713307_1 CDM 0278 RC inpatient 994 646.1 AETNA AETNA 785.26 79 999999999 601.87 964.18 percent of total billed charges H-PLATE/RT EXT-1.5MM 446.482 48713307_1 CDM 0278 RC inpatient 994 646.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 646.1 65 999999999 601.87 964.18 percent of total billed charges H-PLATE/RT EXT-1.5MM 446.482 48713307_1 CDM 0278 RC inpatient 994 646.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 964.18 97 999999999 601.87 964.18 percent of total billed charges H-PLATE/RT EXT-1.5MM 446.482 48713307_1 CDM 0278 RC inpatient 994 646.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 775.32 78 999999999 601.87 964.18 percent of total billed charges H-PLATE/RT EXT-1.5MM 446.482 48713307_1 CDM 0278 RC inpatient 994 646.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 685.86 69 999999999 601.87 964.18 percent of total billed charges H-PLATE/RT EXT-1.5MM 446.482 48713307_1 CDM 0278 RC inpatient 994 646.1 UMR - ALL PLANS UMR - ALL PLANS 695.8 70 999999999 601.87 964.18 percent of total billed charges H-PLATE/RT EXT-1.5MM 446.482 48713307_1 CDM 0278 RC inpatient 994 646.1 SIHO - ALL PLANS SIHO - ALL PLANS 894.6 90 999999999 601.87 964.18 percent of total billed charges H-PLATE/RT EXT-1.5MM 446.482 48713307_1 CDM 0278 RC inpatient 994 646.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 601.87 60.55 999999999 601.87 964.18 percent of total billed charges H-PLATE/RT EXT-1.5MM 446.482 48713307_1 CDM 0278 RC inpatient 994 646.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 601.87 964.18 H-PLATE/RT EXT-1.5MM 446.482 48713307_1 CDM 0278 RC inpatient 994 646.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 601.87 964.18 H-PLATE/RT EXT-1.5MM 446.482 48713307_1 CDM 0278 RC inpatient 994 646.1 ANTHEM HMO ANTHEM HMO 999999999 601.87 964.18 H-PLATE/RT EXT-1.5MM 446.482 48713307_1 CDM 0278 RC inpatient 994 646.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 671.94 67.6 999999999 601.87 964.18 percent of total billed charges H-PLATE/RT EXT-1.5MM 446.482 48713307_1 CDM 0278 RC inpatient 994 646.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 601.87 964.18 H-PLATE/RT EXT-1.5MM 446.482 48713307_1 CDM 0278 RC inpatient 994 646.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 601.87 964.18 H-PLATE/LT 1.5MM EXT-446.483 48713308_1 CDM 0278 RC inpatient 994 646.1 AETNA AETNA 785.26 79 999999999 601.87 964.18 percent of total billed charges H-PLATE/LT 1.5MM EXT-446.483 48713308_1 CDM 0278 RC inpatient 994 646.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 646.1 65 999999999 601.87 964.18 percent of total billed charges H-PLATE/LT 1.5MM EXT-446.483 48713308_1 CDM 0278 RC inpatient 994 646.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 964.18 97 999999999 601.87 964.18 percent of total billed charges H-PLATE/LT 1.5MM EXT-446.483 48713308_1 CDM 0278 RC inpatient 994 646.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 775.32 78 999999999 601.87 964.18 percent of total billed charges H-PLATE/LT 1.5MM EXT-446.483 48713308_1 CDM 0278 RC inpatient 994 646.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 685.86 69 999999999 601.87 964.18 percent of total billed charges H-PLATE/LT 1.5MM EXT-446.483 48713308_1 CDM 0278 RC inpatient 994 646.1 UMR - ALL PLANS UMR - ALL PLANS 695.8 70 999999999 601.87 964.18 percent of total billed charges H-PLATE/LT 1.5MM EXT-446.483 48713308_1 CDM 0278 RC inpatient 994 646.1 SIHO - ALL PLANS SIHO - ALL PLANS 894.6 90 999999999 601.87 964.18 percent of total billed charges H-PLATE/LT 1.5MM EXT-446.483 48713308_1 CDM 0278 RC inpatient 994 646.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 601.87 60.55 999999999 601.87 964.18 percent of total billed charges H-PLATE/LT 1.5MM EXT-446.483 48713308_1 CDM 0278 RC inpatient 994 646.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 601.87 964.18 H-PLATE/LT 1.5MM EXT-446.483 48713308_1 CDM 0278 RC inpatient 994 646.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 601.87 964.18 H-PLATE/LT 1.5MM EXT-446.483 48713308_1 CDM 0278 RC inpatient 994 646.1 ANTHEM HMO ANTHEM HMO 999999999 601.87 964.18 H-PLATE/LT 1.5MM EXT-446.483 48713308_1 CDM 0278 RC inpatient 994 646.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 671.94 67.6 999999999 601.87 964.18 percent of total billed charges H-PLATE/LT 1.5MM EXT-446.483 48713308_1 CDM 0278 RC inpatient 994 646.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 601.87 964.18 H-PLATE/LT 1.5MM EXT-446.483 48713308_1 CDM 0278 RC inpatient 994 646.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 601.87 964.18 Y-PLATE 1.5MM 3X8H 446.612 48713309_1 CDM 0278 RC inpatient 950 617.5 AETNA AETNA 750.5 79 999999999 575.23 921.5 percent of total billed charges Y-PLATE 1.5MM 3X8H 446.612 48713309_1 CDM 0278 RC inpatient 950 617.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 617.5 65 999999999 575.23 921.5 percent of total billed charges Y-PLATE 1.5MM 3X8H 446.612 48713309_1 CDM 0278 RC inpatient 950 617.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 921.5 97 999999999 575.23 921.5 percent of total billed charges Y-PLATE 1.5MM 3X8H 446.612 48713309_1 CDM 0278 RC inpatient 950 617.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 741 78 999999999 575.23 921.5 percent of total billed charges Y-PLATE 1.5MM 3X8H 446.612 48713309_1 CDM 0278 RC inpatient 950 617.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 655.5 69 999999999 575.23 921.5 percent of total billed charges Y-PLATE 1.5MM 3X8H 446.612 48713309_1 CDM 0278 RC inpatient 950 617.5 UMR - ALL PLANS UMR - ALL PLANS 665 70 999999999 575.23 921.5 percent of total billed charges Y-PLATE 1.5MM 3X8H 446.612 48713309_1 CDM 0278 RC inpatient 950 617.5 SIHO - ALL PLANS SIHO - ALL PLANS 855 90 999999999 575.23 921.5 percent of total billed charges Y-PLATE 1.5MM 3X8H 446.612 48713309_1 CDM 0278 RC inpatient 950 617.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 575.23 60.55 999999999 575.23 921.5 percent of total billed charges Y-PLATE 1.5MM 3X8H 446.612 48713309_1 CDM 0278 RC inpatient 950 617.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 575.23 921.5 Y-PLATE 1.5MM 3X8H 446.612 48713309_1 CDM 0278 RC inpatient 950 617.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 575.23 921.5 Y-PLATE 1.5MM 3X8H 446.612 48713309_1 CDM 0278 RC inpatient 950 617.5 ANTHEM HMO ANTHEM HMO 999999999 575.23 921.5 Y-PLATE 1.5MM 3X8H 446.612 48713309_1 CDM 0278 RC inpatient 950 617.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 642.2 67.6 999999999 575.23 921.5 percent of total billed charges Y-PLATE 1.5MM 3X8H 446.612 48713309_1 CDM 0278 RC inpatient 950 617.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 575.23 921.5 Y-PLATE 1.5MM 3X8H 446.612 48713309_1 CDM 0278 RC inpatient 950 617.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 575.23 921.5 Y-PLATE 2.0MM 11H HEAD 447.612 48713310_1 CDM 0278 RC inpatient 1086 705.9 AETNA AETNA 857.94 79 999999999 657.57 1053.42 percent of total billed charges Y-PLATE 2.0MM 11H HEAD 447.612 48713310_1 CDM 0278 RC inpatient 1086 705.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 705.9 65 999999999 657.57 1053.42 percent of total billed charges Y-PLATE 2.0MM 11H HEAD 447.612 48713310_1 CDM 0278 RC inpatient 1086 705.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1053.42 97 999999999 657.57 1053.42 percent of total billed charges Y-PLATE 2.0MM 11H HEAD 447.612 48713310_1 CDM 0278 RC inpatient 1086 705.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 847.08 78 999999999 657.57 1053.42 percent of total billed charges Y-PLATE 2.0MM 11H HEAD 447.612 48713310_1 CDM 0278 RC inpatient 1086 705.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 749.34 69 999999999 657.57 1053.42 percent of total billed charges Y-PLATE 2.0MM 11H HEAD 447.612 48713310_1 CDM 0278 RC inpatient 1086 705.9 UMR - ALL PLANS UMR - ALL PLANS 760.2 70 999999999 657.57 1053.42 percent of total billed charges Y-PLATE 2.0MM 11H HEAD 447.612 48713310_1 CDM 0278 RC inpatient 1086 705.9 SIHO - ALL PLANS SIHO - ALL PLANS 977.4 90 999999999 657.57 1053.42 percent of total billed charges Y-PLATE 2.0MM 11H HEAD 447.612 48713310_1 CDM 0278 RC inpatient 1086 705.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 657.57 60.55 999999999 657.57 1053.42 percent of total billed charges Y-PLATE 2.0MM 11H HEAD 447.612 48713310_1 CDM 0278 RC inpatient 1086 705.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 657.57 1053.42 Y-PLATE 2.0MM 11H HEAD 447.612 48713310_1 CDM 0278 RC inpatient 1086 705.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 657.57 1053.42 Y-PLATE 2.0MM 11H HEAD 447.612 48713310_1 CDM 0278 RC inpatient 1086 705.9 ANTHEM HMO ANTHEM HMO 999999999 657.57 1053.42 Y-PLATE 2.0MM 11H HEAD 447.612 48713310_1 CDM 0278 RC inpatient 1086 705.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 734.14 67.6 999999999 657.57 1053.42 percent of total billed charges Y-PLATE 2.0MM 11H HEAD 447.612 48713310_1 CDM 0278 RC inpatient 1086 705.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 657.57 1053.42 Y-PLATE 2.0MM 11H HEAD 447.612 48713310_1 CDM 0278 RC inpatient 1086 705.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 657.57 1053.42 Y-PLATE 2.4MM 11H 449.915 48713311_1 CDM 0278 RC inpatient 1155 750.75 AETNA AETNA 912.45 79 999999999 699.35 1120.35 percent of total billed charges Y-PLATE 2.4MM 11H 449.915 48713311_1 CDM 0278 RC inpatient 1155 750.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 750.75 65 999999999 699.35 1120.35 percent of total billed charges Y-PLATE 2.4MM 11H 449.915 48713311_1 CDM 0278 RC inpatient 1155 750.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1120.35 97 999999999 699.35 1120.35 percent of total billed charges Y-PLATE 2.4MM 11H 449.915 48713311_1 CDM 0278 RC inpatient 1155 750.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 900.9 78 999999999 699.35 1120.35 percent of total billed charges Y-PLATE 2.4MM 11H 449.915 48713311_1 CDM 0278 RC inpatient 1155 750.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 796.95 69 999999999 699.35 1120.35 percent of total billed charges Y-PLATE 2.4MM 11H 449.915 48713311_1 CDM 0278 RC inpatient 1155 750.75 UMR - ALL PLANS UMR - ALL PLANS 808.5 70 999999999 699.35 1120.35 percent of total billed charges Y-PLATE 2.4MM 11H 449.915 48713311_1 CDM 0278 RC inpatient 1155 750.75 SIHO - ALL PLANS SIHO - ALL PLANS 1039.5 90 999999999 699.35 1120.35 percent of total billed charges Y-PLATE 2.4MM 11H 449.915 48713311_1 CDM 0278 RC inpatient 1155 750.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 699.35 60.55 999999999 699.35 1120.35 percent of total billed charges Y-PLATE 2.4MM 11H 449.915 48713311_1 CDM 0278 RC inpatient 1155 750.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 699.35 1120.35 Y-PLATE 2.4MM 11H 449.915 48713311_1 CDM 0278 RC inpatient 1155 750.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 699.35 1120.35 Y-PLATE 2.4MM 11H 449.915 48713311_1 CDM 0278 RC inpatient 1155 750.75 ANTHEM HMO ANTHEM HMO 999999999 699.35 1120.35 Y-PLATE 2.4MM 11H 449.915 48713311_1 CDM 0278 RC inpatient 1155 750.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 780.78 67.6 999999999 699.35 1120.35 percent of total billed charges Y-PLATE 2.4MM 11H 449.915 48713311_1 CDM 0278 RC inpatient 1155 750.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 699.35 1120.35 Y-PLATE 2.4MM 11H 449.915 48713311_1 CDM 0278 RC inpatient 1155 750.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 699.35 1120.35 CORTEX SCREW 1.0 TI 6M 400.526 48713312_1 CDM 0278 RC inpatient 387 251.55 AETNA AETNA 305.73 79 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 6M 400.526 48713312_1 CDM 0278 RC inpatient 387 251.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 251.55 65 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 6M 400.526 48713312_1 CDM 0278 RC inpatient 387 251.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 375.39 97 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 6M 400.526 48713312_1 CDM 0278 RC inpatient 387 251.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.86 78 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 6M 400.526 48713312_1 CDM 0278 RC inpatient 387 251.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.03 69 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 6M 400.526 48713312_1 CDM 0278 RC inpatient 387 251.55 UMR - ALL PLANS UMR - ALL PLANS 270.9 70 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 6M 400.526 48713312_1 CDM 0278 RC inpatient 387 251.55 SIHO - ALL PLANS SIHO - ALL PLANS 348.3 90 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 6M 400.526 48713312_1 CDM 0278 RC inpatient 387 251.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.33 60.55 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 6M 400.526 48713312_1 CDM 0278 RC inpatient 387 251.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 6M 400.526 48713312_1 CDM 0278 RC inpatient 387 251.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 6M 400.526 48713312_1 CDM 0278 RC inpatient 387 251.55 ANTHEM HMO ANTHEM HMO 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 6M 400.526 48713312_1 CDM 0278 RC inpatient 387 251.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 261.61 67.6 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 6M 400.526 48713312_1 CDM 0278 RC inpatient 387 251.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 6M 400.526 48713312_1 CDM 0278 RC inpatient 387 251.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 7M 400.527 48713313_1 CDM 0278 RC inpatient 387 251.55 AETNA AETNA 305.73 79 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 7M 400.527 48713313_1 CDM 0278 RC inpatient 387 251.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 251.55 65 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 7M 400.527 48713313_1 CDM 0278 RC inpatient 387 251.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 375.39 97 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 7M 400.527 48713313_1 CDM 0278 RC inpatient 387 251.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.86 78 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 7M 400.527 48713313_1 CDM 0278 RC inpatient 387 251.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.03 69 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 7M 400.527 48713313_1 CDM 0278 RC inpatient 387 251.55 UMR - ALL PLANS UMR - ALL PLANS 270.9 70 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 7M 400.527 48713313_1 CDM 0278 RC inpatient 387 251.55 SIHO - ALL PLANS SIHO - ALL PLANS 348.3 90 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 7M 400.527 48713313_1 CDM 0278 RC inpatient 387 251.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.33 60.55 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 7M 400.527 48713313_1 CDM 0278 RC inpatient 387 251.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 7M 400.527 48713313_1 CDM 0278 RC inpatient 387 251.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 7M 400.527 48713313_1 CDM 0278 RC inpatient 387 251.55 ANTHEM HMO ANTHEM HMO 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 7M 400.527 48713313_1 CDM 0278 RC inpatient 387 251.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 261.61 67.6 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 7M 400.527 48713313_1 CDM 0278 RC inpatient 387 251.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 7M 400.527 48713313_1 CDM 0278 RC inpatient 387 251.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 8M 400.528 48713314_1 CDM 0278 RC inpatient 387 251.55 AETNA AETNA 305.73 79 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 8M 400.528 48713314_1 CDM 0278 RC inpatient 387 251.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 251.55 65 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 8M 400.528 48713314_1 CDM 0278 RC inpatient 387 251.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 375.39 97 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 8M 400.528 48713314_1 CDM 0278 RC inpatient 387 251.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.86 78 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 8M 400.528 48713314_1 CDM 0278 RC inpatient 387 251.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.03 69 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 8M 400.528 48713314_1 CDM 0278 RC inpatient 387 251.55 UMR - ALL PLANS UMR - ALL PLANS 270.9 70 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 8M 400.528 48713314_1 CDM 0278 RC inpatient 387 251.55 SIHO - ALL PLANS SIHO - ALL PLANS 348.3 90 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 8M 400.528 48713314_1 CDM 0278 RC inpatient 387 251.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.33 60.55 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 8M 400.528 48713314_1 CDM 0278 RC inpatient 387 251.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 8M 400.528 48713314_1 CDM 0278 RC inpatient 387 251.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 8M 400.528 48713314_1 CDM 0278 RC inpatient 387 251.55 ANTHEM HMO ANTHEM HMO 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 8M 400.528 48713314_1 CDM 0278 RC inpatient 387 251.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 261.61 67.6 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 8M 400.528 48713314_1 CDM 0278 RC inpatient 387 251.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 8M 400.528 48713314_1 CDM 0278 RC inpatient 387 251.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 9M 400.529 48713315_1 CDM 0278 RC inpatient 387 251.55 AETNA AETNA 305.73 79 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 9M 400.529 48713315_1 CDM 0278 RC inpatient 387 251.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 251.55 65 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 9M 400.529 48713315_1 CDM 0278 RC inpatient 387 251.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 375.39 97 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 9M 400.529 48713315_1 CDM 0278 RC inpatient 387 251.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.86 78 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 9M 400.529 48713315_1 CDM 0278 RC inpatient 387 251.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.03 69 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 9M 400.529 48713315_1 CDM 0278 RC inpatient 387 251.55 UMR - ALL PLANS UMR - ALL PLANS 270.9 70 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 9M 400.529 48713315_1 CDM 0278 RC inpatient 387 251.55 SIHO - ALL PLANS SIHO - ALL PLANS 348.3 90 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 9M 400.529 48713315_1 CDM 0278 RC inpatient 387 251.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.33 60.55 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 9M 400.529 48713315_1 CDM 0278 RC inpatient 387 251.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 9M 400.529 48713315_1 CDM 0278 RC inpatient 387 251.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 9M 400.529 48713315_1 CDM 0278 RC inpatient 387 251.55 ANTHEM HMO ANTHEM HMO 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 9M 400.529 48713315_1 CDM 0278 RC inpatient 387 251.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 261.61 67.6 999999999 234.33 375.39 percent of total billed charges CORTEX SCREW 1.0 TI 9M 400.529 48713315_1 CDM 0278 RC inpatient 387 251.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.33 375.39 CORTEX SCREW 1.0 TI 9M 400.529 48713315_1 CDM 0278 RC inpatient 387 251.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.33 375.39 CORTEX SCR 1.0 TI 10MM 400.530 48713316_1 CDM 0278 RC inpatient 387 251.55 AETNA AETNA 305.73 79 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 10MM 400.530 48713316_1 CDM 0278 RC inpatient 387 251.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 251.55 65 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 10MM 400.530 48713316_1 CDM 0278 RC inpatient 387 251.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 375.39 97 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 10MM 400.530 48713316_1 CDM 0278 RC inpatient 387 251.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.86 78 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 10MM 400.530 48713316_1 CDM 0278 RC inpatient 387 251.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.03 69 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 10MM 400.530 48713316_1 CDM 0278 RC inpatient 387 251.55 UMR - ALL PLANS UMR - ALL PLANS 270.9 70 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 10MM 400.530 48713316_1 CDM 0278 RC inpatient 387 251.55 SIHO - ALL PLANS SIHO - ALL PLANS 348.3 90 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 10MM 400.530 48713316_1 CDM 0278 RC inpatient 387 251.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.33 60.55 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 10MM 400.530 48713316_1 CDM 0278 RC inpatient 387 251.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.33 375.39 CORTEX SCR 1.0 TI 10MM 400.530 48713316_1 CDM 0278 RC inpatient 387 251.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.33 375.39 CORTEX SCR 1.0 TI 10MM 400.530 48713316_1 CDM 0278 RC inpatient 387 251.55 ANTHEM HMO ANTHEM HMO 999999999 234.33 375.39 CORTEX SCR 1.0 TI 10MM 400.530 48713316_1 CDM 0278 RC inpatient 387 251.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 261.61 67.6 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 10MM 400.530 48713316_1 CDM 0278 RC inpatient 387 251.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.33 375.39 CORTEX SCR 1.0 TI 10MM 400.530 48713316_1 CDM 0278 RC inpatient 387 251.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.33 375.39 CORTEX SCR 1.0 TI 11MM 400.531 48713317_1 CDM 0278 RC inpatient 387 251.55 AETNA AETNA 305.73 79 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 11MM 400.531 48713317_1 CDM 0278 RC inpatient 387 251.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 251.55 65 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 11MM 400.531 48713317_1 CDM 0278 RC inpatient 387 251.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 375.39 97 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 11MM 400.531 48713317_1 CDM 0278 RC inpatient 387 251.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.86 78 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 11MM 400.531 48713317_1 CDM 0278 RC inpatient 387 251.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.03 69 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 11MM 400.531 48713317_1 CDM 0278 RC inpatient 387 251.55 UMR - ALL PLANS UMR - ALL PLANS 270.9 70 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 11MM 400.531 48713317_1 CDM 0278 RC inpatient 387 251.55 SIHO - ALL PLANS SIHO - ALL PLANS 348.3 90 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 11MM 400.531 48713317_1 CDM 0278 RC inpatient 387 251.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.33 60.55 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 11MM 400.531 48713317_1 CDM 0278 RC inpatient 387 251.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.33 375.39 CORTEX SCR 1.0 TI 11MM 400.531 48713317_1 CDM 0278 RC inpatient 387 251.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.33 375.39 CORTEX SCR 1.0 TI 11MM 400.531 48713317_1 CDM 0278 RC inpatient 387 251.55 ANTHEM HMO ANTHEM HMO 999999999 234.33 375.39 CORTEX SCR 1.0 TI 11MM 400.531 48713317_1 CDM 0278 RC inpatient 387 251.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 261.61 67.6 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 11MM 400.531 48713317_1 CDM 0278 RC inpatient 387 251.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.33 375.39 CORTEX SCR 1.0 TI 11MM 400.531 48713317_1 CDM 0278 RC inpatient 387 251.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.33 375.39 CORTEX SCR 1.0 TI 12MM 400.532 48713318_1 CDM 0278 RC inpatient 387 251.55 AETNA AETNA 305.73 79 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 12MM 400.532 48713318_1 CDM 0278 RC inpatient 387 251.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 251.55 65 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 12MM 400.532 48713318_1 CDM 0278 RC inpatient 387 251.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 375.39 97 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 12MM 400.532 48713318_1 CDM 0278 RC inpatient 387 251.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.86 78 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 12MM 400.532 48713318_1 CDM 0278 RC inpatient 387 251.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.03 69 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 12MM 400.532 48713318_1 CDM 0278 RC inpatient 387 251.55 UMR - ALL PLANS UMR - ALL PLANS 270.9 70 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 12MM 400.532 48713318_1 CDM 0278 RC inpatient 387 251.55 SIHO - ALL PLANS SIHO - ALL PLANS 348.3 90 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 12MM 400.532 48713318_1 CDM 0278 RC inpatient 387 251.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.33 60.55 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 12MM 400.532 48713318_1 CDM 0278 RC inpatient 387 251.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.33 375.39 CORTEX SCR 1.0 TI 12MM 400.532 48713318_1 CDM 0278 RC inpatient 387 251.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.33 375.39 CORTEX SCR 1.0 TI 12MM 400.532 48713318_1 CDM 0278 RC inpatient 387 251.55 ANTHEM HMO ANTHEM HMO 999999999 234.33 375.39 CORTEX SCR 1.0 TI 12MM 400.532 48713318_1 CDM 0278 RC inpatient 387 251.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 261.61 67.6 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 12MM 400.532 48713318_1 CDM 0278 RC inpatient 387 251.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.33 375.39 CORTEX SCR 1.0 TI 12MM 400.532 48713318_1 CDM 0278 RC inpatient 387 251.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.33 375.39 CORTEX SCR 1.0 TI 13MM 400.533 48713319_1 CDM 0278 RC inpatient 387 251.55 AETNA AETNA 305.73 79 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 13MM 400.533 48713319_1 CDM 0278 RC inpatient 387 251.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 251.55 65 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 13MM 400.533 48713319_1 CDM 0278 RC inpatient 387 251.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 375.39 97 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 13MM 400.533 48713319_1 CDM 0278 RC inpatient 387 251.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.86 78 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 13MM 400.533 48713319_1 CDM 0278 RC inpatient 387 251.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.03 69 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 13MM 400.533 48713319_1 CDM 0278 RC inpatient 387 251.55 UMR - ALL PLANS UMR - ALL PLANS 270.9 70 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 13MM 400.533 48713319_1 CDM 0278 RC inpatient 387 251.55 SIHO - ALL PLANS SIHO - ALL PLANS 348.3 90 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 13MM 400.533 48713319_1 CDM 0278 RC inpatient 387 251.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.33 60.55 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 13MM 400.533 48713319_1 CDM 0278 RC inpatient 387 251.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.33 375.39 CORTEX SCR 1.0 TI 13MM 400.533 48713319_1 CDM 0278 RC inpatient 387 251.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.33 375.39 CORTEX SCR 1.0 TI 13MM 400.533 48713319_1 CDM 0278 RC inpatient 387 251.55 ANTHEM HMO ANTHEM HMO 999999999 234.33 375.39 CORTEX SCR 1.0 TI 13MM 400.533 48713319_1 CDM 0278 RC inpatient 387 251.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 261.61 67.6 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 13MM 400.533 48713319_1 CDM 0278 RC inpatient 387 251.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.33 375.39 CORTEX SCR 1.0 TI 13MM 400.533 48713319_1 CDM 0278 RC inpatient 387 251.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.33 375.39 CORTEX SCR 1.0 TI 14MM 400.534 48713320_1 CDM 0278 RC inpatient 387 251.55 AETNA AETNA 305.73 79 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 14MM 400.534 48713320_1 CDM 0278 RC inpatient 387 251.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 251.55 65 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 14MM 400.534 48713320_1 CDM 0278 RC inpatient 387 251.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 375.39 97 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 14MM 400.534 48713320_1 CDM 0278 RC inpatient 387 251.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.86 78 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 14MM 400.534 48713320_1 CDM 0278 RC inpatient 387 251.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.03 69 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 14MM 400.534 48713320_1 CDM 0278 RC inpatient 387 251.55 UMR - ALL PLANS UMR - ALL PLANS 270.9 70 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 14MM 400.534 48713320_1 CDM 0278 RC inpatient 387 251.55 SIHO - ALL PLANS SIHO - ALL PLANS 348.3 90 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 14MM 400.534 48713320_1 CDM 0278 RC inpatient 387 251.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.33 60.55 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 14MM 400.534 48713320_1 CDM 0278 RC inpatient 387 251.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.33 375.39 CORTEX SCR 1.0 TI 14MM 400.534 48713320_1 CDM 0278 RC inpatient 387 251.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.33 375.39 CORTEX SCR 1.0 TI 14MM 400.534 48713320_1 CDM 0278 RC inpatient 387 251.55 ANTHEM HMO ANTHEM HMO 999999999 234.33 375.39 CORTEX SCR 1.0 TI 14MM 400.534 48713320_1 CDM 0278 RC inpatient 387 251.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 261.61 67.6 999999999 234.33 375.39 percent of total billed charges CORTEX SCR 1.0 TI 14MM 400.534 48713320_1 CDM 0278 RC inpatient 387 251.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.33 375.39 CORTEX SCR 1.0 TI 14MM 400.534 48713320_1 CDM 0278 RC inpatient 387 251.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.33 375.39 DRILL BIT 1.1MM 310.111 48713321_1 CDM 0272 RC inpatient 302 196.3 AETNA AETNA 238.58 79 999999999 182.86 292.94 percent of total billed charges DRILL BIT 1.1MM 310.111 48713321_1 CDM 0272 RC inpatient 302 196.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 196.3 65 999999999 182.86 292.94 percent of total billed charges DRILL BIT 1.1MM 310.111 48713321_1 CDM 0272 RC inpatient 302 196.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 292.94 97 999999999 182.86 292.94 percent of total billed charges DRILL BIT 1.1MM 310.111 48713321_1 CDM 0272 RC inpatient 302 196.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 235.56 78 999999999 182.86 292.94 percent of total billed charges DRILL BIT 1.1MM 310.111 48713321_1 CDM 0272 RC inpatient 302 196.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 208.38 69 999999999 182.86 292.94 percent of total billed charges DRILL BIT 1.1MM 310.111 48713321_1 CDM 0272 RC inpatient 302 196.3 UMR - ALL PLANS UMR - ALL PLANS 211.4 70 999999999 182.86 292.94 percent of total billed charges DRILL BIT 1.1MM 310.111 48713321_1 CDM 0272 RC inpatient 302 196.3 SIHO - ALL PLANS SIHO - ALL PLANS 271.8 90 999999999 182.86 292.94 percent of total billed charges DRILL BIT 1.1MM 310.111 48713321_1 CDM 0272 RC inpatient 302 196.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.86 60.55 999999999 182.86 292.94 percent of total billed charges DRILL BIT 1.1MM 310.111 48713321_1 CDM 0272 RC inpatient 302 196.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.86 292.94 DRILL BIT 1.1MM 310.111 48713321_1 CDM 0272 RC inpatient 302 196.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.86 292.94 DRILL BIT 1.1MM 310.111 48713321_1 CDM 0272 RC inpatient 302 196.3 ANTHEM HMO ANTHEM HMO 999999999 182.86 292.94 DRILL BIT 1.1MM 310.111 48713321_1 CDM 0272 RC inpatient 302 196.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 204.15 67.6 999999999 182.86 292.94 percent of total billed charges DRILL BIT 1.1MM 310.111 48713321_1 CDM 0272 RC inpatient 302 196.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.86 292.94 DRILL BIT 1.1MM 310.111 48713321_1 CDM 0272 RC inpatient 302 196.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.86 292.94 DRILL BIT 1.5MM 310.141 48713322_1 CDM 0278 RC inpatient 578 375.7 AETNA AETNA 456.62 79 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.5MM 310.141 48713322_1 CDM 0278 RC inpatient 578 375.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 375.7 65 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.5MM 310.141 48713322_1 CDM 0278 RC inpatient 578 375.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 560.66 97 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.5MM 310.141 48713322_1 CDM 0278 RC inpatient 578 375.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 450.84 78 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.5MM 310.141 48713322_1 CDM 0278 RC inpatient 578 375.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 398.82 69 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.5MM 310.141 48713322_1 CDM 0278 RC inpatient 578 375.7 UMR - ALL PLANS UMR - ALL PLANS 404.6 70 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.5MM 310.141 48713322_1 CDM 0278 RC inpatient 578 375.7 SIHO - ALL PLANS SIHO - ALL PLANS 520.2 90 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.5MM 310.141 48713322_1 CDM 0278 RC inpatient 578 375.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 349.98 60.55 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.5MM 310.141 48713322_1 CDM 0278 RC inpatient 578 375.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 349.98 560.66 DRILL BIT 1.5MM 310.141 48713322_1 CDM 0278 RC inpatient 578 375.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 349.98 560.66 DRILL BIT 1.5MM 310.141 48713322_1 CDM 0278 RC inpatient 578 375.7 ANTHEM HMO ANTHEM HMO 999999999 349.98 560.66 DRILL BIT 1.5MM 310.141 48713322_1 CDM 0278 RC inpatient 578 375.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 390.73 67.6 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.5MM 310.141 48713322_1 CDM 0278 RC inpatient 578 375.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 349.98 560.66 DRILL BIT 1.5MM 310.141 48713322_1 CDM 0278 RC inpatient 578 375.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 349.98 560.66 SCREW CAN 7.3 16M/40M 208.840 48713323_1 CDM 0278 RC inpatient 1768 1149.2 AETNA AETNA 1396.72 79 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/40M 208.840 48713323_1 CDM 0278 RC inpatient 1768 1149.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1149.2 65 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/40M 208.840 48713323_1 CDM 0278 RC inpatient 1768 1149.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1714.96 97 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/40M 208.840 48713323_1 CDM 0278 RC inpatient 1768 1149.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1379.04 78 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/40M 208.840 48713323_1 CDM 0278 RC inpatient 1768 1149.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1219.92 69 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/40M 208.840 48713323_1 CDM 0278 RC inpatient 1768 1149.2 UMR - ALL PLANS UMR - ALL PLANS 1237.6 70 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/40M 208.840 48713323_1 CDM 0278 RC inpatient 1768 1149.2 SIHO - ALL PLANS SIHO - ALL PLANS 1591.2 90 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/40M 208.840 48713323_1 CDM 0278 RC inpatient 1768 1149.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1070.52 60.55 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/40M 208.840 48713323_1 CDM 0278 RC inpatient 1768 1149.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1070.52 1714.96 SCREW CAN 7.3 16M/40M 208.840 48713323_1 CDM 0278 RC inpatient 1768 1149.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1070.52 1714.96 SCREW CAN 7.3 16M/40M 208.840 48713323_1 CDM 0278 RC inpatient 1768 1149.2 ANTHEM HMO ANTHEM HMO 999999999 1070.52 1714.96 SCREW CAN 7.3 16M/40M 208.840 48713323_1 CDM 0278 RC inpatient 1768 1149.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1195.17 67.6 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/40M 208.840 48713323_1 CDM 0278 RC inpatient 1768 1149.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1070.52 1714.96 SCREW CAN 7.3 16M/40M 208.840 48713323_1 CDM 0278 RC inpatient 1768 1149.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1070.52 1714.96 COUNTERSINK 1.3M & 1.5 310.971 48713324_1 CDM 0278 RC inpatient 747 485.55 AETNA AETNA 590.13 79 999999999 452.31 724.59 percent of total billed charges COUNTERSINK 1.3M & 1.5 310.971 48713324_1 CDM 0278 RC inpatient 747 485.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 485.55 65 999999999 452.31 724.59 percent of total billed charges COUNTERSINK 1.3M & 1.5 310.971 48713324_1 CDM 0278 RC inpatient 747 485.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 724.59 97 999999999 452.31 724.59 percent of total billed charges COUNTERSINK 1.3M & 1.5 310.971 48713324_1 CDM 0278 RC inpatient 747 485.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 582.66 78 999999999 452.31 724.59 percent of total billed charges COUNTERSINK 1.3M & 1.5 310.971 48713324_1 CDM 0278 RC inpatient 747 485.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 515.43 69 999999999 452.31 724.59 percent of total billed charges COUNTERSINK 1.3M & 1.5 310.971 48713324_1 CDM 0278 RC inpatient 747 485.55 UMR - ALL PLANS UMR - ALL PLANS 522.9 70 999999999 452.31 724.59 percent of total billed charges COUNTERSINK 1.3M & 1.5 310.971 48713324_1 CDM 0278 RC inpatient 747 485.55 SIHO - ALL PLANS SIHO - ALL PLANS 672.3 90 999999999 452.31 724.59 percent of total billed charges COUNTERSINK 1.3M & 1.5 310.971 48713324_1 CDM 0278 RC inpatient 747 485.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 452.31 60.55 999999999 452.31 724.59 percent of total billed charges COUNTERSINK 1.3M & 1.5 310.971 48713324_1 CDM 0278 RC inpatient 747 485.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 452.31 724.59 COUNTERSINK 1.3M & 1.5 310.971 48713324_1 CDM 0278 RC inpatient 747 485.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 452.31 724.59 COUNTERSINK 1.3M & 1.5 310.971 48713324_1 CDM 0278 RC inpatient 747 485.55 ANTHEM HMO ANTHEM HMO 999999999 452.31 724.59 COUNTERSINK 1.3M & 1.5 310.971 48713324_1 CDM 0278 RC inpatient 747 485.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 504.97 67.6 999999999 452.31 724.59 percent of total billed charges COUNTERSINK 1.3M & 1.5 310.971 48713324_1 CDM 0278 RC inpatient 747 485.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 452.31 724.59 COUNTERSINK 1.3M & 1.5 310.971 48713324_1 CDM 0278 RC inpatient 747 485.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 452.31 724.59 COUNTERSINK 2.0 & 2.4 310.972 48713325_1 CDM 0278 RC inpatient 714 464.1 AETNA AETNA 564.06 79 999999999 432.33 692.58 percent of total billed charges COUNTERSINK 2.0 & 2.4 310.972 48713325_1 CDM 0278 RC inpatient 714 464.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 464.1 65 999999999 432.33 692.58 percent of total billed charges COUNTERSINK 2.0 & 2.4 310.972 48713325_1 CDM 0278 RC inpatient 714 464.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 692.58 97 999999999 432.33 692.58 percent of total billed charges COUNTERSINK 2.0 & 2.4 310.972 48713325_1 CDM 0278 RC inpatient 714 464.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 492.66 69 999999999 432.33 692.58 percent of total billed charges COUNTERSINK 2.0 & 2.4 310.972 48713325_1 CDM 0278 RC inpatient 714 464.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 556.92 78 999999999 432.33 692.58 percent of total billed charges COUNTERSINK 2.0 & 2.4 310.972 48713325_1 CDM 0278 RC inpatient 714 464.1 UMR - ALL PLANS UMR - ALL PLANS 499.8 70 999999999 432.33 692.58 percent of total billed charges COUNTERSINK 2.0 & 2.4 310.972 48713325_1 CDM 0278 RC inpatient 714 464.1 SIHO - ALL PLANS SIHO - ALL PLANS 642.6 90 999999999 432.33 692.58 percent of total billed charges COUNTERSINK 2.0 & 2.4 310.972 48713325_1 CDM 0278 RC inpatient 714 464.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 432.33 60.55 999999999 432.33 692.58 percent of total billed charges COUNTERSINK 2.0 & 2.4 310.972 48713325_1 CDM 0278 RC inpatient 714 464.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 432.33 692.58 COUNTERSINK 2.0 & 2.4 310.972 48713325_1 CDM 0278 RC inpatient 714 464.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 432.33 692.58 COUNTERSINK 2.0 & 2.4 310.972 48713325_1 CDM 0278 RC inpatient 714 464.1 ANTHEM HMO ANTHEM HMO 999999999 432.33 692.58 COUNTERSINK 2.0 & 2.4 310.972 48713325_1 CDM 0278 RC inpatient 714 464.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 482.66 67.6 999999999 432.33 692.58 percent of total billed charges COUNTERSINK 2.0 & 2.4 310.972 48713325_1 CDM 0278 RC inpatient 714 464.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 432.33 692.58 COUNTERSINK 2.0 & 2.4 310.972 48713325_1 CDM 0278 RC inpatient 714 464.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 432.33 692.58 DRILL BIT 0.76 6MM 316.286 48713326_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 6MM 316.286 48713326_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 6MM 316.286 48713326_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 6MM 316.286 48713326_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 6MM 316.286 48713326_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 6MM 316.286 48713326_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 6MM 316.286 48713326_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 6MM 316.286 48713326_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 6MM 316.286 48713326_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 DRILL BIT 0.76 6MM 316.286 48713326_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 DRILL BIT 0.76 6MM 316.286 48713326_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 DRILL BIT 0.76 6MM 316.286 48713326_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 6MM 316.286 48713326_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 DRILL BIT 0.76 6MM 316.286 48713326_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 DRILL BIT 0.76 8MM 316.288 48713327_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 8MM 316.288 48713327_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 8MM 316.288 48713327_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 8MM 316.288 48713327_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 8MM 316.288 48713327_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 8MM 316.288 48713327_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 8MM 316.288 48713327_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 8MM 316.288 48713327_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 8MM 316.288 48713327_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 DRILL BIT 0.76 8MM 316.288 48713327_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 DRILL BIT 0.76 8MM 316.288 48713327_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 DRILL BIT 0.76 8MM 316.288 48713327_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 8MM 316.288 48713327_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 DRILL BIT 0.76 8MM 316.288 48713327_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 DRILL BIT 0.76 10MM 316.290 48713328_1 CDM 0278 RC inpatient 938 609.7 AETNA AETNA 741.02 79 999999999 567.96 909.86 percent of total billed charges DRILL BIT 0.76 10MM 316.290 48713328_1 CDM 0278 RC inpatient 938 609.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 609.7 65 999999999 567.96 909.86 percent of total billed charges DRILL BIT 0.76 10MM 316.290 48713328_1 CDM 0278 RC inpatient 938 609.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 909.86 97 999999999 567.96 909.86 percent of total billed charges DRILL BIT 0.76 10MM 316.290 48713328_1 CDM 0278 RC inpatient 938 609.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 647.22 69 999999999 567.96 909.86 percent of total billed charges DRILL BIT 0.76 10MM 316.290 48713328_1 CDM 0278 RC inpatient 938 609.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 731.64 78 999999999 567.96 909.86 percent of total billed charges DRILL BIT 0.76 10MM 316.290 48713328_1 CDM 0278 RC inpatient 938 609.7 UMR - ALL PLANS UMR - ALL PLANS 656.6 70 999999999 567.96 909.86 percent of total billed charges DRILL BIT 0.76 10MM 316.290 48713328_1 CDM 0278 RC inpatient 938 609.7 SIHO - ALL PLANS SIHO - ALL PLANS 844.2 90 999999999 567.96 909.86 percent of total billed charges DRILL BIT 0.76 10MM 316.290 48713328_1 CDM 0278 RC inpatient 938 609.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 567.96 60.55 999999999 567.96 909.86 percent of total billed charges DRILL BIT 0.76 10MM 316.290 48713328_1 CDM 0278 RC inpatient 938 609.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 567.96 909.86 DRILL BIT 0.76 10MM 316.290 48713328_1 CDM 0278 RC inpatient 938 609.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 567.96 909.86 DRILL BIT 0.76 10MM 316.290 48713328_1 CDM 0278 RC inpatient 938 609.7 ANTHEM HMO ANTHEM HMO 999999999 567.96 909.86 DRILL BIT 0.76 10MM 316.290 48713328_1 CDM 0278 RC inpatient 938 609.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 634.09 67.6 999999999 567.96 909.86 percent of total billed charges DRILL BIT 0.76 10MM 316.290 48713328_1 CDM 0278 RC inpatient 938 609.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 567.96 909.86 DRILL BIT 0.76 10MM 316.290 48713328_1 CDM 0278 RC inpatient 938 609.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 567.96 909.86 DRILL BIT 0.76 12MM 316.292 48713329_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 12MM 316.292 48713329_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 12MM 316.292 48713329_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 12MM 316.292 48713329_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 12MM 316.292 48713329_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 12MM 316.292 48713329_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 12MM 316.292 48713329_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 12MM 316.292 48713329_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 12MM 316.292 48713329_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 DRILL BIT 0.76 12MM 316.292 48713329_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 DRILL BIT 0.76 12MM 316.292 48713329_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 DRILL BIT 0.76 12MM 316.292 48713329_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 12MM 316.292 48713329_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 DRILL BIT 0.76 12MM 316.292 48713329_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 DRILL BIT 0.76 14MM 316.294 48713330_1 CDM 0278 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 14MM 316.294 48713330_1 CDM 0278 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 14MM 316.294 48713330_1 CDM 0278 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 14MM 316.294 48713330_1 CDM 0278 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 14MM 316.294 48713330_1 CDM 0278 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 14MM 316.294 48713330_1 CDM 0278 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 14MM 316.294 48713330_1 CDM 0278 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 14MM 316.294 48713330_1 CDM 0278 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 14MM 316.294 48713330_1 CDM 0278 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 DRILL BIT 0.76 14MM 316.294 48713330_1 CDM 0278 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 DRILL BIT 0.76 14MM 316.294 48713330_1 CDM 0278 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 DRILL BIT 0.76 14MM 316.294 48713330_1 CDM 0278 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges DRILL BIT 0.76 14MM 316.294 48713330_1 CDM 0278 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 DRILL BIT 0.76 14MM 316.294 48713330_1 CDM 0278 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713331_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 AETNA AETNA 1396.72 79 999999999 1070.52 1714.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713331_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1149.2 65 999999999 1070.52 1714.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713331_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1714.96 97 999999999 1070.52 1714.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713331_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1219.92 69 999999999 1070.52 1714.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713331_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1379.04 78 999999999 1070.52 1714.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713331_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 UMR - ALL PLANS UMR - ALL PLANS 1237.6 70 999999999 1070.52 1714.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713331_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 SIHO - ALL PLANS SIHO - ALL PLANS 1591.2 90 999999999 1070.52 1714.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713331_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1070.52 60.55 999999999 1070.52 1714.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713331_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1070.52 1714.96 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713331_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1070.52 1714.96 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713331_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 ANTHEM HMO ANTHEM HMO 999999999 1070.52 1714.96 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713331_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1195.17 67.6 999999999 1070.52 1714.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713331_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1070.52 1714.96 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713331_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1070.52 1714.96 DRILL BIT 1.8MM 317.861 48713332_1 CDM 0278 RC inpatient 364 236.6 AETNA AETNA 287.56 79 999999999 220.4 353.08 percent of total billed charges DRILL BIT 1.8MM 317.861 48713332_1 CDM 0278 RC inpatient 364 236.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 236.6 65 999999999 220.4 353.08 percent of total billed charges DRILL BIT 1.8MM 317.861 48713332_1 CDM 0278 RC inpatient 364 236.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 353.08 97 999999999 220.4 353.08 percent of total billed charges DRILL BIT 1.8MM 317.861 48713332_1 CDM 0278 RC inpatient 364 236.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 251.16 69 999999999 220.4 353.08 percent of total billed charges DRILL BIT 1.8MM 317.861 48713332_1 CDM 0278 RC inpatient 364 236.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 283.92 78 999999999 220.4 353.08 percent of total billed charges DRILL BIT 1.8MM 317.861 48713332_1 CDM 0278 RC inpatient 364 236.6 UMR - ALL PLANS UMR - ALL PLANS 254.8 70 999999999 220.4 353.08 percent of total billed charges DRILL BIT 1.8MM 317.861 48713332_1 CDM 0278 RC inpatient 364 236.6 SIHO - ALL PLANS SIHO - ALL PLANS 327.6 90 999999999 220.4 353.08 percent of total billed charges DRILL BIT 1.8MM 317.861 48713332_1 CDM 0278 RC inpatient 364 236.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 220.4 60.55 999999999 220.4 353.08 percent of total billed charges DRILL BIT 1.8MM 317.861 48713332_1 CDM 0278 RC inpatient 364 236.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 220.4 353.08 DRILL BIT 1.8MM 317.861 48713332_1 CDM 0278 RC inpatient 364 236.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 220.4 353.08 DRILL BIT 1.8MM 317.861 48713332_1 CDM 0278 RC inpatient 364 236.6 ANTHEM HMO ANTHEM HMO 999999999 220.4 353.08 DRILL BIT 1.8MM 317.861 48713332_1 CDM 0278 RC inpatient 364 236.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 246.06 67.6 999999999 220.4 353.08 percent of total billed charges DRILL BIT 1.8MM 317.861 48713332_1 CDM 0278 RC inpatient 364 236.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 220.4 353.08 DRILL BIT 1.8MM 317.861 48713332_1 CDM 0278 RC inpatient 364 236.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 220.4 353.08 DRILL BIT 317.872 48713333_1 CDM 0278 RC inpatient 648 421.2 AETNA AETNA 511.92 79 999999999 392.36 628.56 percent of total billed charges DRILL BIT 317.872 48713333_1 CDM 0278 RC inpatient 648 421.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 421.2 65 999999999 392.36 628.56 percent of total billed charges DRILL BIT 317.872 48713333_1 CDM 0278 RC inpatient 648 421.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 628.56 97 999999999 392.36 628.56 percent of total billed charges DRILL BIT 317.872 48713333_1 CDM 0278 RC inpatient 648 421.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 447.12 69 999999999 392.36 628.56 percent of total billed charges DRILL BIT 317.872 48713333_1 CDM 0278 RC inpatient 648 421.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 505.44 78 999999999 392.36 628.56 percent of total billed charges DRILL BIT 317.872 48713333_1 CDM 0278 RC inpatient 648 421.2 UMR - ALL PLANS UMR - ALL PLANS 453.6 70 999999999 392.36 628.56 percent of total billed charges DRILL BIT 317.872 48713333_1 CDM 0278 RC inpatient 648 421.2 SIHO - ALL PLANS SIHO - ALL PLANS 583.2 90 999999999 392.36 628.56 percent of total billed charges DRILL BIT 317.872 48713333_1 CDM 0278 RC inpatient 648 421.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 392.36 60.55 999999999 392.36 628.56 percent of total billed charges DRILL BIT 317.872 48713333_1 CDM 0278 RC inpatient 648 421.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 392.36 628.56 DRILL BIT 317.872 48713333_1 CDM 0278 RC inpatient 648 421.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 392.36 628.56 DRILL BIT 317.872 48713333_1 CDM 0278 RC inpatient 648 421.2 ANTHEM HMO ANTHEM HMO 999999999 392.36 628.56 DRILL BIT 317.872 48713333_1 CDM 0278 RC inpatient 648 421.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 438.05 67.6 999999999 392.36 628.56 percent of total billed charges DRILL BIT 317.872 48713333_1 CDM 0278 RC inpatient 648 421.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 392.36 628.56 DRILL BIT 317.872 48713333_1 CDM 0278 RC inpatient 648 421.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 392.36 628.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713334_1 CDM 0272 RC C1713 HCPCS inpatient 2608 1695.2 AETNA AETNA 2060.32 79 999999999 1579.14 2529.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713334_1 CDM 0272 RC C1713 HCPCS inpatient 2608 1695.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1695.2 65 999999999 1579.14 2529.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713334_1 CDM 0272 RC C1713 HCPCS inpatient 2608 1695.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2529.76 97 999999999 1579.14 2529.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713334_1 CDM 0272 RC C1713 HCPCS inpatient 2608 1695.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1799.52 69 999999999 1579.14 2529.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713334_1 CDM 0272 RC C1713 HCPCS inpatient 2608 1695.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 2034.24 78 999999999 1579.14 2529.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713334_1 CDM 0272 RC C1713 HCPCS inpatient 2608 1695.2 UMR - ALL PLANS UMR - ALL PLANS 1825.6 70 999999999 1579.14 2529.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713334_1 CDM 0272 RC C1713 HCPCS inpatient 2608 1695.2 SIHO - ALL PLANS SIHO - ALL PLANS 2347.2 90 999999999 1579.14 2529.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713334_1 CDM 0272 RC C1713 HCPCS inpatient 2608 1695.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1579.14 60.55 999999999 1579.14 2529.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713334_1 CDM 0272 RC C1713 HCPCS inpatient 2608 1695.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1579.14 2529.76 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713334_1 CDM 0272 RC C1713 HCPCS inpatient 2608 1695.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1579.14 2529.76 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713334_1 CDM 0272 RC C1713 HCPCS inpatient 2608 1695.2 ANTHEM HMO ANTHEM HMO 999999999 1579.14 2529.76 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713334_1 CDM 0272 RC C1713 HCPCS inpatient 2608 1695.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1763.01 67.6 999999999 1579.14 2529.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713334_1 CDM 0272 RC C1713 HCPCS inpatient 2608 1695.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1579.14 2529.76 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713334_1 CDM 0272 RC C1713 HCPCS inpatient 2608 1695.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1579.14 2529.76 4.0 CANN SCREW 16MM 207.716 48713335_1 CDM 0278 RC inpatient 894 581.1 AETNA AETNA 706.26 79 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 16MM 207.716 48713335_1 CDM 0278 RC inpatient 894 581.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 581.1 65 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 16MM 207.716 48713335_1 CDM 0278 RC inpatient 894 581.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 867.18 97 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 16MM 207.716 48713335_1 CDM 0278 RC inpatient 894 581.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 616.86 69 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 16MM 207.716 48713335_1 CDM 0278 RC inpatient 894 581.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 697.32 78 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 16MM 207.716 48713335_1 CDM 0278 RC inpatient 894 581.1 UMR - ALL PLANS UMR - ALL PLANS 625.8 70 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 16MM 207.716 48713335_1 CDM 0278 RC inpatient 894 581.1 SIHO - ALL PLANS SIHO - ALL PLANS 804.6 90 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 16MM 207.716 48713335_1 CDM 0278 RC inpatient 894 581.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 541.32 60.55 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 16MM 207.716 48713335_1 CDM 0278 RC inpatient 894 581.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 541.32 867.18 4.0 CANN SCREW 16MM 207.716 48713335_1 CDM 0278 RC inpatient 894 581.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 541.32 867.18 4.0 CANN SCREW 16MM 207.716 48713335_1 CDM 0278 RC inpatient 894 581.1 ANTHEM HMO ANTHEM HMO 999999999 541.32 867.18 4.0 CANN SCREW 16MM 207.716 48713335_1 CDM 0278 RC inpatient 894 581.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 604.34 67.6 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 16MM 207.716 48713335_1 CDM 0278 RC inpatient 894 581.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 541.32 867.18 4.0 CANN SCREW 16MM 207.716 48713335_1 CDM 0278 RC inpatient 894 581.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 541.32 867.18 SCREW CAN 7.3 16M/50M 208.850 48713336_1 CDM 0278 RC inpatient 1768 1149.2 AETNA AETNA 1396.72 79 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/50M 208.850 48713336_1 CDM 0278 RC inpatient 1768 1149.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1149.2 65 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/50M 208.850 48713336_1 CDM 0278 RC inpatient 1768 1149.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1714.96 97 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/50M 208.850 48713336_1 CDM 0278 RC inpatient 1768 1149.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1219.92 69 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/50M 208.850 48713336_1 CDM 0278 RC inpatient 1768 1149.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1379.04 78 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/50M 208.850 48713336_1 CDM 0278 RC inpatient 1768 1149.2 UMR - ALL PLANS UMR - ALL PLANS 1237.6 70 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/50M 208.850 48713336_1 CDM 0278 RC inpatient 1768 1149.2 SIHO - ALL PLANS SIHO - ALL PLANS 1591.2 90 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/50M 208.850 48713336_1 CDM 0278 RC inpatient 1768 1149.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1070.52 60.55 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/50M 208.850 48713336_1 CDM 0278 RC inpatient 1768 1149.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1070.52 1714.96 SCREW CAN 7.3 16M/50M 208.850 48713336_1 CDM 0278 RC inpatient 1768 1149.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1070.52 1714.96 SCREW CAN 7.3 16M/50M 208.850 48713336_1 CDM 0278 RC inpatient 1768 1149.2 ANTHEM HMO ANTHEM HMO 999999999 1070.52 1714.96 SCREW CAN 7.3 16M/50M 208.850 48713336_1 CDM 0278 RC inpatient 1768 1149.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1195.17 67.6 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/50M 208.850 48713336_1 CDM 0278 RC inpatient 1768 1149.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1070.52 1714.96 SCREW CAN 7.3 16M/50M 208.850 48713336_1 CDM 0278 RC inpatient 1768 1149.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1070.52 1714.96 4.0 CANN SCREW 20MM 207.720 48713337_1 CDM 0278 RC inpatient 963 625.95 AETNA AETNA 760.77 79 999999999 583.1 934.11 percent of total billed charges 4.0 CANN SCREW 20MM 207.720 48713337_1 CDM 0278 RC inpatient 963 625.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 625.95 65 999999999 583.1 934.11 percent of total billed charges 4.0 CANN SCREW 20MM 207.720 48713337_1 CDM 0278 RC inpatient 963 625.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 934.11 97 999999999 583.1 934.11 percent of total billed charges 4.0 CANN SCREW 20MM 207.720 48713337_1 CDM 0278 RC inpatient 963 625.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 664.47 69 999999999 583.1 934.11 percent of total billed charges 4.0 CANN SCREW 20MM 207.720 48713337_1 CDM 0278 RC inpatient 963 625.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 751.14 78 999999999 583.1 934.11 percent of total billed charges 4.0 CANN SCREW 20MM 207.720 48713337_1 CDM 0278 RC inpatient 963 625.95 UMR - ALL PLANS UMR - ALL PLANS 674.1 70 999999999 583.1 934.11 percent of total billed charges 4.0 CANN SCREW 20MM 207.720 48713337_1 CDM 0278 RC inpatient 963 625.95 SIHO - ALL PLANS SIHO - ALL PLANS 866.7 90 999999999 583.1 934.11 percent of total billed charges 4.0 CANN SCREW 20MM 207.720 48713337_1 CDM 0278 RC inpatient 963 625.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 583.1 60.55 999999999 583.1 934.11 percent of total billed charges 4.0 CANN SCREW 20MM 207.720 48713337_1 CDM 0278 RC inpatient 963 625.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 583.1 934.11 4.0 CANN SCREW 20MM 207.720 48713337_1 CDM 0278 RC inpatient 963 625.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 583.1 934.11 4.0 CANN SCREW 20MM 207.720 48713337_1 CDM 0278 RC inpatient 963 625.95 ANTHEM HMO ANTHEM HMO 999999999 583.1 934.11 4.0 CANN SCREW 20MM 207.720 48713337_1 CDM 0278 RC inpatient 963 625.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 650.99 67.6 999999999 583.1 934.11 percent of total billed charges 4.0 CANN SCREW 20MM 207.720 48713337_1 CDM 0278 RC inpatient 963 625.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 583.1 934.11 4.0 CANN SCREW 20MM 207.720 48713337_1 CDM 0278 RC inpatient 963 625.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 583.1 934.11 4.0 CANN SCREW 24MM 207.724 48713338_1 CDM 0278 RC inpatient 894 581.1 AETNA AETNA 706.26 79 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 24MM 207.724 48713338_1 CDM 0278 RC inpatient 894 581.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 581.1 65 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 24MM 207.724 48713338_1 CDM 0278 RC inpatient 894 581.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 867.18 97 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 24MM 207.724 48713338_1 CDM 0278 RC inpatient 894 581.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 616.86 69 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 24MM 207.724 48713338_1 CDM 0278 RC inpatient 894 581.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 697.32 78 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 24MM 207.724 48713338_1 CDM 0278 RC inpatient 894 581.1 UMR - ALL PLANS UMR - ALL PLANS 625.8 70 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 24MM 207.724 48713338_1 CDM 0278 RC inpatient 894 581.1 SIHO - ALL PLANS SIHO - ALL PLANS 804.6 90 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 24MM 207.724 48713338_1 CDM 0278 RC inpatient 894 581.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 541.32 60.55 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 24MM 207.724 48713338_1 CDM 0278 RC inpatient 894 581.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 541.32 867.18 4.0 CANN SCREW 24MM 207.724 48713338_1 CDM 0278 RC inpatient 894 581.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 541.32 867.18 4.0 CANN SCREW 24MM 207.724 48713338_1 CDM 0278 RC inpatient 894 581.1 ANTHEM HMO ANTHEM HMO 999999999 541.32 867.18 4.0 CANN SCREW 24MM 207.724 48713338_1 CDM 0278 RC inpatient 894 581.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 604.34 67.6 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 24MM 207.724 48713338_1 CDM 0278 RC inpatient 894 581.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 541.32 867.18 4.0 CANN SCREW 24MM 207.724 48713338_1 CDM 0278 RC inpatient 894 581.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 541.32 867.18 4.0 CANN SCREW 28MM 207.728 48713339_1 CDM 0278 RC inpatient 1390 903.5 AETNA AETNA 1098.1 79 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 28MM 207.728 48713339_1 CDM 0278 RC inpatient 1390 903.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 903.5 65 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 28MM 207.728 48713339_1 CDM 0278 RC inpatient 1390 903.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1348.3 97 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 28MM 207.728 48713339_1 CDM 0278 RC inpatient 1390 903.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 959.1 69 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 28MM 207.728 48713339_1 CDM 0278 RC inpatient 1390 903.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1084.2 78 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 28MM 207.728 48713339_1 CDM 0278 RC inpatient 1390 903.5 UMR - ALL PLANS UMR - ALL PLANS 973 70 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 28MM 207.728 48713339_1 CDM 0278 RC inpatient 1390 903.5 SIHO - ALL PLANS SIHO - ALL PLANS 1251 90 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 28MM 207.728 48713339_1 CDM 0278 RC inpatient 1390 903.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 841.65 60.55 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 28MM 207.728 48713339_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 841.65 1348.3 4.0 CANN SCREW 28MM 207.728 48713339_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 841.65 1348.3 4.0 CANN SCREW 28MM 207.728 48713339_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM HMO ANTHEM HMO 999999999 841.65 1348.3 4.0 CANN SCREW 28MM 207.728 48713339_1 CDM 0278 RC inpatient 1390 903.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 939.64 67.6 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 28MM 207.728 48713339_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 841.65 1348.3 4.0 CANN SCREW 28MM 207.728 48713339_1 CDM 0278 RC inpatient 1390 903.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 841.65 1348.3 4.0 CANN SCREW 32MM 207.732 48713340_1 CDM 0278 RC inpatient 894 581.1 AETNA AETNA 706.26 79 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 32MM 207.732 48713340_1 CDM 0278 RC inpatient 894 581.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 581.1 65 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 32MM 207.732 48713340_1 CDM 0278 RC inpatient 894 581.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 867.18 97 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 32MM 207.732 48713340_1 CDM 0278 RC inpatient 894 581.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 616.86 69 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 32MM 207.732 48713340_1 CDM 0278 RC inpatient 894 581.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 697.32 78 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 32MM 207.732 48713340_1 CDM 0278 RC inpatient 894 581.1 UMR - ALL PLANS UMR - ALL PLANS 625.8 70 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 32MM 207.732 48713340_1 CDM 0278 RC inpatient 894 581.1 SIHO - ALL PLANS SIHO - ALL PLANS 804.6 90 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 32MM 207.732 48713340_1 CDM 0278 RC inpatient 894 581.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 541.32 60.55 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 32MM 207.732 48713340_1 CDM 0278 RC inpatient 894 581.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 541.32 867.18 4.0 CANN SCREW 32MM 207.732 48713340_1 CDM 0278 RC inpatient 894 581.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 541.32 867.18 4.0 CANN SCREW 32MM 207.732 48713340_1 CDM 0278 RC inpatient 894 581.1 ANTHEM HMO ANTHEM HMO 999999999 541.32 867.18 4.0 CANN SCREW 32MM 207.732 48713340_1 CDM 0278 RC inpatient 894 581.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 604.34 67.6 999999999 541.32 867.18 percent of total billed charges 4.0 CANN SCREW 32MM 207.732 48713340_1 CDM 0278 RC inpatient 894 581.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 541.32 867.18 4.0 CANN SCREW 32MM 207.732 48713340_1 CDM 0278 RC inpatient 894 581.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 541.32 867.18 4.0 CANN SCREW 34MM 207.734 48713341_1 CDM 0278 RC inpatient 1075 698.75 AETNA AETNA 849.25 79 999999999 650.91 1042.75 percent of total billed charges 4.0 CANN SCREW 34MM 207.734 48713341_1 CDM 0278 RC inpatient 1075 698.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 698.75 65 999999999 650.91 1042.75 percent of total billed charges 4.0 CANN SCREW 34MM 207.734 48713341_1 CDM 0278 RC inpatient 1075 698.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1042.75 97 999999999 650.91 1042.75 percent of total billed charges 4.0 CANN SCREW 34MM 207.734 48713341_1 CDM 0278 RC inpatient 1075 698.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 741.75 69 999999999 650.91 1042.75 percent of total billed charges 4.0 CANN SCREW 34MM 207.734 48713341_1 CDM 0278 RC inpatient 1075 698.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 838.5 78 999999999 650.91 1042.75 percent of total billed charges 4.0 CANN SCREW 34MM 207.734 48713341_1 CDM 0278 RC inpatient 1075 698.75 UMR - ALL PLANS UMR - ALL PLANS 752.5 70 999999999 650.91 1042.75 percent of total billed charges 4.0 CANN SCREW 34MM 207.734 48713341_1 CDM 0278 RC inpatient 1075 698.75 SIHO - ALL PLANS SIHO - ALL PLANS 967.5 90 999999999 650.91 1042.75 percent of total billed charges 4.0 CANN SCREW 34MM 207.734 48713341_1 CDM 0278 RC inpatient 1075 698.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 650.91 60.55 999999999 650.91 1042.75 percent of total billed charges 4.0 CANN SCREW 34MM 207.734 48713341_1 CDM 0278 RC inpatient 1075 698.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 650.91 1042.75 4.0 CANN SCREW 34MM 207.734 48713341_1 CDM 0278 RC inpatient 1075 698.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 650.91 1042.75 4.0 CANN SCREW 34MM 207.734 48713341_1 CDM 0278 RC inpatient 1075 698.75 ANTHEM HMO ANTHEM HMO 999999999 650.91 1042.75 4.0 CANN SCREW 34MM 207.734 48713341_1 CDM 0278 RC inpatient 1075 698.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 726.7 67.6 999999999 650.91 1042.75 percent of total billed charges 4.0 CANN SCREW 34MM 207.734 48713341_1 CDM 0278 RC inpatient 1075 698.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 650.91 1042.75 4.0 CANN SCREW 34MM 207.734 48713341_1 CDM 0278 RC inpatient 1075 698.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 650.91 1042.75 SCREW CAN 7.3 16M/55M 208.855 48713342_1 CDM 0278 RC inpatient 1768 1149.2 AETNA AETNA 1396.72 79 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/55M 208.855 48713342_1 CDM 0278 RC inpatient 1768 1149.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1149.2 65 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/55M 208.855 48713342_1 CDM 0278 RC inpatient 1768 1149.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1714.96 97 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/55M 208.855 48713342_1 CDM 0278 RC inpatient 1768 1149.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1219.92 69 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/55M 208.855 48713342_1 CDM 0278 RC inpatient 1768 1149.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1379.04 78 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/55M 208.855 48713342_1 CDM 0278 RC inpatient 1768 1149.2 UMR - ALL PLANS UMR - ALL PLANS 1237.6 70 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/55M 208.855 48713342_1 CDM 0278 RC inpatient 1768 1149.2 SIHO - ALL PLANS SIHO - ALL PLANS 1591.2 90 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/55M 208.855 48713342_1 CDM 0278 RC inpatient 1768 1149.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1070.52 60.55 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/55M 208.855 48713342_1 CDM 0278 RC inpatient 1768 1149.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1070.52 1714.96 SCREW CAN 7.3 16M/55M 208.855 48713342_1 CDM 0278 RC inpatient 1768 1149.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1070.52 1714.96 SCREW CAN 7.3 16M/55M 208.855 48713342_1 CDM 0278 RC inpatient 1768 1149.2 ANTHEM HMO ANTHEM HMO 999999999 1070.52 1714.96 SCREW CAN 7.3 16M/55M 208.855 48713342_1 CDM 0278 RC inpatient 1768 1149.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1195.17 67.6 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 16M/55M 208.855 48713342_1 CDM 0278 RC inpatient 1768 1149.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1070.52 1714.96 SCREW CAN 7.3 16M/55M 208.855 48713342_1 CDM 0278 RC inpatient 1768 1149.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1070.52 1714.96 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713343_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 AETNA AETNA 1034.9 79 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713343_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 851.5 65 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713343_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1270.7 97 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713343_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 903.9 69 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713343_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1021.8 78 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713343_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 UMR - ALL PLANS UMR - ALL PLANS 917 70 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713343_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 SIHO - ALL PLANS SIHO - ALL PLANS 1179 90 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713343_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 793.21 60.55 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713343_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 793.21 1270.7 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713343_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 793.21 1270.7 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713343_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ANTHEM HMO ANTHEM HMO 999999999 793.21 1270.7 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713343_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 885.56 67.6 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713343_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 793.21 1270.7 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713343_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 793.21 1270.7 TOOL LEGEND 14cm 3mm - 14MH30 48713344_1 CDM 0272 RC inpatient 944 613.6 AETNA AETNA 745.76 79 999999999 571.59 915.68 percent of total billed charges TOOL LEGEND 14cm 3mm - 14MH30 48713344_1 CDM 0272 RC inpatient 944 613.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 613.6 65 999999999 571.59 915.68 percent of total billed charges TOOL LEGEND 14cm 3mm - 14MH30 48713344_1 CDM 0272 RC inpatient 944 613.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 915.68 97 999999999 571.59 915.68 percent of total billed charges TOOL LEGEND 14cm 3mm - 14MH30 48713344_1 CDM 0272 RC inpatient 944 613.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 651.36 69 999999999 571.59 915.68 percent of total billed charges TOOL LEGEND 14cm 3mm - 14MH30 48713344_1 CDM 0272 RC inpatient 944 613.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 736.32 78 999999999 571.59 915.68 percent of total billed charges TOOL LEGEND 14cm 3mm - 14MH30 48713344_1 CDM 0272 RC inpatient 944 613.6 UMR - ALL PLANS UMR - ALL PLANS 660.8 70 999999999 571.59 915.68 percent of total billed charges TOOL LEGEND 14cm 3mm - 14MH30 48713344_1 CDM 0272 RC inpatient 944 613.6 SIHO - ALL PLANS SIHO - ALL PLANS 849.6 90 999999999 571.59 915.68 percent of total billed charges TOOL LEGEND 14cm 3mm - 14MH30 48713344_1 CDM 0272 RC inpatient 944 613.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 571.59 60.55 999999999 571.59 915.68 percent of total billed charges TOOL LEGEND 14cm 3mm - 14MH30 48713344_1 CDM 0272 RC inpatient 944 613.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 571.59 915.68 TOOL LEGEND 14cm 3mm - 14MH30 48713344_1 CDM 0272 RC inpatient 944 613.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 571.59 915.68 TOOL LEGEND 14cm 3mm - 14MH30 48713344_1 CDM 0272 RC inpatient 944 613.6 ANTHEM HMO ANTHEM HMO 999999999 571.59 915.68 TOOL LEGEND 14cm 3mm - 14MH30 48713344_1 CDM 0272 RC inpatient 944 613.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 638.14 67.6 999999999 571.59 915.68 percent of total billed charges TOOL LEGEND 14cm 3mm - 14MH30 48713344_1 CDM 0272 RC inpatient 944 613.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 571.59 915.68 TOOL LEGEND 14cm 3mm - 14MH30 48713344_1 CDM 0272 RC inpatient 944 613.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 571.59 915.68 DRILL BIT 317.867 48713345_1 CDM 0272 RC inpatient 648 421.2 AETNA AETNA 511.92 79 999999999 392.36 628.56 percent of total billed charges DRILL BIT 317.867 48713345_1 CDM 0272 RC inpatient 648 421.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 421.2 65 999999999 392.36 628.56 percent of total billed charges DRILL BIT 317.867 48713345_1 CDM 0272 RC inpatient 648 421.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 628.56 97 999999999 392.36 628.56 percent of total billed charges DRILL BIT 317.867 48713345_1 CDM 0272 RC inpatient 648 421.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 447.12 69 999999999 392.36 628.56 percent of total billed charges DRILL BIT 317.867 48713345_1 CDM 0272 RC inpatient 648 421.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 505.44 78 999999999 392.36 628.56 percent of total billed charges DRILL BIT 317.867 48713345_1 CDM 0272 RC inpatient 648 421.2 UMR - ALL PLANS UMR - ALL PLANS 453.6 70 999999999 392.36 628.56 percent of total billed charges DRILL BIT 317.867 48713345_1 CDM 0272 RC inpatient 648 421.2 SIHO - ALL PLANS SIHO - ALL PLANS 583.2 90 999999999 392.36 628.56 percent of total billed charges DRILL BIT 317.867 48713345_1 CDM 0272 RC inpatient 648 421.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 392.36 60.55 999999999 392.36 628.56 percent of total billed charges DRILL BIT 317.867 48713345_1 CDM 0272 RC inpatient 648 421.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 392.36 628.56 DRILL BIT 317.867 48713345_1 CDM 0272 RC inpatient 648 421.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 392.36 628.56 DRILL BIT 317.867 48713345_1 CDM 0272 RC inpatient 648 421.2 ANTHEM HMO ANTHEM HMO 999999999 392.36 628.56 DRILL BIT 317.867 48713345_1 CDM 0272 RC inpatient 648 421.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 438.05 67.6 999999999 392.36 628.56 percent of total billed charges DRILL BIT 317.867 48713345_1 CDM 0272 RC inpatient 648 421.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 392.36 628.56 DRILL BIT 317.867 48713345_1 CDM 0272 RC inpatient 648 421.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 392.36 628.56 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713346_1 CDM 0278 RC C1713 HCPCS inpatient 984 639.6 AETNA AETNA 777.36 79 999999999 595.81 954.48 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713346_1 CDM 0278 RC C1713 HCPCS inpatient 984 639.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 639.6 65 999999999 595.81 954.48 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713346_1 CDM 0278 RC C1713 HCPCS inpatient 984 639.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 954.48 97 999999999 595.81 954.48 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713346_1 CDM 0278 RC C1713 HCPCS inpatient 984 639.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 678.96 69 999999999 595.81 954.48 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713346_1 CDM 0278 RC C1713 HCPCS inpatient 984 639.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 767.52 78 999999999 595.81 954.48 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713346_1 CDM 0278 RC C1713 HCPCS inpatient 984 639.6 UMR - ALL PLANS UMR - ALL PLANS 688.8 70 999999999 595.81 954.48 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713346_1 CDM 0278 RC C1713 HCPCS inpatient 984 639.6 SIHO - ALL PLANS SIHO - ALL PLANS 885.6 90 999999999 595.81 954.48 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713346_1 CDM 0278 RC C1713 HCPCS inpatient 984 639.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 595.81 60.55 999999999 595.81 954.48 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713346_1 CDM 0278 RC C1713 HCPCS inpatient 984 639.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 595.81 954.48 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713346_1 CDM 0278 RC C1713 HCPCS inpatient 984 639.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 595.81 954.48 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713346_1 CDM 0278 RC C1713 HCPCS inpatient 984 639.6 ANTHEM HMO ANTHEM HMO 999999999 595.81 954.48 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713346_1 CDM 0278 RC C1713 HCPCS inpatient 984 639.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 665.18 67.6 999999999 595.81 954.48 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713346_1 CDM 0278 RC C1713 HCPCS inpatient 984 639.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 595.81 954.48 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713346_1 CDM 0278 RC C1713 HCPCS inpatient 984 639.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 595.81 954.48 4.5 CORTEX SHAFT 214.238 48713347_1 CDM 0278 RC inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.238 48713347_1 CDM 0278 RC inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.238 48713347_1 CDM 0278 RC inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.238 48713347_1 CDM 0278 RC inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.238 48713347_1 CDM 0278 RC inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.238 48713347_1 CDM 0278 RC inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.238 48713347_1 CDM 0278 RC inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.238 48713347_1 CDM 0278 RC inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.238 48713347_1 CDM 0278 RC inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.238 48713347_1 CDM 0278 RC inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.238 48713347_1 CDM 0278 RC inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.238 48713347_1 CDM 0278 RC inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.238 48713347_1 CDM 0278 RC inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.238 48713347_1 CDM 0278 RC inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.236 48713348_1 CDM 0278 RC inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.236 48713348_1 CDM 0278 RC inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.236 48713348_1 CDM 0278 RC inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.236 48713348_1 CDM 0278 RC inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.236 48713348_1 CDM 0278 RC inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.236 48713348_1 CDM 0278 RC inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.236 48713348_1 CDM 0278 RC inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.236 48713348_1 CDM 0278 RC inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.236 48713348_1 CDM 0278 RC inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.236 48713348_1 CDM 0278 RC inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.236 48713348_1 CDM 0278 RC inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.236 48713348_1 CDM 0278 RC inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.236 48713348_1 CDM 0278 RC inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.236 48713348_1 CDM 0278 RC inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.234 48713349_1 CDM 0278 RC inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.234 48713349_1 CDM 0278 RC inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.234 48713349_1 CDM 0278 RC inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.234 48713349_1 CDM 0278 RC inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.234 48713349_1 CDM 0278 RC inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.234 48713349_1 CDM 0278 RC inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.234 48713349_1 CDM 0278 RC inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.234 48713349_1 CDM 0278 RC inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.234 48713349_1 CDM 0278 RC inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.234 48713349_1 CDM 0278 RC inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.234 48713349_1 CDM 0278 RC inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.234 48713349_1 CDM 0278 RC inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.234 48713349_1 CDM 0278 RC inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.234 48713349_1 CDM 0278 RC inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.232 48713350_1 CDM 0278 RC inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.232 48713350_1 CDM 0278 RC inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.232 48713350_1 CDM 0278 RC inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.232 48713350_1 CDM 0278 RC inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.232 48713350_1 CDM 0278 RC inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.232 48713350_1 CDM 0278 RC inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.232 48713350_1 CDM 0278 RC inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.232 48713350_1 CDM 0278 RC inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.232 48713350_1 CDM 0278 RC inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.232 48713350_1 CDM 0278 RC inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.232 48713350_1 CDM 0278 RC inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.232 48713350_1 CDM 0278 RC inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.232 48713350_1 CDM 0278 RC inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.232 48713350_1 CDM 0278 RC inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.230 48713351_1 CDM 0278 RC inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.230 48713351_1 CDM 0278 RC inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.230 48713351_1 CDM 0278 RC inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.230 48713351_1 CDM 0278 RC inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.230 48713351_1 CDM 0278 RC inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.230 48713351_1 CDM 0278 RC inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.230 48713351_1 CDM 0278 RC inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.230 48713351_1 CDM 0278 RC inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.230 48713351_1 CDM 0278 RC inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.230 48713351_1 CDM 0278 RC inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.230 48713351_1 CDM 0278 RC inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.230 48713351_1 CDM 0278 RC inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.230 48713351_1 CDM 0278 RC inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.230 48713351_1 CDM 0278 RC inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.228 48713352_1 CDM 0278 RC inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.228 48713352_1 CDM 0278 RC inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.228 48713352_1 CDM 0278 RC inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.228 48713352_1 CDM 0278 RC inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.228 48713352_1 CDM 0278 RC inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.228 48713352_1 CDM 0278 RC inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.228 48713352_1 CDM 0278 RC inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.228 48713352_1 CDM 0278 RC inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.228 48713352_1 CDM 0278 RC inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.228 48713352_1 CDM 0278 RC inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.228 48713352_1 CDM 0278 RC inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.228 48713352_1 CDM 0278 RC inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.228 48713352_1 CDM 0278 RC inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.228 48713352_1 CDM 0278 RC inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.240 48713353_1 CDM 0278 RC inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.240 48713353_1 CDM 0278 RC inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.240 48713353_1 CDM 0278 RC inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.240 48713353_1 CDM 0278 RC inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.240 48713353_1 CDM 0278 RC inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.240 48713353_1 CDM 0278 RC inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.240 48713353_1 CDM 0278 RC inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.240 48713353_1 CDM 0278 RC inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.240 48713353_1 CDM 0278 RC inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.240 48713353_1 CDM 0278 RC inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.240 48713353_1 CDM 0278 RC inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.240 48713353_1 CDM 0278 RC inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges 4.5 CORTEX SHAFT 214.240 48713353_1 CDM 0278 RC inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.240 48713353_1 CDM 0278 RC inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 4.5 CORTEX SHAFT 214.242 48713354_1 CDM 0278 RC inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.242 48713354_1 CDM 0278 RC inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.242 48713354_1 CDM 0278 RC inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.242 48713354_1 CDM 0278 RC inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.242 48713354_1 CDM 0278 RC inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.242 48713354_1 CDM 0278 RC inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.242 48713354_1 CDM 0278 RC inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.242 48713354_1 CDM 0278 RC inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.242 48713354_1 CDM 0278 RC inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.242 48713354_1 CDM 0278 RC inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.242 48713354_1 CDM 0278 RC inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.242 48713354_1 CDM 0278 RC inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.242 48713354_1 CDM 0278 RC inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.242 48713354_1 CDM 0278 RC inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.244 48713355_1 CDM 0278 RC inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.244 48713355_1 CDM 0278 RC inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.244 48713355_1 CDM 0278 RC inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.244 48713355_1 CDM 0278 RC inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.244 48713355_1 CDM 0278 RC inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.244 48713355_1 CDM 0278 RC inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.244 48713355_1 CDM 0278 RC inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.244 48713355_1 CDM 0278 RC inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.244 48713355_1 CDM 0278 RC inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.244 48713355_1 CDM 0278 RC inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.244 48713355_1 CDM 0278 RC inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.244 48713355_1 CDM 0278 RC inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.244 48713355_1 CDM 0278 RC inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.244 48713355_1 CDM 0278 RC inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.246 48713356_1 CDM 0278 RC inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.246 48713356_1 CDM 0278 RC inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.246 48713356_1 CDM 0278 RC inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.246 48713356_1 CDM 0278 RC inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.246 48713356_1 CDM 0278 RC inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.246 48713356_1 CDM 0278 RC inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.246 48713356_1 CDM 0278 RC inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.246 48713356_1 CDM 0278 RC inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.246 48713356_1 CDM 0278 RC inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.246 48713356_1 CDM 0278 RC inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.246 48713356_1 CDM 0278 RC inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.246 48713356_1 CDM 0278 RC inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.246 48713356_1 CDM 0278 RC inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.246 48713356_1 CDM 0278 RC inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.248 48713357_1 CDM 0278 RC inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.248 48713357_1 CDM 0278 RC inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.248 48713357_1 CDM 0278 RC inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.248 48713357_1 CDM 0278 RC inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.248 48713357_1 CDM 0278 RC inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.248 48713357_1 CDM 0278 RC inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.248 48713357_1 CDM 0278 RC inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.248 48713357_1 CDM 0278 RC inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.248 48713357_1 CDM 0278 RC inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.248 48713357_1 CDM 0278 RC inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.248 48713357_1 CDM 0278 RC inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.248 48713357_1 CDM 0278 RC inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.248 48713357_1 CDM 0278 RC inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.248 48713357_1 CDM 0278 RC inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.250 48713358_1 CDM 0278 RC inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.250 48713358_1 CDM 0278 RC inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.250 48713358_1 CDM 0278 RC inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.250 48713358_1 CDM 0278 RC inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.250 48713358_1 CDM 0278 RC inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.250 48713358_1 CDM 0278 RC inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.250 48713358_1 CDM 0278 RC inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.250 48713358_1 CDM 0278 RC inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.250 48713358_1 CDM 0278 RC inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.250 48713358_1 CDM 0278 RC inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.250 48713358_1 CDM 0278 RC inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.250 48713358_1 CDM 0278 RC inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges 4.5 CORTEX SHAFT 214.250 48713358_1 CDM 0278 RC inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 4.5 CORTEX SHAFT 214.250 48713358_1 CDM 0278 RC inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 2.0MM DRILL BIT DHS 310.19 48713359_1 CDM 0272 RC inpatient 595 386.75 AETNA AETNA 470.05 79 999999999 360.27 577.15 percent of total billed charges 2.0MM DRILL BIT DHS 310.19 48713359_1 CDM 0272 RC inpatient 595 386.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 386.75 65 999999999 360.27 577.15 percent of total billed charges 2.0MM DRILL BIT DHS 310.19 48713359_1 CDM 0272 RC inpatient 595 386.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 577.15 97 999999999 360.27 577.15 percent of total billed charges 2.0MM DRILL BIT DHS 310.19 48713359_1 CDM 0272 RC inpatient 595 386.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 410.55 69 999999999 360.27 577.15 percent of total billed charges 2.0MM DRILL BIT DHS 310.19 48713359_1 CDM 0272 RC inpatient 595 386.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 464.1 78 999999999 360.27 577.15 percent of total billed charges 2.0MM DRILL BIT DHS 310.19 48713359_1 CDM 0272 RC inpatient 595 386.75 UMR - ALL PLANS UMR - ALL PLANS 416.5 70 999999999 360.27 577.15 percent of total billed charges 2.0MM DRILL BIT DHS 310.19 48713359_1 CDM 0272 RC inpatient 595 386.75 SIHO - ALL PLANS SIHO - ALL PLANS 535.5 90 999999999 360.27 577.15 percent of total billed charges 2.0MM DRILL BIT DHS 310.19 48713359_1 CDM 0272 RC inpatient 595 386.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 360.27 60.55 999999999 360.27 577.15 percent of total billed charges 2.0MM DRILL BIT DHS 310.19 48713359_1 CDM 0272 RC inpatient 595 386.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 360.27 577.15 2.0MM DRILL BIT DHS 310.19 48713359_1 CDM 0272 RC inpatient 595 386.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 360.27 577.15 2.0MM DRILL BIT DHS 310.19 48713359_1 CDM 0272 RC inpatient 595 386.75 ANTHEM HMO ANTHEM HMO 999999999 360.27 577.15 2.0MM DRILL BIT DHS 310.19 48713359_1 CDM 0272 RC inpatient 595 386.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 402.22 67.6 999999999 360.27 577.15 percent of total billed charges 2.0MM DRILL BIT DHS 310.19 48713359_1 CDM 0272 RC inpatient 595 386.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 360.27 577.15 2.0MM DRILL BIT DHS 310.19 48713359_1 CDM 0272 RC inpatient 595 386.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 360.27 577.15 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713360_1 CDM 0278 RC C1713 HCPCS inpatient 1528 993.2 AETNA AETNA 1207.12 79 999999999 925.2 1482.16 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713360_1 CDM 0278 RC C1713 HCPCS inpatient 1528 993.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 993.2 65 999999999 925.2 1482.16 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713360_1 CDM 0278 RC C1713 HCPCS inpatient 1528 993.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1482.16 97 999999999 925.2 1482.16 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713360_1 CDM 0278 RC C1713 HCPCS inpatient 1528 993.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1054.32 69 999999999 925.2 1482.16 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713360_1 CDM 0278 RC C1713 HCPCS inpatient 1528 993.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1191.84 78 999999999 925.2 1482.16 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713360_1 CDM 0278 RC C1713 HCPCS inpatient 1528 993.2 UMR - ALL PLANS UMR - ALL PLANS 1069.6 70 999999999 925.2 1482.16 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713360_1 CDM 0278 RC C1713 HCPCS inpatient 1528 993.2 SIHO - ALL PLANS SIHO - ALL PLANS 1375.2 90 999999999 925.2 1482.16 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713360_1 CDM 0278 RC C1713 HCPCS inpatient 1528 993.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 925.2 60.55 999999999 925.2 1482.16 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713360_1 CDM 0278 RC C1713 HCPCS inpatient 1528 993.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 925.2 1482.16 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713360_1 CDM 0278 RC C1713 HCPCS inpatient 1528 993.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 925.2 1482.16 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713360_1 CDM 0278 RC C1713 HCPCS inpatient 1528 993.2 ANTHEM HMO ANTHEM HMO 999999999 925.2 1482.16 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713360_1 CDM 0278 RC C1713 HCPCS inpatient 1528 993.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1032.93 67.6 999999999 925.2 1482.16 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713360_1 CDM 0278 RC C1713 HCPCS inpatient 1528 993.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 925.2 1482.16 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713360_1 CDM 0278 RC C1713 HCPCS inpatient 1528 993.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 925.2 1482.16 4.5MM DRILL BIT DHS 310.44 48713361_1 CDM 0278 RC inpatient 499 324.35 AETNA AETNA 394.21 79 999999999 302.14 484.03 percent of total billed charges 4.5MM DRILL BIT DHS 310.44 48713361_1 CDM 0278 RC inpatient 499 324.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 324.35 65 999999999 302.14 484.03 percent of total billed charges 4.5MM DRILL BIT DHS 310.44 48713361_1 CDM 0278 RC inpatient 499 324.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 484.03 97 999999999 302.14 484.03 percent of total billed charges 4.5MM DRILL BIT DHS 310.44 48713361_1 CDM 0278 RC inpatient 499 324.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 344.31 69 999999999 302.14 484.03 percent of total billed charges 4.5MM DRILL BIT DHS 310.44 48713361_1 CDM 0278 RC inpatient 499 324.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 389.22 78 999999999 302.14 484.03 percent of total billed charges 4.5MM DRILL BIT DHS 310.44 48713361_1 CDM 0278 RC inpatient 499 324.35 UMR - ALL PLANS UMR - ALL PLANS 349.3 70 999999999 302.14 484.03 percent of total billed charges 4.5MM DRILL BIT DHS 310.44 48713361_1 CDM 0278 RC inpatient 499 324.35 SIHO - ALL PLANS SIHO - ALL PLANS 449.1 90 999999999 302.14 484.03 percent of total billed charges 4.5MM DRILL BIT DHS 310.44 48713361_1 CDM 0278 RC inpatient 499 324.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 302.14 60.55 999999999 302.14 484.03 percent of total billed charges 4.5MM DRILL BIT DHS 310.44 48713361_1 CDM 0278 RC inpatient 499 324.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 302.14 484.03 4.5MM DRILL BIT DHS 310.44 48713361_1 CDM 0278 RC inpatient 499 324.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 302.14 484.03 4.5MM DRILL BIT DHS 310.44 48713361_1 CDM 0278 RC inpatient 499 324.35 ANTHEM HMO ANTHEM HMO 999999999 302.14 484.03 4.5MM DRILL BIT DHS 310.44 48713361_1 CDM 0278 RC inpatient 499 324.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 337.32 67.6 999999999 302.14 484.03 percent of total billed charges 4.5MM DRILL BIT DHS 310.44 48713361_1 CDM 0278 RC inpatient 499 324.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 302.14 484.03 4.5MM DRILL BIT DHS 310.44 48713361_1 CDM 0278 RC inpatient 499 324.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 302.14 484.03 4.5MM DRILL BIT 310.45 48713362_1 CDM 0278 RC inpatient 295 191.75 AETNA AETNA 233.05 79 999999999 178.62 286.15 percent of total billed charges 4.5MM DRILL BIT 310.45 48713362_1 CDM 0278 RC inpatient 295 191.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 191.75 65 999999999 178.62 286.15 percent of total billed charges 4.5MM DRILL BIT 310.45 48713362_1 CDM 0278 RC inpatient 295 191.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 286.15 97 999999999 178.62 286.15 percent of total billed charges 4.5MM DRILL BIT 310.45 48713362_1 CDM 0278 RC inpatient 295 191.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 203.55 69 999999999 178.62 286.15 percent of total billed charges 4.5MM DRILL BIT 310.45 48713362_1 CDM 0278 RC inpatient 295 191.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 230.1 78 999999999 178.62 286.15 percent of total billed charges 4.5MM DRILL BIT 310.45 48713362_1 CDM 0278 RC inpatient 295 191.75 UMR - ALL PLANS UMR - ALL PLANS 206.5 70 999999999 178.62 286.15 percent of total billed charges 4.5MM DRILL BIT 310.45 48713362_1 CDM 0278 RC inpatient 295 191.75 SIHO - ALL PLANS SIHO - ALL PLANS 265.5 90 999999999 178.62 286.15 percent of total billed charges 4.5MM DRILL BIT 310.45 48713362_1 CDM 0278 RC inpatient 295 191.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 178.62 60.55 999999999 178.62 286.15 percent of total billed charges 4.5MM DRILL BIT 310.45 48713362_1 CDM 0278 RC inpatient 295 191.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 178.62 286.15 4.5MM DRILL BIT 310.45 48713362_1 CDM 0278 RC inpatient 295 191.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 178.62 286.15 4.5MM DRILL BIT 310.45 48713362_1 CDM 0278 RC inpatient 295 191.75 ANTHEM HMO ANTHEM HMO 999999999 178.62 286.15 4.5MM DRILL BIT 310.45 48713362_1 CDM 0278 RC inpatient 295 191.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 199.42 67.6 999999999 178.62 286.15 percent of total billed charges 4.5MM DRILL BIT 310.45 48713362_1 CDM 0278 RC inpatient 295 191.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 178.62 286.15 4.5MM DRILL BIT 310.45 48713362_1 CDM 0278 RC inpatient 295 191.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 178.62 286.15 2.0MM DRILL BIT 310.20 48713363_1 CDM 0278 RC inpatient 427 277.55 AETNA AETNA 337.33 79 999999999 258.55 414.19 percent of total billed charges 2.0MM DRILL BIT 310.20 48713363_1 CDM 0278 RC inpatient 427 277.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 277.55 65 999999999 258.55 414.19 percent of total billed charges 2.0MM DRILL BIT 310.20 48713363_1 CDM 0278 RC inpatient 427 277.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 414.19 97 999999999 258.55 414.19 percent of total billed charges 2.0MM DRILL BIT 310.20 48713363_1 CDM 0278 RC inpatient 427 277.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 294.63 69 999999999 258.55 414.19 percent of total billed charges 2.0MM DRILL BIT 310.20 48713363_1 CDM 0278 RC inpatient 427 277.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.06 78 999999999 258.55 414.19 percent of total billed charges 2.0MM DRILL BIT 310.20 48713363_1 CDM 0278 RC inpatient 427 277.55 UMR - ALL PLANS UMR - ALL PLANS 298.9 70 999999999 258.55 414.19 percent of total billed charges 2.0MM DRILL BIT 310.20 48713363_1 CDM 0278 RC inpatient 427 277.55 SIHO - ALL PLANS SIHO - ALL PLANS 384.3 90 999999999 258.55 414.19 percent of total billed charges 2.0MM DRILL BIT 310.20 48713363_1 CDM 0278 RC inpatient 427 277.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 258.55 60.55 999999999 258.55 414.19 percent of total billed charges 2.0MM DRILL BIT 310.20 48713363_1 CDM 0278 RC inpatient 427 277.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 258.55 414.19 2.0MM DRILL BIT 310.20 48713363_1 CDM 0278 RC inpatient 427 277.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 258.55 414.19 2.0MM DRILL BIT 310.20 48713363_1 CDM 0278 RC inpatient 427 277.55 ANTHEM HMO ANTHEM HMO 999999999 258.55 414.19 2.0MM DRILL BIT 310.20 48713363_1 CDM 0278 RC inpatient 427 277.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 288.65 67.6 999999999 258.55 414.19 percent of total billed charges 2.0MM DRILL BIT 310.20 48713363_1 CDM 0278 RC inpatient 427 277.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 258.55 414.19 2.0MM DRILL BIT 310.20 48713363_1 CDM 0278 RC inpatient 427 277.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 258.55 414.19 TAP 4.5 CORTEX DHS 311.46 48713364_1 CDM 0278 RC inpatient 732 475.8 AETNA AETNA 578.28 79 999999999 443.23 710.04 percent of total billed charges TAP 4.5 CORTEX DHS 311.46 48713364_1 CDM 0278 RC inpatient 732 475.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 475.8 65 999999999 443.23 710.04 percent of total billed charges TAP 4.5 CORTEX DHS 311.46 48713364_1 CDM 0278 RC inpatient 732 475.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 710.04 97 999999999 443.23 710.04 percent of total billed charges TAP 4.5 CORTEX DHS 311.46 48713364_1 CDM 0278 RC inpatient 732 475.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 505.08 69 999999999 443.23 710.04 percent of total billed charges TAP 4.5 CORTEX DHS 311.46 48713364_1 CDM 0278 RC inpatient 732 475.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 570.96 78 999999999 443.23 710.04 percent of total billed charges TAP 4.5 CORTEX DHS 311.46 48713364_1 CDM 0278 RC inpatient 732 475.8 UMR - ALL PLANS UMR - ALL PLANS 512.4 70 999999999 443.23 710.04 percent of total billed charges TAP 4.5 CORTEX DHS 311.46 48713364_1 CDM 0278 RC inpatient 732 475.8 SIHO - ALL PLANS SIHO - ALL PLANS 658.8 90 999999999 443.23 710.04 percent of total billed charges TAP 4.5 CORTEX DHS 311.46 48713364_1 CDM 0278 RC inpatient 732 475.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 443.23 60.55 999999999 443.23 710.04 percent of total billed charges TAP 4.5 CORTEX DHS 311.46 48713364_1 CDM 0278 RC inpatient 732 475.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 443.23 710.04 TAP 4.5 CORTEX DHS 311.46 48713364_1 CDM 0278 RC inpatient 732 475.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 443.23 710.04 TAP 4.5 CORTEX DHS 311.46 48713364_1 CDM 0278 RC inpatient 732 475.8 ANTHEM HMO ANTHEM HMO 999999999 443.23 710.04 TAP 4.5 CORTEX DHS 311.46 48713364_1 CDM 0278 RC inpatient 732 475.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 494.83 67.6 999999999 443.23 710.04 percent of total billed charges TAP 4.5 CORTEX DHS 311.46 48713364_1 CDM 0278 RC inpatient 732 475.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 443.23 710.04 TAP 4.5 CORTEX DHS 311.46 48713364_1 CDM 0278 RC inpatient 732 475.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 443.23 710.04 PLATE LC-DCP 4.5MM 226.61 48713365_1 CDM 0278 RC inpatient 1111 722.15 AETNA AETNA 877.69 79 999999999 672.71 1077.67 percent of total billed charges PLATE LC-DCP 4.5MM 226.61 48713365_1 CDM 0278 RC inpatient 1111 722.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 722.15 65 999999999 672.71 1077.67 percent of total billed charges PLATE LC-DCP 4.5MM 226.61 48713365_1 CDM 0278 RC inpatient 1111 722.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1077.67 97 999999999 672.71 1077.67 percent of total billed charges PLATE LC-DCP 4.5MM 226.61 48713365_1 CDM 0278 RC inpatient 1111 722.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 766.59 69 999999999 672.71 1077.67 percent of total billed charges PLATE LC-DCP 4.5MM 226.61 48713365_1 CDM 0278 RC inpatient 1111 722.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 866.58 78 999999999 672.71 1077.67 percent of total billed charges PLATE LC-DCP 4.5MM 226.61 48713365_1 CDM 0278 RC inpatient 1111 722.15 UMR - ALL PLANS UMR - ALL PLANS 777.7 70 999999999 672.71 1077.67 percent of total billed charges PLATE LC-DCP 4.5MM 226.61 48713365_1 CDM 0278 RC inpatient 1111 722.15 SIHO - ALL PLANS SIHO - ALL PLANS 999.9 90 999999999 672.71 1077.67 percent of total billed charges PLATE LC-DCP 4.5MM 226.61 48713365_1 CDM 0278 RC inpatient 1111 722.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 672.71 60.55 999999999 672.71 1077.67 percent of total billed charges PLATE LC-DCP 4.5MM 226.61 48713365_1 CDM 0278 RC inpatient 1111 722.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 672.71 1077.67 PLATE LC-DCP 4.5MM 226.61 48713365_1 CDM 0278 RC inpatient 1111 722.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 672.71 1077.67 PLATE LC-DCP 4.5MM 226.61 48713365_1 CDM 0278 RC inpatient 1111 722.15 ANTHEM HMO ANTHEM HMO 999999999 672.71 1077.67 PLATE LC-DCP 4.5MM 226.61 48713365_1 CDM 0278 RC inpatient 1111 722.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 751.04 67.6 999999999 672.71 1077.67 percent of total billed charges PLATE LC-DCP 4.5MM 226.61 48713365_1 CDM 0278 RC inpatient 1111 722.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 672.71 1077.67 PLATE LC-DCP 4.5MM 226.61 48713365_1 CDM 0278 RC inpatient 1111 722.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 672.71 1077.67 PLATE 4.5 NAR LC-DCP 224.61 48713366_1 CDM 0278 RC inpatient 852 553.8 AETNA AETNA 673.08 79 999999999 515.89 826.44 percent of total billed charges PLATE 4.5 NAR LC-DCP 224.61 48713366_1 CDM 0278 RC inpatient 852 553.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 553.8 65 999999999 515.89 826.44 percent of total billed charges PLATE 4.5 NAR LC-DCP 224.61 48713366_1 CDM 0278 RC inpatient 852 553.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 826.44 97 999999999 515.89 826.44 percent of total billed charges PLATE 4.5 NAR LC-DCP 224.61 48713366_1 CDM 0278 RC inpatient 852 553.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 587.88 69 999999999 515.89 826.44 percent of total billed charges PLATE 4.5 NAR LC-DCP 224.61 48713366_1 CDM 0278 RC inpatient 852 553.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 664.56 78 999999999 515.89 826.44 percent of total billed charges PLATE 4.5 NAR LC-DCP 224.61 48713366_1 CDM 0278 RC inpatient 852 553.8 UMR - ALL PLANS UMR - ALL PLANS 596.4 70 999999999 515.89 826.44 percent of total billed charges PLATE 4.5 NAR LC-DCP 224.61 48713366_1 CDM 0278 RC inpatient 852 553.8 SIHO - ALL PLANS SIHO - ALL PLANS 766.8 90 999999999 515.89 826.44 percent of total billed charges PLATE 4.5 NAR LC-DCP 224.61 48713366_1 CDM 0278 RC inpatient 852 553.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 515.89 60.55 999999999 515.89 826.44 percent of total billed charges PLATE 4.5 NAR LC-DCP 224.61 48713366_1 CDM 0278 RC inpatient 852 553.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 515.89 826.44 PLATE 4.5 NAR LC-DCP 224.61 48713366_1 CDM 0278 RC inpatient 852 553.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 515.89 826.44 PLATE 4.5 NAR LC-DCP 224.61 48713366_1 CDM 0278 RC inpatient 852 553.8 ANTHEM HMO ANTHEM HMO 999999999 515.89 826.44 PLATE 4.5 NAR LC-DCP 224.61 48713366_1 CDM 0278 RC inpatient 852 553.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 575.95 67.6 999999999 515.89 826.44 percent of total billed charges PLATE 4.5 NAR LC-DCP 224.61 48713366_1 CDM 0278 RC inpatient 852 553.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 515.89 826.44 PLATE 4.5 NAR LC-DCP 224.61 48713366_1 CDM 0278 RC inpatient 852 553.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 515.89 826.44 TAP FOR DHS/DCS 12.5MM 338.17 48713367_1 CDM 0278 RC inpatient 2253 1464.45 AETNA AETNA 1779.87 79 999999999 1364.19 2185.41 percent of total billed charges TAP FOR DHS/DCS 12.5MM 338.17 48713367_1 CDM 0278 RC inpatient 2253 1464.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1464.45 65 999999999 1364.19 2185.41 percent of total billed charges TAP FOR DHS/DCS 12.5MM 338.17 48713367_1 CDM 0278 RC inpatient 2253 1464.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2185.41 97 999999999 1364.19 2185.41 percent of total billed charges TAP FOR DHS/DCS 12.5MM 338.17 48713367_1 CDM 0278 RC inpatient 2253 1464.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1554.57 69 999999999 1364.19 2185.41 percent of total billed charges TAP FOR DHS/DCS 12.5MM 338.17 48713367_1 CDM 0278 RC inpatient 2253 1464.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1757.34 78 999999999 1364.19 2185.41 percent of total billed charges TAP FOR DHS/DCS 12.5MM 338.17 48713367_1 CDM 0278 RC inpatient 2253 1464.45 UMR - ALL PLANS UMR - ALL PLANS 1577.1 70 999999999 1364.19 2185.41 percent of total billed charges TAP FOR DHS/DCS 12.5MM 338.17 48713367_1 CDM 0278 RC inpatient 2253 1464.45 SIHO - ALL PLANS SIHO - ALL PLANS 2027.7 90 999999999 1364.19 2185.41 percent of total billed charges TAP FOR DHS/DCS 12.5MM 338.17 48713367_1 CDM 0278 RC inpatient 2253 1464.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1364.19 60.55 999999999 1364.19 2185.41 percent of total billed charges TAP FOR DHS/DCS 12.5MM 338.17 48713367_1 CDM 0278 RC inpatient 2253 1464.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1364.19 2185.41 TAP FOR DHS/DCS 12.5MM 338.17 48713367_1 CDM 0278 RC inpatient 2253 1464.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1364.19 2185.41 TAP FOR DHS/DCS 12.5MM 338.17 48713367_1 CDM 0278 RC inpatient 2253 1464.45 ANTHEM HMO ANTHEM HMO 999999999 1364.19 2185.41 TAP FOR DHS/DCS 12.5MM 338.17 48713367_1 CDM 0278 RC inpatient 2253 1464.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1523.03 67.6 999999999 1364.19 2185.41 percent of total billed charges TAP FOR DHS/DCS 12.5MM 338.17 48713367_1 CDM 0278 RC inpatient 2253 1464.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1364.19 2185.41 TAP FOR DHS/DCS 12.5MM 338.17 48713367_1 CDM 0278 RC inpatient 2253 1464.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1364.19 2185.41 SCREW CAN 7.3 16M/65M 208.865 48713368_1 CDM 0278 RC inpatient 1739 1130.35 AETNA AETNA 1373.81 79 999999999 1052.96 1686.83 percent of total billed charges SCREW CAN 7.3 16M/65M 208.865 48713368_1 CDM 0278 RC inpatient 1739 1130.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1130.35 65 999999999 1052.96 1686.83 percent of total billed charges SCREW CAN 7.3 16M/65M 208.865 48713368_1 CDM 0278 RC inpatient 1739 1130.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1686.83 97 999999999 1052.96 1686.83 percent of total billed charges SCREW CAN 7.3 16M/65M 208.865 48713368_1 CDM 0278 RC inpatient 1739 1130.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1199.91 69 999999999 1052.96 1686.83 percent of total billed charges SCREW CAN 7.3 16M/65M 208.865 48713368_1 CDM 0278 RC inpatient 1739 1130.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1356.42 78 999999999 1052.96 1686.83 percent of total billed charges SCREW CAN 7.3 16M/65M 208.865 48713368_1 CDM 0278 RC inpatient 1739 1130.35 UMR - ALL PLANS UMR - ALL PLANS 1217.3 70 999999999 1052.96 1686.83 percent of total billed charges SCREW CAN 7.3 16M/65M 208.865 48713368_1 CDM 0278 RC inpatient 1739 1130.35 SIHO - ALL PLANS SIHO - ALL PLANS 1565.1 90 999999999 1052.96 1686.83 percent of total billed charges SCREW CAN 7.3 16M/65M 208.865 48713368_1 CDM 0278 RC inpatient 1739 1130.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1052.96 60.55 999999999 1052.96 1686.83 percent of total billed charges SCREW CAN 7.3 16M/65M 208.865 48713368_1 CDM 0278 RC inpatient 1739 1130.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1052.96 1686.83 SCREW CAN 7.3 16M/65M 208.865 48713368_1 CDM 0278 RC inpatient 1739 1130.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1052.96 1686.83 SCREW CAN 7.3 16M/65M 208.865 48713368_1 CDM 0278 RC inpatient 1739 1130.35 ANTHEM HMO ANTHEM HMO 999999999 1052.96 1686.83 SCREW CAN 7.3 16M/65M 208.865 48713368_1 CDM 0278 RC inpatient 1739 1130.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1175.56 67.6 999999999 1052.96 1686.83 percent of total billed charges SCREW CAN 7.3 16M/65M 208.865 48713368_1 CDM 0278 RC inpatient 1739 1130.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1052.96 1686.83 SCREW CAN 7.3 16M/65M 208.865 48713368_1 CDM 0278 RC inpatient 1739 1130.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1052.96 1686.83 DRILL BIT 1.5M J-LATCH 310.143 48713369_1 CDM 0278 RC inpatient 578 375.7 AETNA AETNA 456.62 79 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.5M J-LATCH 310.143 48713369_1 CDM 0278 RC inpatient 578 375.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 375.7 65 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.5M J-LATCH 310.143 48713369_1 CDM 0278 RC inpatient 578 375.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 560.66 97 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.5M J-LATCH 310.143 48713369_1 CDM 0278 RC inpatient 578 375.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 398.82 69 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.5M J-LATCH 310.143 48713369_1 CDM 0278 RC inpatient 578 375.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 450.84 78 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.5M J-LATCH 310.143 48713369_1 CDM 0278 RC inpatient 578 375.7 UMR - ALL PLANS UMR - ALL PLANS 404.6 70 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.5M J-LATCH 310.143 48713369_1 CDM 0278 RC inpatient 578 375.7 SIHO - ALL PLANS SIHO - ALL PLANS 520.2 90 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.5M J-LATCH 310.143 48713369_1 CDM 0278 RC inpatient 578 375.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 349.98 60.55 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.5M J-LATCH 310.143 48713369_1 CDM 0278 RC inpatient 578 375.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 349.98 560.66 DRILL BIT 1.5M J-LATCH 310.143 48713369_1 CDM 0278 RC inpatient 578 375.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 349.98 560.66 DRILL BIT 1.5M J-LATCH 310.143 48713369_1 CDM 0278 RC inpatient 578 375.7 ANTHEM HMO ANTHEM HMO 999999999 349.98 560.66 DRILL BIT 1.5M J-LATCH 310.143 48713369_1 CDM 0278 RC inpatient 578 375.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 390.73 67.6 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.5M J-LATCH 310.143 48713369_1 CDM 0278 RC inpatient 578 375.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 349.98 560.66 DRILL BIT 1.5M J-LATCH 310.143 48713369_1 CDM 0278 RC inpatient 578 375.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 349.98 560.66 DRILL BIT 2.0M J-LATCH 310.203 48713370_1 CDM 0278 RC inpatient 483 313.95 AETNA AETNA 381.57 79 999999999 292.46 468.51 percent of total billed charges DRILL BIT 2.0M J-LATCH 310.203 48713370_1 CDM 0278 RC inpatient 483 313.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 313.95 65 999999999 292.46 468.51 percent of total billed charges DRILL BIT 2.0M J-LATCH 310.203 48713370_1 CDM 0278 RC inpatient 483 313.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 468.51 97 999999999 292.46 468.51 percent of total billed charges DRILL BIT 2.0M J-LATCH 310.203 48713370_1 CDM 0278 RC inpatient 483 313.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 333.27 69 999999999 292.46 468.51 percent of total billed charges DRILL BIT 2.0M J-LATCH 310.203 48713370_1 CDM 0278 RC inpatient 483 313.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 376.74 78 999999999 292.46 468.51 percent of total billed charges DRILL BIT 2.0M J-LATCH 310.203 48713370_1 CDM 0278 RC inpatient 483 313.95 UMR - ALL PLANS UMR - ALL PLANS 338.1 70 999999999 292.46 468.51 percent of total billed charges DRILL BIT 2.0M J-LATCH 310.203 48713370_1 CDM 0278 RC inpatient 483 313.95 SIHO - ALL PLANS SIHO - ALL PLANS 434.7 90 999999999 292.46 468.51 percent of total billed charges DRILL BIT 2.0M J-LATCH 310.203 48713370_1 CDM 0278 RC inpatient 483 313.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 292.46 60.55 999999999 292.46 468.51 percent of total billed charges DRILL BIT 2.0M J-LATCH 310.203 48713370_1 CDM 0278 RC inpatient 483 313.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 292.46 468.51 DRILL BIT 2.0M J-LATCH 310.203 48713370_1 CDM 0278 RC inpatient 483 313.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 292.46 468.51 DRILL BIT 2.0M J-LATCH 310.203 48713370_1 CDM 0278 RC inpatient 483 313.95 ANTHEM HMO ANTHEM HMO 999999999 292.46 468.51 DRILL BIT 2.0M J-LATCH 310.203 48713370_1 CDM 0278 RC inpatient 483 313.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 326.51 67.6 999999999 292.46 468.51 percent of total billed charges DRILL BIT 2.0M J-LATCH 310.203 48713370_1 CDM 0278 RC inpatient 483 313.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 292.46 468.51 DRILL BIT 2.0M J-LATCH 310.203 48713370_1 CDM 0278 RC inpatient 483 313.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 292.46 468.51 COUNTERSINK 310.86 48713371_1 CDM 0278 RC inpatient 2474 1608.1 AETNA AETNA 1954.46 79 999999999 1498.01 2399.78 percent of total billed charges COUNTERSINK 310.86 48713371_1 CDM 0278 RC inpatient 2474 1608.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1608.1 65 999999999 1498.01 2399.78 percent of total billed charges COUNTERSINK 310.86 48713371_1 CDM 0278 RC inpatient 2474 1608.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2399.78 97 999999999 1498.01 2399.78 percent of total billed charges COUNTERSINK 310.86 48713371_1 CDM 0278 RC inpatient 2474 1608.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 1707.06 69 999999999 1498.01 2399.78 percent of total billed charges COUNTERSINK 310.86 48713371_1 CDM 0278 RC inpatient 2474 1608.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1929.72 78 999999999 1498.01 2399.78 percent of total billed charges COUNTERSINK 310.86 48713371_1 CDM 0278 RC inpatient 2474 1608.1 UMR - ALL PLANS UMR - ALL PLANS 1731.8 70 999999999 1498.01 2399.78 percent of total billed charges COUNTERSINK 310.86 48713371_1 CDM 0278 RC inpatient 2474 1608.1 SIHO - ALL PLANS SIHO - ALL PLANS 2226.6 90 999999999 1498.01 2399.78 percent of total billed charges COUNTERSINK 310.86 48713371_1 CDM 0278 RC inpatient 2474 1608.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1498.01 60.55 999999999 1498.01 2399.78 percent of total billed charges COUNTERSINK 310.86 48713371_1 CDM 0278 RC inpatient 2474 1608.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1498.01 2399.78 COUNTERSINK 310.86 48713371_1 CDM 0278 RC inpatient 2474 1608.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1498.01 2399.78 COUNTERSINK 310.86 48713371_1 CDM 0278 RC inpatient 2474 1608.1 ANTHEM HMO ANTHEM HMO 999999999 1498.01 2399.78 COUNTERSINK 310.86 48713371_1 CDM 0278 RC inpatient 2474 1608.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1672.42 67.6 999999999 1498.01 2399.78 percent of total billed charges COUNTERSINK 310.86 48713371_1 CDM 0278 RC inpatient 2474 1608.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1498.01 2399.78 COUNTERSINK 310.86 48713371_1 CDM 0278 RC inpatient 2474 1608.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1498.01 2399.78 DRILL BIT 314.465 48713372_1 CDM 0278 RC inpatient 1269 824.85 AETNA AETNA 1002.51 79 999999999 768.38 1230.93 percent of total billed charges DRILL BIT 314.465 48713372_1 CDM 0278 RC inpatient 1269 824.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 824.85 65 999999999 768.38 1230.93 percent of total billed charges DRILL BIT 314.465 48713372_1 CDM 0278 RC inpatient 1269 824.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1230.93 97 999999999 768.38 1230.93 percent of total billed charges DRILL BIT 314.465 48713372_1 CDM 0278 RC inpatient 1269 824.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 875.61 69 999999999 768.38 1230.93 percent of total billed charges DRILL BIT 314.465 48713372_1 CDM 0278 RC inpatient 1269 824.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 989.82 78 999999999 768.38 1230.93 percent of total billed charges DRILL BIT 314.465 48713372_1 CDM 0278 RC inpatient 1269 824.85 UMR - ALL PLANS UMR - ALL PLANS 888.3 70 999999999 768.38 1230.93 percent of total billed charges DRILL BIT 314.465 48713372_1 CDM 0278 RC inpatient 1269 824.85 SIHO - ALL PLANS SIHO - ALL PLANS 1142.1 90 999999999 768.38 1230.93 percent of total billed charges DRILL BIT 314.465 48713372_1 CDM 0278 RC inpatient 1269 824.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 768.38 60.55 999999999 768.38 1230.93 percent of total billed charges DRILL BIT 314.465 48713372_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 768.38 1230.93 DRILL BIT 314.465 48713372_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 768.38 1230.93 DRILL BIT 314.465 48713372_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM HMO ANTHEM HMO 999999999 768.38 1230.93 DRILL BIT 314.465 48713372_1 CDM 0278 RC inpatient 1269 824.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 857.84 67.6 999999999 768.38 1230.93 percent of total billed charges DRILL BIT 314.465 48713372_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 768.38 1230.93 DRILL BIT 314.465 48713372_1 CDM 0278 RC inpatient 1269 824.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 768.38 1230.93 DRILL BIT 1.1MM 310.113 48713373_1 CDM 0272 RC inpatient 578 375.7 AETNA AETNA 456.62 79 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.1MM 310.113 48713373_1 CDM 0272 RC inpatient 578 375.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 375.7 65 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.1MM 310.113 48713373_1 CDM 0272 RC inpatient 578 375.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 560.66 97 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.1MM 310.113 48713373_1 CDM 0272 RC inpatient 578 375.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 398.82 69 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.1MM 310.113 48713373_1 CDM 0272 RC inpatient 578 375.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 450.84 78 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.1MM 310.113 48713373_1 CDM 0272 RC inpatient 578 375.7 UMR - ALL PLANS UMR - ALL PLANS 404.6 70 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.1MM 310.113 48713373_1 CDM 0272 RC inpatient 578 375.7 SIHO - ALL PLANS SIHO - ALL PLANS 520.2 90 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.1MM 310.113 48713373_1 CDM 0272 RC inpatient 578 375.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 349.98 60.55 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.1MM 310.113 48713373_1 CDM 0272 RC inpatient 578 375.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 349.98 560.66 DRILL BIT 1.1MM 310.113 48713373_1 CDM 0272 RC inpatient 578 375.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 349.98 560.66 DRILL BIT 1.1MM 310.113 48713373_1 CDM 0272 RC inpatient 578 375.7 ANTHEM HMO ANTHEM HMO 999999999 349.98 560.66 DRILL BIT 1.1MM 310.113 48713373_1 CDM 0272 RC inpatient 578 375.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 390.73 67.6 999999999 349.98 560.66 percent of total billed charges DRILL BIT 1.1MM 310.113 48713373_1 CDM 0272 RC inpatient 578 375.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 349.98 560.66 DRILL BIT 1.1MM 310.113 48713373_1 CDM 0272 RC inpatient 578 375.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 349.98 560.66 TAP 6.5MM CANCEL SCREW 311.66 48713374_1 CDM 0278 RC inpatient 1142 742.3 AETNA AETNA 902.18 79 999999999 691.48 1107.74 percent of total billed charges TAP 6.5MM CANCEL SCREW 311.66 48713374_1 CDM 0278 RC inpatient 1142 742.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 742.3 65 999999999 691.48 1107.74 percent of total billed charges TAP 6.5MM CANCEL SCREW 311.66 48713374_1 CDM 0278 RC inpatient 1142 742.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1107.74 97 999999999 691.48 1107.74 percent of total billed charges TAP 6.5MM CANCEL SCREW 311.66 48713374_1 CDM 0278 RC inpatient 1142 742.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 787.98 69 999999999 691.48 1107.74 percent of total billed charges TAP 6.5MM CANCEL SCREW 311.66 48713374_1 CDM 0278 RC inpatient 1142 742.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 890.76 78 999999999 691.48 1107.74 percent of total billed charges TAP 6.5MM CANCEL SCREW 311.66 48713374_1 CDM 0278 RC inpatient 1142 742.3 UMR - ALL PLANS UMR - ALL PLANS 799.4 70 999999999 691.48 1107.74 percent of total billed charges TAP 6.5MM CANCEL SCREW 311.66 48713374_1 CDM 0278 RC inpatient 1142 742.3 SIHO - ALL PLANS SIHO - ALL PLANS 1027.8 90 999999999 691.48 1107.74 percent of total billed charges TAP 6.5MM CANCEL SCREW 311.66 48713374_1 CDM 0278 RC inpatient 1142 742.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 691.48 60.55 999999999 691.48 1107.74 percent of total billed charges TAP 6.5MM CANCEL SCREW 311.66 48713374_1 CDM 0278 RC inpatient 1142 742.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 691.48 1107.74 TAP 6.5MM CANCEL SCREW 311.66 48713374_1 CDM 0278 RC inpatient 1142 742.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 691.48 1107.74 TAP 6.5MM CANCEL SCREW 311.66 48713374_1 CDM 0278 RC inpatient 1142 742.3 ANTHEM HMO ANTHEM HMO 999999999 691.48 1107.74 TAP 6.5MM CANCEL SCREW 311.66 48713374_1 CDM 0278 RC inpatient 1142 742.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 771.99 67.6 999999999 691.48 1107.74 percent of total billed charges TAP 6.5MM CANCEL SCREW 311.66 48713374_1 CDM 0278 RC inpatient 1142 742.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 691.48 1107.74 TAP 6.5MM CANCEL SCREW 311.66 48713374_1 CDM 0278 RC inpatient 1142 742.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 691.48 1107.74 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713375_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 AETNA AETNA 1373.81 79 999999999 1052.96 1686.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713375_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1130.35 65 999999999 1052.96 1686.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713375_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1686.83 97 999999999 1052.96 1686.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713375_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1199.91 69 999999999 1052.96 1686.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713375_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1356.42 78 999999999 1052.96 1686.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713375_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 UMR - ALL PLANS UMR - ALL PLANS 1217.3 70 999999999 1052.96 1686.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713375_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 SIHO - ALL PLANS SIHO - ALL PLANS 1565.1 90 999999999 1052.96 1686.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713375_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1052.96 60.55 999999999 1052.96 1686.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713375_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1052.96 1686.83 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713375_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1052.96 1686.83 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713375_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 ANTHEM HMO ANTHEM HMO 999999999 1052.96 1686.83 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713375_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1175.56 67.6 999999999 1052.96 1686.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713375_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1052.96 1686.83 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713375_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1052.96 1686.83 1.3MM DRILL BIT 316.403 48713376_1 CDM 0272 RC inpatient 338 219.7 AETNA AETNA 267.02 79 999999999 204.66 327.86 percent of total billed charges 1.3MM DRILL BIT 316.403 48713376_1 CDM 0272 RC inpatient 338 219.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 219.7 65 999999999 204.66 327.86 percent of total billed charges 1.3MM DRILL BIT 316.403 48713376_1 CDM 0272 RC inpatient 338 219.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 327.86 97 999999999 204.66 327.86 percent of total billed charges 1.3MM DRILL BIT 316.403 48713376_1 CDM 0272 RC inpatient 338 219.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 233.22 69 999999999 204.66 327.86 percent of total billed charges 1.3MM DRILL BIT 316.403 48713376_1 CDM 0272 RC inpatient 338 219.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 263.64 78 999999999 204.66 327.86 percent of total billed charges 1.3MM DRILL BIT 316.403 48713376_1 CDM 0272 RC inpatient 338 219.7 UMR - ALL PLANS UMR - ALL PLANS 236.6 70 999999999 204.66 327.86 percent of total billed charges 1.3MM DRILL BIT 316.403 48713376_1 CDM 0272 RC inpatient 338 219.7 SIHO - ALL PLANS SIHO - ALL PLANS 304.2 90 999999999 204.66 327.86 percent of total billed charges 1.3MM DRILL BIT 316.403 48713376_1 CDM 0272 RC inpatient 338 219.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 204.66 60.55 999999999 204.66 327.86 percent of total billed charges 1.3MM DRILL BIT 316.403 48713376_1 CDM 0272 RC inpatient 338 219.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 204.66 327.86 1.3MM DRILL BIT 316.403 48713376_1 CDM 0272 RC inpatient 338 219.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 204.66 327.86 1.3MM DRILL BIT 316.403 48713376_1 CDM 0272 RC inpatient 338 219.7 ANTHEM HMO ANTHEM HMO 999999999 204.66 327.86 1.3MM DRILL BIT 316.403 48713376_1 CDM 0272 RC inpatient 338 219.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 228.49 67.6 999999999 204.66 327.86 percent of total billed charges 1.3MM DRILL BIT 316.403 48713376_1 CDM 0272 RC inpatient 338 219.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 204.66 327.86 1.3MM DRILL BIT 316.403 48713376_1 CDM 0272 RC inpatient 338 219.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 204.66 327.86 1.0MM DRILL BIT 316.236 48713377_1 CDM 0278 RC inpatient 338 219.7 AETNA AETNA 267.02 79 999999999 204.66 327.86 percent of total billed charges 1.0MM DRILL BIT 316.236 48713377_1 CDM 0278 RC inpatient 338 219.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 219.7 65 999999999 204.66 327.86 percent of total billed charges 1.0MM DRILL BIT 316.236 48713377_1 CDM 0278 RC inpatient 338 219.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 327.86 97 999999999 204.66 327.86 percent of total billed charges 1.0MM DRILL BIT 316.236 48713377_1 CDM 0278 RC inpatient 338 219.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 233.22 69 999999999 204.66 327.86 percent of total billed charges 1.0MM DRILL BIT 316.236 48713377_1 CDM 0278 RC inpatient 338 219.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 263.64 78 999999999 204.66 327.86 percent of total billed charges 1.0MM DRILL BIT 316.236 48713377_1 CDM 0278 RC inpatient 338 219.7 UMR - ALL PLANS UMR - ALL PLANS 236.6 70 999999999 204.66 327.86 percent of total billed charges 1.0MM DRILL BIT 316.236 48713377_1 CDM 0278 RC inpatient 338 219.7 SIHO - ALL PLANS SIHO - ALL PLANS 304.2 90 999999999 204.66 327.86 percent of total billed charges 1.0MM DRILL BIT 316.236 48713377_1 CDM 0278 RC inpatient 338 219.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 204.66 60.55 999999999 204.66 327.86 percent of total billed charges 1.0MM DRILL BIT 316.236 48713377_1 CDM 0278 RC inpatient 338 219.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 204.66 327.86 1.0MM DRILL BIT 316.236 48713377_1 CDM 0278 RC inpatient 338 219.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 204.66 327.86 1.0MM DRILL BIT 316.236 48713377_1 CDM 0278 RC inpatient 338 219.7 ANTHEM HMO ANTHEM HMO 999999999 204.66 327.86 1.0MM DRILL BIT 316.236 48713377_1 CDM 0278 RC inpatient 338 219.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 228.49 67.6 999999999 204.66 327.86 percent of total billed charges 1.0MM DRILL BIT 316.236 48713377_1 CDM 0278 RC inpatient 338 219.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 204.66 327.86 1.0MM DRILL BIT 316.236 48713377_1 CDM 0278 RC inpatient 338 219.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 204.66 327.86 DRILL BIT J-LATCK 316.306 48713378_1 CDM 0278 RC inpatient 858 557.7 AETNA AETNA 677.82 79 999999999 519.52 832.26 percent of total billed charges DRILL BIT J-LATCK 316.306 48713378_1 CDM 0278 RC inpatient 858 557.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 557.7 65 999999999 519.52 832.26 percent of total billed charges DRILL BIT J-LATCK 316.306 48713378_1 CDM 0278 RC inpatient 858 557.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 832.26 97 999999999 519.52 832.26 percent of total billed charges DRILL BIT J-LATCK 316.306 48713378_1 CDM 0278 RC inpatient 858 557.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 592.02 69 999999999 519.52 832.26 percent of total billed charges DRILL BIT J-LATCK 316.306 48713378_1 CDM 0278 RC inpatient 858 557.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 669.24 78 999999999 519.52 832.26 percent of total billed charges DRILL BIT J-LATCK 316.306 48713378_1 CDM 0278 RC inpatient 858 557.7 UMR - ALL PLANS UMR - ALL PLANS 600.6 70 999999999 519.52 832.26 percent of total billed charges DRILL BIT J-LATCK 316.306 48713378_1 CDM 0278 RC inpatient 858 557.7 SIHO - ALL PLANS SIHO - ALL PLANS 772.2 90 999999999 519.52 832.26 percent of total billed charges DRILL BIT J-LATCK 316.306 48713378_1 CDM 0278 RC inpatient 858 557.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 519.52 60.55 999999999 519.52 832.26 percent of total billed charges DRILL BIT J-LATCK 316.306 48713378_1 CDM 0278 RC inpatient 858 557.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 519.52 832.26 DRILL BIT J-LATCK 316.306 48713378_1 CDM 0278 RC inpatient 858 557.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 519.52 832.26 DRILL BIT J-LATCK 316.306 48713378_1 CDM 0278 RC inpatient 858 557.7 ANTHEM HMO ANTHEM HMO 999999999 519.52 832.26 DRILL BIT J-LATCK 316.306 48713378_1 CDM 0278 RC inpatient 858 557.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 580.01 67.6 999999999 519.52 832.26 percent of total billed charges DRILL BIT J-LATCK 316.306 48713378_1 CDM 0278 RC inpatient 858 557.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 519.52 832.26 DRILL BIT J-LATCK 316.306 48713378_1 CDM 0278 RC inpatient 858 557.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 519.52 832.26 DRILL BIT J-LATCH 316.308 48713379_1 CDM 0278 RC inpatient 728 473.2 AETNA AETNA 575.12 79 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.308 48713379_1 CDM 0278 RC inpatient 728 473.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 473.2 65 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.308 48713379_1 CDM 0278 RC inpatient 728 473.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 706.16 97 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.308 48713379_1 CDM 0278 RC inpatient 728 473.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 502.32 69 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.308 48713379_1 CDM 0278 RC inpatient 728 473.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 567.84 78 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.308 48713379_1 CDM 0278 RC inpatient 728 473.2 UMR - ALL PLANS UMR - ALL PLANS 509.6 70 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.308 48713379_1 CDM 0278 RC inpatient 728 473.2 SIHO - ALL PLANS SIHO - ALL PLANS 655.2 90 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.308 48713379_1 CDM 0278 RC inpatient 728 473.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 440.8 60.55 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.308 48713379_1 CDM 0278 RC inpatient 728 473.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 440.8 706.16 DRILL BIT J-LATCH 316.308 48713379_1 CDM 0278 RC inpatient 728 473.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 440.8 706.16 DRILL BIT J-LATCH 316.308 48713379_1 CDM 0278 RC inpatient 728 473.2 ANTHEM HMO ANTHEM HMO 999999999 440.8 706.16 DRILL BIT J-LATCH 316.308 48713379_1 CDM 0278 RC inpatient 728 473.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 492.13 67.6 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.308 48713379_1 CDM 0278 RC inpatient 728 473.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 440.8 706.16 DRILL BIT J-LATCH 316.308 48713379_1 CDM 0278 RC inpatient 728 473.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 440.8 706.16 DRILL BIT J-LATCH 316.310 48713380_1 CDM 0278 RC inpatient 728 473.2 AETNA AETNA 575.12 79 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.310 48713380_1 CDM 0278 RC inpatient 728 473.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 473.2 65 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.310 48713380_1 CDM 0278 RC inpatient 728 473.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 706.16 97 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.310 48713380_1 CDM 0278 RC inpatient 728 473.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 502.32 69 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.310 48713380_1 CDM 0278 RC inpatient 728 473.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 567.84 78 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.310 48713380_1 CDM 0278 RC inpatient 728 473.2 UMR - ALL PLANS UMR - ALL PLANS 509.6 70 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.310 48713380_1 CDM 0278 RC inpatient 728 473.2 SIHO - ALL PLANS SIHO - ALL PLANS 655.2 90 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.310 48713380_1 CDM 0278 RC inpatient 728 473.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 440.8 60.55 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.310 48713380_1 CDM 0278 RC inpatient 728 473.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 440.8 706.16 DRILL BIT J-LATCH 316.310 48713380_1 CDM 0278 RC inpatient 728 473.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 440.8 706.16 DRILL BIT J-LATCH 316.310 48713380_1 CDM 0278 RC inpatient 728 473.2 ANTHEM HMO ANTHEM HMO 999999999 440.8 706.16 DRILL BIT J-LATCH 316.310 48713380_1 CDM 0278 RC inpatient 728 473.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 492.13 67.6 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.310 48713380_1 CDM 0278 RC inpatient 728 473.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 440.8 706.16 DRILL BIT J-LATCH 316.310 48713380_1 CDM 0278 RC inpatient 728 473.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 440.8 706.16 DRILL BIT J-LATCH 316.312 48713381_1 CDM 0278 RC inpatient 728 473.2 AETNA AETNA 575.12 79 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.312 48713381_1 CDM 0278 RC inpatient 728 473.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 473.2 65 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.312 48713381_1 CDM 0278 RC inpatient 728 473.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 706.16 97 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.312 48713381_1 CDM 0278 RC inpatient 728 473.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 502.32 69 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.312 48713381_1 CDM 0278 RC inpatient 728 473.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 567.84 78 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.312 48713381_1 CDM 0278 RC inpatient 728 473.2 UMR - ALL PLANS UMR - ALL PLANS 509.6 70 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.312 48713381_1 CDM 0278 RC inpatient 728 473.2 SIHO - ALL PLANS SIHO - ALL PLANS 655.2 90 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.312 48713381_1 CDM 0278 RC inpatient 728 473.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 440.8 60.55 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.312 48713381_1 CDM 0278 RC inpatient 728 473.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 440.8 706.16 DRILL BIT J-LATCH 316.312 48713381_1 CDM 0278 RC inpatient 728 473.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 440.8 706.16 DRILL BIT J-LATCH 316.312 48713381_1 CDM 0278 RC inpatient 728 473.2 ANTHEM HMO ANTHEM HMO 999999999 440.8 706.16 DRILL BIT J-LATCH 316.312 48713381_1 CDM 0278 RC inpatient 728 473.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 492.13 67.6 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.312 48713381_1 CDM 0278 RC inpatient 728 473.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 440.8 706.16 DRILL BIT J-LATCH 316.312 48713381_1 CDM 0278 RC inpatient 728 473.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 440.8 706.16 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713382_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 AETNA AETNA 1617.13 79 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713382_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1330.55 65 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713382_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1985.59 97 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713382_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1412.43 69 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713382_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1596.66 78 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713382_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 UMR - ALL PLANS UMR - ALL PLANS 1432.9 70 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713382_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 SIHO - ALL PLANS SIHO - ALL PLANS 1842.3 90 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713382_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1239.46 60.55 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713382_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713382_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713382_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM HMO ANTHEM HMO 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713382_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1383.77 67.6 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713382_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713382_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1239.46 1985.59 DRILL BIT J-LATCH 316.314 48713383_1 CDM 0278 RC inpatient 728 473.2 AETNA AETNA 575.12 79 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.314 48713383_1 CDM 0278 RC inpatient 728 473.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 473.2 65 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.314 48713383_1 CDM 0278 RC inpatient 728 473.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 706.16 97 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.314 48713383_1 CDM 0278 RC inpatient 728 473.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 502.32 69 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.314 48713383_1 CDM 0278 RC inpatient 728 473.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 567.84 78 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.314 48713383_1 CDM 0278 RC inpatient 728 473.2 UMR - ALL PLANS UMR - ALL PLANS 509.6 70 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.314 48713383_1 CDM 0278 RC inpatient 728 473.2 SIHO - ALL PLANS SIHO - ALL PLANS 655.2 90 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.314 48713383_1 CDM 0278 RC inpatient 728 473.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 440.8 60.55 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.314 48713383_1 CDM 0278 RC inpatient 728 473.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 440.8 706.16 DRILL BIT J-LATCH 316.314 48713383_1 CDM 0278 RC inpatient 728 473.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 440.8 706.16 DRILL BIT J-LATCH 316.314 48713383_1 CDM 0278 RC inpatient 728 473.2 ANTHEM HMO ANTHEM HMO 999999999 440.8 706.16 DRILL BIT J-LATCH 316.314 48713383_1 CDM 0278 RC inpatient 728 473.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 492.13 67.6 999999999 440.8 706.16 percent of total billed charges DRILL BIT J-LATCH 316.314 48713383_1 CDM 0278 RC inpatient 728 473.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 440.8 706.16 DRILL BIT J-LATCH 316.314 48713383_1 CDM 0278 RC inpatient 728 473.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 440.8 706.16 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713384_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 AETNA AETNA 1617.13 79 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713384_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1330.55 65 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713384_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1985.59 97 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713384_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1412.43 69 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713384_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1596.66 78 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713384_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 UMR - ALL PLANS UMR - ALL PLANS 1432.9 70 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713384_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 SIHO - ALL PLANS SIHO - ALL PLANS 1842.3 90 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713384_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1239.46 60.55 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713384_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713384_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713384_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM HMO ANTHEM HMO 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713384_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1383.77 67.6 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713384_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713384_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713385_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 AETNA AETNA 1617.13 79 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713385_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1330.55 65 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713385_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1985.59 97 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713385_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1412.43 69 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713385_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1596.66 78 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713385_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 UMR - ALL PLANS UMR - ALL PLANS 1432.9 70 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713385_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 SIHO - ALL PLANS SIHO - ALL PLANS 1842.3 90 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713385_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1239.46 60.55 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713385_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713385_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713385_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM HMO ANTHEM HMO 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713385_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1383.77 67.6 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713385_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713385_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713386_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 AETNA AETNA 1617.13 79 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713386_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1330.55 65 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713386_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1985.59 97 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713386_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1412.43 69 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713386_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1596.66 78 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713386_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 UMR - ALL PLANS UMR - ALL PLANS 1432.9 70 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713386_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 SIHO - ALL PLANS SIHO - ALL PLANS 1842.3 90 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713386_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1239.46 60.55 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713386_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713386_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713386_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM HMO ANTHEM HMO 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713386_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1383.77 67.6 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713386_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713386_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713387_1 CDM 0278 RC C1713 HCPCS inpatient 1721 1118.65 AETNA AETNA 1359.59 79 999999999 1042.07 1669.37 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713387_1 CDM 0278 RC C1713 HCPCS inpatient 1721 1118.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1118.65 65 999999999 1042.07 1669.37 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713387_1 CDM 0278 RC C1713 HCPCS inpatient 1721 1118.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1669.37 97 999999999 1042.07 1669.37 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713387_1 CDM 0278 RC C1713 HCPCS inpatient 1721 1118.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1187.49 69 999999999 1042.07 1669.37 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713387_1 CDM 0278 RC C1713 HCPCS inpatient 1721 1118.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1342.38 78 999999999 1042.07 1669.37 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713387_1 CDM 0278 RC C1713 HCPCS inpatient 1721 1118.65 UMR - ALL PLANS UMR - ALL PLANS 1204.7 70 999999999 1042.07 1669.37 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713387_1 CDM 0278 RC C1713 HCPCS inpatient 1721 1118.65 SIHO - ALL PLANS SIHO - ALL PLANS 1548.9 90 999999999 1042.07 1669.37 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713387_1 CDM 0278 RC C1713 HCPCS inpatient 1721 1118.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1042.07 60.55 999999999 1042.07 1669.37 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713387_1 CDM 0278 RC C1713 HCPCS inpatient 1721 1118.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1042.07 1669.37 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713387_1 CDM 0278 RC C1713 HCPCS inpatient 1721 1118.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1042.07 1669.37 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713387_1 CDM 0278 RC C1713 HCPCS inpatient 1721 1118.65 ANTHEM HMO ANTHEM HMO 999999999 1042.07 1669.37 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713387_1 CDM 0278 RC C1713 HCPCS inpatient 1721 1118.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1163.4 67.6 999999999 1042.07 1669.37 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713387_1 CDM 0278 RC C1713 HCPCS inpatient 1721 1118.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1042.07 1669.37 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713387_1 CDM 0278 RC C1713 HCPCS inpatient 1721 1118.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1042.07 1669.37 SCREW CAN 7.3 16M/115M 208.915 48713388_1 CDM 0278 RC inpatient 826 536.9 AETNA AETNA 652.54 79 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 16M/115M 208.915 48713388_1 CDM 0278 RC inpatient 826 536.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 536.9 65 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 16M/115M 208.915 48713388_1 CDM 0278 RC inpatient 826 536.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 801.22 97 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 16M/115M 208.915 48713388_1 CDM 0278 RC inpatient 826 536.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 569.94 69 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 16M/115M 208.915 48713388_1 CDM 0278 RC inpatient 826 536.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 644.28 78 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 16M/115M 208.915 48713388_1 CDM 0278 RC inpatient 826 536.9 UMR - ALL PLANS UMR - ALL PLANS 578.2 70 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 16M/115M 208.915 48713388_1 CDM 0278 RC inpatient 826 536.9 SIHO - ALL PLANS SIHO - ALL PLANS 743.4 90 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 16M/115M 208.915 48713388_1 CDM 0278 RC inpatient 826 536.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 500.14 60.55 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 16M/115M 208.915 48713388_1 CDM 0278 RC inpatient 826 536.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 500.14 801.22 SCREW CAN 7.3 16M/115M 208.915 48713388_1 CDM 0278 RC inpatient 826 536.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 500.14 801.22 SCREW CAN 7.3 16M/115M 208.915 48713388_1 CDM 0278 RC inpatient 826 536.9 ANTHEM HMO ANTHEM HMO 999999999 500.14 801.22 SCREW CAN 7.3 16M/115M 208.915 48713388_1 CDM 0278 RC inpatient 826 536.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 558.38 67.6 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 16M/115M 208.915 48713388_1 CDM 0278 RC inpatient 826 536.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 500.14 801.22 SCREW CAN 7.3 16M/115M 208.915 48713388_1 CDM 0278 RC inpatient 826 536.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 500.14 801.22 SCREW CAN 7.3 16M/120M 208.920 48713389_1 CDM 0278 RC inpatient 826 536.9 AETNA AETNA 652.54 79 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 16M/120M 208.920 48713389_1 CDM 0278 RC inpatient 826 536.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 536.9 65 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 16M/120M 208.920 48713389_1 CDM 0278 RC inpatient 826 536.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 801.22 97 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 16M/120M 208.920 48713389_1 CDM 0278 RC inpatient 826 536.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 569.94 69 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 16M/120M 208.920 48713389_1 CDM 0278 RC inpatient 826 536.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 644.28 78 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 16M/120M 208.920 48713389_1 CDM 0278 RC inpatient 826 536.9 UMR - ALL PLANS UMR - ALL PLANS 578.2 70 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 16M/120M 208.920 48713389_1 CDM 0278 RC inpatient 826 536.9 SIHO - ALL PLANS SIHO - ALL PLANS 743.4 90 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 16M/120M 208.920 48713389_1 CDM 0278 RC inpatient 826 536.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 500.14 60.55 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 16M/120M 208.920 48713389_1 CDM 0278 RC inpatient 826 536.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 500.14 801.22 SCREW CAN 7.3 16M/120M 208.920 48713389_1 CDM 0278 RC inpatient 826 536.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 500.14 801.22 SCREW CAN 7.3 16M/120M 208.920 48713389_1 CDM 0278 RC inpatient 826 536.9 ANTHEM HMO ANTHEM HMO 999999999 500.14 801.22 SCREW CAN 7.3 16M/120M 208.920 48713389_1 CDM 0278 RC inpatient 826 536.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 558.38 67.6 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 16M/120M 208.920 48713389_1 CDM 0278 RC inpatient 826 536.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 500.14 801.22 SCREW CAN 7.3 16M/120M 208.920 48713389_1 CDM 0278 RC inpatient 826 536.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 500.14 801.22 SCREW CAN 7.3 16M/125M 208.925 48713390_1 CDM 0278 RC inpatient 933 606.45 AETNA AETNA 737.07 79 999999999 564.93 905.01 percent of total billed charges SCREW CAN 7.3 16M/125M 208.925 48713390_1 CDM 0278 RC inpatient 933 606.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 606.45 65 999999999 564.93 905.01 percent of total billed charges SCREW CAN 7.3 16M/125M 208.925 48713390_1 CDM 0278 RC inpatient 933 606.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 905.01 97 999999999 564.93 905.01 percent of total billed charges SCREW CAN 7.3 16M/125M 208.925 48713390_1 CDM 0278 RC inpatient 933 606.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 643.77 69 999999999 564.93 905.01 percent of total billed charges SCREW CAN 7.3 16M/125M 208.925 48713390_1 CDM 0278 RC inpatient 933 606.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 727.74 78 999999999 564.93 905.01 percent of total billed charges SCREW CAN 7.3 16M/125M 208.925 48713390_1 CDM 0278 RC inpatient 933 606.45 UMR - ALL PLANS UMR - ALL PLANS 653.1 70 999999999 564.93 905.01 percent of total billed charges SCREW CAN 7.3 16M/125M 208.925 48713390_1 CDM 0278 RC inpatient 933 606.45 SIHO - ALL PLANS SIHO - ALL PLANS 839.7 90 999999999 564.93 905.01 percent of total billed charges SCREW CAN 7.3 16M/125M 208.925 48713390_1 CDM 0278 RC inpatient 933 606.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 564.93 60.55 999999999 564.93 905.01 percent of total billed charges SCREW CAN 7.3 16M/125M 208.925 48713390_1 CDM 0278 RC inpatient 933 606.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 564.93 905.01 SCREW CAN 7.3 16M/125M 208.925 48713390_1 CDM 0278 RC inpatient 933 606.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 564.93 905.01 SCREW CAN 7.3 16M/125M 208.925 48713390_1 CDM 0278 RC inpatient 933 606.45 ANTHEM HMO ANTHEM HMO 999999999 564.93 905.01 SCREW CAN 7.3 16M/125M 208.925 48713390_1 CDM 0278 RC inpatient 933 606.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 630.71 67.6 999999999 564.93 905.01 percent of total billed charges SCREW CAN 7.3 16M/125M 208.925 48713390_1 CDM 0278 RC inpatient 933 606.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 564.93 905.01 SCREW CAN 7.3 16M/125M 208.925 48713390_1 CDM 0278 RC inpatient 933 606.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 564.93 905.01 SCREW CAN 7.3 16M/130M 208.930 48713391_1 CDM 0278 RC inpatient 1173 762.45 AETNA AETNA 926.67 79 999999999 710.25 1137.81 percent of total billed charges SCREW CAN 7.3 16M/130M 208.930 48713391_1 CDM 0278 RC inpatient 1173 762.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 762.45 65 999999999 710.25 1137.81 percent of total billed charges SCREW CAN 7.3 16M/130M 208.930 48713391_1 CDM 0278 RC inpatient 1173 762.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1137.81 97 999999999 710.25 1137.81 percent of total billed charges SCREW CAN 7.3 16M/130M 208.930 48713391_1 CDM 0278 RC inpatient 1173 762.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 809.37 69 999999999 710.25 1137.81 percent of total billed charges SCREW CAN 7.3 16M/130M 208.930 48713391_1 CDM 0278 RC inpatient 1173 762.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 914.94 78 999999999 710.25 1137.81 percent of total billed charges SCREW CAN 7.3 16M/130M 208.930 48713391_1 CDM 0278 RC inpatient 1173 762.45 UMR - ALL PLANS UMR - ALL PLANS 821.1 70 999999999 710.25 1137.81 percent of total billed charges SCREW CAN 7.3 16M/130M 208.930 48713391_1 CDM 0278 RC inpatient 1173 762.45 SIHO - ALL PLANS SIHO - ALL PLANS 1055.7 90 999999999 710.25 1137.81 percent of total billed charges SCREW CAN 7.3 16M/130M 208.930 48713391_1 CDM 0278 RC inpatient 1173 762.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 710.25 60.55 999999999 710.25 1137.81 percent of total billed charges SCREW CAN 7.3 16M/130M 208.930 48713391_1 CDM 0278 RC inpatient 1173 762.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 710.25 1137.81 SCREW CAN 7.3 16M/130M 208.930 48713391_1 CDM 0278 RC inpatient 1173 762.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 710.25 1137.81 SCREW CAN 7.3 16M/130M 208.930 48713391_1 CDM 0278 RC inpatient 1173 762.45 ANTHEM HMO ANTHEM HMO 999999999 710.25 1137.81 SCREW CAN 7.3 16M/130M 208.930 48713391_1 CDM 0278 RC inpatient 1173 762.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 792.95 67.6 999999999 710.25 1137.81 percent of total billed charges SCREW CAN 7.3 16M/130M 208.930 48713391_1 CDM 0278 RC inpatient 1173 762.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 710.25 1137.81 SCREW CAN 7.3 16M/130M 208.930 48713391_1 CDM 0278 RC inpatient 1173 762.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 710.25 1137.81 SCREW CAN 7.3 32M/50M 209.850 48713392_1 CDM 0278 RC inpatient 1771 1151.15 AETNA AETNA 1399.09 79 999999999 1072.34 1717.87 percent of total billed charges SCREW CAN 7.3 32M/50M 209.850 48713392_1 CDM 0278 RC inpatient 1771 1151.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1151.15 65 999999999 1072.34 1717.87 percent of total billed charges SCREW CAN 7.3 32M/50M 209.850 48713392_1 CDM 0278 RC inpatient 1771 1151.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1717.87 97 999999999 1072.34 1717.87 percent of total billed charges SCREW CAN 7.3 32M/50M 209.850 48713392_1 CDM 0278 RC inpatient 1771 1151.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1221.99 69 999999999 1072.34 1717.87 percent of total billed charges SCREW CAN 7.3 32M/50M 209.850 48713392_1 CDM 0278 RC inpatient 1771 1151.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1381.38 78 999999999 1072.34 1717.87 percent of total billed charges SCREW CAN 7.3 32M/50M 209.850 48713392_1 CDM 0278 RC inpatient 1771 1151.15 UMR - ALL PLANS UMR - ALL PLANS 1239.7 70 999999999 1072.34 1717.87 percent of total billed charges SCREW CAN 7.3 32M/50M 209.850 48713392_1 CDM 0278 RC inpatient 1771 1151.15 SIHO - ALL PLANS SIHO - ALL PLANS 1593.9 90 999999999 1072.34 1717.87 percent of total billed charges SCREW CAN 7.3 32M/50M 209.850 48713392_1 CDM 0278 RC inpatient 1771 1151.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1072.34 60.55 999999999 1072.34 1717.87 percent of total billed charges SCREW CAN 7.3 32M/50M 209.850 48713392_1 CDM 0278 RC inpatient 1771 1151.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1072.34 1717.87 SCREW CAN 7.3 32M/50M 209.850 48713392_1 CDM 0278 RC inpatient 1771 1151.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1072.34 1717.87 SCREW CAN 7.3 32M/50M 209.850 48713392_1 CDM 0278 RC inpatient 1771 1151.15 ANTHEM HMO ANTHEM HMO 999999999 1072.34 1717.87 SCREW CAN 7.3 32M/50M 209.850 48713392_1 CDM 0278 RC inpatient 1771 1151.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1197.2 67.6 999999999 1072.34 1717.87 percent of total billed charges SCREW CAN 7.3 32M/50M 209.850 48713392_1 CDM 0278 RC inpatient 1771 1151.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1072.34 1717.87 SCREW CAN 7.3 32M/50M 209.850 48713392_1 CDM 0278 RC inpatient 1771 1151.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1072.34 1717.87 SCREW CAN 7.3 32M/55M 209.855 48713393_1 CDM 0278 RC inpatient 1173 762.45 AETNA AETNA 926.67 79 999999999 710.25 1137.81 percent of total billed charges SCREW CAN 7.3 32M/55M 209.855 48713393_1 CDM 0278 RC inpatient 1173 762.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 762.45 65 999999999 710.25 1137.81 percent of total billed charges SCREW CAN 7.3 32M/55M 209.855 48713393_1 CDM 0278 RC inpatient 1173 762.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1137.81 97 999999999 710.25 1137.81 percent of total billed charges SCREW CAN 7.3 32M/55M 209.855 48713393_1 CDM 0278 RC inpatient 1173 762.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 809.37 69 999999999 710.25 1137.81 percent of total billed charges SCREW CAN 7.3 32M/55M 209.855 48713393_1 CDM 0278 RC inpatient 1173 762.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 914.94 78 999999999 710.25 1137.81 percent of total billed charges SCREW CAN 7.3 32M/55M 209.855 48713393_1 CDM 0278 RC inpatient 1173 762.45 UMR - ALL PLANS UMR - ALL PLANS 821.1 70 999999999 710.25 1137.81 percent of total billed charges SCREW CAN 7.3 32M/55M 209.855 48713393_1 CDM 0278 RC inpatient 1173 762.45 SIHO - ALL PLANS SIHO - ALL PLANS 1055.7 90 999999999 710.25 1137.81 percent of total billed charges SCREW CAN 7.3 32M/55M 209.855 48713393_1 CDM 0278 RC inpatient 1173 762.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 710.25 60.55 999999999 710.25 1137.81 percent of total billed charges SCREW CAN 7.3 32M/55M 209.855 48713393_1 CDM 0278 RC inpatient 1173 762.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 710.25 1137.81 SCREW CAN 7.3 32M/55M 209.855 48713393_1 CDM 0278 RC inpatient 1173 762.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 710.25 1137.81 SCREW CAN 7.3 32M/55M 209.855 48713393_1 CDM 0278 RC inpatient 1173 762.45 ANTHEM HMO ANTHEM HMO 999999999 710.25 1137.81 SCREW CAN 7.3 32M/55M 209.855 48713393_1 CDM 0278 RC inpatient 1173 762.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 792.95 67.6 999999999 710.25 1137.81 percent of total billed charges SCREW CAN 7.3 32M/55M 209.855 48713393_1 CDM 0278 RC inpatient 1173 762.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 710.25 1137.81 SCREW CAN 7.3 32M/55M 209.855 48713393_1 CDM 0278 RC inpatient 1173 762.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 710.25 1137.81 SCREW CAN 7.3 32M/60M 209.860 48713394_1 CDM 0278 RC inpatient 1768 1149.2 AETNA AETNA 1396.72 79 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 32M/60M 209.860 48713394_1 CDM 0278 RC inpatient 1768 1149.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1149.2 65 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 32M/60M 209.860 48713394_1 CDM 0278 RC inpatient 1768 1149.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1714.96 97 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 32M/60M 209.860 48713394_1 CDM 0278 RC inpatient 1768 1149.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1219.92 69 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 32M/60M 209.860 48713394_1 CDM 0278 RC inpatient 1768 1149.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1379.04 78 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 32M/60M 209.860 48713394_1 CDM 0278 RC inpatient 1768 1149.2 UMR - ALL PLANS UMR - ALL PLANS 1237.6 70 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 32M/60M 209.860 48713394_1 CDM 0278 RC inpatient 1768 1149.2 SIHO - ALL PLANS SIHO - ALL PLANS 1591.2 90 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 32M/60M 209.860 48713394_1 CDM 0278 RC inpatient 1768 1149.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1070.52 60.55 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 32M/60M 209.860 48713394_1 CDM 0278 RC inpatient 1768 1149.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1070.52 1714.96 SCREW CAN 7.3 32M/60M 209.860 48713394_1 CDM 0278 RC inpatient 1768 1149.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1070.52 1714.96 SCREW CAN 7.3 32M/60M 209.860 48713394_1 CDM 0278 RC inpatient 1768 1149.2 ANTHEM HMO ANTHEM HMO 999999999 1070.52 1714.96 SCREW CAN 7.3 32M/60M 209.860 48713394_1 CDM 0278 RC inpatient 1768 1149.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1195.17 67.6 999999999 1070.52 1714.96 percent of total billed charges SCREW CAN 7.3 32M/60M 209.860 48713394_1 CDM 0278 RC inpatient 1768 1149.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1070.52 1714.96 SCREW CAN 7.3 32M/60M 209.860 48713394_1 CDM 0278 RC inpatient 1768 1149.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1070.52 1714.96 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713395_1 CDM 0278 RC C1713 HCPCS inpatient 1669 1084.85 AETNA AETNA 1318.51 79 999999999 1010.58 1618.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713395_1 CDM 0278 RC C1713 HCPCS inpatient 1669 1084.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1084.85 65 999999999 1010.58 1618.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713395_1 CDM 0278 RC C1713 HCPCS inpatient 1669 1084.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1618.93 97 999999999 1010.58 1618.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713395_1 CDM 0278 RC C1713 HCPCS inpatient 1669 1084.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1151.61 69 999999999 1010.58 1618.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713395_1 CDM 0278 RC C1713 HCPCS inpatient 1669 1084.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1301.82 78 999999999 1010.58 1618.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713395_1 CDM 0278 RC C1713 HCPCS inpatient 1669 1084.85 UMR - ALL PLANS UMR - ALL PLANS 1168.3 70 999999999 1010.58 1618.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713395_1 CDM 0278 RC C1713 HCPCS inpatient 1669 1084.85 SIHO - ALL PLANS SIHO - ALL PLANS 1502.1 90 999999999 1010.58 1618.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713395_1 CDM 0278 RC C1713 HCPCS inpatient 1669 1084.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1010.58 60.55 999999999 1010.58 1618.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713395_1 CDM 0278 RC C1713 HCPCS inpatient 1669 1084.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1010.58 1618.93 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713395_1 CDM 0278 RC C1713 HCPCS inpatient 1669 1084.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1010.58 1618.93 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713395_1 CDM 0278 RC C1713 HCPCS inpatient 1669 1084.85 ANTHEM HMO ANTHEM HMO 999999999 1010.58 1618.93 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713395_1 CDM 0278 RC C1713 HCPCS inpatient 1669 1084.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1128.24 67.6 999999999 1010.58 1618.93 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713395_1 CDM 0278 RC C1713 HCPCS inpatient 1669 1084.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1010.58 1618.93 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713395_1 CDM 0278 RC C1713 HCPCS inpatient 1669 1084.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1010.58 1618.93 SCREW CAN 7.3 32M/70M 209.870 48713396_1 CDM 0278 RC inpatient 1360 884 AETNA AETNA 1074.4 79 999999999 823.48 1319.2 percent of total billed charges SCREW CAN 7.3 32M/70M 209.870 48713396_1 CDM 0278 RC inpatient 1360 884 SELF PAY DISCOUNT SELF PAY DISCOUNT 884 65 999999999 823.48 1319.2 percent of total billed charges SCREW CAN 7.3 32M/70M 209.870 48713396_1 CDM 0278 RC inpatient 1360 884 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1319.2 97 999999999 823.48 1319.2 percent of total billed charges SCREW CAN 7.3 32M/70M 209.870 48713396_1 CDM 0278 RC inpatient 1360 884 ENCORE - ALL PLANS ENCORE - ALL PLANS 938.4 69 999999999 823.48 1319.2 percent of total billed charges SCREW CAN 7.3 32M/70M 209.870 48713396_1 CDM 0278 RC inpatient 1360 884 HUMANA - ALL PLANS HUMANA - ALL PLANS 1060.8 78 999999999 823.48 1319.2 percent of total billed charges SCREW CAN 7.3 32M/70M 209.870 48713396_1 CDM 0278 RC inpatient 1360 884 UMR - ALL PLANS UMR - ALL PLANS 952 70 999999999 823.48 1319.2 percent of total billed charges SCREW CAN 7.3 32M/70M 209.870 48713396_1 CDM 0278 RC inpatient 1360 884 SIHO - ALL PLANS SIHO - ALL PLANS 1224 90 999999999 823.48 1319.2 percent of total billed charges SCREW CAN 7.3 32M/70M 209.870 48713396_1 CDM 0278 RC inpatient 1360 884 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 823.48 60.55 999999999 823.48 1319.2 percent of total billed charges SCREW CAN 7.3 32M/70M 209.870 48713396_1 CDM 0278 RC inpatient 1360 884 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 823.48 1319.2 SCREW CAN 7.3 32M/70M 209.870 48713396_1 CDM 0278 RC inpatient 1360 884 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 823.48 1319.2 SCREW CAN 7.3 32M/70M 209.870 48713396_1 CDM 0278 RC inpatient 1360 884 ANTHEM HMO ANTHEM HMO 999999999 823.48 1319.2 SCREW CAN 7.3 32M/70M 209.870 48713396_1 CDM 0278 RC inpatient 1360 884 CIGNA - ALL PLANS CIGNA - ALL PLANS 919.36 67.6 999999999 823.48 1319.2 percent of total billed charges SCREW CAN 7.3 32M/70M 209.870 48713396_1 CDM 0278 RC inpatient 1360 884 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 823.48 1319.2 SCREW CAN 7.3 32M/70M 209.870 48713396_1 CDM 0278 RC inpatient 1360 884 UHC - ALL PLANS UHC - ALL PLANS 999999999 823.48 1319.2 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713397_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 AETNA AETNA 1396.72 79 999999999 1070.52 1714.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713397_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1149.2 65 999999999 1070.52 1714.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713397_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1714.96 97 999999999 1070.52 1714.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713397_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1219.92 69 999999999 1070.52 1714.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713397_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1379.04 78 999999999 1070.52 1714.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713397_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 UMR - ALL PLANS UMR - ALL PLANS 1237.6 70 999999999 1070.52 1714.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713397_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 SIHO - ALL PLANS SIHO - ALL PLANS 1591.2 90 999999999 1070.52 1714.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713397_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1070.52 60.55 999999999 1070.52 1714.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713397_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1070.52 1714.96 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713397_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1070.52 1714.96 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713397_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 ANTHEM HMO ANTHEM HMO 999999999 1070.52 1714.96 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713397_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1195.17 67.6 999999999 1070.52 1714.96 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713397_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1070.52 1714.96 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713397_1 CDM 0278 RC C1713 HCPCS inpatient 1768 1149.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1070.52 1714.96 SCREW CAN 7.3 32M/80M 209.880 48713398_1 CDM 0278 RC inpatient 1721 1118.65 AETNA AETNA 1359.59 79 999999999 1042.07 1669.37 percent of total billed charges SCREW CAN 7.3 32M/80M 209.880 48713398_1 CDM 0278 RC inpatient 1721 1118.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1118.65 65 999999999 1042.07 1669.37 percent of total billed charges SCREW CAN 7.3 32M/80M 209.880 48713398_1 CDM 0278 RC inpatient 1721 1118.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1669.37 97 999999999 1042.07 1669.37 percent of total billed charges SCREW CAN 7.3 32M/80M 209.880 48713398_1 CDM 0278 RC inpatient 1721 1118.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1187.49 69 999999999 1042.07 1669.37 percent of total billed charges SCREW CAN 7.3 32M/80M 209.880 48713398_1 CDM 0278 RC inpatient 1721 1118.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1342.38 78 999999999 1042.07 1669.37 percent of total billed charges SCREW CAN 7.3 32M/80M 209.880 48713398_1 CDM 0278 RC inpatient 1721 1118.65 UMR - ALL PLANS UMR - ALL PLANS 1204.7 70 999999999 1042.07 1669.37 percent of total billed charges SCREW CAN 7.3 32M/80M 209.880 48713398_1 CDM 0278 RC inpatient 1721 1118.65 SIHO - ALL PLANS SIHO - ALL PLANS 1548.9 90 999999999 1042.07 1669.37 percent of total billed charges SCREW CAN 7.3 32M/80M 209.880 48713398_1 CDM 0278 RC inpatient 1721 1118.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1042.07 60.55 999999999 1042.07 1669.37 percent of total billed charges SCREW CAN 7.3 32M/80M 209.880 48713398_1 CDM 0278 RC inpatient 1721 1118.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1042.07 1669.37 SCREW CAN 7.3 32M/80M 209.880 48713398_1 CDM 0278 RC inpatient 1721 1118.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1042.07 1669.37 SCREW CAN 7.3 32M/80M 209.880 48713398_1 CDM 0278 RC inpatient 1721 1118.65 ANTHEM HMO ANTHEM HMO 999999999 1042.07 1669.37 SCREW CAN 7.3 32M/80M 209.880 48713398_1 CDM 0278 RC inpatient 1721 1118.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1163.4 67.6 999999999 1042.07 1669.37 percent of total billed charges SCREW CAN 7.3 32M/80M 209.880 48713398_1 CDM 0278 RC inpatient 1721 1118.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1042.07 1669.37 SCREW CAN 7.3 32M/80M 209.880 48713398_1 CDM 0278 RC inpatient 1721 1118.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1042.07 1669.37 SCREW CAN 7.3 32M/90M 209.890 48713399_1 CDM 0278 RC inpatient 1708 1110.2 AETNA AETNA 1349.32 79 999999999 1034.19 1656.76 percent of total billed charges SCREW CAN 7.3 32M/90M 209.890 48713399_1 CDM 0278 RC inpatient 1708 1110.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1110.2 65 999999999 1034.19 1656.76 percent of total billed charges SCREW CAN 7.3 32M/90M 209.890 48713399_1 CDM 0278 RC inpatient 1708 1110.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1656.76 97 999999999 1034.19 1656.76 percent of total billed charges SCREW CAN 7.3 32M/90M 209.890 48713399_1 CDM 0278 RC inpatient 1708 1110.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1178.52 69 999999999 1034.19 1656.76 percent of total billed charges SCREW CAN 7.3 32M/90M 209.890 48713399_1 CDM 0278 RC inpatient 1708 1110.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1332.24 78 999999999 1034.19 1656.76 percent of total billed charges SCREW CAN 7.3 32M/90M 209.890 48713399_1 CDM 0278 RC inpatient 1708 1110.2 UMR - ALL PLANS UMR - ALL PLANS 1195.6 70 999999999 1034.19 1656.76 percent of total billed charges SCREW CAN 7.3 32M/90M 209.890 48713399_1 CDM 0278 RC inpatient 1708 1110.2 SIHO - ALL PLANS SIHO - ALL PLANS 1537.2 90 999999999 1034.19 1656.76 percent of total billed charges SCREW CAN 7.3 32M/90M 209.890 48713399_1 CDM 0278 RC inpatient 1708 1110.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1034.19 60.55 999999999 1034.19 1656.76 percent of total billed charges SCREW CAN 7.3 32M/90M 209.890 48713399_1 CDM 0278 RC inpatient 1708 1110.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1034.19 1656.76 SCREW CAN 7.3 32M/90M 209.890 48713399_1 CDM 0278 RC inpatient 1708 1110.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1034.19 1656.76 SCREW CAN 7.3 32M/90M 209.890 48713399_1 CDM 0278 RC inpatient 1708 1110.2 ANTHEM HMO ANTHEM HMO 999999999 1034.19 1656.76 SCREW CAN 7.3 32M/90M 209.890 48713399_1 CDM 0278 RC inpatient 1708 1110.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1154.61 67.6 999999999 1034.19 1656.76 percent of total billed charges SCREW CAN 7.3 32M/90M 209.890 48713399_1 CDM 0278 RC inpatient 1708 1110.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1034.19 1656.76 SCREW CAN 7.3 32M/90M 209.890 48713399_1 CDM 0278 RC inpatient 1708 1110.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1034.19 1656.76 DISCONTINUED BY MEGAN PALMER FAST FIX 360 CURVED NDL SYSTEM 48713400_1 CDM 0272 RC inpatient 2488 1617.2 AETNA AETNA 1965.52 79 999999999 1506.48 2413.36 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 CURVED NDL SYSTEM 48713400_1 CDM 0272 RC inpatient 2488 1617.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1617.2 65 999999999 1506.48 2413.36 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 CURVED NDL SYSTEM 48713400_1 CDM 0272 RC inpatient 2488 1617.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2413.36 97 999999999 1506.48 2413.36 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 CURVED NDL SYSTEM 48713400_1 CDM 0272 RC inpatient 2488 1617.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1716.72 69 999999999 1506.48 2413.36 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 CURVED NDL SYSTEM 48713400_1 CDM 0272 RC inpatient 2488 1617.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1940.64 78 999999999 1506.48 2413.36 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 CURVED NDL SYSTEM 48713400_1 CDM 0272 RC inpatient 2488 1617.2 UMR - ALL PLANS UMR - ALL PLANS 1741.6 70 999999999 1506.48 2413.36 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 CURVED NDL SYSTEM 48713400_1 CDM 0272 RC inpatient 2488 1617.2 SIHO - ALL PLANS SIHO - ALL PLANS 2239.2 90 999999999 1506.48 2413.36 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 CURVED NDL SYSTEM 48713400_1 CDM 0272 RC inpatient 2488 1617.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1506.48 60.55 999999999 1506.48 2413.36 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 CURVED NDL SYSTEM 48713400_1 CDM 0272 RC inpatient 2488 1617.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1506.48 2413.36 DISCONTINUED BY MEGAN PALMER FAST FIX 360 CURVED NDL SYSTEM 48713400_1 CDM 0272 RC inpatient 2488 1617.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1506.48 2413.36 DISCONTINUED BY MEGAN PALMER FAST FIX 360 CURVED NDL SYSTEM 48713400_1 CDM 0272 RC inpatient 2488 1617.2 ANTHEM HMO ANTHEM HMO 999999999 1506.48 2413.36 DISCONTINUED BY MEGAN PALMER FAST FIX 360 CURVED NDL SYSTEM 48713400_1 CDM 0272 RC inpatient 2488 1617.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1681.89 67.6 999999999 1506.48 2413.36 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 CURVED NDL SYSTEM 48713400_1 CDM 0272 RC inpatient 2488 1617.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1506.48 2413.36 DISCONTINUED BY MEGAN PALMER FAST FIX 360 CURVED NDL SYSTEM 48713400_1 CDM 0272 RC inpatient 2488 1617.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1506.48 2413.36 DISCONTINUED BY MEGAN PALMER FAST FIX 360 STRAIGHT NDL SYS 48713401_1 CDM 0272 RC inpatient 2488 1617.2 AETNA AETNA 1965.52 79 999999999 1506.48 2413.36 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 STRAIGHT NDL SYS 48713401_1 CDM 0272 RC inpatient 2488 1617.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1617.2 65 999999999 1506.48 2413.36 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 STRAIGHT NDL SYS 48713401_1 CDM 0272 RC inpatient 2488 1617.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2413.36 97 999999999 1506.48 2413.36 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 STRAIGHT NDL SYS 48713401_1 CDM 0272 RC inpatient 2488 1617.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1716.72 69 999999999 1506.48 2413.36 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 STRAIGHT NDL SYS 48713401_1 CDM 0272 RC inpatient 2488 1617.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1940.64 78 999999999 1506.48 2413.36 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 STRAIGHT NDL SYS 48713401_1 CDM 0272 RC inpatient 2488 1617.2 UMR - ALL PLANS UMR - ALL PLANS 1741.6 70 999999999 1506.48 2413.36 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 STRAIGHT NDL SYS 48713401_1 CDM 0272 RC inpatient 2488 1617.2 SIHO - ALL PLANS SIHO - ALL PLANS 2239.2 90 999999999 1506.48 2413.36 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 STRAIGHT NDL SYS 48713401_1 CDM 0272 RC inpatient 2488 1617.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1506.48 60.55 999999999 1506.48 2413.36 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 STRAIGHT NDL SYS 48713401_1 CDM 0272 RC inpatient 2488 1617.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1506.48 2413.36 DISCONTINUED BY MEGAN PALMER FAST FIX 360 STRAIGHT NDL SYS 48713401_1 CDM 0272 RC inpatient 2488 1617.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1506.48 2413.36 DISCONTINUED BY MEGAN PALMER FAST FIX 360 STRAIGHT NDL SYS 48713401_1 CDM 0272 RC inpatient 2488 1617.2 ANTHEM HMO ANTHEM HMO 999999999 1506.48 2413.36 DISCONTINUED BY MEGAN PALMER FAST FIX 360 STRAIGHT NDL SYS 48713401_1 CDM 0272 RC inpatient 2488 1617.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1681.89 67.6 999999999 1506.48 2413.36 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 STRAIGHT NDL SYS 48713401_1 CDM 0272 RC inpatient 2488 1617.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1506.48 2413.36 DISCONTINUED BY MEGAN PALMER FAST FIX 360 STRAIGHT NDL SYS 48713401_1 CDM 0272 RC inpatient 2488 1617.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1506.48 2413.36 DISCONTINUED BY MEGAN PALMER FAST FIX 360 KNOT PUSHER CURVD 48713402_1 CDM 0272 RC inpatient 795 516.75 AETNA AETNA 628.05 79 999999999 481.37 771.15 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 KNOT PUSHER CURVD 48713402_1 CDM 0272 RC inpatient 795 516.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 516.75 65 999999999 481.37 771.15 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 KNOT PUSHER CURVD 48713402_1 CDM 0272 RC inpatient 795 516.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 771.15 97 999999999 481.37 771.15 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 KNOT PUSHER CURVD 48713402_1 CDM 0272 RC inpatient 795 516.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 548.55 69 999999999 481.37 771.15 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 KNOT PUSHER CURVD 48713402_1 CDM 0272 RC inpatient 795 516.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 620.1 78 999999999 481.37 771.15 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 KNOT PUSHER CURVD 48713402_1 CDM 0272 RC inpatient 795 516.75 UMR - ALL PLANS UMR - ALL PLANS 556.5 70 999999999 481.37 771.15 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 KNOT PUSHER CURVD 48713402_1 CDM 0272 RC inpatient 795 516.75 SIHO - ALL PLANS SIHO - ALL PLANS 715.5 90 999999999 481.37 771.15 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 KNOT PUSHER CURVD 48713402_1 CDM 0272 RC inpatient 795 516.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 481.37 60.55 999999999 481.37 771.15 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 KNOT PUSHER CURVD 48713402_1 CDM 0272 RC inpatient 795 516.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 481.37 771.15 DISCONTINUED BY MEGAN PALMER FAST FIX 360 KNOT PUSHER CURVD 48713402_1 CDM 0272 RC inpatient 795 516.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 481.37 771.15 DISCONTINUED BY MEGAN PALMER FAST FIX 360 KNOT PUSHER CURVD 48713402_1 CDM 0272 RC inpatient 795 516.75 ANTHEM HMO ANTHEM HMO 999999999 481.37 771.15 DISCONTINUED BY MEGAN PALMER FAST FIX 360 KNOT PUSHER CURVD 48713402_1 CDM 0272 RC inpatient 795 516.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 537.42 67.6 999999999 481.37 771.15 percent of total billed charges DISCONTINUED BY MEGAN PALMER FAST FIX 360 KNOT PUSHER CURVD 48713402_1 CDM 0272 RC inpatient 795 516.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 481.37 771.15 DISCONTINUED BY MEGAN PALMER FAST FIX 360 KNOT PUSHER CURVD 48713402_1 CDM 0272 RC inpatient 795 516.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 481.37 771.15 SCREW CAN 7.3 32M/95M 209.895 48713403_1 CDM 0278 RC inpatient 1528 993.2 AETNA AETNA 1207.12 79 999999999 925.2 1482.16 percent of total billed charges SCREW CAN 7.3 32M/95M 209.895 48713403_1 CDM 0278 RC inpatient 1528 993.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 993.2 65 999999999 925.2 1482.16 percent of total billed charges SCREW CAN 7.3 32M/95M 209.895 48713403_1 CDM 0278 RC inpatient 1528 993.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1482.16 97 999999999 925.2 1482.16 percent of total billed charges SCREW CAN 7.3 32M/95M 209.895 48713403_1 CDM 0278 RC inpatient 1528 993.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1054.32 69 999999999 925.2 1482.16 percent of total billed charges SCREW CAN 7.3 32M/95M 209.895 48713403_1 CDM 0278 RC inpatient 1528 993.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1191.84 78 999999999 925.2 1482.16 percent of total billed charges SCREW CAN 7.3 32M/95M 209.895 48713403_1 CDM 0278 RC inpatient 1528 993.2 UMR - ALL PLANS UMR - ALL PLANS 1069.6 70 999999999 925.2 1482.16 percent of total billed charges SCREW CAN 7.3 32M/95M 209.895 48713403_1 CDM 0278 RC inpatient 1528 993.2 SIHO - ALL PLANS SIHO - ALL PLANS 1375.2 90 999999999 925.2 1482.16 percent of total billed charges SCREW CAN 7.3 32M/95M 209.895 48713403_1 CDM 0278 RC inpatient 1528 993.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 925.2 60.55 999999999 925.2 1482.16 percent of total billed charges SCREW CAN 7.3 32M/95M 209.895 48713403_1 CDM 0278 RC inpatient 1528 993.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 925.2 1482.16 SCREW CAN 7.3 32M/95M 209.895 48713403_1 CDM 0278 RC inpatient 1528 993.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 925.2 1482.16 SCREW CAN 7.3 32M/95M 209.895 48713403_1 CDM 0278 RC inpatient 1528 993.2 ANTHEM HMO ANTHEM HMO 999999999 925.2 1482.16 SCREW CAN 7.3 32M/95M 209.895 48713403_1 CDM 0278 RC inpatient 1528 993.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1032.93 67.6 999999999 925.2 1482.16 percent of total billed charges SCREW CAN 7.3 32M/95M 209.895 48713403_1 CDM 0278 RC inpatient 1528 993.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 925.2 1482.16 SCREW CAN 7.3 32M/95M 209.895 48713403_1 CDM 0278 RC inpatient 1528 993.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 925.2 1482.16 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713404_1 CDM 0278 RC C1713 HCPCS inpatient 1646 1069.9 AETNA AETNA 1300.34 79 999999999 996.65 1596.62 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713404_1 CDM 0278 RC C1713 HCPCS inpatient 1646 1069.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1069.9 65 999999999 996.65 1596.62 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713404_1 CDM 0278 RC C1713 HCPCS inpatient 1646 1069.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1596.62 97 999999999 996.65 1596.62 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713404_1 CDM 0278 RC C1713 HCPCS inpatient 1646 1069.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1135.74 69 999999999 996.65 1596.62 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713404_1 CDM 0278 RC C1713 HCPCS inpatient 1646 1069.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1283.88 78 999999999 996.65 1596.62 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713404_1 CDM 0278 RC C1713 HCPCS inpatient 1646 1069.9 UMR - ALL PLANS UMR - ALL PLANS 1152.2 70 999999999 996.65 1596.62 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713404_1 CDM 0278 RC C1713 HCPCS inpatient 1646 1069.9 SIHO - ALL PLANS SIHO - ALL PLANS 1481.4 90 999999999 996.65 1596.62 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713404_1 CDM 0278 RC C1713 HCPCS inpatient 1646 1069.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 996.65 60.55 999999999 996.65 1596.62 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713404_1 CDM 0278 RC C1713 HCPCS inpatient 1646 1069.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 996.65 1596.62 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713404_1 CDM 0278 RC C1713 HCPCS inpatient 1646 1069.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 996.65 1596.62 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713404_1 CDM 0278 RC C1713 HCPCS inpatient 1646 1069.9 ANTHEM HMO ANTHEM HMO 999999999 996.65 1596.62 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713404_1 CDM 0278 RC C1713 HCPCS inpatient 1646 1069.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1112.7 67.6 999999999 996.65 1596.62 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713404_1 CDM 0278 RC C1713 HCPCS inpatient 1646 1069.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 996.65 1596.62 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713404_1 CDM 0278 RC C1713 HCPCS inpatient 1646 1069.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 996.65 1596.62 SCREW CAN 7.3 32M/105M 209.905 48713405_1 CDM 0278 RC inpatient 982 638.3 AETNA AETNA 775.78 79 999999999 594.6 952.54 percent of total billed charges SCREW CAN 7.3 32M/105M 209.905 48713405_1 CDM 0278 RC inpatient 982 638.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 638.3 65 999999999 594.6 952.54 percent of total billed charges SCREW CAN 7.3 32M/105M 209.905 48713405_1 CDM 0278 RC inpatient 982 638.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 952.54 97 999999999 594.6 952.54 percent of total billed charges SCREW CAN 7.3 32M/105M 209.905 48713405_1 CDM 0278 RC inpatient 982 638.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 677.58 69 999999999 594.6 952.54 percent of total billed charges SCREW CAN 7.3 32M/105M 209.905 48713405_1 CDM 0278 RC inpatient 982 638.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.96 78 999999999 594.6 952.54 percent of total billed charges SCREW CAN 7.3 32M/105M 209.905 48713405_1 CDM 0278 RC inpatient 982 638.3 UMR - ALL PLANS UMR - ALL PLANS 687.4 70 999999999 594.6 952.54 percent of total billed charges SCREW CAN 7.3 32M/105M 209.905 48713405_1 CDM 0278 RC inpatient 982 638.3 SIHO - ALL PLANS SIHO - ALL PLANS 883.8 90 999999999 594.6 952.54 percent of total billed charges SCREW CAN 7.3 32M/105M 209.905 48713405_1 CDM 0278 RC inpatient 982 638.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594.6 60.55 999999999 594.6 952.54 percent of total billed charges SCREW CAN 7.3 32M/105M 209.905 48713405_1 CDM 0278 RC inpatient 982 638.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594.6 952.54 SCREW CAN 7.3 32M/105M 209.905 48713405_1 CDM 0278 RC inpatient 982 638.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594.6 952.54 SCREW CAN 7.3 32M/105M 209.905 48713405_1 CDM 0278 RC inpatient 982 638.3 ANTHEM HMO ANTHEM HMO 999999999 594.6 952.54 SCREW CAN 7.3 32M/105M 209.905 48713405_1 CDM 0278 RC inpatient 982 638.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.83 67.6 999999999 594.6 952.54 percent of total billed charges SCREW CAN 7.3 32M/105M 209.905 48713405_1 CDM 0278 RC inpatient 982 638.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594.6 952.54 SCREW CAN 7.3 32M/105M 209.905 48713405_1 CDM 0278 RC inpatient 982 638.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 594.6 952.54 SCREW CAN 7.3 32M/110M 209.910 48713406_1 CDM 0278 RC inpatient 1652 1073.8 AETNA AETNA 1305.08 79 999999999 1000.29 1602.44 percent of total billed charges SCREW CAN 7.3 32M/110M 209.910 48713406_1 CDM 0278 RC inpatient 1652 1073.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1073.8 65 999999999 1000.29 1602.44 percent of total billed charges SCREW CAN 7.3 32M/110M 209.910 48713406_1 CDM 0278 RC inpatient 1652 1073.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1602.44 97 999999999 1000.29 1602.44 percent of total billed charges SCREW CAN 7.3 32M/110M 209.910 48713406_1 CDM 0278 RC inpatient 1652 1073.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1139.88 69 999999999 1000.29 1602.44 percent of total billed charges SCREW CAN 7.3 32M/110M 209.910 48713406_1 CDM 0278 RC inpatient 1652 1073.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1288.56 78 999999999 1000.29 1602.44 percent of total billed charges SCREW CAN 7.3 32M/110M 209.910 48713406_1 CDM 0278 RC inpatient 1652 1073.8 UMR - ALL PLANS UMR - ALL PLANS 1156.4 70 999999999 1000.29 1602.44 percent of total billed charges SCREW CAN 7.3 32M/110M 209.910 48713406_1 CDM 0278 RC inpatient 1652 1073.8 SIHO - ALL PLANS SIHO - ALL PLANS 1486.8 90 999999999 1000.29 1602.44 percent of total billed charges SCREW CAN 7.3 32M/110M 209.910 48713406_1 CDM 0278 RC inpatient 1652 1073.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1000.29 60.55 999999999 1000.29 1602.44 percent of total billed charges SCREW CAN 7.3 32M/110M 209.910 48713406_1 CDM 0278 RC inpatient 1652 1073.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1000.29 1602.44 SCREW CAN 7.3 32M/110M 209.910 48713406_1 CDM 0278 RC inpatient 1652 1073.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1000.29 1602.44 SCREW CAN 7.3 32M/110M 209.910 48713406_1 CDM 0278 RC inpatient 1652 1073.8 ANTHEM HMO ANTHEM HMO 999999999 1000.29 1602.44 SCREW CAN 7.3 32M/110M 209.910 48713406_1 CDM 0278 RC inpatient 1652 1073.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1116.75 67.6 999999999 1000.29 1602.44 percent of total billed charges SCREW CAN 7.3 32M/110M 209.910 48713406_1 CDM 0278 RC inpatient 1652 1073.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1000.29 1602.44 SCREW CAN 7.3 32M/110M 209.910 48713406_1 CDM 0278 RC inpatient 1652 1073.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1000.29 1602.44 SCREW CAN 7.3 32M/115M 209.915 48713407_1 CDM 0278 RC inpatient 1261 819.65 AETNA AETNA 996.19 79 999999999 763.54 1223.17 percent of total billed charges SCREW CAN 7.3 32M/115M 209.915 48713407_1 CDM 0278 RC inpatient 1261 819.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 819.65 65 999999999 763.54 1223.17 percent of total billed charges SCREW CAN 7.3 32M/115M 209.915 48713407_1 CDM 0278 RC inpatient 1261 819.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1223.17 97 999999999 763.54 1223.17 percent of total billed charges SCREW CAN 7.3 32M/115M 209.915 48713407_1 CDM 0278 RC inpatient 1261 819.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 870.09 69 999999999 763.54 1223.17 percent of total billed charges SCREW CAN 7.3 32M/115M 209.915 48713407_1 CDM 0278 RC inpatient 1261 819.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 983.58 78 999999999 763.54 1223.17 percent of total billed charges SCREW CAN 7.3 32M/115M 209.915 48713407_1 CDM 0278 RC inpatient 1261 819.65 UMR - ALL PLANS UMR - ALL PLANS 882.7 70 999999999 763.54 1223.17 percent of total billed charges SCREW CAN 7.3 32M/115M 209.915 48713407_1 CDM 0278 RC inpatient 1261 819.65 SIHO - ALL PLANS SIHO - ALL PLANS 1134.9 90 999999999 763.54 1223.17 percent of total billed charges SCREW CAN 7.3 32M/115M 209.915 48713407_1 CDM 0278 RC inpatient 1261 819.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 763.54 60.55 999999999 763.54 1223.17 percent of total billed charges SCREW CAN 7.3 32M/115M 209.915 48713407_1 CDM 0278 RC inpatient 1261 819.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 763.54 1223.17 SCREW CAN 7.3 32M/115M 209.915 48713407_1 CDM 0278 RC inpatient 1261 819.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 763.54 1223.17 SCREW CAN 7.3 32M/115M 209.915 48713407_1 CDM 0278 RC inpatient 1261 819.65 ANTHEM HMO ANTHEM HMO 999999999 763.54 1223.17 SCREW CAN 7.3 32M/115M 209.915 48713407_1 CDM 0278 RC inpatient 1261 819.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 852.44 67.6 999999999 763.54 1223.17 percent of total billed charges SCREW CAN 7.3 32M/115M 209.915 48713407_1 CDM 0278 RC inpatient 1261 819.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 763.54 1223.17 SCREW CAN 7.3 32M/115M 209.915 48713407_1 CDM 0278 RC inpatient 1261 819.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 763.54 1223.17 SCREW CAN 7.3 32M/120M 209.920 48713408_1 CDM 0278 RC inpatient 826 536.9 AETNA AETNA 652.54 79 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/120M 209.920 48713408_1 CDM 0278 RC inpatient 826 536.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 536.9 65 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/120M 209.920 48713408_1 CDM 0278 RC inpatient 826 536.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 801.22 97 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/120M 209.920 48713408_1 CDM 0278 RC inpatient 826 536.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 569.94 69 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/120M 209.920 48713408_1 CDM 0278 RC inpatient 826 536.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 644.28 78 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/120M 209.920 48713408_1 CDM 0278 RC inpatient 826 536.9 UMR - ALL PLANS UMR - ALL PLANS 578.2 70 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/120M 209.920 48713408_1 CDM 0278 RC inpatient 826 536.9 SIHO - ALL PLANS SIHO - ALL PLANS 743.4 90 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/120M 209.920 48713408_1 CDM 0278 RC inpatient 826 536.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 500.14 60.55 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/120M 209.920 48713408_1 CDM 0278 RC inpatient 826 536.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 500.14 801.22 SCREW CAN 7.3 32M/120M 209.920 48713408_1 CDM 0278 RC inpatient 826 536.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 500.14 801.22 SCREW CAN 7.3 32M/120M 209.920 48713408_1 CDM 0278 RC inpatient 826 536.9 ANTHEM HMO ANTHEM HMO 999999999 500.14 801.22 SCREW CAN 7.3 32M/120M 209.920 48713408_1 CDM 0278 RC inpatient 826 536.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 558.38 67.6 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/120M 209.920 48713408_1 CDM 0278 RC inpatient 826 536.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 500.14 801.22 SCREW CAN 7.3 32M/120M 209.920 48713408_1 CDM 0278 RC inpatient 826 536.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 500.14 801.22 SCREW CAN 7.3 32M/125M 209.925 48713409_1 CDM 0278 RC inpatient 826 536.9 AETNA AETNA 652.54 79 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/125M 209.925 48713409_1 CDM 0278 RC inpatient 826 536.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 536.9 65 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/125M 209.925 48713409_1 CDM 0278 RC inpatient 826 536.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 801.22 97 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/125M 209.925 48713409_1 CDM 0278 RC inpatient 826 536.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 569.94 69 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/125M 209.925 48713409_1 CDM 0278 RC inpatient 826 536.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 644.28 78 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/125M 209.925 48713409_1 CDM 0278 RC inpatient 826 536.9 UMR - ALL PLANS UMR - ALL PLANS 578.2 70 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/125M 209.925 48713409_1 CDM 0278 RC inpatient 826 536.9 SIHO - ALL PLANS SIHO - ALL PLANS 743.4 90 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/125M 209.925 48713409_1 CDM 0278 RC inpatient 826 536.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 500.14 60.55 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/125M 209.925 48713409_1 CDM 0278 RC inpatient 826 536.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 500.14 801.22 SCREW CAN 7.3 32M/125M 209.925 48713409_1 CDM 0278 RC inpatient 826 536.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 500.14 801.22 SCREW CAN 7.3 32M/125M 209.925 48713409_1 CDM 0278 RC inpatient 826 536.9 ANTHEM HMO ANTHEM HMO 999999999 500.14 801.22 SCREW CAN 7.3 32M/125M 209.925 48713409_1 CDM 0278 RC inpatient 826 536.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 558.38 67.6 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/125M 209.925 48713409_1 CDM 0278 RC inpatient 826 536.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 500.14 801.22 SCREW CAN 7.3 32M/125M 209.925 48713409_1 CDM 0278 RC inpatient 826 536.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 500.14 801.22 SCREW 4.0 CANC FT 10MM 206.010 48713410_1 CDM 0278 RC inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 10MM 206.010 48713410_1 CDM 0278 RC inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 10MM 206.010 48713410_1 CDM 0278 RC inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 10MM 206.010 48713410_1 CDM 0278 RC inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 10MM 206.010 48713410_1 CDM 0278 RC inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 10MM 206.010 48713410_1 CDM 0278 RC inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 10MM 206.010 48713410_1 CDM 0278 RC inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 10MM 206.010 48713410_1 CDM 0278 RC inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 10MM 206.010 48713410_1 CDM 0278 RC inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 SCREW 4.0 CANC FT 10MM 206.010 48713410_1 CDM 0278 RC inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 SCREW 4.0 CANC FT 10MM 206.010 48713410_1 CDM 0278 RC inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 SCREW 4.0 CANC FT 10MM 206.010 48713410_1 CDM 0278 RC inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 10MM 206.010 48713410_1 CDM 0278 RC inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 SCREW 4.0 CANC FT 10MM 206.010 48713410_1 CDM 0278 RC inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 SCREW 4.0 CANC FT 12MM 206.012 48713411_1 CDM 0278 RC inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 12MM 206.012 48713411_1 CDM 0278 RC inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 12MM 206.012 48713411_1 CDM 0278 RC inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 12MM 206.012 48713411_1 CDM 0278 RC inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 12MM 206.012 48713411_1 CDM 0278 RC inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 12MM 206.012 48713411_1 CDM 0278 RC inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 12MM 206.012 48713411_1 CDM 0278 RC inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 12MM 206.012 48713411_1 CDM 0278 RC inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 12MM 206.012 48713411_1 CDM 0278 RC inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 SCREW 4.0 CANC FT 12MM 206.012 48713411_1 CDM 0278 RC inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 SCREW 4.0 CANC FT 12MM 206.012 48713411_1 CDM 0278 RC inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 SCREW 4.0 CANC FT 12MM 206.012 48713411_1 CDM 0278 RC inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 12MM 206.012 48713411_1 CDM 0278 RC inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 SCREW 4.0 CANC FT 12MM 206.012 48713411_1 CDM 0278 RC inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713412_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 AETNA AETNA 111.39 79 999999999 85.38 136.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713412_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 91.65 65 999999999 85.38 136.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713412_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 136.77 97 999999999 85.38 136.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713412_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.29 69 999999999 85.38 136.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713412_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 109.98 78 999999999 85.38 136.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713412_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 UMR - ALL PLANS UMR - ALL PLANS 98.7 70 999999999 85.38 136.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713412_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 SIHO - ALL PLANS SIHO - ALL PLANS 126.9 90 999999999 85.38 136.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713412_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.38 60.55 999999999 85.38 136.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713412_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.38 136.77 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713412_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.38 136.77 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713412_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 ANTHEM HMO ANTHEM HMO 999999999 85.38 136.77 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713412_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.32 67.6 999999999 85.38 136.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713412_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.38 136.77 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713412_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.38 136.77 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713413_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 AETNA AETNA 111.39 79 999999999 85.38 136.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713413_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 91.65 65 999999999 85.38 136.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713413_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 136.77 97 999999999 85.38 136.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713413_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.29 69 999999999 85.38 136.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713413_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 109.98 78 999999999 85.38 136.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713413_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 UMR - ALL PLANS UMR - ALL PLANS 98.7 70 999999999 85.38 136.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713413_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 SIHO - ALL PLANS SIHO - ALL PLANS 126.9 90 999999999 85.38 136.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713413_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.38 60.55 999999999 85.38 136.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713413_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.38 136.77 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713413_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.38 136.77 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713413_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 ANTHEM HMO ANTHEM HMO 999999999 85.38 136.77 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713413_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.32 67.6 999999999 85.38 136.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713413_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.38 136.77 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713413_1 CDM 0278 RC C1713 HCPCS inpatient 141 91.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.38 136.77 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713414_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 AETNA AETNA 124.03 79 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713414_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.05 65 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713414_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 152.29 97 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713414_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 108.33 69 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713414_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 122.46 78 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713414_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 UMR - ALL PLANS UMR - ALL PLANS 109.9 70 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713414_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 SIHO - ALL PLANS SIHO - ALL PLANS 141.3 90 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713414_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.06 60.55 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713414_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713414_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713414_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ANTHEM HMO ANTHEM HMO 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713414_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.13 67.6 999999999 95.06 152.29 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713414_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.06 152.29 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713414_1 CDM 0278 RC C1713 HCPCS inpatient 157 102.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.06 152.29 SCREW 4.0 CANC FT 20MM 206.020 48713415_1 CDM 0278 RC inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 20MM 206.020 48713415_1 CDM 0278 RC inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 20MM 206.020 48713415_1 CDM 0278 RC inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 20MM 206.020 48713415_1 CDM 0278 RC inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 20MM 206.020 48713415_1 CDM 0278 RC inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 20MM 206.020 48713415_1 CDM 0278 RC inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 20MM 206.020 48713415_1 CDM 0278 RC inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 20MM 206.020 48713415_1 CDM 0278 RC inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 20MM 206.020 48713415_1 CDM 0278 RC inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 SCREW 4.0 CANC FT 20MM 206.020 48713415_1 CDM 0278 RC inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 SCREW 4.0 CANC FT 20MM 206.020 48713415_1 CDM 0278 RC inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 SCREW 4.0 CANC FT 20MM 206.020 48713415_1 CDM 0278 RC inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 20MM 206.020 48713415_1 CDM 0278 RC inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 SCREW 4.0 CANC FT 20MM 206.020 48713415_1 CDM 0278 RC inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 SCREW 4.0 CANC FT 22MM 206.022 48713416_1 CDM 0278 RC inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges SCREW 4.0 CANC FT 22MM 206.022 48713416_1 CDM 0278 RC inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges SCREW 4.0 CANC FT 22MM 206.022 48713416_1 CDM 0278 RC inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges SCREW 4.0 CANC FT 22MM 206.022 48713416_1 CDM 0278 RC inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges SCREW 4.0 CANC FT 22MM 206.022 48713416_1 CDM 0278 RC inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges SCREW 4.0 CANC FT 22MM 206.022 48713416_1 CDM 0278 RC inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges SCREW 4.0 CANC FT 22MM 206.022 48713416_1 CDM 0278 RC inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges SCREW 4.0 CANC FT 22MM 206.022 48713416_1 CDM 0278 RC inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges SCREW 4.0 CANC FT 22MM 206.022 48713416_1 CDM 0278 RC inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 SCREW 4.0 CANC FT 22MM 206.022 48713416_1 CDM 0278 RC inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 SCREW 4.0 CANC FT 22MM 206.022 48713416_1 CDM 0278 RC inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 SCREW 4.0 CANC FT 22MM 206.022 48713416_1 CDM 0278 RC inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges SCREW 4.0 CANC FT 22MM 206.022 48713416_1 CDM 0278 RC inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 SCREW 4.0 CANC FT 22MM 206.022 48713416_1 CDM 0278 RC inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 SCREW CAN 7.3 32M/130M 209.930 48713417_1 CDM 0278 RC inpatient 826 536.9 AETNA AETNA 652.54 79 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/130M 209.930 48713417_1 CDM 0278 RC inpatient 826 536.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 536.9 65 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/130M 209.930 48713417_1 CDM 0278 RC inpatient 826 536.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 801.22 97 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/130M 209.930 48713417_1 CDM 0278 RC inpatient 826 536.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 569.94 69 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/130M 209.930 48713417_1 CDM 0278 RC inpatient 826 536.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 644.28 78 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/130M 209.930 48713417_1 CDM 0278 RC inpatient 826 536.9 UMR - ALL PLANS UMR - ALL PLANS 578.2 70 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/130M 209.930 48713417_1 CDM 0278 RC inpatient 826 536.9 SIHO - ALL PLANS SIHO - ALL PLANS 743.4 90 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/130M 209.930 48713417_1 CDM 0278 RC inpatient 826 536.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 500.14 60.55 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/130M 209.930 48713417_1 CDM 0278 RC inpatient 826 536.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 500.14 801.22 SCREW CAN 7.3 32M/130M 209.930 48713417_1 CDM 0278 RC inpatient 826 536.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 500.14 801.22 SCREW CAN 7.3 32M/130M 209.930 48713417_1 CDM 0278 RC inpatient 826 536.9 ANTHEM HMO ANTHEM HMO 999999999 500.14 801.22 SCREW CAN 7.3 32M/130M 209.930 48713417_1 CDM 0278 RC inpatient 826 536.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 558.38 67.6 999999999 500.14 801.22 percent of total billed charges SCREW CAN 7.3 32M/130M 209.930 48713417_1 CDM 0278 RC inpatient 826 536.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 500.14 801.22 SCREW CAN 7.3 32M/130M 209.930 48713417_1 CDM 0278 RC inpatient 826 536.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 500.14 801.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713418_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713418_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713418_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713418_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713418_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713418_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713418_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713418_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713418_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713418_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713418_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713418_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713418_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713418_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 SCREW 4.0 CANC FT 26MM 206.026 48713419_1 CDM 0278 RC inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 26MM 206.026 48713419_1 CDM 0278 RC inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 26MM 206.026 48713419_1 CDM 0278 RC inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 26MM 206.026 48713419_1 CDM 0278 RC inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 26MM 206.026 48713419_1 CDM 0278 RC inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 26MM 206.026 48713419_1 CDM 0278 RC inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 26MM 206.026 48713419_1 CDM 0278 RC inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 26MM 206.026 48713419_1 CDM 0278 RC inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 26MM 206.026 48713419_1 CDM 0278 RC inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 SCREW 4.0 CANC FT 26MM 206.026 48713419_1 CDM 0278 RC inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 SCREW 4.0 CANC FT 26MM 206.026 48713419_1 CDM 0278 RC inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 SCREW 4.0 CANC FT 26MM 206.026 48713419_1 CDM 0278 RC inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 26MM 206.026 48713419_1 CDM 0278 RC inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 SCREW 4.0 CANC FT 26MM 206.026 48713419_1 CDM 0278 RC inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713420_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713420_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713420_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713420_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713420_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713420_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713420_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713420_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713420_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713420_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713420_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713420_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713420_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713420_1 CDM 0278 RC C1713 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 SCREW 4.0 CANC FT 30MM 206.030 48713421_1 CDM 0278 RC inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 30MM 206.030 48713421_1 CDM 0278 RC inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 30MM 206.030 48713421_1 CDM 0278 RC inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 30MM 206.030 48713421_1 CDM 0278 RC inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 30MM 206.030 48713421_1 CDM 0278 RC inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 30MM 206.030 48713421_1 CDM 0278 RC inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 30MM 206.030 48713421_1 CDM 0278 RC inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 30MM 206.030 48713421_1 CDM 0278 RC inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 30MM 206.030 48713421_1 CDM 0278 RC inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 SCREW 4.0 CANC FT 30MM 206.030 48713421_1 CDM 0278 RC inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 SCREW 4.0 CANC FT 30MM 206.030 48713421_1 CDM 0278 RC inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 SCREW 4.0 CANC FT 30MM 206.030 48713421_1 CDM 0278 RC inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 30MM 206.030 48713421_1 CDM 0278 RC inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 SCREW 4.0 CANC FT 30MM 206.030 48713421_1 CDM 0278 RC inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 SCREW 4.0 CANC FT 35MM 206.035 48713422_1 CDM 0278 RC inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 35MM 206.035 48713422_1 CDM 0278 RC inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 35MM 206.035 48713422_1 CDM 0278 RC inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 35MM 206.035 48713422_1 CDM 0278 RC inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 35MM 206.035 48713422_1 CDM 0278 RC inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 35MM 206.035 48713422_1 CDM 0278 RC inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 35MM 206.035 48713422_1 CDM 0278 RC inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 35MM 206.035 48713422_1 CDM 0278 RC inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 35MM 206.035 48713422_1 CDM 0278 RC inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 SCREW 4.0 CANC FT 35MM 206.035 48713422_1 CDM 0278 RC inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 SCREW 4.0 CANC FT 35MM 206.035 48713422_1 CDM 0278 RC inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 SCREW 4.0 CANC FT 35MM 206.035 48713422_1 CDM 0278 RC inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 35MM 206.035 48713422_1 CDM 0278 RC inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 SCREW 4.0 CANC FT 35MM 206.035 48713422_1 CDM 0278 RC inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 SCREW 4.0 CANC FT 40MM 206.040 48713423_1 CDM 0278 RC inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 40MM 206.040 48713423_1 CDM 0278 RC inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 40MM 206.040 48713423_1 CDM 0278 RC inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 40MM 206.040 48713423_1 CDM 0278 RC inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 40MM 206.040 48713423_1 CDM 0278 RC inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 40MM 206.040 48713423_1 CDM 0278 RC inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 40MM 206.040 48713423_1 CDM 0278 RC inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 40MM 206.040 48713423_1 CDM 0278 RC inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 40MM 206.040 48713423_1 CDM 0278 RC inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 SCREW 4.0 CANC FT 40MM 206.040 48713423_1 CDM 0278 RC inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 SCREW 4.0 CANC FT 40MM 206.040 48713423_1 CDM 0278 RC inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 SCREW 4.0 CANC FT 40MM 206.040 48713423_1 CDM 0278 RC inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 40MM 206.040 48713423_1 CDM 0278 RC inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 SCREW 4.0 CANC FT 40MM 206.040 48713423_1 CDM 0278 RC inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 SCREW 4.0 CANC FT 45MM 206.045 48713424_1 CDM 0278 RC inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 45MM 206.045 48713424_1 CDM 0278 RC inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 45MM 206.045 48713424_1 CDM 0278 RC inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 45MM 206.045 48713424_1 CDM 0278 RC inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 45MM 206.045 48713424_1 CDM 0278 RC inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 45MM 206.045 48713424_1 CDM 0278 RC inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 45MM 206.045 48713424_1 CDM 0278 RC inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 45MM 206.045 48713424_1 CDM 0278 RC inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 45MM 206.045 48713424_1 CDM 0278 RC inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 SCREW 4.0 CANC FT 45MM 206.045 48713424_1 CDM 0278 RC inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 SCREW 4.0 CANC FT 45MM 206.045 48713424_1 CDM 0278 RC inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 SCREW 4.0 CANC FT 45MM 206.045 48713424_1 CDM 0278 RC inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges SCREW 4.0 CANC FT 45MM 206.045 48713424_1 CDM 0278 RC inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 SCREW 4.0 CANC FT 45MM 206.045 48713424_1 CDM 0278 RC inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 SCREW 4.0 CANC FT 50MM 206.050 48713425_1 CDM 0278 RC inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 50MM 206.050 48713425_1 CDM 0278 RC inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 50MM 206.050 48713425_1 CDM 0278 RC inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 50MM 206.050 48713425_1 CDM 0278 RC inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 50MM 206.050 48713425_1 CDM 0278 RC inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 50MM 206.050 48713425_1 CDM 0278 RC inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 50MM 206.050 48713425_1 CDM 0278 RC inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 50MM 206.050 48713425_1 CDM 0278 RC inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 50MM 206.050 48713425_1 CDM 0278 RC inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 SCREW 4.0 CANC FT 50MM 206.050 48713425_1 CDM 0278 RC inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 SCREW 4.0 CANC FT 50MM 206.050 48713425_1 CDM 0278 RC inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 SCREW 4.0 CANC FT 50MM 206.050 48713425_1 CDM 0278 RC inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges SCREW 4.0 CANC FT 50MM 206.050 48713425_1 CDM 0278 RC inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 SCREW 4.0 CANC FT 50MM 206.050 48713425_1 CDM 0278 RC inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 SCREW 4.0 CANC FT 55MM 206.055 48713426_1 CDM 0278 RC inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 55MM 206.055 48713426_1 CDM 0278 RC inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 55MM 206.055 48713426_1 CDM 0278 RC inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 55MM 206.055 48713426_1 CDM 0278 RC inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 55MM 206.055 48713426_1 CDM 0278 RC inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 55MM 206.055 48713426_1 CDM 0278 RC inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 55MM 206.055 48713426_1 CDM 0278 RC inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 55MM 206.055 48713426_1 CDM 0278 RC inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 55MM 206.055 48713426_1 CDM 0278 RC inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 SCREW 4.0 CANC FT 55MM 206.055 48713426_1 CDM 0278 RC inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 SCREW 4.0 CANC FT 55MM 206.055 48713426_1 CDM 0278 RC inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 SCREW 4.0 CANC FT 55MM 206.055 48713426_1 CDM 0278 RC inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 55MM 206.055 48713426_1 CDM 0278 RC inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 SCREW 4.0 CANC FT 55MM 206.055 48713426_1 CDM 0278 RC inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 SCREW 4.0 CANC FT 60MM 206.060 48713427_1 CDM 0278 RC inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 60MM 206.060 48713427_1 CDM 0278 RC inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 60MM 206.060 48713427_1 CDM 0278 RC inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 60MM 206.060 48713427_1 CDM 0278 RC inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 60MM 206.060 48713427_1 CDM 0278 RC inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 60MM 206.060 48713427_1 CDM 0278 RC inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 60MM 206.060 48713427_1 CDM 0278 RC inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 60MM 206.060 48713427_1 CDM 0278 RC inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 60MM 206.060 48713427_1 CDM 0278 RC inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 SCREW 4.0 CANC FT 60MM 206.060 48713427_1 CDM 0278 RC inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 SCREW 4.0 CANC FT 60MM 206.060 48713427_1 CDM 0278 RC inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 SCREW 4.0 CANC FT 60MM 206.060 48713427_1 CDM 0278 RC inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges SCREW 4.0 CANC FT 60MM 206.060 48713427_1 CDM 0278 RC inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 SCREW 4.0 CANC FT 60MM 206.060 48713427_1 CDM 0278 RC inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 SCREW 4.0 CANC PT 10MM 207.010 48713428_1 CDM 0278 RC inpatient 138 89.7 AETNA AETNA 109.02 79 999999999 83.56 133.86 percent of total billed charges SCREW 4.0 CANC PT 10MM 207.010 48713428_1 CDM 0278 RC inpatient 138 89.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.7 65 999999999 83.56 133.86 percent of total billed charges SCREW 4.0 CANC PT 10MM 207.010 48713428_1 CDM 0278 RC inpatient 138 89.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 133.86 97 999999999 83.56 133.86 percent of total billed charges SCREW 4.0 CANC PT 10MM 207.010 48713428_1 CDM 0278 RC inpatient 138 89.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.22 69 999999999 83.56 133.86 percent of total billed charges SCREW 4.0 CANC PT 10MM 207.010 48713428_1 CDM 0278 RC inpatient 138 89.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 107.64 78 999999999 83.56 133.86 percent of total billed charges SCREW 4.0 CANC PT 10MM 207.010 48713428_1 CDM 0278 RC inpatient 138 89.7 SIHO - ALL PLANS SIHO - ALL PLANS 124.2 90 999999999 83.56 133.86 percent of total billed charges SCREW 4.0 CANC PT 10MM 207.010 48713428_1 CDM 0278 RC inpatient 138 89.7 UMR - ALL PLANS UMR - ALL PLANS 96.6 70 999999999 83.56 133.86 percent of total billed charges SCREW 4.0 CANC PT 10MM 207.010 48713428_1 CDM 0278 RC inpatient 138 89.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 83.56 60.55 999999999 83.56 133.86 percent of total billed charges SCREW 4.0 CANC PT 10MM 207.010 48713428_1 CDM 0278 RC inpatient 138 89.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 83.56 133.86 SCREW 4.0 CANC PT 10MM 207.010 48713428_1 CDM 0278 RC inpatient 138 89.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 83.56 133.86 SCREW 4.0 CANC PT 10MM 207.010 48713428_1 CDM 0278 RC inpatient 138 89.7 ANTHEM HMO ANTHEM HMO 999999999 83.56 133.86 SCREW 4.0 CANC PT 10MM 207.010 48713428_1 CDM 0278 RC inpatient 138 89.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.29 67.6 999999999 83.56 133.86 percent of total billed charges SCREW 4.0 CANC PT 10MM 207.010 48713428_1 CDM 0278 RC inpatient 138 89.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 83.56 133.86 SCREW 4.0 CANC PT 10MM 207.010 48713428_1 CDM 0278 RC inpatient 138 89.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 83.56 133.86 SCREW 4.0 CANC PT 12MM 207.012 48713429_1 CDM 0278 RC inpatient 126 81.9 AETNA AETNA 99.54 79 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 12MM 207.012 48713429_1 CDM 0278 RC inpatient 126 81.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.9 65 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 12MM 207.012 48713429_1 CDM 0278 RC inpatient 126 81.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 122.22 97 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 12MM 207.012 48713429_1 CDM 0278 RC inpatient 126 81.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.94 69 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 12MM 207.012 48713429_1 CDM 0278 RC inpatient 126 81.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 98.28 78 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 12MM 207.012 48713429_1 CDM 0278 RC inpatient 126 81.9 SIHO - ALL PLANS SIHO - ALL PLANS 113.4 90 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 12MM 207.012 48713429_1 CDM 0278 RC inpatient 126 81.9 UMR - ALL PLANS UMR - ALL PLANS 88.2 70 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 12MM 207.012 48713429_1 CDM 0278 RC inpatient 126 81.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.29 60.55 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 12MM 207.012 48713429_1 CDM 0278 RC inpatient 126 81.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.29 122.22 SCREW 4.0 CANC PT 12MM 207.012 48713429_1 CDM 0278 RC inpatient 126 81.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.29 122.22 SCREW 4.0 CANC PT 12MM 207.012 48713429_1 CDM 0278 RC inpatient 126 81.9 ANTHEM HMO ANTHEM HMO 999999999 76.29 122.22 SCREW 4.0 CANC PT 12MM 207.012 48713429_1 CDM 0278 RC inpatient 126 81.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.18 67.6 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 12MM 207.012 48713429_1 CDM 0278 RC inpatient 126 81.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.29 122.22 SCREW 4.0 CANC PT 12MM 207.012 48713429_1 CDM 0278 RC inpatient 126 81.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.29 122.22 SCREW 4.0 CANC PT 14MM 207.014 48713430_1 CDM 0278 RC inpatient 126 81.9 AETNA AETNA 99.54 79 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 14MM 207.014 48713430_1 CDM 0278 RC inpatient 126 81.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.9 65 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 14MM 207.014 48713430_1 CDM 0278 RC inpatient 126 81.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 122.22 97 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 14MM 207.014 48713430_1 CDM 0278 RC inpatient 126 81.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.94 69 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 14MM 207.014 48713430_1 CDM 0278 RC inpatient 126 81.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 98.28 78 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 14MM 207.014 48713430_1 CDM 0278 RC inpatient 126 81.9 SIHO - ALL PLANS SIHO - ALL PLANS 113.4 90 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 14MM 207.014 48713430_1 CDM 0278 RC inpatient 126 81.9 UMR - ALL PLANS UMR - ALL PLANS 88.2 70 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 14MM 207.014 48713430_1 CDM 0278 RC inpatient 126 81.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.29 60.55 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 14MM 207.014 48713430_1 CDM 0278 RC inpatient 126 81.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.29 122.22 SCREW 4.0 CANC PT 14MM 207.014 48713430_1 CDM 0278 RC inpatient 126 81.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.29 122.22 SCREW 4.0 CANC PT 14MM 207.014 48713430_1 CDM 0278 RC inpatient 126 81.9 ANTHEM HMO ANTHEM HMO 999999999 76.29 122.22 SCREW 4.0 CANC PT 14MM 207.014 48713430_1 CDM 0278 RC inpatient 126 81.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.18 67.6 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 14MM 207.014 48713430_1 CDM 0278 RC inpatient 126 81.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.29 122.22 SCREW 4.0 CANC PT 14MM 207.014 48713430_1 CDM 0278 RC inpatient 126 81.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.29 122.22 SCREW 4.0 CANC PT 16MM 207.016 48713431_1 CDM 0278 RC inpatient 126 81.9 AETNA AETNA 99.54 79 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 16MM 207.016 48713431_1 CDM 0278 RC inpatient 126 81.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.9 65 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 16MM 207.016 48713431_1 CDM 0278 RC inpatient 126 81.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 122.22 97 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 16MM 207.016 48713431_1 CDM 0278 RC inpatient 126 81.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.94 69 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 16MM 207.016 48713431_1 CDM 0278 RC inpatient 126 81.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 98.28 78 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 16MM 207.016 48713431_1 CDM 0278 RC inpatient 126 81.9 SIHO - ALL PLANS SIHO - ALL PLANS 113.4 90 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 16MM 207.016 48713431_1 CDM 0278 RC inpatient 126 81.9 UMR - ALL PLANS UMR - ALL PLANS 88.2 70 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 16MM 207.016 48713431_1 CDM 0278 RC inpatient 126 81.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.29 60.55 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 16MM 207.016 48713431_1 CDM 0278 RC inpatient 126 81.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.29 122.22 SCREW 4.0 CANC PT 16MM 207.016 48713431_1 CDM 0278 RC inpatient 126 81.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.29 122.22 SCREW 4.0 CANC PT 16MM 207.016 48713431_1 CDM 0278 RC inpatient 126 81.9 ANTHEM HMO ANTHEM HMO 999999999 76.29 122.22 SCREW 4.0 CANC PT 16MM 207.016 48713431_1 CDM 0278 RC inpatient 126 81.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.18 67.6 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 16MM 207.016 48713431_1 CDM 0278 RC inpatient 126 81.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.29 122.22 SCREW 4.0 CANC PT 16MM 207.016 48713431_1 CDM 0278 RC inpatient 126 81.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.29 122.22 DHS 135 SHORT BAR 4HOLE 281.54 48713432_1 CDM 0278 RC inpatient 2974 1933.1 AETNA AETNA 2349.46 79 999999999 1800.76 2884.78 percent of total billed charges DHS 135 SHORT BAR 4HOLE 281.54 48713432_1 CDM 0278 RC inpatient 2974 1933.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1933.1 65 999999999 1800.76 2884.78 percent of total billed charges DHS 135 SHORT BAR 4HOLE 281.54 48713432_1 CDM 0278 RC inpatient 2974 1933.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2884.78 97 999999999 1800.76 2884.78 percent of total billed charges DHS 135 SHORT BAR 4HOLE 281.54 48713432_1 CDM 0278 RC inpatient 2974 1933.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 2052.06 69 999999999 1800.76 2884.78 percent of total billed charges DHS 135 SHORT BAR 4HOLE 281.54 48713432_1 CDM 0278 RC inpatient 2974 1933.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 2319.72 78 999999999 1800.76 2884.78 percent of total billed charges DHS 135 SHORT BAR 4HOLE 281.54 48713432_1 CDM 0278 RC inpatient 2974 1933.1 SIHO - ALL PLANS SIHO - ALL PLANS 2676.6 90 999999999 1800.76 2884.78 percent of total billed charges DHS 135 SHORT BAR 4HOLE 281.54 48713432_1 CDM 0278 RC inpatient 2974 1933.1 UMR - ALL PLANS UMR - ALL PLANS 2081.8 70 999999999 1800.76 2884.78 percent of total billed charges DHS 135 SHORT BAR 4HOLE 281.54 48713432_1 CDM 0278 RC inpatient 2974 1933.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1800.76 60.55 999999999 1800.76 2884.78 percent of total billed charges DHS 135 SHORT BAR 4HOLE 281.54 48713432_1 CDM 0278 RC inpatient 2974 1933.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1800.76 2884.78 DHS 135 SHORT BAR 4HOLE 281.54 48713432_1 CDM 0278 RC inpatient 2974 1933.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1800.76 2884.78 DHS 135 SHORT BAR 4HOLE 281.54 48713432_1 CDM 0278 RC inpatient 2974 1933.1 ANTHEM HMO ANTHEM HMO 999999999 1800.76 2884.78 DHS 135 SHORT BAR 4HOLE 281.54 48713432_1 CDM 0278 RC inpatient 2974 1933.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 2010.42 67.6 999999999 1800.76 2884.78 percent of total billed charges DHS 135 SHORT BAR 4HOLE 281.54 48713432_1 CDM 0278 RC inpatient 2974 1933.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1800.76 2884.78 DHS 135 SHORT BAR 4HOLE 281.54 48713432_1 CDM 0278 RC inpatient 2974 1933.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1800.76 2884.78 SCREW 4.0 CANC PT 18MM 207.018 48713433_1 CDM 0278 RC inpatient 126 81.9 AETNA AETNA 99.54 79 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 18MM 207.018 48713433_1 CDM 0278 RC inpatient 126 81.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.9 65 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 18MM 207.018 48713433_1 CDM 0278 RC inpatient 126 81.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 122.22 97 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 18MM 207.018 48713433_1 CDM 0278 RC inpatient 126 81.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.94 69 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 18MM 207.018 48713433_1 CDM 0278 RC inpatient 126 81.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 98.28 78 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 18MM 207.018 48713433_1 CDM 0278 RC inpatient 126 81.9 SIHO - ALL PLANS SIHO - ALL PLANS 113.4 90 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 18MM 207.018 48713433_1 CDM 0278 RC inpatient 126 81.9 UMR - ALL PLANS UMR - ALL PLANS 88.2 70 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 18MM 207.018 48713433_1 CDM 0278 RC inpatient 126 81.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.29 60.55 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 18MM 207.018 48713433_1 CDM 0278 RC inpatient 126 81.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.29 122.22 SCREW 4.0 CANC PT 18MM 207.018 48713433_1 CDM 0278 RC inpatient 126 81.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.29 122.22 SCREW 4.0 CANC PT 18MM 207.018 48713433_1 CDM 0278 RC inpatient 126 81.9 ANTHEM HMO ANTHEM HMO 999999999 76.29 122.22 SCREW 4.0 CANC PT 18MM 207.018 48713433_1 CDM 0278 RC inpatient 126 81.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.18 67.6 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 18MM 207.018 48713433_1 CDM 0278 RC inpatient 126 81.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.29 122.22 SCREW 4.0 CANC PT 18MM 207.018 48713433_1 CDM 0278 RC inpatient 126 81.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.29 122.22 SCREW 4.0 CANC PT 20MM 207.020 48713434_1 CDM 0278 RC inpatient 126 81.9 AETNA AETNA 99.54 79 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 20MM 207.020 48713434_1 CDM 0278 RC inpatient 126 81.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.9 65 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 20MM 207.020 48713434_1 CDM 0278 RC inpatient 126 81.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 122.22 97 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 20MM 207.020 48713434_1 CDM 0278 RC inpatient 126 81.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.94 69 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 20MM 207.020 48713434_1 CDM 0278 RC inpatient 126 81.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 98.28 78 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 20MM 207.020 48713434_1 CDM 0278 RC inpatient 126 81.9 SIHO - ALL PLANS SIHO - ALL PLANS 113.4 90 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 20MM 207.020 48713434_1 CDM 0278 RC inpatient 126 81.9 UMR - ALL PLANS UMR - ALL PLANS 88.2 70 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 20MM 207.020 48713434_1 CDM 0278 RC inpatient 126 81.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.29 60.55 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 20MM 207.020 48713434_1 CDM 0278 RC inpatient 126 81.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.29 122.22 SCREW 4.0 CANC PT 20MM 207.020 48713434_1 CDM 0278 RC inpatient 126 81.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.29 122.22 SCREW 4.0 CANC PT 20MM 207.020 48713434_1 CDM 0278 RC inpatient 126 81.9 ANTHEM HMO ANTHEM HMO 999999999 76.29 122.22 SCREW 4.0 CANC PT 20MM 207.020 48713434_1 CDM 0278 RC inpatient 126 81.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.18 67.6 999999999 76.29 122.22 percent of total billed charges SCREW 4.0 CANC PT 20MM 207.020 48713434_1 CDM 0278 RC inpatient 126 81.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.29 122.22 SCREW 4.0 CANC PT 20MM 207.020 48713434_1 CDM 0278 RC inpatient 126 81.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.29 122.22 SCREW 4.0 CANC PT 22MM 207.022 48713435_1 CDM 0278 RC inpatient 130 84.5 AETNA AETNA 102.7 79 999999999 78.72 126.1 percent of total billed charges SCREW 4.0 CANC PT 22MM 207.022 48713435_1 CDM 0278 RC inpatient 130 84.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 84.5 65 999999999 78.72 126.1 percent of total billed charges SCREW 4.0 CANC PT 22MM 207.022 48713435_1 CDM 0278 RC inpatient 130 84.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 126.1 97 999999999 78.72 126.1 percent of total billed charges SCREW 4.0 CANC PT 22MM 207.022 48713435_1 CDM 0278 RC inpatient 130 84.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.7 69 999999999 78.72 126.1 percent of total billed charges SCREW 4.0 CANC PT 22MM 207.022 48713435_1 CDM 0278 RC inpatient 130 84.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 101.4 78 999999999 78.72 126.1 percent of total billed charges SCREW 4.0 CANC PT 22MM 207.022 48713435_1 CDM 0278 RC inpatient 130 84.5 SIHO - ALL PLANS SIHO - ALL PLANS 117 90 999999999 78.72 126.1 percent of total billed charges SCREW 4.0 CANC PT 22MM 207.022 48713435_1 CDM 0278 RC inpatient 130 84.5 UMR - ALL PLANS UMR - ALL PLANS 91 70 999999999 78.72 126.1 percent of total billed charges SCREW 4.0 CANC PT 22MM 207.022 48713435_1 CDM 0278 RC inpatient 130 84.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.72 60.55 999999999 78.72 126.1 percent of total billed charges SCREW 4.0 CANC PT 22MM 207.022 48713435_1 CDM 0278 RC inpatient 130 84.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.72 126.1 SCREW 4.0 CANC PT 22MM 207.022 48713435_1 CDM 0278 RC inpatient 130 84.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.72 126.1 SCREW 4.0 CANC PT 22MM 207.022 48713435_1 CDM 0278 RC inpatient 130 84.5 ANTHEM HMO ANTHEM HMO 999999999 78.72 126.1 SCREW 4.0 CANC PT 22MM 207.022 48713435_1 CDM 0278 RC inpatient 130 84.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.88 67.6 999999999 78.72 126.1 percent of total billed charges SCREW 4.0 CANC PT 22MM 207.022 48713435_1 CDM 0278 RC inpatient 130 84.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.72 126.1 SCREW 4.0 CANC PT 22MM 207.022 48713435_1 CDM 0278 RC inpatient 130 84.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.72 126.1 SCREW 4.0 CANC PT 24MM 207.024 48713436_1 CDM 0278 RC inpatient 127 82.55 AETNA AETNA 100.33 79 999999999 76.9 123.19 percent of total billed charges SCREW 4.0 CANC PT 24MM 207.024 48713436_1 CDM 0278 RC inpatient 127 82.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 82.55 65 999999999 76.9 123.19 percent of total billed charges SCREW 4.0 CANC PT 24MM 207.024 48713436_1 CDM 0278 RC inpatient 127 82.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 123.19 97 999999999 76.9 123.19 percent of total billed charges SCREW 4.0 CANC PT 24MM 207.024 48713436_1 CDM 0278 RC inpatient 127 82.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 87.63 69 999999999 76.9 123.19 percent of total billed charges SCREW 4.0 CANC PT 24MM 207.024 48713436_1 CDM 0278 RC inpatient 127 82.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 99.06 78 999999999 76.9 123.19 percent of total billed charges SCREW 4.0 CANC PT 24MM 207.024 48713436_1 CDM 0278 RC inpatient 127 82.55 SIHO - ALL PLANS SIHO - ALL PLANS 114.3 90 999999999 76.9 123.19 percent of total billed charges SCREW 4.0 CANC PT 24MM 207.024 48713436_1 CDM 0278 RC inpatient 127 82.55 UMR - ALL PLANS UMR - ALL PLANS 88.9 70 999999999 76.9 123.19 percent of total billed charges SCREW 4.0 CANC PT 24MM 207.024 48713436_1 CDM 0278 RC inpatient 127 82.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.9 60.55 999999999 76.9 123.19 percent of total billed charges SCREW 4.0 CANC PT 24MM 207.024 48713436_1 CDM 0278 RC inpatient 127 82.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.9 123.19 SCREW 4.0 CANC PT 24MM 207.024 48713436_1 CDM 0278 RC inpatient 127 82.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.9 123.19 SCREW 4.0 CANC PT 24MM 207.024 48713436_1 CDM 0278 RC inpatient 127 82.55 ANTHEM HMO ANTHEM HMO 999999999 76.9 123.19 SCREW 4.0 CANC PT 24MM 207.024 48713436_1 CDM 0278 RC inpatient 127 82.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.85 67.6 999999999 76.9 123.19 percent of total billed charges SCREW 4.0 CANC PT 24MM 207.024 48713436_1 CDM 0278 RC inpatient 127 82.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.9 123.19 SCREW 4.0 CANC PT 24MM 207.024 48713436_1 CDM 0278 RC inpatient 127 82.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.9 123.19 SCREW 4.0 CANC PT 26MM 207.026 48713437_1 CDM 0278 RC inpatient 127 82.55 AETNA AETNA 100.33 79 999999999 76.9 123.19 percent of total billed charges SCREW 4.0 CANC PT 26MM 207.026 48713437_1 CDM 0278 RC inpatient 127 82.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 82.55 65 999999999 76.9 123.19 percent of total billed charges SCREW 4.0 CANC PT 26MM 207.026 48713437_1 CDM 0278 RC inpatient 127 82.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 123.19 97 999999999 76.9 123.19 percent of total billed charges SCREW 4.0 CANC PT 26MM 207.026 48713437_1 CDM 0278 RC inpatient 127 82.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 87.63 69 999999999 76.9 123.19 percent of total billed charges SCREW 4.0 CANC PT 26MM 207.026 48713437_1 CDM 0278 RC inpatient 127 82.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 99.06 78 999999999 76.9 123.19 percent of total billed charges SCREW 4.0 CANC PT 26MM 207.026 48713437_1 CDM 0278 RC inpatient 127 82.55 SIHO - ALL PLANS SIHO - ALL PLANS 114.3 90 999999999 76.9 123.19 percent of total billed charges SCREW 4.0 CANC PT 26MM 207.026 48713437_1 CDM 0278 RC inpatient 127 82.55 UMR - ALL PLANS UMR - ALL PLANS 88.9 70 999999999 76.9 123.19 percent of total billed charges SCREW 4.0 CANC PT 26MM 207.026 48713437_1 CDM 0278 RC inpatient 127 82.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.9 60.55 999999999 76.9 123.19 percent of total billed charges SCREW 4.0 CANC PT 26MM 207.026 48713437_1 CDM 0278 RC inpatient 127 82.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.9 123.19 SCREW 4.0 CANC PT 26MM 207.026 48713437_1 CDM 0278 RC inpatient 127 82.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.9 123.19 SCREW 4.0 CANC PT 26MM 207.026 48713437_1 CDM 0278 RC inpatient 127 82.55 ANTHEM HMO ANTHEM HMO 999999999 76.9 123.19 SCREW 4.0 CANC PT 26MM 207.026 48713437_1 CDM 0278 RC inpatient 127 82.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.85 67.6 999999999 76.9 123.19 percent of total billed charges SCREW 4.0 CANC PT 26MM 207.026 48713437_1 CDM 0278 RC inpatient 127 82.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.9 123.19 SCREW 4.0 CANC PT 26MM 207.026 48713437_1 CDM 0278 RC inpatient 127 82.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.9 123.19 SCREW 4.0 CANC PT 28MM 207.028 48713438_1 CDM 0278 RC inpatient 134 87.1 AETNA AETNA 105.86 79 999999999 81.14 129.98 percent of total billed charges SCREW 4.0 CANC PT 28MM 207.028 48713438_1 CDM 0278 RC inpatient 134 87.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 87.1 65 999999999 81.14 129.98 percent of total billed charges SCREW 4.0 CANC PT 28MM 207.028 48713438_1 CDM 0278 RC inpatient 134 87.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.98 97 999999999 81.14 129.98 percent of total billed charges SCREW 4.0 CANC PT 28MM 207.028 48713438_1 CDM 0278 RC inpatient 134 87.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 92.46 69 999999999 81.14 129.98 percent of total billed charges SCREW 4.0 CANC PT 28MM 207.028 48713438_1 CDM 0278 RC inpatient 134 87.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 104.52 78 999999999 81.14 129.98 percent of total billed charges SCREW 4.0 CANC PT 28MM 207.028 48713438_1 CDM 0278 RC inpatient 134 87.1 SIHO - ALL PLANS SIHO - ALL PLANS 120.6 90 999999999 81.14 129.98 percent of total billed charges SCREW 4.0 CANC PT 28MM 207.028 48713438_1 CDM 0278 RC inpatient 134 87.1 UMR - ALL PLANS UMR - ALL PLANS 93.8 70 999999999 81.14 129.98 percent of total billed charges SCREW 4.0 CANC PT 28MM 207.028 48713438_1 CDM 0278 RC inpatient 134 87.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 81.14 60.55 999999999 81.14 129.98 percent of total billed charges SCREW 4.0 CANC PT 28MM 207.028 48713438_1 CDM 0278 RC inpatient 134 87.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 81.14 129.98 SCREW 4.0 CANC PT 28MM 207.028 48713438_1 CDM 0278 RC inpatient 134 87.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 81.14 129.98 SCREW 4.0 CANC PT 28MM 207.028 48713438_1 CDM 0278 RC inpatient 134 87.1 ANTHEM HMO ANTHEM HMO 999999999 81.14 129.98 SCREW 4.0 CANC PT 28MM 207.028 48713438_1 CDM 0278 RC inpatient 134 87.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 90.58 67.6 999999999 81.14 129.98 percent of total billed charges SCREW 4.0 CANC PT 28MM 207.028 48713438_1 CDM 0278 RC inpatient 134 87.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 81.14 129.98 SCREW 4.0 CANC PT 28MM 207.028 48713438_1 CDM 0278 RC inpatient 134 87.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 81.14 129.98 SCREW 4.0 CANC PT 30MM 207.030 48713439_1 CDM 0278 RC inpatient 120 78 AETNA AETNA 94.8 79 999999999 72.66 116.4 percent of total billed charges SCREW 4.0 CANC PT 30MM 207.030 48713439_1 CDM 0278 RC inpatient 120 78 SELF PAY DISCOUNT SELF PAY DISCOUNT 78 65 999999999 72.66 116.4 percent of total billed charges SCREW 4.0 CANC PT 30MM 207.030 48713439_1 CDM 0278 RC inpatient 120 78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.4 97 999999999 72.66 116.4 percent of total billed charges SCREW 4.0 CANC PT 30MM 207.030 48713439_1 CDM 0278 RC inpatient 120 78 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.8 69 999999999 72.66 116.4 percent of total billed charges SCREW 4.0 CANC PT 30MM 207.030 48713439_1 CDM 0278 RC inpatient 120 78 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.6 78 999999999 72.66 116.4 percent of total billed charges SCREW 4.0 CANC PT 30MM 207.030 48713439_1 CDM 0278 RC inpatient 120 78 SIHO - ALL PLANS SIHO - ALL PLANS 108 90 999999999 72.66 116.4 percent of total billed charges SCREW 4.0 CANC PT 30MM 207.030 48713439_1 CDM 0278 RC inpatient 120 78 UMR - ALL PLANS UMR - ALL PLANS 84 70 999999999 72.66 116.4 percent of total billed charges SCREW 4.0 CANC PT 30MM 207.030 48713439_1 CDM 0278 RC inpatient 120 78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.66 60.55 999999999 72.66 116.4 percent of total billed charges SCREW 4.0 CANC PT 30MM 207.030 48713439_1 CDM 0278 RC inpatient 120 78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.66 116.4 SCREW 4.0 CANC PT 30MM 207.030 48713439_1 CDM 0278 RC inpatient 120 78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.66 116.4 SCREW 4.0 CANC PT 30MM 207.030 48713439_1 CDM 0278 RC inpatient 120 78 ANTHEM HMO ANTHEM HMO 999999999 72.66 116.4 SCREW 4.0 CANC PT 30MM 207.030 48713439_1 CDM 0278 RC inpatient 120 78 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.12 67.6 999999999 72.66 116.4 percent of total billed charges SCREW 4.0 CANC PT 30MM 207.030 48713439_1 CDM 0278 RC inpatient 120 78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.66 116.4 SCREW 4.0 CANC PT 30MM 207.030 48713439_1 CDM 0278 RC inpatient 120 78 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.66 116.4 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713440_1 CDM 0278 RC C1713 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713440_1 CDM 0278 RC C1713 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713440_1 CDM 0278 RC C1713 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713440_1 CDM 0278 RC C1713 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713440_1 CDM 0278 RC C1713 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713440_1 CDM 0278 RC C1713 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713440_1 CDM 0278 RC C1713 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713440_1 CDM 0278 RC C1713 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713440_1 CDM 0278 RC C1713 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713440_1 CDM 0278 RC C1713 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713440_1 CDM 0278 RC C1713 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713440_1 CDM 0278 RC C1713 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713440_1 CDM 0278 RC C1713 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713440_1 CDM 0278 RC C1713 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713441_1 CDM 0278 RC C1713 HCPCS inpatient 127 82.55 AETNA AETNA 100.33 79 999999999 76.9 123.19 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713441_1 CDM 0278 RC C1713 HCPCS inpatient 127 82.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 82.55 65 999999999 76.9 123.19 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713441_1 CDM 0278 RC C1713 HCPCS inpatient 127 82.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 123.19 97 999999999 76.9 123.19 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713441_1 CDM 0278 RC C1713 HCPCS inpatient 127 82.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 87.63 69 999999999 76.9 123.19 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713441_1 CDM 0278 RC C1713 HCPCS inpatient 127 82.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 99.06 78 999999999 76.9 123.19 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713441_1 CDM 0278 RC C1713 HCPCS inpatient 127 82.55 SIHO - ALL PLANS SIHO - ALL PLANS 114.3 90 999999999 76.9 123.19 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713441_1 CDM 0278 RC C1713 HCPCS inpatient 127 82.55 UMR - ALL PLANS UMR - ALL PLANS 88.9 70 999999999 76.9 123.19 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713441_1 CDM 0278 RC C1713 HCPCS inpatient 127 82.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.9 60.55 999999999 76.9 123.19 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713441_1 CDM 0278 RC C1713 HCPCS inpatient 127 82.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.9 123.19 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713441_1 CDM 0278 RC C1713 HCPCS inpatient 127 82.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.9 123.19 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713441_1 CDM 0278 RC C1713 HCPCS inpatient 127 82.55 ANTHEM HMO ANTHEM HMO 999999999 76.9 123.19 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713441_1 CDM 0278 RC C1713 HCPCS inpatient 127 82.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.85 67.6 999999999 76.9 123.19 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713441_1 CDM 0278 RC C1713 HCPCS inpatient 127 82.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.9 123.19 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713441_1 CDM 0278 RC C1713 HCPCS inpatient 127 82.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.9 123.19 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713442_1 CDM 0278 RC C1713 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713442_1 CDM 0278 RC C1713 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713442_1 CDM 0278 RC C1713 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713442_1 CDM 0278 RC C1713 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713442_1 CDM 0278 RC C1713 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713442_1 CDM 0278 RC C1713 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713442_1 CDM 0278 RC C1713 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713442_1 CDM 0278 RC C1713 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713442_1 CDM 0278 RC C1713 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713442_1 CDM 0278 RC C1713 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713442_1 CDM 0278 RC C1713 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713442_1 CDM 0278 RC C1713 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713442_1 CDM 0278 RC C1713 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713442_1 CDM 0278 RC C1713 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713443_1 CDM 0278 RC C1713 HCPCS inpatient 134 87.1 AETNA AETNA 105.86 79 999999999 81.14 129.98 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713443_1 CDM 0278 RC C1713 HCPCS inpatient 134 87.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 87.1 65 999999999 81.14 129.98 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713443_1 CDM 0278 RC C1713 HCPCS inpatient 134 87.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.98 97 999999999 81.14 129.98 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713443_1 CDM 0278 RC C1713 HCPCS inpatient 134 87.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 92.46 69 999999999 81.14 129.98 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713443_1 CDM 0278 RC C1713 HCPCS inpatient 134 87.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 104.52 78 999999999 81.14 129.98 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713443_1 CDM 0278 RC C1713 HCPCS inpatient 134 87.1 SIHO - ALL PLANS SIHO - ALL PLANS 120.6 90 999999999 81.14 129.98 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713443_1 CDM 0278 RC C1713 HCPCS inpatient 134 87.1 UMR - ALL PLANS UMR - ALL PLANS 93.8 70 999999999 81.14 129.98 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713443_1 CDM 0278 RC C1713 HCPCS inpatient 134 87.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 81.14 60.55 999999999 81.14 129.98 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713443_1 CDM 0278 RC C1713 HCPCS inpatient 134 87.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 81.14 129.98 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713443_1 CDM 0278 RC C1713 HCPCS inpatient 134 87.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 81.14 129.98 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713443_1 CDM 0278 RC C1713 HCPCS inpatient 134 87.1 ANTHEM HMO ANTHEM HMO 999999999 81.14 129.98 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713443_1 CDM 0278 RC C1713 HCPCS inpatient 134 87.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 90.58 67.6 999999999 81.14 129.98 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713443_1 CDM 0278 RC C1713 HCPCS inpatient 134 87.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 81.14 129.98 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713443_1 CDM 0278 RC C1713 HCPCS inpatient 134 87.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 81.14 129.98 DHS 135 SHORT BAR 6HOLE 281-56 48713444_1 CDM 0278 RC inpatient 1521 988.65 AETNA AETNA 1201.59 79 999999999 920.97 1475.37 percent of total billed charges DHS 135 SHORT BAR 6HOLE 281-56 48713444_1 CDM 0278 RC inpatient 1521 988.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 988.65 65 999999999 920.97 1475.37 percent of total billed charges DHS 135 SHORT BAR 6HOLE 281-56 48713444_1 CDM 0278 RC inpatient 1521 988.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1475.37 97 999999999 920.97 1475.37 percent of total billed charges DHS 135 SHORT BAR 6HOLE 281-56 48713444_1 CDM 0278 RC inpatient 1521 988.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1049.49 69 999999999 920.97 1475.37 percent of total billed charges DHS 135 SHORT BAR 6HOLE 281-56 48713444_1 CDM 0278 RC inpatient 1521 988.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1186.38 78 999999999 920.97 1475.37 percent of total billed charges DHS 135 SHORT BAR 6HOLE 281-56 48713444_1 CDM 0278 RC inpatient 1521 988.65 SIHO - ALL PLANS SIHO - ALL PLANS 1368.9 90 999999999 920.97 1475.37 percent of total billed charges DHS 135 SHORT BAR 6HOLE 281-56 48713444_1 CDM 0278 RC inpatient 1521 988.65 UMR - ALL PLANS UMR - ALL PLANS 1064.7 70 999999999 920.97 1475.37 percent of total billed charges DHS 135 SHORT BAR 6HOLE 281-56 48713444_1 CDM 0278 RC inpatient 1521 988.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 920.97 60.55 999999999 920.97 1475.37 percent of total billed charges DHS 135 SHORT BAR 6HOLE 281-56 48713444_1 CDM 0278 RC inpatient 1521 988.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 920.97 1475.37 DHS 135 SHORT BAR 6HOLE 281-56 48713444_1 CDM 0278 RC inpatient 1521 988.65 ANTHEM HMO ANTHEM HMO 999999999 920.97 1475.37 DHS 135 SHORT BAR 6HOLE 281-56 48713444_1 CDM 0278 RC inpatient 1521 988.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 920.97 1475.37 DHS 135 SHORT BAR 6HOLE 281-56 48713444_1 CDM 0278 RC inpatient 1521 988.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1028.2 67.6 999999999 920.97 1475.37 percent of total billed charges DHS 135 SHORT BAR 6HOLE 281-56 48713444_1 CDM 0278 RC inpatient 1521 988.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 920.97 1475.37 DHS 135 SHORT BAR 6HOLE 281-56 48713444_1 CDM 0278 RC inpatient 1521 988.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 920.97 1475.37 DHS 150 SHORT BAR 4HOLE 281.84 48713445_1 CDM 0278 RC inpatient 1695 1101.75 AETNA AETNA 1339.05 79 999999999 1026.32 1644.15 percent of total billed charges DHS 150 SHORT BAR 4HOLE 281.84 48713445_1 CDM 0278 RC inpatient 1695 1101.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1101.75 65 999999999 1026.32 1644.15 percent of total billed charges DHS 150 SHORT BAR 4HOLE 281.84 48713445_1 CDM 0278 RC inpatient 1695 1101.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1644.15 97 999999999 1026.32 1644.15 percent of total billed charges DHS 150 SHORT BAR 4HOLE 281.84 48713445_1 CDM 0278 RC inpatient 1695 1101.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1169.55 69 999999999 1026.32 1644.15 percent of total billed charges DHS 150 SHORT BAR 4HOLE 281.84 48713445_1 CDM 0278 RC inpatient 1695 1101.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1322.1 78 999999999 1026.32 1644.15 percent of total billed charges DHS 150 SHORT BAR 4HOLE 281.84 48713445_1 CDM 0278 RC inpatient 1695 1101.75 SIHO - ALL PLANS SIHO - ALL PLANS 1525.5 90 999999999 1026.32 1644.15 percent of total billed charges DHS 150 SHORT BAR 4HOLE 281.84 48713445_1 CDM 0278 RC inpatient 1695 1101.75 UMR - ALL PLANS UMR - ALL PLANS 1186.5 70 999999999 1026.32 1644.15 percent of total billed charges DHS 150 SHORT BAR 4HOLE 281.84 48713445_1 CDM 0278 RC inpatient 1695 1101.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1026.32 60.55 999999999 1026.32 1644.15 percent of total billed charges DHS 150 SHORT BAR 4HOLE 281.84 48713445_1 CDM 0278 RC inpatient 1695 1101.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1026.32 1644.15 DHS 150 SHORT BAR 4HOLE 281.84 48713445_1 CDM 0278 RC inpatient 1695 1101.75 ANTHEM HMO ANTHEM HMO 999999999 1026.32 1644.15 DHS 150 SHORT BAR 4HOLE 281.84 48713445_1 CDM 0278 RC inpatient 1695 1101.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1026.32 1644.15 DHS 150 SHORT BAR 4HOLE 281.84 48713445_1 CDM 0278 RC inpatient 1695 1101.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1145.82 67.6 999999999 1026.32 1644.15 percent of total billed charges DHS 150 SHORT BAR 4HOLE 281.84 48713445_1 CDM 0278 RC inpatient 1695 1101.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1026.32 1644.15 DHS 150 SHORT BAR 4HOLE 281.84 48713445_1 CDM 0278 RC inpatient 1695 1101.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1026.32 1644.15 DHS 150 SHORT BAR 6HOLE 281.86 48713446_1 CDM 0278 RC inpatient 1521 988.65 AETNA AETNA 1201.59 79 999999999 920.97 1475.37 percent of total billed charges DHS 150 SHORT BAR 6HOLE 281.86 48713446_1 CDM 0278 RC inpatient 1521 988.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 988.65 65 999999999 920.97 1475.37 percent of total billed charges DHS 150 SHORT BAR 6HOLE 281.86 48713446_1 CDM 0278 RC inpatient 1521 988.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1475.37 97 999999999 920.97 1475.37 percent of total billed charges DHS 150 SHORT BAR 6HOLE 281.86 48713446_1 CDM 0278 RC inpatient 1521 988.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1049.49 69 999999999 920.97 1475.37 percent of total billed charges DHS 150 SHORT BAR 6HOLE 281.86 48713446_1 CDM 0278 RC inpatient 1521 988.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1186.38 78 999999999 920.97 1475.37 percent of total billed charges DHS 150 SHORT BAR 6HOLE 281.86 48713446_1 CDM 0278 RC inpatient 1521 988.65 SIHO - ALL PLANS SIHO - ALL PLANS 1368.9 90 999999999 920.97 1475.37 percent of total billed charges DHS 150 SHORT BAR 6HOLE 281.86 48713446_1 CDM 0278 RC inpatient 1521 988.65 UMR - ALL PLANS UMR - ALL PLANS 1064.7 70 999999999 920.97 1475.37 percent of total billed charges DHS 150 SHORT BAR 6HOLE 281.86 48713446_1 CDM 0278 RC inpatient 1521 988.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 920.97 60.55 999999999 920.97 1475.37 percent of total billed charges DHS 150 SHORT BAR 6HOLE 281.86 48713446_1 CDM 0278 RC inpatient 1521 988.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 920.97 1475.37 DHS 150 SHORT BAR 6HOLE 281.86 48713446_1 CDM 0278 RC inpatient 1521 988.65 ANTHEM HMO ANTHEM HMO 999999999 920.97 1475.37 DHS 150 SHORT BAR 6HOLE 281.86 48713446_1 CDM 0278 RC inpatient 1521 988.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 920.97 1475.37 DHS 150 SHORT BAR 6HOLE 281.86 48713446_1 CDM 0278 RC inpatient 1521 988.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1028.2 67.6 999999999 920.97 1475.37 percent of total billed charges DHS 150 SHORT BAR 6HOLE 281.86 48713446_1 CDM 0278 RC inpatient 1521 988.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 920.97 1475.37 DHS 150 SHORT BAR 6HOLE 281.86 48713446_1 CDM 0278 RC inpatient 1521 988.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 920.97 1475.37 SM FRA 3.5 5 HOLE PLATE 445.15 48713447_1 CDM 0278 RC inpatient 1415 919.75 AETNA AETNA 1117.85 79 999999999 856.78 1372.55 percent of total billed charges SM FRA 3.5 5 HOLE PLATE 445.15 48713447_1 CDM 0278 RC inpatient 1415 919.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 919.75 65 999999999 856.78 1372.55 percent of total billed charges SM FRA 3.5 5 HOLE PLATE 445.15 48713447_1 CDM 0278 RC inpatient 1415 919.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1372.55 97 999999999 856.78 1372.55 percent of total billed charges SM FRA 3.5 5 HOLE PLATE 445.15 48713447_1 CDM 0278 RC inpatient 1415 919.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 976.35 69 999999999 856.78 1372.55 percent of total billed charges SM FRA 3.5 5 HOLE PLATE 445.15 48713447_1 CDM 0278 RC inpatient 1415 919.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1103.7 78 999999999 856.78 1372.55 percent of total billed charges SM FRA 3.5 5 HOLE PLATE 445.15 48713447_1 CDM 0278 RC inpatient 1415 919.75 SIHO - ALL PLANS SIHO - ALL PLANS 1273.5 90 999999999 856.78 1372.55 percent of total billed charges SM FRA 3.5 5 HOLE PLATE 445.15 48713447_1 CDM 0278 RC inpatient 1415 919.75 UMR - ALL PLANS UMR - ALL PLANS 990.5 70 999999999 856.78 1372.55 percent of total billed charges SM FRA 3.5 5 HOLE PLATE 445.15 48713447_1 CDM 0278 RC inpatient 1415 919.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 856.78 60.55 999999999 856.78 1372.55 percent of total billed charges SM FRA 3.5 5 HOLE PLATE 445.15 48713447_1 CDM 0278 RC inpatient 1415 919.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 856.78 1372.55 SM FRA 3.5 5 HOLE PLATE 445.15 48713447_1 CDM 0278 RC inpatient 1415 919.75 ANTHEM HMO ANTHEM HMO 999999999 856.78 1372.55 SM FRA 3.5 5 HOLE PLATE 445.15 48713447_1 CDM 0278 RC inpatient 1415 919.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 856.78 1372.55 SM FRA 3.5 5 HOLE PLATE 445.15 48713447_1 CDM 0278 RC inpatient 1415 919.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 956.54 67.6 999999999 856.78 1372.55 percent of total billed charges SM FRA 3.5 5 HOLE PLATE 445.15 48713447_1 CDM 0278 RC inpatient 1415 919.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 856.78 1372.55 SM FRA 3.5 5 HOLE PLATE 445.15 48713447_1 CDM 0278 RC inpatient 1415 919.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 856.78 1372.55 SM FRA 3.5 6 HOLE PLT 445.16 48713448_1 CDM 0278 RC inpatient 1633 1061.45 AETNA AETNA 1290.07 79 999999999 988.78 1584.01 percent of total billed charges SM FRA 3.5 6 HOLE PLT 445.16 48713448_1 CDM 0278 RC inpatient 1633 1061.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1061.45 65 999999999 988.78 1584.01 percent of total billed charges SM FRA 3.5 6 HOLE PLT 445.16 48713448_1 CDM 0278 RC inpatient 1633 1061.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1584.01 97 999999999 988.78 1584.01 percent of total billed charges SM FRA 3.5 6 HOLE PLT 445.16 48713448_1 CDM 0278 RC inpatient 1633 1061.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1126.77 69 999999999 988.78 1584.01 percent of total billed charges SM FRA 3.5 6 HOLE PLT 445.16 48713448_1 CDM 0278 RC inpatient 1633 1061.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1273.74 78 999999999 988.78 1584.01 percent of total billed charges SM FRA 3.5 6 HOLE PLT 445.16 48713448_1 CDM 0278 RC inpatient 1633 1061.45 SIHO - ALL PLANS SIHO - ALL PLANS 1469.7 90 999999999 988.78 1584.01 percent of total billed charges SM FRA 3.5 6 HOLE PLT 445.16 48713448_1 CDM 0278 RC inpatient 1633 1061.45 UMR - ALL PLANS UMR - ALL PLANS 1143.1 70 999999999 988.78 1584.01 percent of total billed charges SM FRA 3.5 6 HOLE PLT 445.16 48713448_1 CDM 0278 RC inpatient 1633 1061.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 988.78 60.55 999999999 988.78 1584.01 percent of total billed charges SM FRA 3.5 6 HOLE PLT 445.16 48713448_1 CDM 0278 RC inpatient 1633 1061.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 988.78 1584.01 SM FRA 3.5 6 HOLE PLT 445.16 48713448_1 CDM 0278 RC inpatient 1633 1061.45 ANTHEM HMO ANTHEM HMO 999999999 988.78 1584.01 SM FRA 3.5 6 HOLE PLT 445.16 48713448_1 CDM 0278 RC inpatient 1633 1061.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 988.78 1584.01 SM FRA 3.5 6 HOLE PLT 445.16 48713448_1 CDM 0278 RC inpatient 1633 1061.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1103.91 67.6 999999999 988.78 1584.01 percent of total billed charges SM FRA 3.5 6 HOLE PLT 445.16 48713448_1 CDM 0278 RC inpatient 1633 1061.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 988.78 1584.01 SM FRA 3.5 6 HOLE PLT 445.16 48713448_1 CDM 0278 RC inpatient 1633 1061.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 988.78 1584.01 SM FRA 3.5 7 HOLE PLT 445.17 48713449_1 CDM 0278 RC inpatient 1788 1162.2 AETNA AETNA 1412.52 79 999999999 1082.63 1734.36 percent of total billed charges SM FRA 3.5 7 HOLE PLT 445.17 48713449_1 CDM 0278 RC inpatient 1788 1162.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1162.2 65 999999999 1082.63 1734.36 percent of total billed charges SM FRA 3.5 7 HOLE PLT 445.17 48713449_1 CDM 0278 RC inpatient 1788 1162.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1734.36 97 999999999 1082.63 1734.36 percent of total billed charges SM FRA 3.5 7 HOLE PLT 445.17 48713449_1 CDM 0278 RC inpatient 1788 1162.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1233.72 69 999999999 1082.63 1734.36 percent of total billed charges SM FRA 3.5 7 HOLE PLT 445.17 48713449_1 CDM 0278 RC inpatient 1788 1162.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1394.64 78 999999999 1082.63 1734.36 percent of total billed charges SM FRA 3.5 7 HOLE PLT 445.17 48713449_1 CDM 0278 RC inpatient 1788 1162.2 SIHO - ALL PLANS SIHO - ALL PLANS 1609.2 90 999999999 1082.63 1734.36 percent of total billed charges SM FRA 3.5 7 HOLE PLT 445.17 48713449_1 CDM 0278 RC inpatient 1788 1162.2 UMR - ALL PLANS UMR - ALL PLANS 1251.6 70 999999999 1082.63 1734.36 percent of total billed charges SM FRA 3.5 7 HOLE PLT 445.17 48713449_1 CDM 0278 RC inpatient 1788 1162.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1082.63 60.55 999999999 1082.63 1734.36 percent of total billed charges SM FRA 3.5 7 HOLE PLT 445.17 48713449_1 CDM 0278 RC inpatient 1788 1162.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1082.63 1734.36 SM FRA 3.5 7 HOLE PLT 445.17 48713449_1 CDM 0278 RC inpatient 1788 1162.2 ANTHEM HMO ANTHEM HMO 999999999 1082.63 1734.36 SM FRA 3.5 7 HOLE PLT 445.17 48713449_1 CDM 0278 RC inpatient 1788 1162.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1082.63 1734.36 SM FRA 3.5 7 HOLE PLT 445.17 48713449_1 CDM 0278 RC inpatient 1788 1162.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1208.69 67.6 999999999 1082.63 1734.36 percent of total billed charges SM FRA 3.5 7 HOLE PLT 445.17 48713449_1 CDM 0278 RC inpatient 1788 1162.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1082.63 1734.36 SM FRA 3.5 7 HOLE PLT 445.17 48713449_1 CDM 0278 RC inpatient 1788 1162.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1082.63 1734.36 SM FRAG 3.5 8 HOLE PLT 445.18 48713450_1 CDM 0278 RC inpatient 1781 1157.65 AETNA AETNA 1406.99 79 999999999 1078.4 1727.57 percent of total billed charges SM FRAG 3.5 8 HOLE PLT 445.18 48713450_1 CDM 0278 RC inpatient 1781 1157.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1157.65 65 999999999 1078.4 1727.57 percent of total billed charges SM FRAG 3.5 8 HOLE PLT 445.18 48713450_1 CDM 0278 RC inpatient 1781 1157.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1727.57 97 999999999 1078.4 1727.57 percent of total billed charges SM FRAG 3.5 8 HOLE PLT 445.18 48713450_1 CDM 0278 RC inpatient 1781 1157.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1228.89 69 999999999 1078.4 1727.57 percent of total billed charges SM FRAG 3.5 8 HOLE PLT 445.18 48713450_1 CDM 0278 RC inpatient 1781 1157.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1389.18 78 999999999 1078.4 1727.57 percent of total billed charges SM FRAG 3.5 8 HOLE PLT 445.18 48713450_1 CDM 0278 RC inpatient 1781 1157.65 SIHO - ALL PLANS SIHO - ALL PLANS 1602.9 90 999999999 1078.4 1727.57 percent of total billed charges SM FRAG 3.5 8 HOLE PLT 445.18 48713450_1 CDM 0278 RC inpatient 1781 1157.65 UMR - ALL PLANS UMR - ALL PLANS 1246.7 70 999999999 1078.4 1727.57 percent of total billed charges SM FRAG 3.5 8 HOLE PLT 445.18 48713450_1 CDM 0278 RC inpatient 1781 1157.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1078.4 60.55 999999999 1078.4 1727.57 percent of total billed charges SM FRAG 3.5 8 HOLE PLT 445.18 48713450_1 CDM 0278 RC inpatient 1781 1157.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1078.4 1727.57 SM FRAG 3.5 8 HOLE PLT 445.18 48713450_1 CDM 0278 RC inpatient 1781 1157.65 ANTHEM HMO ANTHEM HMO 999999999 1078.4 1727.57 SM FRAG 3.5 8 HOLE PLT 445.18 48713450_1 CDM 0278 RC inpatient 1781 1157.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1078.4 1727.57 SM FRAG 3.5 8 HOLE PLT 445.18 48713450_1 CDM 0278 RC inpatient 1781 1157.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1203.96 67.6 999999999 1078.4 1727.57 percent of total billed charges SM FRAG 3.5 8 HOLE PLT 445.18 48713450_1 CDM 0278 RC inpatient 1781 1157.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1078.4 1727.57 SM FRAG 3.5 8 HOLE PLT 445.18 48713450_1 CDM 0278 RC inpatient 1781 1157.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1078.4 1727.57 1.5 DRILL BIT 110/85MM 310.16 48713451_1 CDM 0278 RC inpatient 306 198.9 AETNA AETNA 241.74 79 999999999 185.28 296.82 percent of total billed charges 1.5 DRILL BIT 110/85MM 310.16 48713451_1 CDM 0278 RC inpatient 306 198.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 198.9 65 999999999 185.28 296.82 percent of total billed charges 1.5 DRILL BIT 110/85MM 310.16 48713451_1 CDM 0278 RC inpatient 306 198.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 296.82 97 999999999 185.28 296.82 percent of total billed charges 1.5 DRILL BIT 110/85MM 310.16 48713451_1 CDM 0278 RC inpatient 306 198.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 211.14 69 999999999 185.28 296.82 percent of total billed charges 1.5 DRILL BIT 110/85MM 310.16 48713451_1 CDM 0278 RC inpatient 306 198.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 238.68 78 999999999 185.28 296.82 percent of total billed charges 1.5 DRILL BIT 110/85MM 310.16 48713451_1 CDM 0278 RC inpatient 306 198.9 SIHO - ALL PLANS SIHO - ALL PLANS 275.4 90 999999999 185.28 296.82 percent of total billed charges 1.5 DRILL BIT 110/85MM 310.16 48713451_1 CDM 0278 RC inpatient 306 198.9 UMR - ALL PLANS UMR - ALL PLANS 214.2 70 999999999 185.28 296.82 percent of total billed charges 1.5 DRILL BIT 110/85MM 310.16 48713451_1 CDM 0278 RC inpatient 306 198.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 185.28 60.55 999999999 185.28 296.82 percent of total billed charges 1.5 DRILL BIT 110/85MM 310.16 48713451_1 CDM 0278 RC inpatient 306 198.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 185.28 296.82 1.5 DRILL BIT 110/85MM 310.16 48713451_1 CDM 0278 RC inpatient 306 198.9 ANTHEM HMO ANTHEM HMO 999999999 185.28 296.82 1.5 DRILL BIT 110/85MM 310.16 48713451_1 CDM 0278 RC inpatient 306 198.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 185.28 296.82 1.5 DRILL BIT 110/85MM 310.16 48713451_1 CDM 0278 RC inpatient 306 198.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 206.86 67.6 999999999 185.28 296.82 percent of total billed charges 1.5 DRILL BIT 110/85MM 310.16 48713451_1 CDM 0278 RC inpatient 306 198.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 185.28 296.82 1.5 DRILL BIT 110/85MM 310.16 48713451_1 CDM 0278 RC inpatient 306 198.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 185.28 296.82 DRILL BIT 324.214 48713452_1 CDM 0278 RC inpatient 1371 891.15 AETNA AETNA 1083.09 79 999999999 830.14 1329.87 percent of total billed charges DRILL BIT 324.214 48713452_1 CDM 0278 RC inpatient 1371 891.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 891.15 65 999999999 830.14 1329.87 percent of total billed charges DRILL BIT 324.214 48713452_1 CDM 0278 RC inpatient 1371 891.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1329.87 97 999999999 830.14 1329.87 percent of total billed charges DRILL BIT 324.214 48713452_1 CDM 0278 RC inpatient 1371 891.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 945.99 69 999999999 830.14 1329.87 percent of total billed charges DRILL BIT 324.214 48713452_1 CDM 0278 RC inpatient 1371 891.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1069.38 78 999999999 830.14 1329.87 percent of total billed charges DRILL BIT 324.214 48713452_1 CDM 0278 RC inpatient 1371 891.15 SIHO - ALL PLANS SIHO - ALL PLANS 1233.9 90 999999999 830.14 1329.87 percent of total billed charges DRILL BIT 324.214 48713452_1 CDM 0278 RC inpatient 1371 891.15 UMR - ALL PLANS UMR - ALL PLANS 959.7 70 999999999 830.14 1329.87 percent of total billed charges DRILL BIT 324.214 48713452_1 CDM 0278 RC inpatient 1371 891.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 830.14 60.55 999999999 830.14 1329.87 percent of total billed charges DRILL BIT 324.214 48713452_1 CDM 0278 RC inpatient 1371 891.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 830.14 1329.87 DRILL BIT 324.214 48713452_1 CDM 0278 RC inpatient 1371 891.15 ANTHEM HMO ANTHEM HMO 999999999 830.14 1329.87 DRILL BIT 324.214 48713452_1 CDM 0278 RC inpatient 1371 891.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 830.14 1329.87 DRILL BIT 324.214 48713452_1 CDM 0278 RC inpatient 1371 891.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 926.8 67.6 999999999 830.14 1329.87 percent of total billed charges DRILL BIT 324.214 48713452_1 CDM 0278 RC inpatient 1371 891.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 830.14 1329.87 DRILL BIT 324.214 48713452_1 CDM 0278 RC inpatient 1371 891.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 830.14 1329.87 CANNULATED TAP 311.59 48713453_1 CDM 0278 RC inpatient 1118 726.7 AETNA AETNA 883.22 79 999999999 676.95 1084.46 percent of total billed charges CANNULATED TAP 311.59 48713453_1 CDM 0278 RC inpatient 1118 726.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 726.7 65 999999999 676.95 1084.46 percent of total billed charges CANNULATED TAP 311.59 48713453_1 CDM 0278 RC inpatient 1118 726.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1084.46 97 999999999 676.95 1084.46 percent of total billed charges CANNULATED TAP 311.59 48713453_1 CDM 0278 RC inpatient 1118 726.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 771.42 69 999999999 676.95 1084.46 percent of total billed charges CANNULATED TAP 311.59 48713453_1 CDM 0278 RC inpatient 1118 726.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 872.04 78 999999999 676.95 1084.46 percent of total billed charges CANNULATED TAP 311.59 48713453_1 CDM 0278 RC inpatient 1118 726.7 SIHO - ALL PLANS SIHO - ALL PLANS 1006.2 90 999999999 676.95 1084.46 percent of total billed charges CANNULATED TAP 311.59 48713453_1 CDM 0278 RC inpatient 1118 726.7 UMR - ALL PLANS UMR - ALL PLANS 782.6 70 999999999 676.95 1084.46 percent of total billed charges CANNULATED TAP 311.59 48713453_1 CDM 0278 RC inpatient 1118 726.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 676.95 60.55 999999999 676.95 1084.46 percent of total billed charges CANNULATED TAP 311.59 48713453_1 CDM 0278 RC inpatient 1118 726.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 676.95 1084.46 CANNULATED TAP 311.59 48713453_1 CDM 0278 RC inpatient 1118 726.7 ANTHEM HMO ANTHEM HMO 999999999 676.95 1084.46 CANNULATED TAP 311.59 48713453_1 CDM 0278 RC inpatient 1118 726.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 676.95 1084.46 CANNULATED TAP 311.59 48713453_1 CDM 0278 RC inpatient 1118 726.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 755.77 67.6 999999999 676.95 1084.46 percent of total billed charges CANNULATED TAP 311.59 48713453_1 CDM 0278 RC inpatient 1118 726.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 676.95 1084.46 CANNULATED TAP 311.59 48713453_1 CDM 0278 RC inpatient 1118 726.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 676.95 1084.46 CANNULATED TAP 311.63 48713454_1 CDM 0278 RC inpatient 2173 1412.45 AETNA AETNA 1716.67 79 999999999 1315.75 2107.81 percent of total billed charges CANNULATED TAP 311.63 48713454_1 CDM 0278 RC inpatient 2173 1412.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1412.45 65 999999999 1315.75 2107.81 percent of total billed charges CANNULATED TAP 311.63 48713454_1 CDM 0278 RC inpatient 2173 1412.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2107.81 97 999999999 1315.75 2107.81 percent of total billed charges CANNULATED TAP 311.63 48713454_1 CDM 0278 RC inpatient 2173 1412.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1499.37 69 999999999 1315.75 2107.81 percent of total billed charges CANNULATED TAP 311.63 48713454_1 CDM 0278 RC inpatient 2173 1412.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1694.94 78 999999999 1315.75 2107.81 percent of total billed charges CANNULATED TAP 311.63 48713454_1 CDM 0278 RC inpatient 2173 1412.45 SIHO - ALL PLANS SIHO - ALL PLANS 1955.7 90 999999999 1315.75 2107.81 percent of total billed charges CANNULATED TAP 311.63 48713454_1 CDM 0278 RC inpatient 2173 1412.45 UMR - ALL PLANS UMR - ALL PLANS 1521.1 70 999999999 1315.75 2107.81 percent of total billed charges CANNULATED TAP 311.63 48713454_1 CDM 0278 RC inpatient 2173 1412.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1315.75 60.55 999999999 1315.75 2107.81 percent of total billed charges CANNULATED TAP 311.63 48713454_1 CDM 0278 RC inpatient 2173 1412.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1315.75 2107.81 CANNULATED TAP 311.63 48713454_1 CDM 0278 RC inpatient 2173 1412.45 ANTHEM HMO ANTHEM HMO 999999999 1315.75 2107.81 CANNULATED TAP 311.63 48713454_1 CDM 0278 RC inpatient 2173 1412.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1315.75 2107.81 CANNULATED TAP 311.63 48713454_1 CDM 0278 RC inpatient 2173 1412.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1468.95 67.6 999999999 1315.75 2107.81 percent of total billed charges CANNULATED TAP 311.63 48713454_1 CDM 0278 RC inpatient 2173 1412.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1315.75 2107.81 CANNULATED TAP 311.63 48713454_1 CDM 0278 RC inpatient 2173 1412.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1315.75 2107.81 CANNULATED TAP 7.3MM 311.689 48713455_1 CDM 0278 RC inpatient 2495 1621.75 AETNA AETNA 1971.05 79 999999999 1510.72 2420.15 percent of total billed charges CANNULATED TAP 7.3MM 311.689 48713455_1 CDM 0278 RC inpatient 2495 1621.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1621.75 65 999999999 1510.72 2420.15 percent of total billed charges CANNULATED TAP 7.3MM 311.689 48713455_1 CDM 0278 RC inpatient 2495 1621.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2420.15 97 999999999 1510.72 2420.15 percent of total billed charges CANNULATED TAP 7.3MM 311.689 48713455_1 CDM 0278 RC inpatient 2495 1621.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1721.55 69 999999999 1510.72 2420.15 percent of total billed charges CANNULATED TAP 7.3MM 311.689 48713455_1 CDM 0278 RC inpatient 2495 1621.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1946.1 78 999999999 1510.72 2420.15 percent of total billed charges CANNULATED TAP 7.3MM 311.689 48713455_1 CDM 0278 RC inpatient 2495 1621.75 SIHO - ALL PLANS SIHO - ALL PLANS 2245.5 90 999999999 1510.72 2420.15 percent of total billed charges CANNULATED TAP 7.3MM 311.689 48713455_1 CDM 0278 RC inpatient 2495 1621.75 UMR - ALL PLANS UMR - ALL PLANS 1746.5 70 999999999 1510.72 2420.15 percent of total billed charges CANNULATED TAP 7.3MM 311.689 48713455_1 CDM 0278 RC inpatient 2495 1621.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1510.72 60.55 999999999 1510.72 2420.15 percent of total billed charges CANNULATED TAP 7.3MM 311.689 48713455_1 CDM 0278 RC inpatient 2495 1621.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1510.72 2420.15 CANNULATED TAP 7.3MM 311.689 48713455_1 CDM 0278 RC inpatient 2495 1621.75 ANTHEM HMO ANTHEM HMO 999999999 1510.72 2420.15 CANNULATED TAP 7.3MM 311.689 48713455_1 CDM 0278 RC inpatient 2495 1621.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1510.72 2420.15 CANNULATED TAP 7.3MM 311.689 48713455_1 CDM 0278 RC inpatient 2495 1621.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1686.62 67.6 999999999 1510.72 2420.15 percent of total billed charges CANNULATED TAP 7.3MM 311.689 48713455_1 CDM 0278 RC inpatient 2495 1621.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1510.72 2420.15 CANNULATED TAP 7.3MM 311.689 48713455_1 CDM 0278 RC inpatient 2495 1621.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1510.72 2420.15 SM. FRAG 1/3 TUBULAR 3H 441-33 48713456_1 CDM 0278 RC inpatient 217 141.05 AETNA AETNA 171.43 79 999999999 131.39 210.49 percent of total billed charges SM. FRAG 1/3 TUBULAR 3H 441-33 48713456_1 CDM 0278 RC inpatient 217 141.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 141.05 65 999999999 131.39 210.49 percent of total billed charges SM. FRAG 1/3 TUBULAR 3H 441-33 48713456_1 CDM 0278 RC inpatient 217 141.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 210.49 97 999999999 131.39 210.49 percent of total billed charges SM. FRAG 1/3 TUBULAR 3H 441-33 48713456_1 CDM 0278 RC inpatient 217 141.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 149.73 69 999999999 131.39 210.49 percent of total billed charges SM. FRAG 1/3 TUBULAR 3H 441-33 48713456_1 CDM 0278 RC inpatient 217 141.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 169.26 78 999999999 131.39 210.49 percent of total billed charges SM. FRAG 1/3 TUBULAR 3H 441-33 48713456_1 CDM 0278 RC inpatient 217 141.05 UMR - ALL PLANS UMR - ALL PLANS 151.9 70 999999999 131.39 210.49 percent of total billed charges SM. FRAG 1/3 TUBULAR 3H 441-33 48713456_1 CDM 0278 RC inpatient 217 141.05 SIHO - ALL PLANS SIHO - ALL PLANS 195.3 90 999999999 131.39 210.49 percent of total billed charges SM. FRAG 1/3 TUBULAR 3H 441-33 48713456_1 CDM 0278 RC inpatient 217 141.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 131.39 60.55 999999999 131.39 210.49 percent of total billed charges SM. FRAG 1/3 TUBULAR 3H 441-33 48713456_1 CDM 0278 RC inpatient 217 141.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 131.39 210.49 SM. FRAG 1/3 TUBULAR 3H 441-33 48713456_1 CDM 0278 RC inpatient 217 141.05 ANTHEM HMO ANTHEM HMO 999999999 131.39 210.49 SM. FRAG 1/3 TUBULAR 3H 441-33 48713456_1 CDM 0278 RC inpatient 217 141.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 131.39 210.49 SM. FRAG 1/3 TUBULAR 3H 441-33 48713456_1 CDM 0278 RC inpatient 217 141.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 146.69 67.6 999999999 131.39 210.49 percent of total billed charges SM. FRAG 1/3 TUBULAR 3H 441-33 48713456_1 CDM 0278 RC inpatient 217 141.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 131.39 210.49 SM. FRAG 1/3 TUBULAR 3H 441-33 48713456_1 CDM 0278 RC inpatient 217 141.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 131.39 210.49 SM. FRAG 1/3 TUBU/10H 441.40 48713457_1 CDM 0278 RC inpatient 633 411.45 AETNA AETNA 500.07 79 999999999 383.28 614.01 percent of total billed charges SM. FRAG 1/3 TUBU/10H 441.40 48713457_1 CDM 0278 RC inpatient 633 411.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 411.45 65 999999999 383.28 614.01 percent of total billed charges SM. FRAG 1/3 TUBU/10H 441.40 48713457_1 CDM 0278 RC inpatient 633 411.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 614.01 97 999999999 383.28 614.01 percent of total billed charges SM. FRAG 1/3 TUBU/10H 441.40 48713457_1 CDM 0278 RC inpatient 633 411.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 436.77 69 999999999 383.28 614.01 percent of total billed charges SM. FRAG 1/3 TUBU/10H 441.40 48713457_1 CDM 0278 RC inpatient 633 411.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 493.74 78 999999999 383.28 614.01 percent of total billed charges SM. FRAG 1/3 TUBU/10H 441.40 48713457_1 CDM 0278 RC inpatient 633 411.45 UMR - ALL PLANS UMR - ALL PLANS 443.1 70 999999999 383.28 614.01 percent of total billed charges SM. FRAG 1/3 TUBU/10H 441.40 48713457_1 CDM 0278 RC inpatient 633 411.45 SIHO - ALL PLANS SIHO - ALL PLANS 569.7 90 999999999 383.28 614.01 percent of total billed charges SM. FRAG 1/3 TUBU/10H 441.40 48713457_1 CDM 0278 RC inpatient 633 411.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 383.28 60.55 999999999 383.28 614.01 percent of total billed charges SM. FRAG 1/3 TUBU/10H 441.40 48713457_1 CDM 0278 RC inpatient 633 411.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 383.28 614.01 SM. FRAG 1/3 TUBU/10H 441.40 48713457_1 CDM 0278 RC inpatient 633 411.45 ANTHEM HMO ANTHEM HMO 999999999 383.28 614.01 SM. FRAG 1/3 TUBU/10H 441.40 48713457_1 CDM 0278 RC inpatient 633 411.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 383.28 614.01 SM. FRAG 1/3 TUBU/10H 441.40 48713457_1 CDM 0278 RC inpatient 633 411.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 427.91 67.6 999999999 383.28 614.01 percent of total billed charges SM. FRAG 1/3 TUBU/10H 441.40 48713457_1 CDM 0278 RC inpatient 633 411.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 383.28 614.01 SM. FRAG 1/3 TUBU/10H 441.40 48713457_1 CDM 0278 RC inpatient 633 411.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 383.28 614.01 SM FRAG WASHER 7.0MM 419.98 48713458_1 CDM 0278 RC inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges SM FRAG WASHER 7.0MM 419.98 48713458_1 CDM 0278 RC inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges SM FRAG WASHER 7.0MM 419.98 48713458_1 CDM 0278 RC inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges SM FRAG WASHER 7.0MM 419.98 48713458_1 CDM 0278 RC inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges SM FRAG WASHER 7.0MM 419.98 48713458_1 CDM 0278 RC inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges SM FRAG WASHER 7.0MM 419.98 48713458_1 CDM 0278 RC inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges SM FRAG WASHER 7.0MM 419.98 48713458_1 CDM 0278 RC inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges SM FRAG WASHER 7.0MM 419.98 48713458_1 CDM 0278 RC inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges SM FRAG WASHER 7.0MM 419.98 48713458_1 CDM 0278 RC inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 SM FRAG WASHER 7.0MM 419.98 48713458_1 CDM 0278 RC inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 SM FRAG WASHER 7.0MM 419.98 48713458_1 CDM 0278 RC inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 SM FRAG WASHER 7.0MM 419.98 48713458_1 CDM 0278 RC inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges SM FRAG WASHER 7.0MM 419.98 48713458_1 CDM 0278 RC inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 SM FRAG WASHER 7.0MM 419.98 48713458_1 CDM 0278 RC inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 TAP 4.0MM SM FRAG 311.34 48713459_1 CDM 0278 RC inpatient 639 415.35 AETNA AETNA 504.81 79 999999999 386.91 619.83 percent of total billed charges TAP 4.0MM SM FRAG 311.34 48713459_1 CDM 0278 RC inpatient 639 415.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 415.35 65 999999999 386.91 619.83 percent of total billed charges TAP 4.0MM SM FRAG 311.34 48713459_1 CDM 0278 RC inpatient 639 415.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 619.83 97 999999999 386.91 619.83 percent of total billed charges TAP 4.0MM SM FRAG 311.34 48713459_1 CDM 0278 RC inpatient 639 415.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 440.91 69 999999999 386.91 619.83 percent of total billed charges TAP 4.0MM SM FRAG 311.34 48713459_1 CDM 0278 RC inpatient 639 415.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 498.42 78 999999999 386.91 619.83 percent of total billed charges TAP 4.0MM SM FRAG 311.34 48713459_1 CDM 0278 RC inpatient 639 415.35 UMR - ALL PLANS UMR - ALL PLANS 447.3 70 999999999 386.91 619.83 percent of total billed charges TAP 4.0MM SM FRAG 311.34 48713459_1 CDM 0278 RC inpatient 639 415.35 SIHO - ALL PLANS SIHO - ALL PLANS 575.1 90 999999999 386.91 619.83 percent of total billed charges TAP 4.0MM SM FRAG 311.34 48713459_1 CDM 0278 RC inpatient 639 415.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 386.91 60.55 999999999 386.91 619.83 percent of total billed charges TAP 4.0MM SM FRAG 311.34 48713459_1 CDM 0278 RC inpatient 639 415.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 386.91 619.83 TAP 4.0MM SM FRAG 311.34 48713459_1 CDM 0278 RC inpatient 639 415.35 ANTHEM HMO ANTHEM HMO 999999999 386.91 619.83 TAP 4.0MM SM FRAG 311.34 48713459_1 CDM 0278 RC inpatient 639 415.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 386.91 619.83 TAP 4.0MM SM FRAG 311.34 48713459_1 CDM 0278 RC inpatient 639 415.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 431.96 67.6 999999999 386.91 619.83 percent of total billed charges TAP 4.0MM SM FRAG 311.34 48713459_1 CDM 0278 RC inpatient 639 415.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 386.91 619.83 TAP 4.0MM SM FRAG 311.34 48713459_1 CDM 0278 RC inpatient 639 415.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 386.91 619.83 4.5 CORTEX SCREW 54MM 214.054 48713460_1 CDM 0278 RC inpatient 115 74.75 AETNA AETNA 90.85 79 999999999 69.63 111.55 percent of total billed charges 4.5 CORTEX SCREW 54MM 214.054 48713460_1 CDM 0278 RC inpatient 115 74.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.75 65 999999999 69.63 111.55 percent of total billed charges 4.5 CORTEX SCREW 54MM 214.054 48713460_1 CDM 0278 RC inpatient 115 74.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 111.55 97 999999999 69.63 111.55 percent of total billed charges 4.5 CORTEX SCREW 54MM 214.054 48713460_1 CDM 0278 RC inpatient 115 74.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 79.35 69 999999999 69.63 111.55 percent of total billed charges 4.5 CORTEX SCREW 54MM 214.054 48713460_1 CDM 0278 RC inpatient 115 74.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 89.7 78 999999999 69.63 111.55 percent of total billed charges 4.5 CORTEX SCREW 54MM 214.054 48713460_1 CDM 0278 RC inpatient 115 74.75 UMR - ALL PLANS UMR - ALL PLANS 80.5 70 999999999 69.63 111.55 percent of total billed charges 4.5 CORTEX SCREW 54MM 214.054 48713460_1 CDM 0278 RC inpatient 115 74.75 SIHO - ALL PLANS SIHO - ALL PLANS 103.5 90 999999999 69.63 111.55 percent of total billed charges 4.5 CORTEX SCREW 54MM 214.054 48713460_1 CDM 0278 RC inpatient 115 74.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.63 60.55 999999999 69.63 111.55 percent of total billed charges 4.5 CORTEX SCREW 54MM 214.054 48713460_1 CDM 0278 RC inpatient 115 74.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.63 111.55 4.5 CORTEX SCREW 54MM 214.054 48713460_1 CDM 0278 RC inpatient 115 74.75 ANTHEM HMO ANTHEM HMO 999999999 69.63 111.55 4.5 CORTEX SCREW 54MM 214.054 48713460_1 CDM 0278 RC inpatient 115 74.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.63 111.55 4.5 CORTEX SCREW 54MM 214.054 48713460_1 CDM 0278 RC inpatient 115 74.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.74 67.6 999999999 69.63 111.55 percent of total billed charges 4.5 CORTEX SCREW 54MM 214.054 48713460_1 CDM 0278 RC inpatient 115 74.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.63 111.55 4.5 CORTEX SCREW 54MM 214.054 48713460_1 CDM 0278 RC inpatient 115 74.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.63 111.55 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713461_1 CDM 0278 RC C1713 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713461_1 CDM 0278 RC C1713 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713461_1 CDM 0278 RC C1713 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713461_1 CDM 0278 RC C1713 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713461_1 CDM 0278 RC C1713 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713461_1 CDM 0278 RC C1713 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713461_1 CDM 0278 RC C1713 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713461_1 CDM 0278 RC C1713 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713461_1 CDM 0278 RC C1713 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713461_1 CDM 0278 RC C1713 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713461_1 CDM 0278 RC C1713 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713461_1 CDM 0278 RC C1713 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713461_1 CDM 0278 RC C1713 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713461_1 CDM 0278 RC C1713 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 6.5 CANC 32/45MM 217.045 48713462_1 CDM 0278 RC inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges 6.5 CANC 32/45MM 217.045 48713462_1 CDM 0278 RC inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges 6.5 CANC 32/45MM 217.045 48713462_1 CDM 0278 RC inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges 6.5 CANC 32/45MM 217.045 48713462_1 CDM 0278 RC inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges 6.5 CANC 32/45MM 217.045 48713462_1 CDM 0278 RC inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges 6.5 CANC 32/45MM 217.045 48713462_1 CDM 0278 RC inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges 6.5 CANC 32/45MM 217.045 48713462_1 CDM 0278 RC inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges 6.5 CANC 32/45MM 217.045 48713462_1 CDM 0278 RC inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges 6.5 CANC 32/45MM 217.045 48713462_1 CDM 0278 RC inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 6.5 CANC 32/45MM 217.045 48713462_1 CDM 0278 RC inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 6.5 CANC 32/45MM 217.045 48713462_1 CDM 0278 RC inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 6.5 CANC 32/45MM 217.045 48713462_1 CDM 0278 RC inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges 6.5 CANC 32/45MM 217.045 48713462_1 CDM 0278 RC inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 6.5 CANC 32/45MM 217.045 48713462_1 CDM 0278 RC inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 6.5 CANC 32/55MM 217.055 48713463_1 CDM 0278 RC inpatient 238 154.7 AETNA AETNA 188.02 79 999999999 144.11 230.86 percent of total billed charges 6.5 CANC 32/55MM 217.055 48713463_1 CDM 0278 RC inpatient 238 154.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.7 65 999999999 144.11 230.86 percent of total billed charges 6.5 CANC 32/55MM 217.055 48713463_1 CDM 0278 RC inpatient 238 154.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 230.86 97 999999999 144.11 230.86 percent of total billed charges 6.5 CANC 32/55MM 217.055 48713463_1 CDM 0278 RC inpatient 238 154.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.22 69 999999999 144.11 230.86 percent of total billed charges 6.5 CANC 32/55MM 217.055 48713463_1 CDM 0278 RC inpatient 238 154.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 185.64 78 999999999 144.11 230.86 percent of total billed charges 6.5 CANC 32/55MM 217.055 48713463_1 CDM 0278 RC inpatient 238 154.7 UMR - ALL PLANS UMR - ALL PLANS 166.6 70 999999999 144.11 230.86 percent of total billed charges 6.5 CANC 32/55MM 217.055 48713463_1 CDM 0278 RC inpatient 238 154.7 SIHO - ALL PLANS SIHO - ALL PLANS 214.2 90 999999999 144.11 230.86 percent of total billed charges 6.5 CANC 32/55MM 217.055 48713463_1 CDM 0278 RC inpatient 238 154.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.11 60.55 999999999 144.11 230.86 percent of total billed charges 6.5 CANC 32/55MM 217.055 48713463_1 CDM 0278 RC inpatient 238 154.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.11 230.86 6.5 CANC 32/55MM 217.055 48713463_1 CDM 0278 RC inpatient 238 154.7 ANTHEM HMO ANTHEM HMO 999999999 144.11 230.86 6.5 CANC 32/55MM 217.055 48713463_1 CDM 0278 RC inpatient 238 154.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.11 230.86 6.5 CANC 32/55MM 217.055 48713463_1 CDM 0278 RC inpatient 238 154.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.89 67.6 999999999 144.11 230.86 percent of total billed charges 6.5 CANC 32/55MM 217.055 48713463_1 CDM 0278 RC inpatient 238 154.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.11 230.86 6.5 CANC 32/55MM 217.055 48713463_1 CDM 0278 RC inpatient 238 154.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.11 230.86 6.5 CANC 32/85MM 217.085 48713464_1 CDM 0278 RC inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 32/85MM 217.085 48713464_1 CDM 0278 RC inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 32/85MM 217.085 48713464_1 CDM 0278 RC inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 32/85MM 217.085 48713464_1 CDM 0278 RC inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 32/85MM 217.085 48713464_1 CDM 0278 RC inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 32/85MM 217.085 48713464_1 CDM 0278 RC inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 32/85MM 217.085 48713464_1 CDM 0278 RC inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 32/85MM 217.085 48713464_1 CDM 0278 RC inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 32/85MM 217.085 48713464_1 CDM 0278 RC inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 6.5 CANC 32/85MM 217.085 48713464_1 CDM 0278 RC inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 6.5 CANC 32/85MM 217.085 48713464_1 CDM 0278 RC inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 6.5 CANC 32/85MM 217.085 48713464_1 CDM 0278 RC inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 32/85MM 217.085 48713464_1 CDM 0278 RC inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 6.5 CANC 32/85MM 217.085 48713464_1 CDM 0278 RC inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 6.5 CANC SCREW 32/90MM 217.090 48713465_1 CDM 0278 RC inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges 6.5 CANC SCREW 32/90MM 217.090 48713465_1 CDM 0278 RC inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges 6.5 CANC SCREW 32/90MM 217.090 48713465_1 CDM 0278 RC inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges 6.5 CANC SCREW 32/90MM 217.090 48713465_1 CDM 0278 RC inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges 6.5 CANC SCREW 32/90MM 217.090 48713465_1 CDM 0278 RC inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges 6.5 CANC SCREW 32/90MM 217.090 48713465_1 CDM 0278 RC inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges 6.5 CANC SCREW 32/90MM 217.090 48713465_1 CDM 0278 RC inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges 6.5 CANC SCREW 32/90MM 217.090 48713465_1 CDM 0278 RC inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges 6.5 CANC SCREW 32/90MM 217.090 48713465_1 CDM 0278 RC inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 6.5 CANC SCREW 32/90MM 217.090 48713465_1 CDM 0278 RC inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 6.5 CANC SCREW 32/90MM 217.090 48713465_1 CDM 0278 RC inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 6.5 CANC SCREW 32/90MM 217.090 48713465_1 CDM 0278 RC inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges 6.5 CANC SCREW 32/90MM 217.090 48713465_1 CDM 0278 RC inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 6.5 CANC SCREW 32/90MM 217.090 48713465_1 CDM 0278 RC inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 6.5 CANC 32/100MM 217.100 48713466_1 CDM 0278 RC inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges 6.5 CANC 32/100MM 217.100 48713466_1 CDM 0278 RC inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges 6.5 CANC 32/100MM 217.100 48713466_1 CDM 0278 RC inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges 6.5 CANC 32/100MM 217.100 48713466_1 CDM 0278 RC inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges 6.5 CANC 32/100MM 217.100 48713466_1 CDM 0278 RC inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges 6.5 CANC 32/100MM 217.100 48713466_1 CDM 0278 RC inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges 6.5 CANC 32/100MM 217.100 48713466_1 CDM 0278 RC inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges 6.5 CANC 32/100MM 217.100 48713466_1 CDM 0278 RC inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges 6.5 CANC 32/100MM 217.100 48713466_1 CDM 0278 RC inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 6.5 CANC 32/100MM 217.100 48713466_1 CDM 0278 RC inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 6.5 CANC 32/100MM 217.100 48713466_1 CDM 0278 RC inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 6.5 CANC 32/100MM 217.100 48713466_1 CDM 0278 RC inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges 6.5 CANC 32/100MM 217.100 48713466_1 CDM 0278 RC inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 6.5 CANC 32/100MM 217.100 48713466_1 CDM 0278 RC inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 6.5 CANC 32/110MM 217.110 48713467_1 CDM 0278 RC inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges 6.5 CANC 32/110MM 217.110 48713467_1 CDM 0278 RC inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges 6.5 CANC 32/110MM 217.110 48713467_1 CDM 0278 RC inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges 6.5 CANC 32/110MM 217.110 48713467_1 CDM 0278 RC inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges 6.5 CANC 32/110MM 217.110 48713467_1 CDM 0278 RC inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges 6.5 CANC 32/110MM 217.110 48713467_1 CDM 0278 RC inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges 6.5 CANC 32/110MM 217.110 48713467_1 CDM 0278 RC inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges 6.5 CANC 32/110MM 217.110 48713467_1 CDM 0278 RC inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges 6.5 CANC 32/110MM 217.110 48713467_1 CDM 0278 RC inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 6.5 CANC 32/110MM 217.110 48713467_1 CDM 0278 RC inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 6.5 CANC 32/110MM 217.110 48713467_1 CDM 0278 RC inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 6.5 CANC 32/110MM 217.110 48713467_1 CDM 0278 RC inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges 6.5 CANC 32/110MM 217.110 48713467_1 CDM 0278 RC inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 6.5 CANC 32/110MM 217.110 48713467_1 CDM 0278 RC inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 6.5 CANC FULLY THR 25M 218025 48713468_1 CDM 0278 RC inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 25M 218025 48713468_1 CDM 0278 RC inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 25M 218025 48713468_1 CDM 0278 RC inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 25M 218025 48713468_1 CDM 0278 RC inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 25M 218025 48713468_1 CDM 0278 RC inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 25M 218025 48713468_1 CDM 0278 RC inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 25M 218025 48713468_1 CDM 0278 RC inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 25M 218025 48713468_1 CDM 0278 RC inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 25M 218025 48713468_1 CDM 0278 RC inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 6.5 CANC FULLY THR 25M 218025 48713468_1 CDM 0278 RC inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 6.5 CANC FULLY THR 25M 218025 48713468_1 CDM 0278 RC inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 6.5 CANC FULLY THR 25M 218025 48713468_1 CDM 0278 RC inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 25M 218025 48713468_1 CDM 0278 RC inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 6.5 CANC FULLY THR 25M 218025 48713468_1 CDM 0278 RC inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 6.5 CANC FULLY THR 30M 218.030 48713469_1 CDM 0278 RC inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 30M 218.030 48713469_1 CDM 0278 RC inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 30M 218.030 48713469_1 CDM 0278 RC inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 30M 218.030 48713469_1 CDM 0278 RC inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 30M 218.030 48713469_1 CDM 0278 RC inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 30M 218.030 48713469_1 CDM 0278 RC inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 30M 218.030 48713469_1 CDM 0278 RC inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 30M 218.030 48713469_1 CDM 0278 RC inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 30M 218.030 48713469_1 CDM 0278 RC inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 6.5 CANC FULLY THR 30M 218.030 48713469_1 CDM 0278 RC inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 6.5 CANC FULLY THR 30M 218.030 48713469_1 CDM 0278 RC inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 6.5 CANC FULLY THR 30M 218.030 48713469_1 CDM 0278 RC inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 30M 218.030 48713469_1 CDM 0278 RC inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 6.5 CANC FULLY THR 30M 218.030 48713469_1 CDM 0278 RC inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 6.5 CANC FULLY THR 35M 218.035 48713470_1 CDM 0278 RC inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 35M 218.035 48713470_1 CDM 0278 RC inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 35M 218.035 48713470_1 CDM 0278 RC inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 35M 218.035 48713470_1 CDM 0278 RC inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 35M 218.035 48713470_1 CDM 0278 RC inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 35M 218.035 48713470_1 CDM 0278 RC inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 35M 218.035 48713470_1 CDM 0278 RC inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 35M 218.035 48713470_1 CDM 0278 RC inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 35M 218.035 48713470_1 CDM 0278 RC inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 6.5 CANC FULLY THR 35M 218.035 48713470_1 CDM 0278 RC inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 6.5 CANC FULLY THR 35M 218.035 48713470_1 CDM 0278 RC inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 6.5 CANC FULLY THR 35M 218.035 48713470_1 CDM 0278 RC inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges 6.5 CANC FULLY THR 35M 218.035 48713470_1 CDM 0278 RC inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 6.5 CANC FULLY THR 35M 218.035 48713470_1 CDM 0278 RC inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713471_1 CDM 0278 RC C1713 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713472_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 AETNA AETNA 114.55 79 999999999 87.8 140.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713472_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.25 65 999999999 87.8 140.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713472_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 140.65 97 999999999 87.8 140.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713472_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.05 69 999999999 87.8 140.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713472_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.1 78 999999999 87.8 140.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713472_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 UMR - ALL PLANS UMR - ALL PLANS 101.5 70 999999999 87.8 140.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713472_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 SIHO - ALL PLANS SIHO - ALL PLANS 130.5 90 999999999 87.8 140.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713472_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.8 60.55 999999999 87.8 140.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713472_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.8 140.65 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713472_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.8 140.65 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713472_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 ANTHEM HMO ANTHEM HMO 999999999 87.8 140.65 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713472_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.02 67.6 999999999 87.8 140.65 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713472_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.8 140.65 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713472_1 CDM 0278 RC C1713 HCPCS inpatient 145 94.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.8 140.65 4.5 CORTEX 60MM 214.060 48713473_1 CDM 0278 RC inpatient 126 81.9 AETNA AETNA 99.54 79 999999999 76.29 122.22 percent of total billed charges 4.5 CORTEX 60MM 214.060 48713473_1 CDM 0278 RC inpatient 126 81.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.9 65 999999999 76.29 122.22 percent of total billed charges 4.5 CORTEX 60MM 214.060 48713473_1 CDM 0278 RC inpatient 126 81.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 122.22 97 999999999 76.29 122.22 percent of total billed charges 4.5 CORTEX 60MM 214.060 48713473_1 CDM 0278 RC inpatient 126 81.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.94 69 999999999 76.29 122.22 percent of total billed charges 4.5 CORTEX 60MM 214.060 48713473_1 CDM 0278 RC inpatient 126 81.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 98.28 78 999999999 76.29 122.22 percent of total billed charges 4.5 CORTEX 60MM 214.060 48713473_1 CDM 0278 RC inpatient 126 81.9 UMR - ALL PLANS UMR - ALL PLANS 88.2 70 999999999 76.29 122.22 percent of total billed charges 4.5 CORTEX 60MM 214.060 48713473_1 CDM 0278 RC inpatient 126 81.9 SIHO - ALL PLANS SIHO - ALL PLANS 113.4 90 999999999 76.29 122.22 percent of total billed charges 4.5 CORTEX 60MM 214.060 48713473_1 CDM 0278 RC inpatient 126 81.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.29 60.55 999999999 76.29 122.22 percent of total billed charges 4.5 CORTEX 60MM 214.060 48713473_1 CDM 0278 RC inpatient 126 81.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.29 122.22 4.5 CORTEX 60MM 214.060 48713473_1 CDM 0278 RC inpatient 126 81.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.29 122.22 4.5 CORTEX 60MM 214.060 48713473_1 CDM 0278 RC inpatient 126 81.9 ANTHEM HMO ANTHEM HMO 999999999 76.29 122.22 4.5 CORTEX 60MM 214.060 48713473_1 CDM 0278 RC inpatient 126 81.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.18 67.6 999999999 76.29 122.22 percent of total billed charges 4.5 CORTEX 60MM 214.060 48713473_1 CDM 0278 RC inpatient 126 81.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.29 122.22 4.5 CORTEX 60MM 214.060 48713473_1 CDM 0278 RC inpatient 126 81.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.29 122.22 4.5 CORTEX 70MM 214.070 48713478_1 CDM 0278 RC inpatient 97 63.05 AETNA AETNA 76.63 79 999999999 58.73 94.09 percent of total billed charges 4.5 CORTEX 70MM 214.070 48713478_1 CDM 0278 RC inpatient 97 63.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.05 65 999999999 58.73 94.09 percent of total billed charges 4.5 CORTEX 70MM 214.070 48713478_1 CDM 0278 RC inpatient 97 63.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 94.09 97 999999999 58.73 94.09 percent of total billed charges 4.5 CORTEX 70MM 214.070 48713478_1 CDM 0278 RC inpatient 97 63.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.93 69 999999999 58.73 94.09 percent of total billed charges 4.5 CORTEX 70MM 214.070 48713478_1 CDM 0278 RC inpatient 97 63.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 75.66 78 999999999 58.73 94.09 percent of total billed charges 4.5 CORTEX 70MM 214.070 48713478_1 CDM 0278 RC inpatient 97 63.05 UMR - ALL PLANS UMR - ALL PLANS 67.9 70 999999999 58.73 94.09 percent of total billed charges 4.5 CORTEX 70MM 214.070 48713478_1 CDM 0278 RC inpatient 97 63.05 SIHO - ALL PLANS SIHO - ALL PLANS 87.3 90 999999999 58.73 94.09 percent of total billed charges 4.5 CORTEX 70MM 214.070 48713478_1 CDM 0278 RC inpatient 97 63.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.73 60.55 999999999 58.73 94.09 percent of total billed charges 4.5 CORTEX 70MM 214.070 48713478_1 CDM 0278 RC inpatient 97 63.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.73 94.09 4.5 CORTEX 70MM 214.070 48713478_1 CDM 0278 RC inpatient 97 63.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.73 94.09 4.5 CORTEX 70MM 214.070 48713478_1 CDM 0278 RC inpatient 97 63.05 ANTHEM HMO ANTHEM HMO 999999999 58.73 94.09 4.5 CORTEX 70MM 214.070 48713478_1 CDM 0278 RC inpatient 97 63.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 65.57 67.6 999999999 58.73 94.09 percent of total billed charges 4.5 CORTEX 70MM 214.070 48713478_1 CDM 0278 RC inpatient 97 63.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.73 94.09 4.5 CORTEX 70MM 214.070 48713478_1 CDM 0278 RC inpatient 97 63.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.73 94.09 4.5 MALLEOLAR 25MM 215.025 48713479_1 CDM 0278 RC inpatient 120 78 AETNA AETNA 94.8 79 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 25MM 215.025 48713479_1 CDM 0278 RC inpatient 120 78 SELF PAY DISCOUNT SELF PAY DISCOUNT 78 65 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 25MM 215.025 48713479_1 CDM 0278 RC inpatient 120 78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.4 97 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 25MM 215.025 48713479_1 CDM 0278 RC inpatient 120 78 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.8 69 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 25MM 215.025 48713479_1 CDM 0278 RC inpatient 120 78 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.6 78 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 25MM 215.025 48713479_1 CDM 0278 RC inpatient 120 78 UMR - ALL PLANS UMR - ALL PLANS 84 70 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 25MM 215.025 48713479_1 CDM 0278 RC inpatient 120 78 SIHO - ALL PLANS SIHO - ALL PLANS 108 90 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 25MM 215.025 48713479_1 CDM 0278 RC inpatient 120 78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.66 60.55 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 25MM 215.025 48713479_1 CDM 0278 RC inpatient 120 78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.66 116.4 4.5 MALLEOLAR 25MM 215.025 48713479_1 CDM 0278 RC inpatient 120 78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.66 116.4 4.5 MALLEOLAR 25MM 215.025 48713479_1 CDM 0278 RC inpatient 120 78 ANTHEM HMO ANTHEM HMO 999999999 72.66 116.4 4.5 MALLEOLAR 25MM 215.025 48713479_1 CDM 0278 RC inpatient 120 78 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.12 67.6 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 25MM 215.025 48713479_1 CDM 0278 RC inpatient 120 78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.66 116.4 4.5 MALLEOLAR 25MM 215.025 48713479_1 CDM 0278 RC inpatient 120 78 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.66 116.4 4.5 MALLEOLAR 30MM 215.030 48713480_1 CDM 0278 RC inpatient 120 78 AETNA AETNA 94.8 79 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 30MM 215.030 48713480_1 CDM 0278 RC inpatient 120 78 SELF PAY DISCOUNT SELF PAY DISCOUNT 78 65 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 30MM 215.030 48713480_1 CDM 0278 RC inpatient 120 78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.4 97 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 30MM 215.030 48713480_1 CDM 0278 RC inpatient 120 78 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.8 69 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 30MM 215.030 48713480_1 CDM 0278 RC inpatient 120 78 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.6 78 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 30MM 215.030 48713480_1 CDM 0278 RC inpatient 120 78 UMR - ALL PLANS UMR - ALL PLANS 84 70 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 30MM 215.030 48713480_1 CDM 0278 RC inpatient 120 78 SIHO - ALL PLANS SIHO - ALL PLANS 108 90 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 30MM 215.030 48713480_1 CDM 0278 RC inpatient 120 78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.66 60.55 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 30MM 215.030 48713480_1 CDM 0278 RC inpatient 120 78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.66 116.4 4.5 MALLEOLAR 30MM 215.030 48713480_1 CDM 0278 RC inpatient 120 78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.66 116.4 4.5 MALLEOLAR 30MM 215.030 48713480_1 CDM 0278 RC inpatient 120 78 ANTHEM HMO ANTHEM HMO 999999999 72.66 116.4 4.5 MALLEOLAR 30MM 215.030 48713480_1 CDM 0278 RC inpatient 120 78 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.12 67.6 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 30MM 215.030 48713480_1 CDM 0278 RC inpatient 120 78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.66 116.4 4.5 MALLEOLAR 30MM 215.030 48713480_1 CDM 0278 RC inpatient 120 78 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.66 116.4 4.5 MALLEOLAR 45MM 215.045 48713481_1 CDM 0278 RC inpatient 120 78 AETNA AETNA 94.8 79 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 45MM 215.045 48713481_1 CDM 0278 RC inpatient 120 78 SELF PAY DISCOUNT SELF PAY DISCOUNT 78 65 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 45MM 215.045 48713481_1 CDM 0278 RC inpatient 120 78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.4 97 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 45MM 215.045 48713481_1 CDM 0278 RC inpatient 120 78 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.8 69 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 45MM 215.045 48713481_1 CDM 0278 RC inpatient 120 78 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.6 78 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 45MM 215.045 48713481_1 CDM 0278 RC inpatient 120 78 UMR - ALL PLANS UMR - ALL PLANS 84 70 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 45MM 215.045 48713481_1 CDM 0278 RC inpatient 120 78 SIHO - ALL PLANS SIHO - ALL PLANS 108 90 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 45MM 215.045 48713481_1 CDM 0278 RC inpatient 120 78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.66 60.55 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 45MM 215.045 48713481_1 CDM 0278 RC inpatient 120 78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.66 116.4 4.5 MALLEOLAR 45MM 215.045 48713481_1 CDM 0278 RC inpatient 120 78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.66 116.4 4.5 MALLEOLAR 45MM 215.045 48713481_1 CDM 0278 RC inpatient 120 78 ANTHEM HMO ANTHEM HMO 999999999 72.66 116.4 4.5 MALLEOLAR 45MM 215.045 48713481_1 CDM 0278 RC inpatient 120 78 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.12 67.6 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 45MM 215.045 48713481_1 CDM 0278 RC inpatient 120 78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.66 116.4 4.5 MALLEOLAR 45MM 215.045 48713481_1 CDM 0278 RC inpatient 120 78 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.66 116.4 4.5 MALLEOLAR 65MM 215.065 48713482_1 CDM 0278 RC inpatient 120 78 AETNA AETNA 94.8 79 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 65MM 215.065 48713482_1 CDM 0278 RC inpatient 120 78 SELF PAY DISCOUNT SELF PAY DISCOUNT 78 65 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 65MM 215.065 48713482_1 CDM 0278 RC inpatient 120 78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.4 97 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 65MM 215.065 48713482_1 CDM 0278 RC inpatient 120 78 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.8 69 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 65MM 215.065 48713482_1 CDM 0278 RC inpatient 120 78 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.6 78 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 65MM 215.065 48713482_1 CDM 0278 RC inpatient 120 78 UMR - ALL PLANS UMR - ALL PLANS 84 70 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 65MM 215.065 48713482_1 CDM 0278 RC inpatient 120 78 SIHO - ALL PLANS SIHO - ALL PLANS 108 90 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 65MM 215.065 48713482_1 CDM 0278 RC inpatient 120 78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.66 60.55 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 65MM 215.065 48713482_1 CDM 0278 RC inpatient 120 78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.66 116.4 4.5 MALLEOLAR 65MM 215.065 48713482_1 CDM 0278 RC inpatient 120 78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.66 116.4 4.5 MALLEOLAR 65MM 215.065 48713482_1 CDM 0278 RC inpatient 120 78 ANTHEM HMO ANTHEM HMO 999999999 72.66 116.4 4.5 MALLEOLAR 65MM 215.065 48713482_1 CDM 0278 RC inpatient 120 78 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.12 67.6 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 65MM 215.065 48713482_1 CDM 0278 RC inpatient 120 78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.66 116.4 4.5 MALLEOLAR 65MM 215.065 48713482_1 CDM 0278 RC inpatient 120 78 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.66 116.4 4.5 MALLEOLAR 70MM 215.070 48713483_1 CDM 0278 RC inpatient 120 78 AETNA AETNA 94.8 79 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 70MM 215.070 48713483_1 CDM 0278 RC inpatient 120 78 SELF PAY DISCOUNT SELF PAY DISCOUNT 78 65 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 70MM 215.070 48713483_1 CDM 0278 RC inpatient 120 78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.4 97 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 70MM 215.070 48713483_1 CDM 0278 RC inpatient 120 78 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.8 69 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 70MM 215.070 48713483_1 CDM 0278 RC inpatient 120 78 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.6 78 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 70MM 215.070 48713483_1 CDM 0278 RC inpatient 120 78 UMR - ALL PLANS UMR - ALL PLANS 84 70 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 70MM 215.070 48713483_1 CDM 0278 RC inpatient 120 78 SIHO - ALL PLANS SIHO - ALL PLANS 108 90 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 70MM 215.070 48713483_1 CDM 0278 RC inpatient 120 78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.66 60.55 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 70MM 215.070 48713483_1 CDM 0278 RC inpatient 120 78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.66 116.4 4.5 MALLEOLAR 70MM 215.070 48713483_1 CDM 0278 RC inpatient 120 78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.66 116.4 4.5 MALLEOLAR 70MM 215.070 48713483_1 CDM 0278 RC inpatient 120 78 ANTHEM HMO ANTHEM HMO 999999999 72.66 116.4 4.5 MALLEOLAR 70MM 215.070 48713483_1 CDM 0278 RC inpatient 120 78 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.12 67.6 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 70MM 215.070 48713483_1 CDM 0278 RC inpatient 120 78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.66 116.4 4.5 MALLEOLAR 70MM 215.070 48713483_1 CDM 0278 RC inpatient 120 78 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.66 116.4 CONICAL EXTRAC SCREW 309.530 48713484_1 CDM 0278 RC inpatient 508 330.2 AETNA AETNA 401.32 79 999999999 307.59 492.76 percent of total billed charges CONICAL EXTRAC SCREW 309.530 48713484_1 CDM 0278 RC inpatient 508 330.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 330.2 65 999999999 307.59 492.76 percent of total billed charges CONICAL EXTRAC SCREW 309.530 48713484_1 CDM 0278 RC inpatient 508 330.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 492.76 97 999999999 307.59 492.76 percent of total billed charges CONICAL EXTRAC SCREW 309.530 48713484_1 CDM 0278 RC inpatient 508 330.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 350.52 69 999999999 307.59 492.76 percent of total billed charges CONICAL EXTRAC SCREW 309.530 48713484_1 CDM 0278 RC inpatient 508 330.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 396.24 78 999999999 307.59 492.76 percent of total billed charges CONICAL EXTRAC SCREW 309.530 48713484_1 CDM 0278 RC inpatient 508 330.2 UMR - ALL PLANS UMR - ALL PLANS 355.6 70 999999999 307.59 492.76 percent of total billed charges CONICAL EXTRAC SCREW 309.530 48713484_1 CDM 0278 RC inpatient 508 330.2 SIHO - ALL PLANS SIHO - ALL PLANS 457.2 90 999999999 307.59 492.76 percent of total billed charges CONICAL EXTRAC SCREW 309.530 48713484_1 CDM 0278 RC inpatient 508 330.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 307.59 60.55 999999999 307.59 492.76 percent of total billed charges CONICAL EXTRAC SCREW 309.530 48713484_1 CDM 0278 RC inpatient 508 330.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 307.59 492.76 CONICAL EXTRAC SCREW 309.530 48713484_1 CDM 0278 RC inpatient 508 330.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 307.59 492.76 CONICAL EXTRAC SCREW 309.530 48713484_1 CDM 0278 RC inpatient 508 330.2 ANTHEM HMO ANTHEM HMO 999999999 307.59 492.76 CONICAL EXTRAC SCREW 309.530 48713484_1 CDM 0278 RC inpatient 508 330.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 343.41 67.6 999999999 307.59 492.76 percent of total billed charges CONICAL EXTRAC SCREW 309.530 48713484_1 CDM 0278 RC inpatient 508 330.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 307.59 492.76 CONICAL EXTRAC SCREW 309.530 48713484_1 CDM 0278 RC inpatient 508 330.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 307.59 492.76 CONICAL EXTRAC SCREW 309.520 48713485_1 CDM 0278 RC inpatient 608 395.2 AETNA AETNA 480.32 79 999999999 368.14 589.76 percent of total billed charges CONICAL EXTRAC SCREW 309.520 48713485_1 CDM 0278 RC inpatient 608 395.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 395.2 65 999999999 368.14 589.76 percent of total billed charges CONICAL EXTRAC SCREW 309.520 48713485_1 CDM 0278 RC inpatient 608 395.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 589.76 97 999999999 368.14 589.76 percent of total billed charges CONICAL EXTRAC SCREW 309.520 48713485_1 CDM 0278 RC inpatient 608 395.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 419.52 69 999999999 368.14 589.76 percent of total billed charges CONICAL EXTRAC SCREW 309.520 48713485_1 CDM 0278 RC inpatient 608 395.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 474.24 78 999999999 368.14 589.76 percent of total billed charges CONICAL EXTRAC SCREW 309.520 48713485_1 CDM 0278 RC inpatient 608 395.2 UMR - ALL PLANS UMR - ALL PLANS 425.6 70 999999999 368.14 589.76 percent of total billed charges CONICAL EXTRAC SCREW 309.520 48713485_1 CDM 0278 RC inpatient 608 395.2 SIHO - ALL PLANS SIHO - ALL PLANS 547.2 90 999999999 368.14 589.76 percent of total billed charges CONICAL EXTRAC SCREW 309.520 48713485_1 CDM 0278 RC inpatient 608 395.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 368.14 60.55 999999999 368.14 589.76 percent of total billed charges CONICAL EXTRAC SCREW 309.520 48713485_1 CDM 0278 RC inpatient 608 395.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 368.14 589.76 CONICAL EXTRAC SCREW 309.520 48713485_1 CDM 0278 RC inpatient 608 395.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 368.14 589.76 CONICAL EXTRAC SCREW 309.520 48713485_1 CDM 0278 RC inpatient 608 395.2 ANTHEM HMO ANTHEM HMO 999999999 368.14 589.76 CONICAL EXTRAC SCREW 309.520 48713485_1 CDM 0278 RC inpatient 608 395.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 411.01 67.6 999999999 368.14 589.76 percent of total billed charges CONICAL EXTRAC SCREW 309.520 48713485_1 CDM 0278 RC inpatient 608 395.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 368.14 589.76 CONICAL EXTRAC SCREW 309.520 48713485_1 CDM 0278 RC inpatient 608 395.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 368.14 589.76 ESSURE PERMANENT BIRTH CONTROL 48713486_1 CDM 0278 RC inpatient 6135 3987.75 AETNA AETNA 4846.65 79 999999999 3714.74 5950.95 percent of total billed charges ESSURE PERMANENT BIRTH CONTROL 48713486_1 CDM 0278 RC inpatient 6135 3987.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 3987.75 65 999999999 3714.74 5950.95 percent of total billed charges ESSURE PERMANENT BIRTH CONTROL 48713486_1 CDM 0278 RC inpatient 6135 3987.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5950.95 97 999999999 3714.74 5950.95 percent of total billed charges ESSURE PERMANENT BIRTH CONTROL 48713486_1 CDM 0278 RC inpatient 6135 3987.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 4233.15 69 999999999 3714.74 5950.95 percent of total billed charges ESSURE PERMANENT BIRTH CONTROL 48713486_1 CDM 0278 RC inpatient 6135 3987.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 4785.3 78 999999999 3714.74 5950.95 percent of total billed charges ESSURE PERMANENT BIRTH CONTROL 48713486_1 CDM 0278 RC inpatient 6135 3987.75 UMR - ALL PLANS UMR - ALL PLANS 4294.5 70 999999999 3714.74 5950.95 percent of total billed charges ESSURE PERMANENT BIRTH CONTROL 48713486_1 CDM 0278 RC inpatient 6135 3987.75 SIHO - ALL PLANS SIHO - ALL PLANS 5521.5 90 999999999 3714.74 5950.95 percent of total billed charges ESSURE PERMANENT BIRTH CONTROL 48713486_1 CDM 0278 RC inpatient 6135 3987.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3714.74 60.55 999999999 3714.74 5950.95 percent of total billed charges ESSURE PERMANENT BIRTH CONTROL 48713486_1 CDM 0278 RC inpatient 6135 3987.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3714.74 5950.95 ESSURE PERMANENT BIRTH CONTROL 48713486_1 CDM 0278 RC inpatient 6135 3987.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3714.74 5950.95 ESSURE PERMANENT BIRTH CONTROL 48713486_1 CDM 0278 RC inpatient 6135 3987.75 ANTHEM HMO ANTHEM HMO 999999999 3714.74 5950.95 ESSURE PERMANENT BIRTH CONTROL 48713486_1 CDM 0278 RC inpatient 6135 3987.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 4147.26 67.6 999999999 3714.74 5950.95 percent of total billed charges ESSURE PERMANENT BIRTH CONTROL 48713486_1 CDM 0278 RC inpatient 6135 3987.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3714.74 5950.95 ESSURE PERMANENT BIRTH CONTROL 48713486_1 CDM 0278 RC inpatient 6135 3987.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 3714.74 5950.95 6.5 CANC 16/35MM 216.035 48713487_1 CDM 0278 RC inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/35MM 216.035 48713487_1 CDM 0278 RC inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/35MM 216.035 48713487_1 CDM 0278 RC inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/35MM 216.035 48713487_1 CDM 0278 RC inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/35MM 216.035 48713487_1 CDM 0278 RC inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/35MM 216.035 48713487_1 CDM 0278 RC inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/35MM 216.035 48713487_1 CDM 0278 RC inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/35MM 216.035 48713487_1 CDM 0278 RC inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/35MM 216.035 48713487_1 CDM 0278 RC inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 6.5 CANC 16/35MM 216.035 48713487_1 CDM 0278 RC inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 6.5 CANC 16/35MM 216.035 48713487_1 CDM 0278 RC inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 6.5 CANC 16/35MM 216.035 48713487_1 CDM 0278 RC inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/35MM 216.035 48713487_1 CDM 0278 RC inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 6.5 CANC 16/35MM 216.035 48713487_1 CDM 0278 RC inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 6.5 CANC 16/40MM 216.040 48713488_1 CDM 0278 RC inpatient 236 153.4 AETNA AETNA 186.44 79 999999999 142.9 228.92 percent of total billed charges 6.5 CANC 16/40MM 216.040 48713488_1 CDM 0278 RC inpatient 236 153.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 153.4 65 999999999 142.9 228.92 percent of total billed charges 6.5 CANC 16/40MM 216.040 48713488_1 CDM 0278 RC inpatient 236 153.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 228.92 97 999999999 142.9 228.92 percent of total billed charges 6.5 CANC 16/40MM 216.040 48713488_1 CDM 0278 RC inpatient 236 153.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 162.84 69 999999999 142.9 228.92 percent of total billed charges 6.5 CANC 16/40MM 216.040 48713488_1 CDM 0278 RC inpatient 236 153.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 184.08 78 999999999 142.9 228.92 percent of total billed charges 6.5 CANC 16/40MM 216.040 48713488_1 CDM 0278 RC inpatient 236 153.4 UMR - ALL PLANS UMR - ALL PLANS 165.2 70 999999999 142.9 228.92 percent of total billed charges 6.5 CANC 16/40MM 216.040 48713488_1 CDM 0278 RC inpatient 236 153.4 SIHO - ALL PLANS SIHO - ALL PLANS 212.4 90 999999999 142.9 228.92 percent of total billed charges 6.5 CANC 16/40MM 216.040 48713488_1 CDM 0278 RC inpatient 236 153.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 142.9 60.55 999999999 142.9 228.92 percent of total billed charges 6.5 CANC 16/40MM 216.040 48713488_1 CDM 0278 RC inpatient 236 153.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 142.9 228.92 6.5 CANC 16/40MM 216.040 48713488_1 CDM 0278 RC inpatient 236 153.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 142.9 228.92 6.5 CANC 16/40MM 216.040 48713488_1 CDM 0278 RC inpatient 236 153.4 ANTHEM HMO ANTHEM HMO 999999999 142.9 228.92 6.5 CANC 16/40MM 216.040 48713488_1 CDM 0278 RC inpatient 236 153.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 159.54 67.6 999999999 142.9 228.92 percent of total billed charges 6.5 CANC 16/40MM 216.040 48713488_1 CDM 0278 RC inpatient 236 153.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 142.9 228.92 6.5 CANC 16/40MM 216.040 48713488_1 CDM 0278 RC inpatient 236 153.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 142.9 228.92 6.5 CANC 16/45MM 216.045 48713489_1 CDM 0278 RC inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges 6.5 CANC 16/45MM 216.045 48713489_1 CDM 0278 RC inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges 6.5 CANC 16/45MM 216.045 48713489_1 CDM 0278 RC inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges 6.5 CANC 16/45MM 216.045 48713489_1 CDM 0278 RC inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges 6.5 CANC 16/45MM 216.045 48713489_1 CDM 0278 RC inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges 6.5 CANC 16/45MM 216.045 48713489_1 CDM 0278 RC inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges 6.5 CANC 16/45MM 216.045 48713489_1 CDM 0278 RC inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges 6.5 CANC 16/45MM 216.045 48713489_1 CDM 0278 RC inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges 6.5 CANC 16/45MM 216.045 48713489_1 CDM 0278 RC inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 6.5 CANC 16/45MM 216.045 48713489_1 CDM 0278 RC inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 6.5 CANC 16/45MM 216.045 48713489_1 CDM 0278 RC inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 6.5 CANC 16/45MM 216.045 48713489_1 CDM 0278 RC inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges 6.5 CANC 16/45MM 216.045 48713489_1 CDM 0278 RC inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 6.5 CANC 16/45MM 216.045 48713489_1 CDM 0278 RC inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 6.5 CANC 16/50MM 216.050 48713490_1 CDM 0278 RC inpatient 144 93.6 AETNA AETNA 113.76 79 999999999 87.19 139.68 percent of total billed charges 6.5 CANC 16/50MM 216.050 48713490_1 CDM 0278 RC inpatient 144 93.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 93.6 65 999999999 87.19 139.68 percent of total billed charges 6.5 CANC 16/50MM 216.050 48713490_1 CDM 0278 RC inpatient 144 93.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 139.68 97 999999999 87.19 139.68 percent of total billed charges 6.5 CANC 16/50MM 216.050 48713490_1 CDM 0278 RC inpatient 144 93.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 99.36 69 999999999 87.19 139.68 percent of total billed charges 6.5 CANC 16/50MM 216.050 48713490_1 CDM 0278 RC inpatient 144 93.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 112.32 78 999999999 87.19 139.68 percent of total billed charges 6.5 CANC 16/50MM 216.050 48713490_1 CDM 0278 RC inpatient 144 93.6 UMR - ALL PLANS UMR - ALL PLANS 100.8 70 999999999 87.19 139.68 percent of total billed charges 6.5 CANC 16/50MM 216.050 48713490_1 CDM 0278 RC inpatient 144 93.6 SIHO - ALL PLANS SIHO - ALL PLANS 129.6 90 999999999 87.19 139.68 percent of total billed charges 6.5 CANC 16/50MM 216.050 48713490_1 CDM 0278 RC inpatient 144 93.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.19 60.55 999999999 87.19 139.68 percent of total billed charges 6.5 CANC 16/50MM 216.050 48713490_1 CDM 0278 RC inpatient 144 93.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.19 139.68 6.5 CANC 16/50MM 216.050 48713490_1 CDM 0278 RC inpatient 144 93.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.19 139.68 6.5 CANC 16/50MM 216.050 48713490_1 CDM 0278 RC inpatient 144 93.6 ANTHEM HMO ANTHEM HMO 999999999 87.19 139.68 6.5 CANC 16/50MM 216.050 48713490_1 CDM 0278 RC inpatient 144 93.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 97.34 67.6 999999999 87.19 139.68 percent of total billed charges 6.5 CANC 16/50MM 216.050 48713490_1 CDM 0278 RC inpatient 144 93.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.19 139.68 6.5 CANC 16/50MM 216.050 48713490_1 CDM 0278 RC inpatient 144 93.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.19 139.68 6.5 CANC 16/55MM 216.055 48713491_1 CDM 0278 RC inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/55MM 216.055 48713491_1 CDM 0278 RC inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/55MM 216.055 48713491_1 CDM 0278 RC inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/55MM 216.055 48713491_1 CDM 0278 RC inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/55MM 216.055 48713491_1 CDM 0278 RC inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/55MM 216.055 48713491_1 CDM 0278 RC inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/55MM 216.055 48713491_1 CDM 0278 RC inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/55MM 216.055 48713491_1 CDM 0278 RC inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/55MM 216.055 48713491_1 CDM 0278 RC inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 6.5 CANC 16/55MM 216.055 48713491_1 CDM 0278 RC inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 6.5 CANC 16/55MM 216.055 48713491_1 CDM 0278 RC inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 6.5 CANC 16/55MM 216.055 48713491_1 CDM 0278 RC inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/55MM 216.055 48713491_1 CDM 0278 RC inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 6.5 CANC 16/55MM 216.055 48713491_1 CDM 0278 RC inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 6.5 CANC 16/60MM 216.060 48713492_1 CDM 0278 RC inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/60MM 216.060 48713492_1 CDM 0278 RC inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/60MM 216.060 48713492_1 CDM 0278 RC inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/60MM 216.060 48713492_1 CDM 0278 RC inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/60MM 216.060 48713492_1 CDM 0278 RC inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/60MM 216.060 48713492_1 CDM 0278 RC inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/60MM 216.060 48713492_1 CDM 0278 RC inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/60MM 216.060 48713492_1 CDM 0278 RC inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/60MM 216.060 48713492_1 CDM 0278 RC inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 6.5 CANC 16/60MM 216.060 48713492_1 CDM 0278 RC inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 6.5 CANC 16/60MM 216.060 48713492_1 CDM 0278 RC inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 6.5 CANC 16/60MM 216.060 48713492_1 CDM 0278 RC inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/60MM 216.060 48713492_1 CDM 0278 RC inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 6.5 CANC 16/60MM 216.060 48713492_1 CDM 0278 RC inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 6.5 CANC 16/65MM 216.065 48713493_1 CDM 0278 RC inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/65MM 216.065 48713493_1 CDM 0278 RC inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/65MM 216.065 48713493_1 CDM 0278 RC inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/65MM 216.065 48713493_1 CDM 0278 RC inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/65MM 216.065 48713493_1 CDM 0278 RC inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/65MM 216.065 48713493_1 CDM 0278 RC inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/65MM 216.065 48713493_1 CDM 0278 RC inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/65MM 216.065 48713493_1 CDM 0278 RC inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/65MM 216.065 48713493_1 CDM 0278 RC inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 6.5 CANC 16/65MM 216.065 48713493_1 CDM 0278 RC inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 6.5 CANC 16/65MM 216.065 48713493_1 CDM 0278 RC inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 6.5 CANC 16/65MM 216.065 48713493_1 CDM 0278 RC inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/65MM 216.065 48713493_1 CDM 0278 RC inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 6.5 CANC 16/65MM 216.065 48713493_1 CDM 0278 RC inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 6.5 CANC 16/70MM 216.070 48713494_1 CDM 0278 RC inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/70MM 216.070 48713494_1 CDM 0278 RC inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/70MM 216.070 48713494_1 CDM 0278 RC inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/70MM 216.070 48713494_1 CDM 0278 RC inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/70MM 216.070 48713494_1 CDM 0278 RC inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/70MM 216.070 48713494_1 CDM 0278 RC inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/70MM 216.070 48713494_1 CDM 0278 RC inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/70MM 216.070 48713494_1 CDM 0278 RC inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/70MM 216.070 48713494_1 CDM 0278 RC inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 6.5 CANC 16/70MM 216.070 48713494_1 CDM 0278 RC inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 6.5 CANC 16/70MM 216.070 48713494_1 CDM 0278 RC inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 6.5 CANC 16/70MM 216.070 48713494_1 CDM 0278 RC inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/70MM 216.070 48713494_1 CDM 0278 RC inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 6.5 CANC 16/70MM 216.070 48713494_1 CDM 0278 RC inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 6.5 CANC 16/75MM 216.075 48713495_1 CDM 0278 RC inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/75MM 216.075 48713495_1 CDM 0278 RC inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/75MM 216.075 48713495_1 CDM 0278 RC inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/75MM 216.075 48713495_1 CDM 0278 RC inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/75MM 216.075 48713495_1 CDM 0278 RC inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/75MM 216.075 48713495_1 CDM 0278 RC inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/75MM 216.075 48713495_1 CDM 0278 RC inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/75MM 216.075 48713495_1 CDM 0278 RC inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/75MM 216.075 48713495_1 CDM 0278 RC inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 6.5 CANC 16/75MM 216.075 48713495_1 CDM 0278 RC inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 6.5 CANC 16/75MM 216.075 48713495_1 CDM 0278 RC inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 6.5 CANC 16/75MM 216.075 48713495_1 CDM 0278 RC inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/75MM 216.075 48713495_1 CDM 0278 RC inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 6.5 CANC 16/75MM 216.075 48713495_1 CDM 0278 RC inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 6.5 CANC 16/80MM 216.080 48713496_1 CDM 0278 RC inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/80MM 216.080 48713496_1 CDM 0278 RC inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/80MM 216.080 48713496_1 CDM 0278 RC inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/80MM 216.080 48713496_1 CDM 0278 RC inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/80MM 216.080 48713496_1 CDM 0278 RC inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/80MM 216.080 48713496_1 CDM 0278 RC inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/80MM 216.080 48713496_1 CDM 0278 RC inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/80MM 216.080 48713496_1 CDM 0278 RC inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/80MM 216.080 48713496_1 CDM 0278 RC inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 6.5 CANC 16/80MM 216.080 48713496_1 CDM 0278 RC inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 6.5 CANC 16/80MM 216.080 48713496_1 CDM 0278 RC inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 6.5 CANC 16/80MM 216.080 48713496_1 CDM 0278 RC inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges 6.5 CANC 16/80MM 216.080 48713496_1 CDM 0278 RC inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 6.5 CANC 16/80MM 216.080 48713496_1 CDM 0278 RC inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 6.5 CANC 16/85MM 216.085 48713497_1 CDM 0278 RC inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/85MM 216.085 48713497_1 CDM 0278 RC inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/85MM 216.085 48713497_1 CDM 0278 RC inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/85MM 216.085 48713497_1 CDM 0278 RC inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/85MM 216.085 48713497_1 CDM 0278 RC inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/85MM 216.085 48713497_1 CDM 0278 RC inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/85MM 216.085 48713497_1 CDM 0278 RC inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/85MM 216.085 48713497_1 CDM 0278 RC inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/85MM 216.085 48713497_1 CDM 0278 RC inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 6.5 CANC 16/85MM 216.085 48713497_1 CDM 0278 RC inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 6.5 CANC 16/85MM 216.085 48713497_1 CDM 0278 RC inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 6.5 CANC 16/85MM 216.085 48713497_1 CDM 0278 RC inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/85MM 216.085 48713497_1 CDM 0278 RC inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 6.5 CANC 16/85MM 216.085 48713497_1 CDM 0278 RC inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 6.5 CANC 16/90MM 216.090 48713498_1 CDM 0278 RC inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/90MM 216.090 48713498_1 CDM 0278 RC inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/90MM 216.090 48713498_1 CDM 0278 RC inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/90MM 216.090 48713498_1 CDM 0278 RC inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/90MM 216.090 48713498_1 CDM 0278 RC inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/90MM 216.090 48713498_1 CDM 0278 RC inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/90MM 216.090 48713498_1 CDM 0278 RC inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/90MM 216.090 48713498_1 CDM 0278 RC inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/90MM 216.090 48713498_1 CDM 0278 RC inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 6.5 CANC 16/90MM 216.090 48713498_1 CDM 0278 RC inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 6.5 CANC 16/90MM 216.090 48713498_1 CDM 0278 RC inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 6.5 CANC 16/90MM 216.090 48713498_1 CDM 0278 RC inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/90MM 216.090 48713498_1 CDM 0278 RC inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 6.5 CANC 16/90MM 216.090 48713498_1 CDM 0278 RC inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 6.5 CANC 16/95MM 216.095 48713499_1 CDM 0278 RC inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/95MM 216.095 48713499_1 CDM 0278 RC inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/95MM 216.095 48713499_1 CDM 0278 RC inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/95MM 216.095 48713499_1 CDM 0278 RC inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/95MM 216.095 48713499_1 CDM 0278 RC inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/95MM 216.095 48713499_1 CDM 0278 RC inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/95MM 216.095 48713499_1 CDM 0278 RC inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/95MM 216.095 48713499_1 CDM 0278 RC inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/95MM 216.095 48713499_1 CDM 0278 RC inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 6.5 CANC 16/95MM 216.095 48713499_1 CDM 0278 RC inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 6.5 CANC 16/95MM 216.095 48713499_1 CDM 0278 RC inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 6.5 CANC 16/95MM 216.095 48713499_1 CDM 0278 RC inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/95MM 216.095 48713499_1 CDM 0278 RC inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 6.5 CANC 16/95MM 216.095 48713499_1 CDM 0278 RC inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 6.5 CANC 16/100MM 216.100 48713500_1 CDM 0278 RC inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/100MM 216.100 48713500_1 CDM 0278 RC inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/100MM 216.100 48713500_1 CDM 0278 RC inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/100MM 216.100 48713500_1 CDM 0278 RC inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/100MM 216.100 48713500_1 CDM 0278 RC inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/100MM 216.100 48713500_1 CDM 0278 RC inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/100MM 216.100 48713500_1 CDM 0278 RC inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/100MM 216.100 48713500_1 CDM 0278 RC inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/100MM 216.100 48713500_1 CDM 0278 RC inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 6.5 CANC 16/100MM 216.100 48713500_1 CDM 0278 RC inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 6.5 CANC 16/100MM 216.100 48713500_1 CDM 0278 RC inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 6.5 CANC 16/100MM 216.100 48713500_1 CDM 0278 RC inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/100MM 216.100 48713500_1 CDM 0278 RC inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 6.5 CANC 16/100MM 216.100 48713500_1 CDM 0278 RC inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 6.5 CANC 16/105MM 216.105 48713501_1 CDM 0278 RC inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/105MM 216.105 48713501_1 CDM 0278 RC inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/105MM 216.105 48713501_1 CDM 0278 RC inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/105MM 216.105 48713501_1 CDM 0278 RC inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/105MM 216.105 48713501_1 CDM 0278 RC inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/105MM 216.105 48713501_1 CDM 0278 RC inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/105MM 216.105 48713501_1 CDM 0278 RC inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/105MM 216.105 48713501_1 CDM 0278 RC inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/105MM 216.105 48713501_1 CDM 0278 RC inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 6.5 CANC 16/105MM 216.105 48713501_1 CDM 0278 RC inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 6.5 CANC 16/105MM 216.105 48713501_1 CDM 0278 RC inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 6.5 CANC 16/105MM 216.105 48713501_1 CDM 0278 RC inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/105MM 216.105 48713501_1 CDM 0278 RC inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 6.5 CANC 16/105MM 216.105 48713501_1 CDM 0278 RC inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 6.5 CANC 16/30MM 216.030 48713502_1 CDM 0278 RC inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/30MM 216.030 48713502_1 CDM 0278 RC inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/30MM 216.030 48713502_1 CDM 0278 RC inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/30MM 216.030 48713502_1 CDM 0278 RC inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/30MM 216.030 48713502_1 CDM 0278 RC inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/30MM 216.030 48713502_1 CDM 0278 RC inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/30MM 216.030 48713502_1 CDM 0278 RC inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/30MM 216.030 48713502_1 CDM 0278 RC inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/30MM 216.030 48713502_1 CDM 0278 RC inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 6.5 CANC 16/30MM 216.030 48713502_1 CDM 0278 RC inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 6.5 CANC 16/30MM 216.030 48713502_1 CDM 0278 RC inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 6.5 CANC 16/30MM 216.030 48713502_1 CDM 0278 RC inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges 6.5 CANC 16/30MM 216.030 48713502_1 CDM 0278 RC inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 6.5 CANC 16/30MM 216.030 48713502_1 CDM 0278 RC inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 4.5 MALLEOLAR 35MM 215.035 48713503_1 CDM 0278 RC inpatient 120 78 AETNA AETNA 94.8 79 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 35MM 215.035 48713503_1 CDM 0278 RC inpatient 120 78 SELF PAY DISCOUNT SELF PAY DISCOUNT 78 65 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 35MM 215.035 48713503_1 CDM 0278 RC inpatient 120 78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.4 97 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 35MM 215.035 48713503_1 CDM 0278 RC inpatient 120 78 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.8 69 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 35MM 215.035 48713503_1 CDM 0278 RC inpatient 120 78 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.6 78 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 35MM 215.035 48713503_1 CDM 0278 RC inpatient 120 78 UMR - ALL PLANS UMR - ALL PLANS 84 70 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 35MM 215.035 48713503_1 CDM 0278 RC inpatient 120 78 SIHO - ALL PLANS SIHO - ALL PLANS 108 90 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 35MM 215.035 48713503_1 CDM 0278 RC inpatient 120 78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.66 60.55 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 35MM 215.035 48713503_1 CDM 0278 RC inpatient 120 78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.66 116.4 4.5 MALLEOLAR 35MM 215.035 48713503_1 CDM 0278 RC inpatient 120 78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.66 116.4 4.5 MALLEOLAR 35MM 215.035 48713503_1 CDM 0278 RC inpatient 120 78 ANTHEM HMO ANTHEM HMO 999999999 72.66 116.4 4.5 MALLEOLAR 35MM 215.035 48713503_1 CDM 0278 RC inpatient 120 78 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.12 67.6 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 35MM 215.035 48713503_1 CDM 0278 RC inpatient 120 78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.66 116.4 4.5 MALLEOLAR 35MM 215.035 48713503_1 CDM 0278 RC inpatient 120 78 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.66 116.4 4.5 MALLEOLAR 60MM 215.060 48713504_1 CDM 0278 RC inpatient 120 78 AETNA AETNA 94.8 79 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 60MM 215.060 48713504_1 CDM 0278 RC inpatient 120 78 SELF PAY DISCOUNT SELF PAY DISCOUNT 78 65 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 60MM 215.060 48713504_1 CDM 0278 RC inpatient 120 78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.4 97 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 60MM 215.060 48713504_1 CDM 0278 RC inpatient 120 78 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.8 69 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 60MM 215.060 48713504_1 CDM 0278 RC inpatient 120 78 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.6 78 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 60MM 215.060 48713504_1 CDM 0278 RC inpatient 120 78 UMR - ALL PLANS UMR - ALL PLANS 84 70 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 60MM 215.060 48713504_1 CDM 0278 RC inpatient 120 78 SIHO - ALL PLANS SIHO - ALL PLANS 108 90 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 60MM 215.060 48713504_1 CDM 0278 RC inpatient 120 78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.66 60.55 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 60MM 215.060 48713504_1 CDM 0278 RC inpatient 120 78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.66 116.4 4.5 MALLEOLAR 60MM 215.060 48713504_1 CDM 0278 RC inpatient 120 78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.66 116.4 4.5 MALLEOLAR 60MM 215.060 48713504_1 CDM 0278 RC inpatient 120 78 ANTHEM HMO ANTHEM HMO 999999999 72.66 116.4 4.5 MALLEOLAR 60MM 215.060 48713504_1 CDM 0278 RC inpatient 120 78 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.12 67.6 999999999 72.66 116.4 percent of total billed charges 4.5 MALLEOLAR 60MM 215.060 48713504_1 CDM 0278 RC inpatient 120 78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.66 116.4 4.5 MALLEOLAR 60MM 215.060 48713504_1 CDM 0278 RC inpatient 120 78 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.66 116.4 4.5 CORTEX SCREW 66MM 214.066 48713507_1 CDM 0278 RC inpatient 1193 775.45 AETNA AETNA 942.47 79 999999999 722.36 1157.21 percent of total billed charges 4.5 CORTEX SCREW 66MM 214.066 48713507_1 CDM 0278 RC inpatient 1193 775.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 775.45 65 999999999 722.36 1157.21 percent of total billed charges 4.5 CORTEX SCREW 66MM 214.066 48713507_1 CDM 0278 RC inpatient 1193 775.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1157.21 97 999999999 722.36 1157.21 percent of total billed charges 4.5 CORTEX SCREW 66MM 214.066 48713507_1 CDM 0278 RC inpatient 1193 775.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 823.17 69 999999999 722.36 1157.21 percent of total billed charges 4.5 CORTEX SCREW 66MM 214.066 48713507_1 CDM 0278 RC inpatient 1193 775.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 930.54 78 999999999 722.36 1157.21 percent of total billed charges 4.5 CORTEX SCREW 66MM 214.066 48713507_1 CDM 0278 RC inpatient 1193 775.45 UMR - ALL PLANS UMR - ALL PLANS 835.1 70 999999999 722.36 1157.21 percent of total billed charges 4.5 CORTEX SCREW 66MM 214.066 48713507_1 CDM 0278 RC inpatient 1193 775.45 SIHO - ALL PLANS SIHO - ALL PLANS 1073.7 90 999999999 722.36 1157.21 percent of total billed charges 4.5 CORTEX SCREW 66MM 214.066 48713507_1 CDM 0278 RC inpatient 1193 775.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 722.36 60.55 999999999 722.36 1157.21 percent of total billed charges 4.5 CORTEX SCREW 66MM 214.066 48713507_1 CDM 0278 RC inpatient 1193 775.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 722.36 1157.21 4.5 CORTEX SCREW 66MM 214.066 48713507_1 CDM 0278 RC inpatient 1193 775.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 722.36 1157.21 4.5 CORTEX SCREW 66MM 214.066 48713507_1 CDM 0278 RC inpatient 1193 775.45 ANTHEM HMO ANTHEM HMO 999999999 722.36 1157.21 4.5 CORTEX SCREW 66MM 214.066 48713507_1 CDM 0278 RC inpatient 1193 775.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 806.47 67.6 999999999 722.36 1157.21 percent of total billed charges 4.5 CORTEX SCREW 66MM 214.066 48713507_1 CDM 0278 RC inpatient 1193 775.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 722.36 1157.21 4.5 CORTEX SCREW 66MM 214.066 48713507_1 CDM 0278 RC inpatient 1193 775.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 722.36 1157.21 4.5 CORTEX SCREW 68MM 214.068 48713508_1 CDM 0278 RC inpatient 1913 1243.45 AETNA AETNA 1511.27 79 999999999 1158.32 1855.61 percent of total billed charges 4.5 CORTEX SCREW 68MM 214.068 48713508_1 CDM 0278 RC inpatient 1913 1243.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1243.45 65 999999999 1158.32 1855.61 percent of total billed charges 4.5 CORTEX SCREW 68MM 214.068 48713508_1 CDM 0278 RC inpatient 1913 1243.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1855.61 97 999999999 1158.32 1855.61 percent of total billed charges 4.5 CORTEX SCREW 68MM 214.068 48713508_1 CDM 0278 RC inpatient 1913 1243.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1319.97 69 999999999 1158.32 1855.61 percent of total billed charges 4.5 CORTEX SCREW 68MM 214.068 48713508_1 CDM 0278 RC inpatient 1913 1243.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1492.14 78 999999999 1158.32 1855.61 percent of total billed charges 4.5 CORTEX SCREW 68MM 214.068 48713508_1 CDM 0278 RC inpatient 1913 1243.45 UMR - ALL PLANS UMR - ALL PLANS 1339.1 70 999999999 1158.32 1855.61 percent of total billed charges 4.5 CORTEX SCREW 68MM 214.068 48713508_1 CDM 0278 RC inpatient 1913 1243.45 SIHO - ALL PLANS SIHO - ALL PLANS 1721.7 90 999999999 1158.32 1855.61 percent of total billed charges 4.5 CORTEX SCREW 68MM 214.068 48713508_1 CDM 0278 RC inpatient 1913 1243.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1158.32 60.55 999999999 1158.32 1855.61 percent of total billed charges 4.5 CORTEX SCREW 68MM 214.068 48713508_1 CDM 0278 RC inpatient 1913 1243.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1158.32 1855.61 4.5 CORTEX SCREW 68MM 214.068 48713508_1 CDM 0278 RC inpatient 1913 1243.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1158.32 1855.61 4.5 CORTEX SCREW 68MM 214.068 48713508_1 CDM 0278 RC inpatient 1913 1243.45 ANTHEM HMO ANTHEM HMO 999999999 1158.32 1855.61 4.5 CORTEX SCREW 68MM 214.068 48713508_1 CDM 0278 RC inpatient 1913 1243.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1293.19 67.6 999999999 1158.32 1855.61 percent of total billed charges 4.5 CORTEX SCREW 68MM 214.068 48713508_1 CDM 0278 RC inpatient 1913 1243.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1158.32 1855.61 4.5 CORTEX SCREW 68MM 214.068 48713508_1 CDM 0278 RC inpatient 1913 1243.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1158.32 1855.61 SM FRAG CALCANEAL PLATE 441.61 48713509_1 CDM 0278 RC inpatient 1535 997.75 AETNA AETNA 1212.65 79 999999999 929.44 1488.95 percent of total billed charges SM FRAG CALCANEAL PLATE 441.61 48713509_1 CDM 0278 RC inpatient 1535 997.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 997.75 65 999999999 929.44 1488.95 percent of total billed charges SM FRAG CALCANEAL PLATE 441.61 48713509_1 CDM 0278 RC inpatient 1535 997.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1488.95 97 999999999 929.44 1488.95 percent of total billed charges SM FRAG CALCANEAL PLATE 441.61 48713509_1 CDM 0278 RC inpatient 1535 997.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1059.15 69 999999999 929.44 1488.95 percent of total billed charges SM FRAG CALCANEAL PLATE 441.61 48713509_1 CDM 0278 RC inpatient 1535 997.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1197.3 78 999999999 929.44 1488.95 percent of total billed charges SM FRAG CALCANEAL PLATE 441.61 48713509_1 CDM 0278 RC inpatient 1535 997.75 UMR - ALL PLANS UMR - ALL PLANS 1074.5 70 999999999 929.44 1488.95 percent of total billed charges SM FRAG CALCANEAL PLATE 441.61 48713509_1 CDM 0278 RC inpatient 1535 997.75 SIHO - ALL PLANS SIHO - ALL PLANS 1381.5 90 999999999 929.44 1488.95 percent of total billed charges SM FRAG CALCANEAL PLATE 441.61 48713509_1 CDM 0278 RC inpatient 1535 997.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 929.44 60.55 999999999 929.44 1488.95 percent of total billed charges SM FRAG CALCANEAL PLATE 441.61 48713509_1 CDM 0278 RC inpatient 1535 997.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 929.44 1488.95 SM FRAG CALCANEAL PLATE 441.61 48713509_1 CDM 0278 RC inpatient 1535 997.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 929.44 1488.95 SM FRAG CALCANEAL PLATE 441.61 48713509_1 CDM 0278 RC inpatient 1535 997.75 ANTHEM HMO ANTHEM HMO 999999999 929.44 1488.95 SM FRAG CALCANEAL PLATE 441.61 48713509_1 CDM 0278 RC inpatient 1535 997.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1037.66 67.6 999999999 929.44 1488.95 percent of total billed charges SM FRAG CALCANEAL PLATE 441.61 48713509_1 CDM 0278 RC inpatient 1535 997.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 929.44 1488.95 SM FRAG CALCANEAL PLATE 441.61 48713509_1 CDM 0278 RC inpatient 1535 997.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 929.44 1488.95 SM FRAG CALC. V/PLATE 441.65 48713510_1 CDM 0278 RC inpatient 1640 1066 AETNA AETNA 1295.6 79 999999999 993.02 1590.8 percent of total billed charges SM FRAG CALC. V/PLATE 441.65 48713510_1 CDM 0278 RC inpatient 1640 1066 SELF PAY DISCOUNT SELF PAY DISCOUNT 1066 65 999999999 993.02 1590.8 percent of total billed charges SM FRAG CALC. V/PLATE 441.65 48713510_1 CDM 0278 RC inpatient 1640 1066 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1590.8 97 999999999 993.02 1590.8 percent of total billed charges SM FRAG CALC. V/PLATE 441.65 48713510_1 CDM 0278 RC inpatient 1640 1066 ENCORE - ALL PLANS ENCORE - ALL PLANS 1131.6 69 999999999 993.02 1590.8 percent of total billed charges SM FRAG CALC. V/PLATE 441.65 48713510_1 CDM 0278 RC inpatient 1640 1066 HUMANA - ALL PLANS HUMANA - ALL PLANS 1279.2 78 999999999 993.02 1590.8 percent of total billed charges SM FRAG CALC. V/PLATE 441.65 48713510_1 CDM 0278 RC inpatient 1640 1066 UMR - ALL PLANS UMR - ALL PLANS 1148 70 999999999 993.02 1590.8 percent of total billed charges SM FRAG CALC. V/PLATE 441.65 48713510_1 CDM 0278 RC inpatient 1640 1066 SIHO - ALL PLANS SIHO - ALL PLANS 1476 90 999999999 993.02 1590.8 percent of total billed charges SM FRAG CALC. V/PLATE 441.65 48713510_1 CDM 0278 RC inpatient 1640 1066 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 993.02 60.55 999999999 993.02 1590.8 percent of total billed charges SM FRAG CALC. V/PLATE 441.65 48713510_1 CDM 0278 RC inpatient 1640 1066 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 993.02 1590.8 SM FRAG CALC. V/PLATE 441.65 48713510_1 CDM 0278 RC inpatient 1640 1066 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 993.02 1590.8 SM FRAG CALC. V/PLATE 441.65 48713510_1 CDM 0278 RC inpatient 1640 1066 ANTHEM HMO ANTHEM HMO 999999999 993.02 1590.8 SM FRAG CALC. V/PLATE 441.65 48713510_1 CDM 0278 RC inpatient 1640 1066 CIGNA - ALL PLANS CIGNA - ALL PLANS 1108.64 67.6 999999999 993.02 1590.8 percent of total billed charges SM FRAG CALC. V/PLATE 441.65 48713510_1 CDM 0278 RC inpatient 1640 1066 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 993.02 1590.8 SM FRAG CALC. V/PLATE 441.65 48713510_1 CDM 0278 RC inpatient 1640 1066 UHC - ALL PLANS UHC - ALL PLANS 999999999 993.02 1590.8 EX T-PLATE 68MM 240.13 48713511_1 CDM 0278 RC inpatient 634 412.1 AETNA AETNA 500.86 79 999999999 383.89 614.98 percent of total billed charges EX T-PLATE 68MM 240.13 48713511_1 CDM 0278 RC inpatient 634 412.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 412.1 65 999999999 383.89 614.98 percent of total billed charges EX T-PLATE 68MM 240.13 48713511_1 CDM 0278 RC inpatient 634 412.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 614.98 97 999999999 383.89 614.98 percent of total billed charges EX T-PLATE 68MM 240.13 48713511_1 CDM 0278 RC inpatient 634 412.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 437.46 69 999999999 383.89 614.98 percent of total billed charges EX T-PLATE 68MM 240.13 48713511_1 CDM 0278 RC inpatient 634 412.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 494.52 78 999999999 383.89 614.98 percent of total billed charges EX T-PLATE 68MM 240.13 48713511_1 CDM 0278 RC inpatient 634 412.1 UMR - ALL PLANS UMR - ALL PLANS 443.8 70 999999999 383.89 614.98 percent of total billed charges EX T-PLATE 68MM 240.13 48713511_1 CDM 0278 RC inpatient 634 412.1 SIHO - ALL PLANS SIHO - ALL PLANS 570.6 90 999999999 383.89 614.98 percent of total billed charges EX T-PLATE 68MM 240.13 48713511_1 CDM 0278 RC inpatient 634 412.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 383.89 60.55 999999999 383.89 614.98 percent of total billed charges EX T-PLATE 68MM 240.13 48713511_1 CDM 0278 RC inpatient 634 412.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 383.89 614.98 EX T-PLATE 68MM 240.13 48713511_1 CDM 0278 RC inpatient 634 412.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 383.89 614.98 EX T-PLATE 68MM 240.13 48713511_1 CDM 0278 RC inpatient 634 412.1 ANTHEM HMO ANTHEM HMO 999999999 383.89 614.98 EX T-PLATE 68MM 240.13 48713511_1 CDM 0278 RC inpatient 634 412.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 428.58 67.6 999999999 383.89 614.98 percent of total billed charges EX T-PLATE 68MM 240.13 48713511_1 CDM 0278 RC inpatient 634 412.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 383.89 614.98 EX T-PLATE 68MM 240.13 48713511_1 CDM 0278 RC inpatient 634 412.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 383.89 614.98 EX T-PLATE 100MM 240.15 48713512_1 CDM 0278 RC inpatient 764 496.6 AETNA AETNA 603.56 79 999999999 462.6 741.08 percent of total billed charges EX T-PLATE 100MM 240.15 48713512_1 CDM 0278 RC inpatient 764 496.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 496.6 65 999999999 462.6 741.08 percent of total billed charges EX T-PLATE 100MM 240.15 48713512_1 CDM 0278 RC inpatient 764 496.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 741.08 97 999999999 462.6 741.08 percent of total billed charges EX T-PLATE 100MM 240.15 48713512_1 CDM 0278 RC inpatient 764 496.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 527.16 69 999999999 462.6 741.08 percent of total billed charges EX T-PLATE 100MM 240.15 48713512_1 CDM 0278 RC inpatient 764 496.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 595.92 78 999999999 462.6 741.08 percent of total billed charges EX T-PLATE 100MM 240.15 48713512_1 CDM 0278 RC inpatient 764 496.6 UMR - ALL PLANS UMR - ALL PLANS 534.8 70 999999999 462.6 741.08 percent of total billed charges EX T-PLATE 100MM 240.15 48713512_1 CDM 0278 RC inpatient 764 496.6 SIHO - ALL PLANS SIHO - ALL PLANS 687.6 90 999999999 462.6 741.08 percent of total billed charges EX T-PLATE 100MM 240.15 48713512_1 CDM 0278 RC inpatient 764 496.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 462.6 60.55 999999999 462.6 741.08 percent of total billed charges EX T-PLATE 100MM 240.15 48713512_1 CDM 0278 RC inpatient 764 496.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 462.6 741.08 EX T-PLATE 100MM 240.15 48713512_1 CDM 0278 RC inpatient 764 496.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 462.6 741.08 EX T-PLATE 100MM 240.15 48713512_1 CDM 0278 RC inpatient 764 496.6 ANTHEM HMO ANTHEM HMO 999999999 462.6 741.08 EX T-PLATE 100MM 240.15 48713512_1 CDM 0278 RC inpatient 764 496.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 516.46 67.6 999999999 462.6 741.08 percent of total billed charges EX T-PLATE 100MM 240.15 48713512_1 CDM 0278 RC inpatient 764 496.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 462.6 741.08 EX T-PLATE 100MM 240.15 48713512_1 CDM 0278 RC inpatient 764 496.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 462.6 741.08 EX T-BUT/PLATE 96MM 240.35 48713513_1 CDM 0278 RC inpatient 1086 705.9 AETNA AETNA 857.94 79 999999999 657.57 1053.42 percent of total billed charges EX T-BUT/PLATE 96MM 240.35 48713513_1 CDM 0278 RC inpatient 1086 705.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 705.9 65 999999999 657.57 1053.42 percent of total billed charges EX T-BUT/PLATE 96MM 240.35 48713513_1 CDM 0278 RC inpatient 1086 705.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1053.42 97 999999999 657.57 1053.42 percent of total billed charges EX T-BUT/PLATE 96MM 240.35 48713513_1 CDM 0278 RC inpatient 1086 705.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 749.34 69 999999999 657.57 1053.42 percent of total billed charges EX T-BUT/PLATE 96MM 240.35 48713513_1 CDM 0278 RC inpatient 1086 705.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 847.08 78 999999999 657.57 1053.42 percent of total billed charges EX T-BUT/PLATE 96MM 240.35 48713513_1 CDM 0278 RC inpatient 1086 705.9 UMR - ALL PLANS UMR - ALL PLANS 760.2 70 999999999 657.57 1053.42 percent of total billed charges EX T-BUT/PLATE 96MM 240.35 48713513_1 CDM 0278 RC inpatient 1086 705.9 SIHO - ALL PLANS SIHO - ALL PLANS 977.4 90 999999999 657.57 1053.42 percent of total billed charges EX T-BUT/PLATE 96MM 240.35 48713513_1 CDM 0278 RC inpatient 1086 705.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 657.57 60.55 999999999 657.57 1053.42 percent of total billed charges EX T-BUT/PLATE 96MM 240.35 48713513_1 CDM 0278 RC inpatient 1086 705.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 657.57 1053.42 EX T-BUT/PLATE 96MM 240.35 48713513_1 CDM 0278 RC inpatient 1086 705.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 657.57 1053.42 EX T-BUT/PLATE 96MM 240.35 48713513_1 CDM 0278 RC inpatient 1086 705.9 ANTHEM HMO ANTHEM HMO 999999999 657.57 1053.42 EX T-BUT/PLATE 96MM 240.35 48713513_1 CDM 0278 RC inpatient 1086 705.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 734.14 67.6 999999999 657.57 1053.42 percent of total billed charges EX T-BUT/PLATE 96MM 240.35 48713513_1 CDM 0278 RC inpatient 1086 705.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 657.57 1053.42 EX T-BUT/PLATE 96MM 240.35 48713513_1 CDM 0278 RC inpatient 1086 705.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 657.57 1053.42 EX T-BUT/PLATE 122MM 240.36 48713514_1 CDM 0278 RC inpatient 1187 771.55 AETNA AETNA 937.73 79 999999999 718.73 1151.39 percent of total billed charges EX T-BUT/PLATE 122MM 240.36 48713514_1 CDM 0278 RC inpatient 1187 771.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 771.55 65 999999999 718.73 1151.39 percent of total billed charges EX T-BUT/PLATE 122MM 240.36 48713514_1 CDM 0278 RC inpatient 1187 771.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1151.39 97 999999999 718.73 1151.39 percent of total billed charges EX T-BUT/PLATE 122MM 240.36 48713514_1 CDM 0278 RC inpatient 1187 771.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 819.03 69 999999999 718.73 1151.39 percent of total billed charges EX T-BUT/PLATE 122MM 240.36 48713514_1 CDM 0278 RC inpatient 1187 771.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 925.86 78 999999999 718.73 1151.39 percent of total billed charges EX T-BUT/PLATE 122MM 240.36 48713514_1 CDM 0278 RC inpatient 1187 771.55 UMR - ALL PLANS UMR - ALL PLANS 830.9 70 999999999 718.73 1151.39 percent of total billed charges EX T-BUT/PLATE 122MM 240.36 48713514_1 CDM 0278 RC inpatient 1187 771.55 SIHO - ALL PLANS SIHO - ALL PLANS 1068.3 90 999999999 718.73 1151.39 percent of total billed charges EX T-BUT/PLATE 122MM 240.36 48713514_1 CDM 0278 RC inpatient 1187 771.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 718.73 60.55 999999999 718.73 1151.39 percent of total billed charges EX T-BUT/PLATE 122MM 240.36 48713514_1 CDM 0278 RC inpatient 1187 771.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 718.73 1151.39 EX T-BUT/PLATE 122MM 240.36 48713514_1 CDM 0278 RC inpatient 1187 771.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 718.73 1151.39 EX T-BUT/PLATE 122MM 240.36 48713514_1 CDM 0278 RC inpatient 1187 771.55 ANTHEM HMO ANTHEM HMO 999999999 718.73 1151.39 EX T-BUT/PLATE 122MM 240.36 48713514_1 CDM 0278 RC inpatient 1187 771.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 802.41 67.6 999999999 718.73 1151.39 percent of total billed charges EX T-BUT/PLATE 122MM 240.36 48713514_1 CDM 0278 RC inpatient 1187 771.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 718.73 1151.39 EX T-BUT/PLATE 122MM 240.36 48713514_1 CDM 0278 RC inpatient 1187 771.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 718.73 1151.39 EX CONDYLAR (R) 158MM 240.94 48713515_1 CDM 0278 RC inpatient 2247 1460.55 AETNA AETNA 1775.13 79 999999999 1360.56 2179.59 percent of total billed charges EX CONDYLAR (R) 158MM 240.94 48713515_1 CDM 0278 RC inpatient 2247 1460.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1460.55 65 999999999 1360.56 2179.59 percent of total billed charges EX CONDYLAR (R) 158MM 240.94 48713515_1 CDM 0278 RC inpatient 2247 1460.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2179.59 97 999999999 1360.56 2179.59 percent of total billed charges EX CONDYLAR (R) 158MM 240.94 48713515_1 CDM 0278 RC inpatient 2247 1460.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1550.43 69 999999999 1360.56 2179.59 percent of total billed charges EX CONDYLAR (R) 158MM 240.94 48713515_1 CDM 0278 RC inpatient 2247 1460.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1752.66 78 999999999 1360.56 2179.59 percent of total billed charges EX CONDYLAR (R) 158MM 240.94 48713515_1 CDM 0278 RC inpatient 2247 1460.55 UMR - ALL PLANS UMR - ALL PLANS 1572.9 70 999999999 1360.56 2179.59 percent of total billed charges EX CONDYLAR (R) 158MM 240.94 48713515_1 CDM 0278 RC inpatient 2247 1460.55 SIHO - ALL PLANS SIHO - ALL PLANS 2022.3 90 999999999 1360.56 2179.59 percent of total billed charges EX CONDYLAR (R) 158MM 240.94 48713515_1 CDM 0278 RC inpatient 2247 1460.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1360.56 60.55 999999999 1360.56 2179.59 percent of total billed charges EX CONDYLAR (R) 158MM 240.94 48713515_1 CDM 0278 RC inpatient 2247 1460.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1360.56 2179.59 EX CONDYLAR (R) 158MM 240.94 48713515_1 CDM 0278 RC inpatient 2247 1460.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1360.56 2179.59 EX CONDYLAR (R) 158MM 240.94 48713515_1 CDM 0278 RC inpatient 2247 1460.55 ANTHEM HMO ANTHEM HMO 999999999 1360.56 2179.59 EX CONDYLAR (R) 158MM 240.94 48713515_1 CDM 0278 RC inpatient 2247 1460.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1518.97 67.6 999999999 1360.56 2179.59 percent of total billed charges EX CONDYLAR (R) 158MM 240.94 48713515_1 CDM 0278 RC inpatient 2247 1460.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1360.56 2179.59 EX CONDYLAR (R) 158MM 240.94 48713515_1 CDM 0278 RC inpatient 2247 1460.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1360.56 2179.59 EX CONDYLAR (R) 190MM 240.95 48713516_1 CDM 0278 RC inpatient 2327 1512.55 AETNA AETNA 1838.33 79 999999999 1409 2257.19 percent of total billed charges EX CONDYLAR (R) 190MM 240.95 48713516_1 CDM 0278 RC inpatient 2327 1512.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1512.55 65 999999999 1409 2257.19 percent of total billed charges EX CONDYLAR (R) 190MM 240.95 48713516_1 CDM 0278 RC inpatient 2327 1512.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2257.19 97 999999999 1409 2257.19 percent of total billed charges EX CONDYLAR (R) 190MM 240.95 48713516_1 CDM 0278 RC inpatient 2327 1512.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1605.63 69 999999999 1409 2257.19 percent of total billed charges EX CONDYLAR (R) 190MM 240.95 48713516_1 CDM 0278 RC inpatient 2327 1512.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1815.06 78 999999999 1409 2257.19 percent of total billed charges EX CONDYLAR (R) 190MM 240.95 48713516_1 CDM 0278 RC inpatient 2327 1512.55 UMR - ALL PLANS UMR - ALL PLANS 1628.9 70 999999999 1409 2257.19 percent of total billed charges EX CONDYLAR (R) 190MM 240.95 48713516_1 CDM 0278 RC inpatient 2327 1512.55 SIHO - ALL PLANS SIHO - ALL PLANS 2094.3 90 999999999 1409 2257.19 percent of total billed charges EX CONDYLAR (R) 190MM 240.95 48713516_1 CDM 0278 RC inpatient 2327 1512.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1409 60.55 999999999 1409 2257.19 percent of total billed charges EX CONDYLAR (R) 190MM 240.95 48713516_1 CDM 0278 RC inpatient 2327 1512.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1409 2257.19 EX CONDYLAR (R) 190MM 240.95 48713516_1 CDM 0278 RC inpatient 2327 1512.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1409 2257.19 EX CONDYLAR (R) 190MM 240.95 48713516_1 CDM 0278 RC inpatient 2327 1512.55 ANTHEM HMO ANTHEM HMO 999999999 1409 2257.19 EX CONDYLAR (R) 190MM 240.95 48713516_1 CDM 0278 RC inpatient 2327 1512.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1573.05 67.6 999999999 1409 2257.19 percent of total billed charges EX CONDYLAR (R) 190MM 240.95 48713516_1 CDM 0278 RC inpatient 2327 1512.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1409 2257.19 EX CONDYLAR (R) 190MM 240.95 48713516_1 CDM 0278 RC inpatient 2327 1512.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1409 2257.19 EX CONDYLAR (L) 158MM 240.92 48713517_1 CDM 0278 RC inpatient 2247 1460.55 AETNA AETNA 1775.13 79 999999999 1360.56 2179.59 percent of total billed charges EX CONDYLAR (L) 158MM 240.92 48713517_1 CDM 0278 RC inpatient 2247 1460.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1460.55 65 999999999 1360.56 2179.59 percent of total billed charges EX CONDYLAR (L) 158MM 240.92 48713517_1 CDM 0278 RC inpatient 2247 1460.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2179.59 97 999999999 1360.56 2179.59 percent of total billed charges EX CONDYLAR (L) 158MM 240.92 48713517_1 CDM 0278 RC inpatient 2247 1460.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1550.43 69 999999999 1360.56 2179.59 percent of total billed charges EX CONDYLAR (L) 158MM 240.92 48713517_1 CDM 0278 RC inpatient 2247 1460.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1752.66 78 999999999 1360.56 2179.59 percent of total billed charges EX CONDYLAR (L) 158MM 240.92 48713517_1 CDM 0278 RC inpatient 2247 1460.55 UMR - ALL PLANS UMR - ALL PLANS 1572.9 70 999999999 1360.56 2179.59 percent of total billed charges EX CONDYLAR (L) 158MM 240.92 48713517_1 CDM 0278 RC inpatient 2247 1460.55 SIHO - ALL PLANS SIHO - ALL PLANS 2022.3 90 999999999 1360.56 2179.59 percent of total billed charges EX CONDYLAR (L) 158MM 240.92 48713517_1 CDM 0278 RC inpatient 2247 1460.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1360.56 60.55 999999999 1360.56 2179.59 percent of total billed charges EX CONDYLAR (L) 158MM 240.92 48713517_1 CDM 0278 RC inpatient 2247 1460.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1360.56 2179.59 EX CONDYLAR (L) 158MM 240.92 48713517_1 CDM 0278 RC inpatient 2247 1460.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1360.56 2179.59 EX CONDYLAR (L) 158MM 240.92 48713517_1 CDM 0278 RC inpatient 2247 1460.55 ANTHEM HMO ANTHEM HMO 999999999 1360.56 2179.59 EX CONDYLAR (L) 158MM 240.92 48713517_1 CDM 0278 RC inpatient 2247 1460.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1518.97 67.6 999999999 1360.56 2179.59 percent of total billed charges EX CONDYLAR (L) 158MM 240.92 48713517_1 CDM 0278 RC inpatient 2247 1460.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1360.56 2179.59 EX CONDYLAR (L) 158MM 240.92 48713517_1 CDM 0278 RC inpatient 2247 1460.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1360.56 2179.59 EX CONDYLAR (L) 190MM 240.93 48713518_1 CDM 0278 RC inpatient 2327 1512.55 AETNA AETNA 1838.33 79 999999999 1409 2257.19 percent of total billed charges EX CONDYLAR (L) 190MM 240.93 48713518_1 CDM 0278 RC inpatient 2327 1512.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1512.55 65 999999999 1409 2257.19 percent of total billed charges EX CONDYLAR (L) 190MM 240.93 48713518_1 CDM 0278 RC inpatient 2327 1512.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2257.19 97 999999999 1409 2257.19 percent of total billed charges EX CONDYLAR (L) 190MM 240.93 48713518_1 CDM 0278 RC inpatient 2327 1512.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1605.63 69 999999999 1409 2257.19 percent of total billed charges EX CONDYLAR (L) 190MM 240.93 48713518_1 CDM 0278 RC inpatient 2327 1512.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1815.06 78 999999999 1409 2257.19 percent of total billed charges EX CONDYLAR (L) 190MM 240.93 48713518_1 CDM 0278 RC inpatient 2327 1512.55 UMR - ALL PLANS UMR - ALL PLANS 1628.9 70 999999999 1409 2257.19 percent of total billed charges EX CONDYLAR (L) 190MM 240.93 48713518_1 CDM 0278 RC inpatient 2327 1512.55 SIHO - ALL PLANS SIHO - ALL PLANS 2094.3 90 999999999 1409 2257.19 percent of total billed charges EX CONDYLAR (L) 190MM 240.93 48713518_1 CDM 0278 RC inpatient 2327 1512.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1409 60.55 999999999 1409 2257.19 percent of total billed charges EX CONDYLAR (L) 190MM 240.93 48713518_1 CDM 0278 RC inpatient 2327 1512.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1409 2257.19 EX CONDYLAR (L) 190MM 240.93 48713518_1 CDM 0278 RC inpatient 2327 1512.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1409 2257.19 EX CONDYLAR (L) 190MM 240.93 48713518_1 CDM 0278 RC inpatient 2327 1512.55 ANTHEM HMO ANTHEM HMO 999999999 1409 2257.19 EX CONDYLAR (L) 190MM 240.93 48713518_1 CDM 0278 RC inpatient 2327 1512.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1573.05 67.6 999999999 1409 2257.19 percent of total billed charges EX CONDYLAR (L) 190MM 240.93 48713518_1 CDM 0278 RC inpatient 2327 1512.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1409 2257.19 EX CONDYLAR (L) 190MM 240.93 48713518_1 CDM 0278 RC inpatient 2327 1512.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1409 2257.19 DCP PLATE SEMI-TUB 7H 222.07 48713519_1 CDM 0278 RC inpatient 239 155.35 AETNA AETNA 188.81 79 999999999 144.71 231.83 percent of total billed charges DCP PLATE SEMI-TUB 7H 222.07 48713519_1 CDM 0278 RC inpatient 239 155.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 155.35 65 999999999 144.71 231.83 percent of total billed charges DCP PLATE SEMI-TUB 7H 222.07 48713519_1 CDM 0278 RC inpatient 239 155.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 231.83 97 999999999 144.71 231.83 percent of total billed charges DCP PLATE SEMI-TUB 7H 222.07 48713519_1 CDM 0278 RC inpatient 239 155.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.91 69 999999999 144.71 231.83 percent of total billed charges DCP PLATE SEMI-TUB 7H 222.07 48713519_1 CDM 0278 RC inpatient 239 155.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 186.42 78 999999999 144.71 231.83 percent of total billed charges DCP PLATE SEMI-TUB 7H 222.07 48713519_1 CDM 0278 RC inpatient 239 155.35 UMR - ALL PLANS UMR - ALL PLANS 167.3 70 999999999 144.71 231.83 percent of total billed charges DCP PLATE SEMI-TUB 7H 222.07 48713519_1 CDM 0278 RC inpatient 239 155.35 SIHO - ALL PLANS SIHO - ALL PLANS 215.1 90 999999999 144.71 231.83 percent of total billed charges DCP PLATE SEMI-TUB 7H 222.07 48713519_1 CDM 0278 RC inpatient 239 155.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.71 60.55 999999999 144.71 231.83 percent of total billed charges DCP PLATE SEMI-TUB 7H 222.07 48713519_1 CDM 0278 RC inpatient 239 155.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.71 231.83 DCP PLATE SEMI-TUB 7H 222.07 48713519_1 CDM 0278 RC inpatient 239 155.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.71 231.83 DCP PLATE SEMI-TUB 7H 222.07 48713519_1 CDM 0278 RC inpatient 239 155.35 ANTHEM HMO ANTHEM HMO 999999999 144.71 231.83 DCP PLATE SEMI-TUB 7H 222.07 48713519_1 CDM 0278 RC inpatient 239 155.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 161.56 67.6 999999999 144.71 231.83 percent of total billed charges DCP PLATE SEMI-TUB 7H 222.07 48713519_1 CDM 0278 RC inpatient 239 155.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.71 231.83 DCP PLATE SEMI-TUB 7H 222.07 48713519_1 CDM 0278 RC inpatient 239 155.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.71 231.83 4.5MM NAR DCP 4 HOLE 224.04 48713520_1 CDM 0278 RC inpatient 439 285.35 AETNA AETNA 346.81 79 999999999 265.81 425.83 percent of total billed charges 4.5MM NAR DCP 4 HOLE 224.04 48713520_1 CDM 0278 RC inpatient 439 285.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 285.35 65 999999999 265.81 425.83 percent of total billed charges 4.5MM NAR DCP 4 HOLE 224.04 48713520_1 CDM 0278 RC inpatient 439 285.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 425.83 97 999999999 265.81 425.83 percent of total billed charges 4.5MM NAR DCP 4 HOLE 224.04 48713520_1 CDM 0278 RC inpatient 439 285.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 302.91 69 999999999 265.81 425.83 percent of total billed charges 4.5MM NAR DCP 4 HOLE 224.04 48713520_1 CDM 0278 RC inpatient 439 285.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 342.42 78 999999999 265.81 425.83 percent of total billed charges 4.5MM NAR DCP 4 HOLE 224.04 48713520_1 CDM 0278 RC inpatient 439 285.35 UMR - ALL PLANS UMR - ALL PLANS 307.3 70 999999999 265.81 425.83 percent of total billed charges 4.5MM NAR DCP 4 HOLE 224.04 48713520_1 CDM 0278 RC inpatient 439 285.35 SIHO - ALL PLANS SIHO - ALL PLANS 395.1 90 999999999 265.81 425.83 percent of total billed charges 4.5MM NAR DCP 4 HOLE 224.04 48713520_1 CDM 0278 RC inpatient 439 285.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 265.81 60.55 999999999 265.81 425.83 percent of total billed charges 4.5MM NAR DCP 4 HOLE 224.04 48713520_1 CDM 0278 RC inpatient 439 285.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 265.81 425.83 4.5MM NAR DCP 4 HOLE 224.04 48713520_1 CDM 0278 RC inpatient 439 285.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 265.81 425.83 4.5MM NAR DCP 4 HOLE 224.04 48713520_1 CDM 0278 RC inpatient 439 285.35 ANTHEM HMO ANTHEM HMO 999999999 265.81 425.83 4.5MM NAR DCP 4 HOLE 224.04 48713520_1 CDM 0278 RC inpatient 439 285.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 296.76 67.6 999999999 265.81 425.83 percent of total billed charges 4.5MM NAR DCP 4 HOLE 224.04 48713520_1 CDM 0278 RC inpatient 439 285.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 265.81 425.83 4.5MM NAR DCP 4 HOLE 224.04 48713520_1 CDM 0278 RC inpatient 439 285.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 265.81 425.83 4.5MM NAR DCP 6 HOLE 224.06 48713521_1 CDM 0278 RC inpatient 501 325.65 AETNA AETNA 395.79 79 999999999 303.36 485.97 percent of total billed charges 4.5MM NAR DCP 6 HOLE 224.06 48713521_1 CDM 0278 RC inpatient 501 325.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 325.65 65 999999999 303.36 485.97 percent of total billed charges 4.5MM NAR DCP 6 HOLE 224.06 48713521_1 CDM 0278 RC inpatient 501 325.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 485.97 97 999999999 303.36 485.97 percent of total billed charges 4.5MM NAR DCP 6 HOLE 224.06 48713521_1 CDM 0278 RC inpatient 501 325.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 345.69 69 999999999 303.36 485.97 percent of total billed charges 4.5MM NAR DCP 6 HOLE 224.06 48713521_1 CDM 0278 RC inpatient 501 325.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 390.78 78 999999999 303.36 485.97 percent of total billed charges 4.5MM NAR DCP 6 HOLE 224.06 48713521_1 CDM 0278 RC inpatient 501 325.65 UMR - ALL PLANS UMR - ALL PLANS 350.7 70 999999999 303.36 485.97 percent of total billed charges 4.5MM NAR DCP 6 HOLE 224.06 48713521_1 CDM 0278 RC inpatient 501 325.65 SIHO - ALL PLANS SIHO - ALL PLANS 450.9 90 999999999 303.36 485.97 percent of total billed charges 4.5MM NAR DCP 6 HOLE 224.06 48713521_1 CDM 0278 RC inpatient 501 325.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 303.36 60.55 999999999 303.36 485.97 percent of total billed charges 4.5MM NAR DCP 6 HOLE 224.06 48713521_1 CDM 0278 RC inpatient 501 325.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 303.36 485.97 4.5MM NAR DCP 6 HOLE 224.06 48713521_1 CDM 0278 RC inpatient 501 325.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 303.36 485.97 4.5MM NAR DCP 6 HOLE 224.06 48713521_1 CDM 0278 RC inpatient 501 325.65 ANTHEM HMO ANTHEM HMO 999999999 303.36 485.97 4.5MM NAR DCP 6 HOLE 224.06 48713521_1 CDM 0278 RC inpatient 501 325.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 338.68 67.6 999999999 303.36 485.97 percent of total billed charges 4.5MM NAR DCP 6 HOLE 224.06 48713521_1 CDM 0278 RC inpatient 501 325.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 303.36 485.97 4.5MM NAR DCP 6 HOLE 224.06 48713521_1 CDM 0278 RC inpatient 501 325.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 303.36 485.97 4.5MM NAR DCP 12 HOLE 224.62 48713522_1 CDM 0278 RC inpatient 650 422.5 AETNA AETNA 513.5 79 999999999 393.58 630.5 percent of total billed charges 4.5MM NAR DCP 12 HOLE 224.62 48713522_1 CDM 0278 RC inpatient 650 422.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 422.5 65 999999999 393.58 630.5 percent of total billed charges 4.5MM NAR DCP 12 HOLE 224.62 48713522_1 CDM 0278 RC inpatient 650 422.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 630.5 97 999999999 393.58 630.5 percent of total billed charges 4.5MM NAR DCP 12 HOLE 224.62 48713522_1 CDM 0278 RC inpatient 650 422.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 448.5 69 999999999 393.58 630.5 percent of total billed charges 4.5MM NAR DCP 12 HOLE 224.62 48713522_1 CDM 0278 RC inpatient 650 422.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 507 78 999999999 393.58 630.5 percent of total billed charges 4.5MM NAR DCP 12 HOLE 224.62 48713522_1 CDM 0278 RC inpatient 650 422.5 UMR - ALL PLANS UMR - ALL PLANS 455 70 999999999 393.58 630.5 percent of total billed charges 4.5MM NAR DCP 12 HOLE 224.62 48713522_1 CDM 0278 RC inpatient 650 422.5 SIHO - ALL PLANS SIHO - ALL PLANS 585 90 999999999 393.58 630.5 percent of total billed charges 4.5MM NAR DCP 12 HOLE 224.62 48713522_1 CDM 0278 RC inpatient 650 422.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 393.58 60.55 999999999 393.58 630.5 percent of total billed charges 4.5MM NAR DCP 12 HOLE 224.62 48713522_1 CDM 0278 RC inpatient 650 422.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 393.58 630.5 4.5MM NAR DCP 12 HOLE 224.62 48713522_1 CDM 0278 RC inpatient 650 422.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 393.58 630.5 4.5MM NAR DCP 12 HOLE 224.62 48713522_1 CDM 0278 RC inpatient 650 422.5 ANTHEM HMO ANTHEM HMO 999999999 393.58 630.5 4.5MM NAR DCP 12 HOLE 224.62 48713522_1 CDM 0278 RC inpatient 650 422.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 439.4 67.6 999999999 393.58 630.5 percent of total billed charges 4.5MM NAR DCP 12 HOLE 224.62 48713522_1 CDM 0278 RC inpatient 650 422.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 393.58 630.5 4.5MM NAR DCP 12 HOLE 224.62 48713522_1 CDM 0278 RC inpatient 650 422.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 393.58 630.5 4.5MM BROAD DCP 8 HOLE 226.58 48713523_1 CDM 0278 RC inpatient 746 484.9 AETNA AETNA 589.34 79 999999999 451.7 723.62 percent of total billed charges 4.5MM BROAD DCP 8 HOLE 226.58 48713523_1 CDM 0278 RC inpatient 746 484.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 484.9 65 999999999 451.7 723.62 percent of total billed charges 4.5MM BROAD DCP 8 HOLE 226.58 48713523_1 CDM 0278 RC inpatient 746 484.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 723.62 97 999999999 451.7 723.62 percent of total billed charges 4.5MM BROAD DCP 8 HOLE 226.58 48713523_1 CDM 0278 RC inpatient 746 484.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 514.74 69 999999999 451.7 723.62 percent of total billed charges 4.5MM BROAD DCP 8 HOLE 226.58 48713523_1 CDM 0278 RC inpatient 746 484.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 581.88 78 999999999 451.7 723.62 percent of total billed charges 4.5MM BROAD DCP 8 HOLE 226.58 48713523_1 CDM 0278 RC inpatient 746 484.9 UMR - ALL PLANS UMR - ALL PLANS 522.2 70 999999999 451.7 723.62 percent of total billed charges 4.5MM BROAD DCP 8 HOLE 226.58 48713523_1 CDM 0278 RC inpatient 746 484.9 SIHO - ALL PLANS SIHO - ALL PLANS 671.4 90 999999999 451.7 723.62 percent of total billed charges 4.5MM BROAD DCP 8 HOLE 226.58 48713523_1 CDM 0278 RC inpatient 746 484.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 451.7 60.55 999999999 451.7 723.62 percent of total billed charges 4.5MM BROAD DCP 8 HOLE 226.58 48713523_1 CDM 0278 RC inpatient 746 484.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 451.7 723.62 4.5MM BROAD DCP 8 HOLE 226.58 48713523_1 CDM 0278 RC inpatient 746 484.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 451.7 723.62 4.5MM BROAD DCP 8 HOLE 226.58 48713523_1 CDM 0278 RC inpatient 746 484.9 ANTHEM HMO ANTHEM HMO 999999999 451.7 723.62 4.5MM BROAD DCP 8 HOLE 226.58 48713523_1 CDM 0278 RC inpatient 746 484.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 504.3 67.6 999999999 451.7 723.62 percent of total billed charges 4.5MM BROAD DCP 8 HOLE 226.58 48713523_1 CDM 0278 RC inpatient 746 484.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 451.7 723.62 4.5MM BROAD DCP 8 HOLE 226.58 48713523_1 CDM 0278 RC inpatient 746 484.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 451.7 723.62 4.5MM BROAD DCP 10 HOLE 226.60 48713524_1 CDM 0278 RC inpatient 746 484.9 AETNA AETNA 589.34 79 999999999 451.7 723.62 percent of total billed charges 4.5MM BROAD DCP 10 HOLE 226.60 48713524_1 CDM 0278 RC inpatient 746 484.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 484.9 65 999999999 451.7 723.62 percent of total billed charges 4.5MM BROAD DCP 10 HOLE 226.60 48713524_1 CDM 0278 RC inpatient 746 484.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 723.62 97 999999999 451.7 723.62 percent of total billed charges 4.5MM BROAD DCP 10 HOLE 226.60 48713524_1 CDM 0278 RC inpatient 746 484.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 514.74 69 999999999 451.7 723.62 percent of total billed charges 4.5MM BROAD DCP 10 HOLE 226.60 48713524_1 CDM 0278 RC inpatient 746 484.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 581.88 78 999999999 451.7 723.62 percent of total billed charges 4.5MM BROAD DCP 10 HOLE 226.60 48713524_1 CDM 0278 RC inpatient 746 484.9 UMR - ALL PLANS UMR - ALL PLANS 522.2 70 999999999 451.7 723.62 percent of total billed charges 4.5MM BROAD DCP 10 HOLE 226.60 48713524_1 CDM 0278 RC inpatient 746 484.9 SIHO - ALL PLANS SIHO - ALL PLANS 671.4 90 999999999 451.7 723.62 percent of total billed charges 4.5MM BROAD DCP 10 HOLE 226.60 48713524_1 CDM 0278 RC inpatient 746 484.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 451.7 60.55 999999999 451.7 723.62 percent of total billed charges 4.5MM BROAD DCP 10 HOLE 226.60 48713524_1 CDM 0278 RC inpatient 746 484.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 451.7 723.62 4.5MM BROAD DCP 10 HOLE 226.60 48713524_1 CDM 0278 RC inpatient 746 484.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 451.7 723.62 4.5MM BROAD DCP 10 HOLE 226.60 48713524_1 CDM 0278 RC inpatient 746 484.9 ANTHEM HMO ANTHEM HMO 999999999 451.7 723.62 4.5MM BROAD DCP 10 HOLE 226.60 48713524_1 CDM 0278 RC inpatient 746 484.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 504.3 67.6 999999999 451.7 723.62 percent of total billed charges 4.5MM BROAD DCP 10 HOLE 226.60 48713524_1 CDM 0278 RC inpatient 746 484.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 451.7 723.62 4.5MM BROAD DCP 10 HOLE 226.60 48713524_1 CDM 0278 RC inpatient 746 484.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 451.7 723.62 4.5MM BROAD DCP 12 HOLE 226.62 48713525_1 CDM 0278 RC inpatient 802 521.3 AETNA AETNA 633.58 79 999999999 485.61 777.94 percent of total billed charges 4.5MM BROAD DCP 12 HOLE 226.62 48713525_1 CDM 0278 RC inpatient 802 521.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 521.3 65 999999999 485.61 777.94 percent of total billed charges 4.5MM BROAD DCP 12 HOLE 226.62 48713525_1 CDM 0278 RC inpatient 802 521.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 777.94 97 999999999 485.61 777.94 percent of total billed charges 4.5MM BROAD DCP 12 HOLE 226.62 48713525_1 CDM 0278 RC inpatient 802 521.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 553.38 69 999999999 485.61 777.94 percent of total billed charges 4.5MM BROAD DCP 12 HOLE 226.62 48713525_1 CDM 0278 RC inpatient 802 521.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 625.56 78 999999999 485.61 777.94 percent of total billed charges 4.5MM BROAD DCP 12 HOLE 226.62 48713525_1 CDM 0278 RC inpatient 802 521.3 UMR - ALL PLANS UMR - ALL PLANS 561.4 70 999999999 485.61 777.94 percent of total billed charges 4.5MM BROAD DCP 12 HOLE 226.62 48713525_1 CDM 0278 RC inpatient 802 521.3 SIHO - ALL PLANS SIHO - ALL PLANS 721.8 90 999999999 485.61 777.94 percent of total billed charges 4.5MM BROAD DCP 12 HOLE 226.62 48713525_1 CDM 0278 RC inpatient 802 521.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 485.61 60.55 999999999 485.61 777.94 percent of total billed charges 4.5MM BROAD DCP 12 HOLE 226.62 48713525_1 CDM 0278 RC inpatient 802 521.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 485.61 777.94 4.5MM BROAD DCP 12 HOLE 226.62 48713525_1 CDM 0278 RC inpatient 802 521.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 485.61 777.94 4.5MM BROAD DCP 12 HOLE 226.62 48713525_1 CDM 0278 RC inpatient 802 521.3 ANTHEM HMO ANTHEM HMO 999999999 485.61 777.94 4.5MM BROAD DCP 12 HOLE 226.62 48713525_1 CDM 0278 RC inpatient 802 521.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 542.15 67.6 999999999 485.61 777.94 percent of total billed charges 4.5MM BROAD DCP 12 HOLE 226.62 48713525_1 CDM 0278 RC inpatient 802 521.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 485.61 777.94 4.5MM BROAD DCP 12 HOLE 226.62 48713525_1 CDM 0278 RC inpatient 802 521.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 485.61 777.94 DCP SPOON PLATE 6 HOLE 240.06 48713526_1 CDM 0278 RC inpatient 858 557.7 AETNA AETNA 677.82 79 999999999 519.52 832.26 percent of total billed charges DCP SPOON PLATE 6 HOLE 240.06 48713526_1 CDM 0278 RC inpatient 858 557.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 557.7 65 999999999 519.52 832.26 percent of total billed charges DCP SPOON PLATE 6 HOLE 240.06 48713526_1 CDM 0278 RC inpatient 858 557.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 832.26 97 999999999 519.52 832.26 percent of total billed charges DCP SPOON PLATE 6 HOLE 240.06 48713526_1 CDM 0278 RC inpatient 858 557.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 592.02 69 999999999 519.52 832.26 percent of total billed charges DCP SPOON PLATE 6 HOLE 240.06 48713526_1 CDM 0278 RC inpatient 858 557.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 669.24 78 999999999 519.52 832.26 percent of total billed charges DCP SPOON PLATE 6 HOLE 240.06 48713526_1 CDM 0278 RC inpatient 858 557.7 UMR - ALL PLANS UMR - ALL PLANS 600.6 70 999999999 519.52 832.26 percent of total billed charges DCP SPOON PLATE 6 HOLE 240.06 48713526_1 CDM 0278 RC inpatient 858 557.7 SIHO - ALL PLANS SIHO - ALL PLANS 772.2 90 999999999 519.52 832.26 percent of total billed charges DCP SPOON PLATE 6 HOLE 240.06 48713526_1 CDM 0278 RC inpatient 858 557.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 519.52 60.55 999999999 519.52 832.26 percent of total billed charges DCP SPOON PLATE 6 HOLE 240.06 48713526_1 CDM 0278 RC inpatient 858 557.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 519.52 832.26 DCP SPOON PLATE 6 HOLE 240.06 48713526_1 CDM 0278 RC inpatient 858 557.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 519.52 832.26 DCP SPOON PLATE 6 HOLE 240.06 48713526_1 CDM 0278 RC inpatient 858 557.7 ANTHEM HMO ANTHEM HMO 999999999 519.52 832.26 DCP SPOON PLATE 6 HOLE 240.06 48713526_1 CDM 0278 RC inpatient 858 557.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 580.01 67.6 999999999 519.52 832.26 percent of total billed charges DCP SPOON PLATE 6 HOLE 240.06 48713526_1 CDM 0278 RC inpatient 858 557.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 519.52 832.26 DCP SPOON PLATE 6 HOLE 240.06 48713526_1 CDM 0278 RC inpatient 858 557.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 519.52 832.26 DCP T-PLATE 8 HOLE 240.18 48713527_1 CDM 0278 RC inpatient 1180 767 AETNA AETNA 932.2 79 999999999 714.49 1144.6 percent of total billed charges DCP T-PLATE 8 HOLE 240.18 48713527_1 CDM 0278 RC inpatient 1180 767 SELF PAY DISCOUNT SELF PAY DISCOUNT 767 65 999999999 714.49 1144.6 percent of total billed charges DCP T-PLATE 8 HOLE 240.18 48713527_1 CDM 0278 RC inpatient 1180 767 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1144.6 97 999999999 714.49 1144.6 percent of total billed charges DCP T-PLATE 8 HOLE 240.18 48713527_1 CDM 0278 RC inpatient 1180 767 ENCORE - ALL PLANS ENCORE - ALL PLANS 814.2 69 999999999 714.49 1144.6 percent of total billed charges DCP T-PLATE 8 HOLE 240.18 48713527_1 CDM 0278 RC inpatient 1180 767 HUMANA - ALL PLANS HUMANA - ALL PLANS 920.4 78 999999999 714.49 1144.6 percent of total billed charges DCP T-PLATE 8 HOLE 240.18 48713527_1 CDM 0278 RC inpatient 1180 767 UMR - ALL PLANS UMR - ALL PLANS 826 70 999999999 714.49 1144.6 percent of total billed charges DCP T-PLATE 8 HOLE 240.18 48713527_1 CDM 0278 RC inpatient 1180 767 SIHO - ALL PLANS SIHO - ALL PLANS 1062 90 999999999 714.49 1144.6 percent of total billed charges DCP T-PLATE 8 HOLE 240.18 48713527_1 CDM 0278 RC inpatient 1180 767 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 714.49 60.55 999999999 714.49 1144.6 percent of total billed charges DCP T-PLATE 8 HOLE 240.18 48713527_1 CDM 0278 RC inpatient 1180 767 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 714.49 1144.6 DCP T-PLATE 8 HOLE 240.18 48713527_1 CDM 0278 RC inpatient 1180 767 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 714.49 1144.6 DCP T-PLATE 8 HOLE 240.18 48713527_1 CDM 0278 RC inpatient 1180 767 ANTHEM HMO ANTHEM HMO 999999999 714.49 1144.6 DCP T-PLATE 8 HOLE 240.18 48713527_1 CDM 0278 RC inpatient 1180 767 CIGNA - ALL PLANS CIGNA - ALL PLANS 797.68 67.6 999999999 714.49 1144.6 percent of total billed charges DCP T-PLATE 8 HOLE 240.18 48713527_1 CDM 0278 RC inpatient 1180 767 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 714.49 1144.6 DCP T-PLATE 8 HOLE 240.18 48713527_1 CDM 0278 RC inpatient 1180 767 UHC - ALL PLANS UHC - ALL PLANS 999999999 714.49 1144.6 DCP T-PLATE BUTTRESS 4H 240.34 48713528_1 CDM 0278 RC inpatient 1062 690.3 AETNA AETNA 838.98 79 999999999 643.04 1030.14 percent of total billed charges DCP T-PLATE BUTTRESS 4H 240.34 48713528_1 CDM 0278 RC inpatient 1062 690.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 690.3 65 999999999 643.04 1030.14 percent of total billed charges DCP T-PLATE BUTTRESS 4H 240.34 48713528_1 CDM 0278 RC inpatient 1062 690.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1030.14 97 999999999 643.04 1030.14 percent of total billed charges DCP T-PLATE BUTTRESS 4H 240.34 48713528_1 CDM 0278 RC inpatient 1062 690.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 732.78 69 999999999 643.04 1030.14 percent of total billed charges DCP T-PLATE BUTTRESS 4H 240.34 48713528_1 CDM 0278 RC inpatient 1062 690.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 828.36 78 999999999 643.04 1030.14 percent of total billed charges DCP T-PLATE BUTTRESS 4H 240.34 48713528_1 CDM 0278 RC inpatient 1062 690.3 UMR - ALL PLANS UMR - ALL PLANS 743.4 70 999999999 643.04 1030.14 percent of total billed charges DCP T-PLATE BUTTRESS 4H 240.34 48713528_1 CDM 0278 RC inpatient 1062 690.3 SIHO - ALL PLANS SIHO - ALL PLANS 955.8 90 999999999 643.04 1030.14 percent of total billed charges DCP T-PLATE BUTTRESS 4H 240.34 48713528_1 CDM 0278 RC inpatient 1062 690.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 643.04 60.55 999999999 643.04 1030.14 percent of total billed charges DCP T-PLATE BUTTRESS 4H 240.34 48713528_1 CDM 0278 RC inpatient 1062 690.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 643.04 1030.14 DCP T-PLATE BUTTRESS 4H 240.34 48713528_1 CDM 0278 RC inpatient 1062 690.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 643.04 1030.14 DCP T-PLATE BUTTRESS 4H 240.34 48713528_1 CDM 0278 RC inpatient 1062 690.3 ANTHEM HMO ANTHEM HMO 999999999 643.04 1030.14 DCP T-PLATE BUTTRESS 4H 240.34 48713528_1 CDM 0278 RC inpatient 1062 690.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 717.91 67.6 999999999 643.04 1030.14 percent of total billed charges DCP T-PLATE BUTTRESS 4H 240.34 48713528_1 CDM 0278 RC inpatient 1062 690.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 643.04 1030.14 DCP T-PLATE BUTTRESS 4H 240.34 48713528_1 CDM 0278 RC inpatient 1062 690.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 643.04 1030.14 DCP PLATE SEMI-TUB 3H 222.03 48713529_1 CDM 0278 RC inpatient 239 155.35 AETNA AETNA 188.81 79 999999999 144.71 231.83 percent of total billed charges DCP PLATE SEMI-TUB 3H 222.03 48713529_1 CDM 0278 RC inpatient 239 155.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 155.35 65 999999999 144.71 231.83 percent of total billed charges DCP PLATE SEMI-TUB 3H 222.03 48713529_1 CDM 0278 RC inpatient 239 155.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 231.83 97 999999999 144.71 231.83 percent of total billed charges DCP PLATE SEMI-TUB 3H 222.03 48713529_1 CDM 0278 RC inpatient 239 155.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.91 69 999999999 144.71 231.83 percent of total billed charges DCP PLATE SEMI-TUB 3H 222.03 48713529_1 CDM 0278 RC inpatient 239 155.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 186.42 78 999999999 144.71 231.83 percent of total billed charges DCP PLATE SEMI-TUB 3H 222.03 48713529_1 CDM 0278 RC inpatient 239 155.35 UMR - ALL PLANS UMR - ALL PLANS 167.3 70 999999999 144.71 231.83 percent of total billed charges DCP PLATE SEMI-TUB 3H 222.03 48713529_1 CDM 0278 RC inpatient 239 155.35 SIHO - ALL PLANS SIHO - ALL PLANS 215.1 90 999999999 144.71 231.83 percent of total billed charges DCP PLATE SEMI-TUB 3H 222.03 48713529_1 CDM 0278 RC inpatient 239 155.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.71 60.55 999999999 144.71 231.83 percent of total billed charges DCP PLATE SEMI-TUB 3H 222.03 48713529_1 CDM 0278 RC inpatient 239 155.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.71 231.83 DCP PLATE SEMI-TUB 3H 222.03 48713529_1 CDM 0278 RC inpatient 239 155.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.71 231.83 DCP PLATE SEMI-TUB 3H 222.03 48713529_1 CDM 0278 RC inpatient 239 155.35 ANTHEM HMO ANTHEM HMO 999999999 144.71 231.83 DCP PLATE SEMI-TUB 3H 222.03 48713529_1 CDM 0278 RC inpatient 239 155.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 161.56 67.6 999999999 144.71 231.83 percent of total billed charges DCP PLATE SEMI-TUB 3H 222.03 48713529_1 CDM 0278 RC inpatient 239 155.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.71 231.83 DCP PLATE SEMI-TUB 3H 222.03 48713529_1 CDM 0278 RC inpatient 239 155.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.71 231.83 4.5MM NAR DCP 3 HOLE 224.03 48713530_1 CDM 0278 RC inpatient 543 352.95 AETNA AETNA 428.97 79 999999999 328.79 526.71 percent of total billed charges 4.5MM NAR DCP 3 HOLE 224.03 48713530_1 CDM 0278 RC inpatient 543 352.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 352.95 65 999999999 328.79 526.71 percent of total billed charges 4.5MM NAR DCP 3 HOLE 224.03 48713530_1 CDM 0278 RC inpatient 543 352.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 526.71 97 999999999 328.79 526.71 percent of total billed charges 4.5MM NAR DCP 3 HOLE 224.03 48713530_1 CDM 0278 RC inpatient 543 352.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 374.67 69 999999999 328.79 526.71 percent of total billed charges 4.5MM NAR DCP 3 HOLE 224.03 48713530_1 CDM 0278 RC inpatient 543 352.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 423.54 78 999999999 328.79 526.71 percent of total billed charges 4.5MM NAR DCP 3 HOLE 224.03 48713530_1 CDM 0278 RC inpatient 543 352.95 UMR - ALL PLANS UMR - ALL PLANS 380.1 70 999999999 328.79 526.71 percent of total billed charges 4.5MM NAR DCP 3 HOLE 224.03 48713530_1 CDM 0278 RC inpatient 543 352.95 SIHO - ALL PLANS SIHO - ALL PLANS 488.7 90 999999999 328.79 526.71 percent of total billed charges 4.5MM NAR DCP 3 HOLE 224.03 48713530_1 CDM 0278 RC inpatient 543 352.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 328.79 60.55 999999999 328.79 526.71 percent of total billed charges 4.5MM NAR DCP 3 HOLE 224.03 48713530_1 CDM 0278 RC inpatient 543 352.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 328.79 526.71 4.5MM NAR DCP 3 HOLE 224.03 48713530_1 CDM 0278 RC inpatient 543 352.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 328.79 526.71 4.5MM NAR DCP 3 HOLE 224.03 48713530_1 CDM 0278 RC inpatient 543 352.95 ANTHEM HMO ANTHEM HMO 999999999 328.79 526.71 4.5MM NAR DCP 3 HOLE 224.03 48713530_1 CDM 0278 RC inpatient 543 352.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 367.07 67.6 999999999 328.79 526.71 percent of total billed charges 4.5MM NAR DCP 3 HOLE 224.03 48713530_1 CDM 0278 RC inpatient 543 352.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 328.79 526.71 4.5MM NAR DCP 3 HOLE 224.03 48713530_1 CDM 0278 RC inpatient 543 352.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 328.79 526.71 95 CONDYLAR 5H 92/50MM 237.50 48713531_1 CDM 0278 RC inpatient 1509 980.85 AETNA AETNA 1192.11 79 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/50MM 237.50 48713531_1 CDM 0278 RC inpatient 1509 980.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 980.85 65 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/50MM 237.50 48713531_1 CDM 0278 RC inpatient 1509 980.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1463.73 97 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/50MM 237.50 48713531_1 CDM 0278 RC inpatient 1509 980.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1041.21 69 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/50MM 237.50 48713531_1 CDM 0278 RC inpatient 1509 980.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1177.02 78 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/50MM 237.50 48713531_1 CDM 0278 RC inpatient 1509 980.85 UMR - ALL PLANS UMR - ALL PLANS 1056.3 70 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/50MM 237.50 48713531_1 CDM 0278 RC inpatient 1509 980.85 SIHO - ALL PLANS SIHO - ALL PLANS 1358.1 90 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/50MM 237.50 48713531_1 CDM 0278 RC inpatient 1509 980.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 913.7 60.55 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/50MM 237.50 48713531_1 CDM 0278 RC inpatient 1509 980.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 913.7 1463.73 95 CONDYLAR 5H 92/50MM 237.50 48713531_1 CDM 0278 RC inpatient 1509 980.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 913.7 1463.73 95 CONDYLAR 5H 92/50MM 237.50 48713531_1 CDM 0278 RC inpatient 1509 980.85 ANTHEM HMO ANTHEM HMO 999999999 913.7 1463.73 95 CONDYLAR 5H 92/50MM 237.50 48713531_1 CDM 0278 RC inpatient 1509 980.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1020.08 67.6 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/50MM 237.50 48713531_1 CDM 0278 RC inpatient 1509 980.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 913.7 1463.73 95 CONDYLAR 5H 92/50MM 237.50 48713531_1 CDM 0278 RC inpatient 1509 980.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 913.7 1463.73 95 CONDYLAR 5H 92/60MM 237.52 48713532_1 CDM 0278 RC inpatient 1509 980.85 AETNA AETNA 1192.11 79 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/60MM 237.52 48713532_1 CDM 0278 RC inpatient 1509 980.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 980.85 65 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/60MM 237.52 48713532_1 CDM 0278 RC inpatient 1509 980.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1463.73 97 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/60MM 237.52 48713532_1 CDM 0278 RC inpatient 1509 980.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1041.21 69 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/60MM 237.52 48713532_1 CDM 0278 RC inpatient 1509 980.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1177.02 78 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/60MM 237.52 48713532_1 CDM 0278 RC inpatient 1509 980.85 UMR - ALL PLANS UMR - ALL PLANS 1056.3 70 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/60MM 237.52 48713532_1 CDM 0278 RC inpatient 1509 980.85 SIHO - ALL PLANS SIHO - ALL PLANS 1358.1 90 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/60MM 237.52 48713532_1 CDM 0278 RC inpatient 1509 980.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 913.7 60.55 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/60MM 237.52 48713532_1 CDM 0278 RC inpatient 1509 980.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 913.7 1463.73 95 CONDYLAR 5H 92/60MM 237.52 48713532_1 CDM 0278 RC inpatient 1509 980.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 913.7 1463.73 95 CONDYLAR 5H 92/60MM 237.52 48713532_1 CDM 0278 RC inpatient 1509 980.85 ANTHEM HMO ANTHEM HMO 999999999 913.7 1463.73 95 CONDYLAR 5H 92/60MM 237.52 48713532_1 CDM 0278 RC inpatient 1509 980.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1020.08 67.6 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/60MM 237.52 48713532_1 CDM 0278 RC inpatient 1509 980.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 913.7 1463.73 95 CONDYLAR 5H 92/60MM 237.52 48713532_1 CDM 0278 RC inpatient 1509 980.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 913.7 1463.73 95 CONDYLAR 5H 92/70MM 237.54 48713533_1 CDM 0278 RC inpatient 1453 944.45 AETNA AETNA 1147.87 79 999999999 879.79 1409.41 percent of total billed charges 95 CONDYLAR 5H 92/70MM 237.54 48713533_1 CDM 0278 RC inpatient 1453 944.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 944.45 65 999999999 879.79 1409.41 percent of total billed charges 95 CONDYLAR 5H 92/70MM 237.54 48713533_1 CDM 0278 RC inpatient 1453 944.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1409.41 97 999999999 879.79 1409.41 percent of total billed charges 95 CONDYLAR 5H 92/70MM 237.54 48713533_1 CDM 0278 RC inpatient 1453 944.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1002.57 69 999999999 879.79 1409.41 percent of total billed charges 95 CONDYLAR 5H 92/70MM 237.54 48713533_1 CDM 0278 RC inpatient 1453 944.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1133.34 78 999999999 879.79 1409.41 percent of total billed charges 95 CONDYLAR 5H 92/70MM 237.54 48713533_1 CDM 0278 RC inpatient 1453 944.45 UMR - ALL PLANS UMR - ALL PLANS 1017.1 70 999999999 879.79 1409.41 percent of total billed charges 95 CONDYLAR 5H 92/70MM 237.54 48713533_1 CDM 0278 RC inpatient 1453 944.45 SIHO - ALL PLANS SIHO - ALL PLANS 1307.7 90 999999999 879.79 1409.41 percent of total billed charges 95 CONDYLAR 5H 92/70MM 237.54 48713533_1 CDM 0278 RC inpatient 1453 944.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 879.79 60.55 999999999 879.79 1409.41 percent of total billed charges 95 CONDYLAR 5H 92/70MM 237.54 48713533_1 CDM 0278 RC inpatient 1453 944.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 879.79 1409.41 95 CONDYLAR 5H 92/70MM 237.54 48713533_1 CDM 0278 RC inpatient 1453 944.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 879.79 1409.41 95 CONDYLAR 5H 92/70MM 237.54 48713533_1 CDM 0278 RC inpatient 1453 944.45 ANTHEM HMO ANTHEM HMO 999999999 879.79 1409.41 95 CONDYLAR 5H 92/70MM 237.54 48713533_1 CDM 0278 RC inpatient 1453 944.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 982.23 67.6 999999999 879.79 1409.41 percent of total billed charges 95 CONDYLAR 5H 92/70MM 237.54 48713533_1 CDM 0278 RC inpatient 1453 944.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 879.79 1409.41 95 CONDYLAR 5H 92/70MM 237.54 48713533_1 CDM 0278 RC inpatient 1453 944.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 879.79 1409.41 95 CONDYLAR 5H 92/80MM 237.56 48713534_1 CDM 0278 RC inpatient 1509 980.85 AETNA AETNA 1192.11 79 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/80MM 237.56 48713534_1 CDM 0278 RC inpatient 1509 980.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 980.85 65 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/80MM 237.56 48713534_1 CDM 0278 RC inpatient 1509 980.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1463.73 97 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/80MM 237.56 48713534_1 CDM 0278 RC inpatient 1509 980.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1041.21 69 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/80MM 237.56 48713534_1 CDM 0278 RC inpatient 1509 980.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1177.02 78 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/80MM 237.56 48713534_1 CDM 0278 RC inpatient 1509 980.85 UMR - ALL PLANS UMR - ALL PLANS 1056.3 70 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/80MM 237.56 48713534_1 CDM 0278 RC inpatient 1509 980.85 SIHO - ALL PLANS SIHO - ALL PLANS 1358.1 90 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/80MM 237.56 48713534_1 CDM 0278 RC inpatient 1509 980.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 913.7 60.55 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/80MM 237.56 48713534_1 CDM 0278 RC inpatient 1509 980.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 913.7 1463.73 95 CONDYLAR 5H 92/80MM 237.56 48713534_1 CDM 0278 RC inpatient 1509 980.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 913.7 1463.73 95 CONDYLAR 5H 92/80MM 237.56 48713534_1 CDM 0278 RC inpatient 1509 980.85 ANTHEM HMO ANTHEM HMO 999999999 913.7 1463.73 95 CONDYLAR 5H 92/80MM 237.56 48713534_1 CDM 0278 RC inpatient 1509 980.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1020.08 67.6 999999999 913.7 1463.73 percent of total billed charges 95 CONDYLAR 5H 92/80MM 237.56 48713534_1 CDM 0278 RC inpatient 1509 980.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 913.7 1463.73 95 CONDYLAR 5H 92/80MM 237.56 48713534_1 CDM 0278 RC inpatient 1509 980.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 913.7 1463.73 95 CONDYLAR 7H 124/60MM 237.72 48713535_1 CDM 0278 RC inpatient 1591 1034.15 AETNA AETNA 1256.89 79 999999999 963.35 1543.27 percent of total billed charges 95 CONDYLAR 7H 124/60MM 237.72 48713535_1 CDM 0278 RC inpatient 1591 1034.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1034.15 65 999999999 963.35 1543.27 percent of total billed charges 95 CONDYLAR 7H 124/60MM 237.72 48713535_1 CDM 0278 RC inpatient 1591 1034.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1543.27 97 999999999 963.35 1543.27 percent of total billed charges 95 CONDYLAR 7H 124/60MM 237.72 48713535_1 CDM 0278 RC inpatient 1591 1034.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1097.79 69 999999999 963.35 1543.27 percent of total billed charges 95 CONDYLAR 7H 124/60MM 237.72 48713535_1 CDM 0278 RC inpatient 1591 1034.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1240.98 78 999999999 963.35 1543.27 percent of total billed charges 95 CONDYLAR 7H 124/60MM 237.72 48713535_1 CDM 0278 RC inpatient 1591 1034.15 UMR - ALL PLANS UMR - ALL PLANS 1113.7 70 999999999 963.35 1543.27 percent of total billed charges 95 CONDYLAR 7H 124/60MM 237.72 48713535_1 CDM 0278 RC inpatient 1591 1034.15 SIHO - ALL PLANS SIHO - ALL PLANS 1431.9 90 999999999 963.35 1543.27 percent of total billed charges 95 CONDYLAR 7H 124/60MM 237.72 48713535_1 CDM 0278 RC inpatient 1591 1034.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 963.35 60.55 999999999 963.35 1543.27 percent of total billed charges 95 CONDYLAR 7H 124/60MM 237.72 48713535_1 CDM 0278 RC inpatient 1591 1034.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 963.35 1543.27 95 CONDYLAR 7H 124/60MM 237.72 48713535_1 CDM 0278 RC inpatient 1591 1034.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 963.35 1543.27 95 CONDYLAR 7H 124/60MM 237.72 48713535_1 CDM 0278 RC inpatient 1591 1034.15 ANTHEM HMO ANTHEM HMO 999999999 963.35 1543.27 95 CONDYLAR 7H 124/60MM 237.72 48713535_1 CDM 0278 RC inpatient 1591 1034.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1075.52 67.6 999999999 963.35 1543.27 percent of total billed charges 95 CONDYLAR 7H 124/60MM 237.72 48713535_1 CDM 0278 RC inpatient 1591 1034.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 963.35 1543.27 95 CONDYLAR 7H 124/60MM 237.72 48713535_1 CDM 0278 RC inpatient 1591 1034.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 963.35 1543.27 95 CONDYLAR 7H 124/70MM 237.74 48713536_1 CDM 0278 RC inpatient 1999 1299.35 AETNA AETNA 1579.21 79 999999999 1210.39 1939.03 percent of total billed charges 95 CONDYLAR 7H 124/70MM 237.74 48713536_1 CDM 0278 RC inpatient 1999 1299.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1299.35 65 999999999 1210.39 1939.03 percent of total billed charges 95 CONDYLAR 7H 124/70MM 237.74 48713536_1 CDM 0278 RC inpatient 1999 1299.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1939.03 97 999999999 1210.39 1939.03 percent of total billed charges 95 CONDYLAR 7H 124/70MM 237.74 48713536_1 CDM 0278 RC inpatient 1999 1299.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1379.31 69 999999999 1210.39 1939.03 percent of total billed charges 95 CONDYLAR 7H 124/70MM 237.74 48713536_1 CDM 0278 RC inpatient 1999 1299.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1559.22 78 999999999 1210.39 1939.03 percent of total billed charges 95 CONDYLAR 7H 124/70MM 237.74 48713536_1 CDM 0278 RC inpatient 1999 1299.35 UMR - ALL PLANS UMR - ALL PLANS 1399.3 70 999999999 1210.39 1939.03 percent of total billed charges 95 CONDYLAR 7H 124/70MM 237.74 48713536_1 CDM 0278 RC inpatient 1999 1299.35 SIHO - ALL PLANS SIHO - ALL PLANS 1799.1 90 999999999 1210.39 1939.03 percent of total billed charges 95 CONDYLAR 7H 124/70MM 237.74 48713536_1 CDM 0278 RC inpatient 1999 1299.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1210.39 60.55 999999999 1210.39 1939.03 percent of total billed charges 95 CONDYLAR 7H 124/70MM 237.74 48713536_1 CDM 0278 RC inpatient 1999 1299.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1210.39 1939.03 95 CONDYLAR 7H 124/70MM 237.74 48713536_1 CDM 0278 RC inpatient 1999 1299.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1210.39 1939.03 95 CONDYLAR 7H 124/70MM 237.74 48713536_1 CDM 0278 RC inpatient 1999 1299.35 ANTHEM HMO ANTHEM HMO 999999999 1210.39 1939.03 95 CONDYLAR 7H 124/70MM 237.74 48713536_1 CDM 0278 RC inpatient 1999 1299.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1351.32 67.6 999999999 1210.39 1939.03 percent of total billed charges 95 CONDYLAR 7H 124/70MM 237.74 48713536_1 CDM 0278 RC inpatient 1999 1299.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1210.39 1939.03 95 CONDYLAR 7H 124/70MM 237.74 48713536_1 CDM 0278 RC inpatient 1999 1299.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1210.39 1939.03 95 CONDYLAR 7H 124/80MM 237.76 48713537_1 CDM 0278 RC inpatient 1591 1034.15 AETNA AETNA 1256.89 79 999999999 963.35 1543.27 percent of total billed charges 95 CONDYLAR 7H 124/80MM 237.76 48713537_1 CDM 0278 RC inpatient 1591 1034.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1034.15 65 999999999 963.35 1543.27 percent of total billed charges 95 CONDYLAR 7H 124/80MM 237.76 48713537_1 CDM 0278 RC inpatient 1591 1034.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1543.27 97 999999999 963.35 1543.27 percent of total billed charges 95 CONDYLAR 7H 124/80MM 237.76 48713537_1 CDM 0278 RC inpatient 1591 1034.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1097.79 69 999999999 963.35 1543.27 percent of total billed charges 95 CONDYLAR 7H 124/80MM 237.76 48713537_1 CDM 0278 RC inpatient 1591 1034.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1240.98 78 999999999 963.35 1543.27 percent of total billed charges 95 CONDYLAR 7H 124/80MM 237.76 48713537_1 CDM 0278 RC inpatient 1591 1034.15 UMR - ALL PLANS UMR - ALL PLANS 1113.7 70 999999999 963.35 1543.27 percent of total billed charges 95 CONDYLAR 7H 124/80MM 237.76 48713537_1 CDM 0278 RC inpatient 1591 1034.15 SIHO - ALL PLANS SIHO - ALL PLANS 1431.9 90 999999999 963.35 1543.27 percent of total billed charges 95 CONDYLAR 7H 124/80MM 237.76 48713537_1 CDM 0278 RC inpatient 1591 1034.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 963.35 60.55 999999999 963.35 1543.27 percent of total billed charges 95 CONDYLAR 7H 124/80MM 237.76 48713537_1 CDM 0278 RC inpatient 1591 1034.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 963.35 1543.27 95 CONDYLAR 7H 124/80MM 237.76 48713537_1 CDM 0278 RC inpatient 1591 1034.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 963.35 1543.27 95 CONDYLAR 7H 124/80MM 237.76 48713537_1 CDM 0278 RC inpatient 1591 1034.15 ANTHEM HMO ANTHEM HMO 999999999 963.35 1543.27 95 CONDYLAR 7H 124/80MM 237.76 48713537_1 CDM 0278 RC inpatient 1591 1034.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1075.52 67.6 999999999 963.35 1543.27 percent of total billed charges 95 CONDYLAR 7H 124/80MM 237.76 48713537_1 CDM 0278 RC inpatient 1591 1034.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 963.35 1543.27 95 CONDYLAR 7H 124/80MM 237.76 48713537_1 CDM 0278 RC inpatient 1591 1034.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 963.35 1543.27 95 CONDYLAR 9H 156/50MM 237.90 48713538_1 CDM 0278 RC inpatient 1671 1086.15 AETNA AETNA 1320.09 79 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/50MM 237.90 48713538_1 CDM 0278 RC inpatient 1671 1086.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1086.15 65 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/50MM 237.90 48713538_1 CDM 0278 RC inpatient 1671 1086.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1620.87 97 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/50MM 237.90 48713538_1 CDM 0278 RC inpatient 1671 1086.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1152.99 69 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/50MM 237.90 48713538_1 CDM 0278 RC inpatient 1671 1086.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1303.38 78 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/50MM 237.90 48713538_1 CDM 0278 RC inpatient 1671 1086.15 UMR - ALL PLANS UMR - ALL PLANS 1169.7 70 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/50MM 237.90 48713538_1 CDM 0278 RC inpatient 1671 1086.15 SIHO - ALL PLANS SIHO - ALL PLANS 1503.9 90 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/50MM 237.90 48713538_1 CDM 0278 RC inpatient 1671 1086.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1011.79 60.55 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/50MM 237.90 48713538_1 CDM 0278 RC inpatient 1671 1086.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1011.79 1620.87 95 CONDYLAR 9H 156/50MM 237.90 48713538_1 CDM 0278 RC inpatient 1671 1086.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1011.79 1620.87 95 CONDYLAR 9H 156/50MM 237.90 48713538_1 CDM 0278 RC inpatient 1671 1086.15 ANTHEM HMO ANTHEM HMO 999999999 1011.79 1620.87 95 CONDYLAR 9H 156/50MM 237.90 48713538_1 CDM 0278 RC inpatient 1671 1086.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1129.6 67.6 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/50MM 237.90 48713538_1 CDM 0278 RC inpatient 1671 1086.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1011.79 1620.87 95 CONDYLAR 9H 156/50MM 237.90 48713538_1 CDM 0278 RC inpatient 1671 1086.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1011.79 1620.87 95 CONDYLAR 9H 156/70MM 237.94 48713539_1 CDM 0278 RC inpatient 1671 1086.15 AETNA AETNA 1320.09 79 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/70MM 237.94 48713539_1 CDM 0278 RC inpatient 1671 1086.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1086.15 65 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/70MM 237.94 48713539_1 CDM 0278 RC inpatient 1671 1086.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1620.87 97 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/70MM 237.94 48713539_1 CDM 0278 RC inpatient 1671 1086.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1152.99 69 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/70MM 237.94 48713539_1 CDM 0278 RC inpatient 1671 1086.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1303.38 78 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/70MM 237.94 48713539_1 CDM 0278 RC inpatient 1671 1086.15 UMR - ALL PLANS UMR - ALL PLANS 1169.7 70 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/70MM 237.94 48713539_1 CDM 0278 RC inpatient 1671 1086.15 SIHO - ALL PLANS SIHO - ALL PLANS 1503.9 90 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/70MM 237.94 48713539_1 CDM 0278 RC inpatient 1671 1086.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1011.79 60.55 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/70MM 237.94 48713539_1 CDM 0278 RC inpatient 1671 1086.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1011.79 1620.87 95 CONDYLAR 9H 156/70MM 237.94 48713539_1 CDM 0278 RC inpatient 1671 1086.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1011.79 1620.87 95 CONDYLAR 9H 156/70MM 237.94 48713539_1 CDM 0278 RC inpatient 1671 1086.15 ANTHEM HMO ANTHEM HMO 999999999 1011.79 1620.87 95 CONDYLAR 9H 156/70MM 237.94 48713539_1 CDM 0278 RC inpatient 1671 1086.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1129.6 67.6 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/70MM 237.94 48713539_1 CDM 0278 RC inpatient 1671 1086.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1011.79 1620.87 95 CONDYLAR 9H 156/70MM 237.94 48713539_1 CDM 0278 RC inpatient 1671 1086.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1011.79 1620.87 95 CONDYLAR 9H 156/80MM 237.96 48713540_1 CDM 0278 RC inpatient 1671 1086.15 AETNA AETNA 1320.09 79 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/80MM 237.96 48713540_1 CDM 0278 RC inpatient 1671 1086.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1086.15 65 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/80MM 237.96 48713540_1 CDM 0278 RC inpatient 1671 1086.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1620.87 97 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/80MM 237.96 48713540_1 CDM 0278 RC inpatient 1671 1086.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1152.99 69 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/80MM 237.96 48713540_1 CDM 0278 RC inpatient 1671 1086.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1303.38 78 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/80MM 237.96 48713540_1 CDM 0278 RC inpatient 1671 1086.15 UMR - ALL PLANS UMR - ALL PLANS 1169.7 70 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/80MM 237.96 48713540_1 CDM 0278 RC inpatient 1671 1086.15 SIHO - ALL PLANS SIHO - ALL PLANS 1503.9 90 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/80MM 237.96 48713540_1 CDM 0278 RC inpatient 1671 1086.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1011.79 60.55 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/80MM 237.96 48713540_1 CDM 0278 RC inpatient 1671 1086.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1011.79 1620.87 95 CONDYLAR 9H 156/80MM 237.96 48713540_1 CDM 0278 RC inpatient 1671 1086.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1011.79 1620.87 95 CONDYLAR 9H 156/80MM 237.96 48713540_1 CDM 0278 RC inpatient 1671 1086.15 ANTHEM HMO ANTHEM HMO 999999999 1011.79 1620.87 95 CONDYLAR 9H 156/80MM 237.96 48713540_1 CDM 0278 RC inpatient 1671 1086.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1129.6 67.6 999999999 1011.79 1620.87 percent of total billed charges 95 CONDYLAR 9H 156/80MM 237.96 48713540_1 CDM 0278 RC inpatient 1671 1086.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1011.79 1620.87 95 CONDYLAR 9H 156/80MM 237.96 48713540_1 CDM 0278 RC inpatient 1671 1086.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1011.79 1620.87 95 CONDYLAR 12H 204/50M 237.20 48713541_1 CDM 0278 RC inpatient 1819 1182.35 AETNA AETNA 1437.01 79 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/50M 237.20 48713541_1 CDM 0278 RC inpatient 1819 1182.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1182.35 65 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/50M 237.20 48713541_1 CDM 0278 RC inpatient 1819 1182.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1764.43 97 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/50M 237.20 48713541_1 CDM 0278 RC inpatient 1819 1182.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1255.11 69 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/50M 237.20 48713541_1 CDM 0278 RC inpatient 1819 1182.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1418.82 78 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/50M 237.20 48713541_1 CDM 0278 RC inpatient 1819 1182.35 UMR - ALL PLANS UMR - ALL PLANS 1273.3 70 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/50M 237.20 48713541_1 CDM 0278 RC inpatient 1819 1182.35 SIHO - ALL PLANS SIHO - ALL PLANS 1637.1 90 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/50M 237.20 48713541_1 CDM 0278 RC inpatient 1819 1182.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1101.4 60.55 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/50M 237.20 48713541_1 CDM 0278 RC inpatient 1819 1182.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/50M 237.20 48713541_1 CDM 0278 RC inpatient 1819 1182.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/50M 237.20 48713541_1 CDM 0278 RC inpatient 1819 1182.35 ANTHEM HMO ANTHEM HMO 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/50M 237.20 48713541_1 CDM 0278 RC inpatient 1819 1182.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1229.64 67.6 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/50M 237.20 48713541_1 CDM 0278 RC inpatient 1819 1182.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/50M 237.20 48713541_1 CDM 0278 RC inpatient 1819 1182.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/60M 237.22 48713542_1 CDM 0278 RC inpatient 1819 1182.35 AETNA AETNA 1437.01 79 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/60M 237.22 48713542_1 CDM 0278 RC inpatient 1819 1182.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1182.35 65 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/60M 237.22 48713542_1 CDM 0278 RC inpatient 1819 1182.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1764.43 97 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/60M 237.22 48713542_1 CDM 0278 RC inpatient 1819 1182.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1255.11 69 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/60M 237.22 48713542_1 CDM 0278 RC inpatient 1819 1182.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1418.82 78 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/60M 237.22 48713542_1 CDM 0278 RC inpatient 1819 1182.35 UMR - ALL PLANS UMR - ALL PLANS 1273.3 70 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/60M 237.22 48713542_1 CDM 0278 RC inpatient 1819 1182.35 SIHO - ALL PLANS SIHO - ALL PLANS 1637.1 90 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/60M 237.22 48713542_1 CDM 0278 RC inpatient 1819 1182.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1101.4 60.55 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/60M 237.22 48713542_1 CDM 0278 RC inpatient 1819 1182.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/60M 237.22 48713542_1 CDM 0278 RC inpatient 1819 1182.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/60M 237.22 48713542_1 CDM 0278 RC inpatient 1819 1182.35 ANTHEM HMO ANTHEM HMO 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/60M 237.22 48713542_1 CDM 0278 RC inpatient 1819 1182.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1229.64 67.6 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/60M 237.22 48713542_1 CDM 0278 RC inpatient 1819 1182.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/60M 237.22 48713542_1 CDM 0278 RC inpatient 1819 1182.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/70M 237.24 48713543_1 CDM 0278 RC inpatient 1819 1182.35 AETNA AETNA 1437.01 79 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/70M 237.24 48713543_1 CDM 0278 RC inpatient 1819 1182.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1182.35 65 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/70M 237.24 48713543_1 CDM 0278 RC inpatient 1819 1182.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1764.43 97 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/70M 237.24 48713543_1 CDM 0278 RC inpatient 1819 1182.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1255.11 69 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/70M 237.24 48713543_1 CDM 0278 RC inpatient 1819 1182.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1418.82 78 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/70M 237.24 48713543_1 CDM 0278 RC inpatient 1819 1182.35 UMR - ALL PLANS UMR - ALL PLANS 1273.3 70 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/70M 237.24 48713543_1 CDM 0278 RC inpatient 1819 1182.35 SIHO - ALL PLANS SIHO - ALL PLANS 1637.1 90 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/70M 237.24 48713543_1 CDM 0278 RC inpatient 1819 1182.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1101.4 60.55 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/70M 237.24 48713543_1 CDM 0278 RC inpatient 1819 1182.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/70M 237.24 48713543_1 CDM 0278 RC inpatient 1819 1182.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/70M 237.24 48713543_1 CDM 0278 RC inpatient 1819 1182.35 ANTHEM HMO ANTHEM HMO 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/70M 237.24 48713543_1 CDM 0278 RC inpatient 1819 1182.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1229.64 67.6 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/70M 237.24 48713543_1 CDM 0278 RC inpatient 1819 1182.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/70M 237.24 48713543_1 CDM 0278 RC inpatient 1819 1182.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/80M 237.26 48713544_1 CDM 0278 RC inpatient 1819 1182.35 AETNA AETNA 1437.01 79 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/80M 237.26 48713544_1 CDM 0278 RC inpatient 1819 1182.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1182.35 65 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/80M 237.26 48713544_1 CDM 0278 RC inpatient 1819 1182.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1764.43 97 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/80M 237.26 48713544_1 CDM 0278 RC inpatient 1819 1182.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1255.11 69 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/80M 237.26 48713544_1 CDM 0278 RC inpatient 1819 1182.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1418.82 78 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/80M 237.26 48713544_1 CDM 0278 RC inpatient 1819 1182.35 UMR - ALL PLANS UMR - ALL PLANS 1273.3 70 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/80M 237.26 48713544_1 CDM 0278 RC inpatient 1819 1182.35 SIHO - ALL PLANS SIHO - ALL PLANS 1637.1 90 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/80M 237.26 48713544_1 CDM 0278 RC inpatient 1819 1182.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1101.4 60.55 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/80M 237.26 48713544_1 CDM 0278 RC inpatient 1819 1182.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/80M 237.26 48713544_1 CDM 0278 RC inpatient 1819 1182.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/80M 237.26 48713544_1 CDM 0278 RC inpatient 1819 1182.35 ANTHEM HMO ANTHEM HMO 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/80M 237.26 48713544_1 CDM 0278 RC inpatient 1819 1182.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1229.64 67.6 999999999 1101.4 1764.43 percent of total billed charges 95 CONDYLAR 12H 204/80M 237.26 48713544_1 CDM 0278 RC inpatient 1819 1182.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1101.4 1764.43 95 CONDYLAR 12H 204/80M 237.26 48713544_1 CDM 0278 RC inpatient 1819 1182.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1101.4 1764.43 CUTTER AGG 3.5MM 375-534-000 48713545_1 CDM 0272 RC inpatient 327 212.55 AETNA AETNA 258.33 79 999999999 198 317.19 percent of total billed charges CUTTER AGG 3.5MM 375-534-000 48713545_1 CDM 0272 RC inpatient 327 212.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 212.55 65 999999999 198 317.19 percent of total billed charges CUTTER AGG 3.5MM 375-534-000 48713545_1 CDM 0272 RC inpatient 327 212.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 317.19 97 999999999 198 317.19 percent of total billed charges CUTTER AGG 3.5MM 375-534-000 48713545_1 CDM 0272 RC inpatient 327 212.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 225.63 69 999999999 198 317.19 percent of total billed charges CUTTER AGG 3.5MM 375-534-000 48713545_1 CDM 0272 RC inpatient 327 212.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.06 78 999999999 198 317.19 percent of total billed charges CUTTER AGG 3.5MM 375-534-000 48713545_1 CDM 0272 RC inpatient 327 212.55 UMR - ALL PLANS UMR - ALL PLANS 228.9 70 999999999 198 317.19 percent of total billed charges CUTTER AGG 3.5MM 375-534-000 48713545_1 CDM 0272 RC inpatient 327 212.55 SIHO - ALL PLANS SIHO - ALL PLANS 294.3 90 999999999 198 317.19 percent of total billed charges CUTTER AGG 3.5MM 375-534-000 48713545_1 CDM 0272 RC inpatient 327 212.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198 60.55 999999999 198 317.19 percent of total billed charges CUTTER AGG 3.5MM 375-534-000 48713545_1 CDM 0272 RC inpatient 327 212.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198 317.19 CUTTER AGG 3.5MM 375-534-000 48713545_1 CDM 0272 RC inpatient 327 212.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198 317.19 CUTTER AGG 3.5MM 375-534-000 48713545_1 CDM 0272 RC inpatient 327 212.55 ANTHEM HMO ANTHEM HMO 999999999 198 317.19 CUTTER AGG 3.5MM 375-534-000 48713545_1 CDM 0272 RC inpatient 327 212.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.05 67.6 999999999 198 317.19 percent of total billed charges CUTTER AGG 3.5MM 375-534-000 48713545_1 CDM 0272 RC inpatient 327 212.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198 317.19 CUTTER AGG 3.5MM 375-534-000 48713545_1 CDM 0272 RC inpatient 327 212.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 198 317.19 ALLOMATRIX INJ PUTTY 5CC 48713547_1 CDM 0278 RC inpatient 3741 2431.65 AETNA AETNA 2955.39 79 999999999 2265.18 3628.77 percent of total billed charges ALLOMATRIX INJ PUTTY 5CC 48713547_1 CDM 0278 RC inpatient 3741 2431.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 2431.65 65 999999999 2265.18 3628.77 percent of total billed charges ALLOMATRIX INJ PUTTY 5CC 48713547_1 CDM 0278 RC inpatient 3741 2431.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3628.77 97 999999999 2265.18 3628.77 percent of total billed charges ALLOMATRIX INJ PUTTY 5CC 48713547_1 CDM 0278 RC inpatient 3741 2431.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2581.29 69 999999999 2265.18 3628.77 percent of total billed charges ALLOMATRIX INJ PUTTY 5CC 48713547_1 CDM 0278 RC inpatient 3741 2431.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2917.98 78 999999999 2265.18 3628.77 percent of total billed charges ALLOMATRIX INJ PUTTY 5CC 48713547_1 CDM 0278 RC inpatient 3741 2431.65 UMR - ALL PLANS UMR - ALL PLANS 2618.7 70 999999999 2265.18 3628.77 percent of total billed charges ALLOMATRIX INJ PUTTY 5CC 48713547_1 CDM 0278 RC inpatient 3741 2431.65 SIHO - ALL PLANS SIHO - ALL PLANS 3366.9 90 999999999 2265.18 3628.77 percent of total billed charges ALLOMATRIX INJ PUTTY 5CC 48713547_1 CDM 0278 RC inpatient 3741 2431.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2265.18 60.55 999999999 2265.18 3628.77 percent of total billed charges ALLOMATRIX INJ PUTTY 5CC 48713547_1 CDM 0278 RC inpatient 3741 2431.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2265.18 3628.77 ALLOMATRIX INJ PUTTY 5CC 48713547_1 CDM 0278 RC inpatient 3741 2431.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2265.18 3628.77 ALLOMATRIX INJ PUTTY 5CC 48713547_1 CDM 0278 RC inpatient 3741 2431.65 ANTHEM HMO ANTHEM HMO 999999999 2265.18 3628.77 ALLOMATRIX INJ PUTTY 5CC 48713547_1 CDM 0278 RC inpatient 3741 2431.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2528.92 67.6 999999999 2265.18 3628.77 percent of total billed charges ALLOMATRIX INJ PUTTY 5CC 48713547_1 CDM 0278 RC inpatient 3741 2431.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2265.18 3628.77 ALLOMATRIX INJ PUTTY 5CC 48713547_1 CDM 0278 RC inpatient 3741 2431.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 2265.18 3628.77 2.5 REAMING ROD 351.706S 48713548_1 CDM 0272 RC inpatient 785 510.25 AETNA AETNA 620.15 79 999999999 475.32 761.45 percent of total billed charges 2.5 REAMING ROD 351.706S 48713548_1 CDM 0272 RC inpatient 785 510.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 510.25 65 999999999 475.32 761.45 percent of total billed charges 2.5 REAMING ROD 351.706S 48713548_1 CDM 0272 RC inpatient 785 510.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 761.45 97 999999999 475.32 761.45 percent of total billed charges 2.5 REAMING ROD 351.706S 48713548_1 CDM 0272 RC inpatient 785 510.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 541.65 69 999999999 475.32 761.45 percent of total billed charges 2.5 REAMING ROD 351.706S 48713548_1 CDM 0272 RC inpatient 785 510.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 612.3 78 999999999 475.32 761.45 percent of total billed charges 2.5 REAMING ROD 351.706S 48713548_1 CDM 0272 RC inpatient 785 510.25 UMR - ALL PLANS UMR - ALL PLANS 549.5 70 999999999 475.32 761.45 percent of total billed charges 2.5 REAMING ROD 351.706S 48713548_1 CDM 0272 RC inpatient 785 510.25 SIHO - ALL PLANS SIHO - ALL PLANS 706.5 90 999999999 475.32 761.45 percent of total billed charges 2.5 REAMING ROD 351.706S 48713548_1 CDM 0272 RC inpatient 785 510.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 475.32 60.55 999999999 475.32 761.45 percent of total billed charges 2.5 REAMING ROD 351.706S 48713548_1 CDM 0272 RC inpatient 785 510.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 475.32 761.45 2.5 REAMING ROD 351.706S 48713548_1 CDM 0272 RC inpatient 785 510.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 475.32 761.45 2.5 REAMING ROD 351.706S 48713548_1 CDM 0272 RC inpatient 785 510.25 ANTHEM HMO ANTHEM HMO 999999999 475.32 761.45 2.5 REAMING ROD 351.706S 48713548_1 CDM 0272 RC inpatient 785 510.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 530.66 67.6 999999999 475.32 761.45 percent of total billed charges 2.5 REAMING ROD 351.706S 48713548_1 CDM 0272 RC inpatient 785 510.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 475.32 761.45 2.5 REAMING ROD 351.706S 48713548_1 CDM 0272 RC inpatient 785 510.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 475.32 761.45 3.0 CANN SCREW 14MM 202.714 48713549_1 CDM 0278 RC inpatient 1269 824.85 AETNA AETNA 1002.51 79 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 14MM 202.714 48713549_1 CDM 0278 RC inpatient 1269 824.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 824.85 65 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 14MM 202.714 48713549_1 CDM 0278 RC inpatient 1269 824.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1230.93 97 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 14MM 202.714 48713549_1 CDM 0278 RC inpatient 1269 824.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 875.61 69 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 14MM 202.714 48713549_1 CDM 0278 RC inpatient 1269 824.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 989.82 78 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 14MM 202.714 48713549_1 CDM 0278 RC inpatient 1269 824.85 UMR - ALL PLANS UMR - ALL PLANS 888.3 70 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 14MM 202.714 48713549_1 CDM 0278 RC inpatient 1269 824.85 SIHO - ALL PLANS SIHO - ALL PLANS 1142.1 90 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 14MM 202.714 48713549_1 CDM 0278 RC inpatient 1269 824.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 768.38 60.55 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 14MM 202.714 48713549_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 768.38 1230.93 3.0 CANN SCREW 14MM 202.714 48713549_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 768.38 1230.93 3.0 CANN SCREW 14MM 202.714 48713549_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM HMO ANTHEM HMO 999999999 768.38 1230.93 3.0 CANN SCREW 14MM 202.714 48713549_1 CDM 0278 RC inpatient 1269 824.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 857.84 67.6 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 14MM 202.714 48713549_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 768.38 1230.93 3.0 CANN SCREW 14MM 202.714 48713549_1 CDM 0278 RC inpatient 1269 824.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 768.38 1230.93 DRILL BIT DHS 3.2M 310.31 48713550_1 CDM 0272 RC inpatient 607 394.55 AETNA AETNA 479.53 79 999999999 367.54 588.79 percent of total billed charges DRILL BIT DHS 3.2M 310.31 48713550_1 CDM 0272 RC inpatient 607 394.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 394.55 65 999999999 367.54 588.79 percent of total billed charges DRILL BIT DHS 3.2M 310.31 48713550_1 CDM 0272 RC inpatient 607 394.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 588.79 97 999999999 367.54 588.79 percent of total billed charges DRILL BIT DHS 3.2M 310.31 48713550_1 CDM 0272 RC inpatient 607 394.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 418.83 69 999999999 367.54 588.79 percent of total billed charges DRILL BIT DHS 3.2M 310.31 48713550_1 CDM 0272 RC inpatient 607 394.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 473.46 78 999999999 367.54 588.79 percent of total billed charges DRILL BIT DHS 3.2M 310.31 48713550_1 CDM 0272 RC inpatient 607 394.55 UMR - ALL PLANS UMR - ALL PLANS 424.9 70 999999999 367.54 588.79 percent of total billed charges DRILL BIT DHS 3.2M 310.31 48713550_1 CDM 0272 RC inpatient 607 394.55 SIHO - ALL PLANS SIHO - ALL PLANS 546.3 90 999999999 367.54 588.79 percent of total billed charges DRILL BIT DHS 3.2M 310.31 48713550_1 CDM 0272 RC inpatient 607 394.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 367.54 60.55 999999999 367.54 588.79 percent of total billed charges DRILL BIT DHS 3.2M 310.31 48713550_1 CDM 0272 RC inpatient 607 394.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 367.54 588.79 DRILL BIT DHS 3.2M 310.31 48713550_1 CDM 0272 RC inpatient 607 394.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 367.54 588.79 DRILL BIT DHS 3.2M 310.31 48713550_1 CDM 0272 RC inpatient 607 394.55 ANTHEM HMO ANTHEM HMO 999999999 367.54 588.79 DRILL BIT DHS 3.2M 310.31 48713550_1 CDM 0272 RC inpatient 607 394.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 410.33 67.6 999999999 367.54 588.79 percent of total billed charges DRILL BIT DHS 3.2M 310.31 48713550_1 CDM 0272 RC inpatient 607 394.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 367.54 588.79 DRILL BIT DHS 3.2M 310.31 48713550_1 CDM 0272 RC inpatient 607 394.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 367.54 588.79 3.0 CANN SCREW 15MM 202.715 48713551_1 CDM 0278 RC inpatient 1272 826.8 AETNA AETNA 1004.88 79 999999999 770.2 1233.84 percent of total billed charges 3.0 CANN SCREW 15MM 202.715 48713551_1 CDM 0278 RC inpatient 1272 826.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 826.8 65 999999999 770.2 1233.84 percent of total billed charges 3.0 CANN SCREW 15MM 202.715 48713551_1 CDM 0278 RC inpatient 1272 826.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1233.84 97 999999999 770.2 1233.84 percent of total billed charges 3.0 CANN SCREW 15MM 202.715 48713551_1 CDM 0278 RC inpatient 1272 826.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 877.68 69 999999999 770.2 1233.84 percent of total billed charges 3.0 CANN SCREW 15MM 202.715 48713551_1 CDM 0278 RC inpatient 1272 826.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 992.16 78 999999999 770.2 1233.84 percent of total billed charges 3.0 CANN SCREW 15MM 202.715 48713551_1 CDM 0278 RC inpatient 1272 826.8 UMR - ALL PLANS UMR - ALL PLANS 890.4 70 999999999 770.2 1233.84 percent of total billed charges 3.0 CANN SCREW 15MM 202.715 48713551_1 CDM 0278 RC inpatient 1272 826.8 SIHO - ALL PLANS SIHO - ALL PLANS 1144.8 90 999999999 770.2 1233.84 percent of total billed charges 3.0 CANN SCREW 15MM 202.715 48713551_1 CDM 0278 RC inpatient 1272 826.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 770.2 60.55 999999999 770.2 1233.84 percent of total billed charges 3.0 CANN SCREW 15MM 202.715 48713551_1 CDM 0278 RC inpatient 1272 826.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 770.2 1233.84 3.0 CANN SCREW 15MM 202.715 48713551_1 CDM 0278 RC inpatient 1272 826.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 770.2 1233.84 3.0 CANN SCREW 15MM 202.715 48713551_1 CDM 0278 RC inpatient 1272 826.8 ANTHEM HMO ANTHEM HMO 999999999 770.2 1233.84 3.0 CANN SCREW 15MM 202.715 48713551_1 CDM 0278 RC inpatient 1272 826.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 859.87 67.6 999999999 770.2 1233.84 percent of total billed charges 3.0 CANN SCREW 15MM 202.715 48713551_1 CDM 0278 RC inpatient 1272 826.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 770.2 1233.84 3.0 CANN SCREW 15MM 202.715 48713551_1 CDM 0278 RC inpatient 1272 826.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 770.2 1233.84 3.0 CANN SCREW 17MM 202.717 48713552_1 CDM 0278 RC inpatient 1307 849.55 AETNA AETNA 1032.53 79 999999999 791.39 1267.79 percent of total billed charges 3.0 CANN SCREW 17MM 202.717 48713552_1 CDM 0278 RC inpatient 1307 849.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 849.55 65 999999999 791.39 1267.79 percent of total billed charges 3.0 CANN SCREW 17MM 202.717 48713552_1 CDM 0278 RC inpatient 1307 849.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1267.79 97 999999999 791.39 1267.79 percent of total billed charges 3.0 CANN SCREW 17MM 202.717 48713552_1 CDM 0278 RC inpatient 1307 849.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 901.83 69 999999999 791.39 1267.79 percent of total billed charges 3.0 CANN SCREW 17MM 202.717 48713552_1 CDM 0278 RC inpatient 1307 849.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1019.46 78 999999999 791.39 1267.79 percent of total billed charges 3.0 CANN SCREW 17MM 202.717 48713552_1 CDM 0278 RC inpatient 1307 849.55 UMR - ALL PLANS UMR - ALL PLANS 914.9 70 999999999 791.39 1267.79 percent of total billed charges 3.0 CANN SCREW 17MM 202.717 48713552_1 CDM 0278 RC inpatient 1307 849.55 SIHO - ALL PLANS SIHO - ALL PLANS 1176.3 90 999999999 791.39 1267.79 percent of total billed charges 3.0 CANN SCREW 17MM 202.717 48713552_1 CDM 0278 RC inpatient 1307 849.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 791.39 60.55 999999999 791.39 1267.79 percent of total billed charges 3.0 CANN SCREW 17MM 202.717 48713552_1 CDM 0278 RC inpatient 1307 849.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 791.39 1267.79 3.0 CANN SCREW 17MM 202.717 48713552_1 CDM 0278 RC inpatient 1307 849.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 791.39 1267.79 3.0 CANN SCREW 17MM 202.717 48713552_1 CDM 0278 RC inpatient 1307 849.55 ANTHEM HMO ANTHEM HMO 999999999 791.39 1267.79 3.0 CANN SCREW 17MM 202.717 48713552_1 CDM 0278 RC inpatient 1307 849.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 883.53 67.6 999999999 791.39 1267.79 percent of total billed charges 3.0 CANN SCREW 17MM 202.717 48713552_1 CDM 0278 RC inpatient 1307 849.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 791.39 1267.79 3.0 CANN SCREW 17MM 202.717 48713552_1 CDM 0278 RC inpatient 1307 849.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 791.39 1267.79 3.0 CANN SCREW 18MM 202.718 48713553_1 CDM 0278 RC inpatient 1272 826.8 AETNA AETNA 1004.88 79 999999999 770.2 1233.84 percent of total billed charges 3.0 CANN SCREW 18MM 202.718 48713553_1 CDM 0278 RC inpatient 1272 826.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 826.8 65 999999999 770.2 1233.84 percent of total billed charges 3.0 CANN SCREW 18MM 202.718 48713553_1 CDM 0278 RC inpatient 1272 826.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1233.84 97 999999999 770.2 1233.84 percent of total billed charges 3.0 CANN SCREW 18MM 202.718 48713553_1 CDM 0278 RC inpatient 1272 826.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 877.68 69 999999999 770.2 1233.84 percent of total billed charges 3.0 CANN SCREW 18MM 202.718 48713553_1 CDM 0278 RC inpatient 1272 826.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 992.16 78 999999999 770.2 1233.84 percent of total billed charges 3.0 CANN SCREW 18MM 202.718 48713553_1 CDM 0278 RC inpatient 1272 826.8 UMR - ALL PLANS UMR - ALL PLANS 890.4 70 999999999 770.2 1233.84 percent of total billed charges 3.0 CANN SCREW 18MM 202.718 48713553_1 CDM 0278 RC inpatient 1272 826.8 SIHO - ALL PLANS SIHO - ALL PLANS 1144.8 90 999999999 770.2 1233.84 percent of total billed charges 3.0 CANN SCREW 18MM 202.718 48713553_1 CDM 0278 RC inpatient 1272 826.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 770.2 60.55 999999999 770.2 1233.84 percent of total billed charges 3.0 CANN SCREW 18MM 202.718 48713553_1 CDM 0278 RC inpatient 1272 826.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 770.2 1233.84 3.0 CANN SCREW 18MM 202.718 48713553_1 CDM 0278 RC inpatient 1272 826.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 770.2 1233.84 3.0 CANN SCREW 18MM 202.718 48713553_1 CDM 0278 RC inpatient 1272 826.8 ANTHEM HMO ANTHEM HMO 999999999 770.2 1233.84 3.0 CANN SCREW 18MM 202.718 48713553_1 CDM 0278 RC inpatient 1272 826.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 859.87 67.6 999999999 770.2 1233.84 percent of total billed charges 3.0 CANN SCREW 18MM 202.718 48713553_1 CDM 0278 RC inpatient 1272 826.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 770.2 1233.84 3.0 CANN SCREW 18MM 202.718 48713553_1 CDM 0278 RC inpatient 1272 826.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 770.2 1233.84 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713554_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 AETNA AETNA 1079.93 79 999999999 827.72 1325.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713554_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 888.55 65 999999999 827.72 1325.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713554_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1325.99 97 999999999 827.72 1325.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713554_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 943.23 69 999999999 827.72 1325.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713554_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1066.26 78 999999999 827.72 1325.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713554_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 UMR - ALL PLANS UMR - ALL PLANS 956.9 70 999999999 827.72 1325.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713554_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 SIHO - ALL PLANS SIHO - ALL PLANS 1230.3 90 999999999 827.72 1325.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713554_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 827.72 60.55 999999999 827.72 1325.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713554_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 827.72 1325.99 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713554_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 827.72 1325.99 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713554_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 ANTHEM HMO ANTHEM HMO 999999999 827.72 1325.99 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713554_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 924.09 67.6 999999999 827.72 1325.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713554_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 827.72 1325.99 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713554_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 827.72 1325.99 3.0 CANN SCREW 21MM 202.721 48713555_1 CDM 0278 RC inpatient 1269 824.85 AETNA AETNA 1002.51 79 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 21MM 202.721 48713555_1 CDM 0278 RC inpatient 1269 824.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 824.85 65 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 21MM 202.721 48713555_1 CDM 0278 RC inpatient 1269 824.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1230.93 97 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 21MM 202.721 48713555_1 CDM 0278 RC inpatient 1269 824.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 875.61 69 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 21MM 202.721 48713555_1 CDM 0278 RC inpatient 1269 824.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 989.82 78 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 21MM 202.721 48713555_1 CDM 0278 RC inpatient 1269 824.85 UMR - ALL PLANS UMR - ALL PLANS 888.3 70 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 21MM 202.721 48713555_1 CDM 0278 RC inpatient 1269 824.85 SIHO - ALL PLANS SIHO - ALL PLANS 1142.1 90 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 21MM 202.721 48713555_1 CDM 0278 RC inpatient 1269 824.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 768.38 60.55 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 21MM 202.721 48713555_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 768.38 1230.93 3.0 CANN SCREW 21MM 202.721 48713555_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 768.38 1230.93 3.0 CANN SCREW 21MM 202.721 48713555_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM HMO ANTHEM HMO 999999999 768.38 1230.93 3.0 CANN SCREW 21MM 202.721 48713555_1 CDM 0278 RC inpatient 1269 824.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 857.84 67.6 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 21MM 202.721 48713555_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 768.38 1230.93 3.0 CANN SCREW 21MM 202.721 48713555_1 CDM 0278 RC inpatient 1269 824.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 768.38 1230.93 3.0 CANN SCREW 22MM 202.722 48713556_1 CDM 0278 RC inpatient 1354 880.1 AETNA AETNA 1069.66 79 999999999 819.85 1313.38 percent of total billed charges 3.0 CANN SCREW 22MM 202.722 48713556_1 CDM 0278 RC inpatient 1354 880.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 880.1 65 999999999 819.85 1313.38 percent of total billed charges 3.0 CANN SCREW 22MM 202.722 48713556_1 CDM 0278 RC inpatient 1354 880.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1313.38 97 999999999 819.85 1313.38 percent of total billed charges 3.0 CANN SCREW 22MM 202.722 48713556_1 CDM 0278 RC inpatient 1354 880.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 934.26 69 999999999 819.85 1313.38 percent of total billed charges 3.0 CANN SCREW 22MM 202.722 48713556_1 CDM 0278 RC inpatient 1354 880.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1056.12 78 999999999 819.85 1313.38 percent of total billed charges 3.0 CANN SCREW 22MM 202.722 48713556_1 CDM 0278 RC inpatient 1354 880.1 UMR - ALL PLANS UMR - ALL PLANS 947.8 70 999999999 819.85 1313.38 percent of total billed charges 3.0 CANN SCREW 22MM 202.722 48713556_1 CDM 0278 RC inpatient 1354 880.1 SIHO - ALL PLANS SIHO - ALL PLANS 1218.6 90 999999999 819.85 1313.38 percent of total billed charges 3.0 CANN SCREW 22MM 202.722 48713556_1 CDM 0278 RC inpatient 1354 880.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 819.85 60.55 999999999 819.85 1313.38 percent of total billed charges 3.0 CANN SCREW 22MM 202.722 48713556_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 819.85 1313.38 3.0 CANN SCREW 22MM 202.722 48713556_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 819.85 1313.38 3.0 CANN SCREW 22MM 202.722 48713556_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM HMO ANTHEM HMO 999999999 819.85 1313.38 3.0 CANN SCREW 22MM 202.722 48713556_1 CDM 0278 RC inpatient 1354 880.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 915.3 67.6 999999999 819.85 1313.38 percent of total billed charges 3.0 CANN SCREW 22MM 202.722 48713556_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 819.85 1313.38 3.0 CANN SCREW 22MM 202.722 48713556_1 CDM 0278 RC inpatient 1354 880.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 819.85 1313.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713557_1 CDM 0278 RC C1713 HCPCS inpatient 1354 880.1 AETNA AETNA 1069.66 79 999999999 819.85 1313.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713557_1 CDM 0278 RC C1713 HCPCS inpatient 1354 880.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 880.1 65 999999999 819.85 1313.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713557_1 CDM 0278 RC C1713 HCPCS inpatient 1354 880.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1313.38 97 999999999 819.85 1313.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713557_1 CDM 0278 RC C1713 HCPCS inpatient 1354 880.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 934.26 69 999999999 819.85 1313.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713557_1 CDM 0278 RC C1713 HCPCS inpatient 1354 880.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1056.12 78 999999999 819.85 1313.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713557_1 CDM 0278 RC C1713 HCPCS inpatient 1354 880.1 UMR - ALL PLANS UMR - ALL PLANS 947.8 70 999999999 819.85 1313.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713557_1 CDM 0278 RC C1713 HCPCS inpatient 1354 880.1 SIHO - ALL PLANS SIHO - ALL PLANS 1218.6 90 999999999 819.85 1313.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713557_1 CDM 0278 RC C1713 HCPCS inpatient 1354 880.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 819.85 60.55 999999999 819.85 1313.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713557_1 CDM 0278 RC C1713 HCPCS inpatient 1354 880.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 819.85 1313.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713557_1 CDM 0278 RC C1713 HCPCS inpatient 1354 880.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 819.85 1313.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713557_1 CDM 0278 RC C1713 HCPCS inpatient 1354 880.1 ANTHEM HMO ANTHEM HMO 999999999 819.85 1313.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713557_1 CDM 0278 RC C1713 HCPCS inpatient 1354 880.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 915.3 67.6 999999999 819.85 1313.38 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713557_1 CDM 0278 RC C1713 HCPCS inpatient 1354 880.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 819.85 1313.38 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713557_1 CDM 0278 RC C1713 HCPCS inpatient 1354 880.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 819.85 1313.38 3.0 CANN SCREW 28MM 202.728 48713558_1 CDM 0278 RC inpatient 970 630.5 AETNA AETNA 766.3 79 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 28MM 202.728 48713558_1 CDM 0278 RC inpatient 970 630.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 630.5 65 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 28MM 202.728 48713558_1 CDM 0278 RC inpatient 970 630.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 940.9 97 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 28MM 202.728 48713558_1 CDM 0278 RC inpatient 970 630.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 669.3 69 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 28MM 202.728 48713558_1 CDM 0278 RC inpatient 970 630.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 756.6 78 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 28MM 202.728 48713558_1 CDM 0278 RC inpatient 970 630.5 UMR - ALL PLANS UMR - ALL PLANS 679 70 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 28MM 202.728 48713558_1 CDM 0278 RC inpatient 970 630.5 SIHO - ALL PLANS SIHO - ALL PLANS 873 90 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 28MM 202.728 48713558_1 CDM 0278 RC inpatient 970 630.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 587.34 60.55 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 28MM 202.728 48713558_1 CDM 0278 RC inpatient 970 630.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 587.34 940.9 3.0 CANN SCREW 28MM 202.728 48713558_1 CDM 0278 RC inpatient 970 630.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 587.34 940.9 3.0 CANN SCREW 28MM 202.728 48713558_1 CDM 0278 RC inpatient 970 630.5 ANTHEM HMO ANTHEM HMO 999999999 587.34 940.9 3.0 CANN SCREW 28MM 202.728 48713558_1 CDM 0278 RC inpatient 970 630.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 655.72 67.6 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 28MM 202.728 48713558_1 CDM 0278 RC inpatient 970 630.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 587.34 940.9 3.0 CANN SCREW 28MM 202.728 48713558_1 CDM 0278 RC inpatient 970 630.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 587.34 940.9 3.0 CANN SCREW 29MM 202.729 48713559_1 CDM 0278 RC inpatient 970 630.5 AETNA AETNA 766.3 79 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 29MM 202.729 48713559_1 CDM 0278 RC inpatient 970 630.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 630.5 65 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 29MM 202.729 48713559_1 CDM 0278 RC inpatient 970 630.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 940.9 97 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 29MM 202.729 48713559_1 CDM 0278 RC inpatient 970 630.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 669.3 69 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 29MM 202.729 48713559_1 CDM 0278 RC inpatient 970 630.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 756.6 78 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 29MM 202.729 48713559_1 CDM 0278 RC inpatient 970 630.5 UMR - ALL PLANS UMR - ALL PLANS 679 70 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 29MM 202.729 48713559_1 CDM 0278 RC inpatient 970 630.5 SIHO - ALL PLANS SIHO - ALL PLANS 873 90 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 29MM 202.729 48713559_1 CDM 0278 RC inpatient 970 630.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 587.34 60.55 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 29MM 202.729 48713559_1 CDM 0278 RC inpatient 970 630.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 587.34 940.9 3.0 CANN SCREW 29MM 202.729 48713559_1 CDM 0278 RC inpatient 970 630.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 587.34 940.9 3.0 CANN SCREW 29MM 202.729 48713559_1 CDM 0278 RC inpatient 970 630.5 ANTHEM HMO ANTHEM HMO 999999999 587.34 940.9 3.0 CANN SCREW 29MM 202.729 48713559_1 CDM 0278 RC inpatient 970 630.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 655.72 67.6 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 29MM 202.729 48713559_1 CDM 0278 RC inpatient 970 630.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 587.34 940.9 3.0 CANN SCREW 29MM 202.729 48713559_1 CDM 0278 RC inpatient 970 630.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 587.34 940.9 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713560_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 AETNA AETNA 1079.93 79 999999999 827.72 1325.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713560_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 888.55 65 999999999 827.72 1325.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713560_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1325.99 97 999999999 827.72 1325.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713560_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 943.23 69 999999999 827.72 1325.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713560_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1066.26 78 999999999 827.72 1325.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713560_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 UMR - ALL PLANS UMR - ALL PLANS 956.9 70 999999999 827.72 1325.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713560_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 SIHO - ALL PLANS SIHO - ALL PLANS 1230.3 90 999999999 827.72 1325.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713560_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 827.72 60.55 999999999 827.72 1325.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713560_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 827.72 1325.99 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713560_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 827.72 1325.99 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713560_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 ANTHEM HMO ANTHEM HMO 999999999 827.72 1325.99 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713560_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 924.09 67.6 999999999 827.72 1325.99 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713560_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 827.72 1325.99 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713560_1 CDM 0278 RC C1713 HCPCS inpatient 1367 888.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 827.72 1325.99 3.0 CANN SCREW 32MM 202.732 48713561_1 CDM 0278 RC inpatient 1288 837.2 AETNA AETNA 1017.52 79 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 32MM 202.732 48713561_1 CDM 0278 RC inpatient 1288 837.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 837.2 65 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 32MM 202.732 48713561_1 CDM 0278 RC inpatient 1288 837.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1249.36 97 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 32MM 202.732 48713561_1 CDM 0278 RC inpatient 1288 837.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 888.72 69 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 32MM 202.732 48713561_1 CDM 0278 RC inpatient 1288 837.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1004.64 78 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 32MM 202.732 48713561_1 CDM 0278 RC inpatient 1288 837.2 UMR - ALL PLANS UMR - ALL PLANS 901.6 70 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 32MM 202.732 48713561_1 CDM 0278 RC inpatient 1288 837.2 SIHO - ALL PLANS SIHO - ALL PLANS 1159.2 90 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 32MM 202.732 48713561_1 CDM 0278 RC inpatient 1288 837.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 779.88 60.55 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 32MM 202.732 48713561_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 779.88 1249.36 3.0 CANN SCREW 32MM 202.732 48713561_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 779.88 1249.36 3.0 CANN SCREW 32MM 202.732 48713561_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM HMO ANTHEM HMO 999999999 779.88 1249.36 3.0 CANN SCREW 32MM 202.732 48713561_1 CDM 0278 RC inpatient 1288 837.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 870.69 67.6 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 32MM 202.732 48713561_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 779.88 1249.36 3.0 CANN SCREW 32MM 202.732 48713561_1 CDM 0278 RC inpatient 1288 837.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 779.88 1249.36 3.0 CANN SCREW 34MM 202.734 48713562_1 CDM 0278 RC inpatient 970 630.5 AETNA AETNA 766.3 79 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 34MM 202.734 48713562_1 CDM 0278 RC inpatient 970 630.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 630.5 65 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 34MM 202.734 48713562_1 CDM 0278 RC inpatient 970 630.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 940.9 97 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 34MM 202.734 48713562_1 CDM 0278 RC inpatient 970 630.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 669.3 69 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 34MM 202.734 48713562_1 CDM 0278 RC inpatient 970 630.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 756.6 78 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 34MM 202.734 48713562_1 CDM 0278 RC inpatient 970 630.5 UMR - ALL PLANS UMR - ALL PLANS 679 70 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 34MM 202.734 48713562_1 CDM 0278 RC inpatient 970 630.5 SIHO - ALL PLANS SIHO - ALL PLANS 873 90 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 34MM 202.734 48713562_1 CDM 0278 RC inpatient 970 630.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 587.34 60.55 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 34MM 202.734 48713562_1 CDM 0278 RC inpatient 970 630.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 587.34 940.9 3.0 CANN SCREW 34MM 202.734 48713562_1 CDM 0278 RC inpatient 970 630.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 587.34 940.9 3.0 CANN SCREW 34MM 202.734 48713562_1 CDM 0278 RC inpatient 970 630.5 ANTHEM HMO ANTHEM HMO 999999999 587.34 940.9 3.0 CANN SCREW 34MM 202.734 48713562_1 CDM 0278 RC inpatient 970 630.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 655.72 67.6 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 34MM 202.734 48713562_1 CDM 0278 RC inpatient 970 630.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 587.34 940.9 3.0 CANN SCREW 34MM 202.734 48713562_1 CDM 0278 RC inpatient 970 630.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 587.34 940.9 3.0 CANN SCREW 36MM 202.736 48713563_1 CDM 0278 RC inpatient 918 596.7 AETNA AETNA 725.22 79 999999999 555.85 890.46 percent of total billed charges 3.0 CANN SCREW 36MM 202.736 48713563_1 CDM 0278 RC inpatient 918 596.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 596.7 65 999999999 555.85 890.46 percent of total billed charges 3.0 CANN SCREW 36MM 202.736 48713563_1 CDM 0278 RC inpatient 918 596.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 890.46 97 999999999 555.85 890.46 percent of total billed charges 3.0 CANN SCREW 36MM 202.736 48713563_1 CDM 0278 RC inpatient 918 596.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 633.42 69 999999999 555.85 890.46 percent of total billed charges 3.0 CANN SCREW 36MM 202.736 48713563_1 CDM 0278 RC inpatient 918 596.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 716.04 78 999999999 555.85 890.46 percent of total billed charges 3.0 CANN SCREW 36MM 202.736 48713563_1 CDM 0278 RC inpatient 918 596.7 UMR - ALL PLANS UMR - ALL PLANS 642.6 70 999999999 555.85 890.46 percent of total billed charges 3.0 CANN SCREW 36MM 202.736 48713563_1 CDM 0278 RC inpatient 918 596.7 SIHO - ALL PLANS SIHO - ALL PLANS 826.2 90 999999999 555.85 890.46 percent of total billed charges 3.0 CANN SCREW 36MM 202.736 48713563_1 CDM 0278 RC inpatient 918 596.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 555.85 60.55 999999999 555.85 890.46 percent of total billed charges 3.0 CANN SCREW 36MM 202.736 48713563_1 CDM 0278 RC inpatient 918 596.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 555.85 890.46 3.0 CANN SCREW 36MM 202.736 48713563_1 CDM 0278 RC inpatient 918 596.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 555.85 890.46 3.0 CANN SCREW 36MM 202.736 48713563_1 CDM 0278 RC inpatient 918 596.7 ANTHEM HMO ANTHEM HMO 999999999 555.85 890.46 3.0 CANN SCREW 36MM 202.736 48713563_1 CDM 0278 RC inpatient 918 596.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 620.57 67.6 999999999 555.85 890.46 percent of total billed charges 3.0 CANN SCREW 36MM 202.736 48713563_1 CDM 0278 RC inpatient 918 596.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 555.85 890.46 3.0 CANN SCREW 36MM 202.736 48713563_1 CDM 0278 RC inpatient 918 596.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 555.85 890.46 3.0 CANN SCREW 38MM 202.738 48713564_1 CDM 0278 RC inpatient 1288 837.2 AETNA AETNA 1017.52 79 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 38MM 202.738 48713564_1 CDM 0278 RC inpatient 1288 837.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 837.2 65 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 38MM 202.738 48713564_1 CDM 0278 RC inpatient 1288 837.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1249.36 97 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 38MM 202.738 48713564_1 CDM 0278 RC inpatient 1288 837.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 888.72 69 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 38MM 202.738 48713564_1 CDM 0278 RC inpatient 1288 837.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1004.64 78 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 38MM 202.738 48713564_1 CDM 0278 RC inpatient 1288 837.2 UMR - ALL PLANS UMR - ALL PLANS 901.6 70 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 38MM 202.738 48713564_1 CDM 0278 RC inpatient 1288 837.2 SIHO - ALL PLANS SIHO - ALL PLANS 1159.2 90 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 38MM 202.738 48713564_1 CDM 0278 RC inpatient 1288 837.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 779.88 60.55 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 38MM 202.738 48713564_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 779.88 1249.36 3.0 CANN SCREW 38MM 202.738 48713564_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 779.88 1249.36 3.0 CANN SCREW 38MM 202.738 48713564_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM HMO ANTHEM HMO 999999999 779.88 1249.36 3.0 CANN SCREW 38MM 202.738 48713564_1 CDM 0278 RC inpatient 1288 837.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 870.69 67.6 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 38MM 202.738 48713564_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 779.88 1249.36 3.0 CANN SCREW 38MM 202.738 48713564_1 CDM 0278 RC inpatient 1288 837.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 779.88 1249.36 3.0 CANN SCREW 40MM 202.740 48713565_1 CDM 0278 RC inpatient 918 596.7 AETNA AETNA 725.22 79 999999999 555.85 890.46 percent of total billed charges 3.0 CANN SCREW 40MM 202.740 48713565_1 CDM 0278 RC inpatient 918 596.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 596.7 65 999999999 555.85 890.46 percent of total billed charges 3.0 CANN SCREW 40MM 202.740 48713565_1 CDM 0278 RC inpatient 918 596.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 890.46 97 999999999 555.85 890.46 percent of total billed charges 3.0 CANN SCREW 40MM 202.740 48713565_1 CDM 0278 RC inpatient 918 596.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 633.42 69 999999999 555.85 890.46 percent of total billed charges 3.0 CANN SCREW 40MM 202.740 48713565_1 CDM 0278 RC inpatient 918 596.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 716.04 78 999999999 555.85 890.46 percent of total billed charges 3.0 CANN SCREW 40MM 202.740 48713565_1 CDM 0278 RC inpatient 918 596.7 UMR - ALL PLANS UMR - ALL PLANS 642.6 70 999999999 555.85 890.46 percent of total billed charges 3.0 CANN SCREW 40MM 202.740 48713565_1 CDM 0278 RC inpatient 918 596.7 SIHO - ALL PLANS SIHO - ALL PLANS 826.2 90 999999999 555.85 890.46 percent of total billed charges 3.0 CANN SCREW 40MM 202.740 48713565_1 CDM 0278 RC inpatient 918 596.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 555.85 60.55 999999999 555.85 890.46 percent of total billed charges 3.0 CANN SCREW 40MM 202.740 48713565_1 CDM 0278 RC inpatient 918 596.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 555.85 890.46 3.0 CANN SCREW 40MM 202.740 48713565_1 CDM 0278 RC inpatient 918 596.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 555.85 890.46 3.0 CANN SCREW 40MM 202.740 48713565_1 CDM 0278 RC inpatient 918 596.7 ANTHEM HMO ANTHEM HMO 999999999 555.85 890.46 3.0 CANN SCREW 40MM 202.740 48713565_1 CDM 0278 RC inpatient 918 596.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 620.57 67.6 999999999 555.85 890.46 percent of total billed charges 3.0 CANN SCREW 40MM 202.740 48713565_1 CDM 0278 RC inpatient 918 596.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 555.85 890.46 3.0 CANN SCREW 40MM 202.740 48713565_1 CDM 0278 RC inpatient 918 596.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 555.85 890.46 4.0 CANN SCREW 30MM 207.630 48713566_1 CDM 0278 RC inpatient 1467 953.55 AETNA AETNA 1158.93 79 999999999 888.27 1422.99 percent of total billed charges 4.0 CANN SCREW 30MM 207.630 48713566_1 CDM 0278 RC inpatient 1467 953.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 953.55 65 999999999 888.27 1422.99 percent of total billed charges 4.0 CANN SCREW 30MM 207.630 48713566_1 CDM 0278 RC inpatient 1467 953.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1422.99 97 999999999 888.27 1422.99 percent of total billed charges 4.0 CANN SCREW 30MM 207.630 48713566_1 CDM 0278 RC inpatient 1467 953.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1012.23 69 999999999 888.27 1422.99 percent of total billed charges 4.0 CANN SCREW 30MM 207.630 48713566_1 CDM 0278 RC inpatient 1467 953.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1144.26 78 999999999 888.27 1422.99 percent of total billed charges 4.0 CANN SCREW 30MM 207.630 48713566_1 CDM 0278 RC inpatient 1467 953.55 UMR - ALL PLANS UMR - ALL PLANS 1026.9 70 999999999 888.27 1422.99 percent of total billed charges 4.0 CANN SCREW 30MM 207.630 48713566_1 CDM 0278 RC inpatient 1467 953.55 SIHO - ALL PLANS SIHO - ALL PLANS 1320.3 90 999999999 888.27 1422.99 percent of total billed charges 4.0 CANN SCREW 30MM 207.630 48713566_1 CDM 0278 RC inpatient 1467 953.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 888.27 60.55 999999999 888.27 1422.99 percent of total billed charges 4.0 CANN SCREW 30MM 207.630 48713566_1 CDM 0278 RC inpatient 1467 953.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 888.27 1422.99 4.0 CANN SCREW 30MM 207.630 48713566_1 CDM 0278 RC inpatient 1467 953.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 888.27 1422.99 4.0 CANN SCREW 30MM 207.630 48713566_1 CDM 0278 RC inpatient 1467 953.55 ANTHEM HMO ANTHEM HMO 999999999 888.27 1422.99 4.0 CANN SCREW 30MM 207.630 48713566_1 CDM 0278 RC inpatient 1467 953.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 991.69 67.6 999999999 888.27 1422.99 percent of total billed charges 4.0 CANN SCREW 30MM 207.630 48713566_1 CDM 0278 RC inpatient 1467 953.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 888.27 1422.99 4.0 CANN SCREW 30MM 207.630 48713566_1 CDM 0278 RC inpatient 1467 953.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 888.27 1422.99 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713567_1 CDM 0278 RC C1713 HCPCS inpatient 1350 877.5 AETNA AETNA 1066.5 79 999999999 817.43 1309.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713567_1 CDM 0278 RC C1713 HCPCS inpatient 1350 877.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 877.5 65 999999999 817.43 1309.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713567_1 CDM 0278 RC C1713 HCPCS inpatient 1350 877.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1309.5 97 999999999 817.43 1309.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713567_1 CDM 0278 RC C1713 HCPCS inpatient 1350 877.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 931.5 69 999999999 817.43 1309.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713567_1 CDM 0278 RC C1713 HCPCS inpatient 1350 877.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1053 78 999999999 817.43 1309.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713567_1 CDM 0278 RC C1713 HCPCS inpatient 1350 877.5 UMR - ALL PLANS UMR - ALL PLANS 945 70 999999999 817.43 1309.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713567_1 CDM 0278 RC C1713 HCPCS inpatient 1350 877.5 SIHO - ALL PLANS SIHO - ALL PLANS 1215 90 999999999 817.43 1309.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713567_1 CDM 0278 RC C1713 HCPCS inpatient 1350 877.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 817.43 60.55 999999999 817.43 1309.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713567_1 CDM 0278 RC C1713 HCPCS inpatient 1350 877.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 817.43 1309.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713567_1 CDM 0278 RC C1713 HCPCS inpatient 1350 877.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 817.43 1309.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713567_1 CDM 0278 RC C1713 HCPCS inpatient 1350 877.5 ANTHEM HMO ANTHEM HMO 999999999 817.43 1309.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713567_1 CDM 0278 RC C1713 HCPCS inpatient 1350 877.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 912.6 67.6 999999999 817.43 1309.5 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713567_1 CDM 0278 RC C1713 HCPCS inpatient 1350 877.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 817.43 1309.5 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713567_1 CDM 0278 RC C1713 HCPCS inpatient 1350 877.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 817.43 1309.5 4.0 CANN SCREW 36MM 207.636 48713568_1 CDM 0278 RC inpatient 1509 980.85 AETNA AETNA 1192.11 79 999999999 913.7 1463.73 percent of total billed charges 4.0 CANN SCREW 36MM 207.636 48713568_1 CDM 0278 RC inpatient 1509 980.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 980.85 65 999999999 913.7 1463.73 percent of total billed charges 4.0 CANN SCREW 36MM 207.636 48713568_1 CDM 0278 RC inpatient 1509 980.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1463.73 97 999999999 913.7 1463.73 percent of total billed charges 4.0 CANN SCREW 36MM 207.636 48713568_1 CDM 0278 RC inpatient 1509 980.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1041.21 69 999999999 913.7 1463.73 percent of total billed charges 4.0 CANN SCREW 36MM 207.636 48713568_1 CDM 0278 RC inpatient 1509 980.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1177.02 78 999999999 913.7 1463.73 percent of total billed charges 4.0 CANN SCREW 36MM 207.636 48713568_1 CDM 0278 RC inpatient 1509 980.85 UMR - ALL PLANS UMR - ALL PLANS 1056.3 70 999999999 913.7 1463.73 percent of total billed charges 4.0 CANN SCREW 36MM 207.636 48713568_1 CDM 0278 RC inpatient 1509 980.85 SIHO - ALL PLANS SIHO - ALL PLANS 1358.1 90 999999999 913.7 1463.73 percent of total billed charges 4.0 CANN SCREW 36MM 207.636 48713568_1 CDM 0278 RC inpatient 1509 980.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 913.7 60.55 999999999 913.7 1463.73 percent of total billed charges 4.0 CANN SCREW 36MM 207.636 48713568_1 CDM 0278 RC inpatient 1509 980.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 913.7 1463.73 4.0 CANN SCREW 36MM 207.636 48713568_1 CDM 0278 RC inpatient 1509 980.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 913.7 1463.73 4.0 CANN SCREW 36MM 207.636 48713568_1 CDM 0278 RC inpatient 1509 980.85 ANTHEM HMO ANTHEM HMO 999999999 913.7 1463.73 4.0 CANN SCREW 36MM 207.636 48713568_1 CDM 0278 RC inpatient 1509 980.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1020.08 67.6 999999999 913.7 1463.73 percent of total billed charges 4.0 CANN SCREW 36MM 207.636 48713568_1 CDM 0278 RC inpatient 1509 980.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 913.7 1463.73 4.0 CANN SCREW 36MM 207.636 48713568_1 CDM 0278 RC inpatient 1509 980.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 913.7 1463.73 4.0 CANN SCREW 42MM 207.642 48713569_1 CDM 0278 RC inpatient 1272 826.8 AETNA AETNA 1004.88 79 999999999 770.2 1233.84 percent of total billed charges 4.0 CANN SCREW 42MM 207.642 48713569_1 CDM 0278 RC inpatient 1272 826.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 826.8 65 999999999 770.2 1233.84 percent of total billed charges 4.0 CANN SCREW 42MM 207.642 48713569_1 CDM 0278 RC inpatient 1272 826.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1233.84 97 999999999 770.2 1233.84 percent of total billed charges 4.0 CANN SCREW 42MM 207.642 48713569_1 CDM 0278 RC inpatient 1272 826.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 877.68 69 999999999 770.2 1233.84 percent of total billed charges 4.0 CANN SCREW 42MM 207.642 48713569_1 CDM 0278 RC inpatient 1272 826.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 992.16 78 999999999 770.2 1233.84 percent of total billed charges 4.0 CANN SCREW 42MM 207.642 48713569_1 CDM 0278 RC inpatient 1272 826.8 UMR - ALL PLANS UMR - ALL PLANS 890.4 70 999999999 770.2 1233.84 percent of total billed charges 4.0 CANN SCREW 42MM 207.642 48713569_1 CDM 0278 RC inpatient 1272 826.8 SIHO - ALL PLANS SIHO - ALL PLANS 1144.8 90 999999999 770.2 1233.84 percent of total billed charges 4.0 CANN SCREW 42MM 207.642 48713569_1 CDM 0278 RC inpatient 1272 826.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 770.2 60.55 999999999 770.2 1233.84 percent of total billed charges 4.0 CANN SCREW 42MM 207.642 48713569_1 CDM 0278 RC inpatient 1272 826.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 770.2 1233.84 4.0 CANN SCREW 42MM 207.642 48713569_1 CDM 0278 RC inpatient 1272 826.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 770.2 1233.84 4.0 CANN SCREW 42MM 207.642 48713569_1 CDM 0278 RC inpatient 1272 826.8 ANTHEM HMO ANTHEM HMO 999999999 770.2 1233.84 4.0 CANN SCREW 42MM 207.642 48713569_1 CDM 0278 RC inpatient 1272 826.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 859.87 67.6 999999999 770.2 1233.84 percent of total billed charges 4.0 CANN SCREW 42MM 207.642 48713569_1 CDM 0278 RC inpatient 1272 826.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 770.2 1233.84 4.0 CANN SCREW 42MM 207.642 48713569_1 CDM 0278 RC inpatient 1272 826.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 770.2 1233.84 4.0 CANN SCREW 44MM 207.644 48713570_1 CDM 0278 RC inpatient 1340 871 AETNA AETNA 1058.6 79 999999999 811.37 1299.8 percent of total billed charges 4.0 CANN SCREW 44MM 207.644 48713570_1 CDM 0278 RC inpatient 1340 871 SELF PAY DISCOUNT SELF PAY DISCOUNT 871 65 999999999 811.37 1299.8 percent of total billed charges 4.0 CANN SCREW 44MM 207.644 48713570_1 CDM 0278 RC inpatient 1340 871 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1299.8 97 999999999 811.37 1299.8 percent of total billed charges 4.0 CANN SCREW 44MM 207.644 48713570_1 CDM 0278 RC inpatient 1340 871 ENCORE - ALL PLANS ENCORE - ALL PLANS 924.6 69 999999999 811.37 1299.8 percent of total billed charges 4.0 CANN SCREW 44MM 207.644 48713570_1 CDM 0278 RC inpatient 1340 871 HUMANA - ALL PLANS HUMANA - ALL PLANS 1045.2 78 999999999 811.37 1299.8 percent of total billed charges 4.0 CANN SCREW 44MM 207.644 48713570_1 CDM 0278 RC inpatient 1340 871 UMR - ALL PLANS UMR - ALL PLANS 938 70 999999999 811.37 1299.8 percent of total billed charges 4.0 CANN SCREW 44MM 207.644 48713570_1 CDM 0278 RC inpatient 1340 871 SIHO - ALL PLANS SIHO - ALL PLANS 1206 90 999999999 811.37 1299.8 percent of total billed charges 4.0 CANN SCREW 44MM 207.644 48713570_1 CDM 0278 RC inpatient 1340 871 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 811.37 60.55 999999999 811.37 1299.8 percent of total billed charges 4.0 CANN SCREW 44MM 207.644 48713570_1 CDM 0278 RC inpatient 1340 871 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 811.37 1299.8 4.0 CANN SCREW 44MM 207.644 48713570_1 CDM 0278 RC inpatient 1340 871 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 811.37 1299.8 4.0 CANN SCREW 44MM 207.644 48713570_1 CDM 0278 RC inpatient 1340 871 ANTHEM HMO ANTHEM HMO 999999999 811.37 1299.8 4.0 CANN SCREW 44MM 207.644 48713570_1 CDM 0278 RC inpatient 1340 871 CIGNA - ALL PLANS CIGNA - ALL PLANS 905.84 67.6 999999999 811.37 1299.8 percent of total billed charges 4.0 CANN SCREW 44MM 207.644 48713570_1 CDM 0278 RC inpatient 1340 871 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 811.37 1299.8 4.0 CANN SCREW 44MM 207.644 48713570_1 CDM 0278 RC inpatient 1340 871 UHC - ALL PLANS UHC - ALL PLANS 999999999 811.37 1299.8 4.0 CANN SCREW 48MM 207.648 48713571_1 CDM 0278 RC inpatient 1160 754 AETNA AETNA 916.4 79 999999999 702.38 1125.2 percent of total billed charges 4.0 CANN SCREW 48MM 207.648 48713571_1 CDM 0278 RC inpatient 1160 754 SELF PAY DISCOUNT SELF PAY DISCOUNT 754 65 999999999 702.38 1125.2 percent of total billed charges 4.0 CANN SCREW 48MM 207.648 48713571_1 CDM 0278 RC inpatient 1160 754 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1125.2 97 999999999 702.38 1125.2 percent of total billed charges 4.0 CANN SCREW 48MM 207.648 48713571_1 CDM 0278 RC inpatient 1160 754 ENCORE - ALL PLANS ENCORE - ALL PLANS 800.4 69 999999999 702.38 1125.2 percent of total billed charges 4.0 CANN SCREW 48MM 207.648 48713571_1 CDM 0278 RC inpatient 1160 754 HUMANA - ALL PLANS HUMANA - ALL PLANS 904.8 78 999999999 702.38 1125.2 percent of total billed charges 4.0 CANN SCREW 48MM 207.648 48713571_1 CDM 0278 RC inpatient 1160 754 UMR - ALL PLANS UMR - ALL PLANS 812 70 999999999 702.38 1125.2 percent of total billed charges 4.0 CANN SCREW 48MM 207.648 48713571_1 CDM 0278 RC inpatient 1160 754 SIHO - ALL PLANS SIHO - ALL PLANS 1044 90 999999999 702.38 1125.2 percent of total billed charges 4.0 CANN SCREW 48MM 207.648 48713571_1 CDM 0278 RC inpatient 1160 754 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 702.38 60.55 999999999 702.38 1125.2 percent of total billed charges 4.0 CANN SCREW 48MM 207.648 48713571_1 CDM 0278 RC inpatient 1160 754 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 702.38 1125.2 4.0 CANN SCREW 48MM 207.648 48713571_1 CDM 0278 RC inpatient 1160 754 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 702.38 1125.2 4.0 CANN SCREW 48MM 207.648 48713571_1 CDM 0278 RC inpatient 1160 754 ANTHEM HMO ANTHEM HMO 999999999 702.38 1125.2 4.0 CANN SCREW 48MM 207.648 48713571_1 CDM 0278 RC inpatient 1160 754 CIGNA - ALL PLANS CIGNA - ALL PLANS 784.16 67.6 999999999 702.38 1125.2 percent of total billed charges 4.0 CANN SCREW 48MM 207.648 48713571_1 CDM 0278 RC inpatient 1160 754 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 702.38 1125.2 4.0 CANN SCREW 48MM 207.648 48713571_1 CDM 0278 RC inpatient 1160 754 UHC - ALL PLANS UHC - ALL PLANS 999999999 702.38 1125.2 4.0 CANN SCREW 50MM 207.650 48713572_1 CDM 0278 RC inpatient 1467 953.55 AETNA AETNA 1158.93 79 999999999 888.27 1422.99 percent of total billed charges 4.0 CANN SCREW 50MM 207.650 48713572_1 CDM 0278 RC inpatient 1467 953.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 953.55 65 999999999 888.27 1422.99 percent of total billed charges 4.0 CANN SCREW 50MM 207.650 48713572_1 CDM 0278 RC inpatient 1467 953.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1422.99 97 999999999 888.27 1422.99 percent of total billed charges 4.0 CANN SCREW 50MM 207.650 48713572_1 CDM 0278 RC inpatient 1467 953.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1012.23 69 999999999 888.27 1422.99 percent of total billed charges 4.0 CANN SCREW 50MM 207.650 48713572_1 CDM 0278 RC inpatient 1467 953.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1144.26 78 999999999 888.27 1422.99 percent of total billed charges 4.0 CANN SCREW 50MM 207.650 48713572_1 CDM 0278 RC inpatient 1467 953.55 UMR - ALL PLANS UMR - ALL PLANS 1026.9 70 999999999 888.27 1422.99 percent of total billed charges 4.0 CANN SCREW 50MM 207.650 48713572_1 CDM 0278 RC inpatient 1467 953.55 SIHO - ALL PLANS SIHO - ALL PLANS 1320.3 90 999999999 888.27 1422.99 percent of total billed charges 4.0 CANN SCREW 50MM 207.650 48713572_1 CDM 0278 RC inpatient 1467 953.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 888.27 60.55 999999999 888.27 1422.99 percent of total billed charges 4.0 CANN SCREW 50MM 207.650 48713572_1 CDM 0278 RC inpatient 1467 953.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 888.27 1422.99 4.0 CANN SCREW 50MM 207.650 48713572_1 CDM 0278 RC inpatient 1467 953.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 888.27 1422.99 4.0 CANN SCREW 50MM 207.650 48713572_1 CDM 0278 RC inpatient 1467 953.55 ANTHEM HMO ANTHEM HMO 999999999 888.27 1422.99 4.0 CANN SCREW 50MM 207.650 48713572_1 CDM 0278 RC inpatient 1467 953.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 991.69 67.6 999999999 888.27 1422.99 percent of total billed charges 4.0 CANN SCREW 50MM 207.650 48713572_1 CDM 0278 RC inpatient 1467 953.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 888.27 1422.99 4.0 CANN SCREW 50MM 207.650 48713572_1 CDM 0278 RC inpatient 1467 953.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 888.27 1422.99 4.0 CANN SCREW 18MM/ 207.718 48713573_1 CDM 0278 RC inpatient 1310 851.5 AETNA AETNA 1034.9 79 999999999 793.21 1270.7 percent of total billed charges 4.0 CANN SCREW 18MM/ 207.718 48713573_1 CDM 0278 RC inpatient 1310 851.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 851.5 65 999999999 793.21 1270.7 percent of total billed charges 4.0 CANN SCREW 18MM/ 207.718 48713573_1 CDM 0278 RC inpatient 1310 851.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1270.7 97 999999999 793.21 1270.7 percent of total billed charges 4.0 CANN SCREW 18MM/ 207.718 48713573_1 CDM 0278 RC inpatient 1310 851.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 903.9 69 999999999 793.21 1270.7 percent of total billed charges 4.0 CANN SCREW 18MM/ 207.718 48713573_1 CDM 0278 RC inpatient 1310 851.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1021.8 78 999999999 793.21 1270.7 percent of total billed charges 4.0 CANN SCREW 18MM/ 207.718 48713573_1 CDM 0278 RC inpatient 1310 851.5 UMR - ALL PLANS UMR - ALL PLANS 917 70 999999999 793.21 1270.7 percent of total billed charges 4.0 CANN SCREW 18MM/ 207.718 48713573_1 CDM 0278 RC inpatient 1310 851.5 SIHO - ALL PLANS SIHO - ALL PLANS 1179 90 999999999 793.21 1270.7 percent of total billed charges 4.0 CANN SCREW 18MM/ 207.718 48713573_1 CDM 0278 RC inpatient 1310 851.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 793.21 60.55 999999999 793.21 1270.7 percent of total billed charges 4.0 CANN SCREW 18MM/ 207.718 48713573_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 793.21 1270.7 4.0 CANN SCREW 18MM/ 207.718 48713573_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 793.21 1270.7 4.0 CANN SCREW 18MM/ 207.718 48713573_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM HMO ANTHEM HMO 999999999 793.21 1270.7 4.0 CANN SCREW 18MM/ 207.718 48713573_1 CDM 0278 RC inpatient 1310 851.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 885.56 67.6 999999999 793.21 1270.7 percent of total billed charges 4.0 CANN SCREW 18MM/ 207.718 48713573_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 793.21 1270.7 4.0 CANN SCREW 18MM/ 207.718 48713573_1 CDM 0278 RC inpatient 1310 851.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 793.21 1270.7 4.0 CANN SCREW 18MM/ 207.722 48713574_1 CDM 0278 RC inpatient 1310 851.5 AETNA AETNA 1034.9 79 999999999 793.21 1270.7 percent of total billed charges 4.0 CANN SCREW 18MM/ 207.722 48713574_1 CDM 0278 RC inpatient 1310 851.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 851.5 65 999999999 793.21 1270.7 percent of total billed charges 4.0 CANN SCREW 18MM/ 207.722 48713574_1 CDM 0278 RC inpatient 1310 851.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1270.7 97 999999999 793.21 1270.7 percent of total billed charges 4.0 CANN SCREW 18MM/ 207.722 48713574_1 CDM 0278 RC inpatient 1310 851.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 903.9 69 999999999 793.21 1270.7 percent of total billed charges 4.0 CANN SCREW 18MM/ 207.722 48713574_1 CDM 0278 RC inpatient 1310 851.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1021.8 78 999999999 793.21 1270.7 percent of total billed charges 4.0 CANN SCREW 18MM/ 207.722 48713574_1 CDM 0278 RC inpatient 1310 851.5 UMR - ALL PLANS UMR - ALL PLANS 917 70 999999999 793.21 1270.7 percent of total billed charges 4.0 CANN SCREW 18MM/ 207.722 48713574_1 CDM 0278 RC inpatient 1310 851.5 SIHO - ALL PLANS SIHO - ALL PLANS 1179 90 999999999 793.21 1270.7 percent of total billed charges 4.0 CANN SCREW 18MM/ 207.722 48713574_1 CDM 0278 RC inpatient 1310 851.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 793.21 60.55 999999999 793.21 1270.7 percent of total billed charges 4.0 CANN SCREW 18MM/ 207.722 48713574_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 793.21 1270.7 4.0 CANN SCREW 18MM/ 207.722 48713574_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 793.21 1270.7 4.0 CANN SCREW 18MM/ 207.722 48713574_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM HMO ANTHEM HMO 999999999 793.21 1270.7 4.0 CANN SCREW 18MM/ 207.722 48713574_1 CDM 0278 RC inpatient 1310 851.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 885.56 67.6 999999999 793.21 1270.7 percent of total billed charges 4.0 CANN SCREW 18MM/ 207.722 48713574_1 CDM 0278 RC inpatient 1310 851.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 793.21 1270.7 4.0 CANN SCREW 18MM/ 207.722 48713574_1 CDM 0278 RC inpatient 1310 851.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 793.21 1270.7 4.0 CANN SCREW 26MM/ 207.726 48713575_1 CDM 0278 RC inpatient 1390 903.5 AETNA AETNA 1098.1 79 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 26MM/ 207.726 48713575_1 CDM 0278 RC inpatient 1390 903.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 903.5 65 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 26MM/ 207.726 48713575_1 CDM 0278 RC inpatient 1390 903.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1348.3 97 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 26MM/ 207.726 48713575_1 CDM 0278 RC inpatient 1390 903.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 959.1 69 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 26MM/ 207.726 48713575_1 CDM 0278 RC inpatient 1390 903.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1084.2 78 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 26MM/ 207.726 48713575_1 CDM 0278 RC inpatient 1390 903.5 UMR - ALL PLANS UMR - ALL PLANS 973 70 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 26MM/ 207.726 48713575_1 CDM 0278 RC inpatient 1390 903.5 SIHO - ALL PLANS SIHO - ALL PLANS 1251 90 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 26MM/ 207.726 48713575_1 CDM 0278 RC inpatient 1390 903.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 841.65 60.55 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 26MM/ 207.726 48713575_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 841.65 1348.3 4.0 CANN SCREW 26MM/ 207.726 48713575_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 841.65 1348.3 4.0 CANN SCREW 26MM/ 207.726 48713575_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM HMO ANTHEM HMO 999999999 841.65 1348.3 4.0 CANN SCREW 26MM/ 207.726 48713575_1 CDM 0278 RC inpatient 1390 903.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 939.64 67.6 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 26MM/ 207.726 48713575_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 841.65 1348.3 4.0 CANN SCREW 26MM/ 207.726 48713575_1 CDM 0278 RC inpatient 1390 903.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 841.65 1348.3 4.0 CANN SCREW 30MM/ 207.730 48713576_1 CDM 0278 RC inpatient 1390 903.5 AETNA AETNA 1098.1 79 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 30MM/ 207.730 48713576_1 CDM 0278 RC inpatient 1390 903.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 903.5 65 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 30MM/ 207.730 48713576_1 CDM 0278 RC inpatient 1390 903.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1348.3 97 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 30MM/ 207.730 48713576_1 CDM 0278 RC inpatient 1390 903.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 959.1 69 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 30MM/ 207.730 48713576_1 CDM 0278 RC inpatient 1390 903.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1084.2 78 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 30MM/ 207.730 48713576_1 CDM 0278 RC inpatient 1390 903.5 UMR - ALL PLANS UMR - ALL PLANS 973 70 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 30MM/ 207.730 48713576_1 CDM 0278 RC inpatient 1390 903.5 SIHO - ALL PLANS SIHO - ALL PLANS 1251 90 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 30MM/ 207.730 48713576_1 CDM 0278 RC inpatient 1390 903.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 841.65 60.55 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 30MM/ 207.730 48713576_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 841.65 1348.3 4.0 CANN SCREW 30MM/ 207.730 48713576_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 841.65 1348.3 4.0 CANN SCREW 30MM/ 207.730 48713576_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM HMO ANTHEM HMO 999999999 841.65 1348.3 4.0 CANN SCREW 30MM/ 207.730 48713576_1 CDM 0278 RC inpatient 1390 903.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 939.64 67.6 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 30MM/ 207.730 48713576_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 841.65 1348.3 4.0 CANN SCREW 30MM/ 207.730 48713576_1 CDM 0278 RC inpatient 1390 903.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 841.65 1348.3 4.0 CANN SCREW 38MM/ 207.738 48713577_1 CDM 0278 RC inpatient 1390 903.5 AETNA AETNA 1098.1 79 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 38MM/ 207.738 48713577_1 CDM 0278 RC inpatient 1390 903.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 903.5 65 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 38MM/ 207.738 48713577_1 CDM 0278 RC inpatient 1390 903.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1348.3 97 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 38MM/ 207.738 48713577_1 CDM 0278 RC inpatient 1390 903.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 959.1 69 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 38MM/ 207.738 48713577_1 CDM 0278 RC inpatient 1390 903.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1084.2 78 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 38MM/ 207.738 48713577_1 CDM 0278 RC inpatient 1390 903.5 UMR - ALL PLANS UMR - ALL PLANS 973 70 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 38MM/ 207.738 48713577_1 CDM 0278 RC inpatient 1390 903.5 SIHO - ALL PLANS SIHO - ALL PLANS 1251 90 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 38MM/ 207.738 48713577_1 CDM 0278 RC inpatient 1390 903.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 841.65 60.55 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 38MM/ 207.738 48713577_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 841.65 1348.3 4.0 CANN SCREW 38MM/ 207.738 48713577_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 841.65 1348.3 4.0 CANN SCREW 38MM/ 207.738 48713577_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM HMO ANTHEM HMO 999999999 841.65 1348.3 4.0 CANN SCREW 38MM/ 207.738 48713577_1 CDM 0278 RC inpatient 1390 903.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 939.64 67.6 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 38MM/ 207.738 48713577_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 841.65 1348.3 4.0 CANN SCREW 38MM/ 207.738 48713577_1 CDM 0278 RC inpatient 1390 903.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 841.65 1348.3 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713578_1 CDM 0278 RC C1713 HCPCS inpatient 1390 903.5 AETNA AETNA 1098.1 79 999999999 841.65 1348.3 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713578_1 CDM 0278 RC C1713 HCPCS inpatient 1390 903.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 903.5 65 999999999 841.65 1348.3 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713578_1 CDM 0278 RC C1713 HCPCS inpatient 1390 903.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1348.3 97 999999999 841.65 1348.3 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713578_1 CDM 0278 RC C1713 HCPCS inpatient 1390 903.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 959.1 69 999999999 841.65 1348.3 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713578_1 CDM 0278 RC C1713 HCPCS inpatient 1390 903.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1084.2 78 999999999 841.65 1348.3 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713578_1 CDM 0278 RC C1713 HCPCS inpatient 1390 903.5 UMR - ALL PLANS UMR - ALL PLANS 973 70 999999999 841.65 1348.3 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713578_1 CDM 0278 RC C1713 HCPCS inpatient 1390 903.5 SIHO - ALL PLANS SIHO - ALL PLANS 1251 90 999999999 841.65 1348.3 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713578_1 CDM 0278 RC C1713 HCPCS inpatient 1390 903.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 841.65 60.55 999999999 841.65 1348.3 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713578_1 CDM 0278 RC C1713 HCPCS inpatient 1390 903.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 841.65 1348.3 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713578_1 CDM 0278 RC C1713 HCPCS inpatient 1390 903.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 841.65 1348.3 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713578_1 CDM 0278 RC C1713 HCPCS inpatient 1390 903.5 ANTHEM HMO ANTHEM HMO 999999999 841.65 1348.3 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713578_1 CDM 0278 RC C1713 HCPCS inpatient 1390 903.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 939.64 67.6 999999999 841.65 1348.3 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713578_1 CDM 0278 RC C1713 HCPCS inpatient 1390 903.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 841.65 1348.3 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713578_1 CDM 0278 RC C1713 HCPCS inpatient 1390 903.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 841.65 1348.3 4.0 CANN SCREW 42MM 207.742 48713579_1 CDM 0278 RC inpatient 1298 843.7 AETNA AETNA 1025.42 79 999999999 785.94 1259.06 percent of total billed charges 4.0 CANN SCREW 42MM 207.742 48713579_1 CDM 0278 RC inpatient 1298 843.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 843.7 65 999999999 785.94 1259.06 percent of total billed charges 4.0 CANN SCREW 42MM 207.742 48713579_1 CDM 0278 RC inpatient 1298 843.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1259.06 97 999999999 785.94 1259.06 percent of total billed charges 4.0 CANN SCREW 42MM 207.742 48713579_1 CDM 0278 RC inpatient 1298 843.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 895.62 69 999999999 785.94 1259.06 percent of total billed charges 4.0 CANN SCREW 42MM 207.742 48713579_1 CDM 0278 RC inpatient 1298 843.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1012.44 78 999999999 785.94 1259.06 percent of total billed charges 4.0 CANN SCREW 42MM 207.742 48713579_1 CDM 0278 RC inpatient 1298 843.7 UMR - ALL PLANS UMR - ALL PLANS 908.6 70 999999999 785.94 1259.06 percent of total billed charges 4.0 CANN SCREW 42MM 207.742 48713579_1 CDM 0278 RC inpatient 1298 843.7 SIHO - ALL PLANS SIHO - ALL PLANS 1168.2 90 999999999 785.94 1259.06 percent of total billed charges 4.0 CANN SCREW 42MM 207.742 48713579_1 CDM 0278 RC inpatient 1298 843.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 785.94 60.55 999999999 785.94 1259.06 percent of total billed charges 4.0 CANN SCREW 42MM 207.742 48713579_1 CDM 0278 RC inpatient 1298 843.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 785.94 1259.06 4.0 CANN SCREW 42MM 207.742 48713579_1 CDM 0278 RC inpatient 1298 843.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 785.94 1259.06 4.0 CANN SCREW 42MM 207.742 48713579_1 CDM 0278 RC inpatient 1298 843.7 ANTHEM HMO ANTHEM HMO 999999999 785.94 1259.06 4.0 CANN SCREW 42MM 207.742 48713579_1 CDM 0278 RC inpatient 1298 843.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 877.45 67.6 999999999 785.94 1259.06 percent of total billed charges 4.0 CANN SCREW 42MM 207.742 48713579_1 CDM 0278 RC inpatient 1298 843.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 785.94 1259.06 4.0 CANN SCREW 42MM 207.742 48713579_1 CDM 0278 RC inpatient 1298 843.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 785.94 1259.06 4.0 CANN SCREW 44MM 207.744 48713580_1 CDM 0278 RC inpatient 1390 903.5 AETNA AETNA 1098.1 79 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 44MM 207.744 48713580_1 CDM 0278 RC inpatient 1390 903.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 903.5 65 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 44MM 207.744 48713580_1 CDM 0278 RC inpatient 1390 903.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1348.3 97 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 44MM 207.744 48713580_1 CDM 0278 RC inpatient 1390 903.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 959.1 69 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 44MM 207.744 48713580_1 CDM 0278 RC inpatient 1390 903.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1084.2 78 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 44MM 207.744 48713580_1 CDM 0278 RC inpatient 1390 903.5 UMR - ALL PLANS UMR - ALL PLANS 973 70 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 44MM 207.744 48713580_1 CDM 0278 RC inpatient 1390 903.5 SIHO - ALL PLANS SIHO - ALL PLANS 1251 90 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 44MM 207.744 48713580_1 CDM 0278 RC inpatient 1390 903.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 841.65 60.55 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 44MM 207.744 48713580_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 841.65 1348.3 4.0 CANN SCREW 44MM 207.744 48713580_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 841.65 1348.3 4.0 CANN SCREW 44MM 207.744 48713580_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM HMO ANTHEM HMO 999999999 841.65 1348.3 4.0 CANN SCREW 44MM 207.744 48713580_1 CDM 0278 RC inpatient 1390 903.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 939.64 67.6 999999999 841.65 1348.3 percent of total billed charges 4.0 CANN SCREW 44MM 207.744 48713580_1 CDM 0278 RC inpatient 1390 903.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 841.65 1348.3 4.0 CANN SCREW 44MM 207.744 48713580_1 CDM 0278 RC inpatient 1390 903.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 841.65 1348.3 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713581_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 AETNA AETNA 1034.9 79 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713581_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 851.5 65 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713581_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1270.7 97 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713581_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 903.9 69 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713581_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1021.8 78 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713581_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 UMR - ALL PLANS UMR - ALL PLANS 917 70 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713581_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 SIHO - ALL PLANS SIHO - ALL PLANS 1179 90 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713581_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 793.21 60.55 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713581_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 793.21 1270.7 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713581_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 793.21 1270.7 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713581_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ANTHEM HMO ANTHEM HMO 999999999 793.21 1270.7 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713581_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 885.56 67.6 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713581_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 793.21 1270.7 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713581_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 793.21 1270.7 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713582_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 AETNA AETNA 1034.9 79 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713582_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 851.5 65 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713582_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1270.7 97 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713582_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 903.9 69 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713582_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1021.8 78 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713582_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 UMR - ALL PLANS UMR - ALL PLANS 917 70 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713582_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 SIHO - ALL PLANS SIHO - ALL PLANS 1179 90 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713582_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 793.21 60.55 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713582_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 793.21 1270.7 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713582_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 793.21 1270.7 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713582_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ANTHEM HMO ANTHEM HMO 999999999 793.21 1270.7 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713582_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 885.56 67.6 999999999 793.21 1270.7 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713582_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 793.21 1270.7 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713582_1 CDM 0278 RC C1713 HCPCS inpatient 1310 851.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 793.21 1270.7 TROCAR DILATING 12 X 150 D12XT 48713583_1 CDM 0272 RC inpatient 681 442.65 AETNA AETNA 537.99 79 999999999 412.35 660.57 percent of total billed charges TROCAR DILATING 12 X 150 D12XT 48713583_1 CDM 0272 RC inpatient 681 442.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 442.65 65 999999999 412.35 660.57 percent of total billed charges TROCAR DILATING 12 X 150 D12XT 48713583_1 CDM 0272 RC inpatient 681 442.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 660.57 97 999999999 412.35 660.57 percent of total billed charges TROCAR DILATING 12 X 150 D12XT 48713583_1 CDM 0272 RC inpatient 681 442.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 469.89 69 999999999 412.35 660.57 percent of total billed charges TROCAR DILATING 12 X 150 D12XT 48713583_1 CDM 0272 RC inpatient 681 442.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 531.18 78 999999999 412.35 660.57 percent of total billed charges TROCAR DILATING 12 X 150 D12XT 48713583_1 CDM 0272 RC inpatient 681 442.65 UMR - ALL PLANS UMR - ALL PLANS 476.7 70 999999999 412.35 660.57 percent of total billed charges TROCAR DILATING 12 X 150 D12XT 48713583_1 CDM 0272 RC inpatient 681 442.65 SIHO - ALL PLANS SIHO - ALL PLANS 612.9 90 999999999 412.35 660.57 percent of total billed charges TROCAR DILATING 12 X 150 D12XT 48713583_1 CDM 0272 RC inpatient 681 442.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 412.35 60.55 999999999 412.35 660.57 percent of total billed charges TROCAR DILATING 12 X 150 D12XT 48713583_1 CDM 0272 RC inpatient 681 442.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 412.35 660.57 TROCAR DILATING 12 X 150 D12XT 48713583_1 CDM 0272 RC inpatient 681 442.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 412.35 660.57 TROCAR DILATING 12 X 150 D12XT 48713583_1 CDM 0272 RC inpatient 681 442.65 ANTHEM HMO ANTHEM HMO 999999999 412.35 660.57 TROCAR DILATING 12 X 150 D12XT 48713583_1 CDM 0272 RC inpatient 681 442.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 460.36 67.6 999999999 412.35 660.57 percent of total billed charges TROCAR DILATING 12 X 150 D12XT 48713583_1 CDM 0272 RC inpatient 681 442.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 412.35 660.57 TROCAR DILATING 12 X 150 D12XT 48713583_1 CDM 0272 RC inpatient 681 442.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 412.35 660.57 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713584_1 CDM 0278 RC C1713 HCPCS inpatient 1509 980.85 AETNA AETNA 1192.11 79 999999999 913.7 1463.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713584_1 CDM 0278 RC C1713 HCPCS inpatient 1509 980.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 980.85 65 999999999 913.7 1463.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713584_1 CDM 0278 RC C1713 HCPCS inpatient 1509 980.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1463.73 97 999999999 913.7 1463.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713584_1 CDM 0278 RC C1713 HCPCS inpatient 1509 980.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1041.21 69 999999999 913.7 1463.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713584_1 CDM 0278 RC C1713 HCPCS inpatient 1509 980.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1177.02 78 999999999 913.7 1463.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713584_1 CDM 0278 RC C1713 HCPCS inpatient 1509 980.85 UMR - ALL PLANS UMR - ALL PLANS 1056.3 70 999999999 913.7 1463.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713584_1 CDM 0278 RC C1713 HCPCS inpatient 1509 980.85 SIHO - ALL PLANS SIHO - ALL PLANS 1358.1 90 999999999 913.7 1463.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713584_1 CDM 0278 RC C1713 HCPCS inpatient 1509 980.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 913.7 60.55 999999999 913.7 1463.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713584_1 CDM 0278 RC C1713 HCPCS inpatient 1509 980.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 913.7 1463.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713584_1 CDM 0278 RC C1713 HCPCS inpatient 1509 980.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 913.7 1463.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713584_1 CDM 0278 RC C1713 HCPCS inpatient 1509 980.85 ANTHEM HMO ANTHEM HMO 999999999 913.7 1463.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713584_1 CDM 0278 RC C1713 HCPCS inpatient 1509 980.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1020.08 67.6 999999999 913.7 1463.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713584_1 CDM 0278 RC C1713 HCPCS inpatient 1509 980.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 913.7 1463.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713584_1 CDM 0278 RC C1713 HCPCS inpatient 1509 980.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 913.7 1463.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713585_1 CDM 0278 RC C1713 HCPCS inpatient 188 122.2 AETNA AETNA 148.52 79 999999999 113.83 182.36 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713585_1 CDM 0278 RC C1713 HCPCS inpatient 188 122.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.2 65 999999999 113.83 182.36 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713585_1 CDM 0278 RC C1713 HCPCS inpatient 188 122.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 182.36 97 999999999 113.83 182.36 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713585_1 CDM 0278 RC C1713 HCPCS inpatient 188 122.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.72 69 999999999 113.83 182.36 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713585_1 CDM 0278 RC C1713 HCPCS inpatient 188 122.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 146.64 78 999999999 113.83 182.36 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713585_1 CDM 0278 RC C1713 HCPCS inpatient 188 122.2 UMR - ALL PLANS UMR - ALL PLANS 131.6 70 999999999 113.83 182.36 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713585_1 CDM 0278 RC C1713 HCPCS inpatient 188 122.2 SIHO - ALL PLANS SIHO - ALL PLANS 169.2 90 999999999 113.83 182.36 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713585_1 CDM 0278 RC C1713 HCPCS inpatient 188 122.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.83 60.55 999999999 113.83 182.36 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713585_1 CDM 0278 RC C1713 HCPCS inpatient 188 122.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.83 182.36 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713585_1 CDM 0278 RC C1713 HCPCS inpatient 188 122.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.83 182.36 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713585_1 CDM 0278 RC C1713 HCPCS inpatient 188 122.2 ANTHEM HMO ANTHEM HMO 999999999 113.83 182.36 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713585_1 CDM 0278 RC C1713 HCPCS inpatient 188 122.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.09 67.6 999999999 113.83 182.36 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713585_1 CDM 0278 RC C1713 HCPCS inpatient 188 122.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.83 182.36 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713585_1 CDM 0278 RC C1713 HCPCS inpatient 188 122.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.83 182.36 WASHER 3.0MM C/SCREW 219.89 48713586_1 CDM 0278 RC inpatient 874 568.1 AETNA AETNA 690.46 79 999999999 529.21 847.78 percent of total billed charges WASHER 3.0MM C/SCREW 219.89 48713586_1 CDM 0278 RC inpatient 874 568.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 568.1 65 999999999 529.21 847.78 percent of total billed charges WASHER 3.0MM C/SCREW 219.89 48713586_1 CDM 0278 RC inpatient 874 568.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 847.78 97 999999999 529.21 847.78 percent of total billed charges WASHER 3.0MM C/SCREW 219.89 48713586_1 CDM 0278 RC inpatient 874 568.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 603.06 69 999999999 529.21 847.78 percent of total billed charges WASHER 3.0MM C/SCREW 219.89 48713586_1 CDM 0278 RC inpatient 874 568.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 681.72 78 999999999 529.21 847.78 percent of total billed charges WASHER 3.0MM C/SCREW 219.89 48713586_1 CDM 0278 RC inpatient 874 568.1 UMR - ALL PLANS UMR - ALL PLANS 611.8 70 999999999 529.21 847.78 percent of total billed charges WASHER 3.0MM C/SCREW 219.89 48713586_1 CDM 0278 RC inpatient 874 568.1 SIHO - ALL PLANS SIHO - ALL PLANS 786.6 90 999999999 529.21 847.78 percent of total billed charges WASHER 3.0MM C/SCREW 219.89 48713586_1 CDM 0278 RC inpatient 874 568.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 529.21 60.55 999999999 529.21 847.78 percent of total billed charges WASHER 3.0MM C/SCREW 219.89 48713586_1 CDM 0278 RC inpatient 874 568.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 529.21 847.78 WASHER 3.0MM C/SCREW 219.89 48713586_1 CDM 0278 RC inpatient 874 568.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 529.21 847.78 WASHER 3.0MM C/SCREW 219.89 48713586_1 CDM 0278 RC inpatient 874 568.1 ANTHEM HMO ANTHEM HMO 999999999 529.21 847.78 WASHER 3.0MM C/SCREW 219.89 48713586_1 CDM 0278 RC inpatient 874 568.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 590.82 67.6 999999999 529.21 847.78 percent of total billed charges WASHER 3.0MM C/SCREW 219.89 48713586_1 CDM 0278 RC inpatient 874 568.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 529.21 847.78 WASHER 3.0MM C/SCREW 219.89 48713586_1 CDM 0278 RC inpatient 874 568.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 529.21 847.78 WASHER 6.5MM 219.972 48713587_1 CDM 0278 RC inpatient 99 64.35 AETNA AETNA 78.21 79 999999999 59.94 96.03 percent of total billed charges WASHER 6.5MM 219.972 48713587_1 CDM 0278 RC inpatient 99 64.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 64.35 65 999999999 59.94 96.03 percent of total billed charges WASHER 6.5MM 219.972 48713587_1 CDM 0278 RC inpatient 99 64.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 96.03 97 999999999 59.94 96.03 percent of total billed charges WASHER 6.5MM 219.972 48713587_1 CDM 0278 RC inpatient 99 64.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 68.31 69 999999999 59.94 96.03 percent of total billed charges WASHER 6.5MM 219.972 48713587_1 CDM 0278 RC inpatient 99 64.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 77.22 78 999999999 59.94 96.03 percent of total billed charges WASHER 6.5MM 219.972 48713587_1 CDM 0278 RC inpatient 99 64.35 UMR - ALL PLANS UMR - ALL PLANS 69.3 70 999999999 59.94 96.03 percent of total billed charges WASHER 6.5MM 219.972 48713587_1 CDM 0278 RC inpatient 99 64.35 SIHO - ALL PLANS SIHO - ALL PLANS 89.1 90 999999999 59.94 96.03 percent of total billed charges WASHER 6.5MM 219.972 48713587_1 CDM 0278 RC inpatient 99 64.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.94 60.55 999999999 59.94 96.03 percent of total billed charges WASHER 6.5MM 219.972 48713587_1 CDM 0278 RC inpatient 99 64.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.94 96.03 WASHER 6.5MM 219.972 48713587_1 CDM 0278 RC inpatient 99 64.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.94 96.03 WASHER 6.5MM 219.972 48713587_1 CDM 0278 RC inpatient 99 64.35 ANTHEM HMO ANTHEM HMO 999999999 59.94 96.03 WASHER 6.5MM 219.972 48713587_1 CDM 0278 RC inpatient 99 64.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.92 67.6 999999999 59.94 96.03 percent of total billed charges WASHER 6.5MM 219.972 48713587_1 CDM 0278 RC inpatient 99 64.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.94 96.03 WASHER 6.5MM 219.972 48713587_1 CDM 0278 RC inpatient 99 64.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.94 96.03 3.0 CANN SCREW 24MM 202.724 48713588_1 CDM 0278 RC inpatient 1307 849.55 AETNA AETNA 1032.53 79 999999999 791.39 1267.79 percent of total billed charges 3.0 CANN SCREW 24MM 202.724 48713588_1 CDM 0278 RC inpatient 1307 849.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 849.55 65 999999999 791.39 1267.79 percent of total billed charges 3.0 CANN SCREW 24MM 202.724 48713588_1 CDM 0278 RC inpatient 1307 849.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1267.79 97 999999999 791.39 1267.79 percent of total billed charges 3.0 CANN SCREW 24MM 202.724 48713588_1 CDM 0278 RC inpatient 1307 849.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 901.83 69 999999999 791.39 1267.79 percent of total billed charges 3.0 CANN SCREW 24MM 202.724 48713588_1 CDM 0278 RC inpatient 1307 849.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1019.46 78 999999999 791.39 1267.79 percent of total billed charges 3.0 CANN SCREW 24MM 202.724 48713588_1 CDM 0278 RC inpatient 1307 849.55 UMR - ALL PLANS UMR - ALL PLANS 914.9 70 999999999 791.39 1267.79 percent of total billed charges 3.0 CANN SCREW 24MM 202.724 48713588_1 CDM 0278 RC inpatient 1307 849.55 SIHO - ALL PLANS SIHO - ALL PLANS 1176.3 90 999999999 791.39 1267.79 percent of total billed charges 3.0 CANN SCREW 24MM 202.724 48713588_1 CDM 0278 RC inpatient 1307 849.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 791.39 60.55 999999999 791.39 1267.79 percent of total billed charges 3.0 CANN SCREW 24MM 202.724 48713588_1 CDM 0278 RC inpatient 1307 849.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 791.39 1267.79 3.0 CANN SCREW 24MM 202.724 48713588_1 CDM 0278 RC inpatient 1307 849.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 791.39 1267.79 3.0 CANN SCREW 24MM 202.724 48713588_1 CDM 0278 RC inpatient 1307 849.55 ANTHEM HMO ANTHEM HMO 999999999 791.39 1267.79 3.0 CANN SCREW 24MM 202.724 48713588_1 CDM 0278 RC inpatient 1307 849.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 883.53 67.6 999999999 791.39 1267.79 percent of total billed charges 3.0 CANN SCREW 24MM 202.724 48713588_1 CDM 0278 RC inpatient 1307 849.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 791.39 1267.79 3.0 CANN SCREW 24MM 202.724 48713588_1 CDM 0278 RC inpatient 1307 849.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 791.39 1267.79 3.0 CANN SCREW 25MM 202.725 48713589_1 CDM 0278 RC inpatient 970 630.5 AETNA AETNA 766.3 79 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 25MM 202.725 48713589_1 CDM 0278 RC inpatient 970 630.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 630.5 65 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 25MM 202.725 48713589_1 CDM 0278 RC inpatient 970 630.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 940.9 97 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 25MM 202.725 48713589_1 CDM 0278 RC inpatient 970 630.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 669.3 69 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 25MM 202.725 48713589_1 CDM 0278 RC inpatient 970 630.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 756.6 78 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 25MM 202.725 48713589_1 CDM 0278 RC inpatient 970 630.5 UMR - ALL PLANS UMR - ALL PLANS 679 70 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 25MM 202.725 48713589_1 CDM 0278 RC inpatient 970 630.5 SIHO - ALL PLANS SIHO - ALL PLANS 873 90 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 25MM 202.725 48713589_1 CDM 0278 RC inpatient 970 630.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 587.34 60.55 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 25MM 202.725 48713589_1 CDM 0278 RC inpatient 970 630.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 587.34 940.9 3.0 CANN SCREW 25MM 202.725 48713589_1 CDM 0278 RC inpatient 970 630.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 587.34 940.9 3.0 CANN SCREW 25MM 202.725 48713589_1 CDM 0278 RC inpatient 970 630.5 ANTHEM HMO ANTHEM HMO 999999999 587.34 940.9 3.0 CANN SCREW 25MM 202.725 48713589_1 CDM 0278 RC inpatient 970 630.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 655.72 67.6 999999999 587.34 940.9 percent of total billed charges 3.0 CANN SCREW 25MM 202.725 48713589_1 CDM 0278 RC inpatient 970 630.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 587.34 940.9 3.0 CANN SCREW 25MM 202.725 48713589_1 CDM 0278 RC inpatient 970 630.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 587.34 940.9 3.0 CANN SCREW 26MM 202.726 48713590_1 CDM 0278 RC inpatient 1269 824.85 AETNA AETNA 1002.51 79 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 26MM 202.726 48713590_1 CDM 0278 RC inpatient 1269 824.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 824.85 65 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 26MM 202.726 48713590_1 CDM 0278 RC inpatient 1269 824.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1230.93 97 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 26MM 202.726 48713590_1 CDM 0278 RC inpatient 1269 824.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 875.61 69 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 26MM 202.726 48713590_1 CDM 0278 RC inpatient 1269 824.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 989.82 78 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 26MM 202.726 48713590_1 CDM 0278 RC inpatient 1269 824.85 UMR - ALL PLANS UMR - ALL PLANS 888.3 70 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 26MM 202.726 48713590_1 CDM 0278 RC inpatient 1269 824.85 SIHO - ALL PLANS SIHO - ALL PLANS 1142.1 90 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 26MM 202.726 48713590_1 CDM 0278 RC inpatient 1269 824.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 768.38 60.55 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 26MM 202.726 48713590_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 768.38 1230.93 3.0 CANN SCREW 26MM 202.726 48713590_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 768.38 1230.93 3.0 CANN SCREW 26MM 202.726 48713590_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM HMO ANTHEM HMO 999999999 768.38 1230.93 3.0 CANN SCREW 26MM 202.726 48713590_1 CDM 0278 RC inpatient 1269 824.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 857.84 67.6 999999999 768.38 1230.93 percent of total billed charges 3.0 CANN SCREW 26MM 202.726 48713590_1 CDM 0278 RC inpatient 1269 824.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 768.38 1230.93 3.0 CANN SCREW 26MM 202.726 48713590_1 CDM 0278 RC inpatient 1269 824.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 768.38 1230.93 3.0 CANN SCREW 27MM 202.727 48713591_1 CDM 0278 RC inpatient 1288 837.2 AETNA AETNA 1017.52 79 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 27MM 202.727 48713591_1 CDM 0278 RC inpatient 1288 837.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 837.2 65 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 27MM 202.727 48713591_1 CDM 0278 RC inpatient 1288 837.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1249.36 97 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 27MM 202.727 48713591_1 CDM 0278 RC inpatient 1288 837.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 888.72 69 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 27MM 202.727 48713591_1 CDM 0278 RC inpatient 1288 837.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1004.64 78 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 27MM 202.727 48713591_1 CDM 0278 RC inpatient 1288 837.2 UMR - ALL PLANS UMR - ALL PLANS 901.6 70 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 27MM 202.727 48713591_1 CDM 0278 RC inpatient 1288 837.2 SIHO - ALL PLANS SIHO - ALL PLANS 1159.2 90 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 27MM 202.727 48713591_1 CDM 0278 RC inpatient 1288 837.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 779.88 60.55 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 27MM 202.727 48713591_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 779.88 1249.36 3.0 CANN SCREW 27MM 202.727 48713591_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 779.88 1249.36 3.0 CANN SCREW 27MM 202.727 48713591_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM HMO ANTHEM HMO 999999999 779.88 1249.36 3.0 CANN SCREW 27MM 202.727 48713591_1 CDM 0278 RC inpatient 1288 837.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 870.69 67.6 999999999 779.88 1249.36 percent of total billed charges 3.0 CANN SCREW 27MM 202.727 48713591_1 CDM 0278 RC inpatient 1288 837.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 779.88 1249.36 3.0 CANN SCREW 27MM 202.727 48713591_1 CDM 0278 RC inpatient 1288 837.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 779.88 1249.36 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713592_1 CDM 0278 RC C1713 HCPCS inpatient 224 145.6 AETNA AETNA 176.96 79 999999999 135.63 217.28 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713592_1 CDM 0278 RC C1713 HCPCS inpatient 224 145.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 145.6 65 999999999 135.63 217.28 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713592_1 CDM 0278 RC C1713 HCPCS inpatient 224 145.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 217.28 97 999999999 135.63 217.28 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713592_1 CDM 0278 RC C1713 HCPCS inpatient 224 145.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 154.56 69 999999999 135.63 217.28 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713592_1 CDM 0278 RC C1713 HCPCS inpatient 224 145.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 174.72 78 999999999 135.63 217.28 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713592_1 CDM 0278 RC C1713 HCPCS inpatient 224 145.6 UMR - ALL PLANS UMR - ALL PLANS 156.8 70 999999999 135.63 217.28 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713592_1 CDM 0278 RC C1713 HCPCS inpatient 224 145.6 SIHO - ALL PLANS SIHO - ALL PLANS 201.6 90 999999999 135.63 217.28 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713592_1 CDM 0278 RC C1713 HCPCS inpatient 224 145.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 135.63 60.55 999999999 135.63 217.28 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713592_1 CDM 0278 RC C1713 HCPCS inpatient 224 145.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 135.63 217.28 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713592_1 CDM 0278 RC C1713 HCPCS inpatient 224 145.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 135.63 217.28 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713592_1 CDM 0278 RC C1713 HCPCS inpatient 224 145.6 ANTHEM HMO ANTHEM HMO 999999999 135.63 217.28 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713592_1 CDM 0278 RC C1713 HCPCS inpatient 224 145.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 151.42 67.6 999999999 135.63 217.28 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713592_1 CDM 0278 RC C1713 HCPCS inpatient 224 145.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 135.63 217.28 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713592_1 CDM 0278 RC C1713 HCPCS inpatient 224 145.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 135.63 217.28 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713593_1 CDM 0278 RC C1713 HCPCS inpatient 203 131.95 AETNA AETNA 160.37 79 999999999 122.92 196.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713593_1 CDM 0278 RC C1713 HCPCS inpatient 203 131.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 131.95 65 999999999 122.92 196.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713593_1 CDM 0278 RC C1713 HCPCS inpatient 203 131.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 196.91 97 999999999 122.92 196.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713593_1 CDM 0278 RC C1713 HCPCS inpatient 203 131.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.07 69 999999999 122.92 196.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713593_1 CDM 0278 RC C1713 HCPCS inpatient 203 131.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 158.34 78 999999999 122.92 196.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713593_1 CDM 0278 RC C1713 HCPCS inpatient 203 131.95 UMR - ALL PLANS UMR - ALL PLANS 142.1 70 999999999 122.92 196.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713593_1 CDM 0278 RC C1713 HCPCS inpatient 203 131.95 SIHO - ALL PLANS SIHO - ALL PLANS 182.7 90 999999999 122.92 196.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713593_1 CDM 0278 RC C1713 HCPCS inpatient 203 131.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 122.92 60.55 999999999 122.92 196.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713593_1 CDM 0278 RC C1713 HCPCS inpatient 203 131.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 122.92 196.91 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713593_1 CDM 0278 RC C1713 HCPCS inpatient 203 131.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 122.92 196.91 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713593_1 CDM 0278 RC C1713 HCPCS inpatient 203 131.95 ANTHEM HMO ANTHEM HMO 999999999 122.92 196.91 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713593_1 CDM 0278 RC C1713 HCPCS inpatient 203 131.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.23 67.6 999999999 122.92 196.91 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713593_1 CDM 0278 RC C1713 HCPCS inpatient 203 131.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 122.92 196.91 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713593_1 CDM 0278 RC C1713 HCPCS inpatient 203 131.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 122.92 196.91 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713594_1 CDM 0278 RC C1713 HCPCS inpatient 970 630.5 AETNA AETNA 766.3 79 999999999 587.34 940.9 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713594_1 CDM 0278 RC C1713 HCPCS inpatient 970 630.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 630.5 65 999999999 587.34 940.9 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713594_1 CDM 0278 RC C1713 HCPCS inpatient 970 630.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 940.9 97 999999999 587.34 940.9 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713594_1 CDM 0278 RC C1713 HCPCS inpatient 970 630.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 669.3 69 999999999 587.34 940.9 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713594_1 CDM 0278 RC C1713 HCPCS inpatient 970 630.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 756.6 78 999999999 587.34 940.9 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713594_1 CDM 0278 RC C1713 HCPCS inpatient 970 630.5 UMR - ALL PLANS UMR - ALL PLANS 679 70 999999999 587.34 940.9 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713594_1 CDM 0278 RC C1713 HCPCS inpatient 970 630.5 SIHO - ALL PLANS SIHO - ALL PLANS 873 90 999999999 587.34 940.9 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713594_1 CDM 0278 RC C1713 HCPCS inpatient 970 630.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 587.34 60.55 999999999 587.34 940.9 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713594_1 CDM 0278 RC C1713 HCPCS inpatient 970 630.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 587.34 940.9 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713594_1 CDM 0278 RC C1713 HCPCS inpatient 970 630.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 587.34 940.9 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713594_1 CDM 0278 RC C1713 HCPCS inpatient 970 630.5 ANTHEM HMO ANTHEM HMO 999999999 587.34 940.9 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713594_1 CDM 0278 RC C1713 HCPCS inpatient 970 630.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 655.72 67.6 999999999 587.34 940.9 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713594_1 CDM 0278 RC C1713 HCPCS inpatient 970 630.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 587.34 940.9 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713594_1 CDM 0278 RC C1713 HCPCS inpatient 970 630.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 587.34 940.9 3.0MM CANN SCREW 9MM 202.609 48713595_1 CDM 0278 RC inpatient 970 630.5 AETNA AETNA 766.3 79 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 9MM 202.609 48713595_1 CDM 0278 RC inpatient 970 630.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 630.5 65 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 9MM 202.609 48713595_1 CDM 0278 RC inpatient 970 630.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 940.9 97 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 9MM 202.609 48713595_1 CDM 0278 RC inpatient 970 630.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 669.3 69 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 9MM 202.609 48713595_1 CDM 0278 RC inpatient 970 630.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 756.6 78 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 9MM 202.609 48713595_1 CDM 0278 RC inpatient 970 630.5 UMR - ALL PLANS UMR - ALL PLANS 679 70 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 9MM 202.609 48713595_1 CDM 0278 RC inpatient 970 630.5 SIHO - ALL PLANS SIHO - ALL PLANS 873 90 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 9MM 202.609 48713595_1 CDM 0278 RC inpatient 970 630.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 587.34 60.55 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 9MM 202.609 48713595_1 CDM 0278 RC inpatient 970 630.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 587.34 940.9 3.0MM CANN SCREW 9MM 202.609 48713595_1 CDM 0278 RC inpatient 970 630.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 587.34 940.9 3.0MM CANN SCREW 9MM 202.609 48713595_1 CDM 0278 RC inpatient 970 630.5 ANTHEM HMO ANTHEM HMO 999999999 587.34 940.9 3.0MM CANN SCREW 9MM 202.609 48713595_1 CDM 0278 RC inpatient 970 630.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 655.72 67.6 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 9MM 202.609 48713595_1 CDM 0278 RC inpatient 970 630.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 587.34 940.9 3.0MM CANN SCREW 9MM 202.609 48713595_1 CDM 0278 RC inpatient 970 630.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 587.34 940.9 3.0MM CANN SCREW 10MM 202.610 48713596_1 CDM 0278 RC inpatient 970 630.5 AETNA AETNA 766.3 79 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 10MM 202.610 48713596_1 CDM 0278 RC inpatient 970 630.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 630.5 65 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 10MM 202.610 48713596_1 CDM 0278 RC inpatient 970 630.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 940.9 97 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 10MM 202.610 48713596_1 CDM 0278 RC inpatient 970 630.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 669.3 69 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 10MM 202.610 48713596_1 CDM 0278 RC inpatient 970 630.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 756.6 78 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 10MM 202.610 48713596_1 CDM 0278 RC inpatient 970 630.5 UMR - ALL PLANS UMR - ALL PLANS 679 70 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 10MM 202.610 48713596_1 CDM 0278 RC inpatient 970 630.5 SIHO - ALL PLANS SIHO - ALL PLANS 873 90 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 10MM 202.610 48713596_1 CDM 0278 RC inpatient 970 630.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 587.34 60.55 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 10MM 202.610 48713596_1 CDM 0278 RC inpatient 970 630.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 587.34 940.9 3.0MM CANN SCREW 10MM 202.610 48713596_1 CDM 0278 RC inpatient 970 630.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 587.34 940.9 3.0MM CANN SCREW 10MM 202.610 48713596_1 CDM 0278 RC inpatient 970 630.5 ANTHEM HMO ANTHEM HMO 999999999 587.34 940.9 3.0MM CANN SCREW 10MM 202.610 48713596_1 CDM 0278 RC inpatient 970 630.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 655.72 67.6 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 10MM 202.610 48713596_1 CDM 0278 RC inpatient 970 630.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 587.34 940.9 3.0MM CANN SCREW 10MM 202.610 48713596_1 CDM 0278 RC inpatient 970 630.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 587.34 940.9 3.0MM CANN SCREW 11MM 202.611 48713597_1 CDM 0278 RC inpatient 970 630.5 AETNA AETNA 766.3 79 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 11MM 202.611 48713597_1 CDM 0278 RC inpatient 970 630.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 630.5 65 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 11MM 202.611 48713597_1 CDM 0278 RC inpatient 970 630.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 940.9 97 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 11MM 202.611 48713597_1 CDM 0278 RC inpatient 970 630.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 669.3 69 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 11MM 202.611 48713597_1 CDM 0278 RC inpatient 970 630.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 756.6 78 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 11MM 202.611 48713597_1 CDM 0278 RC inpatient 970 630.5 UMR - ALL PLANS UMR - ALL PLANS 679 70 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 11MM 202.611 48713597_1 CDM 0278 RC inpatient 970 630.5 SIHO - ALL PLANS SIHO - ALL PLANS 873 90 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 11MM 202.611 48713597_1 CDM 0278 RC inpatient 970 630.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 587.34 60.55 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 11MM 202.611 48713597_1 CDM 0278 RC inpatient 970 630.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 587.34 940.9 3.0MM CANN SCREW 11MM 202.611 48713597_1 CDM 0278 RC inpatient 970 630.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 587.34 940.9 3.0MM CANN SCREW 11MM 202.611 48713597_1 CDM 0278 RC inpatient 970 630.5 ANTHEM HMO ANTHEM HMO 999999999 587.34 940.9 3.0MM CANN SCREW 11MM 202.611 48713597_1 CDM 0278 RC inpatient 970 630.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 655.72 67.6 999999999 587.34 940.9 percent of total billed charges 3.0MM CANN SCREW 11MM 202.611 48713597_1 CDM 0278 RC inpatient 970 630.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 587.34 940.9 3.0MM CANN SCREW 11MM 202.611 48713597_1 CDM 0278 RC inpatient 970 630.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 587.34 940.9 3.0MM CANN SCREW 12MM 202.612 48713598_1 CDM 0278 RC inpatient 1354 880.1 AETNA AETNA 1069.66 79 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 12MM 202.612 48713598_1 CDM 0278 RC inpatient 1354 880.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 880.1 65 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 12MM 202.612 48713598_1 CDM 0278 RC inpatient 1354 880.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1313.38 97 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 12MM 202.612 48713598_1 CDM 0278 RC inpatient 1354 880.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 934.26 69 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 12MM 202.612 48713598_1 CDM 0278 RC inpatient 1354 880.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1056.12 78 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 12MM 202.612 48713598_1 CDM 0278 RC inpatient 1354 880.1 UMR - ALL PLANS UMR - ALL PLANS 947.8 70 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 12MM 202.612 48713598_1 CDM 0278 RC inpatient 1354 880.1 SIHO - ALL PLANS SIHO - ALL PLANS 1218.6 90 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 12MM 202.612 48713598_1 CDM 0278 RC inpatient 1354 880.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 819.85 60.55 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 12MM 202.612 48713598_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 819.85 1313.38 3.0MM CANN SCREW 12MM 202.612 48713598_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 819.85 1313.38 3.0MM CANN SCREW 12MM 202.612 48713598_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM HMO ANTHEM HMO 999999999 819.85 1313.38 3.0MM CANN SCREW 12MM 202.612 48713598_1 CDM 0278 RC inpatient 1354 880.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 915.3 67.6 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 12MM 202.612 48713598_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 819.85 1313.38 3.0MM CANN SCREW 12MM 202.612 48713598_1 CDM 0278 RC inpatient 1354 880.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 819.85 1313.38 3.0MM CANN SCREW 13MM 202.613 48713599_1 CDM 0278 RC inpatient 1354 880.1 AETNA AETNA 1069.66 79 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 13MM 202.613 48713599_1 CDM 0278 RC inpatient 1354 880.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 880.1 65 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 13MM 202.613 48713599_1 CDM 0278 RC inpatient 1354 880.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1313.38 97 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 13MM 202.613 48713599_1 CDM 0278 RC inpatient 1354 880.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 934.26 69 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 13MM 202.613 48713599_1 CDM 0278 RC inpatient 1354 880.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1056.12 78 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 13MM 202.613 48713599_1 CDM 0278 RC inpatient 1354 880.1 UMR - ALL PLANS UMR - ALL PLANS 947.8 70 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 13MM 202.613 48713599_1 CDM 0278 RC inpatient 1354 880.1 SIHO - ALL PLANS SIHO - ALL PLANS 1218.6 90 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 13MM 202.613 48713599_1 CDM 0278 RC inpatient 1354 880.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 819.85 60.55 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 13MM 202.613 48713599_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 819.85 1313.38 3.0MM CANN SCREW 13MM 202.613 48713599_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 819.85 1313.38 3.0MM CANN SCREW 13MM 202.613 48713599_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM HMO ANTHEM HMO 999999999 819.85 1313.38 3.0MM CANN SCREW 13MM 202.613 48713599_1 CDM 0278 RC inpatient 1354 880.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 915.3 67.6 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 13MM 202.613 48713599_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 819.85 1313.38 3.0MM CANN SCREW 13MM 202.613 48713599_1 CDM 0278 RC inpatient 1354 880.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 819.85 1313.38 3.0MM CANN SCREW 14MM 202.614 48713600_1 CDM 0278 RC inpatient 1354 880.1 AETNA AETNA 1069.66 79 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 14MM 202.614 48713600_1 CDM 0278 RC inpatient 1354 880.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 880.1 65 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 14MM 202.614 48713600_1 CDM 0278 RC inpatient 1354 880.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1313.38 97 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 14MM 202.614 48713600_1 CDM 0278 RC inpatient 1354 880.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 934.26 69 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 14MM 202.614 48713600_1 CDM 0278 RC inpatient 1354 880.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1056.12 78 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 14MM 202.614 48713600_1 CDM 0278 RC inpatient 1354 880.1 UMR - ALL PLANS UMR - ALL PLANS 947.8 70 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 14MM 202.614 48713600_1 CDM 0278 RC inpatient 1354 880.1 SIHO - ALL PLANS SIHO - ALL PLANS 1218.6 90 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 14MM 202.614 48713600_1 CDM 0278 RC inpatient 1354 880.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 819.85 60.55 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 14MM 202.614 48713600_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 819.85 1313.38 3.0MM CANN SCREW 14MM 202.614 48713600_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 819.85 1313.38 3.0MM CANN SCREW 14MM 202.614 48713600_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM HMO ANTHEM HMO 999999999 819.85 1313.38 3.0MM CANN SCREW 14MM 202.614 48713600_1 CDM 0278 RC inpatient 1354 880.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 915.3 67.6 999999999 819.85 1313.38 percent of total billed charges 3.0MM CANN SCREW 14MM 202.614 48713600_1 CDM 0278 RC inpatient 1354 880.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 819.85 1313.38 3.0MM CANN SCREW 14MM 202.614 48713600_1 CDM 0278 RC inpatient 1354 880.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 819.85 1313.38 3.0MM CANN SCREW 15MM 202.615 48713601_1 CDM 0278 RC inpatient 1326 861.9 AETNA AETNA 1047.54 79 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 15MM 202.615 48713601_1 CDM 0278 RC inpatient 1326 861.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 861.9 65 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 15MM 202.615 48713601_1 CDM 0278 RC inpatient 1326 861.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1286.22 97 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 15MM 202.615 48713601_1 CDM 0278 RC inpatient 1326 861.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 914.94 69 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 15MM 202.615 48713601_1 CDM 0278 RC inpatient 1326 861.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1034.28 78 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 15MM 202.615 48713601_1 CDM 0278 RC inpatient 1326 861.9 UMR - ALL PLANS UMR - ALL PLANS 928.2 70 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 15MM 202.615 48713601_1 CDM 0278 RC inpatient 1326 861.9 SIHO - ALL PLANS SIHO - ALL PLANS 1193.4 90 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 15MM 202.615 48713601_1 CDM 0278 RC inpatient 1326 861.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 802.89 60.55 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 15MM 202.615 48713601_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 802.89 1286.22 3.0MM CANN SCREW 15MM 202.615 48713601_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 802.89 1286.22 3.0MM CANN SCREW 15MM 202.615 48713601_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM HMO ANTHEM HMO 999999999 802.89 1286.22 3.0MM CANN SCREW 15MM 202.615 48713601_1 CDM 0278 RC inpatient 1326 861.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 896.38 67.6 999999999 802.89 1286.22 percent of total billed charges 3.0MM CANN SCREW 15MM 202.615 48713601_1 CDM 0278 RC inpatient 1326 861.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 802.89 1286.22 3.0MM CANN SCREW 15MM 202.615 48713601_1 CDM 0278 RC inpatient 1326 861.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 802.89 1286.22 MENISCAL SCREW 11M M#905751 48713602_1 CDM 0278 RC inpatient 1657 1077.05 AETNA AETNA 1309.03 79 999999999 1003.31 1607.29 percent of total billed charges MENISCAL SCREW 11M M#905751 48713602_1 CDM 0278 RC inpatient 1657 1077.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1077.05 65 999999999 1003.31 1607.29 percent of total billed charges MENISCAL SCREW 11M M#905751 48713602_1 CDM 0278 RC inpatient 1657 1077.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1607.29 97 999999999 1003.31 1607.29 percent of total billed charges MENISCAL SCREW 11M M#905751 48713602_1 CDM 0278 RC inpatient 1657 1077.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1143.33 69 999999999 1003.31 1607.29 percent of total billed charges MENISCAL SCREW 11M M#905751 48713602_1 CDM 0278 RC inpatient 1657 1077.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1292.46 78 999999999 1003.31 1607.29 percent of total billed charges MENISCAL SCREW 11M M#905751 48713602_1 CDM 0278 RC inpatient 1657 1077.05 UMR - ALL PLANS UMR - ALL PLANS 1159.9 70 999999999 1003.31 1607.29 percent of total billed charges MENISCAL SCREW 11M M#905751 48713602_1 CDM 0278 RC inpatient 1657 1077.05 SIHO - ALL PLANS SIHO - ALL PLANS 1491.3 90 999999999 1003.31 1607.29 percent of total billed charges MENISCAL SCREW 11M M#905751 48713602_1 CDM 0278 RC inpatient 1657 1077.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1003.31 60.55 999999999 1003.31 1607.29 percent of total billed charges MENISCAL SCREW 11M M#905751 48713602_1 CDM 0278 RC inpatient 1657 1077.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1003.31 1607.29 MENISCAL SCREW 11M M#905751 48713602_1 CDM 0278 RC inpatient 1657 1077.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1003.31 1607.29 MENISCAL SCREW 11M M#905751 48713602_1 CDM 0278 RC inpatient 1657 1077.05 ANTHEM HMO ANTHEM HMO 999999999 1003.31 1607.29 MENISCAL SCREW 11M M#905751 48713602_1 CDM 0278 RC inpatient 1657 1077.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1120.13 67.6 999999999 1003.31 1607.29 percent of total billed charges MENISCAL SCREW 11M M#905751 48713602_1 CDM 0278 RC inpatient 1657 1077.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1003.31 1607.29 MENISCAL SCREW 11M M#905751 48713602_1 CDM 0278 RC inpatient 1657 1077.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1003.31 1607.29 DIEGO BLADE STRAIGHT STANDARD 48713605_1 CDM 0272 RC inpatient 812 527.8 AETNA AETNA 641.48 79 999999999 491.67 787.64 percent of total billed charges DIEGO BLADE STRAIGHT STANDARD 48713605_1 CDM 0272 RC inpatient 812 527.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 527.8 65 999999999 491.67 787.64 percent of total billed charges DIEGO BLADE STRAIGHT STANDARD 48713605_1 CDM 0272 RC inpatient 812 527.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 787.64 97 999999999 491.67 787.64 percent of total billed charges DIEGO BLADE STRAIGHT STANDARD 48713605_1 CDM 0272 RC inpatient 812 527.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 560.28 69 999999999 491.67 787.64 percent of total billed charges DIEGO BLADE STRAIGHT STANDARD 48713605_1 CDM 0272 RC inpatient 812 527.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 633.36 78 999999999 491.67 787.64 percent of total billed charges DIEGO BLADE STRAIGHT STANDARD 48713605_1 CDM 0272 RC inpatient 812 527.8 UMR - ALL PLANS UMR - ALL PLANS 568.4 70 999999999 491.67 787.64 percent of total billed charges DIEGO BLADE STRAIGHT STANDARD 48713605_1 CDM 0272 RC inpatient 812 527.8 SIHO - ALL PLANS SIHO - ALL PLANS 730.8 90 999999999 491.67 787.64 percent of total billed charges DIEGO BLADE STRAIGHT STANDARD 48713605_1 CDM 0272 RC inpatient 812 527.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 491.67 60.55 999999999 491.67 787.64 percent of total billed charges DIEGO BLADE STRAIGHT STANDARD 48713605_1 CDM 0272 RC inpatient 812 527.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 491.67 787.64 DIEGO BLADE STRAIGHT STANDARD 48713605_1 CDM 0272 RC inpatient 812 527.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 491.67 787.64 DIEGO BLADE STRAIGHT STANDARD 48713605_1 CDM 0272 RC inpatient 812 527.8 ANTHEM HMO ANTHEM HMO 999999999 491.67 787.64 DIEGO BLADE STRAIGHT STANDARD 48713605_1 CDM 0272 RC inpatient 812 527.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 548.91 67.6 999999999 491.67 787.64 percent of total billed charges DIEGO BLADE STRAIGHT STANDARD 48713605_1 CDM 0272 RC inpatient 812 527.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 491.67 787.64 DIEGO BLADE STRAIGHT STANDARD 48713605_1 CDM 0272 RC inpatient 812 527.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 491.67 787.64 DIEGO BLADE 40 DEGREE 48713606_1 CDM 0272 RC inpatient 894 581.1 AETNA AETNA 706.26 79 999999999 541.32 867.18 percent of total billed charges DIEGO BLADE 40 DEGREE 48713606_1 CDM 0272 RC inpatient 894 581.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 581.1 65 999999999 541.32 867.18 percent of total billed charges DIEGO BLADE 40 DEGREE 48713606_1 CDM 0272 RC inpatient 894 581.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 867.18 97 999999999 541.32 867.18 percent of total billed charges DIEGO BLADE 40 DEGREE 48713606_1 CDM 0272 RC inpatient 894 581.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 616.86 69 999999999 541.32 867.18 percent of total billed charges DIEGO BLADE 40 DEGREE 48713606_1 CDM 0272 RC inpatient 894 581.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 697.32 78 999999999 541.32 867.18 percent of total billed charges DIEGO BLADE 40 DEGREE 48713606_1 CDM 0272 RC inpatient 894 581.1 UMR - ALL PLANS UMR - ALL PLANS 625.8 70 999999999 541.32 867.18 percent of total billed charges DIEGO BLADE 40 DEGREE 48713606_1 CDM 0272 RC inpatient 894 581.1 SIHO - ALL PLANS SIHO - ALL PLANS 804.6 90 999999999 541.32 867.18 percent of total billed charges DIEGO BLADE 40 DEGREE 48713606_1 CDM 0272 RC inpatient 894 581.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 541.32 60.55 999999999 541.32 867.18 percent of total billed charges DIEGO BLADE 40 DEGREE 48713606_1 CDM 0272 RC inpatient 894 581.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 541.32 867.18 DIEGO BLADE 40 DEGREE 48713606_1 CDM 0272 RC inpatient 894 581.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 541.32 867.18 DIEGO BLADE 40 DEGREE 48713606_1 CDM 0272 RC inpatient 894 581.1 ANTHEM HMO ANTHEM HMO 999999999 541.32 867.18 DIEGO BLADE 40 DEGREE 48713606_1 CDM 0272 RC inpatient 894 581.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 604.34 67.6 999999999 541.32 867.18 percent of total billed charges DIEGO BLADE 40 DEGREE 48713606_1 CDM 0272 RC inpatient 894 581.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 541.32 867.18 DIEGO BLADE 40 DEGREE 48713606_1 CDM 0272 RC inpatient 894 581.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 541.32 867.18 DIEGO BLADE 60 DEGREE STANDARD 48713607_1 CDM 0272 RC inpatient 894 581.1 AETNA AETNA 706.26 79 999999999 541.32 867.18 percent of total billed charges DIEGO BLADE 60 DEGREE STANDARD 48713607_1 CDM 0272 RC inpatient 894 581.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 581.1 65 999999999 541.32 867.18 percent of total billed charges DIEGO BLADE 60 DEGREE STANDARD 48713607_1 CDM 0272 RC inpatient 894 581.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 867.18 97 999999999 541.32 867.18 percent of total billed charges DIEGO BLADE 60 DEGREE STANDARD 48713607_1 CDM 0272 RC inpatient 894 581.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 616.86 69 999999999 541.32 867.18 percent of total billed charges DIEGO BLADE 60 DEGREE STANDARD 48713607_1 CDM 0272 RC inpatient 894 581.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 697.32 78 999999999 541.32 867.18 percent of total billed charges DIEGO BLADE 60 DEGREE STANDARD 48713607_1 CDM 0272 RC inpatient 894 581.1 UMR - ALL PLANS UMR - ALL PLANS 625.8 70 999999999 541.32 867.18 percent of total billed charges DIEGO BLADE 60 DEGREE STANDARD 48713607_1 CDM 0272 RC inpatient 894 581.1 SIHO - ALL PLANS SIHO - ALL PLANS 804.6 90 999999999 541.32 867.18 percent of total billed charges DIEGO BLADE 60 DEGREE STANDARD 48713607_1 CDM 0272 RC inpatient 894 581.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 541.32 60.55 999999999 541.32 867.18 percent of total billed charges DIEGO BLADE 60 DEGREE STANDARD 48713607_1 CDM 0272 RC inpatient 894 581.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 541.32 867.18 DIEGO BLADE 60 DEGREE STANDARD 48713607_1 CDM 0272 RC inpatient 894 581.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 541.32 867.18 DIEGO BLADE 60 DEGREE STANDARD 48713607_1 CDM 0272 RC inpatient 894 581.1 ANTHEM HMO ANTHEM HMO 999999999 541.32 867.18 DIEGO BLADE 60 DEGREE STANDARD 48713607_1 CDM 0272 RC inpatient 894 581.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 604.34 67.6 999999999 541.32 867.18 percent of total billed charges DIEGO BLADE 60 DEGREE STANDARD 48713607_1 CDM 0272 RC inpatient 894 581.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 541.32 867.18 DIEGO BLADE 60 DEGREE STANDARD 48713607_1 CDM 0272 RC inpatient 894 581.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 541.32 867.18 DIEGO AGGRESSIVE BLADE TYPE A 48713608_1 CDM 0272 RC inpatient 812 527.8 AETNA AETNA 641.48 79 999999999 491.67 787.64 percent of total billed charges DIEGO AGGRESSIVE BLADE TYPE A 48713608_1 CDM 0272 RC inpatient 812 527.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 527.8 65 999999999 491.67 787.64 percent of total billed charges DIEGO AGGRESSIVE BLADE TYPE A 48713608_1 CDM 0272 RC inpatient 812 527.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 787.64 97 999999999 491.67 787.64 percent of total billed charges DIEGO AGGRESSIVE BLADE TYPE A 48713608_1 CDM 0272 RC inpatient 812 527.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 560.28 69 999999999 491.67 787.64 percent of total billed charges DIEGO AGGRESSIVE BLADE TYPE A 48713608_1 CDM 0272 RC inpatient 812 527.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 633.36 78 999999999 491.67 787.64 percent of total billed charges DIEGO AGGRESSIVE BLADE TYPE A 48713608_1 CDM 0272 RC inpatient 812 527.8 UMR - ALL PLANS UMR - ALL PLANS 568.4 70 999999999 491.67 787.64 percent of total billed charges DIEGO AGGRESSIVE BLADE TYPE A 48713608_1 CDM 0272 RC inpatient 812 527.8 SIHO - ALL PLANS SIHO - ALL PLANS 730.8 90 999999999 491.67 787.64 percent of total billed charges DIEGO AGGRESSIVE BLADE TYPE A 48713608_1 CDM 0272 RC inpatient 812 527.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 491.67 60.55 999999999 491.67 787.64 percent of total billed charges DIEGO AGGRESSIVE BLADE TYPE A 48713608_1 CDM 0272 RC inpatient 812 527.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 491.67 787.64 DIEGO AGGRESSIVE BLADE TYPE A 48713608_1 CDM 0272 RC inpatient 812 527.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 491.67 787.64 DIEGO AGGRESSIVE BLADE TYPE A 48713608_1 CDM 0272 RC inpatient 812 527.8 ANTHEM HMO ANTHEM HMO 999999999 491.67 787.64 DIEGO AGGRESSIVE BLADE TYPE A 48713608_1 CDM 0272 RC inpatient 812 527.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 548.91 67.6 999999999 491.67 787.64 percent of total billed charges DIEGO AGGRESSIVE BLADE TYPE A 48713608_1 CDM 0272 RC inpatient 812 527.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 491.67 787.64 DIEGO AGGRESSIVE BLADE TYPE A 48713608_1 CDM 0272 RC inpatient 812 527.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 491.67 787.64 "HEAD HALTER, SMALL 7451-01" 48713609_1 CDM 0278 RC inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, SMALL 7451-01" 48713609_1 CDM 0278 RC inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, SMALL 7451-01" 48713609_1 CDM 0278 RC inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, SMALL 7451-01" 48713609_1 CDM 0278 RC inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, SMALL 7451-01" 48713609_1 CDM 0278 RC inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, SMALL 7451-01" 48713609_1 CDM 0278 RC inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, SMALL 7451-01" 48713609_1 CDM 0278 RC inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, SMALL 7451-01" 48713609_1 CDM 0278 RC inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, SMALL 7451-01" 48713609_1 CDM 0278 RC inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 "HEAD HALTER, SMALL 7451-01" 48713609_1 CDM 0278 RC inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 "HEAD HALTER, SMALL 7451-01" 48713609_1 CDM 0278 RC inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 "HEAD HALTER, SMALL 7451-01" 48713609_1 CDM 0278 RC inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, SMALL 7451-01" 48713609_1 CDM 0278 RC inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 "HEAD HALTER, SMALL 7451-01" 48713609_1 CDM 0278 RC inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 "HEAD HALTER, MEDIUM 7451-02" 48713610_1 CDM 0278 RC inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, MEDIUM 7451-02" 48713610_1 CDM 0278 RC inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, MEDIUM 7451-02" 48713610_1 CDM 0278 RC inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, MEDIUM 7451-02" 48713610_1 CDM 0278 RC inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, MEDIUM 7451-02" 48713610_1 CDM 0278 RC inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, MEDIUM 7451-02" 48713610_1 CDM 0278 RC inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, MEDIUM 7451-02" 48713610_1 CDM 0278 RC inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, MEDIUM 7451-02" 48713610_1 CDM 0278 RC inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, MEDIUM 7451-02" 48713610_1 CDM 0278 RC inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 "HEAD HALTER, MEDIUM 7451-02" 48713610_1 CDM 0278 RC inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 "HEAD HALTER, MEDIUM 7451-02" 48713610_1 CDM 0278 RC inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 "HEAD HALTER, MEDIUM 7451-02" 48713610_1 CDM 0278 RC inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, MEDIUM 7451-02" 48713610_1 CDM 0278 RC inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 "HEAD HALTER, MEDIUM 7451-02" 48713610_1 CDM 0278 RC inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 "HEAD HALTER, LARGE 7451-03" 48713611_1 CDM 0278 RC inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, LARGE 7451-03" 48713611_1 CDM 0278 RC inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, LARGE 7451-03" 48713611_1 CDM 0278 RC inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, LARGE 7451-03" 48713611_1 CDM 0278 RC inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, LARGE 7451-03" 48713611_1 CDM 0278 RC inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, LARGE 7451-03" 48713611_1 CDM 0278 RC inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, LARGE 7451-03" 48713611_1 CDM 0278 RC inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, LARGE 7451-03" 48713611_1 CDM 0278 RC inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, LARGE 7451-03" 48713611_1 CDM 0278 RC inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 "HEAD HALTER, LARGE 7451-03" 48713611_1 CDM 0278 RC inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 "HEAD HALTER, LARGE 7451-03" 48713611_1 CDM 0278 RC inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 "HEAD HALTER, LARGE 7451-03" 48713611_1 CDM 0278 RC inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges "HEAD HALTER, LARGE 7451-03" 48713611_1 CDM 0278 RC inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 "HEAD HALTER, LARGE 7451-03" 48713611_1 CDM 0278 RC inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 TUBING SMOKE EVACUATOR SEA3715 48713612_1 CDM 0272 RC inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges TUBING SMOKE EVACUATOR SEA3715 48713612_1 CDM 0272 RC inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges TUBING SMOKE EVACUATOR SEA3715 48713612_1 CDM 0272 RC inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges TUBING SMOKE EVACUATOR SEA3715 48713612_1 CDM 0272 RC inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges TUBING SMOKE EVACUATOR SEA3715 48713612_1 CDM 0272 RC inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges TUBING SMOKE EVACUATOR SEA3715 48713612_1 CDM 0272 RC inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges TUBING SMOKE EVACUATOR SEA3715 48713612_1 CDM 0272 RC inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges TUBING SMOKE EVACUATOR SEA3715 48713612_1 CDM 0272 RC inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges TUBING SMOKE EVACUATOR SEA3715 48713612_1 CDM 0272 RC inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 TUBING SMOKE EVACUATOR SEA3715 48713612_1 CDM 0272 RC inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 TUBING SMOKE EVACUATOR SEA3715 48713612_1 CDM 0272 RC inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 TUBING SMOKE EVACUATOR SEA3715 48713612_1 CDM 0272 RC inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges TUBING SMOKE EVACUATOR SEA3715 48713612_1 CDM 0272 RC inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 TUBING SMOKE EVACUATOR SEA3715 48713612_1 CDM 0272 RC inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 TUBES PAPARELLA 1.14 70240280 48713613_1 CDM 0272 RC inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges TUBES PAPARELLA 1.14 70240280 48713613_1 CDM 0272 RC inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges TUBES PAPARELLA 1.14 70240280 48713613_1 CDM 0272 RC inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges TUBES PAPARELLA 1.14 70240280 48713613_1 CDM 0272 RC inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges TUBES PAPARELLA 1.14 70240280 48713613_1 CDM 0272 RC inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges TUBES PAPARELLA 1.14 70240280 48713613_1 CDM 0272 RC inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges TUBES PAPARELLA 1.14 70240280 48713613_1 CDM 0272 RC inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges TUBES PAPARELLA 1.14 70240280 48713613_1 CDM 0272 RC inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges TUBES PAPARELLA 1.14 70240280 48713613_1 CDM 0272 RC inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 TUBES PAPARELLA 1.14 70240280 48713613_1 CDM 0272 RC inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 TUBES PAPARELLA 1.14 70240280 48713613_1 CDM 0272 RC inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 TUBES PAPARELLA 1.14 70240280 48713613_1 CDM 0272 RC inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges TUBES PAPARELLA 1.14 70240280 48713613_1 CDM 0272 RC inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 TUBES PAPARELLA 1.14 70240280 48713613_1 CDM 0272 RC inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 TUBES GOODE BUTTERFLY T 48713614_1 CDM 0272 RC inpatient 116 75.4 AETNA AETNA 91.64 79 999999999 70.24 112.52 percent of total billed charges TUBES GOODE BUTTERFLY T 48713614_1 CDM 0272 RC inpatient 116 75.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 75.4 65 999999999 70.24 112.52 percent of total billed charges TUBES GOODE BUTTERFLY T 48713614_1 CDM 0272 RC inpatient 116 75.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 112.52 97 999999999 70.24 112.52 percent of total billed charges TUBES GOODE BUTTERFLY T 48713614_1 CDM 0272 RC inpatient 116 75.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.04 69 999999999 70.24 112.52 percent of total billed charges TUBES GOODE BUTTERFLY T 48713614_1 CDM 0272 RC inpatient 116 75.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 90.48 78 999999999 70.24 112.52 percent of total billed charges TUBES GOODE BUTTERFLY T 48713614_1 CDM 0272 RC inpatient 116 75.4 UMR - ALL PLANS UMR - ALL PLANS 81.2 70 999999999 70.24 112.52 percent of total billed charges TUBES GOODE BUTTERFLY T 48713614_1 CDM 0272 RC inpatient 116 75.4 SIHO - ALL PLANS SIHO - ALL PLANS 104.4 90 999999999 70.24 112.52 percent of total billed charges TUBES GOODE BUTTERFLY T 48713614_1 CDM 0272 RC inpatient 116 75.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 70.24 60.55 999999999 70.24 112.52 percent of total billed charges TUBES GOODE BUTTERFLY T 48713614_1 CDM 0272 RC inpatient 116 75.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 70.24 112.52 TUBES GOODE BUTTERFLY T 48713614_1 CDM 0272 RC inpatient 116 75.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 70.24 112.52 TUBES GOODE BUTTERFLY T 48713614_1 CDM 0272 RC inpatient 116 75.4 ANTHEM HMO ANTHEM HMO 999999999 70.24 112.52 TUBES GOODE BUTTERFLY T 48713614_1 CDM 0272 RC inpatient 116 75.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 78.42 67.6 999999999 70.24 112.52 percent of total billed charges TUBES GOODE BUTTERFLY T 48713614_1 CDM 0272 RC inpatient 116 75.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 70.24 112.52 TUBES GOODE BUTTERFLY T 48713614_1 CDM 0272 RC inpatient 116 75.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 70.24 112.52 TURBINATE HANDPIECE 48713615_1 CDM 0272 RC inpatient 993 645.45 AETNA AETNA 784.47 79 999999999 601.26 963.21 percent of total billed charges TURBINATE HANDPIECE 48713615_1 CDM 0272 RC inpatient 993 645.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 645.45 65 999999999 601.26 963.21 percent of total billed charges TURBINATE HANDPIECE 48713615_1 CDM 0272 RC inpatient 993 645.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 963.21 97 999999999 601.26 963.21 percent of total billed charges TURBINATE HANDPIECE 48713615_1 CDM 0272 RC inpatient 993 645.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 685.17 69 999999999 601.26 963.21 percent of total billed charges TURBINATE HANDPIECE 48713615_1 CDM 0272 RC inpatient 993 645.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 774.54 78 999999999 601.26 963.21 percent of total billed charges TURBINATE HANDPIECE 48713615_1 CDM 0272 RC inpatient 993 645.45 UMR - ALL PLANS UMR - ALL PLANS 695.1 70 999999999 601.26 963.21 percent of total billed charges TURBINATE HANDPIECE 48713615_1 CDM 0272 RC inpatient 993 645.45 SIHO - ALL PLANS SIHO - ALL PLANS 893.7 90 999999999 601.26 963.21 percent of total billed charges TURBINATE HANDPIECE 48713615_1 CDM 0272 RC inpatient 993 645.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 601.26 60.55 999999999 601.26 963.21 percent of total billed charges TURBINATE HANDPIECE 48713615_1 CDM 0272 RC inpatient 993 645.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 601.26 963.21 TURBINATE HANDPIECE 48713615_1 CDM 0272 RC inpatient 993 645.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 601.26 963.21 TURBINATE HANDPIECE 48713615_1 CDM 0272 RC inpatient 993 645.45 ANTHEM HMO ANTHEM HMO 999999999 601.26 963.21 TURBINATE HANDPIECE 48713615_1 CDM 0272 RC inpatient 993 645.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 671.27 67.6 999999999 601.26 963.21 percent of total billed charges TURBINATE HANDPIECE 48713615_1 CDM 0272 RC inpatient 993 645.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 601.26 963.21 TURBINATE HANDPIECE 48713615_1 CDM 0272 RC inpatient 993 645.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 601.26 963.21 PC 15 PLASMAKNIFE 70353115 48713616_1 CDM 0272 RC inpatient 1362 885.3 AETNA AETNA 1075.98 79 999999999 824.69 1321.14 percent of total billed charges PC 15 PLASMAKNIFE 70353115 48713616_1 CDM 0272 RC inpatient 1362 885.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 885.3 65 999999999 824.69 1321.14 percent of total billed charges PC 15 PLASMAKNIFE 70353115 48713616_1 CDM 0272 RC inpatient 1362 885.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1321.14 97 999999999 824.69 1321.14 percent of total billed charges PC 15 PLASMAKNIFE 70353115 48713616_1 CDM 0272 RC inpatient 1362 885.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 939.78 69 999999999 824.69 1321.14 percent of total billed charges PC 15 PLASMAKNIFE 70353115 48713616_1 CDM 0272 RC inpatient 1362 885.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1062.36 78 999999999 824.69 1321.14 percent of total billed charges PC 15 PLASMAKNIFE 70353115 48713616_1 CDM 0272 RC inpatient 1362 885.3 UMR - ALL PLANS UMR - ALL PLANS 953.4 70 999999999 824.69 1321.14 percent of total billed charges PC 15 PLASMAKNIFE 70353115 48713616_1 CDM 0272 RC inpatient 1362 885.3 SIHO - ALL PLANS SIHO - ALL PLANS 1225.8 90 999999999 824.69 1321.14 percent of total billed charges PC 15 PLASMAKNIFE 70353115 48713616_1 CDM 0272 RC inpatient 1362 885.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 824.69 60.55 999999999 824.69 1321.14 percent of total billed charges PC 15 PLASMAKNIFE 70353115 48713616_1 CDM 0272 RC inpatient 1362 885.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 824.69 1321.14 PC 15 PLASMAKNIFE 70353115 48713616_1 CDM 0272 RC inpatient 1362 885.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 824.69 1321.14 PC 15 PLASMAKNIFE 70353115 48713616_1 CDM 0272 RC inpatient 1362 885.3 ANTHEM HMO ANTHEM HMO 999999999 824.69 1321.14 PC 15 PLASMAKNIFE 70353115 48713616_1 CDM 0272 RC inpatient 1362 885.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 920.71 67.6 999999999 824.69 1321.14 percent of total billed charges PC 15 PLASMAKNIFE 70353115 48713616_1 CDM 0272 RC inpatient 1362 885.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 824.69 1321.14 PC 15 PLASMAKNIFE 70353115 48713616_1 CDM 0272 RC inpatient 1362 885.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 824.69 1321.14 PC 12 PLASMAKNIFE 70353112 48713617_1 CDM 0272 RC inpatient 940 611 AETNA AETNA 742.6 79 999999999 569.17 911.8 percent of total billed charges PC 12 PLASMAKNIFE 70353112 48713617_1 CDM 0272 RC inpatient 940 611 SELF PAY DISCOUNT SELF PAY DISCOUNT 611 65 999999999 569.17 911.8 percent of total billed charges PC 12 PLASMAKNIFE 70353112 48713617_1 CDM 0272 RC inpatient 940 611 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 911.8 97 999999999 569.17 911.8 percent of total billed charges PC 12 PLASMAKNIFE 70353112 48713617_1 CDM 0272 RC inpatient 940 611 ENCORE - ALL PLANS ENCORE - ALL PLANS 648.6 69 999999999 569.17 911.8 percent of total billed charges PC 12 PLASMAKNIFE 70353112 48713617_1 CDM 0272 RC inpatient 940 611 HUMANA - ALL PLANS HUMANA - ALL PLANS 733.2 78 999999999 569.17 911.8 percent of total billed charges PC 12 PLASMAKNIFE 70353112 48713617_1 CDM 0272 RC inpatient 940 611 UMR - ALL PLANS UMR - ALL PLANS 658 70 999999999 569.17 911.8 percent of total billed charges PC 12 PLASMAKNIFE 70353112 48713617_1 CDM 0272 RC inpatient 940 611 SIHO - ALL PLANS SIHO - ALL PLANS 846 90 999999999 569.17 911.8 percent of total billed charges PC 12 PLASMAKNIFE 70353112 48713617_1 CDM 0272 RC inpatient 940 611 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 569.17 60.55 999999999 569.17 911.8 percent of total billed charges PC 12 PLASMAKNIFE 70353112 48713617_1 CDM 0272 RC inpatient 940 611 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 569.17 911.8 PC 12 PLASMAKNIFE 70353112 48713617_1 CDM 0272 RC inpatient 940 611 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 569.17 911.8 PC 12 PLASMAKNIFE 70353112 48713617_1 CDM 0272 RC inpatient 940 611 ANTHEM HMO ANTHEM HMO 999999999 569.17 911.8 PC 12 PLASMAKNIFE 70353112 48713617_1 CDM 0272 RC inpatient 940 611 CIGNA - ALL PLANS CIGNA - ALL PLANS 635.44 67.6 999999999 569.17 911.8 percent of total billed charges PC 12 PLASMAKNIFE 70353112 48713617_1 CDM 0272 RC inpatient 940 611 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 569.17 911.8 PC 12 PLASMAKNIFE 70353112 48713617_1 CDM 0272 RC inpatient 940 611 UHC - ALL PLANS UHC - ALL PLANS 999999999 569.17 911.8 5.5 BARREL 6 FLUTE 375-951-000 48713618_1 CDM 0272 RC inpatient 416 270.4 AETNA AETNA 328.64 79 999999999 251.89 403.52 percent of total billed charges 5.5 BARREL 6 FLUTE 375-951-000 48713618_1 CDM 0272 RC inpatient 416 270.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 270.4 65 999999999 251.89 403.52 percent of total billed charges 5.5 BARREL 6 FLUTE 375-951-000 48713618_1 CDM 0272 RC inpatient 416 270.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 403.52 97 999999999 251.89 403.52 percent of total billed charges 5.5 BARREL 6 FLUTE 375-951-000 48713618_1 CDM 0272 RC inpatient 416 270.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 287.04 69 999999999 251.89 403.52 percent of total billed charges 5.5 BARREL 6 FLUTE 375-951-000 48713618_1 CDM 0272 RC inpatient 416 270.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 324.48 78 999999999 251.89 403.52 percent of total billed charges 5.5 BARREL 6 FLUTE 375-951-000 48713618_1 CDM 0272 RC inpatient 416 270.4 UMR - ALL PLANS UMR - ALL PLANS 291.2 70 999999999 251.89 403.52 percent of total billed charges 5.5 BARREL 6 FLUTE 375-951-000 48713618_1 CDM 0272 RC inpatient 416 270.4 SIHO - ALL PLANS SIHO - ALL PLANS 374.4 90 999999999 251.89 403.52 percent of total billed charges 5.5 BARREL 6 FLUTE 375-951-000 48713618_1 CDM 0272 RC inpatient 416 270.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 251.89 60.55 999999999 251.89 403.52 percent of total billed charges 5.5 BARREL 6 FLUTE 375-951-000 48713618_1 CDM 0272 RC inpatient 416 270.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 251.89 403.52 5.5 BARREL 6 FLUTE 375-951-000 48713618_1 CDM 0272 RC inpatient 416 270.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 251.89 403.52 5.5 BARREL 6 FLUTE 375-951-000 48713618_1 CDM 0272 RC inpatient 416 270.4 ANTHEM HMO ANTHEM HMO 999999999 251.89 403.52 5.5 BARREL 6 FLUTE 375-951-000 48713618_1 CDM 0272 RC inpatient 416 270.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 281.22 67.6 999999999 251.89 403.52 percent of total billed charges 5.5 BARREL 6 FLUTE 375-951-000 48713618_1 CDM 0272 RC inpatient 416 270.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 251.89 403.52 5.5 BARREL 6 FLUTE 375-951-000 48713618_1 CDM 0272 RC inpatient 416 270.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 251.89 403.52 SHAVER BLADE RESECTOR 3.5 48713619_1 CDM 0272 RC inpatient 353 229.45 AETNA AETNA 278.87 79 999999999 213.74 342.41 percent of total billed charges SHAVER BLADE RESECTOR 3.5 48713619_1 CDM 0272 RC inpatient 353 229.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 229.45 65 999999999 213.74 342.41 percent of total billed charges SHAVER BLADE RESECTOR 3.5 48713619_1 CDM 0272 RC inpatient 353 229.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 342.41 97 999999999 213.74 342.41 percent of total billed charges SHAVER BLADE RESECTOR 3.5 48713619_1 CDM 0272 RC inpatient 353 229.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 243.57 69 999999999 213.74 342.41 percent of total billed charges SHAVER BLADE RESECTOR 3.5 48713619_1 CDM 0272 RC inpatient 353 229.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 275.34 78 999999999 213.74 342.41 percent of total billed charges SHAVER BLADE RESECTOR 3.5 48713619_1 CDM 0272 RC inpatient 353 229.45 UMR - ALL PLANS UMR - ALL PLANS 247.1 70 999999999 213.74 342.41 percent of total billed charges SHAVER BLADE RESECTOR 3.5 48713619_1 CDM 0272 RC inpatient 353 229.45 SIHO - ALL PLANS SIHO - ALL PLANS 317.7 90 999999999 213.74 342.41 percent of total billed charges SHAVER BLADE RESECTOR 3.5 48713619_1 CDM 0272 RC inpatient 353 229.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 213.74 60.55 999999999 213.74 342.41 percent of total billed charges SHAVER BLADE RESECTOR 3.5 48713619_1 CDM 0272 RC inpatient 353 229.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 213.74 342.41 SHAVER BLADE RESECTOR 3.5 48713619_1 CDM 0272 RC inpatient 353 229.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 213.74 342.41 SHAVER BLADE RESECTOR 3.5 48713619_1 CDM 0272 RC inpatient 353 229.45 ANTHEM HMO ANTHEM HMO 999999999 213.74 342.41 SHAVER BLADE RESECTOR 3.5 48713619_1 CDM 0272 RC inpatient 353 229.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 238.63 67.6 999999999 213.74 342.41 percent of total billed charges SHAVER BLADE RESECTOR 3.5 48713619_1 CDM 0272 RC inpatient 353 229.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 213.74 342.41 SHAVER BLADE RESECTOR 3.5 48713619_1 CDM 0272 RC inpatient 353 229.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 213.74 342.41 BUR 5.5MM RND 6 FL 375-950-000 48713620_1 CDM 0272 RC inpatient 335 217.75 AETNA AETNA 264.65 79 999999999 202.84 324.95 percent of total billed charges BUR 5.5MM RND 6 FL 375-950-000 48713620_1 CDM 0272 RC inpatient 335 217.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 217.75 65 999999999 202.84 324.95 percent of total billed charges BUR 5.5MM RND 6 FL 375-950-000 48713620_1 CDM 0272 RC inpatient 335 217.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 324.95 97 999999999 202.84 324.95 percent of total billed charges BUR 5.5MM RND 6 FL 375-950-000 48713620_1 CDM 0272 RC inpatient 335 217.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 231.15 69 999999999 202.84 324.95 percent of total billed charges BUR 5.5MM RND 6 FL 375-950-000 48713620_1 CDM 0272 RC inpatient 335 217.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 261.3 78 999999999 202.84 324.95 percent of total billed charges BUR 5.5MM RND 6 FL 375-950-000 48713620_1 CDM 0272 RC inpatient 335 217.75 UMR - ALL PLANS UMR - ALL PLANS 234.5 70 999999999 202.84 324.95 percent of total billed charges BUR 5.5MM RND 6 FL 375-950-000 48713620_1 CDM 0272 RC inpatient 335 217.75 SIHO - ALL PLANS SIHO - ALL PLANS 301.5 90 999999999 202.84 324.95 percent of total billed charges BUR 5.5MM RND 6 FL 375-950-000 48713620_1 CDM 0272 RC inpatient 335 217.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 202.84 60.55 999999999 202.84 324.95 percent of total billed charges BUR 5.5MM RND 6 FL 375-950-000 48713620_1 CDM 0272 RC inpatient 335 217.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 202.84 324.95 BUR 5.5MM RND 6 FL 375-950-000 48713620_1 CDM 0272 RC inpatient 335 217.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 202.84 324.95 BUR 5.5MM RND 6 FL 375-950-000 48713620_1 CDM 0272 RC inpatient 335 217.75 ANTHEM HMO ANTHEM HMO 999999999 202.84 324.95 BUR 5.5MM RND 6 FL 375-950-000 48713620_1 CDM 0272 RC inpatient 335 217.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 226.46 67.6 999999999 202.84 324.95 percent of total billed charges BUR 5.5MM RND 6 FL 375-950-000 48713620_1 CDM 0272 RC inpatient 335 217.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 202.84 324.95 BUR 5.5MM RND 6 FL 375-950-000 48713620_1 CDM 0272 RC inpatient 335 217.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 202.84 324.95 MICRO BLADE 25MM #2296-3-111 48713621_1 CDM 0272 RC inpatient 193 125.45 AETNA AETNA 152.47 79 999999999 116.86 187.21 percent of total billed charges MICRO BLADE 25MM #2296-3-111 48713621_1 CDM 0272 RC inpatient 193 125.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 125.45 65 999999999 116.86 187.21 percent of total billed charges MICRO BLADE 25MM #2296-3-111 48713621_1 CDM 0272 RC inpatient 193 125.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 187.21 97 999999999 116.86 187.21 percent of total billed charges MICRO BLADE 25MM #2296-3-111 48713621_1 CDM 0272 RC inpatient 193 125.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.17 69 999999999 116.86 187.21 percent of total billed charges MICRO BLADE 25MM #2296-3-111 48713621_1 CDM 0272 RC inpatient 193 125.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 150.54 78 999999999 116.86 187.21 percent of total billed charges MICRO BLADE 25MM #2296-3-111 48713621_1 CDM 0272 RC inpatient 193 125.45 UMR - ALL PLANS UMR - ALL PLANS 135.1 70 999999999 116.86 187.21 percent of total billed charges MICRO BLADE 25MM #2296-3-111 48713621_1 CDM 0272 RC inpatient 193 125.45 SIHO - ALL PLANS SIHO - ALL PLANS 173.7 90 999999999 116.86 187.21 percent of total billed charges MICRO BLADE 25MM #2296-3-111 48713621_1 CDM 0272 RC inpatient 193 125.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.86 60.55 999999999 116.86 187.21 percent of total billed charges MICRO BLADE 25MM #2296-3-111 48713621_1 CDM 0272 RC inpatient 193 125.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.86 187.21 MICRO BLADE 25MM #2296-3-111 48713621_1 CDM 0272 RC inpatient 193 125.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.86 187.21 MICRO BLADE 25MM #2296-3-111 48713621_1 CDM 0272 RC inpatient 193 125.45 ANTHEM HMO ANTHEM HMO 999999999 116.86 187.21 MICRO BLADE 25MM #2296-3-111 48713621_1 CDM 0272 RC inpatient 193 125.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 130.47 67.6 999999999 116.86 187.21 percent of total billed charges MICRO BLADE 25MM #2296-3-111 48713621_1 CDM 0272 RC inpatient 193 125.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.86 187.21 MICRO BLADE 25MM #2296-3-111 48713621_1 CDM 0272 RC inpatient 193 125.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.86 187.21 MICRO BLADE 5.5MM 48713622_1 CDM 0272 RC inpatient 258 167.7 AETNA AETNA 203.82 79 999999999 156.22 250.26 percent of total billed charges MICRO BLADE 5.5MM 48713622_1 CDM 0272 RC inpatient 258 167.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.7 65 999999999 156.22 250.26 percent of total billed charges MICRO BLADE 5.5MM 48713622_1 CDM 0272 RC inpatient 258 167.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 250.26 97 999999999 156.22 250.26 percent of total billed charges MICRO BLADE 5.5MM 48713622_1 CDM 0272 RC inpatient 258 167.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 178.02 69 999999999 156.22 250.26 percent of total billed charges MICRO BLADE 5.5MM 48713622_1 CDM 0272 RC inpatient 258 167.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 201.24 78 999999999 156.22 250.26 percent of total billed charges MICRO BLADE 5.5MM 48713622_1 CDM 0272 RC inpatient 258 167.7 UMR - ALL PLANS UMR - ALL PLANS 180.6 70 999999999 156.22 250.26 percent of total billed charges MICRO BLADE 5.5MM 48713622_1 CDM 0272 RC inpatient 258 167.7 SIHO - ALL PLANS SIHO - ALL PLANS 232.2 90 999999999 156.22 250.26 percent of total billed charges MICRO BLADE 5.5MM 48713622_1 CDM 0272 RC inpatient 258 167.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 156.22 60.55 999999999 156.22 250.26 percent of total billed charges MICRO BLADE 5.5MM 48713622_1 CDM 0272 RC inpatient 258 167.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 156.22 250.26 MICRO BLADE 5.5MM 48713622_1 CDM 0272 RC inpatient 258 167.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 156.22 250.26 MICRO BLADE 5.5MM 48713622_1 CDM 0272 RC inpatient 258 167.7 ANTHEM HMO ANTHEM HMO 999999999 156.22 250.26 MICRO BLADE 5.5MM 48713622_1 CDM 0272 RC inpatient 258 167.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 174.41 67.6 999999999 156.22 250.26 percent of total billed charges MICRO BLADE 5.5MM 48713622_1 CDM 0272 RC inpatient 258 167.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 156.22 250.26 MICRO BLADE 5.5MM 48713622_1 CDM 0272 RC inpatient 258 167.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 156.22 250.26 BUR HOODED ABRASION 3.0MM 48713623_1 CDM 0272 RC inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges BUR HOODED ABRASION 3.0MM 48713623_1 CDM 0272 RC inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges BUR HOODED ABRASION 3.0MM 48713623_1 CDM 0272 RC inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges BUR HOODED ABRASION 3.0MM 48713623_1 CDM 0272 RC inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges BUR HOODED ABRASION 3.0MM 48713623_1 CDM 0272 RC inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges BUR HOODED ABRASION 3.0MM 48713623_1 CDM 0272 RC inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges BUR HOODED ABRASION 3.0MM 48713623_1 CDM 0272 RC inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges BUR HOODED ABRASION 3.0MM 48713623_1 CDM 0272 RC inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges BUR HOODED ABRASION 3.0MM 48713623_1 CDM 0272 RC inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 BUR HOODED ABRASION 3.0MM 48713623_1 CDM 0272 RC inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 BUR HOODED ABRASION 3.0MM 48713623_1 CDM 0272 RC inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 BUR HOODED ABRASION 3.0MM 48713623_1 CDM 0272 RC inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges BUR HOODED ABRASION 3.0MM 48713623_1 CDM 0272 RC inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 BUR HOODED ABRASION 3.0MM 48713623_1 CDM 0272 RC inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 VIT CABLE GRIP MED 2.0MM 48713624_1 CDM 0278 RC inpatient 3492 2269.8 AETNA AETNA 2758.68 79 999999999 2114.41 3387.24 percent of total billed charges VIT CABLE GRIP MED 2.0MM 48713624_1 CDM 0278 RC inpatient 3492 2269.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 2269.8 65 999999999 2114.41 3387.24 percent of total billed charges VIT CABLE GRIP MED 2.0MM 48713624_1 CDM 0278 RC inpatient 3492 2269.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3387.24 97 999999999 2114.41 3387.24 percent of total billed charges VIT CABLE GRIP MED 2.0MM 48713624_1 CDM 0278 RC inpatient 3492 2269.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 2409.48 69 999999999 2114.41 3387.24 percent of total billed charges VIT CABLE GRIP MED 2.0MM 48713624_1 CDM 0278 RC inpatient 3492 2269.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 2723.76 78 999999999 2114.41 3387.24 percent of total billed charges VIT CABLE GRIP MED 2.0MM 48713624_1 CDM 0278 RC inpatient 3492 2269.8 UMR - ALL PLANS UMR - ALL PLANS 2444.4 70 999999999 2114.41 3387.24 percent of total billed charges VIT CABLE GRIP MED 2.0MM 48713624_1 CDM 0278 RC inpatient 3492 2269.8 SIHO - ALL PLANS SIHO - ALL PLANS 3142.8 90 999999999 2114.41 3387.24 percent of total billed charges VIT CABLE GRIP MED 2.0MM 48713624_1 CDM 0278 RC inpatient 3492 2269.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2114.41 60.55 999999999 2114.41 3387.24 percent of total billed charges VIT CABLE GRIP MED 2.0MM 48713624_1 CDM 0278 RC inpatient 3492 2269.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2114.41 3387.24 VIT CABLE GRIP MED 2.0MM 48713624_1 CDM 0278 RC inpatient 3492 2269.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2114.41 3387.24 VIT CABLE GRIP MED 2.0MM 48713624_1 CDM 0278 RC inpatient 3492 2269.8 ANTHEM HMO ANTHEM HMO 999999999 2114.41 3387.24 VIT CABLE GRIP MED 2.0MM 48713624_1 CDM 0278 RC inpatient 3492 2269.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 2360.59 67.6 999999999 2114.41 3387.24 percent of total billed charges VIT CABLE GRIP MED 2.0MM 48713624_1 CDM 0278 RC inpatient 3492 2269.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2114.41 3387.24 VIT CABLE GRIP MED 2.0MM 48713624_1 CDM 0278 RC inpatient 3492 2269.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 2114.41 3387.24 ENDOSCOPIC APPLICATOR 0600125 48713625_1 CDM 0272 RC inpatient 422 274.3 AETNA AETNA 333.38 79 999999999 255.52 409.34 percent of total billed charges ENDOSCOPIC APPLICATOR 0600125 48713625_1 CDM 0272 RC inpatient 422 274.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 274.3 65 999999999 255.52 409.34 percent of total billed charges ENDOSCOPIC APPLICATOR 0600125 48713625_1 CDM 0272 RC inpatient 422 274.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 409.34 97 999999999 255.52 409.34 percent of total billed charges ENDOSCOPIC APPLICATOR 0600125 48713625_1 CDM 0272 RC inpatient 422 274.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 291.18 69 999999999 255.52 409.34 percent of total billed charges ENDOSCOPIC APPLICATOR 0600125 48713625_1 CDM 0272 RC inpatient 422 274.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 329.16 78 999999999 255.52 409.34 percent of total billed charges ENDOSCOPIC APPLICATOR 0600125 48713625_1 CDM 0272 RC inpatient 422 274.3 UMR - ALL PLANS UMR - ALL PLANS 295.4 70 999999999 255.52 409.34 percent of total billed charges ENDOSCOPIC APPLICATOR 0600125 48713625_1 CDM 0272 RC inpatient 422 274.3 SIHO - ALL PLANS SIHO - ALL PLANS 379.8 90 999999999 255.52 409.34 percent of total billed charges ENDOSCOPIC APPLICATOR 0600125 48713625_1 CDM 0272 RC inpatient 422 274.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 255.52 60.55 999999999 255.52 409.34 percent of total billed charges ENDOSCOPIC APPLICATOR 0600125 48713625_1 CDM 0272 RC inpatient 422 274.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 255.52 409.34 ENDOSCOPIC APPLICATOR 0600125 48713625_1 CDM 0272 RC inpatient 422 274.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 255.52 409.34 ENDOSCOPIC APPLICATOR 0600125 48713625_1 CDM 0272 RC inpatient 422 274.3 ANTHEM HMO ANTHEM HMO 999999999 255.52 409.34 ENDOSCOPIC APPLICATOR 0600125 48713625_1 CDM 0272 RC inpatient 422 274.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 285.27 67.6 999999999 255.52 409.34 percent of total billed charges ENDOSCOPIC APPLICATOR 0600125 48713625_1 CDM 0272 RC inpatient 422 274.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 255.52 409.34 ENDOSCOPIC APPLICATOR 0600125 48713625_1 CDM 0272 RC inpatient 422 274.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 255.52 409.34 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713626_1 CDM 0278 RC C1713 HCPCS inpatient 989 642.85 AETNA AETNA 781.31 79 999999999 598.84 959.33 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713626_1 CDM 0278 RC C1713 HCPCS inpatient 989 642.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 642.85 65 999999999 598.84 959.33 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713626_1 CDM 0278 RC C1713 HCPCS inpatient 989 642.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 959.33 97 999999999 598.84 959.33 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713626_1 CDM 0278 RC C1713 HCPCS inpatient 989 642.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 682.41 69 999999999 598.84 959.33 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713626_1 CDM 0278 RC C1713 HCPCS inpatient 989 642.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 771.42 78 999999999 598.84 959.33 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713626_1 CDM 0278 RC C1713 HCPCS inpatient 989 642.85 UMR - ALL PLANS UMR - ALL PLANS 692.3 70 999999999 598.84 959.33 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713626_1 CDM 0278 RC C1713 HCPCS inpatient 989 642.85 SIHO - ALL PLANS SIHO - ALL PLANS 890.1 90 999999999 598.84 959.33 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713626_1 CDM 0278 RC C1713 HCPCS inpatient 989 642.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 598.84 60.55 999999999 598.84 959.33 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713626_1 CDM 0278 RC C1713 HCPCS inpatient 989 642.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 598.84 959.33 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713626_1 CDM 0278 RC C1713 HCPCS inpatient 989 642.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 598.84 959.33 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713626_1 CDM 0278 RC C1713 HCPCS inpatient 989 642.85 ANTHEM HMO ANTHEM HMO 999999999 598.84 959.33 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713626_1 CDM 0278 RC C1713 HCPCS inpatient 989 642.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 668.56 67.6 999999999 598.84 959.33 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713626_1 CDM 0278 RC C1713 HCPCS inpatient 989 642.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 598.84 959.33 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713626_1 CDM 0278 RC C1713 HCPCS inpatient 989 642.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 598.84 959.33 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713627_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 AETNA AETNA 1456.76 79 999999999 1116.54 1788.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713627_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1198.6 65 999999999 1116.54 1788.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713627_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1788.68 97 999999999 1116.54 1788.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713627_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1272.36 69 999999999 1116.54 1788.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713627_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1438.32 78 999999999 1116.54 1788.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713627_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 UMR - ALL PLANS UMR - ALL PLANS 1290.8 70 999999999 1116.54 1788.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713627_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 SIHO - ALL PLANS SIHO - ALL PLANS 1659.6 90 999999999 1116.54 1788.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713627_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1116.54 60.55 999999999 1116.54 1788.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713627_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1116.54 1788.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713627_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1116.54 1788.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713627_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 ANTHEM HMO ANTHEM HMO 999999999 1116.54 1788.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713627_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1246.54 67.6 999999999 1116.54 1788.68 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713627_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1116.54 1788.68 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 48713627_1 CDM 0278 RC C1713 HCPCS inpatient 1844 1198.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1116.54 1788.68 D/M 6.5 IN SS BROAD COMP PLATE 48713628_1 CDM 0278 RC inpatient 2945 1914.25 AETNA AETNA 2326.55 79 999999999 1783.2 2856.65 percent of total billed charges D/M 6.5 IN SS BROAD COMP PLATE 48713628_1 CDM 0278 RC inpatient 2945 1914.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1914.25 65 999999999 1783.2 2856.65 percent of total billed charges D/M 6.5 IN SS BROAD COMP PLATE 48713628_1 CDM 0278 RC inpatient 2945 1914.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2856.65 97 999999999 1783.2 2856.65 percent of total billed charges D/M 6.5 IN SS BROAD COMP PLATE 48713628_1 CDM 0278 RC inpatient 2945 1914.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 2032.05 69 999999999 1783.2 2856.65 percent of total billed charges D/M 6.5 IN SS BROAD COMP PLATE 48713628_1 CDM 0278 RC inpatient 2945 1914.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 2297.1 78 999999999 1783.2 2856.65 percent of total billed charges D/M 6.5 IN SS BROAD COMP PLATE 48713628_1 CDM 0278 RC inpatient 2945 1914.25 UMR - ALL PLANS UMR - ALL PLANS 2061.5 70 999999999 1783.2 2856.65 percent of total billed charges D/M 6.5 IN SS BROAD COMP PLATE 48713628_1 CDM 0278 RC inpatient 2945 1914.25 SIHO - ALL PLANS SIHO - ALL PLANS 2650.5 90 999999999 1783.2 2856.65 percent of total billed charges D/M 6.5 IN SS BROAD COMP PLATE 48713628_1 CDM 0278 RC inpatient 2945 1914.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1783.2 60.55 999999999 1783.2 2856.65 percent of total billed charges D/M 6.5 IN SS BROAD COMP PLATE 48713628_1 CDM 0278 RC inpatient 2945 1914.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1783.2 2856.65 D/M 6.5 IN SS BROAD COMP PLATE 48713628_1 CDM 0278 RC inpatient 2945 1914.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1783.2 2856.65 D/M 6.5 IN SS BROAD COMP PLATE 48713628_1 CDM 0278 RC inpatient 2945 1914.25 ANTHEM HMO ANTHEM HMO 999999999 1783.2 2856.65 D/M 6.5 IN SS BROAD COMP PLATE 48713628_1 CDM 0278 RC inpatient 2945 1914.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1990.82 67.6 999999999 1783.2 2856.65 percent of total billed charges D/M 6.5 IN SS BROAD COMP PLATE 48713628_1 CDM 0278 RC inpatient 2945 1914.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1783.2 2856.65 D/M 6.5 IN SS BROAD COMP PLATE 48713628_1 CDM 0278 RC inpatient 2945 1914.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1783.2 2856.65 D/M 8.0 IN SS BROAD COMP PLATE 48713629_1 CDM 0278 RC inpatient 2945 1914.25 AETNA AETNA 2326.55 79 999999999 1783.2 2856.65 percent of total billed charges D/M 8.0 IN SS BROAD COMP PLATE 48713629_1 CDM 0278 RC inpatient 2945 1914.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1914.25 65 999999999 1783.2 2856.65 percent of total billed charges D/M 8.0 IN SS BROAD COMP PLATE 48713629_1 CDM 0278 RC inpatient 2945 1914.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2856.65 97 999999999 1783.2 2856.65 percent of total billed charges D/M 8.0 IN SS BROAD COMP PLATE 48713629_1 CDM 0278 RC inpatient 2945 1914.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 2032.05 69 999999999 1783.2 2856.65 percent of total billed charges D/M 8.0 IN SS BROAD COMP PLATE 48713629_1 CDM 0278 RC inpatient 2945 1914.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 2297.1 78 999999999 1783.2 2856.65 percent of total billed charges D/M 8.0 IN SS BROAD COMP PLATE 48713629_1 CDM 0278 RC inpatient 2945 1914.25 UMR - ALL PLANS UMR - ALL PLANS 2061.5 70 999999999 1783.2 2856.65 percent of total billed charges D/M 8.0 IN SS BROAD COMP PLATE 48713629_1 CDM 0278 RC inpatient 2945 1914.25 SIHO - ALL PLANS SIHO - ALL PLANS 2650.5 90 999999999 1783.2 2856.65 percent of total billed charges D/M 8.0 IN SS BROAD COMP PLATE 48713629_1 CDM 0278 RC inpatient 2945 1914.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1783.2 60.55 999999999 1783.2 2856.65 percent of total billed charges D/M 8.0 IN SS BROAD COMP PLATE 48713629_1 CDM 0278 RC inpatient 2945 1914.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1783.2 2856.65 D/M 8.0 IN SS BROAD COMP PLATE 48713629_1 CDM 0278 RC inpatient 2945 1914.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1783.2 2856.65 D/M 8.0 IN SS BROAD COMP PLATE 48713629_1 CDM 0278 RC inpatient 2945 1914.25 ANTHEM HMO ANTHEM HMO 999999999 1783.2 2856.65 D/M 8.0 IN SS BROAD COMP PLATE 48713629_1 CDM 0278 RC inpatient 2945 1914.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1990.82 67.6 999999999 1783.2 2856.65 percent of total billed charges D/M 8.0 IN SS BROAD COMP PLATE 48713629_1 CDM 0278 RC inpatient 2945 1914.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1783.2 2856.65 D/M 8.0 IN SS BROAD COMP PLATE 48713629_1 CDM 0278 RC inpatient 2945 1914.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1783.2 2856.65 D/M 10 IN SS BROAD COMP PLATE 48713630_1 CDM 0278 RC inpatient 2945 1914.25 AETNA AETNA 2326.55 79 999999999 1783.2 2856.65 percent of total billed charges D/M 10 IN SS BROAD COMP PLATE 48713630_1 CDM 0278 RC inpatient 2945 1914.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1914.25 65 999999999 1783.2 2856.65 percent of total billed charges D/M 10 IN SS BROAD COMP PLATE 48713630_1 CDM 0278 RC inpatient 2945 1914.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2856.65 97 999999999 1783.2 2856.65 percent of total billed charges D/M 10 IN SS BROAD COMP PLATE 48713630_1 CDM 0278 RC inpatient 2945 1914.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 2032.05 69 999999999 1783.2 2856.65 percent of total billed charges D/M 10 IN SS BROAD COMP PLATE 48713630_1 CDM 0278 RC inpatient 2945 1914.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 2297.1 78 999999999 1783.2 2856.65 percent of total billed charges D/M 10 IN SS BROAD COMP PLATE 48713630_1 CDM 0278 RC inpatient 2945 1914.25 UMR - ALL PLANS UMR - ALL PLANS 2061.5 70 999999999 1783.2 2856.65 percent of total billed charges D/M 10 IN SS BROAD COMP PLATE 48713630_1 CDM 0278 RC inpatient 2945 1914.25 SIHO - ALL PLANS SIHO - ALL PLANS 2650.5 90 999999999 1783.2 2856.65 percent of total billed charges D/M 10 IN SS BROAD COMP PLATE 48713630_1 CDM 0278 RC inpatient 2945 1914.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1783.2 60.55 999999999 1783.2 2856.65 percent of total billed charges D/M 10 IN SS BROAD COMP PLATE 48713630_1 CDM 0278 RC inpatient 2945 1914.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1783.2 2856.65 D/M 10 IN SS BROAD COMP PLATE 48713630_1 CDM 0278 RC inpatient 2945 1914.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1783.2 2856.65 D/M 10 IN SS BROAD COMP PLATE 48713630_1 CDM 0278 RC inpatient 2945 1914.25 ANTHEM HMO ANTHEM HMO 999999999 1783.2 2856.65 D/M 10 IN SS BROAD COMP PLATE 48713630_1 CDM 0278 RC inpatient 2945 1914.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1990.82 67.6 999999999 1783.2 2856.65 percent of total billed charges D/M 10 IN SS BROAD COMP PLATE 48713630_1 CDM 0278 RC inpatient 2945 1914.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1783.2 2856.65 D/M 10 IN SS BROAD COMP PLATE 48713630_1 CDM 0278 RC inpatient 2945 1914.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1783.2 2856.65 D/M 12 IN SS BOARD COMP PLATE 48713631_1 CDM 0278 RC inpatient 2945 1914.25 AETNA AETNA 2326.55 79 999999999 1783.2 2856.65 percent of total billed charges D/M 12 IN SS BOARD COMP PLATE 48713631_1 CDM 0278 RC inpatient 2945 1914.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1914.25 65 999999999 1783.2 2856.65 percent of total billed charges D/M 12 IN SS BOARD COMP PLATE 48713631_1 CDM 0278 RC inpatient 2945 1914.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2856.65 97 999999999 1783.2 2856.65 percent of total billed charges D/M 12 IN SS BOARD COMP PLATE 48713631_1 CDM 0278 RC inpatient 2945 1914.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 2032.05 69 999999999 1783.2 2856.65 percent of total billed charges D/M 12 IN SS BOARD COMP PLATE 48713631_1 CDM 0278 RC inpatient 2945 1914.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 2297.1 78 999999999 1783.2 2856.65 percent of total billed charges D/M 12 IN SS BOARD COMP PLATE 48713631_1 CDM 0278 RC inpatient 2945 1914.25 UMR - ALL PLANS UMR - ALL PLANS 2061.5 70 999999999 1783.2 2856.65 percent of total billed charges D/M 12 IN SS BOARD COMP PLATE 48713631_1 CDM 0278 RC inpatient 2945 1914.25 SIHO - ALL PLANS SIHO - ALL PLANS 2650.5 90 999999999 1783.2 2856.65 percent of total billed charges D/M 12 IN SS BOARD COMP PLATE 48713631_1 CDM 0278 RC inpatient 2945 1914.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1783.2 60.55 999999999 1783.2 2856.65 percent of total billed charges D/M 12 IN SS BOARD COMP PLATE 48713631_1 CDM 0278 RC inpatient 2945 1914.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1783.2 2856.65 D/M 12 IN SS BOARD COMP PLATE 48713631_1 CDM 0278 RC inpatient 2945 1914.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1783.2 2856.65 D/M 12 IN SS BOARD COMP PLATE 48713631_1 CDM 0278 RC inpatient 2945 1914.25 ANTHEM HMO ANTHEM HMO 999999999 1783.2 2856.65 D/M 12 IN SS BOARD COMP PLATE 48713631_1 CDM 0278 RC inpatient 2945 1914.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1990.82 67.6 999999999 1783.2 2856.65 percent of total billed charges D/M 12 IN SS BOARD COMP PLATE 48713631_1 CDM 0278 RC inpatient 2945 1914.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1783.2 2856.65 D/M 12 IN SS BOARD COMP PLATE 48713631_1 CDM 0278 RC inpatient 2945 1914.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1783.2 2856.65 SM SS CABLE SLEEVE W/1.6 CABLE 48713632_1 CDM 0278 RC inpatient 2096 1362.4 AETNA AETNA 1655.84 79 999999999 1269.13 2033.12 percent of total billed charges SM SS CABLE SLEEVE W/1.6 CABLE 48713632_1 CDM 0278 RC inpatient 2096 1362.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1362.4 65 999999999 1269.13 2033.12 percent of total billed charges SM SS CABLE SLEEVE W/1.6 CABLE 48713632_1 CDM 0278 RC inpatient 2096 1362.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2033.12 97 999999999 1269.13 2033.12 percent of total billed charges SM SS CABLE SLEEVE W/1.6 CABLE 48713632_1 CDM 0278 RC inpatient 2096 1362.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1446.24 69 999999999 1269.13 2033.12 percent of total billed charges SM SS CABLE SLEEVE W/1.6 CABLE 48713632_1 CDM 0278 RC inpatient 2096 1362.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1634.88 78 999999999 1269.13 2033.12 percent of total billed charges SM SS CABLE SLEEVE W/1.6 CABLE 48713632_1 CDM 0278 RC inpatient 2096 1362.4 UMR - ALL PLANS UMR - ALL PLANS 1467.2 70 999999999 1269.13 2033.12 percent of total billed charges SM SS CABLE SLEEVE W/1.6 CABLE 48713632_1 CDM 0278 RC inpatient 2096 1362.4 SIHO - ALL PLANS SIHO - ALL PLANS 1886.4 90 999999999 1269.13 2033.12 percent of total billed charges SM SS CABLE SLEEVE W/1.6 CABLE 48713632_1 CDM 0278 RC inpatient 2096 1362.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1269.13 60.55 999999999 1269.13 2033.12 percent of total billed charges SM SS CABLE SLEEVE W/1.6 CABLE 48713632_1 CDM 0278 RC inpatient 2096 1362.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1269.13 2033.12 SM SS CABLE SLEEVE W/1.6 CABLE 48713632_1 CDM 0278 RC inpatient 2096 1362.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1269.13 2033.12 SM SS CABLE SLEEVE W/1.6 CABLE 48713632_1 CDM 0278 RC inpatient 2096 1362.4 ANTHEM HMO ANTHEM HMO 999999999 1269.13 2033.12 SM SS CABLE SLEEVE W/1.6 CABLE 48713632_1 CDM 0278 RC inpatient 2096 1362.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1416.9 67.6 999999999 1269.13 2033.12 percent of total billed charges SM SS CABLE SLEEVE W/1.6 CABLE 48713632_1 CDM 0278 RC inpatient 2096 1362.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1269.13 2033.12 SM SS CABLE SLEEVE W/1.6 CABLE 48713632_1 CDM 0278 RC inpatient 2096 1362.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1269.13 2033.12 VIT CABLE GRIP LARGE 2.0 48713633_1 CDM 0278 RC inpatient 2780 1807 AETNA AETNA 2196.2 79 999999999 1683.29 2696.6 percent of total billed charges VIT CABLE GRIP LARGE 2.0 48713633_1 CDM 0278 RC inpatient 2780 1807 SELF PAY DISCOUNT SELF PAY DISCOUNT 1807 65 999999999 1683.29 2696.6 percent of total billed charges VIT CABLE GRIP LARGE 2.0 48713633_1 CDM 0278 RC inpatient 2780 1807 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2696.6 97 999999999 1683.29 2696.6 percent of total billed charges VIT CABLE GRIP LARGE 2.0 48713633_1 CDM 0278 RC inpatient 2780 1807 ENCORE - ALL PLANS ENCORE - ALL PLANS 1918.2 69 999999999 1683.29 2696.6 percent of total billed charges VIT CABLE GRIP LARGE 2.0 48713633_1 CDM 0278 RC inpatient 2780 1807 HUMANA - ALL PLANS HUMANA - ALL PLANS 2168.4 78 999999999 1683.29 2696.6 percent of total billed charges VIT CABLE GRIP LARGE 2.0 48713633_1 CDM 0278 RC inpatient 2780 1807 UMR - ALL PLANS UMR - ALL PLANS 1946 70 999999999 1683.29 2696.6 percent of total billed charges VIT CABLE GRIP LARGE 2.0 48713633_1 CDM 0278 RC inpatient 2780 1807 SIHO - ALL PLANS SIHO - ALL PLANS 2502 90 999999999 1683.29 2696.6 percent of total billed charges VIT CABLE GRIP LARGE 2.0 48713633_1 CDM 0278 RC inpatient 2780 1807 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1683.29 60.55 999999999 1683.29 2696.6 percent of total billed charges VIT CABLE GRIP LARGE 2.0 48713633_1 CDM 0278 RC inpatient 2780 1807 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1683.29 2696.6 VIT CABLE GRIP LARGE 2.0 48713633_1 CDM 0278 RC inpatient 2780 1807 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1683.29 2696.6 VIT CABLE GRIP LARGE 2.0 48713633_1 CDM 0278 RC inpatient 2780 1807 ANTHEM HMO ANTHEM HMO 999999999 1683.29 2696.6 VIT CABLE GRIP LARGE 2.0 48713633_1 CDM 0278 RC inpatient 2780 1807 CIGNA - ALL PLANS CIGNA - ALL PLANS 1879.28 67.6 999999999 1683.29 2696.6 percent of total billed charges VIT CABLE GRIP LARGE 2.0 48713633_1 CDM 0278 RC inpatient 2780 1807 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1683.29 2696.6 VIT CABLE GRIP LARGE 2.0 48713633_1 CDM 0278 RC inpatient 2780 1807 UHC - ALL PLANS UHC - ALL PLANS 999999999 1683.29 2696.6 VIT CABLE GRIP SMALL 1.6MM 48713634_1 CDM 0278 RC inpatient 3279 2131.35 AETNA AETNA 2590.41 79 999999999 1985.43 3180.63 percent of total billed charges VIT CABLE GRIP SMALL 1.6MM 48713634_1 CDM 0278 RC inpatient 3279 2131.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 2131.35 65 999999999 1985.43 3180.63 percent of total billed charges VIT CABLE GRIP SMALL 1.6MM 48713634_1 CDM 0278 RC inpatient 3279 2131.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3180.63 97 999999999 1985.43 3180.63 percent of total billed charges VIT CABLE GRIP SMALL 1.6MM 48713634_1 CDM 0278 RC inpatient 3279 2131.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 2262.51 69 999999999 1985.43 3180.63 percent of total billed charges VIT CABLE GRIP SMALL 1.6MM 48713634_1 CDM 0278 RC inpatient 3279 2131.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 2557.62 78 999999999 1985.43 3180.63 percent of total billed charges VIT CABLE GRIP SMALL 1.6MM 48713634_1 CDM 0278 RC inpatient 3279 2131.35 UMR - ALL PLANS UMR - ALL PLANS 2295.3 70 999999999 1985.43 3180.63 percent of total billed charges VIT CABLE GRIP SMALL 1.6MM 48713634_1 CDM 0278 RC inpatient 3279 2131.35 SIHO - ALL PLANS SIHO - ALL PLANS 2951.1 90 999999999 1985.43 3180.63 percent of total billed charges VIT CABLE GRIP SMALL 1.6MM 48713634_1 CDM 0278 RC inpatient 3279 2131.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1985.43 60.55 999999999 1985.43 3180.63 percent of total billed charges VIT CABLE GRIP SMALL 1.6MM 48713634_1 CDM 0278 RC inpatient 3279 2131.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1985.43 3180.63 VIT CABLE GRIP SMALL 1.6MM 48713634_1 CDM 0278 RC inpatient 3279 2131.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1985.43 3180.63 VIT CABLE GRIP SMALL 1.6MM 48713634_1 CDM 0278 RC inpatient 3279 2131.35 ANTHEM HMO ANTHEM HMO 999999999 1985.43 3180.63 VIT CABLE GRIP SMALL 1.6MM 48713634_1 CDM 0278 RC inpatient 3279 2131.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 2216.6 67.6 999999999 1985.43 3180.63 percent of total billed charges VIT CABLE GRIP SMALL 1.6MM 48713634_1 CDM 0278 RC inpatient 3279 2131.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1985.43 3180.63 VIT CABLE GRIP SMALL 1.6MM 48713634_1 CDM 0278 RC inpatient 3279 2131.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1985.43 3180.63 GUIDE WIRE 48713635_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 AETNA AETNA 492.96 79 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE 48713635_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 405.6 65 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE 48713635_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 605.28 97 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE 48713635_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 430.56 69 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE 48713635_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 486.72 78 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE 48713635_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 UMR - ALL PLANS UMR - ALL PLANS 436.8 70 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE 48713635_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 SIHO - ALL PLANS SIHO - ALL PLANS 561.6 90 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE 48713635_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 377.83 60.55 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE 48713635_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 377.83 605.28 GUIDE WIRE 48713635_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 377.83 605.28 GUIDE WIRE 48713635_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 ANTHEM HMO ANTHEM HMO 999999999 377.83 605.28 GUIDE WIRE 48713635_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 421.82 67.6 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE 48713635_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 377.83 605.28 GUIDE WIRE 48713635_1 CDM 0272 RC C1769 HCPCS inpatient 624 405.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 377.83 605.28 VAPR COOL PULSE 90 ELECTRODE 228146 48713636_1 CDM 0272 RC inpatient 2271 1476.15 AETNA AETNA 1794.09 79 999999999 1375.09 2202.87 percent of total billed charges VAPR COOL PULSE 90 ELECTRODE 228146 48713636_1 CDM 0272 RC inpatient 2271 1476.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1476.15 65 999999999 1375.09 2202.87 percent of total billed charges VAPR COOL PULSE 90 ELECTRODE 228146 48713636_1 CDM 0272 RC inpatient 2271 1476.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2202.87 97 999999999 1375.09 2202.87 percent of total billed charges VAPR COOL PULSE 90 ELECTRODE 228146 48713636_1 CDM 0272 RC inpatient 2271 1476.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1566.99 69 999999999 1375.09 2202.87 percent of total billed charges VAPR COOL PULSE 90 ELECTRODE 228146 48713636_1 CDM 0272 RC inpatient 2271 1476.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1771.38 78 999999999 1375.09 2202.87 percent of total billed charges VAPR COOL PULSE 90 ELECTRODE 228146 48713636_1 CDM 0272 RC inpatient 2271 1476.15 UMR - ALL PLANS UMR - ALL PLANS 1589.7 70 999999999 1375.09 2202.87 percent of total billed charges VAPR COOL PULSE 90 ELECTRODE 228146 48713636_1 CDM 0272 RC inpatient 2271 1476.15 SIHO - ALL PLANS SIHO - ALL PLANS 2043.9 90 999999999 1375.09 2202.87 percent of total billed charges VAPR COOL PULSE 90 ELECTRODE 228146 48713636_1 CDM 0272 RC inpatient 2271 1476.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1375.09 60.55 999999999 1375.09 2202.87 percent of total billed charges VAPR COOL PULSE 90 ELECTRODE 228146 48713636_1 CDM 0272 RC inpatient 2271 1476.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1375.09 2202.87 VAPR COOL PULSE 90 ELECTRODE 228146 48713636_1 CDM 0272 RC inpatient 2271 1476.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1375.09 2202.87 VAPR COOL PULSE 90 ELECTRODE 228146 48713636_1 CDM 0272 RC inpatient 2271 1476.15 ANTHEM HMO ANTHEM HMO 999999999 1375.09 2202.87 VAPR COOL PULSE 90 ELECTRODE 228146 48713636_1 CDM 0272 RC inpatient 2271 1476.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1535.2 67.6 999999999 1375.09 2202.87 percent of total billed charges VAPR COOL PULSE 90 ELECTRODE 228146 48713636_1 CDM 0272 RC inpatient 2271 1476.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1375.09 2202.87 VAPR COOL PULSE 90 ELECTRODE 228146 48713636_1 CDM 0272 RC inpatient 2271 1476.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1375.09 2202.87 VAPR HOOK ELECTRODE 48713637_1 CDM 0272 RC inpatient 93 60.45 AETNA AETNA 73.47 79 999999999 56.31 90.21 percent of total billed charges VAPR HOOK ELECTRODE 48713637_1 CDM 0272 RC inpatient 93 60.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 60.45 65 999999999 56.31 90.21 percent of total billed charges VAPR HOOK ELECTRODE 48713637_1 CDM 0272 RC inpatient 93 60.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 90.21 97 999999999 56.31 90.21 percent of total billed charges VAPR HOOK ELECTRODE 48713637_1 CDM 0272 RC inpatient 93 60.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.17 69 999999999 56.31 90.21 percent of total billed charges VAPR HOOK ELECTRODE 48713637_1 CDM 0272 RC inpatient 93 60.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 72.54 78 999999999 56.31 90.21 percent of total billed charges VAPR HOOK ELECTRODE 48713637_1 CDM 0272 RC inpatient 93 60.45 UMR - ALL PLANS UMR - ALL PLANS 65.1 70 999999999 56.31 90.21 percent of total billed charges VAPR HOOK ELECTRODE 48713637_1 CDM 0272 RC inpatient 93 60.45 SIHO - ALL PLANS SIHO - ALL PLANS 83.7 90 999999999 56.31 90.21 percent of total billed charges VAPR HOOK ELECTRODE 48713637_1 CDM 0272 RC inpatient 93 60.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.31 60.55 999999999 56.31 90.21 percent of total billed charges VAPR HOOK ELECTRODE 48713637_1 CDM 0272 RC inpatient 93 60.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.31 90.21 VAPR HOOK ELECTRODE 48713637_1 CDM 0272 RC inpatient 93 60.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.31 90.21 VAPR HOOK ELECTRODE 48713637_1 CDM 0272 RC inpatient 93 60.45 ANTHEM HMO ANTHEM HMO 999999999 56.31 90.21 VAPR HOOK ELECTRODE 48713637_1 CDM 0272 RC inpatient 93 60.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.87 67.6 999999999 56.31 90.21 percent of total billed charges VAPR HOOK ELECTRODE 48713637_1 CDM 0272 RC inpatient 93 60.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.31 90.21 VAPR HOOK ELECTRODE 48713637_1 CDM 0272 RC inpatient 93 60.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.31 90.21 PATIENT PROGRAMMER 3037 48713638_1 CDM 0278 RC inpatient 4103 2666.95 AETNA AETNA 3241.37 79 999999999 2484.37 3979.91 percent of total billed charges PATIENT PROGRAMMER 3037 48713638_1 CDM 0278 RC inpatient 4103 2666.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 2666.95 65 999999999 2484.37 3979.91 percent of total billed charges PATIENT PROGRAMMER 3037 48713638_1 CDM 0278 RC inpatient 4103 2666.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3979.91 97 999999999 2484.37 3979.91 percent of total billed charges PATIENT PROGRAMMER 3037 48713638_1 CDM 0278 RC inpatient 4103 2666.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 2831.07 69 999999999 2484.37 3979.91 percent of total billed charges PATIENT PROGRAMMER 3037 48713638_1 CDM 0278 RC inpatient 4103 2666.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 3200.34 78 999999999 2484.37 3979.91 percent of total billed charges PATIENT PROGRAMMER 3037 48713638_1 CDM 0278 RC inpatient 4103 2666.95 UMR - ALL PLANS UMR - ALL PLANS 2872.1 70 999999999 2484.37 3979.91 percent of total billed charges PATIENT PROGRAMMER 3037 48713638_1 CDM 0278 RC inpatient 4103 2666.95 SIHO - ALL PLANS SIHO - ALL PLANS 3692.7 90 999999999 2484.37 3979.91 percent of total billed charges PATIENT PROGRAMMER 3037 48713638_1 CDM 0278 RC inpatient 4103 2666.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2484.37 60.55 999999999 2484.37 3979.91 percent of total billed charges PATIENT PROGRAMMER 3037 48713638_1 CDM 0278 RC inpatient 4103 2666.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2484.37 3979.91 PATIENT PROGRAMMER 3037 48713638_1 CDM 0278 RC inpatient 4103 2666.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2484.37 3979.91 PATIENT PROGRAMMER 3037 48713638_1 CDM 0278 RC inpatient 4103 2666.95 ANTHEM HMO ANTHEM HMO 999999999 2484.37 3979.91 PATIENT PROGRAMMER 3037 48713638_1 CDM 0278 RC inpatient 4103 2666.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 2773.63 67.6 999999999 2484.37 3979.91 percent of total billed charges PATIENT PROGRAMMER 3037 48713638_1 CDM 0278 RC inpatient 4103 2666.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2484.37 3979.91 PATIENT PROGRAMMER 3037 48713638_1 CDM 0278 RC inpatient 4103 2666.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 2484.37 3979.91 VAPR COOL PULSE 90 W/HAND CONT 228147 48713639_1 CDM 0272 RC inpatient 2335 1517.75 AETNA AETNA 1844.65 79 999999999 1413.84 2264.95 percent of total billed charges VAPR COOL PULSE 90 W/HAND CONT 228147 48713639_1 CDM 0272 RC inpatient 2335 1517.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1517.75 65 999999999 1413.84 2264.95 percent of total billed charges VAPR COOL PULSE 90 W/HAND CONT 228147 48713639_1 CDM 0272 RC inpatient 2335 1517.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2264.95 97 999999999 1413.84 2264.95 percent of total billed charges VAPR COOL PULSE 90 W/HAND CONT 228147 48713639_1 CDM 0272 RC inpatient 2335 1517.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1611.15 69 999999999 1413.84 2264.95 percent of total billed charges VAPR COOL PULSE 90 W/HAND CONT 228147 48713639_1 CDM 0272 RC inpatient 2335 1517.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1821.3 78 999999999 1413.84 2264.95 percent of total billed charges VAPR COOL PULSE 90 W/HAND CONT 228147 48713639_1 CDM 0272 RC inpatient 2335 1517.75 UMR - ALL PLANS UMR - ALL PLANS 1634.5 70 999999999 1413.84 2264.95 percent of total billed charges VAPR COOL PULSE 90 W/HAND CONT 228147 48713639_1 CDM 0272 RC inpatient 2335 1517.75 SIHO - ALL PLANS SIHO - ALL PLANS 2101.5 90 999999999 1413.84 2264.95 percent of total billed charges VAPR COOL PULSE 90 W/HAND CONT 228147 48713639_1 CDM 0272 RC inpatient 2335 1517.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1413.84 60.55 999999999 1413.84 2264.95 percent of total billed charges VAPR COOL PULSE 90 W/HAND CONT 228147 48713639_1 CDM 0272 RC inpatient 2335 1517.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1413.84 2264.95 VAPR COOL PULSE 90 W/HAND CONT 228147 48713639_1 CDM 0272 RC inpatient 2335 1517.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1413.84 2264.95 VAPR COOL PULSE 90 W/HAND CONT 228147 48713639_1 CDM 0272 RC inpatient 2335 1517.75 ANTHEM HMO ANTHEM HMO 999999999 1413.84 2264.95 VAPR COOL PULSE 90 W/HAND CONT 228147 48713639_1 CDM 0272 RC inpatient 2335 1517.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1578.46 67.6 999999999 1413.84 2264.95 percent of total billed charges VAPR COOL PULSE 90 W/HAND CONT 228147 48713639_1 CDM 0272 RC inpatient 2335 1517.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1413.84 2264.95 VAPR COOL PULSE 90 W/HAND CONT 228147 48713639_1 CDM 0272 RC inpatient 2335 1517.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1413.84 2264.95 GUIDE WIRE 48713640_1 CDM 0272 RC C1769 HCPCS inpatient 193 125.45 AETNA AETNA 152.47 79 999999999 116.86 187.21 percent of total billed charges GUIDE WIRE 48713640_1 CDM 0272 RC C1769 HCPCS inpatient 193 125.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 125.45 65 999999999 116.86 187.21 percent of total billed charges GUIDE WIRE 48713640_1 CDM 0272 RC C1769 HCPCS inpatient 193 125.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 187.21 97 999999999 116.86 187.21 percent of total billed charges GUIDE WIRE 48713640_1 CDM 0272 RC C1769 HCPCS inpatient 193 125.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.17 69 999999999 116.86 187.21 percent of total billed charges GUIDE WIRE 48713640_1 CDM 0272 RC C1769 HCPCS inpatient 193 125.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 150.54 78 999999999 116.86 187.21 percent of total billed charges GUIDE WIRE 48713640_1 CDM 0272 RC C1769 HCPCS inpatient 193 125.45 UMR - ALL PLANS UMR - ALL PLANS 135.1 70 999999999 116.86 187.21 percent of total billed charges GUIDE WIRE 48713640_1 CDM 0272 RC C1769 HCPCS inpatient 193 125.45 SIHO - ALL PLANS SIHO - ALL PLANS 173.7 90 999999999 116.86 187.21 percent of total billed charges GUIDE WIRE 48713640_1 CDM 0272 RC C1769 HCPCS inpatient 193 125.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.86 60.55 999999999 116.86 187.21 percent of total billed charges GUIDE WIRE 48713640_1 CDM 0272 RC C1769 HCPCS inpatient 193 125.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.86 187.21 GUIDE WIRE 48713640_1 CDM 0272 RC C1769 HCPCS inpatient 193 125.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.86 187.21 GUIDE WIRE 48713640_1 CDM 0272 RC C1769 HCPCS inpatient 193 125.45 ANTHEM HMO ANTHEM HMO 999999999 116.86 187.21 GUIDE WIRE 48713640_1 CDM 0272 RC C1769 HCPCS inpatient 193 125.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 130.47 67.6 999999999 116.86 187.21 percent of total billed charges GUIDE WIRE 48713640_1 CDM 0272 RC C1769 HCPCS inpatient 193 125.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.86 187.21 GUIDE WIRE 48713640_1 CDM 0272 RC C1769 HCPCS inpatient 193 125.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.86 187.21 DILATOR ESOPH BALLOON 18-20MM 48713641_1 CDM 0272 RC inpatient 1253 814.45 AETNA AETNA 989.87 79 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 18-20MM 48713641_1 CDM 0272 RC inpatient 1253 814.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 814.45 65 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 18-20MM 48713641_1 CDM 0272 RC inpatient 1253 814.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1215.41 97 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 18-20MM 48713641_1 CDM 0272 RC inpatient 1253 814.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 864.57 69 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 18-20MM 48713641_1 CDM 0272 RC inpatient 1253 814.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 977.34 78 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 18-20MM 48713641_1 CDM 0272 RC inpatient 1253 814.45 UMR - ALL PLANS UMR - ALL PLANS 877.1 70 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 18-20MM 48713641_1 CDM 0272 RC inpatient 1253 814.45 SIHO - ALL PLANS SIHO - ALL PLANS 1127.7 90 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 18-20MM 48713641_1 CDM 0272 RC inpatient 1253 814.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 758.69 60.55 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 18-20MM 48713641_1 CDM 0272 RC inpatient 1253 814.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 758.69 1215.41 DILATOR ESOPH BALLOON 18-20MM 48713641_1 CDM 0272 RC inpatient 1253 814.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 758.69 1215.41 DILATOR ESOPH BALLOON 18-20MM 48713641_1 CDM 0272 RC inpatient 1253 814.45 ANTHEM HMO ANTHEM HMO 999999999 758.69 1215.41 DILATOR ESOPH BALLOON 18-20MM 48713641_1 CDM 0272 RC inpatient 1253 814.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 847.03 67.6 999999999 758.69 1215.41 percent of total billed charges DILATOR ESOPH BALLOON 18-20MM 48713641_1 CDM 0272 RC inpatient 1253 814.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 758.69 1215.41 DILATOR ESOPH BALLOON 18-20MM 48713641_1 CDM 0272 RC inpatient 1253 814.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 758.69 1215.41 SEGURA STONE R-BASKET 380-112 48713642_1 CDM 0272 RC inpatient 1160 754 AETNA AETNA 916.4 79 999999999 702.38 1125.2 percent of total billed charges SEGURA STONE R-BASKET 380-112 48713642_1 CDM 0272 RC inpatient 1160 754 SELF PAY DISCOUNT SELF PAY DISCOUNT 754 65 999999999 702.38 1125.2 percent of total billed charges SEGURA STONE R-BASKET 380-112 48713642_1 CDM 0272 RC inpatient 1160 754 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1125.2 97 999999999 702.38 1125.2 percent of total billed charges SEGURA STONE R-BASKET 380-112 48713642_1 CDM 0272 RC inpatient 1160 754 ENCORE - ALL PLANS ENCORE - ALL PLANS 800.4 69 999999999 702.38 1125.2 percent of total billed charges SEGURA STONE R-BASKET 380-112 48713642_1 CDM 0272 RC inpatient 1160 754 HUMANA - ALL PLANS HUMANA - ALL PLANS 904.8 78 999999999 702.38 1125.2 percent of total billed charges SEGURA STONE R-BASKET 380-112 48713642_1 CDM 0272 RC inpatient 1160 754 UMR - ALL PLANS UMR - ALL PLANS 812 70 999999999 702.38 1125.2 percent of total billed charges SEGURA STONE R-BASKET 380-112 48713642_1 CDM 0272 RC inpatient 1160 754 SIHO - ALL PLANS SIHO - ALL PLANS 1044 90 999999999 702.38 1125.2 percent of total billed charges SEGURA STONE R-BASKET 380-112 48713642_1 CDM 0272 RC inpatient 1160 754 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 702.38 60.55 999999999 702.38 1125.2 percent of total billed charges SEGURA STONE R-BASKET 380-112 48713642_1 CDM 0272 RC inpatient 1160 754 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 702.38 1125.2 SEGURA STONE R-BASKET 380-112 48713642_1 CDM 0272 RC inpatient 1160 754 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 702.38 1125.2 SEGURA STONE R-BASKET 380-112 48713642_1 CDM 0272 RC inpatient 1160 754 ANTHEM HMO ANTHEM HMO 999999999 702.38 1125.2 SEGURA STONE R-BASKET 380-112 48713642_1 CDM 0272 RC inpatient 1160 754 CIGNA - ALL PLANS CIGNA - ALL PLANS 784.16 67.6 999999999 702.38 1125.2 percent of total billed charges SEGURA STONE R-BASKET 380-112 48713642_1 CDM 0272 RC inpatient 1160 754 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 702.38 1125.2 SEGURA STONE R-BASKET 380-112 48713642_1 CDM 0272 RC inpatient 1160 754 UHC - ALL PLANS UHC - ALL PLANS 999999999 702.38 1125.2 GUIDEWIRE SUPER STIFF.038 14BX 48713643_1 CDM 0272 RC inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges GUIDEWIRE SUPER STIFF.038 14BX 48713643_1 CDM 0272 RC inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges GUIDEWIRE SUPER STIFF.038 14BX 48713643_1 CDM 0272 RC inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges GUIDEWIRE SUPER STIFF.038 14BX 48713643_1 CDM 0272 RC inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges GUIDEWIRE SUPER STIFF.038 14BX 48713643_1 CDM 0272 RC inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges GUIDEWIRE SUPER STIFF.038 14BX 48713643_1 CDM 0272 RC inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges GUIDEWIRE SUPER STIFF.038 14BX 48713643_1 CDM 0272 RC inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges GUIDEWIRE SUPER STIFF.038 14BX 48713643_1 CDM 0272 RC inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges GUIDEWIRE SUPER STIFF.038 14BX 48713643_1 CDM 0272 RC inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 GUIDEWIRE SUPER STIFF.038 14BX 48713643_1 CDM 0272 RC inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 GUIDEWIRE SUPER STIFF.038 14BX 48713643_1 CDM 0272 RC inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 GUIDEWIRE SUPER STIFF.038 14BX 48713643_1 CDM 0272 RC inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges GUIDEWIRE SUPER STIFF.038 14BX 48713643_1 CDM 0272 RC inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 GUIDEWIRE SUPER STIFF.038 14BX 48713643_1 CDM 0272 RC inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713644_1 CDM 0278 RC C1874 HCPCS inpatient 2496 1622.4 AETNA AETNA 1971.84 79 999999999 1511.33 2421.12 percent of total billed charges "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713644_1 CDM 0278 RC C1874 HCPCS inpatient 2496 1622.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1622.4 65 999999999 1511.33 2421.12 percent of total billed charges "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713644_1 CDM 0278 RC C1874 HCPCS inpatient 2496 1622.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2421.12 97 999999999 1511.33 2421.12 percent of total billed charges "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713644_1 CDM 0278 RC C1874 HCPCS inpatient 2496 1622.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1722.24 69 999999999 1511.33 2421.12 percent of total billed charges "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713644_1 CDM 0278 RC C1874 HCPCS inpatient 2496 1622.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1946.88 78 999999999 1511.33 2421.12 percent of total billed charges "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713644_1 CDM 0278 RC C1874 HCPCS inpatient 2496 1622.4 UMR - ALL PLANS UMR - ALL PLANS 1747.2 70 999999999 1511.33 2421.12 percent of total billed charges "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713644_1 CDM 0278 RC C1874 HCPCS inpatient 2496 1622.4 SIHO - ALL PLANS SIHO - ALL PLANS 2246.4 90 999999999 1511.33 2421.12 percent of total billed charges "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713644_1 CDM 0278 RC C1874 HCPCS inpatient 2496 1622.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1511.33 60.55 999999999 1511.33 2421.12 percent of total billed charges "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713644_1 CDM 0278 RC C1874 HCPCS inpatient 2496 1622.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1511.33 2421.12 "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713644_1 CDM 0278 RC C1874 HCPCS inpatient 2496 1622.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1511.33 2421.12 "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713644_1 CDM 0278 RC C1874 HCPCS inpatient 2496 1622.4 ANTHEM HMO ANTHEM HMO 999999999 1511.33 2421.12 "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713644_1 CDM 0278 RC C1874 HCPCS inpatient 2496 1622.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1687.3 67.6 999999999 1511.33 2421.12 percent of total billed charges "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713644_1 CDM 0278 RC C1874 HCPCS inpatient 2496 1622.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1511.33 2421.12 "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713644_1 CDM 0278 RC C1874 HCPCS inpatient 2496 1622.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1511.33 2421.12 ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE MED YELLOW A-30522-3-A8 48713645_1 CDM 0272 RC inpatient 172 111.8 AETNA AETNA 135.88 79 999999999 104.15 166.84 percent of total billed charges ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE MED YELLOW A-30522-3-A8 48713645_1 CDM 0272 RC inpatient 172 111.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.8 65 999999999 104.15 166.84 percent of total billed charges ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE MED YELLOW A-30522-3-A8 48713645_1 CDM 0272 RC inpatient 172 111.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 166.84 97 999999999 104.15 166.84 percent of total billed charges ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE MED YELLOW A-30522-3-A8 48713645_1 CDM 0272 RC inpatient 172 111.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 118.68 69 999999999 104.15 166.84 percent of total billed charges ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE MED YELLOW A-30522-3-A8 48713645_1 CDM 0272 RC inpatient 172 111.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.16 78 999999999 104.15 166.84 percent of total billed charges ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE MED YELLOW A-30522-3-A8 48713645_1 CDM 0272 RC inpatient 172 111.8 UMR - ALL PLANS UMR - ALL PLANS 120.4 70 999999999 104.15 166.84 percent of total billed charges ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE MED YELLOW A-30522-3-A8 48713645_1 CDM 0272 RC inpatient 172 111.8 SIHO - ALL PLANS SIHO - ALL PLANS 154.8 90 999999999 104.15 166.84 percent of total billed charges ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE MED YELLOW A-30522-3-A8 48713645_1 CDM 0272 RC inpatient 172 111.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.15 60.55 999999999 104.15 166.84 percent of total billed charges ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE MED YELLOW A-30522-3-A8 48713645_1 CDM 0272 RC inpatient 172 111.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.15 166.84 ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE MED YELLOW A-30522-3-A8 48713645_1 CDM 0272 RC inpatient 172 111.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.15 166.84 ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE MED YELLOW A-30522-3-A8 48713645_1 CDM 0272 RC inpatient 172 111.8 ANTHEM HMO ANTHEM HMO 999999999 104.15 166.84 ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE MED YELLOW A-30522-3-A8 48713645_1 CDM 0272 RC inpatient 172 111.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.27 67.6 999999999 104.15 166.84 percent of total billed charges ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE MED YELLOW A-30522-3-A8 48713645_1 CDM 0272 RC inpatient 172 111.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.15 166.84 ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE MED YELLOW A-30522-3-A8 48713645_1 CDM 0272 RC inpatient 172 111.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.15 166.84 ****BLANKET PER MEGAN FINGER TRAP DOUBLE SM RED 48713646_1 CDM 0272 RC inpatient 155 100.75 AETNA AETNA 122.45 79 999999999 93.85 150.35 percent of total billed charges ****BLANKET PER MEGAN FINGER TRAP DOUBLE SM RED 48713646_1 CDM 0272 RC inpatient 155 100.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.75 65 999999999 93.85 150.35 percent of total billed charges ****BLANKET PER MEGAN FINGER TRAP DOUBLE SM RED 48713646_1 CDM 0272 RC inpatient 155 100.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 150.35 97 999999999 93.85 150.35 percent of total billed charges ****BLANKET PER MEGAN FINGER TRAP DOUBLE SM RED 48713646_1 CDM 0272 RC inpatient 155 100.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.95 69 999999999 93.85 150.35 percent of total billed charges ****BLANKET PER MEGAN FINGER TRAP DOUBLE SM RED 48713646_1 CDM 0272 RC inpatient 155 100.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.9 78 999999999 93.85 150.35 percent of total billed charges ****BLANKET PER MEGAN FINGER TRAP DOUBLE SM RED 48713646_1 CDM 0272 RC inpatient 155 100.75 UMR - ALL PLANS UMR - ALL PLANS 108.5 70 999999999 93.85 150.35 percent of total billed charges ****BLANKET PER MEGAN FINGER TRAP DOUBLE SM RED 48713646_1 CDM 0272 RC inpatient 155 100.75 SIHO - ALL PLANS SIHO - ALL PLANS 139.5 90 999999999 93.85 150.35 percent of total billed charges ****BLANKET PER MEGAN FINGER TRAP DOUBLE SM RED 48713646_1 CDM 0272 RC inpatient 155 100.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.85 60.55 999999999 93.85 150.35 percent of total billed charges ****BLANKET PER MEGAN FINGER TRAP DOUBLE SM RED 48713646_1 CDM 0272 RC inpatient 155 100.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.85 150.35 ****BLANKET PER MEGAN FINGER TRAP DOUBLE SM RED 48713646_1 CDM 0272 RC inpatient 155 100.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.85 150.35 ****BLANKET PER MEGAN FINGER TRAP DOUBLE SM RED 48713646_1 CDM 0272 RC inpatient 155 100.75 ANTHEM HMO ANTHEM HMO 999999999 93.85 150.35 ****BLANKET PER MEGAN FINGER TRAP DOUBLE SM RED 48713646_1 CDM 0272 RC inpatient 155 100.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.78 67.6 999999999 93.85 150.35 percent of total billed charges ****BLANKET PER MEGAN FINGER TRAP DOUBLE SM RED 48713646_1 CDM 0272 RC inpatient 155 100.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.85 150.35 ****BLANKET PER MEGAN FINGER TRAP DOUBLE SM RED 48713646_1 CDM 0272 RC inpatient 155 100.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.85 150.35 ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE LG BLUE 48713647_1 CDM 0271 RC inpatient 172 111.8 AETNA AETNA 135.88 79 999999999 104.15 166.84 percent of total billed charges ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE LG BLUE 48713647_1 CDM 0271 RC inpatient 172 111.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.8 65 999999999 104.15 166.84 percent of total billed charges ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE LG BLUE 48713647_1 CDM 0271 RC inpatient 172 111.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 166.84 97 999999999 104.15 166.84 percent of total billed charges ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE LG BLUE 48713647_1 CDM 0271 RC inpatient 172 111.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 118.68 69 999999999 104.15 166.84 percent of total billed charges ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE LG BLUE 48713647_1 CDM 0271 RC inpatient 172 111.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.16 78 999999999 104.15 166.84 percent of total billed charges ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE LG BLUE 48713647_1 CDM 0271 RC inpatient 172 111.8 UMR - ALL PLANS UMR - ALL PLANS 120.4 70 999999999 104.15 166.84 percent of total billed charges ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE LG BLUE 48713647_1 CDM 0271 RC inpatient 172 111.8 SIHO - ALL PLANS SIHO - ALL PLANS 154.8 90 999999999 104.15 166.84 percent of total billed charges ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE LG BLUE 48713647_1 CDM 0271 RC inpatient 172 111.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.15 60.55 999999999 104.15 166.84 percent of total billed charges ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE LG BLUE 48713647_1 CDM 0271 RC inpatient 172 111.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.15 166.84 ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE LG BLUE 48713647_1 CDM 0271 RC inpatient 172 111.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.15 166.84 ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE LG BLUE 48713647_1 CDM 0271 RC inpatient 172 111.8 ANTHEM HMO ANTHEM HMO 999999999 104.15 166.84 ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE LG BLUE 48713647_1 CDM 0271 RC inpatient 172 111.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.27 67.6 999999999 104.15 166.84 percent of total billed charges ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE LG BLUE 48713647_1 CDM 0271 RC inpatient 172 111.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.15 166.84 ****** BLANKET BY M. PALMER 07/26/2023***** FINGER TRAP DOUBLE LG BLUE 48713647_1 CDM 0271 RC inpatient 172 111.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.15 166.84 WAFFLE HEEL ELEVATOR MDT6300CS 48713648_1 CDM 0272 RC inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges WAFFLE HEEL ELEVATOR MDT6300CS 48713648_1 CDM 0272 RC inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges WAFFLE HEEL ELEVATOR MDT6300CS 48713648_1 CDM 0272 RC inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges WAFFLE HEEL ELEVATOR MDT6300CS 48713648_1 CDM 0272 RC inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges WAFFLE HEEL ELEVATOR MDT6300CS 48713648_1 CDM 0272 RC inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges WAFFLE HEEL ELEVATOR MDT6300CS 48713648_1 CDM 0272 RC inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges WAFFLE HEEL ELEVATOR MDT6300CS 48713648_1 CDM 0272 RC inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges WAFFLE HEEL ELEVATOR MDT6300CS 48713648_1 CDM 0272 RC inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges WAFFLE HEEL ELEVATOR MDT6300CS 48713648_1 CDM 0272 RC inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 WAFFLE HEEL ELEVATOR MDT6300CS 48713648_1 CDM 0272 RC inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 WAFFLE HEEL ELEVATOR MDT6300CS 48713648_1 CDM 0272 RC inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 WAFFLE HEEL ELEVATOR MDT6300CS 48713648_1 CDM 0272 RC inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges WAFFLE HEEL ELEVATOR MDT6300CS 48713648_1 CDM 0272 RC inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 WAFFLE HEEL ELEVATOR MDT6300CS 48713648_1 CDM 0272 RC inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 WAFFLE SEAT CUSHION MSCBUB1818H 48713649_1 CDM 0272 RC inpatient 134 87.1 AETNA AETNA 105.86 79 999999999 81.14 129.98 percent of total billed charges WAFFLE SEAT CUSHION MSCBUB1818H 48713649_1 CDM 0272 RC inpatient 134 87.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 87.1 65 999999999 81.14 129.98 percent of total billed charges WAFFLE SEAT CUSHION MSCBUB1818H 48713649_1 CDM 0272 RC inpatient 134 87.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.98 97 999999999 81.14 129.98 percent of total billed charges WAFFLE SEAT CUSHION MSCBUB1818H 48713649_1 CDM 0272 RC inpatient 134 87.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 92.46 69 999999999 81.14 129.98 percent of total billed charges WAFFLE SEAT CUSHION MSCBUB1818H 48713649_1 CDM 0272 RC inpatient 134 87.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 104.52 78 999999999 81.14 129.98 percent of total billed charges WAFFLE SEAT CUSHION MSCBUB1818H 48713649_1 CDM 0272 RC inpatient 134 87.1 UMR - ALL PLANS UMR - ALL PLANS 93.8 70 999999999 81.14 129.98 percent of total billed charges WAFFLE SEAT CUSHION MSCBUB1818H 48713649_1 CDM 0272 RC inpatient 134 87.1 SIHO - ALL PLANS SIHO - ALL PLANS 120.6 90 999999999 81.14 129.98 percent of total billed charges WAFFLE SEAT CUSHION MSCBUB1818H 48713649_1 CDM 0272 RC inpatient 134 87.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 81.14 60.55 999999999 81.14 129.98 percent of total billed charges WAFFLE SEAT CUSHION MSCBUB1818H 48713649_1 CDM 0272 RC inpatient 134 87.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 81.14 129.98 WAFFLE SEAT CUSHION MSCBUB1818H 48713649_1 CDM 0272 RC inpatient 134 87.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 81.14 129.98 WAFFLE SEAT CUSHION MSCBUB1818H 48713649_1 CDM 0272 RC inpatient 134 87.1 ANTHEM HMO ANTHEM HMO 999999999 81.14 129.98 WAFFLE SEAT CUSHION MSCBUB1818H 48713649_1 CDM 0272 RC inpatient 134 87.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 90.58 67.6 999999999 81.14 129.98 percent of total billed charges WAFFLE SEAT CUSHION MSCBUB1818H 48713649_1 CDM 0272 RC inpatient 134 87.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 81.14 129.98 WAFFLE SEAT CUSHION MSCBUB1818H 48713649_1 CDM 0272 RC inpatient 134 87.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 81.14 129.98 BARIATRIC WAFFLE OVERLAY 48713650_1 CDM 0271 RC inpatient 629 408.85 AETNA AETNA 496.91 79 999999999 380.86 610.13 percent of total billed charges BARIATRIC WAFFLE OVERLAY 48713650_1 CDM 0271 RC inpatient 629 408.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 408.85 65 999999999 380.86 610.13 percent of total billed charges BARIATRIC WAFFLE OVERLAY 48713650_1 CDM 0271 RC inpatient 629 408.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 610.13 97 999999999 380.86 610.13 percent of total billed charges BARIATRIC WAFFLE OVERLAY 48713650_1 CDM 0271 RC inpatient 629 408.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 434.01 69 999999999 380.86 610.13 percent of total billed charges BARIATRIC WAFFLE OVERLAY 48713650_1 CDM 0271 RC inpatient 629 408.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 490.62 78 999999999 380.86 610.13 percent of total billed charges BARIATRIC WAFFLE OVERLAY 48713650_1 CDM 0271 RC inpatient 629 408.85 UMR - ALL PLANS UMR - ALL PLANS 440.3 70 999999999 380.86 610.13 percent of total billed charges BARIATRIC WAFFLE OVERLAY 48713650_1 CDM 0271 RC inpatient 629 408.85 SIHO - ALL PLANS SIHO - ALL PLANS 566.1 90 999999999 380.86 610.13 percent of total billed charges BARIATRIC WAFFLE OVERLAY 48713650_1 CDM 0271 RC inpatient 629 408.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 380.86 60.55 999999999 380.86 610.13 percent of total billed charges BARIATRIC WAFFLE OVERLAY 48713650_1 CDM 0271 RC inpatient 629 408.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 380.86 610.13 BARIATRIC WAFFLE OVERLAY 48713650_1 CDM 0271 RC inpatient 629 408.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 380.86 610.13 BARIATRIC WAFFLE OVERLAY 48713650_1 CDM 0271 RC inpatient 629 408.85 ANTHEM HMO ANTHEM HMO 999999999 380.86 610.13 BARIATRIC WAFFLE OVERLAY 48713650_1 CDM 0271 RC inpatient 629 408.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 425.2 67.6 999999999 380.86 610.13 percent of total billed charges BARIATRIC WAFFLE OVERLAY 48713650_1 CDM 0271 RC inpatient 629 408.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 380.86 610.13 BARIATRIC WAFFLE OVERLAY 48713650_1 CDM 0271 RC inpatient 629 408.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 380.86 610.13 WAFFLE CUSHION BARIATRIC 48713651_1 CDM 0271 RC inpatient 338 219.7 AETNA AETNA 267.02 79 999999999 204.66 327.86 percent of total billed charges WAFFLE CUSHION BARIATRIC 48713651_1 CDM 0271 RC inpatient 338 219.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 219.7 65 999999999 204.66 327.86 percent of total billed charges WAFFLE CUSHION BARIATRIC 48713651_1 CDM 0271 RC inpatient 338 219.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 327.86 97 999999999 204.66 327.86 percent of total billed charges WAFFLE CUSHION BARIATRIC 48713651_1 CDM 0271 RC inpatient 338 219.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 233.22 69 999999999 204.66 327.86 percent of total billed charges WAFFLE CUSHION BARIATRIC 48713651_1 CDM 0271 RC inpatient 338 219.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 263.64 78 999999999 204.66 327.86 percent of total billed charges WAFFLE CUSHION BARIATRIC 48713651_1 CDM 0271 RC inpatient 338 219.7 UMR - ALL PLANS UMR - ALL PLANS 236.6 70 999999999 204.66 327.86 percent of total billed charges WAFFLE CUSHION BARIATRIC 48713651_1 CDM 0271 RC inpatient 338 219.7 SIHO - ALL PLANS SIHO - ALL PLANS 304.2 90 999999999 204.66 327.86 percent of total billed charges WAFFLE CUSHION BARIATRIC 48713651_1 CDM 0271 RC inpatient 338 219.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 204.66 60.55 999999999 204.66 327.86 percent of total billed charges WAFFLE CUSHION BARIATRIC 48713651_1 CDM 0271 RC inpatient 338 219.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 204.66 327.86 WAFFLE CUSHION BARIATRIC 48713651_1 CDM 0271 RC inpatient 338 219.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 204.66 327.86 WAFFLE CUSHION BARIATRIC 48713651_1 CDM 0271 RC inpatient 338 219.7 ANTHEM HMO ANTHEM HMO 999999999 204.66 327.86 WAFFLE CUSHION BARIATRIC 48713651_1 CDM 0271 RC inpatient 338 219.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 228.49 67.6 999999999 204.66 327.86 percent of total billed charges WAFFLE CUSHION BARIATRIC 48713651_1 CDM 0271 RC inpatient 338 219.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 204.66 327.86 WAFFLE CUSHION BARIATRIC 48713651_1 CDM 0271 RC inpatient 338 219.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 204.66 327.86 "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713652_1 CDM 0278 RC C1874 HCPCS inpatient 243 157.95 AETNA AETNA 191.97 79 999999999 147.14 235.71 percent of total billed charges "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713652_1 CDM 0278 RC C1874 HCPCS inpatient 243 157.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 157.95 65 999999999 147.14 235.71 percent of total billed charges "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713652_1 CDM 0278 RC C1874 HCPCS inpatient 243 157.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 235.71 97 999999999 147.14 235.71 percent of total billed charges "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713652_1 CDM 0278 RC C1874 HCPCS inpatient 243 157.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 167.67 69 999999999 147.14 235.71 percent of total billed charges "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713652_1 CDM 0278 RC C1874 HCPCS inpatient 243 157.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 189.54 78 999999999 147.14 235.71 percent of total billed charges "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713652_1 CDM 0278 RC C1874 HCPCS inpatient 243 157.95 UMR - ALL PLANS UMR - ALL PLANS 170.1 70 999999999 147.14 235.71 percent of total billed charges "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713652_1 CDM 0278 RC C1874 HCPCS inpatient 243 157.95 SIHO - ALL PLANS SIHO - ALL PLANS 218.7 90 999999999 147.14 235.71 percent of total billed charges "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713652_1 CDM 0278 RC C1874 HCPCS inpatient 243 157.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.14 60.55 999999999 147.14 235.71 percent of total billed charges "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713652_1 CDM 0278 RC C1874 HCPCS inpatient 243 157.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.14 235.71 "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713652_1 CDM 0278 RC C1874 HCPCS inpatient 243 157.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.14 235.71 "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713652_1 CDM 0278 RC C1874 HCPCS inpatient 243 157.95 ANTHEM HMO ANTHEM HMO 999999999 147.14 235.71 "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713652_1 CDM 0278 RC C1874 HCPCS inpatient 243 157.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.27 67.6 999999999 147.14 235.71 percent of total billed charges "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713652_1 CDM 0278 RC C1874 HCPCS inpatient 243 157.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.14 235.71 "STENT, COATED/COVERED, WITH DELIVERY SYSTEM" 48713652_1 CDM 0278 RC C1874 HCPCS inpatient 243 157.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.14 235.71 STIMUCATH NERVE BLOCK AB19608K 48713653_1 CDM 0272 RC inpatient 619 402.35 AETNA AETNA 489.01 79 999999999 374.8 600.43 percent of total billed charges STIMUCATH NERVE BLOCK AB19608K 48713653_1 CDM 0272 RC inpatient 619 402.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 402.35 65 999999999 374.8 600.43 percent of total billed charges STIMUCATH NERVE BLOCK AB19608K 48713653_1 CDM 0272 RC inpatient 619 402.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 600.43 97 999999999 374.8 600.43 percent of total billed charges STIMUCATH NERVE BLOCK AB19608K 48713653_1 CDM 0272 RC inpatient 619 402.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 427.11 69 999999999 374.8 600.43 percent of total billed charges STIMUCATH NERVE BLOCK AB19608K 48713653_1 CDM 0272 RC inpatient 619 402.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 482.82 78 999999999 374.8 600.43 percent of total billed charges STIMUCATH NERVE BLOCK AB19608K 48713653_1 CDM 0272 RC inpatient 619 402.35 UMR - ALL PLANS UMR - ALL PLANS 433.3 70 999999999 374.8 600.43 percent of total billed charges STIMUCATH NERVE BLOCK AB19608K 48713653_1 CDM 0272 RC inpatient 619 402.35 SIHO - ALL PLANS SIHO - ALL PLANS 557.1 90 999999999 374.8 600.43 percent of total billed charges STIMUCATH NERVE BLOCK AB19608K 48713653_1 CDM 0272 RC inpatient 619 402.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 374.8 60.55 999999999 374.8 600.43 percent of total billed charges STIMUCATH NERVE BLOCK AB19608K 48713653_1 CDM 0272 RC inpatient 619 402.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 374.8 600.43 STIMUCATH NERVE BLOCK AB19608K 48713653_1 CDM 0272 RC inpatient 619 402.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 374.8 600.43 STIMUCATH NERVE BLOCK AB19608K 48713653_1 CDM 0272 RC inpatient 619 402.35 ANTHEM HMO ANTHEM HMO 999999999 374.8 600.43 STIMUCATH NERVE BLOCK AB19608K 48713653_1 CDM 0272 RC inpatient 619 402.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 418.44 67.6 999999999 374.8 600.43 percent of total billed charges STIMUCATH NERVE BLOCK AB19608K 48713653_1 CDM 0272 RC inpatient 619 402.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 374.8 600.43 STIMUCATH NERVE BLOCK AB19608K 48713653_1 CDM 0272 RC inpatient 619 402.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 374.8 600.43 IV START KIT CSS275A 48714043_1 CDM 0272 RC inpatient 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges IV START KIT CSS275A 48714043_1 CDM 0272 RC inpatient 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges IV START KIT CSS275A 48714043_1 CDM 0272 RC inpatient 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges IV START KIT CSS275A 48714043_1 CDM 0272 RC inpatient 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges IV START KIT CSS275A 48714043_1 CDM 0272 RC inpatient 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges IV START KIT CSS275A 48714043_1 CDM 0272 RC inpatient 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges IV START KIT CSS275A 48714043_1 CDM 0272 RC inpatient 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges IV START KIT CSS275A 48714043_1 CDM 0272 RC inpatient 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges IV START KIT CSS275A 48714043_1 CDM 0272 RC inpatient 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 IV START KIT CSS275A 48714043_1 CDM 0272 RC inpatient 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 IV START KIT CSS275A 48714043_1 CDM 0272 RC inpatient 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 IV START KIT CSS275A 48714043_1 CDM 0272 RC inpatient 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges IV START KIT CSS275A 48714043_1 CDM 0272 RC inpatient 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 IV START KIT CSS275A 48714043_1 CDM 0272 RC inpatient 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 ANGIOCATH 14GA X 3.25 382268 48714044_1 CDM 0272 RC inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges ANGIOCATH 14GA X 3.25 382268 48714044_1 CDM 0272 RC inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges ANGIOCATH 14GA X 3.25 382268 48714044_1 CDM 0272 RC inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges ANGIOCATH 14GA X 3.25 382268 48714044_1 CDM 0272 RC inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges ANGIOCATH 14GA X 3.25 382268 48714044_1 CDM 0272 RC inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges ANGIOCATH 14GA X 3.25 382268 48714044_1 CDM 0272 RC inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges ANGIOCATH 14GA X 3.25 382268 48714044_1 CDM 0272 RC inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges ANGIOCATH 14GA X 3.25 382268 48714044_1 CDM 0272 RC inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges ANGIOCATH 14GA X 3.25 382268 48714044_1 CDM 0272 RC inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 ANGIOCATH 14GA X 3.25 382268 48714044_1 CDM 0272 RC inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 ANGIOCATH 14GA X 3.25 382268 48714044_1 CDM 0272 RC inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 ANGIOCATH 14GA X 3.25 382268 48714044_1 CDM 0272 RC inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges ANGIOCATH 14GA X 3.25 382268 48714044_1 CDM 0272 RC inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 ANGIOCATH 14GA X 3.25 382268 48714044_1 CDM 0272 RC inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 "ANGIOCATH 12GA X 3"" 382277" 48714045_1 CDM 0272 RC inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges "ANGIOCATH 12GA X 3"" 382277" 48714045_1 CDM 0272 RC inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges "ANGIOCATH 12GA X 3"" 382277" 48714045_1 CDM 0272 RC inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges "ANGIOCATH 12GA X 3"" 382277" 48714045_1 CDM 0272 RC inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges "ANGIOCATH 12GA X 3"" 382277" 48714045_1 CDM 0272 RC inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges "ANGIOCATH 12GA X 3"" 382277" 48714045_1 CDM 0272 RC inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges "ANGIOCATH 12GA X 3"" 382277" 48714045_1 CDM 0272 RC inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges "ANGIOCATH 12GA X 3"" 382277" 48714045_1 CDM 0272 RC inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges "ANGIOCATH 12GA X 3"" 382277" 48714045_1 CDM 0272 RC inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 "ANGIOCATH 12GA X 3"" 382277" 48714045_1 CDM 0272 RC inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 "ANGIOCATH 12GA X 3"" 382277" 48714045_1 CDM 0272 RC inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 "ANGIOCATH 12GA X 3"" 382277" 48714045_1 CDM 0272 RC inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges "ANGIOCATH 12GA X 3"" 382277" 48714045_1 CDM 0272 RC inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 "ANGIOCATH 12GA X 3"" 382277" 48714045_1 CDM 0272 RC inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 ANGIOCATH 16GAX3.25 GRAY 382258 48714047_1 CDM 0272 RC inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges ANGIOCATH 16GAX3.25 GRAY 382258 48714047_1 CDM 0272 RC inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges ANGIOCATH 16GAX3.25 GRAY 382258 48714047_1 CDM 0272 RC inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges ANGIOCATH 16GAX3.25 GRAY 382258 48714047_1 CDM 0272 RC inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges ANGIOCATH 16GAX3.25 GRAY 382258 48714047_1 CDM 0272 RC inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges ANGIOCATH 16GAX3.25 GRAY 382258 48714047_1 CDM 0272 RC inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges ANGIOCATH 16GAX3.25 GRAY 382258 48714047_1 CDM 0272 RC inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges ANGIOCATH 16GAX3.25 GRAY 382258 48714047_1 CDM 0272 RC inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges ANGIOCATH 16GAX3.25 GRAY 382258 48714047_1 CDM 0272 RC inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 ANGIOCATH 16GAX3.25 GRAY 382258 48714047_1 CDM 0272 RC inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 ANGIOCATH 16GAX3.25 GRAY 382258 48714047_1 CDM 0272 RC inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 ANGIOCATH 16GAX3.25 GRAY 382258 48714047_1 CDM 0272 RC inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges ANGIOCATH 16GAX3.25 GRAY 382258 48714047_1 CDM 0272 RC inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 ANGIOCATH 16GAX3.25 GRAY 382258 48714047_1 CDM 0272 RC inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 INJECTION SITE M-PLUS MP1000-C 48714053_1 CDM 0272 RC inpatient 9 5.85 AETNA AETNA 7.11 79 999999999 5.45 8.73 percent of total billed charges INJECTION SITE M-PLUS MP1000-C 48714053_1 CDM 0272 RC inpatient 9 5.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.85 65 999999999 5.45 8.73 percent of total billed charges INJECTION SITE M-PLUS MP1000-C 48714053_1 CDM 0272 RC inpatient 9 5.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.73 97 999999999 5.45 8.73 percent of total billed charges INJECTION SITE M-PLUS MP1000-C 48714053_1 CDM 0272 RC inpatient 9 5.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.21 69 999999999 5.45 8.73 percent of total billed charges INJECTION SITE M-PLUS MP1000-C 48714053_1 CDM 0272 RC inpatient 9 5.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.02 78 999999999 5.45 8.73 percent of total billed charges INJECTION SITE M-PLUS MP1000-C 48714053_1 CDM 0272 RC inpatient 9 5.85 UMR - ALL PLANS UMR - ALL PLANS 6.3 70 999999999 5.45 8.73 percent of total billed charges INJECTION SITE M-PLUS MP1000-C 48714053_1 CDM 0272 RC inpatient 9 5.85 SIHO - ALL PLANS SIHO - ALL PLANS 8.1 90 999999999 5.45 8.73 percent of total billed charges INJECTION SITE M-PLUS MP1000-C 48714053_1 CDM 0272 RC inpatient 9 5.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.45 60.55 999999999 5.45 8.73 percent of total billed charges INJECTION SITE M-PLUS MP1000-C 48714053_1 CDM 0272 RC inpatient 9 5.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.45 8.73 INJECTION SITE M-PLUS MP1000-C 48714053_1 CDM 0272 RC inpatient 9 5.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.45 8.73 INJECTION SITE M-PLUS MP1000-C 48714053_1 CDM 0272 RC inpatient 9 5.85 ANTHEM HMO ANTHEM HMO 999999999 5.45 8.73 INJECTION SITE M-PLUS MP1000-C 48714053_1 CDM 0272 RC inpatient 9 5.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.08 67.6 999999999 5.45 8.73 percent of total billed charges INJECTION SITE M-PLUS MP1000-C 48714053_1 CDM 0272 RC inpatient 9 5.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.45 8.73 INJECTION SITE M-PLUS MP1000-C 48714053_1 CDM 0272 RC inpatient 9 5.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.45 8.73 "EXTENSION SET 8.5"" MP5303-C" 48714055_1 CDM 0272 RC inpatient 66 42.9 AETNA AETNA 52.14 79 999999999 39.96 64.02 percent of total billed charges "EXTENSION SET 8.5"" MP5303-C" 48714055_1 CDM 0272 RC inpatient 66 42.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.9 65 999999999 39.96 64.02 percent of total billed charges "EXTENSION SET 8.5"" MP5303-C" 48714055_1 CDM 0272 RC inpatient 66 42.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.02 97 999999999 39.96 64.02 percent of total billed charges "EXTENSION SET 8.5"" MP5303-C" 48714055_1 CDM 0272 RC inpatient 66 42.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.54 69 999999999 39.96 64.02 percent of total billed charges "EXTENSION SET 8.5"" MP5303-C" 48714055_1 CDM 0272 RC inpatient 66 42.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.48 78 999999999 39.96 64.02 percent of total billed charges "EXTENSION SET 8.5"" MP5303-C" 48714055_1 CDM 0272 RC inpatient 66 42.9 UMR - ALL PLANS UMR - ALL PLANS 46.2 70 999999999 39.96 64.02 percent of total billed charges "EXTENSION SET 8.5"" MP5303-C" 48714055_1 CDM 0272 RC inpatient 66 42.9 SIHO - ALL PLANS SIHO - ALL PLANS 59.4 90 999999999 39.96 64.02 percent of total billed charges "EXTENSION SET 8.5"" MP5303-C" 48714055_1 CDM 0272 RC inpatient 66 42.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.96 60.55 999999999 39.96 64.02 percent of total billed charges "EXTENSION SET 8.5"" MP5303-C" 48714055_1 CDM 0272 RC inpatient 66 42.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.96 64.02 "EXTENSION SET 8.5"" MP5303-C" 48714055_1 CDM 0272 RC inpatient 66 42.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.96 64.02 "EXTENSION SET 8.5"" MP5303-C" 48714055_1 CDM 0272 RC inpatient 66 42.9 ANTHEM HMO ANTHEM HMO 999999999 39.96 64.02 "EXTENSION SET 8.5"" MP5303-C" 48714055_1 CDM 0272 RC inpatient 66 42.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.62 67.6 999999999 39.96 64.02 percent of total billed charges "EXTENSION SET 8.5"" MP5303-C" 48714055_1 CDM 0272 RC inpatient 66 42.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.96 64.02 "EXTENSION SET 8.5"" MP5303-C" 48714055_1 CDM 0272 RC inpatient 66 42.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.96 64.02 SAF-T INTIMA 20Gx1 #383336 48714059_1 CDM 0272 RC inpatient 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 20Gx1 #383336 48714059_1 CDM 0272 RC inpatient 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 20Gx1 #383336 48714059_1 CDM 0272 RC inpatient 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 20Gx1 #383336 48714059_1 CDM 0272 RC inpatient 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 20Gx1 #383336 48714059_1 CDM 0272 RC inpatient 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 20Gx1 #383336 48714059_1 CDM 0272 RC inpatient 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 20Gx1 #383336 48714059_1 CDM 0272 RC inpatient 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 20Gx1 #383336 48714059_1 CDM 0272 RC inpatient 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 20Gx1 #383336 48714059_1 CDM 0272 RC inpatient 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 SAF-T INTIMA 20Gx1 #383336 48714059_1 CDM 0272 RC inpatient 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 SAF-T INTIMA 20Gx1 #383336 48714059_1 CDM 0272 RC inpatient 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 SAF-T INTIMA 20Gx1 #383336 48714059_1 CDM 0272 RC inpatient 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 20Gx1 #383336 48714059_1 CDM 0272 RC inpatient 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 SAF-T INTIMA 20Gx1 #383336 48714059_1 CDM 0272 RC inpatient 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 SAF-T INTIMA 22Gx3/4 383323 48714060_1 CDM 0270 RC inpatient 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 22Gx3/4 383323 48714060_1 CDM 0270 RC inpatient 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 22Gx3/4 383323 48714060_1 CDM 0270 RC inpatient 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 22Gx3/4 383323 48714060_1 CDM 0270 RC inpatient 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 22Gx3/4 383323 48714060_1 CDM 0270 RC inpatient 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 22Gx3/4 383323 48714060_1 CDM 0270 RC inpatient 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 22Gx3/4 383323 48714060_1 CDM 0270 RC inpatient 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 22Gx3/4 383323 48714060_1 CDM 0270 RC inpatient 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 22Gx3/4 383323 48714060_1 CDM 0270 RC inpatient 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 SAF-T INTIMA 22Gx3/4 383323 48714060_1 CDM 0270 RC inpatient 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 SAF-T INTIMA 22Gx3/4 383323 48714060_1 CDM 0270 RC inpatient 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 SAF-T INTIMA 22Gx3/4 383323 48714060_1 CDM 0270 RC inpatient 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 22Gx3/4 383323 48714060_1 CDM 0270 RC inpatient 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 SAF-T INTIMA 22Gx3/4 383323 48714060_1 CDM 0270 RC inpatient 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 SAF-T INTIMA 24x3/4 383313 48714061_1 CDM 0272 RC inpatient 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 24x3/4 383313 48714061_1 CDM 0272 RC inpatient 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 24x3/4 383313 48714061_1 CDM 0272 RC inpatient 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 24x3/4 383313 48714061_1 CDM 0272 RC inpatient 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 24x3/4 383313 48714061_1 CDM 0272 RC inpatient 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 24x3/4 383313 48714061_1 CDM 0272 RC inpatient 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 24x3/4 383313 48714061_1 CDM 0272 RC inpatient 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 24x3/4 383313 48714061_1 CDM 0272 RC inpatient 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 24x3/4 383313 48714061_1 CDM 0272 RC inpatient 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 SAF-T INTIMA 24x3/4 383313 48714061_1 CDM 0272 RC inpatient 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 SAF-T INTIMA 24x3/4 383313 48714061_1 CDM 0272 RC inpatient 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 SAF-T INTIMA 24x3/4 383313 48714061_1 CDM 0272 RC inpatient 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges SAF-T INTIMA 24x3/4 383313 48714061_1 CDM 0272 RC inpatient 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 SAF-T INTIMA 24x3/4 383313 48714061_1 CDM 0272 RC inpatient 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 INSYTE AUTO 20G X 1 381433 48714062_1 CDM 0270 RC inpatient 13 8.45 AETNA AETNA 10.27 79 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20G X 1 381433 48714062_1 CDM 0270 RC inpatient 13 8.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.45 65 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20G X 1 381433 48714062_1 CDM 0270 RC inpatient 13 8.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.61 97 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20G X 1 381433 48714062_1 CDM 0270 RC inpatient 13 8.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.97 69 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20G X 1 381433 48714062_1 CDM 0270 RC inpatient 13 8.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.14 78 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20G X 1 381433 48714062_1 CDM 0270 RC inpatient 13 8.45 UMR - ALL PLANS UMR - ALL PLANS 9.1 70 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20G X 1 381433 48714062_1 CDM 0270 RC inpatient 13 8.45 SIHO - ALL PLANS SIHO - ALL PLANS 11.7 90 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20G X 1 381433 48714062_1 CDM 0270 RC inpatient 13 8.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.87 60.55 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20G X 1 381433 48714062_1 CDM 0270 RC inpatient 13 8.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.87 12.61 INSYTE AUTO 20G X 1 381433 48714062_1 CDM 0270 RC inpatient 13 8.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.87 12.61 INSYTE AUTO 20G X 1 381433 48714062_1 CDM 0270 RC inpatient 13 8.45 ANTHEM HMO ANTHEM HMO 999999999 7.87 12.61 INSYTE AUTO 20G X 1 381433 48714062_1 CDM 0270 RC inpatient 13 8.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.79 67.6 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20G X 1 381433 48714062_1 CDM 0270 RC inpatient 13 8.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.87 12.61 INSYTE AUTO 20G X 1 381433 48714062_1 CDM 0270 RC inpatient 13 8.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.87 12.61 INSYTE AUTO 24Gx3/4 381412 48714063_1 CDM 0272 RC inpatient 13 8.45 AETNA AETNA 10.27 79 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 24Gx3/4 381412 48714063_1 CDM 0272 RC inpatient 13 8.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.45 65 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 24Gx3/4 381412 48714063_1 CDM 0272 RC inpatient 13 8.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.61 97 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 24Gx3/4 381412 48714063_1 CDM 0272 RC inpatient 13 8.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.97 69 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 24Gx3/4 381412 48714063_1 CDM 0272 RC inpatient 13 8.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.14 78 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 24Gx3/4 381412 48714063_1 CDM 0272 RC inpatient 13 8.45 UMR - ALL PLANS UMR - ALL PLANS 9.1 70 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 24Gx3/4 381412 48714063_1 CDM 0272 RC inpatient 13 8.45 SIHO - ALL PLANS SIHO - ALL PLANS 11.7 90 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 24Gx3/4 381412 48714063_1 CDM 0272 RC inpatient 13 8.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.87 60.55 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 24Gx3/4 381412 48714063_1 CDM 0272 RC inpatient 13 8.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.87 12.61 INSYTE AUTO 24Gx3/4 381412 48714063_1 CDM 0272 RC inpatient 13 8.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.87 12.61 INSYTE AUTO 24Gx3/4 381412 48714063_1 CDM 0272 RC inpatient 13 8.45 ANTHEM HMO ANTHEM HMO 999999999 7.87 12.61 INSYTE AUTO 24Gx3/4 381412 48714063_1 CDM 0272 RC inpatient 13 8.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.79 67.6 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 24Gx3/4 381412 48714063_1 CDM 0272 RC inpatient 13 8.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.87 12.61 INSYTE AUTO 24Gx3/4 381412 48714063_1 CDM 0272 RC inpatient 13 8.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.87 12.61 INSYTE AUTO 22x1 381423 48714064_1 CDM 0272 RC inpatient 13 8.45 AETNA AETNA 10.27 79 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 22x1 381423 48714064_1 CDM 0272 RC inpatient 13 8.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.45 65 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 22x1 381423 48714064_1 CDM 0272 RC inpatient 13 8.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.61 97 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 22x1 381423 48714064_1 CDM 0272 RC inpatient 13 8.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.97 69 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 22x1 381423 48714064_1 CDM 0272 RC inpatient 13 8.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.14 78 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 22x1 381423 48714064_1 CDM 0272 RC inpatient 13 8.45 UMR - ALL PLANS UMR - ALL PLANS 9.1 70 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 22x1 381423 48714064_1 CDM 0272 RC inpatient 13 8.45 SIHO - ALL PLANS SIHO - ALL PLANS 11.7 90 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 22x1 381423 48714064_1 CDM 0272 RC inpatient 13 8.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.87 60.55 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 22x1 381423 48714064_1 CDM 0272 RC inpatient 13 8.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.87 12.61 INSYTE AUTO 22x1 381423 48714064_1 CDM 0272 RC inpatient 13 8.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.87 12.61 INSYTE AUTO 22x1 381423 48714064_1 CDM 0272 RC inpatient 13 8.45 ANTHEM HMO ANTHEM HMO 999999999 7.87 12.61 INSYTE AUTO 22x1 381423 48714064_1 CDM 0272 RC inpatient 13 8.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.79 67.6 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 22x1 381423 48714064_1 CDM 0272 RC inpatient 13 8.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.87 12.61 INSYTE AUTO 22x1 381423 48714064_1 CDM 0272 RC inpatient 13 8.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.87 12.61 INSYTE AUTO 20 x1.16 BD 381434 48714065_1 CDM 0272 RC inpatient 13 8.45 AETNA AETNA 10.27 79 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20 x1.16 BD 381434 48714065_1 CDM 0272 RC inpatient 13 8.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.45 65 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20 x1.16 BD 381434 48714065_1 CDM 0272 RC inpatient 13 8.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.61 97 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20 x1.16 BD 381434 48714065_1 CDM 0272 RC inpatient 13 8.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.97 69 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20 x1.16 BD 381434 48714065_1 CDM 0272 RC inpatient 13 8.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.14 78 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20 x1.16 BD 381434 48714065_1 CDM 0272 RC inpatient 13 8.45 UMR - ALL PLANS UMR - ALL PLANS 9.1 70 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20 x1.16 BD 381434 48714065_1 CDM 0272 RC inpatient 13 8.45 SIHO - ALL PLANS SIHO - ALL PLANS 11.7 90 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20 x1.16 BD 381434 48714065_1 CDM 0272 RC inpatient 13 8.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.87 60.55 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20 x1.16 BD 381434 48714065_1 CDM 0272 RC inpatient 13 8.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.87 12.61 INSYTE AUTO 20 x1.16 BD 381434 48714065_1 CDM 0272 RC inpatient 13 8.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.87 12.61 INSYTE AUTO 20 x1.16 BD 381434 48714065_1 CDM 0272 RC inpatient 13 8.45 ANTHEM HMO ANTHEM HMO 999999999 7.87 12.61 INSYTE AUTO 20 x1.16 BD 381434 48714065_1 CDM 0272 RC inpatient 13 8.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.79 67.6 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20 x1.16 BD 381434 48714065_1 CDM 0272 RC inpatient 13 8.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.87 12.61 INSYTE AUTO 20 x1.16 BD 381434 48714065_1 CDM 0272 RC inpatient 13 8.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.87 12.61 INSYTE AUTO 18x11/4 381444 48714066_1 CDM 0270 RC inpatient 13 8.45 AETNA AETNA 10.27 79 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 18x11/4 381444 48714066_1 CDM 0270 RC inpatient 13 8.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.45 65 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 18x11/4 381444 48714066_1 CDM 0270 RC inpatient 13 8.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.61 97 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 18x11/4 381444 48714066_1 CDM 0270 RC inpatient 13 8.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.97 69 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 18x11/4 381444 48714066_1 CDM 0270 RC inpatient 13 8.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.14 78 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 18x11/4 381444 48714066_1 CDM 0270 RC inpatient 13 8.45 UMR - ALL PLANS UMR - ALL PLANS 9.1 70 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 18x11/4 381444 48714066_1 CDM 0270 RC inpatient 13 8.45 SIHO - ALL PLANS SIHO - ALL PLANS 11.7 90 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 18x11/4 381444 48714066_1 CDM 0270 RC inpatient 13 8.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.87 60.55 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 18x11/4 381444 48714066_1 CDM 0270 RC inpatient 13 8.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.87 12.61 INSYTE AUTO 18x11/4 381444 48714066_1 CDM 0270 RC inpatient 13 8.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.87 12.61 INSYTE AUTO 18x11/4 381444 48714066_1 CDM 0270 RC inpatient 13 8.45 ANTHEM HMO ANTHEM HMO 999999999 7.87 12.61 INSYTE AUTO 18x11/4 381444 48714066_1 CDM 0270 RC inpatient 13 8.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.79 67.6 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 18x11/4 381444 48714066_1 CDM 0270 RC inpatient 13 8.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.87 12.61 INSYTE AUTO 18x11/4 381444 48714066_1 CDM 0270 RC inpatient 13 8.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.87 12.61 ANESTHESIA CLEARLINK MANIFOLD 48714068_1 CDM 0270 RC inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges ANESTHESIA CLEARLINK MANIFOLD 48714068_1 CDM 0270 RC inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges ANESTHESIA CLEARLINK MANIFOLD 48714068_1 CDM 0270 RC inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges ANESTHESIA CLEARLINK MANIFOLD 48714068_1 CDM 0270 RC inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges ANESTHESIA CLEARLINK MANIFOLD 48714068_1 CDM 0270 RC inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges ANESTHESIA CLEARLINK MANIFOLD 48714068_1 CDM 0270 RC inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges ANESTHESIA CLEARLINK MANIFOLD 48714068_1 CDM 0270 RC inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges ANESTHESIA CLEARLINK MANIFOLD 48714068_1 CDM 0270 RC inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges ANESTHESIA CLEARLINK MANIFOLD 48714068_1 CDM 0270 RC inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 ANESTHESIA CLEARLINK MANIFOLD 48714068_1 CDM 0270 RC inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 ANESTHESIA CLEARLINK MANIFOLD 48714068_1 CDM 0270 RC inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 ANESTHESIA CLEARLINK MANIFOLD 48714068_1 CDM 0270 RC inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges ANESTHESIA CLEARLINK MANIFOLD 48714068_1 CDM 0270 RC inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 ANESTHESIA CLEARLINK MANIFOLD 48714068_1 CDM 0270 RC inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 LACT RINGERS 1000ML 2B2324X 48714069_1 CDM 0258 RC inpatient 14 9.1 AETNA AETNA 11.06 79 999999999 8.48 13.58 percent of total billed charges LACT RINGERS 1000ML 2B2324X 48714069_1 CDM 0258 RC inpatient 14 9.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.1 65 999999999 8.48 13.58 percent of total billed charges LACT RINGERS 1000ML 2B2324X 48714069_1 CDM 0258 RC inpatient 14 9.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13.58 97 999999999 8.48 13.58 percent of total billed charges LACT RINGERS 1000ML 2B2324X 48714069_1 CDM 0258 RC inpatient 14 9.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.66 69 999999999 8.48 13.58 percent of total billed charges LACT RINGERS 1000ML 2B2324X 48714069_1 CDM 0258 RC inpatient 14 9.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.92 78 999999999 8.48 13.58 percent of total billed charges LACT RINGERS 1000ML 2B2324X 48714069_1 CDM 0258 RC inpatient 14 9.1 UMR - ALL PLANS UMR - ALL PLANS 9.8 70 999999999 8.48 13.58 percent of total billed charges LACT RINGERS 1000ML 2B2324X 48714069_1 CDM 0258 RC inpatient 14 9.1 SIHO - ALL PLANS SIHO - ALL PLANS 12.6 90 999999999 8.48 13.58 percent of total billed charges LACT RINGERS 1000ML 2B2324X 48714069_1 CDM 0258 RC inpatient 14 9.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.48 60.55 999999999 8.48 13.58 percent of total billed charges LACT RINGERS 1000ML 2B2324X 48714069_1 CDM 0258 RC inpatient 14 9.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.48 13.58 LACT RINGERS 1000ML 2B2324X 48714069_1 CDM 0258 RC inpatient 14 9.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.48 13.58 LACT RINGERS 1000ML 2B2324X 48714069_1 CDM 0258 RC inpatient 14 9.1 ANTHEM HMO ANTHEM HMO 999999999 8.48 13.58 LACT RINGERS 1000ML 2B2324X 48714069_1 CDM 0258 RC inpatient 14 9.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.46 67.6 999999999 8.48 13.58 percent of total billed charges LACT RINGERS 1000ML 2B2324X 48714069_1 CDM 0258 RC inpatient 14 9.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.48 13.58 LACT RINGERS 1000ML 2B2324X 48714069_1 CDM 0258 RC inpatient 14 9.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.48 13.58 DEX 5% 0.45% N/S 1000ML 48714070_1 CDM 0258 RC inpatient 31 20.15 AETNA AETNA 24.49 79 999999999 18.77 30.07 percent of total billed charges DEX 5% 0.45% N/S 1000ML 48714070_1 CDM 0258 RC inpatient 31 20.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.15 65 999999999 18.77 30.07 percent of total billed charges DEX 5% 0.45% N/S 1000ML 48714070_1 CDM 0258 RC inpatient 31 20.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.07 97 999999999 18.77 30.07 percent of total billed charges DEX 5% 0.45% N/S 1000ML 48714070_1 CDM 0258 RC inpatient 31 20.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.39 69 999999999 18.77 30.07 percent of total billed charges DEX 5% 0.45% N/S 1000ML 48714070_1 CDM 0258 RC inpatient 31 20.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.18 78 999999999 18.77 30.07 percent of total billed charges DEX 5% 0.45% N/S 1000ML 48714070_1 CDM 0258 RC inpatient 31 20.15 UMR - ALL PLANS UMR - ALL PLANS 21.7 70 999999999 18.77 30.07 percent of total billed charges DEX 5% 0.45% N/S 1000ML 48714070_1 CDM 0258 RC inpatient 31 20.15 SIHO - ALL PLANS SIHO - ALL PLANS 27.9 90 999999999 18.77 30.07 percent of total billed charges DEX 5% 0.45% N/S 1000ML 48714070_1 CDM 0258 RC inpatient 31 20.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.77 60.55 999999999 18.77 30.07 percent of total billed charges DEX 5% 0.45% N/S 1000ML 48714070_1 CDM 0258 RC inpatient 31 20.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.77 30.07 DEX 5% 0.45% N/S 1000ML 48714070_1 CDM 0258 RC inpatient 31 20.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.77 30.07 DEX 5% 0.45% N/S 1000ML 48714070_1 CDM 0258 RC inpatient 31 20.15 ANTHEM HMO ANTHEM HMO 999999999 18.77 30.07 DEX 5% 0.45% N/S 1000ML 48714070_1 CDM 0258 RC inpatient 31 20.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.96 67.6 999999999 18.77 30.07 percent of total billed charges DEX 5% 0.45% N/S 1000ML 48714070_1 CDM 0258 RC inpatient 31 20.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.77 30.07 DEX 5% 0.45% N/S 1000ML 48714070_1 CDM 0258 RC inpatient 31 20.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.77 30.07 SOD CHL 0.45% 1000ML 2B1314X 48714071_1 CDM 0258 RC inpatient 31 20.15 AETNA AETNA 24.49 79 999999999 18.77 30.07 percent of total billed charges SOD CHL 0.45% 1000ML 2B1314X 48714071_1 CDM 0258 RC inpatient 31 20.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.15 65 999999999 18.77 30.07 percent of total billed charges SOD CHL 0.45% 1000ML 2B1314X 48714071_1 CDM 0258 RC inpatient 31 20.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.07 97 999999999 18.77 30.07 percent of total billed charges SOD CHL 0.45% 1000ML 2B1314X 48714071_1 CDM 0258 RC inpatient 31 20.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.39 69 999999999 18.77 30.07 percent of total billed charges SOD CHL 0.45% 1000ML 2B1314X 48714071_1 CDM 0258 RC inpatient 31 20.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.18 78 999999999 18.77 30.07 percent of total billed charges SOD CHL 0.45% 1000ML 2B1314X 48714071_1 CDM 0258 RC inpatient 31 20.15 UMR - ALL PLANS UMR - ALL PLANS 21.7 70 999999999 18.77 30.07 percent of total billed charges SOD CHL 0.45% 1000ML 2B1314X 48714071_1 CDM 0258 RC inpatient 31 20.15 SIHO - ALL PLANS SIHO - ALL PLANS 27.9 90 999999999 18.77 30.07 percent of total billed charges SOD CHL 0.45% 1000ML 2B1314X 48714071_1 CDM 0258 RC inpatient 31 20.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.77 60.55 999999999 18.77 30.07 percent of total billed charges SOD CHL 0.45% 1000ML 2B1314X 48714071_1 CDM 0258 RC inpatient 31 20.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.77 30.07 SOD CHL 0.45% 1000ML 2B1314X 48714071_1 CDM 0258 RC inpatient 31 20.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.77 30.07 SOD CHL 0.45% 1000ML 2B1314X 48714071_1 CDM 0258 RC inpatient 31 20.15 ANTHEM HMO ANTHEM HMO 999999999 18.77 30.07 SOD CHL 0.45% 1000ML 2B1314X 48714071_1 CDM 0258 RC inpatient 31 20.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.96 67.6 999999999 18.77 30.07 percent of total billed charges SOD CHL 0.45% 1000ML 2B1314X 48714071_1 CDM 0258 RC inpatient 31 20.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.77 30.07 SOD CHL 0.45% 1000ML 2B1314X 48714071_1 CDM 0258 RC inpatient 31 20.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.77 30.07 SOD CHL 0.9% 250ML 2B1322Q 48714072_1 CDM 0258 RC inpatient 12 7.8 AETNA AETNA 9.48 79 999999999 7.27 11.64 percent of total billed charges SOD CHL 0.9% 250ML 2B1322Q 48714072_1 CDM 0258 RC inpatient 12 7.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.8 65 999999999 7.27 11.64 percent of total billed charges SOD CHL 0.9% 250ML 2B1322Q 48714072_1 CDM 0258 RC inpatient 12 7.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11.64 97 999999999 7.27 11.64 percent of total billed charges SOD CHL 0.9% 250ML 2B1322Q 48714072_1 CDM 0258 RC inpatient 12 7.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.28 69 999999999 7.27 11.64 percent of total billed charges SOD CHL 0.9% 250ML 2B1322Q 48714072_1 CDM 0258 RC inpatient 12 7.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.36 78 999999999 7.27 11.64 percent of total billed charges SOD CHL 0.9% 250ML 2B1322Q 48714072_1 CDM 0258 RC inpatient 12 7.8 UMR - ALL PLANS UMR - ALL PLANS 8.4 70 999999999 7.27 11.64 percent of total billed charges SOD CHL 0.9% 250ML 2B1322Q 48714072_1 CDM 0258 RC inpatient 12 7.8 SIHO - ALL PLANS SIHO - ALL PLANS 10.8 90 999999999 7.27 11.64 percent of total billed charges SOD CHL 0.9% 250ML 2B1322Q 48714072_1 CDM 0258 RC inpatient 12 7.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.27 60.55 999999999 7.27 11.64 percent of total billed charges SOD CHL 0.9% 250ML 2B1322Q 48714072_1 CDM 0258 RC inpatient 12 7.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.27 11.64 SOD CHL 0.9% 250ML 2B1322Q 48714072_1 CDM 0258 RC inpatient 12 7.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.27 11.64 SOD CHL 0.9% 250ML 2B1322Q 48714072_1 CDM 0258 RC inpatient 12 7.8 ANTHEM HMO ANTHEM HMO 999999999 7.27 11.64 SOD CHL 0.9% 250ML 2B1322Q 48714072_1 CDM 0258 RC inpatient 12 7.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.11 67.6 999999999 7.27 11.64 percent of total billed charges SOD CHL 0.9% 250ML 2B1322Q 48714072_1 CDM 0258 RC inpatient 12 7.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.27 11.64 SOD CHL 0.9% 250ML 2B1322Q 48714072_1 CDM 0258 RC inpatient 12 7.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.27 11.64 SOD CHL 0.9% FILL 50ML 2B1306 48714073_1 CDM 0258 RC inpatient 12 7.8 AETNA AETNA 9.48 79 999999999 7.27 11.64 percent of total billed charges SOD CHL 0.9% FILL 50ML 2B1306 48714073_1 CDM 0258 RC inpatient 12 7.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.8 65 999999999 7.27 11.64 percent of total billed charges SOD CHL 0.9% FILL 50ML 2B1306 48714073_1 CDM 0258 RC inpatient 12 7.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11.64 97 999999999 7.27 11.64 percent of total billed charges SOD CHL 0.9% FILL 50ML 2B1306 48714073_1 CDM 0258 RC inpatient 12 7.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.28 69 999999999 7.27 11.64 percent of total billed charges SOD CHL 0.9% FILL 50ML 2B1306 48714073_1 CDM 0258 RC inpatient 12 7.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.36 78 999999999 7.27 11.64 percent of total billed charges SOD CHL 0.9% FILL 50ML 2B1306 48714073_1 CDM 0258 RC inpatient 12 7.8 UMR - ALL PLANS UMR - ALL PLANS 8.4 70 999999999 7.27 11.64 percent of total billed charges SOD CHL 0.9% FILL 50ML 2B1306 48714073_1 CDM 0258 RC inpatient 12 7.8 SIHO - ALL PLANS SIHO - ALL PLANS 10.8 90 999999999 7.27 11.64 percent of total billed charges SOD CHL 0.9% FILL 50ML 2B1306 48714073_1 CDM 0258 RC inpatient 12 7.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.27 60.55 999999999 7.27 11.64 percent of total billed charges SOD CHL 0.9% FILL 50ML 2B1306 48714073_1 CDM 0258 RC inpatient 12 7.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.27 11.64 SOD CHL 0.9% FILL 50ML 2B1306 48714073_1 CDM 0258 RC inpatient 12 7.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.27 11.64 SOD CHL 0.9% FILL 50ML 2B1306 48714073_1 CDM 0258 RC inpatient 12 7.8 ANTHEM HMO ANTHEM HMO 999999999 7.27 11.64 SOD CHL 0.9% FILL 50ML 2B1306 48714073_1 CDM 0258 RC inpatient 12 7.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.11 67.6 999999999 7.27 11.64 percent of total billed charges SOD CHL 0.9% FILL 50ML 2B1306 48714073_1 CDM 0258 RC inpatient 12 7.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.27 11.64 SOD CHL 0.9% FILL 50ML 2B1306 48714073_1 CDM 0258 RC inpatient 12 7.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.27 11.64 SOD CHL 0.9% 500ML 2B1323Q 48714074_1 CDM 0258 RC inpatient 31 20.15 AETNA AETNA 24.49 79 999999999 18.77 30.07 percent of total billed charges SOD CHL 0.9% 500ML 2B1323Q 48714074_1 CDM 0258 RC inpatient 31 20.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.15 65 999999999 18.77 30.07 percent of total billed charges SOD CHL 0.9% 500ML 2B1323Q 48714074_1 CDM 0258 RC inpatient 31 20.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.07 97 999999999 18.77 30.07 percent of total billed charges SOD CHL 0.9% 500ML 2B1323Q 48714074_1 CDM 0258 RC inpatient 31 20.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.39 69 999999999 18.77 30.07 percent of total billed charges SOD CHL 0.9% 500ML 2B1323Q 48714074_1 CDM 0258 RC inpatient 31 20.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.18 78 999999999 18.77 30.07 percent of total billed charges SOD CHL 0.9% 500ML 2B1323Q 48714074_1 CDM 0258 RC inpatient 31 20.15 UMR - ALL PLANS UMR - ALL PLANS 21.7 70 999999999 18.77 30.07 percent of total billed charges SOD CHL 0.9% 500ML 2B1323Q 48714074_1 CDM 0258 RC inpatient 31 20.15 SIHO - ALL PLANS SIHO - ALL PLANS 27.9 90 999999999 18.77 30.07 percent of total billed charges SOD CHL 0.9% 500ML 2B1323Q 48714074_1 CDM 0258 RC inpatient 31 20.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.77 60.55 999999999 18.77 30.07 percent of total billed charges SOD CHL 0.9% 500ML 2B1323Q 48714074_1 CDM 0258 RC inpatient 31 20.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.77 30.07 SOD CHL 0.9% 500ML 2B1323Q 48714074_1 CDM 0258 RC inpatient 31 20.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.77 30.07 SOD CHL 0.9% 500ML 2B1323Q 48714074_1 CDM 0258 RC inpatient 31 20.15 ANTHEM HMO ANTHEM HMO 999999999 18.77 30.07 SOD CHL 0.9% 500ML 2B1323Q 48714074_1 CDM 0258 RC inpatient 31 20.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.96 67.6 999999999 18.77 30.07 percent of total billed charges SOD CHL 0.9% 500ML 2B1323Q 48714074_1 CDM 0258 RC inpatient 31 20.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.77 30.07 SOD CHL 0.9% 500ML 2B1323Q 48714074_1 CDM 0258 RC inpatient 31 20.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.77 30.07 D5W 100 FILL 1 WRAP 48714075_1 CDM 0250 RC inpatient 13 8.45 AETNA AETNA 10.27 79 999999999 7.87 12.61 percent of total billed charges D5W 100 FILL 1 WRAP 48714075_1 CDM 0250 RC inpatient 13 8.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.45 65 999999999 7.87 12.61 percent of total billed charges D5W 100 FILL 1 WRAP 48714075_1 CDM 0250 RC inpatient 13 8.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.61 97 999999999 7.87 12.61 percent of total billed charges D5W 100 FILL 1 WRAP 48714075_1 CDM 0250 RC inpatient 13 8.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.97 69 999999999 7.87 12.61 percent of total billed charges D5W 100 FILL 1 WRAP 48714075_1 CDM 0250 RC inpatient 13 8.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.14 78 999999999 7.87 12.61 percent of total billed charges D5W 100 FILL 1 WRAP 48714075_1 CDM 0250 RC inpatient 13 8.45 UMR - ALL PLANS UMR - ALL PLANS 9.1 70 999999999 7.87 12.61 percent of total billed charges D5W 100 FILL 1 WRAP 48714075_1 CDM 0250 RC inpatient 13 8.45 SIHO - ALL PLANS SIHO - ALL PLANS 11.7 90 999999999 7.87 12.61 percent of total billed charges D5W 100 FILL 1 WRAP 48714075_1 CDM 0250 RC inpatient 13 8.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.87 60.55 999999999 7.87 12.61 percent of total billed charges D5W 100 FILL 1 WRAP 48714075_1 CDM 0250 RC inpatient 13 8.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.87 12.61 D5W 100 FILL 1 WRAP 48714075_1 CDM 0250 RC inpatient 13 8.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.87 12.61 D5W 100 FILL 1 WRAP 48714075_1 CDM 0250 RC inpatient 13 8.45 ANTHEM HMO ANTHEM HMO 999999999 7.87 12.61 D5W 100 FILL 1 WRAP 48714075_1 CDM 0250 RC inpatient 13 8.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.79 67.6 999999999 7.87 12.61 percent of total billed charges D5W 100 FILL 1 WRAP 48714075_1 CDM 0250 RC inpatient 13 8.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.87 12.61 D5W 100 FILL 1 WRAP 48714075_1 CDM 0250 RC inpatient 13 8.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.87 12.61 DEX 5% IN WATER 250ML 2B0062Q 48714076_1 CDM 0258 RC inpatient 12 7.8 AETNA AETNA 9.48 79 999999999 7.27 11.64 percent of total billed charges DEX 5% IN WATER 250ML 2B0062Q 48714076_1 CDM 0258 RC inpatient 12 7.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.8 65 999999999 7.27 11.64 percent of total billed charges DEX 5% IN WATER 250ML 2B0062Q 48714076_1 CDM 0258 RC inpatient 12 7.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11.64 97 999999999 7.27 11.64 percent of total billed charges DEX 5% IN WATER 250ML 2B0062Q 48714076_1 CDM 0258 RC inpatient 12 7.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.28 69 999999999 7.27 11.64 percent of total billed charges DEX 5% IN WATER 250ML 2B0062Q 48714076_1 CDM 0258 RC inpatient 12 7.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.36 78 999999999 7.27 11.64 percent of total billed charges DEX 5% IN WATER 250ML 2B0062Q 48714076_1 CDM 0258 RC inpatient 12 7.8 UMR - ALL PLANS UMR - ALL PLANS 8.4 70 999999999 7.27 11.64 percent of total billed charges DEX 5% IN WATER 250ML 2B0062Q 48714076_1 CDM 0258 RC inpatient 12 7.8 SIHO - ALL PLANS SIHO - ALL PLANS 10.8 90 999999999 7.27 11.64 percent of total billed charges DEX 5% IN WATER 250ML 2B0062Q 48714076_1 CDM 0258 RC inpatient 12 7.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.27 60.55 999999999 7.27 11.64 percent of total billed charges DEX 5% IN WATER 250ML 2B0062Q 48714076_1 CDM 0258 RC inpatient 12 7.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.27 11.64 DEX 5% IN WATER 250ML 2B0062Q 48714076_1 CDM 0258 RC inpatient 12 7.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.27 11.64 DEX 5% IN WATER 250ML 2B0062Q 48714076_1 CDM 0258 RC inpatient 12 7.8 ANTHEM HMO ANTHEM HMO 999999999 7.27 11.64 DEX 5% IN WATER 250ML 2B0062Q 48714076_1 CDM 0258 RC inpatient 12 7.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.11 67.6 999999999 7.27 11.64 percent of total billed charges DEX 5% IN WATER 250ML 2B0062Q 48714076_1 CDM 0258 RC inpatient 12 7.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.27 11.64 DEX 5% IN WATER 250ML 2B0062Q 48714076_1 CDM 0258 RC inpatient 12 7.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.27 11.64 D5W 50ML FILL 1 WRAP 2B0086 48714077_1 CDM 0258 RC inpatient 13 8.45 AETNA AETNA 10.27 79 999999999 7.87 12.61 percent of total billed charges D5W 50ML FILL 1 WRAP 2B0086 48714077_1 CDM 0258 RC inpatient 13 8.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.45 65 999999999 7.87 12.61 percent of total billed charges D5W 50ML FILL 1 WRAP 2B0086 48714077_1 CDM 0258 RC inpatient 13 8.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.61 97 999999999 7.87 12.61 percent of total billed charges D5W 50ML FILL 1 WRAP 2B0086 48714077_1 CDM 0258 RC inpatient 13 8.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.97 69 999999999 7.87 12.61 percent of total billed charges D5W 50ML FILL 1 WRAP 2B0086 48714077_1 CDM 0258 RC inpatient 13 8.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.14 78 999999999 7.87 12.61 percent of total billed charges D5W 50ML FILL 1 WRAP 2B0086 48714077_1 CDM 0258 RC inpatient 13 8.45 UMR - ALL PLANS UMR - ALL PLANS 9.1 70 999999999 7.87 12.61 percent of total billed charges D5W 50ML FILL 1 WRAP 2B0086 48714077_1 CDM 0258 RC inpatient 13 8.45 SIHO - ALL PLANS SIHO - ALL PLANS 11.7 90 999999999 7.87 12.61 percent of total billed charges D5W 50ML FILL 1 WRAP 2B0086 48714077_1 CDM 0258 RC inpatient 13 8.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.87 60.55 999999999 7.87 12.61 percent of total billed charges D5W 50ML FILL 1 WRAP 2B0086 48714077_1 CDM 0258 RC inpatient 13 8.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.87 12.61 D5W 50ML FILL 1 WRAP 2B0086 48714077_1 CDM 0258 RC inpatient 13 8.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.87 12.61 D5W 50ML FILL 1 WRAP 2B0086 48714077_1 CDM 0258 RC inpatient 13 8.45 ANTHEM HMO ANTHEM HMO 999999999 7.87 12.61 D5W 50ML FILL 1 WRAP 2B0086 48714077_1 CDM 0258 RC inpatient 13 8.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.79 67.6 999999999 7.87 12.61 percent of total billed charges D5W 50ML FILL 1 WRAP 2B0086 48714077_1 CDM 0258 RC inpatient 13 8.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.87 12.61 D5W 50ML FILL 1 WRAP 2B0086 48714077_1 CDM 0258 RC inpatient 13 8.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.87 12.61 DEX 5% WATER 500ML 2B0063Q 48714078_1 CDM 0258 RC inpatient 31 20.15 AETNA AETNA 24.49 79 999999999 18.77 30.07 percent of total billed charges DEX 5% WATER 500ML 2B0063Q 48714078_1 CDM 0258 RC inpatient 31 20.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.15 65 999999999 18.77 30.07 percent of total billed charges DEX 5% WATER 500ML 2B0063Q 48714078_1 CDM 0258 RC inpatient 31 20.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.07 97 999999999 18.77 30.07 percent of total billed charges DEX 5% WATER 500ML 2B0063Q 48714078_1 CDM 0258 RC inpatient 31 20.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.39 69 999999999 18.77 30.07 percent of total billed charges DEX 5% WATER 500ML 2B0063Q 48714078_1 CDM 0258 RC inpatient 31 20.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.18 78 999999999 18.77 30.07 percent of total billed charges DEX 5% WATER 500ML 2B0063Q 48714078_1 CDM 0258 RC inpatient 31 20.15 UMR - ALL PLANS UMR - ALL PLANS 21.7 70 999999999 18.77 30.07 percent of total billed charges DEX 5% WATER 500ML 2B0063Q 48714078_1 CDM 0258 RC inpatient 31 20.15 SIHO - ALL PLANS SIHO - ALL PLANS 27.9 90 999999999 18.77 30.07 percent of total billed charges DEX 5% WATER 500ML 2B0063Q 48714078_1 CDM 0258 RC inpatient 31 20.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.77 60.55 999999999 18.77 30.07 percent of total billed charges DEX 5% WATER 500ML 2B0063Q 48714078_1 CDM 0258 RC inpatient 31 20.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.77 30.07 DEX 5% WATER 500ML 2B0063Q 48714078_1 CDM 0258 RC inpatient 31 20.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.77 30.07 DEX 5% WATER 500ML 2B0063Q 48714078_1 CDM 0258 RC inpatient 31 20.15 ANTHEM HMO ANTHEM HMO 999999999 18.77 30.07 DEX 5% WATER 500ML 2B0063Q 48714078_1 CDM 0258 RC inpatient 31 20.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.96 67.6 999999999 18.77 30.07 percent of total billed charges DEX 5% WATER 500ML 2B0063Q 48714078_1 CDM 0258 RC inpatient 31 20.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.77 30.07 DEX 5% WATER 500ML 2B0063Q 48714078_1 CDM 0258 RC inpatient 31 20.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.77 30.07 DEX 5%/L/RINGERS 1000M 2B2074X 48714079_1 CDM 0258 RC inpatient 31 20.15 AETNA AETNA 24.49 79 999999999 18.77 30.07 percent of total billed charges DEX 5%/L/RINGERS 1000M 2B2074X 48714079_1 CDM 0258 RC inpatient 31 20.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.15 65 999999999 18.77 30.07 percent of total billed charges DEX 5%/L/RINGERS 1000M 2B2074X 48714079_1 CDM 0258 RC inpatient 31 20.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.07 97 999999999 18.77 30.07 percent of total billed charges DEX 5%/L/RINGERS 1000M 2B2074X 48714079_1 CDM 0258 RC inpatient 31 20.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.39 69 999999999 18.77 30.07 percent of total billed charges DEX 5%/L/RINGERS 1000M 2B2074X 48714079_1 CDM 0258 RC inpatient 31 20.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.18 78 999999999 18.77 30.07 percent of total billed charges DEX 5%/L/RINGERS 1000M 2B2074X 48714079_1 CDM 0258 RC inpatient 31 20.15 UMR - ALL PLANS UMR - ALL PLANS 21.7 70 999999999 18.77 30.07 percent of total billed charges DEX 5%/L/RINGERS 1000M 2B2074X 48714079_1 CDM 0258 RC inpatient 31 20.15 SIHO - ALL PLANS SIHO - ALL PLANS 27.9 90 999999999 18.77 30.07 percent of total billed charges DEX 5%/L/RINGERS 1000M 2B2074X 48714079_1 CDM 0258 RC inpatient 31 20.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.77 60.55 999999999 18.77 30.07 percent of total billed charges DEX 5%/L/RINGERS 1000M 2B2074X 48714079_1 CDM 0258 RC inpatient 31 20.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.77 30.07 DEX 5%/L/RINGERS 1000M 2B2074X 48714079_1 CDM 0258 RC inpatient 31 20.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.77 30.07 DEX 5%/L/RINGERS 1000M 2B2074X 48714079_1 CDM 0258 RC inpatient 31 20.15 ANTHEM HMO ANTHEM HMO 999999999 18.77 30.07 DEX 5%/L/RINGERS 1000M 2B2074X 48714079_1 CDM 0258 RC inpatient 31 20.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.96 67.6 999999999 18.77 30.07 percent of total billed charges DEX 5%/L/RINGERS 1000M 2B2074X 48714079_1 CDM 0258 RC inpatient 31 20.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.77 30.07 DEX 5%/L/RINGERS 1000M 2B2074X 48714079_1 CDM 0258 RC inpatient 31 20.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.77 30.07 SOD CHL 0.9% 100ML 2B1307 48714080_1 CDM 0258 RC inpatient 13 8.45 AETNA AETNA 10.27 79 999999999 7.87 12.61 percent of total billed charges SOD CHL 0.9% 100ML 2B1307 48714080_1 CDM 0258 RC inpatient 13 8.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.45 65 999999999 7.87 12.61 percent of total billed charges SOD CHL 0.9% 100ML 2B1307 48714080_1 CDM 0258 RC inpatient 13 8.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.61 97 999999999 7.87 12.61 percent of total billed charges SOD CHL 0.9% 100ML 2B1307 48714080_1 CDM 0258 RC inpatient 13 8.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.97 69 999999999 7.87 12.61 percent of total billed charges SOD CHL 0.9% 100ML 2B1307 48714080_1 CDM 0258 RC inpatient 13 8.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.14 78 999999999 7.87 12.61 percent of total billed charges SOD CHL 0.9% 100ML 2B1307 48714080_1 CDM 0258 RC inpatient 13 8.45 UMR - ALL PLANS UMR - ALL PLANS 9.1 70 999999999 7.87 12.61 percent of total billed charges SOD CHL 0.9% 100ML 2B1307 48714080_1 CDM 0258 RC inpatient 13 8.45 SIHO - ALL PLANS SIHO - ALL PLANS 11.7 90 999999999 7.87 12.61 percent of total billed charges SOD CHL 0.9% 100ML 2B1307 48714080_1 CDM 0258 RC inpatient 13 8.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.87 60.55 999999999 7.87 12.61 percent of total billed charges SOD CHL 0.9% 100ML 2B1307 48714080_1 CDM 0258 RC inpatient 13 8.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.87 12.61 SOD CHL 0.9% 100ML 2B1307 48714080_1 CDM 0258 RC inpatient 13 8.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.87 12.61 SOD CHL 0.9% 100ML 2B1307 48714080_1 CDM 0258 RC inpatient 13 8.45 ANTHEM HMO ANTHEM HMO 999999999 7.87 12.61 SOD CHL 0.9% 100ML 2B1307 48714080_1 CDM 0258 RC inpatient 13 8.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.79 67.6 999999999 7.87 12.61 percent of total billed charges SOD CHL 0.9% 100ML 2B1307 48714080_1 CDM 0258 RC inpatient 13 8.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.87 12.61 SOD CHL 0.9% 100ML 2B1307 48714080_1 CDM 0258 RC inpatient 13 8.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.87 12.61 LEVEL 1 SYSTEM SET D70 48714081_1 CDM 0272 RC inpatient 285 185.25 AETNA AETNA 225.15 79 999999999 172.57 276.45 percent of total billed charges LEVEL 1 SYSTEM SET D70 48714081_1 CDM 0272 RC inpatient 285 185.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.25 65 999999999 172.57 276.45 percent of total billed charges LEVEL 1 SYSTEM SET D70 48714081_1 CDM 0272 RC inpatient 285 185.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 276.45 97 999999999 172.57 276.45 percent of total billed charges LEVEL 1 SYSTEM SET D70 48714081_1 CDM 0272 RC inpatient 285 185.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 196.65 69 999999999 172.57 276.45 percent of total billed charges LEVEL 1 SYSTEM SET D70 48714081_1 CDM 0272 RC inpatient 285 185.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 222.3 78 999999999 172.57 276.45 percent of total billed charges LEVEL 1 SYSTEM SET D70 48714081_1 CDM 0272 RC inpatient 285 185.25 UMR - ALL PLANS UMR - ALL PLANS 199.5 70 999999999 172.57 276.45 percent of total billed charges LEVEL 1 SYSTEM SET D70 48714081_1 CDM 0272 RC inpatient 285 185.25 SIHO - ALL PLANS SIHO - ALL PLANS 256.5 90 999999999 172.57 276.45 percent of total billed charges LEVEL 1 SYSTEM SET D70 48714081_1 CDM 0272 RC inpatient 285 185.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 172.57 60.55 999999999 172.57 276.45 percent of total billed charges LEVEL 1 SYSTEM SET D70 48714081_1 CDM 0272 RC inpatient 285 185.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 172.57 276.45 LEVEL 1 SYSTEM SET D70 48714081_1 CDM 0272 RC inpatient 285 185.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 172.57 276.45 LEVEL 1 SYSTEM SET D70 48714081_1 CDM 0272 RC inpatient 285 185.25 ANTHEM HMO ANTHEM HMO 999999999 172.57 276.45 LEVEL 1 SYSTEM SET D70 48714081_1 CDM 0272 RC inpatient 285 185.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 192.66 67.6 999999999 172.57 276.45 percent of total billed charges LEVEL 1 SYSTEM SET D70 48714081_1 CDM 0272 RC inpatient 285 185.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 172.57 276.45 LEVEL 1 SYSTEM SET D70 48714081_1 CDM 0272 RC inpatient 285 185.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 172.57 276.45 "POWER LOC SAFETY INFUSION SET 20g X 1"" 0672010" 48714083_1 CDM 0272 RC inpatient 94 61.1 AETNA AETNA 74.26 79 999999999 56.92 91.18 percent of total billed charges "POWER LOC SAFETY INFUSION SET 20g X 1"" 0672010" 48714083_1 CDM 0272 RC inpatient 94 61.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.1 65 999999999 56.92 91.18 percent of total billed charges "POWER LOC SAFETY INFUSION SET 20g X 1"" 0672010" 48714083_1 CDM 0272 RC inpatient 94 61.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.18 97 999999999 56.92 91.18 percent of total billed charges "POWER LOC SAFETY INFUSION SET 20g X 1"" 0672010" 48714083_1 CDM 0272 RC inpatient 94 61.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.86 69 999999999 56.92 91.18 percent of total billed charges "POWER LOC SAFETY INFUSION SET 20g X 1"" 0672010" 48714083_1 CDM 0272 RC inpatient 94 61.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.32 78 999999999 56.92 91.18 percent of total billed charges "POWER LOC SAFETY INFUSION SET 20g X 1"" 0672010" 48714083_1 CDM 0272 RC inpatient 94 61.1 UMR - ALL PLANS UMR - ALL PLANS 65.8 70 999999999 56.92 91.18 percent of total billed charges "POWER LOC SAFETY INFUSION SET 20g X 1"" 0672010" 48714083_1 CDM 0272 RC inpatient 94 61.1 SIHO - ALL PLANS SIHO - ALL PLANS 84.6 90 999999999 56.92 91.18 percent of total billed charges "POWER LOC SAFETY INFUSION SET 20g X 1"" 0672010" 48714083_1 CDM 0272 RC inpatient 94 61.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.92 60.55 999999999 56.92 91.18 percent of total billed charges "POWER LOC SAFETY INFUSION SET 20g X 1"" 0672010" 48714083_1 CDM 0272 RC inpatient 94 61.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.92 91.18 "POWER LOC SAFETY INFUSION SET 20g X 1"" 0672010" 48714083_1 CDM 0272 RC inpatient 94 61.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.92 91.18 "POWER LOC SAFETY INFUSION SET 20g X 1"" 0672010" 48714083_1 CDM 0272 RC inpatient 94 61.1 ANTHEM HMO ANTHEM HMO 999999999 56.92 91.18 "POWER LOC SAFETY INFUSION SET 20g X 1"" 0672010" 48714083_1 CDM 0272 RC inpatient 94 61.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.54 67.6 999999999 56.92 91.18 percent of total billed charges "POWER LOC SAFETY INFUSION SET 20g X 1"" 0672010" 48714083_1 CDM 0272 RC inpatient 94 61.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.92 91.18 "POWER LOC SAFETY INFUSION SET 20g X 1"" 0672010" 48714083_1 CDM 0272 RC inpatient 94 61.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.92 91.18 POWER LOC SAFETY INFUSION 20X3.75 0672034 48714084_1 CDM 0272 RC inpatient 94 61.1 AETNA AETNA 74.26 79 999999999 56.92 91.18 percent of total billed charges POWER LOC SAFETY INFUSION 20X3.75 0672034 48714084_1 CDM 0272 RC inpatient 94 61.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.1 65 999999999 56.92 91.18 percent of total billed charges POWER LOC SAFETY INFUSION 20X3.75 0672034 48714084_1 CDM 0272 RC inpatient 94 61.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.18 97 999999999 56.92 91.18 percent of total billed charges POWER LOC SAFETY INFUSION 20X3.75 0672034 48714084_1 CDM 0272 RC inpatient 94 61.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.86 69 999999999 56.92 91.18 percent of total billed charges POWER LOC SAFETY INFUSION 20X3.75 0672034 48714084_1 CDM 0272 RC inpatient 94 61.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.32 78 999999999 56.92 91.18 percent of total billed charges POWER LOC SAFETY INFUSION 20X3.75 0672034 48714084_1 CDM 0272 RC inpatient 94 61.1 UMR - ALL PLANS UMR - ALL PLANS 65.8 70 999999999 56.92 91.18 percent of total billed charges POWER LOC SAFETY INFUSION 20X3.75 0672034 48714084_1 CDM 0272 RC inpatient 94 61.1 SIHO - ALL PLANS SIHO - ALL PLANS 84.6 90 999999999 56.92 91.18 percent of total billed charges POWER LOC SAFETY INFUSION 20X3.75 0672034 48714084_1 CDM 0272 RC inpatient 94 61.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.92 60.55 999999999 56.92 91.18 percent of total billed charges POWER LOC SAFETY INFUSION 20X3.75 0672034 48714084_1 CDM 0272 RC inpatient 94 61.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.92 91.18 POWER LOC SAFETY INFUSION 20X3.75 0672034 48714084_1 CDM 0272 RC inpatient 94 61.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.92 91.18 POWER LOC SAFETY INFUSION 20X3.75 0672034 48714084_1 CDM 0272 RC inpatient 94 61.1 ANTHEM HMO ANTHEM HMO 999999999 56.92 91.18 POWER LOC SAFETY INFUSION 20X3.75 0672034 48714084_1 CDM 0272 RC inpatient 94 61.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.54 67.6 999999999 56.92 91.18 percent of total billed charges POWER LOC SAFETY INFUSION 20X3.75 0672034 48714084_1 CDM 0272 RC inpatient 94 61.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.92 91.18 POWER LOC SAFETY INFUSION 20X3.75 0672034 48714084_1 CDM 0272 RC inpatient 94 61.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.92 91.18 NEEDLE HUBER 20X1.5 SHW20150Y 48714085_1 CDM 0272 RC inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges NEEDLE HUBER 20X1.5 SHW20150Y 48714085_1 CDM 0272 RC inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges NEEDLE HUBER 20X1.5 SHW20150Y 48714085_1 CDM 0272 RC inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges NEEDLE HUBER 20X1.5 SHW20150Y 48714085_1 CDM 0272 RC inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges NEEDLE HUBER 20X1.5 SHW20150Y 48714085_1 CDM 0272 RC inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges NEEDLE HUBER 20X1.5 SHW20150Y 48714085_1 CDM 0272 RC inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges NEEDLE HUBER 20X1.5 SHW20150Y 48714085_1 CDM 0272 RC inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges NEEDLE HUBER 20X1.5 SHW20150Y 48714085_1 CDM 0272 RC inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges NEEDLE HUBER 20X1.5 SHW20150Y 48714085_1 CDM 0272 RC inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 NEEDLE HUBER 20X1.5 SHW20150Y 48714085_1 CDM 0272 RC inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 NEEDLE HUBER 20X1.5 SHW20150Y 48714085_1 CDM 0272 RC inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 NEEDLE HUBER 20X1.5 SHW20150Y 48714085_1 CDM 0272 RC inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges NEEDLE HUBER 20X1.5 SHW20150Y 48714085_1 CDM 0272 RC inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 NEEDLE HUBER 20X1.5 SHW20150Y 48714085_1 CDM 0272 RC inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 "EXTENSION 6"" SET MP9232-C" 48714086_1 CDM 0272 RC inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "EXTENSION 6"" SET MP9232-C" 48714086_1 CDM 0272 RC inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "EXTENSION 6"" SET MP9232-C" 48714086_1 CDM 0272 RC inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "EXTENSION 6"" SET MP9232-C" 48714086_1 CDM 0272 RC inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "EXTENSION 6"" SET MP9232-C" 48714086_1 CDM 0272 RC inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "EXTENSION 6"" SET MP9232-C" 48714086_1 CDM 0272 RC inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "EXTENSION 6"" SET MP9232-C" 48714086_1 CDM 0272 RC inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "EXTENSION 6"" SET MP9232-C" 48714086_1 CDM 0272 RC inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "EXTENSION 6"" SET MP9232-C" 48714086_1 CDM 0272 RC inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "EXTENSION 6"" SET MP9232-C" 48714086_1 CDM 0272 RC inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "EXTENSION 6"" SET MP9232-C" 48714086_1 CDM 0272 RC inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "EXTENSION 6"" SET MP9232-C" 48714086_1 CDM 0272 RC inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges "EXTENSION 6"" SET MP9232-C" 48714086_1 CDM 0272 RC inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "EXTENSION 6"" SET MP9232-C" 48714086_1 CDM 0272 RC inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 GUIDE WIRE 48714091_1 CDM 0272 RC C1769 HCPCS inpatient 69 44.85 AETNA AETNA 54.51 79 999999999 41.78 66.93 percent of total billed charges GUIDE WIRE 48714091_1 CDM 0272 RC C1769 HCPCS inpatient 69 44.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.85 65 999999999 41.78 66.93 percent of total billed charges GUIDE WIRE 48714091_1 CDM 0272 RC C1769 HCPCS inpatient 69 44.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 66.93 97 999999999 41.78 66.93 percent of total billed charges GUIDE WIRE 48714091_1 CDM 0272 RC C1769 HCPCS inpatient 69 44.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 47.61 69 999999999 41.78 66.93 percent of total billed charges GUIDE WIRE 48714091_1 CDM 0272 RC C1769 HCPCS inpatient 69 44.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.82 78 999999999 41.78 66.93 percent of total billed charges GUIDE WIRE 48714091_1 CDM 0272 RC C1769 HCPCS inpatient 69 44.85 UMR - ALL PLANS UMR - ALL PLANS 48.3 70 999999999 41.78 66.93 percent of total billed charges GUIDE WIRE 48714091_1 CDM 0272 RC C1769 HCPCS inpatient 69 44.85 SIHO - ALL PLANS SIHO - ALL PLANS 62.1 90 999999999 41.78 66.93 percent of total billed charges GUIDE WIRE 48714091_1 CDM 0272 RC C1769 HCPCS inpatient 69 44.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.78 60.55 999999999 41.78 66.93 percent of total billed charges GUIDE WIRE 48714091_1 CDM 0272 RC C1769 HCPCS inpatient 69 44.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.78 66.93 GUIDE WIRE 48714091_1 CDM 0272 RC C1769 HCPCS inpatient 69 44.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.78 66.93 GUIDE WIRE 48714091_1 CDM 0272 RC C1769 HCPCS inpatient 69 44.85 ANTHEM HMO ANTHEM HMO 999999999 41.78 66.93 GUIDE WIRE 48714091_1 CDM 0272 RC C1769 HCPCS inpatient 69 44.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 46.64 67.6 999999999 41.78 66.93 percent of total billed charges GUIDE WIRE 48714091_1 CDM 0272 RC C1769 HCPCS inpatient 69 44.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.78 66.93 GUIDE WIRE 48714091_1 CDM 0272 RC C1769 HCPCS inpatient 69 44.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.78 66.93 CATH SELECTIVE 4F RIM SOFT VU 48714092_1 CDM 0272 RC inpatient 240 156 AETNA AETNA 189.6 79 999999999 145.32 232.8 percent of total billed charges CATH SELECTIVE 4F RIM SOFT VU 48714092_1 CDM 0272 RC inpatient 240 156 SELF PAY DISCOUNT SELF PAY DISCOUNT 156 65 999999999 145.32 232.8 percent of total billed charges CATH SELECTIVE 4F RIM SOFT VU 48714092_1 CDM 0272 RC inpatient 240 156 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 232.8 97 999999999 145.32 232.8 percent of total billed charges CATH SELECTIVE 4F RIM SOFT VU 48714092_1 CDM 0272 RC inpatient 240 156 ENCORE - ALL PLANS ENCORE - ALL PLANS 165.6 69 999999999 145.32 232.8 percent of total billed charges CATH SELECTIVE 4F RIM SOFT VU 48714092_1 CDM 0272 RC inpatient 240 156 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.2 78 999999999 145.32 232.8 percent of total billed charges CATH SELECTIVE 4F RIM SOFT VU 48714092_1 CDM 0272 RC inpatient 240 156 UMR - ALL PLANS UMR - ALL PLANS 168 70 999999999 145.32 232.8 percent of total billed charges CATH SELECTIVE 4F RIM SOFT VU 48714092_1 CDM 0272 RC inpatient 240 156 SIHO - ALL PLANS SIHO - ALL PLANS 216 90 999999999 145.32 232.8 percent of total billed charges CATH SELECTIVE 4F RIM SOFT VU 48714092_1 CDM 0272 RC inpatient 240 156 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.32 60.55 999999999 145.32 232.8 percent of total billed charges CATH SELECTIVE 4F RIM SOFT VU 48714092_1 CDM 0272 RC inpatient 240 156 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.32 232.8 CATH SELECTIVE 4F RIM SOFT VU 48714092_1 CDM 0272 RC inpatient 240 156 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.32 232.8 CATH SELECTIVE 4F RIM SOFT VU 48714092_1 CDM 0272 RC inpatient 240 156 ANTHEM HMO ANTHEM HMO 999999999 145.32 232.8 CATH SELECTIVE 4F RIM SOFT VU 48714092_1 CDM 0272 RC inpatient 240 156 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.24 67.6 999999999 145.32 232.8 percent of total billed charges CATH SELECTIVE 4F RIM SOFT VU 48714092_1 CDM 0272 RC inpatient 240 156 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.32 232.8 CATH SELECTIVE 4F RIM SOFT VU 48714092_1 CDM 0272 RC inpatient 240 156 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.32 232.8 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714093_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 AETNA AETNA 432.92 79 999999999 331.81 531.56 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714093_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 356.2 65 999999999 331.81 531.56 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714093_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 531.56 97 999999999 331.81 531.56 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714093_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 378.12 69 999999999 331.81 531.56 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714093_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 427.44 78 999999999 331.81 531.56 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714093_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 UMR - ALL PLANS UMR - ALL PLANS 383.6 70 999999999 331.81 531.56 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714093_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 SIHO - ALL PLANS SIHO - ALL PLANS 493.2 90 999999999 331.81 531.56 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714093_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 331.81 60.55 999999999 331.81 531.56 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714093_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 331.81 531.56 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714093_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 331.81 531.56 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714093_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 ANTHEM HMO ANTHEM HMO 999999999 331.81 531.56 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714093_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 370.45 67.6 999999999 331.81 531.56 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714093_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 331.81 531.56 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714093_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 331.81 531.56 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714094_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 AETNA AETNA 432.92 79 999999999 331.81 531.56 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714094_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 356.2 65 999999999 331.81 531.56 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714094_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 531.56 97 999999999 331.81 531.56 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714094_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 378.12 69 999999999 331.81 531.56 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714094_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 427.44 78 999999999 331.81 531.56 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714094_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 UMR - ALL PLANS UMR - ALL PLANS 383.6 70 999999999 331.81 531.56 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714094_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 SIHO - ALL PLANS SIHO - ALL PLANS 493.2 90 999999999 331.81 531.56 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714094_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 331.81 60.55 999999999 331.81 531.56 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714094_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 331.81 531.56 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714094_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 331.81 531.56 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714094_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 ANTHEM HMO ANTHEM HMO 999999999 331.81 531.56 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714094_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 370.45 67.6 999999999 331.81 531.56 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714094_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 331.81 531.56 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714094_1 CDM 0278 RC C1887 HCPCS inpatient 548 356.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 331.81 531.56 BAND TR STANDARD W/INFLATOR 48714095_1 CDM 0272 RC inpatient 243 157.95 AETNA AETNA 191.97 79 999999999 147.14 235.71 percent of total billed charges BAND TR STANDARD W/INFLATOR 48714095_1 CDM 0272 RC inpatient 243 157.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 157.95 65 999999999 147.14 235.71 percent of total billed charges BAND TR STANDARD W/INFLATOR 48714095_1 CDM 0272 RC inpatient 243 157.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 235.71 97 999999999 147.14 235.71 percent of total billed charges BAND TR STANDARD W/INFLATOR 48714095_1 CDM 0272 RC inpatient 243 157.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 167.67 69 999999999 147.14 235.71 percent of total billed charges BAND TR STANDARD W/INFLATOR 48714095_1 CDM 0272 RC inpatient 243 157.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 189.54 78 999999999 147.14 235.71 percent of total billed charges BAND TR STANDARD W/INFLATOR 48714095_1 CDM 0272 RC inpatient 243 157.95 UMR - ALL PLANS UMR - ALL PLANS 170.1 70 999999999 147.14 235.71 percent of total billed charges BAND TR STANDARD W/INFLATOR 48714095_1 CDM 0272 RC inpatient 243 157.95 SIHO - ALL PLANS SIHO - ALL PLANS 218.7 90 999999999 147.14 235.71 percent of total billed charges BAND TR STANDARD W/INFLATOR 48714095_1 CDM 0272 RC inpatient 243 157.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.14 60.55 999999999 147.14 235.71 percent of total billed charges BAND TR STANDARD W/INFLATOR 48714095_1 CDM 0272 RC inpatient 243 157.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.14 235.71 BAND TR STANDARD W/INFLATOR 48714095_1 CDM 0272 RC inpatient 243 157.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.14 235.71 BAND TR STANDARD W/INFLATOR 48714095_1 CDM 0272 RC inpatient 243 157.95 ANTHEM HMO ANTHEM HMO 999999999 147.14 235.71 BAND TR STANDARD W/INFLATOR 48714095_1 CDM 0272 RC inpatient 243 157.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.27 67.6 999999999 147.14 235.71 percent of total billed charges BAND TR STANDARD W/INFLATOR 48714095_1 CDM 0272 RC inpatient 243 157.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.14 235.71 BAND TR STANDARD W/INFLATOR 48714095_1 CDM 0272 RC inpatient 243 157.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.14 235.71 BAND TR LONG W/INFLATOR 48714096_1 CDM 0272 RC inpatient 228 148.2 AETNA AETNA 180.12 79 999999999 138.05 221.16 percent of total billed charges BAND TR LONG W/INFLATOR 48714096_1 CDM 0272 RC inpatient 228 148.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 148.2 65 999999999 138.05 221.16 percent of total billed charges BAND TR LONG W/INFLATOR 48714096_1 CDM 0272 RC inpatient 228 148.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 221.16 97 999999999 138.05 221.16 percent of total billed charges BAND TR LONG W/INFLATOR 48714096_1 CDM 0272 RC inpatient 228 148.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 157.32 69 999999999 138.05 221.16 percent of total billed charges BAND TR LONG W/INFLATOR 48714096_1 CDM 0272 RC inpatient 228 148.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 177.84 78 999999999 138.05 221.16 percent of total billed charges BAND TR LONG W/INFLATOR 48714096_1 CDM 0272 RC inpatient 228 148.2 UMR - ALL PLANS UMR - ALL PLANS 159.6 70 999999999 138.05 221.16 percent of total billed charges BAND TR LONG W/INFLATOR 48714096_1 CDM 0272 RC inpatient 228 148.2 SIHO - ALL PLANS SIHO - ALL PLANS 205.2 90 999999999 138.05 221.16 percent of total billed charges BAND TR LONG W/INFLATOR 48714096_1 CDM 0272 RC inpatient 228 148.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 138.05 60.55 999999999 138.05 221.16 percent of total billed charges BAND TR LONG W/INFLATOR 48714096_1 CDM 0272 RC inpatient 228 148.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 138.05 221.16 BAND TR LONG W/INFLATOR 48714096_1 CDM 0272 RC inpatient 228 148.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 138.05 221.16 BAND TR LONG W/INFLATOR 48714096_1 CDM 0272 RC inpatient 228 148.2 ANTHEM HMO ANTHEM HMO 999999999 138.05 221.16 BAND TR LONG W/INFLATOR 48714096_1 CDM 0272 RC inpatient 228 148.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 154.13 67.6 999999999 138.05 221.16 percent of total billed charges BAND TR LONG W/INFLATOR 48714096_1 CDM 0272 RC inpatient 228 148.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 138.05 221.16 BAND TR LONG W/INFLATOR 48714096_1 CDM 0272 RC inpatient 228 148.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 138.05 221.16 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714097_1 CDM 0278 RC C1887 HCPCS inpatient 243 157.95 AETNA AETNA 191.97 79 999999999 147.14 235.71 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714097_1 CDM 0278 RC C1887 HCPCS inpatient 243 157.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 157.95 65 999999999 147.14 235.71 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714097_1 CDM 0278 RC C1887 HCPCS inpatient 243 157.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 235.71 97 999999999 147.14 235.71 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714097_1 CDM 0278 RC C1887 HCPCS inpatient 243 157.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 167.67 69 999999999 147.14 235.71 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714097_1 CDM 0278 RC C1887 HCPCS inpatient 243 157.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 189.54 78 999999999 147.14 235.71 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714097_1 CDM 0278 RC C1887 HCPCS inpatient 243 157.95 UMR - ALL PLANS UMR - ALL PLANS 170.1 70 999999999 147.14 235.71 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714097_1 CDM 0278 RC C1887 HCPCS inpatient 243 157.95 SIHO - ALL PLANS SIHO - ALL PLANS 218.7 90 999999999 147.14 235.71 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714097_1 CDM 0278 RC C1887 HCPCS inpatient 243 157.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.14 60.55 999999999 147.14 235.71 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714097_1 CDM 0278 RC C1887 HCPCS inpatient 243 157.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.14 235.71 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714097_1 CDM 0278 RC C1887 HCPCS inpatient 243 157.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.14 235.71 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714097_1 CDM 0278 RC C1887 HCPCS inpatient 243 157.95 ANTHEM HMO ANTHEM HMO 999999999 147.14 235.71 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714097_1 CDM 0278 RC C1887 HCPCS inpatient 243 157.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.27 67.6 999999999 147.14 235.71 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714097_1 CDM 0278 RC C1887 HCPCS inpatient 243 157.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.14 235.71 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714097_1 CDM 0278 RC C1887 HCPCS inpatient 243 157.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.14 235.71 CATH OPTITORQUE 5F RAD TIG 4.5 48714098_1 CDM 0278 RC inpatient 243 157.95 AETNA AETNA 191.97 79 999999999 147.14 235.71 percent of total billed charges CATH OPTITORQUE 5F RAD TIG 4.5 48714098_1 CDM 0278 RC inpatient 243 157.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 157.95 65 999999999 147.14 235.71 percent of total billed charges CATH OPTITORQUE 5F RAD TIG 4.5 48714098_1 CDM 0278 RC inpatient 243 157.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 235.71 97 999999999 147.14 235.71 percent of total billed charges CATH OPTITORQUE 5F RAD TIG 4.5 48714098_1 CDM 0278 RC inpatient 243 157.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 167.67 69 999999999 147.14 235.71 percent of total billed charges CATH OPTITORQUE 5F RAD TIG 4.5 48714098_1 CDM 0278 RC inpatient 243 157.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 189.54 78 999999999 147.14 235.71 percent of total billed charges CATH OPTITORQUE 5F RAD TIG 4.5 48714098_1 CDM 0278 RC inpatient 243 157.95 UMR - ALL PLANS UMR - ALL PLANS 170.1 70 999999999 147.14 235.71 percent of total billed charges CATH OPTITORQUE 5F RAD TIG 4.5 48714098_1 CDM 0278 RC inpatient 243 157.95 SIHO - ALL PLANS SIHO - ALL PLANS 218.7 90 999999999 147.14 235.71 percent of total billed charges CATH OPTITORQUE 5F RAD TIG 4.5 48714098_1 CDM 0278 RC inpatient 243 157.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.14 60.55 999999999 147.14 235.71 percent of total billed charges CATH OPTITORQUE 5F RAD TIG 4.5 48714098_1 CDM 0278 RC inpatient 243 157.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.14 235.71 CATH OPTITORQUE 5F RAD TIG 4.5 48714098_1 CDM 0278 RC inpatient 243 157.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.14 235.71 CATH OPTITORQUE 5F RAD TIG 4.5 48714098_1 CDM 0278 RC inpatient 243 157.95 ANTHEM HMO ANTHEM HMO 999999999 147.14 235.71 CATH OPTITORQUE 5F RAD TIG 4.5 48714098_1 CDM 0278 RC inpatient 243 157.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.27 67.6 999999999 147.14 235.71 percent of total billed charges CATH OPTITORQUE 5F RAD TIG 4.5 48714098_1 CDM 0278 RC inpatient 243 157.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.14 235.71 CATH OPTITORQUE 5F RAD TIG 4.5 48714098_1 CDM 0278 RC inpatient 243 157.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.14 235.71 GLIDEWIRE STD 0.035X150X3CM JG 48714099_1 CDM 0272 RC inpatient 107 69.55 AETNA AETNA 84.53 79 999999999 64.79 103.79 percent of total billed charges GLIDEWIRE STD 0.035X150X3CM JG 48714099_1 CDM 0272 RC inpatient 107 69.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 69.55 65 999999999 64.79 103.79 percent of total billed charges GLIDEWIRE STD 0.035X150X3CM JG 48714099_1 CDM 0272 RC inpatient 107 69.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 103.79 97 999999999 64.79 103.79 percent of total billed charges GLIDEWIRE STD 0.035X150X3CM JG 48714099_1 CDM 0272 RC inpatient 107 69.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.83 69 999999999 64.79 103.79 percent of total billed charges GLIDEWIRE STD 0.035X150X3CM JG 48714099_1 CDM 0272 RC inpatient 107 69.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 83.46 78 999999999 64.79 103.79 percent of total billed charges GLIDEWIRE STD 0.035X150X3CM JG 48714099_1 CDM 0272 RC inpatient 107 69.55 UMR - ALL PLANS UMR - ALL PLANS 74.9 70 999999999 64.79 103.79 percent of total billed charges GLIDEWIRE STD 0.035X150X3CM JG 48714099_1 CDM 0272 RC inpatient 107 69.55 SIHO - ALL PLANS SIHO - ALL PLANS 96.3 90 999999999 64.79 103.79 percent of total billed charges GLIDEWIRE STD 0.035X150X3CM JG 48714099_1 CDM 0272 RC inpatient 107 69.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.79 60.55 999999999 64.79 103.79 percent of total billed charges GLIDEWIRE STD 0.035X150X3CM JG 48714099_1 CDM 0272 RC inpatient 107 69.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.79 103.79 GLIDEWIRE STD 0.035X150X3CM JG 48714099_1 CDM 0272 RC inpatient 107 69.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.79 103.79 GLIDEWIRE STD 0.035X150X3CM JG 48714099_1 CDM 0272 RC inpatient 107 69.55 ANTHEM HMO ANTHEM HMO 999999999 64.79 103.79 GLIDEWIRE STD 0.035X150X3CM JG 48714099_1 CDM 0272 RC inpatient 107 69.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 72.33 67.6 999999999 64.79 103.79 percent of total billed charges GLIDEWIRE STD 0.035X150X3CM JG 48714099_1 CDM 0272 RC inpatient 107 69.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.79 103.79 GLIDEWIRE STD 0.035X150X3CM JG 48714099_1 CDM 0272 RC inpatient 107 69.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.79 103.79 PEEL AWAY INTRODUCER 22FR 48714100_1 CDM 0272 RC inpatient 290 188.5 AETNA AETNA 229.1 79 999999999 175.6 281.3 percent of total billed charges PEEL AWAY INTRODUCER 22FR 48714100_1 CDM 0272 RC inpatient 290 188.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 188.5 65 999999999 175.6 281.3 percent of total billed charges PEEL AWAY INTRODUCER 22FR 48714100_1 CDM 0272 RC inpatient 290 188.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 281.3 97 999999999 175.6 281.3 percent of total billed charges PEEL AWAY INTRODUCER 22FR 48714100_1 CDM 0272 RC inpatient 290 188.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 200.1 69 999999999 175.6 281.3 percent of total billed charges PEEL AWAY INTRODUCER 22FR 48714100_1 CDM 0272 RC inpatient 290 188.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 226.2 78 999999999 175.6 281.3 percent of total billed charges PEEL AWAY INTRODUCER 22FR 48714100_1 CDM 0272 RC inpatient 290 188.5 UMR - ALL PLANS UMR - ALL PLANS 203 70 999999999 175.6 281.3 percent of total billed charges PEEL AWAY INTRODUCER 22FR 48714100_1 CDM 0272 RC inpatient 290 188.5 SIHO - ALL PLANS SIHO - ALL PLANS 261 90 999999999 175.6 281.3 percent of total billed charges PEEL AWAY INTRODUCER 22FR 48714100_1 CDM 0272 RC inpatient 290 188.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 175.6 60.55 999999999 175.6 281.3 percent of total billed charges PEEL AWAY INTRODUCER 22FR 48714100_1 CDM 0272 RC inpatient 290 188.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 175.6 281.3 PEEL AWAY INTRODUCER 22FR 48714100_1 CDM 0272 RC inpatient 290 188.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 175.6 281.3 PEEL AWAY INTRODUCER 22FR 48714100_1 CDM 0272 RC inpatient 290 188.5 ANTHEM HMO ANTHEM HMO 999999999 175.6 281.3 PEEL AWAY INTRODUCER 22FR 48714100_1 CDM 0272 RC inpatient 290 188.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 196.04 67.6 999999999 175.6 281.3 percent of total billed charges PEEL AWAY INTRODUCER 22FR 48714100_1 CDM 0272 RC inpatient 290 188.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 175.6 281.3 PEEL AWAY INTRODUCER 22FR 48714100_1 CDM 0272 RC inpatient 290 188.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 175.6 281.3 INTRODUCER CORDIS 4FR MSX11CM 48714101_1 CDM 0272 RC inpatient 59 38.35 AETNA AETNA 46.61 79 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 4FR MSX11CM 48714101_1 CDM 0272 RC inpatient 59 38.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 38.35 65 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 4FR MSX11CM 48714101_1 CDM 0272 RC inpatient 59 38.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 57.23 97 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 4FR MSX11CM 48714101_1 CDM 0272 RC inpatient 59 38.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.71 69 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 4FR MSX11CM 48714101_1 CDM 0272 RC inpatient 59 38.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.02 78 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 4FR MSX11CM 48714101_1 CDM 0272 RC inpatient 59 38.35 UMR - ALL PLANS UMR - ALL PLANS 41.3 70 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 4FR MSX11CM 48714101_1 CDM 0272 RC inpatient 59 38.35 SIHO - ALL PLANS SIHO - ALL PLANS 53.1 90 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 4FR MSX11CM 48714101_1 CDM 0272 RC inpatient 59 38.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.72 60.55 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 4FR MSX11CM 48714101_1 CDM 0272 RC inpatient 59 38.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.72 57.23 INTRODUCER CORDIS 4FR MSX11CM 48714101_1 CDM 0272 RC inpatient 59 38.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.72 57.23 INTRODUCER CORDIS 4FR MSX11CM 48714101_1 CDM 0272 RC inpatient 59 38.35 ANTHEM HMO ANTHEM HMO 999999999 35.72 57.23 INTRODUCER CORDIS 4FR MSX11CM 48714101_1 CDM 0272 RC inpatient 59 38.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.88 67.6 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 4FR MSX11CM 48714101_1 CDM 0272 RC inpatient 59 38.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.72 57.23 INTRODUCER CORDIS 4FR MSX11CM 48714101_1 CDM 0272 RC inpatient 59 38.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.72 57.23 INTRODUCER CORDIS 5FR MSX11CM 48714102_1 CDM 0272 RC inpatient 59 38.35 AETNA AETNA 46.61 79 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 5FR MSX11CM 48714102_1 CDM 0272 RC inpatient 59 38.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 38.35 65 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 5FR MSX11CM 48714102_1 CDM 0272 RC inpatient 59 38.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 57.23 97 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 5FR MSX11CM 48714102_1 CDM 0272 RC inpatient 59 38.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.71 69 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 5FR MSX11CM 48714102_1 CDM 0272 RC inpatient 59 38.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.02 78 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 5FR MSX11CM 48714102_1 CDM 0272 RC inpatient 59 38.35 UMR - ALL PLANS UMR - ALL PLANS 41.3 70 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 5FR MSX11CM 48714102_1 CDM 0272 RC inpatient 59 38.35 SIHO - ALL PLANS SIHO - ALL PLANS 53.1 90 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 5FR MSX11CM 48714102_1 CDM 0272 RC inpatient 59 38.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.72 60.55 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 5FR MSX11CM 48714102_1 CDM 0272 RC inpatient 59 38.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.72 57.23 INTRODUCER CORDIS 5FR MSX11CM 48714102_1 CDM 0272 RC inpatient 59 38.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.72 57.23 INTRODUCER CORDIS 5FR MSX11CM 48714102_1 CDM 0272 RC inpatient 59 38.35 ANTHEM HMO ANTHEM HMO 999999999 35.72 57.23 INTRODUCER CORDIS 5FR MSX11CM 48714102_1 CDM 0272 RC inpatient 59 38.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.88 67.6 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 5FR MSX11CM 48714102_1 CDM 0272 RC inpatient 59 38.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.72 57.23 INTRODUCER CORDIS 5FR MSX11CM 48714102_1 CDM 0272 RC inpatient 59 38.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.72 57.23 INTRODUCER CORDIS 7FR MSX11CM 48714103_1 CDM 0272 RC inpatient 59 38.35 AETNA AETNA 46.61 79 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 7FR MSX11CM 48714103_1 CDM 0272 RC inpatient 59 38.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 38.35 65 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 7FR MSX11CM 48714103_1 CDM 0272 RC inpatient 59 38.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 57.23 97 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 7FR MSX11CM 48714103_1 CDM 0272 RC inpatient 59 38.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.71 69 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 7FR MSX11CM 48714103_1 CDM 0272 RC inpatient 59 38.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.02 78 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 7FR MSX11CM 48714103_1 CDM 0272 RC inpatient 59 38.35 UMR - ALL PLANS UMR - ALL PLANS 41.3 70 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 7FR MSX11CM 48714103_1 CDM 0272 RC inpatient 59 38.35 SIHO - ALL PLANS SIHO - ALL PLANS 53.1 90 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 7FR MSX11CM 48714103_1 CDM 0272 RC inpatient 59 38.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.72 60.55 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 7FR MSX11CM 48714103_1 CDM 0272 RC inpatient 59 38.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.72 57.23 INTRODUCER CORDIS 7FR MSX11CM 48714103_1 CDM 0272 RC inpatient 59 38.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.72 57.23 INTRODUCER CORDIS 7FR MSX11CM 48714103_1 CDM 0272 RC inpatient 59 38.35 ANTHEM HMO ANTHEM HMO 999999999 35.72 57.23 INTRODUCER CORDIS 7FR MSX11CM 48714103_1 CDM 0272 RC inpatient 59 38.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.88 67.6 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 7FR MSX11CM 48714103_1 CDM 0272 RC inpatient 59 38.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.72 57.23 INTRODUCER CORDIS 7FR MSX11CM 48714103_1 CDM 0272 RC inpatient 59 38.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.72 57.23 INTRODUCER CORDIS 6FR MSX11CM 48714104_1 CDM 0272 RC inpatient 59 38.35 AETNA AETNA 46.61 79 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 6FR MSX11CM 48714104_1 CDM 0272 RC inpatient 59 38.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 38.35 65 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 6FR MSX11CM 48714104_1 CDM 0272 RC inpatient 59 38.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 57.23 97 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 6FR MSX11CM 48714104_1 CDM 0272 RC inpatient 59 38.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.71 69 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 6FR MSX11CM 48714104_1 CDM 0272 RC inpatient 59 38.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.02 78 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 6FR MSX11CM 48714104_1 CDM 0272 RC inpatient 59 38.35 UMR - ALL PLANS UMR - ALL PLANS 41.3 70 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 6FR MSX11CM 48714104_1 CDM 0272 RC inpatient 59 38.35 SIHO - ALL PLANS SIHO - ALL PLANS 53.1 90 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 6FR MSX11CM 48714104_1 CDM 0272 RC inpatient 59 38.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.72 60.55 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 6FR MSX11CM 48714104_1 CDM 0272 RC inpatient 59 38.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.72 57.23 INTRODUCER CORDIS 6FR MSX11CM 48714104_1 CDM 0272 RC inpatient 59 38.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.72 57.23 INTRODUCER CORDIS 6FR MSX11CM 48714104_1 CDM 0272 RC inpatient 59 38.35 ANTHEM HMO ANTHEM HMO 999999999 35.72 57.23 INTRODUCER CORDIS 6FR MSX11CM 48714104_1 CDM 0272 RC inpatient 59 38.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.88 67.6 999999999 35.72 57.23 percent of total billed charges INTRODUCER CORDIS 6FR MSX11CM 48714104_1 CDM 0272 RC inpatient 59 38.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.72 57.23 INTRODUCER CORDIS 6FR MSX11CM 48714104_1 CDM 0272 RC inpatient 59 38.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.72 57.23 CATHETER 6FR JL4.5 48714105_1 CDM 0272 RC inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL4.5 48714105_1 CDM 0272 RC inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL4.5 48714105_1 CDM 0272 RC inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL4.5 48714105_1 CDM 0272 RC inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL4.5 48714105_1 CDM 0272 RC inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL4.5 48714105_1 CDM 0272 RC inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL4.5 48714105_1 CDM 0272 RC inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL4.5 48714105_1 CDM 0272 RC inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL4.5 48714105_1 CDM 0272 RC inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 CATHETER 6FR JL4.5 48714105_1 CDM 0272 RC inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 CATHETER 6FR JL4.5 48714105_1 CDM 0272 RC inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 CATHETER 6FR JL4.5 48714105_1 CDM 0272 RC inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL4.5 48714105_1 CDM 0272 RC inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 CATHETER 6FR JL4.5 48714105_1 CDM 0272 RC inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 CATHETER 6FR JL4 534620T 48714107_1 CDM 0272 RC inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL4 534620T 48714107_1 CDM 0272 RC inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL4 534620T 48714107_1 CDM 0272 RC inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL4 534620T 48714107_1 CDM 0272 RC inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL4 534620T 48714107_1 CDM 0272 RC inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL4 534620T 48714107_1 CDM 0272 RC inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL4 534620T 48714107_1 CDM 0272 RC inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL4 534620T 48714107_1 CDM 0272 RC inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL4 534620T 48714107_1 CDM 0272 RC inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 CATHETER 6FR JL4 534620T 48714107_1 CDM 0272 RC inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 CATHETER 6FR JL4 534620T 48714107_1 CDM 0272 RC inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 CATHETER 6FR JL4 534620T 48714107_1 CDM 0272 RC inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL4 534620T 48714107_1 CDM 0272 RC inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 CATHETER 6FR JL4 534620T 48714107_1 CDM 0272 RC inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 CATHETER 6FR JR4 534621T 48714108_1 CDM 0272 RC inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JR4 534621T 48714108_1 CDM 0272 RC inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JR4 534621T 48714108_1 CDM 0272 RC inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JR4 534621T 48714108_1 CDM 0272 RC inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JR4 534621T 48714108_1 CDM 0272 RC inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JR4 534621T 48714108_1 CDM 0272 RC inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JR4 534621T 48714108_1 CDM 0272 RC inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JR4 534621T 48714108_1 CDM 0272 RC inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JR4 534621T 48714108_1 CDM 0272 RC inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 CATHETER 6FR JR4 534621T 48714108_1 CDM 0272 RC inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 CATHETER 6FR JR4 534621T 48714108_1 CDM 0272 RC inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 CATHETER 6FR JR4 534621T 48714108_1 CDM 0272 RC inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JR4 534621T 48714108_1 CDM 0272 RC inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 CATHETER 6FR JR4 534621T 48714108_1 CDM 0272 RC inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 CATHETER 6FR JL5 48714109_1 CDM 0272 RC inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL5 48714109_1 CDM 0272 RC inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL5 48714109_1 CDM 0272 RC inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL5 48714109_1 CDM 0272 RC inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL5 48714109_1 CDM 0272 RC inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL5 48714109_1 CDM 0272 RC inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL5 48714109_1 CDM 0272 RC inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL5 48714109_1 CDM 0272 RC inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL5 48714109_1 CDM 0272 RC inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 CATHETER 6FR JL5 48714109_1 CDM 0272 RC inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 CATHETER 6FR JL5 48714109_1 CDM 0272 RC inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 CATHETER 6FR JL5 48714109_1 CDM 0272 RC inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR JL5 48714109_1 CDM 0272 RC inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 CATHETER 6FR JL5 48714109_1 CDM 0272 RC inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 CATHETER 6FR AR1 MOD 48714110_1 CDM 0272 RC inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR AR1 MOD 48714110_1 CDM 0272 RC inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR AR1 MOD 48714110_1 CDM 0272 RC inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR AR1 MOD 48714110_1 CDM 0272 RC inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR AR1 MOD 48714110_1 CDM 0272 RC inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR AR1 MOD 48714110_1 CDM 0272 RC inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR AR1 MOD 48714110_1 CDM 0272 RC inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR AR1 MOD 48714110_1 CDM 0272 RC inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR AR1 MOD 48714110_1 CDM 0272 RC inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 CATHETER 6FR AR1 MOD 48714110_1 CDM 0272 RC inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 CATHETER 6FR AR1 MOD 48714110_1 CDM 0272 RC inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 CATHETER 6FR AR1 MOD 48714110_1 CDM 0272 RC inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR AR1 MOD 48714110_1 CDM 0272 RC inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 CATHETER 6FR AR1 MOD 48714110_1 CDM 0272 RC inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 CATHETER 6FR PIG 534650S 48714115_1 CDM 0272 RC inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR PIG 534650S 48714115_1 CDM 0272 RC inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR PIG 534650S 48714115_1 CDM 0272 RC inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR PIG 534650S 48714115_1 CDM 0272 RC inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR PIG 534650S 48714115_1 CDM 0272 RC inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR PIG 534650S 48714115_1 CDM 0272 RC inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR PIG 534650S 48714115_1 CDM 0272 RC inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR PIG 534650S 48714115_1 CDM 0272 RC inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR PIG 534650S 48714115_1 CDM 0272 RC inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 CATHETER 6FR PIG 534650S 48714115_1 CDM 0272 RC inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 CATHETER 6FR PIG 534650S 48714115_1 CDM 0272 RC inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 CATHETER 6FR PIG 534650S 48714115_1 CDM 0272 RC inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR PIG 534650S 48714115_1 CDM 0272 RC inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 CATHETER 6FR PIG 534650S 48714115_1 CDM 0272 RC inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 CATHETER 6FR 3DRC 534676T 48714118_1 CDM 0272 RC inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR 3DRC 534676T 48714118_1 CDM 0272 RC inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR 3DRC 534676T 48714118_1 CDM 0272 RC inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR 3DRC 534676T 48714118_1 CDM 0272 RC inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR 3DRC 534676T 48714118_1 CDM 0272 RC inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR 3DRC 534676T 48714118_1 CDM 0272 RC inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR 3DRC 534676T 48714118_1 CDM 0272 RC inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR 3DRC 534676T 48714118_1 CDM 0272 RC inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR 3DRC 534676T 48714118_1 CDM 0272 RC inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 CATHETER 6FR 3DRC 534676T 48714118_1 CDM 0272 RC inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 CATHETER 6FR 3DRC 534676T 48714118_1 CDM 0272 RC inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 CATHETER 6FR 3DRC 534676T 48714118_1 CDM 0272 RC inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges CATHETER 6FR 3DRC 534676T 48714118_1 CDM 0272 RC inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 CATHETER 6FR 3DRC 534676T 48714118_1 CDM 0272 RC inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 CATHETER 4FR JL 3.5 48714122_1 CDM 0272 RC inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR JL 3.5 48714122_1 CDM 0272 RC inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR JL 3.5 48714122_1 CDM 0272 RC inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR JL 3.5 48714122_1 CDM 0272 RC inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR JL 3.5 48714122_1 CDM 0272 RC inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR JL 3.5 48714122_1 CDM 0272 RC inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR JL 3.5 48714122_1 CDM 0272 RC inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR JL 3.5 48714122_1 CDM 0272 RC inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR JL 3.5 48714122_1 CDM 0272 RC inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 CATHETER 4FR JL 3.5 48714122_1 CDM 0272 RC inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 CATHETER 4FR JL 3.5 48714122_1 CDM 0272 RC inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 CATHETER 4FR JL 3.5 48714122_1 CDM 0272 RC inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR JL 3.5 48714122_1 CDM 0272 RC inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 CATHETER 4FR JL 3.5 48714122_1 CDM 0272 RC inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 CORDIS CATHETER 4FR AR1 MOD 48714125_1 CDM 0272 RC inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges CORDIS CATHETER 4FR AR1 MOD 48714125_1 CDM 0272 RC inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges CORDIS CATHETER 4FR AR1 MOD 48714125_1 CDM 0272 RC inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges CORDIS CATHETER 4FR AR1 MOD 48714125_1 CDM 0272 RC inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges CORDIS CATHETER 4FR AR1 MOD 48714125_1 CDM 0272 RC inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges CORDIS CATHETER 4FR AR1 MOD 48714125_1 CDM 0272 RC inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges CORDIS CATHETER 4FR AR1 MOD 48714125_1 CDM 0272 RC inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges CORDIS CATHETER 4FR AR1 MOD 48714125_1 CDM 0272 RC inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges CORDIS CATHETER 4FR AR1 MOD 48714125_1 CDM 0272 RC inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 CORDIS CATHETER 4FR AR1 MOD 48714125_1 CDM 0272 RC inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 CORDIS CATHETER 4FR AR1 MOD 48714125_1 CDM 0272 RC inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 CORDIS CATHETER 4FR AR1 MOD 48714125_1 CDM 0272 RC inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges CORDIS CATHETER 4FR AR1 MOD 48714125_1 CDM 0272 RC inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 CORDIS CATHETER 4FR AR1 MOD 48714125_1 CDM 0272 RC inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 CATHETER 4FR PIG 48714128_1 CDM 0272 RC inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR PIG 48714128_1 CDM 0272 RC inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR PIG 48714128_1 CDM 0272 RC inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR PIG 48714128_1 CDM 0272 RC inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR PIG 48714128_1 CDM 0272 RC inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR PIG 48714128_1 CDM 0272 RC inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR PIG 48714128_1 CDM 0272 RC inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR PIG 48714128_1 CDM 0272 RC inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR PIG 48714128_1 CDM 0272 RC inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 CATHETER 4FR PIG 48714128_1 CDM 0272 RC inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 CATHETER 4FR PIG 48714128_1 CDM 0272 RC inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 CATHETER 4FR PIG 48714128_1 CDM 0272 RC inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR PIG 48714128_1 CDM 0272 RC inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 CATHETER 4FR PIG 48714128_1 CDM 0272 RC inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 CATHETER 4FR LCB 48714131_1 CDM 0272 RC inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR LCB 48714131_1 CDM 0272 RC inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR LCB 48714131_1 CDM 0272 RC inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR LCB 48714131_1 CDM 0272 RC inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR LCB 48714131_1 CDM 0272 RC inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR LCB 48714131_1 CDM 0272 RC inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR LCB 48714131_1 CDM 0272 RC inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR LCB 48714131_1 CDM 0272 RC inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR LCB 48714131_1 CDM 0272 RC inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 CATHETER 4FR LCB 48714131_1 CDM 0272 RC inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 CATHETER 4FR LCB 48714131_1 CDM 0272 RC inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 CATHETER 4FR LCB 48714131_1 CDM 0272 RC inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR LCB 48714131_1 CDM 0272 RC inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 CATHETER 4FR LCB 48714131_1 CDM 0272 RC inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 DRAPE BRACHIAL 38.5x60in 48714133_1 CDM 0272 RC inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges DRAPE BRACHIAL 38.5x60in 48714133_1 CDM 0272 RC inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges DRAPE BRACHIAL 38.5x60in 48714133_1 CDM 0272 RC inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges DRAPE BRACHIAL 38.5x60in 48714133_1 CDM 0272 RC inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges DRAPE BRACHIAL 38.5x60in 48714133_1 CDM 0272 RC inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges DRAPE BRACHIAL 38.5x60in 48714133_1 CDM 0272 RC inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges DRAPE BRACHIAL 38.5x60in 48714133_1 CDM 0272 RC inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges DRAPE BRACHIAL 38.5x60in 48714133_1 CDM 0272 RC inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges DRAPE BRACHIAL 38.5x60in 48714133_1 CDM 0272 RC inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 DRAPE BRACHIAL 38.5x60in 48714133_1 CDM 0272 RC inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 DRAPE BRACHIAL 38.5x60in 48714133_1 CDM 0272 RC inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 DRAPE BRACHIAL 38.5x60in 48714133_1 CDM 0272 RC inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges DRAPE BRACHIAL 38.5x60in 48714133_1 CDM 0272 RC inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 DRAPE BRACHIAL 38.5x60in 48714133_1 CDM 0272 RC inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 SET CLOSED INJECTION DELIVERY 48714135_1 CDM 0272 RC inpatient 155 100.75 AETNA AETNA 122.45 79 999999999 93.85 150.35 percent of total billed charges SET CLOSED INJECTION DELIVERY 48714135_1 CDM 0272 RC inpatient 155 100.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.75 65 999999999 93.85 150.35 percent of total billed charges SET CLOSED INJECTION DELIVERY 48714135_1 CDM 0272 RC inpatient 155 100.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 150.35 97 999999999 93.85 150.35 percent of total billed charges SET CLOSED INJECTION DELIVERY 48714135_1 CDM 0272 RC inpatient 155 100.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.95 69 999999999 93.85 150.35 percent of total billed charges SET CLOSED INJECTION DELIVERY 48714135_1 CDM 0272 RC inpatient 155 100.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.9 78 999999999 93.85 150.35 percent of total billed charges SET CLOSED INJECTION DELIVERY 48714135_1 CDM 0272 RC inpatient 155 100.75 UMR - ALL PLANS UMR - ALL PLANS 108.5 70 999999999 93.85 150.35 percent of total billed charges SET CLOSED INJECTION DELIVERY 48714135_1 CDM 0272 RC inpatient 155 100.75 SIHO - ALL PLANS SIHO - ALL PLANS 139.5 90 999999999 93.85 150.35 percent of total billed charges SET CLOSED INJECTION DELIVERY 48714135_1 CDM 0272 RC inpatient 155 100.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.85 60.55 999999999 93.85 150.35 percent of total billed charges SET CLOSED INJECTION DELIVERY 48714135_1 CDM 0272 RC inpatient 155 100.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.85 150.35 SET CLOSED INJECTION DELIVERY 48714135_1 CDM 0272 RC inpatient 155 100.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.85 150.35 SET CLOSED INJECTION DELIVERY 48714135_1 CDM 0272 RC inpatient 155 100.75 ANTHEM HMO ANTHEM HMO 999999999 93.85 150.35 SET CLOSED INJECTION DELIVERY 48714135_1 CDM 0272 RC inpatient 155 100.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.78 67.6 999999999 93.85 150.35 percent of total billed charges SET CLOSED INJECTION DELIVERY 48714135_1 CDM 0272 RC inpatient 155 100.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.85 150.35 SET CLOSED INJECTION DELIVERY 48714135_1 CDM 0272 RC inpatient 155 100.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.85 150.35 PORT POWER INJECTABLE XCELA 48714136_1 CDM 0272 RC inpatient 1700 1105 AETNA AETNA 1343 79 999999999 1029.35 1649 percent of total billed charges PORT POWER INJECTABLE XCELA 48714136_1 CDM 0272 RC inpatient 1700 1105 SELF PAY DISCOUNT SELF PAY DISCOUNT 1105 65 999999999 1029.35 1649 percent of total billed charges PORT POWER INJECTABLE XCELA 48714136_1 CDM 0272 RC inpatient 1700 1105 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1649 97 999999999 1029.35 1649 percent of total billed charges PORT POWER INJECTABLE XCELA 48714136_1 CDM 0272 RC inpatient 1700 1105 ENCORE - ALL PLANS ENCORE - ALL PLANS 1173 69 999999999 1029.35 1649 percent of total billed charges PORT POWER INJECTABLE XCELA 48714136_1 CDM 0272 RC inpatient 1700 1105 HUMANA - ALL PLANS HUMANA - ALL PLANS 1326 78 999999999 1029.35 1649 percent of total billed charges PORT POWER INJECTABLE XCELA 48714136_1 CDM 0272 RC inpatient 1700 1105 UMR - ALL PLANS UMR - ALL PLANS 1190 70 999999999 1029.35 1649 percent of total billed charges PORT POWER INJECTABLE XCELA 48714136_1 CDM 0272 RC inpatient 1700 1105 SIHO - ALL PLANS SIHO - ALL PLANS 1530 90 999999999 1029.35 1649 percent of total billed charges PORT POWER INJECTABLE XCELA 48714136_1 CDM 0272 RC inpatient 1700 1105 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1029.35 60.55 999999999 1029.35 1649 percent of total billed charges PORT POWER INJECTABLE XCELA 48714136_1 CDM 0272 RC inpatient 1700 1105 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1029.35 1649 PORT POWER INJECTABLE XCELA 48714136_1 CDM 0272 RC inpatient 1700 1105 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1029.35 1649 PORT POWER INJECTABLE XCELA 48714136_1 CDM 0272 RC inpatient 1700 1105 ANTHEM HMO ANTHEM HMO 999999999 1029.35 1649 PORT POWER INJECTABLE XCELA 48714136_1 CDM 0272 RC inpatient 1700 1105 CIGNA - ALL PLANS CIGNA - ALL PLANS 1149.2 67.6 999999999 1029.35 1649 percent of total billed charges PORT POWER INJECTABLE XCELA 48714136_1 CDM 0272 RC inpatient 1700 1105 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1029.35 1649 PORT POWER INJECTABLE XCELA 48714136_1 CDM 0272 RC inpatient 1700 1105 UHC - ALL PLANS UHC - ALL PLANS 999999999 1029.35 1649 PACK ANGIOPLASTY W\ACCESS-9 48714137_1 CDM 0272 RC inpatient 107 69.55 AETNA AETNA 84.53 79 999999999 64.79 103.79 percent of total billed charges PACK ANGIOPLASTY W\ACCESS-9 48714137_1 CDM 0272 RC inpatient 107 69.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 69.55 65 999999999 64.79 103.79 percent of total billed charges PACK ANGIOPLASTY W\ACCESS-9 48714137_1 CDM 0272 RC inpatient 107 69.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 103.79 97 999999999 64.79 103.79 percent of total billed charges PACK ANGIOPLASTY W\ACCESS-9 48714137_1 CDM 0272 RC inpatient 107 69.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.83 69 999999999 64.79 103.79 percent of total billed charges PACK ANGIOPLASTY W\ACCESS-9 48714137_1 CDM 0272 RC inpatient 107 69.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 83.46 78 999999999 64.79 103.79 percent of total billed charges PACK ANGIOPLASTY W\ACCESS-9 48714137_1 CDM 0272 RC inpatient 107 69.55 UMR - ALL PLANS UMR - ALL PLANS 74.9 70 999999999 64.79 103.79 percent of total billed charges PACK ANGIOPLASTY W\ACCESS-9 48714137_1 CDM 0272 RC inpatient 107 69.55 SIHO - ALL PLANS SIHO - ALL PLANS 96.3 90 999999999 64.79 103.79 percent of total billed charges PACK ANGIOPLASTY W\ACCESS-9 48714137_1 CDM 0272 RC inpatient 107 69.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.79 60.55 999999999 64.79 103.79 percent of total billed charges PACK ANGIOPLASTY W\ACCESS-9 48714137_1 CDM 0272 RC inpatient 107 69.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.79 103.79 PACK ANGIOPLASTY W\ACCESS-9 48714137_1 CDM 0272 RC inpatient 107 69.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.79 103.79 PACK ANGIOPLASTY W\ACCESS-9 48714137_1 CDM 0272 RC inpatient 107 69.55 ANTHEM HMO ANTHEM HMO 999999999 64.79 103.79 PACK ANGIOPLASTY W\ACCESS-9 48714137_1 CDM 0272 RC inpatient 107 69.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 72.33 67.6 999999999 64.79 103.79 percent of total billed charges PACK ANGIOPLASTY W\ACCESS-9 48714137_1 CDM 0272 RC inpatient 107 69.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.79 103.79 PACK ANGIOPLASTY W\ACCESS-9 48714137_1 CDM 0272 RC inpatient 107 69.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.79 103.79 KIT PA CATH 6 FR 2 LUMEN 48714139_1 CDM 0272 RC inpatient 265 172.25 AETNA AETNA 209.35 79 999999999 160.46 257.05 percent of total billed charges KIT PA CATH 6 FR 2 LUMEN 48714139_1 CDM 0272 RC inpatient 265 172.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 172.25 65 999999999 160.46 257.05 percent of total billed charges KIT PA CATH 6 FR 2 LUMEN 48714139_1 CDM 0272 RC inpatient 265 172.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 257.05 97 999999999 160.46 257.05 percent of total billed charges KIT PA CATH 6 FR 2 LUMEN 48714139_1 CDM 0272 RC inpatient 265 172.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 182.85 69 999999999 160.46 257.05 percent of total billed charges KIT PA CATH 6 FR 2 LUMEN 48714139_1 CDM 0272 RC inpatient 265 172.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 206.7 78 999999999 160.46 257.05 percent of total billed charges KIT PA CATH 6 FR 2 LUMEN 48714139_1 CDM 0272 RC inpatient 265 172.25 UMR - ALL PLANS UMR - ALL PLANS 185.5 70 999999999 160.46 257.05 percent of total billed charges KIT PA CATH 6 FR 2 LUMEN 48714139_1 CDM 0272 RC inpatient 265 172.25 SIHO - ALL PLANS SIHO - ALL PLANS 238.5 90 999999999 160.46 257.05 percent of total billed charges KIT PA CATH 6 FR 2 LUMEN 48714139_1 CDM 0272 RC inpatient 265 172.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 160.46 60.55 999999999 160.46 257.05 percent of total billed charges KIT PA CATH 6 FR 2 LUMEN 48714139_1 CDM 0272 RC inpatient 265 172.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 160.46 257.05 KIT PA CATH 6 FR 2 LUMEN 48714139_1 CDM 0272 RC inpatient 265 172.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 160.46 257.05 KIT PA CATH 6 FR 2 LUMEN 48714139_1 CDM 0272 RC inpatient 265 172.25 ANTHEM HMO ANTHEM HMO 999999999 160.46 257.05 KIT PA CATH 6 FR 2 LUMEN 48714139_1 CDM 0272 RC inpatient 265 172.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 179.14 67.6 999999999 160.46 257.05 percent of total billed charges KIT PA CATH 6 FR 2 LUMEN 48714139_1 CDM 0272 RC inpatient 265 172.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 160.46 257.05 KIT PA CATH 6 FR 2 LUMEN 48714139_1 CDM 0272 RC inpatient 265 172.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 160.46 257.05 CATHETER 6FR MPA 48714140_1 CDM 0272 RC inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges CATHETER 6FR MPA 48714140_1 CDM 0272 RC inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges CATHETER 6FR MPA 48714140_1 CDM 0272 RC inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges CATHETER 6FR MPA 48714140_1 CDM 0272 RC inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges CATHETER 6FR MPA 48714140_1 CDM 0272 RC inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges CATHETER 6FR MPA 48714140_1 CDM 0272 RC inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges CATHETER 6FR MPA 48714140_1 CDM 0272 RC inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges CATHETER 6FR MPA 48714140_1 CDM 0272 RC inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges CATHETER 6FR MPA 48714140_1 CDM 0272 RC inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 CATHETER 6FR MPA 48714140_1 CDM 0272 RC inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 CATHETER 6FR MPA 48714140_1 CDM 0272 RC inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 CATHETER 6FR MPA 48714140_1 CDM 0272 RC inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges CATHETER 6FR MPA 48714140_1 CDM 0272 RC inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 CATHETER 6FR MPA 48714140_1 CDM 0272 RC inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 "INTRODUCER/SHEATH, OTHER THAN GUIDING, OTHER THAN INTRACARDIAC ELECTROPHYSIOLOGICAL, NON-LASER" 48714141_1 CDM 0272 RC C1894 HCPCS inpatient 230 149.5 AETNA AETNA 181.7 79 999999999 139.27 223.1 percent of total billed charges "INTRODUCER/SHEATH, OTHER THAN GUIDING, OTHER THAN INTRACARDIAC ELECTROPHYSIOLOGICAL, NON-LASER" 48714141_1 CDM 0272 RC C1894 HCPCS inpatient 230 149.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 149.5 65 999999999 139.27 223.1 percent of total billed charges "INTRODUCER/SHEATH, OTHER THAN GUIDING, OTHER THAN INTRACARDIAC ELECTROPHYSIOLOGICAL, NON-LASER" 48714141_1 CDM 0272 RC C1894 HCPCS inpatient 230 149.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 223.1 97 999999999 139.27 223.1 percent of total billed charges "INTRODUCER/SHEATH, OTHER THAN GUIDING, OTHER THAN INTRACARDIAC ELECTROPHYSIOLOGICAL, NON-LASER" 48714141_1 CDM 0272 RC C1894 HCPCS inpatient 230 149.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 158.7 69 999999999 139.27 223.1 percent of total billed charges "INTRODUCER/SHEATH, OTHER THAN GUIDING, OTHER THAN INTRACARDIAC ELECTROPHYSIOLOGICAL, NON-LASER" 48714141_1 CDM 0272 RC C1894 HCPCS inpatient 230 149.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 179.4 78 999999999 139.27 223.1 percent of total billed charges "INTRODUCER/SHEATH, OTHER THAN GUIDING, OTHER THAN INTRACARDIAC ELECTROPHYSIOLOGICAL, NON-LASER" 48714141_1 CDM 0272 RC C1894 HCPCS inpatient 230 149.5 UMR - ALL PLANS UMR - ALL PLANS 161 70 999999999 139.27 223.1 percent of total billed charges "INTRODUCER/SHEATH, OTHER THAN GUIDING, OTHER THAN INTRACARDIAC ELECTROPHYSIOLOGICAL, NON-LASER" 48714141_1 CDM 0272 RC C1894 HCPCS inpatient 230 149.5 SIHO - ALL PLANS SIHO - ALL PLANS 207 90 999999999 139.27 223.1 percent of total billed charges "INTRODUCER/SHEATH, OTHER THAN GUIDING, OTHER THAN INTRACARDIAC ELECTROPHYSIOLOGICAL, NON-LASER" 48714141_1 CDM 0272 RC C1894 HCPCS inpatient 230 149.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 139.27 60.55 999999999 139.27 223.1 percent of total billed charges "INTRODUCER/SHEATH, OTHER THAN GUIDING, OTHER THAN INTRACARDIAC ELECTROPHYSIOLOGICAL, NON-LASER" 48714141_1 CDM 0272 RC C1894 HCPCS inpatient 230 149.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 139.27 223.1 "INTRODUCER/SHEATH, OTHER THAN GUIDING, OTHER THAN INTRACARDIAC ELECTROPHYSIOLOGICAL, NON-LASER" 48714141_1 CDM 0272 RC C1894 HCPCS inpatient 230 149.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 139.27 223.1 "INTRODUCER/SHEATH, OTHER THAN GUIDING, OTHER THAN INTRACARDIAC ELECTROPHYSIOLOGICAL, NON-LASER" 48714141_1 CDM 0272 RC C1894 HCPCS inpatient 230 149.5 ANTHEM HMO ANTHEM HMO 999999999 139.27 223.1 "INTRODUCER/SHEATH, OTHER THAN GUIDING, OTHER THAN INTRACARDIAC ELECTROPHYSIOLOGICAL, NON-LASER" 48714141_1 CDM 0272 RC C1894 HCPCS inpatient 230 149.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 155.48 67.6 999999999 139.27 223.1 percent of total billed charges "INTRODUCER/SHEATH, OTHER THAN GUIDING, OTHER THAN INTRACARDIAC ELECTROPHYSIOLOGICAL, NON-LASER" 48714141_1 CDM 0272 RC C1894 HCPCS inpatient 230 149.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 139.27 223.1 "INTRODUCER/SHEATH, OTHER THAN GUIDING, OTHER THAN INTRACARDIAC ELECTROPHYSIOLOGICAL, NON-LASER" 48714141_1 CDM 0272 RC C1894 HCPCS inpatient 230 149.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 139.27 223.1 SYRINGE INFLAT 35ATM ANAL 13in 48714142_1 CDM 0272 RC inpatient 173 112.45 AETNA AETNA 136.67 79 999999999 104.75 167.81 percent of total billed charges SYRINGE INFLAT 35ATM ANAL 13in 48714142_1 CDM 0272 RC inpatient 173 112.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 112.45 65 999999999 104.75 167.81 percent of total billed charges SYRINGE INFLAT 35ATM ANAL 13in 48714142_1 CDM 0272 RC inpatient 173 112.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 167.81 97 999999999 104.75 167.81 percent of total billed charges SYRINGE INFLAT 35ATM ANAL 13in 48714142_1 CDM 0272 RC inpatient 173 112.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 119.37 69 999999999 104.75 167.81 percent of total billed charges SYRINGE INFLAT 35ATM ANAL 13in 48714142_1 CDM 0272 RC inpatient 173 112.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.94 78 999999999 104.75 167.81 percent of total billed charges SYRINGE INFLAT 35ATM ANAL 13in 48714142_1 CDM 0272 RC inpatient 173 112.45 UMR - ALL PLANS UMR - ALL PLANS 121.1 70 999999999 104.75 167.81 percent of total billed charges SYRINGE INFLAT 35ATM ANAL 13in 48714142_1 CDM 0272 RC inpatient 173 112.45 SIHO - ALL PLANS SIHO - ALL PLANS 155.7 90 999999999 104.75 167.81 percent of total billed charges SYRINGE INFLAT 35ATM ANAL 13in 48714142_1 CDM 0272 RC inpatient 173 112.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.75 60.55 999999999 104.75 167.81 percent of total billed charges SYRINGE INFLAT 35ATM ANAL 13in 48714142_1 CDM 0272 RC inpatient 173 112.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.75 167.81 SYRINGE INFLAT 35ATM ANAL 13in 48714142_1 CDM 0272 RC inpatient 173 112.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.75 167.81 SYRINGE INFLAT 35ATM ANAL 13in 48714142_1 CDM 0272 RC inpatient 173 112.45 ANTHEM HMO ANTHEM HMO 999999999 104.75 167.81 SYRINGE INFLAT 35ATM ANAL 13in 48714142_1 CDM 0272 RC inpatient 173 112.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.95 67.6 999999999 104.75 167.81 percent of total billed charges SYRINGE INFLAT 35ATM ANAL 13in 48714142_1 CDM 0272 RC inpatient 173 112.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.75 167.81 SYRINGE INFLAT 35ATM ANAL 13in 48714142_1 CDM 0272 RC inpatient 173 112.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.75 167.81 CATHETER VERRATA FFR 185CM 48714143_1 CDM 0272 RC inpatient 3585 2330.25 AETNA AETNA 2832.15 79 999999999 2170.72 3477.45 percent of total billed charges CATHETER VERRATA FFR 185CM 48714143_1 CDM 0272 RC inpatient 3585 2330.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 2330.25 65 999999999 2170.72 3477.45 percent of total billed charges CATHETER VERRATA FFR 185CM 48714143_1 CDM 0272 RC inpatient 3585 2330.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3477.45 97 999999999 2170.72 3477.45 percent of total billed charges CATHETER VERRATA FFR 185CM 48714143_1 CDM 0272 RC inpatient 3585 2330.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 2473.65 69 999999999 2170.72 3477.45 percent of total billed charges CATHETER VERRATA FFR 185CM 48714143_1 CDM 0272 RC inpatient 3585 2330.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 2796.3 78 999999999 2170.72 3477.45 percent of total billed charges CATHETER VERRATA FFR 185CM 48714143_1 CDM 0272 RC inpatient 3585 2330.25 UMR - ALL PLANS UMR - ALL PLANS 2509.5 70 999999999 2170.72 3477.45 percent of total billed charges CATHETER VERRATA FFR 185CM 48714143_1 CDM 0272 RC inpatient 3585 2330.25 SIHO - ALL PLANS SIHO - ALL PLANS 3226.5 90 999999999 2170.72 3477.45 percent of total billed charges CATHETER VERRATA FFR 185CM 48714143_1 CDM 0272 RC inpatient 3585 2330.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2170.72 60.55 999999999 2170.72 3477.45 percent of total billed charges CATHETER VERRATA FFR 185CM 48714143_1 CDM 0272 RC inpatient 3585 2330.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2170.72 3477.45 CATHETER VERRATA FFR 185CM 48714143_1 CDM 0272 RC inpatient 3585 2330.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2170.72 3477.45 CATHETER VERRATA FFR 185CM 48714143_1 CDM 0272 RC inpatient 3585 2330.25 ANTHEM HMO ANTHEM HMO 999999999 2170.72 3477.45 CATHETER VERRATA FFR 185CM 48714143_1 CDM 0272 RC inpatient 3585 2330.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 2423.46 67.6 999999999 2170.72 3477.45 percent of total billed charges CATHETER VERRATA FFR 185CM 48714143_1 CDM 0272 RC inpatient 3585 2330.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2170.72 3477.45 CATHETER VERRATA FFR 185CM 48714143_1 CDM 0272 RC inpatient 3585 2330.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 2170.72 3477.45 "CATHETER, INTRAVASCULAR ULTRASOUND" 48714144_1 CDM 0278 RC C1753 HCPCS inpatient 3917 2546.05 AETNA AETNA 3094.43 79 999999999 2371.74 3799.49 percent of total billed charges "CATHETER, INTRAVASCULAR ULTRASOUND" 48714144_1 CDM 0278 RC C1753 HCPCS inpatient 3917 2546.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 2546.05 65 999999999 2371.74 3799.49 percent of total billed charges "CATHETER, INTRAVASCULAR ULTRASOUND" 48714144_1 CDM 0278 RC C1753 HCPCS inpatient 3917 2546.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3799.49 97 999999999 2371.74 3799.49 percent of total billed charges "CATHETER, INTRAVASCULAR ULTRASOUND" 48714144_1 CDM 0278 RC C1753 HCPCS inpatient 3917 2546.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2702.73 69 999999999 2371.74 3799.49 percent of total billed charges "CATHETER, INTRAVASCULAR ULTRASOUND" 48714144_1 CDM 0278 RC C1753 HCPCS inpatient 3917 2546.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 3055.26 78 999999999 2371.74 3799.49 percent of total billed charges "CATHETER, INTRAVASCULAR ULTRASOUND" 48714144_1 CDM 0278 RC C1753 HCPCS inpatient 3917 2546.05 UMR - ALL PLANS UMR - ALL PLANS 2741.9 70 999999999 2371.74 3799.49 percent of total billed charges "CATHETER, INTRAVASCULAR ULTRASOUND" 48714144_1 CDM 0278 RC C1753 HCPCS inpatient 3917 2546.05 SIHO - ALL PLANS SIHO - ALL PLANS 3525.3 90 999999999 2371.74 3799.49 percent of total billed charges "CATHETER, INTRAVASCULAR ULTRASOUND" 48714144_1 CDM 0278 RC C1753 HCPCS inpatient 3917 2546.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2371.74 60.55 999999999 2371.74 3799.49 percent of total billed charges "CATHETER, INTRAVASCULAR ULTRASOUND" 48714144_1 CDM 0278 RC C1753 HCPCS inpatient 3917 2546.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2371.74 3799.49 "CATHETER, INTRAVASCULAR ULTRASOUND" 48714144_1 CDM 0278 RC C1753 HCPCS inpatient 3917 2546.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2371.74 3799.49 "CATHETER, INTRAVASCULAR ULTRASOUND" 48714144_1 CDM 0278 RC C1753 HCPCS inpatient 3917 2546.05 ANTHEM HMO ANTHEM HMO 999999999 2371.74 3799.49 "CATHETER, INTRAVASCULAR ULTRASOUND" 48714144_1 CDM 0278 RC C1753 HCPCS inpatient 3917 2546.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2647.89 67.6 999999999 2371.74 3799.49 percent of total billed charges "CATHETER, INTRAVASCULAR ULTRASOUND" 48714144_1 CDM 0278 RC C1753 HCPCS inpatient 3917 2546.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2371.74 3799.49 "CATHETER, INTRAVASCULAR ULTRASOUND" 48714144_1 CDM 0278 RC C1753 HCPCS inpatient 3917 2546.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 2371.74 3799.49 CATHETER SWAN GANZ TD 131F7P 48714145_1 CDM 0272 RC inpatient 515 334.75 AETNA AETNA 406.85 79 999999999 311.83 499.55 percent of total billed charges CATHETER SWAN GANZ TD 131F7P 48714145_1 CDM 0272 RC inpatient 515 334.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 334.75 65 999999999 311.83 499.55 percent of total billed charges CATHETER SWAN GANZ TD 131F7P 48714145_1 CDM 0272 RC inpatient 515 334.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 499.55 97 999999999 311.83 499.55 percent of total billed charges CATHETER SWAN GANZ TD 131F7P 48714145_1 CDM 0272 RC inpatient 515 334.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 355.35 69 999999999 311.83 499.55 percent of total billed charges CATHETER SWAN GANZ TD 131F7P 48714145_1 CDM 0272 RC inpatient 515 334.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 401.7 78 999999999 311.83 499.55 percent of total billed charges CATHETER SWAN GANZ TD 131F7P 48714145_1 CDM 0272 RC inpatient 515 334.75 UMR - ALL PLANS UMR - ALL PLANS 360.5 70 999999999 311.83 499.55 percent of total billed charges CATHETER SWAN GANZ TD 131F7P 48714145_1 CDM 0272 RC inpatient 515 334.75 SIHO - ALL PLANS SIHO - ALL PLANS 463.5 90 999999999 311.83 499.55 percent of total billed charges CATHETER SWAN GANZ TD 131F7P 48714145_1 CDM 0272 RC inpatient 515 334.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 311.83 60.55 999999999 311.83 499.55 percent of total billed charges CATHETER SWAN GANZ TD 131F7P 48714145_1 CDM 0272 RC inpatient 515 334.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 311.83 499.55 CATHETER SWAN GANZ TD 131F7P 48714145_1 CDM 0272 RC inpatient 515 334.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 311.83 499.55 CATHETER SWAN GANZ TD 131F7P 48714145_1 CDM 0272 RC inpatient 515 334.75 ANTHEM HMO ANTHEM HMO 999999999 311.83 499.55 CATHETER SWAN GANZ TD 131F7P 48714145_1 CDM 0272 RC inpatient 515 334.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 348.14 67.6 999999999 311.83 499.55 percent of total billed charges CATHETER SWAN GANZ TD 131F7P 48714145_1 CDM 0272 RC inpatient 515 334.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 311.83 499.55 CATHETER SWAN GANZ TD 131F7P 48714145_1 CDM 0272 RC inpatient 515 334.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 311.83 499.55 CORONARY STENT 4.50 X 12 48714146_1 CDM 0272 RC inpatient 3033 1971.45 AETNA AETNA 2396.07 79 999999999 1836.48 2942.01 percent of total billed charges CORONARY STENT 4.50 X 12 48714146_1 CDM 0272 RC inpatient 3033 1971.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1971.45 65 999999999 1836.48 2942.01 percent of total billed charges CORONARY STENT 4.50 X 12 48714146_1 CDM 0272 RC inpatient 3033 1971.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2942.01 97 999999999 1836.48 2942.01 percent of total billed charges CORONARY STENT 4.50 X 12 48714146_1 CDM 0272 RC inpatient 3033 1971.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 2092.77 69 999999999 1836.48 2942.01 percent of total billed charges CORONARY STENT 4.50 X 12 48714146_1 CDM 0272 RC inpatient 3033 1971.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 2365.74 78 999999999 1836.48 2942.01 percent of total billed charges CORONARY STENT 4.50 X 12 48714146_1 CDM 0272 RC inpatient 3033 1971.45 UMR - ALL PLANS UMR - ALL PLANS 2123.1 70 999999999 1836.48 2942.01 percent of total billed charges CORONARY STENT 4.50 X 12 48714146_1 CDM 0272 RC inpatient 3033 1971.45 SIHO - ALL PLANS SIHO - ALL PLANS 2729.7 90 999999999 1836.48 2942.01 percent of total billed charges CORONARY STENT 4.50 X 12 48714146_1 CDM 0272 RC inpatient 3033 1971.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1836.48 60.55 999999999 1836.48 2942.01 percent of total billed charges CORONARY STENT 4.50 X 12 48714146_1 CDM 0272 RC inpatient 3033 1971.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1836.48 2942.01 CORONARY STENT 4.50 X 12 48714146_1 CDM 0272 RC inpatient 3033 1971.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1836.48 2942.01 CORONARY STENT 4.50 X 12 48714146_1 CDM 0272 RC inpatient 3033 1971.45 ANTHEM HMO ANTHEM HMO 999999999 1836.48 2942.01 CORONARY STENT 4.50 X 12 48714146_1 CDM 0272 RC inpatient 3033 1971.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 2050.31 67.6 999999999 1836.48 2942.01 percent of total billed charges CORONARY STENT 4.50 X 12 48714146_1 CDM 0272 RC inpatient 3033 1971.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1836.48 2942.01 CORONARY STENT 4.50 X 12 48714146_1 CDM 0272 RC inpatient 3033 1971.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1836.48 2942.01 PTCA DILATATION CATH 3.0 X 15 48714147_1 CDM 0272 RC inpatient 684 444.6 AETNA AETNA 540.36 79 999999999 414.16 663.48 percent of total billed charges PTCA DILATATION CATH 3.0 X 15 48714147_1 CDM 0272 RC inpatient 684 444.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 444.6 65 999999999 414.16 663.48 percent of total billed charges PTCA DILATATION CATH 3.0 X 15 48714147_1 CDM 0272 RC inpatient 684 444.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 663.48 97 999999999 414.16 663.48 percent of total billed charges PTCA DILATATION CATH 3.0 X 15 48714147_1 CDM 0272 RC inpatient 684 444.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 471.96 69 999999999 414.16 663.48 percent of total billed charges PTCA DILATATION CATH 3.0 X 15 48714147_1 CDM 0272 RC inpatient 684 444.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 533.52 78 999999999 414.16 663.48 percent of total billed charges PTCA DILATATION CATH 3.0 X 15 48714147_1 CDM 0272 RC inpatient 684 444.6 UMR - ALL PLANS UMR - ALL PLANS 478.8 70 999999999 414.16 663.48 percent of total billed charges PTCA DILATATION CATH 3.0 X 15 48714147_1 CDM 0272 RC inpatient 684 444.6 SIHO - ALL PLANS SIHO - ALL PLANS 615.6 90 999999999 414.16 663.48 percent of total billed charges PTCA DILATATION CATH 3.0 X 15 48714147_1 CDM 0272 RC inpatient 684 444.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 414.16 60.55 999999999 414.16 663.48 percent of total billed charges PTCA DILATATION CATH 3.0 X 15 48714147_1 CDM 0272 RC inpatient 684 444.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 414.16 663.48 PTCA DILATATION CATH 3.0 X 15 48714147_1 CDM 0272 RC inpatient 684 444.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 414.16 663.48 PTCA DILATATION CATH 3.0 X 15 48714147_1 CDM 0272 RC inpatient 684 444.6 ANTHEM HMO ANTHEM HMO 999999999 414.16 663.48 PTCA DILATATION CATH 3.0 X 15 48714147_1 CDM 0272 RC inpatient 684 444.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 462.38 67.6 999999999 414.16 663.48 percent of total billed charges PTCA DILATATION CATH 3.0 X 15 48714147_1 CDM 0272 RC inpatient 684 444.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 414.16 663.48 PTCA DILATATION CATH 3.0 X 15 48714147_1 CDM 0272 RC inpatient 684 444.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 414.16 663.48 PTCA DILATATION CATH 4.5 X 12 48714148_1 CDM 0272 RC inpatient 684 444.6 AETNA AETNA 540.36 79 999999999 414.16 663.48 percent of total billed charges PTCA DILATATION CATH 4.5 X 12 48714148_1 CDM 0272 RC inpatient 684 444.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 444.6 65 999999999 414.16 663.48 percent of total billed charges PTCA DILATATION CATH 4.5 X 12 48714148_1 CDM 0272 RC inpatient 684 444.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 663.48 97 999999999 414.16 663.48 percent of total billed charges PTCA DILATATION CATH 4.5 X 12 48714148_1 CDM 0272 RC inpatient 684 444.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 471.96 69 999999999 414.16 663.48 percent of total billed charges PTCA DILATATION CATH 4.5 X 12 48714148_1 CDM 0272 RC inpatient 684 444.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 533.52 78 999999999 414.16 663.48 percent of total billed charges PTCA DILATATION CATH 4.5 X 12 48714148_1 CDM 0272 RC inpatient 684 444.6 UMR - ALL PLANS UMR - ALL PLANS 478.8 70 999999999 414.16 663.48 percent of total billed charges PTCA DILATATION CATH 4.5 X 12 48714148_1 CDM 0272 RC inpatient 684 444.6 SIHO - ALL PLANS SIHO - ALL PLANS 615.6 90 999999999 414.16 663.48 percent of total billed charges PTCA DILATATION CATH 4.5 X 12 48714148_1 CDM 0272 RC inpatient 684 444.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 414.16 60.55 999999999 414.16 663.48 percent of total billed charges PTCA DILATATION CATH 4.5 X 12 48714148_1 CDM 0272 RC inpatient 684 444.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 414.16 663.48 PTCA DILATATION CATH 4.5 X 12 48714148_1 CDM 0272 RC inpatient 684 444.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 414.16 663.48 PTCA DILATATION CATH 4.5 X 12 48714148_1 CDM 0272 RC inpatient 684 444.6 ANTHEM HMO ANTHEM HMO 999999999 414.16 663.48 PTCA DILATATION CATH 4.5 X 12 48714148_1 CDM 0272 RC inpatient 684 444.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 462.38 67.6 999999999 414.16 663.48 percent of total billed charges PTCA DILATATION CATH 4.5 X 12 48714148_1 CDM 0272 RC inpatient 684 444.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 414.16 663.48 PTCA DILATATION CATH 4.5 X 12 48714148_1 CDM 0272 RC inpatient 684 444.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 414.16 663.48 SYRINGE INFLATION DIG W\MAP 48714149_1 CDM 0272 RC inpatient 449 291.85 AETNA AETNA 354.71 79 999999999 271.87 435.53 percent of total billed charges SYRINGE INFLATION DIG W\MAP 48714149_1 CDM 0272 RC inpatient 449 291.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 291.85 65 999999999 271.87 435.53 percent of total billed charges SYRINGE INFLATION DIG W\MAP 48714149_1 CDM 0272 RC inpatient 449 291.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 435.53 97 999999999 271.87 435.53 percent of total billed charges SYRINGE INFLATION DIG W\MAP 48714149_1 CDM 0272 RC inpatient 449 291.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 309.81 69 999999999 271.87 435.53 percent of total billed charges SYRINGE INFLATION DIG W\MAP 48714149_1 CDM 0272 RC inpatient 449 291.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 350.22 78 999999999 271.87 435.53 percent of total billed charges SYRINGE INFLATION DIG W\MAP 48714149_1 CDM 0272 RC inpatient 449 291.85 UMR - ALL PLANS UMR - ALL PLANS 314.3 70 999999999 271.87 435.53 percent of total billed charges SYRINGE INFLATION DIG W\MAP 48714149_1 CDM 0272 RC inpatient 449 291.85 SIHO - ALL PLANS SIHO - ALL PLANS 404.1 90 999999999 271.87 435.53 percent of total billed charges SYRINGE INFLATION DIG W\MAP 48714149_1 CDM 0272 RC inpatient 449 291.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 271.87 60.55 999999999 271.87 435.53 percent of total billed charges SYRINGE INFLATION DIG W\MAP 48714149_1 CDM 0272 RC inpatient 449 291.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 271.87 435.53 SYRINGE INFLATION DIG W\MAP 48714149_1 CDM 0272 RC inpatient 449 291.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 271.87 435.53 SYRINGE INFLATION DIG W\MAP 48714149_1 CDM 0272 RC inpatient 449 291.85 ANTHEM HMO ANTHEM HMO 999999999 271.87 435.53 SYRINGE INFLATION DIG W\MAP 48714149_1 CDM 0272 RC inpatient 449 291.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 303.52 67.6 999999999 271.87 435.53 percent of total billed charges SYRINGE INFLATION DIG W\MAP 48714149_1 CDM 0272 RC inpatient 449 291.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 271.87 435.53 SYRINGE INFLATION DIG W\MAP 48714149_1 CDM 0272 RC inpatient 449 291.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 271.87 435.53 "LEAD, PACEMAKER, TRANSVENOUS VDD SINGLE PASS" 48714150_1 CDM 0278 RC C1779 HCPCS inpatient 1163 755.95 AETNA AETNA 918.77 79 999999999 704.2 1128.11 percent of total billed charges "LEAD, PACEMAKER, TRANSVENOUS VDD SINGLE PASS" 48714150_1 CDM 0278 RC C1779 HCPCS inpatient 1163 755.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 755.95 65 999999999 704.2 1128.11 percent of total billed charges "LEAD, PACEMAKER, TRANSVENOUS VDD SINGLE PASS" 48714150_1 CDM 0278 RC C1779 HCPCS inpatient 1163 755.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1128.11 97 999999999 704.2 1128.11 percent of total billed charges "LEAD, PACEMAKER, TRANSVENOUS VDD SINGLE PASS" 48714150_1 CDM 0278 RC C1779 HCPCS inpatient 1163 755.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 802.47 69 999999999 704.2 1128.11 percent of total billed charges "LEAD, PACEMAKER, TRANSVENOUS VDD SINGLE PASS" 48714150_1 CDM 0278 RC C1779 HCPCS inpatient 1163 755.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 907.14 78 999999999 704.2 1128.11 percent of total billed charges "LEAD, PACEMAKER, TRANSVENOUS VDD SINGLE PASS" 48714150_1 CDM 0278 RC C1779 HCPCS inpatient 1163 755.95 UMR - ALL PLANS UMR - ALL PLANS 814.1 70 999999999 704.2 1128.11 percent of total billed charges "LEAD, PACEMAKER, TRANSVENOUS VDD SINGLE PASS" 48714150_1 CDM 0278 RC C1779 HCPCS inpatient 1163 755.95 SIHO - ALL PLANS SIHO - ALL PLANS 1046.7 90 999999999 704.2 1128.11 percent of total billed charges "LEAD, PACEMAKER, TRANSVENOUS VDD SINGLE PASS" 48714150_1 CDM 0278 RC C1779 HCPCS inpatient 1163 755.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 704.2 60.55 999999999 704.2 1128.11 percent of total billed charges "LEAD, PACEMAKER, TRANSVENOUS VDD SINGLE PASS" 48714150_1 CDM 0278 RC C1779 HCPCS inpatient 1163 755.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 704.2 1128.11 "LEAD, PACEMAKER, TRANSVENOUS VDD SINGLE PASS" 48714150_1 CDM 0278 RC C1779 HCPCS inpatient 1163 755.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 704.2 1128.11 "LEAD, PACEMAKER, TRANSVENOUS VDD SINGLE PASS" 48714150_1 CDM 0278 RC C1779 HCPCS inpatient 1163 755.95 ANTHEM HMO ANTHEM HMO 999999999 704.2 1128.11 "LEAD, PACEMAKER, TRANSVENOUS VDD SINGLE PASS" 48714150_1 CDM 0278 RC C1779 HCPCS inpatient 1163 755.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 786.19 67.6 999999999 704.2 1128.11 percent of total billed charges "LEAD, PACEMAKER, TRANSVENOUS VDD SINGLE PASS" 48714150_1 CDM 0278 RC C1779 HCPCS inpatient 1163 755.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 704.2 1128.11 "LEAD, PACEMAKER, TRANSVENOUS VDD SINGLE PASS" 48714150_1 CDM 0278 RC C1779 HCPCS inpatient 1163 755.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 704.2 1128.11 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48714151_1 CDM 0272 RC C1760 HCPCS inpatient 1056 686.4 AETNA AETNA 834.24 79 999999999 639.41 1024.32 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48714151_1 CDM 0272 RC C1760 HCPCS inpatient 1056 686.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 686.4 65 999999999 639.41 1024.32 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48714151_1 CDM 0272 RC C1760 HCPCS inpatient 1056 686.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1024.32 97 999999999 639.41 1024.32 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48714151_1 CDM 0272 RC C1760 HCPCS inpatient 1056 686.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 728.64 69 999999999 639.41 1024.32 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48714151_1 CDM 0272 RC C1760 HCPCS inpatient 1056 686.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 823.68 78 999999999 639.41 1024.32 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48714151_1 CDM 0272 RC C1760 HCPCS inpatient 1056 686.4 UMR - ALL PLANS UMR - ALL PLANS 739.2 70 999999999 639.41 1024.32 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48714151_1 CDM 0272 RC C1760 HCPCS inpatient 1056 686.4 SIHO - ALL PLANS SIHO - ALL PLANS 950.4 90 999999999 639.41 1024.32 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48714151_1 CDM 0272 RC C1760 HCPCS inpatient 1056 686.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 639.41 60.55 999999999 639.41 1024.32 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48714151_1 CDM 0272 RC C1760 HCPCS inpatient 1056 686.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 639.41 1024.32 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48714151_1 CDM 0272 RC C1760 HCPCS inpatient 1056 686.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 639.41 1024.32 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48714151_1 CDM 0272 RC C1760 HCPCS inpatient 1056 686.4 ANTHEM HMO ANTHEM HMO 999999999 639.41 1024.32 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48714151_1 CDM 0272 RC C1760 HCPCS inpatient 1056 686.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 713.86 67.6 999999999 639.41 1024.32 percent of total billed charges "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48714151_1 CDM 0272 RC C1760 HCPCS inpatient 1056 686.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 639.41 1024.32 "CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE)" 48714151_1 CDM 0272 RC C1760 HCPCS inpatient 1056 686.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 639.41 1024.32 CATHETER lAB 8F X 25CC 48714152_1 CDM 0272 RC inpatient 3878 2520.7 AETNA AETNA 3063.62 79 999999999 2348.13 3761.66 percent of total billed charges CATHETER lAB 8F X 25CC 48714152_1 CDM 0272 RC inpatient 3878 2520.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 2520.7 65 999999999 2348.13 3761.66 percent of total billed charges CATHETER lAB 8F X 25CC 48714152_1 CDM 0272 RC inpatient 3878 2520.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3761.66 97 999999999 2348.13 3761.66 percent of total billed charges CATHETER lAB 8F X 25CC 48714152_1 CDM 0272 RC inpatient 3878 2520.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 2675.82 69 999999999 2348.13 3761.66 percent of total billed charges CATHETER lAB 8F X 25CC 48714152_1 CDM 0272 RC inpatient 3878 2520.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 3024.84 78 999999999 2348.13 3761.66 percent of total billed charges CATHETER lAB 8F X 25CC 48714152_1 CDM 0272 RC inpatient 3878 2520.7 UMR - ALL PLANS UMR - ALL PLANS 2714.6 70 999999999 2348.13 3761.66 percent of total billed charges CATHETER lAB 8F X 25CC 48714152_1 CDM 0272 RC inpatient 3878 2520.7 SIHO - ALL PLANS SIHO - ALL PLANS 3490.2 90 999999999 2348.13 3761.66 percent of total billed charges CATHETER lAB 8F X 25CC 48714152_1 CDM 0272 RC inpatient 3878 2520.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2348.13 60.55 999999999 2348.13 3761.66 percent of total billed charges CATHETER lAB 8F X 25CC 48714152_1 CDM 0272 RC inpatient 3878 2520.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2348.13 3761.66 CATHETER lAB 8F X 25CC 48714152_1 CDM 0272 RC inpatient 3878 2520.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2348.13 3761.66 CATHETER lAB 8F X 25CC 48714152_1 CDM 0272 RC inpatient 3878 2520.7 ANTHEM HMO ANTHEM HMO 999999999 2348.13 3761.66 CATHETER lAB 8F X 25CC 48714152_1 CDM 0272 RC inpatient 3878 2520.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 2621.53 67.6 999999999 2348.13 3761.66 percent of total billed charges CATHETER lAB 8F X 25CC 48714152_1 CDM 0272 RC inpatient 3878 2520.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2348.13 3761.66 CATHETER lAB 8F X 25CC 48714152_1 CDM 0272 RC inpatient 3878 2520.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 2348.13 3761.66 CATHETER 4FR 3DRC 48714153_1 CDM 0272 RC inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR 3DRC 48714153_1 CDM 0272 RC inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR 3DRC 48714153_1 CDM 0272 RC inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR 3DRC 48714153_1 CDM 0272 RC inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR 3DRC 48714153_1 CDM 0272 RC inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR 3DRC 48714153_1 CDM 0272 RC inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR 3DRC 48714153_1 CDM 0272 RC inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR 3DRC 48714153_1 CDM 0272 RC inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR 3DRC 48714153_1 CDM 0272 RC inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 CATHETER 4FR 3DRC 48714153_1 CDM 0272 RC inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 CATHETER 4FR 3DRC 48714153_1 CDM 0272 RC inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 CATHETER 4FR 3DRC 48714153_1 CDM 0272 RC inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges CATHETER 4FR 3DRC 48714153_1 CDM 0272 RC inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 CATHETER 4FR 3DRC 48714153_1 CDM 0272 RC inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 INTRODUCER CORDIS 8FR MSX11CM 48714154_1 CDM 0270 RC inpatient 122 79.3 AETNA AETNA 96.38 79 999999999 73.87 118.34 percent of total billed charges INTRODUCER CORDIS 8FR MSX11CM 48714154_1 CDM 0270 RC inpatient 122 79.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.3 65 999999999 73.87 118.34 percent of total billed charges INTRODUCER CORDIS 8FR MSX11CM 48714154_1 CDM 0270 RC inpatient 122 79.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 118.34 97 999999999 73.87 118.34 percent of total billed charges INTRODUCER CORDIS 8FR MSX11CM 48714154_1 CDM 0270 RC inpatient 122 79.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.18 69 999999999 73.87 118.34 percent of total billed charges INTRODUCER CORDIS 8FR MSX11CM 48714154_1 CDM 0270 RC inpatient 122 79.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.16 78 999999999 73.87 118.34 percent of total billed charges INTRODUCER CORDIS 8FR MSX11CM 48714154_1 CDM 0270 RC inpatient 122 79.3 UMR - ALL PLANS UMR - ALL PLANS 85.4 70 999999999 73.87 118.34 percent of total billed charges INTRODUCER CORDIS 8FR MSX11CM 48714154_1 CDM 0270 RC inpatient 122 79.3 SIHO - ALL PLANS SIHO - ALL PLANS 109.8 90 999999999 73.87 118.34 percent of total billed charges INTRODUCER CORDIS 8FR MSX11CM 48714154_1 CDM 0270 RC inpatient 122 79.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.87 60.55 999999999 73.87 118.34 percent of total billed charges INTRODUCER CORDIS 8FR MSX11CM 48714154_1 CDM 0270 RC inpatient 122 79.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.87 118.34 INTRODUCER CORDIS 8FR MSX11CM 48714154_1 CDM 0270 RC inpatient 122 79.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.87 118.34 INTRODUCER CORDIS 8FR MSX11CM 48714154_1 CDM 0270 RC inpatient 122 79.3 ANTHEM HMO ANTHEM HMO 999999999 73.87 118.34 INTRODUCER CORDIS 8FR MSX11CM 48714154_1 CDM 0270 RC inpatient 122 79.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 82.47 67.6 999999999 73.87 118.34 percent of total billed charges INTRODUCER CORDIS 8FR MSX11CM 48714154_1 CDM 0270 RC inpatient 122 79.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.87 118.34 INTRODUCER CORDIS 8FR MSX11CM 48714154_1 CDM 0270 RC inpatient 122 79.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.87 118.34 NEEDLE HLDR WEBSTR ST SNFR 48714155_1 CDM 0272 RC inpatient 48 31.2 AETNA AETNA 37.92 79 999999999 29.06 46.56 percent of total billed charges NEEDLE HLDR WEBSTR ST SNFR 48714155_1 CDM 0272 RC inpatient 48 31.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.2 65 999999999 29.06 46.56 percent of total billed charges NEEDLE HLDR WEBSTR ST SNFR 48714155_1 CDM 0272 RC inpatient 48 31.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 46.56 97 999999999 29.06 46.56 percent of total billed charges NEEDLE HLDR WEBSTR ST SNFR 48714155_1 CDM 0272 RC inpatient 48 31.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.12 69 999999999 29.06 46.56 percent of total billed charges NEEDLE HLDR WEBSTR ST SNFR 48714155_1 CDM 0272 RC inpatient 48 31.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 37.44 78 999999999 29.06 46.56 percent of total billed charges NEEDLE HLDR WEBSTR ST SNFR 48714155_1 CDM 0272 RC inpatient 48 31.2 UMR - ALL PLANS UMR - ALL PLANS 33.6 70 999999999 29.06 46.56 percent of total billed charges NEEDLE HLDR WEBSTR ST SNFR 48714155_1 CDM 0272 RC inpatient 48 31.2 SIHO - ALL PLANS SIHO - ALL PLANS 43.2 90 999999999 29.06 46.56 percent of total billed charges NEEDLE HLDR WEBSTR ST SNFR 48714155_1 CDM 0272 RC inpatient 48 31.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.06 60.55 999999999 29.06 46.56 percent of total billed charges NEEDLE HLDR WEBSTR ST SNFR 48714155_1 CDM 0272 RC inpatient 48 31.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.06 46.56 NEEDLE HLDR WEBSTR ST SNFR 48714155_1 CDM 0272 RC inpatient 48 31.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.06 46.56 NEEDLE HLDR WEBSTR ST SNFR 48714155_1 CDM 0272 RC inpatient 48 31.2 ANTHEM HMO ANTHEM HMO 999999999 29.06 46.56 NEEDLE HLDR WEBSTR ST SNFR 48714155_1 CDM 0272 RC inpatient 48 31.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 32.45 67.6 999999999 29.06 46.56 percent of total billed charges NEEDLE HLDR WEBSTR ST SNFR 48714155_1 CDM 0272 RC inpatient 48 31.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.06 46.56 NEEDLE HLDR WEBSTR ST SNFR 48714155_1 CDM 0272 RC inpatient 48 31.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.06 46.56 "GLIDEWIRE STD ANG .035""X260CM" 48714156_1 CDM 0272 RC inpatient 308 200.2 AETNA AETNA 243.32 79 999999999 186.49 298.76 percent of total billed charges "GLIDEWIRE STD ANG .035""X260CM" 48714156_1 CDM 0272 RC inpatient 308 200.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 200.2 65 999999999 186.49 298.76 percent of total billed charges "GLIDEWIRE STD ANG .035""X260CM" 48714156_1 CDM 0272 RC inpatient 308 200.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 298.76 97 999999999 186.49 298.76 percent of total billed charges "GLIDEWIRE STD ANG .035""X260CM" 48714156_1 CDM 0272 RC inpatient 308 200.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 212.52 69 999999999 186.49 298.76 percent of total billed charges "GLIDEWIRE STD ANG .035""X260CM" 48714156_1 CDM 0272 RC inpatient 308 200.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 240.24 78 999999999 186.49 298.76 percent of total billed charges "GLIDEWIRE STD ANG .035""X260CM" 48714156_1 CDM 0272 RC inpatient 308 200.2 UMR - ALL PLANS UMR - ALL PLANS 215.6 70 999999999 186.49 298.76 percent of total billed charges "GLIDEWIRE STD ANG .035""X260CM" 48714156_1 CDM 0272 RC inpatient 308 200.2 SIHO - ALL PLANS SIHO - ALL PLANS 277.2 90 999999999 186.49 298.76 percent of total billed charges "GLIDEWIRE STD ANG .035""X260CM" 48714156_1 CDM 0272 RC inpatient 308 200.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 186.49 60.55 999999999 186.49 298.76 percent of total billed charges "GLIDEWIRE STD ANG .035""X260CM" 48714156_1 CDM 0272 RC inpatient 308 200.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 186.49 298.76 "GLIDEWIRE STD ANG .035""X260CM" 48714156_1 CDM 0272 RC inpatient 308 200.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 186.49 298.76 "GLIDEWIRE STD ANG .035""X260CM" 48714156_1 CDM 0272 RC inpatient 308 200.2 ANTHEM HMO ANTHEM HMO 999999999 186.49 298.76 "GLIDEWIRE STD ANG .035""X260CM" 48714156_1 CDM 0272 RC inpatient 308 200.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 208.21 67.6 999999999 186.49 298.76 percent of total billed charges "GLIDEWIRE STD ANG .035""X260CM" 48714156_1 CDM 0272 RC inpatient 308 200.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 186.49 298.76 "GLIDEWIRE STD ANG .035""X260CM" 48714156_1 CDM 0272 RC inpatient 308 200.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 186.49 298.76 "GLIDEWIRE STIFF ANG .035""X150C" 48714157_1 CDM 0272 RC inpatient 313 203.45 AETNA AETNA 247.27 79 999999999 189.52 303.61 percent of total billed charges "GLIDEWIRE STIFF ANG .035""X150C" 48714157_1 CDM 0272 RC inpatient 313 203.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 203.45 65 999999999 189.52 303.61 percent of total billed charges "GLIDEWIRE STIFF ANG .035""X150C" 48714157_1 CDM 0272 RC inpatient 313 203.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 303.61 97 999999999 189.52 303.61 percent of total billed charges "GLIDEWIRE STIFF ANG .035""X150C" 48714157_1 CDM 0272 RC inpatient 313 203.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 215.97 69 999999999 189.52 303.61 percent of total billed charges "GLIDEWIRE STIFF ANG .035""X150C" 48714157_1 CDM 0272 RC inpatient 313 203.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 244.14 78 999999999 189.52 303.61 percent of total billed charges "GLIDEWIRE STIFF ANG .035""X150C" 48714157_1 CDM 0272 RC inpatient 313 203.45 UMR - ALL PLANS UMR - ALL PLANS 219.1 70 999999999 189.52 303.61 percent of total billed charges "GLIDEWIRE STIFF ANG .035""X150C" 48714157_1 CDM 0272 RC inpatient 313 203.45 SIHO - ALL PLANS SIHO - ALL PLANS 281.7 90 999999999 189.52 303.61 percent of total billed charges "GLIDEWIRE STIFF ANG .035""X150C" 48714157_1 CDM 0272 RC inpatient 313 203.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 189.52 60.55 999999999 189.52 303.61 percent of total billed charges "GLIDEWIRE STIFF ANG .035""X150C" 48714157_1 CDM 0272 RC inpatient 313 203.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 189.52 303.61 "GLIDEWIRE STIFF ANG .035""X150C" 48714157_1 CDM 0272 RC inpatient 313 203.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 189.52 303.61 "GLIDEWIRE STIFF ANG .035""X150C" 48714157_1 CDM 0272 RC inpatient 313 203.45 ANTHEM HMO ANTHEM HMO 999999999 189.52 303.61 "GLIDEWIRE STIFF ANG .035""X150C" 48714157_1 CDM 0272 RC inpatient 313 203.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 211.59 67.6 999999999 189.52 303.61 percent of total billed charges "GLIDEWIRE STIFF ANG .035""X150C" 48714157_1 CDM 0272 RC inpatient 313 203.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 189.52 303.61 "GLIDEWIRE STIFF ANG .035""X150C" 48714157_1 CDM 0272 RC inpatient 313 203.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 189.52 303.61 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714158_1 CDM 0278 RC C1725 HCPCS inpatient 1407 914.55 AETNA AETNA 1111.53 79 999999999 851.94 1364.79 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714158_1 CDM 0278 RC C1725 HCPCS inpatient 1407 914.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 914.55 65 999999999 851.94 1364.79 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714158_1 CDM 0278 RC C1725 HCPCS inpatient 1407 914.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1364.79 97 999999999 851.94 1364.79 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714158_1 CDM 0278 RC C1725 HCPCS inpatient 1407 914.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 970.83 69 999999999 851.94 1364.79 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714158_1 CDM 0278 RC C1725 HCPCS inpatient 1407 914.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1097.46 78 999999999 851.94 1364.79 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714158_1 CDM 0278 RC C1725 HCPCS inpatient 1407 914.55 UMR - ALL PLANS UMR - ALL PLANS 984.9 70 999999999 851.94 1364.79 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714158_1 CDM 0278 RC C1725 HCPCS inpatient 1407 914.55 SIHO - ALL PLANS SIHO - ALL PLANS 1266.3 90 999999999 851.94 1364.79 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714158_1 CDM 0278 RC C1725 HCPCS inpatient 1407 914.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 851.94 60.55 999999999 851.94 1364.79 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714158_1 CDM 0278 RC C1725 HCPCS inpatient 1407 914.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 851.94 1364.79 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714158_1 CDM 0278 RC C1725 HCPCS inpatient 1407 914.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 851.94 1364.79 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714158_1 CDM 0278 RC C1725 HCPCS inpatient 1407 914.55 ANTHEM HMO ANTHEM HMO 999999999 851.94 1364.79 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714158_1 CDM 0278 RC C1725 HCPCS inpatient 1407 914.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 951.13 67.6 999999999 851.94 1364.79 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714158_1 CDM 0278 RC C1725 HCPCS inpatient 1407 914.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 851.94 1364.79 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714158_1 CDM 0278 RC C1725 HCPCS inpatient 1407 914.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 851.94 1364.79 5F LA LAUNCHER GUIDE CATH 3.5 48714159_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges 5F LA LAUNCHER GUIDE CATH 3.5 48714159_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges 5F LA LAUNCHER GUIDE CATH 3.5 48714159_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges 5F LA LAUNCHER GUIDE CATH 3.5 48714159_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges 5F LA LAUNCHER GUIDE CATH 3.5 48714159_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges 5F LA LAUNCHER GUIDE CATH 3.5 48714159_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges 5F LA LAUNCHER GUIDE CATH 3.5 48714159_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges 5F LA LAUNCHER GUIDE CATH 3.5 48714159_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges 5F LA LAUNCHER GUIDE CATH 3.5 48714159_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 5F LA LAUNCHER GUIDE CATH 3.5 48714159_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 5F LA LAUNCHER GUIDE CATH 3.5 48714159_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 5F LA LAUNCHER GUIDE CATH 3.5 48714159_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges 5F LA LAUNCHER GUIDE CATH 3.5 48714159_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 5F LA LAUNCHER GUIDE CATH 3.5 48714159_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714160_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714160_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714160_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714160_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714160_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714160_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714160_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714160_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714160_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714160_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714160_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714160_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714160_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714160_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 5F EBU LAUNCHER GUIDE CATH 3.5 48714161_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges 5F EBU LAUNCHER GUIDE CATH 3.5 48714161_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges 5F EBU LAUNCHER GUIDE CATH 3.5 48714161_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges 5F EBU LAUNCHER GUIDE CATH 3.5 48714161_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges 5F EBU LAUNCHER GUIDE CATH 3.5 48714161_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges 5F EBU LAUNCHER GUIDE CATH 3.5 48714161_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges 5F EBU LAUNCHER GUIDE CATH 3.5 48714161_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges 5F EBU LAUNCHER GUIDE CATH 3.5 48714161_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges 5F EBU LAUNCHER GUIDE CATH 3.5 48714161_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 5F EBU LAUNCHER GUIDE CATH 3.5 48714161_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 5F EBU LAUNCHER GUIDE CATH 3.5 48714161_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 5F EBU LAUNCHER GUIDE CATH 3.5 48714161_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges 5F EBU LAUNCHER GUIDE CATH 3.5 48714161_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 5F EBU LAUNCHER GUIDE CATH 3.5 48714161_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714162_1 CDM 0278 RC C1887 HCPCS inpatient 808 525.2 AETNA AETNA 638.32 79 999999999 489.24 783.76 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714162_1 CDM 0278 RC C1887 HCPCS inpatient 808 525.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 525.2 65 999999999 489.24 783.76 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714162_1 CDM 0278 RC C1887 HCPCS inpatient 808 525.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 783.76 97 999999999 489.24 783.76 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714162_1 CDM 0278 RC C1887 HCPCS inpatient 808 525.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 557.52 69 999999999 489.24 783.76 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714162_1 CDM 0278 RC C1887 HCPCS inpatient 808 525.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 630.24 78 999999999 489.24 783.76 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714162_1 CDM 0278 RC C1887 HCPCS inpatient 808 525.2 UMR - ALL PLANS UMR - ALL PLANS 565.6 70 999999999 489.24 783.76 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714162_1 CDM 0278 RC C1887 HCPCS inpatient 808 525.2 SIHO - ALL PLANS SIHO - ALL PLANS 727.2 90 999999999 489.24 783.76 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714162_1 CDM 0278 RC C1887 HCPCS inpatient 808 525.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 489.24 60.55 999999999 489.24 783.76 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714162_1 CDM 0278 RC C1887 HCPCS inpatient 808 525.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 489.24 783.76 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714162_1 CDM 0278 RC C1887 HCPCS inpatient 808 525.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 489.24 783.76 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714162_1 CDM 0278 RC C1887 HCPCS inpatient 808 525.2 ANTHEM HMO ANTHEM HMO 999999999 489.24 783.76 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714162_1 CDM 0278 RC C1887 HCPCS inpatient 808 525.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 546.21 67.6 999999999 489.24 783.76 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714162_1 CDM 0278 RC C1887 HCPCS inpatient 808 525.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 489.24 783.76 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714162_1 CDM 0278 RC C1887 HCPCS inpatient 808 525.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 489.24 783.76 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714163_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714163_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714163_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714163_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714163_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714163_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714163_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714163_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714163_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714163_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714163_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714163_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714163_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 "CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION CAPABILITY)" 48714163_1 CDM 0278 RC C1887 HCPCS inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 5FR JR LAUNCHER GUIDE CATH 3.5 48714164_1 CDM 0272 RC inpatient 808 525.2 AETNA AETNA 638.32 79 999999999 489.24 783.76 percent of total billed charges 5FR JR LAUNCHER GUIDE CATH 3.5 48714164_1 CDM 0272 RC inpatient 808 525.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 525.2 65 999999999 489.24 783.76 percent of total billed charges 5FR JR LAUNCHER GUIDE CATH 3.5 48714164_1 CDM 0272 RC inpatient 808 525.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 783.76 97 999999999 489.24 783.76 percent of total billed charges 5FR JR LAUNCHER GUIDE CATH 3.5 48714164_1 CDM 0272 RC inpatient 808 525.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 557.52 69 999999999 489.24 783.76 percent of total billed charges 5FR JR LAUNCHER GUIDE CATH 3.5 48714164_1 CDM 0272 RC inpatient 808 525.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 630.24 78 999999999 489.24 783.76 percent of total billed charges 5FR JR LAUNCHER GUIDE CATH 3.5 48714164_1 CDM 0272 RC inpatient 808 525.2 UMR - ALL PLANS UMR - ALL PLANS 565.6 70 999999999 489.24 783.76 percent of total billed charges 5FR JR LAUNCHER GUIDE CATH 3.5 48714164_1 CDM 0272 RC inpatient 808 525.2 SIHO - ALL PLANS SIHO - ALL PLANS 727.2 90 999999999 489.24 783.76 percent of total billed charges 5FR JR LAUNCHER GUIDE CATH 3.5 48714164_1 CDM 0272 RC inpatient 808 525.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 489.24 60.55 999999999 489.24 783.76 percent of total billed charges 5FR JR LAUNCHER GUIDE CATH 3.5 48714164_1 CDM 0272 RC inpatient 808 525.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 489.24 783.76 5FR JR LAUNCHER GUIDE CATH 3.5 48714164_1 CDM 0272 RC inpatient 808 525.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 489.24 783.76 5FR JR LAUNCHER GUIDE CATH 3.5 48714164_1 CDM 0272 RC inpatient 808 525.2 ANTHEM HMO ANTHEM HMO 999999999 489.24 783.76 5FR JR LAUNCHER GUIDE CATH 3.5 48714164_1 CDM 0272 RC inpatient 808 525.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 546.21 67.6 999999999 489.24 783.76 percent of total billed charges 5FR JR LAUNCHER GUIDE CATH 3.5 48714164_1 CDM 0272 RC inpatient 808 525.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 489.24 783.76 5FR JR LAUNCHER GUIDE CATH 3.5 48714164_1 CDM 0272 RC inpatient 808 525.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 489.24 783.76 5F LA LAUNCHER GUIDE CATH 3.0 48714165_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges 5F LA LAUNCHER GUIDE CATH 3.0 48714165_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges 5F LA LAUNCHER GUIDE CATH 3.0 48714165_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges 5F LA LAUNCHER GUIDE CATH 3.0 48714165_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges 5F LA LAUNCHER GUIDE CATH 3.0 48714165_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges 5F LA LAUNCHER GUIDE CATH 3.0 48714165_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges 5F LA LAUNCHER GUIDE CATH 3.0 48714165_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges 5F LA LAUNCHER GUIDE CATH 3.0 48714165_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges 5F LA LAUNCHER GUIDE CATH 3.0 48714165_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 5F LA LAUNCHER GUIDE CATH 3.0 48714165_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 5F LA LAUNCHER GUIDE CATH 3.0 48714165_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 5F LA LAUNCHER GUIDE CATH 3.0 48714165_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges 5F LA LAUNCHER GUIDE CATH 3.0 48714165_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 5F LA LAUNCHER GUIDE CATH 3.0 48714165_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATH SET 32CM DURAFLO 10301203 48714166_1 CDM 0272 RC inpatient 1367 888.55 AETNA AETNA 1079.93 79 999999999 827.72 1325.99 percent of total billed charges CATH SET 32CM DURAFLO 10301203 48714166_1 CDM 0272 RC inpatient 1367 888.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 888.55 65 999999999 827.72 1325.99 percent of total billed charges CATH SET 32CM DURAFLO 10301203 48714166_1 CDM 0272 RC inpatient 1367 888.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1325.99 97 999999999 827.72 1325.99 percent of total billed charges CATH SET 32CM DURAFLO 10301203 48714166_1 CDM 0272 RC inpatient 1367 888.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 943.23 69 999999999 827.72 1325.99 percent of total billed charges CATH SET 32CM DURAFLO 10301203 48714166_1 CDM 0272 RC inpatient 1367 888.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1066.26 78 999999999 827.72 1325.99 percent of total billed charges CATH SET 32CM DURAFLO 10301203 48714166_1 CDM 0272 RC inpatient 1367 888.55 UMR - ALL PLANS UMR - ALL PLANS 956.9 70 999999999 827.72 1325.99 percent of total billed charges CATH SET 32CM DURAFLO 10301203 48714166_1 CDM 0272 RC inpatient 1367 888.55 SIHO - ALL PLANS SIHO - ALL PLANS 1230.3 90 999999999 827.72 1325.99 percent of total billed charges CATH SET 32CM DURAFLO 10301203 48714166_1 CDM 0272 RC inpatient 1367 888.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 827.72 60.55 999999999 827.72 1325.99 percent of total billed charges CATH SET 32CM DURAFLO 10301203 48714166_1 CDM 0272 RC inpatient 1367 888.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 827.72 1325.99 CATH SET 32CM DURAFLO 10301203 48714166_1 CDM 0272 RC inpatient 1367 888.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 827.72 1325.99 CATH SET 32CM DURAFLO 10301203 48714166_1 CDM 0272 RC inpatient 1367 888.55 ANTHEM HMO ANTHEM HMO 999999999 827.72 1325.99 CATH SET 32CM DURAFLO 10301203 48714166_1 CDM 0272 RC inpatient 1367 888.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 924.09 67.6 999999999 827.72 1325.99 percent of total billed charges CATH SET 32CM DURAFLO 10301203 48714166_1 CDM 0272 RC inpatient 1367 888.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 827.72 1325.99 CATH SET 32CM DURAFLO 10301203 48714166_1 CDM 0272 RC inpatient 1367 888.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 827.72 1325.99 CATH SET 36CM DURAFLO 10301204 48714167_1 CDM 0272 RC inpatient 3906 2538.9 AETNA AETNA 3085.74 79 999999999 2365.08 3788.82 percent of total billed charges CATH SET 36CM DURAFLO 10301204 48714167_1 CDM 0272 RC inpatient 3906 2538.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 2538.9 65 999999999 2365.08 3788.82 percent of total billed charges CATH SET 36CM DURAFLO 10301204 48714167_1 CDM 0272 RC inpatient 3906 2538.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3788.82 97 999999999 2365.08 3788.82 percent of total billed charges CATH SET 36CM DURAFLO 10301204 48714167_1 CDM 0272 RC inpatient 3906 2538.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 2695.14 69 999999999 2365.08 3788.82 percent of total billed charges CATH SET 36CM DURAFLO 10301204 48714167_1 CDM 0272 RC inpatient 3906 2538.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 3046.68 78 999999999 2365.08 3788.82 percent of total billed charges CATH SET 36CM DURAFLO 10301204 48714167_1 CDM 0272 RC inpatient 3906 2538.9 UMR - ALL PLANS UMR - ALL PLANS 2734.2 70 999999999 2365.08 3788.82 percent of total billed charges CATH SET 36CM DURAFLO 10301204 48714167_1 CDM 0272 RC inpatient 3906 2538.9 SIHO - ALL PLANS SIHO - ALL PLANS 3515.4 90 999999999 2365.08 3788.82 percent of total billed charges CATH SET 36CM DURAFLO 10301204 48714167_1 CDM 0272 RC inpatient 3906 2538.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2365.08 60.55 999999999 2365.08 3788.82 percent of total billed charges CATH SET 36CM DURAFLO 10301204 48714167_1 CDM 0272 RC inpatient 3906 2538.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2365.08 3788.82 CATH SET 36CM DURAFLO 10301204 48714167_1 CDM 0272 RC inpatient 3906 2538.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2365.08 3788.82 CATH SET 36CM DURAFLO 10301204 48714167_1 CDM 0272 RC inpatient 3906 2538.9 ANTHEM HMO ANTHEM HMO 999999999 2365.08 3788.82 CATH SET 36CM DURAFLO 10301204 48714167_1 CDM 0272 RC inpatient 3906 2538.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 2640.46 67.6 999999999 2365.08 3788.82 percent of total billed charges CATH SET 36CM DURAFLO 10301204 48714167_1 CDM 0272 RC inpatient 3906 2538.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2365.08 3788.82 CATH SET 36CM DURAFLO 10301204 48714167_1 CDM 0272 RC inpatient 3906 2538.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 2365.08 3788.82 CATH SET 40CM DURAFLO 10301205 48714168_1 CDM 0272 RC inpatient 1367 888.55 AETNA AETNA 1079.93 79 999999999 827.72 1325.99 percent of total billed charges CATH SET 40CM DURAFLO 10301205 48714168_1 CDM 0272 RC inpatient 1367 888.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 888.55 65 999999999 827.72 1325.99 percent of total billed charges CATH SET 40CM DURAFLO 10301205 48714168_1 CDM 0272 RC inpatient 1367 888.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1325.99 97 999999999 827.72 1325.99 percent of total billed charges CATH SET 40CM DURAFLO 10301205 48714168_1 CDM 0272 RC inpatient 1367 888.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 943.23 69 999999999 827.72 1325.99 percent of total billed charges CATH SET 40CM DURAFLO 10301205 48714168_1 CDM 0272 RC inpatient 1367 888.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1066.26 78 999999999 827.72 1325.99 percent of total billed charges CATH SET 40CM DURAFLO 10301205 48714168_1 CDM 0272 RC inpatient 1367 888.55 UMR - ALL PLANS UMR - ALL PLANS 956.9 70 999999999 827.72 1325.99 percent of total billed charges CATH SET 40CM DURAFLO 10301205 48714168_1 CDM 0272 RC inpatient 1367 888.55 SIHO - ALL PLANS SIHO - ALL PLANS 1230.3 90 999999999 827.72 1325.99 percent of total billed charges CATH SET 40CM DURAFLO 10301205 48714168_1 CDM 0272 RC inpatient 1367 888.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 827.72 60.55 999999999 827.72 1325.99 percent of total billed charges CATH SET 40CM DURAFLO 10301205 48714168_1 CDM 0272 RC inpatient 1367 888.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 827.72 1325.99 CATH SET 40CM DURAFLO 10301205 48714168_1 CDM 0272 RC inpatient 1367 888.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 827.72 1325.99 CATH SET 40CM DURAFLO 10301205 48714168_1 CDM 0272 RC inpatient 1367 888.55 ANTHEM HMO ANTHEM HMO 999999999 827.72 1325.99 CATH SET 40CM DURAFLO 10301205 48714168_1 CDM 0272 RC inpatient 1367 888.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 924.09 67.6 999999999 827.72 1325.99 percent of total billed charges CATH SET 40CM DURAFLO 10301205 48714168_1 CDM 0272 RC inpatient 1367 888.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 827.72 1325.99 CATH SET 40CM DURAFLO 10301205 48714168_1 CDM 0272 RC inpatient 1367 888.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 827.72 1325.99 CATH SET 55CM DURAFLO 10301211 48714169_1 CDM 0272 RC inpatient 1367 888.55 AETNA AETNA 1079.93 79 999999999 827.72 1325.99 percent of total billed charges CATH SET 55CM DURAFLO 10301211 48714169_1 CDM 0272 RC inpatient 1367 888.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 888.55 65 999999999 827.72 1325.99 percent of total billed charges CATH SET 55CM DURAFLO 10301211 48714169_1 CDM 0272 RC inpatient 1367 888.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1325.99 97 999999999 827.72 1325.99 percent of total billed charges CATH SET 55CM DURAFLO 10301211 48714169_1 CDM 0272 RC inpatient 1367 888.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 943.23 69 999999999 827.72 1325.99 percent of total billed charges CATH SET 55CM DURAFLO 10301211 48714169_1 CDM 0272 RC inpatient 1367 888.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1066.26 78 999999999 827.72 1325.99 percent of total billed charges CATH SET 55CM DURAFLO 10301211 48714169_1 CDM 0272 RC inpatient 1367 888.55 UMR - ALL PLANS UMR - ALL PLANS 956.9 70 999999999 827.72 1325.99 percent of total billed charges CATH SET 55CM DURAFLO 10301211 48714169_1 CDM 0272 RC inpatient 1367 888.55 SIHO - ALL PLANS SIHO - ALL PLANS 1230.3 90 999999999 827.72 1325.99 percent of total billed charges CATH SET 55CM DURAFLO 10301211 48714169_1 CDM 0272 RC inpatient 1367 888.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 827.72 60.55 999999999 827.72 1325.99 percent of total billed charges CATH SET 55CM DURAFLO 10301211 48714169_1 CDM 0272 RC inpatient 1367 888.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 827.72 1325.99 CATH SET 55CM DURAFLO 10301211 48714169_1 CDM 0272 RC inpatient 1367 888.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 827.72 1325.99 CATH SET 55CM DURAFLO 10301211 48714169_1 CDM 0272 RC inpatient 1367 888.55 ANTHEM HMO ANTHEM HMO 999999999 827.72 1325.99 CATH SET 55CM DURAFLO 10301211 48714169_1 CDM 0272 RC inpatient 1367 888.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 924.09 67.6 999999999 827.72 1325.99 percent of total billed charges CATH SET 55CM DURAFLO 10301211 48714169_1 CDM 0272 RC inpatient 1367 888.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 827.72 1325.99 CATH SET 55CM DURAFLO 10301211 48714169_1 CDM 0272 RC inpatient 1367 888.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 827.72 1325.99 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714170_1 CDM 0278 RC C1725 HCPCS inpatient 640 416 AETNA AETNA 505.6 79 999999999 387.52 620.8 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714170_1 CDM 0278 RC C1725 HCPCS inpatient 640 416 SELF PAY DISCOUNT SELF PAY DISCOUNT 416 65 999999999 387.52 620.8 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714170_1 CDM 0278 RC C1725 HCPCS inpatient 640 416 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 620.8 97 999999999 387.52 620.8 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714170_1 CDM 0278 RC C1725 HCPCS inpatient 640 416 ENCORE - ALL PLANS ENCORE - ALL PLANS 441.6 69 999999999 387.52 620.8 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714170_1 CDM 0278 RC C1725 HCPCS inpatient 640 416 HUMANA - ALL PLANS HUMANA - ALL PLANS 499.2 78 999999999 387.52 620.8 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714170_1 CDM 0278 RC C1725 HCPCS inpatient 640 416 UMR - ALL PLANS UMR - ALL PLANS 448 70 999999999 387.52 620.8 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714170_1 CDM 0278 RC C1725 HCPCS inpatient 640 416 SIHO - ALL PLANS SIHO - ALL PLANS 576 90 999999999 387.52 620.8 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714170_1 CDM 0278 RC C1725 HCPCS inpatient 640 416 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 387.52 60.55 999999999 387.52 620.8 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714170_1 CDM 0278 RC C1725 HCPCS inpatient 640 416 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 387.52 620.8 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714170_1 CDM 0278 RC C1725 HCPCS inpatient 640 416 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 387.52 620.8 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714170_1 CDM 0278 RC C1725 HCPCS inpatient 640 416 ANTHEM HMO ANTHEM HMO 999999999 387.52 620.8 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714170_1 CDM 0278 RC C1725 HCPCS inpatient 640 416 CIGNA - ALL PLANS CIGNA - ALL PLANS 432.64 67.6 999999999 387.52 620.8 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714170_1 CDM 0278 RC C1725 HCPCS inpatient 640 416 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 387.52 620.8 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714170_1 CDM 0278 RC C1725 HCPCS inpatient 640 416 UHC - ALL PLANS UHC - ALL PLANS 999999999 387.52 620.8 "CATHETER, DRAINAGE" 48714171_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 AETNA AETNA 511.92 79 999999999 392.36 628.56 percent of total billed charges "CATHETER, DRAINAGE" 48714171_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 421.2 65 999999999 392.36 628.56 percent of total billed charges "CATHETER, DRAINAGE" 48714171_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 628.56 97 999999999 392.36 628.56 percent of total billed charges "CATHETER, DRAINAGE" 48714171_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 447.12 69 999999999 392.36 628.56 percent of total billed charges "CATHETER, DRAINAGE" 48714171_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 505.44 78 999999999 392.36 628.56 percent of total billed charges "CATHETER, DRAINAGE" 48714171_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 UMR - ALL PLANS UMR - ALL PLANS 453.6 70 999999999 392.36 628.56 percent of total billed charges "CATHETER, DRAINAGE" 48714171_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 SIHO - ALL PLANS SIHO - ALL PLANS 583.2 90 999999999 392.36 628.56 percent of total billed charges "CATHETER, DRAINAGE" 48714171_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 392.36 60.55 999999999 392.36 628.56 percent of total billed charges "CATHETER, DRAINAGE" 48714171_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 392.36 628.56 "CATHETER, DRAINAGE" 48714171_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 392.36 628.56 "CATHETER, DRAINAGE" 48714171_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 ANTHEM HMO ANTHEM HMO 999999999 392.36 628.56 "CATHETER, DRAINAGE" 48714171_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 438.05 67.6 999999999 392.36 628.56 percent of total billed charges "CATHETER, DRAINAGE" 48714171_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 392.36 628.56 "CATHETER, DRAINAGE" 48714171_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 392.36 628.56 CATH FLEXIMA 12FR 25C 1271810 48714172_1 CDM 0272 RC inpatient 648 421.2 AETNA AETNA 511.92 79 999999999 392.36 628.56 percent of total billed charges CATH FLEXIMA 12FR 25C 1271810 48714172_1 CDM 0272 RC inpatient 648 421.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 421.2 65 999999999 392.36 628.56 percent of total billed charges CATH FLEXIMA 12FR 25C 1271810 48714172_1 CDM 0272 RC inpatient 648 421.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 628.56 97 999999999 392.36 628.56 percent of total billed charges CATH FLEXIMA 12FR 25C 1271810 48714172_1 CDM 0272 RC inpatient 648 421.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 447.12 69 999999999 392.36 628.56 percent of total billed charges CATH FLEXIMA 12FR 25C 1271810 48714172_1 CDM 0272 RC inpatient 648 421.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 505.44 78 999999999 392.36 628.56 percent of total billed charges CATH FLEXIMA 12FR 25C 1271810 48714172_1 CDM 0272 RC inpatient 648 421.2 UMR - ALL PLANS UMR - ALL PLANS 453.6 70 999999999 392.36 628.56 percent of total billed charges CATH FLEXIMA 12FR 25C 1271810 48714172_1 CDM 0272 RC inpatient 648 421.2 SIHO - ALL PLANS SIHO - ALL PLANS 583.2 90 999999999 392.36 628.56 percent of total billed charges CATH FLEXIMA 12FR 25C 1271810 48714172_1 CDM 0272 RC inpatient 648 421.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 392.36 60.55 999999999 392.36 628.56 percent of total billed charges CATH FLEXIMA 12FR 25C 1271810 48714172_1 CDM 0272 RC inpatient 648 421.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 392.36 628.56 CATH FLEXIMA 12FR 25C 1271810 48714172_1 CDM 0272 RC inpatient 648 421.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 392.36 628.56 CATH FLEXIMA 12FR 25C 1271810 48714172_1 CDM 0272 RC inpatient 648 421.2 ANTHEM HMO ANTHEM HMO 999999999 392.36 628.56 CATH FLEXIMA 12FR 25C 1271810 48714172_1 CDM 0272 RC inpatient 648 421.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 438.05 67.6 999999999 392.36 628.56 percent of total billed charges CATH FLEXIMA 12FR 25C 1271810 48714172_1 CDM 0272 RC inpatient 648 421.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 392.36 628.56 CATH FLEXIMA 12FR 25C 1271810 48714172_1 CDM 0272 RC inpatient 648 421.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 392.36 628.56 "CATHETER, DRAINAGE" 48714173_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 AETNA AETNA 511.92 79 999999999 392.36 628.56 percent of total billed charges "CATHETER, DRAINAGE" 48714173_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 421.2 65 999999999 392.36 628.56 percent of total billed charges "CATHETER, DRAINAGE" 48714173_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 628.56 97 999999999 392.36 628.56 percent of total billed charges "CATHETER, DRAINAGE" 48714173_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 447.12 69 999999999 392.36 628.56 percent of total billed charges "CATHETER, DRAINAGE" 48714173_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 505.44 78 999999999 392.36 628.56 percent of total billed charges "CATHETER, DRAINAGE" 48714173_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 UMR - ALL PLANS UMR - ALL PLANS 453.6 70 999999999 392.36 628.56 percent of total billed charges "CATHETER, DRAINAGE" 48714173_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 SIHO - ALL PLANS SIHO - ALL PLANS 583.2 90 999999999 392.36 628.56 percent of total billed charges "CATHETER, DRAINAGE" 48714173_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 392.36 60.55 999999999 392.36 628.56 percent of total billed charges "CATHETER, DRAINAGE" 48714173_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 392.36 628.56 "CATHETER, DRAINAGE" 48714173_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 392.36 628.56 "CATHETER, DRAINAGE" 48714173_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 ANTHEM HMO ANTHEM HMO 999999999 392.36 628.56 "CATHETER, DRAINAGE" 48714173_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 438.05 67.6 999999999 392.36 628.56 percent of total billed charges "CATHETER, DRAINAGE" 48714173_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 392.36 628.56 "CATHETER, DRAINAGE" 48714173_1 CDM 0278 RC C1729 HCPCS inpatient 648 421.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 392.36 628.56 CATH FLEXIMA 14FR 25C 1271850 48714174_1 CDM 0272 RC inpatient 648 421.2 AETNA AETNA 511.92 79 999999999 392.36 628.56 percent of total billed charges CATH FLEXIMA 14FR 25C 1271850 48714174_1 CDM 0272 RC inpatient 648 421.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 421.2 65 999999999 392.36 628.56 percent of total billed charges CATH FLEXIMA 14FR 25C 1271850 48714174_1 CDM 0272 RC inpatient 648 421.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 628.56 97 999999999 392.36 628.56 percent of total billed charges CATH FLEXIMA 14FR 25C 1271850 48714174_1 CDM 0272 RC inpatient 648 421.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 447.12 69 999999999 392.36 628.56 percent of total billed charges CATH FLEXIMA 14FR 25C 1271850 48714174_1 CDM 0272 RC inpatient 648 421.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 505.44 78 999999999 392.36 628.56 percent of total billed charges CATH FLEXIMA 14FR 25C 1271850 48714174_1 CDM 0272 RC inpatient 648 421.2 UMR - ALL PLANS UMR - ALL PLANS 453.6 70 999999999 392.36 628.56 percent of total billed charges CATH FLEXIMA 14FR 25C 1271850 48714174_1 CDM 0272 RC inpatient 648 421.2 SIHO - ALL PLANS SIHO - ALL PLANS 583.2 90 999999999 392.36 628.56 percent of total billed charges CATH FLEXIMA 14FR 25C 1271850 48714174_1 CDM 0272 RC inpatient 648 421.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 392.36 60.55 999999999 392.36 628.56 percent of total billed charges CATH FLEXIMA 14FR 25C 1271850 48714174_1 CDM 0272 RC inpatient 648 421.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 392.36 628.56 CATH FLEXIMA 14FR 25C 1271850 48714174_1 CDM 0272 RC inpatient 648 421.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 392.36 628.56 CATH FLEXIMA 14FR 25C 1271850 48714174_1 CDM 0272 RC inpatient 648 421.2 ANTHEM HMO ANTHEM HMO 999999999 392.36 628.56 CATH FLEXIMA 14FR 25C 1271850 48714174_1 CDM 0272 RC inpatient 648 421.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 438.05 67.6 999999999 392.36 628.56 percent of total billed charges CATH FLEXIMA 14FR 25C 1271850 48714174_1 CDM 0272 RC inpatient 648 421.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 392.36 628.56 CATH FLEXIMA 14FR 25C 1271850 48714174_1 CDM 0272 RC inpatient 648 421.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 392.36 628.56 CATH BILIARY 12FR X 35 1272620 48714175_1 CDM 0272 RC inpatient 627 407.55 AETNA AETNA 495.33 79 999999999 379.65 608.19 percent of total billed charges CATH BILIARY 12FR X 35 1272620 48714175_1 CDM 0272 RC inpatient 627 407.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 407.55 65 999999999 379.65 608.19 percent of total billed charges CATH BILIARY 12FR X 35 1272620 48714175_1 CDM 0272 RC inpatient 627 407.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 608.19 97 999999999 379.65 608.19 percent of total billed charges CATH BILIARY 12FR X 35 1272620 48714175_1 CDM 0272 RC inpatient 627 407.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 432.63 69 999999999 379.65 608.19 percent of total billed charges CATH BILIARY 12FR X 35 1272620 48714175_1 CDM 0272 RC inpatient 627 407.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 489.06 78 999999999 379.65 608.19 percent of total billed charges CATH BILIARY 12FR X 35 1272620 48714175_1 CDM 0272 RC inpatient 627 407.55 UMR - ALL PLANS UMR - ALL PLANS 438.9 70 999999999 379.65 608.19 percent of total billed charges CATH BILIARY 12FR X 35 1272620 48714175_1 CDM 0272 RC inpatient 627 407.55 SIHO - ALL PLANS SIHO - ALL PLANS 564.3 90 999999999 379.65 608.19 percent of total billed charges CATH BILIARY 12FR X 35 1272620 48714175_1 CDM 0272 RC inpatient 627 407.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 379.65 60.55 999999999 379.65 608.19 percent of total billed charges CATH BILIARY 12FR X 35 1272620 48714175_1 CDM 0272 RC inpatient 627 407.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 379.65 608.19 CATH BILIARY 12FR X 35 1272620 48714175_1 CDM 0272 RC inpatient 627 407.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 379.65 608.19 CATH BILIARY 12FR X 35 1272620 48714175_1 CDM 0272 RC inpatient 627 407.55 ANTHEM HMO ANTHEM HMO 999999999 379.65 608.19 CATH BILIARY 12FR X 35 1272620 48714175_1 CDM 0272 RC inpatient 627 407.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 423.85 67.6 999999999 379.65 608.19 percent of total billed charges CATH BILIARY 12FR X 35 1272620 48714175_1 CDM 0272 RC inpatient 627 407.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 379.65 608.19 CATH BILIARY 12FR X 35 1272620 48714175_1 CDM 0272 RC inpatient 627 407.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 379.65 608.19 NEEDLE TROCAR 18G X 15C G00945 48714176_1 CDM 0278 RC inpatient 132 85.8 AETNA AETNA 104.28 79 999999999 79.93 128.04 percent of total billed charges NEEDLE TROCAR 18G X 15C G00945 48714176_1 CDM 0278 RC inpatient 132 85.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.8 65 999999999 79.93 128.04 percent of total billed charges NEEDLE TROCAR 18G X 15C G00945 48714176_1 CDM 0278 RC inpatient 132 85.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 128.04 97 999999999 79.93 128.04 percent of total billed charges NEEDLE TROCAR 18G X 15C G00945 48714176_1 CDM 0278 RC inpatient 132 85.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.08 69 999999999 79.93 128.04 percent of total billed charges NEEDLE TROCAR 18G X 15C G00945 48714176_1 CDM 0278 RC inpatient 132 85.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.96 78 999999999 79.93 128.04 percent of total billed charges NEEDLE TROCAR 18G X 15C G00945 48714176_1 CDM 0278 RC inpatient 132 85.8 UMR - ALL PLANS UMR - ALL PLANS 92.4 70 999999999 79.93 128.04 percent of total billed charges NEEDLE TROCAR 18G X 15C G00945 48714176_1 CDM 0278 RC inpatient 132 85.8 SIHO - ALL PLANS SIHO - ALL PLANS 118.8 90 999999999 79.93 128.04 percent of total billed charges NEEDLE TROCAR 18G X 15C G00945 48714176_1 CDM 0278 RC inpatient 132 85.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.93 60.55 999999999 79.93 128.04 percent of total billed charges NEEDLE TROCAR 18G X 15C G00945 48714176_1 CDM 0278 RC inpatient 132 85.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.93 128.04 NEEDLE TROCAR 18G X 15C G00945 48714176_1 CDM 0278 RC inpatient 132 85.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.93 128.04 NEEDLE TROCAR 18G X 15C G00945 48714176_1 CDM 0278 RC inpatient 132 85.8 ANTHEM HMO ANTHEM HMO 999999999 79.93 128.04 NEEDLE TROCAR 18G X 15C G00945 48714176_1 CDM 0278 RC inpatient 132 85.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.23 67.6 999999999 79.93 128.04 percent of total billed charges NEEDLE TROCAR 18G X 15C G00945 48714176_1 CDM 0278 RC inpatient 132 85.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.93 128.04 NEEDLE TROCAR 18G X 15C G00945 48714176_1 CDM 0278 RC inpatient 132 85.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.93 128.04 NEEDLE BIOPSY 18GX 5.875 53818 48714177_1 CDM 0272 RC inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges NEEDLE BIOPSY 18GX 5.875 53818 48714177_1 CDM 0272 RC inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges NEEDLE BIOPSY 18GX 5.875 53818 48714177_1 CDM 0272 RC inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges NEEDLE BIOPSY 18GX 5.875 53818 48714177_1 CDM 0272 RC inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges NEEDLE BIOPSY 18GX 5.875 53818 48714177_1 CDM 0272 RC inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges NEEDLE BIOPSY 18GX 5.875 53818 48714177_1 CDM 0272 RC inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges NEEDLE BIOPSY 18GX 5.875 53818 48714177_1 CDM 0272 RC inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges NEEDLE BIOPSY 18GX 5.875 53818 48714177_1 CDM 0272 RC inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges NEEDLE BIOPSY 18GX 5.875 53818 48714177_1 CDM 0272 RC inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 NEEDLE BIOPSY 18GX 5.875 53818 48714177_1 CDM 0272 RC inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 NEEDLE BIOPSY 18GX 5.875 53818 48714177_1 CDM 0272 RC inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 NEEDLE BIOPSY 18GX 5.875 53818 48714177_1 CDM 0272 RC inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges NEEDLE BIOPSY 18GX 5.875 53818 48714177_1 CDM 0272 RC inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 NEEDLE BIOPSY 18GX 5.875 53818 48714177_1 CDM 0272 RC inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 NEEDLE TROCAR 18G X 2O 48714179_1 CDM 0278 RC inpatient 132 85.8 AETNA AETNA 104.28 79 999999999 79.93 128.04 percent of total billed charges NEEDLE TROCAR 18G X 2O 48714179_1 CDM 0278 RC inpatient 132 85.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.8 65 999999999 79.93 128.04 percent of total billed charges NEEDLE TROCAR 18G X 2O 48714179_1 CDM 0278 RC inpatient 132 85.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 128.04 97 999999999 79.93 128.04 percent of total billed charges NEEDLE TROCAR 18G X 2O 48714179_1 CDM 0278 RC inpatient 132 85.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.08 69 999999999 79.93 128.04 percent of total billed charges NEEDLE TROCAR 18G X 2O 48714179_1 CDM 0278 RC inpatient 132 85.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.96 78 999999999 79.93 128.04 percent of total billed charges NEEDLE TROCAR 18G X 2O 48714179_1 CDM 0278 RC inpatient 132 85.8 UMR - ALL PLANS UMR - ALL PLANS 92.4 70 999999999 79.93 128.04 percent of total billed charges NEEDLE TROCAR 18G X 2O 48714179_1 CDM 0278 RC inpatient 132 85.8 SIHO - ALL PLANS SIHO - ALL PLANS 118.8 90 999999999 79.93 128.04 percent of total billed charges NEEDLE TROCAR 18G X 2O 48714179_1 CDM 0278 RC inpatient 132 85.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.93 60.55 999999999 79.93 128.04 percent of total billed charges NEEDLE TROCAR 18G X 2O 48714179_1 CDM 0278 RC inpatient 132 85.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.93 128.04 NEEDLE TROCAR 18G X 2O 48714179_1 CDM 0278 RC inpatient 132 85.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.93 128.04 NEEDLE TROCAR 18G X 2O 48714179_1 CDM 0278 RC inpatient 132 85.8 ANTHEM HMO ANTHEM HMO 999999999 79.93 128.04 NEEDLE TROCAR 18G X 2O 48714179_1 CDM 0278 RC inpatient 132 85.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.23 67.6 999999999 79.93 128.04 percent of total billed charges NEEDLE TROCAR 18G X 2O 48714179_1 CDM 0278 RC inpatient 132 85.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.93 128.04 NEEDLE TROCAR 18G X 2O 48714179_1 CDM 0278 RC inpatient 132 85.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.93 128.04 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714180_1 CDM 0278 RC C1725 HCPCS inpatient 1367 888.55 AETNA AETNA 1079.93 79 999999999 827.72 1325.99 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714180_1 CDM 0278 RC C1725 HCPCS inpatient 1367 888.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 888.55 65 999999999 827.72 1325.99 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714180_1 CDM 0278 RC C1725 HCPCS inpatient 1367 888.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1325.99 97 999999999 827.72 1325.99 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714180_1 CDM 0278 RC C1725 HCPCS inpatient 1367 888.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 943.23 69 999999999 827.72 1325.99 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714180_1 CDM 0278 RC C1725 HCPCS inpatient 1367 888.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1066.26 78 999999999 827.72 1325.99 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714180_1 CDM 0278 RC C1725 HCPCS inpatient 1367 888.55 UMR - ALL PLANS UMR - ALL PLANS 956.9 70 999999999 827.72 1325.99 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714180_1 CDM 0278 RC C1725 HCPCS inpatient 1367 888.55 SIHO - ALL PLANS SIHO - ALL PLANS 1230.3 90 999999999 827.72 1325.99 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714180_1 CDM 0278 RC C1725 HCPCS inpatient 1367 888.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 827.72 60.55 999999999 827.72 1325.99 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714180_1 CDM 0278 RC C1725 HCPCS inpatient 1367 888.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 827.72 1325.99 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714180_1 CDM 0278 RC C1725 HCPCS inpatient 1367 888.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 827.72 1325.99 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714180_1 CDM 0278 RC C1725 HCPCS inpatient 1367 888.55 ANTHEM HMO ANTHEM HMO 999999999 827.72 1325.99 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714180_1 CDM 0278 RC C1725 HCPCS inpatient 1367 888.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 924.09 67.6 999999999 827.72 1325.99 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714180_1 CDM 0278 RC C1725 HCPCS inpatient 1367 888.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 827.72 1325.99 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714180_1 CDM 0278 RC C1725 HCPCS inpatient 1367 888.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 827.72 1325.99 STENT PERCUFLEX GLIDEX 8F X 28 48714181_1 CDM 0272 RC inpatient 979 636.35 AETNA AETNA 773.41 79 999999999 592.78 949.63 percent of total billed charges STENT PERCUFLEX GLIDEX 8F X 28 48714181_1 CDM 0272 RC inpatient 979 636.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 636.35 65 999999999 592.78 949.63 percent of total billed charges STENT PERCUFLEX GLIDEX 8F X 28 48714181_1 CDM 0272 RC inpatient 979 636.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 949.63 97 999999999 592.78 949.63 percent of total billed charges STENT PERCUFLEX GLIDEX 8F X 28 48714181_1 CDM 0272 RC inpatient 979 636.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 675.51 69 999999999 592.78 949.63 percent of total billed charges STENT PERCUFLEX GLIDEX 8F X 28 48714181_1 CDM 0272 RC inpatient 979 636.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 763.62 78 999999999 592.78 949.63 percent of total billed charges STENT PERCUFLEX GLIDEX 8F X 28 48714181_1 CDM 0272 RC inpatient 979 636.35 UMR - ALL PLANS UMR - ALL PLANS 685.3 70 999999999 592.78 949.63 percent of total billed charges STENT PERCUFLEX GLIDEX 8F X 28 48714181_1 CDM 0272 RC inpatient 979 636.35 SIHO - ALL PLANS SIHO - ALL PLANS 881.1 90 999999999 592.78 949.63 percent of total billed charges STENT PERCUFLEX GLIDEX 8F X 28 48714181_1 CDM 0272 RC inpatient 979 636.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 592.78 60.55 999999999 592.78 949.63 percent of total billed charges STENT PERCUFLEX GLIDEX 8F X 28 48714181_1 CDM 0272 RC inpatient 979 636.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 592.78 949.63 STENT PERCUFLEX GLIDEX 8F X 28 48714181_1 CDM 0272 RC inpatient 979 636.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 592.78 949.63 STENT PERCUFLEX GLIDEX 8F X 28 48714181_1 CDM 0272 RC inpatient 979 636.35 ANTHEM HMO ANTHEM HMO 999999999 592.78 949.63 STENT PERCUFLEX GLIDEX 8F X 28 48714181_1 CDM 0272 RC inpatient 979 636.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 661.8 67.6 999999999 592.78 949.63 percent of total billed charges STENT PERCUFLEX GLIDEX 8F X 28 48714181_1 CDM 0272 RC inpatient 979 636.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 592.78 949.63 STENT PERCUFLEX GLIDEX 8F X 28 48714181_1 CDM 0272 RC inpatient 979 636.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 592.78 949.63 STENT PERCUFLEX GLIDEX 8F X 24 48714182_1 CDM 0272 RC inpatient 979 636.35 AETNA AETNA 773.41 79 999999999 592.78 949.63 percent of total billed charges STENT PERCUFLEX GLIDEX 8F X 24 48714182_1 CDM 0272 RC inpatient 979 636.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 636.35 65 999999999 592.78 949.63 percent of total billed charges STENT PERCUFLEX GLIDEX 8F X 24 48714182_1 CDM 0272 RC inpatient 979 636.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 949.63 97 999999999 592.78 949.63 percent of total billed charges STENT PERCUFLEX GLIDEX 8F X 24 48714182_1 CDM 0272 RC inpatient 979 636.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 675.51 69 999999999 592.78 949.63 percent of total billed charges STENT PERCUFLEX GLIDEX 8F X 24 48714182_1 CDM 0272 RC inpatient 979 636.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 763.62 78 999999999 592.78 949.63 percent of total billed charges STENT PERCUFLEX GLIDEX 8F X 24 48714182_1 CDM 0272 RC inpatient 979 636.35 UMR - ALL PLANS UMR - ALL PLANS 685.3 70 999999999 592.78 949.63 percent of total billed charges STENT PERCUFLEX GLIDEX 8F X 24 48714182_1 CDM 0272 RC inpatient 979 636.35 SIHO - ALL PLANS SIHO - ALL PLANS 881.1 90 999999999 592.78 949.63 percent of total billed charges STENT PERCUFLEX GLIDEX 8F X 24 48714182_1 CDM 0272 RC inpatient 979 636.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 592.78 60.55 999999999 592.78 949.63 percent of total billed charges STENT PERCUFLEX GLIDEX 8F X 24 48714182_1 CDM 0272 RC inpatient 979 636.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 592.78 949.63 STENT PERCUFLEX GLIDEX 8F X 24 48714182_1 CDM 0272 RC inpatient 979 636.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 592.78 949.63 STENT PERCUFLEX GLIDEX 8F X 24 48714182_1 CDM 0272 RC inpatient 979 636.35 ANTHEM HMO ANTHEM HMO 999999999 592.78 949.63 STENT PERCUFLEX GLIDEX 8F X 24 48714182_1 CDM 0272 RC inpatient 979 636.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 661.8 67.6 999999999 592.78 949.63 percent of total billed charges STENT PERCUFLEX GLIDEX 8F X 24 48714182_1 CDM 0272 RC inpatient 979 636.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 592.78 949.63 STENT PERCUFLEX GLIDEX 8F X 24 48714182_1 CDM 0272 RC inpatient 979 636.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 592.78 949.63 STENT PERCUFLEX 8FR X 26CM 48714183_1 CDM 0272 RC inpatient 736 478.4 AETNA AETNA 581.44 79 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 26CM 48714183_1 CDM 0272 RC inpatient 736 478.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 478.4 65 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 26CM 48714183_1 CDM 0272 RC inpatient 736 478.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 713.92 97 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 26CM 48714183_1 CDM 0272 RC inpatient 736 478.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 507.84 69 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 26CM 48714183_1 CDM 0272 RC inpatient 736 478.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 574.08 78 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 26CM 48714183_1 CDM 0272 RC inpatient 736 478.4 SIHO - ALL PLANS SIHO - ALL PLANS 662.4 90 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 26CM 48714183_1 CDM 0272 RC inpatient 736 478.4 UMR - ALL PLANS UMR - ALL PLANS 515.2 70 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 26CM 48714183_1 CDM 0272 RC inpatient 736 478.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 445.65 60.55 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 26CM 48714183_1 CDM 0272 RC inpatient 736 478.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 445.65 713.92 STENT PERCUFLEX 8FR X 26CM 48714183_1 CDM 0272 RC inpatient 736 478.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 445.65 713.92 STENT PERCUFLEX 8FR X 26CM 48714183_1 CDM 0272 RC inpatient 736 478.4 ANTHEM HMO ANTHEM HMO 999999999 445.65 713.92 STENT PERCUFLEX 8FR X 26CM 48714183_1 CDM 0272 RC inpatient 736 478.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 497.54 67.6 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 26CM 48714183_1 CDM 0272 RC inpatient 736 478.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 445.65 713.92 STENT PERCUFLEX 8FR X 26CM 48714183_1 CDM 0272 RC inpatient 736 478.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 445.65 713.92 STENT PERCUFLEX 8FR X 24CM 48714184_1 CDM 0272 RC inpatient 736 478.4 AETNA AETNA 581.44 79 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 24CM 48714184_1 CDM 0272 RC inpatient 736 478.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 478.4 65 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 24CM 48714184_1 CDM 0272 RC inpatient 736 478.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 713.92 97 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 24CM 48714184_1 CDM 0272 RC inpatient 736 478.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 507.84 69 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 24CM 48714184_1 CDM 0272 RC inpatient 736 478.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 574.08 78 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 24CM 48714184_1 CDM 0272 RC inpatient 736 478.4 SIHO - ALL PLANS SIHO - ALL PLANS 662.4 90 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 24CM 48714184_1 CDM 0272 RC inpatient 736 478.4 UMR - ALL PLANS UMR - ALL PLANS 515.2 70 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 24CM 48714184_1 CDM 0272 RC inpatient 736 478.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 445.65 60.55 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 24CM 48714184_1 CDM 0272 RC inpatient 736 478.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 445.65 713.92 STENT PERCUFLEX 8FR X 24CM 48714184_1 CDM 0272 RC inpatient 736 478.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 445.65 713.92 STENT PERCUFLEX 8FR X 24CM 48714184_1 CDM 0272 RC inpatient 736 478.4 ANTHEM HMO ANTHEM HMO 999999999 445.65 713.92 STENT PERCUFLEX 8FR X 24CM 48714184_1 CDM 0272 RC inpatient 736 478.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 497.54 67.6 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 24CM 48714184_1 CDM 0272 RC inpatient 736 478.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 445.65 713.92 STENT PERCUFLEX 8FR X 24CM 48714184_1 CDM 0272 RC inpatient 736 478.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 445.65 713.92 STENT PERCUFLEX 8FR X 28CM 48714185_1 CDM 0272 RC inpatient 736 478.4 AETNA AETNA 581.44 79 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 28CM 48714185_1 CDM 0272 RC inpatient 736 478.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 478.4 65 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 28CM 48714185_1 CDM 0272 RC inpatient 736 478.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 713.92 97 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 28CM 48714185_1 CDM 0272 RC inpatient 736 478.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 507.84 69 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 28CM 48714185_1 CDM 0272 RC inpatient 736 478.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 574.08 78 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 28CM 48714185_1 CDM 0272 RC inpatient 736 478.4 SIHO - ALL PLANS SIHO - ALL PLANS 662.4 90 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 28CM 48714185_1 CDM 0272 RC inpatient 736 478.4 UMR - ALL PLANS UMR - ALL PLANS 515.2 70 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 28CM 48714185_1 CDM 0272 RC inpatient 736 478.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 445.65 60.55 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 28CM 48714185_1 CDM 0272 RC inpatient 736 478.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 445.65 713.92 STENT PERCUFLEX 8FR X 28CM 48714185_1 CDM 0272 RC inpatient 736 478.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 445.65 713.92 STENT PERCUFLEX 8FR X 28CM 48714185_1 CDM 0272 RC inpatient 736 478.4 ANTHEM HMO ANTHEM HMO 999999999 445.65 713.92 STENT PERCUFLEX 8FR X 28CM 48714185_1 CDM 0272 RC inpatient 736 478.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 497.54 67.6 999999999 445.65 713.92 percent of total billed charges STENT PERCUFLEX 8FR X 28CM 48714185_1 CDM 0272 RC inpatient 736 478.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 445.65 713.92 STENT PERCUFLEX 8FR X 28CM 48714185_1 CDM 0272 RC inpatient 736 478.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 445.65 713.92 URETERAL STENT SYSTEM 24-552 48714186_1 CDM 0272 RC inpatient 979 636.35 AETNA AETNA 773.41 79 999999999 592.78 949.63 percent of total billed charges URETERAL STENT SYSTEM 24-552 48714186_1 CDM 0272 RC inpatient 979 636.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 636.35 65 999999999 592.78 949.63 percent of total billed charges URETERAL STENT SYSTEM 24-552 48714186_1 CDM 0272 RC inpatient 979 636.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 949.63 97 999999999 592.78 949.63 percent of total billed charges URETERAL STENT SYSTEM 24-552 48714186_1 CDM 0272 RC inpatient 979 636.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 675.51 69 999999999 592.78 949.63 percent of total billed charges URETERAL STENT SYSTEM 24-552 48714186_1 CDM 0272 RC inpatient 979 636.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 763.62 78 999999999 592.78 949.63 percent of total billed charges URETERAL STENT SYSTEM 24-552 48714186_1 CDM 0272 RC inpatient 979 636.35 SIHO - ALL PLANS SIHO - ALL PLANS 881.1 90 999999999 592.78 949.63 percent of total billed charges URETERAL STENT SYSTEM 24-552 48714186_1 CDM 0272 RC inpatient 979 636.35 UMR - ALL PLANS UMR - ALL PLANS 685.3 70 999999999 592.78 949.63 percent of total billed charges URETERAL STENT SYSTEM 24-552 48714186_1 CDM 0272 RC inpatient 979 636.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 592.78 60.55 999999999 592.78 949.63 percent of total billed charges URETERAL STENT SYSTEM 24-552 48714186_1 CDM 0272 RC inpatient 979 636.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 592.78 949.63 URETERAL STENT SYSTEM 24-552 48714186_1 CDM 0272 RC inpatient 979 636.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 592.78 949.63 URETERAL STENT SYSTEM 24-552 48714186_1 CDM 0272 RC inpatient 979 636.35 ANTHEM HMO ANTHEM HMO 999999999 592.78 949.63 URETERAL STENT SYSTEM 24-552 48714186_1 CDM 0272 RC inpatient 979 636.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 661.8 67.6 999999999 592.78 949.63 percent of total billed charges URETERAL STENT SYSTEM 24-552 48714186_1 CDM 0272 RC inpatient 979 636.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 592.78 949.63 URETERAL STENT SYSTEM 24-552 48714186_1 CDM 0272 RC inpatient 979 636.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 592.78 949.63 ELECTRODE BLADE 2.75 E1450X 48714187_1 CDM 0272 RC inpatient 362 235.3 AETNA AETNA 285.98 79 999999999 219.19 351.14 percent of total billed charges ELECTRODE BLADE 2.75 E1450X 48714187_1 CDM 0272 RC inpatient 362 235.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 235.3 65 999999999 219.19 351.14 percent of total billed charges ELECTRODE BLADE 2.75 E1450X 48714187_1 CDM 0272 RC inpatient 362 235.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 351.14 97 999999999 219.19 351.14 percent of total billed charges ELECTRODE BLADE 2.75 E1450X 48714187_1 CDM 0272 RC inpatient 362 235.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 249.78 69 999999999 219.19 351.14 percent of total billed charges ELECTRODE BLADE 2.75 E1450X 48714187_1 CDM 0272 RC inpatient 362 235.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 282.36 78 999999999 219.19 351.14 percent of total billed charges ELECTRODE BLADE 2.75 E1450X 48714187_1 CDM 0272 RC inpatient 362 235.3 SIHO - ALL PLANS SIHO - ALL PLANS 325.8 90 999999999 219.19 351.14 percent of total billed charges ELECTRODE BLADE 2.75 E1450X 48714187_1 CDM 0272 RC inpatient 362 235.3 UMR - ALL PLANS UMR - ALL PLANS 253.4 70 999999999 219.19 351.14 percent of total billed charges ELECTRODE BLADE 2.75 E1450X 48714187_1 CDM 0272 RC inpatient 362 235.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 219.19 60.55 999999999 219.19 351.14 percent of total billed charges ELECTRODE BLADE 2.75 E1450X 48714187_1 CDM 0272 RC inpatient 362 235.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 219.19 351.14 ELECTRODE BLADE 2.75 E1450X 48714187_1 CDM 0272 RC inpatient 362 235.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 219.19 351.14 ELECTRODE BLADE 2.75 E1450X 48714187_1 CDM 0272 RC inpatient 362 235.3 ANTHEM HMO ANTHEM HMO 999999999 219.19 351.14 ELECTRODE BLADE 2.75 E1450X 48714187_1 CDM 0272 RC inpatient 362 235.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 244.71 67.6 999999999 219.19 351.14 percent of total billed charges ELECTRODE BLADE 2.75 E1450X 48714187_1 CDM 0272 RC inpatient 362 235.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 219.19 351.14 ELECTRODE BLADE 2.75 E1450X 48714187_1 CDM 0272 RC inpatient 362 235.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 219.19 351.14 DRAPE THYROID 76 X 120 089251 48714188_1 CDM 0272 RC inpatient 36 23.4 AETNA AETNA 28.44 79 999999999 21.8 34.92 percent of total billed charges DRAPE THYROID 76 X 120 089251 48714188_1 CDM 0272 RC inpatient 36 23.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 23.4 65 999999999 21.8 34.92 percent of total billed charges DRAPE THYROID 76 X 120 089251 48714188_1 CDM 0272 RC inpatient 36 23.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34.92 97 999999999 21.8 34.92 percent of total billed charges DRAPE THYROID 76 X 120 089251 48714188_1 CDM 0272 RC inpatient 36 23.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.84 69 999999999 21.8 34.92 percent of total billed charges DRAPE THYROID 76 X 120 089251 48714188_1 CDM 0272 RC inpatient 36 23.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.08 78 999999999 21.8 34.92 percent of total billed charges DRAPE THYROID 76 X 120 089251 48714188_1 CDM 0272 RC inpatient 36 23.4 SIHO - ALL PLANS SIHO - ALL PLANS 32.4 90 999999999 21.8 34.92 percent of total billed charges DRAPE THYROID 76 X 120 089251 48714188_1 CDM 0272 RC inpatient 36 23.4 UMR - ALL PLANS UMR - ALL PLANS 25.2 70 999999999 21.8 34.92 percent of total billed charges DRAPE THYROID 76 X 120 089251 48714188_1 CDM 0272 RC inpatient 36 23.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.8 60.55 999999999 21.8 34.92 percent of total billed charges DRAPE THYROID 76 X 120 089251 48714188_1 CDM 0272 RC inpatient 36 23.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.8 34.92 DRAPE THYROID 76 X 120 089251 48714188_1 CDM 0272 RC inpatient 36 23.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.8 34.92 DRAPE THYROID 76 X 120 089251 48714188_1 CDM 0272 RC inpatient 36 23.4 ANTHEM HMO ANTHEM HMO 999999999 21.8 34.92 DRAPE THYROID 76 X 120 089251 48714188_1 CDM 0272 RC inpatient 36 23.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 24.34 67.6 999999999 21.8 34.92 percent of total billed charges DRAPE THYROID 76 X 120 089251 48714188_1 CDM 0272 RC inpatient 36 23.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.8 34.92 DRAPE THYROID 76 X 120 089251 48714188_1 CDM 0272 RC inpatient 36 23.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.8 34.92 CATHETER BALLOON IAB 7.5 X 34C 48714189_1 CDM 0278 RC inpatient 4709 3060.85 AETNA AETNA 3720.11 79 999999999 2851.3 4567.73 percent of total billed charges CATHETER BALLOON IAB 7.5 X 34C 48714189_1 CDM 0278 RC inpatient 4709 3060.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 3060.85 65 999999999 2851.3 4567.73 percent of total billed charges CATHETER BALLOON IAB 7.5 X 34C 48714189_1 CDM 0278 RC inpatient 4709 3060.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4567.73 97 999999999 2851.3 4567.73 percent of total billed charges CATHETER BALLOON IAB 7.5 X 34C 48714189_1 CDM 0278 RC inpatient 4709 3060.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 3249.21 69 999999999 2851.3 4567.73 percent of total billed charges CATHETER BALLOON IAB 7.5 X 34C 48714189_1 CDM 0278 RC inpatient 4709 3060.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 3673.02 78 999999999 2851.3 4567.73 percent of total billed charges CATHETER BALLOON IAB 7.5 X 34C 48714189_1 CDM 0278 RC inpatient 4709 3060.85 SIHO - ALL PLANS SIHO - ALL PLANS 4238.1 90 999999999 2851.3 4567.73 percent of total billed charges CATHETER BALLOON IAB 7.5 X 34C 48714189_1 CDM 0278 RC inpatient 4709 3060.85 UMR - ALL PLANS UMR - ALL PLANS 3296.3 70 999999999 2851.3 4567.73 percent of total billed charges CATHETER BALLOON IAB 7.5 X 34C 48714189_1 CDM 0278 RC inpatient 4709 3060.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2851.3 60.55 999999999 2851.3 4567.73 percent of total billed charges CATHETER BALLOON IAB 7.5 X 34C 48714189_1 CDM 0278 RC inpatient 4709 3060.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2851.3 4567.73 CATHETER BALLOON IAB 7.5 X 34C 48714189_1 CDM 0278 RC inpatient 4709 3060.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2851.3 4567.73 CATHETER BALLOON IAB 7.5 X 34C 48714189_1 CDM 0278 RC inpatient 4709 3060.85 ANTHEM HMO ANTHEM HMO 999999999 2851.3 4567.73 CATHETER BALLOON IAB 7.5 X 34C 48714189_1 CDM 0278 RC inpatient 4709 3060.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 3183.28 67.6 999999999 2851.3 4567.73 percent of total billed charges CATHETER BALLOON IAB 7.5 X 34C 48714189_1 CDM 0278 RC inpatient 4709 3060.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2851.3 4567.73 CATHETER BALLOON IAB 7.5 X 34C 48714189_1 CDM 0278 RC inpatient 4709 3060.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 2851.3 4567.73 CATHETER BALLOON IAB 7.5 X 40 48714190_1 CDM 0278 RC inpatient 4709 3060.85 AETNA AETNA 3720.11 79 999999999 2851.3 4567.73 percent of total billed charges CATHETER BALLOON IAB 7.5 X 40 48714190_1 CDM 0278 RC inpatient 4709 3060.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 3060.85 65 999999999 2851.3 4567.73 percent of total billed charges CATHETER BALLOON IAB 7.5 X 40 48714190_1 CDM 0278 RC inpatient 4709 3060.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4567.73 97 999999999 2851.3 4567.73 percent of total billed charges CATHETER BALLOON IAB 7.5 X 40 48714190_1 CDM 0278 RC inpatient 4709 3060.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 3249.21 69 999999999 2851.3 4567.73 percent of total billed charges CATHETER BALLOON IAB 7.5 X 40 48714190_1 CDM 0278 RC inpatient 4709 3060.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 3673.02 78 999999999 2851.3 4567.73 percent of total billed charges CATHETER BALLOON IAB 7.5 X 40 48714190_1 CDM 0278 RC inpatient 4709 3060.85 SIHO - ALL PLANS SIHO - ALL PLANS 4238.1 90 999999999 2851.3 4567.73 percent of total billed charges CATHETER BALLOON IAB 7.5 X 40 48714190_1 CDM 0278 RC inpatient 4709 3060.85 UMR - ALL PLANS UMR - ALL PLANS 3296.3 70 999999999 2851.3 4567.73 percent of total billed charges CATHETER BALLOON IAB 7.5 X 40 48714190_1 CDM 0278 RC inpatient 4709 3060.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2851.3 60.55 999999999 2851.3 4567.73 percent of total billed charges CATHETER BALLOON IAB 7.5 X 40 48714190_1 CDM 0278 RC inpatient 4709 3060.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2851.3 4567.73 CATHETER BALLOON IAB 7.5 X 40 48714190_1 CDM 0278 RC inpatient 4709 3060.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2851.3 4567.73 CATHETER BALLOON IAB 7.5 X 40 48714190_1 CDM 0278 RC inpatient 4709 3060.85 ANTHEM HMO ANTHEM HMO 999999999 2851.3 4567.73 CATHETER BALLOON IAB 7.5 X 40 48714190_1 CDM 0278 RC inpatient 4709 3060.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 3183.28 67.6 999999999 2851.3 4567.73 percent of total billed charges CATHETER BALLOON IAB 7.5 X 40 48714190_1 CDM 0278 RC inpatient 4709 3060.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2851.3 4567.73 CATHETER BALLOON IAB 7.5 X 40 48714190_1 CDM 0278 RC inpatient 4709 3060.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 2851.3 4567.73 PACK ANGIO TRAY DYNJ37047 48714191_1 CDM 0272 RC inpatient 375 243.75 AETNA AETNA 296.25 79 999999999 227.06 363.75 percent of total billed charges PACK ANGIO TRAY DYNJ37047 48714191_1 CDM 0272 RC inpatient 375 243.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 243.75 65 999999999 227.06 363.75 percent of total billed charges PACK ANGIO TRAY DYNJ37047 48714191_1 CDM 0272 RC inpatient 375 243.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 363.75 97 999999999 227.06 363.75 percent of total billed charges PACK ANGIO TRAY DYNJ37047 48714191_1 CDM 0272 RC inpatient 375 243.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 258.75 69 999999999 227.06 363.75 percent of total billed charges PACK ANGIO TRAY DYNJ37047 48714191_1 CDM 0272 RC inpatient 375 243.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 292.5 78 999999999 227.06 363.75 percent of total billed charges PACK ANGIO TRAY DYNJ37047 48714191_1 CDM 0272 RC inpatient 375 243.75 SIHO - ALL PLANS SIHO - ALL PLANS 337.5 90 999999999 227.06 363.75 percent of total billed charges PACK ANGIO TRAY DYNJ37047 48714191_1 CDM 0272 RC inpatient 375 243.75 UMR - ALL PLANS UMR - ALL PLANS 262.5 70 999999999 227.06 363.75 percent of total billed charges PACK ANGIO TRAY DYNJ37047 48714191_1 CDM 0272 RC inpatient 375 243.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 227.06 60.55 999999999 227.06 363.75 percent of total billed charges PACK ANGIO TRAY DYNJ37047 48714191_1 CDM 0272 RC inpatient 375 243.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 227.06 363.75 PACK ANGIO TRAY DYNJ37047 48714191_1 CDM 0272 RC inpatient 375 243.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 227.06 363.75 PACK ANGIO TRAY DYNJ37047 48714191_1 CDM 0272 RC inpatient 375 243.75 ANTHEM HMO ANTHEM HMO 999999999 227.06 363.75 PACK ANGIO TRAY DYNJ37047 48714191_1 CDM 0272 RC inpatient 375 243.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 253.5 67.6 999999999 227.06 363.75 percent of total billed charges PACK ANGIO TRAY DYNJ37047 48714191_1 CDM 0272 RC inpatient 375 243.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 227.06 363.75 PACK ANGIO TRAY DYNJ37047 48714191_1 CDM 0272 RC inpatient 375 243.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 227.06 363.75 VENA CAVA FILTER 48714192_1 CDM 0278 RC C1880 HCPCS inpatient 5947 3865.55 AETNA AETNA 4698.13 79 999999999 3600.91 5768.59 percent of total billed charges VENA CAVA FILTER 48714192_1 CDM 0278 RC C1880 HCPCS inpatient 5947 3865.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 3865.55 65 999999999 3600.91 5768.59 percent of total billed charges VENA CAVA FILTER 48714192_1 CDM 0278 RC C1880 HCPCS inpatient 5947 3865.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5768.59 97 999999999 3600.91 5768.59 percent of total billed charges VENA CAVA FILTER 48714192_1 CDM 0278 RC C1880 HCPCS inpatient 5947 3865.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 4103.43 69 999999999 3600.91 5768.59 percent of total billed charges VENA CAVA FILTER 48714192_1 CDM 0278 RC C1880 HCPCS inpatient 5947 3865.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 4638.66 78 999999999 3600.91 5768.59 percent of total billed charges VENA CAVA FILTER 48714192_1 CDM 0278 RC C1880 HCPCS inpatient 5947 3865.55 SIHO - ALL PLANS SIHO - ALL PLANS 5352.3 90 999999999 3600.91 5768.59 percent of total billed charges VENA CAVA FILTER 48714192_1 CDM 0278 RC C1880 HCPCS inpatient 5947 3865.55 UMR - ALL PLANS UMR - ALL PLANS 4162.9 70 999999999 3600.91 5768.59 percent of total billed charges VENA CAVA FILTER 48714192_1 CDM 0278 RC C1880 HCPCS inpatient 5947 3865.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3600.91 60.55 999999999 3600.91 5768.59 percent of total billed charges VENA CAVA FILTER 48714192_1 CDM 0278 RC C1880 HCPCS inpatient 5947 3865.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3600.91 5768.59 VENA CAVA FILTER 48714192_1 CDM 0278 RC C1880 HCPCS inpatient 5947 3865.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3600.91 5768.59 VENA CAVA FILTER 48714192_1 CDM 0278 RC C1880 HCPCS inpatient 5947 3865.55 ANTHEM HMO ANTHEM HMO 999999999 3600.91 5768.59 VENA CAVA FILTER 48714192_1 CDM 0278 RC C1880 HCPCS inpatient 5947 3865.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 4020.17 67.6 999999999 3600.91 5768.59 percent of total billed charges VENA CAVA FILTER 48714192_1 CDM 0278 RC C1880 HCPCS inpatient 5947 3865.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3600.91 5768.59 VENA CAVA FILTER 48714192_1 CDM 0278 RC C1880 HCPCS inpatient 5947 3865.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 3600.91 5768.59 GUIDEWIRE BMW .014 X 300CM 48714193_1 CDM 0272 RC inpatient 621 403.65 AETNA AETNA 490.59 79 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE BMW .014 X 300CM 48714193_1 CDM 0272 RC inpatient 621 403.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 403.65 65 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE BMW .014 X 300CM 48714193_1 CDM 0272 RC inpatient 621 403.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 602.37 97 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE BMW .014 X 300CM 48714193_1 CDM 0272 RC inpatient 621 403.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 428.49 69 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE BMW .014 X 300CM 48714193_1 CDM 0272 RC inpatient 621 403.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 484.38 78 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE BMW .014 X 300CM 48714193_1 CDM 0272 RC inpatient 621 403.65 SIHO - ALL PLANS SIHO - ALL PLANS 558.9 90 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE BMW .014 X 300CM 48714193_1 CDM 0272 RC inpatient 621 403.65 UMR - ALL PLANS UMR - ALL PLANS 434.7 70 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE BMW .014 X 300CM 48714193_1 CDM 0272 RC inpatient 621 403.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 376.02 60.55 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE BMW .014 X 300CM 48714193_1 CDM 0272 RC inpatient 621 403.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 376.02 602.37 GUIDEWIRE BMW .014 X 300CM 48714193_1 CDM 0272 RC inpatient 621 403.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 376.02 602.37 GUIDEWIRE BMW .014 X 300CM 48714193_1 CDM 0272 RC inpatient 621 403.65 ANTHEM HMO ANTHEM HMO 999999999 376.02 602.37 GUIDEWIRE BMW .014 X 300CM 48714193_1 CDM 0272 RC inpatient 621 403.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 419.8 67.6 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE BMW .014 X 300CM 48714193_1 CDM 0272 RC inpatient 621 403.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 376.02 602.37 GUIDEWIRE BMW .014 X 300CM 48714193_1 CDM 0272 RC inpatient 621 403.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 376.02 602.37 GUIDEWIRE WHISPER MS 0.014X300 48714194_1 CDM 0272 RC inpatient 621 403.65 AETNA AETNA 490.59 79 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE WHISPER MS 0.014X300 48714194_1 CDM 0272 RC inpatient 621 403.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 403.65 65 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE WHISPER MS 0.014X300 48714194_1 CDM 0272 RC inpatient 621 403.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 602.37 97 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE WHISPER MS 0.014X300 48714194_1 CDM 0272 RC inpatient 621 403.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 428.49 69 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE WHISPER MS 0.014X300 48714194_1 CDM 0272 RC inpatient 621 403.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 484.38 78 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE WHISPER MS 0.014X300 48714194_1 CDM 0272 RC inpatient 621 403.65 SIHO - ALL PLANS SIHO - ALL PLANS 558.9 90 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE WHISPER MS 0.014X300 48714194_1 CDM 0272 RC inpatient 621 403.65 UMR - ALL PLANS UMR - ALL PLANS 434.7 70 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE WHISPER MS 0.014X300 48714194_1 CDM 0272 RC inpatient 621 403.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 376.02 60.55 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE WHISPER MS 0.014X300 48714194_1 CDM 0272 RC inpatient 621 403.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 376.02 602.37 GUIDEWIRE WHISPER MS 0.014X300 48714194_1 CDM 0272 RC inpatient 621 403.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 376.02 602.37 GUIDEWIRE WHISPER MS 0.014X300 48714194_1 CDM 0272 RC inpatient 621 403.65 ANTHEM HMO ANTHEM HMO 999999999 376.02 602.37 GUIDEWIRE WHISPER MS 0.014X300 48714194_1 CDM 0272 RC inpatient 621 403.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 419.8 67.6 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE WHISPER MS 0.014X300 48714194_1 CDM 0272 RC inpatient 621 403.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 376.02 602.37 GUIDEWIRE WHISPER MS 0.014X300 48714194_1 CDM 0272 RC inpatient 621 403.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 376.02 602.37 GUIDE WIRE 48714195_1 CDM 0272 RC C1769 HCPCS inpatient 621 403.65 AETNA AETNA 490.59 79 999999999 376.02 602.37 percent of total billed charges GUIDE WIRE 48714195_1 CDM 0272 RC C1769 HCPCS inpatient 621 403.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 403.65 65 999999999 376.02 602.37 percent of total billed charges GUIDE WIRE 48714195_1 CDM 0272 RC C1769 HCPCS inpatient 621 403.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 602.37 97 999999999 376.02 602.37 percent of total billed charges GUIDE WIRE 48714195_1 CDM 0272 RC C1769 HCPCS inpatient 621 403.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 428.49 69 999999999 376.02 602.37 percent of total billed charges GUIDE WIRE 48714195_1 CDM 0272 RC C1769 HCPCS inpatient 621 403.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 484.38 78 999999999 376.02 602.37 percent of total billed charges GUIDE WIRE 48714195_1 CDM 0272 RC C1769 HCPCS inpatient 621 403.65 SIHO - ALL PLANS SIHO - ALL PLANS 558.9 90 999999999 376.02 602.37 percent of total billed charges GUIDE WIRE 48714195_1 CDM 0272 RC C1769 HCPCS inpatient 621 403.65 UMR - ALL PLANS UMR - ALL PLANS 434.7 70 999999999 376.02 602.37 percent of total billed charges GUIDE WIRE 48714195_1 CDM 0272 RC C1769 HCPCS inpatient 621 403.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 376.02 60.55 999999999 376.02 602.37 percent of total billed charges GUIDE WIRE 48714195_1 CDM 0272 RC C1769 HCPCS inpatient 621 403.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 376.02 602.37 GUIDE WIRE 48714195_1 CDM 0272 RC C1769 HCPCS inpatient 621 403.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 376.02 602.37 GUIDE WIRE 48714195_1 CDM 0272 RC C1769 HCPCS inpatient 621 403.65 ANTHEM HMO ANTHEM HMO 999999999 376.02 602.37 GUIDE WIRE 48714195_1 CDM 0272 RC C1769 HCPCS inpatient 621 403.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 419.8 67.6 999999999 376.02 602.37 percent of total billed charges GUIDE WIRE 48714195_1 CDM 0272 RC C1769 HCPCS inpatient 621 403.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 376.02 602.37 GUIDE WIRE 48714195_1 CDM 0272 RC C1769 HCPCS inpatient 621 403.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 376.02 602.37 GUIDEWIRE WHISPER MS 0.014X190 48714196_1 CDM 0272 RC inpatient 621 403.65 AETNA AETNA 490.59 79 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE WHISPER MS 0.014X190 48714196_1 CDM 0272 RC inpatient 621 403.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 403.65 65 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE WHISPER MS 0.014X190 48714196_1 CDM 0272 RC inpatient 621 403.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 602.37 97 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE WHISPER MS 0.014X190 48714196_1 CDM 0272 RC inpatient 621 403.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 428.49 69 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE WHISPER MS 0.014X190 48714196_1 CDM 0272 RC inpatient 621 403.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 484.38 78 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE WHISPER MS 0.014X190 48714196_1 CDM 0272 RC inpatient 621 403.65 SIHO - ALL PLANS SIHO - ALL PLANS 558.9 90 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE WHISPER MS 0.014X190 48714196_1 CDM 0272 RC inpatient 621 403.65 UMR - ALL PLANS UMR - ALL PLANS 434.7 70 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE WHISPER MS 0.014X190 48714196_1 CDM 0272 RC inpatient 621 403.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 376.02 60.55 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE WHISPER MS 0.014X190 48714196_1 CDM 0272 RC inpatient 621 403.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 376.02 602.37 GUIDEWIRE WHISPER MS 0.014X190 48714196_1 CDM 0272 RC inpatient 621 403.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 376.02 602.37 GUIDEWIRE WHISPER MS 0.014X190 48714196_1 CDM 0272 RC inpatient 621 403.65 ANTHEM HMO ANTHEM HMO 999999999 376.02 602.37 GUIDEWIRE WHISPER MS 0.014X190 48714196_1 CDM 0272 RC inpatient 621 403.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 419.8 67.6 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE WHISPER MS 0.014X190 48714196_1 CDM 0272 RC inpatient 621 403.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 376.02 602.37 GUIDEWIRE WHISPER MS 0.014X190 48714196_1 CDM 0272 RC inpatient 621 403.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 376.02 602.37 GUIDE WIRE 48714197_1 CDM 0272 RC C1769 HCPCS inpatient 504 327.6 AETNA AETNA 398.16 79 999999999 305.17 488.88 percent of total billed charges GUIDE WIRE 48714197_1 CDM 0272 RC C1769 HCPCS inpatient 504 327.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 327.6 65 999999999 305.17 488.88 percent of total billed charges GUIDE WIRE 48714197_1 CDM 0272 RC C1769 HCPCS inpatient 504 327.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 488.88 97 999999999 305.17 488.88 percent of total billed charges GUIDE WIRE 48714197_1 CDM 0272 RC C1769 HCPCS inpatient 504 327.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 347.76 69 999999999 305.17 488.88 percent of total billed charges GUIDE WIRE 48714197_1 CDM 0272 RC C1769 HCPCS inpatient 504 327.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 393.12 78 999999999 305.17 488.88 percent of total billed charges GUIDE WIRE 48714197_1 CDM 0272 RC C1769 HCPCS inpatient 504 327.6 SIHO - ALL PLANS SIHO - ALL PLANS 453.6 90 999999999 305.17 488.88 percent of total billed charges GUIDE WIRE 48714197_1 CDM 0272 RC C1769 HCPCS inpatient 504 327.6 UMR - ALL PLANS UMR - ALL PLANS 352.8 70 999999999 305.17 488.88 percent of total billed charges GUIDE WIRE 48714197_1 CDM 0272 RC C1769 HCPCS inpatient 504 327.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 305.17 60.55 999999999 305.17 488.88 percent of total billed charges GUIDE WIRE 48714197_1 CDM 0272 RC C1769 HCPCS inpatient 504 327.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 305.17 488.88 GUIDE WIRE 48714197_1 CDM 0272 RC C1769 HCPCS inpatient 504 327.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 305.17 488.88 GUIDE WIRE 48714197_1 CDM 0272 RC C1769 HCPCS inpatient 504 327.6 ANTHEM HMO ANTHEM HMO 999999999 305.17 488.88 GUIDE WIRE 48714197_1 CDM 0272 RC C1769 HCPCS inpatient 504 327.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 340.7 67.6 999999999 305.17 488.88 percent of total billed charges GUIDE WIRE 48714197_1 CDM 0272 RC C1769 HCPCS inpatient 504 327.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 305.17 488.88 GUIDE WIRE 48714197_1 CDM 0272 RC C1769 HCPCS inpatient 504 327.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 305.17 488.88 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714198_1 CDM 0278 RC C1725 HCPCS inpatient 4193 2725.45 AETNA AETNA 3312.47 79 999999999 2538.86 4067.21 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714198_1 CDM 0278 RC C1725 HCPCS inpatient 4193 2725.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 2725.45 65 999999999 2538.86 4067.21 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714198_1 CDM 0278 RC C1725 HCPCS inpatient 4193 2725.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4067.21 97 999999999 2538.86 4067.21 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714198_1 CDM 0278 RC C1725 HCPCS inpatient 4193 2725.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 2893.17 69 999999999 2538.86 4067.21 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714198_1 CDM 0278 RC C1725 HCPCS inpatient 4193 2725.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 3270.54 78 999999999 2538.86 4067.21 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714198_1 CDM 0278 RC C1725 HCPCS inpatient 4193 2725.45 SIHO - ALL PLANS SIHO - ALL PLANS 3773.7 90 999999999 2538.86 4067.21 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714198_1 CDM 0278 RC C1725 HCPCS inpatient 4193 2725.45 UMR - ALL PLANS UMR - ALL PLANS 2935.1 70 999999999 2538.86 4067.21 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714198_1 CDM 0278 RC C1725 HCPCS inpatient 4193 2725.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2538.86 60.55 999999999 2538.86 4067.21 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714198_1 CDM 0278 RC C1725 HCPCS inpatient 4193 2725.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2538.86 4067.21 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714198_1 CDM 0278 RC C1725 HCPCS inpatient 4193 2725.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2538.86 4067.21 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714198_1 CDM 0278 RC C1725 HCPCS inpatient 4193 2725.45 ANTHEM HMO ANTHEM HMO 999999999 2538.86 4067.21 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714198_1 CDM 0278 RC C1725 HCPCS inpatient 4193 2725.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 2834.47 67.6 999999999 2538.86 4067.21 percent of total billed charges "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714198_1 CDM 0278 RC C1725 HCPCS inpatient 4193 2725.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2538.86 4067.21 "CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY)" 48714198_1 CDM 0278 RC C1725 HCPCS inpatient 4193 2725.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 2538.86 4067.21 BALLOON MR CUTTING 06 X 2.50 48714199_1 CDM 0278 RC inpatient 4193 2725.45 AETNA AETNA 3312.47 79 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 06 X 2.50 48714199_1 CDM 0278 RC inpatient 4193 2725.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 2725.45 65 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 06 X 2.50 48714199_1 CDM 0278 RC inpatient 4193 2725.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4067.21 97 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 06 X 2.50 48714199_1 CDM 0278 RC inpatient 4193 2725.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 2893.17 69 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 06 X 2.50 48714199_1 CDM 0278 RC inpatient 4193 2725.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 3270.54 78 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 06 X 2.50 48714199_1 CDM 0278 RC inpatient 4193 2725.45 SIHO - ALL PLANS SIHO - ALL PLANS 3773.7 90 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 06 X 2.50 48714199_1 CDM 0278 RC inpatient 4193 2725.45 UMR - ALL PLANS UMR - ALL PLANS 2935.1 70 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 06 X 2.50 48714199_1 CDM 0278 RC inpatient 4193 2725.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2538.86 60.55 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 06 X 2.50 48714199_1 CDM 0278 RC inpatient 4193 2725.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2538.86 4067.21 BALLOON MR CUTTING 06 X 2.50 48714199_1 CDM 0278 RC inpatient 4193 2725.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2538.86 4067.21 BALLOON MR CUTTING 06 X 2.50 48714199_1 CDM 0278 RC inpatient 4193 2725.45 ANTHEM HMO ANTHEM HMO 999999999 2538.86 4067.21 BALLOON MR CUTTING 06 X 2.50 48714199_1 CDM 0278 RC inpatient 4193 2725.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 2834.47 67.6 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 06 X 2.50 48714199_1 CDM 0278 RC inpatient 4193 2725.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2538.86 4067.21 BALLOON MR CUTTING 06 X 2.50 48714199_1 CDM 0278 RC inpatient 4193 2725.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 2538.86 4067.21 BALLOON MR CUTTING 10 X 3.00 48714200_1 CDM 0278 RC inpatient 4193 2725.45 AETNA AETNA 3312.47 79 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 3.00 48714200_1 CDM 0278 RC inpatient 4193 2725.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 2725.45 65 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 3.00 48714200_1 CDM 0278 RC inpatient 4193 2725.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4067.21 97 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 3.00 48714200_1 CDM 0278 RC inpatient 4193 2725.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 2893.17 69 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 3.00 48714200_1 CDM 0278 RC inpatient 4193 2725.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 3270.54 78 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 3.00 48714200_1 CDM 0278 RC inpatient 4193 2725.45 SIHO - ALL PLANS SIHO - ALL PLANS 3773.7 90 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 3.00 48714200_1 CDM 0278 RC inpatient 4193 2725.45 UMR - ALL PLANS UMR - ALL PLANS 2935.1 70 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 3.00 48714200_1 CDM 0278 RC inpatient 4193 2725.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2538.86 60.55 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 3.00 48714200_1 CDM 0278 RC inpatient 4193 2725.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2538.86 4067.21 BALLOON MR CUTTING 10 X 3.00 48714200_1 CDM 0278 RC inpatient 4193 2725.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2538.86 4067.21 BALLOON MR CUTTING 10 X 3.00 48714200_1 CDM 0278 RC inpatient 4193 2725.45 ANTHEM HMO ANTHEM HMO 999999999 2538.86 4067.21 BALLOON MR CUTTING 10 X 3.00 48714200_1 CDM 0278 RC inpatient 4193 2725.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 2834.47 67.6 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 3.00 48714200_1 CDM 0278 RC inpatient 4193 2725.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2538.86 4067.21 BALLOON MR CUTTING 10 X 3.00 48714200_1 CDM 0278 RC inpatient 4193 2725.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 2538.86 4067.21 BALLOON MR CUTTING 10 X 4.00 48714201_1 CDM 0278 RC inpatient 4193 2725.45 AETNA AETNA 3312.47 79 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 4.00 48714201_1 CDM 0278 RC inpatient 4193 2725.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 2725.45 65 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 4.00 48714201_1 CDM 0278 RC inpatient 4193 2725.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4067.21 97 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 4.00 48714201_1 CDM 0278 RC inpatient 4193 2725.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 2893.17 69 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 4.00 48714201_1 CDM 0278 RC inpatient 4193 2725.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 3270.54 78 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 4.00 48714201_1 CDM 0278 RC inpatient 4193 2725.45 SIHO - ALL PLANS SIHO - ALL PLANS 3773.7 90 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 4.00 48714201_1 CDM 0278 RC inpatient 4193 2725.45 UMR - ALL PLANS UMR - ALL PLANS 2935.1 70 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 4.00 48714201_1 CDM 0278 RC inpatient 4193 2725.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2538.86 60.55 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 4.00 48714201_1 CDM 0278 RC inpatient 4193 2725.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2538.86 4067.21 BALLOON MR CUTTING 10 X 4.00 48714201_1 CDM 0278 RC inpatient 4193 2725.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2538.86 4067.21 BALLOON MR CUTTING 10 X 4.00 48714201_1 CDM 0278 RC inpatient 4193 2725.45 ANTHEM HMO ANTHEM HMO 999999999 2538.86 4067.21 BALLOON MR CUTTING 10 X 4.00 48714201_1 CDM 0278 RC inpatient 4193 2725.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 2834.47 67.6 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 4.00 48714201_1 CDM 0278 RC inpatient 4193 2725.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2538.86 4067.21 BALLOON MR CUTTING 10 X 4.00 48714201_1 CDM 0278 RC inpatient 4193 2725.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 2538.86 4067.21 BALLOON MR CUTTING 10 X 3.50 48714202_1 CDM 0278 RC inpatient 4193 2725.45 AETNA AETNA 3312.47 79 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 3.50 48714202_1 CDM 0278 RC inpatient 4193 2725.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 2725.45 65 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 3.50 48714202_1 CDM 0278 RC inpatient 4193 2725.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4067.21 97 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 3.50 48714202_1 CDM 0278 RC inpatient 4193 2725.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 2893.17 69 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 3.50 48714202_1 CDM 0278 RC inpatient 4193 2725.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 3270.54 78 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 3.50 48714202_1 CDM 0278 RC inpatient 4193 2725.45 SIHO - ALL PLANS SIHO - ALL PLANS 3773.7 90 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 3.50 48714202_1 CDM 0278 RC inpatient 4193 2725.45 UMR - ALL PLANS UMR - ALL PLANS 2935.1 70 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 3.50 48714202_1 CDM 0278 RC inpatient 4193 2725.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2538.86 60.55 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 3.50 48714202_1 CDM 0278 RC inpatient 4193 2725.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2538.86 4067.21 BALLOON MR CUTTING 10 X 3.50 48714202_1 CDM 0278 RC inpatient 4193 2725.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2538.86 4067.21 BALLOON MR CUTTING 10 X 3.50 48714202_1 CDM 0278 RC inpatient 4193 2725.45 ANTHEM HMO ANTHEM HMO 999999999 2538.86 4067.21 BALLOON MR CUTTING 10 X 3.50 48714202_1 CDM 0278 RC inpatient 4193 2725.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 2834.47 67.6 999999999 2538.86 4067.21 percent of total billed charges BALLOON MR CUTTING 10 X 3.50 48714202_1 CDM 0278 RC inpatient 4193 2725.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2538.86 4067.21 BALLOON MR CUTTING 10 X 3.50 48714202_1 CDM 0278 RC inpatient 4193 2725.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 2538.86 4067.21 GUIDEWIRE BALANCE HW .014 X190 48714203_1 CDM 0272 RC inpatient 621 403.65 AETNA AETNA 490.59 79 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE BALANCE HW .014 X190 48714203_1 CDM 0272 RC inpatient 621 403.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 403.65 65 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE BALANCE HW .014 X190 48714203_1 CDM 0272 RC inpatient 621 403.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 602.37 97 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE BALANCE HW .014 X190 48714203_1 CDM 0272 RC inpatient 621 403.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 428.49 69 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE BALANCE HW .014 X190 48714203_1 CDM 0272 RC inpatient 621 403.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 484.38 78 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE BALANCE HW .014 X190 48714203_1 CDM 0272 RC inpatient 621 403.65 SIHO - ALL PLANS SIHO - ALL PLANS 558.9 90 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE BALANCE HW .014 X190 48714203_1 CDM 0272 RC inpatient 621 403.65 UMR - ALL PLANS UMR - ALL PLANS 434.7 70 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE BALANCE HW .014 X190 48714203_1 CDM 0272 RC inpatient 621 403.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 376.02 60.55 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE BALANCE HW .014 X190 48714203_1 CDM 0272 RC inpatient 621 403.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 376.02 602.37 GUIDEWIRE BALANCE HW .014 X190 48714203_1 CDM 0272 RC inpatient 621 403.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 376.02 602.37 GUIDEWIRE BALANCE HW .014 X190 48714203_1 CDM 0272 RC inpatient 621 403.65 ANTHEM HMO ANTHEM HMO 999999999 376.02 602.37 GUIDEWIRE BALANCE HW .014 X190 48714203_1 CDM 0272 RC inpatient 621 403.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 419.8 67.6 999999999 376.02 602.37 percent of total billed charges GUIDEWIRE BALANCE HW .014 X190 48714203_1 CDM 0272 RC inpatient 621 403.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 376.02 602.37 GUIDEWIRE BALANCE HW .014 X190 48714203_1 CDM 0272 RC inpatient 621 403.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 376.02 602.37 GUIDE WIRE 48714204_1 CDM 0272 RC C1769 HCPCS inpatient 553 359.45 AETNA AETNA 436.87 79 999999999 334.84 536.41 percent of total billed charges GUIDE WIRE 48714204_1 CDM 0272 RC C1769 HCPCS inpatient 553 359.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 359.45 65 999999999 334.84 536.41 percent of total billed charges GUIDE WIRE 48714204_1 CDM 0272 RC C1769 HCPCS inpatient 553 359.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 536.41 97 999999999 334.84 536.41 percent of total billed charges GUIDE WIRE 48714204_1 CDM 0272 RC C1769 HCPCS inpatient 553 359.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 381.57 69 999999999 334.84 536.41 percent of total billed charges GUIDE WIRE 48714204_1 CDM 0272 RC C1769 HCPCS inpatient 553 359.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 431.34 78 999999999 334.84 536.41 percent of total billed charges GUIDE WIRE 48714204_1 CDM 0272 RC C1769 HCPCS inpatient 553 359.45 SIHO - ALL PLANS SIHO - ALL PLANS 497.7 90 999999999 334.84 536.41 percent of total billed charges GUIDE WIRE 48714204_1 CDM 0272 RC C1769 HCPCS inpatient 553 359.45 UMR - ALL PLANS UMR - ALL PLANS 387.1 70 999999999 334.84 536.41 percent of total billed charges GUIDE WIRE 48714204_1 CDM 0272 RC C1769 HCPCS inpatient 553 359.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 334.84 60.55 999999999 334.84 536.41 percent of total billed charges GUIDE WIRE 48714204_1 CDM 0272 RC C1769 HCPCS inpatient 553 359.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 334.84 536.41 GUIDE WIRE 48714204_1 CDM 0272 RC C1769 HCPCS inpatient 553 359.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 334.84 536.41 GUIDE WIRE 48714204_1 CDM 0272 RC C1769 HCPCS inpatient 553 359.45 ANTHEM HMO ANTHEM HMO 999999999 334.84 536.41 GUIDE WIRE 48714204_1 CDM 0272 RC C1769 HCPCS inpatient 553 359.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 373.83 67.6 999999999 334.84 536.41 percent of total billed charges GUIDE WIRE 48714204_1 CDM 0272 RC C1769 HCPCS inpatient 553 359.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 334.84 536.41 GUIDE WIRE 48714204_1 CDM 0272 RC C1769 HCPCS inpatient 553 359.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 334.84 536.41 GUARDWIRE 6FR EXPORT XT CATH 48714205_1 CDM 0272 RC inpatient 3834 2492.1 AETNA AETNA 3028.86 79 999999999 2321.49 3718.98 percent of total billed charges GUARDWIRE 6FR EXPORT XT CATH 48714205_1 CDM 0272 RC inpatient 3834 2492.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 2492.1 65 999999999 2321.49 3718.98 percent of total billed charges GUARDWIRE 6FR EXPORT XT CATH 48714205_1 CDM 0272 RC inpatient 3834 2492.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3718.98 97 999999999 2321.49 3718.98 percent of total billed charges GUARDWIRE 6FR EXPORT XT CATH 48714205_1 CDM 0272 RC inpatient 3834 2492.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 2645.46 69 999999999 2321.49 3718.98 percent of total billed charges GUARDWIRE 6FR EXPORT XT CATH 48714205_1 CDM 0272 RC inpatient 3834 2492.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 2990.52 78 999999999 2321.49 3718.98 percent of total billed charges GUARDWIRE 6FR EXPORT XT CATH 48714205_1 CDM 0272 RC inpatient 3834 2492.1 SIHO - ALL PLANS SIHO - ALL PLANS 3450.6 90 999999999 2321.49 3718.98 percent of total billed charges GUARDWIRE 6FR EXPORT XT CATH 48714205_1 CDM 0272 RC inpatient 3834 2492.1 UMR - ALL PLANS UMR - ALL PLANS 2683.8 70 999999999 2321.49 3718.98 percent of total billed charges GUARDWIRE 6FR EXPORT XT CATH 48714205_1 CDM 0272 RC inpatient 3834 2492.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2321.49 60.55 999999999 2321.49 3718.98 percent of total billed charges GUARDWIRE 6FR EXPORT XT CATH 48714205_1 CDM 0272 RC inpatient 3834 2492.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2321.49 3718.98 GUARDWIRE 6FR EXPORT XT CATH 48714205_1 CDM 0272 RC inpatient 3834 2492.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2321.49 3718.98 GUARDWIRE 6FR EXPORT XT CATH 48714205_1 CDM 0272 RC inpatient 3834 2492.1 ANTHEM HMO ANTHEM HMO 999999999 2321.49 3718.98 GUARDWIRE 6FR EXPORT XT CATH 48714205_1 CDM 0272 RC inpatient 3834 2492.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 2591.78 67.6 999999999 2321.49 3718.98 percent of total billed charges GUARDWIRE 6FR EXPORT XT CATH 48714205_1 CDM 0272 RC inpatient 3834 2492.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2321.49 3718.98 GUARDWIRE 6FR EXPORT XT CATH 48714205_1 CDM 0272 RC inpatient 3834 2492.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 2321.49 3718.98 FILTER WIRE 300CM 48714206_1 CDM 0272 RC inpatient 4310 2801.5 AETNA AETNA 3404.9 79 999999999 2609.71 4180.7 percent of total billed charges FILTER WIRE 300CM 48714206_1 CDM 0272 RC inpatient 4310 2801.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 2801.5 65 999999999 2609.71 4180.7 percent of total billed charges FILTER WIRE 300CM 48714206_1 CDM 0272 RC inpatient 4310 2801.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4180.7 97 999999999 2609.71 4180.7 percent of total billed charges FILTER WIRE 300CM 48714206_1 CDM 0272 RC inpatient 4310 2801.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 2973.9 69 999999999 2609.71 4180.7 percent of total billed charges FILTER WIRE 300CM 48714206_1 CDM 0272 RC inpatient 4310 2801.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 3361.8 78 999999999 2609.71 4180.7 percent of total billed charges FILTER WIRE 300CM 48714206_1 CDM 0272 RC inpatient 4310 2801.5 SIHO - ALL PLANS SIHO - ALL PLANS 3879 90 999999999 2609.71 4180.7 percent of total billed charges FILTER WIRE 300CM 48714206_1 CDM 0272 RC inpatient 4310 2801.5 UMR - ALL PLANS UMR - ALL PLANS 3017 70 999999999 2609.71 4180.7 percent of total billed charges FILTER WIRE 300CM 48714206_1 CDM 0272 RC inpatient 4310 2801.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2609.71 60.55 999999999 2609.71 4180.7 percent of total billed charges FILTER WIRE 300CM 48714206_1 CDM 0272 RC inpatient 4310 2801.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2609.71 4180.7 FILTER WIRE 300CM 48714206_1 CDM 0272 RC inpatient 4310 2801.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2609.71 4180.7 FILTER WIRE 300CM 48714206_1 CDM 0272 RC inpatient 4310 2801.5 ANTHEM HMO ANTHEM HMO 999999999 2609.71 4180.7 FILTER WIRE 300CM 48714206_1 CDM 0272 RC inpatient 4310 2801.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 2913.56 67.6 999999999 2609.71 4180.7 percent of total billed charges FILTER WIRE 300CM 48714206_1 CDM 0272 RC inpatient 4310 2801.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2609.71 4180.7 FILTER WIRE 300CM 48714206_1 CDM 0272 RC inpatient 4310 2801.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 2609.71 4180.7 INTRODUCER SAFESHEATH 7FR X 13 48714207_1 CDM 0272 RC inpatient 359 233.35 AETNA AETNA 283.61 79 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 7FR X 13 48714207_1 CDM 0272 RC inpatient 359 233.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 233.35 65 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 7FR X 13 48714207_1 CDM 0272 RC inpatient 359 233.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 348.23 97 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 7FR X 13 48714207_1 CDM 0272 RC inpatient 359 233.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 247.71 69 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 7FR X 13 48714207_1 CDM 0272 RC inpatient 359 233.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 280.02 78 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 7FR X 13 48714207_1 CDM 0272 RC inpatient 359 233.35 SIHO - ALL PLANS SIHO - ALL PLANS 323.1 90 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 7FR X 13 48714207_1 CDM 0272 RC inpatient 359 233.35 UMR - ALL PLANS UMR - ALL PLANS 251.3 70 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 7FR X 13 48714207_1 CDM 0272 RC inpatient 359 233.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 217.37 60.55 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 7FR X 13 48714207_1 CDM 0272 RC inpatient 359 233.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 217.37 348.23 INTRODUCER SAFESHEATH 7FR X 13 48714207_1 CDM 0272 RC inpatient 359 233.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 217.37 348.23 INTRODUCER SAFESHEATH 7FR X 13 48714207_1 CDM 0272 RC inpatient 359 233.35 ANTHEM HMO ANTHEM HMO 999999999 217.37 348.23 INTRODUCER SAFESHEATH 7FR X 13 48714207_1 CDM 0272 RC inpatient 359 233.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 242.68 67.6 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 7FR X 13 48714207_1 CDM 0272 RC inpatient 359 233.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 217.37 348.23 INTRODUCER SAFESHEATH 7FR X 13 48714207_1 CDM 0272 RC inpatient 359 233.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 217.37 348.23 INTRODUCER SAFESHEATH 9FR X 13 48714208_1 CDM 0272 RC inpatient 315 204.75 AETNA AETNA 248.85 79 999999999 190.73 305.55 percent of total billed charges INTRODUCER SAFESHEATH 9FR X 13 48714208_1 CDM 0272 RC inpatient 315 204.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 204.75 65 999999999 190.73 305.55 percent of total billed charges INTRODUCER SAFESHEATH 9FR X 13 48714208_1 CDM 0272 RC inpatient 315 204.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 305.55 97 999999999 190.73 305.55 percent of total billed charges INTRODUCER SAFESHEATH 9FR X 13 48714208_1 CDM 0272 RC inpatient 315 204.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 217.35 69 999999999 190.73 305.55 percent of total billed charges INTRODUCER SAFESHEATH 9FR X 13 48714208_1 CDM 0272 RC inpatient 315 204.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 245.7 78 999999999 190.73 305.55 percent of total billed charges INTRODUCER SAFESHEATH 9FR X 13 48714208_1 CDM 0272 RC inpatient 315 204.75 SIHO - ALL PLANS SIHO - ALL PLANS 283.5 90 999999999 190.73 305.55 percent of total billed charges INTRODUCER SAFESHEATH 9FR X 13 48714208_1 CDM 0272 RC inpatient 315 204.75 UMR - ALL PLANS UMR - ALL PLANS 220.5 70 999999999 190.73 305.55 percent of total billed charges INTRODUCER SAFESHEATH 9FR X 13 48714208_1 CDM 0272 RC inpatient 315 204.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 190.73 60.55 999999999 190.73 305.55 percent of total billed charges INTRODUCER SAFESHEATH 9FR X 13 48714208_1 CDM 0272 RC inpatient 315 204.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 190.73 305.55 INTRODUCER SAFESHEATH 9FR X 13 48714208_1 CDM 0272 RC inpatient 315 204.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 190.73 305.55 INTRODUCER SAFESHEATH 9FR X 13 48714208_1 CDM 0272 RC inpatient 315 204.75 ANTHEM HMO ANTHEM HMO 999999999 190.73 305.55 INTRODUCER SAFESHEATH 9FR X 13 48714208_1 CDM 0272 RC inpatient 315 204.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 212.94 67.6 999999999 190.73 305.55 percent of total billed charges INTRODUCER SAFESHEATH 9FR X 13 48714208_1 CDM 0272 RC inpatient 315 204.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 190.73 305.55 INTRODUCER SAFESHEATH 9FR X 13 48714208_1 CDM 0272 RC inpatient 315 204.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 190.73 305.55 INTRODUCER SAFESHEATH 7FR X 25 48714209_1 CDM 0272 RC inpatient 359 233.35 AETNA AETNA 283.61 79 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 7FR X 25 48714209_1 CDM 0272 RC inpatient 359 233.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 233.35 65 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 7FR X 25 48714209_1 CDM 0272 RC inpatient 359 233.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 348.23 97 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 7FR X 25 48714209_1 CDM 0272 RC inpatient 359 233.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 247.71 69 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 7FR X 25 48714209_1 CDM 0272 RC inpatient 359 233.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 280.02 78 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 7FR X 25 48714209_1 CDM 0272 RC inpatient 359 233.35 SIHO - ALL PLANS SIHO - ALL PLANS 323.1 90 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 7FR X 25 48714209_1 CDM 0272 RC inpatient 359 233.35 UMR - ALL PLANS UMR - ALL PLANS 251.3 70 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 7FR X 25 48714209_1 CDM 0272 RC inpatient 359 233.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 217.37 60.55 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 7FR X 25 48714209_1 CDM 0272 RC inpatient 359 233.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 217.37 348.23 INTRODUCER SAFESHEATH 7FR X 25 48714209_1 CDM 0272 RC inpatient 359 233.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 217.37 348.23 INTRODUCER SAFESHEATH 7FR X 25 48714209_1 CDM 0272 RC inpatient 359 233.35 ANTHEM HMO ANTHEM HMO 999999999 217.37 348.23 INTRODUCER SAFESHEATH 7FR X 25 48714209_1 CDM 0272 RC inpatient 359 233.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 242.68 67.6 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 7FR X 25 48714209_1 CDM 0272 RC inpatient 359 233.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 217.37 348.23 INTRODUCER SAFESHEATH 7FR X 25 48714209_1 CDM 0272 RC inpatient 359 233.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 217.37 348.23 INTRODUCER SAFESHEATH 9FR X 25 48714210_1 CDM 0272 RC inpatient 359 233.35 AETNA AETNA 283.61 79 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 9FR X 25 48714210_1 CDM 0272 RC inpatient 359 233.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 233.35 65 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 9FR X 25 48714210_1 CDM 0272 RC inpatient 359 233.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 348.23 97 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 9FR X 25 48714210_1 CDM 0272 RC inpatient 359 233.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 247.71 69 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 9FR X 25 48714210_1 CDM 0272 RC inpatient 359 233.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 280.02 78 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 9FR X 25 48714210_1 CDM 0272 RC inpatient 359 233.35 SIHO - ALL PLANS SIHO - ALL PLANS 323.1 90 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 9FR X 25 48714210_1 CDM 0272 RC inpatient 359 233.35 UMR - ALL PLANS UMR - ALL PLANS 251.3 70 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 9FR X 25 48714210_1 CDM 0272 RC inpatient 359 233.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 217.37 60.55 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 9FR X 25 48714210_1 CDM 0272 RC inpatient 359 233.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 217.37 348.23 INTRODUCER SAFESHEATH 9FR X 25 48714210_1 CDM 0272 RC inpatient 359 233.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 217.37 348.23 INTRODUCER SAFESHEATH 9FR X 25 48714210_1 CDM 0272 RC inpatient 359 233.35 ANTHEM HMO ANTHEM HMO 999999999 217.37 348.23 INTRODUCER SAFESHEATH 9FR X 25 48714210_1 CDM 0272 RC inpatient 359 233.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 242.68 67.6 999999999 217.37 348.23 percent of total billed charges INTRODUCER SAFESHEATH 9FR X 25 48714210_1 CDM 0272 RC inpatient 359 233.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 217.37 348.23 INTRODUCER SAFESHEATH 9FR X 25 48714210_1 CDM 0272 RC inpatient 359 233.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 217.37 348.23 TRAY PACEMAKER PHS794190000 48714211_1 CDM 0272 RC inpatient 415 269.75 AETNA AETNA 327.85 79 999999999 251.28 402.55 percent of total billed charges TRAY PACEMAKER PHS794190000 48714211_1 CDM 0272 RC inpatient 415 269.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 269.75 65 999999999 251.28 402.55 percent of total billed charges TRAY PACEMAKER PHS794190000 48714211_1 CDM 0272 RC inpatient 415 269.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 402.55 97 999999999 251.28 402.55 percent of total billed charges TRAY PACEMAKER PHS794190000 48714211_1 CDM 0272 RC inpatient 415 269.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 286.35 69 999999999 251.28 402.55 percent of total billed charges TRAY PACEMAKER PHS794190000 48714211_1 CDM 0272 RC inpatient 415 269.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 323.7 78 999999999 251.28 402.55 percent of total billed charges TRAY PACEMAKER PHS794190000 48714211_1 CDM 0272 RC inpatient 415 269.75 SIHO - ALL PLANS SIHO - ALL PLANS 373.5 90 999999999 251.28 402.55 percent of total billed charges TRAY PACEMAKER PHS794190000 48714211_1 CDM 0272 RC inpatient 415 269.75 UMR - ALL PLANS UMR - ALL PLANS 290.5 70 999999999 251.28 402.55 percent of total billed charges TRAY PACEMAKER PHS794190000 48714211_1 CDM 0272 RC inpatient 415 269.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 251.28 60.55 999999999 251.28 402.55 percent of total billed charges TRAY PACEMAKER PHS794190000 48714211_1 CDM 0272 RC inpatient 415 269.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 251.28 402.55 TRAY PACEMAKER PHS794190000 48714211_1 CDM 0272 RC inpatient 415 269.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 251.28 402.55 TRAY PACEMAKER PHS794190000 48714211_1 CDM 0272 RC inpatient 415 269.75 ANTHEM HMO ANTHEM HMO 999999999 251.28 402.55 TRAY PACEMAKER PHS794190000 48714211_1 CDM 0272 RC inpatient 415 269.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 280.54 67.6 999999999 251.28 402.55 percent of total billed charges TRAY PACEMAKER PHS794190000 48714211_1 CDM 0272 RC inpatient 415 269.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 251.28 402.55 TRAY PACEMAKER PHS794190000 48714211_1 CDM 0272 RC inpatient 415 269.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 251.28 402.55 GUIDE WIRE 48714212_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714212_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714212_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714212_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714212_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714212_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714212_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714212_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714212_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 GUIDE WIRE 48714212_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 GUIDE WIRE 48714212_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 GUIDE WIRE 48714212_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714212_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 GUIDE WIRE 48714212_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F JR4 SH 48714213_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JR4 SH 48714213_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JR4 SH 48714213_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JR4 SH 48714213_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JR4 SH 48714213_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JR4 SH 48714213_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JR4 SH 48714213_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JR4 SH 48714213_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JR4 SH 48714213_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F JR4 SH 48714213_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F JR4 SH 48714213_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F JR4 SH 48714213_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JR4 SH 48714213_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F JR4 SH 48714213_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F LCB 48714214_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F LCB 48714214_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F LCB 48714214_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F LCB 48714214_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F LCB 48714214_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F LCB 48714214_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F LCB 48714214_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F LCB 48714214_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F LCB 48714214_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F LCB 48714214_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F LCB 48714214_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F LCB 48714214_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F LCB 48714214_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F LCB 48714214_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F MPA1 48714215_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F MPA1 48714215_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F MPA1 48714215_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F MPA1 48714215_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F MPA1 48714215_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F MPA1 48714215_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F MPA1 48714215_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F MPA1 48714215_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F MPA1 48714215_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F MPA1 48714215_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F MPA1 48714215_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F MPA1 48714215_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F MPA1 48714215_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F MPA1 48714215_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 GUIDE WIRE 48714216_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714216_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714216_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714216_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714216_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714216_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714216_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714216_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714216_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 GUIDE WIRE 48714216_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 GUIDE WIRE 48714216_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 GUIDE WIRE 48714216_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714216_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 GUIDE WIRE 48714216_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F XB4 48714217_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XB4 48714217_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XB4 48714217_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XB4 48714217_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XB4 48714217_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XB4 48714217_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XB4 48714217_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XB4 48714217_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XB4 48714217_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F XB4 48714217_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F XB4 48714217_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F XB4 48714217_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XB4 48714217_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F XB4 48714217_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F XBLAD3.5 48714218_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBLAD3.5 48714218_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBLAD3.5 48714218_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBLAD3.5 48714218_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBLAD3.5 48714218_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBLAD3.5 48714218_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBLAD3.5 48714218_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBLAD3.5 48714218_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBLAD3.5 48714218_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F XBLAD3.5 48714218_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F XBLAD3.5 48714218_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F XBLAD3.5 48714218_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBLAD3.5 48714218_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F XBLAD3.5 48714218_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F JL3.5 48714219_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL3.5 48714219_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL3.5 48714219_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL3.5 48714219_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL3.5 48714219_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL3.5 48714219_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL3.5 48714219_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL3.5 48714219_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL3.5 48714219_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F JL3.5 48714219_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F JL3.5 48714219_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F JL3.5 48714219_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL3.5 48714219_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F JL3.5 48714219_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F JR3.5 48714220_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JR3.5 48714220_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JR3.5 48714220_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JR3.5 48714220_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JR3.5 48714220_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JR3.5 48714220_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JR3.5 48714220_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JR3.5 48714220_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JR3.5 48714220_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F JR3.5 48714220_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F JR3.5 48714220_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F JR3.5 48714220_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JR3.5 48714220_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F JR3.5 48714220_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F XBAD4.0 48714221_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBAD4.0 48714221_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBAD4.0 48714221_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBAD4.0 48714221_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBAD4.0 48714221_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBAD4.0 48714221_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBAD4.0 48714221_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBAD4.0 48714221_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBAD4.0 48714221_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F XBAD4.0 48714221_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F XBAD4.0 48714221_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F XBAD4.0 48714221_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBAD4.0 48714221_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F XBAD4.0 48714221_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F XBRCA 48714222_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBRCA 48714222_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBRCA 48714222_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBRCA 48714222_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBRCA 48714222_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBRCA 48714222_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBRCA 48714222_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBRCA 48714222_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBRCA 48714222_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F XBRCA 48714222_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F XBRCA 48714222_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F XBRCA 48714222_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XBRCA 48714222_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F XBRCA 48714222_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F 3DRC 48714223_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F 3DRC 48714223_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F 3DRC 48714223_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F 3DRC 48714223_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F 3DRC 48714223_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F 3DRC 48714223_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F 3DRC 48714223_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F 3DRC 48714223_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F 3DRC 48714223_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F 3DRC 48714223_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F 3DRC 48714223_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F 3DRC 48714223_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F 3DRC 48714223_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F 3DRC 48714223_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F AL1 48714224_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL1 48714224_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL1 48714224_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL1 48714224_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL1 48714224_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL1 48714224_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL1 48714224_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL1 48714224_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL1 48714224_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F AL1 48714224_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F AL1 48714224_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F AL1 48714224_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL1 48714224_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F AL1 48714224_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F AL2 48714225_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL2 48714225_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL2 48714225_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL2 48714225_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL2 48714225_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL2 48714225_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL2 48714225_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL2 48714225_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL2 48714225_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F AL2 48714225_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F AL2 48714225_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F AL2 48714225_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL2 48714225_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F AL2 48714225_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F AL3 48714226_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL3 48714226_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL3 48714226_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL3 48714226_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL3 48714226_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL3 48714226_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL3 48714226_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL3 48714226_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL3 48714226_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F AL3 48714226_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F AL3 48714226_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F AL3 48714226_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AL3 48714226_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F AL3 48714226_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 GUIDE WIRE 48714227_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714227_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714227_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714227_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714227_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714227_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714227_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714227_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714227_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 GUIDE WIRE 48714227_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 GUIDE WIRE 48714227_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 GUIDE WIRE 48714227_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714227_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 GUIDE WIRE 48714227_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F AR2 48714228_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AR2 48714228_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AR2 48714228_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AR2 48714228_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AR2 48714228_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AR2 48714228_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AR2 48714228_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AR2 48714228_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AR2 48714228_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F AR2 48714228_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F AR2 48714228_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F AR2 48714228_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F AR2 48714228_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F AR2 48714228_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F H-STICK SH 48714229_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F H-STICK SH 48714229_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F H-STICK SH 48714229_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F H-STICK SH 48714229_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F H-STICK SH 48714229_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F H-STICK SH 48714229_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F H-STICK SH 48714229_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F H-STICK SH 48714229_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F H-STICK SH 48714229_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F H-STICK SH 48714229_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F H-STICK SH 48714229_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F H-STICK SH 48714229_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F H-STICK SH 48714229_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F H-STICK SH 48714229_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 GUIDE WIRE 48714230_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714230_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714230_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714230_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714230_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714230_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714230_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714230_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714230_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 GUIDE WIRE 48714230_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 GUIDE WIRE 48714230_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 GUIDE WIRE 48714230_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges GUIDE WIRE 48714230_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 GUIDE WIRE 48714230_1 CDM 0272 RC C1769 HCPCS inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F JL4.5 48714231_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL4.5 48714231_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL4.5 48714231_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL4.5 48714231_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL4.5 48714231_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL4.5 48714231_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL4.5 48714231_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL4.5 48714231_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL4.5 48714231_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F JL4.5 48714231_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F JL4.5 48714231_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F JL4.5 48714231_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL4.5 48714231_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F JL4.5 48714231_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F RCB 48714232_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F RCB 48714232_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F RCB 48714232_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F RCB 48714232_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F RCB 48714232_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F RCB 48714232_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F RCB 48714232_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F RCB 48714232_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F RCB 48714232_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F RCB 48714232_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F RCB 48714232_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F RCB 48714232_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F RCB 48714232_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F RCB 48714232_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F 3DRC SH 48714233_1 CDM 0272 RC inpatient 940 611 AETNA AETNA 742.6 79 999999999 569.17 911.8 percent of total billed charges CATHETER GUIDE 6F 3DRC SH 48714233_1 CDM 0272 RC inpatient 940 611 SELF PAY DISCOUNT SELF PAY DISCOUNT 611 65 999999999 569.17 911.8 percent of total billed charges CATHETER GUIDE 6F 3DRC SH 48714233_1 CDM 0272 RC inpatient 940 611 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 911.8 97 999999999 569.17 911.8 percent of total billed charges CATHETER GUIDE 6F 3DRC SH 48714233_1 CDM 0272 RC inpatient 940 611 ENCORE - ALL PLANS ENCORE - ALL PLANS 648.6 69 999999999 569.17 911.8 percent of total billed charges CATHETER GUIDE 6F 3DRC SH 48714233_1 CDM 0272 RC inpatient 940 611 HUMANA - ALL PLANS HUMANA - ALL PLANS 733.2 78 999999999 569.17 911.8 percent of total billed charges CATHETER GUIDE 6F 3DRC SH 48714233_1 CDM 0272 RC inpatient 940 611 SIHO - ALL PLANS SIHO - ALL PLANS 846 90 999999999 569.17 911.8 percent of total billed charges CATHETER GUIDE 6F 3DRC SH 48714233_1 CDM 0272 RC inpatient 940 611 UMR - ALL PLANS UMR - ALL PLANS 658 70 999999999 569.17 911.8 percent of total billed charges CATHETER GUIDE 6F 3DRC SH 48714233_1 CDM 0272 RC inpatient 940 611 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 569.17 60.55 999999999 569.17 911.8 percent of total billed charges CATHETER GUIDE 6F 3DRC SH 48714233_1 CDM 0272 RC inpatient 940 611 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 569.17 911.8 CATHETER GUIDE 6F 3DRC SH 48714233_1 CDM 0272 RC inpatient 940 611 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 569.17 911.8 CATHETER GUIDE 6F 3DRC SH 48714233_1 CDM 0272 RC inpatient 940 611 ANTHEM HMO ANTHEM HMO 999999999 569.17 911.8 CATHETER GUIDE 6F 3DRC SH 48714233_1 CDM 0272 RC inpatient 940 611 CIGNA - ALL PLANS CIGNA - ALL PLANS 635.44 67.6 999999999 569.17 911.8 percent of total billed charges CATHETER GUIDE 6F 3DRC SH 48714233_1 CDM 0272 RC inpatient 940 611 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 569.17 911.8 CATHETER GUIDE 6F 3DRC SH 48714233_1 CDM 0272 RC inpatient 940 611 UHC - ALL PLANS UHC - ALL PLANS 999999999 569.17 911.8 CATHETER GUIDE 6F XB3 48714234_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XB3 48714234_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XB3 48714234_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XB3 48714234_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XB3 48714234_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XB3 48714234_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XB3 48714234_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XB3 48714234_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XB3 48714234_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F XB3 48714234_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F XB3 48714234_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F XB3 48714234_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F XB3 48714234_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F XB3 48714234_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 7FR JR3.5 SH 48714235_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR JR3.5 SH 48714235_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR JR3.5 SH 48714235_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR JR3.5 SH 48714235_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR JR3.5 SH 48714235_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR JR3.5 SH 48714235_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR JR3.5 SH 48714235_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR JR3.5 SH 48714235_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR JR3.5 SH 48714235_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 7FR JR3.5 SH 48714235_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 7FR JR3.5 SH 48714235_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 7FR JR3.5 SH 48714235_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR JR3.5 SH 48714235_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 7FR JR3.5 SH 48714235_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 7FR XB3.5 48714236_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB3.5 48714236_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB3.5 48714236_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB3.5 48714236_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB3.5 48714236_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB3.5 48714236_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB3.5 48714236_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB3.5 48714236_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB3.5 48714236_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 7FR XB3.5 48714236_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 7FR XB3.5 48714236_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 7FR XB3.5 48714236_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB3.5 48714236_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 7FR XB3.5 48714236_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 7FR XB3.5 SH 48714237_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB3.5 SH 48714237_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB3.5 SH 48714237_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB3.5 SH 48714237_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB3.5 SH 48714237_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB3.5 SH 48714237_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB3.5 SH 48714237_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB3.5 SH 48714237_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB3.5 SH 48714237_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 7FR XB3.5 SH 48714237_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 7FR XB3.5 SH 48714237_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 7FR XB3.5 SH 48714237_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB3.5 SH 48714237_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 7FR XB3.5 SH 48714237_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 7FR XB4 48714238_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB4 48714238_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB4 48714238_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB4 48714238_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB4 48714238_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB4 48714238_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB4 48714238_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB4 48714238_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB4 48714238_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 7FR XB4 48714238_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 7FR XB4 48714238_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 7FR XB4 48714238_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XB4 48714238_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 7FR XB4 48714238_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 8FR IM 588817 48714239_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR IM 588817 48714239_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR IM 588817 48714239_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR IM 588817 48714239_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR IM 588817 48714239_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR IM 588817 48714239_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR IM 588817 48714239_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR IM 588817 48714239_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR IM 588817 48714239_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 8FR IM 588817 48714239_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 8FR IM 588817 48714239_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 8FR IM 588817 48714239_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR IM 588817 48714239_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 8FR IM 588817 48714239_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 8FR XB4 SH 48714240_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR XB4 SH 48714240_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR XB4 SH 48714240_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR XB4 SH 48714240_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR XB4 SH 48714240_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR XB4 SH 48714240_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR XB4 SH 48714240_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR XB4 SH 48714240_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR XB4 SH 48714240_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 8FR XB4 SH 48714240_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 8FR XB4 SH 48714240_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 8FR XB4 SH 48714240_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR XB4 SH 48714240_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 8FR XB4 SH 48714240_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6FR AR2 SH 48714241_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6FR AR2 SH 48714241_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6FR AR2 SH 48714241_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6FR AR2 SH 48714241_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6FR AR2 SH 48714241_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6FR AR2 SH 48714241_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6FR AR2 SH 48714241_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6FR AR2 SH 48714241_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6FR AR2 SH 48714241_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6FR AR2 SH 48714241_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6FR AR2 SH 48714241_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6FR AR2 SH 48714241_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6FR AR2 SH 48714241_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6FR AR2 SH 48714241_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 7FR XBLAD 4.0 48714242_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XBLAD 4.0 48714242_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XBLAD 4.0 48714242_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XBLAD 4.0 48714242_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XBLAD 4.0 48714242_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XBLAD 4.0 48714242_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XBLAD 4.0 48714242_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XBLAD 4.0 48714242_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XBLAD 4.0 48714242_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 7FR XBLAD 4.0 48714242_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 7FR XBLAD 4.0 48714242_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 7FR XBLAD 4.0 48714242_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 7FR XBLAD 4.0 48714242_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 7FR XBLAD 4.0 48714242_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 8FR MPA1 SH 48714243_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR MPA1 SH 48714243_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR MPA1 SH 48714243_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR MPA1 SH 48714243_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR MPA1 SH 48714243_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR MPA1 SH 48714243_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR MPA1 SH 48714243_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR MPA1 SH 48714243_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR MPA1 SH 48714243_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 8FR MPA1 SH 48714243_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 8FR MPA1 SH 48714243_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 8FR MPA1 SH 48714243_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 8FR MPA1 SH 48714243_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 8FR MPA1 SH 48714243_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 GUIDEWIRE SHINOBI PLS .014X180 48714244_1 CDM 0272 RC inpatient 553 359.45 AETNA AETNA 436.87 79 999999999 334.84 536.41 percent of total billed charges GUIDEWIRE SHINOBI PLS .014X180 48714244_1 CDM 0272 RC inpatient 553 359.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 359.45 65 999999999 334.84 536.41 percent of total billed charges GUIDEWIRE SHINOBI PLS .014X180 48714244_1 CDM 0272 RC inpatient 553 359.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 536.41 97 999999999 334.84 536.41 percent of total billed charges GUIDEWIRE SHINOBI PLS .014X180 48714244_1 CDM 0272 RC inpatient 553 359.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 381.57 69 999999999 334.84 536.41 percent of total billed charges GUIDEWIRE SHINOBI PLS .014X180 48714244_1 CDM 0272 RC inpatient 553 359.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 431.34 78 999999999 334.84 536.41 percent of total billed charges GUIDEWIRE SHINOBI PLS .014X180 48714244_1 CDM 0272 RC inpatient 553 359.45 SIHO - ALL PLANS SIHO - ALL PLANS 497.7 90 999999999 334.84 536.41 percent of total billed charges GUIDEWIRE SHINOBI PLS .014X180 48714244_1 CDM 0272 RC inpatient 553 359.45 UMR - ALL PLANS UMR - ALL PLANS 387.1 70 999999999 334.84 536.41 percent of total billed charges GUIDEWIRE SHINOBI PLS .014X180 48714244_1 CDM 0272 RC inpatient 553 359.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 334.84 60.55 999999999 334.84 536.41 percent of total billed charges GUIDEWIRE SHINOBI PLS .014X180 48714244_1 CDM 0272 RC inpatient 553 359.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 334.84 536.41 GUIDEWIRE SHINOBI PLS .014X180 48714244_1 CDM 0272 RC inpatient 553 359.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 334.84 536.41 GUIDEWIRE SHINOBI PLS .014X180 48714244_1 CDM 0272 RC inpatient 553 359.45 ANTHEM HMO ANTHEM HMO 999999999 334.84 536.41 GUIDEWIRE SHINOBI PLS .014X180 48714244_1 CDM 0272 RC inpatient 553 359.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 373.83 67.6 999999999 334.84 536.41 percent of total billed charges GUIDEWIRE SHINOBI PLS .014X180 48714244_1 CDM 0272 RC inpatient 553 359.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 334.84 536.41 GUIDEWIRE SHINOBI PLS .014X180 48714244_1 CDM 0272 RC inpatient 553 359.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 334.84 536.41 CATHETER GUIDE 6FRX55CM LIMA 48714245_1 CDM 0272 RC inpatient 413 268.45 AETNA AETNA 326.27 79 999999999 250.07 400.61 percent of total billed charges CATHETER GUIDE 6FRX55CM LIMA 48714245_1 CDM 0272 RC inpatient 413 268.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 268.45 65 999999999 250.07 400.61 percent of total billed charges CATHETER GUIDE 6FRX55CM LIMA 48714245_1 CDM 0272 RC inpatient 413 268.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 400.61 97 999999999 250.07 400.61 percent of total billed charges CATHETER GUIDE 6FRX55CM LIMA 48714245_1 CDM 0272 RC inpatient 413 268.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 284.97 69 999999999 250.07 400.61 percent of total billed charges CATHETER GUIDE 6FRX55CM LIMA 48714245_1 CDM 0272 RC inpatient 413 268.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 322.14 78 999999999 250.07 400.61 percent of total billed charges CATHETER GUIDE 6FRX55CM LIMA 48714245_1 CDM 0272 RC inpatient 413 268.45 SIHO - ALL PLANS SIHO - ALL PLANS 371.7 90 999999999 250.07 400.61 percent of total billed charges CATHETER GUIDE 6FRX55CM LIMA 48714245_1 CDM 0272 RC inpatient 413 268.45 UMR - ALL PLANS UMR - ALL PLANS 289.1 70 999999999 250.07 400.61 percent of total billed charges CATHETER GUIDE 6FRX55CM LIMA 48714245_1 CDM 0272 RC inpatient 413 268.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 250.07 60.55 999999999 250.07 400.61 percent of total billed charges CATHETER GUIDE 6FRX55CM LIMA 48714245_1 CDM 0272 RC inpatient 413 268.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 250.07 400.61 CATHETER GUIDE 6FRX55CM LIMA 48714245_1 CDM 0272 RC inpatient 413 268.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 250.07 400.61 CATHETER GUIDE 6FRX55CM LIMA 48714245_1 CDM 0272 RC inpatient 413 268.45 ANTHEM HMO ANTHEM HMO 999999999 250.07 400.61 CATHETER GUIDE 6FRX55CM LIMA 48714245_1 CDM 0272 RC inpatient 413 268.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 279.19 67.6 999999999 250.07 400.61 percent of total billed charges CATHETER GUIDE 6FRX55CM LIMA 48714245_1 CDM 0272 RC inpatient 413 268.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 250.07 400.61 CATHETER GUIDE 6FRX55CM LIMA 48714245_1 CDM 0272 RC inpatient 413 268.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 250.07 400.61 CATH SOS OMNI SELECT 5FRX80CM 48714249_1 CDM 0272 RC inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges CATH SOS OMNI SELECT 5FRX80CM 48714249_1 CDM 0272 RC inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges CATH SOS OMNI SELECT 5FRX80CM 48714249_1 CDM 0272 RC inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges CATH SOS OMNI SELECT 5FRX80CM 48714249_1 CDM 0272 RC inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges CATH SOS OMNI SELECT 5FRX80CM 48714249_1 CDM 0272 RC inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges CATH SOS OMNI SELECT 5FRX80CM 48714249_1 CDM 0272 RC inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges CATH SOS OMNI SELECT 5FRX80CM 48714249_1 CDM 0272 RC inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges CATH SOS OMNI SELECT 5FRX80CM 48714249_1 CDM 0272 RC inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges CATH SOS OMNI SELECT 5FRX80CM 48714249_1 CDM 0272 RC inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 CATH SOS OMNI SELECT 5FRX80CM 48714249_1 CDM 0272 RC inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 CATH SOS OMNI SELECT 5FRX80CM 48714249_1 CDM 0272 RC inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 CATH SOS OMNI SELECT 5FRX80CM 48714249_1 CDM 0272 RC inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges CATH SOS OMNI SELECT 5FRX80CM 48714249_1 CDM 0272 RC inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 CATH SOS OMNI SELECT 5FRX80CM 48714249_1 CDM 0272 RC inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 CATH 5FR RDC 65CM IMAGER II 48714250_1 CDM 0272 RC inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges CATH 5FR RDC 65CM IMAGER II 48714250_1 CDM 0272 RC inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges CATH 5FR RDC 65CM IMAGER II 48714250_1 CDM 0272 RC inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges CATH 5FR RDC 65CM IMAGER II 48714250_1 CDM 0272 RC inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges CATH 5FR RDC 65CM IMAGER II 48714250_1 CDM 0272 RC inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges CATH 5FR RDC 65CM IMAGER II 48714250_1 CDM 0272 RC inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges CATH 5FR RDC 65CM IMAGER II 48714250_1 CDM 0272 RC inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges CATH 5FR RDC 65CM IMAGER II 48714250_1 CDM 0272 RC inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges CATH 5FR RDC 65CM IMAGER II 48714250_1 CDM 0272 RC inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 CATH 5FR RDC 65CM IMAGER II 48714250_1 CDM 0272 RC inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 CATH 5FR RDC 65CM IMAGER II 48714250_1 CDM 0272 RC inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 CATH 5FR RDC 65CM IMAGER II 48714250_1 CDM 0272 RC inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges CATH 5FR RDC 65CM IMAGER II 48714250_1 CDM 0272 RC inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 CATH 5FR RDC 65CM IMAGER II 48714250_1 CDM 0272 RC inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 GUIDE WIRE 48714251_1 CDM 0272 RC C1769 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges GUIDE WIRE 48714251_1 CDM 0272 RC C1769 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges GUIDE WIRE 48714251_1 CDM 0272 RC C1769 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges GUIDE WIRE 48714251_1 CDM 0272 RC C1769 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges GUIDE WIRE 48714251_1 CDM 0272 RC C1769 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges GUIDE WIRE 48714251_1 CDM 0272 RC C1769 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges GUIDE WIRE 48714251_1 CDM 0272 RC C1769 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges GUIDE WIRE 48714251_1 CDM 0272 RC C1769 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges GUIDE WIRE 48714251_1 CDM 0272 RC C1769 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 GUIDE WIRE 48714251_1 CDM 0272 RC C1769 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 GUIDE WIRE 48714251_1 CDM 0272 RC C1769 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 GUIDE WIRE 48714251_1 CDM 0272 RC C1769 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges GUIDE WIRE 48714251_1 CDM 0272 RC C1769 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 GUIDE WIRE 48714251_1 CDM 0272 RC C1769 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 GUIDE WIRE 48714252_1 CDM 0272 RC C1769 HCPCS inpatient 352 228.8 AETNA AETNA 278.08 79 999999999 213.14 341.44 percent of total billed charges GUIDE WIRE 48714252_1 CDM 0272 RC C1769 HCPCS inpatient 352 228.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 228.8 65 999999999 213.14 341.44 percent of total billed charges GUIDE WIRE 48714252_1 CDM 0272 RC C1769 HCPCS inpatient 352 228.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 341.44 97 999999999 213.14 341.44 percent of total billed charges GUIDE WIRE 48714252_1 CDM 0272 RC C1769 HCPCS inpatient 352 228.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 242.88 69 999999999 213.14 341.44 percent of total billed charges GUIDE WIRE 48714252_1 CDM 0272 RC C1769 HCPCS inpatient 352 228.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 274.56 78 999999999 213.14 341.44 percent of total billed charges GUIDE WIRE 48714252_1 CDM 0272 RC C1769 HCPCS inpatient 352 228.8 SIHO - ALL PLANS SIHO - ALL PLANS 316.8 90 999999999 213.14 341.44 percent of total billed charges GUIDE WIRE 48714252_1 CDM 0272 RC C1769 HCPCS inpatient 352 228.8 UMR - ALL PLANS UMR - ALL PLANS 246.4 70 999999999 213.14 341.44 percent of total billed charges GUIDE WIRE 48714252_1 CDM 0272 RC C1769 HCPCS inpatient 352 228.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 213.14 60.55 999999999 213.14 341.44 percent of total billed charges GUIDE WIRE 48714252_1 CDM 0272 RC C1769 HCPCS inpatient 352 228.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 213.14 341.44 GUIDE WIRE 48714252_1 CDM 0272 RC C1769 HCPCS inpatient 352 228.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 213.14 341.44 GUIDE WIRE 48714252_1 CDM 0272 RC C1769 HCPCS inpatient 352 228.8 ANTHEM HMO ANTHEM HMO 999999999 213.14 341.44 GUIDE WIRE 48714252_1 CDM 0272 RC C1769 HCPCS inpatient 352 228.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 237.95 67.6 999999999 213.14 341.44 percent of total billed charges GUIDE WIRE 48714252_1 CDM 0272 RC C1769 HCPCS inpatient 352 228.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 213.14 341.44 GUIDE WIRE 48714252_1 CDM 0272 RC C1769 HCPCS inpatient 352 228.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 213.14 341.44 INTRODUCER SHEATH 5FRX11CM 48714253_1 CDM 0272 RC inpatient 194 126.1 AETNA AETNA 153.26 79 999999999 117.47 188.18 percent of total billed charges INTRODUCER SHEATH 5FRX11CM 48714253_1 CDM 0272 RC inpatient 194 126.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 126.1 65 999999999 117.47 188.18 percent of total billed charges INTRODUCER SHEATH 5FRX11CM 48714253_1 CDM 0272 RC inpatient 194 126.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 188.18 97 999999999 117.47 188.18 percent of total billed charges INTRODUCER SHEATH 5FRX11CM 48714253_1 CDM 0272 RC inpatient 194 126.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.86 69 999999999 117.47 188.18 percent of total billed charges INTRODUCER SHEATH 5FRX11CM 48714253_1 CDM 0272 RC inpatient 194 126.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 151.32 78 999999999 117.47 188.18 percent of total billed charges INTRODUCER SHEATH 5FRX11CM 48714253_1 CDM 0272 RC inpatient 194 126.1 SIHO - ALL PLANS SIHO - ALL PLANS 174.6 90 999999999 117.47 188.18 percent of total billed charges INTRODUCER SHEATH 5FRX11CM 48714253_1 CDM 0272 RC inpatient 194 126.1 UMR - ALL PLANS UMR - ALL PLANS 135.8 70 999999999 117.47 188.18 percent of total billed charges INTRODUCER SHEATH 5FRX11CM 48714253_1 CDM 0272 RC inpatient 194 126.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 117.47 60.55 999999999 117.47 188.18 percent of total billed charges INTRODUCER SHEATH 5FRX11CM 48714253_1 CDM 0272 RC inpatient 194 126.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 117.47 188.18 INTRODUCER SHEATH 5FRX11CM 48714253_1 CDM 0272 RC inpatient 194 126.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 117.47 188.18 INTRODUCER SHEATH 5FRX11CM 48714253_1 CDM 0272 RC inpatient 194 126.1 ANTHEM HMO ANTHEM HMO 999999999 117.47 188.18 INTRODUCER SHEATH 5FRX11CM 48714253_1 CDM 0272 RC inpatient 194 126.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 131.14 67.6 999999999 117.47 188.18 percent of total billed charges INTRODUCER SHEATH 5FRX11CM 48714253_1 CDM 0272 RC inpatient 194 126.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 117.47 188.18 INTRODUCER SHEATH 5FRX11CM 48714253_1 CDM 0272 RC inpatient 194 126.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 117.47 188.18 INTRODUCER SHEATH 6FRX11CM 48714254_1 CDM 0272 RC inpatient 200 130 AETNA AETNA 158 79 999999999 121.1 194 percent of total billed charges INTRODUCER SHEATH 6FRX11CM 48714254_1 CDM 0272 RC inpatient 200 130 SELF PAY DISCOUNT SELF PAY DISCOUNT 130 65 999999999 121.1 194 percent of total billed charges INTRODUCER SHEATH 6FRX11CM 48714254_1 CDM 0272 RC inpatient 200 130 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 194 97 999999999 121.1 194 percent of total billed charges INTRODUCER SHEATH 6FRX11CM 48714254_1 CDM 0272 RC inpatient 200 130 ENCORE - ALL PLANS ENCORE - ALL PLANS 138 69 999999999 121.1 194 percent of total billed charges INTRODUCER SHEATH 6FRX11CM 48714254_1 CDM 0272 RC inpatient 200 130 HUMANA - ALL PLANS HUMANA - ALL PLANS 156 78 999999999 121.1 194 percent of total billed charges INTRODUCER SHEATH 6FRX11CM 48714254_1 CDM 0272 RC inpatient 200 130 SIHO - ALL PLANS SIHO - ALL PLANS 180 90 999999999 121.1 194 percent of total billed charges INTRODUCER SHEATH 6FRX11CM 48714254_1 CDM 0272 RC inpatient 200 130 UMR - ALL PLANS UMR - ALL PLANS 140 70 999999999 121.1 194 percent of total billed charges INTRODUCER SHEATH 6FRX11CM 48714254_1 CDM 0272 RC inpatient 200 130 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 121.1 60.55 999999999 121.1 194 percent of total billed charges INTRODUCER SHEATH 6FRX11CM 48714254_1 CDM 0272 RC inpatient 200 130 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 121.1 194 INTRODUCER SHEATH 6FRX11CM 48714254_1 CDM 0272 RC inpatient 200 130 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 121.1 194 INTRODUCER SHEATH 6FRX11CM 48714254_1 CDM 0272 RC inpatient 200 130 ANTHEM HMO ANTHEM HMO 999999999 121.1 194 INTRODUCER SHEATH 6FRX11CM 48714254_1 CDM 0272 RC inpatient 200 130 CIGNA - ALL PLANS CIGNA - ALL PLANS 135.2 67.6 999999999 121.1 194 percent of total billed charges INTRODUCER SHEATH 6FRX11CM 48714254_1 CDM 0272 RC inpatient 200 130 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 121.1 194 INTRODUCER SHEATH 6FRX11CM 48714254_1 CDM 0272 RC inpatient 200 130 UHC - ALL PLANS UHC - ALL PLANS 999999999 121.1 194 GLIDECATH 4FR ANG TPR A TIP 48714255_1 CDM 0272 RC inpatient 495 321.75 AETNA AETNA 391.05 79 999999999 299.72 480.15 percent of total billed charges GLIDECATH 4FR ANG TPR A TIP 48714255_1 CDM 0272 RC inpatient 495 321.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 321.75 65 999999999 299.72 480.15 percent of total billed charges GLIDECATH 4FR ANG TPR A TIP 48714255_1 CDM 0272 RC inpatient 495 321.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 480.15 97 999999999 299.72 480.15 percent of total billed charges GLIDECATH 4FR ANG TPR A TIP 48714255_1 CDM 0272 RC inpatient 495 321.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 341.55 69 999999999 299.72 480.15 percent of total billed charges GLIDECATH 4FR ANG TPR A TIP 48714255_1 CDM 0272 RC inpatient 495 321.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 386.1 78 999999999 299.72 480.15 percent of total billed charges GLIDECATH 4FR ANG TPR A TIP 48714255_1 CDM 0272 RC inpatient 495 321.75 SIHO - ALL PLANS SIHO - ALL PLANS 445.5 90 999999999 299.72 480.15 percent of total billed charges GLIDECATH 4FR ANG TPR A TIP 48714255_1 CDM 0272 RC inpatient 495 321.75 UMR - ALL PLANS UMR - ALL PLANS 346.5 70 999999999 299.72 480.15 percent of total billed charges GLIDECATH 4FR ANG TPR A TIP 48714255_1 CDM 0272 RC inpatient 495 321.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 299.72 60.55 999999999 299.72 480.15 percent of total billed charges GLIDECATH 4FR ANG TPR A TIP 48714255_1 CDM 0272 RC inpatient 495 321.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 299.72 480.15 GLIDECATH 4FR ANG TPR A TIP 48714255_1 CDM 0272 RC inpatient 495 321.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 299.72 480.15 GLIDECATH 4FR ANG TPR A TIP 48714255_1 CDM 0272 RC inpatient 495 321.75 ANTHEM HMO ANTHEM HMO 999999999 299.72 480.15 GLIDECATH 4FR ANG TPR A TIP 48714255_1 CDM 0272 RC inpatient 495 321.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 334.62 67.6 999999999 299.72 480.15 percent of total billed charges GLIDECATH 4FR ANG TPR A TIP 48714255_1 CDM 0272 RC inpatient 495 321.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 299.72 480.15 GLIDECATH 4FR ANG TPR A TIP 48714255_1 CDM 0272 RC inpatient 495 321.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 299.72 480.15 GUIDEWIRE STIFF .035IN 260 3CM 48714256_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges GUIDEWIRE STIFF .035IN 260 3CM 48714256_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges GUIDEWIRE STIFF .035IN 260 3CM 48714256_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges GUIDEWIRE STIFF .035IN 260 3CM 48714256_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges GUIDEWIRE STIFF .035IN 260 3CM 48714256_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges GUIDEWIRE STIFF .035IN 260 3CM 48714256_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges GUIDEWIRE STIFF .035IN 260 3CM 48714256_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges GUIDEWIRE STIFF .035IN 260 3CM 48714256_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges GUIDEWIRE STIFF .035IN 260 3CM 48714256_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 GUIDEWIRE STIFF .035IN 260 3CM 48714256_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 GUIDEWIRE STIFF .035IN 260 3CM 48714256_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 GUIDEWIRE STIFF .035IN 260 3CM 48714256_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges GUIDEWIRE STIFF .035IN 260 3CM 48714256_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 GUIDEWIRE STIFF .035IN 260 3CM 48714256_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 INTRODUCER SHEATH 7FR BRITE 48714257_1 CDM 0272 RC inpatient 200 130 AETNA AETNA 158 79 999999999 121.1 194 percent of total billed charges INTRODUCER SHEATH 7FR BRITE 48714257_1 CDM 0272 RC inpatient 200 130 SELF PAY DISCOUNT SELF PAY DISCOUNT 130 65 999999999 121.1 194 percent of total billed charges INTRODUCER SHEATH 7FR BRITE 48714257_1 CDM 0272 RC inpatient 200 130 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 194 97 999999999 121.1 194 percent of total billed charges INTRODUCER SHEATH 7FR BRITE 48714257_1 CDM 0272 RC inpatient 200 130 ENCORE - ALL PLANS ENCORE - ALL PLANS 138 69 999999999 121.1 194 percent of total billed charges INTRODUCER SHEATH 7FR BRITE 48714257_1 CDM 0272 RC inpatient 200 130 HUMANA - ALL PLANS HUMANA - ALL PLANS 156 78 999999999 121.1 194 percent of total billed charges INTRODUCER SHEATH 7FR BRITE 48714257_1 CDM 0272 RC inpatient 200 130 SIHO - ALL PLANS SIHO - ALL PLANS 180 90 999999999 121.1 194 percent of total billed charges INTRODUCER SHEATH 7FR BRITE 48714257_1 CDM 0272 RC inpatient 200 130 UMR - ALL PLANS UMR - ALL PLANS 140 70 999999999 121.1 194 percent of total billed charges INTRODUCER SHEATH 7FR BRITE 48714257_1 CDM 0272 RC inpatient 200 130 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 121.1 60.55 999999999 121.1 194 percent of total billed charges INTRODUCER SHEATH 7FR BRITE 48714257_1 CDM 0272 RC inpatient 200 130 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 121.1 194 INTRODUCER SHEATH 7FR BRITE 48714257_1 CDM 0272 RC inpatient 200 130 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 121.1 194 INTRODUCER SHEATH 7FR BRITE 48714257_1 CDM 0272 RC inpatient 200 130 ANTHEM HMO ANTHEM HMO 999999999 121.1 194 INTRODUCER SHEATH 7FR BRITE 48714257_1 CDM 0272 RC inpatient 200 130 CIGNA - ALL PLANS CIGNA - ALL PLANS 135.2 67.6 999999999 121.1 194 percent of total billed charges INTRODUCER SHEATH 7FR BRITE 48714257_1 CDM 0272 RC inpatient 200 130 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 121.1 194 INTRODUCER SHEATH 7FR BRITE 48714257_1 CDM 0272 RC inpatient 200 130 UHC - ALL PLANS UHC - ALL PLANS 999999999 121.1 194 CATH 4.0FRX100CM JBI SLIP CATH 48714258_1 CDM 0272 RC inpatient 387 251.55 AETNA AETNA 305.73 79 999999999 234.33 375.39 percent of total billed charges CATH 4.0FRX100CM JBI SLIP CATH 48714258_1 CDM 0272 RC inpatient 387 251.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 251.55 65 999999999 234.33 375.39 percent of total billed charges CATH 4.0FRX100CM JBI SLIP CATH 48714258_1 CDM 0272 RC inpatient 387 251.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 375.39 97 999999999 234.33 375.39 percent of total billed charges CATH 4.0FRX100CM JBI SLIP CATH 48714258_1 CDM 0272 RC inpatient 387 251.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.03 69 999999999 234.33 375.39 percent of total billed charges CATH 4.0FRX100CM JBI SLIP CATH 48714258_1 CDM 0272 RC inpatient 387 251.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.86 78 999999999 234.33 375.39 percent of total billed charges CATH 4.0FRX100CM JBI SLIP CATH 48714258_1 CDM 0272 RC inpatient 387 251.55 SIHO - ALL PLANS SIHO - ALL PLANS 348.3 90 999999999 234.33 375.39 percent of total billed charges CATH 4.0FRX100CM JBI SLIP CATH 48714258_1 CDM 0272 RC inpatient 387 251.55 UMR - ALL PLANS UMR - ALL PLANS 270.9 70 999999999 234.33 375.39 percent of total billed charges CATH 4.0FRX100CM JBI SLIP CATH 48714258_1 CDM 0272 RC inpatient 387 251.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.33 60.55 999999999 234.33 375.39 percent of total billed charges CATH 4.0FRX100CM JBI SLIP CATH 48714258_1 CDM 0272 RC inpatient 387 251.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.33 375.39 CATH 4.0FRX100CM JBI SLIP CATH 48714258_1 CDM 0272 RC inpatient 387 251.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.33 375.39 CATH 4.0FRX100CM JBI SLIP CATH 48714258_1 CDM 0272 RC inpatient 387 251.55 ANTHEM HMO ANTHEM HMO 999999999 234.33 375.39 CATH 4.0FRX100CM JBI SLIP CATH 48714258_1 CDM 0272 RC inpatient 387 251.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 261.61 67.6 999999999 234.33 375.39 percent of total billed charges CATH 4.0FRX100CM JBI SLIP CATH 48714258_1 CDM 0272 RC inpatient 387 251.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.33 375.39 CATH 4.0FRX100CM JBI SLIP CATH 48714258_1 CDM 0272 RC inpatient 387 251.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.33 375.39 GUIDEWIRE SS .035X145CM STR 48714260_1 CDM 0272 RC inpatient 134 87.1 AETNA AETNA 105.86 79 999999999 81.14 129.98 percent of total billed charges GUIDEWIRE SS .035X145CM STR 48714260_1 CDM 0272 RC inpatient 134 87.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 87.1 65 999999999 81.14 129.98 percent of total billed charges GUIDEWIRE SS .035X145CM STR 48714260_1 CDM 0272 RC inpatient 134 87.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.98 97 999999999 81.14 129.98 percent of total billed charges GUIDEWIRE SS .035X145CM STR 48714260_1 CDM 0272 RC inpatient 134 87.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 92.46 69 999999999 81.14 129.98 percent of total billed charges GUIDEWIRE SS .035X145CM STR 48714260_1 CDM 0272 RC inpatient 134 87.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 104.52 78 999999999 81.14 129.98 percent of total billed charges GUIDEWIRE SS .035X145CM STR 48714260_1 CDM 0272 RC inpatient 134 87.1 SIHO - ALL PLANS SIHO - ALL PLANS 120.6 90 999999999 81.14 129.98 percent of total billed charges GUIDEWIRE SS .035X145CM STR 48714260_1 CDM 0272 RC inpatient 134 87.1 UMR - ALL PLANS UMR - ALL PLANS 93.8 70 999999999 81.14 129.98 percent of total billed charges GUIDEWIRE SS .035X145CM STR 48714260_1 CDM 0272 RC inpatient 134 87.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 81.14 60.55 999999999 81.14 129.98 percent of total billed charges GUIDEWIRE SS .035X145CM STR 48714260_1 CDM 0272 RC inpatient 134 87.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 81.14 129.98 GUIDEWIRE SS .035X145CM STR 48714260_1 CDM 0272 RC inpatient 134 87.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 81.14 129.98 GUIDEWIRE SS .035X145CM STR 48714260_1 CDM 0272 RC inpatient 134 87.1 ANTHEM HMO ANTHEM HMO 999999999 81.14 129.98 GUIDEWIRE SS .035X145CM STR 48714260_1 CDM 0272 RC inpatient 134 87.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 90.58 67.6 999999999 81.14 129.98 percent of total billed charges GUIDEWIRE SS .035X145CM STR 48714260_1 CDM 0272 RC inpatient 134 87.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 81.14 129.98 GUIDEWIRE SS .035X145CM STR 48714260_1 CDM 0272 RC inpatient 134 87.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 81.14 129.98 CATH 6FRX110CM 2LM 145DEG PIG 48714261_1 CDM 0272 RC inpatient 802 521.3 AETNA AETNA 633.58 79 999999999 485.61 777.94 percent of total billed charges CATH 6FRX110CM 2LM 145DEG PIG 48714261_1 CDM 0272 RC inpatient 802 521.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 521.3 65 999999999 485.61 777.94 percent of total billed charges CATH 6FRX110CM 2LM 145DEG PIG 48714261_1 CDM 0272 RC inpatient 802 521.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 777.94 97 999999999 485.61 777.94 percent of total billed charges CATH 6FRX110CM 2LM 145DEG PIG 48714261_1 CDM 0272 RC inpatient 802 521.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 553.38 69 999999999 485.61 777.94 percent of total billed charges CATH 6FRX110CM 2LM 145DEG PIG 48714261_1 CDM 0272 RC inpatient 802 521.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 625.56 78 999999999 485.61 777.94 percent of total billed charges CATH 6FRX110CM 2LM 145DEG PIG 48714261_1 CDM 0272 RC inpatient 802 521.3 SIHO - ALL PLANS SIHO - ALL PLANS 721.8 90 999999999 485.61 777.94 percent of total billed charges CATH 6FRX110CM 2LM 145DEG PIG 48714261_1 CDM 0272 RC inpatient 802 521.3 UMR - ALL PLANS UMR - ALL PLANS 561.4 70 999999999 485.61 777.94 percent of total billed charges CATH 6FRX110CM 2LM 145DEG PIG 48714261_1 CDM 0272 RC inpatient 802 521.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 485.61 60.55 999999999 485.61 777.94 percent of total billed charges CATH 6FRX110CM 2LM 145DEG PIG 48714261_1 CDM 0272 RC inpatient 802 521.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 485.61 777.94 CATH 6FRX110CM 2LM 145DEG PIG 48714261_1 CDM 0272 RC inpatient 802 521.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 485.61 777.94 CATH 6FRX110CM 2LM 145DEG PIG 48714261_1 CDM 0272 RC inpatient 802 521.3 ANTHEM HMO ANTHEM HMO 999999999 485.61 777.94 CATH 6FRX110CM 2LM 145DEG PIG 48714261_1 CDM 0272 RC inpatient 802 521.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 542.15 67.6 999999999 485.61 777.94 percent of total billed charges CATH 6FRX110CM 2LM 145DEG PIG 48714261_1 CDM 0272 RC inpatient 802 521.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 485.61 777.94 CATH 6FRX110CM 2LM 145DEG PIG 48714261_1 CDM 0272 RC inpatient 802 521.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 485.61 777.94 GUIDE LINER V3 CATH 6FR 5571 48714262_1 CDM 0272 RC inpatient 3098 2013.7 AETNA AETNA 2447.42 79 999999999 1875.84 3005.06 percent of total billed charges GUIDE LINER V3 CATH 6FR 5571 48714262_1 CDM 0272 RC inpatient 3098 2013.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 2013.7 65 999999999 1875.84 3005.06 percent of total billed charges GUIDE LINER V3 CATH 6FR 5571 48714262_1 CDM 0272 RC inpatient 3098 2013.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3005.06 97 999999999 1875.84 3005.06 percent of total billed charges GUIDE LINER V3 CATH 6FR 5571 48714262_1 CDM 0272 RC inpatient 3098 2013.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 2137.62 69 999999999 1875.84 3005.06 percent of total billed charges GUIDE LINER V3 CATH 6FR 5571 48714262_1 CDM 0272 RC inpatient 3098 2013.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 2416.44 78 999999999 1875.84 3005.06 percent of total billed charges GUIDE LINER V3 CATH 6FR 5571 48714262_1 CDM 0272 RC inpatient 3098 2013.7 SIHO - ALL PLANS SIHO - ALL PLANS 2788.2 90 999999999 1875.84 3005.06 percent of total billed charges GUIDE LINER V3 CATH 6FR 5571 48714262_1 CDM 0272 RC inpatient 3098 2013.7 UMR - ALL PLANS UMR - ALL PLANS 2168.6 70 999999999 1875.84 3005.06 percent of total billed charges GUIDE LINER V3 CATH 6FR 5571 48714262_1 CDM 0272 RC inpatient 3098 2013.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1875.84 60.55 999999999 1875.84 3005.06 percent of total billed charges GUIDE LINER V3 CATH 6FR 5571 48714262_1 CDM 0272 RC inpatient 3098 2013.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1875.84 3005.06 GUIDE LINER V3 CATH 6FR 5571 48714262_1 CDM 0272 RC inpatient 3098 2013.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1875.84 3005.06 GUIDE LINER V3 CATH 6FR 5571 48714262_1 CDM 0272 RC inpatient 3098 2013.7 ANTHEM HMO ANTHEM HMO 999999999 1875.84 3005.06 GUIDE LINER V3 CATH 6FR 5571 48714262_1 CDM 0272 RC inpatient 3098 2013.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 2094.25 67.6 999999999 1875.84 3005.06 percent of total billed charges GUIDE LINER V3 CATH 6FR 5571 48714262_1 CDM 0272 RC inpatient 3098 2013.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1875.84 3005.06 GUIDE LINER V3 CATH 6FR 5571 48714262_1 CDM 0272 RC inpatient 3098 2013.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 1875.84 3005.06 CELERO-12 VACUUM ASSISTED 48714263_1 CDM 0272 RC inpatient 1521 988.65 AETNA AETNA 1201.59 79 999999999 920.97 1475.37 percent of total billed charges CELERO-12 VACUUM ASSISTED 48714263_1 CDM 0272 RC inpatient 1521 988.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 988.65 65 999999999 920.97 1475.37 percent of total billed charges CELERO-12 VACUUM ASSISTED 48714263_1 CDM 0272 RC inpatient 1521 988.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1475.37 97 999999999 920.97 1475.37 percent of total billed charges CELERO-12 VACUUM ASSISTED 48714263_1 CDM 0272 RC inpatient 1521 988.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1049.49 69 999999999 920.97 1475.37 percent of total billed charges CELERO-12 VACUUM ASSISTED 48714263_1 CDM 0272 RC inpatient 1521 988.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1186.38 78 999999999 920.97 1475.37 percent of total billed charges CELERO-12 VACUUM ASSISTED 48714263_1 CDM 0272 RC inpatient 1521 988.65 SIHO - ALL PLANS SIHO - ALL PLANS 1368.9 90 999999999 920.97 1475.37 percent of total billed charges CELERO-12 VACUUM ASSISTED 48714263_1 CDM 0272 RC inpatient 1521 988.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 920.97 60.55 999999999 920.97 1475.37 percent of total billed charges CELERO-12 VACUUM ASSISTED 48714263_1 CDM 0272 RC inpatient 1521 988.65 UMR - ALL PLANS UMR - ALL PLANS 1064.7 70 999999999 920.97 1475.37 percent of total billed charges CELERO-12 VACUUM ASSISTED 48714263_1 CDM 0272 RC inpatient 1521 988.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 920.97 1475.37 CELERO-12 VACUUM ASSISTED 48714263_1 CDM 0272 RC inpatient 1521 988.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 920.97 1475.37 CELERO-12 VACUUM ASSISTED 48714263_1 CDM 0272 RC inpatient 1521 988.65 ANTHEM HMO ANTHEM HMO 999999999 920.97 1475.37 CELERO-12 VACUUM ASSISTED 48714263_1 CDM 0272 RC inpatient 1521 988.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1028.2 67.6 999999999 920.97 1475.37 percent of total billed charges CELERO-12 VACUUM ASSISTED 48714263_1 CDM 0272 RC inpatient 1521 988.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 920.97 1475.37 CELERO-12 VACUUM ASSISTED 48714263_1 CDM 0272 RC inpatient 1521 988.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 920.97 1475.37 "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48714264_1 CDM 0278 RC A4648 HCPCS inpatient 588 382.2 AETNA AETNA 464.52 79 999999999 356.03 570.36 percent of total billed charges "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48714264_1 CDM 0278 RC A4648 HCPCS inpatient 588 382.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 382.2 65 999999999 356.03 570.36 percent of total billed charges "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48714264_1 CDM 0278 RC A4648 HCPCS inpatient 588 382.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 570.36 97 999999999 356.03 570.36 percent of total billed charges "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48714264_1 CDM 0278 RC A4648 HCPCS inpatient 588 382.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 405.72 69 999999999 356.03 570.36 percent of total billed charges "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48714264_1 CDM 0278 RC A4648 HCPCS inpatient 588 382.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 458.64 78 999999999 356.03 570.36 percent of total billed charges "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48714264_1 CDM 0278 RC A4648 HCPCS inpatient 588 382.2 SIHO - ALL PLANS SIHO - ALL PLANS 529.2 90 999999999 356.03 570.36 percent of total billed charges "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48714264_1 CDM 0278 RC A4648 HCPCS inpatient 588 382.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 356.03 60.55 999999999 356.03 570.36 percent of total billed charges "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48714264_1 CDM 0278 RC A4648 HCPCS inpatient 588 382.2 UMR - ALL PLANS UMR - ALL PLANS 411.6 70 999999999 356.03 570.36 percent of total billed charges "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48714264_1 CDM 0278 RC A4648 HCPCS inpatient 588 382.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 356.03 570.36 "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48714264_1 CDM 0278 RC A4648 HCPCS inpatient 588 382.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 356.03 570.36 "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48714264_1 CDM 0278 RC A4648 HCPCS inpatient 588 382.2 ANTHEM HMO ANTHEM HMO 999999999 356.03 570.36 "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48714264_1 CDM 0278 RC A4648 HCPCS inpatient 588 382.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 397.49 67.6 999999999 356.03 570.36 percent of total billed charges "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48714264_1 CDM 0278 RC A4648 HCPCS inpatient 588 382.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 356.03 570.36 "TISSUE MARKER, IMPLANTABLE, ANY TYPE, EACH" 48714264_1 CDM 0278 RC A4648 HCPCS inpatient 588 382.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 356.03 570.36 CARDIAC MONITOR RHYTHM 48714282_1 CDM 0272 RC inpatient 405 263.25 AETNA AETNA 319.95 79 999999999 245.23 392.85 percent of total billed charges CARDIAC MONITOR RHYTHM 48714282_1 CDM 0272 RC inpatient 405 263.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 263.25 65 999999999 245.23 392.85 percent of total billed charges CARDIAC MONITOR RHYTHM 48714282_1 CDM 0272 RC inpatient 405 263.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 392.85 97 999999999 245.23 392.85 percent of total billed charges CARDIAC MONITOR RHYTHM 48714282_1 CDM 0272 RC inpatient 405 263.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 279.45 69 999999999 245.23 392.85 percent of total billed charges CARDIAC MONITOR RHYTHM 48714282_1 CDM 0272 RC inpatient 405 263.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 315.9 78 999999999 245.23 392.85 percent of total billed charges CARDIAC MONITOR RHYTHM 48714282_1 CDM 0272 RC inpatient 405 263.25 SIHO - ALL PLANS SIHO - ALL PLANS 364.5 90 999999999 245.23 392.85 percent of total billed charges CARDIAC MONITOR RHYTHM 48714282_1 CDM 0272 RC inpatient 405 263.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 245.23 60.55 999999999 245.23 392.85 percent of total billed charges CARDIAC MONITOR RHYTHM 48714282_1 CDM 0272 RC inpatient 405 263.25 UMR - ALL PLANS UMR - ALL PLANS 283.5 70 999999999 245.23 392.85 percent of total billed charges CARDIAC MONITOR RHYTHM 48714282_1 CDM 0272 RC inpatient 405 263.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 245.23 392.85 CARDIAC MONITOR RHYTHM 48714282_1 CDM 0272 RC inpatient 405 263.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 245.23 392.85 CARDIAC MONITOR RHYTHM 48714282_1 CDM 0272 RC inpatient 405 263.25 ANTHEM HMO ANTHEM HMO 999999999 245.23 392.85 CARDIAC MONITOR RHYTHM 48714282_1 CDM 0272 RC inpatient 405 263.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 273.78 67.6 999999999 245.23 392.85 percent of total billed charges CARDIAC MONITOR RHYTHM 48714282_1 CDM 0272 RC inpatient 405 263.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 245.23 392.85 CARDIAC MONITOR RHYTHM 48714282_1 CDM 0272 RC inpatient 405 263.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 245.23 392.85 TUN L CATHETER 19G 155-1520 48714286_1 CDM 0272 RC inpatient 564 366.6 AETNA AETNA 445.56 79 999999999 341.5 547.08 percent of total billed charges TUN L CATHETER 19G 155-1520 48714286_1 CDM 0272 RC inpatient 564 366.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 366.6 65 999999999 341.5 547.08 percent of total billed charges TUN L CATHETER 19G 155-1520 48714286_1 CDM 0272 RC inpatient 564 366.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 547.08 97 999999999 341.5 547.08 percent of total billed charges TUN L CATHETER 19G 155-1520 48714286_1 CDM 0272 RC inpatient 564 366.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 389.16 69 999999999 341.5 547.08 percent of total billed charges TUN L CATHETER 19G 155-1520 48714286_1 CDM 0272 RC inpatient 564 366.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 439.92 78 999999999 341.5 547.08 percent of total billed charges TUN L CATHETER 19G 155-1520 48714286_1 CDM 0272 RC inpatient 564 366.6 SIHO - ALL PLANS SIHO - ALL PLANS 507.6 90 999999999 341.5 547.08 percent of total billed charges TUN L CATHETER 19G 155-1520 48714286_1 CDM 0272 RC inpatient 564 366.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 341.5 60.55 999999999 341.5 547.08 percent of total billed charges TUN L CATHETER 19G 155-1520 48714286_1 CDM 0272 RC inpatient 564 366.6 UMR - ALL PLANS UMR - ALL PLANS 394.8 70 999999999 341.5 547.08 percent of total billed charges TUN L CATHETER 19G 155-1520 48714286_1 CDM 0272 RC inpatient 564 366.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 341.5 547.08 TUN L CATHETER 19G 155-1520 48714286_1 CDM 0272 RC inpatient 564 366.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 341.5 547.08 TUN L CATHETER 19G 155-1520 48714286_1 CDM 0272 RC inpatient 564 366.6 ANTHEM HMO ANTHEM HMO 999999999 341.5 547.08 TUN L CATHETER 19G 155-1520 48714286_1 CDM 0272 RC inpatient 564 366.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 381.26 67.6 999999999 341.5 547.08 percent of total billed charges TUN L CATHETER 19G 155-1520 48714286_1 CDM 0272 RC inpatient 564 366.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 341.5 547.08 TUN L CATHETER 19G 155-1520 48714286_1 CDM 0272 RC inpatient 564 366.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 341.5 547.08 ENDO GIA UNIV 60 2.5 #30412 - DELETE AFTER GONE 48714287_1 CDM 0272 RC inpatient 934 607.1 AETNA AETNA 737.86 79 999999999 565.54 905.98 percent of total billed charges ENDO GIA UNIV 60 2.5 #30412 - DELETE AFTER GONE 48714287_1 CDM 0272 RC inpatient 934 607.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 607.1 65 999999999 565.54 905.98 percent of total billed charges ENDO GIA UNIV 60 2.5 #30412 - DELETE AFTER GONE 48714287_1 CDM 0272 RC inpatient 934 607.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 905.98 97 999999999 565.54 905.98 percent of total billed charges ENDO GIA UNIV 60 2.5 #30412 - DELETE AFTER GONE 48714287_1 CDM 0272 RC inpatient 934 607.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 644.46 69 999999999 565.54 905.98 percent of total billed charges ENDO GIA UNIV 60 2.5 #30412 - DELETE AFTER GONE 48714287_1 CDM 0272 RC inpatient 934 607.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 728.52 78 999999999 565.54 905.98 percent of total billed charges ENDO GIA UNIV 60 2.5 #30412 - DELETE AFTER GONE 48714287_1 CDM 0272 RC inpatient 934 607.1 SIHO - ALL PLANS SIHO - ALL PLANS 840.6 90 999999999 565.54 905.98 percent of total billed charges ENDO GIA UNIV 60 2.5 #30412 - DELETE AFTER GONE 48714287_1 CDM 0272 RC inpatient 934 607.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 565.54 60.55 999999999 565.54 905.98 percent of total billed charges ENDO GIA UNIV 60 2.5 #30412 - DELETE AFTER GONE 48714287_1 CDM 0272 RC inpatient 934 607.1 UMR - ALL PLANS UMR - ALL PLANS 653.8 70 999999999 565.54 905.98 percent of total billed charges ENDO GIA UNIV 60 2.5 #30412 - DELETE AFTER GONE 48714287_1 CDM 0272 RC inpatient 934 607.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 565.54 905.98 ENDO GIA UNIV 60 2.5 #30412 - DELETE AFTER GONE 48714287_1 CDM 0272 RC inpatient 934 607.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 565.54 905.98 ENDO GIA UNIV 60 2.5 #30412 - DELETE AFTER GONE 48714287_1 CDM 0272 RC inpatient 934 607.1 ANTHEM HMO ANTHEM HMO 999999999 565.54 905.98 ENDO GIA UNIV 60 2.5 #30412 - DELETE AFTER GONE 48714287_1 CDM 0272 RC inpatient 934 607.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 631.38 67.6 999999999 565.54 905.98 percent of total billed charges ENDO GIA UNIV 60 2.5 #30412 - DELETE AFTER GONE 48714287_1 CDM 0272 RC inpatient 934 607.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 565.54 905.98 ENDO GIA UNIV 60 2.5 #30412 - DELETE AFTER GONE 48714287_1 CDM 0272 RC inpatient 934 607.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 565.54 905.98 ENDO GIA II 45 2.0 #030426 48714288_1 CDM 0272 RC inpatient 633 411.45 AETNA AETNA 500.07 79 999999999 383.28 614.01 percent of total billed charges ENDO GIA II 45 2.0 #030426 48714288_1 CDM 0272 RC inpatient 633 411.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 411.45 65 999999999 383.28 614.01 percent of total billed charges ENDO GIA II 45 2.0 #030426 48714288_1 CDM 0272 RC inpatient 633 411.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 614.01 97 999999999 383.28 614.01 percent of total billed charges ENDO GIA II 45 2.0 #030426 48714288_1 CDM 0272 RC inpatient 633 411.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 436.77 69 999999999 383.28 614.01 percent of total billed charges ENDO GIA II 45 2.0 #030426 48714288_1 CDM 0272 RC inpatient 633 411.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 493.74 78 999999999 383.28 614.01 percent of total billed charges ENDO GIA II 45 2.0 #030426 48714288_1 CDM 0272 RC inpatient 633 411.45 SIHO - ALL PLANS SIHO - ALL PLANS 569.7 90 999999999 383.28 614.01 percent of total billed charges ENDO GIA II 45 2.0 #030426 48714288_1 CDM 0272 RC inpatient 633 411.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 383.28 60.55 999999999 383.28 614.01 percent of total billed charges ENDO GIA II 45 2.0 #030426 48714288_1 CDM 0272 RC inpatient 633 411.45 UMR - ALL PLANS UMR - ALL PLANS 443.1 70 999999999 383.28 614.01 percent of total billed charges ENDO GIA II 45 2.0 #030426 48714288_1 CDM 0272 RC inpatient 633 411.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 383.28 614.01 ENDO GIA II 45 2.0 #030426 48714288_1 CDM 0272 RC inpatient 633 411.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 383.28 614.01 ENDO GIA II 45 2.0 #030426 48714288_1 CDM 0272 RC inpatient 633 411.45 ANTHEM HMO ANTHEM HMO 999999999 383.28 614.01 ENDO GIA II 45 2.0 #030426 48714288_1 CDM 0272 RC inpatient 633 411.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 427.91 67.6 999999999 383.28 614.01 percent of total billed charges ENDO GIA II 45 2.0 #030426 48714288_1 CDM 0272 RC inpatient 633 411.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 383.28 614.01 ENDO GIA II 45 2.0 #030426 48714288_1 CDM 0272 RC inpatient 633 411.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 383.28 614.01 VERSASTEP NEEDLE #S100000 48714289_1 CDM 0272 RC inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges VERSASTEP NEEDLE #S100000 48714289_1 CDM 0272 RC inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges VERSASTEP NEEDLE #S100000 48714289_1 CDM 0272 RC inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges VERSASTEP NEEDLE #S100000 48714289_1 CDM 0272 RC inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges VERSASTEP NEEDLE #S100000 48714289_1 CDM 0272 RC inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges VERSASTEP NEEDLE #S100000 48714289_1 CDM 0272 RC inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges VERSASTEP NEEDLE #S100000 48714289_1 CDM 0272 RC inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges VERSASTEP NEEDLE #S100000 48714289_1 CDM 0272 RC inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges VERSASTEP NEEDLE #S100000 48714289_1 CDM 0272 RC inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 VERSASTEP NEEDLE #S100000 48714289_1 CDM 0272 RC inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 VERSASTEP NEEDLE #S100000 48714289_1 CDM 0272 RC inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 VERSASTEP NEEDLE #S100000 48714289_1 CDM 0272 RC inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges VERSASTEP NEEDLE #S100000 48714289_1 CDM 0272 RC inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 VERSASTEP NEEDLE #S100000 48714289_1 CDM 0272 RC inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 VERSASTEP 12M SLEEVE VS101000 48714290_1 CDM 0272 RC inpatient 333 216.45 AETNA AETNA 263.07 79 999999999 201.63 323.01 percent of total billed charges VERSASTEP 12M SLEEVE VS101000 48714290_1 CDM 0272 RC inpatient 333 216.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 216.45 65 999999999 201.63 323.01 percent of total billed charges VERSASTEP 12M SLEEVE VS101000 48714290_1 CDM 0272 RC inpatient 333 216.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 323.01 97 999999999 201.63 323.01 percent of total billed charges VERSASTEP 12M SLEEVE VS101000 48714290_1 CDM 0272 RC inpatient 333 216.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 229.77 69 999999999 201.63 323.01 percent of total billed charges VERSASTEP 12M SLEEVE VS101000 48714290_1 CDM 0272 RC inpatient 333 216.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 259.74 78 999999999 201.63 323.01 percent of total billed charges VERSASTEP 12M SLEEVE VS101000 48714290_1 CDM 0272 RC inpatient 333 216.45 SIHO - ALL PLANS SIHO - ALL PLANS 299.7 90 999999999 201.63 323.01 percent of total billed charges VERSASTEP 12M SLEEVE VS101000 48714290_1 CDM 0272 RC inpatient 333 216.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 201.63 60.55 999999999 201.63 323.01 percent of total billed charges VERSASTEP 12M SLEEVE VS101000 48714290_1 CDM 0272 RC inpatient 333 216.45 UMR - ALL PLANS UMR - ALL PLANS 233.1 70 999999999 201.63 323.01 percent of total billed charges VERSASTEP 12M SLEEVE VS101000 48714290_1 CDM 0272 RC inpatient 333 216.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 201.63 323.01 VERSASTEP 12M SLEEVE VS101000 48714290_1 CDM 0272 RC inpatient 333 216.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 201.63 323.01 VERSASTEP 12M SLEEVE VS101000 48714290_1 CDM 0272 RC inpatient 333 216.45 ANTHEM HMO ANTHEM HMO 999999999 201.63 323.01 VERSASTEP 12M SLEEVE VS101000 48714290_1 CDM 0272 RC inpatient 333 216.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 225.11 67.6 999999999 201.63 323.01 percent of total billed charges VERSASTEP 12M SLEEVE VS101000 48714290_1 CDM 0272 RC inpatient 333 216.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 201.63 323.01 VERSASTEP 12M SLEEVE VS101000 48714290_1 CDM 0272 RC inpatient 333 216.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 201.63 323.01 STRYKER BLADE 277-96-275 48714291_1 CDM 0272 RC inpatient 222 144.3 AETNA AETNA 175.38 79 999999999 134.42 215.34 percent of total billed charges STRYKER BLADE 277-96-275 48714291_1 CDM 0272 RC inpatient 222 144.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 144.3 65 999999999 134.42 215.34 percent of total billed charges STRYKER BLADE 277-96-275 48714291_1 CDM 0272 RC inpatient 222 144.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 215.34 97 999999999 134.42 215.34 percent of total billed charges STRYKER BLADE 277-96-275 48714291_1 CDM 0272 RC inpatient 222 144.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 153.18 69 999999999 134.42 215.34 percent of total billed charges STRYKER BLADE 277-96-275 48714291_1 CDM 0272 RC inpatient 222 144.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 173.16 78 999999999 134.42 215.34 percent of total billed charges STRYKER BLADE 277-96-275 48714291_1 CDM 0272 RC inpatient 222 144.3 SIHO - ALL PLANS SIHO - ALL PLANS 199.8 90 999999999 134.42 215.34 percent of total billed charges STRYKER BLADE 277-96-275 48714291_1 CDM 0272 RC inpatient 222 144.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 134.42 60.55 999999999 134.42 215.34 percent of total billed charges STRYKER BLADE 277-96-275 48714291_1 CDM 0272 RC inpatient 222 144.3 UMR - ALL PLANS UMR - ALL PLANS 155.4 70 999999999 134.42 215.34 percent of total billed charges STRYKER BLADE 277-96-275 48714291_1 CDM 0272 RC inpatient 222 144.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 134.42 215.34 STRYKER BLADE 277-96-275 48714291_1 CDM 0272 RC inpatient 222 144.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 134.42 215.34 STRYKER BLADE 277-96-275 48714291_1 CDM 0272 RC inpatient 222 144.3 ANTHEM HMO ANTHEM HMO 999999999 134.42 215.34 STRYKER BLADE 277-96-275 48714291_1 CDM 0272 RC inpatient 222 144.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 150.07 67.6 999999999 134.42 215.34 percent of total billed charges STRYKER BLADE 277-96-275 48714291_1 CDM 0272 RC inpatient 222 144.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 134.42 215.34 STRYKER BLADE 277-96-275 48714291_1 CDM 0272 RC inpatient 222 144.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 134.42 215.34 ROTICULATOR ENDO DISSECT 5MM 174213 48714292_1 CDM 0272 RC inpatient 650 422.5 AETNA AETNA 513.5 79 999999999 393.58 630.5 percent of total billed charges ROTICULATOR ENDO DISSECT 5MM 174213 48714292_1 CDM 0272 RC inpatient 650 422.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 422.5 65 999999999 393.58 630.5 percent of total billed charges ROTICULATOR ENDO DISSECT 5MM 174213 48714292_1 CDM 0272 RC inpatient 650 422.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 630.5 97 999999999 393.58 630.5 percent of total billed charges ROTICULATOR ENDO DISSECT 5MM 174213 48714292_1 CDM 0272 RC inpatient 650 422.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 448.5 69 999999999 393.58 630.5 percent of total billed charges ROTICULATOR ENDO DISSECT 5MM 174213 48714292_1 CDM 0272 RC inpatient 650 422.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 507 78 999999999 393.58 630.5 percent of total billed charges ROTICULATOR ENDO DISSECT 5MM 174213 48714292_1 CDM 0272 RC inpatient 650 422.5 SIHO - ALL PLANS SIHO - ALL PLANS 585 90 999999999 393.58 630.5 percent of total billed charges ROTICULATOR ENDO DISSECT 5MM 174213 48714292_1 CDM 0272 RC inpatient 650 422.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 393.58 60.55 999999999 393.58 630.5 percent of total billed charges ROTICULATOR ENDO DISSECT 5MM 174213 48714292_1 CDM 0272 RC inpatient 650 422.5 UMR - ALL PLANS UMR - ALL PLANS 455 70 999999999 393.58 630.5 percent of total billed charges ROTICULATOR ENDO DISSECT 5MM 174213 48714292_1 CDM 0272 RC inpatient 650 422.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 393.58 630.5 ROTICULATOR ENDO DISSECT 5MM 174213 48714292_1 CDM 0272 RC inpatient 650 422.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 393.58 630.5 ROTICULATOR ENDO DISSECT 5MM 174213 48714292_1 CDM 0272 RC inpatient 650 422.5 ANTHEM HMO ANTHEM HMO 999999999 393.58 630.5 ROTICULATOR ENDO DISSECT 5MM 174213 48714292_1 CDM 0272 RC inpatient 650 422.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 439.4 67.6 999999999 393.58 630.5 percent of total billed charges ROTICULATOR ENDO DISSECT 5MM 174213 48714292_1 CDM 0272 RC inpatient 650 422.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 393.58 630.5 ROTICULATOR ENDO DISSECT 5MM 174213 48714292_1 CDM 0272 RC inpatient 650 422.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 393.58 630.5 RADIAL JAW 4 M00515191 48714293_1 CDM 0272 RC inpatient 269 174.85 AETNA AETNA 212.51 79 999999999 162.88 260.93 percent of total billed charges RADIAL JAW 4 M00515191 48714293_1 CDM 0272 RC inpatient 269 174.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 174.85 65 999999999 162.88 260.93 percent of total billed charges RADIAL JAW 4 M00515191 48714293_1 CDM 0272 RC inpatient 269 174.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 260.93 97 999999999 162.88 260.93 percent of total billed charges RADIAL JAW 4 M00515191 48714293_1 CDM 0272 RC inpatient 269 174.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 185.61 69 999999999 162.88 260.93 percent of total billed charges RADIAL JAW 4 M00515191 48714293_1 CDM 0272 RC inpatient 269 174.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 209.82 78 999999999 162.88 260.93 percent of total billed charges RADIAL JAW 4 M00515191 48714293_1 CDM 0272 RC inpatient 269 174.85 SIHO - ALL PLANS SIHO - ALL PLANS 242.1 90 999999999 162.88 260.93 percent of total billed charges RADIAL JAW 4 M00515191 48714293_1 CDM 0272 RC inpatient 269 174.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 162.88 60.55 999999999 162.88 260.93 percent of total billed charges RADIAL JAW 4 M00515191 48714293_1 CDM 0272 RC inpatient 269 174.85 UMR - ALL PLANS UMR - ALL PLANS 188.3 70 999999999 162.88 260.93 percent of total billed charges RADIAL JAW 4 M00515191 48714293_1 CDM 0272 RC inpatient 269 174.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 162.88 260.93 RADIAL JAW 4 M00515191 48714293_1 CDM 0272 RC inpatient 269 174.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 162.88 260.93 RADIAL JAW 4 M00515191 48714293_1 CDM 0272 RC inpatient 269 174.85 ANTHEM HMO ANTHEM HMO 999999999 162.88 260.93 RADIAL JAW 4 M00515191 48714293_1 CDM 0272 RC inpatient 269 174.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 181.84 67.6 999999999 162.88 260.93 percent of total billed charges RADIAL JAW 4 M00515191 48714293_1 CDM 0272 RC inpatient 269 174.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 162.88 260.93 RADIAL JAW 4 M00515191 48714293_1 CDM 0272 RC inpatient 269 174.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 162.88 260.93 VERSASTEP PLUS LONG VS101512P 48714294_1 CDM 0272 RC inpatient 451 293.15 AETNA AETNA 356.29 79 999999999 273.08 437.47 percent of total billed charges VERSASTEP PLUS LONG VS101512P 48714294_1 CDM 0272 RC inpatient 451 293.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 293.15 65 999999999 273.08 437.47 percent of total billed charges VERSASTEP PLUS LONG VS101512P 48714294_1 CDM 0272 RC inpatient 451 293.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 437.47 97 999999999 273.08 437.47 percent of total billed charges VERSASTEP PLUS LONG VS101512P 48714294_1 CDM 0272 RC inpatient 451 293.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 311.19 69 999999999 273.08 437.47 percent of total billed charges VERSASTEP PLUS LONG VS101512P 48714294_1 CDM 0272 RC inpatient 451 293.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 351.78 78 999999999 273.08 437.47 percent of total billed charges VERSASTEP PLUS LONG VS101512P 48714294_1 CDM 0272 RC inpatient 451 293.15 SIHO - ALL PLANS SIHO - ALL PLANS 405.9 90 999999999 273.08 437.47 percent of total billed charges VERSASTEP PLUS LONG VS101512P 48714294_1 CDM 0272 RC inpatient 451 293.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 273.08 60.55 999999999 273.08 437.47 percent of total billed charges VERSASTEP PLUS LONG VS101512P 48714294_1 CDM 0272 RC inpatient 451 293.15 UMR - ALL PLANS UMR - ALL PLANS 315.7 70 999999999 273.08 437.47 percent of total billed charges VERSASTEP PLUS LONG VS101512P 48714294_1 CDM 0272 RC inpatient 451 293.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 273.08 437.47 VERSASTEP PLUS LONG VS101512P 48714294_1 CDM 0272 RC inpatient 451 293.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 273.08 437.47 VERSASTEP PLUS LONG VS101512P 48714294_1 CDM 0272 RC inpatient 451 293.15 ANTHEM HMO ANTHEM HMO 999999999 273.08 437.47 VERSASTEP PLUS LONG VS101512P 48714294_1 CDM 0272 RC inpatient 451 293.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 304.88 67.6 999999999 273.08 437.47 percent of total billed charges VERSASTEP PLUS LONG VS101512P 48714294_1 CDM 0272 RC inpatient 451 293.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 273.08 437.47 VERSASTEP PLUS LONG VS101512P 48714294_1 CDM 0272 RC inpatient 451 293.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 273.08 437.47 STONE RET BASKET 2.4FR X 90CM 48714295_1 CDM 0272 RC inpatient 742 482.3 AETNA AETNA 586.18 79 999999999 449.28 719.74 percent of total billed charges STONE RET BASKET 2.4FR X 90CM 48714295_1 CDM 0272 RC inpatient 742 482.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 482.3 65 999999999 449.28 719.74 percent of total billed charges STONE RET BASKET 2.4FR X 90CM 48714295_1 CDM 0272 RC inpatient 742 482.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 719.74 97 999999999 449.28 719.74 percent of total billed charges STONE RET BASKET 2.4FR X 90CM 48714295_1 CDM 0272 RC inpatient 742 482.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 511.98 69 999999999 449.28 719.74 percent of total billed charges STONE RET BASKET 2.4FR X 90CM 48714295_1 CDM 0272 RC inpatient 742 482.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 578.76 78 999999999 449.28 719.74 percent of total billed charges STONE RET BASKET 2.4FR X 90CM 48714295_1 CDM 0272 RC inpatient 742 482.3 SIHO - ALL PLANS SIHO - ALL PLANS 667.8 90 999999999 449.28 719.74 percent of total billed charges STONE RET BASKET 2.4FR X 90CM 48714295_1 CDM 0272 RC inpatient 742 482.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 449.28 60.55 999999999 449.28 719.74 percent of total billed charges STONE RET BASKET 2.4FR X 90CM 48714295_1 CDM 0272 RC inpatient 742 482.3 UMR - ALL PLANS UMR - ALL PLANS 519.4 70 999999999 449.28 719.74 percent of total billed charges STONE RET BASKET 2.4FR X 90CM 48714295_1 CDM 0272 RC inpatient 742 482.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 449.28 719.74 STONE RET BASKET 2.4FR X 90CM 48714295_1 CDM 0272 RC inpatient 742 482.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 449.28 719.74 STONE RET BASKET 2.4FR X 90CM 48714295_1 CDM 0272 RC inpatient 742 482.3 ANTHEM HMO ANTHEM HMO 999999999 449.28 719.74 STONE RET BASKET 2.4FR X 90CM 48714295_1 CDM 0272 RC inpatient 742 482.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 501.59 67.6 999999999 449.28 719.74 percent of total billed charges STONE RET BASKET 2.4FR X 90CM 48714295_1 CDM 0272 RC inpatient 742 482.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 449.28 719.74 STONE RET BASKET 2.4FR X 90CM 48714295_1 CDM 0272 RC inpatient 742 482.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 449.28 719.74 TRICEP GRASPING FORCEP 370-123 48714296_1 CDM 0272 RC inpatient 1137 739.05 AETNA AETNA 898.23 79 999999999 688.45 1102.89 percent of total billed charges TRICEP GRASPING FORCEP 370-123 48714296_1 CDM 0272 RC inpatient 1137 739.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 739.05 65 999999999 688.45 1102.89 percent of total billed charges TRICEP GRASPING FORCEP 370-123 48714296_1 CDM 0272 RC inpatient 1137 739.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1102.89 97 999999999 688.45 1102.89 percent of total billed charges TRICEP GRASPING FORCEP 370-123 48714296_1 CDM 0272 RC inpatient 1137 739.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 784.53 69 999999999 688.45 1102.89 percent of total billed charges TRICEP GRASPING FORCEP 370-123 48714296_1 CDM 0272 RC inpatient 1137 739.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 886.86 78 999999999 688.45 1102.89 percent of total billed charges TRICEP GRASPING FORCEP 370-123 48714296_1 CDM 0272 RC inpatient 1137 739.05 SIHO - ALL PLANS SIHO - ALL PLANS 1023.3 90 999999999 688.45 1102.89 percent of total billed charges TRICEP GRASPING FORCEP 370-123 48714296_1 CDM 0272 RC inpatient 1137 739.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 688.45 60.55 999999999 688.45 1102.89 percent of total billed charges TRICEP GRASPING FORCEP 370-123 48714296_1 CDM 0272 RC inpatient 1137 739.05 UMR - ALL PLANS UMR - ALL PLANS 795.9 70 999999999 688.45 1102.89 percent of total billed charges TRICEP GRASPING FORCEP 370-123 48714296_1 CDM 0272 RC inpatient 1137 739.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 688.45 1102.89 TRICEP GRASPING FORCEP 370-123 48714296_1 CDM 0272 RC inpatient 1137 739.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 688.45 1102.89 TRICEP GRASPING FORCEP 370-123 48714296_1 CDM 0272 RC inpatient 1137 739.05 ANTHEM HMO ANTHEM HMO 999999999 688.45 1102.89 TRICEP GRASPING FORCEP 370-123 48714296_1 CDM 0272 RC inpatient 1137 739.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 768.61 67.6 999999999 688.45 1102.89 percent of total billed charges TRICEP GRASPING FORCEP 370-123 48714296_1 CDM 0272 RC inpatient 1137 739.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 688.45 1102.89 TRICEP GRASPING FORCEP 370-123 48714296_1 CDM 0272 RC inpatient 1137 739.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 688.45 1102.89 STONE RET BASKET 1.8FR 48714297_1 CDM 0272 RC inpatient 1025 666.25 AETNA AETNA 809.75 79 999999999 620.64 994.25 percent of total billed charges STONE RET BASKET 1.8FR 48714297_1 CDM 0272 RC inpatient 1025 666.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 666.25 65 999999999 620.64 994.25 percent of total billed charges STONE RET BASKET 1.8FR 48714297_1 CDM 0272 RC inpatient 1025 666.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 994.25 97 999999999 620.64 994.25 percent of total billed charges STONE RET BASKET 1.8FR 48714297_1 CDM 0272 RC inpatient 1025 666.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 707.25 69 999999999 620.64 994.25 percent of total billed charges STONE RET BASKET 1.8FR 48714297_1 CDM 0272 RC inpatient 1025 666.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 799.5 78 999999999 620.64 994.25 percent of total billed charges STONE RET BASKET 1.8FR 48714297_1 CDM 0272 RC inpatient 1025 666.25 SIHO - ALL PLANS SIHO - ALL PLANS 922.5 90 999999999 620.64 994.25 percent of total billed charges STONE RET BASKET 1.8FR 48714297_1 CDM 0272 RC inpatient 1025 666.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 620.64 60.55 999999999 620.64 994.25 percent of total billed charges STONE RET BASKET 1.8FR 48714297_1 CDM 0272 RC inpatient 1025 666.25 UMR - ALL PLANS UMR - ALL PLANS 717.5 70 999999999 620.64 994.25 percent of total billed charges STONE RET BASKET 1.8FR 48714297_1 CDM 0272 RC inpatient 1025 666.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 620.64 994.25 STONE RET BASKET 1.8FR 48714297_1 CDM 0272 RC inpatient 1025 666.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 620.64 994.25 STONE RET BASKET 1.8FR 48714297_1 CDM 0272 RC inpatient 1025 666.25 ANTHEM HMO ANTHEM HMO 999999999 620.64 994.25 STONE RET BASKET 1.8FR 48714297_1 CDM 0272 RC inpatient 1025 666.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 692.9 67.6 999999999 620.64 994.25 percent of total billed charges STONE RET BASKET 1.8FR 48714297_1 CDM 0272 RC inpatient 1025 666.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 620.64 994.25 STONE RET BASKET 1.8FR 48714297_1 CDM 0272 RC inpatient 1025 666.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 620.64 994.25 "HYBRID WIRE .035"" GWH3505R" 48714298_1 CDM 0272 RC inpatient 258 167.7 AETNA AETNA 203.82 79 999999999 156.22 250.26 percent of total billed charges "HYBRID WIRE .035"" GWH3505R" 48714298_1 CDM 0272 RC inpatient 258 167.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.7 65 999999999 156.22 250.26 percent of total billed charges "HYBRID WIRE .035"" GWH3505R" 48714298_1 CDM 0272 RC inpatient 258 167.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 250.26 97 999999999 156.22 250.26 percent of total billed charges "HYBRID WIRE .035"" GWH3505R" 48714298_1 CDM 0272 RC inpatient 258 167.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 178.02 69 999999999 156.22 250.26 percent of total billed charges "HYBRID WIRE .035"" GWH3505R" 48714298_1 CDM 0272 RC inpatient 258 167.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 201.24 78 999999999 156.22 250.26 percent of total billed charges "HYBRID WIRE .035"" GWH3505R" 48714298_1 CDM 0272 RC inpatient 258 167.7 SIHO - ALL PLANS SIHO - ALL PLANS 232.2 90 999999999 156.22 250.26 percent of total billed charges "HYBRID WIRE .035"" GWH3505R" 48714298_1 CDM 0272 RC inpatient 258 167.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 156.22 60.55 999999999 156.22 250.26 percent of total billed charges "HYBRID WIRE .035"" GWH3505R" 48714298_1 CDM 0272 RC inpatient 258 167.7 UMR - ALL PLANS UMR - ALL PLANS 180.6 70 999999999 156.22 250.26 percent of total billed charges "HYBRID WIRE .035"" GWH3505R" 48714298_1 CDM 0272 RC inpatient 258 167.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 156.22 250.26 "HYBRID WIRE .035"" GWH3505R" 48714298_1 CDM 0272 RC inpatient 258 167.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 156.22 250.26 "HYBRID WIRE .035"" GWH3505R" 48714298_1 CDM 0272 RC inpatient 258 167.7 ANTHEM HMO ANTHEM HMO 999999999 156.22 250.26 "HYBRID WIRE .035"" GWH3505R" 48714298_1 CDM 0272 RC inpatient 258 167.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 174.41 67.6 999999999 156.22 250.26 percent of total billed charges "HYBRID WIRE .035"" GWH3505R" 48714298_1 CDM 0272 RC inpatient 258 167.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 156.22 250.26 "HYBRID WIRE .035"" GWH3505R" 48714298_1 CDM 0272 RC inpatient 258 167.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 156.22 250.26 GRAY ARTICULATING EGIA45AV 48714299_1 CDM 0272 RC inpatient 1407 914.55 AETNA AETNA 1111.53 79 999999999 851.94 1364.79 percent of total billed charges GRAY ARTICULATING EGIA45AV 48714299_1 CDM 0272 RC inpatient 1407 914.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 914.55 65 999999999 851.94 1364.79 percent of total billed charges GRAY ARTICULATING EGIA45AV 48714299_1 CDM 0272 RC inpatient 1407 914.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1364.79 97 999999999 851.94 1364.79 percent of total billed charges GRAY ARTICULATING EGIA45AV 48714299_1 CDM 0272 RC inpatient 1407 914.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 970.83 69 999999999 851.94 1364.79 percent of total billed charges GRAY ARTICULATING EGIA45AV 48714299_1 CDM 0272 RC inpatient 1407 914.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1097.46 78 999999999 851.94 1364.79 percent of total billed charges GRAY ARTICULATING EGIA45AV 48714299_1 CDM 0272 RC inpatient 1407 914.55 SIHO - ALL PLANS SIHO - ALL PLANS 1266.3 90 999999999 851.94 1364.79 percent of total billed charges GRAY ARTICULATING EGIA45AV 48714299_1 CDM 0272 RC inpatient 1407 914.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 851.94 60.55 999999999 851.94 1364.79 percent of total billed charges GRAY ARTICULATING EGIA45AV 48714299_1 CDM 0272 RC inpatient 1407 914.55 UMR - ALL PLANS UMR - ALL PLANS 984.9 70 999999999 851.94 1364.79 percent of total billed charges GRAY ARTICULATING EGIA45AV 48714299_1 CDM 0272 RC inpatient 1407 914.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 851.94 1364.79 GRAY ARTICULATING EGIA45AV 48714299_1 CDM 0272 RC inpatient 1407 914.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 851.94 1364.79 GRAY ARTICULATING EGIA45AV 48714299_1 CDM 0272 RC inpatient 1407 914.55 ANTHEM HMO ANTHEM HMO 999999999 851.94 1364.79 GRAY ARTICULATING EGIA45AV 48714299_1 CDM 0272 RC inpatient 1407 914.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 951.13 67.6 999999999 851.94 1364.79 percent of total billed charges GRAY ARTICULATING EGIA45AV 48714299_1 CDM 0272 RC inpatient 1407 914.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 851.94 1364.79 GRAY ARTICULATING EGIA45AV 48714299_1 CDM 0272 RC inpatient 1407 914.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 851.94 1364.79 ENDO PADDLE RETRACTOR 173046 48714300_1 CDM 0272 RC inpatient 762 495.3 AETNA AETNA 601.98 79 999999999 461.39 739.14 percent of total billed charges ENDO PADDLE RETRACTOR 173046 48714300_1 CDM 0272 RC inpatient 762 495.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 495.3 65 999999999 461.39 739.14 percent of total billed charges ENDO PADDLE RETRACTOR 173046 48714300_1 CDM 0272 RC inpatient 762 495.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 739.14 97 999999999 461.39 739.14 percent of total billed charges ENDO PADDLE RETRACTOR 173046 48714300_1 CDM 0272 RC inpatient 762 495.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 525.78 69 999999999 461.39 739.14 percent of total billed charges ENDO PADDLE RETRACTOR 173046 48714300_1 CDM 0272 RC inpatient 762 495.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 594.36 78 999999999 461.39 739.14 percent of total billed charges ENDO PADDLE RETRACTOR 173046 48714300_1 CDM 0272 RC inpatient 762 495.3 SIHO - ALL PLANS SIHO - ALL PLANS 685.8 90 999999999 461.39 739.14 percent of total billed charges ENDO PADDLE RETRACTOR 173046 48714300_1 CDM 0272 RC inpatient 762 495.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 461.39 60.55 999999999 461.39 739.14 percent of total billed charges ENDO PADDLE RETRACTOR 173046 48714300_1 CDM 0272 RC inpatient 762 495.3 UMR - ALL PLANS UMR - ALL PLANS 533.4 70 999999999 461.39 739.14 percent of total billed charges ENDO PADDLE RETRACTOR 173046 48714300_1 CDM 0272 RC inpatient 762 495.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 461.39 739.14 ENDO PADDLE RETRACTOR 173046 48714300_1 CDM 0272 RC inpatient 762 495.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 461.39 739.14 ENDO PADDLE RETRACTOR 173046 48714300_1 CDM 0272 RC inpatient 762 495.3 ANTHEM HMO ANTHEM HMO 999999999 461.39 739.14 ENDO PADDLE RETRACTOR 173046 48714300_1 CDM 0272 RC inpatient 762 495.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 515.11 67.6 999999999 461.39 739.14 percent of total billed charges ENDO PADDLE RETRACTOR 173046 48714300_1 CDM 0272 RC inpatient 762 495.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 461.39 739.14 ENDO PADDLE RETRACTOR 173046 48714300_1 CDM 0272 RC inpatient 762 495.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 461.39 739.14 BEVELED GROMMET TUBE 1.14MM ID 48714301_1 CDM 0272 RC inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges BEVELED GROMMET TUBE 1.14MM ID 48714301_1 CDM 0272 RC inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges BEVELED GROMMET TUBE 1.14MM ID 48714301_1 CDM 0272 RC inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges BEVELED GROMMET TUBE 1.14MM ID 48714301_1 CDM 0272 RC inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges BEVELED GROMMET TUBE 1.14MM ID 48714301_1 CDM 0272 RC inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges BEVELED GROMMET TUBE 1.14MM ID 48714301_1 CDM 0272 RC inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges BEVELED GROMMET TUBE 1.14MM ID 48714301_1 CDM 0272 RC inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges BEVELED GROMMET TUBE 1.14MM ID 48714301_1 CDM 0272 RC inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges BEVELED GROMMET TUBE 1.14MM ID 48714301_1 CDM 0272 RC inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 BEVELED GROMMET TUBE 1.14MM ID 48714301_1 CDM 0272 RC inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 BEVELED GROMMET TUBE 1.14MM ID 48714301_1 CDM 0272 RC inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 BEVELED GROMMET TUBE 1.14MM ID 48714301_1 CDM 0272 RC inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges BEVELED GROMMET TUBE 1.14MM ID 48714301_1 CDM 0272 RC inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 BEVELED GROMMET TUBE 1.14MM ID 48714301_1 CDM 0272 RC inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 COLD KNIFE STRAIGHT BLADE K-SB 48714302_1 CDM 0272 RC inpatient 972 631.8 AETNA AETNA 767.88 79 999999999 588.55 942.84 percent of total billed charges COLD KNIFE STRAIGHT BLADE K-SB 48714302_1 CDM 0272 RC inpatient 972 631.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 631.8 65 999999999 588.55 942.84 percent of total billed charges COLD KNIFE STRAIGHT BLADE K-SB 48714302_1 CDM 0272 RC inpatient 972 631.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 942.84 97 999999999 588.55 942.84 percent of total billed charges COLD KNIFE STRAIGHT BLADE K-SB 48714302_1 CDM 0272 RC inpatient 972 631.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 670.68 69 999999999 588.55 942.84 percent of total billed charges COLD KNIFE STRAIGHT BLADE K-SB 48714302_1 CDM 0272 RC inpatient 972 631.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 758.16 78 999999999 588.55 942.84 percent of total billed charges COLD KNIFE STRAIGHT BLADE K-SB 48714302_1 CDM 0272 RC inpatient 972 631.8 SIHO - ALL PLANS SIHO - ALL PLANS 874.8 90 999999999 588.55 942.84 percent of total billed charges COLD KNIFE STRAIGHT BLADE K-SB 48714302_1 CDM 0272 RC inpatient 972 631.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 588.55 60.55 999999999 588.55 942.84 percent of total billed charges COLD KNIFE STRAIGHT BLADE K-SB 48714302_1 CDM 0272 RC inpatient 972 631.8 UMR - ALL PLANS UMR - ALL PLANS 680.4 70 999999999 588.55 942.84 percent of total billed charges COLD KNIFE STRAIGHT BLADE K-SB 48714302_1 CDM 0272 RC inpatient 972 631.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 588.55 942.84 COLD KNIFE STRAIGHT BLADE K-SB 48714302_1 CDM 0272 RC inpatient 972 631.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 588.55 942.84 COLD KNIFE STRAIGHT BLADE K-SB 48714302_1 CDM 0272 RC inpatient 972 631.8 ANTHEM HMO ANTHEM HMO 999999999 588.55 942.84 COLD KNIFE STRAIGHT BLADE K-SB 48714302_1 CDM 0272 RC inpatient 972 631.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 657.07 67.6 999999999 588.55 942.84 percent of total billed charges COLD KNIFE STRAIGHT BLADE K-SB 48714302_1 CDM 0272 RC inpatient 972 631.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 588.55 942.84 COLD KNIFE STRAIGHT BLADE K-SB 48714302_1 CDM 0272 RC inpatient 972 631.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 588.55 942.84 LAPARSCOPIC ROUX EN Y KIT 48714303_1 CDM 0272 RC inpatient 15284 9934.6 AETNA AETNA 12074.36 79 999999999 9254.46 14825.48 percent of total billed charges LAPARSCOPIC ROUX EN Y KIT 48714303_1 CDM 0272 RC inpatient 15284 9934.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 9934.6 65 999999999 9254.46 14825.48 percent of total billed charges LAPARSCOPIC ROUX EN Y KIT 48714303_1 CDM 0272 RC inpatient 15284 9934.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14825.48 97 999999999 9254.46 14825.48 percent of total billed charges LAPARSCOPIC ROUX EN Y KIT 48714303_1 CDM 0272 RC inpatient 15284 9934.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 10545.96 69 999999999 9254.46 14825.48 percent of total billed charges LAPARSCOPIC ROUX EN Y KIT 48714303_1 CDM 0272 RC inpatient 15284 9934.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 11921.52 78 999999999 9254.46 14825.48 percent of total billed charges LAPARSCOPIC ROUX EN Y KIT 48714303_1 CDM 0272 RC inpatient 15284 9934.6 SIHO - ALL PLANS SIHO - ALL PLANS 13755.6 90 999999999 9254.46 14825.48 percent of total billed charges LAPARSCOPIC ROUX EN Y KIT 48714303_1 CDM 0272 RC inpatient 15284 9934.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9254.46 60.55 999999999 9254.46 14825.48 percent of total billed charges LAPARSCOPIC ROUX EN Y KIT 48714303_1 CDM 0272 RC inpatient 15284 9934.6 UMR - ALL PLANS UMR - ALL PLANS 10698.8 70 999999999 9254.46 14825.48 percent of total billed charges LAPARSCOPIC ROUX EN Y KIT 48714303_1 CDM 0272 RC inpatient 15284 9934.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9254.46 14825.48 LAPARSCOPIC ROUX EN Y KIT 48714303_1 CDM 0272 RC inpatient 15284 9934.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9254.46 14825.48 LAPARSCOPIC ROUX EN Y KIT 48714303_1 CDM 0272 RC inpatient 15284 9934.6 ANTHEM HMO ANTHEM HMO 999999999 9254.46 14825.48 LAPARSCOPIC ROUX EN Y KIT 48714303_1 CDM 0272 RC inpatient 15284 9934.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 10331.98 67.6 999999999 9254.46 14825.48 percent of total billed charges LAPARSCOPIC ROUX EN Y KIT 48714303_1 CDM 0272 RC inpatient 15284 9934.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9254.46 14825.48 LAPARSCOPIC ROUX EN Y KIT 48714303_1 CDM 0272 RC inpatient 15284 9934.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 9254.46 14825.48 FILIFORM SPIRAL TIP 5FR 022005 48714304_1 CDM 0278 RC inpatient 466 302.9 AETNA AETNA 368.14 79 999999999 282.16 452.02 percent of total billed charges FILIFORM SPIRAL TIP 5FR 022005 48714304_1 CDM 0278 RC inpatient 466 302.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 302.9 65 999999999 282.16 452.02 percent of total billed charges FILIFORM SPIRAL TIP 5FR 022005 48714304_1 CDM 0278 RC inpatient 466 302.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 452.02 97 999999999 282.16 452.02 percent of total billed charges FILIFORM SPIRAL TIP 5FR 022005 48714304_1 CDM 0278 RC inpatient 466 302.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 321.54 69 999999999 282.16 452.02 percent of total billed charges FILIFORM SPIRAL TIP 5FR 022005 48714304_1 CDM 0278 RC inpatient 466 302.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 363.48 78 999999999 282.16 452.02 percent of total billed charges FILIFORM SPIRAL TIP 5FR 022005 48714304_1 CDM 0278 RC inpatient 466 302.9 SIHO - ALL PLANS SIHO - ALL PLANS 419.4 90 999999999 282.16 452.02 percent of total billed charges FILIFORM SPIRAL TIP 5FR 022005 48714304_1 CDM 0278 RC inpatient 466 302.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 282.16 60.55 999999999 282.16 452.02 percent of total billed charges FILIFORM SPIRAL TIP 5FR 022005 48714304_1 CDM 0278 RC inpatient 466 302.9 UMR - ALL PLANS UMR - ALL PLANS 326.2 70 999999999 282.16 452.02 percent of total billed charges FILIFORM SPIRAL TIP 5FR 022005 48714304_1 CDM 0278 RC inpatient 466 302.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 282.16 452.02 FILIFORM SPIRAL TIP 5FR 022005 48714304_1 CDM 0278 RC inpatient 466 302.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 282.16 452.02 FILIFORM SPIRAL TIP 5FR 022005 48714304_1 CDM 0278 RC inpatient 466 302.9 ANTHEM HMO ANTHEM HMO 999999999 282.16 452.02 FILIFORM SPIRAL TIP 5FR 022005 48714304_1 CDM 0278 RC inpatient 466 302.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 315.02 67.6 999999999 282.16 452.02 percent of total billed charges FILIFORM SPIRAL TIP 5FR 022005 48714304_1 CDM 0278 RC inpatient 466 302.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 282.16 452.02 FILIFORM SPIRAL TIP 5FR 022005 48714304_1 CDM 0278 RC inpatient 466 302.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 282.16 452.02 FOLLOWER 18FR. #021518 48714305_1 CDM 0272 RC inpatient 650 422.5 AETNA AETNA 513.5 79 999999999 393.58 630.5 percent of total billed charges FOLLOWER 18FR. #021518 48714305_1 CDM 0272 RC inpatient 650 422.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 422.5 65 999999999 393.58 630.5 percent of total billed charges FOLLOWER 18FR. #021518 48714305_1 CDM 0272 RC inpatient 650 422.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 630.5 97 999999999 393.58 630.5 percent of total billed charges FOLLOWER 18FR. #021518 48714305_1 CDM 0272 RC inpatient 650 422.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 448.5 69 999999999 393.58 630.5 percent of total billed charges FOLLOWER 18FR. #021518 48714305_1 CDM 0272 RC inpatient 650 422.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 507 78 999999999 393.58 630.5 percent of total billed charges FOLLOWER 18FR. #021518 48714305_1 CDM 0272 RC inpatient 650 422.5 SIHO - ALL PLANS SIHO - ALL PLANS 585 90 999999999 393.58 630.5 percent of total billed charges FOLLOWER 18FR. #021518 48714305_1 CDM 0272 RC inpatient 650 422.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 393.58 60.55 999999999 393.58 630.5 percent of total billed charges FOLLOWER 18FR. #021518 48714305_1 CDM 0272 RC inpatient 650 422.5 UMR - ALL PLANS UMR - ALL PLANS 455 70 999999999 393.58 630.5 percent of total billed charges FOLLOWER 18FR. #021518 48714305_1 CDM 0272 RC inpatient 650 422.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 393.58 630.5 FOLLOWER 18FR. #021518 48714305_1 CDM 0272 RC inpatient 650 422.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 393.58 630.5 FOLLOWER 18FR. #021518 48714305_1 CDM 0272 RC inpatient 650 422.5 ANTHEM HMO ANTHEM HMO 999999999 393.58 630.5 FOLLOWER 18FR. #021518 48714305_1 CDM 0272 RC inpatient 650 422.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 439.4 67.6 999999999 393.58 630.5 percent of total billed charges FOLLOWER 18FR. #021518 48714305_1 CDM 0272 RC inpatient 650 422.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 393.58 630.5 FOLLOWER 18FR. #021518 48714305_1 CDM 0272 RC inpatient 650 422.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 393.58 630.5 FOLLOWER 24FR. #021524 48714306_1 CDM 0272 RC inpatient 350 227.5 AETNA AETNA 276.5 79 999999999 211.93 339.5 percent of total billed charges FOLLOWER 24FR. #021524 48714306_1 CDM 0272 RC inpatient 350 227.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 227.5 65 999999999 211.93 339.5 percent of total billed charges FOLLOWER 24FR. #021524 48714306_1 CDM 0272 RC inpatient 350 227.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 339.5 97 999999999 211.93 339.5 percent of total billed charges FOLLOWER 24FR. #021524 48714306_1 CDM 0272 RC inpatient 350 227.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 241.5 69 999999999 211.93 339.5 percent of total billed charges FOLLOWER 24FR. #021524 48714306_1 CDM 0272 RC inpatient 350 227.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 273 78 999999999 211.93 339.5 percent of total billed charges FOLLOWER 24FR. #021524 48714306_1 CDM 0272 RC inpatient 350 227.5 SIHO - ALL PLANS SIHO - ALL PLANS 315 90 999999999 211.93 339.5 percent of total billed charges FOLLOWER 24FR. #021524 48714306_1 CDM 0272 RC inpatient 350 227.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 211.93 60.55 999999999 211.93 339.5 percent of total billed charges FOLLOWER 24FR. #021524 48714306_1 CDM 0272 RC inpatient 350 227.5 UMR - ALL PLANS UMR - ALL PLANS 245 70 999999999 211.93 339.5 percent of total billed charges FOLLOWER 24FR. #021524 48714306_1 CDM 0272 RC inpatient 350 227.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 211.93 339.5 FOLLOWER 24FR. #021524 48714306_1 CDM 0272 RC inpatient 350 227.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 211.93 339.5 FOLLOWER 24FR. #021524 48714306_1 CDM 0272 RC inpatient 350 227.5 ANTHEM HMO ANTHEM HMO 999999999 211.93 339.5 FOLLOWER 24FR. #021524 48714306_1 CDM 0272 RC inpatient 350 227.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 236.6 67.6 999999999 211.93 339.5 percent of total billed charges FOLLOWER 24FR. #021524 48714306_1 CDM 0272 RC inpatient 350 227.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 211.93 339.5 FOLLOWER 24FR. #021524 48714306_1 CDM 0272 RC inpatient 350 227.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 211.93 339.5 "SURGICAL PATTIES 1/2"" X 1""" 48714307_1 CDM 0272 RC inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "SURGICAL PATTIES 1/2"" X 1""" 48714307_1 CDM 0272 RC inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "SURGICAL PATTIES 1/2"" X 1""" 48714307_1 CDM 0272 RC inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "SURGICAL PATTIES 1/2"" X 1""" 48714307_1 CDM 0272 RC inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "SURGICAL PATTIES 1/2"" X 1""" 48714307_1 CDM 0272 RC inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "SURGICAL PATTIES 1/2"" X 1""" 48714307_1 CDM 0272 RC inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "SURGICAL PATTIES 1/2"" X 1""" 48714307_1 CDM 0272 RC inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "SURGICAL PATTIES 1/2"" X 1""" 48714307_1 CDM 0272 RC inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "SURGICAL PATTIES 1/2"" X 1""" 48714307_1 CDM 0272 RC inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "SURGICAL PATTIES 1/2"" X 1""" 48714307_1 CDM 0272 RC inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "SURGICAL PATTIES 1/2"" X 1""" 48714307_1 CDM 0272 RC inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "SURGICAL PATTIES 1/2"" X 1""" 48714307_1 CDM 0272 RC inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "SURGICAL PATTIES 1/2"" X 1""" 48714307_1 CDM 0272 RC inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "SURGICAL PATTIES 1/2"" X 1""" 48714307_1 CDM 0272 RC inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 INLET CLOSURE PROCEDURE KIT 48714308_1 CDM 0272 RC inpatient 898 583.7 AETNA AETNA 709.42 79 999999999 543.74 871.06 percent of total billed charges INLET CLOSURE PROCEDURE KIT 48714308_1 CDM 0272 RC inpatient 898 583.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 583.7 65 999999999 543.74 871.06 percent of total billed charges INLET CLOSURE PROCEDURE KIT 48714308_1 CDM 0272 RC inpatient 898 583.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 871.06 97 999999999 543.74 871.06 percent of total billed charges INLET CLOSURE PROCEDURE KIT 48714308_1 CDM 0272 RC inpatient 898 583.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 619.62 69 999999999 543.74 871.06 percent of total billed charges INLET CLOSURE PROCEDURE KIT 48714308_1 CDM 0272 RC inpatient 898 583.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 700.44 78 999999999 543.74 871.06 percent of total billed charges INLET CLOSURE PROCEDURE KIT 48714308_1 CDM 0272 RC inpatient 898 583.7 SIHO - ALL PLANS SIHO - ALL PLANS 808.2 90 999999999 543.74 871.06 percent of total billed charges INLET CLOSURE PROCEDURE KIT 48714308_1 CDM 0272 RC inpatient 898 583.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 543.74 60.55 999999999 543.74 871.06 percent of total billed charges INLET CLOSURE PROCEDURE KIT 48714308_1 CDM 0272 RC inpatient 898 583.7 UMR - ALL PLANS UMR - ALL PLANS 628.6 70 999999999 543.74 871.06 percent of total billed charges INLET CLOSURE PROCEDURE KIT 48714308_1 CDM 0272 RC inpatient 898 583.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 543.74 871.06 INLET CLOSURE PROCEDURE KIT 48714308_1 CDM 0272 RC inpatient 898 583.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 543.74 871.06 INLET CLOSURE PROCEDURE KIT 48714308_1 CDM 0272 RC inpatient 898 583.7 ANTHEM HMO ANTHEM HMO 999999999 543.74 871.06 INLET CLOSURE PROCEDURE KIT 48714308_1 CDM 0272 RC inpatient 898 583.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 607.05 67.6 999999999 543.74 871.06 percent of total billed charges INLET CLOSURE PROCEDURE KIT 48714308_1 CDM 0272 RC inpatient 898 583.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 543.74 871.06 INLET CLOSURE PROCEDURE KIT 48714308_1 CDM 0272 RC inpatient 898 583.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 543.74 871.06 OSTEOSET RESORB/MINI BEAD KIT 48714309_1 CDM 0270 RC inpatient 3293 2140.45 AETNA AETNA 2601.47 79 999999999 1993.91 3194.21 percent of total billed charges OSTEOSET RESORB/MINI BEAD KIT 48714309_1 CDM 0270 RC inpatient 3293 2140.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 2140.45 65 999999999 1993.91 3194.21 percent of total billed charges OSTEOSET RESORB/MINI BEAD KIT 48714309_1 CDM 0270 RC inpatient 3293 2140.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3194.21 97 999999999 1993.91 3194.21 percent of total billed charges OSTEOSET RESORB/MINI BEAD KIT 48714309_1 CDM 0270 RC inpatient 3293 2140.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 2272.17 69 999999999 1993.91 3194.21 percent of total billed charges OSTEOSET RESORB/MINI BEAD KIT 48714309_1 CDM 0270 RC inpatient 3293 2140.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 2568.54 78 999999999 1993.91 3194.21 percent of total billed charges OSTEOSET RESORB/MINI BEAD KIT 48714309_1 CDM 0270 RC inpatient 3293 2140.45 SIHO - ALL PLANS SIHO - ALL PLANS 2963.7 90 999999999 1993.91 3194.21 percent of total billed charges OSTEOSET RESORB/MINI BEAD KIT 48714309_1 CDM 0270 RC inpatient 3293 2140.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1993.91 60.55 999999999 1993.91 3194.21 percent of total billed charges OSTEOSET RESORB/MINI BEAD KIT 48714309_1 CDM 0270 RC inpatient 3293 2140.45 UMR - ALL PLANS UMR - ALL PLANS 2305.1 70 999999999 1993.91 3194.21 percent of total billed charges OSTEOSET RESORB/MINI BEAD KIT 48714309_1 CDM 0270 RC inpatient 3293 2140.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1993.91 3194.21 OSTEOSET RESORB/MINI BEAD KIT 48714309_1 CDM 0270 RC inpatient 3293 2140.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1993.91 3194.21 OSTEOSET RESORB/MINI BEAD KIT 48714309_1 CDM 0270 RC inpatient 3293 2140.45 ANTHEM HMO ANTHEM HMO 999999999 1993.91 3194.21 OSTEOSET RESORB/MINI BEAD KIT 48714309_1 CDM 0270 RC inpatient 3293 2140.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 2226.07 67.6 999999999 1993.91 3194.21 percent of total billed charges OSTEOSET RESORB/MINI BEAD KIT 48714309_1 CDM 0270 RC inpatient 3293 2140.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1993.91 3194.21 OSTEOSET RESORB/MINI BEAD KIT 48714309_1 CDM 0270 RC inpatient 3293 2140.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1993.91 3194.21 3.5 AGG CUTTER 375-638-000 48714310_1 CDM 0272 RC inpatient 327 212.55 AETNA AETNA 258.33 79 999999999 198 317.19 percent of total billed charges 3.5 AGG CUTTER 375-638-000 48714310_1 CDM 0272 RC inpatient 327 212.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 212.55 65 999999999 198 317.19 percent of total billed charges 3.5 AGG CUTTER 375-638-000 48714310_1 CDM 0272 RC inpatient 327 212.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 317.19 97 999999999 198 317.19 percent of total billed charges 3.5 AGG CUTTER 375-638-000 48714310_1 CDM 0272 RC inpatient 327 212.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 225.63 69 999999999 198 317.19 percent of total billed charges 3.5 AGG CUTTER 375-638-000 48714310_1 CDM 0272 RC inpatient 327 212.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.06 78 999999999 198 317.19 percent of total billed charges 3.5 AGG CUTTER 375-638-000 48714310_1 CDM 0272 RC inpatient 327 212.55 SIHO - ALL PLANS SIHO - ALL PLANS 294.3 90 999999999 198 317.19 percent of total billed charges 3.5 AGG CUTTER 375-638-000 48714310_1 CDM 0272 RC inpatient 327 212.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198 60.55 999999999 198 317.19 percent of total billed charges 3.5 AGG CUTTER 375-638-000 48714310_1 CDM 0272 RC inpatient 327 212.55 UMR - ALL PLANS UMR - ALL PLANS 228.9 70 999999999 198 317.19 percent of total billed charges 3.5 AGG CUTTER 375-638-000 48714310_1 CDM 0272 RC inpatient 327 212.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198 317.19 3.5 AGG CUTTER 375-638-000 48714310_1 CDM 0272 RC inpatient 327 212.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198 317.19 3.5 AGG CUTTER 375-638-000 48714310_1 CDM 0272 RC inpatient 327 212.55 ANTHEM HMO ANTHEM HMO 999999999 198 317.19 3.5 AGG CUTTER 375-638-000 48714310_1 CDM 0272 RC inpatient 327 212.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.05 67.6 999999999 198 317.19 percent of total billed charges 3.5 AGG CUTTER 375-638-000 48714310_1 CDM 0272 RC inpatient 327 212.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198 317.19 3.5 AGG CUTTER 375-638-000 48714310_1 CDM 0272 RC inpatient 327 212.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 198 317.19 TAP 3.5MM 311.32 48714311_1 CDM 0278 RC inpatient 708 460.2 AETNA AETNA 559.32 79 999999999 428.69 686.76 percent of total billed charges TAP 3.5MM 311.32 48714311_1 CDM 0278 RC inpatient 708 460.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 460.2 65 999999999 428.69 686.76 percent of total billed charges TAP 3.5MM 311.32 48714311_1 CDM 0278 RC inpatient 708 460.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 686.76 97 999999999 428.69 686.76 percent of total billed charges TAP 3.5MM 311.32 48714311_1 CDM 0278 RC inpatient 708 460.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 488.52 69 999999999 428.69 686.76 percent of total billed charges TAP 3.5MM 311.32 48714311_1 CDM 0278 RC inpatient 708 460.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 552.24 78 999999999 428.69 686.76 percent of total billed charges TAP 3.5MM 311.32 48714311_1 CDM 0278 RC inpatient 708 460.2 SIHO - ALL PLANS SIHO - ALL PLANS 637.2 90 999999999 428.69 686.76 percent of total billed charges TAP 3.5MM 311.32 48714311_1 CDM 0278 RC inpatient 708 460.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 428.69 60.55 999999999 428.69 686.76 percent of total billed charges TAP 3.5MM 311.32 48714311_1 CDM 0278 RC inpatient 708 460.2 UMR - ALL PLANS UMR - ALL PLANS 495.6 70 999999999 428.69 686.76 percent of total billed charges TAP 3.5MM 311.32 48714311_1 CDM 0278 RC inpatient 708 460.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 428.69 686.76 TAP 3.5MM 311.32 48714311_1 CDM 0278 RC inpatient 708 460.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 428.69 686.76 TAP 3.5MM 311.32 48714311_1 CDM 0278 RC inpatient 708 460.2 ANTHEM HMO ANTHEM HMO 999999999 428.69 686.76 TAP 3.5MM 311.32 48714311_1 CDM 0278 RC inpatient 708 460.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 478.61 67.6 999999999 428.69 686.76 percent of total billed charges TAP 3.5MM 311.32 48714311_1 CDM 0278 RC inpatient 708 460.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 428.69 686.76 TAP 3.5MM 311.32 48714311_1 CDM 0278 RC inpatient 708 460.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 428.69 686.76 DRILL BIT SM FRAG 2.5MM 310.25 48714312_1 CDM 0272 RC inpatient 533 346.45 AETNA AETNA 421.07 79 999999999 322.73 517.01 percent of total billed charges DRILL BIT SM FRAG 2.5MM 310.25 48714312_1 CDM 0272 RC inpatient 533 346.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 346.45 65 999999999 322.73 517.01 percent of total billed charges DRILL BIT SM FRAG 2.5MM 310.25 48714312_1 CDM 0272 RC inpatient 533 346.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 517.01 97 999999999 322.73 517.01 percent of total billed charges DRILL BIT SM FRAG 2.5MM 310.25 48714312_1 CDM 0272 RC inpatient 533 346.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 367.77 69 999999999 322.73 517.01 percent of total billed charges DRILL BIT SM FRAG 2.5MM 310.25 48714312_1 CDM 0272 RC inpatient 533 346.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 415.74 78 999999999 322.73 517.01 percent of total billed charges DRILL BIT SM FRAG 2.5MM 310.25 48714312_1 CDM 0272 RC inpatient 533 346.45 SIHO - ALL PLANS SIHO - ALL PLANS 479.7 90 999999999 322.73 517.01 percent of total billed charges DRILL BIT SM FRAG 2.5MM 310.25 48714312_1 CDM 0272 RC inpatient 533 346.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 322.73 60.55 999999999 322.73 517.01 percent of total billed charges DRILL BIT SM FRAG 2.5MM 310.25 48714312_1 CDM 0272 RC inpatient 533 346.45 UMR - ALL PLANS UMR - ALL PLANS 373.1 70 999999999 322.73 517.01 percent of total billed charges DRILL BIT SM FRAG 2.5MM 310.25 48714312_1 CDM 0272 RC inpatient 533 346.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 322.73 517.01 DRILL BIT SM FRAG 2.5MM 310.25 48714312_1 CDM 0272 RC inpatient 533 346.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 322.73 517.01 DRILL BIT SM FRAG 2.5MM 310.25 48714312_1 CDM 0272 RC inpatient 533 346.45 ANTHEM HMO ANTHEM HMO 999999999 322.73 517.01 DRILL BIT SM FRAG 2.5MM 310.25 48714312_1 CDM 0272 RC inpatient 533 346.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 360.31 67.6 999999999 322.73 517.01 percent of total billed charges DRILL BIT SM FRAG 2.5MM 310.25 48714312_1 CDM 0272 RC inpatient 533 346.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 322.73 517.01 DRILL BIT SM FRAG 2.5MM 310.25 48714312_1 CDM 0272 RC inpatient 533 346.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 322.73 517.01 FILIFORM ST-TIP 5FR. #021905 48714313_1 CDM 0278 RC inpatient 482 313.3 AETNA AETNA 380.78 79 999999999 291.85 467.54 percent of total billed charges FILIFORM ST-TIP 5FR. #021905 48714313_1 CDM 0278 RC inpatient 482 313.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 313.3 65 999999999 291.85 467.54 percent of total billed charges FILIFORM ST-TIP 5FR. #021905 48714313_1 CDM 0278 RC inpatient 482 313.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 467.54 97 999999999 291.85 467.54 percent of total billed charges FILIFORM ST-TIP 5FR. #021905 48714313_1 CDM 0278 RC inpatient 482 313.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 332.58 69 999999999 291.85 467.54 percent of total billed charges FILIFORM ST-TIP 5FR. #021905 48714313_1 CDM 0278 RC inpatient 482 313.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 375.96 78 999999999 291.85 467.54 percent of total billed charges FILIFORM ST-TIP 5FR. #021905 48714313_1 CDM 0278 RC inpatient 482 313.3 SIHO - ALL PLANS SIHO - ALL PLANS 433.8 90 999999999 291.85 467.54 percent of total billed charges FILIFORM ST-TIP 5FR. #021905 48714313_1 CDM 0278 RC inpatient 482 313.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 291.85 60.55 999999999 291.85 467.54 percent of total billed charges FILIFORM ST-TIP 5FR. #021905 48714313_1 CDM 0278 RC inpatient 482 313.3 UMR - ALL PLANS UMR - ALL PLANS 337.4 70 999999999 291.85 467.54 percent of total billed charges FILIFORM ST-TIP 5FR. #021905 48714313_1 CDM 0278 RC inpatient 482 313.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 291.85 467.54 FILIFORM ST-TIP 5FR. #021905 48714313_1 CDM 0278 RC inpatient 482 313.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 291.85 467.54 FILIFORM ST-TIP 5FR. #021905 48714313_1 CDM 0278 RC inpatient 482 313.3 ANTHEM HMO ANTHEM HMO 999999999 291.85 467.54 FILIFORM ST-TIP 5FR. #021905 48714313_1 CDM 0278 RC inpatient 482 313.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 325.83 67.6 999999999 291.85 467.54 percent of total billed charges FILIFORM ST-TIP 5FR. #021905 48714313_1 CDM 0278 RC inpatient 482 313.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 291.85 467.54 FILIFORM ST-TIP 5FR. #021905 48714313_1 CDM 0278 RC inpatient 482 313.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 291.85 467.54 FILIFORM THR TIP 10FR 021510 48714314_1 CDM 0278 RC inpatient 650 422.5 AETNA AETNA 513.5 79 999999999 393.58 630.5 percent of total billed charges FILIFORM THR TIP 10FR 021510 48714314_1 CDM 0278 RC inpatient 650 422.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 422.5 65 999999999 393.58 630.5 percent of total billed charges FILIFORM THR TIP 10FR 021510 48714314_1 CDM 0278 RC inpatient 650 422.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 630.5 97 999999999 393.58 630.5 percent of total billed charges FILIFORM THR TIP 10FR 021510 48714314_1 CDM 0278 RC inpatient 650 422.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 448.5 69 999999999 393.58 630.5 percent of total billed charges FILIFORM THR TIP 10FR 021510 48714314_1 CDM 0278 RC inpatient 650 422.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 507 78 999999999 393.58 630.5 percent of total billed charges FILIFORM THR TIP 10FR 021510 48714314_1 CDM 0278 RC inpatient 650 422.5 SIHO - ALL PLANS SIHO - ALL PLANS 585 90 999999999 393.58 630.5 percent of total billed charges FILIFORM THR TIP 10FR 021510 48714314_1 CDM 0278 RC inpatient 650 422.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 393.58 60.55 999999999 393.58 630.5 percent of total billed charges FILIFORM THR TIP 10FR 021510 48714314_1 CDM 0278 RC inpatient 650 422.5 UMR - ALL PLANS UMR - ALL PLANS 455 70 999999999 393.58 630.5 percent of total billed charges FILIFORM THR TIP 10FR 021510 48714314_1 CDM 0278 RC inpatient 650 422.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 393.58 630.5 FILIFORM THR TIP 10FR 021510 48714314_1 CDM 0278 RC inpatient 650 422.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 393.58 630.5 FILIFORM THR TIP 10FR 021510 48714314_1 CDM 0278 RC inpatient 650 422.5 ANTHEM HMO ANTHEM HMO 999999999 393.58 630.5 FILIFORM THR TIP 10FR 021510 48714314_1 CDM 0278 RC inpatient 650 422.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 439.4 67.6 999999999 393.58 630.5 percent of total billed charges FILIFORM THR TIP 10FR 021510 48714314_1 CDM 0278 RC inpatient 650 422.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 393.58 630.5 FILIFORM THR TIP 10FR 021510 48714314_1 CDM 0278 RC inpatient 650 422.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 393.58 630.5 FILIFORM THRTIP 12FR 021512 48714315_1 CDM 0278 RC inpatient 650 422.5 AETNA AETNA 513.5 79 999999999 393.58 630.5 percent of total billed charges FILIFORM THRTIP 12FR 021512 48714315_1 CDM 0278 RC inpatient 650 422.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 422.5 65 999999999 393.58 630.5 percent of total billed charges FILIFORM THRTIP 12FR 021512 48714315_1 CDM 0278 RC inpatient 650 422.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 630.5 97 999999999 393.58 630.5 percent of total billed charges FILIFORM THRTIP 12FR 021512 48714315_1 CDM 0278 RC inpatient 650 422.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 448.5 69 999999999 393.58 630.5 percent of total billed charges FILIFORM THRTIP 12FR 021512 48714315_1 CDM 0278 RC inpatient 650 422.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 507 78 999999999 393.58 630.5 percent of total billed charges FILIFORM THRTIP 12FR 021512 48714315_1 CDM 0278 RC inpatient 650 422.5 SIHO - ALL PLANS SIHO - ALL PLANS 585 90 999999999 393.58 630.5 percent of total billed charges FILIFORM THRTIP 12FR 021512 48714315_1 CDM 0278 RC inpatient 650 422.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 393.58 60.55 999999999 393.58 630.5 percent of total billed charges FILIFORM THRTIP 12FR 021512 48714315_1 CDM 0278 RC inpatient 650 422.5 UMR - ALL PLANS UMR - ALL PLANS 455 70 999999999 393.58 630.5 percent of total billed charges FILIFORM THRTIP 12FR 021512 48714315_1 CDM 0278 RC inpatient 650 422.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 393.58 630.5 FILIFORM THRTIP 12FR 021512 48714315_1 CDM 0278 RC inpatient 650 422.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 393.58 630.5 FILIFORM THRTIP 12FR 021512 48714315_1 CDM 0278 RC inpatient 650 422.5 ANTHEM HMO ANTHEM HMO 999999999 393.58 630.5 FILIFORM THRTIP 12FR 021512 48714315_1 CDM 0278 RC inpatient 650 422.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 439.4 67.6 999999999 393.58 630.5 percent of total billed charges FILIFORM THRTIP 12FR 021512 48714315_1 CDM 0278 RC inpatient 650 422.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 393.58 630.5 FILIFORM THRTIP 12FR 021512 48714315_1 CDM 0278 RC inpatient 650 422.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 393.58 630.5 FILIFORM THR TIP 14FR 021514 48714316_1 CDM 0278 RC inpatient 650 422.5 AETNA AETNA 513.5 79 999999999 393.58 630.5 percent of total billed charges FILIFORM THR TIP 14FR 021514 48714316_1 CDM 0278 RC inpatient 650 422.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 422.5 65 999999999 393.58 630.5 percent of total billed charges FILIFORM THR TIP 14FR 021514 48714316_1 CDM 0278 RC inpatient 650 422.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 630.5 97 999999999 393.58 630.5 percent of total billed charges FILIFORM THR TIP 14FR 021514 48714316_1 CDM 0278 RC inpatient 650 422.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 448.5 69 999999999 393.58 630.5 percent of total billed charges FILIFORM THR TIP 14FR 021514 48714316_1 CDM 0278 RC inpatient 650 422.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 507 78 999999999 393.58 630.5 percent of total billed charges FILIFORM THR TIP 14FR 021514 48714316_1 CDM 0278 RC inpatient 650 422.5 SIHO - ALL PLANS SIHO - ALL PLANS 585 90 999999999 393.58 630.5 percent of total billed charges FILIFORM THR TIP 14FR 021514 48714316_1 CDM 0278 RC inpatient 650 422.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 393.58 60.55 999999999 393.58 630.5 percent of total billed charges FILIFORM THR TIP 14FR 021514 48714316_1 CDM 0278 RC inpatient 650 422.5 UMR - ALL PLANS UMR - ALL PLANS 455 70 999999999 393.58 630.5 percent of total billed charges FILIFORM THR TIP 14FR 021514 48714316_1 CDM 0278 RC inpatient 650 422.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 393.58 630.5 FILIFORM THR TIP 14FR 021514 48714316_1 CDM 0278 RC inpatient 650 422.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 393.58 630.5 FILIFORM THR TIP 14FR 021514 48714316_1 CDM 0278 RC inpatient 650 422.5 ANTHEM HMO ANTHEM HMO 999999999 393.58 630.5 FILIFORM THR TIP 14FR 021514 48714316_1 CDM 0278 RC inpatient 650 422.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 439.4 67.6 999999999 393.58 630.5 percent of total billed charges FILIFORM THR TIP 14FR 021514 48714316_1 CDM 0278 RC inpatient 650 422.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 393.58 630.5 FILIFORM THR TIP 14FR 021514 48714316_1 CDM 0278 RC inpatient 650 422.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 393.58 630.5 "PLATELET RICH PLASMA, EACH UNIT" 48714317_1 CDM 0309 RC P9020 HCPCS inpatient 4688 3047.2 AETNA AETNA 3703.52 79 999999999 2838.58 4547.36 percent of total billed charges "PLATELET RICH PLASMA, EACH UNIT" 48714317_1 CDM 0309 RC P9020 HCPCS inpatient 4688 3047.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 3047.2 65 999999999 2838.58 4547.36 percent of total billed charges "PLATELET RICH PLASMA, EACH UNIT" 48714317_1 CDM 0309 RC P9020 HCPCS inpatient 4688 3047.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4547.36 97 999999999 2838.58 4547.36 percent of total billed charges "PLATELET RICH PLASMA, EACH UNIT" 48714317_1 CDM 0309 RC P9020 HCPCS inpatient 4688 3047.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 3234.72 69 999999999 2838.58 4547.36 percent of total billed charges "PLATELET RICH PLASMA, EACH UNIT" 48714317_1 CDM 0309 RC P9020 HCPCS inpatient 4688 3047.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 3656.64 78 999999999 2838.58 4547.36 percent of total billed charges "PLATELET RICH PLASMA, EACH UNIT" 48714317_1 CDM 0309 RC P9020 HCPCS inpatient 4688 3047.2 SIHO - ALL PLANS SIHO - ALL PLANS 4219.2 90 999999999 2838.58 4547.36 percent of total billed charges "PLATELET RICH PLASMA, EACH UNIT" 48714317_1 CDM 0309 RC P9020 HCPCS inpatient 4688 3047.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2838.58 60.55 999999999 2838.58 4547.36 percent of total billed charges "PLATELET RICH PLASMA, EACH UNIT" 48714317_1 CDM 0309 RC P9020 HCPCS inpatient 4688 3047.2 UMR - ALL PLANS UMR - ALL PLANS 3281.6 70 999999999 2838.58 4547.36 percent of total billed charges "PLATELET RICH PLASMA, EACH UNIT" 48714317_1 CDM 0309 RC P9020 HCPCS inpatient 4688 3047.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2838.58 4547.36 "PLATELET RICH PLASMA, EACH UNIT" 48714317_1 CDM 0309 RC P9020 HCPCS inpatient 4688 3047.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2838.58 4547.36 "PLATELET RICH PLASMA, EACH UNIT" 48714317_1 CDM 0309 RC P9020 HCPCS inpatient 4688 3047.2 ANTHEM HMO ANTHEM HMO 999999999 2838.58 4547.36 "PLATELET RICH PLASMA, EACH UNIT" 48714317_1 CDM 0309 RC P9020 HCPCS inpatient 4688 3047.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 3169.09 67.6 999999999 2838.58 4547.36 percent of total billed charges "PLATELET RICH PLASMA, EACH UNIT" 48714317_1 CDM 0309 RC P9020 HCPCS inpatient 4688 3047.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2838.58 4547.36 "PLATELET RICH PLASMA, EACH UNIT" 48714317_1 CDM 0309 RC P9020 HCPCS inpatient 4688 3047.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 2838.58 4547.36 TISSEEL PRIMA FROZEN 4ML 1506079 48714318_1 CDM 0272 RC inpatient 1451 943.15 AETNA AETNA 1146.29 79 999999999 878.58 1407.47 percent of total billed charges TISSEEL PRIMA FROZEN 4ML 1506079 48714318_1 CDM 0272 RC inpatient 1451 943.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 943.15 65 999999999 878.58 1407.47 percent of total billed charges TISSEEL PRIMA FROZEN 4ML 1506079 48714318_1 CDM 0272 RC inpatient 1451 943.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1407.47 97 999999999 878.58 1407.47 percent of total billed charges TISSEEL PRIMA FROZEN 4ML 1506079 48714318_1 CDM 0272 RC inpatient 1451 943.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1001.19 69 999999999 878.58 1407.47 percent of total billed charges TISSEEL PRIMA FROZEN 4ML 1506079 48714318_1 CDM 0272 RC inpatient 1451 943.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1131.78 78 999999999 878.58 1407.47 percent of total billed charges TISSEEL PRIMA FROZEN 4ML 1506079 48714318_1 CDM 0272 RC inpatient 1451 943.15 SIHO - ALL PLANS SIHO - ALL PLANS 1305.9 90 999999999 878.58 1407.47 percent of total billed charges TISSEEL PRIMA FROZEN 4ML 1506079 48714318_1 CDM 0272 RC inpatient 1451 943.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 878.58 60.55 999999999 878.58 1407.47 percent of total billed charges TISSEEL PRIMA FROZEN 4ML 1506079 48714318_1 CDM 0272 RC inpatient 1451 943.15 UMR - ALL PLANS UMR - ALL PLANS 1015.7 70 999999999 878.58 1407.47 percent of total billed charges TISSEEL PRIMA FROZEN 4ML 1506079 48714318_1 CDM 0272 RC inpatient 1451 943.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 878.58 1407.47 TISSEEL PRIMA FROZEN 4ML 1506079 48714318_1 CDM 0272 RC inpatient 1451 943.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 878.58 1407.47 TISSEEL PRIMA FROZEN 4ML 1506079 48714318_1 CDM 0272 RC inpatient 1451 943.15 ANTHEM HMO ANTHEM HMO 999999999 878.58 1407.47 TISSEEL PRIMA FROZEN 4ML 1506079 48714318_1 CDM 0272 RC inpatient 1451 943.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 980.88 67.6 999999999 878.58 1407.47 percent of total billed charges TISSEEL PRIMA FROZEN 4ML 1506079 48714318_1 CDM 0272 RC inpatient 1451 943.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 878.58 1407.47 TISSEEL PRIMA FROZEN 4ML 1506079 48714318_1 CDM 0272 RC inpatient 1451 943.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 878.58 1407.47 TISSEEL VHSD FROZEN PRIMA 10ML 1506080 48714319_1 CDM 0272 RC inpatient 3163 2055.95 AETNA AETNA 2498.77 79 999999999 1915.2 3068.11 percent of total billed charges TISSEEL VHSD FROZEN PRIMA 10ML 1506080 48714319_1 CDM 0272 RC inpatient 3163 2055.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 2055.95 65 999999999 1915.2 3068.11 percent of total billed charges TISSEEL VHSD FROZEN PRIMA 10ML 1506080 48714319_1 CDM 0272 RC inpatient 3163 2055.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3068.11 97 999999999 1915.2 3068.11 percent of total billed charges TISSEEL VHSD FROZEN PRIMA 10ML 1506080 48714319_1 CDM 0272 RC inpatient 3163 2055.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 2182.47 69 999999999 1915.2 3068.11 percent of total billed charges TISSEEL VHSD FROZEN PRIMA 10ML 1506080 48714319_1 CDM 0272 RC inpatient 3163 2055.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 2467.14 78 999999999 1915.2 3068.11 percent of total billed charges TISSEEL VHSD FROZEN PRIMA 10ML 1506080 48714319_1 CDM 0272 RC inpatient 3163 2055.95 SIHO - ALL PLANS SIHO - ALL PLANS 2846.7 90 999999999 1915.2 3068.11 percent of total billed charges TISSEEL VHSD FROZEN PRIMA 10ML 1506080 48714319_1 CDM 0272 RC inpatient 3163 2055.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1915.2 60.55 999999999 1915.2 3068.11 percent of total billed charges TISSEEL VHSD FROZEN PRIMA 10ML 1506080 48714319_1 CDM 0272 RC inpatient 3163 2055.95 UMR - ALL PLANS UMR - ALL PLANS 2214.1 70 999999999 1915.2 3068.11 percent of total billed charges TISSEEL VHSD FROZEN PRIMA 10ML 1506080 48714319_1 CDM 0272 RC inpatient 3163 2055.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1915.2 3068.11 TISSEEL VHSD FROZEN PRIMA 10ML 1506080 48714319_1 CDM 0272 RC inpatient 3163 2055.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1915.2 3068.11 TISSEEL VHSD FROZEN PRIMA 10ML 1506080 48714319_1 CDM 0272 RC inpatient 3163 2055.95 ANTHEM HMO ANTHEM HMO 999999999 1915.2 3068.11 TISSEEL VHSD FROZEN PRIMA 10ML 1506080 48714319_1 CDM 0272 RC inpatient 3163 2055.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 2138.19 67.6 999999999 1915.2 3068.11 percent of total billed charges TISSEEL VHSD FROZEN PRIMA 10ML 1506080 48714319_1 CDM 0272 RC inpatient 3163 2055.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1915.2 3068.11 TISSEEL VHSD FROZEN PRIMA 10ML 1506080 48714319_1 CDM 0272 RC inpatient 3163 2055.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1915.2 3068.11 DUPLOTIP FOR TISSEEL 0601138 48714320_1 CDM 0272 RC inpatient 386 250.9 AETNA AETNA 304.94 79 999999999 233.72 374.42 percent of total billed charges DUPLOTIP FOR TISSEEL 0601138 48714320_1 CDM 0272 RC inpatient 386 250.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 250.9 65 999999999 233.72 374.42 percent of total billed charges DUPLOTIP FOR TISSEEL 0601138 48714320_1 CDM 0272 RC inpatient 386 250.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 374.42 97 999999999 233.72 374.42 percent of total billed charges DUPLOTIP FOR TISSEEL 0601138 48714320_1 CDM 0272 RC inpatient 386 250.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 266.34 69 999999999 233.72 374.42 percent of total billed charges DUPLOTIP FOR TISSEEL 0601138 48714320_1 CDM 0272 RC inpatient 386 250.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.08 78 999999999 233.72 374.42 percent of total billed charges DUPLOTIP FOR TISSEEL 0601138 48714320_1 CDM 0272 RC inpatient 386 250.9 SIHO - ALL PLANS SIHO - ALL PLANS 347.4 90 999999999 233.72 374.42 percent of total billed charges DUPLOTIP FOR TISSEEL 0601138 48714320_1 CDM 0272 RC inpatient 386 250.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 233.72 60.55 999999999 233.72 374.42 percent of total billed charges DUPLOTIP FOR TISSEEL 0601138 48714320_1 CDM 0272 RC inpatient 386 250.9 UMR - ALL PLANS UMR - ALL PLANS 270.2 70 999999999 233.72 374.42 percent of total billed charges DUPLOTIP FOR TISSEEL 0601138 48714320_1 CDM 0272 RC inpatient 386 250.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 233.72 374.42 DUPLOTIP FOR TISSEEL 0601138 48714320_1 CDM 0272 RC inpatient 386 250.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 233.72 374.42 DUPLOTIP FOR TISSEEL 0601138 48714320_1 CDM 0272 RC inpatient 386 250.9 ANTHEM HMO ANTHEM HMO 999999999 233.72 374.42 DUPLOTIP FOR TISSEEL 0601138 48714320_1 CDM 0272 RC inpatient 386 250.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 260.94 67.6 999999999 233.72 374.42 percent of total billed charges DUPLOTIP FOR TISSEEL 0601138 48714320_1 CDM 0272 RC inpatient 386 250.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 233.72 374.42 DUPLOTIP FOR TISSEEL 0601138 48714320_1 CDM 0272 RC inpatient 386 250.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 233.72 374.42 SPRAY TIP FOR TISSEEL 0600065 48714321_1 CDM 0270 RC inpatient 353 229.45 AETNA AETNA 278.87 79 999999999 213.74 342.41 percent of total billed charges SPRAY TIP FOR TISSEEL 0600065 48714321_1 CDM 0270 RC inpatient 353 229.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 229.45 65 999999999 213.74 342.41 percent of total billed charges SPRAY TIP FOR TISSEEL 0600065 48714321_1 CDM 0270 RC inpatient 353 229.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 342.41 97 999999999 213.74 342.41 percent of total billed charges SPRAY TIP FOR TISSEEL 0600065 48714321_1 CDM 0270 RC inpatient 353 229.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 243.57 69 999999999 213.74 342.41 percent of total billed charges SPRAY TIP FOR TISSEEL 0600065 48714321_1 CDM 0270 RC inpatient 353 229.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 275.34 78 999999999 213.74 342.41 percent of total billed charges SPRAY TIP FOR TISSEEL 0600065 48714321_1 CDM 0270 RC inpatient 353 229.45 SIHO - ALL PLANS SIHO - ALL PLANS 317.7 90 999999999 213.74 342.41 percent of total billed charges SPRAY TIP FOR TISSEEL 0600065 48714321_1 CDM 0270 RC inpatient 353 229.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 213.74 60.55 999999999 213.74 342.41 percent of total billed charges SPRAY TIP FOR TISSEEL 0600065 48714321_1 CDM 0270 RC inpatient 353 229.45 UMR - ALL PLANS UMR - ALL PLANS 247.1 70 999999999 213.74 342.41 percent of total billed charges SPRAY TIP FOR TISSEEL 0600065 48714321_1 CDM 0270 RC inpatient 353 229.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 213.74 342.41 SPRAY TIP FOR TISSEEL 0600065 48714321_1 CDM 0270 RC inpatient 353 229.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 213.74 342.41 SPRAY TIP FOR TISSEEL 0600065 48714321_1 CDM 0270 RC inpatient 353 229.45 ANTHEM HMO ANTHEM HMO 999999999 213.74 342.41 SPRAY TIP FOR TISSEEL 0600065 48714321_1 CDM 0270 RC inpatient 353 229.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 238.63 67.6 999999999 213.74 342.41 percent of total billed charges SPRAY TIP FOR TISSEEL 0600065 48714321_1 CDM 0270 RC inpatient 353 229.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 213.74 342.41 SPRAY TIP FOR TISSEEL 0600065 48714321_1 CDM 0270 RC inpatient 353 229.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 213.74 342.41 PROBE NIM THORACIC PEDICLE 48714322_1 CDM 0272 RC inpatient 4137 2689.05 AETNA AETNA 3268.23 79 999999999 2504.95 4012.89 percent of total billed charges PROBE NIM THORACIC PEDICLE 48714322_1 CDM 0272 RC inpatient 4137 2689.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 2689.05 65 999999999 2504.95 4012.89 percent of total billed charges PROBE NIM THORACIC PEDICLE 48714322_1 CDM 0272 RC inpatient 4137 2689.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4012.89 97 999999999 2504.95 4012.89 percent of total billed charges PROBE NIM THORACIC PEDICLE 48714322_1 CDM 0272 RC inpatient 4137 2689.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2854.53 69 999999999 2504.95 4012.89 percent of total billed charges PROBE NIM THORACIC PEDICLE 48714322_1 CDM 0272 RC inpatient 4137 2689.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 3226.86 78 999999999 2504.95 4012.89 percent of total billed charges PROBE NIM THORACIC PEDICLE 48714322_1 CDM 0272 RC inpatient 4137 2689.05 SIHO - ALL PLANS SIHO - ALL PLANS 3723.3 90 999999999 2504.95 4012.89 percent of total billed charges PROBE NIM THORACIC PEDICLE 48714322_1 CDM 0272 RC inpatient 4137 2689.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2504.95 60.55 999999999 2504.95 4012.89 percent of total billed charges PROBE NIM THORACIC PEDICLE 48714322_1 CDM 0272 RC inpatient 4137 2689.05 UMR - ALL PLANS UMR - ALL PLANS 2895.9 70 999999999 2504.95 4012.89 percent of total billed charges PROBE NIM THORACIC PEDICLE 48714322_1 CDM 0272 RC inpatient 4137 2689.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2504.95 4012.89 PROBE NIM THORACIC PEDICLE 48714322_1 CDM 0272 RC inpatient 4137 2689.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2504.95 4012.89 PROBE NIM THORACIC PEDICLE 48714322_1 CDM 0272 RC inpatient 4137 2689.05 ANTHEM HMO ANTHEM HMO 999999999 2504.95 4012.89 PROBE NIM THORACIC PEDICLE 48714322_1 CDM 0272 RC inpatient 4137 2689.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2796.61 67.6 999999999 2504.95 4012.89 percent of total billed charges PROBE NIM THORACIC PEDICLE 48714322_1 CDM 0272 RC inpatient 4137 2689.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2504.95 4012.89 PROBE NIM THORACIC PEDICLE 48714322_1 CDM 0272 RC inpatient 4137 2689.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 2504.95 4012.89 VERSASTEP PLUS 12MM VS101012P 48714323_1 CDM 0272 RC inpatient 432 280.8 AETNA AETNA 341.28 79 999999999 261.58 419.04 percent of total billed charges VERSASTEP PLUS 12MM VS101012P 48714323_1 CDM 0272 RC inpatient 432 280.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 280.8 65 999999999 261.58 419.04 percent of total billed charges VERSASTEP PLUS 12MM VS101012P 48714323_1 CDM 0272 RC inpatient 432 280.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 419.04 97 999999999 261.58 419.04 percent of total billed charges VERSASTEP PLUS 12MM VS101012P 48714323_1 CDM 0272 RC inpatient 432 280.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 298.08 69 999999999 261.58 419.04 percent of total billed charges VERSASTEP PLUS 12MM VS101012P 48714323_1 CDM 0272 RC inpatient 432 280.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 336.96 78 999999999 261.58 419.04 percent of total billed charges VERSASTEP PLUS 12MM VS101012P 48714323_1 CDM 0272 RC inpatient 432 280.8 SIHO - ALL PLANS SIHO - ALL PLANS 388.8 90 999999999 261.58 419.04 percent of total billed charges VERSASTEP PLUS 12MM VS101012P 48714323_1 CDM 0272 RC inpatient 432 280.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 261.58 60.55 999999999 261.58 419.04 percent of total billed charges VERSASTEP PLUS 12MM VS101012P 48714323_1 CDM 0272 RC inpatient 432 280.8 UMR - ALL PLANS UMR - ALL PLANS 302.4 70 999999999 261.58 419.04 percent of total billed charges VERSASTEP PLUS 12MM VS101012P 48714323_1 CDM 0272 RC inpatient 432 280.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 261.58 419.04 VERSASTEP PLUS 12MM VS101012P 48714323_1 CDM 0272 RC inpatient 432 280.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 261.58 419.04 VERSASTEP PLUS 12MM VS101012P 48714323_1 CDM 0272 RC inpatient 432 280.8 ANTHEM HMO ANTHEM HMO 999999999 261.58 419.04 VERSASTEP PLUS 12MM VS101012P 48714323_1 CDM 0272 RC inpatient 432 280.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 292.03 67.6 999999999 261.58 419.04 percent of total billed charges VERSASTEP PLUS 12MM VS101012P 48714323_1 CDM 0272 RC inpatient 432 280.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 261.58 419.04 VERSASTEP PLUS 12MM VS101012P 48714323_1 CDM 0272 RC inpatient 432 280.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 261.58 419.04 "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48714853_1 CDM 0250 RC 68084-0220-01 NDC Q0162 HCPCS inpatient 1 UN 1.93 1.25 AETNA AETNA 1.52 79 999999999 1.17 1.87 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48714853_1 CDM 0250 RC 68084-0220-01 NDC Q0162 HCPCS inpatient 1 UN 1.93 1.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.25 65 999999999 1.17 1.87 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48714853_1 CDM 0250 RC 68084-0220-01 NDC Q0162 HCPCS inpatient 1 UN 1.93 1.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.87 97 999999999 1.17 1.87 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48714853_1 CDM 0250 RC 68084-0220-01 NDC Q0162 HCPCS inpatient 1 UN 1.93 1.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.33 69 999999999 1.17 1.87 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48714853_1 CDM 0250 RC 68084-0220-01 NDC Q0162 HCPCS inpatient 1 UN 1.93 1.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.51 78 999999999 1.17 1.87 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48714853_1 CDM 0250 RC 68084-0220-01 NDC Q0162 HCPCS inpatient 1 UN 1.93 1.25 SIHO - ALL PLANS SIHO - ALL PLANS 1.74 90 999999999 1.17 1.87 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48714853_1 CDM 0250 RC 68084-0220-01 NDC Q0162 HCPCS inpatient 1 UN 1.93 1.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.17 60.55 999999999 1.17 1.87 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48714853_1 CDM 0250 RC 68084-0220-01 NDC Q0162 HCPCS inpatient 1 UN 1.93 1.25 UMR - ALL PLANS UMR - ALL PLANS 1.35 70 999999999 1.17 1.87 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48714853_1 CDM 0250 RC 68084-0220-01 NDC Q0162 HCPCS inpatient 1 UN 1.93 1.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.17 1.87 "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48714853_1 CDM 0250 RC 68084-0220-01 NDC Q0162 HCPCS inpatient 1 UN 1.93 1.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.17 1.87 "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48714853_1 CDM 0250 RC 68084-0220-01 NDC Q0162 HCPCS inpatient 1 UN 1.93 1.25 ANTHEM HMO ANTHEM HMO 999999999 1.17 1.87 "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48714853_1 CDM 0250 RC 68084-0220-01 NDC Q0162 HCPCS inpatient 1 UN 1.93 1.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.3 67.6 999999999 1.17 1.87 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48714853_1 CDM 0250 RC 68084-0220-01 NDC Q0162 HCPCS inpatient 1 UN 1.93 1.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.17 1.87 "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 48714853_1 CDM 0250 RC 68084-0220-01 NDC Q0162 HCPCS inpatient 1 UN 1.93 1.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.17 1.87 "NYSTATIN 100,000 UNIT/GM CREAM" 48714856_1 CDM 0250 RC 00713-0678-15 NDC inpatient 1 UN 17.6 11.44 AETNA AETNA 13.9 79 999999999 10.66 17.07 percent of total billed charges "NYSTATIN 100,000 UNIT/GM CREAM" 48714856_1 CDM 0250 RC 00713-0678-15 NDC inpatient 1 UN 17.6 11.44 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.44 65 999999999 10.66 17.07 percent of total billed charges "NYSTATIN 100,000 UNIT/GM CREAM" 48714856_1 CDM 0250 RC 00713-0678-15 NDC inpatient 1 UN 17.6 11.44 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.07 97 999999999 10.66 17.07 percent of total billed charges "NYSTATIN 100,000 UNIT/GM CREAM" 48714856_1 CDM 0250 RC 00713-0678-15 NDC inpatient 1 UN 17.6 11.44 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.14 69 999999999 10.66 17.07 percent of total billed charges "NYSTATIN 100,000 UNIT/GM CREAM" 48714856_1 CDM 0250 RC 00713-0678-15 NDC inpatient 1 UN 17.6 11.44 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.73 78 999999999 10.66 17.07 percent of total billed charges "NYSTATIN 100,000 UNIT/GM CREAM" 48714856_1 CDM 0250 RC 00713-0678-15 NDC inpatient 1 UN 17.6 11.44 SIHO - ALL PLANS SIHO - ALL PLANS 15.84 90 999999999 10.66 17.07 percent of total billed charges "NYSTATIN 100,000 UNIT/GM CREAM" 48714856_1 CDM 0250 RC 00713-0678-15 NDC inpatient 1 UN 17.6 11.44 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.66 60.55 999999999 10.66 17.07 percent of total billed charges "NYSTATIN 100,000 UNIT/GM CREAM" 48714856_1 CDM 0250 RC 00713-0678-15 NDC inpatient 1 UN 17.6 11.44 UMR - ALL PLANS UMR - ALL PLANS 12.32 70 999999999 10.66 17.07 percent of total billed charges "NYSTATIN 100,000 UNIT/GM CREAM" 48714856_1 CDM 0250 RC 00713-0678-15 NDC inpatient 1 UN 17.6 11.44 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.66 17.07 "NYSTATIN 100,000 UNIT/GM CREAM" 48714856_1 CDM 0250 RC 00713-0678-15 NDC inpatient 1 UN 17.6 11.44 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.66 17.07 "NYSTATIN 100,000 UNIT/GM CREAM" 48714856_1 CDM 0250 RC 00713-0678-15 NDC inpatient 1 UN 17.6 11.44 ANTHEM HMO ANTHEM HMO 999999999 10.66 17.07 "NYSTATIN 100,000 UNIT/GM CREAM" 48714856_1 CDM 0250 RC 00713-0678-15 NDC inpatient 1 UN 17.6 11.44 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.9 67.6 999999999 10.66 17.07 percent of total billed charges "NYSTATIN 100,000 UNIT/GM CREAM" 48714856_1 CDM 0250 RC 00713-0678-15 NDC inpatient 1 UN 17.6 11.44 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.66 17.07 "NYSTATIN 100,000 UNIT/GM CREAM" 48714856_1 CDM 0250 RC 00713-0678-15 NDC inpatient 1 UN 17.6 11.44 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.66 17.07 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716376_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716376_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716376_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716376_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716376_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716376_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716376_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716376_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716376_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716376_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716376_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716376_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716376_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716376_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716381_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716381_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716381_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716381_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716381_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716381_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716381_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716381_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716381_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716381_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716381_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716381_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716381_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48716381_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 Fentanyl level 48718411_1 CDM 0301 RC 80354 HCPCS inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges Fentanyl level 48718411_1 CDM 0301 RC 80354 HCPCS inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges Fentanyl level 48718411_1 CDM 0301 RC 80354 HCPCS inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges Fentanyl level 48718411_1 CDM 0301 RC 80354 HCPCS inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges Fentanyl level 48718411_1 CDM 0301 RC 80354 HCPCS inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges Fentanyl level 48718411_1 CDM 0301 RC 80354 HCPCS inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges Fentanyl level 48718411_1 CDM 0301 RC 80354 HCPCS inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges Fentanyl level 48718411_1 CDM 0301 RC 80354 HCPCS inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges Fentanyl level 48718411_1 CDM 0301 RC 80354 HCPCS inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 Fentanyl level 48718411_1 CDM 0301 RC 80354 HCPCS inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 Fentanyl level 48718411_1 CDM 0301 RC 80354 HCPCS inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 Fentanyl level 48718411_1 CDM 0301 RC 80354 HCPCS inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges Fentanyl level 48718411_1 CDM 0301 RC 80354 HCPCS inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 Fentanyl level 48718411_1 CDM 0301 RC 80354 HCPCS inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 "INJECTION, LEVOFLOXACIN, 250 MG" 48719262_1 CDM 0250 RC 00143-9720-24 NDC J1956 HCPCS inpatient 3 UN 59.79 38.86 AETNA AETNA 47.23 79 999999999 36.2 58 percent of total billed charges "INJECTION, LEVOFLOXACIN, 250 MG" 48719262_1 CDM 0250 RC 00143-9720-24 NDC J1956 HCPCS inpatient 3 UN 59.79 38.86 SELF PAY DISCOUNT SELF PAY DISCOUNT 38.86 65 999999999 36.2 58 percent of total billed charges "INJECTION, LEVOFLOXACIN, 250 MG" 48719262_1 CDM 0250 RC 00143-9720-24 NDC J1956 HCPCS inpatient 3 UN 59.79 38.86 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58 97 999999999 36.2 58 percent of total billed charges "INJECTION, LEVOFLOXACIN, 250 MG" 48719262_1 CDM 0250 RC 00143-9720-24 NDC J1956 HCPCS inpatient 3 UN 59.79 38.86 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.26 69 999999999 36.2 58 percent of total billed charges "INJECTION, LEVOFLOXACIN, 250 MG" 48719262_1 CDM 0250 RC 00143-9720-24 NDC J1956 HCPCS inpatient 3 UN 59.79 38.86 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.64 78 999999999 36.2 58 percent of total billed charges "INJECTION, LEVOFLOXACIN, 250 MG" 48719262_1 CDM 0250 RC 00143-9720-24 NDC J1956 HCPCS inpatient 3 UN 59.79 38.86 SIHO - ALL PLANS SIHO - ALL PLANS 53.81 90 999999999 36.2 58 percent of total billed charges "INJECTION, LEVOFLOXACIN, 250 MG" 48719262_1 CDM 0250 RC 00143-9720-24 NDC J1956 HCPCS inpatient 3 UN 59.79 38.86 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.2 60.55 999999999 36.2 58 percent of total billed charges "INJECTION, LEVOFLOXACIN, 250 MG" 48719262_1 CDM 0250 RC 00143-9720-24 NDC J1956 HCPCS inpatient 3 UN 59.79 38.86 UMR - ALL PLANS UMR - ALL PLANS 41.85 70 999999999 36.2 58 percent of total billed charges "INJECTION, LEVOFLOXACIN, 250 MG" 48719262_1 CDM 0250 RC 00143-9720-24 NDC J1956 HCPCS inpatient 3 UN 59.79 38.86 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.2 58 "INJECTION, LEVOFLOXACIN, 250 MG" 48719262_1 CDM 0250 RC 00143-9720-24 NDC J1956 HCPCS inpatient 3 UN 59.79 38.86 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.2 58 "INJECTION, LEVOFLOXACIN, 250 MG" 48719262_1 CDM 0250 RC 00143-9720-24 NDC J1956 HCPCS inpatient 3 UN 59.79 38.86 ANTHEM HMO ANTHEM HMO 999999999 36.2 58 "INJECTION, LEVOFLOXACIN, 250 MG" 48719262_1 CDM 0250 RC 00143-9720-24 NDC J1956 HCPCS inpatient 3 UN 59.79 38.86 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.42 67.6 999999999 36.2 58 percent of total billed charges "INJECTION, LEVOFLOXACIN, 250 MG" 48719262_1 CDM 0250 RC 00143-9720-24 NDC J1956 HCPCS inpatient 3 UN 59.79 38.86 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.2 58 "INJECTION, LEVOFLOXACIN, 250 MG" 48719262_1 CDM 0250 RC 00143-9720-24 NDC J1956 HCPCS inpatient 3 UN 59.79 38.86 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.2 58 "Smoking and tobacco use intensive counseling, 4-10 minutes" 48719782_1 CDM 0942 RC 99406 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges "Smoking and tobacco use intensive counseling, 4-10 minutes" 48719782_1 CDM 0942 RC 99406 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges "Smoking and tobacco use intensive counseling, 4-10 minutes" 48719782_1 CDM 0942 RC 99406 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges "Smoking and tobacco use intensive counseling, 4-10 minutes" 48719782_1 CDM 0942 RC 99406 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges "Smoking and tobacco use intensive counseling, 4-10 minutes" 48719782_1 CDM 0942 RC 99406 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges "Smoking and tobacco use intensive counseling, 4-10 minutes" 48719782_1 CDM 0942 RC 99406 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges "Smoking and tobacco use intensive counseling, 4-10 minutes" 48719782_1 CDM 0942 RC 99406 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges "Smoking and tobacco use intensive counseling, 4-10 minutes" 48719782_1 CDM 0942 RC 99406 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges "Smoking and tobacco use intensive counseling, 4-10 minutes" 48719782_1 CDM 0942 RC 99406 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 "Smoking and tobacco use intensive counseling, 4-10 minutes" 48719782_1 CDM 0942 RC 99406 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 "Smoking and tobacco use intensive counseling, 4-10 minutes" 48719782_1 CDM 0942 RC 99406 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 "Smoking and tobacco use intensive counseling, 4-10 minutes" 48719782_1 CDM 0942 RC 99406 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges "Smoking and tobacco use intensive counseling, 4-10 minutes" 48719782_1 CDM 0942 RC 99406 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 "Smoking and tobacco use intensive counseling, 4-10 minutes" 48719782_1 CDM 0942 RC 99406 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 CHLORTHALIDONE 25 MG TABLET 48733912_1 CDM 0250 RC 57664-0648-88 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CHLORTHALIDONE 25 MG TABLET 48733912_1 CDM 0250 RC 57664-0648-88 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CHLORTHALIDONE 25 MG TABLET 48733912_1 CDM 0250 RC 57664-0648-88 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CHLORTHALIDONE 25 MG TABLET 48733912_1 CDM 0250 RC 57664-0648-88 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CHLORTHALIDONE 25 MG TABLET 48733912_1 CDM 0250 RC 57664-0648-88 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CHLORTHALIDONE 25 MG TABLET 48733912_1 CDM 0250 RC 57664-0648-88 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CHLORTHALIDONE 25 MG TABLET 48733912_1 CDM 0250 RC 57664-0648-88 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CHLORTHALIDONE 25 MG TABLET 48733912_1 CDM 0250 RC 57664-0648-88 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CHLORTHALIDONE 25 MG TABLET 48733912_1 CDM 0250 RC 57664-0648-88 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CHLORTHALIDONE 25 MG TABLET 48733912_1 CDM 0250 RC 57664-0648-88 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CHLORTHALIDONE 25 MG TABLET 48733912_1 CDM 0250 RC 57664-0648-88 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CHLORTHALIDONE 25 MG TABLET 48733912_1 CDM 0250 RC 57664-0648-88 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CHLORTHALIDONE 25 MG TABLET 48733912_1 CDM 0250 RC 57664-0648-88 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CHLORTHALIDONE 25 MG TABLET 48733912_1 CDM 0250 RC 57664-0648-88 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "Microscopic genetic analysis of tumor, manual" 48744520_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 AETNA AETNA 270.18 79 999999999 207.08 331.74 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 48744520_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 222.3 65 999999999 207.08 331.74 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 48744520_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 331.74 97 999999999 207.08 331.74 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 48744520_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 235.98 69 999999999 207.08 331.74 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 48744520_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 266.76 78 999999999 207.08 331.74 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 48744520_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 SIHO - ALL PLANS SIHO - ALL PLANS 307.8 90 999999999 207.08 331.74 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 48744520_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 207.08 60.55 999999999 207.08 331.74 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 48744520_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 UMR - ALL PLANS UMR - ALL PLANS 239.4 70 999999999 207.08 331.74 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 48744520_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 207.08 331.74 "Microscopic genetic analysis of tumor, manual" 48744520_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 207.08 331.74 "Microscopic genetic analysis of tumor, manual" 48744520_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 ANTHEM HMO ANTHEM HMO 999999999 207.08 331.74 "Microscopic genetic analysis of tumor, manual" 48744520_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 231.19 67.6 999999999 207.08 331.74 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 48744520_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 207.08 331.74 "Microscopic genetic analysis of tumor, manual" 48744520_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 207.08 331.74 "Blood gas, oxygen saturation measurement" 48744614_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 AETNA AETNA 177.75 79 999999999 136.24 218.25 percent of total billed charges "Blood gas, oxygen saturation measurement" 48744614_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 146.25 65 999999999 136.24 218.25 percent of total billed charges "Blood gas, oxygen saturation measurement" 48744614_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 218.25 97 999999999 136.24 218.25 percent of total billed charges "Blood gas, oxygen saturation measurement" 48744614_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 155.25 69 999999999 136.24 218.25 percent of total billed charges "Blood gas, oxygen saturation measurement" 48744614_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 175.5 78 999999999 136.24 218.25 percent of total billed charges "Blood gas, oxygen saturation measurement" 48744614_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 SIHO - ALL PLANS SIHO - ALL PLANS 202.5 90 999999999 136.24 218.25 percent of total billed charges "Blood gas, oxygen saturation measurement" 48744614_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 136.24 60.55 999999999 136.24 218.25 percent of total billed charges "Blood gas, oxygen saturation measurement" 48744614_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 UMR - ALL PLANS UMR - ALL PLANS 157.5 70 999999999 136.24 218.25 percent of total billed charges "Blood gas, oxygen saturation measurement" 48744614_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 136.24 218.25 "Blood gas, oxygen saturation measurement" 48744614_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 136.24 218.25 "Blood gas, oxygen saturation measurement" 48744614_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 ANTHEM HMO ANTHEM HMO 999999999 136.24 218.25 "Blood gas, oxygen saturation measurement" 48744614_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 152.1 67.6 999999999 136.24 218.25 percent of total billed charges "Blood gas, oxygen saturation measurement" 48744614_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 136.24 218.25 "Blood gas, oxygen saturation measurement" 48744614_1 CDM 0301 RC 82810 HCPCS inpatient 225 146.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 136.24 218.25 Insertion of needle into vein for collection of blood sample 48755866_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 AETNA AETNA 36.34 79 999999999 27.85 44.62 percent of total billed charges Insertion of needle into vein for collection of blood sample 48755866_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 29.9 65 999999999 27.85 44.62 percent of total billed charges Insertion of needle into vein for collection of blood sample 48755866_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 44.62 97 999999999 27.85 44.62 percent of total billed charges Insertion of needle into vein for collection of blood sample 48755866_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 31.74 69 999999999 27.85 44.62 percent of total billed charges Insertion of needle into vein for collection of blood sample 48755866_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 35.88 78 999999999 27.85 44.62 percent of total billed charges Insertion of needle into vein for collection of blood sample 48755866_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 SIHO - ALL PLANS SIHO - ALL PLANS 41.4 90 999999999 27.85 44.62 percent of total billed charges Insertion of needle into vein for collection of blood sample 48755866_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27.85 60.55 999999999 27.85 44.62 percent of total billed charges Insertion of needle into vein for collection of blood sample 48755866_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 UMR - ALL PLANS UMR - ALL PLANS 32.2 70 999999999 27.85 44.62 percent of total billed charges Insertion of needle into vein for collection of blood sample 48755866_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 27.85 44.62 Insertion of needle into vein for collection of blood sample 48755866_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 27.85 44.62 Insertion of needle into vein for collection of blood sample 48755866_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 ANTHEM HMO ANTHEM HMO 999999999 27.85 44.62 Insertion of needle into vein for collection of blood sample 48755866_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 31.1 67.6 999999999 27.85 44.62 percent of total billed charges Insertion of needle into vein for collection of blood sample 48755866_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 27.85 44.62 Insertion of needle into vein for collection of blood sample 48755866_1 CDM 0300 RC 36415 HCPCS inpatient 46 29.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 27.85 44.62 Collection of blood sample from implanted device 48755867_1 CDM 0300 RC 36591 HCPCS inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges Collection of blood sample from implanted device 48755867_1 CDM 0300 RC 36591 HCPCS inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges Collection of blood sample from implanted device 48755867_1 CDM 0300 RC 36591 HCPCS inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges Collection of blood sample from implanted device 48755867_1 CDM 0300 RC 36591 HCPCS inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges Collection of blood sample from implanted device 48755867_1 CDM 0300 RC 36591 HCPCS inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges Collection of blood sample from implanted device 48755867_1 CDM 0300 RC 36591 HCPCS inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges Collection of blood sample from implanted device 48755867_1 CDM 0300 RC 36591 HCPCS inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges Collection of blood sample from implanted device 48755867_1 CDM 0300 RC 36591 HCPCS inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges Collection of blood sample from implanted device 48755867_1 CDM 0300 RC 36591 HCPCS inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 Collection of blood sample from implanted device 48755867_1 CDM 0300 RC 36591 HCPCS inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 Collection of blood sample from implanted device 48755867_1 CDM 0300 RC 36591 HCPCS inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 Collection of blood sample from implanted device 48755867_1 CDM 0300 RC 36591 HCPCS inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges Collection of blood sample from implanted device 48755867_1 CDM 0300 RC 36591 HCPCS inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 Collection of blood sample from implanted device 48755867_1 CDM 0300 RC 36591 HCPCS inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 Collection of blood sample from central venous tube 48755868_1 CDM 0300 RC 36592 HCPCS inpatient 388 252.2 AETNA AETNA 306.52 79 999999999 234.93 376.36 percent of total billed charges Collection of blood sample from central venous tube 48755868_1 CDM 0300 RC 36592 HCPCS inpatient 388 252.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 252.2 65 999999999 234.93 376.36 percent of total billed charges Collection of blood sample from central venous tube 48755868_1 CDM 0300 RC 36592 HCPCS inpatient 388 252.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 376.36 97 999999999 234.93 376.36 percent of total billed charges Collection of blood sample from central venous tube 48755868_1 CDM 0300 RC 36592 HCPCS inpatient 388 252.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.72 69 999999999 234.93 376.36 percent of total billed charges Collection of blood sample from central venous tube 48755868_1 CDM 0300 RC 36592 HCPCS inpatient 388 252.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 302.64 78 999999999 234.93 376.36 percent of total billed charges Collection of blood sample from central venous tube 48755868_1 CDM 0300 RC 36592 HCPCS inpatient 388 252.2 SIHO - ALL PLANS SIHO - ALL PLANS 349.2 90 999999999 234.93 376.36 percent of total billed charges Collection of blood sample from central venous tube 48755868_1 CDM 0300 RC 36592 HCPCS inpatient 388 252.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.93 60.55 999999999 234.93 376.36 percent of total billed charges Collection of blood sample from central venous tube 48755868_1 CDM 0300 RC 36592 HCPCS inpatient 388 252.2 UMR - ALL PLANS UMR - ALL PLANS 271.6 70 999999999 234.93 376.36 percent of total billed charges Collection of blood sample from central venous tube 48755868_1 CDM 0300 RC 36592 HCPCS inpatient 388 252.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.93 376.36 Collection of blood sample from central venous tube 48755868_1 CDM 0300 RC 36592 HCPCS inpatient 388 252.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.93 376.36 Collection of blood sample from central venous tube 48755868_1 CDM 0300 RC 36592 HCPCS inpatient 388 252.2 ANTHEM HMO ANTHEM HMO 999999999 234.93 376.36 Collection of blood sample from central venous tube 48755868_1 CDM 0300 RC 36592 HCPCS inpatient 388 252.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 262.29 67.6 999999999 234.93 376.36 percent of total billed charges Collection of blood sample from central venous tube 48755868_1 CDM 0300 RC 36592 HCPCS inpatient 388 252.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.93 376.36 Collection of blood sample from central venous tube 48755868_1 CDM 0300 RC 36592 HCPCS inpatient 388 252.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.93 376.36 Administration of non-hormonal anti-neoplastic chemotherapy under skin or into muscle 48755870_1 CDM 0331 RC 96401 HCPCS inpatient 479 311.35 AETNA AETNA 378.41 79 999999999 290.03 464.63 percent of total billed charges Administration of non-hormonal anti-neoplastic chemotherapy under skin or into muscle 48755870_1 CDM 0331 RC 96401 HCPCS inpatient 479 311.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 311.35 65 999999999 290.03 464.63 percent of total billed charges Administration of non-hormonal anti-neoplastic chemotherapy under skin or into muscle 48755870_1 CDM 0331 RC 96401 HCPCS inpatient 479 311.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 464.63 97 999999999 290.03 464.63 percent of total billed charges Administration of non-hormonal anti-neoplastic chemotherapy under skin or into muscle 48755870_1 CDM 0331 RC 96401 HCPCS inpatient 479 311.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 330.51 69 999999999 290.03 464.63 percent of total billed charges Administration of non-hormonal anti-neoplastic chemotherapy under skin or into muscle 48755870_1 CDM 0331 RC 96401 HCPCS inpatient 479 311.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 373.62 78 999999999 290.03 464.63 percent of total billed charges Administration of non-hormonal anti-neoplastic chemotherapy under skin or into muscle 48755870_1 CDM 0331 RC 96401 HCPCS inpatient 479 311.35 SIHO - ALL PLANS SIHO - ALL PLANS 431.1 90 999999999 290.03 464.63 percent of total billed charges Administration of non-hormonal anti-neoplastic chemotherapy under skin or into muscle 48755870_1 CDM 0331 RC 96401 HCPCS inpatient 479 311.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 290.03 60.55 999999999 290.03 464.63 percent of total billed charges Administration of non-hormonal anti-neoplastic chemotherapy under skin or into muscle 48755870_1 CDM 0331 RC 96401 HCPCS inpatient 479 311.35 UMR - ALL PLANS UMR - ALL PLANS 335.3 70 999999999 290.03 464.63 percent of total billed charges Administration of non-hormonal anti-neoplastic chemotherapy under skin or into muscle 48755870_1 CDM 0331 RC 96401 HCPCS inpatient 479 311.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 290.03 464.63 Administration of non-hormonal anti-neoplastic chemotherapy under skin or into muscle 48755870_1 CDM 0331 RC 96401 HCPCS inpatient 479 311.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 290.03 464.63 Administration of non-hormonal anti-neoplastic chemotherapy under skin or into muscle 48755870_1 CDM 0331 RC 96401 HCPCS inpatient 479 311.35 ANTHEM HMO ANTHEM HMO 999999999 290.03 464.63 Administration of non-hormonal anti-neoplastic chemotherapy under skin or into muscle 48755870_1 CDM 0331 RC 96401 HCPCS inpatient 479 311.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 323.8 67.6 999999999 290.03 464.63 percent of total billed charges Administration of non-hormonal anti-neoplastic chemotherapy under skin or into muscle 48755870_1 CDM 0331 RC 96401 HCPCS inpatient 479 311.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 290.03 464.63 Administration of non-hormonal anti-neoplastic chemotherapy under skin or into muscle 48755870_1 CDM 0331 RC 96401 HCPCS inpatient 479 311.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 290.03 464.63 Administration of chemotherapy into vein using push technique 48755871_1 CDM 0331 RC 96409 HCPCS inpatient 486 315.9 AETNA AETNA 383.94 79 999999999 294.27 471.42 percent of total billed charges Administration of chemotherapy into vein using push technique 48755871_1 CDM 0331 RC 96409 HCPCS inpatient 486 315.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 315.9 65 999999999 294.27 471.42 percent of total billed charges Administration of chemotherapy into vein using push technique 48755871_1 CDM 0331 RC 96409 HCPCS inpatient 486 315.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 471.42 97 999999999 294.27 471.42 percent of total billed charges Administration of chemotherapy into vein using push technique 48755871_1 CDM 0331 RC 96409 HCPCS inpatient 486 315.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 335.34 69 999999999 294.27 471.42 percent of total billed charges Administration of chemotherapy into vein using push technique 48755871_1 CDM 0331 RC 96409 HCPCS inpatient 486 315.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 379.08 78 999999999 294.27 471.42 percent of total billed charges Administration of chemotherapy into vein using push technique 48755871_1 CDM 0331 RC 96409 HCPCS inpatient 486 315.9 SIHO - ALL PLANS SIHO - ALL PLANS 437.4 90 999999999 294.27 471.42 percent of total billed charges Administration of chemotherapy into vein using push technique 48755871_1 CDM 0331 RC 96409 HCPCS inpatient 486 315.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 294.27 60.55 999999999 294.27 471.42 percent of total billed charges Administration of chemotherapy into vein using push technique 48755871_1 CDM 0331 RC 96409 HCPCS inpatient 486 315.9 UMR - ALL PLANS UMR - ALL PLANS 340.2 70 999999999 294.27 471.42 percent of total billed charges Administration of chemotherapy into vein using push technique 48755871_1 CDM 0331 RC 96409 HCPCS inpatient 486 315.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 294.27 471.42 Administration of chemotherapy into vein using push technique 48755871_1 CDM 0331 RC 96409 HCPCS inpatient 486 315.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 294.27 471.42 Administration of chemotherapy into vein using push technique 48755871_1 CDM 0331 RC 96409 HCPCS inpatient 486 315.9 ANTHEM HMO ANTHEM HMO 999999999 294.27 471.42 Administration of chemotherapy into vein using push technique 48755871_1 CDM 0331 RC 96409 HCPCS inpatient 486 315.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 328.54 67.6 999999999 294.27 471.42 percent of total billed charges Administration of chemotherapy into vein using push technique 48755871_1 CDM 0331 RC 96409 HCPCS inpatient 486 315.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 294.27 471.42 Administration of chemotherapy into vein using push technique 48755871_1 CDM 0331 RC 96409 HCPCS inpatient 486 315.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 294.27 471.42 96545 ONC ORAL CHEMOTHERAPY CHARGE 48755872_1 CDM 0332 RC 96545 HCPCS inpatient 204 132.6 AETNA AETNA 161.16 79 999999999 123.52 197.88 percent of total billed charges 96545 ONC ORAL CHEMOTHERAPY CHARGE 48755872_1 CDM 0332 RC 96545 HCPCS inpatient 204 132.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.6 65 999999999 123.52 197.88 percent of total billed charges 96545 ONC ORAL CHEMOTHERAPY CHARGE 48755872_1 CDM 0332 RC 96545 HCPCS inpatient 204 132.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.88 97 999999999 123.52 197.88 percent of total billed charges 96545 ONC ORAL CHEMOTHERAPY CHARGE 48755872_1 CDM 0332 RC 96545 HCPCS inpatient 204 132.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.76 69 999999999 123.52 197.88 percent of total billed charges 96545 ONC ORAL CHEMOTHERAPY CHARGE 48755872_1 CDM 0332 RC 96545 HCPCS inpatient 204 132.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.12 78 999999999 123.52 197.88 percent of total billed charges 96545 ONC ORAL CHEMOTHERAPY CHARGE 48755872_1 CDM 0332 RC 96545 HCPCS inpatient 204 132.6 SIHO - ALL PLANS SIHO - ALL PLANS 183.6 90 999999999 123.52 197.88 percent of total billed charges 96545 ONC ORAL CHEMOTHERAPY CHARGE 48755872_1 CDM 0332 RC 96545 HCPCS inpatient 204 132.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.52 60.55 999999999 123.52 197.88 percent of total billed charges 96545 ONC ORAL CHEMOTHERAPY CHARGE 48755872_1 CDM 0332 RC 96545 HCPCS inpatient 204 132.6 UMR - ALL PLANS UMR - ALL PLANS 142.8 70 999999999 123.52 197.88 percent of total billed charges 96545 ONC ORAL CHEMOTHERAPY CHARGE 48755872_1 CDM 0332 RC 96545 HCPCS inpatient 204 132.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.52 197.88 96545 ONC ORAL CHEMOTHERAPY CHARGE 48755872_1 CDM 0332 RC 96545 HCPCS inpatient 204 132.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.52 197.88 96545 ONC ORAL CHEMOTHERAPY CHARGE 48755872_1 CDM 0332 RC 96545 HCPCS inpatient 204 132.6 ANTHEM HMO ANTHEM HMO 999999999 123.52 197.88 96545 ONC ORAL CHEMOTHERAPY CHARGE 48755872_1 CDM 0332 RC 96545 HCPCS inpatient 204 132.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.9 67.6 999999999 123.52 197.88 percent of total billed charges 96545 ONC ORAL CHEMOTHERAPY CHARGE 48755872_1 CDM 0332 RC 96545 HCPCS inpatient 204 132.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.52 197.88 96545 ONC ORAL CHEMOTHERAPY CHARGE 48755872_1 CDM 0332 RC 96545 HCPCS inpatient 204 132.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.52 197.88 "Administration of chemotherapy into vein, 1 hour or less" 48755873_1 CDM 0335 RC 96413 HCPCS inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges "Administration of chemotherapy into vein, 1 hour or less" 48755873_1 CDM 0335 RC 96413 HCPCS inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges "Administration of chemotherapy into vein, 1 hour or less" 48755873_1 CDM 0335 RC 96413 HCPCS inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges "Administration of chemotherapy into vein, 1 hour or less" 48755873_1 CDM 0335 RC 96413 HCPCS inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges "Administration of chemotherapy into vein, 1 hour or less" 48755873_1 CDM 0335 RC 96413 HCPCS inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges "Administration of chemotherapy into vein, 1 hour or less" 48755873_1 CDM 0335 RC 96413 HCPCS inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges "Administration of chemotherapy into vein, 1 hour or less" 48755873_1 CDM 0335 RC 96413 HCPCS inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges "Administration of chemotherapy into vein, 1 hour or less" 48755873_1 CDM 0335 RC 96413 HCPCS inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges "Administration of chemotherapy into vein, 1 hour or less" 48755873_1 CDM 0335 RC 96413 HCPCS inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 "Administration of chemotherapy into vein, 1 hour or less" 48755873_1 CDM 0335 RC 96413 HCPCS inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 "Administration of chemotherapy into vein, 1 hour or less" 48755873_1 CDM 0335 RC 96413 HCPCS inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 "Administration of chemotherapy into vein, 1 hour or less" 48755873_1 CDM 0335 RC 96413 HCPCS inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges "Administration of chemotherapy into vein, 1 hour or less" 48755873_1 CDM 0335 RC 96413 HCPCS inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 "Administration of chemotherapy into vein, 1 hour or less" 48755873_1 CDM 0335 RC 96413 HCPCS inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 "Administration of chemotherapy into vein, each additional hour" 48755874_1 CDM 0335 RC 96415 HCPCS inpatient 715 464.75 AETNA AETNA 564.85 79 999999999 432.93 693.55 percent of total billed charges "Administration of chemotherapy into vein, each additional hour" 48755874_1 CDM 0335 RC 96415 HCPCS inpatient 715 464.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 464.75 65 999999999 432.93 693.55 percent of total billed charges "Administration of chemotherapy into vein, each additional hour" 48755874_1 CDM 0335 RC 96415 HCPCS inpatient 715 464.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 693.55 97 999999999 432.93 693.55 percent of total billed charges "Administration of chemotherapy into vein, each additional hour" 48755874_1 CDM 0335 RC 96415 HCPCS inpatient 715 464.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 493.35 69 999999999 432.93 693.55 percent of total billed charges "Administration of chemotherapy into vein, each additional hour" 48755874_1 CDM 0335 RC 96415 HCPCS inpatient 715 464.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 557.7 78 999999999 432.93 693.55 percent of total billed charges "Administration of chemotherapy into vein, each additional hour" 48755874_1 CDM 0335 RC 96415 HCPCS inpatient 715 464.75 SIHO - ALL PLANS SIHO - ALL PLANS 643.5 90 999999999 432.93 693.55 percent of total billed charges "Administration of chemotherapy into vein, each additional hour" 48755874_1 CDM 0335 RC 96415 HCPCS inpatient 715 464.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 432.93 60.55 999999999 432.93 693.55 percent of total billed charges "Administration of chemotherapy into vein, each additional hour" 48755874_1 CDM 0335 RC 96415 HCPCS inpatient 715 464.75 UMR - ALL PLANS UMR - ALL PLANS 500.5 70 999999999 432.93 693.55 percent of total billed charges "Administration of chemotherapy into vein, each additional hour" 48755874_1 CDM 0335 RC 96415 HCPCS inpatient 715 464.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 432.93 693.55 "Administration of chemotherapy into vein, each additional hour" 48755874_1 CDM 0335 RC 96415 HCPCS inpatient 715 464.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 432.93 693.55 "Administration of chemotherapy into vein, each additional hour" 48755874_1 CDM 0335 RC 96415 HCPCS inpatient 715 464.75 ANTHEM HMO ANTHEM HMO 999999999 432.93 693.55 "Administration of chemotherapy into vein, each additional hour" 48755874_1 CDM 0335 RC 96415 HCPCS inpatient 715 464.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 483.34 67.6 999999999 432.93 693.55 percent of total billed charges "Administration of chemotherapy into vein, each additional hour" 48755874_1 CDM 0335 RC 96415 HCPCS inpatient 715 464.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 432.93 693.55 "Administration of chemotherapy into vein, each additional hour" 48755874_1 CDM 0335 RC 96415 HCPCS inpatient 715 464.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 432.93 693.55 "INTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; INITIATION OF PROLONGED INFUSION (MORE THAN 8 HOURS), REQUIRING USE OF PORTABLE OR IMPLANTABLE PUMP" 48755875_1 CDM 0335 RC C8957 HCPCS inpatient 715 464.75 AETNA AETNA 564.85 79 999999999 432.93 693.55 percent of total billed charges "INTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; INITIATION OF PROLONGED INFUSION (MORE THAN 8 HOURS), REQUIRING USE OF PORTABLE OR IMPLANTABLE PUMP" 48755875_1 CDM 0335 RC C8957 HCPCS inpatient 715 464.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 464.75 65 999999999 432.93 693.55 percent of total billed charges "INTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; INITIATION OF PROLONGED INFUSION (MORE THAN 8 HOURS), REQUIRING USE OF PORTABLE OR IMPLANTABLE PUMP" 48755875_1 CDM 0335 RC C8957 HCPCS inpatient 715 464.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 693.55 97 999999999 432.93 693.55 percent of total billed charges "INTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; INITIATION OF PROLONGED INFUSION (MORE THAN 8 HOURS), REQUIRING USE OF PORTABLE OR IMPLANTABLE PUMP" 48755875_1 CDM 0335 RC C8957 HCPCS inpatient 715 464.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 493.35 69 999999999 432.93 693.55 percent of total billed charges "INTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; INITIATION OF PROLONGED INFUSION (MORE THAN 8 HOURS), REQUIRING USE OF PORTABLE OR IMPLANTABLE PUMP" 48755875_1 CDM 0335 RC C8957 HCPCS inpatient 715 464.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 557.7 78 999999999 432.93 693.55 percent of total billed charges "INTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; INITIATION OF PROLONGED INFUSION (MORE THAN 8 HOURS), REQUIRING USE OF PORTABLE OR IMPLANTABLE PUMP" 48755875_1 CDM 0335 RC C8957 HCPCS inpatient 715 464.75 SIHO - ALL PLANS SIHO - ALL PLANS 643.5 90 999999999 432.93 693.55 percent of total billed charges "INTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; INITIATION OF PROLONGED INFUSION (MORE THAN 8 HOURS), REQUIRING USE OF PORTABLE OR IMPLANTABLE PUMP" 48755875_1 CDM 0335 RC C8957 HCPCS inpatient 715 464.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 432.93 60.55 999999999 432.93 693.55 percent of total billed charges "INTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; INITIATION OF PROLONGED INFUSION (MORE THAN 8 HOURS), REQUIRING USE OF PORTABLE OR IMPLANTABLE PUMP" 48755875_1 CDM 0335 RC C8957 HCPCS inpatient 715 464.75 UMR - ALL PLANS UMR - ALL PLANS 500.5 70 999999999 432.93 693.55 percent of total billed charges "INTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; INITIATION OF PROLONGED INFUSION (MORE THAN 8 HOURS), REQUIRING USE OF PORTABLE OR IMPLANTABLE PUMP" 48755875_1 CDM 0335 RC C8957 HCPCS inpatient 715 464.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 432.93 693.55 "INTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; INITIATION OF PROLONGED INFUSION (MORE THAN 8 HOURS), REQUIRING USE OF PORTABLE OR IMPLANTABLE PUMP" 48755875_1 CDM 0335 RC C8957 HCPCS inpatient 715 464.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 432.93 693.55 "INTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; INITIATION OF PROLONGED INFUSION (MORE THAN 8 HOURS), REQUIRING USE OF PORTABLE OR IMPLANTABLE PUMP" 48755875_1 CDM 0335 RC C8957 HCPCS inpatient 715 464.75 ANTHEM HMO ANTHEM HMO 999999999 432.93 693.55 "INTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; INITIATION OF PROLONGED INFUSION (MORE THAN 8 HOURS), REQUIRING USE OF PORTABLE OR IMPLANTABLE PUMP" 48755875_1 CDM 0335 RC C8957 HCPCS inpatient 715 464.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 483.34 67.6 999999999 432.93 693.55 percent of total billed charges "INTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; INITIATION OF PROLONGED INFUSION (MORE THAN 8 HOURS), REQUIRING USE OF PORTABLE OR IMPLANTABLE PUMP" 48755875_1 CDM 0335 RC C8957 HCPCS inpatient 715 464.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 432.93 693.55 "INTRAVENOUS INFUSION FOR THERAPY/DIAGNOSIS; INITIATION OF PROLONGED INFUSION (MORE THAN 8 HOURS), REQUIRING USE OF PORTABLE OR IMPLANTABLE PUMP" 48755875_1 CDM 0335 RC C8957 HCPCS inpatient 715 464.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 432.93 693.55 "Administration of additional new drug or substance into vein, 1 hour or less" 48755876_1 CDM 0335 RC 96417 HCPCS inpatient 187 121.55 AETNA AETNA 147.73 79 999999999 113.23 181.39 percent of total billed charges "Administration of additional new drug or substance into vein, 1 hour or less" 48755876_1 CDM 0335 RC 96417 HCPCS inpatient 187 121.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 121.55 65 999999999 113.23 181.39 percent of total billed charges "Administration of additional new drug or substance into vein, 1 hour or less" 48755876_1 CDM 0335 RC 96417 HCPCS inpatient 187 121.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 181.39 97 999999999 113.23 181.39 percent of total billed charges "Administration of additional new drug or substance into vein, 1 hour or less" 48755876_1 CDM 0335 RC 96417 HCPCS inpatient 187 121.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.03 69 999999999 113.23 181.39 percent of total billed charges "Administration of additional new drug or substance into vein, 1 hour or less" 48755876_1 CDM 0335 RC 96417 HCPCS inpatient 187 121.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 145.86 78 999999999 113.23 181.39 percent of total billed charges "Administration of additional new drug or substance into vein, 1 hour or less" 48755876_1 CDM 0335 RC 96417 HCPCS inpatient 187 121.55 SIHO - ALL PLANS SIHO - ALL PLANS 168.3 90 999999999 113.23 181.39 percent of total billed charges "Administration of additional new drug or substance into vein, 1 hour or less" 48755876_1 CDM 0335 RC 96417 HCPCS inpatient 187 121.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.23 60.55 999999999 113.23 181.39 percent of total billed charges "Administration of additional new drug or substance into vein, 1 hour or less" 48755876_1 CDM 0335 RC 96417 HCPCS inpatient 187 121.55 UMR - ALL PLANS UMR - ALL PLANS 130.9 70 999999999 113.23 181.39 percent of total billed charges "Administration of additional new drug or substance into vein, 1 hour or less" 48755876_1 CDM 0335 RC 96417 HCPCS inpatient 187 121.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.23 181.39 "Administration of additional new drug or substance into vein, 1 hour or less" 48755876_1 CDM 0335 RC 96417 HCPCS inpatient 187 121.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.23 181.39 "Administration of additional new drug or substance into vein, 1 hour or less" 48755876_1 CDM 0335 RC 96417 HCPCS inpatient 187 121.55 ANTHEM HMO ANTHEM HMO 999999999 113.23 181.39 "Administration of additional new drug or substance into vein, 1 hour or less" 48755876_1 CDM 0335 RC 96417 HCPCS inpatient 187 121.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 126.41 67.6 999999999 113.23 181.39 percent of total billed charges "Administration of additional new drug or substance into vein, 1 hour or less" 48755876_1 CDM 0335 RC 96417 HCPCS inpatient 187 121.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.23 181.39 "Administration of additional new drug or substance into vein, 1 hour or less" 48755876_1 CDM 0335 RC 96417 HCPCS inpatient 187 121.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.23 181.39 Computer-assisted image-guided navigation of lung airways using an endoscope 48755880_1 CDM 0361 RC 31627 HCPCS inpatient 470 305.5 AETNA AETNA 371.3 79 999999999 284.59 455.9 percent of total billed charges Computer-assisted image-guided navigation of lung airways using an endoscope 48755880_1 CDM 0361 RC 31627 HCPCS inpatient 470 305.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 305.5 65 999999999 284.59 455.9 percent of total billed charges Computer-assisted image-guided navigation of lung airways using an endoscope 48755880_1 CDM 0361 RC 31627 HCPCS inpatient 470 305.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 455.9 97 999999999 284.59 455.9 percent of total billed charges Computer-assisted image-guided navigation of lung airways using an endoscope 48755880_1 CDM 0361 RC 31627 HCPCS inpatient 470 305.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 324.3 69 999999999 284.59 455.9 percent of total billed charges Computer-assisted image-guided navigation of lung airways using an endoscope 48755880_1 CDM 0361 RC 31627 HCPCS inpatient 470 305.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 366.6 78 999999999 284.59 455.9 percent of total billed charges Computer-assisted image-guided navigation of lung airways using an endoscope 48755880_1 CDM 0361 RC 31627 HCPCS inpatient 470 305.5 SIHO - ALL PLANS SIHO - ALL PLANS 423 90 999999999 284.59 455.9 percent of total billed charges Computer-assisted image-guided navigation of lung airways using an endoscope 48755880_1 CDM 0361 RC 31627 HCPCS inpatient 470 305.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 284.59 60.55 999999999 284.59 455.9 percent of total billed charges Computer-assisted image-guided navigation of lung airways using an endoscope 48755880_1 CDM 0361 RC 31627 HCPCS inpatient 470 305.5 UMR - ALL PLANS UMR - ALL PLANS 329 70 999999999 284.59 455.9 percent of total billed charges Computer-assisted image-guided navigation of lung airways using an endoscope 48755880_1 CDM 0361 RC 31627 HCPCS inpatient 470 305.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 284.59 455.9 Computer-assisted image-guided navigation of lung airways using an endoscope 48755880_1 CDM 0361 RC 31627 HCPCS inpatient 470 305.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 284.59 455.9 Computer-assisted image-guided navigation of lung airways using an endoscope 48755880_1 CDM 0361 RC 31627 HCPCS inpatient 470 305.5 ANTHEM HMO ANTHEM HMO 999999999 284.59 455.9 Computer-assisted image-guided navigation of lung airways using an endoscope 48755880_1 CDM 0361 RC 31627 HCPCS inpatient 470 305.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 317.72 67.6 999999999 284.59 455.9 percent of total billed charges Computer-assisted image-guided navigation of lung airways using an endoscope 48755880_1 CDM 0361 RC 31627 HCPCS inpatient 470 305.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 284.59 455.9 Computer-assisted image-guided navigation of lung airways using an endoscope 48755880_1 CDM 0361 RC 31627 HCPCS inpatient 470 305.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 284.59 455.9 OPERATING ROOM SERVICES - MINOR SURGERY 48755881_1 CDM 0361 RC inpatient 1394 906.1 AETNA AETNA 1101.26 79 999999999 844.07 1352.18 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48755881_1 CDM 0361 RC inpatient 1394 906.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 906.1 65 999999999 844.07 1352.18 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48755881_1 CDM 0361 RC inpatient 1394 906.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1352.18 97 999999999 844.07 1352.18 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48755881_1 CDM 0361 RC inpatient 1394 906.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 961.86 69 999999999 844.07 1352.18 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48755881_1 CDM 0361 RC inpatient 1394 906.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1087.32 78 999999999 844.07 1352.18 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48755881_1 CDM 0361 RC inpatient 1394 906.1 SIHO - ALL PLANS SIHO - ALL PLANS 1254.6 90 999999999 844.07 1352.18 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48755881_1 CDM 0361 RC inpatient 1394 906.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 844.07 60.55 999999999 844.07 1352.18 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48755881_1 CDM 0361 RC inpatient 1394 906.1 UMR - ALL PLANS UMR - ALL PLANS 975.8 70 999999999 844.07 1352.18 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48755881_1 CDM 0361 RC inpatient 1394 906.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 844.07 1352.18 OPERATING ROOM SERVICES - MINOR SURGERY 48755881_1 CDM 0361 RC inpatient 1394 906.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 844.07 1352.18 OPERATING ROOM SERVICES - MINOR SURGERY 48755881_1 CDM 0361 RC inpatient 1394 906.1 ANTHEM HMO ANTHEM HMO 999999999 844.07 1352.18 OPERATING ROOM SERVICES - MINOR SURGERY 48755881_1 CDM 0361 RC inpatient 1394 906.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 942.34 67.6 999999999 844.07 1352.18 percent of total billed charges OPERATING ROOM SERVICES - MINOR SURGERY 48755881_1 CDM 0361 RC inpatient 1394 906.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 844.07 1352.18 OPERATING ROOM SERVICES - MINOR SURGERY 48755881_1 CDM 0361 RC inpatient 1394 906.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 844.07 1352.18 Transfusion of blood or blood products 48755883_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 AETNA AETNA 981.18 79 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48755883_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 807.3 65 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48755883_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1204.74 97 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48755883_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 856.98 69 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48755883_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 968.76 78 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48755883_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 SIHO - ALL PLANS SIHO - ALL PLANS 1117.8 90 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48755883_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 752.03 60.55 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48755883_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 UMR - ALL PLANS UMR - ALL PLANS 869.4 70 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48755883_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 752.03 1204.74 Transfusion of blood or blood products 48755883_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 752.03 1204.74 Transfusion of blood or blood products 48755883_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM HMO ANTHEM HMO 999999999 752.03 1204.74 Transfusion of blood or blood products 48755883_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 839.59 67.6 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 48755883_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 752.03 1204.74 Transfusion of blood or blood products 48755883_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 752.03 1204.74 Declotting of central venous tube 48755884_1 CDM 0510 RC 36593 HCPCS inpatient 715 464.75 AETNA AETNA 564.85 79 999999999 432.93 693.55 percent of total billed charges Declotting of central venous tube 48755884_1 CDM 0510 RC 36593 HCPCS inpatient 715 464.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 464.75 65 999999999 432.93 693.55 percent of total billed charges Declotting of central venous tube 48755884_1 CDM 0510 RC 36593 HCPCS inpatient 715 464.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 693.55 97 999999999 432.93 693.55 percent of total billed charges Declotting of central venous tube 48755884_1 CDM 0510 RC 36593 HCPCS inpatient 715 464.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 493.35 69 999999999 432.93 693.55 percent of total billed charges Declotting of central venous tube 48755884_1 CDM 0510 RC 36593 HCPCS inpatient 715 464.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 557.7 78 999999999 432.93 693.55 percent of total billed charges Declotting of central venous tube 48755884_1 CDM 0510 RC 36593 HCPCS inpatient 715 464.75 SIHO - ALL PLANS SIHO - ALL PLANS 643.5 90 999999999 432.93 693.55 percent of total billed charges Declotting of central venous tube 48755884_1 CDM 0510 RC 36593 HCPCS inpatient 715 464.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 432.93 60.55 999999999 432.93 693.55 percent of total billed charges Declotting of central venous tube 48755884_1 CDM 0510 RC 36593 HCPCS inpatient 715 464.75 UMR - ALL PLANS UMR - ALL PLANS 500.5 70 999999999 432.93 693.55 percent of total billed charges Declotting of central venous tube 48755884_1 CDM 0510 RC 36593 HCPCS inpatient 715 464.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 432.93 693.55 Declotting of central venous tube 48755884_1 CDM 0510 RC 36593 HCPCS inpatient 715 464.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 432.93 693.55 Declotting of central venous tube 48755884_1 CDM 0510 RC 36593 HCPCS inpatient 715 464.75 ANTHEM HMO ANTHEM HMO 999999999 432.93 693.55 Declotting of central venous tube 48755884_1 CDM 0510 RC 36593 HCPCS inpatient 715 464.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 483.34 67.6 999999999 432.93 693.55 percent of total billed charges Declotting of central venous tube 48755884_1 CDM 0510 RC 36593 HCPCS inpatient 715 464.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 432.93 693.55 Declotting of central venous tube 48755884_1 CDM 0510 RC 36593 HCPCS inpatient 715 464.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 432.93 693.55 REV - IHS-MOA CLINIC VISIT 48755885_1 CDM 0510 RC 90768 HCPCS inpatient 172 111.8 AETNA AETNA 135.88 79 999999999 104.15 166.84 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48755885_1 CDM 0510 RC 90768 HCPCS inpatient 172 111.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.8 65 999999999 104.15 166.84 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48755885_1 CDM 0510 RC 90768 HCPCS inpatient 172 111.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 166.84 97 999999999 104.15 166.84 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48755885_1 CDM 0510 RC 90768 HCPCS inpatient 172 111.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 118.68 69 999999999 104.15 166.84 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48755885_1 CDM 0510 RC 90768 HCPCS inpatient 172 111.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.16 78 999999999 104.15 166.84 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48755885_1 CDM 0510 RC 90768 HCPCS inpatient 172 111.8 SIHO - ALL PLANS SIHO - ALL PLANS 154.8 90 999999999 104.15 166.84 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48755885_1 CDM 0510 RC 90768 HCPCS inpatient 172 111.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.15 60.55 999999999 104.15 166.84 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48755885_1 CDM 0510 RC 90768 HCPCS inpatient 172 111.8 UMR - ALL PLANS UMR - ALL PLANS 120.4 70 999999999 104.15 166.84 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48755885_1 CDM 0510 RC 90768 HCPCS inpatient 172 111.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.15 166.84 REV - IHS-MOA CLINIC VISIT 48755885_1 CDM 0510 RC 90768 HCPCS inpatient 172 111.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.15 166.84 REV - IHS-MOA CLINIC VISIT 48755885_1 CDM 0510 RC 90768 HCPCS inpatient 172 111.8 ANTHEM HMO ANTHEM HMO 999999999 104.15 166.84 REV - IHS-MOA CLINIC VISIT 48755885_1 CDM 0510 RC 90768 HCPCS inpatient 172 111.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.27 67.6 999999999 104.15 166.84 percent of total billed charges REV - IHS-MOA CLINIC VISIT 48755885_1 CDM 0510 RC 90768 HCPCS inpatient 172 111.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.15 166.84 REV - IHS-MOA CLINIC VISIT 48755885_1 CDM 0510 RC 90768 HCPCS inpatient 172 111.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.15 166.84 "Infusion into a vein for hydration, 31-60 minutes" 48755886_1 CDM 0510 RC 96360 HCPCS inpatient 220 143 AETNA AETNA 173.8 79 999999999 133.21 213.4 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 48755886_1 CDM 0510 RC 96360 HCPCS inpatient 220 143 SELF PAY DISCOUNT SELF PAY DISCOUNT 143 65 999999999 133.21 213.4 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 48755886_1 CDM 0510 RC 96360 HCPCS inpatient 220 143 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 213.4 97 999999999 133.21 213.4 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 48755886_1 CDM 0510 RC 96360 HCPCS inpatient 220 143 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.8 69 999999999 133.21 213.4 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 48755886_1 CDM 0510 RC 96360 HCPCS inpatient 220 143 HUMANA - ALL PLANS HUMANA - ALL PLANS 171.6 78 999999999 133.21 213.4 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 48755886_1 CDM 0510 RC 96360 HCPCS inpatient 220 143 SIHO - ALL PLANS SIHO - ALL PLANS 198 90 999999999 133.21 213.4 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 48755886_1 CDM 0510 RC 96360 HCPCS inpatient 220 143 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 133.21 60.55 999999999 133.21 213.4 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 48755886_1 CDM 0510 RC 96360 HCPCS inpatient 220 143 UMR - ALL PLANS UMR - ALL PLANS 154 70 999999999 133.21 213.4 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 48755886_1 CDM 0510 RC 96360 HCPCS inpatient 220 143 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 133.21 213.4 "Infusion into a vein for hydration, 31-60 minutes" 48755886_1 CDM 0510 RC 96360 HCPCS inpatient 220 143 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 133.21 213.4 "Infusion into a vein for hydration, 31-60 minutes" 48755886_1 CDM 0510 RC 96360 HCPCS inpatient 220 143 ANTHEM HMO ANTHEM HMO 999999999 133.21 213.4 "Infusion into a vein for hydration, 31-60 minutes" 48755886_1 CDM 0510 RC 96360 HCPCS inpatient 220 143 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.72 67.6 999999999 133.21 213.4 percent of total billed charges "Infusion into a vein for hydration, 31-60 minutes" 48755886_1 CDM 0510 RC 96360 HCPCS inpatient 220 143 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 133.21 213.4 "Infusion into a vein for hydration, 31-60 minutes" 48755886_1 CDM 0510 RC 96360 HCPCS inpatient 220 143 UHC - ALL PLANS UHC - ALL PLANS 999999999 133.21 213.4 "Infusion into a vein for hydration, each additional hour" 48755891_1 CDM 0510 RC 96361 HCPCS inpatient 74 48.1 AETNA AETNA 58.46 79 999999999 44.81 71.78 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 48755891_1 CDM 0510 RC 96361 HCPCS inpatient 74 48.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.1 65 999999999 44.81 71.78 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 48755891_1 CDM 0510 RC 96361 HCPCS inpatient 74 48.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 71.78 97 999999999 44.81 71.78 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 48755891_1 CDM 0510 RC 96361 HCPCS inpatient 74 48.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.06 69 999999999 44.81 71.78 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 48755891_1 CDM 0510 RC 96361 HCPCS inpatient 74 48.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 57.72 78 999999999 44.81 71.78 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 48755891_1 CDM 0510 RC 96361 HCPCS inpatient 74 48.1 SIHO - ALL PLANS SIHO - ALL PLANS 66.6 90 999999999 44.81 71.78 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 48755891_1 CDM 0510 RC 96361 HCPCS inpatient 74 48.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.81 60.55 999999999 44.81 71.78 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 48755891_1 CDM 0510 RC 96361 HCPCS inpatient 74 48.1 UMR - ALL PLANS UMR - ALL PLANS 51.8 70 999999999 44.81 71.78 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 48755891_1 CDM 0510 RC 96361 HCPCS inpatient 74 48.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.81 71.78 "Infusion into a vein for hydration, each additional hour" 48755891_1 CDM 0510 RC 96361 HCPCS inpatient 74 48.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.81 71.78 "Infusion into a vein for hydration, each additional hour" 48755891_1 CDM 0510 RC 96361 HCPCS inpatient 74 48.1 ANTHEM HMO ANTHEM HMO 999999999 44.81 71.78 "Infusion into a vein for hydration, each additional hour" 48755891_1 CDM 0510 RC 96361 HCPCS inpatient 74 48.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.02 67.6 999999999 44.81 71.78 percent of total billed charges "Infusion into a vein for hydration, each additional hour" 48755891_1 CDM 0510 RC 96361 HCPCS inpatient 74 48.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.81 71.78 "Infusion into a vein for hydration, each additional hour" 48755891_1 CDM 0510 RC 96361 HCPCS inpatient 74 48.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.81 71.78 "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48755894_1 CDM 0263 RC 96365 HCPCS inpatient 548 356.2 AETNA AETNA 432.92 79 999999999 331.81 531.56 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48755894_1 CDM 0263 RC 96365 HCPCS inpatient 548 356.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 356.2 65 999999999 331.81 531.56 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48755894_1 CDM 0263 RC 96365 HCPCS inpatient 548 356.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 531.56 97 999999999 331.81 531.56 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48755894_1 CDM 0263 RC 96365 HCPCS inpatient 548 356.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 378.12 69 999999999 331.81 531.56 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48755894_1 CDM 0263 RC 96365 HCPCS inpatient 548 356.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 427.44 78 999999999 331.81 531.56 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48755894_1 CDM 0263 RC 96365 HCPCS inpatient 548 356.2 SIHO - ALL PLANS SIHO - ALL PLANS 493.2 90 999999999 331.81 531.56 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48755894_1 CDM 0263 RC 96365 HCPCS inpatient 548 356.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 331.81 60.55 999999999 331.81 531.56 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48755894_1 CDM 0263 RC 96365 HCPCS inpatient 548 356.2 UMR - ALL PLANS UMR - ALL PLANS 383.6 70 999999999 331.81 531.56 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48755894_1 CDM 0263 RC 96365 HCPCS inpatient 548 356.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 331.81 531.56 "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48755894_1 CDM 0263 RC 96365 HCPCS inpatient 548 356.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 331.81 531.56 "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48755894_1 CDM 0263 RC 96365 HCPCS inpatient 548 356.2 ANTHEM HMO ANTHEM HMO 999999999 331.81 531.56 "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48755894_1 CDM 0263 RC 96365 HCPCS inpatient 548 356.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 370.45 67.6 999999999 331.81 531.56 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48755894_1 CDM 0263 RC 96365 HCPCS inpatient 548 356.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 331.81 531.56 "Infusion into a vein for therapy, prevention, or diagnosis, 1 hour or less" 48755894_1 CDM 0263 RC 96365 HCPCS inpatient 548 356.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 331.81 531.56 "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48755895_1 CDM 0510 RC 96366 HCPCS inpatient 85 55.25 AETNA AETNA 67.15 79 999999999 51.47 82.45 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48755895_1 CDM 0510 RC 96366 HCPCS inpatient 85 55.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.25 65 999999999 51.47 82.45 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48755895_1 CDM 0510 RC 96366 HCPCS inpatient 85 55.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 82.45 97 999999999 51.47 82.45 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48755895_1 CDM 0510 RC 96366 HCPCS inpatient 85 55.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 58.65 69 999999999 51.47 82.45 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48755895_1 CDM 0510 RC 96366 HCPCS inpatient 85 55.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 66.3 78 999999999 51.47 82.45 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48755895_1 CDM 0510 RC 96366 HCPCS inpatient 85 55.25 SIHO - ALL PLANS SIHO - ALL PLANS 76.5 90 999999999 51.47 82.45 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48755895_1 CDM 0510 RC 96366 HCPCS inpatient 85 55.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 51.47 60.55 999999999 51.47 82.45 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48755895_1 CDM 0510 RC 96366 HCPCS inpatient 85 55.25 UMR - ALL PLANS UMR - ALL PLANS 59.5 70 999999999 51.47 82.45 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48755895_1 CDM 0510 RC 96366 HCPCS inpatient 85 55.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 51.47 82.45 "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48755895_1 CDM 0510 RC 96366 HCPCS inpatient 85 55.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 51.47 82.45 "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48755895_1 CDM 0510 RC 96366 HCPCS inpatient 85 55.25 ANTHEM HMO ANTHEM HMO 999999999 51.47 82.45 "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48755895_1 CDM 0510 RC 96366 HCPCS inpatient 85 55.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 57.46 67.6 999999999 51.47 82.45 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48755895_1 CDM 0510 RC 96366 HCPCS inpatient 85 55.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 51.47 82.45 "Infusion into a vein for therapy, prevention, or diagnosis, each additional hour" 48755895_1 CDM 0510 RC 96366 HCPCS inpatient 85 55.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 51.47 82.45 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48755896_1 CDM 0510 RC 96367 HCPCS inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48755896_1 CDM 0510 RC 96367 HCPCS inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48755896_1 CDM 0510 RC 96367 HCPCS inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48755896_1 CDM 0510 RC 96367 HCPCS inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48755896_1 CDM 0510 RC 96367 HCPCS inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48755896_1 CDM 0510 RC 96367 HCPCS inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48755896_1 CDM 0510 RC 96367 HCPCS inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48755896_1 CDM 0510 RC 96367 HCPCS inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48755896_1 CDM 0510 RC 96367 HCPCS inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48755896_1 CDM 0510 RC 96367 HCPCS inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48755896_1 CDM 0510 RC 96367 HCPCS inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48755896_1 CDM 0510 RC 96367 HCPCS inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48755896_1 CDM 0510 RC 96367 HCPCS inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 "Infusion into a vein for therapy, prevention, or diagnosis, additional sequential infusion, 1 hour or less" 48755896_1 CDM 0510 RC 96367 HCPCS inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48755897_1 CDM 0510 RC 96368 HCPCS inpatient 103 66.95 AETNA AETNA 81.37 79 999999999 62.37 99.91 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48755897_1 CDM 0510 RC 96368 HCPCS inpatient 103 66.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.95 65 999999999 62.37 99.91 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48755897_1 CDM 0510 RC 96368 HCPCS inpatient 103 66.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 99.91 97 999999999 62.37 99.91 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48755897_1 CDM 0510 RC 96368 HCPCS inpatient 103 66.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.07 69 999999999 62.37 99.91 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48755897_1 CDM 0510 RC 96368 HCPCS inpatient 103 66.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 80.34 78 999999999 62.37 99.91 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48755897_1 CDM 0510 RC 96368 HCPCS inpatient 103 66.95 SIHO - ALL PLANS SIHO - ALL PLANS 92.7 90 999999999 62.37 99.91 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48755897_1 CDM 0510 RC 96368 HCPCS inpatient 103 66.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.37 60.55 999999999 62.37 99.91 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48755897_1 CDM 0510 RC 96368 HCPCS inpatient 103 66.95 UMR - ALL PLANS UMR - ALL PLANS 72.1 70 999999999 62.37 99.91 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48755897_1 CDM 0510 RC 96368 HCPCS inpatient 103 66.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.37 99.91 "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48755897_1 CDM 0510 RC 96368 HCPCS inpatient 103 66.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.37 99.91 "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48755897_1 CDM 0510 RC 96368 HCPCS inpatient 103 66.95 ANTHEM HMO ANTHEM HMO 999999999 62.37 99.91 "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48755897_1 CDM 0510 RC 96368 HCPCS inpatient 103 66.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 69.63 67.6 999999999 62.37 99.91 percent of total billed charges "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48755897_1 CDM 0510 RC 96368 HCPCS inpatient 103 66.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.37 99.91 "Infusion into a vein for therapy, prevention, or diagnosis concurrent with another infusion" 48755897_1 CDM 0510 RC 96368 HCPCS inpatient 103 66.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.37 99.91 Injection of drug or substance under skin or into muscle 48755899_1 CDM 0510 RC 96372 HCPCS inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges Injection of drug or substance under skin or into muscle 48755899_1 CDM 0510 RC 96372 HCPCS inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges Injection of drug or substance under skin or into muscle 48755899_1 CDM 0510 RC 96372 HCPCS inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges Injection of drug or substance under skin or into muscle 48755899_1 CDM 0510 RC 96372 HCPCS inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges Injection of drug or substance under skin or into muscle 48755899_1 CDM 0510 RC 96372 HCPCS inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges Injection of drug or substance under skin or into muscle 48755899_1 CDM 0510 RC 96372 HCPCS inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges Injection of drug or substance under skin or into muscle 48755899_1 CDM 0510 RC 96372 HCPCS inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges Injection of drug or substance under skin or into muscle 48755899_1 CDM 0510 RC 96372 HCPCS inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges Injection of drug or substance under skin or into muscle 48755899_1 CDM 0510 RC 96372 HCPCS inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 Injection of drug or substance under skin or into muscle 48755899_1 CDM 0510 RC 96372 HCPCS inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 Injection of drug or substance under skin or into muscle 48755899_1 CDM 0510 RC 96372 HCPCS inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 Injection of drug or substance under skin or into muscle 48755899_1 CDM 0510 RC 96372 HCPCS inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges Injection of drug or substance under skin or into muscle 48755899_1 CDM 0510 RC 96372 HCPCS inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 Injection of drug or substance under skin or into muscle 48755899_1 CDM 0510 RC 96372 HCPCS inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 Injection of drug or substance into artery 48755900_1 CDM 0510 RC 96373 HCPCS inpatient 172 111.8 AETNA AETNA 135.88 79 999999999 104.15 166.84 percent of total billed charges Injection of drug or substance into artery 48755900_1 CDM 0510 RC 96373 HCPCS inpatient 172 111.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.8 65 999999999 104.15 166.84 percent of total billed charges Injection of drug or substance into artery 48755900_1 CDM 0510 RC 96373 HCPCS inpatient 172 111.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 166.84 97 999999999 104.15 166.84 percent of total billed charges Injection of drug or substance into artery 48755900_1 CDM 0510 RC 96373 HCPCS inpatient 172 111.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 118.68 69 999999999 104.15 166.84 percent of total billed charges Injection of drug or substance into artery 48755900_1 CDM 0510 RC 96373 HCPCS inpatient 172 111.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.16 78 999999999 104.15 166.84 percent of total billed charges Injection of drug or substance into artery 48755900_1 CDM 0510 RC 96373 HCPCS inpatient 172 111.8 SIHO - ALL PLANS SIHO - ALL PLANS 154.8 90 999999999 104.15 166.84 percent of total billed charges Injection of drug or substance into artery 48755900_1 CDM 0510 RC 96373 HCPCS inpatient 172 111.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.15 60.55 999999999 104.15 166.84 percent of total billed charges Injection of drug or substance into artery 48755900_1 CDM 0510 RC 96373 HCPCS inpatient 172 111.8 UMR - ALL PLANS UMR - ALL PLANS 120.4 70 999999999 104.15 166.84 percent of total billed charges Injection of drug or substance into artery 48755900_1 CDM 0510 RC 96373 HCPCS inpatient 172 111.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.15 166.84 Injection of drug or substance into artery 48755900_1 CDM 0510 RC 96373 HCPCS inpatient 172 111.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.15 166.84 Injection of drug or substance into artery 48755900_1 CDM 0510 RC 96373 HCPCS inpatient 172 111.8 ANTHEM HMO ANTHEM HMO 999999999 104.15 166.84 Injection of drug or substance into artery 48755900_1 CDM 0510 RC 96373 HCPCS inpatient 172 111.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.27 67.6 999999999 104.15 166.84 percent of total billed charges Injection of drug or substance into artery 48755900_1 CDM 0510 RC 96373 HCPCS inpatient 172 111.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.15 166.84 Injection of drug or substance into artery 48755900_1 CDM 0510 RC 96373 HCPCS inpatient 172 111.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.15 166.84 Injection of drug or substance into vein 48755901_1 CDM 0510 RC 96374 HCPCS inpatient 251 163.15 AETNA AETNA 198.29 79 999999999 151.98 243.47 percent of total billed charges Injection of drug or substance into vein 48755901_1 CDM 0510 RC 96374 HCPCS inpatient 251 163.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.15 65 999999999 151.98 243.47 percent of total billed charges Injection of drug or substance into vein 48755901_1 CDM 0510 RC 96374 HCPCS inpatient 251 163.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 243.47 97 999999999 151.98 243.47 percent of total billed charges Injection of drug or substance into vein 48755901_1 CDM 0510 RC 96374 HCPCS inpatient 251 163.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.19 69 999999999 151.98 243.47 percent of total billed charges Injection of drug or substance into vein 48755901_1 CDM 0510 RC 96374 HCPCS inpatient 251 163.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 195.78 78 999999999 151.98 243.47 percent of total billed charges Injection of drug or substance into vein 48755901_1 CDM 0510 RC 96374 HCPCS inpatient 251 163.15 SIHO - ALL PLANS SIHO - ALL PLANS 225.9 90 999999999 151.98 243.47 percent of total billed charges Injection of drug or substance into vein 48755901_1 CDM 0510 RC 96374 HCPCS inpatient 251 163.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.98 60.55 999999999 151.98 243.47 percent of total billed charges Injection of drug or substance into vein 48755901_1 CDM 0510 RC 96374 HCPCS inpatient 251 163.15 UMR - ALL PLANS UMR - ALL PLANS 175.7 70 999999999 151.98 243.47 percent of total billed charges Injection of drug or substance into vein 48755901_1 CDM 0510 RC 96374 HCPCS inpatient 251 163.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.98 243.47 Injection of drug or substance into vein 48755901_1 CDM 0510 RC 96374 HCPCS inpatient 251 163.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.98 243.47 Injection of drug or substance into vein 48755901_1 CDM 0510 RC 96374 HCPCS inpatient 251 163.15 ANTHEM HMO ANTHEM HMO 999999999 151.98 243.47 Injection of drug or substance into vein 48755901_1 CDM 0510 RC 96374 HCPCS inpatient 251 163.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 169.68 67.6 999999999 151.98 243.47 percent of total billed charges Injection of drug or substance into vein 48755901_1 CDM 0510 RC 96374 HCPCS inpatient 251 163.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.98 243.47 Injection of drug or substance into vein 48755901_1 CDM 0510 RC 96374 HCPCS inpatient 251 163.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.98 243.47 Injection of additional new drug or substance into vein 48755902_1 CDM 0510 RC 96375 HCPCS inpatient 186 120.9 AETNA AETNA 146.94 79 999999999 112.62 180.42 percent of total billed charges Injection of additional new drug or substance into vein 48755902_1 CDM 0510 RC 96375 HCPCS inpatient 186 120.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 120.9 65 999999999 112.62 180.42 percent of total billed charges Injection of additional new drug or substance into vein 48755902_1 CDM 0510 RC 96375 HCPCS inpatient 186 120.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 180.42 97 999999999 112.62 180.42 percent of total billed charges Injection of additional new drug or substance into vein 48755902_1 CDM 0510 RC 96375 HCPCS inpatient 186 120.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 128.34 69 999999999 112.62 180.42 percent of total billed charges Injection of additional new drug or substance into vein 48755902_1 CDM 0510 RC 96375 HCPCS inpatient 186 120.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 145.08 78 999999999 112.62 180.42 percent of total billed charges Injection of additional new drug or substance into vein 48755902_1 CDM 0510 RC 96375 HCPCS inpatient 186 120.9 SIHO - ALL PLANS SIHO - ALL PLANS 167.4 90 999999999 112.62 180.42 percent of total billed charges Injection of additional new drug or substance into vein 48755902_1 CDM 0510 RC 96375 HCPCS inpatient 186 120.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 112.62 60.55 999999999 112.62 180.42 percent of total billed charges Injection of additional new drug or substance into vein 48755902_1 CDM 0510 RC 96375 HCPCS inpatient 186 120.9 UMR - ALL PLANS UMR - ALL PLANS 130.2 70 999999999 112.62 180.42 percent of total billed charges Injection of additional new drug or substance into vein 48755902_1 CDM 0510 RC 96375 HCPCS inpatient 186 120.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 112.62 180.42 Injection of additional new drug or substance into vein 48755902_1 CDM 0510 RC 96375 HCPCS inpatient 186 120.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 112.62 180.42 Injection of additional new drug or substance into vein 48755902_1 CDM 0510 RC 96375 HCPCS inpatient 186 120.9 ANTHEM HMO ANTHEM HMO 999999999 112.62 180.42 Injection of additional new drug or substance into vein 48755902_1 CDM 0510 RC 96375 HCPCS inpatient 186 120.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 125.74 67.6 999999999 112.62 180.42 percent of total billed charges Injection of additional new drug or substance into vein 48755902_1 CDM 0510 RC 96375 HCPCS inpatient 186 120.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 112.62 180.42 Injection of additional new drug or substance into vein 48755902_1 CDM 0510 RC 96375 HCPCS inpatient 186 120.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 112.62 180.42 Injection of additional drug or substance into vein provided in a facility 48755903_1 CDM 0510 RC 96376 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges Injection of additional drug or substance into vein provided in a facility 48755903_1 CDM 0510 RC 96376 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges Injection of additional drug or substance into vein provided in a facility 48755903_1 CDM 0510 RC 96376 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges Injection of additional drug or substance into vein provided in a facility 48755903_1 CDM 0510 RC 96376 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges Injection of additional drug or substance into vein provided in a facility 48755903_1 CDM 0510 RC 96376 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges Injection of additional drug or substance into vein provided in a facility 48755903_1 CDM 0510 RC 96376 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges Injection of additional drug or substance into vein provided in a facility 48755903_1 CDM 0510 RC 96376 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges Injection of additional drug or substance into vein provided in a facility 48755903_1 CDM 0510 RC 96376 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges Injection of additional drug or substance into vein provided in a facility 48755903_1 CDM 0510 RC 96376 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 Injection of additional drug or substance into vein provided in a facility 48755903_1 CDM 0510 RC 96376 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 Injection of additional drug or substance into vein provided in a facility 48755903_1 CDM 0510 RC 96376 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 Injection of additional drug or substance into vein provided in a facility 48755903_1 CDM 0510 RC 96376 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges Injection of additional drug or substance into vein provided in a facility 48755903_1 CDM 0510 RC 96376 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 Injection of additional drug or substance into vein provided in a facility 48755903_1 CDM 0510 RC 96376 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 Administration of hormonal anti-neoplastic chemotherapy under skin or into muscle 48755904_1 CDM 0510 RC 96402 HCPCS inpatient 407 264.55 AETNA AETNA 321.53 79 999999999 246.44 394.79 percent of total billed charges Administration of hormonal anti-neoplastic chemotherapy under skin or into muscle 48755904_1 CDM 0510 RC 96402 HCPCS inpatient 407 264.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 264.55 65 999999999 246.44 394.79 percent of total billed charges Administration of hormonal anti-neoplastic chemotherapy under skin or into muscle 48755904_1 CDM 0510 RC 96402 HCPCS inpatient 407 264.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 394.79 97 999999999 246.44 394.79 percent of total billed charges Administration of hormonal anti-neoplastic chemotherapy under skin or into muscle 48755904_1 CDM 0510 RC 96402 HCPCS inpatient 407 264.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 280.83 69 999999999 246.44 394.79 percent of total billed charges Administration of hormonal anti-neoplastic chemotherapy under skin or into muscle 48755904_1 CDM 0510 RC 96402 HCPCS inpatient 407 264.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 317.46 78 999999999 246.44 394.79 percent of total billed charges Administration of hormonal anti-neoplastic chemotherapy under skin or into muscle 48755904_1 CDM 0510 RC 96402 HCPCS inpatient 407 264.55 SIHO - ALL PLANS SIHO - ALL PLANS 366.3 90 999999999 246.44 394.79 percent of total billed charges Administration of hormonal anti-neoplastic chemotherapy under skin or into muscle 48755904_1 CDM 0510 RC 96402 HCPCS inpatient 407 264.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 246.44 60.55 999999999 246.44 394.79 percent of total billed charges Administration of hormonal anti-neoplastic chemotherapy under skin or into muscle 48755904_1 CDM 0510 RC 96402 HCPCS inpatient 407 264.55 UMR - ALL PLANS UMR - ALL PLANS 284.9 70 999999999 246.44 394.79 percent of total billed charges Administration of hormonal anti-neoplastic chemotherapy under skin or into muscle 48755904_1 CDM 0510 RC 96402 HCPCS inpatient 407 264.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 246.44 394.79 Administration of hormonal anti-neoplastic chemotherapy under skin or into muscle 48755904_1 CDM 0510 RC 96402 HCPCS inpatient 407 264.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 246.44 394.79 Administration of hormonal anti-neoplastic chemotherapy under skin or into muscle 48755904_1 CDM 0510 RC 96402 HCPCS inpatient 407 264.55 ANTHEM HMO ANTHEM HMO 999999999 246.44 394.79 Administration of hormonal anti-neoplastic chemotherapy under skin or into muscle 48755904_1 CDM 0510 RC 96402 HCPCS inpatient 407 264.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 275.13 67.6 999999999 246.44 394.79 percent of total billed charges Administration of hormonal anti-neoplastic chemotherapy under skin or into muscle 48755904_1 CDM 0510 RC 96402 HCPCS inpatient 407 264.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 246.44 394.79 Administration of hormonal anti-neoplastic chemotherapy under skin or into muscle 48755904_1 CDM 0510 RC 96402 HCPCS inpatient 407 264.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 246.44 394.79 "Administration of chemotherapy into growth, 1-7" 48755908_1 CDM 0510 RC 96405 HCPCS inpatient 172 111.8 AETNA AETNA 135.88 79 999999999 104.15 166.84 percent of total billed charges "Administration of chemotherapy into growth, 1-7" 48755908_1 CDM 0510 RC 96405 HCPCS inpatient 172 111.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.8 65 999999999 104.15 166.84 percent of total billed charges "Administration of chemotherapy into growth, 1-7" 48755908_1 CDM 0510 RC 96405 HCPCS inpatient 172 111.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 166.84 97 999999999 104.15 166.84 percent of total billed charges "Administration of chemotherapy into growth, 1-7" 48755908_1 CDM 0510 RC 96405 HCPCS inpatient 172 111.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 118.68 69 999999999 104.15 166.84 percent of total billed charges "Administration of chemotherapy into growth, 1-7" 48755908_1 CDM 0510 RC 96405 HCPCS inpatient 172 111.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.16 78 999999999 104.15 166.84 percent of total billed charges "Administration of chemotherapy into growth, 1-7" 48755908_1 CDM 0510 RC 96405 HCPCS inpatient 172 111.8 SIHO - ALL PLANS SIHO - ALL PLANS 154.8 90 999999999 104.15 166.84 percent of total billed charges "Administration of chemotherapy into growth, 1-7" 48755908_1 CDM 0510 RC 96405 HCPCS inpatient 172 111.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.15 60.55 999999999 104.15 166.84 percent of total billed charges "Administration of chemotherapy into growth, 1-7" 48755908_1 CDM 0510 RC 96405 HCPCS inpatient 172 111.8 UMR - ALL PLANS UMR - ALL PLANS 120.4 70 999999999 104.15 166.84 percent of total billed charges "Administration of chemotherapy into growth, 1-7" 48755908_1 CDM 0510 RC 96405 HCPCS inpatient 172 111.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.15 166.84 "Administration of chemotherapy into growth, 1-7" 48755908_1 CDM 0510 RC 96405 HCPCS inpatient 172 111.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.15 166.84 "Administration of chemotherapy into growth, 1-7" 48755908_1 CDM 0510 RC 96405 HCPCS inpatient 172 111.8 ANTHEM HMO ANTHEM HMO 999999999 104.15 166.84 "Administration of chemotherapy into growth, 1-7" 48755908_1 CDM 0510 RC 96405 HCPCS inpatient 172 111.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.27 67.6 999999999 104.15 166.84 percent of total billed charges "Administration of chemotherapy into growth, 1-7" 48755908_1 CDM 0510 RC 96405 HCPCS inpatient 172 111.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.15 166.84 "Administration of chemotherapy into growth, 1-7" 48755908_1 CDM 0510 RC 96405 HCPCS inpatient 172 111.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.15 166.84 "Administration of chemotherapy into growth, more than 7" 48755910_1 CDM 0510 RC 96406 HCPCS inpatient 172 111.8 AETNA AETNA 135.88 79 999999999 104.15 166.84 percent of total billed charges "Administration of chemotherapy into growth, more than 7" 48755910_1 CDM 0510 RC 96406 HCPCS inpatient 172 111.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.8 65 999999999 104.15 166.84 percent of total billed charges "Administration of chemotherapy into growth, more than 7" 48755910_1 CDM 0510 RC 96406 HCPCS inpatient 172 111.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 166.84 97 999999999 104.15 166.84 percent of total billed charges "Administration of chemotherapy into growth, more than 7" 48755910_1 CDM 0510 RC 96406 HCPCS inpatient 172 111.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 118.68 69 999999999 104.15 166.84 percent of total billed charges "Administration of chemotherapy into growth, more than 7" 48755910_1 CDM 0510 RC 96406 HCPCS inpatient 172 111.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.16 78 999999999 104.15 166.84 percent of total billed charges "Administration of chemotherapy into growth, more than 7" 48755910_1 CDM 0510 RC 96406 HCPCS inpatient 172 111.8 SIHO - ALL PLANS SIHO - ALL PLANS 154.8 90 999999999 104.15 166.84 percent of total billed charges "Administration of chemotherapy into growth, more than 7" 48755910_1 CDM 0510 RC 96406 HCPCS inpatient 172 111.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.15 60.55 999999999 104.15 166.84 percent of total billed charges "Administration of chemotherapy into growth, more than 7" 48755910_1 CDM 0510 RC 96406 HCPCS inpatient 172 111.8 UMR - ALL PLANS UMR - ALL PLANS 120.4 70 999999999 104.15 166.84 percent of total billed charges "Administration of chemotherapy into growth, more than 7" 48755910_1 CDM 0510 RC 96406 HCPCS inpatient 172 111.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.15 166.84 "Administration of chemotherapy into growth, more than 7" 48755910_1 CDM 0510 RC 96406 HCPCS inpatient 172 111.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.15 166.84 "Administration of chemotherapy into growth, more than 7" 48755910_1 CDM 0510 RC 96406 HCPCS inpatient 172 111.8 ANTHEM HMO ANTHEM HMO 999999999 104.15 166.84 "Administration of chemotherapy into growth, more than 7" 48755910_1 CDM 0510 RC 96406 HCPCS inpatient 172 111.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.27 67.6 999999999 104.15 166.84 percent of total billed charges "Administration of chemotherapy into growth, more than 7" 48755910_1 CDM 0510 RC 96406 HCPCS inpatient 172 111.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.15 166.84 "Administration of chemotherapy into growth, more than 7" 48755910_1 CDM 0510 RC 96406 HCPCS inpatient 172 111.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.15 166.84 Administration of additional new drug or substance into vein using push technique 48755913_1 CDM 0510 RC 96411 HCPCS inpatient 486 315.9 AETNA AETNA 383.94 79 999999999 294.27 471.42 percent of total billed charges Administration of additional new drug or substance into vein using push technique 48755913_1 CDM 0510 RC 96411 HCPCS inpatient 486 315.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 315.9 65 999999999 294.27 471.42 percent of total billed charges Administration of additional new drug or substance into vein using push technique 48755913_1 CDM 0510 RC 96411 HCPCS inpatient 486 315.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 471.42 97 999999999 294.27 471.42 percent of total billed charges Administration of additional new drug or substance into vein using push technique 48755913_1 CDM 0510 RC 96411 HCPCS inpatient 486 315.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 335.34 69 999999999 294.27 471.42 percent of total billed charges Administration of additional new drug or substance into vein using push technique 48755913_1 CDM 0510 RC 96411 HCPCS inpatient 486 315.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 379.08 78 999999999 294.27 471.42 percent of total billed charges Administration of additional new drug or substance into vein using push technique 48755913_1 CDM 0510 RC 96411 HCPCS inpatient 486 315.9 SIHO - ALL PLANS SIHO - ALL PLANS 437.4 90 999999999 294.27 471.42 percent of total billed charges Administration of additional new drug or substance into vein using push technique 48755913_1 CDM 0510 RC 96411 HCPCS inpatient 486 315.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 294.27 60.55 999999999 294.27 471.42 percent of total billed charges Administration of additional new drug or substance into vein using push technique 48755913_1 CDM 0510 RC 96411 HCPCS inpatient 486 315.9 UMR - ALL PLANS UMR - ALL PLANS 340.2 70 999999999 294.27 471.42 percent of total billed charges Administration of additional new drug or substance into vein using push technique 48755913_1 CDM 0510 RC 96411 HCPCS inpatient 486 315.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 294.27 471.42 Administration of additional new drug or substance into vein using push technique 48755913_1 CDM 0510 RC 96411 HCPCS inpatient 486 315.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 294.27 471.42 Administration of additional new drug or substance into vein using push technique 48755913_1 CDM 0510 RC 96411 HCPCS inpatient 486 315.9 ANTHEM HMO ANTHEM HMO 999999999 294.27 471.42 Administration of additional new drug or substance into vein using push technique 48755913_1 CDM 0510 RC 96411 HCPCS inpatient 486 315.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 328.54 67.6 999999999 294.27 471.42 percent of total billed charges Administration of additional new drug or substance into vein using push technique 48755913_1 CDM 0510 RC 96411 HCPCS inpatient 486 315.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 294.27 471.42 Administration of additional new drug or substance into vein using push technique 48755913_1 CDM 0510 RC 96411 HCPCS inpatient 486 315.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 294.27 471.42 Refilling and maintenance of portable pump 48755914_1 CDM 0510 RC 96521 HCPCS inpatient 794 516.1 AETNA AETNA 627.26 79 999999999 480.77 770.18 percent of total billed charges Refilling and maintenance of portable pump 48755914_1 CDM 0510 RC 96521 HCPCS inpatient 794 516.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 516.1 65 999999999 480.77 770.18 percent of total billed charges Refilling and maintenance of portable pump 48755914_1 CDM 0510 RC 96521 HCPCS inpatient 794 516.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 770.18 97 999999999 480.77 770.18 percent of total billed charges Refilling and maintenance of portable pump 48755914_1 CDM 0510 RC 96521 HCPCS inpatient 794 516.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 547.86 69 999999999 480.77 770.18 percent of total billed charges Refilling and maintenance of portable pump 48755914_1 CDM 0510 RC 96521 HCPCS inpatient 794 516.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 619.32 78 999999999 480.77 770.18 percent of total billed charges Refilling and maintenance of portable pump 48755914_1 CDM 0510 RC 96521 HCPCS inpatient 794 516.1 SIHO - ALL PLANS SIHO - ALL PLANS 714.6 90 999999999 480.77 770.18 percent of total billed charges Refilling and maintenance of portable pump 48755914_1 CDM 0510 RC 96521 HCPCS inpatient 794 516.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 480.77 60.55 999999999 480.77 770.18 percent of total billed charges Refilling and maintenance of portable pump 48755914_1 CDM 0510 RC 96521 HCPCS inpatient 794 516.1 UMR - ALL PLANS UMR - ALL PLANS 555.8 70 999999999 480.77 770.18 percent of total billed charges Refilling and maintenance of portable pump 48755914_1 CDM 0510 RC 96521 HCPCS inpatient 794 516.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 480.77 770.18 Refilling and maintenance of portable pump 48755914_1 CDM 0510 RC 96521 HCPCS inpatient 794 516.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 480.77 770.18 Refilling and maintenance of portable pump 48755914_1 CDM 0510 RC 96521 HCPCS inpatient 794 516.1 ANTHEM HMO ANTHEM HMO 999999999 480.77 770.18 Refilling and maintenance of portable pump 48755914_1 CDM 0510 RC 96521 HCPCS inpatient 794 516.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 536.74 67.6 999999999 480.77 770.18 percent of total billed charges Refilling and maintenance of portable pump 48755914_1 CDM 0510 RC 96521 HCPCS inpatient 794 516.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 480.77 770.18 Refilling and maintenance of portable pump 48755914_1 CDM 0510 RC 96521 HCPCS inpatient 794 516.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 480.77 770.18 Irrigation of implanted venous access drug delivery device 48755918_1 CDM 0510 RC 96523 HCPCS inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges Irrigation of implanted venous access drug delivery device 48755918_1 CDM 0510 RC 96523 HCPCS inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges Irrigation of implanted venous access drug delivery device 48755918_1 CDM 0510 RC 96523 HCPCS inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges Irrigation of implanted venous access drug delivery device 48755918_1 CDM 0510 RC 96523 HCPCS inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges Irrigation of implanted venous access drug delivery device 48755918_1 CDM 0510 RC 96523 HCPCS inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges Irrigation of implanted venous access drug delivery device 48755918_1 CDM 0510 RC 96523 HCPCS inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges Irrigation of implanted venous access drug delivery device 48755918_1 CDM 0510 RC 96523 HCPCS inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges Irrigation of implanted venous access drug delivery device 48755918_1 CDM 0510 RC 96523 HCPCS inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges Irrigation of implanted venous access drug delivery device 48755918_1 CDM 0510 RC 96523 HCPCS inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 Irrigation of implanted venous access drug delivery device 48755918_1 CDM 0510 RC 96523 HCPCS inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 Irrigation of implanted venous access drug delivery device 48755918_1 CDM 0510 RC 96523 HCPCS inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 Irrigation of implanted venous access drug delivery device 48755918_1 CDM 0510 RC 96523 HCPCS inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges Irrigation of implanted venous access drug delivery device 48755918_1 CDM 0510 RC 96523 HCPCS inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 Irrigation of implanted venous access drug delivery device 48755918_1 CDM 0510 RC 96523 HCPCS inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 Drawing of blood for a medical problem 48755919_1 CDM 0510 RC 99195 HCPCS inpatient 223 144.95 AETNA AETNA 176.17 79 999999999 135.03 216.31 percent of total billed charges Drawing of blood for a medical problem 48755919_1 CDM 0510 RC 99195 HCPCS inpatient 223 144.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 144.95 65 999999999 135.03 216.31 percent of total billed charges Drawing of blood for a medical problem 48755919_1 CDM 0510 RC 99195 HCPCS inpatient 223 144.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 216.31 97 999999999 135.03 216.31 percent of total billed charges Drawing of blood for a medical problem 48755919_1 CDM 0510 RC 99195 HCPCS inpatient 223 144.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 153.87 69 999999999 135.03 216.31 percent of total billed charges Drawing of blood for a medical problem 48755919_1 CDM 0510 RC 99195 HCPCS inpatient 223 144.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 173.94 78 999999999 135.03 216.31 percent of total billed charges Drawing of blood for a medical problem 48755919_1 CDM 0510 RC 99195 HCPCS inpatient 223 144.95 SIHO - ALL PLANS SIHO - ALL PLANS 200.7 90 999999999 135.03 216.31 percent of total billed charges Drawing of blood for a medical problem 48755919_1 CDM 0510 RC 99195 HCPCS inpatient 223 144.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 135.03 60.55 999999999 135.03 216.31 percent of total billed charges Drawing of blood for a medical problem 48755919_1 CDM 0510 RC 99195 HCPCS inpatient 223 144.95 UMR - ALL PLANS UMR - ALL PLANS 156.1 70 999999999 135.03 216.31 percent of total billed charges Drawing of blood for a medical problem 48755919_1 CDM 0510 RC 99195 HCPCS inpatient 223 144.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 135.03 216.31 Drawing of blood for a medical problem 48755919_1 CDM 0510 RC 99195 HCPCS inpatient 223 144.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 135.03 216.31 Drawing of blood for a medical problem 48755919_1 CDM 0510 RC 99195 HCPCS inpatient 223 144.95 ANTHEM HMO ANTHEM HMO 999999999 135.03 216.31 Drawing of blood for a medical problem 48755919_1 CDM 0510 RC 99195 HCPCS inpatient 223 144.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 150.75 67.6 999999999 135.03 216.31 percent of total billed charges Drawing of blood for a medical problem 48755919_1 CDM 0510 RC 99195 HCPCS inpatient 223 144.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 135.03 216.31 Drawing of blood for a medical problem 48755919_1 CDM 0510 RC 99195 HCPCS inpatient 223 144.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 135.03 216.31 Electrocardiogram (ECG) 1 to 3 leads 48755956_1 CDM 0730 RC 93041 HCPCS inpatient 295 191.75 AETNA AETNA 233.05 79 999999999 178.62 286.15 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads 48755956_1 CDM 0730 RC 93041 HCPCS inpatient 295 191.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 191.75 65 999999999 178.62 286.15 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads 48755956_1 CDM 0730 RC 93041 HCPCS inpatient 295 191.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 286.15 97 999999999 178.62 286.15 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads 48755956_1 CDM 0730 RC 93041 HCPCS inpatient 295 191.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 203.55 69 999999999 178.62 286.15 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads 48755956_1 CDM 0730 RC 93041 HCPCS inpatient 295 191.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 230.1 78 999999999 178.62 286.15 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads 48755956_1 CDM 0730 RC 93041 HCPCS inpatient 295 191.75 SIHO - ALL PLANS SIHO - ALL PLANS 265.5 90 999999999 178.62 286.15 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads 48755956_1 CDM 0730 RC 93041 HCPCS inpatient 295 191.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 178.62 60.55 999999999 178.62 286.15 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads 48755956_1 CDM 0730 RC 93041 HCPCS inpatient 295 191.75 UMR - ALL PLANS UMR - ALL PLANS 206.5 70 999999999 178.62 286.15 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads 48755956_1 CDM 0730 RC 93041 HCPCS inpatient 295 191.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 178.62 286.15 Electrocardiogram (ECG) 1 to 3 leads 48755956_1 CDM 0730 RC 93041 HCPCS inpatient 295 191.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 178.62 286.15 Electrocardiogram (ECG) 1 to 3 leads 48755956_1 CDM 0730 RC 93041 HCPCS inpatient 295 191.75 ANTHEM HMO ANTHEM HMO 999999999 178.62 286.15 Electrocardiogram (ECG) 1 to 3 leads 48755956_1 CDM 0730 RC 93041 HCPCS inpatient 295 191.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 199.42 67.6 999999999 178.62 286.15 percent of total billed charges Electrocardiogram (ECG) 1 to 3 leads 48755956_1 CDM 0730 RC 93041 HCPCS inpatient 295 191.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 178.62 286.15 Electrocardiogram (ECG) 1 to 3 leads 48755956_1 CDM 0730 RC 93041 HCPCS inpatient 295 191.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 178.62 286.15 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755957_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 AETNA AETNA 267.02 79 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755957_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 219.7 65 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755957_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 327.86 97 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755957_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 233.22 69 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755957_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 263.64 78 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755957_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 SIHO - ALL PLANS SIHO - ALL PLANS 304.2 90 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755957_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 204.66 60.55 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755957_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 UMR - ALL PLANS UMR - ALL PLANS 236.6 70 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755957_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 204.66 327.86 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755957_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 204.66 327.86 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755957_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 ANTHEM HMO ANTHEM HMO 999999999 204.66 327.86 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755957_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 228.49 67.6 999999999 204.66 327.86 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755957_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 204.66 327.86 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755957_1 CDM 0730 RC 93005 HCPCS inpatient 338 219.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 204.66 327.86 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755958_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 AETNA AETNA 293.88 79 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755958_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 241.8 65 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755958_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 360.84 97 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755958_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 256.68 69 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755958_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 290.16 78 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755958_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 SIHO - ALL PLANS SIHO - ALL PLANS 334.8 90 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755958_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 225.25 60.55 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755958_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 UMR - ALL PLANS UMR - ALL PLANS 260.4 70 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755958_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 225.25 360.84 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755958_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 225.25 360.84 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755958_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 ANTHEM HMO ANTHEM HMO 999999999 225.25 360.84 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755958_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 251.47 67.6 999999999 225.25 360.84 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755958_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 225.25 360.84 Routine electrocardiogram (ECG) using at least 12 leads with tracing 48755958_1 CDM 0730 RC 93005 HCPCS inpatient 372 241.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 225.25 360.84 Electrocardiogram (ECG) 2-day continuous 48755959_1 CDM 0731 RC 93225 HCPCS inpatient 479 311.35 AETNA AETNA 378.41 79 999999999 290.03 464.63 percent of total billed charges Electrocardiogram (ECG) 2-day continuous 48755959_1 CDM 0731 RC 93225 HCPCS inpatient 479 311.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 311.35 65 999999999 290.03 464.63 percent of total billed charges Electrocardiogram (ECG) 2-day continuous 48755959_1 CDM 0731 RC 93225 HCPCS inpatient 479 311.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 464.63 97 999999999 290.03 464.63 percent of total billed charges Electrocardiogram (ECG) 2-day continuous 48755959_1 CDM 0731 RC 93225 HCPCS inpatient 479 311.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 330.51 69 999999999 290.03 464.63 percent of total billed charges Electrocardiogram (ECG) 2-day continuous 48755959_1 CDM 0731 RC 93225 HCPCS inpatient 479 311.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 373.62 78 999999999 290.03 464.63 percent of total billed charges Electrocardiogram (ECG) 2-day continuous 48755959_1 CDM 0731 RC 93225 HCPCS inpatient 479 311.35 SIHO - ALL PLANS SIHO - ALL PLANS 431.1 90 999999999 290.03 464.63 percent of total billed charges Electrocardiogram (ECG) 2-day continuous 48755959_1 CDM 0731 RC 93225 HCPCS inpatient 479 311.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 290.03 60.55 999999999 290.03 464.63 percent of total billed charges Electrocardiogram (ECG) 2-day continuous 48755959_1 CDM 0731 RC 93225 HCPCS inpatient 479 311.35 UMR - ALL PLANS UMR - ALL PLANS 335.3 70 999999999 290.03 464.63 percent of total billed charges Electrocardiogram (ECG) 2-day continuous 48755959_1 CDM 0731 RC 93225 HCPCS inpatient 479 311.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 290.03 464.63 Electrocardiogram (ECG) 2-day continuous 48755959_1 CDM 0731 RC 93225 HCPCS inpatient 479 311.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 290.03 464.63 Electrocardiogram (ECG) 2-day continuous 48755959_1 CDM 0731 RC 93225 HCPCS inpatient 479 311.35 ANTHEM HMO ANTHEM HMO 999999999 290.03 464.63 Electrocardiogram (ECG) 2-day continuous 48755959_1 CDM 0731 RC 93225 HCPCS inpatient 479 311.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 323.8 67.6 999999999 290.03 464.63 percent of total billed charges Electrocardiogram (ECG) 2-day continuous 48755959_1 CDM 0731 RC 93225 HCPCS inpatient 479 311.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 290.03 464.63 Electrocardiogram (ECG) 2-day continuous 48755959_1 CDM 0731 RC 93225 HCPCS inpatient 479 311.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 290.03 464.63 Electrocardiogram (ECG) 2-day continuous with report 48755960_1 CDM 0731 RC 93226 HCPCS inpatient 979 636.35 AETNA AETNA 773.41 79 999999999 592.78 949.63 percent of total billed charges Electrocardiogram (ECG) 2-day continuous with report 48755960_1 CDM 0731 RC 93226 HCPCS inpatient 979 636.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 636.35 65 999999999 592.78 949.63 percent of total billed charges Electrocardiogram (ECG) 2-day continuous with report 48755960_1 CDM 0731 RC 93226 HCPCS inpatient 979 636.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 949.63 97 999999999 592.78 949.63 percent of total billed charges Electrocardiogram (ECG) 2-day continuous with report 48755960_1 CDM 0731 RC 93226 HCPCS inpatient 979 636.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 675.51 69 999999999 592.78 949.63 percent of total billed charges Electrocardiogram (ECG) 2-day continuous with report 48755960_1 CDM 0731 RC 93226 HCPCS inpatient 979 636.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 763.62 78 999999999 592.78 949.63 percent of total billed charges Electrocardiogram (ECG) 2-day continuous with report 48755960_1 CDM 0731 RC 93226 HCPCS inpatient 979 636.35 SIHO - ALL PLANS SIHO - ALL PLANS 881.1 90 999999999 592.78 949.63 percent of total billed charges Electrocardiogram (ECG) 2-day continuous with report 48755960_1 CDM 0731 RC 93226 HCPCS inpatient 979 636.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 592.78 60.55 999999999 592.78 949.63 percent of total billed charges Electrocardiogram (ECG) 2-day continuous with report 48755960_1 CDM 0731 RC 93226 HCPCS inpatient 979 636.35 UMR - ALL PLANS UMR - ALL PLANS 685.3 70 999999999 592.78 949.63 percent of total billed charges Electrocardiogram (ECG) 2-day continuous with report 48755960_1 CDM 0731 RC 93226 HCPCS inpatient 979 636.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 592.78 949.63 Electrocardiogram (ECG) 2-day continuous with report 48755960_1 CDM 0731 RC 93226 HCPCS inpatient 979 636.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 592.78 949.63 Electrocardiogram (ECG) 2-day continuous with report 48755960_1 CDM 0731 RC 93226 HCPCS inpatient 979 636.35 ANTHEM HMO ANTHEM HMO 999999999 592.78 949.63 Electrocardiogram (ECG) 2-day continuous with report 48755960_1 CDM 0731 RC 93226 HCPCS inpatient 979 636.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 661.8 67.6 999999999 592.78 949.63 percent of total billed charges Electrocardiogram (ECG) 2-day continuous with report 48755960_1 CDM 0731 RC 93226 HCPCS inpatient 979 636.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 592.78 949.63 Electrocardiogram (ECG) 2-day continuous with report 48755960_1 CDM 0731 RC 93226 HCPCS inpatient 979 636.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 592.78 949.63 Ultrasound of heart 48755961_1 CDM 0480 RC 93307 HCPCS inpatient 1431 930.15 AETNA AETNA 1130.49 79 999999999 866.47 1388.07 percent of total billed charges Ultrasound of heart 48755961_1 CDM 0480 RC 93307 HCPCS inpatient 1431 930.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 930.15 65 999999999 866.47 1388.07 percent of total billed charges Ultrasound of heart 48755961_1 CDM 0480 RC 93307 HCPCS inpatient 1431 930.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1388.07 97 999999999 866.47 1388.07 percent of total billed charges Ultrasound of heart 48755961_1 CDM 0480 RC 93307 HCPCS inpatient 1431 930.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 987.39 69 999999999 866.47 1388.07 percent of total billed charges Ultrasound of heart 48755961_1 CDM 0480 RC 93307 HCPCS inpatient 1431 930.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1116.18 78 999999999 866.47 1388.07 percent of total billed charges Ultrasound of heart 48755961_1 CDM 0480 RC 93307 HCPCS inpatient 1431 930.15 SIHO - ALL PLANS SIHO - ALL PLANS 1287.9 90 999999999 866.47 1388.07 percent of total billed charges Ultrasound of heart 48755961_1 CDM 0480 RC 93307 HCPCS inpatient 1431 930.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 866.47 60.55 999999999 866.47 1388.07 percent of total billed charges Ultrasound of heart 48755961_1 CDM 0480 RC 93307 HCPCS inpatient 1431 930.15 UMR - ALL PLANS UMR - ALL PLANS 1001.7 70 999999999 866.47 1388.07 percent of total billed charges Ultrasound of heart 48755961_1 CDM 0480 RC 93307 HCPCS inpatient 1431 930.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 866.47 1388.07 Ultrasound of heart 48755961_1 CDM 0480 RC 93307 HCPCS inpatient 1431 930.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 866.47 1388.07 Ultrasound of heart 48755961_1 CDM 0480 RC 93307 HCPCS inpatient 1431 930.15 ANTHEM HMO ANTHEM HMO 999999999 866.47 1388.07 Ultrasound of heart 48755961_1 CDM 0480 RC 93307 HCPCS inpatient 1431 930.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 967.36 67.6 999999999 866.47 1388.07 percent of total billed charges Ultrasound of heart 48755961_1 CDM 0480 RC 93307 HCPCS inpatient 1431 930.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 866.47 1388.07 Ultrasound of heart 48755961_1 CDM 0480 RC 93307 HCPCS inpatient 1431 930.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 866.47 1388.07 "Ultrasound of heart with probe in esophagus, with report" 48755962_1 CDM 0480 RC 93312 HCPCS inpatient 2197 1428.05 AETNA AETNA 1735.63 79 999999999 1330.28 2131.09 percent of total billed charges "Ultrasound of heart with probe in esophagus, with report" 48755962_1 CDM 0480 RC 93312 HCPCS inpatient 2197 1428.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1428.05 65 999999999 1330.28 2131.09 percent of total billed charges "Ultrasound of heart with probe in esophagus, with report" 48755962_1 CDM 0480 RC 93312 HCPCS inpatient 2197 1428.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2131.09 97 999999999 1330.28 2131.09 percent of total billed charges "Ultrasound of heart with probe in esophagus, with report" 48755962_1 CDM 0480 RC 93312 HCPCS inpatient 2197 1428.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1515.93 69 999999999 1330.28 2131.09 percent of total billed charges "Ultrasound of heart with probe in esophagus, with report" 48755962_1 CDM 0480 RC 93312 HCPCS inpatient 2197 1428.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1713.66 78 999999999 1330.28 2131.09 percent of total billed charges "Ultrasound of heart with probe in esophagus, with report" 48755962_1 CDM 0480 RC 93312 HCPCS inpatient 2197 1428.05 SIHO - ALL PLANS SIHO - ALL PLANS 1977.3 90 999999999 1330.28 2131.09 percent of total billed charges "Ultrasound of heart with probe in esophagus, with report" 48755962_1 CDM 0480 RC 93312 HCPCS inpatient 2197 1428.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1330.28 60.55 999999999 1330.28 2131.09 percent of total billed charges "Ultrasound of heart with probe in esophagus, with report" 48755962_1 CDM 0480 RC 93312 HCPCS inpatient 2197 1428.05 UMR - ALL PLANS UMR - ALL PLANS 1537.9 70 999999999 1330.28 2131.09 percent of total billed charges "Ultrasound of heart with probe in esophagus, with report" 48755962_1 CDM 0480 RC 93312 HCPCS inpatient 2197 1428.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1330.28 2131.09 "Ultrasound of heart with probe in esophagus, with report" 48755962_1 CDM 0480 RC 93312 HCPCS inpatient 2197 1428.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1330.28 2131.09 "Ultrasound of heart with probe in esophagus, with report" 48755962_1 CDM 0480 RC 93312 HCPCS inpatient 2197 1428.05 ANTHEM HMO ANTHEM HMO 999999999 1330.28 2131.09 "Ultrasound of heart with probe in esophagus, with report" 48755962_1 CDM 0480 RC 93312 HCPCS inpatient 2197 1428.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1485.17 67.6 999999999 1330.28 2131.09 percent of total billed charges "Ultrasound of heart with probe in esophagus, with report" 48755962_1 CDM 0480 RC 93312 HCPCS inpatient 2197 1428.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1330.28 2131.09 "Ultrasound of heart with probe in esophagus, with report" 48755962_1 CDM 0480 RC 93312 HCPCS inpatient 2197 1428.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1330.28 2131.09 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755963_1 CDM 0480 RC 93351 HCPCS inpatient 4684 3044.6 AETNA AETNA 3700.36 79 999999999 2836.16 4543.48 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755963_1 CDM 0480 RC 93351 HCPCS inpatient 4684 3044.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 3044.6 65 999999999 2836.16 4543.48 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755963_1 CDM 0480 RC 93351 HCPCS inpatient 4684 3044.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4543.48 97 999999999 2836.16 4543.48 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755963_1 CDM 0480 RC 93351 HCPCS inpatient 4684 3044.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 3231.96 69 999999999 2836.16 4543.48 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755963_1 CDM 0480 RC 93351 HCPCS inpatient 4684 3044.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 3653.52 78 999999999 2836.16 4543.48 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755963_1 CDM 0480 RC 93351 HCPCS inpatient 4684 3044.6 SIHO - ALL PLANS SIHO - ALL PLANS 4215.6 90 999999999 2836.16 4543.48 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755963_1 CDM 0480 RC 93351 HCPCS inpatient 4684 3044.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2836.16 60.55 999999999 2836.16 4543.48 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755963_1 CDM 0480 RC 93351 HCPCS inpatient 4684 3044.6 UMR - ALL PLANS UMR - ALL PLANS 3278.8 70 999999999 2836.16 4543.48 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755963_1 CDM 0480 RC 93351 HCPCS inpatient 4684 3044.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2836.16 4543.48 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755963_1 CDM 0480 RC 93351 HCPCS inpatient 4684 3044.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2836.16 4543.48 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755963_1 CDM 0480 RC 93351 HCPCS inpatient 4684 3044.6 ANTHEM HMO ANTHEM HMO 999999999 2836.16 4543.48 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755963_1 CDM 0480 RC 93351 HCPCS inpatient 4684 3044.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 3166.38 67.6 999999999 2836.16 4543.48 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755963_1 CDM 0480 RC 93351 HCPCS inpatient 4684 3044.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2836.16 4543.48 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755963_1 CDM 0480 RC 93351 HCPCS inpatient 4684 3044.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 2836.16 4543.48 "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755964_1 CDM 0480 RC 93306 HCPCS inpatient 3114 2024.1 AETNA AETNA 2460.06 79 999999999 1885.53 3020.58 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755964_1 CDM 0480 RC 93306 HCPCS inpatient 3114 2024.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 2024.1 65 999999999 1885.53 3020.58 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755964_1 CDM 0480 RC 93306 HCPCS inpatient 3114 2024.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3020.58 97 999999999 1885.53 3020.58 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755964_1 CDM 0480 RC 93306 HCPCS inpatient 3114 2024.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 2148.66 69 999999999 1885.53 3020.58 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755964_1 CDM 0480 RC 93306 HCPCS inpatient 3114 2024.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 2428.92 78 999999999 1885.53 3020.58 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755964_1 CDM 0480 RC 93306 HCPCS inpatient 3114 2024.1 SIHO - ALL PLANS SIHO - ALL PLANS 2802.6 90 999999999 1885.53 3020.58 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755964_1 CDM 0480 RC 93306 HCPCS inpatient 3114 2024.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1885.53 60.55 999999999 1885.53 3020.58 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755964_1 CDM 0480 RC 93306 HCPCS inpatient 3114 2024.1 UMR - ALL PLANS UMR - ALL PLANS 2179.8 70 999999999 1885.53 3020.58 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755964_1 CDM 0480 RC 93306 HCPCS inpatient 3114 2024.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1885.53 3020.58 "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755964_1 CDM 0480 RC 93306 HCPCS inpatient 3114 2024.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1885.53 3020.58 "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755964_1 CDM 0480 RC 93306 HCPCS inpatient 3114 2024.1 ANTHEM HMO ANTHEM HMO 999999999 1885.53 3020.58 "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755964_1 CDM 0480 RC 93306 HCPCS inpatient 3114 2024.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 2105.06 67.6 999999999 1885.53 3020.58 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755964_1 CDM 0480 RC 93306 HCPCS inpatient 3114 2024.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1885.53 3020.58 "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755964_1 CDM 0480 RC 93306 HCPCS inpatient 3114 2024.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1885.53 3020.58 "Ultrasound of heart with color-depicted blood flow, rate and valve function" 48755965_1 CDM 0483 RC 93325 HCPCS inpatient 1493 970.45 AETNA AETNA 1179.47 79 999999999 904.01 1448.21 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate and valve function" 48755965_1 CDM 0483 RC 93325 HCPCS inpatient 1493 970.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 970.45 65 999999999 904.01 1448.21 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate and valve function" 48755965_1 CDM 0483 RC 93325 HCPCS inpatient 1493 970.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1448.21 97 999999999 904.01 1448.21 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate and valve function" 48755965_1 CDM 0483 RC 93325 HCPCS inpatient 1493 970.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1030.17 69 999999999 904.01 1448.21 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate and valve function" 48755965_1 CDM 0483 RC 93325 HCPCS inpatient 1493 970.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1164.54 78 999999999 904.01 1448.21 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate and valve function" 48755965_1 CDM 0483 RC 93325 HCPCS inpatient 1493 970.45 SIHO - ALL PLANS SIHO - ALL PLANS 1343.7 90 999999999 904.01 1448.21 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate and valve function" 48755965_1 CDM 0483 RC 93325 HCPCS inpatient 1493 970.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 904.01 60.55 999999999 904.01 1448.21 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate and valve function" 48755965_1 CDM 0483 RC 93325 HCPCS inpatient 1493 970.45 UMR - ALL PLANS UMR - ALL PLANS 1045.1 70 999999999 904.01 1448.21 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate and valve function" 48755965_1 CDM 0483 RC 93325 HCPCS inpatient 1493 970.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 904.01 1448.21 "Ultrasound of heart with color-depicted blood flow, rate and valve function" 48755965_1 CDM 0483 RC 93325 HCPCS inpatient 1493 970.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 904.01 1448.21 "Ultrasound of heart with color-depicted blood flow, rate and valve function" 48755965_1 CDM 0483 RC 93325 HCPCS inpatient 1493 970.45 ANTHEM HMO ANTHEM HMO 999999999 904.01 1448.21 "Ultrasound of heart with color-depicted blood flow, rate and valve function" 48755965_1 CDM 0483 RC 93325 HCPCS inpatient 1493 970.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1009.27 67.6 999999999 904.01 1448.21 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate and valve function" 48755965_1 CDM 0483 RC 93325 HCPCS inpatient 1493 970.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 904.01 1448.21 "Ultrasound of heart with color-depicted blood flow, rate and valve function" 48755965_1 CDM 0483 RC 93325 HCPCS inpatient 1493 970.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 904.01 1448.21 "Ultrasound of heart blood flow, valves and chambers" 48755966_1 CDM 0483 RC 93320 HCPCS inpatient 934 607.1 AETNA AETNA 737.86 79 999999999 565.54 905.98 percent of total billed charges "Ultrasound of heart blood flow, valves and chambers" 48755966_1 CDM 0483 RC 93320 HCPCS inpatient 934 607.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 607.1 65 999999999 565.54 905.98 percent of total billed charges "Ultrasound of heart blood flow, valves and chambers" 48755966_1 CDM 0483 RC 93320 HCPCS inpatient 934 607.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 905.98 97 999999999 565.54 905.98 percent of total billed charges "Ultrasound of heart blood flow, valves and chambers" 48755966_1 CDM 0483 RC 93320 HCPCS inpatient 934 607.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 644.46 69 999999999 565.54 905.98 percent of total billed charges "Ultrasound of heart blood flow, valves and chambers" 48755966_1 CDM 0483 RC 93320 HCPCS inpatient 934 607.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 728.52 78 999999999 565.54 905.98 percent of total billed charges "Ultrasound of heart blood flow, valves and chambers" 48755966_1 CDM 0483 RC 93320 HCPCS inpatient 934 607.1 SIHO - ALL PLANS SIHO - ALL PLANS 840.6 90 999999999 565.54 905.98 percent of total billed charges "Ultrasound of heart blood flow, valves and chambers" 48755966_1 CDM 0483 RC 93320 HCPCS inpatient 934 607.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 565.54 60.55 999999999 565.54 905.98 percent of total billed charges "Ultrasound of heart blood flow, valves and chambers" 48755966_1 CDM 0483 RC 93320 HCPCS inpatient 934 607.1 UMR - ALL PLANS UMR - ALL PLANS 653.8 70 999999999 565.54 905.98 percent of total billed charges "Ultrasound of heart blood flow, valves and chambers" 48755966_1 CDM 0483 RC 93320 HCPCS inpatient 934 607.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 565.54 905.98 "Ultrasound of heart blood flow, valves and chambers" 48755966_1 CDM 0483 RC 93320 HCPCS inpatient 934 607.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 565.54 905.98 "Ultrasound of heart blood flow, valves and chambers" 48755966_1 CDM 0483 RC 93320 HCPCS inpatient 934 607.1 ANTHEM HMO ANTHEM HMO 999999999 565.54 905.98 "Ultrasound of heart blood flow, valves and chambers" 48755966_1 CDM 0483 RC 93320 HCPCS inpatient 934 607.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 631.38 67.6 999999999 565.54 905.98 percent of total billed charges "Ultrasound of heart blood flow, valves and chambers" 48755966_1 CDM 0483 RC 93320 HCPCS inpatient 934 607.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 565.54 905.98 "Ultrasound of heart blood flow, valves and chambers" 48755966_1 CDM 0483 RC 93320 HCPCS inpatient 934 607.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 565.54 905.98 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755967_1 CDM 0483 RC 93351 HCPCS inpatient 3362 2185.3 AETNA AETNA 2655.98 79 999999999 2035.69 3261.14 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755967_1 CDM 0483 RC 93351 HCPCS inpatient 3362 2185.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 2185.3 65 999999999 2035.69 3261.14 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755967_1 CDM 0483 RC 93351 HCPCS inpatient 3362 2185.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3261.14 97 999999999 2035.69 3261.14 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755967_1 CDM 0483 RC 93351 HCPCS inpatient 3362 2185.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 2319.78 69 999999999 2035.69 3261.14 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755967_1 CDM 0483 RC 93351 HCPCS inpatient 3362 2185.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 2622.36 78 999999999 2035.69 3261.14 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755967_1 CDM 0483 RC 93351 HCPCS inpatient 3362 2185.3 SIHO - ALL PLANS SIHO - ALL PLANS 3025.8 90 999999999 2035.69 3261.14 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755967_1 CDM 0483 RC 93351 HCPCS inpatient 3362 2185.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2035.69 60.55 999999999 2035.69 3261.14 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755967_1 CDM 0483 RC 93351 HCPCS inpatient 3362 2185.3 UMR - ALL PLANS UMR - ALL PLANS 2353.4 70 999999999 2035.69 3261.14 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755967_1 CDM 0483 RC 93351 HCPCS inpatient 3362 2185.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2035.69 3261.14 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755967_1 CDM 0483 RC 93351 HCPCS inpatient 3362 2185.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2035.69 3261.14 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755967_1 CDM 0483 RC 93351 HCPCS inpatient 3362 2185.3 ANTHEM HMO ANTHEM HMO 999999999 2035.69 3261.14 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755967_1 CDM 0483 RC 93351 HCPCS inpatient 3362 2185.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 2272.71 67.6 999999999 2035.69 3261.14 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755967_1 CDM 0483 RC 93351 HCPCS inpatient 3362 2185.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2035.69 3261.14 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755967_1 CDM 0483 RC 93351 HCPCS inpatient 3362 2185.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 2035.69 3261.14 Electrocardiogram (ECG) up to 30 days continuous with symptom monitoring 48755968_1 CDM 0732 RC 93270 HCPCS inpatient 218 141.7 AETNA AETNA 172.22 79 999999999 132 211.46 percent of total billed charges Electrocardiogram (ECG) up to 30 days continuous with symptom monitoring 48755968_1 CDM 0732 RC 93270 HCPCS inpatient 218 141.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 141.7 65 999999999 132 211.46 percent of total billed charges Electrocardiogram (ECG) up to 30 days continuous with symptom monitoring 48755968_1 CDM 0732 RC 93270 HCPCS inpatient 218 141.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 211.46 97 999999999 132 211.46 percent of total billed charges Electrocardiogram (ECG) up to 30 days continuous with symptom monitoring 48755968_1 CDM 0732 RC 93270 HCPCS inpatient 218 141.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 150.42 69 999999999 132 211.46 percent of total billed charges Electrocardiogram (ECG) up to 30 days continuous with symptom monitoring 48755968_1 CDM 0732 RC 93270 HCPCS inpatient 218 141.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.04 78 999999999 132 211.46 percent of total billed charges Electrocardiogram (ECG) up to 30 days continuous with symptom monitoring 48755968_1 CDM 0732 RC 93270 HCPCS inpatient 218 141.7 SIHO - ALL PLANS SIHO - ALL PLANS 196.2 90 999999999 132 211.46 percent of total billed charges Electrocardiogram (ECG) up to 30 days continuous with symptom monitoring 48755968_1 CDM 0732 RC 93270 HCPCS inpatient 218 141.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132 60.55 999999999 132 211.46 percent of total billed charges Electrocardiogram (ECG) up to 30 days continuous with symptom monitoring 48755968_1 CDM 0732 RC 93270 HCPCS inpatient 218 141.7 UMR - ALL PLANS UMR - ALL PLANS 152.6 70 999999999 132 211.46 percent of total billed charges Electrocardiogram (ECG) up to 30 days continuous with symptom monitoring 48755968_1 CDM 0732 RC 93270 HCPCS inpatient 218 141.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132 211.46 Electrocardiogram (ECG) up to 30 days continuous with symptom monitoring 48755968_1 CDM 0732 RC 93270 HCPCS inpatient 218 141.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132 211.46 Electrocardiogram (ECG) up to 30 days continuous with symptom monitoring 48755968_1 CDM 0732 RC 93270 HCPCS inpatient 218 141.7 ANTHEM HMO ANTHEM HMO 999999999 132 211.46 Electrocardiogram (ECG) up to 30 days continuous with symptom monitoring 48755968_1 CDM 0732 RC 93270 HCPCS inpatient 218 141.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 147.37 67.6 999999999 132 211.46 percent of total billed charges Electrocardiogram (ECG) up to 30 days continuous with symptom monitoring 48755968_1 CDM 0732 RC 93270 HCPCS inpatient 218 141.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132 211.46 Electrocardiogram (ECG) up to 30 days continuous with symptom monitoring 48755968_1 CDM 0732 RC 93270 HCPCS inpatient 218 141.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 132 211.46 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755969_1 CDM 0460 RC 93017 HCPCS inpatient 986 640.9 AETNA AETNA 778.94 79 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755969_1 CDM 0460 RC 93017 HCPCS inpatient 986 640.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 640.9 65 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755969_1 CDM 0460 RC 93017 HCPCS inpatient 986 640.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 956.42 97 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755969_1 CDM 0460 RC 93017 HCPCS inpatient 986 640.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 680.34 69 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755969_1 CDM 0460 RC 93017 HCPCS inpatient 986 640.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 769.08 78 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755969_1 CDM 0460 RC 93017 HCPCS inpatient 986 640.9 SIHO - ALL PLANS SIHO - ALL PLANS 887.4 90 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755969_1 CDM 0460 RC 93017 HCPCS inpatient 986 640.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 597.02 60.55 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755969_1 CDM 0460 RC 93017 HCPCS inpatient 986 640.9 UMR - ALL PLANS UMR - ALL PLANS 690.2 70 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755969_1 CDM 0460 RC 93017 HCPCS inpatient 986 640.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 597.02 956.42 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755969_1 CDM 0460 RC 93017 HCPCS inpatient 986 640.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 597.02 956.42 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755969_1 CDM 0460 RC 93017 HCPCS inpatient 986 640.9 ANTHEM HMO ANTHEM HMO 999999999 597.02 956.42 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755969_1 CDM 0460 RC 93017 HCPCS inpatient 986 640.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 666.54 67.6 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755969_1 CDM 0460 RC 93017 HCPCS inpatient 986 640.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 597.02 956.42 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755969_1 CDM 0460 RC 93017 HCPCS inpatient 986 640.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 597.02 956.42 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755970_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 AETNA AETNA 778.94 79 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755970_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 640.9 65 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755970_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 956.42 97 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755970_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 680.34 69 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755970_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 769.08 78 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755970_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 SIHO - ALL PLANS SIHO - ALL PLANS 887.4 90 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755970_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 597.02 60.55 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755970_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 UMR - ALL PLANS UMR - ALL PLANS 690.2 70 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755970_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 597.02 956.42 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755970_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 597.02 956.42 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755970_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 ANTHEM HMO ANTHEM HMO 999999999 597.02 956.42 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755970_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 666.54 67.6 999999999 597.02 956.42 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755970_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 597.02 956.42 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755970_1 CDM 0482 RC 93017 HCPCS inpatient 986 640.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 597.02 956.42 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755971_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 AETNA AETNA 845.3 79 999999999 647.89 1037.9 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755971_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 695.5 65 999999999 647.89 1037.9 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755971_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1037.9 97 999999999 647.89 1037.9 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755971_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 738.3 69 999999999 647.89 1037.9 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755971_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 834.6 78 999999999 647.89 1037.9 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755971_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 SIHO - ALL PLANS SIHO - ALL PLANS 963 90 999999999 647.89 1037.9 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755971_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 647.89 60.55 999999999 647.89 1037.9 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755971_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 UMR - ALL PLANS UMR - ALL PLANS 749 70 999999999 647.89 1037.9 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755971_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 647.89 1037.9 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755971_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 647.89 1037.9 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755971_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 ANTHEM HMO ANTHEM HMO 999999999 647.89 1037.9 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755971_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 723.32 67.6 999999999 647.89 1037.9 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755971_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 647.89 1037.9 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755971_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 647.89 1037.9 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755972_1 CDM 0482 RC 93017 HCPCS inpatient 1085 705.25 AETNA AETNA 857.15 79 999999999 656.97 1052.45 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755972_1 CDM 0482 RC 93017 HCPCS inpatient 1085 705.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 705.25 65 999999999 656.97 1052.45 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755972_1 CDM 0482 RC 93017 HCPCS inpatient 1085 705.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1052.45 97 999999999 656.97 1052.45 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755972_1 CDM 0482 RC 93017 HCPCS inpatient 1085 705.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 748.65 69 999999999 656.97 1052.45 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755972_1 CDM 0482 RC 93017 HCPCS inpatient 1085 705.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 846.3 78 999999999 656.97 1052.45 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755972_1 CDM 0482 RC 93017 HCPCS inpatient 1085 705.25 SIHO - ALL PLANS SIHO - ALL PLANS 976.5 90 999999999 656.97 1052.45 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755972_1 CDM 0482 RC 93017 HCPCS inpatient 1085 705.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 656.97 60.55 999999999 656.97 1052.45 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755972_1 CDM 0482 RC 93017 HCPCS inpatient 1085 705.25 UMR - ALL PLANS UMR - ALL PLANS 759.5 70 999999999 656.97 1052.45 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755972_1 CDM 0482 RC 93017 HCPCS inpatient 1085 705.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 656.97 1052.45 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755972_1 CDM 0482 RC 93017 HCPCS inpatient 1085 705.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 656.97 1052.45 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755972_1 CDM 0482 RC 93017 HCPCS inpatient 1085 705.25 ANTHEM HMO ANTHEM HMO 999999999 656.97 1052.45 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755972_1 CDM 0482 RC 93017 HCPCS inpatient 1085 705.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 733.46 67.6 999999999 656.97 1052.45 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755972_1 CDM 0482 RC 93017 HCPCS inpatient 1085 705.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 656.97 1052.45 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755972_1 CDM 0482 RC 93017 HCPCS inpatient 1085 705.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 656.97 1052.45 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755973_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 AETNA AETNA 845.3 79 999999999 647.89 1037.9 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755973_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 695.5 65 999999999 647.89 1037.9 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755973_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1037.9 97 999999999 647.89 1037.9 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755973_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 738.3 69 999999999 647.89 1037.9 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755973_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 834.6 78 999999999 647.89 1037.9 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755973_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 SIHO - ALL PLANS SIHO - ALL PLANS 963 90 999999999 647.89 1037.9 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755973_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 647.89 60.55 999999999 647.89 1037.9 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755973_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 UMR - ALL PLANS UMR - ALL PLANS 749 70 999999999 647.89 1037.9 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755973_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 647.89 1037.9 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755973_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 647.89 1037.9 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755973_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 ANTHEM HMO ANTHEM HMO 999999999 647.89 1037.9 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755973_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 723.32 67.6 999999999 647.89 1037.9 percent of total billed charges Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755973_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 647.89 1037.9 Exercise or drug-induced heart stress test with electrocardiogram (ECG) 48755973_1 CDM 0482 RC 93017 HCPCS inpatient 1070 695.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 647.89 1037.9 "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48755974_1 CDM 0943 RC 93798 HCPCS inpatient 243 157.95 AETNA AETNA 191.97 79 999999999 147.14 235.71 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48755974_1 CDM 0943 RC 93798 HCPCS inpatient 243 157.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 157.95 65 999999999 147.14 235.71 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48755974_1 CDM 0943 RC 93798 HCPCS inpatient 243 157.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 235.71 97 999999999 147.14 235.71 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48755974_1 CDM 0943 RC 93798 HCPCS inpatient 243 157.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 167.67 69 999999999 147.14 235.71 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48755974_1 CDM 0943 RC 93798 HCPCS inpatient 243 157.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 189.54 78 999999999 147.14 235.71 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48755974_1 CDM 0943 RC 93798 HCPCS inpatient 243 157.95 SIHO - ALL PLANS SIHO - ALL PLANS 218.7 90 999999999 147.14 235.71 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48755974_1 CDM 0943 RC 93798 HCPCS inpatient 243 157.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.14 60.55 999999999 147.14 235.71 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48755974_1 CDM 0943 RC 93798 HCPCS inpatient 243 157.95 UMR - ALL PLANS UMR - ALL PLANS 170.1 70 999999999 147.14 235.71 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48755974_1 CDM 0943 RC 93798 HCPCS inpatient 243 157.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.14 235.71 "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48755974_1 CDM 0943 RC 93798 HCPCS inpatient 243 157.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.14 235.71 "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48755974_1 CDM 0943 RC 93798 HCPCS inpatient 243 157.95 ANTHEM HMO ANTHEM HMO 999999999 147.14 235.71 "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48755974_1 CDM 0943 RC 93798 HCPCS inpatient 243 157.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.27 67.6 999999999 147.14 235.71 percent of total billed charges "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48755974_1 CDM 0943 RC 93798 HCPCS inpatient 243 157.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.14 235.71 "Outpatient heart rehabilitation with electrocardiogram (ECG) monitoring, quality health care professional services" 48755974_1 CDM 0943 RC 93798 HCPCS inpatient 243 157.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.14 235.71 "TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY" 48755976_1 CDM 0483 RC C8924 HCPCS inpatient 1431 930.15 AETNA AETNA 1130.49 79 999999999 866.47 1388.07 percent of total billed charges "TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY" 48755976_1 CDM 0483 RC C8924 HCPCS inpatient 1431 930.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 930.15 65 999999999 866.47 1388.07 percent of total billed charges "TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY" 48755976_1 CDM 0483 RC C8924 HCPCS inpatient 1431 930.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1388.07 97 999999999 866.47 1388.07 percent of total billed charges "TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY" 48755976_1 CDM 0483 RC C8924 HCPCS inpatient 1431 930.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 987.39 69 999999999 866.47 1388.07 percent of total billed charges "TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY" 48755976_1 CDM 0483 RC C8924 HCPCS inpatient 1431 930.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1116.18 78 999999999 866.47 1388.07 percent of total billed charges "TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY" 48755976_1 CDM 0483 RC C8924 HCPCS inpatient 1431 930.15 SIHO - ALL PLANS SIHO - ALL PLANS 1287.9 90 999999999 866.47 1388.07 percent of total billed charges "TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY" 48755976_1 CDM 0483 RC C8924 HCPCS inpatient 1431 930.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 866.47 60.55 999999999 866.47 1388.07 percent of total billed charges "TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY" 48755976_1 CDM 0483 RC C8924 HCPCS inpatient 1431 930.15 UMR - ALL PLANS UMR - ALL PLANS 1001.7 70 999999999 866.47 1388.07 percent of total billed charges "TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY" 48755976_1 CDM 0483 RC C8924 HCPCS inpatient 1431 930.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 866.47 1388.07 "TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY" 48755976_1 CDM 0483 RC C8924 HCPCS inpatient 1431 930.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 866.47 1388.07 "TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY" 48755976_1 CDM 0483 RC C8924 HCPCS inpatient 1431 930.15 ANTHEM HMO ANTHEM HMO 999999999 866.47 1388.07 "TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY" 48755976_1 CDM 0483 RC C8924 HCPCS inpatient 1431 930.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 967.36 67.6 999999999 866.47 1388.07 percent of total billed charges "TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY" 48755976_1 CDM 0483 RC C8924 HCPCS inpatient 1431 930.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 866.47 1388.07 "TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN PERFORMED, FOLLOW-UP OR LIMITED STUDY" 48755976_1 CDM 0483 RC C8924 HCPCS inpatient 1431 930.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 866.47 1388.07 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755977_1 CDM 0483 RC 93351 HCPCS inpatient 4861 3159.65 AETNA AETNA 3840.19 79 999999999 2943.34 4715.17 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755977_1 CDM 0483 RC 93351 HCPCS inpatient 4861 3159.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 3159.65 65 999999999 2943.34 4715.17 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755977_1 CDM 0483 RC 93351 HCPCS inpatient 4861 3159.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4715.17 97 999999999 2943.34 4715.17 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755977_1 CDM 0483 RC 93351 HCPCS inpatient 4861 3159.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 3354.09 69 999999999 2943.34 4715.17 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755977_1 CDM 0483 RC 93351 HCPCS inpatient 4861 3159.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 3791.58 78 999999999 2943.34 4715.17 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755977_1 CDM 0483 RC 93351 HCPCS inpatient 4861 3159.65 SIHO - ALL PLANS SIHO - ALL PLANS 4374.9 90 999999999 2943.34 4715.17 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755977_1 CDM 0483 RC 93351 HCPCS inpatient 4861 3159.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2943.34 60.55 999999999 2943.34 4715.17 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755977_1 CDM 0483 RC 93351 HCPCS inpatient 4861 3159.65 UMR - ALL PLANS UMR - ALL PLANS 3402.7 70 999999999 2943.34 4715.17 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755977_1 CDM 0483 RC 93351 HCPCS inpatient 4861 3159.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2943.34 4715.17 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755977_1 CDM 0483 RC 93351 HCPCS inpatient 4861 3159.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2943.34 4715.17 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755977_1 CDM 0483 RC 93351 HCPCS inpatient 4861 3159.65 ANTHEM HMO ANTHEM HMO 999999999 2943.34 4715.17 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755977_1 CDM 0483 RC 93351 HCPCS inpatient 4861 3159.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 3286.04 67.6 999999999 2943.34 4715.17 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755977_1 CDM 0483 RC 93351 HCPCS inpatient 4861 3159.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2943.34 4715.17 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 48755977_1 CDM 0483 RC 93351 HCPCS inpatient 4861 3159.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 2943.34 4715.17 "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755978_1 CDM 0480 RC 93306 HCPCS inpatient 2898 1883.7 AETNA AETNA 2289.42 79 999999999 1754.74 2811.06 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755978_1 CDM 0480 RC 93306 HCPCS inpatient 2898 1883.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1883.7 65 999999999 1754.74 2811.06 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755978_1 CDM 0480 RC 93306 HCPCS inpatient 2898 1883.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2811.06 97 999999999 1754.74 2811.06 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755978_1 CDM 0480 RC 93306 HCPCS inpatient 2898 1883.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1999.62 69 999999999 1754.74 2811.06 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755978_1 CDM 0480 RC 93306 HCPCS inpatient 2898 1883.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 2260.44 78 999999999 1754.74 2811.06 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755978_1 CDM 0480 RC 93306 HCPCS inpatient 2898 1883.7 SIHO - ALL PLANS SIHO - ALL PLANS 2608.2 90 999999999 1754.74 2811.06 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755978_1 CDM 0480 RC 93306 HCPCS inpatient 2898 1883.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1754.74 60.55 999999999 1754.74 2811.06 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755978_1 CDM 0480 RC 93306 HCPCS inpatient 2898 1883.7 UMR - ALL PLANS UMR - ALL PLANS 2028.6 70 999999999 1754.74 2811.06 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755978_1 CDM 0480 RC 93306 HCPCS inpatient 2898 1883.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1754.74 2811.06 "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755978_1 CDM 0480 RC 93306 HCPCS inpatient 2898 1883.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1754.74 2811.06 "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755978_1 CDM 0480 RC 93306 HCPCS inpatient 2898 1883.7 ANTHEM HMO ANTHEM HMO 999999999 1754.74 2811.06 "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755978_1 CDM 0480 RC 93306 HCPCS inpatient 2898 1883.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1959.05 67.6 999999999 1754.74 2811.06 percent of total billed charges "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755978_1 CDM 0480 RC 93306 HCPCS inpatient 2898 1883.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1754.74 2811.06 "Ultrasound of heart with color-depicted blood flow, rate, direction and valve function" 48755978_1 CDM 0480 RC 93306 HCPCS inpatient 2898 1883.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 1754.74 2811.06 Injection of drug or substance into vein 48755979_1 CDM 0480 RC 96374 HCPCS inpatient 268 174.2 AETNA AETNA 211.72 79 999999999 162.27 259.96 percent of total billed charges Injection of drug or substance into vein 48755979_1 CDM 0480 RC 96374 HCPCS inpatient 268 174.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 174.2 65 999999999 162.27 259.96 percent of total billed charges Injection of drug or substance into vein 48755979_1 CDM 0480 RC 96374 HCPCS inpatient 268 174.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 259.96 97 999999999 162.27 259.96 percent of total billed charges Injection of drug or substance into vein 48755979_1 CDM 0480 RC 96374 HCPCS inpatient 268 174.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.92 69 999999999 162.27 259.96 percent of total billed charges Injection of drug or substance into vein 48755979_1 CDM 0480 RC 96374 HCPCS inpatient 268 174.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 209.04 78 999999999 162.27 259.96 percent of total billed charges Injection of drug or substance into vein 48755979_1 CDM 0480 RC 96374 HCPCS inpatient 268 174.2 SIHO - ALL PLANS SIHO - ALL PLANS 241.2 90 999999999 162.27 259.96 percent of total billed charges Injection of drug or substance into vein 48755979_1 CDM 0480 RC 96374 HCPCS inpatient 268 174.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 162.27 60.55 999999999 162.27 259.96 percent of total billed charges Injection of drug or substance into vein 48755979_1 CDM 0480 RC 96374 HCPCS inpatient 268 174.2 UMR - ALL PLANS UMR - ALL PLANS 187.6 70 999999999 162.27 259.96 percent of total billed charges Injection of drug or substance into vein 48755979_1 CDM 0480 RC 96374 HCPCS inpatient 268 174.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 162.27 259.96 Injection of drug or substance into vein 48755979_1 CDM 0480 RC 96374 HCPCS inpatient 268 174.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 162.27 259.96 Injection of drug or substance into vein 48755979_1 CDM 0480 RC 96374 HCPCS inpatient 268 174.2 ANTHEM HMO ANTHEM HMO 999999999 162.27 259.96 Injection of drug or substance into vein 48755979_1 CDM 0480 RC 96374 HCPCS inpatient 268 174.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 181.17 67.6 999999999 162.27 259.96 percent of total billed charges Injection of drug or substance into vein 48755979_1 CDM 0480 RC 96374 HCPCS inpatient 268 174.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 162.27 259.96 Injection of drug or substance into vein 48755979_1 CDM 0480 RC 96374 HCPCS inpatient 268 174.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 162.27 259.96 RECOVERY ROOM - GENERAL CLASSIFICATION 48755989_1 CDM 0710 RC inpatient 618 401.7 AETNA AETNA 488.22 79 999999999 374.2 599.46 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48755989_1 CDM 0710 RC inpatient 618 401.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 401.7 65 999999999 374.2 599.46 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48755989_1 CDM 0710 RC inpatient 618 401.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 599.46 97 999999999 374.2 599.46 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48755989_1 CDM 0710 RC inpatient 618 401.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 426.42 69 999999999 374.2 599.46 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48755989_1 CDM 0710 RC inpatient 618 401.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 482.04 78 999999999 374.2 599.46 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48755989_1 CDM 0710 RC inpatient 618 401.7 SIHO - ALL PLANS SIHO - ALL PLANS 556.2 90 999999999 374.2 599.46 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48755989_1 CDM 0710 RC inpatient 618 401.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 374.2 60.55 999999999 374.2 599.46 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48755989_1 CDM 0710 RC inpatient 618 401.7 UMR - ALL PLANS UMR - ALL PLANS 432.6 70 999999999 374.2 599.46 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48755989_1 CDM 0710 RC inpatient 618 401.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 374.2 599.46 RECOVERY ROOM - GENERAL CLASSIFICATION 48755989_1 CDM 0710 RC inpatient 618 401.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 374.2 599.46 RECOVERY ROOM - GENERAL CLASSIFICATION 48755989_1 CDM 0710 RC inpatient 618 401.7 ANTHEM HMO ANTHEM HMO 999999999 374.2 599.46 RECOVERY ROOM - GENERAL CLASSIFICATION 48755989_1 CDM 0710 RC inpatient 618 401.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 417.77 67.6 999999999 374.2 599.46 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 48755989_1 CDM 0710 RC inpatient 618 401.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 374.2 599.46 RECOVERY ROOM - GENERAL CLASSIFICATION 48755989_1 CDM 0710 RC inpatient 618 401.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 374.2 599.46 "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48755991_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 AETNA AETNA 443.98 79 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48755991_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 365.3 65 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48755991_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 545.14 97 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48755991_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 387.78 69 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48755991_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 438.36 78 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48755991_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 SIHO - ALL PLANS SIHO - ALL PLANS 505.8 90 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48755991_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 340.29 60.55 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48755991_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 UMR - ALL PLANS UMR - ALL PLANS 393.4 70 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48755991_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 340.29 545.14 "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48755991_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 340.29 545.14 "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48755991_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 ANTHEM HMO ANTHEM HMO 999999999 340.29 545.14 "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48755991_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 379.91 67.6 999999999 340.29 545.14 percent of total billed charges "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48755991_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 340.29 545.14 "Use of a drug to induce depression of consciousness by physician not performing a procedure (5 years or older), initial 15 minutes" 48755991_1 CDM 0370 RC 99156 HCPCS inpatient 562 365.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 340.29 545.14 MOD SED DIFF PHYS/QHP ADD ON 48755992_1 CDM 0370 RC 99150 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges MOD SED DIFF PHYS/QHP ADD ON 48755992_1 CDM 0370 RC 99150 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges MOD SED DIFF PHYS/QHP ADD ON 48755992_1 CDM 0370 RC 99150 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges MOD SED DIFF PHYS/QHP ADD ON 48755992_1 CDM 0370 RC 99150 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges MOD SED DIFF PHYS/QHP ADD ON 48755992_1 CDM 0370 RC 99150 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges MOD SED DIFF PHYS/QHP ADD ON 48755992_1 CDM 0370 RC 99150 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges MOD SED DIFF PHYS/QHP ADD ON 48755992_1 CDM 0370 RC 99150 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges MOD SED DIFF PHYS/QHP ADD ON 48755992_1 CDM 0370 RC 99150 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges MOD SED DIFF PHYS/QHP ADD ON 48755992_1 CDM 0370 RC 99150 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 MOD SED DIFF PHYS/QHP ADD ON 48755992_1 CDM 0370 RC 99150 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 MOD SED DIFF PHYS/QHP ADD ON 48755992_1 CDM 0370 RC 99150 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 MOD SED DIFF PHYS/QHP ADD ON 48755992_1 CDM 0370 RC 99150 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges MOD SED DIFF PHYS/QHP ADD ON 48755992_1 CDM 0370 RC 99150 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 MOD SED DIFF PHYS/QHP ADD ON 48755992_1 CDM 0370 RC 99150 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Buprenorphine level 48756456_1 CDM 0301 RC 80348 HCPCS inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges Buprenorphine level 48756456_1 CDM 0301 RC 80348 HCPCS inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges Buprenorphine level 48756456_1 CDM 0301 RC 80348 HCPCS inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges Buprenorphine level 48756456_1 CDM 0301 RC 80348 HCPCS inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges Buprenorphine level 48756456_1 CDM 0301 RC 80348 HCPCS inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges Buprenorphine level 48756456_1 CDM 0301 RC 80348 HCPCS inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges Buprenorphine level 48756456_1 CDM 0301 RC 80348 HCPCS inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges Buprenorphine level 48756456_1 CDM 0301 RC 80348 HCPCS inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges Buprenorphine level 48756456_1 CDM 0301 RC 80348 HCPCS inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 Buprenorphine level 48756456_1 CDM 0301 RC 80348 HCPCS inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 Buprenorphine level 48756456_1 CDM 0301 RC 80348 HCPCS inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 Buprenorphine level 48756456_1 CDM 0301 RC 80348 HCPCS inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges Buprenorphine level 48756456_1 CDM 0301 RC 80348 HCPCS inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 Buprenorphine level 48756456_1 CDM 0301 RC 80348 HCPCS inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 96412 ONC CHEMO INFUSION CHARGE 48756533_1 CDM 0335 RC 96412 HCPCS inpatient 724 470.6 AETNA AETNA 571.96 79 999999999 438.38 702.28 percent of total billed charges 96412 ONC CHEMO INFUSION CHARGE 48756533_1 CDM 0335 RC 96412 HCPCS inpatient 724 470.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 470.6 65 999999999 438.38 702.28 percent of total billed charges 96412 ONC CHEMO INFUSION CHARGE 48756533_1 CDM 0335 RC 96412 HCPCS inpatient 724 470.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 702.28 97 999999999 438.38 702.28 percent of total billed charges 96412 ONC CHEMO INFUSION CHARGE 48756533_1 CDM 0335 RC 96412 HCPCS inpatient 724 470.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 499.56 69 999999999 438.38 702.28 percent of total billed charges 96412 ONC CHEMO INFUSION CHARGE 48756533_1 CDM 0335 RC 96412 HCPCS inpatient 724 470.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 564.72 78 999999999 438.38 702.28 percent of total billed charges 96412 ONC CHEMO INFUSION CHARGE 48756533_1 CDM 0335 RC 96412 HCPCS inpatient 724 470.6 SIHO - ALL PLANS SIHO - ALL PLANS 651.6 90 999999999 438.38 702.28 percent of total billed charges 96412 ONC CHEMO INFUSION CHARGE 48756533_1 CDM 0335 RC 96412 HCPCS inpatient 724 470.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 438.38 60.55 999999999 438.38 702.28 percent of total billed charges 96412 ONC CHEMO INFUSION CHARGE 48756533_1 CDM 0335 RC 96412 HCPCS inpatient 724 470.6 UMR - ALL PLANS UMR - ALL PLANS 506.8 70 999999999 438.38 702.28 percent of total billed charges 96412 ONC CHEMO INFUSION CHARGE 48756533_1 CDM 0335 RC 96412 HCPCS inpatient 724 470.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 438.38 702.28 96412 ONC CHEMO INFUSION CHARGE 48756533_1 CDM 0335 RC 96412 HCPCS inpatient 724 470.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 438.38 702.28 96412 ONC CHEMO INFUSION CHARGE 48756533_1 CDM 0335 RC 96412 HCPCS inpatient 724 470.6 ANTHEM HMO ANTHEM HMO 999999999 438.38 702.28 96412 ONC CHEMO INFUSION CHARGE 48756533_1 CDM 0335 RC 96412 HCPCS inpatient 724 470.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 489.42 67.6 999999999 438.38 702.28 percent of total billed charges 96412 ONC CHEMO INFUSION CHARGE 48756533_1 CDM 0335 RC 96412 HCPCS inpatient 724 470.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 438.38 702.28 96412 ONC CHEMO INFUSION CHARGE 48756533_1 CDM 0335 RC 96412 HCPCS inpatient 724 470.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 438.38 702.28 DILTIAZEM 50 MG/10 ML VIAL 48757171_1 CDM 0250 RC 00641-9218-10 NDC inpatient 1 UN 20.32 13.21 AETNA AETNA 16.05 79 999999999 12.3 19.71 percent of total billed charges DILTIAZEM 50 MG/10 ML VIAL 48757171_1 CDM 0250 RC 00641-9218-10 NDC inpatient 1 UN 20.32 13.21 SELF PAY DISCOUNT SELF PAY DISCOUNT 13.21 65 999999999 12.3 19.71 percent of total billed charges DILTIAZEM 50 MG/10 ML VIAL 48757171_1 CDM 0250 RC 00641-9218-10 NDC inpatient 1 UN 20.32 13.21 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.71 97 999999999 12.3 19.71 percent of total billed charges DILTIAZEM 50 MG/10 ML VIAL 48757171_1 CDM 0250 RC 00641-9218-10 NDC inpatient 1 UN 20.32 13.21 ENCORE - ALL PLANS ENCORE - ALL PLANS 14.02 69 999999999 12.3 19.71 percent of total billed charges DILTIAZEM 50 MG/10 ML VIAL 48757171_1 CDM 0250 RC 00641-9218-10 NDC inpatient 1 UN 20.32 13.21 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.85 78 999999999 12.3 19.71 percent of total billed charges DILTIAZEM 50 MG/10 ML VIAL 48757171_1 CDM 0250 RC 00641-9218-10 NDC inpatient 1 UN 20.32 13.21 SIHO - ALL PLANS SIHO - ALL PLANS 18.29 90 999999999 12.3 19.71 percent of total billed charges DILTIAZEM 50 MG/10 ML VIAL 48757171_1 CDM 0250 RC 00641-9218-10 NDC inpatient 1 UN 20.32 13.21 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.3 60.55 999999999 12.3 19.71 percent of total billed charges DILTIAZEM 50 MG/10 ML VIAL 48757171_1 CDM 0250 RC 00641-9218-10 NDC inpatient 1 UN 20.32 13.21 UMR - ALL PLANS UMR - ALL PLANS 14.22 70 999999999 12.3 19.71 percent of total billed charges DILTIAZEM 50 MG/10 ML VIAL 48757171_1 CDM 0250 RC 00641-9218-10 NDC inpatient 1 UN 20.32 13.21 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.3 19.71 DILTIAZEM 50 MG/10 ML VIAL 48757171_1 CDM 0250 RC 00641-9218-10 NDC inpatient 1 UN 20.32 13.21 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.3 19.71 DILTIAZEM 50 MG/10 ML VIAL 48757171_1 CDM 0250 RC 00641-9218-10 NDC inpatient 1 UN 20.32 13.21 ANTHEM HMO ANTHEM HMO 999999999 12.3 19.71 DILTIAZEM 50 MG/10 ML VIAL 48757171_1 CDM 0250 RC 00641-9218-10 NDC inpatient 1 UN 20.32 13.21 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.74 67.6 999999999 12.3 19.71 percent of total billed charges DILTIAZEM 50 MG/10 ML VIAL 48757171_1 CDM 0250 RC 00641-9218-10 NDC inpatient 1 UN 20.32 13.21 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.3 19.71 DILTIAZEM 50 MG/10 ML VIAL 48757171_1 CDM 0250 RC 00641-9218-10 NDC inpatient 1 UN 20.32 13.21 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.3 19.71 SPECIALTY SERVICES - TREATMENT ROOM 48757561_1 CDM 0761 RC inpatient 789 512.85 AETNA AETNA 623.31 79 999999999 477.74 765.33 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48757561_1 CDM 0761 RC inpatient 789 512.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 512.85 65 999999999 477.74 765.33 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48757561_1 CDM 0761 RC inpatient 789 512.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 765.33 97 999999999 477.74 765.33 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48757561_1 CDM 0761 RC inpatient 789 512.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 544.41 69 999999999 477.74 765.33 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48757561_1 CDM 0761 RC inpatient 789 512.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 615.42 78 999999999 477.74 765.33 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48757561_1 CDM 0761 RC inpatient 789 512.85 SIHO - ALL PLANS SIHO - ALL PLANS 710.1 90 999999999 477.74 765.33 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48757561_1 CDM 0761 RC inpatient 789 512.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 477.74 60.55 999999999 477.74 765.33 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48757561_1 CDM 0761 RC inpatient 789 512.85 UMR - ALL PLANS UMR - ALL PLANS 552.3 70 999999999 477.74 765.33 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48757561_1 CDM 0761 RC inpatient 789 512.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 477.74 765.33 SPECIALTY SERVICES - TREATMENT ROOM 48757561_1 CDM 0761 RC inpatient 789 512.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 477.74 765.33 SPECIALTY SERVICES - TREATMENT ROOM 48757561_1 CDM 0761 RC inpatient 789 512.85 ANTHEM HMO ANTHEM HMO 999999999 477.74 765.33 SPECIALTY SERVICES - TREATMENT ROOM 48757561_1 CDM 0761 RC inpatient 789 512.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 533.36 67.6 999999999 477.74 765.33 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48757561_1 CDM 0761 RC inpatient 789 512.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 477.74 765.33 SPECIALTY SERVICES - TREATMENT ROOM 48757561_1 CDM 0761 RC inpatient 789 512.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 477.74 765.33 Thoracentesis with Arrow Pluera Seal 48757569_1 CDM 0760 RC inpatient 801 520.65 AETNA AETNA 632.79 79 999999999 485.01 776.97 percent of total billed charges Thoracentesis with Arrow Pluera Seal 48757569_1 CDM 0760 RC inpatient 801 520.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 520.65 65 999999999 485.01 776.97 percent of total billed charges Thoracentesis with Arrow Pluera Seal 48757569_1 CDM 0760 RC inpatient 801 520.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 776.97 97 999999999 485.01 776.97 percent of total billed charges Thoracentesis with Arrow Pluera Seal 48757569_1 CDM 0760 RC inpatient 801 520.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 552.69 69 999999999 485.01 776.97 percent of total billed charges Thoracentesis with Arrow Pluera Seal 48757569_1 CDM 0760 RC inpatient 801 520.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 624.78 78 999999999 485.01 776.97 percent of total billed charges Thoracentesis with Arrow Pluera Seal 48757569_1 CDM 0760 RC inpatient 801 520.65 SIHO - ALL PLANS SIHO - ALL PLANS 720.9 90 999999999 485.01 776.97 percent of total billed charges Thoracentesis with Arrow Pluera Seal 48757569_1 CDM 0760 RC inpatient 801 520.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 485.01 60.55 999999999 485.01 776.97 percent of total billed charges Thoracentesis with Arrow Pluera Seal 48757569_1 CDM 0760 RC inpatient 801 520.65 UMR - ALL PLANS UMR - ALL PLANS 560.7 70 999999999 485.01 776.97 percent of total billed charges Thoracentesis with Arrow Pluera Seal 48757569_1 CDM 0760 RC inpatient 801 520.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 485.01 776.97 Thoracentesis with Arrow Pluera Seal 48757569_1 CDM 0760 RC inpatient 801 520.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 485.01 776.97 Thoracentesis with Arrow Pluera Seal 48757569_1 CDM 0760 RC inpatient 801 520.65 ANTHEM HMO ANTHEM HMO 999999999 485.01 776.97 Thoracentesis with Arrow Pluera Seal 48757569_1 CDM 0760 RC inpatient 801 520.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 541.48 67.6 999999999 485.01 776.97 percent of total billed charges Thoracentesis with Arrow Pluera Seal 48757569_1 CDM 0760 RC inpatient 801 520.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 485.01 776.97 Thoracentesis with Arrow Pluera Seal 48757569_1 CDM 0760 RC inpatient 801 520.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 485.01 776.97 Thoracentesis with Kendell Tray 48757570_1 CDM 0760 RC inpatient 801 520.65 AETNA AETNA 632.79 79 999999999 485.01 776.97 percent of total billed charges Thoracentesis with Kendell Tray 48757570_1 CDM 0760 RC inpatient 801 520.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 520.65 65 999999999 485.01 776.97 percent of total billed charges Thoracentesis with Kendell Tray 48757570_1 CDM 0760 RC inpatient 801 520.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 776.97 97 999999999 485.01 776.97 percent of total billed charges Thoracentesis with Kendell Tray 48757570_1 CDM 0760 RC inpatient 801 520.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 552.69 69 999999999 485.01 776.97 percent of total billed charges Thoracentesis with Kendell Tray 48757570_1 CDM 0760 RC inpatient 801 520.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 624.78 78 999999999 485.01 776.97 percent of total billed charges Thoracentesis with Kendell Tray 48757570_1 CDM 0760 RC inpatient 801 520.65 SIHO - ALL PLANS SIHO - ALL PLANS 720.9 90 999999999 485.01 776.97 percent of total billed charges Thoracentesis with Kendell Tray 48757570_1 CDM 0760 RC inpatient 801 520.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 485.01 60.55 999999999 485.01 776.97 percent of total billed charges Thoracentesis with Kendell Tray 48757570_1 CDM 0760 RC inpatient 801 520.65 UMR - ALL PLANS UMR - ALL PLANS 560.7 70 999999999 485.01 776.97 percent of total billed charges Thoracentesis with Kendell Tray 48757570_1 CDM 0760 RC inpatient 801 520.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 485.01 776.97 Thoracentesis with Kendell Tray 48757570_1 CDM 0760 RC inpatient 801 520.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 485.01 776.97 Thoracentesis with Kendell Tray 48757570_1 CDM 0760 RC inpatient 801 520.65 ANTHEM HMO ANTHEM HMO 999999999 485.01 776.97 Thoracentesis with Kendell Tray 48757570_1 CDM 0760 RC inpatient 801 520.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 541.48 67.6 999999999 485.01 776.97 percent of total billed charges Thoracentesis with Kendell Tray 48757570_1 CDM 0760 RC inpatient 801 520.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 485.01 776.97 Thoracentesis with Kendell Tray 48757570_1 CDM 0760 RC inpatient 801 520.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 485.01 776.97 Biopsy of bone marrow 48757571_1 CDM 0760 RC 38221 HCPCS inpatient 533 346.45 AETNA AETNA 421.07 79 999999999 322.73 517.01 percent of total billed charges Biopsy of bone marrow 48757571_1 CDM 0760 RC 38221 HCPCS inpatient 533 346.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 346.45 65 999999999 322.73 517.01 percent of total billed charges Biopsy of bone marrow 48757571_1 CDM 0760 RC 38221 HCPCS inpatient 533 346.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 517.01 97 999999999 322.73 517.01 percent of total billed charges Biopsy of bone marrow 48757571_1 CDM 0760 RC 38221 HCPCS inpatient 533 346.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 367.77 69 999999999 322.73 517.01 percent of total billed charges Biopsy of bone marrow 48757571_1 CDM 0760 RC 38221 HCPCS inpatient 533 346.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 415.74 78 999999999 322.73 517.01 percent of total billed charges Biopsy of bone marrow 48757571_1 CDM 0760 RC 38221 HCPCS inpatient 533 346.45 SIHO - ALL PLANS SIHO - ALL PLANS 479.7 90 999999999 322.73 517.01 percent of total billed charges Biopsy of bone marrow 48757571_1 CDM 0760 RC 38221 HCPCS inpatient 533 346.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 322.73 60.55 999999999 322.73 517.01 percent of total billed charges Biopsy of bone marrow 48757571_1 CDM 0760 RC 38221 HCPCS inpatient 533 346.45 UMR - ALL PLANS UMR - ALL PLANS 373.1 70 999999999 322.73 517.01 percent of total billed charges Biopsy of bone marrow 48757571_1 CDM 0760 RC 38221 HCPCS inpatient 533 346.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 322.73 517.01 Biopsy of bone marrow 48757571_1 CDM 0760 RC 38221 HCPCS inpatient 533 346.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 322.73 517.01 Biopsy of bone marrow 48757571_1 CDM 0760 RC 38221 HCPCS inpatient 533 346.45 ANTHEM HMO ANTHEM HMO 999999999 322.73 517.01 Biopsy of bone marrow 48757571_1 CDM 0760 RC 38221 HCPCS inpatient 533 346.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 360.31 67.6 999999999 322.73 517.01 percent of total billed charges Biopsy of bone marrow 48757571_1 CDM 0760 RC 38221 HCPCS inpatient 533 346.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 322.73 517.01 Biopsy of bone marrow 48757571_1 CDM 0760 RC 38221 HCPCS inpatient 533 346.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 322.73 517.01 Paracentesis 48757572_1 CDM 0760 RC inpatient 533 346.45 AETNA AETNA 421.07 79 999999999 322.73 517.01 percent of total billed charges Paracentesis 48757572_1 CDM 0760 RC inpatient 533 346.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 346.45 65 999999999 322.73 517.01 percent of total billed charges Paracentesis 48757572_1 CDM 0760 RC inpatient 533 346.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 517.01 97 999999999 322.73 517.01 percent of total billed charges Paracentesis 48757572_1 CDM 0760 RC inpatient 533 346.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 367.77 69 999999999 322.73 517.01 percent of total billed charges Paracentesis 48757572_1 CDM 0760 RC inpatient 533 346.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 415.74 78 999999999 322.73 517.01 percent of total billed charges Paracentesis 48757572_1 CDM 0760 RC inpatient 533 346.45 SIHO - ALL PLANS SIHO - ALL PLANS 479.7 90 999999999 322.73 517.01 percent of total billed charges Paracentesis 48757572_1 CDM 0760 RC inpatient 533 346.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 322.73 60.55 999999999 322.73 517.01 percent of total billed charges Paracentesis 48757572_1 CDM 0760 RC inpatient 533 346.45 UMR - ALL PLANS UMR - ALL PLANS 373.1 70 999999999 322.73 517.01 percent of total billed charges Paracentesis 48757572_1 CDM 0760 RC inpatient 533 346.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 322.73 517.01 Paracentesis 48757572_1 CDM 0760 RC inpatient 533 346.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 322.73 517.01 Paracentesis 48757572_1 CDM 0760 RC inpatient 533 346.45 ANTHEM HMO ANTHEM HMO 999999999 322.73 517.01 Paracentesis 48757572_1 CDM 0760 RC inpatient 533 346.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 360.31 67.6 999999999 322.73 517.01 percent of total billed charges Paracentesis 48757572_1 CDM 0760 RC inpatient 533 346.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 322.73 517.01 Paracentesis 48757572_1 CDM 0760 RC inpatient 533 346.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 322.73 517.01 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757573_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 AETNA AETNA 681.77 79 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757573_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 560.95 65 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757573_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 837.11 97 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757573_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 595.47 69 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757573_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 673.14 78 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757573_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 SIHO - ALL PLANS SIHO - ALL PLANS 776.7 90 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757573_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 522.55 60.55 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757573_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 UMR - ALL PLANS UMR - ALL PLANS 604.1 70 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757573_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 522.55 837.11 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757573_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 522.55 837.11 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757573_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 ANTHEM HMO ANTHEM HMO 999999999 522.55 837.11 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757573_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 583.39 67.6 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757573_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 522.55 837.11 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757573_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 522.55 837.11 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757574_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 AETNA AETNA 681.77 79 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757574_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 560.95 65 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757574_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 837.11 97 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757574_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 595.47 69 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757574_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 673.14 78 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757574_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 SIHO - ALL PLANS SIHO - ALL PLANS 776.7 90 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757574_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 522.55 60.55 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757574_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 UMR - ALL PLANS UMR - ALL PLANS 604.1 70 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757574_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 522.55 837.11 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757574_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 522.55 837.11 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757574_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 ANTHEM HMO ANTHEM HMO 999999999 522.55 837.11 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757574_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 583.39 67.6 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757574_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 522.55 837.11 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757574_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 522.55 837.11 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757575_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 AETNA AETNA 681.77 79 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757575_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 560.95 65 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757575_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 837.11 97 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757575_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 595.47 69 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757575_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 673.14 78 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757575_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 SIHO - ALL PLANS SIHO - ALL PLANS 776.7 90 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757575_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 522.55 60.55 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757575_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 UMR - ALL PLANS UMR - ALL PLANS 604.1 70 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757575_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 522.55 837.11 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757575_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 522.55 837.11 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757575_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 ANTHEM HMO ANTHEM HMO 999999999 522.55 837.11 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757575_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 583.39 67.6 999999999 522.55 837.11 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757575_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 522.55 837.11 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 48757575_1 CDM 0760 RC 62270 HCPCS inpatient 863 560.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 522.55 837.11 Ultrasound measurement of bladder capacity after voiding 48757578_1 CDM 0761 RC 51798 HCPCS inpatient 132 85.8 AETNA AETNA 104.28 79 999999999 79.93 128.04 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 48757578_1 CDM 0761 RC 51798 HCPCS inpatient 132 85.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.8 65 999999999 79.93 128.04 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 48757578_1 CDM 0761 RC 51798 HCPCS inpatient 132 85.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 128.04 97 999999999 79.93 128.04 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 48757578_1 CDM 0761 RC 51798 HCPCS inpatient 132 85.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.08 69 999999999 79.93 128.04 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 48757578_1 CDM 0761 RC 51798 HCPCS inpatient 132 85.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.96 78 999999999 79.93 128.04 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 48757578_1 CDM 0761 RC 51798 HCPCS inpatient 132 85.8 SIHO - ALL PLANS SIHO - ALL PLANS 118.8 90 999999999 79.93 128.04 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 48757578_1 CDM 0761 RC 51798 HCPCS inpatient 132 85.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.93 60.55 999999999 79.93 128.04 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 48757578_1 CDM 0761 RC 51798 HCPCS inpatient 132 85.8 UMR - ALL PLANS UMR - ALL PLANS 92.4 70 999999999 79.93 128.04 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 48757578_1 CDM 0761 RC 51798 HCPCS inpatient 132 85.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.93 128.04 Ultrasound measurement of bladder capacity after voiding 48757578_1 CDM 0761 RC 51798 HCPCS inpatient 132 85.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.93 128.04 Ultrasound measurement of bladder capacity after voiding 48757578_1 CDM 0761 RC 51798 HCPCS inpatient 132 85.8 ANTHEM HMO ANTHEM HMO 999999999 79.93 128.04 Ultrasound measurement of bladder capacity after voiding 48757578_1 CDM 0761 RC 51798 HCPCS inpatient 132 85.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.23 67.6 999999999 79.93 128.04 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 48757578_1 CDM 0761 RC 51798 HCPCS inpatient 132 85.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.93 128.04 Ultrasound measurement of bladder capacity after voiding 48757578_1 CDM 0761 RC 51798 HCPCS inpatient 132 85.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.93 128.04 Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757587_1 CDM 0761 RC 36556 HCPCS inpatient 2929 1903.85 AETNA AETNA 2313.91 79 999999999 1773.51 2841.13 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757587_1 CDM 0761 RC 36556 HCPCS inpatient 2929 1903.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1903.85 65 999999999 1773.51 2841.13 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757587_1 CDM 0761 RC 36556 HCPCS inpatient 2929 1903.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2841.13 97 999999999 1773.51 2841.13 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757587_1 CDM 0761 RC 36556 HCPCS inpatient 2929 1903.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 2021.01 69 999999999 1773.51 2841.13 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757587_1 CDM 0761 RC 36556 HCPCS inpatient 2929 1903.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 2284.62 78 999999999 1773.51 2841.13 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757587_1 CDM 0761 RC 36556 HCPCS inpatient 2929 1903.85 SIHO - ALL PLANS SIHO - ALL PLANS 2636.1 90 999999999 1773.51 2841.13 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757587_1 CDM 0761 RC 36556 HCPCS inpatient 2929 1903.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1773.51 60.55 999999999 1773.51 2841.13 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757587_1 CDM 0761 RC 36556 HCPCS inpatient 2929 1903.85 UMR - ALL PLANS UMR - ALL PLANS 2050.3 70 999999999 1773.51 2841.13 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757587_1 CDM 0761 RC 36556 HCPCS inpatient 2929 1903.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1773.51 2841.13 Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757587_1 CDM 0761 RC 36556 HCPCS inpatient 2929 1903.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1773.51 2841.13 Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757587_1 CDM 0761 RC 36556 HCPCS inpatient 2929 1903.85 ANTHEM HMO ANTHEM HMO 999999999 1773.51 2841.13 Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757587_1 CDM 0761 RC 36556 HCPCS inpatient 2929 1903.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1980 67.6 999999999 1773.51 2841.13 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757587_1 CDM 0761 RC 36556 HCPCS inpatient 2929 1903.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1773.51 2841.13 Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757587_1 CDM 0761 RC 36556 HCPCS inpatient 2929 1903.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1773.51 2841.13 Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757776_1 CDM 0761 RC 36556 HCPCS inpatient 2134 1387.1 AETNA AETNA 1685.86 79 999999999 1292.14 2069.98 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757776_1 CDM 0761 RC 36556 HCPCS inpatient 2134 1387.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1387.1 65 999999999 1292.14 2069.98 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757776_1 CDM 0761 RC 36556 HCPCS inpatient 2134 1387.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2069.98 97 999999999 1292.14 2069.98 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757776_1 CDM 0761 RC 36556 HCPCS inpatient 2134 1387.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 1472.46 69 999999999 1292.14 2069.98 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757776_1 CDM 0761 RC 36556 HCPCS inpatient 2134 1387.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1664.52 78 999999999 1292.14 2069.98 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757776_1 CDM 0761 RC 36556 HCPCS inpatient 2134 1387.1 SIHO - ALL PLANS SIHO - ALL PLANS 1920.6 90 999999999 1292.14 2069.98 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757776_1 CDM 0761 RC 36556 HCPCS inpatient 2134 1387.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1292.14 60.55 999999999 1292.14 2069.98 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757776_1 CDM 0761 RC 36556 HCPCS inpatient 2134 1387.1 UMR - ALL PLANS UMR - ALL PLANS 1493.8 70 999999999 1292.14 2069.98 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757776_1 CDM 0761 RC 36556 HCPCS inpatient 2134 1387.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1292.14 2069.98 Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757776_1 CDM 0761 RC 36556 HCPCS inpatient 2134 1387.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1292.14 2069.98 Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757776_1 CDM 0761 RC 36556 HCPCS inpatient 2134 1387.1 ANTHEM HMO ANTHEM HMO 999999999 1292.14 2069.98 Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757776_1 CDM 0761 RC 36556 HCPCS inpatient 2134 1387.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1442.58 67.6 999999999 1292.14 2069.98 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757776_1 CDM 0761 RC 36556 HCPCS inpatient 2134 1387.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1292.14 2069.98 Insertion of non-tunneled central venous tube for infusion (5 years or older) 48757776_1 CDM 0761 RC 36556 HCPCS inpatient 2134 1387.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1292.14 2069.98 Repositioning of central venous tube using fluoroscopic guidance 48758523_1 CDM 0761 RC 36597 HCPCS inpatient 3296 2142.4 AETNA AETNA 2603.84 79 999999999 1995.73 3197.12 percent of total billed charges Repositioning of central venous tube using fluoroscopic guidance 48758523_1 CDM 0761 RC 36597 HCPCS inpatient 3296 2142.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 2142.4 65 999999999 1995.73 3197.12 percent of total billed charges Repositioning of central venous tube using fluoroscopic guidance 48758523_1 CDM 0761 RC 36597 HCPCS inpatient 3296 2142.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3197.12 97 999999999 1995.73 3197.12 percent of total billed charges Repositioning of central venous tube using fluoroscopic guidance 48758523_1 CDM 0761 RC 36597 HCPCS inpatient 3296 2142.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 2274.24 69 999999999 1995.73 3197.12 percent of total billed charges Repositioning of central venous tube using fluoroscopic guidance 48758523_1 CDM 0761 RC 36597 HCPCS inpatient 3296 2142.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 2570.88 78 999999999 1995.73 3197.12 percent of total billed charges Repositioning of central venous tube using fluoroscopic guidance 48758523_1 CDM 0761 RC 36597 HCPCS inpatient 3296 2142.4 SIHO - ALL PLANS SIHO - ALL PLANS 2966.4 90 999999999 1995.73 3197.12 percent of total billed charges Repositioning of central venous tube using fluoroscopic guidance 48758523_1 CDM 0761 RC 36597 HCPCS inpatient 3296 2142.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1995.73 60.55 999999999 1995.73 3197.12 percent of total billed charges Repositioning of central venous tube using fluoroscopic guidance 48758523_1 CDM 0761 RC 36597 HCPCS inpatient 3296 2142.4 UMR - ALL PLANS UMR - ALL PLANS 2307.2 70 999999999 1995.73 3197.12 percent of total billed charges Repositioning of central venous tube using fluoroscopic guidance 48758523_1 CDM 0761 RC 36597 HCPCS inpatient 3296 2142.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1995.73 3197.12 Repositioning of central venous tube using fluoroscopic guidance 48758523_1 CDM 0761 RC 36597 HCPCS inpatient 3296 2142.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1995.73 3197.12 Repositioning of central venous tube using fluoroscopic guidance 48758523_1 CDM 0761 RC 36597 HCPCS inpatient 3296 2142.4 ANTHEM HMO ANTHEM HMO 999999999 1995.73 3197.12 Repositioning of central venous tube using fluoroscopic guidance 48758523_1 CDM 0761 RC 36597 HCPCS inpatient 3296 2142.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 2228.1 67.6 999999999 1995.73 3197.12 percent of total billed charges Repositioning of central venous tube using fluoroscopic guidance 48758523_1 CDM 0761 RC 36597 HCPCS inpatient 3296 2142.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1995.73 3197.12 Repositioning of central venous tube using fluoroscopic guidance 48758523_1 CDM 0761 RC 36597 HCPCS inpatient 3296 2142.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1995.73 3197.12 Collection of blood sample from central venous tube 48758759_1 CDM 0300 RC 36592 HCPCS inpatient 330 214.5 AETNA AETNA 260.7 79 999999999 199.82 320.1 percent of total billed charges Collection of blood sample from central venous tube 48758759_1 CDM 0300 RC 36592 HCPCS inpatient 330 214.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 214.5 65 999999999 199.82 320.1 percent of total billed charges Collection of blood sample from central venous tube 48758759_1 CDM 0300 RC 36592 HCPCS inpatient 330 214.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 320.1 97 999999999 199.82 320.1 percent of total billed charges Collection of blood sample from central venous tube 48758759_1 CDM 0300 RC 36592 HCPCS inpatient 330 214.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 227.7 69 999999999 199.82 320.1 percent of total billed charges Collection of blood sample from central venous tube 48758759_1 CDM 0300 RC 36592 HCPCS inpatient 330 214.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 257.4 78 999999999 199.82 320.1 percent of total billed charges Collection of blood sample from central venous tube 48758759_1 CDM 0300 RC 36592 HCPCS inpatient 330 214.5 SIHO - ALL PLANS SIHO - ALL PLANS 297 90 999999999 199.82 320.1 percent of total billed charges Collection of blood sample from central venous tube 48758759_1 CDM 0300 RC 36592 HCPCS inpatient 330 214.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 199.82 60.55 999999999 199.82 320.1 percent of total billed charges Collection of blood sample from central venous tube 48758759_1 CDM 0300 RC 36592 HCPCS inpatient 330 214.5 UMR - ALL PLANS UMR - ALL PLANS 231 70 999999999 199.82 320.1 percent of total billed charges Collection of blood sample from central venous tube 48758759_1 CDM 0300 RC 36592 HCPCS inpatient 330 214.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 199.82 320.1 Collection of blood sample from central venous tube 48758759_1 CDM 0300 RC 36592 HCPCS inpatient 330 214.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 199.82 320.1 Collection of blood sample from central venous tube 48758759_1 CDM 0300 RC 36592 HCPCS inpatient 330 214.5 ANTHEM HMO ANTHEM HMO 999999999 199.82 320.1 Collection of blood sample from central venous tube 48758759_1 CDM 0300 RC 36592 HCPCS inpatient 330 214.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 223.08 67.6 999999999 199.82 320.1 percent of total billed charges Collection of blood sample from central venous tube 48758759_1 CDM 0300 RC 36592 HCPCS inpatient 330 214.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 199.82 320.1 Collection of blood sample from central venous tube 48758759_1 CDM 0300 RC 36592 HCPCS inpatient 330 214.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 199.82 320.1 Declotting of central venous tube 48758760_1 CDM 0761 RC 36593 HCPCS inpatient 608 395.2 AETNA AETNA 480.32 79 999999999 368.14 589.76 percent of total billed charges Declotting of central venous tube 48758760_1 CDM 0761 RC 36593 HCPCS inpatient 608 395.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 395.2 65 999999999 368.14 589.76 percent of total billed charges Declotting of central venous tube 48758760_1 CDM 0761 RC 36593 HCPCS inpatient 608 395.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 589.76 97 999999999 368.14 589.76 percent of total billed charges Declotting of central venous tube 48758760_1 CDM 0761 RC 36593 HCPCS inpatient 608 395.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 419.52 69 999999999 368.14 589.76 percent of total billed charges Declotting of central venous tube 48758760_1 CDM 0761 RC 36593 HCPCS inpatient 608 395.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 474.24 78 999999999 368.14 589.76 percent of total billed charges Declotting of central venous tube 48758760_1 CDM 0761 RC 36593 HCPCS inpatient 608 395.2 SIHO - ALL PLANS SIHO - ALL PLANS 547.2 90 999999999 368.14 589.76 percent of total billed charges Declotting of central venous tube 48758760_1 CDM 0761 RC 36593 HCPCS inpatient 608 395.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 368.14 60.55 999999999 368.14 589.76 percent of total billed charges Declotting of central venous tube 48758760_1 CDM 0761 RC 36593 HCPCS inpatient 608 395.2 UMR - ALL PLANS UMR - ALL PLANS 425.6 70 999999999 368.14 589.76 percent of total billed charges Declotting of central venous tube 48758760_1 CDM 0761 RC 36593 HCPCS inpatient 608 395.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 368.14 589.76 Declotting of central venous tube 48758760_1 CDM 0761 RC 36593 HCPCS inpatient 608 395.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 368.14 589.76 Declotting of central venous tube 48758760_1 CDM 0761 RC 36593 HCPCS inpatient 608 395.2 ANTHEM HMO ANTHEM HMO 999999999 368.14 589.76 Declotting of central venous tube 48758760_1 CDM 0761 RC 36593 HCPCS inpatient 608 395.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 411.01 67.6 999999999 368.14 589.76 percent of total billed charges Declotting of central venous tube 48758760_1 CDM 0761 RC 36593 HCPCS inpatient 608 395.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 368.14 589.76 Declotting of central venous tube 48758760_1 CDM 0761 RC 36593 HCPCS inpatient 608 395.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 368.14 589.76 Insertion of tube for infusion (5 years or older) 48759062_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 2692.3 65 999999999 2507.98 4017.74 percent of total billed charges Insertion of tube for infusion (5 years or older) 48759062_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 AETNA AETNA 3272.18 79 999999999 2507.98 4017.74 percent of total billed charges Insertion of tube for infusion (5 years or older) 48759062_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4017.74 97 999999999 2507.98 4017.74 percent of total billed charges Insertion of tube for infusion (5 years or older) 48759062_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 2857.98 69 999999999 2507.98 4017.74 percent of total billed charges Insertion of tube for infusion (5 years or older) 48759062_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 3230.76 78 999999999 2507.98 4017.74 percent of total billed charges Insertion of tube for infusion (5 years or older) 48759062_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 SIHO - ALL PLANS SIHO - ALL PLANS 3727.8 90 999999999 2507.98 4017.74 percent of total billed charges Insertion of tube for infusion (5 years or older) 48759062_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2507.98 60.55 999999999 2507.98 4017.74 percent of total billed charges Insertion of tube for infusion (5 years or older) 48759062_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 UMR - ALL PLANS UMR - ALL PLANS 2899.4 70 999999999 2507.98 4017.74 percent of total billed charges Insertion of tube for infusion (5 years or older) 48759062_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2507.98 4017.74 Insertion of tube for infusion (5 years or older) 48759062_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2507.98 4017.74 Insertion of tube for infusion (5 years or older) 48759062_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 ANTHEM HMO ANTHEM HMO 999999999 2507.98 4017.74 Insertion of tube for infusion (5 years or older) 48759062_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2507.98 4017.74 Insertion of tube for infusion (5 years or older) 48759062_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 2799.99 67.6 999999999 2507.98 4017.74 percent of total billed charges Insertion of tube for infusion (5 years or older) 48759062_1 CDM 0761 RC 36569 HCPCS inpatient 4142 2692.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 2507.98 4017.74 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759925_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759925_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759925_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759925_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759925_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759925_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759925_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759925_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759925_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759925_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759925_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759925_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759925_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759925_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759927_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 238.55 65 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759927_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 AETNA AETNA 289.93 79 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759927_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.99 97 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759927_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 253.23 69 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759927_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 286.26 78 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759927_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 SIHO - ALL PLANS SIHO - ALL PLANS 330.3 90 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759927_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 222.22 60.55 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759927_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UMR - ALL PLANS UMR - ALL PLANS 256.9 70 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759927_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759927_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759927_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM HMO ANTHEM HMO 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759927_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759927_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 248.09 67.6 999999999 222.22 355.99 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759927_1 CDM 0390 RC P9017 HCPCS inpatient 367 238.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 222.22 355.99 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759933_1 CDM 0390 RC P9017 HCPCS inpatient 327 212.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 212.55 65 999999999 198 317.19 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759933_1 CDM 0390 RC P9017 HCPCS inpatient 327 212.55 AETNA AETNA 258.33 79 999999999 198 317.19 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759933_1 CDM 0390 RC P9017 HCPCS inpatient 327 212.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 317.19 97 999999999 198 317.19 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759933_1 CDM 0390 RC P9017 HCPCS inpatient 327 212.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 225.63 69 999999999 198 317.19 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759933_1 CDM 0390 RC P9017 HCPCS inpatient 327 212.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.06 78 999999999 198 317.19 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759933_1 CDM 0390 RC P9017 HCPCS inpatient 327 212.55 SIHO - ALL PLANS SIHO - ALL PLANS 294.3 90 999999999 198 317.19 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759933_1 CDM 0390 RC P9017 HCPCS inpatient 327 212.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198 60.55 999999999 198 317.19 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759933_1 CDM 0390 RC P9017 HCPCS inpatient 327 212.55 UMR - ALL PLANS UMR - ALL PLANS 228.9 70 999999999 198 317.19 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759933_1 CDM 0390 RC P9017 HCPCS inpatient 327 212.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198 317.19 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759933_1 CDM 0390 RC P9017 HCPCS inpatient 327 212.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198 317.19 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759933_1 CDM 0390 RC P9017 HCPCS inpatient 327 212.55 ANTHEM HMO ANTHEM HMO 999999999 198 317.19 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759933_1 CDM 0390 RC P9017 HCPCS inpatient 327 212.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198 317.19 "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759933_1 CDM 0390 RC P9017 HCPCS inpatient 327 212.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.05 67.6 999999999 198 317.19 percent of total billed charges "FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT" 48759933_1 CDM 0390 RC P9017 HCPCS inpatient 327 212.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 198 317.19 COSYNTROPIN 0.25 MG VIAL 48762140_1 CDM 0250 RC 00781-3440-95 NDC inpatient 1 UN 100.15 65.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.1 65 999999999 60.64 97.15 percent of total billed charges COSYNTROPIN 0.25 MG VIAL 48762140_1 CDM 0250 RC 00781-3440-95 NDC inpatient 1 UN 100.15 65.1 AETNA AETNA 79.12 79 999999999 60.64 97.15 percent of total billed charges COSYNTROPIN 0.25 MG VIAL 48762140_1 CDM 0250 RC 00781-3440-95 NDC inpatient 1 UN 100.15 65.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.15 97 999999999 60.64 97.15 percent of total billed charges COSYNTROPIN 0.25 MG VIAL 48762140_1 CDM 0250 RC 00781-3440-95 NDC inpatient 1 UN 100.15 65.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.1 69 999999999 60.64 97.15 percent of total billed charges COSYNTROPIN 0.25 MG VIAL 48762140_1 CDM 0250 RC 00781-3440-95 NDC inpatient 1 UN 100.15 65.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.12 78 999999999 60.64 97.15 percent of total billed charges COSYNTROPIN 0.25 MG VIAL 48762140_1 CDM 0250 RC 00781-3440-95 NDC inpatient 1 UN 100.15 65.1 SIHO - ALL PLANS SIHO - ALL PLANS 90.14 90 999999999 60.64 97.15 percent of total billed charges COSYNTROPIN 0.25 MG VIAL 48762140_1 CDM 0250 RC 00781-3440-95 NDC inpatient 1 UN 100.15 65.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.64 60.55 999999999 60.64 97.15 percent of total billed charges COSYNTROPIN 0.25 MG VIAL 48762140_1 CDM 0250 RC 00781-3440-95 NDC inpatient 1 UN 100.15 65.1 UMR - ALL PLANS UMR - ALL PLANS 70.11 70 999999999 60.64 97.15 percent of total billed charges COSYNTROPIN 0.25 MG VIAL 48762140_1 CDM 0250 RC 00781-3440-95 NDC inpatient 1 UN 100.15 65.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.64 97.15 COSYNTROPIN 0.25 MG VIAL 48762140_1 CDM 0250 RC 00781-3440-95 NDC inpatient 1 UN 100.15 65.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.64 97.15 COSYNTROPIN 0.25 MG VIAL 48762140_1 CDM 0250 RC 00781-3440-95 NDC inpatient 1 UN 100.15 65.1 ANTHEM HMO ANTHEM HMO 999999999 60.64 97.15 COSYNTROPIN 0.25 MG VIAL 48762140_1 CDM 0250 RC 00781-3440-95 NDC inpatient 1 UN 100.15 65.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.64 97.15 COSYNTROPIN 0.25 MG VIAL 48762140_1 CDM 0250 RC 00781-3440-95 NDC inpatient 1 UN 100.15 65.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.7 67.6 999999999 60.64 97.15 percent of total billed charges COSYNTROPIN 0.25 MG VIAL 48762140_1 CDM 0250 RC 00781-3440-95 NDC inpatient 1 UN 100.15 65.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.64 97.15 "Evaluation for occupational therapy, typically 30 minutes" 48762528_1 CDM 0430 RC 97165 HCPCS inpatient 497 323.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 323.05 65 999999999 300.93 482.09 percent of total billed charges "Evaluation for occupational therapy, typically 30 minutes" 48762528_1 CDM 0430 RC 97165 HCPCS inpatient 497 323.05 AETNA AETNA 392.63 79 999999999 300.93 482.09 percent of total billed charges "Evaluation for occupational therapy, typically 30 minutes" 48762528_1 CDM 0430 RC 97165 HCPCS inpatient 497 323.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 482.09 97 999999999 300.93 482.09 percent of total billed charges "Evaluation for occupational therapy, typically 30 minutes" 48762528_1 CDM 0430 RC 97165 HCPCS inpatient 497 323.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 342.93 69 999999999 300.93 482.09 percent of total billed charges "Evaluation for occupational therapy, typically 30 minutes" 48762528_1 CDM 0430 RC 97165 HCPCS inpatient 497 323.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 387.66 78 999999999 300.93 482.09 percent of total billed charges "Evaluation for occupational therapy, typically 30 minutes" 48762528_1 CDM 0430 RC 97165 HCPCS inpatient 497 323.05 SIHO - ALL PLANS SIHO - ALL PLANS 447.3 90 999999999 300.93 482.09 percent of total billed charges "Evaluation for occupational therapy, typically 30 minutes" 48762528_1 CDM 0430 RC 97165 HCPCS inpatient 497 323.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 300.93 60.55 999999999 300.93 482.09 percent of total billed charges "Evaluation for occupational therapy, typically 30 minutes" 48762528_1 CDM 0430 RC 97165 HCPCS inpatient 497 323.05 UMR - ALL PLANS UMR - ALL PLANS 347.9 70 999999999 300.93 482.09 percent of total billed charges "Evaluation for occupational therapy, typically 30 minutes" 48762528_1 CDM 0430 RC 97165 HCPCS inpatient 497 323.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 300.93 482.09 "Evaluation for occupational therapy, typically 30 minutes" 48762528_1 CDM 0430 RC 97165 HCPCS inpatient 497 323.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 300.93 482.09 "Evaluation for occupational therapy, typically 30 minutes" 48762528_1 CDM 0430 RC 97165 HCPCS inpatient 497 323.05 ANTHEM HMO ANTHEM HMO 999999999 300.93 482.09 "Evaluation for occupational therapy, typically 30 minutes" 48762528_1 CDM 0430 RC 97165 HCPCS inpatient 497 323.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 300.93 482.09 "Evaluation for occupational therapy, typically 30 minutes" 48762528_1 CDM 0430 RC 97165 HCPCS inpatient 497 323.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 335.97 67.6 999999999 300.93 482.09 percent of total billed charges "Evaluation for occupational therapy, typically 30 minutes" 48762528_1 CDM 0430 RC 97165 HCPCS inpatient 497 323.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 300.93 482.09 "Evaluation for occupational therapy, typically 45 minutes" 48762529_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 45 minutes" 48762529_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 45 minutes" 48762529_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 45 minutes" 48762529_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 45 minutes" 48762529_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 45 minutes" 48762529_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 45 minutes" 48762529_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 45 minutes" 48762529_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 45 minutes" 48762529_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 "Evaluation for occupational therapy, typically 45 minutes" 48762529_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 "Evaluation for occupational therapy, typically 45 minutes" 48762529_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 "Evaluation for occupational therapy, typically 45 minutes" 48762529_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 "Evaluation for occupational therapy, typically 45 minutes" 48762529_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 45 minutes" 48762529_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 "Evaluation for occupational therapy, typically 1 hour" 48762530_1 CDM 0430 RC 97167 HCPCS inpatient 458 297.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 297.7 65 999999999 277.32 444.26 percent of total billed charges "Evaluation for occupational therapy, typically 1 hour" 48762530_1 CDM 0430 RC 97167 HCPCS inpatient 458 297.7 AETNA AETNA 361.82 79 999999999 277.32 444.26 percent of total billed charges "Evaluation for occupational therapy, typically 1 hour" 48762530_1 CDM 0430 RC 97167 HCPCS inpatient 458 297.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 444.26 97 999999999 277.32 444.26 percent of total billed charges "Evaluation for occupational therapy, typically 1 hour" 48762530_1 CDM 0430 RC 97167 HCPCS inpatient 458 297.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 316.02 69 999999999 277.32 444.26 percent of total billed charges "Evaluation for occupational therapy, typically 1 hour" 48762530_1 CDM 0430 RC 97167 HCPCS inpatient 458 297.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 357.24 78 999999999 277.32 444.26 percent of total billed charges "Evaluation for occupational therapy, typically 1 hour" 48762530_1 CDM 0430 RC 97167 HCPCS inpatient 458 297.7 SIHO - ALL PLANS SIHO - ALL PLANS 412.2 90 999999999 277.32 444.26 percent of total billed charges "Evaluation for occupational therapy, typically 1 hour" 48762530_1 CDM 0430 RC 97167 HCPCS inpatient 458 297.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 277.32 60.55 999999999 277.32 444.26 percent of total billed charges "Evaluation for occupational therapy, typically 1 hour" 48762530_1 CDM 0430 RC 97167 HCPCS inpatient 458 297.7 UMR - ALL PLANS UMR - ALL PLANS 320.6 70 999999999 277.32 444.26 percent of total billed charges "Evaluation for occupational therapy, typically 1 hour" 48762530_1 CDM 0430 RC 97167 HCPCS inpatient 458 297.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 277.32 444.26 "Evaluation for occupational therapy, typically 1 hour" 48762530_1 CDM 0430 RC 97167 HCPCS inpatient 458 297.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 277.32 444.26 "Evaluation for occupational therapy, typically 1 hour" 48762530_1 CDM 0430 RC 97167 HCPCS inpatient 458 297.7 ANTHEM HMO ANTHEM HMO 999999999 277.32 444.26 "Evaluation for occupational therapy, typically 1 hour" 48762530_1 CDM 0430 RC 97167 HCPCS inpatient 458 297.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 277.32 444.26 "Evaluation for occupational therapy, typically 1 hour" 48762530_1 CDM 0430 RC 97167 HCPCS inpatient 458 297.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 309.61 67.6 999999999 277.32 444.26 percent of total billed charges "Evaluation for occupational therapy, typically 1 hour" 48762530_1 CDM 0430 RC 97167 HCPCS inpatient 458 297.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 277.32 444.26 "Evaluation for physical therapy, typically 20 minutes" 48762639_1 CDM 0420 RC 97161 HCPCS inpatient 497 323.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 323.05 65 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762639_1 CDM 0420 RC 97161 HCPCS inpatient 497 323.05 AETNA AETNA 392.63 79 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762639_1 CDM 0420 RC 97161 HCPCS inpatient 497 323.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 482.09 97 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762639_1 CDM 0420 RC 97161 HCPCS inpatient 497 323.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 342.93 69 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762639_1 CDM 0420 RC 97161 HCPCS inpatient 497 323.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 387.66 78 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762639_1 CDM 0420 RC 97161 HCPCS inpatient 497 323.05 SIHO - ALL PLANS SIHO - ALL PLANS 447.3 90 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762639_1 CDM 0420 RC 97161 HCPCS inpatient 497 323.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 300.93 60.55 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762639_1 CDM 0420 RC 97161 HCPCS inpatient 497 323.05 UMR - ALL PLANS UMR - ALL PLANS 347.9 70 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762639_1 CDM 0420 RC 97161 HCPCS inpatient 497 323.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 300.93 482.09 "Evaluation for physical therapy, typically 20 minutes" 48762639_1 CDM 0420 RC 97161 HCPCS inpatient 497 323.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 300.93 482.09 "Evaluation for physical therapy, typically 20 minutes" 48762639_1 CDM 0420 RC 97161 HCPCS inpatient 497 323.05 ANTHEM HMO ANTHEM HMO 999999999 300.93 482.09 "Evaluation for physical therapy, typically 20 minutes" 48762639_1 CDM 0420 RC 97161 HCPCS inpatient 497 323.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 300.93 482.09 "Evaluation for physical therapy, typically 20 minutes" 48762639_1 CDM 0420 RC 97161 HCPCS inpatient 497 323.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 335.97 67.6 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762639_1 CDM 0420 RC 97161 HCPCS inpatient 497 323.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 300.93 482.09 "Evaluation for physical therapy, typically 30 minutes" 48762640_1 CDM 0420 RC 97162 HCPCS inpatient 497 323.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 323.05 65 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 30 minutes" 48762640_1 CDM 0420 RC 97162 HCPCS inpatient 497 323.05 AETNA AETNA 392.63 79 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 30 minutes" 48762640_1 CDM 0420 RC 97162 HCPCS inpatient 497 323.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 482.09 97 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 30 minutes" 48762640_1 CDM 0420 RC 97162 HCPCS inpatient 497 323.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 342.93 69 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 30 minutes" 48762640_1 CDM 0420 RC 97162 HCPCS inpatient 497 323.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 387.66 78 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 30 minutes" 48762640_1 CDM 0420 RC 97162 HCPCS inpatient 497 323.05 SIHO - ALL PLANS SIHO - ALL PLANS 447.3 90 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 30 minutes" 48762640_1 CDM 0420 RC 97162 HCPCS inpatient 497 323.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 300.93 60.55 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 30 minutes" 48762640_1 CDM 0420 RC 97162 HCPCS inpatient 497 323.05 UMR - ALL PLANS UMR - ALL PLANS 347.9 70 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 30 minutes" 48762640_1 CDM 0420 RC 97162 HCPCS inpatient 497 323.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 300.93 482.09 "Evaluation for physical therapy, typically 30 minutes" 48762640_1 CDM 0420 RC 97162 HCPCS inpatient 497 323.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 300.93 482.09 "Evaluation for physical therapy, typically 30 minutes" 48762640_1 CDM 0420 RC 97162 HCPCS inpatient 497 323.05 ANTHEM HMO ANTHEM HMO 999999999 300.93 482.09 "Evaluation for physical therapy, typically 30 minutes" 48762640_1 CDM 0420 RC 97162 HCPCS inpatient 497 323.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 300.93 482.09 "Evaluation for physical therapy, typically 30 minutes" 48762640_1 CDM 0420 RC 97162 HCPCS inpatient 497 323.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 335.97 67.6 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 30 minutes" 48762640_1 CDM 0420 RC 97162 HCPCS inpatient 497 323.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 300.93 482.09 "Evaluation for physical therapy, typically 45 minutes" 48762641_1 CDM 0420 RC 97163 HCPCS inpatient 497 323.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 323.05 65 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 45 minutes" 48762641_1 CDM 0420 RC 97163 HCPCS inpatient 497 323.05 AETNA AETNA 392.63 79 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 45 minutes" 48762641_1 CDM 0420 RC 97163 HCPCS inpatient 497 323.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 482.09 97 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 45 minutes" 48762641_1 CDM 0420 RC 97163 HCPCS inpatient 497 323.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 342.93 69 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 45 minutes" 48762641_1 CDM 0420 RC 97163 HCPCS inpatient 497 323.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 387.66 78 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 45 minutes" 48762641_1 CDM 0420 RC 97163 HCPCS inpatient 497 323.05 SIHO - ALL PLANS SIHO - ALL PLANS 447.3 90 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 45 minutes" 48762641_1 CDM 0420 RC 97163 HCPCS inpatient 497 323.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 300.93 60.55 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 45 minutes" 48762641_1 CDM 0420 RC 97163 HCPCS inpatient 497 323.05 UMR - ALL PLANS UMR - ALL PLANS 347.9 70 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 45 minutes" 48762641_1 CDM 0420 RC 97163 HCPCS inpatient 497 323.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 300.93 482.09 "Evaluation for physical therapy, typically 45 minutes" 48762641_1 CDM 0420 RC 97163 HCPCS inpatient 497 323.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 300.93 482.09 "Evaluation for physical therapy, typically 45 minutes" 48762641_1 CDM 0420 RC 97163 HCPCS inpatient 497 323.05 ANTHEM HMO ANTHEM HMO 999999999 300.93 482.09 "Evaluation for physical therapy, typically 45 minutes" 48762641_1 CDM 0420 RC 97163 HCPCS inpatient 497 323.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 300.93 482.09 "Evaluation for physical therapy, typically 45 minutes" 48762641_1 CDM 0420 RC 97163 HCPCS inpatient 497 323.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 335.97 67.6 999999999 300.93 482.09 percent of total billed charges "Evaluation for physical therapy, typically 45 minutes" 48762641_1 CDM 0420 RC 97163 HCPCS inpatient 497 323.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 300.93 482.09 "Re-evaluation for physical therapy, typically 20 minutes" 48762642_1 CDM 0420 RC 97164 HCPCS inpatient 186 120.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 120.9 65 999999999 112.62 180.42 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 48762642_1 CDM 0420 RC 97164 HCPCS inpatient 186 120.9 AETNA AETNA 146.94 79 999999999 112.62 180.42 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 48762642_1 CDM 0420 RC 97164 HCPCS inpatient 186 120.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 180.42 97 999999999 112.62 180.42 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 48762642_1 CDM 0420 RC 97164 HCPCS inpatient 186 120.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 128.34 69 999999999 112.62 180.42 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 48762642_1 CDM 0420 RC 97164 HCPCS inpatient 186 120.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 145.08 78 999999999 112.62 180.42 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 48762642_1 CDM 0420 RC 97164 HCPCS inpatient 186 120.9 SIHO - ALL PLANS SIHO - ALL PLANS 167.4 90 999999999 112.62 180.42 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 48762642_1 CDM 0420 RC 97164 HCPCS inpatient 186 120.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 112.62 60.55 999999999 112.62 180.42 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 48762642_1 CDM 0420 RC 97164 HCPCS inpatient 186 120.9 UMR - ALL PLANS UMR - ALL PLANS 130.2 70 999999999 112.62 180.42 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 48762642_1 CDM 0420 RC 97164 HCPCS inpatient 186 120.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 112.62 180.42 "Re-evaluation for physical therapy, typically 20 minutes" 48762642_1 CDM 0420 RC 97164 HCPCS inpatient 186 120.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 112.62 180.42 "Re-evaluation for physical therapy, typically 20 minutes" 48762642_1 CDM 0420 RC 97164 HCPCS inpatient 186 120.9 ANTHEM HMO ANTHEM HMO 999999999 112.62 180.42 "Re-evaluation for physical therapy, typically 20 minutes" 48762642_1 CDM 0420 RC 97164 HCPCS inpatient 186 120.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 112.62 180.42 "Re-evaluation for physical therapy, typically 20 minutes" 48762642_1 CDM 0420 RC 97164 HCPCS inpatient 186 120.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 125.74 67.6 999999999 112.62 180.42 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 48762642_1 CDM 0420 RC 97164 HCPCS inpatient 186 120.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 112.62 180.42 "Evaluation for physical therapy, typically 20 minutes" 48762834_1 CDM 0420 RC 97161 HCPCS inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762834_1 CDM 0420 RC 97161 HCPCS inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762834_1 CDM 0420 RC 97161 HCPCS inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762834_1 CDM 0420 RC 97161 HCPCS inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762834_1 CDM 0420 RC 97161 HCPCS inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762834_1 CDM 0420 RC 97161 HCPCS inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762834_1 CDM 0420 RC 97161 HCPCS inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762834_1 CDM 0420 RC 97161 HCPCS inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762834_1 CDM 0420 RC 97161 HCPCS inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 "Evaluation for physical therapy, typically 20 minutes" 48762834_1 CDM 0420 RC 97161 HCPCS inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 "Evaluation for physical therapy, typically 20 minutes" 48762834_1 CDM 0420 RC 97161 HCPCS inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 "Evaluation for physical therapy, typically 20 minutes" 48762834_1 CDM 0420 RC 97161 HCPCS inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 "Evaluation for physical therapy, typically 20 minutes" 48762834_1 CDM 0420 RC 97161 HCPCS inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762834_1 CDM 0420 RC 97161 HCPCS inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 "Evaluation for physical therapy, typically 30 minutes" 48762836_1 CDM 0420 RC 97162 HCPCS inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 30 minutes" 48762836_1 CDM 0420 RC 97162 HCPCS inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 30 minutes" 48762836_1 CDM 0420 RC 97162 HCPCS inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 30 minutes" 48762836_1 CDM 0420 RC 97162 HCPCS inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 30 minutes" 48762836_1 CDM 0420 RC 97162 HCPCS inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 30 minutes" 48762836_1 CDM 0420 RC 97162 HCPCS inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 30 minutes" 48762836_1 CDM 0420 RC 97162 HCPCS inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 30 minutes" 48762836_1 CDM 0420 RC 97162 HCPCS inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 30 minutes" 48762836_1 CDM 0420 RC 97162 HCPCS inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 "Evaluation for physical therapy, typically 30 minutes" 48762836_1 CDM 0420 RC 97162 HCPCS inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 "Evaluation for physical therapy, typically 30 minutes" 48762836_1 CDM 0420 RC 97162 HCPCS inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 "Evaluation for physical therapy, typically 30 minutes" 48762836_1 CDM 0420 RC 97162 HCPCS inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 "Evaluation for physical therapy, typically 30 minutes" 48762836_1 CDM 0420 RC 97162 HCPCS inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 30 minutes" 48762836_1 CDM 0420 RC 97162 HCPCS inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 "Evaluation for physical therapy, typically 45 minutes" 48762838_1 CDM 0420 RC 97163 HCPCS inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 45 minutes" 48762838_1 CDM 0420 RC 97163 HCPCS inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 45 minutes" 48762838_1 CDM 0420 RC 97163 HCPCS inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 45 minutes" 48762838_1 CDM 0420 RC 97163 HCPCS inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 45 minutes" 48762838_1 CDM 0420 RC 97163 HCPCS inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 45 minutes" 48762838_1 CDM 0420 RC 97163 HCPCS inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 45 minutes" 48762838_1 CDM 0420 RC 97163 HCPCS inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 45 minutes" 48762838_1 CDM 0420 RC 97163 HCPCS inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 45 minutes" 48762838_1 CDM 0420 RC 97163 HCPCS inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 "Evaluation for physical therapy, typically 45 minutes" 48762838_1 CDM 0420 RC 97163 HCPCS inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 "Evaluation for physical therapy, typically 45 minutes" 48762838_1 CDM 0420 RC 97163 HCPCS inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 "Evaluation for physical therapy, typically 45 minutes" 48762838_1 CDM 0420 RC 97163 HCPCS inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 "Evaluation for physical therapy, typically 45 minutes" 48762838_1 CDM 0420 RC 97163 HCPCS inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges "Evaluation for physical therapy, typically 45 minutes" 48762838_1 CDM 0420 RC 97163 HCPCS inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 "Evaluation for physical therapy, typically 20 minutes" 48762841_1 CDM 0420 RC 97161 HCPCS inpatient 199 129.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 129.35 65 999999999 120.49 193.03 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762841_1 CDM 0420 RC 97161 HCPCS inpatient 199 129.35 AETNA AETNA 157.21 79 999999999 120.49 193.03 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762841_1 CDM 0420 RC 97161 HCPCS inpatient 199 129.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 193.03 97 999999999 120.49 193.03 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762841_1 CDM 0420 RC 97161 HCPCS inpatient 199 129.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 137.31 69 999999999 120.49 193.03 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762841_1 CDM 0420 RC 97161 HCPCS inpatient 199 129.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 155.22 78 999999999 120.49 193.03 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762841_1 CDM 0420 RC 97161 HCPCS inpatient 199 129.35 SIHO - ALL PLANS SIHO - ALL PLANS 179.1 90 999999999 120.49 193.03 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762841_1 CDM 0420 RC 97161 HCPCS inpatient 199 129.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 120.49 60.55 999999999 120.49 193.03 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762841_1 CDM 0420 RC 97161 HCPCS inpatient 199 129.35 UMR - ALL PLANS UMR - ALL PLANS 139.3 70 999999999 120.49 193.03 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762841_1 CDM 0420 RC 97161 HCPCS inpatient 199 129.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 120.49 193.03 "Evaluation for physical therapy, typically 20 minutes" 48762841_1 CDM 0420 RC 97161 HCPCS inpatient 199 129.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 120.49 193.03 "Evaluation for physical therapy, typically 20 minutes" 48762841_1 CDM 0420 RC 97161 HCPCS inpatient 199 129.35 ANTHEM HMO ANTHEM HMO 999999999 120.49 193.03 "Evaluation for physical therapy, typically 20 minutes" 48762841_1 CDM 0420 RC 97161 HCPCS inpatient 199 129.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 120.49 193.03 "Evaluation for physical therapy, typically 20 minutes" 48762841_1 CDM 0420 RC 97161 HCPCS inpatient 199 129.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 134.52 67.6 999999999 120.49 193.03 percent of total billed charges "Evaluation for physical therapy, typically 20 minutes" 48762841_1 CDM 0420 RC 97161 HCPCS inpatient 199 129.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 120.49 193.03 "Evaluation for occupational therapy, typically 1 hour" 48763001_1 CDM 0430 RC 97167 HCPCS inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 1 hour" 48763001_1 CDM 0430 RC 97167 HCPCS inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 1 hour" 48763001_1 CDM 0430 RC 97167 HCPCS inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 1 hour" 48763001_1 CDM 0430 RC 97167 HCPCS inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 1 hour" 48763001_1 CDM 0430 RC 97167 HCPCS inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 1 hour" 48763001_1 CDM 0430 RC 97167 HCPCS inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 1 hour" 48763001_1 CDM 0430 RC 97167 HCPCS inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 1 hour" 48763001_1 CDM 0430 RC 97167 HCPCS inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 1 hour" 48763001_1 CDM 0430 RC 97167 HCPCS inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 "Evaluation for occupational therapy, typically 1 hour" 48763001_1 CDM 0430 RC 97167 HCPCS inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 "Evaluation for occupational therapy, typically 1 hour" 48763001_1 CDM 0430 RC 97167 HCPCS inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 "Evaluation for occupational therapy, typically 1 hour" 48763001_1 CDM 0430 RC 97167 HCPCS inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 "Evaluation for occupational therapy, typically 1 hour" 48763001_1 CDM 0430 RC 97167 HCPCS inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 1 hour" 48763001_1 CDM 0430 RC 97167 HCPCS inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 "Re-evaluation for occupational therapy, typically 30 minutes" 48763197_1 CDM 0430 RC 97168 HCPCS inpatient 199 129.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 129.35 65 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for occupational therapy, typically 30 minutes" 48763197_1 CDM 0430 RC 97168 HCPCS inpatient 199 129.35 AETNA AETNA 157.21 79 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for occupational therapy, typically 30 minutes" 48763197_1 CDM 0430 RC 97168 HCPCS inpatient 199 129.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 193.03 97 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for occupational therapy, typically 30 minutes" 48763197_1 CDM 0430 RC 97168 HCPCS inpatient 199 129.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 137.31 69 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for occupational therapy, typically 30 minutes" 48763197_1 CDM 0430 RC 97168 HCPCS inpatient 199 129.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 155.22 78 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for occupational therapy, typically 30 minutes" 48763197_1 CDM 0430 RC 97168 HCPCS inpatient 199 129.35 SIHO - ALL PLANS SIHO - ALL PLANS 179.1 90 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for occupational therapy, typically 30 minutes" 48763197_1 CDM 0430 RC 97168 HCPCS inpatient 199 129.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 120.49 60.55 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for occupational therapy, typically 30 minutes" 48763197_1 CDM 0430 RC 97168 HCPCS inpatient 199 129.35 UMR - ALL PLANS UMR - ALL PLANS 139.3 70 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for occupational therapy, typically 30 minutes" 48763197_1 CDM 0430 RC 97168 HCPCS inpatient 199 129.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 120.49 193.03 "Re-evaluation for occupational therapy, typically 30 minutes" 48763197_1 CDM 0430 RC 97168 HCPCS inpatient 199 129.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 120.49 193.03 "Re-evaluation for occupational therapy, typically 30 minutes" 48763197_1 CDM 0430 RC 97168 HCPCS inpatient 199 129.35 ANTHEM HMO ANTHEM HMO 999999999 120.49 193.03 "Re-evaluation for occupational therapy, typically 30 minutes" 48763197_1 CDM 0430 RC 97168 HCPCS inpatient 199 129.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 120.49 193.03 "Re-evaluation for occupational therapy, typically 30 minutes" 48763197_1 CDM 0430 RC 97168 HCPCS inpatient 199 129.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 134.52 67.6 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for occupational therapy, typically 30 minutes" 48763197_1 CDM 0430 RC 97168 HCPCS inpatient 199 129.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 120.49 193.03 "Re-evaluation for occupational therapy, typically 30 minutes" 48763478_1 CDM 0430 RC 97168 HCPCS inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges "Re-evaluation for occupational therapy, typically 30 minutes" 48763478_1 CDM 0430 RC 97168 HCPCS inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges "Re-evaluation for occupational therapy, typically 30 minutes" 48763478_1 CDM 0430 RC 97168 HCPCS inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges "Re-evaluation for occupational therapy, typically 30 minutes" 48763478_1 CDM 0430 RC 97168 HCPCS inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges "Re-evaluation for occupational therapy, typically 30 minutes" 48763478_1 CDM 0430 RC 97168 HCPCS inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges "Re-evaluation for occupational therapy, typically 30 minutes" 48763478_1 CDM 0430 RC 97168 HCPCS inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges "Re-evaluation for occupational therapy, typically 30 minutes" 48763478_1 CDM 0430 RC 97168 HCPCS inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges "Re-evaluation for occupational therapy, typically 30 minutes" 48763478_1 CDM 0430 RC 97168 HCPCS inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges "Re-evaluation for occupational therapy, typically 30 minutes" 48763478_1 CDM 0430 RC 97168 HCPCS inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 "Re-evaluation for occupational therapy, typically 30 minutes" 48763478_1 CDM 0430 RC 97168 HCPCS inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 "Re-evaluation for occupational therapy, typically 30 minutes" 48763478_1 CDM 0430 RC 97168 HCPCS inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 "Re-evaluation for occupational therapy, typically 30 minutes" 48763478_1 CDM 0430 RC 97168 HCPCS inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 "Re-evaluation for occupational therapy, typically 30 minutes" 48763478_1 CDM 0430 RC 97168 HCPCS inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges "Re-evaluation for occupational therapy, typically 30 minutes" 48763478_1 CDM 0430 RC 97168 HCPCS inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 "Injection into skin growth, 1-7 growths" 48763765_1 CDM 0510 RC 11900 HCPCS inpatient 258 167.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.7 65 999999999 156.22 250.26 percent of total billed charges "Injection into skin growth, 1-7 growths" 48763765_1 CDM 0510 RC 11900 HCPCS inpatient 258 167.7 AETNA AETNA 203.82 79 999999999 156.22 250.26 percent of total billed charges "Injection into skin growth, 1-7 growths" 48763765_1 CDM 0510 RC 11900 HCPCS inpatient 258 167.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 250.26 97 999999999 156.22 250.26 percent of total billed charges "Injection into skin growth, 1-7 growths" 48763765_1 CDM 0510 RC 11900 HCPCS inpatient 258 167.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 178.02 69 999999999 156.22 250.26 percent of total billed charges "Injection into skin growth, 1-7 growths" 48763765_1 CDM 0510 RC 11900 HCPCS inpatient 258 167.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 201.24 78 999999999 156.22 250.26 percent of total billed charges "Injection into skin growth, 1-7 growths" 48763765_1 CDM 0510 RC 11900 HCPCS inpatient 258 167.7 SIHO - ALL PLANS SIHO - ALL PLANS 232.2 90 999999999 156.22 250.26 percent of total billed charges "Injection into skin growth, 1-7 growths" 48763765_1 CDM 0510 RC 11900 HCPCS inpatient 258 167.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 156.22 60.55 999999999 156.22 250.26 percent of total billed charges "Injection into skin growth, 1-7 growths" 48763765_1 CDM 0510 RC 11900 HCPCS inpatient 258 167.7 UMR - ALL PLANS UMR - ALL PLANS 180.6 70 999999999 156.22 250.26 percent of total billed charges "Injection into skin growth, 1-7 growths" 48763765_1 CDM 0510 RC 11900 HCPCS inpatient 258 167.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 156.22 250.26 "Injection into skin growth, 1-7 growths" 48763765_1 CDM 0510 RC 11900 HCPCS inpatient 258 167.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 156.22 250.26 "Injection into skin growth, 1-7 growths" 48763765_1 CDM 0510 RC 11900 HCPCS inpatient 258 167.7 ANTHEM HMO ANTHEM HMO 999999999 156.22 250.26 "Injection into skin growth, 1-7 growths" 48763765_1 CDM 0510 RC 11900 HCPCS inpatient 258 167.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 156.22 250.26 "Injection into skin growth, 1-7 growths" 48763765_1 CDM 0510 RC 11900 HCPCS inpatient 258 167.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 174.41 67.6 999999999 156.22 250.26 percent of total billed charges "Injection into skin growth, 1-7 growths" 48763765_1 CDM 0510 RC 11900 HCPCS inpatient 258 167.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 156.22 250.26 Injection into tendon at attachment to bone or muscle 48763766_1 CDM 0510 RC 20551 HCPCS inpatient 981 637.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 637.65 65 999999999 594 951.57 percent of total billed charges Injection into tendon at attachment to bone or muscle 48763766_1 CDM 0510 RC 20551 HCPCS inpatient 981 637.65 AETNA AETNA 774.99 79 999999999 594 951.57 percent of total billed charges Injection into tendon at attachment to bone or muscle 48763766_1 CDM 0510 RC 20551 HCPCS inpatient 981 637.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 951.57 97 999999999 594 951.57 percent of total billed charges Injection into tendon at attachment to bone or muscle 48763766_1 CDM 0510 RC 20551 HCPCS inpatient 981 637.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 676.89 69 999999999 594 951.57 percent of total billed charges Injection into tendon at attachment to bone or muscle 48763766_1 CDM 0510 RC 20551 HCPCS inpatient 981 637.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.18 78 999999999 594 951.57 percent of total billed charges Injection into tendon at attachment to bone or muscle 48763766_1 CDM 0510 RC 20551 HCPCS inpatient 981 637.65 SIHO - ALL PLANS SIHO - ALL PLANS 882.9 90 999999999 594 951.57 percent of total billed charges Injection into tendon at attachment to bone or muscle 48763766_1 CDM 0510 RC 20551 HCPCS inpatient 981 637.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594 60.55 999999999 594 951.57 percent of total billed charges Injection into tendon at attachment to bone or muscle 48763766_1 CDM 0510 RC 20551 HCPCS inpatient 981 637.65 UMR - ALL PLANS UMR - ALL PLANS 686.7 70 999999999 594 951.57 percent of total billed charges Injection into tendon at attachment to bone or muscle 48763766_1 CDM 0510 RC 20551 HCPCS inpatient 981 637.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594 951.57 Injection into tendon at attachment to bone or muscle 48763766_1 CDM 0510 RC 20551 HCPCS inpatient 981 637.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594 951.57 Injection into tendon at attachment to bone or muscle 48763766_1 CDM 0510 RC 20551 HCPCS inpatient 981 637.65 ANTHEM HMO ANTHEM HMO 999999999 594 951.57 Injection into tendon at attachment to bone or muscle 48763766_1 CDM 0510 RC 20551 HCPCS inpatient 981 637.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594 951.57 Injection into tendon at attachment to bone or muscle 48763766_1 CDM 0510 RC 20551 HCPCS inpatient 981 637.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.16 67.6 999999999 594 951.57 percent of total billed charges Injection into tendon at attachment to bone or muscle 48763766_1 CDM 0510 RC 20551 HCPCS inpatient 981 637.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 594 951.57 "Injection of trigger points, 1-2 muscles" 48763767_1 CDM 0510 RC 20552 HCPCS inpatient 981 637.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 637.65 65 999999999 594 951.57 percent of total billed charges "Injection of trigger points, 1-2 muscles" 48763767_1 CDM 0510 RC 20552 HCPCS inpatient 981 637.65 AETNA AETNA 774.99 79 999999999 594 951.57 percent of total billed charges "Injection of trigger points, 1-2 muscles" 48763767_1 CDM 0510 RC 20552 HCPCS inpatient 981 637.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 951.57 97 999999999 594 951.57 percent of total billed charges "Injection of trigger points, 1-2 muscles" 48763767_1 CDM 0510 RC 20552 HCPCS inpatient 981 637.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 676.89 69 999999999 594 951.57 percent of total billed charges "Injection of trigger points, 1-2 muscles" 48763767_1 CDM 0510 RC 20552 HCPCS inpatient 981 637.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.18 78 999999999 594 951.57 percent of total billed charges "Injection of trigger points, 1-2 muscles" 48763767_1 CDM 0510 RC 20552 HCPCS inpatient 981 637.65 SIHO - ALL PLANS SIHO - ALL PLANS 882.9 90 999999999 594 951.57 percent of total billed charges "Injection of trigger points, 1-2 muscles" 48763767_1 CDM 0510 RC 20552 HCPCS inpatient 981 637.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594 60.55 999999999 594 951.57 percent of total billed charges "Injection of trigger points, 1-2 muscles" 48763767_1 CDM 0510 RC 20552 HCPCS inpatient 981 637.65 UMR - ALL PLANS UMR - ALL PLANS 686.7 70 999999999 594 951.57 percent of total billed charges "Injection of trigger points, 1-2 muscles" 48763767_1 CDM 0510 RC 20552 HCPCS inpatient 981 637.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594 951.57 "Injection of trigger points, 1-2 muscles" 48763767_1 CDM 0510 RC 20552 HCPCS inpatient 981 637.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594 951.57 "Injection of trigger points, 1-2 muscles" 48763767_1 CDM 0510 RC 20552 HCPCS inpatient 981 637.65 ANTHEM HMO ANTHEM HMO 999999999 594 951.57 "Injection of trigger points, 1-2 muscles" 48763767_1 CDM 0510 RC 20552 HCPCS inpatient 981 637.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594 951.57 "Injection of trigger points, 1-2 muscles" 48763767_1 CDM 0510 RC 20552 HCPCS inpatient 981 637.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.16 67.6 999999999 594 951.57 percent of total billed charges "Injection of trigger points, 1-2 muscles" 48763767_1 CDM 0510 RC 20552 HCPCS inpatient 981 637.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 594 951.57 "Injection of trigger points, 3 or more muscles" 48763768_1 CDM 0510 RC 20553 HCPCS inpatient 981 637.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 637.65 65 999999999 594 951.57 percent of total billed charges "Injection of trigger points, 3 or more muscles" 48763768_1 CDM 0510 RC 20553 HCPCS inpatient 981 637.65 AETNA AETNA 774.99 79 999999999 594 951.57 percent of total billed charges "Injection of trigger points, 3 or more muscles" 48763768_1 CDM 0510 RC 20553 HCPCS inpatient 981 637.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 951.57 97 999999999 594 951.57 percent of total billed charges "Injection of trigger points, 3 or more muscles" 48763768_1 CDM 0510 RC 20553 HCPCS inpatient 981 637.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 676.89 69 999999999 594 951.57 percent of total billed charges "Injection of trigger points, 3 or more muscles" 48763768_1 CDM 0510 RC 20553 HCPCS inpatient 981 637.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.18 78 999999999 594 951.57 percent of total billed charges "Injection of trigger points, 3 or more muscles" 48763768_1 CDM 0510 RC 20553 HCPCS inpatient 981 637.65 SIHO - ALL PLANS SIHO - ALL PLANS 882.9 90 999999999 594 951.57 percent of total billed charges "Injection of trigger points, 3 or more muscles" 48763768_1 CDM 0510 RC 20553 HCPCS inpatient 981 637.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594 60.55 999999999 594 951.57 percent of total billed charges "Injection of trigger points, 3 or more muscles" 48763768_1 CDM 0510 RC 20553 HCPCS inpatient 981 637.65 UMR - ALL PLANS UMR - ALL PLANS 686.7 70 999999999 594 951.57 percent of total billed charges "Injection of trigger points, 3 or more muscles" 48763768_1 CDM 0510 RC 20553 HCPCS inpatient 981 637.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594 951.57 "Injection of trigger points, 3 or more muscles" 48763768_1 CDM 0510 RC 20553 HCPCS inpatient 981 637.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594 951.57 "Injection of trigger points, 3 or more muscles" 48763768_1 CDM 0510 RC 20553 HCPCS inpatient 981 637.65 ANTHEM HMO ANTHEM HMO 999999999 594 951.57 "Injection of trigger points, 3 or more muscles" 48763768_1 CDM 0510 RC 20553 HCPCS inpatient 981 637.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594 951.57 "Injection of trigger points, 3 or more muscles" 48763768_1 CDM 0510 RC 20553 HCPCS inpatient 981 637.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.16 67.6 999999999 594 951.57 percent of total billed charges "Injection of trigger points, 3 or more muscles" 48763768_1 CDM 0510 RC 20553 HCPCS inpatient 981 637.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 594 951.57 Aspiration and/or injection of fluid from medium joint 48763775_1 CDM 0510 RC 20605 HCPCS inpatient 981 637.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 637.65 65 999999999 594 951.57 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48763775_1 CDM 0510 RC 20605 HCPCS inpatient 981 637.65 AETNA AETNA 774.99 79 999999999 594 951.57 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48763775_1 CDM 0510 RC 20605 HCPCS inpatient 981 637.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 951.57 97 999999999 594 951.57 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48763775_1 CDM 0510 RC 20605 HCPCS inpatient 981 637.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 676.89 69 999999999 594 951.57 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48763775_1 CDM 0510 RC 20605 HCPCS inpatient 981 637.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.18 78 999999999 594 951.57 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48763775_1 CDM 0510 RC 20605 HCPCS inpatient 981 637.65 SIHO - ALL PLANS SIHO - ALL PLANS 882.9 90 999999999 594 951.57 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48763775_1 CDM 0510 RC 20605 HCPCS inpatient 981 637.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594 60.55 999999999 594 951.57 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48763775_1 CDM 0510 RC 20605 HCPCS inpatient 981 637.65 UMR - ALL PLANS UMR - ALL PLANS 686.7 70 999999999 594 951.57 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48763775_1 CDM 0510 RC 20605 HCPCS inpatient 981 637.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594 951.57 Aspiration and/or injection of fluid from medium joint 48763775_1 CDM 0510 RC 20605 HCPCS inpatient 981 637.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594 951.57 Aspiration and/or injection of fluid from medium joint 48763775_1 CDM 0510 RC 20605 HCPCS inpatient 981 637.65 ANTHEM HMO ANTHEM HMO 999999999 594 951.57 Aspiration and/or injection of fluid from medium joint 48763775_1 CDM 0510 RC 20605 HCPCS inpatient 981 637.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594 951.57 Aspiration and/or injection of fluid from medium joint 48763775_1 CDM 0510 RC 20605 HCPCS inpatient 981 637.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.16 67.6 999999999 594 951.57 percent of total billed charges Aspiration and/or injection of fluid from medium joint 48763775_1 CDM 0510 RC 20605 HCPCS inpatient 981 637.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 594 951.57 Injection of substance into lower spine canal 48763778_1 CDM 0510 RC 62322 HCPCS inpatient 2020 1313 SELF PAY DISCOUNT SELF PAY DISCOUNT 1313 65 999999999 1223.11 1959.4 percent of total billed charges Injection of substance into lower spine canal 48763778_1 CDM 0510 RC 62322 HCPCS inpatient 2020 1313 AETNA AETNA 1595.8 79 999999999 1223.11 1959.4 percent of total billed charges Injection of substance into lower spine canal 48763778_1 CDM 0510 RC 62322 HCPCS inpatient 2020 1313 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1959.4 97 999999999 1223.11 1959.4 percent of total billed charges Injection of substance into lower spine canal 48763778_1 CDM 0510 RC 62322 HCPCS inpatient 2020 1313 ENCORE - ALL PLANS ENCORE - ALL PLANS 1393.8 69 999999999 1223.11 1959.4 percent of total billed charges Injection of substance into lower spine canal 48763778_1 CDM 0510 RC 62322 HCPCS inpatient 2020 1313 HUMANA - ALL PLANS HUMANA - ALL PLANS 1575.6 78 999999999 1223.11 1959.4 percent of total billed charges Injection of substance into lower spine canal 48763778_1 CDM 0510 RC 62322 HCPCS inpatient 2020 1313 SIHO - ALL PLANS SIHO - ALL PLANS 1818 90 999999999 1223.11 1959.4 percent of total billed charges Injection of substance into lower spine canal 48763778_1 CDM 0510 RC 62322 HCPCS inpatient 2020 1313 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1223.11 60.55 999999999 1223.11 1959.4 percent of total billed charges Injection of substance into lower spine canal 48763778_1 CDM 0510 RC 62322 HCPCS inpatient 2020 1313 UMR - ALL PLANS UMR - ALL PLANS 1414 70 999999999 1223.11 1959.4 percent of total billed charges Injection of substance into lower spine canal 48763778_1 CDM 0510 RC 62322 HCPCS inpatient 2020 1313 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1223.11 1959.4 Injection of substance into lower spine canal 48763778_1 CDM 0510 RC 62322 HCPCS inpatient 2020 1313 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1223.11 1959.4 Injection of substance into lower spine canal 48763778_1 CDM 0510 RC 62322 HCPCS inpatient 2020 1313 ANTHEM HMO ANTHEM HMO 999999999 1223.11 1959.4 Injection of substance into lower spine canal 48763778_1 CDM 0510 RC 62322 HCPCS inpatient 2020 1313 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1223.11 1959.4 Injection of substance into lower spine canal 48763778_1 CDM 0510 RC 62322 HCPCS inpatient 2020 1313 CIGNA - ALL PLANS CIGNA - ALL PLANS 1365.52 67.6 999999999 1223.11 1959.4 percent of total billed charges Injection of substance into lower spine canal 48763778_1 CDM 0510 RC 62322 HCPCS inpatient 2020 1313 UHC - ALL PLANS UHC - ALL PLANS 999999999 1223.11 1959.4 Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 48763779_1 CDM 0510 RC 64405 HCPCS inpatient 982 638.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 638.3 65 999999999 594.6 952.54 percent of total billed charges Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 48763779_1 CDM 0510 RC 64405 HCPCS inpatient 982 638.3 AETNA AETNA 775.78 79 999999999 594.6 952.54 percent of total billed charges Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 48763779_1 CDM 0510 RC 64405 HCPCS inpatient 982 638.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 952.54 97 999999999 594.6 952.54 percent of total billed charges Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 48763779_1 CDM 0510 RC 64405 HCPCS inpatient 982 638.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 677.58 69 999999999 594.6 952.54 percent of total billed charges Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 48763779_1 CDM 0510 RC 64405 HCPCS inpatient 982 638.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.96 78 999999999 594.6 952.54 percent of total billed charges Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 48763779_1 CDM 0510 RC 64405 HCPCS inpatient 982 638.3 SIHO - ALL PLANS SIHO - ALL PLANS 883.8 90 999999999 594.6 952.54 percent of total billed charges Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 48763779_1 CDM 0510 RC 64405 HCPCS inpatient 982 638.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594.6 60.55 999999999 594.6 952.54 percent of total billed charges Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 48763779_1 CDM 0510 RC 64405 HCPCS inpatient 982 638.3 UMR - ALL PLANS UMR - ALL PLANS 687.4 70 999999999 594.6 952.54 percent of total billed charges Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 48763779_1 CDM 0510 RC 64405 HCPCS inpatient 982 638.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594.6 952.54 Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 48763779_1 CDM 0510 RC 64405 HCPCS inpatient 982 638.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594.6 952.54 Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 48763779_1 CDM 0510 RC 64405 HCPCS inpatient 982 638.3 ANTHEM HMO ANTHEM HMO 999999999 594.6 952.54 Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 48763779_1 CDM 0510 RC 64405 HCPCS inpatient 982 638.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594.6 952.54 Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 48763779_1 CDM 0510 RC 64405 HCPCS inpatient 982 638.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.83 67.6 999999999 594.6 952.54 percent of total billed charges Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 48763779_1 CDM 0510 RC 64405 HCPCS inpatient 982 638.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 594.6 952.54 Injection of anesthetic agent and/or steroid into suprascapular shoulder nerve 48763780_1 CDM 0510 RC 64418 HCPCS inpatient 2291 1489.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1489.15 65 999999999 1387.2 2222.27 percent of total billed charges Injection of anesthetic agent and/or steroid into suprascapular shoulder nerve 48763780_1 CDM 0510 RC 64418 HCPCS inpatient 2291 1489.15 AETNA AETNA 1809.89 79 999999999 1387.2 2222.27 percent of total billed charges Injection of anesthetic agent and/or steroid into suprascapular shoulder nerve 48763780_1 CDM 0510 RC 64418 HCPCS inpatient 2291 1489.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2222.27 97 999999999 1387.2 2222.27 percent of total billed charges Injection of anesthetic agent and/or steroid into suprascapular shoulder nerve 48763780_1 CDM 0510 RC 64418 HCPCS inpatient 2291 1489.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1580.79 69 999999999 1387.2 2222.27 percent of total billed charges Injection of anesthetic agent and/or steroid into suprascapular shoulder nerve 48763780_1 CDM 0510 RC 64418 HCPCS inpatient 2291 1489.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1786.98 78 999999999 1387.2 2222.27 percent of total billed charges Injection of anesthetic agent and/or steroid into suprascapular shoulder nerve 48763780_1 CDM 0510 RC 64418 HCPCS inpatient 2291 1489.15 SIHO - ALL PLANS SIHO - ALL PLANS 2061.9 90 999999999 1387.2 2222.27 percent of total billed charges Injection of anesthetic agent and/or steroid into suprascapular shoulder nerve 48763780_1 CDM 0510 RC 64418 HCPCS inpatient 2291 1489.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1387.2 60.55 999999999 1387.2 2222.27 percent of total billed charges Injection of anesthetic agent and/or steroid into suprascapular shoulder nerve 48763780_1 CDM 0510 RC 64418 HCPCS inpatient 2291 1489.15 UMR - ALL PLANS UMR - ALL PLANS 1603.7 70 999999999 1387.2 2222.27 percent of total billed charges Injection of anesthetic agent and/or steroid into suprascapular shoulder nerve 48763780_1 CDM 0510 RC 64418 HCPCS inpatient 2291 1489.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1387.2 2222.27 Injection of anesthetic agent and/or steroid into suprascapular shoulder nerve 48763780_1 CDM 0510 RC 64418 HCPCS inpatient 2291 1489.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1387.2 2222.27 Injection of anesthetic agent and/or steroid into suprascapular shoulder nerve 48763780_1 CDM 0510 RC 64418 HCPCS inpatient 2291 1489.15 ANTHEM HMO ANTHEM HMO 999999999 1387.2 2222.27 Injection of anesthetic agent and/or steroid into suprascapular shoulder nerve 48763780_1 CDM 0510 RC 64418 HCPCS inpatient 2291 1489.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1387.2 2222.27 Injection of anesthetic agent and/or steroid into suprascapular shoulder nerve 48763780_1 CDM 0510 RC 64418 HCPCS inpatient 2291 1489.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1548.72 67.6 999999999 1387.2 2222.27 percent of total billed charges Injection of anesthetic agent and/or steroid into suprascapular shoulder nerve 48763780_1 CDM 0510 RC 64418 HCPCS inpatient 2291 1489.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1387.2 2222.27 Injection of anesthetic agent and/or steroid into other nerve or branch 48763787_1 CDM 0510 RC 64450 HCPCS inpatient 715 464.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 464.75 65 999999999 432.93 693.55 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48763787_1 CDM 0510 RC 64450 HCPCS inpatient 715 464.75 AETNA AETNA 564.85 79 999999999 432.93 693.55 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48763787_1 CDM 0510 RC 64450 HCPCS inpatient 715 464.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 693.55 97 999999999 432.93 693.55 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48763787_1 CDM 0510 RC 64450 HCPCS inpatient 715 464.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 493.35 69 999999999 432.93 693.55 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48763787_1 CDM 0510 RC 64450 HCPCS inpatient 715 464.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 557.7 78 999999999 432.93 693.55 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48763787_1 CDM 0510 RC 64450 HCPCS inpatient 715 464.75 SIHO - ALL PLANS SIHO - ALL PLANS 643.5 90 999999999 432.93 693.55 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48763787_1 CDM 0510 RC 64450 HCPCS inpatient 715 464.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 432.93 60.55 999999999 432.93 693.55 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48763787_1 CDM 0510 RC 64450 HCPCS inpatient 715 464.75 UMR - ALL PLANS UMR - ALL PLANS 500.5 70 999999999 432.93 693.55 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48763787_1 CDM 0510 RC 64450 HCPCS inpatient 715 464.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 432.93 693.55 Injection of anesthetic agent and/or steroid into other nerve or branch 48763787_1 CDM 0510 RC 64450 HCPCS inpatient 715 464.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 432.93 693.55 Injection of anesthetic agent and/or steroid into other nerve or branch 48763787_1 CDM 0510 RC 64450 HCPCS inpatient 715 464.75 ANTHEM HMO ANTHEM HMO 999999999 432.93 693.55 Injection of anesthetic agent and/or steroid into other nerve or branch 48763787_1 CDM 0510 RC 64450 HCPCS inpatient 715 464.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 432.93 693.55 Injection of anesthetic agent and/or steroid into other nerve or branch 48763787_1 CDM 0510 RC 64450 HCPCS inpatient 715 464.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 483.34 67.6 999999999 432.93 693.55 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 48763787_1 CDM 0510 RC 64450 HCPCS inpatient 715 464.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 432.93 693.55 Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 48763788_1 CDM 0510 RC 95971 HCPCS inpatient 442 287.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 287.3 65 999999999 267.63 428.74 percent of total billed charges Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 48763788_1 CDM 0510 RC 95971 HCPCS inpatient 442 287.3 AETNA AETNA 349.18 79 999999999 267.63 428.74 percent of total billed charges Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 48763788_1 CDM 0510 RC 95971 HCPCS inpatient 442 287.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 428.74 97 999999999 267.63 428.74 percent of total billed charges Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 48763788_1 CDM 0510 RC 95971 HCPCS inpatient 442 287.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 304.98 69 999999999 267.63 428.74 percent of total billed charges Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 48763788_1 CDM 0510 RC 95971 HCPCS inpatient 442 287.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 344.76 78 999999999 267.63 428.74 percent of total billed charges Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 48763788_1 CDM 0510 RC 95971 HCPCS inpatient 442 287.3 SIHO - ALL PLANS SIHO - ALL PLANS 397.8 90 999999999 267.63 428.74 percent of total billed charges Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 48763788_1 CDM 0510 RC 95971 HCPCS inpatient 442 287.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 267.63 60.55 999999999 267.63 428.74 percent of total billed charges Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 48763788_1 CDM 0510 RC 95971 HCPCS inpatient 442 287.3 UMR - ALL PLANS UMR - ALL PLANS 309.4 70 999999999 267.63 428.74 percent of total billed charges Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 48763788_1 CDM 0510 RC 95971 HCPCS inpatient 442 287.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 267.63 428.74 Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 48763788_1 CDM 0510 RC 95971 HCPCS inpatient 442 287.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 267.63 428.74 Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 48763788_1 CDM 0510 RC 95971 HCPCS inpatient 442 287.3 ANTHEM HMO ANTHEM HMO 999999999 267.63 428.74 Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 48763788_1 CDM 0510 RC 95971 HCPCS inpatient 442 287.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 267.63 428.74 Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 48763788_1 CDM 0510 RC 95971 HCPCS inpatient 442 287.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 298.79 67.6 999999999 267.63 428.74 percent of total billed charges Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 48763788_1 CDM 0510 RC 95971 HCPCS inpatient 442 287.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 267.63 428.74 ATORVASTATIN 80 MG TABLET 48764934_1 CDM 0250 RC 68084-0590-25 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 80 MG TABLET 48764934_1 CDM 0250 RC 68084-0590-25 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 80 MG TABLET 48764934_1 CDM 0250 RC 68084-0590-25 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 80 MG TABLET 48764934_1 CDM 0250 RC 68084-0590-25 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 80 MG TABLET 48764934_1 CDM 0250 RC 68084-0590-25 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 80 MG TABLET 48764934_1 CDM 0250 RC 68084-0590-25 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 80 MG TABLET 48764934_1 CDM 0250 RC 68084-0590-25 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 80 MG TABLET 48764934_1 CDM 0250 RC 68084-0590-25 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 80 MG TABLET 48764934_1 CDM 0250 RC 68084-0590-25 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ATORVASTATIN 80 MG TABLET 48764934_1 CDM 0250 RC 68084-0590-25 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ATORVASTATIN 80 MG TABLET 48764934_1 CDM 0250 RC 68084-0590-25 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ATORVASTATIN 80 MG TABLET 48764934_1 CDM 0250 RC 68084-0590-25 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ATORVASTATIN 80 MG TABLET 48764934_1 CDM 0250 RC 68084-0590-25 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 80 MG TABLET 48764934_1 CDM 0250 RC 68084-0590-25 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "Evaluation for occupational therapy, typically 30 minutes" 48767005_1 CDM 0430 RC 97165 HCPCS inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 30 minutes" 48767005_1 CDM 0430 RC 97165 HCPCS inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 30 minutes" 48767005_1 CDM 0430 RC 97165 HCPCS inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 30 minutes" 48767005_1 CDM 0430 RC 97165 HCPCS inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 30 minutes" 48767005_1 CDM 0430 RC 97165 HCPCS inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 30 minutes" 48767005_1 CDM 0430 RC 97165 HCPCS inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 30 minutes" 48767005_1 CDM 0430 RC 97165 HCPCS inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 30 minutes" 48767005_1 CDM 0430 RC 97165 HCPCS inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 30 minutes" 48767005_1 CDM 0430 RC 97165 HCPCS inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 "Evaluation for occupational therapy, typically 30 minutes" 48767005_1 CDM 0430 RC 97165 HCPCS inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 "Evaluation for occupational therapy, typically 30 minutes" 48767005_1 CDM 0430 RC 97165 HCPCS inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 "Evaluation for occupational therapy, typically 30 minutes" 48767005_1 CDM 0430 RC 97165 HCPCS inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 "Evaluation for occupational therapy, typically 30 minutes" 48767005_1 CDM 0430 RC 97165 HCPCS inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 30 minutes" 48767005_1 CDM 0430 RC 97165 HCPCS inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 "Evaluation for occupational therapy, typically 45 minutes" 48767007_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 45 minutes" 48767007_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 45 minutes" 48767007_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 45 minutes" 48767007_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 45 minutes" 48767007_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 45 minutes" 48767007_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 45 minutes" 48767007_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 45 minutes" 48767007_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 45 minutes" 48767007_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 "Evaluation for occupational therapy, typically 45 minutes" 48767007_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 "Evaluation for occupational therapy, typically 45 minutes" 48767007_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 "Evaluation for occupational therapy, typically 45 minutes" 48767007_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 "Evaluation for occupational therapy, typically 45 minutes" 48767007_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges "Evaluation for occupational therapy, typically 45 minutes" 48767007_1 CDM 0430 RC 97166 HCPCS inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 SYNTHROID 112 MCG TABLET 48772041_1 CDM 0250 RC 00074-9296-90 NDC inpatient 1 UN 1.92 1.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.25 65 999999999 1.16 1.86 percent of total billed charges SYNTHROID 112 MCG TABLET 48772041_1 CDM 0250 RC 00074-9296-90 NDC inpatient 1 UN 1.92 1.25 AETNA AETNA 1.52 79 999999999 1.16 1.86 percent of total billed charges SYNTHROID 112 MCG TABLET 48772041_1 CDM 0250 RC 00074-9296-90 NDC inpatient 1 UN 1.92 1.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.86 97 999999999 1.16 1.86 percent of total billed charges SYNTHROID 112 MCG TABLET 48772041_1 CDM 0250 RC 00074-9296-90 NDC inpatient 1 UN 1.92 1.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.32 69 999999999 1.16 1.86 percent of total billed charges SYNTHROID 112 MCG TABLET 48772041_1 CDM 0250 RC 00074-9296-90 NDC inpatient 1 UN 1.92 1.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.5 78 999999999 1.16 1.86 percent of total billed charges SYNTHROID 112 MCG TABLET 48772041_1 CDM 0250 RC 00074-9296-90 NDC inpatient 1 UN 1.92 1.25 SIHO - ALL PLANS SIHO - ALL PLANS 1.73 90 999999999 1.16 1.86 percent of total billed charges SYNTHROID 112 MCG TABLET 48772041_1 CDM 0250 RC 00074-9296-90 NDC inpatient 1 UN 1.92 1.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.16 60.55 999999999 1.16 1.86 percent of total billed charges SYNTHROID 112 MCG TABLET 48772041_1 CDM 0250 RC 00074-9296-90 NDC inpatient 1 UN 1.92 1.25 UMR - ALL PLANS UMR - ALL PLANS 1.34 70 999999999 1.16 1.86 percent of total billed charges SYNTHROID 112 MCG TABLET 48772041_1 CDM 0250 RC 00074-9296-90 NDC inpatient 1 UN 1.92 1.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.16 1.86 SYNTHROID 112 MCG TABLET 48772041_1 CDM 0250 RC 00074-9296-90 NDC inpatient 1 UN 1.92 1.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.16 1.86 SYNTHROID 112 MCG TABLET 48772041_1 CDM 0250 RC 00074-9296-90 NDC inpatient 1 UN 1.92 1.25 ANTHEM HMO ANTHEM HMO 999999999 1.16 1.86 SYNTHROID 112 MCG TABLET 48772041_1 CDM 0250 RC 00074-9296-90 NDC inpatient 1 UN 1.92 1.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.16 1.86 SYNTHROID 112 MCG TABLET 48772041_1 CDM 0250 RC 00074-9296-90 NDC inpatient 1 UN 1.92 1.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.3 67.6 999999999 1.16 1.86 percent of total billed charges SYNTHROID 112 MCG TABLET 48772041_1 CDM 0250 RC 00074-9296-90 NDC inpatient 1 UN 1.92 1.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.16 1.86 NORTRIPTYLINE HCL 25 MG CAP 48778191_1 CDM 0250 RC 51672-4002-01 NDC inpatient 1 UN 1.11 0.72 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.72 65 999999999 0.67 1.08 percent of total billed charges NORTRIPTYLINE HCL 25 MG CAP 48778191_1 CDM 0250 RC 51672-4002-01 NDC inpatient 1 UN 1.11 0.72 AETNA AETNA 0.88 79 999999999 0.67 1.08 percent of total billed charges NORTRIPTYLINE HCL 25 MG CAP 48778191_1 CDM 0250 RC 51672-4002-01 NDC inpatient 1 UN 1.11 0.72 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.08 97 999999999 0.67 1.08 percent of total billed charges NORTRIPTYLINE HCL 25 MG CAP 48778191_1 CDM 0250 RC 51672-4002-01 NDC inpatient 1 UN 1.11 0.72 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.77 69 999999999 0.67 1.08 percent of total billed charges NORTRIPTYLINE HCL 25 MG CAP 48778191_1 CDM 0250 RC 51672-4002-01 NDC inpatient 1 UN 1.11 0.72 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.87 78 999999999 0.67 1.08 percent of total billed charges NORTRIPTYLINE HCL 25 MG CAP 48778191_1 CDM 0250 RC 51672-4002-01 NDC inpatient 1 UN 1.11 0.72 SIHO - ALL PLANS SIHO - ALL PLANS 1 90 999999999 0.67 1.08 percent of total billed charges NORTRIPTYLINE HCL 25 MG CAP 48778191_1 CDM 0250 RC 51672-4002-01 NDC inpatient 1 UN 1.11 0.72 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.67 60.55 999999999 0.67 1.08 percent of total billed charges NORTRIPTYLINE HCL 25 MG CAP 48778191_1 CDM 0250 RC 51672-4002-01 NDC inpatient 1 UN 1.11 0.72 UMR - ALL PLANS UMR - ALL PLANS 0.78 70 999999999 0.67 1.08 percent of total billed charges NORTRIPTYLINE HCL 25 MG CAP 48778191_1 CDM 0250 RC 51672-4002-01 NDC inpatient 1 UN 1.11 0.72 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.67 1.08 NORTRIPTYLINE HCL 25 MG CAP 48778191_1 CDM 0250 RC 51672-4002-01 NDC inpatient 1 UN 1.11 0.72 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.67 1.08 NORTRIPTYLINE HCL 25 MG CAP 48778191_1 CDM 0250 RC 51672-4002-01 NDC inpatient 1 UN 1.11 0.72 ANTHEM HMO ANTHEM HMO 999999999 0.67 1.08 NORTRIPTYLINE HCL 25 MG CAP 48778191_1 CDM 0250 RC 51672-4002-01 NDC inpatient 1 UN 1.11 0.72 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.67 1.08 NORTRIPTYLINE HCL 25 MG CAP 48778191_1 CDM 0250 RC 51672-4002-01 NDC inpatient 1 UN 1.11 0.72 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.75 67.6 999999999 0.67 1.08 percent of total billed charges NORTRIPTYLINE HCL 25 MG CAP 48778191_1 CDM 0250 RC 51672-4002-01 NDC inpatient 1 UN 1.11 0.72 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.67 1.08 PHENYTOIN 100 MG/2 ML VIAL 48803174_1 CDM 0250 RC 00641-6138-25 NDC inpatient 1 UN 13.08 8.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.5 65 999999999 7.92 12.69 percent of total billed charges PHENYTOIN 100 MG/2 ML VIAL 48803174_1 CDM 0250 RC 00641-6138-25 NDC inpatient 1 UN 13.08 8.5 AETNA AETNA 10.33 79 999999999 7.92 12.69 percent of total billed charges PHENYTOIN 100 MG/2 ML VIAL 48803174_1 CDM 0250 RC 00641-6138-25 NDC inpatient 1 UN 13.08 8.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.69 97 999999999 7.92 12.69 percent of total billed charges PHENYTOIN 100 MG/2 ML VIAL 48803174_1 CDM 0250 RC 00641-6138-25 NDC inpatient 1 UN 13.08 8.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.03 69 999999999 7.92 12.69 percent of total billed charges PHENYTOIN 100 MG/2 ML VIAL 48803174_1 CDM 0250 RC 00641-6138-25 NDC inpatient 1 UN 13.08 8.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.2 78 999999999 7.92 12.69 percent of total billed charges PHENYTOIN 100 MG/2 ML VIAL 48803174_1 CDM 0250 RC 00641-6138-25 NDC inpatient 1 UN 13.08 8.5 SIHO - ALL PLANS SIHO - ALL PLANS 11.77 90 999999999 7.92 12.69 percent of total billed charges PHENYTOIN 100 MG/2 ML VIAL 48803174_1 CDM 0250 RC 00641-6138-25 NDC inpatient 1 UN 13.08 8.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.92 60.55 999999999 7.92 12.69 percent of total billed charges PHENYTOIN 100 MG/2 ML VIAL 48803174_1 CDM 0250 RC 00641-6138-25 NDC inpatient 1 UN 13.08 8.5 UMR - ALL PLANS UMR - ALL PLANS 9.16 70 999999999 7.92 12.69 percent of total billed charges PHENYTOIN 100 MG/2 ML VIAL 48803174_1 CDM 0250 RC 00641-6138-25 NDC inpatient 1 UN 13.08 8.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.92 12.69 PHENYTOIN 100 MG/2 ML VIAL 48803174_1 CDM 0250 RC 00641-6138-25 NDC inpatient 1 UN 13.08 8.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.92 12.69 PHENYTOIN 100 MG/2 ML VIAL 48803174_1 CDM 0250 RC 00641-6138-25 NDC inpatient 1 UN 13.08 8.5 ANTHEM HMO ANTHEM HMO 999999999 7.92 12.69 PHENYTOIN 100 MG/2 ML VIAL 48803174_1 CDM 0250 RC 00641-6138-25 NDC inpatient 1 UN 13.08 8.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.92 12.69 PHENYTOIN 100 MG/2 ML VIAL 48803174_1 CDM 0250 RC 00641-6138-25 NDC inpatient 1 UN 13.08 8.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.84 67.6 999999999 7.92 12.69 percent of total billed charges PHENYTOIN 100 MG/2 ML VIAL 48803174_1 CDM 0250 RC 00641-6138-25 NDC inpatient 1 UN 13.08 8.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.92 12.69 PT BIOMECHANICAL CORRCT DEVIC 48803188_1 CDM 0274 RC inpatient 588 382.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 382.2 65 999999999 356.03 570.36 percent of total billed charges PT BIOMECHANICAL CORRCT DEVIC 48803188_1 CDM 0274 RC inpatient 588 382.2 AETNA AETNA 464.52 79 999999999 356.03 570.36 percent of total billed charges PT BIOMECHANICAL CORRCT DEVIC 48803188_1 CDM 0274 RC inpatient 588 382.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 570.36 97 999999999 356.03 570.36 percent of total billed charges PT BIOMECHANICAL CORRCT DEVIC 48803188_1 CDM 0274 RC inpatient 588 382.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 405.72 69 999999999 356.03 570.36 percent of total billed charges PT BIOMECHANICAL CORRCT DEVIC 48803188_1 CDM 0274 RC inpatient 588 382.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 458.64 78 999999999 356.03 570.36 percent of total billed charges PT BIOMECHANICAL CORRCT DEVIC 48803188_1 CDM 0274 RC inpatient 588 382.2 SIHO - ALL PLANS SIHO - ALL PLANS 529.2 90 999999999 356.03 570.36 percent of total billed charges PT BIOMECHANICAL CORRCT DEVIC 48803188_1 CDM 0274 RC inpatient 588 382.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 356.03 60.55 999999999 356.03 570.36 percent of total billed charges PT BIOMECHANICAL CORRCT DEVIC 48803188_1 CDM 0274 RC inpatient 588 382.2 UMR - ALL PLANS UMR - ALL PLANS 411.6 70 999999999 356.03 570.36 percent of total billed charges PT BIOMECHANICAL CORRCT DEVIC 48803188_1 CDM 0274 RC inpatient 588 382.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 356.03 570.36 PT BIOMECHANICAL CORRCT DEVIC 48803188_1 CDM 0274 RC inpatient 588 382.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 356.03 570.36 PT BIOMECHANICAL CORRCT DEVIC 48803188_1 CDM 0274 RC inpatient 588 382.2 ANTHEM HMO ANTHEM HMO 999999999 356.03 570.36 PT BIOMECHANICAL CORRCT DEVIC 48803188_1 CDM 0274 RC inpatient 588 382.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 356.03 570.36 PT BIOMECHANICAL CORRCT DEVIC 48803188_1 CDM 0274 RC inpatient 588 382.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 397.49 67.6 999999999 356.03 570.36 percent of total billed charges PT BIOMECHANICAL CORRCT DEVIC 48803188_1 CDM 0274 RC inpatient 588 382.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 356.03 570.36 REV - PHYSICAL THERAPY 48803189_1 CDM 0420 RC inpatient 122 79.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.3 65 999999999 73.87 118.34 percent of total billed charges REV - PHYSICAL THERAPY 48803189_1 CDM 0420 RC inpatient 122 79.3 AETNA AETNA 96.38 79 999999999 73.87 118.34 percent of total billed charges REV - PHYSICAL THERAPY 48803189_1 CDM 0420 RC inpatient 122 79.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 118.34 97 999999999 73.87 118.34 percent of total billed charges REV - PHYSICAL THERAPY 48803189_1 CDM 0420 RC inpatient 122 79.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.18 69 999999999 73.87 118.34 percent of total billed charges REV - PHYSICAL THERAPY 48803189_1 CDM 0420 RC inpatient 122 79.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.16 78 999999999 73.87 118.34 percent of total billed charges REV - PHYSICAL THERAPY 48803189_1 CDM 0420 RC inpatient 122 79.3 SIHO - ALL PLANS SIHO - ALL PLANS 109.8 90 999999999 73.87 118.34 percent of total billed charges REV - PHYSICAL THERAPY 48803189_1 CDM 0420 RC inpatient 122 79.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.87 60.55 999999999 73.87 118.34 percent of total billed charges REV - PHYSICAL THERAPY 48803189_1 CDM 0420 RC inpatient 122 79.3 UMR - ALL PLANS UMR - ALL PLANS 85.4 70 999999999 73.87 118.34 percent of total billed charges REV - PHYSICAL THERAPY 48803189_1 CDM 0420 RC inpatient 122 79.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.87 118.34 REV - PHYSICAL THERAPY 48803189_1 CDM 0420 RC inpatient 122 79.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.87 118.34 REV - PHYSICAL THERAPY 48803189_1 CDM 0420 RC inpatient 122 79.3 ANTHEM HMO ANTHEM HMO 999999999 73.87 118.34 REV - PHYSICAL THERAPY 48803189_1 CDM 0420 RC inpatient 122 79.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.87 118.34 REV - PHYSICAL THERAPY 48803189_1 CDM 0420 RC inpatient 122 79.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 82.47 67.6 999999999 73.87 118.34 percent of total billed charges REV - PHYSICAL THERAPY 48803189_1 CDM 0420 RC inpatient 122 79.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.87 118.34 REV - PHYSICAL THERAPY 48803190_1 CDM 0420 RC inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges REV - PHYSICAL THERAPY 48803190_1 CDM 0420 RC inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges REV - PHYSICAL THERAPY 48803190_1 CDM 0420 RC inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges REV - PHYSICAL THERAPY 48803190_1 CDM 0420 RC inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges REV - PHYSICAL THERAPY 48803190_1 CDM 0420 RC inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges REV - PHYSICAL THERAPY 48803190_1 CDM 0420 RC inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges REV - PHYSICAL THERAPY 48803190_1 CDM 0420 RC inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges REV - PHYSICAL THERAPY 48803190_1 CDM 0420 RC inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges REV - PHYSICAL THERAPY 48803190_1 CDM 0420 RC inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 REV - PHYSICAL THERAPY 48803190_1 CDM 0420 RC inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 REV - PHYSICAL THERAPY 48803190_1 CDM 0420 RC inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 REV - PHYSICAL THERAPY 48803190_1 CDM 0420 RC inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 REV - PHYSICAL THERAPY 48803190_1 CDM 0420 RC inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges REV - PHYSICAL THERAPY 48803190_1 CDM 0420 RC inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 REV - PHYSICAL THERAPY 48803191_1 CDM 0420 RC inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges REV - PHYSICAL THERAPY 48803191_1 CDM 0420 RC inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges REV - PHYSICAL THERAPY 48803191_1 CDM 0420 RC inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges REV - PHYSICAL THERAPY 48803191_1 CDM 0420 RC inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges REV - PHYSICAL THERAPY 48803191_1 CDM 0420 RC inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges REV - PHYSICAL THERAPY 48803191_1 CDM 0420 RC inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges REV - PHYSICAL THERAPY 48803191_1 CDM 0420 RC inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges REV - PHYSICAL THERAPY 48803191_1 CDM 0420 RC inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges REV - PHYSICAL THERAPY 48803191_1 CDM 0420 RC inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 REV - PHYSICAL THERAPY 48803191_1 CDM 0420 RC inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 REV - PHYSICAL THERAPY 48803191_1 CDM 0420 RC inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 REV - PHYSICAL THERAPY 48803191_1 CDM 0420 RC inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 REV - PHYSICAL THERAPY 48803191_1 CDM 0420 RC inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges REV - PHYSICAL THERAPY 48803191_1 CDM 0420 RC inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 PT UNIVERS NEOPREN WRIST SPLN 48803192_1 CDM 0274 RC inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges PT UNIVERS NEOPREN WRIST SPLN 48803192_1 CDM 0274 RC inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges PT UNIVERS NEOPREN WRIST SPLN 48803192_1 CDM 0274 RC inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges PT UNIVERS NEOPREN WRIST SPLN 48803192_1 CDM 0274 RC inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges PT UNIVERS NEOPREN WRIST SPLN 48803192_1 CDM 0274 RC inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges PT UNIVERS NEOPREN WRIST SPLN 48803192_1 CDM 0274 RC inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges PT UNIVERS NEOPREN WRIST SPLN 48803192_1 CDM 0274 RC inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges PT UNIVERS NEOPREN WRIST SPLN 48803192_1 CDM 0274 RC inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges PT UNIVERS NEOPREN WRIST SPLN 48803192_1 CDM 0274 RC inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 PT UNIVERS NEOPREN WRIST SPLN 48803192_1 CDM 0274 RC inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 PT UNIVERS NEOPREN WRIST SPLN 48803192_1 CDM 0274 RC inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 PT UNIVERS NEOPREN WRIST SPLN 48803192_1 CDM 0274 RC inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 PT UNIVERS NEOPREN WRIST SPLN 48803192_1 CDM 0274 RC inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges PT UNIVERS NEOPREN WRIST SPLN 48803192_1 CDM 0274 RC inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 PT UNIVERS THUMB/WRIST SUPPRT 48803193_1 CDM 0274 RC inpatient 104 67.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 67.6 65 999999999 62.97 100.88 percent of total billed charges PT UNIVERS THUMB/WRIST SUPPRT 48803193_1 CDM 0274 RC inpatient 104 67.6 AETNA AETNA 82.16 79 999999999 62.97 100.88 percent of total billed charges PT UNIVERS THUMB/WRIST SUPPRT 48803193_1 CDM 0274 RC inpatient 104 67.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 100.88 97 999999999 62.97 100.88 percent of total billed charges PT UNIVERS THUMB/WRIST SUPPRT 48803193_1 CDM 0274 RC inpatient 104 67.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.76 69 999999999 62.97 100.88 percent of total billed charges PT UNIVERS THUMB/WRIST SUPPRT 48803193_1 CDM 0274 RC inpatient 104 67.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.12 78 999999999 62.97 100.88 percent of total billed charges PT UNIVERS THUMB/WRIST SUPPRT 48803193_1 CDM 0274 RC inpatient 104 67.6 SIHO - ALL PLANS SIHO - ALL PLANS 93.6 90 999999999 62.97 100.88 percent of total billed charges PT UNIVERS THUMB/WRIST SUPPRT 48803193_1 CDM 0274 RC inpatient 104 67.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.97 60.55 999999999 62.97 100.88 percent of total billed charges PT UNIVERS THUMB/WRIST SUPPRT 48803193_1 CDM 0274 RC inpatient 104 67.6 UMR - ALL PLANS UMR - ALL PLANS 72.8 70 999999999 62.97 100.88 percent of total billed charges PT UNIVERS THUMB/WRIST SUPPRT 48803193_1 CDM 0274 RC inpatient 104 67.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.97 100.88 PT UNIVERS THUMB/WRIST SUPPRT 48803193_1 CDM 0274 RC inpatient 104 67.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.97 100.88 PT UNIVERS THUMB/WRIST SUPPRT 48803193_1 CDM 0274 RC inpatient 104 67.6 ANTHEM HMO ANTHEM HMO 999999999 62.97 100.88 PT UNIVERS THUMB/WRIST SUPPRT 48803193_1 CDM 0274 RC inpatient 104 67.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.97 100.88 PT UNIVERS THUMB/WRIST SUPPRT 48803193_1 CDM 0274 RC inpatient 104 67.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.3 67.6 999999999 62.97 100.88 percent of total billed charges PT UNIVERS THUMB/WRIST SUPPRT 48803193_1 CDM 0274 RC inpatient 104 67.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.97 100.88 PT WARM & FORM 48803194_1 CDM 0274 RC inpatient 204 132.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.6 65 999999999 123.52 197.88 percent of total billed charges PT WARM & FORM 48803194_1 CDM 0274 RC inpatient 204 132.6 AETNA AETNA 161.16 79 999999999 123.52 197.88 percent of total billed charges PT WARM & FORM 48803194_1 CDM 0274 RC inpatient 204 132.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.88 97 999999999 123.52 197.88 percent of total billed charges PT WARM & FORM 48803194_1 CDM 0274 RC inpatient 204 132.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.76 69 999999999 123.52 197.88 percent of total billed charges PT WARM & FORM 48803194_1 CDM 0274 RC inpatient 204 132.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.12 78 999999999 123.52 197.88 percent of total billed charges PT WARM & FORM 48803194_1 CDM 0274 RC inpatient 204 132.6 SIHO - ALL PLANS SIHO - ALL PLANS 183.6 90 999999999 123.52 197.88 percent of total billed charges PT WARM & FORM 48803194_1 CDM 0274 RC inpatient 204 132.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.52 60.55 999999999 123.52 197.88 percent of total billed charges PT WARM & FORM 48803194_1 CDM 0274 RC inpatient 204 132.6 UMR - ALL PLANS UMR - ALL PLANS 142.8 70 999999999 123.52 197.88 percent of total billed charges PT WARM & FORM 48803194_1 CDM 0274 RC inpatient 204 132.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.52 197.88 PT WARM & FORM 48803194_1 CDM 0274 RC inpatient 204 132.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.52 197.88 PT WARM & FORM 48803194_1 CDM 0274 RC inpatient 204 132.6 ANTHEM HMO ANTHEM HMO 999999999 123.52 197.88 PT WARM & FORM 48803194_1 CDM 0274 RC inpatient 204 132.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.52 197.88 PT WARM & FORM 48803194_1 CDM 0274 RC inpatient 204 132.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.9 67.6 999999999 123.52 197.88 percent of total billed charges PT WARM & FORM 48803194_1 CDM 0274 RC inpatient 204 132.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.52 197.88 "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 48803195_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 48803195_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 48803195_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 48803195_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 48803195_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 48803195_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 48803195_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 48803195_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 48803195_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 48803195_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 48803195_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 48803195_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 48803195_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 48803195_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 REV - OCCUPATIONAL THERAPY 48803196_1 CDM 0430 RC inpatient 182 118.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.3 65 999999999 110.2 176.54 percent of total billed charges REV - OCCUPATIONAL THERAPY 48803196_1 CDM 0430 RC inpatient 182 118.3 AETNA AETNA 143.78 79 999999999 110.2 176.54 percent of total billed charges REV - OCCUPATIONAL THERAPY 48803196_1 CDM 0430 RC inpatient 182 118.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 176.54 97 999999999 110.2 176.54 percent of total billed charges REV - OCCUPATIONAL THERAPY 48803196_1 CDM 0430 RC inpatient 182 118.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 125.58 69 999999999 110.2 176.54 percent of total billed charges REV - OCCUPATIONAL THERAPY 48803196_1 CDM 0430 RC inpatient 182 118.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.96 78 999999999 110.2 176.54 percent of total billed charges REV - OCCUPATIONAL THERAPY 48803196_1 CDM 0430 RC inpatient 182 118.3 SIHO - ALL PLANS SIHO - ALL PLANS 163.8 90 999999999 110.2 176.54 percent of total billed charges REV - OCCUPATIONAL THERAPY 48803196_1 CDM 0430 RC inpatient 182 118.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.2 60.55 999999999 110.2 176.54 percent of total billed charges REV - OCCUPATIONAL THERAPY 48803196_1 CDM 0430 RC inpatient 182 118.3 UMR - ALL PLANS UMR - ALL PLANS 127.4 70 999999999 110.2 176.54 percent of total billed charges REV - OCCUPATIONAL THERAPY 48803196_1 CDM 0430 RC inpatient 182 118.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.2 176.54 REV - OCCUPATIONAL THERAPY 48803196_1 CDM 0430 RC inpatient 182 118.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.2 176.54 REV - OCCUPATIONAL THERAPY 48803196_1 CDM 0430 RC inpatient 182 118.3 ANTHEM HMO ANTHEM HMO 999999999 110.2 176.54 REV - OCCUPATIONAL THERAPY 48803196_1 CDM 0430 RC inpatient 182 118.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.2 176.54 REV - OCCUPATIONAL THERAPY 48803196_1 CDM 0430 RC inpatient 182 118.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.03 67.6 999999999 110.2 176.54 percent of total billed charges REV - OCCUPATIONAL THERAPY 48803196_1 CDM 0430 RC inpatient 182 118.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.2 176.54 OT DORSAL BLOCKING SPLINT 48803197_1 CDM 0274 RC inpatient 126 81.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.9 65 999999999 76.29 122.22 percent of total billed charges OT DORSAL BLOCKING SPLINT 48803197_1 CDM 0274 RC inpatient 126 81.9 AETNA AETNA 99.54 79 999999999 76.29 122.22 percent of total billed charges OT DORSAL BLOCKING SPLINT 48803197_1 CDM 0274 RC inpatient 126 81.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 122.22 97 999999999 76.29 122.22 percent of total billed charges OT DORSAL BLOCKING SPLINT 48803197_1 CDM 0274 RC inpatient 126 81.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.94 69 999999999 76.29 122.22 percent of total billed charges OT DORSAL BLOCKING SPLINT 48803197_1 CDM 0274 RC inpatient 126 81.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 98.28 78 999999999 76.29 122.22 percent of total billed charges OT DORSAL BLOCKING SPLINT 48803197_1 CDM 0274 RC inpatient 126 81.9 SIHO - ALL PLANS SIHO - ALL PLANS 113.4 90 999999999 76.29 122.22 percent of total billed charges OT DORSAL BLOCKING SPLINT 48803197_1 CDM 0274 RC inpatient 126 81.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.29 60.55 999999999 76.29 122.22 percent of total billed charges OT DORSAL BLOCKING SPLINT 48803197_1 CDM 0274 RC inpatient 126 81.9 UMR - ALL PLANS UMR - ALL PLANS 88.2 70 999999999 76.29 122.22 percent of total billed charges OT DORSAL BLOCKING SPLINT 48803197_1 CDM 0274 RC inpatient 126 81.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.29 122.22 OT DORSAL BLOCKING SPLINT 48803197_1 CDM 0274 RC inpatient 126 81.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.29 122.22 OT DORSAL BLOCKING SPLINT 48803197_1 CDM 0274 RC inpatient 126 81.9 ANTHEM HMO ANTHEM HMO 999999999 76.29 122.22 OT DORSAL BLOCKING SPLINT 48803197_1 CDM 0274 RC inpatient 126 81.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.29 122.22 OT DORSAL BLOCKING SPLINT 48803197_1 CDM 0274 RC inpatient 126 81.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.18 67.6 999999999 76.29 122.22 percent of total billed charges OT DORSAL BLOCKING SPLINT 48803197_1 CDM 0274 RC inpatient 126 81.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.29 122.22 OT DYNAMIC WRIST SPLINT 48803198_1 CDM 0274 RC inpatient 96 62.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.4 65 999999999 58.13 93.12 percent of total billed charges OT DYNAMIC WRIST SPLINT 48803198_1 CDM 0274 RC inpatient 96 62.4 AETNA AETNA 75.84 79 999999999 58.13 93.12 percent of total billed charges OT DYNAMIC WRIST SPLINT 48803198_1 CDM 0274 RC inpatient 96 62.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.12 97 999999999 58.13 93.12 percent of total billed charges OT DYNAMIC WRIST SPLINT 48803198_1 CDM 0274 RC inpatient 96 62.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.24 69 999999999 58.13 93.12 percent of total billed charges OT DYNAMIC WRIST SPLINT 48803198_1 CDM 0274 RC inpatient 96 62.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.88 78 999999999 58.13 93.12 percent of total billed charges OT DYNAMIC WRIST SPLINT 48803198_1 CDM 0274 RC inpatient 96 62.4 SIHO - ALL PLANS SIHO - ALL PLANS 86.4 90 999999999 58.13 93.12 percent of total billed charges OT DYNAMIC WRIST SPLINT 48803198_1 CDM 0274 RC inpatient 96 62.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.13 60.55 999999999 58.13 93.12 percent of total billed charges OT DYNAMIC WRIST SPLINT 48803198_1 CDM 0274 RC inpatient 96 62.4 UMR - ALL PLANS UMR - ALL PLANS 67.2 70 999999999 58.13 93.12 percent of total billed charges OT DYNAMIC WRIST SPLINT 48803198_1 CDM 0274 RC inpatient 96 62.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.13 93.12 OT DYNAMIC WRIST SPLINT 48803198_1 CDM 0274 RC inpatient 96 62.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.13 93.12 OT DYNAMIC WRIST SPLINT 48803198_1 CDM 0274 RC inpatient 96 62.4 ANTHEM HMO ANTHEM HMO 999999999 58.13 93.12 OT DYNAMIC WRIST SPLINT 48803198_1 CDM 0274 RC inpatient 96 62.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.13 93.12 OT DYNAMIC WRIST SPLINT 48803198_1 CDM 0274 RC inpatient 96 62.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.9 67.6 999999999 58.13 93.12 percent of total billed charges OT DYNAMIC WRIST SPLINT 48803198_1 CDM 0274 RC inpatient 96 62.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.13 93.12 OT FINGER GUTTER SPLINT 48803199_1 CDM 0274 RC inpatient 31 20.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.15 65 999999999 18.77 30.07 percent of total billed charges OT FINGER GUTTER SPLINT 48803199_1 CDM 0274 RC inpatient 31 20.15 AETNA AETNA 24.49 79 999999999 18.77 30.07 percent of total billed charges OT FINGER GUTTER SPLINT 48803199_1 CDM 0274 RC inpatient 31 20.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.07 97 999999999 18.77 30.07 percent of total billed charges OT FINGER GUTTER SPLINT 48803199_1 CDM 0274 RC inpatient 31 20.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.39 69 999999999 18.77 30.07 percent of total billed charges OT FINGER GUTTER SPLINT 48803199_1 CDM 0274 RC inpatient 31 20.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.18 78 999999999 18.77 30.07 percent of total billed charges OT FINGER GUTTER SPLINT 48803199_1 CDM 0274 RC inpatient 31 20.15 SIHO - ALL PLANS SIHO - ALL PLANS 27.9 90 999999999 18.77 30.07 percent of total billed charges OT FINGER GUTTER SPLINT 48803199_1 CDM 0274 RC inpatient 31 20.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.77 60.55 999999999 18.77 30.07 percent of total billed charges OT FINGER GUTTER SPLINT 48803199_1 CDM 0274 RC inpatient 31 20.15 UMR - ALL PLANS UMR - ALL PLANS 21.7 70 999999999 18.77 30.07 percent of total billed charges OT FINGER GUTTER SPLINT 48803199_1 CDM 0274 RC inpatient 31 20.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.77 30.07 OT FINGER GUTTER SPLINT 48803199_1 CDM 0274 RC inpatient 31 20.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.77 30.07 OT FINGER GUTTER SPLINT 48803199_1 CDM 0274 RC inpatient 31 20.15 ANTHEM HMO ANTHEM HMO 999999999 18.77 30.07 OT FINGER GUTTER SPLINT 48803199_1 CDM 0274 RC inpatient 31 20.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.77 30.07 OT FINGER GUTTER SPLINT 48803199_1 CDM 0274 RC inpatient 31 20.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.96 67.6 999999999 18.77 30.07 percent of total billed charges OT FINGER GUTTER SPLINT 48803199_1 CDM 0274 RC inpatient 31 20.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.77 30.07 OT RESTING PAN SPLINT 48803200_1 CDM 0274 RC inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges OT RESTING PAN SPLINT 48803200_1 CDM 0274 RC inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges OT RESTING PAN SPLINT 48803200_1 CDM 0274 RC inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges OT RESTING PAN SPLINT 48803200_1 CDM 0274 RC inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges OT RESTING PAN SPLINT 48803200_1 CDM 0274 RC inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges OT RESTING PAN SPLINT 48803200_1 CDM 0274 RC inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges OT RESTING PAN SPLINT 48803200_1 CDM 0274 RC inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges OT RESTING PAN SPLINT 48803200_1 CDM 0274 RC inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges OT RESTING PAN SPLINT 48803200_1 CDM 0274 RC inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 OT RESTING PAN SPLINT 48803200_1 CDM 0274 RC inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 OT RESTING PAN SPLINT 48803200_1 CDM 0274 RC inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 OT RESTING PAN SPLINT 48803200_1 CDM 0274 RC inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 OT RESTING PAN SPLINT 48803200_1 CDM 0274 RC inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges OT RESTING PAN SPLINT 48803200_1 CDM 0274 RC inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 OT THUMB SPICA SPLINT 48803201_1 CDM 0270 RC inpatient 94 61.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.1 65 999999999 56.92 91.18 percent of total billed charges OT THUMB SPICA SPLINT 48803201_1 CDM 0270 RC inpatient 94 61.1 AETNA AETNA 74.26 79 999999999 56.92 91.18 percent of total billed charges OT THUMB SPICA SPLINT 48803201_1 CDM 0270 RC inpatient 94 61.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.18 97 999999999 56.92 91.18 percent of total billed charges OT THUMB SPICA SPLINT 48803201_1 CDM 0270 RC inpatient 94 61.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.86 69 999999999 56.92 91.18 percent of total billed charges OT THUMB SPICA SPLINT 48803201_1 CDM 0270 RC inpatient 94 61.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.32 78 999999999 56.92 91.18 percent of total billed charges OT THUMB SPICA SPLINT 48803201_1 CDM 0270 RC inpatient 94 61.1 SIHO - ALL PLANS SIHO - ALL PLANS 84.6 90 999999999 56.92 91.18 percent of total billed charges OT THUMB SPICA SPLINT 48803201_1 CDM 0270 RC inpatient 94 61.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.92 60.55 999999999 56.92 91.18 percent of total billed charges OT THUMB SPICA SPLINT 48803201_1 CDM 0270 RC inpatient 94 61.1 UMR - ALL PLANS UMR - ALL PLANS 65.8 70 999999999 56.92 91.18 percent of total billed charges OT THUMB SPICA SPLINT 48803201_1 CDM 0270 RC inpatient 94 61.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.92 91.18 OT THUMB SPICA SPLINT 48803201_1 CDM 0270 RC inpatient 94 61.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.92 91.18 OT THUMB SPICA SPLINT 48803201_1 CDM 0270 RC inpatient 94 61.1 ANTHEM HMO ANTHEM HMO 999999999 56.92 91.18 OT THUMB SPICA SPLINT 48803201_1 CDM 0270 RC inpatient 94 61.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.92 91.18 OT THUMB SPICA SPLINT 48803201_1 CDM 0270 RC inpatient 94 61.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.54 67.6 999999999 56.92 91.18 percent of total billed charges OT THUMB SPICA SPLINT 48803201_1 CDM 0270 RC inpatient 94 61.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.92 91.18 OT WRIST COCK UP SPLINT 48803203_1 CDM 0274 RC inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges OT WRIST COCK UP SPLINT 48803203_1 CDM 0274 RC inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges OT WRIST COCK UP SPLINT 48803203_1 CDM 0274 RC inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges OT WRIST COCK UP SPLINT 48803203_1 CDM 0274 RC inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges OT WRIST COCK UP SPLINT 48803203_1 CDM 0274 RC inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges OT WRIST COCK UP SPLINT 48803203_1 CDM 0274 RC inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges OT WRIST COCK UP SPLINT 48803203_1 CDM 0274 RC inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges OT WRIST COCK UP SPLINT 48803203_1 CDM 0274 RC inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges OT WRIST COCK UP SPLINT 48803203_1 CDM 0274 RC inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 OT WRIST COCK UP SPLINT 48803203_1 CDM 0274 RC inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 OT WRIST COCK UP SPLINT 48803203_1 CDM 0274 RC inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 OT WRIST COCK UP SPLINT 48803203_1 CDM 0274 RC inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 OT WRIST COCK UP SPLINT 48803203_1 CDM 0274 RC inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges OT WRIST COCK UP SPLINT 48803203_1 CDM 0274 RC inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 Thawing of fresh frozen plasma unit 48804015_1 CDM 0300 RC 86927 HCPCS inpatient 684 444.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 444.6 65 999999999 414.16 663.48 percent of total billed charges Thawing of fresh frozen plasma unit 48804015_1 CDM 0300 RC 86927 HCPCS inpatient 684 444.6 AETNA AETNA 540.36 79 999999999 414.16 663.48 percent of total billed charges Thawing of fresh frozen plasma unit 48804015_1 CDM 0300 RC 86927 HCPCS inpatient 684 444.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 663.48 97 999999999 414.16 663.48 percent of total billed charges Thawing of fresh frozen plasma unit 48804015_1 CDM 0300 RC 86927 HCPCS inpatient 684 444.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 471.96 69 999999999 414.16 663.48 percent of total billed charges Thawing of fresh frozen plasma unit 48804015_1 CDM 0300 RC 86927 HCPCS inpatient 684 444.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 533.52 78 999999999 414.16 663.48 percent of total billed charges Thawing of fresh frozen plasma unit 48804015_1 CDM 0300 RC 86927 HCPCS inpatient 684 444.6 SIHO - ALL PLANS SIHO - ALL PLANS 615.6 90 999999999 414.16 663.48 percent of total billed charges Thawing of fresh frozen plasma unit 48804015_1 CDM 0300 RC 86927 HCPCS inpatient 684 444.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 414.16 60.55 999999999 414.16 663.48 percent of total billed charges Thawing of fresh frozen plasma unit 48804015_1 CDM 0300 RC 86927 HCPCS inpatient 684 444.6 UMR - ALL PLANS UMR - ALL PLANS 478.8 70 999999999 414.16 663.48 percent of total billed charges Thawing of fresh frozen plasma unit 48804015_1 CDM 0300 RC 86927 HCPCS inpatient 684 444.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 414.16 663.48 Thawing of fresh frozen plasma unit 48804015_1 CDM 0300 RC 86927 HCPCS inpatient 684 444.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 414.16 663.48 Thawing of fresh frozen plasma unit 48804015_1 CDM 0300 RC 86927 HCPCS inpatient 684 444.6 ANTHEM HMO ANTHEM HMO 999999999 414.16 663.48 Thawing of fresh frozen plasma unit 48804015_1 CDM 0300 RC 86927 HCPCS inpatient 684 444.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 414.16 663.48 Thawing of fresh frozen plasma unit 48804015_1 CDM 0300 RC 86927 HCPCS inpatient 684 444.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 462.38 67.6 999999999 414.16 663.48 percent of total billed charges Thawing of fresh frozen plasma unit 48804015_1 CDM 0300 RC 86927 HCPCS inpatient 684 444.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 414.16 663.48 SANTYL OINTMENT 48805417_1 CDM 0250 RC 50484-0010-30 NDC inpatient 1 UN 1034.36 672.33 SELF PAY DISCOUNT SELF PAY DISCOUNT 672.33 65 999999999 626.31 1003.33 percent of total billed charges SANTYL OINTMENT 48805417_1 CDM 0250 RC 50484-0010-30 NDC inpatient 1 UN 1034.36 672.33 AETNA AETNA 817.14 79 999999999 626.31 1003.33 percent of total billed charges SANTYL OINTMENT 48805417_1 CDM 0250 RC 50484-0010-30 NDC inpatient 1 UN 1034.36 672.33 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1003.33 97 999999999 626.31 1003.33 percent of total billed charges SANTYL OINTMENT 48805417_1 CDM 0250 RC 50484-0010-30 NDC inpatient 1 UN 1034.36 672.33 ENCORE - ALL PLANS ENCORE - ALL PLANS 713.71 69 999999999 626.31 1003.33 percent of total billed charges SANTYL OINTMENT 48805417_1 CDM 0250 RC 50484-0010-30 NDC inpatient 1 UN 1034.36 672.33 HUMANA - ALL PLANS HUMANA - ALL PLANS 806.8 78 999999999 626.31 1003.33 percent of total billed charges SANTYL OINTMENT 48805417_1 CDM 0250 RC 50484-0010-30 NDC inpatient 1 UN 1034.36 672.33 SIHO - ALL PLANS SIHO - ALL PLANS 930.92 90 999999999 626.31 1003.33 percent of total billed charges SANTYL OINTMENT 48805417_1 CDM 0250 RC 50484-0010-30 NDC inpatient 1 UN 1034.36 672.33 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 626.31 60.55 999999999 626.31 1003.33 percent of total billed charges SANTYL OINTMENT 48805417_1 CDM 0250 RC 50484-0010-30 NDC inpatient 1 UN 1034.36 672.33 UMR - ALL PLANS UMR - ALL PLANS 724.05 70 999999999 626.31 1003.33 percent of total billed charges SANTYL OINTMENT 48805417_1 CDM 0250 RC 50484-0010-30 NDC inpatient 1 UN 1034.36 672.33 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 626.31 1003.33 SANTYL OINTMENT 48805417_1 CDM 0250 RC 50484-0010-30 NDC inpatient 1 UN 1034.36 672.33 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 626.31 1003.33 SANTYL OINTMENT 48805417_1 CDM 0250 RC 50484-0010-30 NDC inpatient 1 UN 1034.36 672.33 ANTHEM HMO ANTHEM HMO 999999999 626.31 1003.33 SANTYL OINTMENT 48805417_1 CDM 0250 RC 50484-0010-30 NDC inpatient 1 UN 1034.36 672.33 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 626.31 1003.33 SANTYL OINTMENT 48805417_1 CDM 0250 RC 50484-0010-30 NDC inpatient 1 UN 1034.36 672.33 CIGNA - ALL PLANS CIGNA - ALL PLANS 699.23 67.6 999999999 626.31 1003.33 percent of total billed charges SANTYL OINTMENT 48805417_1 CDM 0250 RC 50484-0010-30 NDC inpatient 1 UN 1034.36 672.33 UHC - ALL PLANS UHC - ALL PLANS 999999999 626.31 1003.33 TAMSULOSIN HCL 0.4 MG CAPSULE 48812010_1 CDM 0250 RC 68084-0299-01 NDC inpatient 1 UN 1.89 1.23 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.23 65 999999999 1.14 1.83 percent of total billed charges TAMSULOSIN HCL 0.4 MG CAPSULE 48812010_1 CDM 0250 RC 68084-0299-01 NDC inpatient 1 UN 1.89 1.23 AETNA AETNA 1.49 79 999999999 1.14 1.83 percent of total billed charges TAMSULOSIN HCL 0.4 MG CAPSULE 48812010_1 CDM 0250 RC 68084-0299-01 NDC inpatient 1 UN 1.89 1.23 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.83 97 999999999 1.14 1.83 percent of total billed charges TAMSULOSIN HCL 0.4 MG CAPSULE 48812010_1 CDM 0250 RC 68084-0299-01 NDC inpatient 1 UN 1.89 1.23 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.3 69 999999999 1.14 1.83 percent of total billed charges TAMSULOSIN HCL 0.4 MG CAPSULE 48812010_1 CDM 0250 RC 68084-0299-01 NDC inpatient 1 UN 1.89 1.23 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.47 78 999999999 1.14 1.83 percent of total billed charges TAMSULOSIN HCL 0.4 MG CAPSULE 48812010_1 CDM 0250 RC 68084-0299-01 NDC inpatient 1 UN 1.89 1.23 SIHO - ALL PLANS SIHO - ALL PLANS 1.7 90 999999999 1.14 1.83 percent of total billed charges TAMSULOSIN HCL 0.4 MG CAPSULE 48812010_1 CDM 0250 RC 68084-0299-01 NDC inpatient 1 UN 1.89 1.23 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.14 60.55 999999999 1.14 1.83 percent of total billed charges TAMSULOSIN HCL 0.4 MG CAPSULE 48812010_1 CDM 0250 RC 68084-0299-01 NDC inpatient 1 UN 1.89 1.23 UMR - ALL PLANS UMR - ALL PLANS 1.32 70 999999999 1.14 1.83 percent of total billed charges TAMSULOSIN HCL 0.4 MG CAPSULE 48812010_1 CDM 0250 RC 68084-0299-01 NDC inpatient 1 UN 1.89 1.23 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.14 1.83 TAMSULOSIN HCL 0.4 MG CAPSULE 48812010_1 CDM 0250 RC 68084-0299-01 NDC inpatient 1 UN 1.89 1.23 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.14 1.83 TAMSULOSIN HCL 0.4 MG CAPSULE 48812010_1 CDM 0250 RC 68084-0299-01 NDC inpatient 1 UN 1.89 1.23 ANTHEM HMO ANTHEM HMO 999999999 1.14 1.83 TAMSULOSIN HCL 0.4 MG CAPSULE 48812010_1 CDM 0250 RC 68084-0299-01 NDC inpatient 1 UN 1.89 1.23 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.14 1.83 TAMSULOSIN HCL 0.4 MG CAPSULE 48812010_1 CDM 0250 RC 68084-0299-01 NDC inpatient 1 UN 1.89 1.23 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.28 67.6 999999999 1.14 1.83 percent of total billed charges TAMSULOSIN HCL 0.4 MG CAPSULE 48812010_1 CDM 0250 RC 68084-0299-01 NDC inpatient 1 UN 1.89 1.23 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.14 1.83 Fetal test 48816316_1 CDM 0761 RC 59025 HCPCS inpatient 366 237.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 237.9 65 999999999 221.61 355.02 percent of total billed charges Fetal test 48816316_1 CDM 0761 RC 59025 HCPCS inpatient 366 237.9 AETNA AETNA 289.14 79 999999999 221.61 355.02 percent of total billed charges Fetal test 48816316_1 CDM 0761 RC 59025 HCPCS inpatient 366 237.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 355.02 97 999999999 221.61 355.02 percent of total billed charges Fetal test 48816316_1 CDM 0761 RC 59025 HCPCS inpatient 366 237.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 252.54 69 999999999 221.61 355.02 percent of total billed charges Fetal test 48816316_1 CDM 0761 RC 59025 HCPCS inpatient 366 237.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 285.48 78 999999999 221.61 355.02 percent of total billed charges Fetal test 48816316_1 CDM 0761 RC 59025 HCPCS inpatient 366 237.9 SIHO - ALL PLANS SIHO - ALL PLANS 329.4 90 999999999 221.61 355.02 percent of total billed charges Fetal test 48816316_1 CDM 0761 RC 59025 HCPCS inpatient 366 237.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 221.61 60.55 999999999 221.61 355.02 percent of total billed charges Fetal test 48816316_1 CDM 0761 RC 59025 HCPCS inpatient 366 237.9 UMR - ALL PLANS UMR - ALL PLANS 256.2 70 999999999 221.61 355.02 percent of total billed charges Fetal test 48816316_1 CDM 0761 RC 59025 HCPCS inpatient 366 237.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 221.61 355.02 Fetal test 48816316_1 CDM 0761 RC 59025 HCPCS inpatient 366 237.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 221.61 355.02 Fetal test 48816316_1 CDM 0761 RC 59025 HCPCS inpatient 366 237.9 ANTHEM HMO ANTHEM HMO 999999999 221.61 355.02 Fetal test 48816316_1 CDM 0761 RC 59025 HCPCS inpatient 366 237.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 221.61 355.02 Fetal test 48816316_1 CDM 0761 RC 59025 HCPCS inpatient 366 237.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 247.42 67.6 999999999 221.61 355.02 percent of total billed charges Fetal test 48816316_1 CDM 0761 RC 59025 HCPCS inpatient 366 237.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 221.61 355.02 SPECIALTY SERVICES - TREATMENT ROOM 48816335_1 CDM 0761 RC inpatient 420 273 SELF PAY DISCOUNT SELF PAY DISCOUNT 273 65 999999999 254.31 407.4 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48816335_1 CDM 0761 RC inpatient 420 273 AETNA AETNA 331.8 79 999999999 254.31 407.4 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48816335_1 CDM 0761 RC inpatient 420 273 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 407.4 97 999999999 254.31 407.4 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48816335_1 CDM 0761 RC inpatient 420 273 ENCORE - ALL PLANS ENCORE - ALL PLANS 289.8 69 999999999 254.31 407.4 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48816335_1 CDM 0761 RC inpatient 420 273 HUMANA - ALL PLANS HUMANA - ALL PLANS 327.6 78 999999999 254.31 407.4 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48816335_1 CDM 0761 RC inpatient 420 273 SIHO - ALL PLANS SIHO - ALL PLANS 378 90 999999999 254.31 407.4 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48816335_1 CDM 0761 RC inpatient 420 273 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 254.31 60.55 999999999 254.31 407.4 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48816335_1 CDM 0761 RC inpatient 420 273 UMR - ALL PLANS UMR - ALL PLANS 294 70 999999999 254.31 407.4 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48816335_1 CDM 0761 RC inpatient 420 273 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 254.31 407.4 SPECIALTY SERVICES - TREATMENT ROOM 48816335_1 CDM 0761 RC inpatient 420 273 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 254.31 407.4 SPECIALTY SERVICES - TREATMENT ROOM 48816335_1 CDM 0761 RC inpatient 420 273 ANTHEM HMO ANTHEM HMO 999999999 254.31 407.4 SPECIALTY SERVICES - TREATMENT ROOM 48816335_1 CDM 0761 RC inpatient 420 273 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 254.31 407.4 SPECIALTY SERVICES - TREATMENT ROOM 48816335_1 CDM 0761 RC inpatient 420 273 CIGNA - ALL PLANS CIGNA - ALL PLANS 283.92 67.6 999999999 254.31 407.4 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 48816335_1 CDM 0761 RC inpatient 420 273 UHC - ALL PLANS UHC - ALL PLANS 999999999 254.31 407.4 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48816338_1 CDM 0720 RC inpatient 532 345.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 345.8 65 999999999 322.13 516.04 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48816338_1 CDM 0720 RC inpatient 532 345.8 AETNA AETNA 420.28 79 999999999 322.13 516.04 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48816338_1 CDM 0720 RC inpatient 532 345.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 516.04 97 999999999 322.13 516.04 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48816338_1 CDM 0720 RC inpatient 532 345.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 367.08 69 999999999 322.13 516.04 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48816338_1 CDM 0720 RC inpatient 532 345.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 414.96 78 999999999 322.13 516.04 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48816338_1 CDM 0720 RC inpatient 532 345.8 SIHO - ALL PLANS SIHO - ALL PLANS 478.8 90 999999999 322.13 516.04 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48816338_1 CDM 0720 RC inpatient 532 345.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 322.13 60.55 999999999 322.13 516.04 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48816338_1 CDM 0720 RC inpatient 532 345.8 UMR - ALL PLANS UMR - ALL PLANS 372.4 70 999999999 322.13 516.04 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48816338_1 CDM 0720 RC inpatient 532 345.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 322.13 516.04 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48816338_1 CDM 0720 RC inpatient 532 345.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 322.13 516.04 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48816338_1 CDM 0720 RC inpatient 532 345.8 ANTHEM HMO ANTHEM HMO 999999999 322.13 516.04 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48816338_1 CDM 0720 RC inpatient 532 345.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 322.13 516.04 LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48816338_1 CDM 0720 RC inpatient 532 345.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 359.63 67.6 999999999 322.13 516.04 percent of total billed charges LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION 48816338_1 CDM 0720 RC inpatient 532 345.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 322.13 516.04 "INJECTION, MEROPENEM, 100 MG" 48816602_1 CDM 0250 RC 63323-0508-31 NDC J2185 HCPCS inpatient 10 UN 45.87 29.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 29.82 65 999999999 27.77 44.49 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 48816602_1 CDM 0250 RC 63323-0508-31 NDC J2185 HCPCS inpatient 10 UN 45.87 29.82 AETNA AETNA 36.24 79 999999999 27.77 44.49 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 48816602_1 CDM 0250 RC 63323-0508-31 NDC J2185 HCPCS inpatient 10 UN 45.87 29.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 44.49 97 999999999 27.77 44.49 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 48816602_1 CDM 0250 RC 63323-0508-31 NDC J2185 HCPCS inpatient 10 UN 45.87 29.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 31.65 69 999999999 27.77 44.49 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 48816602_1 CDM 0250 RC 63323-0508-31 NDC J2185 HCPCS inpatient 10 UN 45.87 29.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 35.78 78 999999999 27.77 44.49 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 48816602_1 CDM 0250 RC 63323-0508-31 NDC J2185 HCPCS inpatient 10 UN 45.87 29.82 SIHO - ALL PLANS SIHO - ALL PLANS 41.28 90 999999999 27.77 44.49 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 48816602_1 CDM 0250 RC 63323-0508-31 NDC J2185 HCPCS inpatient 10 UN 45.87 29.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27.77 60.55 999999999 27.77 44.49 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 48816602_1 CDM 0250 RC 63323-0508-31 NDC J2185 HCPCS inpatient 10 UN 45.87 29.82 UMR - ALL PLANS UMR - ALL PLANS 32.11 70 999999999 27.77 44.49 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 48816602_1 CDM 0250 RC 63323-0508-31 NDC J2185 HCPCS inpatient 10 UN 45.87 29.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 27.77 44.49 "INJECTION, MEROPENEM, 100 MG" 48816602_1 CDM 0250 RC 63323-0508-31 NDC J2185 HCPCS inpatient 10 UN 45.87 29.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 27.77 44.49 "INJECTION, MEROPENEM, 100 MG" 48816602_1 CDM 0250 RC 63323-0508-31 NDC J2185 HCPCS inpatient 10 UN 45.87 29.82 ANTHEM HMO ANTHEM HMO 999999999 27.77 44.49 "INJECTION, MEROPENEM, 100 MG" 48816602_1 CDM 0250 RC 63323-0508-31 NDC J2185 HCPCS inpatient 10 UN 45.87 29.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 27.77 44.49 "INJECTION, MEROPENEM, 100 MG" 48816602_1 CDM 0250 RC 63323-0508-31 NDC J2185 HCPCS inpatient 10 UN 45.87 29.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 31.01 67.6 999999999 27.77 44.49 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 48816602_1 CDM 0250 RC 63323-0508-31 NDC J2185 HCPCS inpatient 10 UN 45.87 29.82 UHC - ALL PLANS UHC - ALL PLANS 999999999 27.77 44.49 Creatinine level to test for kidney function or muscle injury 48821659_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 48821659_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 48821659_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 48821659_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 48821659_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 48821659_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 48821659_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 48821659_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 48821659_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 Creatinine level to test for kidney function or muscle injury 48821659_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 Creatinine level to test for kidney function or muscle injury 48821659_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 Creatinine level to test for kidney function or muscle injury 48821659_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 Creatinine level to test for kidney function or muscle injury 48821659_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 48821659_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" 48821799_1 CDM 0306 RC 87640 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" 48821799_1 CDM 0306 RC 87640 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" 48821799_1 CDM 0306 RC 87640 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" 48821799_1 CDM 0306 RC 87640 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" 48821799_1 CDM 0306 RC 87640 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" 48821799_1 CDM 0306 RC 87640 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" 48821799_1 CDM 0306 RC 87640 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" 48821799_1 CDM 0306 RC 87640 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" 48821799_1 CDM 0306 RC 87640 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" 48821799_1 CDM 0306 RC 87640 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" 48821799_1 CDM 0306 RC 87640 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" 48821799_1 CDM 0306 RC 87640 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" 48821799_1 CDM 0306 RC 87640 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for Staphylococcus aureus (bacteria), amplified probe technique" 48821799_1 CDM 0306 RC 87640 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" 48821800_1 CDM 0306 RC 87641 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" 48821800_1 CDM 0306 RC 87641 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" 48821800_1 CDM 0306 RC 87641 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" 48821800_1 CDM 0306 RC 87641 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" 48821800_1 CDM 0306 RC 87641 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" 48821800_1 CDM 0306 RC 87641 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" 48821800_1 CDM 0306 RC 87641 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" 48821800_1 CDM 0306 RC 87641 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" 48821800_1 CDM 0306 RC 87641 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" 48821800_1 CDM 0306 RC 87641 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" 48821800_1 CDM 0306 RC 87641 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" 48821800_1 CDM 0306 RC 87641 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" 48821800_1 CDM 0306 RC 87641 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for Staphylococcus aureus, methicillin resistant (MRSA bacteria), amplified probe technique" 48821800_1 CDM 0306 RC 87641 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 Detection test by immunoassay with direct visual observation for other organism 48821801_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.9 65 999999999 39.96 64.02 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 48821801_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 AETNA AETNA 52.14 79 999999999 39.96 64.02 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 48821801_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.02 97 999999999 39.96 64.02 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 48821801_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.54 69 999999999 39.96 64.02 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 48821801_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.48 78 999999999 39.96 64.02 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 48821801_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 SIHO - ALL PLANS SIHO - ALL PLANS 59.4 90 999999999 39.96 64.02 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 48821801_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.96 60.55 999999999 39.96 64.02 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 48821801_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 UMR - ALL PLANS UMR - ALL PLANS 46.2 70 999999999 39.96 64.02 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 48821801_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.96 64.02 Detection test by immunoassay with direct visual observation for other organism 48821801_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.96 64.02 Detection test by immunoassay with direct visual observation for other organism 48821801_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 ANTHEM HMO ANTHEM HMO 999999999 39.96 64.02 Detection test by immunoassay with direct visual observation for other organism 48821801_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.96 64.02 Detection test by immunoassay with direct visual observation for other organism 48821801_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.62 67.6 999999999 39.96 64.02 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 48821801_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.96 64.02 Detection test by immunoassay with direct visual observation for other organism 48821802_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.9 65 999999999 39.96 64.02 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 48821802_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 AETNA AETNA 52.14 79 999999999 39.96 64.02 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 48821802_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.02 97 999999999 39.96 64.02 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 48821802_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.54 69 999999999 39.96 64.02 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 48821802_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.48 78 999999999 39.96 64.02 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 48821802_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 SIHO - ALL PLANS SIHO - ALL PLANS 59.4 90 999999999 39.96 64.02 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 48821802_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.96 60.55 999999999 39.96 64.02 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 48821802_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 UMR - ALL PLANS UMR - ALL PLANS 46.2 70 999999999 39.96 64.02 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 48821802_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.96 64.02 Detection test by immunoassay with direct visual observation for other organism 48821802_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.96 64.02 Detection test by immunoassay with direct visual observation for other organism 48821802_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 ANTHEM HMO ANTHEM HMO 999999999 39.96 64.02 Detection test by immunoassay with direct visual observation for other organism 48821802_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.96 64.02 Detection test by immunoassay with direct visual observation for other organism 48821802_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.62 67.6 999999999 39.96 64.02 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 48821802_1 CDM 0306 RC 87899 HCPCS inpatient 66 42.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.96 64.02 Other service or procedure on lung 48823247_1 CDM 0460 RC 94799 HCPCS inpatient 161 104.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 104.65 65 999999999 97.49 156.17 percent of total billed charges Other service or procedure on lung 48823247_1 CDM 0460 RC 94799 HCPCS inpatient 161 104.65 AETNA AETNA 127.19 79 999999999 97.49 156.17 percent of total billed charges Other service or procedure on lung 48823247_1 CDM 0460 RC 94799 HCPCS inpatient 161 104.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 156.17 97 999999999 97.49 156.17 percent of total billed charges Other service or procedure on lung 48823247_1 CDM 0460 RC 94799 HCPCS inpatient 161 104.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 111.09 69 999999999 97.49 156.17 percent of total billed charges Other service or procedure on lung 48823247_1 CDM 0460 RC 94799 HCPCS inpatient 161 104.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 125.58 78 999999999 97.49 156.17 percent of total billed charges Other service or procedure on lung 48823247_1 CDM 0460 RC 94799 HCPCS inpatient 161 104.65 SIHO - ALL PLANS SIHO - ALL PLANS 144.9 90 999999999 97.49 156.17 percent of total billed charges Other service or procedure on lung 48823247_1 CDM 0460 RC 94799 HCPCS inpatient 161 104.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 97.49 60.55 999999999 97.49 156.17 percent of total billed charges Other service or procedure on lung 48823247_1 CDM 0460 RC 94799 HCPCS inpatient 161 104.65 UMR - ALL PLANS UMR - ALL PLANS 112.7 70 999999999 97.49 156.17 percent of total billed charges Other service or procedure on lung 48823247_1 CDM 0460 RC 94799 HCPCS inpatient 161 104.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 97.49 156.17 Other service or procedure on lung 48823247_1 CDM 0460 RC 94799 HCPCS inpatient 161 104.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 97.49 156.17 Other service or procedure on lung 48823247_1 CDM 0460 RC 94799 HCPCS inpatient 161 104.65 ANTHEM HMO ANTHEM HMO 999999999 97.49 156.17 Other service or procedure on lung 48823247_1 CDM 0460 RC 94799 HCPCS inpatient 161 104.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 97.49 156.17 Other service or procedure on lung 48823247_1 CDM 0460 RC 94799 HCPCS inpatient 161 104.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.84 67.6 999999999 97.49 156.17 percent of total billed charges Other service or procedure on lung 48823247_1 CDM 0460 RC 94799 HCPCS inpatient 161 104.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 97.49 156.17 DIVALPROEX SOD ER 250 MG TAB 48826917_1 CDM 0250 RC 68084-0310-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges DIVALPROEX SOD ER 250 MG TAB 48826917_1 CDM 0250 RC 68084-0310-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges DIVALPROEX SOD ER 250 MG TAB 48826917_1 CDM 0250 RC 68084-0310-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges DIVALPROEX SOD ER 250 MG TAB 48826917_1 CDM 0250 RC 68084-0310-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges DIVALPROEX SOD ER 250 MG TAB 48826917_1 CDM 0250 RC 68084-0310-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges DIVALPROEX SOD ER 250 MG TAB 48826917_1 CDM 0250 RC 68084-0310-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges DIVALPROEX SOD ER 250 MG TAB 48826917_1 CDM 0250 RC 68084-0310-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges DIVALPROEX SOD ER 250 MG TAB 48826917_1 CDM 0250 RC 68084-0310-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges DIVALPROEX SOD ER 250 MG TAB 48826917_1 CDM 0250 RC 68084-0310-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 DIVALPROEX SOD ER 250 MG TAB 48826917_1 CDM 0250 RC 68084-0310-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 DIVALPROEX SOD ER 250 MG TAB 48826917_1 CDM 0250 RC 68084-0310-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 DIVALPROEX SOD ER 250 MG TAB 48826917_1 CDM 0250 RC 68084-0310-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 DIVALPROEX SOD ER 250 MG TAB 48826917_1 CDM 0250 RC 68084-0310-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges DIVALPROEX SOD ER 250 MG TAB 48826917_1 CDM 0250 RC 68084-0310-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 Buprenorphine level 48826921_1 CDM 0301 RC 80348 HCPCS inpatient 261 169.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 169.65 65 999999999 158.04 253.17 percent of total billed charges Buprenorphine level 48826921_1 CDM 0301 RC 80348 HCPCS inpatient 261 169.65 AETNA AETNA 206.19 79 999999999 158.04 253.17 percent of total billed charges Buprenorphine level 48826921_1 CDM 0301 RC 80348 HCPCS inpatient 261 169.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 253.17 97 999999999 158.04 253.17 percent of total billed charges Buprenorphine level 48826921_1 CDM 0301 RC 80348 HCPCS inpatient 261 169.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.09 69 999999999 158.04 253.17 percent of total billed charges Buprenorphine level 48826921_1 CDM 0301 RC 80348 HCPCS inpatient 261 169.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 203.58 78 999999999 158.04 253.17 percent of total billed charges Buprenorphine level 48826921_1 CDM 0301 RC 80348 HCPCS inpatient 261 169.65 SIHO - ALL PLANS SIHO - ALL PLANS 234.9 90 999999999 158.04 253.17 percent of total billed charges Buprenorphine level 48826921_1 CDM 0301 RC 80348 HCPCS inpatient 261 169.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.04 60.55 999999999 158.04 253.17 percent of total billed charges Buprenorphine level 48826921_1 CDM 0301 RC 80348 HCPCS inpatient 261 169.65 UMR - ALL PLANS UMR - ALL PLANS 182.7 70 999999999 158.04 253.17 percent of total billed charges Buprenorphine level 48826921_1 CDM 0301 RC 80348 HCPCS inpatient 261 169.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.04 253.17 Buprenorphine level 48826921_1 CDM 0301 RC 80348 HCPCS inpatient 261 169.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.04 253.17 Buprenorphine level 48826921_1 CDM 0301 RC 80348 HCPCS inpatient 261 169.65 ANTHEM HMO ANTHEM HMO 999999999 158.04 253.17 Buprenorphine level 48826921_1 CDM 0301 RC 80348 HCPCS inpatient 261 169.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.04 253.17 Buprenorphine level 48826921_1 CDM 0301 RC 80348 HCPCS inpatient 261 169.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 176.44 67.6 999999999 158.04 253.17 percent of total billed charges Buprenorphine level 48826921_1 CDM 0301 RC 80348 HCPCS inpatient 261 169.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.04 253.17 "Processing and storage of blood unit or component, predeposited" 48827448_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 237.25 65 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48827448_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 AETNA AETNA 288.35 79 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48827448_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 354.05 97 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48827448_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 251.85 69 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48827448_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 284.7 78 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48827448_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 SIHO - ALL PLANS SIHO - ALL PLANS 328.5 90 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48827448_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 221.01 60.55 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48827448_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 UMR - ALL PLANS UMR - ALL PLANS 255.5 70 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48827448_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 221.01 354.05 "Processing and storage of blood unit or component, predeposited" 48827448_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 221.01 354.05 "Processing and storage of blood unit or component, predeposited" 48827448_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ANTHEM HMO ANTHEM HMO 999999999 221.01 354.05 "Processing and storage of blood unit or component, predeposited" 48827448_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 221.01 354.05 "Processing and storage of blood unit or component, predeposited" 48827448_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 246.74 67.6 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48827448_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 221.01 354.05 "Processing and storage of blood unit or component, predeposited" 48827449_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 237.25 65 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48827449_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 AETNA AETNA 288.35 79 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48827449_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 354.05 97 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48827449_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 251.85 69 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48827449_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 284.7 78 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48827449_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 SIHO - ALL PLANS SIHO - ALL PLANS 328.5 90 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48827449_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 221.01 60.55 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48827449_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 UMR - ALL PLANS UMR - ALL PLANS 255.5 70 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48827449_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 221.01 354.05 "Processing and storage of blood unit or component, predeposited" 48827449_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 221.01 354.05 "Processing and storage of blood unit or component, predeposited" 48827449_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ANTHEM HMO ANTHEM HMO 999999999 221.01 354.05 "Processing and storage of blood unit or component, predeposited" 48827449_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 221.01 354.05 "Processing and storage of blood unit or component, predeposited" 48827449_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 246.74 67.6 999999999 221.01 354.05 percent of total billed charges "Processing and storage of blood unit or component, predeposited" 48827449_1 CDM 0300 RC 86890 HCPCS inpatient 365 237.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 221.01 354.05 "New patient office or other outpatient visit, 15-29 minutes" 48827844_1 CDM 0510 RC 99202 HCPCS inpatient 350 227.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 227.5 65 999999999 211.93 339.5 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48827844_1 CDM 0510 RC 99202 HCPCS inpatient 350 227.5 AETNA AETNA 276.5 79 999999999 211.93 339.5 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48827844_1 CDM 0510 RC 99202 HCPCS inpatient 350 227.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 339.5 97 999999999 211.93 339.5 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48827844_1 CDM 0510 RC 99202 HCPCS inpatient 350 227.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 241.5 69 999999999 211.93 339.5 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48827844_1 CDM 0510 RC 99202 HCPCS inpatient 350 227.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 273 78 999999999 211.93 339.5 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48827844_1 CDM 0510 RC 99202 HCPCS inpatient 350 227.5 SIHO - ALL PLANS SIHO - ALL PLANS 315 90 999999999 211.93 339.5 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48827844_1 CDM 0510 RC 99202 HCPCS inpatient 350 227.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 211.93 60.55 999999999 211.93 339.5 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48827844_1 CDM 0510 RC 99202 HCPCS inpatient 350 227.5 UMR - ALL PLANS UMR - ALL PLANS 245 70 999999999 211.93 339.5 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48827844_1 CDM 0510 RC 99202 HCPCS inpatient 350 227.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 211.93 339.5 "New patient office or other outpatient visit, 15-29 minutes" 48827844_1 CDM 0510 RC 99202 HCPCS inpatient 350 227.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 211.93 339.5 "New patient office or other outpatient visit, 15-29 minutes" 48827844_1 CDM 0510 RC 99202 HCPCS inpatient 350 227.5 ANTHEM HMO ANTHEM HMO 999999999 211.93 339.5 "New patient office or other outpatient visit, 15-29 minutes" 48827844_1 CDM 0510 RC 99202 HCPCS inpatient 350 227.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 211.93 339.5 "New patient office or other outpatient visit, 15-29 minutes" 48827844_1 CDM 0510 RC 99202 HCPCS inpatient 350 227.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 236.6 67.6 999999999 211.93 339.5 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 48827844_1 CDM 0510 RC 99202 HCPCS inpatient 350 227.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 211.93 339.5 "New patient office or other outpatient visit, 30-44 minutes" 48827845_1 CDM 0510 RC 99203 HCPCS inpatient 458 297.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 297.7 65 999999999 277.32 444.26 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 48827845_1 CDM 0510 RC 99203 HCPCS inpatient 458 297.7 AETNA AETNA 361.82 79 999999999 277.32 444.26 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 48827845_1 CDM 0510 RC 99203 HCPCS inpatient 458 297.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 444.26 97 999999999 277.32 444.26 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 48827845_1 CDM 0510 RC 99203 HCPCS inpatient 458 297.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 316.02 69 999999999 277.32 444.26 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 48827845_1 CDM 0510 RC 99203 HCPCS inpatient 458 297.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 357.24 78 999999999 277.32 444.26 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 48827845_1 CDM 0510 RC 99203 HCPCS inpatient 458 297.7 SIHO - ALL PLANS SIHO - ALL PLANS 412.2 90 999999999 277.32 444.26 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 48827845_1 CDM 0510 RC 99203 HCPCS inpatient 458 297.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 277.32 60.55 999999999 277.32 444.26 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 48827845_1 CDM 0510 RC 99203 HCPCS inpatient 458 297.7 UMR - ALL PLANS UMR - ALL PLANS 320.6 70 999999999 277.32 444.26 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 48827845_1 CDM 0510 RC 99203 HCPCS inpatient 458 297.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 277.32 444.26 "New patient office or other outpatient visit, 30-44 minutes" 48827845_1 CDM 0510 RC 99203 HCPCS inpatient 458 297.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 277.32 444.26 "New patient office or other outpatient visit, 30-44 minutes" 48827845_1 CDM 0510 RC 99203 HCPCS inpatient 458 297.7 ANTHEM HMO ANTHEM HMO 999999999 277.32 444.26 "New patient office or other outpatient visit, 30-44 minutes" 48827845_1 CDM 0510 RC 99203 HCPCS inpatient 458 297.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 277.32 444.26 "New patient office or other outpatient visit, 30-44 minutes" 48827845_1 CDM 0510 RC 99203 HCPCS inpatient 458 297.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 309.61 67.6 999999999 277.32 444.26 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 48827845_1 CDM 0510 RC 99203 HCPCS inpatient 458 297.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 277.32 444.26 "New patient office or other outpatient visit, 45-59 minutes" 48827846_1 CDM 0510 RC 99204 HCPCS inpatient 614 399.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 399.1 65 999999999 371.78 595.58 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 48827846_1 CDM 0510 RC 99204 HCPCS inpatient 614 399.1 AETNA AETNA 485.06 79 999999999 371.78 595.58 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 48827846_1 CDM 0510 RC 99204 HCPCS inpatient 614 399.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 595.58 97 999999999 371.78 595.58 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 48827846_1 CDM 0510 RC 99204 HCPCS inpatient 614 399.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 423.66 69 999999999 371.78 595.58 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 48827846_1 CDM 0510 RC 99204 HCPCS inpatient 614 399.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 478.92 78 999999999 371.78 595.58 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 48827846_1 CDM 0510 RC 99204 HCPCS inpatient 614 399.1 SIHO - ALL PLANS SIHO - ALL PLANS 552.6 90 999999999 371.78 595.58 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 48827846_1 CDM 0510 RC 99204 HCPCS inpatient 614 399.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 371.78 60.55 999999999 371.78 595.58 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 48827846_1 CDM 0510 RC 99204 HCPCS inpatient 614 399.1 UMR - ALL PLANS UMR - ALL PLANS 429.8 70 999999999 371.78 595.58 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 48827846_1 CDM 0510 RC 99204 HCPCS inpatient 614 399.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 371.78 595.58 "New patient office or other outpatient visit, 45-59 minutes" 48827846_1 CDM 0510 RC 99204 HCPCS inpatient 614 399.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 371.78 595.58 "New patient office or other outpatient visit, 45-59 minutes" 48827846_1 CDM 0510 RC 99204 HCPCS inpatient 614 399.1 ANTHEM HMO ANTHEM HMO 999999999 371.78 595.58 "New patient office or other outpatient visit, 45-59 minutes" 48827846_1 CDM 0510 RC 99204 HCPCS inpatient 614 399.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 371.78 595.58 "New patient office or other outpatient visit, 45-59 minutes" 48827846_1 CDM 0510 RC 99204 HCPCS inpatient 614 399.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 415.06 67.6 999999999 371.78 595.58 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 48827846_1 CDM 0510 RC 99204 HCPCS inpatient 614 399.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 371.78 595.58 "New patient office or other outpatient visit, 60-74 minutes" 48827847_1 CDM 0510 RC 99205 HCPCS inpatient 762 495.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 495.3 65 999999999 461.39 739.14 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 48827847_1 CDM 0510 RC 99205 HCPCS inpatient 762 495.3 AETNA AETNA 601.98 79 999999999 461.39 739.14 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 48827847_1 CDM 0510 RC 99205 HCPCS inpatient 762 495.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 739.14 97 999999999 461.39 739.14 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 48827847_1 CDM 0510 RC 99205 HCPCS inpatient 762 495.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 525.78 69 999999999 461.39 739.14 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 48827847_1 CDM 0510 RC 99205 HCPCS inpatient 762 495.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 594.36 78 999999999 461.39 739.14 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 48827847_1 CDM 0510 RC 99205 HCPCS inpatient 762 495.3 SIHO - ALL PLANS SIHO - ALL PLANS 685.8 90 999999999 461.39 739.14 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 48827847_1 CDM 0510 RC 99205 HCPCS inpatient 762 495.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 461.39 60.55 999999999 461.39 739.14 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 48827847_1 CDM 0510 RC 99205 HCPCS inpatient 762 495.3 UMR - ALL PLANS UMR - ALL PLANS 533.4 70 999999999 461.39 739.14 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 48827847_1 CDM 0510 RC 99205 HCPCS inpatient 762 495.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 461.39 739.14 "New patient office or other outpatient visit, 60-74 minutes" 48827847_1 CDM 0510 RC 99205 HCPCS inpatient 762 495.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 461.39 739.14 "New patient office or other outpatient visit, 60-74 minutes" 48827847_1 CDM 0510 RC 99205 HCPCS inpatient 762 495.3 ANTHEM HMO ANTHEM HMO 999999999 461.39 739.14 "New patient office or other outpatient visit, 60-74 minutes" 48827847_1 CDM 0510 RC 99205 HCPCS inpatient 762 495.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 461.39 739.14 "New patient office or other outpatient visit, 60-74 minutes" 48827847_1 CDM 0510 RC 99205 HCPCS inpatient 762 495.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 515.11 67.6 999999999 461.39 739.14 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 48827847_1 CDM 0510 RC 99205 HCPCS inpatient 762 495.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 461.39 739.14 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48827848_1 CDM 0510 RC 99211 HCPCS inpatient 210 136.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 136.5 65 999999999 127.16 203.7 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48827848_1 CDM 0510 RC 99211 HCPCS inpatient 210 136.5 AETNA AETNA 165.9 79 999999999 127.16 203.7 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48827848_1 CDM 0510 RC 99211 HCPCS inpatient 210 136.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 203.7 97 999999999 127.16 203.7 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48827848_1 CDM 0510 RC 99211 HCPCS inpatient 210 136.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 144.9 69 999999999 127.16 203.7 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48827848_1 CDM 0510 RC 99211 HCPCS inpatient 210 136.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 163.8 78 999999999 127.16 203.7 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48827848_1 CDM 0510 RC 99211 HCPCS inpatient 210 136.5 SIHO - ALL PLANS SIHO - ALL PLANS 189 90 999999999 127.16 203.7 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48827848_1 CDM 0510 RC 99211 HCPCS inpatient 210 136.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.16 60.55 999999999 127.16 203.7 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48827848_1 CDM 0510 RC 99211 HCPCS inpatient 210 136.5 UMR - ALL PLANS UMR - ALL PLANS 147 70 999999999 127.16 203.7 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48827848_1 CDM 0510 RC 99211 HCPCS inpatient 210 136.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.16 203.7 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48827848_1 CDM 0510 RC 99211 HCPCS inpatient 210 136.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.16 203.7 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48827848_1 CDM 0510 RC 99211 HCPCS inpatient 210 136.5 ANTHEM HMO ANTHEM HMO 999999999 127.16 203.7 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48827848_1 CDM 0510 RC 99211 HCPCS inpatient 210 136.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.16 203.7 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48827848_1 CDM 0510 RC 99211 HCPCS inpatient 210 136.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 141.96 67.6 999999999 127.16 203.7 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 48827848_1 CDM 0510 RC 99211 HCPCS inpatient 210 136.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.16 203.7 "Established patient office or other outpatient visit, 20-29 minutes" 48827850_1 CDM 0510 RC 99213 HCPCS inpatient 453 294.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 294.45 65 999999999 274.29 439.41 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48827850_1 CDM 0510 RC 99213 HCPCS inpatient 453 294.45 AETNA AETNA 357.87 79 999999999 274.29 439.41 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48827850_1 CDM 0510 RC 99213 HCPCS inpatient 453 294.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 439.41 97 999999999 274.29 439.41 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48827850_1 CDM 0510 RC 99213 HCPCS inpatient 453 294.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 312.57 69 999999999 274.29 439.41 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48827850_1 CDM 0510 RC 99213 HCPCS inpatient 453 294.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 353.34 78 999999999 274.29 439.41 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48827850_1 CDM 0510 RC 99213 HCPCS inpatient 453 294.45 SIHO - ALL PLANS SIHO - ALL PLANS 407.7 90 999999999 274.29 439.41 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48827850_1 CDM 0510 RC 99213 HCPCS inpatient 453 294.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 274.29 60.55 999999999 274.29 439.41 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48827850_1 CDM 0510 RC 99213 HCPCS inpatient 453 294.45 UMR - ALL PLANS UMR - ALL PLANS 317.1 70 999999999 274.29 439.41 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48827850_1 CDM 0510 RC 99213 HCPCS inpatient 453 294.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 274.29 439.41 "Established patient office or other outpatient visit, 20-29 minutes" 48827850_1 CDM 0510 RC 99213 HCPCS inpatient 453 294.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 274.29 439.41 "Established patient office or other outpatient visit, 20-29 minutes" 48827850_1 CDM 0510 RC 99213 HCPCS inpatient 453 294.45 ANTHEM HMO ANTHEM HMO 999999999 274.29 439.41 "Established patient office or other outpatient visit, 20-29 minutes" 48827850_1 CDM 0510 RC 99213 HCPCS inpatient 453 294.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 274.29 439.41 "Established patient office or other outpatient visit, 20-29 minutes" 48827850_1 CDM 0510 RC 99213 HCPCS inpatient 453 294.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 306.23 67.6 999999999 274.29 439.41 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 48827850_1 CDM 0510 RC 99213 HCPCS inpatient 453 294.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 274.29 439.41 "Established patient office or other outpatient visit, 30-39 minutes" 48827851_1 CDM 0510 RC 99214 HCPCS inpatient 507 329.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 329.55 65 999999999 306.99 491.79 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48827851_1 CDM 0510 RC 99214 HCPCS inpatient 507 329.55 AETNA AETNA 400.53 79 999999999 306.99 491.79 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48827851_1 CDM 0510 RC 99214 HCPCS inpatient 507 329.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 491.79 97 999999999 306.99 491.79 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48827851_1 CDM 0510 RC 99214 HCPCS inpatient 507 329.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 349.83 69 999999999 306.99 491.79 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48827851_1 CDM 0510 RC 99214 HCPCS inpatient 507 329.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 395.46 78 999999999 306.99 491.79 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48827851_1 CDM 0510 RC 99214 HCPCS inpatient 507 329.55 SIHO - ALL PLANS SIHO - ALL PLANS 456.3 90 999999999 306.99 491.79 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48827851_1 CDM 0510 RC 99214 HCPCS inpatient 507 329.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 306.99 60.55 999999999 306.99 491.79 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48827851_1 CDM 0510 RC 99214 HCPCS inpatient 507 329.55 UMR - ALL PLANS UMR - ALL PLANS 354.9 70 999999999 306.99 491.79 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48827851_1 CDM 0510 RC 99214 HCPCS inpatient 507 329.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 306.99 491.79 "Established patient office or other outpatient visit, 30-39 minutes" 48827851_1 CDM 0510 RC 99214 HCPCS inpatient 507 329.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 306.99 491.79 "Established patient office or other outpatient visit, 30-39 minutes" 48827851_1 CDM 0510 RC 99214 HCPCS inpatient 507 329.55 ANTHEM HMO ANTHEM HMO 999999999 306.99 491.79 "Established patient office or other outpatient visit, 30-39 minutes" 48827851_1 CDM 0510 RC 99214 HCPCS inpatient 507 329.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 306.99 491.79 "Established patient office or other outpatient visit, 30-39 minutes" 48827851_1 CDM 0510 RC 99214 HCPCS inpatient 507 329.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 342.73 67.6 999999999 306.99 491.79 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 48827851_1 CDM 0510 RC 99214 HCPCS inpatient 507 329.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 306.99 491.79 "Established patient office or other outpatient visit, 40-54 minutes" 48827852_1 CDM 0510 RC 99215 HCPCS inpatient 653 424.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 424.45 65 999999999 395.39 633.41 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 48827852_1 CDM 0510 RC 99215 HCPCS inpatient 653 424.45 AETNA AETNA 515.87 79 999999999 395.39 633.41 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 48827852_1 CDM 0510 RC 99215 HCPCS inpatient 653 424.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 633.41 97 999999999 395.39 633.41 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 48827852_1 CDM 0510 RC 99215 HCPCS inpatient 653 424.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 450.57 69 999999999 395.39 633.41 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 48827852_1 CDM 0510 RC 99215 HCPCS inpatient 653 424.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 509.34 78 999999999 395.39 633.41 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 48827852_1 CDM 0510 RC 99215 HCPCS inpatient 653 424.45 SIHO - ALL PLANS SIHO - ALL PLANS 587.7 90 999999999 395.39 633.41 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 48827852_1 CDM 0510 RC 99215 HCPCS inpatient 653 424.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 395.39 60.55 999999999 395.39 633.41 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 48827852_1 CDM 0510 RC 99215 HCPCS inpatient 653 424.45 UMR - ALL PLANS UMR - ALL PLANS 457.1 70 999999999 395.39 633.41 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 48827852_1 CDM 0510 RC 99215 HCPCS inpatient 653 424.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 395.39 633.41 "Established patient office or other outpatient visit, 40-54 minutes" 48827852_1 CDM 0510 RC 99215 HCPCS inpatient 653 424.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 395.39 633.41 "Established patient office or other outpatient visit, 40-54 minutes" 48827852_1 CDM 0510 RC 99215 HCPCS inpatient 653 424.45 ANTHEM HMO ANTHEM HMO 999999999 395.39 633.41 "Established patient office or other outpatient visit, 40-54 minutes" 48827852_1 CDM 0510 RC 99215 HCPCS inpatient 653 424.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 395.39 633.41 "Established patient office or other outpatient visit, 40-54 minutes" 48827852_1 CDM 0510 RC 99215 HCPCS inpatient 653 424.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 441.43 67.6 999999999 395.39 633.41 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 48827852_1 CDM 0510 RC 99215 HCPCS inpatient 653 424.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 395.39 633.41 SUMATRIPTAN SUCC 25 MG TABLET 48854776_1 CDM 0250 RC 65862-0146-36 NDC inpatient 1 UN 2.71 1.76 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.76 65 999999999 1.64 2.63 percent of total billed charges SUMATRIPTAN SUCC 25 MG TABLET 48854776_1 CDM 0250 RC 65862-0146-36 NDC inpatient 1 UN 2.71 1.76 AETNA AETNA 2.14 79 999999999 1.64 2.63 percent of total billed charges SUMATRIPTAN SUCC 25 MG TABLET 48854776_1 CDM 0250 RC 65862-0146-36 NDC inpatient 1 UN 2.71 1.76 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.63 97 999999999 1.64 2.63 percent of total billed charges SUMATRIPTAN SUCC 25 MG TABLET 48854776_1 CDM 0250 RC 65862-0146-36 NDC inpatient 1 UN 2.71 1.76 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.87 69 999999999 1.64 2.63 percent of total billed charges SUMATRIPTAN SUCC 25 MG TABLET 48854776_1 CDM 0250 RC 65862-0146-36 NDC inpatient 1 UN 2.71 1.76 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.11 78 999999999 1.64 2.63 percent of total billed charges SUMATRIPTAN SUCC 25 MG TABLET 48854776_1 CDM 0250 RC 65862-0146-36 NDC inpatient 1 UN 2.71 1.76 SIHO - ALL PLANS SIHO - ALL PLANS 2.44 90 999999999 1.64 2.63 percent of total billed charges SUMATRIPTAN SUCC 25 MG TABLET 48854776_1 CDM 0250 RC 65862-0146-36 NDC inpatient 1 UN 2.71 1.76 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.64 60.55 999999999 1.64 2.63 percent of total billed charges SUMATRIPTAN SUCC 25 MG TABLET 48854776_1 CDM 0250 RC 65862-0146-36 NDC inpatient 1 UN 2.71 1.76 UMR - ALL PLANS UMR - ALL PLANS 1.9 70 999999999 1.64 2.63 percent of total billed charges SUMATRIPTAN SUCC 25 MG TABLET 48854776_1 CDM 0250 RC 65862-0146-36 NDC inpatient 1 UN 2.71 1.76 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.64 2.63 SUMATRIPTAN SUCC 25 MG TABLET 48854776_1 CDM 0250 RC 65862-0146-36 NDC inpatient 1 UN 2.71 1.76 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.64 2.63 SUMATRIPTAN SUCC 25 MG TABLET 48854776_1 CDM 0250 RC 65862-0146-36 NDC inpatient 1 UN 2.71 1.76 ANTHEM HMO ANTHEM HMO 999999999 1.64 2.63 SUMATRIPTAN SUCC 25 MG TABLET 48854776_1 CDM 0250 RC 65862-0146-36 NDC inpatient 1 UN 2.71 1.76 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.64 2.63 SUMATRIPTAN SUCC 25 MG TABLET 48854776_1 CDM 0250 RC 65862-0146-36 NDC inpatient 1 UN 2.71 1.76 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.83 67.6 999999999 1.64 2.63 percent of total billed charges SUMATRIPTAN SUCC 25 MG TABLET 48854776_1 CDM 0250 RC 65862-0146-36 NDC inpatient 1 UN 2.71 1.76 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.64 2.63 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48855236_1 CDM 0250 RC 63323-0594-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 SELF PAY DISCOUNT SELF PAY DISCOUNT 378.41 65 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48855236_1 CDM 0250 RC 63323-0594-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 AETNA AETNA 459.91 79 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48855236_1 CDM 0250 RC 63323-0594-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 564.7 97 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48855236_1 CDM 0250 RC 63323-0594-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 ENCORE - ALL PLANS ENCORE - ALL PLANS 401.7 69 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48855236_1 CDM 0250 RC 63323-0594-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 HUMANA - ALL PLANS HUMANA - ALL PLANS 454.09 78 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48855236_1 CDM 0250 RC 63323-0594-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 SIHO - ALL PLANS SIHO - ALL PLANS 523.95 90 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48855236_1 CDM 0250 RC 63323-0594-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 352.5 60.55 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48855236_1 CDM 0250 RC 63323-0594-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 UMR - ALL PLANS UMR - ALL PLANS 407.52 70 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48855236_1 CDM 0250 RC 63323-0594-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 352.5 564.7 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48855236_1 CDM 0250 RC 63323-0594-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 352.5 564.7 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48855236_1 CDM 0250 RC 63323-0594-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 ANTHEM HMO ANTHEM HMO 999999999 352.5 564.7 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48855236_1 CDM 0250 RC 63323-0594-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 352.5 564.7 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48855236_1 CDM 0250 RC 63323-0594-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 CIGNA - ALL PLANS CIGNA - ALL PLANS 393.55 67.6 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 48855236_1 CDM 0250 RC 63323-0594-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 UHC - ALL PLANS UHC - ALL PLANS 999999999 352.5 564.7 Analysis for antibody to john cunningham virus 48861125_1 CDM 0301 RC 86711 HCPCS inpatient 2173 1412.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1412.45 65 999999999 1315.75 2107.81 percent of total billed charges Analysis for antibody to john cunningham virus 48861125_1 CDM 0301 RC 86711 HCPCS inpatient 2173 1412.45 AETNA AETNA 1716.67 79 999999999 1315.75 2107.81 percent of total billed charges Analysis for antibody to john cunningham virus 48861125_1 CDM 0301 RC 86711 HCPCS inpatient 2173 1412.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1499.37 69 999999999 1315.75 2107.81 percent of total billed charges Analysis for antibody to john cunningham virus 48861125_1 CDM 0301 RC 86711 HCPCS inpatient 2173 1412.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2107.81 97 999999999 1315.75 2107.81 percent of total billed charges Analysis for antibody to john cunningham virus 48861125_1 CDM 0301 RC 86711 HCPCS inpatient 2173 1412.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1694.94 78 999999999 1315.75 2107.81 percent of total billed charges Analysis for antibody to john cunningham virus 48861125_1 CDM 0301 RC 86711 HCPCS inpatient 2173 1412.45 SIHO - ALL PLANS SIHO - ALL PLANS 1955.7 90 999999999 1315.75 2107.81 percent of total billed charges Analysis for antibody to john cunningham virus 48861125_1 CDM 0301 RC 86711 HCPCS inpatient 2173 1412.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1315.75 60.55 999999999 1315.75 2107.81 percent of total billed charges Analysis for antibody to john cunningham virus 48861125_1 CDM 0301 RC 86711 HCPCS inpatient 2173 1412.45 UMR - ALL PLANS UMR - ALL PLANS 1521.1 70 999999999 1315.75 2107.81 percent of total billed charges Analysis for antibody to john cunningham virus 48861125_1 CDM 0301 RC 86711 HCPCS inpatient 2173 1412.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1315.75 2107.81 Analysis for antibody to john cunningham virus 48861125_1 CDM 0301 RC 86711 HCPCS inpatient 2173 1412.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1315.75 2107.81 Analysis for antibody to john cunningham virus 48861125_1 CDM 0301 RC 86711 HCPCS inpatient 2173 1412.45 ANTHEM HMO ANTHEM HMO 999999999 1315.75 2107.81 Analysis for antibody to john cunningham virus 48861125_1 CDM 0301 RC 86711 HCPCS inpatient 2173 1412.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1315.75 2107.81 Analysis for antibody to john cunningham virus 48861125_1 CDM 0301 RC 86711 HCPCS inpatient 2173 1412.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1468.95 67.6 999999999 1315.75 2107.81 percent of total billed charges Analysis for antibody to john cunningham virus 48861125_1 CDM 0301 RC 86711 HCPCS inpatient 2173 1412.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1315.75 2107.81 "Cannabinoids levels, natural" 48861127_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 48861127_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 48861127_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 48861127_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 48861127_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 48861127_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 48861127_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 48861127_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 48861127_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 "Cannabinoids levels, natural" 48861127_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 "Cannabinoids levels, natural" 48861127_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 "Cannabinoids levels, natural" 48861127_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 "Cannabinoids levels, natural" 48861127_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 48861127_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 Methadone level 48861128_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 137.15 65 999999999 127.76 204.67 percent of total billed charges Methadone level 48861128_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 AETNA AETNA 166.69 79 999999999 127.76 204.67 percent of total billed charges Methadone level 48861128_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 145.59 69 999999999 127.76 204.67 percent of total billed charges Methadone level 48861128_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 204.67 97 999999999 127.76 204.67 percent of total billed charges Methadone level 48861128_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 164.58 78 999999999 127.76 204.67 percent of total billed charges Methadone level 48861128_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 SIHO - ALL PLANS SIHO - ALL PLANS 189.9 90 999999999 127.76 204.67 percent of total billed charges Methadone level 48861128_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.76 60.55 999999999 127.76 204.67 percent of total billed charges Methadone level 48861128_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 UMR - ALL PLANS UMR - ALL PLANS 147.7 70 999999999 127.76 204.67 percent of total billed charges Methadone level 48861128_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.76 204.67 Methadone level 48861128_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.76 204.67 Methadone level 48861128_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ANTHEM HMO ANTHEM HMO 999999999 127.76 204.67 Methadone level 48861128_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.76 204.67 Methadone level 48861128_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 142.64 67.6 999999999 127.76 204.67 percent of total billed charges Methadone level 48861128_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.76 204.67 Buprenorphine level 48861129_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 48861129_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 48861129_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 48861129_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 48861129_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 48861129_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 48861129_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 48861129_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 48861129_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 Buprenorphine level 48861129_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 Buprenorphine level 48861129_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 Buprenorphine level 48861129_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 Buprenorphine level 48861129_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 48861129_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 Measurement of antibody to noninfectious agent 48861130_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 48861130_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 48861130_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 48861130_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 48861130_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 48861130_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 48861130_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 48861130_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 48861130_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 48861130_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 48861130_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 48861130_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 48861130_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 48861130_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 "Analysis of substance using immunoassay technique, multiple step method" 48861132_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.5 65 999999999 102.94 164.9 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861132_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 AETNA AETNA 134.3 79 999999999 102.94 164.9 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861132_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.3 69 999999999 102.94 164.9 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861132_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.9 97 999999999 102.94 164.9 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861132_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.6 78 999999999 102.94 164.9 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861132_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 SIHO - ALL PLANS SIHO - ALL PLANS 153 90 999999999 102.94 164.9 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861132_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.94 60.55 999999999 102.94 164.9 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861132_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 UMR - ALL PLANS UMR - ALL PLANS 119 70 999999999 102.94 164.9 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861132_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.94 164.9 "Analysis of substance using immunoassay technique, multiple step method" 48861132_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.94 164.9 "Analysis of substance using immunoassay technique, multiple step method" 48861132_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 ANTHEM HMO ANTHEM HMO 999999999 102.94 164.9 "Analysis of substance using immunoassay technique, multiple step method" 48861132_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.94 164.9 "Analysis of substance using immunoassay technique, multiple step method" 48861132_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.92 67.6 999999999 102.94 164.9 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861132_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.94 164.9 Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 48861134_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 169.65 65 999999999 158.04 253.17 percent of total billed charges Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 48861134_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 AETNA AETNA 206.19 79 999999999 158.04 253.17 percent of total billed charges Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 48861134_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.09 69 999999999 158.04 253.17 percent of total billed charges Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 48861134_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 253.17 97 999999999 158.04 253.17 percent of total billed charges Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 48861134_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 203.58 78 999999999 158.04 253.17 percent of total billed charges Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 48861134_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 SIHO - ALL PLANS SIHO - ALL PLANS 234.9 90 999999999 158.04 253.17 percent of total billed charges Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 48861134_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.04 60.55 999999999 158.04 253.17 percent of total billed charges Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 48861134_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 UMR - ALL PLANS UMR - ALL PLANS 182.7 70 999999999 158.04 253.17 percent of total billed charges Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 48861134_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.04 253.17 Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 48861134_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.04 253.17 Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 48861134_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 ANTHEM HMO ANTHEM HMO 999999999 158.04 253.17 Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 48861134_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.04 253.17 Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 48861134_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 176.44 67.6 999999999 158.04 253.17 percent of total billed charges Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 48861134_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.04 253.17 PCP drug level 48861135_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges PCP drug level 48861135_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges PCP drug level 48861135_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges PCP drug level 48861135_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges PCP drug level 48861135_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges PCP drug level 48861135_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges PCP drug level 48861135_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges PCP drug level 48861135_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges PCP drug level 48861135_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 PCP drug level 48861135_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 PCP drug level 48861135_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 PCP drug level 48861135_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 PCP drug level 48861135_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges PCP drug level 48861135_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 Barbiturates levels 48861136_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.8 65 999999999 104.15 166.84 percent of total billed charges Barbiturates levels 48861136_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 AETNA AETNA 135.88 79 999999999 104.15 166.84 percent of total billed charges Barbiturates levels 48861136_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 118.68 69 999999999 104.15 166.84 percent of total billed charges Barbiturates levels 48861136_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 166.84 97 999999999 104.15 166.84 percent of total billed charges Barbiturates levels 48861136_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.16 78 999999999 104.15 166.84 percent of total billed charges Barbiturates levels 48861136_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 SIHO - ALL PLANS SIHO - ALL PLANS 154.8 90 999999999 104.15 166.84 percent of total billed charges Barbiturates levels 48861136_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.15 60.55 999999999 104.15 166.84 percent of total billed charges Barbiturates levels 48861136_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 UMR - ALL PLANS UMR - ALL PLANS 120.4 70 999999999 104.15 166.84 percent of total billed charges Barbiturates levels 48861136_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.15 166.84 Barbiturates levels 48861136_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.15 166.84 Barbiturates levels 48861136_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 ANTHEM HMO ANTHEM HMO 999999999 104.15 166.84 Barbiturates levels 48861136_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.15 166.84 Barbiturates levels 48861136_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.27 67.6 999999999 104.15 166.84 percent of total billed charges Barbiturates levels 48861136_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.15 166.84 "Analysis of substance using immunoassay technique, multiple step method" 48861149_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861149_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861149_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861149_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861149_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861149_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861149_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861149_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861149_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48861149_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48861149_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48861149_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48861149_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861149_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 48861152_1 CDM 0306 RC 87529 HCPCS inpatient 447 290.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 290.55 65 999999999 270.66 433.59 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 48861152_1 CDM 0306 RC 87529 HCPCS inpatient 447 290.55 AETNA AETNA 353.13 79 999999999 270.66 433.59 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 48861152_1 CDM 0306 RC 87529 HCPCS inpatient 447 290.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 308.43 69 999999999 270.66 433.59 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 48861152_1 CDM 0306 RC 87529 HCPCS inpatient 447 290.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 433.59 97 999999999 270.66 433.59 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 48861152_1 CDM 0306 RC 87529 HCPCS inpatient 447 290.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 348.66 78 999999999 270.66 433.59 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 48861152_1 CDM 0306 RC 87529 HCPCS inpatient 447 290.55 SIHO - ALL PLANS SIHO - ALL PLANS 402.3 90 999999999 270.66 433.59 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 48861152_1 CDM 0306 RC 87529 HCPCS inpatient 447 290.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.66 60.55 999999999 270.66 433.59 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 48861152_1 CDM 0306 RC 87529 HCPCS inpatient 447 290.55 UMR - ALL PLANS UMR - ALL PLANS 312.9 70 999999999 270.66 433.59 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 48861152_1 CDM 0306 RC 87529 HCPCS inpatient 447 290.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.66 433.59 "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 48861152_1 CDM 0306 RC 87529 HCPCS inpatient 447 290.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.66 433.59 "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 48861152_1 CDM 0306 RC 87529 HCPCS inpatient 447 290.55 ANTHEM HMO ANTHEM HMO 999999999 270.66 433.59 "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 48861152_1 CDM 0306 RC 87529 HCPCS inpatient 447 290.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.66 433.59 "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 48861152_1 CDM 0306 RC 87529 HCPCS inpatient 447 290.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 302.17 67.6 999999999 270.66 433.59 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 48861152_1 CDM 0306 RC 87529 HCPCS inpatient 447 290.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.66 433.59 "Analysis of substance using immunoassay technique, multiple step method" 48861154_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861154_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861154_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861154_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861154_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861154_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861154_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861154_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861154_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48861154_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48861154_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48861154_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 48861154_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 48861154_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 48861155_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 48861155_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 48861155_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 48861155_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 48861155_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 48861155_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 48861155_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 48861155_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 48861155_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 48861155_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 48861155_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 48861155_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 48861155_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 48861155_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 Microbial toxin or antitoxin assay 48861158_1 CDM 0301 RC 87230 HCPCS inpatient 256 166.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 166.4 65 999999999 155.01 248.32 percent of total billed charges Microbial toxin or antitoxin assay 48861158_1 CDM 0301 RC 87230 HCPCS inpatient 256 166.4 AETNA AETNA 202.24 79 999999999 155.01 248.32 percent of total billed charges Microbial toxin or antitoxin assay 48861158_1 CDM 0301 RC 87230 HCPCS inpatient 256 166.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 176.64 69 999999999 155.01 248.32 percent of total billed charges Microbial toxin or antitoxin assay 48861158_1 CDM 0301 RC 87230 HCPCS inpatient 256 166.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 248.32 97 999999999 155.01 248.32 percent of total billed charges Microbial toxin or antitoxin assay 48861158_1 CDM 0301 RC 87230 HCPCS inpatient 256 166.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 199.68 78 999999999 155.01 248.32 percent of total billed charges Microbial toxin or antitoxin assay 48861158_1 CDM 0301 RC 87230 HCPCS inpatient 256 166.4 SIHO - ALL PLANS SIHO - ALL PLANS 230.4 90 999999999 155.01 248.32 percent of total billed charges Microbial toxin or antitoxin assay 48861158_1 CDM 0301 RC 87230 HCPCS inpatient 256 166.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.01 60.55 999999999 155.01 248.32 percent of total billed charges Microbial toxin or antitoxin assay 48861158_1 CDM 0301 RC 87230 HCPCS inpatient 256 166.4 UMR - ALL PLANS UMR - ALL PLANS 179.2 70 999999999 155.01 248.32 percent of total billed charges Microbial toxin or antitoxin assay 48861158_1 CDM 0301 RC 87230 HCPCS inpatient 256 166.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.01 248.32 Microbial toxin or antitoxin assay 48861158_1 CDM 0301 RC 87230 HCPCS inpatient 256 166.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.01 248.32 Microbial toxin or antitoxin assay 48861158_1 CDM 0301 RC 87230 HCPCS inpatient 256 166.4 ANTHEM HMO ANTHEM HMO 999999999 155.01 248.32 Microbial toxin or antitoxin assay 48861158_1 CDM 0301 RC 87230 HCPCS inpatient 256 166.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.01 248.32 Microbial toxin or antitoxin assay 48861158_1 CDM 0301 RC 87230 HCPCS inpatient 256 166.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.06 67.6 999999999 155.01 248.32 percent of total billed charges Microbial toxin or antitoxin assay 48861158_1 CDM 0301 RC 87230 HCPCS inpatient 256 166.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.01 248.32 Chemical analysis using spectrophotometry (light) 48861159_1 CDM 0302 RC 84311 HCPCS inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges Chemical analysis using spectrophotometry (light) 48861159_1 CDM 0302 RC 84311 HCPCS inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges Chemical analysis using spectrophotometry (light) 48861159_1 CDM 0302 RC 84311 HCPCS inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges Chemical analysis using spectrophotometry (light) 48861159_1 CDM 0302 RC 84311 HCPCS inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges Chemical analysis using spectrophotometry (light) 48861159_1 CDM 0302 RC 84311 HCPCS inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges Chemical analysis using spectrophotometry (light) 48861159_1 CDM 0302 RC 84311 HCPCS inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges Chemical analysis using spectrophotometry (light) 48861159_1 CDM 0302 RC 84311 HCPCS inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges Chemical analysis using spectrophotometry (light) 48861159_1 CDM 0302 RC 84311 HCPCS inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges Chemical analysis using spectrophotometry (light) 48861159_1 CDM 0302 RC 84311 HCPCS inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 Chemical analysis using spectrophotometry (light) 48861159_1 CDM 0302 RC 84311 HCPCS inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 Chemical analysis using spectrophotometry (light) 48861159_1 CDM 0302 RC 84311 HCPCS inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 Chemical analysis using spectrophotometry (light) 48861159_1 CDM 0302 RC 84311 HCPCS inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 Chemical analysis using spectrophotometry (light) 48861159_1 CDM 0302 RC 84311 HCPCS inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges Chemical analysis using spectrophotometry (light) 48861159_1 CDM 0302 RC 84311 HCPCS inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 Measurement of complement function (immune system proteins) 48861178_1 CDM 0302 RC 86161 HCPCS inpatient 144 93.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 93.6 65 999999999 87.19 139.68 percent of total billed charges Measurement of complement function (immune system proteins) 48861178_1 CDM 0302 RC 86161 HCPCS inpatient 144 93.6 AETNA AETNA 113.76 79 999999999 87.19 139.68 percent of total billed charges Measurement of complement function (immune system proteins) 48861178_1 CDM 0302 RC 86161 HCPCS inpatient 144 93.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 99.36 69 999999999 87.19 139.68 percent of total billed charges Measurement of complement function (immune system proteins) 48861178_1 CDM 0302 RC 86161 HCPCS inpatient 144 93.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 139.68 97 999999999 87.19 139.68 percent of total billed charges Measurement of complement function (immune system proteins) 48861178_1 CDM 0302 RC 86161 HCPCS inpatient 144 93.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 112.32 78 999999999 87.19 139.68 percent of total billed charges Measurement of complement function (immune system proteins) 48861178_1 CDM 0302 RC 86161 HCPCS inpatient 144 93.6 SIHO - ALL PLANS SIHO - ALL PLANS 129.6 90 999999999 87.19 139.68 percent of total billed charges Measurement of complement function (immune system proteins) 48861178_1 CDM 0302 RC 86161 HCPCS inpatient 144 93.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.19 60.55 999999999 87.19 139.68 percent of total billed charges Measurement of complement function (immune system proteins) 48861178_1 CDM 0302 RC 86161 HCPCS inpatient 144 93.6 UMR - ALL PLANS UMR - ALL PLANS 100.8 70 999999999 87.19 139.68 percent of total billed charges Measurement of complement function (immune system proteins) 48861178_1 CDM 0302 RC 86161 HCPCS inpatient 144 93.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.19 139.68 Measurement of complement function (immune system proteins) 48861178_1 CDM 0302 RC 86161 HCPCS inpatient 144 93.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.19 139.68 Measurement of complement function (immune system proteins) 48861178_1 CDM 0302 RC 86161 HCPCS inpatient 144 93.6 ANTHEM HMO ANTHEM HMO 999999999 87.19 139.68 Measurement of complement function (immune system proteins) 48861178_1 CDM 0302 RC 86161 HCPCS inpatient 144 93.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.19 139.68 Measurement of complement function (immune system proteins) 48861178_1 CDM 0302 RC 86161 HCPCS inpatient 144 93.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 97.34 67.6 999999999 87.19 139.68 percent of total billed charges Measurement of complement function (immune system proteins) 48861178_1 CDM 0302 RC 86161 HCPCS inpatient 144 93.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.19 139.68 Measurement of complement function (immune system proteins) 48861182_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.1 65 999999999 93.25 149.38 percent of total billed charges Measurement of complement function (immune system proteins) 48861182_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 AETNA AETNA 121.66 79 999999999 93.25 149.38 percent of total billed charges Measurement of complement function (immune system proteins) 48861182_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.26 69 999999999 93.25 149.38 percent of total billed charges Measurement of complement function (immune system proteins) 48861182_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 149.38 97 999999999 93.25 149.38 percent of total billed charges Measurement of complement function (immune system proteins) 48861182_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.12 78 999999999 93.25 149.38 percent of total billed charges Measurement of complement function (immune system proteins) 48861182_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 SIHO - ALL PLANS SIHO - ALL PLANS 138.6 90 999999999 93.25 149.38 percent of total billed charges Measurement of complement function (immune system proteins) 48861182_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.25 60.55 999999999 93.25 149.38 percent of total billed charges Measurement of complement function (immune system proteins) 48861182_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 UMR - ALL PLANS UMR - ALL PLANS 107.8 70 999999999 93.25 149.38 percent of total billed charges Measurement of complement function (immune system proteins) 48861182_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.25 149.38 Measurement of complement function (immune system proteins) 48861182_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.25 149.38 Measurement of complement function (immune system proteins) 48861182_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 ANTHEM HMO ANTHEM HMO 999999999 93.25 149.38 Measurement of complement function (immune system proteins) 48861182_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.25 149.38 Measurement of complement function (immune system proteins) 48861182_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.1 67.6 999999999 93.25 149.38 percent of total billed charges Measurement of complement function (immune system proteins) 48861182_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.25 149.38 Alkaloids levels 48861186_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges Alkaloids levels 48861186_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges Alkaloids levels 48861186_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges Alkaloids levels 48861186_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges Alkaloids levels 48861186_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges Alkaloids levels 48861186_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges Alkaloids levels 48861186_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges Alkaloids levels 48861186_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges Alkaloids levels 48861186_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 Alkaloids levels 48861186_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 Alkaloids levels 48861186_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 Alkaloids levels 48861186_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 Alkaloids levels 48861186_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges Alkaloids levels 48861186_1 CDM 0301 RC 80323 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 Protoporphyrin (metabolism substance) level 48861190_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 137.15 65 999999999 127.76 204.67 percent of total billed charges Protoporphyrin (metabolism substance) level 48861190_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 AETNA AETNA 166.69 79 999999999 127.76 204.67 percent of total billed charges Protoporphyrin (metabolism substance) level 48861190_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 145.59 69 999999999 127.76 204.67 percent of total billed charges Protoporphyrin (metabolism substance) level 48861190_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 204.67 97 999999999 127.76 204.67 percent of total billed charges Protoporphyrin (metabolism substance) level 48861190_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 164.58 78 999999999 127.76 204.67 percent of total billed charges Protoporphyrin (metabolism substance) level 48861190_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 SIHO - ALL PLANS SIHO - ALL PLANS 189.9 90 999999999 127.76 204.67 percent of total billed charges Protoporphyrin (metabolism substance) level 48861190_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.76 60.55 999999999 127.76 204.67 percent of total billed charges Protoporphyrin (metabolism substance) level 48861190_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 UMR - ALL PLANS UMR - ALL PLANS 147.7 70 999999999 127.76 204.67 percent of total billed charges Protoporphyrin (metabolism substance) level 48861190_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.76 204.67 Protoporphyrin (metabolism substance) level 48861190_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.76 204.67 Protoporphyrin (metabolism substance) level 48861190_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 ANTHEM HMO ANTHEM HMO 999999999 127.76 204.67 Protoporphyrin (metabolism substance) level 48861190_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.76 204.67 Protoporphyrin (metabolism substance) level 48861190_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 142.64 67.6 999999999 127.76 204.67 percent of total billed charges Protoporphyrin (metabolism substance) level 48861190_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.76 204.67 "Gene analysis (epidermal growth factor receptor), common variants" 48861194_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 645.45 65 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 48861194_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 AETNA AETNA 784.47 79 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 48861194_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 685.17 69 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 48861194_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 963.21 97 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 48861194_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 774.54 78 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 48861194_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 SIHO - ALL PLANS SIHO - ALL PLANS 893.7 90 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 48861194_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 601.26 60.55 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 48861194_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 UMR - ALL PLANS UMR - ALL PLANS 695.1 70 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 48861194_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 601.26 963.21 "Gene analysis (epidermal growth factor receptor), common variants" 48861194_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 601.26 963.21 "Gene analysis (epidermal growth factor receptor), common variants" 48861194_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 ANTHEM HMO ANTHEM HMO 999999999 601.26 963.21 "Gene analysis (epidermal growth factor receptor), common variants" 48861194_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 601.26 963.21 "Gene analysis (epidermal growth factor receptor), common variants" 48861194_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 671.27 67.6 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 48861194_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 601.26 963.21 "Benzodiazepines levels, 1-12" 48861195_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 113.75 65 999999999 105.96 169.75 percent of total billed charges "Benzodiazepines levels, 1-12" 48861195_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 AETNA AETNA 138.25 79 999999999 105.96 169.75 percent of total billed charges "Benzodiazepines levels, 1-12" 48861195_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 120.75 69 999999999 105.96 169.75 percent of total billed charges "Benzodiazepines levels, 1-12" 48861195_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 169.75 97 999999999 105.96 169.75 percent of total billed charges "Benzodiazepines levels, 1-12" 48861195_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 136.5 78 999999999 105.96 169.75 percent of total billed charges "Benzodiazepines levels, 1-12" 48861195_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 SIHO - ALL PLANS SIHO - ALL PLANS 157.5 90 999999999 105.96 169.75 percent of total billed charges "Benzodiazepines levels, 1-12" 48861195_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 105.96 60.55 999999999 105.96 169.75 percent of total billed charges "Benzodiazepines levels, 1-12" 48861195_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 UMR - ALL PLANS UMR - ALL PLANS 122.5 70 999999999 105.96 169.75 percent of total billed charges "Benzodiazepines levels, 1-12" 48861195_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 105.96 169.75 "Benzodiazepines levels, 1-12" 48861195_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 105.96 169.75 "Benzodiazepines levels, 1-12" 48861195_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 ANTHEM HMO ANTHEM HMO 999999999 105.96 169.75 "Benzodiazepines levels, 1-12" 48861195_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 105.96 169.75 "Benzodiazepines levels, 1-12" 48861195_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.3 67.6 999999999 105.96 169.75 percent of total billed charges "Benzodiazepines levels, 1-12" 48861195_1 CDM 0301 RC 80346 HCPCS inpatient 175 113.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 105.96 169.75 EDS SPLINT FINGER CHARGE 48864245_1 CDM 0271 RC inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges EDS SPLINT FINGER CHARGE 48864245_1 CDM 0271 RC inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges EDS SPLINT FINGER CHARGE 48864245_1 CDM 0271 RC inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges EDS SPLINT FINGER CHARGE 48864245_1 CDM 0271 RC inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges EDS SPLINT FINGER CHARGE 48864245_1 CDM 0271 RC inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges EDS SPLINT FINGER CHARGE 48864245_1 CDM 0271 RC inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges EDS SPLINT FINGER CHARGE 48864245_1 CDM 0271 RC inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges EDS SPLINT FINGER CHARGE 48864245_1 CDM 0271 RC inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges EDS SPLINT FINGER CHARGE 48864245_1 CDM 0271 RC inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 EDS SPLINT FINGER CHARGE 48864245_1 CDM 0271 RC inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 EDS SPLINT FINGER CHARGE 48864245_1 CDM 0271 RC inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 EDS SPLINT FINGER CHARGE 48864245_1 CDM 0271 RC inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 EDS SPLINT FINGER CHARGE 48864245_1 CDM 0271 RC inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges EDS SPLINT FINGER CHARGE 48864245_1 CDM 0271 RC inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 EDS SPLINT FINGER CHILD CHARGE 48864289_1 CDM 0271 RC inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges EDS SPLINT FINGER CHILD CHARGE 48864289_1 CDM 0271 RC inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges EDS SPLINT FINGER CHILD CHARGE 48864289_1 CDM 0271 RC inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges EDS SPLINT FINGER CHILD CHARGE 48864289_1 CDM 0271 RC inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges EDS SPLINT FINGER CHILD CHARGE 48864289_1 CDM 0271 RC inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges EDS SPLINT FINGER CHILD CHARGE 48864289_1 CDM 0271 RC inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges EDS SPLINT FINGER CHILD CHARGE 48864289_1 CDM 0271 RC inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges EDS SPLINT FINGER CHILD CHARGE 48864289_1 CDM 0271 RC inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges EDS SPLINT FINGER CHILD CHARGE 48864289_1 CDM 0271 RC inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 EDS SPLINT FINGER CHILD CHARGE 48864289_1 CDM 0271 RC inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 EDS SPLINT FINGER CHILD CHARGE 48864289_1 CDM 0271 RC inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 EDS SPLINT FINGER CHILD CHARGE 48864289_1 CDM 0271 RC inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 EDS SPLINT FINGER CHILD CHARGE 48864289_1 CDM 0271 RC inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges EDS SPLINT FINGER CHILD CHARGE 48864289_1 CDM 0271 RC inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 EDS SPLINT SHORT ARM CHARGE 48864311_1 CDM 0271 RC inpatient 264 171.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 171.6 65 999999999 159.85 256.08 percent of total billed charges EDS SPLINT SHORT ARM CHARGE 48864311_1 CDM 0271 RC inpatient 264 171.6 AETNA AETNA 208.56 79 999999999 159.85 256.08 percent of total billed charges EDS SPLINT SHORT ARM CHARGE 48864311_1 CDM 0271 RC inpatient 264 171.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 182.16 69 999999999 159.85 256.08 percent of total billed charges EDS SPLINT SHORT ARM CHARGE 48864311_1 CDM 0271 RC inpatient 264 171.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 256.08 97 999999999 159.85 256.08 percent of total billed charges EDS SPLINT SHORT ARM CHARGE 48864311_1 CDM 0271 RC inpatient 264 171.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 205.92 78 999999999 159.85 256.08 percent of total billed charges EDS SPLINT SHORT ARM CHARGE 48864311_1 CDM 0271 RC inpatient 264 171.6 SIHO - ALL PLANS SIHO - ALL PLANS 237.6 90 999999999 159.85 256.08 percent of total billed charges EDS SPLINT SHORT ARM CHARGE 48864311_1 CDM 0271 RC inpatient 264 171.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 159.85 60.55 999999999 159.85 256.08 percent of total billed charges EDS SPLINT SHORT ARM CHARGE 48864311_1 CDM 0271 RC inpatient 264 171.6 UMR - ALL PLANS UMR - ALL PLANS 184.8 70 999999999 159.85 256.08 percent of total billed charges EDS SPLINT SHORT ARM CHARGE 48864311_1 CDM 0271 RC inpatient 264 171.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 159.85 256.08 EDS SPLINT SHORT ARM CHARGE 48864311_1 CDM 0271 RC inpatient 264 171.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 159.85 256.08 EDS SPLINT SHORT ARM CHARGE 48864311_1 CDM 0271 RC inpatient 264 171.6 ANTHEM HMO ANTHEM HMO 999999999 159.85 256.08 EDS SPLINT SHORT ARM CHARGE 48864311_1 CDM 0271 RC inpatient 264 171.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 159.85 256.08 EDS SPLINT SHORT ARM CHARGE 48864311_1 CDM 0271 RC inpatient 264 171.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 178.46 67.6 999999999 159.85 256.08 percent of total billed charges EDS SPLINT SHORT ARM CHARGE 48864311_1 CDM 0271 RC inpatient 264 171.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 159.85 256.08 EDS SPLINT R ARM CHLD PL POSTR CHARGE 48864312_1 CDM 0271 RC inpatient 193 125.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 125.45 65 999999999 116.86 187.21 percent of total billed charges EDS SPLINT R ARM CHLD PL POSTR CHARGE 48864312_1 CDM 0271 RC inpatient 193 125.45 AETNA AETNA 152.47 79 999999999 116.86 187.21 percent of total billed charges EDS SPLINT R ARM CHLD PL POSTR CHARGE 48864312_1 CDM 0271 RC inpatient 193 125.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.17 69 999999999 116.86 187.21 percent of total billed charges EDS SPLINT R ARM CHLD PL POSTR CHARGE 48864312_1 CDM 0271 RC inpatient 193 125.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 187.21 97 999999999 116.86 187.21 percent of total billed charges EDS SPLINT R ARM CHLD PL POSTR CHARGE 48864312_1 CDM 0271 RC inpatient 193 125.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 150.54 78 999999999 116.86 187.21 percent of total billed charges EDS SPLINT R ARM CHLD PL POSTR CHARGE 48864312_1 CDM 0271 RC inpatient 193 125.45 SIHO - ALL PLANS SIHO - ALL PLANS 173.7 90 999999999 116.86 187.21 percent of total billed charges EDS SPLINT R ARM CHLD PL POSTR CHARGE 48864312_1 CDM 0271 RC inpatient 193 125.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.86 60.55 999999999 116.86 187.21 percent of total billed charges EDS SPLINT R ARM CHLD PL POSTR CHARGE 48864312_1 CDM 0271 RC inpatient 193 125.45 UMR - ALL PLANS UMR - ALL PLANS 135.1 70 999999999 116.86 187.21 percent of total billed charges EDS SPLINT R ARM CHLD PL POSTR CHARGE 48864312_1 CDM 0271 RC inpatient 193 125.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.86 187.21 EDS SPLINT R ARM CHLD PL POSTR CHARGE 48864312_1 CDM 0271 RC inpatient 193 125.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.86 187.21 EDS SPLINT R ARM CHLD PL POSTR CHARGE 48864312_1 CDM 0271 RC inpatient 193 125.45 ANTHEM HMO ANTHEM HMO 999999999 116.86 187.21 EDS SPLINT R ARM CHLD PL POSTR CHARGE 48864312_1 CDM 0271 RC inpatient 193 125.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.86 187.21 EDS SPLINT R ARM CHLD PL POSTR CHARGE 48864312_1 CDM 0271 RC inpatient 193 125.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 130.47 67.6 999999999 116.86 187.21 percent of total billed charges EDS SPLINT R ARM CHLD PL POSTR CHARGE 48864312_1 CDM 0271 RC inpatient 193 125.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.86 187.21 EDS SPLINT SHORT LEG CHARGE 48864313_1 CDM 0271 RC inpatient 267 173.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 173.55 65 999999999 161.67 258.99 percent of total billed charges EDS SPLINT SHORT LEG CHARGE 48864313_1 CDM 0271 RC inpatient 267 173.55 AETNA AETNA 210.93 79 999999999 161.67 258.99 percent of total billed charges EDS SPLINT SHORT LEG CHARGE 48864313_1 CDM 0271 RC inpatient 267 173.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.23 69 999999999 161.67 258.99 percent of total billed charges EDS SPLINT SHORT LEG CHARGE 48864313_1 CDM 0271 RC inpatient 267 173.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 258.99 97 999999999 161.67 258.99 percent of total billed charges EDS SPLINT SHORT LEG CHARGE 48864313_1 CDM 0271 RC inpatient 267 173.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 208.26 78 999999999 161.67 258.99 percent of total billed charges EDS SPLINT SHORT LEG CHARGE 48864313_1 CDM 0271 RC inpatient 267 173.55 SIHO - ALL PLANS SIHO - ALL PLANS 240.3 90 999999999 161.67 258.99 percent of total billed charges EDS SPLINT SHORT LEG CHARGE 48864313_1 CDM 0271 RC inpatient 267 173.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 161.67 60.55 999999999 161.67 258.99 percent of total billed charges EDS SPLINT SHORT LEG CHARGE 48864313_1 CDM 0271 RC inpatient 267 173.55 UMR - ALL PLANS UMR - ALL PLANS 186.9 70 999999999 161.67 258.99 percent of total billed charges EDS SPLINT SHORT LEG CHARGE 48864313_1 CDM 0271 RC inpatient 267 173.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 161.67 258.99 EDS SPLINT SHORT LEG CHARGE 48864313_1 CDM 0271 RC inpatient 267 173.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 161.67 258.99 EDS SPLINT SHORT LEG CHARGE 48864313_1 CDM 0271 RC inpatient 267 173.55 ANTHEM HMO ANTHEM HMO 999999999 161.67 258.99 EDS SPLINT SHORT LEG CHARGE 48864313_1 CDM 0271 RC inpatient 267 173.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 161.67 258.99 EDS SPLINT SHORT LEG CHARGE 48864313_1 CDM 0271 RC inpatient 267 173.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 180.49 67.6 999999999 161.67 258.99 percent of total billed charges EDS SPLINT SHORT LEG CHARGE 48864313_1 CDM 0271 RC inpatient 267 173.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 161.67 258.99 EDS SPLINT PL TOE TO KNEE CHLD CHARGE 48864314_1 CDM 0271 RC inpatient 224 145.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 145.6 65 999999999 135.63 217.28 percent of total billed charges EDS SPLINT PL TOE TO KNEE CHLD CHARGE 48864314_1 CDM 0271 RC inpatient 224 145.6 AETNA AETNA 176.96 79 999999999 135.63 217.28 percent of total billed charges EDS SPLINT PL TOE TO KNEE CHLD CHARGE 48864314_1 CDM 0271 RC inpatient 224 145.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 154.56 69 999999999 135.63 217.28 percent of total billed charges EDS SPLINT PL TOE TO KNEE CHLD CHARGE 48864314_1 CDM 0271 RC inpatient 224 145.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 217.28 97 999999999 135.63 217.28 percent of total billed charges EDS SPLINT PL TOE TO KNEE CHLD CHARGE 48864314_1 CDM 0271 RC inpatient 224 145.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 174.72 78 999999999 135.63 217.28 percent of total billed charges EDS SPLINT PL TOE TO KNEE CHLD CHARGE 48864314_1 CDM 0271 RC inpatient 224 145.6 SIHO - ALL PLANS SIHO - ALL PLANS 201.6 90 999999999 135.63 217.28 percent of total billed charges EDS SPLINT PL TOE TO KNEE CHLD CHARGE 48864314_1 CDM 0271 RC inpatient 224 145.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 135.63 60.55 999999999 135.63 217.28 percent of total billed charges EDS SPLINT PL TOE TO KNEE CHLD CHARGE 48864314_1 CDM 0271 RC inpatient 224 145.6 UMR - ALL PLANS UMR - ALL PLANS 156.8 70 999999999 135.63 217.28 percent of total billed charges EDS SPLINT PL TOE TO KNEE CHLD CHARGE 48864314_1 CDM 0271 RC inpatient 224 145.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 135.63 217.28 EDS SPLINT PL TOE TO KNEE CHLD CHARGE 48864314_1 CDM 0271 RC inpatient 224 145.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 135.63 217.28 EDS SPLINT PL TOE TO KNEE CHLD CHARGE 48864314_1 CDM 0271 RC inpatient 224 145.6 ANTHEM HMO ANTHEM HMO 999999999 135.63 217.28 EDS SPLINT PL TOE TO KNEE CHLD CHARGE 48864314_1 CDM 0271 RC inpatient 224 145.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 135.63 217.28 EDS SPLINT PL TOE TO KNEE CHLD CHARGE 48864314_1 CDM 0271 RC inpatient 224 145.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 151.42 67.6 999999999 135.63 217.28 percent of total billed charges EDS SPLINT PL TOE TO KNEE CHLD CHARGE 48864314_1 CDM 0271 RC inpatient 224 145.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 135.63 217.28 EDS SPLNT LONG LEG CHARGE 48864315_1 CDM 0271 RC inpatient 276 179.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 179.4 65 999999999 167.12 267.72 percent of total billed charges EDS SPLNT LONG LEG CHARGE 48864315_1 CDM 0271 RC inpatient 276 179.4 AETNA AETNA 218.04 79 999999999 167.12 267.72 percent of total billed charges EDS SPLNT LONG LEG CHARGE 48864315_1 CDM 0271 RC inpatient 276 179.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 190.44 69 999999999 167.12 267.72 percent of total billed charges EDS SPLNT LONG LEG CHARGE 48864315_1 CDM 0271 RC inpatient 276 179.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 267.72 97 999999999 167.12 267.72 percent of total billed charges EDS SPLNT LONG LEG CHARGE 48864315_1 CDM 0271 RC inpatient 276 179.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 215.28 78 999999999 167.12 267.72 percent of total billed charges EDS SPLNT LONG LEG CHARGE 48864315_1 CDM 0271 RC inpatient 276 179.4 SIHO - ALL PLANS SIHO - ALL PLANS 248.4 90 999999999 167.12 267.72 percent of total billed charges EDS SPLNT LONG LEG CHARGE 48864315_1 CDM 0271 RC inpatient 276 179.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 167.12 60.55 999999999 167.12 267.72 percent of total billed charges EDS SPLNT LONG LEG CHARGE 48864315_1 CDM 0271 RC inpatient 276 179.4 UMR - ALL PLANS UMR - ALL PLANS 193.2 70 999999999 167.12 267.72 percent of total billed charges EDS SPLNT LONG LEG CHARGE 48864315_1 CDM 0271 RC inpatient 276 179.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 167.12 267.72 EDS SPLNT LONG LEG CHARGE 48864315_1 CDM 0271 RC inpatient 276 179.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 167.12 267.72 EDS SPLNT LONG LEG CHARGE 48864315_1 CDM 0271 RC inpatient 276 179.4 ANTHEM HMO ANTHEM HMO 999999999 167.12 267.72 EDS SPLNT LONG LEG CHARGE 48864315_1 CDM 0271 RC inpatient 276 179.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 167.12 267.72 EDS SPLNT LONG LEG CHARGE 48864315_1 CDM 0271 RC inpatient 276 179.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 186.58 67.6 999999999 167.12 267.72 percent of total billed charges EDS SPLNT LONG LEG CHARGE 48864315_1 CDM 0271 RC inpatient 276 179.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 167.12 267.72 EDS SPLNT PL TOE TO THIGH CHLD CHARGE 48864316_1 CDM 0271 RC inpatient 170 110.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.5 65 999999999 102.94 164.9 percent of total billed charges EDS SPLNT PL TOE TO THIGH CHLD CHARGE 48864316_1 CDM 0271 RC inpatient 170 110.5 AETNA AETNA 134.3 79 999999999 102.94 164.9 percent of total billed charges EDS SPLNT PL TOE TO THIGH CHLD CHARGE 48864316_1 CDM 0271 RC inpatient 170 110.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.3 69 999999999 102.94 164.9 percent of total billed charges EDS SPLNT PL TOE TO THIGH CHLD CHARGE 48864316_1 CDM 0271 RC inpatient 170 110.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.9 97 999999999 102.94 164.9 percent of total billed charges EDS SPLNT PL TOE TO THIGH CHLD CHARGE 48864316_1 CDM 0271 RC inpatient 170 110.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.6 78 999999999 102.94 164.9 percent of total billed charges EDS SPLNT PL TOE TO THIGH CHLD CHARGE 48864316_1 CDM 0271 RC inpatient 170 110.5 SIHO - ALL PLANS SIHO - ALL PLANS 153 90 999999999 102.94 164.9 percent of total billed charges EDS SPLNT PL TOE TO THIGH CHLD CHARGE 48864316_1 CDM 0271 RC inpatient 170 110.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.94 60.55 999999999 102.94 164.9 percent of total billed charges EDS SPLNT PL TOE TO THIGH CHLD CHARGE 48864316_1 CDM 0271 RC inpatient 170 110.5 UMR - ALL PLANS UMR - ALL PLANS 119 70 999999999 102.94 164.9 percent of total billed charges EDS SPLNT PL TOE TO THIGH CHLD CHARGE 48864316_1 CDM 0271 RC inpatient 170 110.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.94 164.9 EDS SPLNT PL TOE TO THIGH CHLD CHARGE 48864316_1 CDM 0271 RC inpatient 170 110.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.94 164.9 EDS SPLNT PL TOE TO THIGH CHLD CHARGE 48864316_1 CDM 0271 RC inpatient 170 110.5 ANTHEM HMO ANTHEM HMO 999999999 102.94 164.9 EDS SPLNT PL TOE TO THIGH CHLD CHARGE 48864316_1 CDM 0271 RC inpatient 170 110.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.94 164.9 EDS SPLNT PL TOE TO THIGH CHLD CHARGE 48864316_1 CDM 0271 RC inpatient 170 110.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.92 67.6 999999999 102.94 164.9 percent of total billed charges EDS SPLNT PL TOE TO THIGH CHLD CHARGE 48864316_1 CDM 0271 RC inpatient 170 110.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.94 164.9 EDS SPLNT LNG ARM CHILD PL PST CHARGE 48864317_1 CDM 0271 RC inpatient 218 141.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 141.7 65 999999999 132 211.46 percent of total billed charges EDS SPLNT LNG ARM CHILD PL PST CHARGE 48864317_1 CDM 0271 RC inpatient 218 141.7 AETNA AETNA 172.22 79 999999999 132 211.46 percent of total billed charges EDS SPLNT LNG ARM CHILD PL PST CHARGE 48864317_1 CDM 0271 RC inpatient 218 141.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 150.42 69 999999999 132 211.46 percent of total billed charges EDS SPLNT LNG ARM CHILD PL PST CHARGE 48864317_1 CDM 0271 RC inpatient 218 141.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 211.46 97 999999999 132 211.46 percent of total billed charges EDS SPLNT LNG ARM CHILD PL PST CHARGE 48864317_1 CDM 0271 RC inpatient 218 141.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.04 78 999999999 132 211.46 percent of total billed charges EDS SPLNT LNG ARM CHILD PL PST CHARGE 48864317_1 CDM 0271 RC inpatient 218 141.7 SIHO - ALL PLANS SIHO - ALL PLANS 196.2 90 999999999 132 211.46 percent of total billed charges EDS SPLNT LNG ARM CHILD PL PST CHARGE 48864317_1 CDM 0271 RC inpatient 218 141.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132 60.55 999999999 132 211.46 percent of total billed charges EDS SPLNT LNG ARM CHILD PL PST CHARGE 48864317_1 CDM 0271 RC inpatient 218 141.7 UMR - ALL PLANS UMR - ALL PLANS 152.6 70 999999999 132 211.46 percent of total billed charges EDS SPLNT LNG ARM CHILD PL PST CHARGE 48864317_1 CDM 0271 RC inpatient 218 141.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132 211.46 EDS SPLNT LNG ARM CHILD PL PST CHARGE 48864317_1 CDM 0271 RC inpatient 218 141.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132 211.46 EDS SPLNT LNG ARM CHILD PL PST CHARGE 48864317_1 CDM 0271 RC inpatient 218 141.7 ANTHEM HMO ANTHEM HMO 999999999 132 211.46 EDS SPLNT LNG ARM CHILD PL PST CHARGE 48864317_1 CDM 0271 RC inpatient 218 141.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132 211.46 EDS SPLNT LNG ARM CHILD PL PST CHARGE 48864317_1 CDM 0271 RC inpatient 218 141.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 147.37 67.6 999999999 132 211.46 percent of total billed charges EDS SPLNT LNG ARM CHILD PL PST CHARGE 48864317_1 CDM 0271 RC inpatient 218 141.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 132 211.46 EDS SPLNT LONG ARM CHARGE 48864318_1 CDM 0271 RC inpatient 223 144.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 144.95 65 999999999 135.03 216.31 percent of total billed charges EDS SPLNT LONG ARM CHARGE 48864318_1 CDM 0271 RC inpatient 223 144.95 AETNA AETNA 176.17 79 999999999 135.03 216.31 percent of total billed charges EDS SPLNT LONG ARM CHARGE 48864318_1 CDM 0271 RC inpatient 223 144.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 153.87 69 999999999 135.03 216.31 percent of total billed charges EDS SPLNT LONG ARM CHARGE 48864318_1 CDM 0271 RC inpatient 223 144.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 216.31 97 999999999 135.03 216.31 percent of total billed charges EDS SPLNT LONG ARM CHARGE 48864318_1 CDM 0271 RC inpatient 223 144.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 173.94 78 999999999 135.03 216.31 percent of total billed charges EDS SPLNT LONG ARM CHARGE 48864318_1 CDM 0271 RC inpatient 223 144.95 SIHO - ALL PLANS SIHO - ALL PLANS 200.7 90 999999999 135.03 216.31 percent of total billed charges EDS SPLNT LONG ARM CHARGE 48864318_1 CDM 0271 RC inpatient 223 144.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 135.03 60.55 999999999 135.03 216.31 percent of total billed charges EDS SPLNT LONG ARM CHARGE 48864318_1 CDM 0271 RC inpatient 223 144.95 UMR - ALL PLANS UMR - ALL PLANS 156.1 70 999999999 135.03 216.31 percent of total billed charges EDS SPLNT LONG ARM CHARGE 48864318_1 CDM 0271 RC inpatient 223 144.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 135.03 216.31 EDS SPLNT LONG ARM CHARGE 48864318_1 CDM 0271 RC inpatient 223 144.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 135.03 216.31 EDS SPLNT LONG ARM CHARGE 48864318_1 CDM 0271 RC inpatient 223 144.95 ANTHEM HMO ANTHEM HMO 999999999 135.03 216.31 EDS SPLNT LONG ARM CHARGE 48864318_1 CDM 0271 RC inpatient 223 144.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 135.03 216.31 EDS SPLNT LONG ARM CHARGE 48864318_1 CDM 0271 RC inpatient 223 144.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 150.75 67.6 999999999 135.03 216.31 percent of total billed charges EDS SPLNT LONG ARM CHARGE 48864318_1 CDM 0271 RC inpatient 223 144.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 135.03 216.31 ED HAZ MAT DECON CHARGE 48864323_1 CDM 0272 RC inpatient 1058 687.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 687.7 65 999999999 640.62 1026.26 percent of total billed charges ED HAZ MAT DECON CHARGE 48864323_1 CDM 0272 RC inpatient 1058 687.7 AETNA AETNA 835.82 79 999999999 640.62 1026.26 percent of total billed charges ED HAZ MAT DECON CHARGE 48864323_1 CDM 0272 RC inpatient 1058 687.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 730.02 69 999999999 640.62 1026.26 percent of total billed charges ED HAZ MAT DECON CHARGE 48864323_1 CDM 0272 RC inpatient 1058 687.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1026.26 97 999999999 640.62 1026.26 percent of total billed charges ED HAZ MAT DECON CHARGE 48864323_1 CDM 0272 RC inpatient 1058 687.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 825.24 78 999999999 640.62 1026.26 percent of total billed charges ED HAZ MAT DECON CHARGE 48864323_1 CDM 0272 RC inpatient 1058 687.7 SIHO - ALL PLANS SIHO - ALL PLANS 952.2 90 999999999 640.62 1026.26 percent of total billed charges ED HAZ MAT DECON CHARGE 48864323_1 CDM 0272 RC inpatient 1058 687.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 640.62 60.55 999999999 640.62 1026.26 percent of total billed charges ED HAZ MAT DECON CHARGE 48864323_1 CDM 0272 RC inpatient 1058 687.7 UMR - ALL PLANS UMR - ALL PLANS 740.6 70 999999999 640.62 1026.26 percent of total billed charges ED HAZ MAT DECON CHARGE 48864323_1 CDM 0272 RC inpatient 1058 687.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 640.62 1026.26 ED HAZ MAT DECON CHARGE 48864323_1 CDM 0272 RC inpatient 1058 687.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 640.62 1026.26 ED HAZ MAT DECON CHARGE 48864323_1 CDM 0272 RC inpatient 1058 687.7 ANTHEM HMO ANTHEM HMO 999999999 640.62 1026.26 ED HAZ MAT DECON CHARGE 48864323_1 CDM 0272 RC inpatient 1058 687.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 640.62 1026.26 ED HAZ MAT DECON CHARGE 48864323_1 CDM 0272 RC inpatient 1058 687.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 715.21 67.6 999999999 640.62 1026.26 percent of total billed charges ED HAZ MAT DECON CHARGE 48864323_1 CDM 0272 RC inpatient 1058 687.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 640.62 1026.26 ED POISON CONTROL CONSULTATN CHARGE 48864324_1 CDM 0450 RC inpatient 582 378.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 378.3 65 999999999 352.4 564.54 percent of total billed charges ED POISON CONTROL CONSULTATN CHARGE 48864324_1 CDM 0450 RC inpatient 582 378.3 AETNA AETNA 459.78 79 999999999 352.4 564.54 percent of total billed charges ED POISON CONTROL CONSULTATN CHARGE 48864324_1 CDM 0450 RC inpatient 582 378.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 401.58 69 999999999 352.4 564.54 percent of total billed charges ED POISON CONTROL CONSULTATN CHARGE 48864324_1 CDM 0450 RC inpatient 582 378.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 564.54 97 999999999 352.4 564.54 percent of total billed charges ED POISON CONTROL CONSULTATN CHARGE 48864324_1 CDM 0450 RC inpatient 582 378.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 453.96 78 999999999 352.4 564.54 percent of total billed charges ED POISON CONTROL CONSULTATN CHARGE 48864324_1 CDM 0450 RC inpatient 582 378.3 SIHO - ALL PLANS SIHO - ALL PLANS 523.8 90 999999999 352.4 564.54 percent of total billed charges ED POISON CONTROL CONSULTATN CHARGE 48864324_1 CDM 0450 RC inpatient 582 378.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 352.4 60.55 999999999 352.4 564.54 percent of total billed charges ED POISON CONTROL CONSULTATN CHARGE 48864324_1 CDM 0450 RC inpatient 582 378.3 UMR - ALL PLANS UMR - ALL PLANS 407.4 70 999999999 352.4 564.54 percent of total billed charges ED POISON CONTROL CONSULTATN CHARGE 48864324_1 CDM 0450 RC inpatient 582 378.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 352.4 564.54 ED POISON CONTROL CONSULTATN CHARGE 48864324_1 CDM 0450 RC inpatient 582 378.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 352.4 564.54 ED POISON CONTROL CONSULTATN CHARGE 48864324_1 CDM 0450 RC inpatient 582 378.3 ANTHEM HMO ANTHEM HMO 999999999 352.4 564.54 ED POISON CONTROL CONSULTATN CHARGE 48864324_1 CDM 0450 RC inpatient 582 378.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 352.4 564.54 ED POISON CONTROL CONSULTATN CHARGE 48864324_1 CDM 0450 RC inpatient 582 378.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 393.43 67.6 999999999 352.4 564.54 percent of total billed charges ED POISON CONTROL CONSULTATN CHARGE 48864324_1 CDM 0450 RC inpatient 582 378.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 352.4 564.54 Insertion of needle or tube into vein 48864325_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges Insertion of needle or tube into vein 48864325_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges Insertion of needle or tube into vein 48864325_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges Insertion of needle or tube into vein 48864325_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges Insertion of needle or tube into vein 48864325_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges Insertion of needle or tube into vein 48864325_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges Insertion of needle or tube into vein 48864325_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges Insertion of needle or tube into vein 48864325_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges Insertion of needle or tube into vein 48864325_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 Insertion of needle or tube into vein 48864325_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 Insertion of needle or tube into vein 48864325_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 Insertion of needle or tube into vein 48864325_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 Insertion of needle or tube into vein 48864325_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges Insertion of needle or tube into vein 48864325_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 Cocaine level 48875246_1 CDM 0302 RC 80353 HCPCS inpatient 442 287.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 287.3 65 999999999 267.63 428.74 percent of total billed charges Cocaine level 48875246_1 CDM 0302 RC 80353 HCPCS inpatient 442 287.3 AETNA AETNA 349.18 79 999999999 267.63 428.74 percent of total billed charges Cocaine level 48875246_1 CDM 0302 RC 80353 HCPCS inpatient 442 287.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 304.98 69 999999999 267.63 428.74 percent of total billed charges Cocaine level 48875246_1 CDM 0302 RC 80353 HCPCS inpatient 442 287.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 428.74 97 999999999 267.63 428.74 percent of total billed charges Cocaine level 48875246_1 CDM 0302 RC 80353 HCPCS inpatient 442 287.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 344.76 78 999999999 267.63 428.74 percent of total billed charges Cocaine level 48875246_1 CDM 0302 RC 80353 HCPCS inpatient 442 287.3 SIHO - ALL PLANS SIHO - ALL PLANS 397.8 90 999999999 267.63 428.74 percent of total billed charges Cocaine level 48875246_1 CDM 0302 RC 80353 HCPCS inpatient 442 287.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 267.63 60.55 999999999 267.63 428.74 percent of total billed charges Cocaine level 48875246_1 CDM 0302 RC 80353 HCPCS inpatient 442 287.3 UMR - ALL PLANS UMR - ALL PLANS 309.4 70 999999999 267.63 428.74 percent of total billed charges Cocaine level 48875246_1 CDM 0302 RC 80353 HCPCS inpatient 442 287.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 267.63 428.74 Cocaine level 48875246_1 CDM 0302 RC 80353 HCPCS inpatient 442 287.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 267.63 428.74 Cocaine level 48875246_1 CDM 0302 RC 80353 HCPCS inpatient 442 287.3 ANTHEM HMO ANTHEM HMO 999999999 267.63 428.74 Cocaine level 48875246_1 CDM 0302 RC 80353 HCPCS inpatient 442 287.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 267.63 428.74 Cocaine level 48875246_1 CDM 0302 RC 80353 HCPCS inpatient 442 287.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 298.79 67.6 999999999 267.63 428.74 percent of total billed charges Cocaine level 48875246_1 CDM 0302 RC 80353 HCPCS inpatient 442 287.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 267.63 428.74 "Microscopic genetic analysis of tumor, manual" 48875247_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 222.3 65 999999999 207.08 331.74 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 48875247_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 AETNA AETNA 270.18 79 999999999 207.08 331.74 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 48875247_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 235.98 69 999999999 207.08 331.74 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 48875247_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 331.74 97 999999999 207.08 331.74 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 48875247_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 266.76 78 999999999 207.08 331.74 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 48875247_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 SIHO - ALL PLANS SIHO - ALL PLANS 307.8 90 999999999 207.08 331.74 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 48875247_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 207.08 60.55 999999999 207.08 331.74 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 48875247_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 UMR - ALL PLANS UMR - ALL PLANS 239.4 70 999999999 207.08 331.74 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 48875247_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 207.08 331.74 "Microscopic genetic analysis of tumor, manual" 48875247_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 207.08 331.74 "Microscopic genetic analysis of tumor, manual" 48875247_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 ANTHEM HMO ANTHEM HMO 999999999 207.08 331.74 "Microscopic genetic analysis of tumor, manual" 48875247_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 207.08 331.74 "Microscopic genetic analysis of tumor, manual" 48875247_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 231.19 67.6 999999999 207.08 331.74 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 48875247_1 CDM 0312 RC 88360 HCPCS inpatient 342 222.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 207.08 331.74 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875249_1 CDM 0309 RC P9603 HCPCS inpatient 27 17.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.55 65 999999999 16.35 26.19 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875249_1 CDM 0309 RC P9603 HCPCS inpatient 27 17.55 AETNA AETNA 21.33 79 999999999 16.35 26.19 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875249_1 CDM 0309 RC P9603 HCPCS inpatient 27 17.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.63 69 999999999 16.35 26.19 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875249_1 CDM 0309 RC P9603 HCPCS inpatient 27 17.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26.19 97 999999999 16.35 26.19 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875249_1 CDM 0309 RC P9603 HCPCS inpatient 27 17.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.06 78 999999999 16.35 26.19 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875249_1 CDM 0309 RC P9603 HCPCS inpatient 27 17.55 SIHO - ALL PLANS SIHO - ALL PLANS 24.3 90 999999999 16.35 26.19 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875249_1 CDM 0309 RC P9603 HCPCS inpatient 27 17.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.35 60.55 999999999 16.35 26.19 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875249_1 CDM 0309 RC P9603 HCPCS inpatient 27 17.55 UMR - ALL PLANS UMR - ALL PLANS 18.9 70 999999999 16.35 26.19 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875249_1 CDM 0309 RC P9603 HCPCS inpatient 27 17.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.35 26.19 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875249_1 CDM 0309 RC P9603 HCPCS inpatient 27 17.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.35 26.19 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875249_1 CDM 0309 RC P9603 HCPCS inpatient 27 17.55 ANTHEM HMO ANTHEM HMO 999999999 16.35 26.19 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875249_1 CDM 0309 RC P9603 HCPCS inpatient 27 17.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.35 26.19 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875249_1 CDM 0309 RC P9603 HCPCS inpatient 27 17.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.25 67.6 999999999 16.35 26.19 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875249_1 CDM 0309 RC P9603 HCPCS inpatient 27 17.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.35 26.19 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875250_1 CDM 0309 RC P9603 HCPCS inpatient 62 40.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.3 65 999999999 37.54 60.14 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875250_1 CDM 0309 RC P9603 HCPCS inpatient 62 40.3 AETNA AETNA 48.98 79 999999999 37.54 60.14 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875250_1 CDM 0309 RC P9603 HCPCS inpatient 62 40.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.78 69 999999999 37.54 60.14 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875250_1 CDM 0309 RC P9603 HCPCS inpatient 62 40.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 60.14 97 999999999 37.54 60.14 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875250_1 CDM 0309 RC P9603 HCPCS inpatient 62 40.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 48.36 78 999999999 37.54 60.14 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875250_1 CDM 0309 RC P9603 HCPCS inpatient 62 40.3 SIHO - ALL PLANS SIHO - ALL PLANS 55.8 90 999999999 37.54 60.14 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875250_1 CDM 0309 RC P9603 HCPCS inpatient 62 40.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 37.54 60.55 999999999 37.54 60.14 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875250_1 CDM 0309 RC P9603 HCPCS inpatient 62 40.3 UMR - ALL PLANS UMR - ALL PLANS 43.4 70 999999999 37.54 60.14 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875250_1 CDM 0309 RC P9603 HCPCS inpatient 62 40.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 37.54 60.14 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875250_1 CDM 0309 RC P9603 HCPCS inpatient 62 40.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 37.54 60.14 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875250_1 CDM 0309 RC P9603 HCPCS inpatient 62 40.3 ANTHEM HMO ANTHEM HMO 999999999 37.54 60.14 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875250_1 CDM 0309 RC P9603 HCPCS inpatient 62 40.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 37.54 60.14 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875250_1 CDM 0309 RC P9603 HCPCS inpatient 62 40.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.91 67.6 999999999 37.54 60.14 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875250_1 CDM 0309 RC P9603 HCPCS inpatient 62 40.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 37.54 60.14 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875251_1 CDM 0309 RC P9603 HCPCS inpatient 35 22.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.75 65 999999999 21.19 33.95 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875251_1 CDM 0309 RC P9603 HCPCS inpatient 35 22.75 AETNA AETNA 27.65 79 999999999 21.19 33.95 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875251_1 CDM 0309 RC P9603 HCPCS inpatient 35 22.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.15 69 999999999 21.19 33.95 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875251_1 CDM 0309 RC P9603 HCPCS inpatient 35 22.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33.95 97 999999999 21.19 33.95 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875251_1 CDM 0309 RC P9603 HCPCS inpatient 35 22.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.3 78 999999999 21.19 33.95 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875251_1 CDM 0309 RC P9603 HCPCS inpatient 35 22.75 SIHO - ALL PLANS SIHO - ALL PLANS 31.5 90 999999999 21.19 33.95 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875251_1 CDM 0309 RC P9603 HCPCS inpatient 35 22.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.19 60.55 999999999 21.19 33.95 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875251_1 CDM 0309 RC P9603 HCPCS inpatient 35 22.75 UMR - ALL PLANS UMR - ALL PLANS 24.5 70 999999999 21.19 33.95 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875251_1 CDM 0309 RC P9603 HCPCS inpatient 35 22.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.19 33.95 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875251_1 CDM 0309 RC P9603 HCPCS inpatient 35 22.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.19 33.95 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875251_1 CDM 0309 RC P9603 HCPCS inpatient 35 22.75 ANTHEM HMO ANTHEM HMO 999999999 21.19 33.95 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875251_1 CDM 0309 RC P9603 HCPCS inpatient 35 22.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.19 33.95 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875251_1 CDM 0309 RC P9603 HCPCS inpatient 35 22.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 23.66 67.6 999999999 21.19 33.95 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 48875251_1 CDM 0309 RC P9603 HCPCS inpatient 35 22.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.19 33.95 "00409-9042-10 - bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 30 mL [JOHN]" 48875316_1 CDM 0250 RC 00409-9042-10 NDC inpatient 1 UN 30.2 19.63 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.63 65 999999999 18.29 29.29 percent of total billed charges "00409-9042-10 - bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 30 mL [JOHN]" 48875316_1 CDM 0250 RC 00409-9042-10 NDC inpatient 1 UN 30.2 19.63 AETNA AETNA 23.86 79 999999999 18.29 29.29 percent of total billed charges "00409-9042-10 - bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 30 mL [JOHN]" 48875316_1 CDM 0250 RC 00409-9042-10 NDC inpatient 1 UN 30.2 19.63 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.84 69 999999999 18.29 29.29 percent of total billed charges "00409-9042-10 - bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 30 mL [JOHN]" 48875316_1 CDM 0250 RC 00409-9042-10 NDC inpatient 1 UN 30.2 19.63 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.29 97 999999999 18.29 29.29 percent of total billed charges "00409-9042-10 - bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 30 mL [JOHN]" 48875316_1 CDM 0250 RC 00409-9042-10 NDC inpatient 1 UN 30.2 19.63 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.56 78 999999999 18.29 29.29 percent of total billed charges "00409-9042-10 - bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 30 mL [JOHN]" 48875316_1 CDM 0250 RC 00409-9042-10 NDC inpatient 1 UN 30.2 19.63 SIHO - ALL PLANS SIHO - ALL PLANS 27.18 90 999999999 18.29 29.29 percent of total billed charges "00409-9042-10 - bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 30 mL [JOHN]" 48875316_1 CDM 0250 RC 00409-9042-10 NDC inpatient 1 UN 30.2 19.63 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.29 60.55 999999999 18.29 29.29 percent of total billed charges "00409-9042-10 - bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 30 mL [JOHN]" 48875316_1 CDM 0250 RC 00409-9042-10 NDC inpatient 1 UN 30.2 19.63 UMR - ALL PLANS UMR - ALL PLANS 21.14 70 999999999 18.29 29.29 percent of total billed charges "00409-9042-10 - bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 30 mL [JOHN]" 48875316_1 CDM 0250 RC 00409-9042-10 NDC inpatient 1 UN 30.2 19.63 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.29 29.29 "00409-9042-10 - bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 30 mL [JOHN]" 48875316_1 CDM 0250 RC 00409-9042-10 NDC inpatient 1 UN 30.2 19.63 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.29 29.29 "00409-9042-10 - bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 30 mL [JOHN]" 48875316_1 CDM 0250 RC 00409-9042-10 NDC inpatient 1 UN 30.2 19.63 ANTHEM HMO ANTHEM HMO 999999999 18.29 29.29 "00409-9042-10 - bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 30 mL [JOHN]" 48875316_1 CDM 0250 RC 00409-9042-10 NDC inpatient 1 UN 30.2 19.63 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.29 29.29 "00409-9042-10 - bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 30 mL [JOHN]" 48875316_1 CDM 0250 RC 00409-9042-10 NDC inpatient 1 UN 30.2 19.63 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.42 67.6 999999999 18.29 29.29 percent of total billed charges "00409-9042-10 - bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 30 mL [JOHN]" 48875316_1 CDM 0250 RC 00409-9042-10 NDC inpatient 1 UN 30.2 19.63 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.29 29.29 DIGOXIN 500 MCG/2 ML AMPULE 48875317_1 CDM 0250 RC 00641-6184-25 NDC inpatient 1 UN 34.69 22.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.55 65 999999999 21 33.65 percent of total billed charges DIGOXIN 500 MCG/2 ML AMPULE 48875317_1 CDM 0250 RC 00641-6184-25 NDC inpatient 1 UN 34.69 22.55 AETNA AETNA 27.41 79 999999999 21 33.65 percent of total billed charges DIGOXIN 500 MCG/2 ML AMPULE 48875317_1 CDM 0250 RC 00641-6184-25 NDC inpatient 1 UN 34.69 22.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 23.94 69 999999999 21 33.65 percent of total billed charges DIGOXIN 500 MCG/2 ML AMPULE 48875317_1 CDM 0250 RC 00641-6184-25 NDC inpatient 1 UN 34.69 22.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33.65 97 999999999 21 33.65 percent of total billed charges DIGOXIN 500 MCG/2 ML AMPULE 48875317_1 CDM 0250 RC 00641-6184-25 NDC inpatient 1 UN 34.69 22.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.06 78 999999999 21 33.65 percent of total billed charges DIGOXIN 500 MCG/2 ML AMPULE 48875317_1 CDM 0250 RC 00641-6184-25 NDC inpatient 1 UN 34.69 22.55 SIHO - ALL PLANS SIHO - ALL PLANS 31.22 90 999999999 21 33.65 percent of total billed charges DIGOXIN 500 MCG/2 ML AMPULE 48875317_1 CDM 0250 RC 00641-6184-25 NDC inpatient 1 UN 34.69 22.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21 60.55 999999999 21 33.65 percent of total billed charges DIGOXIN 500 MCG/2 ML AMPULE 48875317_1 CDM 0250 RC 00641-6184-25 NDC inpatient 1 UN 34.69 22.55 UMR - ALL PLANS UMR - ALL PLANS 24.28 70 999999999 21 33.65 percent of total billed charges DIGOXIN 500 MCG/2 ML AMPULE 48875317_1 CDM 0250 RC 00641-6184-25 NDC inpatient 1 UN 34.69 22.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21 33.65 DIGOXIN 500 MCG/2 ML AMPULE 48875317_1 CDM 0250 RC 00641-6184-25 NDC inpatient 1 UN 34.69 22.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21 33.65 DIGOXIN 500 MCG/2 ML AMPULE 48875317_1 CDM 0250 RC 00641-6184-25 NDC inpatient 1 UN 34.69 22.55 ANTHEM HMO ANTHEM HMO 999999999 21 33.65 DIGOXIN 500 MCG/2 ML AMPULE 48875317_1 CDM 0250 RC 00641-6184-25 NDC inpatient 1 UN 34.69 22.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21 33.65 DIGOXIN 500 MCG/2 ML AMPULE 48875317_1 CDM 0250 RC 00641-6184-25 NDC inpatient 1 UN 34.69 22.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 23.45 67.6 999999999 21 33.65 percent of total billed charges DIGOXIN 500 MCG/2 ML AMPULE 48875317_1 CDM 0250 RC 00641-6184-25 NDC inpatient 1 UN 34.69 22.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 21 33.65 MIDAZOLAM HCL 2 MG/ML SYRUP 48875318_1 CDM 0250 RC 00054-3566-99 NDC inpatient 1 UN 339.58 220.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 220.73 65 999999999 205.62 329.39 percent of total billed charges MIDAZOLAM HCL 2 MG/ML SYRUP 48875318_1 CDM 0250 RC 00054-3566-99 NDC inpatient 1 UN 339.58 220.73 AETNA AETNA 268.27 79 999999999 205.62 329.39 percent of total billed charges MIDAZOLAM HCL 2 MG/ML SYRUP 48875318_1 CDM 0250 RC 00054-3566-99 NDC inpatient 1 UN 339.58 220.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 234.31 69 999999999 205.62 329.39 percent of total billed charges MIDAZOLAM HCL 2 MG/ML SYRUP 48875318_1 CDM 0250 RC 00054-3566-99 NDC inpatient 1 UN 339.58 220.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 329.39 97 999999999 205.62 329.39 percent of total billed charges MIDAZOLAM HCL 2 MG/ML SYRUP 48875318_1 CDM 0250 RC 00054-3566-99 NDC inpatient 1 UN 339.58 220.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 264.87 78 999999999 205.62 329.39 percent of total billed charges MIDAZOLAM HCL 2 MG/ML SYRUP 48875318_1 CDM 0250 RC 00054-3566-99 NDC inpatient 1 UN 339.58 220.73 SIHO - ALL PLANS SIHO - ALL PLANS 305.62 90 999999999 205.62 329.39 percent of total billed charges MIDAZOLAM HCL 2 MG/ML SYRUP 48875318_1 CDM 0250 RC 00054-3566-99 NDC inpatient 1 UN 339.58 220.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.62 60.55 999999999 205.62 329.39 percent of total billed charges MIDAZOLAM HCL 2 MG/ML SYRUP 48875318_1 CDM 0250 RC 00054-3566-99 NDC inpatient 1 UN 339.58 220.73 UMR - ALL PLANS UMR - ALL PLANS 237.71 70 999999999 205.62 329.39 percent of total billed charges MIDAZOLAM HCL 2 MG/ML SYRUP 48875318_1 CDM 0250 RC 00054-3566-99 NDC inpatient 1 UN 339.58 220.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.62 329.39 MIDAZOLAM HCL 2 MG/ML SYRUP 48875318_1 CDM 0250 RC 00054-3566-99 NDC inpatient 1 UN 339.58 220.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.62 329.39 MIDAZOLAM HCL 2 MG/ML SYRUP 48875318_1 CDM 0250 RC 00054-3566-99 NDC inpatient 1 UN 339.58 220.73 ANTHEM HMO ANTHEM HMO 999999999 205.62 329.39 MIDAZOLAM HCL 2 MG/ML SYRUP 48875318_1 CDM 0250 RC 00054-3566-99 NDC inpatient 1 UN 339.58 220.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.62 329.39 MIDAZOLAM HCL 2 MG/ML SYRUP 48875318_1 CDM 0250 RC 00054-3566-99 NDC inpatient 1 UN 339.58 220.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.56 67.6 999999999 205.62 329.39 percent of total billed charges MIDAZOLAM HCL 2 MG/ML SYRUP 48875318_1 CDM 0250 RC 00054-3566-99 NDC inpatient 1 UN 339.58 220.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.62 329.39 "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 48875403_1 CDM 0250 RC 00487-9701-01 NDC J7633 HCPCS inpatient 1 UN 32.09 20.86 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.86 65 999999999 19.43 31.13 percent of total billed charges "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 48875403_1 CDM 0250 RC 00487-9701-01 NDC J7633 HCPCS inpatient 1 UN 32.09 20.86 AETNA AETNA 25.35 79 999999999 19.43 31.13 percent of total billed charges "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 48875403_1 CDM 0250 RC 00487-9701-01 NDC J7633 HCPCS inpatient 1 UN 32.09 20.86 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.14 69 999999999 19.43 31.13 percent of total billed charges "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 48875403_1 CDM 0250 RC 00487-9701-01 NDC J7633 HCPCS inpatient 1 UN 32.09 20.86 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31.13 97 999999999 19.43 31.13 percent of total billed charges "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 48875403_1 CDM 0250 RC 00487-9701-01 NDC J7633 HCPCS inpatient 1 UN 32.09 20.86 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.03 78 999999999 19.43 31.13 percent of total billed charges "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 48875403_1 CDM 0250 RC 00487-9701-01 NDC J7633 HCPCS inpatient 1 UN 32.09 20.86 SIHO - ALL PLANS SIHO - ALL PLANS 28.88 90 999999999 19.43 31.13 percent of total billed charges "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 48875403_1 CDM 0250 RC 00487-9701-01 NDC J7633 HCPCS inpatient 1 UN 32.09 20.86 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.43 60.55 999999999 19.43 31.13 percent of total billed charges "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 48875403_1 CDM 0250 RC 00487-9701-01 NDC J7633 HCPCS inpatient 1 UN 32.09 20.86 UMR - ALL PLANS UMR - ALL PLANS 22.46 70 999999999 19.43 31.13 percent of total billed charges "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 48875403_1 CDM 0250 RC 00487-9701-01 NDC J7633 HCPCS inpatient 1 UN 32.09 20.86 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.43 31.13 "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 48875403_1 CDM 0250 RC 00487-9701-01 NDC J7633 HCPCS inpatient 1 UN 32.09 20.86 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.43 31.13 "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 48875403_1 CDM 0250 RC 00487-9701-01 NDC J7633 HCPCS inpatient 1 UN 32.09 20.86 ANTHEM HMO ANTHEM HMO 999999999 19.43 31.13 "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 48875403_1 CDM 0250 RC 00487-9701-01 NDC J7633 HCPCS inpatient 1 UN 32.09 20.86 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.43 31.13 "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 48875403_1 CDM 0250 RC 00487-9701-01 NDC J7633 HCPCS inpatient 1 UN 32.09 20.86 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.69 67.6 999999999 19.43 31.13 percent of total billed charges "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 48875403_1 CDM 0250 RC 00487-9701-01 NDC J7633 HCPCS inpatient 1 UN 32.09 20.86 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.43 31.13 BUPROPION HCL XL 300 MG TABLET 48892338_1 CDM 0250 RC 68084-0252-21 NDC inpatient 1 UN 4.8 3.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.12 65 999999999 2.91 4.66 percent of total billed charges BUPROPION HCL XL 300 MG TABLET 48892338_1 CDM 0250 RC 68084-0252-21 NDC inpatient 1 UN 4.8 3.12 AETNA AETNA 3.79 79 999999999 2.91 4.66 percent of total billed charges BUPROPION HCL XL 300 MG TABLET 48892338_1 CDM 0250 RC 68084-0252-21 NDC inpatient 1 UN 4.8 3.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.31 69 999999999 2.91 4.66 percent of total billed charges BUPROPION HCL XL 300 MG TABLET 48892338_1 CDM 0250 RC 68084-0252-21 NDC inpatient 1 UN 4.8 3.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4.66 97 999999999 2.91 4.66 percent of total billed charges BUPROPION HCL XL 300 MG TABLET 48892338_1 CDM 0250 RC 68084-0252-21 NDC inpatient 1 UN 4.8 3.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.74 78 999999999 2.91 4.66 percent of total billed charges BUPROPION HCL XL 300 MG TABLET 48892338_1 CDM 0250 RC 68084-0252-21 NDC inpatient 1 UN 4.8 3.12 SIHO - ALL PLANS SIHO - ALL PLANS 4.32 90 999999999 2.91 4.66 percent of total billed charges BUPROPION HCL XL 300 MG TABLET 48892338_1 CDM 0250 RC 68084-0252-21 NDC inpatient 1 UN 4.8 3.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.91 60.55 999999999 2.91 4.66 percent of total billed charges BUPROPION HCL XL 300 MG TABLET 48892338_1 CDM 0250 RC 68084-0252-21 NDC inpatient 1 UN 4.8 3.12 UMR - ALL PLANS UMR - ALL PLANS 3.36 70 999999999 2.91 4.66 percent of total billed charges BUPROPION HCL XL 300 MG TABLET 48892338_1 CDM 0250 RC 68084-0252-21 NDC inpatient 1 UN 4.8 3.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.91 4.66 BUPROPION HCL XL 300 MG TABLET 48892338_1 CDM 0250 RC 68084-0252-21 NDC inpatient 1 UN 4.8 3.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.91 4.66 BUPROPION HCL XL 300 MG TABLET 48892338_1 CDM 0250 RC 68084-0252-21 NDC inpatient 1 UN 4.8 3.12 ANTHEM HMO ANTHEM HMO 999999999 2.91 4.66 BUPROPION HCL XL 300 MG TABLET 48892338_1 CDM 0250 RC 68084-0252-21 NDC inpatient 1 UN 4.8 3.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.91 4.66 BUPROPION HCL XL 300 MG TABLET 48892338_1 CDM 0250 RC 68084-0252-21 NDC inpatient 1 UN 4.8 3.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.24 67.6 999999999 2.91 4.66 percent of total billed charges BUPROPION HCL XL 300 MG TABLET 48892338_1 CDM 0250 RC 68084-0252-21 NDC inpatient 1 UN 4.8 3.12 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.91 4.66 Concentration of specimen for infectious agents 48893994_1 CDM 0306 RC 87015 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges Concentration of specimen for infectious agents 48893994_1 CDM 0306 RC 87015 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges Concentration of specimen for infectious agents 48893994_1 CDM 0306 RC 87015 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges Concentration of specimen for infectious agents 48893994_1 CDM 0306 RC 87015 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges Concentration of specimen for infectious agents 48893994_1 CDM 0306 RC 87015 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges Concentration of specimen for infectious agents 48893994_1 CDM 0306 RC 87015 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges Concentration of specimen for infectious agents 48893994_1 CDM 0306 RC 87015 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges Concentration of specimen for infectious agents 48893994_1 CDM 0306 RC 87015 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges Concentration of specimen for infectious agents 48893994_1 CDM 0306 RC 87015 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 Concentration of specimen for infectious agents 48893994_1 CDM 0306 RC 87015 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 Concentration of specimen for infectious agents 48893994_1 CDM 0306 RC 87015 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 Concentration of specimen for infectious agents 48893994_1 CDM 0306 RC 87015 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 Concentration of specimen for infectious agents 48893994_1 CDM 0306 RC 87015 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges Concentration of specimen for infectious agents 48893994_1 CDM 0306 RC 87015 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 Other service or procedure on lung 4890616_1 CDM 0460 RC 94799 HCPCS inpatient 436 283.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 283.4 65 999999999 264 422.92 percent of total billed charges Other service or procedure on lung 4890616_1 CDM 0460 RC 94799 HCPCS inpatient 436 283.4 AETNA AETNA 344.44 79 999999999 264 422.92 percent of total billed charges Other service or procedure on lung 4890616_1 CDM 0460 RC 94799 HCPCS inpatient 436 283.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 300.84 69 999999999 264 422.92 percent of total billed charges Other service or procedure on lung 4890616_1 CDM 0460 RC 94799 HCPCS inpatient 436 283.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 422.92 97 999999999 264 422.92 percent of total billed charges Other service or procedure on lung 4890616_1 CDM 0460 RC 94799 HCPCS inpatient 436 283.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 340.08 78 999999999 264 422.92 percent of total billed charges Other service or procedure on lung 4890616_1 CDM 0460 RC 94799 HCPCS inpatient 436 283.4 SIHO - ALL PLANS SIHO - ALL PLANS 392.4 90 999999999 264 422.92 percent of total billed charges Other service or procedure on lung 4890616_1 CDM 0460 RC 94799 HCPCS inpatient 436 283.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 264 60.55 999999999 264 422.92 percent of total billed charges Other service or procedure on lung 4890616_1 CDM 0460 RC 94799 HCPCS inpatient 436 283.4 UMR - ALL PLANS UMR - ALL PLANS 305.2 70 999999999 264 422.92 percent of total billed charges Other service or procedure on lung 4890616_1 CDM 0460 RC 94799 HCPCS inpatient 436 283.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 264 422.92 Other service or procedure on lung 4890616_1 CDM 0460 RC 94799 HCPCS inpatient 436 283.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 264 422.92 Other service or procedure on lung 4890616_1 CDM 0460 RC 94799 HCPCS inpatient 436 283.4 ANTHEM HMO ANTHEM HMO 999999999 264 422.92 Other service or procedure on lung 4890616_1 CDM 0460 RC 94799 HCPCS inpatient 436 283.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 264 422.92 Other service or procedure on lung 4890616_1 CDM 0460 RC 94799 HCPCS inpatient 436 283.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 294.74 67.6 999999999 264 422.92 percent of total billed charges Other service or procedure on lung 4890616_1 CDM 0460 RC 94799 HCPCS inpatient 436 283.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 264 422.92 Ultrasound measurement of bladder capacity after voiding 4890742_1 CDM 0761 RC 51798 HCPCS inpatient 123 79.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.95 65 999999999 74.48 119.31 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 4890742_1 CDM 0761 RC 51798 HCPCS inpatient 123 79.95 AETNA AETNA 97.17 79 999999999 74.48 119.31 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 4890742_1 CDM 0761 RC 51798 HCPCS inpatient 123 79.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.87 69 999999999 74.48 119.31 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 4890742_1 CDM 0761 RC 51798 HCPCS inpatient 123 79.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 119.31 97 999999999 74.48 119.31 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 4890742_1 CDM 0761 RC 51798 HCPCS inpatient 123 79.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.94 78 999999999 74.48 119.31 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 4890742_1 CDM 0761 RC 51798 HCPCS inpatient 123 79.95 SIHO - ALL PLANS SIHO - ALL PLANS 110.7 90 999999999 74.48 119.31 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 4890742_1 CDM 0761 RC 51798 HCPCS inpatient 123 79.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 74.48 60.55 999999999 74.48 119.31 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 4890742_1 CDM 0761 RC 51798 HCPCS inpatient 123 79.95 UMR - ALL PLANS UMR - ALL PLANS 86.1 70 999999999 74.48 119.31 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 4890742_1 CDM 0761 RC 51798 HCPCS inpatient 123 79.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 74.48 119.31 Ultrasound measurement of bladder capacity after voiding 4890742_1 CDM 0761 RC 51798 HCPCS inpatient 123 79.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 74.48 119.31 Ultrasound measurement of bladder capacity after voiding 4890742_1 CDM 0761 RC 51798 HCPCS inpatient 123 79.95 ANTHEM HMO ANTHEM HMO 999999999 74.48 119.31 Ultrasound measurement of bladder capacity after voiding 4890742_1 CDM 0761 RC 51798 HCPCS inpatient 123 79.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 74.48 119.31 Ultrasound measurement of bladder capacity after voiding 4890742_1 CDM 0761 RC 51798 HCPCS inpatient 123 79.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.15 67.6 999999999 74.48 119.31 percent of total billed charges Ultrasound measurement of bladder capacity after voiding 4890742_1 CDM 0761 RC 51798 HCPCS inpatient 123 79.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 74.48 119.31 Hepatitis B surface antibody measurement 48923401_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 48923401_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 48923401_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 48923401_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 48923401_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 48923401_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 48923401_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 48923401_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 48923401_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 Hepatitis B surface antibody measurement 48923401_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 Hepatitis B surface antibody measurement 48923401_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 Hepatitis B surface antibody measurement 48923401_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 Hepatitis B surface antibody measurement 48923401_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 48923401_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 Other service or procedure on lung 48943054_1 CDM 0730 RC 94799 HCPCS inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges Other service or procedure on lung 48943054_1 CDM 0730 RC 94799 HCPCS inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges Other service or procedure on lung 48943054_1 CDM 0730 RC 94799 HCPCS inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges Other service or procedure on lung 48943054_1 CDM 0730 RC 94799 HCPCS inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges Other service or procedure on lung 48943054_1 CDM 0730 RC 94799 HCPCS inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges Other service or procedure on lung 48943054_1 CDM 0730 RC 94799 HCPCS inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges Other service or procedure on lung 48943054_1 CDM 0730 RC 94799 HCPCS inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges Other service or procedure on lung 48943054_1 CDM 0730 RC 94799 HCPCS inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges Other service or procedure on lung 48943054_1 CDM 0730 RC 94799 HCPCS inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 Other service or procedure on lung 48943054_1 CDM 0730 RC 94799 HCPCS inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 Other service or procedure on lung 48943054_1 CDM 0730 RC 94799 HCPCS inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 Other service or procedure on lung 48943054_1 CDM 0730 RC 94799 HCPCS inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 Other service or procedure on lung 48943054_1 CDM 0730 RC 94799 HCPCS inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges Other service or procedure on lung 48943054_1 CDM 0730 RC 94799 HCPCS inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 "Opioids levels, 1 or 2" 48958353_1 CDM 0301 RC 80362 HCPCS inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges "Opioids levels, 1 or 2" 48958353_1 CDM 0301 RC 80362 HCPCS inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges "Opioids levels, 1 or 2" 48958353_1 CDM 0301 RC 80362 HCPCS inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges "Opioids levels, 1 or 2" 48958353_1 CDM 0301 RC 80362 HCPCS inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges "Opioids levels, 1 or 2" 48958353_1 CDM 0301 RC 80362 HCPCS inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges "Opioids levels, 1 or 2" 48958353_1 CDM 0301 RC 80362 HCPCS inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges "Opioids levels, 1 or 2" 48958353_1 CDM 0301 RC 80362 HCPCS inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges "Opioids levels, 1 or 2" 48958353_1 CDM 0301 RC 80362 HCPCS inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges "Opioids levels, 1 or 2" 48958353_1 CDM 0301 RC 80362 HCPCS inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 "Opioids levels, 1 or 2" 48958353_1 CDM 0301 RC 80362 HCPCS inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 "Opioids levels, 1 or 2" 48958353_1 CDM 0301 RC 80362 HCPCS inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 "Opioids levels, 1 or 2" 48958353_1 CDM 0301 RC 80362 HCPCS inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 "Opioids levels, 1 or 2" 48958353_1 CDM 0301 RC 80362 HCPCS inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges "Opioids levels, 1 or 2" 48958353_1 CDM 0301 RC 80362 HCPCS inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 "Analysis for antibody, Treponema pallidum" 48958355_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 48958355_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 48958355_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 48958355_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 48958355_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 48958355_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 48958355_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 48958355_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 48958355_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 "Analysis for antibody, Treponema pallidum" 48958355_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 "Analysis for antibody, Treponema pallidum" 48958355_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 "Analysis for antibody, Treponema pallidum" 48958355_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 "Analysis for antibody, Treponema pallidum" 48958355_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 48958355_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 Methylenedioxyamphetamines levels 48958356_1 CDM 0300 RC 80359 HCPCS inpatient 388 252.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 252.2 65 999999999 234.93 376.36 percent of total billed charges Methylenedioxyamphetamines levels 48958356_1 CDM 0300 RC 80359 HCPCS inpatient 388 252.2 AETNA AETNA 306.52 79 999999999 234.93 376.36 percent of total billed charges Methylenedioxyamphetamines levels 48958356_1 CDM 0300 RC 80359 HCPCS inpatient 388 252.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.72 69 999999999 234.93 376.36 percent of total billed charges Methylenedioxyamphetamines levels 48958356_1 CDM 0300 RC 80359 HCPCS inpatient 388 252.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 376.36 97 999999999 234.93 376.36 percent of total billed charges Methylenedioxyamphetamines levels 48958356_1 CDM 0300 RC 80359 HCPCS inpatient 388 252.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 302.64 78 999999999 234.93 376.36 percent of total billed charges Methylenedioxyamphetamines levels 48958356_1 CDM 0300 RC 80359 HCPCS inpatient 388 252.2 SIHO - ALL PLANS SIHO - ALL PLANS 349.2 90 999999999 234.93 376.36 percent of total billed charges Methylenedioxyamphetamines levels 48958356_1 CDM 0300 RC 80359 HCPCS inpatient 388 252.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.93 60.55 999999999 234.93 376.36 percent of total billed charges Methylenedioxyamphetamines levels 48958356_1 CDM 0300 RC 80359 HCPCS inpatient 388 252.2 UMR - ALL PLANS UMR - ALL PLANS 271.6 70 999999999 234.93 376.36 percent of total billed charges Methylenedioxyamphetamines levels 48958356_1 CDM 0300 RC 80359 HCPCS inpatient 388 252.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.93 376.36 Methylenedioxyamphetamines levels 48958356_1 CDM 0300 RC 80359 HCPCS inpatient 388 252.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.93 376.36 Methylenedioxyamphetamines levels 48958356_1 CDM 0300 RC 80359 HCPCS inpatient 388 252.2 ANTHEM HMO ANTHEM HMO 999999999 234.93 376.36 Methylenedioxyamphetamines levels 48958356_1 CDM 0300 RC 80359 HCPCS inpatient 388 252.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.93 376.36 Methylenedioxyamphetamines levels 48958356_1 CDM 0300 RC 80359 HCPCS inpatient 388 252.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 262.29 67.6 999999999 234.93 376.36 percent of total billed charges Methylenedioxyamphetamines levels 48958356_1 CDM 0300 RC 80359 HCPCS inpatient 388 252.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.93 376.36 "Benzodiazepines levels, 1-12" 48958357_1 CDM 0301 RC 80346 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges "Benzodiazepines levels, 1-12" 48958357_1 CDM 0301 RC 80346 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges "Benzodiazepines levels, 1-12" 48958357_1 CDM 0301 RC 80346 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges "Benzodiazepines levels, 1-12" 48958357_1 CDM 0301 RC 80346 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges "Benzodiazepines levels, 1-12" 48958357_1 CDM 0301 RC 80346 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges "Benzodiazepines levels, 1-12" 48958357_1 CDM 0301 RC 80346 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges "Benzodiazepines levels, 1-12" 48958357_1 CDM 0301 RC 80346 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges "Benzodiazepines levels, 1-12" 48958357_1 CDM 0301 RC 80346 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges "Benzodiazepines levels, 1-12" 48958357_1 CDM 0301 RC 80346 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 "Benzodiazepines levels, 1-12" 48958357_1 CDM 0301 RC 80346 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 "Benzodiazepines levels, 1-12" 48958357_1 CDM 0301 RC 80346 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 "Benzodiazepines levels, 1-12" 48958357_1 CDM 0301 RC 80346 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 "Benzodiazepines levels, 1-12" 48958357_1 CDM 0301 RC 80346 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges "Benzodiazepines levels, 1-12" 48958357_1 CDM 0301 RC 80346 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 Heroin metabolite level 48958358_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.2 65 999999999 113.83 182.36 percent of total billed charges Heroin metabolite level 48958358_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 AETNA AETNA 148.52 79 999999999 113.83 182.36 percent of total billed charges Heroin metabolite level 48958358_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.72 69 999999999 113.83 182.36 percent of total billed charges Heroin metabolite level 48958358_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 182.36 97 999999999 113.83 182.36 percent of total billed charges Heroin metabolite level 48958358_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 146.64 78 999999999 113.83 182.36 percent of total billed charges Heroin metabolite level 48958358_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 SIHO - ALL PLANS SIHO - ALL PLANS 169.2 90 999999999 113.83 182.36 percent of total billed charges Heroin metabolite level 48958358_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.83 60.55 999999999 113.83 182.36 percent of total billed charges Heroin metabolite level 48958358_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 UMR - ALL PLANS UMR - ALL PLANS 131.6 70 999999999 113.83 182.36 percent of total billed charges Heroin metabolite level 48958358_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.83 182.36 Heroin metabolite level 48958358_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.83 182.36 Heroin metabolite level 48958358_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 ANTHEM HMO ANTHEM HMO 999999999 113.83 182.36 Heroin metabolite level 48958358_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.83 182.36 Heroin metabolite level 48958358_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.09 67.6 999999999 113.83 182.36 percent of total billed charges Heroin metabolite level 48958358_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.83 182.36 Exam of uterus with destruction of lining of uterus using an endoscope 48961335_1 CDM 0360 RC 58563 HCPCS inpatient 3644.2 2368.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 2368.73 65 999999999 2206.56 3534.87 percent of total billed charges Exam of uterus with destruction of lining of uterus using an endoscope 48961335_1 CDM 0360 RC 58563 HCPCS inpatient 3644.2 2368.73 AETNA AETNA 2878.92 79 999999999 2206.56 3534.87 percent of total billed charges Exam of uterus with destruction of lining of uterus using an endoscope 48961335_1 CDM 0360 RC 58563 HCPCS inpatient 3644.2 2368.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 2514.5 69 999999999 2206.56 3534.87 percent of total billed charges Exam of uterus with destruction of lining of uterus using an endoscope 48961335_1 CDM 0360 RC 58563 HCPCS inpatient 3644.2 2368.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3534.87 97 999999999 2206.56 3534.87 percent of total billed charges Exam of uterus with destruction of lining of uterus using an endoscope 48961335_1 CDM 0360 RC 58563 HCPCS inpatient 3644.2 2368.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 2842.48 78 999999999 2206.56 3534.87 percent of total billed charges Exam of uterus with destruction of lining of uterus using an endoscope 48961335_1 CDM 0360 RC 58563 HCPCS inpatient 3644.2 2368.73 SIHO - ALL PLANS SIHO - ALL PLANS 3279.78 90 999999999 2206.56 3534.87 percent of total billed charges Exam of uterus with destruction of lining of uterus using an endoscope 48961335_1 CDM 0360 RC 58563 HCPCS inpatient 3644.2 2368.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2206.56 60.55 999999999 2206.56 3534.87 percent of total billed charges Exam of uterus with destruction of lining of uterus using an endoscope 48961335_1 CDM 0360 RC 58563 HCPCS inpatient 3644.2 2368.73 UMR - ALL PLANS UMR - ALL PLANS 2550.94 70 999999999 2206.56 3534.87 percent of total billed charges Exam of uterus with destruction of lining of uterus using an endoscope 48961335_1 CDM 0360 RC 58563 HCPCS inpatient 3644.2 2368.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2206.56 3534.87 Exam of uterus with destruction of lining of uterus using an endoscope 48961335_1 CDM 0360 RC 58563 HCPCS inpatient 3644.2 2368.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2206.56 3534.87 Exam of uterus with destruction of lining of uterus using an endoscope 48961335_1 CDM 0360 RC 58563 HCPCS inpatient 3644.2 2368.73 ANTHEM HMO ANTHEM HMO 999999999 2206.56 3534.87 Exam of uterus with destruction of lining of uterus using an endoscope 48961335_1 CDM 0360 RC 58563 HCPCS inpatient 3644.2 2368.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2206.56 3534.87 Exam of uterus with destruction of lining of uterus using an endoscope 48961335_1 CDM 0360 RC 58563 HCPCS inpatient 3644.2 2368.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 2463.48 67.6 999999999 2206.56 3534.87 percent of total billed charges Exam of uterus with destruction of lining of uterus using an endoscope 48961335_1 CDM 0360 RC 58563 HCPCS inpatient 3644.2 2368.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 2206.56 3534.87 Handling and/or conveyance of specimen for transfer from physician office to laboratory 48970816_1 CDM 0309 RC 99000 HCPCS inpatient 42 27.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 27.3 65 999999999 25.43 40.74 percent of total billed charges Handling and/or conveyance of specimen for transfer from physician office to laboratory 48970816_1 CDM 0309 RC 99000 HCPCS inpatient 42 27.3 AETNA AETNA 33.18 79 999999999 25.43 40.74 percent of total billed charges Handling and/or conveyance of specimen for transfer from physician office to laboratory 48970816_1 CDM 0309 RC 99000 HCPCS inpatient 42 27.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.98 69 999999999 25.43 40.74 percent of total billed charges Handling and/or conveyance of specimen for transfer from physician office to laboratory 48970816_1 CDM 0309 RC 99000 HCPCS inpatient 42 27.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 40.74 97 999999999 25.43 40.74 percent of total billed charges Handling and/or conveyance of specimen for transfer from physician office to laboratory 48970816_1 CDM 0309 RC 99000 HCPCS inpatient 42 27.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 32.76 78 999999999 25.43 40.74 percent of total billed charges Handling and/or conveyance of specimen for transfer from physician office to laboratory 48970816_1 CDM 0309 RC 99000 HCPCS inpatient 42 27.3 SIHO - ALL PLANS SIHO - ALL PLANS 37.8 90 999999999 25.43 40.74 percent of total billed charges Handling and/or conveyance of specimen for transfer from physician office to laboratory 48970816_1 CDM 0309 RC 99000 HCPCS inpatient 42 27.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 25.43 60.55 999999999 25.43 40.74 percent of total billed charges Handling and/or conveyance of specimen for transfer from physician office to laboratory 48970816_1 CDM 0309 RC 99000 HCPCS inpatient 42 27.3 UMR - ALL PLANS UMR - ALL PLANS 29.4 70 999999999 25.43 40.74 percent of total billed charges Handling and/or conveyance of specimen for transfer from physician office to laboratory 48970816_1 CDM 0309 RC 99000 HCPCS inpatient 42 27.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 25.43 40.74 Handling and/or conveyance of specimen for transfer from physician office to laboratory 48970816_1 CDM 0309 RC 99000 HCPCS inpatient 42 27.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 25.43 40.74 Handling and/or conveyance of specimen for transfer from physician office to laboratory 48970816_1 CDM 0309 RC 99000 HCPCS inpatient 42 27.3 ANTHEM HMO ANTHEM HMO 999999999 25.43 40.74 Handling and/or conveyance of specimen for transfer from physician office to laboratory 48970816_1 CDM 0309 RC 99000 HCPCS inpatient 42 27.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 25.43 40.74 Handling and/or conveyance of specimen for transfer from physician office to laboratory 48970816_1 CDM 0309 RC 99000 HCPCS inpatient 42 27.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 28.39 67.6 999999999 25.43 40.74 percent of total billed charges Handling and/or conveyance of specimen for transfer from physician office to laboratory 48970816_1 CDM 0309 RC 99000 HCPCS inpatient 42 27.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 25.43 40.74 DRUG SCREEN NON TLC DEVICES 48970817_1 CDM 0309 RC 80300 HCPCS inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges DRUG SCREEN NON TLC DEVICES 48970817_1 CDM 0309 RC 80300 HCPCS inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges DRUG SCREEN NON TLC DEVICES 48970817_1 CDM 0309 RC 80300 HCPCS inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges DRUG SCREEN NON TLC DEVICES 48970817_1 CDM 0309 RC 80300 HCPCS inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges DRUG SCREEN NON TLC DEVICES 48970817_1 CDM 0309 RC 80300 HCPCS inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges DRUG SCREEN NON TLC DEVICES 48970817_1 CDM 0309 RC 80300 HCPCS inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges DRUG SCREEN NON TLC DEVICES 48970817_1 CDM 0309 RC 80300 HCPCS inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges DRUG SCREEN NON TLC DEVICES 48970817_1 CDM 0309 RC 80300 HCPCS inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges DRUG SCREEN NON TLC DEVICES 48970817_1 CDM 0309 RC 80300 HCPCS inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 DRUG SCREEN NON TLC DEVICES 48970817_1 CDM 0309 RC 80300 HCPCS inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 DRUG SCREEN NON TLC DEVICES 48970817_1 CDM 0309 RC 80300 HCPCS inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 DRUG SCREEN NON TLC DEVICES 48970817_1 CDM 0309 RC 80300 HCPCS inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 DRUG SCREEN NON TLC DEVICES 48970817_1 CDM 0309 RC 80300 HCPCS inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges DRUG SCREEN NON TLC DEVICES 48970817_1 CDM 0309 RC 80300 HCPCS inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 "Testing for presence of drug, read by instrument assisted observation" 48970819_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 43.55 65 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, read by instrument assisted observation" 48970819_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 AETNA AETNA 52.93 79 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, read by instrument assisted observation" 48970819_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.23 69 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, read by instrument assisted observation" 48970819_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.99 97 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, read by instrument assisted observation" 48970819_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 52.26 78 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, read by instrument assisted observation" 48970819_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 SIHO - ALL PLANS SIHO - ALL PLANS 60.3 90 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, read by instrument assisted observation" 48970819_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 40.57 60.55 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, read by instrument assisted observation" 48970819_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 UMR - ALL PLANS UMR - ALL PLANS 46.9 70 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, read by instrument assisted observation" 48970819_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 40.57 64.99 "Testing for presence of drug, read by instrument assisted observation" 48970819_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 40.57 64.99 "Testing for presence of drug, read by instrument assisted observation" 48970819_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 ANTHEM HMO ANTHEM HMO 999999999 40.57 64.99 "Testing for presence of drug, read by instrument assisted observation" 48970819_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 40.57 64.99 "Testing for presence of drug, read by instrument assisted observation" 48970819_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.29 67.6 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, read by instrument assisted observation" 48970819_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 40.57 64.99 "Testing for presence of drug, read by instrument assisted observation" 48970820_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 43.55 65 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, read by instrument assisted observation" 48970820_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 AETNA AETNA 52.93 79 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, read by instrument assisted observation" 48970820_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.99 97 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, read by instrument assisted observation" 48970820_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.23 69 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, read by instrument assisted observation" 48970820_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 52.26 78 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, read by instrument assisted observation" 48970820_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 SIHO - ALL PLANS SIHO - ALL PLANS 60.3 90 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, read by instrument assisted observation" 48970820_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 40.57 60.55 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, read by instrument assisted observation" 48970820_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 UMR - ALL PLANS UMR - ALL PLANS 46.9 70 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, read by instrument assisted observation" 48970820_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 40.57 64.99 "Testing for presence of drug, read by instrument assisted observation" 48970820_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 40.57 64.99 "Testing for presence of drug, read by instrument assisted observation" 48970820_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 ANTHEM HMO ANTHEM HMO 999999999 40.57 64.99 "Testing for presence of drug, read by instrument assisted observation" 48970820_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 40.57 64.99 "Testing for presence of drug, read by instrument assisted observation" 48970820_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.29 67.6 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, read by instrument assisted observation" 48970820_1 CDM 0309 RC 80306 HCPCS inpatient 67 43.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 40.57 64.99 DICLOFENAC SOD DR 25 MG TAB 48975556_1 CDM 0250 RC 68001-0279-00 NDC inpatient 1 UN 3.36 2.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.18 65 999999999 2.03 3.26 percent of total billed charges DICLOFENAC SOD DR 25 MG TAB 48975556_1 CDM 0250 RC 68001-0279-00 NDC inpatient 1 UN 3.36 2.18 AETNA AETNA 2.65 79 999999999 2.03 3.26 percent of total billed charges DICLOFENAC SOD DR 25 MG TAB 48975556_1 CDM 0250 RC 68001-0279-00 NDC inpatient 1 UN 3.36 2.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.26 97 999999999 2.03 3.26 percent of total billed charges DICLOFENAC SOD DR 25 MG TAB 48975556_1 CDM 0250 RC 68001-0279-00 NDC inpatient 1 UN 3.36 2.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.32 69 999999999 2.03 3.26 percent of total billed charges DICLOFENAC SOD DR 25 MG TAB 48975556_1 CDM 0250 RC 68001-0279-00 NDC inpatient 1 UN 3.36 2.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.62 78 999999999 2.03 3.26 percent of total billed charges DICLOFENAC SOD DR 25 MG TAB 48975556_1 CDM 0250 RC 68001-0279-00 NDC inpatient 1 UN 3.36 2.18 SIHO - ALL PLANS SIHO - ALL PLANS 3.02 90 999999999 2.03 3.26 percent of total billed charges DICLOFENAC SOD DR 25 MG TAB 48975556_1 CDM 0250 RC 68001-0279-00 NDC inpatient 1 UN 3.36 2.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.03 60.55 999999999 2.03 3.26 percent of total billed charges DICLOFENAC SOD DR 25 MG TAB 48975556_1 CDM 0250 RC 68001-0279-00 NDC inpatient 1 UN 3.36 2.18 UMR - ALL PLANS UMR - ALL PLANS 2.35 70 999999999 2.03 3.26 percent of total billed charges DICLOFENAC SOD DR 25 MG TAB 48975556_1 CDM 0250 RC 68001-0279-00 NDC inpatient 1 UN 3.36 2.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.03 3.26 DICLOFENAC SOD DR 25 MG TAB 48975556_1 CDM 0250 RC 68001-0279-00 NDC inpatient 1 UN 3.36 2.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.03 3.26 DICLOFENAC SOD DR 25 MG TAB 48975556_1 CDM 0250 RC 68001-0279-00 NDC inpatient 1 UN 3.36 2.18 ANTHEM HMO ANTHEM HMO 999999999 2.03 3.26 DICLOFENAC SOD DR 25 MG TAB 48975556_1 CDM 0250 RC 68001-0279-00 NDC inpatient 1 UN 3.36 2.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.03 3.26 DICLOFENAC SOD DR 25 MG TAB 48975556_1 CDM 0250 RC 68001-0279-00 NDC inpatient 1 UN 3.36 2.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.27 67.6 999999999 2.03 3.26 percent of total billed charges DICLOFENAC SOD DR 25 MG TAB 48975556_1 CDM 0250 RC 68001-0279-00 NDC inpatient 1 UN 3.36 2.18 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.03 3.26 TETRACAINE 0.5% STERI-UNIT SOL 48975581_1 CDM 0250 RC 00065-0741-14 NDC inpatient 1 UN 92.86 60.36 SELF PAY DISCOUNT SELF PAY DISCOUNT 60.36 65 999999999 56.23 90.07 percent of total billed charges TETRACAINE 0.5% STERI-UNIT SOL 48975581_1 CDM 0250 RC 00065-0741-14 NDC inpatient 1 UN 92.86 60.36 AETNA AETNA 73.36 79 999999999 56.23 90.07 percent of total billed charges TETRACAINE 0.5% STERI-UNIT SOL 48975581_1 CDM 0250 RC 00065-0741-14 NDC inpatient 1 UN 92.86 60.36 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 90.07 97 999999999 56.23 90.07 percent of total billed charges TETRACAINE 0.5% STERI-UNIT SOL 48975581_1 CDM 0250 RC 00065-0741-14 NDC inpatient 1 UN 92.86 60.36 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.07 69 999999999 56.23 90.07 percent of total billed charges TETRACAINE 0.5% STERI-UNIT SOL 48975581_1 CDM 0250 RC 00065-0741-14 NDC inpatient 1 UN 92.86 60.36 HUMANA - ALL PLANS HUMANA - ALL PLANS 72.43 78 999999999 56.23 90.07 percent of total billed charges TETRACAINE 0.5% STERI-UNIT SOL 48975581_1 CDM 0250 RC 00065-0741-14 NDC inpatient 1 UN 92.86 60.36 SIHO - ALL PLANS SIHO - ALL PLANS 83.57 90 999999999 56.23 90.07 percent of total billed charges TETRACAINE 0.5% STERI-UNIT SOL 48975581_1 CDM 0250 RC 00065-0741-14 NDC inpatient 1 UN 92.86 60.36 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.23 60.55 999999999 56.23 90.07 percent of total billed charges TETRACAINE 0.5% STERI-UNIT SOL 48975581_1 CDM 0250 RC 00065-0741-14 NDC inpatient 1 UN 92.86 60.36 UMR - ALL PLANS UMR - ALL PLANS 65 70 999999999 56.23 90.07 percent of total billed charges TETRACAINE 0.5% STERI-UNIT SOL 48975581_1 CDM 0250 RC 00065-0741-14 NDC inpatient 1 UN 92.86 60.36 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.23 90.07 TETRACAINE 0.5% STERI-UNIT SOL 48975581_1 CDM 0250 RC 00065-0741-14 NDC inpatient 1 UN 92.86 60.36 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.23 90.07 TETRACAINE 0.5% STERI-UNIT SOL 48975581_1 CDM 0250 RC 00065-0741-14 NDC inpatient 1 UN 92.86 60.36 ANTHEM HMO ANTHEM HMO 999999999 56.23 90.07 TETRACAINE 0.5% STERI-UNIT SOL 48975581_1 CDM 0250 RC 00065-0741-14 NDC inpatient 1 UN 92.86 60.36 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.23 90.07 TETRACAINE 0.5% STERI-UNIT SOL 48975581_1 CDM 0250 RC 00065-0741-14 NDC inpatient 1 UN 92.86 60.36 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.77 67.6 999999999 56.23 90.07 percent of total billed charges TETRACAINE 0.5% STERI-UNIT SOL 48975581_1 CDM 0250 RC 00065-0741-14 NDC inpatient 1 UN 92.86 60.36 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.23 90.07 Urine vanillylmandelic acid 48982899_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 235.3 65 999999999 219.19 351.14 percent of total billed charges Urine vanillylmandelic acid 48982899_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 AETNA AETNA 285.98 79 999999999 219.19 351.14 percent of total billed charges Urine vanillylmandelic acid 48982899_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 351.14 97 999999999 219.19 351.14 percent of total billed charges Urine vanillylmandelic acid 48982899_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 249.78 69 999999999 219.19 351.14 percent of total billed charges Urine vanillylmandelic acid 48982899_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 282.36 78 999999999 219.19 351.14 percent of total billed charges Urine vanillylmandelic acid 48982899_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 SIHO - ALL PLANS SIHO - ALL PLANS 325.8 90 999999999 219.19 351.14 percent of total billed charges Urine vanillylmandelic acid 48982899_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 219.19 60.55 999999999 219.19 351.14 percent of total billed charges Urine vanillylmandelic acid 48982899_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 UMR - ALL PLANS UMR - ALL PLANS 253.4 70 999999999 219.19 351.14 percent of total billed charges Urine vanillylmandelic acid 48982899_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 219.19 351.14 Urine vanillylmandelic acid 48982899_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 219.19 351.14 Urine vanillylmandelic acid 48982899_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 ANTHEM HMO ANTHEM HMO 999999999 219.19 351.14 Urine vanillylmandelic acid 48982899_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 219.19 351.14 Urine vanillylmandelic acid 48982899_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 244.71 67.6 999999999 219.19 351.14 percent of total billed charges Urine vanillylmandelic acid 48982899_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 219.19 351.14 Cardiolipin antibody (tissue antibody) measurement 48982917_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 48982917_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 48982917_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 48982917_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 48982917_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 48982917_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 48982917_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 48982917_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 48982917_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 48982917_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 48982917_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 48982917_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 48982917_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 48982917_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 48982919_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 48982919_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 48982919_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 48982919_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 48982919_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 48982919_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 48982919_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 48982919_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 48982919_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 48982919_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 48982919_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 48982919_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 48982919_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 48982919_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 Analysis for antibody to Cytomegalovirus (CMV) 48982944_1 CDM 0302 RC 86644 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Cytomegalovirus (CMV) 48982944_1 CDM 0302 RC 86644 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Cytomegalovirus (CMV) 48982944_1 CDM 0302 RC 86644 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Cytomegalovirus (CMV) 48982944_1 CDM 0302 RC 86644 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Cytomegalovirus (CMV) 48982944_1 CDM 0302 RC 86644 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Cytomegalovirus (CMV) 48982944_1 CDM 0302 RC 86644 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Cytomegalovirus (CMV) 48982944_1 CDM 0302 RC 86644 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Cytomegalovirus (CMV) 48982944_1 CDM 0302 RC 86644 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Cytomegalovirus (CMV) 48982944_1 CDM 0302 RC 86644 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 Analysis for antibody to Cytomegalovirus (CMV) 48982944_1 CDM 0302 RC 86644 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Cytomegalovirus (CMV) 48982944_1 CDM 0302 RC 86644 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 Analysis for antibody to Cytomegalovirus (CMV) 48982944_1 CDM 0302 RC 86644 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Cytomegalovirus (CMV) 48982944_1 CDM 0302 RC 86644 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Cytomegalovirus (CMV) 48982944_1 CDM 0302 RC 86644 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 Analysis for antibody (IgM) to Cytomegalovirus (CMV) 48982945_1 CDM 0302 RC 86645 HCPCS inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges Analysis for antibody (IgM) to Cytomegalovirus (CMV) 48982945_1 CDM 0302 RC 86645 HCPCS inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges Analysis for antibody (IgM) to Cytomegalovirus (CMV) 48982945_1 CDM 0302 RC 86645 HCPCS inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges Analysis for antibody (IgM) to Cytomegalovirus (CMV) 48982945_1 CDM 0302 RC 86645 HCPCS inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges Analysis for antibody (IgM) to Cytomegalovirus (CMV) 48982945_1 CDM 0302 RC 86645 HCPCS inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges Analysis for antibody (IgM) to Cytomegalovirus (CMV) 48982945_1 CDM 0302 RC 86645 HCPCS inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges Analysis for antibody (IgM) to Cytomegalovirus (CMV) 48982945_1 CDM 0302 RC 86645 HCPCS inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges Analysis for antibody (IgM) to Cytomegalovirus (CMV) 48982945_1 CDM 0302 RC 86645 HCPCS inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges Analysis for antibody (IgM) to Cytomegalovirus (CMV) 48982945_1 CDM 0302 RC 86645 HCPCS inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 Analysis for antibody (IgM) to Cytomegalovirus (CMV) 48982945_1 CDM 0302 RC 86645 HCPCS inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 Analysis for antibody (IgM) to Cytomegalovirus (CMV) 48982945_1 CDM 0302 RC 86645 HCPCS inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 Analysis for antibody (IgM) to Cytomegalovirus (CMV) 48982945_1 CDM 0302 RC 86645 HCPCS inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 Analysis for antibody (IgM) to Cytomegalovirus (CMV) 48982945_1 CDM 0302 RC 86645 HCPCS inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges Analysis for antibody (IgM) to Cytomegalovirus (CMV) 48982945_1 CDM 0302 RC 86645 HCPCS inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 Analysis for antibody to Herpes simplex virus 48982946_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982946_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982946_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982946_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982946_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982946_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982946_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982946_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982946_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 48982946_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 48982946_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 48982946_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 48982946_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982946_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 "Analysis for antibody to Herpes simplex virus, type 1" 48982947_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 48982947_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 48982947_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 48982947_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 48982947_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 48982947_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 48982947_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 48982947_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 48982947_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 "Analysis for antibody to Herpes simplex virus, type 1" 48982947_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 "Analysis for antibody to Herpes simplex virus, type 1" 48982947_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 "Analysis for antibody to Herpes simplex virus, type 1" 48982947_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 "Analysis for antibody to Herpes simplex virus, type 1" 48982947_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 48982947_1 CDM 0302 RC 86695 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 Analysis for antibody to Herpes simplex virus 48982948_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982948_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982948_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982948_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982948_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982948_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982948_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982948_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982948_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 48982948_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 48982948_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 48982948_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 48982948_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982948_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 48982949_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982949_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982949_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982949_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982949_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982949_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982949_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982949_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982949_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 48982949_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 48982949_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 48982949_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 48982949_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 48982949_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 Analysis for antibody to parvovirus 48982950_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 126.1 65 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 48982950_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 AETNA AETNA 153.26 79 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 48982950_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 188.18 97 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 48982950_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.86 69 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 48982950_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 151.32 78 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 48982950_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 SIHO - ALL PLANS SIHO - ALL PLANS 174.6 90 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 48982950_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 117.47 60.55 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 48982950_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 UMR - ALL PLANS UMR - ALL PLANS 135.8 70 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 48982950_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 117.47 188.18 Analysis for antibody to parvovirus 48982950_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 117.47 188.18 Analysis for antibody to parvovirus 48982950_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 ANTHEM HMO ANTHEM HMO 999999999 117.47 188.18 Analysis for antibody to parvovirus 48982950_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 117.47 188.18 Analysis for antibody to parvovirus 48982950_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 131.14 67.6 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 48982950_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 117.47 188.18 Analysis for antibody to parvovirus 48982951_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 126.1 65 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 48982951_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 AETNA AETNA 153.26 79 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 48982951_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 188.18 97 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 48982951_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.86 69 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 48982951_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 151.32 78 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 48982951_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 SIHO - ALL PLANS SIHO - ALL PLANS 174.6 90 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 48982951_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 117.47 60.55 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 48982951_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 UMR - ALL PLANS UMR - ALL PLANS 135.8 70 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 48982951_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 117.47 188.18 Analysis for antibody to parvovirus 48982951_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 117.47 188.18 Analysis for antibody to parvovirus 48982951_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 ANTHEM HMO ANTHEM HMO 999999999 117.47 188.18 Analysis for antibody to parvovirus 48982951_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 117.47 188.18 Analysis for antibody to parvovirus 48982951_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 131.14 67.6 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 48982951_1 CDM 0302 RC 86747 HCPCS inpatient 194 126.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 117.47 188.18 Phospholipid antibody (autoimmune antibody) measurement 48982952_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982952_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982952_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982952_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982952_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982952_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982952_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982952_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982952_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 48982952_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 48982952_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 48982952_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 48982952_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982952_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 48982953_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982953_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982953_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982953_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982953_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982953_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982953_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982953_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982953_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 48982953_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 48982953_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 48982953_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 48982953_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982953_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 48982954_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982954_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982954_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982954_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982954_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982954_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982954_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982954_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982954_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 48982954_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 48982954_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 48982954_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 48982954_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 48982954_1 CDM 0301 RC 86148 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 Analysis for antibody to tetanus bacteria (Clostridium tetanus) 48982955_1 CDM 0301 RC 86774 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to tetanus bacteria (Clostridium tetanus) 48982955_1 CDM 0301 RC 86774 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to tetanus bacteria (Clostridium tetanus) 48982955_1 CDM 0301 RC 86774 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to tetanus bacteria (Clostridium tetanus) 48982955_1 CDM 0301 RC 86774 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to tetanus bacteria (Clostridium tetanus) 48982955_1 CDM 0301 RC 86774 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to tetanus bacteria (Clostridium tetanus) 48982955_1 CDM 0301 RC 86774 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to tetanus bacteria (Clostridium tetanus) 48982955_1 CDM 0301 RC 86774 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to tetanus bacteria (Clostridium tetanus) 48982955_1 CDM 0301 RC 86774 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to tetanus bacteria (Clostridium tetanus) 48982955_1 CDM 0301 RC 86774 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 Analysis for antibody to tetanus bacteria (Clostridium tetanus) 48982955_1 CDM 0301 RC 86774 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 Analysis for antibody to tetanus bacteria (Clostridium tetanus) 48982955_1 CDM 0301 RC 86774 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 Analysis for antibody to tetanus bacteria (Clostridium tetanus) 48982955_1 CDM 0301 RC 86774 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 Analysis for antibody to tetanus bacteria (Clostridium tetanus) 48982955_1 CDM 0301 RC 86774 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to tetanus bacteria (Clostridium tetanus) 48982955_1 CDM 0301 RC 86774 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 Analysis for antibody to Diphtheria (bacteria) 48982956_1 CDM 0302 RC 86648 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to Diphtheria (bacteria) 48982956_1 CDM 0302 RC 86648 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to Diphtheria (bacteria) 48982956_1 CDM 0302 RC 86648 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to Diphtheria (bacteria) 48982956_1 CDM 0302 RC 86648 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to Diphtheria (bacteria) 48982956_1 CDM 0302 RC 86648 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to Diphtheria (bacteria) 48982956_1 CDM 0302 RC 86648 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to Diphtheria (bacteria) 48982956_1 CDM 0302 RC 86648 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to Diphtheria (bacteria) 48982956_1 CDM 0302 RC 86648 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to Diphtheria (bacteria) 48982956_1 CDM 0302 RC 86648 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 Analysis for antibody to Diphtheria (bacteria) 48982956_1 CDM 0302 RC 86648 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 Analysis for antibody to Diphtheria (bacteria) 48982956_1 CDM 0302 RC 86648 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 Analysis for antibody to Diphtheria (bacteria) 48982956_1 CDM 0302 RC 86648 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 Analysis for antibody to Diphtheria (bacteria) 48982956_1 CDM 0302 RC 86648 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to Diphtheria (bacteria) 48982956_1 CDM 0302 RC 86648 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 Analysis for antibody to Haemophilus influenza (respiratory bacteria) 48982957_1 CDM 0302 RC 86684 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges Analysis for antibody to Haemophilus influenza (respiratory bacteria) 48982957_1 CDM 0302 RC 86684 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges Analysis for antibody to Haemophilus influenza (respiratory bacteria) 48982957_1 CDM 0302 RC 86684 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges Analysis for antibody to Haemophilus influenza (respiratory bacteria) 48982957_1 CDM 0302 RC 86684 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges Analysis for antibody to Haemophilus influenza (respiratory bacteria) 48982957_1 CDM 0302 RC 86684 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges Analysis for antibody to Haemophilus influenza (respiratory bacteria) 48982957_1 CDM 0302 RC 86684 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges Analysis for antibody to Haemophilus influenza (respiratory bacteria) 48982957_1 CDM 0302 RC 86684 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges Analysis for antibody to Haemophilus influenza (respiratory bacteria) 48982957_1 CDM 0302 RC 86684 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges Analysis for antibody to Haemophilus influenza (respiratory bacteria) 48982957_1 CDM 0302 RC 86684 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 Analysis for antibody to Haemophilus influenza (respiratory bacteria) 48982957_1 CDM 0302 RC 86684 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 Analysis for antibody to Haemophilus influenza (respiratory bacteria) 48982957_1 CDM 0302 RC 86684 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 Analysis for antibody to Haemophilus influenza (respiratory bacteria) 48982957_1 CDM 0302 RC 86684 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 Analysis for antibody to Haemophilus influenza (respiratory bacteria) 48982957_1 CDM 0302 RC 86684 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges Analysis for antibody to Haemophilus influenza (respiratory bacteria) 48982957_1 CDM 0302 RC 86684 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 Analysis for antibody bacteria 48982958_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982958_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982958_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982958_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982958_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982958_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982958_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982958_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982958_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 Analysis for antibody bacteria 48982958_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 Analysis for antibody bacteria 48982958_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 Analysis for antibody bacteria 48982958_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 Analysis for antibody bacteria 48982958_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982958_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 Analysis for antibody bacteria 48982959_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982959_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982959_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982959_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982959_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982959_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982959_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982959_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982959_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 Analysis for antibody bacteria 48982959_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 Analysis for antibody bacteria 48982959_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 Analysis for antibody bacteria 48982959_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 Analysis for antibody bacteria 48982959_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982959_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 Analysis for antibody bacteria 48982960_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982960_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982960_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982960_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982960_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982960_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982960_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982960_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982960_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 Analysis for antibody bacteria 48982960_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 Analysis for antibody bacteria 48982960_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 Analysis for antibody bacteria 48982960_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 Analysis for antibody bacteria 48982960_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982960_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 Analysis for antibody bacteria 48982961_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982961_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982961_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982961_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982961_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982961_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982961_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982961_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982961_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 Analysis for antibody bacteria 48982961_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 Analysis for antibody bacteria 48982961_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 Analysis for antibody bacteria 48982961_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 Analysis for antibody bacteria 48982961_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges Analysis for antibody bacteria 48982961_1 CDM 0302 RC 86609 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982964_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982964_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982964_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982964_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982964_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982964_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982964_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982964_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982964_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982964_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982964_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982964_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982964_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982964_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982965_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982965_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982965_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982965_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982965_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982965_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982965_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982965_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982965_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982965_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982965_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982965_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982965_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982965_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982966_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982966_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982966_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982966_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982966_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982966_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982966_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982966_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982966_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982966_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982966_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982966_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982966_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982966_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982967_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982967_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982967_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982967_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982967_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982967_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982967_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982967_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982967_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982967_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982967_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982967_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982967_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982967_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982968_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982968_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982968_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982968_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982968_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982968_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982968_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982968_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982968_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982968_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982968_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982968_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982968_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982968_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982969_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982969_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982969_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982969_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982969_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982969_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982969_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982969_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982969_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982969_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982969_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982969_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982969_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982969_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982970_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982970_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982970_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982970_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982970_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982970_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982970_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982970_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982970_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982970_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982970_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982970_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982970_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982970_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982971_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982971_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982971_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982971_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982971_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982971_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982971_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982971_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982971_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982971_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982971_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982971_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982971_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982971_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982972_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982972_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982972_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982972_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982972_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982972_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982972_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982972_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982972_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982972_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982972_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982972_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982972_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982972_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 Analysis for antibody to Chlamydia (bacteria) 48982973_1 CDM 0302 RC 86631 HCPCS inpatient 85 55.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.25 65 999999999 51.47 82.45 percent of total billed charges Analysis for antibody to Chlamydia (bacteria) 48982973_1 CDM 0302 RC 86631 HCPCS inpatient 85 55.25 AETNA AETNA 67.15 79 999999999 51.47 82.45 percent of total billed charges Analysis for antibody to Chlamydia (bacteria) 48982973_1 CDM 0302 RC 86631 HCPCS inpatient 85 55.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 82.45 97 999999999 51.47 82.45 percent of total billed charges Analysis for antibody to Chlamydia (bacteria) 48982973_1 CDM 0302 RC 86631 HCPCS inpatient 85 55.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 58.65 69 999999999 51.47 82.45 percent of total billed charges Analysis for antibody to Chlamydia (bacteria) 48982973_1 CDM 0302 RC 86631 HCPCS inpatient 85 55.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 66.3 78 999999999 51.47 82.45 percent of total billed charges Analysis for antibody to Chlamydia (bacteria) 48982973_1 CDM 0302 RC 86631 HCPCS inpatient 85 55.25 SIHO - ALL PLANS SIHO - ALL PLANS 76.5 90 999999999 51.47 82.45 percent of total billed charges Analysis for antibody to Chlamydia (bacteria) 48982973_1 CDM 0302 RC 86631 HCPCS inpatient 85 55.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 51.47 60.55 999999999 51.47 82.45 percent of total billed charges Analysis for antibody to Chlamydia (bacteria) 48982973_1 CDM 0302 RC 86631 HCPCS inpatient 85 55.25 UMR - ALL PLANS UMR - ALL PLANS 59.5 70 999999999 51.47 82.45 percent of total billed charges Analysis for antibody to Chlamydia (bacteria) 48982973_1 CDM 0302 RC 86631 HCPCS inpatient 85 55.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 51.47 82.45 Analysis for antibody to Chlamydia (bacteria) 48982973_1 CDM 0302 RC 86631 HCPCS inpatient 85 55.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 51.47 82.45 Analysis for antibody to Chlamydia (bacteria) 48982973_1 CDM 0302 RC 86631 HCPCS inpatient 85 55.25 ANTHEM HMO ANTHEM HMO 999999999 51.47 82.45 Analysis for antibody to Chlamydia (bacteria) 48982973_1 CDM 0302 RC 86631 HCPCS inpatient 85 55.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 51.47 82.45 Analysis for antibody to Chlamydia (bacteria) 48982973_1 CDM 0302 RC 86631 HCPCS inpatient 85 55.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 57.46 67.6 999999999 51.47 82.45 percent of total billed charges Analysis for antibody to Chlamydia (bacteria) 48982973_1 CDM 0302 RC 86631 HCPCS inpatient 85 55.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 51.47 82.45 Analysis for antibody (IgM) to Chlamydia (bacteria) 48982974_1 CDM 0302 RC 86632 HCPCS inpatient 85 55.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.25 65 999999999 51.47 82.45 percent of total billed charges Analysis for antibody (IgM) to Chlamydia (bacteria) 48982974_1 CDM 0302 RC 86632 HCPCS inpatient 85 55.25 AETNA AETNA 67.15 79 999999999 51.47 82.45 percent of total billed charges Analysis for antibody (IgM) to Chlamydia (bacteria) 48982974_1 CDM 0302 RC 86632 HCPCS inpatient 85 55.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 82.45 97 999999999 51.47 82.45 percent of total billed charges Analysis for antibody (IgM) to Chlamydia (bacteria) 48982974_1 CDM 0302 RC 86632 HCPCS inpatient 85 55.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 58.65 69 999999999 51.47 82.45 percent of total billed charges Analysis for antibody (IgM) to Chlamydia (bacteria) 48982974_1 CDM 0302 RC 86632 HCPCS inpatient 85 55.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 66.3 78 999999999 51.47 82.45 percent of total billed charges Analysis for antibody (IgM) to Chlamydia (bacteria) 48982974_1 CDM 0302 RC 86632 HCPCS inpatient 85 55.25 SIHO - ALL PLANS SIHO - ALL PLANS 76.5 90 999999999 51.47 82.45 percent of total billed charges Analysis for antibody (IgM) to Chlamydia (bacteria) 48982974_1 CDM 0302 RC 86632 HCPCS inpatient 85 55.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 51.47 60.55 999999999 51.47 82.45 percent of total billed charges Analysis for antibody (IgM) to Chlamydia (bacteria) 48982974_1 CDM 0302 RC 86632 HCPCS inpatient 85 55.25 UMR - ALL PLANS UMR - ALL PLANS 59.5 70 999999999 51.47 82.45 percent of total billed charges Analysis for antibody (IgM) to Chlamydia (bacteria) 48982974_1 CDM 0302 RC 86632 HCPCS inpatient 85 55.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 51.47 82.45 Analysis for antibody (IgM) to Chlamydia (bacteria) 48982974_1 CDM 0302 RC 86632 HCPCS inpatient 85 55.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 51.47 82.45 Analysis for antibody (IgM) to Chlamydia (bacteria) 48982974_1 CDM 0302 RC 86632 HCPCS inpatient 85 55.25 ANTHEM HMO ANTHEM HMO 999999999 51.47 82.45 Analysis for antibody (IgM) to Chlamydia (bacteria) 48982974_1 CDM 0302 RC 86632 HCPCS inpatient 85 55.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 51.47 82.45 Analysis for antibody (IgM) to Chlamydia (bacteria) 48982974_1 CDM 0302 RC 86632 HCPCS inpatient 85 55.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 57.46 67.6 999999999 51.47 82.45 percent of total billed charges Analysis for antibody (IgM) to Chlamydia (bacteria) 48982974_1 CDM 0302 RC 86632 HCPCS inpatient 85 55.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 51.47 82.45 Analysis for antibody to Chlamydia (bacteria) 48982975_1 CDM 0302 RC 86631 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to Chlamydia (bacteria) 48982975_1 CDM 0302 RC 86631 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to Chlamydia (bacteria) 48982975_1 CDM 0302 RC 86631 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to Chlamydia (bacteria) 48982975_1 CDM 0302 RC 86631 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to Chlamydia (bacteria) 48982975_1 CDM 0302 RC 86631 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to Chlamydia (bacteria) 48982975_1 CDM 0302 RC 86631 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to Chlamydia (bacteria) 48982975_1 CDM 0302 RC 86631 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to Chlamydia (bacteria) 48982975_1 CDM 0302 RC 86631 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to Chlamydia (bacteria) 48982975_1 CDM 0302 RC 86631 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 Analysis for antibody to Chlamydia (bacteria) 48982975_1 CDM 0302 RC 86631 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 Analysis for antibody to Chlamydia (bacteria) 48982975_1 CDM 0302 RC 86631 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 Analysis for antibody to Chlamydia (bacteria) 48982975_1 CDM 0302 RC 86631 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 Analysis for antibody to Chlamydia (bacteria) 48982975_1 CDM 0302 RC 86631 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to Chlamydia (bacteria) 48982975_1 CDM 0302 RC 86631 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982977_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982977_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982977_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982977_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982977_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982977_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982977_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982977_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982977_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982977_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982977_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982977_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48982977_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48982977_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 Analysis for antibody to varicella-zoster virus (chicken pox) 48982980_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 48982980_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 48982980_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 48982980_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 48982980_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 48982980_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 48982980_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 48982980_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 48982980_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 48982980_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 48982980_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 48982980_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 48982980_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 48982980_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 48982981_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 48982981_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 48982981_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 48982981_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 48982981_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 48982981_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 48982981_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 48982981_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 48982981_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 48982981_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 48982981_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 48982981_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 48982981_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 48982981_1 CDM 0302 RC 86787 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 "Clotting factor X assessment test, diluted" 48982982_1 CDM 0305 RC 85613 HCPCS inpatient 125 81.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.25 65 999999999 75.69 121.25 percent of total billed charges "Clotting factor X assessment test, diluted" 48982982_1 CDM 0305 RC 85613 HCPCS inpatient 125 81.25 AETNA AETNA 98.75 79 999999999 75.69 121.25 percent of total billed charges "Clotting factor X assessment test, diluted" 48982982_1 CDM 0305 RC 85613 HCPCS inpatient 125 81.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 121.25 97 999999999 75.69 121.25 percent of total billed charges "Clotting factor X assessment test, diluted" 48982982_1 CDM 0305 RC 85613 HCPCS inpatient 125 81.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.25 69 999999999 75.69 121.25 percent of total billed charges "Clotting factor X assessment test, diluted" 48982982_1 CDM 0305 RC 85613 HCPCS inpatient 125 81.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.5 78 999999999 75.69 121.25 percent of total billed charges "Clotting factor X assessment test, diluted" 48982982_1 CDM 0305 RC 85613 HCPCS inpatient 125 81.25 SIHO - ALL PLANS SIHO - ALL PLANS 112.5 90 999999999 75.69 121.25 percent of total billed charges "Clotting factor X assessment test, diluted" 48982982_1 CDM 0305 RC 85613 HCPCS inpatient 125 81.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.69 60.55 999999999 75.69 121.25 percent of total billed charges "Clotting factor X assessment test, diluted" 48982982_1 CDM 0305 RC 85613 HCPCS inpatient 125 81.25 UMR - ALL PLANS UMR - ALL PLANS 87.5 70 999999999 75.69 121.25 percent of total billed charges "Clotting factor X assessment test, diluted" 48982982_1 CDM 0305 RC 85613 HCPCS inpatient 125 81.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.69 121.25 "Clotting factor X assessment test, diluted" 48982982_1 CDM 0305 RC 85613 HCPCS inpatient 125 81.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.69 121.25 "Clotting factor X assessment test, diluted" 48982982_1 CDM 0305 RC 85613 HCPCS inpatient 125 81.25 ANTHEM HMO ANTHEM HMO 999999999 75.69 121.25 "Clotting factor X assessment test, diluted" 48982982_1 CDM 0305 RC 85613 HCPCS inpatient 125 81.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.69 121.25 "Clotting factor X assessment test, diluted" 48982982_1 CDM 0305 RC 85613 HCPCS inpatient 125 81.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.5 67.6 999999999 75.69 121.25 percent of total billed charges "Clotting factor X assessment test, diluted" 48982982_1 CDM 0305 RC 85613 HCPCS inpatient 125 81.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.69 121.25 "Coagulation assessment blood test, plasma or whole blood" 48982983_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 48982983_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 48982983_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 48982983_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 48982983_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 48982983_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 48982983_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 48982983_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 48982983_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 "Coagulation assessment blood test, plasma or whole blood" 48982983_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 "Coagulation assessment blood test, plasma or whole blood" 48982983_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 "Coagulation assessment blood test, plasma or whole blood" 48982983_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 "Coagulation assessment blood test, plasma or whole blood" 48982983_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 48982983_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 "Blood test, clotting time" 48982984_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 48982984_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 48982984_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 48982984_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 48982984_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 48982984_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 48982984_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 48982984_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 48982984_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 "Blood test, clotting time" 48982984_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 "Blood test, clotting time" 48982984_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 "Blood test, clotting time" 48982984_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 "Blood test, clotting time" 48982984_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 48982984_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 Thromboplastin inhibition (circulating anticoagulant) measurement 48982985_1 CDM 0305 RC 85705 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges Thromboplastin inhibition (circulating anticoagulant) measurement 48982985_1 CDM 0305 RC 85705 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges Thromboplastin inhibition (circulating anticoagulant) measurement 48982985_1 CDM 0305 RC 85705 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges Thromboplastin inhibition (circulating anticoagulant) measurement 48982985_1 CDM 0305 RC 85705 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges Thromboplastin inhibition (circulating anticoagulant) measurement 48982985_1 CDM 0305 RC 85705 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges Thromboplastin inhibition (circulating anticoagulant) measurement 48982985_1 CDM 0305 RC 85705 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges Thromboplastin inhibition (circulating anticoagulant) measurement 48982985_1 CDM 0305 RC 85705 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges Thromboplastin inhibition (circulating anticoagulant) measurement 48982985_1 CDM 0305 RC 85705 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges Thromboplastin inhibition (circulating anticoagulant) measurement 48982985_1 CDM 0305 RC 85705 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 Thromboplastin inhibition (circulating anticoagulant) measurement 48982985_1 CDM 0305 RC 85705 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 Thromboplastin inhibition (circulating anticoagulant) measurement 48982985_1 CDM 0305 RC 85705 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 Thromboplastin inhibition (circulating anticoagulant) measurement 48982985_1 CDM 0305 RC 85705 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 Thromboplastin inhibition (circulating anticoagulant) measurement 48982985_1 CDM 0305 RC 85705 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges Thromboplastin inhibition (circulating anticoagulant) measurement 48982985_1 CDM 0305 RC 85705 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 Clotting factor VIII (AHG) measurement 48982986_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges Clotting factor VIII (AHG) measurement 48982986_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges Clotting factor VIII (AHG) measurement 48982986_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges Clotting factor VIII (AHG) measurement 48982986_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges Clotting factor VIII (AHG) measurement 48982986_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges Clotting factor VIII (AHG) measurement 48982986_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges Clotting factor VIII (AHG) measurement 48982986_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges Clotting factor VIII (AHG) measurement 48982986_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges Clotting factor VIII (AHG) measurement 48982986_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 Clotting factor VIII (AHG) measurement 48982986_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 Clotting factor VIII (AHG) measurement 48982986_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 Clotting factor VIII (AHG) measurement 48982986_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 Clotting factor VIII (AHG) measurement 48982986_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges Clotting factor VIII (AHG) measurement 48982986_1 CDM 0305 RC 85240 HCPCS inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 Clotting factor VIII (VW factor) antigen 48982987_1 CDM 0305 RC 85246 HCPCS inpatient 167 108.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 108.55 65 999999999 101.12 161.99 percent of total billed charges Clotting factor VIII (VW factor) antigen 48982987_1 CDM 0305 RC 85246 HCPCS inpatient 167 108.55 AETNA AETNA 131.93 79 999999999 101.12 161.99 percent of total billed charges Clotting factor VIII (VW factor) antigen 48982987_1 CDM 0305 RC 85246 HCPCS inpatient 167 108.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.99 97 999999999 101.12 161.99 percent of total billed charges Clotting factor VIII (VW factor) antigen 48982987_1 CDM 0305 RC 85246 HCPCS inpatient 167 108.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.23 69 999999999 101.12 161.99 percent of total billed charges Clotting factor VIII (VW factor) antigen 48982987_1 CDM 0305 RC 85246 HCPCS inpatient 167 108.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 130.26 78 999999999 101.12 161.99 percent of total billed charges Clotting factor VIII (VW factor) antigen 48982987_1 CDM 0305 RC 85246 HCPCS inpatient 167 108.55 SIHO - ALL PLANS SIHO - ALL PLANS 150.3 90 999999999 101.12 161.99 percent of total billed charges Clotting factor VIII (VW factor) antigen 48982987_1 CDM 0305 RC 85246 HCPCS inpatient 167 108.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.12 60.55 999999999 101.12 161.99 percent of total billed charges Clotting factor VIII (VW factor) antigen 48982987_1 CDM 0305 RC 85246 HCPCS inpatient 167 108.55 UMR - ALL PLANS UMR - ALL PLANS 116.9 70 999999999 101.12 161.99 percent of total billed charges Clotting factor VIII (VW factor) antigen 48982987_1 CDM 0305 RC 85246 HCPCS inpatient 167 108.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.12 161.99 Clotting factor VIII (VW factor) antigen 48982987_1 CDM 0305 RC 85246 HCPCS inpatient 167 108.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.12 161.99 Clotting factor VIII (VW factor) antigen 48982987_1 CDM 0305 RC 85246 HCPCS inpatient 167 108.55 ANTHEM HMO ANTHEM HMO 999999999 101.12 161.99 Clotting factor VIII (VW factor) antigen 48982987_1 CDM 0305 RC 85246 HCPCS inpatient 167 108.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.12 161.99 Clotting factor VIII (VW factor) antigen 48982987_1 CDM 0305 RC 85246 HCPCS inpatient 167 108.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.89 67.6 999999999 101.12 161.99 percent of total billed charges Clotting factor VIII (VW factor) antigen 48982987_1 CDM 0305 RC 85246 HCPCS inpatient 167 108.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.12 161.99 Clotting factor VIII (VW factor) measurement 48982988_1 CDM 0305 RC 85245 HCPCS inpatient 157 102.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.05 65 999999999 95.06 152.29 percent of total billed charges Clotting factor VIII (VW factor) measurement 48982988_1 CDM 0305 RC 85245 HCPCS inpatient 157 102.05 AETNA AETNA 124.03 79 999999999 95.06 152.29 percent of total billed charges Clotting factor VIII (VW factor) measurement 48982988_1 CDM 0305 RC 85245 HCPCS inpatient 157 102.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 152.29 97 999999999 95.06 152.29 percent of total billed charges Clotting factor VIII (VW factor) measurement 48982988_1 CDM 0305 RC 85245 HCPCS inpatient 157 102.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 108.33 69 999999999 95.06 152.29 percent of total billed charges Clotting factor VIII (VW factor) measurement 48982988_1 CDM 0305 RC 85245 HCPCS inpatient 157 102.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 122.46 78 999999999 95.06 152.29 percent of total billed charges Clotting factor VIII (VW factor) measurement 48982988_1 CDM 0305 RC 85245 HCPCS inpatient 157 102.05 SIHO - ALL PLANS SIHO - ALL PLANS 141.3 90 999999999 95.06 152.29 percent of total billed charges Clotting factor VIII (VW factor) measurement 48982988_1 CDM 0305 RC 85245 HCPCS inpatient 157 102.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.06 60.55 999999999 95.06 152.29 percent of total billed charges Clotting factor VIII (VW factor) measurement 48982988_1 CDM 0305 RC 85245 HCPCS inpatient 157 102.05 UMR - ALL PLANS UMR - ALL PLANS 109.9 70 999999999 95.06 152.29 percent of total billed charges Clotting factor VIII (VW factor) measurement 48982988_1 CDM 0305 RC 85245 HCPCS inpatient 157 102.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.06 152.29 Clotting factor VIII (VW factor) measurement 48982988_1 CDM 0305 RC 85245 HCPCS inpatient 157 102.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.06 152.29 Clotting factor VIII (VW factor) measurement 48982988_1 CDM 0305 RC 85245 HCPCS inpatient 157 102.05 ANTHEM HMO ANTHEM HMO 999999999 95.06 152.29 Clotting factor VIII (VW factor) measurement 48982988_1 CDM 0305 RC 85245 HCPCS inpatient 157 102.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.06 152.29 Clotting factor VIII (VW factor) measurement 48982988_1 CDM 0305 RC 85245 HCPCS inpatient 157 102.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.13 67.6 999999999 95.06 152.29 percent of total billed charges Clotting factor VIII (VW factor) measurement 48982988_1 CDM 0305 RC 85245 HCPCS inpatient 157 102.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.06 152.29 "Detection test for candida species (yeast), direct probe technique" 48982989_1 CDM 0306 RC 87480 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 48982989_1 CDM 0306 RC 87480 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 48982989_1 CDM 0306 RC 87480 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 48982989_1 CDM 0306 RC 87480 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 48982989_1 CDM 0306 RC 87480 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 48982989_1 CDM 0306 RC 87480 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 48982989_1 CDM 0306 RC 87480 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 48982989_1 CDM 0306 RC 87480 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 48982989_1 CDM 0306 RC 87480 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 "Detection test for candida species (yeast), direct probe technique" 48982989_1 CDM 0306 RC 87480 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 "Detection test for candida species (yeast), direct probe technique" 48982989_1 CDM 0306 RC 87480 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 "Detection test for candida species (yeast), direct probe technique" 48982989_1 CDM 0306 RC 87480 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 "Detection test for candida species (yeast), direct probe technique" 48982989_1 CDM 0306 RC 87480 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 48982989_1 CDM 0306 RC 87480 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982990_1 CDM 0311 RC 88185 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982990_1 CDM 0311 RC 88185 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982990_1 CDM 0311 RC 88185 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982990_1 CDM 0311 RC 88185 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982990_1 CDM 0311 RC 88185 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982990_1 CDM 0311 RC 88185 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982990_1 CDM 0311 RC 88185 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982990_1 CDM 0311 RC 88185 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982990_1 CDM 0311 RC 88185 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982990_1 CDM 0311 RC 88185 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982990_1 CDM 0311 RC 88185 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982990_1 CDM 0311 RC 88185 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982990_1 CDM 0311 RC 88185 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982990_1 CDM 0311 RC 88185 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982991_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982991_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982991_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982991_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982991_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982991_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982991_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982991_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982991_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982991_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982991_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982991_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982991_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982991_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, first marker" 48982992_1 CDM 0311 RC 88184 HCPCS inpatient 945 614.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 614.25 65 999999999 572.2 916.65 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 48982992_1 CDM 0311 RC 88184 HCPCS inpatient 945 614.25 AETNA AETNA 746.55 79 999999999 572.2 916.65 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 48982992_1 CDM 0311 RC 88184 HCPCS inpatient 945 614.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 916.65 97 999999999 572.2 916.65 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 48982992_1 CDM 0311 RC 88184 HCPCS inpatient 945 614.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 652.05 69 999999999 572.2 916.65 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 48982992_1 CDM 0311 RC 88184 HCPCS inpatient 945 614.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 737.1 78 999999999 572.2 916.65 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 48982992_1 CDM 0311 RC 88184 HCPCS inpatient 945 614.25 SIHO - ALL PLANS SIHO - ALL PLANS 850.5 90 999999999 572.2 916.65 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 48982992_1 CDM 0311 RC 88184 HCPCS inpatient 945 614.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 572.2 60.55 999999999 572.2 916.65 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 48982992_1 CDM 0311 RC 88184 HCPCS inpatient 945 614.25 UMR - ALL PLANS UMR - ALL PLANS 661.5 70 999999999 572.2 916.65 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 48982992_1 CDM 0311 RC 88184 HCPCS inpatient 945 614.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 572.2 916.65 "Flow cytometry technique for DNA or cell analysis, first marker" 48982992_1 CDM 0311 RC 88184 HCPCS inpatient 945 614.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 572.2 916.65 "Flow cytometry technique for DNA or cell analysis, first marker" 48982992_1 CDM 0311 RC 88184 HCPCS inpatient 945 614.25 ANTHEM HMO ANTHEM HMO 999999999 572.2 916.65 "Flow cytometry technique for DNA or cell analysis, first marker" 48982992_1 CDM 0311 RC 88184 HCPCS inpatient 945 614.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 572.2 916.65 "Flow cytometry technique for DNA or cell analysis, first marker" 48982992_1 CDM 0311 RC 88184 HCPCS inpatient 945 614.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 638.82 67.6 999999999 572.2 916.65 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 48982992_1 CDM 0311 RC 88184 HCPCS inpatient 945 614.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 572.2 916.65 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982993_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982993_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982993_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982993_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982993_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982993_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982993_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982993_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982993_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982993_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982993_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982993_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982993_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982993_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982994_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982994_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982994_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982994_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982994_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982994_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982994_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982994_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982994_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982994_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982994_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982994_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982994_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982994_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, first marker" 48982995_1 CDM 0311 RC 88184 HCPCS inpatient 859 558.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 558.35 65 999999999 520.12 833.23 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 48982995_1 CDM 0311 RC 88184 HCPCS inpatient 859 558.35 AETNA AETNA 678.61 79 999999999 520.12 833.23 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 48982995_1 CDM 0311 RC 88184 HCPCS inpatient 859 558.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 833.23 97 999999999 520.12 833.23 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 48982995_1 CDM 0311 RC 88184 HCPCS inpatient 859 558.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 592.71 69 999999999 520.12 833.23 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 48982995_1 CDM 0311 RC 88184 HCPCS inpatient 859 558.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 670.02 78 999999999 520.12 833.23 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 48982995_1 CDM 0311 RC 88184 HCPCS inpatient 859 558.35 SIHO - ALL PLANS SIHO - ALL PLANS 773.1 90 999999999 520.12 833.23 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 48982995_1 CDM 0311 RC 88184 HCPCS inpatient 859 558.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 520.12 60.55 999999999 520.12 833.23 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 48982995_1 CDM 0311 RC 88184 HCPCS inpatient 859 558.35 UMR - ALL PLANS UMR - ALL PLANS 601.3 70 999999999 520.12 833.23 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 48982995_1 CDM 0311 RC 88184 HCPCS inpatient 859 558.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 520.12 833.23 "Flow cytometry technique for DNA or cell analysis, first marker" 48982995_1 CDM 0311 RC 88184 HCPCS inpatient 859 558.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 520.12 833.23 "Flow cytometry technique for DNA or cell analysis, first marker" 48982995_1 CDM 0311 RC 88184 HCPCS inpatient 859 558.35 ANTHEM HMO ANTHEM HMO 999999999 520.12 833.23 "Flow cytometry technique for DNA or cell analysis, first marker" 48982995_1 CDM 0311 RC 88184 HCPCS inpatient 859 558.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 520.12 833.23 "Flow cytometry technique for DNA or cell analysis, first marker" 48982995_1 CDM 0311 RC 88184 HCPCS inpatient 859 558.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 580.68 67.6 999999999 520.12 833.23 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 48982995_1 CDM 0311 RC 88184 HCPCS inpatient 859 558.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 520.12 833.23 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982996_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982996_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982996_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982996_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982996_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982996_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982996_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982996_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982996_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982996_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982996_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982996_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982996_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982996_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982997_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982997_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982997_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982997_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982997_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982997_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982997_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982997_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982997_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982997_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982997_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982997_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982997_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 48982997_1 CDM 0311 RC 88185 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 "Chromosome analysis for genetic defects, additional karyotypes, each study" 48982998_1 CDM 0301 RC 88280 HCPCS inpatient 295 191.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 191.75 65 999999999 178.62 286.15 percent of total billed charges "Chromosome analysis for genetic defects, additional karyotypes, each study" 48982998_1 CDM 0301 RC 88280 HCPCS inpatient 295 191.75 AETNA AETNA 233.05 79 999999999 178.62 286.15 percent of total billed charges "Chromosome analysis for genetic defects, additional karyotypes, each study" 48982998_1 CDM 0301 RC 88280 HCPCS inpatient 295 191.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 286.15 97 999999999 178.62 286.15 percent of total billed charges "Chromosome analysis for genetic defects, additional karyotypes, each study" 48982998_1 CDM 0301 RC 88280 HCPCS inpatient 295 191.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 203.55 69 999999999 178.62 286.15 percent of total billed charges "Chromosome analysis for genetic defects, additional karyotypes, each study" 48982998_1 CDM 0301 RC 88280 HCPCS inpatient 295 191.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 230.1 78 999999999 178.62 286.15 percent of total billed charges "Chromosome analysis for genetic defects, additional karyotypes, each study" 48982998_1 CDM 0301 RC 88280 HCPCS inpatient 295 191.75 SIHO - ALL PLANS SIHO - ALL PLANS 265.5 90 999999999 178.62 286.15 percent of total billed charges "Chromosome analysis for genetic defects, additional karyotypes, each study" 48982998_1 CDM 0301 RC 88280 HCPCS inpatient 295 191.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 178.62 60.55 999999999 178.62 286.15 percent of total billed charges "Chromosome analysis for genetic defects, additional karyotypes, each study" 48982998_1 CDM 0301 RC 88280 HCPCS inpatient 295 191.75 UMR - ALL PLANS UMR - ALL PLANS 206.5 70 999999999 178.62 286.15 percent of total billed charges "Chromosome analysis for genetic defects, additional karyotypes, each study" 48982998_1 CDM 0301 RC 88280 HCPCS inpatient 295 191.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 178.62 286.15 "Chromosome analysis for genetic defects, additional karyotypes, each study" 48982998_1 CDM 0301 RC 88280 HCPCS inpatient 295 191.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 178.62 286.15 "Chromosome analysis for genetic defects, additional karyotypes, each study" 48982998_1 CDM 0301 RC 88280 HCPCS inpatient 295 191.75 ANTHEM HMO ANTHEM HMO 999999999 178.62 286.15 "Chromosome analysis for genetic defects, additional karyotypes, each study" 48982998_1 CDM 0301 RC 88280 HCPCS inpatient 295 191.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 178.62 286.15 "Chromosome analysis for genetic defects, additional karyotypes, each study" 48982998_1 CDM 0301 RC 88280 HCPCS inpatient 295 191.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 199.42 67.6 999999999 178.62 286.15 percent of total billed charges "Chromosome analysis for genetic defects, additional karyotypes, each study" 48982998_1 CDM 0301 RC 88280 HCPCS inpatient 295 191.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 178.62 286.15 "Chromosome analysis for genetic defects, count 15-20 cells" 48982999_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 399.75 65 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 48982999_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 AETNA AETNA 485.85 79 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 48982999_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 596.55 97 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 48982999_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 424.35 69 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 48982999_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 479.7 78 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 48982999_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 SIHO - ALL PLANS SIHO - ALL PLANS 553.5 90 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 48982999_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 372.38 60.55 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 48982999_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 UMR - ALL PLANS UMR - ALL PLANS 430.5 70 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 48982999_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 48982999_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 48982999_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ANTHEM HMO ANTHEM HMO 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 48982999_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 48982999_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 415.74 67.6 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 48982999_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 372.38 596.55 Tissue culture for tumor disorders of bone marrow and blood cells 48983000_1 CDM 0301 RC 88237 HCPCS inpatient 283 183.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 183.95 65 999999999 171.36 274.51 percent of total billed charges Tissue culture for tumor disorders of bone marrow and blood cells 48983000_1 CDM 0301 RC 88237 HCPCS inpatient 283 183.95 AETNA AETNA 223.57 79 999999999 171.36 274.51 percent of total billed charges Tissue culture for tumor disorders of bone marrow and blood cells 48983000_1 CDM 0301 RC 88237 HCPCS inpatient 283 183.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 274.51 97 999999999 171.36 274.51 percent of total billed charges Tissue culture for tumor disorders of bone marrow and blood cells 48983000_1 CDM 0301 RC 88237 HCPCS inpatient 283 183.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 195.27 69 999999999 171.36 274.51 percent of total billed charges Tissue culture for tumor disorders of bone marrow and blood cells 48983000_1 CDM 0301 RC 88237 HCPCS inpatient 283 183.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 220.74 78 999999999 171.36 274.51 percent of total billed charges Tissue culture for tumor disorders of bone marrow and blood cells 48983000_1 CDM 0301 RC 88237 HCPCS inpatient 283 183.95 SIHO - ALL PLANS SIHO - ALL PLANS 254.7 90 999999999 171.36 274.51 percent of total billed charges Tissue culture for tumor disorders of bone marrow and blood cells 48983000_1 CDM 0301 RC 88237 HCPCS inpatient 283 183.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 171.36 60.55 999999999 171.36 274.51 percent of total billed charges Tissue culture for tumor disorders of bone marrow and blood cells 48983000_1 CDM 0301 RC 88237 HCPCS inpatient 283 183.95 UMR - ALL PLANS UMR - ALL PLANS 198.1 70 999999999 171.36 274.51 percent of total billed charges Tissue culture for tumor disorders of bone marrow and blood cells 48983000_1 CDM 0301 RC 88237 HCPCS inpatient 283 183.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 171.36 274.51 Tissue culture for tumor disorders of bone marrow and blood cells 48983000_1 CDM 0301 RC 88237 HCPCS inpatient 283 183.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 171.36 274.51 Tissue culture for tumor disorders of bone marrow and blood cells 48983000_1 CDM 0301 RC 88237 HCPCS inpatient 283 183.95 ANTHEM HMO ANTHEM HMO 999999999 171.36 274.51 Tissue culture for tumor disorders of bone marrow and blood cells 48983000_1 CDM 0301 RC 88237 HCPCS inpatient 283 183.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 171.36 274.51 Tissue culture for tumor disorders of bone marrow and blood cells 48983000_1 CDM 0301 RC 88237 HCPCS inpatient 283 183.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 191.31 67.6 999999999 171.36 274.51 percent of total billed charges Tissue culture for tumor disorders of bone marrow and blood cells 48983000_1 CDM 0301 RC 88237 HCPCS inpatient 283 183.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 171.36 274.51 Tissue culture to identify skin disorders 48983002_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 174.2 65 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 48983002_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 AETNA AETNA 211.72 79 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 48983002_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 259.96 97 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 48983002_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.92 69 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 48983002_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 209.04 78 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 48983002_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 SIHO - ALL PLANS SIHO - ALL PLANS 241.2 90 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 48983002_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 162.27 60.55 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 48983002_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 UMR - ALL PLANS UMR - ALL PLANS 187.6 70 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 48983002_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 162.27 259.96 Tissue culture to identify skin disorders 48983002_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 162.27 259.96 Tissue culture to identify skin disorders 48983002_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 ANTHEM HMO ANTHEM HMO 999999999 162.27 259.96 Tissue culture to identify skin disorders 48983002_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 162.27 259.96 Tissue culture to identify skin disorders 48983002_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 181.17 67.6 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 48983002_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 162.27 259.96 "Chromosome analysis for genetic defects, additional karyotypes, each study" 48983004_1 CDM 0311 RC 88280 HCPCS inpatient 607 394.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 394.55 65 999999999 367.54 588.79 percent of total billed charges "Chromosome analysis for genetic defects, additional karyotypes, each study" 48983004_1 CDM 0311 RC 88280 HCPCS inpatient 607 394.55 AETNA AETNA 479.53 79 999999999 367.54 588.79 percent of total billed charges "Chromosome analysis for genetic defects, additional karyotypes, each study" 48983004_1 CDM 0311 RC 88280 HCPCS inpatient 607 394.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 588.79 97 999999999 367.54 588.79 percent of total billed charges "Chromosome analysis for genetic defects, additional karyotypes, each study" 48983004_1 CDM 0311 RC 88280 HCPCS inpatient 607 394.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 418.83 69 999999999 367.54 588.79 percent of total billed charges "Chromosome analysis for genetic defects, additional karyotypes, each study" 48983004_1 CDM 0311 RC 88280 HCPCS inpatient 607 394.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 473.46 78 999999999 367.54 588.79 percent of total billed charges "Chromosome analysis for genetic defects, additional karyotypes, each study" 48983004_1 CDM 0311 RC 88280 HCPCS inpatient 607 394.55 SIHO - ALL PLANS SIHO - ALL PLANS 546.3 90 999999999 367.54 588.79 percent of total billed charges "Chromosome analysis for genetic defects, additional karyotypes, each study" 48983004_1 CDM 0311 RC 88280 HCPCS inpatient 607 394.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 367.54 60.55 999999999 367.54 588.79 percent of total billed charges "Chromosome analysis for genetic defects, additional karyotypes, each study" 48983004_1 CDM 0311 RC 88280 HCPCS inpatient 607 394.55 UMR - ALL PLANS UMR - ALL PLANS 424.9 70 999999999 367.54 588.79 percent of total billed charges "Chromosome analysis for genetic defects, additional karyotypes, each study" 48983004_1 CDM 0311 RC 88280 HCPCS inpatient 607 394.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 367.54 588.79 "Chromosome analysis for genetic defects, additional karyotypes, each study" 48983004_1 CDM 0311 RC 88280 HCPCS inpatient 607 394.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 367.54 588.79 "Chromosome analysis for genetic defects, additional karyotypes, each study" 48983004_1 CDM 0311 RC 88280 HCPCS inpatient 607 394.55 ANTHEM HMO ANTHEM HMO 999999999 367.54 588.79 "Chromosome analysis for genetic defects, additional karyotypes, each study" 48983004_1 CDM 0311 RC 88280 HCPCS inpatient 607 394.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 367.54 588.79 "Chromosome analysis for genetic defects, additional karyotypes, each study" 48983004_1 CDM 0311 RC 88280 HCPCS inpatient 607 394.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 410.33 67.6 999999999 367.54 588.79 percent of total billed charges "Chromosome analysis for genetic defects, additional karyotypes, each study" 48983004_1 CDM 0311 RC 88280 HCPCS inpatient 607 394.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 367.54 588.79 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48983008_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48983008_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48983008_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48983008_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48983008_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48983008_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48983008_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48983008_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48983008_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48983008_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48983008_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48983008_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 48983008_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 48983008_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983009_1 CDM 0311 RC 87624 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983009_1 CDM 0311 RC 87624 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983009_1 CDM 0311 RC 87624 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983009_1 CDM 0311 RC 87624 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983009_1 CDM 0311 RC 87624 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983009_1 CDM 0311 RC 87624 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983009_1 CDM 0311 RC 87624 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983009_1 CDM 0311 RC 87624 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983009_1 CDM 0311 RC 87624 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983009_1 CDM 0311 RC 87624 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983009_1 CDM 0311 RC 87624 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983009_1 CDM 0311 RC 87624 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983009_1 CDM 0311 RC 87624 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983009_1 CDM 0311 RC 87624 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48983011_1 CDM 0306 RC 87591 HCPCS inpatient 106 68.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.9 65 999999999 64.18 102.82 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48983011_1 CDM 0306 RC 87591 HCPCS inpatient 106 68.9 AETNA AETNA 83.74 79 999999999 64.18 102.82 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48983011_1 CDM 0306 RC 87591 HCPCS inpatient 106 68.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 102.82 97 999999999 64.18 102.82 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48983011_1 CDM 0306 RC 87591 HCPCS inpatient 106 68.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.14 69 999999999 64.18 102.82 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48983011_1 CDM 0306 RC 87591 HCPCS inpatient 106 68.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 82.68 78 999999999 64.18 102.82 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48983011_1 CDM 0306 RC 87591 HCPCS inpatient 106 68.9 SIHO - ALL PLANS SIHO - ALL PLANS 95.4 90 999999999 64.18 102.82 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48983011_1 CDM 0306 RC 87591 HCPCS inpatient 106 68.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.18 60.55 999999999 64.18 102.82 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48983011_1 CDM 0306 RC 87591 HCPCS inpatient 106 68.9 UMR - ALL PLANS UMR - ALL PLANS 74.2 70 999999999 64.18 102.82 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48983011_1 CDM 0306 RC 87591 HCPCS inpatient 106 68.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.18 102.82 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48983011_1 CDM 0306 RC 87591 HCPCS inpatient 106 68.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.18 102.82 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48983011_1 CDM 0306 RC 87591 HCPCS inpatient 106 68.9 ANTHEM HMO ANTHEM HMO 999999999 64.18 102.82 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48983011_1 CDM 0306 RC 87591 HCPCS inpatient 106 68.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.18 102.82 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48983011_1 CDM 0306 RC 87591 HCPCS inpatient 106 68.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 71.66 67.6 999999999 64.18 102.82 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 48983011_1 CDM 0306 RC 87591 HCPCS inpatient 106 68.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.18 102.82 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48983012_1 CDM 0306 RC 87491 HCPCS inpatient 106 68.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.9 65 999999999 64.18 102.82 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48983012_1 CDM 0306 RC 87491 HCPCS inpatient 106 68.9 AETNA AETNA 83.74 79 999999999 64.18 102.82 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48983012_1 CDM 0306 RC 87491 HCPCS inpatient 106 68.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 102.82 97 999999999 64.18 102.82 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48983012_1 CDM 0306 RC 87491 HCPCS inpatient 106 68.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.14 69 999999999 64.18 102.82 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48983012_1 CDM 0306 RC 87491 HCPCS inpatient 106 68.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 82.68 78 999999999 64.18 102.82 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48983012_1 CDM 0306 RC 87491 HCPCS inpatient 106 68.9 SIHO - ALL PLANS SIHO - ALL PLANS 95.4 90 999999999 64.18 102.82 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48983012_1 CDM 0306 RC 87491 HCPCS inpatient 106 68.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.18 60.55 999999999 64.18 102.82 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48983012_1 CDM 0306 RC 87491 HCPCS inpatient 106 68.9 UMR - ALL PLANS UMR - ALL PLANS 74.2 70 999999999 64.18 102.82 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48983012_1 CDM 0306 RC 87491 HCPCS inpatient 106 68.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.18 102.82 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48983012_1 CDM 0306 RC 87491 HCPCS inpatient 106 68.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.18 102.82 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48983012_1 CDM 0306 RC 87491 HCPCS inpatient 106 68.9 ANTHEM HMO ANTHEM HMO 999999999 64.18 102.82 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48983012_1 CDM 0306 RC 87491 HCPCS inpatient 106 68.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.18 102.82 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48983012_1 CDM 0306 RC 87491 HCPCS inpatient 106 68.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 71.66 67.6 999999999 64.18 102.82 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 48983012_1 CDM 0306 RC 87491 HCPCS inpatient 106 68.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.18 102.82 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983013_1 CDM 0311 RC 87624 HCPCS inpatient 161 104.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 104.65 65 999999999 97.49 156.17 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983013_1 CDM 0311 RC 87624 HCPCS inpatient 161 104.65 AETNA AETNA 127.19 79 999999999 97.49 156.17 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983013_1 CDM 0311 RC 87624 HCPCS inpatient 161 104.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 156.17 97 999999999 97.49 156.17 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983013_1 CDM 0311 RC 87624 HCPCS inpatient 161 104.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 111.09 69 999999999 97.49 156.17 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983013_1 CDM 0311 RC 87624 HCPCS inpatient 161 104.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 125.58 78 999999999 97.49 156.17 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983013_1 CDM 0311 RC 87624 HCPCS inpatient 161 104.65 SIHO - ALL PLANS SIHO - ALL PLANS 144.9 90 999999999 97.49 156.17 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983013_1 CDM 0311 RC 87624 HCPCS inpatient 161 104.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 97.49 60.55 999999999 97.49 156.17 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983013_1 CDM 0311 RC 87624 HCPCS inpatient 161 104.65 UMR - ALL PLANS UMR - ALL PLANS 112.7 70 999999999 97.49 156.17 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983013_1 CDM 0311 RC 87624 HCPCS inpatient 161 104.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 97.49 156.17 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983013_1 CDM 0311 RC 87624 HCPCS inpatient 161 104.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 97.49 156.17 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983013_1 CDM 0311 RC 87624 HCPCS inpatient 161 104.65 ANTHEM HMO ANTHEM HMO 999999999 97.49 156.17 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983013_1 CDM 0311 RC 87624 HCPCS inpatient 161 104.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 97.49 156.17 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983013_1 CDM 0311 RC 87624 HCPCS inpatient 161 104.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.84 67.6 999999999 97.49 156.17 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983013_1 CDM 0311 RC 87624 HCPCS inpatient 161 104.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 97.49 156.17 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983015_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983015_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983015_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983015_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983015_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983015_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983015_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983015_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983015_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983015_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983015_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983015_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983015_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), high-risk types" 48983015_1 CDM 0311 RC 87624 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 "Detection test for candida species (yeast), amplified probe technique" 48983031_1 CDM 0311 RC 87481 HCPCS inpatient 173 112.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 112.45 65 999999999 104.75 167.81 percent of total billed charges "Detection test for candida species (yeast), amplified probe technique" 48983031_1 CDM 0311 RC 87481 HCPCS inpatient 173 112.45 AETNA AETNA 136.67 79 999999999 104.75 167.81 percent of total billed charges "Detection test for candida species (yeast), amplified probe technique" 48983031_1 CDM 0311 RC 87481 HCPCS inpatient 173 112.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 167.81 97 999999999 104.75 167.81 percent of total billed charges "Detection test for candida species (yeast), amplified probe technique" 48983031_1 CDM 0311 RC 87481 HCPCS inpatient 173 112.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 119.37 69 999999999 104.75 167.81 percent of total billed charges "Detection test for candida species (yeast), amplified probe technique" 48983031_1 CDM 0311 RC 87481 HCPCS inpatient 173 112.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.94 78 999999999 104.75 167.81 percent of total billed charges "Detection test for candida species (yeast), amplified probe technique" 48983031_1 CDM 0311 RC 87481 HCPCS inpatient 173 112.45 SIHO - ALL PLANS SIHO - ALL PLANS 155.7 90 999999999 104.75 167.81 percent of total billed charges "Detection test for candida species (yeast), amplified probe technique" 48983031_1 CDM 0311 RC 87481 HCPCS inpatient 173 112.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.75 60.55 999999999 104.75 167.81 percent of total billed charges "Detection test for candida species (yeast), amplified probe technique" 48983031_1 CDM 0311 RC 87481 HCPCS inpatient 173 112.45 UMR - ALL PLANS UMR - ALL PLANS 121.1 70 999999999 104.75 167.81 percent of total billed charges "Detection test for candida species (yeast), amplified probe technique" 48983031_1 CDM 0311 RC 87481 HCPCS inpatient 173 112.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.75 167.81 "Detection test for candida species (yeast), amplified probe technique" 48983031_1 CDM 0311 RC 87481 HCPCS inpatient 173 112.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.75 167.81 "Detection test for candida species (yeast), amplified probe technique" 48983031_1 CDM 0311 RC 87481 HCPCS inpatient 173 112.45 ANTHEM HMO ANTHEM HMO 999999999 104.75 167.81 "Detection test for candida species (yeast), amplified probe technique" 48983031_1 CDM 0311 RC 87481 HCPCS inpatient 173 112.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.75 167.81 "Detection test for candida species (yeast), amplified probe technique" 48983031_1 CDM 0311 RC 87481 HCPCS inpatient 173 112.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.95 67.6 999999999 104.75 167.81 percent of total billed charges "Detection test for candida species (yeast), amplified probe technique" 48983031_1 CDM 0311 RC 87481 HCPCS inpatient 173 112.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.75 167.81 "Detection test for gardnerella vaginalis (bacteria), amplified probe technique" 48983032_1 CDM 0311 RC 87511 HCPCS inpatient 173 112.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 112.45 65 999999999 104.75 167.81 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), amplified probe technique" 48983032_1 CDM 0311 RC 87511 HCPCS inpatient 173 112.45 AETNA AETNA 136.67 79 999999999 104.75 167.81 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), amplified probe technique" 48983032_1 CDM 0311 RC 87511 HCPCS inpatient 173 112.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 167.81 97 999999999 104.75 167.81 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), amplified probe technique" 48983032_1 CDM 0311 RC 87511 HCPCS inpatient 173 112.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 119.37 69 999999999 104.75 167.81 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), amplified probe technique" 48983032_1 CDM 0311 RC 87511 HCPCS inpatient 173 112.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.94 78 999999999 104.75 167.81 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), amplified probe technique" 48983032_1 CDM 0311 RC 87511 HCPCS inpatient 173 112.45 SIHO - ALL PLANS SIHO - ALL PLANS 155.7 90 999999999 104.75 167.81 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), amplified probe technique" 48983032_1 CDM 0311 RC 87511 HCPCS inpatient 173 112.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.75 60.55 999999999 104.75 167.81 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), amplified probe technique" 48983032_1 CDM 0311 RC 87511 HCPCS inpatient 173 112.45 UMR - ALL PLANS UMR - ALL PLANS 121.1 70 999999999 104.75 167.81 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), amplified probe technique" 48983032_1 CDM 0311 RC 87511 HCPCS inpatient 173 112.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.75 167.81 "Detection test for gardnerella vaginalis (bacteria), amplified probe technique" 48983032_1 CDM 0311 RC 87511 HCPCS inpatient 173 112.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.75 167.81 "Detection test for gardnerella vaginalis (bacteria), amplified probe technique" 48983032_1 CDM 0311 RC 87511 HCPCS inpatient 173 112.45 ANTHEM HMO ANTHEM HMO 999999999 104.75 167.81 "Detection test for gardnerella vaginalis (bacteria), amplified probe technique" 48983032_1 CDM 0311 RC 87511 HCPCS inpatient 173 112.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.75 167.81 "Detection test for gardnerella vaginalis (bacteria), amplified probe technique" 48983032_1 CDM 0311 RC 87511 HCPCS inpatient 173 112.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.95 67.6 999999999 104.75 167.81 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), amplified probe technique" 48983032_1 CDM 0311 RC 87511 HCPCS inpatient 173 112.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.75 167.81 "Detection test by nucleic acid for organism, amplified probe technique" 48983033_1 CDM 0311 RC 87798 HCPCS inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 48983033_1 CDM 0311 RC 87798 HCPCS inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 48983033_1 CDM 0311 RC 87798 HCPCS inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 48983033_1 CDM 0311 RC 87798 HCPCS inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 48983033_1 CDM 0311 RC 87798 HCPCS inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 48983033_1 CDM 0311 RC 87798 HCPCS inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 48983033_1 CDM 0311 RC 87798 HCPCS inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 48983033_1 CDM 0311 RC 87798 HCPCS inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 48983033_1 CDM 0311 RC 87798 HCPCS inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 48983033_1 CDM 0311 RC 87798 HCPCS inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 48983033_1 CDM 0311 RC 87798 HCPCS inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 48983033_1 CDM 0311 RC 87798 HCPCS inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 48983033_1 CDM 0311 RC 87798 HCPCS inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 48983033_1 CDM 0311 RC 87798 HCPCS inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 99999-9999-01 - patch removal [JOHN] 48983560_1 CDM 0250 RC 99999-9999-01 NDC inpatient 1 UN 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges 99999-9999-01 - patch removal [JOHN] 48983560_1 CDM 0250 RC 99999-9999-01 NDC inpatient 1 UN 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges 99999-9999-01 - patch removal [JOHN] 48983560_1 CDM 0250 RC 99999-9999-01 NDC inpatient 1 UN 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges 99999-9999-01 - patch removal [JOHN] 48983560_1 CDM 0250 RC 99999-9999-01 NDC inpatient 1 UN 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges 99999-9999-01 - patch removal [JOHN] 48983560_1 CDM 0250 RC 99999-9999-01 NDC inpatient 1 UN 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges 99999-9999-01 - patch removal [JOHN] 48983560_1 CDM 0250 RC 99999-9999-01 NDC inpatient 1 UN 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges 99999-9999-01 - patch removal [JOHN] 48983560_1 CDM 0250 RC 99999-9999-01 NDC inpatient 1 UN 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges 99999-9999-01 - patch removal [JOHN] 48983560_1 CDM 0250 RC 99999-9999-01 NDC inpatient 1 UN 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges 99999-9999-01 - patch removal [JOHN] 48983560_1 CDM 0250 RC 99999-9999-01 NDC inpatient 1 UN 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 99999-9999-01 - patch removal [JOHN] 48983560_1 CDM 0250 RC 99999-9999-01 NDC inpatient 1 UN 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 99999-9999-01 - patch removal [JOHN] 48983560_1 CDM 0250 RC 99999-9999-01 NDC inpatient 1 UN 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 99999-9999-01 - patch removal [JOHN] 48983560_1 CDM 0250 RC 99999-9999-01 NDC inpatient 1 UN 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 99999-9999-01 - patch removal [JOHN] 48983560_1 CDM 0250 RC 99999-9999-01 NDC inpatient 1 UN 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges 99999-9999-01 - patch removal [JOHN] 48983560_1 CDM 0250 RC 99999-9999-01 NDC inpatient 1 UN 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48985310_1 CDM 0250 RC 44567-0410-24 NDC J3475 HCPCS inpatient 2 UN 65.36 42.48 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.48 65 999999999 39.58 63.4 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48985310_1 CDM 0250 RC 44567-0410-24 NDC J3475 HCPCS inpatient 2 UN 65.36 42.48 AETNA AETNA 51.63 79 999999999 39.58 63.4 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48985310_1 CDM 0250 RC 44567-0410-24 NDC J3475 HCPCS inpatient 2 UN 65.36 42.48 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 63.4 97 999999999 39.58 63.4 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48985310_1 CDM 0250 RC 44567-0410-24 NDC J3475 HCPCS inpatient 2 UN 65.36 42.48 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.1 69 999999999 39.58 63.4 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48985310_1 CDM 0250 RC 44567-0410-24 NDC J3475 HCPCS inpatient 2 UN 65.36 42.48 HUMANA - ALL PLANS HUMANA - ALL PLANS 50.98 78 999999999 39.58 63.4 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48985310_1 CDM 0250 RC 44567-0410-24 NDC J3475 HCPCS inpatient 2 UN 65.36 42.48 SIHO - ALL PLANS SIHO - ALL PLANS 58.82 90 999999999 39.58 63.4 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48985310_1 CDM 0250 RC 44567-0410-24 NDC J3475 HCPCS inpatient 2 UN 65.36 42.48 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.58 60.55 999999999 39.58 63.4 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48985310_1 CDM 0250 RC 44567-0410-24 NDC J3475 HCPCS inpatient 2 UN 65.36 42.48 UMR - ALL PLANS UMR - ALL PLANS 45.75 70 999999999 39.58 63.4 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48985310_1 CDM 0250 RC 44567-0410-24 NDC J3475 HCPCS inpatient 2 UN 65.36 42.48 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.58 63.4 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48985310_1 CDM 0250 RC 44567-0410-24 NDC J3475 HCPCS inpatient 2 UN 65.36 42.48 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.58 63.4 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48985310_1 CDM 0250 RC 44567-0410-24 NDC J3475 HCPCS inpatient 2 UN 65.36 42.48 ANTHEM HMO ANTHEM HMO 999999999 39.58 63.4 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48985310_1 CDM 0250 RC 44567-0410-24 NDC J3475 HCPCS inpatient 2 UN 65.36 42.48 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.58 63.4 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48985310_1 CDM 0250 RC 44567-0410-24 NDC J3475 HCPCS inpatient 2 UN 65.36 42.48 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.18 67.6 999999999 39.58 63.4 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 48985310_1 CDM 0250 RC 44567-0410-24 NDC J3475 HCPCS inpatient 2 UN 65.36 42.48 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.58 63.4 "ACYCLOVIR 1,000 MG/20 ML VIAL" 48985311_1 CDM 0250 RC 55150-0155-21 NDC inpatient 1 UN 38.72 25.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 25.17 65 999999999 23.45 37.56 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 48985311_1 CDM 0250 RC 55150-0155-21 NDC inpatient 1 UN 38.72 25.17 AETNA AETNA 30.59 79 999999999 23.45 37.56 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 48985311_1 CDM 0250 RC 55150-0155-21 NDC inpatient 1 UN 38.72 25.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37.56 97 999999999 23.45 37.56 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 48985311_1 CDM 0250 RC 55150-0155-21 NDC inpatient 1 UN 38.72 25.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.72 69 999999999 23.45 37.56 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 48985311_1 CDM 0250 RC 55150-0155-21 NDC inpatient 1 UN 38.72 25.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 30.2 78 999999999 23.45 37.56 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 48985311_1 CDM 0250 RC 55150-0155-21 NDC inpatient 1 UN 38.72 25.17 SIHO - ALL PLANS SIHO - ALL PLANS 34.85 90 999999999 23.45 37.56 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 48985311_1 CDM 0250 RC 55150-0155-21 NDC inpatient 1 UN 38.72 25.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.45 60.55 999999999 23.45 37.56 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 48985311_1 CDM 0250 RC 55150-0155-21 NDC inpatient 1 UN 38.72 25.17 UMR - ALL PLANS UMR - ALL PLANS 27.1 70 999999999 23.45 37.56 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 48985311_1 CDM 0250 RC 55150-0155-21 NDC inpatient 1 UN 38.72 25.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.45 37.56 "ACYCLOVIR 1,000 MG/20 ML VIAL" 48985311_1 CDM 0250 RC 55150-0155-21 NDC inpatient 1 UN 38.72 25.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.45 37.56 "ACYCLOVIR 1,000 MG/20 ML VIAL" 48985311_1 CDM 0250 RC 55150-0155-21 NDC inpatient 1 UN 38.72 25.17 ANTHEM HMO ANTHEM HMO 999999999 23.45 37.56 "ACYCLOVIR 1,000 MG/20 ML VIAL" 48985311_1 CDM 0250 RC 55150-0155-21 NDC inpatient 1 UN 38.72 25.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.45 37.56 "ACYCLOVIR 1,000 MG/20 ML VIAL" 48985311_1 CDM 0250 RC 55150-0155-21 NDC inpatient 1 UN 38.72 25.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 26.17 67.6 999999999 23.45 37.56 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 48985311_1 CDM 0250 RC 55150-0155-21 NDC inpatient 1 UN 38.72 25.17 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.45 37.56 99999-9999-02 - Mary's Magic Mouthwash [JOHN] 48985385_1 CDM 0250 RC 99999-9999-02 NDC inpatient 1 UN 42.75 27.79 SELF PAY DISCOUNT SELF PAY DISCOUNT 27.79 65 999999999 25.89 41.47 percent of total billed charges 99999-9999-02 - Mary's Magic Mouthwash [JOHN] 48985385_1 CDM 0250 RC 99999-9999-02 NDC inpatient 1 UN 42.75 27.79 AETNA AETNA 33.77 79 999999999 25.89 41.47 percent of total billed charges 99999-9999-02 - Mary's Magic Mouthwash [JOHN] 48985385_1 CDM 0250 RC 99999-9999-02 NDC inpatient 1 UN 42.75 27.79 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 41.47 97 999999999 25.89 41.47 percent of total billed charges 99999-9999-02 - Mary's Magic Mouthwash [JOHN] 48985385_1 CDM 0250 RC 99999-9999-02 NDC inpatient 1 UN 42.75 27.79 ENCORE - ALL PLANS ENCORE - ALL PLANS 29.5 69 999999999 25.89 41.47 percent of total billed charges 99999-9999-02 - Mary's Magic Mouthwash [JOHN] 48985385_1 CDM 0250 RC 99999-9999-02 NDC inpatient 1 UN 42.75 27.79 HUMANA - ALL PLANS HUMANA - ALL PLANS 33.35 78 999999999 25.89 41.47 percent of total billed charges 99999-9999-02 - Mary's Magic Mouthwash [JOHN] 48985385_1 CDM 0250 RC 99999-9999-02 NDC inpatient 1 UN 42.75 27.79 SIHO - ALL PLANS SIHO - ALL PLANS 38.48 90 999999999 25.89 41.47 percent of total billed charges 99999-9999-02 - Mary's Magic Mouthwash [JOHN] 48985385_1 CDM 0250 RC 99999-9999-02 NDC inpatient 1 UN 42.75 27.79 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 25.89 60.55 999999999 25.89 41.47 percent of total billed charges 99999-9999-02 - Mary's Magic Mouthwash [JOHN] 48985385_1 CDM 0250 RC 99999-9999-02 NDC inpatient 1 UN 42.75 27.79 UMR - ALL PLANS UMR - ALL PLANS 29.93 70 999999999 25.89 41.47 percent of total billed charges 99999-9999-02 - Mary's Magic Mouthwash [JOHN] 48985385_1 CDM 0250 RC 99999-9999-02 NDC inpatient 1 UN 42.75 27.79 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 25.89 41.47 99999-9999-02 - Mary's Magic Mouthwash [JOHN] 48985385_1 CDM 0250 RC 99999-9999-02 NDC inpatient 1 UN 42.75 27.79 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 25.89 41.47 99999-9999-02 - Mary's Magic Mouthwash [JOHN] 48985385_1 CDM 0250 RC 99999-9999-02 NDC inpatient 1 UN 42.75 27.79 ANTHEM HMO ANTHEM HMO 999999999 25.89 41.47 99999-9999-02 - Mary's Magic Mouthwash [JOHN] 48985385_1 CDM 0250 RC 99999-9999-02 NDC inpatient 1 UN 42.75 27.79 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 25.89 41.47 99999-9999-02 - Mary's Magic Mouthwash [JOHN] 48985385_1 CDM 0250 RC 99999-9999-02 NDC inpatient 1 UN 42.75 27.79 CIGNA - ALL PLANS CIGNA - ALL PLANS 28.9 67.6 999999999 25.89 41.47 percent of total billed charges 99999-9999-02 - Mary's Magic Mouthwash [JOHN] 48985385_1 CDM 0250 RC 99999-9999-02 NDC inpatient 1 UN 42.75 27.79 UHC - ALL PLANS UHC - ALL PLANS 999999999 25.89 41.47 "Testing for presence of drug, by chemistry analyzers" 48986576_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.6 65 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48986576_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 AETNA AETNA 161.16 79 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48986576_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.88 97 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48986576_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.76 69 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48986576_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.12 78 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48986576_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 SIHO - ALL PLANS SIHO - ALL PLANS 183.6 90 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48986576_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.52 60.55 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48986576_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 UMR - ALL PLANS UMR - ALL PLANS 142.8 70 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48986576_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.52 197.88 "Testing for presence of drug, by chemistry analyzers" 48986576_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.52 197.88 "Testing for presence of drug, by chemistry analyzers" 48986576_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 ANTHEM HMO ANTHEM HMO 999999999 123.52 197.88 "Testing for presence of drug, by chemistry analyzers" 48986576_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.52 197.88 "Testing for presence of drug, by chemistry analyzers" 48986576_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.9 67.6 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 48986576_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.52 197.88 "Measurement of DNA antibody, native or double stranded" 48991042_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.05 65 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 48991042_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 AETNA AETNA 203.03 79 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 48991042_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 249.29 97 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 48991042_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 177.33 69 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 48991042_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 200.46 78 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 48991042_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 SIHO - ALL PLANS SIHO - ALL PLANS 231.3 90 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 48991042_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.61 60.55 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 48991042_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 UMR - ALL PLANS UMR - ALL PLANS 179.9 70 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 48991042_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.61 249.29 "Measurement of DNA antibody, native or double stranded" 48991042_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.61 249.29 "Measurement of DNA antibody, native or double stranded" 48991042_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 ANTHEM HMO ANTHEM HMO 999999999 155.61 249.29 "Measurement of DNA antibody, native or double stranded" 48991042_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.61 249.29 "Measurement of DNA antibody, native or double stranded" 48991042_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.73 67.6 999999999 155.61 249.29 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 48991042_1 CDM 0302 RC 86225 HCPCS inpatient 257 167.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.61 249.29 "Measurement of antibody for assessment of autoimmune disorder, any method" 48991043_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48991043_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48991043_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48991043_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48991043_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48991043_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48991043_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48991043_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48991043_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48991043_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48991043_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48991043_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 48991043_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 48991043_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 48992336_1 CDM 0306 RC 87510 HCPCS inpatient 95 61.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.75 65 999999999 57.52 92.15 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 48992336_1 CDM 0306 RC 87510 HCPCS inpatient 95 61.75 AETNA AETNA 75.05 79 999999999 57.52 92.15 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 48992336_1 CDM 0306 RC 87510 HCPCS inpatient 95 61.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 92.15 97 999999999 57.52 92.15 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 48992336_1 CDM 0306 RC 87510 HCPCS inpatient 95 61.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 65.55 69 999999999 57.52 92.15 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 48992336_1 CDM 0306 RC 87510 HCPCS inpatient 95 61.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.1 78 999999999 57.52 92.15 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 48992336_1 CDM 0306 RC 87510 HCPCS inpatient 95 61.75 SIHO - ALL PLANS SIHO - ALL PLANS 85.5 90 999999999 57.52 92.15 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 48992336_1 CDM 0306 RC 87510 HCPCS inpatient 95 61.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 57.52 60.55 999999999 57.52 92.15 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 48992336_1 CDM 0306 RC 87510 HCPCS inpatient 95 61.75 UMR - ALL PLANS UMR - ALL PLANS 66.5 70 999999999 57.52 92.15 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 48992336_1 CDM 0306 RC 87510 HCPCS inpatient 95 61.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 57.52 92.15 "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 48992336_1 CDM 0306 RC 87510 HCPCS inpatient 95 61.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 57.52 92.15 "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 48992336_1 CDM 0306 RC 87510 HCPCS inpatient 95 61.75 ANTHEM HMO ANTHEM HMO 999999999 57.52 92.15 "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 48992336_1 CDM 0306 RC 87510 HCPCS inpatient 95 61.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 57.52 92.15 "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 48992336_1 CDM 0306 RC 87510 HCPCS inpatient 95 61.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.22 67.6 999999999 57.52 92.15 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 48992336_1 CDM 0306 RC 87510 HCPCS inpatient 95 61.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 57.52 92.15 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 48992337_1 CDM 0306 RC 87660 HCPCS inpatient 95 61.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.75 65 999999999 57.52 92.15 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 48992337_1 CDM 0306 RC 87660 HCPCS inpatient 95 61.75 AETNA AETNA 75.05 79 999999999 57.52 92.15 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 48992337_1 CDM 0306 RC 87660 HCPCS inpatient 95 61.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 92.15 97 999999999 57.52 92.15 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 48992337_1 CDM 0306 RC 87660 HCPCS inpatient 95 61.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 65.55 69 999999999 57.52 92.15 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 48992337_1 CDM 0306 RC 87660 HCPCS inpatient 95 61.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.1 78 999999999 57.52 92.15 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 48992337_1 CDM 0306 RC 87660 HCPCS inpatient 95 61.75 SIHO - ALL PLANS SIHO - ALL PLANS 85.5 90 999999999 57.52 92.15 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 48992337_1 CDM 0306 RC 87660 HCPCS inpatient 95 61.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 57.52 60.55 999999999 57.52 92.15 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 48992337_1 CDM 0306 RC 87660 HCPCS inpatient 95 61.75 UMR - ALL PLANS UMR - ALL PLANS 66.5 70 999999999 57.52 92.15 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 48992337_1 CDM 0306 RC 87660 HCPCS inpatient 95 61.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 57.52 92.15 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 48992337_1 CDM 0306 RC 87660 HCPCS inpatient 95 61.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 57.52 92.15 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 48992337_1 CDM 0306 RC 87660 HCPCS inpatient 95 61.75 ANTHEM HMO ANTHEM HMO 999999999 57.52 92.15 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 48992337_1 CDM 0306 RC 87660 HCPCS inpatient 95 61.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 57.52 92.15 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 48992337_1 CDM 0306 RC 87660 HCPCS inpatient 95 61.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.22 67.6 999999999 57.52 92.15 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 48992337_1 CDM 0306 RC 87660 HCPCS inpatient 95 61.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 57.52 92.15 Fibrinogen (factor 1) activity measurement 49017271_1 CDM 0300 RC 85384 HCPCS inpatient 312 202.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 202.8 65 999999999 188.92 302.64 percent of total billed charges Fibrinogen (factor 1) activity measurement 49017271_1 CDM 0300 RC 85384 HCPCS inpatient 312 202.8 AETNA AETNA 246.48 79 999999999 188.92 302.64 percent of total billed charges Fibrinogen (factor 1) activity measurement 49017271_1 CDM 0300 RC 85384 HCPCS inpatient 312 202.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 302.64 97 999999999 188.92 302.64 percent of total billed charges Fibrinogen (factor 1) activity measurement 49017271_1 CDM 0300 RC 85384 HCPCS inpatient 312 202.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 215.28 69 999999999 188.92 302.64 percent of total billed charges Fibrinogen (factor 1) activity measurement 49017271_1 CDM 0300 RC 85384 HCPCS inpatient 312 202.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 243.36 78 999999999 188.92 302.64 percent of total billed charges Fibrinogen (factor 1) activity measurement 49017271_1 CDM 0300 RC 85384 HCPCS inpatient 312 202.8 SIHO - ALL PLANS SIHO - ALL PLANS 280.8 90 999999999 188.92 302.64 percent of total billed charges Fibrinogen (factor 1) activity measurement 49017271_1 CDM 0300 RC 85384 HCPCS inpatient 312 202.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 188.92 60.55 999999999 188.92 302.64 percent of total billed charges Fibrinogen (factor 1) activity measurement 49017271_1 CDM 0300 RC 85384 HCPCS inpatient 312 202.8 UMR - ALL PLANS UMR - ALL PLANS 218.4 70 999999999 188.92 302.64 percent of total billed charges Fibrinogen (factor 1) activity measurement 49017271_1 CDM 0300 RC 85384 HCPCS inpatient 312 202.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 188.92 302.64 Fibrinogen (factor 1) activity measurement 49017271_1 CDM 0300 RC 85384 HCPCS inpatient 312 202.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 188.92 302.64 Fibrinogen (factor 1) activity measurement 49017271_1 CDM 0300 RC 85384 HCPCS inpatient 312 202.8 ANTHEM HMO ANTHEM HMO 999999999 188.92 302.64 Fibrinogen (factor 1) activity measurement 49017271_1 CDM 0300 RC 85384 HCPCS inpatient 312 202.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 188.92 302.64 Fibrinogen (factor 1) activity measurement 49017271_1 CDM 0300 RC 85384 HCPCS inpatient 312 202.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 210.91 67.6 999999999 188.92 302.64 percent of total billed charges Fibrinogen (factor 1) activity measurement 49017271_1 CDM 0300 RC 85384 HCPCS inpatient 312 202.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 188.92 302.64 "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 49018089_1 CDM 0302 RC 87801 HCPCS inpatient 323 209.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 209.95 65 999999999 195.58 313.31 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 49018089_1 CDM 0302 RC 87801 HCPCS inpatient 323 209.95 AETNA AETNA 255.17 79 999999999 195.58 313.31 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 49018089_1 CDM 0302 RC 87801 HCPCS inpatient 323 209.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 313.31 97 999999999 195.58 313.31 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 49018089_1 CDM 0302 RC 87801 HCPCS inpatient 323 209.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 222.87 69 999999999 195.58 313.31 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 49018089_1 CDM 0302 RC 87801 HCPCS inpatient 323 209.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 251.94 78 999999999 195.58 313.31 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 49018089_1 CDM 0302 RC 87801 HCPCS inpatient 323 209.95 SIHO - ALL PLANS SIHO - ALL PLANS 290.7 90 999999999 195.58 313.31 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 49018089_1 CDM 0302 RC 87801 HCPCS inpatient 323 209.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 195.58 60.55 999999999 195.58 313.31 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 49018089_1 CDM 0302 RC 87801 HCPCS inpatient 323 209.95 UMR - ALL PLANS UMR - ALL PLANS 226.1 70 999999999 195.58 313.31 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 49018089_1 CDM 0302 RC 87801 HCPCS inpatient 323 209.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 195.58 313.31 "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 49018089_1 CDM 0302 RC 87801 HCPCS inpatient 323 209.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 195.58 313.31 "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 49018089_1 CDM 0302 RC 87801 HCPCS inpatient 323 209.95 ANTHEM HMO ANTHEM HMO 999999999 195.58 313.31 "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 49018089_1 CDM 0302 RC 87801 HCPCS inpatient 323 209.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 195.58 313.31 "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 49018089_1 CDM 0302 RC 87801 HCPCS inpatient 323 209.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 218.35 67.6 999999999 195.58 313.31 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 49018089_1 CDM 0302 RC 87801 HCPCS inpatient 323 209.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 195.58 313.31 NASAL MASK -- B -- LOT-RT 73-1133662 10/PK 49019379_1 CDM 0270 RC inpatient 125 81.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.25 65 999999999 75.69 121.25 percent of total billed charges NASAL MASK -- B -- LOT-RT 73-1133662 10/PK 49019379_1 CDM 0270 RC inpatient 125 81.25 AETNA AETNA 98.75 79 999999999 75.69 121.25 percent of total billed charges NASAL MASK -- B -- LOT-RT 73-1133662 10/PK 49019379_1 CDM 0270 RC inpatient 125 81.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 121.25 97 999999999 75.69 121.25 percent of total billed charges NASAL MASK -- B -- LOT-RT 73-1133662 10/PK 49019379_1 CDM 0270 RC inpatient 125 81.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.25 69 999999999 75.69 121.25 percent of total billed charges NASAL MASK -- B -- LOT-RT 73-1133662 10/PK 49019379_1 CDM 0270 RC inpatient 125 81.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.5 78 999999999 75.69 121.25 percent of total billed charges NASAL MASK -- B -- LOT-RT 73-1133662 10/PK 49019379_1 CDM 0270 RC inpatient 125 81.25 SIHO - ALL PLANS SIHO - ALL PLANS 112.5 90 999999999 75.69 121.25 percent of total billed charges NASAL MASK -- B -- LOT-RT 73-1133662 10/PK 49019379_1 CDM 0270 RC inpatient 125 81.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.69 60.55 999999999 75.69 121.25 percent of total billed charges NASAL MASK -- B -- LOT-RT 73-1133662 10/PK 49019379_1 CDM 0270 RC inpatient 125 81.25 UMR - ALL PLANS UMR - ALL PLANS 87.5 70 999999999 75.69 121.25 percent of total billed charges NASAL MASK -- B -- LOT-RT 73-1133662 10/PK 49019379_1 CDM 0270 RC inpatient 125 81.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.69 121.25 NASAL MASK -- B -- LOT-RT 73-1133662 10/PK 49019379_1 CDM 0270 RC inpatient 125 81.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.69 121.25 NASAL MASK -- B -- LOT-RT 73-1133662 10/PK 49019379_1 CDM 0270 RC inpatient 125 81.25 ANTHEM HMO ANTHEM HMO 999999999 75.69 121.25 NASAL MASK -- B -- LOT-RT 73-1133662 10/PK 49019379_1 CDM 0270 RC inpatient 125 81.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.69 121.25 NASAL MASK -- B -- LOT-RT 73-1133662 10/PK 49019379_1 CDM 0270 RC inpatient 125 81.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.5 67.6 999999999 75.69 121.25 percent of total billed charges NASAL MASK -- B -- LOT-RT 73-1133662 10/PK 49019379_1 CDM 0270 RC inpatient 125 81.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.69 121.25 CATH FOLEY 3-W 5CC 22F COVIDIEN 8887664224 49019570_1 CDM 0274 RC inpatient 55 35.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 35.75 65 999999999 33.3 53.35 percent of total billed charges CATH FOLEY 3-W 5CC 22F COVIDIEN 8887664224 49019570_1 CDM 0274 RC inpatient 55 35.75 AETNA AETNA 43.45 79 999999999 33.3 53.35 percent of total billed charges CATH FOLEY 3-W 5CC 22F COVIDIEN 8887664224 49019570_1 CDM 0274 RC inpatient 55 35.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 53.35 97 999999999 33.3 53.35 percent of total billed charges CATH FOLEY 3-W 5CC 22F COVIDIEN 8887664224 49019570_1 CDM 0274 RC inpatient 55 35.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 37.95 69 999999999 33.3 53.35 percent of total billed charges CATH FOLEY 3-W 5CC 22F COVIDIEN 8887664224 49019570_1 CDM 0274 RC inpatient 55 35.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 42.9 78 999999999 33.3 53.35 percent of total billed charges CATH FOLEY 3-W 5CC 22F COVIDIEN 8887664224 49019570_1 CDM 0274 RC inpatient 55 35.75 SIHO - ALL PLANS SIHO - ALL PLANS 49.5 90 999999999 33.3 53.35 percent of total billed charges CATH FOLEY 3-W 5CC 22F COVIDIEN 8887664224 49019570_1 CDM 0274 RC inpatient 55 35.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33.3 60.55 999999999 33.3 53.35 percent of total billed charges CATH FOLEY 3-W 5CC 22F COVIDIEN 8887664224 49019570_1 CDM 0274 RC inpatient 55 35.75 UMR - ALL PLANS UMR - ALL PLANS 38.5 70 999999999 33.3 53.35 percent of total billed charges CATH FOLEY 3-W 5CC 22F COVIDIEN 8887664224 49019570_1 CDM 0274 RC inpatient 55 35.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 33.3 53.35 CATH FOLEY 3-W 5CC 22F COVIDIEN 8887664224 49019570_1 CDM 0274 RC inpatient 55 35.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 33.3 53.35 CATH FOLEY 3-W 5CC 22F COVIDIEN 8887664224 49019570_1 CDM 0274 RC inpatient 55 35.75 ANTHEM HMO ANTHEM HMO 999999999 33.3 53.35 CATH FOLEY 3-W 5CC 22F COVIDIEN 8887664224 49019570_1 CDM 0274 RC inpatient 55 35.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 33.3 53.35 CATH FOLEY 3-W 5CC 22F COVIDIEN 8887664224 49019570_1 CDM 0274 RC inpatient 55 35.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 37.18 67.6 999999999 33.3 53.35 percent of total billed charges CATH FOLEY 3-W 5CC 22F COVIDIEN 8887664224 49019570_1 CDM 0274 RC inpatient 55 35.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 33.3 53.35 CANNULA ARTHROSCOPY 5.5X75MM DEPUY MITEK 214108 49019574_1 CDM 0272 RC inpatient 269 174.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 174.85 65 999999999 162.88 260.93 percent of total billed charges CANNULA ARTHROSCOPY 5.5X75MM DEPUY MITEK 214108 49019574_1 CDM 0272 RC inpatient 269 174.85 AETNA AETNA 212.51 79 999999999 162.88 260.93 percent of total billed charges CANNULA ARTHROSCOPY 5.5X75MM DEPUY MITEK 214108 49019574_1 CDM 0272 RC inpatient 269 174.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 260.93 97 999999999 162.88 260.93 percent of total billed charges CANNULA ARTHROSCOPY 5.5X75MM DEPUY MITEK 214108 49019574_1 CDM 0272 RC inpatient 269 174.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 185.61 69 999999999 162.88 260.93 percent of total billed charges CANNULA ARTHROSCOPY 5.5X75MM DEPUY MITEK 214108 49019574_1 CDM 0272 RC inpatient 269 174.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 209.82 78 999999999 162.88 260.93 percent of total billed charges CANNULA ARTHROSCOPY 5.5X75MM DEPUY MITEK 214108 49019574_1 CDM 0272 RC inpatient 269 174.85 SIHO - ALL PLANS SIHO - ALL PLANS 242.1 90 999999999 162.88 260.93 percent of total billed charges CANNULA ARTHROSCOPY 5.5X75MM DEPUY MITEK 214108 49019574_1 CDM 0272 RC inpatient 269 174.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 162.88 60.55 999999999 162.88 260.93 percent of total billed charges CANNULA ARTHROSCOPY 5.5X75MM DEPUY MITEK 214108 49019574_1 CDM 0272 RC inpatient 269 174.85 UMR - ALL PLANS UMR - ALL PLANS 188.3 70 999999999 162.88 260.93 percent of total billed charges CANNULA ARTHROSCOPY 5.5X75MM DEPUY MITEK 214108 49019574_1 CDM 0272 RC inpatient 269 174.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 162.88 260.93 CANNULA ARTHROSCOPY 5.5X75MM DEPUY MITEK 214108 49019574_1 CDM 0272 RC inpatient 269 174.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 162.88 260.93 CANNULA ARTHROSCOPY 5.5X75MM DEPUY MITEK 214108 49019574_1 CDM 0272 RC inpatient 269 174.85 ANTHEM HMO ANTHEM HMO 999999999 162.88 260.93 CANNULA ARTHROSCOPY 5.5X75MM DEPUY MITEK 214108 49019574_1 CDM 0272 RC inpatient 269 174.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 162.88 260.93 CANNULA ARTHROSCOPY 5.5X75MM DEPUY MITEK 214108 49019574_1 CDM 0272 RC inpatient 269 174.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 181.84 67.6 999999999 162.88 260.93 percent of total billed charges CANNULA ARTHROSCOPY 5.5X75MM DEPUY MITEK 214108 49019574_1 CDM 0272 RC inpatient 269 174.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 162.88 260.93 2.4 LK SCREW ST/SD 12M 212.812 49019576_1 CDM 0278 RC inpatient 723 469.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 469.95 65 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 12M 212.812 49019576_1 CDM 0278 RC inpatient 723 469.95 AETNA AETNA 571.17 79 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 12M 212.812 49019576_1 CDM 0278 RC inpatient 723 469.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 701.31 97 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 12M 212.812 49019576_1 CDM 0278 RC inpatient 723 469.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 498.87 69 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 12M 212.812 49019576_1 CDM 0278 RC inpatient 723 469.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 563.94 78 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 12M 212.812 49019576_1 CDM 0278 RC inpatient 723 469.95 SIHO - ALL PLANS SIHO - ALL PLANS 650.7 90 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 12M 212.812 49019576_1 CDM 0278 RC inpatient 723 469.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 437.78 60.55 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 12M 212.812 49019576_1 CDM 0278 RC inpatient 723 469.95 UMR - ALL PLANS UMR - ALL PLANS 506.1 70 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 12M 212.812 49019576_1 CDM 0278 RC inpatient 723 469.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 437.78 701.31 2.4 LK SCREW ST/SD 12M 212.812 49019576_1 CDM 0278 RC inpatient 723 469.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 437.78 701.31 2.4 LK SCREW ST/SD 12M 212.812 49019576_1 CDM 0278 RC inpatient 723 469.95 ANTHEM HMO ANTHEM HMO 999999999 437.78 701.31 2.4 LK SCREW ST/SD 12M 212.812 49019576_1 CDM 0278 RC inpatient 723 469.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 437.78 701.31 2.4 LK SCREW ST/SD 12M 212.812 49019576_1 CDM 0278 RC inpatient 723 469.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 488.75 67.6 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 12M 212.812 49019576_1 CDM 0278 RC inpatient 723 469.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 437.78 701.31 2.4 LK SCREW ST/SD 14M 212.814 49019577_1 CDM 0278 RC inpatient 723 469.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 469.95 65 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 14M 212.814 49019577_1 CDM 0278 RC inpatient 723 469.95 AETNA AETNA 571.17 79 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 14M 212.814 49019577_1 CDM 0278 RC inpatient 723 469.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 701.31 97 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 14M 212.814 49019577_1 CDM 0278 RC inpatient 723 469.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 498.87 69 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 14M 212.814 49019577_1 CDM 0278 RC inpatient 723 469.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 563.94 78 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 14M 212.814 49019577_1 CDM 0278 RC inpatient 723 469.95 SIHO - ALL PLANS SIHO - ALL PLANS 650.7 90 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 14M 212.814 49019577_1 CDM 0278 RC inpatient 723 469.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 437.78 60.55 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 14M 212.814 49019577_1 CDM 0278 RC inpatient 723 469.95 UMR - ALL PLANS UMR - ALL PLANS 506.1 70 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 14M 212.814 49019577_1 CDM 0278 RC inpatient 723 469.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 437.78 701.31 2.4 LK SCREW ST/SD 14M 212.814 49019577_1 CDM 0278 RC inpatient 723 469.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 437.78 701.31 2.4 LK SCREW ST/SD 14M 212.814 49019577_1 CDM 0278 RC inpatient 723 469.95 ANTHEM HMO ANTHEM HMO 999999999 437.78 701.31 2.4 LK SCREW ST/SD 14M 212.814 49019577_1 CDM 0278 RC inpatient 723 469.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 437.78 701.31 2.4 LK SCREW ST/SD 14M 212.814 49019577_1 CDM 0278 RC inpatient 723 469.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 488.75 67.6 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 14M 212.814 49019577_1 CDM 0278 RC inpatient 723 469.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 437.78 701.31 2.4 LK SCREW ST/SD 16M 212.816 49019578_1 CDM 0278 RC inpatient 723 469.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 469.95 65 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 16M 212.816 49019578_1 CDM 0278 RC inpatient 723 469.95 AETNA AETNA 571.17 79 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 16M 212.816 49019578_1 CDM 0278 RC inpatient 723 469.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 701.31 97 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 16M 212.816 49019578_1 CDM 0278 RC inpatient 723 469.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 498.87 69 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 16M 212.816 49019578_1 CDM 0278 RC inpatient 723 469.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 563.94 78 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 16M 212.816 49019578_1 CDM 0278 RC inpatient 723 469.95 SIHO - ALL PLANS SIHO - ALL PLANS 650.7 90 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 16M 212.816 49019578_1 CDM 0278 RC inpatient 723 469.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 437.78 60.55 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 16M 212.816 49019578_1 CDM 0278 RC inpatient 723 469.95 UMR - ALL PLANS UMR - ALL PLANS 506.1 70 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 16M 212.816 49019578_1 CDM 0278 RC inpatient 723 469.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 437.78 701.31 2.4 LK SCREW ST/SD 16M 212.816 49019578_1 CDM 0278 RC inpatient 723 469.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 437.78 701.31 2.4 LK SCREW ST/SD 16M 212.816 49019578_1 CDM 0278 RC inpatient 723 469.95 ANTHEM HMO ANTHEM HMO 999999999 437.78 701.31 2.4 LK SCREW ST/SD 16M 212.816 49019578_1 CDM 0278 RC inpatient 723 469.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 437.78 701.31 2.4 LK SCREW ST/SD 16M 212.816 49019578_1 CDM 0278 RC inpatient 723 469.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 488.75 67.6 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 16M 212.816 49019578_1 CDM 0278 RC inpatient 723 469.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 437.78 701.31 2.4 LK SCREW ST/SD 18M 212.818 49019579_1 CDM 0278 RC inpatient 723 469.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 469.95 65 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 18M 212.818 49019579_1 CDM 0278 RC inpatient 723 469.95 AETNA AETNA 571.17 79 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 18M 212.818 49019579_1 CDM 0278 RC inpatient 723 469.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 701.31 97 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 18M 212.818 49019579_1 CDM 0278 RC inpatient 723 469.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 498.87 69 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 18M 212.818 49019579_1 CDM 0278 RC inpatient 723 469.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 563.94 78 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 18M 212.818 49019579_1 CDM 0278 RC inpatient 723 469.95 SIHO - ALL PLANS SIHO - ALL PLANS 650.7 90 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 18M 212.818 49019579_1 CDM 0278 RC inpatient 723 469.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 437.78 60.55 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 18M 212.818 49019579_1 CDM 0278 RC inpatient 723 469.95 UMR - ALL PLANS UMR - ALL PLANS 506.1 70 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 18M 212.818 49019579_1 CDM 0278 RC inpatient 723 469.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 437.78 701.31 2.4 LK SCREW ST/SD 18M 212.818 49019579_1 CDM 0278 RC inpatient 723 469.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 437.78 701.31 2.4 LK SCREW ST/SD 18M 212.818 49019579_1 CDM 0278 RC inpatient 723 469.95 ANTHEM HMO ANTHEM HMO 999999999 437.78 701.31 2.4 LK SCREW ST/SD 18M 212.818 49019579_1 CDM 0278 RC inpatient 723 469.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 437.78 701.31 2.4 LK SCREW ST/SD 18M 212.818 49019579_1 CDM 0278 RC inpatient 723 469.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 488.75 67.6 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 18M 212.818 49019579_1 CDM 0278 RC inpatient 723 469.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 437.78 701.31 2.4 LK SCREW ST/SD 20M 212.820 49019580_1 CDM 0278 RC inpatient 723 469.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 469.95 65 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 20M 212.820 49019580_1 CDM 0278 RC inpatient 723 469.95 AETNA AETNA 571.17 79 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 20M 212.820 49019580_1 CDM 0278 RC inpatient 723 469.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 701.31 97 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 20M 212.820 49019580_1 CDM 0278 RC inpatient 723 469.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 498.87 69 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 20M 212.820 49019580_1 CDM 0278 RC inpatient 723 469.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 563.94 78 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 20M 212.820 49019580_1 CDM 0278 RC inpatient 723 469.95 SIHO - ALL PLANS SIHO - ALL PLANS 650.7 90 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 20M 212.820 49019580_1 CDM 0278 RC inpatient 723 469.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 437.78 60.55 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 20M 212.820 49019580_1 CDM 0278 RC inpatient 723 469.95 UMR - ALL PLANS UMR - ALL PLANS 506.1 70 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 20M 212.820 49019580_1 CDM 0278 RC inpatient 723 469.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 437.78 701.31 2.4 LK SCREW ST/SD 20M 212.820 49019580_1 CDM 0278 RC inpatient 723 469.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 437.78 701.31 2.4 LK SCREW ST/SD 20M 212.820 49019580_1 CDM 0278 RC inpatient 723 469.95 ANTHEM HMO ANTHEM HMO 999999999 437.78 701.31 2.4 LK SCREW ST/SD 20M 212.820 49019580_1 CDM 0278 RC inpatient 723 469.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 437.78 701.31 2.4 LK SCREW ST/SD 20M 212.820 49019580_1 CDM 0278 RC inpatient 723 469.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 488.75 67.6 999999999 437.78 701.31 percent of total billed charges 2.4 LK SCREW ST/SD 20M 212.820 49019580_1 CDM 0278 RC inpatient 723 469.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 437.78 701.31 2.4 CTX SCREW S/T 22MM 201.772 49019581_1 CDM 0278 RC inpatient 432 280.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 280.8 65 999999999 261.58 419.04 percent of total billed charges 2.4 CTX SCREW S/T 22MM 201.772 49019581_1 CDM 0278 RC inpatient 432 280.8 AETNA AETNA 341.28 79 999999999 261.58 419.04 percent of total billed charges 2.4 CTX SCREW S/T 22MM 201.772 49019581_1 CDM 0278 RC inpatient 432 280.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 419.04 97 999999999 261.58 419.04 percent of total billed charges 2.4 CTX SCREW S/T 22MM 201.772 49019581_1 CDM 0278 RC inpatient 432 280.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 298.08 69 999999999 261.58 419.04 percent of total billed charges 2.4 CTX SCREW S/T 22MM 201.772 49019581_1 CDM 0278 RC inpatient 432 280.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 336.96 78 999999999 261.58 419.04 percent of total billed charges 2.4 CTX SCREW S/T 22MM 201.772 49019581_1 CDM 0278 RC inpatient 432 280.8 SIHO - ALL PLANS SIHO - ALL PLANS 388.8 90 999999999 261.58 419.04 percent of total billed charges 2.4 CTX SCREW S/T 22MM 201.772 49019581_1 CDM 0278 RC inpatient 432 280.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 261.58 60.55 999999999 261.58 419.04 percent of total billed charges 2.4 CTX SCREW S/T 22MM 201.772 49019581_1 CDM 0278 RC inpatient 432 280.8 UMR - ALL PLANS UMR - ALL PLANS 302.4 70 999999999 261.58 419.04 percent of total billed charges 2.4 CTX SCREW S/T 22MM 201.772 49019581_1 CDM 0278 RC inpatient 432 280.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 261.58 419.04 2.4 CTX SCREW S/T 22MM 201.772 49019581_1 CDM 0278 RC inpatient 432 280.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 261.58 419.04 2.4 CTX SCREW S/T 22MM 201.772 49019581_1 CDM 0278 RC inpatient 432 280.8 ANTHEM HMO ANTHEM HMO 999999999 261.58 419.04 2.4 CTX SCREW S/T 22MM 201.772 49019581_1 CDM 0278 RC inpatient 432 280.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 261.58 419.04 2.4 CTX SCREW S/T 22MM 201.772 49019581_1 CDM 0278 RC inpatient 432 280.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 292.03 67.6 999999999 261.58 419.04 percent of total billed charges 2.4 CTX SCREW S/T 22MM 201.772 49019581_1 CDM 0278 RC inpatient 432 280.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 261.58 419.04 2.7 CTX SCREW S/T 14MM 202.874 49019582_1 CDM 0278 RC inpatient 294 191.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 191.1 65 999999999 178.02 285.18 percent of total billed charges 2.7 CTX SCREW S/T 14MM 202.874 49019582_1 CDM 0278 RC inpatient 294 191.1 AETNA AETNA 232.26 79 999999999 178.02 285.18 percent of total billed charges 2.7 CTX SCREW S/T 14MM 202.874 49019582_1 CDM 0278 RC inpatient 294 191.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 285.18 97 999999999 178.02 285.18 percent of total billed charges 2.7 CTX SCREW S/T 14MM 202.874 49019582_1 CDM 0278 RC inpatient 294 191.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 202.86 69 999999999 178.02 285.18 percent of total billed charges 2.7 CTX SCREW S/T 14MM 202.874 49019582_1 CDM 0278 RC inpatient 294 191.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 229.32 78 999999999 178.02 285.18 percent of total billed charges 2.7 CTX SCREW S/T 14MM 202.874 49019582_1 CDM 0278 RC inpatient 294 191.1 SIHO - ALL PLANS SIHO - ALL PLANS 264.6 90 999999999 178.02 285.18 percent of total billed charges 2.7 CTX SCREW S/T 14MM 202.874 49019582_1 CDM 0278 RC inpatient 294 191.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 178.02 60.55 999999999 178.02 285.18 percent of total billed charges 2.7 CTX SCREW S/T 14MM 202.874 49019582_1 CDM 0278 RC inpatient 294 191.1 UMR - ALL PLANS UMR - ALL PLANS 205.8 70 999999999 178.02 285.18 percent of total billed charges 2.7 CTX SCREW S/T 14MM 202.874 49019582_1 CDM 0278 RC inpatient 294 191.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 178.02 285.18 2.7 CTX SCREW S/T 14MM 202.874 49019582_1 CDM 0278 RC inpatient 294 191.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 178.02 285.18 2.7 CTX SCREW S/T 14MM 202.874 49019582_1 CDM 0278 RC inpatient 294 191.1 ANTHEM HMO ANTHEM HMO 999999999 178.02 285.18 2.7 CTX SCREW S/T 14MM 202.874 49019582_1 CDM 0278 RC inpatient 294 191.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 178.02 285.18 2.7 CTX SCREW S/T 14MM 202.874 49019582_1 CDM 0278 RC inpatient 294 191.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 198.74 67.6 999999999 178.02 285.18 percent of total billed charges 2.7 CTX SCREW S/T 14MM 202.874 49019582_1 CDM 0278 RC inpatient 294 191.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 178.02 285.18 PLATE DIS RAD 4 H RHT 242.464 49019583_1 CDM 0278 RC inpatient 4577 2975.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 2975.05 65 999999999 2771.37 4439.69 percent of total billed charges PLATE DIS RAD 4 H RHT 242.464 49019583_1 CDM 0278 RC inpatient 4577 2975.05 AETNA AETNA 3615.83 79 999999999 2771.37 4439.69 percent of total billed charges PLATE DIS RAD 4 H RHT 242.464 49019583_1 CDM 0278 RC inpatient 4577 2975.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4439.69 97 999999999 2771.37 4439.69 percent of total billed charges PLATE DIS RAD 4 H RHT 242.464 49019583_1 CDM 0278 RC inpatient 4577 2975.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 3158.13 69 999999999 2771.37 4439.69 percent of total billed charges PLATE DIS RAD 4 H RHT 242.464 49019583_1 CDM 0278 RC inpatient 4577 2975.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 3570.06 78 999999999 2771.37 4439.69 percent of total billed charges PLATE DIS RAD 4 H RHT 242.464 49019583_1 CDM 0278 RC inpatient 4577 2975.05 SIHO - ALL PLANS SIHO - ALL PLANS 4119.3 90 999999999 2771.37 4439.69 percent of total billed charges PLATE DIS RAD 4 H RHT 242.464 49019583_1 CDM 0278 RC inpatient 4577 2975.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2771.37 60.55 999999999 2771.37 4439.69 percent of total billed charges PLATE DIS RAD 4 H RHT 242.464 49019583_1 CDM 0278 RC inpatient 4577 2975.05 UMR - ALL PLANS UMR - ALL PLANS 3203.9 70 999999999 2771.37 4439.69 percent of total billed charges PLATE DIS RAD 4 H RHT 242.464 49019583_1 CDM 0278 RC inpatient 4577 2975.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2771.37 4439.69 PLATE DIS RAD 4 H RHT 242.464 49019583_1 CDM 0278 RC inpatient 4577 2975.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2771.37 4439.69 PLATE DIS RAD 4 H RHT 242.464 49019583_1 CDM 0278 RC inpatient 4577 2975.05 ANTHEM HMO ANTHEM HMO 999999999 2771.37 4439.69 PLATE DIS RAD 4 H RHT 242.464 49019583_1 CDM 0278 RC inpatient 4577 2975.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2771.37 4439.69 PLATE DIS RAD 4 H RHT 242.464 49019583_1 CDM 0278 RC inpatient 4577 2975.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 3094.05 67.6 999999999 2771.37 4439.69 percent of total billed charges PLATE DIS RAD 4 H RHT 242.464 49019583_1 CDM 0278 RC inpatient 4577 2975.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 2771.37 4439.69 DRILL BIT SM FRAG 310.35 LOC-SUR 49019584_1 CDM 0272 RC inpatient 595 386.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 386.75 65 999999999 360.27 577.15 percent of total billed charges DRILL BIT SM FRAG 310.35 LOC-SUR 49019584_1 CDM 0272 RC inpatient 595 386.75 AETNA AETNA 470.05 79 999999999 360.27 577.15 percent of total billed charges DRILL BIT SM FRAG 310.35 LOC-SUR 49019584_1 CDM 0272 RC inpatient 595 386.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 577.15 97 999999999 360.27 577.15 percent of total billed charges DRILL BIT SM FRAG 310.35 LOC-SUR 49019584_1 CDM 0272 RC inpatient 595 386.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 410.55 69 999999999 360.27 577.15 percent of total billed charges DRILL BIT SM FRAG 310.35 LOC-SUR 49019584_1 CDM 0272 RC inpatient 595 386.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 464.1 78 999999999 360.27 577.15 percent of total billed charges DRILL BIT SM FRAG 310.35 LOC-SUR 49019584_1 CDM 0272 RC inpatient 595 386.75 SIHO - ALL PLANS SIHO - ALL PLANS 535.5 90 999999999 360.27 577.15 percent of total billed charges DRILL BIT SM FRAG 310.35 LOC-SUR 49019584_1 CDM 0272 RC inpatient 595 386.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 360.27 60.55 999999999 360.27 577.15 percent of total billed charges DRILL BIT SM FRAG 310.35 LOC-SUR 49019584_1 CDM 0272 RC inpatient 595 386.75 UMR - ALL PLANS UMR - ALL PLANS 416.5 70 999999999 360.27 577.15 percent of total billed charges DRILL BIT SM FRAG 310.35 LOC-SUR 49019584_1 CDM 0272 RC inpatient 595 386.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 360.27 577.15 DRILL BIT SM FRAG 310.35 LOC-SUR 49019584_1 CDM 0272 RC inpatient 595 386.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 360.27 577.15 DRILL BIT SM FRAG 310.35 LOC-SUR 49019584_1 CDM 0272 RC inpatient 595 386.75 ANTHEM HMO ANTHEM HMO 999999999 360.27 577.15 DRILL BIT SM FRAG 310.35 LOC-SUR 49019584_1 CDM 0272 RC inpatient 595 386.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 360.27 577.15 DRILL BIT SM FRAG 310.35 LOC-SUR 49019584_1 CDM 0272 RC inpatient 595 386.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 402.22 67.6 999999999 360.27 577.15 percent of total billed charges DRILL BIT SM FRAG 310.35 LOC-SUR 49019584_1 CDM 0272 RC inpatient 595 386.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 360.27 577.15 BOOT ST FRACTURE LG BLEDSOE AL032007BB- 49019586_1 CDM 0271 RC inpatient 353 229.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 229.45 65 999999999 213.74 342.41 percent of total billed charges BOOT ST FRACTURE LG BLEDSOE AL032007BB- 49019586_1 CDM 0271 RC inpatient 353 229.45 AETNA AETNA 278.87 79 999999999 213.74 342.41 percent of total billed charges BOOT ST FRACTURE LG BLEDSOE AL032007BB- 49019586_1 CDM 0271 RC inpatient 353 229.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 342.41 97 999999999 213.74 342.41 percent of total billed charges BOOT ST FRACTURE LG BLEDSOE AL032007BB- 49019586_1 CDM 0271 RC inpatient 353 229.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 243.57 69 999999999 213.74 342.41 percent of total billed charges BOOT ST FRACTURE LG BLEDSOE AL032007BB- 49019586_1 CDM 0271 RC inpatient 353 229.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 275.34 78 999999999 213.74 342.41 percent of total billed charges BOOT ST FRACTURE LG BLEDSOE AL032007BB- 49019586_1 CDM 0271 RC inpatient 353 229.45 SIHO - ALL PLANS SIHO - ALL PLANS 317.7 90 999999999 213.74 342.41 percent of total billed charges BOOT ST FRACTURE LG BLEDSOE AL032007BB- 49019586_1 CDM 0271 RC inpatient 353 229.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 213.74 60.55 999999999 213.74 342.41 percent of total billed charges BOOT ST FRACTURE LG BLEDSOE AL032007BB- 49019586_1 CDM 0271 RC inpatient 353 229.45 UMR - ALL PLANS UMR - ALL PLANS 247.1 70 999999999 213.74 342.41 percent of total billed charges BOOT ST FRACTURE LG BLEDSOE AL032007BB- 49019586_1 CDM 0271 RC inpatient 353 229.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 213.74 342.41 BOOT ST FRACTURE LG BLEDSOE AL032007BB- 49019586_1 CDM 0271 RC inpatient 353 229.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 213.74 342.41 BOOT ST FRACTURE LG BLEDSOE AL032007BB- 49019586_1 CDM 0271 RC inpatient 353 229.45 ANTHEM HMO ANTHEM HMO 999999999 213.74 342.41 BOOT ST FRACTURE LG BLEDSOE AL032007BB- 49019586_1 CDM 0271 RC inpatient 353 229.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 213.74 342.41 BOOT ST FRACTURE LG BLEDSOE AL032007BB- 49019586_1 CDM 0271 RC inpatient 353 229.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 238.63 67.6 999999999 213.74 342.41 percent of total billed charges BOOT ST FRACTURE LG BLEDSOE AL032007BB- 49019586_1 CDM 0271 RC inpatient 353 229.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 213.74 342.41 BAYONET BIPOLAR FORCEP DISPOSABLE 20-1370 49019589_1 CDM 0272 RC inpatient 156 101.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.4 65 999999999 94.46 151.32 percent of total billed charges BAYONET BIPOLAR FORCEP DISPOSABLE 20-1370 49019589_1 CDM 0272 RC inpatient 156 101.4 AETNA AETNA 123.24 79 999999999 94.46 151.32 percent of total billed charges BAYONET BIPOLAR FORCEP DISPOSABLE 20-1370 49019589_1 CDM 0272 RC inpatient 156 101.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 151.32 97 999999999 94.46 151.32 percent of total billed charges BAYONET BIPOLAR FORCEP DISPOSABLE 20-1370 49019589_1 CDM 0272 RC inpatient 156 101.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.64 69 999999999 94.46 151.32 percent of total billed charges BAYONET BIPOLAR FORCEP DISPOSABLE 20-1370 49019589_1 CDM 0272 RC inpatient 156 101.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.68 78 999999999 94.46 151.32 percent of total billed charges BAYONET BIPOLAR FORCEP DISPOSABLE 20-1370 49019589_1 CDM 0272 RC inpatient 156 101.4 SIHO - ALL PLANS SIHO - ALL PLANS 140.4 90 999999999 94.46 151.32 percent of total billed charges BAYONET BIPOLAR FORCEP DISPOSABLE 20-1370 49019589_1 CDM 0272 RC inpatient 156 101.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.46 60.55 999999999 94.46 151.32 percent of total billed charges BAYONET BIPOLAR FORCEP DISPOSABLE 20-1370 49019589_1 CDM 0272 RC inpatient 156 101.4 UMR - ALL PLANS UMR - ALL PLANS 109.2 70 999999999 94.46 151.32 percent of total billed charges BAYONET BIPOLAR FORCEP DISPOSABLE 20-1370 49019589_1 CDM 0272 RC inpatient 156 101.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.46 151.32 BAYONET BIPOLAR FORCEP DISPOSABLE 20-1370 49019589_1 CDM 0272 RC inpatient 156 101.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.46 151.32 BAYONET BIPOLAR FORCEP DISPOSABLE 20-1370 49019589_1 CDM 0272 RC inpatient 156 101.4 ANTHEM HMO ANTHEM HMO 999999999 94.46 151.32 BAYONET BIPOLAR FORCEP DISPOSABLE 20-1370 49019589_1 CDM 0272 RC inpatient 156 101.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.46 151.32 BAYONET BIPOLAR FORCEP DISPOSABLE 20-1370 49019589_1 CDM 0272 RC inpatient 156 101.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.46 67.6 999999999 94.46 151.32 percent of total billed charges BAYONET BIPOLAR FORCEP DISPOSABLE 20-1370 49019589_1 CDM 0272 RC inpatient 156 101.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.46 151.32 **** BLANKETED PER MEGAN P 09/22/2023 **** CERVICAL VISUALIZATION HARNESS 49019590_1 CDM 0271 RC inpatient 351 228.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 228.15 65 999999999 212.53 340.47 percent of total billed charges **** BLANKETED PER MEGAN P 09/22/2023 **** CERVICAL VISUALIZATION HARNESS 49019590_1 CDM 0271 RC inpatient 351 228.15 AETNA AETNA 277.29 79 999999999 212.53 340.47 percent of total billed charges **** BLANKETED PER MEGAN P 09/22/2023 **** CERVICAL VISUALIZATION HARNESS 49019590_1 CDM 0271 RC inpatient 351 228.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 340.47 97 999999999 212.53 340.47 percent of total billed charges **** BLANKETED PER MEGAN P 09/22/2023 **** CERVICAL VISUALIZATION HARNESS 49019590_1 CDM 0271 RC inpatient 351 228.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 242.19 69 999999999 212.53 340.47 percent of total billed charges **** BLANKETED PER MEGAN P 09/22/2023 **** CERVICAL VISUALIZATION HARNESS 49019590_1 CDM 0271 RC inpatient 351 228.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 273.78 78 999999999 212.53 340.47 percent of total billed charges **** BLANKETED PER MEGAN P 09/22/2023 **** CERVICAL VISUALIZATION HARNESS 49019590_1 CDM 0271 RC inpatient 351 228.15 SIHO - ALL PLANS SIHO - ALL PLANS 315.9 90 999999999 212.53 340.47 percent of total billed charges **** BLANKETED PER MEGAN P 09/22/2023 **** CERVICAL VISUALIZATION HARNESS 49019590_1 CDM 0271 RC inpatient 351 228.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 212.53 60.55 999999999 212.53 340.47 percent of total billed charges **** BLANKETED PER MEGAN P 09/22/2023 **** CERVICAL VISUALIZATION HARNESS 49019590_1 CDM 0271 RC inpatient 351 228.15 UMR - ALL PLANS UMR - ALL PLANS 245.7 70 999999999 212.53 340.47 percent of total billed charges **** BLANKETED PER MEGAN P 09/22/2023 **** CERVICAL VISUALIZATION HARNESS 49019590_1 CDM 0271 RC inpatient 351 228.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 212.53 340.47 **** BLANKETED PER MEGAN P 09/22/2023 **** CERVICAL VISUALIZATION HARNESS 49019590_1 CDM 0271 RC inpatient 351 228.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 212.53 340.47 **** BLANKETED PER MEGAN P 09/22/2023 **** CERVICAL VISUALIZATION HARNESS 49019590_1 CDM 0271 RC inpatient 351 228.15 ANTHEM HMO ANTHEM HMO 999999999 212.53 340.47 **** BLANKETED PER MEGAN P 09/22/2023 **** CERVICAL VISUALIZATION HARNESS 49019590_1 CDM 0271 RC inpatient 351 228.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 212.53 340.47 **** BLANKETED PER MEGAN P 09/22/2023 **** CERVICAL VISUALIZATION HARNESS 49019590_1 CDM 0271 RC inpatient 351 228.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 237.28 67.6 999999999 212.53 340.47 percent of total billed charges **** BLANKETED PER MEGAN P 09/22/2023 **** CERVICAL VISUALIZATION HARNESS 49019590_1 CDM 0271 RC inpatient 351 228.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 212.53 340.47 INTUBATED CAPNOLINE LONG TERM XS04624 49019591_1 CDM 0272 RC inpatient 84 54.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 54.6 65 999999999 50.86 81.48 percent of total billed charges INTUBATED CAPNOLINE LONG TERM XS04624 49019591_1 CDM 0272 RC inpatient 84 54.6 AETNA AETNA 66.36 79 999999999 50.86 81.48 percent of total billed charges INTUBATED CAPNOLINE LONG TERM XS04624 49019591_1 CDM 0272 RC inpatient 84 54.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 81.48 97 999999999 50.86 81.48 percent of total billed charges INTUBATED CAPNOLINE LONG TERM XS04624 49019591_1 CDM 0272 RC inpatient 84 54.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.96 69 999999999 50.86 81.48 percent of total billed charges INTUBATED CAPNOLINE LONG TERM XS04624 49019591_1 CDM 0272 RC inpatient 84 54.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 65.52 78 999999999 50.86 81.48 percent of total billed charges INTUBATED CAPNOLINE LONG TERM XS04624 49019591_1 CDM 0272 RC inpatient 84 54.6 SIHO - ALL PLANS SIHO - ALL PLANS 75.6 90 999999999 50.86 81.48 percent of total billed charges INTUBATED CAPNOLINE LONG TERM XS04624 49019591_1 CDM 0272 RC inpatient 84 54.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.86 60.55 999999999 50.86 81.48 percent of total billed charges INTUBATED CAPNOLINE LONG TERM XS04624 49019591_1 CDM 0272 RC inpatient 84 54.6 UMR - ALL PLANS UMR - ALL PLANS 58.8 70 999999999 50.86 81.48 percent of total billed charges INTUBATED CAPNOLINE LONG TERM XS04624 49019591_1 CDM 0272 RC inpatient 84 54.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.86 81.48 INTUBATED CAPNOLINE LONG TERM XS04624 49019591_1 CDM 0272 RC inpatient 84 54.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.86 81.48 INTUBATED CAPNOLINE LONG TERM XS04624 49019591_1 CDM 0272 RC inpatient 84 54.6 ANTHEM HMO ANTHEM HMO 999999999 50.86 81.48 INTUBATED CAPNOLINE LONG TERM XS04624 49019591_1 CDM 0272 RC inpatient 84 54.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.86 81.48 INTUBATED CAPNOLINE LONG TERM XS04624 49019591_1 CDM 0272 RC inpatient 84 54.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.78 67.6 999999999 50.86 81.48 percent of total billed charges INTUBATED CAPNOLINE LONG TERM XS04624 49019591_1 CDM 0272 RC inpatient 84 54.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.86 81.48 LONESTAR VAG RETRACTOR 3715 49019592_1 CDM 0272 RC inpatient 566 367.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 367.9 65 999999999 342.71 549.02 percent of total billed charges LONESTAR VAG RETRACTOR 3715 49019592_1 CDM 0272 RC inpatient 566 367.9 AETNA AETNA 447.14 79 999999999 342.71 549.02 percent of total billed charges LONESTAR VAG RETRACTOR 3715 49019592_1 CDM 0272 RC inpatient 566 367.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 549.02 97 999999999 342.71 549.02 percent of total billed charges LONESTAR VAG RETRACTOR 3715 49019592_1 CDM 0272 RC inpatient 566 367.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 390.54 69 999999999 342.71 549.02 percent of total billed charges LONESTAR VAG RETRACTOR 3715 49019592_1 CDM 0272 RC inpatient 566 367.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 441.48 78 999999999 342.71 549.02 percent of total billed charges LONESTAR VAG RETRACTOR 3715 49019592_1 CDM 0272 RC inpatient 566 367.9 SIHO - ALL PLANS SIHO - ALL PLANS 509.4 90 999999999 342.71 549.02 percent of total billed charges LONESTAR VAG RETRACTOR 3715 49019592_1 CDM 0272 RC inpatient 566 367.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 342.71 60.55 999999999 342.71 549.02 percent of total billed charges LONESTAR VAG RETRACTOR 3715 49019592_1 CDM 0272 RC inpatient 566 367.9 UMR - ALL PLANS UMR - ALL PLANS 396.2 70 999999999 342.71 549.02 percent of total billed charges LONESTAR VAG RETRACTOR 3715 49019592_1 CDM 0272 RC inpatient 566 367.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 342.71 549.02 LONESTAR VAG RETRACTOR 3715 49019592_1 CDM 0272 RC inpatient 566 367.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 342.71 549.02 LONESTAR VAG RETRACTOR 3715 49019592_1 CDM 0272 RC inpatient 566 367.9 ANTHEM HMO ANTHEM HMO 999999999 342.71 549.02 LONESTAR VAG RETRACTOR 3715 49019592_1 CDM 0272 RC inpatient 566 367.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 342.71 549.02 LONESTAR VAG RETRACTOR 3715 49019592_1 CDM 0272 RC inpatient 566 367.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 382.62 67.6 999999999 342.71 549.02 percent of total billed charges LONESTAR VAG RETRACTOR 3715 49019592_1 CDM 0272 RC inpatient 566 367.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 342.71 549.02 LONESTAR ELASTIC STAYS 3311-8G 49019593_1 CDM 0272 RC inpatient 482 313.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 313.3 65 999999999 291.85 467.54 percent of total billed charges LONESTAR ELASTIC STAYS 3311-8G 49019593_1 CDM 0272 RC inpatient 482 313.3 AETNA AETNA 380.78 79 999999999 291.85 467.54 percent of total billed charges LONESTAR ELASTIC STAYS 3311-8G 49019593_1 CDM 0272 RC inpatient 482 313.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 467.54 97 999999999 291.85 467.54 percent of total billed charges LONESTAR ELASTIC STAYS 3311-8G 49019593_1 CDM 0272 RC inpatient 482 313.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 332.58 69 999999999 291.85 467.54 percent of total billed charges LONESTAR ELASTIC STAYS 3311-8G 49019593_1 CDM 0272 RC inpatient 482 313.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 375.96 78 999999999 291.85 467.54 percent of total billed charges LONESTAR ELASTIC STAYS 3311-8G 49019593_1 CDM 0272 RC inpatient 482 313.3 SIHO - ALL PLANS SIHO - ALL PLANS 433.8 90 999999999 291.85 467.54 percent of total billed charges LONESTAR ELASTIC STAYS 3311-8G 49019593_1 CDM 0272 RC inpatient 482 313.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 291.85 60.55 999999999 291.85 467.54 percent of total billed charges LONESTAR ELASTIC STAYS 3311-8G 49019593_1 CDM 0272 RC inpatient 482 313.3 UMR - ALL PLANS UMR - ALL PLANS 337.4 70 999999999 291.85 467.54 percent of total billed charges LONESTAR ELASTIC STAYS 3311-8G 49019593_1 CDM 0272 RC inpatient 482 313.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 291.85 467.54 LONESTAR ELASTIC STAYS 3311-8G 49019593_1 CDM 0272 RC inpatient 482 313.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 291.85 467.54 LONESTAR ELASTIC STAYS 3311-8G 49019593_1 CDM 0272 RC inpatient 482 313.3 ANTHEM HMO ANTHEM HMO 999999999 291.85 467.54 LONESTAR ELASTIC STAYS 3311-8G 49019593_1 CDM 0272 RC inpatient 482 313.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 291.85 467.54 LONESTAR ELASTIC STAYS 3311-8G 49019593_1 CDM 0272 RC inpatient 482 313.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 325.83 67.6 999999999 291.85 467.54 percent of total billed charges LONESTAR ELASTIC STAYS 3311-8G 49019593_1 CDM 0272 RC inpatient 482 313.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 291.85 467.54 SCREW CAN 7.3 16M/80M 208.880 49019594_1 CDM 0278 RC inpatient 1777 1155.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1155.05 65 999999999 1075.97 1723.69 percent of total billed charges SCREW CAN 7.3 16M/80M 208.880 49019594_1 CDM 0278 RC inpatient 1777 1155.05 AETNA AETNA 1403.83 79 999999999 1075.97 1723.69 percent of total billed charges SCREW CAN 7.3 16M/80M 208.880 49019594_1 CDM 0278 RC inpatient 1777 1155.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1723.69 97 999999999 1075.97 1723.69 percent of total billed charges SCREW CAN 7.3 16M/80M 208.880 49019594_1 CDM 0278 RC inpatient 1777 1155.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1226.13 69 999999999 1075.97 1723.69 percent of total billed charges SCREW CAN 7.3 16M/80M 208.880 49019594_1 CDM 0278 RC inpatient 1777 1155.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1386.06 78 999999999 1075.97 1723.69 percent of total billed charges SCREW CAN 7.3 16M/80M 208.880 49019594_1 CDM 0278 RC inpatient 1777 1155.05 SIHO - ALL PLANS SIHO - ALL PLANS 1599.3 90 999999999 1075.97 1723.69 percent of total billed charges SCREW CAN 7.3 16M/80M 208.880 49019594_1 CDM 0278 RC inpatient 1777 1155.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1075.97 60.55 999999999 1075.97 1723.69 percent of total billed charges SCREW CAN 7.3 16M/80M 208.880 49019594_1 CDM 0278 RC inpatient 1777 1155.05 UMR - ALL PLANS UMR - ALL PLANS 1243.9 70 999999999 1075.97 1723.69 percent of total billed charges SCREW CAN 7.3 16M/80M 208.880 49019594_1 CDM 0278 RC inpatient 1777 1155.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1075.97 1723.69 SCREW CAN 7.3 16M/80M 208.880 49019594_1 CDM 0278 RC inpatient 1777 1155.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1075.97 1723.69 SCREW CAN 7.3 16M/80M 208.880 49019594_1 CDM 0278 RC inpatient 1777 1155.05 ANTHEM HMO ANTHEM HMO 999999999 1075.97 1723.69 SCREW CAN 7.3 16M/80M 208.880 49019594_1 CDM 0278 RC inpatient 1777 1155.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1075.97 1723.69 SCREW CAN 7.3 16M/80M 208.880 49019594_1 CDM 0278 RC inpatient 1777 1155.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1201.25 67.6 999999999 1075.97 1723.69 percent of total billed charges SCREW CAN 7.3 16M/80M 208.880 49019594_1 CDM 0278 RC inpatient 1777 1155.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1075.97 1723.69 SPINAL TABLE DRAPE KIT 5808PV SUR 49019595_1 CDM 0271 RC inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges SPINAL TABLE DRAPE KIT 5808PV SUR 49019595_1 CDM 0271 RC inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges SPINAL TABLE DRAPE KIT 5808PV SUR 49019595_1 CDM 0271 RC inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges SPINAL TABLE DRAPE KIT 5808PV SUR 49019595_1 CDM 0271 RC inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges SPINAL TABLE DRAPE KIT 5808PV SUR 49019595_1 CDM 0271 RC inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges SPINAL TABLE DRAPE KIT 5808PV SUR 49019595_1 CDM 0271 RC inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges SPINAL TABLE DRAPE KIT 5808PV SUR 49019595_1 CDM 0271 RC inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges SPINAL TABLE DRAPE KIT 5808PV SUR 49019595_1 CDM 0271 RC inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges SPINAL TABLE DRAPE KIT 5808PV SUR 49019595_1 CDM 0271 RC inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 SPINAL TABLE DRAPE KIT 5808PV SUR 49019595_1 CDM 0271 RC inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 SPINAL TABLE DRAPE KIT 5808PV SUR 49019595_1 CDM 0271 RC inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 SPINAL TABLE DRAPE KIT 5808PV SUR 49019595_1 CDM 0271 RC inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 SPINAL TABLE DRAPE KIT 5808PV SUR 49019595_1 CDM 0271 RC inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges SPINAL TABLE DRAPE KIT 5808PV SUR 49019595_1 CDM 0271 RC inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 WAFFLE MATTRESS W/PUMP LATEX FREE 49019596_1 CDM 0272 RC inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges WAFFLE MATTRESS W/PUMP LATEX FREE 49019596_1 CDM 0272 RC inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges WAFFLE MATTRESS W/PUMP LATEX FREE 49019596_1 CDM 0272 RC inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges WAFFLE MATTRESS W/PUMP LATEX FREE 49019596_1 CDM 0272 RC inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges WAFFLE MATTRESS W/PUMP LATEX FREE 49019596_1 CDM 0272 RC inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges WAFFLE MATTRESS W/PUMP LATEX FREE 49019596_1 CDM 0272 RC inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges WAFFLE MATTRESS W/PUMP LATEX FREE 49019596_1 CDM 0272 RC inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges WAFFLE MATTRESS W/PUMP LATEX FREE 49019596_1 CDM 0272 RC inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges WAFFLE MATTRESS W/PUMP LATEX FREE 49019596_1 CDM 0272 RC inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 WAFFLE MATTRESS W/PUMP LATEX FREE 49019596_1 CDM 0272 RC inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 WAFFLE MATTRESS W/PUMP LATEX FREE 49019596_1 CDM 0272 RC inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 WAFFLE MATTRESS W/PUMP LATEX FREE 49019596_1 CDM 0272 RC inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 WAFFLE MATTRESS W/PUMP LATEX FREE 49019596_1 CDM 0272 RC inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges WAFFLE MATTRESS W/PUMP LATEX FREE 49019596_1 CDM 0272 RC inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 GUIDEWIRE .035X260CMJ 5/BOX 49019606_1 CDM 0272 RC inpatient 460 299 SELF PAY DISCOUNT SELF PAY DISCOUNT 299 65 999999999 278.53 446.2 percent of total billed charges GUIDEWIRE .035X260CMJ 5/BOX 49019606_1 CDM 0272 RC inpatient 460 299 AETNA AETNA 363.4 79 999999999 278.53 446.2 percent of total billed charges GUIDEWIRE .035X260CMJ 5/BOX 49019606_1 CDM 0272 RC inpatient 460 299 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 446.2 97 999999999 278.53 446.2 percent of total billed charges GUIDEWIRE .035X260CMJ 5/BOX 49019606_1 CDM 0272 RC inpatient 460 299 ENCORE - ALL PLANS ENCORE - ALL PLANS 317.4 69 999999999 278.53 446.2 percent of total billed charges GUIDEWIRE .035X260CMJ 5/BOX 49019606_1 CDM 0272 RC inpatient 460 299 HUMANA - ALL PLANS HUMANA - ALL PLANS 358.8 78 999999999 278.53 446.2 percent of total billed charges GUIDEWIRE .035X260CMJ 5/BOX 49019606_1 CDM 0272 RC inpatient 460 299 SIHO - ALL PLANS SIHO - ALL PLANS 414 90 999999999 278.53 446.2 percent of total billed charges GUIDEWIRE .035X260CMJ 5/BOX 49019606_1 CDM 0272 RC inpatient 460 299 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 278.53 60.55 999999999 278.53 446.2 percent of total billed charges GUIDEWIRE .035X260CMJ 5/BOX 49019606_1 CDM 0272 RC inpatient 460 299 UMR - ALL PLANS UMR - ALL PLANS 322 70 999999999 278.53 446.2 percent of total billed charges GUIDEWIRE .035X260CMJ 5/BOX 49019606_1 CDM 0272 RC inpatient 460 299 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 278.53 446.2 GUIDEWIRE .035X260CMJ 5/BOX 49019606_1 CDM 0272 RC inpatient 460 299 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 278.53 446.2 GUIDEWIRE .035X260CMJ 5/BOX 49019606_1 CDM 0272 RC inpatient 460 299 ANTHEM HMO ANTHEM HMO 999999999 278.53 446.2 GUIDEWIRE .035X260CMJ 5/BOX 49019606_1 CDM 0272 RC inpatient 460 299 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 278.53 446.2 GUIDEWIRE .035X260CMJ 5/BOX 49019606_1 CDM 0272 RC inpatient 460 299 CIGNA - ALL PLANS CIGNA - ALL PLANS 310.96 67.6 999999999 278.53 446.2 percent of total billed charges GUIDEWIRE .035X260CMJ 5/BOX 49019606_1 CDM 0272 RC inpatient 460 299 UHC - ALL PLANS UHC - ALL PLANS 999999999 278.53 446.2 CATHETER 4FR JR4 538421 5/BX 49019607_1 CDM 0272 RC inpatient 462 300.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 300.3 65 999999999 279.74 448.14 percent of total billed charges CATHETER 4FR JR4 538421 5/BX 49019607_1 CDM 0272 RC inpatient 462 300.3 AETNA AETNA 364.98 79 999999999 279.74 448.14 percent of total billed charges CATHETER 4FR JR4 538421 5/BX 49019607_1 CDM 0272 RC inpatient 462 300.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 448.14 97 999999999 279.74 448.14 percent of total billed charges CATHETER 4FR JR4 538421 5/BX 49019607_1 CDM 0272 RC inpatient 462 300.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 318.78 69 999999999 279.74 448.14 percent of total billed charges CATHETER 4FR JR4 538421 5/BX 49019607_1 CDM 0272 RC inpatient 462 300.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 360.36 78 999999999 279.74 448.14 percent of total billed charges CATHETER 4FR JR4 538421 5/BX 49019607_1 CDM 0272 RC inpatient 462 300.3 SIHO - ALL PLANS SIHO - ALL PLANS 415.8 90 999999999 279.74 448.14 percent of total billed charges CATHETER 4FR JR4 538421 5/BX 49019607_1 CDM 0272 RC inpatient 462 300.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 279.74 60.55 999999999 279.74 448.14 percent of total billed charges CATHETER 4FR JR4 538421 5/BX 49019607_1 CDM 0272 RC inpatient 462 300.3 UMR - ALL PLANS UMR - ALL PLANS 323.4 70 999999999 279.74 448.14 percent of total billed charges CATHETER 4FR JR4 538421 5/BX 49019607_1 CDM 0272 RC inpatient 462 300.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 279.74 448.14 CATHETER 4FR JR4 538421 5/BX 49019607_1 CDM 0272 RC inpatient 462 300.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 279.74 448.14 CATHETER 4FR JR4 538421 5/BX 49019607_1 CDM 0272 RC inpatient 462 300.3 ANTHEM HMO ANTHEM HMO 999999999 279.74 448.14 CATHETER 4FR JR4 538421 5/BX 49019607_1 CDM 0272 RC inpatient 462 300.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 279.74 448.14 CATHETER 4FR JR4 538421 5/BX 49019607_1 CDM 0272 RC inpatient 462 300.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 312.31 67.6 999999999 279.74 448.14 percent of total billed charges CATHETER 4FR JR4 538421 5/BX 49019607_1 CDM 0272 RC inpatient 462 300.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 279.74 448.14 CATHETER 4FR AR2 MOD 49019608_1 CDM 0272 RC inpatient 116 75.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 75.4 65 999999999 70.24 112.52 percent of total billed charges CATHETER 4FR AR2 MOD 49019608_1 CDM 0272 RC inpatient 116 75.4 AETNA AETNA 91.64 79 999999999 70.24 112.52 percent of total billed charges CATHETER 4FR AR2 MOD 49019608_1 CDM 0272 RC inpatient 116 75.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 112.52 97 999999999 70.24 112.52 percent of total billed charges CATHETER 4FR AR2 MOD 49019608_1 CDM 0272 RC inpatient 116 75.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.04 69 999999999 70.24 112.52 percent of total billed charges CATHETER 4FR AR2 MOD 49019608_1 CDM 0272 RC inpatient 116 75.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 90.48 78 999999999 70.24 112.52 percent of total billed charges CATHETER 4FR AR2 MOD 49019608_1 CDM 0272 RC inpatient 116 75.4 SIHO - ALL PLANS SIHO - ALL PLANS 104.4 90 999999999 70.24 112.52 percent of total billed charges CATHETER 4FR AR2 MOD 49019608_1 CDM 0272 RC inpatient 116 75.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 70.24 60.55 999999999 70.24 112.52 percent of total billed charges CATHETER 4FR AR2 MOD 49019608_1 CDM 0272 RC inpatient 116 75.4 UMR - ALL PLANS UMR - ALL PLANS 81.2 70 999999999 70.24 112.52 percent of total billed charges CATHETER 4FR AR2 MOD 49019608_1 CDM 0272 RC inpatient 116 75.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 70.24 112.52 CATHETER 4FR AR2 MOD 49019608_1 CDM 0272 RC inpatient 116 75.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 70.24 112.52 CATHETER 4FR AR2 MOD 49019608_1 CDM 0272 RC inpatient 116 75.4 ANTHEM HMO ANTHEM HMO 999999999 70.24 112.52 CATHETER 4FR AR2 MOD 49019608_1 CDM 0272 RC inpatient 116 75.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 70.24 112.52 CATHETER 4FR AR2 MOD 49019608_1 CDM 0272 RC inpatient 116 75.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 78.42 67.6 999999999 70.24 112.52 percent of total billed charges CATHETER 4FR AR2 MOD 49019608_1 CDM 0272 RC inpatient 116 75.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 70.24 112.52 AEROCHAMBER W/PED MASK PLUS Z STAT 58-78710 49019653_1 CDM 0272 RC inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges AEROCHAMBER W/PED MASK PLUS Z STAT 58-78710 49019653_1 CDM 0272 RC inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges AEROCHAMBER W/PED MASK PLUS Z STAT 58-78710 49019653_1 CDM 0272 RC inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges AEROCHAMBER W/PED MASK PLUS Z STAT 58-78710 49019653_1 CDM 0272 RC inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges AEROCHAMBER W/PED MASK PLUS Z STAT 58-78710 49019653_1 CDM 0272 RC inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges AEROCHAMBER W/PED MASK PLUS Z STAT 58-78710 49019653_1 CDM 0272 RC inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges AEROCHAMBER W/PED MASK PLUS Z STAT 58-78710 49019653_1 CDM 0272 RC inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges AEROCHAMBER W/PED MASK PLUS Z STAT 58-78710 49019653_1 CDM 0272 RC inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges AEROCHAMBER W/PED MASK PLUS Z STAT 58-78710 49019653_1 CDM 0272 RC inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 AEROCHAMBER W/PED MASK PLUS Z STAT 58-78710 49019653_1 CDM 0272 RC inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 AEROCHAMBER W/PED MASK PLUS Z STAT 58-78710 49019653_1 CDM 0272 RC inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 AEROCHAMBER W/PED MASK PLUS Z STAT 58-78710 49019653_1 CDM 0272 RC inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 AEROCHAMBER W/PED MASK PLUS Z STAT 58-78710 49019653_1 CDM 0272 RC inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges AEROCHAMBER W/PED MASK PLUS Z STAT 58-78710 49019653_1 CDM 0272 RC inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 BIOPSY INST-MONOPTY 18GA X 10C 49019659_1 CDM 0272 RC inpatient 184 119.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 119.6 65 999999999 111.41 178.48 percent of total billed charges BIOPSY INST-MONOPTY 18GA X 10C 49019659_1 CDM 0272 RC inpatient 184 119.6 AETNA AETNA 145.36 79 999999999 111.41 178.48 percent of total billed charges BIOPSY INST-MONOPTY 18GA X 10C 49019659_1 CDM 0272 RC inpatient 184 119.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 178.48 97 999999999 111.41 178.48 percent of total billed charges BIOPSY INST-MONOPTY 18GA X 10C 49019659_1 CDM 0272 RC inpatient 184 119.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.96 69 999999999 111.41 178.48 percent of total billed charges BIOPSY INST-MONOPTY 18GA X 10C 49019659_1 CDM 0272 RC inpatient 184 119.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 143.52 78 999999999 111.41 178.48 percent of total billed charges BIOPSY INST-MONOPTY 18GA X 10C 49019659_1 CDM 0272 RC inpatient 184 119.6 SIHO - ALL PLANS SIHO - ALL PLANS 165.6 90 999999999 111.41 178.48 percent of total billed charges BIOPSY INST-MONOPTY 18GA X 10C 49019659_1 CDM 0272 RC inpatient 184 119.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 111.41 60.55 999999999 111.41 178.48 percent of total billed charges BIOPSY INST-MONOPTY 18GA X 10C 49019659_1 CDM 0272 RC inpatient 184 119.6 UMR - ALL PLANS UMR - ALL PLANS 128.8 70 999999999 111.41 178.48 percent of total billed charges BIOPSY INST-MONOPTY 18GA X 10C 49019659_1 CDM 0272 RC inpatient 184 119.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 111.41 178.48 BIOPSY INST-MONOPTY 18GA X 10C 49019659_1 CDM 0272 RC inpatient 184 119.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 111.41 178.48 BIOPSY INST-MONOPTY 18GA X 10C 49019659_1 CDM 0272 RC inpatient 184 119.6 ANTHEM HMO ANTHEM HMO 999999999 111.41 178.48 BIOPSY INST-MONOPTY 18GA X 10C 49019659_1 CDM 0272 RC inpatient 184 119.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 111.41 178.48 BIOPSY INST-MONOPTY 18GA X 10C 49019659_1 CDM 0272 RC inpatient 184 119.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 124.38 67.6 999999999 111.41 178.48 percent of total billed charges BIOPSY INST-MONOPTY 18GA X 10C 49019659_1 CDM 0272 RC inpatient 184 119.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 111.41 178.48 QUIK COMBO ADULT REDI ELECTRO 49019663_1 CDM 0272 RC inpatient 173 112.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 112.45 65 999999999 104.75 167.81 percent of total billed charges QUIK COMBO ADULT REDI ELECTRO 49019663_1 CDM 0272 RC inpatient 173 112.45 AETNA AETNA 136.67 79 999999999 104.75 167.81 percent of total billed charges QUIK COMBO ADULT REDI ELECTRO 49019663_1 CDM 0272 RC inpatient 173 112.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 167.81 97 999999999 104.75 167.81 percent of total billed charges QUIK COMBO ADULT REDI ELECTRO 49019663_1 CDM 0272 RC inpatient 173 112.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 119.37 69 999999999 104.75 167.81 percent of total billed charges QUIK COMBO ADULT REDI ELECTRO 49019663_1 CDM 0272 RC inpatient 173 112.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.94 78 999999999 104.75 167.81 percent of total billed charges QUIK COMBO ADULT REDI ELECTRO 49019663_1 CDM 0272 RC inpatient 173 112.45 SIHO - ALL PLANS SIHO - ALL PLANS 155.7 90 999999999 104.75 167.81 percent of total billed charges QUIK COMBO ADULT REDI ELECTRO 49019663_1 CDM 0272 RC inpatient 173 112.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.75 60.55 999999999 104.75 167.81 percent of total billed charges QUIK COMBO ADULT REDI ELECTRO 49019663_1 CDM 0272 RC inpatient 173 112.45 UMR - ALL PLANS UMR - ALL PLANS 121.1 70 999999999 104.75 167.81 percent of total billed charges QUIK COMBO ADULT REDI ELECTRO 49019663_1 CDM 0272 RC inpatient 173 112.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.75 167.81 QUIK COMBO ADULT REDI ELECTRO 49019663_1 CDM 0272 RC inpatient 173 112.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.75 167.81 QUIK COMBO ADULT REDI ELECTRO 49019663_1 CDM 0272 RC inpatient 173 112.45 ANTHEM HMO ANTHEM HMO 999999999 104.75 167.81 QUIK COMBO ADULT REDI ELECTRO 49019663_1 CDM 0272 RC inpatient 173 112.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.75 167.81 QUIK COMBO ADULT REDI ELECTRO 49019663_1 CDM 0272 RC inpatient 173 112.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.95 67.6 999999999 104.75 167.81 percent of total billed charges QUIK COMBO ADULT REDI ELECTRO 49019663_1 CDM 0272 RC inpatient 173 112.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.75 167.81 BLAKE DRAIN W\TROCAR ROUND 15 49019666_1 CDM 0272 RC inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges BLAKE DRAIN W\TROCAR ROUND 15 49019666_1 CDM 0272 RC inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges BLAKE DRAIN W\TROCAR ROUND 15 49019666_1 CDM 0272 RC inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges BLAKE DRAIN W\TROCAR ROUND 15 49019666_1 CDM 0272 RC inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges BLAKE DRAIN W\TROCAR ROUND 15 49019666_1 CDM 0272 RC inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges BLAKE DRAIN W\TROCAR ROUND 15 49019666_1 CDM 0272 RC inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges BLAKE DRAIN W\TROCAR ROUND 15 49019666_1 CDM 0272 RC inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges BLAKE DRAIN W\TROCAR ROUND 15 49019666_1 CDM 0272 RC inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges BLAKE DRAIN W\TROCAR ROUND 15 49019666_1 CDM 0272 RC inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 BLAKE DRAIN W\TROCAR ROUND 15 49019666_1 CDM 0272 RC inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 BLAKE DRAIN W\TROCAR ROUND 15 49019666_1 CDM 0272 RC inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 BLAKE DRAIN W\TROCAR ROUND 15 49019666_1 CDM 0272 RC inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 BLAKE DRAIN W\TROCAR ROUND 15 49019666_1 CDM 0272 RC inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges BLAKE DRAIN W\TROCAR ROUND 15 49019666_1 CDM 0272 RC inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 DOUBLE PUMPING BREAST LACTINA 49019668_1 CDM 0272 RC inpatient 139 90.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 90.35 65 999999999 84.16 134.83 percent of total billed charges DOUBLE PUMPING BREAST LACTINA 49019668_1 CDM 0272 RC inpatient 139 90.35 AETNA AETNA 109.81 79 999999999 84.16 134.83 percent of total billed charges DOUBLE PUMPING BREAST LACTINA 49019668_1 CDM 0272 RC inpatient 139 90.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 134.83 97 999999999 84.16 134.83 percent of total billed charges DOUBLE PUMPING BREAST LACTINA 49019668_1 CDM 0272 RC inpatient 139 90.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.91 69 999999999 84.16 134.83 percent of total billed charges DOUBLE PUMPING BREAST LACTINA 49019668_1 CDM 0272 RC inpatient 139 90.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 108.42 78 999999999 84.16 134.83 percent of total billed charges DOUBLE PUMPING BREAST LACTINA 49019668_1 CDM 0272 RC inpatient 139 90.35 SIHO - ALL PLANS SIHO - ALL PLANS 125.1 90 999999999 84.16 134.83 percent of total billed charges DOUBLE PUMPING BREAST LACTINA 49019668_1 CDM 0272 RC inpatient 139 90.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 84.16 60.55 999999999 84.16 134.83 percent of total billed charges DOUBLE PUMPING BREAST LACTINA 49019668_1 CDM 0272 RC inpatient 139 90.35 UMR - ALL PLANS UMR - ALL PLANS 97.3 70 999999999 84.16 134.83 percent of total billed charges DOUBLE PUMPING BREAST LACTINA 49019668_1 CDM 0272 RC inpatient 139 90.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 84.16 134.83 DOUBLE PUMPING BREAST LACTINA 49019668_1 CDM 0272 RC inpatient 139 90.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 84.16 134.83 DOUBLE PUMPING BREAST LACTINA 49019668_1 CDM 0272 RC inpatient 139 90.35 ANTHEM HMO ANTHEM HMO 999999999 84.16 134.83 DOUBLE PUMPING BREAST LACTINA 49019668_1 CDM 0272 RC inpatient 139 90.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 84.16 134.83 DOUBLE PUMPING BREAST LACTINA 49019668_1 CDM 0272 RC inpatient 139 90.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.96 67.6 999999999 84.16 134.83 percent of total billed charges DOUBLE PUMPING BREAST LACTINA 49019668_1 CDM 0272 RC inpatient 139 90.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 84.16 134.83 CATH 8.5FR DRAIN G09501 (OE) 49019674_1 CDM 0621 RC inpatient 594 386.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 386.1 65 999999999 359.67 576.18 percent of total billed charges CATH 8.5FR DRAIN G09501 (OE) 49019674_1 CDM 0621 RC inpatient 594 386.1 AETNA AETNA 469.26 79 999999999 359.67 576.18 percent of total billed charges CATH 8.5FR DRAIN G09501 (OE) 49019674_1 CDM 0621 RC inpatient 594 386.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 576.18 97 999999999 359.67 576.18 percent of total billed charges CATH 8.5FR DRAIN G09501 (OE) 49019674_1 CDM 0621 RC inpatient 594 386.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 409.86 69 999999999 359.67 576.18 percent of total billed charges CATH 8.5FR DRAIN G09501 (OE) 49019674_1 CDM 0621 RC inpatient 594 386.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 463.32 78 999999999 359.67 576.18 percent of total billed charges CATH 8.5FR DRAIN G09501 (OE) 49019674_1 CDM 0621 RC inpatient 594 386.1 SIHO - ALL PLANS SIHO - ALL PLANS 534.6 90 999999999 359.67 576.18 percent of total billed charges CATH 8.5FR DRAIN G09501 (OE) 49019674_1 CDM 0621 RC inpatient 594 386.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 359.67 60.55 999999999 359.67 576.18 percent of total billed charges CATH 8.5FR DRAIN G09501 (OE) 49019674_1 CDM 0621 RC inpatient 594 386.1 UMR - ALL PLANS UMR - ALL PLANS 415.8 70 999999999 359.67 576.18 percent of total billed charges CATH 8.5FR DRAIN G09501 (OE) 49019674_1 CDM 0621 RC inpatient 594 386.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 359.67 576.18 CATH 8.5FR DRAIN G09501 (OE) 49019674_1 CDM 0621 RC inpatient 594 386.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 359.67 576.18 CATH 8.5FR DRAIN G09501 (OE) 49019674_1 CDM 0621 RC inpatient 594 386.1 ANTHEM HMO ANTHEM HMO 999999999 359.67 576.18 CATH 8.5FR DRAIN G09501 (OE) 49019674_1 CDM 0621 RC inpatient 594 386.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 359.67 576.18 CATH 8.5FR DRAIN G09501 (OE) 49019674_1 CDM 0621 RC inpatient 594 386.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 401.54 67.6 999999999 359.67 576.18 percent of total billed charges CATH 8.5FR DRAIN G09501 (OE) 49019674_1 CDM 0621 RC inpatient 594 386.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 359.67 576.18 CATH ULTRATHANE LOOP 10.2FR 49019675_1 CDM 0621 RC inpatient 606 393.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 393.9 65 999999999 366.93 587.82 percent of total billed charges CATH ULTRATHANE LOOP 10.2FR 49019675_1 CDM 0621 RC inpatient 606 393.9 AETNA AETNA 478.74 79 999999999 366.93 587.82 percent of total billed charges CATH ULTRATHANE LOOP 10.2FR 49019675_1 CDM 0621 RC inpatient 606 393.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 587.82 97 999999999 366.93 587.82 percent of total billed charges CATH ULTRATHANE LOOP 10.2FR 49019675_1 CDM 0621 RC inpatient 606 393.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 418.14 69 999999999 366.93 587.82 percent of total billed charges CATH ULTRATHANE LOOP 10.2FR 49019675_1 CDM 0621 RC inpatient 606 393.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 472.68 78 999999999 366.93 587.82 percent of total billed charges CATH ULTRATHANE LOOP 10.2FR 49019675_1 CDM 0621 RC inpatient 606 393.9 SIHO - ALL PLANS SIHO - ALL PLANS 545.4 90 999999999 366.93 587.82 percent of total billed charges CATH ULTRATHANE LOOP 10.2FR 49019675_1 CDM 0621 RC inpatient 606 393.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 366.93 60.55 999999999 366.93 587.82 percent of total billed charges CATH ULTRATHANE LOOP 10.2FR 49019675_1 CDM 0621 RC inpatient 606 393.9 UMR - ALL PLANS UMR - ALL PLANS 424.2 70 999999999 366.93 587.82 percent of total billed charges CATH ULTRATHANE LOOP 10.2FR 49019675_1 CDM 0621 RC inpatient 606 393.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 366.93 587.82 CATH ULTRATHANE LOOP 10.2FR 49019675_1 CDM 0621 RC inpatient 606 393.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 366.93 587.82 CATH ULTRATHANE LOOP 10.2FR 49019675_1 CDM 0621 RC inpatient 606 393.9 ANTHEM HMO ANTHEM HMO 999999999 366.93 587.82 CATH ULTRATHANE LOOP 10.2FR 49019675_1 CDM 0621 RC inpatient 606 393.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 366.93 587.82 CATH ULTRATHANE LOOP 10.2FR 49019675_1 CDM 0621 RC inpatient 606 393.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 409.66 67.6 999999999 366.93 587.82 percent of total billed charges CATH ULTRATHANE LOOP 10.2FR 49019675_1 CDM 0621 RC inpatient 606 393.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 366.93 587.82 CATH 12.0FR #G09503 49019676_1 CDM 0278 RC inpatient 685 445.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 445.25 65 999999999 414.77 664.45 percent of total billed charges CATH 12.0FR #G09503 49019676_1 CDM 0278 RC inpatient 685 445.25 AETNA AETNA 541.15 79 999999999 414.77 664.45 percent of total billed charges CATH 12.0FR #G09503 49019676_1 CDM 0278 RC inpatient 685 445.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 664.45 97 999999999 414.77 664.45 percent of total billed charges CATH 12.0FR #G09503 49019676_1 CDM 0278 RC inpatient 685 445.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 472.65 69 999999999 414.77 664.45 percent of total billed charges CATH 12.0FR #G09503 49019676_1 CDM 0278 RC inpatient 685 445.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 534.3 78 999999999 414.77 664.45 percent of total billed charges CATH 12.0FR #G09503 49019676_1 CDM 0278 RC inpatient 685 445.25 SIHO - ALL PLANS SIHO - ALL PLANS 616.5 90 999999999 414.77 664.45 percent of total billed charges CATH 12.0FR #G09503 49019676_1 CDM 0278 RC inpatient 685 445.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 414.77 60.55 999999999 414.77 664.45 percent of total billed charges CATH 12.0FR #G09503 49019676_1 CDM 0278 RC inpatient 685 445.25 UMR - ALL PLANS UMR - ALL PLANS 479.5 70 999999999 414.77 664.45 percent of total billed charges CATH 12.0FR #G09503 49019676_1 CDM 0278 RC inpatient 685 445.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 414.77 664.45 CATH 12.0FR #G09503 49019676_1 CDM 0278 RC inpatient 685 445.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 414.77 664.45 CATH 12.0FR #G09503 49019676_1 CDM 0278 RC inpatient 685 445.25 ANTHEM HMO ANTHEM HMO 999999999 414.77 664.45 CATH 12.0FR #G09503 49019676_1 CDM 0278 RC inpatient 685 445.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 414.77 664.45 CATH 12.0FR #G09503 49019676_1 CDM 0278 RC inpatient 685 445.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 463.06 67.6 999999999 414.77 664.45 percent of total billed charges CATH 12.0FR #G09503 49019676_1 CDM 0278 RC inpatient 685 445.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 414.77 664.45 QUIK-COMBO ADULT DEFIB PADS 49019701_1 CDM 0272 RC inpatient 201 130.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 130.65 65 999999999 121.71 194.97 percent of total billed charges QUIK-COMBO ADULT DEFIB PADS 49019701_1 CDM 0272 RC inpatient 201 130.65 AETNA AETNA 158.79 79 999999999 121.71 194.97 percent of total billed charges QUIK-COMBO ADULT DEFIB PADS 49019701_1 CDM 0272 RC inpatient 201 130.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 194.97 97 999999999 121.71 194.97 percent of total billed charges QUIK-COMBO ADULT DEFIB PADS 49019701_1 CDM 0272 RC inpatient 201 130.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 138.69 69 999999999 121.71 194.97 percent of total billed charges QUIK-COMBO ADULT DEFIB PADS 49019701_1 CDM 0272 RC inpatient 201 130.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 156.78 78 999999999 121.71 194.97 percent of total billed charges QUIK-COMBO ADULT DEFIB PADS 49019701_1 CDM 0272 RC inpatient 201 130.65 SIHO - ALL PLANS SIHO - ALL PLANS 180.9 90 999999999 121.71 194.97 percent of total billed charges QUIK-COMBO ADULT DEFIB PADS 49019701_1 CDM 0272 RC inpatient 201 130.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 121.71 60.55 999999999 121.71 194.97 percent of total billed charges QUIK-COMBO ADULT DEFIB PADS 49019701_1 CDM 0272 RC inpatient 201 130.65 UMR - ALL PLANS UMR - ALL PLANS 140.7 70 999999999 121.71 194.97 percent of total billed charges QUIK-COMBO ADULT DEFIB PADS 49019701_1 CDM 0272 RC inpatient 201 130.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 121.71 194.97 QUIK-COMBO ADULT DEFIB PADS 49019701_1 CDM 0272 RC inpatient 201 130.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 121.71 194.97 QUIK-COMBO ADULT DEFIB PADS 49019701_1 CDM 0272 RC inpatient 201 130.65 ANTHEM HMO ANTHEM HMO 999999999 121.71 194.97 QUIK-COMBO ADULT DEFIB PADS 49019701_1 CDM 0272 RC inpatient 201 130.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 121.71 194.97 QUIK-COMBO ADULT DEFIB PADS 49019701_1 CDM 0272 RC inpatient 201 130.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 135.88 67.6 999999999 121.71 194.97 percent of total billed charges QUIK-COMBO ADULT DEFIB PADS 49019701_1 CDM 0272 RC inpatient 201 130.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 121.71 194.97 CERVICAL RIPENING BALLOON OE 49019705_1 CDM 0272 RC inpatient 271 176.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 176.15 65 999999999 164.09 262.87 percent of total billed charges CERVICAL RIPENING BALLOON OE 49019705_1 CDM 0272 RC inpatient 271 176.15 AETNA AETNA 214.09 79 999999999 164.09 262.87 percent of total billed charges CERVICAL RIPENING BALLOON OE 49019705_1 CDM 0272 RC inpatient 271 176.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 262.87 97 999999999 164.09 262.87 percent of total billed charges CERVICAL RIPENING BALLOON OE 49019705_1 CDM 0272 RC inpatient 271 176.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 186.99 69 999999999 164.09 262.87 percent of total billed charges CERVICAL RIPENING BALLOON OE 49019705_1 CDM 0272 RC inpatient 271 176.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 211.38 78 999999999 164.09 262.87 percent of total billed charges CERVICAL RIPENING BALLOON OE 49019705_1 CDM 0272 RC inpatient 271 176.15 SIHO - ALL PLANS SIHO - ALL PLANS 243.9 90 999999999 164.09 262.87 percent of total billed charges CERVICAL RIPENING BALLOON OE 49019705_1 CDM 0272 RC inpatient 271 176.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 164.09 60.55 999999999 164.09 262.87 percent of total billed charges CERVICAL RIPENING BALLOON OE 49019705_1 CDM 0272 RC inpatient 271 176.15 UMR - ALL PLANS UMR - ALL PLANS 189.7 70 999999999 164.09 262.87 percent of total billed charges CERVICAL RIPENING BALLOON OE 49019705_1 CDM 0272 RC inpatient 271 176.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 164.09 262.87 CERVICAL RIPENING BALLOON OE 49019705_1 CDM 0272 RC inpatient 271 176.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 164.09 262.87 CERVICAL RIPENING BALLOON OE 49019705_1 CDM 0272 RC inpatient 271 176.15 ANTHEM HMO ANTHEM HMO 999999999 164.09 262.87 CERVICAL RIPENING BALLOON OE 49019705_1 CDM 0272 RC inpatient 271 176.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 164.09 262.87 CERVICAL RIPENING BALLOON OE 49019705_1 CDM 0272 RC inpatient 271 176.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 183.2 67.6 999999999 164.09 262.87 percent of total billed charges CERVICAL RIPENING BALLOON OE 49019705_1 CDM 0272 RC inpatient 271 176.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 164.09 262.87 CHOLANGIOGRAPHY CATHETER 6FR. 49019748_1 CDM 0272 RC inpatient 278 180.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 180.7 65 999999999 168.33 269.66 percent of total billed charges CHOLANGIOGRAPHY CATHETER 6FR. 49019748_1 CDM 0272 RC inpatient 278 180.7 AETNA AETNA 219.62 79 999999999 168.33 269.66 percent of total billed charges CHOLANGIOGRAPHY CATHETER 6FR. 49019748_1 CDM 0272 RC inpatient 278 180.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 269.66 97 999999999 168.33 269.66 percent of total billed charges CHOLANGIOGRAPHY CATHETER 6FR. 49019748_1 CDM 0272 RC inpatient 278 180.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 191.82 69 999999999 168.33 269.66 percent of total billed charges CHOLANGIOGRAPHY CATHETER 6FR. 49019748_1 CDM 0272 RC inpatient 278 180.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 216.84 78 999999999 168.33 269.66 percent of total billed charges CHOLANGIOGRAPHY CATHETER 6FR. 49019748_1 CDM 0272 RC inpatient 278 180.7 SIHO - ALL PLANS SIHO - ALL PLANS 250.2 90 999999999 168.33 269.66 percent of total billed charges CHOLANGIOGRAPHY CATHETER 6FR. 49019748_1 CDM 0272 RC inpatient 278 180.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.33 60.55 999999999 168.33 269.66 percent of total billed charges CHOLANGIOGRAPHY CATHETER 6FR. 49019748_1 CDM 0272 RC inpatient 278 180.7 UMR - ALL PLANS UMR - ALL PLANS 194.6 70 999999999 168.33 269.66 percent of total billed charges CHOLANGIOGRAPHY CATHETER 6FR. 49019748_1 CDM 0272 RC inpatient 278 180.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.33 269.66 CHOLANGIOGRAPHY CATHETER 6FR. 49019748_1 CDM 0272 RC inpatient 278 180.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.33 269.66 CHOLANGIOGRAPHY CATHETER 6FR. 49019748_1 CDM 0272 RC inpatient 278 180.7 ANTHEM HMO ANTHEM HMO 999999999 168.33 269.66 CHOLANGIOGRAPHY CATHETER 6FR. 49019748_1 CDM 0272 RC inpatient 278 180.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.33 269.66 CHOLANGIOGRAPHY CATHETER 6FR. 49019748_1 CDM 0272 RC inpatient 278 180.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 187.93 67.6 999999999 168.33 269.66 percent of total billed charges CHOLANGIOGRAPHY CATHETER 6FR. 49019748_1 CDM 0272 RC inpatient 278 180.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.33 269.66 HIS CATH LATEX FREE SET SIZE 5 49019759_1 CDM 0621 RC inpatient 170 110.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.5 65 999999999 102.94 164.9 percent of total billed charges HIS CATH LATEX FREE SET SIZE 5 49019759_1 CDM 0621 RC inpatient 170 110.5 AETNA AETNA 134.3 79 999999999 102.94 164.9 percent of total billed charges HIS CATH LATEX FREE SET SIZE 5 49019759_1 CDM 0621 RC inpatient 170 110.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.9 97 999999999 102.94 164.9 percent of total billed charges HIS CATH LATEX FREE SET SIZE 5 49019759_1 CDM 0621 RC inpatient 170 110.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.3 69 999999999 102.94 164.9 percent of total billed charges HIS CATH LATEX FREE SET SIZE 5 49019759_1 CDM 0621 RC inpatient 170 110.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.6 78 999999999 102.94 164.9 percent of total billed charges HIS CATH LATEX FREE SET SIZE 5 49019759_1 CDM 0621 RC inpatient 170 110.5 SIHO - ALL PLANS SIHO - ALL PLANS 153 90 999999999 102.94 164.9 percent of total billed charges HIS CATH LATEX FREE SET SIZE 5 49019759_1 CDM 0621 RC inpatient 170 110.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.94 60.55 999999999 102.94 164.9 percent of total billed charges HIS CATH LATEX FREE SET SIZE 5 49019759_1 CDM 0621 RC inpatient 170 110.5 UMR - ALL PLANS UMR - ALL PLANS 119 70 999999999 102.94 164.9 percent of total billed charges HIS CATH LATEX FREE SET SIZE 5 49019759_1 CDM 0621 RC inpatient 170 110.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.94 164.9 HIS CATH LATEX FREE SET SIZE 5 49019759_1 CDM 0621 RC inpatient 170 110.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.94 164.9 HIS CATH LATEX FREE SET SIZE 5 49019759_1 CDM 0621 RC inpatient 170 110.5 ANTHEM HMO ANTHEM HMO 999999999 102.94 164.9 HIS CATH LATEX FREE SET SIZE 5 49019759_1 CDM 0621 RC inpatient 170 110.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.94 164.9 HIS CATH LATEX FREE SET SIZE 5 49019759_1 CDM 0621 RC inpatient 170 110.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.92 67.6 999999999 102.94 164.9 percent of total billed charges HIS CATH LATEX FREE SET SIZE 5 49019759_1 CDM 0621 RC inpatient 170 110.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.94 164.9 HIS CATHETER SET SIZE 7 49019760_1 CDM 0621 RC inpatient 170 110.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.5 65 999999999 102.94 164.9 percent of total billed charges HIS CATHETER SET SIZE 7 49019760_1 CDM 0621 RC inpatient 170 110.5 AETNA AETNA 134.3 79 999999999 102.94 164.9 percent of total billed charges HIS CATHETER SET SIZE 7 49019760_1 CDM 0621 RC inpatient 170 110.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.9 97 999999999 102.94 164.9 percent of total billed charges HIS CATHETER SET SIZE 7 49019760_1 CDM 0621 RC inpatient 170 110.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.3 69 999999999 102.94 164.9 percent of total billed charges HIS CATHETER SET SIZE 7 49019760_1 CDM 0621 RC inpatient 170 110.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.6 78 999999999 102.94 164.9 percent of total billed charges HIS CATHETER SET SIZE 7 49019760_1 CDM 0621 RC inpatient 170 110.5 SIHO - ALL PLANS SIHO - ALL PLANS 153 90 999999999 102.94 164.9 percent of total billed charges HIS CATHETER SET SIZE 7 49019760_1 CDM 0621 RC inpatient 170 110.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.94 60.55 999999999 102.94 164.9 percent of total billed charges HIS CATHETER SET SIZE 7 49019760_1 CDM 0621 RC inpatient 170 110.5 UMR - ALL PLANS UMR - ALL PLANS 119 70 999999999 102.94 164.9 percent of total billed charges HIS CATHETER SET SIZE 7 49019760_1 CDM 0621 RC inpatient 170 110.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.94 164.9 HIS CATHETER SET SIZE 7 49019760_1 CDM 0621 RC inpatient 170 110.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.94 164.9 HIS CATHETER SET SIZE 7 49019760_1 CDM 0621 RC inpatient 170 110.5 ANTHEM HMO ANTHEM HMO 999999999 102.94 164.9 HIS CATHETER SET SIZE 7 49019760_1 CDM 0621 RC inpatient 170 110.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.94 164.9 HIS CATHETER SET SIZE 7 49019760_1 CDM 0621 RC inpatient 170 110.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.92 67.6 999999999 102.94 164.9 percent of total billed charges HIS CATHETER SET SIZE 7 49019760_1 CDM 0621 RC inpatient 170 110.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.94 164.9 PACK LAP PERI GYN DYNJ16100K 49019773_1 CDM 0272 RC inpatient 542 352.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 352.3 65 999999999 328.18 525.74 percent of total billed charges PACK LAP PERI GYN DYNJ16100K 49019773_1 CDM 0272 RC inpatient 542 352.3 AETNA AETNA 428.18 79 999999999 328.18 525.74 percent of total billed charges PACK LAP PERI GYN DYNJ16100K 49019773_1 CDM 0272 RC inpatient 542 352.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 525.74 97 999999999 328.18 525.74 percent of total billed charges PACK LAP PERI GYN DYNJ16100K 49019773_1 CDM 0272 RC inpatient 542 352.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 373.98 69 999999999 328.18 525.74 percent of total billed charges PACK LAP PERI GYN DYNJ16100K 49019773_1 CDM 0272 RC inpatient 542 352.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 422.76 78 999999999 328.18 525.74 percent of total billed charges PACK LAP PERI GYN DYNJ16100K 49019773_1 CDM 0272 RC inpatient 542 352.3 SIHO - ALL PLANS SIHO - ALL PLANS 487.8 90 999999999 328.18 525.74 percent of total billed charges PACK LAP PERI GYN DYNJ16100K 49019773_1 CDM 0272 RC inpatient 542 352.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 328.18 60.55 999999999 328.18 525.74 percent of total billed charges PACK LAP PERI GYN DYNJ16100K 49019773_1 CDM 0272 RC inpatient 542 352.3 UMR - ALL PLANS UMR - ALL PLANS 379.4 70 999999999 328.18 525.74 percent of total billed charges PACK LAP PERI GYN DYNJ16100K 49019773_1 CDM 0272 RC inpatient 542 352.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 328.18 525.74 PACK LAP PERI GYN DYNJ16100K 49019773_1 CDM 0272 RC inpatient 542 352.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 328.18 525.74 PACK LAP PERI GYN DYNJ16100K 49019773_1 CDM 0272 RC inpatient 542 352.3 ANTHEM HMO ANTHEM HMO 999999999 328.18 525.74 PACK LAP PERI GYN DYNJ16100K 49019773_1 CDM 0272 RC inpatient 542 352.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 328.18 525.74 PACK LAP PERI GYN DYNJ16100K 49019773_1 CDM 0272 RC inpatient 542 352.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 366.39 67.6 999999999 328.18 525.74 percent of total billed charges PACK LAP PERI GYN DYNJ16100K 49019773_1 CDM 0272 RC inpatient 542 352.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 328.18 525.74 PACK LAPAROSCOPY DYNJ16099L 49019774_1 CDM 0272 RC inpatient 448 291.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 291.2 65 999999999 271.26 434.56 percent of total billed charges PACK LAPAROSCOPY DYNJ16099L 49019774_1 CDM 0272 RC inpatient 448 291.2 AETNA AETNA 353.92 79 999999999 271.26 434.56 percent of total billed charges PACK LAPAROSCOPY DYNJ16099L 49019774_1 CDM 0272 RC inpatient 448 291.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 434.56 97 999999999 271.26 434.56 percent of total billed charges PACK LAPAROSCOPY DYNJ16099L 49019774_1 CDM 0272 RC inpatient 448 291.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 309.12 69 999999999 271.26 434.56 percent of total billed charges PACK LAPAROSCOPY DYNJ16099L 49019774_1 CDM 0272 RC inpatient 448 291.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 349.44 78 999999999 271.26 434.56 percent of total billed charges PACK LAPAROSCOPY DYNJ16099L 49019774_1 CDM 0272 RC inpatient 448 291.2 SIHO - ALL PLANS SIHO - ALL PLANS 403.2 90 999999999 271.26 434.56 percent of total billed charges PACK LAPAROSCOPY DYNJ16099L 49019774_1 CDM 0272 RC inpatient 448 291.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 271.26 60.55 999999999 271.26 434.56 percent of total billed charges PACK LAPAROSCOPY DYNJ16099L 49019774_1 CDM 0272 RC inpatient 448 291.2 UMR - ALL PLANS UMR - ALL PLANS 313.6 70 999999999 271.26 434.56 percent of total billed charges PACK LAPAROSCOPY DYNJ16099L 49019774_1 CDM 0272 RC inpatient 448 291.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 271.26 434.56 PACK LAPAROSCOPY DYNJ16099L 49019774_1 CDM 0272 RC inpatient 448 291.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 271.26 434.56 PACK LAPAROSCOPY DYNJ16099L 49019774_1 CDM 0272 RC inpatient 448 291.2 ANTHEM HMO ANTHEM HMO 999999999 271.26 434.56 PACK LAPAROSCOPY DYNJ16099L 49019774_1 CDM 0272 RC inpatient 448 291.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 271.26 434.56 PACK LAPAROSCOPY DYNJ16099L 49019774_1 CDM 0272 RC inpatient 448 291.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 302.85 67.6 999999999 271.26 434.56 percent of total billed charges PACK LAPAROSCOPY DYNJ16099L 49019774_1 CDM 0272 RC inpatient 448 291.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 271.26 434.56 PROLENE MESH 3 X 6 PMII 49019778_1 CDM 0278 RC inpatient 970 630.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 630.5 65 999999999 587.34 940.9 percent of total billed charges PROLENE MESH 3 X 6 PMII 49019778_1 CDM 0278 RC inpatient 970 630.5 AETNA AETNA 766.3 79 999999999 587.34 940.9 percent of total billed charges PROLENE MESH 3 X 6 PMII 49019778_1 CDM 0278 RC inpatient 970 630.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 940.9 97 999999999 587.34 940.9 percent of total billed charges PROLENE MESH 3 X 6 PMII 49019778_1 CDM 0278 RC inpatient 970 630.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 669.3 69 999999999 587.34 940.9 percent of total billed charges PROLENE MESH 3 X 6 PMII 49019778_1 CDM 0278 RC inpatient 970 630.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 756.6 78 999999999 587.34 940.9 percent of total billed charges PROLENE MESH 3 X 6 PMII 49019778_1 CDM 0278 RC inpatient 970 630.5 SIHO - ALL PLANS SIHO - ALL PLANS 873 90 999999999 587.34 940.9 percent of total billed charges PROLENE MESH 3 X 6 PMII 49019778_1 CDM 0278 RC inpatient 970 630.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 587.34 60.55 999999999 587.34 940.9 percent of total billed charges PROLENE MESH 3 X 6 PMII 49019778_1 CDM 0278 RC inpatient 970 630.5 UMR - ALL PLANS UMR - ALL PLANS 679 70 999999999 587.34 940.9 percent of total billed charges PROLENE MESH 3 X 6 PMII 49019778_1 CDM 0278 RC inpatient 970 630.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 587.34 940.9 PROLENE MESH 3 X 6 PMII 49019778_1 CDM 0278 RC inpatient 970 630.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 587.34 940.9 PROLENE MESH 3 X 6 PMII 49019778_1 CDM 0278 RC inpatient 970 630.5 ANTHEM HMO ANTHEM HMO 999999999 587.34 940.9 PROLENE MESH 3 X 6 PMII 49019778_1 CDM 0278 RC inpatient 970 630.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 587.34 940.9 PROLENE MESH 3 X 6 PMII 49019778_1 CDM 0278 RC inpatient 970 630.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 655.72 67.6 999999999 587.34 940.9 percent of total billed charges PROLENE MESH 3 X 6 PMII 49019778_1 CDM 0278 RC inpatient 970 630.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 587.34 940.9 COAXIAL ACHIEVE 14GX11C (OE) 49019782_1 CDM 0272 RC inpatient 460 299 SELF PAY DISCOUNT SELF PAY DISCOUNT 299 65 999999999 278.53 446.2 percent of total billed charges COAXIAL ACHIEVE 14GX11C (OE) 49019782_1 CDM 0272 RC inpatient 460 299 AETNA AETNA 363.4 79 999999999 278.53 446.2 percent of total billed charges COAXIAL ACHIEVE 14GX11C (OE) 49019782_1 CDM 0272 RC inpatient 460 299 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 446.2 97 999999999 278.53 446.2 percent of total billed charges COAXIAL ACHIEVE 14GX11C (OE) 49019782_1 CDM 0272 RC inpatient 460 299 ENCORE - ALL PLANS ENCORE - ALL PLANS 317.4 69 999999999 278.53 446.2 percent of total billed charges COAXIAL ACHIEVE 14GX11C (OE) 49019782_1 CDM 0272 RC inpatient 460 299 HUMANA - ALL PLANS HUMANA - ALL PLANS 358.8 78 999999999 278.53 446.2 percent of total billed charges COAXIAL ACHIEVE 14GX11C (OE) 49019782_1 CDM 0272 RC inpatient 460 299 SIHO - ALL PLANS SIHO - ALL PLANS 414 90 999999999 278.53 446.2 percent of total billed charges COAXIAL ACHIEVE 14GX11C (OE) 49019782_1 CDM 0272 RC inpatient 460 299 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 278.53 60.55 999999999 278.53 446.2 percent of total billed charges COAXIAL ACHIEVE 14GX11C (OE) 49019782_1 CDM 0272 RC inpatient 460 299 UMR - ALL PLANS UMR - ALL PLANS 322 70 999999999 278.53 446.2 percent of total billed charges COAXIAL ACHIEVE 14GX11C (OE) 49019782_1 CDM 0272 RC inpatient 460 299 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 278.53 446.2 COAXIAL ACHIEVE 14GX11C (OE) 49019782_1 CDM 0272 RC inpatient 460 299 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 278.53 446.2 COAXIAL ACHIEVE 14GX11C (OE) 49019782_1 CDM 0272 RC inpatient 460 299 ANTHEM HMO ANTHEM HMO 999999999 278.53 446.2 COAXIAL ACHIEVE 14GX11C (OE) 49019782_1 CDM 0272 RC inpatient 460 299 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 278.53 446.2 COAXIAL ACHIEVE 14GX11C (OE) 49019782_1 CDM 0272 RC inpatient 460 299 CIGNA - ALL PLANS CIGNA - ALL PLANS 310.96 67.6 999999999 278.53 446.2 percent of total billed charges COAXIAL ACHIEVE 14GX11C (OE) 49019782_1 CDM 0272 RC inpatient 460 299 UHC - ALL PLANS UHC - ALL PLANS 999999999 278.53 446.2 ECHO M3 COAXIAL GUIDE 16GA X10 49019783_1 CDM 0272 RC inpatient 222 144.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 144.3 65 999999999 134.42 215.34 percent of total billed charges ECHO M3 COAXIAL GUIDE 16GA X10 49019783_1 CDM 0272 RC inpatient 222 144.3 AETNA AETNA 175.38 79 999999999 134.42 215.34 percent of total billed charges ECHO M3 COAXIAL GUIDE 16GA X10 49019783_1 CDM 0272 RC inpatient 222 144.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 215.34 97 999999999 134.42 215.34 percent of total billed charges ECHO M3 COAXIAL GUIDE 16GA X10 49019783_1 CDM 0272 RC inpatient 222 144.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 153.18 69 999999999 134.42 215.34 percent of total billed charges ECHO M3 COAXIAL GUIDE 16GA X10 49019783_1 CDM 0272 RC inpatient 222 144.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 173.16 78 999999999 134.42 215.34 percent of total billed charges ECHO M3 COAXIAL GUIDE 16GA X10 49019783_1 CDM 0272 RC inpatient 222 144.3 SIHO - ALL PLANS SIHO - ALL PLANS 199.8 90 999999999 134.42 215.34 percent of total billed charges ECHO M3 COAXIAL GUIDE 16GA X10 49019783_1 CDM 0272 RC inpatient 222 144.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 134.42 60.55 999999999 134.42 215.34 percent of total billed charges ECHO M3 COAXIAL GUIDE 16GA X10 49019783_1 CDM 0272 RC inpatient 222 144.3 UMR - ALL PLANS UMR - ALL PLANS 155.4 70 999999999 134.42 215.34 percent of total billed charges ECHO M3 COAXIAL GUIDE 16GA X10 49019783_1 CDM 0272 RC inpatient 222 144.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 134.42 215.34 ECHO M3 COAXIAL GUIDE 16GA X10 49019783_1 CDM 0272 RC inpatient 222 144.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 134.42 215.34 ECHO M3 COAXIAL GUIDE 16GA X10 49019783_1 CDM 0272 RC inpatient 222 144.3 ANTHEM HMO ANTHEM HMO 999999999 134.42 215.34 ECHO M3 COAXIAL GUIDE 16GA X10 49019783_1 CDM 0272 RC inpatient 222 144.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 134.42 215.34 ECHO M3 COAXIAL GUIDE 16GA X10 49019783_1 CDM 0272 RC inpatient 222 144.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 150.07 67.6 999999999 134.42 215.34 percent of total billed charges ECHO M3 COAXIAL GUIDE 16GA X10 49019783_1 CDM 0272 RC inpatient 222 144.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 134.42 215.34 NEEDLE BIOPINCE CORE 18G X20CM 49019784_1 CDM 0270 RC inpatient 1458 947.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 947.7 65 999999999 882.82 1414.26 percent of total billed charges NEEDLE BIOPINCE CORE 18G X20CM 49019784_1 CDM 0270 RC inpatient 1458 947.7 AETNA AETNA 1151.82 79 999999999 882.82 1414.26 percent of total billed charges NEEDLE BIOPINCE CORE 18G X20CM 49019784_1 CDM 0270 RC inpatient 1458 947.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1414.26 97 999999999 882.82 1414.26 percent of total billed charges NEEDLE BIOPINCE CORE 18G X20CM 49019784_1 CDM 0270 RC inpatient 1458 947.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1006.02 69 999999999 882.82 1414.26 percent of total billed charges NEEDLE BIOPINCE CORE 18G X20CM 49019784_1 CDM 0270 RC inpatient 1458 947.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1137.24 78 999999999 882.82 1414.26 percent of total billed charges NEEDLE BIOPINCE CORE 18G X20CM 49019784_1 CDM 0270 RC inpatient 1458 947.7 SIHO - ALL PLANS SIHO - ALL PLANS 1312.2 90 999999999 882.82 1414.26 percent of total billed charges NEEDLE BIOPINCE CORE 18G X20CM 49019784_1 CDM 0270 RC inpatient 1458 947.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 882.82 60.55 999999999 882.82 1414.26 percent of total billed charges NEEDLE BIOPINCE CORE 18G X20CM 49019784_1 CDM 0270 RC inpatient 1458 947.7 UMR - ALL PLANS UMR - ALL PLANS 1020.6 70 999999999 882.82 1414.26 percent of total billed charges NEEDLE BIOPINCE CORE 18G X20CM 49019784_1 CDM 0270 RC inpatient 1458 947.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 882.82 1414.26 NEEDLE BIOPINCE CORE 18G X20CM 49019784_1 CDM 0270 RC inpatient 1458 947.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 882.82 1414.26 NEEDLE BIOPINCE CORE 18G X20CM 49019784_1 CDM 0270 RC inpatient 1458 947.7 ANTHEM HMO ANTHEM HMO 999999999 882.82 1414.26 NEEDLE BIOPINCE CORE 18G X20CM 49019784_1 CDM 0270 RC inpatient 1458 947.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 882.82 1414.26 NEEDLE BIOPINCE CORE 18G X20CM 49019784_1 CDM 0270 RC inpatient 1458 947.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 985.61 67.6 999999999 882.82 1414.26 percent of total billed charges NEEDLE BIOPINCE CORE 18G X20CM 49019784_1 CDM 0270 RC inpatient 1458 947.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 882.82 1414.26 NEEDLE COAXIAL INTRODUCE 17X16 49019785_1 CDM 0270 RC inpatient 554 360.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 360.1 65 999999999 335.45 537.38 percent of total billed charges NEEDLE COAXIAL INTRODUCE 17X16 49019785_1 CDM 0270 RC inpatient 554 360.1 AETNA AETNA 437.66 79 999999999 335.45 537.38 percent of total billed charges NEEDLE COAXIAL INTRODUCE 17X16 49019785_1 CDM 0270 RC inpatient 554 360.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 537.38 97 999999999 335.45 537.38 percent of total billed charges NEEDLE COAXIAL INTRODUCE 17X16 49019785_1 CDM 0270 RC inpatient 554 360.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 382.26 69 999999999 335.45 537.38 percent of total billed charges NEEDLE COAXIAL INTRODUCE 17X16 49019785_1 CDM 0270 RC inpatient 554 360.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 432.12 78 999999999 335.45 537.38 percent of total billed charges NEEDLE COAXIAL INTRODUCE 17X16 49019785_1 CDM 0270 RC inpatient 554 360.1 SIHO - ALL PLANS SIHO - ALL PLANS 498.6 90 999999999 335.45 537.38 percent of total billed charges NEEDLE COAXIAL INTRODUCE 17X16 49019785_1 CDM 0270 RC inpatient 554 360.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 335.45 60.55 999999999 335.45 537.38 percent of total billed charges NEEDLE COAXIAL INTRODUCE 17X16 49019785_1 CDM 0270 RC inpatient 554 360.1 UMR - ALL PLANS UMR - ALL PLANS 387.8 70 999999999 335.45 537.38 percent of total billed charges NEEDLE COAXIAL INTRODUCE 17X16 49019785_1 CDM 0270 RC inpatient 554 360.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 335.45 537.38 NEEDLE COAXIAL INTRODUCE 17X16 49019785_1 CDM 0270 RC inpatient 554 360.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 335.45 537.38 NEEDLE COAXIAL INTRODUCE 17X16 49019785_1 CDM 0270 RC inpatient 554 360.1 ANTHEM HMO ANTHEM HMO 999999999 335.45 537.38 NEEDLE COAXIAL INTRODUCE 17X16 49019785_1 CDM 0270 RC inpatient 554 360.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 335.45 537.38 NEEDLE COAXIAL INTRODUCE 17X16 49019785_1 CDM 0270 RC inpatient 554 360.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 374.5 67.6 999999999 335.45 537.38 percent of total billed charges NEEDLE COAXIAL INTRODUCE 17X16 49019785_1 CDM 0270 RC inpatient 554 360.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 335.45 537.38 NEEDLE 1/2 CIRCLE #216703 49019790_1 CDM 0272 RC inpatient 35 22.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.75 65 999999999 21.19 33.95 percent of total billed charges NEEDLE 1/2 CIRCLE #216703 49019790_1 CDM 0272 RC inpatient 35 22.75 AETNA AETNA 27.65 79 999999999 21.19 33.95 percent of total billed charges NEEDLE 1/2 CIRCLE #216703 49019790_1 CDM 0272 RC inpatient 35 22.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33.95 97 999999999 21.19 33.95 percent of total billed charges NEEDLE 1/2 CIRCLE #216703 49019790_1 CDM 0272 RC inpatient 35 22.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.15 69 999999999 21.19 33.95 percent of total billed charges NEEDLE 1/2 CIRCLE #216703 49019790_1 CDM 0272 RC inpatient 35 22.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.3 78 999999999 21.19 33.95 percent of total billed charges NEEDLE 1/2 CIRCLE #216703 49019790_1 CDM 0272 RC inpatient 35 22.75 SIHO - ALL PLANS SIHO - ALL PLANS 31.5 90 999999999 21.19 33.95 percent of total billed charges NEEDLE 1/2 CIRCLE #216703 49019790_1 CDM 0272 RC inpatient 35 22.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.19 60.55 999999999 21.19 33.95 percent of total billed charges NEEDLE 1/2 CIRCLE #216703 49019790_1 CDM 0272 RC inpatient 35 22.75 UMR - ALL PLANS UMR - ALL PLANS 24.5 70 999999999 21.19 33.95 percent of total billed charges NEEDLE 1/2 CIRCLE #216703 49019790_1 CDM 0272 RC inpatient 35 22.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.19 33.95 NEEDLE 1/2 CIRCLE #216703 49019790_1 CDM 0272 RC inpatient 35 22.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.19 33.95 NEEDLE 1/2 CIRCLE #216703 49019790_1 CDM 0272 RC inpatient 35 22.75 ANTHEM HMO ANTHEM HMO 999999999 21.19 33.95 NEEDLE 1/2 CIRCLE #216703 49019790_1 CDM 0272 RC inpatient 35 22.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.19 33.95 NEEDLE 1/2 CIRCLE #216703 49019790_1 CDM 0272 RC inpatient 35 22.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 23.66 67.6 999999999 21.19 33.95 percent of total billed charges NEEDLE 1/2 CIRCLE #216703 49019790_1 CDM 0272 RC inpatient 35 22.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.19 33.95 NEEDLE STRAIGHT CUTTING KEITH ABDOMINAL 213406 49019791_1 CDM 0272 RC inpatient 22 14.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.3 65 999999999 13.32 21.34 percent of total billed charges NEEDLE STRAIGHT CUTTING KEITH ABDOMINAL 213406 49019791_1 CDM 0272 RC inpatient 22 14.3 AETNA AETNA 17.38 79 999999999 13.32 21.34 percent of total billed charges NEEDLE STRAIGHT CUTTING KEITH ABDOMINAL 213406 49019791_1 CDM 0272 RC inpatient 22 14.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21.34 97 999999999 13.32 21.34 percent of total billed charges NEEDLE STRAIGHT CUTTING KEITH ABDOMINAL 213406 49019791_1 CDM 0272 RC inpatient 22 14.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.18 69 999999999 13.32 21.34 percent of total billed charges NEEDLE STRAIGHT CUTTING KEITH ABDOMINAL 213406 49019791_1 CDM 0272 RC inpatient 22 14.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.16 78 999999999 13.32 21.34 percent of total billed charges NEEDLE STRAIGHT CUTTING KEITH ABDOMINAL 213406 49019791_1 CDM 0272 RC inpatient 22 14.3 SIHO - ALL PLANS SIHO - ALL PLANS 19.8 90 999999999 13.32 21.34 percent of total billed charges NEEDLE STRAIGHT CUTTING KEITH ABDOMINAL 213406 49019791_1 CDM 0272 RC inpatient 22 14.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.32 60.55 999999999 13.32 21.34 percent of total billed charges NEEDLE STRAIGHT CUTTING KEITH ABDOMINAL 213406 49019791_1 CDM 0272 RC inpatient 22 14.3 UMR - ALL PLANS UMR - ALL PLANS 15.4 70 999999999 13.32 21.34 percent of total billed charges NEEDLE STRAIGHT CUTTING KEITH ABDOMINAL 213406 49019791_1 CDM 0272 RC inpatient 22 14.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.32 21.34 NEEDLE STRAIGHT CUTTING KEITH ABDOMINAL 213406 49019791_1 CDM 0272 RC inpatient 22 14.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.32 21.34 NEEDLE STRAIGHT CUTTING KEITH ABDOMINAL 213406 49019791_1 CDM 0272 RC inpatient 22 14.3 ANTHEM HMO ANTHEM HMO 999999999 13.32 21.34 NEEDLE STRAIGHT CUTTING KEITH ABDOMINAL 213406 49019791_1 CDM 0272 RC inpatient 22 14.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.32 21.34 NEEDLE STRAIGHT CUTTING KEITH ABDOMINAL 213406 49019791_1 CDM 0272 RC inpatient 22 14.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.87 67.6 999999999 13.32 21.34 percent of total billed charges NEEDLE STRAIGHT CUTTING KEITH ABDOMINAL 213406 49019791_1 CDM 0272 RC inpatient 22 14.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.32 21.34 NEEDLE 20GA X 20CM 49019795_1 CDM 0621 RC inpatient 205 133.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.25 65 999999999 124.13 198.85 percent of total billed charges NEEDLE 20GA X 20CM 49019795_1 CDM 0621 RC inpatient 205 133.25 AETNA AETNA 161.95 79 999999999 124.13 198.85 percent of total billed charges NEEDLE 20GA X 20CM 49019795_1 CDM 0621 RC inpatient 205 133.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 198.85 97 999999999 124.13 198.85 percent of total billed charges NEEDLE 20GA X 20CM 49019795_1 CDM 0621 RC inpatient 205 133.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 141.45 69 999999999 124.13 198.85 percent of total billed charges NEEDLE 20GA X 20CM 49019795_1 CDM 0621 RC inpatient 205 133.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.9 78 999999999 124.13 198.85 percent of total billed charges NEEDLE 20GA X 20CM 49019795_1 CDM 0621 RC inpatient 205 133.25 SIHO - ALL PLANS SIHO - ALL PLANS 184.5 90 999999999 124.13 198.85 percent of total billed charges NEEDLE 20GA X 20CM 49019795_1 CDM 0621 RC inpatient 205 133.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.13 60.55 999999999 124.13 198.85 percent of total billed charges NEEDLE 20GA X 20CM 49019795_1 CDM 0621 RC inpatient 205 133.25 UMR - ALL PLANS UMR - ALL PLANS 143.5 70 999999999 124.13 198.85 percent of total billed charges NEEDLE 20GA X 20CM 49019795_1 CDM 0621 RC inpatient 205 133.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.13 198.85 NEEDLE 20GA X 20CM 49019795_1 CDM 0621 RC inpatient 205 133.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.13 198.85 NEEDLE 20GA X 20CM 49019795_1 CDM 0621 RC inpatient 205 133.25 ANTHEM HMO ANTHEM HMO 999999999 124.13 198.85 NEEDLE 20GA X 20CM 49019795_1 CDM 0621 RC inpatient 205 133.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.13 198.85 NEEDLE 20GA X 20CM 49019795_1 CDM 0621 RC inpatient 205 133.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 138.58 67.6 999999999 124.13 198.85 percent of total billed charges NEEDLE 20GA X 20CM 49019795_1 CDM 0621 RC inpatient 205 133.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.13 198.85 REV - IHS-MOA CLINIC VISIT 49019796_1 CDM 0510 RC inpatient 205 133.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.25 65 999999999 124.13 198.85 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49019796_1 CDM 0510 RC inpatient 205 133.25 AETNA AETNA 161.95 79 999999999 124.13 198.85 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49019796_1 CDM 0510 RC inpatient 205 133.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 198.85 97 999999999 124.13 198.85 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49019796_1 CDM 0510 RC inpatient 205 133.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 141.45 69 999999999 124.13 198.85 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49019796_1 CDM 0510 RC inpatient 205 133.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.9 78 999999999 124.13 198.85 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49019796_1 CDM 0510 RC inpatient 205 133.25 SIHO - ALL PLANS SIHO - ALL PLANS 184.5 90 999999999 124.13 198.85 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49019796_1 CDM 0510 RC inpatient 205 133.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.13 60.55 999999999 124.13 198.85 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49019796_1 CDM 0510 RC inpatient 205 133.25 UMR - ALL PLANS UMR - ALL PLANS 143.5 70 999999999 124.13 198.85 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49019796_1 CDM 0510 RC inpatient 205 133.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.13 198.85 REV - IHS-MOA CLINIC VISIT 49019796_1 CDM 0510 RC inpatient 205 133.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.13 198.85 REV - IHS-MOA CLINIC VISIT 49019796_1 CDM 0510 RC inpatient 205 133.25 ANTHEM HMO ANTHEM HMO 999999999 124.13 198.85 REV - IHS-MOA CLINIC VISIT 49019796_1 CDM 0510 RC inpatient 205 133.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.13 198.85 REV - IHS-MOA CLINIC VISIT 49019796_1 CDM 0510 RC inpatient 205 133.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 138.58 67.6 999999999 124.13 198.85 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49019796_1 CDM 0510 RC inpatient 205 133.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.13 198.85 NEEDLE KOPAN SPRING HOOK 5.0 GO2900 DKBL-21-5.0-A 49019804_1 CDM 0621 RC inpatient 227 147.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 147.55 65 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 5.0 GO2900 DKBL-21-5.0-A 49019804_1 CDM 0621 RC inpatient 227 147.55 AETNA AETNA 179.33 79 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 5.0 GO2900 DKBL-21-5.0-A 49019804_1 CDM 0621 RC inpatient 227 147.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 220.19 97 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 5.0 GO2900 DKBL-21-5.0-A 49019804_1 CDM 0621 RC inpatient 227 147.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 156.63 69 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 5.0 GO2900 DKBL-21-5.0-A 49019804_1 CDM 0621 RC inpatient 227 147.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 177.06 78 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 5.0 GO2900 DKBL-21-5.0-A 49019804_1 CDM 0621 RC inpatient 227 147.55 SIHO - ALL PLANS SIHO - ALL PLANS 204.3 90 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 5.0 GO2900 DKBL-21-5.0-A 49019804_1 CDM 0621 RC inpatient 227 147.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 137.45 60.55 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 5.0 GO2900 DKBL-21-5.0-A 49019804_1 CDM 0621 RC inpatient 227 147.55 UMR - ALL PLANS UMR - ALL PLANS 158.9 70 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 5.0 GO2900 DKBL-21-5.0-A 49019804_1 CDM 0621 RC inpatient 227 147.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 137.45 220.19 NEEDLE KOPAN SPRING HOOK 5.0 GO2900 DKBL-21-5.0-A 49019804_1 CDM 0621 RC inpatient 227 147.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 137.45 220.19 NEEDLE KOPAN SPRING HOOK 5.0 GO2900 DKBL-21-5.0-A 49019804_1 CDM 0621 RC inpatient 227 147.55 ANTHEM HMO ANTHEM HMO 999999999 137.45 220.19 NEEDLE KOPAN SPRING HOOK 5.0 GO2900 DKBL-21-5.0-A 49019804_1 CDM 0621 RC inpatient 227 147.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 137.45 220.19 NEEDLE KOPAN SPRING HOOK 5.0 GO2900 DKBL-21-5.0-A 49019804_1 CDM 0621 RC inpatient 227 147.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 153.45 67.6 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 5.0 GO2900 DKBL-21-5.0-A 49019804_1 CDM 0621 RC inpatient 227 147.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 137.45 220.19 NEEDLE KOPAN SPRING HOOK 7.0 G03507 DKBL-21-7.0-A 49019805_1 CDM 0621 RC inpatient 227 147.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 147.55 65 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 7.0 G03507 DKBL-21-7.0-A 49019805_1 CDM 0621 RC inpatient 227 147.55 AETNA AETNA 179.33 79 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 7.0 G03507 DKBL-21-7.0-A 49019805_1 CDM 0621 RC inpatient 227 147.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 220.19 97 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 7.0 G03507 DKBL-21-7.0-A 49019805_1 CDM 0621 RC inpatient 227 147.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 156.63 69 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 7.0 G03507 DKBL-21-7.0-A 49019805_1 CDM 0621 RC inpatient 227 147.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 177.06 78 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 7.0 G03507 DKBL-21-7.0-A 49019805_1 CDM 0621 RC inpatient 227 147.55 SIHO - ALL PLANS SIHO - ALL PLANS 204.3 90 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 7.0 G03507 DKBL-21-7.0-A 49019805_1 CDM 0621 RC inpatient 227 147.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 137.45 60.55 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 7.0 G03507 DKBL-21-7.0-A 49019805_1 CDM 0621 RC inpatient 227 147.55 UMR - ALL PLANS UMR - ALL PLANS 158.9 70 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 7.0 G03507 DKBL-21-7.0-A 49019805_1 CDM 0621 RC inpatient 227 147.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 137.45 220.19 NEEDLE KOPAN SPRING HOOK 7.0 G03507 DKBL-21-7.0-A 49019805_1 CDM 0621 RC inpatient 227 147.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 137.45 220.19 NEEDLE KOPAN SPRING HOOK 7.0 G03507 DKBL-21-7.0-A 49019805_1 CDM 0621 RC inpatient 227 147.55 ANTHEM HMO ANTHEM HMO 999999999 137.45 220.19 NEEDLE KOPAN SPRING HOOK 7.0 G03507 DKBL-21-7.0-A 49019805_1 CDM 0621 RC inpatient 227 147.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 137.45 220.19 NEEDLE KOPAN SPRING HOOK 7.0 G03507 DKBL-21-7.0-A 49019805_1 CDM 0621 RC inpatient 227 147.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 153.45 67.6 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 7.0 G03507 DKBL-21-7.0-A 49019805_1 CDM 0621 RC inpatient 227 147.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 137.45 220.19 NEEDLE KOPAN SPRING HOOK 9.0 DKBL-21-9.0-A G02554 49019806_1 CDM 0272 RC inpatient 227 147.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 147.55 65 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 9.0 DKBL-21-9.0-A G02554 49019806_1 CDM 0272 RC inpatient 227 147.55 AETNA AETNA 179.33 79 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 9.0 DKBL-21-9.0-A G02554 49019806_1 CDM 0272 RC inpatient 227 147.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 220.19 97 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 9.0 DKBL-21-9.0-A G02554 49019806_1 CDM 0272 RC inpatient 227 147.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 156.63 69 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 9.0 DKBL-21-9.0-A G02554 49019806_1 CDM 0272 RC inpatient 227 147.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 177.06 78 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 9.0 DKBL-21-9.0-A G02554 49019806_1 CDM 0272 RC inpatient 227 147.55 SIHO - ALL PLANS SIHO - ALL PLANS 204.3 90 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 9.0 DKBL-21-9.0-A G02554 49019806_1 CDM 0272 RC inpatient 227 147.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 137.45 60.55 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 9.0 DKBL-21-9.0-A G02554 49019806_1 CDM 0272 RC inpatient 227 147.55 UMR - ALL PLANS UMR - ALL PLANS 158.9 70 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 9.0 DKBL-21-9.0-A G02554 49019806_1 CDM 0272 RC inpatient 227 147.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 137.45 220.19 NEEDLE KOPAN SPRING HOOK 9.0 DKBL-21-9.0-A G02554 49019806_1 CDM 0272 RC inpatient 227 147.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 137.45 220.19 NEEDLE KOPAN SPRING HOOK 9.0 DKBL-21-9.0-A G02554 49019806_1 CDM 0272 RC inpatient 227 147.55 ANTHEM HMO ANTHEM HMO 999999999 137.45 220.19 NEEDLE KOPAN SPRING HOOK 9.0 DKBL-21-9.0-A G02554 49019806_1 CDM 0272 RC inpatient 227 147.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 137.45 220.19 NEEDLE KOPAN SPRING HOOK 9.0 DKBL-21-9.0-A G02554 49019806_1 CDM 0272 RC inpatient 227 147.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 153.45 67.6 999999999 137.45 220.19 percent of total billed charges NEEDLE KOPAN SPRING HOOK 9.0 DKBL-21-9.0-A G02554 49019806_1 CDM 0272 RC inpatient 227 147.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 137.45 220.19 YUEH CENT CATH NDLE 4.0 (OE) 49019813_1 CDM 0272 RC inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges YUEH CENT CATH NDLE 4.0 (OE) 49019813_1 CDM 0272 RC inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges YUEH CENT CATH NDLE 4.0 (OE) 49019813_1 CDM 0272 RC inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges YUEH CENT CATH NDLE 4.0 (OE) 49019813_1 CDM 0272 RC inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges YUEH CENT CATH NDLE 4.0 (OE) 49019813_1 CDM 0272 RC inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges YUEH CENT CATH NDLE 4.0 (OE) 49019813_1 CDM 0272 RC inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges YUEH CENT CATH NDLE 4.0 (OE) 49019813_1 CDM 0272 RC inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges YUEH CENT CATH NDLE 4.0 (OE) 49019813_1 CDM 0272 RC inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges YUEH CENT CATH NDLE 4.0 (OE) 49019813_1 CDM 0272 RC inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 YUEH CENT CATH NDLE 4.0 (OE) 49019813_1 CDM 0272 RC inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 YUEH CENT CATH NDLE 4.0 (OE) 49019813_1 CDM 0272 RC inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 YUEH CENT CATH NDLE 4.0 (OE) 49019813_1 CDM 0272 RC inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 YUEH CENT CATH NDLE 4.0 (OE) 49019813_1 CDM 0272 RC inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges YUEH CENT CATH NDLE 4.0 (OE) 49019813_1 CDM 0272 RC inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 YUEH CENT- CATH NDLE 15.0 (OE) 49019814_1 CDM 0272 RC inpatient 125 81.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.25 65 999999999 75.69 121.25 percent of total billed charges YUEH CENT- CATH NDLE 15.0 (OE) 49019814_1 CDM 0272 RC inpatient 125 81.25 AETNA AETNA 98.75 79 999999999 75.69 121.25 percent of total billed charges YUEH CENT- CATH NDLE 15.0 (OE) 49019814_1 CDM 0272 RC inpatient 125 81.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 121.25 97 999999999 75.69 121.25 percent of total billed charges YUEH CENT- CATH NDLE 15.0 (OE) 49019814_1 CDM 0272 RC inpatient 125 81.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.25 69 999999999 75.69 121.25 percent of total billed charges YUEH CENT- CATH NDLE 15.0 (OE) 49019814_1 CDM 0272 RC inpatient 125 81.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.5 78 999999999 75.69 121.25 percent of total billed charges YUEH CENT- CATH NDLE 15.0 (OE) 49019814_1 CDM 0272 RC inpatient 125 81.25 SIHO - ALL PLANS SIHO - ALL PLANS 112.5 90 999999999 75.69 121.25 percent of total billed charges YUEH CENT- CATH NDLE 15.0 (OE) 49019814_1 CDM 0272 RC inpatient 125 81.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.69 60.55 999999999 75.69 121.25 percent of total billed charges YUEH CENT- CATH NDLE 15.0 (OE) 49019814_1 CDM 0272 RC inpatient 125 81.25 UMR - ALL PLANS UMR - ALL PLANS 87.5 70 999999999 75.69 121.25 percent of total billed charges YUEH CENT- CATH NDLE 15.0 (OE) 49019814_1 CDM 0272 RC inpatient 125 81.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.69 121.25 YUEH CENT- CATH NDLE 15.0 (OE) 49019814_1 CDM 0272 RC inpatient 125 81.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.69 121.25 YUEH CENT- CATH NDLE 15.0 (OE) 49019814_1 CDM 0272 RC inpatient 125 81.25 ANTHEM HMO ANTHEM HMO 999999999 75.69 121.25 YUEH CENT- CATH NDLE 15.0 (OE) 49019814_1 CDM 0272 RC inpatient 125 81.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.69 121.25 YUEH CENT- CATH NDLE 15.0 (OE) 49019814_1 CDM 0272 RC inpatient 125 81.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.5 67.6 999999999 75.69 121.25 percent of total billed charges YUEH CENT- CATH NDLE 15.0 (OE) 49019814_1 CDM 0272 RC inpatient 125 81.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.69 121.25 BIO/NEEDLE TEMNO ACT2011 49019815_1 CDM 0272 RC inpatient 2140 1391 SELF PAY DISCOUNT SELF PAY DISCOUNT 1391 65 999999999 1295.77 2075.8 percent of total billed charges BIO/NEEDLE TEMNO ACT2011 49019815_1 CDM 0272 RC inpatient 2140 1391 AETNA AETNA 1690.6 79 999999999 1295.77 2075.8 percent of total billed charges BIO/NEEDLE TEMNO ACT2011 49019815_1 CDM 0272 RC inpatient 2140 1391 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2075.8 97 999999999 1295.77 2075.8 percent of total billed charges BIO/NEEDLE TEMNO ACT2011 49019815_1 CDM 0272 RC inpatient 2140 1391 ENCORE - ALL PLANS ENCORE - ALL PLANS 1476.6 69 999999999 1295.77 2075.8 percent of total billed charges BIO/NEEDLE TEMNO ACT2011 49019815_1 CDM 0272 RC inpatient 2140 1391 HUMANA - ALL PLANS HUMANA - ALL PLANS 1669.2 78 999999999 1295.77 2075.8 percent of total billed charges BIO/NEEDLE TEMNO ACT2011 49019815_1 CDM 0272 RC inpatient 2140 1391 SIHO - ALL PLANS SIHO - ALL PLANS 1926 90 999999999 1295.77 2075.8 percent of total billed charges BIO/NEEDLE TEMNO ACT2011 49019815_1 CDM 0272 RC inpatient 2140 1391 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1295.77 60.55 999999999 1295.77 2075.8 percent of total billed charges BIO/NEEDLE TEMNO ACT2011 49019815_1 CDM 0272 RC inpatient 2140 1391 UMR - ALL PLANS UMR - ALL PLANS 1498 70 999999999 1295.77 2075.8 percent of total billed charges BIO/NEEDLE TEMNO ACT2011 49019815_1 CDM 0272 RC inpatient 2140 1391 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1295.77 2075.8 BIO/NEEDLE TEMNO ACT2011 49019815_1 CDM 0272 RC inpatient 2140 1391 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1295.77 2075.8 BIO/NEEDLE TEMNO ACT2011 49019815_1 CDM 0272 RC inpatient 2140 1391 ANTHEM HMO ANTHEM HMO 999999999 1295.77 2075.8 BIO/NEEDLE TEMNO ACT2011 49019815_1 CDM 0272 RC inpatient 2140 1391 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1295.77 2075.8 BIO/NEEDLE TEMNO ACT2011 49019815_1 CDM 0272 RC inpatient 2140 1391 CIGNA - ALL PLANS CIGNA - ALL PLANS 1446.64 67.6 999999999 1295.77 2075.8 percent of total billed charges BIO/NEEDLE TEMNO ACT2011 49019815_1 CDM 0272 RC inpatient 2140 1391 UHC - ALL PLANS UHC - ALL PLANS 999999999 1295.77 2075.8 BIOPSY NEEDLE TEMNO ACT20/15 49019816_1 CDM 0621 RC inpatient 411 267.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 267.15 65 999999999 248.86 398.67 percent of total billed charges BIOPSY NEEDLE TEMNO ACT20/15 49019816_1 CDM 0621 RC inpatient 411 267.15 AETNA AETNA 324.69 79 999999999 248.86 398.67 percent of total billed charges BIOPSY NEEDLE TEMNO ACT20/15 49019816_1 CDM 0621 RC inpatient 411 267.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 398.67 97 999999999 248.86 398.67 percent of total billed charges BIOPSY NEEDLE TEMNO ACT20/15 49019816_1 CDM 0621 RC inpatient 411 267.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 283.59 69 999999999 248.86 398.67 percent of total billed charges BIOPSY NEEDLE TEMNO ACT20/15 49019816_1 CDM 0621 RC inpatient 411 267.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 320.58 78 999999999 248.86 398.67 percent of total billed charges BIOPSY NEEDLE TEMNO ACT20/15 49019816_1 CDM 0621 RC inpatient 411 267.15 SIHO - ALL PLANS SIHO - ALL PLANS 369.9 90 999999999 248.86 398.67 percent of total billed charges BIOPSY NEEDLE TEMNO ACT20/15 49019816_1 CDM 0621 RC inpatient 411 267.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 248.86 60.55 999999999 248.86 398.67 percent of total billed charges BIOPSY NEEDLE TEMNO ACT20/15 49019816_1 CDM 0621 RC inpatient 411 267.15 UMR - ALL PLANS UMR - ALL PLANS 287.7 70 999999999 248.86 398.67 percent of total billed charges BIOPSY NEEDLE TEMNO ACT20/15 49019816_1 CDM 0621 RC inpatient 411 267.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 248.86 398.67 BIOPSY NEEDLE TEMNO ACT20/15 49019816_1 CDM 0621 RC inpatient 411 267.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 248.86 398.67 BIOPSY NEEDLE TEMNO ACT20/15 49019816_1 CDM 0621 RC inpatient 411 267.15 ANTHEM HMO ANTHEM HMO 999999999 248.86 398.67 BIOPSY NEEDLE TEMNO ACT20/15 49019816_1 CDM 0621 RC inpatient 411 267.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 248.86 398.67 BIOPSY NEEDLE TEMNO ACT20/15 49019816_1 CDM 0621 RC inpatient 411 267.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 277.84 67.6 999999999 248.86 398.67 percent of total billed charges BIOPSY NEEDLE TEMNO ACT20/15 49019816_1 CDM 0621 RC inpatient 411 267.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 248.86 398.67 PACK BASIC #DYNJ16113M 49019828_1 CDM 0272 RC inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges PACK BASIC #DYNJ16113M 49019828_1 CDM 0272 RC inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges PACK BASIC #DYNJ16113M 49019828_1 CDM 0272 RC inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges PACK BASIC #DYNJ16113M 49019828_1 CDM 0272 RC inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges PACK BASIC #DYNJ16113M 49019828_1 CDM 0272 RC inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges PACK BASIC #DYNJ16113M 49019828_1 CDM 0272 RC inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges PACK BASIC #DYNJ16113M 49019828_1 CDM 0272 RC inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges PACK BASIC #DYNJ16113M 49019828_1 CDM 0272 RC inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges PACK BASIC #DYNJ16113M 49019828_1 CDM 0272 RC inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 PACK BASIC #DYNJ16113M 49019828_1 CDM 0272 RC inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 PACK BASIC #DYNJ16113M 49019828_1 CDM 0272 RC inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 PACK BASIC #DYNJ16113M 49019828_1 CDM 0272 RC inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 PACK BASIC #DYNJ16113M 49019828_1 CDM 0272 RC inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges PACK BASIC #DYNJ16113M 49019828_1 CDM 0272 RC inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 PACK ARTHROSCOPY #DYNJ16115M 49019829_1 CDM 0272 RC inpatient 593 385.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 385.45 65 999999999 359.06 575.21 percent of total billed charges PACK ARTHROSCOPY #DYNJ16115M 49019829_1 CDM 0272 RC inpatient 593 385.45 AETNA AETNA 468.47 79 999999999 359.06 575.21 percent of total billed charges PACK ARTHROSCOPY #DYNJ16115M 49019829_1 CDM 0272 RC inpatient 593 385.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 575.21 97 999999999 359.06 575.21 percent of total billed charges PACK ARTHROSCOPY #DYNJ16115M 49019829_1 CDM 0272 RC inpatient 593 385.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 409.17 69 999999999 359.06 575.21 percent of total billed charges PACK ARTHROSCOPY #DYNJ16115M 49019829_1 CDM 0272 RC inpatient 593 385.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 462.54 78 999999999 359.06 575.21 percent of total billed charges PACK ARTHROSCOPY #DYNJ16115M 49019829_1 CDM 0272 RC inpatient 593 385.45 SIHO - ALL PLANS SIHO - ALL PLANS 533.7 90 999999999 359.06 575.21 percent of total billed charges PACK ARTHROSCOPY #DYNJ16115M 49019829_1 CDM 0272 RC inpatient 593 385.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 359.06 60.55 999999999 359.06 575.21 percent of total billed charges PACK ARTHROSCOPY #DYNJ16115M 49019829_1 CDM 0272 RC inpatient 593 385.45 UMR - ALL PLANS UMR - ALL PLANS 415.1 70 999999999 359.06 575.21 percent of total billed charges PACK ARTHROSCOPY #DYNJ16115M 49019829_1 CDM 0272 RC inpatient 593 385.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 359.06 575.21 PACK ARTHROSCOPY #DYNJ16115M 49019829_1 CDM 0272 RC inpatient 593 385.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 359.06 575.21 PACK ARTHROSCOPY #DYNJ16115M 49019829_1 CDM 0272 RC inpatient 593 385.45 ANTHEM HMO ANTHEM HMO 999999999 359.06 575.21 PACK ARTHROSCOPY #DYNJ16115M 49019829_1 CDM 0272 RC inpatient 593 385.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 359.06 575.21 PACK ARTHROSCOPY #DYNJ16115M 49019829_1 CDM 0272 RC inpatient 593 385.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 400.87 67.6 999999999 359.06 575.21 percent of total billed charges PACK ARTHROSCOPY #DYNJ16115M 49019829_1 CDM 0272 RC inpatient 593 385.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 359.06 575.21 PACK CYSTO STANDARD DYNJS0503 49019831_1 CDM 0272 RC inpatient 157 102.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.05 65 999999999 95.06 152.29 percent of total billed charges PACK CYSTO STANDARD DYNJS0503 49019831_1 CDM 0272 RC inpatient 157 102.05 AETNA AETNA 124.03 79 999999999 95.06 152.29 percent of total billed charges PACK CYSTO STANDARD DYNJS0503 49019831_1 CDM 0272 RC inpatient 157 102.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 152.29 97 999999999 95.06 152.29 percent of total billed charges PACK CYSTO STANDARD DYNJS0503 49019831_1 CDM 0272 RC inpatient 157 102.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 108.33 69 999999999 95.06 152.29 percent of total billed charges PACK CYSTO STANDARD DYNJS0503 49019831_1 CDM 0272 RC inpatient 157 102.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 122.46 78 999999999 95.06 152.29 percent of total billed charges PACK CYSTO STANDARD DYNJS0503 49019831_1 CDM 0272 RC inpatient 157 102.05 SIHO - ALL PLANS SIHO - ALL PLANS 141.3 90 999999999 95.06 152.29 percent of total billed charges PACK CYSTO STANDARD DYNJS0503 49019831_1 CDM 0272 RC inpatient 157 102.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.06 60.55 999999999 95.06 152.29 percent of total billed charges PACK CYSTO STANDARD DYNJS0503 49019831_1 CDM 0272 RC inpatient 157 102.05 UMR - ALL PLANS UMR - ALL PLANS 109.9 70 999999999 95.06 152.29 percent of total billed charges PACK CYSTO STANDARD DYNJS0503 49019831_1 CDM 0272 RC inpatient 157 102.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.06 152.29 PACK CYSTO STANDARD DYNJS0503 49019831_1 CDM 0272 RC inpatient 157 102.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.06 152.29 PACK CYSTO STANDARD DYNJS0503 49019831_1 CDM 0272 RC inpatient 157 102.05 ANTHEM HMO ANTHEM HMO 999999999 95.06 152.29 PACK CYSTO STANDARD DYNJS0503 49019831_1 CDM 0272 RC inpatient 157 102.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.06 152.29 PACK CYSTO STANDARD DYNJS0503 49019831_1 CDM 0272 RC inpatient 157 102.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.13 67.6 999999999 95.06 152.29 percent of total billed charges PACK CYSTO STANDARD DYNJS0503 49019831_1 CDM 0272 RC inpatient 157 102.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.06 152.29 SM FRAG 3.5 CORTEX 10M 404.010 49019845_1 CDM 0278 RC inpatient 107 69.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 69.55 65 999999999 64.79 103.79 percent of total billed charges SM FRAG 3.5 CORTEX 10M 404.010 49019845_1 CDM 0278 RC inpatient 107 69.55 AETNA AETNA 84.53 79 999999999 64.79 103.79 percent of total billed charges SM FRAG 3.5 CORTEX 10M 404.010 49019845_1 CDM 0278 RC inpatient 107 69.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 103.79 97 999999999 64.79 103.79 percent of total billed charges SM FRAG 3.5 CORTEX 10M 404.010 49019845_1 CDM 0278 RC inpatient 107 69.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.83 69 999999999 64.79 103.79 percent of total billed charges SM FRAG 3.5 CORTEX 10M 404.010 49019845_1 CDM 0278 RC inpatient 107 69.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 83.46 78 999999999 64.79 103.79 percent of total billed charges SM FRAG 3.5 CORTEX 10M 404.010 49019845_1 CDM 0278 RC inpatient 107 69.55 SIHO - ALL PLANS SIHO - ALL PLANS 96.3 90 999999999 64.79 103.79 percent of total billed charges SM FRAG 3.5 CORTEX 10M 404.010 49019845_1 CDM 0278 RC inpatient 107 69.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.79 60.55 999999999 64.79 103.79 percent of total billed charges SM FRAG 3.5 CORTEX 10M 404.010 49019845_1 CDM 0278 RC inpatient 107 69.55 UMR - ALL PLANS UMR - ALL PLANS 74.9 70 999999999 64.79 103.79 percent of total billed charges SM FRAG 3.5 CORTEX 10M 404.010 49019845_1 CDM 0278 RC inpatient 107 69.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.79 103.79 SM FRAG 3.5 CORTEX 10M 404.010 49019845_1 CDM 0278 RC inpatient 107 69.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.79 103.79 SM FRAG 3.5 CORTEX 10M 404.010 49019845_1 CDM 0278 RC inpatient 107 69.55 ANTHEM HMO ANTHEM HMO 999999999 64.79 103.79 SM FRAG 3.5 CORTEX 10M 404.010 49019845_1 CDM 0278 RC inpatient 107 69.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.79 103.79 SM FRAG 3.5 CORTEX 10M 404.010 49019845_1 CDM 0278 RC inpatient 107 69.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 72.33 67.6 999999999 64.79 103.79 percent of total billed charges SM FRAG 3.5 CORTEX 10M 404.010 49019845_1 CDM 0278 RC inpatient 107 69.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.79 103.79 SM FRAG 3.5 CORTEX 14M 404.014 49019846_1 CDM 0278 RC inpatient 94 61.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.1 65 999999999 56.92 91.18 percent of total billed charges SM FRAG 3.5 CORTEX 14M 404.014 49019846_1 CDM 0278 RC inpatient 94 61.1 AETNA AETNA 74.26 79 999999999 56.92 91.18 percent of total billed charges SM FRAG 3.5 CORTEX 14M 404.014 49019846_1 CDM 0278 RC inpatient 94 61.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.18 97 999999999 56.92 91.18 percent of total billed charges SM FRAG 3.5 CORTEX 14M 404.014 49019846_1 CDM 0278 RC inpatient 94 61.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.86 69 999999999 56.92 91.18 percent of total billed charges SM FRAG 3.5 CORTEX 14M 404.014 49019846_1 CDM 0278 RC inpatient 94 61.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.32 78 999999999 56.92 91.18 percent of total billed charges SM FRAG 3.5 CORTEX 14M 404.014 49019846_1 CDM 0278 RC inpatient 94 61.1 SIHO - ALL PLANS SIHO - ALL PLANS 84.6 90 999999999 56.92 91.18 percent of total billed charges SM FRAG 3.5 CORTEX 14M 404.014 49019846_1 CDM 0278 RC inpatient 94 61.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.92 60.55 999999999 56.92 91.18 percent of total billed charges SM FRAG 3.5 CORTEX 14M 404.014 49019846_1 CDM 0278 RC inpatient 94 61.1 UMR - ALL PLANS UMR - ALL PLANS 65.8 70 999999999 56.92 91.18 percent of total billed charges SM FRAG 3.5 CORTEX 14M 404.014 49019846_1 CDM 0278 RC inpatient 94 61.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.92 91.18 SM FRAG 3.5 CORTEX 14M 404.014 49019846_1 CDM 0278 RC inpatient 94 61.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.92 91.18 SM FRAG 3.5 CORTEX 14M 404.014 49019846_1 CDM 0278 RC inpatient 94 61.1 ANTHEM HMO ANTHEM HMO 999999999 56.92 91.18 SM FRAG 3.5 CORTEX 14M 404.014 49019846_1 CDM 0278 RC inpatient 94 61.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.92 91.18 SM FRAG 3.5 CORTEX 14M 404.014 49019846_1 CDM 0278 RC inpatient 94 61.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.54 67.6 999999999 56.92 91.18 percent of total billed charges SM FRAG 3.5 CORTEX 14M 404.014 49019846_1 CDM 0278 RC inpatient 94 61.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.92 91.18 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019854_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.9 65 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019854_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 AETNA AETNA 20.54 79 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019854_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.22 97 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019854_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.94 69 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019854_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.28 78 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019854_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 SIHO - ALL PLANS SIHO - ALL PLANS 23.4 90 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019854_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.74 60.55 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019854_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UMR - ALL PLANS UMR - ALL PLANS 18.2 70 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019854_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019854_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019854_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM HMO ANTHEM HMO 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019854_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019854_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.58 67.6 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019854_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019855_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.9 65 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019855_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 AETNA AETNA 20.54 79 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019855_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.22 97 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019855_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.94 69 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019855_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.28 78 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019855_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 SIHO - ALL PLANS SIHO - ALL PLANS 23.4 90 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019855_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.74 60.55 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019855_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UMR - ALL PLANS UMR - ALL PLANS 18.2 70 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019855_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019855_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019855_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM HMO ANTHEM HMO 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019855_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019855_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.58 67.6 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019855_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019856_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.9 65 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019856_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 AETNA AETNA 20.54 79 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019856_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.22 97 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019856_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.94 69 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019856_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.28 78 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019856_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 SIHO - ALL PLANS SIHO - ALL PLANS 23.4 90 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019856_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.74 60.55 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019856_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UMR - ALL PLANS UMR - ALL PLANS 18.2 70 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019856_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019856_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019856_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM HMO ANTHEM HMO 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019856_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019856_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.58 67.6 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019856_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019857_1 CDM 0278 RC C1713 HCPCS inpatient 13 8.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.45 65 999999999 7.87 12.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019857_1 CDM 0278 RC C1713 HCPCS inpatient 13 8.45 AETNA AETNA 10.27 79 999999999 7.87 12.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019857_1 CDM 0278 RC C1713 HCPCS inpatient 13 8.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.61 97 999999999 7.87 12.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019857_1 CDM 0278 RC C1713 HCPCS inpatient 13 8.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.97 69 999999999 7.87 12.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019857_1 CDM 0278 RC C1713 HCPCS inpatient 13 8.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.14 78 999999999 7.87 12.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019857_1 CDM 0278 RC C1713 HCPCS inpatient 13 8.45 SIHO - ALL PLANS SIHO - ALL PLANS 11.7 90 999999999 7.87 12.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019857_1 CDM 0278 RC C1713 HCPCS inpatient 13 8.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.87 60.55 999999999 7.87 12.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019857_1 CDM 0278 RC C1713 HCPCS inpatient 13 8.45 UMR - ALL PLANS UMR - ALL PLANS 9.1 70 999999999 7.87 12.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019857_1 CDM 0278 RC C1713 HCPCS inpatient 13 8.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.87 12.61 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019857_1 CDM 0278 RC C1713 HCPCS inpatient 13 8.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.87 12.61 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019857_1 CDM 0278 RC C1713 HCPCS inpatient 13 8.45 ANTHEM HMO ANTHEM HMO 999999999 7.87 12.61 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019857_1 CDM 0278 RC C1713 HCPCS inpatient 13 8.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.87 12.61 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019857_1 CDM 0278 RC C1713 HCPCS inpatient 13 8.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.79 67.6 999999999 7.87 12.61 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019857_1 CDM 0278 RC C1713 HCPCS inpatient 13 8.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.87 12.61 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019860_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.9 65 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019860_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 AETNA AETNA 20.54 79 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019860_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.22 97 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019860_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.94 69 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019860_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.28 78 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019860_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 SIHO - ALL PLANS SIHO - ALL PLANS 23.4 90 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019860_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.74 60.55 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019860_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UMR - ALL PLANS UMR - ALL PLANS 18.2 70 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019860_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019860_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019860_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM HMO ANTHEM HMO 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019860_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019860_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.58 67.6 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019860_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019867_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.9 65 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019867_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 AETNA AETNA 20.54 79 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019867_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.22 97 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019867_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.94 69 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019867_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.28 78 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019867_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 SIHO - ALL PLANS SIHO - ALL PLANS 23.4 90 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019867_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.74 60.55 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019867_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UMR - ALL PLANS UMR - ALL PLANS 18.2 70 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019867_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019867_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019867_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM HMO ANTHEM HMO 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019867_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019867_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.58 67.6 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019867_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019868_1 CDM 0278 RC C1713 HCPCS inpatient 9 5.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.85 65 999999999 5.45 8.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019868_1 CDM 0278 RC C1713 HCPCS inpatient 9 5.85 AETNA AETNA 7.11 79 999999999 5.45 8.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019868_1 CDM 0278 RC C1713 HCPCS inpatient 9 5.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.73 97 999999999 5.45 8.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019868_1 CDM 0278 RC C1713 HCPCS inpatient 9 5.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.21 69 999999999 5.45 8.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019868_1 CDM 0278 RC C1713 HCPCS inpatient 9 5.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.02 78 999999999 5.45 8.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019868_1 CDM 0278 RC C1713 HCPCS inpatient 9 5.85 SIHO - ALL PLANS SIHO - ALL PLANS 8.1 90 999999999 5.45 8.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019868_1 CDM 0278 RC C1713 HCPCS inpatient 9 5.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.45 60.55 999999999 5.45 8.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019868_1 CDM 0278 RC C1713 HCPCS inpatient 9 5.85 UMR - ALL PLANS UMR - ALL PLANS 6.3 70 999999999 5.45 8.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019868_1 CDM 0278 RC C1713 HCPCS inpatient 9 5.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.45 8.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019868_1 CDM 0278 RC C1713 HCPCS inpatient 9 5.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.45 8.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019868_1 CDM 0278 RC C1713 HCPCS inpatient 9 5.85 ANTHEM HMO ANTHEM HMO 999999999 5.45 8.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019868_1 CDM 0278 RC C1713 HCPCS inpatient 9 5.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.45 8.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019868_1 CDM 0278 RC C1713 HCPCS inpatient 9 5.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.08 67.6 999999999 5.45 8.73 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019868_1 CDM 0278 RC C1713 HCPCS inpatient 9 5.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.45 8.73 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019869_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.9 65 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019869_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 AETNA AETNA 20.54 79 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019869_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.22 97 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019869_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.94 69 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019869_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.28 78 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019869_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 SIHO - ALL PLANS SIHO - ALL PLANS 23.4 90 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019869_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.74 60.55 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019869_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UMR - ALL PLANS UMR - ALL PLANS 18.2 70 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019869_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019869_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019869_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM HMO ANTHEM HMO 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019869_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019869_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.58 67.6 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019869_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019870_1 CDM 0278 RC C1713 HCPCS inpatient 8 5.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.2 65 999999999 4.84 7.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019870_1 CDM 0278 RC C1713 HCPCS inpatient 8 5.2 AETNA AETNA 6.32 79 999999999 4.84 7.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019870_1 CDM 0278 RC C1713 HCPCS inpatient 8 5.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7.76 97 999999999 4.84 7.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019870_1 CDM 0278 RC C1713 HCPCS inpatient 8 5.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.52 69 999999999 4.84 7.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019870_1 CDM 0278 RC C1713 HCPCS inpatient 8 5.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.24 78 999999999 4.84 7.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019870_1 CDM 0278 RC C1713 HCPCS inpatient 8 5.2 SIHO - ALL PLANS SIHO - ALL PLANS 7.2 90 999999999 4.84 7.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019870_1 CDM 0278 RC C1713 HCPCS inpatient 8 5.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.84 60.55 999999999 4.84 7.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019870_1 CDM 0278 RC C1713 HCPCS inpatient 8 5.2 UMR - ALL PLANS UMR - ALL PLANS 5.6 70 999999999 4.84 7.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019870_1 CDM 0278 RC C1713 HCPCS inpatient 8 5.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.84 7.76 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019870_1 CDM 0278 RC C1713 HCPCS inpatient 8 5.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.84 7.76 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019870_1 CDM 0278 RC C1713 HCPCS inpatient 8 5.2 ANTHEM HMO ANTHEM HMO 999999999 4.84 7.76 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019870_1 CDM 0278 RC C1713 HCPCS inpatient 8 5.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.84 7.76 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019870_1 CDM 0278 RC C1713 HCPCS inpatient 8 5.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.41 67.6 999999999 4.84 7.76 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019870_1 CDM 0278 RC C1713 HCPCS inpatient 8 5.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.84 7.76 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019873_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.9 65 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019873_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 AETNA AETNA 20.54 79 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019873_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.22 97 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019873_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.94 69 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019873_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.28 78 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019873_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 SIHO - ALL PLANS SIHO - ALL PLANS 23.4 90 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019873_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.74 60.55 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019873_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UMR - ALL PLANS UMR - ALL PLANS 18.2 70 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019873_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019873_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019873_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM HMO ANTHEM HMO 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019873_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.74 25.22 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019873_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.58 67.6 999999999 15.74 25.22 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49019873_1 CDM 0278 RC C1713 HCPCS inpatient 26 16.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.74 25.22 SUTURE SILK 3-0 A184H 36/BX 49019895_1 CDM 0272 RC inpatient 11 7.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.15 65 999999999 6.66 10.67 percent of total billed charges SUTURE SILK 3-0 A184H 36/BX 49019895_1 CDM 0272 RC inpatient 11 7.15 AETNA AETNA 8.69 79 999999999 6.66 10.67 percent of total billed charges SUTURE SILK 3-0 A184H 36/BX 49019895_1 CDM 0272 RC inpatient 11 7.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10.67 97 999999999 6.66 10.67 percent of total billed charges SUTURE SILK 3-0 A184H 36/BX 49019895_1 CDM 0272 RC inpatient 11 7.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.59 69 999999999 6.66 10.67 percent of total billed charges SUTURE SILK 3-0 A184H 36/BX 49019895_1 CDM 0272 RC inpatient 11 7.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 8.58 78 999999999 6.66 10.67 percent of total billed charges SUTURE SILK 3-0 A184H 36/BX 49019895_1 CDM 0272 RC inpatient 11 7.15 SIHO - ALL PLANS SIHO - ALL PLANS 9.9 90 999999999 6.66 10.67 percent of total billed charges SUTURE SILK 3-0 A184H 36/BX 49019895_1 CDM 0272 RC inpatient 11 7.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.66 60.55 999999999 6.66 10.67 percent of total billed charges SUTURE SILK 3-0 A184H 36/BX 49019895_1 CDM 0272 RC inpatient 11 7.15 UMR - ALL PLANS UMR - ALL PLANS 7.7 70 999999999 6.66 10.67 percent of total billed charges SUTURE SILK 3-0 A184H 36/BX 49019895_1 CDM 0272 RC inpatient 11 7.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.66 10.67 SUTURE SILK 3-0 A184H 36/BX 49019895_1 CDM 0272 RC inpatient 11 7.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.66 10.67 SUTURE SILK 3-0 A184H 36/BX 49019895_1 CDM 0272 RC inpatient 11 7.15 ANTHEM HMO ANTHEM HMO 999999999 6.66 10.67 SUTURE SILK 3-0 A184H 36/BX 49019895_1 CDM 0272 RC inpatient 11 7.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.66 10.67 SUTURE SILK 3-0 A184H 36/BX 49019895_1 CDM 0272 RC inpatient 11 7.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 7.44 67.6 999999999 6.66 10.67 percent of total billed charges SUTURE SILK 3-0 A184H 36/BX 49019895_1 CDM 0272 RC inpatient 11 7.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.66 10.67 SUTURE SILK 2-0 A185H SUTUPAK 49019896_1 CDM 0272 RC inpatient 15 9.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.75 65 999999999 9.08 14.55 percent of total billed charges SUTURE SILK 2-0 A185H SUTUPAK 49019896_1 CDM 0272 RC inpatient 15 9.75 AETNA AETNA 11.85 79 999999999 9.08 14.55 percent of total billed charges SUTURE SILK 2-0 A185H SUTUPAK 49019896_1 CDM 0272 RC inpatient 15 9.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14.55 97 999999999 9.08 14.55 percent of total billed charges SUTURE SILK 2-0 A185H SUTUPAK 49019896_1 CDM 0272 RC inpatient 15 9.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.35 69 999999999 9.08 14.55 percent of total billed charges SUTURE SILK 2-0 A185H SUTUPAK 49019896_1 CDM 0272 RC inpatient 15 9.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.7 78 999999999 9.08 14.55 percent of total billed charges SUTURE SILK 2-0 A185H SUTUPAK 49019896_1 CDM 0272 RC inpatient 15 9.75 SIHO - ALL PLANS SIHO - ALL PLANS 13.5 90 999999999 9.08 14.55 percent of total billed charges SUTURE SILK 2-0 A185H SUTUPAK 49019896_1 CDM 0272 RC inpatient 15 9.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.08 60.55 999999999 9.08 14.55 percent of total billed charges SUTURE SILK 2-0 A185H SUTUPAK 49019896_1 CDM 0272 RC inpatient 15 9.75 UMR - ALL PLANS UMR - ALL PLANS 10.5 70 999999999 9.08 14.55 percent of total billed charges SUTURE SILK 2-0 A185H SUTUPAK 49019896_1 CDM 0272 RC inpatient 15 9.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.08 14.55 SUTURE SILK 2-0 A185H SUTUPAK 49019896_1 CDM 0272 RC inpatient 15 9.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.08 14.55 SUTURE SILK 2-0 A185H SUTUPAK 49019896_1 CDM 0272 RC inpatient 15 9.75 ANTHEM HMO ANTHEM HMO 999999999 9.08 14.55 SUTURE SILK 2-0 A185H SUTUPAK 49019896_1 CDM 0272 RC inpatient 15 9.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.08 14.55 SUTURE SILK 2-0 A185H SUTUPAK 49019896_1 CDM 0272 RC inpatient 15 9.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.14 67.6 999999999 9.08 14.55 percent of total billed charges SUTURE SILK 2-0 A185H SUTUPAK 49019896_1 CDM 0272 RC inpatient 15 9.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.08 14.55 SUTURE ETHIBOND #0 X424H 49019901_1 CDM 0272 RC inpatient 18 11.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.7 65 999999999 10.9 17.46 percent of total billed charges SUTURE ETHIBOND #0 X424H 49019901_1 CDM 0272 RC inpatient 18 11.7 AETNA AETNA 14.22 79 999999999 10.9 17.46 percent of total billed charges SUTURE ETHIBOND #0 X424H 49019901_1 CDM 0272 RC inpatient 18 11.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.46 97 999999999 10.9 17.46 percent of total billed charges SUTURE ETHIBOND #0 X424H 49019901_1 CDM 0272 RC inpatient 18 11.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.42 69 999999999 10.9 17.46 percent of total billed charges SUTURE ETHIBOND #0 X424H 49019901_1 CDM 0272 RC inpatient 18 11.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.04 78 999999999 10.9 17.46 percent of total billed charges SUTURE ETHIBOND #0 X424H 49019901_1 CDM 0272 RC inpatient 18 11.7 SIHO - ALL PLANS SIHO - ALL PLANS 16.2 90 999999999 10.9 17.46 percent of total billed charges SUTURE ETHIBOND #0 X424H 49019901_1 CDM 0272 RC inpatient 18 11.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.9 60.55 999999999 10.9 17.46 percent of total billed charges SUTURE ETHIBOND #0 X424H 49019901_1 CDM 0272 RC inpatient 18 11.7 UMR - ALL PLANS UMR - ALL PLANS 12.6 70 999999999 10.9 17.46 percent of total billed charges SUTURE ETHIBOND #0 X424H 49019901_1 CDM 0272 RC inpatient 18 11.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.9 17.46 SUTURE ETHIBOND #0 X424H 49019901_1 CDM 0272 RC inpatient 18 11.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.9 17.46 SUTURE ETHIBOND #0 X424H 49019901_1 CDM 0272 RC inpatient 18 11.7 ANTHEM HMO ANTHEM HMO 999999999 10.9 17.46 SUTURE ETHIBOND #0 X424H 49019901_1 CDM 0272 RC inpatient 18 11.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.9 17.46 SUTURE ETHIBOND #0 X424H 49019901_1 CDM 0272 RC inpatient 18 11.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.17 67.6 999999999 10.9 17.46 percent of total billed charges SUTURE ETHIBOND #0 X424H 49019901_1 CDM 0272 RC inpatient 18 11.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.9 17.46 SUTURE ETHIBOND 4-0 X692G 49019902_1 CDM 0272 RC inpatient 24 15.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 15.6 65 999999999 14.53 23.28 percent of total billed charges SUTURE ETHIBOND 4-0 X692G 49019902_1 CDM 0272 RC inpatient 24 15.6 AETNA AETNA 18.96 79 999999999 14.53 23.28 percent of total billed charges SUTURE ETHIBOND 4-0 X692G 49019902_1 CDM 0272 RC inpatient 24 15.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23.28 97 999999999 14.53 23.28 percent of total billed charges SUTURE ETHIBOND 4-0 X692G 49019902_1 CDM 0272 RC inpatient 24 15.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 16.56 69 999999999 14.53 23.28 percent of total billed charges SUTURE ETHIBOND 4-0 X692G 49019902_1 CDM 0272 RC inpatient 24 15.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 18.72 78 999999999 14.53 23.28 percent of total billed charges SUTURE ETHIBOND 4-0 X692G 49019902_1 CDM 0272 RC inpatient 24 15.6 SIHO - ALL PLANS SIHO - ALL PLANS 21.6 90 999999999 14.53 23.28 percent of total billed charges SUTURE ETHIBOND 4-0 X692G 49019902_1 CDM 0272 RC inpatient 24 15.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.53 60.55 999999999 14.53 23.28 percent of total billed charges SUTURE ETHIBOND 4-0 X692G 49019902_1 CDM 0272 RC inpatient 24 15.6 UMR - ALL PLANS UMR - ALL PLANS 16.8 70 999999999 14.53 23.28 percent of total billed charges SUTURE ETHIBOND 4-0 X692G 49019902_1 CDM 0272 RC inpatient 24 15.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.53 23.28 SUTURE ETHIBOND 4-0 X692G 49019902_1 CDM 0272 RC inpatient 24 15.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.53 23.28 SUTURE ETHIBOND 4-0 X692G 49019902_1 CDM 0272 RC inpatient 24 15.6 ANTHEM HMO ANTHEM HMO 999999999 14.53 23.28 SUTURE ETHIBOND 4-0 X692G 49019902_1 CDM 0272 RC inpatient 24 15.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.53 23.28 SUTURE ETHIBOND 4-0 X692G 49019902_1 CDM 0272 RC inpatient 24 15.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.22 67.6 999999999 14.53 23.28 percent of total billed charges SUTURE ETHIBOND 4-0 X692G 49019902_1 CDM 0272 RC inpatient 24 15.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.53 23.28 SUTURE ETHIBOND 2-0 X423H 49019903_1 CDM 0272 RC inpatient 18 11.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.7 65 999999999 10.9 17.46 percent of total billed charges SUTURE ETHIBOND 2-0 X423H 49019903_1 CDM 0272 RC inpatient 18 11.7 AETNA AETNA 14.22 79 999999999 10.9 17.46 percent of total billed charges SUTURE ETHIBOND 2-0 X423H 49019903_1 CDM 0272 RC inpatient 18 11.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.46 97 999999999 10.9 17.46 percent of total billed charges SUTURE ETHIBOND 2-0 X423H 49019903_1 CDM 0272 RC inpatient 18 11.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.42 69 999999999 10.9 17.46 percent of total billed charges SUTURE ETHIBOND 2-0 X423H 49019903_1 CDM 0272 RC inpatient 18 11.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.04 78 999999999 10.9 17.46 percent of total billed charges SUTURE ETHIBOND 2-0 X423H 49019903_1 CDM 0272 RC inpatient 18 11.7 SIHO - ALL PLANS SIHO - ALL PLANS 16.2 90 999999999 10.9 17.46 percent of total billed charges SUTURE ETHIBOND 2-0 X423H 49019903_1 CDM 0272 RC inpatient 18 11.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.9 60.55 999999999 10.9 17.46 percent of total billed charges SUTURE ETHIBOND 2-0 X423H 49019903_1 CDM 0272 RC inpatient 18 11.7 UMR - ALL PLANS UMR - ALL PLANS 12.6 70 999999999 10.9 17.46 percent of total billed charges SUTURE ETHIBOND 2-0 X423H 49019903_1 CDM 0272 RC inpatient 18 11.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.9 17.46 SUTURE ETHIBOND 2-0 X423H 49019903_1 CDM 0272 RC inpatient 18 11.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.9 17.46 SUTURE ETHIBOND 2-0 X423H 49019903_1 CDM 0272 RC inpatient 18 11.7 ANTHEM HMO ANTHEM HMO 999999999 10.9 17.46 SUTURE ETHIBOND 2-0 X423H 49019903_1 CDM 0272 RC inpatient 18 11.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.9 17.46 SUTURE ETHIBOND 2-0 X423H 49019903_1 CDM 0272 RC inpatient 18 11.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.17 67.6 999999999 10.9 17.46 percent of total billed charges SUTURE ETHIBOND 2-0 X423H 49019903_1 CDM 0272 RC inpatient 18 11.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.9 17.46 SUTR ETHIBOND #2 X519H 49019906_1 CDM 0272 RC inpatient 25 16.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.25 65 999999999 15.14 24.25 percent of total billed charges SUTR ETHIBOND #2 X519H 49019906_1 CDM 0272 RC inpatient 25 16.25 AETNA AETNA 19.75 79 999999999 15.14 24.25 percent of total billed charges SUTR ETHIBOND #2 X519H 49019906_1 CDM 0272 RC inpatient 25 16.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.25 97 999999999 15.14 24.25 percent of total billed charges SUTR ETHIBOND #2 X519H 49019906_1 CDM 0272 RC inpatient 25 16.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.25 69 999999999 15.14 24.25 percent of total billed charges SUTR ETHIBOND #2 X519H 49019906_1 CDM 0272 RC inpatient 25 16.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.5 78 999999999 15.14 24.25 percent of total billed charges SUTR ETHIBOND #2 X519H 49019906_1 CDM 0272 RC inpatient 25 16.25 SIHO - ALL PLANS SIHO - ALL PLANS 22.5 90 999999999 15.14 24.25 percent of total billed charges SUTR ETHIBOND #2 X519H 49019906_1 CDM 0272 RC inpatient 25 16.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.14 60.55 999999999 15.14 24.25 percent of total billed charges SUTR ETHIBOND #2 X519H 49019906_1 CDM 0272 RC inpatient 25 16.25 UMR - ALL PLANS UMR - ALL PLANS 17.5 70 999999999 15.14 24.25 percent of total billed charges SUTR ETHIBOND #2 X519H 49019906_1 CDM 0272 RC inpatient 25 16.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.14 24.25 SUTR ETHIBOND #2 X519H 49019906_1 CDM 0272 RC inpatient 25 16.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.14 24.25 SUTR ETHIBOND #2 X519H 49019906_1 CDM 0272 RC inpatient 25 16.25 ANTHEM HMO ANTHEM HMO 999999999 15.14 24.25 SUTR ETHIBOND #2 X519H 49019906_1 CDM 0272 RC inpatient 25 16.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.14 24.25 SUTR ETHIBOND #2 X519H 49019906_1 CDM 0272 RC inpatient 25 16.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.9 67.6 999999999 15.14 24.25 percent of total billed charges SUTR ETHIBOND #2 X519H 49019906_1 CDM 0272 RC inpatient 25 16.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.14 24.25 SUTURE ETHIBOND X517H-OS4 49019907_1 CDM 0272 RC inpatient 27 17.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.55 65 999999999 16.35 26.19 percent of total billed charges SUTURE ETHIBOND X517H-OS4 49019907_1 CDM 0272 RC inpatient 27 17.55 AETNA AETNA 21.33 79 999999999 16.35 26.19 percent of total billed charges SUTURE ETHIBOND X517H-OS4 49019907_1 CDM 0272 RC inpatient 27 17.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26.19 97 999999999 16.35 26.19 percent of total billed charges SUTURE ETHIBOND X517H-OS4 49019907_1 CDM 0272 RC inpatient 27 17.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.63 69 999999999 16.35 26.19 percent of total billed charges SUTURE ETHIBOND X517H-OS4 49019907_1 CDM 0272 RC inpatient 27 17.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.06 78 999999999 16.35 26.19 percent of total billed charges SUTURE ETHIBOND X517H-OS4 49019907_1 CDM 0272 RC inpatient 27 17.55 SIHO - ALL PLANS SIHO - ALL PLANS 24.3 90 999999999 16.35 26.19 percent of total billed charges SUTURE ETHIBOND X517H-OS4 49019907_1 CDM 0272 RC inpatient 27 17.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.35 60.55 999999999 16.35 26.19 percent of total billed charges SUTURE ETHIBOND X517H-OS4 49019907_1 CDM 0272 RC inpatient 27 17.55 UMR - ALL PLANS UMR - ALL PLANS 18.9 70 999999999 16.35 26.19 percent of total billed charges SUTURE ETHIBOND X517H-OS4 49019907_1 CDM 0272 RC inpatient 27 17.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.35 26.19 SUTURE ETHIBOND X517H-OS4 49019907_1 CDM 0272 RC inpatient 27 17.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.35 26.19 SUTURE ETHIBOND X517H-OS4 49019907_1 CDM 0272 RC inpatient 27 17.55 ANTHEM HMO ANTHEM HMO 999999999 16.35 26.19 SUTURE ETHIBOND X517H-OS4 49019907_1 CDM 0272 RC inpatient 27 17.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.35 26.19 SUTURE ETHIBOND X517H-OS4 49019907_1 CDM 0272 RC inpatient 27 17.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.25 67.6 999999999 16.35 26.19 percent of total billed charges SUTURE ETHIBOND X517H-OS4 49019907_1 CDM 0272 RC inpatient 27 17.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.35 26.19 SUTURE ETHIBOND #1 X425H 49019909_1 CDM 0272 RC inpatient 10 6.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.5 65 999999999 6.06 9.7 percent of total billed charges SUTURE ETHIBOND #1 X425H 49019909_1 CDM 0272 RC inpatient 10 6.5 AETNA AETNA 7.9 79 999999999 6.06 9.7 percent of total billed charges SUTURE ETHIBOND #1 X425H 49019909_1 CDM 0272 RC inpatient 10 6.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.7 97 999999999 6.06 9.7 percent of total billed charges SUTURE ETHIBOND #1 X425H 49019909_1 CDM 0272 RC inpatient 10 6.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.9 69 999999999 6.06 9.7 percent of total billed charges SUTURE ETHIBOND #1 X425H 49019909_1 CDM 0272 RC inpatient 10 6.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.8 78 999999999 6.06 9.7 percent of total billed charges SUTURE ETHIBOND #1 X425H 49019909_1 CDM 0272 RC inpatient 10 6.5 SIHO - ALL PLANS SIHO - ALL PLANS 9 90 999999999 6.06 9.7 percent of total billed charges SUTURE ETHIBOND #1 X425H 49019909_1 CDM 0272 RC inpatient 10 6.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.06 60.55 999999999 6.06 9.7 percent of total billed charges SUTURE ETHIBOND #1 X425H 49019909_1 CDM 0272 RC inpatient 10 6.5 UMR - ALL PLANS UMR - ALL PLANS 7 70 999999999 6.06 9.7 percent of total billed charges SUTURE ETHIBOND #1 X425H 49019909_1 CDM 0272 RC inpatient 10 6.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.06 9.7 SUTURE ETHIBOND #1 X425H 49019909_1 CDM 0272 RC inpatient 10 6.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.06 9.7 SUTURE ETHIBOND #1 X425H 49019909_1 CDM 0272 RC inpatient 10 6.5 ANTHEM HMO ANTHEM HMO 999999999 6.06 9.7 SUTURE ETHIBOND #1 X425H 49019909_1 CDM 0272 RC inpatient 10 6.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.06 9.7 SUTURE ETHIBOND #1 X425H 49019909_1 CDM 0272 RC inpatient 10 6.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.76 67.6 999999999 6.06 9.7 percent of total billed charges SUTURE ETHIBOND #1 X425H 49019909_1 CDM 0272 RC inpatient 10 6.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.06 9.7 SPOT X GIS-45 49019911_1 CDM 0270 RC inpatient 235 152.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 152.75 65 999999999 142.29 227.95 percent of total billed charges SPOT X GIS-45 49019911_1 CDM 0270 RC inpatient 235 152.75 AETNA AETNA 185.65 79 999999999 142.29 227.95 percent of total billed charges SPOT X GIS-45 49019911_1 CDM 0270 RC inpatient 235 152.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 227.95 97 999999999 142.29 227.95 percent of total billed charges SPOT X GIS-45 49019911_1 CDM 0270 RC inpatient 235 152.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 162.15 69 999999999 142.29 227.95 percent of total billed charges SPOT X GIS-45 49019911_1 CDM 0270 RC inpatient 235 152.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 183.3 78 999999999 142.29 227.95 percent of total billed charges SPOT X GIS-45 49019911_1 CDM 0270 RC inpatient 235 152.75 SIHO - ALL PLANS SIHO - ALL PLANS 211.5 90 999999999 142.29 227.95 percent of total billed charges SPOT X GIS-45 49019911_1 CDM 0270 RC inpatient 235 152.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 142.29 60.55 999999999 142.29 227.95 percent of total billed charges SPOT X GIS-45 49019911_1 CDM 0270 RC inpatient 235 152.75 UMR - ALL PLANS UMR - ALL PLANS 164.5 70 999999999 142.29 227.95 percent of total billed charges SPOT X GIS-45 49019911_1 CDM 0270 RC inpatient 235 152.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 142.29 227.95 SPOT X GIS-45 49019911_1 CDM 0270 RC inpatient 235 152.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 142.29 227.95 SPOT X GIS-45 49019911_1 CDM 0270 RC inpatient 235 152.75 ANTHEM HMO ANTHEM HMO 999999999 142.29 227.95 SPOT X GIS-45 49019911_1 CDM 0270 RC inpatient 235 152.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 142.29 227.95 SPOT X GIS-45 49019911_1 CDM 0270 RC inpatient 235 152.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 158.86 67.6 999999999 142.29 227.95 percent of total billed charges SPOT X GIS-45 49019911_1 CDM 0270 RC inpatient 235 152.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 142.29 227.95 SUTR ETHIBOND #5 B409T 24/BX 49019913_1 CDM 0272 RC inpatient 27 17.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.55 65 999999999 16.35 26.19 percent of total billed charges SUTR ETHIBOND #5 B409T 24/BX 49019913_1 CDM 0272 RC inpatient 27 17.55 AETNA AETNA 21.33 79 999999999 16.35 26.19 percent of total billed charges SUTR ETHIBOND #5 B409T 24/BX 49019913_1 CDM 0272 RC inpatient 27 17.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26.19 97 999999999 16.35 26.19 percent of total billed charges SUTR ETHIBOND #5 B409T 24/BX 49019913_1 CDM 0272 RC inpatient 27 17.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.63 69 999999999 16.35 26.19 percent of total billed charges SUTR ETHIBOND #5 B409T 24/BX 49019913_1 CDM 0272 RC inpatient 27 17.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.06 78 999999999 16.35 26.19 percent of total billed charges SUTR ETHIBOND #5 B409T 24/BX 49019913_1 CDM 0272 RC inpatient 27 17.55 SIHO - ALL PLANS SIHO - ALL PLANS 24.3 90 999999999 16.35 26.19 percent of total billed charges SUTR ETHIBOND #5 B409T 24/BX 49019913_1 CDM 0272 RC inpatient 27 17.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.35 60.55 999999999 16.35 26.19 percent of total billed charges SUTR ETHIBOND #5 B409T 24/BX 49019913_1 CDM 0272 RC inpatient 27 17.55 UMR - ALL PLANS UMR - ALL PLANS 18.9 70 999999999 16.35 26.19 percent of total billed charges SUTR ETHIBOND #5 B409T 24/BX 49019913_1 CDM 0272 RC inpatient 27 17.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.35 26.19 SUTR ETHIBOND #5 B409T 24/BX 49019913_1 CDM 0272 RC inpatient 27 17.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.35 26.19 SUTR ETHIBOND #5 B409T 24/BX 49019913_1 CDM 0272 RC inpatient 27 17.55 ANTHEM HMO ANTHEM HMO 999999999 16.35 26.19 SUTR ETHIBOND #5 B409T 24/BX 49019913_1 CDM 0272 RC inpatient 27 17.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.35 26.19 SUTR ETHIBOND #5 B409T 24/BX 49019913_1 CDM 0272 RC inpatient 27 17.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.25 67.6 999999999 16.35 26.19 percent of total billed charges SUTR ETHIBOND #5 B409T 24/BX 49019913_1 CDM 0272 RC inpatient 27 17.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.35 26.19 SUTURE GUT CHROMIC 3-0 G122H 49019915_1 CDM 0272 RC inpatient 31 20.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.15 65 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 3-0 G122H 49019915_1 CDM 0272 RC inpatient 31 20.15 AETNA AETNA 24.49 79 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 3-0 G122H 49019915_1 CDM 0272 RC inpatient 31 20.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.07 97 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 3-0 G122H 49019915_1 CDM 0272 RC inpatient 31 20.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.39 69 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 3-0 G122H 49019915_1 CDM 0272 RC inpatient 31 20.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.18 78 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 3-0 G122H 49019915_1 CDM 0272 RC inpatient 31 20.15 SIHO - ALL PLANS SIHO - ALL PLANS 27.9 90 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 3-0 G122H 49019915_1 CDM 0272 RC inpatient 31 20.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.77 60.55 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 3-0 G122H 49019915_1 CDM 0272 RC inpatient 31 20.15 UMR - ALL PLANS UMR - ALL PLANS 21.7 70 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 3-0 G122H 49019915_1 CDM 0272 RC inpatient 31 20.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.77 30.07 SUTURE GUT CHROMIC 3-0 G122H 49019915_1 CDM 0272 RC inpatient 31 20.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.77 30.07 SUTURE GUT CHROMIC 3-0 G122H 49019915_1 CDM 0272 RC inpatient 31 20.15 ANTHEM HMO ANTHEM HMO 999999999 18.77 30.07 SUTURE GUT CHROMIC 3-0 G122H 49019915_1 CDM 0272 RC inpatient 31 20.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.77 30.07 SUTURE GUT CHROMIC 3-0 G122H 49019915_1 CDM 0272 RC inpatient 31 20.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.96 67.6 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 3-0 G122H 49019915_1 CDM 0272 RC inpatient 31 20.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.77 30.07 SUTURE GUT CHROMIC 4-0 G181H 49019917_1 CDM 0272 RC inpatient 31 20.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.15 65 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 4-0 G181H 49019917_1 CDM 0272 RC inpatient 31 20.15 AETNA AETNA 24.49 79 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 4-0 G181H 49019917_1 CDM 0272 RC inpatient 31 20.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.07 97 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 4-0 G181H 49019917_1 CDM 0272 RC inpatient 31 20.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.39 69 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 4-0 G181H 49019917_1 CDM 0272 RC inpatient 31 20.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.18 78 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 4-0 G181H 49019917_1 CDM 0272 RC inpatient 31 20.15 SIHO - ALL PLANS SIHO - ALL PLANS 27.9 90 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 4-0 G181H 49019917_1 CDM 0272 RC inpatient 31 20.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.77 60.55 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 4-0 G181H 49019917_1 CDM 0272 RC inpatient 31 20.15 UMR - ALL PLANS UMR - ALL PLANS 21.7 70 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 4-0 G181H 49019917_1 CDM 0272 RC inpatient 31 20.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.77 30.07 SUTURE GUT CHROMIC 4-0 G181H 49019917_1 CDM 0272 RC inpatient 31 20.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.77 30.07 SUTURE GUT CHROMIC 4-0 G181H 49019917_1 CDM 0272 RC inpatient 31 20.15 ANTHEM HMO ANTHEM HMO 999999999 18.77 30.07 SUTURE GUT CHROMIC 4-0 G181H 49019917_1 CDM 0272 RC inpatient 31 20.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.77 30.07 SUTURE GUT CHROMIC 4-0 G181H 49019917_1 CDM 0272 RC inpatient 31 20.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.96 67.6 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 4-0 G181H 49019917_1 CDM 0272 RC inpatient 31 20.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.77 30.07 SUTURE GUT CHROMIC 4-0 U203H 49019918_1 CDM 0272 RC inpatient 33 21.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.45 65 999999999 19.98 32.01 percent of total billed charges SUTURE GUT CHROMIC 4-0 U203H 49019918_1 CDM 0272 RC inpatient 33 21.45 AETNA AETNA 26.07 79 999999999 19.98 32.01 percent of total billed charges SUTURE GUT CHROMIC 4-0 U203H 49019918_1 CDM 0272 RC inpatient 33 21.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.01 97 999999999 19.98 32.01 percent of total billed charges SUTURE GUT CHROMIC 4-0 U203H 49019918_1 CDM 0272 RC inpatient 33 21.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.77 69 999999999 19.98 32.01 percent of total billed charges SUTURE GUT CHROMIC 4-0 U203H 49019918_1 CDM 0272 RC inpatient 33 21.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.74 78 999999999 19.98 32.01 percent of total billed charges SUTURE GUT CHROMIC 4-0 U203H 49019918_1 CDM 0272 RC inpatient 33 21.45 SIHO - ALL PLANS SIHO - ALL PLANS 29.7 90 999999999 19.98 32.01 percent of total billed charges SUTURE GUT CHROMIC 4-0 U203H 49019918_1 CDM 0272 RC inpatient 33 21.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.98 60.55 999999999 19.98 32.01 percent of total billed charges SUTURE GUT CHROMIC 4-0 U203H 49019918_1 CDM 0272 RC inpatient 33 21.45 UMR - ALL PLANS UMR - ALL PLANS 23.1 70 999999999 19.98 32.01 percent of total billed charges SUTURE GUT CHROMIC 4-0 U203H 49019918_1 CDM 0272 RC inpatient 33 21.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.98 32.01 SUTURE GUT CHROMIC 4-0 U203H 49019918_1 CDM 0272 RC inpatient 33 21.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.98 32.01 SUTURE GUT CHROMIC 4-0 U203H 49019918_1 CDM 0272 RC inpatient 33 21.45 ANTHEM HMO ANTHEM HMO 999999999 19.98 32.01 SUTURE GUT CHROMIC 4-0 U203H 49019918_1 CDM 0272 RC inpatient 33 21.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.98 32.01 SUTURE GUT CHROMIC 4-0 U203H 49019918_1 CDM 0272 RC inpatient 33 21.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.31 67.6 999999999 19.98 32.01 percent of total billed charges SUTURE GUT CHROMIC 4-0 U203H 49019918_1 CDM 0272 RC inpatient 33 21.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.98 32.01 SUTURE PLAIN GUT 2-0 843H 49019922_1 CDM 0272 RC inpatient 29 18.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 18.85 65 999999999 17.56 28.13 percent of total billed charges SUTURE PLAIN GUT 2-0 843H 49019922_1 CDM 0272 RC inpatient 29 18.85 AETNA AETNA 22.91 79 999999999 17.56 28.13 percent of total billed charges SUTURE PLAIN GUT 2-0 843H 49019922_1 CDM 0272 RC inpatient 29 18.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 28.13 97 999999999 17.56 28.13 percent of total billed charges SUTURE PLAIN GUT 2-0 843H 49019922_1 CDM 0272 RC inpatient 29 18.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.01 69 999999999 17.56 28.13 percent of total billed charges SUTURE PLAIN GUT 2-0 843H 49019922_1 CDM 0272 RC inpatient 29 18.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 22.62 78 999999999 17.56 28.13 percent of total billed charges SUTURE PLAIN GUT 2-0 843H 49019922_1 CDM 0272 RC inpatient 29 18.85 SIHO - ALL PLANS SIHO - ALL PLANS 26.1 90 999999999 17.56 28.13 percent of total billed charges SUTURE PLAIN GUT 2-0 843H 49019922_1 CDM 0272 RC inpatient 29 18.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17.56 60.55 999999999 17.56 28.13 percent of total billed charges SUTURE PLAIN GUT 2-0 843H 49019922_1 CDM 0272 RC inpatient 29 18.85 UMR - ALL PLANS UMR - ALL PLANS 20.3 70 999999999 17.56 28.13 percent of total billed charges SUTURE PLAIN GUT 2-0 843H 49019922_1 CDM 0272 RC inpatient 29 18.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 17.56 28.13 SUTURE PLAIN GUT 2-0 843H 49019922_1 CDM 0272 RC inpatient 29 18.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 17.56 28.13 SUTURE PLAIN GUT 2-0 843H 49019922_1 CDM 0272 RC inpatient 29 18.85 ANTHEM HMO ANTHEM HMO 999999999 17.56 28.13 SUTURE PLAIN GUT 2-0 843H 49019922_1 CDM 0272 RC inpatient 29 18.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 17.56 28.13 SUTURE PLAIN GUT 2-0 843H 49019922_1 CDM 0272 RC inpatient 29 18.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 19.6 67.6 999999999 17.56 28.13 percent of total billed charges SUTURE PLAIN GUT 2-0 843H 49019922_1 CDM 0272 RC inpatient 29 18.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 17.56 28.13 SUTURE SILK 3-0 K832H GI 49019923_1 CDM 0272 RC inpatient 8 5.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.2 65 999999999 4.84 7.76 percent of total billed charges SUTURE SILK 3-0 K832H GI 49019923_1 CDM 0272 RC inpatient 8 5.2 AETNA AETNA 6.32 79 999999999 4.84 7.76 percent of total billed charges SUTURE SILK 3-0 K832H GI 49019923_1 CDM 0272 RC inpatient 8 5.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7.76 97 999999999 4.84 7.76 percent of total billed charges SUTURE SILK 3-0 K832H GI 49019923_1 CDM 0272 RC inpatient 8 5.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.52 69 999999999 4.84 7.76 percent of total billed charges SUTURE SILK 3-0 K832H GI 49019923_1 CDM 0272 RC inpatient 8 5.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.24 78 999999999 4.84 7.76 percent of total billed charges SUTURE SILK 3-0 K832H GI 49019923_1 CDM 0272 RC inpatient 8 5.2 SIHO - ALL PLANS SIHO - ALL PLANS 7.2 90 999999999 4.84 7.76 percent of total billed charges SUTURE SILK 3-0 K832H GI 49019923_1 CDM 0272 RC inpatient 8 5.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.84 60.55 999999999 4.84 7.76 percent of total billed charges SUTURE SILK 3-0 K832H GI 49019923_1 CDM 0272 RC inpatient 8 5.2 UMR - ALL PLANS UMR - ALL PLANS 5.6 70 999999999 4.84 7.76 percent of total billed charges SUTURE SILK 3-0 K832H GI 49019923_1 CDM 0272 RC inpatient 8 5.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.84 7.76 SUTURE SILK 3-0 K832H GI 49019923_1 CDM 0272 RC inpatient 8 5.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.84 7.76 SUTURE SILK 3-0 K832H GI 49019923_1 CDM 0272 RC inpatient 8 5.2 ANTHEM HMO ANTHEM HMO 999999999 4.84 7.76 SUTURE SILK 3-0 K832H GI 49019923_1 CDM 0272 RC inpatient 8 5.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.84 7.76 SUTURE SILK 3-0 K832H GI 49019923_1 CDM 0272 RC inpatient 8 5.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.41 67.6 999999999 4.84 7.76 percent of total billed charges SUTURE SILK 3-0 K832H GI 49019923_1 CDM 0272 RC inpatient 8 5.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.84 7.76 SUTURE SILK 2-0 K833H GI 49019924_1 CDM 0272 RC inpatient 13 8.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.45 65 999999999 7.87 12.61 percent of total billed charges SUTURE SILK 2-0 K833H GI 49019924_1 CDM 0272 RC inpatient 13 8.45 AETNA AETNA 10.27 79 999999999 7.87 12.61 percent of total billed charges SUTURE SILK 2-0 K833H GI 49019924_1 CDM 0272 RC inpatient 13 8.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.61 97 999999999 7.87 12.61 percent of total billed charges SUTURE SILK 2-0 K833H GI 49019924_1 CDM 0272 RC inpatient 13 8.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.97 69 999999999 7.87 12.61 percent of total billed charges SUTURE SILK 2-0 K833H GI 49019924_1 CDM 0272 RC inpatient 13 8.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.14 78 999999999 7.87 12.61 percent of total billed charges SUTURE SILK 2-0 K833H GI 49019924_1 CDM 0272 RC inpatient 13 8.45 SIHO - ALL PLANS SIHO - ALL PLANS 11.7 90 999999999 7.87 12.61 percent of total billed charges SUTURE SILK 2-0 K833H GI 49019924_1 CDM 0272 RC inpatient 13 8.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.87 60.55 999999999 7.87 12.61 percent of total billed charges SUTURE SILK 2-0 K833H GI 49019924_1 CDM 0272 RC inpatient 13 8.45 UMR - ALL PLANS UMR - ALL PLANS 9.1 70 999999999 7.87 12.61 percent of total billed charges SUTURE SILK 2-0 K833H GI 49019924_1 CDM 0272 RC inpatient 13 8.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.87 12.61 SUTURE SILK 2-0 K833H GI 49019924_1 CDM 0272 RC inpatient 13 8.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.87 12.61 SUTURE SILK 2-0 K833H GI 49019924_1 CDM 0272 RC inpatient 13 8.45 ANTHEM HMO ANTHEM HMO 999999999 7.87 12.61 SUTURE SILK 2-0 K833H GI 49019924_1 CDM 0272 RC inpatient 13 8.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.87 12.61 SUTURE SILK 2-0 K833H GI 49019924_1 CDM 0272 RC inpatient 13 8.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.79 67.6 999999999 7.87 12.61 percent of total billed charges SUTURE SILK 2-0 K833H GI 49019924_1 CDM 0272 RC inpatient 13 8.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.87 12.61 SUTR MONOCRYL 3-0 Y936H 36/BX 49019931_1 CDM 0272 RC inpatient 61 39.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.65 65 999999999 36.94 59.17 percent of total billed charges SUTR MONOCRYL 3-0 Y936H 36/BX 49019931_1 CDM 0272 RC inpatient 61 39.65 AETNA AETNA 48.19 79 999999999 36.94 59.17 percent of total billed charges SUTR MONOCRYL 3-0 Y936H 36/BX 49019931_1 CDM 0272 RC inpatient 61 39.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59.17 97 999999999 36.94 59.17 percent of total billed charges SUTR MONOCRYL 3-0 Y936H 36/BX 49019931_1 CDM 0272 RC inpatient 61 39.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.09 69 999999999 36.94 59.17 percent of total billed charges SUTR MONOCRYL 3-0 Y936H 36/BX 49019931_1 CDM 0272 RC inpatient 61 39.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.58 78 999999999 36.94 59.17 percent of total billed charges SUTR MONOCRYL 3-0 Y936H 36/BX 49019931_1 CDM 0272 RC inpatient 61 39.65 SIHO - ALL PLANS SIHO - ALL PLANS 54.9 90 999999999 36.94 59.17 percent of total billed charges SUTR MONOCRYL 3-0 Y936H 36/BX 49019931_1 CDM 0272 RC inpatient 61 39.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.94 60.55 999999999 36.94 59.17 percent of total billed charges SUTR MONOCRYL 3-0 Y936H 36/BX 49019931_1 CDM 0272 RC inpatient 61 39.65 UMR - ALL PLANS UMR - ALL PLANS 42.7 70 999999999 36.94 59.17 percent of total billed charges SUTR MONOCRYL 3-0 Y936H 36/BX 49019931_1 CDM 0272 RC inpatient 61 39.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.94 59.17 SUTR MONOCRYL 3-0 Y936H 36/BX 49019931_1 CDM 0272 RC inpatient 61 39.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.94 59.17 SUTR MONOCRYL 3-0 Y936H 36/BX 49019931_1 CDM 0272 RC inpatient 61 39.65 ANTHEM HMO ANTHEM HMO 999999999 36.94 59.17 SUTR MONOCRYL 3-0 Y936H 36/BX 49019931_1 CDM 0272 RC inpatient 61 39.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.94 59.17 SUTR MONOCRYL 3-0 Y936H 36/BX 49019931_1 CDM 0272 RC inpatient 61 39.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.24 67.6 999999999 36.94 59.17 percent of total billed charges SUTR MONOCRYL 3-0 Y936H 36/BX 49019931_1 CDM 0272 RC inpatient 61 39.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.94 59.17 SUT MONOCRYL 0 Y946H 36/BX 49019933_1 CDM 0272 RC inpatient 22 14.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.3 65 999999999 13.32 21.34 percent of total billed charges SUT MONOCRYL 0 Y946H 36/BX 49019933_1 CDM 0272 RC inpatient 22 14.3 AETNA AETNA 17.38 79 999999999 13.32 21.34 percent of total billed charges SUT MONOCRYL 0 Y946H 36/BX 49019933_1 CDM 0272 RC inpatient 22 14.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21.34 97 999999999 13.32 21.34 percent of total billed charges SUT MONOCRYL 0 Y946H 36/BX 49019933_1 CDM 0272 RC inpatient 22 14.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.18 69 999999999 13.32 21.34 percent of total billed charges SUT MONOCRYL 0 Y946H 36/BX 49019933_1 CDM 0272 RC inpatient 22 14.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.16 78 999999999 13.32 21.34 percent of total billed charges SUT MONOCRYL 0 Y946H 36/BX 49019933_1 CDM 0272 RC inpatient 22 14.3 SIHO - ALL PLANS SIHO - ALL PLANS 19.8 90 999999999 13.32 21.34 percent of total billed charges SUT MONOCRYL 0 Y946H 36/BX 49019933_1 CDM 0272 RC inpatient 22 14.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.32 60.55 999999999 13.32 21.34 percent of total billed charges SUT MONOCRYL 0 Y946H 36/BX 49019933_1 CDM 0272 RC inpatient 22 14.3 UMR - ALL PLANS UMR - ALL PLANS 15.4 70 999999999 13.32 21.34 percent of total billed charges SUT MONOCRYL 0 Y946H 36/BX 49019933_1 CDM 0272 RC inpatient 22 14.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.32 21.34 SUT MONOCRYL 0 Y946H 36/BX 49019933_1 CDM 0272 RC inpatient 22 14.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.32 21.34 SUT MONOCRYL 0 Y946H 36/BX 49019933_1 CDM 0272 RC inpatient 22 14.3 ANTHEM HMO ANTHEM HMO 999999999 13.32 21.34 SUT MONOCRYL 0 Y946H 36/BX 49019933_1 CDM 0272 RC inpatient 22 14.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.32 21.34 SUT MONOCRYL 0 Y946H 36/BX 49019933_1 CDM 0272 RC inpatient 22 14.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.87 67.6 999999999 13.32 21.34 percent of total billed charges SUT MONOCRYL 0 Y946H 36/BX 49019933_1 CDM 0272 RC inpatient 22 14.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.32 21.34 SUTR MONOCRYL 4-0 Y426H 36/BX 49019934_1 CDM 0272 RC inpatient 58 37.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.7 65 999999999 35.12 56.26 percent of total billed charges SUTR MONOCRYL 4-0 Y426H 36/BX 49019934_1 CDM 0272 RC inpatient 58 37.7 AETNA AETNA 45.82 79 999999999 35.12 56.26 percent of total billed charges SUTR MONOCRYL 4-0 Y426H 36/BX 49019934_1 CDM 0272 RC inpatient 58 37.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.26 97 999999999 35.12 56.26 percent of total billed charges SUTR MONOCRYL 4-0 Y426H 36/BX 49019934_1 CDM 0272 RC inpatient 58 37.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.02 69 999999999 35.12 56.26 percent of total billed charges SUTR MONOCRYL 4-0 Y426H 36/BX 49019934_1 CDM 0272 RC inpatient 58 37.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.24 78 999999999 35.12 56.26 percent of total billed charges SUTR MONOCRYL 4-0 Y426H 36/BX 49019934_1 CDM 0272 RC inpatient 58 37.7 SIHO - ALL PLANS SIHO - ALL PLANS 52.2 90 999999999 35.12 56.26 percent of total billed charges SUTR MONOCRYL 4-0 Y426H 36/BX 49019934_1 CDM 0272 RC inpatient 58 37.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.12 60.55 999999999 35.12 56.26 percent of total billed charges SUTR MONOCRYL 4-0 Y426H 36/BX 49019934_1 CDM 0272 RC inpatient 58 37.7 UMR - ALL PLANS UMR - ALL PLANS 40.6 70 999999999 35.12 56.26 percent of total billed charges SUTR MONOCRYL 4-0 Y426H 36/BX 49019934_1 CDM 0272 RC inpatient 58 37.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.12 56.26 SUTR MONOCRYL 4-0 Y426H 36/BX 49019934_1 CDM 0272 RC inpatient 58 37.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.12 56.26 SUTR MONOCRYL 4-0 Y426H 36/BX 49019934_1 CDM 0272 RC inpatient 58 37.7 ANTHEM HMO ANTHEM HMO 999999999 35.12 56.26 SUTR MONOCRYL 4-0 Y426H 36/BX 49019934_1 CDM 0272 RC inpatient 58 37.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.12 56.26 SUTR MONOCRYL 4-0 Y426H 36/BX 49019934_1 CDM 0272 RC inpatient 58 37.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.21 67.6 999999999 35.12 56.26 percent of total billed charges SUTR MONOCRYL 4-0 Y426H 36/BX 49019934_1 CDM 0272 RC inpatient 58 37.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.12 56.26 SUTURE GUT PL 4-0 1828H 49019935_1 CDM 0272 RC inpatient 60 39 SELF PAY DISCOUNT SELF PAY DISCOUNT 39 65 999999999 36.33 58.2 percent of total billed charges SUTURE GUT PL 4-0 1828H 49019935_1 CDM 0272 RC inpatient 60 39 AETNA AETNA 47.4 79 999999999 36.33 58.2 percent of total billed charges SUTURE GUT PL 4-0 1828H 49019935_1 CDM 0272 RC inpatient 60 39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.2 97 999999999 36.33 58.2 percent of total billed charges SUTURE GUT PL 4-0 1828H 49019935_1 CDM 0272 RC inpatient 60 39 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.4 69 999999999 36.33 58.2 percent of total billed charges SUTURE GUT PL 4-0 1828H 49019935_1 CDM 0272 RC inpatient 60 39 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.8 78 999999999 36.33 58.2 percent of total billed charges SUTURE GUT PL 4-0 1828H 49019935_1 CDM 0272 RC inpatient 60 39 SIHO - ALL PLANS SIHO - ALL PLANS 54 90 999999999 36.33 58.2 percent of total billed charges SUTURE GUT PL 4-0 1828H 49019935_1 CDM 0272 RC inpatient 60 39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.33 60.55 999999999 36.33 58.2 percent of total billed charges SUTURE GUT PL 4-0 1828H 49019935_1 CDM 0272 RC inpatient 60 39 UMR - ALL PLANS UMR - ALL PLANS 42 70 999999999 36.33 58.2 percent of total billed charges SUTURE GUT PL 4-0 1828H 49019935_1 CDM 0272 RC inpatient 60 39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.33 58.2 SUTURE GUT PL 4-0 1828H 49019935_1 CDM 0272 RC inpatient 60 39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.33 58.2 SUTURE GUT PL 4-0 1828H 49019935_1 CDM 0272 RC inpatient 60 39 ANTHEM HMO ANTHEM HMO 999999999 36.33 58.2 SUTURE GUT PL 4-0 1828H 49019935_1 CDM 0272 RC inpatient 60 39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.33 58.2 SUTURE GUT PL 4-0 1828H 49019935_1 CDM 0272 RC inpatient 60 39 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.56 67.6 999999999 36.33 58.2 percent of total billed charges SUTURE GUT PL 4-0 1828H 49019935_1 CDM 0272 RC inpatient 60 39 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.33 58.2 RETENTION GUARD 49019936_1 CDM 0272 RC inpatient 89 57.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.85 65 999999999 53.89 86.33 percent of total billed charges RETENTION GUARD 49019936_1 CDM 0272 RC inpatient 89 57.85 AETNA AETNA 70.31 79 999999999 53.89 86.33 percent of total billed charges RETENTION GUARD 49019936_1 CDM 0272 RC inpatient 89 57.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 86.33 97 999999999 53.89 86.33 percent of total billed charges RETENTION GUARD 49019936_1 CDM 0272 RC inpatient 89 57.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 61.41 69 999999999 53.89 86.33 percent of total billed charges RETENTION GUARD 49019936_1 CDM 0272 RC inpatient 89 57.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 69.42 78 999999999 53.89 86.33 percent of total billed charges RETENTION GUARD 49019936_1 CDM 0272 RC inpatient 89 57.85 SIHO - ALL PLANS SIHO - ALL PLANS 80.1 90 999999999 53.89 86.33 percent of total billed charges RETENTION GUARD 49019936_1 CDM 0272 RC inpatient 89 57.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.89 60.55 999999999 53.89 86.33 percent of total billed charges RETENTION GUARD 49019936_1 CDM 0272 RC inpatient 89 57.85 UMR - ALL PLANS UMR - ALL PLANS 62.3 70 999999999 53.89 86.33 percent of total billed charges RETENTION GUARD 49019936_1 CDM 0272 RC inpatient 89 57.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.89 86.33 RETENTION GUARD 49019936_1 CDM 0272 RC inpatient 89 57.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.89 86.33 RETENTION GUARD 49019936_1 CDM 0272 RC inpatient 89 57.85 ANTHEM HMO ANTHEM HMO 999999999 53.89 86.33 RETENTION GUARD 49019936_1 CDM 0272 RC inpatient 89 57.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.89 86.33 RETENTION GUARD 49019936_1 CDM 0272 RC inpatient 89 57.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.16 67.6 999999999 53.89 86.33 percent of total billed charges RETENTION GUARD 49019936_1 CDM 0272 RC inpatient 89 57.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.89 86.33 SUTURE GUT CHROMIC #0 S114H 49019939_1 CDM 0272 RC inpatient 18 11.7 AETNA AETNA 14.22 79 999999999 10.9 17.46 percent of total billed charges SUTURE GUT CHROMIC #0 S114H 49019939_1 CDM 0272 RC inpatient 18 11.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.7 65 999999999 10.9 17.46 percent of total billed charges SUTURE GUT CHROMIC #0 S114H 49019939_1 CDM 0272 RC inpatient 18 11.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.46 97 999999999 10.9 17.46 percent of total billed charges SUTURE GUT CHROMIC #0 S114H 49019939_1 CDM 0272 RC inpatient 18 11.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.42 69 999999999 10.9 17.46 percent of total billed charges SUTURE GUT CHROMIC #0 S114H 49019939_1 CDM 0272 RC inpatient 18 11.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.04 78 999999999 10.9 17.46 percent of total billed charges SUTURE GUT CHROMIC #0 S114H 49019939_1 CDM 0272 RC inpatient 18 11.7 SIHO - ALL PLANS SIHO - ALL PLANS 16.2 90 999999999 10.9 17.46 percent of total billed charges SUTURE GUT CHROMIC #0 S114H 49019939_1 CDM 0272 RC inpatient 18 11.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.9 60.55 999999999 10.9 17.46 percent of total billed charges SUTURE GUT CHROMIC #0 S114H 49019939_1 CDM 0272 RC inpatient 18 11.7 UMR - ALL PLANS UMR - ALL PLANS 12.6 70 999999999 10.9 17.46 percent of total billed charges SUTURE GUT CHROMIC #0 S114H 49019939_1 CDM 0272 RC inpatient 18 11.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.9 17.46 SUTURE GUT CHROMIC #0 S114H 49019939_1 CDM 0272 RC inpatient 18 11.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.9 17.46 SUTURE GUT CHROMIC #0 S114H 49019939_1 CDM 0272 RC inpatient 18 11.7 ANTHEM HMO ANTHEM HMO 999999999 10.9 17.46 SUTURE GUT CHROMIC #0 S114H 49019939_1 CDM 0272 RC inpatient 18 11.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.9 17.46 SUTURE GUT CHROMIC #0 S114H 49019939_1 CDM 0272 RC inpatient 18 11.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.17 67.6 999999999 10.9 17.46 percent of total billed charges SUTURE GUT CHROMIC #0 S114H 49019939_1 CDM 0272 RC inpatient 18 11.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.9 17.46 SUTURE SILK 2-0 SA85H SUTUPAK 49019940_1 CDM 0272 RC inpatient 14 9.1 AETNA AETNA 11.06 79 999999999 8.48 13.58 percent of total billed charges SUTURE SILK 2-0 SA85H SUTUPAK 49019940_1 CDM 0272 RC inpatient 14 9.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.1 65 999999999 8.48 13.58 percent of total billed charges SUTURE SILK 2-0 SA85H SUTUPAK 49019940_1 CDM 0272 RC inpatient 14 9.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13.58 97 999999999 8.48 13.58 percent of total billed charges SUTURE SILK 2-0 SA85H SUTUPAK 49019940_1 CDM 0272 RC inpatient 14 9.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.66 69 999999999 8.48 13.58 percent of total billed charges SUTURE SILK 2-0 SA85H SUTUPAK 49019940_1 CDM 0272 RC inpatient 14 9.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.92 78 999999999 8.48 13.58 percent of total billed charges SUTURE SILK 2-0 SA85H SUTUPAK 49019940_1 CDM 0272 RC inpatient 14 9.1 SIHO - ALL PLANS SIHO - ALL PLANS 12.6 90 999999999 8.48 13.58 percent of total billed charges SUTURE SILK 2-0 SA85H SUTUPAK 49019940_1 CDM 0272 RC inpatient 14 9.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.48 60.55 999999999 8.48 13.58 percent of total billed charges SUTURE SILK 2-0 SA85H SUTUPAK 49019940_1 CDM 0272 RC inpatient 14 9.1 UMR - ALL PLANS UMR - ALL PLANS 9.8 70 999999999 8.48 13.58 percent of total billed charges SUTURE SILK 2-0 SA85H SUTUPAK 49019940_1 CDM 0272 RC inpatient 14 9.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.48 13.58 SUTURE SILK 2-0 SA85H SUTUPAK 49019940_1 CDM 0272 RC inpatient 14 9.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.48 13.58 SUTURE SILK 2-0 SA85H SUTUPAK 49019940_1 CDM 0272 RC inpatient 14 9.1 ANTHEM HMO ANTHEM HMO 999999999 8.48 13.58 SUTURE SILK 2-0 SA85H SUTUPAK 49019940_1 CDM 0272 RC inpatient 14 9.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.48 13.58 SUTURE SILK 2-0 SA85H SUTUPAK 49019940_1 CDM 0272 RC inpatient 14 9.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.46 67.6 999999999 8.48 13.58 percent of total billed charges SUTURE SILK 2-0 SA85H SUTUPAK 49019940_1 CDM 0272 RC inpatient 14 9.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.48 13.58 SUTURE 0-SILK SURGUPAK SA86G 49019941_1 CDM 0272 RC inpatient 24 15.6 AETNA AETNA 18.96 79 999999999 14.53 23.28 percent of total billed charges SUTURE 0-SILK SURGUPAK SA86G 49019941_1 CDM 0272 RC inpatient 24 15.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 15.6 65 999999999 14.53 23.28 percent of total billed charges SUTURE 0-SILK SURGUPAK SA86G 49019941_1 CDM 0272 RC inpatient 24 15.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23.28 97 999999999 14.53 23.28 percent of total billed charges SUTURE 0-SILK SURGUPAK SA86G 49019941_1 CDM 0272 RC inpatient 24 15.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 16.56 69 999999999 14.53 23.28 percent of total billed charges SUTURE 0-SILK SURGUPAK SA86G 49019941_1 CDM 0272 RC inpatient 24 15.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 18.72 78 999999999 14.53 23.28 percent of total billed charges SUTURE 0-SILK SURGUPAK SA86G 49019941_1 CDM 0272 RC inpatient 24 15.6 SIHO - ALL PLANS SIHO - ALL PLANS 21.6 90 999999999 14.53 23.28 percent of total billed charges SUTURE 0-SILK SURGUPAK SA86G 49019941_1 CDM 0272 RC inpatient 24 15.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.53 60.55 999999999 14.53 23.28 percent of total billed charges SUTURE 0-SILK SURGUPAK SA86G 49019941_1 CDM 0272 RC inpatient 24 15.6 UMR - ALL PLANS UMR - ALL PLANS 16.8 70 999999999 14.53 23.28 percent of total billed charges SUTURE 0-SILK SURGUPAK SA86G 49019941_1 CDM 0272 RC inpatient 24 15.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.53 23.28 SUTURE 0-SILK SURGUPAK SA86G 49019941_1 CDM 0272 RC inpatient 24 15.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.53 23.28 SUTURE 0-SILK SURGUPAK SA86G 49019941_1 CDM 0272 RC inpatient 24 15.6 ANTHEM HMO ANTHEM HMO 999999999 14.53 23.28 SUTURE 0-SILK SURGUPAK SA86G 49019941_1 CDM 0272 RC inpatient 24 15.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.53 23.28 SUTURE 0-SILK SURGUPAK SA86G 49019941_1 CDM 0272 RC inpatient 24 15.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.22 67.6 999999999 14.53 23.28 percent of total billed charges SUTURE 0-SILK SURGUPAK SA86G 49019941_1 CDM 0272 RC inpatient 24 15.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.53 23.28 SUTURE UMBILICAL TAPE COTTON 49019942_1 CDM 0272 RC inpatient 14 9.1 AETNA AETNA 11.06 79 999999999 8.48 13.58 percent of total billed charges SUTURE UMBILICAL TAPE COTTON 49019942_1 CDM 0272 RC inpatient 14 9.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.1 65 999999999 8.48 13.58 percent of total billed charges SUTURE UMBILICAL TAPE COTTON 49019942_1 CDM 0272 RC inpatient 14 9.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13.58 97 999999999 8.48 13.58 percent of total billed charges SUTURE UMBILICAL TAPE COTTON 49019942_1 CDM 0272 RC inpatient 14 9.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.66 69 999999999 8.48 13.58 percent of total billed charges SUTURE UMBILICAL TAPE COTTON 49019942_1 CDM 0272 RC inpatient 14 9.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.92 78 999999999 8.48 13.58 percent of total billed charges SUTURE UMBILICAL TAPE COTTON 49019942_1 CDM 0272 RC inpatient 14 9.1 SIHO - ALL PLANS SIHO - ALL PLANS 12.6 90 999999999 8.48 13.58 percent of total billed charges SUTURE UMBILICAL TAPE COTTON 49019942_1 CDM 0272 RC inpatient 14 9.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.48 60.55 999999999 8.48 13.58 percent of total billed charges SUTURE UMBILICAL TAPE COTTON 49019942_1 CDM 0272 RC inpatient 14 9.1 UMR - ALL PLANS UMR - ALL PLANS 9.8 70 999999999 8.48 13.58 percent of total billed charges SUTURE UMBILICAL TAPE COTTON 49019942_1 CDM 0272 RC inpatient 14 9.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.48 13.58 SUTURE UMBILICAL TAPE COTTON 49019942_1 CDM 0272 RC inpatient 14 9.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.48 13.58 SUTURE UMBILICAL TAPE COTTON 49019942_1 CDM 0272 RC inpatient 14 9.1 ANTHEM HMO ANTHEM HMO 999999999 8.48 13.58 SUTURE UMBILICAL TAPE COTTON 49019942_1 CDM 0272 RC inpatient 14 9.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.48 13.58 SUTURE UMBILICAL TAPE COTTON 49019942_1 CDM 0272 RC inpatient 14 9.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.46 67.6 999999999 8.48 13.58 percent of total billed charges SUTURE UMBILICAL TAPE COTTON 49019942_1 CDM 0272 RC inpatient 14 9.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.48 13.58 SUTURE 0 VICRYL J946H 49019944_1 CDM 0272 RC inpatient 16 10.4 AETNA AETNA 12.64 79 999999999 9.69 15.52 percent of total billed charges SUTURE 0 VICRYL J946H 49019944_1 CDM 0272 RC inpatient 16 10.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.4 65 999999999 9.69 15.52 percent of total billed charges SUTURE 0 VICRYL J946H 49019944_1 CDM 0272 RC inpatient 16 10.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15.52 97 999999999 9.69 15.52 percent of total billed charges SUTURE 0 VICRYL J946H 49019944_1 CDM 0272 RC inpatient 16 10.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.04 69 999999999 9.69 15.52 percent of total billed charges SUTURE 0 VICRYL J946H 49019944_1 CDM 0272 RC inpatient 16 10.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.48 78 999999999 9.69 15.52 percent of total billed charges SUTURE 0 VICRYL J946H 49019944_1 CDM 0272 RC inpatient 16 10.4 SIHO - ALL PLANS SIHO - ALL PLANS 14.4 90 999999999 9.69 15.52 percent of total billed charges SUTURE 0 VICRYL J946H 49019944_1 CDM 0272 RC inpatient 16 10.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.69 60.55 999999999 9.69 15.52 percent of total billed charges SUTURE 0 VICRYL J946H 49019944_1 CDM 0272 RC inpatient 16 10.4 UMR - ALL PLANS UMR - ALL PLANS 11.2 70 999999999 9.69 15.52 percent of total billed charges SUTURE 0 VICRYL J946H 49019944_1 CDM 0272 RC inpatient 16 10.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.69 15.52 SUTURE 0 VICRYL J946H 49019944_1 CDM 0272 RC inpatient 16 10.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.69 15.52 SUTURE 0 VICRYL J946H 49019944_1 CDM 0272 RC inpatient 16 10.4 ANTHEM HMO ANTHEM HMO 999999999 9.69 15.52 SUTURE 0 VICRYL J946H 49019944_1 CDM 0272 RC inpatient 16 10.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.69 15.52 SUTURE 0 VICRYL J946H 49019944_1 CDM 0272 RC inpatient 16 10.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.82 67.6 999999999 9.69 15.52 percent of total billed charges SUTURE 0 VICRYL J946H 49019944_1 CDM 0272 RC inpatient 16 10.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.69 15.52 SUTURE 2-0 SH COATED J317H 49019945_1 CDM 0272 RC inpatient 15 9.75 AETNA AETNA 11.85 79 999999999 9.08 14.55 percent of total billed charges SUTURE 2-0 SH COATED J317H 49019945_1 CDM 0272 RC inpatient 15 9.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.75 65 999999999 9.08 14.55 percent of total billed charges SUTURE 2-0 SH COATED J317H 49019945_1 CDM 0272 RC inpatient 15 9.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14.55 97 999999999 9.08 14.55 percent of total billed charges SUTURE 2-0 SH COATED J317H 49019945_1 CDM 0272 RC inpatient 15 9.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.35 69 999999999 9.08 14.55 percent of total billed charges SUTURE 2-0 SH COATED J317H 49019945_1 CDM 0272 RC inpatient 15 9.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.7 78 999999999 9.08 14.55 percent of total billed charges SUTURE 2-0 SH COATED J317H 49019945_1 CDM 0272 RC inpatient 15 9.75 SIHO - ALL PLANS SIHO - ALL PLANS 13.5 90 999999999 9.08 14.55 percent of total billed charges SUTURE 2-0 SH COATED J317H 49019945_1 CDM 0272 RC inpatient 15 9.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.08 60.55 999999999 9.08 14.55 percent of total billed charges SUTURE 2-0 SH COATED J317H 49019945_1 CDM 0272 RC inpatient 15 9.75 UMR - ALL PLANS UMR - ALL PLANS 10.5 70 999999999 9.08 14.55 percent of total billed charges SUTURE 2-0 SH COATED J317H 49019945_1 CDM 0272 RC inpatient 15 9.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.08 14.55 SUTURE 2-0 SH COATED J317H 49019945_1 CDM 0272 RC inpatient 15 9.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.08 14.55 SUTURE 2-0 SH COATED J317H 49019945_1 CDM 0272 RC inpatient 15 9.75 ANTHEM HMO ANTHEM HMO 999999999 9.08 14.55 SUTURE 2-0 SH COATED J317H 49019945_1 CDM 0272 RC inpatient 15 9.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.08 14.55 SUTURE 2-0 SH COATED J317H 49019945_1 CDM 0272 RC inpatient 15 9.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.14 67.6 999999999 9.08 14.55 percent of total billed charges SUTURE 2-0 SH COATED J317H 49019945_1 CDM 0272 RC inpatient 15 9.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.08 14.55 SUTURE 1 OS-6 COATED J535h 49019946_1 CDM 0272 RC inpatient 6 3.9 AETNA AETNA 4.74 79 999999999 3.63 5.82 percent of total billed charges SUTURE 1 OS-6 COATED J535h 49019946_1 CDM 0272 RC inpatient 6 3.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.9 65 999999999 3.63 5.82 percent of total billed charges SUTURE 1 OS-6 COATED J535h 49019946_1 CDM 0272 RC inpatient 6 3.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.82 97 999999999 3.63 5.82 percent of total billed charges SUTURE 1 OS-6 COATED J535h 49019946_1 CDM 0272 RC inpatient 6 3.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.14 69 999999999 3.63 5.82 percent of total billed charges SUTURE 1 OS-6 COATED J535h 49019946_1 CDM 0272 RC inpatient 6 3.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.68 78 999999999 3.63 5.82 percent of total billed charges SUTURE 1 OS-6 COATED J535h 49019946_1 CDM 0272 RC inpatient 6 3.9 SIHO - ALL PLANS SIHO - ALL PLANS 5.4 90 999999999 3.63 5.82 percent of total billed charges SUTURE 1 OS-6 COATED J535h 49019946_1 CDM 0272 RC inpatient 6 3.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.63 60.55 999999999 3.63 5.82 percent of total billed charges SUTURE 1 OS-6 COATED J535h 49019946_1 CDM 0272 RC inpatient 6 3.9 UMR - ALL PLANS UMR - ALL PLANS 4.2 70 999999999 3.63 5.82 percent of total billed charges SUTURE 1 OS-6 COATED J535h 49019946_1 CDM 0272 RC inpatient 6 3.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.63 5.82 SUTURE 1 OS-6 COATED J535h 49019946_1 CDM 0272 RC inpatient 6 3.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.63 5.82 SUTURE 1 OS-6 COATED J535h 49019946_1 CDM 0272 RC inpatient 6 3.9 ANTHEM HMO ANTHEM HMO 999999999 3.63 5.82 SUTURE 1 OS-6 COATED J535h 49019946_1 CDM 0272 RC inpatient 6 3.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.63 5.82 SUTURE 1 OS-6 COATED J535h 49019946_1 CDM 0272 RC inpatient 6 3.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.06 67.6 999999999 3.63 5.82 percent of total billed charges SUTURE 1 OS-6 COATED J535h 49019946_1 CDM 0272 RC inpatient 6 3.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.63 5.82 SUTURE 1 OS-4 COATED J695H 49019947_1 CDM 0272 RC inpatient 25 16.25 AETNA AETNA 19.75 79 999999999 15.14 24.25 percent of total billed charges SUTURE 1 OS-4 COATED J695H 49019947_1 CDM 0272 RC inpatient 25 16.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.25 65 999999999 15.14 24.25 percent of total billed charges SUTURE 1 OS-4 COATED J695H 49019947_1 CDM 0272 RC inpatient 25 16.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.25 97 999999999 15.14 24.25 percent of total billed charges SUTURE 1 OS-4 COATED J695H 49019947_1 CDM 0272 RC inpatient 25 16.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.25 69 999999999 15.14 24.25 percent of total billed charges SUTURE 1 OS-4 COATED J695H 49019947_1 CDM 0272 RC inpatient 25 16.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.5 78 999999999 15.14 24.25 percent of total billed charges SUTURE 1 OS-4 COATED J695H 49019947_1 CDM 0272 RC inpatient 25 16.25 SIHO - ALL PLANS SIHO - ALL PLANS 22.5 90 999999999 15.14 24.25 percent of total billed charges SUTURE 1 OS-4 COATED J695H 49019947_1 CDM 0272 RC inpatient 25 16.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.14 60.55 999999999 15.14 24.25 percent of total billed charges SUTURE 1 OS-4 COATED J695H 49019947_1 CDM 0272 RC inpatient 25 16.25 UMR - ALL PLANS UMR - ALL PLANS 17.5 70 999999999 15.14 24.25 percent of total billed charges SUTURE 1 OS-4 COATED J695H 49019947_1 CDM 0272 RC inpatient 25 16.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.14 24.25 SUTURE 1 OS-4 COATED J695H 49019947_1 CDM 0272 RC inpatient 25 16.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.14 24.25 SUTURE 1 OS-4 COATED J695H 49019947_1 CDM 0272 RC inpatient 25 16.25 ANTHEM HMO ANTHEM HMO 999999999 15.14 24.25 SUTURE 1 OS-4 COATED J695H 49019947_1 CDM 0272 RC inpatient 25 16.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.14 24.25 SUTURE 1 OS-4 COATED J695H 49019947_1 CDM 0272 RC inpatient 25 16.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.9 67.6 999999999 15.14 24.25 percent of total billed charges SUTURE 1 OS-4 COATED J695H 49019947_1 CDM 0272 RC inpatient 25 16.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.14 24.25 SUTURE VICRYL 3-0 J205G 49019949_1 CDM 0272 RC inpatient 21 13.65 AETNA AETNA 16.59 79 999999999 12.72 20.37 percent of total billed charges SUTURE VICRYL 3-0 J205G 49019949_1 CDM 0272 RC inpatient 21 13.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 13.65 65 999999999 12.72 20.37 percent of total billed charges SUTURE VICRYL 3-0 J205G 49019949_1 CDM 0272 RC inpatient 21 13.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20.37 97 999999999 12.72 20.37 percent of total billed charges SUTURE VICRYL 3-0 J205G 49019949_1 CDM 0272 RC inpatient 21 13.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 14.49 69 999999999 12.72 20.37 percent of total billed charges SUTURE VICRYL 3-0 J205G 49019949_1 CDM 0272 RC inpatient 21 13.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 16.38 78 999999999 12.72 20.37 percent of total billed charges SUTURE VICRYL 3-0 J205G 49019949_1 CDM 0272 RC inpatient 21 13.65 SIHO - ALL PLANS SIHO - ALL PLANS 18.9 90 999999999 12.72 20.37 percent of total billed charges SUTURE VICRYL 3-0 J205G 49019949_1 CDM 0272 RC inpatient 21 13.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.72 60.55 999999999 12.72 20.37 percent of total billed charges SUTURE VICRYL 3-0 J205G 49019949_1 CDM 0272 RC inpatient 21 13.65 UMR - ALL PLANS UMR - ALL PLANS 14.7 70 999999999 12.72 20.37 percent of total billed charges SUTURE VICRYL 3-0 J205G 49019949_1 CDM 0272 RC inpatient 21 13.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.72 20.37 SUTURE VICRYL 3-0 J205G 49019949_1 CDM 0272 RC inpatient 21 13.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.72 20.37 SUTURE VICRYL 3-0 J205G 49019949_1 CDM 0272 RC inpatient 21 13.65 ANTHEM HMO ANTHEM HMO 999999999 12.72 20.37 SUTURE VICRYL 3-0 J205G 49019949_1 CDM 0272 RC inpatient 21 13.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.72 20.37 SUTURE VICRYL 3-0 J205G 49019949_1 CDM 0272 RC inpatient 21 13.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.2 67.6 999999999 12.72 20.37 percent of total billed charges SUTURE VICRYL 3-0 J205G 49019949_1 CDM 0272 RC inpatient 21 13.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.72 20.37 SUTURE VICRYL 2-0 J206G 49019951_1 CDM 0272 RC inpatient 21 13.65 AETNA AETNA 16.59 79 999999999 12.72 20.37 percent of total billed charges SUTURE VICRYL 2-0 J206G 49019951_1 CDM 0272 RC inpatient 21 13.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 13.65 65 999999999 12.72 20.37 percent of total billed charges SUTURE VICRYL 2-0 J206G 49019951_1 CDM 0272 RC inpatient 21 13.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20.37 97 999999999 12.72 20.37 percent of total billed charges SUTURE VICRYL 2-0 J206G 49019951_1 CDM 0272 RC inpatient 21 13.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 14.49 69 999999999 12.72 20.37 percent of total billed charges SUTURE VICRYL 2-0 J206G 49019951_1 CDM 0272 RC inpatient 21 13.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 16.38 78 999999999 12.72 20.37 percent of total billed charges SUTURE VICRYL 2-0 J206G 49019951_1 CDM 0272 RC inpatient 21 13.65 SIHO - ALL PLANS SIHO - ALL PLANS 18.9 90 999999999 12.72 20.37 percent of total billed charges SUTURE VICRYL 2-0 J206G 49019951_1 CDM 0272 RC inpatient 21 13.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.72 60.55 999999999 12.72 20.37 percent of total billed charges SUTURE VICRYL 2-0 J206G 49019951_1 CDM 0272 RC inpatient 21 13.65 UMR - ALL PLANS UMR - ALL PLANS 14.7 70 999999999 12.72 20.37 percent of total billed charges SUTURE VICRYL 2-0 J206G 49019951_1 CDM 0272 RC inpatient 21 13.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.72 20.37 SUTURE VICRYL 2-0 J206G 49019951_1 CDM 0272 RC inpatient 21 13.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.72 20.37 SUTURE VICRYL 2-0 J206G 49019951_1 CDM 0272 RC inpatient 21 13.65 ANTHEM HMO ANTHEM HMO 999999999 12.72 20.37 SUTURE VICRYL 2-0 J206G 49019951_1 CDM 0272 RC inpatient 21 13.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.72 20.37 SUTURE VICRYL 2-0 J206G 49019951_1 CDM 0272 RC inpatient 21 13.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.2 67.6 999999999 12.72 20.37 percent of total billed charges SUTURE VICRYL 2-0 J206G 49019951_1 CDM 0272 RC inpatient 21 13.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.72 20.37 SUTURE VICRYL 2-0 J266H CP-1 49019952_1 CDM 0272 RC inpatient 16 10.4 AETNA AETNA 12.64 79 999999999 9.69 15.52 percent of total billed charges SUTURE VICRYL 2-0 J266H CP-1 49019952_1 CDM 0272 RC inpatient 16 10.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.4 65 999999999 9.69 15.52 percent of total billed charges SUTURE VICRYL 2-0 J266H CP-1 49019952_1 CDM 0272 RC inpatient 16 10.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15.52 97 999999999 9.69 15.52 percent of total billed charges SUTURE VICRYL 2-0 J266H CP-1 49019952_1 CDM 0272 RC inpatient 16 10.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.04 69 999999999 9.69 15.52 percent of total billed charges SUTURE VICRYL 2-0 J266H CP-1 49019952_1 CDM 0272 RC inpatient 16 10.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.48 78 999999999 9.69 15.52 percent of total billed charges SUTURE VICRYL 2-0 J266H CP-1 49019952_1 CDM 0272 RC inpatient 16 10.4 SIHO - ALL PLANS SIHO - ALL PLANS 14.4 90 999999999 9.69 15.52 percent of total billed charges SUTURE VICRYL 2-0 J266H CP-1 49019952_1 CDM 0272 RC inpatient 16 10.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.69 60.55 999999999 9.69 15.52 percent of total billed charges SUTURE VICRYL 2-0 J266H CP-1 49019952_1 CDM 0272 RC inpatient 16 10.4 UMR - ALL PLANS UMR - ALL PLANS 11.2 70 999999999 9.69 15.52 percent of total billed charges SUTURE VICRYL 2-0 J266H CP-1 49019952_1 CDM 0272 RC inpatient 16 10.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.69 15.52 SUTURE VICRYL 2-0 J266H CP-1 49019952_1 CDM 0272 RC inpatient 16 10.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.69 15.52 SUTURE VICRYL 2-0 J266H CP-1 49019952_1 CDM 0272 RC inpatient 16 10.4 ANTHEM HMO ANTHEM HMO 999999999 9.69 15.52 SUTURE VICRYL 2-0 J266H CP-1 49019952_1 CDM 0272 RC inpatient 16 10.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.69 15.52 SUTURE VICRYL 2-0 J266H CP-1 49019952_1 CDM 0272 RC inpatient 16 10.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.82 67.6 999999999 9.69 15.52 percent of total billed charges SUTURE VICRYL 2-0 J266H CP-1 49019952_1 CDM 0272 RC inpatient 16 10.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.69 15.52 SUTURE VICRYL #1 J268H 49019954_1 CDM 0272 RC inpatient 17 11.05 AETNA AETNA 13.43 79 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL #1 J268H 49019954_1 CDM 0272 RC inpatient 17 11.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.05 65 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL #1 J268H 49019954_1 CDM 0272 RC inpatient 17 11.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16.49 97 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL #1 J268H 49019954_1 CDM 0272 RC inpatient 17 11.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.73 69 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL #1 J268H 49019954_1 CDM 0272 RC inpatient 17 11.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.26 78 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL #1 J268H 49019954_1 CDM 0272 RC inpatient 17 11.05 SIHO - ALL PLANS SIHO - ALL PLANS 15.3 90 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL #1 J268H 49019954_1 CDM 0272 RC inpatient 17 11.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.29 60.55 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL #1 J268H 49019954_1 CDM 0272 RC inpatient 17 11.05 UMR - ALL PLANS UMR - ALL PLANS 11.9 70 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL #1 J268H 49019954_1 CDM 0272 RC inpatient 17 11.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.29 16.49 SUTURE VICRYL #1 J268H 49019954_1 CDM 0272 RC inpatient 17 11.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.29 16.49 SUTURE VICRYL #1 J268H 49019954_1 CDM 0272 RC inpatient 17 11.05 ANTHEM HMO ANTHEM HMO 999999999 10.29 16.49 SUTURE VICRYL #1 J268H 49019954_1 CDM 0272 RC inpatient 17 11.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.29 16.49 SUTURE VICRYL #1 J268H 49019954_1 CDM 0272 RC inpatient 17 11.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.49 67.6 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL #1 J268H 49019954_1 CDM 0272 RC inpatient 17 11.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.29 16.49 SUTURE VICRYL 4-0 J310H GI 49019956_1 CDM 0272 RC inpatient 9 5.85 AETNA AETNA 7.11 79 999999999 5.45 8.73 percent of total billed charges SUTURE VICRYL 4-0 J310H GI 49019956_1 CDM 0272 RC inpatient 9 5.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.85 65 999999999 5.45 8.73 percent of total billed charges SUTURE VICRYL 4-0 J310H GI 49019956_1 CDM 0272 RC inpatient 9 5.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.73 97 999999999 5.45 8.73 percent of total billed charges SUTURE VICRYL 4-0 J310H GI 49019956_1 CDM 0272 RC inpatient 9 5.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.21 69 999999999 5.45 8.73 percent of total billed charges SUTURE VICRYL 4-0 J310H GI 49019956_1 CDM 0272 RC inpatient 9 5.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.02 78 999999999 5.45 8.73 percent of total billed charges SUTURE VICRYL 4-0 J310H GI 49019956_1 CDM 0272 RC inpatient 9 5.85 SIHO - ALL PLANS SIHO - ALL PLANS 8.1 90 999999999 5.45 8.73 percent of total billed charges SUTURE VICRYL 4-0 J310H GI 49019956_1 CDM 0272 RC inpatient 9 5.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.45 60.55 999999999 5.45 8.73 percent of total billed charges SUTURE VICRYL 4-0 J310H GI 49019956_1 CDM 0272 RC inpatient 9 5.85 UMR - ALL PLANS UMR - ALL PLANS 6.3 70 999999999 5.45 8.73 percent of total billed charges SUTURE VICRYL 4-0 J310H GI 49019956_1 CDM 0272 RC inpatient 9 5.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.45 8.73 SUTURE VICRYL 4-0 J310H GI 49019956_1 CDM 0272 RC inpatient 9 5.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.45 8.73 SUTURE VICRYL 4-0 J310H GI 49019956_1 CDM 0272 RC inpatient 9 5.85 ANTHEM HMO ANTHEM HMO 999999999 5.45 8.73 SUTURE VICRYL 4-0 J310H GI 49019956_1 CDM 0272 RC inpatient 9 5.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.45 8.73 SUTURE VICRYL 4-0 J310H GI 49019956_1 CDM 0272 RC inpatient 9 5.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.08 67.6 999999999 5.45 8.73 percent of total billed charges SUTURE VICRYL 4-0 J310H GI 49019956_1 CDM 0272 RC inpatient 9 5.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.45 8.73 SUTURE VICRYL 3-0 J311H GI 49019957_1 CDM 0272 RC inpatient 18 11.7 AETNA AETNA 14.22 79 999999999 10.9 17.46 percent of total billed charges SUTURE VICRYL 3-0 J311H GI 49019957_1 CDM 0272 RC inpatient 18 11.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.7 65 999999999 10.9 17.46 percent of total billed charges SUTURE VICRYL 3-0 J311H GI 49019957_1 CDM 0272 RC inpatient 18 11.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.46 97 999999999 10.9 17.46 percent of total billed charges SUTURE VICRYL 3-0 J311H GI 49019957_1 CDM 0272 RC inpatient 18 11.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.42 69 999999999 10.9 17.46 percent of total billed charges SUTURE VICRYL 3-0 J311H GI 49019957_1 CDM 0272 RC inpatient 18 11.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.04 78 999999999 10.9 17.46 percent of total billed charges SUTURE VICRYL 3-0 J311H GI 49019957_1 CDM 0272 RC inpatient 18 11.7 SIHO - ALL PLANS SIHO - ALL PLANS 16.2 90 999999999 10.9 17.46 percent of total billed charges SUTURE VICRYL 3-0 J311H GI 49019957_1 CDM 0272 RC inpatient 18 11.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.9 60.55 999999999 10.9 17.46 percent of total billed charges SUTURE VICRYL 3-0 J311H GI 49019957_1 CDM 0272 RC inpatient 18 11.7 UMR - ALL PLANS UMR - ALL PLANS 12.6 70 999999999 10.9 17.46 percent of total billed charges SUTURE VICRYL 3-0 J311H GI 49019957_1 CDM 0272 RC inpatient 18 11.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.9 17.46 SUTURE VICRYL 3-0 J311H GI 49019957_1 CDM 0272 RC inpatient 18 11.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.9 17.46 SUTURE VICRYL 3-0 J311H GI 49019957_1 CDM 0272 RC inpatient 18 11.7 ANTHEM HMO ANTHEM HMO 999999999 10.9 17.46 SUTURE VICRYL 3-0 J311H GI 49019957_1 CDM 0272 RC inpatient 18 11.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.9 17.46 SUTURE VICRYL 3-0 J311H GI 49019957_1 CDM 0272 RC inpatient 18 11.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.17 67.6 999999999 10.9 17.46 percent of total billed charges SUTURE VICRYL 3-0 J311H GI 49019957_1 CDM 0272 RC inpatient 18 11.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.9 17.46 SUTURE VICRYL 3-0 J338H 49019958_1 CDM 0272 RC inpatient 15 9.75 AETNA AETNA 11.85 79 999999999 9.08 14.55 percent of total billed charges SUTURE VICRYL 3-0 J338H 49019958_1 CDM 0272 RC inpatient 15 9.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.75 65 999999999 9.08 14.55 percent of total billed charges SUTURE VICRYL 3-0 J338H 49019958_1 CDM 0272 RC inpatient 15 9.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14.55 97 999999999 9.08 14.55 percent of total billed charges SUTURE VICRYL 3-0 J338H 49019958_1 CDM 0272 RC inpatient 15 9.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.35 69 999999999 9.08 14.55 percent of total billed charges SUTURE VICRYL 3-0 J338H 49019958_1 CDM 0272 RC inpatient 15 9.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.7 78 999999999 9.08 14.55 percent of total billed charges SUTURE VICRYL 3-0 J338H 49019958_1 CDM 0272 RC inpatient 15 9.75 SIHO - ALL PLANS SIHO - ALL PLANS 13.5 90 999999999 9.08 14.55 percent of total billed charges SUTURE VICRYL 3-0 J338H 49019958_1 CDM 0272 RC inpatient 15 9.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.08 60.55 999999999 9.08 14.55 percent of total billed charges SUTURE VICRYL 3-0 J338H 49019958_1 CDM 0272 RC inpatient 15 9.75 UMR - ALL PLANS UMR - ALL PLANS 10.5 70 999999999 9.08 14.55 percent of total billed charges SUTURE VICRYL 3-0 J338H 49019958_1 CDM 0272 RC inpatient 15 9.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.08 14.55 SUTURE VICRYL 3-0 J338H 49019958_1 CDM 0272 RC inpatient 15 9.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.08 14.55 SUTURE VICRYL 3-0 J338H 49019958_1 CDM 0272 RC inpatient 15 9.75 ANTHEM HMO ANTHEM HMO 999999999 9.08 14.55 SUTURE VICRYL 3-0 J338H 49019958_1 CDM 0272 RC inpatient 15 9.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.08 14.55 SUTURE VICRYL 3-0 J338H 49019958_1 CDM 0272 RC inpatient 15 9.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.14 67.6 999999999 9.08 14.55 percent of total billed charges SUTURE VICRYL 3-0 J338H 49019958_1 CDM 0272 RC inpatient 15 9.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.08 14.55 SUTURE VICRYL 2-0 J339H CLO 49019959_1 CDM 0272 RC inpatient 15 9.75 AETNA AETNA 11.85 79 999999999 9.08 14.55 percent of total billed charges SUTURE VICRYL 2-0 J339H CLO 49019959_1 CDM 0272 RC inpatient 15 9.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.75 65 999999999 9.08 14.55 percent of total billed charges SUTURE VICRYL 2-0 J339H CLO 49019959_1 CDM 0272 RC inpatient 15 9.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14.55 97 999999999 9.08 14.55 percent of total billed charges SUTURE VICRYL 2-0 J339H CLO 49019959_1 CDM 0272 RC inpatient 15 9.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.35 69 999999999 9.08 14.55 percent of total billed charges SUTURE VICRYL 2-0 J339H CLO 49019959_1 CDM 0272 RC inpatient 15 9.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.7 78 999999999 9.08 14.55 percent of total billed charges SUTURE VICRYL 2-0 J339H CLO 49019959_1 CDM 0272 RC inpatient 15 9.75 SIHO - ALL PLANS SIHO - ALL PLANS 13.5 90 999999999 9.08 14.55 percent of total billed charges SUTURE VICRYL 2-0 J339H CLO 49019959_1 CDM 0272 RC inpatient 15 9.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.08 60.55 999999999 9.08 14.55 percent of total billed charges SUTURE VICRYL 2-0 J339H CLO 49019959_1 CDM 0272 RC inpatient 15 9.75 UMR - ALL PLANS UMR - ALL PLANS 10.5 70 999999999 9.08 14.55 percent of total billed charges SUTURE VICRYL 2-0 J339H CLO 49019959_1 CDM 0272 RC inpatient 15 9.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.08 14.55 SUTURE VICRYL 2-0 J339H CLO 49019959_1 CDM 0272 RC inpatient 15 9.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.08 14.55 SUTURE VICRYL 2-0 J339H CLO 49019959_1 CDM 0272 RC inpatient 15 9.75 ANTHEM HMO ANTHEM HMO 999999999 9.08 14.55 SUTURE VICRYL 2-0 J339H CLO 49019959_1 CDM 0272 RC inpatient 15 9.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.08 14.55 SUTURE VICRYL 2-0 J339H CLO 49019959_1 CDM 0272 RC inpatient 15 9.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.14 67.6 999999999 9.08 14.55 percent of total billed charges SUTURE VICRYL 2-0 J339H CLO 49019959_1 CDM 0272 RC inpatient 15 9.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.08 14.55 SUTURE VICRYL #0 J340H CLO 49019960_1 CDM 0272 RC inpatient 16 10.4 AETNA AETNA 12.64 79 999999999 9.69 15.52 percent of total billed charges SUTURE VICRYL #0 J340H CLO 49019960_1 CDM 0272 RC inpatient 16 10.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.4 65 999999999 9.69 15.52 percent of total billed charges SUTURE VICRYL #0 J340H CLO 49019960_1 CDM 0272 RC inpatient 16 10.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15.52 97 999999999 9.69 15.52 percent of total billed charges SUTURE VICRYL #0 J340H CLO 49019960_1 CDM 0272 RC inpatient 16 10.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.04 69 999999999 9.69 15.52 percent of total billed charges SUTURE VICRYL #0 J340H CLO 49019960_1 CDM 0272 RC inpatient 16 10.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.48 78 999999999 9.69 15.52 percent of total billed charges SUTURE VICRYL #0 J340H CLO 49019960_1 CDM 0272 RC inpatient 16 10.4 SIHO - ALL PLANS SIHO - ALL PLANS 14.4 90 999999999 9.69 15.52 percent of total billed charges SUTURE VICRYL #0 J340H CLO 49019960_1 CDM 0272 RC inpatient 16 10.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.69 60.55 999999999 9.69 15.52 percent of total billed charges SUTURE VICRYL #0 J340H CLO 49019960_1 CDM 0272 RC inpatient 16 10.4 UMR - ALL PLANS UMR - ALL PLANS 11.2 70 999999999 9.69 15.52 percent of total billed charges SUTURE VICRYL #0 J340H CLO 49019960_1 CDM 0272 RC inpatient 16 10.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.69 15.52 SUTURE VICRYL #0 J340H CLO 49019960_1 CDM 0272 RC inpatient 16 10.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.69 15.52 SUTURE VICRYL #0 J340H CLO 49019960_1 CDM 0272 RC inpatient 16 10.4 ANTHEM HMO ANTHEM HMO 999999999 9.69 15.52 SUTURE VICRYL #0 J340H CLO 49019960_1 CDM 0272 RC inpatient 16 10.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.69 15.52 SUTURE VICRYL #0 J340H CLO 49019960_1 CDM 0272 RC inpatient 16 10.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.82 67.6 999999999 9.69 15.52 percent of total billed charges SUTURE VICRYL #0 J340H CLO 49019960_1 CDM 0272 RC inpatient 16 10.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.69 15.52 SUTURE 3-0 VICRYL J427H 49019961_1 CDM 0272 RC inpatient 40 26 AETNA AETNA 31.6 79 999999999 24.22 38.8 percent of total billed charges SUTURE 3-0 VICRYL J427H 49019961_1 CDM 0272 RC inpatient 40 26 SELF PAY DISCOUNT SELF PAY DISCOUNT 26 65 999999999 24.22 38.8 percent of total billed charges SUTURE 3-0 VICRYL J427H 49019961_1 CDM 0272 RC inpatient 40 26 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 38.8 97 999999999 24.22 38.8 percent of total billed charges SUTURE 3-0 VICRYL J427H 49019961_1 CDM 0272 RC inpatient 40 26 ENCORE - ALL PLANS ENCORE - ALL PLANS 27.6 69 999999999 24.22 38.8 percent of total billed charges SUTURE 3-0 VICRYL J427H 49019961_1 CDM 0272 RC inpatient 40 26 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.2 78 999999999 24.22 38.8 percent of total billed charges SUTURE 3-0 VICRYL J427H 49019961_1 CDM 0272 RC inpatient 40 26 SIHO - ALL PLANS SIHO - ALL PLANS 36 90 999999999 24.22 38.8 percent of total billed charges SUTURE 3-0 VICRYL J427H 49019961_1 CDM 0272 RC inpatient 40 26 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.22 60.55 999999999 24.22 38.8 percent of total billed charges SUTURE 3-0 VICRYL J427H 49019961_1 CDM 0272 RC inpatient 40 26 UMR - ALL PLANS UMR - ALL PLANS 28 70 999999999 24.22 38.8 percent of total billed charges SUTURE 3-0 VICRYL J427H 49019961_1 CDM 0272 RC inpatient 40 26 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.22 38.8 SUTURE 3-0 VICRYL J427H 49019961_1 CDM 0272 RC inpatient 40 26 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.22 38.8 SUTURE 3-0 VICRYL J427H 49019961_1 CDM 0272 RC inpatient 40 26 ANTHEM HMO ANTHEM HMO 999999999 24.22 38.8 SUTURE 3-0 VICRYL J427H 49019961_1 CDM 0272 RC inpatient 40 26 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.22 38.8 SUTURE 3-0 VICRYL J427H 49019961_1 CDM 0272 RC inpatient 40 26 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.04 67.6 999999999 24.22 38.8 percent of total billed charges SUTURE 3-0 VICRYL J427H 49019961_1 CDM 0272 RC inpatient 40 26 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.22 38.8 SUTURE VICRYL 2-0 J428H 49019962_1 CDM 0272 RC inpatient 40 26 AETNA AETNA 31.6 79 999999999 24.22 38.8 percent of total billed charges SUTURE VICRYL 2-0 J428H 49019962_1 CDM 0272 RC inpatient 40 26 SELF PAY DISCOUNT SELF PAY DISCOUNT 26 65 999999999 24.22 38.8 percent of total billed charges SUTURE VICRYL 2-0 J428H 49019962_1 CDM 0272 RC inpatient 40 26 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 38.8 97 999999999 24.22 38.8 percent of total billed charges SUTURE VICRYL 2-0 J428H 49019962_1 CDM 0272 RC inpatient 40 26 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.2 78 999999999 24.22 38.8 percent of total billed charges SUTURE VICRYL 2-0 J428H 49019962_1 CDM 0272 RC inpatient 40 26 ENCORE - ALL PLANS ENCORE - ALL PLANS 27.6 69 999999999 24.22 38.8 percent of total billed charges SUTURE VICRYL 2-0 J428H 49019962_1 CDM 0272 RC inpatient 40 26 SIHO - ALL PLANS SIHO - ALL PLANS 36 90 999999999 24.22 38.8 percent of total billed charges SUTURE VICRYL 2-0 J428H 49019962_1 CDM 0272 RC inpatient 40 26 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.22 60.55 999999999 24.22 38.8 percent of total billed charges SUTURE VICRYL 2-0 J428H 49019962_1 CDM 0272 RC inpatient 40 26 UMR - ALL PLANS UMR - ALL PLANS 28 70 999999999 24.22 38.8 percent of total billed charges SUTURE VICRYL 2-0 J428H 49019962_1 CDM 0272 RC inpatient 40 26 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.22 38.8 SUTURE VICRYL 2-0 J428H 49019962_1 CDM 0272 RC inpatient 40 26 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.22 38.8 SUTURE VICRYL 2-0 J428H 49019962_1 CDM 0272 RC inpatient 40 26 ANTHEM HMO ANTHEM HMO 999999999 24.22 38.8 SUTURE VICRYL 2-0 J428H 49019962_1 CDM 0272 RC inpatient 40 26 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.22 38.8 SUTURE VICRYL 2-0 J428H 49019962_1 CDM 0272 RC inpatient 40 26 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.04 67.6 999999999 24.22 38.8 percent of total billed charges SUTURE VICRYL 2-0 J428H 49019962_1 CDM 0272 RC inpatient 40 26 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.22 38.8 SUTURE VICRYL 5-0 J493G PLA 49019963_1 CDM 0272 RC inpatient 26 16.9 AETNA AETNA 20.54 79 999999999 15.74 25.22 percent of total billed charges SUTURE VICRYL 5-0 J493G PLA 49019963_1 CDM 0272 RC inpatient 26 16.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.9 65 999999999 15.74 25.22 percent of total billed charges SUTURE VICRYL 5-0 J493G PLA 49019963_1 CDM 0272 RC inpatient 26 16.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.22 97 999999999 15.74 25.22 percent of total billed charges SUTURE VICRYL 5-0 J493G PLA 49019963_1 CDM 0272 RC inpatient 26 16.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.28 78 999999999 15.74 25.22 percent of total billed charges SUTURE VICRYL 5-0 J493G PLA 49019963_1 CDM 0272 RC inpatient 26 16.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.94 69 999999999 15.74 25.22 percent of total billed charges SUTURE VICRYL 5-0 J493G PLA 49019963_1 CDM 0272 RC inpatient 26 16.9 SIHO - ALL PLANS SIHO - ALL PLANS 23.4 90 999999999 15.74 25.22 percent of total billed charges SUTURE VICRYL 5-0 J493G PLA 49019963_1 CDM 0272 RC inpatient 26 16.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.74 60.55 999999999 15.74 25.22 percent of total billed charges SUTURE VICRYL 5-0 J493G PLA 49019963_1 CDM 0272 RC inpatient 26 16.9 UMR - ALL PLANS UMR - ALL PLANS 18.2 70 999999999 15.74 25.22 percent of total billed charges SUTURE VICRYL 5-0 J493G PLA 49019963_1 CDM 0272 RC inpatient 26 16.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.74 25.22 SUTURE VICRYL 5-0 J493G PLA 49019963_1 CDM 0272 RC inpatient 26 16.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.74 25.22 SUTURE VICRYL 5-0 J493G PLA 49019963_1 CDM 0272 RC inpatient 26 16.9 ANTHEM HMO ANTHEM HMO 999999999 15.74 25.22 SUTURE VICRYL 5-0 J493G PLA 49019963_1 CDM 0272 RC inpatient 26 16.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.74 25.22 SUTURE VICRYL 5-0 J493G PLA 49019963_1 CDM 0272 RC inpatient 26 16.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.58 67.6 999999999 15.74 25.22 percent of total billed charges SUTURE VICRYL 5-0 J493G PLA 49019963_1 CDM 0272 RC inpatient 26 16.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.74 25.22 SUTURE VICRYL 4-0 J494G PLA 49019964_1 CDM 0272 RC inpatient 44 28.6 AETNA AETNA 34.76 79 999999999 26.64 42.68 percent of total billed charges SUTURE VICRYL 4-0 J494G PLA 49019964_1 CDM 0272 RC inpatient 44 28.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 28.6 65 999999999 26.64 42.68 percent of total billed charges SUTURE VICRYL 4-0 J494G PLA 49019964_1 CDM 0272 RC inpatient 44 28.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 42.68 97 999999999 26.64 42.68 percent of total billed charges SUTURE VICRYL 4-0 J494G PLA 49019964_1 CDM 0272 RC inpatient 44 28.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 34.32 78 999999999 26.64 42.68 percent of total billed charges SUTURE VICRYL 4-0 J494G PLA 49019964_1 CDM 0272 RC inpatient 44 28.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 30.36 69 999999999 26.64 42.68 percent of total billed charges SUTURE VICRYL 4-0 J494G PLA 49019964_1 CDM 0272 RC inpatient 44 28.6 SIHO - ALL PLANS SIHO - ALL PLANS 39.6 90 999999999 26.64 42.68 percent of total billed charges SUTURE VICRYL 4-0 J494G PLA 49019964_1 CDM 0272 RC inpatient 44 28.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26.64 60.55 999999999 26.64 42.68 percent of total billed charges SUTURE VICRYL 4-0 J494G PLA 49019964_1 CDM 0272 RC inpatient 44 28.6 UMR - ALL PLANS UMR - ALL PLANS 30.8 70 999999999 26.64 42.68 percent of total billed charges SUTURE VICRYL 4-0 J494G PLA 49019964_1 CDM 0272 RC inpatient 44 28.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26.64 42.68 SUTURE VICRYL 4-0 J494G PLA 49019964_1 CDM 0272 RC inpatient 44 28.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26.64 42.68 SUTURE VICRYL 4-0 J494G PLA 49019964_1 CDM 0272 RC inpatient 44 28.6 ANTHEM HMO ANTHEM HMO 999999999 26.64 42.68 SUTURE VICRYL 4-0 J494G PLA 49019964_1 CDM 0272 RC inpatient 44 28.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26.64 42.68 SUTURE VICRYL 4-0 J494G PLA 49019964_1 CDM 0272 RC inpatient 44 28.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 29.74 67.6 999999999 26.64 42.68 percent of total billed charges SUTURE VICRYL 4-0 J494G PLA 49019964_1 CDM 0272 RC inpatient 44 28.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 26.64 42.68 SUTURE VICRYL J603H SZ-0 49019966_1 CDM 0272 RC inpatient 19 12.35 AETNA AETNA 15.01 79 999999999 11.5 18.43 percent of total billed charges SUTURE VICRYL J603H SZ-0 49019966_1 CDM 0272 RC inpatient 19 12.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.35 65 999999999 11.5 18.43 percent of total billed charges SUTURE VICRYL J603H SZ-0 49019966_1 CDM 0272 RC inpatient 19 12.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 18.43 97 999999999 11.5 18.43 percent of total billed charges SUTURE VICRYL J603H SZ-0 49019966_1 CDM 0272 RC inpatient 19 12.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.82 78 999999999 11.5 18.43 percent of total billed charges SUTURE VICRYL J603H SZ-0 49019966_1 CDM 0272 RC inpatient 19 12.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.11 69 999999999 11.5 18.43 percent of total billed charges SUTURE VICRYL J603H SZ-0 49019966_1 CDM 0272 RC inpatient 19 12.35 SIHO - ALL PLANS SIHO - ALL PLANS 17.1 90 999999999 11.5 18.43 percent of total billed charges SUTURE VICRYL J603H SZ-0 49019966_1 CDM 0272 RC inpatient 19 12.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.5 60.55 999999999 11.5 18.43 percent of total billed charges SUTURE VICRYL J603H SZ-0 49019966_1 CDM 0272 RC inpatient 19 12.35 UMR - ALL PLANS UMR - ALL PLANS 13.3 70 999999999 11.5 18.43 percent of total billed charges SUTURE VICRYL J603H SZ-0 49019966_1 CDM 0272 RC inpatient 19 12.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.5 18.43 SUTURE VICRYL J603H SZ-0 49019966_1 CDM 0272 RC inpatient 19 12.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.5 18.43 SUTURE VICRYL J603H SZ-0 49019966_1 CDM 0272 RC inpatient 19 12.35 ANTHEM HMO ANTHEM HMO 999999999 11.5 18.43 SUTURE VICRYL J603H SZ-0 49019966_1 CDM 0272 RC inpatient 19 12.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.5 18.43 SUTURE VICRYL J603H SZ-0 49019966_1 CDM 0272 RC inpatient 19 12.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.84 67.6 999999999 11.5 18.43 percent of total billed charges SUTURE VICRYL J603H SZ-0 49019966_1 CDM 0272 RC inpatient 19 12.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.5 18.43 SUTURE VICRYL 2-0 J602H UROL 49019967_1 CDM 0272 RC inpatient 19 12.35 AETNA AETNA 15.01 79 999999999 11.5 18.43 percent of total billed charges SUTURE VICRYL 2-0 J602H UROL 49019967_1 CDM 0272 RC inpatient 19 12.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.35 65 999999999 11.5 18.43 percent of total billed charges SUTURE VICRYL 2-0 J602H UROL 49019967_1 CDM 0272 RC inpatient 19 12.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 18.43 97 999999999 11.5 18.43 percent of total billed charges SUTURE VICRYL 2-0 J602H UROL 49019967_1 CDM 0272 RC inpatient 19 12.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.82 78 999999999 11.5 18.43 percent of total billed charges SUTURE VICRYL 2-0 J602H UROL 49019967_1 CDM 0272 RC inpatient 19 12.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.11 69 999999999 11.5 18.43 percent of total billed charges SUTURE VICRYL 2-0 J602H UROL 49019967_1 CDM 0272 RC inpatient 19 12.35 SIHO - ALL PLANS SIHO - ALL PLANS 17.1 90 999999999 11.5 18.43 percent of total billed charges SUTURE VICRYL 2-0 J602H UROL 49019967_1 CDM 0272 RC inpatient 19 12.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.5 60.55 999999999 11.5 18.43 percent of total billed charges SUTURE VICRYL 2-0 J602H UROL 49019967_1 CDM 0272 RC inpatient 19 12.35 UMR - ALL PLANS UMR - ALL PLANS 13.3 70 999999999 11.5 18.43 percent of total billed charges SUTURE VICRYL 2-0 J602H UROL 49019967_1 CDM 0272 RC inpatient 19 12.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.5 18.43 SUTURE VICRYL 2-0 J602H UROL 49019967_1 CDM 0272 RC inpatient 19 12.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.5 18.43 SUTURE VICRYL 2-0 J602H UROL 49019967_1 CDM 0272 RC inpatient 19 12.35 ANTHEM HMO ANTHEM HMO 999999999 11.5 18.43 SUTURE VICRYL 2-0 J602H UROL 49019967_1 CDM 0272 RC inpatient 19 12.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.5 18.43 SUTURE VICRYL 2-0 J602H UROL 49019967_1 CDM 0272 RC inpatient 19 12.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.84 67.6 999999999 11.5 18.43 percent of total billed charges SUTURE VICRYL 2-0 J602H UROL 49019967_1 CDM 0272 RC inpatient 19 12.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.5 18.43 SUTURE VICRYL 3-0 J683G 49019968_1 CDM 0272 RC inpatient 43 27.95 AETNA AETNA 33.97 79 999999999 26.04 41.71 percent of total billed charges SUTURE VICRYL 3-0 J683G 49019968_1 CDM 0272 RC inpatient 43 27.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 27.95 65 999999999 26.04 41.71 percent of total billed charges SUTURE VICRYL 3-0 J683G 49019968_1 CDM 0272 RC inpatient 43 27.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 41.71 97 999999999 26.04 41.71 percent of total billed charges SUTURE VICRYL 3-0 J683G 49019968_1 CDM 0272 RC inpatient 43 27.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 33.54 78 999999999 26.04 41.71 percent of total billed charges SUTURE VICRYL 3-0 J683G 49019968_1 CDM 0272 RC inpatient 43 27.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 29.67 69 999999999 26.04 41.71 percent of total billed charges SUTURE VICRYL 3-0 J683G 49019968_1 CDM 0272 RC inpatient 43 27.95 SIHO - ALL PLANS SIHO - ALL PLANS 38.7 90 999999999 26.04 41.71 percent of total billed charges SUTURE VICRYL 3-0 J683G 49019968_1 CDM 0272 RC inpatient 43 27.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26.04 60.55 999999999 26.04 41.71 percent of total billed charges SUTURE VICRYL 3-0 J683G 49019968_1 CDM 0272 RC inpatient 43 27.95 UMR - ALL PLANS UMR - ALL PLANS 30.1 70 999999999 26.04 41.71 percent of total billed charges SUTURE VICRYL 3-0 J683G 49019968_1 CDM 0272 RC inpatient 43 27.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26.04 41.71 SUTURE VICRYL 3-0 J683G 49019968_1 CDM 0272 RC inpatient 43 27.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26.04 41.71 SUTURE VICRYL 3-0 J683G 49019968_1 CDM 0272 RC inpatient 43 27.95 ANTHEM HMO ANTHEM HMO 999999999 26.04 41.71 SUTURE VICRYL 3-0 J683G 49019968_1 CDM 0272 RC inpatient 43 27.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26.04 41.71 SUTURE VICRYL 3-0 J683G 49019968_1 CDM 0272 RC inpatient 43 27.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 29.07 67.6 999999999 26.04 41.71 percent of total billed charges SUTURE VICRYL 3-0 J683G 49019968_1 CDM 0272 RC inpatient 43 27.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 26.04 41.71 SUT VICRYL PLUS 0 VCP340H 49019970_1 CDM 0272 RC inpatient 18 11.7 AETNA AETNA 14.22 79 999999999 10.9 17.46 percent of total billed charges SUT VICRYL PLUS 0 VCP340H 49019970_1 CDM 0272 RC inpatient 18 11.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.7 65 999999999 10.9 17.46 percent of total billed charges SUT VICRYL PLUS 0 VCP340H 49019970_1 CDM 0272 RC inpatient 18 11.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.46 97 999999999 10.9 17.46 percent of total billed charges SUT VICRYL PLUS 0 VCP340H 49019970_1 CDM 0272 RC inpatient 18 11.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.04 78 999999999 10.9 17.46 percent of total billed charges SUT VICRYL PLUS 0 VCP340H 49019970_1 CDM 0272 RC inpatient 18 11.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.42 69 999999999 10.9 17.46 percent of total billed charges SUT VICRYL PLUS 0 VCP340H 49019970_1 CDM 0272 RC inpatient 18 11.7 SIHO - ALL PLANS SIHO - ALL PLANS 16.2 90 999999999 10.9 17.46 percent of total billed charges SUT VICRYL PLUS 0 VCP340H 49019970_1 CDM 0272 RC inpatient 18 11.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.9 60.55 999999999 10.9 17.46 percent of total billed charges SUT VICRYL PLUS 0 VCP340H 49019970_1 CDM 0272 RC inpatient 18 11.7 UMR - ALL PLANS UMR - ALL PLANS 12.6 70 999999999 10.9 17.46 percent of total billed charges SUT VICRYL PLUS 0 VCP340H 49019970_1 CDM 0272 RC inpatient 18 11.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.9 17.46 SUT VICRYL PLUS 0 VCP340H 49019970_1 CDM 0272 RC inpatient 18 11.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.9 17.46 SUT VICRYL PLUS 0 VCP340H 49019970_1 CDM 0272 RC inpatient 18 11.7 ANTHEM HMO ANTHEM HMO 999999999 10.9 17.46 SUT VICRYL PLUS 0 VCP340H 49019970_1 CDM 0272 RC inpatient 18 11.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.9 17.46 SUT VICRYL PLUS 0 VCP340H 49019970_1 CDM 0272 RC inpatient 18 11.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.17 67.6 999999999 10.9 17.46 percent of total billed charges SUT VICRYL PLUS 0 VCP340H 49019970_1 CDM 0272 RC inpatient 18 11.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.9 17.46 SUT VICRYL PLUS 2-0 VCP339H 49019971_1 CDM 0272 RC inpatient 18 11.7 AETNA AETNA 14.22 79 999999999 10.9 17.46 percent of total billed charges SUT VICRYL PLUS 2-0 VCP339H 49019971_1 CDM 0272 RC inpatient 18 11.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.7 65 999999999 10.9 17.46 percent of total billed charges SUT VICRYL PLUS 2-0 VCP339H 49019971_1 CDM 0272 RC inpatient 18 11.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.46 97 999999999 10.9 17.46 percent of total billed charges SUT VICRYL PLUS 2-0 VCP339H 49019971_1 CDM 0272 RC inpatient 18 11.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.04 78 999999999 10.9 17.46 percent of total billed charges SUT VICRYL PLUS 2-0 VCP339H 49019971_1 CDM 0272 RC inpatient 18 11.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.42 69 999999999 10.9 17.46 percent of total billed charges SUT VICRYL PLUS 2-0 VCP339H 49019971_1 CDM 0272 RC inpatient 18 11.7 SIHO - ALL PLANS SIHO - ALL PLANS 16.2 90 999999999 10.9 17.46 percent of total billed charges SUT VICRYL PLUS 2-0 VCP339H 49019971_1 CDM 0272 RC inpatient 18 11.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.9 60.55 999999999 10.9 17.46 percent of total billed charges SUT VICRYL PLUS 2-0 VCP339H 49019971_1 CDM 0272 RC inpatient 18 11.7 UMR - ALL PLANS UMR - ALL PLANS 12.6 70 999999999 10.9 17.46 percent of total billed charges SUT VICRYL PLUS 2-0 VCP339H 49019971_1 CDM 0272 RC inpatient 18 11.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.9 17.46 SUT VICRYL PLUS 2-0 VCP339H 49019971_1 CDM 0272 RC inpatient 18 11.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.9 17.46 SUT VICRYL PLUS 2-0 VCP339H 49019971_1 CDM 0272 RC inpatient 18 11.7 ANTHEM HMO ANTHEM HMO 999999999 10.9 17.46 SUT VICRYL PLUS 2-0 VCP339H 49019971_1 CDM 0272 RC inpatient 18 11.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.9 17.46 SUT VICRYL PLUS 2-0 VCP339H 49019971_1 CDM 0272 RC inpatient 18 11.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.17 67.6 999999999 10.9 17.46 percent of total billed charges SUT VICRYL PLUS 2-0 VCP339H 49019971_1 CDM 0272 RC inpatient 18 11.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.9 17.46 BONE WAX W-31G 137398 49019973_1 CDM 0272 RC inpatient 52 33.8 AETNA AETNA 41.08 79 999999999 31.49 50.44 percent of total billed charges BONE WAX W-31G 137398 49019973_1 CDM 0272 RC inpatient 52 33.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 33.8 65 999999999 31.49 50.44 percent of total billed charges BONE WAX W-31G 137398 49019973_1 CDM 0272 RC inpatient 52 33.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 50.44 97 999999999 31.49 50.44 percent of total billed charges BONE WAX W-31G 137398 49019973_1 CDM 0272 RC inpatient 52 33.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 40.56 78 999999999 31.49 50.44 percent of total billed charges BONE WAX W-31G 137398 49019973_1 CDM 0272 RC inpatient 52 33.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 35.88 69 999999999 31.49 50.44 percent of total billed charges BONE WAX W-31G 137398 49019973_1 CDM 0272 RC inpatient 52 33.8 SIHO - ALL PLANS SIHO - ALL PLANS 46.8 90 999999999 31.49 50.44 percent of total billed charges BONE WAX W-31G 137398 49019973_1 CDM 0272 RC inpatient 52 33.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 31.49 60.55 999999999 31.49 50.44 percent of total billed charges BONE WAX W-31G 137398 49019973_1 CDM 0272 RC inpatient 52 33.8 UMR - ALL PLANS UMR - ALL PLANS 36.4 70 999999999 31.49 50.44 percent of total billed charges BONE WAX W-31G 137398 49019973_1 CDM 0272 RC inpatient 52 33.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 31.49 50.44 BONE WAX W-31G 137398 49019973_1 CDM 0272 RC inpatient 52 33.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 31.49 50.44 BONE WAX W-31G 137398 49019973_1 CDM 0272 RC inpatient 52 33.8 ANTHEM HMO ANTHEM HMO 999999999 31.49 50.44 BONE WAX W-31G 137398 49019973_1 CDM 0272 RC inpatient 52 33.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 31.49 50.44 BONE WAX W-31G 137398 49019973_1 CDM 0272 RC inpatient 52 33.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.15 67.6 999999999 31.49 50.44 percent of total billed charges BONE WAX W-31G 137398 49019973_1 CDM 0272 RC inpatient 52 33.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 31.49 50.44 SUTURE ETHILON 3-0 PS-1 1663G 49019975_1 CDM 0272 RC inpatient 26 16.9 AETNA AETNA 20.54 79 999999999 15.74 25.22 percent of total billed charges SUTURE ETHILON 3-0 PS-1 1663G 49019975_1 CDM 0272 RC inpatient 26 16.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.9 65 999999999 15.74 25.22 percent of total billed charges SUTURE ETHILON 3-0 PS-1 1663G 49019975_1 CDM 0272 RC inpatient 26 16.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.22 97 999999999 15.74 25.22 percent of total billed charges SUTURE ETHILON 3-0 PS-1 1663G 49019975_1 CDM 0272 RC inpatient 26 16.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.28 78 999999999 15.74 25.22 percent of total billed charges SUTURE ETHILON 3-0 PS-1 1663G 49019975_1 CDM 0272 RC inpatient 26 16.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.94 69 999999999 15.74 25.22 percent of total billed charges SUTURE ETHILON 3-0 PS-1 1663G 49019975_1 CDM 0272 RC inpatient 26 16.9 SIHO - ALL PLANS SIHO - ALL PLANS 23.4 90 999999999 15.74 25.22 percent of total billed charges SUTURE ETHILON 3-0 PS-1 1663G 49019975_1 CDM 0272 RC inpatient 26 16.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.74 60.55 999999999 15.74 25.22 percent of total billed charges SUTURE ETHILON 3-0 PS-1 1663G 49019975_1 CDM 0272 RC inpatient 26 16.9 UMR - ALL PLANS UMR - ALL PLANS 18.2 70 999999999 15.74 25.22 percent of total billed charges SUTURE ETHILON 3-0 PS-1 1663G 49019975_1 CDM 0272 RC inpatient 26 16.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.74 25.22 SUTURE ETHILON 3-0 PS-1 1663G 49019975_1 CDM 0272 RC inpatient 26 16.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.74 25.22 SUTURE ETHILON 3-0 PS-1 1663G 49019975_1 CDM 0272 RC inpatient 26 16.9 ANTHEM HMO ANTHEM HMO 999999999 15.74 25.22 SUTURE ETHILON 3-0 PS-1 1663G 49019975_1 CDM 0272 RC inpatient 26 16.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.74 25.22 SUTURE ETHILON 3-0 PS-1 1663G 49019975_1 CDM 0272 RC inpatient 26 16.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.58 67.6 999999999 15.74 25.22 percent of total billed charges SUTURE ETHILON 3-0 PS-1 1663G 49019975_1 CDM 0272 RC inpatient 26 16.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.74 25.22 SUTURE ETHILON 5-0 1666G P2 49019977_1 CDM 0272 RC inpatient 24 15.6 AETNA AETNA 18.96 79 999999999 14.53 23.28 percent of total billed charges SUTURE ETHILON 5-0 1666G P2 49019977_1 CDM 0272 RC inpatient 24 15.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 15.6 65 999999999 14.53 23.28 percent of total billed charges SUTURE ETHILON 5-0 1666G P2 49019977_1 CDM 0272 RC inpatient 24 15.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23.28 97 999999999 14.53 23.28 percent of total billed charges SUTURE ETHILON 5-0 1666G P2 49019977_1 CDM 0272 RC inpatient 24 15.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 18.72 78 999999999 14.53 23.28 percent of total billed charges SUTURE ETHILON 5-0 1666G P2 49019977_1 CDM 0272 RC inpatient 24 15.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 16.56 69 999999999 14.53 23.28 percent of total billed charges SUTURE ETHILON 5-0 1666G P2 49019977_1 CDM 0272 RC inpatient 24 15.6 SIHO - ALL PLANS SIHO - ALL PLANS 21.6 90 999999999 14.53 23.28 percent of total billed charges SUTURE ETHILON 5-0 1666G P2 49019977_1 CDM 0272 RC inpatient 24 15.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.53 60.55 999999999 14.53 23.28 percent of total billed charges SUTURE ETHILON 5-0 1666G P2 49019977_1 CDM 0272 RC inpatient 24 15.6 UMR - ALL PLANS UMR - ALL PLANS 16.8 70 999999999 14.53 23.28 percent of total billed charges SUTURE ETHILON 5-0 1666G P2 49019977_1 CDM 0272 RC inpatient 24 15.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.53 23.28 SUTURE ETHILON 5-0 1666G P2 49019977_1 CDM 0272 RC inpatient 24 15.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.53 23.28 SUTURE ETHILON 5-0 1666G P2 49019977_1 CDM 0272 RC inpatient 24 15.6 ANTHEM HMO ANTHEM HMO 999999999 14.53 23.28 SUTURE ETHILON 5-0 1666G P2 49019977_1 CDM 0272 RC inpatient 24 15.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.53 23.28 SUTURE ETHILON 5-0 1666G P2 49019977_1 CDM 0272 RC inpatient 24 15.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.22 67.6 999999999 14.53 23.28 percent of total billed charges SUTURE ETHILON 5-0 1666G P2 49019977_1 CDM 0272 RC inpatient 24 15.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.53 23.28 SUTURE ETHILON 4-0 1667G PS-2 49019978_1 CDM 0272 RC inpatient 24 15.6 AETNA AETNA 18.96 79 999999999 14.53 23.28 percent of total billed charges SUTURE ETHILON 4-0 1667G PS-2 49019978_1 CDM 0272 RC inpatient 24 15.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 15.6 65 999999999 14.53 23.28 percent of total billed charges SUTURE ETHILON 4-0 1667G PS-2 49019978_1 CDM 0272 RC inpatient 24 15.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23.28 97 999999999 14.53 23.28 percent of total billed charges SUTURE ETHILON 4-0 1667G PS-2 49019978_1 CDM 0272 RC inpatient 24 15.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 18.72 78 999999999 14.53 23.28 percent of total billed charges SUTURE ETHILON 4-0 1667G PS-2 49019978_1 CDM 0272 RC inpatient 24 15.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 16.56 69 999999999 14.53 23.28 percent of total billed charges SUTURE ETHILON 4-0 1667G PS-2 49019978_1 CDM 0272 RC inpatient 24 15.6 SIHO - ALL PLANS SIHO - ALL PLANS 21.6 90 999999999 14.53 23.28 percent of total billed charges SUTURE ETHILON 4-0 1667G PS-2 49019978_1 CDM 0272 RC inpatient 24 15.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.53 60.55 999999999 14.53 23.28 percent of total billed charges SUTURE ETHILON 4-0 1667G PS-2 49019978_1 CDM 0272 RC inpatient 24 15.6 UMR - ALL PLANS UMR - ALL PLANS 16.8 70 999999999 14.53 23.28 percent of total billed charges SUTURE ETHILON 4-0 1667G PS-2 49019978_1 CDM 0272 RC inpatient 24 15.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.53 23.28 SUTURE ETHILON 4-0 1667G PS-2 49019978_1 CDM 0272 RC inpatient 24 15.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.53 23.28 SUTURE ETHILON 4-0 1667G PS-2 49019978_1 CDM 0272 RC inpatient 24 15.6 ANTHEM HMO ANTHEM HMO 999999999 14.53 23.28 SUTURE ETHILON 4-0 1667G PS-2 49019978_1 CDM 0272 RC inpatient 24 15.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.53 23.28 SUTURE ETHILON 4-0 1667G PS-2 49019978_1 CDM 0272 RC inpatient 24 15.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.22 67.6 999999999 14.53 23.28 percent of total billed charges SUTURE ETHILON 4-0 1667G PS-2 49019978_1 CDM 0272 RC inpatient 24 15.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.53 23.28 SUTURE SILK 4-0 1677G PLAS 49019979_1 CDM 0272 RC inpatient 33 21.45 AETNA AETNA 26.07 79 999999999 19.98 32.01 percent of total billed charges SUTURE SILK 4-0 1677G PLAS 49019979_1 CDM 0272 RC inpatient 33 21.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.45 65 999999999 19.98 32.01 percent of total billed charges SUTURE SILK 4-0 1677G PLAS 49019979_1 CDM 0272 RC inpatient 33 21.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.01 97 999999999 19.98 32.01 percent of total billed charges SUTURE SILK 4-0 1677G PLAS 49019979_1 CDM 0272 RC inpatient 33 21.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.74 78 999999999 19.98 32.01 percent of total billed charges SUTURE SILK 4-0 1677G PLAS 49019979_1 CDM 0272 RC inpatient 33 21.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.77 69 999999999 19.98 32.01 percent of total billed charges SUTURE SILK 4-0 1677G PLAS 49019979_1 CDM 0272 RC inpatient 33 21.45 SIHO - ALL PLANS SIHO - ALL PLANS 29.7 90 999999999 19.98 32.01 percent of total billed charges SUTURE SILK 4-0 1677G PLAS 49019979_1 CDM 0272 RC inpatient 33 21.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.98 60.55 999999999 19.98 32.01 percent of total billed charges SUTURE SILK 4-0 1677G PLAS 49019979_1 CDM 0272 RC inpatient 33 21.45 UMR - ALL PLANS UMR - ALL PLANS 23.1 70 999999999 19.98 32.01 percent of total billed charges SUTURE SILK 4-0 1677G PLAS 49019979_1 CDM 0272 RC inpatient 33 21.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.98 32.01 SUTURE SILK 4-0 1677G PLAS 49019979_1 CDM 0272 RC inpatient 33 21.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.98 32.01 SUTURE SILK 4-0 1677G PLAS 49019979_1 CDM 0272 RC inpatient 33 21.45 ANTHEM HMO ANTHEM HMO 999999999 19.98 32.01 SUTURE SILK 4-0 1677G PLAS 49019979_1 CDM 0272 RC inpatient 33 21.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.98 32.01 SUTURE SILK 4-0 1677G PLAS 49019979_1 CDM 0272 RC inpatient 33 21.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.31 67.6 999999999 19.98 32.01 percent of total billed charges SUTURE SILK 4-0 1677G PLAS 49019979_1 CDM 0272 RC inpatient 33 21.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.98 32.01 SUTURE ETHILON 6-0 1698G P2 49019981_1 CDM 0272 RC inpatient 37 24.05 AETNA AETNA 29.23 79 999999999 22.4 35.89 percent of total billed charges SUTURE ETHILON 6-0 1698G P2 49019981_1 CDM 0272 RC inpatient 37 24.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.05 65 999999999 22.4 35.89 percent of total billed charges SUTURE ETHILON 6-0 1698G P2 49019981_1 CDM 0272 RC inpatient 37 24.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.89 97 999999999 22.4 35.89 percent of total billed charges SUTURE ETHILON 6-0 1698G P2 49019981_1 CDM 0272 RC inpatient 37 24.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.86 78 999999999 22.4 35.89 percent of total billed charges SUTURE ETHILON 6-0 1698G P2 49019981_1 CDM 0272 RC inpatient 37 24.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.53 69 999999999 22.4 35.89 percent of total billed charges SUTURE ETHILON 6-0 1698G P2 49019981_1 CDM 0272 RC inpatient 37 24.05 SIHO - ALL PLANS SIHO - ALL PLANS 33.3 90 999999999 22.4 35.89 percent of total billed charges SUTURE ETHILON 6-0 1698G P2 49019981_1 CDM 0272 RC inpatient 37 24.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.4 60.55 999999999 22.4 35.89 percent of total billed charges SUTURE ETHILON 6-0 1698G P2 49019981_1 CDM 0272 RC inpatient 37 24.05 UMR - ALL PLANS UMR - ALL PLANS 25.9 70 999999999 22.4 35.89 percent of total billed charges SUTURE ETHILON 6-0 1698G P2 49019981_1 CDM 0272 RC inpatient 37 24.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.4 35.89 SUTURE ETHILON 6-0 1698G P2 49019981_1 CDM 0272 RC inpatient 37 24.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.4 35.89 SUTURE ETHILON 6-0 1698G P2 49019981_1 CDM 0272 RC inpatient 37 24.05 ANTHEM HMO ANTHEM HMO 999999999 22.4 35.89 SUTURE ETHILON 6-0 1698G P2 49019981_1 CDM 0272 RC inpatient 37 24.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.4 35.89 SUTURE ETHILON 6-0 1698G P2 49019981_1 CDM 0272 RC inpatient 37 24.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.01 67.6 999999999 22.4 35.89 percent of total billed charges SUTURE ETHILON 6-0 1698G P2 49019981_1 CDM 0272 RC inpatient 37 24.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.4 35.89 SUTURE POLYSORB 4-0 SL-691 49019982_1 CDM 0272 RC inpatient 37 24.05 AETNA AETNA 29.23 79 999999999 22.4 35.89 percent of total billed charges SUTURE POLYSORB 4-0 SL-691 49019982_1 CDM 0272 RC inpatient 37 24.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.05 65 999999999 22.4 35.89 percent of total billed charges SUTURE POLYSORB 4-0 SL-691 49019982_1 CDM 0272 RC inpatient 37 24.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.89 97 999999999 22.4 35.89 percent of total billed charges SUTURE POLYSORB 4-0 SL-691 49019982_1 CDM 0272 RC inpatient 37 24.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.86 78 999999999 22.4 35.89 percent of total billed charges SUTURE POLYSORB 4-0 SL-691 49019982_1 CDM 0272 RC inpatient 37 24.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.53 69 999999999 22.4 35.89 percent of total billed charges SUTURE POLYSORB 4-0 SL-691 49019982_1 CDM 0272 RC inpatient 37 24.05 SIHO - ALL PLANS SIHO - ALL PLANS 33.3 90 999999999 22.4 35.89 percent of total billed charges SUTURE POLYSORB 4-0 SL-691 49019982_1 CDM 0272 RC inpatient 37 24.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.4 60.55 999999999 22.4 35.89 percent of total billed charges SUTURE POLYSORB 4-0 SL-691 49019982_1 CDM 0272 RC inpatient 37 24.05 UMR - ALL PLANS UMR - ALL PLANS 25.9 70 999999999 22.4 35.89 percent of total billed charges SUTURE POLYSORB 4-0 SL-691 49019982_1 CDM 0272 RC inpatient 37 24.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.4 35.89 SUTURE POLYSORB 4-0 SL-691 49019982_1 CDM 0272 RC inpatient 37 24.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.4 35.89 SUTURE POLYSORB 4-0 SL-691 49019982_1 CDM 0272 RC inpatient 37 24.05 ANTHEM HMO ANTHEM HMO 999999999 22.4 35.89 SUTURE POLYSORB 4-0 SL-691 49019982_1 CDM 0272 RC inpatient 37 24.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.4 35.89 SUTURE POLYSORB 4-0 SL-691 49019982_1 CDM 0272 RC inpatient 37 24.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.01 67.6 999999999 22.4 35.89 percent of total billed charges SUTURE POLYSORB 4-0 SL-691 49019982_1 CDM 0272 RC inpatient 37 24.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.4 35.89 SUTURE ETHILON 3-0 627H 49019986_1 CDM 0272 RC inpatient 13 8.45 AETNA AETNA 10.27 79 999999999 7.87 12.61 percent of total billed charges SUTURE ETHILON 3-0 627H 49019986_1 CDM 0272 RC inpatient 13 8.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.45 65 999999999 7.87 12.61 percent of total billed charges SUTURE ETHILON 3-0 627H 49019986_1 CDM 0272 RC inpatient 13 8.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.61 97 999999999 7.87 12.61 percent of total billed charges SUTURE ETHILON 3-0 627H 49019986_1 CDM 0272 RC inpatient 13 8.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.14 78 999999999 7.87 12.61 percent of total billed charges SUTURE ETHILON 3-0 627H 49019986_1 CDM 0272 RC inpatient 13 8.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.97 69 999999999 7.87 12.61 percent of total billed charges SUTURE ETHILON 3-0 627H 49019986_1 CDM 0272 RC inpatient 13 8.45 SIHO - ALL PLANS SIHO - ALL PLANS 11.7 90 999999999 7.87 12.61 percent of total billed charges SUTURE ETHILON 3-0 627H 49019986_1 CDM 0272 RC inpatient 13 8.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.87 60.55 999999999 7.87 12.61 percent of total billed charges SUTURE ETHILON 3-0 627H 49019986_1 CDM 0272 RC inpatient 13 8.45 UMR - ALL PLANS UMR - ALL PLANS 9.1 70 999999999 7.87 12.61 percent of total billed charges SUTURE ETHILON 3-0 627H 49019986_1 CDM 0272 RC inpatient 13 8.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.87 12.61 SUTURE ETHILON 3-0 627H 49019986_1 CDM 0272 RC inpatient 13 8.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.87 12.61 SUTURE ETHILON 3-0 627H 49019986_1 CDM 0272 RC inpatient 13 8.45 ANTHEM HMO ANTHEM HMO 999999999 7.87 12.61 SUTURE ETHILON 3-0 627H 49019986_1 CDM 0272 RC inpatient 13 8.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.87 12.61 SUTURE ETHILON 3-0 627H 49019986_1 CDM 0272 RC inpatient 13 8.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.79 67.6 999999999 7.87 12.61 percent of total billed charges SUTURE ETHILON 3-0 627H 49019986_1 CDM 0272 RC inpatient 13 8.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.87 12.61 SUTURE GUT CHROMIC 3-0 636H 49019997_1 CDM 0272 RC inpatient 31 20.15 AETNA AETNA 24.49 79 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 3-0 636H 49019997_1 CDM 0272 RC inpatient 31 20.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.15 65 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 3-0 636H 49019997_1 CDM 0272 RC inpatient 31 20.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.07 97 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 3-0 636H 49019997_1 CDM 0272 RC inpatient 31 20.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.18 78 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 3-0 636H 49019997_1 CDM 0272 RC inpatient 31 20.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.39 69 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 3-0 636H 49019997_1 CDM 0272 RC inpatient 31 20.15 SIHO - ALL PLANS SIHO - ALL PLANS 27.9 90 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 3-0 636H 49019997_1 CDM 0272 RC inpatient 31 20.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.77 60.55 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 3-0 636H 49019997_1 CDM 0272 RC inpatient 31 20.15 UMR - ALL PLANS UMR - ALL PLANS 21.7 70 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 3-0 636H 49019997_1 CDM 0272 RC inpatient 31 20.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.77 30.07 SUTURE GUT CHROMIC 3-0 636H 49019997_1 CDM 0272 RC inpatient 31 20.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.77 30.07 SUTURE GUT CHROMIC 3-0 636H 49019997_1 CDM 0272 RC inpatient 31 20.15 ANTHEM HMO ANTHEM HMO 999999999 18.77 30.07 SUTURE GUT CHROMIC 3-0 636H 49019997_1 CDM 0272 RC inpatient 31 20.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.77 30.07 SUTURE GUT CHROMIC 3-0 636H 49019997_1 CDM 0272 RC inpatient 31 20.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.96 67.6 999999999 18.77 30.07 percent of total billed charges SUTURE GUT CHROMIC 3-0 636H 49019997_1 CDM 0272 RC inpatient 31 20.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.77 30.07 Inactive per Stacey Prosser 49020001_1 CDM 0272 RC inpatient 26 16.9 AETNA AETNA 20.54 79 999999999 15.74 25.22 percent of total billed charges Inactive per Stacey Prosser 49020001_1 CDM 0272 RC inpatient 26 16.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.9 65 999999999 15.74 25.22 percent of total billed charges Inactive per Stacey Prosser 49020001_1 CDM 0272 RC inpatient 26 16.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.22 97 999999999 15.74 25.22 percent of total billed charges Inactive per Stacey Prosser 49020001_1 CDM 0272 RC inpatient 26 16.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.28 78 999999999 15.74 25.22 percent of total billed charges Inactive per Stacey Prosser 49020001_1 CDM 0272 RC inpatient 26 16.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.94 69 999999999 15.74 25.22 percent of total billed charges Inactive per Stacey Prosser 49020001_1 CDM 0272 RC inpatient 26 16.9 SIHO - ALL PLANS SIHO - ALL PLANS 23.4 90 999999999 15.74 25.22 percent of total billed charges Inactive per Stacey Prosser 49020001_1 CDM 0272 RC inpatient 26 16.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.74 60.55 999999999 15.74 25.22 percent of total billed charges Inactive per Stacey Prosser 49020001_1 CDM 0272 RC inpatient 26 16.9 UMR - ALL PLANS UMR - ALL PLANS 18.2 70 999999999 15.74 25.22 percent of total billed charges Inactive per Stacey Prosser 49020001_1 CDM 0272 RC inpatient 26 16.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.74 25.22 Inactive per Stacey Prosser 49020001_1 CDM 0272 RC inpatient 26 16.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.74 25.22 Inactive per Stacey Prosser 49020001_1 CDM 0272 RC inpatient 26 16.9 ANTHEM HMO ANTHEM HMO 999999999 15.74 25.22 Inactive per Stacey Prosser 49020001_1 CDM 0272 RC inpatient 26 16.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.74 25.22 Inactive per Stacey Prosser 49020001_1 CDM 0272 RC inpatient 26 16.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.58 67.6 999999999 15.74 25.22 percent of total billed charges Inactive per Stacey Prosser 49020001_1 CDM 0272 RC inpatient 26 16.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.74 25.22 RUMI KOH EFFICIENT 4.0CM 49020003_1 CDM 0272 RC inpatient 589 382.85 AETNA AETNA 465.31 79 999999999 356.64 571.33 percent of total billed charges RUMI KOH EFFICIENT 4.0CM 49020003_1 CDM 0272 RC inpatient 589 382.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 382.85 65 999999999 356.64 571.33 percent of total billed charges RUMI KOH EFFICIENT 4.0CM 49020003_1 CDM 0272 RC inpatient 589 382.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 571.33 97 999999999 356.64 571.33 percent of total billed charges RUMI KOH EFFICIENT 4.0CM 49020003_1 CDM 0272 RC inpatient 589 382.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 459.42 78 999999999 356.64 571.33 percent of total billed charges RUMI KOH EFFICIENT 4.0CM 49020003_1 CDM 0272 RC inpatient 589 382.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 406.41 69 999999999 356.64 571.33 percent of total billed charges RUMI KOH EFFICIENT 4.0CM 49020003_1 CDM 0272 RC inpatient 589 382.85 SIHO - ALL PLANS SIHO - ALL PLANS 530.1 90 999999999 356.64 571.33 percent of total billed charges RUMI KOH EFFICIENT 4.0CM 49020003_1 CDM 0272 RC inpatient 589 382.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 356.64 60.55 999999999 356.64 571.33 percent of total billed charges RUMI KOH EFFICIENT 4.0CM 49020003_1 CDM 0272 RC inpatient 589 382.85 UMR - ALL PLANS UMR - ALL PLANS 412.3 70 999999999 356.64 571.33 percent of total billed charges RUMI KOH EFFICIENT 4.0CM 49020003_1 CDM 0272 RC inpatient 589 382.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 356.64 571.33 RUMI KOH EFFICIENT 4.0CM 49020003_1 CDM 0272 RC inpatient 589 382.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 356.64 571.33 RUMI KOH EFFICIENT 4.0CM 49020003_1 CDM 0272 RC inpatient 589 382.85 ANTHEM HMO ANTHEM HMO 999999999 356.64 571.33 RUMI KOH EFFICIENT 4.0CM 49020003_1 CDM 0272 RC inpatient 589 382.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 356.64 571.33 RUMI KOH EFFICIENT 4.0CM 49020003_1 CDM 0272 RC inpatient 589 382.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 398.16 67.6 999999999 356.64 571.33 percent of total billed charges RUMI KOH EFFICIENT 4.0CM 49020003_1 CDM 0272 RC inpatient 589 382.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 356.64 571.33 SUTURE ETHILON 5-0 698G P3 49020004_1 CDM 0272 RC inpatient 37 24.05 AETNA AETNA 29.23 79 999999999 22.4 35.89 percent of total billed charges SUTURE ETHILON 5-0 698G P3 49020004_1 CDM 0272 RC inpatient 37 24.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.05 65 999999999 22.4 35.89 percent of total billed charges SUTURE ETHILON 5-0 698G P3 49020004_1 CDM 0272 RC inpatient 37 24.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.89 97 999999999 22.4 35.89 percent of total billed charges SUTURE ETHILON 5-0 698G P3 49020004_1 CDM 0272 RC inpatient 37 24.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.86 78 999999999 22.4 35.89 percent of total billed charges SUTURE ETHILON 5-0 698G P3 49020004_1 CDM 0272 RC inpatient 37 24.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.53 69 999999999 22.4 35.89 percent of total billed charges SUTURE ETHILON 5-0 698G P3 49020004_1 CDM 0272 RC inpatient 37 24.05 SIHO - ALL PLANS SIHO - ALL PLANS 33.3 90 999999999 22.4 35.89 percent of total billed charges SUTURE ETHILON 5-0 698G P3 49020004_1 CDM 0272 RC inpatient 37 24.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.4 60.55 999999999 22.4 35.89 percent of total billed charges SUTURE ETHILON 5-0 698G P3 49020004_1 CDM 0272 RC inpatient 37 24.05 UMR - ALL PLANS UMR - ALL PLANS 25.9 70 999999999 22.4 35.89 percent of total billed charges SUTURE ETHILON 5-0 698G P3 49020004_1 CDM 0272 RC inpatient 37 24.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.4 35.89 SUTURE ETHILON 5-0 698G P3 49020004_1 CDM 0272 RC inpatient 37 24.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.4 35.89 SUTURE ETHILON 5-0 698G P3 49020004_1 CDM 0272 RC inpatient 37 24.05 ANTHEM HMO ANTHEM HMO 999999999 22.4 35.89 SUTURE ETHILON 5-0 698G P3 49020004_1 CDM 0272 RC inpatient 37 24.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.4 35.89 SUTURE ETHILON 5-0 698G P3 49020004_1 CDM 0272 RC inpatient 37 24.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.01 67.6 999999999 22.4 35.89 percent of total billed charges SUTURE ETHILON 5-0 698G P3 49020004_1 CDM 0272 RC inpatient 37 24.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.4 35.89 SUTURE GUT CHROMIC 2-0 811H 49020008_1 CDM 0272 RC inpatient 18 11.7 AETNA AETNA 14.22 79 999999999 10.9 17.46 percent of total billed charges SUTURE GUT CHROMIC 2-0 811H 49020008_1 CDM 0272 RC inpatient 18 11.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.7 65 999999999 10.9 17.46 percent of total billed charges SUTURE GUT CHROMIC 2-0 811H 49020008_1 CDM 0272 RC inpatient 18 11.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.46 97 999999999 10.9 17.46 percent of total billed charges SUTURE GUT CHROMIC 2-0 811H 49020008_1 CDM 0272 RC inpatient 18 11.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.04 78 999999999 10.9 17.46 percent of total billed charges SUTURE GUT CHROMIC 2-0 811H 49020008_1 CDM 0272 RC inpatient 18 11.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.42 69 999999999 10.9 17.46 percent of total billed charges SUTURE GUT CHROMIC 2-0 811H 49020008_1 CDM 0272 RC inpatient 18 11.7 SIHO - ALL PLANS SIHO - ALL PLANS 16.2 90 999999999 10.9 17.46 percent of total billed charges SUTURE GUT CHROMIC 2-0 811H 49020008_1 CDM 0272 RC inpatient 18 11.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.9 60.55 999999999 10.9 17.46 percent of total billed charges SUTURE GUT CHROMIC 2-0 811H 49020008_1 CDM 0272 RC inpatient 18 11.7 UMR - ALL PLANS UMR - ALL PLANS 12.6 70 999999999 10.9 17.46 percent of total billed charges SUTURE GUT CHROMIC 2-0 811H 49020008_1 CDM 0272 RC inpatient 18 11.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.9 17.46 SUTURE GUT CHROMIC 2-0 811H 49020008_1 CDM 0272 RC inpatient 18 11.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.9 17.46 SUTURE GUT CHROMIC 2-0 811H 49020008_1 CDM 0272 RC inpatient 18 11.7 ANTHEM HMO ANTHEM HMO 999999999 10.9 17.46 SUTURE GUT CHROMIC 2-0 811H 49020008_1 CDM 0272 RC inpatient 18 11.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.9 17.46 SUTURE GUT CHROMIC 2-0 811H 49020008_1 CDM 0272 RC inpatient 18 11.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.17 67.6 999999999 10.9 17.46 percent of total billed charges SUTURE GUT CHROMIC 2-0 811H 49020008_1 CDM 0272 RC inpatient 18 11.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.9 17.46 SUTURE GUT CHROMIC #0 812H 49020009_1 CDM 0272 RC inpatient 67 43.55 AETNA AETNA 52.93 79 999999999 40.57 64.99 percent of total billed charges SUTURE GUT CHROMIC #0 812H 49020009_1 CDM 0272 RC inpatient 67 43.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 43.55 65 999999999 40.57 64.99 percent of total billed charges SUTURE GUT CHROMIC #0 812H 49020009_1 CDM 0272 RC inpatient 67 43.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.99 97 999999999 40.57 64.99 percent of total billed charges SUTURE GUT CHROMIC #0 812H 49020009_1 CDM 0272 RC inpatient 67 43.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 52.26 78 999999999 40.57 64.99 percent of total billed charges SUTURE GUT CHROMIC #0 812H 49020009_1 CDM 0272 RC inpatient 67 43.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.23 69 999999999 40.57 64.99 percent of total billed charges SUTURE GUT CHROMIC #0 812H 49020009_1 CDM 0272 RC inpatient 67 43.55 SIHO - ALL PLANS SIHO - ALL PLANS 60.3 90 999999999 40.57 64.99 percent of total billed charges SUTURE GUT CHROMIC #0 812H 49020009_1 CDM 0272 RC inpatient 67 43.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 40.57 60.55 999999999 40.57 64.99 percent of total billed charges SUTURE GUT CHROMIC #0 812H 49020009_1 CDM 0272 RC inpatient 67 43.55 UMR - ALL PLANS UMR - ALL PLANS 46.9 70 999999999 40.57 64.99 percent of total billed charges SUTURE GUT CHROMIC #0 812H 49020009_1 CDM 0272 RC inpatient 67 43.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 40.57 64.99 SUTURE GUT CHROMIC #0 812H 49020009_1 CDM 0272 RC inpatient 67 43.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 40.57 64.99 SUTURE GUT CHROMIC #0 812H 49020009_1 CDM 0272 RC inpatient 67 43.55 ANTHEM HMO ANTHEM HMO 999999999 40.57 64.99 SUTURE GUT CHROMIC #0 812H 49020009_1 CDM 0272 RC inpatient 67 43.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 40.57 64.99 SUTURE GUT CHROMIC #0 812H 49020009_1 CDM 0272 RC inpatient 67 43.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.29 67.6 999999999 40.57 64.99 percent of total billed charges SUTURE GUT CHROMIC #0 812H 49020009_1 CDM 0272 RC inpatient 67 43.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 40.57 64.99 SUTURE GUT CHROMIC #1 813H 49020011_1 CDM 0272 RC inpatient 19 12.35 AETNA AETNA 15.01 79 999999999 11.5 18.43 percent of total billed charges SUTURE GUT CHROMIC #1 813H 49020011_1 CDM 0272 RC inpatient 19 12.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.35 65 999999999 11.5 18.43 percent of total billed charges SUTURE GUT CHROMIC #1 813H 49020011_1 CDM 0272 RC inpatient 19 12.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 18.43 97 999999999 11.5 18.43 percent of total billed charges SUTURE GUT CHROMIC #1 813H 49020011_1 CDM 0272 RC inpatient 19 12.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.82 78 999999999 11.5 18.43 percent of total billed charges SUTURE GUT CHROMIC #1 813H 49020011_1 CDM 0272 RC inpatient 19 12.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.11 69 999999999 11.5 18.43 percent of total billed charges SUTURE GUT CHROMIC #1 813H 49020011_1 CDM 0272 RC inpatient 19 12.35 SIHO - ALL PLANS SIHO - ALL PLANS 17.1 90 999999999 11.5 18.43 percent of total billed charges SUTURE GUT CHROMIC #1 813H 49020011_1 CDM 0272 RC inpatient 19 12.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.5 60.55 999999999 11.5 18.43 percent of total billed charges SUTURE GUT CHROMIC #1 813H 49020011_1 CDM 0272 RC inpatient 19 12.35 UMR - ALL PLANS UMR - ALL PLANS 13.3 70 999999999 11.5 18.43 percent of total billed charges SUTURE GUT CHROMIC #1 813H 49020011_1 CDM 0272 RC inpatient 19 12.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.5 18.43 SUTURE GUT CHROMIC #1 813H 49020011_1 CDM 0272 RC inpatient 19 12.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.5 18.43 SUTURE GUT CHROMIC #1 813H 49020011_1 CDM 0272 RC inpatient 19 12.35 ANTHEM HMO ANTHEM HMO 999999999 11.5 18.43 SUTURE GUT CHROMIC #1 813H 49020011_1 CDM 0272 RC inpatient 19 12.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.5 18.43 SUTURE GUT CHROMIC #1 813H 49020011_1 CDM 0272 RC inpatient 19 12.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.84 67.6 999999999 11.5 18.43 percent of total billed charges SUTURE GUT CHROMIC #1 813H 49020011_1 CDM 0272 RC inpatient 19 12.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.5 18.43 SUTURE CHO GUT 0 924H 49020013_1 CDM 0272 RC inpatient 32 20.8 AETNA AETNA 25.28 79 999999999 19.38 31.04 percent of total billed charges SUTURE CHO GUT 0 924H 49020013_1 CDM 0272 RC inpatient 32 20.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.8 65 999999999 19.38 31.04 percent of total billed charges SUTURE CHO GUT 0 924H 49020013_1 CDM 0272 RC inpatient 32 20.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31.04 97 999999999 19.38 31.04 percent of total billed charges SUTURE CHO GUT 0 924H 49020013_1 CDM 0272 RC inpatient 32 20.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.96 78 999999999 19.38 31.04 percent of total billed charges SUTURE CHO GUT 0 924H 49020013_1 CDM 0272 RC inpatient 32 20.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.08 69 999999999 19.38 31.04 percent of total billed charges SUTURE CHO GUT 0 924H 49020013_1 CDM 0272 RC inpatient 32 20.8 SIHO - ALL PLANS SIHO - ALL PLANS 28.8 90 999999999 19.38 31.04 percent of total billed charges SUTURE CHO GUT 0 924H 49020013_1 CDM 0272 RC inpatient 32 20.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.38 60.55 999999999 19.38 31.04 percent of total billed charges SUTURE CHO GUT 0 924H 49020013_1 CDM 0272 RC inpatient 32 20.8 UMR - ALL PLANS UMR - ALL PLANS 22.4 70 999999999 19.38 31.04 percent of total billed charges SUTURE CHO GUT 0 924H 49020013_1 CDM 0272 RC inpatient 32 20.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.38 31.04 SUTURE CHO GUT 0 924H 49020013_1 CDM 0272 RC inpatient 32 20.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.38 31.04 SUTURE CHO GUT 0 924H 49020013_1 CDM 0272 RC inpatient 32 20.8 ANTHEM HMO ANTHEM HMO 999999999 19.38 31.04 SUTURE CHO GUT 0 924H 49020013_1 CDM 0272 RC inpatient 32 20.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.38 31.04 SUTURE CHO GUT 0 924H 49020013_1 CDM 0272 RC inpatient 32 20.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.63 67.6 999999999 19.38 31.04 percent of total billed charges SUTURE CHO GUT 0 924H 49020013_1 CDM 0272 RC inpatient 32 20.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.38 31.04 SUTURE CHROMIC 2-0 N878H 49020014_1 CDM 0272 RC inpatient 35 22.75 AETNA AETNA 27.65 79 999999999 21.19 33.95 percent of total billed charges SUTURE CHROMIC 2-0 N878H 49020014_1 CDM 0272 RC inpatient 35 22.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.75 65 999999999 21.19 33.95 percent of total billed charges SUTURE CHROMIC 2-0 N878H 49020014_1 CDM 0272 RC inpatient 35 22.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33.95 97 999999999 21.19 33.95 percent of total billed charges SUTURE CHROMIC 2-0 N878H 49020014_1 CDM 0272 RC inpatient 35 22.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.3 78 999999999 21.19 33.95 percent of total billed charges SUTURE CHROMIC 2-0 N878H 49020014_1 CDM 0272 RC inpatient 35 22.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.15 69 999999999 21.19 33.95 percent of total billed charges SUTURE CHROMIC 2-0 N878H 49020014_1 CDM 0272 RC inpatient 35 22.75 SIHO - ALL PLANS SIHO - ALL PLANS 31.5 90 999999999 21.19 33.95 percent of total billed charges SUTURE CHROMIC 2-0 N878H 49020014_1 CDM 0272 RC inpatient 35 22.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.19 60.55 999999999 21.19 33.95 percent of total billed charges SUTURE CHROMIC 2-0 N878H 49020014_1 CDM 0272 RC inpatient 35 22.75 UMR - ALL PLANS UMR - ALL PLANS 24.5 70 999999999 21.19 33.95 percent of total billed charges SUTURE CHROMIC 2-0 N878H 49020014_1 CDM 0272 RC inpatient 35 22.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.19 33.95 SUTURE CHROMIC 2-0 N878H 49020014_1 CDM 0272 RC inpatient 35 22.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.19 33.95 SUTURE CHROMIC 2-0 N878H 49020014_1 CDM 0272 RC inpatient 35 22.75 ANTHEM HMO ANTHEM HMO 999999999 21.19 33.95 SUTURE CHROMIC 2-0 N878H 49020014_1 CDM 0272 RC inpatient 35 22.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.19 33.95 SUTURE CHROMIC 2-0 N878H 49020014_1 CDM 0272 RC inpatient 35 22.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 23.66 67.6 999999999 21.19 33.95 percent of total billed charges SUTURE CHROMIC 2-0 N878H 49020014_1 CDM 0272 RC inpatient 35 22.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.19 33.95 SUTURE PROLENE #0 8424H CLOS 49020016_1 CDM 0272 RC inpatient 25 16.25 AETNA AETNA 19.75 79 999999999 15.14 24.25 percent of total billed charges SUTURE PROLENE #0 8424H CLOS 49020016_1 CDM 0272 RC inpatient 25 16.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.25 65 999999999 15.14 24.25 percent of total billed charges SUTURE PROLENE #0 8424H CLOS 49020016_1 CDM 0272 RC inpatient 25 16.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.25 97 999999999 15.14 24.25 percent of total billed charges SUTURE PROLENE #0 8424H CLOS 49020016_1 CDM 0272 RC inpatient 25 16.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.5 78 999999999 15.14 24.25 percent of total billed charges SUTURE PROLENE #0 8424H CLOS 49020016_1 CDM 0272 RC inpatient 25 16.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.25 69 999999999 15.14 24.25 percent of total billed charges SUTURE PROLENE #0 8424H CLOS 49020016_1 CDM 0272 RC inpatient 25 16.25 SIHO - ALL PLANS SIHO - ALL PLANS 22.5 90 999999999 15.14 24.25 percent of total billed charges SUTURE PROLENE #0 8424H CLOS 49020016_1 CDM 0272 RC inpatient 25 16.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.14 60.55 999999999 15.14 24.25 percent of total billed charges SUTURE PROLENE #0 8424H CLOS 49020016_1 CDM 0272 RC inpatient 25 16.25 UMR - ALL PLANS UMR - ALL PLANS 17.5 70 999999999 15.14 24.25 percent of total billed charges SUTURE PROLENE #0 8424H CLOS 49020016_1 CDM 0272 RC inpatient 25 16.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.14 24.25 SUTURE PROLENE #0 8424H CLOS 49020016_1 CDM 0272 RC inpatient 25 16.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.14 24.25 SUTURE PROLENE #0 8424H CLOS 49020016_1 CDM 0272 RC inpatient 25 16.25 ANTHEM HMO ANTHEM HMO 999999999 15.14 24.25 SUTURE PROLENE #0 8424H CLOS 49020016_1 CDM 0272 RC inpatient 25 16.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.14 24.25 SUTURE PROLENE #0 8424H CLOS 49020016_1 CDM 0272 RC inpatient 25 16.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.9 67.6 999999999 15.14 24.25 percent of total billed charges SUTURE PROLENE #0 8424H CLOS 49020016_1 CDM 0272 RC inpatient 25 16.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.14 24.25 SUTURE PROLENE 2-0 8411H 49020018_1 CDM 0272 RC inpatient 26 16.9 AETNA AETNA 20.54 79 999999999 15.74 25.22 percent of total billed charges SUTURE PROLENE 2-0 8411H 49020018_1 CDM 0272 RC inpatient 26 16.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.9 65 999999999 15.74 25.22 percent of total billed charges SUTURE PROLENE 2-0 8411H 49020018_1 CDM 0272 RC inpatient 26 16.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.22 97 999999999 15.74 25.22 percent of total billed charges SUTURE PROLENE 2-0 8411H 49020018_1 CDM 0272 RC inpatient 26 16.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.28 78 999999999 15.74 25.22 percent of total billed charges SUTURE PROLENE 2-0 8411H 49020018_1 CDM 0272 RC inpatient 26 16.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.94 69 999999999 15.74 25.22 percent of total billed charges SUTURE PROLENE 2-0 8411H 49020018_1 CDM 0272 RC inpatient 26 16.9 SIHO - ALL PLANS SIHO - ALL PLANS 23.4 90 999999999 15.74 25.22 percent of total billed charges SUTURE PROLENE 2-0 8411H 49020018_1 CDM 0272 RC inpatient 26 16.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.74 60.55 999999999 15.74 25.22 percent of total billed charges SUTURE PROLENE 2-0 8411H 49020018_1 CDM 0272 RC inpatient 26 16.9 UMR - ALL PLANS UMR - ALL PLANS 18.2 70 999999999 15.74 25.22 percent of total billed charges SUTURE PROLENE 2-0 8411H 49020018_1 CDM 0272 RC inpatient 26 16.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.74 25.22 SUTURE PROLENE 2-0 8411H 49020018_1 CDM 0272 RC inpatient 26 16.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.74 25.22 SUTURE PROLENE 2-0 8411H 49020018_1 CDM 0272 RC inpatient 26 16.9 ANTHEM HMO ANTHEM HMO 999999999 15.74 25.22 SUTURE PROLENE 2-0 8411H 49020018_1 CDM 0272 RC inpatient 26 16.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.74 25.22 SUTURE PROLENE 2-0 8411H 49020018_1 CDM 0272 RC inpatient 26 16.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.58 67.6 999999999 15.74 25.22 percent of total billed charges SUTURE PROLENE 2-0 8411H 49020018_1 CDM 0272 RC inpatient 26 16.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.74 25.22 SUTURE PROLENE 3-0 8675H 49020024_1 CDM 0272 RC inpatient 19 12.35 AETNA AETNA 15.01 79 999999999 11.5 18.43 percent of total billed charges SUTURE PROLENE 3-0 8675H 49020024_1 CDM 0272 RC inpatient 19 12.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.35 65 999999999 11.5 18.43 percent of total billed charges SUTURE PROLENE 3-0 8675H 49020024_1 CDM 0272 RC inpatient 19 12.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 18.43 97 999999999 11.5 18.43 percent of total billed charges SUTURE PROLENE 3-0 8675H 49020024_1 CDM 0272 RC inpatient 19 12.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.82 78 999999999 11.5 18.43 percent of total billed charges SUTURE PROLENE 3-0 8675H 49020024_1 CDM 0272 RC inpatient 19 12.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.11 69 999999999 11.5 18.43 percent of total billed charges SUTURE PROLENE 3-0 8675H 49020024_1 CDM 0272 RC inpatient 19 12.35 SIHO - ALL PLANS SIHO - ALL PLANS 17.1 90 999999999 11.5 18.43 percent of total billed charges SUTURE PROLENE 3-0 8675H 49020024_1 CDM 0272 RC inpatient 19 12.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.5 60.55 999999999 11.5 18.43 percent of total billed charges SUTURE PROLENE 3-0 8675H 49020024_1 CDM 0272 RC inpatient 19 12.35 UMR - ALL PLANS UMR - ALL PLANS 13.3 70 999999999 11.5 18.43 percent of total billed charges SUTURE PROLENE 3-0 8675H 49020024_1 CDM 0272 RC inpatient 19 12.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.5 18.43 SUTURE PROLENE 3-0 8675H 49020024_1 CDM 0272 RC inpatient 19 12.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.5 18.43 SUTURE PROLENE 3-0 8675H 49020024_1 CDM 0272 RC inpatient 19 12.35 ANTHEM HMO ANTHEM HMO 999999999 11.5 18.43 SUTURE PROLENE 3-0 8675H 49020024_1 CDM 0272 RC inpatient 19 12.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.5 18.43 SUTURE PROLENE 3-0 8675H 49020024_1 CDM 0272 RC inpatient 19 12.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.84 67.6 999999999 11.5 18.43 percent of total billed charges SUTURE PROLENE 3-0 8675H 49020024_1 CDM 0272 RC inpatient 19 12.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.5 18.43 SUTURE PROLENE 4-0 8557H 49020026_1 CDM 0272 RC inpatient 52 33.8 AETNA AETNA 41.08 79 999999999 31.49 50.44 percent of total billed charges SUTURE PROLENE 4-0 8557H 49020026_1 CDM 0272 RC inpatient 52 33.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 33.8 65 999999999 31.49 50.44 percent of total billed charges SUTURE PROLENE 4-0 8557H 49020026_1 CDM 0272 RC inpatient 52 33.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 50.44 97 999999999 31.49 50.44 percent of total billed charges SUTURE PROLENE 4-0 8557H 49020026_1 CDM 0272 RC inpatient 52 33.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 40.56 78 999999999 31.49 50.44 percent of total billed charges SUTURE PROLENE 4-0 8557H 49020026_1 CDM 0272 RC inpatient 52 33.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 35.88 69 999999999 31.49 50.44 percent of total billed charges SUTURE PROLENE 4-0 8557H 49020026_1 CDM 0272 RC inpatient 52 33.8 SIHO - ALL PLANS SIHO - ALL PLANS 46.8 90 999999999 31.49 50.44 percent of total billed charges SUTURE PROLENE 4-0 8557H 49020026_1 CDM 0272 RC inpatient 52 33.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 31.49 60.55 999999999 31.49 50.44 percent of total billed charges SUTURE PROLENE 4-0 8557H 49020026_1 CDM 0272 RC inpatient 52 33.8 UMR - ALL PLANS UMR - ALL PLANS 36.4 70 999999999 31.49 50.44 percent of total billed charges SUTURE PROLENE 4-0 8557H 49020026_1 CDM 0272 RC inpatient 52 33.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 31.49 50.44 SUTURE PROLENE 4-0 8557H 49020026_1 CDM 0272 RC inpatient 52 33.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 31.49 50.44 SUTURE PROLENE 4-0 8557H 49020026_1 CDM 0272 RC inpatient 52 33.8 ANTHEM HMO ANTHEM HMO 999999999 31.49 50.44 SUTURE PROLENE 4-0 8557H 49020026_1 CDM 0272 RC inpatient 52 33.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 31.49 50.44 SUTURE PROLENE 4-0 8557H 49020026_1 CDM 0272 RC inpatient 52 33.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.15 67.6 999999999 31.49 50.44 percent of total billed charges SUTURE PROLENE 4-0 8557H 49020026_1 CDM 0272 RC inpatient 52 33.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 31.49 50.44 SUTURE PROLENE 3-0 8558H 49020027_1 CDM 0272 RC inpatient 59 38.35 AETNA AETNA 46.61 79 999999999 35.72 57.23 percent of total billed charges SUTURE PROLENE 3-0 8558H 49020027_1 CDM 0272 RC inpatient 59 38.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 38.35 65 999999999 35.72 57.23 percent of total billed charges SUTURE PROLENE 3-0 8558H 49020027_1 CDM 0272 RC inpatient 59 38.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 57.23 97 999999999 35.72 57.23 percent of total billed charges SUTURE PROLENE 3-0 8558H 49020027_1 CDM 0272 RC inpatient 59 38.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.02 78 999999999 35.72 57.23 percent of total billed charges SUTURE PROLENE 3-0 8558H 49020027_1 CDM 0272 RC inpatient 59 38.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.71 69 999999999 35.72 57.23 percent of total billed charges SUTURE PROLENE 3-0 8558H 49020027_1 CDM 0272 RC inpatient 59 38.35 SIHO - ALL PLANS SIHO - ALL PLANS 53.1 90 999999999 35.72 57.23 percent of total billed charges SUTURE PROLENE 3-0 8558H 49020027_1 CDM 0272 RC inpatient 59 38.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.72 60.55 999999999 35.72 57.23 percent of total billed charges SUTURE PROLENE 3-0 8558H 49020027_1 CDM 0272 RC inpatient 59 38.35 UMR - ALL PLANS UMR - ALL PLANS 41.3 70 999999999 35.72 57.23 percent of total billed charges SUTURE PROLENE 3-0 8558H 49020027_1 CDM 0272 RC inpatient 59 38.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.72 57.23 SUTURE PROLENE 3-0 8558H 49020027_1 CDM 0272 RC inpatient 59 38.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.72 57.23 SUTURE PROLENE 3-0 8558H 49020027_1 CDM 0272 RC inpatient 59 38.35 ANTHEM HMO ANTHEM HMO 999999999 35.72 57.23 SUTURE PROLENE 3-0 8558H 49020027_1 CDM 0272 RC inpatient 59 38.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.72 57.23 SUTURE PROLENE 3-0 8558H 49020027_1 CDM 0272 RC inpatient 59 38.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.88 67.6 999999999 35.72 57.23 percent of total billed charges SUTURE PROLENE 3-0 8558H 49020027_1 CDM 0272 RC inpatient 59 38.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.72 57.23 SUTURE PROLENE 4-0 8682G PS-2 49020030_1 CDM 0272 RC inpatient 57 37.05 AETNA AETNA 45.03 79 999999999 34.51 55.29 percent of total billed charges SUTURE PROLENE 4-0 8682G PS-2 49020030_1 CDM 0272 RC inpatient 57 37.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.05 65 999999999 34.51 55.29 percent of total billed charges SUTURE PROLENE 4-0 8682G PS-2 49020030_1 CDM 0272 RC inpatient 57 37.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.29 97 999999999 34.51 55.29 percent of total billed charges SUTURE PROLENE 4-0 8682G PS-2 49020030_1 CDM 0272 RC inpatient 57 37.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.46 78 999999999 34.51 55.29 percent of total billed charges SUTURE PROLENE 4-0 8682G PS-2 49020030_1 CDM 0272 RC inpatient 57 37.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.33 69 999999999 34.51 55.29 percent of total billed charges SUTURE PROLENE 4-0 8682G PS-2 49020030_1 CDM 0272 RC inpatient 57 37.05 SIHO - ALL PLANS SIHO - ALL PLANS 51.3 90 999999999 34.51 55.29 percent of total billed charges SUTURE PROLENE 4-0 8682G PS-2 49020030_1 CDM 0272 RC inpatient 57 37.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.51 60.55 999999999 34.51 55.29 percent of total billed charges SUTURE PROLENE 4-0 8682G PS-2 49020030_1 CDM 0272 RC inpatient 57 37.05 UMR - ALL PLANS UMR - ALL PLANS 39.9 70 999999999 34.51 55.29 percent of total billed charges SUTURE PROLENE 4-0 8682G PS-2 49020030_1 CDM 0272 RC inpatient 57 37.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.51 55.29 SUTURE PROLENE 4-0 8682G PS-2 49020030_1 CDM 0272 RC inpatient 57 37.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.51 55.29 SUTURE PROLENE 4-0 8682G PS-2 49020030_1 CDM 0272 RC inpatient 57 37.05 ANTHEM HMO ANTHEM HMO 999999999 34.51 55.29 SUTURE PROLENE 4-0 8682G PS-2 49020030_1 CDM 0272 RC inpatient 57 37.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.51 55.29 SUTURE PROLENE 4-0 8682G PS-2 49020030_1 CDM 0272 RC inpatient 57 37.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.53 67.6 999999999 34.51 55.29 percent of total billed charges SUTURE PROLENE 4-0 8682G PS-2 49020030_1 CDM 0272 RC inpatient 57 37.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.51 55.29 SUTURE PROLENE 5-0 8686G PS2 49020031_1 CDM 0272 RC inpatient 46 29.9 AETNA AETNA 36.34 79 999999999 27.85 44.62 percent of total billed charges SUTURE PROLENE 5-0 8686G PS2 49020031_1 CDM 0272 RC inpatient 46 29.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 29.9 65 999999999 27.85 44.62 percent of total billed charges SUTURE PROLENE 5-0 8686G PS2 49020031_1 CDM 0272 RC inpatient 46 29.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 44.62 97 999999999 27.85 44.62 percent of total billed charges SUTURE PROLENE 5-0 8686G PS2 49020031_1 CDM 0272 RC inpatient 46 29.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 35.88 78 999999999 27.85 44.62 percent of total billed charges SUTURE PROLENE 5-0 8686G PS2 49020031_1 CDM 0272 RC inpatient 46 29.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 31.74 69 999999999 27.85 44.62 percent of total billed charges SUTURE PROLENE 5-0 8686G PS2 49020031_1 CDM 0272 RC inpatient 46 29.9 SIHO - ALL PLANS SIHO - ALL PLANS 41.4 90 999999999 27.85 44.62 percent of total billed charges SUTURE PROLENE 5-0 8686G PS2 49020031_1 CDM 0272 RC inpatient 46 29.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27.85 60.55 999999999 27.85 44.62 percent of total billed charges SUTURE PROLENE 5-0 8686G PS2 49020031_1 CDM 0272 RC inpatient 46 29.9 UMR - ALL PLANS UMR - ALL PLANS 32.2 70 999999999 27.85 44.62 percent of total billed charges SUTURE PROLENE 5-0 8686G PS2 49020031_1 CDM 0272 RC inpatient 46 29.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 27.85 44.62 SUTURE PROLENE 5-0 8686G PS2 49020031_1 CDM 0272 RC inpatient 46 29.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 27.85 44.62 SUTURE PROLENE 5-0 8686G PS2 49020031_1 CDM 0272 RC inpatient 46 29.9 ANTHEM HMO ANTHEM HMO 999999999 27.85 44.62 SUTURE PROLENE 5-0 8686G PS2 49020031_1 CDM 0272 RC inpatient 46 29.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 27.85 44.62 SUTURE PROLENE 5-0 8686G PS2 49020031_1 CDM 0272 RC inpatient 46 29.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 31.1 67.6 999999999 27.85 44.62 percent of total billed charges SUTURE PROLENE 5-0 8686G PS2 49020031_1 CDM 0272 RC inpatient 46 29.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 27.85 44.62 SUTURE PROLENE 6-0 8695G PLAS 49020034_1 CDM 0272 RC inpatient 61 39.65 AETNA AETNA 48.19 79 999999999 36.94 59.17 percent of total billed charges SUTURE PROLENE 6-0 8695G PLAS 49020034_1 CDM 0272 RC inpatient 61 39.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.65 65 999999999 36.94 59.17 percent of total billed charges SUTURE PROLENE 6-0 8695G PLAS 49020034_1 CDM 0272 RC inpatient 61 39.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59.17 97 999999999 36.94 59.17 percent of total billed charges SUTURE PROLENE 6-0 8695G PLAS 49020034_1 CDM 0272 RC inpatient 61 39.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.58 78 999999999 36.94 59.17 percent of total billed charges SUTURE PROLENE 6-0 8695G PLAS 49020034_1 CDM 0272 RC inpatient 61 39.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.09 69 999999999 36.94 59.17 percent of total billed charges SUTURE PROLENE 6-0 8695G PLAS 49020034_1 CDM 0272 RC inpatient 61 39.65 SIHO - ALL PLANS SIHO - ALL PLANS 54.9 90 999999999 36.94 59.17 percent of total billed charges SUTURE PROLENE 6-0 8695G PLAS 49020034_1 CDM 0272 RC inpatient 61 39.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.94 60.55 999999999 36.94 59.17 percent of total billed charges SUTURE PROLENE 6-0 8695G PLAS 49020034_1 CDM 0272 RC inpatient 61 39.65 UMR - ALL PLANS UMR - ALL PLANS 42.7 70 999999999 36.94 59.17 percent of total billed charges SUTURE PROLENE 6-0 8695G PLAS 49020034_1 CDM 0272 RC inpatient 61 39.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.94 59.17 SUTURE PROLENE 6-0 8695G PLAS 49020034_1 CDM 0272 RC inpatient 61 39.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.94 59.17 SUTURE PROLENE 6-0 8695G PLAS 49020034_1 CDM 0272 RC inpatient 61 39.65 ANTHEM HMO ANTHEM HMO 999999999 36.94 59.17 SUTURE PROLENE 6-0 8695G PLAS 49020034_1 CDM 0272 RC inpatient 61 39.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.94 59.17 SUTURE PROLENE 6-0 8695G PLAS 49020034_1 CDM 0272 RC inpatient 61 39.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.24 67.6 999999999 36.94 59.17 percent of total billed charges SUTURE PROLENE 6-0 8695G PLAS 49020034_1 CDM 0272 RC inpatient 61 39.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.94 59.17 SUTURE PROLENE 5-0 8698G P3 49020035_1 CDM 0272 RC inpatient 49 31.85 AETNA AETNA 38.71 79 999999999 29.67 47.53 percent of total billed charges SUTURE PROLENE 5-0 8698G P3 49020035_1 CDM 0272 RC inpatient 49 31.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.85 65 999999999 29.67 47.53 percent of total billed charges SUTURE PROLENE 5-0 8698G P3 49020035_1 CDM 0272 RC inpatient 49 31.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 47.53 97 999999999 29.67 47.53 percent of total billed charges SUTURE PROLENE 5-0 8698G P3 49020035_1 CDM 0272 RC inpatient 49 31.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 38.22 78 999999999 29.67 47.53 percent of total billed charges SUTURE PROLENE 5-0 8698G P3 49020035_1 CDM 0272 RC inpatient 49 31.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.81 69 999999999 29.67 47.53 percent of total billed charges SUTURE PROLENE 5-0 8698G P3 49020035_1 CDM 0272 RC inpatient 49 31.85 SIHO - ALL PLANS SIHO - ALL PLANS 44.1 90 999999999 29.67 47.53 percent of total billed charges SUTURE PROLENE 5-0 8698G P3 49020035_1 CDM 0272 RC inpatient 49 31.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.67 60.55 999999999 29.67 47.53 percent of total billed charges SUTURE PROLENE 5-0 8698G P3 49020035_1 CDM 0272 RC inpatient 49 31.85 UMR - ALL PLANS UMR - ALL PLANS 34.3 70 999999999 29.67 47.53 percent of total billed charges SUTURE PROLENE 5-0 8698G P3 49020035_1 CDM 0272 RC inpatient 49 31.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.67 47.53 SUTURE PROLENE 5-0 8698G P3 49020035_1 CDM 0272 RC inpatient 49 31.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.67 47.53 SUTURE PROLENE 5-0 8698G P3 49020035_1 CDM 0272 RC inpatient 49 31.85 ANTHEM HMO ANTHEM HMO 999999999 29.67 47.53 SUTURE PROLENE 5-0 8698G P3 49020035_1 CDM 0272 RC inpatient 49 31.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.67 47.53 SUTURE PROLENE 5-0 8698G P3 49020035_1 CDM 0272 RC inpatient 49 31.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.12 67.6 999999999 29.67 47.53 percent of total billed charges SUTURE PROLENE 5-0 8698G P3 49020035_1 CDM 0272 RC inpatient 49 31.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.67 47.53 SUTR SILK 2-0 737G 49020038_1 CDM 0272 RC inpatient 10 6.5 AETNA AETNA 7.9 79 999999999 6.06 9.7 percent of total billed charges SUTR SILK 2-0 737G 49020038_1 CDM 0272 RC inpatient 10 6.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.5 65 999999999 6.06 9.7 percent of total billed charges SUTR SILK 2-0 737G 49020038_1 CDM 0272 RC inpatient 10 6.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.7 97 999999999 6.06 9.7 percent of total billed charges SUTR SILK 2-0 737G 49020038_1 CDM 0272 RC inpatient 10 6.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.8 78 999999999 6.06 9.7 percent of total billed charges SUTR SILK 2-0 737G 49020038_1 CDM 0272 RC inpatient 10 6.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.9 69 999999999 6.06 9.7 percent of total billed charges SUTR SILK 2-0 737G 49020038_1 CDM 0272 RC inpatient 10 6.5 SIHO - ALL PLANS SIHO - ALL PLANS 9 90 999999999 6.06 9.7 percent of total billed charges SUTR SILK 2-0 737G 49020038_1 CDM 0272 RC inpatient 10 6.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.06 60.55 999999999 6.06 9.7 percent of total billed charges SUTR SILK 2-0 737G 49020038_1 CDM 0272 RC inpatient 10 6.5 UMR - ALL PLANS UMR - ALL PLANS 7 70 999999999 6.06 9.7 percent of total billed charges SUTR SILK 2-0 737G 49020038_1 CDM 0272 RC inpatient 10 6.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.06 9.7 SUTR SILK 2-0 737G 49020038_1 CDM 0272 RC inpatient 10 6.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.06 9.7 SUTR SILK 2-0 737G 49020038_1 CDM 0272 RC inpatient 10 6.5 ANTHEM HMO ANTHEM HMO 999999999 6.06 9.7 SUTR SILK 2-0 737G 49020038_1 CDM 0272 RC inpatient 10 6.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.06 9.7 SUTR SILK 2-0 737G 49020038_1 CDM 0272 RC inpatient 10 6.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.76 67.6 999999999 6.06 9.7 percent of total billed charges SUTR SILK 2-0 737G 49020038_1 CDM 0272 RC inpatient 10 6.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.06 9.7 SUTURE MAXON 0 #6301-61 49020041_1 CDM 0272 RC inpatient 44 28.6 AETNA AETNA 34.76 79 999999999 26.64 42.68 percent of total billed charges SUTURE MAXON 0 #6301-61 49020041_1 CDM 0272 RC inpatient 44 28.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 28.6 65 999999999 26.64 42.68 percent of total billed charges SUTURE MAXON 0 #6301-61 49020041_1 CDM 0272 RC inpatient 44 28.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 42.68 97 999999999 26.64 42.68 percent of total billed charges SUTURE MAXON 0 #6301-61 49020041_1 CDM 0272 RC inpatient 44 28.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 34.32 78 999999999 26.64 42.68 percent of total billed charges SUTURE MAXON 0 #6301-61 49020041_1 CDM 0272 RC inpatient 44 28.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 30.36 69 999999999 26.64 42.68 percent of total billed charges SUTURE MAXON 0 #6301-61 49020041_1 CDM 0272 RC inpatient 44 28.6 SIHO - ALL PLANS SIHO - ALL PLANS 39.6 90 999999999 26.64 42.68 percent of total billed charges SUTURE MAXON 0 #6301-61 49020041_1 CDM 0272 RC inpatient 44 28.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26.64 60.55 999999999 26.64 42.68 percent of total billed charges SUTURE MAXON 0 #6301-61 49020041_1 CDM 0272 RC inpatient 44 28.6 UMR - ALL PLANS UMR - ALL PLANS 30.8 70 999999999 26.64 42.68 percent of total billed charges SUTURE MAXON 0 #6301-61 49020041_1 CDM 0272 RC inpatient 44 28.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26.64 42.68 SUTURE MAXON 0 #6301-61 49020041_1 CDM 0272 RC inpatient 44 28.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26.64 42.68 SUTURE MAXON 0 #6301-61 49020041_1 CDM 0272 RC inpatient 44 28.6 ANTHEM HMO ANTHEM HMO 999999999 26.64 42.68 SUTURE MAXON 0 #6301-61 49020041_1 CDM 0272 RC inpatient 44 28.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26.64 42.68 SUTURE MAXON 0 #6301-61 49020041_1 CDM 0272 RC inpatient 44 28.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 29.74 67.6 999999999 26.64 42.68 percent of total billed charges SUTURE MAXON 0 #6301-61 49020041_1 CDM 0272 RC inpatient 44 28.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 26.64 42.68 SUTR VICRYL 3-0 J458H 49020044_1 CDM 0272 RC inpatient 21 13.65 AETNA AETNA 16.59 79 999999999 12.72 20.37 percent of total billed charges SUTR VICRYL 3-0 J458H 49020044_1 CDM 0272 RC inpatient 21 13.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 13.65 65 999999999 12.72 20.37 percent of total billed charges SUTR VICRYL 3-0 J458H 49020044_1 CDM 0272 RC inpatient 21 13.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20.37 97 999999999 12.72 20.37 percent of total billed charges SUTR VICRYL 3-0 J458H 49020044_1 CDM 0272 RC inpatient 21 13.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 16.38 78 999999999 12.72 20.37 percent of total billed charges SUTR VICRYL 3-0 J458H 49020044_1 CDM 0272 RC inpatient 21 13.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 14.49 69 999999999 12.72 20.37 percent of total billed charges SUTR VICRYL 3-0 J458H 49020044_1 CDM 0272 RC inpatient 21 13.65 SIHO - ALL PLANS SIHO - ALL PLANS 18.9 90 999999999 12.72 20.37 percent of total billed charges SUTR VICRYL 3-0 J458H 49020044_1 CDM 0272 RC inpatient 21 13.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.72 60.55 999999999 12.72 20.37 percent of total billed charges SUTR VICRYL 3-0 J458H 49020044_1 CDM 0272 RC inpatient 21 13.65 UMR - ALL PLANS UMR - ALL PLANS 14.7 70 999999999 12.72 20.37 percent of total billed charges SUTR VICRYL 3-0 J458H 49020044_1 CDM 0272 RC inpatient 21 13.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.72 20.37 SUTR VICRYL 3-0 J458H 49020044_1 CDM 0272 RC inpatient 21 13.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.72 20.37 SUTR VICRYL 3-0 J458H 49020044_1 CDM 0272 RC inpatient 21 13.65 ANTHEM HMO ANTHEM HMO 999999999 12.72 20.37 SUTR VICRYL 3-0 J458H 49020044_1 CDM 0272 RC inpatient 21 13.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.72 20.37 SUTR VICRYL 3-0 J458H 49020044_1 CDM 0272 RC inpatient 21 13.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.2 67.6 999999999 12.72 20.37 percent of total billed charges SUTR VICRYL 3-0 J458H 49020044_1 CDM 0272 RC inpatient 21 13.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.72 20.37 SUTURE VICRYL 4-0 J496H 49020047_1 CDM 0272 RC inpatient 40 26 AETNA AETNA 31.6 79 999999999 24.22 38.8 percent of total billed charges SUTURE VICRYL 4-0 J496H 49020047_1 CDM 0272 RC inpatient 40 26 SELF PAY DISCOUNT SELF PAY DISCOUNT 26 65 999999999 24.22 38.8 percent of total billed charges SUTURE VICRYL 4-0 J496H 49020047_1 CDM 0272 RC inpatient 40 26 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 38.8 97 999999999 24.22 38.8 percent of total billed charges SUTURE VICRYL 4-0 J496H 49020047_1 CDM 0272 RC inpatient 40 26 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.2 78 999999999 24.22 38.8 percent of total billed charges SUTURE VICRYL 4-0 J496H 49020047_1 CDM 0272 RC inpatient 40 26 ENCORE - ALL PLANS ENCORE - ALL PLANS 27.6 69 999999999 24.22 38.8 percent of total billed charges SUTURE VICRYL 4-0 J496H 49020047_1 CDM 0272 RC inpatient 40 26 SIHO - ALL PLANS SIHO - ALL PLANS 36 90 999999999 24.22 38.8 percent of total billed charges SUTURE VICRYL 4-0 J496H 49020047_1 CDM 0272 RC inpatient 40 26 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.22 60.55 999999999 24.22 38.8 percent of total billed charges SUTURE VICRYL 4-0 J496H 49020047_1 CDM 0272 RC inpatient 40 26 UMR - ALL PLANS UMR - ALL PLANS 28 70 999999999 24.22 38.8 percent of total billed charges SUTURE VICRYL 4-0 J496H 49020047_1 CDM 0272 RC inpatient 40 26 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.22 38.8 SUTURE VICRYL 4-0 J496H 49020047_1 CDM 0272 RC inpatient 40 26 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.22 38.8 SUTURE VICRYL 4-0 J496H 49020047_1 CDM 0272 RC inpatient 40 26 ANTHEM HMO ANTHEM HMO 999999999 24.22 38.8 SUTURE VICRYL 4-0 J496H 49020047_1 CDM 0272 RC inpatient 40 26 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.22 38.8 SUTURE VICRYL 4-0 J496H 49020047_1 CDM 0272 RC inpatient 40 26 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.04 67.6 999999999 24.22 38.8 percent of total billed charges SUTURE VICRYL 4-0 J496H 49020047_1 CDM 0272 RC inpatient 40 26 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.22 38.8 SUTURE PROLENE #1 8824G CLOS 49020048_1 CDM 0272 RC inpatient 23 14.95 AETNA AETNA 18.17 79 999999999 13.93 22.31 percent of total billed charges SUTURE PROLENE #1 8824G CLOS 49020048_1 CDM 0272 RC inpatient 23 14.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.95 65 999999999 13.93 22.31 percent of total billed charges SUTURE PROLENE #1 8824G CLOS 49020048_1 CDM 0272 RC inpatient 23 14.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22.31 97 999999999 13.93 22.31 percent of total billed charges SUTURE PROLENE #1 8824G CLOS 49020048_1 CDM 0272 RC inpatient 23 14.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.94 78 999999999 13.93 22.31 percent of total billed charges SUTURE PROLENE #1 8824G CLOS 49020048_1 CDM 0272 RC inpatient 23 14.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.87 69 999999999 13.93 22.31 percent of total billed charges SUTURE PROLENE #1 8824G CLOS 49020048_1 CDM 0272 RC inpatient 23 14.95 SIHO - ALL PLANS SIHO - ALL PLANS 20.7 90 999999999 13.93 22.31 percent of total billed charges SUTURE PROLENE #1 8824G CLOS 49020048_1 CDM 0272 RC inpatient 23 14.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.93 60.55 999999999 13.93 22.31 percent of total billed charges SUTURE PROLENE #1 8824G CLOS 49020048_1 CDM 0272 RC inpatient 23 14.95 UMR - ALL PLANS UMR - ALL PLANS 16.1 70 999999999 13.93 22.31 percent of total billed charges SUTURE PROLENE #1 8824G CLOS 49020048_1 CDM 0272 RC inpatient 23 14.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.93 22.31 SUTURE PROLENE #1 8824G CLOS 49020048_1 CDM 0272 RC inpatient 23 14.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.93 22.31 SUTURE PROLENE #1 8824G CLOS 49020048_1 CDM 0272 RC inpatient 23 14.95 ANTHEM HMO ANTHEM HMO 999999999 13.93 22.31 SUTURE PROLENE #1 8824G CLOS 49020048_1 CDM 0272 RC inpatient 23 14.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.93 22.31 SUTURE PROLENE #1 8824G CLOS 49020048_1 CDM 0272 RC inpatient 23 14.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 15.55 67.6 999999999 13.93 22.31 percent of total billed charges SUTURE PROLENE #1 8824G CLOS 49020048_1 CDM 0272 RC inpatient 23 14.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.93 22.31 SUTR PDS II O Z990G 49020051_1 CDM 0272 RC inpatient 57 37.05 AETNA AETNA 45.03 79 999999999 34.51 55.29 percent of total billed charges SUTR PDS II O Z990G 49020051_1 CDM 0272 RC inpatient 57 37.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.05 65 999999999 34.51 55.29 percent of total billed charges SUTR PDS II O Z990G 49020051_1 CDM 0272 RC inpatient 57 37.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.29 97 999999999 34.51 55.29 percent of total billed charges SUTR PDS II O Z990G 49020051_1 CDM 0272 RC inpatient 57 37.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.46 78 999999999 34.51 55.29 percent of total billed charges SUTR PDS II O Z990G 49020051_1 CDM 0272 RC inpatient 57 37.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.33 69 999999999 34.51 55.29 percent of total billed charges SUTR PDS II O Z990G 49020051_1 CDM 0272 RC inpatient 57 37.05 SIHO - ALL PLANS SIHO - ALL PLANS 51.3 90 999999999 34.51 55.29 percent of total billed charges SUTR PDS II O Z990G 49020051_1 CDM 0272 RC inpatient 57 37.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.51 60.55 999999999 34.51 55.29 percent of total billed charges SUTR PDS II O Z990G 49020051_1 CDM 0272 RC inpatient 57 37.05 UMR - ALL PLANS UMR - ALL PLANS 39.9 70 999999999 34.51 55.29 percent of total billed charges SUTR PDS II O Z990G 49020051_1 CDM 0272 RC inpatient 57 37.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.51 55.29 SUTR PDS II O Z990G 49020051_1 CDM 0272 RC inpatient 57 37.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.51 55.29 SUTR PDS II O Z990G 49020051_1 CDM 0272 RC inpatient 57 37.05 ANTHEM HMO ANTHEM HMO 999999999 34.51 55.29 SUTR PDS II O Z990G 49020051_1 CDM 0272 RC inpatient 57 37.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.51 55.29 SUTR PDS II O Z990G 49020051_1 CDM 0272 RC inpatient 57 37.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.53 67.6 999999999 34.51 55.29 percent of total billed charges SUTR PDS II O Z990G 49020051_1 CDM 0272 RC inpatient 57 37.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.51 55.29 "SUTURE PDS3-027"" Z316" 49020053_1 CDM 0272 RC inpatient 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges "SUTURE PDS3-027"" Z316" 49020053_1 CDM 0272 RC inpatient 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges "SUTURE PDS3-027"" Z316" 49020053_1 CDM 0272 RC inpatient 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges "SUTURE PDS3-027"" Z316" 49020053_1 CDM 0272 RC inpatient 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges "SUTURE PDS3-027"" Z316" 49020053_1 CDM 0272 RC inpatient 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges "SUTURE PDS3-027"" Z316" 49020053_1 CDM 0272 RC inpatient 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges "SUTURE PDS3-027"" Z316" 49020053_1 CDM 0272 RC inpatient 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges "SUTURE PDS3-027"" Z316" 49020053_1 CDM 0272 RC inpatient 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges "SUTURE PDS3-027"" Z316" 49020053_1 CDM 0272 RC inpatient 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 "SUTURE PDS3-027"" Z316" 49020053_1 CDM 0272 RC inpatient 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 "SUTURE PDS3-027"" Z316" 49020053_1 CDM 0272 RC inpatient 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 "SUTURE PDS3-027"" Z316" 49020053_1 CDM 0272 RC inpatient 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 "SUTURE PDS3-027"" Z316" 49020053_1 CDM 0272 RC inpatient 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges "SUTURE PDS3-027"" Z316" 49020053_1 CDM 0272 RC inpatient 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 SUTURE ETHICON 3-0 Z338H PDSII 49020056_1 CDM 0272 RC inpatient 27 17.55 AETNA AETNA 21.33 79 999999999 16.35 26.19 percent of total billed charges SUTURE ETHICON 3-0 Z338H PDSII 49020056_1 CDM 0272 RC inpatient 27 17.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.55 65 999999999 16.35 26.19 percent of total billed charges SUTURE ETHICON 3-0 Z338H PDSII 49020056_1 CDM 0272 RC inpatient 27 17.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26.19 97 999999999 16.35 26.19 percent of total billed charges SUTURE ETHICON 3-0 Z338H PDSII 49020056_1 CDM 0272 RC inpatient 27 17.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.06 78 999999999 16.35 26.19 percent of total billed charges SUTURE ETHICON 3-0 Z338H PDSII 49020056_1 CDM 0272 RC inpatient 27 17.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.63 69 999999999 16.35 26.19 percent of total billed charges SUTURE ETHICON 3-0 Z338H PDSII 49020056_1 CDM 0272 RC inpatient 27 17.55 SIHO - ALL PLANS SIHO - ALL PLANS 24.3 90 999999999 16.35 26.19 percent of total billed charges SUTURE ETHICON 3-0 Z338H PDSII 49020056_1 CDM 0272 RC inpatient 27 17.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.35 60.55 999999999 16.35 26.19 percent of total billed charges SUTURE ETHICON 3-0 Z338H PDSII 49020056_1 CDM 0272 RC inpatient 27 17.55 UMR - ALL PLANS UMR - ALL PLANS 18.9 70 999999999 16.35 26.19 percent of total billed charges SUTURE ETHICON 3-0 Z338H PDSII 49020056_1 CDM 0272 RC inpatient 27 17.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.35 26.19 SUTURE ETHICON 3-0 Z338H PDSII 49020056_1 CDM 0272 RC inpatient 27 17.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.35 26.19 SUTURE ETHICON 3-0 Z338H PDSII 49020056_1 CDM 0272 RC inpatient 27 17.55 ANTHEM HMO ANTHEM HMO 999999999 16.35 26.19 SUTURE ETHICON 3-0 Z338H PDSII 49020056_1 CDM 0272 RC inpatient 27 17.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.35 26.19 SUTURE ETHICON 3-0 Z338H PDSII 49020056_1 CDM 0272 RC inpatient 27 17.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.25 67.6 999999999 16.35 26.19 percent of total billed charges SUTURE ETHICON 3-0 Z338H PDSII 49020056_1 CDM 0272 RC inpatient 27 17.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.35 26.19 TRAY AMNIOCENTESIS 4545A OE 49020063_1 CDM 0272 RC inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges TRAY AMNIOCENTESIS 4545A OE 49020063_1 CDM 0272 RC inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges TRAY AMNIOCENTESIS 4545A OE 49020063_1 CDM 0272 RC inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges TRAY AMNIOCENTESIS 4545A OE 49020063_1 CDM 0272 RC inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges TRAY AMNIOCENTESIS 4545A OE 49020063_1 CDM 0272 RC inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges TRAY AMNIOCENTESIS 4545A OE 49020063_1 CDM 0272 RC inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges TRAY AMNIOCENTESIS 4545A OE 49020063_1 CDM 0272 RC inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges TRAY AMNIOCENTESIS 4545A OE 49020063_1 CDM 0272 RC inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges TRAY AMNIOCENTESIS 4545A OE 49020063_1 CDM 0272 RC inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 TRAY AMNIOCENTESIS 4545A OE 49020063_1 CDM 0272 RC inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 TRAY AMNIOCENTESIS 4545A OE 49020063_1 CDM 0272 RC inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 TRAY AMNIOCENTESIS 4545A OE 49020063_1 CDM 0272 RC inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 TRAY AMNIOCENTESIS 4545A OE 49020063_1 CDM 0272 RC inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges TRAY AMNIOCENTESIS 4545A OE 49020063_1 CDM 0272 RC inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 TROCAR DTN-18-15.0 49020070_1 CDM 0621 RC inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges TROCAR DTN-18-15.0 49020070_1 CDM 0621 RC inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges TROCAR DTN-18-15.0 49020070_1 CDM 0621 RC inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges TROCAR DTN-18-15.0 49020070_1 CDM 0621 RC inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges TROCAR DTN-18-15.0 49020070_1 CDM 0621 RC inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges TROCAR DTN-18-15.0 49020070_1 CDM 0621 RC inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges TROCAR DTN-18-15.0 49020070_1 CDM 0621 RC inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges TROCAR DTN-18-15.0 49020070_1 CDM 0621 RC inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges TROCAR DTN-18-15.0 49020070_1 CDM 0621 RC inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 TROCAR DTN-18-15.0 49020070_1 CDM 0621 RC inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 TROCAR DTN-18-15.0 49020070_1 CDM 0621 RC inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 TROCAR DTN-18-15.0 49020070_1 CDM 0621 RC inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 TROCAR DTN-18-15.0 49020070_1 CDM 0621 RC inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges TROCAR DTN-18-15.0 49020070_1 CDM 0621 RC inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 NEEDLE EZ HUBER 20GA X 1 49020075_1 CDM 0272 RC inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges NEEDLE EZ HUBER 20GA X 1 49020075_1 CDM 0272 RC inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges NEEDLE EZ HUBER 20GA X 1 49020075_1 CDM 0272 RC inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges NEEDLE EZ HUBER 20GA X 1 49020075_1 CDM 0272 RC inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges NEEDLE EZ HUBER 20GA X 1 49020075_1 CDM 0272 RC inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges NEEDLE EZ HUBER 20GA X 1 49020075_1 CDM 0272 RC inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges NEEDLE EZ HUBER 20GA X 1 49020075_1 CDM 0272 RC inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges NEEDLE EZ HUBER 20GA X 1 49020075_1 CDM 0272 RC inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges NEEDLE EZ HUBER 20GA X 1 49020075_1 CDM 0272 RC inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 NEEDLE EZ HUBER 20GA X 1 49020075_1 CDM 0272 RC inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 NEEDLE EZ HUBER 20GA X 1 49020075_1 CDM 0272 RC inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 NEEDLE EZ HUBER 20GA X 1 49020075_1 CDM 0272 RC inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 NEEDLE EZ HUBER 20GA X 1 49020075_1 CDM 0272 RC inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges NEEDLE EZ HUBER 20GA X 1 49020075_1 CDM 0272 RC inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 POLARIS ULTRA STENT 4.5X26 49020085_1 CDM 0272 RC inpatient 512 332.8 AETNA AETNA 404.48 79 999999999 310.02 496.64 percent of total billed charges POLARIS ULTRA STENT 4.5X26 49020085_1 CDM 0272 RC inpatient 512 332.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 332.8 65 999999999 310.02 496.64 percent of total billed charges POLARIS ULTRA STENT 4.5X26 49020085_1 CDM 0272 RC inpatient 512 332.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 496.64 97 999999999 310.02 496.64 percent of total billed charges POLARIS ULTRA STENT 4.5X26 49020085_1 CDM 0272 RC inpatient 512 332.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 399.36 78 999999999 310.02 496.64 percent of total billed charges POLARIS ULTRA STENT 4.5X26 49020085_1 CDM 0272 RC inpatient 512 332.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 353.28 69 999999999 310.02 496.64 percent of total billed charges POLARIS ULTRA STENT 4.5X26 49020085_1 CDM 0272 RC inpatient 512 332.8 SIHO - ALL PLANS SIHO - ALL PLANS 460.8 90 999999999 310.02 496.64 percent of total billed charges POLARIS ULTRA STENT 4.5X26 49020085_1 CDM 0272 RC inpatient 512 332.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 310.02 60.55 999999999 310.02 496.64 percent of total billed charges POLARIS ULTRA STENT 4.5X26 49020085_1 CDM 0272 RC inpatient 512 332.8 UMR - ALL PLANS UMR - ALL PLANS 358.4 70 999999999 310.02 496.64 percent of total billed charges POLARIS ULTRA STENT 4.5X26 49020085_1 CDM 0272 RC inpatient 512 332.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 310.02 496.64 POLARIS ULTRA STENT 4.5X26 49020085_1 CDM 0272 RC inpatient 512 332.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 310.02 496.64 POLARIS ULTRA STENT 4.5X26 49020085_1 CDM 0272 RC inpatient 512 332.8 ANTHEM HMO ANTHEM HMO 999999999 310.02 496.64 POLARIS ULTRA STENT 4.5X26 49020085_1 CDM 0272 RC inpatient 512 332.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 310.02 496.64 POLARIS ULTRA STENT 4.5X26 49020085_1 CDM 0272 RC inpatient 512 332.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 346.11 67.6 999999999 310.02 496.64 percent of total billed charges POLARIS ULTRA STENT 4.5X26 49020085_1 CDM 0272 RC inpatient 512 332.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 310.02 496.64 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020088_1 CDM 0278 RC C1713 HCPCS inpatient 41 26.65 AETNA AETNA 32.39 79 999999999 24.83 39.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020088_1 CDM 0278 RC C1713 HCPCS inpatient 41 26.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.65 65 999999999 24.83 39.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020088_1 CDM 0278 RC C1713 HCPCS inpatient 41 26.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39.77 97 999999999 24.83 39.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020088_1 CDM 0278 RC C1713 HCPCS inpatient 41 26.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.98 78 999999999 24.83 39.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020088_1 CDM 0278 RC C1713 HCPCS inpatient 41 26.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.29 69 999999999 24.83 39.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020088_1 CDM 0278 RC C1713 HCPCS inpatient 41 26.65 SIHO - ALL PLANS SIHO - ALL PLANS 36.9 90 999999999 24.83 39.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020088_1 CDM 0278 RC C1713 HCPCS inpatient 41 26.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.83 60.55 999999999 24.83 39.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020088_1 CDM 0278 RC C1713 HCPCS inpatient 41 26.65 UMR - ALL PLANS UMR - ALL PLANS 28.7 70 999999999 24.83 39.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020088_1 CDM 0278 RC C1713 HCPCS inpatient 41 26.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.83 39.77 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020088_1 CDM 0278 RC C1713 HCPCS inpatient 41 26.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.83 39.77 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020088_1 CDM 0278 RC C1713 HCPCS inpatient 41 26.65 ANTHEM HMO ANTHEM HMO 999999999 24.83 39.77 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020088_1 CDM 0278 RC C1713 HCPCS inpatient 41 26.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.83 39.77 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020088_1 CDM 0278 RC C1713 HCPCS inpatient 41 26.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.72 67.6 999999999 24.83 39.77 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020088_1 CDM 0278 RC C1713 HCPCS inpatient 41 26.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.83 39.77 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020091_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 AETNA AETNA 1617.13 79 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020091_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1330.55 65 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020091_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1985.59 97 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020091_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1596.66 78 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020091_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1412.43 69 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020091_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 SIHO - ALL PLANS SIHO - ALL PLANS 1842.3 90 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020091_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1239.46 60.55 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020091_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 UMR - ALL PLANS UMR - ALL PLANS 1432.9 70 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020091_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020091_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020091_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM HMO ANTHEM HMO 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020091_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020091_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1383.77 67.6 999999999 1239.46 1985.59 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020091_1 CDM 0278 RC C1713 HCPCS inpatient 2047 1330.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1239.46 1985.59 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020092_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 AETNA AETNA 1373.81 79 999999999 1052.96 1686.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020092_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1130.35 65 999999999 1052.96 1686.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020092_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1686.83 97 999999999 1052.96 1686.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020092_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1356.42 78 999999999 1052.96 1686.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020092_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1199.91 69 999999999 1052.96 1686.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020092_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 SIHO - ALL PLANS SIHO - ALL PLANS 1565.1 90 999999999 1052.96 1686.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020092_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1052.96 60.55 999999999 1052.96 1686.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020092_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 UMR - ALL PLANS UMR - ALL PLANS 1217.3 70 999999999 1052.96 1686.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020092_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1052.96 1686.83 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020092_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1052.96 1686.83 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020092_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 ANTHEM HMO ANTHEM HMO 999999999 1052.96 1686.83 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020092_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1052.96 1686.83 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020092_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1175.56 67.6 999999999 1052.96 1686.83 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49020092_1 CDM 0278 RC C1713 HCPCS inpatient 1739 1130.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1052.96 1686.83 GUIDE WIRE CANN 2.8MM 292.68 49020093_1 CDM 0272 RC inpatient 386 250.9 AETNA AETNA 304.94 79 999999999 233.72 374.42 percent of total billed charges GUIDE WIRE CANN 2.8MM 292.68 49020093_1 CDM 0272 RC inpatient 386 250.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 250.9 65 999999999 233.72 374.42 percent of total billed charges GUIDE WIRE CANN 2.8MM 292.68 49020093_1 CDM 0272 RC inpatient 386 250.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 374.42 97 999999999 233.72 374.42 percent of total billed charges GUIDE WIRE CANN 2.8MM 292.68 49020093_1 CDM 0272 RC inpatient 386 250.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.08 78 999999999 233.72 374.42 percent of total billed charges GUIDE WIRE CANN 2.8MM 292.68 49020093_1 CDM 0272 RC inpatient 386 250.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 266.34 69 999999999 233.72 374.42 percent of total billed charges GUIDE WIRE CANN 2.8MM 292.68 49020093_1 CDM 0272 RC inpatient 386 250.9 SIHO - ALL PLANS SIHO - ALL PLANS 347.4 90 999999999 233.72 374.42 percent of total billed charges GUIDE WIRE CANN 2.8MM 292.68 49020093_1 CDM 0272 RC inpatient 386 250.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 233.72 60.55 999999999 233.72 374.42 percent of total billed charges GUIDE WIRE CANN 2.8MM 292.68 49020093_1 CDM 0272 RC inpatient 386 250.9 UMR - ALL PLANS UMR - ALL PLANS 270.2 70 999999999 233.72 374.42 percent of total billed charges GUIDE WIRE CANN 2.8MM 292.68 49020093_1 CDM 0272 RC inpatient 386 250.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 233.72 374.42 GUIDE WIRE CANN 2.8MM 292.68 49020093_1 CDM 0272 RC inpatient 386 250.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 233.72 374.42 GUIDE WIRE CANN 2.8MM 292.68 49020093_1 CDM 0272 RC inpatient 386 250.9 ANTHEM HMO ANTHEM HMO 999999999 233.72 374.42 GUIDE WIRE CANN 2.8MM 292.68 49020093_1 CDM 0272 RC inpatient 386 250.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 233.72 374.42 GUIDE WIRE CANN 2.8MM 292.68 49020093_1 CDM 0272 RC inpatient 386 250.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 260.94 67.6 999999999 233.72 374.42 percent of total billed charges GUIDE WIRE CANN 2.8MM 292.68 49020093_1 CDM 0272 RC inpatient 386 250.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 233.72 374.42 DBX PUTTY 1CC #038010 49020097_1 CDM 0278 RC inpatient 1347 875.55 AETNA AETNA 1064.13 79 999999999 815.61 1306.59 percent of total billed charges DBX PUTTY 1CC #038010 49020097_1 CDM 0278 RC inpatient 1347 875.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 875.55 65 999999999 815.61 1306.59 percent of total billed charges DBX PUTTY 1CC #038010 49020097_1 CDM 0278 RC inpatient 1347 875.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1306.59 97 999999999 815.61 1306.59 percent of total billed charges DBX PUTTY 1CC #038010 49020097_1 CDM 0278 RC inpatient 1347 875.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1050.66 78 999999999 815.61 1306.59 percent of total billed charges DBX PUTTY 1CC #038010 49020097_1 CDM 0278 RC inpatient 1347 875.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 929.43 69 999999999 815.61 1306.59 percent of total billed charges DBX PUTTY 1CC #038010 49020097_1 CDM 0278 RC inpatient 1347 875.55 SIHO - ALL PLANS SIHO - ALL PLANS 1212.3 90 999999999 815.61 1306.59 percent of total billed charges DBX PUTTY 1CC #038010 49020097_1 CDM 0278 RC inpatient 1347 875.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 815.61 60.55 999999999 815.61 1306.59 percent of total billed charges DBX PUTTY 1CC #038010 49020097_1 CDM 0278 RC inpatient 1347 875.55 UMR - ALL PLANS UMR - ALL PLANS 942.9 70 999999999 815.61 1306.59 percent of total billed charges DBX PUTTY 1CC #038010 49020097_1 CDM 0278 RC inpatient 1347 875.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 815.61 1306.59 DBX PUTTY 1CC #038010 49020097_1 CDM 0278 RC inpatient 1347 875.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 815.61 1306.59 DBX PUTTY 1CC #038010 49020097_1 CDM 0278 RC inpatient 1347 875.55 ANTHEM HMO ANTHEM HMO 999999999 815.61 1306.59 DBX PUTTY 1CC #038010 49020097_1 CDM 0278 RC inpatient 1347 875.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 815.61 1306.59 DBX PUTTY 1CC #038010 49020097_1 CDM 0278 RC inpatient 1347 875.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 910.57 67.6 999999999 815.61 1306.59 percent of total billed charges DBX PUTTY 1CC #038010 49020097_1 CDM 0278 RC inpatient 1347 875.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 815.61 1306.59 DBX PUTTY 5CC #038050 49020098_1 CDM 0278 RC inpatient 4995 3246.75 AETNA AETNA 3946.05 79 999999999 3024.47 4845.15 percent of total billed charges DBX PUTTY 5CC #038050 49020098_1 CDM 0278 RC inpatient 4995 3246.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 3246.75 65 999999999 3024.47 4845.15 percent of total billed charges DBX PUTTY 5CC #038050 49020098_1 CDM 0278 RC inpatient 4995 3246.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4845.15 97 999999999 3024.47 4845.15 percent of total billed charges DBX PUTTY 5CC #038050 49020098_1 CDM 0278 RC inpatient 4995 3246.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 3896.1 78 999999999 3024.47 4845.15 percent of total billed charges DBX PUTTY 5CC #038050 49020098_1 CDM 0278 RC inpatient 4995 3246.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 3446.55 69 999999999 3024.47 4845.15 percent of total billed charges DBX PUTTY 5CC #038050 49020098_1 CDM 0278 RC inpatient 4995 3246.75 SIHO - ALL PLANS SIHO - ALL PLANS 4495.5 90 999999999 3024.47 4845.15 percent of total billed charges DBX PUTTY 5CC #038050 49020098_1 CDM 0278 RC inpatient 4995 3246.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3024.47 60.55 999999999 3024.47 4845.15 percent of total billed charges DBX PUTTY 5CC #038050 49020098_1 CDM 0278 RC inpatient 4995 3246.75 UMR - ALL PLANS UMR - ALL PLANS 3496.5 70 999999999 3024.47 4845.15 percent of total billed charges DBX PUTTY 5CC #038050 49020098_1 CDM 0278 RC inpatient 4995 3246.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3024.47 4845.15 DBX PUTTY 5CC #038050 49020098_1 CDM 0278 RC inpatient 4995 3246.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3024.47 4845.15 DBX PUTTY 5CC #038050 49020098_1 CDM 0278 RC inpatient 4995 3246.75 ANTHEM HMO ANTHEM HMO 999999999 3024.47 4845.15 DBX PUTTY 5CC #038050 49020098_1 CDM 0278 RC inpatient 4995 3246.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3024.47 4845.15 DBX PUTTY 5CC #038050 49020098_1 CDM 0278 RC inpatient 4995 3246.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 3376.62 67.6 999999999 3024.47 4845.15 percent of total billed charges DBX PUTTY 5CC #038050 49020098_1 CDM 0278 RC inpatient 4995 3246.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 3024.47 4845.15 DIEGO TUBESET TS100S 49020129_1 CDM 0272 RC inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges DIEGO TUBESET TS100S 49020129_1 CDM 0272 RC inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges DIEGO TUBESET TS100S 49020129_1 CDM 0272 RC inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges DIEGO TUBESET TS100S 49020129_1 CDM 0272 RC inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges DIEGO TUBESET TS100S 49020129_1 CDM 0272 RC inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges DIEGO TUBESET TS100S 49020129_1 CDM 0272 RC inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges DIEGO TUBESET TS100S 49020129_1 CDM 0272 RC inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges DIEGO TUBESET TS100S 49020129_1 CDM 0272 RC inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges DIEGO TUBESET TS100S 49020129_1 CDM 0272 RC inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 DIEGO TUBESET TS100S 49020129_1 CDM 0272 RC inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 DIEGO TUBESET TS100S 49020129_1 CDM 0272 RC inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 DIEGO TUBESET TS100S 49020129_1 CDM 0272 RC inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 DIEGO TUBESET TS100S 49020129_1 CDM 0272 RC inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges DIEGO TUBESET TS100S 49020129_1 CDM 0272 RC inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 MCNEALY/GLASS VISCERA HS3204-1 49020137_1 CDM 0272 RC inpatient 500 325 AETNA AETNA 395 79 999999999 302.75 485 percent of total billed charges MCNEALY/GLASS VISCERA HS3204-1 49020137_1 CDM 0272 RC inpatient 500 325 SELF PAY DISCOUNT SELF PAY DISCOUNT 325 65 999999999 302.75 485 percent of total billed charges MCNEALY/GLASS VISCERA HS3204-1 49020137_1 CDM 0272 RC inpatient 500 325 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 485 97 999999999 302.75 485 percent of total billed charges MCNEALY/GLASS VISCERA HS3204-1 49020137_1 CDM 0272 RC inpatient 500 325 HUMANA - ALL PLANS HUMANA - ALL PLANS 390 78 999999999 302.75 485 percent of total billed charges MCNEALY/GLASS VISCERA HS3204-1 49020137_1 CDM 0272 RC inpatient 500 325 ENCORE - ALL PLANS ENCORE - ALL PLANS 345 69 999999999 302.75 485 percent of total billed charges MCNEALY/GLASS VISCERA HS3204-1 49020137_1 CDM 0272 RC inpatient 500 325 SIHO - ALL PLANS SIHO - ALL PLANS 450 90 999999999 302.75 485 percent of total billed charges MCNEALY/GLASS VISCERA HS3204-1 49020137_1 CDM 0272 RC inpatient 500 325 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 302.75 60.55 999999999 302.75 485 percent of total billed charges MCNEALY/GLASS VISCERA HS3204-1 49020137_1 CDM 0272 RC inpatient 500 325 UMR - ALL PLANS UMR - ALL PLANS 350 70 999999999 302.75 485 percent of total billed charges MCNEALY/GLASS VISCERA HS3204-1 49020137_1 CDM 0272 RC inpatient 500 325 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 302.75 485 MCNEALY/GLASS VISCERA HS3204-1 49020137_1 CDM 0272 RC inpatient 500 325 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 302.75 485 MCNEALY/GLASS VISCERA HS3204-1 49020137_1 CDM 0272 RC inpatient 500 325 ANTHEM HMO ANTHEM HMO 999999999 302.75 485 MCNEALY/GLASS VISCERA HS3204-1 49020137_1 CDM 0272 RC inpatient 500 325 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 302.75 485 MCNEALY/GLASS VISCERA HS3204-1 49020137_1 CDM 0272 RC inpatient 500 325 CIGNA - ALL PLANS CIGNA - ALL PLANS 338 67.6 999999999 302.75 485 percent of total billed charges MCNEALY/GLASS VISCERA HS3204-1 49020137_1 CDM 0272 RC inpatient 500 325 UHC - ALL PLANS UHC - ALL PLANS 999999999 302.75 485 TUBES SHEEHY ACTIVENT COLLAR 49020138_1 CDM 0272 RC inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges TUBES SHEEHY ACTIVENT COLLAR 49020138_1 CDM 0272 RC inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges TUBES SHEEHY ACTIVENT COLLAR 49020138_1 CDM 0272 RC inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges TUBES SHEEHY ACTIVENT COLLAR 49020138_1 CDM 0272 RC inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges TUBES SHEEHY ACTIVENT COLLAR 49020138_1 CDM 0272 RC inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges TUBES SHEEHY ACTIVENT COLLAR 49020138_1 CDM 0272 RC inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges TUBES SHEEHY ACTIVENT COLLAR 49020138_1 CDM 0272 RC inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges TUBES SHEEHY ACTIVENT COLLAR 49020138_1 CDM 0272 RC inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges TUBES SHEEHY ACTIVENT COLLAR 49020138_1 CDM 0272 RC inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 TUBES SHEEHY ACTIVENT COLLAR 49020138_1 CDM 0272 RC inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 TUBES SHEEHY ACTIVENT COLLAR 49020138_1 CDM 0272 RC inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 TUBES SHEEHY ACTIVENT COLLAR 49020138_1 CDM 0272 RC inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 TUBES SHEEHY ACTIVENT COLLAR 49020138_1 CDM 0272 RC inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges TUBES SHEEHY ACTIVENT COLLAR 49020138_1 CDM 0272 RC inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 TUBES RICHARD T 7024-1071 49020139_1 CDM 0272 RC inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges TUBES RICHARD T 7024-1071 49020139_1 CDM 0272 RC inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges TUBES RICHARD T 7024-1071 49020139_1 CDM 0272 RC inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges TUBES RICHARD T 7024-1071 49020139_1 CDM 0272 RC inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges TUBES RICHARD T 7024-1071 49020139_1 CDM 0272 RC inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges TUBES RICHARD T 7024-1071 49020139_1 CDM 0272 RC inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges TUBES RICHARD T 7024-1071 49020139_1 CDM 0272 RC inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges TUBES RICHARD T 7024-1071 49020139_1 CDM 0272 RC inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges TUBES RICHARD T 7024-1071 49020139_1 CDM 0272 RC inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 TUBES RICHARD T 7024-1071 49020139_1 CDM 0272 RC inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 TUBES RICHARD T 7024-1071 49020139_1 CDM 0272 RC inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 TUBES RICHARD T 7024-1071 49020139_1 CDM 0272 RC inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 TUBES RICHARD T 7024-1071 49020139_1 CDM 0272 RC inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges TUBES RICHARD T 7024-1071 49020139_1 CDM 0272 RC inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 DEX 10% INJ 1000ML 2B0164X 49020223_1 CDM 0258 RC inpatient 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges DEX 10% INJ 1000ML 2B0164X 49020223_1 CDM 0258 RC inpatient 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges DEX 10% INJ 1000ML 2B0164X 49020223_1 CDM 0258 RC inpatient 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges DEX 10% INJ 1000ML 2B0164X 49020223_1 CDM 0258 RC inpatient 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges DEX 10% INJ 1000ML 2B0164X 49020223_1 CDM 0258 RC inpatient 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges DEX 10% INJ 1000ML 2B0164X 49020223_1 CDM 0258 RC inpatient 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges DEX 10% INJ 1000ML 2B0164X 49020223_1 CDM 0258 RC inpatient 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges DEX 10% INJ 1000ML 2B0164X 49020223_1 CDM 0258 RC inpatient 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges DEX 10% INJ 1000ML 2B0164X 49020223_1 CDM 0258 RC inpatient 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 DEX 10% INJ 1000ML 2B0164X 49020223_1 CDM 0258 RC inpatient 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 DEX 10% INJ 1000ML 2B0164X 49020223_1 CDM 0258 RC inpatient 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 DEX 10% INJ 1000ML 2B0164X 49020223_1 CDM 0258 RC inpatient 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 DEX 10% INJ 1000ML 2B0164X 49020223_1 CDM 0258 RC inpatient 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges DEX 10% INJ 1000ML 2B0164X 49020223_1 CDM 0258 RC inpatient 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 "INFUSION, D5W, 1000 CC" 49020224_1 CDM 0636 RC J7070 HCPCS inpatient 14 9.1 AETNA AETNA 11.06 79 999999999 8.48 13.58 percent of total billed charges "INFUSION, D5W, 1000 CC" 49020224_1 CDM 0636 RC J7070 HCPCS inpatient 14 9.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.1 65 999999999 8.48 13.58 percent of total billed charges "INFUSION, D5W, 1000 CC" 49020224_1 CDM 0636 RC J7070 HCPCS inpatient 14 9.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13.58 97 999999999 8.48 13.58 percent of total billed charges "INFUSION, D5W, 1000 CC" 49020224_1 CDM 0636 RC J7070 HCPCS inpatient 14 9.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.92 78 999999999 8.48 13.58 percent of total billed charges "INFUSION, D5W, 1000 CC" 49020224_1 CDM 0636 RC J7070 HCPCS inpatient 14 9.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.66 69 999999999 8.48 13.58 percent of total billed charges "INFUSION, D5W, 1000 CC" 49020224_1 CDM 0636 RC J7070 HCPCS inpatient 14 9.1 SIHO - ALL PLANS SIHO - ALL PLANS 12.6 90 999999999 8.48 13.58 percent of total billed charges "INFUSION, D5W, 1000 CC" 49020224_1 CDM 0636 RC J7070 HCPCS inpatient 14 9.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.48 60.55 999999999 8.48 13.58 percent of total billed charges "INFUSION, D5W, 1000 CC" 49020224_1 CDM 0636 RC J7070 HCPCS inpatient 14 9.1 UMR - ALL PLANS UMR - ALL PLANS 9.8 70 999999999 8.48 13.58 percent of total billed charges "INFUSION, D5W, 1000 CC" 49020224_1 CDM 0636 RC J7070 HCPCS inpatient 14 9.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.48 13.58 "INFUSION, D5W, 1000 CC" 49020224_1 CDM 0636 RC J7070 HCPCS inpatient 14 9.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.48 13.58 "INFUSION, D5W, 1000 CC" 49020224_1 CDM 0636 RC J7070 HCPCS inpatient 14 9.1 ANTHEM HMO ANTHEM HMO 999999999 8.48 13.58 "INFUSION, D5W, 1000 CC" 49020224_1 CDM 0636 RC J7070 HCPCS inpatient 14 9.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.48 13.58 "INFUSION, D5W, 1000 CC" 49020224_1 CDM 0636 RC J7070 HCPCS inpatient 14 9.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.46 67.6 999999999 8.48 13.58 percent of total billed charges "INFUSION, D5W, 1000 CC" 49020224_1 CDM 0636 RC J7070 HCPCS inpatient 14 9.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.48 13.58 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 49020225_1 CDM 0636 RC J7042 HCPCS inpatient 14 9.1 AETNA AETNA 11.06 79 999999999 8.48 13.58 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 49020225_1 CDM 0636 RC J7042 HCPCS inpatient 14 9.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.1 65 999999999 8.48 13.58 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 49020225_1 CDM 0636 RC J7042 HCPCS inpatient 14 9.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13.58 97 999999999 8.48 13.58 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 49020225_1 CDM 0636 RC J7042 HCPCS inpatient 14 9.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.92 78 999999999 8.48 13.58 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 49020225_1 CDM 0636 RC J7042 HCPCS inpatient 14 9.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.66 69 999999999 8.48 13.58 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 49020225_1 CDM 0636 RC J7042 HCPCS inpatient 14 9.1 SIHO - ALL PLANS SIHO - ALL PLANS 12.6 90 999999999 8.48 13.58 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 49020225_1 CDM 0636 RC J7042 HCPCS inpatient 14 9.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.48 60.55 999999999 8.48 13.58 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 49020225_1 CDM 0636 RC J7042 HCPCS inpatient 14 9.1 UMR - ALL PLANS UMR - ALL PLANS 9.8 70 999999999 8.48 13.58 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 49020225_1 CDM 0636 RC J7042 HCPCS inpatient 14 9.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.48 13.58 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 49020225_1 CDM 0636 RC J7042 HCPCS inpatient 14 9.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.48 13.58 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 49020225_1 CDM 0636 RC J7042 HCPCS inpatient 14 9.1 ANTHEM HMO ANTHEM HMO 999999999 8.48 13.58 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 49020225_1 CDM 0636 RC J7042 HCPCS inpatient 14 9.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.48 13.58 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 49020225_1 CDM 0636 RC J7042 HCPCS inpatient 14 9.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.46 67.6 999999999 8.48 13.58 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 49020225_1 CDM 0636 RC J7042 HCPCS inpatient 14 9.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.48 13.58 KIT RADIAL 5FX23CM 259730 49020243_1 CDM 0272 RC inpatient 344 223.6 AETNA AETNA 271.76 79 999999999 208.29 333.68 percent of total billed charges KIT RADIAL 5FX23CM 259730 49020243_1 CDM 0272 RC inpatient 344 223.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 223.6 65 999999999 208.29 333.68 percent of total billed charges KIT RADIAL 5FX23CM 259730 49020243_1 CDM 0272 RC inpatient 344 223.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 333.68 97 999999999 208.29 333.68 percent of total billed charges KIT RADIAL 5FX23CM 259730 49020243_1 CDM 0272 RC inpatient 344 223.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 268.32 78 999999999 208.29 333.68 percent of total billed charges KIT RADIAL 5FX23CM 259730 49020243_1 CDM 0272 RC inpatient 344 223.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 237.36 69 999999999 208.29 333.68 percent of total billed charges KIT RADIAL 5FX23CM 259730 49020243_1 CDM 0272 RC inpatient 344 223.6 SIHO - ALL PLANS SIHO - ALL PLANS 309.6 90 999999999 208.29 333.68 percent of total billed charges KIT RADIAL 5FX23CM 259730 49020243_1 CDM 0272 RC inpatient 344 223.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 208.29 60.55 999999999 208.29 333.68 percent of total billed charges KIT RADIAL 5FX23CM 259730 49020243_1 CDM 0272 RC inpatient 344 223.6 UMR - ALL PLANS UMR - ALL PLANS 240.8 70 999999999 208.29 333.68 percent of total billed charges KIT RADIAL 5FX23CM 259730 49020243_1 CDM 0272 RC inpatient 344 223.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 208.29 333.68 KIT RADIAL 5FX23CM 259730 49020243_1 CDM 0272 RC inpatient 344 223.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 208.29 333.68 KIT RADIAL 5FX23CM 259730 49020243_1 CDM 0272 RC inpatient 344 223.6 ANTHEM HMO ANTHEM HMO 999999999 208.29 333.68 KIT RADIAL 5FX23CM 259730 49020243_1 CDM 0272 RC inpatient 344 223.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 208.29 333.68 KIT RADIAL 5FX23CM 259730 49020243_1 CDM 0272 RC inpatient 344 223.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 232.54 67.6 999999999 208.29 333.68 percent of total billed charges KIT RADIAL 5FX23CM 259730 49020243_1 CDM 0272 RC inpatient 344 223.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 208.29 333.68 SUTURE ETHILON 2-0 664G 49020249_1 CDM 0272 RC inpatient 12 7.8 AETNA AETNA 9.48 79 999999999 7.27 11.64 percent of total billed charges SUTURE ETHILON 2-0 664G 49020249_1 CDM 0272 RC inpatient 12 7.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.8 65 999999999 7.27 11.64 percent of total billed charges SUTURE ETHILON 2-0 664G 49020249_1 CDM 0272 RC inpatient 12 7.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11.64 97 999999999 7.27 11.64 percent of total billed charges SUTURE ETHILON 2-0 664G 49020249_1 CDM 0272 RC inpatient 12 7.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.36 78 999999999 7.27 11.64 percent of total billed charges SUTURE ETHILON 2-0 664G 49020249_1 CDM 0272 RC inpatient 12 7.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.28 69 999999999 7.27 11.64 percent of total billed charges SUTURE ETHILON 2-0 664G 49020249_1 CDM 0272 RC inpatient 12 7.8 SIHO - ALL PLANS SIHO - ALL PLANS 10.8 90 999999999 7.27 11.64 percent of total billed charges SUTURE ETHILON 2-0 664G 49020249_1 CDM 0272 RC inpatient 12 7.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.27 60.55 999999999 7.27 11.64 percent of total billed charges SUTURE ETHILON 2-0 664G 49020249_1 CDM 0272 RC inpatient 12 7.8 UMR - ALL PLANS UMR - ALL PLANS 8.4 70 999999999 7.27 11.64 percent of total billed charges SUTURE ETHILON 2-0 664G 49020249_1 CDM 0272 RC inpatient 12 7.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.27 11.64 SUTURE ETHILON 2-0 664G 49020249_1 CDM 0272 RC inpatient 12 7.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.27 11.64 SUTURE ETHILON 2-0 664G 49020249_1 CDM 0272 RC inpatient 12 7.8 ANTHEM HMO ANTHEM HMO 999999999 7.27 11.64 SUTURE ETHILON 2-0 664G 49020249_1 CDM 0272 RC inpatient 12 7.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.27 11.64 SUTURE ETHILON 2-0 664G 49020249_1 CDM 0272 RC inpatient 12 7.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.11 67.6 999999999 7.27 11.64 percent of total billed charges SUTURE ETHILON 2-0 664G 49020249_1 CDM 0272 RC inpatient 12 7.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.27 11.64 SET INTRODUCER 4FR STRL DISP 49020261_1 CDM 0272 RC inpatient 327 212.55 AETNA AETNA 258.33 79 999999999 198 317.19 percent of total billed charges SET INTRODUCER 4FR STRL DISP 49020261_1 CDM 0272 RC inpatient 327 212.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 212.55 65 999999999 198 317.19 percent of total billed charges SET INTRODUCER 4FR STRL DISP 49020261_1 CDM 0272 RC inpatient 327 212.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 317.19 97 999999999 198 317.19 percent of total billed charges SET INTRODUCER 4FR STRL DISP 49020261_1 CDM 0272 RC inpatient 327 212.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.06 78 999999999 198 317.19 percent of total billed charges SET INTRODUCER 4FR STRL DISP 49020261_1 CDM 0272 RC inpatient 327 212.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 225.63 69 999999999 198 317.19 percent of total billed charges SET INTRODUCER 4FR STRL DISP 49020261_1 CDM 0272 RC inpatient 327 212.55 SIHO - ALL PLANS SIHO - ALL PLANS 294.3 90 999999999 198 317.19 percent of total billed charges SET INTRODUCER 4FR STRL DISP 49020261_1 CDM 0272 RC inpatient 327 212.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198 60.55 999999999 198 317.19 percent of total billed charges SET INTRODUCER 4FR STRL DISP 49020261_1 CDM 0272 RC inpatient 327 212.55 UMR - ALL PLANS UMR - ALL PLANS 228.9 70 999999999 198 317.19 percent of total billed charges SET INTRODUCER 4FR STRL DISP 49020261_1 CDM 0272 RC inpatient 327 212.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198 317.19 SET INTRODUCER 4FR STRL DISP 49020261_1 CDM 0272 RC inpatient 327 212.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198 317.19 SET INTRODUCER 4FR STRL DISP 49020261_1 CDM 0272 RC inpatient 327 212.55 ANTHEM HMO ANTHEM HMO 999999999 198 317.19 SET INTRODUCER 4FR STRL DISP 49020261_1 CDM 0272 RC inpatient 327 212.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198 317.19 SET INTRODUCER 4FR STRL DISP 49020261_1 CDM 0272 RC inpatient 327 212.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.05 67.6 999999999 198 317.19 percent of total billed charges SET INTRODUCER 4FR STRL DISP 49020261_1 CDM 0272 RC inpatient 327 212.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 198 317.19 GUIDEWIRE NITINOL .018X45CM 49020268_1 CDM 0272 RC inpatient 338 219.7 AETNA AETNA 267.02 79 999999999 204.66 327.86 percent of total billed charges GUIDEWIRE NITINOL .018X45CM 49020268_1 CDM 0272 RC inpatient 338 219.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 219.7 65 999999999 204.66 327.86 percent of total billed charges GUIDEWIRE NITINOL .018X45CM 49020268_1 CDM 0272 RC inpatient 338 219.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 327.86 97 999999999 204.66 327.86 percent of total billed charges GUIDEWIRE NITINOL .018X45CM 49020268_1 CDM 0272 RC inpatient 338 219.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 263.64 78 999999999 204.66 327.86 percent of total billed charges GUIDEWIRE NITINOL .018X45CM 49020268_1 CDM 0272 RC inpatient 338 219.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 233.22 69 999999999 204.66 327.86 percent of total billed charges GUIDEWIRE NITINOL .018X45CM 49020268_1 CDM 0272 RC inpatient 338 219.7 SIHO - ALL PLANS SIHO - ALL PLANS 304.2 90 999999999 204.66 327.86 percent of total billed charges GUIDEWIRE NITINOL .018X45CM 49020268_1 CDM 0272 RC inpatient 338 219.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 204.66 60.55 999999999 204.66 327.86 percent of total billed charges GUIDEWIRE NITINOL .018X45CM 49020268_1 CDM 0272 RC inpatient 338 219.7 UMR - ALL PLANS UMR - ALL PLANS 236.6 70 999999999 204.66 327.86 percent of total billed charges GUIDEWIRE NITINOL .018X45CM 49020268_1 CDM 0272 RC inpatient 338 219.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 204.66 327.86 GUIDEWIRE NITINOL .018X45CM 49020268_1 CDM 0272 RC inpatient 338 219.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 204.66 327.86 GUIDEWIRE NITINOL .018X45CM 49020268_1 CDM 0272 RC inpatient 338 219.7 ANTHEM HMO ANTHEM HMO 999999999 204.66 327.86 GUIDEWIRE NITINOL .018X45CM 49020268_1 CDM 0272 RC inpatient 338 219.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 204.66 327.86 GUIDEWIRE NITINOL .018X45CM 49020268_1 CDM 0272 RC inpatient 338 219.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 228.49 67.6 999999999 204.66 327.86 percent of total billed charges GUIDEWIRE NITINOL .018X45CM 49020268_1 CDM 0272 RC inpatient 338 219.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 204.66 327.86 VERSA STEP LONG 14GA VS150000 49020294_1 CDM 0272 RC inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges VERSA STEP LONG 14GA VS150000 49020294_1 CDM 0272 RC inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges VERSA STEP LONG 14GA VS150000 49020294_1 CDM 0272 RC inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges VERSA STEP LONG 14GA VS150000 49020294_1 CDM 0272 RC inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges VERSA STEP LONG 14GA VS150000 49020294_1 CDM 0272 RC inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges VERSA STEP LONG 14GA VS150000 49020294_1 CDM 0272 RC inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges VERSA STEP LONG 14GA VS150000 49020294_1 CDM 0272 RC inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges VERSA STEP LONG 14GA VS150000 49020294_1 CDM 0272 RC inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges VERSA STEP LONG 14GA VS150000 49020294_1 CDM 0272 RC inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 VERSA STEP LONG 14GA VS150000 49020294_1 CDM 0272 RC inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 VERSA STEP LONG 14GA VS150000 49020294_1 CDM 0272 RC inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 VERSA STEP LONG 14GA VS150000 49020294_1 CDM 0272 RC inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 VERSA STEP LONG 14GA VS150000 49020294_1 CDM 0272 RC inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges VERSA STEP LONG 14GA VS150000 49020294_1 CDM 0272 RC inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 SUT AUTO SURGIDAC 2-0 #170044 49020302_1 CDM 0272 RC inpatient 422 274.3 AETNA AETNA 333.38 79 999999999 255.52 409.34 percent of total billed charges SUT AUTO SURGIDAC 2-0 #170044 49020302_1 CDM 0272 RC inpatient 422 274.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 274.3 65 999999999 255.52 409.34 percent of total billed charges SUT AUTO SURGIDAC 2-0 #170044 49020302_1 CDM 0272 RC inpatient 422 274.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 409.34 97 999999999 255.52 409.34 percent of total billed charges SUT AUTO SURGIDAC 2-0 #170044 49020302_1 CDM 0272 RC inpatient 422 274.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 329.16 78 999999999 255.52 409.34 percent of total billed charges SUT AUTO SURGIDAC 2-0 #170044 49020302_1 CDM 0272 RC inpatient 422 274.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 291.18 69 999999999 255.52 409.34 percent of total billed charges SUT AUTO SURGIDAC 2-0 #170044 49020302_1 CDM 0272 RC inpatient 422 274.3 SIHO - ALL PLANS SIHO - ALL PLANS 379.8 90 999999999 255.52 409.34 percent of total billed charges SUT AUTO SURGIDAC 2-0 #170044 49020302_1 CDM 0272 RC inpatient 422 274.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 255.52 60.55 999999999 255.52 409.34 percent of total billed charges SUT AUTO SURGIDAC 2-0 #170044 49020302_1 CDM 0272 RC inpatient 422 274.3 UMR - ALL PLANS UMR - ALL PLANS 295.4 70 999999999 255.52 409.34 percent of total billed charges SUT AUTO SURGIDAC 2-0 #170044 49020302_1 CDM 0272 RC inpatient 422 274.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 255.52 409.34 SUT AUTO SURGIDAC 2-0 #170044 49020302_1 CDM 0272 RC inpatient 422 274.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 255.52 409.34 SUT AUTO SURGIDAC 2-0 #170044 49020302_1 CDM 0272 RC inpatient 422 274.3 ANTHEM HMO ANTHEM HMO 999999999 255.52 409.34 SUT AUTO SURGIDAC 2-0 #170044 49020302_1 CDM 0272 RC inpatient 422 274.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 255.52 409.34 SUT AUTO SURGIDAC 2-0 #170044 49020302_1 CDM 0272 RC inpatient 422 274.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 285.27 67.6 999999999 255.52 409.34 percent of total billed charges SUT AUTO SURGIDAC 2-0 #170044 49020302_1 CDM 0272 RC inpatient 422 274.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 255.52 409.34 PACK SPLIT UNIVERSAL II 49020309_1 CDM 0272 RC inpatient 108 70.2 AETNA AETNA 85.32 79 999999999 65.39 104.76 percent of total billed charges PACK SPLIT UNIVERSAL II 49020309_1 CDM 0272 RC inpatient 108 70.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.2 65 999999999 65.39 104.76 percent of total billed charges PACK SPLIT UNIVERSAL II 49020309_1 CDM 0272 RC inpatient 108 70.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 104.76 97 999999999 65.39 104.76 percent of total billed charges PACK SPLIT UNIVERSAL II 49020309_1 CDM 0272 RC inpatient 108 70.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 84.24 78 999999999 65.39 104.76 percent of total billed charges PACK SPLIT UNIVERSAL II 49020309_1 CDM 0272 RC inpatient 108 70.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 74.52 69 999999999 65.39 104.76 percent of total billed charges PACK SPLIT UNIVERSAL II 49020309_1 CDM 0272 RC inpatient 108 70.2 SIHO - ALL PLANS SIHO - ALL PLANS 97.2 90 999999999 65.39 104.76 percent of total billed charges PACK SPLIT UNIVERSAL II 49020309_1 CDM 0272 RC inpatient 108 70.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 65.39 60.55 999999999 65.39 104.76 percent of total billed charges PACK SPLIT UNIVERSAL II 49020309_1 CDM 0272 RC inpatient 108 70.2 UMR - ALL PLANS UMR - ALL PLANS 75.6 70 999999999 65.39 104.76 percent of total billed charges PACK SPLIT UNIVERSAL II 49020309_1 CDM 0272 RC inpatient 108 70.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 65.39 104.76 PACK SPLIT UNIVERSAL II 49020309_1 CDM 0272 RC inpatient 108 70.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 65.39 104.76 PACK SPLIT UNIVERSAL II 49020309_1 CDM 0272 RC inpatient 108 70.2 ANTHEM HMO ANTHEM HMO 999999999 65.39 104.76 PACK SPLIT UNIVERSAL II 49020309_1 CDM 0272 RC inpatient 108 70.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 65.39 104.76 PACK SPLIT UNIVERSAL II 49020309_1 CDM 0272 RC inpatient 108 70.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.01 67.6 999999999 65.39 104.76 percent of total billed charges PACK SPLIT UNIVERSAL II 49020309_1 CDM 0272 RC inpatient 108 70.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 65.39 104.76 WIRE GUIDE TSCF-38-100-3BH 49022570_1 CDM 0621 RC inpatient 126 81.9 AETNA AETNA 99.54 79 999999999 76.29 122.22 percent of total billed charges WIRE GUIDE TSCF-38-100-3BH 49022570_1 CDM 0621 RC inpatient 126 81.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.9 65 999999999 76.29 122.22 percent of total billed charges WIRE GUIDE TSCF-38-100-3BH 49022570_1 CDM 0621 RC inpatient 126 81.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 122.22 97 999999999 76.29 122.22 percent of total billed charges WIRE GUIDE TSCF-38-100-3BH 49022570_1 CDM 0621 RC inpatient 126 81.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 98.28 78 999999999 76.29 122.22 percent of total billed charges WIRE GUIDE TSCF-38-100-3BH 49022570_1 CDM 0621 RC inpatient 126 81.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.94 69 999999999 76.29 122.22 percent of total billed charges WIRE GUIDE TSCF-38-100-3BH 49022570_1 CDM 0621 RC inpatient 126 81.9 SIHO - ALL PLANS SIHO - ALL PLANS 113.4 90 999999999 76.29 122.22 percent of total billed charges WIRE GUIDE TSCF-38-100-3BH 49022570_1 CDM 0621 RC inpatient 126 81.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.29 60.55 999999999 76.29 122.22 percent of total billed charges WIRE GUIDE TSCF-38-100-3BH 49022570_1 CDM 0621 RC inpatient 126 81.9 UMR - ALL PLANS UMR - ALL PLANS 88.2 70 999999999 76.29 122.22 percent of total billed charges WIRE GUIDE TSCF-38-100-3BH 49022570_1 CDM 0621 RC inpatient 126 81.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.29 122.22 WIRE GUIDE TSCF-38-100-3BH 49022570_1 CDM 0621 RC inpatient 126 81.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.29 122.22 WIRE GUIDE TSCF-38-100-3BH 49022570_1 CDM 0621 RC inpatient 126 81.9 ANTHEM HMO ANTHEM HMO 999999999 76.29 122.22 WIRE GUIDE TSCF-38-100-3BH 49022570_1 CDM 0621 RC inpatient 126 81.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.29 122.22 WIRE GUIDE TSCF-38-100-3BH 49022570_1 CDM 0621 RC inpatient 126 81.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.18 67.6 999999999 76.29 122.22 percent of total billed charges WIRE GUIDE TSCF-38-100-3BH 49022570_1 CDM 0621 RC inpatient 126 81.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.29 122.22 00093-3044-01 - verapamil 180 mg ER Tab [JOHN] 49024421_1 CDM 0250 RC 00093-3044-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 00093-3044-01 - verapamil 180 mg ER Tab [JOHN] 49024421_1 CDM 0250 RC 00093-3044-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 00093-3044-01 - verapamil 180 mg ER Tab [JOHN] 49024421_1 CDM 0250 RC 00093-3044-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 00093-3044-01 - verapamil 180 mg ER Tab [JOHN] 49024421_1 CDM 0250 RC 00093-3044-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 00093-3044-01 - verapamil 180 mg ER Tab [JOHN] 49024421_1 CDM 0250 RC 00093-3044-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 00093-3044-01 - verapamil 180 mg ER Tab [JOHN] 49024421_1 CDM 0250 RC 00093-3044-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 00093-3044-01 - verapamil 180 mg ER Tab [JOHN] 49024421_1 CDM 0250 RC 00093-3044-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 00093-3044-01 - verapamil 180 mg ER Tab [JOHN] 49024421_1 CDM 0250 RC 00093-3044-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 00093-3044-01 - verapamil 180 mg ER Tab [JOHN] 49024421_1 CDM 0250 RC 00093-3044-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 00093-3044-01 - verapamil 180 mg ER Tab [JOHN] 49024421_1 CDM 0250 RC 00093-3044-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 00093-3044-01 - verapamil 180 mg ER Tab [JOHN] 49024421_1 CDM 0250 RC 00093-3044-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 00093-3044-01 - verapamil 180 mg ER Tab [JOHN] 49024421_1 CDM 0250 RC 00093-3044-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 00093-3044-01 - verapamil 180 mg ER Tab [JOHN] 49024421_1 CDM 0250 RC 00093-3044-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 00093-3044-01 - verapamil 180 mg ER Tab [JOHN] 49024421_1 CDM 0250 RC 00093-3044-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CITALOPRAM HBR 10 MG TABLET 49024422_1 CDM 0250 RC 00904-6084-61 NDC inpatient 1 UN 1.87 1.22 AETNA AETNA 1.48 79 999999999 1.13 1.81 percent of total billed charges CITALOPRAM HBR 10 MG TABLET 49024422_1 CDM 0250 RC 00904-6084-61 NDC inpatient 1 UN 1.87 1.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.22 65 999999999 1.13 1.81 percent of total billed charges CITALOPRAM HBR 10 MG TABLET 49024422_1 CDM 0250 RC 00904-6084-61 NDC inpatient 1 UN 1.87 1.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.81 97 999999999 1.13 1.81 percent of total billed charges CITALOPRAM HBR 10 MG TABLET 49024422_1 CDM 0250 RC 00904-6084-61 NDC inpatient 1 UN 1.87 1.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.46 78 999999999 1.13 1.81 percent of total billed charges CITALOPRAM HBR 10 MG TABLET 49024422_1 CDM 0250 RC 00904-6084-61 NDC inpatient 1 UN 1.87 1.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.29 69 999999999 1.13 1.81 percent of total billed charges CITALOPRAM HBR 10 MG TABLET 49024422_1 CDM 0250 RC 00904-6084-61 NDC inpatient 1 UN 1.87 1.22 SIHO - ALL PLANS SIHO - ALL PLANS 1.68 90 999999999 1.13 1.81 percent of total billed charges CITALOPRAM HBR 10 MG TABLET 49024422_1 CDM 0250 RC 00904-6084-61 NDC inpatient 1 UN 1.87 1.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.13 60.55 999999999 1.13 1.81 percent of total billed charges CITALOPRAM HBR 10 MG TABLET 49024422_1 CDM 0250 RC 00904-6084-61 NDC inpatient 1 UN 1.87 1.22 UMR - ALL PLANS UMR - ALL PLANS 1.31 70 999999999 1.13 1.81 percent of total billed charges CITALOPRAM HBR 10 MG TABLET 49024422_1 CDM 0250 RC 00904-6084-61 NDC inpatient 1 UN 1.87 1.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.13 1.81 CITALOPRAM HBR 10 MG TABLET 49024422_1 CDM 0250 RC 00904-6084-61 NDC inpatient 1 UN 1.87 1.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.13 1.81 CITALOPRAM HBR 10 MG TABLET 49024422_1 CDM 0250 RC 00904-6084-61 NDC inpatient 1 UN 1.87 1.22 ANTHEM HMO ANTHEM HMO 999999999 1.13 1.81 CITALOPRAM HBR 10 MG TABLET 49024422_1 CDM 0250 RC 00904-6084-61 NDC inpatient 1 UN 1.87 1.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.13 1.81 CITALOPRAM HBR 10 MG TABLET 49024422_1 CDM 0250 RC 00904-6084-61 NDC inpatient 1 UN 1.87 1.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.26 67.6 999999999 1.13 1.81 percent of total billed charges CITALOPRAM HBR 10 MG TABLET 49024422_1 CDM 0250 RC 00904-6084-61 NDC inpatient 1 UN 1.87 1.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.13 1.81 ISOSORBIDE DINITRATE 20 MG TAB 49024431_1 CDM 0250 RC 68084-0083-01 NDC inpatient 1 UN 1.82 1.18 AETNA AETNA 1.44 79 999999999 1.1 1.77 percent of total billed charges ISOSORBIDE DINITRATE 20 MG TAB 49024431_1 CDM 0250 RC 68084-0083-01 NDC inpatient 1 UN 1.82 1.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.18 65 999999999 1.1 1.77 percent of total billed charges ISOSORBIDE DINITRATE 20 MG TAB 49024431_1 CDM 0250 RC 68084-0083-01 NDC inpatient 1 UN 1.82 1.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.77 97 999999999 1.1 1.77 percent of total billed charges ISOSORBIDE DINITRATE 20 MG TAB 49024431_1 CDM 0250 RC 68084-0083-01 NDC inpatient 1 UN 1.82 1.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.42 78 999999999 1.1 1.77 percent of total billed charges ISOSORBIDE DINITRATE 20 MG TAB 49024431_1 CDM 0250 RC 68084-0083-01 NDC inpatient 1 UN 1.82 1.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.26 69 999999999 1.1 1.77 percent of total billed charges ISOSORBIDE DINITRATE 20 MG TAB 49024431_1 CDM 0250 RC 68084-0083-01 NDC inpatient 1 UN 1.82 1.18 SIHO - ALL PLANS SIHO - ALL PLANS 1.64 90 999999999 1.1 1.77 percent of total billed charges ISOSORBIDE DINITRATE 20 MG TAB 49024431_1 CDM 0250 RC 68084-0083-01 NDC inpatient 1 UN 1.82 1.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.1 60.55 999999999 1.1 1.77 percent of total billed charges ISOSORBIDE DINITRATE 20 MG TAB 49024431_1 CDM 0250 RC 68084-0083-01 NDC inpatient 1 UN 1.82 1.18 UMR - ALL PLANS UMR - ALL PLANS 1.27 70 999999999 1.1 1.77 percent of total billed charges ISOSORBIDE DINITRATE 20 MG TAB 49024431_1 CDM 0250 RC 68084-0083-01 NDC inpatient 1 UN 1.82 1.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.1 1.77 ISOSORBIDE DINITRATE 20 MG TAB 49024431_1 CDM 0250 RC 68084-0083-01 NDC inpatient 1 UN 1.82 1.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.1 1.77 ISOSORBIDE DINITRATE 20 MG TAB 49024431_1 CDM 0250 RC 68084-0083-01 NDC inpatient 1 UN 1.82 1.18 ANTHEM HMO ANTHEM HMO 999999999 1.1 1.77 ISOSORBIDE DINITRATE 20 MG TAB 49024431_1 CDM 0250 RC 68084-0083-01 NDC inpatient 1 UN 1.82 1.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.1 1.77 ISOSORBIDE DINITRATE 20 MG TAB 49024431_1 CDM 0250 RC 68084-0083-01 NDC inpatient 1 UN 1.82 1.18 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.1 1.77 ISOSORBIDE DINITRATE 20 MG TAB 49024431_1 CDM 0250 RC 68084-0083-01 NDC inpatient 1 UN 1.82 1.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.23 67.6 999999999 1.1 1.77 percent of total billed charges ACETAZOLAMIDE 250 MG TABLET 49024921_1 CDM 0250 RC 51672-4023-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ACETAZOLAMIDE 250 MG TABLET 49024921_1 CDM 0250 RC 51672-4023-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ACETAZOLAMIDE 250 MG TABLET 49024921_1 CDM 0250 RC 51672-4023-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ACETAZOLAMIDE 250 MG TABLET 49024921_1 CDM 0250 RC 51672-4023-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ACETAZOLAMIDE 250 MG TABLET 49024921_1 CDM 0250 RC 51672-4023-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ACETAZOLAMIDE 250 MG TABLET 49024921_1 CDM 0250 RC 51672-4023-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ACETAZOLAMIDE 250 MG TABLET 49024921_1 CDM 0250 RC 51672-4023-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ACETAZOLAMIDE 250 MG TABLET 49024921_1 CDM 0250 RC 51672-4023-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ACETAZOLAMIDE 250 MG TABLET 49024921_1 CDM 0250 RC 51672-4023-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ACETAZOLAMIDE 250 MG TABLET 49024921_1 CDM 0250 RC 51672-4023-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ACETAZOLAMIDE 250 MG TABLET 49024921_1 CDM 0250 RC 51672-4023-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ACETAZOLAMIDE 250 MG TABLET 49024921_1 CDM 0250 RC 51672-4023-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ACETAZOLAMIDE 250 MG TABLET 49024921_1 CDM 0250 RC 51672-4023-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ACETAZOLAMIDE 250 MG TABLET 49024921_1 CDM 0250 RC 51672-4023-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 9.5 MG/24HR PATCH 49024923_1 CDM 0250 RC 00781-7309-31 NDC inpatient 1 UN 16.93 11 AETNA AETNA 13.37 79 999999999 10.25 16.42 percent of total billed charges RIVASTIGMINE 9.5 MG/24HR PATCH 49024923_1 CDM 0250 RC 00781-7309-31 NDC inpatient 1 UN 16.93 11 SELF PAY DISCOUNT SELF PAY DISCOUNT 11 65 999999999 10.25 16.42 percent of total billed charges RIVASTIGMINE 9.5 MG/24HR PATCH 49024923_1 CDM 0250 RC 00781-7309-31 NDC inpatient 1 UN 16.93 11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16.42 97 999999999 10.25 16.42 percent of total billed charges RIVASTIGMINE 9.5 MG/24HR PATCH 49024923_1 CDM 0250 RC 00781-7309-31 NDC inpatient 1 UN 16.93 11 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.21 78 999999999 10.25 16.42 percent of total billed charges RIVASTIGMINE 9.5 MG/24HR PATCH 49024923_1 CDM 0250 RC 00781-7309-31 NDC inpatient 1 UN 16.93 11 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.68 69 999999999 10.25 16.42 percent of total billed charges RIVASTIGMINE 9.5 MG/24HR PATCH 49024923_1 CDM 0250 RC 00781-7309-31 NDC inpatient 1 UN 16.93 11 SIHO - ALL PLANS SIHO - ALL PLANS 15.24 90 999999999 10.25 16.42 percent of total billed charges RIVASTIGMINE 9.5 MG/24HR PATCH 49024923_1 CDM 0250 RC 00781-7309-31 NDC inpatient 1 UN 16.93 11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.25 60.55 999999999 10.25 16.42 percent of total billed charges RIVASTIGMINE 9.5 MG/24HR PATCH 49024923_1 CDM 0250 RC 00781-7309-31 NDC inpatient 1 UN 16.93 11 UMR - ALL PLANS UMR - ALL PLANS 11.85 70 999999999 10.25 16.42 percent of total billed charges RIVASTIGMINE 9.5 MG/24HR PATCH 49024923_1 CDM 0250 RC 00781-7309-31 NDC inpatient 1 UN 16.93 11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.25 16.42 RIVASTIGMINE 9.5 MG/24HR PATCH 49024923_1 CDM 0250 RC 00781-7309-31 NDC inpatient 1 UN 16.93 11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.25 16.42 RIVASTIGMINE 9.5 MG/24HR PATCH 49024923_1 CDM 0250 RC 00781-7309-31 NDC inpatient 1 UN 16.93 11 ANTHEM HMO ANTHEM HMO 999999999 10.25 16.42 RIVASTIGMINE 9.5 MG/24HR PATCH 49024923_1 CDM 0250 RC 00781-7309-31 NDC inpatient 1 UN 16.93 11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.25 16.42 RIVASTIGMINE 9.5 MG/24HR PATCH 49024923_1 CDM 0250 RC 00781-7309-31 NDC inpatient 1 UN 16.93 11 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.25 16.42 RIVASTIGMINE 9.5 MG/24HR PATCH 49024923_1 CDM 0250 RC 00781-7309-31 NDC inpatient 1 UN 16.93 11 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.44 67.6 999999999 10.25 16.42 percent of total billed charges CARBAMAZEPINE 100 MG/5 ML SUSP 49024939_1 CDM 0250 RC 60432-0129-16 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CARBAMAZEPINE 100 MG/5 ML SUSP 49024939_1 CDM 0250 RC 60432-0129-16 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CARBAMAZEPINE 100 MG/5 ML SUSP 49024939_1 CDM 0250 RC 60432-0129-16 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CARBAMAZEPINE 100 MG/5 ML SUSP 49024939_1 CDM 0250 RC 60432-0129-16 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CARBAMAZEPINE 100 MG/5 ML SUSP 49024939_1 CDM 0250 RC 60432-0129-16 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CARBAMAZEPINE 100 MG/5 ML SUSP 49024939_1 CDM 0250 RC 60432-0129-16 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CARBAMAZEPINE 100 MG/5 ML SUSP 49024939_1 CDM 0250 RC 60432-0129-16 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CARBAMAZEPINE 100 MG/5 ML SUSP 49024939_1 CDM 0250 RC 60432-0129-16 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CARBAMAZEPINE 100 MG/5 ML SUSP 49024939_1 CDM 0250 RC 60432-0129-16 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CARBAMAZEPINE 100 MG/5 ML SUSP 49024939_1 CDM 0250 RC 60432-0129-16 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CARBAMAZEPINE 100 MG/5 ML SUSP 49024939_1 CDM 0250 RC 60432-0129-16 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CARBAMAZEPINE 100 MG/5 ML SUSP 49024939_1 CDM 0250 RC 60432-0129-16 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CARBAMAZEPINE 100 MG/5 ML SUSP 49024939_1 CDM 0250 RC 60432-0129-16 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CARBAMAZEPINE 100 MG/5 ML SUSP 49024939_1 CDM 0250 RC 60432-0129-16 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "00338-0519-19 - fat emulsion, intravenous 20%" 49028859_1 CDM 0250 RC 00338-0519-19 NDC inpatient 1 UN 421.7 274.11 AETNA AETNA 333.14 79 999999999 255.34 409.05 percent of total billed charges "00338-0519-19 - fat emulsion, intravenous 20%" 49028859_1 CDM 0250 RC 00338-0519-19 NDC inpatient 1 UN 421.7 274.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 274.11 65 999999999 255.34 409.05 percent of total billed charges "00338-0519-19 - fat emulsion, intravenous 20%" 49028859_1 CDM 0250 RC 00338-0519-19 NDC inpatient 1 UN 421.7 274.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 409.05 97 999999999 255.34 409.05 percent of total billed charges "00338-0519-19 - fat emulsion, intravenous 20%" 49028859_1 CDM 0250 RC 00338-0519-19 NDC inpatient 1 UN 421.7 274.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 328.93 78 999999999 255.34 409.05 percent of total billed charges "00338-0519-19 - fat emulsion, intravenous 20%" 49028859_1 CDM 0250 RC 00338-0519-19 NDC inpatient 1 UN 421.7 274.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 290.97 69 999999999 255.34 409.05 percent of total billed charges "00338-0519-19 - fat emulsion, intravenous 20%" 49028859_1 CDM 0250 RC 00338-0519-19 NDC inpatient 1 UN 421.7 274.11 SIHO - ALL PLANS SIHO - ALL PLANS 379.53 90 999999999 255.34 409.05 percent of total billed charges "00338-0519-19 - fat emulsion, intravenous 20%" 49028859_1 CDM 0250 RC 00338-0519-19 NDC inpatient 1 UN 421.7 274.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 255.34 60.55 999999999 255.34 409.05 percent of total billed charges "00338-0519-19 - fat emulsion, intravenous 20%" 49028859_1 CDM 0250 RC 00338-0519-19 NDC inpatient 1 UN 421.7 274.11 UMR - ALL PLANS UMR - ALL PLANS 295.19 70 999999999 255.34 409.05 percent of total billed charges "00338-0519-19 - fat emulsion, intravenous 20%" 49028859_1 CDM 0250 RC 00338-0519-19 NDC inpatient 1 UN 421.7 274.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 255.34 409.05 "00338-0519-19 - fat emulsion, intravenous 20%" 49028859_1 CDM 0250 RC 00338-0519-19 NDC inpatient 1 UN 421.7 274.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 255.34 409.05 "00338-0519-19 - fat emulsion, intravenous 20%" 49028859_1 CDM 0250 RC 00338-0519-19 NDC inpatient 1 UN 421.7 274.11 ANTHEM HMO ANTHEM HMO 999999999 255.34 409.05 "00338-0519-19 - fat emulsion, intravenous 20%" 49028859_1 CDM 0250 RC 00338-0519-19 NDC inpatient 1 UN 421.7 274.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 255.34 409.05 "00338-0519-19 - fat emulsion, intravenous 20%" 49028859_1 CDM 0250 RC 00338-0519-19 NDC inpatient 1 UN 421.7 274.11 UHC - ALL PLANS UHC - ALL PLANS 999999999 255.34 409.05 "00338-0519-19 - fat emulsion, intravenous 20%" 49028859_1 CDM 0250 RC 00338-0519-19 NDC inpatient 1 UN 421.7 274.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 285.07 67.6 999999999 255.34 409.05 percent of total billed charges METHYLERGONOVINE 0.2 MG/ML AMP 49044245_1 CDM 0250 RC 51991-0144-17 NDC inpatient 1 UN 107.99 70.19 AETNA AETNA 85.31 79 999999999 65.39 104.75 percent of total billed charges METHYLERGONOVINE 0.2 MG/ML AMP 49044245_1 CDM 0250 RC 51991-0144-17 NDC inpatient 1 UN 107.99 70.19 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.19 65 999999999 65.39 104.75 percent of total billed charges METHYLERGONOVINE 0.2 MG/ML AMP 49044245_1 CDM 0250 RC 51991-0144-17 NDC inpatient 1 UN 107.99 70.19 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 104.75 97 999999999 65.39 104.75 percent of total billed charges METHYLERGONOVINE 0.2 MG/ML AMP 49044245_1 CDM 0250 RC 51991-0144-17 NDC inpatient 1 UN 107.99 70.19 HUMANA - ALL PLANS HUMANA - ALL PLANS 84.23 78 999999999 65.39 104.75 percent of total billed charges METHYLERGONOVINE 0.2 MG/ML AMP 49044245_1 CDM 0250 RC 51991-0144-17 NDC inpatient 1 UN 107.99 70.19 ENCORE - ALL PLANS ENCORE - ALL PLANS 74.51 69 999999999 65.39 104.75 percent of total billed charges METHYLERGONOVINE 0.2 MG/ML AMP 49044245_1 CDM 0250 RC 51991-0144-17 NDC inpatient 1 UN 107.99 70.19 SIHO - ALL PLANS SIHO - ALL PLANS 97.19 90 999999999 65.39 104.75 percent of total billed charges METHYLERGONOVINE 0.2 MG/ML AMP 49044245_1 CDM 0250 RC 51991-0144-17 NDC inpatient 1 UN 107.99 70.19 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 65.39 60.55 999999999 65.39 104.75 percent of total billed charges METHYLERGONOVINE 0.2 MG/ML AMP 49044245_1 CDM 0250 RC 51991-0144-17 NDC inpatient 1 UN 107.99 70.19 UMR - ALL PLANS UMR - ALL PLANS 75.59 70 999999999 65.39 104.75 percent of total billed charges METHYLERGONOVINE 0.2 MG/ML AMP 49044245_1 CDM 0250 RC 51991-0144-17 NDC inpatient 1 UN 107.99 70.19 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 65.39 104.75 METHYLERGONOVINE 0.2 MG/ML AMP 49044245_1 CDM 0250 RC 51991-0144-17 NDC inpatient 1 UN 107.99 70.19 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 65.39 104.75 METHYLERGONOVINE 0.2 MG/ML AMP 49044245_1 CDM 0250 RC 51991-0144-17 NDC inpatient 1 UN 107.99 70.19 ANTHEM HMO ANTHEM HMO 999999999 65.39 104.75 METHYLERGONOVINE 0.2 MG/ML AMP 49044245_1 CDM 0250 RC 51991-0144-17 NDC inpatient 1 UN 107.99 70.19 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 65.39 104.75 METHYLERGONOVINE 0.2 MG/ML AMP 49044245_1 CDM 0250 RC 51991-0144-17 NDC inpatient 1 UN 107.99 70.19 UHC - ALL PLANS UHC - ALL PLANS 999999999 65.39 104.75 METHYLERGONOVINE 0.2 MG/ML AMP 49044245_1 CDM 0250 RC 51991-0144-17 NDC inpatient 1 UN 107.99 70.19 CIGNA - ALL PLANS CIGNA - ALL PLANS 73 67.6 999999999 65.39 104.75 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 49044272_1 CDM 0636 RC 00703-4248-91 NDC J9045 HCPCS inpatient 9 UN 167.79 109.06 AETNA AETNA 132.55 79 999999999 101.6 162.76 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 49044272_1 CDM 0636 RC 00703-4248-91 NDC J9045 HCPCS inpatient 9 UN 167.79 109.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.06 65 999999999 101.6 162.76 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 49044272_1 CDM 0636 RC 00703-4248-91 NDC J9045 HCPCS inpatient 9 UN 167.79 109.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.76 97 999999999 101.6 162.76 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 49044272_1 CDM 0636 RC 00703-4248-91 NDC J9045 HCPCS inpatient 9 UN 167.79 109.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 130.88 78 999999999 101.6 162.76 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 49044272_1 CDM 0636 RC 00703-4248-91 NDC J9045 HCPCS inpatient 9 UN 167.79 109.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.78 69 999999999 101.6 162.76 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 49044272_1 CDM 0636 RC 00703-4248-91 NDC J9045 HCPCS inpatient 9 UN 167.79 109.06 SIHO - ALL PLANS SIHO - ALL PLANS 151.01 90 999999999 101.6 162.76 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 49044272_1 CDM 0636 RC 00703-4248-91 NDC J9045 HCPCS inpatient 9 UN 167.79 109.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.6 60.55 999999999 101.6 162.76 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 49044272_1 CDM 0636 RC 00703-4248-91 NDC J9045 HCPCS inpatient 9 UN 167.79 109.06 UMR - ALL PLANS UMR - ALL PLANS 117.45 70 999999999 101.6 162.76 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 49044272_1 CDM 0636 RC 00703-4248-91 NDC J9045 HCPCS inpatient 9 UN 167.79 109.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.6 162.76 "INJECTION, CARBOPLATIN, 50 MG" 49044272_1 CDM 0636 RC 00703-4248-91 NDC J9045 HCPCS inpatient 9 UN 167.79 109.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.6 162.76 "INJECTION, CARBOPLATIN, 50 MG" 49044272_1 CDM 0636 RC 00703-4248-91 NDC J9045 HCPCS inpatient 9 UN 167.79 109.06 ANTHEM HMO ANTHEM HMO 999999999 101.6 162.76 "INJECTION, CARBOPLATIN, 50 MG" 49044272_1 CDM 0636 RC 00703-4248-91 NDC J9045 HCPCS inpatient 9 UN 167.79 109.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.6 162.76 "INJECTION, CARBOPLATIN, 50 MG" 49044272_1 CDM 0636 RC 00703-4248-91 NDC J9045 HCPCS inpatient 9 UN 167.79 109.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.6 162.76 "INJECTION, CARBOPLATIN, 50 MG" 49044272_1 CDM 0636 RC 00703-4248-91 NDC J9045 HCPCS inpatient 9 UN 167.79 109.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.43 67.6 999999999 101.6 162.76 percent of total billed charges METOPROLOL TARTRATE 50 MG TAB 49044665_1 CDM 0250 RC 51079-0801-20 NDC inpatient 1 UN 1.91 1.24 AETNA AETNA 1.51 79 999999999 1.16 1.85 percent of total billed charges METOPROLOL TARTRATE 50 MG TAB 49044665_1 CDM 0250 RC 51079-0801-20 NDC inpatient 1 UN 1.91 1.24 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.24 65 999999999 1.16 1.85 percent of total billed charges METOPROLOL TARTRATE 50 MG TAB 49044665_1 CDM 0250 RC 51079-0801-20 NDC inpatient 1 UN 1.91 1.24 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.85 97 999999999 1.16 1.85 percent of total billed charges METOPROLOL TARTRATE 50 MG TAB 49044665_1 CDM 0250 RC 51079-0801-20 NDC inpatient 1 UN 1.91 1.24 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.49 78 999999999 1.16 1.85 percent of total billed charges METOPROLOL TARTRATE 50 MG TAB 49044665_1 CDM 0250 RC 51079-0801-20 NDC inpatient 1 UN 1.91 1.24 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.32 69 999999999 1.16 1.85 percent of total billed charges METOPROLOL TARTRATE 50 MG TAB 49044665_1 CDM 0250 RC 51079-0801-20 NDC inpatient 1 UN 1.91 1.24 SIHO - ALL PLANS SIHO - ALL PLANS 1.72 90 999999999 1.16 1.85 percent of total billed charges METOPROLOL TARTRATE 50 MG TAB 49044665_1 CDM 0250 RC 51079-0801-20 NDC inpatient 1 UN 1.91 1.24 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.16 60.55 999999999 1.16 1.85 percent of total billed charges METOPROLOL TARTRATE 50 MG TAB 49044665_1 CDM 0250 RC 51079-0801-20 NDC inpatient 1 UN 1.91 1.24 UMR - ALL PLANS UMR - ALL PLANS 1.34 70 999999999 1.16 1.85 percent of total billed charges METOPROLOL TARTRATE 50 MG TAB 49044665_1 CDM 0250 RC 51079-0801-20 NDC inpatient 1 UN 1.91 1.24 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.16 1.85 METOPROLOL TARTRATE 50 MG TAB 49044665_1 CDM 0250 RC 51079-0801-20 NDC inpatient 1 UN 1.91 1.24 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.16 1.85 METOPROLOL TARTRATE 50 MG TAB 49044665_1 CDM 0250 RC 51079-0801-20 NDC inpatient 1 UN 1.91 1.24 ANTHEM HMO ANTHEM HMO 999999999 1.16 1.85 METOPROLOL TARTRATE 50 MG TAB 49044665_1 CDM 0250 RC 51079-0801-20 NDC inpatient 1 UN 1.91 1.24 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.16 1.85 METOPROLOL TARTRATE 50 MG TAB 49044665_1 CDM 0250 RC 51079-0801-20 NDC inpatient 1 UN 1.91 1.24 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.16 1.85 METOPROLOL TARTRATE 50 MG TAB 49044665_1 CDM 0250 RC 51079-0801-20 NDC inpatient 1 UN 1.91 1.24 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.29 67.6 999999999 1.16 1.85 percent of total billed charges MISOPROSTOL 200 MCG TABLET 49044668_1 CDM 0250 RC 68084-0041-01 NDC inpatient 1 UN 7.08 4.6 AETNA AETNA 5.59 79 999999999 4.29 6.87 percent of total billed charges MISOPROSTOL 200 MCG TABLET 49044668_1 CDM 0250 RC 68084-0041-01 NDC inpatient 1 UN 7.08 4.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.6 65 999999999 4.29 6.87 percent of total billed charges MISOPROSTOL 200 MCG TABLET 49044668_1 CDM 0250 RC 68084-0041-01 NDC inpatient 1 UN 7.08 4.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.87 97 999999999 4.29 6.87 percent of total billed charges MISOPROSTOL 200 MCG TABLET 49044668_1 CDM 0250 RC 68084-0041-01 NDC inpatient 1 UN 7.08 4.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 5.52 78 999999999 4.29 6.87 percent of total billed charges MISOPROSTOL 200 MCG TABLET 49044668_1 CDM 0250 RC 68084-0041-01 NDC inpatient 1 UN 7.08 4.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.89 69 999999999 4.29 6.87 percent of total billed charges MISOPROSTOL 200 MCG TABLET 49044668_1 CDM 0250 RC 68084-0041-01 NDC inpatient 1 UN 7.08 4.6 SIHO - ALL PLANS SIHO - ALL PLANS 6.37 90 999999999 4.29 6.87 percent of total billed charges MISOPROSTOL 200 MCG TABLET 49044668_1 CDM 0250 RC 68084-0041-01 NDC inpatient 1 UN 7.08 4.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.29 60.55 999999999 4.29 6.87 percent of total billed charges MISOPROSTOL 200 MCG TABLET 49044668_1 CDM 0250 RC 68084-0041-01 NDC inpatient 1 UN 7.08 4.6 UMR - ALL PLANS UMR - ALL PLANS 4.96 70 999999999 4.29 6.87 percent of total billed charges MISOPROSTOL 200 MCG TABLET 49044668_1 CDM 0250 RC 68084-0041-01 NDC inpatient 1 UN 7.08 4.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.29 6.87 MISOPROSTOL 200 MCG TABLET 49044668_1 CDM 0250 RC 68084-0041-01 NDC inpatient 1 UN 7.08 4.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.29 6.87 MISOPROSTOL 200 MCG TABLET 49044668_1 CDM 0250 RC 68084-0041-01 NDC inpatient 1 UN 7.08 4.6 ANTHEM HMO ANTHEM HMO 999999999 4.29 6.87 MISOPROSTOL 200 MCG TABLET 49044668_1 CDM 0250 RC 68084-0041-01 NDC inpatient 1 UN 7.08 4.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.29 6.87 MISOPROSTOL 200 MCG TABLET 49044668_1 CDM 0250 RC 68084-0041-01 NDC inpatient 1 UN 7.08 4.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.29 6.87 MISOPROSTOL 200 MCG TABLET 49044668_1 CDM 0250 RC 68084-0041-01 NDC inpatient 1 UN 7.08 4.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.79 67.6 999999999 4.29 6.87 percent of total billed charges ENOXAPARIN 150 MG/ML SYRINGE 49067266_1 CDM 0250 RC 63323-0569-95 NDC inpatient 1 UN 81.72 53.12 AETNA AETNA 64.56 79 999999999 49.48 79.27 percent of total billed charges ENOXAPARIN 150 MG/ML SYRINGE 49067266_1 CDM 0250 RC 63323-0569-95 NDC inpatient 1 UN 81.72 53.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.12 65 999999999 49.48 79.27 percent of total billed charges ENOXAPARIN 150 MG/ML SYRINGE 49067266_1 CDM 0250 RC 63323-0569-95 NDC inpatient 1 UN 81.72 53.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.27 97 999999999 49.48 79.27 percent of total billed charges ENOXAPARIN 150 MG/ML SYRINGE 49067266_1 CDM 0250 RC 63323-0569-95 NDC inpatient 1 UN 81.72 53.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.74 78 999999999 49.48 79.27 percent of total billed charges ENOXAPARIN 150 MG/ML SYRINGE 49067266_1 CDM 0250 RC 63323-0569-95 NDC inpatient 1 UN 81.72 53.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.39 69 999999999 49.48 79.27 percent of total billed charges ENOXAPARIN 150 MG/ML SYRINGE 49067266_1 CDM 0250 RC 63323-0569-95 NDC inpatient 1 UN 81.72 53.12 SIHO - ALL PLANS SIHO - ALL PLANS 73.55 90 999999999 49.48 79.27 percent of total billed charges ENOXAPARIN 150 MG/ML SYRINGE 49067266_1 CDM 0250 RC 63323-0569-95 NDC inpatient 1 UN 81.72 53.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.48 60.55 999999999 49.48 79.27 percent of total billed charges ENOXAPARIN 150 MG/ML SYRINGE 49067266_1 CDM 0250 RC 63323-0569-95 NDC inpatient 1 UN 81.72 53.12 UMR - ALL PLANS UMR - ALL PLANS 57.2 70 999999999 49.48 79.27 percent of total billed charges ENOXAPARIN 150 MG/ML SYRINGE 49067266_1 CDM 0250 RC 63323-0569-95 NDC inpatient 1 UN 81.72 53.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.48 79.27 ENOXAPARIN 150 MG/ML SYRINGE 49067266_1 CDM 0250 RC 63323-0569-95 NDC inpatient 1 UN 81.72 53.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.48 79.27 ENOXAPARIN 150 MG/ML SYRINGE 49067266_1 CDM 0250 RC 63323-0569-95 NDC inpatient 1 UN 81.72 53.12 ANTHEM HMO ANTHEM HMO 999999999 49.48 79.27 ENOXAPARIN 150 MG/ML SYRINGE 49067266_1 CDM 0250 RC 63323-0569-95 NDC inpatient 1 UN 81.72 53.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.48 79.27 ENOXAPARIN 150 MG/ML SYRINGE 49067266_1 CDM 0250 RC 63323-0569-95 NDC inpatient 1 UN 81.72 53.12 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.48 79.27 ENOXAPARIN 150 MG/ML SYRINGE 49067266_1 CDM 0250 RC 63323-0569-95 NDC inpatient 1 UN 81.72 53.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.24 67.6 999999999 49.48 79.27 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 49069189_1 CDM 0636 RC 00703-4246-01 NDC J9045 HCPCS inpatient 3 UN 66.99 43.54 AETNA AETNA 52.92 79 999999999 40.56 64.98 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 49069189_1 CDM 0636 RC 00703-4246-01 NDC J9045 HCPCS inpatient 3 UN 66.99 43.54 SELF PAY DISCOUNT SELF PAY DISCOUNT 43.54 65 999999999 40.56 64.98 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 49069189_1 CDM 0636 RC 00703-4246-01 NDC J9045 HCPCS inpatient 3 UN 66.99 43.54 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.98 97 999999999 40.56 64.98 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 49069189_1 CDM 0636 RC 00703-4246-01 NDC J9045 HCPCS inpatient 3 UN 66.99 43.54 HUMANA - ALL PLANS HUMANA - ALL PLANS 52.25 78 999999999 40.56 64.98 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 49069189_1 CDM 0636 RC 00703-4246-01 NDC J9045 HCPCS inpatient 3 UN 66.99 43.54 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.22 69 999999999 40.56 64.98 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 49069189_1 CDM 0636 RC 00703-4246-01 NDC J9045 HCPCS inpatient 3 UN 66.99 43.54 SIHO - ALL PLANS SIHO - ALL PLANS 60.29 90 999999999 40.56 64.98 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 49069189_1 CDM 0636 RC 00703-4246-01 NDC J9045 HCPCS inpatient 3 UN 66.99 43.54 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 40.56 60.55 999999999 40.56 64.98 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 49069189_1 CDM 0636 RC 00703-4246-01 NDC J9045 HCPCS inpatient 3 UN 66.99 43.54 UMR - ALL PLANS UMR - ALL PLANS 46.89 70 999999999 40.56 64.98 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 49069189_1 CDM 0636 RC 00703-4246-01 NDC J9045 HCPCS inpatient 3 UN 66.99 43.54 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 40.56 64.98 "INJECTION, CARBOPLATIN, 50 MG" 49069189_1 CDM 0636 RC 00703-4246-01 NDC J9045 HCPCS inpatient 3 UN 66.99 43.54 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 40.56 64.98 "INJECTION, CARBOPLATIN, 50 MG" 49069189_1 CDM 0636 RC 00703-4246-01 NDC J9045 HCPCS inpatient 3 UN 66.99 43.54 ANTHEM HMO ANTHEM HMO 999999999 40.56 64.98 "INJECTION, CARBOPLATIN, 50 MG" 49069189_1 CDM 0636 RC 00703-4246-01 NDC J9045 HCPCS inpatient 3 UN 66.99 43.54 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 40.56 64.98 "INJECTION, CARBOPLATIN, 50 MG" 49069189_1 CDM 0636 RC 00703-4246-01 NDC J9045 HCPCS inpatient 3 UN 66.99 43.54 UHC - ALL PLANS UHC - ALL PLANS 999999999 40.56 64.98 "INJECTION, CARBOPLATIN, 50 MG" 49069189_1 CDM 0636 RC 00703-4246-01 NDC J9045 HCPCS inpatient 3 UN 66.99 43.54 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.29 67.6 999999999 40.56 64.98 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069423_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069423_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069423_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069423_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069423_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069423_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069423_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069423_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069423_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069423_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069423_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069423_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069423_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069423_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069427_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069427_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069427_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069427_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069427_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069427_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069427_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069427_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069427_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069427_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069427_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069427_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069427_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 "Professional services for outpatient pulmonary rehabilitation with continuous monitoring of blood oxygen, per session" 49069427_1 CDM 0948 RC 94626 HCPCS inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges Phase 3 Pulmonary Rehab 13 visits 49069428_1 CDM 0948 RC inpatient 60 39 AETNA AETNA 47.4 79 999999999 36.33 58.2 percent of total billed charges Phase 3 Pulmonary Rehab 13 visits 49069428_1 CDM 0948 RC inpatient 60 39 SELF PAY DISCOUNT SELF PAY DISCOUNT 39 65 999999999 36.33 58.2 percent of total billed charges Phase 3 Pulmonary Rehab 13 visits 49069428_1 CDM 0948 RC inpatient 60 39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.2 97 999999999 36.33 58.2 percent of total billed charges Phase 3 Pulmonary Rehab 13 visits 49069428_1 CDM 0948 RC inpatient 60 39 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.8 78 999999999 36.33 58.2 percent of total billed charges Phase 3 Pulmonary Rehab 13 visits 49069428_1 CDM 0948 RC inpatient 60 39 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.4 69 999999999 36.33 58.2 percent of total billed charges Phase 3 Pulmonary Rehab 13 visits 49069428_1 CDM 0948 RC inpatient 60 39 SIHO - ALL PLANS SIHO - ALL PLANS 54 90 999999999 36.33 58.2 percent of total billed charges Phase 3 Pulmonary Rehab 13 visits 49069428_1 CDM 0948 RC inpatient 60 39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.33 60.55 999999999 36.33 58.2 percent of total billed charges Phase 3 Pulmonary Rehab 13 visits 49069428_1 CDM 0948 RC inpatient 60 39 UMR - ALL PLANS UMR - ALL PLANS 42 70 999999999 36.33 58.2 percent of total billed charges Phase 3 Pulmonary Rehab 13 visits 49069428_1 CDM 0948 RC inpatient 60 39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.33 58.2 Phase 3 Pulmonary Rehab 13 visits 49069428_1 CDM 0948 RC inpatient 60 39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.33 58.2 Phase 3 Pulmonary Rehab 13 visits 49069428_1 CDM 0948 RC inpatient 60 39 ANTHEM HMO ANTHEM HMO 999999999 36.33 58.2 Phase 3 Pulmonary Rehab 13 visits 49069428_1 CDM 0948 RC inpatient 60 39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.33 58.2 Phase 3 Pulmonary Rehab 13 visits 49069428_1 CDM 0948 RC inpatient 60 39 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.33 58.2 Phase 3 Pulmonary Rehab 13 visits 49069428_1 CDM 0948 RC inpatient 60 39 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.56 67.6 999999999 36.33 58.2 percent of total billed charges Phase 3 Pulmonary Rehab 28 visits 49069432_1 CDM 0948 RC inpatient 120 78 AETNA AETNA 94.8 79 999999999 72.66 116.4 percent of total billed charges Phase 3 Pulmonary Rehab 28 visits 49069432_1 CDM 0948 RC inpatient 120 78 SELF PAY DISCOUNT SELF PAY DISCOUNT 78 65 999999999 72.66 116.4 percent of total billed charges Phase 3 Pulmonary Rehab 28 visits 49069432_1 CDM 0948 RC inpatient 120 78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.4 97 999999999 72.66 116.4 percent of total billed charges Phase 3 Pulmonary Rehab 28 visits 49069432_1 CDM 0948 RC inpatient 120 78 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.6 78 999999999 72.66 116.4 percent of total billed charges Phase 3 Pulmonary Rehab 28 visits 49069432_1 CDM 0948 RC inpatient 120 78 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.8 69 999999999 72.66 116.4 percent of total billed charges Phase 3 Pulmonary Rehab 28 visits 49069432_1 CDM 0948 RC inpatient 120 78 SIHO - ALL PLANS SIHO - ALL PLANS 108 90 999999999 72.66 116.4 percent of total billed charges Phase 3 Pulmonary Rehab 28 visits 49069432_1 CDM 0948 RC inpatient 120 78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.66 60.55 999999999 72.66 116.4 percent of total billed charges Phase 3 Pulmonary Rehab 28 visits 49069432_1 CDM 0948 RC inpatient 120 78 UMR - ALL PLANS UMR - ALL PLANS 84 70 999999999 72.66 116.4 percent of total billed charges Phase 3 Pulmonary Rehab 28 visits 49069432_1 CDM 0948 RC inpatient 120 78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.66 116.4 Phase 3 Pulmonary Rehab 28 visits 49069432_1 CDM 0948 RC inpatient 120 78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.66 116.4 Phase 3 Pulmonary Rehab 28 visits 49069432_1 CDM 0948 RC inpatient 120 78 ANTHEM HMO ANTHEM HMO 999999999 72.66 116.4 Phase 3 Pulmonary Rehab 28 visits 49069432_1 CDM 0948 RC inpatient 120 78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.66 116.4 Phase 3 Pulmonary Rehab 28 visits 49069432_1 CDM 0948 RC inpatient 120 78 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.66 116.4 Phase 3 Pulmonary Rehab 28 visits 49069432_1 CDM 0948 RC inpatient 120 78 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.12 67.6 999999999 72.66 116.4 percent of total billed charges TAZICEF 2 GRAM VIAL 49070290_1 CDM 0250 RC 00409-5084-11 NDC inpatient 1 UN 46.38 30.15 AETNA AETNA 36.64 79 999999999 28.08 44.99 percent of total billed charges TAZICEF 2 GRAM VIAL 49070290_1 CDM 0250 RC 00409-5084-11 NDC inpatient 1 UN 46.38 30.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 30.15 65 999999999 28.08 44.99 percent of total billed charges TAZICEF 2 GRAM VIAL 49070290_1 CDM 0250 RC 00409-5084-11 NDC inpatient 1 UN 46.38 30.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 44.99 97 999999999 28.08 44.99 percent of total billed charges TAZICEF 2 GRAM VIAL 49070290_1 CDM 0250 RC 00409-5084-11 NDC inpatient 1 UN 46.38 30.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 36.18 78 999999999 28.08 44.99 percent of total billed charges TAZICEF 2 GRAM VIAL 49070290_1 CDM 0250 RC 00409-5084-11 NDC inpatient 1 UN 46.38 30.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 32 69 999999999 28.08 44.99 percent of total billed charges TAZICEF 2 GRAM VIAL 49070290_1 CDM 0250 RC 00409-5084-11 NDC inpatient 1 UN 46.38 30.15 SIHO - ALL PLANS SIHO - ALL PLANS 41.74 90 999999999 28.08 44.99 percent of total billed charges TAZICEF 2 GRAM VIAL 49070290_1 CDM 0250 RC 00409-5084-11 NDC inpatient 1 UN 46.38 30.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 28.08 60.55 999999999 28.08 44.99 percent of total billed charges TAZICEF 2 GRAM VIAL 49070290_1 CDM 0250 RC 00409-5084-11 NDC inpatient 1 UN 46.38 30.15 UMR - ALL PLANS UMR - ALL PLANS 32.47 70 999999999 28.08 44.99 percent of total billed charges TAZICEF 2 GRAM VIAL 49070290_1 CDM 0250 RC 00409-5084-11 NDC inpatient 1 UN 46.38 30.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 28.08 44.99 TAZICEF 2 GRAM VIAL 49070290_1 CDM 0250 RC 00409-5084-11 NDC inpatient 1 UN 46.38 30.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 28.08 44.99 TAZICEF 2 GRAM VIAL 49070290_1 CDM 0250 RC 00409-5084-11 NDC inpatient 1 UN 46.38 30.15 ANTHEM HMO ANTHEM HMO 999999999 28.08 44.99 TAZICEF 2 GRAM VIAL 49070290_1 CDM 0250 RC 00409-5084-11 NDC inpatient 1 UN 46.38 30.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 28.08 44.99 TAZICEF 2 GRAM VIAL 49070290_1 CDM 0250 RC 00409-5084-11 NDC inpatient 1 UN 46.38 30.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 28.08 44.99 TAZICEF 2 GRAM VIAL 49070290_1 CDM 0250 RC 00409-5084-11 NDC inpatient 1 UN 46.38 30.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 31.35 67.6 999999999 28.08 44.99 percent of total billed charges Mercury level 49070982_1 CDM 0301 RC 83825 HCPCS inpatient 264 171.6 AETNA AETNA 208.56 79 999999999 159.85 256.08 percent of total billed charges Mercury level 49070982_1 CDM 0301 RC 83825 HCPCS inpatient 264 171.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 171.6 65 999999999 159.85 256.08 percent of total billed charges Mercury level 49070982_1 CDM 0301 RC 83825 HCPCS inpatient 264 171.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 256.08 97 999999999 159.85 256.08 percent of total billed charges Mercury level 49070982_1 CDM 0301 RC 83825 HCPCS inpatient 264 171.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 205.92 78 999999999 159.85 256.08 percent of total billed charges Mercury level 49070982_1 CDM 0301 RC 83825 HCPCS inpatient 264 171.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 182.16 69 999999999 159.85 256.08 percent of total billed charges Mercury level 49070982_1 CDM 0301 RC 83825 HCPCS inpatient 264 171.6 SIHO - ALL PLANS SIHO - ALL PLANS 237.6 90 999999999 159.85 256.08 percent of total billed charges Mercury level 49070982_1 CDM 0301 RC 83825 HCPCS inpatient 264 171.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 159.85 60.55 999999999 159.85 256.08 percent of total billed charges Mercury level 49070982_1 CDM 0301 RC 83825 HCPCS inpatient 264 171.6 UMR - ALL PLANS UMR - ALL PLANS 184.8 70 999999999 159.85 256.08 percent of total billed charges Mercury level 49070982_1 CDM 0301 RC 83825 HCPCS inpatient 264 171.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 159.85 256.08 Mercury level 49070982_1 CDM 0301 RC 83825 HCPCS inpatient 264 171.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 159.85 256.08 Mercury level 49070982_1 CDM 0301 RC 83825 HCPCS inpatient 264 171.6 ANTHEM HMO ANTHEM HMO 999999999 159.85 256.08 Mercury level 49070982_1 CDM 0301 RC 83825 HCPCS inpatient 264 171.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 159.85 256.08 Mercury level 49070982_1 CDM 0301 RC 83825 HCPCS inpatient 264 171.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 159.85 256.08 Mercury level 49070982_1 CDM 0301 RC 83825 HCPCS inpatient 264 171.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 178.46 67.6 999999999 159.85 256.08 percent of total billed charges Cadmium level 49070983_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Cadmium level 49070983_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Cadmium level 49070983_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Cadmium level 49070983_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Cadmium level 49070983_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Cadmium level 49070983_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Cadmium level 49070983_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Cadmium level 49070983_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Cadmium level 49070983_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Cadmium level 49070983_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Cadmium level 49070983_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Cadmium level 49070983_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Cadmium level 49070983_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Cadmium level 49070983_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Arsenic level 49070985_1 CDM 0301 RC 82175 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges Arsenic level 49070985_1 CDM 0301 RC 82175 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges Arsenic level 49070985_1 CDM 0301 RC 82175 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges Arsenic level 49070985_1 CDM 0301 RC 82175 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges Arsenic level 49070985_1 CDM 0301 RC 82175 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges Arsenic level 49070985_1 CDM 0301 RC 82175 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges Arsenic level 49070985_1 CDM 0301 RC 82175 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges Arsenic level 49070985_1 CDM 0301 RC 82175 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges Arsenic level 49070985_1 CDM 0301 RC 82175 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 Arsenic level 49070985_1 CDM 0301 RC 82175 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 Arsenic level 49070985_1 CDM 0301 RC 82175 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 Arsenic level 49070985_1 CDM 0301 RC 82175 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 Arsenic level 49070985_1 CDM 0301 RC 82175 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 Arsenic level 49070985_1 CDM 0301 RC 82175 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges Lead level 49070986_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 AETNA AETNA 188.02 79 999999999 144.11 230.86 percent of total billed charges Lead level 49070986_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.7 65 999999999 144.11 230.86 percent of total billed charges Lead level 49070986_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 230.86 97 999999999 144.11 230.86 percent of total billed charges Lead level 49070986_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 185.64 78 999999999 144.11 230.86 percent of total billed charges Lead level 49070986_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.22 69 999999999 144.11 230.86 percent of total billed charges Lead level 49070986_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 SIHO - ALL PLANS SIHO - ALL PLANS 214.2 90 999999999 144.11 230.86 percent of total billed charges Lead level 49070986_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.11 60.55 999999999 144.11 230.86 percent of total billed charges Lead level 49070986_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 UMR - ALL PLANS UMR - ALL PLANS 166.6 70 999999999 144.11 230.86 percent of total billed charges Lead level 49070986_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.11 230.86 Lead level 49070986_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.11 230.86 Lead level 49070986_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 ANTHEM HMO ANTHEM HMO 999999999 144.11 230.86 Lead level 49070986_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.11 230.86 Lead level 49070986_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.11 230.86 Lead level 49070986_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.89 67.6 999999999 144.11 230.86 percent of total billed charges Lead level 49070987_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 AETNA AETNA 170.64 79 999999999 130.79 209.52 percent of total billed charges Lead level 49070987_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 140.4 65 999999999 130.79 209.52 percent of total billed charges Lead level 49070987_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 209.52 97 999999999 130.79 209.52 percent of total billed charges Lead level 49070987_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 168.48 78 999999999 130.79 209.52 percent of total billed charges Lead level 49070987_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 149.04 69 999999999 130.79 209.52 percent of total billed charges Lead level 49070987_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 SIHO - ALL PLANS SIHO - ALL PLANS 194.4 90 999999999 130.79 209.52 percent of total billed charges Lead level 49070987_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 130.79 60.55 999999999 130.79 209.52 percent of total billed charges Lead level 49070987_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 UMR - ALL PLANS UMR - ALL PLANS 151.2 70 999999999 130.79 209.52 percent of total billed charges Lead level 49070987_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 130.79 209.52 Lead level 49070987_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 130.79 209.52 Lead level 49070987_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ANTHEM HMO ANTHEM HMO 999999999 130.79 209.52 Lead level 49070987_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 130.79 209.52 Lead level 49070987_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 130.79 209.52 Lead level 49070987_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 146.02 67.6 999999999 130.79 209.52 percent of total billed charges Cadmium level 49070988_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Cadmium level 49070988_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Cadmium level 49070988_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Cadmium level 49070988_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Cadmium level 49070988_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Cadmium level 49070988_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Cadmium level 49070988_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Cadmium level 49070988_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Cadmium level 49070988_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Cadmium level 49070988_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Cadmium level 49070988_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Cadmium level 49070988_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Cadmium level 49070988_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Cadmium level 49070988_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Arsenic level 49070990_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 AETNA AETNA 89.27 79 999999999 68.42 109.61 percent of total billed charges Arsenic level 49070990_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 73.45 65 999999999 68.42 109.61 percent of total billed charges Arsenic level 49070990_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 109.61 97 999999999 68.42 109.61 percent of total billed charges Arsenic level 49070990_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.14 78 999999999 68.42 109.61 percent of total billed charges Arsenic level 49070990_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.97 69 999999999 68.42 109.61 percent of total billed charges Arsenic level 49070990_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 SIHO - ALL PLANS SIHO - ALL PLANS 101.7 90 999999999 68.42 109.61 percent of total billed charges Arsenic level 49070990_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 68.42 60.55 999999999 68.42 109.61 percent of total billed charges Arsenic level 49070990_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 UMR - ALL PLANS UMR - ALL PLANS 79.1 70 999999999 68.42 109.61 percent of total billed charges Arsenic level 49070990_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 68.42 109.61 Arsenic level 49070990_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 68.42 109.61 Arsenic level 49070990_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 ANTHEM HMO ANTHEM HMO 999999999 68.42 109.61 Arsenic level 49070990_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 68.42 109.61 Arsenic level 49070990_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 68.42 109.61 Arsenic level 49070990_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 76.39 67.6 999999999 68.42 109.61 percent of total billed charges Chemical analysis using chromatography technique 49071209_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges Chemical analysis using chromatography technique 49071209_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges Chemical analysis using chromatography technique 49071209_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges Chemical analysis using chromatography technique 49071209_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges Chemical analysis using chromatography technique 49071209_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges Chemical analysis using chromatography technique 49071209_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges Chemical analysis using chromatography technique 49071209_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges Chemical analysis using chromatography technique 49071209_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges Chemical analysis using chromatography technique 49071209_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 Chemical analysis using chromatography technique 49071209_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 Chemical analysis using chromatography technique 49071209_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 Chemical analysis using chromatography technique 49071209_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 Chemical analysis using chromatography technique 49071209_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 Chemical analysis using chromatography technique 49071209_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges Carnitine level 49071210_1 CDM 0301 RC 82379 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges Carnitine level 49071210_1 CDM 0301 RC 82379 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges Carnitine level 49071210_1 CDM 0301 RC 82379 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges Carnitine level 49071210_1 CDM 0301 RC 82379 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges Carnitine level 49071210_1 CDM 0301 RC 82379 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges Carnitine level 49071210_1 CDM 0301 RC 82379 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges Carnitine level 49071210_1 CDM 0301 RC 82379 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges Carnitine level 49071210_1 CDM 0301 RC 82379 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges Carnitine level 49071210_1 CDM 0301 RC 82379 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 Carnitine level 49071210_1 CDM 0301 RC 82379 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 Carnitine level 49071210_1 CDM 0301 RC 82379 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 Carnitine level 49071210_1 CDM 0301 RC 82379 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 Carnitine level 49071210_1 CDM 0301 RC 82379 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 Carnitine level 49071210_1 CDM 0301 RC 82379 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges Carnitine level 49071211_1 CDM 0301 RC 82379 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges Carnitine level 49071211_1 CDM 0301 RC 82379 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges Carnitine level 49071211_1 CDM 0301 RC 82379 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges Carnitine level 49071211_1 CDM 0301 RC 82379 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges Carnitine level 49071211_1 CDM 0301 RC 82379 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges Carnitine level 49071211_1 CDM 0301 RC 82379 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges Carnitine level 49071211_1 CDM 0301 RC 82379 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges Carnitine level 49071211_1 CDM 0301 RC 82379 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges Carnitine level 49071211_1 CDM 0301 RC 82379 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 Carnitine level 49071211_1 CDM 0301 RC 82379 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 Carnitine level 49071211_1 CDM 0301 RC 82379 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 Carnitine level 49071211_1 CDM 0301 RC 82379 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 Carnitine level 49071211_1 CDM 0301 RC 82379 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 Carnitine level 49071211_1 CDM 0301 RC 82379 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49071212_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49071212_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49071212_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49071212_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49071212_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49071212_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49071212_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49071212_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49071212_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 "Testing for presence of drug, by chemistry analyzers" 49071212_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 "Testing for presence of drug, by chemistry analyzers" 49071212_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 "Testing for presence of drug, by chemistry analyzers" 49071212_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 "Testing for presence of drug, by chemistry analyzers" 49071212_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 "Testing for presence of drug, by chemistry analyzers" 49071212_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges Chemical analysis using chromatography technique 49071214_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges Chemical analysis using chromatography technique 49071214_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges Chemical analysis using chromatography technique 49071214_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges Chemical analysis using chromatography technique 49071214_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges Chemical analysis using chromatography technique 49071214_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges Chemical analysis using chromatography technique 49071214_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges Chemical analysis using chromatography technique 49071214_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges Chemical analysis using chromatography technique 49071214_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges Chemical analysis using chromatography technique 49071214_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 Chemical analysis using chromatography technique 49071214_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 Chemical analysis using chromatography technique 49071214_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 Chemical analysis using chromatography technique 49071214_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 Chemical analysis using chromatography technique 49071214_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 Chemical analysis using chromatography technique 49071214_1 CDM 0301 RC 82542 HCPCS inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071215_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071215_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071215_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071215_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071215_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071215_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071215_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071215_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071215_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49071215_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49071215_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49071215_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49071215_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49071215_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071216_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071216_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071216_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071216_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071216_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071216_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071216_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071216_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071216_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49071216_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49071216_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49071216_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49071216_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49071216_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071217_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071217_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071217_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071217_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071217_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071217_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071217_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071217_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49071217_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49071217_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49071217_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49071217_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49071217_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49071217_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071218_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071218_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071218_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071218_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071218_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071218_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071218_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071218_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071218_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071218_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071218_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071218_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071218_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071218_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071219_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071219_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071219_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071219_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071219_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071219_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071219_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071219_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071219_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071219_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071219_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071219_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071219_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071219_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071221_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071221_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071221_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071221_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071221_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071221_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071221_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071221_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071221_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071221_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071221_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071221_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071221_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071221_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071222_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071222_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071222_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071222_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071222_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071222_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071222_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071222_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071222_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071222_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071222_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071222_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071222_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 49071222_1 CDM 0301 RC 82787 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49071223_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49071223_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49071223_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49071223_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49071223_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49071223_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49071223_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49071223_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49071223_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49071223_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49071223_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49071223_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49071223_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49071223_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49071225_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49071225_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49071225_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49071225_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49071225_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49071225_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49071225_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49071225_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49071225_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49071225_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49071225_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49071225_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49071225_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49071225_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges Urine volume measurement 49071227_1 CDM 0301 RC 81050 HCPCS inpatient 55 35.75 AETNA AETNA 43.45 79 999999999 33.3 53.35 percent of total billed charges Urine volume measurement 49071227_1 CDM 0301 RC 81050 HCPCS inpatient 55 35.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 35.75 65 999999999 33.3 53.35 percent of total billed charges Urine volume measurement 49071227_1 CDM 0301 RC 81050 HCPCS inpatient 55 35.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 53.35 97 999999999 33.3 53.35 percent of total billed charges Urine volume measurement 49071227_1 CDM 0301 RC 81050 HCPCS inpatient 55 35.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 42.9 78 999999999 33.3 53.35 percent of total billed charges Urine volume measurement 49071227_1 CDM 0301 RC 81050 HCPCS inpatient 55 35.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 37.95 69 999999999 33.3 53.35 percent of total billed charges Urine volume measurement 49071227_1 CDM 0301 RC 81050 HCPCS inpatient 55 35.75 SIHO - ALL PLANS SIHO - ALL PLANS 49.5 90 999999999 33.3 53.35 percent of total billed charges Urine volume measurement 49071227_1 CDM 0301 RC 81050 HCPCS inpatient 55 35.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33.3 60.55 999999999 33.3 53.35 percent of total billed charges Urine volume measurement 49071227_1 CDM 0301 RC 81050 HCPCS inpatient 55 35.75 UMR - ALL PLANS UMR - ALL PLANS 38.5 70 999999999 33.3 53.35 percent of total billed charges Urine volume measurement 49071227_1 CDM 0301 RC 81050 HCPCS inpatient 55 35.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 33.3 53.35 Urine volume measurement 49071227_1 CDM 0301 RC 81050 HCPCS inpatient 55 35.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 33.3 53.35 Urine volume measurement 49071227_1 CDM 0301 RC 81050 HCPCS inpatient 55 35.75 ANTHEM HMO ANTHEM HMO 999999999 33.3 53.35 Urine volume measurement 49071227_1 CDM 0301 RC 81050 HCPCS inpatient 55 35.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 33.3 53.35 Urine volume measurement 49071227_1 CDM 0301 RC 81050 HCPCS inpatient 55 35.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 33.3 53.35 Urine volume measurement 49071227_1 CDM 0301 RC 81050 HCPCS inpatient 55 35.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 37.18 67.6 999999999 33.3 53.35 percent of total billed charges "Protein measurement, body fluid" 49071228_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges "Protein measurement, body fluid" 49071228_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges "Protein measurement, body fluid" 49071228_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges "Protein measurement, body fluid" 49071228_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges "Protein measurement, body fluid" 49071228_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges "Protein measurement, body fluid" 49071228_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges "Protein measurement, body fluid" 49071228_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges "Protein measurement, body fluid" 49071228_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges "Protein measurement, body fluid" 49071228_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 "Protein measurement, body fluid" 49071228_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 "Protein measurement, body fluid" 49071228_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 "Protein measurement, body fluid" 49071228_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 "Protein measurement, body fluid" 49071228_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 "Protein measurement, body fluid" 49071228_1 CDM 0301 RC 84166 HCPCS inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges Phosphatidylglycerol (amniotic fluid organic acid) level 49071230_1 CDM 0301 RC 84081 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges Phosphatidylglycerol (amniotic fluid organic acid) level 49071230_1 CDM 0301 RC 84081 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges Phosphatidylglycerol (amniotic fluid organic acid) level 49071230_1 CDM 0301 RC 84081 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges Phosphatidylglycerol (amniotic fluid organic acid) level 49071230_1 CDM 0301 RC 84081 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges Phosphatidylglycerol (amniotic fluid organic acid) level 49071230_1 CDM 0301 RC 84081 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges Phosphatidylglycerol (amniotic fluid organic acid) level 49071230_1 CDM 0301 RC 84081 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges Phosphatidylglycerol (amniotic fluid organic acid) level 49071230_1 CDM 0301 RC 84081 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges Phosphatidylglycerol (amniotic fluid organic acid) level 49071230_1 CDM 0301 RC 84081 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges Phosphatidylglycerol (amniotic fluid organic acid) level 49071230_1 CDM 0301 RC 84081 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 Phosphatidylglycerol (amniotic fluid organic acid) level 49071230_1 CDM 0301 RC 84081 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 Phosphatidylglycerol (amniotic fluid organic acid) level 49071230_1 CDM 0301 RC 84081 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 Phosphatidylglycerol (amniotic fluid organic acid) level 49071230_1 CDM 0301 RC 84081 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 Phosphatidylglycerol (amniotic fluid organic acid) level 49071230_1 CDM 0301 RC 84081 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 Phosphatidylglycerol (amniotic fluid organic acid) level 49071230_1 CDM 0301 RC 84081 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges Chemical analysis using spectrophotometry (light) 49071232_1 CDM 0301 RC 84311 HCPCS inpatient 199 129.35 AETNA AETNA 157.21 79 999999999 120.49 193.03 percent of total billed charges Chemical analysis using spectrophotometry (light) 49071232_1 CDM 0301 RC 84311 HCPCS inpatient 199 129.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 129.35 65 999999999 120.49 193.03 percent of total billed charges Chemical analysis using spectrophotometry (light) 49071232_1 CDM 0301 RC 84311 HCPCS inpatient 199 129.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 193.03 97 999999999 120.49 193.03 percent of total billed charges Chemical analysis using spectrophotometry (light) 49071232_1 CDM 0301 RC 84311 HCPCS inpatient 199 129.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 155.22 78 999999999 120.49 193.03 percent of total billed charges Chemical analysis using spectrophotometry (light) 49071232_1 CDM 0301 RC 84311 HCPCS inpatient 199 129.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 137.31 69 999999999 120.49 193.03 percent of total billed charges Chemical analysis using spectrophotometry (light) 49071232_1 CDM 0301 RC 84311 HCPCS inpatient 199 129.35 SIHO - ALL PLANS SIHO - ALL PLANS 179.1 90 999999999 120.49 193.03 percent of total billed charges Chemical analysis using spectrophotometry (light) 49071232_1 CDM 0301 RC 84311 HCPCS inpatient 199 129.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 120.49 60.55 999999999 120.49 193.03 percent of total billed charges Chemical analysis using spectrophotometry (light) 49071232_1 CDM 0301 RC 84311 HCPCS inpatient 199 129.35 UMR - ALL PLANS UMR - ALL PLANS 139.3 70 999999999 120.49 193.03 percent of total billed charges Chemical analysis using spectrophotometry (light) 49071232_1 CDM 0301 RC 84311 HCPCS inpatient 199 129.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 120.49 193.03 Chemical analysis using spectrophotometry (light) 49071232_1 CDM 0301 RC 84311 HCPCS inpatient 199 129.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 120.49 193.03 Chemical analysis using spectrophotometry (light) 49071232_1 CDM 0301 RC 84311 HCPCS inpatient 199 129.35 ANTHEM HMO ANTHEM HMO 999999999 120.49 193.03 Chemical analysis using spectrophotometry (light) 49071232_1 CDM 0301 RC 84311 HCPCS inpatient 199 129.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 120.49 193.03 Chemical analysis using spectrophotometry (light) 49071232_1 CDM 0301 RC 84311 HCPCS inpatient 199 129.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 120.49 193.03 Chemical analysis using spectrophotometry (light) 49071232_1 CDM 0301 RC 84311 HCPCS inpatient 199 129.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 134.52 67.6 999999999 120.49 193.03 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 49071245_1 CDM 0302 RC 86611 HCPCS inpatient 78 50.7 AETNA AETNA 61.62 79 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 49071245_1 CDM 0302 RC 86611 HCPCS inpatient 78 50.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.7 65 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 49071245_1 CDM 0302 RC 86611 HCPCS inpatient 78 50.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 75.66 97 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 49071245_1 CDM 0302 RC 86611 HCPCS inpatient 78 50.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.84 78 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 49071245_1 CDM 0302 RC 86611 HCPCS inpatient 78 50.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.82 69 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 49071245_1 CDM 0302 RC 86611 HCPCS inpatient 78 50.7 SIHO - ALL PLANS SIHO - ALL PLANS 70.2 90 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 49071245_1 CDM 0302 RC 86611 HCPCS inpatient 78 50.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.23 60.55 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 49071245_1 CDM 0302 RC 86611 HCPCS inpatient 78 50.7 UMR - ALL PLANS UMR - ALL PLANS 54.6 70 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 49071245_1 CDM 0302 RC 86611 HCPCS inpatient 78 50.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.23 75.66 Analysis for antibody to Bartonella (bacteria) 49071245_1 CDM 0302 RC 86611 HCPCS inpatient 78 50.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.23 75.66 Analysis for antibody to Bartonella (bacteria) 49071245_1 CDM 0302 RC 86611 HCPCS inpatient 78 50.7 ANTHEM HMO ANTHEM HMO 999999999 47.23 75.66 Analysis for antibody to Bartonella (bacteria) 49071245_1 CDM 0302 RC 86611 HCPCS inpatient 78 50.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.23 75.66 Analysis for antibody to Bartonella (bacteria) 49071245_1 CDM 0302 RC 86611 HCPCS inpatient 78 50.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.23 75.66 Analysis for antibody to Bartonella (bacteria) 49071245_1 CDM 0302 RC 86611 HCPCS inpatient 78 50.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.73 67.6 999999999 47.23 75.66 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071249_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071249_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071249_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071249_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071249_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071249_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071249_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071249_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071249_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071249_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071249_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071249_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071249_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071249_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071251_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071251_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071251_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071251_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071251_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071251_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071251_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071251_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071251_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49071251_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49071251_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49071251_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49071251_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49071251_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071252_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071252_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071252_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071252_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071252_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071252_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071252_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071252_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071252_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071252_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071252_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071252_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071252_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071252_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071253_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071253_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071253_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071253_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071253_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071253_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071253_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071253_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071253_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071253_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071253_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071253_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071253_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49071253_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071255_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071255_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071255_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071255_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071255_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071255_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071255_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071255_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071255_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49071255_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49071255_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49071255_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49071255_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49071255_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071256_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071256_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071256_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071256_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071256_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071256_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071256_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071256_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071256_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 49071256_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 49071256_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 49071256_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 49071256_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 49071256_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071257_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071257_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071257_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071257_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071257_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071257_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071257_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071257_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071257_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 49071257_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 49071257_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 49071257_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 49071257_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 49071257_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071258_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071258_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071258_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071258_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071258_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071258_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071258_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071258_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 49071258_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 49071258_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 49071258_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 49071258_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 49071258_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 Phospholipid antibody (autoimmune antibody) measurement 49071258_1 CDM 0302 RC 86148 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071260_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071260_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071260_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071260_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071260_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071260_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071260_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071260_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49071260_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49071260_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49071260_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49071260_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49071260_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49071260_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071261_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071261_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071261_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071261_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071261_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071261_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071261_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071261_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071261_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071261_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071261_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071261_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071261_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071261_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071262_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071262_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071262_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071262_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071262_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071262_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071262_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071262_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071262_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071262_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071262_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071262_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071262_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071262_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071263_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071263_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071263_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071263_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071263_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071263_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071263_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071263_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071263_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071263_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071263_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071263_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071263_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071263_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071264_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071264_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071264_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071264_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071264_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071264_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071264_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071264_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49071264_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071264_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071264_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071264_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071264_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49071264_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 49071266_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 49071266_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 49071266_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 49071266_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 49071266_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 49071266_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 49071266_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 49071266_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 49071266_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 49071266_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 49071266_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 49071266_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 49071266_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 49071266_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 49071268_1 CDM 0301 RC 84702 HCPCS inpatient 197 128.05 AETNA AETNA 155.63 79 999999999 119.28 191.09 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 49071268_1 CDM 0301 RC 84702 HCPCS inpatient 197 128.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.05 65 999999999 119.28 191.09 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 49071268_1 CDM 0301 RC 84702 HCPCS inpatient 197 128.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 191.09 97 999999999 119.28 191.09 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 49071268_1 CDM 0301 RC 84702 HCPCS inpatient 197 128.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 153.66 78 999999999 119.28 191.09 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 49071268_1 CDM 0301 RC 84702 HCPCS inpatient 197 128.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 135.93 69 999999999 119.28 191.09 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 49071268_1 CDM 0301 RC 84702 HCPCS inpatient 197 128.05 SIHO - ALL PLANS SIHO - ALL PLANS 177.3 90 999999999 119.28 191.09 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 49071268_1 CDM 0301 RC 84702 HCPCS inpatient 197 128.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.28 60.55 999999999 119.28 191.09 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 49071268_1 CDM 0301 RC 84702 HCPCS inpatient 197 128.05 UMR - ALL PLANS UMR - ALL PLANS 137.9 70 999999999 119.28 191.09 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 49071268_1 CDM 0301 RC 84702 HCPCS inpatient 197 128.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.28 191.09 "Gonadotropin, chorionic (reproductive hormone) level" 49071268_1 CDM 0301 RC 84702 HCPCS inpatient 197 128.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.28 191.09 "Gonadotropin, chorionic (reproductive hormone) level" 49071268_1 CDM 0301 RC 84702 HCPCS inpatient 197 128.05 ANTHEM HMO ANTHEM HMO 999999999 119.28 191.09 "Gonadotropin, chorionic (reproductive hormone) level" 49071268_1 CDM 0301 RC 84702 HCPCS inpatient 197 128.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.28 191.09 "Gonadotropin, chorionic (reproductive hormone) level" 49071268_1 CDM 0301 RC 84702 HCPCS inpatient 197 128.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.28 191.09 "Gonadotropin, chorionic (reproductive hormone) level" 49071268_1 CDM 0301 RC 84702 HCPCS inpatient 197 128.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.17 67.6 999999999 119.28 191.09 percent of total billed charges Estriol (hormone) level 49071269_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges Estriol (hormone) level 49071269_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges Estriol (hormone) level 49071269_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges Estriol (hormone) level 49071269_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges Estriol (hormone) level 49071269_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges Estriol (hormone) level 49071269_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges Estriol (hormone) level 49071269_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges Estriol (hormone) level 49071269_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges Estriol (hormone) level 49071269_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 Estriol (hormone) level 49071269_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 Estriol (hormone) level 49071269_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 Estriol (hormone) level 49071269_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 Estriol (hormone) level 49071269_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 Estriol (hormone) level 49071269_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 49071270_1 CDM 0302 RC 86336 HCPCS inpatient 241 156.65 AETNA AETNA 190.39 79 999999999 145.93 233.77 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 49071270_1 CDM 0302 RC 86336 HCPCS inpatient 241 156.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 156.65 65 999999999 145.93 233.77 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 49071270_1 CDM 0302 RC 86336 HCPCS inpatient 241 156.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 233.77 97 999999999 145.93 233.77 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 49071270_1 CDM 0302 RC 86336 HCPCS inpatient 241 156.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.98 78 999999999 145.93 233.77 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 49071270_1 CDM 0302 RC 86336 HCPCS inpatient 241 156.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 166.29 69 999999999 145.93 233.77 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 49071270_1 CDM 0302 RC 86336 HCPCS inpatient 241 156.65 SIHO - ALL PLANS SIHO - ALL PLANS 216.9 90 999999999 145.93 233.77 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 49071270_1 CDM 0302 RC 86336 HCPCS inpatient 241 156.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.93 60.55 999999999 145.93 233.77 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 49071270_1 CDM 0302 RC 86336 HCPCS inpatient 241 156.65 UMR - ALL PLANS UMR - ALL PLANS 168.7 70 999999999 145.93 233.77 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 49071270_1 CDM 0302 RC 86336 HCPCS inpatient 241 156.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.93 233.77 Inhibin A (reproductive organ hormone) measurement 49071270_1 CDM 0302 RC 86336 HCPCS inpatient 241 156.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.93 233.77 Inhibin A (reproductive organ hormone) measurement 49071270_1 CDM 0302 RC 86336 HCPCS inpatient 241 156.65 ANTHEM HMO ANTHEM HMO 999999999 145.93 233.77 Inhibin A (reproductive organ hormone) measurement 49071270_1 CDM 0302 RC 86336 HCPCS inpatient 241 156.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.93 233.77 Inhibin A (reproductive organ hormone) measurement 49071270_1 CDM 0302 RC 86336 HCPCS inpatient 241 156.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.93 233.77 Inhibin A (reproductive organ hormone) measurement 49071270_1 CDM 0302 RC 86336 HCPCS inpatient 241 156.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.92 67.6 999999999 145.93 233.77 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071274_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071274_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071274_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071274_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071274_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071274_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071274_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071274_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071274_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071274_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071274_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071274_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071274_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071274_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071275_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071275_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071275_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071275_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071275_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071275_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071275_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071275_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071275_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071275_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071275_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071275_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071275_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071275_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071276_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071276_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071276_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071276_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071276_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071276_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071276_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071276_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071276_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071276_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071276_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071276_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071276_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 Confirmation test for antibody to Borrelia burgdorferi (Lyme disease bacteria) 49071276_1 CDM 0302 RC 86617 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49071277_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49071277_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49071277_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49071277_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49071277_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49071277_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49071277_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49071277_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49071277_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49071277_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49071277_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49071277_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49071277_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49071277_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Analysis for antibody to mumps virus 49071278_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges Analysis for antibody to mumps virus 49071278_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges Analysis for antibody to mumps virus 49071278_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges Analysis for antibody to mumps virus 49071278_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges Analysis for antibody to mumps virus 49071278_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges Analysis for antibody to mumps virus 49071278_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges Analysis for antibody to mumps virus 49071278_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges Analysis for antibody to mumps virus 49071278_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges Analysis for antibody to mumps virus 49071278_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 Analysis for antibody to mumps virus 49071278_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 Analysis for antibody to mumps virus 49071278_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 Analysis for antibody to mumps virus 49071278_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 Analysis for antibody to mumps virus 49071278_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 Analysis for antibody to mumps virus 49071278_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges Analysis for antibody to mumps virus 49071279_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges Analysis for antibody to mumps virus 49071279_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges Analysis for antibody to mumps virus 49071279_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges Analysis for antibody to mumps virus 49071279_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges Analysis for antibody to mumps virus 49071279_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges Analysis for antibody to mumps virus 49071279_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges Analysis for antibody to mumps virus 49071279_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges Analysis for antibody to mumps virus 49071279_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges Analysis for antibody to mumps virus 49071279_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 Analysis for antibody to mumps virus 49071279_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 Analysis for antibody to mumps virus 49071279_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 Analysis for antibody to mumps virus 49071279_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 Analysis for antibody to mumps virus 49071279_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 Analysis for antibody to mumps virus 49071279_1 CDM 0302 RC 86735 HCPCS inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges Sex hormone binding globulin (protein) level 49074867_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges Sex hormone binding globulin (protein) level 49074867_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges Sex hormone binding globulin (protein) level 49074867_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges Sex hormone binding globulin (protein) level 49074867_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges Sex hormone binding globulin (protein) level 49074867_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges Sex hormone binding globulin (protein) level 49074867_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges Sex hormone binding globulin (protein) level 49074867_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges Sex hormone binding globulin (protein) level 49074867_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges Sex hormone binding globulin (protein) level 49074867_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 Sex hormone binding globulin (protein) level 49074867_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 Sex hormone binding globulin (protein) level 49074867_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 Sex hormone binding globulin (protein) level 49074867_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 Sex hormone binding globulin (protein) level 49074867_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 Sex hormone binding globulin (protein) level 49074867_1 CDM 0301 RC 84270 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges Total cell count for natural killer cells (white blood cell) 49075070_1 CDM 0312 RC 86357 HCPCS inpatient 121 78.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 78.65 65 999999999 73.27 117.37 percent of total billed charges Total cell count for natural killer cells (white blood cell) 49075070_1 CDM 0312 RC 86357 HCPCS inpatient 121 78.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 117.37 97 999999999 73.27 117.37 percent of total billed charges Total cell count for natural killer cells (white blood cell) 49075070_1 CDM 0312 RC 86357 HCPCS inpatient 121 78.65 AETNA AETNA 95.59 79 999999999 73.27 117.37 percent of total billed charges Total cell count for natural killer cells (white blood cell) 49075070_1 CDM 0312 RC 86357 HCPCS inpatient 121 78.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 94.38 78 999999999 73.27 117.37 percent of total billed charges Total cell count for natural killer cells (white blood cell) 49075070_1 CDM 0312 RC 86357 HCPCS inpatient 121 78.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 83.49 69 999999999 73.27 117.37 percent of total billed charges Total cell count for natural killer cells (white blood cell) 49075070_1 CDM 0312 RC 86357 HCPCS inpatient 121 78.65 SIHO - ALL PLANS SIHO - ALL PLANS 108.9 90 999999999 73.27 117.37 percent of total billed charges Total cell count for natural killer cells (white blood cell) 49075070_1 CDM 0312 RC 86357 HCPCS inpatient 121 78.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.27 60.55 999999999 73.27 117.37 percent of total billed charges Total cell count for natural killer cells (white blood cell) 49075070_1 CDM 0312 RC 86357 HCPCS inpatient 121 78.65 UMR - ALL PLANS UMR - ALL PLANS 84.7 70 999999999 73.27 117.37 percent of total billed charges Total cell count for natural killer cells (white blood cell) 49075070_1 CDM 0312 RC 86357 HCPCS inpatient 121 78.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.27 117.37 Total cell count for natural killer cells (white blood cell) 49075070_1 CDM 0312 RC 86357 HCPCS inpatient 121 78.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.27 117.37 Total cell count for natural killer cells (white blood cell) 49075070_1 CDM 0312 RC 86357 HCPCS inpatient 121 78.65 ANTHEM HMO ANTHEM HMO 999999999 73.27 117.37 Total cell count for natural killer cells (white blood cell) 49075070_1 CDM 0312 RC 86357 HCPCS inpatient 121 78.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.27 117.37 Total cell count for natural killer cells (white blood cell) 49075070_1 CDM 0312 RC 86357 HCPCS inpatient 121 78.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.27 117.37 Total cell count for natural killer cells (white blood cell) 49075070_1 CDM 0312 RC 86357 HCPCS inpatient 121 78.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.8 67.6 999999999 73.27 117.37 percent of total billed charges "T cell count and ratio, including ratio" 49075071_1 CDM 0312 RC 86360 HCPCS inpatient 127 82.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 82.55 65 999999999 76.9 123.19 percent of total billed charges "T cell count and ratio, including ratio" 49075071_1 CDM 0312 RC 86360 HCPCS inpatient 127 82.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 123.19 97 999999999 76.9 123.19 percent of total billed charges "T cell count and ratio, including ratio" 49075071_1 CDM 0312 RC 86360 HCPCS inpatient 127 82.55 AETNA AETNA 100.33 79 999999999 76.9 123.19 percent of total billed charges "T cell count and ratio, including ratio" 49075071_1 CDM 0312 RC 86360 HCPCS inpatient 127 82.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 99.06 78 999999999 76.9 123.19 percent of total billed charges "T cell count and ratio, including ratio" 49075071_1 CDM 0312 RC 86360 HCPCS inpatient 127 82.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 87.63 69 999999999 76.9 123.19 percent of total billed charges "T cell count and ratio, including ratio" 49075071_1 CDM 0312 RC 86360 HCPCS inpatient 127 82.55 SIHO - ALL PLANS SIHO - ALL PLANS 114.3 90 999999999 76.9 123.19 percent of total billed charges "T cell count and ratio, including ratio" 49075071_1 CDM 0312 RC 86360 HCPCS inpatient 127 82.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.9 60.55 999999999 76.9 123.19 percent of total billed charges "T cell count and ratio, including ratio" 49075071_1 CDM 0312 RC 86360 HCPCS inpatient 127 82.55 UMR - ALL PLANS UMR - ALL PLANS 88.9 70 999999999 76.9 123.19 percent of total billed charges "T cell count and ratio, including ratio" 49075071_1 CDM 0312 RC 86360 HCPCS inpatient 127 82.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.9 123.19 "T cell count and ratio, including ratio" 49075071_1 CDM 0312 RC 86360 HCPCS inpatient 127 82.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.9 123.19 "T cell count and ratio, including ratio" 49075071_1 CDM 0312 RC 86360 HCPCS inpatient 127 82.55 ANTHEM HMO ANTHEM HMO 999999999 76.9 123.19 "T cell count and ratio, including ratio" 49075071_1 CDM 0312 RC 86360 HCPCS inpatient 127 82.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.9 123.19 "T cell count and ratio, including ratio" 49075071_1 CDM 0312 RC 86360 HCPCS inpatient 127 82.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.9 123.19 "T cell count and ratio, including ratio" 49075071_1 CDM 0312 RC 86360 HCPCS inpatient 127 82.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.85 67.6 999999999 76.9 123.19 percent of total billed charges Total cell count for B cells (white blood cells) 49075072_1 CDM 0312 RC 86355 HCPCS inpatient 120 78 SELF PAY DISCOUNT SELF PAY DISCOUNT 78 65 999999999 72.66 116.4 percent of total billed charges Total cell count for B cells (white blood cells) 49075072_1 CDM 0312 RC 86355 HCPCS inpatient 120 78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.4 97 999999999 72.66 116.4 percent of total billed charges Total cell count for B cells (white blood cells) 49075072_1 CDM 0312 RC 86355 HCPCS inpatient 120 78 AETNA AETNA 94.8 79 999999999 72.66 116.4 percent of total billed charges Total cell count for B cells (white blood cells) 49075072_1 CDM 0312 RC 86355 HCPCS inpatient 120 78 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.6 78 999999999 72.66 116.4 percent of total billed charges Total cell count for B cells (white blood cells) 49075072_1 CDM 0312 RC 86355 HCPCS inpatient 120 78 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.8 69 999999999 72.66 116.4 percent of total billed charges Total cell count for B cells (white blood cells) 49075072_1 CDM 0312 RC 86355 HCPCS inpatient 120 78 SIHO - ALL PLANS SIHO - ALL PLANS 108 90 999999999 72.66 116.4 percent of total billed charges Total cell count for B cells (white blood cells) 49075072_1 CDM 0312 RC 86355 HCPCS inpatient 120 78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.66 60.55 999999999 72.66 116.4 percent of total billed charges Total cell count for B cells (white blood cells) 49075072_1 CDM 0312 RC 86355 HCPCS inpatient 120 78 UMR - ALL PLANS UMR - ALL PLANS 84 70 999999999 72.66 116.4 percent of total billed charges Total cell count for B cells (white blood cells) 49075072_1 CDM 0312 RC 86355 HCPCS inpatient 120 78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.66 116.4 Total cell count for B cells (white blood cells) 49075072_1 CDM 0312 RC 86355 HCPCS inpatient 120 78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.66 116.4 Total cell count for B cells (white blood cells) 49075072_1 CDM 0312 RC 86355 HCPCS inpatient 120 78 ANTHEM HMO ANTHEM HMO 999999999 72.66 116.4 Total cell count for B cells (white blood cells) 49075072_1 CDM 0312 RC 86355 HCPCS inpatient 120 78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.66 116.4 Total cell count for B cells (white blood cells) 49075072_1 CDM 0312 RC 86355 HCPCS inpatient 120 78 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.66 116.4 Total cell count for B cells (white blood cells) 49075072_1 CDM 0312 RC 86355 HCPCS inpatient 120 78 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.12 67.6 999999999 72.66 116.4 percent of total billed charges "T cells count, total" 49075073_1 CDM 0312 RC 86359 HCPCS inpatient 125 81.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.25 65 999999999 75.69 121.25 percent of total billed charges "T cells count, total" 49075073_1 CDM 0312 RC 86359 HCPCS inpatient 125 81.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 121.25 97 999999999 75.69 121.25 percent of total billed charges "T cells count, total" 49075073_1 CDM 0312 RC 86359 HCPCS inpatient 125 81.25 AETNA AETNA 98.75 79 999999999 75.69 121.25 percent of total billed charges "T cells count, total" 49075073_1 CDM 0312 RC 86359 HCPCS inpatient 125 81.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.5 78 999999999 75.69 121.25 percent of total billed charges "T cells count, total" 49075073_1 CDM 0312 RC 86359 HCPCS inpatient 125 81.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.25 69 999999999 75.69 121.25 percent of total billed charges "T cells count, total" 49075073_1 CDM 0312 RC 86359 HCPCS inpatient 125 81.25 SIHO - ALL PLANS SIHO - ALL PLANS 112.5 90 999999999 75.69 121.25 percent of total billed charges "T cells count, total" 49075073_1 CDM 0312 RC 86359 HCPCS inpatient 125 81.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.69 60.55 999999999 75.69 121.25 percent of total billed charges "T cells count, total" 49075073_1 CDM 0312 RC 86359 HCPCS inpatient 125 81.25 UMR - ALL PLANS UMR - ALL PLANS 87.5 70 999999999 75.69 121.25 percent of total billed charges "T cells count, total" 49075073_1 CDM 0312 RC 86359 HCPCS inpatient 125 81.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.69 121.25 "T cells count, total" 49075073_1 CDM 0312 RC 86359 HCPCS inpatient 125 81.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.69 121.25 "T cells count, total" 49075073_1 CDM 0312 RC 86359 HCPCS inpatient 125 81.25 ANTHEM HMO ANTHEM HMO 999999999 75.69 121.25 "T cells count, total" 49075073_1 CDM 0312 RC 86359 HCPCS inpatient 125 81.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.69 121.25 "T cells count, total" 49075073_1 CDM 0312 RC 86359 HCPCS inpatient 125 81.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.69 121.25 "T cells count, total" 49075073_1 CDM 0312 RC 86359 HCPCS inpatient 125 81.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.5 67.6 999999999 75.69 121.25 percent of total billed charges Thyroglobulin (thyroid related hormone) level 49075074_1 CDM 0302 RC 84432 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges Thyroglobulin (thyroid related hormone) level 49075074_1 CDM 0302 RC 84432 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges Thyroglobulin (thyroid related hormone) level 49075074_1 CDM 0302 RC 84432 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges Thyroglobulin (thyroid related hormone) level 49075074_1 CDM 0302 RC 84432 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges Thyroglobulin (thyroid related hormone) level 49075074_1 CDM 0302 RC 84432 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges Thyroglobulin (thyroid related hormone) level 49075074_1 CDM 0302 RC 84432 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges Thyroglobulin (thyroid related hormone) level 49075074_1 CDM 0302 RC 84432 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges Thyroglobulin (thyroid related hormone) level 49075074_1 CDM 0302 RC 84432 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges Thyroglobulin (thyroid related hormone) level 49075074_1 CDM 0302 RC 84432 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 Thyroglobulin (thyroid related hormone) level 49075074_1 CDM 0302 RC 84432 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 Thyroglobulin (thyroid related hormone) level 49075074_1 CDM 0302 RC 84432 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 Thyroglobulin (thyroid related hormone) level 49075074_1 CDM 0302 RC 84432 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 Thyroglobulin (thyroid related hormone) level 49075074_1 CDM 0302 RC 84432 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 Thyroglobulin (thyroid related hormone) level 49075074_1 CDM 0302 RC 84432 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 49075075_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 93.6 65 999999999 87.19 139.68 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 49075075_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 139.68 97 999999999 87.19 139.68 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 49075075_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 AETNA AETNA 113.76 79 999999999 87.19 139.68 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 49075075_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 112.32 78 999999999 87.19 139.68 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 49075075_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 99.36 69 999999999 87.19 139.68 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 49075075_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 SIHO - ALL PLANS SIHO - ALL PLANS 129.6 90 999999999 87.19 139.68 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 49075075_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.19 60.55 999999999 87.19 139.68 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 49075075_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 UMR - ALL PLANS UMR - ALL PLANS 100.8 70 999999999 87.19 139.68 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 49075075_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.19 139.68 Thyroglobulin (thyroid protein) antibody measurement 49075075_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.19 139.68 Thyroglobulin (thyroid protein) antibody measurement 49075075_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 ANTHEM HMO ANTHEM HMO 999999999 87.19 139.68 Thyroglobulin (thyroid protein) antibody measurement 49075075_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.19 139.68 Thyroglobulin (thyroid protein) antibody measurement 49075075_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.19 139.68 Thyroglobulin (thyroid protein) antibody measurement 49075075_1 CDM 0302 RC 86800 HCPCS inpatient 144 93.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 97.34 67.6 999999999 87.19 139.68 percent of total billed charges OXYCODONE-ACETAMINOPHEN 10-325 49075901_1 CDM 0250 RC 68084-0710-01 NDC inpatient 1 UN 2.35 1.53 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.53 65 999999999 1.42 2.28 percent of total billed charges OXYCODONE-ACETAMINOPHEN 10-325 49075901_1 CDM 0250 RC 68084-0710-01 NDC inpatient 1 UN 2.35 1.53 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.28 97 999999999 1.42 2.28 percent of total billed charges OXYCODONE-ACETAMINOPHEN 10-325 49075901_1 CDM 0250 RC 68084-0710-01 NDC inpatient 1 UN 2.35 1.53 AETNA AETNA 1.86 79 999999999 1.42 2.28 percent of total billed charges OXYCODONE-ACETAMINOPHEN 10-325 49075901_1 CDM 0250 RC 68084-0710-01 NDC inpatient 1 UN 2.35 1.53 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.83 78 999999999 1.42 2.28 percent of total billed charges OXYCODONE-ACETAMINOPHEN 10-325 49075901_1 CDM 0250 RC 68084-0710-01 NDC inpatient 1 UN 2.35 1.53 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.62 69 999999999 1.42 2.28 percent of total billed charges OXYCODONE-ACETAMINOPHEN 10-325 49075901_1 CDM 0250 RC 68084-0710-01 NDC inpatient 1 UN 2.35 1.53 SIHO - ALL PLANS SIHO - ALL PLANS 2.12 90 999999999 1.42 2.28 percent of total billed charges OXYCODONE-ACETAMINOPHEN 10-325 49075901_1 CDM 0250 RC 68084-0710-01 NDC inpatient 1 UN 2.35 1.53 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.42 60.55 999999999 1.42 2.28 percent of total billed charges OXYCODONE-ACETAMINOPHEN 10-325 49075901_1 CDM 0250 RC 68084-0710-01 NDC inpatient 1 UN 2.35 1.53 UMR - ALL PLANS UMR - ALL PLANS 1.65 70 999999999 1.42 2.28 percent of total billed charges OXYCODONE-ACETAMINOPHEN 10-325 49075901_1 CDM 0250 RC 68084-0710-01 NDC inpatient 1 UN 2.35 1.53 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.42 2.28 OXYCODONE-ACETAMINOPHEN 10-325 49075901_1 CDM 0250 RC 68084-0710-01 NDC inpatient 1 UN 2.35 1.53 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.42 2.28 OXYCODONE-ACETAMINOPHEN 10-325 49075901_1 CDM 0250 RC 68084-0710-01 NDC inpatient 1 UN 2.35 1.53 ANTHEM HMO ANTHEM HMO 999999999 1.42 2.28 OXYCODONE-ACETAMINOPHEN 10-325 49075901_1 CDM 0250 RC 68084-0710-01 NDC inpatient 1 UN 2.35 1.53 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.42 2.28 OXYCODONE-ACETAMINOPHEN 10-325 49075901_1 CDM 0250 RC 68084-0710-01 NDC inpatient 1 UN 2.35 1.53 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.42 2.28 OXYCODONE-ACETAMINOPHEN 10-325 49075901_1 CDM 0250 RC 68084-0710-01 NDC inpatient 1 UN 2.35 1.53 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.59 67.6 999999999 1.42 2.28 percent of total billed charges Chemical test for genetic disorder 49077677_1 CDM 0301 RC 82017 HCPCS inpatient 404 262.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 262.6 65 999999999 244.62 391.88 percent of total billed charges Chemical test for genetic disorder 49077677_1 CDM 0301 RC 82017 HCPCS inpatient 404 262.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 391.88 97 999999999 244.62 391.88 percent of total billed charges Chemical test for genetic disorder 49077677_1 CDM 0301 RC 82017 HCPCS inpatient 404 262.6 AETNA AETNA 319.16 79 999999999 244.62 391.88 percent of total billed charges Chemical test for genetic disorder 49077677_1 CDM 0301 RC 82017 HCPCS inpatient 404 262.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 315.12 78 999999999 244.62 391.88 percent of total billed charges Chemical test for genetic disorder 49077677_1 CDM 0301 RC 82017 HCPCS inpatient 404 262.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 278.76 69 999999999 244.62 391.88 percent of total billed charges Chemical test for genetic disorder 49077677_1 CDM 0301 RC 82017 HCPCS inpatient 404 262.6 SIHO - ALL PLANS SIHO - ALL PLANS 363.6 90 999999999 244.62 391.88 percent of total billed charges Chemical test for genetic disorder 49077677_1 CDM 0301 RC 82017 HCPCS inpatient 404 262.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 244.62 60.55 999999999 244.62 391.88 percent of total billed charges Chemical test for genetic disorder 49077677_1 CDM 0301 RC 82017 HCPCS inpatient 404 262.6 UMR - ALL PLANS UMR - ALL PLANS 282.8 70 999999999 244.62 391.88 percent of total billed charges Chemical test for genetic disorder 49077677_1 CDM 0301 RC 82017 HCPCS inpatient 404 262.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 244.62 391.88 Chemical test for genetic disorder 49077677_1 CDM 0301 RC 82017 HCPCS inpatient 404 262.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 244.62 391.88 Chemical test for genetic disorder 49077677_1 CDM 0301 RC 82017 HCPCS inpatient 404 262.6 ANTHEM HMO ANTHEM HMO 999999999 244.62 391.88 Chemical test for genetic disorder 49077677_1 CDM 0301 RC 82017 HCPCS inpatient 404 262.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 244.62 391.88 Chemical test for genetic disorder 49077677_1 CDM 0301 RC 82017 HCPCS inpatient 404 262.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 244.62 391.88 Chemical test for genetic disorder 49077677_1 CDM 0301 RC 82017 HCPCS inpatient 404 262.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 273.1 67.6 999999999 244.62 391.88 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49077683_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49077683_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49077683_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49077683_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49077683_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49077683_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49077683_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49077683_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49077683_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49077683_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49077683_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49077683_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49077683_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49077683_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Amino acid level, 6 or more amino acids, quantitative, each specimen" 49077684_1 CDM 0301 RC 82139 HCPCS inpatient 288 187.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 187.2 65 999999999 174.38 279.36 percent of total billed charges "Amino acid level, 6 or more amino acids, quantitative, each specimen" 49077684_1 CDM 0301 RC 82139 HCPCS inpatient 288 187.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 279.36 97 999999999 174.38 279.36 percent of total billed charges "Amino acid level, 6 or more amino acids, quantitative, each specimen" 49077684_1 CDM 0301 RC 82139 HCPCS inpatient 288 187.2 AETNA AETNA 227.52 79 999999999 174.38 279.36 percent of total billed charges "Amino acid level, 6 or more amino acids, quantitative, each specimen" 49077684_1 CDM 0301 RC 82139 HCPCS inpatient 288 187.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 224.64 78 999999999 174.38 279.36 percent of total billed charges "Amino acid level, 6 or more amino acids, quantitative, each specimen" 49077684_1 CDM 0301 RC 82139 HCPCS inpatient 288 187.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 198.72 69 999999999 174.38 279.36 percent of total billed charges "Amino acid level, 6 or more amino acids, quantitative, each specimen" 49077684_1 CDM 0301 RC 82139 HCPCS inpatient 288 187.2 SIHO - ALL PLANS SIHO - ALL PLANS 259.2 90 999999999 174.38 279.36 percent of total billed charges "Amino acid level, 6 or more amino acids, quantitative, each specimen" 49077684_1 CDM 0301 RC 82139 HCPCS inpatient 288 187.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 174.38 60.55 999999999 174.38 279.36 percent of total billed charges "Amino acid level, 6 or more amino acids, quantitative, each specimen" 49077684_1 CDM 0301 RC 82139 HCPCS inpatient 288 187.2 UMR - ALL PLANS UMR - ALL PLANS 201.6 70 999999999 174.38 279.36 percent of total billed charges "Amino acid level, 6 or more amino acids, quantitative, each specimen" 49077684_1 CDM 0301 RC 82139 HCPCS inpatient 288 187.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 174.38 279.36 "Amino acid level, 6 or more amino acids, quantitative, each specimen" 49077684_1 CDM 0301 RC 82139 HCPCS inpatient 288 187.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 174.38 279.36 "Amino acid level, 6 or more amino acids, quantitative, each specimen" 49077684_1 CDM 0301 RC 82139 HCPCS inpatient 288 187.2 ANTHEM HMO ANTHEM HMO 999999999 174.38 279.36 "Amino acid level, 6 or more amino acids, quantitative, each specimen" 49077684_1 CDM 0301 RC 82139 HCPCS inpatient 288 187.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 174.38 279.36 "Amino acid level, 6 or more amino acids, quantitative, each specimen" 49077684_1 CDM 0301 RC 82139 HCPCS inpatient 288 187.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 174.38 279.36 "Amino acid level, 6 or more amino acids, quantitative, each specimen" 49077684_1 CDM 0301 RC 82139 HCPCS inpatient 288 187.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 194.69 67.6 999999999 174.38 279.36 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 49077692_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 49077692_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 49077692_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 49077692_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 49077692_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 49077692_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 49077692_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 49077692_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 49077692_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 49077692_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 49077692_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 49077692_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 49077692_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 49077692_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges Heavy metal level 49077911_1 CDM 0301 RC 83018 HCPCS inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges Heavy metal level 49077911_1 CDM 0301 RC 83018 HCPCS inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges Heavy metal level 49077911_1 CDM 0301 RC 83018 HCPCS inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges Heavy metal level 49077911_1 CDM 0301 RC 83018 HCPCS inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges Heavy metal level 49077911_1 CDM 0301 RC 83018 HCPCS inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges Heavy metal level 49077911_1 CDM 0301 RC 83018 HCPCS inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges Heavy metal level 49077911_1 CDM 0301 RC 83018 HCPCS inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges Heavy metal level 49077911_1 CDM 0301 RC 83018 HCPCS inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges Heavy metal level 49077911_1 CDM 0301 RC 83018 HCPCS inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 Heavy metal level 49077911_1 CDM 0301 RC 83018 HCPCS inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 Heavy metal level 49077911_1 CDM 0301 RC 83018 HCPCS inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 Heavy metal level 49077911_1 CDM 0301 RC 83018 HCPCS inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 Heavy metal level 49077911_1 CDM 0301 RC 83018 HCPCS inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 Heavy metal level 49077911_1 CDM 0301 RC 83018 HCPCS inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges Oxalate level 49077934_1 CDM 0301 RC 83945 HCPCS inpatient 307 199.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 199.55 65 999999999 185.89 297.79 percent of total billed charges Oxalate level 49077934_1 CDM 0301 RC 83945 HCPCS inpatient 307 199.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 297.79 97 999999999 185.89 297.79 percent of total billed charges Oxalate level 49077934_1 CDM 0301 RC 83945 HCPCS inpatient 307 199.55 AETNA AETNA 242.53 79 999999999 185.89 297.79 percent of total billed charges Oxalate level 49077934_1 CDM 0301 RC 83945 HCPCS inpatient 307 199.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 239.46 78 999999999 185.89 297.79 percent of total billed charges Oxalate level 49077934_1 CDM 0301 RC 83945 HCPCS inpatient 307 199.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 211.83 69 999999999 185.89 297.79 percent of total billed charges Oxalate level 49077934_1 CDM 0301 RC 83945 HCPCS inpatient 307 199.55 SIHO - ALL PLANS SIHO - ALL PLANS 276.3 90 999999999 185.89 297.79 percent of total billed charges Oxalate level 49077934_1 CDM 0301 RC 83945 HCPCS inpatient 307 199.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 185.89 60.55 999999999 185.89 297.79 percent of total billed charges Oxalate level 49077934_1 CDM 0301 RC 83945 HCPCS inpatient 307 199.55 UMR - ALL PLANS UMR - ALL PLANS 214.9 70 999999999 185.89 297.79 percent of total billed charges Oxalate level 49077934_1 CDM 0301 RC 83945 HCPCS inpatient 307 199.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 185.89 297.79 Oxalate level 49077934_1 CDM 0301 RC 83945 HCPCS inpatient 307 199.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 185.89 297.79 Oxalate level 49077934_1 CDM 0301 RC 83945 HCPCS inpatient 307 199.55 ANTHEM HMO ANTHEM HMO 999999999 185.89 297.79 Oxalate level 49077934_1 CDM 0301 RC 83945 HCPCS inpatient 307 199.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 185.89 297.79 Oxalate level 49077934_1 CDM 0301 RC 83945 HCPCS inpatient 307 199.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 185.89 297.79 Oxalate level 49077934_1 CDM 0301 RC 83945 HCPCS inpatient 307 199.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 207.53 67.6 999999999 185.89 297.79 percent of total billed charges Measurement of substance using immunoassay technique 49078232_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.95 65 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 49078232_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.51 97 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 49078232_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 AETNA AETNA 144.57 79 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 49078232_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 142.74 78 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 49078232_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.27 69 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 49078232_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 SIHO - ALL PLANS SIHO - ALL PLANS 164.7 90 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 49078232_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.81 60.55 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 49078232_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 UMR - ALL PLANS UMR - ALL PLANS 128.1 70 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 49078232_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.81 177.51 Measurement of substance using immunoassay technique 49078232_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.81 177.51 Measurement of substance using immunoassay technique 49078232_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM HMO ANTHEM HMO 999999999 110.81 177.51 Measurement of substance using immunoassay technique 49078232_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.81 177.51 Measurement of substance using immunoassay technique 49078232_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.81 177.51 Measurement of substance using immunoassay technique 49078232_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.71 67.6 999999999 110.81 177.51 percent of total billed charges Injection of drug or substance under skin or into muscle 49084873_1 CDM 0340 RC 96372 HCPCS inpatient 3253 2114.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 2114.45 65 999999999 1969.69 3155.41 percent of total billed charges Injection of drug or substance under skin or into muscle 49084873_1 CDM 0340 RC 96372 HCPCS inpatient 3253 2114.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3155.41 97 999999999 1969.69 3155.41 percent of total billed charges Injection of drug or substance under skin or into muscle 49084873_1 CDM 0340 RC 96372 HCPCS inpatient 3253 2114.45 AETNA AETNA 2569.87 79 999999999 1969.69 3155.41 percent of total billed charges Injection of drug or substance under skin or into muscle 49084873_1 CDM 0340 RC 96372 HCPCS inpatient 3253 2114.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 2537.34 78 999999999 1969.69 3155.41 percent of total billed charges Injection of drug or substance under skin or into muscle 49084873_1 CDM 0340 RC 96372 HCPCS inpatient 3253 2114.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 2244.57 69 999999999 1969.69 3155.41 percent of total billed charges Injection of drug or substance under skin or into muscle 49084873_1 CDM 0340 RC 96372 HCPCS inpatient 3253 2114.45 SIHO - ALL PLANS SIHO - ALL PLANS 2927.7 90 999999999 1969.69 3155.41 percent of total billed charges Injection of drug or substance under skin or into muscle 49084873_1 CDM 0340 RC 96372 HCPCS inpatient 3253 2114.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1969.69 60.55 999999999 1969.69 3155.41 percent of total billed charges Injection of drug or substance under skin or into muscle 49084873_1 CDM 0340 RC 96372 HCPCS inpatient 3253 2114.45 UMR - ALL PLANS UMR - ALL PLANS 2277.1 70 999999999 1969.69 3155.41 percent of total billed charges Injection of drug or substance under skin or into muscle 49084873_1 CDM 0340 RC 96372 HCPCS inpatient 3253 2114.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1969.69 3155.41 Injection of drug or substance under skin or into muscle 49084873_1 CDM 0340 RC 96372 HCPCS inpatient 3253 2114.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1969.69 3155.41 Injection of drug or substance under skin or into muscle 49084873_1 CDM 0340 RC 96372 HCPCS inpatient 3253 2114.45 ANTHEM HMO ANTHEM HMO 999999999 1969.69 3155.41 Injection of drug or substance under skin or into muscle 49084873_1 CDM 0340 RC 96372 HCPCS inpatient 3253 2114.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1969.69 3155.41 Injection of drug or substance under skin or into muscle 49084873_1 CDM 0340 RC 96372 HCPCS inpatient 3253 2114.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1969.69 3155.41 Injection of drug or substance under skin or into muscle 49084873_1 CDM 0340 RC 96372 HCPCS inpatient 3253 2114.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 2199.03 67.6 999999999 1969.69 3155.41 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 49084875_1 CDM 0255 RC Q9967 HCPCS inpatient 5 3.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.25 65 999999999 3.03 4.85 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 49084875_1 CDM 0255 RC Q9967 HCPCS inpatient 5 3.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4.85 97 999999999 3.03 4.85 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 49084875_1 CDM 0255 RC Q9967 HCPCS inpatient 5 3.25 AETNA AETNA 3.95 79 999999999 3.03 4.85 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 49084875_1 CDM 0255 RC Q9967 HCPCS inpatient 5 3.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.9 78 999999999 3.03 4.85 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 49084875_1 CDM 0255 RC Q9967 HCPCS inpatient 5 3.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.45 69 999999999 3.03 4.85 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 49084875_1 CDM 0255 RC Q9967 HCPCS inpatient 5 3.25 SIHO - ALL PLANS SIHO - ALL PLANS 4.5 90 999999999 3.03 4.85 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 49084875_1 CDM 0255 RC Q9967 HCPCS inpatient 5 3.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.03 60.55 999999999 3.03 4.85 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 49084875_1 CDM 0255 RC Q9967 HCPCS inpatient 5 3.25 UMR - ALL PLANS UMR - ALL PLANS 3.5 70 999999999 3.03 4.85 percent of total billed charges "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 49084875_1 CDM 0255 RC Q9967 HCPCS inpatient 5 3.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.03 4.85 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 49084875_1 CDM 0255 RC Q9967 HCPCS inpatient 5 3.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.03 4.85 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 49084875_1 CDM 0255 RC Q9967 HCPCS inpatient 5 3.25 ANTHEM HMO ANTHEM HMO 999999999 3.03 4.85 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 49084875_1 CDM 0255 RC Q9967 HCPCS inpatient 5 3.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.03 4.85 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 49084875_1 CDM 0255 RC Q9967 HCPCS inpatient 5 3.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.03 4.85 "LOW OSMOLAR CONTRAST MATERIAL, 300-399 MG/ML IODINE CONCENTRATION, PER ML" 49084875_1 CDM 0255 RC Q9967 HCPCS inpatient 5 3.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.38 67.6 999999999 3.03 4.85 percent of total billed charges "INJECTION, OMALIZUMAB, 5 MG" 49088780_1 CDM 0636 RC 50242-0040-62 NDC J2357 HCPCS inpatient 30 UN 5168.41 3359.47 SELF PAY DISCOUNT SELF PAY DISCOUNT 3359.47 65 999999999 3129.47 5013.36 percent of total billed charges "INJECTION, OMALIZUMAB, 5 MG" 49088780_1 CDM 0636 RC 50242-0040-62 NDC J2357 HCPCS inpatient 30 UN 5168.41 3359.47 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5013.36 97 999999999 3129.47 5013.36 percent of total billed charges "INJECTION, OMALIZUMAB, 5 MG" 49088780_1 CDM 0636 RC 50242-0040-62 NDC J2357 HCPCS inpatient 30 UN 5168.41 3359.47 AETNA AETNA 4083.04 79 999999999 3129.47 5013.36 percent of total billed charges "INJECTION, OMALIZUMAB, 5 MG" 49088780_1 CDM 0636 RC 50242-0040-62 NDC J2357 HCPCS inpatient 30 UN 5168.41 3359.47 HUMANA - ALL PLANS HUMANA - ALL PLANS 4031.36 78 999999999 3129.47 5013.36 percent of total billed charges "INJECTION, OMALIZUMAB, 5 MG" 49088780_1 CDM 0636 RC 50242-0040-62 NDC J2357 HCPCS inpatient 30 UN 5168.41 3359.47 ENCORE - ALL PLANS ENCORE - ALL PLANS 3566.2 69 999999999 3129.47 5013.36 percent of total billed charges "INJECTION, OMALIZUMAB, 5 MG" 49088780_1 CDM 0636 RC 50242-0040-62 NDC J2357 HCPCS inpatient 30 UN 5168.41 3359.47 SIHO - ALL PLANS SIHO - ALL PLANS 4651.57 90 999999999 3129.47 5013.36 percent of total billed charges "INJECTION, OMALIZUMAB, 5 MG" 49088780_1 CDM 0636 RC 50242-0040-62 NDC J2357 HCPCS inpatient 30 UN 5168.41 3359.47 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3129.47 60.55 999999999 3129.47 5013.36 percent of total billed charges "INJECTION, OMALIZUMAB, 5 MG" 49088780_1 CDM 0636 RC 50242-0040-62 NDC J2357 HCPCS inpatient 30 UN 5168.41 3359.47 UMR - ALL PLANS UMR - ALL PLANS 3617.89 70 999999999 3129.47 5013.36 percent of total billed charges "INJECTION, OMALIZUMAB, 5 MG" 49088780_1 CDM 0636 RC 50242-0040-62 NDC J2357 HCPCS inpatient 30 UN 5168.41 3359.47 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3129.47 5013.36 "INJECTION, OMALIZUMAB, 5 MG" 49088780_1 CDM 0636 RC 50242-0040-62 NDC J2357 HCPCS inpatient 30 UN 5168.41 3359.47 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3129.47 5013.36 "INJECTION, OMALIZUMAB, 5 MG" 49088780_1 CDM 0636 RC 50242-0040-62 NDC J2357 HCPCS inpatient 30 UN 5168.41 3359.47 ANTHEM HMO ANTHEM HMO 999999999 3129.47 5013.36 "INJECTION, OMALIZUMAB, 5 MG" 49088780_1 CDM 0636 RC 50242-0040-62 NDC J2357 HCPCS inpatient 30 UN 5168.41 3359.47 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3129.47 5013.36 "INJECTION, OMALIZUMAB, 5 MG" 49088780_1 CDM 0636 RC 50242-0040-62 NDC J2357 HCPCS inpatient 30 UN 5168.41 3359.47 UHC - ALL PLANS UHC - ALL PLANS 999999999 3129.47 5013.36 "INJECTION, OMALIZUMAB, 5 MG" 49088780_1 CDM 0636 RC 50242-0040-62 NDC J2357 HCPCS inpatient 30 UN 5168.41 3359.47 CIGNA - ALL PLANS CIGNA - ALL PLANS 3493.85 67.6 999999999 3129.47 5013.36 percent of total billed charges Blood pH level 49089917_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 169.65 65 999999999 158.04 253.17 percent of total billed charges Blood pH level 49089917_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 253.17 97 999999999 158.04 253.17 percent of total billed charges Blood pH level 49089917_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 AETNA AETNA 206.19 79 999999999 158.04 253.17 percent of total billed charges Blood pH level 49089917_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 203.58 78 999999999 158.04 253.17 percent of total billed charges Blood pH level 49089917_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.09 69 999999999 158.04 253.17 percent of total billed charges Blood pH level 49089917_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 SIHO - ALL PLANS SIHO - ALL PLANS 234.9 90 999999999 158.04 253.17 percent of total billed charges Blood pH level 49089917_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.04 60.55 999999999 158.04 253.17 percent of total billed charges Blood pH level 49089917_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 UMR - ALL PLANS UMR - ALL PLANS 182.7 70 999999999 158.04 253.17 percent of total billed charges Blood pH level 49089917_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.04 253.17 Blood pH level 49089917_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.04 253.17 Blood pH level 49089917_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 ANTHEM HMO ANTHEM HMO 999999999 158.04 253.17 Blood pH level 49089917_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.04 253.17 Blood pH level 49089917_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.04 253.17 Blood pH level 49089917_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 176.44 67.6 999999999 158.04 253.17 percent of total billed charges Blood pH level 49089919_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 169.65 65 999999999 158.04 253.17 percent of total billed charges Blood pH level 49089919_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 253.17 97 999999999 158.04 253.17 percent of total billed charges Blood pH level 49089919_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 AETNA AETNA 206.19 79 999999999 158.04 253.17 percent of total billed charges Blood pH level 49089919_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 203.58 78 999999999 158.04 253.17 percent of total billed charges Blood pH level 49089919_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.09 69 999999999 158.04 253.17 percent of total billed charges Blood pH level 49089919_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 SIHO - ALL PLANS SIHO - ALL PLANS 234.9 90 999999999 158.04 253.17 percent of total billed charges Blood pH level 49089919_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.04 60.55 999999999 158.04 253.17 percent of total billed charges Blood pH level 49089919_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 UMR - ALL PLANS UMR - ALL PLANS 182.7 70 999999999 158.04 253.17 percent of total billed charges Blood pH level 49089919_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.04 253.17 Blood pH level 49089919_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.04 253.17 Blood pH level 49089919_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 ANTHEM HMO ANTHEM HMO 999999999 158.04 253.17 Blood pH level 49089919_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.04 253.17 Blood pH level 49089919_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.04 253.17 Blood pH level 49089919_1 CDM 0301 RC 82800 HCPCS inpatient 261 169.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 176.44 67.6 999999999 158.04 253.17 percent of total billed charges "Red blood cell antibody detection test, direct" 49101873_1 CDM 0302 RC 86880 HCPCS inpatient 89 57.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.85 65 999999999 53.89 86.33 percent of total billed charges "Red blood cell antibody detection test, direct" 49101873_1 CDM 0302 RC 86880 HCPCS inpatient 89 57.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 86.33 97 999999999 53.89 86.33 percent of total billed charges "Red blood cell antibody detection test, direct" 49101873_1 CDM 0302 RC 86880 HCPCS inpatient 89 57.85 AETNA AETNA 70.31 79 999999999 53.89 86.33 percent of total billed charges "Red blood cell antibody detection test, direct" 49101873_1 CDM 0302 RC 86880 HCPCS inpatient 89 57.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 69.42 78 999999999 53.89 86.33 percent of total billed charges "Red blood cell antibody detection test, direct" 49101873_1 CDM 0302 RC 86880 HCPCS inpatient 89 57.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 61.41 69 999999999 53.89 86.33 percent of total billed charges "Red blood cell antibody detection test, direct" 49101873_1 CDM 0302 RC 86880 HCPCS inpatient 89 57.85 SIHO - ALL PLANS SIHO - ALL PLANS 80.1 90 999999999 53.89 86.33 percent of total billed charges "Red blood cell antibody detection test, direct" 49101873_1 CDM 0302 RC 86880 HCPCS inpatient 89 57.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.89 60.55 999999999 53.89 86.33 percent of total billed charges "Red blood cell antibody detection test, direct" 49101873_1 CDM 0302 RC 86880 HCPCS inpatient 89 57.85 UMR - ALL PLANS UMR - ALL PLANS 62.3 70 999999999 53.89 86.33 percent of total billed charges "Red blood cell antibody detection test, direct" 49101873_1 CDM 0302 RC 86880 HCPCS inpatient 89 57.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.89 86.33 "Red blood cell antibody detection test, direct" 49101873_1 CDM 0302 RC 86880 HCPCS inpatient 89 57.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.89 86.33 "Red blood cell antibody detection test, direct" 49101873_1 CDM 0302 RC 86880 HCPCS inpatient 89 57.85 ANTHEM HMO ANTHEM HMO 999999999 53.89 86.33 "Red blood cell antibody detection test, direct" 49101873_1 CDM 0302 RC 86880 HCPCS inpatient 89 57.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.89 86.33 "Red blood cell antibody detection test, direct" 49101873_1 CDM 0302 RC 86880 HCPCS inpatient 89 57.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.89 86.33 "Red blood cell antibody detection test, direct" 49101873_1 CDM 0302 RC 86880 HCPCS inpatient 89 57.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.16 67.6 999999999 53.89 86.33 percent of total billed charges HYDROCODONE-ACETAMIN 5-325 MG 49101951_1 CDM 0250 RC 68084-0895-01 NDC inpatient 1 UN 1.74 1.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.13 65 999999999 1.05 1.69 percent of total billed charges HYDROCODONE-ACETAMIN 5-325 MG 49101951_1 CDM 0250 RC 68084-0895-01 NDC inpatient 1 UN 1.74 1.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.69 97 999999999 1.05 1.69 percent of total billed charges HYDROCODONE-ACETAMIN 5-325 MG 49101951_1 CDM 0250 RC 68084-0895-01 NDC inpatient 1 UN 1.74 1.13 AETNA AETNA 1.37 79 999999999 1.05 1.69 percent of total billed charges HYDROCODONE-ACETAMIN 5-325 MG 49101951_1 CDM 0250 RC 68084-0895-01 NDC inpatient 1 UN 1.74 1.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.36 78 999999999 1.05 1.69 percent of total billed charges HYDROCODONE-ACETAMIN 5-325 MG 49101951_1 CDM 0250 RC 68084-0895-01 NDC inpatient 1 UN 1.74 1.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.2 69 999999999 1.05 1.69 percent of total billed charges HYDROCODONE-ACETAMIN 5-325 MG 49101951_1 CDM 0250 RC 68084-0895-01 NDC inpatient 1 UN 1.74 1.13 SIHO - ALL PLANS SIHO - ALL PLANS 1.57 90 999999999 1.05 1.69 percent of total billed charges HYDROCODONE-ACETAMIN 5-325 MG 49101951_1 CDM 0250 RC 68084-0895-01 NDC inpatient 1 UN 1.74 1.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.05 60.55 999999999 1.05 1.69 percent of total billed charges HYDROCODONE-ACETAMIN 5-325 MG 49101951_1 CDM 0250 RC 68084-0895-01 NDC inpatient 1 UN 1.74 1.13 UMR - ALL PLANS UMR - ALL PLANS 1.22 70 999999999 1.05 1.69 percent of total billed charges HYDROCODONE-ACETAMIN 5-325 MG 49101951_1 CDM 0250 RC 68084-0895-01 NDC inpatient 1 UN 1.74 1.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.05 1.69 HYDROCODONE-ACETAMIN 5-325 MG 49101951_1 CDM 0250 RC 68084-0895-01 NDC inpatient 1 UN 1.74 1.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.05 1.69 HYDROCODONE-ACETAMIN 5-325 MG 49101951_1 CDM 0250 RC 68084-0895-01 NDC inpatient 1 UN 1.74 1.13 ANTHEM HMO ANTHEM HMO 999999999 1.05 1.69 HYDROCODONE-ACETAMIN 5-325 MG 49101951_1 CDM 0250 RC 68084-0895-01 NDC inpatient 1 UN 1.74 1.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.05 1.69 HYDROCODONE-ACETAMIN 5-325 MG 49101951_1 CDM 0250 RC 68084-0895-01 NDC inpatient 1 UN 1.74 1.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.05 1.69 HYDROCODONE-ACETAMIN 5-325 MG 49101951_1 CDM 0250 RC 68084-0895-01 NDC inpatient 1 UN 1.74 1.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.18 67.6 999999999 1.05 1.69 percent of total billed charges Application of stress by physician for joint imaging 49106172_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 200.2 65 999999999 186.49 298.76 percent of total billed charges Application of stress by physician for joint imaging 49106172_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 298.76 97 999999999 186.49 298.76 percent of total billed charges Application of stress by physician for joint imaging 49106172_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 AETNA AETNA 243.32 79 999999999 186.49 298.76 percent of total billed charges Application of stress by physician for joint imaging 49106172_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 240.24 78 999999999 186.49 298.76 percent of total billed charges Application of stress by physician for joint imaging 49106172_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 212.52 69 999999999 186.49 298.76 percent of total billed charges Application of stress by physician for joint imaging 49106172_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 SIHO - ALL PLANS SIHO - ALL PLANS 277.2 90 999999999 186.49 298.76 percent of total billed charges Application of stress by physician for joint imaging 49106172_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 186.49 60.55 999999999 186.49 298.76 percent of total billed charges Application of stress by physician for joint imaging 49106172_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 UMR - ALL PLANS UMR - ALL PLANS 215.6 70 999999999 186.49 298.76 percent of total billed charges Application of stress by physician for joint imaging 49106172_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 186.49 298.76 Application of stress by physician for joint imaging 49106172_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 186.49 298.76 Application of stress by physician for joint imaging 49106172_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 ANTHEM HMO ANTHEM HMO 999999999 186.49 298.76 Application of stress by physician for joint imaging 49106172_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 186.49 298.76 Application of stress by physician for joint imaging 49106172_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 186.49 298.76 Application of stress by physician for joint imaging 49106172_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 208.21 67.6 999999999 186.49 298.76 percent of total billed charges "INJECTION, LORAZEPAM, 2 MG" 49114268_1 CDM 0250 RC 00641-6044-25 NDC J2060 HCPCS inpatient 1 UN 19.82 12.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.88 65 999999999 12 19.23 percent of total billed charges "INJECTION, LORAZEPAM, 2 MG" 49114268_1 CDM 0250 RC 00641-6044-25 NDC J2060 HCPCS inpatient 1 UN 19.82 12.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.23 97 999999999 12 19.23 percent of total billed charges "INJECTION, LORAZEPAM, 2 MG" 49114268_1 CDM 0250 RC 00641-6044-25 NDC J2060 HCPCS inpatient 1 UN 19.82 12.88 AETNA AETNA 15.66 79 999999999 12 19.23 percent of total billed charges "INJECTION, LORAZEPAM, 2 MG" 49114268_1 CDM 0250 RC 00641-6044-25 NDC J2060 HCPCS inpatient 1 UN 19.82 12.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.46 78 999999999 12 19.23 percent of total billed charges "INJECTION, LORAZEPAM, 2 MG" 49114268_1 CDM 0250 RC 00641-6044-25 NDC J2060 HCPCS inpatient 1 UN 19.82 12.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.68 69 999999999 12 19.23 percent of total billed charges "INJECTION, LORAZEPAM, 2 MG" 49114268_1 CDM 0250 RC 00641-6044-25 NDC J2060 HCPCS inpatient 1 UN 19.82 12.88 SIHO - ALL PLANS SIHO - ALL PLANS 17.84 90 999999999 12 19.23 percent of total billed charges "INJECTION, LORAZEPAM, 2 MG" 49114268_1 CDM 0250 RC 00641-6044-25 NDC J2060 HCPCS inpatient 1 UN 19.82 12.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12 60.55 999999999 12 19.23 percent of total billed charges "INJECTION, LORAZEPAM, 2 MG" 49114268_1 CDM 0250 RC 00641-6044-25 NDC J2060 HCPCS inpatient 1 UN 19.82 12.88 UMR - ALL PLANS UMR - ALL PLANS 13.87 70 999999999 12 19.23 percent of total billed charges "INJECTION, LORAZEPAM, 2 MG" 49114268_1 CDM 0250 RC 00641-6044-25 NDC J2060 HCPCS inpatient 1 UN 19.82 12.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12 19.23 "INJECTION, LORAZEPAM, 2 MG" 49114268_1 CDM 0250 RC 00641-6044-25 NDC J2060 HCPCS inpatient 1 UN 19.82 12.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12 19.23 "INJECTION, LORAZEPAM, 2 MG" 49114268_1 CDM 0250 RC 00641-6044-25 NDC J2060 HCPCS inpatient 1 UN 19.82 12.88 ANTHEM HMO ANTHEM HMO 999999999 12 19.23 "INJECTION, LORAZEPAM, 2 MG" 49114268_1 CDM 0250 RC 00641-6044-25 NDC J2060 HCPCS inpatient 1 UN 19.82 12.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12 19.23 "INJECTION, LORAZEPAM, 2 MG" 49114268_1 CDM 0250 RC 00641-6044-25 NDC J2060 HCPCS inpatient 1 UN 19.82 12.88 UHC - ALL PLANS UHC - ALL PLANS 999999999 12 19.23 "INJECTION, LORAZEPAM, 2 MG" 49114268_1 CDM 0250 RC 00641-6044-25 NDC J2060 HCPCS inpatient 1 UN 19.82 12.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.4 67.6 999999999 12 19.23 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 49114272_1 CDM 0250 RC 63323-0651-02 NDC J0153 HCPCS inpatient 6 UN 31.67 20.59 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.59 65 999999999 19.18 30.72 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 49114272_1 CDM 0250 RC 63323-0651-02 NDC J0153 HCPCS inpatient 6 UN 31.67 20.59 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.72 97 999999999 19.18 30.72 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 49114272_1 CDM 0250 RC 63323-0651-02 NDC J0153 HCPCS inpatient 6 UN 31.67 20.59 AETNA AETNA 25.02 79 999999999 19.18 30.72 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 49114272_1 CDM 0250 RC 63323-0651-02 NDC J0153 HCPCS inpatient 6 UN 31.67 20.59 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.7 78 999999999 19.18 30.72 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 49114272_1 CDM 0250 RC 63323-0651-02 NDC J0153 HCPCS inpatient 6 UN 31.67 20.59 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.85 69 999999999 19.18 30.72 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 49114272_1 CDM 0250 RC 63323-0651-02 NDC J0153 HCPCS inpatient 6 UN 31.67 20.59 SIHO - ALL PLANS SIHO - ALL PLANS 28.5 90 999999999 19.18 30.72 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 49114272_1 CDM 0250 RC 63323-0651-02 NDC J0153 HCPCS inpatient 6 UN 31.67 20.59 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.18 60.55 999999999 19.18 30.72 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 49114272_1 CDM 0250 RC 63323-0651-02 NDC J0153 HCPCS inpatient 6 UN 31.67 20.59 UMR - ALL PLANS UMR - ALL PLANS 22.17 70 999999999 19.18 30.72 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 49114272_1 CDM 0250 RC 63323-0651-02 NDC J0153 HCPCS inpatient 6 UN 31.67 20.59 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.18 30.72 "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 49114272_1 CDM 0250 RC 63323-0651-02 NDC J0153 HCPCS inpatient 6 UN 31.67 20.59 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.18 30.72 "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 49114272_1 CDM 0250 RC 63323-0651-02 NDC J0153 HCPCS inpatient 6 UN 31.67 20.59 ANTHEM HMO ANTHEM HMO 999999999 19.18 30.72 "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 49114272_1 CDM 0250 RC 63323-0651-02 NDC J0153 HCPCS inpatient 6 UN 31.67 20.59 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.18 30.72 "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 49114272_1 CDM 0250 RC 63323-0651-02 NDC J0153 HCPCS inpatient 6 UN 31.67 20.59 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.18 30.72 "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 49114272_1 CDM 0250 RC 63323-0651-02 NDC J0153 HCPCS inpatient 6 UN 31.67 20.59 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.41 67.6 999999999 19.18 30.72 percent of total billed charges "Hepatitis B vaccine, pediatric or adolescent dosage (3 dose schedule)" 49123606_1 CDM 0250 RC 58160-0820-52 NDC 90744 HCPCS inpatient 1 UN 30.58 19.88 AETNA AETNA 24.16 79 999999999 18.52 29.66 percent of total billed charges "Hepatitis B vaccine, pediatric or adolescent dosage (3 dose schedule)" 49123606_1 CDM 0250 RC 58160-0820-52 NDC 90744 HCPCS inpatient 1 UN 30.58 19.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.88 65 999999999 18.52 29.66 percent of total billed charges "Hepatitis B vaccine, pediatric or adolescent dosage (3 dose schedule)" 49123606_1 CDM 0250 RC 58160-0820-52 NDC 90744 HCPCS inpatient 1 UN 30.58 19.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.66 97 999999999 18.52 29.66 percent of total billed charges "Hepatitis B vaccine, pediatric or adolescent dosage (3 dose schedule)" 49123606_1 CDM 0250 RC 58160-0820-52 NDC 90744 HCPCS inpatient 1 UN 30.58 19.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.85 78 999999999 18.52 29.66 percent of total billed charges "Hepatitis B vaccine, pediatric or adolescent dosage (3 dose schedule)" 49123606_1 CDM 0250 RC 58160-0820-52 NDC 90744 HCPCS inpatient 1 UN 30.58 19.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.1 69 999999999 18.52 29.66 percent of total billed charges "Hepatitis B vaccine, pediatric or adolescent dosage (3 dose schedule)" 49123606_1 CDM 0250 RC 58160-0820-52 NDC 90744 HCPCS inpatient 1 UN 30.58 19.88 SIHO - ALL PLANS SIHO - ALL PLANS 27.52 90 999999999 18.52 29.66 percent of total billed charges "Hepatitis B vaccine, pediatric or adolescent dosage (3 dose schedule)" 49123606_1 CDM 0250 RC 58160-0820-52 NDC 90744 HCPCS inpatient 1 UN 30.58 19.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.52 60.55 999999999 18.52 29.66 percent of total billed charges "Hepatitis B vaccine, pediatric or adolescent dosage (3 dose schedule)" 49123606_1 CDM 0250 RC 58160-0820-52 NDC 90744 HCPCS inpatient 1 UN 30.58 19.88 UMR - ALL PLANS UMR - ALL PLANS 21.41 70 999999999 18.52 29.66 percent of total billed charges "Hepatitis B vaccine, pediatric or adolescent dosage (3 dose schedule)" 49123606_1 CDM 0250 RC 58160-0820-52 NDC 90744 HCPCS inpatient 1 UN 30.58 19.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.52 29.66 "Hepatitis B vaccine, pediatric or adolescent dosage (3 dose schedule)" 49123606_1 CDM 0250 RC 58160-0820-52 NDC 90744 HCPCS inpatient 1 UN 30.58 19.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.52 29.66 "Hepatitis B vaccine, pediatric or adolescent dosage (3 dose schedule)" 49123606_1 CDM 0250 RC 58160-0820-52 NDC 90744 HCPCS inpatient 1 UN 30.58 19.88 ANTHEM HMO ANTHEM HMO 999999999 18.52 29.66 "Hepatitis B vaccine, pediatric or adolescent dosage (3 dose schedule)" 49123606_1 CDM 0250 RC 58160-0820-52 NDC 90744 HCPCS inpatient 1 UN 30.58 19.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.52 29.66 "Hepatitis B vaccine, pediatric or adolescent dosage (3 dose schedule)" 49123606_1 CDM 0250 RC 58160-0820-52 NDC 90744 HCPCS inpatient 1 UN 30.58 19.88 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.52 29.66 "Hepatitis B vaccine, pediatric or adolescent dosage (3 dose schedule)" 49123606_1 CDM 0250 RC 58160-0820-52 NDC 90744 HCPCS inpatient 1 UN 30.58 19.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.67 67.6 999999999 18.52 29.66 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 49135637_1 CDM 0636 RC 25021-0826-67 NDC J3489 HCPCS inpatient 4 UN 225.22 146.39 AETNA AETNA 177.92 79 999999999 136.37 218.46 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 49135637_1 CDM 0636 RC 25021-0826-67 NDC J3489 HCPCS inpatient 4 UN 225.22 146.39 SELF PAY DISCOUNT SELF PAY DISCOUNT 146.39 65 999999999 136.37 218.46 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 49135637_1 CDM 0636 RC 25021-0826-67 NDC J3489 HCPCS inpatient 4 UN 225.22 146.39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 218.46 97 999999999 136.37 218.46 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 49135637_1 CDM 0636 RC 25021-0826-67 NDC J3489 HCPCS inpatient 4 UN 225.22 146.39 HUMANA - ALL PLANS HUMANA - ALL PLANS 175.67 78 999999999 136.37 218.46 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 49135637_1 CDM 0636 RC 25021-0826-67 NDC J3489 HCPCS inpatient 4 UN 225.22 146.39 ENCORE - ALL PLANS ENCORE - ALL PLANS 155.4 69 999999999 136.37 218.46 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 49135637_1 CDM 0636 RC 25021-0826-67 NDC J3489 HCPCS inpatient 4 UN 225.22 146.39 SIHO - ALL PLANS SIHO - ALL PLANS 202.7 90 999999999 136.37 218.46 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 49135637_1 CDM 0636 RC 25021-0826-67 NDC J3489 HCPCS inpatient 4 UN 225.22 146.39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 136.37 60.55 999999999 136.37 218.46 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 49135637_1 CDM 0636 RC 25021-0826-67 NDC J3489 HCPCS inpatient 4 UN 225.22 146.39 UMR - ALL PLANS UMR - ALL PLANS 157.65 70 999999999 136.37 218.46 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 49135637_1 CDM 0636 RC 25021-0826-67 NDC J3489 HCPCS inpatient 4 UN 225.22 146.39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 136.37 218.46 "INJECTION, ZOLEDRONIC ACID, 1 MG" 49135637_1 CDM 0636 RC 25021-0826-67 NDC J3489 HCPCS inpatient 4 UN 225.22 146.39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 136.37 218.46 "INJECTION, ZOLEDRONIC ACID, 1 MG" 49135637_1 CDM 0636 RC 25021-0826-67 NDC J3489 HCPCS inpatient 4 UN 225.22 146.39 ANTHEM HMO ANTHEM HMO 999999999 136.37 218.46 "INJECTION, ZOLEDRONIC ACID, 1 MG" 49135637_1 CDM 0636 RC 25021-0826-67 NDC J3489 HCPCS inpatient 4 UN 225.22 146.39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 136.37 218.46 "INJECTION, ZOLEDRONIC ACID, 1 MG" 49135637_1 CDM 0636 RC 25021-0826-67 NDC J3489 HCPCS inpatient 4 UN 225.22 146.39 UHC - ALL PLANS UHC - ALL PLANS 999999999 136.37 218.46 "INJECTION, ZOLEDRONIC ACID, 1 MG" 49135637_1 CDM 0636 RC 25021-0826-67 NDC J3489 HCPCS inpatient 4 UN 225.22 146.39 CIGNA - ALL PLANS CIGNA - ALL PLANS 152.25 67.6 999999999 136.37 218.46 percent of total billed charges 48582-0033-09 - Biotene Oral Rinse [JOHN] 49135690_1 CDM 0250 RC 48582-0033-09 NDC inpatient 1 UN 11.44 7.44 AETNA AETNA 9.04 79 999999999 6.93 11.1 percent of total billed charges 48582-0033-09 - Biotene Oral Rinse [JOHN] 49135690_1 CDM 0250 RC 48582-0033-09 NDC inpatient 1 UN 11.44 7.44 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.44 65 999999999 6.93 11.1 percent of total billed charges 48582-0033-09 - Biotene Oral Rinse [JOHN] 49135690_1 CDM 0250 RC 48582-0033-09 NDC inpatient 1 UN 11.44 7.44 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11.1 97 999999999 6.93 11.1 percent of total billed charges 48582-0033-09 - Biotene Oral Rinse [JOHN] 49135690_1 CDM 0250 RC 48582-0033-09 NDC inpatient 1 UN 11.44 7.44 HUMANA - ALL PLANS HUMANA - ALL PLANS 8.92 78 999999999 6.93 11.1 percent of total billed charges 48582-0033-09 - Biotene Oral Rinse [JOHN] 49135690_1 CDM 0250 RC 48582-0033-09 NDC inpatient 1 UN 11.44 7.44 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.89 69 999999999 6.93 11.1 percent of total billed charges 48582-0033-09 - Biotene Oral Rinse [JOHN] 49135690_1 CDM 0250 RC 48582-0033-09 NDC inpatient 1 UN 11.44 7.44 SIHO - ALL PLANS SIHO - ALL PLANS 10.3 90 999999999 6.93 11.1 percent of total billed charges 48582-0033-09 - Biotene Oral Rinse [JOHN] 49135690_1 CDM 0250 RC 48582-0033-09 NDC inpatient 1 UN 11.44 7.44 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.93 60.55 999999999 6.93 11.1 percent of total billed charges 48582-0033-09 - Biotene Oral Rinse [JOHN] 49135690_1 CDM 0250 RC 48582-0033-09 NDC inpatient 1 UN 11.44 7.44 UMR - ALL PLANS UMR - ALL PLANS 8.01 70 999999999 6.93 11.1 percent of total billed charges 48582-0033-09 - Biotene Oral Rinse [JOHN] 49135690_1 CDM 0250 RC 48582-0033-09 NDC inpatient 1 UN 11.44 7.44 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.93 11.1 48582-0033-09 - Biotene Oral Rinse [JOHN] 49135690_1 CDM 0250 RC 48582-0033-09 NDC inpatient 1 UN 11.44 7.44 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.93 11.1 48582-0033-09 - Biotene Oral Rinse [JOHN] 49135690_1 CDM 0250 RC 48582-0033-09 NDC inpatient 1 UN 11.44 7.44 ANTHEM HMO ANTHEM HMO 999999999 6.93 11.1 48582-0033-09 - Biotene Oral Rinse [JOHN] 49135690_1 CDM 0250 RC 48582-0033-09 NDC inpatient 1 UN 11.44 7.44 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.93 11.1 48582-0033-09 - Biotene Oral Rinse [JOHN] 49135690_1 CDM 0250 RC 48582-0033-09 NDC inpatient 1 UN 11.44 7.44 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.93 11.1 48582-0033-09 - Biotene Oral Rinse [JOHN] 49135690_1 CDM 0250 RC 48582-0033-09 NDC inpatient 1 UN 11.44 7.44 CIGNA - ALL PLANS CIGNA - ALL PLANS 7.73 67.6 999999999 6.93 11.1 percent of total billed charges GELFOAM POWDER 49136509_1 CDM 0250 RC 00009-0433-04 NDC inpatient 1 UN 242.54 157.65 AETNA AETNA 191.61 79 999999999 146.86 235.26 percent of total billed charges GELFOAM POWDER 49136509_1 CDM 0250 RC 00009-0433-04 NDC inpatient 1 UN 242.54 157.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 157.65 65 999999999 146.86 235.26 percent of total billed charges GELFOAM POWDER 49136509_1 CDM 0250 RC 00009-0433-04 NDC inpatient 1 UN 242.54 157.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 235.26 97 999999999 146.86 235.26 percent of total billed charges GELFOAM POWDER 49136509_1 CDM 0250 RC 00009-0433-04 NDC inpatient 1 UN 242.54 157.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 189.18 78 999999999 146.86 235.26 percent of total billed charges GELFOAM POWDER 49136509_1 CDM 0250 RC 00009-0433-04 NDC inpatient 1 UN 242.54 157.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 167.35 69 999999999 146.86 235.26 percent of total billed charges GELFOAM POWDER 49136509_1 CDM 0250 RC 00009-0433-04 NDC inpatient 1 UN 242.54 157.65 SIHO - ALL PLANS SIHO - ALL PLANS 218.29 90 999999999 146.86 235.26 percent of total billed charges GELFOAM POWDER 49136509_1 CDM 0250 RC 00009-0433-04 NDC inpatient 1 UN 242.54 157.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 146.86 60.55 999999999 146.86 235.26 percent of total billed charges GELFOAM POWDER 49136509_1 CDM 0250 RC 00009-0433-04 NDC inpatient 1 UN 242.54 157.65 UMR - ALL PLANS UMR - ALL PLANS 169.78 70 999999999 146.86 235.26 percent of total billed charges GELFOAM POWDER 49136509_1 CDM 0250 RC 00009-0433-04 NDC inpatient 1 UN 242.54 157.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 146.86 235.26 GELFOAM POWDER 49136509_1 CDM 0250 RC 00009-0433-04 NDC inpatient 1 UN 242.54 157.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 146.86 235.26 GELFOAM POWDER 49136509_1 CDM 0250 RC 00009-0433-04 NDC inpatient 1 UN 242.54 157.65 ANTHEM HMO ANTHEM HMO 999999999 146.86 235.26 GELFOAM POWDER 49136509_1 CDM 0250 RC 00009-0433-04 NDC inpatient 1 UN 242.54 157.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 146.86 235.26 GELFOAM POWDER 49136509_1 CDM 0250 RC 00009-0433-04 NDC inpatient 1 UN 242.54 157.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 146.86 235.26 GELFOAM POWDER 49136509_1 CDM 0250 RC 00009-0433-04 NDC inpatient 1 UN 242.54 157.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 163.96 67.6 999999999 146.86 235.26 percent of total billed charges LIDOCAINE HCL 4% SOLUTION 49142316_1 CDM 0250 RC 76329-6300-05 NDC inpatient 1 UN 101.88 66.22 AETNA AETNA 80.49 79 999999999 61.69 98.82 percent of total billed charges LIDOCAINE HCL 4% SOLUTION 49142316_1 CDM 0250 RC 76329-6300-05 NDC inpatient 1 UN 101.88 66.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.22 65 999999999 61.69 98.82 percent of total billed charges LIDOCAINE HCL 4% SOLUTION 49142316_1 CDM 0250 RC 76329-6300-05 NDC inpatient 1 UN 101.88 66.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.82 97 999999999 61.69 98.82 percent of total billed charges LIDOCAINE HCL 4% SOLUTION 49142316_1 CDM 0250 RC 76329-6300-05 NDC inpatient 1 UN 101.88 66.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.47 78 999999999 61.69 98.82 percent of total billed charges LIDOCAINE HCL 4% SOLUTION 49142316_1 CDM 0250 RC 76329-6300-05 NDC inpatient 1 UN 101.88 66.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.3 69 999999999 61.69 98.82 percent of total billed charges LIDOCAINE HCL 4% SOLUTION 49142316_1 CDM 0250 RC 76329-6300-05 NDC inpatient 1 UN 101.88 66.22 SIHO - ALL PLANS SIHO - ALL PLANS 91.69 90 999999999 61.69 98.82 percent of total billed charges LIDOCAINE HCL 4% SOLUTION 49142316_1 CDM 0250 RC 76329-6300-05 NDC inpatient 1 UN 101.88 66.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.69 60.55 999999999 61.69 98.82 percent of total billed charges LIDOCAINE HCL 4% SOLUTION 49142316_1 CDM 0250 RC 76329-6300-05 NDC inpatient 1 UN 101.88 66.22 UMR - ALL PLANS UMR - ALL PLANS 71.32 70 999999999 61.69 98.82 percent of total billed charges LIDOCAINE HCL 4% SOLUTION 49142316_1 CDM 0250 RC 76329-6300-05 NDC inpatient 1 UN 101.88 66.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.69 98.82 LIDOCAINE HCL 4% SOLUTION 49142316_1 CDM 0250 RC 76329-6300-05 NDC inpatient 1 UN 101.88 66.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.69 98.82 LIDOCAINE HCL 4% SOLUTION 49142316_1 CDM 0250 RC 76329-6300-05 NDC inpatient 1 UN 101.88 66.22 ANTHEM HMO ANTHEM HMO 999999999 61.69 98.82 LIDOCAINE HCL 4% SOLUTION 49142316_1 CDM 0250 RC 76329-6300-05 NDC inpatient 1 UN 101.88 66.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.69 98.82 LIDOCAINE HCL 4% SOLUTION 49142316_1 CDM 0250 RC 76329-6300-05 NDC inpatient 1 UN 101.88 66.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.69 98.82 LIDOCAINE HCL 4% SOLUTION 49142316_1 CDM 0250 RC 76329-6300-05 NDC inpatient 1 UN 101.88 66.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.87 67.6 999999999 61.69 98.82 percent of total billed charges LATUDA 20 MG TABLET 49151226_1 CDM 0250 RC 63402-0302-30 NDC inpatient 1 UN 193.34 125.67 AETNA AETNA 152.74 79 999999999 117.07 187.54 percent of total billed charges LATUDA 20 MG TABLET 49151226_1 CDM 0250 RC 63402-0302-30 NDC inpatient 1 UN 193.34 125.67 SELF PAY DISCOUNT SELF PAY DISCOUNT 125.67 65 999999999 117.07 187.54 percent of total billed charges LATUDA 20 MG TABLET 49151226_1 CDM 0250 RC 63402-0302-30 NDC inpatient 1 UN 193.34 125.67 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 187.54 97 999999999 117.07 187.54 percent of total billed charges LATUDA 20 MG TABLET 49151226_1 CDM 0250 RC 63402-0302-30 NDC inpatient 1 UN 193.34 125.67 HUMANA - ALL PLANS HUMANA - ALL PLANS 150.81 78 999999999 117.07 187.54 percent of total billed charges LATUDA 20 MG TABLET 49151226_1 CDM 0250 RC 63402-0302-30 NDC inpatient 1 UN 193.34 125.67 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.4 69 999999999 117.07 187.54 percent of total billed charges LATUDA 20 MG TABLET 49151226_1 CDM 0250 RC 63402-0302-30 NDC inpatient 1 UN 193.34 125.67 SIHO - ALL PLANS SIHO - ALL PLANS 174.01 90 999999999 117.07 187.54 percent of total billed charges LATUDA 20 MG TABLET 49151226_1 CDM 0250 RC 63402-0302-30 NDC inpatient 1 UN 193.34 125.67 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 117.07 60.55 999999999 117.07 187.54 percent of total billed charges LATUDA 20 MG TABLET 49151226_1 CDM 0250 RC 63402-0302-30 NDC inpatient 1 UN 193.34 125.67 UMR - ALL PLANS UMR - ALL PLANS 135.34 70 999999999 117.07 187.54 percent of total billed charges LATUDA 20 MG TABLET 49151226_1 CDM 0250 RC 63402-0302-30 NDC inpatient 1 UN 193.34 125.67 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 117.07 187.54 LATUDA 20 MG TABLET 49151226_1 CDM 0250 RC 63402-0302-30 NDC inpatient 1 UN 193.34 125.67 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 117.07 187.54 LATUDA 20 MG TABLET 49151226_1 CDM 0250 RC 63402-0302-30 NDC inpatient 1 UN 193.34 125.67 ANTHEM HMO ANTHEM HMO 999999999 117.07 187.54 LATUDA 20 MG TABLET 49151226_1 CDM 0250 RC 63402-0302-30 NDC inpatient 1 UN 193.34 125.67 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 117.07 187.54 LATUDA 20 MG TABLET 49151226_1 CDM 0250 RC 63402-0302-30 NDC inpatient 1 UN 193.34 125.67 UHC - ALL PLANS UHC - ALL PLANS 999999999 117.07 187.54 LATUDA 20 MG TABLET 49151226_1 CDM 0250 RC 63402-0302-30 NDC inpatient 1 UN 193.34 125.67 CIGNA - ALL PLANS CIGNA - ALL PLANS 130.7 67.6 999999999 117.07 187.54 percent of total billed charges 61553-0664-44 - fentaNYL 10 mcg/mL Sol 30 mL PCA [JOHN] 49151228_1 CDM 0250 RC 61553-0664-44 NDC inpatient 1 UN 124.1 80.67 AETNA AETNA 98.04 79 999999999 75.14 120.38 percent of total billed charges 61553-0664-44 - fentaNYL 10 mcg/mL Sol 30 mL PCA [JOHN] 49151228_1 CDM 0250 RC 61553-0664-44 NDC inpatient 1 UN 124.1 80.67 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.67 65 999999999 75.14 120.38 percent of total billed charges 61553-0664-44 - fentaNYL 10 mcg/mL Sol 30 mL PCA [JOHN] 49151228_1 CDM 0250 RC 61553-0664-44 NDC inpatient 1 UN 124.1 80.67 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.38 97 999999999 75.14 120.38 percent of total billed charges 61553-0664-44 - fentaNYL 10 mcg/mL Sol 30 mL PCA [JOHN] 49151228_1 CDM 0250 RC 61553-0664-44 NDC inpatient 1 UN 124.1 80.67 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.8 78 999999999 75.14 120.38 percent of total billed charges 61553-0664-44 - fentaNYL 10 mcg/mL Sol 30 mL PCA [JOHN] 49151228_1 CDM 0250 RC 61553-0664-44 NDC inpatient 1 UN 124.1 80.67 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.63 69 999999999 75.14 120.38 percent of total billed charges 61553-0664-44 - fentaNYL 10 mcg/mL Sol 30 mL PCA [JOHN] 49151228_1 CDM 0250 RC 61553-0664-44 NDC inpatient 1 UN 124.1 80.67 SIHO - ALL PLANS SIHO - ALL PLANS 111.69 90 999999999 75.14 120.38 percent of total billed charges 61553-0664-44 - fentaNYL 10 mcg/mL Sol 30 mL PCA [JOHN] 49151228_1 CDM 0250 RC 61553-0664-44 NDC inpatient 1 UN 124.1 80.67 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.14 60.55 999999999 75.14 120.38 percent of total billed charges 61553-0664-44 - fentaNYL 10 mcg/mL Sol 30 mL PCA [JOHN] 49151228_1 CDM 0250 RC 61553-0664-44 NDC inpatient 1 UN 124.1 80.67 UMR - ALL PLANS UMR - ALL PLANS 86.87 70 999999999 75.14 120.38 percent of total billed charges 61553-0664-44 - fentaNYL 10 mcg/mL Sol 30 mL PCA [JOHN] 49151228_1 CDM 0250 RC 61553-0664-44 NDC inpatient 1 UN 124.1 80.67 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.14 120.38 61553-0664-44 - fentaNYL 10 mcg/mL Sol 30 mL PCA [JOHN] 49151228_1 CDM 0250 RC 61553-0664-44 NDC inpatient 1 UN 124.1 80.67 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.14 120.38 61553-0664-44 - fentaNYL 10 mcg/mL Sol 30 mL PCA [JOHN] 49151228_1 CDM 0250 RC 61553-0664-44 NDC inpatient 1 UN 124.1 80.67 ANTHEM HMO ANTHEM HMO 999999999 75.14 120.38 61553-0664-44 - fentaNYL 10 mcg/mL Sol 30 mL PCA [JOHN] 49151228_1 CDM 0250 RC 61553-0664-44 NDC inpatient 1 UN 124.1 80.67 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.14 120.38 61553-0664-44 - fentaNYL 10 mcg/mL Sol 30 mL PCA [JOHN] 49151228_1 CDM 0250 RC 61553-0664-44 NDC inpatient 1 UN 124.1 80.67 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.14 120.38 61553-0664-44 - fentaNYL 10 mcg/mL Sol 30 mL PCA [JOHN] 49151228_1 CDM 0250 RC 61553-0664-44 NDC inpatient 1 UN 124.1 80.67 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.89 67.6 999999999 75.14 120.38 percent of total billed charges "INJECTION, DOCETAXEL, 1 MG" 49151280_1 CDM 0636 RC 43598-0259-40 NDC J9171 HCPCS inpatient 80 UN 887.41 576.82 AETNA AETNA 701.05 79 999999999 537.33 860.79 percent of total billed charges "INJECTION, DOCETAXEL, 1 MG" 49151280_1 CDM 0636 RC 43598-0259-40 NDC J9171 HCPCS inpatient 80 UN 887.41 576.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 576.82 65 999999999 537.33 860.79 percent of total billed charges "INJECTION, DOCETAXEL, 1 MG" 49151280_1 CDM 0636 RC 43598-0259-40 NDC J9171 HCPCS inpatient 80 UN 887.41 576.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 860.79 97 999999999 537.33 860.79 percent of total billed charges "INJECTION, DOCETAXEL, 1 MG" 49151280_1 CDM 0636 RC 43598-0259-40 NDC J9171 HCPCS inpatient 80 UN 887.41 576.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 692.18 78 999999999 537.33 860.79 percent of total billed charges "INJECTION, DOCETAXEL, 1 MG" 49151280_1 CDM 0636 RC 43598-0259-40 NDC J9171 HCPCS inpatient 80 UN 887.41 576.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 612.31 69 999999999 537.33 860.79 percent of total billed charges "INJECTION, DOCETAXEL, 1 MG" 49151280_1 CDM 0636 RC 43598-0259-40 NDC J9171 HCPCS inpatient 80 UN 887.41 576.82 SIHO - ALL PLANS SIHO - ALL PLANS 798.67 90 999999999 537.33 860.79 percent of total billed charges "INJECTION, DOCETAXEL, 1 MG" 49151280_1 CDM 0636 RC 43598-0259-40 NDC J9171 HCPCS inpatient 80 UN 887.41 576.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 537.33 60.55 999999999 537.33 860.79 percent of total billed charges "INJECTION, DOCETAXEL, 1 MG" 49151280_1 CDM 0636 RC 43598-0259-40 NDC J9171 HCPCS inpatient 80 UN 887.41 576.82 UMR - ALL PLANS UMR - ALL PLANS 621.19 70 999999999 537.33 860.79 percent of total billed charges "INJECTION, DOCETAXEL, 1 MG" 49151280_1 CDM 0636 RC 43598-0259-40 NDC J9171 HCPCS inpatient 80 UN 887.41 576.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 537.33 860.79 "INJECTION, DOCETAXEL, 1 MG" 49151280_1 CDM 0636 RC 43598-0259-40 NDC J9171 HCPCS inpatient 80 UN 887.41 576.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 537.33 860.79 "INJECTION, DOCETAXEL, 1 MG" 49151280_1 CDM 0636 RC 43598-0259-40 NDC J9171 HCPCS inpatient 80 UN 887.41 576.82 ANTHEM HMO ANTHEM HMO 999999999 537.33 860.79 "INJECTION, DOCETAXEL, 1 MG" 49151280_1 CDM 0636 RC 43598-0259-40 NDC J9171 HCPCS inpatient 80 UN 887.41 576.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 537.33 860.79 "INJECTION, DOCETAXEL, 1 MG" 49151280_1 CDM 0636 RC 43598-0259-40 NDC J9171 HCPCS inpatient 80 UN 887.41 576.82 UHC - ALL PLANS UHC - ALL PLANS 999999999 537.33 860.79 "INJECTION, DOCETAXEL, 1 MG" 49151280_1 CDM 0636 RC 43598-0259-40 NDC J9171 HCPCS inpatient 80 UN 887.41 576.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 599.89 67.6 999999999 537.33 860.79 percent of total billed charges 61553-0466-78 - lidocaine-sodium bicarbonate 1%-8.4% Sol 1 mL [JOHN] 49151283_1 CDM 0250 RC 61553-0466-78 NDC inpatient 1 UN 175.33 113.96 AETNA AETNA 138.51 79 999999999 106.16 170.07 percent of total billed charges 61553-0466-78 - lidocaine-sodium bicarbonate 1%-8.4% Sol 1 mL [JOHN] 49151283_1 CDM 0250 RC 61553-0466-78 NDC inpatient 1 UN 175.33 113.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 113.96 65 999999999 106.16 170.07 percent of total billed charges 61553-0466-78 - lidocaine-sodium bicarbonate 1%-8.4% Sol 1 mL [JOHN] 49151283_1 CDM 0250 RC 61553-0466-78 NDC inpatient 1 UN 175.33 113.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 170.07 97 999999999 106.16 170.07 percent of total billed charges 61553-0466-78 - lidocaine-sodium bicarbonate 1%-8.4% Sol 1 mL [JOHN] 49151283_1 CDM 0250 RC 61553-0466-78 NDC inpatient 1 UN 175.33 113.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 136.76 78 999999999 106.16 170.07 percent of total billed charges 61553-0466-78 - lidocaine-sodium bicarbonate 1%-8.4% Sol 1 mL [JOHN] 49151283_1 CDM 0250 RC 61553-0466-78 NDC inpatient 1 UN 175.33 113.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 120.98 69 999999999 106.16 170.07 percent of total billed charges 61553-0466-78 - lidocaine-sodium bicarbonate 1%-8.4% Sol 1 mL [JOHN] 49151283_1 CDM 0250 RC 61553-0466-78 NDC inpatient 1 UN 175.33 113.96 SIHO - ALL PLANS SIHO - ALL PLANS 157.8 90 999999999 106.16 170.07 percent of total billed charges 61553-0466-78 - lidocaine-sodium bicarbonate 1%-8.4% Sol 1 mL [JOHN] 49151283_1 CDM 0250 RC 61553-0466-78 NDC inpatient 1 UN 175.33 113.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 106.16 60.55 999999999 106.16 170.07 percent of total billed charges 61553-0466-78 - lidocaine-sodium bicarbonate 1%-8.4% Sol 1 mL [JOHN] 49151283_1 CDM 0250 RC 61553-0466-78 NDC inpatient 1 UN 175.33 113.96 UMR - ALL PLANS UMR - ALL PLANS 122.73 70 999999999 106.16 170.07 percent of total billed charges 61553-0466-78 - lidocaine-sodium bicarbonate 1%-8.4% Sol 1 mL [JOHN] 49151283_1 CDM 0250 RC 61553-0466-78 NDC inpatient 1 UN 175.33 113.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 106.16 170.07 61553-0466-78 - lidocaine-sodium bicarbonate 1%-8.4% Sol 1 mL [JOHN] 49151283_1 CDM 0250 RC 61553-0466-78 NDC inpatient 1 UN 175.33 113.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 106.16 170.07 61553-0466-78 - lidocaine-sodium bicarbonate 1%-8.4% Sol 1 mL [JOHN] 49151283_1 CDM 0250 RC 61553-0466-78 NDC inpatient 1 UN 175.33 113.96 ANTHEM HMO ANTHEM HMO 999999999 106.16 170.07 61553-0466-78 - lidocaine-sodium bicarbonate 1%-8.4% Sol 1 mL [JOHN] 49151283_1 CDM 0250 RC 61553-0466-78 NDC inpatient 1 UN 175.33 113.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 106.16 170.07 61553-0466-78 - lidocaine-sodium bicarbonate 1%-8.4% Sol 1 mL [JOHN] 49151283_1 CDM 0250 RC 61553-0466-78 NDC inpatient 1 UN 175.33 113.96 UHC - ALL PLANS UHC - ALL PLANS 999999999 106.16 170.07 61553-0466-78 - lidocaine-sodium bicarbonate 1%-8.4% Sol 1 mL [JOHN] 49151283_1 CDM 0250 RC 61553-0466-78 NDC inpatient 1 UN 175.33 113.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.52 67.6 999999999 106.16 170.07 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 49151285_1 CDM 0250 RC 68001-0246-17 NDC Q0162 HCPCS inpatient 1 UN 1.98 1.29 AETNA AETNA 1.56 79 999999999 1.2 1.92 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 49151285_1 CDM 0250 RC 68001-0246-17 NDC Q0162 HCPCS inpatient 1 UN 1.98 1.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.29 65 999999999 1.2 1.92 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 49151285_1 CDM 0250 RC 68001-0246-17 NDC Q0162 HCPCS inpatient 1 UN 1.98 1.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.92 97 999999999 1.2 1.92 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 49151285_1 CDM 0250 RC 68001-0246-17 NDC Q0162 HCPCS inpatient 1 UN 1.98 1.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.54 78 999999999 1.2 1.92 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 49151285_1 CDM 0250 RC 68001-0246-17 NDC Q0162 HCPCS inpatient 1 UN 1.98 1.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.37 69 999999999 1.2 1.92 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 49151285_1 CDM 0250 RC 68001-0246-17 NDC Q0162 HCPCS inpatient 1 UN 1.98 1.29 SIHO - ALL PLANS SIHO - ALL PLANS 1.78 90 999999999 1.2 1.92 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 49151285_1 CDM 0250 RC 68001-0246-17 NDC Q0162 HCPCS inpatient 1 UN 1.98 1.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.2 60.55 999999999 1.2 1.92 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 49151285_1 CDM 0250 RC 68001-0246-17 NDC Q0162 HCPCS inpatient 1 UN 1.98 1.29 UMR - ALL PLANS UMR - ALL PLANS 1.39 70 999999999 1.2 1.92 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 49151285_1 CDM 0250 RC 68001-0246-17 NDC Q0162 HCPCS inpatient 1 UN 1.98 1.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.2 1.92 "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 49151285_1 CDM 0250 RC 68001-0246-17 NDC Q0162 HCPCS inpatient 1 UN 1.98 1.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.2 1.92 "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 49151285_1 CDM 0250 RC 68001-0246-17 NDC Q0162 HCPCS inpatient 1 UN 1.98 1.29 ANTHEM HMO ANTHEM HMO 999999999 1.2 1.92 "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 49151285_1 CDM 0250 RC 68001-0246-17 NDC Q0162 HCPCS inpatient 1 UN 1.98 1.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.2 1.92 "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 49151285_1 CDM 0250 RC 68001-0246-17 NDC Q0162 HCPCS inpatient 1 UN 1.98 1.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.2 1.92 "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 49151285_1 CDM 0250 RC 68001-0246-17 NDC Q0162 HCPCS inpatient 1 UN 1.98 1.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.34 67.6 999999999 1.2 1.92 percent of total billed charges ELIQUIS 2.5 MG TABLET 49151546_1 CDM 0250 RC 00003-0893-31 NDC inpatient 1 UN 27.34 17.77 AETNA AETNA 21.6 79 999999999 16.55 26.52 percent of total billed charges ELIQUIS 2.5 MG TABLET 49151546_1 CDM 0250 RC 00003-0893-31 NDC inpatient 1 UN 27.34 17.77 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.77 65 999999999 16.55 26.52 percent of total billed charges ELIQUIS 2.5 MG TABLET 49151546_1 CDM 0250 RC 00003-0893-31 NDC inpatient 1 UN 27.34 17.77 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26.52 97 999999999 16.55 26.52 percent of total billed charges ELIQUIS 2.5 MG TABLET 49151546_1 CDM 0250 RC 00003-0893-31 NDC inpatient 1 UN 27.34 17.77 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.33 78 999999999 16.55 26.52 percent of total billed charges ELIQUIS 2.5 MG TABLET 49151546_1 CDM 0250 RC 00003-0893-31 NDC inpatient 1 UN 27.34 17.77 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.86 69 999999999 16.55 26.52 percent of total billed charges ELIQUIS 2.5 MG TABLET 49151546_1 CDM 0250 RC 00003-0893-31 NDC inpatient 1 UN 27.34 17.77 SIHO - ALL PLANS SIHO - ALL PLANS 24.61 90 999999999 16.55 26.52 percent of total billed charges ELIQUIS 2.5 MG TABLET 49151546_1 CDM 0250 RC 00003-0893-31 NDC inpatient 1 UN 27.34 17.77 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.55 60.55 999999999 16.55 26.52 percent of total billed charges ELIQUIS 2.5 MG TABLET 49151546_1 CDM 0250 RC 00003-0893-31 NDC inpatient 1 UN 27.34 17.77 UMR - ALL PLANS UMR - ALL PLANS 19.14 70 999999999 16.55 26.52 percent of total billed charges ELIQUIS 2.5 MG TABLET 49151546_1 CDM 0250 RC 00003-0893-31 NDC inpatient 1 UN 27.34 17.77 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.55 26.52 ELIQUIS 2.5 MG TABLET 49151546_1 CDM 0250 RC 00003-0893-31 NDC inpatient 1 UN 27.34 17.77 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.55 26.52 ELIQUIS 2.5 MG TABLET 49151546_1 CDM 0250 RC 00003-0893-31 NDC inpatient 1 UN 27.34 17.77 ANTHEM HMO ANTHEM HMO 999999999 16.55 26.52 ELIQUIS 2.5 MG TABLET 49151546_1 CDM 0250 RC 00003-0893-31 NDC inpatient 1 UN 27.34 17.77 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.55 26.52 ELIQUIS 2.5 MG TABLET 49151546_1 CDM 0250 RC 00003-0893-31 NDC inpatient 1 UN 27.34 17.77 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.55 26.52 ELIQUIS 2.5 MG TABLET 49151546_1 CDM 0250 RC 00003-0893-31 NDC inpatient 1 UN 27.34 17.77 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.48 67.6 999999999 16.55 26.52 percent of total billed charges DEXTROSE 50%-WATER SYRINGE 49159908_1 CDM 0250 RC 00409-7517-16 NDC inpatient 1 UN 58.38 37.95 AETNA AETNA 46.12 79 999999999 35.35 56.63 percent of total billed charges DEXTROSE 50%-WATER SYRINGE 49159908_1 CDM 0250 RC 00409-7517-16 NDC inpatient 1 UN 58.38 37.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.95 65 999999999 35.35 56.63 percent of total billed charges DEXTROSE 50%-WATER SYRINGE 49159908_1 CDM 0250 RC 00409-7517-16 NDC inpatient 1 UN 58.38 37.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.63 97 999999999 35.35 56.63 percent of total billed charges DEXTROSE 50%-WATER SYRINGE 49159908_1 CDM 0250 RC 00409-7517-16 NDC inpatient 1 UN 58.38 37.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.54 78 999999999 35.35 56.63 percent of total billed charges DEXTROSE 50%-WATER SYRINGE 49159908_1 CDM 0250 RC 00409-7517-16 NDC inpatient 1 UN 58.38 37.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.28 69 999999999 35.35 56.63 percent of total billed charges DEXTROSE 50%-WATER SYRINGE 49159908_1 CDM 0250 RC 00409-7517-16 NDC inpatient 1 UN 58.38 37.95 SIHO - ALL PLANS SIHO - ALL PLANS 52.54 90 999999999 35.35 56.63 percent of total billed charges DEXTROSE 50%-WATER SYRINGE 49159908_1 CDM 0250 RC 00409-7517-16 NDC inpatient 1 UN 58.38 37.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.35 60.55 999999999 35.35 56.63 percent of total billed charges DEXTROSE 50%-WATER SYRINGE 49159908_1 CDM 0250 RC 00409-7517-16 NDC inpatient 1 UN 58.38 37.95 UMR - ALL PLANS UMR - ALL PLANS 40.87 70 999999999 35.35 56.63 percent of total billed charges DEXTROSE 50%-WATER SYRINGE 49159908_1 CDM 0250 RC 00409-7517-16 NDC inpatient 1 UN 58.38 37.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.35 56.63 DEXTROSE 50%-WATER SYRINGE 49159908_1 CDM 0250 RC 00409-7517-16 NDC inpatient 1 UN 58.38 37.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.35 56.63 DEXTROSE 50%-WATER SYRINGE 49159908_1 CDM 0250 RC 00409-7517-16 NDC inpatient 1 UN 58.38 37.95 ANTHEM HMO ANTHEM HMO 999999999 35.35 56.63 DEXTROSE 50%-WATER SYRINGE 49159908_1 CDM 0250 RC 00409-7517-16 NDC inpatient 1 UN 58.38 37.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.35 56.63 DEXTROSE 50%-WATER SYRINGE 49159908_1 CDM 0250 RC 00409-7517-16 NDC inpatient 1 UN 58.38 37.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.35 56.63 DEXTROSE 50%-WATER SYRINGE 49159908_1 CDM 0250 RC 00409-7517-16 NDC inpatient 1 UN 58.38 37.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.46 67.6 999999999 35.35 56.63 percent of total billed charges "INJECTION, PEMBROLIZUMAB, 1 MG" 49160003_1 CDM 0636 RC 00006-3026-02 NDC J9271 HCPCS inpatient 100 UN 142094.59 92361.48 AETNA AETNA 112254.73 79 999999999 86038.27 137831.75 percent of total billed charges "INJECTION, PEMBROLIZUMAB, 1 MG" 49160003_1 CDM 0636 RC 00006-3026-02 NDC J9271 HCPCS inpatient 100 UN 142094.59 92361.48 SELF PAY DISCOUNT SELF PAY DISCOUNT 92361.48 65 999999999 86038.27 137831.75 percent of total billed charges "INJECTION, PEMBROLIZUMAB, 1 MG" 49160003_1 CDM 0636 RC 00006-3026-02 NDC J9271 HCPCS inpatient 100 UN 142094.59 92361.48 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137831.75 97 999999999 86038.27 137831.75 percent of total billed charges "INJECTION, PEMBROLIZUMAB, 1 MG" 49160003_1 CDM 0636 RC 00006-3026-02 NDC J9271 HCPCS inpatient 100 UN 142094.59 92361.48 HUMANA - ALL PLANS HUMANA - ALL PLANS 110833.78 78 999999999 86038.27 137831.75 percent of total billed charges "INJECTION, PEMBROLIZUMAB, 1 MG" 49160003_1 CDM 0636 RC 00006-3026-02 NDC J9271 HCPCS inpatient 100 UN 142094.59 92361.48 ENCORE - ALL PLANS ENCORE - ALL PLANS 98045.27 69 999999999 86038.27 137831.75 percent of total billed charges "INJECTION, PEMBROLIZUMAB, 1 MG" 49160003_1 CDM 0636 RC 00006-3026-02 NDC J9271 HCPCS inpatient 100 UN 142094.59 92361.48 UMR - ALL PLANS UMR - ALL PLANS 99466.21 70 999999999 86038.27 137831.75 percent of total billed charges "INJECTION, PEMBROLIZUMAB, 1 MG" 49160003_1 CDM 0636 RC 00006-3026-02 NDC J9271 HCPCS inpatient 100 UN 142094.59 92361.48 SIHO - ALL PLANS SIHO - ALL PLANS 127885.13 90 999999999 86038.27 137831.75 percent of total billed charges "INJECTION, PEMBROLIZUMAB, 1 MG" 49160003_1 CDM 0636 RC 00006-3026-02 NDC J9271 HCPCS inpatient 100 UN 142094.59 92361.48 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86038.27 60.55 999999999 86038.27 137831.75 percent of total billed charges "INJECTION, PEMBROLIZUMAB, 1 MG" 49160003_1 CDM 0636 RC 00006-3026-02 NDC J9271 HCPCS inpatient 100 UN 142094.59 92361.48 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86038.27 137831.75 "INJECTION, PEMBROLIZUMAB, 1 MG" 49160003_1 CDM 0636 RC 00006-3026-02 NDC J9271 HCPCS inpatient 100 UN 142094.59 92361.48 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86038.27 137831.75 "INJECTION, PEMBROLIZUMAB, 1 MG" 49160003_1 CDM 0636 RC 00006-3026-02 NDC J9271 HCPCS inpatient 100 UN 142094.59 92361.48 ANTHEM HMO ANTHEM HMO 999999999 86038.27 137831.75 "INJECTION, PEMBROLIZUMAB, 1 MG" 49160003_1 CDM 0636 RC 00006-3026-02 NDC J9271 HCPCS inpatient 100 UN 142094.59 92361.48 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86038.27 137831.75 "INJECTION, PEMBROLIZUMAB, 1 MG" 49160003_1 CDM 0636 RC 00006-3026-02 NDC J9271 HCPCS inpatient 100 UN 142094.59 92361.48 UHC - ALL PLANS UHC - ALL PLANS 999999999 86038.27 137831.75 "INJECTION, PEMBROLIZUMAB, 1 MG" 49160003_1 CDM 0636 RC 00006-3026-02 NDC J9271 HCPCS inpatient 100 UN 142094.59 92361.48 CIGNA - ALL PLANS CIGNA - ALL PLANS 96055.94 67.6 999999999 86038.27 137831.75 percent of total billed charges Dehydroepiandrosterone (DHEA) hormone level 49163639_1 CDM 0301 RC 82626 HCPCS inpatient 268 174.2 AETNA AETNA 211.72 79 999999999 162.27 259.96 percent of total billed charges Dehydroepiandrosterone (DHEA) hormone level 49163639_1 CDM 0301 RC 82626 HCPCS inpatient 268 174.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 174.2 65 999999999 162.27 259.96 percent of total billed charges Dehydroepiandrosterone (DHEA) hormone level 49163639_1 CDM 0301 RC 82626 HCPCS inpatient 268 174.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 259.96 97 999999999 162.27 259.96 percent of total billed charges Dehydroepiandrosterone (DHEA) hormone level 49163639_1 CDM 0301 RC 82626 HCPCS inpatient 268 174.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 209.04 78 999999999 162.27 259.96 percent of total billed charges Dehydroepiandrosterone (DHEA) hormone level 49163639_1 CDM 0301 RC 82626 HCPCS inpatient 268 174.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.92 69 999999999 162.27 259.96 percent of total billed charges Dehydroepiandrosterone (DHEA) hormone level 49163639_1 CDM 0301 RC 82626 HCPCS inpatient 268 174.2 UMR - ALL PLANS UMR - ALL PLANS 187.6 70 999999999 162.27 259.96 percent of total billed charges Dehydroepiandrosterone (DHEA) hormone level 49163639_1 CDM 0301 RC 82626 HCPCS inpatient 268 174.2 SIHO - ALL PLANS SIHO - ALL PLANS 241.2 90 999999999 162.27 259.96 percent of total billed charges Dehydroepiandrosterone (DHEA) hormone level 49163639_1 CDM 0301 RC 82626 HCPCS inpatient 268 174.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 162.27 60.55 999999999 162.27 259.96 percent of total billed charges Dehydroepiandrosterone (DHEA) hormone level 49163639_1 CDM 0301 RC 82626 HCPCS inpatient 268 174.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 162.27 259.96 Dehydroepiandrosterone (DHEA) hormone level 49163639_1 CDM 0301 RC 82626 HCPCS inpatient 268 174.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 162.27 259.96 Dehydroepiandrosterone (DHEA) hormone level 49163639_1 CDM 0301 RC 82626 HCPCS inpatient 268 174.2 ANTHEM HMO ANTHEM HMO 999999999 162.27 259.96 Dehydroepiandrosterone (DHEA) hormone level 49163639_1 CDM 0301 RC 82626 HCPCS inpatient 268 174.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 162.27 259.96 Dehydroepiandrosterone (DHEA) hormone level 49163639_1 CDM 0301 RC 82626 HCPCS inpatient 268 174.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 162.27 259.96 Dehydroepiandrosterone (DHEA) hormone level 49163639_1 CDM 0301 RC 82626 HCPCS inpatient 268 174.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 181.17 67.6 999999999 162.27 259.96 percent of total billed charges "Identification of organisms by immunologic analysis, immunofluorescent method" 49163643_1 CDM 0301 RC 87140 HCPCS inpatient 107 69.55 AETNA AETNA 84.53 79 999999999 64.79 103.79 percent of total billed charges "Identification of organisms by immunologic analysis, immunofluorescent method" 49163643_1 CDM 0301 RC 87140 HCPCS inpatient 107 69.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 69.55 65 999999999 64.79 103.79 percent of total billed charges "Identification of organisms by immunologic analysis, immunofluorescent method" 49163643_1 CDM 0301 RC 87140 HCPCS inpatient 107 69.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 103.79 97 999999999 64.79 103.79 percent of total billed charges "Identification of organisms by immunologic analysis, immunofluorescent method" 49163643_1 CDM 0301 RC 87140 HCPCS inpatient 107 69.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 83.46 78 999999999 64.79 103.79 percent of total billed charges "Identification of organisms by immunologic analysis, immunofluorescent method" 49163643_1 CDM 0301 RC 87140 HCPCS inpatient 107 69.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.83 69 999999999 64.79 103.79 percent of total billed charges "Identification of organisms by immunologic analysis, immunofluorescent method" 49163643_1 CDM 0301 RC 87140 HCPCS inpatient 107 69.55 UMR - ALL PLANS UMR - ALL PLANS 74.9 70 999999999 64.79 103.79 percent of total billed charges "Identification of organisms by immunologic analysis, immunofluorescent method" 49163643_1 CDM 0301 RC 87140 HCPCS inpatient 107 69.55 SIHO - ALL PLANS SIHO - ALL PLANS 96.3 90 999999999 64.79 103.79 percent of total billed charges "Identification of organisms by immunologic analysis, immunofluorescent method" 49163643_1 CDM 0301 RC 87140 HCPCS inpatient 107 69.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.79 60.55 999999999 64.79 103.79 percent of total billed charges "Identification of organisms by immunologic analysis, immunofluorescent method" 49163643_1 CDM 0301 RC 87140 HCPCS inpatient 107 69.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.79 103.79 "Identification of organisms by immunologic analysis, immunofluorescent method" 49163643_1 CDM 0301 RC 87140 HCPCS inpatient 107 69.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.79 103.79 "Identification of organisms by immunologic analysis, immunofluorescent method" 49163643_1 CDM 0301 RC 87140 HCPCS inpatient 107 69.55 ANTHEM HMO ANTHEM HMO 999999999 64.79 103.79 "Identification of organisms by immunologic analysis, immunofluorescent method" 49163643_1 CDM 0301 RC 87140 HCPCS inpatient 107 69.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.79 103.79 "Identification of organisms by immunologic analysis, immunofluorescent method" 49163643_1 CDM 0301 RC 87140 HCPCS inpatient 107 69.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.79 103.79 "Identification of organisms by immunologic analysis, immunofluorescent method" 49163643_1 CDM 0301 RC 87140 HCPCS inpatient 107 69.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 72.33 67.6 999999999 64.79 103.79 percent of total billed charges CEFOXITIN 1 GM VIAL 49164477_1 CDM 0250 RC 44567-0245-25 NDC inpatient 1 UN 31.29 20.34 AETNA AETNA 24.72 79 999999999 18.95 30.35 percent of total billed charges CEFOXITIN 1 GM VIAL 49164477_1 CDM 0250 RC 44567-0245-25 NDC inpatient 1 UN 31.29 20.34 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.34 65 999999999 18.95 30.35 percent of total billed charges CEFOXITIN 1 GM VIAL 49164477_1 CDM 0250 RC 44567-0245-25 NDC inpatient 1 UN 31.29 20.34 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.35 97 999999999 18.95 30.35 percent of total billed charges CEFOXITIN 1 GM VIAL 49164477_1 CDM 0250 RC 44567-0245-25 NDC inpatient 1 UN 31.29 20.34 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.41 78 999999999 18.95 30.35 percent of total billed charges CEFOXITIN 1 GM VIAL 49164477_1 CDM 0250 RC 44567-0245-25 NDC inpatient 1 UN 31.29 20.34 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.59 69 999999999 18.95 30.35 percent of total billed charges CEFOXITIN 1 GM VIAL 49164477_1 CDM 0250 RC 44567-0245-25 NDC inpatient 1 UN 31.29 20.34 UMR - ALL PLANS UMR - ALL PLANS 21.9 70 999999999 18.95 30.35 percent of total billed charges CEFOXITIN 1 GM VIAL 49164477_1 CDM 0250 RC 44567-0245-25 NDC inpatient 1 UN 31.29 20.34 SIHO - ALL PLANS SIHO - ALL PLANS 28.16 90 999999999 18.95 30.35 percent of total billed charges CEFOXITIN 1 GM VIAL 49164477_1 CDM 0250 RC 44567-0245-25 NDC inpatient 1 UN 31.29 20.34 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.95 60.55 999999999 18.95 30.35 percent of total billed charges CEFOXITIN 1 GM VIAL 49164477_1 CDM 0250 RC 44567-0245-25 NDC inpatient 1 UN 31.29 20.34 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.95 30.35 CEFOXITIN 1 GM VIAL 49164477_1 CDM 0250 RC 44567-0245-25 NDC inpatient 1 UN 31.29 20.34 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.95 30.35 CEFOXITIN 1 GM VIAL 49164477_1 CDM 0250 RC 44567-0245-25 NDC inpatient 1 UN 31.29 20.34 ANTHEM HMO ANTHEM HMO 999999999 18.95 30.35 CEFOXITIN 1 GM VIAL 49164477_1 CDM 0250 RC 44567-0245-25 NDC inpatient 1 UN 31.29 20.34 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.95 30.35 CEFOXITIN 1 GM VIAL 49164477_1 CDM 0250 RC 44567-0245-25 NDC inpatient 1 UN 31.29 20.34 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.95 30.35 CEFOXITIN 1 GM VIAL 49164477_1 CDM 0250 RC 44567-0245-25 NDC inpatient 1 UN 31.29 20.34 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.15 67.6 999999999 18.95 30.35 percent of total billed charges AZOPT 1% EYE DROPS 49166123_1 CDM 0250 RC 00065-0275-10 NDC inpatient 1 UN 480.21 312.14 AETNA AETNA 379.37 79 999999999 290.77 465.8 percent of total billed charges AZOPT 1% EYE DROPS 49166123_1 CDM 0250 RC 00065-0275-10 NDC inpatient 1 UN 480.21 312.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 312.14 65 999999999 290.77 465.8 percent of total billed charges AZOPT 1% EYE DROPS 49166123_1 CDM 0250 RC 00065-0275-10 NDC inpatient 1 UN 480.21 312.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 465.8 97 999999999 290.77 465.8 percent of total billed charges AZOPT 1% EYE DROPS 49166123_1 CDM 0250 RC 00065-0275-10 NDC inpatient 1 UN 480.21 312.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 374.56 78 999999999 290.77 465.8 percent of total billed charges AZOPT 1% EYE DROPS 49166123_1 CDM 0250 RC 00065-0275-10 NDC inpatient 1 UN 480.21 312.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 331.34 69 999999999 290.77 465.8 percent of total billed charges AZOPT 1% EYE DROPS 49166123_1 CDM 0250 RC 00065-0275-10 NDC inpatient 1 UN 480.21 312.14 UMR - ALL PLANS UMR - ALL PLANS 336.15 70 999999999 290.77 465.8 percent of total billed charges AZOPT 1% EYE DROPS 49166123_1 CDM 0250 RC 00065-0275-10 NDC inpatient 1 UN 480.21 312.14 SIHO - ALL PLANS SIHO - ALL PLANS 432.19 90 999999999 290.77 465.8 percent of total billed charges AZOPT 1% EYE DROPS 49166123_1 CDM 0250 RC 00065-0275-10 NDC inpatient 1 UN 480.21 312.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 290.77 60.55 999999999 290.77 465.8 percent of total billed charges AZOPT 1% EYE DROPS 49166123_1 CDM 0250 RC 00065-0275-10 NDC inpatient 1 UN 480.21 312.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 290.77 465.8 AZOPT 1% EYE DROPS 49166123_1 CDM 0250 RC 00065-0275-10 NDC inpatient 1 UN 480.21 312.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 290.77 465.8 AZOPT 1% EYE DROPS 49166123_1 CDM 0250 RC 00065-0275-10 NDC inpatient 1 UN 480.21 312.14 ANTHEM HMO ANTHEM HMO 999999999 290.77 465.8 AZOPT 1% EYE DROPS 49166123_1 CDM 0250 RC 00065-0275-10 NDC inpatient 1 UN 480.21 312.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 290.77 465.8 AZOPT 1% EYE DROPS 49166123_1 CDM 0250 RC 00065-0275-10 NDC inpatient 1 UN 480.21 312.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 290.77 465.8 AZOPT 1% EYE DROPS 49166123_1 CDM 0250 RC 00065-0275-10 NDC inpatient 1 UN 480.21 312.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 324.62 67.6 999999999 290.77 465.8 percent of total billed charges TIMOLOL MALEATE 0.25% EYE DROP 49167475_1 CDM 0250 RC 61314-0226-05 NDC inpatient 1 UN 6.1 3.97 AETNA AETNA 4.82 79 999999999 3.69 5.92 percent of total billed charges TIMOLOL MALEATE 0.25% EYE DROP 49167475_1 CDM 0250 RC 61314-0226-05 NDC inpatient 1 UN 6.1 3.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.97 65 999999999 3.69 5.92 percent of total billed charges TIMOLOL MALEATE 0.25% EYE DROP 49167475_1 CDM 0250 RC 61314-0226-05 NDC inpatient 1 UN 6.1 3.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.92 97 999999999 3.69 5.92 percent of total billed charges TIMOLOL MALEATE 0.25% EYE DROP 49167475_1 CDM 0250 RC 61314-0226-05 NDC inpatient 1 UN 6.1 3.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.76 78 999999999 3.69 5.92 percent of total billed charges TIMOLOL MALEATE 0.25% EYE DROP 49167475_1 CDM 0250 RC 61314-0226-05 NDC inpatient 1 UN 6.1 3.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.21 69 999999999 3.69 5.92 percent of total billed charges TIMOLOL MALEATE 0.25% EYE DROP 49167475_1 CDM 0250 RC 61314-0226-05 NDC inpatient 1 UN 6.1 3.97 UMR - ALL PLANS UMR - ALL PLANS 4.27 70 999999999 3.69 5.92 percent of total billed charges TIMOLOL MALEATE 0.25% EYE DROP 49167475_1 CDM 0250 RC 61314-0226-05 NDC inpatient 1 UN 6.1 3.97 SIHO - ALL PLANS SIHO - ALL PLANS 5.49 90 999999999 3.69 5.92 percent of total billed charges TIMOLOL MALEATE 0.25% EYE DROP 49167475_1 CDM 0250 RC 61314-0226-05 NDC inpatient 1 UN 6.1 3.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.69 60.55 999999999 3.69 5.92 percent of total billed charges TIMOLOL MALEATE 0.25% EYE DROP 49167475_1 CDM 0250 RC 61314-0226-05 NDC inpatient 1 UN 6.1 3.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.69 5.92 TIMOLOL MALEATE 0.25% EYE DROP 49167475_1 CDM 0250 RC 61314-0226-05 NDC inpatient 1 UN 6.1 3.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.69 5.92 TIMOLOL MALEATE 0.25% EYE DROP 49167475_1 CDM 0250 RC 61314-0226-05 NDC inpatient 1 UN 6.1 3.97 ANTHEM HMO ANTHEM HMO 999999999 3.69 5.92 TIMOLOL MALEATE 0.25% EYE DROP 49167475_1 CDM 0250 RC 61314-0226-05 NDC inpatient 1 UN 6.1 3.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.69 5.92 TIMOLOL MALEATE 0.25% EYE DROP 49167475_1 CDM 0250 RC 61314-0226-05 NDC inpatient 1 UN 6.1 3.97 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.69 5.92 TIMOLOL MALEATE 0.25% EYE DROP 49167475_1 CDM 0250 RC 61314-0226-05 NDC inpatient 1 UN 6.1 3.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.12 67.6 999999999 3.69 5.92 percent of total billed charges NITROFURANTOIN MONO-MCR 100 MG 49169550_1 CDM 0250 RC 68084-0446-01 NDC inpatient 1 UN 10.59 6.88 AETNA AETNA 8.37 79 999999999 6.41 10.27 percent of total billed charges NITROFURANTOIN MONO-MCR 100 MG 49169550_1 CDM 0250 RC 68084-0446-01 NDC inpatient 1 UN 10.59 6.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.88 65 999999999 6.41 10.27 percent of total billed charges NITROFURANTOIN MONO-MCR 100 MG 49169550_1 CDM 0250 RC 68084-0446-01 NDC inpatient 1 UN 10.59 6.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10.27 97 999999999 6.41 10.27 percent of total billed charges NITROFURANTOIN MONO-MCR 100 MG 49169550_1 CDM 0250 RC 68084-0446-01 NDC inpatient 1 UN 10.59 6.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 8.26 78 999999999 6.41 10.27 percent of total billed charges NITROFURANTOIN MONO-MCR 100 MG 49169550_1 CDM 0250 RC 68084-0446-01 NDC inpatient 1 UN 10.59 6.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.31 69 999999999 6.41 10.27 percent of total billed charges NITROFURANTOIN MONO-MCR 100 MG 49169550_1 CDM 0250 RC 68084-0446-01 NDC inpatient 1 UN 10.59 6.88 UMR - ALL PLANS UMR - ALL PLANS 7.41 70 999999999 6.41 10.27 percent of total billed charges NITROFURANTOIN MONO-MCR 100 MG 49169550_1 CDM 0250 RC 68084-0446-01 NDC inpatient 1 UN 10.59 6.88 SIHO - ALL PLANS SIHO - ALL PLANS 9.53 90 999999999 6.41 10.27 percent of total billed charges NITROFURANTOIN MONO-MCR 100 MG 49169550_1 CDM 0250 RC 68084-0446-01 NDC inpatient 1 UN 10.59 6.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.41 60.55 999999999 6.41 10.27 percent of total billed charges NITROFURANTOIN MONO-MCR 100 MG 49169550_1 CDM 0250 RC 68084-0446-01 NDC inpatient 1 UN 10.59 6.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.41 10.27 NITROFURANTOIN MONO-MCR 100 MG 49169550_1 CDM 0250 RC 68084-0446-01 NDC inpatient 1 UN 10.59 6.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.41 10.27 NITROFURANTOIN MONO-MCR 100 MG 49169550_1 CDM 0250 RC 68084-0446-01 NDC inpatient 1 UN 10.59 6.88 ANTHEM HMO ANTHEM HMO 999999999 6.41 10.27 NITROFURANTOIN MONO-MCR 100 MG 49169550_1 CDM 0250 RC 68084-0446-01 NDC inpatient 1 UN 10.59 6.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.41 10.27 NITROFURANTOIN MONO-MCR 100 MG 49169550_1 CDM 0250 RC 68084-0446-01 NDC inpatient 1 UN 10.59 6.88 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.41 10.27 NITROFURANTOIN MONO-MCR 100 MG 49169550_1 CDM 0250 RC 68084-0446-01 NDC inpatient 1 UN 10.59 6.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 7.16 67.6 999999999 6.41 10.27 percent of total billed charges "INJECTION, DOCETAXEL, 1 MG" 49178796_1 CDM 0636 RC 66758-0950-02 NDC J9171 HCPCS inpatient 20 UN 227.22 147.69 AETNA AETNA 179.5 79 999999999 137.58 220.4 percent of total billed charges "INJECTION, DOCETAXEL, 1 MG" 49178796_1 CDM 0636 RC 66758-0950-02 NDC J9171 HCPCS inpatient 20 UN 227.22 147.69 SELF PAY DISCOUNT SELF PAY DISCOUNT 147.69 65 999999999 137.58 220.4 percent of total billed charges "INJECTION, DOCETAXEL, 1 MG" 49178796_1 CDM 0636 RC 66758-0950-02 NDC J9171 HCPCS inpatient 20 UN 227.22 147.69 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 220.4 97 999999999 137.58 220.4 percent of total billed charges "INJECTION, DOCETAXEL, 1 MG" 49178796_1 CDM 0636 RC 66758-0950-02 NDC J9171 HCPCS inpatient 20 UN 227.22 147.69 HUMANA - ALL PLANS HUMANA - ALL PLANS 177.23 78 999999999 137.58 220.4 percent of total billed charges "INJECTION, DOCETAXEL, 1 MG" 49178796_1 CDM 0636 RC 66758-0950-02 NDC J9171 HCPCS inpatient 20 UN 227.22 147.69 ENCORE - ALL PLANS ENCORE - ALL PLANS 156.78 69 999999999 137.58 220.4 percent of total billed charges "INJECTION, DOCETAXEL, 1 MG" 49178796_1 CDM 0636 RC 66758-0950-02 NDC J9171 HCPCS inpatient 20 UN 227.22 147.69 UMR - ALL PLANS UMR - ALL PLANS 159.05 70 999999999 137.58 220.4 percent of total billed charges "INJECTION, DOCETAXEL, 1 MG" 49178796_1 CDM 0636 RC 66758-0950-02 NDC J9171 HCPCS inpatient 20 UN 227.22 147.69 SIHO - ALL PLANS SIHO - ALL PLANS 204.5 90 999999999 137.58 220.4 percent of total billed charges "INJECTION, DOCETAXEL, 1 MG" 49178796_1 CDM 0636 RC 66758-0950-02 NDC J9171 HCPCS inpatient 20 UN 227.22 147.69 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 137.58 60.55 999999999 137.58 220.4 percent of total billed charges "INJECTION, DOCETAXEL, 1 MG" 49178796_1 CDM 0636 RC 66758-0950-02 NDC J9171 HCPCS inpatient 20 UN 227.22 147.69 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 137.58 220.4 "INJECTION, DOCETAXEL, 1 MG" 49178796_1 CDM 0636 RC 66758-0950-02 NDC J9171 HCPCS inpatient 20 UN 227.22 147.69 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 137.58 220.4 "INJECTION, DOCETAXEL, 1 MG" 49178796_1 CDM 0636 RC 66758-0950-02 NDC J9171 HCPCS inpatient 20 UN 227.22 147.69 ANTHEM HMO ANTHEM HMO 999999999 137.58 220.4 "INJECTION, DOCETAXEL, 1 MG" 49178796_1 CDM 0636 RC 66758-0950-02 NDC J9171 HCPCS inpatient 20 UN 227.22 147.69 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 137.58 220.4 "INJECTION, DOCETAXEL, 1 MG" 49178796_1 CDM 0636 RC 66758-0950-02 NDC J9171 HCPCS inpatient 20 UN 227.22 147.69 UHC - ALL PLANS UHC - ALL PLANS 999999999 137.58 220.4 "INJECTION, DOCETAXEL, 1 MG" 49178796_1 CDM 0636 RC 66758-0950-02 NDC J9171 HCPCS inpatient 20 UN 227.22 147.69 CIGNA - ALL PLANS CIGNA - ALL PLANS 153.6 67.6 999999999 137.58 220.4 percent of total billed charges 00472-0179-56 - bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin 28.35 gm [JOHN] 49179243_1 CDM 0250 RC 00472-0179-56 NDC inpatient 1 UN 8.35 5.43 AETNA AETNA 6.6 79 999999999 5.06 8.1 percent of total billed charges 00472-0179-56 - bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin 28.35 gm [JOHN] 49179243_1 CDM 0250 RC 00472-0179-56 NDC inpatient 1 UN 8.35 5.43 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.43 65 999999999 5.06 8.1 percent of total billed charges 00472-0179-56 - bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin 28.35 gm [JOHN] 49179243_1 CDM 0250 RC 00472-0179-56 NDC inpatient 1 UN 8.35 5.43 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.1 97 999999999 5.06 8.1 percent of total billed charges 00472-0179-56 - bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin 28.35 gm [JOHN] 49179243_1 CDM 0250 RC 00472-0179-56 NDC inpatient 1 UN 8.35 5.43 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.51 78 999999999 5.06 8.1 percent of total billed charges 00472-0179-56 - bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin 28.35 gm [JOHN] 49179243_1 CDM 0250 RC 00472-0179-56 NDC inpatient 1 UN 8.35 5.43 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.76 69 999999999 5.06 8.1 percent of total billed charges 00472-0179-56 - bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin 28.35 gm [JOHN] 49179243_1 CDM 0250 RC 00472-0179-56 NDC inpatient 1 UN 8.35 5.43 UMR - ALL PLANS UMR - ALL PLANS 5.85 70 999999999 5.06 8.1 percent of total billed charges 00472-0179-56 - bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin 28.35 gm [JOHN] 49179243_1 CDM 0250 RC 00472-0179-56 NDC inpatient 1 UN 8.35 5.43 SIHO - ALL PLANS SIHO - ALL PLANS 7.52 90 999999999 5.06 8.1 percent of total billed charges 00472-0179-56 - bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin 28.35 gm [JOHN] 49179243_1 CDM 0250 RC 00472-0179-56 NDC inpatient 1 UN 8.35 5.43 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.06 60.55 999999999 5.06 8.1 percent of total billed charges 00472-0179-56 - bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin 28.35 gm [JOHN] 49179243_1 CDM 0250 RC 00472-0179-56 NDC inpatient 1 UN 8.35 5.43 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.06 8.1 00472-0179-56 - bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin 28.35 gm [JOHN] 49179243_1 CDM 0250 RC 00472-0179-56 NDC inpatient 1 UN 8.35 5.43 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.06 8.1 00472-0179-56 - bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin 28.35 gm [JOHN] 49179243_1 CDM 0250 RC 00472-0179-56 NDC inpatient 1 UN 8.35 5.43 ANTHEM HMO ANTHEM HMO 999999999 5.06 8.1 00472-0179-56 - bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin 28.35 gm [JOHN] 49179243_1 CDM 0250 RC 00472-0179-56 NDC inpatient 1 UN 8.35 5.43 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.06 8.1 00472-0179-56 - bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin 28.35 gm [JOHN] 49179243_1 CDM 0250 RC 00472-0179-56 NDC inpatient 1 UN 8.35 5.43 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.06 8.1 00472-0179-56 - bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin 28.35 gm [JOHN] 49179243_1 CDM 0250 RC 00472-0179-56 NDC inpatient 1 UN 8.35 5.43 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.64 67.6 999999999 5.06 8.1 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 49180654_1 CDM 0250 RC 55150-0155-20 NDC inpatient 1 UN 51.09 33.21 AETNA AETNA 40.36 79 999999999 30.94 49.56 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 49180654_1 CDM 0250 RC 55150-0155-20 NDC inpatient 1 UN 51.09 33.21 SELF PAY DISCOUNT SELF PAY DISCOUNT 33.21 65 999999999 30.94 49.56 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 49180654_1 CDM 0250 RC 55150-0155-20 NDC inpatient 1 UN 51.09 33.21 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 49.56 97 999999999 30.94 49.56 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 49180654_1 CDM 0250 RC 55150-0155-20 NDC inpatient 1 UN 51.09 33.21 HUMANA - ALL PLANS HUMANA - ALL PLANS 39.85 78 999999999 30.94 49.56 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 49180654_1 CDM 0250 RC 55150-0155-20 NDC inpatient 1 UN 51.09 33.21 ENCORE - ALL PLANS ENCORE - ALL PLANS 35.25 69 999999999 30.94 49.56 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 49180654_1 CDM 0250 RC 55150-0155-20 NDC inpatient 1 UN 51.09 33.21 UMR - ALL PLANS UMR - ALL PLANS 35.76 70 999999999 30.94 49.56 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 49180654_1 CDM 0250 RC 55150-0155-20 NDC inpatient 1 UN 51.09 33.21 SIHO - ALL PLANS SIHO - ALL PLANS 45.98 90 999999999 30.94 49.56 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 49180654_1 CDM 0250 RC 55150-0155-20 NDC inpatient 1 UN 51.09 33.21 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.94 60.55 999999999 30.94 49.56 percent of total billed charges "ACYCLOVIR 1,000 MG/20 ML VIAL" 49180654_1 CDM 0250 RC 55150-0155-20 NDC inpatient 1 UN 51.09 33.21 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.94 49.56 "ACYCLOVIR 1,000 MG/20 ML VIAL" 49180654_1 CDM 0250 RC 55150-0155-20 NDC inpatient 1 UN 51.09 33.21 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.94 49.56 "ACYCLOVIR 1,000 MG/20 ML VIAL" 49180654_1 CDM 0250 RC 55150-0155-20 NDC inpatient 1 UN 51.09 33.21 ANTHEM HMO ANTHEM HMO 999999999 30.94 49.56 "ACYCLOVIR 1,000 MG/20 ML VIAL" 49180654_1 CDM 0250 RC 55150-0155-20 NDC inpatient 1 UN 51.09 33.21 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.94 49.56 "ACYCLOVIR 1,000 MG/20 ML VIAL" 49180654_1 CDM 0250 RC 55150-0155-20 NDC inpatient 1 UN 51.09 33.21 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.94 49.56 "ACYCLOVIR 1,000 MG/20 ML VIAL" 49180654_1 CDM 0250 RC 55150-0155-20 NDC inpatient 1 UN 51.09 33.21 CIGNA - ALL PLANS CIGNA - ALL PLANS 34.54 67.6 999999999 30.94 49.56 percent of total billed charges VANCOMYCIN 1 GM ADD-VAN VIAL 49180662_1 CDM 0250 RC 00409-6535-01 NDC inpatient 1 UN 75.58 49.13 AETNA AETNA 59.71 79 999999999 45.76 73.31 percent of total billed charges VANCOMYCIN 1 GM ADD-VAN VIAL 49180662_1 CDM 0250 RC 00409-6535-01 NDC inpatient 1 UN 75.58 49.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.13 65 999999999 45.76 73.31 percent of total billed charges VANCOMYCIN 1 GM ADD-VAN VIAL 49180662_1 CDM 0250 RC 00409-6535-01 NDC inpatient 1 UN 75.58 49.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.31 97 999999999 45.76 73.31 percent of total billed charges VANCOMYCIN 1 GM ADD-VAN VIAL 49180662_1 CDM 0250 RC 00409-6535-01 NDC inpatient 1 UN 75.58 49.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.95 78 999999999 45.76 73.31 percent of total billed charges VANCOMYCIN 1 GM ADD-VAN VIAL 49180662_1 CDM 0250 RC 00409-6535-01 NDC inpatient 1 UN 75.58 49.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.15 69 999999999 45.76 73.31 percent of total billed charges VANCOMYCIN 1 GM ADD-VAN VIAL 49180662_1 CDM 0250 RC 00409-6535-01 NDC inpatient 1 UN 75.58 49.13 UMR - ALL PLANS UMR - ALL PLANS 52.91 70 999999999 45.76 73.31 percent of total billed charges VANCOMYCIN 1 GM ADD-VAN VIAL 49180662_1 CDM 0250 RC 00409-6535-01 NDC inpatient 1 UN 75.58 49.13 SIHO - ALL PLANS SIHO - ALL PLANS 68.02 90 999999999 45.76 73.31 percent of total billed charges VANCOMYCIN 1 GM ADD-VAN VIAL 49180662_1 CDM 0250 RC 00409-6535-01 NDC inpatient 1 UN 75.58 49.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.76 60.55 999999999 45.76 73.31 percent of total billed charges VANCOMYCIN 1 GM ADD-VAN VIAL 49180662_1 CDM 0250 RC 00409-6535-01 NDC inpatient 1 UN 75.58 49.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.76 73.31 VANCOMYCIN 1 GM ADD-VAN VIAL 49180662_1 CDM 0250 RC 00409-6535-01 NDC inpatient 1 UN 75.58 49.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.76 73.31 VANCOMYCIN 1 GM ADD-VAN VIAL 49180662_1 CDM 0250 RC 00409-6535-01 NDC inpatient 1 UN 75.58 49.13 ANTHEM HMO ANTHEM HMO 999999999 45.76 73.31 VANCOMYCIN 1 GM ADD-VAN VIAL 49180662_1 CDM 0250 RC 00409-6535-01 NDC inpatient 1 UN 75.58 49.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.76 73.31 VANCOMYCIN 1 GM ADD-VAN VIAL 49180662_1 CDM 0250 RC 00409-6535-01 NDC inpatient 1 UN 75.58 49.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.76 73.31 VANCOMYCIN 1 GM ADD-VAN VIAL 49180662_1 CDM 0250 RC 00409-6535-01 NDC inpatient 1 UN 75.58 49.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.09 67.6 999999999 45.76 73.31 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 49181425_1 CDM 0250 RC 43825-0102-01 NDC J0131 HCPCS inpatient 100 UN 221.57 144.02 AETNA AETNA 175.04 79 999999999 134.16 214.92 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 49181425_1 CDM 0250 RC 43825-0102-01 NDC J0131 HCPCS inpatient 100 UN 221.57 144.02 SELF PAY DISCOUNT SELF PAY DISCOUNT 144.02 65 999999999 134.16 214.92 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 49181425_1 CDM 0250 RC 43825-0102-01 NDC J0131 HCPCS inpatient 100 UN 221.57 144.02 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 214.92 97 999999999 134.16 214.92 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 49181425_1 CDM 0250 RC 43825-0102-01 NDC J0131 HCPCS inpatient 100 UN 221.57 144.02 HUMANA - ALL PLANS HUMANA - ALL PLANS 172.82 78 999999999 134.16 214.92 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 49181425_1 CDM 0250 RC 43825-0102-01 NDC J0131 HCPCS inpatient 100 UN 221.57 144.02 ENCORE - ALL PLANS ENCORE - ALL PLANS 152.88 69 999999999 134.16 214.92 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 49181425_1 CDM 0250 RC 43825-0102-01 NDC J0131 HCPCS inpatient 100 UN 221.57 144.02 UMR - ALL PLANS UMR - ALL PLANS 155.1 70 999999999 134.16 214.92 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 49181425_1 CDM 0250 RC 43825-0102-01 NDC J0131 HCPCS inpatient 100 UN 221.57 144.02 SIHO - ALL PLANS SIHO - ALL PLANS 199.41 90 999999999 134.16 214.92 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 49181425_1 CDM 0250 RC 43825-0102-01 NDC J0131 HCPCS inpatient 100 UN 221.57 144.02 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 134.16 60.55 999999999 134.16 214.92 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 49181425_1 CDM 0250 RC 43825-0102-01 NDC J0131 HCPCS inpatient 100 UN 221.57 144.02 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 134.16 214.92 "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 49181425_1 CDM 0250 RC 43825-0102-01 NDC J0131 HCPCS inpatient 100 UN 221.57 144.02 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 134.16 214.92 "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 49181425_1 CDM 0250 RC 43825-0102-01 NDC J0131 HCPCS inpatient 100 UN 221.57 144.02 ANTHEM HMO ANTHEM HMO 999999999 134.16 214.92 "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 49181425_1 CDM 0250 RC 43825-0102-01 NDC J0131 HCPCS inpatient 100 UN 221.57 144.02 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 134.16 214.92 "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 49181425_1 CDM 0250 RC 43825-0102-01 NDC J0131 HCPCS inpatient 100 UN 221.57 144.02 UHC - ALL PLANS UHC - ALL PLANS 999999999 134.16 214.92 "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 49181425_1 CDM 0250 RC 43825-0102-01 NDC J0131 HCPCS inpatient 100 UN 221.57 144.02 CIGNA - ALL PLANS CIGNA - ALL PLANS 149.78 67.6 999999999 134.16 214.92 percent of total billed charges CHLORASEPTIC SORE THROAT LOZNG 49181464_1 CDM 0250 RC 78112-0011-06 NDC inpatient 1 UN 4.73 3.07 AETNA AETNA 3.74 79 999999999 2.86 4.59 percent of total billed charges CHLORASEPTIC SORE THROAT LOZNG 49181464_1 CDM 0250 RC 78112-0011-06 NDC inpatient 1 UN 4.73 3.07 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.07 65 999999999 2.86 4.59 percent of total billed charges CHLORASEPTIC SORE THROAT LOZNG 49181464_1 CDM 0250 RC 78112-0011-06 NDC inpatient 1 UN 4.73 3.07 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4.59 97 999999999 2.86 4.59 percent of total billed charges CHLORASEPTIC SORE THROAT LOZNG 49181464_1 CDM 0250 RC 78112-0011-06 NDC inpatient 1 UN 4.73 3.07 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.69 78 999999999 2.86 4.59 percent of total billed charges CHLORASEPTIC SORE THROAT LOZNG 49181464_1 CDM 0250 RC 78112-0011-06 NDC inpatient 1 UN 4.73 3.07 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.26 69 999999999 2.86 4.59 percent of total billed charges CHLORASEPTIC SORE THROAT LOZNG 49181464_1 CDM 0250 RC 78112-0011-06 NDC inpatient 1 UN 4.73 3.07 UMR - ALL PLANS UMR - ALL PLANS 3.31 70 999999999 2.86 4.59 percent of total billed charges CHLORASEPTIC SORE THROAT LOZNG 49181464_1 CDM 0250 RC 78112-0011-06 NDC inpatient 1 UN 4.73 3.07 SIHO - ALL PLANS SIHO - ALL PLANS 4.26 90 999999999 2.86 4.59 percent of total billed charges CHLORASEPTIC SORE THROAT LOZNG 49181464_1 CDM 0250 RC 78112-0011-06 NDC inpatient 1 UN 4.73 3.07 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.86 60.55 999999999 2.86 4.59 percent of total billed charges CHLORASEPTIC SORE THROAT LOZNG 49181464_1 CDM 0250 RC 78112-0011-06 NDC inpatient 1 UN 4.73 3.07 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.86 4.59 CHLORASEPTIC SORE THROAT LOZNG 49181464_1 CDM 0250 RC 78112-0011-06 NDC inpatient 1 UN 4.73 3.07 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.86 4.59 CHLORASEPTIC SORE THROAT LOZNG 49181464_1 CDM 0250 RC 78112-0011-06 NDC inpatient 1 UN 4.73 3.07 ANTHEM HMO ANTHEM HMO 999999999 2.86 4.59 CHLORASEPTIC SORE THROAT LOZNG 49181464_1 CDM 0250 RC 78112-0011-06 NDC inpatient 1 UN 4.73 3.07 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.86 4.59 CHLORASEPTIC SORE THROAT LOZNG 49181464_1 CDM 0250 RC 78112-0011-06 NDC inpatient 1 UN 4.73 3.07 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.86 4.59 CHLORASEPTIC SORE THROAT LOZNG 49181464_1 CDM 0250 RC 78112-0011-06 NDC inpatient 1 UN 4.73 3.07 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.2 67.6 999999999 2.86 4.59 percent of total billed charges HURRICAINE ONE 20% U-D SPRAY 49181475_1 CDM 0250 RC 00283-0610-26 NDC inpatient 1 UN 19.49 12.67 AETNA AETNA 15.4 79 999999999 11.8 18.91 percent of total billed charges HURRICAINE ONE 20% U-D SPRAY 49181475_1 CDM 0250 RC 00283-0610-26 NDC inpatient 1 UN 19.49 12.67 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.67 65 999999999 11.8 18.91 percent of total billed charges HURRICAINE ONE 20% U-D SPRAY 49181475_1 CDM 0250 RC 00283-0610-26 NDC inpatient 1 UN 19.49 12.67 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 18.91 97 999999999 11.8 18.91 percent of total billed charges HURRICAINE ONE 20% U-D SPRAY 49181475_1 CDM 0250 RC 00283-0610-26 NDC inpatient 1 UN 19.49 12.67 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.2 78 999999999 11.8 18.91 percent of total billed charges HURRICAINE ONE 20% U-D SPRAY 49181475_1 CDM 0250 RC 00283-0610-26 NDC inpatient 1 UN 19.49 12.67 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.45 69 999999999 11.8 18.91 percent of total billed charges HURRICAINE ONE 20% U-D SPRAY 49181475_1 CDM 0250 RC 00283-0610-26 NDC inpatient 1 UN 19.49 12.67 UMR - ALL PLANS UMR - ALL PLANS 13.64 70 999999999 11.8 18.91 percent of total billed charges HURRICAINE ONE 20% U-D SPRAY 49181475_1 CDM 0250 RC 00283-0610-26 NDC inpatient 1 UN 19.49 12.67 SIHO - ALL PLANS SIHO - ALL PLANS 17.54 90 999999999 11.8 18.91 percent of total billed charges HURRICAINE ONE 20% U-D SPRAY 49181475_1 CDM 0250 RC 00283-0610-26 NDC inpatient 1 UN 19.49 12.67 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.8 60.55 999999999 11.8 18.91 percent of total billed charges HURRICAINE ONE 20% U-D SPRAY 49181475_1 CDM 0250 RC 00283-0610-26 NDC inpatient 1 UN 19.49 12.67 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.8 18.91 HURRICAINE ONE 20% U-D SPRAY 49181475_1 CDM 0250 RC 00283-0610-26 NDC inpatient 1 UN 19.49 12.67 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.8 18.91 HURRICAINE ONE 20% U-D SPRAY 49181475_1 CDM 0250 RC 00283-0610-26 NDC inpatient 1 UN 19.49 12.67 ANTHEM HMO ANTHEM HMO 999999999 11.8 18.91 HURRICAINE ONE 20% U-D SPRAY 49181475_1 CDM 0250 RC 00283-0610-26 NDC inpatient 1 UN 19.49 12.67 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.8 18.91 HURRICAINE ONE 20% U-D SPRAY 49181475_1 CDM 0250 RC 00283-0610-26 NDC inpatient 1 UN 19.49 12.67 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.8 18.91 HURRICAINE ONE 20% U-D SPRAY 49181475_1 CDM 0250 RC 00283-0610-26 NDC inpatient 1 UN 19.49 12.67 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.18 67.6 999999999 11.8 18.91 percent of total billed charges 45802-0356-53 - trolamine salicylate topical 10% Cr [JOHN] 49181483_1 CDM 0250 RC 45802-0356-53 NDC inpatient 1 UN 3.42 2.22 AETNA AETNA 2.7 79 999999999 2.07 3.32 percent of total billed charges 45802-0356-53 - trolamine salicylate topical 10% Cr [JOHN] 49181483_1 CDM 0250 RC 45802-0356-53 NDC inpatient 1 UN 3.42 2.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.22 65 999999999 2.07 3.32 percent of total billed charges 45802-0356-53 - trolamine salicylate topical 10% Cr [JOHN] 49181483_1 CDM 0250 RC 45802-0356-53 NDC inpatient 1 UN 3.42 2.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.32 97 999999999 2.07 3.32 percent of total billed charges 45802-0356-53 - trolamine salicylate topical 10% Cr [JOHN] 49181483_1 CDM 0250 RC 45802-0356-53 NDC inpatient 1 UN 3.42 2.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.67 78 999999999 2.07 3.32 percent of total billed charges 45802-0356-53 - trolamine salicylate topical 10% Cr [JOHN] 49181483_1 CDM 0250 RC 45802-0356-53 NDC inpatient 1 UN 3.42 2.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.36 69 999999999 2.07 3.32 percent of total billed charges 45802-0356-53 - trolamine salicylate topical 10% Cr [JOHN] 49181483_1 CDM 0250 RC 45802-0356-53 NDC inpatient 1 UN 3.42 2.22 UMR - ALL PLANS UMR - ALL PLANS 2.39 70 999999999 2.07 3.32 percent of total billed charges 45802-0356-53 - trolamine salicylate topical 10% Cr [JOHN] 49181483_1 CDM 0250 RC 45802-0356-53 NDC inpatient 1 UN 3.42 2.22 SIHO - ALL PLANS SIHO - ALL PLANS 3.08 90 999999999 2.07 3.32 percent of total billed charges 45802-0356-53 - trolamine salicylate topical 10% Cr [JOHN] 49181483_1 CDM 0250 RC 45802-0356-53 NDC inpatient 1 UN 3.42 2.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.07 60.55 999999999 2.07 3.32 percent of total billed charges 45802-0356-53 - trolamine salicylate topical 10% Cr [JOHN] 49181483_1 CDM 0250 RC 45802-0356-53 NDC inpatient 1 UN 3.42 2.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.07 3.32 45802-0356-53 - trolamine salicylate topical 10% Cr [JOHN] 49181483_1 CDM 0250 RC 45802-0356-53 NDC inpatient 1 UN 3.42 2.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.07 3.32 45802-0356-53 - trolamine salicylate topical 10% Cr [JOHN] 49181483_1 CDM 0250 RC 45802-0356-53 NDC inpatient 1 UN 3.42 2.22 ANTHEM HMO ANTHEM HMO 999999999 2.07 3.32 45802-0356-53 - trolamine salicylate topical 10% Cr [JOHN] 49181483_1 CDM 0250 RC 45802-0356-53 NDC inpatient 1 UN 3.42 2.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.07 3.32 45802-0356-53 - trolamine salicylate topical 10% Cr [JOHN] 49181483_1 CDM 0250 RC 45802-0356-53 NDC inpatient 1 UN 3.42 2.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.07 3.32 45802-0356-53 - trolamine salicylate topical 10% Cr [JOHN] 49181483_1 CDM 0250 RC 45802-0356-53 NDC inpatient 1 UN 3.42 2.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.31 67.6 999999999 2.07 3.32 percent of total billed charges "INSTILLATION, CIPROFLOXACIN OTIC SUSPENSION, 6 MG" 49181522_1 CDM 0250 RC 69251-0201-01 NDC J7342 HCPCS inpatient 10 UN 420.56 273.36 AETNA AETNA 332.24 79 999999999 254.65 407.94 percent of total billed charges "INSTILLATION, CIPROFLOXACIN OTIC SUSPENSION, 6 MG" 49181522_1 CDM 0250 RC 69251-0201-01 NDC J7342 HCPCS inpatient 10 UN 420.56 273.36 SELF PAY DISCOUNT SELF PAY DISCOUNT 273.36 65 999999999 254.65 407.94 percent of total billed charges "INSTILLATION, CIPROFLOXACIN OTIC SUSPENSION, 6 MG" 49181522_1 CDM 0250 RC 69251-0201-01 NDC J7342 HCPCS inpatient 10 UN 420.56 273.36 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 407.94 97 999999999 254.65 407.94 percent of total billed charges "INSTILLATION, CIPROFLOXACIN OTIC SUSPENSION, 6 MG" 49181522_1 CDM 0250 RC 69251-0201-01 NDC J7342 HCPCS inpatient 10 UN 420.56 273.36 HUMANA - ALL PLANS HUMANA - ALL PLANS 328.04 78 999999999 254.65 407.94 percent of total billed charges "INSTILLATION, CIPROFLOXACIN OTIC SUSPENSION, 6 MG" 49181522_1 CDM 0250 RC 69251-0201-01 NDC J7342 HCPCS inpatient 10 UN 420.56 273.36 ENCORE - ALL PLANS ENCORE - ALL PLANS 290.19 69 999999999 254.65 407.94 percent of total billed charges "INSTILLATION, CIPROFLOXACIN OTIC SUSPENSION, 6 MG" 49181522_1 CDM 0250 RC 69251-0201-01 NDC J7342 HCPCS inpatient 10 UN 420.56 273.36 UMR - ALL PLANS UMR - ALL PLANS 294.39 70 999999999 254.65 407.94 percent of total billed charges "INSTILLATION, CIPROFLOXACIN OTIC SUSPENSION, 6 MG" 49181522_1 CDM 0250 RC 69251-0201-01 NDC J7342 HCPCS inpatient 10 UN 420.56 273.36 SIHO - ALL PLANS SIHO - ALL PLANS 378.5 90 999999999 254.65 407.94 percent of total billed charges "INSTILLATION, CIPROFLOXACIN OTIC SUSPENSION, 6 MG" 49181522_1 CDM 0250 RC 69251-0201-01 NDC J7342 HCPCS inpatient 10 UN 420.56 273.36 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 254.65 60.55 999999999 254.65 407.94 percent of total billed charges "INSTILLATION, CIPROFLOXACIN OTIC SUSPENSION, 6 MG" 49181522_1 CDM 0250 RC 69251-0201-01 NDC J7342 HCPCS inpatient 10 UN 420.56 273.36 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 254.65 407.94 "INSTILLATION, CIPROFLOXACIN OTIC SUSPENSION, 6 MG" 49181522_1 CDM 0250 RC 69251-0201-01 NDC J7342 HCPCS inpatient 10 UN 420.56 273.36 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 254.65 407.94 "INSTILLATION, CIPROFLOXACIN OTIC SUSPENSION, 6 MG" 49181522_1 CDM 0250 RC 69251-0201-01 NDC J7342 HCPCS inpatient 10 UN 420.56 273.36 ANTHEM HMO ANTHEM HMO 999999999 254.65 407.94 "INSTILLATION, CIPROFLOXACIN OTIC SUSPENSION, 6 MG" 49181522_1 CDM 0250 RC 69251-0201-01 NDC J7342 HCPCS inpatient 10 UN 420.56 273.36 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 254.65 407.94 "INSTILLATION, CIPROFLOXACIN OTIC SUSPENSION, 6 MG" 49181522_1 CDM 0250 RC 69251-0201-01 NDC J7342 HCPCS inpatient 10 UN 420.56 273.36 UHC - ALL PLANS UHC - ALL PLANS 999999999 254.65 407.94 "INSTILLATION, CIPROFLOXACIN OTIC SUSPENSION, 6 MG" 49181522_1 CDM 0250 RC 69251-0201-01 NDC J7342 HCPCS inpatient 10 UN 420.56 273.36 CIGNA - ALL PLANS CIGNA - ALL PLANS 284.3 67.6 999999999 254.65 407.94 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49181534_1 CDM 0250 RC 55513-0023-04 NDC J0881 HCPCS inpatient 60 UN 1190.57 773.87 AETNA AETNA 940.55 79 999999999 720.89 1154.85 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49181534_1 CDM 0250 RC 55513-0023-04 NDC J0881 HCPCS inpatient 60 UN 1190.57 773.87 SELF PAY DISCOUNT SELF PAY DISCOUNT 773.87 65 999999999 720.89 1154.85 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49181534_1 CDM 0250 RC 55513-0023-04 NDC J0881 HCPCS inpatient 60 UN 1190.57 773.87 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1154.85 97 999999999 720.89 1154.85 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49181534_1 CDM 0250 RC 55513-0023-04 NDC J0881 HCPCS inpatient 60 UN 1190.57 773.87 HUMANA - ALL PLANS HUMANA - ALL PLANS 928.64 78 999999999 720.89 1154.85 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49181534_1 CDM 0250 RC 55513-0023-04 NDC J0881 HCPCS inpatient 60 UN 1190.57 773.87 ENCORE - ALL PLANS ENCORE - ALL PLANS 821.49 69 999999999 720.89 1154.85 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49181534_1 CDM 0250 RC 55513-0023-04 NDC J0881 HCPCS inpatient 60 UN 1190.57 773.87 UMR - ALL PLANS UMR - ALL PLANS 833.4 70 999999999 720.89 1154.85 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49181534_1 CDM 0250 RC 55513-0023-04 NDC J0881 HCPCS inpatient 60 UN 1190.57 773.87 SIHO - ALL PLANS SIHO - ALL PLANS 1071.51 90 999999999 720.89 1154.85 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49181534_1 CDM 0250 RC 55513-0023-04 NDC J0881 HCPCS inpatient 60 UN 1190.57 773.87 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 720.89 60.55 999999999 720.89 1154.85 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49181534_1 CDM 0250 RC 55513-0023-04 NDC J0881 HCPCS inpatient 60 UN 1190.57 773.87 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 720.89 1154.85 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49181534_1 CDM 0250 RC 55513-0023-04 NDC J0881 HCPCS inpatient 60 UN 1190.57 773.87 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 720.89 1154.85 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49181534_1 CDM 0250 RC 55513-0023-04 NDC J0881 HCPCS inpatient 60 UN 1190.57 773.87 ANTHEM HMO ANTHEM HMO 999999999 720.89 1154.85 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49181534_1 CDM 0250 RC 55513-0023-04 NDC J0881 HCPCS inpatient 60 UN 1190.57 773.87 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 720.89 1154.85 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49181534_1 CDM 0250 RC 55513-0023-04 NDC J0881 HCPCS inpatient 60 UN 1190.57 773.87 UHC - ALL PLANS UHC - ALL PLANS 999999999 720.89 1154.85 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49181534_1 CDM 0250 RC 55513-0023-04 NDC J0881 HCPCS inpatient 60 UN 1190.57 773.87 CIGNA - ALL PLANS CIGNA - ALL PLANS 804.83 67.6 999999999 720.89 1154.85 percent of total billed charges AMPICILLIN 2 GM VIAL 49185275_1 CDM 0250 RC 00781-9408-95 NDC inpatient 1 UN 61.5 39.98 AETNA AETNA 48.59 79 999999999 37.24 59.66 percent of total billed charges AMPICILLIN 2 GM VIAL 49185275_1 CDM 0250 RC 00781-9408-95 NDC inpatient 1 UN 61.5 39.98 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.98 65 999999999 37.24 59.66 percent of total billed charges AMPICILLIN 2 GM VIAL 49185275_1 CDM 0250 RC 00781-9408-95 NDC inpatient 1 UN 61.5 39.98 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59.66 97 999999999 37.24 59.66 percent of total billed charges AMPICILLIN 2 GM VIAL 49185275_1 CDM 0250 RC 00781-9408-95 NDC inpatient 1 UN 61.5 39.98 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.97 78 999999999 37.24 59.66 percent of total billed charges AMPICILLIN 2 GM VIAL 49185275_1 CDM 0250 RC 00781-9408-95 NDC inpatient 1 UN 61.5 39.98 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.44 69 999999999 37.24 59.66 percent of total billed charges AMPICILLIN 2 GM VIAL 49185275_1 CDM 0250 RC 00781-9408-95 NDC inpatient 1 UN 61.5 39.98 UMR - ALL PLANS UMR - ALL PLANS 43.05 70 999999999 37.24 59.66 percent of total billed charges AMPICILLIN 2 GM VIAL 49185275_1 CDM 0250 RC 00781-9408-95 NDC inpatient 1 UN 61.5 39.98 SIHO - ALL PLANS SIHO - ALL PLANS 55.35 90 999999999 37.24 59.66 percent of total billed charges AMPICILLIN 2 GM VIAL 49185275_1 CDM 0250 RC 00781-9408-95 NDC inpatient 1 UN 61.5 39.98 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 37.24 60.55 999999999 37.24 59.66 percent of total billed charges AMPICILLIN 2 GM VIAL 49185275_1 CDM 0250 RC 00781-9408-95 NDC inpatient 1 UN 61.5 39.98 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 37.24 59.66 AMPICILLIN 2 GM VIAL 49185275_1 CDM 0250 RC 00781-9408-95 NDC inpatient 1 UN 61.5 39.98 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 37.24 59.66 AMPICILLIN 2 GM VIAL 49185275_1 CDM 0250 RC 00781-9408-95 NDC inpatient 1 UN 61.5 39.98 ANTHEM HMO ANTHEM HMO 999999999 37.24 59.66 AMPICILLIN 2 GM VIAL 49185275_1 CDM 0250 RC 00781-9408-95 NDC inpatient 1 UN 61.5 39.98 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 37.24 59.66 AMPICILLIN 2 GM VIAL 49185275_1 CDM 0250 RC 00781-9408-95 NDC inpatient 1 UN 61.5 39.98 UHC - ALL PLANS UHC - ALL PLANS 999999999 37.24 59.66 AMPICILLIN 2 GM VIAL 49185275_1 CDM 0250 RC 00781-9408-95 NDC inpatient 1 UN 61.5 39.98 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.57 67.6 999999999 37.24 59.66 percent of total billed charges MYRBETRIQ ER 25 MG TABLET 49185300_1 CDM 0250 RC 00469-2601-30 NDC inpatient 1 UN 60.61 39.4 AETNA AETNA 47.88 79 999999999 36.7 58.79 percent of total billed charges MYRBETRIQ ER 25 MG TABLET 49185300_1 CDM 0250 RC 00469-2601-30 NDC inpatient 1 UN 60.61 39.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.4 65 999999999 36.7 58.79 percent of total billed charges MYRBETRIQ ER 25 MG TABLET 49185300_1 CDM 0250 RC 00469-2601-30 NDC inpatient 1 UN 60.61 39.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.79 97 999999999 36.7 58.79 percent of total billed charges MYRBETRIQ ER 25 MG TABLET 49185300_1 CDM 0250 RC 00469-2601-30 NDC inpatient 1 UN 60.61 39.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.28 78 999999999 36.7 58.79 percent of total billed charges MYRBETRIQ ER 25 MG TABLET 49185300_1 CDM 0250 RC 00469-2601-30 NDC inpatient 1 UN 60.61 39.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.82 69 999999999 36.7 58.79 percent of total billed charges MYRBETRIQ ER 25 MG TABLET 49185300_1 CDM 0250 RC 00469-2601-30 NDC inpatient 1 UN 60.61 39.4 UMR - ALL PLANS UMR - ALL PLANS 42.43 70 999999999 36.7 58.79 percent of total billed charges MYRBETRIQ ER 25 MG TABLET 49185300_1 CDM 0250 RC 00469-2601-30 NDC inpatient 1 UN 60.61 39.4 SIHO - ALL PLANS SIHO - ALL PLANS 54.55 90 999999999 36.7 58.79 percent of total billed charges MYRBETRIQ ER 25 MG TABLET 49185300_1 CDM 0250 RC 00469-2601-30 NDC inpatient 1 UN 60.61 39.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.7 60.55 999999999 36.7 58.79 percent of total billed charges MYRBETRIQ ER 25 MG TABLET 49185300_1 CDM 0250 RC 00469-2601-30 NDC inpatient 1 UN 60.61 39.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.7 58.79 MYRBETRIQ ER 25 MG TABLET 49185300_1 CDM 0250 RC 00469-2601-30 NDC inpatient 1 UN 60.61 39.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.7 58.79 MYRBETRIQ ER 25 MG TABLET 49185300_1 CDM 0250 RC 00469-2601-30 NDC inpatient 1 UN 60.61 39.4 ANTHEM HMO ANTHEM HMO 999999999 36.7 58.79 MYRBETRIQ ER 25 MG TABLET 49185300_1 CDM 0250 RC 00469-2601-30 NDC inpatient 1 UN 60.61 39.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.7 58.79 MYRBETRIQ ER 25 MG TABLET 49185300_1 CDM 0250 RC 00469-2601-30 NDC inpatient 1 UN 60.61 39.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.7 58.79 MYRBETRIQ ER 25 MG TABLET 49185300_1 CDM 0250 RC 00469-2601-30 NDC inpatient 1 UN 60.61 39.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.97 67.6 999999999 36.7 58.79 percent of total billed charges APLISOL 5T UNIT/0.1 ML VIAL 49190944_1 CDM 0250 RC 42023-0104-01 NDC inpatient 1 UN 56.63 36.81 AETNA AETNA 44.74 79 999999999 34.29 54.93 percent of total billed charges APLISOL 5T UNIT/0.1 ML VIAL 49190944_1 CDM 0250 RC 42023-0104-01 NDC inpatient 1 UN 56.63 36.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 36.81 65 999999999 34.29 54.93 percent of total billed charges APLISOL 5T UNIT/0.1 ML VIAL 49190944_1 CDM 0250 RC 42023-0104-01 NDC inpatient 1 UN 56.63 36.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 54.93 97 999999999 34.29 54.93 percent of total billed charges APLISOL 5T UNIT/0.1 ML VIAL 49190944_1 CDM 0250 RC 42023-0104-01 NDC inpatient 1 UN 56.63 36.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.17 78 999999999 34.29 54.93 percent of total billed charges APLISOL 5T UNIT/0.1 ML VIAL 49190944_1 CDM 0250 RC 42023-0104-01 NDC inpatient 1 UN 56.63 36.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.07 69 999999999 34.29 54.93 percent of total billed charges APLISOL 5T UNIT/0.1 ML VIAL 49190944_1 CDM 0250 RC 42023-0104-01 NDC inpatient 1 UN 56.63 36.81 UMR - ALL PLANS UMR - ALL PLANS 39.64 70 999999999 34.29 54.93 percent of total billed charges APLISOL 5T UNIT/0.1 ML VIAL 49190944_1 CDM 0250 RC 42023-0104-01 NDC inpatient 1 UN 56.63 36.81 SIHO - ALL PLANS SIHO - ALL PLANS 50.97 90 999999999 34.29 54.93 percent of total billed charges APLISOL 5T UNIT/0.1 ML VIAL 49190944_1 CDM 0250 RC 42023-0104-01 NDC inpatient 1 UN 56.63 36.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.29 60.55 999999999 34.29 54.93 percent of total billed charges APLISOL 5T UNIT/0.1 ML VIAL 49190944_1 CDM 0250 RC 42023-0104-01 NDC inpatient 1 UN 56.63 36.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.29 54.93 APLISOL 5T UNIT/0.1 ML VIAL 49190944_1 CDM 0250 RC 42023-0104-01 NDC inpatient 1 UN 56.63 36.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.29 54.93 APLISOL 5T UNIT/0.1 ML VIAL 49190944_1 CDM 0250 RC 42023-0104-01 NDC inpatient 1 UN 56.63 36.81 ANTHEM HMO ANTHEM HMO 999999999 34.29 54.93 APLISOL 5T UNIT/0.1 ML VIAL 49190944_1 CDM 0250 RC 42023-0104-01 NDC inpatient 1 UN 56.63 36.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.29 54.93 APLISOL 5T UNIT/0.1 ML VIAL 49190944_1 CDM 0250 RC 42023-0104-01 NDC inpatient 1 UN 56.63 36.81 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.29 54.93 APLISOL 5T UNIT/0.1 ML VIAL 49190944_1 CDM 0250 RC 42023-0104-01 NDC inpatient 1 UN 56.63 36.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.28 67.6 999999999 34.29 54.93 percent of total billed charges "INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML" 49190945_1 CDM 0636 RC 11994-0011-16 NDC Q9957 HCPCS inpatient 2 UN 556.14 361.49 AETNA AETNA 439.35 79 999999999 336.74 539.46 percent of total billed charges "INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML" 49190945_1 CDM 0636 RC 11994-0011-16 NDC Q9957 HCPCS inpatient 2 UN 556.14 361.49 SELF PAY DISCOUNT SELF PAY DISCOUNT 361.49 65 999999999 336.74 539.46 percent of total billed charges "INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML" 49190945_1 CDM 0636 RC 11994-0011-16 NDC Q9957 HCPCS inpatient 2 UN 556.14 361.49 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 539.46 97 999999999 336.74 539.46 percent of total billed charges "INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML" 49190945_1 CDM 0636 RC 11994-0011-16 NDC Q9957 HCPCS inpatient 2 UN 556.14 361.49 HUMANA - ALL PLANS HUMANA - ALL PLANS 433.79 78 999999999 336.74 539.46 percent of total billed charges "INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML" 49190945_1 CDM 0636 RC 11994-0011-16 NDC Q9957 HCPCS inpatient 2 UN 556.14 361.49 ENCORE - ALL PLANS ENCORE - ALL PLANS 383.74 69 999999999 336.74 539.46 percent of total billed charges "INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML" 49190945_1 CDM 0636 RC 11994-0011-16 NDC Q9957 HCPCS inpatient 2 UN 556.14 361.49 UMR - ALL PLANS UMR - ALL PLANS 389.3 70 999999999 336.74 539.46 percent of total billed charges "INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML" 49190945_1 CDM 0636 RC 11994-0011-16 NDC Q9957 HCPCS inpatient 2 UN 556.14 361.49 SIHO - ALL PLANS SIHO - ALL PLANS 500.53 90 999999999 336.74 539.46 percent of total billed charges "INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML" 49190945_1 CDM 0636 RC 11994-0011-16 NDC Q9957 HCPCS inpatient 2 UN 556.14 361.49 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 336.74 60.55 999999999 336.74 539.46 percent of total billed charges "INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML" 49190945_1 CDM 0636 RC 11994-0011-16 NDC Q9957 HCPCS inpatient 2 UN 556.14 361.49 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 336.74 539.46 "INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML" 49190945_1 CDM 0636 RC 11994-0011-16 NDC Q9957 HCPCS inpatient 2 UN 556.14 361.49 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 336.74 539.46 "INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML" 49190945_1 CDM 0636 RC 11994-0011-16 NDC Q9957 HCPCS inpatient 2 UN 556.14 361.49 ANTHEM HMO ANTHEM HMO 999999999 336.74 539.46 "INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML" 49190945_1 CDM 0636 RC 11994-0011-16 NDC Q9957 HCPCS inpatient 2 UN 556.14 361.49 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 336.74 539.46 "INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML" 49190945_1 CDM 0636 RC 11994-0011-16 NDC Q9957 HCPCS inpatient 2 UN 556.14 361.49 UHC - ALL PLANS UHC - ALL PLANS 999999999 336.74 539.46 "INJECTION, PERFLUTREN LIPID MICROSPHERES, PER ML" 49190945_1 CDM 0636 RC 11994-0011-16 NDC Q9957 HCPCS inpatient 2 UN 556.14 361.49 CIGNA - ALL PLANS CIGNA - ALL PLANS 375.95 67.6 999999999 336.74 539.46 percent of total billed charges "INJECTION, FERRIC CARBOXYMALTOSE, 1 MG" 49190946_1 CDM 0250 RC 00517-0650-01 NDC J1439 HCPCS inpatient 750 UN 4123.26 2680.12 AETNA AETNA 3257.38 79 999999999 2496.63 3999.56 percent of total billed charges "INJECTION, FERRIC CARBOXYMALTOSE, 1 MG" 49190946_1 CDM 0250 RC 00517-0650-01 NDC J1439 HCPCS inpatient 750 UN 4123.26 2680.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 2680.12 65 999999999 2496.63 3999.56 percent of total billed charges "INJECTION, FERRIC CARBOXYMALTOSE, 1 MG" 49190946_1 CDM 0250 RC 00517-0650-01 NDC J1439 HCPCS inpatient 750 UN 4123.26 2680.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3999.56 97 999999999 2496.63 3999.56 percent of total billed charges "INJECTION, FERRIC CARBOXYMALTOSE, 1 MG" 49190946_1 CDM 0250 RC 00517-0650-01 NDC J1439 HCPCS inpatient 750 UN 4123.26 2680.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 3216.14 78 999999999 2496.63 3999.56 percent of total billed charges "INJECTION, FERRIC CARBOXYMALTOSE, 1 MG" 49190946_1 CDM 0250 RC 00517-0650-01 NDC J1439 HCPCS inpatient 750 UN 4123.26 2680.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 2845.05 69 999999999 2496.63 3999.56 percent of total billed charges "INJECTION, FERRIC CARBOXYMALTOSE, 1 MG" 49190946_1 CDM 0250 RC 00517-0650-01 NDC J1439 HCPCS inpatient 750 UN 4123.26 2680.12 UMR - ALL PLANS UMR - ALL PLANS 2886.28 70 999999999 2496.63 3999.56 percent of total billed charges "INJECTION, FERRIC CARBOXYMALTOSE, 1 MG" 49190946_1 CDM 0250 RC 00517-0650-01 NDC J1439 HCPCS inpatient 750 UN 4123.26 2680.12 SIHO - ALL PLANS SIHO - ALL PLANS 3710.93 90 999999999 2496.63 3999.56 percent of total billed charges "INJECTION, FERRIC CARBOXYMALTOSE, 1 MG" 49190946_1 CDM 0250 RC 00517-0650-01 NDC J1439 HCPCS inpatient 750 UN 4123.26 2680.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2496.63 60.55 999999999 2496.63 3999.56 percent of total billed charges "INJECTION, FERRIC CARBOXYMALTOSE, 1 MG" 49190946_1 CDM 0250 RC 00517-0650-01 NDC J1439 HCPCS inpatient 750 UN 4123.26 2680.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2496.63 3999.56 "INJECTION, FERRIC CARBOXYMALTOSE, 1 MG" 49190946_1 CDM 0250 RC 00517-0650-01 NDC J1439 HCPCS inpatient 750 UN 4123.26 2680.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2496.63 3999.56 "INJECTION, FERRIC CARBOXYMALTOSE, 1 MG" 49190946_1 CDM 0250 RC 00517-0650-01 NDC J1439 HCPCS inpatient 750 UN 4123.26 2680.12 ANTHEM HMO ANTHEM HMO 999999999 2496.63 3999.56 "INJECTION, FERRIC CARBOXYMALTOSE, 1 MG" 49190946_1 CDM 0250 RC 00517-0650-01 NDC J1439 HCPCS inpatient 750 UN 4123.26 2680.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2496.63 3999.56 "INJECTION, FERRIC CARBOXYMALTOSE, 1 MG" 49190946_1 CDM 0250 RC 00517-0650-01 NDC J1439 HCPCS inpatient 750 UN 4123.26 2680.12 UHC - ALL PLANS UHC - ALL PLANS 999999999 2496.63 3999.56 "INJECTION, FERRIC CARBOXYMALTOSE, 1 MG" 49190946_1 CDM 0250 RC 00517-0650-01 NDC J1439 HCPCS inpatient 750 UN 4123.26 2680.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 2787.32 67.6 999999999 2496.63 3999.56 percent of total billed charges 61553-0166-44 - HYDROmorphone 1 mg/mL-NaCl 0.9% SolPCA[JOHN] 49190947_1 CDM 0250 RC 61553-0166-44 NDC inpatient 1 UN 104.37 67.84 AETNA AETNA 82.45 79 999999999 63.2 101.24 percent of total billed charges 61553-0166-44 - HYDROmorphone 1 mg/mL-NaCl 0.9% SolPCA[JOHN] 49190947_1 CDM 0250 RC 61553-0166-44 NDC inpatient 1 UN 104.37 67.84 SELF PAY DISCOUNT SELF PAY DISCOUNT 67.84 65 999999999 63.2 101.24 percent of total billed charges 61553-0166-44 - HYDROmorphone 1 mg/mL-NaCl 0.9% SolPCA[JOHN] 49190947_1 CDM 0250 RC 61553-0166-44 NDC inpatient 1 UN 104.37 67.84 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.24 97 999999999 63.2 101.24 percent of total billed charges 61553-0166-44 - HYDROmorphone 1 mg/mL-NaCl 0.9% SolPCA[JOHN] 49190947_1 CDM 0250 RC 61553-0166-44 NDC inpatient 1 UN 104.37 67.84 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.41 78 999999999 63.2 101.24 percent of total billed charges 61553-0166-44 - HYDROmorphone 1 mg/mL-NaCl 0.9% SolPCA[JOHN] 49190947_1 CDM 0250 RC 61553-0166-44 NDC inpatient 1 UN 104.37 67.84 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.02 69 999999999 63.2 101.24 percent of total billed charges 61553-0166-44 - HYDROmorphone 1 mg/mL-NaCl 0.9% SolPCA[JOHN] 49190947_1 CDM 0250 RC 61553-0166-44 NDC inpatient 1 UN 104.37 67.84 UMR - ALL PLANS UMR - ALL PLANS 73.06 70 999999999 63.2 101.24 percent of total billed charges 61553-0166-44 - HYDROmorphone 1 mg/mL-NaCl 0.9% SolPCA[JOHN] 49190947_1 CDM 0250 RC 61553-0166-44 NDC inpatient 1 UN 104.37 67.84 SIHO - ALL PLANS SIHO - ALL PLANS 93.93 90 999999999 63.2 101.24 percent of total billed charges 61553-0166-44 - HYDROmorphone 1 mg/mL-NaCl 0.9% SolPCA[JOHN] 49190947_1 CDM 0250 RC 61553-0166-44 NDC inpatient 1 UN 104.37 67.84 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.2 60.55 999999999 63.2 101.24 percent of total billed charges 61553-0166-44 - HYDROmorphone 1 mg/mL-NaCl 0.9% SolPCA[JOHN] 49190947_1 CDM 0250 RC 61553-0166-44 NDC inpatient 1 UN 104.37 67.84 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.2 101.24 61553-0166-44 - HYDROmorphone 1 mg/mL-NaCl 0.9% SolPCA[JOHN] 49190947_1 CDM 0250 RC 61553-0166-44 NDC inpatient 1 UN 104.37 67.84 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.2 101.24 61553-0166-44 - HYDROmorphone 1 mg/mL-NaCl 0.9% SolPCA[JOHN] 49190947_1 CDM 0250 RC 61553-0166-44 NDC inpatient 1 UN 104.37 67.84 ANTHEM HMO ANTHEM HMO 999999999 63.2 101.24 61553-0166-44 - HYDROmorphone 1 mg/mL-NaCl 0.9% SolPCA[JOHN] 49190947_1 CDM 0250 RC 61553-0166-44 NDC inpatient 1 UN 104.37 67.84 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.2 101.24 61553-0166-44 - HYDROmorphone 1 mg/mL-NaCl 0.9% SolPCA[JOHN] 49190947_1 CDM 0250 RC 61553-0166-44 NDC inpatient 1 UN 104.37 67.84 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.2 101.24 61553-0166-44 - HYDROmorphone 1 mg/mL-NaCl 0.9% SolPCA[JOHN] 49190947_1 CDM 0250 RC 61553-0166-44 NDC inpatient 1 UN 104.37 67.84 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.55 67.6 999999999 63.2 101.24 percent of total billed charges ALLOPURINOL 300 MG TABLET 49190992_1 CDM 0250 RC 00591-5544-01 NDC inpatient 1 UN 2.14 1.39 AETNA AETNA 1.69 79 999999999 1.3 2.08 percent of total billed charges ALLOPURINOL 300 MG TABLET 49190992_1 CDM 0250 RC 00591-5544-01 NDC inpatient 1 UN 2.14 1.39 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.39 65 999999999 1.3 2.08 percent of total billed charges ALLOPURINOL 300 MG TABLET 49190992_1 CDM 0250 RC 00591-5544-01 NDC inpatient 1 UN 2.14 1.39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.08 97 999999999 1.3 2.08 percent of total billed charges ALLOPURINOL 300 MG TABLET 49190992_1 CDM 0250 RC 00591-5544-01 NDC inpatient 1 UN 2.14 1.39 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.67 78 999999999 1.3 2.08 percent of total billed charges ALLOPURINOL 300 MG TABLET 49190992_1 CDM 0250 RC 00591-5544-01 NDC inpatient 1 UN 2.14 1.39 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.48 69 999999999 1.3 2.08 percent of total billed charges ALLOPURINOL 300 MG TABLET 49190992_1 CDM 0250 RC 00591-5544-01 NDC inpatient 1 UN 2.14 1.39 UMR - ALL PLANS UMR - ALL PLANS 1.5 70 999999999 1.3 2.08 percent of total billed charges ALLOPURINOL 300 MG TABLET 49190992_1 CDM 0250 RC 00591-5544-01 NDC inpatient 1 UN 2.14 1.39 SIHO - ALL PLANS SIHO - ALL PLANS 1.93 90 999999999 1.3 2.08 percent of total billed charges ALLOPURINOL 300 MG TABLET 49190992_1 CDM 0250 RC 00591-5544-01 NDC inpatient 1 UN 2.14 1.39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.3 60.55 999999999 1.3 2.08 percent of total billed charges ALLOPURINOL 300 MG TABLET 49190992_1 CDM 0250 RC 00591-5544-01 NDC inpatient 1 UN 2.14 1.39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.3 2.08 ALLOPURINOL 300 MG TABLET 49190992_1 CDM 0250 RC 00591-5544-01 NDC inpatient 1 UN 2.14 1.39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.3 2.08 ALLOPURINOL 300 MG TABLET 49190992_1 CDM 0250 RC 00591-5544-01 NDC inpatient 1 UN 2.14 1.39 ANTHEM HMO ANTHEM HMO 999999999 1.3 2.08 ALLOPURINOL 300 MG TABLET 49190992_1 CDM 0250 RC 00591-5544-01 NDC inpatient 1 UN 2.14 1.39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.3 2.08 ALLOPURINOL 300 MG TABLET 49190992_1 CDM 0250 RC 00591-5544-01 NDC inpatient 1 UN 2.14 1.39 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.3 2.08 ALLOPURINOL 300 MG TABLET 49190992_1 CDM 0250 RC 00591-5544-01 NDC inpatient 1 UN 2.14 1.39 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.45 67.6 999999999 1.3 2.08 percent of total billed charges CLOPIDOGREL 300 MG TABLET 49190994_1 CDM 0250 RC 68084-0752-25 NDC inpatient 1 UN 38 24.7 AETNA AETNA 30.02 79 999999999 23.01 36.86 percent of total billed charges CLOPIDOGREL 300 MG TABLET 49190994_1 CDM 0250 RC 68084-0752-25 NDC inpatient 1 UN 38 24.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.7 65 999999999 23.01 36.86 percent of total billed charges CLOPIDOGREL 300 MG TABLET 49190994_1 CDM 0250 RC 68084-0752-25 NDC inpatient 1 UN 38 24.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 36.86 97 999999999 23.01 36.86 percent of total billed charges CLOPIDOGREL 300 MG TABLET 49190994_1 CDM 0250 RC 68084-0752-25 NDC inpatient 1 UN 38 24.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 29.64 78 999999999 23.01 36.86 percent of total billed charges CLOPIDOGREL 300 MG TABLET 49190994_1 CDM 0250 RC 68084-0752-25 NDC inpatient 1 UN 38 24.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.22 69 999999999 23.01 36.86 percent of total billed charges CLOPIDOGREL 300 MG TABLET 49190994_1 CDM 0250 RC 68084-0752-25 NDC inpatient 1 UN 38 24.7 UMR - ALL PLANS UMR - ALL PLANS 26.6 70 999999999 23.01 36.86 percent of total billed charges CLOPIDOGREL 300 MG TABLET 49190994_1 CDM 0250 RC 68084-0752-25 NDC inpatient 1 UN 38 24.7 SIHO - ALL PLANS SIHO - ALL PLANS 34.2 90 999999999 23.01 36.86 percent of total billed charges CLOPIDOGREL 300 MG TABLET 49190994_1 CDM 0250 RC 68084-0752-25 NDC inpatient 1 UN 38 24.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.01 60.55 999999999 23.01 36.86 percent of total billed charges CLOPIDOGREL 300 MG TABLET 49190994_1 CDM 0250 RC 68084-0752-25 NDC inpatient 1 UN 38 24.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.01 36.86 CLOPIDOGREL 300 MG TABLET 49190994_1 CDM 0250 RC 68084-0752-25 NDC inpatient 1 UN 38 24.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.01 36.86 CLOPIDOGREL 300 MG TABLET 49190994_1 CDM 0250 RC 68084-0752-25 NDC inpatient 1 UN 38 24.7 ANTHEM HMO ANTHEM HMO 999999999 23.01 36.86 CLOPIDOGREL 300 MG TABLET 49190994_1 CDM 0250 RC 68084-0752-25 NDC inpatient 1 UN 38 24.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.01 36.86 CLOPIDOGREL 300 MG TABLET 49190994_1 CDM 0250 RC 68084-0752-25 NDC inpatient 1 UN 38 24.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.01 36.86 CLOPIDOGREL 300 MG TABLET 49190994_1 CDM 0250 RC 68084-0752-25 NDC inpatient 1 UN 38 24.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.69 67.6 999999999 23.01 36.86 percent of total billed charges ESTRADIOL 1 MG TABLET 49190998_1 CDM 0250 RC 51862-0333-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ESTRADIOL 1 MG TABLET 49190998_1 CDM 0250 RC 51862-0333-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ESTRADIOL 1 MG TABLET 49190998_1 CDM 0250 RC 51862-0333-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ESTRADIOL 1 MG TABLET 49190998_1 CDM 0250 RC 51862-0333-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ESTRADIOL 1 MG TABLET 49190998_1 CDM 0250 RC 51862-0333-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ESTRADIOL 1 MG TABLET 49190998_1 CDM 0250 RC 51862-0333-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ESTRADIOL 1 MG TABLET 49190998_1 CDM 0250 RC 51862-0333-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ESTRADIOL 1 MG TABLET 49190998_1 CDM 0250 RC 51862-0333-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ESTRADIOL 1 MG TABLET 49190998_1 CDM 0250 RC 51862-0333-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ESTRADIOL 1 MG TABLET 49190998_1 CDM 0250 RC 51862-0333-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ESTRADIOL 1 MG TABLET 49190998_1 CDM 0250 RC 51862-0333-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ESTRADIOL 1 MG TABLET 49190998_1 CDM 0250 RC 51862-0333-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ESTRADIOL 1 MG TABLET 49190998_1 CDM 0250 RC 51862-0333-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ESTRADIOL 1 MG TABLET 49190998_1 CDM 0250 RC 51862-0333-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges Closed treatment of broken shin bone at lower weight bearing joint with manipulation and/or traction 49192370_1 CDM 0450 RC 27825 HCPCS inpatient 472 306.8 AETNA AETNA 372.88 79 999999999 285.8 457.84 percent of total billed charges Closed treatment of broken shin bone at lower weight bearing joint with manipulation and/or traction 49192370_1 CDM 0450 RC 27825 HCPCS inpatient 472 306.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 306.8 65 999999999 285.8 457.84 percent of total billed charges Closed treatment of broken shin bone at lower weight bearing joint with manipulation and/or traction 49192370_1 CDM 0450 RC 27825 HCPCS inpatient 472 306.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 457.84 97 999999999 285.8 457.84 percent of total billed charges Closed treatment of broken shin bone at lower weight bearing joint with manipulation and/or traction 49192370_1 CDM 0450 RC 27825 HCPCS inpatient 472 306.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 368.16 78 999999999 285.8 457.84 percent of total billed charges Closed treatment of broken shin bone at lower weight bearing joint with manipulation and/or traction 49192370_1 CDM 0450 RC 27825 HCPCS inpatient 472 306.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 325.68 69 999999999 285.8 457.84 percent of total billed charges Closed treatment of broken shin bone at lower weight bearing joint with manipulation and/or traction 49192370_1 CDM 0450 RC 27825 HCPCS inpatient 472 306.8 UMR - ALL PLANS UMR - ALL PLANS 330.4 70 999999999 285.8 457.84 percent of total billed charges Closed treatment of broken shin bone at lower weight bearing joint with manipulation and/or traction 49192370_1 CDM 0450 RC 27825 HCPCS inpatient 472 306.8 SIHO - ALL PLANS SIHO - ALL PLANS 424.8 90 999999999 285.8 457.84 percent of total billed charges Closed treatment of broken shin bone at lower weight bearing joint with manipulation and/or traction 49192370_1 CDM 0450 RC 27825 HCPCS inpatient 472 306.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 285.8 60.55 999999999 285.8 457.84 percent of total billed charges Closed treatment of broken shin bone at lower weight bearing joint with manipulation and/or traction 49192370_1 CDM 0450 RC 27825 HCPCS inpatient 472 306.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 285.8 457.84 Closed treatment of broken shin bone at lower weight bearing joint with manipulation and/or traction 49192370_1 CDM 0450 RC 27825 HCPCS inpatient 472 306.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 285.8 457.84 Closed treatment of broken shin bone at lower weight bearing joint with manipulation and/or traction 49192370_1 CDM 0450 RC 27825 HCPCS inpatient 472 306.8 ANTHEM HMO ANTHEM HMO 999999999 285.8 457.84 Closed treatment of broken shin bone at lower weight bearing joint with manipulation and/or traction 49192370_1 CDM 0450 RC 27825 HCPCS inpatient 472 306.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 285.8 457.84 Closed treatment of broken shin bone at lower weight bearing joint with manipulation and/or traction 49192370_1 CDM 0450 RC 27825 HCPCS inpatient 472 306.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 285.8 457.84 Closed treatment of broken shin bone at lower weight bearing joint with manipulation and/or traction 49192370_1 CDM 0450 RC 27825 HCPCS inpatient 472 306.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 319.07 67.6 999999999 285.8 457.84 percent of total billed charges ADHESIVE SP02 SENSOR INFANT MAXI 49192699_1 CDM 0272 RC inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges ADHESIVE SP02 SENSOR INFANT MAXI 49192699_1 CDM 0272 RC inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges ADHESIVE SP02 SENSOR INFANT MAXI 49192699_1 CDM 0272 RC inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges ADHESIVE SP02 SENSOR INFANT MAXI 49192699_1 CDM 0272 RC inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges ADHESIVE SP02 SENSOR INFANT MAXI 49192699_1 CDM 0272 RC inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges ADHESIVE SP02 SENSOR INFANT MAXI 49192699_1 CDM 0272 RC inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges ADHESIVE SP02 SENSOR INFANT MAXI 49192699_1 CDM 0272 RC inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges ADHESIVE SP02 SENSOR INFANT MAXI 49192699_1 CDM 0272 RC inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges ADHESIVE SP02 SENSOR INFANT MAXI 49192699_1 CDM 0272 RC inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 ADHESIVE SP02 SENSOR INFANT MAXI 49192699_1 CDM 0272 RC inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 ADHESIVE SP02 SENSOR INFANT MAXI 49192699_1 CDM 0272 RC inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 ADHESIVE SP02 SENSOR INFANT MAXI 49192699_1 CDM 0272 RC inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 ADHESIVE SP02 SENSOR INFANT MAXI 49192699_1 CDM 0272 RC inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 ADHESIVE SP02 SENSOR INFANT MAXI 49192699_1 CDM 0272 RC inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges TRACH TUBE XLT CUFFED 60XLTCD 49192703_1 CDM 0272 RC inpatient 443 287.95 AETNA AETNA 349.97 79 999999999 268.24 429.71 percent of total billed charges TRACH TUBE XLT CUFFED 60XLTCD 49192703_1 CDM 0272 RC inpatient 443 287.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 287.95 65 999999999 268.24 429.71 percent of total billed charges TRACH TUBE XLT CUFFED 60XLTCD 49192703_1 CDM 0272 RC inpatient 443 287.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 429.71 97 999999999 268.24 429.71 percent of total billed charges TRACH TUBE XLT CUFFED 60XLTCD 49192703_1 CDM 0272 RC inpatient 443 287.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 345.54 78 999999999 268.24 429.71 percent of total billed charges TRACH TUBE XLT CUFFED 60XLTCD 49192703_1 CDM 0272 RC inpatient 443 287.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 305.67 69 999999999 268.24 429.71 percent of total billed charges TRACH TUBE XLT CUFFED 60XLTCD 49192703_1 CDM 0272 RC inpatient 443 287.95 UMR - ALL PLANS UMR - ALL PLANS 310.1 70 999999999 268.24 429.71 percent of total billed charges TRACH TUBE XLT CUFFED 60XLTCD 49192703_1 CDM 0272 RC inpatient 443 287.95 SIHO - ALL PLANS SIHO - ALL PLANS 398.7 90 999999999 268.24 429.71 percent of total billed charges TRACH TUBE XLT CUFFED 60XLTCD 49192703_1 CDM 0272 RC inpatient 443 287.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 268.24 60.55 999999999 268.24 429.71 percent of total billed charges TRACH TUBE XLT CUFFED 60XLTCD 49192703_1 CDM 0272 RC inpatient 443 287.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 268.24 429.71 TRACH TUBE XLT CUFFED 60XLTCD 49192703_1 CDM 0272 RC inpatient 443 287.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 268.24 429.71 TRACH TUBE XLT CUFFED 60XLTCD 49192703_1 CDM 0272 RC inpatient 443 287.95 ANTHEM HMO ANTHEM HMO 999999999 268.24 429.71 TRACH TUBE XLT CUFFED 60XLTCD 49192703_1 CDM 0272 RC inpatient 443 287.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 268.24 429.71 TRACH TUBE XLT CUFFED 60XLTCD 49192703_1 CDM 0272 RC inpatient 443 287.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 268.24 429.71 TRACH TUBE XLT CUFFED 60XLTCD 49192703_1 CDM 0272 RC inpatient 443 287.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 299.47 67.6 999999999 268.24 429.71 percent of total billed charges PLATE 3.5MM LCP 7 HOLE 49192706_1 CDM 0278 RC inpatient 2093 1360.45 AETNA AETNA 1653.47 79 999999999 1267.31 2030.21 percent of total billed charges PLATE 3.5MM LCP 7 HOLE 49192706_1 CDM 0278 RC inpatient 2093 1360.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1360.45 65 999999999 1267.31 2030.21 percent of total billed charges PLATE 3.5MM LCP 7 HOLE 49192706_1 CDM 0278 RC inpatient 2093 1360.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2030.21 97 999999999 1267.31 2030.21 percent of total billed charges PLATE 3.5MM LCP 7 HOLE 49192706_1 CDM 0278 RC inpatient 2093 1360.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1632.54 78 999999999 1267.31 2030.21 percent of total billed charges PLATE 3.5MM LCP 7 HOLE 49192706_1 CDM 0278 RC inpatient 2093 1360.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1444.17 69 999999999 1267.31 2030.21 percent of total billed charges PLATE 3.5MM LCP 7 HOLE 49192706_1 CDM 0278 RC inpatient 2093 1360.45 UMR - ALL PLANS UMR - ALL PLANS 1465.1 70 999999999 1267.31 2030.21 percent of total billed charges PLATE 3.5MM LCP 7 HOLE 49192706_1 CDM 0278 RC inpatient 2093 1360.45 SIHO - ALL PLANS SIHO - ALL PLANS 1883.7 90 999999999 1267.31 2030.21 percent of total billed charges PLATE 3.5MM LCP 7 HOLE 49192706_1 CDM 0278 RC inpatient 2093 1360.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1267.31 60.55 999999999 1267.31 2030.21 percent of total billed charges PLATE 3.5MM LCP 7 HOLE 49192706_1 CDM 0278 RC inpatient 2093 1360.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1267.31 2030.21 PLATE 3.5MM LCP 7 HOLE 49192706_1 CDM 0278 RC inpatient 2093 1360.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1267.31 2030.21 PLATE 3.5MM LCP 7 HOLE 49192706_1 CDM 0278 RC inpatient 2093 1360.45 ANTHEM HMO ANTHEM HMO 999999999 1267.31 2030.21 PLATE 3.5MM LCP 7 HOLE 49192706_1 CDM 0278 RC inpatient 2093 1360.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1267.31 2030.21 PLATE 3.5MM LCP 7 HOLE 49192706_1 CDM 0278 RC inpatient 2093 1360.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1267.31 2030.21 PLATE 3.5MM LCP 7 HOLE 49192706_1 CDM 0278 RC inpatient 2093 1360.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1414.87 67.6 999999999 1267.31 2030.21 percent of total billed charges TRAY EPISIOTOMY MNS10055A 49192714_1 CDM 0272 RC inpatient 277 180.05 AETNA AETNA 218.83 79 999999999 167.72 268.69 percent of total billed charges TRAY EPISIOTOMY MNS10055A 49192714_1 CDM 0272 RC inpatient 277 180.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 180.05 65 999999999 167.72 268.69 percent of total billed charges TRAY EPISIOTOMY MNS10055A 49192714_1 CDM 0272 RC inpatient 277 180.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 268.69 97 999999999 167.72 268.69 percent of total billed charges TRAY EPISIOTOMY MNS10055A 49192714_1 CDM 0272 RC inpatient 277 180.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 216.06 78 999999999 167.72 268.69 percent of total billed charges TRAY EPISIOTOMY MNS10055A 49192714_1 CDM 0272 RC inpatient 277 180.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 191.13 69 999999999 167.72 268.69 percent of total billed charges TRAY EPISIOTOMY MNS10055A 49192714_1 CDM 0272 RC inpatient 277 180.05 UMR - ALL PLANS UMR - ALL PLANS 193.9 70 999999999 167.72 268.69 percent of total billed charges TRAY EPISIOTOMY MNS10055A 49192714_1 CDM 0272 RC inpatient 277 180.05 SIHO - ALL PLANS SIHO - ALL PLANS 249.3 90 999999999 167.72 268.69 percent of total billed charges TRAY EPISIOTOMY MNS10055A 49192714_1 CDM 0272 RC inpatient 277 180.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 167.72 60.55 999999999 167.72 268.69 percent of total billed charges TRAY EPISIOTOMY MNS10055A 49192714_1 CDM 0272 RC inpatient 277 180.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 167.72 268.69 TRAY EPISIOTOMY MNS10055A 49192714_1 CDM 0272 RC inpatient 277 180.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 167.72 268.69 TRAY EPISIOTOMY MNS10055A 49192714_1 CDM 0272 RC inpatient 277 180.05 ANTHEM HMO ANTHEM HMO 999999999 167.72 268.69 TRAY EPISIOTOMY MNS10055A 49192714_1 CDM 0272 RC inpatient 277 180.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 167.72 268.69 TRAY EPISIOTOMY MNS10055A 49192714_1 CDM 0272 RC inpatient 277 180.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 167.72 268.69 TRAY EPISIOTOMY MNS10055A 49192714_1 CDM 0272 RC inpatient 277 180.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 187.25 67.6 999999999 167.72 268.69 percent of total billed charges BLADE QUADCUT 1884380HR 49192717_1 CDM 0272 RC inpatient 1219 792.35 AETNA AETNA 963.01 79 999999999 738.1 1182.43 percent of total billed charges BLADE QUADCUT 1884380HR 49192717_1 CDM 0272 RC inpatient 1219 792.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 792.35 65 999999999 738.1 1182.43 percent of total billed charges BLADE QUADCUT 1884380HR 49192717_1 CDM 0272 RC inpatient 1219 792.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1182.43 97 999999999 738.1 1182.43 percent of total billed charges BLADE QUADCUT 1884380HR 49192717_1 CDM 0272 RC inpatient 1219 792.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 950.82 78 999999999 738.1 1182.43 percent of total billed charges BLADE QUADCUT 1884380HR 49192717_1 CDM 0272 RC inpatient 1219 792.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 841.11 69 999999999 738.1 1182.43 percent of total billed charges BLADE QUADCUT 1884380HR 49192717_1 CDM 0272 RC inpatient 1219 792.35 UMR - ALL PLANS UMR - ALL PLANS 853.3 70 999999999 738.1 1182.43 percent of total billed charges BLADE QUADCUT 1884380HR 49192717_1 CDM 0272 RC inpatient 1219 792.35 SIHO - ALL PLANS SIHO - ALL PLANS 1097.1 90 999999999 738.1 1182.43 percent of total billed charges BLADE QUADCUT 1884380HR 49192717_1 CDM 0272 RC inpatient 1219 792.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 738.1 60.55 999999999 738.1 1182.43 percent of total billed charges BLADE QUADCUT 1884380HR 49192717_1 CDM 0272 RC inpatient 1219 792.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 738.1 1182.43 BLADE QUADCUT 1884380HR 49192717_1 CDM 0272 RC inpatient 1219 792.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 738.1 1182.43 BLADE QUADCUT 1884380HR 49192717_1 CDM 0272 RC inpatient 1219 792.35 ANTHEM HMO ANTHEM HMO 999999999 738.1 1182.43 BLADE QUADCUT 1884380HR 49192717_1 CDM 0272 RC inpatient 1219 792.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 738.1 1182.43 BLADE QUADCUT 1884380HR 49192717_1 CDM 0272 RC inpatient 1219 792.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 738.1 1182.43 BLADE QUADCUT 1884380HR 49192717_1 CDM 0272 RC inpatient 1219 792.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 824.04 67.6 999999999 738.1 1182.43 percent of total billed charges BLADE RAD60 ROTATE 49192718_1 CDM 0272 RC inpatient 595 386.75 AETNA AETNA 470.05 79 999999999 360.27 577.15 percent of total billed charges BLADE RAD60 ROTATE 49192718_1 CDM 0272 RC inpatient 595 386.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 386.75 65 999999999 360.27 577.15 percent of total billed charges BLADE RAD60 ROTATE 49192718_1 CDM 0272 RC inpatient 595 386.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 577.15 97 999999999 360.27 577.15 percent of total billed charges BLADE RAD60 ROTATE 49192718_1 CDM 0272 RC inpatient 595 386.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 464.1 78 999999999 360.27 577.15 percent of total billed charges BLADE RAD60 ROTATE 49192718_1 CDM 0272 RC inpatient 595 386.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 410.55 69 999999999 360.27 577.15 percent of total billed charges BLADE RAD60 ROTATE 49192718_1 CDM 0272 RC inpatient 595 386.75 UMR - ALL PLANS UMR - ALL PLANS 416.5 70 999999999 360.27 577.15 percent of total billed charges BLADE RAD60 ROTATE 49192718_1 CDM 0272 RC inpatient 595 386.75 SIHO - ALL PLANS SIHO - ALL PLANS 535.5 90 999999999 360.27 577.15 percent of total billed charges BLADE RAD60 ROTATE 49192718_1 CDM 0272 RC inpatient 595 386.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 360.27 60.55 999999999 360.27 577.15 percent of total billed charges BLADE RAD60 ROTATE 49192718_1 CDM 0272 RC inpatient 595 386.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 360.27 577.15 BLADE RAD60 ROTATE 49192718_1 CDM 0272 RC inpatient 595 386.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 360.27 577.15 BLADE RAD60 ROTATE 49192718_1 CDM 0272 RC inpatient 595 386.75 ANTHEM HMO ANTHEM HMO 999999999 360.27 577.15 BLADE RAD60 ROTATE 49192718_1 CDM 0272 RC inpatient 595 386.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 360.27 577.15 BLADE RAD60 ROTATE 49192718_1 CDM 0272 RC inpatient 595 386.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 360.27 577.15 BLADE RAD60 ROTATE 49192718_1 CDM 0272 RC inpatient 595 386.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 402.22 67.6 999999999 360.27 577.15 percent of total billed charges BLADE TURB ROTATE 1882040HR 49192719_1 CDM 0272 RC inpatient 1411 917.15 AETNA AETNA 1114.69 79 999999999 854.36 1368.67 percent of total billed charges BLADE TURB ROTATE 1882040HR 49192719_1 CDM 0272 RC inpatient 1411 917.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 917.15 65 999999999 854.36 1368.67 percent of total billed charges BLADE TURB ROTATE 1882040HR 49192719_1 CDM 0272 RC inpatient 1411 917.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1368.67 97 999999999 854.36 1368.67 percent of total billed charges BLADE TURB ROTATE 1882040HR 49192719_1 CDM 0272 RC inpatient 1411 917.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1100.58 78 999999999 854.36 1368.67 percent of total billed charges BLADE TURB ROTATE 1882040HR 49192719_1 CDM 0272 RC inpatient 1411 917.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 973.59 69 999999999 854.36 1368.67 percent of total billed charges BLADE TURB ROTATE 1882040HR 49192719_1 CDM 0272 RC inpatient 1411 917.15 UMR - ALL PLANS UMR - ALL PLANS 987.7 70 999999999 854.36 1368.67 percent of total billed charges BLADE TURB ROTATE 1882040HR 49192719_1 CDM 0272 RC inpatient 1411 917.15 SIHO - ALL PLANS SIHO - ALL PLANS 1269.9 90 999999999 854.36 1368.67 percent of total billed charges BLADE TURB ROTATE 1882040HR 49192719_1 CDM 0272 RC inpatient 1411 917.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 854.36 60.55 999999999 854.36 1368.67 percent of total billed charges BLADE TURB ROTATE 1882040HR 49192719_1 CDM 0272 RC inpatient 1411 917.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 854.36 1368.67 BLADE TURB ROTATE 1882040HR 49192719_1 CDM 0272 RC inpatient 1411 917.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 854.36 1368.67 BLADE TURB ROTATE 1882040HR 49192719_1 CDM 0272 RC inpatient 1411 917.15 ANTHEM HMO ANTHEM HMO 999999999 854.36 1368.67 BLADE TURB ROTATE 1882040HR 49192719_1 CDM 0272 RC inpatient 1411 917.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 854.36 1368.67 BLADE TURB ROTATE 1882040HR 49192719_1 CDM 0272 RC inpatient 1411 917.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 854.36 1368.67 BLADE TURB ROTATE 1882040HR 49192719_1 CDM 0272 RC inpatient 1411 917.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 953.84 67.6 999999999 854.36 1368.67 percent of total billed charges IRIS URETERAL INFARED STENT 0220-180-518 49192724_1 CDM 0272 RC inpatient 2810 1826.5 AETNA AETNA 2219.9 79 999999999 1701.46 2725.7 percent of total billed charges IRIS URETERAL INFARED STENT 0220-180-518 49192724_1 CDM 0272 RC inpatient 2810 1826.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1826.5 65 999999999 1701.46 2725.7 percent of total billed charges IRIS URETERAL INFARED STENT 0220-180-518 49192724_1 CDM 0272 RC inpatient 2810 1826.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2725.7 97 999999999 1701.46 2725.7 percent of total billed charges IRIS URETERAL INFARED STENT 0220-180-518 49192724_1 CDM 0272 RC inpatient 2810 1826.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 2191.8 78 999999999 1701.46 2725.7 percent of total billed charges IRIS URETERAL INFARED STENT 0220-180-518 49192724_1 CDM 0272 RC inpatient 2810 1826.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1938.9 69 999999999 1701.46 2725.7 percent of total billed charges IRIS URETERAL INFARED STENT 0220-180-518 49192724_1 CDM 0272 RC inpatient 2810 1826.5 UMR - ALL PLANS UMR - ALL PLANS 1967 70 999999999 1701.46 2725.7 percent of total billed charges IRIS URETERAL INFARED STENT 0220-180-518 49192724_1 CDM 0272 RC inpatient 2810 1826.5 SIHO - ALL PLANS SIHO - ALL PLANS 2529 90 999999999 1701.46 2725.7 percent of total billed charges IRIS URETERAL INFARED STENT 0220-180-518 49192724_1 CDM 0272 RC inpatient 2810 1826.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1701.46 60.55 999999999 1701.46 2725.7 percent of total billed charges IRIS URETERAL INFARED STENT 0220-180-518 49192724_1 CDM 0272 RC inpatient 2810 1826.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1701.46 2725.7 IRIS URETERAL INFARED STENT 0220-180-518 49192724_1 CDM 0272 RC inpatient 2810 1826.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1701.46 2725.7 IRIS URETERAL INFARED STENT 0220-180-518 49192724_1 CDM 0272 RC inpatient 2810 1826.5 ANTHEM HMO ANTHEM HMO 999999999 1701.46 2725.7 IRIS URETERAL INFARED STENT 0220-180-518 49192724_1 CDM 0272 RC inpatient 2810 1826.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1701.46 2725.7 IRIS URETERAL INFARED STENT 0220-180-518 49192724_1 CDM 0272 RC inpatient 2810 1826.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1701.46 2725.7 IRIS URETERAL INFARED STENT 0220-180-518 49192724_1 CDM 0272 RC inpatient 2810 1826.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1899.56 67.6 999999999 1701.46 2725.7 percent of total billed charges XERO GEL 49192725_1 CDM 0272 RC inpatient 554 360.1 AETNA AETNA 437.66 79 999999999 335.45 537.38 percent of total billed charges XERO GEL 49192725_1 CDM 0272 RC inpatient 554 360.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 360.1 65 999999999 335.45 537.38 percent of total billed charges XERO GEL 49192725_1 CDM 0272 RC inpatient 554 360.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 537.38 97 999999999 335.45 537.38 percent of total billed charges XERO GEL 49192725_1 CDM 0272 RC inpatient 554 360.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 432.12 78 999999999 335.45 537.38 percent of total billed charges XERO GEL 49192725_1 CDM 0272 RC inpatient 554 360.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 382.26 69 999999999 335.45 537.38 percent of total billed charges XERO GEL 49192725_1 CDM 0272 RC inpatient 554 360.1 UMR - ALL PLANS UMR - ALL PLANS 387.8 70 999999999 335.45 537.38 percent of total billed charges XERO GEL 49192725_1 CDM 0272 RC inpatient 554 360.1 SIHO - ALL PLANS SIHO - ALL PLANS 498.6 90 999999999 335.45 537.38 percent of total billed charges XERO GEL 49192725_1 CDM 0272 RC inpatient 554 360.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 335.45 60.55 999999999 335.45 537.38 percent of total billed charges XERO GEL 49192725_1 CDM 0272 RC inpatient 554 360.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 335.45 537.38 XERO GEL 49192725_1 CDM 0272 RC inpatient 554 360.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 335.45 537.38 XERO GEL 49192725_1 CDM 0272 RC inpatient 554 360.1 ANTHEM HMO ANTHEM HMO 999999999 335.45 537.38 XERO GEL 49192725_1 CDM 0272 RC inpatient 554 360.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 335.45 537.38 XERO GEL 49192725_1 CDM 0272 RC inpatient 554 360.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 335.45 537.38 XERO GEL 49192725_1 CDM 0272 RC inpatient 554 360.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 374.5 67.6 999999999 335.45 537.38 percent of total billed charges BLADED BALLOON TROCAR 5X100 49192747_1 CDM 0272 RC inpatient 414 269.1 AETNA AETNA 327.06 79 999999999 250.68 401.58 percent of total billed charges BLADED BALLOON TROCAR 5X100 49192747_1 CDM 0272 RC inpatient 414 269.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 269.1 65 999999999 250.68 401.58 percent of total billed charges BLADED BALLOON TROCAR 5X100 49192747_1 CDM 0272 RC inpatient 414 269.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 401.58 97 999999999 250.68 401.58 percent of total billed charges BLADED BALLOON TROCAR 5X100 49192747_1 CDM 0272 RC inpatient 414 269.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 322.92 78 999999999 250.68 401.58 percent of total billed charges BLADED BALLOON TROCAR 5X100 49192747_1 CDM 0272 RC inpatient 414 269.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 285.66 69 999999999 250.68 401.58 percent of total billed charges BLADED BALLOON TROCAR 5X100 49192747_1 CDM 0272 RC inpatient 414 269.1 UMR - ALL PLANS UMR - ALL PLANS 289.8 70 999999999 250.68 401.58 percent of total billed charges BLADED BALLOON TROCAR 5X100 49192747_1 CDM 0272 RC inpatient 414 269.1 SIHO - ALL PLANS SIHO - ALL PLANS 372.6 90 999999999 250.68 401.58 percent of total billed charges BLADED BALLOON TROCAR 5X100 49192747_1 CDM 0272 RC inpatient 414 269.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 250.68 60.55 999999999 250.68 401.58 percent of total billed charges BLADED BALLOON TROCAR 5X100 49192747_1 CDM 0272 RC inpatient 414 269.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 250.68 401.58 BLADED BALLOON TROCAR 5X100 49192747_1 CDM 0272 RC inpatient 414 269.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 250.68 401.58 BLADED BALLOON TROCAR 5X100 49192747_1 CDM 0272 RC inpatient 414 269.1 ANTHEM HMO ANTHEM HMO 999999999 250.68 401.58 BLADED BALLOON TROCAR 5X100 49192747_1 CDM 0272 RC inpatient 414 269.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 250.68 401.58 BLADED BALLOON TROCAR 5X100 49192747_1 CDM 0272 RC inpatient 414 269.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 250.68 401.58 BLADED BALLOON TROCAR 5X100 49192747_1 CDM 0272 RC inpatient 414 269.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 279.86 67.6 999999999 250.68 401.58 percent of total billed charges TROCAR SLEEVE 5X100 49192748_1 CDM 0272 RC inpatient 207 134.55 AETNA AETNA 163.53 79 999999999 125.34 200.79 percent of total billed charges TROCAR SLEEVE 5X100 49192748_1 CDM 0272 RC inpatient 207 134.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 134.55 65 999999999 125.34 200.79 percent of total billed charges TROCAR SLEEVE 5X100 49192748_1 CDM 0272 RC inpatient 207 134.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 200.79 97 999999999 125.34 200.79 percent of total billed charges TROCAR SLEEVE 5X100 49192748_1 CDM 0272 RC inpatient 207 134.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 161.46 78 999999999 125.34 200.79 percent of total billed charges TROCAR SLEEVE 5X100 49192748_1 CDM 0272 RC inpatient 207 134.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.83 69 999999999 125.34 200.79 percent of total billed charges TROCAR SLEEVE 5X100 49192748_1 CDM 0272 RC inpatient 207 134.55 UMR - ALL PLANS UMR - ALL PLANS 144.9 70 999999999 125.34 200.79 percent of total billed charges TROCAR SLEEVE 5X100 49192748_1 CDM 0272 RC inpatient 207 134.55 SIHO - ALL PLANS SIHO - ALL PLANS 186.3 90 999999999 125.34 200.79 percent of total billed charges TROCAR SLEEVE 5X100 49192748_1 CDM 0272 RC inpatient 207 134.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 125.34 60.55 999999999 125.34 200.79 percent of total billed charges TROCAR SLEEVE 5X100 49192748_1 CDM 0272 RC inpatient 207 134.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 125.34 200.79 TROCAR SLEEVE 5X100 49192748_1 CDM 0272 RC inpatient 207 134.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 125.34 200.79 TROCAR SLEEVE 5X100 49192748_1 CDM 0272 RC inpatient 207 134.55 ANTHEM HMO ANTHEM HMO 999999999 125.34 200.79 TROCAR SLEEVE 5X100 49192748_1 CDM 0272 RC inpatient 207 134.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 125.34 200.79 TROCAR SLEEVE 5X100 49192748_1 CDM 0272 RC inpatient 207 134.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 125.34 200.79 TROCAR SLEEVE 5X100 49192748_1 CDM 0272 RC inpatient 207 134.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.93 67.6 999999999 125.34 200.79 percent of total billed charges CROSS CUT RASP 49192749_1 CDM 0272 RC inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges CROSS CUT RASP 49192749_1 CDM 0272 RC inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges CROSS CUT RASP 49192749_1 CDM 0272 RC inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges CROSS CUT RASP 49192749_1 CDM 0272 RC inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges CROSS CUT RASP 49192749_1 CDM 0272 RC inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges CROSS CUT RASP 49192749_1 CDM 0272 RC inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges CROSS CUT RASP 49192749_1 CDM 0272 RC inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges CROSS CUT RASP 49192749_1 CDM 0272 RC inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges CROSS CUT RASP 49192749_1 CDM 0272 RC inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 CROSS CUT RASP 49192749_1 CDM 0272 RC inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 CROSS CUT RASP 49192749_1 CDM 0272 RC inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 CROSS CUT RASP 49192749_1 CDM 0272 RC inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 CROSS CUT RASP 49192749_1 CDM 0272 RC inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 CROSS CUT RASP 49192749_1 CDM 0272 RC inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges 2.0 CABLE DALL MILES 49192750_1 CDM 0278 RC inpatient 1822 1184.3 AETNA AETNA 1439.38 79 999999999 1103.22 1767.34 percent of total billed charges 2.0 CABLE DALL MILES 49192750_1 CDM 0278 RC inpatient 1822 1184.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1184.3 65 999999999 1103.22 1767.34 percent of total billed charges 2.0 CABLE DALL MILES 49192750_1 CDM 0278 RC inpatient 1822 1184.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1767.34 97 999999999 1103.22 1767.34 percent of total billed charges 2.0 CABLE DALL MILES 49192750_1 CDM 0278 RC inpatient 1822 1184.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1421.16 78 999999999 1103.22 1767.34 percent of total billed charges 2.0 CABLE DALL MILES 49192750_1 CDM 0278 RC inpatient 1822 1184.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1257.18 69 999999999 1103.22 1767.34 percent of total billed charges 2.0 CABLE DALL MILES 49192750_1 CDM 0278 RC inpatient 1822 1184.3 UMR - ALL PLANS UMR - ALL PLANS 1275.4 70 999999999 1103.22 1767.34 percent of total billed charges 2.0 CABLE DALL MILES 49192750_1 CDM 0278 RC inpatient 1822 1184.3 SIHO - ALL PLANS SIHO - ALL PLANS 1639.8 90 999999999 1103.22 1767.34 percent of total billed charges 2.0 CABLE DALL MILES 49192750_1 CDM 0278 RC inpatient 1822 1184.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1103.22 60.55 999999999 1103.22 1767.34 percent of total billed charges 2.0 CABLE DALL MILES 49192750_1 CDM 0278 RC inpatient 1822 1184.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1103.22 1767.34 2.0 CABLE DALL MILES 49192750_1 CDM 0278 RC inpatient 1822 1184.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1103.22 1767.34 2.0 CABLE DALL MILES 49192750_1 CDM 0278 RC inpatient 1822 1184.3 ANTHEM HMO ANTHEM HMO 999999999 1103.22 1767.34 2.0 CABLE DALL MILES 49192750_1 CDM 0278 RC inpatient 1822 1184.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1103.22 1767.34 2.0 CABLE DALL MILES 49192750_1 CDM 0278 RC inpatient 1822 1184.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1103.22 1767.34 2.0 CABLE DALL MILES 49192750_1 CDM 0278 RC inpatient 1822 1184.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1231.67 67.6 999999999 1103.22 1767.34 percent of total billed charges 2 HOLE CABLE SLEEVE DALL MILES 49192751_1 CDM 0278 RC inpatient 981 637.65 AETNA AETNA 774.99 79 999999999 594 951.57 percent of total billed charges 2 HOLE CABLE SLEEVE DALL MILES 49192751_1 CDM 0278 RC inpatient 981 637.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 637.65 65 999999999 594 951.57 percent of total billed charges 2 HOLE CABLE SLEEVE DALL MILES 49192751_1 CDM 0278 RC inpatient 981 637.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 951.57 97 999999999 594 951.57 percent of total billed charges 2 HOLE CABLE SLEEVE DALL MILES 49192751_1 CDM 0278 RC inpatient 981 637.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.18 78 999999999 594 951.57 percent of total billed charges 2 HOLE CABLE SLEEVE DALL MILES 49192751_1 CDM 0278 RC inpatient 981 637.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 676.89 69 999999999 594 951.57 percent of total billed charges 2 HOLE CABLE SLEEVE DALL MILES 49192751_1 CDM 0278 RC inpatient 981 637.65 UMR - ALL PLANS UMR - ALL PLANS 686.7 70 999999999 594 951.57 percent of total billed charges 2 HOLE CABLE SLEEVE DALL MILES 49192751_1 CDM 0278 RC inpatient 981 637.65 SIHO - ALL PLANS SIHO - ALL PLANS 882.9 90 999999999 594 951.57 percent of total billed charges 2 HOLE CABLE SLEEVE DALL MILES 49192751_1 CDM 0278 RC inpatient 981 637.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594 60.55 999999999 594 951.57 percent of total billed charges 2 HOLE CABLE SLEEVE DALL MILES 49192751_1 CDM 0278 RC inpatient 981 637.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594 951.57 2 HOLE CABLE SLEEVE DALL MILES 49192751_1 CDM 0278 RC inpatient 981 637.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594 951.57 2 HOLE CABLE SLEEVE DALL MILES 49192751_1 CDM 0278 RC inpatient 981 637.65 ANTHEM HMO ANTHEM HMO 999999999 594 951.57 2 HOLE CABLE SLEEVE DALL MILES 49192751_1 CDM 0278 RC inpatient 981 637.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594 951.57 2 HOLE CABLE SLEEVE DALL MILES 49192751_1 CDM 0278 RC inpatient 981 637.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 594 951.57 2 HOLE CABLE SLEEVE DALL MILES 49192751_1 CDM 0278 RC inpatient 981 637.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.16 67.6 999999999 594 951.57 percent of total billed charges POWERLINE CENTRAL VENOUS CATH 49192752_1 CDM 0278 RC inpatient 1949 1266.85 AETNA AETNA 1539.71 79 999999999 1180.12 1890.53 percent of total billed charges POWERLINE CENTRAL VENOUS CATH 49192752_1 CDM 0278 RC inpatient 1949 1266.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1266.85 65 999999999 1180.12 1890.53 percent of total billed charges POWERLINE CENTRAL VENOUS CATH 49192752_1 CDM 0278 RC inpatient 1949 1266.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1890.53 97 999999999 1180.12 1890.53 percent of total billed charges POWERLINE CENTRAL VENOUS CATH 49192752_1 CDM 0278 RC inpatient 1949 1266.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1520.22 78 999999999 1180.12 1890.53 percent of total billed charges POWERLINE CENTRAL VENOUS CATH 49192752_1 CDM 0278 RC inpatient 1949 1266.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1344.81 69 999999999 1180.12 1890.53 percent of total billed charges POWERLINE CENTRAL VENOUS CATH 49192752_1 CDM 0278 RC inpatient 1949 1266.85 UMR - ALL PLANS UMR - ALL PLANS 1364.3 70 999999999 1180.12 1890.53 percent of total billed charges POWERLINE CENTRAL VENOUS CATH 49192752_1 CDM 0278 RC inpatient 1949 1266.85 SIHO - ALL PLANS SIHO - ALL PLANS 1754.1 90 999999999 1180.12 1890.53 percent of total billed charges POWERLINE CENTRAL VENOUS CATH 49192752_1 CDM 0278 RC inpatient 1949 1266.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1180.12 60.55 999999999 1180.12 1890.53 percent of total billed charges POWERLINE CENTRAL VENOUS CATH 49192752_1 CDM 0278 RC inpatient 1949 1266.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1180.12 1890.53 POWERLINE CENTRAL VENOUS CATH 49192752_1 CDM 0278 RC inpatient 1949 1266.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1180.12 1890.53 POWERLINE CENTRAL VENOUS CATH 49192752_1 CDM 0278 RC inpatient 1949 1266.85 ANTHEM HMO ANTHEM HMO 999999999 1180.12 1890.53 POWERLINE CENTRAL VENOUS CATH 49192752_1 CDM 0278 RC inpatient 1949 1266.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1180.12 1890.53 POWERLINE CENTRAL VENOUS CATH 49192752_1 CDM 0278 RC inpatient 1949 1266.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1180.12 1890.53 POWERLINE CENTRAL VENOUS CATH 49192752_1 CDM 0278 RC inpatient 1949 1266.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1317.52 67.6 999999999 1180.12 1890.53 percent of total billed charges GLIDECATH PV CATHETER 49192758_1 CDM 0272 RC inpatient 336 218.4 AETNA AETNA 265.44 79 999999999 203.45 325.92 percent of total billed charges GLIDECATH PV CATHETER 49192758_1 CDM 0272 RC inpatient 336 218.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 218.4 65 999999999 203.45 325.92 percent of total billed charges GLIDECATH PV CATHETER 49192758_1 CDM 0272 RC inpatient 336 218.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 325.92 97 999999999 203.45 325.92 percent of total billed charges GLIDECATH PV CATHETER 49192758_1 CDM 0272 RC inpatient 336 218.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 262.08 78 999999999 203.45 325.92 percent of total billed charges GLIDECATH PV CATHETER 49192758_1 CDM 0272 RC inpatient 336 218.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 231.84 69 999999999 203.45 325.92 percent of total billed charges GLIDECATH PV CATHETER 49192758_1 CDM 0272 RC inpatient 336 218.4 UMR - ALL PLANS UMR - ALL PLANS 235.2 70 999999999 203.45 325.92 percent of total billed charges GLIDECATH PV CATHETER 49192758_1 CDM 0272 RC inpatient 336 218.4 SIHO - ALL PLANS SIHO - ALL PLANS 302.4 90 999999999 203.45 325.92 percent of total billed charges GLIDECATH PV CATHETER 49192758_1 CDM 0272 RC inpatient 336 218.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 203.45 60.55 999999999 203.45 325.92 percent of total billed charges GLIDECATH PV CATHETER 49192758_1 CDM 0272 RC inpatient 336 218.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 203.45 325.92 GLIDECATH PV CATHETER 49192758_1 CDM 0272 RC inpatient 336 218.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 203.45 325.92 GLIDECATH PV CATHETER 49192758_1 CDM 0272 RC inpatient 336 218.4 ANTHEM HMO ANTHEM HMO 999999999 203.45 325.92 GLIDECATH PV CATHETER 49192758_1 CDM 0272 RC inpatient 336 218.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 203.45 325.92 GLIDECATH PV CATHETER 49192758_1 CDM 0272 RC inpatient 336 218.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 203.45 325.92 GLIDECATH PV CATHETER 49192758_1 CDM 0272 RC inpatient 336 218.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 227.14 67.6 999999999 203.45 325.92 percent of total billed charges SIX SHOOTER MBL-U-6-F 49192761_1 CDM 0272 RC inpatient 1504 977.6 AETNA AETNA 1188.16 79 999999999 910.67 1458.88 percent of total billed charges SIX SHOOTER MBL-U-6-F 49192761_1 CDM 0272 RC inpatient 1504 977.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 977.6 65 999999999 910.67 1458.88 percent of total billed charges SIX SHOOTER MBL-U-6-F 49192761_1 CDM 0272 RC inpatient 1504 977.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1458.88 97 999999999 910.67 1458.88 percent of total billed charges SIX SHOOTER MBL-U-6-F 49192761_1 CDM 0272 RC inpatient 1504 977.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1173.12 78 999999999 910.67 1458.88 percent of total billed charges SIX SHOOTER MBL-U-6-F 49192761_1 CDM 0272 RC inpatient 1504 977.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1037.76 69 999999999 910.67 1458.88 percent of total billed charges SIX SHOOTER MBL-U-6-F 49192761_1 CDM 0272 RC inpatient 1504 977.6 UMR - ALL PLANS UMR - ALL PLANS 1052.8 70 999999999 910.67 1458.88 percent of total billed charges SIX SHOOTER MBL-U-6-F 49192761_1 CDM 0272 RC inpatient 1504 977.6 SIHO - ALL PLANS SIHO - ALL PLANS 1353.6 90 999999999 910.67 1458.88 percent of total billed charges SIX SHOOTER MBL-U-6-F 49192761_1 CDM 0272 RC inpatient 1504 977.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 910.67 60.55 999999999 910.67 1458.88 percent of total billed charges SIX SHOOTER MBL-U-6-F 49192761_1 CDM 0272 RC inpatient 1504 977.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 910.67 1458.88 SIX SHOOTER MBL-U-6-F 49192761_1 CDM 0272 RC inpatient 1504 977.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 910.67 1458.88 SIX SHOOTER MBL-U-6-F 49192761_1 CDM 0272 RC inpatient 1504 977.6 ANTHEM HMO ANTHEM HMO 999999999 910.67 1458.88 SIX SHOOTER MBL-U-6-F 49192761_1 CDM 0272 RC inpatient 1504 977.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 910.67 1458.88 SIX SHOOTER MBL-U-6-F 49192761_1 CDM 0272 RC inpatient 1504 977.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 910.67 1458.88 SIX SHOOTER MBL-U-6-F 49192761_1 CDM 0272 RC inpatient 1504 977.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1016.7 67.6 999999999 910.67 1458.88 percent of total billed charges MINI GRIP ALLIGATOR GRASPER 49192763_1 CDM 0272 RC inpatient 1219 792.35 AETNA AETNA 963.01 79 999999999 738.1 1182.43 percent of total billed charges MINI GRIP ALLIGATOR GRASPER 49192763_1 CDM 0272 RC inpatient 1219 792.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 792.35 65 999999999 738.1 1182.43 percent of total billed charges MINI GRIP ALLIGATOR GRASPER 49192763_1 CDM 0272 RC inpatient 1219 792.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1182.43 97 999999999 738.1 1182.43 percent of total billed charges MINI GRIP ALLIGATOR GRASPER 49192763_1 CDM 0272 RC inpatient 1219 792.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 950.82 78 999999999 738.1 1182.43 percent of total billed charges MINI GRIP ALLIGATOR GRASPER 49192763_1 CDM 0272 RC inpatient 1219 792.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 841.11 69 999999999 738.1 1182.43 percent of total billed charges MINI GRIP ALLIGATOR GRASPER 49192763_1 CDM 0272 RC inpatient 1219 792.35 UMR - ALL PLANS UMR - ALL PLANS 853.3 70 999999999 738.1 1182.43 percent of total billed charges MINI GRIP ALLIGATOR GRASPER 49192763_1 CDM 0272 RC inpatient 1219 792.35 SIHO - ALL PLANS SIHO - ALL PLANS 1097.1 90 999999999 738.1 1182.43 percent of total billed charges MINI GRIP ALLIGATOR GRASPER 49192763_1 CDM 0272 RC inpatient 1219 792.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 738.1 60.55 999999999 738.1 1182.43 percent of total billed charges MINI GRIP ALLIGATOR GRASPER 49192763_1 CDM 0272 RC inpatient 1219 792.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 738.1 1182.43 MINI GRIP ALLIGATOR GRASPER 49192763_1 CDM 0272 RC inpatient 1219 792.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 738.1 1182.43 MINI GRIP ALLIGATOR GRASPER 49192763_1 CDM 0272 RC inpatient 1219 792.35 ANTHEM HMO ANTHEM HMO 999999999 738.1 1182.43 MINI GRIP ALLIGATOR GRASPER 49192763_1 CDM 0272 RC inpatient 1219 792.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 738.1 1182.43 MINI GRIP ALLIGATOR GRASPER 49192763_1 CDM 0272 RC inpatient 1219 792.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 738.1 1182.43 MINI GRIP ALLIGATOR GRASPER 49192763_1 CDM 0272 RC inpatient 1219 792.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 824.04 67.6 999999999 738.1 1182.43 percent of total billed charges GORTEX MESH TISSUE REINFORCEMENT 49192768_1 CDM 0278 RC inpatient 3029 1968.85 AETNA AETNA 2392.91 79 999999999 1834.06 2938.13 percent of total billed charges GORTEX MESH TISSUE REINFORCEMENT 49192768_1 CDM 0278 RC inpatient 3029 1968.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1968.85 65 999999999 1834.06 2938.13 percent of total billed charges GORTEX MESH TISSUE REINFORCEMENT 49192768_1 CDM 0278 RC inpatient 3029 1968.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2938.13 97 999999999 1834.06 2938.13 percent of total billed charges GORTEX MESH TISSUE REINFORCEMENT 49192768_1 CDM 0278 RC inpatient 3029 1968.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 2362.62 78 999999999 1834.06 2938.13 percent of total billed charges GORTEX MESH TISSUE REINFORCEMENT 49192768_1 CDM 0278 RC inpatient 3029 1968.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 2090.01 69 999999999 1834.06 2938.13 percent of total billed charges GORTEX MESH TISSUE REINFORCEMENT 49192768_1 CDM 0278 RC inpatient 3029 1968.85 UMR - ALL PLANS UMR - ALL PLANS 2120.3 70 999999999 1834.06 2938.13 percent of total billed charges GORTEX MESH TISSUE REINFORCEMENT 49192768_1 CDM 0278 RC inpatient 3029 1968.85 SIHO - ALL PLANS SIHO - ALL PLANS 2726.1 90 999999999 1834.06 2938.13 percent of total billed charges GORTEX MESH TISSUE REINFORCEMENT 49192768_1 CDM 0278 RC inpatient 3029 1968.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1834.06 60.55 999999999 1834.06 2938.13 percent of total billed charges GORTEX MESH TISSUE REINFORCEMENT 49192768_1 CDM 0278 RC inpatient 3029 1968.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1834.06 2938.13 GORTEX MESH TISSUE REINFORCEMENT 49192768_1 CDM 0278 RC inpatient 3029 1968.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1834.06 2938.13 GORTEX MESH TISSUE REINFORCEMENT 49192768_1 CDM 0278 RC inpatient 3029 1968.85 ANTHEM HMO ANTHEM HMO 999999999 1834.06 2938.13 GORTEX MESH TISSUE REINFORCEMENT 49192768_1 CDM 0278 RC inpatient 3029 1968.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1834.06 2938.13 GORTEX MESH TISSUE REINFORCEMENT 49192768_1 CDM 0278 RC inpatient 3029 1968.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1834.06 2938.13 GORTEX MESH TISSUE REINFORCEMENT 49192768_1 CDM 0278 RC inpatient 3029 1968.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 2047.6 67.6 999999999 1834.06 2938.13 percent of total billed charges TROCAR 5MM W/FIX CAN 49192769_1 CDM 0272 RC inpatient 210 136.5 AETNA AETNA 165.9 79 999999999 127.16 203.7 percent of total billed charges TROCAR 5MM W/FIX CAN 49192769_1 CDM 0272 RC inpatient 210 136.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 136.5 65 999999999 127.16 203.7 percent of total billed charges TROCAR 5MM W/FIX CAN 49192769_1 CDM 0272 RC inpatient 210 136.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 203.7 97 999999999 127.16 203.7 percent of total billed charges TROCAR 5MM W/FIX CAN 49192769_1 CDM 0272 RC inpatient 210 136.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 163.8 78 999999999 127.16 203.7 percent of total billed charges TROCAR 5MM W/FIX CAN 49192769_1 CDM 0272 RC inpatient 210 136.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 144.9 69 999999999 127.16 203.7 percent of total billed charges TROCAR 5MM W/FIX CAN 49192769_1 CDM 0272 RC inpatient 210 136.5 UMR - ALL PLANS UMR - ALL PLANS 147 70 999999999 127.16 203.7 percent of total billed charges TROCAR 5MM W/FIX CAN 49192769_1 CDM 0272 RC inpatient 210 136.5 SIHO - ALL PLANS SIHO - ALL PLANS 189 90 999999999 127.16 203.7 percent of total billed charges TROCAR 5MM W/FIX CAN 49192769_1 CDM 0272 RC inpatient 210 136.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.16 60.55 999999999 127.16 203.7 percent of total billed charges TROCAR 5MM W/FIX CAN 49192769_1 CDM 0272 RC inpatient 210 136.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.16 203.7 TROCAR 5MM W/FIX CAN 49192769_1 CDM 0272 RC inpatient 210 136.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.16 203.7 TROCAR 5MM W/FIX CAN 49192769_1 CDM 0272 RC inpatient 210 136.5 ANTHEM HMO ANTHEM HMO 999999999 127.16 203.7 TROCAR 5MM W/FIX CAN 49192769_1 CDM 0272 RC inpatient 210 136.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.16 203.7 TROCAR 5MM W/FIX CAN 49192769_1 CDM 0272 RC inpatient 210 136.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.16 203.7 TROCAR 5MM W/FIX CAN 49192769_1 CDM 0272 RC inpatient 210 136.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 141.96 67.6 999999999 127.16 203.7 percent of total billed charges JEJUNAL FEED TUBE 20FR 49192770_1 CDM 0272 RC inpatient 866 562.9 AETNA AETNA 684.14 79 999999999 524.36 840.02 percent of total billed charges JEJUNAL FEED TUBE 20FR 49192770_1 CDM 0272 RC inpatient 866 562.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 562.9 65 999999999 524.36 840.02 percent of total billed charges JEJUNAL FEED TUBE 20FR 49192770_1 CDM 0272 RC inpatient 866 562.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 840.02 97 999999999 524.36 840.02 percent of total billed charges JEJUNAL FEED TUBE 20FR 49192770_1 CDM 0272 RC inpatient 866 562.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 675.48 78 999999999 524.36 840.02 percent of total billed charges JEJUNAL FEED TUBE 20FR 49192770_1 CDM 0272 RC inpatient 866 562.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 597.54 69 999999999 524.36 840.02 percent of total billed charges JEJUNAL FEED TUBE 20FR 49192770_1 CDM 0272 RC inpatient 866 562.9 UMR - ALL PLANS UMR - ALL PLANS 606.2 70 999999999 524.36 840.02 percent of total billed charges JEJUNAL FEED TUBE 20FR 49192770_1 CDM 0272 RC inpatient 866 562.9 SIHO - ALL PLANS SIHO - ALL PLANS 779.4 90 999999999 524.36 840.02 percent of total billed charges JEJUNAL FEED TUBE 20FR 49192770_1 CDM 0272 RC inpatient 866 562.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 524.36 60.55 999999999 524.36 840.02 percent of total billed charges JEJUNAL FEED TUBE 20FR 49192770_1 CDM 0272 RC inpatient 866 562.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 524.36 840.02 JEJUNAL FEED TUBE 20FR 49192770_1 CDM 0272 RC inpatient 866 562.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 524.36 840.02 JEJUNAL FEED TUBE 20FR 49192770_1 CDM 0272 RC inpatient 866 562.9 ANTHEM HMO ANTHEM HMO 999999999 524.36 840.02 JEJUNAL FEED TUBE 20FR 49192770_1 CDM 0272 RC inpatient 866 562.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 524.36 840.02 JEJUNAL FEED TUBE 20FR 49192770_1 CDM 0272 RC inpatient 866 562.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 524.36 840.02 JEJUNAL FEED TUBE 20FR 49192770_1 CDM 0272 RC inpatient 866 562.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 585.42 67.6 999999999 524.36 840.02 percent of total billed charges PRESSURE COMPASS DEVICE KIT CMPSN001A 49192774_1 CDM 0272 RC inpatient 464 301.6 AETNA AETNA 366.56 79 999999999 280.95 450.08 percent of total billed charges PRESSURE COMPASS DEVICE KIT CMPSN001A 49192774_1 CDM 0272 RC inpatient 464 301.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 301.6 65 999999999 280.95 450.08 percent of total billed charges PRESSURE COMPASS DEVICE KIT CMPSN001A 49192774_1 CDM 0272 RC inpatient 464 301.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 450.08 97 999999999 280.95 450.08 percent of total billed charges PRESSURE COMPASS DEVICE KIT CMPSN001A 49192774_1 CDM 0272 RC inpatient 464 301.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 361.92 78 999999999 280.95 450.08 percent of total billed charges PRESSURE COMPASS DEVICE KIT CMPSN001A 49192774_1 CDM 0272 RC inpatient 464 301.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 320.16 69 999999999 280.95 450.08 percent of total billed charges PRESSURE COMPASS DEVICE KIT CMPSN001A 49192774_1 CDM 0272 RC inpatient 464 301.6 UMR - ALL PLANS UMR - ALL PLANS 324.8 70 999999999 280.95 450.08 percent of total billed charges PRESSURE COMPASS DEVICE KIT CMPSN001A 49192774_1 CDM 0272 RC inpatient 464 301.6 SIHO - ALL PLANS SIHO - ALL PLANS 417.6 90 999999999 280.95 450.08 percent of total billed charges PRESSURE COMPASS DEVICE KIT CMPSN001A 49192774_1 CDM 0272 RC inpatient 464 301.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 280.95 60.55 999999999 280.95 450.08 percent of total billed charges PRESSURE COMPASS DEVICE KIT CMPSN001A 49192774_1 CDM 0272 RC inpatient 464 301.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 280.95 450.08 PRESSURE COMPASS DEVICE KIT CMPSN001A 49192774_1 CDM 0272 RC inpatient 464 301.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 280.95 450.08 PRESSURE COMPASS DEVICE KIT CMPSN001A 49192774_1 CDM 0272 RC inpatient 464 301.6 ANTHEM HMO ANTHEM HMO 999999999 280.95 450.08 PRESSURE COMPASS DEVICE KIT CMPSN001A 49192774_1 CDM 0272 RC inpatient 464 301.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 280.95 450.08 PRESSURE COMPASS DEVICE KIT CMPSN001A 49192774_1 CDM 0272 RC inpatient 464 301.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 280.95 450.08 PRESSURE COMPASS DEVICE KIT CMPSN001A 49192774_1 CDM 0272 RC inpatient 464 301.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 313.66 67.6 999999999 280.95 450.08 percent of total billed charges BLADE QUADCUT 3.0MM 49192776_1 CDM 0272 RC inpatient 1220 793 AETNA AETNA 963.8 79 999999999 738.71 1183.4 percent of total billed charges BLADE QUADCUT 3.0MM 49192776_1 CDM 0272 RC inpatient 1220 793 SELF PAY DISCOUNT SELF PAY DISCOUNT 793 65 999999999 738.71 1183.4 percent of total billed charges BLADE QUADCUT 3.0MM 49192776_1 CDM 0272 RC inpatient 1220 793 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1183.4 97 999999999 738.71 1183.4 percent of total billed charges BLADE QUADCUT 3.0MM 49192776_1 CDM 0272 RC inpatient 1220 793 HUMANA - ALL PLANS HUMANA - ALL PLANS 951.6 78 999999999 738.71 1183.4 percent of total billed charges BLADE QUADCUT 3.0MM 49192776_1 CDM 0272 RC inpatient 1220 793 ENCORE - ALL PLANS ENCORE - ALL PLANS 841.8 69 999999999 738.71 1183.4 percent of total billed charges BLADE QUADCUT 3.0MM 49192776_1 CDM 0272 RC inpatient 1220 793 UMR - ALL PLANS UMR - ALL PLANS 854 70 999999999 738.71 1183.4 percent of total billed charges BLADE QUADCUT 3.0MM 49192776_1 CDM 0272 RC inpatient 1220 793 SIHO - ALL PLANS SIHO - ALL PLANS 1098 90 999999999 738.71 1183.4 percent of total billed charges BLADE QUADCUT 3.0MM 49192776_1 CDM 0272 RC inpatient 1220 793 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 738.71 60.55 999999999 738.71 1183.4 percent of total billed charges BLADE QUADCUT 3.0MM 49192776_1 CDM 0272 RC inpatient 1220 793 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 738.71 1183.4 BLADE QUADCUT 3.0MM 49192776_1 CDM 0272 RC inpatient 1220 793 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 738.71 1183.4 BLADE QUADCUT 3.0MM 49192776_1 CDM 0272 RC inpatient 1220 793 ANTHEM HMO ANTHEM HMO 999999999 738.71 1183.4 BLADE QUADCUT 3.0MM 49192776_1 CDM 0272 RC inpatient 1220 793 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 738.71 1183.4 BLADE QUADCUT 3.0MM 49192776_1 CDM 0272 RC inpatient 1220 793 UHC - ALL PLANS UHC - ALL PLANS 999999999 738.71 1183.4 BLADE QUADCUT 3.0MM 49192776_1 CDM 0272 RC inpatient 1220 793 CIGNA - ALL PLANS CIGNA - ALL PLANS 824.72 67.6 999999999 738.71 1183.4 percent of total billed charges BLADE RAD 40 11CM X 4MM 49192777_1 CDM 0272 RC inpatient 662 430.3 AETNA AETNA 522.98 79 999999999 400.84 642.14 percent of total billed charges BLADE RAD 40 11CM X 4MM 49192777_1 CDM 0272 RC inpatient 662 430.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 430.3 65 999999999 400.84 642.14 percent of total billed charges BLADE RAD 40 11CM X 4MM 49192777_1 CDM 0272 RC inpatient 662 430.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 642.14 97 999999999 400.84 642.14 percent of total billed charges BLADE RAD 40 11CM X 4MM 49192777_1 CDM 0272 RC inpatient 662 430.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 516.36 78 999999999 400.84 642.14 percent of total billed charges BLADE RAD 40 11CM X 4MM 49192777_1 CDM 0272 RC inpatient 662 430.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 456.78 69 999999999 400.84 642.14 percent of total billed charges BLADE RAD 40 11CM X 4MM 49192777_1 CDM 0272 RC inpatient 662 430.3 UMR - ALL PLANS UMR - ALL PLANS 463.4 70 999999999 400.84 642.14 percent of total billed charges BLADE RAD 40 11CM X 4MM 49192777_1 CDM 0272 RC inpatient 662 430.3 SIHO - ALL PLANS SIHO - ALL PLANS 595.8 90 999999999 400.84 642.14 percent of total billed charges BLADE RAD 40 11CM X 4MM 49192777_1 CDM 0272 RC inpatient 662 430.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 400.84 60.55 999999999 400.84 642.14 percent of total billed charges BLADE RAD 40 11CM X 4MM 49192777_1 CDM 0272 RC inpatient 662 430.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 400.84 642.14 BLADE RAD 40 11CM X 4MM 49192777_1 CDM 0272 RC inpatient 662 430.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 400.84 642.14 BLADE RAD 40 11CM X 4MM 49192777_1 CDM 0272 RC inpatient 662 430.3 ANTHEM HMO ANTHEM HMO 999999999 400.84 642.14 BLADE RAD 40 11CM X 4MM 49192777_1 CDM 0272 RC inpatient 662 430.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 400.84 642.14 BLADE RAD 40 11CM X 4MM 49192777_1 CDM 0272 RC inpatient 662 430.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 400.84 642.14 BLADE RAD 40 11CM X 4MM 49192777_1 CDM 0272 RC inpatient 662 430.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 447.51 67.6 999999999 400.84 642.14 percent of total billed charges GUIDE WIRE BALL TIPPED 2.5X800 49192780_1 CDM 0272 RC inpatient 624 405.6 AETNA AETNA 492.96 79 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE BALL TIPPED 2.5X800 49192780_1 CDM 0272 RC inpatient 624 405.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 405.6 65 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE BALL TIPPED 2.5X800 49192780_1 CDM 0272 RC inpatient 624 405.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 605.28 97 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE BALL TIPPED 2.5X800 49192780_1 CDM 0272 RC inpatient 624 405.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 486.72 78 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE BALL TIPPED 2.5X800 49192780_1 CDM 0272 RC inpatient 624 405.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 430.56 69 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE BALL TIPPED 2.5X800 49192780_1 CDM 0272 RC inpatient 624 405.6 UMR - ALL PLANS UMR - ALL PLANS 436.8 70 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE BALL TIPPED 2.5X800 49192780_1 CDM 0272 RC inpatient 624 405.6 SIHO - ALL PLANS SIHO - ALL PLANS 561.6 90 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE BALL TIPPED 2.5X800 49192780_1 CDM 0272 RC inpatient 624 405.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 377.83 60.55 999999999 377.83 605.28 percent of total billed charges GUIDE WIRE BALL TIPPED 2.5X800 49192780_1 CDM 0272 RC inpatient 624 405.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 377.83 605.28 GUIDE WIRE BALL TIPPED 2.5X800 49192780_1 CDM 0272 RC inpatient 624 405.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 377.83 605.28 GUIDE WIRE BALL TIPPED 2.5X800 49192780_1 CDM 0272 RC inpatient 624 405.6 ANTHEM HMO ANTHEM HMO 999999999 377.83 605.28 GUIDE WIRE BALL TIPPED 2.5X800 49192780_1 CDM 0272 RC inpatient 624 405.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 377.83 605.28 GUIDE WIRE BALL TIPPED 2.5X800 49192780_1 CDM 0272 RC inpatient 624 405.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 377.83 605.28 GUIDE WIRE BALL TIPPED 2.5X800 49192780_1 CDM 0272 RC inpatient 624 405.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 421.82 67.6 999999999 377.83 605.28 percent of total billed charges 8MM MODIFIED REAMER SHAFT 49192783_1 CDM 0272 RC inpatient 4419 2872.35 AETNA AETNA 3491.01 79 999999999 2675.7 4286.43 percent of total billed charges 8MM MODIFIED REAMER SHAFT 49192783_1 CDM 0272 RC inpatient 4419 2872.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 2872.35 65 999999999 2675.7 4286.43 percent of total billed charges 8MM MODIFIED REAMER SHAFT 49192783_1 CDM 0272 RC inpatient 4419 2872.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4286.43 97 999999999 2675.7 4286.43 percent of total billed charges 8MM MODIFIED REAMER SHAFT 49192783_1 CDM 0272 RC inpatient 4419 2872.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 3446.82 78 999999999 2675.7 4286.43 percent of total billed charges 8MM MODIFIED REAMER SHAFT 49192783_1 CDM 0272 RC inpatient 4419 2872.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 3049.11 69 999999999 2675.7 4286.43 percent of total billed charges 8MM MODIFIED REAMER SHAFT 49192783_1 CDM 0272 RC inpatient 4419 2872.35 UMR - ALL PLANS UMR - ALL PLANS 3093.3 70 999999999 2675.7 4286.43 percent of total billed charges 8MM MODIFIED REAMER SHAFT 49192783_1 CDM 0272 RC inpatient 4419 2872.35 SIHO - ALL PLANS SIHO - ALL PLANS 3977.1 90 999999999 2675.7 4286.43 percent of total billed charges 8MM MODIFIED REAMER SHAFT 49192783_1 CDM 0272 RC inpatient 4419 2872.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2675.7 60.55 999999999 2675.7 4286.43 percent of total billed charges 8MM MODIFIED REAMER SHAFT 49192783_1 CDM 0272 RC inpatient 4419 2872.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2675.7 4286.43 8MM MODIFIED REAMER SHAFT 49192783_1 CDM 0272 RC inpatient 4419 2872.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2675.7 4286.43 8MM MODIFIED REAMER SHAFT 49192783_1 CDM 0272 RC inpatient 4419 2872.35 ANTHEM HMO ANTHEM HMO 999999999 2675.7 4286.43 8MM MODIFIED REAMER SHAFT 49192783_1 CDM 0272 RC inpatient 4419 2872.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2675.7 4286.43 8MM MODIFIED REAMER SHAFT 49192783_1 CDM 0272 RC inpatient 4419 2872.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 2675.7 4286.43 8MM MODIFIED REAMER SHAFT 49192783_1 CDM 0272 RC inpatient 4419 2872.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 2987.24 67.6 999999999 2675.7 4286.43 percent of total billed charges 7MM MODIFIED REAMER SHAFT 49192784_1 CDM 0272 RC inpatient 4419 2872.35 AETNA AETNA 3491.01 79 999999999 2675.7 4286.43 percent of total billed charges 7MM MODIFIED REAMER SHAFT 49192784_1 CDM 0272 RC inpatient 4419 2872.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 2872.35 65 999999999 2675.7 4286.43 percent of total billed charges 7MM MODIFIED REAMER SHAFT 49192784_1 CDM 0272 RC inpatient 4419 2872.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4286.43 97 999999999 2675.7 4286.43 percent of total billed charges 7MM MODIFIED REAMER SHAFT 49192784_1 CDM 0272 RC inpatient 4419 2872.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 3446.82 78 999999999 2675.7 4286.43 percent of total billed charges 7MM MODIFIED REAMER SHAFT 49192784_1 CDM 0272 RC inpatient 4419 2872.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 3049.11 69 999999999 2675.7 4286.43 percent of total billed charges 7MM MODIFIED REAMER SHAFT 49192784_1 CDM 0272 RC inpatient 4419 2872.35 UMR - ALL PLANS UMR - ALL PLANS 3093.3 70 999999999 2675.7 4286.43 percent of total billed charges 7MM MODIFIED REAMER SHAFT 49192784_1 CDM 0272 RC inpatient 4419 2872.35 SIHO - ALL PLANS SIHO - ALL PLANS 3977.1 90 999999999 2675.7 4286.43 percent of total billed charges 7MM MODIFIED REAMER SHAFT 49192784_1 CDM 0272 RC inpatient 4419 2872.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2675.7 60.55 999999999 2675.7 4286.43 percent of total billed charges 7MM MODIFIED REAMER SHAFT 49192784_1 CDM 0272 RC inpatient 4419 2872.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2675.7 4286.43 7MM MODIFIED REAMER SHAFT 49192784_1 CDM 0272 RC inpatient 4419 2872.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2675.7 4286.43 7MM MODIFIED REAMER SHAFT 49192784_1 CDM 0272 RC inpatient 4419 2872.35 ANTHEM HMO ANTHEM HMO 999999999 2675.7 4286.43 7MM MODIFIED REAMER SHAFT 49192784_1 CDM 0272 RC inpatient 4419 2872.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2675.7 4286.43 7MM MODIFIED REAMER SHAFT 49192784_1 CDM 0272 RC inpatient 4419 2872.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 2675.7 4286.43 7MM MODIFIED REAMER SHAFT 49192784_1 CDM 0272 RC inpatient 4419 2872.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 2987.24 67.6 999999999 2675.7 4286.43 percent of total billed charges 6MM MODIFIED REAMER SHAFT 49192785_1 CDM 0272 RC inpatient 4419 2872.35 AETNA AETNA 3491.01 79 999999999 2675.7 4286.43 percent of total billed charges 6MM MODIFIED REAMER SHAFT 49192785_1 CDM 0272 RC inpatient 4419 2872.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 2872.35 65 999999999 2675.7 4286.43 percent of total billed charges 6MM MODIFIED REAMER SHAFT 49192785_1 CDM 0272 RC inpatient 4419 2872.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4286.43 97 999999999 2675.7 4286.43 percent of total billed charges 6MM MODIFIED REAMER SHAFT 49192785_1 CDM 0272 RC inpatient 4419 2872.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 3446.82 78 999999999 2675.7 4286.43 percent of total billed charges 6MM MODIFIED REAMER SHAFT 49192785_1 CDM 0272 RC inpatient 4419 2872.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 3049.11 69 999999999 2675.7 4286.43 percent of total billed charges 6MM MODIFIED REAMER SHAFT 49192785_1 CDM 0272 RC inpatient 4419 2872.35 UMR - ALL PLANS UMR - ALL PLANS 3093.3 70 999999999 2675.7 4286.43 percent of total billed charges 6MM MODIFIED REAMER SHAFT 49192785_1 CDM 0272 RC inpatient 4419 2872.35 SIHO - ALL PLANS SIHO - ALL PLANS 3977.1 90 999999999 2675.7 4286.43 percent of total billed charges 6MM MODIFIED REAMER SHAFT 49192785_1 CDM 0272 RC inpatient 4419 2872.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2675.7 60.55 999999999 2675.7 4286.43 percent of total billed charges 6MM MODIFIED REAMER SHAFT 49192785_1 CDM 0272 RC inpatient 4419 2872.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2675.7 4286.43 6MM MODIFIED REAMER SHAFT 49192785_1 CDM 0272 RC inpatient 4419 2872.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2675.7 4286.43 6MM MODIFIED REAMER SHAFT 49192785_1 CDM 0272 RC inpatient 4419 2872.35 ANTHEM HMO ANTHEM HMO 999999999 2675.7 4286.43 6MM MODIFIED REAMER SHAFT 49192785_1 CDM 0272 RC inpatient 4419 2872.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2675.7 4286.43 6MM MODIFIED REAMER SHAFT 49192785_1 CDM 0272 RC inpatient 4419 2872.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 2675.7 4286.43 6MM MODIFIED REAMER SHAFT 49192785_1 CDM 0272 RC inpatient 4419 2872.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 2987.24 67.6 999999999 2675.7 4286.43 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** QUAD BLADE 3.0 49192786_1 CDM 0272 RC inpatient 765 497.25 AETNA AETNA 604.35 79 999999999 463.21 742.05 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** QUAD BLADE 3.0 49192786_1 CDM 0272 RC inpatient 765 497.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 497.25 65 999999999 463.21 742.05 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** QUAD BLADE 3.0 49192786_1 CDM 0272 RC inpatient 765 497.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 742.05 97 999999999 463.21 742.05 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** QUAD BLADE 3.0 49192786_1 CDM 0272 RC inpatient 765 497.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 596.7 78 999999999 463.21 742.05 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** QUAD BLADE 3.0 49192786_1 CDM 0272 RC inpatient 765 497.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 527.85 69 999999999 463.21 742.05 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** QUAD BLADE 3.0 49192786_1 CDM 0272 RC inpatient 765 497.25 UMR - ALL PLANS UMR - ALL PLANS 535.5 70 999999999 463.21 742.05 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** QUAD BLADE 3.0 49192786_1 CDM 0272 RC inpatient 765 497.25 SIHO - ALL PLANS SIHO - ALL PLANS 688.5 90 999999999 463.21 742.05 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** QUAD BLADE 3.0 49192786_1 CDM 0272 RC inpatient 765 497.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 463.21 60.55 999999999 463.21 742.05 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** QUAD BLADE 3.0 49192786_1 CDM 0272 RC inpatient 765 497.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 463.21 742.05 **** BLANKET BY M. PALMER 07/26/2023**** QUAD BLADE 3.0 49192786_1 CDM 0272 RC inpatient 765 497.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 463.21 742.05 **** BLANKET BY M. PALMER 07/26/2023**** QUAD BLADE 3.0 49192786_1 CDM 0272 RC inpatient 765 497.25 ANTHEM HMO ANTHEM HMO 999999999 463.21 742.05 **** BLANKET BY M. PALMER 07/26/2023**** QUAD BLADE 3.0 49192786_1 CDM 0272 RC inpatient 765 497.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 463.21 742.05 **** BLANKET BY M. PALMER 07/26/2023**** QUAD BLADE 3.0 49192786_1 CDM 0272 RC inpatient 765 497.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 463.21 742.05 **** BLANKET BY M. PALMER 07/26/2023**** QUAD BLADE 3.0 49192786_1 CDM 0272 RC inpatient 765 497.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 517.14 67.6 999999999 463.21 742.05 percent of total billed charges FLOW REGULATOR SET MFS106 49192788_1 CDM 0270 RC inpatient 21 13.65 AETNA AETNA 16.59 79 999999999 12.72 20.37 percent of total billed charges FLOW REGULATOR SET MFS106 49192788_1 CDM 0270 RC inpatient 21 13.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 13.65 65 999999999 12.72 20.37 percent of total billed charges FLOW REGULATOR SET MFS106 49192788_1 CDM 0270 RC inpatient 21 13.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20.37 97 999999999 12.72 20.37 percent of total billed charges FLOW REGULATOR SET MFS106 49192788_1 CDM 0270 RC inpatient 21 13.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 16.38 78 999999999 12.72 20.37 percent of total billed charges FLOW REGULATOR SET MFS106 49192788_1 CDM 0270 RC inpatient 21 13.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 14.49 69 999999999 12.72 20.37 percent of total billed charges FLOW REGULATOR SET MFS106 49192788_1 CDM 0270 RC inpatient 21 13.65 UMR - ALL PLANS UMR - ALL PLANS 14.7 70 999999999 12.72 20.37 percent of total billed charges FLOW REGULATOR SET MFS106 49192788_1 CDM 0270 RC inpatient 21 13.65 SIHO - ALL PLANS SIHO - ALL PLANS 18.9 90 999999999 12.72 20.37 percent of total billed charges FLOW REGULATOR SET MFS106 49192788_1 CDM 0270 RC inpatient 21 13.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.72 60.55 999999999 12.72 20.37 percent of total billed charges FLOW REGULATOR SET MFS106 49192788_1 CDM 0270 RC inpatient 21 13.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.72 20.37 FLOW REGULATOR SET MFS106 49192788_1 CDM 0270 RC inpatient 21 13.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.72 20.37 FLOW REGULATOR SET MFS106 49192788_1 CDM 0270 RC inpatient 21 13.65 ANTHEM HMO ANTHEM HMO 999999999 12.72 20.37 FLOW REGULATOR SET MFS106 49192788_1 CDM 0270 RC inpatient 21 13.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.72 20.37 FLOW REGULATOR SET MFS106 49192788_1 CDM 0270 RC inpatient 21 13.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.72 20.37 FLOW REGULATOR SET MFS106 49192788_1 CDM 0270 RC inpatient 21 13.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.2 67.6 999999999 12.72 20.37 percent of total billed charges 3 PORT GRAVITY SET 42433E 49192789_1 CDM 0270 RC inpatient 16 10.4 AETNA AETNA 12.64 79 999999999 9.69 15.52 percent of total billed charges 3 PORT GRAVITY SET 42433E 49192789_1 CDM 0270 RC inpatient 16 10.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.4 65 999999999 9.69 15.52 percent of total billed charges 3 PORT GRAVITY SET 42433E 49192789_1 CDM 0270 RC inpatient 16 10.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15.52 97 999999999 9.69 15.52 percent of total billed charges 3 PORT GRAVITY SET 42433E 49192789_1 CDM 0270 RC inpatient 16 10.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.48 78 999999999 9.69 15.52 percent of total billed charges 3 PORT GRAVITY SET 42433E 49192789_1 CDM 0270 RC inpatient 16 10.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.04 69 999999999 9.69 15.52 percent of total billed charges 3 PORT GRAVITY SET 42433E 49192789_1 CDM 0270 RC inpatient 16 10.4 UMR - ALL PLANS UMR - ALL PLANS 11.2 70 999999999 9.69 15.52 percent of total billed charges 3 PORT GRAVITY SET 42433E 49192789_1 CDM 0270 RC inpatient 16 10.4 SIHO - ALL PLANS SIHO - ALL PLANS 14.4 90 999999999 9.69 15.52 percent of total billed charges 3 PORT GRAVITY SET 42433E 49192789_1 CDM 0270 RC inpatient 16 10.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.69 60.55 999999999 9.69 15.52 percent of total billed charges 3 PORT GRAVITY SET 42433E 49192789_1 CDM 0270 RC inpatient 16 10.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.69 15.52 3 PORT GRAVITY SET 42433E 49192789_1 CDM 0270 RC inpatient 16 10.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.69 15.52 3 PORT GRAVITY SET 42433E 49192789_1 CDM 0270 RC inpatient 16 10.4 ANTHEM HMO ANTHEM HMO 999999999 9.69 15.52 3 PORT GRAVITY SET 42433E 49192789_1 CDM 0270 RC inpatient 16 10.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.69 15.52 3 PORT GRAVITY SET 42433E 49192789_1 CDM 0270 RC inpatient 16 10.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.69 15.52 3 PORT GRAVITY SET 42433E 49192789_1 CDM 0270 RC inpatient 16 10.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.82 67.6 999999999 9.69 15.52 percent of total billed charges 1 PORT GRAVITY SET 41173E 49192790_1 CDM 0270 RC inpatient 6 3.9 AETNA AETNA 4.74 79 999999999 3.63 5.82 percent of total billed charges 1 PORT GRAVITY SET 41173E 49192790_1 CDM 0270 RC inpatient 6 3.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.9 65 999999999 3.63 5.82 percent of total billed charges 1 PORT GRAVITY SET 41173E 49192790_1 CDM 0270 RC inpatient 6 3.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.82 97 999999999 3.63 5.82 percent of total billed charges 1 PORT GRAVITY SET 41173E 49192790_1 CDM 0270 RC inpatient 6 3.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.68 78 999999999 3.63 5.82 percent of total billed charges 1 PORT GRAVITY SET 41173E 49192790_1 CDM 0270 RC inpatient 6 3.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.14 69 999999999 3.63 5.82 percent of total billed charges 1 PORT GRAVITY SET 41173E 49192790_1 CDM 0270 RC inpatient 6 3.9 UMR - ALL PLANS UMR - ALL PLANS 4.2 70 999999999 3.63 5.82 percent of total billed charges 1 PORT GRAVITY SET 41173E 49192790_1 CDM 0270 RC inpatient 6 3.9 SIHO - ALL PLANS SIHO - ALL PLANS 5.4 90 999999999 3.63 5.82 percent of total billed charges 1 PORT GRAVITY SET 41173E 49192790_1 CDM 0270 RC inpatient 6 3.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.63 60.55 999999999 3.63 5.82 percent of total billed charges 1 PORT GRAVITY SET 41173E 49192790_1 CDM 0270 RC inpatient 6 3.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.63 5.82 1 PORT GRAVITY SET 41173E 49192790_1 CDM 0270 RC inpatient 6 3.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.63 5.82 1 PORT GRAVITY SET 41173E 49192790_1 CDM 0270 RC inpatient 6 3.9 ANTHEM HMO ANTHEM HMO 999999999 3.63 5.82 1 PORT GRAVITY SET 41173E 49192790_1 CDM 0270 RC inpatient 6 3.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.63 5.82 1 PORT GRAVITY SET 41173E 49192790_1 CDM 0270 RC inpatient 6 3.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.63 5.82 1 PORT GRAVITY SET 41173E 49192790_1 CDM 0270 RC inpatient 6 3.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.06 67.6 999999999 3.63 5.82 percent of total billed charges ADD .2 MICRON FILTER 10010454 49192791_1 CDM 0270 RC inpatient 36 23.4 AETNA AETNA 28.44 79 999999999 21.8 34.92 percent of total billed charges ADD .2 MICRON FILTER 10010454 49192791_1 CDM 0270 RC inpatient 36 23.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 23.4 65 999999999 21.8 34.92 percent of total billed charges ADD .2 MICRON FILTER 10010454 49192791_1 CDM 0270 RC inpatient 36 23.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34.92 97 999999999 21.8 34.92 percent of total billed charges ADD .2 MICRON FILTER 10010454 49192791_1 CDM 0270 RC inpatient 36 23.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.08 78 999999999 21.8 34.92 percent of total billed charges ADD .2 MICRON FILTER 10010454 49192791_1 CDM 0270 RC inpatient 36 23.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.84 69 999999999 21.8 34.92 percent of total billed charges ADD .2 MICRON FILTER 10010454 49192791_1 CDM 0270 RC inpatient 36 23.4 UMR - ALL PLANS UMR - ALL PLANS 25.2 70 999999999 21.8 34.92 percent of total billed charges ADD .2 MICRON FILTER 10010454 49192791_1 CDM 0270 RC inpatient 36 23.4 SIHO - ALL PLANS SIHO - ALL PLANS 32.4 90 999999999 21.8 34.92 percent of total billed charges ADD .2 MICRON FILTER 10010454 49192791_1 CDM 0270 RC inpatient 36 23.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.8 60.55 999999999 21.8 34.92 percent of total billed charges ADD .2 MICRON FILTER 10010454 49192791_1 CDM 0270 RC inpatient 36 23.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.8 34.92 ADD .2 MICRON FILTER 10010454 49192791_1 CDM 0270 RC inpatient 36 23.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.8 34.92 ADD .2 MICRON FILTER 10010454 49192791_1 CDM 0270 RC inpatient 36 23.4 ANTHEM HMO ANTHEM HMO 999999999 21.8 34.92 ADD .2 MICRON FILTER 10010454 49192791_1 CDM 0270 RC inpatient 36 23.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.8 34.92 ADD .2 MICRON FILTER 10010454 49192791_1 CDM 0270 RC inpatient 36 23.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.8 34.92 ADD .2 MICRON FILTER 10010454 49192791_1 CDM 0270 RC inpatient 36 23.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 24.34 67.6 999999999 21.8 34.92 percent of total billed charges BLOOD PUMP SET 2477-0007 49192792_1 CDM 0270 RC inpatient 42 27.3 AETNA AETNA 33.18 79 999999999 25.43 40.74 percent of total billed charges BLOOD PUMP SET 2477-0007 49192792_1 CDM 0270 RC inpatient 42 27.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 27.3 65 999999999 25.43 40.74 percent of total billed charges BLOOD PUMP SET 2477-0007 49192792_1 CDM 0270 RC inpatient 42 27.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 40.74 97 999999999 25.43 40.74 percent of total billed charges BLOOD PUMP SET 2477-0007 49192792_1 CDM 0270 RC inpatient 42 27.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 32.76 78 999999999 25.43 40.74 percent of total billed charges BLOOD PUMP SET 2477-0007 49192792_1 CDM 0270 RC inpatient 42 27.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.98 69 999999999 25.43 40.74 percent of total billed charges BLOOD PUMP SET 2477-0007 49192792_1 CDM 0270 RC inpatient 42 27.3 UMR - ALL PLANS UMR - ALL PLANS 29.4 70 999999999 25.43 40.74 percent of total billed charges BLOOD PUMP SET 2477-0007 49192792_1 CDM 0270 RC inpatient 42 27.3 SIHO - ALL PLANS SIHO - ALL PLANS 37.8 90 999999999 25.43 40.74 percent of total billed charges BLOOD PUMP SET 2477-0007 49192792_1 CDM 0270 RC inpatient 42 27.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 25.43 60.55 999999999 25.43 40.74 percent of total billed charges BLOOD PUMP SET 2477-0007 49192792_1 CDM 0270 RC inpatient 42 27.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 25.43 40.74 BLOOD PUMP SET 2477-0007 49192792_1 CDM 0270 RC inpatient 42 27.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 25.43 40.74 BLOOD PUMP SET 2477-0007 49192792_1 CDM 0270 RC inpatient 42 27.3 ANTHEM HMO ANTHEM HMO 999999999 25.43 40.74 BLOOD PUMP SET 2477-0007 49192792_1 CDM 0270 RC inpatient 42 27.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 25.43 40.74 BLOOD PUMP SET 2477-0007 49192792_1 CDM 0270 RC inpatient 42 27.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 25.43 40.74 BLOOD PUMP SET 2477-0007 49192792_1 CDM 0270 RC inpatient 42 27.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 28.39 67.6 999999999 25.43 40.74 percent of total billed charges PRIMARY PUMP SET 2426-0007 49192793_1 CDM 0270 RC inpatient 37 24.05 AETNA AETNA 29.23 79 999999999 22.4 35.89 percent of total billed charges PRIMARY PUMP SET 2426-0007 49192793_1 CDM 0270 RC inpatient 37 24.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.05 65 999999999 22.4 35.89 percent of total billed charges PRIMARY PUMP SET 2426-0007 49192793_1 CDM 0270 RC inpatient 37 24.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.89 97 999999999 22.4 35.89 percent of total billed charges PRIMARY PUMP SET 2426-0007 49192793_1 CDM 0270 RC inpatient 37 24.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.86 78 999999999 22.4 35.89 percent of total billed charges PRIMARY PUMP SET 2426-0007 49192793_1 CDM 0270 RC inpatient 37 24.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.53 69 999999999 22.4 35.89 percent of total billed charges PRIMARY PUMP SET 2426-0007 49192793_1 CDM 0270 RC inpatient 37 24.05 UMR - ALL PLANS UMR - ALL PLANS 25.9 70 999999999 22.4 35.89 percent of total billed charges PRIMARY PUMP SET 2426-0007 49192793_1 CDM 0270 RC inpatient 37 24.05 SIHO - ALL PLANS SIHO - ALL PLANS 33.3 90 999999999 22.4 35.89 percent of total billed charges PRIMARY PUMP SET 2426-0007 49192793_1 CDM 0270 RC inpatient 37 24.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.4 60.55 999999999 22.4 35.89 percent of total billed charges PRIMARY PUMP SET 2426-0007 49192793_1 CDM 0270 RC inpatient 37 24.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.4 35.89 PRIMARY PUMP SET 2426-0007 49192793_1 CDM 0270 RC inpatient 37 24.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.4 35.89 PRIMARY PUMP SET 2426-0007 49192793_1 CDM 0270 RC inpatient 37 24.05 ANTHEM HMO ANTHEM HMO 999999999 22.4 35.89 PRIMARY PUMP SET 2426-0007 49192793_1 CDM 0270 RC inpatient 37 24.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.4 35.89 PRIMARY PUMP SET 2426-0007 49192793_1 CDM 0270 RC inpatient 37 24.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.4 35.89 PRIMARY PUMP SET 2426-0007 49192793_1 CDM 0270 RC inpatient 37 24.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.01 67.6 999999999 22.4 35.89 percent of total billed charges MANIFOLD PUMP SET 354210 49192794_1 CDM 0270 RC inpatient 93 60.45 AETNA AETNA 73.47 79 999999999 56.31 90.21 percent of total billed charges MANIFOLD PUMP SET 354210 49192794_1 CDM 0270 RC inpatient 93 60.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 60.45 65 999999999 56.31 90.21 percent of total billed charges MANIFOLD PUMP SET 354210 49192794_1 CDM 0270 RC inpatient 93 60.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 90.21 97 999999999 56.31 90.21 percent of total billed charges MANIFOLD PUMP SET 354210 49192794_1 CDM 0270 RC inpatient 93 60.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 72.54 78 999999999 56.31 90.21 percent of total billed charges MANIFOLD PUMP SET 354210 49192794_1 CDM 0270 RC inpatient 93 60.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.17 69 999999999 56.31 90.21 percent of total billed charges MANIFOLD PUMP SET 354210 49192794_1 CDM 0270 RC inpatient 93 60.45 UMR - ALL PLANS UMR - ALL PLANS 65.1 70 999999999 56.31 90.21 percent of total billed charges MANIFOLD PUMP SET 354210 49192794_1 CDM 0270 RC inpatient 93 60.45 SIHO - ALL PLANS SIHO - ALL PLANS 83.7 90 999999999 56.31 90.21 percent of total billed charges MANIFOLD PUMP SET 354210 49192794_1 CDM 0270 RC inpatient 93 60.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.31 60.55 999999999 56.31 90.21 percent of total billed charges MANIFOLD PUMP SET 354210 49192794_1 CDM 0270 RC inpatient 93 60.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.31 90.21 MANIFOLD PUMP SET 354210 49192794_1 CDM 0270 RC inpatient 93 60.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.31 90.21 MANIFOLD PUMP SET 354210 49192794_1 CDM 0270 RC inpatient 93 60.45 ANTHEM HMO ANTHEM HMO 999999999 56.31 90.21 MANIFOLD PUMP SET 354210 49192794_1 CDM 0270 RC inpatient 93 60.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.31 90.21 MANIFOLD PUMP SET 354210 49192794_1 CDM 0270 RC inpatient 93 60.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.31 90.21 MANIFOLD PUMP SET 354210 49192794_1 CDM 0270 RC inpatient 93 60.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.87 67.6 999999999 56.31 90.21 percent of total billed charges LOW SORB PUMP SET 24600-0007 49192795_1 CDM 0270 RC inpatient 39 25.35 AETNA AETNA 30.81 79 999999999 23.61 37.83 percent of total billed charges LOW SORB PUMP SET 24600-0007 49192795_1 CDM 0270 RC inpatient 39 25.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 25.35 65 999999999 23.61 37.83 percent of total billed charges LOW SORB PUMP SET 24600-0007 49192795_1 CDM 0270 RC inpatient 39 25.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37.83 97 999999999 23.61 37.83 percent of total billed charges LOW SORB PUMP SET 24600-0007 49192795_1 CDM 0270 RC inpatient 39 25.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 30.42 78 999999999 23.61 37.83 percent of total billed charges LOW SORB PUMP SET 24600-0007 49192795_1 CDM 0270 RC inpatient 39 25.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.91 69 999999999 23.61 37.83 percent of total billed charges LOW SORB PUMP SET 24600-0007 49192795_1 CDM 0270 RC inpatient 39 25.35 UMR - ALL PLANS UMR - ALL PLANS 27.3 70 999999999 23.61 37.83 percent of total billed charges LOW SORB PUMP SET 24600-0007 49192795_1 CDM 0270 RC inpatient 39 25.35 SIHO - ALL PLANS SIHO - ALL PLANS 35.1 90 999999999 23.61 37.83 percent of total billed charges LOW SORB PUMP SET 24600-0007 49192795_1 CDM 0270 RC inpatient 39 25.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.61 60.55 999999999 23.61 37.83 percent of total billed charges LOW SORB PUMP SET 24600-0007 49192795_1 CDM 0270 RC inpatient 39 25.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.61 37.83 LOW SORB PUMP SET 24600-0007 49192795_1 CDM 0270 RC inpatient 39 25.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.61 37.83 LOW SORB PUMP SET 24600-0007 49192795_1 CDM 0270 RC inpatient 39 25.35 ANTHEM HMO ANTHEM HMO 999999999 23.61 37.83 LOW SORB PUMP SET 24600-0007 49192795_1 CDM 0270 RC inpatient 39 25.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.61 37.83 LOW SORB PUMP SET 24600-0007 49192795_1 CDM 0270 RC inpatient 39 25.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.61 37.83 LOW SORB PUMP SET 24600-0007 49192795_1 CDM 0270 RC inpatient 39 25.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 26.36 67.6 999999999 23.61 37.83 percent of total billed charges XPRESS ULTRA SINUS BALLOON ULF-106 49192801_1 CDM 0272 RC inpatient 6422 4174.3 AETNA AETNA 5073.38 79 999999999 3888.52 6229.34 percent of total billed charges XPRESS ULTRA SINUS BALLOON ULF-106 49192801_1 CDM 0272 RC inpatient 6422 4174.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 4174.3 65 999999999 3888.52 6229.34 percent of total billed charges XPRESS ULTRA SINUS BALLOON ULF-106 49192801_1 CDM 0272 RC inpatient 6422 4174.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6229.34 97 999999999 3888.52 6229.34 percent of total billed charges XPRESS ULTRA SINUS BALLOON ULF-106 49192801_1 CDM 0272 RC inpatient 6422 4174.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 5009.16 78 999999999 3888.52 6229.34 percent of total billed charges XPRESS ULTRA SINUS BALLOON ULF-106 49192801_1 CDM 0272 RC inpatient 6422 4174.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 4431.18 69 999999999 3888.52 6229.34 percent of total billed charges XPRESS ULTRA SINUS BALLOON ULF-106 49192801_1 CDM 0272 RC inpatient 6422 4174.3 UMR - ALL PLANS UMR - ALL PLANS 4495.4 70 999999999 3888.52 6229.34 percent of total billed charges XPRESS ULTRA SINUS BALLOON ULF-106 49192801_1 CDM 0272 RC inpatient 6422 4174.3 SIHO - ALL PLANS SIHO - ALL PLANS 5779.8 90 999999999 3888.52 6229.34 percent of total billed charges XPRESS ULTRA SINUS BALLOON ULF-106 49192801_1 CDM 0272 RC inpatient 6422 4174.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3888.52 60.55 999999999 3888.52 6229.34 percent of total billed charges XPRESS ULTRA SINUS BALLOON ULF-106 49192801_1 CDM 0272 RC inpatient 6422 4174.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3888.52 6229.34 XPRESS ULTRA SINUS BALLOON ULF-106 49192801_1 CDM 0272 RC inpatient 6422 4174.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3888.52 6229.34 XPRESS ULTRA SINUS BALLOON ULF-106 49192801_1 CDM 0272 RC inpatient 6422 4174.3 ANTHEM HMO ANTHEM HMO 999999999 3888.52 6229.34 XPRESS ULTRA SINUS BALLOON ULF-106 49192801_1 CDM 0272 RC inpatient 6422 4174.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3888.52 6229.34 XPRESS ULTRA SINUS BALLOON ULF-106 49192801_1 CDM 0272 RC inpatient 6422 4174.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 3888.52 6229.34 XPRESS ULTRA SINUS BALLOON ULF-106 49192801_1 CDM 0272 RC inpatient 6422 4174.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 4341.27 67.6 999999999 3888.52 6229.34 percent of total billed charges CYCLONE SUCTION IRRIGATION SYSTEM 49192802_1 CDM 0272 RC inpatient 1493 970.45 AETNA AETNA 1179.47 79 999999999 904.01 1448.21 percent of total billed charges CYCLONE SUCTION IRRIGATION SYSTEM 49192802_1 CDM 0272 RC inpatient 1493 970.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 970.45 65 999999999 904.01 1448.21 percent of total billed charges CYCLONE SUCTION IRRIGATION SYSTEM 49192802_1 CDM 0272 RC inpatient 1493 970.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1448.21 97 999999999 904.01 1448.21 percent of total billed charges CYCLONE SUCTION IRRIGATION SYSTEM 49192802_1 CDM 0272 RC inpatient 1493 970.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1164.54 78 999999999 904.01 1448.21 percent of total billed charges CYCLONE SUCTION IRRIGATION SYSTEM 49192802_1 CDM 0272 RC inpatient 1493 970.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1030.17 69 999999999 904.01 1448.21 percent of total billed charges CYCLONE SUCTION IRRIGATION SYSTEM 49192802_1 CDM 0272 RC inpatient 1493 970.45 UMR - ALL PLANS UMR - ALL PLANS 1045.1 70 999999999 904.01 1448.21 percent of total billed charges CYCLONE SUCTION IRRIGATION SYSTEM 49192802_1 CDM 0272 RC inpatient 1493 970.45 SIHO - ALL PLANS SIHO - ALL PLANS 1343.7 90 999999999 904.01 1448.21 percent of total billed charges CYCLONE SUCTION IRRIGATION SYSTEM 49192802_1 CDM 0272 RC inpatient 1493 970.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 904.01 60.55 999999999 904.01 1448.21 percent of total billed charges CYCLONE SUCTION IRRIGATION SYSTEM 49192802_1 CDM 0272 RC inpatient 1493 970.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 904.01 1448.21 CYCLONE SUCTION IRRIGATION SYSTEM 49192802_1 CDM 0272 RC inpatient 1493 970.45 ANTHEM HMO ANTHEM HMO 999999999 904.01 1448.21 CYCLONE SUCTION IRRIGATION SYSTEM 49192802_1 CDM 0272 RC inpatient 1493 970.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 904.01 1448.21 CYCLONE SUCTION IRRIGATION SYSTEM 49192802_1 CDM 0272 RC inpatient 1493 970.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 904.01 1448.21 CYCLONE SUCTION IRRIGATION SYSTEM 49192802_1 CDM 0272 RC inpatient 1493 970.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 904.01 1448.21 CYCLONE SUCTION IRRIGATION SYSTEM 49192802_1 CDM 0272 RC inpatient 1493 970.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1009.27 67.6 999999999 904.01 1448.21 percent of total billed charges BLADE 3.5MM RAD 120 1883517 49192807_1 CDM 0272 RC inpatient 1596 1037.4 AETNA AETNA 1260.84 79 999999999 966.38 1548.12 percent of total billed charges BLADE 3.5MM RAD 120 1883517 49192807_1 CDM 0272 RC inpatient 1596 1037.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1037.4 65 999999999 966.38 1548.12 percent of total billed charges BLADE 3.5MM RAD 120 1883517 49192807_1 CDM 0272 RC inpatient 1596 1037.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1548.12 97 999999999 966.38 1548.12 percent of total billed charges BLADE 3.5MM RAD 120 1883517 49192807_1 CDM 0272 RC inpatient 1596 1037.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1244.88 78 999999999 966.38 1548.12 percent of total billed charges BLADE 3.5MM RAD 120 1883517 49192807_1 CDM 0272 RC inpatient 1596 1037.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1101.24 69 999999999 966.38 1548.12 percent of total billed charges BLADE 3.5MM RAD 120 1883517 49192807_1 CDM 0272 RC inpatient 1596 1037.4 UMR - ALL PLANS UMR - ALL PLANS 1117.2 70 999999999 966.38 1548.12 percent of total billed charges BLADE 3.5MM RAD 120 1883517 49192807_1 CDM 0272 RC inpatient 1596 1037.4 SIHO - ALL PLANS SIHO - ALL PLANS 1436.4 90 999999999 966.38 1548.12 percent of total billed charges BLADE 3.5MM RAD 120 1883517 49192807_1 CDM 0272 RC inpatient 1596 1037.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 966.38 60.55 999999999 966.38 1548.12 percent of total billed charges BLADE 3.5MM RAD 120 1883517 49192807_1 CDM 0272 RC inpatient 1596 1037.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 966.38 1548.12 BLADE 3.5MM RAD 120 1883517 49192807_1 CDM 0272 RC inpatient 1596 1037.4 ANTHEM HMO ANTHEM HMO 999999999 966.38 1548.12 BLADE 3.5MM RAD 120 1883517 49192807_1 CDM 0272 RC inpatient 1596 1037.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 966.38 1548.12 BLADE 3.5MM RAD 120 1883517 49192807_1 CDM 0272 RC inpatient 1596 1037.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 966.38 1548.12 BLADE 3.5MM RAD 120 1883517 49192807_1 CDM 0272 RC inpatient 1596 1037.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 966.38 1548.12 BLADE 3.5MM RAD 120 1883517 49192807_1 CDM 0272 RC inpatient 1596 1037.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1078.9 67.6 999999999 966.38 1548.12 percent of total billed charges BLADE 3.5MM RAD 90 1883519HR 49192808_1 CDM 0278 RC inpatient 1661 1079.65 AETNA AETNA 1312.19 79 999999999 1005.74 1611.17 percent of total billed charges BLADE 3.5MM RAD 90 1883519HR 49192808_1 CDM 0278 RC inpatient 1661 1079.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1079.65 65 999999999 1005.74 1611.17 percent of total billed charges BLADE 3.5MM RAD 90 1883519HR 49192808_1 CDM 0278 RC inpatient 1661 1079.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1611.17 97 999999999 1005.74 1611.17 percent of total billed charges BLADE 3.5MM RAD 90 1883519HR 49192808_1 CDM 0278 RC inpatient 1661 1079.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1295.58 78 999999999 1005.74 1611.17 percent of total billed charges BLADE 3.5MM RAD 90 1883519HR 49192808_1 CDM 0278 RC inpatient 1661 1079.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1146.09 69 999999999 1005.74 1611.17 percent of total billed charges BLADE 3.5MM RAD 90 1883519HR 49192808_1 CDM 0278 RC inpatient 1661 1079.65 UMR - ALL PLANS UMR - ALL PLANS 1162.7 70 999999999 1005.74 1611.17 percent of total billed charges BLADE 3.5MM RAD 90 1883519HR 49192808_1 CDM 0278 RC inpatient 1661 1079.65 SIHO - ALL PLANS SIHO - ALL PLANS 1494.9 90 999999999 1005.74 1611.17 percent of total billed charges BLADE 3.5MM RAD 90 1883519HR 49192808_1 CDM 0278 RC inpatient 1661 1079.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1005.74 60.55 999999999 1005.74 1611.17 percent of total billed charges BLADE 3.5MM RAD 90 1883519HR 49192808_1 CDM 0278 RC inpatient 1661 1079.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1005.74 1611.17 BLADE 3.5MM RAD 90 1883519HR 49192808_1 CDM 0278 RC inpatient 1661 1079.65 ANTHEM HMO ANTHEM HMO 999999999 1005.74 1611.17 BLADE 3.5MM RAD 90 1883519HR 49192808_1 CDM 0278 RC inpatient 1661 1079.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1005.74 1611.17 BLADE 3.5MM RAD 90 1883519HR 49192808_1 CDM 0278 RC inpatient 1661 1079.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1005.74 1611.17 BLADE 3.5MM RAD 90 1883519HR 49192808_1 CDM 0278 RC inpatient 1661 1079.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1005.74 1611.17 BLADE 3.5MM RAD 90 1883519HR 49192808_1 CDM 0278 RC inpatient 1661 1079.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1122.84 67.6 999999999 1005.74 1611.17 percent of total billed charges STIFNECK PEDI-SELECT COLLAR 980200 49192810_1 CDM 0270 RC inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges STIFNECK PEDI-SELECT COLLAR 980200 49192810_1 CDM 0270 RC inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges STIFNECK PEDI-SELECT COLLAR 980200 49192810_1 CDM 0270 RC inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges STIFNECK PEDI-SELECT COLLAR 980200 49192810_1 CDM 0270 RC inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges STIFNECK PEDI-SELECT COLLAR 980200 49192810_1 CDM 0270 RC inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges STIFNECK PEDI-SELECT COLLAR 980200 49192810_1 CDM 0270 RC inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges STIFNECK PEDI-SELECT COLLAR 980200 49192810_1 CDM 0270 RC inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges STIFNECK PEDI-SELECT COLLAR 980200 49192810_1 CDM 0270 RC inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges STIFNECK PEDI-SELECT COLLAR 980200 49192810_1 CDM 0270 RC inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 STIFNECK PEDI-SELECT COLLAR 980200 49192810_1 CDM 0270 RC inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 STIFNECK PEDI-SELECT COLLAR 980200 49192810_1 CDM 0270 RC inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 STIFNECK PEDI-SELECT COLLAR 980200 49192810_1 CDM 0270 RC inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 STIFNECK PEDI-SELECT COLLAR 980200 49192810_1 CDM 0270 RC inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 STIFNECK PEDI-SELECT COLLAR 980200 49192810_1 CDM 0270 RC inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges BIOPSY SYSTEM COMPREHENSIVE 49192816_1 CDM 0272 RC inpatient 913 593.45 AETNA AETNA 721.27 79 999999999 552.82 885.61 percent of total billed charges BIOPSY SYSTEM COMPREHENSIVE 49192816_1 CDM 0272 RC inpatient 913 593.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 593.45 65 999999999 552.82 885.61 percent of total billed charges BIOPSY SYSTEM COMPREHENSIVE 49192816_1 CDM 0272 RC inpatient 913 593.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 885.61 97 999999999 552.82 885.61 percent of total billed charges BIOPSY SYSTEM COMPREHENSIVE 49192816_1 CDM 0272 RC inpatient 913 593.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 712.14 78 999999999 552.82 885.61 percent of total billed charges BIOPSY SYSTEM COMPREHENSIVE 49192816_1 CDM 0272 RC inpatient 913 593.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 629.97 69 999999999 552.82 885.61 percent of total billed charges BIOPSY SYSTEM COMPREHENSIVE 49192816_1 CDM 0272 RC inpatient 913 593.45 UMR - ALL PLANS UMR - ALL PLANS 639.1 70 999999999 552.82 885.61 percent of total billed charges BIOPSY SYSTEM COMPREHENSIVE 49192816_1 CDM 0272 RC inpatient 913 593.45 SIHO - ALL PLANS SIHO - ALL PLANS 821.7 90 999999999 552.82 885.61 percent of total billed charges BIOPSY SYSTEM COMPREHENSIVE 49192816_1 CDM 0272 RC inpatient 913 593.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 552.82 60.55 999999999 552.82 885.61 percent of total billed charges BIOPSY SYSTEM COMPREHENSIVE 49192816_1 CDM 0272 RC inpatient 913 593.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 552.82 885.61 BIOPSY SYSTEM COMPREHENSIVE 49192816_1 CDM 0272 RC inpatient 913 593.45 ANTHEM HMO ANTHEM HMO 999999999 552.82 885.61 BIOPSY SYSTEM COMPREHENSIVE 49192816_1 CDM 0272 RC inpatient 913 593.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 552.82 885.61 BIOPSY SYSTEM COMPREHENSIVE 49192816_1 CDM 0272 RC inpatient 913 593.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 552.82 885.61 BIOPSY SYSTEM COMPREHENSIVE 49192816_1 CDM 0272 RC inpatient 913 593.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 552.82 885.61 BIOPSY SYSTEM COMPREHENSIVE 49192816_1 CDM 0272 RC inpatient 913 593.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 617.19 67.6 999999999 552.82 885.61 percent of total billed charges VICRYL SUTURE 0 J418H 49192834_1 CDM 0272 RC inpatient 16 10.4 AETNA AETNA 12.64 79 999999999 9.69 15.52 percent of total billed charges VICRYL SUTURE 0 J418H 49192834_1 CDM 0272 RC inpatient 16 10.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.4 65 999999999 9.69 15.52 percent of total billed charges VICRYL SUTURE 0 J418H 49192834_1 CDM 0272 RC inpatient 16 10.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15.52 97 999999999 9.69 15.52 percent of total billed charges VICRYL SUTURE 0 J418H 49192834_1 CDM 0272 RC inpatient 16 10.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.48 78 999999999 9.69 15.52 percent of total billed charges VICRYL SUTURE 0 J418H 49192834_1 CDM 0272 RC inpatient 16 10.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.04 69 999999999 9.69 15.52 percent of total billed charges VICRYL SUTURE 0 J418H 49192834_1 CDM 0272 RC inpatient 16 10.4 UMR - ALL PLANS UMR - ALL PLANS 11.2 70 999999999 9.69 15.52 percent of total billed charges VICRYL SUTURE 0 J418H 49192834_1 CDM 0272 RC inpatient 16 10.4 SIHO - ALL PLANS SIHO - ALL PLANS 14.4 90 999999999 9.69 15.52 percent of total billed charges VICRYL SUTURE 0 J418H 49192834_1 CDM 0272 RC inpatient 16 10.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.69 60.55 999999999 9.69 15.52 percent of total billed charges VICRYL SUTURE 0 J418H 49192834_1 CDM 0272 RC inpatient 16 10.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.69 15.52 VICRYL SUTURE 0 J418H 49192834_1 CDM 0272 RC inpatient 16 10.4 ANTHEM HMO ANTHEM HMO 999999999 9.69 15.52 VICRYL SUTURE 0 J418H 49192834_1 CDM 0272 RC inpatient 16 10.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.69 15.52 VICRYL SUTURE 0 J418H 49192834_1 CDM 0272 RC inpatient 16 10.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.69 15.52 VICRYL SUTURE 0 J418H 49192834_1 CDM 0272 RC inpatient 16 10.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.69 15.52 VICRYL SUTURE 0 J418H 49192834_1 CDM 0272 RC inpatient 16 10.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.82 67.6 999999999 9.69 15.52 percent of total billed charges TUBE GASTROSTOMY 22FR 49192839_1 CDM 0272 RC inpatient 256 166.4 AETNA AETNA 202.24 79 999999999 155.01 248.32 percent of total billed charges TUBE GASTROSTOMY 22FR 49192839_1 CDM 0272 RC inpatient 256 166.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 166.4 65 999999999 155.01 248.32 percent of total billed charges TUBE GASTROSTOMY 22FR 49192839_1 CDM 0272 RC inpatient 256 166.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 248.32 97 999999999 155.01 248.32 percent of total billed charges TUBE GASTROSTOMY 22FR 49192839_1 CDM 0272 RC inpatient 256 166.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 199.68 78 999999999 155.01 248.32 percent of total billed charges TUBE GASTROSTOMY 22FR 49192839_1 CDM 0272 RC inpatient 256 166.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 176.64 69 999999999 155.01 248.32 percent of total billed charges TUBE GASTROSTOMY 22FR 49192839_1 CDM 0272 RC inpatient 256 166.4 UMR - ALL PLANS UMR - ALL PLANS 179.2 70 999999999 155.01 248.32 percent of total billed charges TUBE GASTROSTOMY 22FR 49192839_1 CDM 0272 RC inpatient 256 166.4 SIHO - ALL PLANS SIHO - ALL PLANS 230.4 90 999999999 155.01 248.32 percent of total billed charges TUBE GASTROSTOMY 22FR 49192839_1 CDM 0272 RC inpatient 256 166.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.01 60.55 999999999 155.01 248.32 percent of total billed charges TUBE GASTROSTOMY 22FR 49192839_1 CDM 0272 RC inpatient 256 166.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.01 248.32 TUBE GASTROSTOMY 22FR 49192839_1 CDM 0272 RC inpatient 256 166.4 ANTHEM HMO ANTHEM HMO 999999999 155.01 248.32 TUBE GASTROSTOMY 22FR 49192839_1 CDM 0272 RC inpatient 256 166.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.01 248.32 TUBE GASTROSTOMY 22FR 49192839_1 CDM 0272 RC inpatient 256 166.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.01 248.32 TUBE GASTROSTOMY 22FR 49192839_1 CDM 0272 RC inpatient 256 166.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.01 248.32 TUBE GASTROSTOMY 22FR 49192839_1 CDM 0272 RC inpatient 256 166.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.06 67.6 999999999 155.01 248.32 percent of total billed charges FILTER EXT PEDS INFUSION SET 2432-0007 49192840_1 CDM 0270 RC inpatient 33 21.45 AETNA AETNA 26.07 79 999999999 19.98 32.01 percent of total billed charges FILTER EXT PEDS INFUSION SET 2432-0007 49192840_1 CDM 0270 RC inpatient 33 21.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.45 65 999999999 19.98 32.01 percent of total billed charges FILTER EXT PEDS INFUSION SET 2432-0007 49192840_1 CDM 0270 RC inpatient 33 21.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.01 97 999999999 19.98 32.01 percent of total billed charges FILTER EXT PEDS INFUSION SET 2432-0007 49192840_1 CDM 0270 RC inpatient 33 21.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.74 78 999999999 19.98 32.01 percent of total billed charges FILTER EXT PEDS INFUSION SET 2432-0007 49192840_1 CDM 0270 RC inpatient 33 21.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.77 69 999999999 19.98 32.01 percent of total billed charges FILTER EXT PEDS INFUSION SET 2432-0007 49192840_1 CDM 0270 RC inpatient 33 21.45 UMR - ALL PLANS UMR - ALL PLANS 23.1 70 999999999 19.98 32.01 percent of total billed charges FILTER EXT PEDS INFUSION SET 2432-0007 49192840_1 CDM 0270 RC inpatient 33 21.45 SIHO - ALL PLANS SIHO - ALL PLANS 29.7 90 999999999 19.98 32.01 percent of total billed charges FILTER EXT PEDS INFUSION SET 2432-0007 49192840_1 CDM 0270 RC inpatient 33 21.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.98 60.55 999999999 19.98 32.01 percent of total billed charges FILTER EXT PEDS INFUSION SET 2432-0007 49192840_1 CDM 0270 RC inpatient 33 21.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.98 32.01 FILTER EXT PEDS INFUSION SET 2432-0007 49192840_1 CDM 0270 RC inpatient 33 21.45 ANTHEM HMO ANTHEM HMO 999999999 19.98 32.01 FILTER EXT PEDS INFUSION SET 2432-0007 49192840_1 CDM 0270 RC inpatient 33 21.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.98 32.01 FILTER EXT PEDS INFUSION SET 2432-0007 49192840_1 CDM 0270 RC inpatient 33 21.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.98 32.01 FILTER EXT PEDS INFUSION SET 2432-0007 49192840_1 CDM 0270 RC inpatient 33 21.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.98 32.01 FILTER EXT PEDS INFUSION SET 2432-0007 49192840_1 CDM 0270 RC inpatient 33 21.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.31 67.6 999999999 19.98 32.01 percent of total billed charges ENDOCUFF MED BLUE 49192841_1 CDM 0272 RC inpatient 61 39.65 AETNA AETNA 48.19 79 999999999 36.94 59.17 percent of total billed charges ENDOCUFF MED BLUE 49192841_1 CDM 0272 RC inpatient 61 39.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.65 65 999999999 36.94 59.17 percent of total billed charges ENDOCUFF MED BLUE 49192841_1 CDM 0272 RC inpatient 61 39.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59.17 97 999999999 36.94 59.17 percent of total billed charges ENDOCUFF MED BLUE 49192841_1 CDM 0272 RC inpatient 61 39.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.58 78 999999999 36.94 59.17 percent of total billed charges ENDOCUFF MED BLUE 49192841_1 CDM 0272 RC inpatient 61 39.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.09 69 999999999 36.94 59.17 percent of total billed charges ENDOCUFF MED BLUE 49192841_1 CDM 0272 RC inpatient 61 39.65 UMR - ALL PLANS UMR - ALL PLANS 42.7 70 999999999 36.94 59.17 percent of total billed charges ENDOCUFF MED BLUE 49192841_1 CDM 0272 RC inpatient 61 39.65 SIHO - ALL PLANS SIHO - ALL PLANS 54.9 90 999999999 36.94 59.17 percent of total billed charges ENDOCUFF MED BLUE 49192841_1 CDM 0272 RC inpatient 61 39.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.94 60.55 999999999 36.94 59.17 percent of total billed charges ENDOCUFF MED BLUE 49192841_1 CDM 0272 RC inpatient 61 39.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.94 59.17 ENDOCUFF MED BLUE 49192841_1 CDM 0272 RC inpatient 61 39.65 ANTHEM HMO ANTHEM HMO 999999999 36.94 59.17 ENDOCUFF MED BLUE 49192841_1 CDM 0272 RC inpatient 61 39.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.94 59.17 ENDOCUFF MED BLUE 49192841_1 CDM 0272 RC inpatient 61 39.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.94 59.17 ENDOCUFF MED BLUE 49192841_1 CDM 0272 RC inpatient 61 39.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.94 59.17 ENDOCUFF MED BLUE 49192841_1 CDM 0272 RC inpatient 61 39.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.24 67.6 999999999 36.94 59.17 percent of total billed charges ENDOCUFF LARGE GREEN ARV120 49192842_1 CDM 0272 RC inpatient 58 37.7 AETNA AETNA 45.82 79 999999999 35.12 56.26 percent of total billed charges ENDOCUFF LARGE GREEN ARV120 49192842_1 CDM 0272 RC inpatient 58 37.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.7 65 999999999 35.12 56.26 percent of total billed charges ENDOCUFF LARGE GREEN ARV120 49192842_1 CDM 0272 RC inpatient 58 37.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.26 97 999999999 35.12 56.26 percent of total billed charges ENDOCUFF LARGE GREEN ARV120 49192842_1 CDM 0272 RC inpatient 58 37.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.24 78 999999999 35.12 56.26 percent of total billed charges ENDOCUFF LARGE GREEN ARV120 49192842_1 CDM 0272 RC inpatient 58 37.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.02 69 999999999 35.12 56.26 percent of total billed charges ENDOCUFF LARGE GREEN ARV120 49192842_1 CDM 0272 RC inpatient 58 37.7 UMR - ALL PLANS UMR - ALL PLANS 40.6 70 999999999 35.12 56.26 percent of total billed charges ENDOCUFF LARGE GREEN ARV120 49192842_1 CDM 0272 RC inpatient 58 37.7 SIHO - ALL PLANS SIHO - ALL PLANS 52.2 90 999999999 35.12 56.26 percent of total billed charges ENDOCUFF LARGE GREEN ARV120 49192842_1 CDM 0272 RC inpatient 58 37.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.12 60.55 999999999 35.12 56.26 percent of total billed charges ENDOCUFF LARGE GREEN ARV120 49192842_1 CDM 0272 RC inpatient 58 37.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.12 56.26 ENDOCUFF LARGE GREEN ARV120 49192842_1 CDM 0272 RC inpatient 58 37.7 ANTHEM HMO ANTHEM HMO 999999999 35.12 56.26 ENDOCUFF LARGE GREEN ARV120 49192842_1 CDM 0272 RC inpatient 58 37.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.12 56.26 ENDOCUFF LARGE GREEN ARV120 49192842_1 CDM 0272 RC inpatient 58 37.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.12 56.26 ENDOCUFF LARGE GREEN ARV120 49192842_1 CDM 0272 RC inpatient 58 37.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.12 56.26 ENDOCUFF LARGE GREEN ARV120 49192842_1 CDM 0272 RC inpatient 58 37.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.21 67.6 999999999 35.12 56.26 percent of total billed charges DISP GRASPING FORCEPTS SUR ENDO 49192859_1 CDM 0272 RC inpatient 1008 655.2 AETNA AETNA 796.32 79 999999999 610.34 977.76 percent of total billed charges DISP GRASPING FORCEPTS SUR ENDO 49192859_1 CDM 0272 RC inpatient 1008 655.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 655.2 65 999999999 610.34 977.76 percent of total billed charges DISP GRASPING FORCEPTS SUR ENDO 49192859_1 CDM 0272 RC inpatient 1008 655.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 977.76 97 999999999 610.34 977.76 percent of total billed charges DISP GRASPING FORCEPTS SUR ENDO 49192859_1 CDM 0272 RC inpatient 1008 655.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 786.24 78 999999999 610.34 977.76 percent of total billed charges DISP GRASPING FORCEPTS SUR ENDO 49192859_1 CDM 0272 RC inpatient 1008 655.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 695.52 69 999999999 610.34 977.76 percent of total billed charges DISP GRASPING FORCEPTS SUR ENDO 49192859_1 CDM 0272 RC inpatient 1008 655.2 UMR - ALL PLANS UMR - ALL PLANS 705.6 70 999999999 610.34 977.76 percent of total billed charges DISP GRASPING FORCEPTS SUR ENDO 49192859_1 CDM 0272 RC inpatient 1008 655.2 SIHO - ALL PLANS SIHO - ALL PLANS 907.2 90 999999999 610.34 977.76 percent of total billed charges DISP GRASPING FORCEPTS SUR ENDO 49192859_1 CDM 0272 RC inpatient 1008 655.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 610.34 60.55 999999999 610.34 977.76 percent of total billed charges DISP GRASPING FORCEPTS SUR ENDO 49192859_1 CDM 0272 RC inpatient 1008 655.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 610.34 977.76 DISP GRASPING FORCEPTS SUR ENDO 49192859_1 CDM 0272 RC inpatient 1008 655.2 ANTHEM HMO ANTHEM HMO 999999999 610.34 977.76 DISP GRASPING FORCEPTS SUR ENDO 49192859_1 CDM 0272 RC inpatient 1008 655.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 610.34 977.76 DISP GRASPING FORCEPTS SUR ENDO 49192859_1 CDM 0272 RC inpatient 1008 655.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 610.34 977.76 DISP GRASPING FORCEPTS SUR ENDO 49192859_1 CDM 0272 RC inpatient 1008 655.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 610.34 977.76 DISP GRASPING FORCEPTS SUR ENDO 49192859_1 CDM 0272 RC inpatient 1008 655.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 681.41 67.6 999999999 610.34 977.76 percent of total billed charges "REPAIR DEVICE, URINARY, INCONTINENCE, WITH SLING GRAFT" 49192860_1 CDM 0278 RC C1771 HCPCS inpatient 4066 2642.9 AETNA AETNA 3212.14 79 999999999 2461.96 3944.02 percent of total billed charges "REPAIR DEVICE, URINARY, INCONTINENCE, WITH SLING GRAFT" 49192860_1 CDM 0278 RC C1771 HCPCS inpatient 4066 2642.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 2642.9 65 999999999 2461.96 3944.02 percent of total billed charges "REPAIR DEVICE, URINARY, INCONTINENCE, WITH SLING GRAFT" 49192860_1 CDM 0278 RC C1771 HCPCS inpatient 4066 2642.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3944.02 97 999999999 2461.96 3944.02 percent of total billed charges "REPAIR DEVICE, URINARY, INCONTINENCE, WITH SLING GRAFT" 49192860_1 CDM 0278 RC C1771 HCPCS inpatient 4066 2642.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 3171.48 78 999999999 2461.96 3944.02 percent of total billed charges "REPAIR DEVICE, URINARY, INCONTINENCE, WITH SLING GRAFT" 49192860_1 CDM 0278 RC C1771 HCPCS inpatient 4066 2642.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 2805.54 69 999999999 2461.96 3944.02 percent of total billed charges "REPAIR DEVICE, URINARY, INCONTINENCE, WITH SLING GRAFT" 49192860_1 CDM 0278 RC C1771 HCPCS inpatient 4066 2642.9 UMR - ALL PLANS UMR - ALL PLANS 2846.2 70 999999999 2461.96 3944.02 percent of total billed charges "REPAIR DEVICE, URINARY, INCONTINENCE, WITH SLING GRAFT" 49192860_1 CDM 0278 RC C1771 HCPCS inpatient 4066 2642.9 SIHO - ALL PLANS SIHO - ALL PLANS 3659.4 90 999999999 2461.96 3944.02 percent of total billed charges "REPAIR DEVICE, URINARY, INCONTINENCE, WITH SLING GRAFT" 49192860_1 CDM 0278 RC C1771 HCPCS inpatient 4066 2642.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2461.96 60.55 999999999 2461.96 3944.02 percent of total billed charges "REPAIR DEVICE, URINARY, INCONTINENCE, WITH SLING GRAFT" 49192860_1 CDM 0278 RC C1771 HCPCS inpatient 4066 2642.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2461.96 3944.02 "REPAIR DEVICE, URINARY, INCONTINENCE, WITH SLING GRAFT" 49192860_1 CDM 0278 RC C1771 HCPCS inpatient 4066 2642.9 ANTHEM HMO ANTHEM HMO 999999999 2461.96 3944.02 "REPAIR DEVICE, URINARY, INCONTINENCE, WITH SLING GRAFT" 49192860_1 CDM 0278 RC C1771 HCPCS inpatient 4066 2642.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2461.96 3944.02 "REPAIR DEVICE, URINARY, INCONTINENCE, WITH SLING GRAFT" 49192860_1 CDM 0278 RC C1771 HCPCS inpatient 4066 2642.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2461.96 3944.02 "REPAIR DEVICE, URINARY, INCONTINENCE, WITH SLING GRAFT" 49192860_1 CDM 0278 RC C1771 HCPCS inpatient 4066 2642.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 2461.96 3944.02 "REPAIR DEVICE, URINARY, INCONTINENCE, WITH SLING GRAFT" 49192860_1 CDM 0278 RC C1771 HCPCS inpatient 4066 2642.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 2748.62 67.6 999999999 2461.96 3944.02 percent of total billed charges AXIS GRAFT 8X12 49192861_1 CDM 0272 RC inpatient 7317 4756.05 AETNA AETNA 5780.43 79 999999999 4430.44 7097.49 percent of total billed charges AXIS GRAFT 8X12 49192861_1 CDM 0272 RC inpatient 7317 4756.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 4756.05 65 999999999 4430.44 7097.49 percent of total billed charges AXIS GRAFT 8X12 49192861_1 CDM 0272 RC inpatient 7317 4756.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7097.49 97 999999999 4430.44 7097.49 percent of total billed charges AXIS GRAFT 8X12 49192861_1 CDM 0272 RC inpatient 7317 4756.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 5707.26 78 999999999 4430.44 7097.49 percent of total billed charges AXIS GRAFT 8X12 49192861_1 CDM 0272 RC inpatient 7317 4756.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 5048.73 69 999999999 4430.44 7097.49 percent of total billed charges AXIS GRAFT 8X12 49192861_1 CDM 0272 RC inpatient 7317 4756.05 UMR - ALL PLANS UMR - ALL PLANS 5121.9 70 999999999 4430.44 7097.49 percent of total billed charges AXIS GRAFT 8X12 49192861_1 CDM 0272 RC inpatient 7317 4756.05 SIHO - ALL PLANS SIHO - ALL PLANS 6585.3 90 999999999 4430.44 7097.49 percent of total billed charges AXIS GRAFT 8X12 49192861_1 CDM 0272 RC inpatient 7317 4756.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4430.44 60.55 999999999 4430.44 7097.49 percent of total billed charges AXIS GRAFT 8X12 49192861_1 CDM 0272 RC inpatient 7317 4756.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4430.44 7097.49 AXIS GRAFT 8X12 49192861_1 CDM 0272 RC inpatient 7317 4756.05 ANTHEM HMO ANTHEM HMO 999999999 4430.44 7097.49 AXIS GRAFT 8X12 49192861_1 CDM 0272 RC inpatient 7317 4756.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4430.44 7097.49 AXIS GRAFT 8X12 49192861_1 CDM 0272 RC inpatient 7317 4756.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4430.44 7097.49 AXIS GRAFT 8X12 49192861_1 CDM 0272 RC inpatient 7317 4756.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 4430.44 7097.49 AXIS GRAFT 8X12 49192861_1 CDM 0272 RC inpatient 7317 4756.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 4946.29 67.6 999999999 4430.44 7097.49 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 49194518_1 CDM 0250 RC 55150-0246-47 NDC J1953 HCPCS inpatient 50 UN 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 49194518_1 CDM 0250 RC 55150-0246-47 NDC J1953 HCPCS inpatient 50 UN 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 49194518_1 CDM 0250 RC 55150-0246-47 NDC J1953 HCPCS inpatient 50 UN 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 49194518_1 CDM 0250 RC 55150-0246-47 NDC J1953 HCPCS inpatient 50 UN 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 49194518_1 CDM 0250 RC 55150-0246-47 NDC J1953 HCPCS inpatient 50 UN 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 49194518_1 CDM 0250 RC 55150-0246-47 NDC J1953 HCPCS inpatient 50 UN 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 49194518_1 CDM 0250 RC 55150-0246-47 NDC J1953 HCPCS inpatient 50 UN 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 49194518_1 CDM 0250 RC 55150-0246-47 NDC J1953 HCPCS inpatient 50 UN 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 49194518_1 CDM 0250 RC 55150-0246-47 NDC J1953 HCPCS inpatient 50 UN 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 "INJECTION, LEVETIRACETAM, 10 MG" 49194518_1 CDM 0250 RC 55150-0246-47 NDC J1953 HCPCS inpatient 50 UN 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 "INJECTION, LEVETIRACETAM, 10 MG" 49194518_1 CDM 0250 RC 55150-0246-47 NDC J1953 HCPCS inpatient 50 UN 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 "INJECTION, LEVETIRACETAM, 10 MG" 49194518_1 CDM 0250 RC 55150-0246-47 NDC J1953 HCPCS inpatient 50 UN 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 "INJECTION, LEVETIRACETAM, 10 MG" 49194518_1 CDM 0250 RC 55150-0246-47 NDC J1953 HCPCS inpatient 50 UN 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 "INJECTION, LEVETIRACETAM, 10 MG" 49194518_1 CDM 0250 RC 55150-0246-47 NDC J1953 HCPCS inpatient 50 UN 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges GENTIAN VIOLET 1% SOLUTION 49194557_1 CDM 0250 RC 24385-0003-46 NDC inpatient 1 UN 5.04 3.28 AETNA AETNA 3.98 79 999999999 3.05 4.89 percent of total billed charges GENTIAN VIOLET 1% SOLUTION 49194557_1 CDM 0250 RC 24385-0003-46 NDC inpatient 1 UN 5.04 3.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.28 65 999999999 3.05 4.89 percent of total billed charges GENTIAN VIOLET 1% SOLUTION 49194557_1 CDM 0250 RC 24385-0003-46 NDC inpatient 1 UN 5.04 3.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4.89 97 999999999 3.05 4.89 percent of total billed charges GENTIAN VIOLET 1% SOLUTION 49194557_1 CDM 0250 RC 24385-0003-46 NDC inpatient 1 UN 5.04 3.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.93 78 999999999 3.05 4.89 percent of total billed charges GENTIAN VIOLET 1% SOLUTION 49194557_1 CDM 0250 RC 24385-0003-46 NDC inpatient 1 UN 5.04 3.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.48 69 999999999 3.05 4.89 percent of total billed charges GENTIAN VIOLET 1% SOLUTION 49194557_1 CDM 0250 RC 24385-0003-46 NDC inpatient 1 UN 5.04 3.28 UMR - ALL PLANS UMR - ALL PLANS 3.53 70 999999999 3.05 4.89 percent of total billed charges GENTIAN VIOLET 1% SOLUTION 49194557_1 CDM 0250 RC 24385-0003-46 NDC inpatient 1 UN 5.04 3.28 SIHO - ALL PLANS SIHO - ALL PLANS 4.54 90 999999999 3.05 4.89 percent of total billed charges GENTIAN VIOLET 1% SOLUTION 49194557_1 CDM 0250 RC 24385-0003-46 NDC inpatient 1 UN 5.04 3.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.05 60.55 999999999 3.05 4.89 percent of total billed charges GENTIAN VIOLET 1% SOLUTION 49194557_1 CDM 0250 RC 24385-0003-46 NDC inpatient 1 UN 5.04 3.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.05 4.89 GENTIAN VIOLET 1% SOLUTION 49194557_1 CDM 0250 RC 24385-0003-46 NDC inpatient 1 UN 5.04 3.28 ANTHEM HMO ANTHEM HMO 999999999 3.05 4.89 GENTIAN VIOLET 1% SOLUTION 49194557_1 CDM 0250 RC 24385-0003-46 NDC inpatient 1 UN 5.04 3.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.05 4.89 GENTIAN VIOLET 1% SOLUTION 49194557_1 CDM 0250 RC 24385-0003-46 NDC inpatient 1 UN 5.04 3.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.05 4.89 GENTIAN VIOLET 1% SOLUTION 49194557_1 CDM 0250 RC 24385-0003-46 NDC inpatient 1 UN 5.04 3.28 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.05 4.89 GENTIAN VIOLET 1% SOLUTION 49194557_1 CDM 0250 RC 24385-0003-46 NDC inpatient 1 UN 5.04 3.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.41 67.6 999999999 3.05 4.89 percent of total billed charges 61553-0153-17 - norepinephrine 8 mg/Dextrose 5% 250 ml PM bag [JOHN] 49194974_1 CDM 0250 RC 61553-0153-17 NDC inpatient 1 UN 232.88 151.37 AETNA AETNA 183.98 79 999999999 141.01 225.89 percent of total billed charges 61553-0153-17 - norepinephrine 8 mg/Dextrose 5% 250 ml PM bag [JOHN] 49194974_1 CDM 0250 RC 61553-0153-17 NDC inpatient 1 UN 232.88 151.37 SELF PAY DISCOUNT SELF PAY DISCOUNT 151.37 65 999999999 141.01 225.89 percent of total billed charges 61553-0153-17 - norepinephrine 8 mg/Dextrose 5% 250 ml PM bag [JOHN] 49194974_1 CDM 0250 RC 61553-0153-17 NDC inpatient 1 UN 232.88 151.37 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 225.89 97 999999999 141.01 225.89 percent of total billed charges 61553-0153-17 - norepinephrine 8 mg/Dextrose 5% 250 ml PM bag [JOHN] 49194974_1 CDM 0250 RC 61553-0153-17 NDC inpatient 1 UN 232.88 151.37 HUMANA - ALL PLANS HUMANA - ALL PLANS 181.65 78 999999999 141.01 225.89 percent of total billed charges 61553-0153-17 - norepinephrine 8 mg/Dextrose 5% 250 ml PM bag [JOHN] 49194974_1 CDM 0250 RC 61553-0153-17 NDC inpatient 1 UN 232.88 151.37 ENCORE - ALL PLANS ENCORE - ALL PLANS 160.69 69 999999999 141.01 225.89 percent of total billed charges 61553-0153-17 - norepinephrine 8 mg/Dextrose 5% 250 ml PM bag [JOHN] 49194974_1 CDM 0250 RC 61553-0153-17 NDC inpatient 1 UN 232.88 151.37 UMR - ALL PLANS UMR - ALL PLANS 163.02 70 999999999 141.01 225.89 percent of total billed charges 61553-0153-17 - norepinephrine 8 mg/Dextrose 5% 250 ml PM bag [JOHN] 49194974_1 CDM 0250 RC 61553-0153-17 NDC inpatient 1 UN 232.88 151.37 SIHO - ALL PLANS SIHO - ALL PLANS 209.59 90 999999999 141.01 225.89 percent of total billed charges 61553-0153-17 - norepinephrine 8 mg/Dextrose 5% 250 ml PM bag [JOHN] 49194974_1 CDM 0250 RC 61553-0153-17 NDC inpatient 1 UN 232.88 151.37 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 141.01 60.55 999999999 141.01 225.89 percent of total billed charges 61553-0153-17 - norepinephrine 8 mg/Dextrose 5% 250 ml PM bag [JOHN] 49194974_1 CDM 0250 RC 61553-0153-17 NDC inpatient 1 UN 232.88 151.37 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 141.01 225.89 61553-0153-17 - norepinephrine 8 mg/Dextrose 5% 250 ml PM bag [JOHN] 49194974_1 CDM 0250 RC 61553-0153-17 NDC inpatient 1 UN 232.88 151.37 ANTHEM HMO ANTHEM HMO 999999999 141.01 225.89 61553-0153-17 - norepinephrine 8 mg/Dextrose 5% 250 ml PM bag [JOHN] 49194974_1 CDM 0250 RC 61553-0153-17 NDC inpatient 1 UN 232.88 151.37 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 141.01 225.89 61553-0153-17 - norepinephrine 8 mg/Dextrose 5% 250 ml PM bag [JOHN] 49194974_1 CDM 0250 RC 61553-0153-17 NDC inpatient 1 UN 232.88 151.37 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 141.01 225.89 61553-0153-17 - norepinephrine 8 mg/Dextrose 5% 250 ml PM bag [JOHN] 49194974_1 CDM 0250 RC 61553-0153-17 NDC inpatient 1 UN 232.88 151.37 UHC - ALL PLANS UHC - ALL PLANS 999999999 141.01 225.89 61553-0153-17 - norepinephrine 8 mg/Dextrose 5% 250 ml PM bag [JOHN] 49194974_1 CDM 0250 RC 61553-0153-17 NDC inpatient 1 UN 232.88 151.37 CIGNA - ALL PLANS CIGNA - ALL PLANS 157.43 67.6 999999999 141.01 225.89 percent of total billed charges FLUVOXAMINE MALEATE 25 MG TAB 49196743_1 CDM 0250 RC 62559-0158-01 NDC inpatient 1 UN 1.2 0.78 AETNA AETNA 0.95 79 999999999 0.73 1.16 percent of total billed charges FLUVOXAMINE MALEATE 25 MG TAB 49196743_1 CDM 0250 RC 62559-0158-01 NDC inpatient 1 UN 1.2 0.78 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.78 65 999999999 0.73 1.16 percent of total billed charges FLUVOXAMINE MALEATE 25 MG TAB 49196743_1 CDM 0250 RC 62559-0158-01 NDC inpatient 1 UN 1.2 0.78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.16 97 999999999 0.73 1.16 percent of total billed charges FLUVOXAMINE MALEATE 25 MG TAB 49196743_1 CDM 0250 RC 62559-0158-01 NDC inpatient 1 UN 1.2 0.78 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.94 78 999999999 0.73 1.16 percent of total billed charges FLUVOXAMINE MALEATE 25 MG TAB 49196743_1 CDM 0250 RC 62559-0158-01 NDC inpatient 1 UN 1.2 0.78 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.83 69 999999999 0.73 1.16 percent of total billed charges FLUVOXAMINE MALEATE 25 MG TAB 49196743_1 CDM 0250 RC 62559-0158-01 NDC inpatient 1 UN 1.2 0.78 UMR - ALL PLANS UMR - ALL PLANS 0.84 70 999999999 0.73 1.16 percent of total billed charges FLUVOXAMINE MALEATE 25 MG TAB 49196743_1 CDM 0250 RC 62559-0158-01 NDC inpatient 1 UN 1.2 0.78 SIHO - ALL PLANS SIHO - ALL PLANS 1.08 90 999999999 0.73 1.16 percent of total billed charges FLUVOXAMINE MALEATE 25 MG TAB 49196743_1 CDM 0250 RC 62559-0158-01 NDC inpatient 1 UN 1.2 0.78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.73 60.55 999999999 0.73 1.16 percent of total billed charges FLUVOXAMINE MALEATE 25 MG TAB 49196743_1 CDM 0250 RC 62559-0158-01 NDC inpatient 1 UN 1.2 0.78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.73 1.16 FLUVOXAMINE MALEATE 25 MG TAB 49196743_1 CDM 0250 RC 62559-0158-01 NDC inpatient 1 UN 1.2 0.78 ANTHEM HMO ANTHEM HMO 999999999 0.73 1.16 FLUVOXAMINE MALEATE 25 MG TAB 49196743_1 CDM 0250 RC 62559-0158-01 NDC inpatient 1 UN 1.2 0.78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.73 1.16 FLUVOXAMINE MALEATE 25 MG TAB 49196743_1 CDM 0250 RC 62559-0158-01 NDC inpatient 1 UN 1.2 0.78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.73 1.16 FLUVOXAMINE MALEATE 25 MG TAB 49196743_1 CDM 0250 RC 62559-0158-01 NDC inpatient 1 UN 1.2 0.78 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.73 1.16 FLUVOXAMINE MALEATE 25 MG TAB 49196743_1 CDM 0250 RC 62559-0158-01 NDC inpatient 1 UN 1.2 0.78 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.81 67.6 999999999 0.73 1.16 percent of total billed charges Pregnenolone (reproductive hormone) level 49197745_1 CDM 0301 RC 84140 HCPCS inpatient 432 280.8 AETNA AETNA 341.28 79 999999999 261.58 419.04 percent of total billed charges Pregnenolone (reproductive hormone) level 49197745_1 CDM 0301 RC 84140 HCPCS inpatient 432 280.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 280.8 65 999999999 261.58 419.04 percent of total billed charges Pregnenolone (reproductive hormone) level 49197745_1 CDM 0301 RC 84140 HCPCS inpatient 432 280.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 419.04 97 999999999 261.58 419.04 percent of total billed charges Pregnenolone (reproductive hormone) level 49197745_1 CDM 0301 RC 84140 HCPCS inpatient 432 280.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 336.96 78 999999999 261.58 419.04 percent of total billed charges Pregnenolone (reproductive hormone) level 49197745_1 CDM 0301 RC 84140 HCPCS inpatient 432 280.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 298.08 69 999999999 261.58 419.04 percent of total billed charges Pregnenolone (reproductive hormone) level 49197745_1 CDM 0301 RC 84140 HCPCS inpatient 432 280.8 UMR - ALL PLANS UMR - ALL PLANS 302.4 70 999999999 261.58 419.04 percent of total billed charges Pregnenolone (reproductive hormone) level 49197745_1 CDM 0301 RC 84140 HCPCS inpatient 432 280.8 SIHO - ALL PLANS SIHO - ALL PLANS 388.8 90 999999999 261.58 419.04 percent of total billed charges Pregnenolone (reproductive hormone) level 49197745_1 CDM 0301 RC 84140 HCPCS inpatient 432 280.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 261.58 60.55 999999999 261.58 419.04 percent of total billed charges Pregnenolone (reproductive hormone) level 49197745_1 CDM 0301 RC 84140 HCPCS inpatient 432 280.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 261.58 419.04 Pregnenolone (reproductive hormone) level 49197745_1 CDM 0301 RC 84140 HCPCS inpatient 432 280.8 ANTHEM HMO ANTHEM HMO 999999999 261.58 419.04 Pregnenolone (reproductive hormone) level 49197745_1 CDM 0301 RC 84140 HCPCS inpatient 432 280.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 261.58 419.04 Pregnenolone (reproductive hormone) level 49197745_1 CDM 0301 RC 84140 HCPCS inpatient 432 280.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 261.58 419.04 Pregnenolone (reproductive hormone) level 49197745_1 CDM 0301 RC 84140 HCPCS inpatient 432 280.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 261.58 419.04 Pregnenolone (reproductive hormone) level 49197745_1 CDM 0301 RC 84140 HCPCS inpatient 432 280.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 292.03 67.6 999999999 261.58 419.04 percent of total billed charges Transfusion of blood or blood products 49197801_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 AETNA AETNA 981.18 79 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 49197801_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 807.3 65 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 49197801_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1204.74 97 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 49197801_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 968.76 78 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 49197801_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 856.98 69 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 49197801_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 UMR - ALL PLANS UMR - ALL PLANS 869.4 70 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 49197801_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 SIHO - ALL PLANS SIHO - ALL PLANS 1117.8 90 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 49197801_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 752.03 60.55 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 49197801_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 752.03 1204.74 Transfusion of blood or blood products 49197801_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM HMO ANTHEM HMO 999999999 752.03 1204.74 Transfusion of blood or blood products 49197801_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 752.03 1204.74 Transfusion of blood or blood products 49197801_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 752.03 1204.74 Transfusion of blood or blood products 49197801_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 752.03 1204.74 Transfusion of blood or blood products 49197801_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 839.59 67.6 999999999 752.03 1204.74 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 49202479_1 CDM 0636 RC 10019-0939-01 NDC J9070 HCPCS inpatient 10 UN 1613.32 1048.66 AETNA AETNA 1274.52 79 999999999 976.87 1564.92 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 49202479_1 CDM 0636 RC 10019-0939-01 NDC J9070 HCPCS inpatient 10 UN 1613.32 1048.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 1048.66 65 999999999 976.87 1564.92 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 49202479_1 CDM 0636 RC 10019-0939-01 NDC J9070 HCPCS inpatient 10 UN 1613.32 1048.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1564.92 97 999999999 976.87 1564.92 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 49202479_1 CDM 0636 RC 10019-0939-01 NDC J9070 HCPCS inpatient 10 UN 1613.32 1048.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 1258.39 78 999999999 976.87 1564.92 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 49202479_1 CDM 0636 RC 10019-0939-01 NDC J9070 HCPCS inpatient 10 UN 1613.32 1048.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 1113.19 69 999999999 976.87 1564.92 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 49202479_1 CDM 0636 RC 10019-0939-01 NDC J9070 HCPCS inpatient 10 UN 1613.32 1048.66 UMR - ALL PLANS UMR - ALL PLANS 1129.32 70 999999999 976.87 1564.92 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 49202479_1 CDM 0636 RC 10019-0939-01 NDC J9070 HCPCS inpatient 10 UN 1613.32 1048.66 SIHO - ALL PLANS SIHO - ALL PLANS 1451.99 90 999999999 976.87 1564.92 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 49202479_1 CDM 0636 RC 10019-0939-01 NDC J9070 HCPCS inpatient 10 UN 1613.32 1048.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 976.87 60.55 999999999 976.87 1564.92 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 49202479_1 CDM 0636 RC 10019-0939-01 NDC J9070 HCPCS inpatient 10 UN 1613.32 1048.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 976.87 1564.92 "CYCLOPHOSPHAMIDE, 100 MG" 49202479_1 CDM 0636 RC 10019-0939-01 NDC J9070 HCPCS inpatient 10 UN 1613.32 1048.66 ANTHEM HMO ANTHEM HMO 999999999 976.87 1564.92 "CYCLOPHOSPHAMIDE, 100 MG" 49202479_1 CDM 0636 RC 10019-0939-01 NDC J9070 HCPCS inpatient 10 UN 1613.32 1048.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 976.87 1564.92 "CYCLOPHOSPHAMIDE, 100 MG" 49202479_1 CDM 0636 RC 10019-0939-01 NDC J9070 HCPCS inpatient 10 UN 1613.32 1048.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 976.87 1564.92 "CYCLOPHOSPHAMIDE, 100 MG" 49202479_1 CDM 0636 RC 10019-0939-01 NDC J9070 HCPCS inpatient 10 UN 1613.32 1048.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 976.87 1564.92 "CYCLOPHOSPHAMIDE, 100 MG" 49202479_1 CDM 0636 RC 10019-0939-01 NDC J9070 HCPCS inpatient 10 UN 1613.32 1048.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 1090.6 67.6 999999999 976.87 1564.92 percent of total billed charges LACTATED RINGERS INJECTION 49203166_1 CDM 0250 RC 00338-0117-03 NDC inpatient 1 UN 60 39 AETNA AETNA 47.4 79 999999999 36.33 58.2 percent of total billed charges LACTATED RINGERS INJECTION 49203166_1 CDM 0250 RC 00338-0117-03 NDC inpatient 1 UN 60 39 SELF PAY DISCOUNT SELF PAY DISCOUNT 39 65 999999999 36.33 58.2 percent of total billed charges LACTATED RINGERS INJECTION 49203166_1 CDM 0250 RC 00338-0117-03 NDC inpatient 1 UN 60 39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.2 97 999999999 36.33 58.2 percent of total billed charges LACTATED RINGERS INJECTION 49203166_1 CDM 0250 RC 00338-0117-03 NDC inpatient 1 UN 60 39 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.8 78 999999999 36.33 58.2 percent of total billed charges LACTATED RINGERS INJECTION 49203166_1 CDM 0250 RC 00338-0117-03 NDC inpatient 1 UN 60 39 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.4 69 999999999 36.33 58.2 percent of total billed charges LACTATED RINGERS INJECTION 49203166_1 CDM 0250 RC 00338-0117-03 NDC inpatient 1 UN 60 39 UMR - ALL PLANS UMR - ALL PLANS 42 70 999999999 36.33 58.2 percent of total billed charges LACTATED RINGERS INJECTION 49203166_1 CDM 0250 RC 00338-0117-03 NDC inpatient 1 UN 60 39 SIHO - ALL PLANS SIHO - ALL PLANS 54 90 999999999 36.33 58.2 percent of total billed charges LACTATED RINGERS INJECTION 49203166_1 CDM 0250 RC 00338-0117-03 NDC inpatient 1 UN 60 39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.33 60.55 999999999 36.33 58.2 percent of total billed charges LACTATED RINGERS INJECTION 49203166_1 CDM 0250 RC 00338-0117-03 NDC inpatient 1 UN 60 39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.33 58.2 LACTATED RINGERS INJECTION 49203166_1 CDM 0250 RC 00338-0117-03 NDC inpatient 1 UN 60 39 ANTHEM HMO ANTHEM HMO 999999999 36.33 58.2 LACTATED RINGERS INJECTION 49203166_1 CDM 0250 RC 00338-0117-03 NDC inpatient 1 UN 60 39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.33 58.2 LACTATED RINGERS INJECTION 49203166_1 CDM 0250 RC 00338-0117-03 NDC inpatient 1 UN 60 39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.33 58.2 LACTATED RINGERS INJECTION 49203166_1 CDM 0250 RC 00338-0117-03 NDC inpatient 1 UN 60 39 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.33 58.2 LACTATED RINGERS INJECTION 49203166_1 CDM 0250 RC 00338-0117-03 NDC inpatient 1 UN 60 39 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.56 67.6 999999999 36.33 58.2 percent of total billed charges 99999-9999-04 - Tumescent New 1000 mL [JOHN] 49205046_1 CDM 0250 RC 99999-9999-04 NDC inpatient 1 UN 115 74.75 AETNA AETNA 90.85 79 999999999 69.63 111.55 percent of total billed charges 99999-9999-04 - Tumescent New 1000 mL [JOHN] 49205046_1 CDM 0250 RC 99999-9999-04 NDC inpatient 1 UN 115 74.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.75 65 999999999 69.63 111.55 percent of total billed charges 99999-9999-04 - Tumescent New 1000 mL [JOHN] 49205046_1 CDM 0250 RC 99999-9999-04 NDC inpatient 1 UN 115 74.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 111.55 97 999999999 69.63 111.55 percent of total billed charges 99999-9999-04 - Tumescent New 1000 mL [JOHN] 49205046_1 CDM 0250 RC 99999-9999-04 NDC inpatient 1 UN 115 74.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 89.7 78 999999999 69.63 111.55 percent of total billed charges 99999-9999-04 - Tumescent New 1000 mL [JOHN] 49205046_1 CDM 0250 RC 99999-9999-04 NDC inpatient 1 UN 115 74.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 79.35 69 999999999 69.63 111.55 percent of total billed charges 99999-9999-04 - Tumescent New 1000 mL [JOHN] 49205046_1 CDM 0250 RC 99999-9999-04 NDC inpatient 1 UN 115 74.75 UMR - ALL PLANS UMR - ALL PLANS 80.5 70 999999999 69.63 111.55 percent of total billed charges 99999-9999-04 - Tumescent New 1000 mL [JOHN] 49205046_1 CDM 0250 RC 99999-9999-04 NDC inpatient 1 UN 115 74.75 SIHO - ALL PLANS SIHO - ALL PLANS 103.5 90 999999999 69.63 111.55 percent of total billed charges 99999-9999-04 - Tumescent New 1000 mL [JOHN] 49205046_1 CDM 0250 RC 99999-9999-04 NDC inpatient 1 UN 115 74.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.63 60.55 999999999 69.63 111.55 percent of total billed charges 99999-9999-04 - Tumescent New 1000 mL [JOHN] 49205046_1 CDM 0250 RC 99999-9999-04 NDC inpatient 1 UN 115 74.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.63 111.55 99999-9999-04 - Tumescent New 1000 mL [JOHN] 49205046_1 CDM 0250 RC 99999-9999-04 NDC inpatient 1 UN 115 74.75 ANTHEM HMO ANTHEM HMO 999999999 69.63 111.55 99999-9999-04 - Tumescent New 1000 mL [JOHN] 49205046_1 CDM 0250 RC 99999-9999-04 NDC inpatient 1 UN 115 74.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.63 111.55 99999-9999-04 - Tumescent New 1000 mL [JOHN] 49205046_1 CDM 0250 RC 99999-9999-04 NDC inpatient 1 UN 115 74.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.63 111.55 99999-9999-04 - Tumescent New 1000 mL [JOHN] 49205046_1 CDM 0250 RC 99999-9999-04 NDC inpatient 1 UN 115 74.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.63 111.55 99999-9999-04 - Tumescent New 1000 mL [JOHN] 49205046_1 CDM 0250 RC 99999-9999-04 NDC inpatient 1 UN 115 74.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.74 67.6 999999999 69.63 111.55 percent of total billed charges "INJECTION, TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG" 49205128_1 CDM 0636 RC 50242-0132-01 NDC J9355 HCPCS inpatient 15 UN 7416.31 4820.6 AETNA AETNA 5858.88 79 999999999 4490.58 7193.82 percent of total billed charges "INJECTION, TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG" 49205128_1 CDM 0636 RC 50242-0132-01 NDC J9355 HCPCS inpatient 15 UN 7416.31 4820.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 4820.6 65 999999999 4490.58 7193.82 percent of total billed charges "INJECTION, TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG" 49205128_1 CDM 0636 RC 50242-0132-01 NDC J9355 HCPCS inpatient 15 UN 7416.31 4820.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7193.82 97 999999999 4490.58 7193.82 percent of total billed charges "INJECTION, TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG" 49205128_1 CDM 0636 RC 50242-0132-01 NDC J9355 HCPCS inpatient 15 UN 7416.31 4820.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 5784.72 78 999999999 4490.58 7193.82 percent of total billed charges "INJECTION, TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG" 49205128_1 CDM 0636 RC 50242-0132-01 NDC J9355 HCPCS inpatient 15 UN 7416.31 4820.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 5117.25 69 999999999 4490.58 7193.82 percent of total billed charges "INJECTION, TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG" 49205128_1 CDM 0636 RC 50242-0132-01 NDC J9355 HCPCS inpatient 15 UN 7416.31 4820.6 UMR - ALL PLANS UMR - ALL PLANS 5191.42 70 999999999 4490.58 7193.82 percent of total billed charges "INJECTION, TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG" 49205128_1 CDM 0636 RC 50242-0132-01 NDC J9355 HCPCS inpatient 15 UN 7416.31 4820.6 SIHO - ALL PLANS SIHO - ALL PLANS 6674.68 90 999999999 4490.58 7193.82 percent of total billed charges "INJECTION, TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG" 49205128_1 CDM 0636 RC 50242-0132-01 NDC J9355 HCPCS inpatient 15 UN 7416.31 4820.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4490.58 60.55 999999999 4490.58 7193.82 percent of total billed charges "INJECTION, TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG" 49205128_1 CDM 0636 RC 50242-0132-01 NDC J9355 HCPCS inpatient 15 UN 7416.31 4820.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4490.58 7193.82 "INJECTION, TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG" 49205128_1 CDM 0636 RC 50242-0132-01 NDC J9355 HCPCS inpatient 15 UN 7416.31 4820.6 ANTHEM HMO ANTHEM HMO 999999999 4490.58 7193.82 "INJECTION, TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG" 49205128_1 CDM 0636 RC 50242-0132-01 NDC J9355 HCPCS inpatient 15 UN 7416.31 4820.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4490.58 7193.82 "INJECTION, TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG" 49205128_1 CDM 0636 RC 50242-0132-01 NDC J9355 HCPCS inpatient 15 UN 7416.31 4820.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4490.58 7193.82 "INJECTION, TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG" 49205128_1 CDM 0636 RC 50242-0132-01 NDC J9355 HCPCS inpatient 15 UN 7416.31 4820.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 4490.58 7193.82 "INJECTION, TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG" 49205128_1 CDM 0636 RC 50242-0132-01 NDC J9355 HCPCS inpatient 15 UN 7416.31 4820.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 5013.43 67.6 999999999 4490.58 7193.82 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 49205145_1 CDM 0636 RC 00781-9317-80 NDC J9263 HCPCS inpatient 200 UN 112.98 73.44 AETNA AETNA 89.25 79 999999999 68.41 109.59 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 49205145_1 CDM 0636 RC 00781-9317-80 NDC J9263 HCPCS inpatient 200 UN 112.98 73.44 SELF PAY DISCOUNT SELF PAY DISCOUNT 73.44 65 999999999 68.41 109.59 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 49205145_1 CDM 0636 RC 00781-9317-80 NDC J9263 HCPCS inpatient 200 UN 112.98 73.44 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 109.59 97 999999999 68.41 109.59 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 49205145_1 CDM 0636 RC 00781-9317-80 NDC J9263 HCPCS inpatient 200 UN 112.98 73.44 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.12 78 999999999 68.41 109.59 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 49205145_1 CDM 0636 RC 00781-9317-80 NDC J9263 HCPCS inpatient 200 UN 112.98 73.44 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.96 69 999999999 68.41 109.59 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 49205145_1 CDM 0636 RC 00781-9317-80 NDC J9263 HCPCS inpatient 200 UN 112.98 73.44 UMR - ALL PLANS UMR - ALL PLANS 79.09 70 999999999 68.41 109.59 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 49205145_1 CDM 0636 RC 00781-9317-80 NDC J9263 HCPCS inpatient 200 UN 112.98 73.44 SIHO - ALL PLANS SIHO - ALL PLANS 101.68 90 999999999 68.41 109.59 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 49205145_1 CDM 0636 RC 00781-9317-80 NDC J9263 HCPCS inpatient 200 UN 112.98 73.44 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 68.41 60.55 999999999 68.41 109.59 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 49205145_1 CDM 0636 RC 00781-9317-80 NDC J9263 HCPCS inpatient 200 UN 112.98 73.44 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 68.41 109.59 "INJECTION, OXALIPLATIN, 0.5 MG" 49205145_1 CDM 0636 RC 00781-9317-80 NDC J9263 HCPCS inpatient 200 UN 112.98 73.44 ANTHEM HMO ANTHEM HMO 999999999 68.41 109.59 "INJECTION, OXALIPLATIN, 0.5 MG" 49205145_1 CDM 0636 RC 00781-9317-80 NDC J9263 HCPCS inpatient 200 UN 112.98 73.44 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 68.41 109.59 "INJECTION, OXALIPLATIN, 0.5 MG" 49205145_1 CDM 0636 RC 00781-9317-80 NDC J9263 HCPCS inpatient 200 UN 112.98 73.44 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 68.41 109.59 "INJECTION, OXALIPLATIN, 0.5 MG" 49205145_1 CDM 0636 RC 00781-9317-80 NDC J9263 HCPCS inpatient 200 UN 112.98 73.44 UHC - ALL PLANS UHC - ALL PLANS 999999999 68.41 109.59 "INJECTION, OXALIPLATIN, 0.5 MG" 49205145_1 CDM 0636 RC 00781-9317-80 NDC J9263 HCPCS inpatient 200 UN 112.98 73.44 CIGNA - ALL PLANS CIGNA - ALL PLANS 76.37 67.6 999999999 68.41 109.59 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 49205664_1 CDM 0636 RC J1030 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 49205664_1 CDM 0636 RC J1030 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 49205664_1 CDM 0636 RC J1030 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 49205664_1 CDM 0636 RC J1030 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 49205664_1 CDM 0636 RC J1030 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 49205664_1 CDM 0636 RC J1030 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 49205664_1 CDM 0636 RC J1030 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 49205664_1 CDM 0636 RC J1030 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 49205664_1 CDM 0636 RC J1030 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 49205664_1 CDM 0636 RC J1030 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 49205664_1 CDM 0636 RC J1030 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 49205664_1 CDM 0636 RC J1030 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 49205664_1 CDM 0636 RC J1030 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 "INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG" 49205664_1 CDM 0636 RC J1030 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 49205692_1 CDM 0343 RC A9562 HCPCS inpatient 1150 747.5 AETNA AETNA 908.5 79 999999999 696.33 1115.5 percent of total billed charges "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 49205692_1 CDM 0343 RC A9562 HCPCS inpatient 1150 747.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 747.5 65 999999999 696.33 1115.5 percent of total billed charges "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 49205692_1 CDM 0343 RC A9562 HCPCS inpatient 1150 747.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1115.5 97 999999999 696.33 1115.5 percent of total billed charges "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 49205692_1 CDM 0343 RC A9562 HCPCS inpatient 1150 747.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 897 78 999999999 696.33 1115.5 percent of total billed charges "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 49205692_1 CDM 0343 RC A9562 HCPCS inpatient 1150 747.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 793.5 69 999999999 696.33 1115.5 percent of total billed charges "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 49205692_1 CDM 0343 RC A9562 HCPCS inpatient 1150 747.5 UMR - ALL PLANS UMR - ALL PLANS 805 70 999999999 696.33 1115.5 percent of total billed charges "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 49205692_1 CDM 0343 RC A9562 HCPCS inpatient 1150 747.5 SIHO - ALL PLANS SIHO - ALL PLANS 1035 90 999999999 696.33 1115.5 percent of total billed charges "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 49205692_1 CDM 0343 RC A9562 HCPCS inpatient 1150 747.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 696.33 60.55 999999999 696.33 1115.5 percent of total billed charges "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 49205692_1 CDM 0343 RC A9562 HCPCS inpatient 1150 747.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 696.33 1115.5 "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 49205692_1 CDM 0343 RC A9562 HCPCS inpatient 1150 747.5 ANTHEM HMO ANTHEM HMO 999999999 696.33 1115.5 "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 49205692_1 CDM 0343 RC A9562 HCPCS inpatient 1150 747.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 696.33 1115.5 "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 49205692_1 CDM 0343 RC A9562 HCPCS inpatient 1150 747.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 696.33 1115.5 "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 49205692_1 CDM 0343 RC A9562 HCPCS inpatient 1150 747.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 696.33 1115.5 "TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES" 49205692_1 CDM 0343 RC A9562 HCPCS inpatient 1150 747.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 777.4 67.6 999999999 696.33 1115.5 percent of total billed charges LETROZOLE 2.5 MG TABLET 49210522_1 CDM 0250 RC 16729-0034-10 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LETROZOLE 2.5 MG TABLET 49210522_1 CDM 0250 RC 16729-0034-10 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LETROZOLE 2.5 MG TABLET 49210522_1 CDM 0250 RC 16729-0034-10 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LETROZOLE 2.5 MG TABLET 49210522_1 CDM 0250 RC 16729-0034-10 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LETROZOLE 2.5 MG TABLET 49210522_1 CDM 0250 RC 16729-0034-10 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LETROZOLE 2.5 MG TABLET 49210522_1 CDM 0250 RC 16729-0034-10 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LETROZOLE 2.5 MG TABLET 49210522_1 CDM 0250 RC 16729-0034-10 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LETROZOLE 2.5 MG TABLET 49210522_1 CDM 0250 RC 16729-0034-10 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LETROZOLE 2.5 MG TABLET 49210522_1 CDM 0250 RC 16729-0034-10 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LETROZOLE 2.5 MG TABLET 49210522_1 CDM 0250 RC 16729-0034-10 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LETROZOLE 2.5 MG TABLET 49210522_1 CDM 0250 RC 16729-0034-10 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LETROZOLE 2.5 MG TABLET 49210522_1 CDM 0250 RC 16729-0034-10 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LETROZOLE 2.5 MG TABLET 49210522_1 CDM 0250 RC 16729-0034-10 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 LETROZOLE 2.5 MG TABLET 49210522_1 CDM 0250 RC 16729-0034-10 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges PENTASA 250 MG CAPSULE 49210532_1 CDM 0250 RC 54092-0189-81 NDC inpatient 1 UN 13.52 8.79 AETNA AETNA 10.68 79 999999999 8.19 13.11 percent of total billed charges PENTASA 250 MG CAPSULE 49210532_1 CDM 0250 RC 54092-0189-81 NDC inpatient 1 UN 13.52 8.79 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.79 65 999999999 8.19 13.11 percent of total billed charges PENTASA 250 MG CAPSULE 49210532_1 CDM 0250 RC 54092-0189-81 NDC inpatient 1 UN 13.52 8.79 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13.11 97 999999999 8.19 13.11 percent of total billed charges PENTASA 250 MG CAPSULE 49210532_1 CDM 0250 RC 54092-0189-81 NDC inpatient 1 UN 13.52 8.79 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.55 78 999999999 8.19 13.11 percent of total billed charges PENTASA 250 MG CAPSULE 49210532_1 CDM 0250 RC 54092-0189-81 NDC inpatient 1 UN 13.52 8.79 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.33 69 999999999 8.19 13.11 percent of total billed charges PENTASA 250 MG CAPSULE 49210532_1 CDM 0250 RC 54092-0189-81 NDC inpatient 1 UN 13.52 8.79 UMR - ALL PLANS UMR - ALL PLANS 9.46 70 999999999 8.19 13.11 percent of total billed charges PENTASA 250 MG CAPSULE 49210532_1 CDM 0250 RC 54092-0189-81 NDC inpatient 1 UN 13.52 8.79 SIHO - ALL PLANS SIHO - ALL PLANS 12.17 90 999999999 8.19 13.11 percent of total billed charges PENTASA 250 MG CAPSULE 49210532_1 CDM 0250 RC 54092-0189-81 NDC inpatient 1 UN 13.52 8.79 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.19 60.55 999999999 8.19 13.11 percent of total billed charges PENTASA 250 MG CAPSULE 49210532_1 CDM 0250 RC 54092-0189-81 NDC inpatient 1 UN 13.52 8.79 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.19 13.11 PENTASA 250 MG CAPSULE 49210532_1 CDM 0250 RC 54092-0189-81 NDC inpatient 1 UN 13.52 8.79 ANTHEM HMO ANTHEM HMO 999999999 8.19 13.11 PENTASA 250 MG CAPSULE 49210532_1 CDM 0250 RC 54092-0189-81 NDC inpatient 1 UN 13.52 8.79 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.19 13.11 PENTASA 250 MG CAPSULE 49210532_1 CDM 0250 RC 54092-0189-81 NDC inpatient 1 UN 13.52 8.79 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.19 13.11 PENTASA 250 MG CAPSULE 49210532_1 CDM 0250 RC 54092-0189-81 NDC inpatient 1 UN 13.52 8.79 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.19 13.11 PENTASA 250 MG CAPSULE 49210532_1 CDM 0250 RC 54092-0189-81 NDC inpatient 1 UN 13.52 8.79 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.14 67.6 999999999 8.19 13.11 percent of total billed charges Fluoroscopic guidance for spine or back muscle injection 49217198_1 CDM 0320 RC 77003 HCPCS inpatient 1090 708.5 AETNA AETNA 861.1 79 999999999 660 1057.3 percent of total billed charges Fluoroscopic guidance for spine or back muscle injection 49217198_1 CDM 0320 RC 77003 HCPCS inpatient 1090 708.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 708.5 65 999999999 660 1057.3 percent of total billed charges Fluoroscopic guidance for spine or back muscle injection 49217198_1 CDM 0320 RC 77003 HCPCS inpatient 1090 708.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1057.3 97 999999999 660 1057.3 percent of total billed charges Fluoroscopic guidance for spine or back muscle injection 49217198_1 CDM 0320 RC 77003 HCPCS inpatient 1090 708.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 850.2 78 999999999 660 1057.3 percent of total billed charges Fluoroscopic guidance for spine or back muscle injection 49217198_1 CDM 0320 RC 77003 HCPCS inpatient 1090 708.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 752.1 69 999999999 660 1057.3 percent of total billed charges Fluoroscopic guidance for spine or back muscle injection 49217198_1 CDM 0320 RC 77003 HCPCS inpatient 1090 708.5 UMR - ALL PLANS UMR - ALL PLANS 763 70 999999999 660 1057.3 percent of total billed charges Fluoroscopic guidance for spine or back muscle injection 49217198_1 CDM 0320 RC 77003 HCPCS inpatient 1090 708.5 SIHO - ALL PLANS SIHO - ALL PLANS 981 90 999999999 660 1057.3 percent of total billed charges Fluoroscopic guidance for spine or back muscle injection 49217198_1 CDM 0320 RC 77003 HCPCS inpatient 1090 708.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 660 60.55 999999999 660 1057.3 percent of total billed charges Fluoroscopic guidance for spine or back muscle injection 49217198_1 CDM 0320 RC 77003 HCPCS inpatient 1090 708.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 660 1057.3 Fluoroscopic guidance for spine or back muscle injection 49217198_1 CDM 0320 RC 77003 HCPCS inpatient 1090 708.5 ANTHEM HMO ANTHEM HMO 999999999 660 1057.3 Fluoroscopic guidance for spine or back muscle injection 49217198_1 CDM 0320 RC 77003 HCPCS inpatient 1090 708.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 660 1057.3 Fluoroscopic guidance for spine or back muscle injection 49217198_1 CDM 0320 RC 77003 HCPCS inpatient 1090 708.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 660 1057.3 Fluoroscopic guidance for spine or back muscle injection 49217198_1 CDM 0320 RC 77003 HCPCS inpatient 1090 708.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 660 1057.3 Fluoroscopic guidance for spine or back muscle injection 49217198_1 CDM 0320 RC 77003 HCPCS inpatient 1090 708.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 736.84 67.6 999999999 660 1057.3 percent of total billed charges 99999-9999-96 - ferric subsulfate 480 mL [JOHN] 49220770_1 CDM 0250 RC 99999-9999-96 NDC inpatient 1 UN 153.81 99.98 AETNA AETNA 121.51 79 999999999 93.13 149.2 percent of total billed charges 99999-9999-96 - ferric subsulfate 480 mL [JOHN] 49220770_1 CDM 0250 RC 99999-9999-96 NDC inpatient 1 UN 153.81 99.98 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.98 65 999999999 93.13 149.2 percent of total billed charges 99999-9999-96 - ferric subsulfate 480 mL [JOHN] 49220770_1 CDM 0250 RC 99999-9999-96 NDC inpatient 1 UN 153.81 99.98 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 149.2 97 999999999 93.13 149.2 percent of total billed charges 99999-9999-96 - ferric subsulfate 480 mL [JOHN] 49220770_1 CDM 0250 RC 99999-9999-96 NDC inpatient 1 UN 153.81 99.98 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.97 78 999999999 93.13 149.2 percent of total billed charges 99999-9999-96 - ferric subsulfate 480 mL [JOHN] 49220770_1 CDM 0250 RC 99999-9999-96 NDC inpatient 1 UN 153.81 99.98 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.13 69 999999999 93.13 149.2 percent of total billed charges 99999-9999-96 - ferric subsulfate 480 mL [JOHN] 49220770_1 CDM 0250 RC 99999-9999-96 NDC inpatient 1 UN 153.81 99.98 UMR - ALL PLANS UMR - ALL PLANS 107.67 70 999999999 93.13 149.2 percent of total billed charges 99999-9999-96 - ferric subsulfate 480 mL [JOHN] 49220770_1 CDM 0250 RC 99999-9999-96 NDC inpatient 1 UN 153.81 99.98 SIHO - ALL PLANS SIHO - ALL PLANS 138.43 90 999999999 93.13 149.2 percent of total billed charges 99999-9999-96 - ferric subsulfate 480 mL [JOHN] 49220770_1 CDM 0250 RC 99999-9999-96 NDC inpatient 1 UN 153.81 99.98 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.13 60.55 999999999 93.13 149.2 percent of total billed charges 99999-9999-96 - ferric subsulfate 480 mL [JOHN] 49220770_1 CDM 0250 RC 99999-9999-96 NDC inpatient 1 UN 153.81 99.98 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.13 149.2 99999-9999-96 - ferric subsulfate 480 mL [JOHN] 49220770_1 CDM 0250 RC 99999-9999-96 NDC inpatient 1 UN 153.81 99.98 ANTHEM HMO ANTHEM HMO 999999999 93.13 149.2 99999-9999-96 - ferric subsulfate 480 mL [JOHN] 49220770_1 CDM 0250 RC 99999-9999-96 NDC inpatient 1 UN 153.81 99.98 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.13 149.2 99999-9999-96 - ferric subsulfate 480 mL [JOHN] 49220770_1 CDM 0250 RC 99999-9999-96 NDC inpatient 1 UN 153.81 99.98 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.13 149.2 99999-9999-96 - ferric subsulfate 480 mL [JOHN] 49220770_1 CDM 0250 RC 99999-9999-96 NDC inpatient 1 UN 153.81 99.98 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.13 149.2 99999-9999-96 - ferric subsulfate 480 mL [JOHN] 49220770_1 CDM 0250 RC 99999-9999-96 NDC inpatient 1 UN 153.81 99.98 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.98 67.6 999999999 93.13 149.2 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 49224150_1 CDM 0636 RC 00074-3683-03 NDC J9217 HCPCS inpatient 4 UN 3255.92 2116.35 AETNA AETNA 2572.18 79 999999999 1971.46 3158.24 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 49224150_1 CDM 0636 RC 00074-3683-03 NDC J9217 HCPCS inpatient 4 UN 3255.92 2116.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 2116.35 65 999999999 1971.46 3158.24 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 49224150_1 CDM 0636 RC 00074-3683-03 NDC J9217 HCPCS inpatient 4 UN 3255.92 2116.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3158.24 97 999999999 1971.46 3158.24 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 49224150_1 CDM 0636 RC 00074-3683-03 NDC J9217 HCPCS inpatient 4 UN 3255.92 2116.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 2539.62 78 999999999 1971.46 3158.24 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 49224150_1 CDM 0636 RC 00074-3683-03 NDC J9217 HCPCS inpatient 4 UN 3255.92 2116.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 2246.58 69 999999999 1971.46 3158.24 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 49224150_1 CDM 0636 RC 00074-3683-03 NDC J9217 HCPCS inpatient 4 UN 3255.92 2116.35 UMR - ALL PLANS UMR - ALL PLANS 2279.14 70 999999999 1971.46 3158.24 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 49224150_1 CDM 0636 RC 00074-3683-03 NDC J9217 HCPCS inpatient 4 UN 3255.92 2116.35 SIHO - ALL PLANS SIHO - ALL PLANS 2930.33 90 999999999 1971.46 3158.24 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 49224150_1 CDM 0636 RC 00074-3683-03 NDC J9217 HCPCS inpatient 4 UN 3255.92 2116.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1971.46 60.55 999999999 1971.46 3158.24 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 49224150_1 CDM 0636 RC 00074-3683-03 NDC J9217 HCPCS inpatient 4 UN 3255.92 2116.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1971.46 3158.24 "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 49224150_1 CDM 0636 RC 00074-3683-03 NDC J9217 HCPCS inpatient 4 UN 3255.92 2116.35 ANTHEM HMO ANTHEM HMO 999999999 1971.46 3158.24 "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 49224150_1 CDM 0636 RC 00074-3683-03 NDC J9217 HCPCS inpatient 4 UN 3255.92 2116.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1971.46 3158.24 "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 49224150_1 CDM 0636 RC 00074-3683-03 NDC J9217 HCPCS inpatient 4 UN 3255.92 2116.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1971.46 3158.24 "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 49224150_1 CDM 0636 RC 00074-3683-03 NDC J9217 HCPCS inpatient 4 UN 3255.92 2116.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1971.46 3158.24 "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 49224150_1 CDM 0636 RC 00074-3683-03 NDC J9217 HCPCS inpatient 4 UN 3255.92 2116.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 2201 67.6 999999999 1971.46 3158.24 percent of total billed charges "INJECTION, FUROSEMIDE, UP TO 20 MG" 49224159_1 CDM 0636 RC J1940 HCPCS inpatient 39 25.35 AETNA AETNA 30.81 79 999999999 23.61 37.83 percent of total billed charges "INJECTION, FUROSEMIDE, UP TO 20 MG" 49224159_1 CDM 0636 RC J1940 HCPCS inpatient 39 25.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 25.35 65 999999999 23.61 37.83 percent of total billed charges "INJECTION, FUROSEMIDE, UP TO 20 MG" 49224159_1 CDM 0636 RC J1940 HCPCS inpatient 39 25.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37.83 97 999999999 23.61 37.83 percent of total billed charges "INJECTION, FUROSEMIDE, UP TO 20 MG" 49224159_1 CDM 0636 RC J1940 HCPCS inpatient 39 25.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 30.42 78 999999999 23.61 37.83 percent of total billed charges "INJECTION, FUROSEMIDE, UP TO 20 MG" 49224159_1 CDM 0636 RC J1940 HCPCS inpatient 39 25.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.91 69 999999999 23.61 37.83 percent of total billed charges "INJECTION, FUROSEMIDE, UP TO 20 MG" 49224159_1 CDM 0636 RC J1940 HCPCS inpatient 39 25.35 UMR - ALL PLANS UMR - ALL PLANS 27.3 70 999999999 23.61 37.83 percent of total billed charges "INJECTION, FUROSEMIDE, UP TO 20 MG" 49224159_1 CDM 0636 RC J1940 HCPCS inpatient 39 25.35 SIHO - ALL PLANS SIHO - ALL PLANS 35.1 90 999999999 23.61 37.83 percent of total billed charges "INJECTION, FUROSEMIDE, UP TO 20 MG" 49224159_1 CDM 0636 RC J1940 HCPCS inpatient 39 25.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.61 60.55 999999999 23.61 37.83 percent of total billed charges "INJECTION, FUROSEMIDE, UP TO 20 MG" 49224159_1 CDM 0636 RC J1940 HCPCS inpatient 39 25.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.61 37.83 "INJECTION, FUROSEMIDE, UP TO 20 MG" 49224159_1 CDM 0636 RC J1940 HCPCS inpatient 39 25.35 ANTHEM HMO ANTHEM HMO 999999999 23.61 37.83 "INJECTION, FUROSEMIDE, UP TO 20 MG" 49224159_1 CDM 0636 RC J1940 HCPCS inpatient 39 25.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.61 37.83 "INJECTION, FUROSEMIDE, UP TO 20 MG" 49224159_1 CDM 0636 RC J1940 HCPCS inpatient 39 25.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.61 37.83 "INJECTION, FUROSEMIDE, UP TO 20 MG" 49224159_1 CDM 0636 RC J1940 HCPCS inpatient 39 25.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.61 37.83 "INJECTION, FUROSEMIDE, UP TO 20 MG" 49224159_1 CDM 0636 RC J1940 HCPCS inpatient 39 25.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 26.36 67.6 999999999 23.61 37.83 percent of total billed charges ADRENALIN 30 MG/30 ML VIAL 49229391_1 CDM 0250 RC 42023-0168-01 NDC inpatient 1 UN 45.23 29.4 AETNA AETNA 35.73 79 999999999 27.39 43.87 percent of total billed charges ADRENALIN 30 MG/30 ML VIAL 49229391_1 CDM 0250 RC 42023-0168-01 NDC inpatient 1 UN 45.23 29.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 29.4 65 999999999 27.39 43.87 percent of total billed charges ADRENALIN 30 MG/30 ML VIAL 49229391_1 CDM 0250 RC 42023-0168-01 NDC inpatient 1 UN 45.23 29.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 43.87 97 999999999 27.39 43.87 percent of total billed charges ADRENALIN 30 MG/30 ML VIAL 49229391_1 CDM 0250 RC 42023-0168-01 NDC inpatient 1 UN 45.23 29.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 35.28 78 999999999 27.39 43.87 percent of total billed charges ADRENALIN 30 MG/30 ML VIAL 49229391_1 CDM 0250 RC 42023-0168-01 NDC inpatient 1 UN 45.23 29.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 31.21 69 999999999 27.39 43.87 percent of total billed charges ADRENALIN 30 MG/30 ML VIAL 49229391_1 CDM 0250 RC 42023-0168-01 NDC inpatient 1 UN 45.23 29.4 UMR - ALL PLANS UMR - ALL PLANS 31.66 70 999999999 27.39 43.87 percent of total billed charges ADRENALIN 30 MG/30 ML VIAL 49229391_1 CDM 0250 RC 42023-0168-01 NDC inpatient 1 UN 45.23 29.4 SIHO - ALL PLANS SIHO - ALL PLANS 40.71 90 999999999 27.39 43.87 percent of total billed charges ADRENALIN 30 MG/30 ML VIAL 49229391_1 CDM 0250 RC 42023-0168-01 NDC inpatient 1 UN 45.23 29.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27.39 60.55 999999999 27.39 43.87 percent of total billed charges ADRENALIN 30 MG/30 ML VIAL 49229391_1 CDM 0250 RC 42023-0168-01 NDC inpatient 1 UN 45.23 29.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 27.39 43.87 ADRENALIN 30 MG/30 ML VIAL 49229391_1 CDM 0250 RC 42023-0168-01 NDC inpatient 1 UN 45.23 29.4 ANTHEM HMO ANTHEM HMO 999999999 27.39 43.87 ADRENALIN 30 MG/30 ML VIAL 49229391_1 CDM 0250 RC 42023-0168-01 NDC inpatient 1 UN 45.23 29.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 27.39 43.87 ADRENALIN 30 MG/30 ML VIAL 49229391_1 CDM 0250 RC 42023-0168-01 NDC inpatient 1 UN 45.23 29.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 27.39 43.87 ADRENALIN 30 MG/30 ML VIAL 49229391_1 CDM 0250 RC 42023-0168-01 NDC inpatient 1 UN 45.23 29.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 27.39 43.87 ADRENALIN 30 MG/30 ML VIAL 49229391_1 CDM 0250 RC 42023-0168-01 NDC inpatient 1 UN 45.23 29.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 30.58 67.6 999999999 27.39 43.87 percent of total billed charges Other cardiovascular service or procedure 49230395_1 CDM 0943 RC 93799 HCPCS inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges Other cardiovascular service or procedure 49230395_1 CDM 0943 RC 93799 HCPCS inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges Other cardiovascular service or procedure 49230395_1 CDM 0943 RC 93799 HCPCS inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges Other cardiovascular service or procedure 49230395_1 CDM 0943 RC 93799 HCPCS inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges Other cardiovascular service or procedure 49230395_1 CDM 0943 RC 93799 HCPCS inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges Other cardiovascular service or procedure 49230395_1 CDM 0943 RC 93799 HCPCS inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges Other cardiovascular service or procedure 49230395_1 CDM 0943 RC 93799 HCPCS inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges Other cardiovascular service or procedure 49230395_1 CDM 0943 RC 93799 HCPCS inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges Other cardiovascular service or procedure 49230395_1 CDM 0943 RC 93799 HCPCS inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 Other cardiovascular service or procedure 49230395_1 CDM 0943 RC 93799 HCPCS inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 Other cardiovascular service or procedure 49230395_1 CDM 0943 RC 93799 HCPCS inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 Other cardiovascular service or procedure 49230395_1 CDM 0943 RC 93799 HCPCS inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 Other cardiovascular service or procedure 49230395_1 CDM 0943 RC 93799 HCPCS inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 Other cardiovascular service or procedure 49230395_1 CDM 0943 RC 93799 HCPCS inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges Other cardiovascular service or procedure 49230396_1 CDM 0943 RC 93799 HCPCS inpatient 158 102.7 AETNA AETNA 124.82 79 999999999 95.67 153.26 percent of total billed charges Other cardiovascular service or procedure 49230396_1 CDM 0943 RC 93799 HCPCS inpatient 158 102.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.7 65 999999999 95.67 153.26 percent of total billed charges Other cardiovascular service or procedure 49230396_1 CDM 0943 RC 93799 HCPCS inpatient 158 102.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 153.26 97 999999999 95.67 153.26 percent of total billed charges Other cardiovascular service or procedure 49230396_1 CDM 0943 RC 93799 HCPCS inpatient 158 102.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 123.24 78 999999999 95.67 153.26 percent of total billed charges Other cardiovascular service or procedure 49230396_1 CDM 0943 RC 93799 HCPCS inpatient 158 102.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 109.02 69 999999999 95.67 153.26 percent of total billed charges Other cardiovascular service or procedure 49230396_1 CDM 0943 RC 93799 HCPCS inpatient 158 102.7 UMR - ALL PLANS UMR - ALL PLANS 110.6 70 999999999 95.67 153.26 percent of total billed charges Other cardiovascular service or procedure 49230396_1 CDM 0943 RC 93799 HCPCS inpatient 158 102.7 SIHO - ALL PLANS SIHO - ALL PLANS 142.2 90 999999999 95.67 153.26 percent of total billed charges Other cardiovascular service or procedure 49230396_1 CDM 0943 RC 93799 HCPCS inpatient 158 102.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.67 60.55 999999999 95.67 153.26 percent of total billed charges Other cardiovascular service or procedure 49230396_1 CDM 0943 RC 93799 HCPCS inpatient 158 102.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.67 153.26 Other cardiovascular service or procedure 49230396_1 CDM 0943 RC 93799 HCPCS inpatient 158 102.7 ANTHEM HMO ANTHEM HMO 999999999 95.67 153.26 Other cardiovascular service or procedure 49230396_1 CDM 0943 RC 93799 HCPCS inpatient 158 102.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.67 153.26 Other cardiovascular service or procedure 49230396_1 CDM 0943 RC 93799 HCPCS inpatient 158 102.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.67 153.26 Other cardiovascular service or procedure 49230396_1 CDM 0943 RC 93799 HCPCS inpatient 158 102.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.67 153.26 Other cardiovascular service or procedure 49230396_1 CDM 0943 RC 93799 HCPCS inpatient 158 102.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.81 67.6 999999999 95.67 153.26 percent of total billed charges Urine volume measurement 49230625_1 CDM 0307 RC 81050 HCPCS inpatient 55 35.75 AETNA AETNA 43.45 79 999999999 33.3 53.35 percent of total billed charges Urine volume measurement 49230625_1 CDM 0307 RC 81050 HCPCS inpatient 55 35.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 35.75 65 999999999 33.3 53.35 percent of total billed charges Urine volume measurement 49230625_1 CDM 0307 RC 81050 HCPCS inpatient 55 35.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 53.35 97 999999999 33.3 53.35 percent of total billed charges Urine volume measurement 49230625_1 CDM 0307 RC 81050 HCPCS inpatient 55 35.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 42.9 78 999999999 33.3 53.35 percent of total billed charges Urine volume measurement 49230625_1 CDM 0307 RC 81050 HCPCS inpatient 55 35.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 37.95 69 999999999 33.3 53.35 percent of total billed charges Urine volume measurement 49230625_1 CDM 0307 RC 81050 HCPCS inpatient 55 35.75 UMR - ALL PLANS UMR - ALL PLANS 38.5 70 999999999 33.3 53.35 percent of total billed charges Urine volume measurement 49230625_1 CDM 0307 RC 81050 HCPCS inpatient 55 35.75 SIHO - ALL PLANS SIHO - ALL PLANS 49.5 90 999999999 33.3 53.35 percent of total billed charges Urine volume measurement 49230625_1 CDM 0307 RC 81050 HCPCS inpatient 55 35.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33.3 60.55 999999999 33.3 53.35 percent of total billed charges Urine volume measurement 49230625_1 CDM 0307 RC 81050 HCPCS inpatient 55 35.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 33.3 53.35 Urine volume measurement 49230625_1 CDM 0307 RC 81050 HCPCS inpatient 55 35.75 ANTHEM HMO ANTHEM HMO 999999999 33.3 53.35 Urine volume measurement 49230625_1 CDM 0307 RC 81050 HCPCS inpatient 55 35.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 33.3 53.35 Urine volume measurement 49230625_1 CDM 0307 RC 81050 HCPCS inpatient 55 35.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 33.3 53.35 Urine volume measurement 49230625_1 CDM 0307 RC 81050 HCPCS inpatient 55 35.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 33.3 53.35 Urine volume measurement 49230625_1 CDM 0307 RC 81050 HCPCS inpatient 55 35.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 37.18 67.6 999999999 33.3 53.35 percent of total billed charges "Testosterone (hormone) level, total" 49230657_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges "Testosterone (hormone) level, total" 49230657_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges "Testosterone (hormone) level, total" 49230657_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges "Testosterone (hormone) level, total" 49230657_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges "Testosterone (hormone) level, total" 49230657_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges "Testosterone (hormone) level, total" 49230657_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges "Testosterone (hormone) level, total" 49230657_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges "Testosterone (hormone) level, total" 49230657_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges "Testosterone (hormone) level, total" 49230657_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 "Testosterone (hormone) level, total" 49230657_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 "Testosterone (hormone) level, total" 49230657_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 "Testosterone (hormone) level, total" 49230657_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 "Testosterone (hormone) level, total" 49230657_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 "Testosterone (hormone) level, total" 49230657_1 CDM 0301 RC 84403 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges 00574-2003-02 - sodium polystyrene sulfonate 15 g/60 mL Sus[JOHN] 49230675_1 CDM 0250 RC 00574-2003-02 NDC inpatient 1 UN 48.25 31.36 AETNA AETNA 38.12 79 999999999 29.22 46.8 percent of total billed charges 00574-2003-02 - sodium polystyrene sulfonate 15 g/60 mL Sus[JOHN] 49230675_1 CDM 0250 RC 00574-2003-02 NDC inpatient 1 UN 48.25 31.36 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.36 65 999999999 29.22 46.8 percent of total billed charges 00574-2003-02 - sodium polystyrene sulfonate 15 g/60 mL Sus[JOHN] 49230675_1 CDM 0250 RC 00574-2003-02 NDC inpatient 1 UN 48.25 31.36 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 46.8 97 999999999 29.22 46.8 percent of total billed charges 00574-2003-02 - sodium polystyrene sulfonate 15 g/60 mL Sus[JOHN] 49230675_1 CDM 0250 RC 00574-2003-02 NDC inpatient 1 UN 48.25 31.36 HUMANA - ALL PLANS HUMANA - ALL PLANS 37.64 78 999999999 29.22 46.8 percent of total billed charges 00574-2003-02 - sodium polystyrene sulfonate 15 g/60 mL Sus[JOHN] 49230675_1 CDM 0250 RC 00574-2003-02 NDC inpatient 1 UN 48.25 31.36 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.29 69 999999999 29.22 46.8 percent of total billed charges 00574-2003-02 - sodium polystyrene sulfonate 15 g/60 mL Sus[JOHN] 49230675_1 CDM 0250 RC 00574-2003-02 NDC inpatient 1 UN 48.25 31.36 UMR - ALL PLANS UMR - ALL PLANS 33.78 70 999999999 29.22 46.8 percent of total billed charges 00574-2003-02 - sodium polystyrene sulfonate 15 g/60 mL Sus[JOHN] 49230675_1 CDM 0250 RC 00574-2003-02 NDC inpatient 1 UN 48.25 31.36 SIHO - ALL PLANS SIHO - ALL PLANS 43.43 90 999999999 29.22 46.8 percent of total billed charges 00574-2003-02 - sodium polystyrene sulfonate 15 g/60 mL Sus[JOHN] 49230675_1 CDM 0250 RC 00574-2003-02 NDC inpatient 1 UN 48.25 31.36 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.22 60.55 999999999 29.22 46.8 percent of total billed charges 00574-2003-02 - sodium polystyrene sulfonate 15 g/60 mL Sus[JOHN] 49230675_1 CDM 0250 RC 00574-2003-02 NDC inpatient 1 UN 48.25 31.36 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.22 46.8 00574-2003-02 - sodium polystyrene sulfonate 15 g/60 mL Sus[JOHN] 49230675_1 CDM 0250 RC 00574-2003-02 NDC inpatient 1 UN 48.25 31.36 ANTHEM HMO ANTHEM HMO 999999999 29.22 46.8 00574-2003-02 - sodium polystyrene sulfonate 15 g/60 mL Sus[JOHN] 49230675_1 CDM 0250 RC 00574-2003-02 NDC inpatient 1 UN 48.25 31.36 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.22 46.8 00574-2003-02 - sodium polystyrene sulfonate 15 g/60 mL Sus[JOHN] 49230675_1 CDM 0250 RC 00574-2003-02 NDC inpatient 1 UN 48.25 31.36 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.22 46.8 00574-2003-02 - sodium polystyrene sulfonate 15 g/60 mL Sus[JOHN] 49230675_1 CDM 0250 RC 00574-2003-02 NDC inpatient 1 UN 48.25 31.36 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.22 46.8 00574-2003-02 - sodium polystyrene sulfonate 15 g/60 mL Sus[JOHN] 49230675_1 CDM 0250 RC 00574-2003-02 NDC inpatient 1 UN 48.25 31.36 CIGNA - ALL PLANS CIGNA - ALL PLANS 32.62 67.6 999999999 29.22 46.8 percent of total billed charges Destruction of first incompetent vein of arm or leg using radiofrequency and imaging guidance 49232859_1 CDM 0510 RC 36475 HCPCS inpatient 14824 9635.6 AETNA AETNA 11710.96 79 999999999 8975.93 14379.28 percent of total billed charges Destruction of first incompetent vein of arm or leg using radiofrequency and imaging guidance 49232859_1 CDM 0510 RC 36475 HCPCS inpatient 14824 9635.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 9635.6 65 999999999 8975.93 14379.28 percent of total billed charges Destruction of first incompetent vein of arm or leg using radiofrequency and imaging guidance 49232859_1 CDM 0510 RC 36475 HCPCS inpatient 14824 9635.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14379.28 97 999999999 8975.93 14379.28 percent of total billed charges Destruction of first incompetent vein of arm or leg using radiofrequency and imaging guidance 49232859_1 CDM 0510 RC 36475 HCPCS inpatient 14824 9635.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 11562.72 78 999999999 8975.93 14379.28 percent of total billed charges Destruction of first incompetent vein of arm or leg using radiofrequency and imaging guidance 49232859_1 CDM 0510 RC 36475 HCPCS inpatient 14824 9635.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 10228.56 69 999999999 8975.93 14379.28 percent of total billed charges Destruction of first incompetent vein of arm or leg using radiofrequency and imaging guidance 49232859_1 CDM 0510 RC 36475 HCPCS inpatient 14824 9635.6 UMR - ALL PLANS UMR - ALL PLANS 10376.8 70 999999999 8975.93 14379.28 percent of total billed charges Destruction of first incompetent vein of arm or leg using radiofrequency and imaging guidance 49232859_1 CDM 0510 RC 36475 HCPCS inpatient 14824 9635.6 SIHO - ALL PLANS SIHO - ALL PLANS 13341.6 90 999999999 8975.93 14379.28 percent of total billed charges Destruction of first incompetent vein of arm or leg using radiofrequency and imaging guidance 49232859_1 CDM 0510 RC 36475 HCPCS inpatient 14824 9635.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8975.93 60.55 999999999 8975.93 14379.28 percent of total billed charges Destruction of first incompetent vein of arm or leg using radiofrequency and imaging guidance 49232859_1 CDM 0510 RC 36475 HCPCS inpatient 14824 9635.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8975.93 14379.28 Destruction of first incompetent vein of arm or leg using radiofrequency and imaging guidance 49232859_1 CDM 0510 RC 36475 HCPCS inpatient 14824 9635.6 ANTHEM HMO ANTHEM HMO 999999999 8975.93 14379.28 Destruction of first incompetent vein of arm or leg using radiofrequency and imaging guidance 49232859_1 CDM 0510 RC 36475 HCPCS inpatient 14824 9635.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8975.93 14379.28 Destruction of first incompetent vein of arm or leg using radiofrequency and imaging guidance 49232859_1 CDM 0510 RC 36475 HCPCS inpatient 14824 9635.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8975.93 14379.28 Destruction of first incompetent vein of arm or leg using radiofrequency and imaging guidance 49232859_1 CDM 0510 RC 36475 HCPCS inpatient 14824 9635.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 8975.93 14379.28 Destruction of first incompetent vein of arm or leg using radiofrequency and imaging guidance 49232859_1 CDM 0510 RC 36475 HCPCS inpatient 14824 9635.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 10021.02 67.6 999999999 8975.93 14379.28 percent of total billed charges Injection of chemical agent into single incompetent vein 49232862_1 CDM 0510 RC 36470 HCPCS inpatient 1707 1109.55 AETNA AETNA 1348.53 79 999999999 1033.59 1655.79 percent of total billed charges Injection of chemical agent into single incompetent vein 49232862_1 CDM 0510 RC 36470 HCPCS inpatient 1707 1109.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1109.55 65 999999999 1033.59 1655.79 percent of total billed charges Injection of chemical agent into single incompetent vein 49232862_1 CDM 0510 RC 36470 HCPCS inpatient 1707 1109.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1655.79 97 999999999 1033.59 1655.79 percent of total billed charges Injection of chemical agent into single incompetent vein 49232862_1 CDM 0510 RC 36470 HCPCS inpatient 1707 1109.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1331.46 78 999999999 1033.59 1655.79 percent of total billed charges Injection of chemical agent into single incompetent vein 49232862_1 CDM 0510 RC 36470 HCPCS inpatient 1707 1109.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1177.83 69 999999999 1033.59 1655.79 percent of total billed charges Injection of chemical agent into single incompetent vein 49232862_1 CDM 0510 RC 36470 HCPCS inpatient 1707 1109.55 UMR - ALL PLANS UMR - ALL PLANS 1194.9 70 999999999 1033.59 1655.79 percent of total billed charges Injection of chemical agent into single incompetent vein 49232862_1 CDM 0510 RC 36470 HCPCS inpatient 1707 1109.55 SIHO - ALL PLANS SIHO - ALL PLANS 1536.3 90 999999999 1033.59 1655.79 percent of total billed charges Injection of chemical agent into single incompetent vein 49232862_1 CDM 0510 RC 36470 HCPCS inpatient 1707 1109.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1033.59 60.55 999999999 1033.59 1655.79 percent of total billed charges Injection of chemical agent into single incompetent vein 49232862_1 CDM 0510 RC 36470 HCPCS inpatient 1707 1109.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1033.59 1655.79 Injection of chemical agent into single incompetent vein 49232862_1 CDM 0510 RC 36470 HCPCS inpatient 1707 1109.55 ANTHEM HMO ANTHEM HMO 999999999 1033.59 1655.79 Injection of chemical agent into single incompetent vein 49232862_1 CDM 0510 RC 36470 HCPCS inpatient 1707 1109.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1033.59 1655.79 Injection of chemical agent into single incompetent vein 49232862_1 CDM 0510 RC 36470 HCPCS inpatient 1707 1109.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1033.59 1655.79 Injection of chemical agent into single incompetent vein 49232862_1 CDM 0510 RC 36470 HCPCS inpatient 1707 1109.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1033.59 1655.79 Injection of chemical agent into single incompetent vein 49232862_1 CDM 0510 RC 36470 HCPCS inpatient 1707 1109.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1153.93 67.6 999999999 1033.59 1655.79 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49232865_1 CDM 0510 RC 36471 HCPCS inpatient 879 571.35 AETNA AETNA 694.41 79 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49232865_1 CDM 0510 RC 36471 HCPCS inpatient 879 571.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 571.35 65 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49232865_1 CDM 0510 RC 36471 HCPCS inpatient 879 571.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 852.63 97 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49232865_1 CDM 0510 RC 36471 HCPCS inpatient 879 571.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 685.62 78 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49232865_1 CDM 0510 RC 36471 HCPCS inpatient 879 571.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 606.51 69 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49232865_1 CDM 0510 RC 36471 HCPCS inpatient 879 571.35 UMR - ALL PLANS UMR - ALL PLANS 615.3 70 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49232865_1 CDM 0510 RC 36471 HCPCS inpatient 879 571.35 SIHO - ALL PLANS SIHO - ALL PLANS 791.1 90 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49232865_1 CDM 0510 RC 36471 HCPCS inpatient 879 571.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 532.23 60.55 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49232865_1 CDM 0510 RC 36471 HCPCS inpatient 879 571.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 532.23 852.63 Injection of chemical agent into multiple incompetent veins of leg 49232865_1 CDM 0510 RC 36471 HCPCS inpatient 879 571.35 ANTHEM HMO ANTHEM HMO 999999999 532.23 852.63 Injection of chemical agent into multiple incompetent veins of leg 49232865_1 CDM 0510 RC 36471 HCPCS inpatient 879 571.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 532.23 852.63 Injection of chemical agent into multiple incompetent veins of leg 49232865_1 CDM 0510 RC 36471 HCPCS inpatient 879 571.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 532.23 852.63 Injection of chemical agent into multiple incompetent veins of leg 49232865_1 CDM 0510 RC 36471 HCPCS inpatient 879 571.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 532.23 852.63 Injection of chemical agent into multiple incompetent veins of leg 49232865_1 CDM 0510 RC 36471 HCPCS inpatient 879 571.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 594.2 67.6 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49232868_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 AETNA AETNA 694.41 79 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49232868_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 571.35 65 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49232868_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 852.63 97 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49232868_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 685.62 78 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49232868_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 606.51 69 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49232868_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 UMR - ALL PLANS UMR - ALL PLANS 615.3 70 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49232868_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 SIHO - ALL PLANS SIHO - ALL PLANS 791.1 90 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49232868_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 532.23 60.55 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49232868_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein 49232868_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 ANTHEM HMO ANTHEM HMO 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein 49232868_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein 49232868_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein 49232868_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein 49232868_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 594.2 67.6 999999999 532.23 852.63 percent of total billed charges "Cortisol (hormone) measurement, total" 49233548_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 AETNA AETNA 232.26 79 999999999 178.02 285.18 percent of total billed charges "Cortisol (hormone) measurement, total" 49233548_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 191.1 65 999999999 178.02 285.18 percent of total billed charges "Cortisol (hormone) measurement, total" 49233548_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 285.18 97 999999999 178.02 285.18 percent of total billed charges "Cortisol (hormone) measurement, total" 49233548_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 229.32 78 999999999 178.02 285.18 percent of total billed charges "Cortisol (hormone) measurement, total" 49233548_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 202.86 69 999999999 178.02 285.18 percent of total billed charges "Cortisol (hormone) measurement, total" 49233548_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 UMR - ALL PLANS UMR - ALL PLANS 205.8 70 999999999 178.02 285.18 percent of total billed charges "Cortisol (hormone) measurement, total" 49233548_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 SIHO - ALL PLANS SIHO - ALL PLANS 264.6 90 999999999 178.02 285.18 percent of total billed charges "Cortisol (hormone) measurement, total" 49233548_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 178.02 60.55 999999999 178.02 285.18 percent of total billed charges "Cortisol (hormone) measurement, total" 49233548_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 178.02 285.18 "Cortisol (hormone) measurement, total" 49233548_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 ANTHEM HMO ANTHEM HMO 999999999 178.02 285.18 "Cortisol (hormone) measurement, total" 49233548_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 178.02 285.18 "Cortisol (hormone) measurement, total" 49233548_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 178.02 285.18 "Cortisol (hormone) measurement, total" 49233548_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 178.02 285.18 "Cortisol (hormone) measurement, total" 49233548_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 198.74 67.6 999999999 178.02 285.18 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49233587_1 CDM 0250 RC 00264-7510-20 NDC J7060 HCPCS inpatient 1 UN 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49233587_1 CDM 0250 RC 00264-7510-20 NDC J7060 HCPCS inpatient 1 UN 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49233587_1 CDM 0250 RC 00264-7510-20 NDC J7060 HCPCS inpatient 1 UN 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49233587_1 CDM 0250 RC 00264-7510-20 NDC J7060 HCPCS inpatient 1 UN 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49233587_1 CDM 0250 RC 00264-7510-20 NDC J7060 HCPCS inpatient 1 UN 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49233587_1 CDM 0250 RC 00264-7510-20 NDC J7060 HCPCS inpatient 1 UN 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49233587_1 CDM 0250 RC 00264-7510-20 NDC J7060 HCPCS inpatient 1 UN 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49233587_1 CDM 0250 RC 00264-7510-20 NDC J7060 HCPCS inpatient 1 UN 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49233587_1 CDM 0250 RC 00264-7510-20 NDC J7060 HCPCS inpatient 1 UN 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49233587_1 CDM 0250 RC 00264-7510-20 NDC J7060 HCPCS inpatient 1 UN 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49233587_1 CDM 0250 RC 00264-7510-20 NDC J7060 HCPCS inpatient 1 UN 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49233587_1 CDM 0250 RC 00264-7510-20 NDC J7060 HCPCS inpatient 1 UN 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49233587_1 CDM 0250 RC 00264-7510-20 NDC J7060 HCPCS inpatient 1 UN 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49233587_1 CDM 0250 RC 00264-7510-20 NDC J7060 HCPCS inpatient 1 UN 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges Evaluation of use of breathing device 49233724_1 CDM 0410 RC 94664 HCPCS inpatient 289 187.85 AETNA AETNA 228.31 79 999999999 174.99 280.33 percent of total billed charges Evaluation of use of breathing device 49233724_1 CDM 0410 RC 94664 HCPCS inpatient 289 187.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 187.85 65 999999999 174.99 280.33 percent of total billed charges Evaluation of use of breathing device 49233724_1 CDM 0410 RC 94664 HCPCS inpatient 289 187.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 280.33 97 999999999 174.99 280.33 percent of total billed charges Evaluation of use of breathing device 49233724_1 CDM 0410 RC 94664 HCPCS inpatient 289 187.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 225.42 78 999999999 174.99 280.33 percent of total billed charges Evaluation of use of breathing device 49233724_1 CDM 0410 RC 94664 HCPCS inpatient 289 187.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 199.41 69 999999999 174.99 280.33 percent of total billed charges Evaluation of use of breathing device 49233724_1 CDM 0410 RC 94664 HCPCS inpatient 289 187.85 UMR - ALL PLANS UMR - ALL PLANS 202.3 70 999999999 174.99 280.33 percent of total billed charges Evaluation of use of breathing device 49233724_1 CDM 0410 RC 94664 HCPCS inpatient 289 187.85 SIHO - ALL PLANS SIHO - ALL PLANS 260.1 90 999999999 174.99 280.33 percent of total billed charges Evaluation of use of breathing device 49233724_1 CDM 0410 RC 94664 HCPCS inpatient 289 187.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 174.99 60.55 999999999 174.99 280.33 percent of total billed charges Evaluation of use of breathing device 49233724_1 CDM 0410 RC 94664 HCPCS inpatient 289 187.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 174.99 280.33 Evaluation of use of breathing device 49233724_1 CDM 0410 RC 94664 HCPCS inpatient 289 187.85 ANTHEM HMO ANTHEM HMO 999999999 174.99 280.33 Evaluation of use of breathing device 49233724_1 CDM 0410 RC 94664 HCPCS inpatient 289 187.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 174.99 280.33 Evaluation of use of breathing device 49233724_1 CDM 0410 RC 94664 HCPCS inpatient 289 187.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 174.99 280.33 Evaluation of use of breathing device 49233724_1 CDM 0410 RC 94664 HCPCS inpatient 289 187.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 174.99 280.33 Evaluation of use of breathing device 49233724_1 CDM 0410 RC 94664 HCPCS inpatient 289 187.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 195.36 67.6 999999999 174.99 280.33 percent of total billed charges UNCLASSIFIED DRUGS 49233835_1 CDM 0636 RC J3490 HCPCS inpatient 228 148.2 AETNA AETNA 180.12 79 999999999 138.05 221.16 percent of total billed charges UNCLASSIFIED DRUGS 49233835_1 CDM 0636 RC J3490 HCPCS inpatient 228 148.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 148.2 65 999999999 138.05 221.16 percent of total billed charges UNCLASSIFIED DRUGS 49233835_1 CDM 0636 RC J3490 HCPCS inpatient 228 148.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 221.16 97 999999999 138.05 221.16 percent of total billed charges UNCLASSIFIED DRUGS 49233835_1 CDM 0636 RC J3490 HCPCS inpatient 228 148.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 177.84 78 999999999 138.05 221.16 percent of total billed charges UNCLASSIFIED DRUGS 49233835_1 CDM 0636 RC J3490 HCPCS inpatient 228 148.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 157.32 69 999999999 138.05 221.16 percent of total billed charges UNCLASSIFIED DRUGS 49233835_1 CDM 0636 RC J3490 HCPCS inpatient 228 148.2 UMR - ALL PLANS UMR - ALL PLANS 159.6 70 999999999 138.05 221.16 percent of total billed charges UNCLASSIFIED DRUGS 49233835_1 CDM 0636 RC J3490 HCPCS inpatient 228 148.2 SIHO - ALL PLANS SIHO - ALL PLANS 205.2 90 999999999 138.05 221.16 percent of total billed charges UNCLASSIFIED DRUGS 49233835_1 CDM 0636 RC J3490 HCPCS inpatient 228 148.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 138.05 60.55 999999999 138.05 221.16 percent of total billed charges UNCLASSIFIED DRUGS 49233835_1 CDM 0636 RC J3490 HCPCS inpatient 228 148.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 138.05 221.16 UNCLASSIFIED DRUGS 49233835_1 CDM 0636 RC J3490 HCPCS inpatient 228 148.2 ANTHEM HMO ANTHEM HMO 999999999 138.05 221.16 UNCLASSIFIED DRUGS 49233835_1 CDM 0636 RC J3490 HCPCS inpatient 228 148.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 138.05 221.16 UNCLASSIFIED DRUGS 49233835_1 CDM 0636 RC J3490 HCPCS inpatient 228 148.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 138.05 221.16 UNCLASSIFIED DRUGS 49233835_1 CDM 0636 RC J3490 HCPCS inpatient 228 148.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 138.05 221.16 UNCLASSIFIED DRUGS 49233835_1 CDM 0636 RC J3490 HCPCS inpatient 228 148.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 154.13 67.6 999999999 138.05 221.16 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49233837_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 AETNA AETNA 358.66 79 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49233837_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 295.1 65 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49233837_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 440.38 97 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49233837_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 354.12 78 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49233837_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 313.26 69 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49233837_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 UMR - ALL PLANS UMR - ALL PLANS 317.8 70 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49233837_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 SIHO - ALL PLANS SIHO - ALL PLANS 408.6 90 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49233837_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 274.9 60.55 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49233837_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 274.9 440.38 Injection of chemical agent into multiple incompetent veins of leg 49233837_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 ANTHEM HMO ANTHEM HMO 999999999 274.9 440.38 Injection of chemical agent into multiple incompetent veins of leg 49233837_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 274.9 440.38 Injection of chemical agent into multiple incompetent veins of leg 49233837_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 274.9 440.38 Injection of chemical agent into multiple incompetent veins of leg 49233837_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 274.9 440.38 Injection of chemical agent into multiple incompetent veins of leg 49233837_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 306.9 67.6 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49233839_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 AETNA AETNA 358.66 79 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49233839_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 295.1 65 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49233839_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 440.38 97 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49233839_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 354.12 78 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49233839_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 313.26 69 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49233839_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 UMR - ALL PLANS UMR - ALL PLANS 317.8 70 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49233839_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 SIHO - ALL PLANS SIHO - ALL PLANS 408.6 90 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49233839_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 274.9 60.55 999999999 274.9 440.38 percent of total billed charges Injection of chemical agent into multiple incompetent veins of leg 49233839_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 274.9 440.38 Injection of chemical agent into multiple incompetent veins of leg 49233839_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 ANTHEM HMO ANTHEM HMO 999999999 274.9 440.38 Injection of chemical agent into multiple incompetent veins of leg 49233839_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 274.9 440.38 Injection of chemical agent into multiple incompetent veins of leg 49233839_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 274.9 440.38 Injection of chemical agent into multiple incompetent veins of leg 49233839_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 274.9 440.38 Injection of chemical agent into multiple incompetent veins of leg 49233839_1 CDM 0510 RC 36471 HCPCS inpatient 454 295.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 306.9 67.6 999999999 274.9 440.38 percent of total billed charges Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 49233841_1 CDM 0510 RC 36476 HCPCS inpatient 9258 6017.7 AETNA AETNA 7313.82 79 999999999 5605.72 8980.26 percent of total billed charges Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 49233841_1 CDM 0510 RC 36476 HCPCS inpatient 9258 6017.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 6017.7 65 999999999 5605.72 8980.26 percent of total billed charges Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 49233841_1 CDM 0510 RC 36476 HCPCS inpatient 9258 6017.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8980.26 97 999999999 5605.72 8980.26 percent of total billed charges Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 49233841_1 CDM 0510 RC 36476 HCPCS inpatient 9258 6017.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 7221.24 78 999999999 5605.72 8980.26 percent of total billed charges Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 49233841_1 CDM 0510 RC 36476 HCPCS inpatient 9258 6017.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 6388.02 69 999999999 5605.72 8980.26 percent of total billed charges Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 49233841_1 CDM 0510 RC 36476 HCPCS inpatient 9258 6017.7 UMR - ALL PLANS UMR - ALL PLANS 6480.6 70 999999999 5605.72 8980.26 percent of total billed charges Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 49233841_1 CDM 0510 RC 36476 HCPCS inpatient 9258 6017.7 SIHO - ALL PLANS SIHO - ALL PLANS 8332.2 90 999999999 5605.72 8980.26 percent of total billed charges Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 49233841_1 CDM 0510 RC 36476 HCPCS inpatient 9258 6017.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5605.72 60.55 999999999 5605.72 8980.26 percent of total billed charges Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 49233841_1 CDM 0510 RC 36476 HCPCS inpatient 9258 6017.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5605.72 8980.26 Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 49233841_1 CDM 0510 RC 36476 HCPCS inpatient 9258 6017.7 ANTHEM HMO ANTHEM HMO 999999999 5605.72 8980.26 Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 49233841_1 CDM 0510 RC 36476 HCPCS inpatient 9258 6017.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5605.72 8980.26 Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 49233841_1 CDM 0510 RC 36476 HCPCS inpatient 9258 6017.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5605.72 8980.26 Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 49233841_1 CDM 0510 RC 36476 HCPCS inpatient 9258 6017.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 5605.72 8980.26 Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 49233841_1 CDM 0510 RC 36476 HCPCS inpatient 9258 6017.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 6258.41 67.6 999999999 5605.72 8980.26 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233903_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233903_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233903_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233903_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233903_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233903_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233903_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233903_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233903_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233903_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233903_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233903_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233903_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233903_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233904_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233904_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233904_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233904_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233904_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233904_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233904_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233904_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233904_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233904_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233904_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233904_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233904_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233904_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233905_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233905_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233905_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233905_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233905_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233905_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233905_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233905_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233905_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233905_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233905_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233905_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233905_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233905_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233906_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233906_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233906_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233906_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233906_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233906_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233906_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233906_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233906_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233906_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233906_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233906_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233906_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49233906_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 49233911_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 AETNA AETNA 402.11 79 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 49233911_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 330.85 65 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 49233911_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 493.73 97 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 49233911_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 397.02 78 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 49233911_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 351.21 69 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 49233911_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 UMR - ALL PLANS UMR - ALL PLANS 356.3 70 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 49233911_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 SIHO - ALL PLANS SIHO - ALL PLANS 458.1 90 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 49233911_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 308.2 60.55 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 49233911_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 308.2 493.73 Translocation analysis (BCR/ABL1) major breakpoint 49233911_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 308.2 493.73 Translocation analysis (BCR/ABL1) major breakpoint 49233911_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 ANTHEM HMO ANTHEM HMO 999999999 308.2 493.73 Translocation analysis (BCR/ABL1) major breakpoint 49233911_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 308.2 493.73 Translocation analysis (BCR/ABL1) major breakpoint 49233911_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 308.2 493.73 Translocation analysis (BCR/ABL1) major breakpoint 49233911_1 CDM 0301 RC 81206 HCPCS inpatient 509 330.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 344.08 67.6 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 49233912_1 CDM 0301 RC 81207 HCPCS inpatient 509 330.85 AETNA AETNA 402.11 79 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 49233912_1 CDM 0301 RC 81207 HCPCS inpatient 509 330.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 330.85 65 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 49233912_1 CDM 0301 RC 81207 HCPCS inpatient 509 330.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 493.73 97 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 49233912_1 CDM 0301 RC 81207 HCPCS inpatient 509 330.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 397.02 78 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 49233912_1 CDM 0301 RC 81207 HCPCS inpatient 509 330.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 351.21 69 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 49233912_1 CDM 0301 RC 81207 HCPCS inpatient 509 330.85 UMR - ALL PLANS UMR - ALL PLANS 356.3 70 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 49233912_1 CDM 0301 RC 81207 HCPCS inpatient 509 330.85 SIHO - ALL PLANS SIHO - ALL PLANS 458.1 90 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 49233912_1 CDM 0301 RC 81207 HCPCS inpatient 509 330.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 308.2 60.55 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 49233912_1 CDM 0301 RC 81207 HCPCS inpatient 509 330.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 308.2 493.73 Translocation analysis (BCR/ABL1) minor breakpoint 49233912_1 CDM 0301 RC 81207 HCPCS inpatient 509 330.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 308.2 493.73 Translocation analysis (BCR/ABL1) minor breakpoint 49233912_1 CDM 0301 RC 81207 HCPCS inpatient 509 330.85 ANTHEM HMO ANTHEM HMO 999999999 308.2 493.73 Translocation analysis (BCR/ABL1) minor breakpoint 49233912_1 CDM 0301 RC 81207 HCPCS inpatient 509 330.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 308.2 493.73 Translocation analysis (BCR/ABL1) minor breakpoint 49233912_1 CDM 0301 RC 81207 HCPCS inpatient 509 330.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 308.2 493.73 Translocation analysis (BCR/ABL1) minor breakpoint 49233912_1 CDM 0301 RC 81207 HCPCS inpatient 509 330.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 344.08 67.6 999999999 308.2 493.73 percent of total billed charges AMPICILLIN 1 GM ADD-VANTAGE VL 49234939_1 CDM 0250 RC 00781-3412-92 NDC inpatient 1 UN 73.52 47.79 AETNA AETNA 58.08 79 999999999 44.52 71.31 percent of total billed charges AMPICILLIN 1 GM ADD-VANTAGE VL 49234939_1 CDM 0250 RC 00781-3412-92 NDC inpatient 1 UN 73.52 47.79 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.79 65 999999999 44.52 71.31 percent of total billed charges AMPICILLIN 1 GM ADD-VANTAGE VL 49234939_1 CDM 0250 RC 00781-3412-92 NDC inpatient 1 UN 73.52 47.79 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 71.31 97 999999999 44.52 71.31 percent of total billed charges AMPICILLIN 1 GM ADD-VANTAGE VL 49234939_1 CDM 0250 RC 00781-3412-92 NDC inpatient 1 UN 73.52 47.79 HUMANA - ALL PLANS HUMANA - ALL PLANS 57.35 78 999999999 44.52 71.31 percent of total billed charges AMPICILLIN 1 GM ADD-VANTAGE VL 49234939_1 CDM 0250 RC 00781-3412-92 NDC inpatient 1 UN 73.52 47.79 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.73 69 999999999 44.52 71.31 percent of total billed charges AMPICILLIN 1 GM ADD-VANTAGE VL 49234939_1 CDM 0250 RC 00781-3412-92 NDC inpatient 1 UN 73.52 47.79 UMR - ALL PLANS UMR - ALL PLANS 51.46 70 999999999 44.52 71.31 percent of total billed charges AMPICILLIN 1 GM ADD-VANTAGE VL 49234939_1 CDM 0250 RC 00781-3412-92 NDC inpatient 1 UN 73.52 47.79 SIHO - ALL PLANS SIHO - ALL PLANS 66.17 90 999999999 44.52 71.31 percent of total billed charges AMPICILLIN 1 GM ADD-VANTAGE VL 49234939_1 CDM 0250 RC 00781-3412-92 NDC inpatient 1 UN 73.52 47.79 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.52 60.55 999999999 44.52 71.31 percent of total billed charges AMPICILLIN 1 GM ADD-VANTAGE VL 49234939_1 CDM 0250 RC 00781-3412-92 NDC inpatient 1 UN 73.52 47.79 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.52 71.31 AMPICILLIN 1 GM ADD-VANTAGE VL 49234939_1 CDM 0250 RC 00781-3412-92 NDC inpatient 1 UN 73.52 47.79 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.52 71.31 AMPICILLIN 1 GM ADD-VANTAGE VL 49234939_1 CDM 0250 RC 00781-3412-92 NDC inpatient 1 UN 73.52 47.79 ANTHEM HMO ANTHEM HMO 999999999 44.52 71.31 AMPICILLIN 1 GM ADD-VANTAGE VL 49234939_1 CDM 0250 RC 00781-3412-92 NDC inpatient 1 UN 73.52 47.79 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.52 71.31 AMPICILLIN 1 GM ADD-VANTAGE VL 49234939_1 CDM 0250 RC 00781-3412-92 NDC inpatient 1 UN 73.52 47.79 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.52 71.31 AMPICILLIN 1 GM ADD-VANTAGE VL 49234939_1 CDM 0250 RC 00781-3412-92 NDC inpatient 1 UN 73.52 47.79 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.7 67.6 999999999 44.52 71.31 percent of total billed charges Gammaglobulin (immune system protein) measurement 49235591_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49235591_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49235591_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49235591_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49235591_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49235591_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49235591_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49235591_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49235591_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49235591_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49235591_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49235591_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49235591_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49235591_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49235592_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49235592_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49235592_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49235592_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49235592_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49235592_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49235592_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49235592_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49235592_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49235592_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49235592_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49235592_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49235592_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49235592_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges Measurement of antibody to noninfectious agent 49235594_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 49235594_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 49235594_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 49235594_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 49235594_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 49235594_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 49235594_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 49235594_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 49235594_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 49235594_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 49235594_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 49235594_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 49235594_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 49235594_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49235764_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49235764_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49235764_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49235764_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49235764_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49235764_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49235764_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49235764_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49235764_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49235764_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49235764_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49235764_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49235764_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 49235764_1 CDM 0302 RC 86146 HCPCS inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49235893_1 CDM 0302 RC 86765 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49235893_1 CDM 0302 RC 86765 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49235893_1 CDM 0302 RC 86765 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49235893_1 CDM 0302 RC 86765 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49235893_1 CDM 0302 RC 86765 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49235893_1 CDM 0302 RC 86765 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49235893_1 CDM 0302 RC 86765 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49235893_1 CDM 0302 RC 86765 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49235893_1 CDM 0302 RC 86765 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 Analysis for antibody to Rubeola (measles virus) 49235893_1 CDM 0302 RC 86765 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 Analysis for antibody to Rubeola (measles virus) 49235893_1 CDM 0302 RC 86765 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 Analysis for antibody to Rubeola (measles virus) 49235893_1 CDM 0302 RC 86765 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 Analysis for antibody to Rubeola (measles virus) 49235893_1 CDM 0302 RC 86765 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 Analysis for antibody to Rubeola (measles virus) 49235893_1 CDM 0302 RC 86765 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49235903_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49235903_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49235903_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49235903_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49235903_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49235903_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49235903_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49235903_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49235903_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 49235903_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 49235903_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 49235903_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 49235903_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 49235903_1 CDM 0302 RC 86317 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges DULOXETINE HCL DR 60 MG CAP 49235918_1 CDM 0250 RC 68084-0692-01 NDC inpatient 1 UN 2.28 1.48 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.48 65 999999999 1.38 2.21 percent of total billed charges DULOXETINE HCL DR 60 MG CAP 49235918_1 CDM 0250 RC 68084-0692-01 NDC inpatient 1 UN 2.28 1.48 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.21 97 999999999 1.38 2.21 percent of total billed charges DULOXETINE HCL DR 60 MG CAP 49235918_1 CDM 0250 RC 68084-0692-01 NDC inpatient 1 UN 2.28 1.48 AETNA AETNA 1.8 79 999999999 1.38 2.21 percent of total billed charges DULOXETINE HCL DR 60 MG CAP 49235918_1 CDM 0250 RC 68084-0692-01 NDC inpatient 1 UN 2.28 1.48 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.78 78 999999999 1.38 2.21 percent of total billed charges DULOXETINE HCL DR 60 MG CAP 49235918_1 CDM 0250 RC 68084-0692-01 NDC inpatient 1 UN 2.28 1.48 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.57 69 999999999 1.38 2.21 percent of total billed charges DULOXETINE HCL DR 60 MG CAP 49235918_1 CDM 0250 RC 68084-0692-01 NDC inpatient 1 UN 2.28 1.48 UMR - ALL PLANS UMR - ALL PLANS 1.6 70 999999999 1.38 2.21 percent of total billed charges DULOXETINE HCL DR 60 MG CAP 49235918_1 CDM 0250 RC 68084-0692-01 NDC inpatient 1 UN 2.28 1.48 SIHO - ALL PLANS SIHO - ALL PLANS 2.05 90 999999999 1.38 2.21 percent of total billed charges DULOXETINE HCL DR 60 MG CAP 49235918_1 CDM 0250 RC 68084-0692-01 NDC inpatient 1 UN 2.28 1.48 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.38 60.55 999999999 1.38 2.21 percent of total billed charges DULOXETINE HCL DR 60 MG CAP 49235918_1 CDM 0250 RC 68084-0692-01 NDC inpatient 1 UN 2.28 1.48 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.38 2.21 DULOXETINE HCL DR 60 MG CAP 49235918_1 CDM 0250 RC 68084-0692-01 NDC inpatient 1 UN 2.28 1.48 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.38 2.21 DULOXETINE HCL DR 60 MG CAP 49235918_1 CDM 0250 RC 68084-0692-01 NDC inpatient 1 UN 2.28 1.48 ANTHEM HMO ANTHEM HMO 999999999 1.38 2.21 DULOXETINE HCL DR 60 MG CAP 49235918_1 CDM 0250 RC 68084-0692-01 NDC inpatient 1 UN 2.28 1.48 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.38 2.21 DULOXETINE HCL DR 60 MG CAP 49235918_1 CDM 0250 RC 68084-0692-01 NDC inpatient 1 UN 2.28 1.48 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.38 2.21 DULOXETINE HCL DR 60 MG CAP 49235918_1 CDM 0250 RC 68084-0692-01 NDC inpatient 1 UN 2.28 1.48 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.54 67.6 999999999 1.38 2.21 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 49235938_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 173.55 65 999999999 161.67 258.99 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 49235938_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 258.99 97 999999999 161.67 258.99 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 49235938_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 AETNA AETNA 210.93 79 999999999 161.67 258.99 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 49235938_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 208.26 78 999999999 161.67 258.99 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 49235938_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.23 69 999999999 161.67 258.99 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 49235938_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 UMR - ALL PLANS UMR - ALL PLANS 186.9 70 999999999 161.67 258.99 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 49235938_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 SIHO - ALL PLANS SIHO - ALL PLANS 240.3 90 999999999 161.67 258.99 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 49235938_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 161.67 60.55 999999999 161.67 258.99 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 49235938_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 161.67 258.99 "PSA (prostate specific antigen) measurement, free" 49235938_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 161.67 258.99 "PSA (prostate specific antigen) measurement, free" 49235938_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 ANTHEM HMO ANTHEM HMO 999999999 161.67 258.99 "PSA (prostate specific antigen) measurement, free" 49235938_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 161.67 258.99 "PSA (prostate specific antigen) measurement, free" 49235938_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 161.67 258.99 "PSA (prostate specific antigen) measurement, free" 49235938_1 CDM 0301 RC 84154 HCPCS inpatient 267 173.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 180.49 67.6 999999999 161.67 258.99 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 49235939_1 CDM 0301 RC 84153 HCPCS inpatient 283 183.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 183.95 65 999999999 171.36 274.51 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 49235939_1 CDM 0301 RC 84153 HCPCS inpatient 283 183.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 274.51 97 999999999 171.36 274.51 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 49235939_1 CDM 0301 RC 84153 HCPCS inpatient 283 183.95 AETNA AETNA 223.57 79 999999999 171.36 274.51 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 49235939_1 CDM 0301 RC 84153 HCPCS inpatient 283 183.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 220.74 78 999999999 171.36 274.51 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 49235939_1 CDM 0301 RC 84153 HCPCS inpatient 283 183.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 195.27 69 999999999 171.36 274.51 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 49235939_1 CDM 0301 RC 84153 HCPCS inpatient 283 183.95 UMR - ALL PLANS UMR - ALL PLANS 198.1 70 999999999 171.36 274.51 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 49235939_1 CDM 0301 RC 84153 HCPCS inpatient 283 183.95 SIHO - ALL PLANS SIHO - ALL PLANS 254.7 90 999999999 171.36 274.51 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 49235939_1 CDM 0301 RC 84153 HCPCS inpatient 283 183.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 171.36 60.55 999999999 171.36 274.51 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 49235939_1 CDM 0301 RC 84153 HCPCS inpatient 283 183.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 171.36 274.51 "PSA (prostate specific antigen) measurement, total" 49235939_1 CDM 0301 RC 84153 HCPCS inpatient 283 183.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 171.36 274.51 "PSA (prostate specific antigen) measurement, total" 49235939_1 CDM 0301 RC 84153 HCPCS inpatient 283 183.95 ANTHEM HMO ANTHEM HMO 999999999 171.36 274.51 "PSA (prostate specific antigen) measurement, total" 49235939_1 CDM 0301 RC 84153 HCPCS inpatient 283 183.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 171.36 274.51 "PSA (prostate specific antigen) measurement, total" 49235939_1 CDM 0301 RC 84153 HCPCS inpatient 283 183.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 171.36 274.51 "PSA (prostate specific antigen) measurement, total" 49235939_1 CDM 0301 RC 84153 HCPCS inpatient 283 183.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 191.31 67.6 999999999 171.36 274.51 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 49236060_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 49236060_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 49236060_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 49236060_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 49236060_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 49236060_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 49236060_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 49236060_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 49236060_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 "Alpha-fetoprotein (AFP) level, serum" 49236060_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 "Alpha-fetoprotein (AFP) level, serum" 49236060_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 "Alpha-fetoprotein (AFP) level, serum" 49236060_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 "Alpha-fetoprotein (AFP) level, serum" 49236060_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 "Alpha-fetoprotein (AFP) level, serum" 49236060_1 CDM 0301 RC 82105 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges Vitamin D-3 level 49236099_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges Vitamin D-3 level 49236099_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges Vitamin D-3 level 49236099_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges Vitamin D-3 level 49236099_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges Vitamin D-3 level 49236099_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges Vitamin D-3 level 49236099_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges Vitamin D-3 level 49236099_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges Vitamin D-3 level 49236099_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges Vitamin D-3 level 49236099_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 Vitamin D-3 level 49236099_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 Vitamin D-3 level 49236099_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 Vitamin D-3 level 49236099_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 Vitamin D-3 level 49236099_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 Vitamin D-3 level 49236099_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49236115_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 176.8 65 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49236115_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 263.84 97 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49236115_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 AETNA AETNA 214.88 79 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49236115_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 212.16 78 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49236115_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 187.68 69 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49236115_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 UMR - ALL PLANS UMR - ALL PLANS 190.4 70 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49236115_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 SIHO - ALL PLANS SIHO - ALL PLANS 244.8 90 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49236115_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 164.7 60.55 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49236115_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 164.7 263.84 "Measurement of substance using immunoassay technique, by radioimmunoassay" 49236115_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 164.7 263.84 "Measurement of substance using immunoassay technique, by radioimmunoassay" 49236115_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 ANTHEM HMO ANTHEM HMO 999999999 164.7 263.84 "Measurement of substance using immunoassay technique, by radioimmunoassay" 49236115_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 164.7 263.84 "Measurement of substance using immunoassay technique, by radioimmunoassay" 49236115_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 164.7 263.84 "Measurement of substance using immunoassay technique, by radioimmunoassay" 49236115_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 183.87 67.6 999999999 164.7 263.84 percent of total billed charges Measurement of substance using immunoassay technique 49236122_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 64.35 65 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 49236122_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 96.03 97 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 49236122_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 AETNA AETNA 78.21 79 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 49236122_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 77.22 78 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 49236122_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 68.31 69 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 49236122_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 UMR - ALL PLANS UMR - ALL PLANS 69.3 70 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 49236122_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 SIHO - ALL PLANS SIHO - ALL PLANS 89.1 90 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 49236122_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.94 60.55 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 49236122_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.94 96.03 Measurement of substance using immunoassay technique 49236122_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.94 96.03 Measurement of substance using immunoassay technique 49236122_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM HMO ANTHEM HMO 999999999 59.94 96.03 Measurement of substance using immunoassay technique 49236122_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.94 96.03 Measurement of substance using immunoassay technique 49236122_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.94 96.03 Measurement of substance using immunoassay technique 49236122_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.92 67.6 999999999 59.94 96.03 percent of total billed charges Smear for parasites 49236140_1 CDM 0306 RC 87177 HCPCS inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges Smear for parasites 49236140_1 CDM 0306 RC 87177 HCPCS inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges Smear for parasites 49236140_1 CDM 0306 RC 87177 HCPCS inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges Smear for parasites 49236140_1 CDM 0306 RC 87177 HCPCS inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges Smear for parasites 49236140_1 CDM 0306 RC 87177 HCPCS inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges Smear for parasites 49236140_1 CDM 0306 RC 87177 HCPCS inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges Smear for parasites 49236140_1 CDM 0306 RC 87177 HCPCS inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges Smear for parasites 49236140_1 CDM 0306 RC 87177 HCPCS inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges Smear for parasites 49236140_1 CDM 0306 RC 87177 HCPCS inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 Smear for parasites 49236140_1 CDM 0306 RC 87177 HCPCS inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 Smear for parasites 49236140_1 CDM 0306 RC 87177 HCPCS inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 Smear for parasites 49236140_1 CDM 0306 RC 87177 HCPCS inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 Smear for parasites 49236140_1 CDM 0306 RC 87177 HCPCS inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 Smear for parasites 49236140_1 CDM 0306 RC 87177 HCPCS inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 49236151_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 49236151_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 49236151_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 49236151_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 49236151_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 49236151_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 49236151_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 49236151_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 49236151_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 49236151_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 49236151_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 49236151_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 49236151_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 49236151_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 49236152_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 174.2 65 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 49236152_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 259.96 97 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 49236152_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 AETNA AETNA 211.72 79 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 49236152_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 209.04 78 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 49236152_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.92 69 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 49236152_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 UMR - ALL PLANS UMR - ALL PLANS 187.6 70 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 49236152_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 SIHO - ALL PLANS SIHO - ALL PLANS 241.2 90 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 49236152_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 162.27 60.55 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 49236152_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 162.27 259.96 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 49236152_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 162.27 259.96 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 49236152_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 ANTHEM HMO ANTHEM HMO 999999999 162.27 259.96 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 49236152_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 162.27 259.96 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 49236152_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 162.27 259.96 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 49236152_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 181.17 67.6 999999999 162.27 259.96 percent of total billed charges Analysis for antibody to histoplasma (fungus) 49236207_1 CDM 0302 RC 86698 HCPCS inpatient 417 271.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 271.05 65 999999999 252.49 404.49 percent of total billed charges Analysis for antibody to histoplasma (fungus) 49236207_1 CDM 0302 RC 86698 HCPCS inpatient 417 271.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 404.49 97 999999999 252.49 404.49 percent of total billed charges Analysis for antibody to histoplasma (fungus) 49236207_1 CDM 0302 RC 86698 HCPCS inpatient 417 271.05 AETNA AETNA 329.43 79 999999999 252.49 404.49 percent of total billed charges Analysis for antibody to histoplasma (fungus) 49236207_1 CDM 0302 RC 86698 HCPCS inpatient 417 271.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 325.26 78 999999999 252.49 404.49 percent of total billed charges Analysis for antibody to histoplasma (fungus) 49236207_1 CDM 0302 RC 86698 HCPCS inpatient 417 271.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 287.73 69 999999999 252.49 404.49 percent of total billed charges Analysis for antibody to histoplasma (fungus) 49236207_1 CDM 0302 RC 86698 HCPCS inpatient 417 271.05 UMR - ALL PLANS UMR - ALL PLANS 291.9 70 999999999 252.49 404.49 percent of total billed charges Analysis for antibody to histoplasma (fungus) 49236207_1 CDM 0302 RC 86698 HCPCS inpatient 417 271.05 SIHO - ALL PLANS SIHO - ALL PLANS 375.3 90 999999999 252.49 404.49 percent of total billed charges Analysis for antibody to histoplasma (fungus) 49236207_1 CDM 0302 RC 86698 HCPCS inpatient 417 271.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 252.49 60.55 999999999 252.49 404.49 percent of total billed charges Analysis for antibody to histoplasma (fungus) 49236207_1 CDM 0302 RC 86698 HCPCS inpatient 417 271.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 252.49 404.49 Analysis for antibody to histoplasma (fungus) 49236207_1 CDM 0302 RC 86698 HCPCS inpatient 417 271.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 252.49 404.49 Analysis for antibody to histoplasma (fungus) 49236207_1 CDM 0302 RC 86698 HCPCS inpatient 417 271.05 ANTHEM HMO ANTHEM HMO 999999999 252.49 404.49 Analysis for antibody to histoplasma (fungus) 49236207_1 CDM 0302 RC 86698 HCPCS inpatient 417 271.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 252.49 404.49 Analysis for antibody to histoplasma (fungus) 49236207_1 CDM 0302 RC 86698 HCPCS inpatient 417 271.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 252.49 404.49 Analysis for antibody to histoplasma (fungus) 49236207_1 CDM 0302 RC 86698 HCPCS inpatient 417 271.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 281.89 67.6 999999999 252.49 404.49 percent of total billed charges Tissue preparation for culture 49236314_1 CDM 0306 RC 87176 HCPCS inpatient 40 26 SELF PAY DISCOUNT SELF PAY DISCOUNT 26 65 999999999 24.22 38.8 percent of total billed charges Tissue preparation for culture 49236314_1 CDM 0306 RC 87176 HCPCS inpatient 40 26 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 38.8 97 999999999 24.22 38.8 percent of total billed charges Tissue preparation for culture 49236314_1 CDM 0306 RC 87176 HCPCS inpatient 40 26 AETNA AETNA 31.6 79 999999999 24.22 38.8 percent of total billed charges Tissue preparation for culture 49236314_1 CDM 0306 RC 87176 HCPCS inpatient 40 26 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.2 78 999999999 24.22 38.8 percent of total billed charges Tissue preparation for culture 49236314_1 CDM 0306 RC 87176 HCPCS inpatient 40 26 ENCORE - ALL PLANS ENCORE - ALL PLANS 27.6 69 999999999 24.22 38.8 percent of total billed charges Tissue preparation for culture 49236314_1 CDM 0306 RC 87176 HCPCS inpatient 40 26 UMR - ALL PLANS UMR - ALL PLANS 28 70 999999999 24.22 38.8 percent of total billed charges Tissue preparation for culture 49236314_1 CDM 0306 RC 87176 HCPCS inpatient 40 26 SIHO - ALL PLANS SIHO - ALL PLANS 36 90 999999999 24.22 38.8 percent of total billed charges Tissue preparation for culture 49236314_1 CDM 0306 RC 87176 HCPCS inpatient 40 26 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.22 60.55 999999999 24.22 38.8 percent of total billed charges Tissue preparation for culture 49236314_1 CDM 0306 RC 87176 HCPCS inpatient 40 26 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.22 38.8 Tissue preparation for culture 49236314_1 CDM 0306 RC 87176 HCPCS inpatient 40 26 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.22 38.8 Tissue preparation for culture 49236314_1 CDM 0306 RC 87176 HCPCS inpatient 40 26 ANTHEM HMO ANTHEM HMO 999999999 24.22 38.8 Tissue preparation for culture 49236314_1 CDM 0306 RC 87176 HCPCS inpatient 40 26 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.22 38.8 Tissue preparation for culture 49236314_1 CDM 0306 RC 87176 HCPCS inpatient 40 26 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.22 38.8 Tissue preparation for culture 49236314_1 CDM 0306 RC 87176 HCPCS inpatient 40 26 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.04 67.6 999999999 24.22 38.8 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49236330_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49236330_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49236330_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49236330_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49236330_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49236330_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49236330_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49236330_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49236330_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49236330_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49236330_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49236330_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49236330_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49236330_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Phosphatase (enzyme) measurement, alkaline, isoenzymes" 49236364_1 CDM 0301 RC 84080 HCPCS inpatient 247 160.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 160.55 65 999999999 149.56 239.59 percent of total billed charges "Phosphatase (enzyme) measurement, alkaline, isoenzymes" 49236364_1 CDM 0301 RC 84080 HCPCS inpatient 247 160.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 239.59 97 999999999 149.56 239.59 percent of total billed charges "Phosphatase (enzyme) measurement, alkaline, isoenzymes" 49236364_1 CDM 0301 RC 84080 HCPCS inpatient 247 160.55 AETNA AETNA 195.13 79 999999999 149.56 239.59 percent of total billed charges "Phosphatase (enzyme) measurement, alkaline, isoenzymes" 49236364_1 CDM 0301 RC 84080 HCPCS inpatient 247 160.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 192.66 78 999999999 149.56 239.59 percent of total billed charges "Phosphatase (enzyme) measurement, alkaline, isoenzymes" 49236364_1 CDM 0301 RC 84080 HCPCS inpatient 247 160.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 170.43 69 999999999 149.56 239.59 percent of total billed charges "Phosphatase (enzyme) measurement, alkaline, isoenzymes" 49236364_1 CDM 0301 RC 84080 HCPCS inpatient 247 160.55 UMR - ALL PLANS UMR - ALL PLANS 172.9 70 999999999 149.56 239.59 percent of total billed charges "Phosphatase (enzyme) measurement, alkaline, isoenzymes" 49236364_1 CDM 0301 RC 84080 HCPCS inpatient 247 160.55 SIHO - ALL PLANS SIHO - ALL PLANS 222.3 90 999999999 149.56 239.59 percent of total billed charges "Phosphatase (enzyme) measurement, alkaline, isoenzymes" 49236364_1 CDM 0301 RC 84080 HCPCS inpatient 247 160.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 149.56 60.55 999999999 149.56 239.59 percent of total billed charges "Phosphatase (enzyme) measurement, alkaline, isoenzymes" 49236364_1 CDM 0301 RC 84080 HCPCS inpatient 247 160.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 149.56 239.59 "Phosphatase (enzyme) measurement, alkaline, isoenzymes" 49236364_1 CDM 0301 RC 84080 HCPCS inpatient 247 160.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 149.56 239.59 "Phosphatase (enzyme) measurement, alkaline, isoenzymes" 49236364_1 CDM 0301 RC 84080 HCPCS inpatient 247 160.55 ANTHEM HMO ANTHEM HMO 999999999 149.56 239.59 "Phosphatase (enzyme) measurement, alkaline, isoenzymes" 49236364_1 CDM 0301 RC 84080 HCPCS inpatient 247 160.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 149.56 239.59 "Phosphatase (enzyme) measurement, alkaline, isoenzymes" 49236364_1 CDM 0301 RC 84080 HCPCS inpatient 247 160.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 149.56 239.59 "Phosphatase (enzyme) measurement, alkaline, isoenzymes" 49236364_1 CDM 0301 RC 84080 HCPCS inpatient 247 160.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 166.97 67.6 999999999 149.56 239.59 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49236389_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49236389_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49236389_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49236389_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49236389_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49236389_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49236389_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49236389_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49236389_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49236389_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49236389_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49236389_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49236389_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49236389_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Creatine kinase (cardiac enzyme) level, isoenzymes" 49236411_1 CDM 0301 RC 82552 HCPCS inpatient 464 301.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 301.6 65 999999999 280.95 450.08 percent of total billed charges "Creatine kinase (cardiac enzyme) level, isoenzymes" 49236411_1 CDM 0301 RC 82552 HCPCS inpatient 464 301.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 450.08 97 999999999 280.95 450.08 percent of total billed charges "Creatine kinase (cardiac enzyme) level, isoenzymes" 49236411_1 CDM 0301 RC 82552 HCPCS inpatient 464 301.6 AETNA AETNA 366.56 79 999999999 280.95 450.08 percent of total billed charges "Creatine kinase (cardiac enzyme) level, isoenzymes" 49236411_1 CDM 0301 RC 82552 HCPCS inpatient 464 301.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 361.92 78 999999999 280.95 450.08 percent of total billed charges "Creatine kinase (cardiac enzyme) level, isoenzymes" 49236411_1 CDM 0301 RC 82552 HCPCS inpatient 464 301.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 320.16 69 999999999 280.95 450.08 percent of total billed charges "Creatine kinase (cardiac enzyme) level, isoenzymes" 49236411_1 CDM 0301 RC 82552 HCPCS inpatient 464 301.6 UMR - ALL PLANS UMR - ALL PLANS 324.8 70 999999999 280.95 450.08 percent of total billed charges "Creatine kinase (cardiac enzyme) level, isoenzymes" 49236411_1 CDM 0301 RC 82552 HCPCS inpatient 464 301.6 SIHO - ALL PLANS SIHO - ALL PLANS 417.6 90 999999999 280.95 450.08 percent of total billed charges "Creatine kinase (cardiac enzyme) level, isoenzymes" 49236411_1 CDM 0301 RC 82552 HCPCS inpatient 464 301.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 280.95 60.55 999999999 280.95 450.08 percent of total billed charges "Creatine kinase (cardiac enzyme) level, isoenzymes" 49236411_1 CDM 0301 RC 82552 HCPCS inpatient 464 301.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 280.95 450.08 "Creatine kinase (cardiac enzyme) level, isoenzymes" 49236411_1 CDM 0301 RC 82552 HCPCS inpatient 464 301.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 280.95 450.08 "Creatine kinase (cardiac enzyme) level, isoenzymes" 49236411_1 CDM 0301 RC 82552 HCPCS inpatient 464 301.6 ANTHEM HMO ANTHEM HMO 999999999 280.95 450.08 "Creatine kinase (cardiac enzyme) level, isoenzymes" 49236411_1 CDM 0301 RC 82552 HCPCS inpatient 464 301.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 280.95 450.08 "Creatine kinase (cardiac enzyme) level, isoenzymes" 49236411_1 CDM 0301 RC 82552 HCPCS inpatient 464 301.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 280.95 450.08 "Creatine kinase (cardiac enzyme) level, isoenzymes" 49236411_1 CDM 0301 RC 82552 HCPCS inpatient 464 301.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 313.66 67.6 999999999 280.95 450.08 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 49236413_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 49236413_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 49236413_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 49236413_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 49236413_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 49236413_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 49236413_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 49236413_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 49236413_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 "Creatine kinase (cardiac enzyme) level, total" 49236413_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 "Creatine kinase (cardiac enzyme) level, total" 49236413_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 "Creatine kinase (cardiac enzyme) level, total" 49236413_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 "Creatine kinase (cardiac enzyme) level, total" 49236413_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 "Creatine kinase (cardiac enzyme) level, total" 49236413_1 CDM 0301 RC 82550 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges NUVIGIL 150 MG TABLET 49236613_1 CDM 0250 RC 63459-0215-30 NDC inpatient 1 UN 90.44 58.79 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.79 65 999999999 54.76 87.73 percent of total billed charges NUVIGIL 150 MG TABLET 49236613_1 CDM 0250 RC 63459-0215-30 NDC inpatient 1 UN 90.44 58.79 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.73 97 999999999 54.76 87.73 percent of total billed charges NUVIGIL 150 MG TABLET 49236613_1 CDM 0250 RC 63459-0215-30 NDC inpatient 1 UN 90.44 58.79 AETNA AETNA 71.45 79 999999999 54.76 87.73 percent of total billed charges NUVIGIL 150 MG TABLET 49236613_1 CDM 0250 RC 63459-0215-30 NDC inpatient 1 UN 90.44 58.79 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.54 78 999999999 54.76 87.73 percent of total billed charges NUVIGIL 150 MG TABLET 49236613_1 CDM 0250 RC 63459-0215-30 NDC inpatient 1 UN 90.44 58.79 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.4 69 999999999 54.76 87.73 percent of total billed charges NUVIGIL 150 MG TABLET 49236613_1 CDM 0250 RC 63459-0215-30 NDC inpatient 1 UN 90.44 58.79 UMR - ALL PLANS UMR - ALL PLANS 63.31 70 999999999 54.76 87.73 percent of total billed charges NUVIGIL 150 MG TABLET 49236613_1 CDM 0250 RC 63459-0215-30 NDC inpatient 1 UN 90.44 58.79 SIHO - ALL PLANS SIHO - ALL PLANS 81.4 90 999999999 54.76 87.73 percent of total billed charges NUVIGIL 150 MG TABLET 49236613_1 CDM 0250 RC 63459-0215-30 NDC inpatient 1 UN 90.44 58.79 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.76 60.55 999999999 54.76 87.73 percent of total billed charges NUVIGIL 150 MG TABLET 49236613_1 CDM 0250 RC 63459-0215-30 NDC inpatient 1 UN 90.44 58.79 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.76 87.73 NUVIGIL 150 MG TABLET 49236613_1 CDM 0250 RC 63459-0215-30 NDC inpatient 1 UN 90.44 58.79 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.76 87.73 NUVIGIL 150 MG TABLET 49236613_1 CDM 0250 RC 63459-0215-30 NDC inpatient 1 UN 90.44 58.79 ANTHEM HMO ANTHEM HMO 999999999 54.76 87.73 NUVIGIL 150 MG TABLET 49236613_1 CDM 0250 RC 63459-0215-30 NDC inpatient 1 UN 90.44 58.79 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.76 87.73 NUVIGIL 150 MG TABLET 49236613_1 CDM 0250 RC 63459-0215-30 NDC inpatient 1 UN 90.44 58.79 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.76 87.73 NUVIGIL 150 MG TABLET 49236613_1 CDM 0250 RC 63459-0215-30 NDC inpatient 1 UN 90.44 58.79 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.14 67.6 999999999 54.76 87.73 percent of total billed charges ADHESIVE SPO2 SENESOR PED MAXP 49237110_1 CDM 0272 RC inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges ADHESIVE SPO2 SENESOR PED MAXP 49237110_1 CDM 0272 RC inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges ADHESIVE SPO2 SENESOR PED MAXP 49237110_1 CDM 0272 RC inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges ADHESIVE SPO2 SENESOR PED MAXP 49237110_1 CDM 0272 RC inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges ADHESIVE SPO2 SENESOR PED MAXP 49237110_1 CDM 0272 RC inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges ADHESIVE SPO2 SENESOR PED MAXP 49237110_1 CDM 0272 RC inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges ADHESIVE SPO2 SENESOR PED MAXP 49237110_1 CDM 0272 RC inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges ADHESIVE SPO2 SENESOR PED MAXP 49237110_1 CDM 0272 RC inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges ADHESIVE SPO2 SENESOR PED MAXP 49237110_1 CDM 0272 RC inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 ADHESIVE SPO2 SENESOR PED MAXP 49237110_1 CDM 0272 RC inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 ADHESIVE SPO2 SENESOR PED MAXP 49237110_1 CDM 0272 RC inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 ADHESIVE SPO2 SENESOR PED MAXP 49237110_1 CDM 0272 RC inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 ADHESIVE SPO2 SENESOR PED MAXP 49237110_1 CDM 0272 RC inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 ADHESIVE SPO2 SENESOR PED MAXP 49237110_1 CDM 0272 RC inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges CATH-URETERAL ANGLED TIP 49237113_1 CDM 0272 RC inpatient 199 129.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 129.35 65 999999999 120.49 193.03 percent of total billed charges CATH-URETERAL ANGLED TIP 49237113_1 CDM 0272 RC inpatient 199 129.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 193.03 97 999999999 120.49 193.03 percent of total billed charges CATH-URETERAL ANGLED TIP 49237113_1 CDM 0272 RC inpatient 199 129.35 AETNA AETNA 157.21 79 999999999 120.49 193.03 percent of total billed charges CATH-URETERAL ANGLED TIP 49237113_1 CDM 0272 RC inpatient 199 129.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 155.22 78 999999999 120.49 193.03 percent of total billed charges CATH-URETERAL ANGLED TIP 49237113_1 CDM 0272 RC inpatient 199 129.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 137.31 69 999999999 120.49 193.03 percent of total billed charges CATH-URETERAL ANGLED TIP 49237113_1 CDM 0272 RC inpatient 199 129.35 UMR - ALL PLANS UMR - ALL PLANS 139.3 70 999999999 120.49 193.03 percent of total billed charges CATH-URETERAL ANGLED TIP 49237113_1 CDM 0272 RC inpatient 199 129.35 SIHO - ALL PLANS SIHO - ALL PLANS 179.1 90 999999999 120.49 193.03 percent of total billed charges CATH-URETERAL ANGLED TIP 49237113_1 CDM 0272 RC inpatient 199 129.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 120.49 60.55 999999999 120.49 193.03 percent of total billed charges CATH-URETERAL ANGLED TIP 49237113_1 CDM 0272 RC inpatient 199 129.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 120.49 193.03 CATH-URETERAL ANGLED TIP 49237113_1 CDM 0272 RC inpatient 199 129.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 120.49 193.03 CATH-URETERAL ANGLED TIP 49237113_1 CDM 0272 RC inpatient 199 129.35 ANTHEM HMO ANTHEM HMO 999999999 120.49 193.03 CATH-URETERAL ANGLED TIP 49237113_1 CDM 0272 RC inpatient 199 129.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 120.49 193.03 CATH-URETERAL ANGLED TIP 49237113_1 CDM 0272 RC inpatient 199 129.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 120.49 193.03 CATH-URETERAL ANGLED TIP 49237113_1 CDM 0272 RC inpatient 199 129.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 134.52 67.6 999999999 120.49 193.03 percent of total billed charges CATH COBRA RENAL ACCESS 49237114_1 CDM 0272 RC inpatient 166 107.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.9 65 999999999 100.51 161.02 percent of total billed charges CATH COBRA RENAL ACCESS 49237114_1 CDM 0272 RC inpatient 166 107.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.02 97 999999999 100.51 161.02 percent of total billed charges CATH COBRA RENAL ACCESS 49237114_1 CDM 0272 RC inpatient 166 107.9 AETNA AETNA 131.14 79 999999999 100.51 161.02 percent of total billed charges CATH COBRA RENAL ACCESS 49237114_1 CDM 0272 RC inpatient 166 107.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 129.48 78 999999999 100.51 161.02 percent of total billed charges CATH COBRA RENAL ACCESS 49237114_1 CDM 0272 RC inpatient 166 107.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 114.54 69 999999999 100.51 161.02 percent of total billed charges CATH COBRA RENAL ACCESS 49237114_1 CDM 0272 RC inpatient 166 107.9 UMR - ALL PLANS UMR - ALL PLANS 116.2 70 999999999 100.51 161.02 percent of total billed charges CATH COBRA RENAL ACCESS 49237114_1 CDM 0272 RC inpatient 166 107.9 SIHO - ALL PLANS SIHO - ALL PLANS 149.4 90 999999999 100.51 161.02 percent of total billed charges CATH COBRA RENAL ACCESS 49237114_1 CDM 0272 RC inpatient 166 107.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 100.51 60.55 999999999 100.51 161.02 percent of total billed charges CATH COBRA RENAL ACCESS 49237114_1 CDM 0272 RC inpatient 166 107.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 100.51 161.02 CATH COBRA RENAL ACCESS 49237114_1 CDM 0272 RC inpatient 166 107.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 100.51 161.02 CATH COBRA RENAL ACCESS 49237114_1 CDM 0272 RC inpatient 166 107.9 ANTHEM HMO ANTHEM HMO 999999999 100.51 161.02 CATH COBRA RENAL ACCESS 49237114_1 CDM 0272 RC inpatient 166 107.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 100.51 161.02 CATH COBRA RENAL ACCESS 49237114_1 CDM 0272 RC inpatient 166 107.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 100.51 161.02 CATH COBRA RENAL ACCESS 49237114_1 CDM 0272 RC inpatient 166 107.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.22 67.6 999999999 100.51 161.02 percent of total billed charges MESH (IMPLANTABLE) 49237120_1 CDM 0278 RC C1781 HCPCS inpatient 3394 2206.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 2206.1 65 999999999 2055.07 3292.18 percent of total billed charges MESH (IMPLANTABLE) 49237120_1 CDM 0278 RC C1781 HCPCS inpatient 3394 2206.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3292.18 97 999999999 2055.07 3292.18 percent of total billed charges MESH (IMPLANTABLE) 49237120_1 CDM 0278 RC C1781 HCPCS inpatient 3394 2206.1 AETNA AETNA 2681.26 79 999999999 2055.07 3292.18 percent of total billed charges MESH (IMPLANTABLE) 49237120_1 CDM 0278 RC C1781 HCPCS inpatient 3394 2206.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 2647.32 78 999999999 2055.07 3292.18 percent of total billed charges MESH (IMPLANTABLE) 49237120_1 CDM 0278 RC C1781 HCPCS inpatient 3394 2206.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 2341.86 69 999999999 2055.07 3292.18 percent of total billed charges MESH (IMPLANTABLE) 49237120_1 CDM 0278 RC C1781 HCPCS inpatient 3394 2206.1 UMR - ALL PLANS UMR - ALL PLANS 2375.8 70 999999999 2055.07 3292.18 percent of total billed charges MESH (IMPLANTABLE) 49237120_1 CDM 0278 RC C1781 HCPCS inpatient 3394 2206.1 SIHO - ALL PLANS SIHO - ALL PLANS 3054.6 90 999999999 2055.07 3292.18 percent of total billed charges MESH (IMPLANTABLE) 49237120_1 CDM 0278 RC C1781 HCPCS inpatient 3394 2206.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2055.07 60.55 999999999 2055.07 3292.18 percent of total billed charges MESH (IMPLANTABLE) 49237120_1 CDM 0278 RC C1781 HCPCS inpatient 3394 2206.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2055.07 3292.18 MESH (IMPLANTABLE) 49237120_1 CDM 0278 RC C1781 HCPCS inpatient 3394 2206.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2055.07 3292.18 MESH (IMPLANTABLE) 49237120_1 CDM 0278 RC C1781 HCPCS inpatient 3394 2206.1 ANTHEM HMO ANTHEM HMO 999999999 2055.07 3292.18 MESH (IMPLANTABLE) 49237120_1 CDM 0278 RC C1781 HCPCS inpatient 3394 2206.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2055.07 3292.18 MESH (IMPLANTABLE) 49237120_1 CDM 0278 RC C1781 HCPCS inpatient 3394 2206.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 2055.07 3292.18 MESH (IMPLANTABLE) 49237120_1 CDM 0278 RC C1781 HCPCS inpatient 3394 2206.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 2294.34 67.6 999999999 2055.07 3292.18 percent of total billed charges MESH (IMPLANTABLE) 49237121_1 CDM 0278 RC C1781 HCPCS inpatient 2892 1879.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1879.8 65 999999999 1751.11 2805.24 percent of total billed charges MESH (IMPLANTABLE) 49237121_1 CDM 0278 RC C1781 HCPCS inpatient 2892 1879.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2805.24 97 999999999 1751.11 2805.24 percent of total billed charges MESH (IMPLANTABLE) 49237121_1 CDM 0278 RC C1781 HCPCS inpatient 2892 1879.8 AETNA AETNA 2284.68 79 999999999 1751.11 2805.24 percent of total billed charges MESH (IMPLANTABLE) 49237121_1 CDM 0278 RC C1781 HCPCS inpatient 2892 1879.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 2255.76 78 999999999 1751.11 2805.24 percent of total billed charges MESH (IMPLANTABLE) 49237121_1 CDM 0278 RC C1781 HCPCS inpatient 2892 1879.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1995.48 69 999999999 1751.11 2805.24 percent of total billed charges MESH (IMPLANTABLE) 49237121_1 CDM 0278 RC C1781 HCPCS inpatient 2892 1879.8 UMR - ALL PLANS UMR - ALL PLANS 2024.4 70 999999999 1751.11 2805.24 percent of total billed charges MESH (IMPLANTABLE) 49237121_1 CDM 0278 RC C1781 HCPCS inpatient 2892 1879.8 SIHO - ALL PLANS SIHO - ALL PLANS 2602.8 90 999999999 1751.11 2805.24 percent of total billed charges MESH (IMPLANTABLE) 49237121_1 CDM 0278 RC C1781 HCPCS inpatient 2892 1879.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1751.11 60.55 999999999 1751.11 2805.24 percent of total billed charges MESH (IMPLANTABLE) 49237121_1 CDM 0278 RC C1781 HCPCS inpatient 2892 1879.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1751.11 2805.24 MESH (IMPLANTABLE) 49237121_1 CDM 0278 RC C1781 HCPCS inpatient 2892 1879.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1751.11 2805.24 MESH (IMPLANTABLE) 49237121_1 CDM 0278 RC C1781 HCPCS inpatient 2892 1879.8 ANTHEM HMO ANTHEM HMO 999999999 1751.11 2805.24 MESH (IMPLANTABLE) 49237121_1 CDM 0278 RC C1781 HCPCS inpatient 2892 1879.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1751.11 2805.24 MESH (IMPLANTABLE) 49237121_1 CDM 0278 RC C1781 HCPCS inpatient 2892 1879.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1751.11 2805.24 MESH (IMPLANTABLE) 49237121_1 CDM 0278 RC C1781 HCPCS inpatient 2892 1879.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1954.99 67.6 999999999 1751.11 2805.24 percent of total billed charges MESH (IMPLANTABLE) 49237122_1 CDM 0278 RC C1781 HCPCS inpatient 2284 1484.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1484.6 65 999999999 1382.96 2215.48 percent of total billed charges MESH (IMPLANTABLE) 49237122_1 CDM 0278 RC C1781 HCPCS inpatient 2284 1484.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2215.48 97 999999999 1382.96 2215.48 percent of total billed charges MESH (IMPLANTABLE) 49237122_1 CDM 0278 RC C1781 HCPCS inpatient 2284 1484.6 AETNA AETNA 1804.36 79 999999999 1382.96 2215.48 percent of total billed charges MESH (IMPLANTABLE) 49237122_1 CDM 0278 RC C1781 HCPCS inpatient 2284 1484.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1781.52 78 999999999 1382.96 2215.48 percent of total billed charges MESH (IMPLANTABLE) 49237122_1 CDM 0278 RC C1781 HCPCS inpatient 2284 1484.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1575.96 69 999999999 1382.96 2215.48 percent of total billed charges MESH (IMPLANTABLE) 49237122_1 CDM 0278 RC C1781 HCPCS inpatient 2284 1484.6 UMR - ALL PLANS UMR - ALL PLANS 1598.8 70 999999999 1382.96 2215.48 percent of total billed charges MESH (IMPLANTABLE) 49237122_1 CDM 0278 RC C1781 HCPCS inpatient 2284 1484.6 SIHO - ALL PLANS SIHO - ALL PLANS 2055.6 90 999999999 1382.96 2215.48 percent of total billed charges MESH (IMPLANTABLE) 49237122_1 CDM 0278 RC C1781 HCPCS inpatient 2284 1484.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1382.96 60.55 999999999 1382.96 2215.48 percent of total billed charges MESH (IMPLANTABLE) 49237122_1 CDM 0278 RC C1781 HCPCS inpatient 2284 1484.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1382.96 2215.48 MESH (IMPLANTABLE) 49237122_1 CDM 0278 RC C1781 HCPCS inpatient 2284 1484.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1382.96 2215.48 MESH (IMPLANTABLE) 49237122_1 CDM 0278 RC C1781 HCPCS inpatient 2284 1484.6 ANTHEM HMO ANTHEM HMO 999999999 1382.96 2215.48 MESH (IMPLANTABLE) 49237122_1 CDM 0278 RC C1781 HCPCS inpatient 2284 1484.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1382.96 2215.48 MESH (IMPLANTABLE) 49237122_1 CDM 0278 RC C1781 HCPCS inpatient 2284 1484.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1382.96 2215.48 MESH (IMPLANTABLE) 49237122_1 CDM 0278 RC C1781 HCPCS inpatient 2284 1484.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1543.98 67.6 999999999 1382.96 2215.48 percent of total billed charges RESOLUTION CLIP 49237123_1 CDM 0272 RC inpatient 994 646.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 646.1 65 999999999 601.87 964.18 percent of total billed charges RESOLUTION CLIP 49237123_1 CDM 0272 RC inpatient 994 646.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 964.18 97 999999999 601.87 964.18 percent of total billed charges RESOLUTION CLIP 49237123_1 CDM 0272 RC inpatient 994 646.1 AETNA AETNA 785.26 79 999999999 601.87 964.18 percent of total billed charges RESOLUTION CLIP 49237123_1 CDM 0272 RC inpatient 994 646.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 775.32 78 999999999 601.87 964.18 percent of total billed charges RESOLUTION CLIP 49237123_1 CDM 0272 RC inpatient 994 646.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 685.86 69 999999999 601.87 964.18 percent of total billed charges RESOLUTION CLIP 49237123_1 CDM 0272 RC inpatient 994 646.1 UMR - ALL PLANS UMR - ALL PLANS 695.8 70 999999999 601.87 964.18 percent of total billed charges RESOLUTION CLIP 49237123_1 CDM 0272 RC inpatient 994 646.1 SIHO - ALL PLANS SIHO - ALL PLANS 894.6 90 999999999 601.87 964.18 percent of total billed charges RESOLUTION CLIP 49237123_1 CDM 0272 RC inpatient 994 646.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 601.87 60.55 999999999 601.87 964.18 percent of total billed charges RESOLUTION CLIP 49237123_1 CDM 0272 RC inpatient 994 646.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 601.87 964.18 RESOLUTION CLIP 49237123_1 CDM 0272 RC inpatient 994 646.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 601.87 964.18 RESOLUTION CLIP 49237123_1 CDM 0272 RC inpatient 994 646.1 ANTHEM HMO ANTHEM HMO 999999999 601.87 964.18 RESOLUTION CLIP 49237123_1 CDM 0272 RC inpatient 994 646.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 601.87 964.18 RESOLUTION CLIP 49237123_1 CDM 0272 RC inpatient 994 646.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 601.87 964.18 RESOLUTION CLIP 49237123_1 CDM 0272 RC inpatient 994 646.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 671.94 67.6 999999999 601.87 964.18 percent of total billed charges BIODESIGN OTOLOGIC REPAIR GRAFT ENT-OTO-0.9 G44839 BOX/1 EACH 49237124_1 CDM 0278 RC inpatient 1136 738.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 738.4 65 999999999 687.85 1101.92 percent of total billed charges BIODESIGN OTOLOGIC REPAIR GRAFT ENT-OTO-0.9 G44839 BOX/1 EACH 49237124_1 CDM 0278 RC inpatient 1136 738.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1101.92 97 999999999 687.85 1101.92 percent of total billed charges BIODESIGN OTOLOGIC REPAIR GRAFT ENT-OTO-0.9 G44839 BOX/1 EACH 49237124_1 CDM 0278 RC inpatient 1136 738.4 AETNA AETNA 897.44 79 999999999 687.85 1101.92 percent of total billed charges BIODESIGN OTOLOGIC REPAIR GRAFT ENT-OTO-0.9 G44839 BOX/1 EACH 49237124_1 CDM 0278 RC inpatient 1136 738.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 886.08 78 999999999 687.85 1101.92 percent of total billed charges BIODESIGN OTOLOGIC REPAIR GRAFT ENT-OTO-0.9 G44839 BOX/1 EACH 49237124_1 CDM 0278 RC inpatient 1136 738.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 783.84 69 999999999 687.85 1101.92 percent of total billed charges BIODESIGN OTOLOGIC REPAIR GRAFT ENT-OTO-0.9 G44839 BOX/1 EACH 49237124_1 CDM 0278 RC inpatient 1136 738.4 UMR - ALL PLANS UMR - ALL PLANS 795.2 70 999999999 687.85 1101.92 percent of total billed charges BIODESIGN OTOLOGIC REPAIR GRAFT ENT-OTO-0.9 G44839 BOX/1 EACH 49237124_1 CDM 0278 RC inpatient 1136 738.4 SIHO - ALL PLANS SIHO - ALL PLANS 1022.4 90 999999999 687.85 1101.92 percent of total billed charges BIODESIGN OTOLOGIC REPAIR GRAFT ENT-OTO-0.9 G44839 BOX/1 EACH 49237124_1 CDM 0278 RC inpatient 1136 738.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 687.85 60.55 999999999 687.85 1101.92 percent of total billed charges BIODESIGN OTOLOGIC REPAIR GRAFT ENT-OTO-0.9 G44839 BOX/1 EACH 49237124_1 CDM 0278 RC inpatient 1136 738.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 687.85 1101.92 BIODESIGN OTOLOGIC REPAIR GRAFT ENT-OTO-0.9 G44839 BOX/1 EACH 49237124_1 CDM 0278 RC inpatient 1136 738.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 687.85 1101.92 BIODESIGN OTOLOGIC REPAIR GRAFT ENT-OTO-0.9 G44839 BOX/1 EACH 49237124_1 CDM 0278 RC inpatient 1136 738.4 ANTHEM HMO ANTHEM HMO 999999999 687.85 1101.92 BIODESIGN OTOLOGIC REPAIR GRAFT ENT-OTO-0.9 G44839 BOX/1 EACH 49237124_1 CDM 0278 RC inpatient 1136 738.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 687.85 1101.92 BIODESIGN OTOLOGIC REPAIR GRAFT ENT-OTO-0.9 G44839 BOX/1 EACH 49237124_1 CDM 0278 RC inpatient 1136 738.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 687.85 1101.92 BIODESIGN OTOLOGIC REPAIR GRAFT ENT-OTO-0.9 G44839 BOX/1 EACH 49237124_1 CDM 0278 RC inpatient 1136 738.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 767.94 67.6 999999999 687.85 1101.92 percent of total billed charges TRACH CUFFLESS #4 SHILEY 49237125_1 CDM 0274 RC inpatient 295 191.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 191.75 65 999999999 178.62 286.15 percent of total billed charges TRACH CUFFLESS #4 SHILEY 49237125_1 CDM 0274 RC inpatient 295 191.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 286.15 97 999999999 178.62 286.15 percent of total billed charges TRACH CUFFLESS #4 SHILEY 49237125_1 CDM 0274 RC inpatient 295 191.75 AETNA AETNA 233.05 79 999999999 178.62 286.15 percent of total billed charges TRACH CUFFLESS #4 SHILEY 49237125_1 CDM 0274 RC inpatient 295 191.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 230.1 78 999999999 178.62 286.15 percent of total billed charges TRACH CUFFLESS #4 SHILEY 49237125_1 CDM 0274 RC inpatient 295 191.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 203.55 69 999999999 178.62 286.15 percent of total billed charges TRACH CUFFLESS #4 SHILEY 49237125_1 CDM 0274 RC inpatient 295 191.75 UMR - ALL PLANS UMR - ALL PLANS 206.5 70 999999999 178.62 286.15 percent of total billed charges TRACH CUFFLESS #4 SHILEY 49237125_1 CDM 0274 RC inpatient 295 191.75 SIHO - ALL PLANS SIHO - ALL PLANS 265.5 90 999999999 178.62 286.15 percent of total billed charges TRACH CUFFLESS #4 SHILEY 49237125_1 CDM 0274 RC inpatient 295 191.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 178.62 60.55 999999999 178.62 286.15 percent of total billed charges TRACH CUFFLESS #4 SHILEY 49237125_1 CDM 0274 RC inpatient 295 191.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 178.62 286.15 TRACH CUFFLESS #4 SHILEY 49237125_1 CDM 0274 RC inpatient 295 191.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 178.62 286.15 TRACH CUFFLESS #4 SHILEY 49237125_1 CDM 0274 RC inpatient 295 191.75 ANTHEM HMO ANTHEM HMO 999999999 178.62 286.15 TRACH CUFFLESS #4 SHILEY 49237125_1 CDM 0274 RC inpatient 295 191.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 178.62 286.15 TRACH CUFFLESS #4 SHILEY 49237125_1 CDM 0274 RC inpatient 295 191.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 178.62 286.15 TRACH CUFFLESS #4 SHILEY 49237125_1 CDM 0274 RC inpatient 295 191.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 199.42 67.6 999999999 178.62 286.15 percent of total billed charges TRACH SHILEY CUFFLESS SZ 6CFN 49237126_1 CDM 0274 RC inpatient 340 221 SELF PAY DISCOUNT SELF PAY DISCOUNT 221 65 999999999 205.87 329.8 percent of total billed charges TRACH SHILEY CUFFLESS SZ 6CFN 49237126_1 CDM 0274 RC inpatient 340 221 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 329.8 97 999999999 205.87 329.8 percent of total billed charges TRACH SHILEY CUFFLESS SZ 6CFN 49237126_1 CDM 0274 RC inpatient 340 221 AETNA AETNA 268.6 79 999999999 205.87 329.8 percent of total billed charges TRACH SHILEY CUFFLESS SZ 6CFN 49237126_1 CDM 0274 RC inpatient 340 221 HUMANA - ALL PLANS HUMANA - ALL PLANS 265.2 78 999999999 205.87 329.8 percent of total billed charges TRACH SHILEY CUFFLESS SZ 6CFN 49237126_1 CDM 0274 RC inpatient 340 221 ENCORE - ALL PLANS ENCORE - ALL PLANS 234.6 69 999999999 205.87 329.8 percent of total billed charges TRACH SHILEY CUFFLESS SZ 6CFN 49237126_1 CDM 0274 RC inpatient 340 221 UMR - ALL PLANS UMR - ALL PLANS 238 70 999999999 205.87 329.8 percent of total billed charges TRACH SHILEY CUFFLESS SZ 6CFN 49237126_1 CDM 0274 RC inpatient 340 221 SIHO - ALL PLANS SIHO - ALL PLANS 306 90 999999999 205.87 329.8 percent of total billed charges TRACH SHILEY CUFFLESS SZ 6CFN 49237126_1 CDM 0274 RC inpatient 340 221 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.87 60.55 999999999 205.87 329.8 percent of total billed charges TRACH SHILEY CUFFLESS SZ 6CFN 49237126_1 CDM 0274 RC inpatient 340 221 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.87 329.8 TRACH SHILEY CUFFLESS SZ 6CFN 49237126_1 CDM 0274 RC inpatient 340 221 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.87 329.8 TRACH SHILEY CUFFLESS SZ 6CFN 49237126_1 CDM 0274 RC inpatient 340 221 ANTHEM HMO ANTHEM HMO 999999999 205.87 329.8 TRACH SHILEY CUFFLESS SZ 6CFN 49237126_1 CDM 0274 RC inpatient 340 221 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.87 329.8 TRACH SHILEY CUFFLESS SZ 6CFN 49237126_1 CDM 0274 RC inpatient 340 221 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.87 329.8 TRACH SHILEY CUFFLESS SZ 6CFN 49237126_1 CDM 0274 RC inpatient 340 221 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.84 67.6 999999999 205.87 329.8 percent of total billed charges TRACH TUBE XLT CUFFLESS OE 60XLTUD 49237127_1 CDM 0272 RC inpatient 443 287.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 287.95 65 999999999 268.24 429.71 percent of total billed charges TRACH TUBE XLT CUFFLESS OE 60XLTUD 49237127_1 CDM 0272 RC inpatient 443 287.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 429.71 97 999999999 268.24 429.71 percent of total billed charges TRACH TUBE XLT CUFFLESS OE 60XLTUD 49237127_1 CDM 0272 RC inpatient 443 287.95 AETNA AETNA 349.97 79 999999999 268.24 429.71 percent of total billed charges TRACH TUBE XLT CUFFLESS OE 60XLTUD 49237127_1 CDM 0272 RC inpatient 443 287.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 345.54 78 999999999 268.24 429.71 percent of total billed charges TRACH TUBE XLT CUFFLESS OE 60XLTUD 49237127_1 CDM 0272 RC inpatient 443 287.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 305.67 69 999999999 268.24 429.71 percent of total billed charges TRACH TUBE XLT CUFFLESS OE 60XLTUD 49237127_1 CDM 0272 RC inpatient 443 287.95 UMR - ALL PLANS UMR - ALL PLANS 310.1 70 999999999 268.24 429.71 percent of total billed charges TRACH TUBE XLT CUFFLESS OE 60XLTUD 49237127_1 CDM 0272 RC inpatient 443 287.95 SIHO - ALL PLANS SIHO - ALL PLANS 398.7 90 999999999 268.24 429.71 percent of total billed charges TRACH TUBE XLT CUFFLESS OE 60XLTUD 49237127_1 CDM 0272 RC inpatient 443 287.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 268.24 60.55 999999999 268.24 429.71 percent of total billed charges TRACH TUBE XLT CUFFLESS OE 60XLTUD 49237127_1 CDM 0272 RC inpatient 443 287.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 268.24 429.71 TRACH TUBE XLT CUFFLESS OE 60XLTUD 49237127_1 CDM 0272 RC inpatient 443 287.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 268.24 429.71 TRACH TUBE XLT CUFFLESS OE 60XLTUD 49237127_1 CDM 0272 RC inpatient 443 287.95 ANTHEM HMO ANTHEM HMO 999999999 268.24 429.71 TRACH TUBE XLT CUFFLESS OE 60XLTUD 49237127_1 CDM 0272 RC inpatient 443 287.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 268.24 429.71 TRACH TUBE XLT CUFFLESS OE 60XLTUD 49237127_1 CDM 0272 RC inpatient 443 287.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 268.24 429.71 TRACH TUBE XLT CUFFLESS OE 60XLTUD 49237127_1 CDM 0272 RC inpatient 443 287.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 299.47 67.6 999999999 268.24 429.71 percent of total billed charges CIRCUMCISON TRAY CIT6465A 49237128_1 CDM 0272 RC inpatient 213 138.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 138.45 65 999999999 128.97 206.61 percent of total billed charges CIRCUMCISON TRAY CIT6465A 49237128_1 CDM 0272 RC inpatient 213 138.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 206.61 97 999999999 128.97 206.61 percent of total billed charges CIRCUMCISON TRAY CIT6465A 49237128_1 CDM 0272 RC inpatient 213 138.45 AETNA AETNA 168.27 79 999999999 128.97 206.61 percent of total billed charges CIRCUMCISON TRAY CIT6465A 49237128_1 CDM 0272 RC inpatient 213 138.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 166.14 78 999999999 128.97 206.61 percent of total billed charges CIRCUMCISON TRAY CIT6465A 49237128_1 CDM 0272 RC inpatient 213 138.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 146.97 69 999999999 128.97 206.61 percent of total billed charges CIRCUMCISON TRAY CIT6465A 49237128_1 CDM 0272 RC inpatient 213 138.45 UMR - ALL PLANS UMR - ALL PLANS 149.1 70 999999999 128.97 206.61 percent of total billed charges CIRCUMCISON TRAY CIT6465A 49237128_1 CDM 0272 RC inpatient 213 138.45 SIHO - ALL PLANS SIHO - ALL PLANS 191.7 90 999999999 128.97 206.61 percent of total billed charges CIRCUMCISON TRAY CIT6465A 49237128_1 CDM 0272 RC inpatient 213 138.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 128.97 60.55 999999999 128.97 206.61 percent of total billed charges CIRCUMCISON TRAY CIT6465A 49237128_1 CDM 0272 RC inpatient 213 138.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 128.97 206.61 CIRCUMCISON TRAY CIT6465A 49237128_1 CDM 0272 RC inpatient 213 138.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 128.97 206.61 CIRCUMCISON TRAY CIT6465A 49237128_1 CDM 0272 RC inpatient 213 138.45 ANTHEM HMO ANTHEM HMO 999999999 128.97 206.61 CIRCUMCISON TRAY CIT6465A 49237128_1 CDM 0272 RC inpatient 213 138.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 128.97 206.61 CIRCUMCISON TRAY CIT6465A 49237128_1 CDM 0272 RC inpatient 213 138.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 128.97 206.61 CIRCUMCISON TRAY CIT6465A 49237128_1 CDM 0272 RC inpatient 213 138.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 143.99 67.6 999999999 128.97 206.61 percent of total billed charges VERIFY EXT NEUROSTIMULATOR 49237130_1 CDM 0278 RC inpatient 2483 1613.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1613.95 65 999999999 1503.46 2408.51 percent of total billed charges VERIFY EXT NEUROSTIMULATOR 49237130_1 CDM 0278 RC inpatient 2483 1613.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2408.51 97 999999999 1503.46 2408.51 percent of total billed charges VERIFY EXT NEUROSTIMULATOR 49237130_1 CDM 0278 RC inpatient 2483 1613.95 AETNA AETNA 1961.57 79 999999999 1503.46 2408.51 percent of total billed charges VERIFY EXT NEUROSTIMULATOR 49237130_1 CDM 0278 RC inpatient 2483 1613.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1936.74 78 999999999 1503.46 2408.51 percent of total billed charges VERIFY EXT NEUROSTIMULATOR 49237130_1 CDM 0278 RC inpatient 2483 1613.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1713.27 69 999999999 1503.46 2408.51 percent of total billed charges VERIFY EXT NEUROSTIMULATOR 49237130_1 CDM 0278 RC inpatient 2483 1613.95 UMR - ALL PLANS UMR - ALL PLANS 1738.1 70 999999999 1503.46 2408.51 percent of total billed charges VERIFY EXT NEUROSTIMULATOR 49237130_1 CDM 0278 RC inpatient 2483 1613.95 SIHO - ALL PLANS SIHO - ALL PLANS 2234.7 90 999999999 1503.46 2408.51 percent of total billed charges VERIFY EXT NEUROSTIMULATOR 49237130_1 CDM 0278 RC inpatient 2483 1613.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1503.46 60.55 999999999 1503.46 2408.51 percent of total billed charges VERIFY EXT NEUROSTIMULATOR 49237130_1 CDM 0278 RC inpatient 2483 1613.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1503.46 2408.51 VERIFY EXT NEUROSTIMULATOR 49237130_1 CDM 0278 RC inpatient 2483 1613.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1503.46 2408.51 VERIFY EXT NEUROSTIMULATOR 49237130_1 CDM 0278 RC inpatient 2483 1613.95 ANTHEM HMO ANTHEM HMO 999999999 1503.46 2408.51 VERIFY EXT NEUROSTIMULATOR 49237130_1 CDM 0278 RC inpatient 2483 1613.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1503.46 2408.51 VERIFY EXT NEUROSTIMULATOR 49237130_1 CDM 0278 RC inpatient 2483 1613.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1503.46 2408.51 VERIFY EXT NEUROSTIMULATOR 49237130_1 CDM 0278 RC inpatient 2483 1613.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1678.51 67.6 999999999 1503.46 2408.51 percent of total billed charges SAFFRON FIXATION TOOL DEVICE 520340 05708932757423 49237131_1 CDM 0272 RC inpatient 1824 1185.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1185.6 65 999999999 1104.43 1769.28 percent of total billed charges SAFFRON FIXATION TOOL DEVICE 520340 05708932757423 49237131_1 CDM 0272 RC inpatient 1824 1185.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1769.28 97 999999999 1104.43 1769.28 percent of total billed charges SAFFRON FIXATION TOOL DEVICE 520340 05708932757423 49237131_1 CDM 0272 RC inpatient 1824 1185.6 AETNA AETNA 1440.96 79 999999999 1104.43 1769.28 percent of total billed charges SAFFRON FIXATION TOOL DEVICE 520340 05708932757423 49237131_1 CDM 0272 RC inpatient 1824 1185.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1422.72 78 999999999 1104.43 1769.28 percent of total billed charges SAFFRON FIXATION TOOL DEVICE 520340 05708932757423 49237131_1 CDM 0272 RC inpatient 1824 1185.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1258.56 69 999999999 1104.43 1769.28 percent of total billed charges SAFFRON FIXATION TOOL DEVICE 520340 05708932757423 49237131_1 CDM 0272 RC inpatient 1824 1185.6 UMR - ALL PLANS UMR - ALL PLANS 1276.8 70 999999999 1104.43 1769.28 percent of total billed charges SAFFRON FIXATION TOOL DEVICE 520340 05708932757423 49237131_1 CDM 0272 RC inpatient 1824 1185.6 SIHO - ALL PLANS SIHO - ALL PLANS 1641.6 90 999999999 1104.43 1769.28 percent of total billed charges SAFFRON FIXATION TOOL DEVICE 520340 05708932757423 49237131_1 CDM 0272 RC inpatient 1824 1185.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1104.43 60.55 999999999 1104.43 1769.28 percent of total billed charges SAFFRON FIXATION TOOL DEVICE 520340 05708932757423 49237131_1 CDM 0272 RC inpatient 1824 1185.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1104.43 1769.28 SAFFRON FIXATION TOOL DEVICE 520340 05708932757423 49237131_1 CDM 0272 RC inpatient 1824 1185.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1104.43 1769.28 SAFFRON FIXATION TOOL DEVICE 520340 05708932757423 49237131_1 CDM 0272 RC inpatient 1824 1185.6 ANTHEM HMO ANTHEM HMO 999999999 1104.43 1769.28 SAFFRON FIXATION TOOL DEVICE 520340 05708932757423 49237131_1 CDM 0272 RC inpatient 1824 1185.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1104.43 1769.28 SAFFRON FIXATION TOOL DEVICE 520340 05708932757423 49237131_1 CDM 0272 RC inpatient 1824 1185.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1104.43 1769.28 SAFFRON FIXATION TOOL DEVICE 520340 05708932757423 49237131_1 CDM 0272 RC inpatient 1824 1185.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1233.02 67.6 999999999 1104.43 1769.28 percent of total billed charges FIXATION ANCHORS 520350 49237132_1 CDM 0272 RC inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges FIXATION ANCHORS 520350 49237132_1 CDM 0272 RC inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges FIXATION ANCHORS 520350 49237132_1 CDM 0272 RC inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges FIXATION ANCHORS 520350 49237132_1 CDM 0272 RC inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges FIXATION ANCHORS 520350 49237132_1 CDM 0272 RC inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges FIXATION ANCHORS 520350 49237132_1 CDM 0272 RC inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges FIXATION ANCHORS 520350 49237132_1 CDM 0272 RC inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges FIXATION ANCHORS 520350 49237132_1 CDM 0272 RC inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges FIXATION ANCHORS 520350 49237132_1 CDM 0272 RC inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 FIXATION ANCHORS 520350 49237132_1 CDM 0272 RC inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 FIXATION ANCHORS 520350 49237132_1 CDM 0272 RC inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 FIXATION ANCHORS 520350 49237132_1 CDM 0272 RC inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 FIXATION ANCHORS 520350 49237132_1 CDM 0272 RC inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 FIXATION ANCHORS 520350 49237132_1 CDM 0272 RC inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges MINERVA DISPO HANDPIECE - MUST REQUEST HEGAR DIALTOR 1:1 49237133_1 CDM 0272 RC inpatient 3998 2598.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 2598.7 65 999999999 2420.79 3878.06 percent of total billed charges MINERVA DISPO HANDPIECE - MUST REQUEST HEGAR DIALTOR 1:1 49237133_1 CDM 0272 RC inpatient 3998 2598.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3878.06 97 999999999 2420.79 3878.06 percent of total billed charges MINERVA DISPO HANDPIECE - MUST REQUEST HEGAR DIALTOR 1:1 49237133_1 CDM 0272 RC inpatient 3998 2598.7 AETNA AETNA 3158.42 79 999999999 2420.79 3878.06 percent of total billed charges MINERVA DISPO HANDPIECE - MUST REQUEST HEGAR DIALTOR 1:1 49237133_1 CDM 0272 RC inpatient 3998 2598.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 3118.44 78 999999999 2420.79 3878.06 percent of total billed charges MINERVA DISPO HANDPIECE - MUST REQUEST HEGAR DIALTOR 1:1 49237133_1 CDM 0272 RC inpatient 3998 2598.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 2758.62 69 999999999 2420.79 3878.06 percent of total billed charges MINERVA DISPO HANDPIECE - MUST REQUEST HEGAR DIALTOR 1:1 49237133_1 CDM 0272 RC inpatient 3998 2598.7 UMR - ALL PLANS UMR - ALL PLANS 2798.6 70 999999999 2420.79 3878.06 percent of total billed charges MINERVA DISPO HANDPIECE - MUST REQUEST HEGAR DIALTOR 1:1 49237133_1 CDM 0272 RC inpatient 3998 2598.7 SIHO - ALL PLANS SIHO - ALL PLANS 3598.2 90 999999999 2420.79 3878.06 percent of total billed charges MINERVA DISPO HANDPIECE - MUST REQUEST HEGAR DIALTOR 1:1 49237133_1 CDM 0272 RC inpatient 3998 2598.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2420.79 60.55 999999999 2420.79 3878.06 percent of total billed charges MINERVA DISPO HANDPIECE - MUST REQUEST HEGAR DIALTOR 1:1 49237133_1 CDM 0272 RC inpatient 3998 2598.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2420.79 3878.06 MINERVA DISPO HANDPIECE - MUST REQUEST HEGAR DIALTOR 1:1 49237133_1 CDM 0272 RC inpatient 3998 2598.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2420.79 3878.06 MINERVA DISPO HANDPIECE - MUST REQUEST HEGAR DIALTOR 1:1 49237133_1 CDM 0272 RC inpatient 3998 2598.7 ANTHEM HMO ANTHEM HMO 999999999 2420.79 3878.06 MINERVA DISPO HANDPIECE - MUST REQUEST HEGAR DIALTOR 1:1 49237133_1 CDM 0272 RC inpatient 3998 2598.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2420.79 3878.06 MINERVA DISPO HANDPIECE - MUST REQUEST HEGAR DIALTOR 1:1 49237133_1 CDM 0272 RC inpatient 3998 2598.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 2420.79 3878.06 MINERVA DISPO HANDPIECE - MUST REQUEST HEGAR DIALTOR 1:1 49237133_1 CDM 0272 RC inpatient 3998 2598.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 2702.65 67.6 999999999 2420.79 3878.06 percent of total billed charges TEST STIMULATOR CABLE 49237134_1 CDM 0272 RC inpatient 277 180.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 180.05 65 999999999 167.72 268.69 percent of total billed charges TEST STIMULATOR CABLE 49237134_1 CDM 0272 RC inpatient 277 180.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 268.69 97 999999999 167.72 268.69 percent of total billed charges TEST STIMULATOR CABLE 49237134_1 CDM 0272 RC inpatient 277 180.05 AETNA AETNA 218.83 79 999999999 167.72 268.69 percent of total billed charges TEST STIMULATOR CABLE 49237134_1 CDM 0272 RC inpatient 277 180.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 216.06 78 999999999 167.72 268.69 percent of total billed charges TEST STIMULATOR CABLE 49237134_1 CDM 0272 RC inpatient 277 180.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 191.13 69 999999999 167.72 268.69 percent of total billed charges TEST STIMULATOR CABLE 49237134_1 CDM 0272 RC inpatient 277 180.05 UMR - ALL PLANS UMR - ALL PLANS 193.9 70 999999999 167.72 268.69 percent of total billed charges TEST STIMULATOR CABLE 49237134_1 CDM 0272 RC inpatient 277 180.05 SIHO - ALL PLANS SIHO - ALL PLANS 249.3 90 999999999 167.72 268.69 percent of total billed charges TEST STIMULATOR CABLE 49237134_1 CDM 0272 RC inpatient 277 180.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 167.72 60.55 999999999 167.72 268.69 percent of total billed charges TEST STIMULATOR CABLE 49237134_1 CDM 0272 RC inpatient 277 180.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 167.72 268.69 TEST STIMULATOR CABLE 49237134_1 CDM 0272 RC inpatient 277 180.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 167.72 268.69 TEST STIMULATOR CABLE 49237134_1 CDM 0272 RC inpatient 277 180.05 ANTHEM HMO ANTHEM HMO 999999999 167.72 268.69 TEST STIMULATOR CABLE 49237134_1 CDM 0272 RC inpatient 277 180.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 167.72 268.69 TEST STIMULATOR CABLE 49237134_1 CDM 0272 RC inpatient 277 180.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 167.72 268.69 TEST STIMULATOR CABLE 49237134_1 CDM 0272 RC inpatient 277 180.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 187.25 67.6 999999999 167.72 268.69 percent of total billed charges BOTOX INJECTION NEEDLE 49237136_1 CDM 0272 RC inpatient 376 244.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 244.4 65 999999999 227.67 364.72 percent of total billed charges BOTOX INJECTION NEEDLE 49237136_1 CDM 0272 RC inpatient 376 244.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 364.72 97 999999999 227.67 364.72 percent of total billed charges BOTOX INJECTION NEEDLE 49237136_1 CDM 0272 RC inpatient 376 244.4 AETNA AETNA 297.04 79 999999999 227.67 364.72 percent of total billed charges BOTOX INJECTION NEEDLE 49237136_1 CDM 0272 RC inpatient 376 244.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 293.28 78 999999999 227.67 364.72 percent of total billed charges BOTOX INJECTION NEEDLE 49237136_1 CDM 0272 RC inpatient 376 244.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 259.44 69 999999999 227.67 364.72 percent of total billed charges BOTOX INJECTION NEEDLE 49237136_1 CDM 0272 RC inpatient 376 244.4 UMR - ALL PLANS UMR - ALL PLANS 263.2 70 999999999 227.67 364.72 percent of total billed charges BOTOX INJECTION NEEDLE 49237136_1 CDM 0272 RC inpatient 376 244.4 SIHO - ALL PLANS SIHO - ALL PLANS 338.4 90 999999999 227.67 364.72 percent of total billed charges BOTOX INJECTION NEEDLE 49237136_1 CDM 0272 RC inpatient 376 244.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 227.67 60.55 999999999 227.67 364.72 percent of total billed charges BOTOX INJECTION NEEDLE 49237136_1 CDM 0272 RC inpatient 376 244.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 227.67 364.72 BOTOX INJECTION NEEDLE 49237136_1 CDM 0272 RC inpatient 376 244.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 227.67 364.72 BOTOX INJECTION NEEDLE 49237136_1 CDM 0272 RC inpatient 376 244.4 ANTHEM HMO ANTHEM HMO 999999999 227.67 364.72 BOTOX INJECTION NEEDLE 49237136_1 CDM 0272 RC inpatient 376 244.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 227.67 364.72 BOTOX INJECTION NEEDLE 49237136_1 CDM 0272 RC inpatient 376 244.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 227.67 364.72 BOTOX INJECTION NEEDLE 49237136_1 CDM 0272 RC inpatient 376 244.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 254.18 67.6 999999999 227.67 364.72 percent of total billed charges MYOSURE LITE 30-403LITE 49237137_1 CDM 0272 RC inpatient 3642 2367.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 2367.3 65 999999999 2205.23 3532.74 percent of total billed charges MYOSURE LITE 30-403LITE 49237137_1 CDM 0272 RC inpatient 3642 2367.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3532.74 97 999999999 2205.23 3532.74 percent of total billed charges MYOSURE LITE 30-403LITE 49237137_1 CDM 0272 RC inpatient 3642 2367.3 AETNA AETNA 2877.18 79 999999999 2205.23 3532.74 percent of total billed charges MYOSURE LITE 30-403LITE 49237137_1 CDM 0272 RC inpatient 3642 2367.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 2840.76 78 999999999 2205.23 3532.74 percent of total billed charges MYOSURE LITE 30-403LITE 49237137_1 CDM 0272 RC inpatient 3642 2367.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 2512.98 69 999999999 2205.23 3532.74 percent of total billed charges MYOSURE LITE 30-403LITE 49237137_1 CDM 0272 RC inpatient 3642 2367.3 UMR - ALL PLANS UMR - ALL PLANS 2549.4 70 999999999 2205.23 3532.74 percent of total billed charges MYOSURE LITE 30-403LITE 49237137_1 CDM 0272 RC inpatient 3642 2367.3 SIHO - ALL PLANS SIHO - ALL PLANS 3277.8 90 999999999 2205.23 3532.74 percent of total billed charges MYOSURE LITE 30-403LITE 49237137_1 CDM 0272 RC inpatient 3642 2367.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2205.23 60.55 999999999 2205.23 3532.74 percent of total billed charges MYOSURE LITE 30-403LITE 49237137_1 CDM 0272 RC inpatient 3642 2367.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2205.23 3532.74 MYOSURE LITE 30-403LITE 49237137_1 CDM 0272 RC inpatient 3642 2367.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2205.23 3532.74 MYOSURE LITE 30-403LITE 49237137_1 CDM 0272 RC inpatient 3642 2367.3 ANTHEM HMO ANTHEM HMO 999999999 2205.23 3532.74 MYOSURE LITE 30-403LITE 49237137_1 CDM 0272 RC inpatient 3642 2367.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2205.23 3532.74 MYOSURE LITE 30-403LITE 49237137_1 CDM 0272 RC inpatient 3642 2367.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 2205.23 3532.74 MYOSURE LITE 30-403LITE 49237137_1 CDM 0272 RC inpatient 3642 2367.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 2461.99 67.6 999999999 2205.23 3532.74 percent of total billed charges MYOSURE REACH 3-PACK CAT# 10-403FC (INDIVIDUAL CAT# 10-401FC) 49237138_1 CDM 0272 RC inpatient 5150 3347.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 3347.5 65 999999999 3118.33 4995.5 percent of total billed charges MYOSURE REACH 3-PACK CAT# 10-403FC (INDIVIDUAL CAT# 10-401FC) 49237138_1 CDM 0272 RC inpatient 5150 3347.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4995.5 97 999999999 3118.33 4995.5 percent of total billed charges MYOSURE REACH 3-PACK CAT# 10-403FC (INDIVIDUAL CAT# 10-401FC) 49237138_1 CDM 0272 RC inpatient 5150 3347.5 AETNA AETNA 4068.5 79 999999999 3118.33 4995.5 percent of total billed charges MYOSURE REACH 3-PACK CAT# 10-403FC (INDIVIDUAL CAT# 10-401FC) 49237138_1 CDM 0272 RC inpatient 5150 3347.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 4017 78 999999999 3118.33 4995.5 percent of total billed charges MYOSURE REACH 3-PACK CAT# 10-403FC (INDIVIDUAL CAT# 10-401FC) 49237138_1 CDM 0272 RC inpatient 5150 3347.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 3553.5 69 999999999 3118.33 4995.5 percent of total billed charges MYOSURE REACH 3-PACK CAT# 10-403FC (INDIVIDUAL CAT# 10-401FC) 49237138_1 CDM 0272 RC inpatient 5150 3347.5 UMR - ALL PLANS UMR - ALL PLANS 3605 70 999999999 3118.33 4995.5 percent of total billed charges MYOSURE REACH 3-PACK CAT# 10-403FC (INDIVIDUAL CAT# 10-401FC) 49237138_1 CDM 0272 RC inpatient 5150 3347.5 SIHO - ALL PLANS SIHO - ALL PLANS 4635 90 999999999 3118.33 4995.5 percent of total billed charges MYOSURE REACH 3-PACK CAT# 10-403FC (INDIVIDUAL CAT# 10-401FC) 49237138_1 CDM 0272 RC inpatient 5150 3347.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3118.33 60.55 999999999 3118.33 4995.5 percent of total billed charges MYOSURE REACH 3-PACK CAT# 10-403FC (INDIVIDUAL CAT# 10-401FC) 49237138_1 CDM 0272 RC inpatient 5150 3347.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3118.33 4995.5 MYOSURE REACH 3-PACK CAT# 10-403FC (INDIVIDUAL CAT# 10-401FC) 49237138_1 CDM 0272 RC inpatient 5150 3347.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3118.33 4995.5 MYOSURE REACH 3-PACK CAT# 10-403FC (INDIVIDUAL CAT# 10-401FC) 49237138_1 CDM 0272 RC inpatient 5150 3347.5 ANTHEM HMO ANTHEM HMO 999999999 3118.33 4995.5 MYOSURE REACH 3-PACK CAT# 10-403FC (INDIVIDUAL CAT# 10-401FC) 49237138_1 CDM 0272 RC inpatient 5150 3347.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3118.33 4995.5 MYOSURE REACH 3-PACK CAT# 10-403FC (INDIVIDUAL CAT# 10-401FC) 49237138_1 CDM 0272 RC inpatient 5150 3347.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 3118.33 4995.5 MYOSURE REACH 3-PACK CAT# 10-403FC (INDIVIDUAL CAT# 10-401FC) 49237138_1 CDM 0272 RC inpatient 5150 3347.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 3481.4 67.6 999999999 3118.33 4995.5 percent of total billed charges EGIA 45AR MED THKSUL 49237139_1 CDM 0272 RC inpatient 1183 768.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 768.95 65 999999999 716.31 1147.51 percent of total billed charges EGIA 45AR MED THKSUL 49237139_1 CDM 0272 RC inpatient 1183 768.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1147.51 97 999999999 716.31 1147.51 percent of total billed charges EGIA 45AR MED THKSUL 49237139_1 CDM 0272 RC inpatient 1183 768.95 AETNA AETNA 934.57 79 999999999 716.31 1147.51 percent of total billed charges EGIA 45AR MED THKSUL 49237139_1 CDM 0272 RC inpatient 1183 768.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 922.74 78 999999999 716.31 1147.51 percent of total billed charges EGIA 45AR MED THKSUL 49237139_1 CDM 0272 RC inpatient 1183 768.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 816.27 69 999999999 716.31 1147.51 percent of total billed charges EGIA 45AR MED THKSUL 49237139_1 CDM 0272 RC inpatient 1183 768.95 UMR - ALL PLANS UMR - ALL PLANS 828.1 70 999999999 716.31 1147.51 percent of total billed charges EGIA 45AR MED THKSUL 49237139_1 CDM 0272 RC inpatient 1183 768.95 SIHO - ALL PLANS SIHO - ALL PLANS 1064.7 90 999999999 716.31 1147.51 percent of total billed charges EGIA 45AR MED THKSUL 49237139_1 CDM 0272 RC inpatient 1183 768.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 716.31 60.55 999999999 716.31 1147.51 percent of total billed charges EGIA 45AR MED THKSUL 49237139_1 CDM 0272 RC inpatient 1183 768.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 716.31 1147.51 EGIA 45AR MED THKSUL 49237139_1 CDM 0272 RC inpatient 1183 768.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 716.31 1147.51 EGIA 45AR MED THKSUL 49237139_1 CDM 0272 RC inpatient 1183 768.95 ANTHEM HMO ANTHEM HMO 999999999 716.31 1147.51 EGIA 45AR MED THKSUL 49237139_1 CDM 0272 RC inpatient 1183 768.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 716.31 1147.51 EGIA 45AR MED THKSUL 49237139_1 CDM 0272 RC inpatient 1183 768.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 716.31 1147.51 EGIA 45AR MED THKSUL 49237139_1 CDM 0272 RC inpatient 1183 768.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 799.71 67.6 999999999 716.31 1147.51 percent of total billed charges ***BLANKETED PER MEGAN PALMER 6-27-23 PROPEL CONTOUR SINUS STENT 49237140_1 CDM 0278 RC inpatient 4423 2874.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 2874.95 65 999999999 2678.13 4290.31 percent of total billed charges ***BLANKETED PER MEGAN PALMER 6-27-23 PROPEL CONTOUR SINUS STENT 49237140_1 CDM 0278 RC inpatient 4423 2874.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4290.31 97 999999999 2678.13 4290.31 percent of total billed charges ***BLANKETED PER MEGAN PALMER 6-27-23 PROPEL CONTOUR SINUS STENT 49237140_1 CDM 0278 RC inpatient 4423 2874.95 AETNA AETNA 3494.17 79 999999999 2678.13 4290.31 percent of total billed charges ***BLANKETED PER MEGAN PALMER 6-27-23 PROPEL CONTOUR SINUS STENT 49237140_1 CDM 0278 RC inpatient 4423 2874.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 3449.94 78 999999999 2678.13 4290.31 percent of total billed charges ***BLANKETED PER MEGAN PALMER 6-27-23 PROPEL CONTOUR SINUS STENT 49237140_1 CDM 0278 RC inpatient 4423 2874.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 3051.87 69 999999999 2678.13 4290.31 percent of total billed charges ***BLANKETED PER MEGAN PALMER 6-27-23 PROPEL CONTOUR SINUS STENT 49237140_1 CDM 0278 RC inpatient 4423 2874.95 UMR - ALL PLANS UMR - ALL PLANS 3096.1 70 999999999 2678.13 4290.31 percent of total billed charges ***BLANKETED PER MEGAN PALMER 6-27-23 PROPEL CONTOUR SINUS STENT 49237140_1 CDM 0278 RC inpatient 4423 2874.95 SIHO - ALL PLANS SIHO - ALL PLANS 3980.7 90 999999999 2678.13 4290.31 percent of total billed charges ***BLANKETED PER MEGAN PALMER 6-27-23 PROPEL CONTOUR SINUS STENT 49237140_1 CDM 0278 RC inpatient 4423 2874.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2678.13 60.55 999999999 2678.13 4290.31 percent of total billed charges ***BLANKETED PER MEGAN PALMER 6-27-23 PROPEL CONTOUR SINUS STENT 49237140_1 CDM 0278 RC inpatient 4423 2874.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2678.13 4290.31 ***BLANKETED PER MEGAN PALMER 6-27-23 PROPEL CONTOUR SINUS STENT 49237140_1 CDM 0278 RC inpatient 4423 2874.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2678.13 4290.31 ***BLANKETED PER MEGAN PALMER 6-27-23 PROPEL CONTOUR SINUS STENT 49237140_1 CDM 0278 RC inpatient 4423 2874.95 ANTHEM HMO ANTHEM HMO 999999999 2678.13 4290.31 ***BLANKETED PER MEGAN PALMER 6-27-23 PROPEL CONTOUR SINUS STENT 49237140_1 CDM 0278 RC inpatient 4423 2874.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2678.13 4290.31 ***BLANKETED PER MEGAN PALMER 6-27-23 PROPEL CONTOUR SINUS STENT 49237140_1 CDM 0278 RC inpatient 4423 2874.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 2678.13 4290.31 ***BLANKETED PER MEGAN PALMER 6-27-23 PROPEL CONTOUR SINUS STENT 49237140_1 CDM 0278 RC inpatient 4423 2874.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 2989.95 67.6 999999999 2678.13 4290.31 percent of total billed charges SOD CHL 0.9% 1000ML 49237144_1 CDM 0258 RC inpatient 18 11.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.7 65 999999999 10.9 17.46 percent of total billed charges SOD CHL 0.9% 1000ML 49237144_1 CDM 0258 RC inpatient 18 11.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.46 97 999999999 10.9 17.46 percent of total billed charges SOD CHL 0.9% 1000ML 49237144_1 CDM 0258 RC inpatient 18 11.7 AETNA AETNA 14.22 79 999999999 10.9 17.46 percent of total billed charges SOD CHL 0.9% 1000ML 49237144_1 CDM 0258 RC inpatient 18 11.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.04 78 999999999 10.9 17.46 percent of total billed charges SOD CHL 0.9% 1000ML 49237144_1 CDM 0258 RC inpatient 18 11.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.42 69 999999999 10.9 17.46 percent of total billed charges SOD CHL 0.9% 1000ML 49237144_1 CDM 0258 RC inpatient 18 11.7 UMR - ALL PLANS UMR - ALL PLANS 12.6 70 999999999 10.9 17.46 percent of total billed charges SOD CHL 0.9% 1000ML 49237144_1 CDM 0258 RC inpatient 18 11.7 SIHO - ALL PLANS SIHO - ALL PLANS 16.2 90 999999999 10.9 17.46 percent of total billed charges SOD CHL 0.9% 1000ML 49237144_1 CDM 0258 RC inpatient 18 11.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.9 60.55 999999999 10.9 17.46 percent of total billed charges SOD CHL 0.9% 1000ML 49237144_1 CDM 0258 RC inpatient 18 11.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.9 17.46 SOD CHL 0.9% 1000ML 49237144_1 CDM 0258 RC inpatient 18 11.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.9 17.46 SOD CHL 0.9% 1000ML 49237144_1 CDM 0258 RC inpatient 18 11.7 ANTHEM HMO ANTHEM HMO 999999999 10.9 17.46 SOD CHL 0.9% 1000ML 49237144_1 CDM 0258 RC inpatient 18 11.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.9 17.46 SOD CHL 0.9% 1000ML 49237144_1 CDM 0258 RC inpatient 18 11.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.9 17.46 SOD CHL 0.9% 1000ML 49237144_1 CDM 0258 RC inpatient 18 11.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.17 67.6 999999999 10.9 17.46 percent of total billed charges PK BUTTONS 49237145_1 CDM 0272 RC inpatient 3442 2237.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 2237.3 65 999999999 2084.13 3338.74 percent of total billed charges PK BUTTONS 49237145_1 CDM 0272 RC inpatient 3442 2237.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3338.74 97 999999999 2084.13 3338.74 percent of total billed charges PK BUTTONS 49237145_1 CDM 0272 RC inpatient 3442 2237.3 AETNA AETNA 2719.18 79 999999999 2084.13 3338.74 percent of total billed charges PK BUTTONS 49237145_1 CDM 0272 RC inpatient 3442 2237.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 2684.76 78 999999999 2084.13 3338.74 percent of total billed charges PK BUTTONS 49237145_1 CDM 0272 RC inpatient 3442 2237.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 2374.98 69 999999999 2084.13 3338.74 percent of total billed charges PK BUTTONS 49237145_1 CDM 0272 RC inpatient 3442 2237.3 UMR - ALL PLANS UMR - ALL PLANS 2409.4 70 999999999 2084.13 3338.74 percent of total billed charges PK BUTTONS 49237145_1 CDM 0272 RC inpatient 3442 2237.3 SIHO - ALL PLANS SIHO - ALL PLANS 3097.8 90 999999999 2084.13 3338.74 percent of total billed charges PK BUTTONS 49237145_1 CDM 0272 RC inpatient 3442 2237.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2084.13 60.55 999999999 2084.13 3338.74 percent of total billed charges PK BUTTONS 49237145_1 CDM 0272 RC inpatient 3442 2237.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2084.13 3338.74 PK BUTTONS 49237145_1 CDM 0272 RC inpatient 3442 2237.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2084.13 3338.74 PK BUTTONS 49237145_1 CDM 0272 RC inpatient 3442 2237.3 ANTHEM HMO ANTHEM HMO 999999999 2084.13 3338.74 PK BUTTONS 49237145_1 CDM 0272 RC inpatient 3442 2237.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2084.13 3338.74 PK BUTTONS 49237145_1 CDM 0272 RC inpatient 3442 2237.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 2084.13 3338.74 PK BUTTONS 49237145_1 CDM 0272 RC inpatient 3442 2237.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 2326.79 67.6 999999999 2084.13 3338.74 percent of total billed charges HEARTRAIL III 6F IL 3.5 LEFT 49237146_1 CDM 0270 RC inpatient 483 313.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 313.95 65 999999999 292.46 468.51 percent of total billed charges HEARTRAIL III 6F IL 3.5 LEFT 49237146_1 CDM 0270 RC inpatient 483 313.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 468.51 97 999999999 292.46 468.51 percent of total billed charges HEARTRAIL III 6F IL 3.5 LEFT 49237146_1 CDM 0270 RC inpatient 483 313.95 AETNA AETNA 381.57 79 999999999 292.46 468.51 percent of total billed charges HEARTRAIL III 6F IL 3.5 LEFT 49237146_1 CDM 0270 RC inpatient 483 313.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 376.74 78 999999999 292.46 468.51 percent of total billed charges HEARTRAIL III 6F IL 3.5 LEFT 49237146_1 CDM 0270 RC inpatient 483 313.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 333.27 69 999999999 292.46 468.51 percent of total billed charges HEARTRAIL III 6F IL 3.5 LEFT 49237146_1 CDM 0270 RC inpatient 483 313.95 UMR - ALL PLANS UMR - ALL PLANS 338.1 70 999999999 292.46 468.51 percent of total billed charges HEARTRAIL III 6F IL 3.5 LEFT 49237146_1 CDM 0270 RC inpatient 483 313.95 SIHO - ALL PLANS SIHO - ALL PLANS 434.7 90 999999999 292.46 468.51 percent of total billed charges HEARTRAIL III 6F IL 3.5 LEFT 49237146_1 CDM 0270 RC inpatient 483 313.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 292.46 60.55 999999999 292.46 468.51 percent of total billed charges HEARTRAIL III 6F IL 3.5 LEFT 49237146_1 CDM 0270 RC inpatient 483 313.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 292.46 468.51 HEARTRAIL III 6F IL 3.5 LEFT 49237146_1 CDM 0270 RC inpatient 483 313.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 292.46 468.51 HEARTRAIL III 6F IL 3.5 LEFT 49237146_1 CDM 0270 RC inpatient 483 313.95 ANTHEM HMO ANTHEM HMO 999999999 292.46 468.51 HEARTRAIL III 6F IL 3.5 LEFT 49237146_1 CDM 0270 RC inpatient 483 313.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 292.46 468.51 HEARTRAIL III 6F IL 3.5 LEFT 49237146_1 CDM 0270 RC inpatient 483 313.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 292.46 468.51 HEARTRAIL III 6F IL 3.5 LEFT 49237146_1 CDM 0270 RC inpatient 483 313.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 326.51 67.6 999999999 292.46 468.51 percent of total billed charges HEARTRAIL III 6F IL 4.0 LEFT 49237147_1 CDM 0270 RC inpatient 483 313.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 313.95 65 999999999 292.46 468.51 percent of total billed charges HEARTRAIL III 6F IL 4.0 LEFT 49237147_1 CDM 0270 RC inpatient 483 313.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 468.51 97 999999999 292.46 468.51 percent of total billed charges HEARTRAIL III 6F IL 4.0 LEFT 49237147_1 CDM 0270 RC inpatient 483 313.95 AETNA AETNA 381.57 79 999999999 292.46 468.51 percent of total billed charges HEARTRAIL III 6F IL 4.0 LEFT 49237147_1 CDM 0270 RC inpatient 483 313.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 376.74 78 999999999 292.46 468.51 percent of total billed charges HEARTRAIL III 6F IL 4.0 LEFT 49237147_1 CDM 0270 RC inpatient 483 313.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 333.27 69 999999999 292.46 468.51 percent of total billed charges HEARTRAIL III 6F IL 4.0 LEFT 49237147_1 CDM 0270 RC inpatient 483 313.95 UMR - ALL PLANS UMR - ALL PLANS 338.1 70 999999999 292.46 468.51 percent of total billed charges HEARTRAIL III 6F IL 4.0 LEFT 49237147_1 CDM 0270 RC inpatient 483 313.95 SIHO - ALL PLANS SIHO - ALL PLANS 434.7 90 999999999 292.46 468.51 percent of total billed charges HEARTRAIL III 6F IL 4.0 LEFT 49237147_1 CDM 0270 RC inpatient 483 313.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 292.46 60.55 999999999 292.46 468.51 percent of total billed charges HEARTRAIL III 6F IL 4.0 LEFT 49237147_1 CDM 0270 RC inpatient 483 313.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 292.46 468.51 HEARTRAIL III 6F IL 4.0 LEFT 49237147_1 CDM 0270 RC inpatient 483 313.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 292.46 468.51 HEARTRAIL III 6F IL 4.0 LEFT 49237147_1 CDM 0270 RC inpatient 483 313.95 ANTHEM HMO ANTHEM HMO 999999999 292.46 468.51 HEARTRAIL III 6F IL 4.0 LEFT 49237147_1 CDM 0270 RC inpatient 483 313.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 292.46 468.51 HEARTRAIL III 6F IL 4.0 LEFT 49237147_1 CDM 0270 RC inpatient 483 313.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 292.46 468.51 HEARTRAIL III 6F IL 4.0 LEFT 49237147_1 CDM 0270 RC inpatient 483 313.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 326.51 67.6 999999999 292.46 468.51 percent of total billed charges "GLIDEWIRE ADVANTAGE 035"" 180CM" 49237148_1 CDM 0272 RC inpatient 994 646.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 646.1 65 999999999 601.87 964.18 percent of total billed charges "GLIDEWIRE ADVANTAGE 035"" 180CM" 49237148_1 CDM 0272 RC inpatient 994 646.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 964.18 97 999999999 601.87 964.18 percent of total billed charges "GLIDEWIRE ADVANTAGE 035"" 180CM" 49237148_1 CDM 0272 RC inpatient 994 646.1 AETNA AETNA 785.26 79 999999999 601.87 964.18 percent of total billed charges "GLIDEWIRE ADVANTAGE 035"" 180CM" 49237148_1 CDM 0272 RC inpatient 994 646.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 775.32 78 999999999 601.87 964.18 percent of total billed charges "GLIDEWIRE ADVANTAGE 035"" 180CM" 49237148_1 CDM 0272 RC inpatient 994 646.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 685.86 69 999999999 601.87 964.18 percent of total billed charges "GLIDEWIRE ADVANTAGE 035"" 180CM" 49237148_1 CDM 0272 RC inpatient 994 646.1 UMR - ALL PLANS UMR - ALL PLANS 695.8 70 999999999 601.87 964.18 percent of total billed charges "GLIDEWIRE ADVANTAGE 035"" 180CM" 49237148_1 CDM 0272 RC inpatient 994 646.1 SIHO - ALL PLANS SIHO - ALL PLANS 894.6 90 999999999 601.87 964.18 percent of total billed charges "GLIDEWIRE ADVANTAGE 035"" 180CM" 49237148_1 CDM 0272 RC inpatient 994 646.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 601.87 60.55 999999999 601.87 964.18 percent of total billed charges "GLIDEWIRE ADVANTAGE 035"" 180CM" 49237148_1 CDM 0272 RC inpatient 994 646.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 601.87 964.18 "GLIDEWIRE ADVANTAGE 035"" 180CM" 49237148_1 CDM 0272 RC inpatient 994 646.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 601.87 964.18 "GLIDEWIRE ADVANTAGE 035"" 180CM" 49237148_1 CDM 0272 RC inpatient 994 646.1 ANTHEM HMO ANTHEM HMO 999999999 601.87 964.18 "GLIDEWIRE ADVANTAGE 035"" 180CM" 49237148_1 CDM 0272 RC inpatient 994 646.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 601.87 964.18 "GLIDEWIRE ADVANTAGE 035"" 180CM" 49237148_1 CDM 0272 RC inpatient 994 646.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 601.87 964.18 "GLIDEWIRE ADVANTAGE 035"" 180CM" 49237148_1 CDM 0272 RC inpatient 994 646.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 671.94 67.6 999999999 601.87 964.18 percent of total billed charges "GLIDEWIRE ADVANTAGE 035"" 260CM" 49237149_1 CDM 0272 RC inpatient 1118 726.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 726.7 65 999999999 676.95 1084.46 percent of total billed charges "GLIDEWIRE ADVANTAGE 035"" 260CM" 49237149_1 CDM 0272 RC inpatient 1118 726.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1084.46 97 999999999 676.95 1084.46 percent of total billed charges "GLIDEWIRE ADVANTAGE 035"" 260CM" 49237149_1 CDM 0272 RC inpatient 1118 726.7 AETNA AETNA 883.22 79 999999999 676.95 1084.46 percent of total billed charges "GLIDEWIRE ADVANTAGE 035"" 260CM" 49237149_1 CDM 0272 RC inpatient 1118 726.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 872.04 78 999999999 676.95 1084.46 percent of total billed charges "GLIDEWIRE ADVANTAGE 035"" 260CM" 49237149_1 CDM 0272 RC inpatient 1118 726.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 771.42 69 999999999 676.95 1084.46 percent of total billed charges "GLIDEWIRE ADVANTAGE 035"" 260CM" 49237149_1 CDM 0272 RC inpatient 1118 726.7 UMR - ALL PLANS UMR - ALL PLANS 782.6 70 999999999 676.95 1084.46 percent of total billed charges "GLIDEWIRE ADVANTAGE 035"" 260CM" 49237149_1 CDM 0272 RC inpatient 1118 726.7 SIHO - ALL PLANS SIHO - ALL PLANS 1006.2 90 999999999 676.95 1084.46 percent of total billed charges "GLIDEWIRE ADVANTAGE 035"" 260CM" 49237149_1 CDM 0272 RC inpatient 1118 726.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 676.95 60.55 999999999 676.95 1084.46 percent of total billed charges "GLIDEWIRE ADVANTAGE 035"" 260CM" 49237149_1 CDM 0272 RC inpatient 1118 726.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 676.95 1084.46 "GLIDEWIRE ADVANTAGE 035"" 260CM" 49237149_1 CDM 0272 RC inpatient 1118 726.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 676.95 1084.46 "GLIDEWIRE ADVANTAGE 035"" 260CM" 49237149_1 CDM 0272 RC inpatient 1118 726.7 ANTHEM HMO ANTHEM HMO 999999999 676.95 1084.46 "GLIDEWIRE ADVANTAGE 035"" 260CM" 49237149_1 CDM 0272 RC inpatient 1118 726.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 676.95 1084.46 "GLIDEWIRE ADVANTAGE 035"" 260CM" 49237149_1 CDM 0272 RC inpatient 1118 726.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 676.95 1084.46 "GLIDEWIRE ADVANTAGE 035"" 260CM" 49237149_1 CDM 0272 RC inpatient 1118 726.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 755.77 67.6 999999999 676.95 1084.46 percent of total billed charges CATHETER FETCH 2 ASPIRATION 49237150_1 CDM 0272 RC inpatient 2327 1512.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1512.55 65 999999999 1409 2257.19 percent of total billed charges CATHETER FETCH 2 ASPIRATION 49237150_1 CDM 0272 RC inpatient 2327 1512.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2257.19 97 999999999 1409 2257.19 percent of total billed charges CATHETER FETCH 2 ASPIRATION 49237150_1 CDM 0272 RC inpatient 2327 1512.55 AETNA AETNA 1838.33 79 999999999 1409 2257.19 percent of total billed charges CATHETER FETCH 2 ASPIRATION 49237150_1 CDM 0272 RC inpatient 2327 1512.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1815.06 78 999999999 1409 2257.19 percent of total billed charges CATHETER FETCH 2 ASPIRATION 49237150_1 CDM 0272 RC inpatient 2327 1512.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1605.63 69 999999999 1409 2257.19 percent of total billed charges CATHETER FETCH 2 ASPIRATION 49237150_1 CDM 0272 RC inpatient 2327 1512.55 UMR - ALL PLANS UMR - ALL PLANS 1628.9 70 999999999 1409 2257.19 percent of total billed charges CATHETER FETCH 2 ASPIRATION 49237150_1 CDM 0272 RC inpatient 2327 1512.55 SIHO - ALL PLANS SIHO - ALL PLANS 2094.3 90 999999999 1409 2257.19 percent of total billed charges CATHETER FETCH 2 ASPIRATION 49237150_1 CDM 0272 RC inpatient 2327 1512.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1409 60.55 999999999 1409 2257.19 percent of total billed charges CATHETER FETCH 2 ASPIRATION 49237150_1 CDM 0272 RC inpatient 2327 1512.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1409 2257.19 CATHETER FETCH 2 ASPIRATION 49237150_1 CDM 0272 RC inpatient 2327 1512.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1409 2257.19 CATHETER FETCH 2 ASPIRATION 49237150_1 CDM 0272 RC inpatient 2327 1512.55 ANTHEM HMO ANTHEM HMO 999999999 1409 2257.19 CATHETER FETCH 2 ASPIRATION 49237150_1 CDM 0272 RC inpatient 2327 1512.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1409 2257.19 CATHETER FETCH 2 ASPIRATION 49237150_1 CDM 0272 RC inpatient 2327 1512.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1409 2257.19 CATHETER FETCH 2 ASPIRATION 49237150_1 CDM 0272 RC inpatient 2327 1512.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1573.05 67.6 999999999 1409 2257.19 percent of total billed charges CATHETER SWAN GANZ TD 49237151_1 CDM 0272 RC inpatient 556 361.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 361.4 65 999999999 336.66 539.32 percent of total billed charges CATHETER SWAN GANZ TD 49237151_1 CDM 0272 RC inpatient 556 361.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 539.32 97 999999999 336.66 539.32 percent of total billed charges CATHETER SWAN GANZ TD 49237151_1 CDM 0272 RC inpatient 556 361.4 AETNA AETNA 439.24 79 999999999 336.66 539.32 percent of total billed charges CATHETER SWAN GANZ TD 49237151_1 CDM 0272 RC inpatient 556 361.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 433.68 78 999999999 336.66 539.32 percent of total billed charges CATHETER SWAN GANZ TD 49237151_1 CDM 0272 RC inpatient 556 361.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 383.64 69 999999999 336.66 539.32 percent of total billed charges CATHETER SWAN GANZ TD 49237151_1 CDM 0272 RC inpatient 556 361.4 UMR - ALL PLANS UMR - ALL PLANS 389.2 70 999999999 336.66 539.32 percent of total billed charges CATHETER SWAN GANZ TD 49237151_1 CDM 0272 RC inpatient 556 361.4 SIHO - ALL PLANS SIHO - ALL PLANS 500.4 90 999999999 336.66 539.32 percent of total billed charges CATHETER SWAN GANZ TD 49237151_1 CDM 0272 RC inpatient 556 361.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 336.66 60.55 999999999 336.66 539.32 percent of total billed charges CATHETER SWAN GANZ TD 49237151_1 CDM 0272 RC inpatient 556 361.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 336.66 539.32 CATHETER SWAN GANZ TD 49237151_1 CDM 0272 RC inpatient 556 361.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 336.66 539.32 CATHETER SWAN GANZ TD 49237151_1 CDM 0272 RC inpatient 556 361.4 ANTHEM HMO ANTHEM HMO 999999999 336.66 539.32 CATHETER SWAN GANZ TD 49237151_1 CDM 0272 RC inpatient 556 361.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 336.66 539.32 CATHETER SWAN GANZ TD 49237151_1 CDM 0272 RC inpatient 556 361.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 336.66 539.32 CATHETER SWAN GANZ TD 49237151_1 CDM 0272 RC inpatient 556 361.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 375.86 67.6 999999999 336.66 539.32 percent of total billed charges BIOFLO PICC 45-895 49237152_1 CDM 0272 RC inpatient 656 426.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 426.4 65 999999999 397.21 636.32 percent of total billed charges BIOFLO PICC 45-895 49237152_1 CDM 0272 RC inpatient 656 426.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 636.32 97 999999999 397.21 636.32 percent of total billed charges BIOFLO PICC 45-895 49237152_1 CDM 0272 RC inpatient 656 426.4 AETNA AETNA 518.24 79 999999999 397.21 636.32 percent of total billed charges BIOFLO PICC 45-895 49237152_1 CDM 0272 RC inpatient 656 426.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 511.68 78 999999999 397.21 636.32 percent of total billed charges BIOFLO PICC 45-895 49237152_1 CDM 0272 RC inpatient 656 426.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 452.64 69 999999999 397.21 636.32 percent of total billed charges BIOFLO PICC 45-895 49237152_1 CDM 0272 RC inpatient 656 426.4 UMR - ALL PLANS UMR - ALL PLANS 459.2 70 999999999 397.21 636.32 percent of total billed charges BIOFLO PICC 45-895 49237152_1 CDM 0272 RC inpatient 656 426.4 SIHO - ALL PLANS SIHO - ALL PLANS 590.4 90 999999999 397.21 636.32 percent of total billed charges BIOFLO PICC 45-895 49237152_1 CDM 0272 RC inpatient 656 426.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 397.21 60.55 999999999 397.21 636.32 percent of total billed charges BIOFLO PICC 45-895 49237152_1 CDM 0272 RC inpatient 656 426.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 397.21 636.32 BIOFLO PICC 45-895 49237152_1 CDM 0272 RC inpatient 656 426.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 397.21 636.32 BIOFLO PICC 45-895 49237152_1 CDM 0272 RC inpatient 656 426.4 ANTHEM HMO ANTHEM HMO 999999999 397.21 636.32 BIOFLO PICC 45-895 49237152_1 CDM 0272 RC inpatient 656 426.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 397.21 636.32 BIOFLO PICC 45-895 49237152_1 CDM 0272 RC inpatient 656 426.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 397.21 636.32 BIOFLO PICC 45-895 49237152_1 CDM 0272 RC inpatient 656 426.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 443.46 67.6 999999999 397.21 636.32 percent of total billed charges CATHETER GUIDE 6F JL4 49237153_1 CDM 0272 RC inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL4 49237153_1 CDM 0272 RC inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL4 49237153_1 CDM 0272 RC inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL4 49237153_1 CDM 0272 RC inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL4 49237153_1 CDM 0272 RC inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL4 49237153_1 CDM 0272 RC inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL4 49237153_1 CDM 0272 RC inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL4 49237153_1 CDM 0272 RC inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges CATHETER GUIDE 6F JL4 49237153_1 CDM 0272 RC inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F JL4 49237153_1 CDM 0272 RC inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F JL4 49237153_1 CDM 0272 RC inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 CATHETER GUIDE 6F JL4 49237153_1 CDM 0272 RC inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 CATHETER GUIDE 6F JL4 49237153_1 CDM 0272 RC inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 CATHETER GUIDE 6F JL4 49237153_1 CDM 0272 RC inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges CATH ELECTROPHYSIOLOGY 7F RESPONSE DECAPOLAR W/LUMEN 49237154_1 CDM 0272 RC inpatient 2793 1815.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1815.45 65 999999999 1691.16 2709.21 percent of total billed charges CATH ELECTROPHYSIOLOGY 7F RESPONSE DECAPOLAR W/LUMEN 49237154_1 CDM 0272 RC inpatient 2793 1815.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2709.21 97 999999999 1691.16 2709.21 percent of total billed charges CATH ELECTROPHYSIOLOGY 7F RESPONSE DECAPOLAR W/LUMEN 49237154_1 CDM 0272 RC inpatient 2793 1815.45 AETNA AETNA 2206.47 79 999999999 1691.16 2709.21 percent of total billed charges CATH ELECTROPHYSIOLOGY 7F RESPONSE DECAPOLAR W/LUMEN 49237154_1 CDM 0272 RC inpatient 2793 1815.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 2178.54 78 999999999 1691.16 2709.21 percent of total billed charges CATH ELECTROPHYSIOLOGY 7F RESPONSE DECAPOLAR W/LUMEN 49237154_1 CDM 0272 RC inpatient 2793 1815.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1927.17 69 999999999 1691.16 2709.21 percent of total billed charges CATH ELECTROPHYSIOLOGY 7F RESPONSE DECAPOLAR W/LUMEN 49237154_1 CDM 0272 RC inpatient 2793 1815.45 UMR - ALL PLANS UMR - ALL PLANS 1955.1 70 999999999 1691.16 2709.21 percent of total billed charges CATH ELECTROPHYSIOLOGY 7F RESPONSE DECAPOLAR W/LUMEN 49237154_1 CDM 0272 RC inpatient 2793 1815.45 SIHO - ALL PLANS SIHO - ALL PLANS 2513.7 90 999999999 1691.16 2709.21 percent of total billed charges CATH ELECTROPHYSIOLOGY 7F RESPONSE DECAPOLAR W/LUMEN 49237154_1 CDM 0272 RC inpatient 2793 1815.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1691.16 60.55 999999999 1691.16 2709.21 percent of total billed charges CATH ELECTROPHYSIOLOGY 7F RESPONSE DECAPOLAR W/LUMEN 49237154_1 CDM 0272 RC inpatient 2793 1815.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1691.16 2709.21 CATH ELECTROPHYSIOLOGY 7F RESPONSE DECAPOLAR W/LUMEN 49237154_1 CDM 0272 RC inpatient 2793 1815.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1691.16 2709.21 CATH ELECTROPHYSIOLOGY 7F RESPONSE DECAPOLAR W/LUMEN 49237154_1 CDM 0272 RC inpatient 2793 1815.45 ANTHEM HMO ANTHEM HMO 999999999 1691.16 2709.21 CATH ELECTROPHYSIOLOGY 7F RESPONSE DECAPOLAR W/LUMEN 49237154_1 CDM 0272 RC inpatient 2793 1815.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1691.16 2709.21 CATH ELECTROPHYSIOLOGY 7F RESPONSE DECAPOLAR W/LUMEN 49237154_1 CDM 0272 RC inpatient 2793 1815.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1691.16 2709.21 CATH ELECTROPHYSIOLOGY 7F RESPONSE DECAPOLAR W/LUMEN 49237154_1 CDM 0272 RC inpatient 2793 1815.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1888.07 67.6 999999999 1691.16 2709.21 percent of total billed charges "5 1/2"" ALLIGATOR FORCEP STERILE 66735" 49237174_1 CDM 0272 RC inpatient 205 133.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.25 65 999999999 124.13 198.85 percent of total billed charges "5 1/2"" ALLIGATOR FORCEP STERILE 66735" 49237174_1 CDM 0272 RC inpatient 205 133.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 198.85 97 999999999 124.13 198.85 percent of total billed charges "5 1/2"" ALLIGATOR FORCEP STERILE 66735" 49237174_1 CDM 0272 RC inpatient 205 133.25 AETNA AETNA 161.95 79 999999999 124.13 198.85 percent of total billed charges "5 1/2"" ALLIGATOR FORCEP STERILE 66735" 49237174_1 CDM 0272 RC inpatient 205 133.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.9 78 999999999 124.13 198.85 percent of total billed charges "5 1/2"" ALLIGATOR FORCEP STERILE 66735" 49237174_1 CDM 0272 RC inpatient 205 133.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 141.45 69 999999999 124.13 198.85 percent of total billed charges "5 1/2"" ALLIGATOR FORCEP STERILE 66735" 49237174_1 CDM 0272 RC inpatient 205 133.25 UMR - ALL PLANS UMR - ALL PLANS 143.5 70 999999999 124.13 198.85 percent of total billed charges "5 1/2"" ALLIGATOR FORCEP STERILE 66735" 49237174_1 CDM 0272 RC inpatient 205 133.25 SIHO - ALL PLANS SIHO - ALL PLANS 184.5 90 999999999 124.13 198.85 percent of total billed charges "5 1/2"" ALLIGATOR FORCEP STERILE 66735" 49237174_1 CDM 0272 RC inpatient 205 133.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.13 60.55 999999999 124.13 198.85 percent of total billed charges "5 1/2"" ALLIGATOR FORCEP STERILE 66735" 49237174_1 CDM 0272 RC inpatient 205 133.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.13 198.85 "5 1/2"" ALLIGATOR FORCEP STERILE 66735" 49237174_1 CDM 0272 RC inpatient 205 133.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.13 198.85 "5 1/2"" ALLIGATOR FORCEP STERILE 66735" 49237174_1 CDM 0272 RC inpatient 205 133.25 ANTHEM HMO ANTHEM HMO 999999999 124.13 198.85 "5 1/2"" ALLIGATOR FORCEP STERILE 66735" 49237174_1 CDM 0272 RC inpatient 205 133.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.13 198.85 "5 1/2"" ALLIGATOR FORCEP STERILE 66735" 49237174_1 CDM 0272 RC inpatient 205 133.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.13 198.85 "5 1/2"" ALLIGATOR FORCEP STERILE 66735" 49237174_1 CDM 0272 RC inpatient 205 133.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 138.58 67.6 999999999 124.13 198.85 percent of total billed charges NORMAL SALINE FLUSH 10 ML SYR 49239452_1 CDM 0250 RC 08290-3065-46 NDC inpatient 1 UN 18.5 12.03 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.03 65 999999999 11.2 17.95 percent of total billed charges NORMAL SALINE FLUSH 10 ML SYR 49239452_1 CDM 0250 RC 08290-3065-46 NDC inpatient 1 UN 18.5 12.03 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.95 97 999999999 11.2 17.95 percent of total billed charges NORMAL SALINE FLUSH 10 ML SYR 49239452_1 CDM 0250 RC 08290-3065-46 NDC inpatient 1 UN 18.5 12.03 AETNA AETNA 14.62 79 999999999 11.2 17.95 percent of total billed charges NORMAL SALINE FLUSH 10 ML SYR 49239452_1 CDM 0250 RC 08290-3065-46 NDC inpatient 1 UN 18.5 12.03 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.43 78 999999999 11.2 17.95 percent of total billed charges NORMAL SALINE FLUSH 10 ML SYR 49239452_1 CDM 0250 RC 08290-3065-46 NDC inpatient 1 UN 18.5 12.03 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.77 69 999999999 11.2 17.95 percent of total billed charges NORMAL SALINE FLUSH 10 ML SYR 49239452_1 CDM 0250 RC 08290-3065-46 NDC inpatient 1 UN 18.5 12.03 UMR - ALL PLANS UMR - ALL PLANS 12.95 70 999999999 11.2 17.95 percent of total billed charges NORMAL SALINE FLUSH 10 ML SYR 49239452_1 CDM 0250 RC 08290-3065-46 NDC inpatient 1 UN 18.5 12.03 SIHO - ALL PLANS SIHO - ALL PLANS 16.65 90 999999999 11.2 17.95 percent of total billed charges NORMAL SALINE FLUSH 10 ML SYR 49239452_1 CDM 0250 RC 08290-3065-46 NDC inpatient 1 UN 18.5 12.03 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.2 60.55 999999999 11.2 17.95 percent of total billed charges NORMAL SALINE FLUSH 10 ML SYR 49239452_1 CDM 0250 RC 08290-3065-46 NDC inpatient 1 UN 18.5 12.03 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.2 17.95 NORMAL SALINE FLUSH 10 ML SYR 49239452_1 CDM 0250 RC 08290-3065-46 NDC inpatient 1 UN 18.5 12.03 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.2 17.95 NORMAL SALINE FLUSH 10 ML SYR 49239452_1 CDM 0250 RC 08290-3065-46 NDC inpatient 1 UN 18.5 12.03 ANTHEM HMO ANTHEM HMO 999999999 11.2 17.95 NORMAL SALINE FLUSH 10 ML SYR 49239452_1 CDM 0250 RC 08290-3065-46 NDC inpatient 1 UN 18.5 12.03 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.2 17.95 NORMAL SALINE FLUSH 10 ML SYR 49239452_1 CDM 0250 RC 08290-3065-46 NDC inpatient 1 UN 18.5 12.03 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.2 17.95 NORMAL SALINE FLUSH 10 ML SYR 49239452_1 CDM 0250 RC 08290-3065-46 NDC inpatient 1 UN 18.5 12.03 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.51 67.6 999999999 11.2 17.95 percent of total billed charges DILTIAZEM 24H ER(CD) 180 MG CP 49239468_1 CDM 0250 RC 60687-0206-11 NDC inpatient 1 UN 1.55 1.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.01 65 999999999 0.94 1.5 percent of total billed charges DILTIAZEM 24H ER(CD) 180 MG CP 49239468_1 CDM 0250 RC 60687-0206-11 NDC inpatient 1 UN 1.55 1.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.5 97 999999999 0.94 1.5 percent of total billed charges DILTIAZEM 24H ER(CD) 180 MG CP 49239468_1 CDM 0250 RC 60687-0206-11 NDC inpatient 1 UN 1.55 1.01 AETNA AETNA 1.22 79 999999999 0.94 1.5 percent of total billed charges DILTIAZEM 24H ER(CD) 180 MG CP 49239468_1 CDM 0250 RC 60687-0206-11 NDC inpatient 1 UN 1.55 1.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.21 78 999999999 0.94 1.5 percent of total billed charges DILTIAZEM 24H ER(CD) 180 MG CP 49239468_1 CDM 0250 RC 60687-0206-11 NDC inpatient 1 UN 1.55 1.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.07 69 999999999 0.94 1.5 percent of total billed charges DILTIAZEM 24H ER(CD) 180 MG CP 49239468_1 CDM 0250 RC 60687-0206-11 NDC inpatient 1 UN 1.55 1.01 UMR - ALL PLANS UMR - ALL PLANS 1.09 70 999999999 0.94 1.5 percent of total billed charges DILTIAZEM 24H ER(CD) 180 MG CP 49239468_1 CDM 0250 RC 60687-0206-11 NDC inpatient 1 UN 1.55 1.01 SIHO - ALL PLANS SIHO - ALL PLANS 1.4 90 999999999 0.94 1.5 percent of total billed charges DILTIAZEM 24H ER(CD) 180 MG CP 49239468_1 CDM 0250 RC 60687-0206-11 NDC inpatient 1 UN 1.55 1.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.94 60.55 999999999 0.94 1.5 percent of total billed charges DILTIAZEM 24H ER(CD) 180 MG CP 49239468_1 CDM 0250 RC 60687-0206-11 NDC inpatient 1 UN 1.55 1.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.94 1.5 DILTIAZEM 24H ER(CD) 180 MG CP 49239468_1 CDM 0250 RC 60687-0206-11 NDC inpatient 1 UN 1.55 1.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.94 1.5 DILTIAZEM 24H ER(CD) 180 MG CP 49239468_1 CDM 0250 RC 60687-0206-11 NDC inpatient 1 UN 1.55 1.01 ANTHEM HMO ANTHEM HMO 999999999 0.94 1.5 DILTIAZEM 24H ER(CD) 180 MG CP 49239468_1 CDM 0250 RC 60687-0206-11 NDC inpatient 1 UN 1.55 1.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.94 1.5 DILTIAZEM 24H ER(CD) 180 MG CP 49239468_1 CDM 0250 RC 60687-0206-11 NDC inpatient 1 UN 1.55 1.01 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.94 1.5 DILTIAZEM 24H ER(CD) 180 MG CP 49239468_1 CDM 0250 RC 60687-0206-11 NDC inpatient 1 UN 1.55 1.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.05 67.6 999999999 0.94 1.5 percent of total billed charges AK-FLUOR 10% VIAL 49239475_1 CDM 0250 RC 17478-0253-10 NDC inpatient 1 UN 211.28 137.33 SELF PAY DISCOUNT SELF PAY DISCOUNT 137.33 65 999999999 127.93 204.94 percent of total billed charges AK-FLUOR 10% VIAL 49239475_1 CDM 0250 RC 17478-0253-10 NDC inpatient 1 UN 211.28 137.33 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 204.94 97 999999999 127.93 204.94 percent of total billed charges AK-FLUOR 10% VIAL 49239475_1 CDM 0250 RC 17478-0253-10 NDC inpatient 1 UN 211.28 137.33 AETNA AETNA 166.91 79 999999999 127.93 204.94 percent of total billed charges AK-FLUOR 10% VIAL 49239475_1 CDM 0250 RC 17478-0253-10 NDC inpatient 1 UN 211.28 137.33 HUMANA - ALL PLANS HUMANA - ALL PLANS 164.8 78 999999999 127.93 204.94 percent of total billed charges AK-FLUOR 10% VIAL 49239475_1 CDM 0250 RC 17478-0253-10 NDC inpatient 1 UN 211.28 137.33 ENCORE - ALL PLANS ENCORE - ALL PLANS 145.78 69 999999999 127.93 204.94 percent of total billed charges AK-FLUOR 10% VIAL 49239475_1 CDM 0250 RC 17478-0253-10 NDC inpatient 1 UN 211.28 137.33 UMR - ALL PLANS UMR - ALL PLANS 147.9 70 999999999 127.93 204.94 percent of total billed charges AK-FLUOR 10% VIAL 49239475_1 CDM 0250 RC 17478-0253-10 NDC inpatient 1 UN 211.28 137.33 SIHO - ALL PLANS SIHO - ALL PLANS 190.15 90 999999999 127.93 204.94 percent of total billed charges AK-FLUOR 10% VIAL 49239475_1 CDM 0250 RC 17478-0253-10 NDC inpatient 1 UN 211.28 137.33 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.93 60.55 999999999 127.93 204.94 percent of total billed charges AK-FLUOR 10% VIAL 49239475_1 CDM 0250 RC 17478-0253-10 NDC inpatient 1 UN 211.28 137.33 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.93 204.94 AK-FLUOR 10% VIAL 49239475_1 CDM 0250 RC 17478-0253-10 NDC inpatient 1 UN 211.28 137.33 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.93 204.94 AK-FLUOR 10% VIAL 49239475_1 CDM 0250 RC 17478-0253-10 NDC inpatient 1 UN 211.28 137.33 ANTHEM HMO ANTHEM HMO 999999999 127.93 204.94 AK-FLUOR 10% VIAL 49239475_1 CDM 0250 RC 17478-0253-10 NDC inpatient 1 UN 211.28 137.33 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.93 204.94 AK-FLUOR 10% VIAL 49239475_1 CDM 0250 RC 17478-0253-10 NDC inpatient 1 UN 211.28 137.33 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.93 204.94 AK-FLUOR 10% VIAL 49239475_1 CDM 0250 RC 17478-0253-10 NDC inpatient 1 UN 211.28 137.33 CIGNA - ALL PLANS CIGNA - ALL PLANS 142.83 67.6 999999999 127.93 204.94 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49240852_1 CDM 0921 RC 93971 HCPCS inpatient 1298 843.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 843.7 65 999999999 785.94 1259.06 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49240852_1 CDM 0921 RC 93971 HCPCS inpatient 1298 843.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1259.06 97 999999999 785.94 1259.06 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49240852_1 CDM 0921 RC 93971 HCPCS inpatient 1298 843.7 AETNA AETNA 1025.42 79 999999999 785.94 1259.06 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49240852_1 CDM 0921 RC 93971 HCPCS inpatient 1298 843.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1012.44 78 999999999 785.94 1259.06 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49240852_1 CDM 0921 RC 93971 HCPCS inpatient 1298 843.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 895.62 69 999999999 785.94 1259.06 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49240852_1 CDM 0921 RC 93971 HCPCS inpatient 1298 843.7 UMR - ALL PLANS UMR - ALL PLANS 908.6 70 999999999 785.94 1259.06 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49240852_1 CDM 0921 RC 93971 HCPCS inpatient 1298 843.7 SIHO - ALL PLANS SIHO - ALL PLANS 1168.2 90 999999999 785.94 1259.06 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49240852_1 CDM 0921 RC 93971 HCPCS inpatient 1298 843.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 785.94 60.55 999999999 785.94 1259.06 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49240852_1 CDM 0921 RC 93971 HCPCS inpatient 1298 843.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 785.94 1259.06 Ultrasound study of one arm or leg veins with compression and maneuvers 49240852_1 CDM 0921 RC 93971 HCPCS inpatient 1298 843.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 785.94 1259.06 Ultrasound study of one arm or leg veins with compression and maneuvers 49240852_1 CDM 0921 RC 93971 HCPCS inpatient 1298 843.7 ANTHEM HMO ANTHEM HMO 999999999 785.94 1259.06 Ultrasound study of one arm or leg veins with compression and maneuvers 49240852_1 CDM 0921 RC 93971 HCPCS inpatient 1298 843.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 785.94 1259.06 Ultrasound study of one arm or leg veins with compression and maneuvers 49240852_1 CDM 0921 RC 93971 HCPCS inpatient 1298 843.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 785.94 1259.06 Ultrasound study of one arm or leg veins with compression and maneuvers 49240852_1 CDM 0921 RC 93971 HCPCS inpatient 1298 843.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 877.45 67.6 999999999 785.94 1259.06 percent of total billed charges Injection of chemical agent into single incompetent vein 49240859_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 571.35 65 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49240859_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 852.63 97 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49240859_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 AETNA AETNA 694.41 79 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49240859_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 685.62 78 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49240859_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 606.51 69 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49240859_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 UMR - ALL PLANS UMR - ALL PLANS 615.3 70 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49240859_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 SIHO - ALL PLANS SIHO - ALL PLANS 791.1 90 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49240859_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 532.23 60.55 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49240859_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein 49240859_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein 49240859_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 ANTHEM HMO ANTHEM HMO 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein 49240859_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein 49240859_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein 49240859_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 594.2 67.6 999999999 532.23 852.63 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49240879_1 CDM 0510 RC 93971 HCPCS inpatient 1298 843.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 843.7 65 999999999 785.94 1259.06 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49240879_1 CDM 0510 RC 93971 HCPCS inpatient 1298 843.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1259.06 97 999999999 785.94 1259.06 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49240879_1 CDM 0510 RC 93971 HCPCS inpatient 1298 843.7 AETNA AETNA 1025.42 79 999999999 785.94 1259.06 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49240879_1 CDM 0510 RC 93971 HCPCS inpatient 1298 843.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1012.44 78 999999999 785.94 1259.06 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49240879_1 CDM 0510 RC 93971 HCPCS inpatient 1298 843.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 895.62 69 999999999 785.94 1259.06 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49240879_1 CDM 0510 RC 93971 HCPCS inpatient 1298 843.7 UMR - ALL PLANS UMR - ALL PLANS 908.6 70 999999999 785.94 1259.06 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49240879_1 CDM 0510 RC 93971 HCPCS inpatient 1298 843.7 SIHO - ALL PLANS SIHO - ALL PLANS 1168.2 90 999999999 785.94 1259.06 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49240879_1 CDM 0510 RC 93971 HCPCS inpatient 1298 843.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 785.94 60.55 999999999 785.94 1259.06 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49240879_1 CDM 0510 RC 93971 HCPCS inpatient 1298 843.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 785.94 1259.06 Ultrasound study of one arm or leg veins with compression and maneuvers 49240879_1 CDM 0510 RC 93971 HCPCS inpatient 1298 843.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 785.94 1259.06 Ultrasound study of one arm or leg veins with compression and maneuvers 49240879_1 CDM 0510 RC 93971 HCPCS inpatient 1298 843.7 ANTHEM HMO ANTHEM HMO 999999999 785.94 1259.06 Ultrasound study of one arm or leg veins with compression and maneuvers 49240879_1 CDM 0510 RC 93971 HCPCS inpatient 1298 843.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 785.94 1259.06 Ultrasound study of one arm or leg veins with compression and maneuvers 49240879_1 CDM 0510 RC 93971 HCPCS inpatient 1298 843.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 785.94 1259.06 Ultrasound study of one arm or leg veins with compression and maneuvers 49240879_1 CDM 0510 RC 93971 HCPCS inpatient 1298 843.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 877.45 67.6 999999999 785.94 1259.06 percent of total billed charges Injection of chemical agent into single incompetent vein 49240883_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 571.35 65 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49240883_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 852.63 97 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49240883_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 AETNA AETNA 694.41 79 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49240883_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 685.62 78 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49240883_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 606.51 69 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49240883_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 UMR - ALL PLANS UMR - ALL PLANS 615.3 70 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49240883_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 SIHO - ALL PLANS SIHO - ALL PLANS 791.1 90 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49240883_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 532.23 60.55 999999999 532.23 852.63 percent of total billed charges Injection of chemical agent into single incompetent vein 49240883_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein 49240883_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein 49240883_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 ANTHEM HMO ANTHEM HMO 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein 49240883_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein 49240883_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 532.23 852.63 Injection of chemical agent into single incompetent vein 49240883_1 CDM 0510 RC 36470 HCPCS inpatient 879 571.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 594.2 67.6 999999999 532.23 852.63 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240890_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240890_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240890_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240890_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240890_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240890_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240890_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240890_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240890_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240890_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240890_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240890_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240890_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240890_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240891_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240891_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240891_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240891_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240891_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240891_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240891_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240891_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240891_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240891_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240891_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240891_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240891_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240891_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240892_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240892_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240892_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240892_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240892_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240892_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240892_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240892_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240892_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240892_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240892_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240892_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240892_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240892_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240893_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240893_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240893_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240893_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240893_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240893_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240893_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240893_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240893_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240893_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240893_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240893_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240893_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49240893_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 49240928_1 CDM 0510 RC 93970 HCPCS inpatient 2589 1682.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1682.85 65 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 49240928_1 CDM 0510 RC 93970 HCPCS inpatient 2589 1682.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2511.33 97 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 49240928_1 CDM 0510 RC 93970 HCPCS inpatient 2589 1682.85 AETNA AETNA 2045.31 79 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 49240928_1 CDM 0510 RC 93970 HCPCS inpatient 2589 1682.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 2019.42 78 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 49240928_1 CDM 0510 RC 93970 HCPCS inpatient 2589 1682.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1786.41 69 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 49240928_1 CDM 0510 RC 93970 HCPCS inpatient 2589 1682.85 UMR - ALL PLANS UMR - ALL PLANS 1812.3 70 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 49240928_1 CDM 0510 RC 93970 HCPCS inpatient 2589 1682.85 SIHO - ALL PLANS SIHO - ALL PLANS 2330.1 90 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 49240928_1 CDM 0510 RC 93970 HCPCS inpatient 2589 1682.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1567.64 60.55 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 49240928_1 CDM 0510 RC 93970 HCPCS inpatient 2589 1682.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 49240928_1 CDM 0510 RC 93970 HCPCS inpatient 2589 1682.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 49240928_1 CDM 0510 RC 93970 HCPCS inpatient 2589 1682.85 ANTHEM HMO ANTHEM HMO 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 49240928_1 CDM 0510 RC 93970 HCPCS inpatient 2589 1682.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 49240928_1 CDM 0510 RC 93970 HCPCS inpatient 2589 1682.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 49240928_1 CDM 0510 RC 93970 HCPCS inpatient 2589 1682.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1750.16 67.6 999999999 1567.64 2511.33 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49240937_1 CDM 0510 RC inpatient 1757 1142.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1142.05 65 999999999 1063.86 1704.29 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49240937_1 CDM 0510 RC inpatient 1757 1142.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1704.29 97 999999999 1063.86 1704.29 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49240937_1 CDM 0510 RC inpatient 1757 1142.05 AETNA AETNA 1388.03 79 999999999 1063.86 1704.29 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49240937_1 CDM 0510 RC inpatient 1757 1142.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1370.46 78 999999999 1063.86 1704.29 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49240937_1 CDM 0510 RC inpatient 1757 1142.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1212.33 69 999999999 1063.86 1704.29 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49240937_1 CDM 0510 RC inpatient 1757 1142.05 UMR - ALL PLANS UMR - ALL PLANS 1229.9 70 999999999 1063.86 1704.29 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49240937_1 CDM 0510 RC inpatient 1757 1142.05 SIHO - ALL PLANS SIHO - ALL PLANS 1581.3 90 999999999 1063.86 1704.29 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49240937_1 CDM 0510 RC inpatient 1757 1142.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1063.86 60.55 999999999 1063.86 1704.29 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49240937_1 CDM 0510 RC inpatient 1757 1142.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1063.86 1704.29 REV - IHS-MOA CLINIC VISIT 49240937_1 CDM 0510 RC inpatient 1757 1142.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1063.86 1704.29 REV - IHS-MOA CLINIC VISIT 49240937_1 CDM 0510 RC inpatient 1757 1142.05 ANTHEM HMO ANTHEM HMO 999999999 1063.86 1704.29 REV - IHS-MOA CLINIC VISIT 49240937_1 CDM 0510 RC inpatient 1757 1142.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1063.86 1704.29 REV - IHS-MOA CLINIC VISIT 49240937_1 CDM 0510 RC inpatient 1757 1142.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1063.86 1704.29 REV - IHS-MOA CLINIC VISIT 49240937_1 CDM 0510 RC inpatient 1757 1142.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1187.73 67.6 999999999 1063.86 1704.29 percent of total billed charges 50742-0153-30-half - Modafinil half tab [JOHN] 49253167_1 CDM 0250 RC 50742-0153-30 NDC inpatient 1 UN 24.6 15.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 15.99 65 999999999 14.9 23.86 percent of total billed charges 50742-0153-30-half - Modafinil half tab [JOHN] 49253167_1 CDM 0250 RC 50742-0153-30 NDC inpatient 1 UN 24.6 15.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23.86 97 999999999 14.9 23.86 percent of total billed charges 50742-0153-30-half - Modafinil half tab [JOHN] 49253167_1 CDM 0250 RC 50742-0153-30 NDC inpatient 1 UN 24.6 15.99 AETNA AETNA 19.43 79 999999999 14.9 23.86 percent of total billed charges 50742-0153-30-half - Modafinil half tab [JOHN] 49253167_1 CDM 0250 RC 50742-0153-30 NDC inpatient 1 UN 24.6 15.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.19 78 999999999 14.9 23.86 percent of total billed charges 50742-0153-30-half - Modafinil half tab [JOHN] 49253167_1 CDM 0250 RC 50742-0153-30 NDC inpatient 1 UN 24.6 15.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 16.97 69 999999999 14.9 23.86 percent of total billed charges 50742-0153-30-half - Modafinil half tab [JOHN] 49253167_1 CDM 0250 RC 50742-0153-30 NDC inpatient 1 UN 24.6 15.99 UMR - ALL PLANS UMR - ALL PLANS 17.22 70 999999999 14.9 23.86 percent of total billed charges 50742-0153-30-half - Modafinil half tab [JOHN] 49253167_1 CDM 0250 RC 50742-0153-30 NDC inpatient 1 UN 24.6 15.99 SIHO - ALL PLANS SIHO - ALL PLANS 22.14 90 999999999 14.9 23.86 percent of total billed charges 50742-0153-30-half - Modafinil half tab [JOHN] 49253167_1 CDM 0250 RC 50742-0153-30 NDC inpatient 1 UN 24.6 15.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.9 60.55 999999999 14.9 23.86 percent of total billed charges 50742-0153-30-half - Modafinil half tab [JOHN] 49253167_1 CDM 0250 RC 50742-0153-30 NDC inpatient 1 UN 24.6 15.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.9 23.86 50742-0153-30-half - Modafinil half tab [JOHN] 49253167_1 CDM 0250 RC 50742-0153-30 NDC inpatient 1 UN 24.6 15.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.9 23.86 50742-0153-30-half - Modafinil half tab [JOHN] 49253167_1 CDM 0250 RC 50742-0153-30 NDC inpatient 1 UN 24.6 15.99 ANTHEM HMO ANTHEM HMO 999999999 14.9 23.86 50742-0153-30-half - Modafinil half tab [JOHN] 49253167_1 CDM 0250 RC 50742-0153-30 NDC inpatient 1 UN 24.6 15.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.9 23.86 50742-0153-30-half - Modafinil half tab [JOHN] 49253167_1 CDM 0250 RC 50742-0153-30 NDC inpatient 1 UN 24.6 15.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.9 23.86 50742-0153-30-half - Modafinil half tab [JOHN] 49253167_1 CDM 0250 RC 50742-0153-30 NDC inpatient 1 UN 24.6 15.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.63 67.6 999999999 14.9 23.86 percent of total billed charges FUROSEMIDE 20 MG TABLET 49253188_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 20 MG TABLET 49253188_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 20 MG TABLET 49253188_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 20 MG TABLET 49253188_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 20 MG TABLET 49253188_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 20 MG TABLET 49253188_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 20 MG TABLET 49253188_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 20 MG TABLET 49253188_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges FUROSEMIDE 20 MG TABLET 49253188_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 FUROSEMIDE 20 MG TABLET 49253188_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 FUROSEMIDE 20 MG TABLET 49253188_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 FUROSEMIDE 20 MG TABLET 49253188_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 FUROSEMIDE 20 MG TABLET 49253188_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 FUROSEMIDE 20 MG TABLET 49253188_1 CDM 0250 RC 51079-0072-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges Complete ultrasound scan of joint 49253309_1 CDM 0402 RC 76881 HCPCS inpatient 798 518.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 518.7 65 999999999 483.19 774.06 percent of total billed charges Complete ultrasound scan of joint 49253309_1 CDM 0402 RC 76881 HCPCS inpatient 798 518.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 774.06 97 999999999 483.19 774.06 percent of total billed charges Complete ultrasound scan of joint 49253309_1 CDM 0402 RC 76881 HCPCS inpatient 798 518.7 AETNA AETNA 630.42 79 999999999 483.19 774.06 percent of total billed charges Complete ultrasound scan of joint 49253309_1 CDM 0402 RC 76881 HCPCS inpatient 798 518.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 622.44 78 999999999 483.19 774.06 percent of total billed charges Complete ultrasound scan of joint 49253309_1 CDM 0402 RC 76881 HCPCS inpatient 798 518.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 550.62 69 999999999 483.19 774.06 percent of total billed charges Complete ultrasound scan of joint 49253309_1 CDM 0402 RC 76881 HCPCS inpatient 798 518.7 UMR - ALL PLANS UMR - ALL PLANS 558.6 70 999999999 483.19 774.06 percent of total billed charges Complete ultrasound scan of joint 49253309_1 CDM 0402 RC 76881 HCPCS inpatient 798 518.7 SIHO - ALL PLANS SIHO - ALL PLANS 718.2 90 999999999 483.19 774.06 percent of total billed charges Complete ultrasound scan of joint 49253309_1 CDM 0402 RC 76881 HCPCS inpatient 798 518.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 483.19 60.55 999999999 483.19 774.06 percent of total billed charges Complete ultrasound scan of joint 49253309_1 CDM 0402 RC 76881 HCPCS inpatient 798 518.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 483.19 774.06 Complete ultrasound scan of joint 49253309_1 CDM 0402 RC 76881 HCPCS inpatient 798 518.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 483.19 774.06 Complete ultrasound scan of joint 49253309_1 CDM 0402 RC 76881 HCPCS inpatient 798 518.7 ANTHEM HMO ANTHEM HMO 999999999 483.19 774.06 Complete ultrasound scan of joint 49253309_1 CDM 0402 RC 76881 HCPCS inpatient 798 518.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 483.19 774.06 Complete ultrasound scan of joint 49253309_1 CDM 0402 RC 76881 HCPCS inpatient 798 518.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 539.45 67.6 999999999 483.19 774.06 percent of total billed charges Complete ultrasound scan of joint 49253309_1 CDM 0402 RC 76881 HCPCS inpatient 798 518.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 483.19 774.06 Blood glucose (sugar) level 49253349_1 CDM 0301 RC 82947 HCPCS inpatient 104 67.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 67.6 65 999999999 62.97 100.88 percent of total billed charges Blood glucose (sugar) level 49253349_1 CDM 0301 RC 82947 HCPCS inpatient 104 67.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 100.88 97 999999999 62.97 100.88 percent of total billed charges Blood glucose (sugar) level 49253349_1 CDM 0301 RC 82947 HCPCS inpatient 104 67.6 AETNA AETNA 82.16 79 999999999 62.97 100.88 percent of total billed charges Blood glucose (sugar) level 49253349_1 CDM 0301 RC 82947 HCPCS inpatient 104 67.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.12 78 999999999 62.97 100.88 percent of total billed charges Blood glucose (sugar) level 49253349_1 CDM 0301 RC 82947 HCPCS inpatient 104 67.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.76 69 999999999 62.97 100.88 percent of total billed charges Blood glucose (sugar) level 49253349_1 CDM 0301 RC 82947 HCPCS inpatient 104 67.6 UMR - ALL PLANS UMR - ALL PLANS 72.8 70 999999999 62.97 100.88 percent of total billed charges Blood glucose (sugar) level 49253349_1 CDM 0301 RC 82947 HCPCS inpatient 104 67.6 SIHO - ALL PLANS SIHO - ALL PLANS 93.6 90 999999999 62.97 100.88 percent of total billed charges Blood glucose (sugar) level 49253349_1 CDM 0301 RC 82947 HCPCS inpatient 104 67.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.97 60.55 999999999 62.97 100.88 percent of total billed charges Blood glucose (sugar) level 49253349_1 CDM 0301 RC 82947 HCPCS inpatient 104 67.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.97 100.88 Blood glucose (sugar) level 49253349_1 CDM 0301 RC 82947 HCPCS inpatient 104 67.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.97 100.88 Blood glucose (sugar) level 49253349_1 CDM 0301 RC 82947 HCPCS inpatient 104 67.6 ANTHEM HMO ANTHEM HMO 999999999 62.97 100.88 Blood glucose (sugar) level 49253349_1 CDM 0301 RC 82947 HCPCS inpatient 104 67.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.97 100.88 Blood glucose (sugar) level 49253349_1 CDM 0301 RC 82947 HCPCS inpatient 104 67.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.3 67.6 999999999 62.97 100.88 percent of total billed charges Blood glucose (sugar) level 49253349_1 CDM 0301 RC 82947 HCPCS inpatient 104 67.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.97 100.88 Creatinine level to test for kidney function or muscle injury 49253354_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49253354_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49253354_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49253354_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49253354_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49253354_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49253354_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49253354_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49253354_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 Creatinine level to test for kidney function or muscle injury 49253354_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 Creatinine level to test for kidney function or muscle injury 49253354_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 Creatinine level to test for kidney function or muscle injury 49253354_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 Creatinine level to test for kidney function or muscle injury 49253354_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49253354_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 Urine volume measurement 49253359_1 CDM 0301 RC 81050 HCPCS inpatient 60 39 SELF PAY DISCOUNT SELF PAY DISCOUNT 39 65 999999999 36.33 58.2 percent of total billed charges Urine volume measurement 49253359_1 CDM 0301 RC 81050 HCPCS inpatient 60 39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.2 97 999999999 36.33 58.2 percent of total billed charges Urine volume measurement 49253359_1 CDM 0301 RC 81050 HCPCS inpatient 60 39 AETNA AETNA 47.4 79 999999999 36.33 58.2 percent of total billed charges Urine volume measurement 49253359_1 CDM 0301 RC 81050 HCPCS inpatient 60 39 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.8 78 999999999 36.33 58.2 percent of total billed charges Urine volume measurement 49253359_1 CDM 0301 RC 81050 HCPCS inpatient 60 39 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.4 69 999999999 36.33 58.2 percent of total billed charges Urine volume measurement 49253359_1 CDM 0301 RC 81050 HCPCS inpatient 60 39 UMR - ALL PLANS UMR - ALL PLANS 42 70 999999999 36.33 58.2 percent of total billed charges Urine volume measurement 49253359_1 CDM 0301 RC 81050 HCPCS inpatient 60 39 SIHO - ALL PLANS SIHO - ALL PLANS 54 90 999999999 36.33 58.2 percent of total billed charges Urine volume measurement 49253359_1 CDM 0301 RC 81050 HCPCS inpatient 60 39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.33 60.55 999999999 36.33 58.2 percent of total billed charges Urine volume measurement 49253359_1 CDM 0301 RC 81050 HCPCS inpatient 60 39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.33 58.2 Urine volume measurement 49253359_1 CDM 0301 RC 81050 HCPCS inpatient 60 39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.33 58.2 Urine volume measurement 49253359_1 CDM 0301 RC 81050 HCPCS inpatient 60 39 ANTHEM HMO ANTHEM HMO 999999999 36.33 58.2 Urine volume measurement 49253359_1 CDM 0301 RC 81050 HCPCS inpatient 60 39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.33 58.2 Urine volume measurement 49253359_1 CDM 0301 RC 81050 HCPCS inpatient 60 39 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.56 67.6 999999999 36.33 58.2 percent of total billed charges Urine volume measurement 49253359_1 CDM 0301 RC 81050 HCPCS inpatient 60 39 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.33 58.2 Urine calcium level 49253423_1 CDM 0301 RC 82340 HCPCS inpatient 163 105.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 105.95 65 999999999 98.7 158.11 percent of total billed charges Urine calcium level 49253423_1 CDM 0301 RC 82340 HCPCS inpatient 163 105.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 158.11 97 999999999 98.7 158.11 percent of total billed charges Urine calcium level 49253423_1 CDM 0301 RC 82340 HCPCS inpatient 163 105.95 AETNA AETNA 128.77 79 999999999 98.7 158.11 percent of total billed charges Urine calcium level 49253423_1 CDM 0301 RC 82340 HCPCS inpatient 163 105.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.14 78 999999999 98.7 158.11 percent of total billed charges Urine calcium level 49253423_1 CDM 0301 RC 82340 HCPCS inpatient 163 105.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 112.47 69 999999999 98.7 158.11 percent of total billed charges Urine calcium level 49253423_1 CDM 0301 RC 82340 HCPCS inpatient 163 105.95 UMR - ALL PLANS UMR - ALL PLANS 114.1 70 999999999 98.7 158.11 percent of total billed charges Urine calcium level 49253423_1 CDM 0301 RC 82340 HCPCS inpatient 163 105.95 SIHO - ALL PLANS SIHO - ALL PLANS 146.7 90 999999999 98.7 158.11 percent of total billed charges Urine calcium level 49253423_1 CDM 0301 RC 82340 HCPCS inpatient 163 105.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 98.7 60.55 999999999 98.7 158.11 percent of total billed charges Urine calcium level 49253423_1 CDM 0301 RC 82340 HCPCS inpatient 163 105.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 98.7 158.11 Urine calcium level 49253423_1 CDM 0301 RC 82340 HCPCS inpatient 163 105.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 98.7 158.11 Urine calcium level 49253423_1 CDM 0301 RC 82340 HCPCS inpatient 163 105.95 ANTHEM HMO ANTHEM HMO 999999999 98.7 158.11 Urine calcium level 49253423_1 CDM 0301 RC 82340 HCPCS inpatient 163 105.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 98.7 158.11 Urine calcium level 49253423_1 CDM 0301 RC 82340 HCPCS inpatient 163 105.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.19 67.6 999999999 98.7 158.11 percent of total billed charges Urine calcium level 49253423_1 CDM 0301 RC 82340 HCPCS inpatient 163 105.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 98.7 158.11 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49253430_1 CDM 0250 RC 71019-0243-03 NDC J2590 HCPCS inpatient 3 UN 95.93 62.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.35 65 999999999 58.09 93.05 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49253430_1 CDM 0250 RC 71019-0243-03 NDC J2590 HCPCS inpatient 3 UN 95.93 62.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.05 97 999999999 58.09 93.05 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49253430_1 CDM 0250 RC 71019-0243-03 NDC J2590 HCPCS inpatient 3 UN 95.93 62.35 AETNA AETNA 75.78 79 999999999 58.09 93.05 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49253430_1 CDM 0250 RC 71019-0243-03 NDC J2590 HCPCS inpatient 3 UN 95.93 62.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.83 78 999999999 58.09 93.05 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49253430_1 CDM 0250 RC 71019-0243-03 NDC J2590 HCPCS inpatient 3 UN 95.93 62.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.19 69 999999999 58.09 93.05 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49253430_1 CDM 0250 RC 71019-0243-03 NDC J2590 HCPCS inpatient 3 UN 95.93 62.35 UMR - ALL PLANS UMR - ALL PLANS 67.15 70 999999999 58.09 93.05 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49253430_1 CDM 0250 RC 71019-0243-03 NDC J2590 HCPCS inpatient 3 UN 95.93 62.35 SIHO - ALL PLANS SIHO - ALL PLANS 86.34 90 999999999 58.09 93.05 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49253430_1 CDM 0250 RC 71019-0243-03 NDC J2590 HCPCS inpatient 3 UN 95.93 62.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.09 60.55 999999999 58.09 93.05 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49253430_1 CDM 0250 RC 71019-0243-03 NDC J2590 HCPCS inpatient 3 UN 95.93 62.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.09 93.05 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49253430_1 CDM 0250 RC 71019-0243-03 NDC J2590 HCPCS inpatient 3 UN 95.93 62.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.09 93.05 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49253430_1 CDM 0250 RC 71019-0243-03 NDC J2590 HCPCS inpatient 3 UN 95.93 62.35 ANTHEM HMO ANTHEM HMO 999999999 58.09 93.05 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49253430_1 CDM 0250 RC 71019-0243-03 NDC J2590 HCPCS inpatient 3 UN 95.93 62.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.09 93.05 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49253430_1 CDM 0250 RC 71019-0243-03 NDC J2590 HCPCS inpatient 3 UN 95.93 62.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.85 67.6 999999999 58.09 93.05 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49253430_1 CDM 0250 RC 71019-0243-03 NDC J2590 HCPCS inpatient 3 UN 95.93 62.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.09 93.05 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253458_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253458_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253458_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253458_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253458_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253458_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253458_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253458_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253458_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253458_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253458_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253458_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253458_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253458_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253460_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253460_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253460_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253460_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253460_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253460_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253460_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253460_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253460_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253460_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253460_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253460_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253460_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253460_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253515_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253515_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253515_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253515_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253515_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253515_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253515_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253515_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253515_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253515_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253515_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253515_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253515_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253515_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253516_1 CDM 0300 RC 86008 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253516_1 CDM 0300 RC 86008 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253516_1 CDM 0300 RC 86008 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253516_1 CDM 0300 RC 86008 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253516_1 CDM 0300 RC 86008 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253516_1 CDM 0300 RC 86008 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253516_1 CDM 0300 RC 86008 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253516_1 CDM 0300 RC 86008 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253516_1 CDM 0300 RC 86008 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253516_1 CDM 0300 RC 86008 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253516_1 CDM 0300 RC 86008 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253516_1 CDM 0300 RC 86008 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253516_1 CDM 0300 RC 86008 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253516_1 CDM 0300 RC 86008 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253517_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253517_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253517_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253517_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253517_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253517_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253517_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253517_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253517_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253517_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253517_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253517_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253517_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253517_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253520_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253520_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253520_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253520_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253520_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253520_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253520_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253520_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253520_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253520_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253520_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253520_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253520_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253520_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253521_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253521_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253521_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253521_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253521_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253521_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253521_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253521_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253521_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253521_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253521_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253521_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253521_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 49253521_1 CDM 0301 RC 86008 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253522_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253522_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253522_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253522_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253522_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253522_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253522_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253522_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253522_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253522_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253522_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253522_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253522_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49253522_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Chromium level to test for poisoning or deficiency 49253540_1 CDM 0301 RC 82495 HCPCS inpatient 198 128.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.7 65 999999999 119.89 192.06 percent of total billed charges Chromium level to test for poisoning or deficiency 49253540_1 CDM 0301 RC 82495 HCPCS inpatient 198 128.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 192.06 97 999999999 119.89 192.06 percent of total billed charges Chromium level to test for poisoning or deficiency 49253540_1 CDM 0301 RC 82495 HCPCS inpatient 198 128.7 AETNA AETNA 156.42 79 999999999 119.89 192.06 percent of total billed charges Chromium level to test for poisoning or deficiency 49253540_1 CDM 0301 RC 82495 HCPCS inpatient 198 128.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 154.44 78 999999999 119.89 192.06 percent of total billed charges Chromium level to test for poisoning or deficiency 49253540_1 CDM 0301 RC 82495 HCPCS inpatient 198 128.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 136.62 69 999999999 119.89 192.06 percent of total billed charges Chromium level to test for poisoning or deficiency 49253540_1 CDM 0301 RC 82495 HCPCS inpatient 198 128.7 UMR - ALL PLANS UMR - ALL PLANS 138.6 70 999999999 119.89 192.06 percent of total billed charges Chromium level to test for poisoning or deficiency 49253540_1 CDM 0301 RC 82495 HCPCS inpatient 198 128.7 SIHO - ALL PLANS SIHO - ALL PLANS 178.2 90 999999999 119.89 192.06 percent of total billed charges Chromium level to test for poisoning or deficiency 49253540_1 CDM 0301 RC 82495 HCPCS inpatient 198 128.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.89 60.55 999999999 119.89 192.06 percent of total billed charges Chromium level to test for poisoning or deficiency 49253540_1 CDM 0301 RC 82495 HCPCS inpatient 198 128.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.89 192.06 Chromium level to test for poisoning or deficiency 49253540_1 CDM 0301 RC 82495 HCPCS inpatient 198 128.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.89 192.06 Chromium level to test for poisoning or deficiency 49253540_1 CDM 0301 RC 82495 HCPCS inpatient 198 128.7 ANTHEM HMO ANTHEM HMO 999999999 119.89 192.06 Chromium level to test for poisoning or deficiency 49253540_1 CDM 0301 RC 82495 HCPCS inpatient 198 128.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.89 192.06 Chromium level to test for poisoning or deficiency 49253540_1 CDM 0301 RC 82495 HCPCS inpatient 198 128.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.85 67.6 999999999 119.89 192.06 percent of total billed charges Chromium level to test for poisoning or deficiency 49253540_1 CDM 0301 RC 82495 HCPCS inpatient 198 128.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.89 192.06 Analysis for detection of tumor marker 49253541_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 124.8 65 999999999 116.26 186.24 percent of total billed charges Analysis for detection of tumor marker 49253541_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 186.24 97 999999999 116.26 186.24 percent of total billed charges Analysis for detection of tumor marker 49253541_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 AETNA AETNA 151.68 79 999999999 116.26 186.24 percent of total billed charges Analysis for detection of tumor marker 49253541_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 149.76 78 999999999 116.26 186.24 percent of total billed charges Analysis for detection of tumor marker 49253541_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 132.48 69 999999999 116.26 186.24 percent of total billed charges Analysis for detection of tumor marker 49253541_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 UMR - ALL PLANS UMR - ALL PLANS 134.4 70 999999999 116.26 186.24 percent of total billed charges Analysis for detection of tumor marker 49253541_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 SIHO - ALL PLANS SIHO - ALL PLANS 172.8 90 999999999 116.26 186.24 percent of total billed charges Analysis for detection of tumor marker 49253541_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.26 60.55 999999999 116.26 186.24 percent of total billed charges Analysis for detection of tumor marker 49253541_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.26 186.24 Analysis for detection of tumor marker 49253541_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.26 186.24 Analysis for detection of tumor marker 49253541_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 ANTHEM HMO ANTHEM HMO 999999999 116.26 186.24 Analysis for detection of tumor marker 49253541_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.26 186.24 Analysis for detection of tumor marker 49253541_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 129.79 67.6 999999999 116.26 186.24 percent of total billed charges Analysis for detection of tumor marker 49253541_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.26 186.24 Heroin metabolite level 49253581_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.2 65 999999999 113.83 182.36 percent of total billed charges Heroin metabolite level 49253581_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 182.36 97 999999999 113.83 182.36 percent of total billed charges Heroin metabolite level 49253581_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 AETNA AETNA 148.52 79 999999999 113.83 182.36 percent of total billed charges Heroin metabolite level 49253581_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 146.64 78 999999999 113.83 182.36 percent of total billed charges Heroin metabolite level 49253581_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.72 69 999999999 113.83 182.36 percent of total billed charges Heroin metabolite level 49253581_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 UMR - ALL PLANS UMR - ALL PLANS 131.6 70 999999999 113.83 182.36 percent of total billed charges Heroin metabolite level 49253581_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 SIHO - ALL PLANS SIHO - ALL PLANS 169.2 90 999999999 113.83 182.36 percent of total billed charges Heroin metabolite level 49253581_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.83 60.55 999999999 113.83 182.36 percent of total billed charges Heroin metabolite level 49253581_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.83 182.36 Heroin metabolite level 49253581_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.83 182.36 Heroin metabolite level 49253581_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 ANTHEM HMO ANTHEM HMO 999999999 113.83 182.36 Heroin metabolite level 49253581_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.83 182.36 Heroin metabolite level 49253581_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.09 67.6 999999999 113.83 182.36 percent of total billed charges Heroin metabolite level 49253581_1 CDM 0301 RC 80356 HCPCS inpatient 188 122.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.83 182.36 Opiates levels 49253582_1 CDM 0301 RC 80361 HCPCS inpatient 188 122.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.2 65 999999999 113.83 182.36 percent of total billed charges Opiates levels 49253582_1 CDM 0301 RC 80361 HCPCS inpatient 188 122.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 182.36 97 999999999 113.83 182.36 percent of total billed charges Opiates levels 49253582_1 CDM 0301 RC 80361 HCPCS inpatient 188 122.2 AETNA AETNA 148.52 79 999999999 113.83 182.36 percent of total billed charges Opiates levels 49253582_1 CDM 0301 RC 80361 HCPCS inpatient 188 122.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 146.64 78 999999999 113.83 182.36 percent of total billed charges Opiates levels 49253582_1 CDM 0301 RC 80361 HCPCS inpatient 188 122.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.72 69 999999999 113.83 182.36 percent of total billed charges Opiates levels 49253582_1 CDM 0301 RC 80361 HCPCS inpatient 188 122.2 UMR - ALL PLANS UMR - ALL PLANS 131.6 70 999999999 113.83 182.36 percent of total billed charges Opiates levels 49253582_1 CDM 0301 RC 80361 HCPCS inpatient 188 122.2 SIHO - ALL PLANS SIHO - ALL PLANS 169.2 90 999999999 113.83 182.36 percent of total billed charges Opiates levels 49253582_1 CDM 0301 RC 80361 HCPCS inpatient 188 122.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.83 60.55 999999999 113.83 182.36 percent of total billed charges Opiates levels 49253582_1 CDM 0301 RC 80361 HCPCS inpatient 188 122.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.83 182.36 Opiates levels 49253582_1 CDM 0301 RC 80361 HCPCS inpatient 188 122.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.83 182.36 Opiates levels 49253582_1 CDM 0301 RC 80361 HCPCS inpatient 188 122.2 ANTHEM HMO ANTHEM HMO 999999999 113.83 182.36 Opiates levels 49253582_1 CDM 0301 RC 80361 HCPCS inpatient 188 122.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.83 182.36 Opiates levels 49253582_1 CDM 0301 RC 80361 HCPCS inpatient 188 122.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.09 67.6 999999999 113.83 182.36 percent of total billed charges Opiates levels 49253582_1 CDM 0301 RC 80361 HCPCS inpatient 188 122.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.83 182.36 Oxycodone levels 49253583_1 CDM 0301 RC 80365 HCPCS inpatient 118 76.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 76.7 65 999999999 71.45 114.46 percent of total billed charges Oxycodone levels 49253583_1 CDM 0301 RC 80365 HCPCS inpatient 118 76.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 114.46 97 999999999 71.45 114.46 percent of total billed charges Oxycodone levels 49253583_1 CDM 0301 RC 80365 HCPCS inpatient 118 76.7 AETNA AETNA 93.22 79 999999999 71.45 114.46 percent of total billed charges Oxycodone levels 49253583_1 CDM 0301 RC 80365 HCPCS inpatient 118 76.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.04 78 999999999 71.45 114.46 percent of total billed charges Oxycodone levels 49253583_1 CDM 0301 RC 80365 HCPCS inpatient 118 76.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 81.42 69 999999999 71.45 114.46 percent of total billed charges Oxycodone levels 49253583_1 CDM 0301 RC 80365 HCPCS inpatient 118 76.7 UMR - ALL PLANS UMR - ALL PLANS 82.6 70 999999999 71.45 114.46 percent of total billed charges Oxycodone levels 49253583_1 CDM 0301 RC 80365 HCPCS inpatient 118 76.7 SIHO - ALL PLANS SIHO - ALL PLANS 106.2 90 999999999 71.45 114.46 percent of total billed charges Oxycodone levels 49253583_1 CDM 0301 RC 80365 HCPCS inpatient 118 76.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 71.45 60.55 999999999 71.45 114.46 percent of total billed charges Oxycodone levels 49253583_1 CDM 0301 RC 80365 HCPCS inpatient 118 76.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 71.45 114.46 Oxycodone levels 49253583_1 CDM 0301 RC 80365 HCPCS inpatient 118 76.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 71.45 114.46 Oxycodone levels 49253583_1 CDM 0301 RC 80365 HCPCS inpatient 118 76.7 ANTHEM HMO ANTHEM HMO 999999999 71.45 114.46 Oxycodone levels 49253583_1 CDM 0301 RC 80365 HCPCS inpatient 118 76.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 71.45 114.46 Oxycodone levels 49253583_1 CDM 0301 RC 80365 HCPCS inpatient 118 76.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 79.77 67.6 999999999 71.45 114.46 percent of total billed charges Oxycodone levels 49253583_1 CDM 0301 RC 80365 HCPCS inpatient 118 76.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 71.45 114.46 Heavy metal level 49253635_1 CDM 0301 RC 83018 HCPCS inpatient 85 55.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.25 65 999999999 51.47 82.45 percent of total billed charges Heavy metal level 49253635_1 CDM 0301 RC 83018 HCPCS inpatient 85 55.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 82.45 97 999999999 51.47 82.45 percent of total billed charges Heavy metal level 49253635_1 CDM 0301 RC 83018 HCPCS inpatient 85 55.25 AETNA AETNA 67.15 79 999999999 51.47 82.45 percent of total billed charges Heavy metal level 49253635_1 CDM 0301 RC 83018 HCPCS inpatient 85 55.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 66.3 78 999999999 51.47 82.45 percent of total billed charges Heavy metal level 49253635_1 CDM 0301 RC 83018 HCPCS inpatient 85 55.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 58.65 69 999999999 51.47 82.45 percent of total billed charges Heavy metal level 49253635_1 CDM 0301 RC 83018 HCPCS inpatient 85 55.25 UMR - ALL PLANS UMR - ALL PLANS 59.5 70 999999999 51.47 82.45 percent of total billed charges Heavy metal level 49253635_1 CDM 0301 RC 83018 HCPCS inpatient 85 55.25 SIHO - ALL PLANS SIHO - ALL PLANS 76.5 90 999999999 51.47 82.45 percent of total billed charges Heavy metal level 49253635_1 CDM 0301 RC 83018 HCPCS inpatient 85 55.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 51.47 60.55 999999999 51.47 82.45 percent of total billed charges Heavy metal level 49253635_1 CDM 0301 RC 83018 HCPCS inpatient 85 55.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 51.47 82.45 Heavy metal level 49253635_1 CDM 0301 RC 83018 HCPCS inpatient 85 55.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 51.47 82.45 Heavy metal level 49253635_1 CDM 0301 RC 83018 HCPCS inpatient 85 55.25 ANTHEM HMO ANTHEM HMO 999999999 51.47 82.45 Heavy metal level 49253635_1 CDM 0301 RC 83018 HCPCS inpatient 85 55.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 51.47 82.45 Heavy metal level 49253635_1 CDM 0301 RC 83018 HCPCS inpatient 85 55.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 57.46 67.6 999999999 51.47 82.45 percent of total billed charges Heavy metal level 49253635_1 CDM 0301 RC 83018 HCPCS inpatient 85 55.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 51.47 82.45 "Estrogen analysis, fractionated" 49253639_1 CDM 0301 RC 82671 HCPCS inpatient 426 276.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 276.9 65 999999999 257.94 413.22 percent of total billed charges "Estrogen analysis, fractionated" 49253639_1 CDM 0301 RC 82671 HCPCS inpatient 426 276.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 413.22 97 999999999 257.94 413.22 percent of total billed charges "Estrogen analysis, fractionated" 49253639_1 CDM 0301 RC 82671 HCPCS inpatient 426 276.9 AETNA AETNA 336.54 79 999999999 257.94 413.22 percent of total billed charges "Estrogen analysis, fractionated" 49253639_1 CDM 0301 RC 82671 HCPCS inpatient 426 276.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 332.28 78 999999999 257.94 413.22 percent of total billed charges "Estrogen analysis, fractionated" 49253639_1 CDM 0301 RC 82671 HCPCS inpatient 426 276.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 293.94 69 999999999 257.94 413.22 percent of total billed charges "Estrogen analysis, fractionated" 49253639_1 CDM 0301 RC 82671 HCPCS inpatient 426 276.9 UMR - ALL PLANS UMR - ALL PLANS 298.2 70 999999999 257.94 413.22 percent of total billed charges "Estrogen analysis, fractionated" 49253639_1 CDM 0301 RC 82671 HCPCS inpatient 426 276.9 SIHO - ALL PLANS SIHO - ALL PLANS 383.4 90 999999999 257.94 413.22 percent of total billed charges "Estrogen analysis, fractionated" 49253639_1 CDM 0301 RC 82671 HCPCS inpatient 426 276.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 257.94 60.55 999999999 257.94 413.22 percent of total billed charges "Estrogen analysis, fractionated" 49253639_1 CDM 0301 RC 82671 HCPCS inpatient 426 276.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 257.94 413.22 "Estrogen analysis, fractionated" 49253639_1 CDM 0301 RC 82671 HCPCS inpatient 426 276.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 257.94 413.22 "Estrogen analysis, fractionated" 49253639_1 CDM 0301 RC 82671 HCPCS inpatient 426 276.9 ANTHEM HMO ANTHEM HMO 999999999 257.94 413.22 "Estrogen analysis, fractionated" 49253639_1 CDM 0301 RC 82671 HCPCS inpatient 426 276.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 257.94 413.22 "Estrogen analysis, fractionated" 49253639_1 CDM 0301 RC 82671 HCPCS inpatient 426 276.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 287.98 67.6 999999999 257.94 413.22 percent of total billed charges "Estrogen analysis, fractionated" 49253639_1 CDM 0301 RC 82671 HCPCS inpatient 426 276.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 257.94 413.22 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49253672_1 CDM 0312 RC 81210 HCPCS inpatient 569 369.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 369.85 65 999999999 344.53 551.93 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49253672_1 CDM 0312 RC 81210 HCPCS inpatient 569 369.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 551.93 97 999999999 344.53 551.93 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49253672_1 CDM 0312 RC 81210 HCPCS inpatient 569 369.85 AETNA AETNA 449.51 79 999999999 344.53 551.93 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49253672_1 CDM 0312 RC 81210 HCPCS inpatient 569 369.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 443.82 78 999999999 344.53 551.93 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49253672_1 CDM 0312 RC 81210 HCPCS inpatient 569 369.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 392.61 69 999999999 344.53 551.93 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49253672_1 CDM 0312 RC 81210 HCPCS inpatient 569 369.85 UMR - ALL PLANS UMR - ALL PLANS 398.3 70 999999999 344.53 551.93 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49253672_1 CDM 0312 RC 81210 HCPCS inpatient 569 369.85 SIHO - ALL PLANS SIHO - ALL PLANS 512.1 90 999999999 344.53 551.93 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49253672_1 CDM 0312 RC 81210 HCPCS inpatient 569 369.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 344.53 60.55 999999999 344.53 551.93 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49253672_1 CDM 0312 RC 81210 HCPCS inpatient 569 369.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 344.53 551.93 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49253672_1 CDM 0312 RC 81210 HCPCS inpatient 569 369.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 344.53 551.93 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49253672_1 CDM 0312 RC 81210 HCPCS inpatient 569 369.85 ANTHEM HMO ANTHEM HMO 999999999 344.53 551.93 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49253672_1 CDM 0312 RC 81210 HCPCS inpatient 569 369.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 344.53 551.93 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49253672_1 CDM 0312 RC 81210 HCPCS inpatient 569 369.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 384.64 67.6 999999999 344.53 551.93 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49253672_1 CDM 0312 RC 81210 HCPCS inpatient 569 369.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 344.53 551.93 Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49253673_1 CDM 0312 RC 81275 HCPCS inpatient 569 369.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 369.85 65 999999999 344.53 551.93 percent of total billed charges Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49253673_1 CDM 0312 RC 81275 HCPCS inpatient 569 369.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 551.93 97 999999999 344.53 551.93 percent of total billed charges Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49253673_1 CDM 0312 RC 81275 HCPCS inpatient 569 369.85 AETNA AETNA 449.51 79 999999999 344.53 551.93 percent of total billed charges Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49253673_1 CDM 0312 RC 81275 HCPCS inpatient 569 369.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 443.82 78 999999999 344.53 551.93 percent of total billed charges Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49253673_1 CDM 0312 RC 81275 HCPCS inpatient 569 369.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 392.61 69 999999999 344.53 551.93 percent of total billed charges Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49253673_1 CDM 0312 RC 81275 HCPCS inpatient 569 369.85 UMR - ALL PLANS UMR - ALL PLANS 398.3 70 999999999 344.53 551.93 percent of total billed charges Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49253673_1 CDM 0312 RC 81275 HCPCS inpatient 569 369.85 SIHO - ALL PLANS SIHO - ALL PLANS 512.1 90 999999999 344.53 551.93 percent of total billed charges Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49253673_1 CDM 0312 RC 81275 HCPCS inpatient 569 369.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 344.53 60.55 999999999 344.53 551.93 percent of total billed charges Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49253673_1 CDM 0312 RC 81275 HCPCS inpatient 569 369.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 344.53 551.93 Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49253673_1 CDM 0312 RC 81275 HCPCS inpatient 569 369.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 344.53 551.93 Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49253673_1 CDM 0312 RC 81275 HCPCS inpatient 569 369.85 ANTHEM HMO ANTHEM HMO 999999999 344.53 551.93 Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49253673_1 CDM 0312 RC 81275 HCPCS inpatient 569 369.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 344.53 551.93 Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49253673_1 CDM 0312 RC 81275 HCPCS inpatient 569 369.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 384.64 67.6 999999999 344.53 551.93 percent of total billed charges Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49253673_1 CDM 0312 RC 81275 HCPCS inpatient 569 369.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 344.53 551.93 "Alpha-1-antitrypsin (protein) blood test, total" 49253688_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 87.1 65 999999999 81.14 129.98 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 49253688_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.98 97 999999999 81.14 129.98 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 49253688_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 AETNA AETNA 105.86 79 999999999 81.14 129.98 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 49253688_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 104.52 78 999999999 81.14 129.98 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 49253688_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 92.46 69 999999999 81.14 129.98 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 49253688_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 UMR - ALL PLANS UMR - ALL PLANS 93.8 70 999999999 81.14 129.98 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 49253688_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 SIHO - ALL PLANS SIHO - ALL PLANS 120.6 90 999999999 81.14 129.98 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 49253688_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 81.14 60.55 999999999 81.14 129.98 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 49253688_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 81.14 129.98 "Alpha-1-antitrypsin (protein) blood test, total" 49253688_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 81.14 129.98 "Alpha-1-antitrypsin (protein) blood test, total" 49253688_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 ANTHEM HMO ANTHEM HMO 999999999 81.14 129.98 "Alpha-1-antitrypsin (protein) blood test, total" 49253688_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 81.14 129.98 "Alpha-1-antitrypsin (protein) blood test, total" 49253688_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 90.58 67.6 999999999 81.14 129.98 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 49253688_1 CDM 0301 RC 82103 HCPCS inpatient 134 87.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 81.14 129.98 "Alpha-1-antitrypsin (protein) blood test, phenotype" 49253689_1 CDM 0301 RC 82104 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, phenotype" 49253689_1 CDM 0301 RC 82104 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, phenotype" 49253689_1 CDM 0301 RC 82104 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, phenotype" 49253689_1 CDM 0301 RC 82104 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, phenotype" 49253689_1 CDM 0301 RC 82104 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, phenotype" 49253689_1 CDM 0301 RC 82104 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, phenotype" 49253689_1 CDM 0301 RC 82104 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, phenotype" 49253689_1 CDM 0301 RC 82104 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, phenotype" 49253689_1 CDM 0301 RC 82104 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 "Alpha-1-antitrypsin (protein) blood test, phenotype" 49253689_1 CDM 0301 RC 82104 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 "Alpha-1-antitrypsin (protein) blood test, phenotype" 49253689_1 CDM 0301 RC 82104 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 "Alpha-1-antitrypsin (protein) blood test, phenotype" 49253689_1 CDM 0301 RC 82104 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 "Alpha-1-antitrypsin (protein) blood test, phenotype" 49253689_1 CDM 0301 RC 82104 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, phenotype" 49253689_1 CDM 0301 RC 82104 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 "Analysis of substance using immunoassay technique, multiple step method" 49253877_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 113.75 65 999999999 105.96 169.75 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49253877_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 169.75 97 999999999 105.96 169.75 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49253877_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 AETNA AETNA 138.25 79 999999999 105.96 169.75 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49253877_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 136.5 78 999999999 105.96 169.75 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49253877_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 120.75 69 999999999 105.96 169.75 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49253877_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 UMR - ALL PLANS UMR - ALL PLANS 122.5 70 999999999 105.96 169.75 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49253877_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 SIHO - ALL PLANS SIHO - ALL PLANS 157.5 90 999999999 105.96 169.75 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49253877_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 105.96 60.55 999999999 105.96 169.75 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49253877_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 105.96 169.75 "Analysis of substance using immunoassay technique, multiple step method" 49253877_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 105.96 169.75 "Analysis of substance using immunoassay technique, multiple step method" 49253877_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 ANTHEM HMO ANTHEM HMO 999999999 105.96 169.75 "Analysis of substance using immunoassay technique, multiple step method" 49253877_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 105.96 169.75 "Analysis of substance using immunoassay technique, multiple step method" 49253877_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.3 67.6 999999999 105.96 169.75 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49253877_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 105.96 169.75 "INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG" 49253928_1 CDM 0250 RC 69374-0902-05 NDC J2710 HCPCS inpatient 1 UN 117.34 76.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 76.27 65 999999999 71.05 113.82 percent of total billed charges "INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG" 49253928_1 CDM 0250 RC 69374-0902-05 NDC J2710 HCPCS inpatient 1 UN 117.34 76.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 113.82 97 999999999 71.05 113.82 percent of total billed charges "INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG" 49253928_1 CDM 0250 RC 69374-0902-05 NDC J2710 HCPCS inpatient 1 UN 117.34 76.27 AETNA AETNA 92.7 79 999999999 71.05 113.82 percent of total billed charges "INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG" 49253928_1 CDM 0250 RC 69374-0902-05 NDC J2710 HCPCS inpatient 1 UN 117.34 76.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 91.53 78 999999999 71.05 113.82 percent of total billed charges "INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG" 49253928_1 CDM 0250 RC 69374-0902-05 NDC J2710 HCPCS inpatient 1 UN 117.34 76.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.96 69 999999999 71.05 113.82 percent of total billed charges "INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG" 49253928_1 CDM 0250 RC 69374-0902-05 NDC J2710 HCPCS inpatient 1 UN 117.34 76.27 UMR - ALL PLANS UMR - ALL PLANS 82.14 70 999999999 71.05 113.82 percent of total billed charges "INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG" 49253928_1 CDM 0250 RC 69374-0902-05 NDC J2710 HCPCS inpatient 1 UN 117.34 76.27 SIHO - ALL PLANS SIHO - ALL PLANS 105.61 90 999999999 71.05 113.82 percent of total billed charges "INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG" 49253928_1 CDM 0250 RC 69374-0902-05 NDC J2710 HCPCS inpatient 1 UN 117.34 76.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 71.05 60.55 999999999 71.05 113.82 percent of total billed charges "INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG" 49253928_1 CDM 0250 RC 69374-0902-05 NDC J2710 HCPCS inpatient 1 UN 117.34 76.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 71.05 113.82 "INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG" 49253928_1 CDM 0250 RC 69374-0902-05 NDC J2710 HCPCS inpatient 1 UN 117.34 76.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 71.05 113.82 "INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG" 49253928_1 CDM 0250 RC 69374-0902-05 NDC J2710 HCPCS inpatient 1 UN 117.34 76.27 ANTHEM HMO ANTHEM HMO 999999999 71.05 113.82 "INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG" 49253928_1 CDM 0250 RC 69374-0902-05 NDC J2710 HCPCS inpatient 1 UN 117.34 76.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 71.05 113.82 "INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG" 49253928_1 CDM 0250 RC 69374-0902-05 NDC J2710 HCPCS inpatient 1 UN 117.34 76.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 79.32 67.6 999999999 71.05 113.82 percent of total billed charges "INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG" 49253928_1 CDM 0250 RC 69374-0902-05 NDC J2710 HCPCS inpatient 1 UN 117.34 76.27 UHC - ALL PLANS UHC - ALL PLANS 999999999 71.05 113.82 CALCIUM CHLORIDE 1 GM/10ML SYR 49254171_1 CDM 0250 RC 76329-3304-01 NDC inpatient 1 UN 58.07 37.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.75 65 999999999 35.16 56.33 percent of total billed charges CALCIUM CHLORIDE 1 GM/10ML SYR 49254171_1 CDM 0250 RC 76329-3304-01 NDC inpatient 1 UN 58.07 37.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.33 97 999999999 35.16 56.33 percent of total billed charges CALCIUM CHLORIDE 1 GM/10ML SYR 49254171_1 CDM 0250 RC 76329-3304-01 NDC inpatient 1 UN 58.07 37.75 AETNA AETNA 45.88 79 999999999 35.16 56.33 percent of total billed charges CALCIUM CHLORIDE 1 GM/10ML SYR 49254171_1 CDM 0250 RC 76329-3304-01 NDC inpatient 1 UN 58.07 37.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.29 78 999999999 35.16 56.33 percent of total billed charges CALCIUM CHLORIDE 1 GM/10ML SYR 49254171_1 CDM 0250 RC 76329-3304-01 NDC inpatient 1 UN 58.07 37.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.07 69 999999999 35.16 56.33 percent of total billed charges CALCIUM CHLORIDE 1 GM/10ML SYR 49254171_1 CDM 0250 RC 76329-3304-01 NDC inpatient 1 UN 58.07 37.75 UMR - ALL PLANS UMR - ALL PLANS 40.65 70 999999999 35.16 56.33 percent of total billed charges CALCIUM CHLORIDE 1 GM/10ML SYR 49254171_1 CDM 0250 RC 76329-3304-01 NDC inpatient 1 UN 58.07 37.75 SIHO - ALL PLANS SIHO - ALL PLANS 52.26 90 999999999 35.16 56.33 percent of total billed charges CALCIUM CHLORIDE 1 GM/10ML SYR 49254171_1 CDM 0250 RC 76329-3304-01 NDC inpatient 1 UN 58.07 37.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.16 60.55 999999999 35.16 56.33 percent of total billed charges CALCIUM CHLORIDE 1 GM/10ML SYR 49254171_1 CDM 0250 RC 76329-3304-01 NDC inpatient 1 UN 58.07 37.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.16 56.33 CALCIUM CHLORIDE 1 GM/10ML SYR 49254171_1 CDM 0250 RC 76329-3304-01 NDC inpatient 1 UN 58.07 37.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.16 56.33 CALCIUM CHLORIDE 1 GM/10ML SYR 49254171_1 CDM 0250 RC 76329-3304-01 NDC inpatient 1 UN 58.07 37.75 ANTHEM HMO ANTHEM HMO 999999999 35.16 56.33 CALCIUM CHLORIDE 1 GM/10ML SYR 49254171_1 CDM 0250 RC 76329-3304-01 NDC inpatient 1 UN 58.07 37.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.16 56.33 CALCIUM CHLORIDE 1 GM/10ML SYR 49254171_1 CDM 0250 RC 76329-3304-01 NDC inpatient 1 UN 58.07 37.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.26 67.6 999999999 35.16 56.33 percent of total billed charges CALCIUM CHLORIDE 1 GM/10ML SYR 49254171_1 CDM 0250 RC 76329-3304-01 NDC inpatient 1 UN 58.07 37.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.16 56.33 Ultrasound study of arm or leg veins with compression and maneuvers 49254358_1 CDM 0921 RC 93970 HCPCS inpatient 2589 1682.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1682.85 65 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 49254358_1 CDM 0921 RC 93970 HCPCS inpatient 2589 1682.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2511.33 97 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 49254358_1 CDM 0921 RC 93970 HCPCS inpatient 2589 1682.85 AETNA AETNA 2045.31 79 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 49254358_1 CDM 0921 RC 93970 HCPCS inpatient 2589 1682.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 2019.42 78 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 49254358_1 CDM 0921 RC 93970 HCPCS inpatient 2589 1682.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1786.41 69 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 49254358_1 CDM 0921 RC 93970 HCPCS inpatient 2589 1682.85 UMR - ALL PLANS UMR - ALL PLANS 1812.3 70 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 49254358_1 CDM 0921 RC 93970 HCPCS inpatient 2589 1682.85 SIHO - ALL PLANS SIHO - ALL PLANS 2330.1 90 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 49254358_1 CDM 0921 RC 93970 HCPCS inpatient 2589 1682.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1567.64 60.55 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 49254358_1 CDM 0921 RC 93970 HCPCS inpatient 2589 1682.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 49254358_1 CDM 0921 RC 93970 HCPCS inpatient 2589 1682.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 49254358_1 CDM 0921 RC 93970 HCPCS inpatient 2589 1682.85 ANTHEM HMO ANTHEM HMO 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 49254358_1 CDM 0921 RC 93970 HCPCS inpatient 2589 1682.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 49254358_1 CDM 0921 RC 93970 HCPCS inpatient 2589 1682.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1750.16 67.6 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 49254358_1 CDM 0921 RC 93970 HCPCS inpatient 2589 1682.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1567.64 2511.33 Ultrasound study of one arm or leg veins with compression and maneuvers 49254360_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 SELF PAY DISCOUNT SELF PAY DISCOUNT 845 65 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49254360_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1261 97 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49254360_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 AETNA AETNA 1027 79 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49254360_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 HUMANA - ALL PLANS HUMANA - ALL PLANS 1014 78 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49254360_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 ENCORE - ALL PLANS ENCORE - ALL PLANS 897 69 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49254360_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 UMR - ALL PLANS UMR - ALL PLANS 910 70 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49254360_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 SIHO - ALL PLANS SIHO - ALL PLANS 1170 90 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49254360_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 787.15 60.55 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49254360_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 787.15 1261 Ultrasound study of one arm or leg veins with compression and maneuvers 49254360_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 787.15 1261 Ultrasound study of one arm or leg veins with compression and maneuvers 49254360_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 ANTHEM HMO ANTHEM HMO 999999999 787.15 1261 Ultrasound study of one arm or leg veins with compression and maneuvers 49254360_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 787.15 1261 Ultrasound study of one arm or leg veins with compression and maneuvers 49254360_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 CIGNA - ALL PLANS CIGNA - ALL PLANS 878.8 67.6 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49254360_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 UHC - ALL PLANS UHC - ALL PLANS 999999999 787.15 1261 Ultrasound study of one arm or leg veins with compression and maneuvers 49254362_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 SELF PAY DISCOUNT SELF PAY DISCOUNT 845 65 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49254362_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1261 97 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49254362_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 AETNA AETNA 1027 79 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49254362_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 HUMANA - ALL PLANS HUMANA - ALL PLANS 1014 78 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49254362_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 ENCORE - ALL PLANS ENCORE - ALL PLANS 897 69 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49254362_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 UMR - ALL PLANS UMR - ALL PLANS 910 70 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49254362_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 SIHO - ALL PLANS SIHO - ALL PLANS 1170 90 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49254362_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 787.15 60.55 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49254362_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 787.15 1261 Ultrasound study of one arm or leg veins with compression and maneuvers 49254362_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 787.15 1261 Ultrasound study of one arm or leg veins with compression and maneuvers 49254362_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 ANTHEM HMO ANTHEM HMO 999999999 787.15 1261 Ultrasound study of one arm or leg veins with compression and maneuvers 49254362_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 787.15 1261 Ultrasound study of one arm or leg veins with compression and maneuvers 49254362_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 CIGNA - ALL PLANS CIGNA - ALL PLANS 878.8 67.6 999999999 787.15 1261 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 49254362_1 CDM 0921 RC 93971 HCPCS inpatient 1300 845 UHC - ALL PLANS UHC - ALL PLANS 999999999 787.15 1261 CARBIDOPA-LEVODOPA 25-250 TAB 49254399_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVODOPA 25-250 TAB 49254399_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVODOPA 25-250 TAB 49254399_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVODOPA 25-250 TAB 49254399_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVODOPA 25-250 TAB 49254399_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVODOPA 25-250 TAB 49254399_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVODOPA 25-250 TAB 49254399_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVODOPA 25-250 TAB 49254399_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVODOPA 25-250 TAB 49254399_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CARBIDOPA-LEVODOPA 25-250 TAB 49254399_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CARBIDOPA-LEVODOPA 25-250 TAB 49254399_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CARBIDOPA-LEVODOPA 25-250 TAB 49254399_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CARBIDOPA-LEVODOPA 25-250 TAB 49254399_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVODOPA 25-250 TAB 49254399_1 CDM 0250 RC 68084-0094-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 00904-6554-61-half - traZODone 25 mg Tab 49254410_1 CDM 0250 RC 00904-6554-61 NDC inpatient 1 UN 1.69 1.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.1 65 999999999 1.02 1.64 percent of total billed charges 00904-6554-61-half - traZODone 25 mg Tab 49254410_1 CDM 0250 RC 00904-6554-61 NDC inpatient 1 UN 1.69 1.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.64 97 999999999 1.02 1.64 percent of total billed charges 00904-6554-61-half - traZODone 25 mg Tab 49254410_1 CDM 0250 RC 00904-6554-61 NDC inpatient 1 UN 1.69 1.1 AETNA AETNA 1.34 79 999999999 1.02 1.64 percent of total billed charges 00904-6554-61-half - traZODone 25 mg Tab 49254410_1 CDM 0250 RC 00904-6554-61 NDC inpatient 1 UN 1.69 1.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.32 78 999999999 1.02 1.64 percent of total billed charges 00904-6554-61-half - traZODone 25 mg Tab 49254410_1 CDM 0250 RC 00904-6554-61 NDC inpatient 1 UN 1.69 1.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.17 69 999999999 1.02 1.64 percent of total billed charges 00904-6554-61-half - traZODone 25 mg Tab 49254410_1 CDM 0250 RC 00904-6554-61 NDC inpatient 1 UN 1.69 1.1 UMR - ALL PLANS UMR - ALL PLANS 1.18 70 999999999 1.02 1.64 percent of total billed charges 00904-6554-61-half - traZODone 25 mg Tab 49254410_1 CDM 0250 RC 00904-6554-61 NDC inpatient 1 UN 1.69 1.1 SIHO - ALL PLANS SIHO - ALL PLANS 1.52 90 999999999 1.02 1.64 percent of total billed charges 00904-6554-61-half - traZODone 25 mg Tab 49254410_1 CDM 0250 RC 00904-6554-61 NDC inpatient 1 UN 1.69 1.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.02 60.55 999999999 1.02 1.64 percent of total billed charges 00904-6554-61-half - traZODone 25 mg Tab 49254410_1 CDM 0250 RC 00904-6554-61 NDC inpatient 1 UN 1.69 1.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.02 1.64 00904-6554-61-half - traZODone 25 mg Tab 49254410_1 CDM 0250 RC 00904-6554-61 NDC inpatient 1 UN 1.69 1.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.02 1.64 00904-6554-61-half - traZODone 25 mg Tab 49254410_1 CDM 0250 RC 00904-6554-61 NDC inpatient 1 UN 1.69 1.1 ANTHEM HMO ANTHEM HMO 999999999 1.02 1.64 00904-6554-61-half - traZODone 25 mg Tab 49254410_1 CDM 0250 RC 00904-6554-61 NDC inpatient 1 UN 1.69 1.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.02 1.64 00904-6554-61-half - traZODone 25 mg Tab 49254410_1 CDM 0250 RC 00904-6554-61 NDC inpatient 1 UN 1.69 1.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.14 67.6 999999999 1.02 1.64 percent of total billed charges 00904-6554-61-half - traZODone 25 mg Tab 49254410_1 CDM 0250 RC 00904-6554-61 NDC inpatient 1 UN 1.69 1.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.02 1.64 Complete ultrasound of abdomen and pelvis artery and vein blood flow 49254477_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 617.5 65 999999999 575.23 921.5 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 49254477_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 921.5 97 999999999 575.23 921.5 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 49254477_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 AETNA AETNA 750.5 79 999999999 575.23 921.5 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 49254477_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 741 78 999999999 575.23 921.5 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 49254477_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 655.5 69 999999999 575.23 921.5 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 49254477_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 UMR - ALL PLANS UMR - ALL PLANS 665 70 999999999 575.23 921.5 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 49254477_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 SIHO - ALL PLANS SIHO - ALL PLANS 855 90 999999999 575.23 921.5 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 49254477_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 575.23 60.55 999999999 575.23 921.5 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 49254477_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 575.23 921.5 Complete ultrasound of abdomen and pelvis artery and vein blood flow 49254477_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 575.23 921.5 Complete ultrasound of abdomen and pelvis artery and vein blood flow 49254477_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 ANTHEM HMO ANTHEM HMO 999999999 575.23 921.5 Complete ultrasound of abdomen and pelvis artery and vein blood flow 49254477_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 575.23 921.5 Complete ultrasound of abdomen and pelvis artery and vein blood flow 49254477_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 642.2 67.6 999999999 575.23 921.5 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 49254477_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 575.23 921.5 Measurement of antibody to noninfectious agent 49254488_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 49254488_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 49254488_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 49254488_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 49254488_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 49254488_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 49254488_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 49254488_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 49254488_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 49254488_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 49254488_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 49254488_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 49254488_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 49254488_1 CDM 0302 RC 86256 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 "Measurement of substance using immunoassay technique, by radioimmunoassay" 49254489_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 195.65 65 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49254489_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291.97 97 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49254489_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 AETNA AETNA 237.79 79 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49254489_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 234.78 78 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49254489_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 207.69 69 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49254489_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 UMR - ALL PLANS UMR - ALL PLANS 210.7 70 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49254489_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 SIHO - ALL PLANS SIHO - ALL PLANS 270.9 90 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49254489_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.26 60.55 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49254489_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 49254489_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 49254489_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM HMO ANTHEM HMO 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 49254489_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 49254489_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 203.48 67.6 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49254489_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.26 291.97 "Nephelometry, test method using light" 49254546_1 CDM 0301 RC 83883 HCPCS inpatient 134 87.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 87.1 65 999999999 81.14 129.98 percent of total billed charges "Nephelometry, test method using light" 49254546_1 CDM 0301 RC 83883 HCPCS inpatient 134 87.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.98 97 999999999 81.14 129.98 percent of total billed charges "Nephelometry, test method using light" 49254546_1 CDM 0301 RC 83883 HCPCS inpatient 134 87.1 AETNA AETNA 105.86 79 999999999 81.14 129.98 percent of total billed charges "Nephelometry, test method using light" 49254546_1 CDM 0301 RC 83883 HCPCS inpatient 134 87.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 104.52 78 999999999 81.14 129.98 percent of total billed charges "Nephelometry, test method using light" 49254546_1 CDM 0301 RC 83883 HCPCS inpatient 134 87.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 92.46 69 999999999 81.14 129.98 percent of total billed charges "Nephelometry, test method using light" 49254546_1 CDM 0301 RC 83883 HCPCS inpatient 134 87.1 UMR - ALL PLANS UMR - ALL PLANS 93.8 70 999999999 81.14 129.98 percent of total billed charges "Nephelometry, test method using light" 49254546_1 CDM 0301 RC 83883 HCPCS inpatient 134 87.1 SIHO - ALL PLANS SIHO - ALL PLANS 120.6 90 999999999 81.14 129.98 percent of total billed charges "Nephelometry, test method using light" 49254546_1 CDM 0301 RC 83883 HCPCS inpatient 134 87.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 81.14 60.55 999999999 81.14 129.98 percent of total billed charges "Nephelometry, test method using light" 49254546_1 CDM 0301 RC 83883 HCPCS inpatient 134 87.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 81.14 129.98 "Nephelometry, test method using light" 49254546_1 CDM 0301 RC 83883 HCPCS inpatient 134 87.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 81.14 129.98 "Nephelometry, test method using light" 49254546_1 CDM 0301 RC 83883 HCPCS inpatient 134 87.1 ANTHEM HMO ANTHEM HMO 999999999 81.14 129.98 "Nephelometry, test method using light" 49254546_1 CDM 0301 RC 83883 HCPCS inpatient 134 87.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 81.14 129.98 "Nephelometry, test method using light" 49254546_1 CDM 0301 RC 83883 HCPCS inpatient 134 87.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 90.58 67.6 999999999 81.14 129.98 percent of total billed charges "Nephelometry, test method using light" 49254546_1 CDM 0301 RC 83883 HCPCS inpatient 134 87.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 81.14 129.98 NEOMYCIN-POLYMYXIN-HC EAR SUSP 49254551_1 CDM 0250 RC 61314-0645-11 NDC inpatient 1 UN 85.88 55.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.82 65 999999999 52 83.3 percent of total billed charges NEOMYCIN-POLYMYXIN-HC EAR SUSP 49254551_1 CDM 0250 RC 61314-0645-11 NDC inpatient 1 UN 85.88 55.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.3 97 999999999 52 83.3 percent of total billed charges NEOMYCIN-POLYMYXIN-HC EAR SUSP 49254551_1 CDM 0250 RC 61314-0645-11 NDC inpatient 1 UN 85.88 55.82 AETNA AETNA 67.85 79 999999999 52 83.3 percent of total billed charges NEOMYCIN-POLYMYXIN-HC EAR SUSP 49254551_1 CDM 0250 RC 61314-0645-11 NDC inpatient 1 UN 85.88 55.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 66.99 78 999999999 52 83.3 percent of total billed charges NEOMYCIN-POLYMYXIN-HC EAR SUSP 49254551_1 CDM 0250 RC 61314-0645-11 NDC inpatient 1 UN 85.88 55.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.26 69 999999999 52 83.3 percent of total billed charges NEOMYCIN-POLYMYXIN-HC EAR SUSP 49254551_1 CDM 0250 RC 61314-0645-11 NDC inpatient 1 UN 85.88 55.82 UMR - ALL PLANS UMR - ALL PLANS 60.12 70 999999999 52 83.3 percent of total billed charges NEOMYCIN-POLYMYXIN-HC EAR SUSP 49254551_1 CDM 0250 RC 61314-0645-11 NDC inpatient 1 UN 85.88 55.82 SIHO - ALL PLANS SIHO - ALL PLANS 77.29 90 999999999 52 83.3 percent of total billed charges NEOMYCIN-POLYMYXIN-HC EAR SUSP 49254551_1 CDM 0250 RC 61314-0645-11 NDC inpatient 1 UN 85.88 55.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52 60.55 999999999 52 83.3 percent of total billed charges NEOMYCIN-POLYMYXIN-HC EAR SUSP 49254551_1 CDM 0250 RC 61314-0645-11 NDC inpatient 1 UN 85.88 55.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52 83.3 NEOMYCIN-POLYMYXIN-HC EAR SUSP 49254551_1 CDM 0250 RC 61314-0645-11 NDC inpatient 1 UN 85.88 55.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52 83.3 NEOMYCIN-POLYMYXIN-HC EAR SUSP 49254551_1 CDM 0250 RC 61314-0645-11 NDC inpatient 1 UN 85.88 55.82 ANTHEM HMO ANTHEM HMO 999999999 52 83.3 NEOMYCIN-POLYMYXIN-HC EAR SUSP 49254551_1 CDM 0250 RC 61314-0645-11 NDC inpatient 1 UN 85.88 55.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52 83.3 NEOMYCIN-POLYMYXIN-HC EAR SUSP 49254551_1 CDM 0250 RC 61314-0645-11 NDC inpatient 1 UN 85.88 55.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.05 67.6 999999999 52 83.3 percent of total billed charges NEOMYCIN-POLYMYXIN-HC EAR SUSP 49254551_1 CDM 0250 RC 61314-0645-11 NDC inpatient 1 UN 85.88 55.82 UHC - ALL PLANS UHC - ALL PLANS 999999999 52 83.3 Analysis using chemiluminescent technique (light and chemical )reaction 49254642_1 CDM 0301 RC 82397 HCPCS inpatient 391 254.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 254.15 65 999999999 236.75 379.27 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 49254642_1 CDM 0301 RC 82397 HCPCS inpatient 391 254.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 379.27 97 999999999 236.75 379.27 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 49254642_1 CDM 0301 RC 82397 HCPCS inpatient 391 254.15 AETNA AETNA 308.89 79 999999999 236.75 379.27 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 49254642_1 CDM 0301 RC 82397 HCPCS inpatient 391 254.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 304.98 78 999999999 236.75 379.27 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 49254642_1 CDM 0301 RC 82397 HCPCS inpatient 391 254.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 269.79 69 999999999 236.75 379.27 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 49254642_1 CDM 0301 RC 82397 HCPCS inpatient 391 254.15 UMR - ALL PLANS UMR - ALL PLANS 273.7 70 999999999 236.75 379.27 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 49254642_1 CDM 0301 RC 82397 HCPCS inpatient 391 254.15 SIHO - ALL PLANS SIHO - ALL PLANS 351.9 90 999999999 236.75 379.27 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 49254642_1 CDM 0301 RC 82397 HCPCS inpatient 391 254.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 236.75 60.55 999999999 236.75 379.27 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 49254642_1 CDM 0301 RC 82397 HCPCS inpatient 391 254.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 236.75 379.27 Analysis using chemiluminescent technique (light and chemical )reaction 49254642_1 CDM 0301 RC 82397 HCPCS inpatient 391 254.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 236.75 379.27 Analysis using chemiluminescent technique (light and chemical )reaction 49254642_1 CDM 0301 RC 82397 HCPCS inpatient 391 254.15 ANTHEM HMO ANTHEM HMO 999999999 236.75 379.27 Analysis using chemiluminescent technique (light and chemical )reaction 49254642_1 CDM 0301 RC 82397 HCPCS inpatient 391 254.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 236.75 379.27 Analysis using chemiluminescent technique (light and chemical )reaction 49254642_1 CDM 0301 RC 82397 HCPCS inpatient 391 254.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 264.32 67.6 999999999 236.75 379.27 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 49254642_1 CDM 0301 RC 82397 HCPCS inpatient 391 254.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 236.75 379.27 White blood cell enzyme activity measurement 49254645_1 CDM 0301 RC 85549 HCPCS inpatient 211 137.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 137.15 65 999999999 127.76 204.67 percent of total billed charges White blood cell enzyme activity measurement 49254645_1 CDM 0301 RC 85549 HCPCS inpatient 211 137.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 204.67 97 999999999 127.76 204.67 percent of total billed charges White blood cell enzyme activity measurement 49254645_1 CDM 0301 RC 85549 HCPCS inpatient 211 137.15 AETNA AETNA 166.69 79 999999999 127.76 204.67 percent of total billed charges White blood cell enzyme activity measurement 49254645_1 CDM 0301 RC 85549 HCPCS inpatient 211 137.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 164.58 78 999999999 127.76 204.67 percent of total billed charges White blood cell enzyme activity measurement 49254645_1 CDM 0301 RC 85549 HCPCS inpatient 211 137.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 145.59 69 999999999 127.76 204.67 percent of total billed charges White blood cell enzyme activity measurement 49254645_1 CDM 0301 RC 85549 HCPCS inpatient 211 137.15 UMR - ALL PLANS UMR - ALL PLANS 147.7 70 999999999 127.76 204.67 percent of total billed charges White blood cell enzyme activity measurement 49254645_1 CDM 0301 RC 85549 HCPCS inpatient 211 137.15 SIHO - ALL PLANS SIHO - ALL PLANS 189.9 90 999999999 127.76 204.67 percent of total billed charges White blood cell enzyme activity measurement 49254645_1 CDM 0301 RC 85549 HCPCS inpatient 211 137.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.76 60.55 999999999 127.76 204.67 percent of total billed charges White blood cell enzyme activity measurement 49254645_1 CDM 0301 RC 85549 HCPCS inpatient 211 137.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.76 204.67 White blood cell enzyme activity measurement 49254645_1 CDM 0301 RC 85549 HCPCS inpatient 211 137.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.76 204.67 White blood cell enzyme activity measurement 49254645_1 CDM 0301 RC 85549 HCPCS inpatient 211 137.15 ANTHEM HMO ANTHEM HMO 999999999 127.76 204.67 White blood cell enzyme activity measurement 49254645_1 CDM 0301 RC 85549 HCPCS inpatient 211 137.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.76 204.67 White blood cell enzyme activity measurement 49254645_1 CDM 0301 RC 85549 HCPCS inpatient 211 137.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 142.64 67.6 999999999 127.76 204.67 percent of total billed charges White blood cell enzyme activity measurement 49254645_1 CDM 0301 RC 85549 HCPCS inpatient 211 137.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.76 204.67 Magnesium level 49254646_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges Magnesium level 49254646_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges Magnesium level 49254646_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges Magnesium level 49254646_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges Magnesium level 49254646_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges Magnesium level 49254646_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges Magnesium level 49254646_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges Magnesium level 49254646_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges Magnesium level 49254646_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 Magnesium level 49254646_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 Magnesium level 49254646_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 Magnesium level 49254646_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 Magnesium level 49254646_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges Magnesium level 49254646_1 CDM 0301 RC 83735 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 Organic acids level 49254727_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.9 65 999999999 173.17 277.42 percent of total billed charges Organic acids level 49254727_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 277.42 97 999999999 173.17 277.42 percent of total billed charges Organic acids level 49254727_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 AETNA AETNA 225.94 79 999999999 173.17 277.42 percent of total billed charges Organic acids level 49254727_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 223.08 78 999999999 173.17 277.42 percent of total billed charges Organic acids level 49254727_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 197.34 69 999999999 173.17 277.42 percent of total billed charges Organic acids level 49254727_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 UMR - ALL PLANS UMR - ALL PLANS 200.2 70 999999999 173.17 277.42 percent of total billed charges Organic acids level 49254727_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 SIHO - ALL PLANS SIHO - ALL PLANS 257.4 90 999999999 173.17 277.42 percent of total billed charges Organic acids level 49254727_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 173.17 60.55 999999999 173.17 277.42 percent of total billed charges Organic acids level 49254727_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 173.17 277.42 Organic acids level 49254727_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 173.17 277.42 Organic acids level 49254727_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 ANTHEM HMO ANTHEM HMO 999999999 173.17 277.42 Organic acids level 49254727_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 173.17 277.42 Organic acids level 49254727_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 193.34 67.6 999999999 173.17 277.42 percent of total billed charges Organic acids level 49254727_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 173.17 277.42 71019-0053-01 - diltiazem 100 mg/100 mL-D5W IV Sol [JOHN] 49254807_1 CDM 0250 RC 71019-0053-01 NDC inpatient 1 UN 141.67 92.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.09 65 999999999 85.78 137.42 percent of total billed charges 71019-0053-01 - diltiazem 100 mg/100 mL-D5W IV Sol [JOHN] 49254807_1 CDM 0250 RC 71019-0053-01 NDC inpatient 1 UN 141.67 92.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.42 97 999999999 85.78 137.42 percent of total billed charges 71019-0053-01 - diltiazem 100 mg/100 mL-D5W IV Sol [JOHN] 49254807_1 CDM 0250 RC 71019-0053-01 NDC inpatient 1 UN 141.67 92.09 AETNA AETNA 111.92 79 999999999 85.78 137.42 percent of total billed charges 71019-0053-01 - diltiazem 100 mg/100 mL-D5W IV Sol [JOHN] 49254807_1 CDM 0250 RC 71019-0053-01 NDC inpatient 1 UN 141.67 92.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.5 78 999999999 85.78 137.42 percent of total billed charges 71019-0053-01 - diltiazem 100 mg/100 mL-D5W IV Sol [JOHN] 49254807_1 CDM 0250 RC 71019-0053-01 NDC inpatient 1 UN 141.67 92.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.75 69 999999999 85.78 137.42 percent of total billed charges 71019-0053-01 - diltiazem 100 mg/100 mL-D5W IV Sol [JOHN] 49254807_1 CDM 0250 RC 71019-0053-01 NDC inpatient 1 UN 141.67 92.09 UMR - ALL PLANS UMR - ALL PLANS 99.17 70 999999999 85.78 137.42 percent of total billed charges 71019-0053-01 - diltiazem 100 mg/100 mL-D5W IV Sol [JOHN] 49254807_1 CDM 0250 RC 71019-0053-01 NDC inpatient 1 UN 141.67 92.09 SIHO - ALL PLANS SIHO - ALL PLANS 127.5 90 999999999 85.78 137.42 percent of total billed charges 71019-0053-01 - diltiazem 100 mg/100 mL-D5W IV Sol [JOHN] 49254807_1 CDM 0250 RC 71019-0053-01 NDC inpatient 1 UN 141.67 92.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.78 60.55 999999999 85.78 137.42 percent of total billed charges 71019-0053-01 - diltiazem 100 mg/100 mL-D5W IV Sol [JOHN] 49254807_1 CDM 0250 RC 71019-0053-01 NDC inpatient 1 UN 141.67 92.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.78 137.42 71019-0053-01 - diltiazem 100 mg/100 mL-D5W IV Sol [JOHN] 49254807_1 CDM 0250 RC 71019-0053-01 NDC inpatient 1 UN 141.67 92.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.78 137.42 71019-0053-01 - diltiazem 100 mg/100 mL-D5W IV Sol [JOHN] 49254807_1 CDM 0250 RC 71019-0053-01 NDC inpatient 1 UN 141.67 92.09 ANTHEM HMO ANTHEM HMO 999999999 85.78 137.42 71019-0053-01 - diltiazem 100 mg/100 mL-D5W IV Sol [JOHN] 49254807_1 CDM 0250 RC 71019-0053-01 NDC inpatient 1 UN 141.67 92.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.78 137.42 71019-0053-01 - diltiazem 100 mg/100 mL-D5W IV Sol [JOHN] 49254807_1 CDM 0250 RC 71019-0053-01 NDC inpatient 1 UN 141.67 92.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.77 67.6 999999999 85.78 137.42 percent of total billed charges 71019-0053-01 - diltiazem 100 mg/100 mL-D5W IV Sol [JOHN] 49254807_1 CDM 0250 RC 71019-0053-01 NDC inpatient 1 UN 141.67 92.09 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.78 137.42 05363-0542-01 - cyanocobalamin 100 mcg tab [JOHN] 49254856_1 CDM 0250 RC 05363-0542-01 NDC inpatient 10 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 05363-0542-01 - cyanocobalamin 100 mcg tab [JOHN] 49254856_1 CDM 0250 RC 05363-0542-01 NDC inpatient 10 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 05363-0542-01 - cyanocobalamin 100 mcg tab [JOHN] 49254856_1 CDM 0250 RC 05363-0542-01 NDC inpatient 10 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 05363-0542-01 - cyanocobalamin 100 mcg tab [JOHN] 49254856_1 CDM 0250 RC 05363-0542-01 NDC inpatient 10 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 05363-0542-01 - cyanocobalamin 100 mcg tab [JOHN] 49254856_1 CDM 0250 RC 05363-0542-01 NDC inpatient 10 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 05363-0542-01 - cyanocobalamin 100 mcg tab [JOHN] 49254856_1 CDM 0250 RC 05363-0542-01 NDC inpatient 10 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 05363-0542-01 - cyanocobalamin 100 mcg tab [JOHN] 49254856_1 CDM 0250 RC 05363-0542-01 NDC inpatient 10 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 05363-0542-01 - cyanocobalamin 100 mcg tab [JOHN] 49254856_1 CDM 0250 RC 05363-0542-01 NDC inpatient 10 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 05363-0542-01 - cyanocobalamin 100 mcg tab [JOHN] 49254856_1 CDM 0250 RC 05363-0542-01 NDC inpatient 10 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 05363-0542-01 - cyanocobalamin 100 mcg tab [JOHN] 49254856_1 CDM 0250 RC 05363-0542-01 NDC inpatient 10 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 05363-0542-01 - cyanocobalamin 100 mcg tab [JOHN] 49254856_1 CDM 0250 RC 05363-0542-01 NDC inpatient 10 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 05363-0542-01 - cyanocobalamin 100 mcg tab [JOHN] 49254856_1 CDM 0250 RC 05363-0542-01 NDC inpatient 10 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 05363-0542-01 - cyanocobalamin 100 mcg tab [JOHN] 49254856_1 CDM 0250 RC 05363-0542-01 NDC inpatient 10 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 05363-0542-01 - cyanocobalamin 100 mcg tab [JOHN] 49254856_1 CDM 0250 RC 05363-0542-01 NDC inpatient 10 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 BACLOFEN 10 MG TABLET 49254969_1 CDM 0250 RC 00904-6475-61 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges BACLOFEN 10 MG TABLET 49254969_1 CDM 0250 RC 00904-6475-61 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges BACLOFEN 10 MG TABLET 49254969_1 CDM 0250 RC 00904-6475-61 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges BACLOFEN 10 MG TABLET 49254969_1 CDM 0250 RC 00904-6475-61 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges BACLOFEN 10 MG TABLET 49254969_1 CDM 0250 RC 00904-6475-61 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges BACLOFEN 10 MG TABLET 49254969_1 CDM 0250 RC 00904-6475-61 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges BACLOFEN 10 MG TABLET 49254969_1 CDM 0250 RC 00904-6475-61 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges BACLOFEN 10 MG TABLET 49254969_1 CDM 0250 RC 00904-6475-61 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges BACLOFEN 10 MG TABLET 49254969_1 CDM 0250 RC 00904-6475-61 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 BACLOFEN 10 MG TABLET 49254969_1 CDM 0250 RC 00904-6475-61 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 BACLOFEN 10 MG TABLET 49254969_1 CDM 0250 RC 00904-6475-61 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 BACLOFEN 10 MG TABLET 49254969_1 CDM 0250 RC 00904-6475-61 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 BACLOFEN 10 MG TABLET 49254969_1 CDM 0250 RC 00904-6475-61 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges BACLOFEN 10 MG TABLET 49254969_1 CDM 0250 RC 00904-6475-61 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ***BLANKET BY M. PALMER 07/26/2023**** INSTRUMENT TRACKER 9733533XOM 49255071_1 CDM 0272 RC inpatient 640 416 SELF PAY DISCOUNT SELF PAY DISCOUNT 416 65 999999999 387.52 620.8 percent of total billed charges ***BLANKET BY M. PALMER 07/26/2023**** INSTRUMENT TRACKER 9733533XOM 49255071_1 CDM 0272 RC inpatient 640 416 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 620.8 97 999999999 387.52 620.8 percent of total billed charges ***BLANKET BY M. PALMER 07/26/2023**** INSTRUMENT TRACKER 9733533XOM 49255071_1 CDM 0272 RC inpatient 640 416 AETNA AETNA 505.6 79 999999999 387.52 620.8 percent of total billed charges ***BLANKET BY M. PALMER 07/26/2023**** INSTRUMENT TRACKER 9733533XOM 49255071_1 CDM 0272 RC inpatient 640 416 HUMANA - ALL PLANS HUMANA - ALL PLANS 499.2 78 999999999 387.52 620.8 percent of total billed charges ***BLANKET BY M. PALMER 07/26/2023**** INSTRUMENT TRACKER 9733533XOM 49255071_1 CDM 0272 RC inpatient 640 416 ENCORE - ALL PLANS ENCORE - ALL PLANS 441.6 69 999999999 387.52 620.8 percent of total billed charges ***BLANKET BY M. PALMER 07/26/2023**** INSTRUMENT TRACKER 9733533XOM 49255071_1 CDM 0272 RC inpatient 640 416 UMR - ALL PLANS UMR - ALL PLANS 448 70 999999999 387.52 620.8 percent of total billed charges ***BLANKET BY M. PALMER 07/26/2023**** INSTRUMENT TRACKER 9733533XOM 49255071_1 CDM 0272 RC inpatient 640 416 SIHO - ALL PLANS SIHO - ALL PLANS 576 90 999999999 387.52 620.8 percent of total billed charges ***BLANKET BY M. PALMER 07/26/2023**** INSTRUMENT TRACKER 9733533XOM 49255071_1 CDM 0272 RC inpatient 640 416 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 387.52 60.55 999999999 387.52 620.8 percent of total billed charges ***BLANKET BY M. PALMER 07/26/2023**** INSTRUMENT TRACKER 9733533XOM 49255071_1 CDM 0272 RC inpatient 640 416 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 387.52 620.8 ***BLANKET BY M. PALMER 07/26/2023**** INSTRUMENT TRACKER 9733533XOM 49255071_1 CDM 0272 RC inpatient 640 416 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 387.52 620.8 ***BLANKET BY M. PALMER 07/26/2023**** INSTRUMENT TRACKER 9733533XOM 49255071_1 CDM 0272 RC inpatient 640 416 ANTHEM HMO ANTHEM HMO 999999999 387.52 620.8 ***BLANKET BY M. PALMER 07/26/2023**** INSTRUMENT TRACKER 9733533XOM 49255071_1 CDM 0272 RC inpatient 640 416 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 387.52 620.8 ***BLANKET BY M. PALMER 07/26/2023**** INSTRUMENT TRACKER 9733533XOM 49255071_1 CDM 0272 RC inpatient 640 416 CIGNA - ALL PLANS CIGNA - ALL PLANS 432.64 67.6 999999999 387.52 620.8 percent of total billed charges ***BLANKET BY M. PALMER 07/26/2023**** INSTRUMENT TRACKER 9733533XOM 49255071_1 CDM 0272 RC inpatient 640 416 UHC - ALL PLANS UHC - ALL PLANS 999999999 387.52 620.8 68084-0423-01-half - hydromorphone 1 mg tab [JOHN] 49257042_1 CDM 0250 RC 68084-0423-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 68084-0423-01-half - hydromorphone 1 mg tab [JOHN] 49257042_1 CDM 0250 RC 68084-0423-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 68084-0423-01-half - hydromorphone 1 mg tab [JOHN] 49257042_1 CDM 0250 RC 68084-0423-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 68084-0423-01-half - hydromorphone 1 mg tab [JOHN] 49257042_1 CDM 0250 RC 68084-0423-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 68084-0423-01-half - hydromorphone 1 mg tab [JOHN] 49257042_1 CDM 0250 RC 68084-0423-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 68084-0423-01-half - hydromorphone 1 mg tab [JOHN] 49257042_1 CDM 0250 RC 68084-0423-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 68084-0423-01-half - hydromorphone 1 mg tab [JOHN] 49257042_1 CDM 0250 RC 68084-0423-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 68084-0423-01-half - hydromorphone 1 mg tab [JOHN] 49257042_1 CDM 0250 RC 68084-0423-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 68084-0423-01-half - hydromorphone 1 mg tab [JOHN] 49257042_1 CDM 0250 RC 68084-0423-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 68084-0423-01-half - hydromorphone 1 mg tab [JOHN] 49257042_1 CDM 0250 RC 68084-0423-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 68084-0423-01-half - hydromorphone 1 mg tab [JOHN] 49257042_1 CDM 0250 RC 68084-0423-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 68084-0423-01-half - hydromorphone 1 mg tab [JOHN] 49257042_1 CDM 0250 RC 68084-0423-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 68084-0423-01-half - hydromorphone 1 mg tab [JOHN] 49257042_1 CDM 0250 RC 68084-0423-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 68084-0423-01-half - hydromorphone 1 mg tab [JOHN] 49257042_1 CDM 0250 RC 68084-0423-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 00090-3150-85 - Gelfoam 12-7MM Sponge [JOHN] 49257043_1 CDM 0250 RC 00090-3150-85 NDC inpatient 1 UN 17.62 11.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.45 65 999999999 10.67 17.09 percent of total billed charges 00090-3150-85 - Gelfoam 12-7MM Sponge [JOHN] 49257043_1 CDM 0250 RC 00090-3150-85 NDC inpatient 1 UN 17.62 11.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.09 97 999999999 10.67 17.09 percent of total billed charges 00090-3150-85 - Gelfoam 12-7MM Sponge [JOHN] 49257043_1 CDM 0250 RC 00090-3150-85 NDC inpatient 1 UN 17.62 11.45 AETNA AETNA 13.92 79 999999999 10.67 17.09 percent of total billed charges 00090-3150-85 - Gelfoam 12-7MM Sponge [JOHN] 49257043_1 CDM 0250 RC 00090-3150-85 NDC inpatient 1 UN 17.62 11.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.74 78 999999999 10.67 17.09 percent of total billed charges 00090-3150-85 - Gelfoam 12-7MM Sponge [JOHN] 49257043_1 CDM 0250 RC 00090-3150-85 NDC inpatient 1 UN 17.62 11.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.16 69 999999999 10.67 17.09 percent of total billed charges 00090-3150-85 - Gelfoam 12-7MM Sponge [JOHN] 49257043_1 CDM 0250 RC 00090-3150-85 NDC inpatient 1 UN 17.62 11.45 UMR - ALL PLANS UMR - ALL PLANS 12.33 70 999999999 10.67 17.09 percent of total billed charges 00090-3150-85 - Gelfoam 12-7MM Sponge [JOHN] 49257043_1 CDM 0250 RC 00090-3150-85 NDC inpatient 1 UN 17.62 11.45 SIHO - ALL PLANS SIHO - ALL PLANS 15.86 90 999999999 10.67 17.09 percent of total billed charges 00090-3150-85 - Gelfoam 12-7MM Sponge [JOHN] 49257043_1 CDM 0250 RC 00090-3150-85 NDC inpatient 1 UN 17.62 11.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.67 60.55 999999999 10.67 17.09 percent of total billed charges 00090-3150-85 - Gelfoam 12-7MM Sponge [JOHN] 49257043_1 CDM 0250 RC 00090-3150-85 NDC inpatient 1 UN 17.62 11.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.67 17.09 00090-3150-85 - Gelfoam 12-7MM Sponge [JOHN] 49257043_1 CDM 0250 RC 00090-3150-85 NDC inpatient 1 UN 17.62 11.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.67 17.09 00090-3150-85 - Gelfoam 12-7MM Sponge [JOHN] 49257043_1 CDM 0250 RC 00090-3150-85 NDC inpatient 1 UN 17.62 11.45 ANTHEM HMO ANTHEM HMO 999999999 10.67 17.09 00090-3150-85 - Gelfoam 12-7MM Sponge [JOHN] 49257043_1 CDM 0250 RC 00090-3150-85 NDC inpatient 1 UN 17.62 11.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.67 17.09 00090-3150-85 - Gelfoam 12-7MM Sponge [JOHN] 49257043_1 CDM 0250 RC 00090-3150-85 NDC inpatient 1 UN 17.62 11.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.91 67.6 999999999 10.67 17.09 percent of total billed charges 00090-3150-85 - Gelfoam 12-7MM Sponge [JOHN] 49257043_1 CDM 0250 RC 00090-3150-85 NDC inpatient 1 UN 17.62 11.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.67 17.09 00090-3420-12 - Gelfoam 100CM Sponge [JOHN] 49257044_1 CDM 0250 RC 00090-3420-12 NDC inpatient 1 UN 84.87 55.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.17 65 999999999 51.39 82.32 percent of total billed charges 00090-3420-12 - Gelfoam 100CM Sponge [JOHN] 49257044_1 CDM 0250 RC 00090-3420-12 NDC inpatient 1 UN 84.87 55.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 82.32 97 999999999 51.39 82.32 percent of total billed charges 00090-3420-12 - Gelfoam 100CM Sponge [JOHN] 49257044_1 CDM 0250 RC 00090-3420-12 NDC inpatient 1 UN 84.87 55.17 AETNA AETNA 67.05 79 999999999 51.39 82.32 percent of total billed charges 00090-3420-12 - Gelfoam 100CM Sponge [JOHN] 49257044_1 CDM 0250 RC 00090-3420-12 NDC inpatient 1 UN 84.87 55.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 66.2 78 999999999 51.39 82.32 percent of total billed charges 00090-3420-12 - Gelfoam 100CM Sponge [JOHN] 49257044_1 CDM 0250 RC 00090-3420-12 NDC inpatient 1 UN 84.87 55.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 58.56 69 999999999 51.39 82.32 percent of total billed charges 00090-3420-12 - Gelfoam 100CM Sponge [JOHN] 49257044_1 CDM 0250 RC 00090-3420-12 NDC inpatient 1 UN 84.87 55.17 UMR - ALL PLANS UMR - ALL PLANS 59.41 70 999999999 51.39 82.32 percent of total billed charges 00090-3420-12 - Gelfoam 100CM Sponge [JOHN] 49257044_1 CDM 0250 RC 00090-3420-12 NDC inpatient 1 UN 84.87 55.17 SIHO - ALL PLANS SIHO - ALL PLANS 76.38 90 999999999 51.39 82.32 percent of total billed charges 00090-3420-12 - Gelfoam 100CM Sponge [JOHN] 49257044_1 CDM 0250 RC 00090-3420-12 NDC inpatient 1 UN 84.87 55.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 51.39 60.55 999999999 51.39 82.32 percent of total billed charges 00090-3420-12 - Gelfoam 100CM Sponge [JOHN] 49257044_1 CDM 0250 RC 00090-3420-12 NDC inpatient 1 UN 84.87 55.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 51.39 82.32 00090-3420-12 - Gelfoam 100CM Sponge [JOHN] 49257044_1 CDM 0250 RC 00090-3420-12 NDC inpatient 1 UN 84.87 55.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 51.39 82.32 00090-3420-12 - Gelfoam 100CM Sponge [JOHN] 49257044_1 CDM 0250 RC 00090-3420-12 NDC inpatient 1 UN 84.87 55.17 ANTHEM HMO ANTHEM HMO 999999999 51.39 82.32 00090-3420-12 - Gelfoam 100CM Sponge [JOHN] 49257044_1 CDM 0250 RC 00090-3420-12 NDC inpatient 1 UN 84.87 55.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 51.39 82.32 00090-3420-12 - Gelfoam 100CM Sponge [JOHN] 49257044_1 CDM 0250 RC 00090-3420-12 NDC inpatient 1 UN 84.87 55.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 57.37 67.6 999999999 51.39 82.32 percent of total billed charges 00090-3420-12 - Gelfoam 100CM Sponge [JOHN] 49257044_1 CDM 0250 RC 00090-3420-12 NDC inpatient 1 UN 84.87 55.17 UHC - ALL PLANS UHC - ALL PLANS 999999999 51.39 82.32 OXYCODONE HCL (IR) 5 MG TABLET 49257045_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 1.81 1.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.18 65 999999999 1.1 1.76 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 49257045_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 1.81 1.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.76 97 999999999 1.1 1.76 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 49257045_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 1.81 1.18 AETNA AETNA 1.43 79 999999999 1.1 1.76 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 49257045_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 1.81 1.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.41 78 999999999 1.1 1.76 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 49257045_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 1.81 1.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.25 69 999999999 1.1 1.76 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 49257045_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 1.81 1.18 UMR - ALL PLANS UMR - ALL PLANS 1.27 70 999999999 1.1 1.76 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 49257045_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 1.81 1.18 SIHO - ALL PLANS SIHO - ALL PLANS 1.63 90 999999999 1.1 1.76 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 49257045_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 1.81 1.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.1 60.55 999999999 1.1 1.76 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 49257045_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 1.81 1.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.1 1.76 OXYCODONE HCL (IR) 5 MG TABLET 49257045_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 1.81 1.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.1 1.76 OXYCODONE HCL (IR) 5 MG TABLET 49257045_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 1.81 1.18 ANTHEM HMO ANTHEM HMO 999999999 1.1 1.76 OXYCODONE HCL (IR) 5 MG TABLET 49257045_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 1.81 1.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.1 1.76 OXYCODONE HCL (IR) 5 MG TABLET 49257045_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 1.81 1.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.22 67.6 999999999 1.1 1.76 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 49257045_1 CDM 0250 RC 00406-0552-62 NDC inpatient 1 UN 1.81 1.18 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.1 1.76 "INJECTION, ATEZOLIZUMAB, 10 MG" 49257046_1 CDM 0636 RC 50242-0917-01 NDC J9022 HCPCS inpatient 120 UN 43721.64 28419.07 SELF PAY DISCOUNT SELF PAY DISCOUNT 28419.07 65 999999999 26473.45 42409.99 percent of total billed charges "INJECTION, ATEZOLIZUMAB, 10 MG" 49257046_1 CDM 0636 RC 50242-0917-01 NDC J9022 HCPCS inpatient 120 UN 43721.64 28419.07 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 42409.99 97 999999999 26473.45 42409.99 percent of total billed charges "INJECTION, ATEZOLIZUMAB, 10 MG" 49257046_1 CDM 0636 RC 50242-0917-01 NDC J9022 HCPCS inpatient 120 UN 43721.64 28419.07 AETNA AETNA 34540.1 79 999999999 26473.45 42409.99 percent of total billed charges "INJECTION, ATEZOLIZUMAB, 10 MG" 49257046_1 CDM 0636 RC 50242-0917-01 NDC J9022 HCPCS inpatient 120 UN 43721.64 28419.07 HUMANA - ALL PLANS HUMANA - ALL PLANS 34102.88 78 999999999 26473.45 42409.99 percent of total billed charges "INJECTION, ATEZOLIZUMAB, 10 MG" 49257046_1 CDM 0636 RC 50242-0917-01 NDC J9022 HCPCS inpatient 120 UN 43721.64 28419.07 ENCORE - ALL PLANS ENCORE - ALL PLANS 30167.93 69 999999999 26473.45 42409.99 percent of total billed charges "INJECTION, ATEZOLIZUMAB, 10 MG" 49257046_1 CDM 0636 RC 50242-0917-01 NDC J9022 HCPCS inpatient 120 UN 43721.64 28419.07 UMR - ALL PLANS UMR - ALL PLANS 30605.15 70 999999999 26473.45 42409.99 percent of total billed charges "INJECTION, ATEZOLIZUMAB, 10 MG" 49257046_1 CDM 0636 RC 50242-0917-01 NDC J9022 HCPCS inpatient 120 UN 43721.64 28419.07 SIHO - ALL PLANS SIHO - ALL PLANS 39349.48 90 999999999 26473.45 42409.99 percent of total billed charges "INJECTION, ATEZOLIZUMAB, 10 MG" 49257046_1 CDM 0636 RC 50242-0917-01 NDC J9022 HCPCS inpatient 120 UN 43721.64 28419.07 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26473.45 60.55 999999999 26473.45 42409.99 percent of total billed charges "INJECTION, ATEZOLIZUMAB, 10 MG" 49257046_1 CDM 0636 RC 50242-0917-01 NDC J9022 HCPCS inpatient 120 UN 43721.64 28419.07 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26473.45 42409.99 "INJECTION, ATEZOLIZUMAB, 10 MG" 49257046_1 CDM 0636 RC 50242-0917-01 NDC J9022 HCPCS inpatient 120 UN 43721.64 28419.07 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26473.45 42409.99 "INJECTION, ATEZOLIZUMAB, 10 MG" 49257046_1 CDM 0636 RC 50242-0917-01 NDC J9022 HCPCS inpatient 120 UN 43721.64 28419.07 ANTHEM HMO ANTHEM HMO 999999999 26473.45 42409.99 "INJECTION, ATEZOLIZUMAB, 10 MG" 49257046_1 CDM 0636 RC 50242-0917-01 NDC J9022 HCPCS inpatient 120 UN 43721.64 28419.07 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26473.45 42409.99 "INJECTION, ATEZOLIZUMAB, 10 MG" 49257046_1 CDM 0636 RC 50242-0917-01 NDC J9022 HCPCS inpatient 120 UN 43721.64 28419.07 CIGNA - ALL PLANS CIGNA - ALL PLANS 29555.83 67.6 999999999 26473.45 42409.99 percent of total billed charges "INJECTION, ATEZOLIZUMAB, 10 MG" 49257046_1 CDM 0636 RC 50242-0917-01 NDC J9022 HCPCS inpatient 120 UN 43721.64 28419.07 UHC - ALL PLANS UHC - ALL PLANS 999999999 26473.45 42409.99 00409-7901-09 - Dextrose 5% with 0.225% NaCl and KCl 20 mEq/L intravenous solution Dextrose 5% with 49257057_1 CDM 0258 RC 00409-7901-09 NDC inpatient 1 UN 60.02 39.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.01 65 999999999 36.34 58.22 percent of total billed charges 00409-7901-09 - Dextrose 5% with 0.225% NaCl and KCl 20 mEq/L intravenous solution Dextrose 5% with 49257057_1 CDM 0258 RC 00409-7901-09 NDC inpatient 1 UN 60.02 39.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.22 97 999999999 36.34 58.22 percent of total billed charges 00409-7901-09 - Dextrose 5% with 0.225% NaCl and KCl 20 mEq/L intravenous solution Dextrose 5% with 49257057_1 CDM 0258 RC 00409-7901-09 NDC inpatient 1 UN 60.02 39.01 AETNA AETNA 47.42 79 999999999 36.34 58.22 percent of total billed charges 00409-7901-09 - Dextrose 5% with 0.225% NaCl and KCl 20 mEq/L intravenous solution Dextrose 5% with 49257057_1 CDM 0258 RC 00409-7901-09 NDC inpatient 1 UN 60.02 39.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.82 78 999999999 36.34 58.22 percent of total billed charges 00409-7901-09 - Dextrose 5% with 0.225% NaCl and KCl 20 mEq/L intravenous solution Dextrose 5% with 49257057_1 CDM 0258 RC 00409-7901-09 NDC inpatient 1 UN 60.02 39.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.41 69 999999999 36.34 58.22 percent of total billed charges 00409-7901-09 - Dextrose 5% with 0.225% NaCl and KCl 20 mEq/L intravenous solution Dextrose 5% with 49257057_1 CDM 0258 RC 00409-7901-09 NDC inpatient 1 UN 60.02 39.01 UMR - ALL PLANS UMR - ALL PLANS 42.01 70 999999999 36.34 58.22 percent of total billed charges 00409-7901-09 - Dextrose 5% with 0.225% NaCl and KCl 20 mEq/L intravenous solution Dextrose 5% with 49257057_1 CDM 0258 RC 00409-7901-09 NDC inpatient 1 UN 60.02 39.01 SIHO - ALL PLANS SIHO - ALL PLANS 54.02 90 999999999 36.34 58.22 percent of total billed charges 00409-7901-09 - Dextrose 5% with 0.225% NaCl and KCl 20 mEq/L intravenous solution Dextrose 5% with 49257057_1 CDM 0258 RC 00409-7901-09 NDC inpatient 1 UN 60.02 39.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.34 60.55 999999999 36.34 58.22 percent of total billed charges 00409-7901-09 - Dextrose 5% with 0.225% NaCl and KCl 20 mEq/L intravenous solution Dextrose 5% with 49257057_1 CDM 0258 RC 00409-7901-09 NDC inpatient 1 UN 60.02 39.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.34 58.22 00409-7901-09 - Dextrose 5% with 0.225% NaCl and KCl 20 mEq/L intravenous solution Dextrose 5% with 49257057_1 CDM 0258 RC 00409-7901-09 NDC inpatient 1 UN 60.02 39.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.34 58.22 00409-7901-09 - Dextrose 5% with 0.225% NaCl and KCl 20 mEq/L intravenous solution Dextrose 5% with 49257057_1 CDM 0258 RC 00409-7901-09 NDC inpatient 1 UN 60.02 39.01 ANTHEM HMO ANTHEM HMO 999999999 36.34 58.22 00409-7901-09 - Dextrose 5% with 0.225% NaCl and KCl 20 mEq/L intravenous solution Dextrose 5% with 49257057_1 CDM 0258 RC 00409-7901-09 NDC inpatient 1 UN 60.02 39.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.34 58.22 00409-7901-09 - Dextrose 5% with 0.225% NaCl and KCl 20 mEq/L intravenous solution Dextrose 5% with 49257057_1 CDM 0258 RC 00409-7901-09 NDC inpatient 1 UN 60.02 39.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.57 67.6 999999999 36.34 58.22 percent of total billed charges 00409-7901-09 - Dextrose 5% with 0.225% NaCl and KCl 20 mEq/L intravenous solution Dextrose 5% with 49257057_1 CDM 0258 RC 00409-7901-09 NDC inpatient 1 UN 60.02 39.01 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.34 58.22 SPECIALTY SERVICES - TREATMENT ROOM 49257062_1 CDM 0761 RC inpatient 96 62.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.4 65 999999999 58.13 93.12 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 49257062_1 CDM 0761 RC inpatient 96 62.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.12 97 999999999 58.13 93.12 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 49257062_1 CDM 0761 RC inpatient 96 62.4 AETNA AETNA 75.84 79 999999999 58.13 93.12 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 49257062_1 CDM 0761 RC inpatient 96 62.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.88 78 999999999 58.13 93.12 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 49257062_1 CDM 0761 RC inpatient 96 62.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.24 69 999999999 58.13 93.12 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 49257062_1 CDM 0761 RC inpatient 96 62.4 UMR - ALL PLANS UMR - ALL PLANS 67.2 70 999999999 58.13 93.12 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 49257062_1 CDM 0761 RC inpatient 96 62.4 SIHO - ALL PLANS SIHO - ALL PLANS 86.4 90 999999999 58.13 93.12 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 49257062_1 CDM 0761 RC inpatient 96 62.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.13 60.55 999999999 58.13 93.12 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 49257062_1 CDM 0761 RC inpatient 96 62.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.13 93.12 SPECIALTY SERVICES - TREATMENT ROOM 49257062_1 CDM 0761 RC inpatient 96 62.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.13 93.12 SPECIALTY SERVICES - TREATMENT ROOM 49257062_1 CDM 0761 RC inpatient 96 62.4 ANTHEM HMO ANTHEM HMO 999999999 58.13 93.12 SPECIALTY SERVICES - TREATMENT ROOM 49257062_1 CDM 0761 RC inpatient 96 62.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.13 93.12 SPECIALTY SERVICES - TREATMENT ROOM 49257062_1 CDM 0761 RC inpatient 96 62.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.9 67.6 999999999 58.13 93.12 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 49257062_1 CDM 0761 RC inpatient 96 62.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.13 93.12 99999-9999-90 - ON-Q C-Bloc With Select A Flow Ball [JOHN] 49257066_1 CDM 0250 RC 99999-9999-90 NDC inpatient 1 UN 470 305.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 305.5 65 999999999 284.59 455.9 percent of total billed charges 99999-9999-90 - ON-Q C-Bloc With Select A Flow Ball [JOHN] 49257066_1 CDM 0250 RC 99999-9999-90 NDC inpatient 1 UN 470 305.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 455.9 97 999999999 284.59 455.9 percent of total billed charges 99999-9999-90 - ON-Q C-Bloc With Select A Flow Ball [JOHN] 49257066_1 CDM 0250 RC 99999-9999-90 NDC inpatient 1 UN 470 305.5 AETNA AETNA 371.3 79 999999999 284.59 455.9 percent of total billed charges 99999-9999-90 - ON-Q C-Bloc With Select A Flow Ball [JOHN] 49257066_1 CDM 0250 RC 99999-9999-90 NDC inpatient 1 UN 470 305.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 366.6 78 999999999 284.59 455.9 percent of total billed charges 99999-9999-90 - ON-Q C-Bloc With Select A Flow Ball [JOHN] 49257066_1 CDM 0250 RC 99999-9999-90 NDC inpatient 1 UN 470 305.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 324.3 69 999999999 284.59 455.9 percent of total billed charges 99999-9999-90 - ON-Q C-Bloc With Select A Flow Ball [JOHN] 49257066_1 CDM 0250 RC 99999-9999-90 NDC inpatient 1 UN 470 305.5 UMR - ALL PLANS UMR - ALL PLANS 329 70 999999999 284.59 455.9 percent of total billed charges 99999-9999-90 - ON-Q C-Bloc With Select A Flow Ball [JOHN] 49257066_1 CDM 0250 RC 99999-9999-90 NDC inpatient 1 UN 470 305.5 SIHO - ALL PLANS SIHO - ALL PLANS 423 90 999999999 284.59 455.9 percent of total billed charges 99999-9999-90 - ON-Q C-Bloc With Select A Flow Ball [JOHN] 49257066_1 CDM 0250 RC 99999-9999-90 NDC inpatient 1 UN 470 305.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 284.59 60.55 999999999 284.59 455.9 percent of total billed charges 99999-9999-90 - ON-Q C-Bloc With Select A Flow Ball [JOHN] 49257066_1 CDM 0250 RC 99999-9999-90 NDC inpatient 1 UN 470 305.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 284.59 455.9 99999-9999-90 - ON-Q C-Bloc With Select A Flow Ball [JOHN] 49257066_1 CDM 0250 RC 99999-9999-90 NDC inpatient 1 UN 470 305.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 284.59 455.9 99999-9999-90 - ON-Q C-Bloc With Select A Flow Ball [JOHN] 49257066_1 CDM 0250 RC 99999-9999-90 NDC inpatient 1 UN 470 305.5 ANTHEM HMO ANTHEM HMO 999999999 284.59 455.9 99999-9999-90 - ON-Q C-Bloc With Select A Flow Ball [JOHN] 49257066_1 CDM 0250 RC 99999-9999-90 NDC inpatient 1 UN 470 305.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 284.59 455.9 99999-9999-90 - ON-Q C-Bloc With Select A Flow Ball [JOHN] 49257066_1 CDM 0250 RC 99999-9999-90 NDC inpatient 1 UN 470 305.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 317.72 67.6 999999999 284.59 455.9 percent of total billed charges 99999-9999-90 - ON-Q C-Bloc With Select A Flow Ball [JOHN] 49257066_1 CDM 0250 RC 99999-9999-90 NDC inpatient 1 UN 470 305.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 284.59 455.9 "INJECTION, LEVETIRACETAM, 10 MG" 49257067_1 CDM 0250 RC 55150-0247-17 NDC J1953 HCPCS inpatient 100 UN 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 49257067_1 CDM 0250 RC 55150-0247-17 NDC J1953 HCPCS inpatient 100 UN 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 49257067_1 CDM 0250 RC 55150-0247-17 NDC J1953 HCPCS inpatient 100 UN 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 49257067_1 CDM 0250 RC 55150-0247-17 NDC J1953 HCPCS inpatient 100 UN 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 49257067_1 CDM 0250 RC 55150-0247-17 NDC J1953 HCPCS inpatient 100 UN 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 49257067_1 CDM 0250 RC 55150-0247-17 NDC J1953 HCPCS inpatient 100 UN 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 49257067_1 CDM 0250 RC 55150-0247-17 NDC J1953 HCPCS inpatient 100 UN 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 49257067_1 CDM 0250 RC 55150-0247-17 NDC J1953 HCPCS inpatient 100 UN 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 49257067_1 CDM 0250 RC 55150-0247-17 NDC J1953 HCPCS inpatient 100 UN 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 "INJECTION, LEVETIRACETAM, 10 MG" 49257067_1 CDM 0250 RC 55150-0247-17 NDC J1953 HCPCS inpatient 100 UN 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 "INJECTION, LEVETIRACETAM, 10 MG" 49257067_1 CDM 0250 RC 55150-0247-17 NDC J1953 HCPCS inpatient 100 UN 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 "INJECTION, LEVETIRACETAM, 10 MG" 49257067_1 CDM 0250 RC 55150-0247-17 NDC J1953 HCPCS inpatient 100 UN 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 "INJECTION, LEVETIRACETAM, 10 MG" 49257067_1 CDM 0250 RC 55150-0247-17 NDC J1953 HCPCS inpatient 100 UN 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 49257067_1 CDM 0250 RC 55150-0247-17 NDC J1953 HCPCS inpatient 100 UN 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49257078_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49257078_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49257078_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49257078_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49257078_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49257078_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49257078_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49257078_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49257078_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49257078_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49257078_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49257078_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49257078_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49257078_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 71019-0341-14 - Succinylcholine Chloride 20mg/ml 7ml Syringe [JOHN] 49257361_1 CDM 0250 RC 71019-0341-14 NDC inpatient 1 UN 155.42 101.02 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.02 65 999999999 94.11 150.76 percent of total billed charges 71019-0341-14 - Succinylcholine Chloride 20mg/ml 7ml Syringe [JOHN] 49257361_1 CDM 0250 RC 71019-0341-14 NDC inpatient 1 UN 155.42 101.02 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 150.76 97 999999999 94.11 150.76 percent of total billed charges 71019-0341-14 - Succinylcholine Chloride 20mg/ml 7ml Syringe [JOHN] 49257361_1 CDM 0250 RC 71019-0341-14 NDC inpatient 1 UN 155.42 101.02 AETNA AETNA 122.78 79 999999999 94.11 150.76 percent of total billed charges 71019-0341-14 - Succinylcholine Chloride 20mg/ml 7ml Syringe [JOHN] 49257361_1 CDM 0250 RC 71019-0341-14 NDC inpatient 1 UN 155.42 101.02 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.23 78 999999999 94.11 150.76 percent of total billed charges 71019-0341-14 - Succinylcholine Chloride 20mg/ml 7ml Syringe [JOHN] 49257361_1 CDM 0250 RC 71019-0341-14 NDC inpatient 1 UN 155.42 101.02 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.24 69 999999999 94.11 150.76 percent of total billed charges 71019-0341-14 - Succinylcholine Chloride 20mg/ml 7ml Syringe [JOHN] 49257361_1 CDM 0250 RC 71019-0341-14 NDC inpatient 1 UN 155.42 101.02 UMR - ALL PLANS UMR - ALL PLANS 108.79 70 999999999 94.11 150.76 percent of total billed charges 71019-0341-14 - Succinylcholine Chloride 20mg/ml 7ml Syringe [JOHN] 49257361_1 CDM 0250 RC 71019-0341-14 NDC inpatient 1 UN 155.42 101.02 SIHO - ALL PLANS SIHO - ALL PLANS 139.88 90 999999999 94.11 150.76 percent of total billed charges 71019-0341-14 - Succinylcholine Chloride 20mg/ml 7ml Syringe [JOHN] 49257361_1 CDM 0250 RC 71019-0341-14 NDC inpatient 1 UN 155.42 101.02 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.11 60.55 999999999 94.11 150.76 percent of total billed charges 71019-0341-14 - Succinylcholine Chloride 20mg/ml 7ml Syringe [JOHN] 49257361_1 CDM 0250 RC 71019-0341-14 NDC inpatient 1 UN 155.42 101.02 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.11 150.76 71019-0341-14 - Succinylcholine Chloride 20mg/ml 7ml Syringe [JOHN] 49257361_1 CDM 0250 RC 71019-0341-14 NDC inpatient 1 UN 155.42 101.02 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.11 150.76 71019-0341-14 - Succinylcholine Chloride 20mg/ml 7ml Syringe [JOHN] 49257361_1 CDM 0250 RC 71019-0341-14 NDC inpatient 1 UN 155.42 101.02 ANTHEM HMO ANTHEM HMO 999999999 94.11 150.76 71019-0341-14 - Succinylcholine Chloride 20mg/ml 7ml Syringe [JOHN] 49257361_1 CDM 0250 RC 71019-0341-14 NDC inpatient 1 UN 155.42 101.02 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.11 150.76 71019-0341-14 - Succinylcholine Chloride 20mg/ml 7ml Syringe [JOHN] 49257361_1 CDM 0250 RC 71019-0341-14 NDC inpatient 1 UN 155.42 101.02 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.06 67.6 999999999 94.11 150.76 percent of total billed charges 71019-0341-14 - Succinylcholine Chloride 20mg/ml 7ml Syringe [JOHN] 49257361_1 CDM 0250 RC 71019-0341-14 NDC inpatient 1 UN 155.42 101.02 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.11 150.76 REV - IHS-MOA CLINIC VISIT 49259101_1 CDM 0510 RC inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259101_1 CDM 0510 RC inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259101_1 CDM 0510 RC inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259101_1 CDM 0510 RC inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259101_1 CDM 0510 RC inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259101_1 CDM 0510 RC inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259101_1 CDM 0510 RC inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259101_1 CDM 0510 RC inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259101_1 CDM 0510 RC inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 REV - IHS-MOA CLINIC VISIT 49259101_1 CDM 0510 RC inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 REV - IHS-MOA CLINIC VISIT 49259101_1 CDM 0510 RC inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 REV - IHS-MOA CLINIC VISIT 49259101_1 CDM 0510 RC inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 REV - IHS-MOA CLINIC VISIT 49259101_1 CDM 0510 RC inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259101_1 CDM 0510 RC inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 REV - IHS-MOA CLINIC VISIT 49259102_1 CDM 0510 RC inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259102_1 CDM 0510 RC inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259102_1 CDM 0510 RC inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259102_1 CDM 0510 RC inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259102_1 CDM 0510 RC inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259102_1 CDM 0510 RC inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259102_1 CDM 0510 RC inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259102_1 CDM 0510 RC inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259102_1 CDM 0510 RC inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 REV - IHS-MOA CLINIC VISIT 49259102_1 CDM 0510 RC inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 REV - IHS-MOA CLINIC VISIT 49259102_1 CDM 0510 RC inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 REV - IHS-MOA CLINIC VISIT 49259102_1 CDM 0510 RC inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 REV - IHS-MOA CLINIC VISIT 49259102_1 CDM 0510 RC inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259102_1 CDM 0510 RC inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 REV - IHS-MOA CLINIC VISIT 49259103_1 CDM 0510 RC inpatient 196 127.4 AETNA AETNA 154.84 79 999999999 118.68 190.12 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259103_1 CDM 0510 RC inpatient 196 127.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 127.4 65 999999999 118.68 190.12 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259103_1 CDM 0510 RC inpatient 196 127.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 190.12 97 999999999 118.68 190.12 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259103_1 CDM 0510 RC inpatient 196 127.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 152.88 78 999999999 118.68 190.12 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259103_1 CDM 0510 RC inpatient 196 127.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 135.24 69 999999999 118.68 190.12 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259103_1 CDM 0510 RC inpatient 196 127.4 UMR - ALL PLANS UMR - ALL PLANS 137.2 70 999999999 118.68 190.12 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259103_1 CDM 0510 RC inpatient 196 127.4 SIHO - ALL PLANS SIHO - ALL PLANS 176.4 90 999999999 118.68 190.12 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259103_1 CDM 0510 RC inpatient 196 127.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 118.68 60.55 999999999 118.68 190.12 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259103_1 CDM 0510 RC inpatient 196 127.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 118.68 190.12 REV - IHS-MOA CLINIC VISIT 49259103_1 CDM 0510 RC inpatient 196 127.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 118.68 190.12 REV - IHS-MOA CLINIC VISIT 49259103_1 CDM 0510 RC inpatient 196 127.4 ANTHEM HMO ANTHEM HMO 999999999 118.68 190.12 REV - IHS-MOA CLINIC VISIT 49259103_1 CDM 0510 RC inpatient 196 127.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 118.68 190.12 REV - IHS-MOA CLINIC VISIT 49259103_1 CDM 0510 RC inpatient 196 127.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 132.5 67.6 999999999 118.68 190.12 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259103_1 CDM 0510 RC inpatient 196 127.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 118.68 190.12 REV - IHS-MOA CLINIC VISIT 49259104_1 CDM 0510 RC inpatient 100 65 AETNA AETNA 79 79 999999999 60.55 97 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259104_1 CDM 0510 RC inpatient 100 65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65 65 999999999 60.55 97 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259104_1 CDM 0510 RC inpatient 100 65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97 97 999999999 60.55 97 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259104_1 CDM 0510 RC inpatient 100 65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78 78 999999999 60.55 97 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259104_1 CDM 0510 RC inpatient 100 65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69 69 999999999 60.55 97 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259104_1 CDM 0510 RC inpatient 100 65 UMR - ALL PLANS UMR - ALL PLANS 70 70 999999999 60.55 97 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259104_1 CDM 0510 RC inpatient 100 65 SIHO - ALL PLANS SIHO - ALL PLANS 90 90 999999999 60.55 97 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259104_1 CDM 0510 RC inpatient 100 65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.55 60.55 999999999 60.55 97 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259104_1 CDM 0510 RC inpatient 100 65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.55 97 REV - IHS-MOA CLINIC VISIT 49259104_1 CDM 0510 RC inpatient 100 65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.55 97 REV - IHS-MOA CLINIC VISIT 49259104_1 CDM 0510 RC inpatient 100 65 ANTHEM HMO ANTHEM HMO 999999999 60.55 97 REV - IHS-MOA CLINIC VISIT 49259104_1 CDM 0510 RC inpatient 100 65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.55 97 REV - IHS-MOA CLINIC VISIT 49259104_1 CDM 0510 RC inpatient 100 65 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.6 67.6 999999999 60.55 97 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259104_1 CDM 0510 RC inpatient 100 65 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.55 97 REV - IHS-MOA CLINIC VISIT 49259105_1 CDM 0510 RC inpatient 250 162.5 AETNA AETNA 197.5 79 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259105_1 CDM 0510 RC inpatient 250 162.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 162.5 65 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259105_1 CDM 0510 RC inpatient 250 162.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 242.5 97 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259105_1 CDM 0510 RC inpatient 250 162.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 195 78 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259105_1 CDM 0510 RC inpatient 250 162.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 172.5 69 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259105_1 CDM 0510 RC inpatient 250 162.5 UMR - ALL PLANS UMR - ALL PLANS 175 70 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259105_1 CDM 0510 RC inpatient 250 162.5 SIHO - ALL PLANS SIHO - ALL PLANS 225 90 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259105_1 CDM 0510 RC inpatient 250 162.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.38 60.55 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259105_1 CDM 0510 RC inpatient 250 162.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.38 242.5 REV - IHS-MOA CLINIC VISIT 49259105_1 CDM 0510 RC inpatient 250 162.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.38 242.5 REV - IHS-MOA CLINIC VISIT 49259105_1 CDM 0510 RC inpatient 250 162.5 ANTHEM HMO ANTHEM HMO 999999999 151.38 242.5 REV - IHS-MOA CLINIC VISIT 49259105_1 CDM 0510 RC inpatient 250 162.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.38 242.5 REV - IHS-MOA CLINIC VISIT 49259105_1 CDM 0510 RC inpatient 250 162.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 169 67.6 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259105_1 CDM 0510 RC inpatient 250 162.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.38 242.5 REV - IHS-MOA CLINIC VISIT 49259106_1 CDM 0510 RC inpatient 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259106_1 CDM 0510 RC inpatient 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259106_1 CDM 0510 RC inpatient 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259106_1 CDM 0510 RC inpatient 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259106_1 CDM 0510 RC inpatient 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259106_1 CDM 0510 RC inpatient 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259106_1 CDM 0510 RC inpatient 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259106_1 CDM 0510 RC inpatient 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259106_1 CDM 0510 RC inpatient 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 REV - IHS-MOA CLINIC VISIT 49259106_1 CDM 0510 RC inpatient 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 REV - IHS-MOA CLINIC VISIT 49259106_1 CDM 0510 RC inpatient 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 REV - IHS-MOA CLINIC VISIT 49259106_1 CDM 0510 RC inpatient 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 REV - IHS-MOA CLINIC VISIT 49259106_1 CDM 0510 RC inpatient 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259106_1 CDM 0510 RC inpatient 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 REV - IHS-MOA CLINIC VISIT 49259107_1 CDM 0510 RC inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259107_1 CDM 0510 RC inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259107_1 CDM 0510 RC inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259107_1 CDM 0510 RC inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259107_1 CDM 0510 RC inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259107_1 CDM 0510 RC inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259107_1 CDM 0510 RC inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259107_1 CDM 0510 RC inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259107_1 CDM 0510 RC inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 REV - IHS-MOA CLINIC VISIT 49259107_1 CDM 0510 RC inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 REV - IHS-MOA CLINIC VISIT 49259107_1 CDM 0510 RC inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 REV - IHS-MOA CLINIC VISIT 49259107_1 CDM 0510 RC inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 REV - IHS-MOA CLINIC VISIT 49259107_1 CDM 0510 RC inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259107_1 CDM 0510 RC inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 "Flow cytometry technique for DNA or cell analysis, first marker" 49259260_1 CDM 0301 RC 88184 HCPCS inpatient 859 558.35 AETNA AETNA 678.61 79 999999999 520.12 833.23 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 49259260_1 CDM 0301 RC 88184 HCPCS inpatient 859 558.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 558.35 65 999999999 520.12 833.23 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 49259260_1 CDM 0301 RC 88184 HCPCS inpatient 859 558.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 833.23 97 999999999 520.12 833.23 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 49259260_1 CDM 0301 RC 88184 HCPCS inpatient 859 558.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 670.02 78 999999999 520.12 833.23 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 49259260_1 CDM 0301 RC 88184 HCPCS inpatient 859 558.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 592.71 69 999999999 520.12 833.23 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 49259260_1 CDM 0301 RC 88184 HCPCS inpatient 859 558.35 UMR - ALL PLANS UMR - ALL PLANS 601.3 70 999999999 520.12 833.23 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 49259260_1 CDM 0301 RC 88184 HCPCS inpatient 859 558.35 SIHO - ALL PLANS SIHO - ALL PLANS 773.1 90 999999999 520.12 833.23 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 49259260_1 CDM 0301 RC 88184 HCPCS inpatient 859 558.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 520.12 60.55 999999999 520.12 833.23 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 49259260_1 CDM 0301 RC 88184 HCPCS inpatient 859 558.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 520.12 833.23 "Flow cytometry technique for DNA or cell analysis, first marker" 49259260_1 CDM 0301 RC 88184 HCPCS inpatient 859 558.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 520.12 833.23 "Flow cytometry technique for DNA or cell analysis, first marker" 49259260_1 CDM 0301 RC 88184 HCPCS inpatient 859 558.35 ANTHEM HMO ANTHEM HMO 999999999 520.12 833.23 "Flow cytometry technique for DNA or cell analysis, first marker" 49259260_1 CDM 0301 RC 88184 HCPCS inpatient 859 558.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 520.12 833.23 "Flow cytometry technique for DNA or cell analysis, first marker" 49259260_1 CDM 0301 RC 88184 HCPCS inpatient 859 558.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 580.68 67.6 999999999 520.12 833.23 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 49259260_1 CDM 0301 RC 88184 HCPCS inpatient 859 558.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 520.12 833.23 "Flow cytometry technique for DNA or cell analysis, each additional marker" 49259261_1 CDM 0301 RC 88185 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 49259261_1 CDM 0301 RC 88185 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 49259261_1 CDM 0301 RC 88185 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 49259261_1 CDM 0301 RC 88185 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 49259261_1 CDM 0301 RC 88185 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 49259261_1 CDM 0301 RC 88185 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 49259261_1 CDM 0301 RC 88185 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 49259261_1 CDM 0301 RC 88185 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 49259261_1 CDM 0301 RC 88185 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 49259261_1 CDM 0301 RC 88185 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 49259261_1 CDM 0301 RC 88185 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 49259261_1 CDM 0301 RC 88185 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 "Flow cytometry technique for DNA or cell analysis, each additional marker" 49259261_1 CDM 0301 RC 88185 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 49259261_1 CDM 0301 RC 88185 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 "Testing for presence of drug, by chemistry analyzers" 49259308_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49259308_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49259308_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49259308_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49259308_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49259308_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49259308_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49259308_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49259308_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49259308_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49259308_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49259308_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49259308_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49259308_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 REV - IHS-MOA CLINIC VISIT 49259429_1 CDM 0510 RC inpatient 140 91 AETNA AETNA 110.6 79 999999999 84.77 135.8 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259429_1 CDM 0510 RC inpatient 140 91 SELF PAY DISCOUNT SELF PAY DISCOUNT 91 65 999999999 84.77 135.8 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259429_1 CDM 0510 RC inpatient 140 91 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 135.8 97 999999999 84.77 135.8 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259429_1 CDM 0510 RC inpatient 140 91 HUMANA - ALL PLANS HUMANA - ALL PLANS 109.2 78 999999999 84.77 135.8 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259429_1 CDM 0510 RC inpatient 140 91 ENCORE - ALL PLANS ENCORE - ALL PLANS 96.6 69 999999999 84.77 135.8 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259429_1 CDM 0510 RC inpatient 140 91 UMR - ALL PLANS UMR - ALL PLANS 98 70 999999999 84.77 135.8 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259429_1 CDM 0510 RC inpatient 140 91 SIHO - ALL PLANS SIHO - ALL PLANS 126 90 999999999 84.77 135.8 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259429_1 CDM 0510 RC inpatient 140 91 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 84.77 60.55 999999999 84.77 135.8 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259429_1 CDM 0510 RC inpatient 140 91 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 84.77 135.8 REV - IHS-MOA CLINIC VISIT 49259429_1 CDM 0510 RC inpatient 140 91 ANTHEM HMO ANTHEM HMO 999999999 84.77 135.8 REV - IHS-MOA CLINIC VISIT 49259429_1 CDM 0510 RC inpatient 140 91 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 84.77 135.8 REV - IHS-MOA CLINIC VISIT 49259429_1 CDM 0510 RC inpatient 140 91 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 84.77 135.8 REV - IHS-MOA CLINIC VISIT 49259429_1 CDM 0510 RC inpatient 140 91 CIGNA - ALL PLANS CIGNA - ALL PLANS 94.64 67.6 999999999 84.77 135.8 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259429_1 CDM 0510 RC inpatient 140 91 UHC - ALL PLANS UHC - ALL PLANS 999999999 84.77 135.8 REV - IHS-MOA CLINIC VISIT 49259430_1 CDM 0510 RC inpatient 250 162.5 AETNA AETNA 197.5 79 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259430_1 CDM 0510 RC inpatient 250 162.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 162.5 65 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259430_1 CDM 0510 RC inpatient 250 162.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 242.5 97 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259430_1 CDM 0510 RC inpatient 250 162.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 195 78 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259430_1 CDM 0510 RC inpatient 250 162.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 172.5 69 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259430_1 CDM 0510 RC inpatient 250 162.5 UMR - ALL PLANS UMR - ALL PLANS 175 70 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259430_1 CDM 0510 RC inpatient 250 162.5 SIHO - ALL PLANS SIHO - ALL PLANS 225 90 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259430_1 CDM 0510 RC inpatient 250 162.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.38 60.55 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259430_1 CDM 0510 RC inpatient 250 162.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.38 242.5 REV - IHS-MOA CLINIC VISIT 49259430_1 CDM 0510 RC inpatient 250 162.5 ANTHEM HMO ANTHEM HMO 999999999 151.38 242.5 REV - IHS-MOA CLINIC VISIT 49259430_1 CDM 0510 RC inpatient 250 162.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.38 242.5 REV - IHS-MOA CLINIC VISIT 49259430_1 CDM 0510 RC inpatient 250 162.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.38 242.5 REV - IHS-MOA CLINIC VISIT 49259430_1 CDM 0510 RC inpatient 250 162.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 169 67.6 999999999 151.38 242.5 percent of total billed charges REV - IHS-MOA CLINIC VISIT 49259430_1 CDM 0510 RC inpatient 250 162.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.38 242.5 "Phenytoin level, free" 49259952_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 AETNA AETNA 170.64 79 999999999 130.79 209.52 percent of total billed charges "Phenytoin level, free" 49259952_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 140.4 65 999999999 130.79 209.52 percent of total billed charges "Phenytoin level, free" 49259952_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 209.52 97 999999999 130.79 209.52 percent of total billed charges "Phenytoin level, free" 49259952_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 168.48 78 999999999 130.79 209.52 percent of total billed charges "Phenytoin level, free" 49259952_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 149.04 69 999999999 130.79 209.52 percent of total billed charges "Phenytoin level, free" 49259952_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 UMR - ALL PLANS UMR - ALL PLANS 151.2 70 999999999 130.79 209.52 percent of total billed charges "Phenytoin level, free" 49259952_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 SIHO - ALL PLANS SIHO - ALL PLANS 194.4 90 999999999 130.79 209.52 percent of total billed charges "Phenytoin level, free" 49259952_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 130.79 60.55 999999999 130.79 209.52 percent of total billed charges "Phenytoin level, free" 49259952_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 130.79 209.52 "Phenytoin level, free" 49259952_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 ANTHEM HMO ANTHEM HMO 999999999 130.79 209.52 "Phenytoin level, free" 49259952_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 130.79 209.52 "Phenytoin level, free" 49259952_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 130.79 209.52 "Phenytoin level, free" 49259952_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 146.02 67.6 999999999 130.79 209.52 percent of total billed charges "Phenytoin level, free" 49259952_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 130.79 209.52 Protein S (clotting inhibitor) measurement 49259955_1 CDM 0301 RC 85306 HCPCS inpatient 315 204.75 AETNA AETNA 248.85 79 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) measurement 49259955_1 CDM 0301 RC 85306 HCPCS inpatient 315 204.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 204.75 65 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) measurement 49259955_1 CDM 0301 RC 85306 HCPCS inpatient 315 204.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 305.55 97 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) measurement 49259955_1 CDM 0301 RC 85306 HCPCS inpatient 315 204.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 245.7 78 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) measurement 49259955_1 CDM 0301 RC 85306 HCPCS inpatient 315 204.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 217.35 69 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) measurement 49259955_1 CDM 0301 RC 85306 HCPCS inpatient 315 204.75 UMR - ALL PLANS UMR - ALL PLANS 220.5 70 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) measurement 49259955_1 CDM 0301 RC 85306 HCPCS inpatient 315 204.75 SIHO - ALL PLANS SIHO - ALL PLANS 283.5 90 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) measurement 49259955_1 CDM 0301 RC 85306 HCPCS inpatient 315 204.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 190.73 60.55 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) measurement 49259955_1 CDM 0301 RC 85306 HCPCS inpatient 315 204.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 190.73 305.55 Protein S (clotting inhibitor) measurement 49259955_1 CDM 0301 RC 85306 HCPCS inpatient 315 204.75 ANTHEM HMO ANTHEM HMO 999999999 190.73 305.55 Protein S (clotting inhibitor) measurement 49259955_1 CDM 0301 RC 85306 HCPCS inpatient 315 204.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 190.73 305.55 Protein S (clotting inhibitor) measurement 49259955_1 CDM 0301 RC 85306 HCPCS inpatient 315 204.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 190.73 305.55 Protein S (clotting inhibitor) measurement 49259955_1 CDM 0301 RC 85306 HCPCS inpatient 315 204.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 212.94 67.6 999999999 190.73 305.55 percent of total billed charges Protein S (clotting inhibitor) measurement 49259955_1 CDM 0301 RC 85306 HCPCS inpatient 315 204.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 190.73 305.55 "Enzyme activity measurement, nonradioactive substrate" 49259963_1 CDM 0301 RC 82657 HCPCS inpatient 277 180.05 AETNA AETNA 218.83 79 999999999 167.72 268.69 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49259963_1 CDM 0301 RC 82657 HCPCS inpatient 277 180.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 180.05 65 999999999 167.72 268.69 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49259963_1 CDM 0301 RC 82657 HCPCS inpatient 277 180.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 268.69 97 999999999 167.72 268.69 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49259963_1 CDM 0301 RC 82657 HCPCS inpatient 277 180.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 216.06 78 999999999 167.72 268.69 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49259963_1 CDM 0301 RC 82657 HCPCS inpatient 277 180.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 191.13 69 999999999 167.72 268.69 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49259963_1 CDM 0301 RC 82657 HCPCS inpatient 277 180.05 UMR - ALL PLANS UMR - ALL PLANS 193.9 70 999999999 167.72 268.69 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49259963_1 CDM 0301 RC 82657 HCPCS inpatient 277 180.05 SIHO - ALL PLANS SIHO - ALL PLANS 249.3 90 999999999 167.72 268.69 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49259963_1 CDM 0301 RC 82657 HCPCS inpatient 277 180.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 167.72 60.55 999999999 167.72 268.69 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49259963_1 CDM 0301 RC 82657 HCPCS inpatient 277 180.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 167.72 268.69 "Enzyme activity measurement, nonradioactive substrate" 49259963_1 CDM 0301 RC 82657 HCPCS inpatient 277 180.05 ANTHEM HMO ANTHEM HMO 999999999 167.72 268.69 "Enzyme activity measurement, nonradioactive substrate" 49259963_1 CDM 0301 RC 82657 HCPCS inpatient 277 180.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 167.72 268.69 "Enzyme activity measurement, nonradioactive substrate" 49259963_1 CDM 0301 RC 82657 HCPCS inpatient 277 180.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 167.72 268.69 "Enzyme activity measurement, nonradioactive substrate" 49259963_1 CDM 0301 RC 82657 HCPCS inpatient 277 180.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 187.25 67.6 999999999 167.72 268.69 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49259963_1 CDM 0301 RC 82657 HCPCS inpatient 277 180.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 167.72 268.69 Measurement of substance using immunoassay technique 49259964_1 CDM 0301 RC 83520 HCPCS inpatient 93 60.45 AETNA AETNA 73.47 79 999999999 56.31 90.21 percent of total billed charges Measurement of substance using immunoassay technique 49259964_1 CDM 0301 RC 83520 HCPCS inpatient 93 60.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 60.45 65 999999999 56.31 90.21 percent of total billed charges Measurement of substance using immunoassay technique 49259964_1 CDM 0301 RC 83520 HCPCS inpatient 93 60.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 90.21 97 999999999 56.31 90.21 percent of total billed charges Measurement of substance using immunoassay technique 49259964_1 CDM 0301 RC 83520 HCPCS inpatient 93 60.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 72.54 78 999999999 56.31 90.21 percent of total billed charges Measurement of substance using immunoassay technique 49259964_1 CDM 0301 RC 83520 HCPCS inpatient 93 60.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.17 69 999999999 56.31 90.21 percent of total billed charges Measurement of substance using immunoassay technique 49259964_1 CDM 0301 RC 83520 HCPCS inpatient 93 60.45 UMR - ALL PLANS UMR - ALL PLANS 65.1 70 999999999 56.31 90.21 percent of total billed charges Measurement of substance using immunoassay technique 49259964_1 CDM 0301 RC 83520 HCPCS inpatient 93 60.45 SIHO - ALL PLANS SIHO - ALL PLANS 83.7 90 999999999 56.31 90.21 percent of total billed charges Measurement of substance using immunoassay technique 49259964_1 CDM 0301 RC 83520 HCPCS inpatient 93 60.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.31 60.55 999999999 56.31 90.21 percent of total billed charges Measurement of substance using immunoassay technique 49259964_1 CDM 0301 RC 83520 HCPCS inpatient 93 60.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.31 90.21 Measurement of substance using immunoassay technique 49259964_1 CDM 0301 RC 83520 HCPCS inpatient 93 60.45 ANTHEM HMO ANTHEM HMO 999999999 56.31 90.21 Measurement of substance using immunoassay technique 49259964_1 CDM 0301 RC 83520 HCPCS inpatient 93 60.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.31 90.21 Measurement of substance using immunoassay technique 49259964_1 CDM 0301 RC 83520 HCPCS inpatient 93 60.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.31 90.21 Measurement of substance using immunoassay technique 49259964_1 CDM 0301 RC 83520 HCPCS inpatient 93 60.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.87 67.6 999999999 56.31 90.21 percent of total billed charges Measurement of substance using immunoassay technique 49259964_1 CDM 0301 RC 83520 HCPCS inpatient 93 60.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.31 90.21 Blood viscosity measurement 49259965_1 CDM 0301 RC 85810 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Blood viscosity measurement 49259965_1 CDM 0301 RC 85810 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Blood viscosity measurement 49259965_1 CDM 0301 RC 85810 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Blood viscosity measurement 49259965_1 CDM 0301 RC 85810 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Blood viscosity measurement 49259965_1 CDM 0301 RC 85810 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Blood viscosity measurement 49259965_1 CDM 0301 RC 85810 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Blood viscosity measurement 49259965_1 CDM 0301 RC 85810 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Blood viscosity measurement 49259965_1 CDM 0301 RC 85810 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Blood viscosity measurement 49259965_1 CDM 0301 RC 85810 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Blood viscosity measurement 49259965_1 CDM 0301 RC 85810 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Blood viscosity measurement 49259965_1 CDM 0301 RC 85810 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Blood viscosity measurement 49259965_1 CDM 0301 RC 85810 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Blood viscosity measurement 49259965_1 CDM 0301 RC 85810 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges Blood viscosity measurement 49259965_1 CDM 0301 RC 85810 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 Vitamin measurement 49259966_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 AETNA AETNA 156.42 79 999999999 119.89 192.06 percent of total billed charges Vitamin measurement 49259966_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.7 65 999999999 119.89 192.06 percent of total billed charges Vitamin measurement 49259966_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 192.06 97 999999999 119.89 192.06 percent of total billed charges Vitamin measurement 49259966_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 154.44 78 999999999 119.89 192.06 percent of total billed charges Vitamin measurement 49259966_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 136.62 69 999999999 119.89 192.06 percent of total billed charges Vitamin measurement 49259966_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 UMR - ALL PLANS UMR - ALL PLANS 138.6 70 999999999 119.89 192.06 percent of total billed charges Vitamin measurement 49259966_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 SIHO - ALL PLANS SIHO - ALL PLANS 178.2 90 999999999 119.89 192.06 percent of total billed charges Vitamin measurement 49259966_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.89 60.55 999999999 119.89 192.06 percent of total billed charges Vitamin measurement 49259966_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.89 192.06 Vitamin measurement 49259966_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 ANTHEM HMO ANTHEM HMO 999999999 119.89 192.06 Vitamin measurement 49259966_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.89 192.06 Vitamin measurement 49259966_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.89 192.06 Vitamin measurement 49259966_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.85 67.6 999999999 119.89 192.06 percent of total billed charges Vitamin measurement 49259966_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.89 192.06 Vitamin K level 49259967_1 CDM 0301 RC 84597 HCPCS inpatient 239 155.35 AETNA AETNA 188.81 79 999999999 144.71 231.83 percent of total billed charges Vitamin K level 49259967_1 CDM 0301 RC 84597 HCPCS inpatient 239 155.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 155.35 65 999999999 144.71 231.83 percent of total billed charges Vitamin K level 49259967_1 CDM 0301 RC 84597 HCPCS inpatient 239 155.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 231.83 97 999999999 144.71 231.83 percent of total billed charges Vitamin K level 49259967_1 CDM 0301 RC 84597 HCPCS inpatient 239 155.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 186.42 78 999999999 144.71 231.83 percent of total billed charges Vitamin K level 49259967_1 CDM 0301 RC 84597 HCPCS inpatient 239 155.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.91 69 999999999 144.71 231.83 percent of total billed charges Vitamin K level 49259967_1 CDM 0301 RC 84597 HCPCS inpatient 239 155.35 UMR - ALL PLANS UMR - ALL PLANS 167.3 70 999999999 144.71 231.83 percent of total billed charges Vitamin K level 49259967_1 CDM 0301 RC 84597 HCPCS inpatient 239 155.35 SIHO - ALL PLANS SIHO - ALL PLANS 215.1 90 999999999 144.71 231.83 percent of total billed charges Vitamin K level 49259967_1 CDM 0301 RC 84597 HCPCS inpatient 239 155.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.71 60.55 999999999 144.71 231.83 percent of total billed charges Vitamin K level 49259967_1 CDM 0301 RC 84597 HCPCS inpatient 239 155.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.71 231.83 Vitamin K level 49259967_1 CDM 0301 RC 84597 HCPCS inpatient 239 155.35 ANTHEM HMO ANTHEM HMO 999999999 144.71 231.83 Vitamin K level 49259967_1 CDM 0301 RC 84597 HCPCS inpatient 239 155.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.71 231.83 Vitamin K level 49259967_1 CDM 0301 RC 84597 HCPCS inpatient 239 155.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.71 231.83 Vitamin K level 49259967_1 CDM 0301 RC 84597 HCPCS inpatient 239 155.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 161.56 67.6 999999999 144.71 231.83 percent of total billed charges Vitamin K level 49259967_1 CDM 0301 RC 84597 HCPCS inpatient 239 155.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.71 231.83 Zonisamide level 49259968_1 CDM 0301 RC 80203 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges Zonisamide level 49259968_1 CDM 0301 RC 80203 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges Zonisamide level 49259968_1 CDM 0301 RC 80203 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges Zonisamide level 49259968_1 CDM 0301 RC 80203 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges Zonisamide level 49259968_1 CDM 0301 RC 80203 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges Zonisamide level 49259968_1 CDM 0301 RC 80203 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges Zonisamide level 49259968_1 CDM 0301 RC 80203 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges Zonisamide level 49259968_1 CDM 0301 RC 80203 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges Zonisamide level 49259968_1 CDM 0301 RC 80203 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 Zonisamide level 49259968_1 CDM 0301 RC 80203 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 Zonisamide level 49259968_1 CDM 0301 RC 80203 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 Zonisamide level 49259968_1 CDM 0301 RC 80203 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 Zonisamide level 49259968_1 CDM 0301 RC 80203 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges Zonisamide level 49259968_1 CDM 0301 RC 80203 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 Detection test by immunoassay technique for other organism 49261934_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 49261934_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 49261934_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 49261934_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 49261934_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 49261934_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 49261934_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 49261934_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 49261934_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 Detection test by immunoassay technique for other organism 49261934_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 Detection test by immunoassay technique for other organism 49261934_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 Detection test by immunoassay technique for other organism 49261934_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 Detection test by immunoassay technique for other organism 49261934_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 49261934_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 NEUPOGEN 480 MCG/0.8 ML SYR 49262183_1 CDM 0250 RC 55513-0209-91 NDC J1441 HCPCS inpatient 480 UN 1913.02 1243.46 AETNA AETNA 1511.29 79 999999999 1158.33 1855.63 percent of total billed charges NEUPOGEN 480 MCG/0.8 ML SYR 49262183_1 CDM 0250 RC 55513-0209-91 NDC J1441 HCPCS inpatient 480 UN 1913.02 1243.46 SELF PAY DISCOUNT SELF PAY DISCOUNT 1243.46 65 999999999 1158.33 1855.63 percent of total billed charges NEUPOGEN 480 MCG/0.8 ML SYR 49262183_1 CDM 0250 RC 55513-0209-91 NDC J1441 HCPCS inpatient 480 UN 1913.02 1243.46 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1855.63 97 999999999 1158.33 1855.63 percent of total billed charges NEUPOGEN 480 MCG/0.8 ML SYR 49262183_1 CDM 0250 RC 55513-0209-91 NDC J1441 HCPCS inpatient 480 UN 1913.02 1243.46 HUMANA - ALL PLANS HUMANA - ALL PLANS 1492.16 78 999999999 1158.33 1855.63 percent of total billed charges NEUPOGEN 480 MCG/0.8 ML SYR 49262183_1 CDM 0250 RC 55513-0209-91 NDC J1441 HCPCS inpatient 480 UN 1913.02 1243.46 ENCORE - ALL PLANS ENCORE - ALL PLANS 1319.98 69 999999999 1158.33 1855.63 percent of total billed charges NEUPOGEN 480 MCG/0.8 ML SYR 49262183_1 CDM 0250 RC 55513-0209-91 NDC J1441 HCPCS inpatient 480 UN 1913.02 1243.46 UMR - ALL PLANS UMR - ALL PLANS 1339.11 70 999999999 1158.33 1855.63 percent of total billed charges NEUPOGEN 480 MCG/0.8 ML SYR 49262183_1 CDM 0250 RC 55513-0209-91 NDC J1441 HCPCS inpatient 480 UN 1913.02 1243.46 SIHO - ALL PLANS SIHO - ALL PLANS 1721.72 90 999999999 1158.33 1855.63 percent of total billed charges NEUPOGEN 480 MCG/0.8 ML SYR 49262183_1 CDM 0250 RC 55513-0209-91 NDC J1441 HCPCS inpatient 480 UN 1913.02 1243.46 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1158.33 60.55 999999999 1158.33 1855.63 percent of total billed charges NEUPOGEN 480 MCG/0.8 ML SYR 49262183_1 CDM 0250 RC 55513-0209-91 NDC J1441 HCPCS inpatient 480 UN 1913.02 1243.46 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1158.33 1855.63 NEUPOGEN 480 MCG/0.8 ML SYR 49262183_1 CDM 0250 RC 55513-0209-91 NDC J1441 HCPCS inpatient 480 UN 1913.02 1243.46 ANTHEM HMO ANTHEM HMO 999999999 1158.33 1855.63 NEUPOGEN 480 MCG/0.8 ML SYR 49262183_1 CDM 0250 RC 55513-0209-91 NDC J1441 HCPCS inpatient 480 UN 1913.02 1243.46 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1158.33 1855.63 NEUPOGEN 480 MCG/0.8 ML SYR 49262183_1 CDM 0250 RC 55513-0209-91 NDC J1441 HCPCS inpatient 480 UN 1913.02 1243.46 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1158.33 1855.63 NEUPOGEN 480 MCG/0.8 ML SYR 49262183_1 CDM 0250 RC 55513-0209-91 NDC J1441 HCPCS inpatient 480 UN 1913.02 1243.46 CIGNA - ALL PLANS CIGNA - ALL PLANS 1293.2 67.6 999999999 1158.33 1855.63 percent of total billed charges NEUPOGEN 480 MCG/0.8 ML SYR 49262183_1 CDM 0250 RC 55513-0209-91 NDC J1441 HCPCS inpatient 480 UN 1913.02 1243.46 UHC - ALL PLANS UHC - ALL PLANS 999999999 1158.33 1855.63 Citrate level 49262243_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 AETNA AETNA 225.94 79 999999999 173.17 277.42 percent of total billed charges Citrate level 49262243_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.9 65 999999999 173.17 277.42 percent of total billed charges Citrate level 49262243_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 277.42 97 999999999 173.17 277.42 percent of total billed charges Citrate level 49262243_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 223.08 78 999999999 173.17 277.42 percent of total billed charges Citrate level 49262243_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 197.34 69 999999999 173.17 277.42 percent of total billed charges Citrate level 49262243_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 UMR - ALL PLANS UMR - ALL PLANS 200.2 70 999999999 173.17 277.42 percent of total billed charges Citrate level 49262243_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 SIHO - ALL PLANS SIHO - ALL PLANS 257.4 90 999999999 173.17 277.42 percent of total billed charges Citrate level 49262243_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 173.17 60.55 999999999 173.17 277.42 percent of total billed charges Citrate level 49262243_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 173.17 277.42 Citrate level 49262243_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 ANTHEM HMO ANTHEM HMO 999999999 173.17 277.42 Citrate level 49262243_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 173.17 277.42 Citrate level 49262243_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 173.17 277.42 Citrate level 49262243_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 193.34 67.6 999999999 173.17 277.42 percent of total billed charges Citrate level 49262243_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 173.17 277.42 Biopsy of bone marrow 49262274_1 CDM 0320 RC 38221 HCPCS inpatient 2817 1831.05 AETNA AETNA 2225.43 79 999999999 1705.69 2732.49 percent of total billed charges Biopsy of bone marrow 49262274_1 CDM 0320 RC 38221 HCPCS inpatient 2817 1831.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1831.05 65 999999999 1705.69 2732.49 percent of total billed charges Biopsy of bone marrow 49262274_1 CDM 0320 RC 38221 HCPCS inpatient 2817 1831.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2732.49 97 999999999 1705.69 2732.49 percent of total billed charges Biopsy of bone marrow 49262274_1 CDM 0320 RC 38221 HCPCS inpatient 2817 1831.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 2197.26 78 999999999 1705.69 2732.49 percent of total billed charges Biopsy of bone marrow 49262274_1 CDM 0320 RC 38221 HCPCS inpatient 2817 1831.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1943.73 69 999999999 1705.69 2732.49 percent of total billed charges Biopsy of bone marrow 49262274_1 CDM 0320 RC 38221 HCPCS inpatient 2817 1831.05 UMR - ALL PLANS UMR - ALL PLANS 1971.9 70 999999999 1705.69 2732.49 percent of total billed charges Biopsy of bone marrow 49262274_1 CDM 0320 RC 38221 HCPCS inpatient 2817 1831.05 SIHO - ALL PLANS SIHO - ALL PLANS 2535.3 90 999999999 1705.69 2732.49 percent of total billed charges Biopsy of bone marrow 49262274_1 CDM 0320 RC 38221 HCPCS inpatient 2817 1831.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1705.69 60.55 999999999 1705.69 2732.49 percent of total billed charges Biopsy of bone marrow 49262274_1 CDM 0320 RC 38221 HCPCS inpatient 2817 1831.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1705.69 2732.49 Biopsy of bone marrow 49262274_1 CDM 0320 RC 38221 HCPCS inpatient 2817 1831.05 ANTHEM HMO ANTHEM HMO 999999999 1705.69 2732.49 Biopsy of bone marrow 49262274_1 CDM 0320 RC 38221 HCPCS inpatient 2817 1831.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1705.69 2732.49 Biopsy of bone marrow 49262274_1 CDM 0320 RC 38221 HCPCS inpatient 2817 1831.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1705.69 2732.49 Biopsy of bone marrow 49262274_1 CDM 0320 RC 38221 HCPCS inpatient 2817 1831.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1904.29 67.6 999999999 1705.69 2732.49 percent of total billed charges Biopsy of bone marrow 49262274_1 CDM 0320 RC 38221 HCPCS inpatient 2817 1831.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1705.69 2732.49 Review by radiologist of CT guidance for needle placement 49262275_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 AETNA AETNA 1467.82 79 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 49262275_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1207.7 65 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 49262275_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1802.26 97 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 49262275_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1449.24 78 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 49262275_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1282.02 69 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 49262275_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 UMR - ALL PLANS UMR - ALL PLANS 1300.6 70 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 49262275_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 SIHO - ALL PLANS SIHO - ALL PLANS 1672.2 90 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 49262275_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1125.02 60.55 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 49262275_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 49262275_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 ANTHEM HMO ANTHEM HMO 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 49262275_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 49262275_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1125.02 1802.26 Review by radiologist of CT guidance for needle placement 49262275_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1256.01 67.6 999999999 1125.02 1802.26 percent of total billed charges Review by radiologist of CT guidance for needle placement 49262275_1 CDM 0320 RC 77012 HCPCS inpatient 1858 1207.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 1125.02 1802.26 Ethosuximide level 49262289_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 AETNA AETNA 126.4 79 999999999 96.88 155.2 percent of total billed charges Ethosuximide level 49262289_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 SELF PAY DISCOUNT SELF PAY DISCOUNT 104 65 999999999 96.88 155.2 percent of total billed charges Ethosuximide level 49262289_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 155.2 97 999999999 96.88 155.2 percent of total billed charges Ethosuximide level 49262289_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 HUMANA - ALL PLANS HUMANA - ALL PLANS 124.8 78 999999999 96.88 155.2 percent of total billed charges Ethosuximide level 49262289_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 ENCORE - ALL PLANS ENCORE - ALL PLANS 110.4 69 999999999 96.88 155.2 percent of total billed charges Ethosuximide level 49262289_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 UMR - ALL PLANS UMR - ALL PLANS 112 70 999999999 96.88 155.2 percent of total billed charges Ethosuximide level 49262289_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 SIHO - ALL PLANS SIHO - ALL PLANS 144 90 999999999 96.88 155.2 percent of total billed charges Ethosuximide level 49262289_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 96.88 60.55 999999999 96.88 155.2 percent of total billed charges Ethosuximide level 49262289_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 96.88 155.2 Ethosuximide level 49262289_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 ANTHEM HMO ANTHEM HMO 999999999 96.88 155.2 Ethosuximide level 49262289_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 96.88 155.2 Ethosuximide level 49262289_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 96.88 155.2 Ethosuximide level 49262289_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.16 67.6 999999999 96.88 155.2 percent of total billed charges Ethosuximide level 49262289_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 UHC - ALL PLANS UHC - ALL PLANS 999999999 96.88 155.2 ELIQUIS 5 MG TABLET 49263358_1 CDM 0250 RC 00003-0894-31 NDC inpatient 1 UN 28.79 18.71 AETNA AETNA 22.74 79 999999999 17.43 27.93 percent of total billed charges ELIQUIS 5 MG TABLET 49263358_1 CDM 0250 RC 00003-0894-31 NDC inpatient 1 UN 28.79 18.71 SELF PAY DISCOUNT SELF PAY DISCOUNT 18.71 65 999999999 17.43 27.93 percent of total billed charges ELIQUIS 5 MG TABLET 49263358_1 CDM 0250 RC 00003-0894-31 NDC inpatient 1 UN 28.79 18.71 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 27.93 97 999999999 17.43 27.93 percent of total billed charges ELIQUIS 5 MG TABLET 49263358_1 CDM 0250 RC 00003-0894-31 NDC inpatient 1 UN 28.79 18.71 HUMANA - ALL PLANS HUMANA - ALL PLANS 22.46 78 999999999 17.43 27.93 percent of total billed charges ELIQUIS 5 MG TABLET 49263358_1 CDM 0250 RC 00003-0894-31 NDC inpatient 1 UN 28.79 18.71 ENCORE - ALL PLANS ENCORE - ALL PLANS 19.87 69 999999999 17.43 27.93 percent of total billed charges ELIQUIS 5 MG TABLET 49263358_1 CDM 0250 RC 00003-0894-31 NDC inpatient 1 UN 28.79 18.71 UMR - ALL PLANS UMR - ALL PLANS 20.15 70 999999999 17.43 27.93 percent of total billed charges ELIQUIS 5 MG TABLET 49263358_1 CDM 0250 RC 00003-0894-31 NDC inpatient 1 UN 28.79 18.71 SIHO - ALL PLANS SIHO - ALL PLANS 25.91 90 999999999 17.43 27.93 percent of total billed charges ELIQUIS 5 MG TABLET 49263358_1 CDM 0250 RC 00003-0894-31 NDC inpatient 1 UN 28.79 18.71 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17.43 60.55 999999999 17.43 27.93 percent of total billed charges ELIQUIS 5 MG TABLET 49263358_1 CDM 0250 RC 00003-0894-31 NDC inpatient 1 UN 28.79 18.71 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 17.43 27.93 ELIQUIS 5 MG TABLET 49263358_1 CDM 0250 RC 00003-0894-31 NDC inpatient 1 UN 28.79 18.71 ANTHEM HMO ANTHEM HMO 999999999 17.43 27.93 ELIQUIS 5 MG TABLET 49263358_1 CDM 0250 RC 00003-0894-31 NDC inpatient 1 UN 28.79 18.71 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 17.43 27.93 ELIQUIS 5 MG TABLET 49263358_1 CDM 0250 RC 00003-0894-31 NDC inpatient 1 UN 28.79 18.71 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 17.43 27.93 ELIQUIS 5 MG TABLET 49263358_1 CDM 0250 RC 00003-0894-31 NDC inpatient 1 UN 28.79 18.71 CIGNA - ALL PLANS CIGNA - ALL PLANS 19.46 67.6 999999999 17.43 27.93 percent of total billed charges ELIQUIS 5 MG TABLET 49263358_1 CDM 0250 RC 00003-0894-31 NDC inpatient 1 UN 28.79 18.71 UHC - ALL PLANS UHC - ALL PLANS 999999999 17.43 27.93 LINZESS 290 MCG CAPSULE 49263392_1 CDM 0250 RC 00456-1202-30 NDC inpatient 1 UN 62.88 40.87 AETNA AETNA 49.68 79 999999999 38.07 60.99 percent of total billed charges LINZESS 290 MCG CAPSULE 49263392_1 CDM 0250 RC 00456-1202-30 NDC inpatient 1 UN 62.88 40.87 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.87 65 999999999 38.07 60.99 percent of total billed charges LINZESS 290 MCG CAPSULE 49263392_1 CDM 0250 RC 00456-1202-30 NDC inpatient 1 UN 62.88 40.87 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 60.99 97 999999999 38.07 60.99 percent of total billed charges LINZESS 290 MCG CAPSULE 49263392_1 CDM 0250 RC 00456-1202-30 NDC inpatient 1 UN 62.88 40.87 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.05 78 999999999 38.07 60.99 percent of total billed charges LINZESS 290 MCG CAPSULE 49263392_1 CDM 0250 RC 00456-1202-30 NDC inpatient 1 UN 62.88 40.87 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.39 69 999999999 38.07 60.99 percent of total billed charges LINZESS 290 MCG CAPSULE 49263392_1 CDM 0250 RC 00456-1202-30 NDC inpatient 1 UN 62.88 40.87 UMR - ALL PLANS UMR - ALL PLANS 44.02 70 999999999 38.07 60.99 percent of total billed charges LINZESS 290 MCG CAPSULE 49263392_1 CDM 0250 RC 00456-1202-30 NDC inpatient 1 UN 62.88 40.87 SIHO - ALL PLANS SIHO - ALL PLANS 56.59 90 999999999 38.07 60.99 percent of total billed charges LINZESS 290 MCG CAPSULE 49263392_1 CDM 0250 RC 00456-1202-30 NDC inpatient 1 UN 62.88 40.87 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.07 60.55 999999999 38.07 60.99 percent of total billed charges LINZESS 290 MCG CAPSULE 49263392_1 CDM 0250 RC 00456-1202-30 NDC inpatient 1 UN 62.88 40.87 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.07 60.99 LINZESS 290 MCG CAPSULE 49263392_1 CDM 0250 RC 00456-1202-30 NDC inpatient 1 UN 62.88 40.87 ANTHEM HMO ANTHEM HMO 999999999 38.07 60.99 LINZESS 290 MCG CAPSULE 49263392_1 CDM 0250 RC 00456-1202-30 NDC inpatient 1 UN 62.88 40.87 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.07 60.99 LINZESS 290 MCG CAPSULE 49263392_1 CDM 0250 RC 00456-1202-30 NDC inpatient 1 UN 62.88 40.87 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.07 60.99 LINZESS 290 MCG CAPSULE 49263392_1 CDM 0250 RC 00456-1202-30 NDC inpatient 1 UN 62.88 40.87 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.51 67.6 999999999 38.07 60.99 percent of total billed charges LINZESS 290 MCG CAPSULE 49263392_1 CDM 0250 RC 00456-1202-30 NDC inpatient 1 UN 62.88 40.87 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.07 60.99 *****BLANKET BY M. PALMER 07/26/2023***** RAD 40 BLADE 1884006EM 49264479_1 CDM 0272 RC inpatient 556 361.4 AETNA AETNA 439.24 79 999999999 336.66 539.32 percent of total billed charges *****BLANKET BY M. PALMER 07/26/2023***** RAD 40 BLADE 1884006EM 49264479_1 CDM 0272 RC inpatient 556 361.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 361.4 65 999999999 336.66 539.32 percent of total billed charges *****BLANKET BY M. PALMER 07/26/2023***** RAD 40 BLADE 1884006EM 49264479_1 CDM 0272 RC inpatient 556 361.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 539.32 97 999999999 336.66 539.32 percent of total billed charges *****BLANKET BY M. PALMER 07/26/2023***** RAD 40 BLADE 1884006EM 49264479_1 CDM 0272 RC inpatient 556 361.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 433.68 78 999999999 336.66 539.32 percent of total billed charges *****BLANKET BY M. PALMER 07/26/2023***** RAD 40 BLADE 1884006EM 49264479_1 CDM 0272 RC inpatient 556 361.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 383.64 69 999999999 336.66 539.32 percent of total billed charges *****BLANKET BY M. PALMER 07/26/2023***** RAD 40 BLADE 1884006EM 49264479_1 CDM 0272 RC inpatient 556 361.4 UMR - ALL PLANS UMR - ALL PLANS 389.2 70 999999999 336.66 539.32 percent of total billed charges *****BLANKET BY M. PALMER 07/26/2023***** RAD 40 BLADE 1884006EM 49264479_1 CDM 0272 RC inpatient 556 361.4 SIHO - ALL PLANS SIHO - ALL PLANS 500.4 90 999999999 336.66 539.32 percent of total billed charges *****BLANKET BY M. PALMER 07/26/2023***** RAD 40 BLADE 1884006EM 49264479_1 CDM 0272 RC inpatient 556 361.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 336.66 60.55 999999999 336.66 539.32 percent of total billed charges *****BLANKET BY M. PALMER 07/26/2023***** RAD 40 BLADE 1884006EM 49264479_1 CDM 0272 RC inpatient 556 361.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 336.66 539.32 *****BLANKET BY M. PALMER 07/26/2023***** RAD 40 BLADE 1884006EM 49264479_1 CDM 0272 RC inpatient 556 361.4 ANTHEM HMO ANTHEM HMO 999999999 336.66 539.32 *****BLANKET BY M. PALMER 07/26/2023***** RAD 40 BLADE 1884006EM 49264479_1 CDM 0272 RC inpatient 556 361.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 336.66 539.32 *****BLANKET BY M. PALMER 07/26/2023***** RAD 40 BLADE 1884006EM 49264479_1 CDM 0272 RC inpatient 556 361.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 336.66 539.32 *****BLANKET BY M. PALMER 07/26/2023***** RAD 40 BLADE 1884006EM 49264479_1 CDM 0272 RC inpatient 556 361.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 375.86 67.6 999999999 336.66 539.32 percent of total billed charges *****BLANKET BY M. PALMER 07/26/2023***** RAD 40 BLADE 1884006EM 49264479_1 CDM 0272 RC inpatient 556 361.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 336.66 539.32 **** BLANKET BY M. PALMER 07/26/2023**** BLADE QUADCUT 4.3MMX13CM 1884380EM 49264496_1 CDM 0272 RC inpatient 1092 709.8 AETNA AETNA 862.68 79 999999999 661.21 1059.24 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** BLADE QUADCUT 4.3MMX13CM 1884380EM 49264496_1 CDM 0272 RC inpatient 1092 709.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 709.8 65 999999999 661.21 1059.24 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** BLADE QUADCUT 4.3MMX13CM 1884380EM 49264496_1 CDM 0272 RC inpatient 1092 709.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1059.24 97 999999999 661.21 1059.24 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** BLADE QUADCUT 4.3MMX13CM 1884380EM 49264496_1 CDM 0272 RC inpatient 1092 709.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 851.76 78 999999999 661.21 1059.24 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** BLADE QUADCUT 4.3MMX13CM 1884380EM 49264496_1 CDM 0272 RC inpatient 1092 709.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 753.48 69 999999999 661.21 1059.24 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** BLADE QUADCUT 4.3MMX13CM 1884380EM 49264496_1 CDM 0272 RC inpatient 1092 709.8 UMR - ALL PLANS UMR - ALL PLANS 764.4 70 999999999 661.21 1059.24 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** BLADE QUADCUT 4.3MMX13CM 1884380EM 49264496_1 CDM 0272 RC inpatient 1092 709.8 SIHO - ALL PLANS SIHO - ALL PLANS 982.8 90 999999999 661.21 1059.24 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** BLADE QUADCUT 4.3MMX13CM 1884380EM 49264496_1 CDM 0272 RC inpatient 1092 709.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 661.21 60.55 999999999 661.21 1059.24 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** BLADE QUADCUT 4.3MMX13CM 1884380EM 49264496_1 CDM 0272 RC inpatient 1092 709.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 661.21 1059.24 **** BLANKET BY M. PALMER 07/26/2023**** BLADE QUADCUT 4.3MMX13CM 1884380EM 49264496_1 CDM 0272 RC inpatient 1092 709.8 ANTHEM HMO ANTHEM HMO 999999999 661.21 1059.24 **** BLANKET BY M. PALMER 07/26/2023**** BLADE QUADCUT 4.3MMX13CM 1884380EM 49264496_1 CDM 0272 RC inpatient 1092 709.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 661.21 1059.24 **** BLANKET BY M. PALMER 07/26/2023**** BLADE QUADCUT 4.3MMX13CM 1884380EM 49264496_1 CDM 0272 RC inpatient 1092 709.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 661.21 1059.24 **** BLANKET BY M. PALMER 07/26/2023**** BLADE QUADCUT 4.3MMX13CM 1884380EM 49264496_1 CDM 0272 RC inpatient 1092 709.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 738.19 67.6 999999999 661.21 1059.24 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** BLADE QUADCUT 4.3MMX13CM 1884380EM 49264496_1 CDM 0272 RC inpatient 1092 709.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 661.21 1059.24 ELECTRODE 2 CHANNEL SET 49265360_1 CDM 0270 RC inpatient 613 398.45 AETNA AETNA 484.27 79 999999999 371.17 594.61 percent of total billed charges ELECTRODE 2 CHANNEL SET 49265360_1 CDM 0270 RC inpatient 613 398.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 398.45 65 999999999 371.17 594.61 percent of total billed charges ELECTRODE 2 CHANNEL SET 49265360_1 CDM 0270 RC inpatient 613 398.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 594.61 97 999999999 371.17 594.61 percent of total billed charges ELECTRODE 2 CHANNEL SET 49265360_1 CDM 0270 RC inpatient 613 398.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 478.14 78 999999999 371.17 594.61 percent of total billed charges ELECTRODE 2 CHANNEL SET 49265360_1 CDM 0270 RC inpatient 613 398.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 422.97 69 999999999 371.17 594.61 percent of total billed charges ELECTRODE 2 CHANNEL SET 49265360_1 CDM 0270 RC inpatient 613 398.45 UMR - ALL PLANS UMR - ALL PLANS 429.1 70 999999999 371.17 594.61 percent of total billed charges ELECTRODE 2 CHANNEL SET 49265360_1 CDM 0270 RC inpatient 613 398.45 SIHO - ALL PLANS SIHO - ALL PLANS 551.7 90 999999999 371.17 594.61 percent of total billed charges ELECTRODE 2 CHANNEL SET 49265360_1 CDM 0270 RC inpatient 613 398.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 371.17 60.55 999999999 371.17 594.61 percent of total billed charges ELECTRODE 2 CHANNEL SET 49265360_1 CDM 0270 RC inpatient 613 398.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 371.17 594.61 ELECTRODE 2 CHANNEL SET 49265360_1 CDM 0270 RC inpatient 613 398.45 ANTHEM HMO ANTHEM HMO 999999999 371.17 594.61 ELECTRODE 2 CHANNEL SET 49265360_1 CDM 0270 RC inpatient 613 398.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 371.17 594.61 ELECTRODE 2 CHANNEL SET 49265360_1 CDM 0270 RC inpatient 613 398.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 371.17 594.61 ELECTRODE 2 CHANNEL SET 49265360_1 CDM 0270 RC inpatient 613 398.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 414.39 67.6 999999999 371.17 594.61 percent of total billed charges ELECTRODE 2 CHANNEL SET 49265360_1 CDM 0270 RC inpatient 613 398.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 371.17 594.61 ELECTRODE 4 CHANNEL SET 8227411 49265361_1 CDM 0270 RC inpatient 820 533 AETNA AETNA 647.8 79 999999999 496.51 795.4 percent of total billed charges ELECTRODE 4 CHANNEL SET 8227411 49265361_1 CDM 0270 RC inpatient 820 533 SELF PAY DISCOUNT SELF PAY DISCOUNT 533 65 999999999 496.51 795.4 percent of total billed charges ELECTRODE 4 CHANNEL SET 8227411 49265361_1 CDM 0270 RC inpatient 820 533 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 795.4 97 999999999 496.51 795.4 percent of total billed charges ELECTRODE 4 CHANNEL SET 8227411 49265361_1 CDM 0270 RC inpatient 820 533 HUMANA - ALL PLANS HUMANA - ALL PLANS 639.6 78 999999999 496.51 795.4 percent of total billed charges ELECTRODE 4 CHANNEL SET 8227411 49265361_1 CDM 0270 RC inpatient 820 533 ENCORE - ALL PLANS ENCORE - ALL PLANS 565.8 69 999999999 496.51 795.4 percent of total billed charges ELECTRODE 4 CHANNEL SET 8227411 49265361_1 CDM 0270 RC inpatient 820 533 UMR - ALL PLANS UMR - ALL PLANS 574 70 999999999 496.51 795.4 percent of total billed charges ELECTRODE 4 CHANNEL SET 8227411 49265361_1 CDM 0270 RC inpatient 820 533 SIHO - ALL PLANS SIHO - ALL PLANS 738 90 999999999 496.51 795.4 percent of total billed charges ELECTRODE 4 CHANNEL SET 8227411 49265361_1 CDM 0270 RC inpatient 820 533 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 496.51 60.55 999999999 496.51 795.4 percent of total billed charges ELECTRODE 4 CHANNEL SET 8227411 49265361_1 CDM 0270 RC inpatient 820 533 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 496.51 795.4 ELECTRODE 4 CHANNEL SET 8227411 49265361_1 CDM 0270 RC inpatient 820 533 ANTHEM HMO ANTHEM HMO 999999999 496.51 795.4 ELECTRODE 4 CHANNEL SET 8227411 49265361_1 CDM 0270 RC inpatient 820 533 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 496.51 795.4 ELECTRODE 4 CHANNEL SET 8227411 49265361_1 CDM 0270 RC inpatient 820 533 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 496.51 795.4 ELECTRODE 4 CHANNEL SET 8227411 49265361_1 CDM 0270 RC inpatient 820 533 CIGNA - ALL PLANS CIGNA - ALL PLANS 554.32 67.6 999999999 496.51 795.4 percent of total billed charges ELECTRODE 4 CHANNEL SET 8227411 49265361_1 CDM 0270 RC inpatient 820 533 UHC - ALL PLANS UHC - ALL PLANS 999999999 496.51 795.4 EMG TUBE NIM 8.0 8229708 49265374_1 CDM 0270 RC inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 8.0 8229708 49265374_1 CDM 0270 RC inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 8.0 8229708 49265374_1 CDM 0270 RC inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 8.0 8229708 49265374_1 CDM 0270 RC inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 8.0 8229708 49265374_1 CDM 0270 RC inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 8.0 8229708 49265374_1 CDM 0270 RC inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 8.0 8229708 49265374_1 CDM 0270 RC inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 8.0 8229708 49265374_1 CDM 0270 RC inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 8.0 8229708 49265374_1 CDM 0270 RC inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 EMG TUBE NIM 8.0 8229708 49265374_1 CDM 0270 RC inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 EMG TUBE NIM 8.0 8229708 49265374_1 CDM 0270 RC inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 EMG TUBE NIM 8.0 8229708 49265374_1 CDM 0270 RC inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 EMG TUBE NIM 8.0 8229708 49265374_1 CDM 0270 RC inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 8.0 8229708 49265374_1 CDM 0270 RC inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 EMG TUBE NIM 6.0MM 8229706 49265375_1 CDM 0270 RC inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 6.0MM 8229706 49265375_1 CDM 0270 RC inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 6.0MM 8229706 49265375_1 CDM 0270 RC inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 6.0MM 8229706 49265375_1 CDM 0270 RC inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 6.0MM 8229706 49265375_1 CDM 0270 RC inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 6.0MM 8229706 49265375_1 CDM 0270 RC inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 6.0MM 8229706 49265375_1 CDM 0270 RC inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 6.0MM 8229706 49265375_1 CDM 0270 RC inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 6.0MM 8229706 49265375_1 CDM 0270 RC inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 EMG TUBE NIM 6.0MM 8229706 49265375_1 CDM 0270 RC inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 EMG TUBE NIM 6.0MM 8229706 49265375_1 CDM 0270 RC inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 EMG TUBE NIM 6.0MM 8229706 49265375_1 CDM 0270 RC inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 EMG TUBE NIM 6.0MM 8229706 49265375_1 CDM 0270 RC inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 6.0MM 8229706 49265375_1 CDM 0270 RC inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 EMG TUBE NIM 7.0 8229707 49265376_1 CDM 0272 RC inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 7.0 8229707 49265376_1 CDM 0272 RC inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 7.0 8229707 49265376_1 CDM 0272 RC inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 7.0 8229707 49265376_1 CDM 0272 RC inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 7.0 8229707 49265376_1 CDM 0272 RC inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 7.0 8229707 49265376_1 CDM 0272 RC inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 7.0 8229707 49265376_1 CDM 0272 RC inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 7.0 8229707 49265376_1 CDM 0272 RC inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 7.0 8229707 49265376_1 CDM 0272 RC inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 EMG TUBE NIM 7.0 8229707 49265376_1 CDM 0272 RC inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 EMG TUBE NIM 7.0 8229707 49265376_1 CDM 0272 RC inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 EMG TUBE NIM 7.0 8229707 49265376_1 CDM 0272 RC inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 EMG TUBE NIM 7.0 8229707 49265376_1 CDM 0272 RC inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges EMG TUBE NIM 7.0 8229707 49265376_1 CDM 0272 RC inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49275346_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49275346_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49275346_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49275346_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49275346_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49275346_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49275346_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49275346_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49275346_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49275346_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49275346_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49275346_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49275346_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49275346_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 Special fluorescent and/or acid fast stain for microorganism 49275553_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 AETNA AETNA 102.7 79 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 49275553_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 84.5 65 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 49275553_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 126.1 97 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 49275553_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 101.4 78 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 49275553_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.7 69 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 49275553_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 UMR - ALL PLANS UMR - ALL PLANS 91 70 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 49275553_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 SIHO - ALL PLANS SIHO - ALL PLANS 117 90 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 49275553_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.72 60.55 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 49275553_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.72 126.1 Special fluorescent and/or acid fast stain for microorganism 49275553_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 ANTHEM HMO ANTHEM HMO 999999999 78.72 126.1 Special fluorescent and/or acid fast stain for microorganism 49275553_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.72 126.1 Special fluorescent and/or acid fast stain for microorganism 49275553_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.72 126.1 Special fluorescent and/or acid fast stain for microorganism 49275553_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.88 67.6 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 49275553_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.72 126.1 "Fungal culture, yeast" 49275554_1 CDM 0306 RC 87106 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Fungal culture, yeast" 49275554_1 CDM 0306 RC 87106 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Fungal culture, yeast" 49275554_1 CDM 0306 RC 87106 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Fungal culture, yeast" 49275554_1 CDM 0306 RC 87106 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Fungal culture, yeast" 49275554_1 CDM 0306 RC 87106 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Fungal culture, yeast" 49275554_1 CDM 0306 RC 87106 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Fungal culture, yeast" 49275554_1 CDM 0306 RC 87106 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Fungal culture, yeast" 49275554_1 CDM 0306 RC 87106 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Fungal culture, yeast" 49275554_1 CDM 0306 RC 87106 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Fungal culture, yeast" 49275554_1 CDM 0306 RC 87106 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Fungal culture, yeast" 49275554_1 CDM 0306 RC 87106 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Fungal culture, yeast" 49275554_1 CDM 0306 RC 87106 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Fungal culture, yeast" 49275554_1 CDM 0306 RC 87106 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Fungal culture, yeast" 49275554_1 CDM 0306 RC 87106 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 Concentration of specimen for infectious agents 49275555_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges Concentration of specimen for infectious agents 49275555_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges Concentration of specimen for infectious agents 49275555_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges Concentration of specimen for infectious agents 49275555_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges Concentration of specimen for infectious agents 49275555_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges Concentration of specimen for infectious agents 49275555_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges Concentration of specimen for infectious agents 49275555_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges Concentration of specimen for infectious agents 49275555_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges Concentration of specimen for infectious agents 49275555_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 Concentration of specimen for infectious agents 49275555_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 Concentration of specimen for infectious agents 49275555_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 Concentration of specimen for infectious agents 49275555_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 Concentration of specimen for infectious agents 49275555_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges Concentration of specimen for infectious agents 49275555_1 CDM 0306 RC 87015 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 Red blood cell sickling measurement 49275556_1 CDM 0301 RC 85660 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges Red blood cell sickling measurement 49275556_1 CDM 0301 RC 85660 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges Red blood cell sickling measurement 49275556_1 CDM 0301 RC 85660 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges Red blood cell sickling measurement 49275556_1 CDM 0301 RC 85660 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges Red blood cell sickling measurement 49275556_1 CDM 0301 RC 85660 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges Red blood cell sickling measurement 49275556_1 CDM 0301 RC 85660 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges Red blood cell sickling measurement 49275556_1 CDM 0301 RC 85660 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges Red blood cell sickling measurement 49275556_1 CDM 0301 RC 85660 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges Red blood cell sickling measurement 49275556_1 CDM 0301 RC 85660 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 Red blood cell sickling measurement 49275556_1 CDM 0301 RC 85660 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 Red blood cell sickling measurement 49275556_1 CDM 0301 RC 85660 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 Red blood cell sickling measurement 49275556_1 CDM 0301 RC 85660 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 Red blood cell sickling measurement 49275556_1 CDM 0301 RC 85660 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges Red blood cell sickling measurement 49275556_1 CDM 0301 RC 85660 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 Special fluorescent and/or acid fast stain for microorganism 49275557_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 AETNA AETNA 102.7 79 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 49275557_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 84.5 65 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 49275557_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 126.1 97 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 49275557_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 101.4 78 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 49275557_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.7 69 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 49275557_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 UMR - ALL PLANS UMR - ALL PLANS 91 70 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 49275557_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 SIHO - ALL PLANS SIHO - ALL PLANS 117 90 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 49275557_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.72 60.55 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 49275557_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.72 126.1 Special fluorescent and/or acid fast stain for microorganism 49275557_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 ANTHEM HMO ANTHEM HMO 999999999 78.72 126.1 Special fluorescent and/or acid fast stain for microorganism 49275557_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.72 126.1 Special fluorescent and/or acid fast stain for microorganism 49275557_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.72 126.1 Special fluorescent and/or acid fast stain for microorganism 49275557_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.88 67.6 999999999 78.72 126.1 percent of total billed charges Special fluorescent and/or acid fast stain for microorganism 49275557_1 CDM 0306 RC 87206 HCPCS inpatient 130 84.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.72 126.1 Detection test by immunoassay with direct visual observation for other organism 49275558_1 CDM 0302 RC 87899 HCPCS inpatient 134 87.1 AETNA AETNA 105.86 79 999999999 81.14 129.98 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 49275558_1 CDM 0302 RC 87899 HCPCS inpatient 134 87.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 87.1 65 999999999 81.14 129.98 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 49275558_1 CDM 0302 RC 87899 HCPCS inpatient 134 87.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.98 97 999999999 81.14 129.98 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 49275558_1 CDM 0302 RC 87899 HCPCS inpatient 134 87.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 104.52 78 999999999 81.14 129.98 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 49275558_1 CDM 0302 RC 87899 HCPCS inpatient 134 87.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 92.46 69 999999999 81.14 129.98 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 49275558_1 CDM 0302 RC 87899 HCPCS inpatient 134 87.1 UMR - ALL PLANS UMR - ALL PLANS 93.8 70 999999999 81.14 129.98 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 49275558_1 CDM 0302 RC 87899 HCPCS inpatient 134 87.1 SIHO - ALL PLANS SIHO - ALL PLANS 120.6 90 999999999 81.14 129.98 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 49275558_1 CDM 0302 RC 87899 HCPCS inpatient 134 87.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 81.14 60.55 999999999 81.14 129.98 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 49275558_1 CDM 0302 RC 87899 HCPCS inpatient 134 87.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 81.14 129.98 Detection test by immunoassay with direct visual observation for other organism 49275558_1 CDM 0302 RC 87899 HCPCS inpatient 134 87.1 ANTHEM HMO ANTHEM HMO 999999999 81.14 129.98 Detection test by immunoassay with direct visual observation for other organism 49275558_1 CDM 0302 RC 87899 HCPCS inpatient 134 87.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 81.14 129.98 Detection test by immunoassay with direct visual observation for other organism 49275558_1 CDM 0302 RC 87899 HCPCS inpatient 134 87.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 81.14 129.98 Detection test by immunoassay with direct visual observation for other organism 49275558_1 CDM 0302 RC 87899 HCPCS inpatient 134 87.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 90.58 67.6 999999999 81.14 129.98 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 49275558_1 CDM 0302 RC 87899 HCPCS inpatient 134 87.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 81.14 129.98 "Measurement of antibody for assessment of autoimmune disorder, titer" 49275560_1 CDM 0301 RC 86039 HCPCS inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 49275560_1 CDM 0301 RC 86039 HCPCS inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 49275560_1 CDM 0301 RC 86039 HCPCS inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 49275560_1 CDM 0301 RC 86039 HCPCS inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 49275560_1 CDM 0301 RC 86039 HCPCS inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 49275560_1 CDM 0301 RC 86039 HCPCS inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 49275560_1 CDM 0301 RC 86039 HCPCS inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 49275560_1 CDM 0301 RC 86039 HCPCS inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 49275560_1 CDM 0301 RC 86039 HCPCS inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 "Measurement of antibody for assessment of autoimmune disorder, titer" 49275560_1 CDM 0301 RC 86039 HCPCS inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 "Measurement of antibody for assessment of autoimmune disorder, titer" 49275560_1 CDM 0301 RC 86039 HCPCS inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 "Measurement of antibody for assessment of autoimmune disorder, titer" 49275560_1 CDM 0301 RC 86039 HCPCS inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 "Measurement of antibody for assessment of autoimmune disorder, titer" 49275560_1 CDM 0301 RC 86039 HCPCS inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 49275560_1 CDM 0301 RC 86039 HCPCS inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 Detection test by immunoassay technique for hepatitis B surface antigen neutralization 49275562_1 CDM 0301 RC 87341 HCPCS inpatient 120 78 AETNA AETNA 94.8 79 999999999 72.66 116.4 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen neutralization 49275562_1 CDM 0301 RC 87341 HCPCS inpatient 120 78 SELF PAY DISCOUNT SELF PAY DISCOUNT 78 65 999999999 72.66 116.4 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen neutralization 49275562_1 CDM 0301 RC 87341 HCPCS inpatient 120 78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.4 97 999999999 72.66 116.4 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen neutralization 49275562_1 CDM 0301 RC 87341 HCPCS inpatient 120 78 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.6 78 999999999 72.66 116.4 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen neutralization 49275562_1 CDM 0301 RC 87341 HCPCS inpatient 120 78 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.8 69 999999999 72.66 116.4 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen neutralization 49275562_1 CDM 0301 RC 87341 HCPCS inpatient 120 78 UMR - ALL PLANS UMR - ALL PLANS 84 70 999999999 72.66 116.4 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen neutralization 49275562_1 CDM 0301 RC 87341 HCPCS inpatient 120 78 SIHO - ALL PLANS SIHO - ALL PLANS 108 90 999999999 72.66 116.4 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen neutralization 49275562_1 CDM 0301 RC 87341 HCPCS inpatient 120 78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.66 60.55 999999999 72.66 116.4 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen neutralization 49275562_1 CDM 0301 RC 87341 HCPCS inpatient 120 78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.66 116.4 Detection test by immunoassay technique for hepatitis B surface antigen neutralization 49275562_1 CDM 0301 RC 87341 HCPCS inpatient 120 78 ANTHEM HMO ANTHEM HMO 999999999 72.66 116.4 Detection test by immunoassay technique for hepatitis B surface antigen neutralization 49275562_1 CDM 0301 RC 87341 HCPCS inpatient 120 78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.66 116.4 Detection test by immunoassay technique for hepatitis B surface antigen neutralization 49275562_1 CDM 0301 RC 87341 HCPCS inpatient 120 78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.66 116.4 Detection test by immunoassay technique for hepatitis B surface antigen neutralization 49275562_1 CDM 0301 RC 87341 HCPCS inpatient 120 78 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.12 67.6 999999999 72.66 116.4 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen neutralization 49275562_1 CDM 0301 RC 87341 HCPCS inpatient 120 78 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.66 116.4 OXYCODONE-ACETAMINOPHEN 5-325 49288566_1 CDM 0250 RC 68084-0355-01 NDC inpatient 500 UN 1.86 1.21 AETNA AETNA 1.47 79 999999999 1.13 1.8 percent of total billed charges OXYCODONE-ACETAMINOPHEN 5-325 49288566_1 CDM 0250 RC 68084-0355-01 NDC inpatient 500 UN 1.86 1.21 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.21 65 999999999 1.13 1.8 percent of total billed charges OXYCODONE-ACETAMINOPHEN 5-325 49288566_1 CDM 0250 RC 68084-0355-01 NDC inpatient 500 UN 1.86 1.21 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.8 97 999999999 1.13 1.8 percent of total billed charges OXYCODONE-ACETAMINOPHEN 5-325 49288566_1 CDM 0250 RC 68084-0355-01 NDC inpatient 500 UN 1.86 1.21 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.45 78 999999999 1.13 1.8 percent of total billed charges OXYCODONE-ACETAMINOPHEN 5-325 49288566_1 CDM 0250 RC 68084-0355-01 NDC inpatient 500 UN 1.86 1.21 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.28 69 999999999 1.13 1.8 percent of total billed charges OXYCODONE-ACETAMINOPHEN 5-325 49288566_1 CDM 0250 RC 68084-0355-01 NDC inpatient 500 UN 1.86 1.21 UMR - ALL PLANS UMR - ALL PLANS 1.3 70 999999999 1.13 1.8 percent of total billed charges OXYCODONE-ACETAMINOPHEN 5-325 49288566_1 CDM 0250 RC 68084-0355-01 NDC inpatient 500 UN 1.86 1.21 SIHO - ALL PLANS SIHO - ALL PLANS 1.67 90 999999999 1.13 1.8 percent of total billed charges OXYCODONE-ACETAMINOPHEN 5-325 49288566_1 CDM 0250 RC 68084-0355-01 NDC inpatient 500 UN 1.86 1.21 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.13 60.55 999999999 1.13 1.8 percent of total billed charges OXYCODONE-ACETAMINOPHEN 5-325 49288566_1 CDM 0250 RC 68084-0355-01 NDC inpatient 500 UN 1.86 1.21 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.13 1.8 OXYCODONE-ACETAMINOPHEN 5-325 49288566_1 CDM 0250 RC 68084-0355-01 NDC inpatient 500 UN 1.86 1.21 ANTHEM HMO ANTHEM HMO 999999999 1.13 1.8 OXYCODONE-ACETAMINOPHEN 5-325 49288566_1 CDM 0250 RC 68084-0355-01 NDC inpatient 500 UN 1.86 1.21 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.13 1.8 OXYCODONE-ACETAMINOPHEN 5-325 49288566_1 CDM 0250 RC 68084-0355-01 NDC inpatient 500 UN 1.86 1.21 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.13 1.8 OXYCODONE-ACETAMINOPHEN 5-325 49288566_1 CDM 0250 RC 68084-0355-01 NDC inpatient 500 UN 1.86 1.21 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.26 67.6 999999999 1.13 1.8 percent of total billed charges OXYCODONE-ACETAMINOPHEN 5-325 49288566_1 CDM 0250 RC 68084-0355-01 NDC inpatient 500 UN 1.86 1.21 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.13 1.8 Procalcitonin (hormone) level 49288797_1 CDM 0301 RC 84145 HCPCS inpatient 250 162.5 AETNA AETNA 197.5 79 999999999 151.38 242.5 percent of total billed charges Procalcitonin (hormone) level 49288797_1 CDM 0301 RC 84145 HCPCS inpatient 250 162.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 162.5 65 999999999 151.38 242.5 percent of total billed charges Procalcitonin (hormone) level 49288797_1 CDM 0301 RC 84145 HCPCS inpatient 250 162.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 242.5 97 999999999 151.38 242.5 percent of total billed charges Procalcitonin (hormone) level 49288797_1 CDM 0301 RC 84145 HCPCS inpatient 250 162.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 195 78 999999999 151.38 242.5 percent of total billed charges Procalcitonin (hormone) level 49288797_1 CDM 0301 RC 84145 HCPCS inpatient 250 162.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 172.5 69 999999999 151.38 242.5 percent of total billed charges Procalcitonin (hormone) level 49288797_1 CDM 0301 RC 84145 HCPCS inpatient 250 162.5 UMR - ALL PLANS UMR - ALL PLANS 175 70 999999999 151.38 242.5 percent of total billed charges Procalcitonin (hormone) level 49288797_1 CDM 0301 RC 84145 HCPCS inpatient 250 162.5 SIHO - ALL PLANS SIHO - ALL PLANS 225 90 999999999 151.38 242.5 percent of total billed charges Procalcitonin (hormone) level 49288797_1 CDM 0301 RC 84145 HCPCS inpatient 250 162.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.38 60.55 999999999 151.38 242.5 percent of total billed charges Procalcitonin (hormone) level 49288797_1 CDM 0301 RC 84145 HCPCS inpatient 250 162.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.38 242.5 Procalcitonin (hormone) level 49288797_1 CDM 0301 RC 84145 HCPCS inpatient 250 162.5 ANTHEM HMO ANTHEM HMO 999999999 151.38 242.5 Procalcitonin (hormone) level 49288797_1 CDM 0301 RC 84145 HCPCS inpatient 250 162.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.38 242.5 Procalcitonin (hormone) level 49288797_1 CDM 0301 RC 84145 HCPCS inpatient 250 162.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.38 242.5 Procalcitonin (hormone) level 49288797_1 CDM 0301 RC 84145 HCPCS inpatient 250 162.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 169 67.6 999999999 151.38 242.5 percent of total billed charges Procalcitonin (hormone) level 49288797_1 CDM 0301 RC 84145 HCPCS inpatient 250 162.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.38 242.5 EPINEPHRINE 1 MG/10 ML ABBOJCT 49305549_1 CDM 0250 RC 00409-4921-20 NDC inpatient 1 UN 41.11 26.72 AETNA AETNA 32.48 79 999999999 24.89 39.88 percent of total billed charges EPINEPHRINE 1 MG/10 ML ABBOJCT 49305549_1 CDM 0250 RC 00409-4921-20 NDC inpatient 1 UN 41.11 26.72 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.72 65 999999999 24.89 39.88 percent of total billed charges EPINEPHRINE 1 MG/10 ML ABBOJCT 49305549_1 CDM 0250 RC 00409-4921-20 NDC inpatient 1 UN 41.11 26.72 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39.88 97 999999999 24.89 39.88 percent of total billed charges EPINEPHRINE 1 MG/10 ML ABBOJCT 49305549_1 CDM 0250 RC 00409-4921-20 NDC inpatient 1 UN 41.11 26.72 HUMANA - ALL PLANS HUMANA - ALL PLANS 32.07 78 999999999 24.89 39.88 percent of total billed charges EPINEPHRINE 1 MG/10 ML ABBOJCT 49305549_1 CDM 0250 RC 00409-4921-20 NDC inpatient 1 UN 41.11 26.72 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.37 69 999999999 24.89 39.88 percent of total billed charges EPINEPHRINE 1 MG/10 ML ABBOJCT 49305549_1 CDM 0250 RC 00409-4921-20 NDC inpatient 1 UN 41.11 26.72 UMR - ALL PLANS UMR - ALL PLANS 28.78 70 999999999 24.89 39.88 percent of total billed charges EPINEPHRINE 1 MG/10 ML ABBOJCT 49305549_1 CDM 0250 RC 00409-4921-20 NDC inpatient 1 UN 41.11 26.72 SIHO - ALL PLANS SIHO - ALL PLANS 37 90 999999999 24.89 39.88 percent of total billed charges EPINEPHRINE 1 MG/10 ML ABBOJCT 49305549_1 CDM 0250 RC 00409-4921-20 NDC inpatient 1 UN 41.11 26.72 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.89 60.55 999999999 24.89 39.88 percent of total billed charges EPINEPHRINE 1 MG/10 ML ABBOJCT 49305549_1 CDM 0250 RC 00409-4921-20 NDC inpatient 1 UN 41.11 26.72 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.89 39.88 EPINEPHRINE 1 MG/10 ML ABBOJCT 49305549_1 CDM 0250 RC 00409-4921-20 NDC inpatient 1 UN 41.11 26.72 ANTHEM HMO ANTHEM HMO 999999999 24.89 39.88 EPINEPHRINE 1 MG/10 ML ABBOJCT 49305549_1 CDM 0250 RC 00409-4921-20 NDC inpatient 1 UN 41.11 26.72 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.89 39.88 EPINEPHRINE 1 MG/10 ML ABBOJCT 49305549_1 CDM 0250 RC 00409-4921-20 NDC inpatient 1 UN 41.11 26.72 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.89 39.88 EPINEPHRINE 1 MG/10 ML ABBOJCT 49305549_1 CDM 0250 RC 00409-4921-20 NDC inpatient 1 UN 41.11 26.72 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.79 67.6 999999999 24.89 39.88 percent of total billed charges EPINEPHRINE 1 MG/10 ML ABBOJCT 49305549_1 CDM 0250 RC 00409-4921-20 NDC inpatient 1 UN 41.11 26.72 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.89 39.88 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 49305626_1 CDM 0300 RC P9603 HCPCS inpatient 15.48 10.06 AETNA AETNA 12.23 79 999999999 9.37 15.02 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 49305626_1 CDM 0300 RC P9603 HCPCS inpatient 15.48 10.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.06 65 999999999 9.37 15.02 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 49305626_1 CDM 0300 RC P9603 HCPCS inpatient 15.48 10.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15.02 97 999999999 9.37 15.02 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 49305626_1 CDM 0300 RC P9603 HCPCS inpatient 15.48 10.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.07 78 999999999 9.37 15.02 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 49305626_1 CDM 0300 RC P9603 HCPCS inpatient 15.48 10.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.68 69 999999999 9.37 15.02 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 49305626_1 CDM 0300 RC P9603 HCPCS inpatient 15.48 10.06 UMR - ALL PLANS UMR - ALL PLANS 10.84 70 999999999 9.37 15.02 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 49305626_1 CDM 0300 RC P9603 HCPCS inpatient 15.48 10.06 SIHO - ALL PLANS SIHO - ALL PLANS 13.93 90 999999999 9.37 15.02 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 49305626_1 CDM 0300 RC P9603 HCPCS inpatient 15.48 10.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.37 60.55 999999999 9.37 15.02 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 49305626_1 CDM 0300 RC P9603 HCPCS inpatient 15.48 10.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.37 15.02 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 49305626_1 CDM 0300 RC P9603 HCPCS inpatient 15.48 10.06 ANTHEM HMO ANTHEM HMO 999999999 9.37 15.02 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 49305626_1 CDM 0300 RC P9603 HCPCS inpatient 15.48 10.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.37 15.02 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 49305626_1 CDM 0300 RC P9603 HCPCS inpatient 15.48 10.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.37 15.02 TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 49305626_1 CDM 0300 RC P9603 HCPCS inpatient 15.48 10.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.46 67.6 999999999 9.37 15.02 percent of total billed charges TRAVEL ALLOWANCE ONE WAY IN CONNECTION WITH MEDICALLY NECESSARY LABORATORY SPECIMEN COLLECTION DRAWN FROM HOME BOUND OR NURSING HOME BOUND PATIENT; PRORATED MILES ACTUALLY TRAVELLED 49305626_1 CDM 0300 RC P9603 HCPCS inpatient 15.48 10.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.37 15.02 Immunologic analysis for detection of antigen or antibody 49305696_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49305696_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49305696_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49305696_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49305696_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49305696_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49305696_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49305696_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49305696_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49305696_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49305696_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49305696_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 Immunologic analysis for detection of antigen or antibody 49305696_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49305696_1 CDM 0302 RC 86331 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 Analysis for antibody to aspergillus (fungus) 49305771_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305771_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305771_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305771_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305771_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305771_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305771_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305771_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305771_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 Analysis for antibody to aspergillus (fungus) 49305771_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 Analysis for antibody to aspergillus (fungus) 49305771_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 Analysis for antibody to aspergillus (fungus) 49305771_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 Analysis for antibody to aspergillus (fungus) 49305771_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305771_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 Analysis for antibody to aspergillus (fungus) 49305773_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305773_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305773_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305773_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305773_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305773_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305773_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305773_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305773_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 Analysis for antibody to aspergillus (fungus) 49305773_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 Analysis for antibody to aspergillus (fungus) 49305773_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 Analysis for antibody to aspergillus (fungus) 49305773_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 Analysis for antibody to aspergillus (fungus) 49305773_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305773_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 Analysis for antibody to aspergillus (fungus) 49305774_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305774_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305774_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305774_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305774_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305774_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305774_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305774_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305774_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 Analysis for antibody to aspergillus (fungus) 49305774_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 Analysis for antibody to aspergillus (fungus) 49305774_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 Analysis for antibody to aspergillus (fungus) 49305774_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 Analysis for antibody to aspergillus (fungus) 49305774_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49305774_1 CDM 0302 RC 86606 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 "INJECTION, OCRELIZUMAB, 1 MG" 49305798_1 CDM 0636 RC 50242-0150-01 NDC J2350 HCPCS inpatient 300 UN 77212.5 50188.13 AETNA AETNA 60997.88 79 999999999 46752.17 74896.13 percent of total billed charges "INJECTION, OCRELIZUMAB, 1 MG" 49305798_1 CDM 0636 RC 50242-0150-01 NDC J2350 HCPCS inpatient 300 UN 77212.5 50188.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 50188.13 65 999999999 46752.17 74896.13 percent of total billed charges "INJECTION, OCRELIZUMAB, 1 MG" 49305798_1 CDM 0636 RC 50242-0150-01 NDC J2350 HCPCS inpatient 300 UN 77212.5 50188.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74896.13 97 999999999 46752.17 74896.13 percent of total billed charges "INJECTION, OCRELIZUMAB, 1 MG" 49305798_1 CDM 0636 RC 50242-0150-01 NDC J2350 HCPCS inpatient 300 UN 77212.5 50188.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 60225.75 78 999999999 46752.17 74896.13 percent of total billed charges "INJECTION, OCRELIZUMAB, 1 MG" 49305798_1 CDM 0636 RC 50242-0150-01 NDC J2350 HCPCS inpatient 300 UN 77212.5 50188.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 53276.63 69 999999999 46752.17 74896.13 percent of total billed charges "INJECTION, OCRELIZUMAB, 1 MG" 49305798_1 CDM 0636 RC 50242-0150-01 NDC J2350 HCPCS inpatient 300 UN 77212.5 50188.13 UMR - ALL PLANS UMR - ALL PLANS 54048.75 70 999999999 46752.17 74896.13 percent of total billed charges "INJECTION, OCRELIZUMAB, 1 MG" 49305798_1 CDM 0636 RC 50242-0150-01 NDC J2350 HCPCS inpatient 300 UN 77212.5 50188.13 SIHO - ALL PLANS SIHO - ALL PLANS 69491.25 90 999999999 46752.17 74896.13 percent of total billed charges "INJECTION, OCRELIZUMAB, 1 MG" 49305798_1 CDM 0636 RC 50242-0150-01 NDC J2350 HCPCS inpatient 300 UN 77212.5 50188.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46752.17 60.55 999999999 46752.17 74896.13 percent of total billed charges "INJECTION, OCRELIZUMAB, 1 MG" 49305798_1 CDM 0636 RC 50242-0150-01 NDC J2350 HCPCS inpatient 300 UN 77212.5 50188.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46752.17 74896.13 "INJECTION, OCRELIZUMAB, 1 MG" 49305798_1 CDM 0636 RC 50242-0150-01 NDC J2350 HCPCS inpatient 300 UN 77212.5 50188.13 ANTHEM HMO ANTHEM HMO 999999999 46752.17 74896.13 "INJECTION, OCRELIZUMAB, 1 MG" 49305798_1 CDM 0636 RC 50242-0150-01 NDC J2350 HCPCS inpatient 300 UN 77212.5 50188.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46752.17 74896.13 "INJECTION, OCRELIZUMAB, 1 MG" 49305798_1 CDM 0636 RC 50242-0150-01 NDC J2350 HCPCS inpatient 300 UN 77212.5 50188.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46752.17 74896.13 "INJECTION, OCRELIZUMAB, 1 MG" 49305798_1 CDM 0636 RC 50242-0150-01 NDC J2350 HCPCS inpatient 300 UN 77212.5 50188.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 52195.65 67.6 999999999 46752.17 74896.13 percent of total billed charges "INJECTION, OCRELIZUMAB, 1 MG" 49305798_1 CDM 0636 RC 50242-0150-01 NDC J2350 HCPCS inpatient 300 UN 77212.5 50188.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 46752.17 74896.13 "ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME" 49306387_1 CDM 0250 RC 00487-0201-01 NDC J7620 HCPCS inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges "ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME" 49306387_1 CDM 0250 RC 00487-0201-01 NDC J7620 HCPCS inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges "ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME" 49306387_1 CDM 0250 RC 00487-0201-01 NDC J7620 HCPCS inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges "ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME" 49306387_1 CDM 0250 RC 00487-0201-01 NDC J7620 HCPCS inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges "ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME" 49306387_1 CDM 0250 RC 00487-0201-01 NDC J7620 HCPCS inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges "ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME" 49306387_1 CDM 0250 RC 00487-0201-01 NDC J7620 HCPCS inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges "ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME" 49306387_1 CDM 0250 RC 00487-0201-01 NDC J7620 HCPCS inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges "ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME" 49306387_1 CDM 0250 RC 00487-0201-01 NDC J7620 HCPCS inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges "ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME" 49306387_1 CDM 0250 RC 00487-0201-01 NDC J7620 HCPCS inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 "ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME" 49306387_1 CDM 0250 RC 00487-0201-01 NDC J7620 HCPCS inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 "ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME" 49306387_1 CDM 0250 RC 00487-0201-01 NDC J7620 HCPCS inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 "ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME" 49306387_1 CDM 0250 RC 00487-0201-01 NDC J7620 HCPCS inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 "ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME" 49306387_1 CDM 0250 RC 00487-0201-01 NDC J7620 HCPCS inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM BROMIDE, UP TO 0.5 MG, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME" 49306387_1 CDM 0250 RC 00487-0201-01 NDC J7620 HCPCS inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 61553-0242-48 - hydromorphone 100 mg in sodium chloride 0.9% 100 mL PM [JOHN] 49306647_1 CDM 0250 RC 61553-0242-48 NDC inpatient 1 UN 186.92 121.5 AETNA AETNA 147.67 79 999999999 113.18 181.31 percent of total billed charges 61553-0242-48 - hydromorphone 100 mg in sodium chloride 0.9% 100 mL PM [JOHN] 49306647_1 CDM 0250 RC 61553-0242-48 NDC inpatient 1 UN 186.92 121.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 121.5 65 999999999 113.18 181.31 percent of total billed charges 61553-0242-48 - hydromorphone 100 mg in sodium chloride 0.9% 100 mL PM [JOHN] 49306647_1 CDM 0250 RC 61553-0242-48 NDC inpatient 1 UN 186.92 121.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 181.31 97 999999999 113.18 181.31 percent of total billed charges 61553-0242-48 - hydromorphone 100 mg in sodium chloride 0.9% 100 mL PM [JOHN] 49306647_1 CDM 0250 RC 61553-0242-48 NDC inpatient 1 UN 186.92 121.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 145.8 78 999999999 113.18 181.31 percent of total billed charges 61553-0242-48 - hydromorphone 100 mg in sodium chloride 0.9% 100 mL PM [JOHN] 49306647_1 CDM 0250 RC 61553-0242-48 NDC inpatient 1 UN 186.92 121.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 128.97 69 999999999 113.18 181.31 percent of total billed charges 61553-0242-48 - hydromorphone 100 mg in sodium chloride 0.9% 100 mL PM [JOHN] 49306647_1 CDM 0250 RC 61553-0242-48 NDC inpatient 1 UN 186.92 121.5 UMR - ALL PLANS UMR - ALL PLANS 130.84 70 999999999 113.18 181.31 percent of total billed charges 61553-0242-48 - hydromorphone 100 mg in sodium chloride 0.9% 100 mL PM [JOHN] 49306647_1 CDM 0250 RC 61553-0242-48 NDC inpatient 1 UN 186.92 121.5 SIHO - ALL PLANS SIHO - ALL PLANS 168.23 90 999999999 113.18 181.31 percent of total billed charges 61553-0242-48 - hydromorphone 100 mg in sodium chloride 0.9% 100 mL PM [JOHN] 49306647_1 CDM 0250 RC 61553-0242-48 NDC inpatient 1 UN 186.92 121.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.18 60.55 999999999 113.18 181.31 percent of total billed charges 61553-0242-48 - hydromorphone 100 mg in sodium chloride 0.9% 100 mL PM [JOHN] 49306647_1 CDM 0250 RC 61553-0242-48 NDC inpatient 1 UN 186.92 121.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.18 181.31 61553-0242-48 - hydromorphone 100 mg in sodium chloride 0.9% 100 mL PM [JOHN] 49306647_1 CDM 0250 RC 61553-0242-48 NDC inpatient 1 UN 186.92 121.5 ANTHEM HMO ANTHEM HMO 999999999 113.18 181.31 61553-0242-48 - hydromorphone 100 mg in sodium chloride 0.9% 100 mL PM [JOHN] 49306647_1 CDM 0250 RC 61553-0242-48 NDC inpatient 1 UN 186.92 121.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.18 181.31 61553-0242-48 - hydromorphone 100 mg in sodium chloride 0.9% 100 mL PM [JOHN] 49306647_1 CDM 0250 RC 61553-0242-48 NDC inpatient 1 UN 186.92 121.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.18 181.31 61553-0242-48 - hydromorphone 100 mg in sodium chloride 0.9% 100 mL PM [JOHN] 49306647_1 CDM 0250 RC 61553-0242-48 NDC inpatient 1 UN 186.92 121.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 126.36 67.6 999999999 113.18 181.31 percent of total billed charges 61553-0242-48 - hydromorphone 100 mg in sodium chloride 0.9% 100 mL PM [JOHN] 49306647_1 CDM 0250 RC 61553-0242-48 NDC inpatient 1 UN 186.92 121.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.18 181.31 SULFACETAMIDE 10% EYE DROPS 49306675_1 CDM 0250 RC 61314-0701-01 NDC inpatient 1 UN 80.32 52.21 AETNA AETNA 63.45 79 999999999 48.63 77.91 percent of total billed charges SULFACETAMIDE 10% EYE DROPS 49306675_1 CDM 0250 RC 61314-0701-01 NDC inpatient 1 UN 80.32 52.21 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.21 65 999999999 48.63 77.91 percent of total billed charges SULFACETAMIDE 10% EYE DROPS 49306675_1 CDM 0250 RC 61314-0701-01 NDC inpatient 1 UN 80.32 52.21 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.91 97 999999999 48.63 77.91 percent of total billed charges SULFACETAMIDE 10% EYE DROPS 49306675_1 CDM 0250 RC 61314-0701-01 NDC inpatient 1 UN 80.32 52.21 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.65 78 999999999 48.63 77.91 percent of total billed charges SULFACETAMIDE 10% EYE DROPS 49306675_1 CDM 0250 RC 61314-0701-01 NDC inpatient 1 UN 80.32 52.21 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.42 69 999999999 48.63 77.91 percent of total billed charges SULFACETAMIDE 10% EYE DROPS 49306675_1 CDM 0250 RC 61314-0701-01 NDC inpatient 1 UN 80.32 52.21 UMR - ALL PLANS UMR - ALL PLANS 56.22 70 999999999 48.63 77.91 percent of total billed charges SULFACETAMIDE 10% EYE DROPS 49306675_1 CDM 0250 RC 61314-0701-01 NDC inpatient 1 UN 80.32 52.21 SIHO - ALL PLANS SIHO - ALL PLANS 72.29 90 999999999 48.63 77.91 percent of total billed charges SULFACETAMIDE 10% EYE DROPS 49306675_1 CDM 0250 RC 61314-0701-01 NDC inpatient 1 UN 80.32 52.21 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.63 60.55 999999999 48.63 77.91 percent of total billed charges SULFACETAMIDE 10% EYE DROPS 49306675_1 CDM 0250 RC 61314-0701-01 NDC inpatient 1 UN 80.32 52.21 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.63 77.91 SULFACETAMIDE 10% EYE DROPS 49306675_1 CDM 0250 RC 61314-0701-01 NDC inpatient 1 UN 80.32 52.21 ANTHEM HMO ANTHEM HMO 999999999 48.63 77.91 SULFACETAMIDE 10% EYE DROPS 49306675_1 CDM 0250 RC 61314-0701-01 NDC inpatient 1 UN 80.32 52.21 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.63 77.91 SULFACETAMIDE 10% EYE DROPS 49306675_1 CDM 0250 RC 61314-0701-01 NDC inpatient 1 UN 80.32 52.21 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.63 77.91 SULFACETAMIDE 10% EYE DROPS 49306675_1 CDM 0250 RC 61314-0701-01 NDC inpatient 1 UN 80.32 52.21 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.3 67.6 999999999 48.63 77.91 percent of total billed charges SULFACETAMIDE 10% EYE DROPS 49306675_1 CDM 0250 RC 61314-0701-01 NDC inpatient 1 UN 80.32 52.21 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.63 77.91 White blood cell antigen measurement 49306676_1 CDM 0301 RC 86356 HCPCS inpatient 225 146.25 AETNA AETNA 177.75 79 999999999 136.24 218.25 percent of total billed charges White blood cell antigen measurement 49306676_1 CDM 0301 RC 86356 HCPCS inpatient 225 146.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 146.25 65 999999999 136.24 218.25 percent of total billed charges White blood cell antigen measurement 49306676_1 CDM 0301 RC 86356 HCPCS inpatient 225 146.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 218.25 97 999999999 136.24 218.25 percent of total billed charges White blood cell antigen measurement 49306676_1 CDM 0301 RC 86356 HCPCS inpatient 225 146.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 175.5 78 999999999 136.24 218.25 percent of total billed charges White blood cell antigen measurement 49306676_1 CDM 0301 RC 86356 HCPCS inpatient 225 146.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 155.25 69 999999999 136.24 218.25 percent of total billed charges White blood cell antigen measurement 49306676_1 CDM 0301 RC 86356 HCPCS inpatient 225 146.25 UMR - ALL PLANS UMR - ALL PLANS 157.5 70 999999999 136.24 218.25 percent of total billed charges White blood cell antigen measurement 49306676_1 CDM 0301 RC 86356 HCPCS inpatient 225 146.25 SIHO - ALL PLANS SIHO - ALL PLANS 202.5 90 999999999 136.24 218.25 percent of total billed charges White blood cell antigen measurement 49306676_1 CDM 0301 RC 86356 HCPCS inpatient 225 146.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 136.24 60.55 999999999 136.24 218.25 percent of total billed charges White blood cell antigen measurement 49306676_1 CDM 0301 RC 86356 HCPCS inpatient 225 146.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 136.24 218.25 White blood cell antigen measurement 49306676_1 CDM 0301 RC 86356 HCPCS inpatient 225 146.25 ANTHEM HMO ANTHEM HMO 999999999 136.24 218.25 White blood cell antigen measurement 49306676_1 CDM 0301 RC 86356 HCPCS inpatient 225 146.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 136.24 218.25 White blood cell antigen measurement 49306676_1 CDM 0301 RC 86356 HCPCS inpatient 225 146.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 136.24 218.25 White blood cell antigen measurement 49306676_1 CDM 0301 RC 86356 HCPCS inpatient 225 146.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 152.1 67.6 999999999 136.24 218.25 percent of total billed charges White blood cell antigen measurement 49306676_1 CDM 0301 RC 86356 HCPCS inpatient 225 146.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 136.24 218.25 Analysis for antibody to helminth (intestinal worm) 49307052_1 CDM 0301 RC 86682 HCPCS inpatient 241 156.65 AETNA AETNA 190.39 79 999999999 145.93 233.77 percent of total billed charges Analysis for antibody to helminth (intestinal worm) 49307052_1 CDM 0301 RC 86682 HCPCS inpatient 241 156.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 156.65 65 999999999 145.93 233.77 percent of total billed charges Analysis for antibody to helminth (intestinal worm) 49307052_1 CDM 0301 RC 86682 HCPCS inpatient 241 156.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 233.77 97 999999999 145.93 233.77 percent of total billed charges Analysis for antibody to helminth (intestinal worm) 49307052_1 CDM 0301 RC 86682 HCPCS inpatient 241 156.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.98 78 999999999 145.93 233.77 percent of total billed charges Analysis for antibody to helminth (intestinal worm) 49307052_1 CDM 0301 RC 86682 HCPCS inpatient 241 156.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 166.29 69 999999999 145.93 233.77 percent of total billed charges Analysis for antibody to helminth (intestinal worm) 49307052_1 CDM 0301 RC 86682 HCPCS inpatient 241 156.65 UMR - ALL PLANS UMR - ALL PLANS 168.7 70 999999999 145.93 233.77 percent of total billed charges Analysis for antibody to helminth (intestinal worm) 49307052_1 CDM 0301 RC 86682 HCPCS inpatient 241 156.65 SIHO - ALL PLANS SIHO - ALL PLANS 216.9 90 999999999 145.93 233.77 percent of total billed charges Analysis for antibody to helminth (intestinal worm) 49307052_1 CDM 0301 RC 86682 HCPCS inpatient 241 156.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.93 60.55 999999999 145.93 233.77 percent of total billed charges Analysis for antibody to helminth (intestinal worm) 49307052_1 CDM 0301 RC 86682 HCPCS inpatient 241 156.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.93 233.77 Analysis for antibody to helminth (intestinal worm) 49307052_1 CDM 0301 RC 86682 HCPCS inpatient 241 156.65 ANTHEM HMO ANTHEM HMO 999999999 145.93 233.77 Analysis for antibody to helminth (intestinal worm) 49307052_1 CDM 0301 RC 86682 HCPCS inpatient 241 156.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.93 233.77 Analysis for antibody to helminth (intestinal worm) 49307052_1 CDM 0301 RC 86682 HCPCS inpatient 241 156.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.93 233.77 Analysis for antibody to helminth (intestinal worm) 49307052_1 CDM 0301 RC 86682 HCPCS inpatient 241 156.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.92 67.6 999999999 145.93 233.77 percent of total billed charges Analysis for antibody to helminth (intestinal worm) 49307052_1 CDM 0301 RC 86682 HCPCS inpatient 241 156.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.93 233.77 PROBE STD PRASS FL TIP 8225101 49315229_1 CDM 0272 RC inpatient 633 411.45 AETNA AETNA 500.07 79 999999999 383.28 614.01 percent of total billed charges PROBE STD PRASS FL TIP 8225101 49315229_1 CDM 0272 RC inpatient 633 411.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 411.45 65 999999999 383.28 614.01 percent of total billed charges PROBE STD PRASS FL TIP 8225101 49315229_1 CDM 0272 RC inpatient 633 411.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 614.01 97 999999999 383.28 614.01 percent of total billed charges PROBE STD PRASS FL TIP 8225101 49315229_1 CDM 0272 RC inpatient 633 411.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 493.74 78 999999999 383.28 614.01 percent of total billed charges PROBE STD PRASS FL TIP 8225101 49315229_1 CDM 0272 RC inpatient 633 411.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 436.77 69 999999999 383.28 614.01 percent of total billed charges PROBE STD PRASS FL TIP 8225101 49315229_1 CDM 0272 RC inpatient 633 411.45 UMR - ALL PLANS UMR - ALL PLANS 443.1 70 999999999 383.28 614.01 percent of total billed charges PROBE STD PRASS FL TIP 8225101 49315229_1 CDM 0272 RC inpatient 633 411.45 SIHO - ALL PLANS SIHO - ALL PLANS 569.7 90 999999999 383.28 614.01 percent of total billed charges PROBE STD PRASS FL TIP 8225101 49315229_1 CDM 0272 RC inpatient 633 411.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 383.28 60.55 999999999 383.28 614.01 percent of total billed charges PROBE STD PRASS FL TIP 8225101 49315229_1 CDM 0272 RC inpatient 633 411.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 383.28 614.01 PROBE STD PRASS FL TIP 8225101 49315229_1 CDM 0272 RC inpatient 633 411.45 ANTHEM HMO ANTHEM HMO 999999999 383.28 614.01 PROBE STD PRASS FL TIP 8225101 49315229_1 CDM 0272 RC inpatient 633 411.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 383.28 614.01 PROBE STD PRASS FL TIP 8225101 49315229_1 CDM 0272 RC inpatient 633 411.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 383.28 614.01 PROBE STD PRASS FL TIP 8225101 49315229_1 CDM 0272 RC inpatient 633 411.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 427.91 67.6 999999999 383.28 614.01 percent of total billed charges PROBE STD PRASS FL TIP 8225101 49315229_1 CDM 0272 RC inpatient 633 411.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 383.28 614.01 **** BLANKET BY M. PALMER 07/26/2023**** PATIENT TRACKER 9734887XOM 49315230_1 CDM 0272 RC inpatient 717 466.05 AETNA AETNA 566.43 79 999999999 434.14 695.49 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** PATIENT TRACKER 9734887XOM 49315230_1 CDM 0272 RC inpatient 717 466.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 466.05 65 999999999 434.14 695.49 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** PATIENT TRACKER 9734887XOM 49315230_1 CDM 0272 RC inpatient 717 466.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 695.49 97 999999999 434.14 695.49 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** PATIENT TRACKER 9734887XOM 49315230_1 CDM 0272 RC inpatient 717 466.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 559.26 78 999999999 434.14 695.49 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** PATIENT TRACKER 9734887XOM 49315230_1 CDM 0272 RC inpatient 717 466.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 494.73 69 999999999 434.14 695.49 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** PATIENT TRACKER 9734887XOM 49315230_1 CDM 0272 RC inpatient 717 466.05 UMR - ALL PLANS UMR - ALL PLANS 501.9 70 999999999 434.14 695.49 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** PATIENT TRACKER 9734887XOM 49315230_1 CDM 0272 RC inpatient 717 466.05 SIHO - ALL PLANS SIHO - ALL PLANS 645.3 90 999999999 434.14 695.49 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** PATIENT TRACKER 9734887XOM 49315230_1 CDM 0272 RC inpatient 717 466.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 434.14 60.55 999999999 434.14 695.49 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** PATIENT TRACKER 9734887XOM 49315230_1 CDM 0272 RC inpatient 717 466.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 434.14 695.49 **** BLANKET BY M. PALMER 07/26/2023**** PATIENT TRACKER 9734887XOM 49315230_1 CDM 0272 RC inpatient 717 466.05 ANTHEM HMO ANTHEM HMO 999999999 434.14 695.49 **** BLANKET BY M. PALMER 07/26/2023**** PATIENT TRACKER 9734887XOM 49315230_1 CDM 0272 RC inpatient 717 466.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 434.14 695.49 **** BLANKET BY M. PALMER 07/26/2023**** PATIENT TRACKER 9734887XOM 49315230_1 CDM 0272 RC inpatient 717 466.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 434.14 695.49 **** BLANKET BY M. PALMER 07/26/2023**** PATIENT TRACKER 9734887XOM 49315230_1 CDM 0272 RC inpatient 717 466.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 484.69 67.6 999999999 434.14 695.49 percent of total billed charges **** BLANKET BY M. PALMER 07/26/2023**** PATIENT TRACKER 9734887XOM 49315230_1 CDM 0272 RC inpatient 717 466.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 434.14 695.49 "DOCUMENTATION OF SYSTEM REASON(S) FOR AN INTERVAL OF LESS THAN 3 YEARS SINCE THE LAST COLONOSCOPY (E.G., UNABLE TO LOCATE PREVIOUS COLONOSCOPY REPORT, PREVIOUS COLONOSCOPY REPORT WAS INCOMPLETE)" 49333170_1 CDM 0301 RC G9999 HCPCS inpatient 30 19.5 AETNA AETNA 23.7 79 999999999 18.17 29.1 percent of total billed charges "DOCUMENTATION OF SYSTEM REASON(S) FOR AN INTERVAL OF LESS THAN 3 YEARS SINCE THE LAST COLONOSCOPY (E.G., UNABLE TO LOCATE PREVIOUS COLONOSCOPY REPORT, PREVIOUS COLONOSCOPY REPORT WAS INCOMPLETE)" 49333170_1 CDM 0301 RC G9999 HCPCS inpatient 30 19.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.5 65 999999999 18.17 29.1 percent of total billed charges "DOCUMENTATION OF SYSTEM REASON(S) FOR AN INTERVAL OF LESS THAN 3 YEARS SINCE THE LAST COLONOSCOPY (E.G., UNABLE TO LOCATE PREVIOUS COLONOSCOPY REPORT, PREVIOUS COLONOSCOPY REPORT WAS INCOMPLETE)" 49333170_1 CDM 0301 RC G9999 HCPCS inpatient 30 19.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.1 97 999999999 18.17 29.1 percent of total billed charges "DOCUMENTATION OF SYSTEM REASON(S) FOR AN INTERVAL OF LESS THAN 3 YEARS SINCE THE LAST COLONOSCOPY (E.G., UNABLE TO LOCATE PREVIOUS COLONOSCOPY REPORT, PREVIOUS COLONOSCOPY REPORT WAS INCOMPLETE)" 49333170_1 CDM 0301 RC G9999 HCPCS inpatient 30 19.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.4 78 999999999 18.17 29.1 percent of total billed charges "DOCUMENTATION OF SYSTEM REASON(S) FOR AN INTERVAL OF LESS THAN 3 YEARS SINCE THE LAST COLONOSCOPY (E.G., UNABLE TO LOCATE PREVIOUS COLONOSCOPY REPORT, PREVIOUS COLONOSCOPY REPORT WAS INCOMPLETE)" 49333170_1 CDM 0301 RC G9999 HCPCS inpatient 30 19.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.7 69 999999999 18.17 29.1 percent of total billed charges "DOCUMENTATION OF SYSTEM REASON(S) FOR AN INTERVAL OF LESS THAN 3 YEARS SINCE THE LAST COLONOSCOPY (E.G., UNABLE TO LOCATE PREVIOUS COLONOSCOPY REPORT, PREVIOUS COLONOSCOPY REPORT WAS INCOMPLETE)" 49333170_1 CDM 0301 RC G9999 HCPCS inpatient 30 19.5 UMR - ALL PLANS UMR - ALL PLANS 21 70 999999999 18.17 29.1 percent of total billed charges "DOCUMENTATION OF SYSTEM REASON(S) FOR AN INTERVAL OF LESS THAN 3 YEARS SINCE THE LAST COLONOSCOPY (E.G., UNABLE TO LOCATE PREVIOUS COLONOSCOPY REPORT, PREVIOUS COLONOSCOPY REPORT WAS INCOMPLETE)" 49333170_1 CDM 0301 RC G9999 HCPCS inpatient 30 19.5 SIHO - ALL PLANS SIHO - ALL PLANS 27 90 999999999 18.17 29.1 percent of total billed charges "DOCUMENTATION OF SYSTEM REASON(S) FOR AN INTERVAL OF LESS THAN 3 YEARS SINCE THE LAST COLONOSCOPY (E.G., UNABLE TO LOCATE PREVIOUS COLONOSCOPY REPORT, PREVIOUS COLONOSCOPY REPORT WAS INCOMPLETE)" 49333170_1 CDM 0301 RC G9999 HCPCS inpatient 30 19.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.17 60.55 999999999 18.17 29.1 percent of total billed charges "DOCUMENTATION OF SYSTEM REASON(S) FOR AN INTERVAL OF LESS THAN 3 YEARS SINCE THE LAST COLONOSCOPY (E.G., UNABLE TO LOCATE PREVIOUS COLONOSCOPY REPORT, PREVIOUS COLONOSCOPY REPORT WAS INCOMPLETE)" 49333170_1 CDM 0301 RC G9999 HCPCS inpatient 30 19.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.17 29.1 "DOCUMENTATION OF SYSTEM REASON(S) FOR AN INTERVAL OF LESS THAN 3 YEARS SINCE THE LAST COLONOSCOPY (E.G., UNABLE TO LOCATE PREVIOUS COLONOSCOPY REPORT, PREVIOUS COLONOSCOPY REPORT WAS INCOMPLETE)" 49333170_1 CDM 0301 RC G9999 HCPCS inpatient 30 19.5 ANTHEM HMO ANTHEM HMO 999999999 18.17 29.1 "DOCUMENTATION OF SYSTEM REASON(S) FOR AN INTERVAL OF LESS THAN 3 YEARS SINCE THE LAST COLONOSCOPY (E.G., UNABLE TO LOCATE PREVIOUS COLONOSCOPY REPORT, PREVIOUS COLONOSCOPY REPORT WAS INCOMPLETE)" 49333170_1 CDM 0301 RC G9999 HCPCS inpatient 30 19.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.17 29.1 "DOCUMENTATION OF SYSTEM REASON(S) FOR AN INTERVAL OF LESS THAN 3 YEARS SINCE THE LAST COLONOSCOPY (E.G., UNABLE TO LOCATE PREVIOUS COLONOSCOPY REPORT, PREVIOUS COLONOSCOPY REPORT WAS INCOMPLETE)" 49333170_1 CDM 0301 RC G9999 HCPCS inpatient 30 19.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.17 29.1 "DOCUMENTATION OF SYSTEM REASON(S) FOR AN INTERVAL OF LESS THAN 3 YEARS SINCE THE LAST COLONOSCOPY (E.G., UNABLE TO LOCATE PREVIOUS COLONOSCOPY REPORT, PREVIOUS COLONOSCOPY REPORT WAS INCOMPLETE)" 49333170_1 CDM 0301 RC G9999 HCPCS inpatient 30 19.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.28 67.6 999999999 18.17 29.1 percent of total billed charges "DOCUMENTATION OF SYSTEM REASON(S) FOR AN INTERVAL OF LESS THAN 3 YEARS SINCE THE LAST COLONOSCOPY (E.G., UNABLE TO LOCATE PREVIOUS COLONOSCOPY REPORT, PREVIOUS COLONOSCOPY REPORT WAS INCOMPLETE)" 49333170_1 CDM 0301 RC G9999 HCPCS inpatient 30 19.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.17 29.1 Insertion of temporary bladder tube 49338299_1 CDM 0450 RC 51701 HCPCS inpatient 238 154.7 AETNA AETNA 188.02 79 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 49338299_1 CDM 0450 RC 51701 HCPCS inpatient 238 154.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.7 65 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 49338299_1 CDM 0450 RC 51701 HCPCS inpatient 238 154.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 230.86 97 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 49338299_1 CDM 0450 RC 51701 HCPCS inpatient 238 154.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 185.64 78 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 49338299_1 CDM 0450 RC 51701 HCPCS inpatient 238 154.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.22 69 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 49338299_1 CDM 0450 RC 51701 HCPCS inpatient 238 154.7 UMR - ALL PLANS UMR - ALL PLANS 166.6 70 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 49338299_1 CDM 0450 RC 51701 HCPCS inpatient 238 154.7 SIHO - ALL PLANS SIHO - ALL PLANS 214.2 90 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 49338299_1 CDM 0450 RC 51701 HCPCS inpatient 238 154.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.11 60.55 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 49338299_1 CDM 0450 RC 51701 HCPCS inpatient 238 154.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.11 230.86 Insertion of temporary bladder tube 49338299_1 CDM 0450 RC 51701 HCPCS inpatient 238 154.7 ANTHEM HMO ANTHEM HMO 999999999 144.11 230.86 Insertion of temporary bladder tube 49338299_1 CDM 0450 RC 51701 HCPCS inpatient 238 154.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.11 230.86 Insertion of temporary bladder tube 49338299_1 CDM 0450 RC 51701 HCPCS inpatient 238 154.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.11 230.86 Insertion of temporary bladder tube 49338299_1 CDM 0450 RC 51701 HCPCS inpatient 238 154.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.89 67.6 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 49338299_1 CDM 0450 RC 51701 HCPCS inpatient 238 154.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.11 230.86 Insertion of temporary bladder tube 49338300_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 AETNA AETNA 176.17 79 999999999 135.03 216.31 percent of total billed charges Insertion of temporary bladder tube 49338300_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 144.95 65 999999999 135.03 216.31 percent of total billed charges Insertion of temporary bladder tube 49338300_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 216.31 97 999999999 135.03 216.31 percent of total billed charges Insertion of temporary bladder tube 49338300_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 173.94 78 999999999 135.03 216.31 percent of total billed charges Insertion of temporary bladder tube 49338300_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 153.87 69 999999999 135.03 216.31 percent of total billed charges Insertion of temporary bladder tube 49338300_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 UMR - ALL PLANS UMR - ALL PLANS 156.1 70 999999999 135.03 216.31 percent of total billed charges Insertion of temporary bladder tube 49338300_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 SIHO - ALL PLANS SIHO - ALL PLANS 200.7 90 999999999 135.03 216.31 percent of total billed charges Insertion of temporary bladder tube 49338300_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 135.03 60.55 999999999 135.03 216.31 percent of total billed charges Insertion of temporary bladder tube 49338300_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 135.03 216.31 Insertion of temporary bladder tube 49338300_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 ANTHEM HMO ANTHEM HMO 999999999 135.03 216.31 Insertion of temporary bladder tube 49338300_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 135.03 216.31 Insertion of temporary bladder tube 49338300_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 135.03 216.31 Insertion of temporary bladder tube 49338300_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 150.75 67.6 999999999 135.03 216.31 percent of total billed charges Insertion of temporary bladder tube 49338300_1 CDM 0450 RC 51701 HCPCS inpatient 223 144.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 135.03 216.31 Insertion of temporary bladder tube 49338301_1 CDM 0450 RC 51701 HCPCS inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges Insertion of temporary bladder tube 49338301_1 CDM 0450 RC 51701 HCPCS inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges Insertion of temporary bladder tube 49338301_1 CDM 0450 RC 51701 HCPCS inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges Insertion of temporary bladder tube 49338301_1 CDM 0450 RC 51701 HCPCS inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges Insertion of temporary bladder tube 49338301_1 CDM 0450 RC 51701 HCPCS inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges Insertion of temporary bladder tube 49338301_1 CDM 0450 RC 51701 HCPCS inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges Insertion of temporary bladder tube 49338301_1 CDM 0450 RC 51701 HCPCS inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges Insertion of temporary bladder tube 49338301_1 CDM 0450 RC 51701 HCPCS inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges Insertion of temporary bladder tube 49338301_1 CDM 0450 RC 51701 HCPCS inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 Insertion of temporary bladder tube 49338301_1 CDM 0450 RC 51701 HCPCS inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 Insertion of temporary bladder tube 49338301_1 CDM 0450 RC 51701 HCPCS inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 Insertion of temporary bladder tube 49338301_1 CDM 0450 RC 51701 HCPCS inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 Insertion of temporary bladder tube 49338301_1 CDM 0450 RC 51701 HCPCS inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges Insertion of temporary bladder tube 49338301_1 CDM 0450 RC 51701 HCPCS inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 PREVNAR 13 SYRINGE 49338427_1 CDM 0250 RC 00005-1971-02 NDC inpatient 1 UN 1819.35 1182.58 AETNA AETNA 1437.29 79 999999999 1101.62 1764.77 percent of total billed charges PREVNAR 13 SYRINGE 49338427_1 CDM 0250 RC 00005-1971-02 NDC inpatient 1 UN 1819.35 1182.58 SELF PAY DISCOUNT SELF PAY DISCOUNT 1182.58 65 999999999 1101.62 1764.77 percent of total billed charges PREVNAR 13 SYRINGE 49338427_1 CDM 0250 RC 00005-1971-02 NDC inpatient 1 UN 1819.35 1182.58 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1764.77 97 999999999 1101.62 1764.77 percent of total billed charges PREVNAR 13 SYRINGE 49338427_1 CDM 0250 RC 00005-1971-02 NDC inpatient 1 UN 1819.35 1182.58 HUMANA - ALL PLANS HUMANA - ALL PLANS 1419.09 78 999999999 1101.62 1764.77 percent of total billed charges PREVNAR 13 SYRINGE 49338427_1 CDM 0250 RC 00005-1971-02 NDC inpatient 1 UN 1819.35 1182.58 ENCORE - ALL PLANS ENCORE - ALL PLANS 1255.35 69 999999999 1101.62 1764.77 percent of total billed charges PREVNAR 13 SYRINGE 49338427_1 CDM 0250 RC 00005-1971-02 NDC inpatient 1 UN 1819.35 1182.58 UMR - ALL PLANS UMR - ALL PLANS 1273.55 70 999999999 1101.62 1764.77 percent of total billed charges PREVNAR 13 SYRINGE 49338427_1 CDM 0250 RC 00005-1971-02 NDC inpatient 1 UN 1819.35 1182.58 SIHO - ALL PLANS SIHO - ALL PLANS 1637.42 90 999999999 1101.62 1764.77 percent of total billed charges PREVNAR 13 SYRINGE 49338427_1 CDM 0250 RC 00005-1971-02 NDC inpatient 1 UN 1819.35 1182.58 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1101.62 60.55 999999999 1101.62 1764.77 percent of total billed charges PREVNAR 13 SYRINGE 49338427_1 CDM 0250 RC 00005-1971-02 NDC inpatient 1 UN 1819.35 1182.58 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1101.62 1764.77 PREVNAR 13 SYRINGE 49338427_1 CDM 0250 RC 00005-1971-02 NDC inpatient 1 UN 1819.35 1182.58 ANTHEM HMO ANTHEM HMO 999999999 1101.62 1764.77 PREVNAR 13 SYRINGE 49338427_1 CDM 0250 RC 00005-1971-02 NDC inpatient 1 UN 1819.35 1182.58 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1101.62 1764.77 PREVNAR 13 SYRINGE 49338427_1 CDM 0250 RC 00005-1971-02 NDC inpatient 1 UN 1819.35 1182.58 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1101.62 1764.77 PREVNAR 13 SYRINGE 49338427_1 CDM 0250 RC 00005-1971-02 NDC inpatient 1 UN 1819.35 1182.58 CIGNA - ALL PLANS CIGNA - ALL PLANS 1229.88 67.6 999999999 1101.62 1764.77 percent of total billed charges PREVNAR 13 SYRINGE 49338427_1 CDM 0250 RC 00005-1971-02 NDC inpatient 1 UN 1819.35 1182.58 UHC - ALL PLANS UHC - ALL PLANS 999999999 1101.62 1764.77 SENSORCN-MPF 0.5%-EPI 1:200000 49342556_1 CDM 0250 RC 63323-0462-17 NDC inpatient 1 UN 10 6.5 AETNA AETNA 7.9 79 999999999 6.06 9.7 percent of total billed charges SENSORCN-MPF 0.5%-EPI 1:200000 49342556_1 CDM 0250 RC 63323-0462-17 NDC inpatient 1 UN 10 6.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.5 65 999999999 6.06 9.7 percent of total billed charges SENSORCN-MPF 0.5%-EPI 1:200000 49342556_1 CDM 0250 RC 63323-0462-17 NDC inpatient 1 UN 10 6.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.7 97 999999999 6.06 9.7 percent of total billed charges SENSORCN-MPF 0.5%-EPI 1:200000 49342556_1 CDM 0250 RC 63323-0462-17 NDC inpatient 1 UN 10 6.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.8 78 999999999 6.06 9.7 percent of total billed charges SENSORCN-MPF 0.5%-EPI 1:200000 49342556_1 CDM 0250 RC 63323-0462-17 NDC inpatient 1 UN 10 6.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.9 69 999999999 6.06 9.7 percent of total billed charges SENSORCN-MPF 0.5%-EPI 1:200000 49342556_1 CDM 0250 RC 63323-0462-17 NDC inpatient 1 UN 10 6.5 UMR - ALL PLANS UMR - ALL PLANS 7 70 999999999 6.06 9.7 percent of total billed charges SENSORCN-MPF 0.5%-EPI 1:200000 49342556_1 CDM 0250 RC 63323-0462-17 NDC inpatient 1 UN 10 6.5 SIHO - ALL PLANS SIHO - ALL PLANS 9 90 999999999 6.06 9.7 percent of total billed charges SENSORCN-MPF 0.5%-EPI 1:200000 49342556_1 CDM 0250 RC 63323-0462-17 NDC inpatient 1 UN 10 6.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.06 60.55 999999999 6.06 9.7 percent of total billed charges SENSORCN-MPF 0.5%-EPI 1:200000 49342556_1 CDM 0250 RC 63323-0462-17 NDC inpatient 1 UN 10 6.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.06 9.7 SENSORCN-MPF 0.5%-EPI 1:200000 49342556_1 CDM 0250 RC 63323-0462-17 NDC inpatient 1 UN 10 6.5 ANTHEM HMO ANTHEM HMO 999999999 6.06 9.7 SENSORCN-MPF 0.5%-EPI 1:200000 49342556_1 CDM 0250 RC 63323-0462-17 NDC inpatient 1 UN 10 6.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.06 9.7 SENSORCN-MPF 0.5%-EPI 1:200000 49342556_1 CDM 0250 RC 63323-0462-17 NDC inpatient 1 UN 10 6.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.06 9.7 SENSORCN-MPF 0.5%-EPI 1:200000 49342556_1 CDM 0250 RC 63323-0462-17 NDC inpatient 1 UN 10 6.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.76 67.6 999999999 6.06 9.7 percent of total billed charges SENSORCN-MPF 0.5%-EPI 1:200000 49342556_1 CDM 0250 RC 63323-0462-17 NDC inpatient 1 UN 10 6.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.06 9.7 00409-6637-34 - sodium bicarbonate 8.4% Sol 49342565_1 CDM 0250 RC 00409-6637-34 NDC inpatient 1 UN 40.43 26.28 AETNA AETNA 31.94 79 999999999 24.48 39.22 percent of total billed charges 00409-6637-34 - sodium bicarbonate 8.4% Sol 49342565_1 CDM 0250 RC 00409-6637-34 NDC inpatient 1 UN 40.43 26.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.28 65 999999999 24.48 39.22 percent of total billed charges 00409-6637-34 - sodium bicarbonate 8.4% Sol 49342565_1 CDM 0250 RC 00409-6637-34 NDC inpatient 1 UN 40.43 26.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39.22 97 999999999 24.48 39.22 percent of total billed charges 00409-6637-34 - sodium bicarbonate 8.4% Sol 49342565_1 CDM 0250 RC 00409-6637-34 NDC inpatient 1 UN 40.43 26.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.54 78 999999999 24.48 39.22 percent of total billed charges 00409-6637-34 - sodium bicarbonate 8.4% Sol 49342565_1 CDM 0250 RC 00409-6637-34 NDC inpatient 1 UN 40.43 26.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 27.9 69 999999999 24.48 39.22 percent of total billed charges 00409-6637-34 - sodium bicarbonate 8.4% Sol 49342565_1 CDM 0250 RC 00409-6637-34 NDC inpatient 1 UN 40.43 26.28 UMR - ALL PLANS UMR - ALL PLANS 28.3 70 999999999 24.48 39.22 percent of total billed charges 00409-6637-34 - sodium bicarbonate 8.4% Sol 49342565_1 CDM 0250 RC 00409-6637-34 NDC inpatient 1 UN 40.43 26.28 SIHO - ALL PLANS SIHO - ALL PLANS 36.39 90 999999999 24.48 39.22 percent of total billed charges 00409-6637-34 - sodium bicarbonate 8.4% Sol 49342565_1 CDM 0250 RC 00409-6637-34 NDC inpatient 1 UN 40.43 26.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.48 60.55 999999999 24.48 39.22 percent of total billed charges 00409-6637-34 - sodium bicarbonate 8.4% Sol 49342565_1 CDM 0250 RC 00409-6637-34 NDC inpatient 1 UN 40.43 26.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.48 39.22 00409-6637-34 - sodium bicarbonate 8.4% Sol 49342565_1 CDM 0250 RC 00409-6637-34 NDC inpatient 1 UN 40.43 26.28 ANTHEM HMO ANTHEM HMO 999999999 24.48 39.22 00409-6637-34 - sodium bicarbonate 8.4% Sol 49342565_1 CDM 0250 RC 00409-6637-34 NDC inpatient 1 UN 40.43 26.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.48 39.22 00409-6637-34 - sodium bicarbonate 8.4% Sol 49342565_1 CDM 0250 RC 00409-6637-34 NDC inpatient 1 UN 40.43 26.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.48 39.22 00409-6637-34 - sodium bicarbonate 8.4% Sol 49342565_1 CDM 0250 RC 00409-6637-34 NDC inpatient 1 UN 40.43 26.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.33 67.6 999999999 24.48 39.22 percent of total billed charges 00409-6637-34 - sodium bicarbonate 8.4% Sol 49342565_1 CDM 0250 RC 00409-6637-34 NDC inpatient 1 UN 40.43 26.28 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.48 39.22 Complete ultrasound scan of pelvis 49342570_1 CDM 0402 RC 76856 HCPCS inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges Complete ultrasound scan of pelvis 49342570_1 CDM 0402 RC 76856 HCPCS inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges Complete ultrasound scan of pelvis 49342570_1 CDM 0402 RC 76856 HCPCS inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges Complete ultrasound scan of pelvis 49342570_1 CDM 0402 RC 76856 HCPCS inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges Complete ultrasound scan of pelvis 49342570_1 CDM 0402 RC 76856 HCPCS inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges Complete ultrasound scan of pelvis 49342570_1 CDM 0402 RC 76856 HCPCS inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges Complete ultrasound scan of pelvis 49342570_1 CDM 0402 RC 76856 HCPCS inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges Complete ultrasound scan of pelvis 49342570_1 CDM 0402 RC 76856 HCPCS inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges Complete ultrasound scan of pelvis 49342570_1 CDM 0402 RC 76856 HCPCS inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 Complete ultrasound scan of pelvis 49342570_1 CDM 0402 RC 76856 HCPCS inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 Complete ultrasound scan of pelvis 49342570_1 CDM 0402 RC 76856 HCPCS inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 Complete ultrasound scan of pelvis 49342570_1 CDM 0402 RC 76856 HCPCS inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 Complete ultrasound scan of pelvis 49342570_1 CDM 0402 RC 76856 HCPCS inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges Complete ultrasound scan of pelvis 49342570_1 CDM 0402 RC 76856 HCPCS inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 "Influenza vaccine split virus, preservative free" 49342651_1 CDM 0250 RC 58160-0907-52 NDC 90662 HCPCS inpatient 1 UN 20.24 13.16 AETNA AETNA 15.99 79 999999999 12.26 19.63 percent of total billed charges "Influenza vaccine split virus, preservative free" 49342651_1 CDM 0250 RC 58160-0907-52 NDC 90662 HCPCS inpatient 1 UN 20.24 13.16 SELF PAY DISCOUNT SELF PAY DISCOUNT 13.16 65 999999999 12.26 19.63 percent of total billed charges "Influenza vaccine split virus, preservative free" 49342651_1 CDM 0250 RC 58160-0907-52 NDC 90662 HCPCS inpatient 1 UN 20.24 13.16 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.63 97 999999999 12.26 19.63 percent of total billed charges "Influenza vaccine split virus, preservative free" 49342651_1 CDM 0250 RC 58160-0907-52 NDC 90662 HCPCS inpatient 1 UN 20.24 13.16 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.79 78 999999999 12.26 19.63 percent of total billed charges "Influenza vaccine split virus, preservative free" 49342651_1 CDM 0250 RC 58160-0907-52 NDC 90662 HCPCS inpatient 1 UN 20.24 13.16 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.97 69 999999999 12.26 19.63 percent of total billed charges "Influenza vaccine split virus, preservative free" 49342651_1 CDM 0250 RC 58160-0907-52 NDC 90662 HCPCS inpatient 1 UN 20.24 13.16 UMR - ALL PLANS UMR - ALL PLANS 14.17 70 999999999 12.26 19.63 percent of total billed charges "Influenza vaccine split virus, preservative free" 49342651_1 CDM 0250 RC 58160-0907-52 NDC 90662 HCPCS inpatient 1 UN 20.24 13.16 SIHO - ALL PLANS SIHO - ALL PLANS 18.22 90 999999999 12.26 19.63 percent of total billed charges "Influenza vaccine split virus, preservative free" 49342651_1 CDM 0250 RC 58160-0907-52 NDC 90662 HCPCS inpatient 1 UN 20.24 13.16 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.26 60.55 999999999 12.26 19.63 percent of total billed charges "Influenza vaccine split virus, preservative free" 49342651_1 CDM 0250 RC 58160-0907-52 NDC 90662 HCPCS inpatient 1 UN 20.24 13.16 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.26 19.63 "Influenza vaccine split virus, preservative free" 49342651_1 CDM 0250 RC 58160-0907-52 NDC 90662 HCPCS inpatient 1 UN 20.24 13.16 ANTHEM HMO ANTHEM HMO 999999999 12.26 19.63 "Influenza vaccine split virus, preservative free" 49342651_1 CDM 0250 RC 58160-0907-52 NDC 90662 HCPCS inpatient 1 UN 20.24 13.16 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.26 19.63 "Influenza vaccine split virus, preservative free" 49342651_1 CDM 0250 RC 58160-0907-52 NDC 90662 HCPCS inpatient 1 UN 20.24 13.16 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.26 19.63 "Influenza vaccine split virus, preservative free" 49342651_1 CDM 0250 RC 58160-0907-52 NDC 90662 HCPCS inpatient 1 UN 20.24 13.16 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.68 67.6 999999999 12.26 19.63 percent of total billed charges "Influenza vaccine split virus, preservative free" 49342651_1 CDM 0250 RC 58160-0907-52 NDC 90662 HCPCS inpatient 1 UN 20.24 13.16 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.26 19.63 Analysis for antibody (IgM) to Toxoplasma (parasite) 49343050_1 CDM 0301 RC 86778 HCPCS inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges Analysis for antibody (IgM) to Toxoplasma (parasite) 49343050_1 CDM 0301 RC 86778 HCPCS inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges Analysis for antibody (IgM) to Toxoplasma (parasite) 49343050_1 CDM 0301 RC 86778 HCPCS inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges Analysis for antibody (IgM) to Toxoplasma (parasite) 49343050_1 CDM 0301 RC 86778 HCPCS inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges Analysis for antibody (IgM) to Toxoplasma (parasite) 49343050_1 CDM 0301 RC 86778 HCPCS inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges Analysis for antibody (IgM) to Toxoplasma (parasite) 49343050_1 CDM 0301 RC 86778 HCPCS inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges Analysis for antibody (IgM) to Toxoplasma (parasite) 49343050_1 CDM 0301 RC 86778 HCPCS inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges Analysis for antibody (IgM) to Toxoplasma (parasite) 49343050_1 CDM 0301 RC 86778 HCPCS inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges Analysis for antibody (IgM) to Toxoplasma (parasite) 49343050_1 CDM 0301 RC 86778 HCPCS inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 Analysis for antibody (IgM) to Toxoplasma (parasite) 49343050_1 CDM 0301 RC 86778 HCPCS inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 Analysis for antibody (IgM) to Toxoplasma (parasite) 49343050_1 CDM 0301 RC 86778 HCPCS inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 Analysis for antibody (IgM) to Toxoplasma (parasite) 49343050_1 CDM 0301 RC 86778 HCPCS inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 Analysis for antibody (IgM) to Toxoplasma (parasite) 49343050_1 CDM 0301 RC 86778 HCPCS inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges Analysis for antibody (IgM) to Toxoplasma (parasite) 49343050_1 CDM 0301 RC 86778 HCPCS inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 Analysis for antibody to Toxoplasma (parasite) 49343051_1 CDM 0301 RC 86777 HCPCS inpatient 125 81.25 AETNA AETNA 98.75 79 999999999 75.69 121.25 percent of total billed charges Analysis for antibody to Toxoplasma (parasite) 49343051_1 CDM 0301 RC 86777 HCPCS inpatient 125 81.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.25 65 999999999 75.69 121.25 percent of total billed charges Analysis for antibody to Toxoplasma (parasite) 49343051_1 CDM 0301 RC 86777 HCPCS inpatient 125 81.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 121.25 97 999999999 75.69 121.25 percent of total billed charges Analysis for antibody to Toxoplasma (parasite) 49343051_1 CDM 0301 RC 86777 HCPCS inpatient 125 81.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.5 78 999999999 75.69 121.25 percent of total billed charges Analysis for antibody to Toxoplasma (parasite) 49343051_1 CDM 0301 RC 86777 HCPCS inpatient 125 81.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.25 69 999999999 75.69 121.25 percent of total billed charges Analysis for antibody to Toxoplasma (parasite) 49343051_1 CDM 0301 RC 86777 HCPCS inpatient 125 81.25 UMR - ALL PLANS UMR - ALL PLANS 87.5 70 999999999 75.69 121.25 percent of total billed charges Analysis for antibody to Toxoplasma (parasite) 49343051_1 CDM 0301 RC 86777 HCPCS inpatient 125 81.25 SIHO - ALL PLANS SIHO - ALL PLANS 112.5 90 999999999 75.69 121.25 percent of total billed charges Analysis for antibody to Toxoplasma (parasite) 49343051_1 CDM 0301 RC 86777 HCPCS inpatient 125 81.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.69 60.55 999999999 75.69 121.25 percent of total billed charges Analysis for antibody to Toxoplasma (parasite) 49343051_1 CDM 0301 RC 86777 HCPCS inpatient 125 81.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.69 121.25 Analysis for antibody to Toxoplasma (parasite) 49343051_1 CDM 0301 RC 86777 HCPCS inpatient 125 81.25 ANTHEM HMO ANTHEM HMO 999999999 75.69 121.25 Analysis for antibody to Toxoplasma (parasite) 49343051_1 CDM 0301 RC 86777 HCPCS inpatient 125 81.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.69 121.25 Analysis for antibody to Toxoplasma (parasite) 49343051_1 CDM 0301 RC 86777 HCPCS inpatient 125 81.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.69 121.25 Analysis for antibody to Toxoplasma (parasite) 49343051_1 CDM 0301 RC 86777 HCPCS inpatient 125 81.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.5 67.6 999999999 75.69 121.25 percent of total billed charges Analysis for antibody to Toxoplasma (parasite) 49343051_1 CDM 0301 RC 86777 HCPCS inpatient 125 81.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.69 121.25 DILTIAZEM 24H ER(CD) 120 MG CP 49343716_1 CDM 0250 RC 60687-0195-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges DILTIAZEM 24H ER(CD) 120 MG CP 49343716_1 CDM 0250 RC 60687-0195-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges DILTIAZEM 24H ER(CD) 120 MG CP 49343716_1 CDM 0250 RC 60687-0195-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges DILTIAZEM 24H ER(CD) 120 MG CP 49343716_1 CDM 0250 RC 60687-0195-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges DILTIAZEM 24H ER(CD) 120 MG CP 49343716_1 CDM 0250 RC 60687-0195-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges DILTIAZEM 24H ER(CD) 120 MG CP 49343716_1 CDM 0250 RC 60687-0195-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges DILTIAZEM 24H ER(CD) 120 MG CP 49343716_1 CDM 0250 RC 60687-0195-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges DILTIAZEM 24H ER(CD) 120 MG CP 49343716_1 CDM 0250 RC 60687-0195-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges DILTIAZEM 24H ER(CD) 120 MG CP 49343716_1 CDM 0250 RC 60687-0195-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 DILTIAZEM 24H ER(CD) 120 MG CP 49343716_1 CDM 0250 RC 60687-0195-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 DILTIAZEM 24H ER(CD) 120 MG CP 49343716_1 CDM 0250 RC 60687-0195-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 DILTIAZEM 24H ER(CD) 120 MG CP 49343716_1 CDM 0250 RC 60687-0195-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 DILTIAZEM 24H ER(CD) 120 MG CP 49343716_1 CDM 0250 RC 60687-0195-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges DILTIAZEM 24H ER(CD) 120 MG CP 49343716_1 CDM 0250 RC 60687-0195-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 Transfusion of blood or blood products 49345555_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 AETNA AETNA 981.18 79 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 49345555_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 807.3 65 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 49345555_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1204.74 97 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 49345555_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 968.76 78 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 49345555_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 856.98 69 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 49345555_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 UMR - ALL PLANS UMR - ALL PLANS 869.4 70 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 49345555_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 SIHO - ALL PLANS SIHO - ALL PLANS 1117.8 90 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 49345555_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 752.03 60.55 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 49345555_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 752.03 1204.74 Transfusion of blood or blood products 49345555_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM HMO ANTHEM HMO 999999999 752.03 1204.74 Transfusion of blood or blood products 49345555_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 752.03 1204.74 Transfusion of blood or blood products 49345555_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 752.03 1204.74 Transfusion of blood or blood products 49345555_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 839.59 67.6 999999999 752.03 1204.74 percent of total billed charges Transfusion of blood or blood products 49345555_1 CDM 0391 RC 36430 HCPCS inpatient 1242 807.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 752.03 1204.74 TEKTURNA 150 MG TABLET 49346718_1 CDM 0250 RC 70839-0150-30 NDC inpatient 1 UN 26.71 17.36 AETNA AETNA 21.1 79 999999999 16.17 25.91 percent of total billed charges TEKTURNA 150 MG TABLET 49346718_1 CDM 0250 RC 70839-0150-30 NDC inpatient 1 UN 26.71 17.36 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.36 65 999999999 16.17 25.91 percent of total billed charges TEKTURNA 150 MG TABLET 49346718_1 CDM 0250 RC 70839-0150-30 NDC inpatient 1 UN 26.71 17.36 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.91 97 999999999 16.17 25.91 percent of total billed charges TEKTURNA 150 MG TABLET 49346718_1 CDM 0250 RC 70839-0150-30 NDC inpatient 1 UN 26.71 17.36 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.83 78 999999999 16.17 25.91 percent of total billed charges TEKTURNA 150 MG TABLET 49346718_1 CDM 0250 RC 70839-0150-30 NDC inpatient 1 UN 26.71 17.36 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.43 69 999999999 16.17 25.91 percent of total billed charges TEKTURNA 150 MG TABLET 49346718_1 CDM 0250 RC 70839-0150-30 NDC inpatient 1 UN 26.71 17.36 UMR - ALL PLANS UMR - ALL PLANS 18.7 70 999999999 16.17 25.91 percent of total billed charges TEKTURNA 150 MG TABLET 49346718_1 CDM 0250 RC 70839-0150-30 NDC inpatient 1 UN 26.71 17.36 SIHO - ALL PLANS SIHO - ALL PLANS 24.04 90 999999999 16.17 25.91 percent of total billed charges TEKTURNA 150 MG TABLET 49346718_1 CDM 0250 RC 70839-0150-30 NDC inpatient 1 UN 26.71 17.36 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.17 60.55 999999999 16.17 25.91 percent of total billed charges TEKTURNA 150 MG TABLET 49346718_1 CDM 0250 RC 70839-0150-30 NDC inpatient 1 UN 26.71 17.36 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.17 25.91 TEKTURNA 150 MG TABLET 49346718_1 CDM 0250 RC 70839-0150-30 NDC inpatient 1 UN 26.71 17.36 ANTHEM HMO ANTHEM HMO 999999999 16.17 25.91 TEKTURNA 150 MG TABLET 49346718_1 CDM 0250 RC 70839-0150-30 NDC inpatient 1 UN 26.71 17.36 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.17 25.91 TEKTURNA 150 MG TABLET 49346718_1 CDM 0250 RC 70839-0150-30 NDC inpatient 1 UN 26.71 17.36 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.17 25.91 TEKTURNA 150 MG TABLET 49346718_1 CDM 0250 RC 70839-0150-30 NDC inpatient 1 UN 26.71 17.36 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.06 67.6 999999999 16.17 25.91 percent of total billed charges TEKTURNA 150 MG TABLET 49346718_1 CDM 0250 RC 70839-0150-30 NDC inpatient 1 UN 26.71 17.36 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.17 25.91 "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 49357028_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 AETNA AETNA 640.69 79 999999999 491.06 786.67 percent of total billed charges "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 49357028_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 527.15 65 999999999 491.06 786.67 percent of total billed charges "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 49357028_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 786.67 97 999999999 491.06 786.67 percent of total billed charges "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 49357028_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 632.58 78 999999999 491.06 786.67 percent of total billed charges "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 49357028_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 559.59 69 999999999 491.06 786.67 percent of total billed charges "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 49357028_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 UMR - ALL PLANS UMR - ALL PLANS 567.7 70 999999999 491.06 786.67 percent of total billed charges "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 49357028_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 SIHO - ALL PLANS SIHO - ALL PLANS 729.9 90 999999999 491.06 786.67 percent of total billed charges "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 49357028_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 491.06 60.55 999999999 491.06 786.67 percent of total billed charges "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 49357028_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 491.06 786.67 "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 49357028_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 ANTHEM HMO ANTHEM HMO 999999999 491.06 786.67 "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 49357028_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 491.06 786.67 "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 49357028_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 491.06 786.67 "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 49357028_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 548.24 67.6 999999999 491.06 786.67 percent of total billed charges "Ultrasound scan of pregnant uterus (less than 14 weeks), single or first fetus" 49357028_1 CDM 0402 RC 76801 HCPCS inpatient 811 527.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 491.06 786.67 CT scan of blood vessels of abdomen with contrast 49357036_1 CDM 0352 RC 74175 HCPCS inpatient 2836 1843.4 AETNA AETNA 2240.44 79 999999999 1717.2 2750.92 percent of total billed charges CT scan of blood vessels of abdomen with contrast 49357036_1 CDM 0352 RC 74175 HCPCS inpatient 2836 1843.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1843.4 65 999999999 1717.2 2750.92 percent of total billed charges CT scan of blood vessels of abdomen with contrast 49357036_1 CDM 0352 RC 74175 HCPCS inpatient 2836 1843.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2750.92 97 999999999 1717.2 2750.92 percent of total billed charges CT scan of blood vessels of abdomen with contrast 49357036_1 CDM 0352 RC 74175 HCPCS inpatient 2836 1843.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 2212.08 78 999999999 1717.2 2750.92 percent of total billed charges CT scan of blood vessels of abdomen with contrast 49357036_1 CDM 0352 RC 74175 HCPCS inpatient 2836 1843.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1956.84 69 999999999 1717.2 2750.92 percent of total billed charges CT scan of blood vessels of abdomen with contrast 49357036_1 CDM 0352 RC 74175 HCPCS inpatient 2836 1843.4 UMR - ALL PLANS UMR - ALL PLANS 1985.2 70 999999999 1717.2 2750.92 percent of total billed charges CT scan of blood vessels of abdomen with contrast 49357036_1 CDM 0352 RC 74175 HCPCS inpatient 2836 1843.4 SIHO - ALL PLANS SIHO - ALL PLANS 2552.4 90 999999999 1717.2 2750.92 percent of total billed charges CT scan of blood vessels of abdomen with contrast 49357036_1 CDM 0352 RC 74175 HCPCS inpatient 2836 1843.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1717.2 60.55 999999999 1717.2 2750.92 percent of total billed charges CT scan of blood vessels of abdomen with contrast 49357036_1 CDM 0352 RC 74175 HCPCS inpatient 2836 1843.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1717.2 2750.92 CT scan of blood vessels of abdomen with contrast 49357036_1 CDM 0352 RC 74175 HCPCS inpatient 2836 1843.4 ANTHEM HMO ANTHEM HMO 999999999 1717.2 2750.92 CT scan of blood vessels of abdomen with contrast 49357036_1 CDM 0352 RC 74175 HCPCS inpatient 2836 1843.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1717.2 2750.92 CT scan of blood vessels of abdomen with contrast 49357036_1 CDM 0352 RC 74175 HCPCS inpatient 2836 1843.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1717.2 2750.92 CT scan of blood vessels of abdomen with contrast 49357036_1 CDM 0352 RC 74175 HCPCS inpatient 2836 1843.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1917.14 67.6 999999999 1717.2 2750.92 percent of total billed charges CT scan of blood vessels of abdomen with contrast 49357036_1 CDM 0352 RC 74175 HCPCS inpatient 2836 1843.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1717.2 2750.92 CT scan of blood vessels of chest with contrast 49357037_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 AETNA AETNA 2399.23 79 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 49357037_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1974.05 65 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 49357037_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2945.89 97 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 49357037_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 2368.86 78 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 49357037_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2095.53 69 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 49357037_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 UMR - ALL PLANS UMR - ALL PLANS 2125.9 70 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 49357037_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 SIHO - ALL PLANS SIHO - ALL PLANS 2733.3 90 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 49357037_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1838.9 60.55 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 49357037_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1838.9 2945.89 CT scan of blood vessels of chest with contrast 49357037_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 ANTHEM HMO ANTHEM HMO 999999999 1838.9 2945.89 CT scan of blood vessels of chest with contrast 49357037_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1838.9 2945.89 CT scan of blood vessels of chest with contrast 49357037_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1838.9 2945.89 CT scan of blood vessels of chest with contrast 49357037_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2053.01 67.6 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 49357037_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1838.9 2945.89 Analysis using chemiluminescent technique (light and chemical )reaction 49357219_1 CDM 0300 RC 82397 HCPCS inpatient 355 230.75 AETNA AETNA 280.45 79 999999999 214.95 344.35 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 49357219_1 CDM 0300 RC 82397 HCPCS inpatient 355 230.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 230.75 65 999999999 214.95 344.35 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 49357219_1 CDM 0300 RC 82397 HCPCS inpatient 355 230.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 344.35 97 999999999 214.95 344.35 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 49357219_1 CDM 0300 RC 82397 HCPCS inpatient 355 230.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 276.9 78 999999999 214.95 344.35 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 49357219_1 CDM 0300 RC 82397 HCPCS inpatient 355 230.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 244.95 69 999999999 214.95 344.35 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 49357219_1 CDM 0300 RC 82397 HCPCS inpatient 355 230.75 UMR - ALL PLANS UMR - ALL PLANS 248.5 70 999999999 214.95 344.35 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 49357219_1 CDM 0300 RC 82397 HCPCS inpatient 355 230.75 SIHO - ALL PLANS SIHO - ALL PLANS 319.5 90 999999999 214.95 344.35 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 49357219_1 CDM 0300 RC 82397 HCPCS inpatient 355 230.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 214.95 60.55 999999999 214.95 344.35 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 49357219_1 CDM 0300 RC 82397 HCPCS inpatient 355 230.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 214.95 344.35 Analysis using chemiluminescent technique (light and chemical )reaction 49357219_1 CDM 0300 RC 82397 HCPCS inpatient 355 230.75 ANTHEM HMO ANTHEM HMO 999999999 214.95 344.35 Analysis using chemiluminescent technique (light and chemical )reaction 49357219_1 CDM 0300 RC 82397 HCPCS inpatient 355 230.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 214.95 344.35 Analysis using chemiluminescent technique (light and chemical )reaction 49357219_1 CDM 0300 RC 82397 HCPCS inpatient 355 230.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 214.95 344.35 Analysis using chemiluminescent technique (light and chemical )reaction 49357219_1 CDM 0300 RC 82397 HCPCS inpatient 355 230.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 239.98 67.6 999999999 214.95 344.35 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 49357219_1 CDM 0300 RC 82397 HCPCS inpatient 355 230.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 214.95 344.35 "INJECTION, MORPHINE SULFATE, PRESERVATIVE-FREE FOR EPIDURAL OR INTRATHECAL USE, 10MG" 49368387_1 CDM 0250 RC 76045-0004-10 NDC J2275 HCPCS inpatient 1 UN 29.24 19.01 AETNA AETNA 23.1 79 999999999 17.7 28.36 percent of total billed charges "INJECTION, MORPHINE SULFATE, PRESERVATIVE-FREE FOR EPIDURAL OR INTRATHECAL USE, 10MG" 49368387_1 CDM 0250 RC 76045-0004-10 NDC J2275 HCPCS inpatient 1 UN 29.24 19.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.01 65 999999999 17.7 28.36 percent of total billed charges "INJECTION, MORPHINE SULFATE, PRESERVATIVE-FREE FOR EPIDURAL OR INTRATHECAL USE, 10MG" 49368387_1 CDM 0250 RC 76045-0004-10 NDC J2275 HCPCS inpatient 1 UN 29.24 19.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 28.36 97 999999999 17.7 28.36 percent of total billed charges "INJECTION, MORPHINE SULFATE, PRESERVATIVE-FREE FOR EPIDURAL OR INTRATHECAL USE, 10MG" 49368387_1 CDM 0250 RC 76045-0004-10 NDC J2275 HCPCS inpatient 1 UN 29.24 19.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 22.81 78 999999999 17.7 28.36 percent of total billed charges "INJECTION, MORPHINE SULFATE, PRESERVATIVE-FREE FOR EPIDURAL OR INTRATHECAL USE, 10MG" 49368387_1 CDM 0250 RC 76045-0004-10 NDC J2275 HCPCS inpatient 1 UN 29.24 19.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.18 69 999999999 17.7 28.36 percent of total billed charges "INJECTION, MORPHINE SULFATE, PRESERVATIVE-FREE FOR EPIDURAL OR INTRATHECAL USE, 10MG" 49368387_1 CDM 0250 RC 76045-0004-10 NDC J2275 HCPCS inpatient 1 UN 29.24 19.01 UMR - ALL PLANS UMR - ALL PLANS 20.47 70 999999999 17.7 28.36 percent of total billed charges "INJECTION, MORPHINE SULFATE, PRESERVATIVE-FREE FOR EPIDURAL OR INTRATHECAL USE, 10MG" 49368387_1 CDM 0250 RC 76045-0004-10 NDC J2275 HCPCS inpatient 1 UN 29.24 19.01 SIHO - ALL PLANS SIHO - ALL PLANS 26.32 90 999999999 17.7 28.36 percent of total billed charges "INJECTION, MORPHINE SULFATE, PRESERVATIVE-FREE FOR EPIDURAL OR INTRATHECAL USE, 10MG" 49368387_1 CDM 0250 RC 76045-0004-10 NDC J2275 HCPCS inpatient 1 UN 29.24 19.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17.7 60.55 999999999 17.7 28.36 percent of total billed charges "INJECTION, MORPHINE SULFATE, PRESERVATIVE-FREE FOR EPIDURAL OR INTRATHECAL USE, 10MG" 49368387_1 CDM 0250 RC 76045-0004-10 NDC J2275 HCPCS inpatient 1 UN 29.24 19.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 17.7 28.36 "INJECTION, MORPHINE SULFATE, PRESERVATIVE-FREE FOR EPIDURAL OR INTRATHECAL USE, 10MG" 49368387_1 CDM 0250 RC 76045-0004-10 NDC J2275 HCPCS inpatient 1 UN 29.24 19.01 ANTHEM HMO ANTHEM HMO 999999999 17.7 28.36 "INJECTION, MORPHINE SULFATE, PRESERVATIVE-FREE FOR EPIDURAL OR INTRATHECAL USE, 10MG" 49368387_1 CDM 0250 RC 76045-0004-10 NDC J2275 HCPCS inpatient 1 UN 29.24 19.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 17.7 28.36 "INJECTION, MORPHINE SULFATE, PRESERVATIVE-FREE FOR EPIDURAL OR INTRATHECAL USE, 10MG" 49368387_1 CDM 0250 RC 76045-0004-10 NDC J2275 HCPCS inpatient 1 UN 29.24 19.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 17.7 28.36 "INJECTION, MORPHINE SULFATE, PRESERVATIVE-FREE FOR EPIDURAL OR INTRATHECAL USE, 10MG" 49368387_1 CDM 0250 RC 76045-0004-10 NDC J2275 HCPCS inpatient 1 UN 29.24 19.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 19.77 67.6 999999999 17.7 28.36 percent of total billed charges "INJECTION, MORPHINE SULFATE, PRESERVATIVE-FREE FOR EPIDURAL OR INTRATHECAL USE, 10MG" 49368387_1 CDM 0250 RC 76045-0004-10 NDC J2275 HCPCS inpatient 1 UN 29.24 19.01 UHC - ALL PLANS UHC - ALL PLANS 999999999 17.7 28.36 METOPROLOL TARTRATE 100 MG TAB 49374383_1 CDM 0250 RC 62584-0267-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges METOPROLOL TARTRATE 100 MG TAB 49374383_1 CDM 0250 RC 62584-0267-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges METOPROLOL TARTRATE 100 MG TAB 49374383_1 CDM 0250 RC 62584-0267-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges METOPROLOL TARTRATE 100 MG TAB 49374383_1 CDM 0250 RC 62584-0267-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges METOPROLOL TARTRATE 100 MG TAB 49374383_1 CDM 0250 RC 62584-0267-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges METOPROLOL TARTRATE 100 MG TAB 49374383_1 CDM 0250 RC 62584-0267-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges METOPROLOL TARTRATE 100 MG TAB 49374383_1 CDM 0250 RC 62584-0267-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges METOPROLOL TARTRATE 100 MG TAB 49374383_1 CDM 0250 RC 62584-0267-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges METOPROLOL TARTRATE 100 MG TAB 49374383_1 CDM 0250 RC 62584-0267-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 METOPROLOL TARTRATE 100 MG TAB 49374383_1 CDM 0250 RC 62584-0267-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 METOPROLOL TARTRATE 100 MG TAB 49374383_1 CDM 0250 RC 62584-0267-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 METOPROLOL TARTRATE 100 MG TAB 49374383_1 CDM 0250 RC 62584-0267-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 METOPROLOL TARTRATE 100 MG TAB 49374383_1 CDM 0250 RC 62584-0267-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges METOPROLOL TARTRATE 100 MG TAB 49374383_1 CDM 0250 RC 62584-0267-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 49380994_1 CDM 0250 RC 67457-0349-10 NDC J0295 HCPCS inpatient 2 UN 37.61 24.45 AETNA AETNA 29.71 79 999999999 22.77 36.48 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 49380994_1 CDM 0250 RC 67457-0349-10 NDC J0295 HCPCS inpatient 2 UN 37.61 24.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.45 65 999999999 22.77 36.48 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 49380994_1 CDM 0250 RC 67457-0349-10 NDC J0295 HCPCS inpatient 2 UN 37.61 24.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 36.48 97 999999999 22.77 36.48 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 49380994_1 CDM 0250 RC 67457-0349-10 NDC J0295 HCPCS inpatient 2 UN 37.61 24.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 29.34 78 999999999 22.77 36.48 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 49380994_1 CDM 0250 RC 67457-0349-10 NDC J0295 HCPCS inpatient 2 UN 37.61 24.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.95 69 999999999 22.77 36.48 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 49380994_1 CDM 0250 RC 67457-0349-10 NDC J0295 HCPCS inpatient 2 UN 37.61 24.45 UMR - ALL PLANS UMR - ALL PLANS 26.33 70 999999999 22.77 36.48 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 49380994_1 CDM 0250 RC 67457-0349-10 NDC J0295 HCPCS inpatient 2 UN 37.61 24.45 SIHO - ALL PLANS SIHO - ALL PLANS 33.85 90 999999999 22.77 36.48 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 49380994_1 CDM 0250 RC 67457-0349-10 NDC J0295 HCPCS inpatient 2 UN 37.61 24.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.77 60.55 999999999 22.77 36.48 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 49380994_1 CDM 0250 RC 67457-0349-10 NDC J0295 HCPCS inpatient 2 UN 37.61 24.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.77 36.48 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 49380994_1 CDM 0250 RC 67457-0349-10 NDC J0295 HCPCS inpatient 2 UN 37.61 24.45 ANTHEM HMO ANTHEM HMO 999999999 22.77 36.48 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 49380994_1 CDM 0250 RC 67457-0349-10 NDC J0295 HCPCS inpatient 2 UN 37.61 24.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.77 36.48 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 49380994_1 CDM 0250 RC 67457-0349-10 NDC J0295 HCPCS inpatient 2 UN 37.61 24.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.77 36.48 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 49380994_1 CDM 0250 RC 67457-0349-10 NDC J0295 HCPCS inpatient 2 UN 37.61 24.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.42 67.6 999999999 22.77 36.48 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 49380994_1 CDM 0250 RC 67457-0349-10 NDC J0295 HCPCS inpatient 2 UN 37.61 24.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.77 36.48 DESVENLAFAXINE SUCCNT ER 50 MG 49384885_1 CDM 0250 RC 00054-0400-13 NDC inpatient 1 UN 2.67 1.74 AETNA AETNA 2.11 79 999999999 1.62 2.59 percent of total billed charges DESVENLAFAXINE SUCCNT ER 50 MG 49384885_1 CDM 0250 RC 00054-0400-13 NDC inpatient 1 UN 2.67 1.74 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.74 65 999999999 1.62 2.59 percent of total billed charges DESVENLAFAXINE SUCCNT ER 50 MG 49384885_1 CDM 0250 RC 00054-0400-13 NDC inpatient 1 UN 2.67 1.74 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.59 97 999999999 1.62 2.59 percent of total billed charges DESVENLAFAXINE SUCCNT ER 50 MG 49384885_1 CDM 0250 RC 00054-0400-13 NDC inpatient 1 UN 2.67 1.74 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.08 78 999999999 1.62 2.59 percent of total billed charges DESVENLAFAXINE SUCCNT ER 50 MG 49384885_1 CDM 0250 RC 00054-0400-13 NDC inpatient 1 UN 2.67 1.74 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.84 69 999999999 1.62 2.59 percent of total billed charges DESVENLAFAXINE SUCCNT ER 50 MG 49384885_1 CDM 0250 RC 00054-0400-13 NDC inpatient 1 UN 2.67 1.74 UMR - ALL PLANS UMR - ALL PLANS 1.87 70 999999999 1.62 2.59 percent of total billed charges DESVENLAFAXINE SUCCNT ER 50 MG 49384885_1 CDM 0250 RC 00054-0400-13 NDC inpatient 1 UN 2.67 1.74 SIHO - ALL PLANS SIHO - ALL PLANS 2.4 90 999999999 1.62 2.59 percent of total billed charges DESVENLAFAXINE SUCCNT ER 50 MG 49384885_1 CDM 0250 RC 00054-0400-13 NDC inpatient 1 UN 2.67 1.74 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.62 60.55 999999999 1.62 2.59 percent of total billed charges DESVENLAFAXINE SUCCNT ER 50 MG 49384885_1 CDM 0250 RC 00054-0400-13 NDC inpatient 1 UN 2.67 1.74 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.62 2.59 DESVENLAFAXINE SUCCNT ER 50 MG 49384885_1 CDM 0250 RC 00054-0400-13 NDC inpatient 1 UN 2.67 1.74 ANTHEM HMO ANTHEM HMO 999999999 1.62 2.59 DESVENLAFAXINE SUCCNT ER 50 MG 49384885_1 CDM 0250 RC 00054-0400-13 NDC inpatient 1 UN 2.67 1.74 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.62 2.59 DESVENLAFAXINE SUCCNT ER 50 MG 49384885_1 CDM 0250 RC 00054-0400-13 NDC inpatient 1 UN 2.67 1.74 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.62 2.59 DESVENLAFAXINE SUCCNT ER 50 MG 49384885_1 CDM 0250 RC 00054-0400-13 NDC inpatient 1 UN 2.67 1.74 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.8 67.6 999999999 1.62 2.59 percent of total billed charges DESVENLAFAXINE SUCCNT ER 50 MG 49384885_1 CDM 0250 RC 00054-0400-13 NDC inpatient 1 UN 2.67 1.74 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.62 2.59 Cystatin C (enzyme inhibitor) level 49385338_1 CDM 0301 RC 82610 HCPCS inpatient 184 119.6 AETNA AETNA 145.36 79 999999999 111.41 178.48 percent of total billed charges Cystatin C (enzyme inhibitor) level 49385338_1 CDM 0301 RC 82610 HCPCS inpatient 184 119.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 119.6 65 999999999 111.41 178.48 percent of total billed charges Cystatin C (enzyme inhibitor) level 49385338_1 CDM 0301 RC 82610 HCPCS inpatient 184 119.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 178.48 97 999999999 111.41 178.48 percent of total billed charges Cystatin C (enzyme inhibitor) level 49385338_1 CDM 0301 RC 82610 HCPCS inpatient 184 119.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 143.52 78 999999999 111.41 178.48 percent of total billed charges Cystatin C (enzyme inhibitor) level 49385338_1 CDM 0301 RC 82610 HCPCS inpatient 184 119.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.96 69 999999999 111.41 178.48 percent of total billed charges Cystatin C (enzyme inhibitor) level 49385338_1 CDM 0301 RC 82610 HCPCS inpatient 184 119.6 UMR - ALL PLANS UMR - ALL PLANS 128.8 70 999999999 111.41 178.48 percent of total billed charges Cystatin C (enzyme inhibitor) level 49385338_1 CDM 0301 RC 82610 HCPCS inpatient 184 119.6 SIHO - ALL PLANS SIHO - ALL PLANS 165.6 90 999999999 111.41 178.48 percent of total billed charges Cystatin C (enzyme inhibitor) level 49385338_1 CDM 0301 RC 82610 HCPCS inpatient 184 119.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 111.41 60.55 999999999 111.41 178.48 percent of total billed charges Cystatin C (enzyme inhibitor) level 49385338_1 CDM 0301 RC 82610 HCPCS inpatient 184 119.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 111.41 178.48 Cystatin C (enzyme inhibitor) level 49385338_1 CDM 0301 RC 82610 HCPCS inpatient 184 119.6 ANTHEM HMO ANTHEM HMO 999999999 111.41 178.48 Cystatin C (enzyme inhibitor) level 49385338_1 CDM 0301 RC 82610 HCPCS inpatient 184 119.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 111.41 178.48 Cystatin C (enzyme inhibitor) level 49385338_1 CDM 0301 RC 82610 HCPCS inpatient 184 119.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 111.41 178.48 Cystatin C (enzyme inhibitor) level 49385338_1 CDM 0301 RC 82610 HCPCS inpatient 184 119.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 124.38 67.6 999999999 111.41 178.48 percent of total billed charges Cystatin C (enzyme inhibitor) level 49385338_1 CDM 0301 RC 82610 HCPCS inpatient 184 119.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 111.41 178.48 Complete ultrasound scan behind abdominal cavity 49386391_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 AETNA AETNA 899.02 79 999999999 689.06 1103.86 percent of total billed charges Complete ultrasound scan behind abdominal cavity 49386391_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 739.7 65 999999999 689.06 1103.86 percent of total billed charges Complete ultrasound scan behind abdominal cavity 49386391_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1103.86 97 999999999 689.06 1103.86 percent of total billed charges Complete ultrasound scan behind abdominal cavity 49386391_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 887.64 78 999999999 689.06 1103.86 percent of total billed charges Complete ultrasound scan behind abdominal cavity 49386391_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 785.22 69 999999999 689.06 1103.86 percent of total billed charges Complete ultrasound scan behind abdominal cavity 49386391_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 SIHO - ALL PLANS SIHO - ALL PLANS 1024.2 90 999999999 689.06 1103.86 percent of total billed charges Complete ultrasound scan behind abdominal cavity 49386391_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 UMR - ALL PLANS UMR - ALL PLANS 796.6 70 999999999 689.06 1103.86 percent of total billed charges Complete ultrasound scan behind abdominal cavity 49386391_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 689.06 60.55 999999999 689.06 1103.86 percent of total billed charges Complete ultrasound scan behind abdominal cavity 49386391_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 689.06 1103.86 Complete ultrasound scan behind abdominal cavity 49386391_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 ANTHEM HMO ANTHEM HMO 999999999 689.06 1103.86 Complete ultrasound scan behind abdominal cavity 49386391_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 689.06 1103.86 Complete ultrasound scan behind abdominal cavity 49386391_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 689.06 1103.86 Complete ultrasound scan behind abdominal cavity 49386391_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 769.29 67.6 999999999 689.06 1103.86 percent of total billed charges Complete ultrasound scan behind abdominal cavity 49386391_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 689.06 1103.86 Complete ultrasound of abdomen and pelvis artery and vein blood flow 49386392_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 AETNA AETNA 750.5 79 999999999 575.23 921.5 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 49386392_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 617.5 65 999999999 575.23 921.5 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 49386392_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 921.5 97 999999999 575.23 921.5 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 49386392_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 741 78 999999999 575.23 921.5 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 49386392_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 655.5 69 999999999 575.23 921.5 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 49386392_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 SIHO - ALL PLANS SIHO - ALL PLANS 855 90 999999999 575.23 921.5 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 49386392_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 UMR - ALL PLANS UMR - ALL PLANS 665 70 999999999 575.23 921.5 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 49386392_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 575.23 60.55 999999999 575.23 921.5 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 49386392_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 575.23 921.5 Complete ultrasound of abdomen and pelvis artery and vein blood flow 49386392_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 ANTHEM HMO ANTHEM HMO 999999999 575.23 921.5 Complete ultrasound of abdomen and pelvis artery and vein blood flow 49386392_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 575.23 921.5 Complete ultrasound of abdomen and pelvis artery and vein blood flow 49386392_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 575.23 921.5 Complete ultrasound of abdomen and pelvis artery and vein blood flow 49386392_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 642.2 67.6 999999999 575.23 921.5 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 49386392_1 CDM 0402 RC 93975 HCPCS inpatient 950 617.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 575.23 921.5 ENALAPRILAT 1.25 MG/ML VIAL 49391559_1 CDM 0250 RC 00143-9787-10 NDC inpatient 1 UN 37.09 24.11 AETNA AETNA 29.3 79 999999999 22.46 35.98 percent of total billed charges ENALAPRILAT 1.25 MG/ML VIAL 49391559_1 CDM 0250 RC 00143-9787-10 NDC inpatient 1 UN 37.09 24.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.11 65 999999999 22.46 35.98 percent of total billed charges ENALAPRILAT 1.25 MG/ML VIAL 49391559_1 CDM 0250 RC 00143-9787-10 NDC inpatient 1 UN 37.09 24.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.98 97 999999999 22.46 35.98 percent of total billed charges ENALAPRILAT 1.25 MG/ML VIAL 49391559_1 CDM 0250 RC 00143-9787-10 NDC inpatient 1 UN 37.09 24.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.93 78 999999999 22.46 35.98 percent of total billed charges ENALAPRILAT 1.25 MG/ML VIAL 49391559_1 CDM 0250 RC 00143-9787-10 NDC inpatient 1 UN 37.09 24.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.59 69 999999999 22.46 35.98 percent of total billed charges ENALAPRILAT 1.25 MG/ML VIAL 49391559_1 CDM 0250 RC 00143-9787-10 NDC inpatient 1 UN 37.09 24.11 SIHO - ALL PLANS SIHO - ALL PLANS 33.38 90 999999999 22.46 35.98 percent of total billed charges ENALAPRILAT 1.25 MG/ML VIAL 49391559_1 CDM 0250 RC 00143-9787-10 NDC inpatient 1 UN 37.09 24.11 UMR - ALL PLANS UMR - ALL PLANS 25.96 70 999999999 22.46 35.98 percent of total billed charges ENALAPRILAT 1.25 MG/ML VIAL 49391559_1 CDM 0250 RC 00143-9787-10 NDC inpatient 1 UN 37.09 24.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.46 60.55 999999999 22.46 35.98 percent of total billed charges ENALAPRILAT 1.25 MG/ML VIAL 49391559_1 CDM 0250 RC 00143-9787-10 NDC inpatient 1 UN 37.09 24.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.46 35.98 ENALAPRILAT 1.25 MG/ML VIAL 49391559_1 CDM 0250 RC 00143-9787-10 NDC inpatient 1 UN 37.09 24.11 ANTHEM HMO ANTHEM HMO 999999999 22.46 35.98 ENALAPRILAT 1.25 MG/ML VIAL 49391559_1 CDM 0250 RC 00143-9787-10 NDC inpatient 1 UN 37.09 24.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.46 35.98 ENALAPRILAT 1.25 MG/ML VIAL 49391559_1 CDM 0250 RC 00143-9787-10 NDC inpatient 1 UN 37.09 24.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.46 35.98 ENALAPRILAT 1.25 MG/ML VIAL 49391559_1 CDM 0250 RC 00143-9787-10 NDC inpatient 1 UN 37.09 24.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.07 67.6 999999999 22.46 35.98 percent of total billed charges ENALAPRILAT 1.25 MG/ML VIAL 49391559_1 CDM 0250 RC 00143-9787-10 NDC inpatient 1 UN 37.09 24.11 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.46 35.98 MYOSURE XL 50-503XL 49400111_1 CDM 0272 RC inpatient 7534 4897.1 AETNA AETNA 5951.86 79 999999999 4561.84 7307.98 percent of total billed charges MYOSURE XL 50-503XL 49400111_1 CDM 0272 RC inpatient 7534 4897.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 4897.1 65 999999999 4561.84 7307.98 percent of total billed charges MYOSURE XL 50-503XL 49400111_1 CDM 0272 RC inpatient 7534 4897.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7307.98 97 999999999 4561.84 7307.98 percent of total billed charges MYOSURE XL 50-503XL 49400111_1 CDM 0272 RC inpatient 7534 4897.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 5876.52 78 999999999 4561.84 7307.98 percent of total billed charges MYOSURE XL 50-503XL 49400111_1 CDM 0272 RC inpatient 7534 4897.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 5198.46 69 999999999 4561.84 7307.98 percent of total billed charges MYOSURE XL 50-503XL 49400111_1 CDM 0272 RC inpatient 7534 4897.1 SIHO - ALL PLANS SIHO - ALL PLANS 6780.6 90 999999999 4561.84 7307.98 percent of total billed charges MYOSURE XL 50-503XL 49400111_1 CDM 0272 RC inpatient 7534 4897.1 UMR - ALL PLANS UMR - ALL PLANS 5273.8 70 999999999 4561.84 7307.98 percent of total billed charges MYOSURE XL 50-503XL 49400111_1 CDM 0272 RC inpatient 7534 4897.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4561.84 60.55 999999999 4561.84 7307.98 percent of total billed charges MYOSURE XL 50-503XL 49400111_1 CDM 0272 RC inpatient 7534 4897.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4561.84 7307.98 MYOSURE XL 50-503XL 49400111_1 CDM 0272 RC inpatient 7534 4897.1 ANTHEM HMO ANTHEM HMO 999999999 4561.84 7307.98 MYOSURE XL 50-503XL 49400111_1 CDM 0272 RC inpatient 7534 4897.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4561.84 7307.98 MYOSURE XL 50-503XL 49400111_1 CDM 0272 RC inpatient 7534 4897.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4561.84 7307.98 MYOSURE XL 50-503XL 49400111_1 CDM 0272 RC inpatient 7534 4897.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 5092.98 67.6 999999999 4561.84 7307.98 percent of total billed charges MYOSURE XL 50-503XL 49400111_1 CDM 0272 RC inpatient 7534 4897.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 4561.84 7307.98 DISPOSABLE BRONCH SUCTION VALVE BIOPSY 49400179_1 CDM 0272 RC inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges DISPOSABLE BRONCH SUCTION VALVE BIOPSY 49400179_1 CDM 0272 RC inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges DISPOSABLE BRONCH SUCTION VALVE BIOPSY 49400179_1 CDM 0272 RC inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges DISPOSABLE BRONCH SUCTION VALVE BIOPSY 49400179_1 CDM 0272 RC inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges DISPOSABLE BRONCH SUCTION VALVE BIOPSY 49400179_1 CDM 0272 RC inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges DISPOSABLE BRONCH SUCTION VALVE BIOPSY 49400179_1 CDM 0272 RC inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges DISPOSABLE BRONCH SUCTION VALVE BIOPSY 49400179_1 CDM 0272 RC inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges DISPOSABLE BRONCH SUCTION VALVE BIOPSY 49400179_1 CDM 0272 RC inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges DISPOSABLE BRONCH SUCTION VALVE BIOPSY 49400179_1 CDM 0272 RC inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 DISPOSABLE BRONCH SUCTION VALVE BIOPSY 49400179_1 CDM 0272 RC inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 DISPOSABLE BRONCH SUCTION VALVE BIOPSY 49400179_1 CDM 0272 RC inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 DISPOSABLE BRONCH SUCTION VALVE BIOPSY 49400179_1 CDM 0272 RC inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 DISPOSABLE BRONCH SUCTION VALVE BIOPSY 49400179_1 CDM 0272 RC inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges DISPOSABLE BRONCH SUCTION VALVE BIOPSY 49400179_1 CDM 0272 RC inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 49427780_1 CDM 0250 RC 76204-0900-01 NDC J7614 HCPCS inpatient 1 UN 5.36 3.48 AETNA AETNA 4.23 79 999999999 3.25 5.2 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 49427780_1 CDM 0250 RC 76204-0900-01 NDC J7614 HCPCS inpatient 1 UN 5.36 3.48 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.48 65 999999999 3.25 5.2 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 49427780_1 CDM 0250 RC 76204-0900-01 NDC J7614 HCPCS inpatient 1 UN 5.36 3.48 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.2 97 999999999 3.25 5.2 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 49427780_1 CDM 0250 RC 76204-0900-01 NDC J7614 HCPCS inpatient 1 UN 5.36 3.48 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.18 78 999999999 3.25 5.2 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 49427780_1 CDM 0250 RC 76204-0900-01 NDC J7614 HCPCS inpatient 1 UN 5.36 3.48 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.7 69 999999999 3.25 5.2 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 49427780_1 CDM 0250 RC 76204-0900-01 NDC J7614 HCPCS inpatient 1 UN 5.36 3.48 SIHO - ALL PLANS SIHO - ALL PLANS 4.82 90 999999999 3.25 5.2 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 49427780_1 CDM 0250 RC 76204-0900-01 NDC J7614 HCPCS inpatient 1 UN 5.36 3.48 UMR - ALL PLANS UMR - ALL PLANS 3.75 70 999999999 3.25 5.2 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 49427780_1 CDM 0250 RC 76204-0900-01 NDC J7614 HCPCS inpatient 1 UN 5.36 3.48 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.25 60.55 999999999 3.25 5.2 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 49427780_1 CDM 0250 RC 76204-0900-01 NDC J7614 HCPCS inpatient 1 UN 5.36 3.48 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.25 5.2 "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 49427780_1 CDM 0250 RC 76204-0900-01 NDC J7614 HCPCS inpatient 1 UN 5.36 3.48 ANTHEM HMO ANTHEM HMO 999999999 3.25 5.2 "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 49427780_1 CDM 0250 RC 76204-0900-01 NDC J7614 HCPCS inpatient 1 UN 5.36 3.48 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.25 5.2 "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 49427780_1 CDM 0250 RC 76204-0900-01 NDC J7614 HCPCS inpatient 1 UN 5.36 3.48 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.25 5.2 "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 49427780_1 CDM 0250 RC 76204-0900-01 NDC J7614 HCPCS inpatient 1 UN 5.36 3.48 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.62 67.6 999999999 3.25 5.2 percent of total billed charges "LEVALBUTEROL, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE, 0.5 MG" 49427780_1 CDM 0250 RC 76204-0900-01 NDC J7614 HCPCS inpatient 1 UN 5.36 3.48 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.25 5.2 Chemistry procedures 49429676_1 CDM 0301 RC 84999 HCPCS inpatient 121 78.65 AETNA AETNA 95.59 79 999999999 73.27 117.37 percent of total billed charges Chemistry procedures 49429676_1 CDM 0301 RC 84999 HCPCS inpatient 121 78.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 78.65 65 999999999 73.27 117.37 percent of total billed charges Chemistry procedures 49429676_1 CDM 0301 RC 84999 HCPCS inpatient 121 78.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 117.37 97 999999999 73.27 117.37 percent of total billed charges Chemistry procedures 49429676_1 CDM 0301 RC 84999 HCPCS inpatient 121 78.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 94.38 78 999999999 73.27 117.37 percent of total billed charges Chemistry procedures 49429676_1 CDM 0301 RC 84999 HCPCS inpatient 121 78.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 83.49 69 999999999 73.27 117.37 percent of total billed charges Chemistry procedures 49429676_1 CDM 0301 RC 84999 HCPCS inpatient 121 78.65 SIHO - ALL PLANS SIHO - ALL PLANS 108.9 90 999999999 73.27 117.37 percent of total billed charges Chemistry procedures 49429676_1 CDM 0301 RC 84999 HCPCS inpatient 121 78.65 UMR - ALL PLANS UMR - ALL PLANS 84.7 70 999999999 73.27 117.37 percent of total billed charges Chemistry procedures 49429676_1 CDM 0301 RC 84999 HCPCS inpatient 121 78.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.27 60.55 999999999 73.27 117.37 percent of total billed charges Chemistry procedures 49429676_1 CDM 0301 RC 84999 HCPCS inpatient 121 78.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.27 117.37 Chemistry procedures 49429676_1 CDM 0301 RC 84999 HCPCS inpatient 121 78.65 ANTHEM HMO ANTHEM HMO 999999999 73.27 117.37 Chemistry procedures 49429676_1 CDM 0301 RC 84999 HCPCS inpatient 121 78.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.27 117.37 Chemistry procedures 49429676_1 CDM 0301 RC 84999 HCPCS inpatient 121 78.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.27 117.37 Chemistry procedures 49429676_1 CDM 0301 RC 84999 HCPCS inpatient 121 78.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.8 67.6 999999999 73.27 117.37 percent of total billed charges Chemistry procedures 49429676_1 CDM 0301 RC 84999 HCPCS inpatient 121 78.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.27 117.37 DOXYCYCLINE MONO 100 MG CAP 49429718_1 CDM 0250 RC 68382-0707-18 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges DOXYCYCLINE MONO 100 MG CAP 49429718_1 CDM 0250 RC 68382-0707-18 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges DOXYCYCLINE MONO 100 MG CAP 49429718_1 CDM 0250 RC 68382-0707-18 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges DOXYCYCLINE MONO 100 MG CAP 49429718_1 CDM 0250 RC 68382-0707-18 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges DOXYCYCLINE MONO 100 MG CAP 49429718_1 CDM 0250 RC 68382-0707-18 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges DOXYCYCLINE MONO 100 MG CAP 49429718_1 CDM 0250 RC 68382-0707-18 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges DOXYCYCLINE MONO 100 MG CAP 49429718_1 CDM 0250 RC 68382-0707-18 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges DOXYCYCLINE MONO 100 MG CAP 49429718_1 CDM 0250 RC 68382-0707-18 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges DOXYCYCLINE MONO 100 MG CAP 49429718_1 CDM 0250 RC 68382-0707-18 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 DOXYCYCLINE MONO 100 MG CAP 49429718_1 CDM 0250 RC 68382-0707-18 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 DOXYCYCLINE MONO 100 MG CAP 49429718_1 CDM 0250 RC 68382-0707-18 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 DOXYCYCLINE MONO 100 MG CAP 49429718_1 CDM 0250 RC 68382-0707-18 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 DOXYCYCLINE MONO 100 MG CAP 49429718_1 CDM 0250 RC 68382-0707-18 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges DOXYCYCLINE MONO 100 MG CAP 49429718_1 CDM 0250 RC 68382-0707-18 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 SUMATRIPTAN 6 MG/0.5 ML VIAL 49432114_1 CDM 0250 RC 55150-0173-05 NDC inpatient 1 UN 52.62 34.2 AETNA AETNA 41.57 79 999999999 31.86 51.04 percent of total billed charges SUMATRIPTAN 6 MG/0.5 ML VIAL 49432114_1 CDM 0250 RC 55150-0173-05 NDC inpatient 1 UN 52.62 34.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.2 65 999999999 31.86 51.04 percent of total billed charges SUMATRIPTAN 6 MG/0.5 ML VIAL 49432114_1 CDM 0250 RC 55150-0173-05 NDC inpatient 1 UN 52.62 34.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.04 97 999999999 31.86 51.04 percent of total billed charges SUMATRIPTAN 6 MG/0.5 ML VIAL 49432114_1 CDM 0250 RC 55150-0173-05 NDC inpatient 1 UN 52.62 34.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.04 78 999999999 31.86 51.04 percent of total billed charges SUMATRIPTAN 6 MG/0.5 ML VIAL 49432114_1 CDM 0250 RC 55150-0173-05 NDC inpatient 1 UN 52.62 34.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.31 69 999999999 31.86 51.04 percent of total billed charges SUMATRIPTAN 6 MG/0.5 ML VIAL 49432114_1 CDM 0250 RC 55150-0173-05 NDC inpatient 1 UN 52.62 34.2 SIHO - ALL PLANS SIHO - ALL PLANS 47.36 90 999999999 31.86 51.04 percent of total billed charges SUMATRIPTAN 6 MG/0.5 ML VIAL 49432114_1 CDM 0250 RC 55150-0173-05 NDC inpatient 1 UN 52.62 34.2 UMR - ALL PLANS UMR - ALL PLANS 36.83 70 999999999 31.86 51.04 percent of total billed charges SUMATRIPTAN 6 MG/0.5 ML VIAL 49432114_1 CDM 0250 RC 55150-0173-05 NDC inpatient 1 UN 52.62 34.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 31.86 60.55 999999999 31.86 51.04 percent of total billed charges SUMATRIPTAN 6 MG/0.5 ML VIAL 49432114_1 CDM 0250 RC 55150-0173-05 NDC inpatient 1 UN 52.62 34.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 31.86 51.04 SUMATRIPTAN 6 MG/0.5 ML VIAL 49432114_1 CDM 0250 RC 55150-0173-05 NDC inpatient 1 UN 52.62 34.2 ANTHEM HMO ANTHEM HMO 999999999 31.86 51.04 SUMATRIPTAN 6 MG/0.5 ML VIAL 49432114_1 CDM 0250 RC 55150-0173-05 NDC inpatient 1 UN 52.62 34.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 31.86 51.04 SUMATRIPTAN 6 MG/0.5 ML VIAL 49432114_1 CDM 0250 RC 55150-0173-05 NDC inpatient 1 UN 52.62 34.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 31.86 51.04 SUMATRIPTAN 6 MG/0.5 ML VIAL 49432114_1 CDM 0250 RC 55150-0173-05 NDC inpatient 1 UN 52.62 34.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.57 67.6 999999999 31.86 51.04 percent of total billed charges SUMATRIPTAN 6 MG/0.5 ML VIAL 49432114_1 CDM 0250 RC 55150-0173-05 NDC inpatient 1 UN 52.62 34.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 31.86 51.04 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49433871_1 CDM 0250 RC 00409-1283-05 NDC J1170 HCPCS inpatient 1 UN 36.24 23.56 AETNA AETNA 28.63 79 999999999 21.94 35.15 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49433871_1 CDM 0250 RC 00409-1283-05 NDC J1170 HCPCS inpatient 1 UN 36.24 23.56 SELF PAY DISCOUNT SELF PAY DISCOUNT 23.56 65 999999999 21.94 35.15 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49433871_1 CDM 0250 RC 00409-1283-05 NDC J1170 HCPCS inpatient 1 UN 36.24 23.56 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.15 97 999999999 21.94 35.15 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49433871_1 CDM 0250 RC 00409-1283-05 NDC J1170 HCPCS inpatient 1 UN 36.24 23.56 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.27 78 999999999 21.94 35.15 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49433871_1 CDM 0250 RC 00409-1283-05 NDC J1170 HCPCS inpatient 1 UN 36.24 23.56 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.01 69 999999999 21.94 35.15 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49433871_1 CDM 0250 RC 00409-1283-05 NDC J1170 HCPCS inpatient 1 UN 36.24 23.56 SIHO - ALL PLANS SIHO - ALL PLANS 32.62 90 999999999 21.94 35.15 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49433871_1 CDM 0250 RC 00409-1283-05 NDC J1170 HCPCS inpatient 1 UN 36.24 23.56 UMR - ALL PLANS UMR - ALL PLANS 25.37 70 999999999 21.94 35.15 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49433871_1 CDM 0250 RC 00409-1283-05 NDC J1170 HCPCS inpatient 1 UN 36.24 23.56 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.94 60.55 999999999 21.94 35.15 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49433871_1 CDM 0250 RC 00409-1283-05 NDC J1170 HCPCS inpatient 1 UN 36.24 23.56 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.94 35.15 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49433871_1 CDM 0250 RC 00409-1283-05 NDC J1170 HCPCS inpatient 1 UN 36.24 23.56 ANTHEM HMO ANTHEM HMO 999999999 21.94 35.15 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49433871_1 CDM 0250 RC 00409-1283-05 NDC J1170 HCPCS inpatient 1 UN 36.24 23.56 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.94 35.15 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49433871_1 CDM 0250 RC 00409-1283-05 NDC J1170 HCPCS inpatient 1 UN 36.24 23.56 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.94 35.15 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49433871_1 CDM 0250 RC 00409-1283-05 NDC J1170 HCPCS inpatient 1 UN 36.24 23.56 CIGNA - ALL PLANS CIGNA - ALL PLANS 24.5 67.6 999999999 21.94 35.15 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49433871_1 CDM 0250 RC 00409-1283-05 NDC J1170 HCPCS inpatient 1 UN 36.24 23.56 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.94 35.15 TERBINAFINE HCL 250 MG TABLET 49438109_1 CDM 0250 RC 65862-0079-30 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges TERBINAFINE HCL 250 MG TABLET 49438109_1 CDM 0250 RC 65862-0079-30 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges TERBINAFINE HCL 250 MG TABLET 49438109_1 CDM 0250 RC 65862-0079-30 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges TERBINAFINE HCL 250 MG TABLET 49438109_1 CDM 0250 RC 65862-0079-30 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges TERBINAFINE HCL 250 MG TABLET 49438109_1 CDM 0250 RC 65862-0079-30 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges TERBINAFINE HCL 250 MG TABLET 49438109_1 CDM 0250 RC 65862-0079-30 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges TERBINAFINE HCL 250 MG TABLET 49438109_1 CDM 0250 RC 65862-0079-30 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges TERBINAFINE HCL 250 MG TABLET 49438109_1 CDM 0250 RC 65862-0079-30 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges TERBINAFINE HCL 250 MG TABLET 49438109_1 CDM 0250 RC 65862-0079-30 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 TERBINAFINE HCL 250 MG TABLET 49438109_1 CDM 0250 RC 65862-0079-30 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 TERBINAFINE HCL 250 MG TABLET 49438109_1 CDM 0250 RC 65862-0079-30 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 TERBINAFINE HCL 250 MG TABLET 49438109_1 CDM 0250 RC 65862-0079-30 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 TERBINAFINE HCL 250 MG TABLET 49438109_1 CDM 0250 RC 65862-0079-30 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges TERBINAFINE HCL 250 MG TABLET 49438109_1 CDM 0250 RC 65862-0079-30 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "Deoxycortisol, 11 (hormone) level" 49439056_1 CDM 0301 RC 82634 HCPCS inpatient 294 191.1 AETNA AETNA 232.26 79 999999999 178.02 285.18 percent of total billed charges "Deoxycortisol, 11 (hormone) level" 49439056_1 CDM 0301 RC 82634 HCPCS inpatient 294 191.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 191.1 65 999999999 178.02 285.18 percent of total billed charges "Deoxycortisol, 11 (hormone) level" 49439056_1 CDM 0301 RC 82634 HCPCS inpatient 294 191.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 285.18 97 999999999 178.02 285.18 percent of total billed charges "Deoxycortisol, 11 (hormone) level" 49439056_1 CDM 0301 RC 82634 HCPCS inpatient 294 191.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 229.32 78 999999999 178.02 285.18 percent of total billed charges "Deoxycortisol, 11 (hormone) level" 49439056_1 CDM 0301 RC 82634 HCPCS inpatient 294 191.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 202.86 69 999999999 178.02 285.18 percent of total billed charges "Deoxycortisol, 11 (hormone) level" 49439056_1 CDM 0301 RC 82634 HCPCS inpatient 294 191.1 SIHO - ALL PLANS SIHO - ALL PLANS 264.6 90 999999999 178.02 285.18 percent of total billed charges "Deoxycortisol, 11 (hormone) level" 49439056_1 CDM 0301 RC 82634 HCPCS inpatient 294 191.1 UMR - ALL PLANS UMR - ALL PLANS 205.8 70 999999999 178.02 285.18 percent of total billed charges "Deoxycortisol, 11 (hormone) level" 49439056_1 CDM 0301 RC 82634 HCPCS inpatient 294 191.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 178.02 60.55 999999999 178.02 285.18 percent of total billed charges "Deoxycortisol, 11 (hormone) level" 49439056_1 CDM 0301 RC 82634 HCPCS inpatient 294 191.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 178.02 285.18 "Deoxycortisol, 11 (hormone) level" 49439056_1 CDM 0301 RC 82634 HCPCS inpatient 294 191.1 ANTHEM HMO ANTHEM HMO 999999999 178.02 285.18 "Deoxycortisol, 11 (hormone) level" 49439056_1 CDM 0301 RC 82634 HCPCS inpatient 294 191.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 178.02 285.18 "Deoxycortisol, 11 (hormone) level" 49439056_1 CDM 0301 RC 82634 HCPCS inpatient 294 191.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 178.02 285.18 "Deoxycortisol, 11 (hormone) level" 49439056_1 CDM 0301 RC 82634 HCPCS inpatient 294 191.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 198.74 67.6 999999999 178.02 285.18 percent of total billed charges "Deoxycortisol, 11 (hormone) level" 49439056_1 CDM 0301 RC 82634 HCPCS inpatient 294 191.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 178.02 285.18 CIALIS 5 MG TABLET 49439370_1 CDM 0250 RC 00002-4462-30 NDC inpatient 1 UN 42.05 27.33 AETNA AETNA 33.22 79 999999999 25.46 40.79 percent of total billed charges CIALIS 5 MG TABLET 49439370_1 CDM 0250 RC 00002-4462-30 NDC inpatient 1 UN 42.05 27.33 SELF PAY DISCOUNT SELF PAY DISCOUNT 27.33 65 999999999 25.46 40.79 percent of total billed charges CIALIS 5 MG TABLET 49439370_1 CDM 0250 RC 00002-4462-30 NDC inpatient 1 UN 42.05 27.33 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 40.79 97 999999999 25.46 40.79 percent of total billed charges CIALIS 5 MG TABLET 49439370_1 CDM 0250 RC 00002-4462-30 NDC inpatient 1 UN 42.05 27.33 HUMANA - ALL PLANS HUMANA - ALL PLANS 32.8 78 999999999 25.46 40.79 percent of total billed charges CIALIS 5 MG TABLET 49439370_1 CDM 0250 RC 00002-4462-30 NDC inpatient 1 UN 42.05 27.33 ENCORE - ALL PLANS ENCORE - ALL PLANS 29.01 69 999999999 25.46 40.79 percent of total billed charges CIALIS 5 MG TABLET 49439370_1 CDM 0250 RC 00002-4462-30 NDC inpatient 1 UN 42.05 27.33 SIHO - ALL PLANS SIHO - ALL PLANS 37.85 90 999999999 25.46 40.79 percent of total billed charges CIALIS 5 MG TABLET 49439370_1 CDM 0250 RC 00002-4462-30 NDC inpatient 1 UN 42.05 27.33 UMR - ALL PLANS UMR - ALL PLANS 29.44 70 999999999 25.46 40.79 percent of total billed charges CIALIS 5 MG TABLET 49439370_1 CDM 0250 RC 00002-4462-30 NDC inpatient 1 UN 42.05 27.33 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 25.46 60.55 999999999 25.46 40.79 percent of total billed charges CIALIS 5 MG TABLET 49439370_1 CDM 0250 RC 00002-4462-30 NDC inpatient 1 UN 42.05 27.33 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 25.46 40.79 CIALIS 5 MG TABLET 49439370_1 CDM 0250 RC 00002-4462-30 NDC inpatient 1 UN 42.05 27.33 ANTHEM HMO ANTHEM HMO 999999999 25.46 40.79 CIALIS 5 MG TABLET 49439370_1 CDM 0250 RC 00002-4462-30 NDC inpatient 1 UN 42.05 27.33 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 25.46 40.79 CIALIS 5 MG TABLET 49439370_1 CDM 0250 RC 00002-4462-30 NDC inpatient 1 UN 42.05 27.33 CIGNA - ALL PLANS CIGNA - ALL PLANS 28.43 67.6 999999999 25.46 40.79 percent of total billed charges CIALIS 5 MG TABLET 49439370_1 CDM 0250 RC 00002-4462-30 NDC inpatient 1 UN 42.05 27.33 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 25.46 40.79 CIALIS 5 MG TABLET 49439370_1 CDM 0250 RC 00002-4462-30 NDC inpatient 1 UN 42.05 27.33 UHC - ALL PLANS UHC - ALL PLANS 999999999 25.46 40.79 HEPARIN 500 UNIT/5 ML (100/ML) 49439754_1 CDM 0250 RC 63323-0545-05 NDC inpatient 1 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges HEPARIN 500 UNIT/5 ML (100/ML) 49439754_1 CDM 0250 RC 63323-0545-05 NDC inpatient 1 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges HEPARIN 500 UNIT/5 ML (100/ML) 49439754_1 CDM 0250 RC 63323-0545-05 NDC inpatient 1 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges HEPARIN 500 UNIT/5 ML (100/ML) 49439754_1 CDM 0250 RC 63323-0545-05 NDC inpatient 1 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges HEPARIN 500 UNIT/5 ML (100/ML) 49439754_1 CDM 0250 RC 63323-0545-05 NDC inpatient 1 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges HEPARIN 500 UNIT/5 ML (100/ML) 49439754_1 CDM 0250 RC 63323-0545-05 NDC inpatient 1 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges HEPARIN 500 UNIT/5 ML (100/ML) 49439754_1 CDM 0250 RC 63323-0545-05 NDC inpatient 1 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges HEPARIN 500 UNIT/5 ML (100/ML) 49439754_1 CDM 0250 RC 63323-0545-05 NDC inpatient 1 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges HEPARIN 500 UNIT/5 ML (100/ML) 49439754_1 CDM 0250 RC 63323-0545-05 NDC inpatient 1 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 HEPARIN 500 UNIT/5 ML (100/ML) 49439754_1 CDM 0250 RC 63323-0545-05 NDC inpatient 1 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 HEPARIN 500 UNIT/5 ML (100/ML) 49439754_1 CDM 0250 RC 63323-0545-05 NDC inpatient 1 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 HEPARIN 500 UNIT/5 ML (100/ML) 49439754_1 CDM 0250 RC 63323-0545-05 NDC inpatient 1 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges HEPARIN 500 UNIT/5 ML (100/ML) 49439754_1 CDM 0250 RC 63323-0545-05 NDC inpatient 1 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 HEPARIN 500 UNIT/5 ML (100/ML) 49439754_1 CDM 0250 RC 63323-0545-05 NDC inpatient 1 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 ROPINIROLE HCL 1 MG TABLET 49439755_1 CDM 0250 RC 62332-0032-31 NDC inpatient 1 UN 1.16 0.75 AETNA AETNA 0.92 79 999999999 0.7 1.13 percent of total billed charges ROPINIROLE HCL 1 MG TABLET 49439755_1 CDM 0250 RC 62332-0032-31 NDC inpatient 1 UN 1.16 0.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.75 65 999999999 0.7 1.13 percent of total billed charges ROPINIROLE HCL 1 MG TABLET 49439755_1 CDM 0250 RC 62332-0032-31 NDC inpatient 1 UN 1.16 0.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.13 97 999999999 0.7 1.13 percent of total billed charges ROPINIROLE HCL 1 MG TABLET 49439755_1 CDM 0250 RC 62332-0032-31 NDC inpatient 1 UN 1.16 0.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.9 78 999999999 0.7 1.13 percent of total billed charges ROPINIROLE HCL 1 MG TABLET 49439755_1 CDM 0250 RC 62332-0032-31 NDC inpatient 1 UN 1.16 0.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.8 69 999999999 0.7 1.13 percent of total billed charges ROPINIROLE HCL 1 MG TABLET 49439755_1 CDM 0250 RC 62332-0032-31 NDC inpatient 1 UN 1.16 0.75 SIHO - ALL PLANS SIHO - ALL PLANS 1.04 90 999999999 0.7 1.13 percent of total billed charges ROPINIROLE HCL 1 MG TABLET 49439755_1 CDM 0250 RC 62332-0032-31 NDC inpatient 1 UN 1.16 0.75 UMR - ALL PLANS UMR - ALL PLANS 0.81 70 999999999 0.7 1.13 percent of total billed charges ROPINIROLE HCL 1 MG TABLET 49439755_1 CDM 0250 RC 62332-0032-31 NDC inpatient 1 UN 1.16 0.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.7 60.55 999999999 0.7 1.13 percent of total billed charges ROPINIROLE HCL 1 MG TABLET 49439755_1 CDM 0250 RC 62332-0032-31 NDC inpatient 1 UN 1.16 0.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.7 1.13 ROPINIROLE HCL 1 MG TABLET 49439755_1 CDM 0250 RC 62332-0032-31 NDC inpatient 1 UN 1.16 0.75 ANTHEM HMO ANTHEM HMO 999999999 0.7 1.13 ROPINIROLE HCL 1 MG TABLET 49439755_1 CDM 0250 RC 62332-0032-31 NDC inpatient 1 UN 1.16 0.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.7 1.13 ROPINIROLE HCL 1 MG TABLET 49439755_1 CDM 0250 RC 62332-0032-31 NDC inpatient 1 UN 1.16 0.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.78 67.6 999999999 0.7 1.13 percent of total billed charges ROPINIROLE HCL 1 MG TABLET 49439755_1 CDM 0250 RC 62332-0032-31 NDC inpatient 1 UN 1.16 0.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.7 1.13 ROPINIROLE HCL 1 MG TABLET 49439755_1 CDM 0250 RC 62332-0032-31 NDC inpatient 1 UN 1.16 0.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.7 1.13 "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49439914_1 CDM 0250 RC 63323-0691-30 NDC J7608 HCPCS inpatient 1 UN 74.23 48.25 AETNA AETNA 58.64 79 999999999 44.95 72 percent of total billed charges "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49439914_1 CDM 0250 RC 63323-0691-30 NDC J7608 HCPCS inpatient 1 UN 74.23 48.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.25 65 999999999 44.95 72 percent of total billed charges "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49439914_1 CDM 0250 RC 63323-0691-30 NDC J7608 HCPCS inpatient 1 UN 74.23 48.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72 97 999999999 44.95 72 percent of total billed charges "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49439914_1 CDM 0250 RC 63323-0691-30 NDC J7608 HCPCS inpatient 1 UN 74.23 48.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 57.9 78 999999999 44.95 72 percent of total billed charges "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49439914_1 CDM 0250 RC 63323-0691-30 NDC J7608 HCPCS inpatient 1 UN 74.23 48.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.22 69 999999999 44.95 72 percent of total billed charges "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49439914_1 CDM 0250 RC 63323-0691-30 NDC J7608 HCPCS inpatient 1 UN 74.23 48.25 SIHO - ALL PLANS SIHO - ALL PLANS 66.81 90 999999999 44.95 72 percent of total billed charges "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49439914_1 CDM 0250 RC 63323-0691-30 NDC J7608 HCPCS inpatient 1 UN 74.23 48.25 UMR - ALL PLANS UMR - ALL PLANS 51.96 70 999999999 44.95 72 percent of total billed charges "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49439914_1 CDM 0250 RC 63323-0691-30 NDC J7608 HCPCS inpatient 1 UN 74.23 48.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.95 60.55 999999999 44.95 72 percent of total billed charges "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49439914_1 CDM 0250 RC 63323-0691-30 NDC J7608 HCPCS inpatient 1 UN 74.23 48.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.95 72 "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49439914_1 CDM 0250 RC 63323-0691-30 NDC J7608 HCPCS inpatient 1 UN 74.23 48.25 ANTHEM HMO ANTHEM HMO 999999999 44.95 72 "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49439914_1 CDM 0250 RC 63323-0691-30 NDC J7608 HCPCS inpatient 1 UN 74.23 48.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.95 72 "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49439914_1 CDM 0250 RC 63323-0691-30 NDC J7608 HCPCS inpatient 1 UN 74.23 48.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.18 67.6 999999999 44.95 72 percent of total billed charges "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49439914_1 CDM 0250 RC 63323-0691-30 NDC J7608 HCPCS inpatient 1 UN 74.23 48.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.95 72 "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49439914_1 CDM 0250 RC 63323-0691-30 NDC J7608 HCPCS inpatient 1 UN 74.23 48.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.95 72 68180-0722-10 - cefdinir 125 mg/5 mL Pow 49439936_1 CDM 0250 RC 68180-0722-10 NDC inpatient 1 UN 27.42 17.82 AETNA AETNA 21.66 79 999999999 16.6 26.6 percent of total billed charges 68180-0722-10 - cefdinir 125 mg/5 mL Pow 49439936_1 CDM 0250 RC 68180-0722-10 NDC inpatient 1 UN 27.42 17.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.82 65 999999999 16.6 26.6 percent of total billed charges 68180-0722-10 - cefdinir 125 mg/5 mL Pow 49439936_1 CDM 0250 RC 68180-0722-10 NDC inpatient 1 UN 27.42 17.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26.6 97 999999999 16.6 26.6 percent of total billed charges 68180-0722-10 - cefdinir 125 mg/5 mL Pow 49439936_1 CDM 0250 RC 68180-0722-10 NDC inpatient 1 UN 27.42 17.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.39 78 999999999 16.6 26.6 percent of total billed charges 68180-0722-10 - cefdinir 125 mg/5 mL Pow 49439936_1 CDM 0250 RC 68180-0722-10 NDC inpatient 1 UN 27.42 17.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.92 69 999999999 16.6 26.6 percent of total billed charges 68180-0722-10 - cefdinir 125 mg/5 mL Pow 49439936_1 CDM 0250 RC 68180-0722-10 NDC inpatient 1 UN 27.42 17.82 SIHO - ALL PLANS SIHO - ALL PLANS 24.68 90 999999999 16.6 26.6 percent of total billed charges 68180-0722-10 - cefdinir 125 mg/5 mL Pow 49439936_1 CDM 0250 RC 68180-0722-10 NDC inpatient 1 UN 27.42 17.82 UMR - ALL PLANS UMR - ALL PLANS 19.19 70 999999999 16.6 26.6 percent of total billed charges 68180-0722-10 - cefdinir 125 mg/5 mL Pow 49439936_1 CDM 0250 RC 68180-0722-10 NDC inpatient 1 UN 27.42 17.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.6 60.55 999999999 16.6 26.6 percent of total billed charges 68180-0722-10 - cefdinir 125 mg/5 mL Pow 49439936_1 CDM 0250 RC 68180-0722-10 NDC inpatient 1 UN 27.42 17.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.6 26.6 68180-0722-10 - cefdinir 125 mg/5 mL Pow 49439936_1 CDM 0250 RC 68180-0722-10 NDC inpatient 1 UN 27.42 17.82 ANTHEM HMO ANTHEM HMO 999999999 16.6 26.6 68180-0722-10 - cefdinir 125 mg/5 mL Pow 49439936_1 CDM 0250 RC 68180-0722-10 NDC inpatient 1 UN 27.42 17.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.6 26.6 68180-0722-10 - cefdinir 125 mg/5 mL Pow 49439936_1 CDM 0250 RC 68180-0722-10 NDC inpatient 1 UN 27.42 17.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.54 67.6 999999999 16.6 26.6 percent of total billed charges 68180-0722-10 - cefdinir 125 mg/5 mL Pow 49439936_1 CDM 0250 RC 68180-0722-10 NDC inpatient 1 UN 27.42 17.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.6 26.6 68180-0722-10 - cefdinir 125 mg/5 mL Pow 49439936_1 CDM 0250 RC 68180-0722-10 NDC inpatient 1 UN 27.42 17.82 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.6 26.6 GEMFIBROZIL 600 MG TABLET 49439972_1 CDM 0250 RC 60687-0224-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges GEMFIBROZIL 600 MG TABLET 49439972_1 CDM 0250 RC 60687-0224-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges GEMFIBROZIL 600 MG TABLET 49439972_1 CDM 0250 RC 60687-0224-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges GEMFIBROZIL 600 MG TABLET 49439972_1 CDM 0250 RC 60687-0224-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges GEMFIBROZIL 600 MG TABLET 49439972_1 CDM 0250 RC 60687-0224-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges GEMFIBROZIL 600 MG TABLET 49439972_1 CDM 0250 RC 60687-0224-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges GEMFIBROZIL 600 MG TABLET 49439972_1 CDM 0250 RC 60687-0224-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges GEMFIBROZIL 600 MG TABLET 49439972_1 CDM 0250 RC 60687-0224-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges GEMFIBROZIL 600 MG TABLET 49439972_1 CDM 0250 RC 60687-0224-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 GEMFIBROZIL 600 MG TABLET 49439972_1 CDM 0250 RC 60687-0224-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 GEMFIBROZIL 600 MG TABLET 49439972_1 CDM 0250 RC 60687-0224-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 GEMFIBROZIL 600 MG TABLET 49439972_1 CDM 0250 RC 60687-0224-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges GEMFIBROZIL 600 MG TABLET 49439972_1 CDM 0250 RC 60687-0224-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 GEMFIBROZIL 600 MG TABLET 49439972_1 CDM 0250 RC 60687-0224-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 Special stain for parasites 49440431_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges Special stain for parasites 49440431_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges Special stain for parasites 49440431_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges Special stain for parasites 49440431_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges Special stain for parasites 49440431_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges Special stain for parasites 49440431_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges Special stain for parasites 49440431_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges Special stain for parasites 49440431_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges Special stain for parasites 49440431_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 Special stain for parasites 49440431_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 Special stain for parasites 49440431_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 Special stain for parasites 49440431_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges Special stain for parasites 49440431_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 Special stain for parasites 49440431_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 VIIBRYD 40 MG TABLET 49440762_1 CDM 0250 RC 00456-1140-30 NDC inpatient 1 UN 43.88 28.52 AETNA AETNA 34.67 79 999999999 26.57 42.56 percent of total billed charges VIIBRYD 40 MG TABLET 49440762_1 CDM 0250 RC 00456-1140-30 NDC inpatient 1 UN 43.88 28.52 SELF PAY DISCOUNT SELF PAY DISCOUNT 28.52 65 999999999 26.57 42.56 percent of total billed charges VIIBRYD 40 MG TABLET 49440762_1 CDM 0250 RC 00456-1140-30 NDC inpatient 1 UN 43.88 28.52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 42.56 97 999999999 26.57 42.56 percent of total billed charges VIIBRYD 40 MG TABLET 49440762_1 CDM 0250 RC 00456-1140-30 NDC inpatient 1 UN 43.88 28.52 HUMANA - ALL PLANS HUMANA - ALL PLANS 34.23 78 999999999 26.57 42.56 percent of total billed charges VIIBRYD 40 MG TABLET 49440762_1 CDM 0250 RC 00456-1140-30 NDC inpatient 1 UN 43.88 28.52 ENCORE - ALL PLANS ENCORE - ALL PLANS 30.28 69 999999999 26.57 42.56 percent of total billed charges VIIBRYD 40 MG TABLET 49440762_1 CDM 0250 RC 00456-1140-30 NDC inpatient 1 UN 43.88 28.52 SIHO - ALL PLANS SIHO - ALL PLANS 39.49 90 999999999 26.57 42.56 percent of total billed charges VIIBRYD 40 MG TABLET 49440762_1 CDM 0250 RC 00456-1140-30 NDC inpatient 1 UN 43.88 28.52 UMR - ALL PLANS UMR - ALL PLANS 30.72 70 999999999 26.57 42.56 percent of total billed charges VIIBRYD 40 MG TABLET 49440762_1 CDM 0250 RC 00456-1140-30 NDC inpatient 1 UN 43.88 28.52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26.57 60.55 999999999 26.57 42.56 percent of total billed charges VIIBRYD 40 MG TABLET 49440762_1 CDM 0250 RC 00456-1140-30 NDC inpatient 1 UN 43.88 28.52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26.57 42.56 VIIBRYD 40 MG TABLET 49440762_1 CDM 0250 RC 00456-1140-30 NDC inpatient 1 UN 43.88 28.52 ANTHEM HMO ANTHEM HMO 999999999 26.57 42.56 VIIBRYD 40 MG TABLET 49440762_1 CDM 0250 RC 00456-1140-30 NDC inpatient 1 UN 43.88 28.52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26.57 42.56 VIIBRYD 40 MG TABLET 49440762_1 CDM 0250 RC 00456-1140-30 NDC inpatient 1 UN 43.88 28.52 CIGNA - ALL PLANS CIGNA - ALL PLANS 29.66 67.6 999999999 26.57 42.56 percent of total billed charges VIIBRYD 40 MG TABLET 49440762_1 CDM 0250 RC 00456-1140-30 NDC inpatient 1 UN 43.88 28.52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26.57 42.56 VIIBRYD 40 MG TABLET 49440762_1 CDM 0250 RC 00456-1140-30 NDC inpatient 1 UN 43.88 28.52 UHC - ALL PLANS UHC - ALL PLANS 999999999 26.57 42.56 Analysis for antibody to fungus 49440859_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440859_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440859_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440859_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440859_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440859_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440859_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440859_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440859_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 Analysis for antibody to fungus 49440859_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 Analysis for antibody to fungus 49440859_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 Analysis for antibody to fungus 49440859_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440859_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 Analysis for antibody to fungus 49440859_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 Analysis for antibody to fungus 49440860_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440860_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440860_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440860_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440860_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440860_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440860_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440860_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440860_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 Analysis for antibody to fungus 49440860_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 Analysis for antibody to fungus 49440860_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 Analysis for antibody to fungus 49440860_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440860_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 Analysis for antibody to fungus 49440860_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 Analysis for antibody to fungus 49440861_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440861_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440861_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440861_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440861_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440861_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440861_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440861_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440861_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 Analysis for antibody to fungus 49440861_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 Analysis for antibody to fungus 49440861_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 Analysis for antibody to fungus 49440861_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49440861_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 Analysis for antibody to fungus 49440861_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 "INJECTION, OXALIPLATIN, 0.5 MG" 49441023_1 CDM 0636 RC 00781-9315-70 NDC J9263 HCPCS inpatient 100 UN 93.65 60.87 AETNA AETNA 73.98 79 999999999 56.71 90.84 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 49441023_1 CDM 0636 RC 00781-9315-70 NDC J9263 HCPCS inpatient 100 UN 93.65 60.87 SELF PAY DISCOUNT SELF PAY DISCOUNT 60.87 65 999999999 56.71 90.84 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 49441023_1 CDM 0636 RC 00781-9315-70 NDC J9263 HCPCS inpatient 100 UN 93.65 60.87 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 90.84 97 999999999 56.71 90.84 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 49441023_1 CDM 0636 RC 00781-9315-70 NDC J9263 HCPCS inpatient 100 UN 93.65 60.87 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.05 78 999999999 56.71 90.84 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 49441023_1 CDM 0636 RC 00781-9315-70 NDC J9263 HCPCS inpatient 100 UN 93.65 60.87 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.62 69 999999999 56.71 90.84 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 49441023_1 CDM 0636 RC 00781-9315-70 NDC J9263 HCPCS inpatient 100 UN 93.65 60.87 SIHO - ALL PLANS SIHO - ALL PLANS 84.29 90 999999999 56.71 90.84 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 49441023_1 CDM 0636 RC 00781-9315-70 NDC J9263 HCPCS inpatient 100 UN 93.65 60.87 UMR - ALL PLANS UMR - ALL PLANS 65.56 70 999999999 56.71 90.84 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 49441023_1 CDM 0636 RC 00781-9315-70 NDC J9263 HCPCS inpatient 100 UN 93.65 60.87 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.71 60.55 999999999 56.71 90.84 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 49441023_1 CDM 0636 RC 00781-9315-70 NDC J9263 HCPCS inpatient 100 UN 93.65 60.87 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.71 90.84 "INJECTION, OXALIPLATIN, 0.5 MG" 49441023_1 CDM 0636 RC 00781-9315-70 NDC J9263 HCPCS inpatient 100 UN 93.65 60.87 ANTHEM HMO ANTHEM HMO 999999999 56.71 90.84 "INJECTION, OXALIPLATIN, 0.5 MG" 49441023_1 CDM 0636 RC 00781-9315-70 NDC J9263 HCPCS inpatient 100 UN 93.65 60.87 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.71 90.84 "INJECTION, OXALIPLATIN, 0.5 MG" 49441023_1 CDM 0636 RC 00781-9315-70 NDC J9263 HCPCS inpatient 100 UN 93.65 60.87 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.31 67.6 999999999 56.71 90.84 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 49441023_1 CDM 0636 RC 00781-9315-70 NDC J9263 HCPCS inpatient 100 UN 93.65 60.87 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.71 90.84 "INJECTION, OXALIPLATIN, 0.5 MG" 49441023_1 CDM 0636 RC 00781-9315-70 NDC J9263 HCPCS inpatient 100 UN 93.65 60.87 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.71 90.84 DILTIAZEM 24H ER(CD) 300 MG CP 49441058_1 CDM 0250 RC 10370-0832-11 NDC inpatient 1 UN 7.88 5.12 AETNA AETNA 6.23 79 999999999 4.77 7.64 percent of total billed charges DILTIAZEM 24H ER(CD) 300 MG CP 49441058_1 CDM 0250 RC 10370-0832-11 NDC inpatient 1 UN 7.88 5.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.12 65 999999999 4.77 7.64 percent of total billed charges DILTIAZEM 24H ER(CD) 300 MG CP 49441058_1 CDM 0250 RC 10370-0832-11 NDC inpatient 1 UN 7.88 5.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7.64 97 999999999 4.77 7.64 percent of total billed charges DILTIAZEM 24H ER(CD) 300 MG CP 49441058_1 CDM 0250 RC 10370-0832-11 NDC inpatient 1 UN 7.88 5.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.15 78 999999999 4.77 7.64 percent of total billed charges DILTIAZEM 24H ER(CD) 300 MG CP 49441058_1 CDM 0250 RC 10370-0832-11 NDC inpatient 1 UN 7.88 5.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.44 69 999999999 4.77 7.64 percent of total billed charges DILTIAZEM 24H ER(CD) 300 MG CP 49441058_1 CDM 0250 RC 10370-0832-11 NDC inpatient 1 UN 7.88 5.12 SIHO - ALL PLANS SIHO - ALL PLANS 7.09 90 999999999 4.77 7.64 percent of total billed charges DILTIAZEM 24H ER(CD) 300 MG CP 49441058_1 CDM 0250 RC 10370-0832-11 NDC inpatient 1 UN 7.88 5.12 UMR - ALL PLANS UMR - ALL PLANS 5.52 70 999999999 4.77 7.64 percent of total billed charges DILTIAZEM 24H ER(CD) 300 MG CP 49441058_1 CDM 0250 RC 10370-0832-11 NDC inpatient 1 UN 7.88 5.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.77 60.55 999999999 4.77 7.64 percent of total billed charges DILTIAZEM 24H ER(CD) 300 MG CP 49441058_1 CDM 0250 RC 10370-0832-11 NDC inpatient 1 UN 7.88 5.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.77 7.64 DILTIAZEM 24H ER(CD) 300 MG CP 49441058_1 CDM 0250 RC 10370-0832-11 NDC inpatient 1 UN 7.88 5.12 ANTHEM HMO ANTHEM HMO 999999999 4.77 7.64 DILTIAZEM 24H ER(CD) 300 MG CP 49441058_1 CDM 0250 RC 10370-0832-11 NDC inpatient 1 UN 7.88 5.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.77 7.64 DILTIAZEM 24H ER(CD) 300 MG CP 49441058_1 CDM 0250 RC 10370-0832-11 NDC inpatient 1 UN 7.88 5.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.33 67.6 999999999 4.77 7.64 percent of total billed charges DILTIAZEM 24H ER(CD) 300 MG CP 49441058_1 CDM 0250 RC 10370-0832-11 NDC inpatient 1 UN 7.88 5.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.77 7.64 DILTIAZEM 24H ER(CD) 300 MG CP 49441058_1 CDM 0250 RC 10370-0832-11 NDC inpatient 1 UN 7.88 5.12 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.77 7.64 "Red blood count automated, with additional calculations" 49447978_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges "Red blood count automated, with additional calculations" 49447978_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges "Red blood count automated, with additional calculations" 49447978_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges "Red blood count automated, with additional calculations" 49447978_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges "Red blood count automated, with additional calculations" 49447978_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges "Red blood count automated, with additional calculations" 49447978_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges "Red blood count automated, with additional calculations" 49447978_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges "Red blood count automated, with additional calculations" 49447978_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges "Red blood count automated, with additional calculations" 49447978_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 "Red blood count automated, with additional calculations" 49447978_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 "Red blood count automated, with additional calculations" 49447978_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 "Red blood count automated, with additional calculations" 49447978_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges "Red blood count automated, with additional calculations" 49447978_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 "Red blood count automated, with additional calculations" 49447978_1 CDM 0305 RC 85046 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 Analysis for antibody to fungus 49448159_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49448159_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49448159_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49448159_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49448159_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49448159_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49448159_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49448159_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49448159_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 Analysis for antibody to fungus 49448159_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 Analysis for antibody to fungus 49448159_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 Analysis for antibody to fungus 49448159_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges Analysis for antibody to fungus 49448159_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 Analysis for antibody to fungus 49448159_1 CDM 0301 RC 86671 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49448363_1 CDM 0250 RC 76045-0009-05 NDC J1170 HCPCS inpatient 1 UN 47.29 30.74 AETNA AETNA 37.36 79 999999999 28.63 45.87 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49448363_1 CDM 0250 RC 76045-0009-05 NDC J1170 HCPCS inpatient 1 UN 47.29 30.74 SELF PAY DISCOUNT SELF PAY DISCOUNT 30.74 65 999999999 28.63 45.87 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49448363_1 CDM 0250 RC 76045-0009-05 NDC J1170 HCPCS inpatient 1 UN 47.29 30.74 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 45.87 97 999999999 28.63 45.87 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49448363_1 CDM 0250 RC 76045-0009-05 NDC J1170 HCPCS inpatient 1 UN 47.29 30.74 HUMANA - ALL PLANS HUMANA - ALL PLANS 36.89 78 999999999 28.63 45.87 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49448363_1 CDM 0250 RC 76045-0009-05 NDC J1170 HCPCS inpatient 1 UN 47.29 30.74 ENCORE - ALL PLANS ENCORE - ALL PLANS 32.63 69 999999999 28.63 45.87 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49448363_1 CDM 0250 RC 76045-0009-05 NDC J1170 HCPCS inpatient 1 UN 47.29 30.74 SIHO - ALL PLANS SIHO - ALL PLANS 42.56 90 999999999 28.63 45.87 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49448363_1 CDM 0250 RC 76045-0009-05 NDC J1170 HCPCS inpatient 1 UN 47.29 30.74 UMR - ALL PLANS UMR - ALL PLANS 33.1 70 999999999 28.63 45.87 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49448363_1 CDM 0250 RC 76045-0009-05 NDC J1170 HCPCS inpatient 1 UN 47.29 30.74 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 28.63 60.55 999999999 28.63 45.87 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49448363_1 CDM 0250 RC 76045-0009-05 NDC J1170 HCPCS inpatient 1 UN 47.29 30.74 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 28.63 45.87 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49448363_1 CDM 0250 RC 76045-0009-05 NDC J1170 HCPCS inpatient 1 UN 47.29 30.74 ANTHEM HMO ANTHEM HMO 999999999 28.63 45.87 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49448363_1 CDM 0250 RC 76045-0009-05 NDC J1170 HCPCS inpatient 1 UN 47.29 30.74 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 28.63 45.87 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49448363_1 CDM 0250 RC 76045-0009-05 NDC J1170 HCPCS inpatient 1 UN 47.29 30.74 CIGNA - ALL PLANS CIGNA - ALL PLANS 31.97 67.6 999999999 28.63 45.87 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49448363_1 CDM 0250 RC 76045-0009-05 NDC J1170 HCPCS inpatient 1 UN 47.29 30.74 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 28.63 45.87 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 49448363_1 CDM 0250 RC 76045-0009-05 NDC J1170 HCPCS inpatient 1 UN 47.29 30.74 UHC - ALL PLANS UHC - ALL PLANS 999999999 28.63 45.87 "INJECTION, MEROPENEM, 100 MG" 49448393_1 CDM 0250 RC 00264-3183-11 NDC J2185 HCPCS inpatient 1 UN 108.12 70.28 AETNA AETNA 85.41 79 999999999 65.47 104.88 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 49448393_1 CDM 0250 RC 00264-3183-11 NDC J2185 HCPCS inpatient 1 UN 108.12 70.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.28 65 999999999 65.47 104.88 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 49448393_1 CDM 0250 RC 00264-3183-11 NDC J2185 HCPCS inpatient 1 UN 108.12 70.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 104.88 97 999999999 65.47 104.88 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 49448393_1 CDM 0250 RC 00264-3183-11 NDC J2185 HCPCS inpatient 1 UN 108.12 70.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 84.33 78 999999999 65.47 104.88 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 49448393_1 CDM 0250 RC 00264-3183-11 NDC J2185 HCPCS inpatient 1 UN 108.12 70.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 74.6 69 999999999 65.47 104.88 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 49448393_1 CDM 0250 RC 00264-3183-11 NDC J2185 HCPCS inpatient 1 UN 108.12 70.28 SIHO - ALL PLANS SIHO - ALL PLANS 97.31 90 999999999 65.47 104.88 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 49448393_1 CDM 0250 RC 00264-3183-11 NDC J2185 HCPCS inpatient 1 UN 108.12 70.28 UMR - ALL PLANS UMR - ALL PLANS 75.68 70 999999999 65.47 104.88 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 49448393_1 CDM 0250 RC 00264-3183-11 NDC J2185 HCPCS inpatient 1 UN 108.12 70.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 65.47 60.55 999999999 65.47 104.88 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 49448393_1 CDM 0250 RC 00264-3183-11 NDC J2185 HCPCS inpatient 1 UN 108.12 70.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 65.47 104.88 "INJECTION, MEROPENEM, 100 MG" 49448393_1 CDM 0250 RC 00264-3183-11 NDC J2185 HCPCS inpatient 1 UN 108.12 70.28 ANTHEM HMO ANTHEM HMO 999999999 65.47 104.88 "INJECTION, MEROPENEM, 100 MG" 49448393_1 CDM 0250 RC 00264-3183-11 NDC J2185 HCPCS inpatient 1 UN 108.12 70.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 65.47 104.88 "INJECTION, MEROPENEM, 100 MG" 49448393_1 CDM 0250 RC 00264-3183-11 NDC J2185 HCPCS inpatient 1 UN 108.12 70.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.09 67.6 999999999 65.47 104.88 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 49448393_1 CDM 0250 RC 00264-3183-11 NDC J2185 HCPCS inpatient 1 UN 108.12 70.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 65.47 104.88 "INJECTION, MEROPENEM, 100 MG" 49448393_1 CDM 0250 RC 00264-3183-11 NDC J2185 HCPCS inpatient 1 UN 108.12 70.28 UHC - ALL PLANS UHC - ALL PLANS 999999999 65.47 104.88 Nucleotidase 5' (enzyme) level 49450964_1 CDM 0301 RC 83915 HCPCS inpatient 172 111.8 AETNA AETNA 135.88 79 999999999 104.15 166.84 percent of total billed charges Nucleotidase 5' (enzyme) level 49450964_1 CDM 0301 RC 83915 HCPCS inpatient 172 111.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.8 65 999999999 104.15 166.84 percent of total billed charges Nucleotidase 5' (enzyme) level 49450964_1 CDM 0301 RC 83915 HCPCS inpatient 172 111.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 166.84 97 999999999 104.15 166.84 percent of total billed charges Nucleotidase 5' (enzyme) level 49450964_1 CDM 0301 RC 83915 HCPCS inpatient 172 111.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.16 78 999999999 104.15 166.84 percent of total billed charges Nucleotidase 5' (enzyme) level 49450964_1 CDM 0301 RC 83915 HCPCS inpatient 172 111.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 118.68 69 999999999 104.15 166.84 percent of total billed charges Nucleotidase 5' (enzyme) level 49450964_1 CDM 0301 RC 83915 HCPCS inpatient 172 111.8 SIHO - ALL PLANS SIHO - ALL PLANS 154.8 90 999999999 104.15 166.84 percent of total billed charges Nucleotidase 5' (enzyme) level 49450964_1 CDM 0301 RC 83915 HCPCS inpatient 172 111.8 UMR - ALL PLANS UMR - ALL PLANS 120.4 70 999999999 104.15 166.84 percent of total billed charges Nucleotidase 5' (enzyme) level 49450964_1 CDM 0301 RC 83915 HCPCS inpatient 172 111.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.15 60.55 999999999 104.15 166.84 percent of total billed charges Nucleotidase 5' (enzyme) level 49450964_1 CDM 0301 RC 83915 HCPCS inpatient 172 111.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.15 166.84 Nucleotidase 5' (enzyme) level 49450964_1 CDM 0301 RC 83915 HCPCS inpatient 172 111.8 ANTHEM HMO ANTHEM HMO 999999999 104.15 166.84 Nucleotidase 5' (enzyme) level 49450964_1 CDM 0301 RC 83915 HCPCS inpatient 172 111.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.15 166.84 Nucleotidase 5' (enzyme) level 49450964_1 CDM 0301 RC 83915 HCPCS inpatient 172 111.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.27 67.6 999999999 104.15 166.84 percent of total billed charges Nucleotidase 5' (enzyme) level 49450964_1 CDM 0301 RC 83915 HCPCS inpatient 172 111.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.15 166.84 Nucleotidase 5' (enzyme) level 49450964_1 CDM 0301 RC 83915 HCPCS inpatient 172 111.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.15 166.84 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450968_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450968_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450968_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450968_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450968_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450968_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450968_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450968_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450968_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450968_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450968_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450968_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450968_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450968_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgG) to allergic substance, each allergen" 49450969_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 AETNA AETNA 45.03 79 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49450969_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.05 65 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49450969_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.29 97 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49450969_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.46 78 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49450969_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.33 69 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49450969_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 SIHO - ALL PLANS SIHO - ALL PLANS 51.3 90 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49450969_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UMR - ALL PLANS UMR - ALL PLANS 39.9 70 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49450969_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.51 60.55 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49450969_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49450969_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM HMO ANTHEM HMO 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49450969_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49450969_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.53 67.6 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49450969_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49450969_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.51 55.29 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450970_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450970_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450970_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450970_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450970_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450970_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450970_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450970_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450970_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450970_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450970_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450970_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450970_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450970_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450972_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450972_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450972_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450972_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450972_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450972_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450972_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450972_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450972_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450972_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450972_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450972_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450972_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450972_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450974_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450974_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450974_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450974_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450974_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450974_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450974_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450974_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450974_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450974_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450974_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450974_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450974_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450974_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450977_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450977_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450977_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450977_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450977_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450977_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450977_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450977_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450977_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450977_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450977_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450977_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450977_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450977_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450980_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450980_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450980_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450980_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450980_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450980_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450980_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450980_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450980_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450980_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450980_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450980_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450980_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450980_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450982_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450982_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450982_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450982_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450982_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450982_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450982_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450982_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450982_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450982_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450982_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450982_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450982_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450982_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450999_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450999_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450999_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450999_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450999_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450999_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450999_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450999_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450999_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450999_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450999_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450999_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450999_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49450999_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451007_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451007_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451007_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451007_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451007_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451007_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451007_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451007_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451007_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451007_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451007_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451007_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451007_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451007_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451008_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451008_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451008_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451008_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451008_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451008_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451008_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451008_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451008_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451008_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451008_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451008_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451008_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451008_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451011_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451011_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451011_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451011_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451011_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451011_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451011_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451011_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451011_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451011_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451011_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451011_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451011_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451011_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451012_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451012_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451012_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451012_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451012_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451012_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451012_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451012_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451012_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451012_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451012_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451012_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451012_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49451012_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Immunologic analysis technique on body fluid, other fluids with concentration" 49451016_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 49451016_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 49451016_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 49451016_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 49451016_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 49451016_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 49451016_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 49451016_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 49451016_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 "Immunologic analysis technique on body fluid, other fluids with concentration" 49451016_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 "Immunologic analysis technique on body fluid, other fluids with concentration" 49451016_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 "Immunologic analysis technique on body fluid, other fluids with concentration" 49451016_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 49451016_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 "Immunologic analysis technique on body fluid, other fluids with concentration" 49451016_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 "Detection test by nucleic acid for organism, amplified probe technique" 49451020_1 CDM 0306 RC 87798 HCPCS inpatient 244 158.6 AETNA AETNA 192.76 79 999999999 147.74 236.68 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49451020_1 CDM 0306 RC 87798 HCPCS inpatient 244 158.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 158.6 65 999999999 147.74 236.68 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49451020_1 CDM 0306 RC 87798 HCPCS inpatient 244 158.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 236.68 97 999999999 147.74 236.68 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49451020_1 CDM 0306 RC 87798 HCPCS inpatient 244 158.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 190.32 78 999999999 147.74 236.68 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49451020_1 CDM 0306 RC 87798 HCPCS inpatient 244 158.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 168.36 69 999999999 147.74 236.68 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49451020_1 CDM 0306 RC 87798 HCPCS inpatient 244 158.6 SIHO - ALL PLANS SIHO - ALL PLANS 219.6 90 999999999 147.74 236.68 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49451020_1 CDM 0306 RC 87798 HCPCS inpatient 244 158.6 UMR - ALL PLANS UMR - ALL PLANS 170.8 70 999999999 147.74 236.68 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49451020_1 CDM 0306 RC 87798 HCPCS inpatient 244 158.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.74 60.55 999999999 147.74 236.68 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49451020_1 CDM 0306 RC 87798 HCPCS inpatient 244 158.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.74 236.68 "Detection test by nucleic acid for organism, amplified probe technique" 49451020_1 CDM 0306 RC 87798 HCPCS inpatient 244 158.6 ANTHEM HMO ANTHEM HMO 999999999 147.74 236.68 "Detection test by nucleic acid for organism, amplified probe technique" 49451020_1 CDM 0306 RC 87798 HCPCS inpatient 244 158.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.74 236.68 "Detection test by nucleic acid for organism, amplified probe technique" 49451020_1 CDM 0306 RC 87798 HCPCS inpatient 244 158.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.94 67.6 999999999 147.74 236.68 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49451020_1 CDM 0306 RC 87798 HCPCS inpatient 244 158.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.74 236.68 "Detection test by nucleic acid for organism, amplified probe technique" 49451020_1 CDM 0306 RC 87798 HCPCS inpatient 244 158.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.74 236.68 Human growth hormone level 49451030_1 CDM 0301 RC 83003 HCPCS inpatient 130 84.5 AETNA AETNA 102.7 79 999999999 78.72 126.1 percent of total billed charges Human growth hormone level 49451030_1 CDM 0301 RC 83003 HCPCS inpatient 130 84.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 84.5 65 999999999 78.72 126.1 percent of total billed charges Human growth hormone level 49451030_1 CDM 0301 RC 83003 HCPCS inpatient 130 84.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 126.1 97 999999999 78.72 126.1 percent of total billed charges Human growth hormone level 49451030_1 CDM 0301 RC 83003 HCPCS inpatient 130 84.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 101.4 78 999999999 78.72 126.1 percent of total billed charges Human growth hormone level 49451030_1 CDM 0301 RC 83003 HCPCS inpatient 130 84.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.7 69 999999999 78.72 126.1 percent of total billed charges Human growth hormone level 49451030_1 CDM 0301 RC 83003 HCPCS inpatient 130 84.5 SIHO - ALL PLANS SIHO - ALL PLANS 117 90 999999999 78.72 126.1 percent of total billed charges Human growth hormone level 49451030_1 CDM 0301 RC 83003 HCPCS inpatient 130 84.5 UMR - ALL PLANS UMR - ALL PLANS 91 70 999999999 78.72 126.1 percent of total billed charges Human growth hormone level 49451030_1 CDM 0301 RC 83003 HCPCS inpatient 130 84.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.72 60.55 999999999 78.72 126.1 percent of total billed charges Human growth hormone level 49451030_1 CDM 0301 RC 83003 HCPCS inpatient 130 84.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.72 126.1 Human growth hormone level 49451030_1 CDM 0301 RC 83003 HCPCS inpatient 130 84.5 ANTHEM HMO ANTHEM HMO 999999999 78.72 126.1 Human growth hormone level 49451030_1 CDM 0301 RC 83003 HCPCS inpatient 130 84.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.72 126.1 Human growth hormone level 49451030_1 CDM 0301 RC 83003 HCPCS inpatient 130 84.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.88 67.6 999999999 78.72 126.1 percent of total billed charges Human growth hormone level 49451030_1 CDM 0301 RC 83003 HCPCS inpatient 130 84.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.72 126.1 Human growth hormone level 49451030_1 CDM 0301 RC 83003 HCPCS inpatient 130 84.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.72 126.1 Gammaglobulin (immune system protein) measurement 49451033_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49451033_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49451033_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49451033_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49451033_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49451033_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49451033_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49451033_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49451033_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49451033_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49451033_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49451033_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 49451033_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 49451033_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 "Insulin measurement, total" 49451036_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 49451036_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 49451036_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 49451036_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 49451036_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 49451036_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 49451036_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 49451036_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 49451036_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 "Insulin measurement, total" 49451036_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 "Insulin measurement, total" 49451036_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 "Insulin measurement, total" 49451036_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 49451036_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 "Insulin measurement, total" 49451036_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 Lead level 49451040_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 AETNA AETNA 170.64 79 999999999 130.79 209.52 percent of total billed charges Lead level 49451040_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 140.4 65 999999999 130.79 209.52 percent of total billed charges Lead level 49451040_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 209.52 97 999999999 130.79 209.52 percent of total billed charges Lead level 49451040_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 168.48 78 999999999 130.79 209.52 percent of total billed charges Lead level 49451040_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 149.04 69 999999999 130.79 209.52 percent of total billed charges Lead level 49451040_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 SIHO - ALL PLANS SIHO - ALL PLANS 194.4 90 999999999 130.79 209.52 percent of total billed charges Lead level 49451040_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 UMR - ALL PLANS UMR - ALL PLANS 151.2 70 999999999 130.79 209.52 percent of total billed charges Lead level 49451040_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 130.79 60.55 999999999 130.79 209.52 percent of total billed charges Lead level 49451040_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 130.79 209.52 Lead level 49451040_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ANTHEM HMO ANTHEM HMO 999999999 130.79 209.52 Lead level 49451040_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 130.79 209.52 Lead level 49451040_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 146.02 67.6 999999999 130.79 209.52 percent of total billed charges Lead level 49451040_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 130.79 209.52 Lead level 49451040_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 130.79 209.52 Lead level 49451041_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 AETNA AETNA 170.64 79 999999999 130.79 209.52 percent of total billed charges Lead level 49451041_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 140.4 65 999999999 130.79 209.52 percent of total billed charges Lead level 49451041_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 209.52 97 999999999 130.79 209.52 percent of total billed charges Lead level 49451041_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 168.48 78 999999999 130.79 209.52 percent of total billed charges Lead level 49451041_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 149.04 69 999999999 130.79 209.52 percent of total billed charges Lead level 49451041_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 SIHO - ALL PLANS SIHO - ALL PLANS 194.4 90 999999999 130.79 209.52 percent of total billed charges Lead level 49451041_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 UMR - ALL PLANS UMR - ALL PLANS 151.2 70 999999999 130.79 209.52 percent of total billed charges Lead level 49451041_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 130.79 60.55 999999999 130.79 209.52 percent of total billed charges Lead level 49451041_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 130.79 209.52 Lead level 49451041_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ANTHEM HMO ANTHEM HMO 999999999 130.79 209.52 Lead level 49451041_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 130.79 209.52 Lead level 49451041_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 146.02 67.6 999999999 130.79 209.52 percent of total billed charges Lead level 49451041_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 130.79 209.52 Lead level 49451041_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 130.79 209.52 Lipoprotein (A) level 49451044_1 CDM 0301 RC 83695 HCPCS inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges Lipoprotein (A) level 49451044_1 CDM 0301 RC 83695 HCPCS inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges Lipoprotein (A) level 49451044_1 CDM 0301 RC 83695 HCPCS inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges Lipoprotein (A) level 49451044_1 CDM 0301 RC 83695 HCPCS inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges Lipoprotein (A) level 49451044_1 CDM 0301 RC 83695 HCPCS inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges Lipoprotein (A) level 49451044_1 CDM 0301 RC 83695 HCPCS inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges Lipoprotein (A) level 49451044_1 CDM 0301 RC 83695 HCPCS inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges Lipoprotein (A) level 49451044_1 CDM 0301 RC 83695 HCPCS inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges Lipoprotein (A) level 49451044_1 CDM 0301 RC 83695 HCPCS inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 Lipoprotein (A) level 49451044_1 CDM 0301 RC 83695 HCPCS inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 Lipoprotein (A) level 49451044_1 CDM 0301 RC 83695 HCPCS inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 Lipoprotein (A) level 49451044_1 CDM 0301 RC 83695 HCPCS inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges Lipoprotein (A) level 49451044_1 CDM 0301 RC 83695 HCPCS inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 Lipoprotein (A) level 49451044_1 CDM 0301 RC 83695 HCPCS inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 Mercury level 49451048_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 AETNA AETNA 189.6 79 999999999 145.32 232.8 percent of total billed charges Mercury level 49451048_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 SELF PAY DISCOUNT SELF PAY DISCOUNT 156 65 999999999 145.32 232.8 percent of total billed charges Mercury level 49451048_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 232.8 97 999999999 145.32 232.8 percent of total billed charges Mercury level 49451048_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.2 78 999999999 145.32 232.8 percent of total billed charges Mercury level 49451048_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 ENCORE - ALL PLANS ENCORE - ALL PLANS 165.6 69 999999999 145.32 232.8 percent of total billed charges Mercury level 49451048_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 SIHO - ALL PLANS SIHO - ALL PLANS 216 90 999999999 145.32 232.8 percent of total billed charges Mercury level 49451048_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 UMR - ALL PLANS UMR - ALL PLANS 168 70 999999999 145.32 232.8 percent of total billed charges Mercury level 49451048_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.32 60.55 999999999 145.32 232.8 percent of total billed charges Mercury level 49451048_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.32 232.8 Mercury level 49451048_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 ANTHEM HMO ANTHEM HMO 999999999 145.32 232.8 Mercury level 49451048_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.32 232.8 Mercury level 49451048_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.24 67.6 999999999 145.32 232.8 percent of total billed charges Mercury level 49451048_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.32 232.8 Mercury level 49451048_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.32 232.8 Serotonin (hormone) level 49451056_1 CDM 0301 RC 84260 HCPCS inpatient 329 213.85 AETNA AETNA 259.91 79 999999999 199.21 319.13 percent of total billed charges Serotonin (hormone) level 49451056_1 CDM 0301 RC 84260 HCPCS inpatient 329 213.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 213.85 65 999999999 199.21 319.13 percent of total billed charges Serotonin (hormone) level 49451056_1 CDM 0301 RC 84260 HCPCS inpatient 329 213.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 319.13 97 999999999 199.21 319.13 percent of total billed charges Serotonin (hormone) level 49451056_1 CDM 0301 RC 84260 HCPCS inpatient 329 213.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 256.62 78 999999999 199.21 319.13 percent of total billed charges Serotonin (hormone) level 49451056_1 CDM 0301 RC 84260 HCPCS inpatient 329 213.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 227.01 69 999999999 199.21 319.13 percent of total billed charges Serotonin (hormone) level 49451056_1 CDM 0301 RC 84260 HCPCS inpatient 329 213.85 SIHO - ALL PLANS SIHO - ALL PLANS 296.1 90 999999999 199.21 319.13 percent of total billed charges Serotonin (hormone) level 49451056_1 CDM 0301 RC 84260 HCPCS inpatient 329 213.85 UMR - ALL PLANS UMR - ALL PLANS 230.3 70 999999999 199.21 319.13 percent of total billed charges Serotonin (hormone) level 49451056_1 CDM 0301 RC 84260 HCPCS inpatient 329 213.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 199.21 60.55 999999999 199.21 319.13 percent of total billed charges Serotonin (hormone) level 49451056_1 CDM 0301 RC 84260 HCPCS inpatient 329 213.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 199.21 319.13 Serotonin (hormone) level 49451056_1 CDM 0301 RC 84260 HCPCS inpatient 329 213.85 ANTHEM HMO ANTHEM HMO 999999999 199.21 319.13 Serotonin (hormone) level 49451056_1 CDM 0301 RC 84260 HCPCS inpatient 329 213.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 199.21 319.13 Serotonin (hormone) level 49451056_1 CDM 0301 RC 84260 HCPCS inpatient 329 213.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 222.4 67.6 999999999 199.21 319.13 percent of total billed charges Serotonin (hormone) level 49451056_1 CDM 0301 RC 84260 HCPCS inpatient 329 213.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 199.21 319.13 Serotonin (hormone) level 49451056_1 CDM 0301 RC 84260 HCPCS inpatient 329 213.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 199.21 319.13 Vasoactive intestinal peptide (intestinal hormone) level 49451067_1 CDM 0301 RC 84586 HCPCS inpatient 273 177.45 AETNA AETNA 215.67 79 999999999 165.3 264.81 percent of total billed charges Vasoactive intestinal peptide (intestinal hormone) level 49451067_1 CDM 0301 RC 84586 HCPCS inpatient 273 177.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 177.45 65 999999999 165.3 264.81 percent of total billed charges Vasoactive intestinal peptide (intestinal hormone) level 49451067_1 CDM 0301 RC 84586 HCPCS inpatient 273 177.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 264.81 97 999999999 165.3 264.81 percent of total billed charges Vasoactive intestinal peptide (intestinal hormone) level 49451067_1 CDM 0301 RC 84586 HCPCS inpatient 273 177.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 212.94 78 999999999 165.3 264.81 percent of total billed charges Vasoactive intestinal peptide (intestinal hormone) level 49451067_1 CDM 0301 RC 84586 HCPCS inpatient 273 177.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 188.37 69 999999999 165.3 264.81 percent of total billed charges Vasoactive intestinal peptide (intestinal hormone) level 49451067_1 CDM 0301 RC 84586 HCPCS inpatient 273 177.45 SIHO - ALL PLANS SIHO - ALL PLANS 245.7 90 999999999 165.3 264.81 percent of total billed charges Vasoactive intestinal peptide (intestinal hormone) level 49451067_1 CDM 0301 RC 84586 HCPCS inpatient 273 177.45 UMR - ALL PLANS UMR - ALL PLANS 191.1 70 999999999 165.3 264.81 percent of total billed charges Vasoactive intestinal peptide (intestinal hormone) level 49451067_1 CDM 0301 RC 84586 HCPCS inpatient 273 177.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.3 60.55 999999999 165.3 264.81 percent of total billed charges Vasoactive intestinal peptide (intestinal hormone) level 49451067_1 CDM 0301 RC 84586 HCPCS inpatient 273 177.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.3 264.81 Vasoactive intestinal peptide (intestinal hormone) level 49451067_1 CDM 0301 RC 84586 HCPCS inpatient 273 177.45 ANTHEM HMO ANTHEM HMO 999999999 165.3 264.81 Vasoactive intestinal peptide (intestinal hormone) level 49451067_1 CDM 0301 RC 84586 HCPCS inpatient 273 177.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.3 264.81 Vasoactive intestinal peptide (intestinal hormone) level 49451067_1 CDM 0301 RC 84586 HCPCS inpatient 273 177.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 184.55 67.6 999999999 165.3 264.81 percent of total billed charges Vasoactive intestinal peptide (intestinal hormone) level 49451067_1 CDM 0301 RC 84586 HCPCS inpatient 273 177.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.3 264.81 Vasoactive intestinal peptide (intestinal hormone) level 49451067_1 CDM 0301 RC 84586 HCPCS inpatient 273 177.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.3 264.81 "STIMUPLEX NEEDLE 22GX3-1/8"" 333644" 49451073_1 CDM 0272 RC inpatient 96 62.4 AETNA AETNA 75.84 79 999999999 58.13 93.12 percent of total billed charges "STIMUPLEX NEEDLE 22GX3-1/8"" 333644" 49451073_1 CDM 0272 RC inpatient 96 62.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.4 65 999999999 58.13 93.12 percent of total billed charges "STIMUPLEX NEEDLE 22GX3-1/8"" 333644" 49451073_1 CDM 0272 RC inpatient 96 62.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.12 97 999999999 58.13 93.12 percent of total billed charges "STIMUPLEX NEEDLE 22GX3-1/8"" 333644" 49451073_1 CDM 0272 RC inpatient 96 62.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.88 78 999999999 58.13 93.12 percent of total billed charges "STIMUPLEX NEEDLE 22GX3-1/8"" 333644" 49451073_1 CDM 0272 RC inpatient 96 62.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.24 69 999999999 58.13 93.12 percent of total billed charges "STIMUPLEX NEEDLE 22GX3-1/8"" 333644" 49451073_1 CDM 0272 RC inpatient 96 62.4 SIHO - ALL PLANS SIHO - ALL PLANS 86.4 90 999999999 58.13 93.12 percent of total billed charges "STIMUPLEX NEEDLE 22GX3-1/8"" 333644" 49451073_1 CDM 0272 RC inpatient 96 62.4 UMR - ALL PLANS UMR - ALL PLANS 67.2 70 999999999 58.13 93.12 percent of total billed charges "STIMUPLEX NEEDLE 22GX3-1/8"" 333644" 49451073_1 CDM 0272 RC inpatient 96 62.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.13 60.55 999999999 58.13 93.12 percent of total billed charges "STIMUPLEX NEEDLE 22GX3-1/8"" 333644" 49451073_1 CDM 0272 RC inpatient 96 62.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.13 93.12 "STIMUPLEX NEEDLE 22GX3-1/8"" 333644" 49451073_1 CDM 0272 RC inpatient 96 62.4 ANTHEM HMO ANTHEM HMO 999999999 58.13 93.12 "STIMUPLEX NEEDLE 22GX3-1/8"" 333644" 49451073_1 CDM 0272 RC inpatient 96 62.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.13 93.12 "STIMUPLEX NEEDLE 22GX3-1/8"" 333644" 49451073_1 CDM 0272 RC inpatient 96 62.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.9 67.6 999999999 58.13 93.12 percent of total billed charges "STIMUPLEX NEEDLE 22GX3-1/8"" 333644" 49451073_1 CDM 0272 RC inpatient 96 62.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.13 93.12 "STIMUPLEX NEEDLE 22GX3-1/8"" 333644" 49451073_1 CDM 0272 RC inpatient 96 62.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.13 93.12 IRRIGATION INFLOW TUBE SET 284508 49451074_1 CDM 0270 RC inpatient 477 310.05 AETNA AETNA 376.83 79 999999999 288.82 462.69 percent of total billed charges IRRIGATION INFLOW TUBE SET 284508 49451074_1 CDM 0270 RC inpatient 477 310.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 310.05 65 999999999 288.82 462.69 percent of total billed charges IRRIGATION INFLOW TUBE SET 284508 49451074_1 CDM 0270 RC inpatient 477 310.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 462.69 97 999999999 288.82 462.69 percent of total billed charges IRRIGATION INFLOW TUBE SET 284508 49451074_1 CDM 0270 RC inpatient 477 310.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 372.06 78 999999999 288.82 462.69 percent of total billed charges IRRIGATION INFLOW TUBE SET 284508 49451074_1 CDM 0270 RC inpatient 477 310.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 329.13 69 999999999 288.82 462.69 percent of total billed charges IRRIGATION INFLOW TUBE SET 284508 49451074_1 CDM 0270 RC inpatient 477 310.05 SIHO - ALL PLANS SIHO - ALL PLANS 429.3 90 999999999 288.82 462.69 percent of total billed charges IRRIGATION INFLOW TUBE SET 284508 49451074_1 CDM 0270 RC inpatient 477 310.05 UMR - ALL PLANS UMR - ALL PLANS 333.9 70 999999999 288.82 462.69 percent of total billed charges IRRIGATION INFLOW TUBE SET 284508 49451074_1 CDM 0270 RC inpatient 477 310.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 288.82 60.55 999999999 288.82 462.69 percent of total billed charges IRRIGATION INFLOW TUBE SET 284508 49451074_1 CDM 0270 RC inpatient 477 310.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 288.82 462.69 IRRIGATION INFLOW TUBE SET 284508 49451074_1 CDM 0270 RC inpatient 477 310.05 ANTHEM HMO ANTHEM HMO 999999999 288.82 462.69 IRRIGATION INFLOW TUBE SET 284508 49451074_1 CDM 0270 RC inpatient 477 310.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 288.82 462.69 IRRIGATION INFLOW TUBE SET 284508 49451074_1 CDM 0270 RC inpatient 477 310.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 322.45 67.6 999999999 288.82 462.69 percent of total billed charges IRRIGATION INFLOW TUBE SET 284508 49451074_1 CDM 0270 RC inpatient 477 310.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 288.82 462.69 IRRIGATION INFLOW TUBE SET 284508 49451074_1 CDM 0270 RC inpatient 477 310.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 288.82 462.69 IRRIGATION OUTFLOW TUBE SET 284649 49451075_1 CDM 0272 RC inpatient 540 351 AETNA AETNA 426.6 79 999999999 326.97 523.8 percent of total billed charges IRRIGATION OUTFLOW TUBE SET 284649 49451075_1 CDM 0272 RC inpatient 540 351 SELF PAY DISCOUNT SELF PAY DISCOUNT 351 65 999999999 326.97 523.8 percent of total billed charges IRRIGATION OUTFLOW TUBE SET 284649 49451075_1 CDM 0272 RC inpatient 540 351 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 523.8 97 999999999 326.97 523.8 percent of total billed charges IRRIGATION OUTFLOW TUBE SET 284649 49451075_1 CDM 0272 RC inpatient 540 351 HUMANA - ALL PLANS HUMANA - ALL PLANS 421.2 78 999999999 326.97 523.8 percent of total billed charges IRRIGATION OUTFLOW TUBE SET 284649 49451075_1 CDM 0272 RC inpatient 540 351 ENCORE - ALL PLANS ENCORE - ALL PLANS 372.6 69 999999999 326.97 523.8 percent of total billed charges IRRIGATION OUTFLOW TUBE SET 284649 49451075_1 CDM 0272 RC inpatient 540 351 SIHO - ALL PLANS SIHO - ALL PLANS 486 90 999999999 326.97 523.8 percent of total billed charges IRRIGATION OUTFLOW TUBE SET 284649 49451075_1 CDM 0272 RC inpatient 540 351 UMR - ALL PLANS UMR - ALL PLANS 378 70 999999999 326.97 523.8 percent of total billed charges IRRIGATION OUTFLOW TUBE SET 284649 49451075_1 CDM 0272 RC inpatient 540 351 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 326.97 60.55 999999999 326.97 523.8 percent of total billed charges IRRIGATION OUTFLOW TUBE SET 284649 49451075_1 CDM 0272 RC inpatient 540 351 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 326.97 523.8 IRRIGATION OUTFLOW TUBE SET 284649 49451075_1 CDM 0272 RC inpatient 540 351 ANTHEM HMO ANTHEM HMO 999999999 326.97 523.8 IRRIGATION OUTFLOW TUBE SET 284649 49451075_1 CDM 0272 RC inpatient 540 351 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 326.97 523.8 IRRIGATION OUTFLOW TUBE SET 284649 49451075_1 CDM 0272 RC inpatient 540 351 CIGNA - ALL PLANS CIGNA - ALL PLANS 365.04 67.6 999999999 326.97 523.8 percent of total billed charges IRRIGATION OUTFLOW TUBE SET 284649 49451075_1 CDM 0272 RC inpatient 540 351 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 326.97 523.8 IRRIGATION OUTFLOW TUBE SET 284649 49451075_1 CDM 0272 RC inpatient 540 351 UHC - ALL PLANS UHC - ALL PLANS 999999999 326.97 523.8 Analysis for antibody to protozoa (parasite) 49451247_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 AETNA AETNA 152.47 79 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to protozoa (parasite) 49451247_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 125.45 65 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to protozoa (parasite) 49451247_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 187.21 97 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to protozoa (parasite) 49451247_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 150.54 78 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to protozoa (parasite) 49451247_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.17 69 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to protozoa (parasite) 49451247_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 SIHO - ALL PLANS SIHO - ALL PLANS 173.7 90 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to protozoa (parasite) 49451247_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 UMR - ALL PLANS UMR - ALL PLANS 135.1 70 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to protozoa (parasite) 49451247_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.86 60.55 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to protozoa (parasite) 49451247_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.86 187.21 Analysis for antibody to protozoa (parasite) 49451247_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 ANTHEM HMO ANTHEM HMO 999999999 116.86 187.21 Analysis for antibody to protozoa (parasite) 49451247_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.86 187.21 Analysis for antibody to protozoa (parasite) 49451247_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 130.47 67.6 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to protozoa (parasite) 49451247_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.86 187.21 Analysis for antibody to protozoa (parasite) 49451247_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.86 187.21 EPINEPHRINE 0.1 MG/ML SYRINGE 49453520_1 CDM 0250 RC 76329-3316-01 NDC inpatient 2 UN 53.44 34.74 AETNA AETNA 42.22 79 999999999 32.36 51.84 percent of total billed charges EPINEPHRINE 0.1 MG/ML SYRINGE 49453520_1 CDM 0250 RC 76329-3316-01 NDC inpatient 2 UN 53.44 34.74 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.74 65 999999999 32.36 51.84 percent of total billed charges EPINEPHRINE 0.1 MG/ML SYRINGE 49453520_1 CDM 0250 RC 76329-3316-01 NDC inpatient 2 UN 53.44 34.74 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.84 97 999999999 32.36 51.84 percent of total billed charges EPINEPHRINE 0.1 MG/ML SYRINGE 49453520_1 CDM 0250 RC 76329-3316-01 NDC inpatient 2 UN 53.44 34.74 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.68 78 999999999 32.36 51.84 percent of total billed charges EPINEPHRINE 0.1 MG/ML SYRINGE 49453520_1 CDM 0250 RC 76329-3316-01 NDC inpatient 2 UN 53.44 34.74 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.87 69 999999999 32.36 51.84 percent of total billed charges EPINEPHRINE 0.1 MG/ML SYRINGE 49453520_1 CDM 0250 RC 76329-3316-01 NDC inpatient 2 UN 53.44 34.74 SIHO - ALL PLANS SIHO - ALL PLANS 48.1 90 999999999 32.36 51.84 percent of total billed charges EPINEPHRINE 0.1 MG/ML SYRINGE 49453520_1 CDM 0250 RC 76329-3316-01 NDC inpatient 2 UN 53.44 34.74 UMR - ALL PLANS UMR - ALL PLANS 37.41 70 999999999 32.36 51.84 percent of total billed charges EPINEPHRINE 0.1 MG/ML SYRINGE 49453520_1 CDM 0250 RC 76329-3316-01 NDC inpatient 2 UN 53.44 34.74 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.36 60.55 999999999 32.36 51.84 percent of total billed charges EPINEPHRINE 0.1 MG/ML SYRINGE 49453520_1 CDM 0250 RC 76329-3316-01 NDC inpatient 2 UN 53.44 34.74 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.36 51.84 EPINEPHRINE 0.1 MG/ML SYRINGE 49453520_1 CDM 0250 RC 76329-3316-01 NDC inpatient 2 UN 53.44 34.74 ANTHEM HMO ANTHEM HMO 999999999 32.36 51.84 EPINEPHRINE 0.1 MG/ML SYRINGE 49453520_1 CDM 0250 RC 76329-3316-01 NDC inpatient 2 UN 53.44 34.74 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.36 51.84 EPINEPHRINE 0.1 MG/ML SYRINGE 49453520_1 CDM 0250 RC 76329-3316-01 NDC inpatient 2 UN 53.44 34.74 CIGNA - ALL PLANS CIGNA - ALL PLANS 36.13 67.6 999999999 32.36 51.84 percent of total billed charges EPINEPHRINE 0.1 MG/ML SYRINGE 49453520_1 CDM 0250 RC 76329-3316-01 NDC inpatient 2 UN 53.44 34.74 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.36 51.84 EPINEPHRINE 0.1 MG/ML SYRINGE 49453520_1 CDM 0250 RC 76329-3316-01 NDC inpatient 2 UN 53.44 34.74 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.36 51.84 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49453531_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49453531_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49453531_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49453531_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49453531_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49453531_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49453531_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49453531_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49453531_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49453531_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49453531_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49453531_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49453531_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49453531_1 CDM 0306 RC 87491 HCPCS inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49453532_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49453532_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49453532_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49453532_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49453532_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49453532_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49453532_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49453532_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49453532_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49453532_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49453532_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49453532_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49453532_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49453532_1 CDM 0306 RC 87591 HCPCS inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 MONUROL 3 GM SACHET 49454165_1 CDM 0250 RC 00456-4300-01 NDC inpatient 1 UN 399.95 259.97 AETNA AETNA 315.96 79 999999999 242.17 387.95 percent of total billed charges MONUROL 3 GM SACHET 49454165_1 CDM 0250 RC 00456-4300-01 NDC inpatient 1 UN 399.95 259.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 259.97 65 999999999 242.17 387.95 percent of total billed charges MONUROL 3 GM SACHET 49454165_1 CDM 0250 RC 00456-4300-01 NDC inpatient 1 UN 399.95 259.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 387.95 97 999999999 242.17 387.95 percent of total billed charges MONUROL 3 GM SACHET 49454165_1 CDM 0250 RC 00456-4300-01 NDC inpatient 1 UN 399.95 259.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 311.96 78 999999999 242.17 387.95 percent of total billed charges MONUROL 3 GM SACHET 49454165_1 CDM 0250 RC 00456-4300-01 NDC inpatient 1 UN 399.95 259.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 275.97 69 999999999 242.17 387.95 percent of total billed charges MONUROL 3 GM SACHET 49454165_1 CDM 0250 RC 00456-4300-01 NDC inpatient 1 UN 399.95 259.97 SIHO - ALL PLANS SIHO - ALL PLANS 359.96 90 999999999 242.17 387.95 percent of total billed charges MONUROL 3 GM SACHET 49454165_1 CDM 0250 RC 00456-4300-01 NDC inpatient 1 UN 399.95 259.97 UMR - ALL PLANS UMR - ALL PLANS 279.97 70 999999999 242.17 387.95 percent of total billed charges MONUROL 3 GM SACHET 49454165_1 CDM 0250 RC 00456-4300-01 NDC inpatient 1 UN 399.95 259.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 242.17 60.55 999999999 242.17 387.95 percent of total billed charges MONUROL 3 GM SACHET 49454165_1 CDM 0250 RC 00456-4300-01 NDC inpatient 1 UN 399.95 259.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 242.17 387.95 MONUROL 3 GM SACHET 49454165_1 CDM 0250 RC 00456-4300-01 NDC inpatient 1 UN 399.95 259.97 ANTHEM HMO ANTHEM HMO 999999999 242.17 387.95 MONUROL 3 GM SACHET 49454165_1 CDM 0250 RC 00456-4300-01 NDC inpatient 1 UN 399.95 259.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 242.17 387.95 MONUROL 3 GM SACHET 49454165_1 CDM 0250 RC 00456-4300-01 NDC inpatient 1 UN 399.95 259.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 270.37 67.6 999999999 242.17 387.95 percent of total billed charges MONUROL 3 GM SACHET 49454165_1 CDM 0250 RC 00456-4300-01 NDC inpatient 1 UN 399.95 259.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 242.17 387.95 MONUROL 3 GM SACHET 49454165_1 CDM 0250 RC 00456-4300-01 NDC inpatient 1 UN 399.95 259.97 UHC - ALL PLANS UHC - ALL PLANS 999999999 242.17 387.95 ATRIPLA TABLET 49454174_1 CDM 0250 RC 15584-0101-01 NDC inpatient 1 UN 444.48 288.91 AETNA AETNA 351.14 79 999999999 269.13 431.15 percent of total billed charges ATRIPLA TABLET 49454174_1 CDM 0250 RC 15584-0101-01 NDC inpatient 1 UN 444.48 288.91 SELF PAY DISCOUNT SELF PAY DISCOUNT 288.91 65 999999999 269.13 431.15 percent of total billed charges ATRIPLA TABLET 49454174_1 CDM 0250 RC 15584-0101-01 NDC inpatient 1 UN 444.48 288.91 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 431.15 97 999999999 269.13 431.15 percent of total billed charges ATRIPLA TABLET 49454174_1 CDM 0250 RC 15584-0101-01 NDC inpatient 1 UN 444.48 288.91 HUMANA - ALL PLANS HUMANA - ALL PLANS 346.69 78 999999999 269.13 431.15 percent of total billed charges ATRIPLA TABLET 49454174_1 CDM 0250 RC 15584-0101-01 NDC inpatient 1 UN 444.48 288.91 ENCORE - ALL PLANS ENCORE - ALL PLANS 306.69 69 999999999 269.13 431.15 percent of total billed charges ATRIPLA TABLET 49454174_1 CDM 0250 RC 15584-0101-01 NDC inpatient 1 UN 444.48 288.91 SIHO - ALL PLANS SIHO - ALL PLANS 400.03 90 999999999 269.13 431.15 percent of total billed charges ATRIPLA TABLET 49454174_1 CDM 0250 RC 15584-0101-01 NDC inpatient 1 UN 444.48 288.91 UMR - ALL PLANS UMR - ALL PLANS 311.14 70 999999999 269.13 431.15 percent of total billed charges ATRIPLA TABLET 49454174_1 CDM 0250 RC 15584-0101-01 NDC inpatient 1 UN 444.48 288.91 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 269.13 60.55 999999999 269.13 431.15 percent of total billed charges ATRIPLA TABLET 49454174_1 CDM 0250 RC 15584-0101-01 NDC inpatient 1 UN 444.48 288.91 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 269.13 431.15 ATRIPLA TABLET 49454174_1 CDM 0250 RC 15584-0101-01 NDC inpatient 1 UN 444.48 288.91 ANTHEM HMO ANTHEM HMO 999999999 269.13 431.15 ATRIPLA TABLET 49454174_1 CDM 0250 RC 15584-0101-01 NDC inpatient 1 UN 444.48 288.91 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 269.13 431.15 ATRIPLA TABLET 49454174_1 CDM 0250 RC 15584-0101-01 NDC inpatient 1 UN 444.48 288.91 CIGNA - ALL PLANS CIGNA - ALL PLANS 300.47 67.6 999999999 269.13 431.15 percent of total billed charges ATRIPLA TABLET 49454174_1 CDM 0250 RC 15584-0101-01 NDC inpatient 1 UN 444.48 288.91 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 269.13 431.15 ATRIPLA TABLET 49454174_1 CDM 0250 RC 15584-0101-01 NDC inpatient 1 UN 444.48 288.91 UHC - ALL PLANS UHC - ALL PLANS 999999999 269.13 431.15 GLUTOSE-15 GEL 49454177_1 CDM 0250 RC 00574-0070-30 NDC inpatient 1 UN 13.43 8.73 AETNA AETNA 10.61 79 999999999 8.13 13.03 percent of total billed charges GLUTOSE-15 GEL 49454177_1 CDM 0250 RC 00574-0070-30 NDC inpatient 1 UN 13.43 8.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.73 65 999999999 8.13 13.03 percent of total billed charges GLUTOSE-15 GEL 49454177_1 CDM 0250 RC 00574-0070-30 NDC inpatient 1 UN 13.43 8.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13.03 97 999999999 8.13 13.03 percent of total billed charges GLUTOSE-15 GEL 49454177_1 CDM 0250 RC 00574-0070-30 NDC inpatient 1 UN 13.43 8.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.48 78 999999999 8.13 13.03 percent of total billed charges GLUTOSE-15 GEL 49454177_1 CDM 0250 RC 00574-0070-30 NDC inpatient 1 UN 13.43 8.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.27 69 999999999 8.13 13.03 percent of total billed charges GLUTOSE-15 GEL 49454177_1 CDM 0250 RC 00574-0070-30 NDC inpatient 1 UN 13.43 8.73 SIHO - ALL PLANS SIHO - ALL PLANS 12.09 90 999999999 8.13 13.03 percent of total billed charges GLUTOSE-15 GEL 49454177_1 CDM 0250 RC 00574-0070-30 NDC inpatient 1 UN 13.43 8.73 UMR - ALL PLANS UMR - ALL PLANS 9.4 70 999999999 8.13 13.03 percent of total billed charges GLUTOSE-15 GEL 49454177_1 CDM 0250 RC 00574-0070-30 NDC inpatient 1 UN 13.43 8.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.13 60.55 999999999 8.13 13.03 percent of total billed charges GLUTOSE-15 GEL 49454177_1 CDM 0250 RC 00574-0070-30 NDC inpatient 1 UN 13.43 8.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.13 13.03 GLUTOSE-15 GEL 49454177_1 CDM 0250 RC 00574-0070-30 NDC inpatient 1 UN 13.43 8.73 ANTHEM HMO ANTHEM HMO 999999999 8.13 13.03 GLUTOSE-15 GEL 49454177_1 CDM 0250 RC 00574-0070-30 NDC inpatient 1 UN 13.43 8.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.13 13.03 GLUTOSE-15 GEL 49454177_1 CDM 0250 RC 00574-0070-30 NDC inpatient 1 UN 13.43 8.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.08 67.6 999999999 8.13 13.03 percent of total billed charges GLUTOSE-15 GEL 49454177_1 CDM 0250 RC 00574-0070-30 NDC inpatient 1 UN 13.43 8.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.13 13.03 GLUTOSE-15 GEL 49454177_1 CDM 0250 RC 00574-0070-30 NDC inpatient 1 UN 13.43 8.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.13 13.03 LACTULOSE 20 GM/30 ML SOLN CUP 49454377_1 CDM 0250 RC 00121-1154-40 NDC inpatient 1 UN 1.38 0.9 AETNA AETNA 1.09 79 999999999 0.84 1.34 percent of total billed charges LACTULOSE 20 GM/30 ML SOLN CUP 49454377_1 CDM 0250 RC 00121-1154-40 NDC inpatient 1 UN 1.38 0.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.9 65 999999999 0.84 1.34 percent of total billed charges LACTULOSE 20 GM/30 ML SOLN CUP 49454377_1 CDM 0250 RC 00121-1154-40 NDC inpatient 1 UN 1.38 0.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.34 97 999999999 0.84 1.34 percent of total billed charges LACTULOSE 20 GM/30 ML SOLN CUP 49454377_1 CDM 0250 RC 00121-1154-40 NDC inpatient 1 UN 1.38 0.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.08 78 999999999 0.84 1.34 percent of total billed charges LACTULOSE 20 GM/30 ML SOLN CUP 49454377_1 CDM 0250 RC 00121-1154-40 NDC inpatient 1 UN 1.38 0.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.95 69 999999999 0.84 1.34 percent of total billed charges LACTULOSE 20 GM/30 ML SOLN CUP 49454377_1 CDM 0250 RC 00121-1154-40 NDC inpatient 1 UN 1.38 0.9 SIHO - ALL PLANS SIHO - ALL PLANS 1.24 90 999999999 0.84 1.34 percent of total billed charges LACTULOSE 20 GM/30 ML SOLN CUP 49454377_1 CDM 0250 RC 00121-1154-40 NDC inpatient 1 UN 1.38 0.9 UMR - ALL PLANS UMR - ALL PLANS 0.97 70 999999999 0.84 1.34 percent of total billed charges LACTULOSE 20 GM/30 ML SOLN CUP 49454377_1 CDM 0250 RC 00121-1154-40 NDC inpatient 1 UN 1.38 0.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.84 60.55 999999999 0.84 1.34 percent of total billed charges LACTULOSE 20 GM/30 ML SOLN CUP 49454377_1 CDM 0250 RC 00121-1154-40 NDC inpatient 1 UN 1.38 0.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.84 1.34 LACTULOSE 20 GM/30 ML SOLN CUP 49454377_1 CDM 0250 RC 00121-1154-40 NDC inpatient 1 UN 1.38 0.9 ANTHEM HMO ANTHEM HMO 999999999 0.84 1.34 LACTULOSE 20 GM/30 ML SOLN CUP 49454377_1 CDM 0250 RC 00121-1154-40 NDC inpatient 1 UN 1.38 0.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.84 1.34 LACTULOSE 20 GM/30 ML SOLN CUP 49454377_1 CDM 0250 RC 00121-1154-40 NDC inpatient 1 UN 1.38 0.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.93 67.6 999999999 0.84 1.34 percent of total billed charges LACTULOSE 20 GM/30 ML SOLN CUP 49454377_1 CDM 0250 RC 00121-1154-40 NDC inpatient 1 UN 1.38 0.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.84 1.34 LACTULOSE 20 GM/30 ML SOLN CUP 49454377_1 CDM 0250 RC 00121-1154-40 NDC inpatient 1 UN 1.38 0.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.84 1.34 Pap test 49454434_1 CDM 0310 RC 88141 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges Pap test 49454434_1 CDM 0310 RC 88141 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges Pap test 49454434_1 CDM 0310 RC 88141 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges Pap test 49454434_1 CDM 0310 RC 88141 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges Pap test 49454434_1 CDM 0310 RC 88141 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges Pap test 49454434_1 CDM 0310 RC 88141 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges Pap test 49454434_1 CDM 0310 RC 88141 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges Pap test 49454434_1 CDM 0310 RC 88141 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges Pap test 49454434_1 CDM 0310 RC 88141 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 Pap test 49454434_1 CDM 0310 RC 88141 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 Pap test 49454434_1 CDM 0310 RC 88141 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 Pap test 49454434_1 CDM 0310 RC 88141 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges Pap test 49454434_1 CDM 0310 RC 88141 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 Pap test 49454434_1 CDM 0310 RC 88141 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 "Identification of organisms by genetic analysis, direct probe technique" 49454703_1 CDM 0310 RC 87149 HCPCS inpatient 211 137.15 AETNA AETNA 166.69 79 999999999 127.76 204.67 percent of total billed charges "Identification of organisms by genetic analysis, direct probe technique" 49454703_1 CDM 0310 RC 87149 HCPCS inpatient 211 137.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 137.15 65 999999999 127.76 204.67 percent of total billed charges "Identification of organisms by genetic analysis, direct probe technique" 49454703_1 CDM 0310 RC 87149 HCPCS inpatient 211 137.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 204.67 97 999999999 127.76 204.67 percent of total billed charges "Identification of organisms by genetic analysis, direct probe technique" 49454703_1 CDM 0310 RC 87149 HCPCS inpatient 211 137.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 164.58 78 999999999 127.76 204.67 percent of total billed charges "Identification of organisms by genetic analysis, direct probe technique" 49454703_1 CDM 0310 RC 87149 HCPCS inpatient 211 137.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 145.59 69 999999999 127.76 204.67 percent of total billed charges "Identification of organisms by genetic analysis, direct probe technique" 49454703_1 CDM 0310 RC 87149 HCPCS inpatient 211 137.15 SIHO - ALL PLANS SIHO - ALL PLANS 189.9 90 999999999 127.76 204.67 percent of total billed charges "Identification of organisms by genetic analysis, direct probe technique" 49454703_1 CDM 0310 RC 87149 HCPCS inpatient 211 137.15 UMR - ALL PLANS UMR - ALL PLANS 147.7 70 999999999 127.76 204.67 percent of total billed charges "Identification of organisms by genetic analysis, direct probe technique" 49454703_1 CDM 0310 RC 87149 HCPCS inpatient 211 137.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.76 60.55 999999999 127.76 204.67 percent of total billed charges "Identification of organisms by genetic analysis, direct probe technique" 49454703_1 CDM 0310 RC 87149 HCPCS inpatient 211 137.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.76 204.67 "Identification of organisms by genetic analysis, direct probe technique" 49454703_1 CDM 0310 RC 87149 HCPCS inpatient 211 137.15 ANTHEM HMO ANTHEM HMO 999999999 127.76 204.67 "Identification of organisms by genetic analysis, direct probe technique" 49454703_1 CDM 0310 RC 87149 HCPCS inpatient 211 137.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.76 204.67 "Identification of organisms by genetic analysis, direct probe technique" 49454703_1 CDM 0310 RC 87149 HCPCS inpatient 211 137.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 142.64 67.6 999999999 127.76 204.67 percent of total billed charges "Identification of organisms by genetic analysis, direct probe technique" 49454703_1 CDM 0310 RC 87149 HCPCS inpatient 211 137.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.76 204.67 "Identification of organisms by genetic analysis, direct probe technique" 49454703_1 CDM 0310 RC 87149 HCPCS inpatient 211 137.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.76 204.67 "INJECTION, MEROPENEM, 100 MG" 49455814_1 CDM 0250 RC 00264-3185-11 NDC J2185 HCPCS inpatient 1 UN 125.89 81.83 AETNA AETNA 99.45 79 999999999 76.23 122.11 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 49455814_1 CDM 0250 RC 00264-3185-11 NDC J2185 HCPCS inpatient 1 UN 125.89 81.83 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.83 65 999999999 76.23 122.11 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 49455814_1 CDM 0250 RC 00264-3185-11 NDC J2185 HCPCS inpatient 1 UN 125.89 81.83 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 122.11 97 999999999 76.23 122.11 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 49455814_1 CDM 0250 RC 00264-3185-11 NDC J2185 HCPCS inpatient 1 UN 125.89 81.83 HUMANA - ALL PLANS HUMANA - ALL PLANS 98.19 78 999999999 76.23 122.11 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 49455814_1 CDM 0250 RC 00264-3185-11 NDC J2185 HCPCS inpatient 1 UN 125.89 81.83 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.86 69 999999999 76.23 122.11 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 49455814_1 CDM 0250 RC 00264-3185-11 NDC J2185 HCPCS inpatient 1 UN 125.89 81.83 SIHO - ALL PLANS SIHO - ALL PLANS 113.3 90 999999999 76.23 122.11 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 49455814_1 CDM 0250 RC 00264-3185-11 NDC J2185 HCPCS inpatient 1 UN 125.89 81.83 UMR - ALL PLANS UMR - ALL PLANS 88.12 70 999999999 76.23 122.11 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 49455814_1 CDM 0250 RC 00264-3185-11 NDC J2185 HCPCS inpatient 1 UN 125.89 81.83 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.23 60.55 999999999 76.23 122.11 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 49455814_1 CDM 0250 RC 00264-3185-11 NDC J2185 HCPCS inpatient 1 UN 125.89 81.83 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.23 122.11 "INJECTION, MEROPENEM, 100 MG" 49455814_1 CDM 0250 RC 00264-3185-11 NDC J2185 HCPCS inpatient 1 UN 125.89 81.83 ANTHEM HMO ANTHEM HMO 999999999 76.23 122.11 "INJECTION, MEROPENEM, 100 MG" 49455814_1 CDM 0250 RC 00264-3185-11 NDC J2185 HCPCS inpatient 1 UN 125.89 81.83 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.23 122.11 "INJECTION, MEROPENEM, 100 MG" 49455814_1 CDM 0250 RC 00264-3185-11 NDC J2185 HCPCS inpatient 1 UN 125.89 81.83 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.1 67.6 999999999 76.23 122.11 percent of total billed charges "INJECTION, MEROPENEM, 100 MG" 49455814_1 CDM 0250 RC 00264-3185-11 NDC J2185 HCPCS inpatient 1 UN 125.89 81.83 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.23 122.11 "INJECTION, MEROPENEM, 100 MG" 49455814_1 CDM 0250 RC 00264-3185-11 NDC J2185 HCPCS inpatient 1 UN 125.89 81.83 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.23 122.11 DEXTROSE 50%-WATER VIAL 49455837_1 CDM 0250 RC 00409-6648-02 NDC inpatient 1 UN 53.55 34.81 AETNA AETNA 42.3 79 999999999 32.42 51.94 percent of total billed charges DEXTROSE 50%-WATER VIAL 49455837_1 CDM 0250 RC 00409-6648-02 NDC inpatient 1 UN 53.55 34.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.81 65 999999999 32.42 51.94 percent of total billed charges DEXTROSE 50%-WATER VIAL 49455837_1 CDM 0250 RC 00409-6648-02 NDC inpatient 1 UN 53.55 34.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.94 97 999999999 32.42 51.94 percent of total billed charges DEXTROSE 50%-WATER VIAL 49455837_1 CDM 0250 RC 00409-6648-02 NDC inpatient 1 UN 53.55 34.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.77 78 999999999 32.42 51.94 percent of total billed charges DEXTROSE 50%-WATER VIAL 49455837_1 CDM 0250 RC 00409-6648-02 NDC inpatient 1 UN 53.55 34.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.95 69 999999999 32.42 51.94 percent of total billed charges DEXTROSE 50%-WATER VIAL 49455837_1 CDM 0250 RC 00409-6648-02 NDC inpatient 1 UN 53.55 34.81 SIHO - ALL PLANS SIHO - ALL PLANS 48.2 90 999999999 32.42 51.94 percent of total billed charges DEXTROSE 50%-WATER VIAL 49455837_1 CDM 0250 RC 00409-6648-02 NDC inpatient 1 UN 53.55 34.81 UMR - ALL PLANS UMR - ALL PLANS 37.49 70 999999999 32.42 51.94 percent of total billed charges DEXTROSE 50%-WATER VIAL 49455837_1 CDM 0250 RC 00409-6648-02 NDC inpatient 1 UN 53.55 34.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.42 60.55 999999999 32.42 51.94 percent of total billed charges DEXTROSE 50%-WATER VIAL 49455837_1 CDM 0250 RC 00409-6648-02 NDC inpatient 1 UN 53.55 34.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.42 51.94 DEXTROSE 50%-WATER VIAL 49455837_1 CDM 0250 RC 00409-6648-02 NDC inpatient 1 UN 53.55 34.81 ANTHEM HMO ANTHEM HMO 999999999 32.42 51.94 DEXTROSE 50%-WATER VIAL 49455837_1 CDM 0250 RC 00409-6648-02 NDC inpatient 1 UN 53.55 34.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.42 51.94 DEXTROSE 50%-WATER VIAL 49455837_1 CDM 0250 RC 00409-6648-02 NDC inpatient 1 UN 53.55 34.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 36.2 67.6 999999999 32.42 51.94 percent of total billed charges DEXTROSE 50%-WATER VIAL 49455837_1 CDM 0250 RC 00409-6648-02 NDC inpatient 1 UN 53.55 34.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.42 51.94 DEXTROSE 50%-WATER VIAL 49455837_1 CDM 0250 RC 00409-6648-02 NDC inpatient 1 UN 53.55 34.81 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.42 51.94 68462-0358-01 - nabumetone 500 mg Tab[JOHN] 49455909_1 CDM 0250 RC 68462-0358-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 68462-0358-01 - nabumetone 500 mg Tab[JOHN] 49455909_1 CDM 0250 RC 68462-0358-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 68462-0358-01 - nabumetone 500 mg Tab[JOHN] 49455909_1 CDM 0250 RC 68462-0358-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 68462-0358-01 - nabumetone 500 mg Tab[JOHN] 49455909_1 CDM 0250 RC 68462-0358-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 68462-0358-01 - nabumetone 500 mg Tab[JOHN] 49455909_1 CDM 0250 RC 68462-0358-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 68462-0358-01 - nabumetone 500 mg Tab[JOHN] 49455909_1 CDM 0250 RC 68462-0358-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 68462-0358-01 - nabumetone 500 mg Tab[JOHN] 49455909_1 CDM 0250 RC 68462-0358-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 68462-0358-01 - nabumetone 500 mg Tab[JOHN] 49455909_1 CDM 0250 RC 68462-0358-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 68462-0358-01 - nabumetone 500 mg Tab[JOHN] 49455909_1 CDM 0250 RC 68462-0358-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 68462-0358-01 - nabumetone 500 mg Tab[JOHN] 49455909_1 CDM 0250 RC 68462-0358-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 68462-0358-01 - nabumetone 500 mg Tab[JOHN] 49455909_1 CDM 0250 RC 68462-0358-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 68462-0358-01 - nabumetone 500 mg Tab[JOHN] 49455909_1 CDM 0250 RC 68462-0358-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 68462-0358-01 - nabumetone 500 mg Tab[JOHN] 49455909_1 CDM 0250 RC 68462-0358-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 68462-0358-01 - nabumetone 500 mg Tab[JOHN] 49455909_1 CDM 0250 RC 68462-0358-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 OXYBUTYNIN CL ER 5 MG TABLET 49455911_1 CDM 0250 RC 62175-0270-37 NDC inpatient 1 UN 1.51 0.98 AETNA AETNA 1.19 79 999999999 0.91 1.46 percent of total billed charges OXYBUTYNIN CL ER 5 MG TABLET 49455911_1 CDM 0250 RC 62175-0270-37 NDC inpatient 1 UN 1.51 0.98 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.98 65 999999999 0.91 1.46 percent of total billed charges OXYBUTYNIN CL ER 5 MG TABLET 49455911_1 CDM 0250 RC 62175-0270-37 NDC inpatient 1 UN 1.51 0.98 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.46 97 999999999 0.91 1.46 percent of total billed charges OXYBUTYNIN CL ER 5 MG TABLET 49455911_1 CDM 0250 RC 62175-0270-37 NDC inpatient 1 UN 1.51 0.98 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.18 78 999999999 0.91 1.46 percent of total billed charges OXYBUTYNIN CL ER 5 MG TABLET 49455911_1 CDM 0250 RC 62175-0270-37 NDC inpatient 1 UN 1.51 0.98 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.04 69 999999999 0.91 1.46 percent of total billed charges OXYBUTYNIN CL ER 5 MG TABLET 49455911_1 CDM 0250 RC 62175-0270-37 NDC inpatient 1 UN 1.51 0.98 SIHO - ALL PLANS SIHO - ALL PLANS 1.36 90 999999999 0.91 1.46 percent of total billed charges OXYBUTYNIN CL ER 5 MG TABLET 49455911_1 CDM 0250 RC 62175-0270-37 NDC inpatient 1 UN 1.51 0.98 UMR - ALL PLANS UMR - ALL PLANS 1.06 70 999999999 0.91 1.46 percent of total billed charges OXYBUTYNIN CL ER 5 MG TABLET 49455911_1 CDM 0250 RC 62175-0270-37 NDC inpatient 1 UN 1.51 0.98 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.91 60.55 999999999 0.91 1.46 percent of total billed charges OXYBUTYNIN CL ER 5 MG TABLET 49455911_1 CDM 0250 RC 62175-0270-37 NDC inpatient 1 UN 1.51 0.98 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.91 1.46 OXYBUTYNIN CL ER 5 MG TABLET 49455911_1 CDM 0250 RC 62175-0270-37 NDC inpatient 1 UN 1.51 0.98 ANTHEM HMO ANTHEM HMO 999999999 0.91 1.46 OXYBUTYNIN CL ER 5 MG TABLET 49455911_1 CDM 0250 RC 62175-0270-37 NDC inpatient 1 UN 1.51 0.98 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.91 1.46 OXYBUTYNIN CL ER 5 MG TABLET 49455911_1 CDM 0250 RC 62175-0270-37 NDC inpatient 1 UN 1.51 0.98 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.02 67.6 999999999 0.91 1.46 percent of total billed charges OXYBUTYNIN CL ER 5 MG TABLET 49455911_1 CDM 0250 RC 62175-0270-37 NDC inpatient 1 UN 1.51 0.98 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.91 1.46 OXYBUTYNIN CL ER 5 MG TABLET 49455911_1 CDM 0250 RC 62175-0270-37 NDC inpatient 1 UN 1.51 0.98 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.91 1.46 OLANZAPINE 5 MG TABLET 49455912_1 CDM 0250 RC 43598-0164-30 NDC inpatient 1 UN 1.07 0.7 AETNA AETNA 0.85 79 999999999 0.65 1.04 percent of total billed charges OLANZAPINE 5 MG TABLET 49455912_1 CDM 0250 RC 43598-0164-30 NDC inpatient 1 UN 1.07 0.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.7 65 999999999 0.65 1.04 percent of total billed charges OLANZAPINE 5 MG TABLET 49455912_1 CDM 0250 RC 43598-0164-30 NDC inpatient 1 UN 1.07 0.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.04 97 999999999 0.65 1.04 percent of total billed charges OLANZAPINE 5 MG TABLET 49455912_1 CDM 0250 RC 43598-0164-30 NDC inpatient 1 UN 1.07 0.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.83 78 999999999 0.65 1.04 percent of total billed charges OLANZAPINE 5 MG TABLET 49455912_1 CDM 0250 RC 43598-0164-30 NDC inpatient 1 UN 1.07 0.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.74 69 999999999 0.65 1.04 percent of total billed charges OLANZAPINE 5 MG TABLET 49455912_1 CDM 0250 RC 43598-0164-30 NDC inpatient 1 UN 1.07 0.7 SIHO - ALL PLANS SIHO - ALL PLANS 0.96 90 999999999 0.65 1.04 percent of total billed charges OLANZAPINE 5 MG TABLET 49455912_1 CDM 0250 RC 43598-0164-30 NDC inpatient 1 UN 1.07 0.7 UMR - ALL PLANS UMR - ALL PLANS 0.75 70 999999999 0.65 1.04 percent of total billed charges OLANZAPINE 5 MG TABLET 49455912_1 CDM 0250 RC 43598-0164-30 NDC inpatient 1 UN 1.07 0.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.65 60.55 999999999 0.65 1.04 percent of total billed charges OLANZAPINE 5 MG TABLET 49455912_1 CDM 0250 RC 43598-0164-30 NDC inpatient 1 UN 1.07 0.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.65 1.04 OLANZAPINE 5 MG TABLET 49455912_1 CDM 0250 RC 43598-0164-30 NDC inpatient 1 UN 1.07 0.7 ANTHEM HMO ANTHEM HMO 999999999 0.65 1.04 OLANZAPINE 5 MG TABLET 49455912_1 CDM 0250 RC 43598-0164-30 NDC inpatient 1 UN 1.07 0.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.65 1.04 OLANZAPINE 5 MG TABLET 49455912_1 CDM 0250 RC 43598-0164-30 NDC inpatient 1 UN 1.07 0.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.72 67.6 999999999 0.65 1.04 percent of total billed charges OLANZAPINE 5 MG TABLET 49455912_1 CDM 0250 RC 43598-0164-30 NDC inpatient 1 UN 1.07 0.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.65 1.04 OLANZAPINE 5 MG TABLET 49455912_1 CDM 0250 RC 43598-0164-30 NDC inpatient 1 UN 1.07 0.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.65 1.04 VERAPAMIL SR 120 MG CAPSULE 49455916_1 CDM 0250 RC 00591-2880-01 NDC inpatient 1 UN 4.82 3.13 AETNA AETNA 3.81 79 999999999 2.92 4.68 percent of total billed charges VERAPAMIL SR 120 MG CAPSULE 49455916_1 CDM 0250 RC 00591-2880-01 NDC inpatient 1 UN 4.82 3.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.13 65 999999999 2.92 4.68 percent of total billed charges VERAPAMIL SR 120 MG CAPSULE 49455916_1 CDM 0250 RC 00591-2880-01 NDC inpatient 1 UN 4.82 3.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4.68 97 999999999 2.92 4.68 percent of total billed charges VERAPAMIL SR 120 MG CAPSULE 49455916_1 CDM 0250 RC 00591-2880-01 NDC inpatient 1 UN 4.82 3.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.76 78 999999999 2.92 4.68 percent of total billed charges VERAPAMIL SR 120 MG CAPSULE 49455916_1 CDM 0250 RC 00591-2880-01 NDC inpatient 1 UN 4.82 3.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.33 69 999999999 2.92 4.68 percent of total billed charges VERAPAMIL SR 120 MG CAPSULE 49455916_1 CDM 0250 RC 00591-2880-01 NDC inpatient 1 UN 4.82 3.13 SIHO - ALL PLANS SIHO - ALL PLANS 4.34 90 999999999 2.92 4.68 percent of total billed charges VERAPAMIL SR 120 MG CAPSULE 49455916_1 CDM 0250 RC 00591-2880-01 NDC inpatient 1 UN 4.82 3.13 UMR - ALL PLANS UMR - ALL PLANS 3.37 70 999999999 2.92 4.68 percent of total billed charges VERAPAMIL SR 120 MG CAPSULE 49455916_1 CDM 0250 RC 00591-2880-01 NDC inpatient 1 UN 4.82 3.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.92 60.55 999999999 2.92 4.68 percent of total billed charges VERAPAMIL SR 120 MG CAPSULE 49455916_1 CDM 0250 RC 00591-2880-01 NDC inpatient 1 UN 4.82 3.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.92 4.68 VERAPAMIL SR 120 MG CAPSULE 49455916_1 CDM 0250 RC 00591-2880-01 NDC inpatient 1 UN 4.82 3.13 ANTHEM HMO ANTHEM HMO 999999999 2.92 4.68 VERAPAMIL SR 120 MG CAPSULE 49455916_1 CDM 0250 RC 00591-2880-01 NDC inpatient 1 UN 4.82 3.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.92 4.68 VERAPAMIL SR 120 MG CAPSULE 49455916_1 CDM 0250 RC 00591-2880-01 NDC inpatient 1 UN 4.82 3.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.26 67.6 999999999 2.92 4.68 percent of total billed charges VERAPAMIL SR 120 MG CAPSULE 49455916_1 CDM 0250 RC 00591-2880-01 NDC inpatient 1 UN 4.82 3.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.92 4.68 VERAPAMIL SR 120 MG CAPSULE 49455916_1 CDM 0250 RC 00591-2880-01 NDC inpatient 1 UN 4.82 3.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.92 4.68 TOLTERODINE TART ER 4 MG CAP 49455922_1 CDM 0250 RC 00093-7164-56 NDC inpatient 1 UN 9.99 6.49 AETNA AETNA 7.89 79 999999999 6.05 9.69 percent of total billed charges TOLTERODINE TART ER 4 MG CAP 49455922_1 CDM 0250 RC 00093-7164-56 NDC inpatient 1 UN 9.99 6.49 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.49 65 999999999 6.05 9.69 percent of total billed charges TOLTERODINE TART ER 4 MG CAP 49455922_1 CDM 0250 RC 00093-7164-56 NDC inpatient 1 UN 9.99 6.49 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.69 97 999999999 6.05 9.69 percent of total billed charges TOLTERODINE TART ER 4 MG CAP 49455922_1 CDM 0250 RC 00093-7164-56 NDC inpatient 1 UN 9.99 6.49 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.79 78 999999999 6.05 9.69 percent of total billed charges TOLTERODINE TART ER 4 MG CAP 49455922_1 CDM 0250 RC 00093-7164-56 NDC inpatient 1 UN 9.99 6.49 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.89 69 999999999 6.05 9.69 percent of total billed charges TOLTERODINE TART ER 4 MG CAP 49455922_1 CDM 0250 RC 00093-7164-56 NDC inpatient 1 UN 9.99 6.49 SIHO - ALL PLANS SIHO - ALL PLANS 8.99 90 999999999 6.05 9.69 percent of total billed charges TOLTERODINE TART ER 4 MG CAP 49455922_1 CDM 0250 RC 00093-7164-56 NDC inpatient 1 UN 9.99 6.49 UMR - ALL PLANS UMR - ALL PLANS 6.99 70 999999999 6.05 9.69 percent of total billed charges TOLTERODINE TART ER 4 MG CAP 49455922_1 CDM 0250 RC 00093-7164-56 NDC inpatient 1 UN 9.99 6.49 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.05 60.55 999999999 6.05 9.69 percent of total billed charges TOLTERODINE TART ER 4 MG CAP 49455922_1 CDM 0250 RC 00093-7164-56 NDC inpatient 1 UN 9.99 6.49 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.05 9.69 TOLTERODINE TART ER 4 MG CAP 49455922_1 CDM 0250 RC 00093-7164-56 NDC inpatient 1 UN 9.99 6.49 ANTHEM HMO ANTHEM HMO 999999999 6.05 9.69 TOLTERODINE TART ER 4 MG CAP 49455922_1 CDM 0250 RC 00093-7164-56 NDC inpatient 1 UN 9.99 6.49 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.05 9.69 TOLTERODINE TART ER 4 MG CAP 49455922_1 CDM 0250 RC 00093-7164-56 NDC inpatient 1 UN 9.99 6.49 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.75 67.6 999999999 6.05 9.69 percent of total billed charges TOLTERODINE TART ER 4 MG CAP 49455922_1 CDM 0250 RC 00093-7164-56 NDC inpatient 1 UN 9.99 6.49 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.05 9.69 TOLTERODINE TART ER 4 MG CAP 49455922_1 CDM 0250 RC 00093-7164-56 NDC inpatient 1 UN 9.99 6.49 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.05 9.69 PHENYLEPHRINE 10% EYE DROPS 49455931_1 CDM 0250 RC 17478-0206-05 NDC inpatient 1 UN 86.73 56.37 AETNA AETNA 68.52 79 999999999 52.52 84.13 percent of total billed charges PHENYLEPHRINE 10% EYE DROPS 49455931_1 CDM 0250 RC 17478-0206-05 NDC inpatient 1 UN 86.73 56.37 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.37 65 999999999 52.52 84.13 percent of total billed charges PHENYLEPHRINE 10% EYE DROPS 49455931_1 CDM 0250 RC 17478-0206-05 NDC inpatient 1 UN 86.73 56.37 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.13 97 999999999 52.52 84.13 percent of total billed charges PHENYLEPHRINE 10% EYE DROPS 49455931_1 CDM 0250 RC 17478-0206-05 NDC inpatient 1 UN 86.73 56.37 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.65 78 999999999 52.52 84.13 percent of total billed charges PHENYLEPHRINE 10% EYE DROPS 49455931_1 CDM 0250 RC 17478-0206-05 NDC inpatient 1 UN 86.73 56.37 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.84 69 999999999 52.52 84.13 percent of total billed charges PHENYLEPHRINE 10% EYE DROPS 49455931_1 CDM 0250 RC 17478-0206-05 NDC inpatient 1 UN 86.73 56.37 SIHO - ALL PLANS SIHO - ALL PLANS 78.06 90 999999999 52.52 84.13 percent of total billed charges PHENYLEPHRINE 10% EYE DROPS 49455931_1 CDM 0250 RC 17478-0206-05 NDC inpatient 1 UN 86.73 56.37 UMR - ALL PLANS UMR - ALL PLANS 60.71 70 999999999 52.52 84.13 percent of total billed charges PHENYLEPHRINE 10% EYE DROPS 49455931_1 CDM 0250 RC 17478-0206-05 NDC inpatient 1 UN 86.73 56.37 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.52 60.55 999999999 52.52 84.13 percent of total billed charges PHENYLEPHRINE 10% EYE DROPS 49455931_1 CDM 0250 RC 17478-0206-05 NDC inpatient 1 UN 86.73 56.37 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.52 84.13 PHENYLEPHRINE 10% EYE DROPS 49455931_1 CDM 0250 RC 17478-0206-05 NDC inpatient 1 UN 86.73 56.37 ANTHEM HMO ANTHEM HMO 999999999 52.52 84.13 PHENYLEPHRINE 10% EYE DROPS 49455931_1 CDM 0250 RC 17478-0206-05 NDC inpatient 1 UN 86.73 56.37 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.52 84.13 PHENYLEPHRINE 10% EYE DROPS 49455931_1 CDM 0250 RC 17478-0206-05 NDC inpatient 1 UN 86.73 56.37 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.63 67.6 999999999 52.52 84.13 percent of total billed charges PHENYLEPHRINE 10% EYE DROPS 49455931_1 CDM 0250 RC 17478-0206-05 NDC inpatient 1 UN 86.73 56.37 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.52 84.13 PHENYLEPHRINE 10% EYE DROPS 49455931_1 CDM 0250 RC 17478-0206-05 NDC inpatient 1 UN 86.73 56.37 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.52 84.13 Detection test by immunoassay with direct visual observation for other organism 49456704_1 CDM 0301 RC 87899 HCPCS inpatient 134 87.1 AETNA AETNA 105.86 79 999999999 81.14 129.98 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 49456704_1 CDM 0301 RC 87899 HCPCS inpatient 134 87.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 87.1 65 999999999 81.14 129.98 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 49456704_1 CDM 0301 RC 87899 HCPCS inpatient 134 87.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.98 97 999999999 81.14 129.98 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 49456704_1 CDM 0301 RC 87899 HCPCS inpatient 134 87.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 104.52 78 999999999 81.14 129.98 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 49456704_1 CDM 0301 RC 87899 HCPCS inpatient 134 87.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 92.46 69 999999999 81.14 129.98 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 49456704_1 CDM 0301 RC 87899 HCPCS inpatient 134 87.1 SIHO - ALL PLANS SIHO - ALL PLANS 120.6 90 999999999 81.14 129.98 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 49456704_1 CDM 0301 RC 87899 HCPCS inpatient 134 87.1 UMR - ALL PLANS UMR - ALL PLANS 93.8 70 999999999 81.14 129.98 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 49456704_1 CDM 0301 RC 87899 HCPCS inpatient 134 87.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 81.14 60.55 999999999 81.14 129.98 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 49456704_1 CDM 0301 RC 87899 HCPCS inpatient 134 87.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 81.14 129.98 Detection test by immunoassay with direct visual observation for other organism 49456704_1 CDM 0301 RC 87899 HCPCS inpatient 134 87.1 ANTHEM HMO ANTHEM HMO 999999999 81.14 129.98 Detection test by immunoassay with direct visual observation for other organism 49456704_1 CDM 0301 RC 87899 HCPCS inpatient 134 87.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 81.14 129.98 Detection test by immunoassay with direct visual observation for other organism 49456704_1 CDM 0301 RC 87899 HCPCS inpatient 134 87.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 90.58 67.6 999999999 81.14 129.98 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 49456704_1 CDM 0301 RC 87899 HCPCS inpatient 134 87.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 81.14 129.98 Detection test by immunoassay with direct visual observation for other organism 49456704_1 CDM 0301 RC 87899 HCPCS inpatient 134 87.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 81.14 129.98 Closed treatment of dislocated shoulder with manipulation 49456760_1 CDM 0450 RC 23650 HCPCS inpatient 386 250.9 AETNA AETNA 304.94 79 999999999 233.72 374.42 percent of total billed charges Closed treatment of dislocated shoulder with manipulation 49456760_1 CDM 0450 RC 23650 HCPCS inpatient 386 250.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 250.9 65 999999999 233.72 374.42 percent of total billed charges Closed treatment of dislocated shoulder with manipulation 49456760_1 CDM 0450 RC 23650 HCPCS inpatient 386 250.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 374.42 97 999999999 233.72 374.42 percent of total billed charges Closed treatment of dislocated shoulder with manipulation 49456760_1 CDM 0450 RC 23650 HCPCS inpatient 386 250.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 301.08 78 999999999 233.72 374.42 percent of total billed charges Closed treatment of dislocated shoulder with manipulation 49456760_1 CDM 0450 RC 23650 HCPCS inpatient 386 250.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 266.34 69 999999999 233.72 374.42 percent of total billed charges Closed treatment of dislocated shoulder with manipulation 49456760_1 CDM 0450 RC 23650 HCPCS inpatient 386 250.9 SIHO - ALL PLANS SIHO - ALL PLANS 347.4 90 999999999 233.72 374.42 percent of total billed charges Closed treatment of dislocated shoulder with manipulation 49456760_1 CDM 0450 RC 23650 HCPCS inpatient 386 250.9 UMR - ALL PLANS UMR - ALL PLANS 270.2 70 999999999 233.72 374.42 percent of total billed charges Closed treatment of dislocated shoulder with manipulation 49456760_1 CDM 0450 RC 23650 HCPCS inpatient 386 250.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 233.72 60.55 999999999 233.72 374.42 percent of total billed charges Closed treatment of dislocated shoulder with manipulation 49456760_1 CDM 0450 RC 23650 HCPCS inpatient 386 250.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 233.72 374.42 Closed treatment of dislocated shoulder with manipulation 49456760_1 CDM 0450 RC 23650 HCPCS inpatient 386 250.9 ANTHEM HMO ANTHEM HMO 999999999 233.72 374.42 Closed treatment of dislocated shoulder with manipulation 49456760_1 CDM 0450 RC 23650 HCPCS inpatient 386 250.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 233.72 374.42 Closed treatment of dislocated shoulder with manipulation 49456760_1 CDM 0450 RC 23650 HCPCS inpatient 386 250.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 260.94 67.6 999999999 233.72 374.42 percent of total billed charges Closed treatment of dislocated shoulder with manipulation 49456760_1 CDM 0450 RC 23650 HCPCS inpatient 386 250.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 233.72 374.42 Closed treatment of dislocated shoulder with manipulation 49456760_1 CDM 0450 RC 23650 HCPCS inpatient 386 250.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 233.72 374.42 Application of short leg splint from calf to foot 49456761_1 CDM 0450 RC 29515 HCPCS inpatient 261 169.65 AETNA AETNA 206.19 79 999999999 158.04 253.17 percent of total billed charges Application of short leg splint from calf to foot 49456761_1 CDM 0450 RC 29515 HCPCS inpatient 261 169.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 169.65 65 999999999 158.04 253.17 percent of total billed charges Application of short leg splint from calf to foot 49456761_1 CDM 0450 RC 29515 HCPCS inpatient 261 169.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 253.17 97 999999999 158.04 253.17 percent of total billed charges Application of short leg splint from calf to foot 49456761_1 CDM 0450 RC 29515 HCPCS inpatient 261 169.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 203.58 78 999999999 158.04 253.17 percent of total billed charges Application of short leg splint from calf to foot 49456761_1 CDM 0450 RC 29515 HCPCS inpatient 261 169.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.09 69 999999999 158.04 253.17 percent of total billed charges Application of short leg splint from calf to foot 49456761_1 CDM 0450 RC 29515 HCPCS inpatient 261 169.65 SIHO - ALL PLANS SIHO - ALL PLANS 234.9 90 999999999 158.04 253.17 percent of total billed charges Application of short leg splint from calf to foot 49456761_1 CDM 0450 RC 29515 HCPCS inpatient 261 169.65 UMR - ALL PLANS UMR - ALL PLANS 182.7 70 999999999 158.04 253.17 percent of total billed charges Application of short leg splint from calf to foot 49456761_1 CDM 0450 RC 29515 HCPCS inpatient 261 169.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.04 60.55 999999999 158.04 253.17 percent of total billed charges Application of short leg splint from calf to foot 49456761_1 CDM 0450 RC 29515 HCPCS inpatient 261 169.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.04 253.17 Application of short leg splint from calf to foot 49456761_1 CDM 0450 RC 29515 HCPCS inpatient 261 169.65 ANTHEM HMO ANTHEM HMO 999999999 158.04 253.17 Application of short leg splint from calf to foot 49456761_1 CDM 0450 RC 29515 HCPCS inpatient 261 169.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.04 253.17 Application of short leg splint from calf to foot 49456761_1 CDM 0450 RC 29515 HCPCS inpatient 261 169.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 176.44 67.6 999999999 158.04 253.17 percent of total billed charges Application of short leg splint from calf to foot 49456761_1 CDM 0450 RC 29515 HCPCS inpatient 261 169.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.04 253.17 Application of short leg splint from calf to foot 49456761_1 CDM 0450 RC 29515 HCPCS inpatient 261 169.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.04 253.17 Application of nonmoveable forearm to hand splint 49456762_1 CDM 0450 RC 29125 HCPCS inpatient 404 262.6 AETNA AETNA 319.16 79 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable forearm to hand splint 49456762_1 CDM 0450 RC 29125 HCPCS inpatient 404 262.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 262.6 65 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable forearm to hand splint 49456762_1 CDM 0450 RC 29125 HCPCS inpatient 404 262.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 391.88 97 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable forearm to hand splint 49456762_1 CDM 0450 RC 29125 HCPCS inpatient 404 262.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 315.12 78 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable forearm to hand splint 49456762_1 CDM 0450 RC 29125 HCPCS inpatient 404 262.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 278.76 69 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable forearm to hand splint 49456762_1 CDM 0450 RC 29125 HCPCS inpatient 404 262.6 SIHO - ALL PLANS SIHO - ALL PLANS 363.6 90 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable forearm to hand splint 49456762_1 CDM 0450 RC 29125 HCPCS inpatient 404 262.6 UMR - ALL PLANS UMR - ALL PLANS 282.8 70 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable forearm to hand splint 49456762_1 CDM 0450 RC 29125 HCPCS inpatient 404 262.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 244.62 60.55 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable forearm to hand splint 49456762_1 CDM 0450 RC 29125 HCPCS inpatient 404 262.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 244.62 391.88 Application of nonmoveable forearm to hand splint 49456762_1 CDM 0450 RC 29125 HCPCS inpatient 404 262.6 ANTHEM HMO ANTHEM HMO 999999999 244.62 391.88 Application of nonmoveable forearm to hand splint 49456762_1 CDM 0450 RC 29125 HCPCS inpatient 404 262.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 244.62 391.88 Application of nonmoveable forearm to hand splint 49456762_1 CDM 0450 RC 29125 HCPCS inpatient 404 262.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 273.1 67.6 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable forearm to hand splint 49456762_1 CDM 0450 RC 29125 HCPCS inpatient 404 262.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 244.62 391.88 Application of nonmoveable forearm to hand splint 49456762_1 CDM 0450 RC 29125 HCPCS inpatient 404 262.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 244.62 391.88 Application of long leg splint from thigh to ankle or toe 49456763_1 CDM 0450 RC 29505 HCPCS inpatient 261 169.65 AETNA AETNA 206.19 79 999999999 158.04 253.17 percent of total billed charges Application of long leg splint from thigh to ankle or toe 49456763_1 CDM 0450 RC 29505 HCPCS inpatient 261 169.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 169.65 65 999999999 158.04 253.17 percent of total billed charges Application of long leg splint from thigh to ankle or toe 49456763_1 CDM 0450 RC 29505 HCPCS inpatient 261 169.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 253.17 97 999999999 158.04 253.17 percent of total billed charges Application of long leg splint from thigh to ankle or toe 49456763_1 CDM 0450 RC 29505 HCPCS inpatient 261 169.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 203.58 78 999999999 158.04 253.17 percent of total billed charges Application of long leg splint from thigh to ankle or toe 49456763_1 CDM 0450 RC 29505 HCPCS inpatient 261 169.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.09 69 999999999 158.04 253.17 percent of total billed charges Application of long leg splint from thigh to ankle or toe 49456763_1 CDM 0450 RC 29505 HCPCS inpatient 261 169.65 SIHO - ALL PLANS SIHO - ALL PLANS 234.9 90 999999999 158.04 253.17 percent of total billed charges Application of long leg splint from thigh to ankle or toe 49456763_1 CDM 0450 RC 29505 HCPCS inpatient 261 169.65 UMR - ALL PLANS UMR - ALL PLANS 182.7 70 999999999 158.04 253.17 percent of total billed charges Application of long leg splint from thigh to ankle or toe 49456763_1 CDM 0450 RC 29505 HCPCS inpatient 261 169.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.04 60.55 999999999 158.04 253.17 percent of total billed charges Application of long leg splint from thigh to ankle or toe 49456763_1 CDM 0450 RC 29505 HCPCS inpatient 261 169.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.04 253.17 Application of long leg splint from thigh to ankle or toe 49456763_1 CDM 0450 RC 29505 HCPCS inpatient 261 169.65 ANTHEM HMO ANTHEM HMO 999999999 158.04 253.17 Application of long leg splint from thigh to ankle or toe 49456763_1 CDM 0450 RC 29505 HCPCS inpatient 261 169.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.04 253.17 Application of long leg splint from thigh to ankle or toe 49456763_1 CDM 0450 RC 29505 HCPCS inpatient 261 169.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 176.44 67.6 999999999 158.04 253.17 percent of total billed charges Application of long leg splint from thigh to ankle or toe 49456763_1 CDM 0450 RC 29505 HCPCS inpatient 261 169.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.04 253.17 Application of long leg splint from thigh to ankle or toe 49456763_1 CDM 0450 RC 29505 HCPCS inpatient 261 169.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.04 253.17 Application of lower and upper arm splint 49456764_1 CDM 0450 RC 29105 HCPCS inpatient 490 318.5 AETNA AETNA 387.1 79 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 49456764_1 CDM 0450 RC 29105 HCPCS inpatient 490 318.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 318.5 65 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 49456764_1 CDM 0450 RC 29105 HCPCS inpatient 490 318.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 475.3 97 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 49456764_1 CDM 0450 RC 29105 HCPCS inpatient 490 318.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 382.2 78 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 49456764_1 CDM 0450 RC 29105 HCPCS inpatient 490 318.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 338.1 69 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 49456764_1 CDM 0450 RC 29105 HCPCS inpatient 490 318.5 SIHO - ALL PLANS SIHO - ALL PLANS 441 90 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 49456764_1 CDM 0450 RC 29105 HCPCS inpatient 490 318.5 UMR - ALL PLANS UMR - ALL PLANS 343 70 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 49456764_1 CDM 0450 RC 29105 HCPCS inpatient 490 318.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 296.7 60.55 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 49456764_1 CDM 0450 RC 29105 HCPCS inpatient 490 318.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 296.7 475.3 Application of lower and upper arm splint 49456764_1 CDM 0450 RC 29105 HCPCS inpatient 490 318.5 ANTHEM HMO ANTHEM HMO 999999999 296.7 475.3 Application of lower and upper arm splint 49456764_1 CDM 0450 RC 29105 HCPCS inpatient 490 318.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 296.7 475.3 Application of lower and upper arm splint 49456764_1 CDM 0450 RC 29105 HCPCS inpatient 490 318.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 331.24 67.6 999999999 296.7 475.3 percent of total billed charges Application of lower and upper arm splint 49456764_1 CDM 0450 RC 29105 HCPCS inpatient 490 318.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 296.7 475.3 Application of lower and upper arm splint 49456764_1 CDM 0450 RC 29105 HCPCS inpatient 490 318.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 296.7 475.3 Application of nonmoveable finger splint 49456765_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 AETNA AETNA 319.16 79 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 49456765_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 262.6 65 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 49456765_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 391.88 97 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 49456765_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 315.12 78 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 49456765_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 278.76 69 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 49456765_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 SIHO - ALL PLANS SIHO - ALL PLANS 363.6 90 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 49456765_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 UMR - ALL PLANS UMR - ALL PLANS 282.8 70 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 49456765_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 244.62 60.55 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 49456765_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 244.62 391.88 Application of nonmoveable finger splint 49456765_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 ANTHEM HMO ANTHEM HMO 999999999 244.62 391.88 Application of nonmoveable finger splint 49456765_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 244.62 391.88 Application of nonmoveable finger splint 49456765_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 273.1 67.6 999999999 244.62 391.88 percent of total billed charges Application of nonmoveable finger splint 49456765_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 244.62 391.88 Application of nonmoveable finger splint 49456765_1 CDM 0450 RC 29130 HCPCS inpatient 404 262.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 244.62 391.88 "Clotting factor VII (proconvertin, stable factor)" 49456925_1 CDM 0301 RC 85230 HCPCS inpatient 402 261.3 AETNA AETNA 317.58 79 999999999 243.41 389.94 percent of total billed charges "Clotting factor VII (proconvertin, stable factor)" 49456925_1 CDM 0301 RC 85230 HCPCS inpatient 402 261.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 261.3 65 999999999 243.41 389.94 percent of total billed charges "Clotting factor VII (proconvertin, stable factor)" 49456925_1 CDM 0301 RC 85230 HCPCS inpatient 402 261.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 389.94 97 999999999 243.41 389.94 percent of total billed charges "Clotting factor VII (proconvertin, stable factor)" 49456925_1 CDM 0301 RC 85230 HCPCS inpatient 402 261.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 313.56 78 999999999 243.41 389.94 percent of total billed charges "Clotting factor VII (proconvertin, stable factor)" 49456925_1 CDM 0301 RC 85230 HCPCS inpatient 402 261.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 277.38 69 999999999 243.41 389.94 percent of total billed charges "Clotting factor VII (proconvertin, stable factor)" 49456925_1 CDM 0301 RC 85230 HCPCS inpatient 402 261.3 SIHO - ALL PLANS SIHO - ALL PLANS 361.8 90 999999999 243.41 389.94 percent of total billed charges "Clotting factor VII (proconvertin, stable factor)" 49456925_1 CDM 0301 RC 85230 HCPCS inpatient 402 261.3 UMR - ALL PLANS UMR - ALL PLANS 281.4 70 999999999 243.41 389.94 percent of total billed charges "Clotting factor VII (proconvertin, stable factor)" 49456925_1 CDM 0301 RC 85230 HCPCS inpatient 402 261.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 243.41 60.55 999999999 243.41 389.94 percent of total billed charges "Clotting factor VII (proconvertin, stable factor)" 49456925_1 CDM 0301 RC 85230 HCPCS inpatient 402 261.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 243.41 389.94 "Clotting factor VII (proconvertin, stable factor)" 49456925_1 CDM 0301 RC 85230 HCPCS inpatient 402 261.3 ANTHEM HMO ANTHEM HMO 999999999 243.41 389.94 "Clotting factor VII (proconvertin, stable factor)" 49456925_1 CDM 0301 RC 85230 HCPCS inpatient 402 261.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 243.41 389.94 "Clotting factor VII (proconvertin, stable factor)" 49456925_1 CDM 0301 RC 85230 HCPCS inpatient 402 261.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 271.75 67.6 999999999 243.41 389.94 percent of total billed charges "Clotting factor VII (proconvertin, stable factor)" 49456925_1 CDM 0301 RC 85230 HCPCS inpatient 402 261.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 243.41 389.94 "Clotting factor VII (proconvertin, stable factor)" 49456925_1 CDM 0301 RC 85230 HCPCS inpatient 402 261.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 243.41 389.94 Therapy procedure using ultrasound 49459827_1 CDM 0510 RC 97610 HCPCS inpatient 446 289.9 AETNA AETNA 352.34 79 999999999 270.05 432.62 percent of total billed charges Therapy procedure using ultrasound 49459827_1 CDM 0510 RC 97610 HCPCS inpatient 446 289.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 289.9 65 999999999 270.05 432.62 percent of total billed charges Therapy procedure using ultrasound 49459827_1 CDM 0510 RC 97610 HCPCS inpatient 446 289.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 432.62 97 999999999 270.05 432.62 percent of total billed charges Therapy procedure using ultrasound 49459827_1 CDM 0510 RC 97610 HCPCS inpatient 446 289.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 347.88 78 999999999 270.05 432.62 percent of total billed charges Therapy procedure using ultrasound 49459827_1 CDM 0510 RC 97610 HCPCS inpatient 446 289.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 307.74 69 999999999 270.05 432.62 percent of total billed charges Therapy procedure using ultrasound 49459827_1 CDM 0510 RC 97610 HCPCS inpatient 446 289.9 SIHO - ALL PLANS SIHO - ALL PLANS 401.4 90 999999999 270.05 432.62 percent of total billed charges Therapy procedure using ultrasound 49459827_1 CDM 0510 RC 97610 HCPCS inpatient 446 289.9 UMR - ALL PLANS UMR - ALL PLANS 312.2 70 999999999 270.05 432.62 percent of total billed charges Therapy procedure using ultrasound 49459827_1 CDM 0510 RC 97610 HCPCS inpatient 446 289.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.05 60.55 999999999 270.05 432.62 percent of total billed charges Therapy procedure using ultrasound 49459827_1 CDM 0510 RC 97610 HCPCS inpatient 446 289.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.05 432.62 Therapy procedure using ultrasound 49459827_1 CDM 0510 RC 97610 HCPCS inpatient 446 289.9 ANTHEM HMO ANTHEM HMO 999999999 270.05 432.62 Therapy procedure using ultrasound 49459827_1 CDM 0510 RC 97610 HCPCS inpatient 446 289.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.05 432.62 Therapy procedure using ultrasound 49459827_1 CDM 0510 RC 97610 HCPCS inpatient 446 289.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 301.5 67.6 999999999 270.05 432.62 percent of total billed charges Therapy procedure using ultrasound 49459827_1 CDM 0510 RC 97610 HCPCS inpatient 446 289.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.05 432.62 Therapy procedure using ultrasound 49459827_1 CDM 0510 RC 97610 HCPCS inpatient 446 289.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.05 432.62 CELECOXIB 200 MG CAPSULE 49460017_1 CDM 0250 RC 62332-0142-31 NDC inpatient 1 UN 1.54 1 AETNA AETNA 1.22 79 999999999 0.93 1.49 percent of total billed charges CELECOXIB 200 MG CAPSULE 49460017_1 CDM 0250 RC 62332-0142-31 NDC inpatient 1 UN 1.54 1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1 65 999999999 0.93 1.49 percent of total billed charges CELECOXIB 200 MG CAPSULE 49460017_1 CDM 0250 RC 62332-0142-31 NDC inpatient 1 UN 1.54 1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.49 97 999999999 0.93 1.49 percent of total billed charges CELECOXIB 200 MG CAPSULE 49460017_1 CDM 0250 RC 62332-0142-31 NDC inpatient 1 UN 1.54 1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.2 78 999999999 0.93 1.49 percent of total billed charges CELECOXIB 200 MG CAPSULE 49460017_1 CDM 0250 RC 62332-0142-31 NDC inpatient 1 UN 1.54 1 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.06 69 999999999 0.93 1.49 percent of total billed charges CELECOXIB 200 MG CAPSULE 49460017_1 CDM 0250 RC 62332-0142-31 NDC inpatient 1 UN 1.54 1 SIHO - ALL PLANS SIHO - ALL PLANS 1.39 90 999999999 0.93 1.49 percent of total billed charges CELECOXIB 200 MG CAPSULE 49460017_1 CDM 0250 RC 62332-0142-31 NDC inpatient 1 UN 1.54 1 UMR - ALL PLANS UMR - ALL PLANS 1.08 70 999999999 0.93 1.49 percent of total billed charges CELECOXIB 200 MG CAPSULE 49460017_1 CDM 0250 RC 62332-0142-31 NDC inpatient 1 UN 1.54 1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.93 60.55 999999999 0.93 1.49 percent of total billed charges CELECOXIB 200 MG CAPSULE 49460017_1 CDM 0250 RC 62332-0142-31 NDC inpatient 1 UN 1.54 1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.93 1.49 CELECOXIB 200 MG CAPSULE 49460017_1 CDM 0250 RC 62332-0142-31 NDC inpatient 1 UN 1.54 1 ANTHEM HMO ANTHEM HMO 999999999 0.93 1.49 CELECOXIB 200 MG CAPSULE 49460017_1 CDM 0250 RC 62332-0142-31 NDC inpatient 1 UN 1.54 1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.93 1.49 CELECOXIB 200 MG CAPSULE 49460017_1 CDM 0250 RC 62332-0142-31 NDC inpatient 1 UN 1.54 1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.04 67.6 999999999 0.93 1.49 percent of total billed charges CELECOXIB 200 MG CAPSULE 49460017_1 CDM 0250 RC 62332-0142-31 NDC inpatient 1 UN 1.54 1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.93 1.49 CELECOXIB 200 MG CAPSULE 49460017_1 CDM 0250 RC 62332-0142-31 NDC inpatient 1 UN 1.54 1 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.93 1.49 SEVELAMER CARBONATE 800 MG TAB 49460054_1 CDM 0250 RC 60687-0328-31 NDC inpatient 1 UN 12.91 8.39 AETNA AETNA 10.2 79 999999999 7.82 12.52 percent of total billed charges SEVELAMER CARBONATE 800 MG TAB 49460054_1 CDM 0250 RC 60687-0328-31 NDC inpatient 1 UN 12.91 8.39 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.39 65 999999999 7.82 12.52 percent of total billed charges SEVELAMER CARBONATE 800 MG TAB 49460054_1 CDM 0250 RC 60687-0328-31 NDC inpatient 1 UN 12.91 8.39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.52 97 999999999 7.82 12.52 percent of total billed charges SEVELAMER CARBONATE 800 MG TAB 49460054_1 CDM 0250 RC 60687-0328-31 NDC inpatient 1 UN 12.91 8.39 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.07 78 999999999 7.82 12.52 percent of total billed charges SEVELAMER CARBONATE 800 MG TAB 49460054_1 CDM 0250 RC 60687-0328-31 NDC inpatient 1 UN 12.91 8.39 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.91 69 999999999 7.82 12.52 percent of total billed charges SEVELAMER CARBONATE 800 MG TAB 49460054_1 CDM 0250 RC 60687-0328-31 NDC inpatient 1 UN 12.91 8.39 SIHO - ALL PLANS SIHO - ALL PLANS 11.62 90 999999999 7.82 12.52 percent of total billed charges SEVELAMER CARBONATE 800 MG TAB 49460054_1 CDM 0250 RC 60687-0328-31 NDC inpatient 1 UN 12.91 8.39 UMR - ALL PLANS UMR - ALL PLANS 9.04 70 999999999 7.82 12.52 percent of total billed charges SEVELAMER CARBONATE 800 MG TAB 49460054_1 CDM 0250 RC 60687-0328-31 NDC inpatient 1 UN 12.91 8.39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.82 60.55 999999999 7.82 12.52 percent of total billed charges SEVELAMER CARBONATE 800 MG TAB 49460054_1 CDM 0250 RC 60687-0328-31 NDC inpatient 1 UN 12.91 8.39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.82 12.52 SEVELAMER CARBONATE 800 MG TAB 49460054_1 CDM 0250 RC 60687-0328-31 NDC inpatient 1 UN 12.91 8.39 ANTHEM HMO ANTHEM HMO 999999999 7.82 12.52 SEVELAMER CARBONATE 800 MG TAB 49460054_1 CDM 0250 RC 60687-0328-31 NDC inpatient 1 UN 12.91 8.39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.82 12.52 SEVELAMER CARBONATE 800 MG TAB 49460054_1 CDM 0250 RC 60687-0328-31 NDC inpatient 1 UN 12.91 8.39 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.73 67.6 999999999 7.82 12.52 percent of total billed charges SEVELAMER CARBONATE 800 MG TAB 49460054_1 CDM 0250 RC 60687-0328-31 NDC inpatient 1 UN 12.91 8.39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.82 12.52 SEVELAMER CARBONATE 800 MG TAB 49460054_1 CDM 0250 RC 60687-0328-31 NDC inpatient 1 UN 12.91 8.39 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.82 12.52 "INJECTION, NIVOLUMAB, 1 MG" 49464297_1 CDM 0636 RC 00003-3774-12 NDC J9299 HCPCS inpatient 100 UN 12300.82 7995.53 AETNA AETNA 9717.65 79 999999999 7448.15 11931.8 percent of total billed charges "INJECTION, NIVOLUMAB, 1 MG" 49464297_1 CDM 0636 RC 00003-3774-12 NDC J9299 HCPCS inpatient 100 UN 12300.82 7995.53 SELF PAY DISCOUNT SELF PAY DISCOUNT 7995.53 65 999999999 7448.15 11931.8 percent of total billed charges "INJECTION, NIVOLUMAB, 1 MG" 49464297_1 CDM 0636 RC 00003-3774-12 NDC J9299 HCPCS inpatient 100 UN 12300.82 7995.53 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11931.8 97 999999999 7448.15 11931.8 percent of total billed charges "INJECTION, NIVOLUMAB, 1 MG" 49464297_1 CDM 0636 RC 00003-3774-12 NDC J9299 HCPCS inpatient 100 UN 12300.82 7995.53 HUMANA - ALL PLANS HUMANA - ALL PLANS 9594.64 78 999999999 7448.15 11931.8 percent of total billed charges "INJECTION, NIVOLUMAB, 1 MG" 49464297_1 CDM 0636 RC 00003-3774-12 NDC J9299 HCPCS inpatient 100 UN 12300.82 7995.53 ENCORE - ALL PLANS ENCORE - ALL PLANS 8487.57 69 999999999 7448.15 11931.8 percent of total billed charges "INJECTION, NIVOLUMAB, 1 MG" 49464297_1 CDM 0636 RC 00003-3774-12 NDC J9299 HCPCS inpatient 100 UN 12300.82 7995.53 SIHO - ALL PLANS SIHO - ALL PLANS 11070.74 90 999999999 7448.15 11931.8 percent of total billed charges "INJECTION, NIVOLUMAB, 1 MG" 49464297_1 CDM 0636 RC 00003-3774-12 NDC J9299 HCPCS inpatient 100 UN 12300.82 7995.53 UMR - ALL PLANS UMR - ALL PLANS 8610.57 70 999999999 7448.15 11931.8 percent of total billed charges "INJECTION, NIVOLUMAB, 1 MG" 49464297_1 CDM 0636 RC 00003-3774-12 NDC J9299 HCPCS inpatient 100 UN 12300.82 7995.53 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7448.15 60.55 999999999 7448.15 11931.8 percent of total billed charges "INJECTION, NIVOLUMAB, 1 MG" 49464297_1 CDM 0636 RC 00003-3774-12 NDC J9299 HCPCS inpatient 100 UN 12300.82 7995.53 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7448.15 11931.8 "INJECTION, NIVOLUMAB, 1 MG" 49464297_1 CDM 0636 RC 00003-3774-12 NDC J9299 HCPCS inpatient 100 UN 12300.82 7995.53 ANTHEM HMO ANTHEM HMO 999999999 7448.15 11931.8 "INJECTION, NIVOLUMAB, 1 MG" 49464297_1 CDM 0636 RC 00003-3774-12 NDC J9299 HCPCS inpatient 100 UN 12300.82 7995.53 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7448.15 11931.8 "INJECTION, NIVOLUMAB, 1 MG" 49464297_1 CDM 0636 RC 00003-3774-12 NDC J9299 HCPCS inpatient 100 UN 12300.82 7995.53 CIGNA - ALL PLANS CIGNA - ALL PLANS 8315.35 67.6 999999999 7448.15 11931.8 percent of total billed charges "INJECTION, NIVOLUMAB, 1 MG" 49464297_1 CDM 0636 RC 00003-3774-12 NDC J9299 HCPCS inpatient 100 UN 12300.82 7995.53 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7448.15 11931.8 "INJECTION, NIVOLUMAB, 1 MG" 49464297_1 CDM 0636 RC 00003-3774-12 NDC J9299 HCPCS inpatient 100 UN 12300.82 7995.53 UHC - ALL PLANS UHC - ALL PLANS 999999999 7448.15 11931.8 JCERX-ANTI-INFLAMMATORY MED 49464336_1 CDM 0250 RC inpatient 37 24.05 AETNA AETNA 29.23 79 999999999 22.4 35.89 percent of total billed charges JCERX-ANTI-INFLAMMATORY MED 49464336_1 CDM 0250 RC inpatient 37 24.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.05 65 999999999 22.4 35.89 percent of total billed charges JCERX-ANTI-INFLAMMATORY MED 49464336_1 CDM 0250 RC inpatient 37 24.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.89 97 999999999 22.4 35.89 percent of total billed charges JCERX-ANTI-INFLAMMATORY MED 49464336_1 CDM 0250 RC inpatient 37 24.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.86 78 999999999 22.4 35.89 percent of total billed charges JCERX-ANTI-INFLAMMATORY MED 49464336_1 CDM 0250 RC inpatient 37 24.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.53 69 999999999 22.4 35.89 percent of total billed charges JCERX-ANTI-INFLAMMATORY MED 49464336_1 CDM 0250 RC inpatient 37 24.05 SIHO - ALL PLANS SIHO - ALL PLANS 33.3 90 999999999 22.4 35.89 percent of total billed charges JCERX-ANTI-INFLAMMATORY MED 49464336_1 CDM 0250 RC inpatient 37 24.05 UMR - ALL PLANS UMR - ALL PLANS 25.9 70 999999999 22.4 35.89 percent of total billed charges JCERX-ANTI-INFLAMMATORY MED 49464336_1 CDM 0250 RC inpatient 37 24.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.4 60.55 999999999 22.4 35.89 percent of total billed charges JCERX-ANTI-INFLAMMATORY MED 49464336_1 CDM 0250 RC inpatient 37 24.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.4 35.89 JCERX-ANTI-INFLAMMATORY MED 49464336_1 CDM 0250 RC inpatient 37 24.05 ANTHEM HMO ANTHEM HMO 999999999 22.4 35.89 JCERX-ANTI-INFLAMMATORY MED 49464336_1 CDM 0250 RC inpatient 37 24.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.4 35.89 JCERX-ANTI-INFLAMMATORY MED 49464336_1 CDM 0250 RC inpatient 37 24.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.01 67.6 999999999 22.4 35.89 percent of total billed charges JCERX-ANTI-INFLAMMATORY MED 49464336_1 CDM 0250 RC inpatient 37 24.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.4 35.89 JCERX-ANTI-INFLAMMATORY MED 49464336_1 CDM 0250 RC inpatient 37 24.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.4 35.89 JCERX-EPI PEN 49464337_1 CDM 0250 RC inpatient 37 24.05 AETNA AETNA 29.23 79 999999999 22.4 35.89 percent of total billed charges JCERX-EPI PEN 49464337_1 CDM 0250 RC inpatient 37 24.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.05 65 999999999 22.4 35.89 percent of total billed charges JCERX-EPI PEN 49464337_1 CDM 0250 RC inpatient 37 24.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.89 97 999999999 22.4 35.89 percent of total billed charges JCERX-EPI PEN 49464337_1 CDM 0250 RC inpatient 37 24.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.86 78 999999999 22.4 35.89 percent of total billed charges JCERX-EPI PEN 49464337_1 CDM 0250 RC inpatient 37 24.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.53 69 999999999 22.4 35.89 percent of total billed charges JCERX-EPI PEN 49464337_1 CDM 0250 RC inpatient 37 24.05 SIHO - ALL PLANS SIHO - ALL PLANS 33.3 90 999999999 22.4 35.89 percent of total billed charges JCERX-EPI PEN 49464337_1 CDM 0250 RC inpatient 37 24.05 UMR - ALL PLANS UMR - ALL PLANS 25.9 70 999999999 22.4 35.89 percent of total billed charges JCERX-EPI PEN 49464337_1 CDM 0250 RC inpatient 37 24.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.4 60.55 999999999 22.4 35.89 percent of total billed charges JCERX-EPI PEN 49464337_1 CDM 0250 RC inpatient 37 24.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.4 35.89 JCERX-EPI PEN 49464337_1 CDM 0250 RC inpatient 37 24.05 ANTHEM HMO ANTHEM HMO 999999999 22.4 35.89 JCERX-EPI PEN 49464337_1 CDM 0250 RC inpatient 37 24.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.4 35.89 JCERX-EPI PEN 49464337_1 CDM 0250 RC inpatient 37 24.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.01 67.6 999999999 22.4 35.89 percent of total billed charges JCERX-EPI PEN 49464337_1 CDM 0250 RC inpatient 37 24.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.4 35.89 JCERX-EPI PEN 49464337_1 CDM 0250 RC inpatient 37 24.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.4 35.89 JCERX-GABAPENTIN 49464338_1 CDM 0250 RC inpatient 37 24.05 AETNA AETNA 29.23 79 999999999 22.4 35.89 percent of total billed charges JCERX-GABAPENTIN 49464338_1 CDM 0250 RC inpatient 37 24.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.05 65 999999999 22.4 35.89 percent of total billed charges JCERX-GABAPENTIN 49464338_1 CDM 0250 RC inpatient 37 24.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.89 97 999999999 22.4 35.89 percent of total billed charges JCERX-GABAPENTIN 49464338_1 CDM 0250 RC inpatient 37 24.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.86 78 999999999 22.4 35.89 percent of total billed charges JCERX-GABAPENTIN 49464338_1 CDM 0250 RC inpatient 37 24.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.53 69 999999999 22.4 35.89 percent of total billed charges JCERX-GABAPENTIN 49464338_1 CDM 0250 RC inpatient 37 24.05 SIHO - ALL PLANS SIHO - ALL PLANS 33.3 90 999999999 22.4 35.89 percent of total billed charges JCERX-GABAPENTIN 49464338_1 CDM 0250 RC inpatient 37 24.05 UMR - ALL PLANS UMR - ALL PLANS 25.9 70 999999999 22.4 35.89 percent of total billed charges JCERX-GABAPENTIN 49464338_1 CDM 0250 RC inpatient 37 24.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.4 60.55 999999999 22.4 35.89 percent of total billed charges JCERX-GABAPENTIN 49464338_1 CDM 0250 RC inpatient 37 24.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.4 35.89 JCERX-GABAPENTIN 49464338_1 CDM 0250 RC inpatient 37 24.05 ANTHEM HMO ANTHEM HMO 999999999 22.4 35.89 JCERX-GABAPENTIN 49464338_1 CDM 0250 RC inpatient 37 24.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.4 35.89 JCERX-GABAPENTIN 49464338_1 CDM 0250 RC inpatient 37 24.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.01 67.6 999999999 22.4 35.89 percent of total billed charges JCERX-GABAPENTIN 49464338_1 CDM 0250 RC inpatient 37 24.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.4 35.89 JCERX-GABAPENTIN 49464338_1 CDM 0250 RC inpatient 37 24.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.4 35.89 JCERX-HYPOTHYROID MEDICATION 49464339_1 CDM 0250 RC inpatient 37 24.05 AETNA AETNA 29.23 79 999999999 22.4 35.89 percent of total billed charges JCERX-HYPOTHYROID MEDICATION 49464339_1 CDM 0250 RC inpatient 37 24.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.05 65 999999999 22.4 35.89 percent of total billed charges JCERX-HYPOTHYROID MEDICATION 49464339_1 CDM 0250 RC inpatient 37 24.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.89 97 999999999 22.4 35.89 percent of total billed charges JCERX-HYPOTHYROID MEDICATION 49464339_1 CDM 0250 RC inpatient 37 24.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.86 78 999999999 22.4 35.89 percent of total billed charges JCERX-HYPOTHYROID MEDICATION 49464339_1 CDM 0250 RC inpatient 37 24.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.53 69 999999999 22.4 35.89 percent of total billed charges JCERX-HYPOTHYROID MEDICATION 49464339_1 CDM 0250 RC inpatient 37 24.05 SIHO - ALL PLANS SIHO - ALL PLANS 33.3 90 999999999 22.4 35.89 percent of total billed charges JCERX-HYPOTHYROID MEDICATION 49464339_1 CDM 0250 RC inpatient 37 24.05 UMR - ALL PLANS UMR - ALL PLANS 25.9 70 999999999 22.4 35.89 percent of total billed charges JCERX-HYPOTHYROID MEDICATION 49464339_1 CDM 0250 RC inpatient 37 24.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.4 60.55 999999999 22.4 35.89 percent of total billed charges JCERX-HYPOTHYROID MEDICATION 49464339_1 CDM 0250 RC inpatient 37 24.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.4 35.89 JCERX-HYPOTHYROID MEDICATION 49464339_1 CDM 0250 RC inpatient 37 24.05 ANTHEM HMO ANTHEM HMO 999999999 22.4 35.89 JCERX-HYPOTHYROID MEDICATION 49464339_1 CDM 0250 RC inpatient 37 24.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.4 35.89 JCERX-HYPOTHYROID MEDICATION 49464339_1 CDM 0250 RC inpatient 37 24.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.01 67.6 999999999 22.4 35.89 percent of total billed charges JCERX-HYPOTHYROID MEDICATION 49464339_1 CDM 0250 RC inpatient 37 24.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.4 35.89 JCERX-HYPOTHYROID MEDICATION 49464339_1 CDM 0250 RC inpatient 37 24.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.4 35.89 JCERX-IMITREX 49464340_1 CDM 0250 RC inpatient 34 22.1 AETNA AETNA 26.86 79 999999999 20.59 32.98 percent of total billed charges JCERX-IMITREX 49464340_1 CDM 0250 RC inpatient 34 22.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.1 65 999999999 20.59 32.98 percent of total billed charges JCERX-IMITREX 49464340_1 CDM 0250 RC inpatient 34 22.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.98 97 999999999 20.59 32.98 percent of total billed charges JCERX-IMITREX 49464340_1 CDM 0250 RC inpatient 34 22.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 26.52 78 999999999 20.59 32.98 percent of total billed charges JCERX-IMITREX 49464340_1 CDM 0250 RC inpatient 34 22.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 23.46 69 999999999 20.59 32.98 percent of total billed charges JCERX-IMITREX 49464340_1 CDM 0250 RC inpatient 34 22.1 SIHO - ALL PLANS SIHO - ALL PLANS 30.6 90 999999999 20.59 32.98 percent of total billed charges JCERX-IMITREX 49464340_1 CDM 0250 RC inpatient 34 22.1 UMR - ALL PLANS UMR - ALL PLANS 23.8 70 999999999 20.59 32.98 percent of total billed charges JCERX-IMITREX 49464340_1 CDM 0250 RC inpatient 34 22.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.59 60.55 999999999 20.59 32.98 percent of total billed charges JCERX-IMITREX 49464340_1 CDM 0250 RC inpatient 34 22.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.59 32.98 JCERX-IMITREX 49464340_1 CDM 0250 RC inpatient 34 22.1 ANTHEM HMO ANTHEM HMO 999999999 20.59 32.98 JCERX-IMITREX 49464340_1 CDM 0250 RC inpatient 34 22.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.59 32.98 JCERX-IMITREX 49464340_1 CDM 0250 RC inpatient 34 22.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.98 67.6 999999999 20.59 32.98 percent of total billed charges JCERX-IMITREX 49464340_1 CDM 0250 RC inpatient 34 22.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.59 32.98 JCERX-IMITREX 49464340_1 CDM 0250 RC inpatient 34 22.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.59 32.98 JCERX-RESPIRATORY INHALERS 49464341_1 CDM 0250 RC inpatient 37 24.05 AETNA AETNA 29.23 79 999999999 22.4 35.89 percent of total billed charges JCERX-RESPIRATORY INHALERS 49464341_1 CDM 0250 RC inpatient 37 24.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.05 65 999999999 22.4 35.89 percent of total billed charges JCERX-RESPIRATORY INHALERS 49464341_1 CDM 0250 RC inpatient 37 24.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.89 97 999999999 22.4 35.89 percent of total billed charges JCERX-RESPIRATORY INHALERS 49464341_1 CDM 0250 RC inpatient 37 24.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.86 78 999999999 22.4 35.89 percent of total billed charges JCERX-RESPIRATORY INHALERS 49464341_1 CDM 0250 RC inpatient 37 24.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.53 69 999999999 22.4 35.89 percent of total billed charges JCERX-RESPIRATORY INHALERS 49464341_1 CDM 0250 RC inpatient 37 24.05 SIHO - ALL PLANS SIHO - ALL PLANS 33.3 90 999999999 22.4 35.89 percent of total billed charges JCERX-RESPIRATORY INHALERS 49464341_1 CDM 0250 RC inpatient 37 24.05 UMR - ALL PLANS UMR - ALL PLANS 25.9 70 999999999 22.4 35.89 percent of total billed charges JCERX-RESPIRATORY INHALERS 49464341_1 CDM 0250 RC inpatient 37 24.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.4 60.55 999999999 22.4 35.89 percent of total billed charges JCERX-RESPIRATORY INHALERS 49464341_1 CDM 0250 RC inpatient 37 24.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.4 35.89 JCERX-RESPIRATORY INHALERS 49464341_1 CDM 0250 RC inpatient 37 24.05 ANTHEM HMO ANTHEM HMO 999999999 22.4 35.89 JCERX-RESPIRATORY INHALERS 49464341_1 CDM 0250 RC inpatient 37 24.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.4 35.89 JCERX-RESPIRATORY INHALERS 49464341_1 CDM 0250 RC inpatient 37 24.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.01 67.6 999999999 22.4 35.89 percent of total billed charges JCERX-RESPIRATORY INHALERS 49464341_1 CDM 0250 RC inpatient 37 24.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.4 35.89 JCERX-RESPIRATORY INHALERS 49464341_1 CDM 0250 RC inpatient 37 24.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.4 35.89 JCERX-LASIX 49464342_1 CDM 0250 RC inpatient 34 22.1 AETNA AETNA 26.86 79 999999999 20.59 32.98 percent of total billed charges JCERX-LASIX 49464342_1 CDM 0250 RC inpatient 34 22.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.1 65 999999999 20.59 32.98 percent of total billed charges JCERX-LASIX 49464342_1 CDM 0250 RC inpatient 34 22.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.98 97 999999999 20.59 32.98 percent of total billed charges JCERX-LASIX 49464342_1 CDM 0250 RC inpatient 34 22.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 26.52 78 999999999 20.59 32.98 percent of total billed charges JCERX-LASIX 49464342_1 CDM 0250 RC inpatient 34 22.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 23.46 69 999999999 20.59 32.98 percent of total billed charges JCERX-LASIX 49464342_1 CDM 0250 RC inpatient 34 22.1 SIHO - ALL PLANS SIHO - ALL PLANS 30.6 90 999999999 20.59 32.98 percent of total billed charges JCERX-LASIX 49464342_1 CDM 0250 RC inpatient 34 22.1 UMR - ALL PLANS UMR - ALL PLANS 23.8 70 999999999 20.59 32.98 percent of total billed charges JCERX-LASIX 49464342_1 CDM 0250 RC inpatient 34 22.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.59 60.55 999999999 20.59 32.98 percent of total billed charges JCERX-LASIX 49464342_1 CDM 0250 RC inpatient 34 22.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.59 32.98 JCERX-LASIX 49464342_1 CDM 0250 RC inpatient 34 22.1 ANTHEM HMO ANTHEM HMO 999999999 20.59 32.98 JCERX-LASIX 49464342_1 CDM 0250 RC inpatient 34 22.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.59 32.98 JCERX-LASIX 49464342_1 CDM 0250 RC inpatient 34 22.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.98 67.6 999999999 20.59 32.98 percent of total billed charges JCERX-LASIX 49464342_1 CDM 0250 RC inpatient 34 22.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.59 32.98 JCERX-LASIX 49464342_1 CDM 0250 RC inpatient 34 22.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.59 32.98 JCERX-MIGRAINE MEDICATION 49464343_1 CDM 0250 RC inpatient 37 24.05 AETNA AETNA 29.23 79 999999999 22.4 35.89 percent of total billed charges JCERX-MIGRAINE MEDICATION 49464343_1 CDM 0250 RC inpatient 37 24.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.05 65 999999999 22.4 35.89 percent of total billed charges JCERX-MIGRAINE MEDICATION 49464343_1 CDM 0250 RC inpatient 37 24.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.89 97 999999999 22.4 35.89 percent of total billed charges JCERX-MIGRAINE MEDICATION 49464343_1 CDM 0250 RC inpatient 37 24.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.86 78 999999999 22.4 35.89 percent of total billed charges JCERX-MIGRAINE MEDICATION 49464343_1 CDM 0250 RC inpatient 37 24.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.53 69 999999999 22.4 35.89 percent of total billed charges JCERX-MIGRAINE MEDICATION 49464343_1 CDM 0250 RC inpatient 37 24.05 SIHO - ALL PLANS SIHO - ALL PLANS 33.3 90 999999999 22.4 35.89 percent of total billed charges JCERX-MIGRAINE MEDICATION 49464343_1 CDM 0250 RC inpatient 37 24.05 UMR - ALL PLANS UMR - ALL PLANS 25.9 70 999999999 22.4 35.89 percent of total billed charges JCERX-MIGRAINE MEDICATION 49464343_1 CDM 0250 RC inpatient 37 24.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.4 60.55 999999999 22.4 35.89 percent of total billed charges JCERX-MIGRAINE MEDICATION 49464343_1 CDM 0250 RC inpatient 37 24.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.4 35.89 JCERX-MIGRAINE MEDICATION 49464343_1 CDM 0250 RC inpatient 37 24.05 ANTHEM HMO ANTHEM HMO 999999999 22.4 35.89 JCERX-MIGRAINE MEDICATION 49464343_1 CDM 0250 RC inpatient 37 24.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.4 35.89 JCERX-MIGRAINE MEDICATION 49464343_1 CDM 0250 RC inpatient 37 24.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.01 67.6 999999999 22.4 35.89 percent of total billed charges JCERX-MIGRAINE MEDICATION 49464343_1 CDM 0250 RC inpatient 37 24.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.4 35.89 JCERX-MIGRAINE MEDICATION 49464343_1 CDM 0250 RC inpatient 37 24.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.4 35.89 JCERX-OMEPRAZOLE 49464344_1 CDM 0250 RC inpatient 34 22.1 AETNA AETNA 26.86 79 999999999 20.59 32.98 percent of total billed charges JCERX-OMEPRAZOLE 49464344_1 CDM 0250 RC inpatient 34 22.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.1 65 999999999 20.59 32.98 percent of total billed charges JCERX-OMEPRAZOLE 49464344_1 CDM 0250 RC inpatient 34 22.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.98 97 999999999 20.59 32.98 percent of total billed charges JCERX-OMEPRAZOLE 49464344_1 CDM 0250 RC inpatient 34 22.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 26.52 78 999999999 20.59 32.98 percent of total billed charges JCERX-OMEPRAZOLE 49464344_1 CDM 0250 RC inpatient 34 22.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 23.46 69 999999999 20.59 32.98 percent of total billed charges JCERX-OMEPRAZOLE 49464344_1 CDM 0250 RC inpatient 34 22.1 SIHO - ALL PLANS SIHO - ALL PLANS 30.6 90 999999999 20.59 32.98 percent of total billed charges JCERX-OMEPRAZOLE 49464344_1 CDM 0250 RC inpatient 34 22.1 UMR - ALL PLANS UMR - ALL PLANS 23.8 70 999999999 20.59 32.98 percent of total billed charges JCERX-OMEPRAZOLE 49464344_1 CDM 0250 RC inpatient 34 22.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.59 60.55 999999999 20.59 32.98 percent of total billed charges JCERX-OMEPRAZOLE 49464344_1 CDM 0250 RC inpatient 34 22.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.59 32.98 JCERX-OMEPRAZOLE 49464344_1 CDM 0250 RC inpatient 34 22.1 ANTHEM HMO ANTHEM HMO 999999999 20.59 32.98 JCERX-OMEPRAZOLE 49464344_1 CDM 0250 RC inpatient 34 22.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.59 32.98 JCERX-OMEPRAZOLE 49464344_1 CDM 0250 RC inpatient 34 22.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.98 67.6 999999999 20.59 32.98 percent of total billed charges JCERX-OMEPRAZOLE 49464344_1 CDM 0250 RC inpatient 34 22.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.59 32.98 JCERX-OMEPRAZOLE 49464344_1 CDM 0250 RC inpatient 34 22.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.59 32.98 JCERX-POTASSIUM 49464345_1 CDM 0250 RC inpatient 34 22.1 AETNA AETNA 26.86 79 999999999 20.59 32.98 percent of total billed charges JCERX-POTASSIUM 49464345_1 CDM 0250 RC inpatient 34 22.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.1 65 999999999 20.59 32.98 percent of total billed charges JCERX-POTASSIUM 49464345_1 CDM 0250 RC inpatient 34 22.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.98 97 999999999 20.59 32.98 percent of total billed charges JCERX-POTASSIUM 49464345_1 CDM 0250 RC inpatient 34 22.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 26.52 78 999999999 20.59 32.98 percent of total billed charges JCERX-POTASSIUM 49464345_1 CDM 0250 RC inpatient 34 22.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 23.46 69 999999999 20.59 32.98 percent of total billed charges JCERX-POTASSIUM 49464345_1 CDM 0250 RC inpatient 34 22.1 SIHO - ALL PLANS SIHO - ALL PLANS 30.6 90 999999999 20.59 32.98 percent of total billed charges JCERX-POTASSIUM 49464345_1 CDM 0250 RC inpatient 34 22.1 UMR - ALL PLANS UMR - ALL PLANS 23.8 70 999999999 20.59 32.98 percent of total billed charges JCERX-POTASSIUM 49464345_1 CDM 0250 RC inpatient 34 22.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.59 60.55 999999999 20.59 32.98 percent of total billed charges JCERX-POTASSIUM 49464345_1 CDM 0250 RC inpatient 34 22.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.59 32.98 JCERX-POTASSIUM 49464345_1 CDM 0250 RC inpatient 34 22.1 ANTHEM HMO ANTHEM HMO 999999999 20.59 32.98 JCERX-POTASSIUM 49464345_1 CDM 0250 RC inpatient 34 22.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.59 32.98 JCERX-POTASSIUM 49464345_1 CDM 0250 RC inpatient 34 22.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.98 67.6 999999999 20.59 32.98 percent of total billed charges JCERX-POTASSIUM 49464345_1 CDM 0250 RC inpatient 34 22.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.59 32.98 JCERX-POTASSIUM 49464345_1 CDM 0250 RC inpatient 34 22.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.59 32.98 JCERX-NEXIUM/PREVACID/PRILOSEC 49464346_1 CDM 0250 RC inpatient 37 24.05 AETNA AETNA 29.23 79 999999999 22.4 35.89 percent of total billed charges JCERX-NEXIUM/PREVACID/PRILOSEC 49464346_1 CDM 0250 RC inpatient 37 24.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.05 65 999999999 22.4 35.89 percent of total billed charges JCERX-NEXIUM/PREVACID/PRILOSEC 49464346_1 CDM 0250 RC inpatient 37 24.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.89 97 999999999 22.4 35.89 percent of total billed charges JCERX-NEXIUM/PREVACID/PRILOSEC 49464346_1 CDM 0250 RC inpatient 37 24.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.86 78 999999999 22.4 35.89 percent of total billed charges JCERX-NEXIUM/PREVACID/PRILOSEC 49464346_1 CDM 0250 RC inpatient 37 24.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.53 69 999999999 22.4 35.89 percent of total billed charges JCERX-NEXIUM/PREVACID/PRILOSEC 49464346_1 CDM 0250 RC inpatient 37 24.05 SIHO - ALL PLANS SIHO - ALL PLANS 33.3 90 999999999 22.4 35.89 percent of total billed charges JCERX-NEXIUM/PREVACID/PRILOSEC 49464346_1 CDM 0250 RC inpatient 37 24.05 UMR - ALL PLANS UMR - ALL PLANS 25.9 70 999999999 22.4 35.89 percent of total billed charges JCERX-NEXIUM/PREVACID/PRILOSEC 49464346_1 CDM 0250 RC inpatient 37 24.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.4 60.55 999999999 22.4 35.89 percent of total billed charges JCERX-NEXIUM/PREVACID/PRILOSEC 49464346_1 CDM 0250 RC inpatient 37 24.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.4 35.89 JCERX-NEXIUM/PREVACID/PRILOSEC 49464346_1 CDM 0250 RC inpatient 37 24.05 ANTHEM HMO ANTHEM HMO 999999999 22.4 35.89 JCERX-NEXIUM/PREVACID/PRILOSEC 49464346_1 CDM 0250 RC inpatient 37 24.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.4 35.89 JCERX-NEXIUM/PREVACID/PRILOSEC 49464346_1 CDM 0250 RC inpatient 37 24.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.01 67.6 999999999 22.4 35.89 percent of total billed charges JCERX-NEXIUM/PREVACID/PRILOSEC 49464346_1 CDM 0250 RC inpatient 37 24.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.4 35.89 JCERX-NEXIUM/PREVACID/PRILOSEC 49464346_1 CDM 0250 RC inpatient 37 24.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.4 35.89 JCERX-PROTONIX 49464347_1 CDM 0250 RC inpatient 34 22.1 AETNA AETNA 26.86 79 999999999 20.59 32.98 percent of total billed charges JCERX-PROTONIX 49464347_1 CDM 0250 RC inpatient 34 22.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.1 65 999999999 20.59 32.98 percent of total billed charges JCERX-PROTONIX 49464347_1 CDM 0250 RC inpatient 34 22.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.98 97 999999999 20.59 32.98 percent of total billed charges JCERX-PROTONIX 49464347_1 CDM 0250 RC inpatient 34 22.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 26.52 78 999999999 20.59 32.98 percent of total billed charges JCERX-PROTONIX 49464347_1 CDM 0250 RC inpatient 34 22.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 23.46 69 999999999 20.59 32.98 percent of total billed charges JCERX-PROTONIX 49464347_1 CDM 0250 RC inpatient 34 22.1 SIHO - ALL PLANS SIHO - ALL PLANS 30.6 90 999999999 20.59 32.98 percent of total billed charges JCERX-PROTONIX 49464347_1 CDM 0250 RC inpatient 34 22.1 UMR - ALL PLANS UMR - ALL PLANS 23.8 70 999999999 20.59 32.98 percent of total billed charges JCERX-PROTONIX 49464347_1 CDM 0250 RC inpatient 34 22.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.59 60.55 999999999 20.59 32.98 percent of total billed charges JCERX-PROTONIX 49464347_1 CDM 0250 RC inpatient 34 22.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.59 32.98 JCERX-PROTONIX 49464347_1 CDM 0250 RC inpatient 34 22.1 ANTHEM HMO ANTHEM HMO 999999999 20.59 32.98 JCERX-PROTONIX 49464347_1 CDM 0250 RC inpatient 34 22.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.59 32.98 JCERX-PROTONIX 49464347_1 CDM 0250 RC inpatient 34 22.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.98 67.6 999999999 20.59 32.98 percent of total billed charges JCERX-PROTONIX 49464347_1 CDM 0250 RC inpatient 34 22.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.59 32.98 JCERX-PROTONIX 49464347_1 CDM 0250 RC inpatient 34 22.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.59 32.98 JCERX-SINGULAIR 49464348_1 CDM 0250 RC inpatient 34 22.1 AETNA AETNA 26.86 79 999999999 20.59 32.98 percent of total billed charges JCERX-SINGULAIR 49464348_1 CDM 0250 RC inpatient 34 22.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.1 65 999999999 20.59 32.98 percent of total billed charges JCERX-SINGULAIR 49464348_1 CDM 0250 RC inpatient 34 22.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.98 97 999999999 20.59 32.98 percent of total billed charges JCERX-SINGULAIR 49464348_1 CDM 0250 RC inpatient 34 22.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 26.52 78 999999999 20.59 32.98 percent of total billed charges JCERX-SINGULAIR 49464348_1 CDM 0250 RC inpatient 34 22.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 23.46 69 999999999 20.59 32.98 percent of total billed charges JCERX-SINGULAIR 49464348_1 CDM 0250 RC inpatient 34 22.1 SIHO - ALL PLANS SIHO - ALL PLANS 30.6 90 999999999 20.59 32.98 percent of total billed charges JCERX-SINGULAIR 49464348_1 CDM 0250 RC inpatient 34 22.1 UMR - ALL PLANS UMR - ALL PLANS 23.8 70 999999999 20.59 32.98 percent of total billed charges JCERX-SINGULAIR 49464348_1 CDM 0250 RC inpatient 34 22.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.59 60.55 999999999 20.59 32.98 percent of total billed charges JCERX-SINGULAIR 49464348_1 CDM 0250 RC inpatient 34 22.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.59 32.98 JCERX-SINGULAIR 49464348_1 CDM 0250 RC inpatient 34 22.1 ANTHEM HMO ANTHEM HMO 999999999 20.59 32.98 JCERX-SINGULAIR 49464348_1 CDM 0250 RC inpatient 34 22.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.59 32.98 JCERX-SINGULAIR 49464348_1 CDM 0250 RC inpatient 34 22.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.98 67.6 999999999 20.59 32.98 percent of total billed charges JCERX-SINGULAIR 49464348_1 CDM 0250 RC inpatient 34 22.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.59 32.98 JCERX-SINGULAIR 49464348_1 CDM 0250 RC inpatient 34 22.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.59 32.98 JCERX-STRATTERA 49464349_1 CDM 0250 RC inpatient 34 22.1 AETNA AETNA 26.86 79 999999999 20.59 32.98 percent of total billed charges JCERX-STRATTERA 49464349_1 CDM 0250 RC inpatient 34 22.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.1 65 999999999 20.59 32.98 percent of total billed charges JCERX-STRATTERA 49464349_1 CDM 0250 RC inpatient 34 22.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.98 97 999999999 20.59 32.98 percent of total billed charges JCERX-STRATTERA 49464349_1 CDM 0250 RC inpatient 34 22.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 26.52 78 999999999 20.59 32.98 percent of total billed charges JCERX-STRATTERA 49464349_1 CDM 0250 RC inpatient 34 22.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 23.46 69 999999999 20.59 32.98 percent of total billed charges JCERX-STRATTERA 49464349_1 CDM 0250 RC inpatient 34 22.1 SIHO - ALL PLANS SIHO - ALL PLANS 30.6 90 999999999 20.59 32.98 percent of total billed charges JCERX-STRATTERA 49464349_1 CDM 0250 RC inpatient 34 22.1 UMR - ALL PLANS UMR - ALL PLANS 23.8 70 999999999 20.59 32.98 percent of total billed charges JCERX-STRATTERA 49464349_1 CDM 0250 RC inpatient 34 22.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.59 60.55 999999999 20.59 32.98 percent of total billed charges JCERX-STRATTERA 49464349_1 CDM 0250 RC inpatient 34 22.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.59 32.98 JCERX-STRATTERA 49464349_1 CDM 0250 RC inpatient 34 22.1 ANTHEM HMO ANTHEM HMO 999999999 20.59 32.98 JCERX-STRATTERA 49464349_1 CDM 0250 RC inpatient 34 22.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.59 32.98 JCERX-STRATTERA 49464349_1 CDM 0250 RC inpatient 34 22.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.98 67.6 999999999 20.59 32.98 percent of total billed charges JCERX-STRATTERA 49464349_1 CDM 0250 RC inpatient 34 22.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.59 32.98 JCERX-STRATTERA 49464349_1 CDM 0250 RC inpatient 34 22.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.59 32.98 ALBUTEIN 25% VIAL 49464767_1 CDM 0250 RC 68516-5216-01 NDC inpatient 1 UN 261.97 170.28 AETNA AETNA 206.96 79 999999999 158.62 254.11 percent of total billed charges ALBUTEIN 25% VIAL 49464767_1 CDM 0250 RC 68516-5216-01 NDC inpatient 1 UN 261.97 170.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.28 65 999999999 158.62 254.11 percent of total billed charges ALBUTEIN 25% VIAL 49464767_1 CDM 0250 RC 68516-5216-01 NDC inpatient 1 UN 261.97 170.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.11 97 999999999 158.62 254.11 percent of total billed charges ALBUTEIN 25% VIAL 49464767_1 CDM 0250 RC 68516-5216-01 NDC inpatient 1 UN 261.97 170.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.34 78 999999999 158.62 254.11 percent of total billed charges ALBUTEIN 25% VIAL 49464767_1 CDM 0250 RC 68516-5216-01 NDC inpatient 1 UN 261.97 170.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.76 69 999999999 158.62 254.11 percent of total billed charges ALBUTEIN 25% VIAL 49464767_1 CDM 0250 RC 68516-5216-01 NDC inpatient 1 UN 261.97 170.28 SIHO - ALL PLANS SIHO - ALL PLANS 235.77 90 999999999 158.62 254.11 percent of total billed charges ALBUTEIN 25% VIAL 49464767_1 CDM 0250 RC 68516-5216-01 NDC inpatient 1 UN 261.97 170.28 UMR - ALL PLANS UMR - ALL PLANS 183.38 70 999999999 158.62 254.11 percent of total billed charges ALBUTEIN 25% VIAL 49464767_1 CDM 0250 RC 68516-5216-01 NDC inpatient 1 UN 261.97 170.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.62 60.55 999999999 158.62 254.11 percent of total billed charges ALBUTEIN 25% VIAL 49464767_1 CDM 0250 RC 68516-5216-01 NDC inpatient 1 UN 261.97 170.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.62 254.11 ALBUTEIN 25% VIAL 49464767_1 CDM 0250 RC 68516-5216-01 NDC inpatient 1 UN 261.97 170.28 ANTHEM HMO ANTHEM HMO 999999999 158.62 254.11 ALBUTEIN 25% VIAL 49464767_1 CDM 0250 RC 68516-5216-01 NDC inpatient 1 UN 261.97 170.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.62 254.11 ALBUTEIN 25% VIAL 49464767_1 CDM 0250 RC 68516-5216-01 NDC inpatient 1 UN 261.97 170.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.09 67.6 999999999 158.62 254.11 percent of total billed charges ALBUTEIN 25% VIAL 49464767_1 CDM 0250 RC 68516-5216-01 NDC inpatient 1 UN 261.97 170.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.62 254.11 ALBUTEIN 25% VIAL 49464767_1 CDM 0250 RC 68516-5216-01 NDC inpatient 1 UN 261.97 170.28 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.62 254.11 Platelet aggregation function test 49464774_1 CDM 0305 RC 85576 HCPCS inpatient 487 316.55 AETNA AETNA 384.73 79 999999999 294.88 472.39 percent of total billed charges Platelet aggregation function test 49464774_1 CDM 0305 RC 85576 HCPCS inpatient 487 316.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 316.55 65 999999999 294.88 472.39 percent of total billed charges Platelet aggregation function test 49464774_1 CDM 0305 RC 85576 HCPCS inpatient 487 316.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 472.39 97 999999999 294.88 472.39 percent of total billed charges Platelet aggregation function test 49464774_1 CDM 0305 RC 85576 HCPCS inpatient 487 316.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 379.86 78 999999999 294.88 472.39 percent of total billed charges Platelet aggregation function test 49464774_1 CDM 0305 RC 85576 HCPCS inpatient 487 316.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 336.03 69 999999999 294.88 472.39 percent of total billed charges Platelet aggregation function test 49464774_1 CDM 0305 RC 85576 HCPCS inpatient 487 316.55 SIHO - ALL PLANS SIHO - ALL PLANS 438.3 90 999999999 294.88 472.39 percent of total billed charges Platelet aggregation function test 49464774_1 CDM 0305 RC 85576 HCPCS inpatient 487 316.55 UMR - ALL PLANS UMR - ALL PLANS 340.9 70 999999999 294.88 472.39 percent of total billed charges Platelet aggregation function test 49464774_1 CDM 0305 RC 85576 HCPCS inpatient 487 316.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 294.88 60.55 999999999 294.88 472.39 percent of total billed charges Platelet aggregation function test 49464774_1 CDM 0305 RC 85576 HCPCS inpatient 487 316.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 294.88 472.39 Platelet aggregation function test 49464774_1 CDM 0305 RC 85576 HCPCS inpatient 487 316.55 ANTHEM HMO ANTHEM HMO 999999999 294.88 472.39 Platelet aggregation function test 49464774_1 CDM 0305 RC 85576 HCPCS inpatient 487 316.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 294.88 472.39 Platelet aggregation function test 49464774_1 CDM 0305 RC 85576 HCPCS inpatient 487 316.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 329.21 67.6 999999999 294.88 472.39 percent of total billed charges Platelet aggregation function test 49464774_1 CDM 0305 RC 85576 HCPCS inpatient 487 316.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 294.88 472.39 Platelet aggregation function test 49464774_1 CDM 0305 RC 85576 HCPCS inpatient 487 316.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 294.88 472.39 "Nephelometry, test method using light" 49464902_1 CDM 0301 RC 83883 HCPCS inpatient 147 95.55 AETNA AETNA 116.13 79 999999999 89.01 142.59 percent of total billed charges "Nephelometry, test method using light" 49464902_1 CDM 0301 RC 83883 HCPCS inpatient 147 95.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 95.55 65 999999999 89.01 142.59 percent of total billed charges "Nephelometry, test method using light" 49464902_1 CDM 0301 RC 83883 HCPCS inpatient 147 95.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 142.59 97 999999999 89.01 142.59 percent of total billed charges "Nephelometry, test method using light" 49464902_1 CDM 0301 RC 83883 HCPCS inpatient 147 95.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 114.66 78 999999999 89.01 142.59 percent of total billed charges "Nephelometry, test method using light" 49464902_1 CDM 0301 RC 83883 HCPCS inpatient 147 95.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 101.43 69 999999999 89.01 142.59 percent of total billed charges "Nephelometry, test method using light" 49464902_1 CDM 0301 RC 83883 HCPCS inpatient 147 95.55 SIHO - ALL PLANS SIHO - ALL PLANS 132.3 90 999999999 89.01 142.59 percent of total billed charges "Nephelometry, test method using light" 49464902_1 CDM 0301 RC 83883 HCPCS inpatient 147 95.55 UMR - ALL PLANS UMR - ALL PLANS 102.9 70 999999999 89.01 142.59 percent of total billed charges "Nephelometry, test method using light" 49464902_1 CDM 0301 RC 83883 HCPCS inpatient 147 95.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 89.01 60.55 999999999 89.01 142.59 percent of total billed charges "Nephelometry, test method using light" 49464902_1 CDM 0301 RC 83883 HCPCS inpatient 147 95.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 89.01 142.59 "Nephelometry, test method using light" 49464902_1 CDM 0301 RC 83883 HCPCS inpatient 147 95.55 ANTHEM HMO ANTHEM HMO 999999999 89.01 142.59 "Nephelometry, test method using light" 49464902_1 CDM 0301 RC 83883 HCPCS inpatient 147 95.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 89.01 142.59 "Nephelometry, test method using light" 49464902_1 CDM 0301 RC 83883 HCPCS inpatient 147 95.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 99.37 67.6 999999999 89.01 142.59 percent of total billed charges "Nephelometry, test method using light" 49464902_1 CDM 0301 RC 83883 HCPCS inpatient 147 95.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 89.01 142.59 "Nephelometry, test method using light" 49464902_1 CDM 0301 RC 83883 HCPCS inpatient 147 95.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 89.01 142.59 ADH (antidiuretic hormone) level 49467649_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 AETNA AETNA 275.71 79 999999999 211.32 338.53 percent of total billed charges ADH (antidiuretic hormone) level 49467649_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 226.85 65 999999999 211.32 338.53 percent of total billed charges ADH (antidiuretic hormone) level 49467649_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 338.53 97 999999999 211.32 338.53 percent of total billed charges ADH (antidiuretic hormone) level 49467649_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 272.22 78 999999999 211.32 338.53 percent of total billed charges ADH (antidiuretic hormone) level 49467649_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 240.81 69 999999999 211.32 338.53 percent of total billed charges ADH (antidiuretic hormone) level 49467649_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 SIHO - ALL PLANS SIHO - ALL PLANS 314.1 90 999999999 211.32 338.53 percent of total billed charges ADH (antidiuretic hormone) level 49467649_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 UMR - ALL PLANS UMR - ALL PLANS 244.3 70 999999999 211.32 338.53 percent of total billed charges ADH (antidiuretic hormone) level 49467649_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 211.32 60.55 999999999 211.32 338.53 percent of total billed charges ADH (antidiuretic hormone) level 49467649_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 211.32 338.53 ADH (antidiuretic hormone) level 49467649_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 ANTHEM HMO ANTHEM HMO 999999999 211.32 338.53 ADH (antidiuretic hormone) level 49467649_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 211.32 338.53 ADH (antidiuretic hormone) level 49467649_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 235.92 67.6 999999999 211.32 338.53 percent of total billed charges ADH (antidiuretic hormone) level 49467649_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 211.32 338.53 ADH (antidiuretic hormone) level 49467649_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 211.32 338.53 Estriol (hormone) level 49468425_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges Estriol (hormone) level 49468425_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges Estriol (hormone) level 49468425_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges Estriol (hormone) level 49468425_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges Estriol (hormone) level 49468425_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges Estriol (hormone) level 49468425_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges Estriol (hormone) level 49468425_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges Estriol (hormone) level 49468425_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges Estriol (hormone) level 49468425_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 Estriol (hormone) level 49468425_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 Estriol (hormone) level 49468425_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 Estriol (hormone) level 49468425_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges Estriol (hormone) level 49468425_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 Estriol (hormone) level 49468425_1 CDM 0301 RC 82677 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 CHLORHEXIDINE 0.12% RINSE 49468858_1 CDM 0250 RC 00116-2001-04 NDC inpatient 1 UN 5.22 3.39 AETNA AETNA 4.12 79 999999999 3.16 5.06 percent of total billed charges CHLORHEXIDINE 0.12% RINSE 49468858_1 CDM 0250 RC 00116-2001-04 NDC inpatient 1 UN 5.22 3.39 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.39 65 999999999 3.16 5.06 percent of total billed charges CHLORHEXIDINE 0.12% RINSE 49468858_1 CDM 0250 RC 00116-2001-04 NDC inpatient 1 UN 5.22 3.39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.06 97 999999999 3.16 5.06 percent of total billed charges CHLORHEXIDINE 0.12% RINSE 49468858_1 CDM 0250 RC 00116-2001-04 NDC inpatient 1 UN 5.22 3.39 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.07 78 999999999 3.16 5.06 percent of total billed charges CHLORHEXIDINE 0.12% RINSE 49468858_1 CDM 0250 RC 00116-2001-04 NDC inpatient 1 UN 5.22 3.39 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.6 69 999999999 3.16 5.06 percent of total billed charges CHLORHEXIDINE 0.12% RINSE 49468858_1 CDM 0250 RC 00116-2001-04 NDC inpatient 1 UN 5.22 3.39 SIHO - ALL PLANS SIHO - ALL PLANS 4.7 90 999999999 3.16 5.06 percent of total billed charges CHLORHEXIDINE 0.12% RINSE 49468858_1 CDM 0250 RC 00116-2001-04 NDC inpatient 1 UN 5.22 3.39 UMR - ALL PLANS UMR - ALL PLANS 3.65 70 999999999 3.16 5.06 percent of total billed charges CHLORHEXIDINE 0.12% RINSE 49468858_1 CDM 0250 RC 00116-2001-04 NDC inpatient 1 UN 5.22 3.39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.16 60.55 999999999 3.16 5.06 percent of total billed charges CHLORHEXIDINE 0.12% RINSE 49468858_1 CDM 0250 RC 00116-2001-04 NDC inpatient 1 UN 5.22 3.39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.16 5.06 CHLORHEXIDINE 0.12% RINSE 49468858_1 CDM 0250 RC 00116-2001-04 NDC inpatient 1 UN 5.22 3.39 ANTHEM HMO ANTHEM HMO 999999999 3.16 5.06 CHLORHEXIDINE 0.12% RINSE 49468858_1 CDM 0250 RC 00116-2001-04 NDC inpatient 1 UN 5.22 3.39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.16 5.06 CHLORHEXIDINE 0.12% RINSE 49468858_1 CDM 0250 RC 00116-2001-04 NDC inpatient 1 UN 5.22 3.39 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.53 67.6 999999999 3.16 5.06 percent of total billed charges CHLORHEXIDINE 0.12% RINSE 49468858_1 CDM 0250 RC 00116-2001-04 NDC inpatient 1 UN 5.22 3.39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.16 5.06 CHLORHEXIDINE 0.12% RINSE 49468858_1 CDM 0250 RC 00116-2001-04 NDC inpatient 1 UN 5.22 3.39 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.16 5.06 Apolipoprotein level 49468906_1 CDM 0301 RC 82172 HCPCS inpatient 439 285.35 AETNA AETNA 346.81 79 999999999 265.81 425.83 percent of total billed charges Apolipoprotein level 49468906_1 CDM 0301 RC 82172 HCPCS inpatient 439 285.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 285.35 65 999999999 265.81 425.83 percent of total billed charges Apolipoprotein level 49468906_1 CDM 0301 RC 82172 HCPCS inpatient 439 285.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 425.83 97 999999999 265.81 425.83 percent of total billed charges Apolipoprotein level 49468906_1 CDM 0301 RC 82172 HCPCS inpatient 439 285.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 342.42 78 999999999 265.81 425.83 percent of total billed charges Apolipoprotein level 49468906_1 CDM 0301 RC 82172 HCPCS inpatient 439 285.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 302.91 69 999999999 265.81 425.83 percent of total billed charges Apolipoprotein level 49468906_1 CDM 0301 RC 82172 HCPCS inpatient 439 285.35 SIHO - ALL PLANS SIHO - ALL PLANS 395.1 90 999999999 265.81 425.83 percent of total billed charges Apolipoprotein level 49468906_1 CDM 0301 RC 82172 HCPCS inpatient 439 285.35 UMR - ALL PLANS UMR - ALL PLANS 307.3 70 999999999 265.81 425.83 percent of total billed charges Apolipoprotein level 49468906_1 CDM 0301 RC 82172 HCPCS inpatient 439 285.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 265.81 60.55 999999999 265.81 425.83 percent of total billed charges Apolipoprotein level 49468906_1 CDM 0301 RC 82172 HCPCS inpatient 439 285.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 265.81 425.83 Apolipoprotein level 49468906_1 CDM 0301 RC 82172 HCPCS inpatient 439 285.35 ANTHEM HMO ANTHEM HMO 999999999 265.81 425.83 Apolipoprotein level 49468906_1 CDM 0301 RC 82172 HCPCS inpatient 439 285.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 265.81 425.83 Apolipoprotein level 49468906_1 CDM 0301 RC 82172 HCPCS inpatient 439 285.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 296.76 67.6 999999999 265.81 425.83 percent of total billed charges Apolipoprotein level 49468906_1 CDM 0301 RC 82172 HCPCS inpatient 439 285.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 265.81 425.83 Apolipoprotein level 49468906_1 CDM 0301 RC 82172 HCPCS inpatient 439 285.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 265.81 425.83 RAD 60 BLADE 3.5MNM 1883516 49480601_1 CDM 0272 RC inpatient 1369 889.85 AETNA AETNA 1081.51 79 999999999 828.93 1327.93 percent of total billed charges RAD 60 BLADE 3.5MNM 1883516 49480601_1 CDM 0272 RC inpatient 1369 889.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 889.85 65 999999999 828.93 1327.93 percent of total billed charges RAD 60 BLADE 3.5MNM 1883516 49480601_1 CDM 0272 RC inpatient 1369 889.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1327.93 97 999999999 828.93 1327.93 percent of total billed charges RAD 60 BLADE 3.5MNM 1883516 49480601_1 CDM 0272 RC inpatient 1369 889.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1067.82 78 999999999 828.93 1327.93 percent of total billed charges RAD 60 BLADE 3.5MNM 1883516 49480601_1 CDM 0272 RC inpatient 1369 889.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 944.61 69 999999999 828.93 1327.93 percent of total billed charges RAD 60 BLADE 3.5MNM 1883516 49480601_1 CDM 0272 RC inpatient 1369 889.85 SIHO - ALL PLANS SIHO - ALL PLANS 1232.1 90 999999999 828.93 1327.93 percent of total billed charges RAD 60 BLADE 3.5MNM 1883516 49480601_1 CDM 0272 RC inpatient 1369 889.85 UMR - ALL PLANS UMR - ALL PLANS 958.3 70 999999999 828.93 1327.93 percent of total billed charges RAD 60 BLADE 3.5MNM 1883516 49480601_1 CDM 0272 RC inpatient 1369 889.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 828.93 60.55 999999999 828.93 1327.93 percent of total billed charges RAD 60 BLADE 3.5MNM 1883516 49480601_1 CDM 0272 RC inpatient 1369 889.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 828.93 1327.93 RAD 60 BLADE 3.5MNM 1883516 49480601_1 CDM 0272 RC inpatient 1369 889.85 ANTHEM HMO ANTHEM HMO 999999999 828.93 1327.93 RAD 60 BLADE 3.5MNM 1883516 49480601_1 CDM 0272 RC inpatient 1369 889.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 828.93 1327.93 RAD 60 BLADE 3.5MNM 1883516 49480601_1 CDM 0272 RC inpatient 1369 889.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 925.44 67.6 999999999 828.93 1327.93 percent of total billed charges RAD 60 BLADE 3.5MNM 1883516 49480601_1 CDM 0272 RC inpatient 1369 889.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 828.93 1327.93 RAD 60 BLADE 3.5MNM 1883516 49480601_1 CDM 0272 RC inpatient 1369 889.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 828.93 1327.93 CT scan of blood vessels of abdomen and pelvis with contrast 49490800_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 AETNA AETNA 3596.87 79 999999999 2756.84 4416.41 percent of total billed charges CT scan of blood vessels of abdomen and pelvis with contrast 49490800_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 2959.45 65 999999999 2756.84 4416.41 percent of total billed charges CT scan of blood vessels of abdomen and pelvis with contrast 49490800_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4416.41 97 999999999 2756.84 4416.41 percent of total billed charges CT scan of blood vessels of abdomen and pelvis with contrast 49490800_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 3551.34 78 999999999 2756.84 4416.41 percent of total billed charges CT scan of blood vessels of abdomen and pelvis with contrast 49490800_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 3141.57 69 999999999 2756.84 4416.41 percent of total billed charges CT scan of blood vessels of abdomen and pelvis with contrast 49490800_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 SIHO - ALL PLANS SIHO - ALL PLANS 4097.7 90 999999999 2756.84 4416.41 percent of total billed charges CT scan of blood vessels of abdomen and pelvis with contrast 49490800_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 UMR - ALL PLANS UMR - ALL PLANS 3187.1 70 999999999 2756.84 4416.41 percent of total billed charges CT scan of blood vessels of abdomen and pelvis with contrast 49490800_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2756.84 60.55 999999999 2756.84 4416.41 percent of total billed charges CT scan of blood vessels of abdomen and pelvis with contrast 49490800_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2756.84 4416.41 CT scan of blood vessels of abdomen and pelvis with contrast 49490800_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 ANTHEM HMO ANTHEM HMO 999999999 2756.84 4416.41 CT scan of blood vessels of abdomen and pelvis with contrast 49490800_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2756.84 4416.41 CT scan of blood vessels of abdomen and pelvis with contrast 49490800_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 3077.83 67.6 999999999 2756.84 4416.41 percent of total billed charges CT scan of blood vessels of abdomen and pelvis with contrast 49490800_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2756.84 4416.41 CT scan of blood vessels of abdomen and pelvis with contrast 49490800_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 2756.84 4416.41 CT scan of blood vessels of chest with contrast 49490801_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 AETNA AETNA 2399.23 79 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 49490801_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1974.05 65 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 49490801_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2945.89 97 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 49490801_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 2368.86 78 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 49490801_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2095.53 69 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 49490801_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 SIHO - ALL PLANS SIHO - ALL PLANS 2733.3 90 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 49490801_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 UMR - ALL PLANS UMR - ALL PLANS 2125.9 70 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 49490801_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1838.9 60.55 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 49490801_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1838.9 2945.89 CT scan of blood vessels of chest with contrast 49490801_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 ANTHEM HMO ANTHEM HMO 999999999 1838.9 2945.89 CT scan of blood vessels of chest with contrast 49490801_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1838.9 2945.89 CT scan of blood vessels of chest with contrast 49490801_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2053.01 67.6 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 49490801_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1838.9 2945.89 CT scan of blood vessels of chest with contrast 49490801_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1838.9 2945.89 Chemistry procedures 49495841_1 CDM 0301 RC 84999 HCPCS inpatient 129 83.85 AETNA AETNA 101.91 79 999999999 78.11 125.13 percent of total billed charges Chemistry procedures 49495841_1 CDM 0301 RC 84999 HCPCS inpatient 129 83.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 83.85 65 999999999 78.11 125.13 percent of total billed charges Chemistry procedures 49495841_1 CDM 0301 RC 84999 HCPCS inpatient 129 83.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 125.13 97 999999999 78.11 125.13 percent of total billed charges Chemistry procedures 49495841_1 CDM 0301 RC 84999 HCPCS inpatient 129 83.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 100.62 78 999999999 78.11 125.13 percent of total billed charges Chemistry procedures 49495841_1 CDM 0301 RC 84999 HCPCS inpatient 129 83.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.01 69 999999999 78.11 125.13 percent of total billed charges Chemistry procedures 49495841_1 CDM 0301 RC 84999 HCPCS inpatient 129 83.85 SIHO - ALL PLANS SIHO - ALL PLANS 116.1 90 999999999 78.11 125.13 percent of total billed charges Chemistry procedures 49495841_1 CDM 0301 RC 84999 HCPCS inpatient 129 83.85 UMR - ALL PLANS UMR - ALL PLANS 90.3 70 999999999 78.11 125.13 percent of total billed charges Chemistry procedures 49495841_1 CDM 0301 RC 84999 HCPCS inpatient 129 83.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.11 60.55 999999999 78.11 125.13 percent of total billed charges Chemistry procedures 49495841_1 CDM 0301 RC 84999 HCPCS inpatient 129 83.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.11 125.13 Chemistry procedures 49495841_1 CDM 0301 RC 84999 HCPCS inpatient 129 83.85 ANTHEM HMO ANTHEM HMO 999999999 78.11 125.13 Chemistry procedures 49495841_1 CDM 0301 RC 84999 HCPCS inpatient 129 83.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.11 125.13 Chemistry procedures 49495841_1 CDM 0301 RC 84999 HCPCS inpatient 129 83.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.2 67.6 999999999 78.11 125.13 percent of total billed charges Chemistry procedures 49495841_1 CDM 0301 RC 84999 HCPCS inpatient 129 83.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.11 125.13 Chemistry procedures 49495841_1 CDM 0301 RC 84999 HCPCS inpatient 129 83.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.11 125.13 DULOXETINE HCL DR 30 MG CAP 49505912_1 CDM 0250 RC 68084-0683-01 NDC inpatient 1 UN 3.25 2.11 AETNA AETNA 2.57 79 999999999 1.97 3.15 percent of total billed charges DULOXETINE HCL DR 30 MG CAP 49505912_1 CDM 0250 RC 68084-0683-01 NDC inpatient 1 UN 3.25 2.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.11 65 999999999 1.97 3.15 percent of total billed charges DULOXETINE HCL DR 30 MG CAP 49505912_1 CDM 0250 RC 68084-0683-01 NDC inpatient 1 UN 3.25 2.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.15 97 999999999 1.97 3.15 percent of total billed charges DULOXETINE HCL DR 30 MG CAP 49505912_1 CDM 0250 RC 68084-0683-01 NDC inpatient 1 UN 3.25 2.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.54 78 999999999 1.97 3.15 percent of total billed charges DULOXETINE HCL DR 30 MG CAP 49505912_1 CDM 0250 RC 68084-0683-01 NDC inpatient 1 UN 3.25 2.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.24 69 999999999 1.97 3.15 percent of total billed charges DULOXETINE HCL DR 30 MG CAP 49505912_1 CDM 0250 RC 68084-0683-01 NDC inpatient 1 UN 3.25 2.11 SIHO - ALL PLANS SIHO - ALL PLANS 2.93 90 999999999 1.97 3.15 percent of total billed charges DULOXETINE HCL DR 30 MG CAP 49505912_1 CDM 0250 RC 68084-0683-01 NDC inpatient 1 UN 3.25 2.11 UMR - ALL PLANS UMR - ALL PLANS 2.28 70 999999999 1.97 3.15 percent of total billed charges DULOXETINE HCL DR 30 MG CAP 49505912_1 CDM 0250 RC 68084-0683-01 NDC inpatient 1 UN 3.25 2.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.97 60.55 999999999 1.97 3.15 percent of total billed charges DULOXETINE HCL DR 30 MG CAP 49505912_1 CDM 0250 RC 68084-0683-01 NDC inpatient 1 UN 3.25 2.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.97 3.15 DULOXETINE HCL DR 30 MG CAP 49505912_1 CDM 0250 RC 68084-0683-01 NDC inpatient 1 UN 3.25 2.11 ANTHEM HMO ANTHEM HMO 999999999 1.97 3.15 DULOXETINE HCL DR 30 MG CAP 49505912_1 CDM 0250 RC 68084-0683-01 NDC inpatient 1 UN 3.25 2.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.97 3.15 DULOXETINE HCL DR 30 MG CAP 49505912_1 CDM 0250 RC 68084-0683-01 NDC inpatient 1 UN 3.25 2.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.2 67.6 999999999 1.97 3.15 percent of total billed charges DULOXETINE HCL DR 30 MG CAP 49505912_1 CDM 0250 RC 68084-0683-01 NDC inpatient 1 UN 3.25 2.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.97 3.15 DULOXETINE HCL DR 30 MG CAP 49505912_1 CDM 0250 RC 68084-0683-01 NDC inpatient 1 UN 3.25 2.11 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.97 3.15 RALOXIFENE HCL 60 MG TABLET 49505916_1 CDM 0250 RC 43598-0505-30 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges RALOXIFENE HCL 60 MG TABLET 49505916_1 CDM 0250 RC 43598-0505-30 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges RALOXIFENE HCL 60 MG TABLET 49505916_1 CDM 0250 RC 43598-0505-30 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges RALOXIFENE HCL 60 MG TABLET 49505916_1 CDM 0250 RC 43598-0505-30 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges RALOXIFENE HCL 60 MG TABLET 49505916_1 CDM 0250 RC 43598-0505-30 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges RALOXIFENE HCL 60 MG TABLET 49505916_1 CDM 0250 RC 43598-0505-30 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges RALOXIFENE HCL 60 MG TABLET 49505916_1 CDM 0250 RC 43598-0505-30 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges RALOXIFENE HCL 60 MG TABLET 49505916_1 CDM 0250 RC 43598-0505-30 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges RALOXIFENE HCL 60 MG TABLET 49505916_1 CDM 0250 RC 43598-0505-30 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 RALOXIFENE HCL 60 MG TABLET 49505916_1 CDM 0250 RC 43598-0505-30 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 RALOXIFENE HCL 60 MG TABLET 49505916_1 CDM 0250 RC 43598-0505-30 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 RALOXIFENE HCL 60 MG TABLET 49505916_1 CDM 0250 RC 43598-0505-30 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges RALOXIFENE HCL 60 MG TABLET 49505916_1 CDM 0250 RC 43598-0505-30 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 RALOXIFENE HCL 60 MG TABLET 49505916_1 CDM 0250 RC 43598-0505-30 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CYCLOBENZAPRINE 5 MG TABLET 49507919_1 CDM 0250 RC 68084-0753-25 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CYCLOBENZAPRINE 5 MG TABLET 49507919_1 CDM 0250 RC 68084-0753-25 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CYCLOBENZAPRINE 5 MG TABLET 49507919_1 CDM 0250 RC 68084-0753-25 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CYCLOBENZAPRINE 5 MG TABLET 49507919_1 CDM 0250 RC 68084-0753-25 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CYCLOBENZAPRINE 5 MG TABLET 49507919_1 CDM 0250 RC 68084-0753-25 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CYCLOBENZAPRINE 5 MG TABLET 49507919_1 CDM 0250 RC 68084-0753-25 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CYCLOBENZAPRINE 5 MG TABLET 49507919_1 CDM 0250 RC 68084-0753-25 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CYCLOBENZAPRINE 5 MG TABLET 49507919_1 CDM 0250 RC 68084-0753-25 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CYCLOBENZAPRINE 5 MG TABLET 49507919_1 CDM 0250 RC 68084-0753-25 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CYCLOBENZAPRINE 5 MG TABLET 49507919_1 CDM 0250 RC 68084-0753-25 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CYCLOBENZAPRINE 5 MG TABLET 49507919_1 CDM 0250 RC 68084-0753-25 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CYCLOBENZAPRINE 5 MG TABLET 49507919_1 CDM 0250 RC 68084-0753-25 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CYCLOBENZAPRINE 5 MG TABLET 49507919_1 CDM 0250 RC 68084-0753-25 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CYCLOBENZAPRINE 5 MG TABLET 49507919_1 CDM 0250 RC 68084-0753-25 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "Blood glucose (sugar) tolerance test, 3 specimens" 49514048_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514048_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514048_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514048_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514048_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514048_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514048_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514048_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514048_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 "Blood glucose (sugar) tolerance test, 3 specimens" 49514048_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 "Blood glucose (sugar) tolerance test, 3 specimens" 49514048_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 "Blood glucose (sugar) tolerance test, 3 specimens" 49514048_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514048_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 "Blood glucose (sugar) tolerance test, 3 specimens" 49514048_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 "Blood glucose (sugar) tolerance test, 3 specimens" 49514136_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514136_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514136_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514136_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514136_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514136_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514136_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514136_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514136_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 49514136_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 49514136_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 49514136_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514136_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 49514136_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 49514137_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514137_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514137_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514137_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514137_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514137_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514137_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514137_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514137_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 49514137_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 49514137_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 49514137_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514137_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 49514137_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 49514138_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514138_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514138_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514138_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514138_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514138_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514138_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514138_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514138_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 49514138_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 49514138_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 49514138_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49514138_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 49514138_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 Analysis for antibody bordetella (respiratory bacteria) 49515339_1 CDM 0300 RC 86615 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges Analysis for antibody bordetella (respiratory bacteria) 49515339_1 CDM 0300 RC 86615 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges Analysis for antibody bordetella (respiratory bacteria) 49515339_1 CDM 0300 RC 86615 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges Analysis for antibody bordetella (respiratory bacteria) 49515339_1 CDM 0300 RC 86615 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges Analysis for antibody bordetella (respiratory bacteria) 49515339_1 CDM 0300 RC 86615 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges Analysis for antibody bordetella (respiratory bacteria) 49515339_1 CDM 0300 RC 86615 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges Analysis for antibody bordetella (respiratory bacteria) 49515339_1 CDM 0300 RC 86615 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges Analysis for antibody bordetella (respiratory bacteria) 49515339_1 CDM 0300 RC 86615 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges Analysis for antibody bordetella (respiratory bacteria) 49515339_1 CDM 0300 RC 86615 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 Analysis for antibody bordetella (respiratory bacteria) 49515339_1 CDM 0300 RC 86615 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 Analysis for antibody bordetella (respiratory bacteria) 49515339_1 CDM 0300 RC 86615 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 Analysis for antibody bordetella (respiratory bacteria) 49515339_1 CDM 0300 RC 86615 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges Analysis for antibody bordetella (respiratory bacteria) 49515339_1 CDM 0300 RC 86615 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 Analysis for antibody bordetella (respiratory bacteria) 49515339_1 CDM 0300 RC 86615 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 Carbohydrate deficient transferrin (protein) level 49515340_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges Carbohydrate deficient transferrin (protein) level 49515340_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges Carbohydrate deficient transferrin (protein) level 49515340_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges Carbohydrate deficient transferrin (protein) level 49515340_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges Carbohydrate deficient transferrin (protein) level 49515340_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges Carbohydrate deficient transferrin (protein) level 49515340_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges Carbohydrate deficient transferrin (protein) level 49515340_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges Carbohydrate deficient transferrin (protein) level 49515340_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges Carbohydrate deficient transferrin (protein) level 49515340_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 Carbohydrate deficient transferrin (protein) level 49515340_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 Carbohydrate deficient transferrin (protein) level 49515340_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 Carbohydrate deficient transferrin (protein) level 49515340_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges Carbohydrate deficient transferrin (protein) level 49515340_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 Carbohydrate deficient transferrin (protein) level 49515340_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 PLATE PATH RED/RAPID BAC TES 49516031_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 AETNA AETNA 1357.22 79 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516031_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1116.7 65 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516031_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1666.46 97 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516031_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1340.04 78 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516031_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1185.42 69 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516031_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 SIHO - ALL PLANS SIHO - ALL PLANS 1546.2 90 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516031_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 UMR - ALL PLANS UMR - ALL PLANS 1202.6 70 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516031_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1040.25 60.55 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516031_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1040.25 1666.46 PLATE PATH RED/RAPID BAC TES 49516031_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 ANTHEM HMO ANTHEM HMO 999999999 1040.25 1666.46 PLATE PATH RED/RAPID BAC TES 49516031_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1040.25 1666.46 PLATE PATH RED/RAPID BAC TES 49516031_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1161.37 67.6 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516031_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1040.25 1666.46 PLATE PATH RED/RAPID BAC TES 49516031_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 1040.25 1666.46 PLATE PATH RED/RAPID BAC TES 49516032_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516032_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516032_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516032_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516032_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516032_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516032_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516032_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516032_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 49516032_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 49516032_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 49516032_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516032_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 49516032_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 49516033_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 AETNA AETNA 1357.22 79 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516033_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1116.7 65 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516033_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1666.46 97 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516033_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1340.04 78 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516033_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1185.42 69 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516033_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 SIHO - ALL PLANS SIHO - ALL PLANS 1546.2 90 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516033_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 UMR - ALL PLANS UMR - ALL PLANS 1202.6 70 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516033_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1040.25 60.55 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516033_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1040.25 1666.46 PLATE PATH RED/RAPID BAC TES 49516033_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 ANTHEM HMO ANTHEM HMO 999999999 1040.25 1666.46 PLATE PATH RED/RAPID BAC TES 49516033_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1040.25 1666.46 PLATE PATH RED/RAPID BAC TES 49516033_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1161.37 67.6 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 49516033_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1040.25 1666.46 PLATE PATH RED/RAPID BAC TES 49516033_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 1040.25 1666.46 MIACALCIN 400 UNIT/2 ML VIAL 49516177_1 CDM 0250 RC 67457-0675-02 NDC inpatient 1 UN 7924.09 5150.66 AETNA AETNA 6260.03 79 999999999 4798.04 7686.37 percent of total billed charges MIACALCIN 400 UNIT/2 ML VIAL 49516177_1 CDM 0250 RC 67457-0675-02 NDC inpatient 1 UN 7924.09 5150.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 5150.66 65 999999999 4798.04 7686.37 percent of total billed charges MIACALCIN 400 UNIT/2 ML VIAL 49516177_1 CDM 0250 RC 67457-0675-02 NDC inpatient 1 UN 7924.09 5150.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7686.37 97 999999999 4798.04 7686.37 percent of total billed charges MIACALCIN 400 UNIT/2 ML VIAL 49516177_1 CDM 0250 RC 67457-0675-02 NDC inpatient 1 UN 7924.09 5150.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 6180.79 78 999999999 4798.04 7686.37 percent of total billed charges MIACALCIN 400 UNIT/2 ML VIAL 49516177_1 CDM 0250 RC 67457-0675-02 NDC inpatient 1 UN 7924.09 5150.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 5467.62 69 999999999 4798.04 7686.37 percent of total billed charges MIACALCIN 400 UNIT/2 ML VIAL 49516177_1 CDM 0250 RC 67457-0675-02 NDC inpatient 1 UN 7924.09 5150.66 SIHO - ALL PLANS SIHO - ALL PLANS 7131.68 90 999999999 4798.04 7686.37 percent of total billed charges MIACALCIN 400 UNIT/2 ML VIAL 49516177_1 CDM 0250 RC 67457-0675-02 NDC inpatient 1 UN 7924.09 5150.66 UMR - ALL PLANS UMR - ALL PLANS 5546.86 70 999999999 4798.04 7686.37 percent of total billed charges MIACALCIN 400 UNIT/2 ML VIAL 49516177_1 CDM 0250 RC 67457-0675-02 NDC inpatient 1 UN 7924.09 5150.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4798.04 60.55 999999999 4798.04 7686.37 percent of total billed charges MIACALCIN 400 UNIT/2 ML VIAL 49516177_1 CDM 0250 RC 67457-0675-02 NDC inpatient 1 UN 7924.09 5150.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4798.04 7686.37 MIACALCIN 400 UNIT/2 ML VIAL 49516177_1 CDM 0250 RC 67457-0675-02 NDC inpatient 1 UN 7924.09 5150.66 ANTHEM HMO ANTHEM HMO 999999999 4798.04 7686.37 MIACALCIN 400 UNIT/2 ML VIAL 49516177_1 CDM 0250 RC 67457-0675-02 NDC inpatient 1 UN 7924.09 5150.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4798.04 7686.37 MIACALCIN 400 UNIT/2 ML VIAL 49516177_1 CDM 0250 RC 67457-0675-02 NDC inpatient 1 UN 7924.09 5150.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 5356.68 67.6 999999999 4798.04 7686.37 percent of total billed charges MIACALCIN 400 UNIT/2 ML VIAL 49516177_1 CDM 0250 RC 67457-0675-02 NDC inpatient 1 UN 7924.09 5150.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4798.04 7686.37 MIACALCIN 400 UNIT/2 ML VIAL 49516177_1 CDM 0250 RC 67457-0675-02 NDC inpatient 1 UN 7924.09 5150.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 4798.04 7686.37 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 49516218_1 CDM 0250 RC 00143-9262-25 NDC J0690 HCPCS inpatient 2 UN 15.58 10.13 AETNA AETNA 12.31 79 999999999 9.43 15.11 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 49516218_1 CDM 0250 RC 00143-9262-25 NDC J0690 HCPCS inpatient 2 UN 15.58 10.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.13 65 999999999 9.43 15.11 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 49516218_1 CDM 0250 RC 00143-9262-25 NDC J0690 HCPCS inpatient 2 UN 15.58 10.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15.11 97 999999999 9.43 15.11 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 49516218_1 CDM 0250 RC 00143-9262-25 NDC J0690 HCPCS inpatient 2 UN 15.58 10.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.15 78 999999999 9.43 15.11 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 49516218_1 CDM 0250 RC 00143-9262-25 NDC J0690 HCPCS inpatient 2 UN 15.58 10.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.75 69 999999999 9.43 15.11 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 49516218_1 CDM 0250 RC 00143-9262-25 NDC J0690 HCPCS inpatient 2 UN 15.58 10.13 SIHO - ALL PLANS SIHO - ALL PLANS 14.02 90 999999999 9.43 15.11 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 49516218_1 CDM 0250 RC 00143-9262-25 NDC J0690 HCPCS inpatient 2 UN 15.58 10.13 UMR - ALL PLANS UMR - ALL PLANS 10.91 70 999999999 9.43 15.11 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 49516218_1 CDM 0250 RC 00143-9262-25 NDC J0690 HCPCS inpatient 2 UN 15.58 10.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.43 60.55 999999999 9.43 15.11 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 49516218_1 CDM 0250 RC 00143-9262-25 NDC J0690 HCPCS inpatient 2 UN 15.58 10.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.43 15.11 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 49516218_1 CDM 0250 RC 00143-9262-25 NDC J0690 HCPCS inpatient 2 UN 15.58 10.13 ANTHEM HMO ANTHEM HMO 999999999 9.43 15.11 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 49516218_1 CDM 0250 RC 00143-9262-25 NDC J0690 HCPCS inpatient 2 UN 15.58 10.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.43 15.11 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 49516218_1 CDM 0250 RC 00143-9262-25 NDC J0690 HCPCS inpatient 2 UN 15.58 10.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.53 67.6 999999999 9.43 15.11 percent of total billed charges "INJECTION, CEFAZOLIN SODIUM, 500 MG" 49516218_1 CDM 0250 RC 00143-9262-25 NDC J0690 HCPCS inpatient 2 UN 15.58 10.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.43 15.11 "INJECTION, CEFAZOLIN SODIUM, 500 MG" 49516218_1 CDM 0250 RC 00143-9262-25 NDC J0690 HCPCS inpatient 2 UN 15.58 10.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.43 15.11 Thyroxine binding globulin (thyroid related protein) level 49516223_1 CDM 0301 RC 84442 HCPCS inpatient 191 124.15 AETNA AETNA 150.89 79 999999999 115.65 185.27 percent of total billed charges Thyroxine binding globulin (thyroid related protein) level 49516223_1 CDM 0301 RC 84442 HCPCS inpatient 191 124.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 124.15 65 999999999 115.65 185.27 percent of total billed charges Thyroxine binding globulin (thyroid related protein) level 49516223_1 CDM 0301 RC 84442 HCPCS inpatient 191 124.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 185.27 97 999999999 115.65 185.27 percent of total billed charges Thyroxine binding globulin (thyroid related protein) level 49516223_1 CDM 0301 RC 84442 HCPCS inpatient 191 124.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 148.98 78 999999999 115.65 185.27 percent of total billed charges Thyroxine binding globulin (thyroid related protein) level 49516223_1 CDM 0301 RC 84442 HCPCS inpatient 191 124.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 131.79 69 999999999 115.65 185.27 percent of total billed charges Thyroxine binding globulin (thyroid related protein) level 49516223_1 CDM 0301 RC 84442 HCPCS inpatient 191 124.15 SIHO - ALL PLANS SIHO - ALL PLANS 171.9 90 999999999 115.65 185.27 percent of total billed charges Thyroxine binding globulin (thyroid related protein) level 49516223_1 CDM 0301 RC 84442 HCPCS inpatient 191 124.15 UMR - ALL PLANS UMR - ALL PLANS 133.7 70 999999999 115.65 185.27 percent of total billed charges Thyroxine binding globulin (thyroid related protein) level 49516223_1 CDM 0301 RC 84442 HCPCS inpatient 191 124.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 115.65 60.55 999999999 115.65 185.27 percent of total billed charges Thyroxine binding globulin (thyroid related protein) level 49516223_1 CDM 0301 RC 84442 HCPCS inpatient 191 124.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 115.65 185.27 Thyroxine binding globulin (thyroid related protein) level 49516223_1 CDM 0301 RC 84442 HCPCS inpatient 191 124.15 ANTHEM HMO ANTHEM HMO 999999999 115.65 185.27 Thyroxine binding globulin (thyroid related protein) level 49516223_1 CDM 0301 RC 84442 HCPCS inpatient 191 124.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 115.65 185.27 Thyroxine binding globulin (thyroid related protein) level 49516223_1 CDM 0301 RC 84442 HCPCS inpatient 191 124.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 129.12 67.6 999999999 115.65 185.27 percent of total billed charges Thyroxine binding globulin (thyroid related protein) level 49516223_1 CDM 0301 RC 84442 HCPCS inpatient 191 124.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 115.65 185.27 Thyroxine binding globulin (thyroid related protein) level 49516223_1 CDM 0301 RC 84442 HCPCS inpatient 191 124.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 115.65 185.27 Clotting factor XIII (fibrin stabilizing) measurement 49516412_1 CDM 0305 RC 85290 HCPCS inpatient 236 153.4 AETNA AETNA 186.44 79 999999999 142.9 228.92 percent of total billed charges Clotting factor XIII (fibrin stabilizing) measurement 49516412_1 CDM 0305 RC 85290 HCPCS inpatient 236 153.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 153.4 65 999999999 142.9 228.92 percent of total billed charges Clotting factor XIII (fibrin stabilizing) measurement 49516412_1 CDM 0305 RC 85290 HCPCS inpatient 236 153.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 228.92 97 999999999 142.9 228.92 percent of total billed charges Clotting factor XIII (fibrin stabilizing) measurement 49516412_1 CDM 0305 RC 85290 HCPCS inpatient 236 153.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 184.08 78 999999999 142.9 228.92 percent of total billed charges Clotting factor XIII (fibrin stabilizing) measurement 49516412_1 CDM 0305 RC 85290 HCPCS inpatient 236 153.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 162.84 69 999999999 142.9 228.92 percent of total billed charges Clotting factor XIII (fibrin stabilizing) measurement 49516412_1 CDM 0305 RC 85290 HCPCS inpatient 236 153.4 SIHO - ALL PLANS SIHO - ALL PLANS 212.4 90 999999999 142.9 228.92 percent of total billed charges Clotting factor XIII (fibrin stabilizing) measurement 49516412_1 CDM 0305 RC 85290 HCPCS inpatient 236 153.4 UMR - ALL PLANS UMR - ALL PLANS 165.2 70 999999999 142.9 228.92 percent of total billed charges Clotting factor XIII (fibrin stabilizing) measurement 49516412_1 CDM 0305 RC 85290 HCPCS inpatient 236 153.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 142.9 60.55 999999999 142.9 228.92 percent of total billed charges Clotting factor XIII (fibrin stabilizing) measurement 49516412_1 CDM 0305 RC 85290 HCPCS inpatient 236 153.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 142.9 228.92 Clotting factor XIII (fibrin stabilizing) measurement 49516412_1 CDM 0305 RC 85290 HCPCS inpatient 236 153.4 ANTHEM HMO ANTHEM HMO 999999999 142.9 228.92 Clotting factor XIII (fibrin stabilizing) measurement 49516412_1 CDM 0305 RC 85290 HCPCS inpatient 236 153.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 142.9 228.92 Clotting factor XIII (fibrin stabilizing) measurement 49516412_1 CDM 0305 RC 85290 HCPCS inpatient 236 153.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 159.54 67.6 999999999 142.9 228.92 percent of total billed charges Clotting factor XIII (fibrin stabilizing) measurement 49516412_1 CDM 0305 RC 85290 HCPCS inpatient 236 153.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 142.9 228.92 Clotting factor XIII (fibrin stabilizing) measurement 49516412_1 CDM 0305 RC 85290 HCPCS inpatient 236 153.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 142.9 228.92 BUPROPION HCL XL 150 MG TABLET 49521653_1 CDM 0250 RC 60687-0312-01 NDC inpatient 1 UN 5.54 3.6 AETNA AETNA 4.38 79 999999999 3.35 5.37 percent of total billed charges BUPROPION HCL XL 150 MG TABLET 49521653_1 CDM 0250 RC 60687-0312-01 NDC inpatient 1 UN 5.54 3.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.6 65 999999999 3.35 5.37 percent of total billed charges BUPROPION HCL XL 150 MG TABLET 49521653_1 CDM 0250 RC 60687-0312-01 NDC inpatient 1 UN 5.54 3.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.37 97 999999999 3.35 5.37 percent of total billed charges BUPROPION HCL XL 150 MG TABLET 49521653_1 CDM 0250 RC 60687-0312-01 NDC inpatient 1 UN 5.54 3.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.32 78 999999999 3.35 5.37 percent of total billed charges BUPROPION HCL XL 150 MG TABLET 49521653_1 CDM 0250 RC 60687-0312-01 NDC inpatient 1 UN 5.54 3.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.82 69 999999999 3.35 5.37 percent of total billed charges BUPROPION HCL XL 150 MG TABLET 49521653_1 CDM 0250 RC 60687-0312-01 NDC inpatient 1 UN 5.54 3.6 SIHO - ALL PLANS SIHO - ALL PLANS 4.99 90 999999999 3.35 5.37 percent of total billed charges BUPROPION HCL XL 150 MG TABLET 49521653_1 CDM 0250 RC 60687-0312-01 NDC inpatient 1 UN 5.54 3.6 UMR - ALL PLANS UMR - ALL PLANS 3.88 70 999999999 3.35 5.37 percent of total billed charges BUPROPION HCL XL 150 MG TABLET 49521653_1 CDM 0250 RC 60687-0312-01 NDC inpatient 1 UN 5.54 3.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.35 60.55 999999999 3.35 5.37 percent of total billed charges BUPROPION HCL XL 150 MG TABLET 49521653_1 CDM 0250 RC 60687-0312-01 NDC inpatient 1 UN 5.54 3.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.35 5.37 BUPROPION HCL XL 150 MG TABLET 49521653_1 CDM 0250 RC 60687-0312-01 NDC inpatient 1 UN 5.54 3.6 ANTHEM HMO ANTHEM HMO 999999999 3.35 5.37 BUPROPION HCL XL 150 MG TABLET 49521653_1 CDM 0250 RC 60687-0312-01 NDC inpatient 1 UN 5.54 3.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.35 5.37 BUPROPION HCL XL 150 MG TABLET 49521653_1 CDM 0250 RC 60687-0312-01 NDC inpatient 1 UN 5.54 3.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.75 67.6 999999999 3.35 5.37 percent of total billed charges BUPROPION HCL XL 150 MG TABLET 49521653_1 CDM 0250 RC 60687-0312-01 NDC inpatient 1 UN 5.54 3.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.35 5.37 BUPROPION HCL XL 150 MG TABLET 49521653_1 CDM 0250 RC 60687-0312-01 NDC inpatient 1 UN 5.54 3.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.35 5.37 ROCURONIUM 50 MG/5 ML SYRINGE 49522089_1 CDM 0250 RC 69374-0924-05 NDC inpatient 1 UN 76.58 49.78 AETNA AETNA 60.5 79 999999999 46.37 74.28 percent of total billed charges ROCURONIUM 50 MG/5 ML SYRINGE 49522089_1 CDM 0250 RC 69374-0924-05 NDC inpatient 1 UN 76.58 49.78 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.78 65 999999999 46.37 74.28 percent of total billed charges ROCURONIUM 50 MG/5 ML SYRINGE 49522089_1 CDM 0250 RC 69374-0924-05 NDC inpatient 1 UN 76.58 49.78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.28 97 999999999 46.37 74.28 percent of total billed charges ROCURONIUM 50 MG/5 ML SYRINGE 49522089_1 CDM 0250 RC 69374-0924-05 NDC inpatient 1 UN 76.58 49.78 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.73 78 999999999 46.37 74.28 percent of total billed charges ROCURONIUM 50 MG/5 ML SYRINGE 49522089_1 CDM 0250 RC 69374-0924-05 NDC inpatient 1 UN 76.58 49.78 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.84 69 999999999 46.37 74.28 percent of total billed charges ROCURONIUM 50 MG/5 ML SYRINGE 49522089_1 CDM 0250 RC 69374-0924-05 NDC inpatient 1 UN 76.58 49.78 SIHO - ALL PLANS SIHO - ALL PLANS 68.92 90 999999999 46.37 74.28 percent of total billed charges ROCURONIUM 50 MG/5 ML SYRINGE 49522089_1 CDM 0250 RC 69374-0924-05 NDC inpatient 1 UN 76.58 49.78 UMR - ALL PLANS UMR - ALL PLANS 53.61 70 999999999 46.37 74.28 percent of total billed charges ROCURONIUM 50 MG/5 ML SYRINGE 49522089_1 CDM 0250 RC 69374-0924-05 NDC inpatient 1 UN 76.58 49.78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.37 60.55 999999999 46.37 74.28 percent of total billed charges ROCURONIUM 50 MG/5 ML SYRINGE 49522089_1 CDM 0250 RC 69374-0924-05 NDC inpatient 1 UN 76.58 49.78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.37 74.28 ROCURONIUM 50 MG/5 ML SYRINGE 49522089_1 CDM 0250 RC 69374-0924-05 NDC inpatient 1 UN 76.58 49.78 ANTHEM HMO ANTHEM HMO 999999999 46.37 74.28 ROCURONIUM 50 MG/5 ML SYRINGE 49522089_1 CDM 0250 RC 69374-0924-05 NDC inpatient 1 UN 76.58 49.78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.37 74.28 ROCURONIUM 50 MG/5 ML SYRINGE 49522089_1 CDM 0250 RC 69374-0924-05 NDC inpatient 1 UN 76.58 49.78 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.77 67.6 999999999 46.37 74.28 percent of total billed charges ROCURONIUM 50 MG/5 ML SYRINGE 49522089_1 CDM 0250 RC 69374-0924-05 NDC inpatient 1 UN 76.58 49.78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.37 74.28 ROCURONIUM 50 MG/5 ML SYRINGE 49522089_1 CDM 0250 RC 69374-0924-05 NDC inpatient 1 UN 76.58 49.78 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.37 74.28 GENTAMICIN 0.3% EYE DROP 49523833_1 CDM 0250 RC 60758-0188-05 NDC inpatient 1 UN 9.3 6.05 AETNA AETNA 7.35 79 999999999 5.63 9.02 percent of total billed charges GENTAMICIN 0.3% EYE DROP 49523833_1 CDM 0250 RC 60758-0188-05 NDC inpatient 1 UN 9.3 6.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.05 65 999999999 5.63 9.02 percent of total billed charges GENTAMICIN 0.3% EYE DROP 49523833_1 CDM 0250 RC 60758-0188-05 NDC inpatient 1 UN 9.3 6.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.02 97 999999999 5.63 9.02 percent of total billed charges GENTAMICIN 0.3% EYE DROP 49523833_1 CDM 0250 RC 60758-0188-05 NDC inpatient 1 UN 9.3 6.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.25 78 999999999 5.63 9.02 percent of total billed charges GENTAMICIN 0.3% EYE DROP 49523833_1 CDM 0250 RC 60758-0188-05 NDC inpatient 1 UN 9.3 6.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.42 69 999999999 5.63 9.02 percent of total billed charges GENTAMICIN 0.3% EYE DROP 49523833_1 CDM 0250 RC 60758-0188-05 NDC inpatient 1 UN 9.3 6.05 SIHO - ALL PLANS SIHO - ALL PLANS 8.37 90 999999999 5.63 9.02 percent of total billed charges GENTAMICIN 0.3% EYE DROP 49523833_1 CDM 0250 RC 60758-0188-05 NDC inpatient 1 UN 9.3 6.05 UMR - ALL PLANS UMR - ALL PLANS 6.51 70 999999999 5.63 9.02 percent of total billed charges GENTAMICIN 0.3% EYE DROP 49523833_1 CDM 0250 RC 60758-0188-05 NDC inpatient 1 UN 9.3 6.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.63 60.55 999999999 5.63 9.02 percent of total billed charges GENTAMICIN 0.3% EYE DROP 49523833_1 CDM 0250 RC 60758-0188-05 NDC inpatient 1 UN 9.3 6.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.63 9.02 GENTAMICIN 0.3% EYE DROP 49523833_1 CDM 0250 RC 60758-0188-05 NDC inpatient 1 UN 9.3 6.05 ANTHEM HMO ANTHEM HMO 999999999 5.63 9.02 GENTAMICIN 0.3% EYE DROP 49523833_1 CDM 0250 RC 60758-0188-05 NDC inpatient 1 UN 9.3 6.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.63 9.02 GENTAMICIN 0.3% EYE DROP 49523833_1 CDM 0250 RC 60758-0188-05 NDC inpatient 1 UN 9.3 6.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.29 67.6 999999999 5.63 9.02 percent of total billed charges GENTAMICIN 0.3% EYE DROP 49523833_1 CDM 0250 RC 60758-0188-05 NDC inpatient 1 UN 9.3 6.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.63 9.02 GENTAMICIN 0.3% EYE DROP 49523833_1 CDM 0250 RC 60758-0188-05 NDC inpatient 1 UN 9.3 6.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.63 9.02 KETOROLAC 0.5% OPHTH SOLUTION 49523834_1 CDM 0250 RC 61314-0126-05 NDC inpatient 1 UN 10.58 6.88 AETNA AETNA 8.36 79 999999999 6.41 10.26 percent of total billed charges KETOROLAC 0.5% OPHTH SOLUTION 49523834_1 CDM 0250 RC 61314-0126-05 NDC inpatient 1 UN 10.58 6.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.88 65 999999999 6.41 10.26 percent of total billed charges KETOROLAC 0.5% OPHTH SOLUTION 49523834_1 CDM 0250 RC 61314-0126-05 NDC inpatient 1 UN 10.58 6.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10.26 97 999999999 6.41 10.26 percent of total billed charges KETOROLAC 0.5% OPHTH SOLUTION 49523834_1 CDM 0250 RC 61314-0126-05 NDC inpatient 1 UN 10.58 6.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 8.25 78 999999999 6.41 10.26 percent of total billed charges KETOROLAC 0.5% OPHTH SOLUTION 49523834_1 CDM 0250 RC 61314-0126-05 NDC inpatient 1 UN 10.58 6.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.3 69 999999999 6.41 10.26 percent of total billed charges KETOROLAC 0.5% OPHTH SOLUTION 49523834_1 CDM 0250 RC 61314-0126-05 NDC inpatient 1 UN 10.58 6.88 SIHO - ALL PLANS SIHO - ALL PLANS 9.52 90 999999999 6.41 10.26 percent of total billed charges KETOROLAC 0.5% OPHTH SOLUTION 49523834_1 CDM 0250 RC 61314-0126-05 NDC inpatient 1 UN 10.58 6.88 UMR - ALL PLANS UMR - ALL PLANS 7.41 70 999999999 6.41 10.26 percent of total billed charges KETOROLAC 0.5% OPHTH SOLUTION 49523834_1 CDM 0250 RC 61314-0126-05 NDC inpatient 1 UN 10.58 6.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.41 60.55 999999999 6.41 10.26 percent of total billed charges KETOROLAC 0.5% OPHTH SOLUTION 49523834_1 CDM 0250 RC 61314-0126-05 NDC inpatient 1 UN 10.58 6.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.41 10.26 KETOROLAC 0.5% OPHTH SOLUTION 49523834_1 CDM 0250 RC 61314-0126-05 NDC inpatient 1 UN 10.58 6.88 ANTHEM HMO ANTHEM HMO 999999999 6.41 10.26 KETOROLAC 0.5% OPHTH SOLUTION 49523834_1 CDM 0250 RC 61314-0126-05 NDC inpatient 1 UN 10.58 6.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.41 10.26 KETOROLAC 0.5% OPHTH SOLUTION 49523834_1 CDM 0250 RC 61314-0126-05 NDC inpatient 1 UN 10.58 6.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 7.15 67.6 999999999 6.41 10.26 percent of total billed charges KETOROLAC 0.5% OPHTH SOLUTION 49523834_1 CDM 0250 RC 61314-0126-05 NDC inpatient 1 UN 10.58 6.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.41 10.26 KETOROLAC 0.5% OPHTH SOLUTION 49523834_1 CDM 0250 RC 61314-0126-05 NDC inpatient 1 UN 10.58 6.88 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.41 10.26 Multianalyte assay procedure with algorithmic analysis 49524233_1 CDM 0301 RC 81599 HCPCS inpatient 575 373.75 AETNA AETNA 454.25 79 999999999 348.16 557.75 percent of total billed charges Multianalyte assay procedure with algorithmic analysis 49524233_1 CDM 0301 RC 81599 HCPCS inpatient 575 373.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 373.75 65 999999999 348.16 557.75 percent of total billed charges Multianalyte assay procedure with algorithmic analysis 49524233_1 CDM 0301 RC 81599 HCPCS inpatient 575 373.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 557.75 97 999999999 348.16 557.75 percent of total billed charges Multianalyte assay procedure with algorithmic analysis 49524233_1 CDM 0301 RC 81599 HCPCS inpatient 575 373.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 448.5 78 999999999 348.16 557.75 percent of total billed charges Multianalyte assay procedure with algorithmic analysis 49524233_1 CDM 0301 RC 81599 HCPCS inpatient 575 373.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 396.75 69 999999999 348.16 557.75 percent of total billed charges Multianalyte assay procedure with algorithmic analysis 49524233_1 CDM 0301 RC 81599 HCPCS inpatient 575 373.75 SIHO - ALL PLANS SIHO - ALL PLANS 517.5 90 999999999 348.16 557.75 percent of total billed charges Multianalyte assay procedure with algorithmic analysis 49524233_1 CDM 0301 RC 81599 HCPCS inpatient 575 373.75 UMR - ALL PLANS UMR - ALL PLANS 402.5 70 999999999 348.16 557.75 percent of total billed charges Multianalyte assay procedure with algorithmic analysis 49524233_1 CDM 0301 RC 81599 HCPCS inpatient 575 373.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 348.16 60.55 999999999 348.16 557.75 percent of total billed charges Multianalyte assay procedure with algorithmic analysis 49524233_1 CDM 0301 RC 81599 HCPCS inpatient 575 373.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 348.16 557.75 Multianalyte assay procedure with algorithmic analysis 49524233_1 CDM 0301 RC 81599 HCPCS inpatient 575 373.75 ANTHEM HMO ANTHEM HMO 999999999 348.16 557.75 Multianalyte assay procedure with algorithmic analysis 49524233_1 CDM 0301 RC 81599 HCPCS inpatient 575 373.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 348.16 557.75 Multianalyte assay procedure with algorithmic analysis 49524233_1 CDM 0301 RC 81599 HCPCS inpatient 575 373.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 388.7 67.6 999999999 348.16 557.75 percent of total billed charges Multianalyte assay procedure with algorithmic analysis 49524233_1 CDM 0301 RC 81599 HCPCS inpatient 575 373.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 348.16 557.75 Multianalyte assay procedure with algorithmic analysis 49524233_1 CDM 0301 RC 81599 HCPCS inpatient 575 373.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 348.16 557.75 PHENOL LIQUID 49524678_1 CDM 0250 RC 38779-1938-05 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges PHENOL LIQUID 49524678_1 CDM 0250 RC 38779-1938-05 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges PHENOL LIQUID 49524678_1 CDM 0250 RC 38779-1938-05 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges PHENOL LIQUID 49524678_1 CDM 0250 RC 38779-1938-05 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges PHENOL LIQUID 49524678_1 CDM 0250 RC 38779-1938-05 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges PHENOL LIQUID 49524678_1 CDM 0250 RC 38779-1938-05 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges PHENOL LIQUID 49524678_1 CDM 0250 RC 38779-1938-05 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges PHENOL LIQUID 49524678_1 CDM 0250 RC 38779-1938-05 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges PHENOL LIQUID 49524678_1 CDM 0250 RC 38779-1938-05 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 PHENOL LIQUID 49524678_1 CDM 0250 RC 38779-1938-05 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 PHENOL LIQUID 49524678_1 CDM 0250 RC 38779-1938-05 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 PHENOL LIQUID 49524678_1 CDM 0250 RC 38779-1938-05 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges PHENOL LIQUID 49524678_1 CDM 0250 RC 38779-1938-05 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 PHENOL LIQUID 49524678_1 CDM 0250 RC 38779-1938-05 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "Antibody evaluation, initial single antibody stain procedure" 49524816_1 CDM 0301 RC 88346 HCPCS inpatient 337 219.05 AETNA AETNA 266.23 79 999999999 204.05 326.89 percent of total billed charges "Antibody evaluation, initial single antibody stain procedure" 49524816_1 CDM 0301 RC 88346 HCPCS inpatient 337 219.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 219.05 65 999999999 204.05 326.89 percent of total billed charges "Antibody evaluation, initial single antibody stain procedure" 49524816_1 CDM 0301 RC 88346 HCPCS inpatient 337 219.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 326.89 97 999999999 204.05 326.89 percent of total billed charges "Antibody evaluation, initial single antibody stain procedure" 49524816_1 CDM 0301 RC 88346 HCPCS inpatient 337 219.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 262.86 78 999999999 204.05 326.89 percent of total billed charges "Antibody evaluation, initial single antibody stain procedure" 49524816_1 CDM 0301 RC 88346 HCPCS inpatient 337 219.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 232.53 69 999999999 204.05 326.89 percent of total billed charges "Antibody evaluation, initial single antibody stain procedure" 49524816_1 CDM 0301 RC 88346 HCPCS inpatient 337 219.05 SIHO - ALL PLANS SIHO - ALL PLANS 303.3 90 999999999 204.05 326.89 percent of total billed charges "Antibody evaluation, initial single antibody stain procedure" 49524816_1 CDM 0301 RC 88346 HCPCS inpatient 337 219.05 UMR - ALL PLANS UMR - ALL PLANS 235.9 70 999999999 204.05 326.89 percent of total billed charges "Antibody evaluation, initial single antibody stain procedure" 49524816_1 CDM 0301 RC 88346 HCPCS inpatient 337 219.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 204.05 60.55 999999999 204.05 326.89 percent of total billed charges "Antibody evaluation, initial single antibody stain procedure" 49524816_1 CDM 0301 RC 88346 HCPCS inpatient 337 219.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 204.05 326.89 "Antibody evaluation, initial single antibody stain procedure" 49524816_1 CDM 0301 RC 88346 HCPCS inpatient 337 219.05 ANTHEM HMO ANTHEM HMO 999999999 204.05 326.89 "Antibody evaluation, initial single antibody stain procedure" 49524816_1 CDM 0301 RC 88346 HCPCS inpatient 337 219.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 204.05 326.89 "Antibody evaluation, initial single antibody stain procedure" 49524816_1 CDM 0301 RC 88346 HCPCS inpatient 337 219.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 227.81 67.6 999999999 204.05 326.89 percent of total billed charges "Antibody evaluation, initial single antibody stain procedure" 49524816_1 CDM 0301 RC 88346 HCPCS inpatient 337 219.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 204.05 326.89 "Antibody evaluation, initial single antibody stain procedure" 49524816_1 CDM 0301 RC 88346 HCPCS inpatient 337 219.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 204.05 326.89 "Antibody evaluation, each additional single antibody stain procedure" 49524818_1 CDM 0300 RC 88350 HCPCS inpatient 665 432.25 AETNA AETNA 525.35 79 999999999 402.66 645.05 percent of total billed charges "Antibody evaluation, each additional single antibody stain procedure" 49524818_1 CDM 0300 RC 88350 HCPCS inpatient 665 432.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 432.25 65 999999999 402.66 645.05 percent of total billed charges "Antibody evaluation, each additional single antibody stain procedure" 49524818_1 CDM 0300 RC 88350 HCPCS inpatient 665 432.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 645.05 97 999999999 402.66 645.05 percent of total billed charges "Antibody evaluation, each additional single antibody stain procedure" 49524818_1 CDM 0300 RC 88350 HCPCS inpatient 665 432.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 518.7 78 999999999 402.66 645.05 percent of total billed charges "Antibody evaluation, each additional single antibody stain procedure" 49524818_1 CDM 0300 RC 88350 HCPCS inpatient 665 432.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 458.85 69 999999999 402.66 645.05 percent of total billed charges "Antibody evaluation, each additional single antibody stain procedure" 49524818_1 CDM 0300 RC 88350 HCPCS inpatient 665 432.25 SIHO - ALL PLANS SIHO - ALL PLANS 598.5 90 999999999 402.66 645.05 percent of total billed charges "Antibody evaluation, each additional single antibody stain procedure" 49524818_1 CDM 0300 RC 88350 HCPCS inpatient 665 432.25 UMR - ALL PLANS UMR - ALL PLANS 465.5 70 999999999 402.66 645.05 percent of total billed charges "Antibody evaluation, each additional single antibody stain procedure" 49524818_1 CDM 0300 RC 88350 HCPCS inpatient 665 432.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 402.66 60.55 999999999 402.66 645.05 percent of total billed charges "Antibody evaluation, each additional single antibody stain procedure" 49524818_1 CDM 0300 RC 88350 HCPCS inpatient 665 432.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 402.66 645.05 "Antibody evaluation, each additional single antibody stain procedure" 49524818_1 CDM 0300 RC 88350 HCPCS inpatient 665 432.25 ANTHEM HMO ANTHEM HMO 999999999 402.66 645.05 "Antibody evaluation, each additional single antibody stain procedure" 49524818_1 CDM 0300 RC 88350 HCPCS inpatient 665 432.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 402.66 645.05 "Antibody evaluation, each additional single antibody stain procedure" 49524818_1 CDM 0300 RC 88350 HCPCS inpatient 665 432.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 449.54 67.6 999999999 402.66 645.05 percent of total billed charges "Antibody evaluation, each additional single antibody stain procedure" 49524818_1 CDM 0300 RC 88350 HCPCS inpatient 665 432.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 402.66 645.05 "Antibody evaluation, each additional single antibody stain procedure" 49524818_1 CDM 0300 RC 88350 HCPCS inpatient 665 432.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 402.66 645.05 "Antibody evaluation, initial single antibody stain procedure" 49524820_1 CDM 0300 RC 88346 HCPCS inpatient 200 130 AETNA AETNA 158 79 999999999 121.1 194 percent of total billed charges "Antibody evaluation, initial single antibody stain procedure" 49524820_1 CDM 0300 RC 88346 HCPCS inpatient 200 130 SELF PAY DISCOUNT SELF PAY DISCOUNT 130 65 999999999 121.1 194 percent of total billed charges "Antibody evaluation, initial single antibody stain procedure" 49524820_1 CDM 0300 RC 88346 HCPCS inpatient 200 130 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 194 97 999999999 121.1 194 percent of total billed charges "Antibody evaluation, initial single antibody stain procedure" 49524820_1 CDM 0300 RC 88346 HCPCS inpatient 200 130 HUMANA - ALL PLANS HUMANA - ALL PLANS 156 78 999999999 121.1 194 percent of total billed charges "Antibody evaluation, initial single antibody stain procedure" 49524820_1 CDM 0300 RC 88346 HCPCS inpatient 200 130 ENCORE - ALL PLANS ENCORE - ALL PLANS 138 69 999999999 121.1 194 percent of total billed charges "Antibody evaluation, initial single antibody stain procedure" 49524820_1 CDM 0300 RC 88346 HCPCS inpatient 200 130 SIHO - ALL PLANS SIHO - ALL PLANS 180 90 999999999 121.1 194 percent of total billed charges "Antibody evaluation, initial single antibody stain procedure" 49524820_1 CDM 0300 RC 88346 HCPCS inpatient 200 130 UMR - ALL PLANS UMR - ALL PLANS 140 70 999999999 121.1 194 percent of total billed charges "Antibody evaluation, initial single antibody stain procedure" 49524820_1 CDM 0300 RC 88346 HCPCS inpatient 200 130 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 121.1 60.55 999999999 121.1 194 percent of total billed charges "Antibody evaluation, initial single antibody stain procedure" 49524820_1 CDM 0300 RC 88346 HCPCS inpatient 200 130 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 121.1 194 "Antibody evaluation, initial single antibody stain procedure" 49524820_1 CDM 0300 RC 88346 HCPCS inpatient 200 130 ANTHEM HMO ANTHEM HMO 999999999 121.1 194 "Antibody evaluation, initial single antibody stain procedure" 49524820_1 CDM 0300 RC 88346 HCPCS inpatient 200 130 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 121.1 194 "Antibody evaluation, initial single antibody stain procedure" 49524820_1 CDM 0300 RC 88346 HCPCS inpatient 200 130 CIGNA - ALL PLANS CIGNA - ALL PLANS 135.2 67.6 999999999 121.1 194 percent of total billed charges "Antibody evaluation, initial single antibody stain procedure" 49524820_1 CDM 0300 RC 88346 HCPCS inpatient 200 130 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 121.1 194 "Antibody evaluation, initial single antibody stain procedure" 49524820_1 CDM 0300 RC 88346 HCPCS inpatient 200 130 UHC - ALL PLANS UHC - ALL PLANS 999999999 121.1 194 "Antibody evaluation, each additional single antibody stain procedure" 49524999_1 CDM 0301 RC 88350 HCPCS inpatient 732 475.8 AETNA AETNA 578.28 79 999999999 443.23 710.04 percent of total billed charges "Antibody evaluation, each additional single antibody stain procedure" 49524999_1 CDM 0301 RC 88350 HCPCS inpatient 732 475.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 475.8 65 999999999 443.23 710.04 percent of total billed charges "Antibody evaluation, each additional single antibody stain procedure" 49524999_1 CDM 0301 RC 88350 HCPCS inpatient 732 475.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 710.04 97 999999999 443.23 710.04 percent of total billed charges "Antibody evaluation, each additional single antibody stain procedure" 49524999_1 CDM 0301 RC 88350 HCPCS inpatient 732 475.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 570.96 78 999999999 443.23 710.04 percent of total billed charges "Antibody evaluation, each additional single antibody stain procedure" 49524999_1 CDM 0301 RC 88350 HCPCS inpatient 732 475.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 505.08 69 999999999 443.23 710.04 percent of total billed charges "Antibody evaluation, each additional single antibody stain procedure" 49524999_1 CDM 0301 RC 88350 HCPCS inpatient 732 475.8 SIHO - ALL PLANS SIHO - ALL PLANS 658.8 90 999999999 443.23 710.04 percent of total billed charges "Antibody evaluation, each additional single antibody stain procedure" 49524999_1 CDM 0301 RC 88350 HCPCS inpatient 732 475.8 UMR - ALL PLANS UMR - ALL PLANS 512.4 70 999999999 443.23 710.04 percent of total billed charges "Antibody evaluation, each additional single antibody stain procedure" 49524999_1 CDM 0301 RC 88350 HCPCS inpatient 732 475.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 443.23 60.55 999999999 443.23 710.04 percent of total billed charges "Antibody evaluation, each additional single antibody stain procedure" 49524999_1 CDM 0301 RC 88350 HCPCS inpatient 732 475.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 443.23 710.04 "Antibody evaluation, each additional single antibody stain procedure" 49524999_1 CDM 0301 RC 88350 HCPCS inpatient 732 475.8 ANTHEM HMO ANTHEM HMO 999999999 443.23 710.04 "Antibody evaluation, each additional single antibody stain procedure" 49524999_1 CDM 0301 RC 88350 HCPCS inpatient 732 475.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 443.23 710.04 "Antibody evaluation, each additional single antibody stain procedure" 49524999_1 CDM 0301 RC 88350 HCPCS inpatient 732 475.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 494.83 67.6 999999999 443.23 710.04 percent of total billed charges "Antibody evaluation, each additional single antibody stain procedure" 49524999_1 CDM 0301 RC 88350 HCPCS inpatient 732 475.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 443.23 710.04 "Antibody evaluation, each additional single antibody stain procedure" 49524999_1 CDM 0301 RC 88350 HCPCS inpatient 732 475.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 443.23 710.04 Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 49527821_1 CDM 0360 RC 64447 HCPCS inpatient 795 516.75 AETNA AETNA 628.05 79 999999999 481.37 771.15 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 49527821_1 CDM 0360 RC 64447 HCPCS inpatient 795 516.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 516.75 65 999999999 481.37 771.15 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 49527821_1 CDM 0360 RC 64447 HCPCS inpatient 795 516.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 771.15 97 999999999 481.37 771.15 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 49527821_1 CDM 0360 RC 64447 HCPCS inpatient 795 516.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 620.1 78 999999999 481.37 771.15 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 49527821_1 CDM 0360 RC 64447 HCPCS inpatient 795 516.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 548.55 69 999999999 481.37 771.15 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 49527821_1 CDM 0360 RC 64447 HCPCS inpatient 795 516.75 SIHO - ALL PLANS SIHO - ALL PLANS 715.5 90 999999999 481.37 771.15 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 49527821_1 CDM 0360 RC 64447 HCPCS inpatient 795 516.75 UMR - ALL PLANS UMR - ALL PLANS 556.5 70 999999999 481.37 771.15 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 49527821_1 CDM 0360 RC 64447 HCPCS inpatient 795 516.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 481.37 60.55 999999999 481.37 771.15 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 49527821_1 CDM 0360 RC 64447 HCPCS inpatient 795 516.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 481.37 771.15 Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 49527821_1 CDM 0360 RC 64447 HCPCS inpatient 795 516.75 ANTHEM HMO ANTHEM HMO 999999999 481.37 771.15 Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 49527821_1 CDM 0360 RC 64447 HCPCS inpatient 795 516.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 481.37 771.15 Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 49527821_1 CDM 0360 RC 64447 HCPCS inpatient 795 516.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 537.42 67.6 999999999 481.37 771.15 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 49527821_1 CDM 0360 RC 64447 HCPCS inpatient 795 516.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 481.37 771.15 Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 49527821_1 CDM 0360 RC 64447 HCPCS inpatient 795 516.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 481.37 771.15 Mass spectrometry (laboratory testing method) 49528211_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 AETNA AETNA 273.34 79 999999999 209.5 335.62 percent of total billed charges Mass spectrometry (laboratory testing method) 49528211_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 224.9 65 999999999 209.5 335.62 percent of total billed charges Mass spectrometry (laboratory testing method) 49528211_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 335.62 97 999999999 209.5 335.62 percent of total billed charges Mass spectrometry (laboratory testing method) 49528211_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 269.88 78 999999999 209.5 335.62 percent of total billed charges Mass spectrometry (laboratory testing method) 49528211_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 238.74 69 999999999 209.5 335.62 percent of total billed charges Mass spectrometry (laboratory testing method) 49528211_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 SIHO - ALL PLANS SIHO - ALL PLANS 311.4 90 999999999 209.5 335.62 percent of total billed charges Mass spectrometry (laboratory testing method) 49528211_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 UMR - ALL PLANS UMR - ALL PLANS 242.2 70 999999999 209.5 335.62 percent of total billed charges Mass spectrometry (laboratory testing method) 49528211_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 209.5 60.55 999999999 209.5 335.62 percent of total billed charges Mass spectrometry (laboratory testing method) 49528211_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 209.5 335.62 Mass spectrometry (laboratory testing method) 49528211_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 ANTHEM HMO ANTHEM HMO 999999999 209.5 335.62 Mass spectrometry (laboratory testing method) 49528211_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 209.5 335.62 Mass spectrometry (laboratory testing method) 49528211_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 233.9 67.6 999999999 209.5 335.62 percent of total billed charges Mass spectrometry (laboratory testing method) 49528211_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 209.5 335.62 Mass spectrometry (laboratory testing method) 49528211_1 CDM 0301 RC 83789 HCPCS inpatient 346 224.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 209.5 335.62 Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 49528213_1 CDM 0311 RC 81229 HCPCS inpatient 4579 2976.35 AETNA AETNA 3617.41 79 999999999 2772.58 4441.63 percent of total billed charges Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 49528213_1 CDM 0311 RC 81229 HCPCS inpatient 4579 2976.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 2976.35 65 999999999 2772.58 4441.63 percent of total billed charges Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 49528213_1 CDM 0311 RC 81229 HCPCS inpatient 4579 2976.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4441.63 97 999999999 2772.58 4441.63 percent of total billed charges Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 49528213_1 CDM 0311 RC 81229 HCPCS inpatient 4579 2976.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 3571.62 78 999999999 2772.58 4441.63 percent of total billed charges Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 49528213_1 CDM 0311 RC 81229 HCPCS inpatient 4579 2976.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 3159.51 69 999999999 2772.58 4441.63 percent of total billed charges Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 49528213_1 CDM 0311 RC 81229 HCPCS inpatient 4579 2976.35 SIHO - ALL PLANS SIHO - ALL PLANS 4121.1 90 999999999 2772.58 4441.63 percent of total billed charges Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 49528213_1 CDM 0311 RC 81229 HCPCS inpatient 4579 2976.35 UMR - ALL PLANS UMR - ALL PLANS 3205.3 70 999999999 2772.58 4441.63 percent of total billed charges Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 49528213_1 CDM 0311 RC 81229 HCPCS inpatient 4579 2976.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2772.58 60.55 999999999 2772.58 4441.63 percent of total billed charges Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 49528213_1 CDM 0311 RC 81229 HCPCS inpatient 4579 2976.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2772.58 4441.63 Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 49528213_1 CDM 0311 RC 81229 HCPCS inpatient 4579 2976.35 ANTHEM HMO ANTHEM HMO 999999999 2772.58 4441.63 Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 49528213_1 CDM 0311 RC 81229 HCPCS inpatient 4579 2976.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2772.58 4441.63 Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 49528213_1 CDM 0311 RC 81229 HCPCS inpatient 4579 2976.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 3095.4 67.6 999999999 2772.58 4441.63 percent of total billed charges Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 49528213_1 CDM 0311 RC 81229 HCPCS inpatient 4579 2976.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2772.58 4441.63 Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 49528213_1 CDM 0311 RC 81229 HCPCS inpatient 4579 2976.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 2772.58 4441.63 00904-6083-61 - zolpidem 10 mg Tab[JOHN] 49529156_1 CDM 0250 RC 00904-6083-61 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 00904-6083-61 - zolpidem 10 mg Tab[JOHN] 49529156_1 CDM 0250 RC 00904-6083-61 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 00904-6083-61 - zolpidem 10 mg Tab[JOHN] 49529156_1 CDM 0250 RC 00904-6083-61 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 00904-6083-61 - zolpidem 10 mg Tab[JOHN] 49529156_1 CDM 0250 RC 00904-6083-61 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 00904-6083-61 - zolpidem 10 mg Tab[JOHN] 49529156_1 CDM 0250 RC 00904-6083-61 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 00904-6083-61 - zolpidem 10 mg Tab[JOHN] 49529156_1 CDM 0250 RC 00904-6083-61 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 00904-6083-61 - zolpidem 10 mg Tab[JOHN] 49529156_1 CDM 0250 RC 00904-6083-61 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 00904-6083-61 - zolpidem 10 mg Tab[JOHN] 49529156_1 CDM 0250 RC 00904-6083-61 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 00904-6083-61 - zolpidem 10 mg Tab[JOHN] 49529156_1 CDM 0250 RC 00904-6083-61 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 00904-6083-61 - zolpidem 10 mg Tab[JOHN] 49529156_1 CDM 0250 RC 00904-6083-61 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 00904-6083-61 - zolpidem 10 mg Tab[JOHN] 49529156_1 CDM 0250 RC 00904-6083-61 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 00904-6083-61 - zolpidem 10 mg Tab[JOHN] 49529156_1 CDM 0250 RC 00904-6083-61 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 00904-6083-61 - zolpidem 10 mg Tab[JOHN] 49529156_1 CDM 0250 RC 00904-6083-61 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 00904-6083-61 - zolpidem 10 mg Tab[JOHN] 49529156_1 CDM 0250 RC 00904-6083-61 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 METHADONE HCL 10 MG TABLET 49530271_1 CDM 0250 RC 68084-0738-01 NDC inpatient 1 UN 1.12 0.73 AETNA AETNA 0.88 79 999999999 0.68 1.09 percent of total billed charges METHADONE HCL 10 MG TABLET 49530271_1 CDM 0250 RC 68084-0738-01 NDC inpatient 1 UN 1.12 0.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.73 65 999999999 0.68 1.09 percent of total billed charges METHADONE HCL 10 MG TABLET 49530271_1 CDM 0250 RC 68084-0738-01 NDC inpatient 1 UN 1.12 0.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.09 97 999999999 0.68 1.09 percent of total billed charges METHADONE HCL 10 MG TABLET 49530271_1 CDM 0250 RC 68084-0738-01 NDC inpatient 1 UN 1.12 0.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.87 78 999999999 0.68 1.09 percent of total billed charges METHADONE HCL 10 MG TABLET 49530271_1 CDM 0250 RC 68084-0738-01 NDC inpatient 1 UN 1.12 0.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.77 69 999999999 0.68 1.09 percent of total billed charges METHADONE HCL 10 MG TABLET 49530271_1 CDM 0250 RC 68084-0738-01 NDC inpatient 1 UN 1.12 0.73 SIHO - ALL PLANS SIHO - ALL PLANS 1.01 90 999999999 0.68 1.09 percent of total billed charges METHADONE HCL 10 MG TABLET 49530271_1 CDM 0250 RC 68084-0738-01 NDC inpatient 1 UN 1.12 0.73 UMR - ALL PLANS UMR - ALL PLANS 0.78 70 999999999 0.68 1.09 percent of total billed charges METHADONE HCL 10 MG TABLET 49530271_1 CDM 0250 RC 68084-0738-01 NDC inpatient 1 UN 1.12 0.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.68 60.55 999999999 0.68 1.09 percent of total billed charges METHADONE HCL 10 MG TABLET 49530271_1 CDM 0250 RC 68084-0738-01 NDC inpatient 1 UN 1.12 0.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.68 1.09 METHADONE HCL 10 MG TABLET 49530271_1 CDM 0250 RC 68084-0738-01 NDC inpatient 1 UN 1.12 0.73 ANTHEM HMO ANTHEM HMO 999999999 0.68 1.09 METHADONE HCL 10 MG TABLET 49530271_1 CDM 0250 RC 68084-0738-01 NDC inpatient 1 UN 1.12 0.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.68 1.09 METHADONE HCL 10 MG TABLET 49530271_1 CDM 0250 RC 68084-0738-01 NDC inpatient 1 UN 1.12 0.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.76 67.6 999999999 0.68 1.09 percent of total billed charges METHADONE HCL 10 MG TABLET 49530271_1 CDM 0250 RC 68084-0738-01 NDC inpatient 1 UN 1.12 0.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.68 1.09 METHADONE HCL 10 MG TABLET 49530271_1 CDM 0250 RC 68084-0738-01 NDC inpatient 1 UN 1.12 0.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.68 1.09 MORPHINE SULF ER 15 MG TABLET 49530387_1 CDM 0250 RC 00406-8315-62 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges MORPHINE SULF ER 15 MG TABLET 49530387_1 CDM 0250 RC 00406-8315-62 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges MORPHINE SULF ER 15 MG TABLET 49530387_1 CDM 0250 RC 00406-8315-62 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges MORPHINE SULF ER 15 MG TABLET 49530387_1 CDM 0250 RC 00406-8315-62 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges MORPHINE SULF ER 15 MG TABLET 49530387_1 CDM 0250 RC 00406-8315-62 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges MORPHINE SULF ER 15 MG TABLET 49530387_1 CDM 0250 RC 00406-8315-62 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges MORPHINE SULF ER 15 MG TABLET 49530387_1 CDM 0250 RC 00406-8315-62 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges MORPHINE SULF ER 15 MG TABLET 49530387_1 CDM 0250 RC 00406-8315-62 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges MORPHINE SULF ER 15 MG TABLET 49530387_1 CDM 0250 RC 00406-8315-62 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 MORPHINE SULF ER 15 MG TABLET 49530387_1 CDM 0250 RC 00406-8315-62 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 MORPHINE SULF ER 15 MG TABLET 49530387_1 CDM 0250 RC 00406-8315-62 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 MORPHINE SULF ER 15 MG TABLET 49530387_1 CDM 0250 RC 00406-8315-62 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges MORPHINE SULF ER 15 MG TABLET 49530387_1 CDM 0250 RC 00406-8315-62 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 MORPHINE SULF ER 15 MG TABLET 49530387_1 CDM 0250 RC 00406-8315-62 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ARIPIPRAZOLE 15 MG TABLET 49534936_1 CDM 0250 RC 62332-0100-30 NDC inpatient 1 UN 1.5 0.98 AETNA AETNA 1.19 79 999999999 0.91 1.46 percent of total billed charges ARIPIPRAZOLE 15 MG TABLET 49534936_1 CDM 0250 RC 62332-0100-30 NDC inpatient 1 UN 1.5 0.98 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.98 65 999999999 0.91 1.46 percent of total billed charges ARIPIPRAZOLE 15 MG TABLET 49534936_1 CDM 0250 RC 62332-0100-30 NDC inpatient 1 UN 1.5 0.98 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.46 97 999999999 0.91 1.46 percent of total billed charges ARIPIPRAZOLE 15 MG TABLET 49534936_1 CDM 0250 RC 62332-0100-30 NDC inpatient 1 UN 1.5 0.98 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.17 78 999999999 0.91 1.46 percent of total billed charges ARIPIPRAZOLE 15 MG TABLET 49534936_1 CDM 0250 RC 62332-0100-30 NDC inpatient 1 UN 1.5 0.98 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.04 69 999999999 0.91 1.46 percent of total billed charges ARIPIPRAZOLE 15 MG TABLET 49534936_1 CDM 0250 RC 62332-0100-30 NDC inpatient 1 UN 1.5 0.98 SIHO - ALL PLANS SIHO - ALL PLANS 1.35 90 999999999 0.91 1.46 percent of total billed charges ARIPIPRAZOLE 15 MG TABLET 49534936_1 CDM 0250 RC 62332-0100-30 NDC inpatient 1 UN 1.5 0.98 UMR - ALL PLANS UMR - ALL PLANS 1.05 70 999999999 0.91 1.46 percent of total billed charges ARIPIPRAZOLE 15 MG TABLET 49534936_1 CDM 0250 RC 62332-0100-30 NDC inpatient 1 UN 1.5 0.98 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.91 60.55 999999999 0.91 1.46 percent of total billed charges ARIPIPRAZOLE 15 MG TABLET 49534936_1 CDM 0250 RC 62332-0100-30 NDC inpatient 1 UN 1.5 0.98 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.91 1.46 ARIPIPRAZOLE 15 MG TABLET 49534936_1 CDM 0250 RC 62332-0100-30 NDC inpatient 1 UN 1.5 0.98 ANTHEM HMO ANTHEM HMO 999999999 0.91 1.46 ARIPIPRAZOLE 15 MG TABLET 49534936_1 CDM 0250 RC 62332-0100-30 NDC inpatient 1 UN 1.5 0.98 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.91 1.46 ARIPIPRAZOLE 15 MG TABLET 49534936_1 CDM 0250 RC 62332-0100-30 NDC inpatient 1 UN 1.5 0.98 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.01 67.6 999999999 0.91 1.46 percent of total billed charges ARIPIPRAZOLE 15 MG TABLET 49534936_1 CDM 0250 RC 62332-0100-30 NDC inpatient 1 UN 1.5 0.98 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.91 1.46 ARIPIPRAZOLE 15 MG TABLET 49534936_1 CDM 0250 RC 62332-0100-30 NDC inpatient 1 UN 1.5 0.98 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.91 1.46 XARELTO 20 MG TABLET 49535025_1 CDM 0250 RC 50458-0579-30 NDC inpatient 1 UN 53.4 34.71 AETNA AETNA 42.19 79 999999999 32.33 51.8 percent of total billed charges XARELTO 20 MG TABLET 49535025_1 CDM 0250 RC 50458-0579-30 NDC inpatient 1 UN 53.4 34.71 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.71 65 999999999 32.33 51.8 percent of total billed charges XARELTO 20 MG TABLET 49535025_1 CDM 0250 RC 50458-0579-30 NDC inpatient 1 UN 53.4 34.71 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.8 97 999999999 32.33 51.8 percent of total billed charges XARELTO 20 MG TABLET 49535025_1 CDM 0250 RC 50458-0579-30 NDC inpatient 1 UN 53.4 34.71 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.65 78 999999999 32.33 51.8 percent of total billed charges XARELTO 20 MG TABLET 49535025_1 CDM 0250 RC 50458-0579-30 NDC inpatient 1 UN 53.4 34.71 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.85 69 999999999 32.33 51.8 percent of total billed charges XARELTO 20 MG TABLET 49535025_1 CDM 0250 RC 50458-0579-30 NDC inpatient 1 UN 53.4 34.71 SIHO - ALL PLANS SIHO - ALL PLANS 48.06 90 999999999 32.33 51.8 percent of total billed charges XARELTO 20 MG TABLET 49535025_1 CDM 0250 RC 50458-0579-30 NDC inpatient 1 UN 53.4 34.71 UMR - ALL PLANS UMR - ALL PLANS 37.38 70 999999999 32.33 51.8 percent of total billed charges XARELTO 20 MG TABLET 49535025_1 CDM 0250 RC 50458-0579-30 NDC inpatient 1 UN 53.4 34.71 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.33 60.55 999999999 32.33 51.8 percent of total billed charges XARELTO 20 MG TABLET 49535025_1 CDM 0250 RC 50458-0579-30 NDC inpatient 1 UN 53.4 34.71 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.33 51.8 XARELTO 20 MG TABLET 49535025_1 CDM 0250 RC 50458-0579-30 NDC inpatient 1 UN 53.4 34.71 ANTHEM HMO ANTHEM HMO 999999999 32.33 51.8 XARELTO 20 MG TABLET 49535025_1 CDM 0250 RC 50458-0579-30 NDC inpatient 1 UN 53.4 34.71 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.33 51.8 XARELTO 20 MG TABLET 49535025_1 CDM 0250 RC 50458-0579-30 NDC inpatient 1 UN 53.4 34.71 CIGNA - ALL PLANS CIGNA - ALL PLANS 36.1 67.6 999999999 32.33 51.8 percent of total billed charges XARELTO 20 MG TABLET 49535025_1 CDM 0250 RC 50458-0579-30 NDC inpatient 1 UN 53.4 34.71 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.33 51.8 XARELTO 20 MG TABLET 49535025_1 CDM 0250 RC 50458-0579-30 NDC inpatient 1 UN 53.4 34.71 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.33 51.8 ADMINISTRATION OF PNEUMOCOCCAL VACCINE 49535134_1 CDM 0510 RC G0009 HCPCS inpatient 51 33.15 AETNA AETNA 40.29 79 999999999 30.88 49.47 percent of total billed charges ADMINISTRATION OF PNEUMOCOCCAL VACCINE 49535134_1 CDM 0510 RC G0009 HCPCS inpatient 51 33.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 33.15 65 999999999 30.88 49.47 percent of total billed charges ADMINISTRATION OF PNEUMOCOCCAL VACCINE 49535134_1 CDM 0510 RC G0009 HCPCS inpatient 51 33.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 49.47 97 999999999 30.88 49.47 percent of total billed charges ADMINISTRATION OF PNEUMOCOCCAL VACCINE 49535134_1 CDM 0510 RC G0009 HCPCS inpatient 51 33.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 39.78 78 999999999 30.88 49.47 percent of total billed charges ADMINISTRATION OF PNEUMOCOCCAL VACCINE 49535134_1 CDM 0510 RC G0009 HCPCS inpatient 51 33.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 35.19 69 999999999 30.88 49.47 percent of total billed charges ADMINISTRATION OF PNEUMOCOCCAL VACCINE 49535134_1 CDM 0510 RC G0009 HCPCS inpatient 51 33.15 SIHO - ALL PLANS SIHO - ALL PLANS 45.9 90 999999999 30.88 49.47 percent of total billed charges ADMINISTRATION OF PNEUMOCOCCAL VACCINE 49535134_1 CDM 0510 RC G0009 HCPCS inpatient 51 33.15 UMR - ALL PLANS UMR - ALL PLANS 35.7 70 999999999 30.88 49.47 percent of total billed charges ADMINISTRATION OF PNEUMOCOCCAL VACCINE 49535134_1 CDM 0510 RC G0009 HCPCS inpatient 51 33.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.88 60.55 999999999 30.88 49.47 percent of total billed charges ADMINISTRATION OF PNEUMOCOCCAL VACCINE 49535134_1 CDM 0510 RC G0009 HCPCS inpatient 51 33.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.88 49.47 ADMINISTRATION OF PNEUMOCOCCAL VACCINE 49535134_1 CDM 0510 RC G0009 HCPCS inpatient 51 33.15 ANTHEM HMO ANTHEM HMO 999999999 30.88 49.47 ADMINISTRATION OF PNEUMOCOCCAL VACCINE 49535134_1 CDM 0510 RC G0009 HCPCS inpatient 51 33.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.88 49.47 ADMINISTRATION OF PNEUMOCOCCAL VACCINE 49535134_1 CDM 0510 RC G0009 HCPCS inpatient 51 33.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 34.48 67.6 999999999 30.88 49.47 percent of total billed charges ADMINISTRATION OF PNEUMOCOCCAL VACCINE 49535134_1 CDM 0510 RC G0009 HCPCS inpatient 51 33.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.88 49.47 ADMINISTRATION OF PNEUMOCOCCAL VACCINE 49535134_1 CDM 0510 RC G0009 HCPCS inpatient 51 33.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.88 49.47 ADMINISTRATION OF INFLUENZA VIRUS VACCINE 49535135_1 CDM 0510 RC G0008 HCPCS inpatient 51 33.15 AETNA AETNA 40.29 79 999999999 30.88 49.47 percent of total billed charges ADMINISTRATION OF INFLUENZA VIRUS VACCINE 49535135_1 CDM 0510 RC G0008 HCPCS inpatient 51 33.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 33.15 65 999999999 30.88 49.47 percent of total billed charges ADMINISTRATION OF INFLUENZA VIRUS VACCINE 49535135_1 CDM 0510 RC G0008 HCPCS inpatient 51 33.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 49.47 97 999999999 30.88 49.47 percent of total billed charges ADMINISTRATION OF INFLUENZA VIRUS VACCINE 49535135_1 CDM 0510 RC G0008 HCPCS inpatient 51 33.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 39.78 78 999999999 30.88 49.47 percent of total billed charges ADMINISTRATION OF INFLUENZA VIRUS VACCINE 49535135_1 CDM 0510 RC G0008 HCPCS inpatient 51 33.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 35.19 69 999999999 30.88 49.47 percent of total billed charges ADMINISTRATION OF INFLUENZA VIRUS VACCINE 49535135_1 CDM 0510 RC G0008 HCPCS inpatient 51 33.15 SIHO - ALL PLANS SIHO - ALL PLANS 45.9 90 999999999 30.88 49.47 percent of total billed charges ADMINISTRATION OF INFLUENZA VIRUS VACCINE 49535135_1 CDM 0510 RC G0008 HCPCS inpatient 51 33.15 UMR - ALL PLANS UMR - ALL PLANS 35.7 70 999999999 30.88 49.47 percent of total billed charges ADMINISTRATION OF INFLUENZA VIRUS VACCINE 49535135_1 CDM 0510 RC G0008 HCPCS inpatient 51 33.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.88 60.55 999999999 30.88 49.47 percent of total billed charges ADMINISTRATION OF INFLUENZA VIRUS VACCINE 49535135_1 CDM 0510 RC G0008 HCPCS inpatient 51 33.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.88 49.47 ADMINISTRATION OF INFLUENZA VIRUS VACCINE 49535135_1 CDM 0510 RC G0008 HCPCS inpatient 51 33.15 ANTHEM HMO ANTHEM HMO 999999999 30.88 49.47 ADMINISTRATION OF INFLUENZA VIRUS VACCINE 49535135_1 CDM 0510 RC G0008 HCPCS inpatient 51 33.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.88 49.47 ADMINISTRATION OF INFLUENZA VIRUS VACCINE 49535135_1 CDM 0510 RC G0008 HCPCS inpatient 51 33.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 34.48 67.6 999999999 30.88 49.47 percent of total billed charges ADMINISTRATION OF INFLUENZA VIRUS VACCINE 49535135_1 CDM 0510 RC G0008 HCPCS inpatient 51 33.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.88 49.47 ADMINISTRATION OF INFLUENZA VIRUS VACCINE 49535135_1 CDM 0510 RC G0008 HCPCS inpatient 51 33.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.88 49.47 Analysis for antibody to blastomyces (fungus) 49538031_1 CDM 0302 RC 86612 HCPCS inpatient 129 83.85 AETNA AETNA 101.91 79 999999999 78.11 125.13 percent of total billed charges Analysis for antibody to blastomyces (fungus) 49538031_1 CDM 0302 RC 86612 HCPCS inpatient 129 83.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 83.85 65 999999999 78.11 125.13 percent of total billed charges Analysis for antibody to blastomyces (fungus) 49538031_1 CDM 0302 RC 86612 HCPCS inpatient 129 83.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 125.13 97 999999999 78.11 125.13 percent of total billed charges Analysis for antibody to blastomyces (fungus) 49538031_1 CDM 0302 RC 86612 HCPCS inpatient 129 83.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 100.62 78 999999999 78.11 125.13 percent of total billed charges Analysis for antibody to blastomyces (fungus) 49538031_1 CDM 0302 RC 86612 HCPCS inpatient 129 83.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.01 69 999999999 78.11 125.13 percent of total billed charges Analysis for antibody to blastomyces (fungus) 49538031_1 CDM 0302 RC 86612 HCPCS inpatient 129 83.85 SIHO - ALL PLANS SIHO - ALL PLANS 116.1 90 999999999 78.11 125.13 percent of total billed charges Analysis for antibody to blastomyces (fungus) 49538031_1 CDM 0302 RC 86612 HCPCS inpatient 129 83.85 UMR - ALL PLANS UMR - ALL PLANS 90.3 70 999999999 78.11 125.13 percent of total billed charges Analysis for antibody to blastomyces (fungus) 49538031_1 CDM 0302 RC 86612 HCPCS inpatient 129 83.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.11 60.55 999999999 78.11 125.13 percent of total billed charges Analysis for antibody to blastomyces (fungus) 49538031_1 CDM 0302 RC 86612 HCPCS inpatient 129 83.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.11 125.13 Analysis for antibody to blastomyces (fungus) 49538031_1 CDM 0302 RC 86612 HCPCS inpatient 129 83.85 ANTHEM HMO ANTHEM HMO 999999999 78.11 125.13 Analysis for antibody to blastomyces (fungus) 49538031_1 CDM 0302 RC 86612 HCPCS inpatient 129 83.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.11 125.13 Analysis for antibody to blastomyces (fungus) 49538031_1 CDM 0302 RC 86612 HCPCS inpatient 129 83.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.2 67.6 999999999 78.11 125.13 percent of total billed charges Analysis for antibody to blastomyces (fungus) 49538031_1 CDM 0302 RC 86612 HCPCS inpatient 129 83.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.11 125.13 Analysis for antibody to blastomyces (fungus) 49538031_1 CDM 0302 RC 86612 HCPCS inpatient 129 83.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.11 125.13 Analysis for antibody to Coccidioides (bacteria) 49538032_1 CDM 0302 RC 86635 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 49538032_1 CDM 0302 RC 86635 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 49538032_1 CDM 0302 RC 86635 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 49538032_1 CDM 0302 RC 86635 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 49538032_1 CDM 0302 RC 86635 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 49538032_1 CDM 0302 RC 86635 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 49538032_1 CDM 0302 RC 86635 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 49538032_1 CDM 0302 RC 86635 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 49538032_1 CDM 0302 RC 86635 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 Analysis for antibody to Coccidioides (bacteria) 49538032_1 CDM 0302 RC 86635 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 Analysis for antibody to Coccidioides (bacteria) 49538032_1 CDM 0302 RC 86635 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 Analysis for antibody to Coccidioides (bacteria) 49538032_1 CDM 0302 RC 86635 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 49538032_1 CDM 0302 RC 86635 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 Analysis for antibody to Coccidioides (bacteria) 49538032_1 CDM 0302 RC 86635 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 Analysis for antibody to histoplasma (fungus) 49538033_1 CDM 0302 RC 86698 HCPCS inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges Analysis for antibody to histoplasma (fungus) 49538033_1 CDM 0302 RC 86698 HCPCS inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges Analysis for antibody to histoplasma (fungus) 49538033_1 CDM 0302 RC 86698 HCPCS inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges Analysis for antibody to histoplasma (fungus) 49538033_1 CDM 0302 RC 86698 HCPCS inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges Analysis for antibody to histoplasma (fungus) 49538033_1 CDM 0302 RC 86698 HCPCS inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges Analysis for antibody to histoplasma (fungus) 49538033_1 CDM 0302 RC 86698 HCPCS inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges Analysis for antibody to histoplasma (fungus) 49538033_1 CDM 0302 RC 86698 HCPCS inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges Analysis for antibody to histoplasma (fungus) 49538033_1 CDM 0302 RC 86698 HCPCS inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges Analysis for antibody to histoplasma (fungus) 49538033_1 CDM 0302 RC 86698 HCPCS inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 Analysis for antibody to histoplasma (fungus) 49538033_1 CDM 0302 RC 86698 HCPCS inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 Analysis for antibody to histoplasma (fungus) 49538033_1 CDM 0302 RC 86698 HCPCS inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 Analysis for antibody to histoplasma (fungus) 49538033_1 CDM 0302 RC 86698 HCPCS inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges Analysis for antibody to histoplasma (fungus) 49538033_1 CDM 0302 RC 86698 HCPCS inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 Analysis for antibody to histoplasma (fungus) 49538033_1 CDM 0302 RC 86698 HCPCS inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 EPINEPHRINE 0.3 MG AUTO-INJECT 49539115_1 CDM 0250 RC 49502-0102-02 NDC inpatient 1 UN 721.3 468.85 AETNA AETNA 569.83 79 999999999 436.75 699.66 percent of total billed charges EPINEPHRINE 0.3 MG AUTO-INJECT 49539115_1 CDM 0250 RC 49502-0102-02 NDC inpatient 1 UN 721.3 468.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 468.85 65 999999999 436.75 699.66 percent of total billed charges EPINEPHRINE 0.3 MG AUTO-INJECT 49539115_1 CDM 0250 RC 49502-0102-02 NDC inpatient 1 UN 721.3 468.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 699.66 97 999999999 436.75 699.66 percent of total billed charges EPINEPHRINE 0.3 MG AUTO-INJECT 49539115_1 CDM 0250 RC 49502-0102-02 NDC inpatient 1 UN 721.3 468.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 562.61 78 999999999 436.75 699.66 percent of total billed charges EPINEPHRINE 0.3 MG AUTO-INJECT 49539115_1 CDM 0250 RC 49502-0102-02 NDC inpatient 1 UN 721.3 468.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 497.7 69 999999999 436.75 699.66 percent of total billed charges EPINEPHRINE 0.3 MG AUTO-INJECT 49539115_1 CDM 0250 RC 49502-0102-02 NDC inpatient 1 UN 721.3 468.85 SIHO - ALL PLANS SIHO - ALL PLANS 649.17 90 999999999 436.75 699.66 percent of total billed charges EPINEPHRINE 0.3 MG AUTO-INJECT 49539115_1 CDM 0250 RC 49502-0102-02 NDC inpatient 1 UN 721.3 468.85 UMR - ALL PLANS UMR - ALL PLANS 504.91 70 999999999 436.75 699.66 percent of total billed charges EPINEPHRINE 0.3 MG AUTO-INJECT 49539115_1 CDM 0250 RC 49502-0102-02 NDC inpatient 1 UN 721.3 468.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 436.75 60.55 999999999 436.75 699.66 percent of total billed charges EPINEPHRINE 0.3 MG AUTO-INJECT 49539115_1 CDM 0250 RC 49502-0102-02 NDC inpatient 1 UN 721.3 468.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 436.75 699.66 EPINEPHRINE 0.3 MG AUTO-INJECT 49539115_1 CDM 0250 RC 49502-0102-02 NDC inpatient 1 UN 721.3 468.85 ANTHEM HMO ANTHEM HMO 999999999 436.75 699.66 EPINEPHRINE 0.3 MG AUTO-INJECT 49539115_1 CDM 0250 RC 49502-0102-02 NDC inpatient 1 UN 721.3 468.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 436.75 699.66 EPINEPHRINE 0.3 MG AUTO-INJECT 49539115_1 CDM 0250 RC 49502-0102-02 NDC inpatient 1 UN 721.3 468.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 487.6 67.6 999999999 436.75 699.66 percent of total billed charges EPINEPHRINE 0.3 MG AUTO-INJECT 49539115_1 CDM 0250 RC 49502-0102-02 NDC inpatient 1 UN 721.3 468.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 436.75 699.66 EPINEPHRINE 0.3 MG AUTO-INJECT 49539115_1 CDM 0250 RC 49502-0102-02 NDC inpatient 1 UN 721.3 468.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 436.75 699.66 63739-0128-10 - hydroCHLOROthiazide 25 mg Tab[JOHN] 49539345_1 CDM 0250 RC 63739-0128-10 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 63739-0128-10 - hydroCHLOROthiazide 25 mg Tab[JOHN] 49539345_1 CDM 0250 RC 63739-0128-10 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 63739-0128-10 - hydroCHLOROthiazide 25 mg Tab[JOHN] 49539345_1 CDM 0250 RC 63739-0128-10 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 63739-0128-10 - hydroCHLOROthiazide 25 mg Tab[JOHN] 49539345_1 CDM 0250 RC 63739-0128-10 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 63739-0128-10 - hydroCHLOROthiazide 25 mg Tab[JOHN] 49539345_1 CDM 0250 RC 63739-0128-10 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 63739-0128-10 - hydroCHLOROthiazide 25 mg Tab[JOHN] 49539345_1 CDM 0250 RC 63739-0128-10 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 63739-0128-10 - hydroCHLOROthiazide 25 mg Tab[JOHN] 49539345_1 CDM 0250 RC 63739-0128-10 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 63739-0128-10 - hydroCHLOROthiazide 25 mg Tab[JOHN] 49539345_1 CDM 0250 RC 63739-0128-10 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 63739-0128-10 - hydroCHLOROthiazide 25 mg Tab[JOHN] 49539345_1 CDM 0250 RC 63739-0128-10 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 63739-0128-10 - hydroCHLOROthiazide 25 mg Tab[JOHN] 49539345_1 CDM 0250 RC 63739-0128-10 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 63739-0128-10 - hydroCHLOROthiazide 25 mg Tab[JOHN] 49539345_1 CDM 0250 RC 63739-0128-10 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 63739-0128-10 - hydroCHLOROthiazide 25 mg Tab[JOHN] 49539345_1 CDM 0250 RC 63739-0128-10 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 63739-0128-10 - hydroCHLOROthiazide 25 mg Tab[JOHN] 49539345_1 CDM 0250 RC 63739-0128-10 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 63739-0128-10 - hydroCHLOROthiazide 25 mg Tab[JOHN] 49539345_1 CDM 0250 RC 63739-0128-10 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49539403_1 CDM 0250 RC 60505-6146-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 AETNA AETNA 24.66 79 999999999 18.9 30.28 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49539403_1 CDM 0250 RC 60505-6146-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.29 65 999999999 18.9 30.28 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49539403_1 CDM 0250 RC 60505-6146-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.28 97 999999999 18.9 30.28 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49539403_1 CDM 0250 RC 60505-6146-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.35 78 999999999 18.9 30.28 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49539403_1 CDM 0250 RC 60505-6146-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.54 69 999999999 18.9 30.28 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49539403_1 CDM 0250 RC 60505-6146-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 SIHO - ALL PLANS SIHO - ALL PLANS 28.1 90 999999999 18.9 30.28 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49539403_1 CDM 0250 RC 60505-6146-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 UMR - ALL PLANS UMR - ALL PLANS 21.85 70 999999999 18.9 30.28 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49539403_1 CDM 0250 RC 60505-6146-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.9 60.55 999999999 18.9 30.28 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49539403_1 CDM 0250 RC 60505-6146-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.9 30.28 "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49539403_1 CDM 0250 RC 60505-6146-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 ANTHEM HMO ANTHEM HMO 999999999 18.9 30.28 "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49539403_1 CDM 0250 RC 60505-6146-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.9 30.28 "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49539403_1 CDM 0250 RC 60505-6146-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.1 67.6 999999999 18.9 30.28 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49539403_1 CDM 0250 RC 60505-6146-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.9 30.28 "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49539403_1 CDM 0250 RC 60505-6146-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.9 30.28 "Measurement of antibody (IgG) to allergic substance, each allergen" 49542243_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 AETNA AETNA 45.03 79 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49542243_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.05 65 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49542243_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.29 97 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49542243_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.46 78 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49542243_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.33 69 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49542243_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 SIHO - ALL PLANS SIHO - ALL PLANS 51.3 90 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49542243_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UMR - ALL PLANS UMR - ALL PLANS 39.9 70 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49542243_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.51 60.55 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49542243_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49542243_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM HMO ANTHEM HMO 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49542243_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49542243_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.53 67.6 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49542243_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49542243_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.51 55.29 Analysis for antibody to Rickettsia (bacteria) 49544251_1 CDM 0301 RC 86757 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 49544251_1 CDM 0301 RC 86757 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 49544251_1 CDM 0301 RC 86757 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 49544251_1 CDM 0301 RC 86757 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 49544251_1 CDM 0301 RC 86757 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 49544251_1 CDM 0301 RC 86757 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 49544251_1 CDM 0301 RC 86757 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 49544251_1 CDM 0301 RC 86757 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 49544251_1 CDM 0301 RC 86757 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 Analysis for antibody to Rickettsia (bacteria) 49544251_1 CDM 0301 RC 86757 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 Analysis for antibody to Rickettsia (bacteria) 49544251_1 CDM 0301 RC 86757 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 Analysis for antibody to Rickettsia (bacteria) 49544251_1 CDM 0301 RC 86757 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 49544251_1 CDM 0301 RC 86757 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 Analysis for antibody to Rickettsia (bacteria) 49544251_1 CDM 0301 RC 86757 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 68084-0797-01 - gabapentin 600 mg Tab [JOHN] 49545059_1 CDM 0250 RC 68084-0797-01 NDC inpatient 1 UN 1.12 0.73 AETNA AETNA 0.88 79 999999999 0.68 1.09 percent of total billed charges 68084-0797-01 - gabapentin 600 mg Tab [JOHN] 49545059_1 CDM 0250 RC 68084-0797-01 NDC inpatient 1 UN 1.12 0.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.73 65 999999999 0.68 1.09 percent of total billed charges 68084-0797-01 - gabapentin 600 mg Tab [JOHN] 49545059_1 CDM 0250 RC 68084-0797-01 NDC inpatient 1 UN 1.12 0.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.09 97 999999999 0.68 1.09 percent of total billed charges 68084-0797-01 - gabapentin 600 mg Tab [JOHN] 49545059_1 CDM 0250 RC 68084-0797-01 NDC inpatient 1 UN 1.12 0.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.87 78 999999999 0.68 1.09 percent of total billed charges 68084-0797-01 - gabapentin 600 mg Tab [JOHN] 49545059_1 CDM 0250 RC 68084-0797-01 NDC inpatient 1 UN 1.12 0.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.77 69 999999999 0.68 1.09 percent of total billed charges 68084-0797-01 - gabapentin 600 mg Tab [JOHN] 49545059_1 CDM 0250 RC 68084-0797-01 NDC inpatient 1 UN 1.12 0.73 SIHO - ALL PLANS SIHO - ALL PLANS 1.01 90 999999999 0.68 1.09 percent of total billed charges 68084-0797-01 - gabapentin 600 mg Tab [JOHN] 49545059_1 CDM 0250 RC 68084-0797-01 NDC inpatient 1 UN 1.12 0.73 UMR - ALL PLANS UMR - ALL PLANS 0.78 70 999999999 0.68 1.09 percent of total billed charges 68084-0797-01 - gabapentin 600 mg Tab [JOHN] 49545059_1 CDM 0250 RC 68084-0797-01 NDC inpatient 1 UN 1.12 0.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.68 60.55 999999999 0.68 1.09 percent of total billed charges 68084-0797-01 - gabapentin 600 mg Tab [JOHN] 49545059_1 CDM 0250 RC 68084-0797-01 NDC inpatient 1 UN 1.12 0.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.68 1.09 68084-0797-01 - gabapentin 600 mg Tab [JOHN] 49545059_1 CDM 0250 RC 68084-0797-01 NDC inpatient 1 UN 1.12 0.73 ANTHEM HMO ANTHEM HMO 999999999 0.68 1.09 68084-0797-01 - gabapentin 600 mg Tab [JOHN] 49545059_1 CDM 0250 RC 68084-0797-01 NDC inpatient 1 UN 1.12 0.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.68 1.09 68084-0797-01 - gabapentin 600 mg Tab [JOHN] 49545059_1 CDM 0250 RC 68084-0797-01 NDC inpatient 1 UN 1.12 0.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.76 67.6 999999999 0.68 1.09 percent of total billed charges 68084-0797-01 - gabapentin 600 mg Tab [JOHN] 49545059_1 CDM 0250 RC 68084-0797-01 NDC inpatient 1 UN 1.12 0.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.68 1.09 68084-0797-01 - gabapentin 600 mg Tab [JOHN] 49545059_1 CDM 0250 RC 68084-0797-01 NDC inpatient 1 UN 1.12 0.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.68 1.09 "Ascorbic acid (Vitamin C) level, blood" 49545546_1 CDM 0301 RC 82180 HCPCS inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges "Ascorbic acid (Vitamin C) level, blood" 49545546_1 CDM 0301 RC 82180 HCPCS inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges "Ascorbic acid (Vitamin C) level, blood" 49545546_1 CDM 0301 RC 82180 HCPCS inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges "Ascorbic acid (Vitamin C) level, blood" 49545546_1 CDM 0301 RC 82180 HCPCS inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges "Ascorbic acid (Vitamin C) level, blood" 49545546_1 CDM 0301 RC 82180 HCPCS inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges "Ascorbic acid (Vitamin C) level, blood" 49545546_1 CDM 0301 RC 82180 HCPCS inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges "Ascorbic acid (Vitamin C) level, blood" 49545546_1 CDM 0301 RC 82180 HCPCS inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges "Ascorbic acid (Vitamin C) level, blood" 49545546_1 CDM 0301 RC 82180 HCPCS inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges "Ascorbic acid (Vitamin C) level, blood" 49545546_1 CDM 0301 RC 82180 HCPCS inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 "Ascorbic acid (Vitamin C) level, blood" 49545546_1 CDM 0301 RC 82180 HCPCS inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 "Ascorbic acid (Vitamin C) level, blood" 49545546_1 CDM 0301 RC 82180 HCPCS inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 "Ascorbic acid (Vitamin C) level, blood" 49545546_1 CDM 0301 RC 82180 HCPCS inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges "Ascorbic acid (Vitamin C) level, blood" 49545546_1 CDM 0301 RC 82180 HCPCS inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 "Ascorbic acid (Vitamin C) level, blood" 49545546_1 CDM 0301 RC 82180 HCPCS inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 Clotting factor VIII (von Willebrand factor) measurement 49545548_1 CDM 0301 RC 85247 HCPCS inpatient 216 140.4 AETNA AETNA 170.64 79 999999999 130.79 209.52 percent of total billed charges Clotting factor VIII (von Willebrand factor) measurement 49545548_1 CDM 0301 RC 85247 HCPCS inpatient 216 140.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 140.4 65 999999999 130.79 209.52 percent of total billed charges Clotting factor VIII (von Willebrand factor) measurement 49545548_1 CDM 0301 RC 85247 HCPCS inpatient 216 140.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 209.52 97 999999999 130.79 209.52 percent of total billed charges Clotting factor VIII (von Willebrand factor) measurement 49545548_1 CDM 0301 RC 85247 HCPCS inpatient 216 140.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 168.48 78 999999999 130.79 209.52 percent of total billed charges Clotting factor VIII (von Willebrand factor) measurement 49545548_1 CDM 0301 RC 85247 HCPCS inpatient 216 140.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 149.04 69 999999999 130.79 209.52 percent of total billed charges Clotting factor VIII (von Willebrand factor) measurement 49545548_1 CDM 0301 RC 85247 HCPCS inpatient 216 140.4 SIHO - ALL PLANS SIHO - ALL PLANS 194.4 90 999999999 130.79 209.52 percent of total billed charges Clotting factor VIII (von Willebrand factor) measurement 49545548_1 CDM 0301 RC 85247 HCPCS inpatient 216 140.4 UMR - ALL PLANS UMR - ALL PLANS 151.2 70 999999999 130.79 209.52 percent of total billed charges Clotting factor VIII (von Willebrand factor) measurement 49545548_1 CDM 0301 RC 85247 HCPCS inpatient 216 140.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 130.79 60.55 999999999 130.79 209.52 percent of total billed charges Clotting factor VIII (von Willebrand factor) measurement 49545548_1 CDM 0301 RC 85247 HCPCS inpatient 216 140.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 130.79 209.52 Clotting factor VIII (von Willebrand factor) measurement 49545548_1 CDM 0301 RC 85247 HCPCS inpatient 216 140.4 ANTHEM HMO ANTHEM HMO 999999999 130.79 209.52 Clotting factor VIII (von Willebrand factor) measurement 49545548_1 CDM 0301 RC 85247 HCPCS inpatient 216 140.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 130.79 209.52 Clotting factor VIII (von Willebrand factor) measurement 49545548_1 CDM 0301 RC 85247 HCPCS inpatient 216 140.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 146.02 67.6 999999999 130.79 209.52 percent of total billed charges Clotting factor VIII (von Willebrand factor) measurement 49545548_1 CDM 0301 RC 85247 HCPCS inpatient 216 140.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 130.79 209.52 Clotting factor VIII (von Willebrand factor) measurement 49545548_1 CDM 0301 RC 85247 HCPCS inpatient 216 140.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 130.79 209.52 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49545618_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49545618_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49545618_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49545618_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49545618_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49545618_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49545618_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49545618_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49545618_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49545618_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49545618_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49545618_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49545618_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49545618_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 SPECTRUM SU LOPRO S2 0270-0877 49546384_1 CDM 0272 RC inpatient 273 177.45 AETNA AETNA 215.67 79 999999999 165.3 264.81 percent of total billed charges SPECTRUM SU LOPRO S2 0270-0877 49546384_1 CDM 0272 RC inpatient 273 177.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 177.45 65 999999999 165.3 264.81 percent of total billed charges SPECTRUM SU LOPRO S2 0270-0877 49546384_1 CDM 0272 RC inpatient 273 177.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 264.81 97 999999999 165.3 264.81 percent of total billed charges SPECTRUM SU LOPRO S2 0270-0877 49546384_1 CDM 0272 RC inpatient 273 177.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 212.94 78 999999999 165.3 264.81 percent of total billed charges SPECTRUM SU LOPRO S2 0270-0877 49546384_1 CDM 0272 RC inpatient 273 177.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 188.37 69 999999999 165.3 264.81 percent of total billed charges SPECTRUM SU LOPRO S2 0270-0877 49546384_1 CDM 0272 RC inpatient 273 177.45 SIHO - ALL PLANS SIHO - ALL PLANS 245.7 90 999999999 165.3 264.81 percent of total billed charges SPECTRUM SU LOPRO S2 0270-0877 49546384_1 CDM 0272 RC inpatient 273 177.45 UMR - ALL PLANS UMR - ALL PLANS 191.1 70 999999999 165.3 264.81 percent of total billed charges SPECTRUM SU LOPRO S2 0270-0877 49546384_1 CDM 0272 RC inpatient 273 177.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.3 60.55 999999999 165.3 264.81 percent of total billed charges SPECTRUM SU LOPRO S2 0270-0877 49546384_1 CDM 0272 RC inpatient 273 177.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.3 264.81 SPECTRUM SU LOPRO S2 0270-0877 49546384_1 CDM 0272 RC inpatient 273 177.45 ANTHEM HMO ANTHEM HMO 999999999 165.3 264.81 SPECTRUM SU LOPRO S2 0270-0877 49546384_1 CDM 0272 RC inpatient 273 177.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.3 264.81 SPECTRUM SU LOPRO S2 0270-0877 49546384_1 CDM 0272 RC inpatient 273 177.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 184.55 67.6 999999999 165.3 264.81 percent of total billed charges SPECTRUM SU LOPRO S2 0270-0877 49546384_1 CDM 0272 RC inpatient 273 177.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.3 264.81 SPECTRUM SU LOPRO S2 0270-0877 49546384_1 CDM 0272 RC inpatient 273 177.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.3 264.81 SPECTRUM SU LOPRO S3 0270-0938 49546388_1 CDM 0272 RC inpatient 210 136.5 AETNA AETNA 165.9 79 999999999 127.16 203.7 percent of total billed charges SPECTRUM SU LOPRO S3 0270-0938 49546388_1 CDM 0272 RC inpatient 210 136.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 136.5 65 999999999 127.16 203.7 percent of total billed charges SPECTRUM SU LOPRO S3 0270-0938 49546388_1 CDM 0272 RC inpatient 210 136.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 203.7 97 999999999 127.16 203.7 percent of total billed charges SPECTRUM SU LOPRO S3 0270-0938 49546388_1 CDM 0272 RC inpatient 210 136.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 163.8 78 999999999 127.16 203.7 percent of total billed charges SPECTRUM SU LOPRO S3 0270-0938 49546388_1 CDM 0272 RC inpatient 210 136.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 144.9 69 999999999 127.16 203.7 percent of total billed charges SPECTRUM SU LOPRO S3 0270-0938 49546388_1 CDM 0272 RC inpatient 210 136.5 SIHO - ALL PLANS SIHO - ALL PLANS 189 90 999999999 127.16 203.7 percent of total billed charges SPECTRUM SU LOPRO S3 0270-0938 49546388_1 CDM 0272 RC inpatient 210 136.5 UMR - ALL PLANS UMR - ALL PLANS 147 70 999999999 127.16 203.7 percent of total billed charges SPECTRUM SU LOPRO S3 0270-0938 49546388_1 CDM 0272 RC inpatient 210 136.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.16 60.55 999999999 127.16 203.7 percent of total billed charges SPECTRUM SU LOPRO S3 0270-0938 49546388_1 CDM 0272 RC inpatient 210 136.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.16 203.7 SPECTRUM SU LOPRO S3 0270-0938 49546388_1 CDM 0272 RC inpatient 210 136.5 ANTHEM HMO ANTHEM HMO 999999999 127.16 203.7 SPECTRUM SU LOPRO S3 0270-0938 49546388_1 CDM 0272 RC inpatient 210 136.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.16 203.7 SPECTRUM SU LOPRO S3 0270-0938 49546388_1 CDM 0272 RC inpatient 210 136.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 141.96 67.6 999999999 127.16 203.7 percent of total billed charges SPECTRUM SU LOPRO S3 0270-0938 49546388_1 CDM 0272 RC inpatient 210 136.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.16 203.7 SPECTRUM SU LOPRO S3 0270-0938 49546388_1 CDM 0272 RC inpatient 210 136.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.16 203.7 SPECTRUM SU LOPRO S4 0270-0939 49546389_1 CDM 0272 RC inpatient 210 136.5 AETNA AETNA 165.9 79 999999999 127.16 203.7 percent of total billed charges SPECTRUM SU LOPRO S4 0270-0939 49546389_1 CDM 0272 RC inpatient 210 136.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 136.5 65 999999999 127.16 203.7 percent of total billed charges SPECTRUM SU LOPRO S4 0270-0939 49546389_1 CDM 0272 RC inpatient 210 136.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 203.7 97 999999999 127.16 203.7 percent of total billed charges SPECTRUM SU LOPRO S4 0270-0939 49546389_1 CDM 0272 RC inpatient 210 136.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 163.8 78 999999999 127.16 203.7 percent of total billed charges SPECTRUM SU LOPRO S4 0270-0939 49546389_1 CDM 0272 RC inpatient 210 136.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 144.9 69 999999999 127.16 203.7 percent of total billed charges SPECTRUM SU LOPRO S4 0270-0939 49546389_1 CDM 0272 RC inpatient 210 136.5 SIHO - ALL PLANS SIHO - ALL PLANS 189 90 999999999 127.16 203.7 percent of total billed charges SPECTRUM SU LOPRO S4 0270-0939 49546389_1 CDM 0272 RC inpatient 210 136.5 UMR - ALL PLANS UMR - ALL PLANS 147 70 999999999 127.16 203.7 percent of total billed charges SPECTRUM SU LOPRO S4 0270-0939 49546389_1 CDM 0272 RC inpatient 210 136.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.16 60.55 999999999 127.16 203.7 percent of total billed charges SPECTRUM SU LOPRO S4 0270-0939 49546389_1 CDM 0272 RC inpatient 210 136.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.16 203.7 SPECTRUM SU LOPRO S4 0270-0939 49546389_1 CDM 0272 RC inpatient 210 136.5 ANTHEM HMO ANTHEM HMO 999999999 127.16 203.7 SPECTRUM SU LOPRO S4 0270-0939 49546389_1 CDM 0272 RC inpatient 210 136.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.16 203.7 SPECTRUM SU LOPRO S4 0270-0939 49546389_1 CDM 0272 RC inpatient 210 136.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 141.96 67.6 999999999 127.16 203.7 percent of total billed charges SPECTRUM SU LOPRO S4 0270-0939 49546389_1 CDM 0272 RC inpatient 210 136.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.16 203.7 SPECTRUM SU LOPRO S4 0270-0939 49546389_1 CDM 0272 RC inpatient 210 136.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.16 203.7 GLIDERITE RIGID STYLET 0270-0681 49546390_1 CDM 0272 RC inpatient 184 119.6 AETNA AETNA 145.36 79 999999999 111.41 178.48 percent of total billed charges GLIDERITE RIGID STYLET 0270-0681 49546390_1 CDM 0272 RC inpatient 184 119.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 119.6 65 999999999 111.41 178.48 percent of total billed charges GLIDERITE RIGID STYLET 0270-0681 49546390_1 CDM 0272 RC inpatient 184 119.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 178.48 97 999999999 111.41 178.48 percent of total billed charges GLIDERITE RIGID STYLET 0270-0681 49546390_1 CDM 0272 RC inpatient 184 119.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 143.52 78 999999999 111.41 178.48 percent of total billed charges GLIDERITE RIGID STYLET 0270-0681 49546390_1 CDM 0272 RC inpatient 184 119.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.96 69 999999999 111.41 178.48 percent of total billed charges GLIDERITE RIGID STYLET 0270-0681 49546390_1 CDM 0272 RC inpatient 184 119.6 SIHO - ALL PLANS SIHO - ALL PLANS 165.6 90 999999999 111.41 178.48 percent of total billed charges GLIDERITE RIGID STYLET 0270-0681 49546390_1 CDM 0272 RC inpatient 184 119.6 UMR - ALL PLANS UMR - ALL PLANS 128.8 70 999999999 111.41 178.48 percent of total billed charges GLIDERITE RIGID STYLET 0270-0681 49546390_1 CDM 0272 RC inpatient 184 119.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 111.41 60.55 999999999 111.41 178.48 percent of total billed charges GLIDERITE RIGID STYLET 0270-0681 49546390_1 CDM 0272 RC inpatient 184 119.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 111.41 178.48 GLIDERITE RIGID STYLET 0270-0681 49546390_1 CDM 0272 RC inpatient 184 119.6 ANTHEM HMO ANTHEM HMO 999999999 111.41 178.48 GLIDERITE RIGID STYLET 0270-0681 49546390_1 CDM 0272 RC inpatient 184 119.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 111.41 178.48 GLIDERITE RIGID STYLET 0270-0681 49546390_1 CDM 0272 RC inpatient 184 119.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 124.38 67.6 999999999 111.41 178.48 percent of total billed charges GLIDERITE RIGID STYLET 0270-0681 49546390_1 CDM 0272 RC inpatient 184 119.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 111.41 178.48 GLIDERITE RIGID STYLET 0270-0681 49546390_1 CDM 0272 RC inpatient 184 119.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 111.41 178.48 NEEDLE COAXIAL INTRO 17GA MCXS1816TX 49546944_1 CDM 0272 RC inpatient 4 2.6 AETNA AETNA 3.16 79 999999999 2.42 3.88 percent of total billed charges NEEDLE COAXIAL INTRO 17GA MCXS1816TX 49546944_1 CDM 0272 RC inpatient 4 2.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.6 65 999999999 2.42 3.88 percent of total billed charges NEEDLE COAXIAL INTRO 17GA MCXS1816TX 49546944_1 CDM 0272 RC inpatient 4 2.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.88 97 999999999 2.42 3.88 percent of total billed charges NEEDLE COAXIAL INTRO 17GA MCXS1816TX 49546944_1 CDM 0272 RC inpatient 4 2.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.12 78 999999999 2.42 3.88 percent of total billed charges NEEDLE COAXIAL INTRO 17GA MCXS1816TX 49546944_1 CDM 0272 RC inpatient 4 2.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.76 69 999999999 2.42 3.88 percent of total billed charges NEEDLE COAXIAL INTRO 17GA MCXS1816TX 49546944_1 CDM 0272 RC inpatient 4 2.6 SIHO - ALL PLANS SIHO - ALL PLANS 3.6 90 999999999 2.42 3.88 percent of total billed charges NEEDLE COAXIAL INTRO 17GA MCXS1816TX 49546944_1 CDM 0272 RC inpatient 4 2.6 UMR - ALL PLANS UMR - ALL PLANS 2.8 70 999999999 2.42 3.88 percent of total billed charges NEEDLE COAXIAL INTRO 17GA MCXS1816TX 49546944_1 CDM 0272 RC inpatient 4 2.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.42 60.55 999999999 2.42 3.88 percent of total billed charges NEEDLE COAXIAL INTRO 17GA MCXS1816TX 49546944_1 CDM 0272 RC inpatient 4 2.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.42 3.88 NEEDLE COAXIAL INTRO 17GA MCXS1816TX 49546944_1 CDM 0272 RC inpatient 4 2.6 ANTHEM HMO ANTHEM HMO 999999999 2.42 3.88 NEEDLE COAXIAL INTRO 17GA MCXS1816TX 49546944_1 CDM 0272 RC inpatient 4 2.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.42 3.88 NEEDLE COAXIAL INTRO 17GA MCXS1816TX 49546944_1 CDM 0272 RC inpatient 4 2.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.7 67.6 999999999 2.42 3.88 percent of total billed charges NEEDLE COAXIAL INTRO 17GA MCXS1816TX 49546944_1 CDM 0272 RC inpatient 4 2.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.42 3.88 NEEDLE COAXIAL INTRO 17GA MCXS1816TX 49546944_1 CDM 0272 RC inpatient 4 2.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.42 3.88 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548012_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548012_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548012_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548012_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548012_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548012_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548012_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548012_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548012_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548012_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548012_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548012_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548012_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548012_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548014_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548014_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548014_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548014_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548014_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548014_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548014_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548014_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548014_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548014_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548014_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548014_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548014_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548014_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548017_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548017_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548017_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548017_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548017_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548017_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548017_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548017_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548017_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548017_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548017_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548017_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548017_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548017_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548019_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548019_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548019_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548019_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548019_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548019_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548019_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548019_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548019_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548019_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548019_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548019_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548019_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 Analysis for antibody to Coxiella burnetii (Q fever bacteria) 49548019_1 CDM 0301 RC 86638 HCPCS inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 "Detection of infectious agent antibody, quantitative" 49548032_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49548032_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49548032_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49548032_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49548032_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49548032_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49548032_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49548032_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49548032_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 49548032_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 49548032_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 49548032_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49548032_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 49548032_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548033_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548033_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548033_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548033_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548033_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548033_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548033_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548033_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548033_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548033_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548033_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548033_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548033_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548033_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548034_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548034_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548034_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548034_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548034_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548034_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548034_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548034_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548034_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548034_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548034_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548034_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548034_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548034_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548035_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548035_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548035_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548035_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548035_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548035_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548035_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548035_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548035_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548035_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548035_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548035_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548035_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49548035_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Detection of infectious agent antibody, quantitative" 49548092_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49548092_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49548092_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49548092_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49548092_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49548092_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49548092_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49548092_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49548092_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 49548092_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 49548092_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 49548092_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Detection of infectious agent antibody, quantitative" 49548092_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Detection of infectious agent antibody, quantitative" 49548092_1 CDM 0301 RC 86317 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 METOPROLOL TART 5 MG/5 ML VIAL 49549257_1 CDM 0250 RC 70860-0300-05 NDC inpatient 1 UN 19.74 12.83 AETNA AETNA 15.59 79 999999999 11.95 19.15 percent of total billed charges METOPROLOL TART 5 MG/5 ML VIAL 49549257_1 CDM 0250 RC 70860-0300-05 NDC inpatient 1 UN 19.74 12.83 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.83 65 999999999 11.95 19.15 percent of total billed charges METOPROLOL TART 5 MG/5 ML VIAL 49549257_1 CDM 0250 RC 70860-0300-05 NDC inpatient 1 UN 19.74 12.83 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.15 97 999999999 11.95 19.15 percent of total billed charges METOPROLOL TART 5 MG/5 ML VIAL 49549257_1 CDM 0250 RC 70860-0300-05 NDC inpatient 1 UN 19.74 12.83 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.4 78 999999999 11.95 19.15 percent of total billed charges METOPROLOL TART 5 MG/5 ML VIAL 49549257_1 CDM 0250 RC 70860-0300-05 NDC inpatient 1 UN 19.74 12.83 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.62 69 999999999 11.95 19.15 percent of total billed charges METOPROLOL TART 5 MG/5 ML VIAL 49549257_1 CDM 0250 RC 70860-0300-05 NDC inpatient 1 UN 19.74 12.83 SIHO - ALL PLANS SIHO - ALL PLANS 17.77 90 999999999 11.95 19.15 percent of total billed charges METOPROLOL TART 5 MG/5 ML VIAL 49549257_1 CDM 0250 RC 70860-0300-05 NDC inpatient 1 UN 19.74 12.83 UMR - ALL PLANS UMR - ALL PLANS 13.82 70 999999999 11.95 19.15 percent of total billed charges METOPROLOL TART 5 MG/5 ML VIAL 49549257_1 CDM 0250 RC 70860-0300-05 NDC inpatient 1 UN 19.74 12.83 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.95 60.55 999999999 11.95 19.15 percent of total billed charges METOPROLOL TART 5 MG/5 ML VIAL 49549257_1 CDM 0250 RC 70860-0300-05 NDC inpatient 1 UN 19.74 12.83 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.95 19.15 METOPROLOL TART 5 MG/5 ML VIAL 49549257_1 CDM 0250 RC 70860-0300-05 NDC inpatient 1 UN 19.74 12.83 ANTHEM HMO ANTHEM HMO 999999999 11.95 19.15 METOPROLOL TART 5 MG/5 ML VIAL 49549257_1 CDM 0250 RC 70860-0300-05 NDC inpatient 1 UN 19.74 12.83 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.95 19.15 METOPROLOL TART 5 MG/5 ML VIAL 49549257_1 CDM 0250 RC 70860-0300-05 NDC inpatient 1 UN 19.74 12.83 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.34 67.6 999999999 11.95 19.15 percent of total billed charges METOPROLOL TART 5 MG/5 ML VIAL 49549257_1 CDM 0250 RC 70860-0300-05 NDC inpatient 1 UN 19.74 12.83 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.95 19.15 METOPROLOL TART 5 MG/5 ML VIAL 49549257_1 CDM 0250 RC 70860-0300-05 NDC inpatient 1 UN 19.74 12.83 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.95 19.15 SERTRALINE HCL 100 MG TABLET 49549959_1 CDM 0250 RC 60687-0253-01 NDC inpatient 1 UN 1.85 1.2 AETNA AETNA 1.46 79 999999999 1.12 1.79 percent of total billed charges SERTRALINE HCL 100 MG TABLET 49549959_1 CDM 0250 RC 60687-0253-01 NDC inpatient 1 UN 1.85 1.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.2 65 999999999 1.12 1.79 percent of total billed charges SERTRALINE HCL 100 MG TABLET 49549959_1 CDM 0250 RC 60687-0253-01 NDC inpatient 1 UN 1.85 1.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.79 97 999999999 1.12 1.79 percent of total billed charges SERTRALINE HCL 100 MG TABLET 49549959_1 CDM 0250 RC 60687-0253-01 NDC inpatient 1 UN 1.85 1.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.44 78 999999999 1.12 1.79 percent of total billed charges SERTRALINE HCL 100 MG TABLET 49549959_1 CDM 0250 RC 60687-0253-01 NDC inpatient 1 UN 1.85 1.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.28 69 999999999 1.12 1.79 percent of total billed charges SERTRALINE HCL 100 MG TABLET 49549959_1 CDM 0250 RC 60687-0253-01 NDC inpatient 1 UN 1.85 1.2 SIHO - ALL PLANS SIHO - ALL PLANS 1.67 90 999999999 1.12 1.79 percent of total billed charges SERTRALINE HCL 100 MG TABLET 49549959_1 CDM 0250 RC 60687-0253-01 NDC inpatient 1 UN 1.85 1.2 UMR - ALL PLANS UMR - ALL PLANS 1.3 70 999999999 1.12 1.79 percent of total billed charges SERTRALINE HCL 100 MG TABLET 49549959_1 CDM 0250 RC 60687-0253-01 NDC inpatient 1 UN 1.85 1.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.12 60.55 999999999 1.12 1.79 percent of total billed charges SERTRALINE HCL 100 MG TABLET 49549959_1 CDM 0250 RC 60687-0253-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.12 1.79 SERTRALINE HCL 100 MG TABLET 49549959_1 CDM 0250 RC 60687-0253-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM HMO ANTHEM HMO 999999999 1.12 1.79 SERTRALINE HCL 100 MG TABLET 49549959_1 CDM 0250 RC 60687-0253-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.12 1.79 SERTRALINE HCL 100 MG TABLET 49549959_1 CDM 0250 RC 60687-0253-01 NDC inpatient 1 UN 1.85 1.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.25 67.6 999999999 1.12 1.79 percent of total billed charges SERTRALINE HCL 100 MG TABLET 49549959_1 CDM 0250 RC 60687-0253-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.12 1.79 SERTRALINE HCL 100 MG TABLET 49549959_1 CDM 0250 RC 60687-0253-01 NDC inpatient 1 UN 1.85 1.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.12 1.79 "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" 49552121_1 CDM 0301 RC 81225 HCPCS inpatient 426 276.9 AETNA AETNA 336.54 79 999999999 257.94 413.22 percent of total billed charges "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" 49552121_1 CDM 0301 RC 81225 HCPCS inpatient 426 276.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 276.9 65 999999999 257.94 413.22 percent of total billed charges "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" 49552121_1 CDM 0301 RC 81225 HCPCS inpatient 426 276.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 413.22 97 999999999 257.94 413.22 percent of total billed charges "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" 49552121_1 CDM 0301 RC 81225 HCPCS inpatient 426 276.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 332.28 78 999999999 257.94 413.22 percent of total billed charges "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" 49552121_1 CDM 0301 RC 81225 HCPCS inpatient 426 276.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 293.94 69 999999999 257.94 413.22 percent of total billed charges "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" 49552121_1 CDM 0301 RC 81225 HCPCS inpatient 426 276.9 SIHO - ALL PLANS SIHO - ALL PLANS 383.4 90 999999999 257.94 413.22 percent of total billed charges "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" 49552121_1 CDM 0301 RC 81225 HCPCS inpatient 426 276.9 UMR - ALL PLANS UMR - ALL PLANS 298.2 70 999999999 257.94 413.22 percent of total billed charges "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" 49552121_1 CDM 0301 RC 81225 HCPCS inpatient 426 276.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 257.94 60.55 999999999 257.94 413.22 percent of total billed charges "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" 49552121_1 CDM 0301 RC 81225 HCPCS inpatient 426 276.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 257.94 413.22 "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" 49552121_1 CDM 0301 RC 81225 HCPCS inpatient 426 276.9 ANTHEM HMO ANTHEM HMO 999999999 257.94 413.22 "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" 49552121_1 CDM 0301 RC 81225 HCPCS inpatient 426 276.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 257.94 413.22 "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" 49552121_1 CDM 0301 RC 81225 HCPCS inpatient 426 276.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 287.98 67.6 999999999 257.94 413.22 percent of total billed charges "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" 49552121_1 CDM 0301 RC 81225 HCPCS inpatient 426 276.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 257.94 413.22 "Gene analysis (cytochrome P450, family 2, subfamily C, polypeptide 19) common variants" 49552121_1 CDM 0301 RC 81225 HCPCS inpatient 426 276.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 257.94 413.22 Analysis for antibody bordetella (respiratory bacteria) 49552122_1 CDM 0301 RC 86615 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Analysis for antibody bordetella (respiratory bacteria) 49552122_1 CDM 0301 RC 86615 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Analysis for antibody bordetella (respiratory bacteria) 49552122_1 CDM 0301 RC 86615 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Analysis for antibody bordetella (respiratory bacteria) 49552122_1 CDM 0301 RC 86615 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Analysis for antibody bordetella (respiratory bacteria) 49552122_1 CDM 0301 RC 86615 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Analysis for antibody bordetella (respiratory bacteria) 49552122_1 CDM 0301 RC 86615 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Analysis for antibody bordetella (respiratory bacteria) 49552122_1 CDM 0301 RC 86615 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Analysis for antibody bordetella (respiratory bacteria) 49552122_1 CDM 0301 RC 86615 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Analysis for antibody bordetella (respiratory bacteria) 49552122_1 CDM 0301 RC 86615 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Analysis for antibody bordetella (respiratory bacteria) 49552122_1 CDM 0301 RC 86615 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Analysis for antibody bordetella (respiratory bacteria) 49552122_1 CDM 0301 RC 86615 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Analysis for antibody bordetella (respiratory bacteria) 49552122_1 CDM 0301 RC 86615 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Analysis for antibody bordetella (respiratory bacteria) 49552122_1 CDM 0301 RC 86615 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Analysis for antibody bordetella (respiratory bacteria) 49552122_1 CDM 0301 RC 86615 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 SERTRALINE HCL 25 MG TABLET 49552206_1 CDM 0250 RC 60687-0231-01 NDC inpatient 1 UN 1.37 0.89 AETNA AETNA 1.08 79 999999999 0.83 1.33 percent of total billed charges SERTRALINE HCL 25 MG TABLET 49552206_1 CDM 0250 RC 60687-0231-01 NDC inpatient 1 UN 1.37 0.89 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.89 65 999999999 0.83 1.33 percent of total billed charges SERTRALINE HCL 25 MG TABLET 49552206_1 CDM 0250 RC 60687-0231-01 NDC inpatient 1 UN 1.37 0.89 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.33 97 999999999 0.83 1.33 percent of total billed charges SERTRALINE HCL 25 MG TABLET 49552206_1 CDM 0250 RC 60687-0231-01 NDC inpatient 1 UN 1.37 0.89 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.07 78 999999999 0.83 1.33 percent of total billed charges SERTRALINE HCL 25 MG TABLET 49552206_1 CDM 0250 RC 60687-0231-01 NDC inpatient 1 UN 1.37 0.89 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.95 69 999999999 0.83 1.33 percent of total billed charges SERTRALINE HCL 25 MG TABLET 49552206_1 CDM 0250 RC 60687-0231-01 NDC inpatient 1 UN 1.37 0.89 SIHO - ALL PLANS SIHO - ALL PLANS 1.23 90 999999999 0.83 1.33 percent of total billed charges SERTRALINE HCL 25 MG TABLET 49552206_1 CDM 0250 RC 60687-0231-01 NDC inpatient 1 UN 1.37 0.89 UMR - ALL PLANS UMR - ALL PLANS 0.96 70 999999999 0.83 1.33 percent of total billed charges SERTRALINE HCL 25 MG TABLET 49552206_1 CDM 0250 RC 60687-0231-01 NDC inpatient 1 UN 1.37 0.89 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.83 60.55 999999999 0.83 1.33 percent of total billed charges SERTRALINE HCL 25 MG TABLET 49552206_1 CDM 0250 RC 60687-0231-01 NDC inpatient 1 UN 1.37 0.89 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.83 1.33 SERTRALINE HCL 25 MG TABLET 49552206_1 CDM 0250 RC 60687-0231-01 NDC inpatient 1 UN 1.37 0.89 ANTHEM HMO ANTHEM HMO 999999999 0.83 1.33 SERTRALINE HCL 25 MG TABLET 49552206_1 CDM 0250 RC 60687-0231-01 NDC inpatient 1 UN 1.37 0.89 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.83 1.33 SERTRALINE HCL 25 MG TABLET 49552206_1 CDM 0250 RC 60687-0231-01 NDC inpatient 1 UN 1.37 0.89 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.93 67.6 999999999 0.83 1.33 percent of total billed charges SERTRALINE HCL 25 MG TABLET 49552206_1 CDM 0250 RC 60687-0231-01 NDC inpatient 1 UN 1.37 0.89 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.83 1.33 SERTRALINE HCL 25 MG TABLET 49552206_1 CDM 0250 RC 60687-0231-01 NDC inpatient 1 UN 1.37 0.89 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.83 1.33 "Microscopic genetic analysis of tumor, manual" 49555346_1 CDM 0300 RC 88360 HCPCS inpatient 317 206.05 AETNA AETNA 250.43 79 999999999 191.94 307.49 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 49555346_1 CDM 0300 RC 88360 HCPCS inpatient 317 206.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 206.05 65 999999999 191.94 307.49 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 49555346_1 CDM 0300 RC 88360 HCPCS inpatient 317 206.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 307.49 97 999999999 191.94 307.49 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 49555346_1 CDM 0300 RC 88360 HCPCS inpatient 317 206.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 247.26 78 999999999 191.94 307.49 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 49555346_1 CDM 0300 RC 88360 HCPCS inpatient 317 206.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 218.73 69 999999999 191.94 307.49 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 49555346_1 CDM 0300 RC 88360 HCPCS inpatient 317 206.05 SIHO - ALL PLANS SIHO - ALL PLANS 285.3 90 999999999 191.94 307.49 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 49555346_1 CDM 0300 RC 88360 HCPCS inpatient 317 206.05 UMR - ALL PLANS UMR - ALL PLANS 221.9 70 999999999 191.94 307.49 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 49555346_1 CDM 0300 RC 88360 HCPCS inpatient 317 206.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 191.94 60.55 999999999 191.94 307.49 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 49555346_1 CDM 0300 RC 88360 HCPCS inpatient 317 206.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 191.94 307.49 "Microscopic genetic analysis of tumor, manual" 49555346_1 CDM 0300 RC 88360 HCPCS inpatient 317 206.05 ANTHEM HMO ANTHEM HMO 999999999 191.94 307.49 "Microscopic genetic analysis of tumor, manual" 49555346_1 CDM 0300 RC 88360 HCPCS inpatient 317 206.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 191.94 307.49 "Microscopic genetic analysis of tumor, manual" 49555346_1 CDM 0300 RC 88360 HCPCS inpatient 317 206.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 214.29 67.6 999999999 191.94 307.49 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 49555346_1 CDM 0300 RC 88360 HCPCS inpatient 317 206.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 191.94 307.49 "Microscopic genetic analysis of tumor, manual" 49555346_1 CDM 0300 RC 88360 HCPCS inpatient 317 206.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 191.94 307.49 ROSUVASTATIN CALCIUM 10 MG TAB 49555376_1 CDM 0250 RC 31722-0883-90 NDC inpatient 1 UN 1.01 0.66 AETNA AETNA 0.8 79 999999999 0.61 0.98 percent of total billed charges ROSUVASTATIN CALCIUM 10 MG TAB 49555376_1 CDM 0250 RC 31722-0883-90 NDC inpatient 1 UN 1.01 0.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.66 65 999999999 0.61 0.98 percent of total billed charges ROSUVASTATIN CALCIUM 10 MG TAB 49555376_1 CDM 0250 RC 31722-0883-90 NDC inpatient 1 UN 1.01 0.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 0.98 97 999999999 0.61 0.98 percent of total billed charges ROSUVASTATIN CALCIUM 10 MG TAB 49555376_1 CDM 0250 RC 31722-0883-90 NDC inpatient 1 UN 1.01 0.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.79 78 999999999 0.61 0.98 percent of total billed charges ROSUVASTATIN CALCIUM 10 MG TAB 49555376_1 CDM 0250 RC 31722-0883-90 NDC inpatient 1 UN 1.01 0.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.7 69 999999999 0.61 0.98 percent of total billed charges ROSUVASTATIN CALCIUM 10 MG TAB 49555376_1 CDM 0250 RC 31722-0883-90 NDC inpatient 1 UN 1.01 0.66 SIHO - ALL PLANS SIHO - ALL PLANS 0.91 90 999999999 0.61 0.98 percent of total billed charges ROSUVASTATIN CALCIUM 10 MG TAB 49555376_1 CDM 0250 RC 31722-0883-90 NDC inpatient 1 UN 1.01 0.66 UMR - ALL PLANS UMR - ALL PLANS 0.71 70 999999999 0.61 0.98 percent of total billed charges ROSUVASTATIN CALCIUM 10 MG TAB 49555376_1 CDM 0250 RC 31722-0883-90 NDC inpatient 1 UN 1.01 0.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.61 60.55 999999999 0.61 0.98 percent of total billed charges ROSUVASTATIN CALCIUM 10 MG TAB 49555376_1 CDM 0250 RC 31722-0883-90 NDC inpatient 1 UN 1.01 0.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.61 0.98 ROSUVASTATIN CALCIUM 10 MG TAB 49555376_1 CDM 0250 RC 31722-0883-90 NDC inpatient 1 UN 1.01 0.66 ANTHEM HMO ANTHEM HMO 999999999 0.61 0.98 ROSUVASTATIN CALCIUM 10 MG TAB 49555376_1 CDM 0250 RC 31722-0883-90 NDC inpatient 1 UN 1.01 0.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.61 0.98 ROSUVASTATIN CALCIUM 10 MG TAB 49555376_1 CDM 0250 RC 31722-0883-90 NDC inpatient 1 UN 1.01 0.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.68 67.6 999999999 0.61 0.98 percent of total billed charges ROSUVASTATIN CALCIUM 10 MG TAB 49555376_1 CDM 0250 RC 31722-0883-90 NDC inpatient 1 UN 1.01 0.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.61 0.98 ROSUVASTATIN CALCIUM 10 MG TAB 49555376_1 CDM 0250 RC 31722-0883-90 NDC inpatient 1 UN 1.01 0.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.61 0.98 GLYCOPYRROLATE 1 MG/5 ML VIAL 49555716_1 CDM 0250 RC 70069-0013-25 NDC inpatient 1 UN 60.78 39.51 AETNA AETNA 48.02 79 999999999 36.8 58.96 percent of total billed charges GLYCOPYRROLATE 1 MG/5 ML VIAL 49555716_1 CDM 0250 RC 70069-0013-25 NDC inpatient 1 UN 60.78 39.51 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.51 65 999999999 36.8 58.96 percent of total billed charges GLYCOPYRROLATE 1 MG/5 ML VIAL 49555716_1 CDM 0250 RC 70069-0013-25 NDC inpatient 1 UN 60.78 39.51 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.96 97 999999999 36.8 58.96 percent of total billed charges GLYCOPYRROLATE 1 MG/5 ML VIAL 49555716_1 CDM 0250 RC 70069-0013-25 NDC inpatient 1 UN 60.78 39.51 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.41 78 999999999 36.8 58.96 percent of total billed charges GLYCOPYRROLATE 1 MG/5 ML VIAL 49555716_1 CDM 0250 RC 70069-0013-25 NDC inpatient 1 UN 60.78 39.51 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.94 69 999999999 36.8 58.96 percent of total billed charges GLYCOPYRROLATE 1 MG/5 ML VIAL 49555716_1 CDM 0250 RC 70069-0013-25 NDC inpatient 1 UN 60.78 39.51 SIHO - ALL PLANS SIHO - ALL PLANS 54.7 90 999999999 36.8 58.96 percent of total billed charges GLYCOPYRROLATE 1 MG/5 ML VIAL 49555716_1 CDM 0250 RC 70069-0013-25 NDC inpatient 1 UN 60.78 39.51 UMR - ALL PLANS UMR - ALL PLANS 42.55 70 999999999 36.8 58.96 percent of total billed charges GLYCOPYRROLATE 1 MG/5 ML VIAL 49555716_1 CDM 0250 RC 70069-0013-25 NDC inpatient 1 UN 60.78 39.51 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.8 60.55 999999999 36.8 58.96 percent of total billed charges GLYCOPYRROLATE 1 MG/5 ML VIAL 49555716_1 CDM 0250 RC 70069-0013-25 NDC inpatient 1 UN 60.78 39.51 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.8 58.96 GLYCOPYRROLATE 1 MG/5 ML VIAL 49555716_1 CDM 0250 RC 70069-0013-25 NDC inpatient 1 UN 60.78 39.51 ANTHEM HMO ANTHEM HMO 999999999 36.8 58.96 GLYCOPYRROLATE 1 MG/5 ML VIAL 49555716_1 CDM 0250 RC 70069-0013-25 NDC inpatient 1 UN 60.78 39.51 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.8 58.96 GLYCOPYRROLATE 1 MG/5 ML VIAL 49555716_1 CDM 0250 RC 70069-0013-25 NDC inpatient 1 UN 60.78 39.51 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.09 67.6 999999999 36.8 58.96 percent of total billed charges GLYCOPYRROLATE 1 MG/5 ML VIAL 49555716_1 CDM 0250 RC 70069-0013-25 NDC inpatient 1 UN 60.78 39.51 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.8 58.96 GLYCOPYRROLATE 1 MG/5 ML VIAL 49555716_1 CDM 0250 RC 70069-0013-25 NDC inpatient 1 UN 60.78 39.51 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.8 58.96 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49555731_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49555731_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49555731_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49555731_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49555731_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49555731_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49555731_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49555731_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49555731_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49555731_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49555731_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49555731_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49555731_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49555731_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Clozapine level 49555736_1 CDM 0301 RC 80159 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges Clozapine level 49555736_1 CDM 0301 RC 80159 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges Clozapine level 49555736_1 CDM 0301 RC 80159 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges Clozapine level 49555736_1 CDM 0301 RC 80159 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges Clozapine level 49555736_1 CDM 0301 RC 80159 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges Clozapine level 49555736_1 CDM 0301 RC 80159 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges Clozapine level 49555736_1 CDM 0301 RC 80159 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges Clozapine level 49555736_1 CDM 0301 RC 80159 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges Clozapine level 49555736_1 CDM 0301 RC 80159 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 Clozapine level 49555736_1 CDM 0301 RC 80159 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 Clozapine level 49555736_1 CDM 0301 RC 80159 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 Clozapine level 49555736_1 CDM 0301 RC 80159 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges Clozapine level 49555736_1 CDM 0301 RC 80159 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 Clozapine level 49555736_1 CDM 0301 RC 80159 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 "Alcohols levels, 1 or 2" 49555739_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 AETNA AETNA 145.36 79 999999999 111.41 178.48 percent of total billed charges "Alcohols levels, 1 or 2" 49555739_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 119.6 65 999999999 111.41 178.48 percent of total billed charges "Alcohols levels, 1 or 2" 49555739_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 178.48 97 999999999 111.41 178.48 percent of total billed charges "Alcohols levels, 1 or 2" 49555739_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 143.52 78 999999999 111.41 178.48 percent of total billed charges "Alcohols levels, 1 or 2" 49555739_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.96 69 999999999 111.41 178.48 percent of total billed charges "Alcohols levels, 1 or 2" 49555739_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 SIHO - ALL PLANS SIHO - ALL PLANS 165.6 90 999999999 111.41 178.48 percent of total billed charges "Alcohols levels, 1 or 2" 49555739_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 UMR - ALL PLANS UMR - ALL PLANS 128.8 70 999999999 111.41 178.48 percent of total billed charges "Alcohols levels, 1 or 2" 49555739_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 111.41 60.55 999999999 111.41 178.48 percent of total billed charges "Alcohols levels, 1 or 2" 49555739_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 111.41 178.48 "Alcohols levels, 1 or 2" 49555739_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 ANTHEM HMO ANTHEM HMO 999999999 111.41 178.48 "Alcohols levels, 1 or 2" 49555739_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 111.41 178.48 "Alcohols levels, 1 or 2" 49555739_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 124.38 67.6 999999999 111.41 178.48 percent of total billed charges "Alcohols levels, 1 or 2" 49555739_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 111.41 178.48 "Alcohols levels, 1 or 2" 49555739_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 111.41 178.48 Histamine (immune system substance) level 49555742_1 CDM 0301 RC 83088 HCPCS inpatient 216 140.4 AETNA AETNA 170.64 79 999999999 130.79 209.52 percent of total billed charges Histamine (immune system substance) level 49555742_1 CDM 0301 RC 83088 HCPCS inpatient 216 140.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 140.4 65 999999999 130.79 209.52 percent of total billed charges Histamine (immune system substance) level 49555742_1 CDM 0301 RC 83088 HCPCS inpatient 216 140.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 209.52 97 999999999 130.79 209.52 percent of total billed charges Histamine (immune system substance) level 49555742_1 CDM 0301 RC 83088 HCPCS inpatient 216 140.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 168.48 78 999999999 130.79 209.52 percent of total billed charges Histamine (immune system substance) level 49555742_1 CDM 0301 RC 83088 HCPCS inpatient 216 140.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 149.04 69 999999999 130.79 209.52 percent of total billed charges Histamine (immune system substance) level 49555742_1 CDM 0301 RC 83088 HCPCS inpatient 216 140.4 SIHO - ALL PLANS SIHO - ALL PLANS 194.4 90 999999999 130.79 209.52 percent of total billed charges Histamine (immune system substance) level 49555742_1 CDM 0301 RC 83088 HCPCS inpatient 216 140.4 UMR - ALL PLANS UMR - ALL PLANS 151.2 70 999999999 130.79 209.52 percent of total billed charges Histamine (immune system substance) level 49555742_1 CDM 0301 RC 83088 HCPCS inpatient 216 140.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 130.79 60.55 999999999 130.79 209.52 percent of total billed charges Histamine (immune system substance) level 49555742_1 CDM 0301 RC 83088 HCPCS inpatient 216 140.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 130.79 209.52 Histamine (immune system substance) level 49555742_1 CDM 0301 RC 83088 HCPCS inpatient 216 140.4 ANTHEM HMO ANTHEM HMO 999999999 130.79 209.52 Histamine (immune system substance) level 49555742_1 CDM 0301 RC 83088 HCPCS inpatient 216 140.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 130.79 209.52 Histamine (immune system substance) level 49555742_1 CDM 0301 RC 83088 HCPCS inpatient 216 140.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 146.02 67.6 999999999 130.79 209.52 percent of total billed charges Histamine (immune system substance) level 49555742_1 CDM 0301 RC 83088 HCPCS inpatient 216 140.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 130.79 209.52 Histamine (immune system substance) level 49555742_1 CDM 0301 RC 83088 HCPCS inpatient 216 140.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 130.79 209.52 Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49555745_1 CDM 0312 RC 81275 HCPCS inpatient 509 330.85 AETNA AETNA 402.11 79 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49555745_1 CDM 0312 RC 81275 HCPCS inpatient 509 330.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 330.85 65 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49555745_1 CDM 0312 RC 81275 HCPCS inpatient 509 330.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 493.73 97 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49555745_1 CDM 0312 RC 81275 HCPCS inpatient 509 330.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 397.02 78 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49555745_1 CDM 0312 RC 81275 HCPCS inpatient 509 330.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 351.21 69 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49555745_1 CDM 0312 RC 81275 HCPCS inpatient 509 330.85 SIHO - ALL PLANS SIHO - ALL PLANS 458.1 90 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49555745_1 CDM 0312 RC 81275 HCPCS inpatient 509 330.85 UMR - ALL PLANS UMR - ALL PLANS 356.3 70 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49555745_1 CDM 0312 RC 81275 HCPCS inpatient 509 330.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 308.2 60.55 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49555745_1 CDM 0312 RC 81275 HCPCS inpatient 509 330.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 308.2 493.73 Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49555745_1 CDM 0312 RC 81275 HCPCS inpatient 509 330.85 ANTHEM HMO ANTHEM HMO 999999999 308.2 493.73 Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49555745_1 CDM 0312 RC 81275 HCPCS inpatient 509 330.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 308.2 493.73 Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49555745_1 CDM 0312 RC 81275 HCPCS inpatient 509 330.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 344.08 67.6 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49555745_1 CDM 0312 RC 81275 HCPCS inpatient 509 330.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 308.2 493.73 Gene analysis (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) variants in codons 12 and 13 49555745_1 CDM 0312 RC 81275 HCPCS inpatient 509 330.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 308.2 493.73 "Special stained specimen slides to examine tissue, initial procedure" 49555746_1 CDM 0310 RC 88342 HCPCS inpatient 332 215.8 AETNA AETNA 262.28 79 999999999 201.03 322.04 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 49555746_1 CDM 0310 RC 88342 HCPCS inpatient 332 215.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 215.8 65 999999999 201.03 322.04 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 49555746_1 CDM 0310 RC 88342 HCPCS inpatient 332 215.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 322.04 97 999999999 201.03 322.04 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 49555746_1 CDM 0310 RC 88342 HCPCS inpatient 332 215.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 258.96 78 999999999 201.03 322.04 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 49555746_1 CDM 0310 RC 88342 HCPCS inpatient 332 215.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 229.08 69 999999999 201.03 322.04 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 49555746_1 CDM 0310 RC 88342 HCPCS inpatient 332 215.8 SIHO - ALL PLANS SIHO - ALL PLANS 298.8 90 999999999 201.03 322.04 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 49555746_1 CDM 0310 RC 88342 HCPCS inpatient 332 215.8 UMR - ALL PLANS UMR - ALL PLANS 232.4 70 999999999 201.03 322.04 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 49555746_1 CDM 0310 RC 88342 HCPCS inpatient 332 215.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 201.03 60.55 999999999 201.03 322.04 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 49555746_1 CDM 0310 RC 88342 HCPCS inpatient 332 215.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 201.03 322.04 "Special stained specimen slides to examine tissue, initial procedure" 49555746_1 CDM 0310 RC 88342 HCPCS inpatient 332 215.8 ANTHEM HMO ANTHEM HMO 999999999 201.03 322.04 "Special stained specimen slides to examine tissue, initial procedure" 49555746_1 CDM 0310 RC 88342 HCPCS inpatient 332 215.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 201.03 322.04 "Special stained specimen slides to examine tissue, initial procedure" 49555746_1 CDM 0310 RC 88342 HCPCS inpatient 332 215.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 224.43 67.6 999999999 201.03 322.04 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 49555746_1 CDM 0310 RC 88342 HCPCS inpatient 332 215.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 201.03 322.04 "Special stained specimen slides to examine tissue, initial procedure" 49555746_1 CDM 0310 RC 88342 HCPCS inpatient 332 215.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 201.03 322.04 Macroscopic examination (visual inspection) of parasite 49555750_1 CDM 0301 RC 87169 HCPCS inpatient 53 34.45 AETNA AETNA 41.87 79 999999999 32.09 51.41 percent of total billed charges Macroscopic examination (visual inspection) of parasite 49555750_1 CDM 0301 RC 87169 HCPCS inpatient 53 34.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.45 65 999999999 32.09 51.41 percent of total billed charges Macroscopic examination (visual inspection) of parasite 49555750_1 CDM 0301 RC 87169 HCPCS inpatient 53 34.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.41 97 999999999 32.09 51.41 percent of total billed charges Macroscopic examination (visual inspection) of parasite 49555750_1 CDM 0301 RC 87169 HCPCS inpatient 53 34.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.34 78 999999999 32.09 51.41 percent of total billed charges Macroscopic examination (visual inspection) of parasite 49555750_1 CDM 0301 RC 87169 HCPCS inpatient 53 34.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.57 69 999999999 32.09 51.41 percent of total billed charges Macroscopic examination (visual inspection) of parasite 49555750_1 CDM 0301 RC 87169 HCPCS inpatient 53 34.45 SIHO - ALL PLANS SIHO - ALL PLANS 47.7 90 999999999 32.09 51.41 percent of total billed charges Macroscopic examination (visual inspection) of parasite 49555750_1 CDM 0301 RC 87169 HCPCS inpatient 53 34.45 UMR - ALL PLANS UMR - ALL PLANS 37.1 70 999999999 32.09 51.41 percent of total billed charges Macroscopic examination (visual inspection) of parasite 49555750_1 CDM 0301 RC 87169 HCPCS inpatient 53 34.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.09 60.55 999999999 32.09 51.41 percent of total billed charges Macroscopic examination (visual inspection) of parasite 49555750_1 CDM 0301 RC 87169 HCPCS inpatient 53 34.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.09 51.41 Macroscopic examination (visual inspection) of parasite 49555750_1 CDM 0301 RC 87169 HCPCS inpatient 53 34.45 ANTHEM HMO ANTHEM HMO 999999999 32.09 51.41 Macroscopic examination (visual inspection) of parasite 49555750_1 CDM 0301 RC 87169 HCPCS inpatient 53 34.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.09 51.41 Macroscopic examination (visual inspection) of parasite 49555750_1 CDM 0301 RC 87169 HCPCS inpatient 53 34.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.83 67.6 999999999 32.09 51.41 percent of total billed charges Macroscopic examination (visual inspection) of parasite 49555750_1 CDM 0301 RC 87169 HCPCS inpatient 53 34.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.09 51.41 Macroscopic examination (visual inspection) of parasite 49555750_1 CDM 0301 RC 87169 HCPCS inpatient 53 34.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.09 51.41 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49557296_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 AETNA AETNA 402.11 79 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49557296_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 330.85 65 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49557296_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 493.73 97 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49557296_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 351.21 69 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49557296_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 397.02 78 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49557296_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 SIHO - ALL PLANS SIHO - ALL PLANS 458.1 90 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49557296_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 UMR - ALL PLANS UMR - ALL PLANS 356.3 70 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49557296_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 308.2 60.55 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49557296_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 308.2 493.73 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49557296_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 ANTHEM HMO ANTHEM HMO 999999999 308.2 493.73 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49557296_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 308.2 493.73 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49557296_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 344.08 67.6 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49557296_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 308.2 493.73 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49557296_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 308.2 493.73 Gene analysis for cancer (neuroblastoma) 49557301_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 AETNA AETNA 983.55 79 999999999 753.85 1207.65 percent of total billed charges Gene analysis for cancer (neuroblastoma) 49557301_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 809.25 65 999999999 753.85 1207.65 percent of total billed charges Gene analysis for cancer (neuroblastoma) 49557301_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1207.65 97 999999999 753.85 1207.65 percent of total billed charges Gene analysis for cancer (neuroblastoma) 49557301_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 859.05 69 999999999 753.85 1207.65 percent of total billed charges Gene analysis for cancer (neuroblastoma) 49557301_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 971.1 78 999999999 753.85 1207.65 percent of total billed charges Gene analysis for cancer (neuroblastoma) 49557301_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 SIHO - ALL PLANS SIHO - ALL PLANS 1120.5 90 999999999 753.85 1207.65 percent of total billed charges Gene analysis for cancer (neuroblastoma) 49557301_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 UMR - ALL PLANS UMR - ALL PLANS 871.5 70 999999999 753.85 1207.65 percent of total billed charges Gene analysis for cancer (neuroblastoma) 49557301_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 753.85 60.55 999999999 753.85 1207.65 percent of total billed charges Gene analysis for cancer (neuroblastoma) 49557301_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 753.85 1207.65 Gene analysis for cancer (neuroblastoma) 49557301_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 ANTHEM HMO ANTHEM HMO 999999999 753.85 1207.65 Gene analysis for cancer (neuroblastoma) 49557301_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 753.85 1207.65 Gene analysis for cancer (neuroblastoma) 49557301_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 841.62 67.6 999999999 753.85 1207.65 percent of total billed charges Gene analysis for cancer (neuroblastoma) 49557301_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 753.85 1207.65 Gene analysis for cancer (neuroblastoma) 49557301_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 753.85 1207.65 VIMPAT 50 MG TABLET 49570497_1 CDM 0250 RC 00131-2477-60 NDC inpatient 1 UN 47.49 30.87 AETNA AETNA 37.52 79 999999999 28.76 46.07 percent of total billed charges VIMPAT 50 MG TABLET 49570497_1 CDM 0250 RC 00131-2477-60 NDC inpatient 1 UN 47.49 30.87 SELF PAY DISCOUNT SELF PAY DISCOUNT 30.87 65 999999999 28.76 46.07 percent of total billed charges VIMPAT 50 MG TABLET 49570497_1 CDM 0250 RC 00131-2477-60 NDC inpatient 1 UN 47.49 30.87 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 46.07 97 999999999 28.76 46.07 percent of total billed charges VIMPAT 50 MG TABLET 49570497_1 CDM 0250 RC 00131-2477-60 NDC inpatient 1 UN 47.49 30.87 ENCORE - ALL PLANS ENCORE - ALL PLANS 32.77 69 999999999 28.76 46.07 percent of total billed charges VIMPAT 50 MG TABLET 49570497_1 CDM 0250 RC 00131-2477-60 NDC inpatient 1 UN 47.49 30.87 HUMANA - ALL PLANS HUMANA - ALL PLANS 37.04 78 999999999 28.76 46.07 percent of total billed charges VIMPAT 50 MG TABLET 49570497_1 CDM 0250 RC 00131-2477-60 NDC inpatient 1 UN 47.49 30.87 SIHO - ALL PLANS SIHO - ALL PLANS 42.74 90 999999999 28.76 46.07 percent of total billed charges VIMPAT 50 MG TABLET 49570497_1 CDM 0250 RC 00131-2477-60 NDC inpatient 1 UN 47.49 30.87 UMR - ALL PLANS UMR - ALL PLANS 33.24 70 999999999 28.76 46.07 percent of total billed charges VIMPAT 50 MG TABLET 49570497_1 CDM 0250 RC 00131-2477-60 NDC inpatient 1 UN 47.49 30.87 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 28.76 60.55 999999999 28.76 46.07 percent of total billed charges VIMPAT 50 MG TABLET 49570497_1 CDM 0250 RC 00131-2477-60 NDC inpatient 1 UN 47.49 30.87 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 28.76 46.07 VIMPAT 50 MG TABLET 49570497_1 CDM 0250 RC 00131-2477-60 NDC inpatient 1 UN 47.49 30.87 ANTHEM HMO ANTHEM HMO 999999999 28.76 46.07 VIMPAT 50 MG TABLET 49570497_1 CDM 0250 RC 00131-2477-60 NDC inpatient 1 UN 47.49 30.87 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 28.76 46.07 VIMPAT 50 MG TABLET 49570497_1 CDM 0250 RC 00131-2477-60 NDC inpatient 1 UN 47.49 30.87 CIGNA - ALL PLANS CIGNA - ALL PLANS 32.1 67.6 999999999 28.76 46.07 percent of total billed charges VIMPAT 50 MG TABLET 49570497_1 CDM 0250 RC 00131-2477-60 NDC inpatient 1 UN 47.49 30.87 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 28.76 46.07 VIMPAT 50 MG TABLET 49570497_1 CDM 0250 RC 00131-2477-60 NDC inpatient 1 UN 47.49 30.87 UHC - ALL PLANS UHC - ALL PLANS 999999999 28.76 46.07 00115-9822-01 - digoxin 250 mcg (0.25 mg) Tab[JOHN] 49570501_1 CDM 0250 RC 00115-9822-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 00115-9822-01 - digoxin 250 mcg (0.25 mg) Tab[JOHN] 49570501_1 CDM 0250 RC 00115-9822-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 00115-9822-01 - digoxin 250 mcg (0.25 mg) Tab[JOHN] 49570501_1 CDM 0250 RC 00115-9822-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 00115-9822-01 - digoxin 250 mcg (0.25 mg) Tab[JOHN] 49570501_1 CDM 0250 RC 00115-9822-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 00115-9822-01 - digoxin 250 mcg (0.25 mg) Tab[JOHN] 49570501_1 CDM 0250 RC 00115-9822-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 00115-9822-01 - digoxin 250 mcg (0.25 mg) Tab[JOHN] 49570501_1 CDM 0250 RC 00115-9822-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 00115-9822-01 - digoxin 250 mcg (0.25 mg) Tab[JOHN] 49570501_1 CDM 0250 RC 00115-9822-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 00115-9822-01 - digoxin 250 mcg (0.25 mg) Tab[JOHN] 49570501_1 CDM 0250 RC 00115-9822-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 00115-9822-01 - digoxin 250 mcg (0.25 mg) Tab[JOHN] 49570501_1 CDM 0250 RC 00115-9822-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 00115-9822-01 - digoxin 250 mcg (0.25 mg) Tab[JOHN] 49570501_1 CDM 0250 RC 00115-9822-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 00115-9822-01 - digoxin 250 mcg (0.25 mg) Tab[JOHN] 49570501_1 CDM 0250 RC 00115-9822-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 00115-9822-01 - digoxin 250 mcg (0.25 mg) Tab[JOHN] 49570501_1 CDM 0250 RC 00115-9822-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 00115-9822-01 - digoxin 250 mcg (0.25 mg) Tab[JOHN] 49570501_1 CDM 0250 RC 00115-9822-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 00115-9822-01 - digoxin 250 mcg (0.25 mg) Tab[JOHN] 49570501_1 CDM 0250 RC 00115-9822-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 49570625_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 49570625_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 49570625_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 49570625_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 49570625_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 49570625_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 49570625_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 49570625_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 49570625_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 49570625_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 49570625_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 49570625_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 49570625_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 49570625_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 Measurement of substance using immunoassay technique 49570694_1 CDM 0301 RC 83520 HCPCS inpatient 98 63.7 AETNA AETNA 77.42 79 999999999 59.34 95.06 percent of total billed charges Measurement of substance using immunoassay technique 49570694_1 CDM 0301 RC 83520 HCPCS inpatient 98 63.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.7 65 999999999 59.34 95.06 percent of total billed charges Measurement of substance using immunoassay technique 49570694_1 CDM 0301 RC 83520 HCPCS inpatient 98 63.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.06 97 999999999 59.34 95.06 percent of total billed charges Measurement of substance using immunoassay technique 49570694_1 CDM 0301 RC 83520 HCPCS inpatient 98 63.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.62 69 999999999 59.34 95.06 percent of total billed charges Measurement of substance using immunoassay technique 49570694_1 CDM 0301 RC 83520 HCPCS inpatient 98 63.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.44 78 999999999 59.34 95.06 percent of total billed charges Measurement of substance using immunoassay technique 49570694_1 CDM 0301 RC 83520 HCPCS inpatient 98 63.7 SIHO - ALL PLANS SIHO - ALL PLANS 88.2 90 999999999 59.34 95.06 percent of total billed charges Measurement of substance using immunoassay technique 49570694_1 CDM 0301 RC 83520 HCPCS inpatient 98 63.7 UMR - ALL PLANS UMR - ALL PLANS 68.6 70 999999999 59.34 95.06 percent of total billed charges Measurement of substance using immunoassay technique 49570694_1 CDM 0301 RC 83520 HCPCS inpatient 98 63.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.34 60.55 999999999 59.34 95.06 percent of total billed charges Measurement of substance using immunoassay technique 49570694_1 CDM 0301 RC 83520 HCPCS inpatient 98 63.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.34 95.06 Measurement of substance using immunoassay technique 49570694_1 CDM 0301 RC 83520 HCPCS inpatient 98 63.7 ANTHEM HMO ANTHEM HMO 999999999 59.34 95.06 Measurement of substance using immunoassay technique 49570694_1 CDM 0301 RC 83520 HCPCS inpatient 98 63.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.34 95.06 Measurement of substance using immunoassay technique 49570694_1 CDM 0301 RC 83520 HCPCS inpatient 98 63.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.25 67.6 999999999 59.34 95.06 percent of total billed charges Measurement of substance using immunoassay technique 49570694_1 CDM 0301 RC 83520 HCPCS inpatient 98 63.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.34 95.06 Measurement of substance using immunoassay technique 49570694_1 CDM 0301 RC 83520 HCPCS inpatient 98 63.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.34 95.06 ROPINIROLE HCL 0.25 MG TABLET 49574413_1 CDM 0250 RC 62332-0030-31 NDC inpatient 1 UN 1.52 0.99 AETNA AETNA 1.2 79 999999999 0.92 1.47 percent of total billed charges ROPINIROLE HCL 0.25 MG TABLET 49574413_1 CDM 0250 RC 62332-0030-31 NDC inpatient 1 UN 1.52 0.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.99 65 999999999 0.92 1.47 percent of total billed charges ROPINIROLE HCL 0.25 MG TABLET 49574413_1 CDM 0250 RC 62332-0030-31 NDC inpatient 1 UN 1.52 0.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.47 97 999999999 0.92 1.47 percent of total billed charges ROPINIROLE HCL 0.25 MG TABLET 49574413_1 CDM 0250 RC 62332-0030-31 NDC inpatient 1 UN 1.52 0.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.05 69 999999999 0.92 1.47 percent of total billed charges ROPINIROLE HCL 0.25 MG TABLET 49574413_1 CDM 0250 RC 62332-0030-31 NDC inpatient 1 UN 1.52 0.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.19 78 999999999 0.92 1.47 percent of total billed charges ROPINIROLE HCL 0.25 MG TABLET 49574413_1 CDM 0250 RC 62332-0030-31 NDC inpatient 1 UN 1.52 0.99 SIHO - ALL PLANS SIHO - ALL PLANS 1.37 90 999999999 0.92 1.47 percent of total billed charges ROPINIROLE HCL 0.25 MG TABLET 49574413_1 CDM 0250 RC 62332-0030-31 NDC inpatient 1 UN 1.52 0.99 UMR - ALL PLANS UMR - ALL PLANS 1.06 70 999999999 0.92 1.47 percent of total billed charges ROPINIROLE HCL 0.25 MG TABLET 49574413_1 CDM 0250 RC 62332-0030-31 NDC inpatient 1 UN 1.52 0.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.92 60.55 999999999 0.92 1.47 percent of total billed charges ROPINIROLE HCL 0.25 MG TABLET 49574413_1 CDM 0250 RC 62332-0030-31 NDC inpatient 1 UN 1.52 0.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.92 1.47 ROPINIROLE HCL 0.25 MG TABLET 49574413_1 CDM 0250 RC 62332-0030-31 NDC inpatient 1 UN 1.52 0.99 ANTHEM HMO ANTHEM HMO 999999999 0.92 1.47 ROPINIROLE HCL 0.25 MG TABLET 49574413_1 CDM 0250 RC 62332-0030-31 NDC inpatient 1 UN 1.52 0.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.92 1.47 ROPINIROLE HCL 0.25 MG TABLET 49574413_1 CDM 0250 RC 62332-0030-31 NDC inpatient 1 UN 1.52 0.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.03 67.6 999999999 0.92 1.47 percent of total billed charges ROPINIROLE HCL 0.25 MG TABLET 49574413_1 CDM 0250 RC 62332-0030-31 NDC inpatient 1 UN 1.52 0.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.92 1.47 ROPINIROLE HCL 0.25 MG TABLET 49574413_1 CDM 0250 RC 62332-0030-31 NDC inpatient 1 UN 1.52 0.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.92 1.47 "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 49576519_1 CDM 0250 RC 00264-9587-20 NDC J1644 HCPCS inpatient 1 UN 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 49576519_1 CDM 0250 RC 00264-9587-20 NDC J1644 HCPCS inpatient 1 UN 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 49576519_1 CDM 0250 RC 00264-9587-20 NDC J1644 HCPCS inpatient 1 UN 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 49576519_1 CDM 0250 RC 00264-9587-20 NDC J1644 HCPCS inpatient 1 UN 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 49576519_1 CDM 0250 RC 00264-9587-20 NDC J1644 HCPCS inpatient 1 UN 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 49576519_1 CDM 0250 RC 00264-9587-20 NDC J1644 HCPCS inpatient 1 UN 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 49576519_1 CDM 0250 RC 00264-9587-20 NDC J1644 HCPCS inpatient 1 UN 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 49576519_1 CDM 0250 RC 00264-9587-20 NDC J1644 HCPCS inpatient 1 UN 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 49576519_1 CDM 0250 RC 00264-9587-20 NDC J1644 HCPCS inpatient 1 UN 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 49576519_1 CDM 0250 RC 00264-9587-20 NDC J1644 HCPCS inpatient 1 UN 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 49576519_1 CDM 0250 RC 00264-9587-20 NDC J1644 HCPCS inpatient 1 UN 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 49576519_1 CDM 0250 RC 00264-9587-20 NDC J1644 HCPCS inpatient 1 UN 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 49576519_1 CDM 0250 RC 00264-9587-20 NDC J1644 HCPCS inpatient 1 UN 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 "INJECTION, HEPARIN SODIUM, PER 1000 UNITS" 49576519_1 CDM 0250 RC 00264-9587-20 NDC J1644 HCPCS inpatient 1 UN 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 HYDROCODONE-CHLORPHEN ER SUSP 49579984_1 CDM 0250 RC 62542-0301-17 NDC inpatient 1 UN 8.94 5.81 AETNA AETNA 7.06 79 999999999 5.41 8.67 percent of total billed charges HYDROCODONE-CHLORPHEN ER SUSP 49579984_1 CDM 0250 RC 62542-0301-17 NDC inpatient 1 UN 8.94 5.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.81 65 999999999 5.41 8.67 percent of total billed charges HYDROCODONE-CHLORPHEN ER SUSP 49579984_1 CDM 0250 RC 62542-0301-17 NDC inpatient 1 UN 8.94 5.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.67 97 999999999 5.41 8.67 percent of total billed charges HYDROCODONE-CHLORPHEN ER SUSP 49579984_1 CDM 0250 RC 62542-0301-17 NDC inpatient 1 UN 8.94 5.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.17 69 999999999 5.41 8.67 percent of total billed charges HYDROCODONE-CHLORPHEN ER SUSP 49579984_1 CDM 0250 RC 62542-0301-17 NDC inpatient 1 UN 8.94 5.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.97 78 999999999 5.41 8.67 percent of total billed charges HYDROCODONE-CHLORPHEN ER SUSP 49579984_1 CDM 0250 RC 62542-0301-17 NDC inpatient 1 UN 8.94 5.81 SIHO - ALL PLANS SIHO - ALL PLANS 8.05 90 999999999 5.41 8.67 percent of total billed charges HYDROCODONE-CHLORPHEN ER SUSP 49579984_1 CDM 0250 RC 62542-0301-17 NDC inpatient 1 UN 8.94 5.81 UMR - ALL PLANS UMR - ALL PLANS 6.26 70 999999999 5.41 8.67 percent of total billed charges HYDROCODONE-CHLORPHEN ER SUSP 49579984_1 CDM 0250 RC 62542-0301-17 NDC inpatient 1 UN 8.94 5.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.41 60.55 999999999 5.41 8.67 percent of total billed charges HYDROCODONE-CHLORPHEN ER SUSP 49579984_1 CDM 0250 RC 62542-0301-17 NDC inpatient 1 UN 8.94 5.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.41 8.67 HYDROCODONE-CHLORPHEN ER SUSP 49579984_1 CDM 0250 RC 62542-0301-17 NDC inpatient 1 UN 8.94 5.81 ANTHEM HMO ANTHEM HMO 999999999 5.41 8.67 HYDROCODONE-CHLORPHEN ER SUSP 49579984_1 CDM 0250 RC 62542-0301-17 NDC inpatient 1 UN 8.94 5.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.41 8.67 HYDROCODONE-CHLORPHEN ER SUSP 49579984_1 CDM 0250 RC 62542-0301-17 NDC inpatient 1 UN 8.94 5.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.04 67.6 999999999 5.41 8.67 percent of total billed charges HYDROCODONE-CHLORPHEN ER SUSP 49579984_1 CDM 0250 RC 62542-0301-17 NDC inpatient 1 UN 8.94 5.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.41 8.67 HYDROCODONE-CHLORPHEN ER SUSP 49579984_1 CDM 0250 RC 62542-0301-17 NDC inpatient 1 UN 8.94 5.81 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.41 8.67 "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 49580483_1 CDM 0250 RC 63323-0360-19 NDC J0610 HCPCS inpatient 1 UN 59.02 38.36 AETNA AETNA 46.63 79 999999999 35.74 57.25 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 49580483_1 CDM 0250 RC 63323-0360-19 NDC J0610 HCPCS inpatient 1 UN 59.02 38.36 SELF PAY DISCOUNT SELF PAY DISCOUNT 38.36 65 999999999 35.74 57.25 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 49580483_1 CDM 0250 RC 63323-0360-19 NDC J0610 HCPCS inpatient 1 UN 59.02 38.36 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 57.25 97 999999999 35.74 57.25 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 49580483_1 CDM 0250 RC 63323-0360-19 NDC J0610 HCPCS inpatient 1 UN 59.02 38.36 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.72 69 999999999 35.74 57.25 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 49580483_1 CDM 0250 RC 63323-0360-19 NDC J0610 HCPCS inpatient 1 UN 59.02 38.36 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.04 78 999999999 35.74 57.25 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 49580483_1 CDM 0250 RC 63323-0360-19 NDC J0610 HCPCS inpatient 1 UN 59.02 38.36 SIHO - ALL PLANS SIHO - ALL PLANS 53.12 90 999999999 35.74 57.25 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 49580483_1 CDM 0250 RC 63323-0360-19 NDC J0610 HCPCS inpatient 1 UN 59.02 38.36 UMR - ALL PLANS UMR - ALL PLANS 41.31 70 999999999 35.74 57.25 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 49580483_1 CDM 0250 RC 63323-0360-19 NDC J0610 HCPCS inpatient 1 UN 59.02 38.36 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.74 60.55 999999999 35.74 57.25 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 49580483_1 CDM 0250 RC 63323-0360-19 NDC J0610 HCPCS inpatient 1 UN 59.02 38.36 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.74 57.25 "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 49580483_1 CDM 0250 RC 63323-0360-19 NDC J0610 HCPCS inpatient 1 UN 59.02 38.36 ANTHEM HMO ANTHEM HMO 999999999 35.74 57.25 "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 49580483_1 CDM 0250 RC 63323-0360-19 NDC J0610 HCPCS inpatient 1 UN 59.02 38.36 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.74 57.25 "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 49580483_1 CDM 0250 RC 63323-0360-19 NDC J0610 HCPCS inpatient 1 UN 59.02 38.36 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.9 67.6 999999999 35.74 57.25 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 49580483_1 CDM 0250 RC 63323-0360-19 NDC J0610 HCPCS inpatient 1 UN 59.02 38.36 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.74 57.25 "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 49580483_1 CDM 0250 RC 63323-0360-19 NDC J0610 HCPCS inpatient 1 UN 59.02 38.36 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.74 57.25 "CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS" 49581505_1 CDM 0250 RC 69784-0205-60 NDC J7631 HCPCS inpatient 1 UN 71.91 46.74 AETNA AETNA 56.81 79 999999999 43.54 69.75 percent of total billed charges "CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS" 49581505_1 CDM 0250 RC 69784-0205-60 NDC J7631 HCPCS inpatient 1 UN 71.91 46.74 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.74 65 999999999 43.54 69.75 percent of total billed charges "CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS" 49581505_1 CDM 0250 RC 69784-0205-60 NDC J7631 HCPCS inpatient 1 UN 71.91 46.74 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.75 97 999999999 43.54 69.75 percent of total billed charges "CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS" 49581505_1 CDM 0250 RC 69784-0205-60 NDC J7631 HCPCS inpatient 1 UN 71.91 46.74 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.62 69 999999999 43.54 69.75 percent of total billed charges "CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS" 49581505_1 CDM 0250 RC 69784-0205-60 NDC J7631 HCPCS inpatient 1 UN 71.91 46.74 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.09 78 999999999 43.54 69.75 percent of total billed charges "CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS" 49581505_1 CDM 0250 RC 69784-0205-60 NDC J7631 HCPCS inpatient 1 UN 71.91 46.74 SIHO - ALL PLANS SIHO - ALL PLANS 64.72 90 999999999 43.54 69.75 percent of total billed charges "CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS" 49581505_1 CDM 0250 RC 69784-0205-60 NDC J7631 HCPCS inpatient 1 UN 71.91 46.74 UMR - ALL PLANS UMR - ALL PLANS 50.34 70 999999999 43.54 69.75 percent of total billed charges "CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS" 49581505_1 CDM 0250 RC 69784-0205-60 NDC J7631 HCPCS inpatient 1 UN 71.91 46.74 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.54 60.55 999999999 43.54 69.75 percent of total billed charges "CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS" 49581505_1 CDM 0250 RC 69784-0205-60 NDC J7631 HCPCS inpatient 1 UN 71.91 46.74 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.54 69.75 "CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS" 49581505_1 CDM 0250 RC 69784-0205-60 NDC J7631 HCPCS inpatient 1 UN 71.91 46.74 ANTHEM HMO ANTHEM HMO 999999999 43.54 69.75 "CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS" 49581505_1 CDM 0250 RC 69784-0205-60 NDC J7631 HCPCS inpatient 1 UN 71.91 46.74 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.54 69.75 "CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS" 49581505_1 CDM 0250 RC 69784-0205-60 NDC J7631 HCPCS inpatient 1 UN 71.91 46.74 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.61 67.6 999999999 43.54 69.75 percent of total billed charges "CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS" 49581505_1 CDM 0250 RC 69784-0205-60 NDC J7631 HCPCS inpatient 1 UN 71.91 46.74 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.54 69.75 "CROMOLYN SODIUM, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER 10 MILLIGRAMS" 49581505_1 CDM 0250 RC 69784-0205-60 NDC J7631 HCPCS inpatient 1 UN 71.91 46.74 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.54 69.75 "Electrophoresis, laboratory testing technique" 49586013_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges "Electrophoresis, laboratory testing technique" 49586013_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges "Electrophoresis, laboratory testing technique" 49586013_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges "Electrophoresis, laboratory testing technique" 49586013_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges "Electrophoresis, laboratory testing technique" 49586013_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges "Electrophoresis, laboratory testing technique" 49586013_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges "Electrophoresis, laboratory testing technique" 49586013_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges "Electrophoresis, laboratory testing technique" 49586013_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges "Electrophoresis, laboratory testing technique" 49586013_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 "Electrophoresis, laboratory testing technique" 49586013_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 "Electrophoresis, laboratory testing technique" 49586013_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 "Electrophoresis, laboratory testing technique" 49586013_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges "Electrophoresis, laboratory testing technique" 49586013_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 "Electrophoresis, laboratory testing technique" 49586013_1 CDM 0301 RC 82664 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 "Total protein level, urine" 49586022_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 49586022_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 49586022_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 49586022_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 49586022_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 49586022_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 49586022_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 49586022_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 49586022_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 "Total protein level, urine" 49586022_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 "Total protein level, urine" 49586022_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 "Total protein level, urine" 49586022_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges "Total protein level, urine" 49586022_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 "Total protein level, urine" 49586022_1 CDM 0301 RC 84156 HCPCS inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 FORAMEN NEEDLE 12.5CM 041829 49588172_1 CDM 0272 RC inpatient 292 189.8 AETNA AETNA 230.68 79 999999999 176.81 283.24 percent of total billed charges FORAMEN NEEDLE 12.5CM 041829 49588172_1 CDM 0272 RC inpatient 292 189.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 189.8 65 999999999 176.81 283.24 percent of total billed charges FORAMEN NEEDLE 12.5CM 041829 49588172_1 CDM 0272 RC inpatient 292 189.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 283.24 97 999999999 176.81 283.24 percent of total billed charges FORAMEN NEEDLE 12.5CM 041829 49588172_1 CDM 0272 RC inpatient 292 189.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 201.48 69 999999999 176.81 283.24 percent of total billed charges FORAMEN NEEDLE 12.5CM 041829 49588172_1 CDM 0272 RC inpatient 292 189.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 227.76 78 999999999 176.81 283.24 percent of total billed charges FORAMEN NEEDLE 12.5CM 041829 49588172_1 CDM 0272 RC inpatient 292 189.8 SIHO - ALL PLANS SIHO - ALL PLANS 262.8 90 999999999 176.81 283.24 percent of total billed charges FORAMEN NEEDLE 12.5CM 041829 49588172_1 CDM 0272 RC inpatient 292 189.8 UMR - ALL PLANS UMR - ALL PLANS 204.4 70 999999999 176.81 283.24 percent of total billed charges FORAMEN NEEDLE 12.5CM 041829 49588172_1 CDM 0272 RC inpatient 292 189.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 176.81 60.55 999999999 176.81 283.24 percent of total billed charges FORAMEN NEEDLE 12.5CM 041829 49588172_1 CDM 0272 RC inpatient 292 189.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 176.81 283.24 FORAMEN NEEDLE 12.5CM 041829 49588172_1 CDM 0272 RC inpatient 292 189.8 ANTHEM HMO ANTHEM HMO 999999999 176.81 283.24 FORAMEN NEEDLE 12.5CM 041829 49588172_1 CDM 0272 RC inpatient 292 189.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 176.81 283.24 FORAMEN NEEDLE 12.5CM 041829 49588172_1 CDM 0272 RC inpatient 292 189.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 197.39 67.6 999999999 176.81 283.24 percent of total billed charges FORAMEN NEEDLE 12.5CM 041829 49588172_1 CDM 0272 RC inpatient 292 189.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 176.81 283.24 FORAMEN NEEDLE 12.5CM 041829 49588172_1 CDM 0272 RC inpatient 292 189.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 176.81 283.24 "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 49590373_1 CDM 0250 RC 69374-0957-10 NDC J2370 HCPCS inpatient 10 UN 43.29 28.14 AETNA AETNA 34.2 79 999999999 26.21 41.99 percent of total billed charges "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 49590373_1 CDM 0250 RC 69374-0957-10 NDC J2370 HCPCS inpatient 10 UN 43.29 28.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 28.14 65 999999999 26.21 41.99 percent of total billed charges "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 49590373_1 CDM 0250 RC 69374-0957-10 NDC J2370 HCPCS inpatient 10 UN 43.29 28.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 41.99 97 999999999 26.21 41.99 percent of total billed charges "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 49590373_1 CDM 0250 RC 69374-0957-10 NDC J2370 HCPCS inpatient 10 UN 43.29 28.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 29.87 69 999999999 26.21 41.99 percent of total billed charges "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 49590373_1 CDM 0250 RC 69374-0957-10 NDC J2370 HCPCS inpatient 10 UN 43.29 28.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 33.77 78 999999999 26.21 41.99 percent of total billed charges "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 49590373_1 CDM 0250 RC 69374-0957-10 NDC J2370 HCPCS inpatient 10 UN 43.29 28.14 SIHO - ALL PLANS SIHO - ALL PLANS 38.96 90 999999999 26.21 41.99 percent of total billed charges "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 49590373_1 CDM 0250 RC 69374-0957-10 NDC J2370 HCPCS inpatient 10 UN 43.29 28.14 UMR - ALL PLANS UMR - ALL PLANS 30.3 70 999999999 26.21 41.99 percent of total billed charges "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 49590373_1 CDM 0250 RC 69374-0957-10 NDC J2370 HCPCS inpatient 10 UN 43.29 28.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26.21 60.55 999999999 26.21 41.99 percent of total billed charges "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 49590373_1 CDM 0250 RC 69374-0957-10 NDC J2370 HCPCS inpatient 10 UN 43.29 28.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26.21 41.99 "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 49590373_1 CDM 0250 RC 69374-0957-10 NDC J2370 HCPCS inpatient 10 UN 43.29 28.14 ANTHEM HMO ANTHEM HMO 999999999 26.21 41.99 "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 49590373_1 CDM 0250 RC 69374-0957-10 NDC J2370 HCPCS inpatient 10 UN 43.29 28.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26.21 41.99 "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 49590373_1 CDM 0250 RC 69374-0957-10 NDC J2370 HCPCS inpatient 10 UN 43.29 28.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 29.26 67.6 999999999 26.21 41.99 percent of total billed charges "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 49590373_1 CDM 0250 RC 69374-0957-10 NDC J2370 HCPCS inpatient 10 UN 43.29 28.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26.21 41.99 "INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML" 49590373_1 CDM 0250 RC 69374-0957-10 NDC J2370 HCPCS inpatient 10 UN 43.29 28.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 26.21 41.99 "Urinalysis, manual test" 49603009_1 CDM 0300 RC 81002 HCPCS inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges "Urinalysis, manual test" 49603009_1 CDM 0300 RC 81002 HCPCS inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges "Urinalysis, manual test" 49603009_1 CDM 0300 RC 81002 HCPCS inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges "Urinalysis, manual test" 49603009_1 CDM 0300 RC 81002 HCPCS inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges "Urinalysis, manual test" 49603009_1 CDM 0300 RC 81002 HCPCS inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges "Urinalysis, manual test" 49603009_1 CDM 0300 RC 81002 HCPCS inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges "Urinalysis, manual test" 49603009_1 CDM 0300 RC 81002 HCPCS inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges "Urinalysis, manual test" 49603009_1 CDM 0300 RC 81002 HCPCS inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges "Urinalysis, manual test" 49603009_1 CDM 0300 RC 81002 HCPCS inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 "Urinalysis, manual test" 49603009_1 CDM 0300 RC 81002 HCPCS inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 "Urinalysis, manual test" 49603009_1 CDM 0300 RC 81002 HCPCS inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 "Urinalysis, manual test" 49603009_1 CDM 0300 RC 81002 HCPCS inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges "Urinalysis, manual test" 49603009_1 CDM 0300 RC 81002 HCPCS inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 "Urinalysis, manual test" 49603009_1 CDM 0300 RC 81002 HCPCS inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 "Antidepressants levels, 6 or more (tricyclic and other cyclicals)" 49619778_1 CDM 0300 RC 80337 HCPCS inpatient 144 93.6 AETNA AETNA 113.76 79 999999999 87.19 139.68 percent of total billed charges "Antidepressants levels, 6 or more (tricyclic and other cyclicals)" 49619778_1 CDM 0300 RC 80337 HCPCS inpatient 144 93.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 93.6 65 999999999 87.19 139.68 percent of total billed charges "Antidepressants levels, 6 or more (tricyclic and other cyclicals)" 49619778_1 CDM 0300 RC 80337 HCPCS inpatient 144 93.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 139.68 97 999999999 87.19 139.68 percent of total billed charges "Antidepressants levels, 6 or more (tricyclic and other cyclicals)" 49619778_1 CDM 0300 RC 80337 HCPCS inpatient 144 93.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 99.36 69 999999999 87.19 139.68 percent of total billed charges "Antidepressants levels, 6 or more (tricyclic and other cyclicals)" 49619778_1 CDM 0300 RC 80337 HCPCS inpatient 144 93.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 112.32 78 999999999 87.19 139.68 percent of total billed charges "Antidepressants levels, 6 or more (tricyclic and other cyclicals)" 49619778_1 CDM 0300 RC 80337 HCPCS inpatient 144 93.6 SIHO - ALL PLANS SIHO - ALL PLANS 129.6 90 999999999 87.19 139.68 percent of total billed charges "Antidepressants levels, 6 or more (tricyclic and other cyclicals)" 49619778_1 CDM 0300 RC 80337 HCPCS inpatient 144 93.6 UMR - ALL PLANS UMR - ALL PLANS 100.8 70 999999999 87.19 139.68 percent of total billed charges "Antidepressants levels, 6 or more (tricyclic and other cyclicals)" 49619778_1 CDM 0300 RC 80337 HCPCS inpatient 144 93.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.19 60.55 999999999 87.19 139.68 percent of total billed charges "Antidepressants levels, 6 or more (tricyclic and other cyclicals)" 49619778_1 CDM 0300 RC 80337 HCPCS inpatient 144 93.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.19 139.68 "Antidepressants levels, 6 or more (tricyclic and other cyclicals)" 49619778_1 CDM 0300 RC 80337 HCPCS inpatient 144 93.6 ANTHEM HMO ANTHEM HMO 999999999 87.19 139.68 "Antidepressants levels, 6 or more (tricyclic and other cyclicals)" 49619778_1 CDM 0300 RC 80337 HCPCS inpatient 144 93.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.19 139.68 "Antidepressants levels, 6 or more (tricyclic and other cyclicals)" 49619778_1 CDM 0300 RC 80337 HCPCS inpatient 144 93.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 97.34 67.6 999999999 87.19 139.68 percent of total billed charges "Antidepressants levels, 6 or more (tricyclic and other cyclicals)" 49619778_1 CDM 0300 RC 80337 HCPCS inpatient 144 93.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.19 139.68 "Antidepressants levels, 6 or more (tricyclic and other cyclicals)" 49619778_1 CDM 0300 RC 80337 HCPCS inpatient 144 93.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.19 139.68 NASAL OXIMETER PROBE R/T 49621892_1 CDM 0271 RC inpatient 97.85 63.6 AETNA AETNA 77.3 79 999999999 59.25 94.91 percent of total billed charges NASAL OXIMETER PROBE R/T 49621892_1 CDM 0271 RC inpatient 97.85 63.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.6 65 999999999 59.25 94.91 percent of total billed charges NASAL OXIMETER PROBE R/T 49621892_1 CDM 0271 RC inpatient 97.85 63.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 94.91 97 999999999 59.25 94.91 percent of total billed charges NASAL OXIMETER PROBE R/T 49621892_1 CDM 0271 RC inpatient 97.85 63.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.52 69 999999999 59.25 94.91 percent of total billed charges NASAL OXIMETER PROBE R/T 49621892_1 CDM 0271 RC inpatient 97.85 63.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.32 78 999999999 59.25 94.91 percent of total billed charges NASAL OXIMETER PROBE R/T 49621892_1 CDM 0271 RC inpatient 97.85 63.6 SIHO - ALL PLANS SIHO - ALL PLANS 88.07 90 999999999 59.25 94.91 percent of total billed charges NASAL OXIMETER PROBE R/T 49621892_1 CDM 0271 RC inpatient 97.85 63.6 UMR - ALL PLANS UMR - ALL PLANS 68.5 70 999999999 59.25 94.91 percent of total billed charges NASAL OXIMETER PROBE R/T 49621892_1 CDM 0271 RC inpatient 97.85 63.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.25 60.55 999999999 59.25 94.91 percent of total billed charges NASAL OXIMETER PROBE R/T 49621892_1 CDM 0271 RC inpatient 97.85 63.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.25 94.91 NASAL OXIMETER PROBE R/T 49621892_1 CDM 0271 RC inpatient 97.85 63.6 ANTHEM HMO ANTHEM HMO 999999999 59.25 94.91 NASAL OXIMETER PROBE R/T 49621892_1 CDM 0271 RC inpatient 97.85 63.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.25 94.91 NASAL OXIMETER PROBE R/T 49621892_1 CDM 0271 RC inpatient 97.85 63.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.15 67.6 999999999 59.25 94.91 percent of total billed charges NASAL OXIMETER PROBE R/T 49621892_1 CDM 0271 RC inpatient 97.85 63.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.25 94.91 NASAL OXIMETER PROBE R/T 49621892_1 CDM 0271 RC inpatient 97.85 63.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.25 94.91 CITRATE OF MAGNESIA SOLN 49624228_1 CDM 0250 RC 24385-0675-10 NDC inpatient 1 UN 7.41 4.82 AETNA AETNA 5.85 79 999999999 4.49 7.19 percent of total billed charges CITRATE OF MAGNESIA SOLN 49624228_1 CDM 0250 RC 24385-0675-10 NDC inpatient 1 UN 7.41 4.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.82 65 999999999 4.49 7.19 percent of total billed charges CITRATE OF MAGNESIA SOLN 49624228_1 CDM 0250 RC 24385-0675-10 NDC inpatient 1 UN 7.41 4.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7.19 97 999999999 4.49 7.19 percent of total billed charges CITRATE OF MAGNESIA SOLN 49624228_1 CDM 0250 RC 24385-0675-10 NDC inpatient 1 UN 7.41 4.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.11 69 999999999 4.49 7.19 percent of total billed charges CITRATE OF MAGNESIA SOLN 49624228_1 CDM 0250 RC 24385-0675-10 NDC inpatient 1 UN 7.41 4.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 5.78 78 999999999 4.49 7.19 percent of total billed charges CITRATE OF MAGNESIA SOLN 49624228_1 CDM 0250 RC 24385-0675-10 NDC inpatient 1 UN 7.41 4.82 SIHO - ALL PLANS SIHO - ALL PLANS 6.67 90 999999999 4.49 7.19 percent of total billed charges CITRATE OF MAGNESIA SOLN 49624228_1 CDM 0250 RC 24385-0675-10 NDC inpatient 1 UN 7.41 4.82 UMR - ALL PLANS UMR - ALL PLANS 5.19 70 999999999 4.49 7.19 percent of total billed charges CITRATE OF MAGNESIA SOLN 49624228_1 CDM 0250 RC 24385-0675-10 NDC inpatient 1 UN 7.41 4.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.49 60.55 999999999 4.49 7.19 percent of total billed charges CITRATE OF MAGNESIA SOLN 49624228_1 CDM 0250 RC 24385-0675-10 NDC inpatient 1 UN 7.41 4.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.49 7.19 CITRATE OF MAGNESIA SOLN 49624228_1 CDM 0250 RC 24385-0675-10 NDC inpatient 1 UN 7.41 4.82 ANTHEM HMO ANTHEM HMO 999999999 4.49 7.19 CITRATE OF MAGNESIA SOLN 49624228_1 CDM 0250 RC 24385-0675-10 NDC inpatient 1 UN 7.41 4.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.49 7.19 CITRATE OF MAGNESIA SOLN 49624228_1 CDM 0250 RC 24385-0675-10 NDC inpatient 1 UN 7.41 4.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.01 67.6 999999999 4.49 7.19 percent of total billed charges CITRATE OF MAGNESIA SOLN 49624228_1 CDM 0250 RC 24385-0675-10 NDC inpatient 1 UN 7.41 4.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.49 7.19 CITRATE OF MAGNESIA SOLN 49624228_1 CDM 0250 RC 24385-0675-10 NDC inpatient 1 UN 7.41 4.82 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.49 7.19 BENZTROPINE MES 1 MG TABLET 49629685_1 CDM 0250 RC 00603-2438-21 NDC inpatient 1 UN 1.09 0.71 AETNA AETNA 0.86 79 999999999 0.66 1.06 percent of total billed charges BENZTROPINE MES 1 MG TABLET 49629685_1 CDM 0250 RC 00603-2438-21 NDC inpatient 1 UN 1.09 0.71 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.71 65 999999999 0.66 1.06 percent of total billed charges BENZTROPINE MES 1 MG TABLET 49629685_1 CDM 0250 RC 00603-2438-21 NDC inpatient 1 UN 1.09 0.71 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.06 97 999999999 0.66 1.06 percent of total billed charges BENZTROPINE MES 1 MG TABLET 49629685_1 CDM 0250 RC 00603-2438-21 NDC inpatient 1 UN 1.09 0.71 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.75 69 999999999 0.66 1.06 percent of total billed charges BENZTROPINE MES 1 MG TABLET 49629685_1 CDM 0250 RC 00603-2438-21 NDC inpatient 1 UN 1.09 0.71 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.85 78 999999999 0.66 1.06 percent of total billed charges BENZTROPINE MES 1 MG TABLET 49629685_1 CDM 0250 RC 00603-2438-21 NDC inpatient 1 UN 1.09 0.71 SIHO - ALL PLANS SIHO - ALL PLANS 0.98 90 999999999 0.66 1.06 percent of total billed charges BENZTROPINE MES 1 MG TABLET 49629685_1 CDM 0250 RC 00603-2438-21 NDC inpatient 1 UN 1.09 0.71 UMR - ALL PLANS UMR - ALL PLANS 0.76 70 999999999 0.66 1.06 percent of total billed charges BENZTROPINE MES 1 MG TABLET 49629685_1 CDM 0250 RC 00603-2438-21 NDC inpatient 1 UN 1.09 0.71 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.66 60.55 999999999 0.66 1.06 percent of total billed charges BENZTROPINE MES 1 MG TABLET 49629685_1 CDM 0250 RC 00603-2438-21 NDC inpatient 1 UN 1.09 0.71 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.66 1.06 BENZTROPINE MES 1 MG TABLET 49629685_1 CDM 0250 RC 00603-2438-21 NDC inpatient 1 UN 1.09 0.71 ANTHEM HMO ANTHEM HMO 999999999 0.66 1.06 BENZTROPINE MES 1 MG TABLET 49629685_1 CDM 0250 RC 00603-2438-21 NDC inpatient 1 UN 1.09 0.71 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.66 1.06 BENZTROPINE MES 1 MG TABLET 49629685_1 CDM 0250 RC 00603-2438-21 NDC inpatient 1 UN 1.09 0.71 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.74 67.6 999999999 0.66 1.06 percent of total billed charges BENZTROPINE MES 1 MG TABLET 49629685_1 CDM 0250 RC 00603-2438-21 NDC inpatient 1 UN 1.09 0.71 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.66 1.06 BENZTROPINE MES 1 MG TABLET 49629685_1 CDM 0250 RC 00603-2438-21 NDC inpatient 1 UN 1.09 0.71 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.66 1.06 MILRINONE-D5W 40 MG/200 ML 49629687_1 CDM 0250 RC 00338-6011-37 NDC inpatient 1 UN 202.54 131.65 AETNA AETNA 160.01 79 999999999 122.64 196.46 percent of total billed charges MILRINONE-D5W 40 MG/200 ML 49629687_1 CDM 0250 RC 00338-6011-37 NDC inpatient 1 UN 202.54 131.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 131.65 65 999999999 122.64 196.46 percent of total billed charges MILRINONE-D5W 40 MG/200 ML 49629687_1 CDM 0250 RC 00338-6011-37 NDC inpatient 1 UN 202.54 131.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 196.46 97 999999999 122.64 196.46 percent of total billed charges MILRINONE-D5W 40 MG/200 ML 49629687_1 CDM 0250 RC 00338-6011-37 NDC inpatient 1 UN 202.54 131.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 139.75 69 999999999 122.64 196.46 percent of total billed charges MILRINONE-D5W 40 MG/200 ML 49629687_1 CDM 0250 RC 00338-6011-37 NDC inpatient 1 UN 202.54 131.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 157.98 78 999999999 122.64 196.46 percent of total billed charges MILRINONE-D5W 40 MG/200 ML 49629687_1 CDM 0250 RC 00338-6011-37 NDC inpatient 1 UN 202.54 131.65 SIHO - ALL PLANS SIHO - ALL PLANS 182.29 90 999999999 122.64 196.46 percent of total billed charges MILRINONE-D5W 40 MG/200 ML 49629687_1 CDM 0250 RC 00338-6011-37 NDC inpatient 1 UN 202.54 131.65 UMR - ALL PLANS UMR - ALL PLANS 141.78 70 999999999 122.64 196.46 percent of total billed charges MILRINONE-D5W 40 MG/200 ML 49629687_1 CDM 0250 RC 00338-6011-37 NDC inpatient 1 UN 202.54 131.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 122.64 60.55 999999999 122.64 196.46 percent of total billed charges MILRINONE-D5W 40 MG/200 ML 49629687_1 CDM 0250 RC 00338-6011-37 NDC inpatient 1 UN 202.54 131.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 122.64 196.46 MILRINONE-D5W 40 MG/200 ML 49629687_1 CDM 0250 RC 00338-6011-37 NDC inpatient 1 UN 202.54 131.65 ANTHEM HMO ANTHEM HMO 999999999 122.64 196.46 MILRINONE-D5W 40 MG/200 ML 49629687_1 CDM 0250 RC 00338-6011-37 NDC inpatient 1 UN 202.54 131.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 122.64 196.46 MILRINONE-D5W 40 MG/200 ML 49629687_1 CDM 0250 RC 00338-6011-37 NDC inpatient 1 UN 202.54 131.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 136.92 67.6 999999999 122.64 196.46 percent of total billed charges MILRINONE-D5W 40 MG/200 ML 49629687_1 CDM 0250 RC 00338-6011-37 NDC inpatient 1 UN 202.54 131.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 122.64 196.46 MILRINONE-D5W 40 MG/200 ML 49629687_1 CDM 0250 RC 00338-6011-37 NDC inpatient 1 UN 202.54 131.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 122.64 196.46 "INJECTION, NIVOLUMAB, 1 MG" 49629870_1 CDM 0636 RC 00003-3734-13 NDC J9299 HCPCS inpatient 240 UN 31478.05 20460.73 AETNA AETNA 24867.66 79 999999999 19059.96 30533.71 percent of total billed charges "INJECTION, NIVOLUMAB, 1 MG" 49629870_1 CDM 0636 RC 00003-3734-13 NDC J9299 HCPCS inpatient 240 UN 31478.05 20460.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 20460.73 65 999999999 19059.96 30533.71 percent of total billed charges "INJECTION, NIVOLUMAB, 1 MG" 49629870_1 CDM 0636 RC 00003-3734-13 NDC J9299 HCPCS inpatient 240 UN 31478.05 20460.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30533.71 97 999999999 19059.96 30533.71 percent of total billed charges "INJECTION, NIVOLUMAB, 1 MG" 49629870_1 CDM 0636 RC 00003-3734-13 NDC J9299 HCPCS inpatient 240 UN 31478.05 20460.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 21719.85 69 999999999 19059.96 30533.71 percent of total billed charges "INJECTION, NIVOLUMAB, 1 MG" 49629870_1 CDM 0636 RC 00003-3734-13 NDC J9299 HCPCS inpatient 240 UN 31478.05 20460.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 24552.88 78 999999999 19059.96 30533.71 percent of total billed charges "INJECTION, NIVOLUMAB, 1 MG" 49629870_1 CDM 0636 RC 00003-3734-13 NDC J9299 HCPCS inpatient 240 UN 31478.05 20460.73 SIHO - ALL PLANS SIHO - ALL PLANS 28330.25 90 999999999 19059.96 30533.71 percent of total billed charges "INJECTION, NIVOLUMAB, 1 MG" 49629870_1 CDM 0636 RC 00003-3734-13 NDC J9299 HCPCS inpatient 240 UN 31478.05 20460.73 UMR - ALL PLANS UMR - ALL PLANS 22034.64 70 999999999 19059.96 30533.71 percent of total billed charges "INJECTION, NIVOLUMAB, 1 MG" 49629870_1 CDM 0636 RC 00003-3734-13 NDC J9299 HCPCS inpatient 240 UN 31478.05 20460.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19059.96 60.55 999999999 19059.96 30533.71 percent of total billed charges "INJECTION, NIVOLUMAB, 1 MG" 49629870_1 CDM 0636 RC 00003-3734-13 NDC J9299 HCPCS inpatient 240 UN 31478.05 20460.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19059.96 30533.71 "INJECTION, NIVOLUMAB, 1 MG" 49629870_1 CDM 0636 RC 00003-3734-13 NDC J9299 HCPCS inpatient 240 UN 31478.05 20460.73 ANTHEM HMO ANTHEM HMO 999999999 19059.96 30533.71 "INJECTION, NIVOLUMAB, 1 MG" 49629870_1 CDM 0636 RC 00003-3734-13 NDC J9299 HCPCS inpatient 240 UN 31478.05 20460.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19059.96 30533.71 "INJECTION, NIVOLUMAB, 1 MG" 49629870_1 CDM 0636 RC 00003-3734-13 NDC J9299 HCPCS inpatient 240 UN 31478.05 20460.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 21279.16 67.6 999999999 19059.96 30533.71 percent of total billed charges "INJECTION, NIVOLUMAB, 1 MG" 49629870_1 CDM 0636 RC 00003-3734-13 NDC J9299 HCPCS inpatient 240 UN 31478.05 20460.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19059.96 30533.71 "INJECTION, NIVOLUMAB, 1 MG" 49629870_1 CDM 0636 RC 00003-3734-13 NDC J9299 HCPCS inpatient 240 UN 31478.05 20460.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 19059.96 30533.71 "Testing for presence of drug, by chemistry analyzers" 49629896_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49629896_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49629896_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49629896_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49629896_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49629896_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49629896_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49629896_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49629896_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49629896_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49629896_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49629896_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49629896_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49629896_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 Creatinine level to test for kidney function or muscle injury 49630027_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49630027_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49630027_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49630027_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49630027_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49630027_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49630027_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49630027_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49630027_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 Creatinine level to test for kidney function or muscle injury 49630027_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 Creatinine level to test for kidney function or muscle injury 49630027_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 Creatinine level to test for kidney function or muscle injury 49630027_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49630027_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 Creatinine level to test for kidney function or muscle injury 49630027_1 CDM 0301 RC 82570 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 Test to assess the ability to complete specific functional tasks applicable to environment 49642444_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 AETNA AETNA 295.46 79 999999999 226.46 362.78 percent of total billed charges Test to assess the ability to complete specific functional tasks applicable to environment 49642444_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 243.1 65 999999999 226.46 362.78 percent of total billed charges Test to assess the ability to complete specific functional tasks applicable to environment 49642444_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 362.78 97 999999999 226.46 362.78 percent of total billed charges Test to assess the ability to complete specific functional tasks applicable to environment 49642444_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 258.06 69 999999999 226.46 362.78 percent of total billed charges Test to assess the ability to complete specific functional tasks applicable to environment 49642444_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 291.72 78 999999999 226.46 362.78 percent of total billed charges Test to assess the ability to complete specific functional tasks applicable to environment 49642444_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 SIHO - ALL PLANS SIHO - ALL PLANS 336.6 90 999999999 226.46 362.78 percent of total billed charges Test to assess the ability to complete specific functional tasks applicable to environment 49642444_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 UMR - ALL PLANS UMR - ALL PLANS 261.8 70 999999999 226.46 362.78 percent of total billed charges Test to assess the ability to complete specific functional tasks applicable to environment 49642444_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 226.46 60.55 999999999 226.46 362.78 percent of total billed charges Test to assess the ability to complete specific functional tasks applicable to environment 49642444_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 226.46 362.78 Test to assess the ability to complete specific functional tasks applicable to environment 49642444_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 ANTHEM HMO ANTHEM HMO 999999999 226.46 362.78 Test to assess the ability to complete specific functional tasks applicable to environment 49642444_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 226.46 362.78 Test to assess the ability to complete specific functional tasks applicable to environment 49642444_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 252.82 67.6 999999999 226.46 362.78 percent of total billed charges Test to assess the ability to complete specific functional tasks applicable to environment 49642444_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 226.46 362.78 Test to assess the ability to complete specific functional tasks applicable to environment 49642444_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 226.46 362.78 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49646425_1 CDM 0250 RC 55513-0025-04 NDC J0881 HCPCS inpatient 100 UN 1898.27 1233.88 AETNA AETNA 1499.63 79 999999999 1149.4 1841.32 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49646425_1 CDM 0250 RC 55513-0025-04 NDC J0881 HCPCS inpatient 100 UN 1898.27 1233.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 1233.88 65 999999999 1149.4 1841.32 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49646425_1 CDM 0250 RC 55513-0025-04 NDC J0881 HCPCS inpatient 100 UN 1898.27 1233.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1841.32 97 999999999 1149.4 1841.32 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49646425_1 CDM 0250 RC 55513-0025-04 NDC J0881 HCPCS inpatient 100 UN 1898.27 1233.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 1309.81 69 999999999 1149.4 1841.32 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49646425_1 CDM 0250 RC 55513-0025-04 NDC J0881 HCPCS inpatient 100 UN 1898.27 1233.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 1480.65 78 999999999 1149.4 1841.32 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49646425_1 CDM 0250 RC 55513-0025-04 NDC J0881 HCPCS inpatient 100 UN 1898.27 1233.88 SIHO - ALL PLANS SIHO - ALL PLANS 1708.44 90 999999999 1149.4 1841.32 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49646425_1 CDM 0250 RC 55513-0025-04 NDC J0881 HCPCS inpatient 100 UN 1898.27 1233.88 UMR - ALL PLANS UMR - ALL PLANS 1328.79 70 999999999 1149.4 1841.32 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49646425_1 CDM 0250 RC 55513-0025-04 NDC J0881 HCPCS inpatient 100 UN 1898.27 1233.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1149.4 60.55 999999999 1149.4 1841.32 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49646425_1 CDM 0250 RC 55513-0025-04 NDC J0881 HCPCS inpatient 100 UN 1898.27 1233.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1149.4 1841.32 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49646425_1 CDM 0250 RC 55513-0025-04 NDC J0881 HCPCS inpatient 100 UN 1898.27 1233.88 ANTHEM HMO ANTHEM HMO 999999999 1149.4 1841.32 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49646425_1 CDM 0250 RC 55513-0025-04 NDC J0881 HCPCS inpatient 100 UN 1898.27 1233.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1149.4 1841.32 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49646425_1 CDM 0250 RC 55513-0025-04 NDC J0881 HCPCS inpatient 100 UN 1898.27 1233.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 1283.23 67.6 999999999 1149.4 1841.32 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49646425_1 CDM 0250 RC 55513-0025-04 NDC J0881 HCPCS inpatient 100 UN 1898.27 1233.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1149.4 1841.32 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49646425_1 CDM 0250 RC 55513-0025-04 NDC J0881 HCPCS inpatient 100 UN 1898.27 1233.88 UHC - ALL PLANS UHC - ALL PLANS 999999999 1149.4 1841.32 Screening test for antibody to noninfectious agent 49646888_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 49646888_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 49646888_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 49646888_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 49646888_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 49646888_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 49646888_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 49646888_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 49646888_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Screening test for antibody to noninfectious agent 49646888_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Screening test for antibody to noninfectious agent 49646888_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Screening test for antibody to noninfectious agent 49646888_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 49646888_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Screening test for antibody to noninfectious agent 49646888_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 "Measurement of substance using immunoassay technique, by radioimmunoassay" 49646959_1 CDM 0301 RC 83519 HCPCS inpatient 852 553.8 AETNA AETNA 673.08 79 999999999 515.89 826.44 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49646959_1 CDM 0301 RC 83519 HCPCS inpatient 852 553.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 553.8 65 999999999 515.89 826.44 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49646959_1 CDM 0301 RC 83519 HCPCS inpatient 852 553.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 826.44 97 999999999 515.89 826.44 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49646959_1 CDM 0301 RC 83519 HCPCS inpatient 852 553.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 587.88 69 999999999 515.89 826.44 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49646959_1 CDM 0301 RC 83519 HCPCS inpatient 852 553.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 664.56 78 999999999 515.89 826.44 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49646959_1 CDM 0301 RC 83519 HCPCS inpatient 852 553.8 SIHO - ALL PLANS SIHO - ALL PLANS 766.8 90 999999999 515.89 826.44 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49646959_1 CDM 0301 RC 83519 HCPCS inpatient 852 553.8 UMR - ALL PLANS UMR - ALL PLANS 596.4 70 999999999 515.89 826.44 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49646959_1 CDM 0301 RC 83519 HCPCS inpatient 852 553.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 515.89 60.55 999999999 515.89 826.44 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49646959_1 CDM 0301 RC 83519 HCPCS inpatient 852 553.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 515.89 826.44 "Measurement of substance using immunoassay technique, by radioimmunoassay" 49646959_1 CDM 0301 RC 83519 HCPCS inpatient 852 553.8 ANTHEM HMO ANTHEM HMO 999999999 515.89 826.44 "Measurement of substance using immunoassay technique, by radioimmunoassay" 49646959_1 CDM 0301 RC 83519 HCPCS inpatient 852 553.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 515.89 826.44 "Measurement of substance using immunoassay technique, by radioimmunoassay" 49646959_1 CDM 0301 RC 83519 HCPCS inpatient 852 553.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 575.95 67.6 999999999 515.89 826.44 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 49646959_1 CDM 0301 RC 83519 HCPCS inpatient 852 553.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 515.89 826.44 "Measurement of substance using immunoassay technique, by radioimmunoassay" 49646959_1 CDM 0301 RC 83519 HCPCS inpatient 852 553.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 515.89 826.44 Removal of cyst or growth of lower leg bone 49651505_1 CDM 0510 RC 27635 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Removal of cyst or growth of lower leg bone 49651505_1 CDM 0510 RC 27635 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Removal of cyst or growth of lower leg bone 49651505_1 CDM 0510 RC 27635 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Removal of cyst or growth of lower leg bone 49651505_1 CDM 0510 RC 27635 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Removal of cyst or growth of lower leg bone 49651505_1 CDM 0510 RC 27635 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Removal of cyst or growth of lower leg bone 49651505_1 CDM 0510 RC 27635 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Removal of cyst or growth of lower leg bone 49651505_1 CDM 0510 RC 27635 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Removal of cyst or growth of lower leg bone 49651505_1 CDM 0510 RC 27635 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Removal of cyst or growth of lower leg bone 49651505_1 CDM 0510 RC 27635 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Removal of cyst or growth of lower leg bone 49651505_1 CDM 0510 RC 27635 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Removal of cyst or growth of lower leg bone 49651505_1 CDM 0510 RC 27635 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Removal of cyst or growth of lower leg bone 49651505_1 CDM 0510 RC 27635 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Removal of cyst or growth of lower leg bone 49651505_1 CDM 0510 RC 27635 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Removal of cyst or growth of lower leg bone 49651505_1 CDM 0510 RC 27635 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Measurement of antibody to noninfectious agent 49651840_1 CDM 0301 RC 86256 HCPCS inpatient 268 174.2 AETNA AETNA 211.72 79 999999999 162.27 259.96 percent of total billed charges Measurement of antibody to noninfectious agent 49651840_1 CDM 0301 RC 86256 HCPCS inpatient 268 174.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 174.2 65 999999999 162.27 259.96 percent of total billed charges Measurement of antibody to noninfectious agent 49651840_1 CDM 0301 RC 86256 HCPCS inpatient 268 174.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 259.96 97 999999999 162.27 259.96 percent of total billed charges Measurement of antibody to noninfectious agent 49651840_1 CDM 0301 RC 86256 HCPCS inpatient 268 174.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.92 69 999999999 162.27 259.96 percent of total billed charges Measurement of antibody to noninfectious agent 49651840_1 CDM 0301 RC 86256 HCPCS inpatient 268 174.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 209.04 78 999999999 162.27 259.96 percent of total billed charges Measurement of antibody to noninfectious agent 49651840_1 CDM 0301 RC 86256 HCPCS inpatient 268 174.2 SIHO - ALL PLANS SIHO - ALL PLANS 241.2 90 999999999 162.27 259.96 percent of total billed charges Measurement of antibody to noninfectious agent 49651840_1 CDM 0301 RC 86256 HCPCS inpatient 268 174.2 UMR - ALL PLANS UMR - ALL PLANS 187.6 70 999999999 162.27 259.96 percent of total billed charges Measurement of antibody to noninfectious agent 49651840_1 CDM 0301 RC 86256 HCPCS inpatient 268 174.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 162.27 60.55 999999999 162.27 259.96 percent of total billed charges Measurement of antibody to noninfectious agent 49651840_1 CDM 0301 RC 86256 HCPCS inpatient 268 174.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 162.27 259.96 Measurement of antibody to noninfectious agent 49651840_1 CDM 0301 RC 86256 HCPCS inpatient 268 174.2 ANTHEM HMO ANTHEM HMO 999999999 162.27 259.96 Measurement of antibody to noninfectious agent 49651840_1 CDM 0301 RC 86256 HCPCS inpatient 268 174.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 162.27 259.96 Measurement of antibody to noninfectious agent 49651840_1 CDM 0301 RC 86256 HCPCS inpatient 268 174.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 181.17 67.6 999999999 162.27 259.96 percent of total billed charges Measurement of antibody to noninfectious agent 49651840_1 CDM 0301 RC 86256 HCPCS inpatient 268 174.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 162.27 259.96 Measurement of antibody to noninfectious agent 49651840_1 CDM 0301 RC 86256 HCPCS inpatient 268 174.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 162.27 259.96 Screening test for antibody to noninfectious agent 49651950_1 CDM 0301 RC 86255 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges Screening test for antibody to noninfectious agent 49651950_1 CDM 0301 RC 86255 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges Screening test for antibody to noninfectious agent 49651950_1 CDM 0301 RC 86255 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges Screening test for antibody to noninfectious agent 49651950_1 CDM 0301 RC 86255 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges Screening test for antibody to noninfectious agent 49651950_1 CDM 0301 RC 86255 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges Screening test for antibody to noninfectious agent 49651950_1 CDM 0301 RC 86255 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges Screening test for antibody to noninfectious agent 49651950_1 CDM 0301 RC 86255 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges Screening test for antibody to noninfectious agent 49651950_1 CDM 0301 RC 86255 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges Screening test for antibody to noninfectious agent 49651950_1 CDM 0301 RC 86255 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 Screening test for antibody to noninfectious agent 49651950_1 CDM 0301 RC 86255 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 Screening test for antibody to noninfectious agent 49651950_1 CDM 0301 RC 86255 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 Screening test for antibody to noninfectious agent 49651950_1 CDM 0301 RC 86255 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges Screening test for antibody to noninfectious agent 49651950_1 CDM 0301 RC 86255 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 Screening test for antibody to noninfectious agent 49651950_1 CDM 0301 RC 86255 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 ARIPIPRAZOLE 5 MG TABLET 49655634_1 CDM 0250 RC 62332-0098-30 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 5 MG TABLET 49655634_1 CDM 0250 RC 62332-0098-30 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 5 MG TABLET 49655634_1 CDM 0250 RC 62332-0098-30 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 5 MG TABLET 49655634_1 CDM 0250 RC 62332-0098-30 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 5 MG TABLET 49655634_1 CDM 0250 RC 62332-0098-30 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 5 MG TABLET 49655634_1 CDM 0250 RC 62332-0098-30 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 5 MG TABLET 49655634_1 CDM 0250 RC 62332-0098-30 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 5 MG TABLET 49655634_1 CDM 0250 RC 62332-0098-30 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 5 MG TABLET 49655634_1 CDM 0250 RC 62332-0098-30 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ARIPIPRAZOLE 5 MG TABLET 49655634_1 CDM 0250 RC 62332-0098-30 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ARIPIPRAZOLE 5 MG TABLET 49655634_1 CDM 0250 RC 62332-0098-30 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ARIPIPRAZOLE 5 MG TABLET 49655634_1 CDM 0250 RC 62332-0098-30 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ARIPIPRAZOLE 5 MG TABLET 49655634_1 CDM 0250 RC 62332-0098-30 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ARIPIPRAZOLE 5 MG TABLET 49655634_1 CDM 0250 RC 62332-0098-30 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges PROGESTERONE 500 MG/10 ML VIAL 49655647_1 CDM 0250 RC 00143-9725-01 NDC inpatient 1 UN 156.37 101.64 AETNA AETNA 123.53 79 999999999 94.68 151.68 percent of total billed charges PROGESTERONE 500 MG/10 ML VIAL 49655647_1 CDM 0250 RC 00143-9725-01 NDC inpatient 1 UN 156.37 101.64 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.64 65 999999999 94.68 151.68 percent of total billed charges PROGESTERONE 500 MG/10 ML VIAL 49655647_1 CDM 0250 RC 00143-9725-01 NDC inpatient 1 UN 156.37 101.64 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 151.68 97 999999999 94.68 151.68 percent of total billed charges PROGESTERONE 500 MG/10 ML VIAL 49655647_1 CDM 0250 RC 00143-9725-01 NDC inpatient 1 UN 156.37 101.64 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.9 69 999999999 94.68 151.68 percent of total billed charges PROGESTERONE 500 MG/10 ML VIAL 49655647_1 CDM 0250 RC 00143-9725-01 NDC inpatient 1 UN 156.37 101.64 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.97 78 999999999 94.68 151.68 percent of total billed charges PROGESTERONE 500 MG/10 ML VIAL 49655647_1 CDM 0250 RC 00143-9725-01 NDC inpatient 1 UN 156.37 101.64 SIHO - ALL PLANS SIHO - ALL PLANS 140.73 90 999999999 94.68 151.68 percent of total billed charges PROGESTERONE 500 MG/10 ML VIAL 49655647_1 CDM 0250 RC 00143-9725-01 NDC inpatient 1 UN 156.37 101.64 UMR - ALL PLANS UMR - ALL PLANS 109.46 70 999999999 94.68 151.68 percent of total billed charges PROGESTERONE 500 MG/10 ML VIAL 49655647_1 CDM 0250 RC 00143-9725-01 NDC inpatient 1 UN 156.37 101.64 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.68 60.55 999999999 94.68 151.68 percent of total billed charges PROGESTERONE 500 MG/10 ML VIAL 49655647_1 CDM 0250 RC 00143-9725-01 NDC inpatient 1 UN 156.37 101.64 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.68 151.68 PROGESTERONE 500 MG/10 ML VIAL 49655647_1 CDM 0250 RC 00143-9725-01 NDC inpatient 1 UN 156.37 101.64 ANTHEM HMO ANTHEM HMO 999999999 94.68 151.68 PROGESTERONE 500 MG/10 ML VIAL 49655647_1 CDM 0250 RC 00143-9725-01 NDC inpatient 1 UN 156.37 101.64 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.68 151.68 PROGESTERONE 500 MG/10 ML VIAL 49655647_1 CDM 0250 RC 00143-9725-01 NDC inpatient 1 UN 156.37 101.64 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.68 151.68 PROGESTERONE 500 MG/10 ML VIAL 49655647_1 CDM 0250 RC 00143-9725-01 NDC inpatient 1 UN 156.37 101.64 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.68 151.68 PROGESTERONE 500 MG/10 ML VIAL 49655647_1 CDM 0250 RC 00143-9725-01 NDC inpatient 1 UN 156.37 101.64 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.71 67.6 999999999 94.68 151.68 percent of total billed charges Bill BBK-Blood Bank STAT transportaion Fee 49657682_1 CDM 0399 RC inpatient 163 105.95 AETNA AETNA 128.77 79 999999999 98.7 158.11 percent of total billed charges Bill BBK-Blood Bank STAT transportaion Fee 49657682_1 CDM 0399 RC inpatient 163 105.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 105.95 65 999999999 98.7 158.11 percent of total billed charges Bill BBK-Blood Bank STAT transportaion Fee 49657682_1 CDM 0399 RC inpatient 163 105.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 158.11 97 999999999 98.7 158.11 percent of total billed charges Bill BBK-Blood Bank STAT transportaion Fee 49657682_1 CDM 0399 RC inpatient 163 105.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 112.47 69 999999999 98.7 158.11 percent of total billed charges Bill BBK-Blood Bank STAT transportaion Fee 49657682_1 CDM 0399 RC inpatient 163 105.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.14 78 999999999 98.7 158.11 percent of total billed charges Bill BBK-Blood Bank STAT transportaion Fee 49657682_1 CDM 0399 RC inpatient 163 105.95 SIHO - ALL PLANS SIHO - ALL PLANS 146.7 90 999999999 98.7 158.11 percent of total billed charges Bill BBK-Blood Bank STAT transportaion Fee 49657682_1 CDM 0399 RC inpatient 163 105.95 UMR - ALL PLANS UMR - ALL PLANS 114.1 70 999999999 98.7 158.11 percent of total billed charges Bill BBK-Blood Bank STAT transportaion Fee 49657682_1 CDM 0399 RC inpatient 163 105.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 98.7 60.55 999999999 98.7 158.11 percent of total billed charges Bill BBK-Blood Bank STAT transportaion Fee 49657682_1 CDM 0399 RC inpatient 163 105.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 98.7 158.11 Bill BBK-Blood Bank STAT transportaion Fee 49657682_1 CDM 0399 RC inpatient 163 105.95 ANTHEM HMO ANTHEM HMO 999999999 98.7 158.11 Bill BBK-Blood Bank STAT transportaion Fee 49657682_1 CDM 0399 RC inpatient 163 105.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 98.7 158.11 Bill BBK-Blood Bank STAT transportaion Fee 49657682_1 CDM 0399 RC inpatient 163 105.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 98.7 158.11 Bill BBK-Blood Bank STAT transportaion Fee 49657682_1 CDM 0399 RC inpatient 163 105.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 98.7 158.11 Bill BBK-Blood Bank STAT transportaion Fee 49657682_1 CDM 0399 RC inpatient 163 105.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.19 67.6 999999999 98.7 158.11 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661330_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661330_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661330_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661330_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661330_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661330_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661330_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661330_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661330_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661330_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661330_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661330_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661330_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661330_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661331_1 CDM 0306 RC 87147 HCPCS inpatient 237 154.05 AETNA AETNA 187.23 79 999999999 143.5 229.89 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661331_1 CDM 0306 RC 87147 HCPCS inpatient 237 154.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.05 65 999999999 143.5 229.89 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661331_1 CDM 0306 RC 87147 HCPCS inpatient 237 154.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 229.89 97 999999999 143.5 229.89 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661331_1 CDM 0306 RC 87147 HCPCS inpatient 237 154.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 163.53 69 999999999 143.5 229.89 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661331_1 CDM 0306 RC 87147 HCPCS inpatient 237 154.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 184.86 78 999999999 143.5 229.89 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661331_1 CDM 0306 RC 87147 HCPCS inpatient 237 154.05 SIHO - ALL PLANS SIHO - ALL PLANS 213.3 90 999999999 143.5 229.89 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661331_1 CDM 0306 RC 87147 HCPCS inpatient 237 154.05 UMR - ALL PLANS UMR - ALL PLANS 165.9 70 999999999 143.5 229.89 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661331_1 CDM 0306 RC 87147 HCPCS inpatient 237 154.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 143.5 60.55 999999999 143.5 229.89 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661331_1 CDM 0306 RC 87147 HCPCS inpatient 237 154.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 143.5 229.89 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661331_1 CDM 0306 RC 87147 HCPCS inpatient 237 154.05 ANTHEM HMO ANTHEM HMO 999999999 143.5 229.89 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661331_1 CDM 0306 RC 87147 HCPCS inpatient 237 154.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 143.5 229.89 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661331_1 CDM 0306 RC 87147 HCPCS inpatient 237 154.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 143.5 229.89 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661331_1 CDM 0306 RC 87147 HCPCS inpatient 237 154.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 143.5 229.89 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661331_1 CDM 0306 RC 87147 HCPCS inpatient 237 154.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.21 67.6 999999999 143.5 229.89 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661332_1 CDM 0306 RC 87147 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661332_1 CDM 0306 RC 87147 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661332_1 CDM 0306 RC 87147 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661332_1 CDM 0306 RC 87147 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661332_1 CDM 0306 RC 87147 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661332_1 CDM 0306 RC 87147 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661332_1 CDM 0306 RC 87147 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661332_1 CDM 0306 RC 87147 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661332_1 CDM 0306 RC 87147 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661332_1 CDM 0306 RC 87147 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661332_1 CDM 0306 RC 87147 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661332_1 CDM 0306 RC 87147 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661332_1 CDM 0306 RC 87147 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 49661332_1 CDM 0306 RC 87147 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges BUPRENORPHINE 0.3 MG/ML VIAL 49669742_1 CDM 0250 RC 42023-0179-05 NDC inpatient 1 UN 75.7 49.21 AETNA AETNA 59.8 79 999999999 45.84 73.43 percent of total billed charges BUPRENORPHINE 0.3 MG/ML VIAL 49669742_1 CDM 0250 RC 42023-0179-05 NDC inpatient 1 UN 75.7 49.21 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.21 65 999999999 45.84 73.43 percent of total billed charges BUPRENORPHINE 0.3 MG/ML VIAL 49669742_1 CDM 0250 RC 42023-0179-05 NDC inpatient 1 UN 75.7 49.21 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.43 97 999999999 45.84 73.43 percent of total billed charges BUPRENORPHINE 0.3 MG/ML VIAL 49669742_1 CDM 0250 RC 42023-0179-05 NDC inpatient 1 UN 75.7 49.21 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.23 69 999999999 45.84 73.43 percent of total billed charges BUPRENORPHINE 0.3 MG/ML VIAL 49669742_1 CDM 0250 RC 42023-0179-05 NDC inpatient 1 UN 75.7 49.21 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.05 78 999999999 45.84 73.43 percent of total billed charges BUPRENORPHINE 0.3 MG/ML VIAL 49669742_1 CDM 0250 RC 42023-0179-05 NDC inpatient 1 UN 75.7 49.21 SIHO - ALL PLANS SIHO - ALL PLANS 68.13 90 999999999 45.84 73.43 percent of total billed charges BUPRENORPHINE 0.3 MG/ML VIAL 49669742_1 CDM 0250 RC 42023-0179-05 NDC inpatient 1 UN 75.7 49.21 UMR - ALL PLANS UMR - ALL PLANS 52.99 70 999999999 45.84 73.43 percent of total billed charges BUPRENORPHINE 0.3 MG/ML VIAL 49669742_1 CDM 0250 RC 42023-0179-05 NDC inpatient 1 UN 75.7 49.21 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.84 60.55 999999999 45.84 73.43 percent of total billed charges BUPRENORPHINE 0.3 MG/ML VIAL 49669742_1 CDM 0250 RC 42023-0179-05 NDC inpatient 1 UN 75.7 49.21 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.84 73.43 BUPRENORPHINE 0.3 MG/ML VIAL 49669742_1 CDM 0250 RC 42023-0179-05 NDC inpatient 1 UN 75.7 49.21 ANTHEM HMO ANTHEM HMO 999999999 45.84 73.43 BUPRENORPHINE 0.3 MG/ML VIAL 49669742_1 CDM 0250 RC 42023-0179-05 NDC inpatient 1 UN 75.7 49.21 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.84 73.43 BUPRENORPHINE 0.3 MG/ML VIAL 49669742_1 CDM 0250 RC 42023-0179-05 NDC inpatient 1 UN 75.7 49.21 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.84 73.43 BUPRENORPHINE 0.3 MG/ML VIAL 49669742_1 CDM 0250 RC 42023-0179-05 NDC inpatient 1 UN 75.7 49.21 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.84 73.43 BUPRENORPHINE 0.3 MG/ML VIAL 49669742_1 CDM 0250 RC 42023-0179-05 NDC inpatient 1 UN 75.7 49.21 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.17 67.6 999999999 45.84 73.43 percent of total billed charges "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 49679526_1 CDM 0250 RC 59730-4202-01 NDC J1571 HCPCS inpatient 2 UN 77.49 50.37 AETNA AETNA 61.22 79 999999999 46.92 75.17 percent of total billed charges "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 49679526_1 CDM 0250 RC 59730-4202-01 NDC J1571 HCPCS inpatient 2 UN 77.49 50.37 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.37 65 999999999 46.92 75.17 percent of total billed charges "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 49679526_1 CDM 0250 RC 59730-4202-01 NDC J1571 HCPCS inpatient 2 UN 77.49 50.37 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 75.17 97 999999999 46.92 75.17 percent of total billed charges "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 49679526_1 CDM 0250 RC 59730-4202-01 NDC J1571 HCPCS inpatient 2 UN 77.49 50.37 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.47 69 999999999 46.92 75.17 percent of total billed charges "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 49679526_1 CDM 0250 RC 59730-4202-01 NDC J1571 HCPCS inpatient 2 UN 77.49 50.37 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.44 78 999999999 46.92 75.17 percent of total billed charges "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 49679526_1 CDM 0250 RC 59730-4202-01 NDC J1571 HCPCS inpatient 2 UN 77.49 50.37 SIHO - ALL PLANS SIHO - ALL PLANS 69.74 90 999999999 46.92 75.17 percent of total billed charges "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 49679526_1 CDM 0250 RC 59730-4202-01 NDC J1571 HCPCS inpatient 2 UN 77.49 50.37 UMR - ALL PLANS UMR - ALL PLANS 54.24 70 999999999 46.92 75.17 percent of total billed charges "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 49679526_1 CDM 0250 RC 59730-4202-01 NDC J1571 HCPCS inpatient 2 UN 77.49 50.37 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.92 60.55 999999999 46.92 75.17 percent of total billed charges "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 49679526_1 CDM 0250 RC 59730-4202-01 NDC J1571 HCPCS inpatient 2 UN 77.49 50.37 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.92 75.17 "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 49679526_1 CDM 0250 RC 59730-4202-01 NDC J1571 HCPCS inpatient 2 UN 77.49 50.37 ANTHEM HMO ANTHEM HMO 999999999 46.92 75.17 "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 49679526_1 CDM 0250 RC 59730-4202-01 NDC J1571 HCPCS inpatient 2 UN 77.49 50.37 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.92 75.17 "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 49679526_1 CDM 0250 RC 59730-4202-01 NDC J1571 HCPCS inpatient 2 UN 77.49 50.37 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.92 75.17 "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 49679526_1 CDM 0250 RC 59730-4202-01 NDC J1571 HCPCS inpatient 2 UN 77.49 50.37 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.92 75.17 "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 49679526_1 CDM 0250 RC 59730-4202-01 NDC J1571 HCPCS inpatient 2 UN 77.49 50.37 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.38 67.6 999999999 46.92 75.17 percent of total billed charges Culture for identification of yeast 49681155_1 CDM 0306 RC 87107 HCPCS inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges Culture for identification of yeast 49681155_1 CDM 0306 RC 87107 HCPCS inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges Culture for identification of yeast 49681155_1 CDM 0306 RC 87107 HCPCS inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges Culture for identification of yeast 49681155_1 CDM 0306 RC 87107 HCPCS inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges Culture for identification of yeast 49681155_1 CDM 0306 RC 87107 HCPCS inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges Culture for identification of yeast 49681155_1 CDM 0306 RC 87107 HCPCS inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges Culture for identification of yeast 49681155_1 CDM 0306 RC 87107 HCPCS inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges Culture for identification of yeast 49681155_1 CDM 0306 RC 87107 HCPCS inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges Culture for identification of yeast 49681155_1 CDM 0306 RC 87107 HCPCS inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 Culture for identification of yeast 49681155_1 CDM 0306 RC 87107 HCPCS inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 Culture for identification of yeast 49681155_1 CDM 0306 RC 87107 HCPCS inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 Culture for identification of yeast 49681155_1 CDM 0306 RC 87107 HCPCS inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 Culture for identification of yeast 49681155_1 CDM 0306 RC 87107 HCPCS inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 Culture for identification of yeast 49681155_1 CDM 0306 RC 87107 HCPCS inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges CHILDREN IBUPROF 100MG/5ML CUP 49688419_1 CDM 0250 RC 68094-0600-61 NDC inpatient 1 UN 3.21 2.09 AETNA AETNA 2.54 79 999999999 1.94 3.11 percent of total billed charges CHILDREN IBUPROF 100MG/5ML CUP 49688419_1 CDM 0250 RC 68094-0600-61 NDC inpatient 1 UN 3.21 2.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.09 65 999999999 1.94 3.11 percent of total billed charges CHILDREN IBUPROF 100MG/5ML CUP 49688419_1 CDM 0250 RC 68094-0600-61 NDC inpatient 1 UN 3.21 2.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.11 97 999999999 1.94 3.11 percent of total billed charges CHILDREN IBUPROF 100MG/5ML CUP 49688419_1 CDM 0250 RC 68094-0600-61 NDC inpatient 1 UN 3.21 2.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.21 69 999999999 1.94 3.11 percent of total billed charges CHILDREN IBUPROF 100MG/5ML CUP 49688419_1 CDM 0250 RC 68094-0600-61 NDC inpatient 1 UN 3.21 2.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.5 78 999999999 1.94 3.11 percent of total billed charges CHILDREN IBUPROF 100MG/5ML CUP 49688419_1 CDM 0250 RC 68094-0600-61 NDC inpatient 1 UN 3.21 2.09 SIHO - ALL PLANS SIHO - ALL PLANS 2.89 90 999999999 1.94 3.11 percent of total billed charges CHILDREN IBUPROF 100MG/5ML CUP 49688419_1 CDM 0250 RC 68094-0600-61 NDC inpatient 1 UN 3.21 2.09 UMR - ALL PLANS UMR - ALL PLANS 2.25 70 999999999 1.94 3.11 percent of total billed charges CHILDREN IBUPROF 100MG/5ML CUP 49688419_1 CDM 0250 RC 68094-0600-61 NDC inpatient 1 UN 3.21 2.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.94 60.55 999999999 1.94 3.11 percent of total billed charges CHILDREN IBUPROF 100MG/5ML CUP 49688419_1 CDM 0250 RC 68094-0600-61 NDC inpatient 1 UN 3.21 2.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.94 3.11 CHILDREN IBUPROF 100MG/5ML CUP 49688419_1 CDM 0250 RC 68094-0600-61 NDC inpatient 1 UN 3.21 2.09 ANTHEM HMO ANTHEM HMO 999999999 1.94 3.11 CHILDREN IBUPROF 100MG/5ML CUP 49688419_1 CDM 0250 RC 68094-0600-61 NDC inpatient 1 UN 3.21 2.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.94 3.11 CHILDREN IBUPROF 100MG/5ML CUP 49688419_1 CDM 0250 RC 68094-0600-61 NDC inpatient 1 UN 3.21 2.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.94 3.11 CHILDREN IBUPROF 100MG/5ML CUP 49688419_1 CDM 0250 RC 68094-0600-61 NDC inpatient 1 UN 3.21 2.09 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.94 3.11 CHILDREN IBUPROF 100MG/5ML CUP 49688419_1 CDM 0250 RC 68094-0600-61 NDC inpatient 1 UN 3.21 2.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.17 67.6 999999999 1.94 3.11 percent of total billed charges DURAMORPH 10 MG/10 ML AMPUL 49688808_1 CDM 0250 RC 00641-6019-10 NDC inpatient 1 UN 142.5 92.63 AETNA AETNA 112.58 79 999999999 86.28 138.23 percent of total billed charges DURAMORPH 10 MG/10 ML AMPUL 49688808_1 CDM 0250 RC 00641-6019-10 NDC inpatient 1 UN 142.5 92.63 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.63 65 999999999 86.28 138.23 percent of total billed charges DURAMORPH 10 MG/10 ML AMPUL 49688808_1 CDM 0250 RC 00641-6019-10 NDC inpatient 1 UN 142.5 92.63 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.23 97 999999999 86.28 138.23 percent of total billed charges DURAMORPH 10 MG/10 ML AMPUL 49688808_1 CDM 0250 RC 00641-6019-10 NDC inpatient 1 UN 142.5 92.63 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.33 69 999999999 86.28 138.23 percent of total billed charges DURAMORPH 10 MG/10 ML AMPUL 49688808_1 CDM 0250 RC 00641-6019-10 NDC inpatient 1 UN 142.5 92.63 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.15 78 999999999 86.28 138.23 percent of total billed charges DURAMORPH 10 MG/10 ML AMPUL 49688808_1 CDM 0250 RC 00641-6019-10 NDC inpatient 1 UN 142.5 92.63 SIHO - ALL PLANS SIHO - ALL PLANS 128.25 90 999999999 86.28 138.23 percent of total billed charges DURAMORPH 10 MG/10 ML AMPUL 49688808_1 CDM 0250 RC 00641-6019-10 NDC inpatient 1 UN 142.5 92.63 UMR - ALL PLANS UMR - ALL PLANS 99.75 70 999999999 86.28 138.23 percent of total billed charges DURAMORPH 10 MG/10 ML AMPUL 49688808_1 CDM 0250 RC 00641-6019-10 NDC inpatient 1 UN 142.5 92.63 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.28 60.55 999999999 86.28 138.23 percent of total billed charges DURAMORPH 10 MG/10 ML AMPUL 49688808_1 CDM 0250 RC 00641-6019-10 NDC inpatient 1 UN 142.5 92.63 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.28 138.23 DURAMORPH 10 MG/10 ML AMPUL 49688808_1 CDM 0250 RC 00641-6019-10 NDC inpatient 1 UN 142.5 92.63 ANTHEM HMO ANTHEM HMO 999999999 86.28 138.23 DURAMORPH 10 MG/10 ML AMPUL 49688808_1 CDM 0250 RC 00641-6019-10 NDC inpatient 1 UN 142.5 92.63 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.28 138.23 DURAMORPH 10 MG/10 ML AMPUL 49688808_1 CDM 0250 RC 00641-6019-10 NDC inpatient 1 UN 142.5 92.63 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.28 138.23 DURAMORPH 10 MG/10 ML AMPUL 49688808_1 CDM 0250 RC 00641-6019-10 NDC inpatient 1 UN 142.5 92.63 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.28 138.23 DURAMORPH 10 MG/10 ML AMPUL 49688808_1 CDM 0250 RC 00641-6019-10 NDC inpatient 1 UN 142.5 92.63 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.33 67.6 999999999 86.28 138.23 percent of total billed charges ARIPIPRAZOLE 10 MG TABLET 49692263_1 CDM 0250 RC 62332-0099-30 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 10 MG TABLET 49692263_1 CDM 0250 RC 62332-0099-30 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 10 MG TABLET 49692263_1 CDM 0250 RC 62332-0099-30 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 10 MG TABLET 49692263_1 CDM 0250 RC 62332-0099-30 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 10 MG TABLET 49692263_1 CDM 0250 RC 62332-0099-30 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 10 MG TABLET 49692263_1 CDM 0250 RC 62332-0099-30 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 10 MG TABLET 49692263_1 CDM 0250 RC 62332-0099-30 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 10 MG TABLET 49692263_1 CDM 0250 RC 62332-0099-30 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 10 MG TABLET 49692263_1 CDM 0250 RC 62332-0099-30 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ARIPIPRAZOLE 10 MG TABLET 49692263_1 CDM 0250 RC 62332-0099-30 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ARIPIPRAZOLE 10 MG TABLET 49692263_1 CDM 0250 RC 62332-0099-30 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ARIPIPRAZOLE 10 MG TABLET 49692263_1 CDM 0250 RC 62332-0099-30 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ARIPIPRAZOLE 10 MG TABLET 49692263_1 CDM 0250 RC 62332-0099-30 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ARIPIPRAZOLE 10 MG TABLET 49692263_1 CDM 0250 RC 62332-0099-30 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49704986_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49704986_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49704986_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49704986_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49704986_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49704986_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49704986_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49704986_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49704986_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 "Testing for presence of drug, by chemistry analyzers" 49704986_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 "Testing for presence of drug, by chemistry analyzers" 49704986_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 "Testing for presence of drug, by chemistry analyzers" 49704986_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 "Testing for presence of drug, by chemistry analyzers" 49704986_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 "Testing for presence of drug, by chemistry analyzers" 49704986_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges SUTURE ENDO STITCH SIZE 0 #170043 49705646_1 CDM 0272 RC inpatient 432 280.8 AETNA AETNA 341.28 79 999999999 261.58 419.04 percent of total billed charges SUTURE ENDO STITCH SIZE 0 #170043 49705646_1 CDM 0272 RC inpatient 432 280.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 280.8 65 999999999 261.58 419.04 percent of total billed charges SUTURE ENDO STITCH SIZE 0 #170043 49705646_1 CDM 0272 RC inpatient 432 280.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 419.04 97 999999999 261.58 419.04 percent of total billed charges SUTURE ENDO STITCH SIZE 0 #170043 49705646_1 CDM 0272 RC inpatient 432 280.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 298.08 69 999999999 261.58 419.04 percent of total billed charges SUTURE ENDO STITCH SIZE 0 #170043 49705646_1 CDM 0272 RC inpatient 432 280.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 336.96 78 999999999 261.58 419.04 percent of total billed charges SUTURE ENDO STITCH SIZE 0 #170043 49705646_1 CDM 0272 RC inpatient 432 280.8 SIHO - ALL PLANS SIHO - ALL PLANS 388.8 90 999999999 261.58 419.04 percent of total billed charges SUTURE ENDO STITCH SIZE 0 #170043 49705646_1 CDM 0272 RC inpatient 432 280.8 UMR - ALL PLANS UMR - ALL PLANS 302.4 70 999999999 261.58 419.04 percent of total billed charges SUTURE ENDO STITCH SIZE 0 #170043 49705646_1 CDM 0272 RC inpatient 432 280.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 261.58 60.55 999999999 261.58 419.04 percent of total billed charges SUTURE ENDO STITCH SIZE 0 #170043 49705646_1 CDM 0272 RC inpatient 432 280.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 261.58 419.04 SUTURE ENDO STITCH SIZE 0 #170043 49705646_1 CDM 0272 RC inpatient 432 280.8 ANTHEM HMO ANTHEM HMO 999999999 261.58 419.04 SUTURE ENDO STITCH SIZE 0 #170043 49705646_1 CDM 0272 RC inpatient 432 280.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 261.58 419.04 SUTURE ENDO STITCH SIZE 0 #170043 49705646_1 CDM 0272 RC inpatient 432 280.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 261.58 419.04 SUTURE ENDO STITCH SIZE 0 #170043 49705646_1 CDM 0272 RC inpatient 432 280.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 261.58 419.04 SUTURE ENDO STITCH SIZE 0 #170043 49705646_1 CDM 0272 RC inpatient 432 280.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 292.03 67.6 999999999 261.58 419.04 percent of total billed charges "Cannabinoids levels, natural" 49708676_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 49708676_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 49708676_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 49708676_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 49708676_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 49708676_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 49708676_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 49708676_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 49708676_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 "Cannabinoids levels, natural" 49708676_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 "Cannabinoids levels, natural" 49708676_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 "Cannabinoids levels, natural" 49708676_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 "Cannabinoids levels, natural" 49708676_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 "Cannabinoids levels, natural" 49708676_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges PHENOBARBITAL 64.8 MG TABLET 49709585_1 CDM 0250 RC 13517-0112-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges PHENOBARBITAL 64.8 MG TABLET 49709585_1 CDM 0250 RC 13517-0112-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges PHENOBARBITAL 64.8 MG TABLET 49709585_1 CDM 0250 RC 13517-0112-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges PHENOBARBITAL 64.8 MG TABLET 49709585_1 CDM 0250 RC 13517-0112-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges PHENOBARBITAL 64.8 MG TABLET 49709585_1 CDM 0250 RC 13517-0112-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges PHENOBARBITAL 64.8 MG TABLET 49709585_1 CDM 0250 RC 13517-0112-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges PHENOBARBITAL 64.8 MG TABLET 49709585_1 CDM 0250 RC 13517-0112-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges PHENOBARBITAL 64.8 MG TABLET 49709585_1 CDM 0250 RC 13517-0112-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges PHENOBARBITAL 64.8 MG TABLET 49709585_1 CDM 0250 RC 13517-0112-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 PHENOBARBITAL 64.8 MG TABLET 49709585_1 CDM 0250 RC 13517-0112-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 PHENOBARBITAL 64.8 MG TABLET 49709585_1 CDM 0250 RC 13517-0112-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 PHENOBARBITAL 64.8 MG TABLET 49709585_1 CDM 0250 RC 13517-0112-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 PHENOBARBITAL 64.8 MG TABLET 49709585_1 CDM 0250 RC 13517-0112-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 PHENOBARBITAL 64.8 MG TABLET 49709585_1 CDM 0250 RC 13517-0112-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges Analysis of cell function and analysis for genetic marker 49722647_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 AETNA AETNA 285.19 79 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 49722647_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 234.65 65 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 49722647_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 350.17 97 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 49722647_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 249.09 69 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 49722647_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 281.58 78 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 49722647_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 SIHO - ALL PLANS SIHO - ALL PLANS 324.9 90 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 49722647_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 UMR - ALL PLANS UMR - ALL PLANS 252.7 70 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 49722647_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 218.59 60.55 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 49722647_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 218.59 350.17 Analysis of cell function and analysis for genetic marker 49722647_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 218.59 350.17 Analysis of cell function and analysis for genetic marker 49722647_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 ANTHEM HMO ANTHEM HMO 999999999 218.59 350.17 Analysis of cell function and analysis for genetic marker 49722647_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 218.59 350.17 Analysis of cell function and analysis for genetic marker 49722647_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 218.59 350.17 Analysis of cell function and analysis for genetic marker 49722647_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 244.04 67.6 999999999 218.59 350.17 percent of total billed charges MIDAZOLAM HCL 2 MG/2 ML VIAL 49723309_1 CDM 0250 RC 00409-2305-17 NDC inpatient 1 UN 19.12 12.43 AETNA AETNA 15.1 79 999999999 11.58 18.55 percent of total billed charges MIDAZOLAM HCL 2 MG/2 ML VIAL 49723309_1 CDM 0250 RC 00409-2305-17 NDC inpatient 1 UN 19.12 12.43 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.43 65 999999999 11.58 18.55 percent of total billed charges MIDAZOLAM HCL 2 MG/2 ML VIAL 49723309_1 CDM 0250 RC 00409-2305-17 NDC inpatient 1 UN 19.12 12.43 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 18.55 97 999999999 11.58 18.55 percent of total billed charges MIDAZOLAM HCL 2 MG/2 ML VIAL 49723309_1 CDM 0250 RC 00409-2305-17 NDC inpatient 1 UN 19.12 12.43 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.19 69 999999999 11.58 18.55 percent of total billed charges MIDAZOLAM HCL 2 MG/2 ML VIAL 49723309_1 CDM 0250 RC 00409-2305-17 NDC inpatient 1 UN 19.12 12.43 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.91 78 999999999 11.58 18.55 percent of total billed charges MIDAZOLAM HCL 2 MG/2 ML VIAL 49723309_1 CDM 0250 RC 00409-2305-17 NDC inpatient 1 UN 19.12 12.43 SIHO - ALL PLANS SIHO - ALL PLANS 17.21 90 999999999 11.58 18.55 percent of total billed charges MIDAZOLAM HCL 2 MG/2 ML VIAL 49723309_1 CDM 0250 RC 00409-2305-17 NDC inpatient 1 UN 19.12 12.43 UMR - ALL PLANS UMR - ALL PLANS 13.38 70 999999999 11.58 18.55 percent of total billed charges MIDAZOLAM HCL 2 MG/2 ML VIAL 49723309_1 CDM 0250 RC 00409-2305-17 NDC inpatient 1 UN 19.12 12.43 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.58 60.55 999999999 11.58 18.55 percent of total billed charges MIDAZOLAM HCL 2 MG/2 ML VIAL 49723309_1 CDM 0250 RC 00409-2305-17 NDC inpatient 1 UN 19.12 12.43 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.58 18.55 MIDAZOLAM HCL 2 MG/2 ML VIAL 49723309_1 CDM 0250 RC 00409-2305-17 NDC inpatient 1 UN 19.12 12.43 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.58 18.55 MIDAZOLAM HCL 2 MG/2 ML VIAL 49723309_1 CDM 0250 RC 00409-2305-17 NDC inpatient 1 UN 19.12 12.43 ANTHEM HMO ANTHEM HMO 999999999 11.58 18.55 MIDAZOLAM HCL 2 MG/2 ML VIAL 49723309_1 CDM 0250 RC 00409-2305-17 NDC inpatient 1 UN 19.12 12.43 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.58 18.55 MIDAZOLAM HCL 2 MG/2 ML VIAL 49723309_1 CDM 0250 RC 00409-2305-17 NDC inpatient 1 UN 19.12 12.43 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.58 18.55 MIDAZOLAM HCL 2 MG/2 ML VIAL 49723309_1 CDM 0250 RC 00409-2305-17 NDC inpatient 1 UN 19.12 12.43 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.93 67.6 999999999 11.58 18.55 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49723966_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49723966_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49723966_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49723966_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49723966_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49723966_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49723966_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49723966_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49723966_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49723966_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49723966_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49723966_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49723966_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49723966_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724338_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 AETNA AETNA 18.17 79 999999999 13.93 22.31 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724338_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.95 65 999999999 13.93 22.31 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724338_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22.31 97 999999999 13.93 22.31 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724338_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.94 78 999999999 13.93 22.31 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724338_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.87 69 999999999 13.93 22.31 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724338_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 SIHO - ALL PLANS SIHO - ALL PLANS 20.7 90 999999999 13.93 22.31 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724338_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 UMR - ALL PLANS UMR - ALL PLANS 16.1 70 999999999 13.93 22.31 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724338_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.93 60.55 999999999 13.93 22.31 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724338_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.93 22.31 "INJECTION, GADOBUTROL, 0.1 ML" 49724338_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.93 22.31 "INJECTION, GADOBUTROL, 0.1 ML" 49724338_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 ANTHEM HMO ANTHEM HMO 999999999 13.93 22.31 "INJECTION, GADOBUTROL, 0.1 ML" 49724338_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.93 22.31 "INJECTION, GADOBUTROL, 0.1 ML" 49724338_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.93 22.31 "INJECTION, GADOBUTROL, 0.1 ML" 49724338_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 15.55 67.6 999999999 13.93 22.31 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724341_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 AETNA AETNA 18.17 79 999999999 13.93 22.31 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724341_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.95 65 999999999 13.93 22.31 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724341_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22.31 97 999999999 13.93 22.31 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724341_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.94 78 999999999 13.93 22.31 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724341_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.87 69 999999999 13.93 22.31 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724341_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 SIHO - ALL PLANS SIHO - ALL PLANS 20.7 90 999999999 13.93 22.31 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724341_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 UMR - ALL PLANS UMR - ALL PLANS 16.1 70 999999999 13.93 22.31 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724341_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.93 60.55 999999999 13.93 22.31 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724341_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.93 22.31 "INJECTION, GADOBUTROL, 0.1 ML" 49724341_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.93 22.31 "INJECTION, GADOBUTROL, 0.1 ML" 49724341_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 ANTHEM HMO ANTHEM HMO 999999999 13.93 22.31 "INJECTION, GADOBUTROL, 0.1 ML" 49724341_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.93 22.31 "INJECTION, GADOBUTROL, 0.1 ML" 49724341_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.93 22.31 "INJECTION, GADOBUTROL, 0.1 ML" 49724341_1 CDM 0636 RC A9585 HCPCS inpatient 23 14.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 15.55 67.6 999999999 13.93 22.31 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724343_1 CDM 0636 RC A9585 HCPCS inpatient 11 7.15 AETNA AETNA 8.69 79 999999999 6.66 10.67 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724343_1 CDM 0636 RC A9585 HCPCS inpatient 11 7.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.15 65 999999999 6.66 10.67 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724343_1 CDM 0636 RC A9585 HCPCS inpatient 11 7.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10.67 97 999999999 6.66 10.67 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724343_1 CDM 0636 RC A9585 HCPCS inpatient 11 7.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 8.58 78 999999999 6.66 10.67 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724343_1 CDM 0636 RC A9585 HCPCS inpatient 11 7.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.59 69 999999999 6.66 10.67 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724343_1 CDM 0636 RC A9585 HCPCS inpatient 11 7.15 SIHO - ALL PLANS SIHO - ALL PLANS 9.9 90 999999999 6.66 10.67 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724343_1 CDM 0636 RC A9585 HCPCS inpatient 11 7.15 UMR - ALL PLANS UMR - ALL PLANS 7.7 70 999999999 6.66 10.67 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724343_1 CDM 0636 RC A9585 HCPCS inpatient 11 7.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.66 60.55 999999999 6.66 10.67 percent of total billed charges "INJECTION, GADOBUTROL, 0.1 ML" 49724343_1 CDM 0636 RC A9585 HCPCS inpatient 11 7.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.66 10.67 "INJECTION, GADOBUTROL, 0.1 ML" 49724343_1 CDM 0636 RC A9585 HCPCS inpatient 11 7.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.66 10.67 "INJECTION, GADOBUTROL, 0.1 ML" 49724343_1 CDM 0636 RC A9585 HCPCS inpatient 11 7.15 ANTHEM HMO ANTHEM HMO 999999999 6.66 10.67 "INJECTION, GADOBUTROL, 0.1 ML" 49724343_1 CDM 0636 RC A9585 HCPCS inpatient 11 7.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.66 10.67 "INJECTION, GADOBUTROL, 0.1 ML" 49724343_1 CDM 0636 RC A9585 HCPCS inpatient 11 7.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.66 10.67 "INJECTION, GADOBUTROL, 0.1 ML" 49724343_1 CDM 0636 RC A9585 HCPCS inpatient 11 7.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 7.44 67.6 999999999 6.66 10.67 percent of total billed charges Microbial identification 49730033_1 CDM 0306 RC 87158 HCPCS inpatient 35 22.75 AETNA AETNA 27.65 79 999999999 21.19 33.95 percent of total billed charges Microbial identification 49730033_1 CDM 0306 RC 87158 HCPCS inpatient 35 22.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.75 65 999999999 21.19 33.95 percent of total billed charges Microbial identification 49730033_1 CDM 0306 RC 87158 HCPCS inpatient 35 22.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33.95 97 999999999 21.19 33.95 percent of total billed charges Microbial identification 49730033_1 CDM 0306 RC 87158 HCPCS inpatient 35 22.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.3 78 999999999 21.19 33.95 percent of total billed charges Microbial identification 49730033_1 CDM 0306 RC 87158 HCPCS inpatient 35 22.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.15 69 999999999 21.19 33.95 percent of total billed charges Microbial identification 49730033_1 CDM 0306 RC 87158 HCPCS inpatient 35 22.75 SIHO - ALL PLANS SIHO - ALL PLANS 31.5 90 999999999 21.19 33.95 percent of total billed charges Microbial identification 49730033_1 CDM 0306 RC 87158 HCPCS inpatient 35 22.75 UMR - ALL PLANS UMR - ALL PLANS 24.5 70 999999999 21.19 33.95 percent of total billed charges Microbial identification 49730033_1 CDM 0306 RC 87158 HCPCS inpatient 35 22.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.19 60.55 999999999 21.19 33.95 percent of total billed charges Microbial identification 49730033_1 CDM 0306 RC 87158 HCPCS inpatient 35 22.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.19 33.95 Microbial identification 49730033_1 CDM 0306 RC 87158 HCPCS inpatient 35 22.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.19 33.95 Microbial identification 49730033_1 CDM 0306 RC 87158 HCPCS inpatient 35 22.75 ANTHEM HMO ANTHEM HMO 999999999 21.19 33.95 Microbial identification 49730033_1 CDM 0306 RC 87158 HCPCS inpatient 35 22.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.19 33.95 Microbial identification 49730033_1 CDM 0306 RC 87158 HCPCS inpatient 35 22.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.19 33.95 Microbial identification 49730033_1 CDM 0306 RC 87158 HCPCS inpatient 35 22.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 23.66 67.6 999999999 21.19 33.95 percent of total billed charges "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 6-11 targets" 49730051_1 CDM 0301 RC 87506 HCPCS inpatient 521 338.65 AETNA AETNA 411.59 79 999999999 315.47 505.37 percent of total billed charges "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 6-11 targets" 49730051_1 CDM 0301 RC 87506 HCPCS inpatient 521 338.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 338.65 65 999999999 315.47 505.37 percent of total billed charges "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 6-11 targets" 49730051_1 CDM 0301 RC 87506 HCPCS inpatient 521 338.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 505.37 97 999999999 315.47 505.37 percent of total billed charges "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 6-11 targets" 49730051_1 CDM 0301 RC 87506 HCPCS inpatient 521 338.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 406.38 78 999999999 315.47 505.37 percent of total billed charges "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 6-11 targets" 49730051_1 CDM 0301 RC 87506 HCPCS inpatient 521 338.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 359.49 69 999999999 315.47 505.37 percent of total billed charges "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 6-11 targets" 49730051_1 CDM 0301 RC 87506 HCPCS inpatient 521 338.65 SIHO - ALL PLANS SIHO - ALL PLANS 468.9 90 999999999 315.47 505.37 percent of total billed charges "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 6-11 targets" 49730051_1 CDM 0301 RC 87506 HCPCS inpatient 521 338.65 UMR - ALL PLANS UMR - ALL PLANS 364.7 70 999999999 315.47 505.37 percent of total billed charges "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 6-11 targets" 49730051_1 CDM 0301 RC 87506 HCPCS inpatient 521 338.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 315.47 60.55 999999999 315.47 505.37 percent of total billed charges "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 6-11 targets" 49730051_1 CDM 0301 RC 87506 HCPCS inpatient 521 338.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 315.47 505.37 "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 6-11 targets" 49730051_1 CDM 0301 RC 87506 HCPCS inpatient 521 338.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 315.47 505.37 "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 6-11 targets" 49730051_1 CDM 0301 RC 87506 HCPCS inpatient 521 338.65 ANTHEM HMO ANTHEM HMO 999999999 315.47 505.37 "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 6-11 targets" 49730051_1 CDM 0301 RC 87506 HCPCS inpatient 521 338.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 315.47 505.37 "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 6-11 targets" 49730051_1 CDM 0301 RC 87506 HCPCS inpatient 521 338.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 315.47 505.37 "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 6-11 targets" 49730051_1 CDM 0301 RC 87506 HCPCS inpatient 521 338.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 352.2 67.6 999999999 315.47 505.37 percent of total billed charges "INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG" 49730258_1 CDM 0250 RC 00143-9570-10 NDC J2916 HCPCS inpatient 5 UN 40.18 26.12 AETNA AETNA 31.74 79 999999999 24.33 38.97 percent of total billed charges "INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG" 49730258_1 CDM 0250 RC 00143-9570-10 NDC J2916 HCPCS inpatient 5 UN 40.18 26.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.12 65 999999999 24.33 38.97 percent of total billed charges "INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG" 49730258_1 CDM 0250 RC 00143-9570-10 NDC J2916 HCPCS inpatient 5 UN 40.18 26.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 38.97 97 999999999 24.33 38.97 percent of total billed charges "INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG" 49730258_1 CDM 0250 RC 00143-9570-10 NDC J2916 HCPCS inpatient 5 UN 40.18 26.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.34 78 999999999 24.33 38.97 percent of total billed charges "INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG" 49730258_1 CDM 0250 RC 00143-9570-10 NDC J2916 HCPCS inpatient 5 UN 40.18 26.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 27.72 69 999999999 24.33 38.97 percent of total billed charges "INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG" 49730258_1 CDM 0250 RC 00143-9570-10 NDC J2916 HCPCS inpatient 5 UN 40.18 26.12 SIHO - ALL PLANS SIHO - ALL PLANS 36.16 90 999999999 24.33 38.97 percent of total billed charges "INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG" 49730258_1 CDM 0250 RC 00143-9570-10 NDC J2916 HCPCS inpatient 5 UN 40.18 26.12 UMR - ALL PLANS UMR - ALL PLANS 28.13 70 999999999 24.33 38.97 percent of total billed charges "INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG" 49730258_1 CDM 0250 RC 00143-9570-10 NDC J2916 HCPCS inpatient 5 UN 40.18 26.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.33 60.55 999999999 24.33 38.97 percent of total billed charges "INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG" 49730258_1 CDM 0250 RC 00143-9570-10 NDC J2916 HCPCS inpatient 5 UN 40.18 26.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.33 38.97 "INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG" 49730258_1 CDM 0250 RC 00143-9570-10 NDC J2916 HCPCS inpatient 5 UN 40.18 26.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.33 38.97 "INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG" 49730258_1 CDM 0250 RC 00143-9570-10 NDC J2916 HCPCS inpatient 5 UN 40.18 26.12 ANTHEM HMO ANTHEM HMO 999999999 24.33 38.97 "INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG" 49730258_1 CDM 0250 RC 00143-9570-10 NDC J2916 HCPCS inpatient 5 UN 40.18 26.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.33 38.97 "INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG" 49730258_1 CDM 0250 RC 00143-9570-10 NDC J2916 HCPCS inpatient 5 UN 40.18 26.12 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.33 38.97 "INJECTION, SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE INJECTION, 12.5 MG" 49730258_1 CDM 0250 RC 00143-9570-10 NDC J2916 HCPCS inpatient 5 UN 40.18 26.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.16 67.6 999999999 24.33 38.97 percent of total billed charges BUPIVACAINE 0.5% VIAL 49730587_1 CDM 0250 RC 55150-0169-10 NDC inpatient 1 UN 28.97 18.83 AETNA AETNA 22.89 79 999999999 17.54 28.1 percent of total billed charges BUPIVACAINE 0.5% VIAL 49730587_1 CDM 0250 RC 55150-0169-10 NDC inpatient 1 UN 28.97 18.83 SELF PAY DISCOUNT SELF PAY DISCOUNT 18.83 65 999999999 17.54 28.1 percent of total billed charges BUPIVACAINE 0.5% VIAL 49730587_1 CDM 0250 RC 55150-0169-10 NDC inpatient 1 UN 28.97 18.83 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 28.1 97 999999999 17.54 28.1 percent of total billed charges BUPIVACAINE 0.5% VIAL 49730587_1 CDM 0250 RC 55150-0169-10 NDC inpatient 1 UN 28.97 18.83 HUMANA - ALL PLANS HUMANA - ALL PLANS 22.6 78 999999999 17.54 28.1 percent of total billed charges BUPIVACAINE 0.5% VIAL 49730587_1 CDM 0250 RC 55150-0169-10 NDC inpatient 1 UN 28.97 18.83 ENCORE - ALL PLANS ENCORE - ALL PLANS 19.99 69 999999999 17.54 28.1 percent of total billed charges BUPIVACAINE 0.5% VIAL 49730587_1 CDM 0250 RC 55150-0169-10 NDC inpatient 1 UN 28.97 18.83 SIHO - ALL PLANS SIHO - ALL PLANS 26.07 90 999999999 17.54 28.1 percent of total billed charges BUPIVACAINE 0.5% VIAL 49730587_1 CDM 0250 RC 55150-0169-10 NDC inpatient 1 UN 28.97 18.83 UMR - ALL PLANS UMR - ALL PLANS 20.28 70 999999999 17.54 28.1 percent of total billed charges BUPIVACAINE 0.5% VIAL 49730587_1 CDM 0250 RC 55150-0169-10 NDC inpatient 1 UN 28.97 18.83 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17.54 60.55 999999999 17.54 28.1 percent of total billed charges BUPIVACAINE 0.5% VIAL 49730587_1 CDM 0250 RC 55150-0169-10 NDC inpatient 1 UN 28.97 18.83 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 17.54 28.1 BUPIVACAINE 0.5% VIAL 49730587_1 CDM 0250 RC 55150-0169-10 NDC inpatient 1 UN 28.97 18.83 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 17.54 28.1 BUPIVACAINE 0.5% VIAL 49730587_1 CDM 0250 RC 55150-0169-10 NDC inpatient 1 UN 28.97 18.83 ANTHEM HMO ANTHEM HMO 999999999 17.54 28.1 BUPIVACAINE 0.5% VIAL 49730587_1 CDM 0250 RC 55150-0169-10 NDC inpatient 1 UN 28.97 18.83 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 17.54 28.1 BUPIVACAINE 0.5% VIAL 49730587_1 CDM 0250 RC 55150-0169-10 NDC inpatient 1 UN 28.97 18.83 UHC - ALL PLANS UHC - ALL PLANS 999999999 17.54 28.1 BUPIVACAINE 0.5% VIAL 49730587_1 CDM 0250 RC 55150-0169-10 NDC inpatient 1 UN 28.97 18.83 CIGNA - ALL PLANS CIGNA - ALL PLANS 19.58 67.6 999999999 17.54 28.1 percent of total billed charges DIPHENOXYLATE-ATROP 2.5-0.025 49730588_1 CDM 0250 RC 62559-0490-01 NDC inpatient 1 UN 1.8 1.17 AETNA AETNA 1.42 79 999999999 1.09 1.75 percent of total billed charges DIPHENOXYLATE-ATROP 2.5-0.025 49730588_1 CDM 0250 RC 62559-0490-01 NDC inpatient 1 UN 1.8 1.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.17 65 999999999 1.09 1.75 percent of total billed charges DIPHENOXYLATE-ATROP 2.5-0.025 49730588_1 CDM 0250 RC 62559-0490-01 NDC inpatient 1 UN 1.8 1.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.75 97 999999999 1.09 1.75 percent of total billed charges DIPHENOXYLATE-ATROP 2.5-0.025 49730588_1 CDM 0250 RC 62559-0490-01 NDC inpatient 1 UN 1.8 1.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.4 78 999999999 1.09 1.75 percent of total billed charges DIPHENOXYLATE-ATROP 2.5-0.025 49730588_1 CDM 0250 RC 62559-0490-01 NDC inpatient 1 UN 1.8 1.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.24 69 999999999 1.09 1.75 percent of total billed charges DIPHENOXYLATE-ATROP 2.5-0.025 49730588_1 CDM 0250 RC 62559-0490-01 NDC inpatient 1 UN 1.8 1.17 SIHO - ALL PLANS SIHO - ALL PLANS 1.62 90 999999999 1.09 1.75 percent of total billed charges DIPHENOXYLATE-ATROP 2.5-0.025 49730588_1 CDM 0250 RC 62559-0490-01 NDC inpatient 1 UN 1.8 1.17 UMR - ALL PLANS UMR - ALL PLANS 1.26 70 999999999 1.09 1.75 percent of total billed charges DIPHENOXYLATE-ATROP 2.5-0.025 49730588_1 CDM 0250 RC 62559-0490-01 NDC inpatient 1 UN 1.8 1.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.09 60.55 999999999 1.09 1.75 percent of total billed charges DIPHENOXYLATE-ATROP 2.5-0.025 49730588_1 CDM 0250 RC 62559-0490-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.09 1.75 DIPHENOXYLATE-ATROP 2.5-0.025 49730588_1 CDM 0250 RC 62559-0490-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.09 1.75 DIPHENOXYLATE-ATROP 2.5-0.025 49730588_1 CDM 0250 RC 62559-0490-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM HMO ANTHEM HMO 999999999 1.09 1.75 DIPHENOXYLATE-ATROP 2.5-0.025 49730588_1 CDM 0250 RC 62559-0490-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.09 1.75 DIPHENOXYLATE-ATROP 2.5-0.025 49730588_1 CDM 0250 RC 62559-0490-01 NDC inpatient 1 UN 1.8 1.17 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.09 1.75 DIPHENOXYLATE-ATROP 2.5-0.025 49730588_1 CDM 0250 RC 62559-0490-01 NDC inpatient 1 UN 1.8 1.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.22 67.6 999999999 1.09 1.75 percent of total billed charges GLYCOPYRROLATE 0.2 MG/ML VIAL 49730595_1 CDM 0250 RC 70069-0011-25 NDC inpatient 1 UN 30.38 19.75 AETNA AETNA 24 79 999999999 18.4 29.47 percent of total billed charges GLYCOPYRROLATE 0.2 MG/ML VIAL 49730595_1 CDM 0250 RC 70069-0011-25 NDC inpatient 1 UN 30.38 19.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.75 65 999999999 18.4 29.47 percent of total billed charges GLYCOPYRROLATE 0.2 MG/ML VIAL 49730595_1 CDM 0250 RC 70069-0011-25 NDC inpatient 1 UN 30.38 19.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.47 97 999999999 18.4 29.47 percent of total billed charges GLYCOPYRROLATE 0.2 MG/ML VIAL 49730595_1 CDM 0250 RC 70069-0011-25 NDC inpatient 1 UN 30.38 19.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.7 78 999999999 18.4 29.47 percent of total billed charges GLYCOPYRROLATE 0.2 MG/ML VIAL 49730595_1 CDM 0250 RC 70069-0011-25 NDC inpatient 1 UN 30.38 19.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.96 69 999999999 18.4 29.47 percent of total billed charges GLYCOPYRROLATE 0.2 MG/ML VIAL 49730595_1 CDM 0250 RC 70069-0011-25 NDC inpatient 1 UN 30.38 19.75 SIHO - ALL PLANS SIHO - ALL PLANS 27.34 90 999999999 18.4 29.47 percent of total billed charges GLYCOPYRROLATE 0.2 MG/ML VIAL 49730595_1 CDM 0250 RC 70069-0011-25 NDC inpatient 1 UN 30.38 19.75 UMR - ALL PLANS UMR - ALL PLANS 21.27 70 999999999 18.4 29.47 percent of total billed charges GLYCOPYRROLATE 0.2 MG/ML VIAL 49730595_1 CDM 0250 RC 70069-0011-25 NDC inpatient 1 UN 30.38 19.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.4 60.55 999999999 18.4 29.47 percent of total billed charges GLYCOPYRROLATE 0.2 MG/ML VIAL 49730595_1 CDM 0250 RC 70069-0011-25 NDC inpatient 1 UN 30.38 19.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.4 29.47 GLYCOPYRROLATE 0.2 MG/ML VIAL 49730595_1 CDM 0250 RC 70069-0011-25 NDC inpatient 1 UN 30.38 19.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.4 29.47 GLYCOPYRROLATE 0.2 MG/ML VIAL 49730595_1 CDM 0250 RC 70069-0011-25 NDC inpatient 1 UN 30.38 19.75 ANTHEM HMO ANTHEM HMO 999999999 18.4 29.47 GLYCOPYRROLATE 0.2 MG/ML VIAL 49730595_1 CDM 0250 RC 70069-0011-25 NDC inpatient 1 UN 30.38 19.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.4 29.47 GLYCOPYRROLATE 0.2 MG/ML VIAL 49730595_1 CDM 0250 RC 70069-0011-25 NDC inpatient 1 UN 30.38 19.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.4 29.47 GLYCOPYRROLATE 0.2 MG/ML VIAL 49730595_1 CDM 0250 RC 70069-0011-25 NDC inpatient 1 UN 30.38 19.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.54 67.6 999999999 18.4 29.47 percent of total billed charges FAMOTIDINE 40 MG/5 ML SUSP 49730598_1 CDM 0250 RC 68180-0150-01 NDC inpatient 1 UN 450.92 293.1 AETNA AETNA 356.23 79 999999999 273.03 437.39 percent of total billed charges FAMOTIDINE 40 MG/5 ML SUSP 49730598_1 CDM 0250 RC 68180-0150-01 NDC inpatient 1 UN 450.92 293.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 293.1 65 999999999 273.03 437.39 percent of total billed charges FAMOTIDINE 40 MG/5 ML SUSP 49730598_1 CDM 0250 RC 68180-0150-01 NDC inpatient 1 UN 450.92 293.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 437.39 97 999999999 273.03 437.39 percent of total billed charges FAMOTIDINE 40 MG/5 ML SUSP 49730598_1 CDM 0250 RC 68180-0150-01 NDC inpatient 1 UN 450.92 293.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 351.72 78 999999999 273.03 437.39 percent of total billed charges FAMOTIDINE 40 MG/5 ML SUSP 49730598_1 CDM 0250 RC 68180-0150-01 NDC inpatient 1 UN 450.92 293.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 311.13 69 999999999 273.03 437.39 percent of total billed charges FAMOTIDINE 40 MG/5 ML SUSP 49730598_1 CDM 0250 RC 68180-0150-01 NDC inpatient 1 UN 450.92 293.1 SIHO - ALL PLANS SIHO - ALL PLANS 405.83 90 999999999 273.03 437.39 percent of total billed charges FAMOTIDINE 40 MG/5 ML SUSP 49730598_1 CDM 0250 RC 68180-0150-01 NDC inpatient 1 UN 450.92 293.1 UMR - ALL PLANS UMR - ALL PLANS 315.64 70 999999999 273.03 437.39 percent of total billed charges FAMOTIDINE 40 MG/5 ML SUSP 49730598_1 CDM 0250 RC 68180-0150-01 NDC inpatient 1 UN 450.92 293.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 273.03 60.55 999999999 273.03 437.39 percent of total billed charges FAMOTIDINE 40 MG/5 ML SUSP 49730598_1 CDM 0250 RC 68180-0150-01 NDC inpatient 1 UN 450.92 293.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 273.03 437.39 FAMOTIDINE 40 MG/5 ML SUSP 49730598_1 CDM 0250 RC 68180-0150-01 NDC inpatient 1 UN 450.92 293.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 273.03 437.39 FAMOTIDINE 40 MG/5 ML SUSP 49730598_1 CDM 0250 RC 68180-0150-01 NDC inpatient 1 UN 450.92 293.1 ANTHEM HMO ANTHEM HMO 999999999 273.03 437.39 FAMOTIDINE 40 MG/5 ML SUSP 49730598_1 CDM 0250 RC 68180-0150-01 NDC inpatient 1 UN 450.92 293.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 273.03 437.39 FAMOTIDINE 40 MG/5 ML SUSP 49730598_1 CDM 0250 RC 68180-0150-01 NDC inpatient 1 UN 450.92 293.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 273.03 437.39 FAMOTIDINE 40 MG/5 ML SUSP 49730598_1 CDM 0250 RC 68180-0150-01 NDC inpatient 1 UN 450.92 293.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 304.82 67.6 999999999 273.03 437.39 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 49731596_1 CDM 0250 RC 63323-0596-16 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 AETNA AETNA 459.91 79 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 49731596_1 CDM 0250 RC 63323-0596-16 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 SELF PAY DISCOUNT SELF PAY DISCOUNT 378.41 65 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 49731596_1 CDM 0250 RC 63323-0596-16 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 564.7 97 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 49731596_1 CDM 0250 RC 63323-0596-16 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 HUMANA - ALL PLANS HUMANA - ALL PLANS 454.09 78 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 49731596_1 CDM 0250 RC 63323-0596-16 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 ENCORE - ALL PLANS ENCORE - ALL PLANS 401.7 69 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 49731596_1 CDM 0250 RC 63323-0596-16 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 SIHO - ALL PLANS SIHO - ALL PLANS 523.95 90 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 49731596_1 CDM 0250 RC 63323-0596-16 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 UMR - ALL PLANS UMR - ALL PLANS 407.52 70 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 49731596_1 CDM 0250 RC 63323-0596-16 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 352.5 60.55 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 49731596_1 CDM 0250 RC 63323-0596-16 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 352.5 564.7 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 49731596_1 CDM 0250 RC 63323-0596-16 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 352.5 564.7 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 49731596_1 CDM 0250 RC 63323-0596-16 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 ANTHEM HMO ANTHEM HMO 999999999 352.5 564.7 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 49731596_1 CDM 0250 RC 63323-0596-16 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 352.5 564.7 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 49731596_1 CDM 0250 RC 63323-0596-16 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 UHC - ALL PLANS UHC - ALL PLANS 999999999 352.5 564.7 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 49731596_1 CDM 0250 RC 63323-0596-16 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 CIGNA - ALL PLANS CIGNA - ALL PLANS 393.55 67.6 999999999 352.5 564.7 percent of total billed charges Insertion of needle or tube into vein 49739250_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges Insertion of needle or tube into vein 49739250_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges Insertion of needle or tube into vein 49739250_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges Insertion of needle or tube into vein 49739250_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges Insertion of needle or tube into vein 49739250_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges Insertion of needle or tube into vein 49739250_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges Insertion of needle or tube into vein 49739250_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges Insertion of needle or tube into vein 49739250_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges Insertion of needle or tube into vein 49739250_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 Insertion of needle or tube into vein 49739250_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 Insertion of needle or tube into vein 49739250_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 Insertion of needle or tube into vein 49739250_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 Insertion of needle or tube into vein 49739250_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 Insertion of needle or tube into vein 49739250_1 CDM 0450 RC 36000 HCPCS inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges "Detection test for candida species (yeast), amplified probe technique" 49739515_1 CDM 0311 RC 87481 HCPCS inpatient 157 102.05 AETNA AETNA 124.03 79 999999999 95.06 152.29 percent of total billed charges "Detection test for candida species (yeast), amplified probe technique" 49739515_1 CDM 0311 RC 87481 HCPCS inpatient 157 102.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.05 65 999999999 95.06 152.29 percent of total billed charges "Detection test for candida species (yeast), amplified probe technique" 49739515_1 CDM 0311 RC 87481 HCPCS inpatient 157 102.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 152.29 97 999999999 95.06 152.29 percent of total billed charges "Detection test for candida species (yeast), amplified probe technique" 49739515_1 CDM 0311 RC 87481 HCPCS inpatient 157 102.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 122.46 78 999999999 95.06 152.29 percent of total billed charges "Detection test for candida species (yeast), amplified probe technique" 49739515_1 CDM 0311 RC 87481 HCPCS inpatient 157 102.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 108.33 69 999999999 95.06 152.29 percent of total billed charges "Detection test for candida species (yeast), amplified probe technique" 49739515_1 CDM 0311 RC 87481 HCPCS inpatient 157 102.05 SIHO - ALL PLANS SIHO - ALL PLANS 141.3 90 999999999 95.06 152.29 percent of total billed charges "Detection test for candida species (yeast), amplified probe technique" 49739515_1 CDM 0311 RC 87481 HCPCS inpatient 157 102.05 UMR - ALL PLANS UMR - ALL PLANS 109.9 70 999999999 95.06 152.29 percent of total billed charges "Detection test for candida species (yeast), amplified probe technique" 49739515_1 CDM 0311 RC 87481 HCPCS inpatient 157 102.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.06 60.55 999999999 95.06 152.29 percent of total billed charges "Detection test for candida species (yeast), amplified probe technique" 49739515_1 CDM 0311 RC 87481 HCPCS inpatient 157 102.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.06 152.29 "Detection test for candida species (yeast), amplified probe technique" 49739515_1 CDM 0311 RC 87481 HCPCS inpatient 157 102.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.06 152.29 "Detection test for candida species (yeast), amplified probe technique" 49739515_1 CDM 0311 RC 87481 HCPCS inpatient 157 102.05 ANTHEM HMO ANTHEM HMO 999999999 95.06 152.29 "Detection test for candida species (yeast), amplified probe technique" 49739515_1 CDM 0311 RC 87481 HCPCS inpatient 157 102.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.06 152.29 "Detection test for candida species (yeast), amplified probe technique" 49739515_1 CDM 0311 RC 87481 HCPCS inpatient 157 102.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.06 152.29 "Detection test for candida species (yeast), amplified probe technique" 49739515_1 CDM 0311 RC 87481 HCPCS inpatient 157 102.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.13 67.6 999999999 95.06 152.29 percent of total billed charges Simple insertion of temporary bladder tube 49740177_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 AETNA AETNA 190.39 79 999999999 145.93 233.77 percent of total billed charges Simple insertion of temporary bladder tube 49740177_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 156.65 65 999999999 145.93 233.77 percent of total billed charges Simple insertion of temporary bladder tube 49740177_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 233.77 97 999999999 145.93 233.77 percent of total billed charges Simple insertion of temporary bladder tube 49740177_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.98 78 999999999 145.93 233.77 percent of total billed charges Simple insertion of temporary bladder tube 49740177_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 166.29 69 999999999 145.93 233.77 percent of total billed charges Simple insertion of temporary bladder tube 49740177_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 SIHO - ALL PLANS SIHO - ALL PLANS 216.9 90 999999999 145.93 233.77 percent of total billed charges Simple insertion of temporary bladder tube 49740177_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 UMR - ALL PLANS UMR - ALL PLANS 168.7 70 999999999 145.93 233.77 percent of total billed charges Simple insertion of temporary bladder tube 49740177_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.93 60.55 999999999 145.93 233.77 percent of total billed charges Simple insertion of temporary bladder tube 49740177_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.93 233.77 Simple insertion of temporary bladder tube 49740177_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.93 233.77 Simple insertion of temporary bladder tube 49740177_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 ANTHEM HMO ANTHEM HMO 999999999 145.93 233.77 Simple insertion of temporary bladder tube 49740177_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.93 233.77 Simple insertion of temporary bladder tube 49740177_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.93 233.77 Simple insertion of temporary bladder tube 49740177_1 CDM 0450 RC 51702 HCPCS inpatient 241 156.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.92 67.6 999999999 145.93 233.77 percent of total billed charges Insertion of needle for infusion into bone 49740183_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 AETNA AETNA 293.09 79 999999999 224.64 359.87 percent of total billed charges Insertion of needle for infusion into bone 49740183_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 241.15 65 999999999 224.64 359.87 percent of total billed charges Insertion of needle for infusion into bone 49740183_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 359.87 97 999999999 224.64 359.87 percent of total billed charges Insertion of needle for infusion into bone 49740183_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 289.38 78 999999999 224.64 359.87 percent of total billed charges Insertion of needle for infusion into bone 49740183_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 255.99 69 999999999 224.64 359.87 percent of total billed charges Insertion of needle for infusion into bone 49740183_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 SIHO - ALL PLANS SIHO - ALL PLANS 333.9 90 999999999 224.64 359.87 percent of total billed charges Insertion of needle for infusion into bone 49740183_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 UMR - ALL PLANS UMR - ALL PLANS 259.7 70 999999999 224.64 359.87 percent of total billed charges Insertion of needle for infusion into bone 49740183_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 224.64 60.55 999999999 224.64 359.87 percent of total billed charges Insertion of needle for infusion into bone 49740183_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 224.64 359.87 Insertion of needle for infusion into bone 49740183_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 224.64 359.87 Insertion of needle for infusion into bone 49740183_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 ANTHEM HMO ANTHEM HMO 999999999 224.64 359.87 Insertion of needle for infusion into bone 49740183_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 224.64 359.87 Insertion of needle for infusion into bone 49740183_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 224.64 359.87 Insertion of needle for infusion into bone 49740183_1 CDM 0450 RC 36680 HCPCS inpatient 371 241.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 250.8 67.6 999999999 224.64 359.87 percent of total billed charges Simple bladder irrigation and/or instillation 49740188_1 CDM 0450 RC 51700 HCPCS inpatient 446 289.9 AETNA AETNA 352.34 79 999999999 270.05 432.62 percent of total billed charges Simple bladder irrigation and/or instillation 49740188_1 CDM 0450 RC 51700 HCPCS inpatient 446 289.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 289.9 65 999999999 270.05 432.62 percent of total billed charges Simple bladder irrigation and/or instillation 49740188_1 CDM 0450 RC 51700 HCPCS inpatient 446 289.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 432.62 97 999999999 270.05 432.62 percent of total billed charges Simple bladder irrigation and/or instillation 49740188_1 CDM 0450 RC 51700 HCPCS inpatient 446 289.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 347.88 78 999999999 270.05 432.62 percent of total billed charges Simple bladder irrigation and/or instillation 49740188_1 CDM 0450 RC 51700 HCPCS inpatient 446 289.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 307.74 69 999999999 270.05 432.62 percent of total billed charges Simple bladder irrigation and/or instillation 49740188_1 CDM 0450 RC 51700 HCPCS inpatient 446 289.9 SIHO - ALL PLANS SIHO - ALL PLANS 401.4 90 999999999 270.05 432.62 percent of total billed charges Simple bladder irrigation and/or instillation 49740188_1 CDM 0450 RC 51700 HCPCS inpatient 446 289.9 UMR - ALL PLANS UMR - ALL PLANS 312.2 70 999999999 270.05 432.62 percent of total billed charges Simple bladder irrigation and/or instillation 49740188_1 CDM 0450 RC 51700 HCPCS inpatient 446 289.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 270.05 60.55 999999999 270.05 432.62 percent of total billed charges Simple bladder irrigation and/or instillation 49740188_1 CDM 0450 RC 51700 HCPCS inpatient 446 289.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 270.05 432.62 Simple bladder irrigation and/or instillation 49740188_1 CDM 0450 RC 51700 HCPCS inpatient 446 289.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 270.05 432.62 Simple bladder irrigation and/or instillation 49740188_1 CDM 0450 RC 51700 HCPCS inpatient 446 289.9 ANTHEM HMO ANTHEM HMO 999999999 270.05 432.62 Simple bladder irrigation and/or instillation 49740188_1 CDM 0450 RC 51700 HCPCS inpatient 446 289.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 270.05 432.62 Simple bladder irrigation and/or instillation 49740188_1 CDM 0450 RC 51700 HCPCS inpatient 446 289.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 270.05 432.62 Simple bladder irrigation and/or instillation 49740188_1 CDM 0450 RC 51700 HCPCS inpatient 446 289.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 301.5 67.6 999999999 270.05 432.62 percent of total billed charges Drainage of fluid from chest cavity with insertion of indwelling tube using imaging guidance 49740193_1 CDM 0450 RC 32557 HCPCS inpatient 1704 1107.6 AETNA AETNA 1346.16 79 999999999 1031.77 1652.88 percent of total billed charges Drainage of fluid from chest cavity with insertion of indwelling tube using imaging guidance 49740193_1 CDM 0450 RC 32557 HCPCS inpatient 1704 1107.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1107.6 65 999999999 1031.77 1652.88 percent of total billed charges Drainage of fluid from chest cavity with insertion of indwelling tube using imaging guidance 49740193_1 CDM 0450 RC 32557 HCPCS inpatient 1704 1107.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1652.88 97 999999999 1031.77 1652.88 percent of total billed charges Drainage of fluid from chest cavity with insertion of indwelling tube using imaging guidance 49740193_1 CDM 0450 RC 32557 HCPCS inpatient 1704 1107.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1329.12 78 999999999 1031.77 1652.88 percent of total billed charges Drainage of fluid from chest cavity with insertion of indwelling tube using imaging guidance 49740193_1 CDM 0450 RC 32557 HCPCS inpatient 1704 1107.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1175.76 69 999999999 1031.77 1652.88 percent of total billed charges Drainage of fluid from chest cavity with insertion of indwelling tube using imaging guidance 49740193_1 CDM 0450 RC 32557 HCPCS inpatient 1704 1107.6 SIHO - ALL PLANS SIHO - ALL PLANS 1533.6 90 999999999 1031.77 1652.88 percent of total billed charges Drainage of fluid from chest cavity with insertion of indwelling tube using imaging guidance 49740193_1 CDM 0450 RC 32557 HCPCS inpatient 1704 1107.6 UMR - ALL PLANS UMR - ALL PLANS 1192.8 70 999999999 1031.77 1652.88 percent of total billed charges Drainage of fluid from chest cavity with insertion of indwelling tube using imaging guidance 49740193_1 CDM 0450 RC 32557 HCPCS inpatient 1704 1107.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1031.77 60.55 999999999 1031.77 1652.88 percent of total billed charges Drainage of fluid from chest cavity with insertion of indwelling tube using imaging guidance 49740193_1 CDM 0450 RC 32557 HCPCS inpatient 1704 1107.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1031.77 1652.88 Drainage of fluid from chest cavity with insertion of indwelling tube using imaging guidance 49740193_1 CDM 0450 RC 32557 HCPCS inpatient 1704 1107.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1031.77 1652.88 Drainage of fluid from chest cavity with insertion of indwelling tube using imaging guidance 49740193_1 CDM 0450 RC 32557 HCPCS inpatient 1704 1107.6 ANTHEM HMO ANTHEM HMO 999999999 1031.77 1652.88 Drainage of fluid from chest cavity with insertion of indwelling tube using imaging guidance 49740193_1 CDM 0450 RC 32557 HCPCS inpatient 1704 1107.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1031.77 1652.88 Drainage of fluid from chest cavity with insertion of indwelling tube using imaging guidance 49740193_1 CDM 0450 RC 32557 HCPCS inpatient 1704 1107.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1031.77 1652.88 Drainage of fluid from chest cavity with insertion of indwelling tube using imaging guidance 49740193_1 CDM 0450 RC 32557 HCPCS inpatient 1704 1107.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1151.9 67.6 999999999 1031.77 1652.88 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 49740204_1 CDM 0450 RC 36556 HCPCS inpatient 4394 2856.1 AETNA AETNA 3471.26 79 999999999 2660.57 4262.18 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 49740204_1 CDM 0450 RC 36556 HCPCS inpatient 4394 2856.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 2856.1 65 999999999 2660.57 4262.18 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 49740204_1 CDM 0450 RC 36556 HCPCS inpatient 4394 2856.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4262.18 97 999999999 2660.57 4262.18 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 49740204_1 CDM 0450 RC 36556 HCPCS inpatient 4394 2856.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 3427.32 78 999999999 2660.57 4262.18 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 49740204_1 CDM 0450 RC 36556 HCPCS inpatient 4394 2856.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 3031.86 69 999999999 2660.57 4262.18 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 49740204_1 CDM 0450 RC 36556 HCPCS inpatient 4394 2856.1 SIHO - ALL PLANS SIHO - ALL PLANS 3954.6 90 999999999 2660.57 4262.18 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 49740204_1 CDM 0450 RC 36556 HCPCS inpatient 4394 2856.1 UMR - ALL PLANS UMR - ALL PLANS 3075.8 70 999999999 2660.57 4262.18 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 49740204_1 CDM 0450 RC 36556 HCPCS inpatient 4394 2856.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2660.57 60.55 999999999 2660.57 4262.18 percent of total billed charges Insertion of non-tunneled central venous tube for infusion (5 years or older) 49740204_1 CDM 0450 RC 36556 HCPCS inpatient 4394 2856.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2660.57 4262.18 Insertion of non-tunneled central venous tube for infusion (5 years or older) 49740204_1 CDM 0450 RC 36556 HCPCS inpatient 4394 2856.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2660.57 4262.18 Insertion of non-tunneled central venous tube for infusion (5 years or older) 49740204_1 CDM 0450 RC 36556 HCPCS inpatient 4394 2856.1 ANTHEM HMO ANTHEM HMO 999999999 2660.57 4262.18 Insertion of non-tunneled central venous tube for infusion (5 years or older) 49740204_1 CDM 0450 RC 36556 HCPCS inpatient 4394 2856.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2660.57 4262.18 Insertion of non-tunneled central venous tube for infusion (5 years or older) 49740204_1 CDM 0450 RC 36556 HCPCS inpatient 4394 2856.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 2660.57 4262.18 Insertion of non-tunneled central venous tube for infusion (5 years or older) 49740204_1 CDM 0450 RC 36556 HCPCS inpatient 4394 2856.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 2970.34 67.6 999999999 2660.57 4262.18 percent of total billed charges Removal of impacted ear wax by washing 49740210_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 AETNA AETNA 114.55 79 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 49740210_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.25 65 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 49740210_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 140.65 97 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 49740210_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.1 78 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 49740210_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.05 69 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 49740210_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 SIHO - ALL PLANS SIHO - ALL PLANS 130.5 90 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 49740210_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 UMR - ALL PLANS UMR - ALL PLANS 101.5 70 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 49740210_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.8 60.55 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 49740210_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.8 140.65 Removal of impacted ear wax by washing 49740210_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.8 140.65 Removal of impacted ear wax by washing 49740210_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 ANTHEM HMO ANTHEM HMO 999999999 87.8 140.65 Removal of impacted ear wax by washing 49740210_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.8 140.65 Removal of impacted ear wax by washing 49740210_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.8 140.65 Removal of impacted ear wax by washing 49740210_1 CDM 0450 RC 69209 HCPCS inpatient 145 94.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.02 67.6 999999999 87.8 140.65 percent of total billed charges Removal of impacted ear wax by washing 49740211_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 AETNA AETNA 122.45 79 999999999 93.85 150.35 percent of total billed charges Removal of impacted ear wax by washing 49740211_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.75 65 999999999 93.85 150.35 percent of total billed charges Removal of impacted ear wax by washing 49740211_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 150.35 97 999999999 93.85 150.35 percent of total billed charges Removal of impacted ear wax by washing 49740211_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.9 78 999999999 93.85 150.35 percent of total billed charges Removal of impacted ear wax by washing 49740211_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.95 69 999999999 93.85 150.35 percent of total billed charges Removal of impacted ear wax by washing 49740211_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 SIHO - ALL PLANS SIHO - ALL PLANS 139.5 90 999999999 93.85 150.35 percent of total billed charges Removal of impacted ear wax by washing 49740211_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 UMR - ALL PLANS UMR - ALL PLANS 108.5 70 999999999 93.85 150.35 percent of total billed charges Removal of impacted ear wax by washing 49740211_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.85 60.55 999999999 93.85 150.35 percent of total billed charges Removal of impacted ear wax by washing 49740211_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.85 150.35 Removal of impacted ear wax by washing 49740211_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.85 150.35 Removal of impacted ear wax by washing 49740211_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 ANTHEM HMO ANTHEM HMO 999999999 93.85 150.35 Removal of impacted ear wax by washing 49740211_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.85 150.35 Removal of impacted ear wax by washing 49740211_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.85 150.35 Removal of impacted ear wax by washing 49740211_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.78 67.6 999999999 93.85 150.35 percent of total billed charges Removal of impacted ear wax by washing 49740212_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 AETNA AETNA 122.45 79 999999999 93.85 150.35 percent of total billed charges Removal of impacted ear wax by washing 49740212_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.75 65 999999999 93.85 150.35 percent of total billed charges Removal of impacted ear wax by washing 49740212_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 150.35 97 999999999 93.85 150.35 percent of total billed charges Removal of impacted ear wax by washing 49740212_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.9 78 999999999 93.85 150.35 percent of total billed charges Removal of impacted ear wax by washing 49740212_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.95 69 999999999 93.85 150.35 percent of total billed charges Removal of impacted ear wax by washing 49740212_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 SIHO - ALL PLANS SIHO - ALL PLANS 139.5 90 999999999 93.85 150.35 percent of total billed charges Removal of impacted ear wax by washing 49740212_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 UMR - ALL PLANS UMR - ALL PLANS 108.5 70 999999999 93.85 150.35 percent of total billed charges Removal of impacted ear wax by washing 49740212_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.85 60.55 999999999 93.85 150.35 percent of total billed charges Removal of impacted ear wax by washing 49740212_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.85 150.35 Removal of impacted ear wax by washing 49740212_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.85 150.35 Removal of impacted ear wax by washing 49740212_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 ANTHEM HMO ANTHEM HMO 999999999 93.85 150.35 Removal of impacted ear wax by washing 49740212_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.85 150.35 Removal of impacted ear wax by washing 49740212_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.85 150.35 Removal of impacted ear wax by washing 49740212_1 CDM 0450 RC 69209 HCPCS inpatient 155 100.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.78 67.6 999999999 93.85 150.35 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), types 16 and 18 only" 49740573_1 CDM 0312 RC 87625 HCPCS inpatient 118 76.7 AETNA AETNA 93.22 79 999999999 71.45 114.46 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), types 16 and 18 only" 49740573_1 CDM 0312 RC 87625 HCPCS inpatient 118 76.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 76.7 65 999999999 71.45 114.46 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), types 16 and 18 only" 49740573_1 CDM 0312 RC 87625 HCPCS inpatient 118 76.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 114.46 97 999999999 71.45 114.46 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), types 16 and 18 only" 49740573_1 CDM 0312 RC 87625 HCPCS inpatient 118 76.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.04 78 999999999 71.45 114.46 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), types 16 and 18 only" 49740573_1 CDM 0312 RC 87625 HCPCS inpatient 118 76.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 81.42 69 999999999 71.45 114.46 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), types 16 and 18 only" 49740573_1 CDM 0312 RC 87625 HCPCS inpatient 118 76.7 SIHO - ALL PLANS SIHO - ALL PLANS 106.2 90 999999999 71.45 114.46 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), types 16 and 18 only" 49740573_1 CDM 0312 RC 87625 HCPCS inpatient 118 76.7 UMR - ALL PLANS UMR - ALL PLANS 82.6 70 999999999 71.45 114.46 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), types 16 and 18 only" 49740573_1 CDM 0312 RC 87625 HCPCS inpatient 118 76.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 71.45 60.55 999999999 71.45 114.46 percent of total billed charges "Detection test by nucleic acid for human papillomavirus (hpv), types 16 and 18 only" 49740573_1 CDM 0312 RC 87625 HCPCS inpatient 118 76.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 71.45 114.46 "Detection test by nucleic acid for human papillomavirus (hpv), types 16 and 18 only" 49740573_1 CDM 0312 RC 87625 HCPCS inpatient 118 76.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 71.45 114.46 "Detection test by nucleic acid for human papillomavirus (hpv), types 16 and 18 only" 49740573_1 CDM 0312 RC 87625 HCPCS inpatient 118 76.7 ANTHEM HMO ANTHEM HMO 999999999 71.45 114.46 "Detection test by nucleic acid for human papillomavirus (hpv), types 16 and 18 only" 49740573_1 CDM 0312 RC 87625 HCPCS inpatient 118 76.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 71.45 114.46 "Detection test by nucleic acid for human papillomavirus (hpv), types 16 and 18 only" 49740573_1 CDM 0312 RC 87625 HCPCS inpatient 118 76.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 71.45 114.46 "Detection test by nucleic acid for human papillomavirus (hpv), types 16 and 18 only" 49740573_1 CDM 0312 RC 87625 HCPCS inpatient 118 76.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 79.77 67.6 999999999 71.45 114.46 percent of total billed charges ENALAPRILAT 2.5 MG/2 ML VIAL 49740610_1 CDM 0250 RC 00143-9786-10 NDC inpatient 1 UN 50.5 32.83 AETNA AETNA 39.9 79 999999999 30.58 48.99 percent of total billed charges ENALAPRILAT 2.5 MG/2 ML VIAL 49740610_1 CDM 0250 RC 00143-9786-10 NDC inpatient 1 UN 50.5 32.83 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.83 65 999999999 30.58 48.99 percent of total billed charges ENALAPRILAT 2.5 MG/2 ML VIAL 49740610_1 CDM 0250 RC 00143-9786-10 NDC inpatient 1 UN 50.5 32.83 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.99 97 999999999 30.58 48.99 percent of total billed charges ENALAPRILAT 2.5 MG/2 ML VIAL 49740610_1 CDM 0250 RC 00143-9786-10 NDC inpatient 1 UN 50.5 32.83 HUMANA - ALL PLANS HUMANA - ALL PLANS 39.39 78 999999999 30.58 48.99 percent of total billed charges ENALAPRILAT 2.5 MG/2 ML VIAL 49740610_1 CDM 0250 RC 00143-9786-10 NDC inpatient 1 UN 50.5 32.83 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.85 69 999999999 30.58 48.99 percent of total billed charges ENALAPRILAT 2.5 MG/2 ML VIAL 49740610_1 CDM 0250 RC 00143-9786-10 NDC inpatient 1 UN 50.5 32.83 SIHO - ALL PLANS SIHO - ALL PLANS 45.45 90 999999999 30.58 48.99 percent of total billed charges ENALAPRILAT 2.5 MG/2 ML VIAL 49740610_1 CDM 0250 RC 00143-9786-10 NDC inpatient 1 UN 50.5 32.83 UMR - ALL PLANS UMR - ALL PLANS 35.35 70 999999999 30.58 48.99 percent of total billed charges ENALAPRILAT 2.5 MG/2 ML VIAL 49740610_1 CDM 0250 RC 00143-9786-10 NDC inpatient 1 UN 50.5 32.83 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.58 60.55 999999999 30.58 48.99 percent of total billed charges ENALAPRILAT 2.5 MG/2 ML VIAL 49740610_1 CDM 0250 RC 00143-9786-10 NDC inpatient 1 UN 50.5 32.83 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.58 48.99 ENALAPRILAT 2.5 MG/2 ML VIAL 49740610_1 CDM 0250 RC 00143-9786-10 NDC inpatient 1 UN 50.5 32.83 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.58 48.99 ENALAPRILAT 2.5 MG/2 ML VIAL 49740610_1 CDM 0250 RC 00143-9786-10 NDC inpatient 1 UN 50.5 32.83 ANTHEM HMO ANTHEM HMO 999999999 30.58 48.99 ENALAPRILAT 2.5 MG/2 ML VIAL 49740610_1 CDM 0250 RC 00143-9786-10 NDC inpatient 1 UN 50.5 32.83 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.58 48.99 ENALAPRILAT 2.5 MG/2 ML VIAL 49740610_1 CDM 0250 RC 00143-9786-10 NDC inpatient 1 UN 50.5 32.83 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.58 48.99 ENALAPRILAT 2.5 MG/2 ML VIAL 49740610_1 CDM 0250 RC 00143-9786-10 NDC inpatient 1 UN 50.5 32.83 CIGNA - ALL PLANS CIGNA - ALL PLANS 34.14 67.6 999999999 30.58 48.99 percent of total billed charges DIPHENHYDRAMINE 25 MG/10ML CUP 49741265_1 CDM 0250 RC 00121-0978-10 NDC inpatient 1 UN 4.55 2.96 AETNA AETNA 3.59 79 999999999 2.76 4.41 percent of total billed charges DIPHENHYDRAMINE 25 MG/10ML CUP 49741265_1 CDM 0250 RC 00121-0978-10 NDC inpatient 1 UN 4.55 2.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.96 65 999999999 2.76 4.41 percent of total billed charges DIPHENHYDRAMINE 25 MG/10ML CUP 49741265_1 CDM 0250 RC 00121-0978-10 NDC inpatient 1 UN 4.55 2.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4.41 97 999999999 2.76 4.41 percent of total billed charges DIPHENHYDRAMINE 25 MG/10ML CUP 49741265_1 CDM 0250 RC 00121-0978-10 NDC inpatient 1 UN 4.55 2.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.55 78 999999999 2.76 4.41 percent of total billed charges DIPHENHYDRAMINE 25 MG/10ML CUP 49741265_1 CDM 0250 RC 00121-0978-10 NDC inpatient 1 UN 4.55 2.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.14 69 999999999 2.76 4.41 percent of total billed charges DIPHENHYDRAMINE 25 MG/10ML CUP 49741265_1 CDM 0250 RC 00121-0978-10 NDC inpatient 1 UN 4.55 2.96 SIHO - ALL PLANS SIHO - ALL PLANS 4.1 90 999999999 2.76 4.41 percent of total billed charges DIPHENHYDRAMINE 25 MG/10ML CUP 49741265_1 CDM 0250 RC 00121-0978-10 NDC inpatient 1 UN 4.55 2.96 UMR - ALL PLANS UMR - ALL PLANS 3.19 70 999999999 2.76 4.41 percent of total billed charges DIPHENHYDRAMINE 25 MG/10ML CUP 49741265_1 CDM 0250 RC 00121-0978-10 NDC inpatient 1 UN 4.55 2.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.76 60.55 999999999 2.76 4.41 percent of total billed charges DIPHENHYDRAMINE 25 MG/10ML CUP 49741265_1 CDM 0250 RC 00121-0978-10 NDC inpatient 1 UN 4.55 2.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.76 4.41 DIPHENHYDRAMINE 25 MG/10ML CUP 49741265_1 CDM 0250 RC 00121-0978-10 NDC inpatient 1 UN 4.55 2.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.76 4.41 DIPHENHYDRAMINE 25 MG/10ML CUP 49741265_1 CDM 0250 RC 00121-0978-10 NDC inpatient 1 UN 4.55 2.96 ANTHEM HMO ANTHEM HMO 999999999 2.76 4.41 DIPHENHYDRAMINE 25 MG/10ML CUP 49741265_1 CDM 0250 RC 00121-0978-10 NDC inpatient 1 UN 4.55 2.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.76 4.41 DIPHENHYDRAMINE 25 MG/10ML CUP 49741265_1 CDM 0250 RC 00121-0978-10 NDC inpatient 1 UN 4.55 2.96 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.76 4.41 DIPHENHYDRAMINE 25 MG/10ML CUP 49741265_1 CDM 0250 RC 00121-0978-10 NDC inpatient 1 UN 4.55 2.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.08 67.6 999999999 2.76 4.41 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 49741271_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 AETNA AETNA 121.66 79 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 49741271_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.1 65 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 49741271_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 149.38 97 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 49741271_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.12 78 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 49741271_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.26 69 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 49741271_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 SIHO - ALL PLANS SIHO - ALL PLANS 138.6 90 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 49741271_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 UMR - ALL PLANS UMR - ALL PLANS 107.8 70 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 49741271_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.25 60.55 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 49741271_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.25 149.38 Analysis for antibody to HIV-1 and HIV-2 virus 49741271_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.25 149.38 Analysis for antibody to HIV-1 and HIV-2 virus 49741271_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 ANTHEM HMO ANTHEM HMO 999999999 93.25 149.38 Analysis for antibody to HIV-1 and HIV-2 virus 49741271_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.25 149.38 Analysis for antibody to HIV-1 and HIV-2 virus 49741271_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.25 149.38 Analysis for antibody to HIV-1 and HIV-2 virus 49741271_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.1 67.6 999999999 93.25 149.38 percent of total billed charges "INJECTION, DOPAMINE HCL, 40 MG" 49741277_1 CDM 0258 RC 00409-7809-22 NDC J1265 HCPCS inpatient 1 UN 81.66 53.08 AETNA AETNA 64.51 79 999999999 49.45 79.21 percent of total billed charges "INJECTION, DOPAMINE HCL, 40 MG" 49741277_1 CDM 0258 RC 00409-7809-22 NDC J1265 HCPCS inpatient 1 UN 81.66 53.08 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.08 65 999999999 49.45 79.21 percent of total billed charges "INJECTION, DOPAMINE HCL, 40 MG" 49741277_1 CDM 0258 RC 00409-7809-22 NDC J1265 HCPCS inpatient 1 UN 81.66 53.08 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.21 97 999999999 49.45 79.21 percent of total billed charges "INJECTION, DOPAMINE HCL, 40 MG" 49741277_1 CDM 0258 RC 00409-7809-22 NDC J1265 HCPCS inpatient 1 UN 81.66 53.08 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.69 78 999999999 49.45 79.21 percent of total billed charges "INJECTION, DOPAMINE HCL, 40 MG" 49741277_1 CDM 0258 RC 00409-7809-22 NDC J1265 HCPCS inpatient 1 UN 81.66 53.08 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.35 69 999999999 49.45 79.21 percent of total billed charges "INJECTION, DOPAMINE HCL, 40 MG" 49741277_1 CDM 0258 RC 00409-7809-22 NDC J1265 HCPCS inpatient 1 UN 81.66 53.08 SIHO - ALL PLANS SIHO - ALL PLANS 73.49 90 999999999 49.45 79.21 percent of total billed charges "INJECTION, DOPAMINE HCL, 40 MG" 49741277_1 CDM 0258 RC 00409-7809-22 NDC J1265 HCPCS inpatient 1 UN 81.66 53.08 UMR - ALL PLANS UMR - ALL PLANS 57.16 70 999999999 49.45 79.21 percent of total billed charges "INJECTION, DOPAMINE HCL, 40 MG" 49741277_1 CDM 0258 RC 00409-7809-22 NDC J1265 HCPCS inpatient 1 UN 81.66 53.08 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.45 60.55 999999999 49.45 79.21 percent of total billed charges "INJECTION, DOPAMINE HCL, 40 MG" 49741277_1 CDM 0258 RC 00409-7809-22 NDC J1265 HCPCS inpatient 1 UN 81.66 53.08 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.45 79.21 "INJECTION, DOPAMINE HCL, 40 MG" 49741277_1 CDM 0258 RC 00409-7809-22 NDC J1265 HCPCS inpatient 1 UN 81.66 53.08 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.45 79.21 "INJECTION, DOPAMINE HCL, 40 MG" 49741277_1 CDM 0258 RC 00409-7809-22 NDC J1265 HCPCS inpatient 1 UN 81.66 53.08 ANTHEM HMO ANTHEM HMO 999999999 49.45 79.21 "INJECTION, DOPAMINE HCL, 40 MG" 49741277_1 CDM 0258 RC 00409-7809-22 NDC J1265 HCPCS inpatient 1 UN 81.66 53.08 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.45 79.21 "INJECTION, DOPAMINE HCL, 40 MG" 49741277_1 CDM 0258 RC 00409-7809-22 NDC J1265 HCPCS inpatient 1 UN 81.66 53.08 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.45 79.21 "INJECTION, DOPAMINE HCL, 40 MG" 49741277_1 CDM 0258 RC 00409-7809-22 NDC J1265 HCPCS inpatient 1 UN 81.66 53.08 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.2 67.6 999999999 49.45 79.21 percent of total billed charges SODIUM CHLORIDE 3% VIAL 49741286_1 CDM 0250 RC 00487-9003-60 NDC inpatient 1 UN 11.34 7.37 AETNA AETNA 8.96 79 999999999 6.87 11 percent of total billed charges SODIUM CHLORIDE 3% VIAL 49741286_1 CDM 0250 RC 00487-9003-60 NDC inpatient 1 UN 11.34 7.37 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.37 65 999999999 6.87 11 percent of total billed charges SODIUM CHLORIDE 3% VIAL 49741286_1 CDM 0250 RC 00487-9003-60 NDC inpatient 1 UN 11.34 7.37 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11 97 999999999 6.87 11 percent of total billed charges SODIUM CHLORIDE 3% VIAL 49741286_1 CDM 0250 RC 00487-9003-60 NDC inpatient 1 UN 11.34 7.37 HUMANA - ALL PLANS HUMANA - ALL PLANS 8.85 78 999999999 6.87 11 percent of total billed charges SODIUM CHLORIDE 3% VIAL 49741286_1 CDM 0250 RC 00487-9003-60 NDC inpatient 1 UN 11.34 7.37 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.82 69 999999999 6.87 11 percent of total billed charges SODIUM CHLORIDE 3% VIAL 49741286_1 CDM 0250 RC 00487-9003-60 NDC inpatient 1 UN 11.34 7.37 SIHO - ALL PLANS SIHO - ALL PLANS 10.21 90 999999999 6.87 11 percent of total billed charges SODIUM CHLORIDE 3% VIAL 49741286_1 CDM 0250 RC 00487-9003-60 NDC inpatient 1 UN 11.34 7.37 UMR - ALL PLANS UMR - ALL PLANS 7.94 70 999999999 6.87 11 percent of total billed charges SODIUM CHLORIDE 3% VIAL 49741286_1 CDM 0250 RC 00487-9003-60 NDC inpatient 1 UN 11.34 7.37 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.87 60.55 999999999 6.87 11 percent of total billed charges SODIUM CHLORIDE 3% VIAL 49741286_1 CDM 0250 RC 00487-9003-60 NDC inpatient 1 UN 11.34 7.37 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.87 11 SODIUM CHLORIDE 3% VIAL 49741286_1 CDM 0250 RC 00487-9003-60 NDC inpatient 1 UN 11.34 7.37 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.87 11 SODIUM CHLORIDE 3% VIAL 49741286_1 CDM 0250 RC 00487-9003-60 NDC inpatient 1 UN 11.34 7.37 ANTHEM HMO ANTHEM HMO 999999999 6.87 11 SODIUM CHLORIDE 3% VIAL 49741286_1 CDM 0250 RC 00487-9003-60 NDC inpatient 1 UN 11.34 7.37 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.87 11 SODIUM CHLORIDE 3% VIAL 49741286_1 CDM 0250 RC 00487-9003-60 NDC inpatient 1 UN 11.34 7.37 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.87 11 SODIUM CHLORIDE 3% VIAL 49741286_1 CDM 0250 RC 00487-9003-60 NDC inpatient 1 UN 11.34 7.37 CIGNA - ALL PLANS CIGNA - ALL PLANS 7.67 67.6 999999999 6.87 11 percent of total billed charges Screening test for pathogenic organisms 49741923_1 CDM 0306 RC 87081 HCPCS inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges Screening test for pathogenic organisms 49741923_1 CDM 0306 RC 87081 HCPCS inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges Screening test for pathogenic organisms 49741923_1 CDM 0306 RC 87081 HCPCS inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges Screening test for pathogenic organisms 49741923_1 CDM 0306 RC 87081 HCPCS inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges Screening test for pathogenic organisms 49741923_1 CDM 0306 RC 87081 HCPCS inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges Screening test for pathogenic organisms 49741923_1 CDM 0306 RC 87081 HCPCS inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges Screening test for pathogenic organisms 49741923_1 CDM 0306 RC 87081 HCPCS inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges Screening test for pathogenic organisms 49741923_1 CDM 0306 RC 87081 HCPCS inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges Screening test for pathogenic organisms 49741923_1 CDM 0306 RC 87081 HCPCS inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 Screening test for pathogenic organisms 49741923_1 CDM 0306 RC 87081 HCPCS inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 Screening test for pathogenic organisms 49741923_1 CDM 0306 RC 87081 HCPCS inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 Screening test for pathogenic organisms 49741923_1 CDM 0306 RC 87081 HCPCS inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 Screening test for pathogenic organisms 49741923_1 CDM 0306 RC 87081 HCPCS inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 Screening test for pathogenic organisms 49741923_1 CDM 0306 RC 87081 HCPCS inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges Vitamin measurement 49742626_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 AETNA AETNA 156.42 79 999999999 119.89 192.06 percent of total billed charges Vitamin measurement 49742626_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.7 65 999999999 119.89 192.06 percent of total billed charges Vitamin measurement 49742626_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 192.06 97 999999999 119.89 192.06 percent of total billed charges Vitamin measurement 49742626_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 154.44 78 999999999 119.89 192.06 percent of total billed charges Vitamin measurement 49742626_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 136.62 69 999999999 119.89 192.06 percent of total billed charges Vitamin measurement 49742626_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 SIHO - ALL PLANS SIHO - ALL PLANS 178.2 90 999999999 119.89 192.06 percent of total billed charges Vitamin measurement 49742626_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 UMR - ALL PLANS UMR - ALL PLANS 138.6 70 999999999 119.89 192.06 percent of total billed charges Vitamin measurement 49742626_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.89 60.55 999999999 119.89 192.06 percent of total billed charges Vitamin measurement 49742626_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.89 192.06 Vitamin measurement 49742626_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.89 192.06 Vitamin measurement 49742626_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 ANTHEM HMO ANTHEM HMO 999999999 119.89 192.06 Vitamin measurement 49742626_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.89 192.06 Vitamin measurement 49742626_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.89 192.06 Vitamin measurement 49742626_1 CDM 0301 RC 84591 HCPCS inpatient 198 128.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.85 67.6 999999999 119.89 192.06 percent of total billed charges FLUTICASONE PROP 50 MCG SPRAY 49743085_1 CDM 0250 RC 60505-0829-01 NDC inpatient 1 UN 18.15 11.8 AETNA AETNA 14.34 79 999999999 10.99 17.61 percent of total billed charges FLUTICASONE PROP 50 MCG SPRAY 49743085_1 CDM 0250 RC 60505-0829-01 NDC inpatient 1 UN 18.15 11.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.8 65 999999999 10.99 17.61 percent of total billed charges FLUTICASONE PROP 50 MCG SPRAY 49743085_1 CDM 0250 RC 60505-0829-01 NDC inpatient 1 UN 18.15 11.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.61 97 999999999 10.99 17.61 percent of total billed charges FLUTICASONE PROP 50 MCG SPRAY 49743085_1 CDM 0250 RC 60505-0829-01 NDC inpatient 1 UN 18.15 11.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.16 78 999999999 10.99 17.61 percent of total billed charges FLUTICASONE PROP 50 MCG SPRAY 49743085_1 CDM 0250 RC 60505-0829-01 NDC inpatient 1 UN 18.15 11.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.52 69 999999999 10.99 17.61 percent of total billed charges FLUTICASONE PROP 50 MCG SPRAY 49743085_1 CDM 0250 RC 60505-0829-01 NDC inpatient 1 UN 18.15 11.8 SIHO - ALL PLANS SIHO - ALL PLANS 16.34 90 999999999 10.99 17.61 percent of total billed charges FLUTICASONE PROP 50 MCG SPRAY 49743085_1 CDM 0250 RC 60505-0829-01 NDC inpatient 1 UN 18.15 11.8 UMR - ALL PLANS UMR - ALL PLANS 12.71 70 999999999 10.99 17.61 percent of total billed charges FLUTICASONE PROP 50 MCG SPRAY 49743085_1 CDM 0250 RC 60505-0829-01 NDC inpatient 1 UN 18.15 11.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.99 60.55 999999999 10.99 17.61 percent of total billed charges FLUTICASONE PROP 50 MCG SPRAY 49743085_1 CDM 0250 RC 60505-0829-01 NDC inpatient 1 UN 18.15 11.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.99 17.61 FLUTICASONE PROP 50 MCG SPRAY 49743085_1 CDM 0250 RC 60505-0829-01 NDC inpatient 1 UN 18.15 11.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.99 17.61 FLUTICASONE PROP 50 MCG SPRAY 49743085_1 CDM 0250 RC 60505-0829-01 NDC inpatient 1 UN 18.15 11.8 ANTHEM HMO ANTHEM HMO 999999999 10.99 17.61 FLUTICASONE PROP 50 MCG SPRAY 49743085_1 CDM 0250 RC 60505-0829-01 NDC inpatient 1 UN 18.15 11.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.99 17.61 FLUTICASONE PROP 50 MCG SPRAY 49743085_1 CDM 0250 RC 60505-0829-01 NDC inpatient 1 UN 18.15 11.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.99 17.61 FLUTICASONE PROP 50 MCG SPRAY 49743085_1 CDM 0250 RC 60505-0829-01 NDC inpatient 1 UN 18.15 11.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.27 67.6 999999999 10.99 17.61 percent of total billed charges Amikacin (antibiotic) level 49745222_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 AETNA AETNA 251.22 79 999999999 192.55 308.46 percent of total billed charges Amikacin (antibiotic) level 49745222_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 206.7 65 999999999 192.55 308.46 percent of total billed charges Amikacin (antibiotic) level 49745222_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 308.46 97 999999999 192.55 308.46 percent of total billed charges Amikacin (antibiotic) level 49745222_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 248.04 78 999999999 192.55 308.46 percent of total billed charges Amikacin (antibiotic) level 49745222_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 219.42 69 999999999 192.55 308.46 percent of total billed charges Amikacin (antibiotic) level 49745222_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 SIHO - ALL PLANS SIHO - ALL PLANS 286.2 90 999999999 192.55 308.46 percent of total billed charges Amikacin (antibiotic) level 49745222_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 UMR - ALL PLANS UMR - ALL PLANS 222.6 70 999999999 192.55 308.46 percent of total billed charges Amikacin (antibiotic) level 49745222_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 192.55 60.55 999999999 192.55 308.46 percent of total billed charges Amikacin (antibiotic) level 49745222_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 192.55 308.46 Amikacin (antibiotic) level 49745222_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 192.55 308.46 Amikacin (antibiotic) level 49745222_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 ANTHEM HMO ANTHEM HMO 999999999 192.55 308.46 Amikacin (antibiotic) level 49745222_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 192.55 308.46 Amikacin (antibiotic) level 49745222_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 192.55 308.46 Amikacin (antibiotic) level 49745222_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 214.97 67.6 999999999 192.55 308.46 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 49745516_1 CDM 0250 RC 47781-0598-91 NDC J3370 HCPCS inpatient 1 UN 30.55 19.86 AETNA AETNA 24.13 79 999999999 18.5 29.63 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 49745516_1 CDM 0250 RC 47781-0598-91 NDC J3370 HCPCS inpatient 1 UN 30.55 19.86 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.86 65 999999999 18.5 29.63 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 49745516_1 CDM 0250 RC 47781-0598-91 NDC J3370 HCPCS inpatient 1 UN 30.55 19.86 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.63 97 999999999 18.5 29.63 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 49745516_1 CDM 0250 RC 47781-0598-91 NDC J3370 HCPCS inpatient 1 UN 30.55 19.86 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.83 78 999999999 18.5 29.63 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 49745516_1 CDM 0250 RC 47781-0598-91 NDC J3370 HCPCS inpatient 1 UN 30.55 19.86 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.08 69 999999999 18.5 29.63 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 49745516_1 CDM 0250 RC 47781-0598-91 NDC J3370 HCPCS inpatient 1 UN 30.55 19.86 SIHO - ALL PLANS SIHO - ALL PLANS 27.5 90 999999999 18.5 29.63 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 49745516_1 CDM 0250 RC 47781-0598-91 NDC J3370 HCPCS inpatient 1 UN 30.55 19.86 UMR - ALL PLANS UMR - ALL PLANS 21.39 70 999999999 18.5 29.63 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 49745516_1 CDM 0250 RC 47781-0598-91 NDC J3370 HCPCS inpatient 1 UN 30.55 19.86 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.5 60.55 999999999 18.5 29.63 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 49745516_1 CDM 0250 RC 47781-0598-91 NDC J3370 HCPCS inpatient 1 UN 30.55 19.86 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.5 29.63 "INJECTION, VANCOMYCIN HCL, 500 MG" 49745516_1 CDM 0250 RC 47781-0598-91 NDC J3370 HCPCS inpatient 1 UN 30.55 19.86 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.5 29.63 "INJECTION, VANCOMYCIN HCL, 500 MG" 49745516_1 CDM 0250 RC 47781-0598-91 NDC J3370 HCPCS inpatient 1 UN 30.55 19.86 ANTHEM HMO ANTHEM HMO 999999999 18.5 29.63 "INJECTION, VANCOMYCIN HCL, 500 MG" 49745516_1 CDM 0250 RC 47781-0598-91 NDC J3370 HCPCS inpatient 1 UN 30.55 19.86 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.5 29.63 "INJECTION, VANCOMYCIN HCL, 500 MG" 49745516_1 CDM 0250 RC 47781-0598-91 NDC J3370 HCPCS inpatient 1 UN 30.55 19.86 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.5 29.63 "INJECTION, VANCOMYCIN HCL, 500 MG" 49745516_1 CDM 0250 RC 47781-0598-91 NDC J3370 HCPCS inpatient 1 UN 30.55 19.86 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.65 67.6 999999999 18.5 29.63 percent of total billed charges Diagnostic mammography of both breasts 49747253_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 AETNA AETNA 458.99 79 999999999 351.8 563.57 percent of total billed charges Diagnostic mammography of both breasts 49747253_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 377.65 65 999999999 351.8 563.57 percent of total billed charges Diagnostic mammography of both breasts 49747253_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 563.57 97 999999999 351.8 563.57 percent of total billed charges Diagnostic mammography of both breasts 49747253_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 453.18 78 999999999 351.8 563.57 percent of total billed charges Diagnostic mammography of both breasts 49747253_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 400.89 69 999999999 351.8 563.57 percent of total billed charges Diagnostic mammography of both breasts 49747253_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 SIHO - ALL PLANS SIHO - ALL PLANS 522.9 90 999999999 351.8 563.57 percent of total billed charges Diagnostic mammography of both breasts 49747253_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 UMR - ALL PLANS UMR - ALL PLANS 406.7 70 999999999 351.8 563.57 percent of total billed charges Diagnostic mammography of both breasts 49747253_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 351.8 60.55 999999999 351.8 563.57 percent of total billed charges Diagnostic mammography of both breasts 49747253_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 351.8 563.57 Diagnostic mammography of both breasts 49747253_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 351.8 563.57 Diagnostic mammography of both breasts 49747253_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 ANTHEM HMO ANTHEM HMO 999999999 351.8 563.57 Diagnostic mammography of both breasts 49747253_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 351.8 563.57 Diagnostic mammography of both breasts 49747253_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 351.8 563.57 Diagnostic mammography of both breasts 49747253_1 CDM 0401 RC 77066 HCPCS inpatient 581 377.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 392.76 67.6 999999999 351.8 563.57 percent of total billed charges 3D breast mammography of both breasts 49747254_1 CDM 0401 RC 77062 HCPCS inpatient 122 79.3 AETNA AETNA 96.38 79 999999999 73.87 118.34 percent of total billed charges 3D breast mammography of both breasts 49747254_1 CDM 0401 RC 77062 HCPCS inpatient 122 79.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.3 65 999999999 73.87 118.34 percent of total billed charges 3D breast mammography of both breasts 49747254_1 CDM 0401 RC 77062 HCPCS inpatient 122 79.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 118.34 97 999999999 73.87 118.34 percent of total billed charges 3D breast mammography of both breasts 49747254_1 CDM 0401 RC 77062 HCPCS inpatient 122 79.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.16 78 999999999 73.87 118.34 percent of total billed charges 3D breast mammography of both breasts 49747254_1 CDM 0401 RC 77062 HCPCS inpatient 122 79.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.18 69 999999999 73.87 118.34 percent of total billed charges 3D breast mammography of both breasts 49747254_1 CDM 0401 RC 77062 HCPCS inpatient 122 79.3 SIHO - ALL PLANS SIHO - ALL PLANS 109.8 90 999999999 73.87 118.34 percent of total billed charges 3D breast mammography of both breasts 49747254_1 CDM 0401 RC 77062 HCPCS inpatient 122 79.3 UMR - ALL PLANS UMR - ALL PLANS 85.4 70 999999999 73.87 118.34 percent of total billed charges 3D breast mammography of both breasts 49747254_1 CDM 0401 RC 77062 HCPCS inpatient 122 79.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.87 60.55 999999999 73.87 118.34 percent of total billed charges 3D breast mammography of both breasts 49747254_1 CDM 0401 RC 77062 HCPCS inpatient 122 79.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.87 118.34 3D breast mammography of both breasts 49747254_1 CDM 0401 RC 77062 HCPCS inpatient 122 79.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.87 118.34 3D breast mammography of both breasts 49747254_1 CDM 0401 RC 77062 HCPCS inpatient 122 79.3 ANTHEM HMO ANTHEM HMO 999999999 73.87 118.34 3D breast mammography of both breasts 49747254_1 CDM 0401 RC 77062 HCPCS inpatient 122 79.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.87 118.34 3D breast mammography of both breasts 49747254_1 CDM 0401 RC 77062 HCPCS inpatient 122 79.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.87 118.34 3D breast mammography of both breasts 49747254_1 CDM 0401 RC 77062 HCPCS inpatient 122 79.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 82.47 67.6 999999999 73.87 118.34 percent of total billed charges Diagnostic mammography of 1 breast 49747257_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 AETNA AETNA 388.68 79 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 49747257_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 319.8 65 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 49747257_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 477.24 97 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 49747257_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 383.76 78 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 49747257_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 339.48 69 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 49747257_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 SIHO - ALL PLANS SIHO - ALL PLANS 442.8 90 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 49747257_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 UMR - ALL PLANS UMR - ALL PLANS 344.4 70 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 49747257_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 297.91 60.55 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 49747257_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 297.91 477.24 Diagnostic mammography of 1 breast 49747257_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 297.91 477.24 Diagnostic mammography of 1 breast 49747257_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM HMO ANTHEM HMO 999999999 297.91 477.24 Diagnostic mammography of 1 breast 49747257_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 297.91 477.24 Diagnostic mammography of 1 breast 49747257_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 297.91 477.24 Diagnostic mammography of 1 breast 49747257_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 332.59 67.6 999999999 297.91 477.24 percent of total billed charges 3D breast mammography of 1 breast 49747258_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges 3D breast mammography of 1 breast 49747258_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges 3D breast mammography of 1 breast 49747258_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges 3D breast mammography of 1 breast 49747258_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges 3D breast mammography of 1 breast 49747258_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges 3D breast mammography of 1 breast 49747258_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges 3D breast mammography of 1 breast 49747258_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges 3D breast mammography of 1 breast 49747258_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges 3D breast mammography of 1 breast 49747258_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 3D breast mammography of 1 breast 49747258_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 3D breast mammography of 1 breast 49747258_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 3D breast mammography of 1 breast 49747258_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 3D breast mammography of 1 breast 49747258_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 3D breast mammography of 1 breast 49747258_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges Diagnostic mammography of 1 breast 49747259_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 AETNA AETNA 388.68 79 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 49747259_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 319.8 65 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 49747259_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 477.24 97 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 49747259_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 383.76 78 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 49747259_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 339.48 69 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 49747259_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 SIHO - ALL PLANS SIHO - ALL PLANS 442.8 90 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 49747259_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 UMR - ALL PLANS UMR - ALL PLANS 344.4 70 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 49747259_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 297.91 60.55 999999999 297.91 477.24 percent of total billed charges Diagnostic mammography of 1 breast 49747259_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 297.91 477.24 Diagnostic mammography of 1 breast 49747259_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 297.91 477.24 Diagnostic mammography of 1 breast 49747259_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM HMO ANTHEM HMO 999999999 297.91 477.24 Diagnostic mammography of 1 breast 49747259_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 297.91 477.24 Diagnostic mammography of 1 breast 49747259_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 297.91 477.24 Diagnostic mammography of 1 breast 49747259_1 CDM 0401 RC 77065 HCPCS inpatient 492 319.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 332.59 67.6 999999999 297.91 477.24 percent of total billed charges 3D breast mammography of 1 breast 49747260_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges 3D breast mammography of 1 breast 49747260_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges 3D breast mammography of 1 breast 49747260_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges 3D breast mammography of 1 breast 49747260_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges 3D breast mammography of 1 breast 49747260_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges 3D breast mammography of 1 breast 49747260_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges 3D breast mammography of 1 breast 49747260_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges 3D breast mammography of 1 breast 49747260_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges 3D breast mammography of 1 breast 49747260_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 3D breast mammography of 1 breast 49747260_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 3D breast mammography of 1 breast 49747260_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 3D breast mammography of 1 breast 49747260_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 3D breast mammography of 1 breast 49747260_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 3D breast mammography of 1 breast 49747260_1 CDM 0401 RC 77061 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges Screening mammography 49747261_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 AETNA AETNA 422.65 79 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747261_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 347.75 65 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747261_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 518.95 97 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747261_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 417.3 78 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747261_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 369.15 69 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747261_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 SIHO - ALL PLANS SIHO - ALL PLANS 481.5 90 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747261_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 UMR - ALL PLANS UMR - ALL PLANS 374.5 70 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747261_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 323.94 60.55 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747261_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 323.94 518.95 Screening mammography 49747261_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 323.94 518.95 Screening mammography 49747261_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ANTHEM HMO ANTHEM HMO 999999999 323.94 518.95 Screening mammography 49747261_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 323.94 518.95 Screening mammography 49747261_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 323.94 518.95 Screening mammography 49747261_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 361.66 67.6 999999999 323.94 518.95 percent of total billed charges Screening 3D breast mammography 49747262_1 CDM 0403 RC 77063 HCPCS inpatient 141 91.65 AETNA AETNA 111.39 79 999999999 85.38 136.77 percent of total billed charges Screening 3D breast mammography 49747262_1 CDM 0403 RC 77063 HCPCS inpatient 141 91.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 91.65 65 999999999 85.38 136.77 percent of total billed charges Screening 3D breast mammography 49747262_1 CDM 0403 RC 77063 HCPCS inpatient 141 91.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 136.77 97 999999999 85.38 136.77 percent of total billed charges Screening 3D breast mammography 49747262_1 CDM 0403 RC 77063 HCPCS inpatient 141 91.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 109.98 78 999999999 85.38 136.77 percent of total billed charges Screening 3D breast mammography 49747262_1 CDM 0403 RC 77063 HCPCS inpatient 141 91.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.29 69 999999999 85.38 136.77 percent of total billed charges Screening 3D breast mammography 49747262_1 CDM 0403 RC 77063 HCPCS inpatient 141 91.65 SIHO - ALL PLANS SIHO - ALL PLANS 126.9 90 999999999 85.38 136.77 percent of total billed charges Screening 3D breast mammography 49747262_1 CDM 0403 RC 77063 HCPCS inpatient 141 91.65 UMR - ALL PLANS UMR - ALL PLANS 98.7 70 999999999 85.38 136.77 percent of total billed charges Screening 3D breast mammography 49747262_1 CDM 0403 RC 77063 HCPCS inpatient 141 91.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.38 60.55 999999999 85.38 136.77 percent of total billed charges Screening 3D breast mammography 49747262_1 CDM 0403 RC 77063 HCPCS inpatient 141 91.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.38 136.77 Screening 3D breast mammography 49747262_1 CDM 0403 RC 77063 HCPCS inpatient 141 91.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.38 136.77 Screening 3D breast mammography 49747262_1 CDM 0403 RC 77063 HCPCS inpatient 141 91.65 ANTHEM HMO ANTHEM HMO 999999999 85.38 136.77 Screening 3D breast mammography 49747262_1 CDM 0403 RC 77063 HCPCS inpatient 141 91.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.38 136.77 Screening 3D breast mammography 49747262_1 CDM 0403 RC 77063 HCPCS inpatient 141 91.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.38 136.77 Screening 3D breast mammography 49747262_1 CDM 0403 RC 77063 HCPCS inpatient 141 91.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.32 67.6 999999999 85.38 136.77 percent of total billed charges Screening mammography 49747263_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 AETNA AETNA 422.65 79 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747263_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 347.75 65 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747263_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 518.95 97 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747263_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 417.3 78 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747263_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 369.15 69 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747263_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 SIHO - ALL PLANS SIHO - ALL PLANS 481.5 90 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747263_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 UMR - ALL PLANS UMR - ALL PLANS 374.5 70 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747263_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 323.94 60.55 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747263_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 323.94 518.95 Screening mammography 49747263_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 323.94 518.95 Screening mammography 49747263_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ANTHEM HMO ANTHEM HMO 999999999 323.94 518.95 Screening mammography 49747263_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 323.94 518.95 Screening mammography 49747263_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 323.94 518.95 Screening mammography 49747263_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 361.66 67.6 999999999 323.94 518.95 percent of total billed charges Screening 3D breast mammography 49747264_1 CDM 0401 RC 77063 HCPCS inpatient 141 91.65 AETNA AETNA 111.39 79 999999999 85.38 136.77 percent of total billed charges Screening 3D breast mammography 49747264_1 CDM 0401 RC 77063 HCPCS inpatient 141 91.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 91.65 65 999999999 85.38 136.77 percent of total billed charges Screening 3D breast mammography 49747264_1 CDM 0401 RC 77063 HCPCS inpatient 141 91.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 136.77 97 999999999 85.38 136.77 percent of total billed charges Screening 3D breast mammography 49747264_1 CDM 0401 RC 77063 HCPCS inpatient 141 91.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 109.98 78 999999999 85.38 136.77 percent of total billed charges Screening 3D breast mammography 49747264_1 CDM 0401 RC 77063 HCPCS inpatient 141 91.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.29 69 999999999 85.38 136.77 percent of total billed charges Screening 3D breast mammography 49747264_1 CDM 0401 RC 77063 HCPCS inpatient 141 91.65 SIHO - ALL PLANS SIHO - ALL PLANS 126.9 90 999999999 85.38 136.77 percent of total billed charges Screening 3D breast mammography 49747264_1 CDM 0401 RC 77063 HCPCS inpatient 141 91.65 UMR - ALL PLANS UMR - ALL PLANS 98.7 70 999999999 85.38 136.77 percent of total billed charges Screening 3D breast mammography 49747264_1 CDM 0401 RC 77063 HCPCS inpatient 141 91.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.38 60.55 999999999 85.38 136.77 percent of total billed charges Screening 3D breast mammography 49747264_1 CDM 0401 RC 77063 HCPCS inpatient 141 91.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.38 136.77 Screening 3D breast mammography 49747264_1 CDM 0401 RC 77063 HCPCS inpatient 141 91.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.38 136.77 Screening 3D breast mammography 49747264_1 CDM 0401 RC 77063 HCPCS inpatient 141 91.65 ANTHEM HMO ANTHEM HMO 999999999 85.38 136.77 Screening 3D breast mammography 49747264_1 CDM 0401 RC 77063 HCPCS inpatient 141 91.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.38 136.77 Screening 3D breast mammography 49747264_1 CDM 0401 RC 77063 HCPCS inpatient 141 91.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.38 136.77 Screening 3D breast mammography 49747264_1 CDM 0401 RC 77063 HCPCS inpatient 141 91.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.32 67.6 999999999 85.38 136.77 percent of total billed charges Screening mammography 49747269_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 AETNA AETNA 422.65 79 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747269_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 347.75 65 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747269_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 518.95 97 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747269_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 417.3 78 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747269_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 369.15 69 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747269_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 SIHO - ALL PLANS SIHO - ALL PLANS 481.5 90 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747269_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 UMR - ALL PLANS UMR - ALL PLANS 374.5 70 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747269_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 323.94 60.55 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747269_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 323.94 518.95 Screening mammography 49747269_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 323.94 518.95 Screening mammography 49747269_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ANTHEM HMO ANTHEM HMO 999999999 323.94 518.95 Screening mammography 49747269_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 323.94 518.95 Screening mammography 49747269_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 361.66 67.6 999999999 323.94 518.95 percent of total billed charges Screening mammography 49747269_1 CDM 0403 RC 77067 HCPCS inpatient 535 347.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 323.94 518.95 Screening 3D breast mammography 49747270_1 CDM 0401 RC 77063 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges Screening 3D breast mammography 49747270_1 CDM 0401 RC 77063 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges Screening 3D breast mammography 49747270_1 CDM 0401 RC 77063 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges Screening 3D breast mammography 49747270_1 CDM 0401 RC 77063 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges Screening 3D breast mammography 49747270_1 CDM 0401 RC 77063 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges Screening 3D breast mammography 49747270_1 CDM 0401 RC 77063 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges Screening 3D breast mammography 49747270_1 CDM 0401 RC 77063 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges Screening 3D breast mammography 49747270_1 CDM 0401 RC 77063 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges Screening 3D breast mammography 49747270_1 CDM 0401 RC 77063 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 Screening 3D breast mammography 49747270_1 CDM 0401 RC 77063 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 Screening 3D breast mammography 49747270_1 CDM 0401 RC 77063 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 Screening 3D breast mammography 49747270_1 CDM 0401 RC 77063 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 Screening 3D breast mammography 49747270_1 CDM 0401 RC 77063 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges Screening 3D breast mammography 49747270_1 CDM 0401 RC 77063 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 Unlisted microbiology procedure 49748014_1 CDM 0306 RC 87999 HCPCS inpatient 26 16.9 AETNA AETNA 20.54 79 999999999 15.74 25.22 percent of total billed charges Unlisted microbiology procedure 49748014_1 CDM 0306 RC 87999 HCPCS inpatient 26 16.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.9 65 999999999 15.74 25.22 percent of total billed charges Unlisted microbiology procedure 49748014_1 CDM 0306 RC 87999 HCPCS inpatient 26 16.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.22 97 999999999 15.74 25.22 percent of total billed charges Unlisted microbiology procedure 49748014_1 CDM 0306 RC 87999 HCPCS inpatient 26 16.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.28 78 999999999 15.74 25.22 percent of total billed charges Unlisted microbiology procedure 49748014_1 CDM 0306 RC 87999 HCPCS inpatient 26 16.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.94 69 999999999 15.74 25.22 percent of total billed charges Unlisted microbiology procedure 49748014_1 CDM 0306 RC 87999 HCPCS inpatient 26 16.9 SIHO - ALL PLANS SIHO - ALL PLANS 23.4 90 999999999 15.74 25.22 percent of total billed charges Unlisted microbiology procedure 49748014_1 CDM 0306 RC 87999 HCPCS inpatient 26 16.9 UMR - ALL PLANS UMR - ALL PLANS 18.2 70 999999999 15.74 25.22 percent of total billed charges Unlisted microbiology procedure 49748014_1 CDM 0306 RC 87999 HCPCS inpatient 26 16.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.74 60.55 999999999 15.74 25.22 percent of total billed charges Unlisted microbiology procedure 49748014_1 CDM 0306 RC 87999 HCPCS inpatient 26 16.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.74 25.22 Unlisted microbiology procedure 49748014_1 CDM 0306 RC 87999 HCPCS inpatient 26 16.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.74 25.22 Unlisted microbiology procedure 49748014_1 CDM 0306 RC 87999 HCPCS inpatient 26 16.9 ANTHEM HMO ANTHEM HMO 999999999 15.74 25.22 Unlisted microbiology procedure 49748014_1 CDM 0306 RC 87999 HCPCS inpatient 26 16.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.74 25.22 Unlisted microbiology procedure 49748014_1 CDM 0306 RC 87999 HCPCS inpatient 26 16.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.58 67.6 999999999 15.74 25.22 percent of total billed charges Unlisted microbiology procedure 49748014_1 CDM 0306 RC 87999 HCPCS inpatient 26 16.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.74 25.22 "LIDOCAINE 2%-EPI 1:100,000" 49752787_1 CDM 0250 RC 00409-3182-01 NDC inpatient 1 UN 26.73 17.37 AETNA AETNA 21.12 79 999999999 16.19 25.93 percent of total billed charges "LIDOCAINE 2%-EPI 1:100,000" 49752787_1 CDM 0250 RC 00409-3182-01 NDC inpatient 1 UN 26.73 17.37 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.37 65 999999999 16.19 25.93 percent of total billed charges "LIDOCAINE 2%-EPI 1:100,000" 49752787_1 CDM 0250 RC 00409-3182-01 NDC inpatient 1 UN 26.73 17.37 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.93 97 999999999 16.19 25.93 percent of total billed charges "LIDOCAINE 2%-EPI 1:100,000" 49752787_1 CDM 0250 RC 00409-3182-01 NDC inpatient 1 UN 26.73 17.37 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.85 78 999999999 16.19 25.93 percent of total billed charges "LIDOCAINE 2%-EPI 1:100,000" 49752787_1 CDM 0250 RC 00409-3182-01 NDC inpatient 1 UN 26.73 17.37 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.44 69 999999999 16.19 25.93 percent of total billed charges "LIDOCAINE 2%-EPI 1:100,000" 49752787_1 CDM 0250 RC 00409-3182-01 NDC inpatient 1 UN 26.73 17.37 SIHO - ALL PLANS SIHO - ALL PLANS 24.06 90 999999999 16.19 25.93 percent of total billed charges "LIDOCAINE 2%-EPI 1:100,000" 49752787_1 CDM 0250 RC 00409-3182-01 NDC inpatient 1 UN 26.73 17.37 UMR - ALL PLANS UMR - ALL PLANS 18.71 70 999999999 16.19 25.93 percent of total billed charges "LIDOCAINE 2%-EPI 1:100,000" 49752787_1 CDM 0250 RC 00409-3182-01 NDC inpatient 1 UN 26.73 17.37 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.19 60.55 999999999 16.19 25.93 percent of total billed charges "LIDOCAINE 2%-EPI 1:100,000" 49752787_1 CDM 0250 RC 00409-3182-01 NDC inpatient 1 UN 26.73 17.37 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.19 25.93 "LIDOCAINE 2%-EPI 1:100,000" 49752787_1 CDM 0250 RC 00409-3182-01 NDC inpatient 1 UN 26.73 17.37 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.19 25.93 "LIDOCAINE 2%-EPI 1:100,000" 49752787_1 CDM 0250 RC 00409-3182-01 NDC inpatient 1 UN 26.73 17.37 ANTHEM HMO ANTHEM HMO 999999999 16.19 25.93 "LIDOCAINE 2%-EPI 1:100,000" 49752787_1 CDM 0250 RC 00409-3182-01 NDC inpatient 1 UN 26.73 17.37 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.19 25.93 "LIDOCAINE 2%-EPI 1:100,000" 49752787_1 CDM 0250 RC 00409-3182-01 NDC inpatient 1 UN 26.73 17.37 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.07 67.6 999999999 16.19 25.93 percent of total billed charges "LIDOCAINE 2%-EPI 1:100,000" 49752787_1 CDM 0250 RC 00409-3182-01 NDC inpatient 1 UN 26.73 17.37 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.19 25.93 FORCEPS ALLIGATOR HARTMAN 3 1/2IN STERILE 49755557_1 CDM 0272 RC inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges FORCEPS ALLIGATOR HARTMAN 3 1/2IN STERILE 49755557_1 CDM 0272 RC inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges FORCEPS ALLIGATOR HARTMAN 3 1/2IN STERILE 49755557_1 CDM 0272 RC inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges FORCEPS ALLIGATOR HARTMAN 3 1/2IN STERILE 49755557_1 CDM 0272 RC inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges FORCEPS ALLIGATOR HARTMAN 3 1/2IN STERILE 49755557_1 CDM 0272 RC inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges FORCEPS ALLIGATOR HARTMAN 3 1/2IN STERILE 49755557_1 CDM 0272 RC inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges FORCEPS ALLIGATOR HARTMAN 3 1/2IN STERILE 49755557_1 CDM 0272 RC inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges FORCEPS ALLIGATOR HARTMAN 3 1/2IN STERILE 49755557_1 CDM 0272 RC inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges FORCEPS ALLIGATOR HARTMAN 3 1/2IN STERILE 49755557_1 CDM 0272 RC inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 FORCEPS ALLIGATOR HARTMAN 3 1/2IN STERILE 49755557_1 CDM 0272 RC inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 FORCEPS ALLIGATOR HARTMAN 3 1/2IN STERILE 49755557_1 CDM 0272 RC inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 FORCEPS ALLIGATOR HARTMAN 3 1/2IN STERILE 49755557_1 CDM 0272 RC inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 FORCEPS ALLIGATOR HARTMAN 3 1/2IN STERILE 49755557_1 CDM 0272 RC inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges FORCEPS ALLIGATOR HARTMAN 3 1/2IN STERILE 49755557_1 CDM 0272 RC inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 "Detection test for gardnerella vaginalis (bacteria), quantification" 49759259_1 CDM 0300 RC 87512 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), quantification" 49759259_1 CDM 0300 RC 87512 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), quantification" 49759259_1 CDM 0300 RC 87512 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), quantification" 49759259_1 CDM 0300 RC 87512 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), quantification" 49759259_1 CDM 0300 RC 87512 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), quantification" 49759259_1 CDM 0300 RC 87512 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), quantification" 49759259_1 CDM 0300 RC 87512 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), quantification" 49759259_1 CDM 0300 RC 87512 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), quantification" 49759259_1 CDM 0300 RC 87512 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 "Detection test for gardnerella vaginalis (bacteria), quantification" 49759259_1 CDM 0300 RC 87512 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 "Detection test for gardnerella vaginalis (bacteria), quantification" 49759259_1 CDM 0300 RC 87512 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 "Detection test for gardnerella vaginalis (bacteria), quantification" 49759259_1 CDM 0300 RC 87512 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 "Detection test for gardnerella vaginalis (bacteria), quantification" 49759259_1 CDM 0300 RC 87512 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), quantification" 49759259_1 CDM 0300 RC 87512 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 "Detection test by nucleic acid for organism, quantification" 49760108_1 CDM 0300 RC 87799 HCPCS inpatient 507 329.55 AETNA AETNA 400.53 79 999999999 306.99 491.79 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 49760108_1 CDM 0300 RC 87799 HCPCS inpatient 507 329.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 329.55 65 999999999 306.99 491.79 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 49760108_1 CDM 0300 RC 87799 HCPCS inpatient 507 329.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 491.79 97 999999999 306.99 491.79 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 49760108_1 CDM 0300 RC 87799 HCPCS inpatient 507 329.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 395.46 78 999999999 306.99 491.79 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 49760108_1 CDM 0300 RC 87799 HCPCS inpatient 507 329.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 349.83 69 999999999 306.99 491.79 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 49760108_1 CDM 0300 RC 87799 HCPCS inpatient 507 329.55 SIHO - ALL PLANS SIHO - ALL PLANS 456.3 90 999999999 306.99 491.79 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 49760108_1 CDM 0300 RC 87799 HCPCS inpatient 507 329.55 UMR - ALL PLANS UMR - ALL PLANS 354.9 70 999999999 306.99 491.79 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 49760108_1 CDM 0300 RC 87799 HCPCS inpatient 507 329.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 306.99 60.55 999999999 306.99 491.79 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 49760108_1 CDM 0300 RC 87799 HCPCS inpatient 507 329.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 306.99 491.79 "Detection test by nucleic acid for organism, quantification" 49760108_1 CDM 0300 RC 87799 HCPCS inpatient 507 329.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 306.99 491.79 "Detection test by nucleic acid for organism, quantification" 49760108_1 CDM 0300 RC 87799 HCPCS inpatient 507 329.55 ANTHEM HMO ANTHEM HMO 999999999 306.99 491.79 "Detection test by nucleic acid for organism, quantification" 49760108_1 CDM 0300 RC 87799 HCPCS inpatient 507 329.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 306.99 491.79 "Detection test by nucleic acid for organism, quantification" 49760108_1 CDM 0300 RC 87799 HCPCS inpatient 507 329.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 342.73 67.6 999999999 306.99 491.79 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 49760108_1 CDM 0300 RC 87799 HCPCS inpatient 507 329.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 306.99 491.79 "Detection test by nucleic acid for organism, amplified probe technique" 49760109_1 CDM 0300 RC 87798 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49760109_1 CDM 0300 RC 87798 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49760109_1 CDM 0300 RC 87798 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49760109_1 CDM 0300 RC 87798 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49760109_1 CDM 0300 RC 87798 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49760109_1 CDM 0300 RC 87798 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49760109_1 CDM 0300 RC 87798 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49760109_1 CDM 0300 RC 87798 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49760109_1 CDM 0300 RC 87798 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 "Detection test by nucleic acid for organism, amplified probe technique" 49760109_1 CDM 0300 RC 87798 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 "Detection test by nucleic acid for organism, amplified probe technique" 49760109_1 CDM 0300 RC 87798 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 "Detection test by nucleic acid for organism, amplified probe technique" 49760109_1 CDM 0300 RC 87798 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 "Detection test by nucleic acid for organism, amplified probe technique" 49760109_1 CDM 0300 RC 87798 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49760109_1 CDM 0300 RC 87798 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 QUETIAPINE FUMARATE 25 MG TAB 49771303_1 CDM 0250 RC 60687-0327-01 NDC inpatient 1 UN 1.31 0.85 AETNA AETNA 1.03 79 999999999 0.79 1.27 percent of total billed charges QUETIAPINE FUMARATE 25 MG TAB 49771303_1 CDM 0250 RC 60687-0327-01 NDC inpatient 1 UN 1.31 0.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.85 65 999999999 0.79 1.27 percent of total billed charges QUETIAPINE FUMARATE 25 MG TAB 49771303_1 CDM 0250 RC 60687-0327-01 NDC inpatient 1 UN 1.31 0.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.27 97 999999999 0.79 1.27 percent of total billed charges QUETIAPINE FUMARATE 25 MG TAB 49771303_1 CDM 0250 RC 60687-0327-01 NDC inpatient 1 UN 1.31 0.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.02 78 999999999 0.79 1.27 percent of total billed charges QUETIAPINE FUMARATE 25 MG TAB 49771303_1 CDM 0250 RC 60687-0327-01 NDC inpatient 1 UN 1.31 0.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.9 69 999999999 0.79 1.27 percent of total billed charges QUETIAPINE FUMARATE 25 MG TAB 49771303_1 CDM 0250 RC 60687-0327-01 NDC inpatient 1 UN 1.31 0.85 SIHO - ALL PLANS SIHO - ALL PLANS 1.18 90 999999999 0.79 1.27 percent of total billed charges QUETIAPINE FUMARATE 25 MG TAB 49771303_1 CDM 0250 RC 60687-0327-01 NDC inpatient 1 UN 1.31 0.85 UMR - ALL PLANS UMR - ALL PLANS 0.92 70 999999999 0.79 1.27 percent of total billed charges QUETIAPINE FUMARATE 25 MG TAB 49771303_1 CDM 0250 RC 60687-0327-01 NDC inpatient 1 UN 1.31 0.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.79 60.55 999999999 0.79 1.27 percent of total billed charges QUETIAPINE FUMARATE 25 MG TAB 49771303_1 CDM 0250 RC 60687-0327-01 NDC inpatient 1 UN 1.31 0.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.79 1.27 QUETIAPINE FUMARATE 25 MG TAB 49771303_1 CDM 0250 RC 60687-0327-01 NDC inpatient 1 UN 1.31 0.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.79 1.27 QUETIAPINE FUMARATE 25 MG TAB 49771303_1 CDM 0250 RC 60687-0327-01 NDC inpatient 1 UN 1.31 0.85 ANTHEM HMO ANTHEM HMO 999999999 0.79 1.27 QUETIAPINE FUMARATE 25 MG TAB 49771303_1 CDM 0250 RC 60687-0327-01 NDC inpatient 1 UN 1.31 0.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.79 1.27 QUETIAPINE FUMARATE 25 MG TAB 49771303_1 CDM 0250 RC 60687-0327-01 NDC inpatient 1 UN 1.31 0.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.89 67.6 999999999 0.79 1.27 percent of total billed charges QUETIAPINE FUMARATE 25 MG TAB 49771303_1 CDM 0250 RC 60687-0327-01 NDC inpatient 1 UN 1.31 0.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.79 1.27 BRILINTA 60 MG TABLET 49772169_1 CDM 0250 RC 00186-0776-60 NDC inpatient 1 UN 27.62 17.95 AETNA AETNA 21.82 79 999999999 16.72 26.79 percent of total billed charges BRILINTA 60 MG TABLET 49772169_1 CDM 0250 RC 00186-0776-60 NDC inpatient 1 UN 27.62 17.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.95 65 999999999 16.72 26.79 percent of total billed charges BRILINTA 60 MG TABLET 49772169_1 CDM 0250 RC 00186-0776-60 NDC inpatient 1 UN 27.62 17.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26.79 97 999999999 16.72 26.79 percent of total billed charges BRILINTA 60 MG TABLET 49772169_1 CDM 0250 RC 00186-0776-60 NDC inpatient 1 UN 27.62 17.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.54 78 999999999 16.72 26.79 percent of total billed charges BRILINTA 60 MG TABLET 49772169_1 CDM 0250 RC 00186-0776-60 NDC inpatient 1 UN 27.62 17.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 19.06 69 999999999 16.72 26.79 percent of total billed charges BRILINTA 60 MG TABLET 49772169_1 CDM 0250 RC 00186-0776-60 NDC inpatient 1 UN 27.62 17.95 SIHO - ALL PLANS SIHO - ALL PLANS 24.86 90 999999999 16.72 26.79 percent of total billed charges BRILINTA 60 MG TABLET 49772169_1 CDM 0250 RC 00186-0776-60 NDC inpatient 1 UN 27.62 17.95 UMR - ALL PLANS UMR - ALL PLANS 19.33 70 999999999 16.72 26.79 percent of total billed charges BRILINTA 60 MG TABLET 49772169_1 CDM 0250 RC 00186-0776-60 NDC inpatient 1 UN 27.62 17.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.72 60.55 999999999 16.72 26.79 percent of total billed charges BRILINTA 60 MG TABLET 49772169_1 CDM 0250 RC 00186-0776-60 NDC inpatient 1 UN 27.62 17.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.72 26.79 BRILINTA 60 MG TABLET 49772169_1 CDM 0250 RC 00186-0776-60 NDC inpatient 1 UN 27.62 17.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.72 26.79 BRILINTA 60 MG TABLET 49772169_1 CDM 0250 RC 00186-0776-60 NDC inpatient 1 UN 27.62 17.95 ANTHEM HMO ANTHEM HMO 999999999 16.72 26.79 BRILINTA 60 MG TABLET 49772169_1 CDM 0250 RC 00186-0776-60 NDC inpatient 1 UN 27.62 17.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.72 26.79 BRILINTA 60 MG TABLET 49772169_1 CDM 0250 RC 00186-0776-60 NDC inpatient 1 UN 27.62 17.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.67 67.6 999999999 16.72 26.79 percent of total billed charges BRILINTA 60 MG TABLET 49772169_1 CDM 0250 RC 00186-0776-60 NDC inpatient 1 UN 27.62 17.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.72 26.79 "INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG" 49772171_1 CDM 0636 RC 69374-0919-10 NDC J0330 HCPCS inpatient 1 UN 113.64 73.87 AETNA AETNA 89.78 79 999999999 68.81 110.23 percent of total billed charges "INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG" 49772171_1 CDM 0636 RC 69374-0919-10 NDC J0330 HCPCS inpatient 1 UN 113.64 73.87 SELF PAY DISCOUNT SELF PAY DISCOUNT 73.87 65 999999999 68.81 110.23 percent of total billed charges "INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG" 49772171_1 CDM 0636 RC 69374-0919-10 NDC J0330 HCPCS inpatient 1 UN 113.64 73.87 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.23 97 999999999 68.81 110.23 percent of total billed charges "INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG" 49772171_1 CDM 0636 RC 69374-0919-10 NDC J0330 HCPCS inpatient 1 UN 113.64 73.87 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.64 78 999999999 68.81 110.23 percent of total billed charges "INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG" 49772171_1 CDM 0636 RC 69374-0919-10 NDC J0330 HCPCS inpatient 1 UN 113.64 73.87 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.41 69 999999999 68.81 110.23 percent of total billed charges "INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG" 49772171_1 CDM 0636 RC 69374-0919-10 NDC J0330 HCPCS inpatient 1 UN 113.64 73.87 SIHO - ALL PLANS SIHO - ALL PLANS 102.28 90 999999999 68.81 110.23 percent of total billed charges "INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG" 49772171_1 CDM 0636 RC 69374-0919-10 NDC J0330 HCPCS inpatient 1 UN 113.64 73.87 UMR - ALL PLANS UMR - ALL PLANS 79.55 70 999999999 68.81 110.23 percent of total billed charges "INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG" 49772171_1 CDM 0636 RC 69374-0919-10 NDC J0330 HCPCS inpatient 1 UN 113.64 73.87 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 68.81 60.55 999999999 68.81 110.23 percent of total billed charges "INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG" 49772171_1 CDM 0636 RC 69374-0919-10 NDC J0330 HCPCS inpatient 1 UN 113.64 73.87 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 68.81 110.23 "INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG" 49772171_1 CDM 0636 RC 69374-0919-10 NDC J0330 HCPCS inpatient 1 UN 113.64 73.87 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 68.81 110.23 "INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG" 49772171_1 CDM 0636 RC 69374-0919-10 NDC J0330 HCPCS inpatient 1 UN 113.64 73.87 ANTHEM HMO ANTHEM HMO 999999999 68.81 110.23 "INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG" 49772171_1 CDM 0636 RC 69374-0919-10 NDC J0330 HCPCS inpatient 1 UN 113.64 73.87 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 68.81 110.23 "INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG" 49772171_1 CDM 0636 RC 69374-0919-10 NDC J0330 HCPCS inpatient 1 UN 113.64 73.87 CIGNA - ALL PLANS CIGNA - ALL PLANS 76.82 67.6 999999999 68.81 110.23 percent of total billed charges "INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG" 49772171_1 CDM 0636 RC 69374-0919-10 NDC J0330 HCPCS inpatient 1 UN 113.64 73.87 UHC - ALL PLANS UHC - ALL PLANS 999999999 68.81 110.23 DONEPEZIL HCL 5 MG TABLET 49773831_1 CDM 0250 RC 00904-6477-61 NDC inpatient 1 UN 1.15 0.75 AETNA AETNA 0.91 79 999999999 0.7 1.12 percent of total billed charges DONEPEZIL HCL 5 MG TABLET 49773831_1 CDM 0250 RC 00904-6477-61 NDC inpatient 1 UN 1.15 0.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.75 65 999999999 0.7 1.12 percent of total billed charges DONEPEZIL HCL 5 MG TABLET 49773831_1 CDM 0250 RC 00904-6477-61 NDC inpatient 1 UN 1.15 0.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.12 97 999999999 0.7 1.12 percent of total billed charges DONEPEZIL HCL 5 MG TABLET 49773831_1 CDM 0250 RC 00904-6477-61 NDC inpatient 1 UN 1.15 0.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.9 78 999999999 0.7 1.12 percent of total billed charges DONEPEZIL HCL 5 MG TABLET 49773831_1 CDM 0250 RC 00904-6477-61 NDC inpatient 1 UN 1.15 0.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.79 69 999999999 0.7 1.12 percent of total billed charges DONEPEZIL HCL 5 MG TABLET 49773831_1 CDM 0250 RC 00904-6477-61 NDC inpatient 1 UN 1.15 0.75 SIHO - ALL PLANS SIHO - ALL PLANS 1.04 90 999999999 0.7 1.12 percent of total billed charges DONEPEZIL HCL 5 MG TABLET 49773831_1 CDM 0250 RC 00904-6477-61 NDC inpatient 1 UN 1.15 0.75 UMR - ALL PLANS UMR - ALL PLANS 0.81 70 999999999 0.7 1.12 percent of total billed charges DONEPEZIL HCL 5 MG TABLET 49773831_1 CDM 0250 RC 00904-6477-61 NDC inpatient 1 UN 1.15 0.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.7 60.55 999999999 0.7 1.12 percent of total billed charges DONEPEZIL HCL 5 MG TABLET 49773831_1 CDM 0250 RC 00904-6477-61 NDC inpatient 1 UN 1.15 0.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.7 1.12 DONEPEZIL HCL 5 MG TABLET 49773831_1 CDM 0250 RC 00904-6477-61 NDC inpatient 1 UN 1.15 0.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.7 1.12 DONEPEZIL HCL 5 MG TABLET 49773831_1 CDM 0250 RC 00904-6477-61 NDC inpatient 1 UN 1.15 0.75 ANTHEM HMO ANTHEM HMO 999999999 0.7 1.12 DONEPEZIL HCL 5 MG TABLET 49773831_1 CDM 0250 RC 00904-6477-61 NDC inpatient 1 UN 1.15 0.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.7 1.12 DONEPEZIL HCL 5 MG TABLET 49773831_1 CDM 0250 RC 00904-6477-61 NDC inpatient 1 UN 1.15 0.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.78 67.6 999999999 0.7 1.12 percent of total billed charges DONEPEZIL HCL 5 MG TABLET 49773831_1 CDM 0250 RC 00904-6477-61 NDC inpatient 1 UN 1.15 0.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.7 1.12 "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49774007_1 CDM 0250 RC 60505-6145-04 NDC J0692 HCPCS inpatient 4 UN 41.06 26.69 AETNA AETNA 32.44 79 999999999 24.86 39.83 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49774007_1 CDM 0250 RC 60505-6145-04 NDC J0692 HCPCS inpatient 4 UN 41.06 26.69 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.69 65 999999999 24.86 39.83 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49774007_1 CDM 0250 RC 60505-6145-04 NDC J0692 HCPCS inpatient 4 UN 41.06 26.69 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39.83 97 999999999 24.86 39.83 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49774007_1 CDM 0250 RC 60505-6145-04 NDC J0692 HCPCS inpatient 4 UN 41.06 26.69 HUMANA - ALL PLANS HUMANA - ALL PLANS 32.03 78 999999999 24.86 39.83 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49774007_1 CDM 0250 RC 60505-6145-04 NDC J0692 HCPCS inpatient 4 UN 41.06 26.69 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.33 69 999999999 24.86 39.83 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49774007_1 CDM 0250 RC 60505-6145-04 NDC J0692 HCPCS inpatient 4 UN 41.06 26.69 SIHO - ALL PLANS SIHO - ALL PLANS 36.95 90 999999999 24.86 39.83 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49774007_1 CDM 0250 RC 60505-6145-04 NDC J0692 HCPCS inpatient 4 UN 41.06 26.69 UMR - ALL PLANS UMR - ALL PLANS 28.74 70 999999999 24.86 39.83 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49774007_1 CDM 0250 RC 60505-6145-04 NDC J0692 HCPCS inpatient 4 UN 41.06 26.69 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.86 60.55 999999999 24.86 39.83 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49774007_1 CDM 0250 RC 60505-6145-04 NDC J0692 HCPCS inpatient 4 UN 41.06 26.69 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.86 39.83 "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49774007_1 CDM 0250 RC 60505-6145-04 NDC J0692 HCPCS inpatient 4 UN 41.06 26.69 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.86 39.83 "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49774007_1 CDM 0250 RC 60505-6145-04 NDC J0692 HCPCS inpatient 4 UN 41.06 26.69 ANTHEM HMO ANTHEM HMO 999999999 24.86 39.83 "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49774007_1 CDM 0250 RC 60505-6145-04 NDC J0692 HCPCS inpatient 4 UN 41.06 26.69 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.86 39.83 "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49774007_1 CDM 0250 RC 60505-6145-04 NDC J0692 HCPCS inpatient 4 UN 41.06 26.69 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.76 67.6 999999999 24.86 39.83 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49774007_1 CDM 0250 RC 60505-6145-04 NDC J0692 HCPCS inpatient 4 UN 41.06 26.69 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.86 39.83 FINASTERIDE 5 MG TABLET 49774914_1 CDM 0250 RC 16729-0090-01 NDC inpatient 510 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges FINASTERIDE 5 MG TABLET 49774914_1 CDM 0250 RC 16729-0090-01 NDC inpatient 510 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges FINASTERIDE 5 MG TABLET 49774914_1 CDM 0250 RC 16729-0090-01 NDC inpatient 510 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges FINASTERIDE 5 MG TABLET 49774914_1 CDM 0250 RC 16729-0090-01 NDC inpatient 510 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges FINASTERIDE 5 MG TABLET 49774914_1 CDM 0250 RC 16729-0090-01 NDC inpatient 510 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges FINASTERIDE 5 MG TABLET 49774914_1 CDM 0250 RC 16729-0090-01 NDC inpatient 510 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges FINASTERIDE 5 MG TABLET 49774914_1 CDM 0250 RC 16729-0090-01 NDC inpatient 510 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges FINASTERIDE 5 MG TABLET 49774914_1 CDM 0250 RC 16729-0090-01 NDC inpatient 510 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges FINASTERIDE 5 MG TABLET 49774914_1 CDM 0250 RC 16729-0090-01 NDC inpatient 510 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 FINASTERIDE 5 MG TABLET 49774914_1 CDM 0250 RC 16729-0090-01 NDC inpatient 510 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 FINASTERIDE 5 MG TABLET 49774914_1 CDM 0250 RC 16729-0090-01 NDC inpatient 510 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 FINASTERIDE 5 MG TABLET 49774914_1 CDM 0250 RC 16729-0090-01 NDC inpatient 510 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 FINASTERIDE 5 MG TABLET 49774914_1 CDM 0250 RC 16729-0090-01 NDC inpatient 510 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges FINASTERIDE 5 MG TABLET 49774914_1 CDM 0250 RC 16729-0090-01 NDC inpatient 510 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 RECOVERY ROOM - GENERAL CLASSIFICATION 49777764_1 CDM 0710 RC inpatient 67 43.55 AETNA AETNA 52.93 79 999999999 40.57 64.99 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 49777764_1 CDM 0710 RC inpatient 67 43.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 43.55 65 999999999 40.57 64.99 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 49777764_1 CDM 0710 RC inpatient 67 43.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.99 97 999999999 40.57 64.99 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 49777764_1 CDM 0710 RC inpatient 67 43.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 52.26 78 999999999 40.57 64.99 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 49777764_1 CDM 0710 RC inpatient 67 43.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.23 69 999999999 40.57 64.99 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 49777764_1 CDM 0710 RC inpatient 67 43.55 SIHO - ALL PLANS SIHO - ALL PLANS 60.3 90 999999999 40.57 64.99 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 49777764_1 CDM 0710 RC inpatient 67 43.55 UMR - ALL PLANS UMR - ALL PLANS 46.9 70 999999999 40.57 64.99 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 49777764_1 CDM 0710 RC inpatient 67 43.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 40.57 60.55 999999999 40.57 64.99 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 49777764_1 CDM 0710 RC inpatient 67 43.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 40.57 64.99 RECOVERY ROOM - GENERAL CLASSIFICATION 49777764_1 CDM 0710 RC inpatient 67 43.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 40.57 64.99 RECOVERY ROOM - GENERAL CLASSIFICATION 49777764_1 CDM 0710 RC inpatient 67 43.55 ANTHEM HMO ANTHEM HMO 999999999 40.57 64.99 RECOVERY ROOM - GENERAL CLASSIFICATION 49777764_1 CDM 0710 RC inpatient 67 43.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 40.57 64.99 RECOVERY ROOM - GENERAL CLASSIFICATION 49777764_1 CDM 0710 RC inpatient 67 43.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.29 67.6 999999999 40.57 64.99 percent of total billed charges RECOVERY ROOM - GENERAL CLASSIFICATION 49777764_1 CDM 0710 RC inpatient 67 43.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 40.57 64.99 Catecholamines (organic nitrogen) level 49778096_1 CDM 0301 RC 82384 HCPCS inpatient 258 167.7 AETNA AETNA 203.82 79 999999999 156.22 250.26 percent of total billed charges Catecholamines (organic nitrogen) level 49778096_1 CDM 0301 RC 82384 HCPCS inpatient 258 167.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.7 65 999999999 156.22 250.26 percent of total billed charges Catecholamines (organic nitrogen) level 49778096_1 CDM 0301 RC 82384 HCPCS inpatient 258 167.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 250.26 97 999999999 156.22 250.26 percent of total billed charges Catecholamines (organic nitrogen) level 49778096_1 CDM 0301 RC 82384 HCPCS inpatient 258 167.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 201.24 78 999999999 156.22 250.26 percent of total billed charges Catecholamines (organic nitrogen) level 49778096_1 CDM 0301 RC 82384 HCPCS inpatient 258 167.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 178.02 69 999999999 156.22 250.26 percent of total billed charges Catecholamines (organic nitrogen) level 49778096_1 CDM 0301 RC 82384 HCPCS inpatient 258 167.7 SIHO - ALL PLANS SIHO - ALL PLANS 232.2 90 999999999 156.22 250.26 percent of total billed charges Catecholamines (organic nitrogen) level 49778096_1 CDM 0301 RC 82384 HCPCS inpatient 258 167.7 UMR - ALL PLANS UMR - ALL PLANS 180.6 70 999999999 156.22 250.26 percent of total billed charges Catecholamines (organic nitrogen) level 49778096_1 CDM 0301 RC 82384 HCPCS inpatient 258 167.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 156.22 60.55 999999999 156.22 250.26 percent of total billed charges Catecholamines (organic nitrogen) level 49778096_1 CDM 0301 RC 82384 HCPCS inpatient 258 167.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 156.22 250.26 Catecholamines (organic nitrogen) level 49778096_1 CDM 0301 RC 82384 HCPCS inpatient 258 167.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 156.22 250.26 Catecholamines (organic nitrogen) level 49778096_1 CDM 0301 RC 82384 HCPCS inpatient 258 167.7 ANTHEM HMO ANTHEM HMO 999999999 156.22 250.26 Catecholamines (organic nitrogen) level 49778096_1 CDM 0301 RC 82384 HCPCS inpatient 258 167.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 156.22 250.26 Catecholamines (organic nitrogen) level 49778096_1 CDM 0301 RC 82384 HCPCS inpatient 258 167.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 174.41 67.6 999999999 156.22 250.26 percent of total billed charges Catecholamines (organic nitrogen) level 49778096_1 CDM 0301 RC 82384 HCPCS inpatient 258 167.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 156.22 250.26 Creatinine level to test for kidney function or muscle injury 49778180_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49778180_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49778180_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49778180_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49778180_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49778180_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49778180_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49778180_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49778180_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 Creatinine level to test for kidney function or muscle injury 49778180_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 Creatinine level to test for kidney function or muscle injury 49778180_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 Creatinine level to test for kidney function or muscle injury 49778180_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 Creatinine level to test for kidney function or muscle injury 49778180_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 49778180_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 HETASTARCH 6%-0.9% NACL BAG 49778293_1 CDM 0250 RC 00409-7248-03 NDC inpatient 1 UN 104.82 68.13 AETNA AETNA 82.81 79 999999999 63.47 101.68 percent of total billed charges HETASTARCH 6%-0.9% NACL BAG 49778293_1 CDM 0250 RC 00409-7248-03 NDC inpatient 1 UN 104.82 68.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.13 65 999999999 63.47 101.68 percent of total billed charges HETASTARCH 6%-0.9% NACL BAG 49778293_1 CDM 0250 RC 00409-7248-03 NDC inpatient 1 UN 104.82 68.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.68 97 999999999 63.47 101.68 percent of total billed charges HETASTARCH 6%-0.9% NACL BAG 49778293_1 CDM 0250 RC 00409-7248-03 NDC inpatient 1 UN 104.82 68.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.76 78 999999999 63.47 101.68 percent of total billed charges HETASTARCH 6%-0.9% NACL BAG 49778293_1 CDM 0250 RC 00409-7248-03 NDC inpatient 1 UN 104.82 68.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.33 69 999999999 63.47 101.68 percent of total billed charges HETASTARCH 6%-0.9% NACL BAG 49778293_1 CDM 0250 RC 00409-7248-03 NDC inpatient 1 UN 104.82 68.13 SIHO - ALL PLANS SIHO - ALL PLANS 94.34 90 999999999 63.47 101.68 percent of total billed charges HETASTARCH 6%-0.9% NACL BAG 49778293_1 CDM 0250 RC 00409-7248-03 NDC inpatient 1 UN 104.82 68.13 UMR - ALL PLANS UMR - ALL PLANS 73.37 70 999999999 63.47 101.68 percent of total billed charges HETASTARCH 6%-0.9% NACL BAG 49778293_1 CDM 0250 RC 00409-7248-03 NDC inpatient 1 UN 104.82 68.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.47 60.55 999999999 63.47 101.68 percent of total billed charges HETASTARCH 6%-0.9% NACL BAG 49778293_1 CDM 0250 RC 00409-7248-03 NDC inpatient 1 UN 104.82 68.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.47 101.68 HETASTARCH 6%-0.9% NACL BAG 49778293_1 CDM 0250 RC 00409-7248-03 NDC inpatient 1 UN 104.82 68.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.47 101.68 HETASTARCH 6%-0.9% NACL BAG 49778293_1 CDM 0250 RC 00409-7248-03 NDC inpatient 1 UN 104.82 68.13 ANTHEM HMO ANTHEM HMO 999999999 63.47 101.68 HETASTARCH 6%-0.9% NACL BAG 49778293_1 CDM 0250 RC 00409-7248-03 NDC inpatient 1 UN 104.82 68.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.47 101.68 HETASTARCH 6%-0.9% NACL BAG 49778293_1 CDM 0250 RC 00409-7248-03 NDC inpatient 1 UN 104.82 68.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.86 67.6 999999999 63.47 101.68 percent of total billed charges HETASTARCH 6%-0.9% NACL BAG 49778293_1 CDM 0250 RC 00409-7248-03 NDC inpatient 1 UN 104.82 68.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.47 101.68 "Chromosome analysis for genetic defects, analyze 100-300 cells" 49778338_1 CDM 0312 RC 88275 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges "Chromosome analysis for genetic defects, analyze 100-300 cells" 49778338_1 CDM 0312 RC 88275 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges "Chromosome analysis for genetic defects, analyze 100-300 cells" 49778338_1 CDM 0312 RC 88275 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges "Chromosome analysis for genetic defects, analyze 100-300 cells" 49778338_1 CDM 0312 RC 88275 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges "Chromosome analysis for genetic defects, analyze 100-300 cells" 49778338_1 CDM 0312 RC 88275 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges "Chromosome analysis for genetic defects, analyze 100-300 cells" 49778338_1 CDM 0312 RC 88275 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges "Chromosome analysis for genetic defects, analyze 100-300 cells" 49778338_1 CDM 0312 RC 88275 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges "Chromosome analysis for genetic defects, analyze 100-300 cells" 49778338_1 CDM 0312 RC 88275 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges "Chromosome analysis for genetic defects, analyze 100-300 cells" 49778338_1 CDM 0312 RC 88275 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 "Chromosome analysis for genetic defects, analyze 100-300 cells" 49778338_1 CDM 0312 RC 88275 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 "Chromosome analysis for genetic defects, analyze 100-300 cells" 49778338_1 CDM 0312 RC 88275 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 "Chromosome analysis for genetic defects, analyze 100-300 cells" 49778338_1 CDM 0312 RC 88275 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 "Chromosome analysis for genetic defects, analyze 100-300 cells" 49778338_1 CDM 0312 RC 88275 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges "Chromosome analysis for genetic defects, analyze 100-300 cells" 49778338_1 CDM 0312 RC 88275 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 DNA testing for genetic defects 49778408_1 CDM 0312 RC 88271 HCPCS inpatient 197 128.05 AETNA AETNA 155.63 79 999999999 119.28 191.09 percent of total billed charges DNA testing for genetic defects 49778408_1 CDM 0312 RC 88271 HCPCS inpatient 197 128.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.05 65 999999999 119.28 191.09 percent of total billed charges DNA testing for genetic defects 49778408_1 CDM 0312 RC 88271 HCPCS inpatient 197 128.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 191.09 97 999999999 119.28 191.09 percent of total billed charges DNA testing for genetic defects 49778408_1 CDM 0312 RC 88271 HCPCS inpatient 197 128.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 153.66 78 999999999 119.28 191.09 percent of total billed charges DNA testing for genetic defects 49778408_1 CDM 0312 RC 88271 HCPCS inpatient 197 128.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 135.93 69 999999999 119.28 191.09 percent of total billed charges DNA testing for genetic defects 49778408_1 CDM 0312 RC 88271 HCPCS inpatient 197 128.05 SIHO - ALL PLANS SIHO - ALL PLANS 177.3 90 999999999 119.28 191.09 percent of total billed charges DNA testing for genetic defects 49778408_1 CDM 0312 RC 88271 HCPCS inpatient 197 128.05 UMR - ALL PLANS UMR - ALL PLANS 137.9 70 999999999 119.28 191.09 percent of total billed charges DNA testing for genetic defects 49778408_1 CDM 0312 RC 88271 HCPCS inpatient 197 128.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.28 60.55 999999999 119.28 191.09 percent of total billed charges DNA testing for genetic defects 49778408_1 CDM 0312 RC 88271 HCPCS inpatient 197 128.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.28 191.09 DNA testing for genetic defects 49778408_1 CDM 0312 RC 88271 HCPCS inpatient 197 128.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.28 191.09 DNA testing for genetic defects 49778408_1 CDM 0312 RC 88271 HCPCS inpatient 197 128.05 ANTHEM HMO ANTHEM HMO 999999999 119.28 191.09 DNA testing for genetic defects 49778408_1 CDM 0312 RC 88271 HCPCS inpatient 197 128.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.17 67.6 999999999 119.28 191.09 percent of total billed charges DNA testing for genetic defects 49778408_1 CDM 0312 RC 88271 HCPCS inpatient 197 128.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.28 191.09 DNA testing for genetic defects 49778408_1 CDM 0312 RC 88271 HCPCS inpatient 197 128.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.28 191.09 RAPID RHINO NASAL 4.5CM RR450 49780705_1 CDM 0272 RC inpatient 198 128.7 AETNA AETNA 156.42 79 999999999 119.89 192.06 percent of total billed charges RAPID RHINO NASAL 4.5CM RR450 49780705_1 CDM 0272 RC inpatient 198 128.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.7 65 999999999 119.89 192.06 percent of total billed charges RAPID RHINO NASAL 4.5CM RR450 49780705_1 CDM 0272 RC inpatient 198 128.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 192.06 97 999999999 119.89 192.06 percent of total billed charges RAPID RHINO NASAL 4.5CM RR450 49780705_1 CDM 0272 RC inpatient 198 128.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 154.44 78 999999999 119.89 192.06 percent of total billed charges RAPID RHINO NASAL 4.5CM RR450 49780705_1 CDM 0272 RC inpatient 198 128.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 136.62 69 999999999 119.89 192.06 percent of total billed charges RAPID RHINO NASAL 4.5CM RR450 49780705_1 CDM 0272 RC inpatient 198 128.7 SIHO - ALL PLANS SIHO - ALL PLANS 178.2 90 999999999 119.89 192.06 percent of total billed charges RAPID RHINO NASAL 4.5CM RR450 49780705_1 CDM 0272 RC inpatient 198 128.7 UMR - ALL PLANS UMR - ALL PLANS 138.6 70 999999999 119.89 192.06 percent of total billed charges RAPID RHINO NASAL 4.5CM RR450 49780705_1 CDM 0272 RC inpatient 198 128.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.89 60.55 999999999 119.89 192.06 percent of total billed charges RAPID RHINO NASAL 4.5CM RR450 49780705_1 CDM 0272 RC inpatient 198 128.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.89 192.06 RAPID RHINO NASAL 4.5CM RR450 49780705_1 CDM 0272 RC inpatient 198 128.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.89 192.06 RAPID RHINO NASAL 4.5CM RR450 49780705_1 CDM 0272 RC inpatient 198 128.7 ANTHEM HMO ANTHEM HMO 999999999 119.89 192.06 RAPID RHINO NASAL 4.5CM RR450 49780705_1 CDM 0272 RC inpatient 198 128.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.85 67.6 999999999 119.89 192.06 percent of total billed charges RAPID RHINO NASAL 4.5CM RR450 49780705_1 CDM 0272 RC inpatient 198 128.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.89 192.06 RAPID RHINO NASAL 4.5CM RR450 49780705_1 CDM 0272 RC inpatient 198 128.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.89 192.06 POSTERIOR INFLATABLE EPISTAXIS DEVICE 9.0CM RR900 49780706_1 CDM 0272 RC inpatient 392 254.8 AETNA AETNA 309.68 79 999999999 237.36 380.24 percent of total billed charges POSTERIOR INFLATABLE EPISTAXIS DEVICE 9.0CM RR900 49780706_1 CDM 0272 RC inpatient 392 254.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 254.8 65 999999999 237.36 380.24 percent of total billed charges POSTERIOR INFLATABLE EPISTAXIS DEVICE 9.0CM RR900 49780706_1 CDM 0272 RC inpatient 392 254.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 380.24 97 999999999 237.36 380.24 percent of total billed charges POSTERIOR INFLATABLE EPISTAXIS DEVICE 9.0CM RR900 49780706_1 CDM 0272 RC inpatient 392 254.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 305.76 78 999999999 237.36 380.24 percent of total billed charges POSTERIOR INFLATABLE EPISTAXIS DEVICE 9.0CM RR900 49780706_1 CDM 0272 RC inpatient 392 254.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 270.48 69 999999999 237.36 380.24 percent of total billed charges POSTERIOR INFLATABLE EPISTAXIS DEVICE 9.0CM RR900 49780706_1 CDM 0272 RC inpatient 392 254.8 SIHO - ALL PLANS SIHO - ALL PLANS 352.8 90 999999999 237.36 380.24 percent of total billed charges POSTERIOR INFLATABLE EPISTAXIS DEVICE 9.0CM RR900 49780706_1 CDM 0272 RC inpatient 392 254.8 UMR - ALL PLANS UMR - ALL PLANS 274.4 70 999999999 237.36 380.24 percent of total billed charges POSTERIOR INFLATABLE EPISTAXIS DEVICE 9.0CM RR900 49780706_1 CDM 0272 RC inpatient 392 254.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 237.36 60.55 999999999 237.36 380.24 percent of total billed charges POSTERIOR INFLATABLE EPISTAXIS DEVICE 9.0CM RR900 49780706_1 CDM 0272 RC inpatient 392 254.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 237.36 380.24 POSTERIOR INFLATABLE EPISTAXIS DEVICE 9.0CM RR900 49780706_1 CDM 0272 RC inpatient 392 254.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 237.36 380.24 POSTERIOR INFLATABLE EPISTAXIS DEVICE 9.0CM RR900 49780706_1 CDM 0272 RC inpatient 392 254.8 ANTHEM HMO ANTHEM HMO 999999999 237.36 380.24 POSTERIOR INFLATABLE EPISTAXIS DEVICE 9.0CM RR900 49780706_1 CDM 0272 RC inpatient 392 254.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 264.99 67.6 999999999 237.36 380.24 percent of total billed charges POSTERIOR INFLATABLE EPISTAXIS DEVICE 9.0CM RR900 49780706_1 CDM 0272 RC inpatient 392 254.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 237.36 380.24 POSTERIOR INFLATABLE EPISTAXIS DEVICE 9.0CM RR900 49780706_1 CDM 0272 RC inpatient 392 254.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 237.36 380.24 "Antipsychotics levels, 1-3" 49781661_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges "Antipsychotics levels, 1-3" 49781661_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges "Antipsychotics levels, 1-3" 49781661_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges "Antipsychotics levels, 1-3" 49781661_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges "Antipsychotics levels, 1-3" 49781661_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges "Antipsychotics levels, 1-3" 49781661_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges "Antipsychotics levels, 1-3" 49781661_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges "Antipsychotics levels, 1-3" 49781661_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges "Antipsychotics levels, 1-3" 49781661_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 "Antipsychotics levels, 1-3" 49781661_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 "Antipsychotics levels, 1-3" 49781661_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 "Antipsychotics levels, 1-3" 49781661_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges "Antipsychotics levels, 1-3" 49781661_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 "Antipsychotics levels, 1-3" 49781661_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 Chromium level to test for poisoning or deficiency 49782242_1 CDM 0300 RC 82495 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges Chromium level to test for poisoning or deficiency 49782242_1 CDM 0300 RC 82495 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges Chromium level to test for poisoning or deficiency 49782242_1 CDM 0300 RC 82495 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges Chromium level to test for poisoning or deficiency 49782242_1 CDM 0300 RC 82495 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges Chromium level to test for poisoning or deficiency 49782242_1 CDM 0300 RC 82495 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges Chromium level to test for poisoning or deficiency 49782242_1 CDM 0300 RC 82495 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges Chromium level to test for poisoning or deficiency 49782242_1 CDM 0300 RC 82495 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges Chromium level to test for poisoning or deficiency 49782242_1 CDM 0300 RC 82495 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges Chromium level to test for poisoning or deficiency 49782242_1 CDM 0300 RC 82495 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 Chromium level to test for poisoning or deficiency 49782242_1 CDM 0300 RC 82495 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 Chromium level to test for poisoning or deficiency 49782242_1 CDM 0300 RC 82495 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 Chromium level to test for poisoning or deficiency 49782242_1 CDM 0300 RC 82495 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges Chromium level to test for poisoning or deficiency 49782242_1 CDM 0300 RC 82495 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 Chromium level to test for poisoning or deficiency 49782242_1 CDM 0300 RC 82495 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 Heavy metal level 49782407_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges Heavy metal level 49782407_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges Heavy metal level 49782407_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges Heavy metal level 49782407_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges Heavy metal level 49782407_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges Heavy metal level 49782407_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges Heavy metal level 49782407_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges Heavy metal level 49782407_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges Heavy metal level 49782407_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 Heavy metal level 49782407_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 Heavy metal level 49782407_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 Heavy metal level 49782407_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges Heavy metal level 49782407_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 Heavy metal level 49782407_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 "Tuberculosis test, gamma interferon" 49782626_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges "Tuberculosis test, gamma interferon" 49782626_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges "Tuberculosis test, gamma interferon" 49782626_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges "Tuberculosis test, gamma interferon" 49782626_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges "Tuberculosis test, gamma interferon" 49782626_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges "Tuberculosis test, gamma interferon" 49782626_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges "Tuberculosis test, gamma interferon" 49782626_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges "Tuberculosis test, gamma interferon" 49782626_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges "Tuberculosis test, gamma interferon" 49782626_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 "Tuberculosis test, gamma interferon" 49782626_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 "Tuberculosis test, gamma interferon" 49782626_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 "Tuberculosis test, gamma interferon" 49782626_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges "Tuberculosis test, gamma interferon" 49782626_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 "Tuberculosis test, gamma interferon" 49782626_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 BUPIVACAINE 0.25% VIAL 49782657_1 CDM 0250 RC 00409-1160-01 NDC inpatient 1 UN 31.04 20.18 AETNA AETNA 24.52 79 999999999 18.79 30.11 percent of total billed charges BUPIVACAINE 0.25% VIAL 49782657_1 CDM 0250 RC 00409-1160-01 NDC inpatient 1 UN 31.04 20.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.18 65 999999999 18.79 30.11 percent of total billed charges BUPIVACAINE 0.25% VIAL 49782657_1 CDM 0250 RC 00409-1160-01 NDC inpatient 1 UN 31.04 20.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.11 97 999999999 18.79 30.11 percent of total billed charges BUPIVACAINE 0.25% VIAL 49782657_1 CDM 0250 RC 00409-1160-01 NDC inpatient 1 UN 31.04 20.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.21 78 999999999 18.79 30.11 percent of total billed charges BUPIVACAINE 0.25% VIAL 49782657_1 CDM 0250 RC 00409-1160-01 NDC inpatient 1 UN 31.04 20.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.42 69 999999999 18.79 30.11 percent of total billed charges BUPIVACAINE 0.25% VIAL 49782657_1 CDM 0250 RC 00409-1160-01 NDC inpatient 1 UN 31.04 20.18 SIHO - ALL PLANS SIHO - ALL PLANS 27.94 90 999999999 18.79 30.11 percent of total billed charges BUPIVACAINE 0.25% VIAL 49782657_1 CDM 0250 RC 00409-1160-01 NDC inpatient 1 UN 31.04 20.18 UMR - ALL PLANS UMR - ALL PLANS 21.73 70 999999999 18.79 30.11 percent of total billed charges BUPIVACAINE 0.25% VIAL 49782657_1 CDM 0250 RC 00409-1160-01 NDC inpatient 1 UN 31.04 20.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.79 60.55 999999999 18.79 30.11 percent of total billed charges BUPIVACAINE 0.25% VIAL 49782657_1 CDM 0250 RC 00409-1160-01 NDC inpatient 1 UN 31.04 20.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.79 30.11 BUPIVACAINE 0.25% VIAL 49782657_1 CDM 0250 RC 00409-1160-01 NDC inpatient 1 UN 31.04 20.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.79 30.11 BUPIVACAINE 0.25% VIAL 49782657_1 CDM 0250 RC 00409-1160-01 NDC inpatient 1 UN 31.04 20.18 ANTHEM HMO ANTHEM HMO 999999999 18.79 30.11 BUPIVACAINE 0.25% VIAL 49782657_1 CDM 0250 RC 00409-1160-01 NDC inpatient 1 UN 31.04 20.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.98 67.6 999999999 18.79 30.11 percent of total billed charges BUPIVACAINE 0.25% VIAL 49782657_1 CDM 0250 RC 00409-1160-01 NDC inpatient 1 UN 31.04 20.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.79 30.11 BUPIVACAINE 0.25% VIAL 49782657_1 CDM 0250 RC 00409-1160-01 NDC inpatient 1 UN 31.04 20.18 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.79 30.11 CLONAZEPAM 0.5 MG TABLET 49789087_1 CDM 0250 RC 16729-0136-00 NDC inpatient 1 UN 1.26 0.82 AETNA AETNA 1 79 999999999 0.76 1.22 percent of total billed charges CLONAZEPAM 0.5 MG TABLET 49789087_1 CDM 0250 RC 16729-0136-00 NDC inpatient 1 UN 1.26 0.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.82 65 999999999 0.76 1.22 percent of total billed charges CLONAZEPAM 0.5 MG TABLET 49789087_1 CDM 0250 RC 16729-0136-00 NDC inpatient 1 UN 1.26 0.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.22 97 999999999 0.76 1.22 percent of total billed charges CLONAZEPAM 0.5 MG TABLET 49789087_1 CDM 0250 RC 16729-0136-00 NDC inpatient 1 UN 1.26 0.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.98 78 999999999 0.76 1.22 percent of total billed charges CLONAZEPAM 0.5 MG TABLET 49789087_1 CDM 0250 RC 16729-0136-00 NDC inpatient 1 UN 1.26 0.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.87 69 999999999 0.76 1.22 percent of total billed charges CLONAZEPAM 0.5 MG TABLET 49789087_1 CDM 0250 RC 16729-0136-00 NDC inpatient 1 UN 1.26 0.82 SIHO - ALL PLANS SIHO - ALL PLANS 1.13 90 999999999 0.76 1.22 percent of total billed charges CLONAZEPAM 0.5 MG TABLET 49789087_1 CDM 0250 RC 16729-0136-00 NDC inpatient 1 UN 1.26 0.82 UMR - ALL PLANS UMR - ALL PLANS 0.88 70 999999999 0.76 1.22 percent of total billed charges CLONAZEPAM 0.5 MG TABLET 49789087_1 CDM 0250 RC 16729-0136-00 NDC inpatient 1 UN 1.26 0.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.76 60.55 999999999 0.76 1.22 percent of total billed charges CLONAZEPAM 0.5 MG TABLET 49789087_1 CDM 0250 RC 16729-0136-00 NDC inpatient 1 UN 1.26 0.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.76 1.22 CLONAZEPAM 0.5 MG TABLET 49789087_1 CDM 0250 RC 16729-0136-00 NDC inpatient 1 UN 1.26 0.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.76 1.22 CLONAZEPAM 0.5 MG TABLET 49789087_1 CDM 0250 RC 16729-0136-00 NDC inpatient 1 UN 1.26 0.82 ANTHEM HMO ANTHEM HMO 999999999 0.76 1.22 CLONAZEPAM 0.5 MG TABLET 49789087_1 CDM 0250 RC 16729-0136-00 NDC inpatient 1 UN 1.26 0.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.85 67.6 999999999 0.76 1.22 percent of total billed charges CLONAZEPAM 0.5 MG TABLET 49789087_1 CDM 0250 RC 16729-0136-00 NDC inpatient 1 UN 1.26 0.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.76 1.22 CLONAZEPAM 0.5 MG TABLET 49789087_1 CDM 0250 RC 16729-0136-00 NDC inpatient 1 UN 1.26 0.82 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.76 1.22 Quantitation of therapeutic drug 49791249_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 49791249_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 49791249_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 49791249_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 49791249_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 49791249_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 49791249_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 49791249_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 49791249_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 Quantitation of therapeutic drug 49791249_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 Quantitation of therapeutic drug 49791249_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 Quantitation of therapeutic drug 49791249_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 49791249_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 Quantitation of therapeutic drug 49791249_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 "INJECTION, IPILIMUMAB, 1 MG" 49791267_1 CDM 0636 RC 00003-2327-11 NDC J9228 HCPCS inpatient 50 UN 35349.77 22977.35 AETNA AETNA 27926.32 79 999999999 21404.29 34289.28 percent of total billed charges "INJECTION, IPILIMUMAB, 1 MG" 49791267_1 CDM 0636 RC 00003-2327-11 NDC J9228 HCPCS inpatient 50 UN 35349.77 22977.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 22977.35 65 999999999 21404.29 34289.28 percent of total billed charges "INJECTION, IPILIMUMAB, 1 MG" 49791267_1 CDM 0636 RC 00003-2327-11 NDC J9228 HCPCS inpatient 50 UN 35349.77 22977.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34289.28 97 999999999 21404.29 34289.28 percent of total billed charges "INJECTION, IPILIMUMAB, 1 MG" 49791267_1 CDM 0636 RC 00003-2327-11 NDC J9228 HCPCS inpatient 50 UN 35349.77 22977.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 27572.82 78 999999999 21404.29 34289.28 percent of total billed charges "INJECTION, IPILIMUMAB, 1 MG" 49791267_1 CDM 0636 RC 00003-2327-11 NDC J9228 HCPCS inpatient 50 UN 35349.77 22977.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 24391.34 69 999999999 21404.29 34289.28 percent of total billed charges "INJECTION, IPILIMUMAB, 1 MG" 49791267_1 CDM 0636 RC 00003-2327-11 NDC J9228 HCPCS inpatient 50 UN 35349.77 22977.35 SIHO - ALL PLANS SIHO - ALL PLANS 31814.79 90 999999999 21404.29 34289.28 percent of total billed charges "INJECTION, IPILIMUMAB, 1 MG" 49791267_1 CDM 0636 RC 00003-2327-11 NDC J9228 HCPCS inpatient 50 UN 35349.77 22977.35 UMR - ALL PLANS UMR - ALL PLANS 24744.84 70 999999999 21404.29 34289.28 percent of total billed charges "INJECTION, IPILIMUMAB, 1 MG" 49791267_1 CDM 0636 RC 00003-2327-11 NDC J9228 HCPCS inpatient 50 UN 35349.77 22977.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21404.29 60.55 999999999 21404.29 34289.28 percent of total billed charges "INJECTION, IPILIMUMAB, 1 MG" 49791267_1 CDM 0636 RC 00003-2327-11 NDC J9228 HCPCS inpatient 50 UN 35349.77 22977.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21404.29 34289.28 "INJECTION, IPILIMUMAB, 1 MG" 49791267_1 CDM 0636 RC 00003-2327-11 NDC J9228 HCPCS inpatient 50 UN 35349.77 22977.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21404.29 34289.28 "INJECTION, IPILIMUMAB, 1 MG" 49791267_1 CDM 0636 RC 00003-2327-11 NDC J9228 HCPCS inpatient 50 UN 35349.77 22977.35 ANTHEM HMO ANTHEM HMO 999999999 21404.29 34289.28 "INJECTION, IPILIMUMAB, 1 MG" 49791267_1 CDM 0636 RC 00003-2327-11 NDC J9228 HCPCS inpatient 50 UN 35349.77 22977.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 23896.44 67.6 999999999 21404.29 34289.28 percent of total billed charges "INJECTION, IPILIMUMAB, 1 MG" 49791267_1 CDM 0636 RC 00003-2327-11 NDC J9228 HCPCS inpatient 50 UN 35349.77 22977.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21404.29 34289.28 "INJECTION, IPILIMUMAB, 1 MG" 49791267_1 CDM 0636 RC 00003-2327-11 NDC J9228 HCPCS inpatient 50 UN 35349.77 22977.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 21404.29 34289.28 TRIAMCINOLONE ACET 40 MG/ML VL 49791373_1 CDM 0250 RC 70121-1049-05 NDC inpatient 1 UN 36.01 23.41 AETNA AETNA 28.45 79 999999999 21.8 34.93 percent of total billed charges TRIAMCINOLONE ACET 40 MG/ML VL 49791373_1 CDM 0250 RC 70121-1049-05 NDC inpatient 1 UN 36.01 23.41 SELF PAY DISCOUNT SELF PAY DISCOUNT 23.41 65 999999999 21.8 34.93 percent of total billed charges TRIAMCINOLONE ACET 40 MG/ML VL 49791373_1 CDM 0250 RC 70121-1049-05 NDC inpatient 1 UN 36.01 23.41 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34.93 97 999999999 21.8 34.93 percent of total billed charges TRIAMCINOLONE ACET 40 MG/ML VL 49791373_1 CDM 0250 RC 70121-1049-05 NDC inpatient 1 UN 36.01 23.41 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.09 78 999999999 21.8 34.93 percent of total billed charges TRIAMCINOLONE ACET 40 MG/ML VL 49791373_1 CDM 0250 RC 70121-1049-05 NDC inpatient 1 UN 36.01 23.41 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.85 69 999999999 21.8 34.93 percent of total billed charges TRIAMCINOLONE ACET 40 MG/ML VL 49791373_1 CDM 0250 RC 70121-1049-05 NDC inpatient 1 UN 36.01 23.41 SIHO - ALL PLANS SIHO - ALL PLANS 32.41 90 999999999 21.8 34.93 percent of total billed charges TRIAMCINOLONE ACET 40 MG/ML VL 49791373_1 CDM 0250 RC 70121-1049-05 NDC inpatient 1 UN 36.01 23.41 UMR - ALL PLANS UMR - ALL PLANS 25.21 70 999999999 21.8 34.93 percent of total billed charges TRIAMCINOLONE ACET 40 MG/ML VL 49791373_1 CDM 0250 RC 70121-1049-05 NDC inpatient 1 UN 36.01 23.41 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.8 60.55 999999999 21.8 34.93 percent of total billed charges TRIAMCINOLONE ACET 40 MG/ML VL 49791373_1 CDM 0250 RC 70121-1049-05 NDC inpatient 1 UN 36.01 23.41 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.8 34.93 TRIAMCINOLONE ACET 40 MG/ML VL 49791373_1 CDM 0250 RC 70121-1049-05 NDC inpatient 1 UN 36.01 23.41 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.8 34.93 TRIAMCINOLONE ACET 40 MG/ML VL 49791373_1 CDM 0250 RC 70121-1049-05 NDC inpatient 1 UN 36.01 23.41 ANTHEM HMO ANTHEM HMO 999999999 21.8 34.93 TRIAMCINOLONE ACET 40 MG/ML VL 49791373_1 CDM 0250 RC 70121-1049-05 NDC inpatient 1 UN 36.01 23.41 CIGNA - ALL PLANS CIGNA - ALL PLANS 24.34 67.6 999999999 21.8 34.93 percent of total billed charges TRIAMCINOLONE ACET 40 MG/ML VL 49791373_1 CDM 0250 RC 70121-1049-05 NDC inpatient 1 UN 36.01 23.41 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.8 34.93 TRIAMCINOLONE ACET 40 MG/ML VL 49791373_1 CDM 0250 RC 70121-1049-05 NDC inpatient 1 UN 36.01 23.41 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.8 34.93 BACTERIOSTATIC SALINE VIAL 49791403_1 CDM 0250 RC 63323-0924-30 NDC inpatient 1 UN 17.44 11.34 AETNA AETNA 13.78 79 999999999 10.56 16.92 percent of total billed charges BACTERIOSTATIC SALINE VIAL 49791403_1 CDM 0250 RC 63323-0924-30 NDC inpatient 1 UN 17.44 11.34 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.34 65 999999999 10.56 16.92 percent of total billed charges BACTERIOSTATIC SALINE VIAL 49791403_1 CDM 0250 RC 63323-0924-30 NDC inpatient 1 UN 17.44 11.34 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16.92 97 999999999 10.56 16.92 percent of total billed charges BACTERIOSTATIC SALINE VIAL 49791403_1 CDM 0250 RC 63323-0924-30 NDC inpatient 1 UN 17.44 11.34 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.6 78 999999999 10.56 16.92 percent of total billed charges BACTERIOSTATIC SALINE VIAL 49791403_1 CDM 0250 RC 63323-0924-30 NDC inpatient 1 UN 17.44 11.34 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.03 69 999999999 10.56 16.92 percent of total billed charges BACTERIOSTATIC SALINE VIAL 49791403_1 CDM 0250 RC 63323-0924-30 NDC inpatient 1 UN 17.44 11.34 SIHO - ALL PLANS SIHO - ALL PLANS 15.7 90 999999999 10.56 16.92 percent of total billed charges BACTERIOSTATIC SALINE VIAL 49791403_1 CDM 0250 RC 63323-0924-30 NDC inpatient 1 UN 17.44 11.34 UMR - ALL PLANS UMR - ALL PLANS 12.21 70 999999999 10.56 16.92 percent of total billed charges BACTERIOSTATIC SALINE VIAL 49791403_1 CDM 0250 RC 63323-0924-30 NDC inpatient 1 UN 17.44 11.34 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.56 60.55 999999999 10.56 16.92 percent of total billed charges BACTERIOSTATIC SALINE VIAL 49791403_1 CDM 0250 RC 63323-0924-30 NDC inpatient 1 UN 17.44 11.34 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.56 16.92 BACTERIOSTATIC SALINE VIAL 49791403_1 CDM 0250 RC 63323-0924-30 NDC inpatient 1 UN 17.44 11.34 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.56 16.92 BACTERIOSTATIC SALINE VIAL 49791403_1 CDM 0250 RC 63323-0924-30 NDC inpatient 1 UN 17.44 11.34 ANTHEM HMO ANTHEM HMO 999999999 10.56 16.92 BACTERIOSTATIC SALINE VIAL 49791403_1 CDM 0250 RC 63323-0924-30 NDC inpatient 1 UN 17.44 11.34 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.79 67.6 999999999 10.56 16.92 percent of total billed charges BACTERIOSTATIC SALINE VIAL 49791403_1 CDM 0250 RC 63323-0924-30 NDC inpatient 1 UN 17.44 11.34 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.56 16.92 BACTERIOSTATIC SALINE VIAL 49791403_1 CDM 0250 RC 63323-0924-30 NDC inpatient 1 UN 17.44 11.34 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.56 16.92 ERYTHROMYCIN 0.5% EYE OINTMENT 49791406_1 CDM 0250 RC 00574-4024-35 NDC inpatient 1 UN 108.99 70.84 AETNA AETNA 86.1 79 999999999 65.99 105.72 percent of total billed charges ERYTHROMYCIN 0.5% EYE OINTMENT 49791406_1 CDM 0250 RC 00574-4024-35 NDC inpatient 1 UN 108.99 70.84 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.84 65 999999999 65.99 105.72 percent of total billed charges ERYTHROMYCIN 0.5% EYE OINTMENT 49791406_1 CDM 0250 RC 00574-4024-35 NDC inpatient 1 UN 108.99 70.84 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.72 97 999999999 65.99 105.72 percent of total billed charges ERYTHROMYCIN 0.5% EYE OINTMENT 49791406_1 CDM 0250 RC 00574-4024-35 NDC inpatient 1 UN 108.99 70.84 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.01 78 999999999 65.99 105.72 percent of total billed charges ERYTHROMYCIN 0.5% EYE OINTMENT 49791406_1 CDM 0250 RC 00574-4024-35 NDC inpatient 1 UN 108.99 70.84 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.2 69 999999999 65.99 105.72 percent of total billed charges ERYTHROMYCIN 0.5% EYE OINTMENT 49791406_1 CDM 0250 RC 00574-4024-35 NDC inpatient 1 UN 108.99 70.84 SIHO - ALL PLANS SIHO - ALL PLANS 98.09 90 999999999 65.99 105.72 percent of total billed charges ERYTHROMYCIN 0.5% EYE OINTMENT 49791406_1 CDM 0250 RC 00574-4024-35 NDC inpatient 1 UN 108.99 70.84 UMR - ALL PLANS UMR - ALL PLANS 76.29 70 999999999 65.99 105.72 percent of total billed charges ERYTHROMYCIN 0.5% EYE OINTMENT 49791406_1 CDM 0250 RC 00574-4024-35 NDC inpatient 1 UN 108.99 70.84 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 65.99 60.55 999999999 65.99 105.72 percent of total billed charges ERYTHROMYCIN 0.5% EYE OINTMENT 49791406_1 CDM 0250 RC 00574-4024-35 NDC inpatient 1 UN 108.99 70.84 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 65.99 105.72 ERYTHROMYCIN 0.5% EYE OINTMENT 49791406_1 CDM 0250 RC 00574-4024-35 NDC inpatient 1 UN 108.99 70.84 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 65.99 105.72 ERYTHROMYCIN 0.5% EYE OINTMENT 49791406_1 CDM 0250 RC 00574-4024-35 NDC inpatient 1 UN 108.99 70.84 ANTHEM HMO ANTHEM HMO 999999999 65.99 105.72 ERYTHROMYCIN 0.5% EYE OINTMENT 49791406_1 CDM 0250 RC 00574-4024-35 NDC inpatient 1 UN 108.99 70.84 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 65.99 105.72 percent of total billed charges ERYTHROMYCIN 0.5% EYE OINTMENT 49791406_1 CDM 0250 RC 00574-4024-35 NDC inpatient 1 UN 108.99 70.84 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 65.99 105.72 ERYTHROMYCIN 0.5% EYE OINTMENT 49791406_1 CDM 0250 RC 00574-4024-35 NDC inpatient 1 UN 108.99 70.84 UHC - ALL PLANS UHC - ALL PLANS 999999999 65.99 105.72 VECURONIUM 10 MG VIAL 49795694_1 CDM 0250 RC 00703-2914-03 NDC inpatient 1 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges VECURONIUM 10 MG VIAL 49795694_1 CDM 0250 RC 00703-2914-03 NDC inpatient 1 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges VECURONIUM 10 MG VIAL 49795694_1 CDM 0250 RC 00703-2914-03 NDC inpatient 1 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges VECURONIUM 10 MG VIAL 49795694_1 CDM 0250 RC 00703-2914-03 NDC inpatient 1 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges VECURONIUM 10 MG VIAL 49795694_1 CDM 0250 RC 00703-2914-03 NDC inpatient 1 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges VECURONIUM 10 MG VIAL 49795694_1 CDM 0250 RC 00703-2914-03 NDC inpatient 1 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges VECURONIUM 10 MG VIAL 49795694_1 CDM 0250 RC 00703-2914-03 NDC inpatient 1 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges VECURONIUM 10 MG VIAL 49795694_1 CDM 0250 RC 00703-2914-03 NDC inpatient 1 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges VECURONIUM 10 MG VIAL 49795694_1 CDM 0250 RC 00703-2914-03 NDC inpatient 1 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 VECURONIUM 10 MG VIAL 49795694_1 CDM 0250 RC 00703-2914-03 NDC inpatient 1 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 VECURONIUM 10 MG VIAL 49795694_1 CDM 0250 RC 00703-2914-03 NDC inpatient 1 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 VECURONIUM 10 MG VIAL 49795694_1 CDM 0250 RC 00703-2914-03 NDC inpatient 1 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges VECURONIUM 10 MG VIAL 49795694_1 CDM 0250 RC 00703-2914-03 NDC inpatient 1 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 VECURONIUM 10 MG VIAL 49795694_1 CDM 0250 RC 00703-2914-03 NDC inpatient 1 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 "Insulin measurement, free" 49801615_1 CDM 0301 RC 83527 HCPCS inpatient 66 42.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.9 65 999999999 39.96 64.02 percent of total billed charges "Insulin measurement, free" 49801615_1 CDM 0301 RC 83527 HCPCS inpatient 66 42.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.02 97 999999999 39.96 64.02 percent of total billed charges "Insulin measurement, free" 49801615_1 CDM 0301 RC 83527 HCPCS inpatient 66 42.9 AETNA AETNA 52.14 79 999999999 39.96 64.02 percent of total billed charges "Insulin measurement, free" 49801615_1 CDM 0301 RC 83527 HCPCS inpatient 66 42.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.48 78 999999999 39.96 64.02 percent of total billed charges "Insulin measurement, free" 49801615_1 CDM 0301 RC 83527 HCPCS inpatient 66 42.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.54 69 999999999 39.96 64.02 percent of total billed charges "Insulin measurement, free" 49801615_1 CDM 0301 RC 83527 HCPCS inpatient 66 42.9 SIHO - ALL PLANS SIHO - ALL PLANS 59.4 90 999999999 39.96 64.02 percent of total billed charges "Insulin measurement, free" 49801615_1 CDM 0301 RC 83527 HCPCS inpatient 66 42.9 UMR - ALL PLANS UMR - ALL PLANS 46.2 70 999999999 39.96 64.02 percent of total billed charges "Insulin measurement, free" 49801615_1 CDM 0301 RC 83527 HCPCS inpatient 66 42.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.96 60.55 999999999 39.96 64.02 percent of total billed charges "Insulin measurement, free" 49801615_1 CDM 0301 RC 83527 HCPCS inpatient 66 42.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.96 64.02 "Insulin measurement, free" 49801615_1 CDM 0301 RC 83527 HCPCS inpatient 66 42.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.96 64.02 "Insulin measurement, free" 49801615_1 CDM 0301 RC 83527 HCPCS inpatient 66 42.9 ANTHEM HMO ANTHEM HMO 999999999 39.96 64.02 "Insulin measurement, free" 49801615_1 CDM 0301 RC 83527 HCPCS inpatient 66 42.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.62 67.6 999999999 39.96 64.02 percent of total billed charges "Insulin measurement, free" 49801615_1 CDM 0301 RC 83527 HCPCS inpatient 66 42.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.96 64.02 "Insulin measurement, free" 49801615_1 CDM 0301 RC 83527 HCPCS inpatient 66 42.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.96 64.02 Microsatellite instability analysis 49802031_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 843.05 65 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 49802031_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1258.09 97 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 49802031_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 AETNA AETNA 1024.63 79 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 49802031_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1011.66 78 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 49802031_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 894.93 69 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 49802031_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 SIHO - ALL PLANS SIHO - ALL PLANS 1167.3 90 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 49802031_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 UMR - ALL PLANS UMR - ALL PLANS 907.9 70 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 49802031_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 785.33 60.55 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 49802031_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 785.33 1258.09 Microsatellite instability analysis 49802031_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 785.33 1258.09 Microsatellite instability analysis 49802031_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 ANTHEM HMO ANTHEM HMO 999999999 785.33 1258.09 Microsatellite instability analysis 49802031_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 876.77 67.6 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 49802031_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 785.33 1258.09 Microsatellite instability analysis 49802031_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 785.33 1258.09 "Analysis of substance using immunoassay technique, multiple step method" 49802256_1 CDM 0302 RC 83516 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49802256_1 CDM 0302 RC 83516 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49802256_1 CDM 0302 RC 83516 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49802256_1 CDM 0302 RC 83516 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49802256_1 CDM 0302 RC 83516 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49802256_1 CDM 0302 RC 83516 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49802256_1 CDM 0302 RC 83516 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49802256_1 CDM 0302 RC 83516 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49802256_1 CDM 0302 RC 83516 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49802256_1 CDM 0302 RC 83516 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49802256_1 CDM 0302 RC 83516 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49802256_1 CDM 0302 RC 83516 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49802256_1 CDM 0302 RC 83516 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49802256_1 CDM 0302 RC 83516 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 White blood cell antigen measurement 49802298_1 CDM 0302 RC 86356 HCPCS inpatient 225 146.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 146.25 65 999999999 136.24 218.25 percent of total billed charges White blood cell antigen measurement 49802298_1 CDM 0302 RC 86356 HCPCS inpatient 225 146.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 218.25 97 999999999 136.24 218.25 percent of total billed charges White blood cell antigen measurement 49802298_1 CDM 0302 RC 86356 HCPCS inpatient 225 146.25 AETNA AETNA 177.75 79 999999999 136.24 218.25 percent of total billed charges White blood cell antigen measurement 49802298_1 CDM 0302 RC 86356 HCPCS inpatient 225 146.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 175.5 78 999999999 136.24 218.25 percent of total billed charges White blood cell antigen measurement 49802298_1 CDM 0302 RC 86356 HCPCS inpatient 225 146.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 155.25 69 999999999 136.24 218.25 percent of total billed charges White blood cell antigen measurement 49802298_1 CDM 0302 RC 86356 HCPCS inpatient 225 146.25 SIHO - ALL PLANS SIHO - ALL PLANS 202.5 90 999999999 136.24 218.25 percent of total billed charges White blood cell antigen measurement 49802298_1 CDM 0302 RC 86356 HCPCS inpatient 225 146.25 UMR - ALL PLANS UMR - ALL PLANS 157.5 70 999999999 136.24 218.25 percent of total billed charges White blood cell antigen measurement 49802298_1 CDM 0302 RC 86356 HCPCS inpatient 225 146.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 136.24 60.55 999999999 136.24 218.25 percent of total billed charges White blood cell antigen measurement 49802298_1 CDM 0302 RC 86356 HCPCS inpatient 225 146.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 136.24 218.25 White blood cell antigen measurement 49802298_1 CDM 0302 RC 86356 HCPCS inpatient 225 146.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 136.24 218.25 White blood cell antigen measurement 49802298_1 CDM 0302 RC 86356 HCPCS inpatient 225 146.25 ANTHEM HMO ANTHEM HMO 999999999 136.24 218.25 White blood cell antigen measurement 49802298_1 CDM 0302 RC 86356 HCPCS inpatient 225 146.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 152.1 67.6 999999999 136.24 218.25 percent of total billed charges White blood cell antigen measurement 49802298_1 CDM 0302 RC 86356 HCPCS inpatient 225 146.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 136.24 218.25 White blood cell antigen measurement 49802298_1 CDM 0302 RC 86356 HCPCS inpatient 225 146.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 136.24 218.25 Very long chain fatty acids level 49802451_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 303.55 65 999999999 282.77 452.99 percent of total billed charges Very long chain fatty acids level 49802451_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 452.99 97 999999999 282.77 452.99 percent of total billed charges Very long chain fatty acids level 49802451_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 AETNA AETNA 368.93 79 999999999 282.77 452.99 percent of total billed charges Very long chain fatty acids level 49802451_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 364.26 78 999999999 282.77 452.99 percent of total billed charges Very long chain fatty acids level 49802451_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 322.23 69 999999999 282.77 452.99 percent of total billed charges Very long chain fatty acids level 49802451_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 SIHO - ALL PLANS SIHO - ALL PLANS 420.3 90 999999999 282.77 452.99 percent of total billed charges Very long chain fatty acids level 49802451_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 UMR - ALL PLANS UMR - ALL PLANS 326.9 70 999999999 282.77 452.99 percent of total billed charges Very long chain fatty acids level 49802451_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 282.77 60.55 999999999 282.77 452.99 percent of total billed charges Very long chain fatty acids level 49802451_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 282.77 452.99 Very long chain fatty acids level 49802451_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 282.77 452.99 Very long chain fatty acids level 49802451_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 ANTHEM HMO ANTHEM HMO 999999999 282.77 452.99 Very long chain fatty acids level 49802451_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 315.69 67.6 999999999 282.77 452.99 percent of total billed charges Very long chain fatty acids level 49802451_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 282.77 452.99 Very long chain fatty acids level 49802451_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 282.77 452.99 Molecular pathology procedure level 7 49802625_1 CDM 0301 RC 81406 HCPCS inpatient 5948 3866.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 3866.2 65 999999999 3601.51 5769.56 percent of total billed charges Molecular pathology procedure level 7 49802625_1 CDM 0301 RC 81406 HCPCS inpatient 5948 3866.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5769.56 97 999999999 3601.51 5769.56 percent of total billed charges Molecular pathology procedure level 7 49802625_1 CDM 0301 RC 81406 HCPCS inpatient 5948 3866.2 AETNA AETNA 4698.92 79 999999999 3601.51 5769.56 percent of total billed charges Molecular pathology procedure level 7 49802625_1 CDM 0301 RC 81406 HCPCS inpatient 5948 3866.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 4639.44 78 999999999 3601.51 5769.56 percent of total billed charges Molecular pathology procedure level 7 49802625_1 CDM 0301 RC 81406 HCPCS inpatient 5948 3866.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 4104.12 69 999999999 3601.51 5769.56 percent of total billed charges Molecular pathology procedure level 7 49802625_1 CDM 0301 RC 81406 HCPCS inpatient 5948 3866.2 SIHO - ALL PLANS SIHO - ALL PLANS 5353.2 90 999999999 3601.51 5769.56 percent of total billed charges Molecular pathology procedure level 7 49802625_1 CDM 0301 RC 81406 HCPCS inpatient 5948 3866.2 UMR - ALL PLANS UMR - ALL PLANS 4163.6 70 999999999 3601.51 5769.56 percent of total billed charges Molecular pathology procedure level 7 49802625_1 CDM 0301 RC 81406 HCPCS inpatient 5948 3866.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3601.51 60.55 999999999 3601.51 5769.56 percent of total billed charges Molecular pathology procedure level 7 49802625_1 CDM 0301 RC 81406 HCPCS inpatient 5948 3866.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3601.51 5769.56 Molecular pathology procedure level 7 49802625_1 CDM 0301 RC 81406 HCPCS inpatient 5948 3866.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3601.51 5769.56 Molecular pathology procedure level 7 49802625_1 CDM 0301 RC 81406 HCPCS inpatient 5948 3866.2 ANTHEM HMO ANTHEM HMO 999999999 3601.51 5769.56 Molecular pathology procedure level 7 49802625_1 CDM 0301 RC 81406 HCPCS inpatient 5948 3866.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 4020.85 67.6 999999999 3601.51 5769.56 percent of total billed charges Molecular pathology procedure level 7 49802625_1 CDM 0301 RC 81406 HCPCS inpatient 5948 3866.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3601.51 5769.56 Molecular pathology procedure level 7 49802625_1 CDM 0301 RC 81406 HCPCS inpatient 5948 3866.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 3601.51 5769.56 Gene analysis (fragile X mental retardation) abnormal alleles 49802630_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges Gene analysis (fragile X mental retardation) abnormal alleles 49802630_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges Gene analysis (fragile X mental retardation) abnormal alleles 49802630_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges Gene analysis (fragile X mental retardation) abnormal alleles 49802630_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges Gene analysis (fragile X mental retardation) abnormal alleles 49802630_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges Gene analysis (fragile X mental retardation) abnormal alleles 49802630_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges Gene analysis (fragile X mental retardation) abnormal alleles 49802630_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges Gene analysis (fragile X mental retardation) abnormal alleles 49802630_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges Gene analysis (fragile X mental retardation) abnormal alleles 49802630_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 Gene analysis (fragile X mental retardation) abnormal alleles 49802630_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 Gene analysis (fragile X mental retardation) abnormal alleles 49802630_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 Gene analysis (fragile X mental retardation) abnormal alleles 49802630_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges Gene analysis (fragile X mental retardation) abnormal alleles 49802630_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 Gene analysis (fragile X mental retardation) abnormal alleles 49802630_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Gene analysis (fragile X mental retardation 1) for characterization of alleles 49802631_1 CDM 0301 RC 81244 HCPCS inpatient 256 166.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 166.4 65 999999999 155.01 248.32 percent of total billed charges Gene analysis (fragile X mental retardation 1) for characterization of alleles 49802631_1 CDM 0301 RC 81244 HCPCS inpatient 256 166.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 248.32 97 999999999 155.01 248.32 percent of total billed charges Gene analysis (fragile X mental retardation 1) for characterization of alleles 49802631_1 CDM 0301 RC 81244 HCPCS inpatient 256 166.4 AETNA AETNA 202.24 79 999999999 155.01 248.32 percent of total billed charges Gene analysis (fragile X mental retardation 1) for characterization of alleles 49802631_1 CDM 0301 RC 81244 HCPCS inpatient 256 166.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 199.68 78 999999999 155.01 248.32 percent of total billed charges Gene analysis (fragile X mental retardation 1) for characterization of alleles 49802631_1 CDM 0301 RC 81244 HCPCS inpatient 256 166.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 176.64 69 999999999 155.01 248.32 percent of total billed charges Gene analysis (fragile X mental retardation 1) for characterization of alleles 49802631_1 CDM 0301 RC 81244 HCPCS inpatient 256 166.4 SIHO - ALL PLANS SIHO - ALL PLANS 230.4 90 999999999 155.01 248.32 percent of total billed charges Gene analysis (fragile X mental retardation 1) for characterization of alleles 49802631_1 CDM 0301 RC 81244 HCPCS inpatient 256 166.4 UMR - ALL PLANS UMR - ALL PLANS 179.2 70 999999999 155.01 248.32 percent of total billed charges Gene analysis (fragile X mental retardation 1) for characterization of alleles 49802631_1 CDM 0301 RC 81244 HCPCS inpatient 256 166.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.01 60.55 999999999 155.01 248.32 percent of total billed charges Gene analysis (fragile X mental retardation 1) for characterization of alleles 49802631_1 CDM 0301 RC 81244 HCPCS inpatient 256 166.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.01 248.32 Gene analysis (fragile X mental retardation 1) for characterization of alleles 49802631_1 CDM 0301 RC 81244 HCPCS inpatient 256 166.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.01 248.32 Gene analysis (fragile X mental retardation 1) for characterization of alleles 49802631_1 CDM 0301 RC 81244 HCPCS inpatient 256 166.4 ANTHEM HMO ANTHEM HMO 999999999 155.01 248.32 Gene analysis (fragile X mental retardation 1) for characterization of alleles 49802631_1 CDM 0301 RC 81244 HCPCS inpatient 256 166.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.06 67.6 999999999 155.01 248.32 percent of total billed charges Gene analysis (fragile X mental retardation 1) for characterization of alleles 49802631_1 CDM 0301 RC 81244 HCPCS inpatient 256 166.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.01 248.32 Gene analysis (fragile X mental retardation 1) for characterization of alleles 49802631_1 CDM 0301 RC 81244 HCPCS inpatient 256 166.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.01 248.32 "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 49805784_1 CDM 0250 RC 00409-4755-03 NDC J2405 HCPCS inpatient 4 UN 19.6 12.74 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.74 65 999999999 11.87 19.01 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 49805784_1 CDM 0250 RC 00409-4755-03 NDC J2405 HCPCS inpatient 4 UN 19.6 12.74 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.01 97 999999999 11.87 19.01 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 49805784_1 CDM 0250 RC 00409-4755-03 NDC J2405 HCPCS inpatient 4 UN 19.6 12.74 AETNA AETNA 15.48 79 999999999 11.87 19.01 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 49805784_1 CDM 0250 RC 00409-4755-03 NDC J2405 HCPCS inpatient 4 UN 19.6 12.74 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.29 78 999999999 11.87 19.01 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 49805784_1 CDM 0250 RC 00409-4755-03 NDC J2405 HCPCS inpatient 4 UN 19.6 12.74 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.52 69 999999999 11.87 19.01 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 49805784_1 CDM 0250 RC 00409-4755-03 NDC J2405 HCPCS inpatient 4 UN 19.6 12.74 SIHO - ALL PLANS SIHO - ALL PLANS 17.64 90 999999999 11.87 19.01 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 49805784_1 CDM 0250 RC 00409-4755-03 NDC J2405 HCPCS inpatient 4 UN 19.6 12.74 UMR - ALL PLANS UMR - ALL PLANS 13.72 70 999999999 11.87 19.01 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 49805784_1 CDM 0250 RC 00409-4755-03 NDC J2405 HCPCS inpatient 4 UN 19.6 12.74 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.87 60.55 999999999 11.87 19.01 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 49805784_1 CDM 0250 RC 00409-4755-03 NDC J2405 HCPCS inpatient 4 UN 19.6 12.74 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.87 19.01 "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 49805784_1 CDM 0250 RC 00409-4755-03 NDC J2405 HCPCS inpatient 4 UN 19.6 12.74 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.87 19.01 "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 49805784_1 CDM 0250 RC 00409-4755-03 NDC J2405 HCPCS inpatient 4 UN 19.6 12.74 ANTHEM HMO ANTHEM HMO 999999999 11.87 19.01 "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 49805784_1 CDM 0250 RC 00409-4755-03 NDC J2405 HCPCS inpatient 4 UN 19.6 12.74 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.25 67.6 999999999 11.87 19.01 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 49805784_1 CDM 0250 RC 00409-4755-03 NDC J2405 HCPCS inpatient 4 UN 19.6 12.74 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.87 19.01 "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 49805784_1 CDM 0250 RC 00409-4755-03 NDC J2405 HCPCS inpatient 4 UN 19.6 12.74 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.87 19.01 AIRWAY I-GEL SIZE 3 SM ADULT 8203000 49807664_1 CDM 0272 RC inpatient 47 30.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 30.55 65 999999999 28.46 45.59 percent of total billed charges AIRWAY I-GEL SIZE 3 SM ADULT 8203000 49807664_1 CDM 0272 RC inpatient 47 30.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 45.59 97 999999999 28.46 45.59 percent of total billed charges AIRWAY I-GEL SIZE 3 SM ADULT 8203000 49807664_1 CDM 0272 RC inpatient 47 30.55 AETNA AETNA 37.13 79 999999999 28.46 45.59 percent of total billed charges AIRWAY I-GEL SIZE 3 SM ADULT 8203000 49807664_1 CDM 0272 RC inpatient 47 30.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 36.66 78 999999999 28.46 45.59 percent of total billed charges AIRWAY I-GEL SIZE 3 SM ADULT 8203000 49807664_1 CDM 0272 RC inpatient 47 30.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 32.43 69 999999999 28.46 45.59 percent of total billed charges AIRWAY I-GEL SIZE 3 SM ADULT 8203000 49807664_1 CDM 0272 RC inpatient 47 30.55 SIHO - ALL PLANS SIHO - ALL PLANS 42.3 90 999999999 28.46 45.59 percent of total billed charges AIRWAY I-GEL SIZE 3 SM ADULT 8203000 49807664_1 CDM 0272 RC inpatient 47 30.55 UMR - ALL PLANS UMR - ALL PLANS 32.9 70 999999999 28.46 45.59 percent of total billed charges AIRWAY I-GEL SIZE 3 SM ADULT 8203000 49807664_1 CDM 0272 RC inpatient 47 30.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 28.46 60.55 999999999 28.46 45.59 percent of total billed charges AIRWAY I-GEL SIZE 3 SM ADULT 8203000 49807664_1 CDM 0272 RC inpatient 47 30.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 28.46 45.59 AIRWAY I-GEL SIZE 3 SM ADULT 8203000 49807664_1 CDM 0272 RC inpatient 47 30.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 28.46 45.59 AIRWAY I-GEL SIZE 3 SM ADULT 8203000 49807664_1 CDM 0272 RC inpatient 47 30.55 ANTHEM HMO ANTHEM HMO 999999999 28.46 45.59 AIRWAY I-GEL SIZE 3 SM ADULT 8203000 49807664_1 CDM 0272 RC inpatient 47 30.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 31.77 67.6 999999999 28.46 45.59 percent of total billed charges AIRWAY I-GEL SIZE 3 SM ADULT 8203000 49807664_1 CDM 0272 RC inpatient 47 30.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 28.46 45.59 AIRWAY I-GEL SIZE 3 SM ADULT 8203000 49807664_1 CDM 0272 RC inpatient 47 30.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 28.46 45.59 AIRWAY I-GEL SIZE 4 MED ADULT 8204000 49807665_1 CDM 0272 RC inpatient 47 30.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 30.55 65 999999999 28.46 45.59 percent of total billed charges AIRWAY I-GEL SIZE 4 MED ADULT 8204000 49807665_1 CDM 0272 RC inpatient 47 30.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 45.59 97 999999999 28.46 45.59 percent of total billed charges AIRWAY I-GEL SIZE 4 MED ADULT 8204000 49807665_1 CDM 0272 RC inpatient 47 30.55 AETNA AETNA 37.13 79 999999999 28.46 45.59 percent of total billed charges AIRWAY I-GEL SIZE 4 MED ADULT 8204000 49807665_1 CDM 0272 RC inpatient 47 30.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 36.66 78 999999999 28.46 45.59 percent of total billed charges AIRWAY I-GEL SIZE 4 MED ADULT 8204000 49807665_1 CDM 0272 RC inpatient 47 30.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 32.43 69 999999999 28.46 45.59 percent of total billed charges AIRWAY I-GEL SIZE 4 MED ADULT 8204000 49807665_1 CDM 0272 RC inpatient 47 30.55 SIHO - ALL PLANS SIHO - ALL PLANS 42.3 90 999999999 28.46 45.59 percent of total billed charges AIRWAY I-GEL SIZE 4 MED ADULT 8204000 49807665_1 CDM 0272 RC inpatient 47 30.55 UMR - ALL PLANS UMR - ALL PLANS 32.9 70 999999999 28.46 45.59 percent of total billed charges AIRWAY I-GEL SIZE 4 MED ADULT 8204000 49807665_1 CDM 0272 RC inpatient 47 30.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 28.46 60.55 999999999 28.46 45.59 percent of total billed charges AIRWAY I-GEL SIZE 4 MED ADULT 8204000 49807665_1 CDM 0272 RC inpatient 47 30.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 28.46 45.59 AIRWAY I-GEL SIZE 4 MED ADULT 8204000 49807665_1 CDM 0272 RC inpatient 47 30.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 28.46 45.59 AIRWAY I-GEL SIZE 4 MED ADULT 8204000 49807665_1 CDM 0272 RC inpatient 47 30.55 ANTHEM HMO ANTHEM HMO 999999999 28.46 45.59 AIRWAY I-GEL SIZE 4 MED ADULT 8204000 49807665_1 CDM 0272 RC inpatient 47 30.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 31.77 67.6 999999999 28.46 45.59 percent of total billed charges AIRWAY I-GEL SIZE 4 MED ADULT 8204000 49807665_1 CDM 0272 RC inpatient 47 30.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 28.46 45.59 AIRWAY I-GEL SIZE 4 MED ADULT 8204000 49807665_1 CDM 0272 RC inpatient 47 30.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 28.46 45.59 AIRWAY I-GEL SIZE 5 LG ADULT 8205000 49807666_1 CDM 0272 RC inpatient 48 31.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.2 65 999999999 29.06 46.56 percent of total billed charges AIRWAY I-GEL SIZE 5 LG ADULT 8205000 49807666_1 CDM 0272 RC inpatient 48 31.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 46.56 97 999999999 29.06 46.56 percent of total billed charges AIRWAY I-GEL SIZE 5 LG ADULT 8205000 49807666_1 CDM 0272 RC inpatient 48 31.2 AETNA AETNA 37.92 79 999999999 29.06 46.56 percent of total billed charges AIRWAY I-GEL SIZE 5 LG ADULT 8205000 49807666_1 CDM 0272 RC inpatient 48 31.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 37.44 78 999999999 29.06 46.56 percent of total billed charges AIRWAY I-GEL SIZE 5 LG ADULT 8205000 49807666_1 CDM 0272 RC inpatient 48 31.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.12 69 999999999 29.06 46.56 percent of total billed charges AIRWAY I-GEL SIZE 5 LG ADULT 8205000 49807666_1 CDM 0272 RC inpatient 48 31.2 SIHO - ALL PLANS SIHO - ALL PLANS 43.2 90 999999999 29.06 46.56 percent of total billed charges AIRWAY I-GEL SIZE 5 LG ADULT 8205000 49807666_1 CDM 0272 RC inpatient 48 31.2 UMR - ALL PLANS UMR - ALL PLANS 33.6 70 999999999 29.06 46.56 percent of total billed charges AIRWAY I-GEL SIZE 5 LG ADULT 8205000 49807666_1 CDM 0272 RC inpatient 48 31.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.06 60.55 999999999 29.06 46.56 percent of total billed charges AIRWAY I-GEL SIZE 5 LG ADULT 8205000 49807666_1 CDM 0272 RC inpatient 48 31.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.06 46.56 AIRWAY I-GEL SIZE 5 LG ADULT 8205000 49807666_1 CDM 0272 RC inpatient 48 31.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.06 46.56 AIRWAY I-GEL SIZE 5 LG ADULT 8205000 49807666_1 CDM 0272 RC inpatient 48 31.2 ANTHEM HMO ANTHEM HMO 999999999 29.06 46.56 AIRWAY I-GEL SIZE 5 LG ADULT 8205000 49807666_1 CDM 0272 RC inpatient 48 31.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 32.45 67.6 999999999 29.06 46.56 percent of total billed charges AIRWAY I-GEL SIZE 5 LG ADULT 8205000 49807666_1 CDM 0272 RC inpatient 48 31.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.06 46.56 AIRWAY I-GEL SIZE 5 LG ADULT 8205000 49807666_1 CDM 0272 RC inpatient 48 31.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.06 46.56 Rabies vaccine for injection into muscle 49809361_1 CDM 0250 RC 58160-0964-12 NDC 90675 HCPCS inpatient 1 UN 482.91 313.89 SELF PAY DISCOUNT SELF PAY DISCOUNT 313.89 65 999999999 292.4 468.42 percent of total billed charges Rabies vaccine for injection into muscle 49809361_1 CDM 0250 RC 58160-0964-12 NDC 90675 HCPCS inpatient 1 UN 482.91 313.89 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 468.42 97 999999999 292.4 468.42 percent of total billed charges Rabies vaccine for injection into muscle 49809361_1 CDM 0250 RC 58160-0964-12 NDC 90675 HCPCS inpatient 1 UN 482.91 313.89 AETNA AETNA 381.5 79 999999999 292.4 468.42 percent of total billed charges Rabies vaccine for injection into muscle 49809361_1 CDM 0250 RC 58160-0964-12 NDC 90675 HCPCS inpatient 1 UN 482.91 313.89 HUMANA - ALL PLANS HUMANA - ALL PLANS 376.67 78 999999999 292.4 468.42 percent of total billed charges Rabies vaccine for injection into muscle 49809361_1 CDM 0250 RC 58160-0964-12 NDC 90675 HCPCS inpatient 1 UN 482.91 313.89 ENCORE - ALL PLANS ENCORE - ALL PLANS 333.21 69 999999999 292.4 468.42 percent of total billed charges Rabies vaccine for injection into muscle 49809361_1 CDM 0250 RC 58160-0964-12 NDC 90675 HCPCS inpatient 1 UN 482.91 313.89 SIHO - ALL PLANS SIHO - ALL PLANS 434.62 90 999999999 292.4 468.42 percent of total billed charges Rabies vaccine for injection into muscle 49809361_1 CDM 0250 RC 58160-0964-12 NDC 90675 HCPCS inpatient 1 UN 482.91 313.89 UMR - ALL PLANS UMR - ALL PLANS 338.04 70 999999999 292.4 468.42 percent of total billed charges Rabies vaccine for injection into muscle 49809361_1 CDM 0250 RC 58160-0964-12 NDC 90675 HCPCS inpatient 1 UN 482.91 313.89 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 292.4 60.55 999999999 292.4 468.42 percent of total billed charges Rabies vaccine for injection into muscle 49809361_1 CDM 0250 RC 58160-0964-12 NDC 90675 HCPCS inpatient 1 UN 482.91 313.89 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 292.4 468.42 Rabies vaccine for injection into muscle 49809361_1 CDM 0250 RC 58160-0964-12 NDC 90675 HCPCS inpatient 1 UN 482.91 313.89 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 292.4 468.42 Rabies vaccine for injection into muscle 49809361_1 CDM 0250 RC 58160-0964-12 NDC 90675 HCPCS inpatient 1 UN 482.91 313.89 ANTHEM HMO ANTHEM HMO 999999999 292.4 468.42 Rabies vaccine for injection into muscle 49809361_1 CDM 0250 RC 58160-0964-12 NDC 90675 HCPCS inpatient 1 UN 482.91 313.89 CIGNA - ALL PLANS CIGNA - ALL PLANS 326.45 67.6 999999999 292.4 468.42 percent of total billed charges Rabies vaccine for injection into muscle 49809361_1 CDM 0250 RC 58160-0964-12 NDC 90675 HCPCS inpatient 1 UN 482.91 313.89 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 292.4 468.42 Rabies vaccine for injection into muscle 49809361_1 CDM 0250 RC 58160-0964-12 NDC 90675 HCPCS inpatient 1 UN 482.91 313.89 UHC - ALL PLANS UHC - ALL PLANS 999999999 292.4 468.42 Maintenance of spinal canal or brain drug infusion pump 49809386_1 CDM 0510 RC 95990 HCPCS inpatient 775 503.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 503.75 65 999999999 469.26 751.75 percent of total billed charges Maintenance of spinal canal or brain drug infusion pump 49809386_1 CDM 0510 RC 95990 HCPCS inpatient 775 503.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 751.75 97 999999999 469.26 751.75 percent of total billed charges Maintenance of spinal canal or brain drug infusion pump 49809386_1 CDM 0510 RC 95990 HCPCS inpatient 775 503.75 AETNA AETNA 612.25 79 999999999 469.26 751.75 percent of total billed charges Maintenance of spinal canal or brain drug infusion pump 49809386_1 CDM 0510 RC 95990 HCPCS inpatient 775 503.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 604.5 78 999999999 469.26 751.75 percent of total billed charges Maintenance of spinal canal or brain drug infusion pump 49809386_1 CDM 0510 RC 95990 HCPCS inpatient 775 503.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 534.75 69 999999999 469.26 751.75 percent of total billed charges Maintenance of spinal canal or brain drug infusion pump 49809386_1 CDM 0510 RC 95990 HCPCS inpatient 775 503.75 SIHO - ALL PLANS SIHO - ALL PLANS 697.5 90 999999999 469.26 751.75 percent of total billed charges Maintenance of spinal canal or brain drug infusion pump 49809386_1 CDM 0510 RC 95990 HCPCS inpatient 775 503.75 UMR - ALL PLANS UMR - ALL PLANS 542.5 70 999999999 469.26 751.75 percent of total billed charges Maintenance of spinal canal or brain drug infusion pump 49809386_1 CDM 0510 RC 95990 HCPCS inpatient 775 503.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 469.26 60.55 999999999 469.26 751.75 percent of total billed charges Maintenance of spinal canal or brain drug infusion pump 49809386_1 CDM 0510 RC 95990 HCPCS inpatient 775 503.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 469.26 751.75 Maintenance of spinal canal or brain drug infusion pump 49809386_1 CDM 0510 RC 95990 HCPCS inpatient 775 503.75 ANTHEM HMO ANTHEM HMO 999999999 469.26 751.75 Maintenance of spinal canal or brain drug infusion pump 49809386_1 CDM 0510 RC 95990 HCPCS inpatient 775 503.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 469.26 751.75 Maintenance of spinal canal or brain drug infusion pump 49809386_1 CDM 0510 RC 95990 HCPCS inpatient 775 503.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 523.9 67.6 999999999 469.26 751.75 percent of total billed charges Maintenance of spinal canal or brain drug infusion pump 49809386_1 CDM 0510 RC 95990 HCPCS inpatient 775 503.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 469.26 751.75 Maintenance of spinal canal or brain drug infusion pump 49809386_1 CDM 0510 RC 95990 HCPCS inpatient 775 503.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 469.26 751.75 Maintenance of spinal canal or brain drug infusion pump by health care professional 49809387_1 CDM 0510 RC 95991 HCPCS inpatient 636 413.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 413.4 65 999999999 385.1 616.92 percent of total billed charges Maintenance of spinal canal or brain drug infusion pump by health care professional 49809387_1 CDM 0510 RC 95991 HCPCS inpatient 636 413.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 616.92 97 999999999 385.1 616.92 percent of total billed charges Maintenance of spinal canal or brain drug infusion pump by health care professional 49809387_1 CDM 0510 RC 95991 HCPCS inpatient 636 413.4 AETNA AETNA 502.44 79 999999999 385.1 616.92 percent of total billed charges Maintenance of spinal canal or brain drug infusion pump by health care professional 49809387_1 CDM 0510 RC 95991 HCPCS inpatient 636 413.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 496.08 78 999999999 385.1 616.92 percent of total billed charges Maintenance of spinal canal or brain drug infusion pump by health care professional 49809387_1 CDM 0510 RC 95991 HCPCS inpatient 636 413.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 438.84 69 999999999 385.1 616.92 percent of total billed charges Maintenance of spinal canal or brain drug infusion pump by health care professional 49809387_1 CDM 0510 RC 95991 HCPCS inpatient 636 413.4 SIHO - ALL PLANS SIHO - ALL PLANS 572.4 90 999999999 385.1 616.92 percent of total billed charges Maintenance of spinal canal or brain drug infusion pump by health care professional 49809387_1 CDM 0510 RC 95991 HCPCS inpatient 636 413.4 UMR - ALL PLANS UMR - ALL PLANS 445.2 70 999999999 385.1 616.92 percent of total billed charges Maintenance of spinal canal or brain drug infusion pump by health care professional 49809387_1 CDM 0510 RC 95991 HCPCS inpatient 636 413.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 385.1 60.55 999999999 385.1 616.92 percent of total billed charges Maintenance of spinal canal or brain drug infusion pump by health care professional 49809387_1 CDM 0510 RC 95991 HCPCS inpatient 636 413.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 385.1 616.92 Maintenance of spinal canal or brain drug infusion pump by health care professional 49809387_1 CDM 0510 RC 95991 HCPCS inpatient 636 413.4 ANTHEM HMO ANTHEM HMO 999999999 385.1 616.92 Maintenance of spinal canal or brain drug infusion pump by health care professional 49809387_1 CDM 0510 RC 95991 HCPCS inpatient 636 413.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 385.1 616.92 Maintenance of spinal canal or brain drug infusion pump by health care professional 49809387_1 CDM 0510 RC 95991 HCPCS inpatient 636 413.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 429.94 67.6 999999999 385.1 616.92 percent of total billed charges Maintenance of spinal canal or brain drug infusion pump by health care professional 49809387_1 CDM 0510 RC 95991 HCPCS inpatient 636 413.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 385.1 616.92 Maintenance of spinal canal or brain drug infusion pump by health care professional 49809387_1 CDM 0510 RC 95991 HCPCS inpatient 636 413.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 385.1 616.92 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 49809966_1 CDM 0306 RC 87661 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 49809966_1 CDM 0306 RC 87661 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 49809966_1 CDM 0306 RC 87661 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 49809966_1 CDM 0306 RC 87661 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 49809966_1 CDM 0306 RC 87661 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 49809966_1 CDM 0306 RC 87661 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 49809966_1 CDM 0306 RC 87661 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 49809966_1 CDM 0306 RC 87661 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 49809966_1 CDM 0306 RC 87661 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 49809966_1 CDM 0306 RC 87661 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 49809966_1 CDM 0306 RC 87661 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 49809966_1 CDM 0306 RC 87661 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 49809966_1 CDM 0306 RC 87661 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 49809966_1 CDM 0306 RC 87661 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49809967_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49809967_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49809967_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49809967_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49809967_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49809967_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49809967_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49809967_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49809967_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49809967_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49809967_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49809967_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49809967_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 49809967_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49809968_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49809968_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49809968_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49809968_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49809968_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49809968_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49809968_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49809968_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49809968_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49809968_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49809968_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49809968_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49809968_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 49809968_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 "Detection test by nucleic acid for organism, amplified probe technique" 49809969_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49809969_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49809969_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49809969_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49809969_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49809969_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49809969_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49809969_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49809969_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 49809969_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 49809969_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 49809969_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 49809969_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 49809969_1 CDM 0306 RC 87798 HCPCS inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 KETOROLAC 10 MG TABLET 49811369_1 CDM 0250 RC 00093-0314-01 NDC inpatient 1 UN 2.18 1.42 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.42 65 999999999 1.32 2.11 percent of total billed charges KETOROLAC 10 MG TABLET 49811369_1 CDM 0250 RC 00093-0314-01 NDC inpatient 1 UN 2.18 1.42 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.11 97 999999999 1.32 2.11 percent of total billed charges KETOROLAC 10 MG TABLET 49811369_1 CDM 0250 RC 00093-0314-01 NDC inpatient 1 UN 2.18 1.42 AETNA AETNA 1.72 79 999999999 1.32 2.11 percent of total billed charges KETOROLAC 10 MG TABLET 49811369_1 CDM 0250 RC 00093-0314-01 NDC inpatient 1 UN 2.18 1.42 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.7 78 999999999 1.32 2.11 percent of total billed charges KETOROLAC 10 MG TABLET 49811369_1 CDM 0250 RC 00093-0314-01 NDC inpatient 1 UN 2.18 1.42 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.5 69 999999999 1.32 2.11 percent of total billed charges KETOROLAC 10 MG TABLET 49811369_1 CDM 0250 RC 00093-0314-01 NDC inpatient 1 UN 2.18 1.42 SIHO - ALL PLANS SIHO - ALL PLANS 1.96 90 999999999 1.32 2.11 percent of total billed charges KETOROLAC 10 MG TABLET 49811369_1 CDM 0250 RC 00093-0314-01 NDC inpatient 1 UN 2.18 1.42 UMR - ALL PLANS UMR - ALL PLANS 1.53 70 999999999 1.32 2.11 percent of total billed charges KETOROLAC 10 MG TABLET 49811369_1 CDM 0250 RC 00093-0314-01 NDC inpatient 1 UN 2.18 1.42 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.32 60.55 999999999 1.32 2.11 percent of total billed charges KETOROLAC 10 MG TABLET 49811369_1 CDM 0250 RC 00093-0314-01 NDC inpatient 1 UN 2.18 1.42 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.32 2.11 KETOROLAC 10 MG TABLET 49811369_1 CDM 0250 RC 00093-0314-01 NDC inpatient 1 UN 2.18 1.42 ANTHEM HMO ANTHEM HMO 999999999 1.32 2.11 KETOROLAC 10 MG TABLET 49811369_1 CDM 0250 RC 00093-0314-01 NDC inpatient 1 UN 2.18 1.42 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.32 2.11 KETOROLAC 10 MG TABLET 49811369_1 CDM 0250 RC 00093-0314-01 NDC inpatient 1 UN 2.18 1.42 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.47 67.6 999999999 1.32 2.11 percent of total billed charges KETOROLAC 10 MG TABLET 49811369_1 CDM 0250 RC 00093-0314-01 NDC inpatient 1 UN 2.18 1.42 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.32 2.11 KETOROLAC 10 MG TABLET 49811369_1 CDM 0250 RC 00093-0314-01 NDC inpatient 1 UN 2.18 1.42 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.32 2.11 "Peripheral arterial disease rehabilitation, each session" 49811902_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges "Peripheral arterial disease rehabilitation, each session" 49811902_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges "Peripheral arterial disease rehabilitation, each session" 49811902_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges "Peripheral arterial disease rehabilitation, each session" 49811902_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges "Peripheral arterial disease rehabilitation, each session" 49811902_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges "Peripheral arterial disease rehabilitation, each session" 49811902_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges "Peripheral arterial disease rehabilitation, each session" 49811902_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges "Peripheral arterial disease rehabilitation, each session" 49811902_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges "Peripheral arterial disease rehabilitation, each session" 49811902_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 "Peripheral arterial disease rehabilitation, each session" 49811902_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 "Peripheral arterial disease rehabilitation, each session" 49811902_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 "Peripheral arterial disease rehabilitation, each session" 49811902_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges "Peripheral arterial disease rehabilitation, each session" 49811902_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 "Peripheral arterial disease rehabilitation, each session" 49811902_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 "Peripheral arterial disease rehabilitation, each session" 49811903_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges "Peripheral arterial disease rehabilitation, each session" 49811903_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges "Peripheral arterial disease rehabilitation, each session" 49811903_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges "Peripheral arterial disease rehabilitation, each session" 49811903_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges "Peripheral arterial disease rehabilitation, each session" 49811903_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges "Peripheral arterial disease rehabilitation, each session" 49811903_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges "Peripheral arterial disease rehabilitation, each session" 49811903_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges "Peripheral arterial disease rehabilitation, each session" 49811903_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges "Peripheral arterial disease rehabilitation, each session" 49811903_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 "Peripheral arterial disease rehabilitation, each session" 49811903_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 "Peripheral arterial disease rehabilitation, each session" 49811903_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 "Peripheral arterial disease rehabilitation, each session" 49811903_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges "Peripheral arterial disease rehabilitation, each session" 49811903_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 "Peripheral arterial disease rehabilitation, each session" 49811903_1 CDM 0420 RC 93668 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 EFX SHIELD PORT SITE CLOSURE SYSTEM EFX002 49813191_1 CDM 0272 RC inpatient 703 456.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 456.95 65 999999999 425.67 681.91 percent of total billed charges EFX SHIELD PORT SITE CLOSURE SYSTEM EFX002 49813191_1 CDM 0272 RC inpatient 703 456.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 681.91 97 999999999 425.67 681.91 percent of total billed charges EFX SHIELD PORT SITE CLOSURE SYSTEM EFX002 49813191_1 CDM 0272 RC inpatient 703 456.95 AETNA AETNA 555.37 79 999999999 425.67 681.91 percent of total billed charges EFX SHIELD PORT SITE CLOSURE SYSTEM EFX002 49813191_1 CDM 0272 RC inpatient 703 456.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 548.34 78 999999999 425.67 681.91 percent of total billed charges EFX SHIELD PORT SITE CLOSURE SYSTEM EFX002 49813191_1 CDM 0272 RC inpatient 703 456.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 485.07 69 999999999 425.67 681.91 percent of total billed charges EFX SHIELD PORT SITE CLOSURE SYSTEM EFX002 49813191_1 CDM 0272 RC inpatient 703 456.95 SIHO - ALL PLANS SIHO - ALL PLANS 632.7 90 999999999 425.67 681.91 percent of total billed charges EFX SHIELD PORT SITE CLOSURE SYSTEM EFX002 49813191_1 CDM 0272 RC inpatient 703 456.95 UMR - ALL PLANS UMR - ALL PLANS 492.1 70 999999999 425.67 681.91 percent of total billed charges EFX SHIELD PORT SITE CLOSURE SYSTEM EFX002 49813191_1 CDM 0272 RC inpatient 703 456.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 425.67 60.55 999999999 425.67 681.91 percent of total billed charges EFX SHIELD PORT SITE CLOSURE SYSTEM EFX002 49813191_1 CDM 0272 RC inpatient 703 456.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 425.67 681.91 EFX SHIELD PORT SITE CLOSURE SYSTEM EFX002 49813191_1 CDM 0272 RC inpatient 703 456.95 ANTHEM HMO ANTHEM HMO 999999999 425.67 681.91 EFX SHIELD PORT SITE CLOSURE SYSTEM EFX002 49813191_1 CDM 0272 RC inpatient 703 456.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 425.67 681.91 EFX SHIELD PORT SITE CLOSURE SYSTEM EFX002 49813191_1 CDM 0272 RC inpatient 703 456.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 475.23 67.6 999999999 425.67 681.91 percent of total billed charges EFX SHIELD PORT SITE CLOSURE SYSTEM EFX002 49813191_1 CDM 0272 RC inpatient 703 456.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 425.67 681.91 EFX SHIELD PORT SITE CLOSURE SYSTEM EFX002 49813191_1 CDM 0272 RC inpatient 703 456.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 425.67 681.91 SIG CURVED 60mm SIG60CTAVM 49813817_1 CDM 0272 RC inpatient 2256 1466.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1466.4 65 999999999 1366.01 2188.32 percent of total billed charges SIG CURVED 60mm SIG60CTAVM 49813817_1 CDM 0272 RC inpatient 2256 1466.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2188.32 97 999999999 1366.01 2188.32 percent of total billed charges SIG CURVED 60mm SIG60CTAVM 49813817_1 CDM 0272 RC inpatient 2256 1466.4 AETNA AETNA 1782.24 79 999999999 1366.01 2188.32 percent of total billed charges SIG CURVED 60mm SIG60CTAVM 49813817_1 CDM 0272 RC inpatient 2256 1466.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1759.68 78 999999999 1366.01 2188.32 percent of total billed charges SIG CURVED 60mm SIG60CTAVM 49813817_1 CDM 0272 RC inpatient 2256 1466.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1556.64 69 999999999 1366.01 2188.32 percent of total billed charges SIG CURVED 60mm SIG60CTAVM 49813817_1 CDM 0272 RC inpatient 2256 1466.4 SIHO - ALL PLANS SIHO - ALL PLANS 2030.4 90 999999999 1366.01 2188.32 percent of total billed charges SIG CURVED 60mm SIG60CTAVM 49813817_1 CDM 0272 RC inpatient 2256 1466.4 UMR - ALL PLANS UMR - ALL PLANS 1579.2 70 999999999 1366.01 2188.32 percent of total billed charges SIG CURVED 60mm SIG60CTAVM 49813817_1 CDM 0272 RC inpatient 2256 1466.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1366.01 60.55 999999999 1366.01 2188.32 percent of total billed charges SIG CURVED 60mm SIG60CTAVM 49813817_1 CDM 0272 RC inpatient 2256 1466.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1366.01 2188.32 SIG CURVED 60mm SIG60CTAVM 49813817_1 CDM 0272 RC inpatient 2256 1466.4 ANTHEM HMO ANTHEM HMO 999999999 1366.01 2188.32 SIG CURVED 60mm SIG60CTAVM 49813817_1 CDM 0272 RC inpatient 2256 1466.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1366.01 2188.32 SIG CURVED 60mm SIG60CTAVM 49813817_1 CDM 0272 RC inpatient 2256 1466.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1525.06 67.6 999999999 1366.01 2188.32 percent of total billed charges SIG CURVED 60mm SIG60CTAVM 49813817_1 CDM 0272 RC inpatient 2256 1466.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1366.01 2188.32 SIG CURVED 60mm SIG60CTAVM 49813817_1 CDM 0272 RC inpatient 2256 1466.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1366.01 2188.32 SIG CURVED 60mm SIG60CTAMT 49813818_1 CDM 0272 RC inpatient 2813 1828.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1828.45 65 999999999 1703.27 2728.61 percent of total billed charges SIG CURVED 60mm SIG60CTAMT 49813818_1 CDM 0272 RC inpatient 2813 1828.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2728.61 97 999999999 1703.27 2728.61 percent of total billed charges SIG CURVED 60mm SIG60CTAMT 49813818_1 CDM 0272 RC inpatient 2813 1828.45 AETNA AETNA 2222.27 79 999999999 1703.27 2728.61 percent of total billed charges SIG CURVED 60mm SIG60CTAMT 49813818_1 CDM 0272 RC inpatient 2813 1828.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 2194.14 78 999999999 1703.27 2728.61 percent of total billed charges SIG CURVED 60mm SIG60CTAMT 49813818_1 CDM 0272 RC inpatient 2813 1828.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1940.97 69 999999999 1703.27 2728.61 percent of total billed charges SIG CURVED 60mm SIG60CTAMT 49813818_1 CDM 0272 RC inpatient 2813 1828.45 SIHO - ALL PLANS SIHO - ALL PLANS 2531.7 90 999999999 1703.27 2728.61 percent of total billed charges SIG CURVED 60mm SIG60CTAMT 49813818_1 CDM 0272 RC inpatient 2813 1828.45 UMR - ALL PLANS UMR - ALL PLANS 1969.1 70 999999999 1703.27 2728.61 percent of total billed charges SIG CURVED 60mm SIG60CTAMT 49813818_1 CDM 0272 RC inpatient 2813 1828.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1703.27 60.55 999999999 1703.27 2728.61 percent of total billed charges SIG CURVED 60mm SIG60CTAMT 49813818_1 CDM 0272 RC inpatient 2813 1828.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1703.27 2728.61 SIG CURVED 60mm SIG60CTAMT 49813818_1 CDM 0272 RC inpatient 2813 1828.45 ANTHEM HMO ANTHEM HMO 999999999 1703.27 2728.61 SIG CURVED 60mm SIG60CTAMT 49813818_1 CDM 0272 RC inpatient 2813 1828.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1703.27 2728.61 SIG CURVED 60mm SIG60CTAMT 49813818_1 CDM 0272 RC inpatient 2813 1828.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1901.59 67.6 999999999 1703.27 2728.61 percent of total billed charges SIG CURVED 60mm SIG60CTAMT 49813818_1 CDM 0272 RC inpatient 2813 1828.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1703.27 2728.61 SIG CURVED 60mm SIG60CTAMT 49813818_1 CDM 0272 RC inpatient 2813 1828.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1703.27 2728.61 CHIA PERCPASSER SUTURE PASSER 214101 5/PK 49813819_1 CDM 0272 RC inpatient 1254 815.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 815.1 65 999999999 759.3 1216.38 percent of total billed charges CHIA PERCPASSER SUTURE PASSER 214101 5/PK 49813819_1 CDM 0272 RC inpatient 1254 815.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1216.38 97 999999999 759.3 1216.38 percent of total billed charges CHIA PERCPASSER SUTURE PASSER 214101 5/PK 49813819_1 CDM 0272 RC inpatient 1254 815.1 AETNA AETNA 990.66 79 999999999 759.3 1216.38 percent of total billed charges CHIA PERCPASSER SUTURE PASSER 214101 5/PK 49813819_1 CDM 0272 RC inpatient 1254 815.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 978.12 78 999999999 759.3 1216.38 percent of total billed charges CHIA PERCPASSER SUTURE PASSER 214101 5/PK 49813819_1 CDM 0272 RC inpatient 1254 815.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 865.26 69 999999999 759.3 1216.38 percent of total billed charges CHIA PERCPASSER SUTURE PASSER 214101 5/PK 49813819_1 CDM 0272 RC inpatient 1254 815.1 SIHO - ALL PLANS SIHO - ALL PLANS 1128.6 90 999999999 759.3 1216.38 percent of total billed charges CHIA PERCPASSER SUTURE PASSER 214101 5/PK 49813819_1 CDM 0272 RC inpatient 1254 815.1 UMR - ALL PLANS UMR - ALL PLANS 877.8 70 999999999 759.3 1216.38 percent of total billed charges CHIA PERCPASSER SUTURE PASSER 214101 5/PK 49813819_1 CDM 0272 RC inpatient 1254 815.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 759.3 60.55 999999999 759.3 1216.38 percent of total billed charges CHIA PERCPASSER SUTURE PASSER 214101 5/PK 49813819_1 CDM 0272 RC inpatient 1254 815.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 759.3 1216.38 CHIA PERCPASSER SUTURE PASSER 214101 5/PK 49813819_1 CDM 0272 RC inpatient 1254 815.1 ANTHEM HMO ANTHEM HMO 999999999 759.3 1216.38 CHIA PERCPASSER SUTURE PASSER 214101 5/PK 49813819_1 CDM 0272 RC inpatient 1254 815.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 759.3 1216.38 CHIA PERCPASSER SUTURE PASSER 214101 5/PK 49813819_1 CDM 0272 RC inpatient 1254 815.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 847.7 67.6 999999999 759.3 1216.38 percent of total billed charges CHIA PERCPASSER SUTURE PASSER 214101 5/PK 49813819_1 CDM 0272 RC inpatient 1254 815.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 759.3 1216.38 CHIA PERCPASSER SUTURE PASSER 214101 5/PK 49813819_1 CDM 0272 RC inpatient 1254 815.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 759.3 1216.38 EXPRESSEW III NEEDLE 214141 5/PK 49813820_1 CDM 0272 RC inpatient 1672 1086.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1086.8 65 999999999 1012.4 1621.84 percent of total billed charges EXPRESSEW III NEEDLE 214141 5/PK 49813820_1 CDM 0272 RC inpatient 1672 1086.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1621.84 97 999999999 1012.4 1621.84 percent of total billed charges EXPRESSEW III NEEDLE 214141 5/PK 49813820_1 CDM 0272 RC inpatient 1672 1086.8 AETNA AETNA 1320.88 79 999999999 1012.4 1621.84 percent of total billed charges EXPRESSEW III NEEDLE 214141 5/PK 49813820_1 CDM 0272 RC inpatient 1672 1086.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1304.16 78 999999999 1012.4 1621.84 percent of total billed charges EXPRESSEW III NEEDLE 214141 5/PK 49813820_1 CDM 0272 RC inpatient 1672 1086.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1153.68 69 999999999 1012.4 1621.84 percent of total billed charges EXPRESSEW III NEEDLE 214141 5/PK 49813820_1 CDM 0272 RC inpatient 1672 1086.8 SIHO - ALL PLANS SIHO - ALL PLANS 1504.8 90 999999999 1012.4 1621.84 percent of total billed charges EXPRESSEW III NEEDLE 214141 5/PK 49813820_1 CDM 0272 RC inpatient 1672 1086.8 UMR - ALL PLANS UMR - ALL PLANS 1170.4 70 999999999 1012.4 1621.84 percent of total billed charges EXPRESSEW III NEEDLE 214141 5/PK 49813820_1 CDM 0272 RC inpatient 1672 1086.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1012.4 60.55 999999999 1012.4 1621.84 percent of total billed charges EXPRESSEW III NEEDLE 214141 5/PK 49813820_1 CDM 0272 RC inpatient 1672 1086.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1012.4 1621.84 EXPRESSEW III NEEDLE 214141 5/PK 49813820_1 CDM 0272 RC inpatient 1672 1086.8 ANTHEM HMO ANTHEM HMO 999999999 1012.4 1621.84 EXPRESSEW III NEEDLE 214141 5/PK 49813820_1 CDM 0272 RC inpatient 1672 1086.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1012.4 1621.84 EXPRESSEW III NEEDLE 214141 5/PK 49813820_1 CDM 0272 RC inpatient 1672 1086.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1130.27 67.6 999999999 1012.4 1621.84 percent of total billed charges EXPRESSEW III NEEDLE 214141 5/PK 49813820_1 CDM 0272 RC inpatient 1672 1086.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1012.4 1621.84 EXPRESSEW III NEEDLE 214141 5/PK 49813820_1 CDM 0272 RC inpatient 1672 1086.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1012.4 1621.84 Ultrasonic guidance for needle placement 49814019_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 627.25 65 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 49814019_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 936.05 97 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 49814019_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 AETNA AETNA 762.35 79 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 49814019_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 752.7 78 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 49814019_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 665.85 69 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 49814019_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SIHO - ALL PLANS SIHO - ALL PLANS 868.5 90 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 49814019_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UMR - ALL PLANS UMR - ALL PLANS 675.5 70 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 49814019_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 584.31 60.55 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 49814019_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 49814019_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM HMO ANTHEM HMO 999999999 584.31 936.05 Ultrasonic guidance for needle placement 49814019_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 49814019_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 652.34 67.6 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 49814019_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 49814019_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 49814023_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 49814023_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 49814023_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 49814023_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 49814023_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 49814023_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 49814023_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 49814023_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 49814023_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 49814023_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Ultrasonic guidance for needle placement 49814023_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 49814023_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 49814023_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 49814023_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Simple control of nose bleed 49816023_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 365.95 65 999999999 340.9 546.11 percent of total billed charges Simple control of nose bleed 49816023_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 546.11 97 999999999 340.9 546.11 percent of total billed charges Simple control of nose bleed 49816023_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 AETNA AETNA 444.77 79 999999999 340.9 546.11 percent of total billed charges Simple control of nose bleed 49816023_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 439.14 78 999999999 340.9 546.11 percent of total billed charges Simple control of nose bleed 49816023_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 388.47 69 999999999 340.9 546.11 percent of total billed charges Simple control of nose bleed 49816023_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 SIHO - ALL PLANS SIHO - ALL PLANS 506.7 90 999999999 340.9 546.11 percent of total billed charges Simple control of nose bleed 49816023_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 UMR - ALL PLANS UMR - ALL PLANS 394.1 70 999999999 340.9 546.11 percent of total billed charges Simple control of nose bleed 49816023_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 340.9 60.55 999999999 340.9 546.11 percent of total billed charges Simple control of nose bleed 49816023_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 340.9 546.11 Simple control of nose bleed 49816023_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 ANTHEM HMO ANTHEM HMO 999999999 340.9 546.11 Simple control of nose bleed 49816023_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 340.9 546.11 Simple control of nose bleed 49816023_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 380.59 67.6 999999999 340.9 546.11 percent of total billed charges Simple control of nose bleed 49816023_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 340.9 546.11 Simple control of nose bleed 49816023_1 CDM 0450 RC 30901 HCPCS inpatient 563 365.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 340.9 546.11 00056-0173-75 - warfarin 7.5 mg Tab[JOHN] 49819899_1 CDM 0250 RC 00056-0173-75 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 00056-0173-75 - warfarin 7.5 mg Tab[JOHN] 49819899_1 CDM 0250 RC 00056-0173-75 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 00056-0173-75 - warfarin 7.5 mg Tab[JOHN] 49819899_1 CDM 0250 RC 00056-0173-75 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 00056-0173-75 - warfarin 7.5 mg Tab[JOHN] 49819899_1 CDM 0250 RC 00056-0173-75 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 00056-0173-75 - warfarin 7.5 mg Tab[JOHN] 49819899_1 CDM 0250 RC 00056-0173-75 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 00056-0173-75 - warfarin 7.5 mg Tab[JOHN] 49819899_1 CDM 0250 RC 00056-0173-75 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 00056-0173-75 - warfarin 7.5 mg Tab[JOHN] 49819899_1 CDM 0250 RC 00056-0173-75 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 00056-0173-75 - warfarin 7.5 mg Tab[JOHN] 49819899_1 CDM 0250 RC 00056-0173-75 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 00056-0173-75 - warfarin 7.5 mg Tab[JOHN] 49819899_1 CDM 0250 RC 00056-0173-75 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 00056-0173-75 - warfarin 7.5 mg Tab[JOHN] 49819899_1 CDM 0250 RC 00056-0173-75 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 00056-0173-75 - warfarin 7.5 mg Tab[JOHN] 49819899_1 CDM 0250 RC 00056-0173-75 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 00056-0173-75 - warfarin 7.5 mg Tab[JOHN] 49819899_1 CDM 0250 RC 00056-0173-75 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 00056-0173-75 - warfarin 7.5 mg Tab[JOHN] 49819899_1 CDM 0250 RC 00056-0173-75 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 00056-0173-75 - warfarin 7.5 mg Tab[JOHN] 49819899_1 CDM 0250 RC 00056-0173-75 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 HALOPERIDOL 5 MG TABLET 49819902_1 CDM 0250 RC 60687-0161-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges HALOPERIDOL 5 MG TABLET 49819902_1 CDM 0250 RC 60687-0161-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges HALOPERIDOL 5 MG TABLET 49819902_1 CDM 0250 RC 60687-0161-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges HALOPERIDOL 5 MG TABLET 49819902_1 CDM 0250 RC 60687-0161-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges HALOPERIDOL 5 MG TABLET 49819902_1 CDM 0250 RC 60687-0161-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges HALOPERIDOL 5 MG TABLET 49819902_1 CDM 0250 RC 60687-0161-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges HALOPERIDOL 5 MG TABLET 49819902_1 CDM 0250 RC 60687-0161-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges HALOPERIDOL 5 MG TABLET 49819902_1 CDM 0250 RC 60687-0161-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges HALOPERIDOL 5 MG TABLET 49819902_1 CDM 0250 RC 60687-0161-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 HALOPERIDOL 5 MG TABLET 49819902_1 CDM 0250 RC 60687-0161-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 HALOPERIDOL 5 MG TABLET 49819902_1 CDM 0250 RC 60687-0161-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 HALOPERIDOL 5 MG TABLET 49819902_1 CDM 0250 RC 60687-0161-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges HALOPERIDOL 5 MG TABLET 49819902_1 CDM 0250 RC 60687-0161-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 HALOPERIDOL 5 MG TABLET 49819902_1 CDM 0250 RC 60687-0161-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ARIPIPRAZOLE 2 MG TABLET 49819913_1 CDM 0250 RC 62332-0097-30 NDC inpatient 1 UN 1.2 0.78 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.78 65 999999999 0.73 1.16 percent of total billed charges ARIPIPRAZOLE 2 MG TABLET 49819913_1 CDM 0250 RC 62332-0097-30 NDC inpatient 1 UN 1.2 0.78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.16 97 999999999 0.73 1.16 percent of total billed charges ARIPIPRAZOLE 2 MG TABLET 49819913_1 CDM 0250 RC 62332-0097-30 NDC inpatient 1 UN 1.2 0.78 AETNA AETNA 0.95 79 999999999 0.73 1.16 percent of total billed charges ARIPIPRAZOLE 2 MG TABLET 49819913_1 CDM 0250 RC 62332-0097-30 NDC inpatient 1 UN 1.2 0.78 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.94 78 999999999 0.73 1.16 percent of total billed charges ARIPIPRAZOLE 2 MG TABLET 49819913_1 CDM 0250 RC 62332-0097-30 NDC inpatient 1 UN 1.2 0.78 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.83 69 999999999 0.73 1.16 percent of total billed charges ARIPIPRAZOLE 2 MG TABLET 49819913_1 CDM 0250 RC 62332-0097-30 NDC inpatient 1 UN 1.2 0.78 SIHO - ALL PLANS SIHO - ALL PLANS 1.08 90 999999999 0.73 1.16 percent of total billed charges ARIPIPRAZOLE 2 MG TABLET 49819913_1 CDM 0250 RC 62332-0097-30 NDC inpatient 1 UN 1.2 0.78 UMR - ALL PLANS UMR - ALL PLANS 0.84 70 999999999 0.73 1.16 percent of total billed charges ARIPIPRAZOLE 2 MG TABLET 49819913_1 CDM 0250 RC 62332-0097-30 NDC inpatient 1 UN 1.2 0.78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.73 60.55 999999999 0.73 1.16 percent of total billed charges ARIPIPRAZOLE 2 MG TABLET 49819913_1 CDM 0250 RC 62332-0097-30 NDC inpatient 1 UN 1.2 0.78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.73 1.16 ARIPIPRAZOLE 2 MG TABLET 49819913_1 CDM 0250 RC 62332-0097-30 NDC inpatient 1 UN 1.2 0.78 ANTHEM HMO ANTHEM HMO 999999999 0.73 1.16 ARIPIPRAZOLE 2 MG TABLET 49819913_1 CDM 0250 RC 62332-0097-30 NDC inpatient 1 UN 1.2 0.78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.73 1.16 ARIPIPRAZOLE 2 MG TABLET 49819913_1 CDM 0250 RC 62332-0097-30 NDC inpatient 1 UN 1.2 0.78 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.81 67.6 999999999 0.73 1.16 percent of total billed charges ARIPIPRAZOLE 2 MG TABLET 49819913_1 CDM 0250 RC 62332-0097-30 NDC inpatient 1 UN 1.2 0.78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.73 1.16 ARIPIPRAZOLE 2 MG TABLET 49819913_1 CDM 0250 RC 62332-0097-30 NDC inpatient 1 UN 1.2 0.78 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.73 1.16 GALANTAMINE ER 8 MG CAPSULE 49819914_1 CDM 0250 RC 65862-0744-30 NDC inpatient 1 UN 6.03 3.92 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.92 65 999999999 3.65 5.85 percent of total billed charges GALANTAMINE ER 8 MG CAPSULE 49819914_1 CDM 0250 RC 65862-0744-30 NDC inpatient 1 UN 6.03 3.92 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.85 97 999999999 3.65 5.85 percent of total billed charges GALANTAMINE ER 8 MG CAPSULE 49819914_1 CDM 0250 RC 65862-0744-30 NDC inpatient 1 UN 6.03 3.92 AETNA AETNA 4.76 79 999999999 3.65 5.85 percent of total billed charges GALANTAMINE ER 8 MG CAPSULE 49819914_1 CDM 0250 RC 65862-0744-30 NDC inpatient 1 UN 6.03 3.92 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.7 78 999999999 3.65 5.85 percent of total billed charges GALANTAMINE ER 8 MG CAPSULE 49819914_1 CDM 0250 RC 65862-0744-30 NDC inpatient 1 UN 6.03 3.92 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.16 69 999999999 3.65 5.85 percent of total billed charges GALANTAMINE ER 8 MG CAPSULE 49819914_1 CDM 0250 RC 65862-0744-30 NDC inpatient 1 UN 6.03 3.92 SIHO - ALL PLANS SIHO - ALL PLANS 5.43 90 999999999 3.65 5.85 percent of total billed charges GALANTAMINE ER 8 MG CAPSULE 49819914_1 CDM 0250 RC 65862-0744-30 NDC inpatient 1 UN 6.03 3.92 UMR - ALL PLANS UMR - ALL PLANS 4.22 70 999999999 3.65 5.85 percent of total billed charges GALANTAMINE ER 8 MG CAPSULE 49819914_1 CDM 0250 RC 65862-0744-30 NDC inpatient 1 UN 6.03 3.92 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.65 60.55 999999999 3.65 5.85 percent of total billed charges GALANTAMINE ER 8 MG CAPSULE 49819914_1 CDM 0250 RC 65862-0744-30 NDC inpatient 1 UN 6.03 3.92 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.65 5.85 GALANTAMINE ER 8 MG CAPSULE 49819914_1 CDM 0250 RC 65862-0744-30 NDC inpatient 1 UN 6.03 3.92 ANTHEM HMO ANTHEM HMO 999999999 3.65 5.85 GALANTAMINE ER 8 MG CAPSULE 49819914_1 CDM 0250 RC 65862-0744-30 NDC inpatient 1 UN 6.03 3.92 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.65 5.85 GALANTAMINE ER 8 MG CAPSULE 49819914_1 CDM 0250 RC 65862-0744-30 NDC inpatient 1 UN 6.03 3.92 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.08 67.6 999999999 3.65 5.85 percent of total billed charges GALANTAMINE ER 8 MG CAPSULE 49819914_1 CDM 0250 RC 65862-0744-30 NDC inpatient 1 UN 6.03 3.92 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.65 5.85 GALANTAMINE ER 8 MG CAPSULE 49819914_1 CDM 0250 RC 65862-0744-30 NDC inpatient 1 UN 6.03 3.92 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.65 5.85 PILOCARPINE HCL 5 MG TABLET 49819916_1 CDM 0250 RC 00527-1313-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges PILOCARPINE HCL 5 MG TABLET 49819916_1 CDM 0250 RC 00527-1313-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges PILOCARPINE HCL 5 MG TABLET 49819916_1 CDM 0250 RC 00527-1313-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges PILOCARPINE HCL 5 MG TABLET 49819916_1 CDM 0250 RC 00527-1313-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges PILOCARPINE HCL 5 MG TABLET 49819916_1 CDM 0250 RC 00527-1313-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges PILOCARPINE HCL 5 MG TABLET 49819916_1 CDM 0250 RC 00527-1313-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges PILOCARPINE HCL 5 MG TABLET 49819916_1 CDM 0250 RC 00527-1313-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges PILOCARPINE HCL 5 MG TABLET 49819916_1 CDM 0250 RC 00527-1313-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges PILOCARPINE HCL 5 MG TABLET 49819916_1 CDM 0250 RC 00527-1313-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 PILOCARPINE HCL 5 MG TABLET 49819916_1 CDM 0250 RC 00527-1313-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 PILOCARPINE HCL 5 MG TABLET 49819916_1 CDM 0250 RC 00527-1313-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 PILOCARPINE HCL 5 MG TABLET 49819916_1 CDM 0250 RC 00527-1313-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges PILOCARPINE HCL 5 MG TABLET 49819916_1 CDM 0250 RC 00527-1313-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 PILOCARPINE HCL 5 MG TABLET 49819916_1 CDM 0250 RC 00527-1313-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 TAMOXIFEN 10 MG TABLET 49819918_1 CDM 0250 RC 00591-2472-60 NDC inpatient 1 UN 1.23 0.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.8 65 999999999 0.74 1.19 percent of total billed charges TAMOXIFEN 10 MG TABLET 49819918_1 CDM 0250 RC 00591-2472-60 NDC inpatient 1 UN 1.23 0.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.19 97 999999999 0.74 1.19 percent of total billed charges TAMOXIFEN 10 MG TABLET 49819918_1 CDM 0250 RC 00591-2472-60 NDC inpatient 1 UN 1.23 0.8 AETNA AETNA 0.97 79 999999999 0.74 1.19 percent of total billed charges TAMOXIFEN 10 MG TABLET 49819918_1 CDM 0250 RC 00591-2472-60 NDC inpatient 1 UN 1.23 0.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.96 78 999999999 0.74 1.19 percent of total billed charges TAMOXIFEN 10 MG TABLET 49819918_1 CDM 0250 RC 00591-2472-60 NDC inpatient 1 UN 1.23 0.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.85 69 999999999 0.74 1.19 percent of total billed charges TAMOXIFEN 10 MG TABLET 49819918_1 CDM 0250 RC 00591-2472-60 NDC inpatient 1 UN 1.23 0.8 SIHO - ALL PLANS SIHO - ALL PLANS 1.11 90 999999999 0.74 1.19 percent of total billed charges TAMOXIFEN 10 MG TABLET 49819918_1 CDM 0250 RC 00591-2472-60 NDC inpatient 1 UN 1.23 0.8 UMR - ALL PLANS UMR - ALL PLANS 0.86 70 999999999 0.74 1.19 percent of total billed charges TAMOXIFEN 10 MG TABLET 49819918_1 CDM 0250 RC 00591-2472-60 NDC inpatient 1 UN 1.23 0.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.74 60.55 999999999 0.74 1.19 percent of total billed charges TAMOXIFEN 10 MG TABLET 49819918_1 CDM 0250 RC 00591-2472-60 NDC inpatient 1 UN 1.23 0.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.74 1.19 TAMOXIFEN 10 MG TABLET 49819918_1 CDM 0250 RC 00591-2472-60 NDC inpatient 1 UN 1.23 0.8 ANTHEM HMO ANTHEM HMO 999999999 0.74 1.19 TAMOXIFEN 10 MG TABLET 49819918_1 CDM 0250 RC 00591-2472-60 NDC inpatient 1 UN 1.23 0.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.74 1.19 TAMOXIFEN 10 MG TABLET 49819918_1 CDM 0250 RC 00591-2472-60 NDC inpatient 1 UN 1.23 0.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.83 67.6 999999999 0.74 1.19 percent of total billed charges TAMOXIFEN 10 MG TABLET 49819918_1 CDM 0250 RC 00591-2472-60 NDC inpatient 1 UN 1.23 0.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.74 1.19 TAMOXIFEN 10 MG TABLET 49819918_1 CDM 0250 RC 00591-2472-60 NDC inpatient 1 UN 1.23 0.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.74 1.19 "INJ PANTOPRAZOLE SODIUM, VIA" 49819920_1 CDM 0250 RC 00143-9300-10 NDC C9113 HCPCS inpatient 1 UN 31.69 20.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.6 65 999999999 19.19 30.74 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 49819920_1 CDM 0250 RC 00143-9300-10 NDC C9113 HCPCS inpatient 1 UN 31.69 20.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.74 97 999999999 19.19 30.74 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 49819920_1 CDM 0250 RC 00143-9300-10 NDC C9113 HCPCS inpatient 1 UN 31.69 20.6 AETNA AETNA 25.04 79 999999999 19.19 30.74 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 49819920_1 CDM 0250 RC 00143-9300-10 NDC C9113 HCPCS inpatient 1 UN 31.69 20.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.72 78 999999999 19.19 30.74 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 49819920_1 CDM 0250 RC 00143-9300-10 NDC C9113 HCPCS inpatient 1 UN 31.69 20.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.87 69 999999999 19.19 30.74 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 49819920_1 CDM 0250 RC 00143-9300-10 NDC C9113 HCPCS inpatient 1 UN 31.69 20.6 SIHO - ALL PLANS SIHO - ALL PLANS 28.52 90 999999999 19.19 30.74 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 49819920_1 CDM 0250 RC 00143-9300-10 NDC C9113 HCPCS inpatient 1 UN 31.69 20.6 UMR - ALL PLANS UMR - ALL PLANS 22.18 70 999999999 19.19 30.74 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 49819920_1 CDM 0250 RC 00143-9300-10 NDC C9113 HCPCS inpatient 1 UN 31.69 20.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.19 60.55 999999999 19.19 30.74 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 49819920_1 CDM 0250 RC 00143-9300-10 NDC C9113 HCPCS inpatient 1 UN 31.69 20.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.19 30.74 "INJ PANTOPRAZOLE SODIUM, VIA" 49819920_1 CDM 0250 RC 00143-9300-10 NDC C9113 HCPCS inpatient 1 UN 31.69 20.6 ANTHEM HMO ANTHEM HMO 999999999 19.19 30.74 "INJ PANTOPRAZOLE SODIUM, VIA" 49819920_1 CDM 0250 RC 00143-9300-10 NDC C9113 HCPCS inpatient 1 UN 31.69 20.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.19 30.74 "INJ PANTOPRAZOLE SODIUM, VIA" 49819920_1 CDM 0250 RC 00143-9300-10 NDC C9113 HCPCS inpatient 1 UN 31.69 20.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.42 67.6 999999999 19.19 30.74 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 49819920_1 CDM 0250 RC 00143-9300-10 NDC C9113 HCPCS inpatient 1 UN 31.69 20.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.19 30.74 "INJ PANTOPRAZOLE SODIUM, VIA" 49819920_1 CDM 0250 RC 00143-9300-10 NDC C9113 HCPCS inpatient 1 UN 31.69 20.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.19 30.74 DOXAZOSIN MESYLATE 2 MG TAB 49819924_1 CDM 0250 RC 60505-0094-00 NDC inpatient 1 UN 1.57 1.02 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.02 65 999999999 0.95 1.52 percent of total billed charges DOXAZOSIN MESYLATE 2 MG TAB 49819924_1 CDM 0250 RC 60505-0094-00 NDC inpatient 1 UN 1.57 1.02 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.52 97 999999999 0.95 1.52 percent of total billed charges DOXAZOSIN MESYLATE 2 MG TAB 49819924_1 CDM 0250 RC 60505-0094-00 NDC inpatient 1 UN 1.57 1.02 AETNA AETNA 1.24 79 999999999 0.95 1.52 percent of total billed charges DOXAZOSIN MESYLATE 2 MG TAB 49819924_1 CDM 0250 RC 60505-0094-00 NDC inpatient 1 UN 1.57 1.02 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.22 78 999999999 0.95 1.52 percent of total billed charges DOXAZOSIN MESYLATE 2 MG TAB 49819924_1 CDM 0250 RC 60505-0094-00 NDC inpatient 1 UN 1.57 1.02 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.08 69 999999999 0.95 1.52 percent of total billed charges DOXAZOSIN MESYLATE 2 MG TAB 49819924_1 CDM 0250 RC 60505-0094-00 NDC inpatient 1 UN 1.57 1.02 SIHO - ALL PLANS SIHO - ALL PLANS 1.41 90 999999999 0.95 1.52 percent of total billed charges DOXAZOSIN MESYLATE 2 MG TAB 49819924_1 CDM 0250 RC 60505-0094-00 NDC inpatient 1 UN 1.57 1.02 UMR - ALL PLANS UMR - ALL PLANS 1.1 70 999999999 0.95 1.52 percent of total billed charges DOXAZOSIN MESYLATE 2 MG TAB 49819924_1 CDM 0250 RC 60505-0094-00 NDC inpatient 1 UN 1.57 1.02 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.95 60.55 999999999 0.95 1.52 percent of total billed charges DOXAZOSIN MESYLATE 2 MG TAB 49819924_1 CDM 0250 RC 60505-0094-00 NDC inpatient 1 UN 1.57 1.02 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.95 1.52 DOXAZOSIN MESYLATE 2 MG TAB 49819924_1 CDM 0250 RC 60505-0094-00 NDC inpatient 1 UN 1.57 1.02 ANTHEM HMO ANTHEM HMO 999999999 0.95 1.52 DOXAZOSIN MESYLATE 2 MG TAB 49819924_1 CDM 0250 RC 60505-0094-00 NDC inpatient 1 UN 1.57 1.02 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.95 1.52 DOXAZOSIN MESYLATE 2 MG TAB 49819924_1 CDM 0250 RC 60505-0094-00 NDC inpatient 1 UN 1.57 1.02 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.06 67.6 999999999 0.95 1.52 percent of total billed charges DOXAZOSIN MESYLATE 2 MG TAB 49819924_1 CDM 0250 RC 60505-0094-00 NDC inpatient 1 UN 1.57 1.02 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.95 1.52 DOXAZOSIN MESYLATE 2 MG TAB 49819924_1 CDM 0250 RC 60505-0094-00 NDC inpatient 1 UN 1.57 1.02 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.95 1.52 LEVOFLOXACIN 250 MG/50 ML-D5W 49820588_1 CDM 0250 RC 00143-9722-01 NDC inpatient 1 UN 56.79 36.91 SELF PAY DISCOUNT SELF PAY DISCOUNT 36.91 65 999999999 34.39 55.09 percent of total billed charges LEVOFLOXACIN 250 MG/50 ML-D5W 49820588_1 CDM 0250 RC 00143-9722-01 NDC inpatient 1 UN 56.79 36.91 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.09 97 999999999 34.39 55.09 percent of total billed charges LEVOFLOXACIN 250 MG/50 ML-D5W 49820588_1 CDM 0250 RC 00143-9722-01 NDC inpatient 1 UN 56.79 36.91 AETNA AETNA 44.86 79 999999999 34.39 55.09 percent of total billed charges LEVOFLOXACIN 250 MG/50 ML-D5W 49820588_1 CDM 0250 RC 00143-9722-01 NDC inpatient 1 UN 56.79 36.91 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.3 78 999999999 34.39 55.09 percent of total billed charges LEVOFLOXACIN 250 MG/50 ML-D5W 49820588_1 CDM 0250 RC 00143-9722-01 NDC inpatient 1 UN 56.79 36.91 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.19 69 999999999 34.39 55.09 percent of total billed charges LEVOFLOXACIN 250 MG/50 ML-D5W 49820588_1 CDM 0250 RC 00143-9722-01 NDC inpatient 1 UN 56.79 36.91 SIHO - ALL PLANS SIHO - ALL PLANS 51.11 90 999999999 34.39 55.09 percent of total billed charges LEVOFLOXACIN 250 MG/50 ML-D5W 49820588_1 CDM 0250 RC 00143-9722-01 NDC inpatient 1 UN 56.79 36.91 UMR - ALL PLANS UMR - ALL PLANS 39.75 70 999999999 34.39 55.09 percent of total billed charges LEVOFLOXACIN 250 MG/50 ML-D5W 49820588_1 CDM 0250 RC 00143-9722-01 NDC inpatient 1 UN 56.79 36.91 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.39 60.55 999999999 34.39 55.09 percent of total billed charges LEVOFLOXACIN 250 MG/50 ML-D5W 49820588_1 CDM 0250 RC 00143-9722-01 NDC inpatient 1 UN 56.79 36.91 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.39 55.09 LEVOFLOXACIN 250 MG/50 ML-D5W 49820588_1 CDM 0250 RC 00143-9722-01 NDC inpatient 1 UN 56.79 36.91 ANTHEM HMO ANTHEM HMO 999999999 34.39 55.09 LEVOFLOXACIN 250 MG/50 ML-D5W 49820588_1 CDM 0250 RC 00143-9722-01 NDC inpatient 1 UN 56.79 36.91 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.39 55.09 LEVOFLOXACIN 250 MG/50 ML-D5W 49820588_1 CDM 0250 RC 00143-9722-01 NDC inpatient 1 UN 56.79 36.91 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.39 67.6 999999999 34.39 55.09 percent of total billed charges LEVOFLOXACIN 250 MG/50 ML-D5W 49820588_1 CDM 0250 RC 00143-9722-01 NDC inpatient 1 UN 56.79 36.91 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.39 55.09 LEVOFLOXACIN 250 MG/50 ML-D5W 49820588_1 CDM 0250 RC 00143-9722-01 NDC inpatient 1 UN 56.79 36.91 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.39 55.09 SUTURE PROLENE #0 FSLX 8690H 49822722_1 CDM 0272 RC inpatient 21 13.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 13.65 65 999999999 12.72 20.37 percent of total billed charges SUTURE PROLENE #0 FSLX 8690H 49822722_1 CDM 0272 RC inpatient 21 13.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20.37 97 999999999 12.72 20.37 percent of total billed charges SUTURE PROLENE #0 FSLX 8690H 49822722_1 CDM 0272 RC inpatient 21 13.65 AETNA AETNA 16.59 79 999999999 12.72 20.37 percent of total billed charges SUTURE PROLENE #0 FSLX 8690H 49822722_1 CDM 0272 RC inpatient 21 13.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 16.38 78 999999999 12.72 20.37 percent of total billed charges SUTURE PROLENE #0 FSLX 8690H 49822722_1 CDM 0272 RC inpatient 21 13.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 14.49 69 999999999 12.72 20.37 percent of total billed charges SUTURE PROLENE #0 FSLX 8690H 49822722_1 CDM 0272 RC inpatient 21 13.65 SIHO - ALL PLANS SIHO - ALL PLANS 18.9 90 999999999 12.72 20.37 percent of total billed charges SUTURE PROLENE #0 FSLX 8690H 49822722_1 CDM 0272 RC inpatient 21 13.65 UMR - ALL PLANS UMR - ALL PLANS 14.7 70 999999999 12.72 20.37 percent of total billed charges SUTURE PROLENE #0 FSLX 8690H 49822722_1 CDM 0272 RC inpatient 21 13.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.72 60.55 999999999 12.72 20.37 percent of total billed charges SUTURE PROLENE #0 FSLX 8690H 49822722_1 CDM 0272 RC inpatient 21 13.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.72 20.37 SUTURE PROLENE #0 FSLX 8690H 49822722_1 CDM 0272 RC inpatient 21 13.65 ANTHEM HMO ANTHEM HMO 999999999 12.72 20.37 SUTURE PROLENE #0 FSLX 8690H 49822722_1 CDM 0272 RC inpatient 21 13.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.72 20.37 SUTURE PROLENE #0 FSLX 8690H 49822722_1 CDM 0272 RC inpatient 21 13.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.2 67.6 999999999 12.72 20.37 percent of total billed charges SUTURE PROLENE #0 FSLX 8690H 49822722_1 CDM 0272 RC inpatient 21 13.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.72 20.37 SUTURE PROLENE #0 FSLX 8690H 49822722_1 CDM 0272 RC inpatient 21 13.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.72 20.37 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, by density gradient separation" 49823410_1 CDM 0302 RC 86972 HCPCS inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, by density gradient separation" 49823410_1 CDM 0302 RC 86972 HCPCS inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, by density gradient separation" 49823410_1 CDM 0302 RC 86972 HCPCS inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, by density gradient separation" 49823410_1 CDM 0302 RC 86972 HCPCS inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, by density gradient separation" 49823410_1 CDM 0302 RC 86972 HCPCS inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, by density gradient separation" 49823410_1 CDM 0302 RC 86972 HCPCS inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, by density gradient separation" 49823410_1 CDM 0302 RC 86972 HCPCS inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, by density gradient separation" 49823410_1 CDM 0302 RC 86972 HCPCS inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, by density gradient separation" 49823410_1 CDM 0302 RC 86972 HCPCS inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, by density gradient separation" 49823410_1 CDM 0302 RC 86972 HCPCS inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, by density gradient separation" 49823410_1 CDM 0302 RC 86972 HCPCS inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, by density gradient separation" 49823410_1 CDM 0302 RC 86972 HCPCS inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, by density gradient separation" 49823410_1 CDM 0302 RC 86972 HCPCS inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, by density gradient separation" 49823410_1 CDM 0302 RC 86972 HCPCS inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 ESMOLOL HCL 100 MG/10 ML VIAL 49823437_1 CDM 0250 RC 55150-0194-10 NDC inpatient 1 UN 30.03 19.52 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.52 65 999999999 18.18 29.13 percent of total billed charges ESMOLOL HCL 100 MG/10 ML VIAL 49823437_1 CDM 0250 RC 55150-0194-10 NDC inpatient 1 UN 30.03 19.52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.13 97 999999999 18.18 29.13 percent of total billed charges ESMOLOL HCL 100 MG/10 ML VIAL 49823437_1 CDM 0250 RC 55150-0194-10 NDC inpatient 1 UN 30.03 19.52 AETNA AETNA 23.72 79 999999999 18.18 29.13 percent of total billed charges ESMOLOL HCL 100 MG/10 ML VIAL 49823437_1 CDM 0250 RC 55150-0194-10 NDC inpatient 1 UN 30.03 19.52 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.42 78 999999999 18.18 29.13 percent of total billed charges ESMOLOL HCL 100 MG/10 ML VIAL 49823437_1 CDM 0250 RC 55150-0194-10 NDC inpatient 1 UN 30.03 19.52 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.72 69 999999999 18.18 29.13 percent of total billed charges ESMOLOL HCL 100 MG/10 ML VIAL 49823437_1 CDM 0250 RC 55150-0194-10 NDC inpatient 1 UN 30.03 19.52 SIHO - ALL PLANS SIHO - ALL PLANS 27.03 90 999999999 18.18 29.13 percent of total billed charges ESMOLOL HCL 100 MG/10 ML VIAL 49823437_1 CDM 0250 RC 55150-0194-10 NDC inpatient 1 UN 30.03 19.52 UMR - ALL PLANS UMR - ALL PLANS 21.02 70 999999999 18.18 29.13 percent of total billed charges ESMOLOL HCL 100 MG/10 ML VIAL 49823437_1 CDM 0250 RC 55150-0194-10 NDC inpatient 1 UN 30.03 19.52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.18 60.55 999999999 18.18 29.13 percent of total billed charges ESMOLOL HCL 100 MG/10 ML VIAL 49823437_1 CDM 0250 RC 55150-0194-10 NDC inpatient 1 UN 30.03 19.52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.18 29.13 ESMOLOL HCL 100 MG/10 ML VIAL 49823437_1 CDM 0250 RC 55150-0194-10 NDC inpatient 1 UN 30.03 19.52 ANTHEM HMO ANTHEM HMO 999999999 18.18 29.13 ESMOLOL HCL 100 MG/10 ML VIAL 49823437_1 CDM 0250 RC 55150-0194-10 NDC inpatient 1 UN 30.03 19.52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.18 29.13 ESMOLOL HCL 100 MG/10 ML VIAL 49823437_1 CDM 0250 RC 55150-0194-10 NDC inpatient 1 UN 30.03 19.52 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.3 67.6 999999999 18.18 29.13 percent of total billed charges ESMOLOL HCL 100 MG/10 ML VIAL 49823437_1 CDM 0250 RC 55150-0194-10 NDC inpatient 1 UN 30.03 19.52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.18 29.13 ESMOLOL HCL 100 MG/10 ML VIAL 49823437_1 CDM 0250 RC 55150-0194-10 NDC inpatient 1 UN 30.03 19.52 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.18 29.13 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49823438_1 CDM 0250 RC 63323-0012-10 NDC J2590 HCPCS inpatient 10 UN 42.09 27.36 SELF PAY DISCOUNT SELF PAY DISCOUNT 27.36 65 999999999 25.49 40.83 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49823438_1 CDM 0250 RC 63323-0012-10 NDC J2590 HCPCS inpatient 10 UN 42.09 27.36 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 40.83 97 999999999 25.49 40.83 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49823438_1 CDM 0250 RC 63323-0012-10 NDC J2590 HCPCS inpatient 10 UN 42.09 27.36 AETNA AETNA 33.25 79 999999999 25.49 40.83 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49823438_1 CDM 0250 RC 63323-0012-10 NDC J2590 HCPCS inpatient 10 UN 42.09 27.36 HUMANA - ALL PLANS HUMANA - ALL PLANS 32.83 78 999999999 25.49 40.83 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49823438_1 CDM 0250 RC 63323-0012-10 NDC J2590 HCPCS inpatient 10 UN 42.09 27.36 ENCORE - ALL PLANS ENCORE - ALL PLANS 29.04 69 999999999 25.49 40.83 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49823438_1 CDM 0250 RC 63323-0012-10 NDC J2590 HCPCS inpatient 10 UN 42.09 27.36 SIHO - ALL PLANS SIHO - ALL PLANS 37.88 90 999999999 25.49 40.83 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49823438_1 CDM 0250 RC 63323-0012-10 NDC J2590 HCPCS inpatient 10 UN 42.09 27.36 UMR - ALL PLANS UMR - ALL PLANS 29.46 70 999999999 25.49 40.83 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49823438_1 CDM 0250 RC 63323-0012-10 NDC J2590 HCPCS inpatient 10 UN 42.09 27.36 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 25.49 60.55 999999999 25.49 40.83 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49823438_1 CDM 0250 RC 63323-0012-10 NDC J2590 HCPCS inpatient 10 UN 42.09 27.36 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 25.49 40.83 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49823438_1 CDM 0250 RC 63323-0012-10 NDC J2590 HCPCS inpatient 10 UN 42.09 27.36 ANTHEM HMO ANTHEM HMO 999999999 25.49 40.83 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49823438_1 CDM 0250 RC 63323-0012-10 NDC J2590 HCPCS inpatient 10 UN 42.09 27.36 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 25.49 40.83 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49823438_1 CDM 0250 RC 63323-0012-10 NDC J2590 HCPCS inpatient 10 UN 42.09 27.36 CIGNA - ALL PLANS CIGNA - ALL PLANS 28.45 67.6 999999999 25.49 40.83 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49823438_1 CDM 0250 RC 63323-0012-10 NDC J2590 HCPCS inpatient 10 UN 42.09 27.36 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 25.49 40.83 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 49823438_1 CDM 0250 RC 63323-0012-10 NDC J2590 HCPCS inpatient 10 UN 42.09 27.36 UHC - ALL PLANS UHC - ALL PLANS 999999999 25.49 40.83 Cardiolipin antibody (tissue antibody) measurement 49823554_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49823554_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49823554_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49823554_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49823554_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49823554_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49823554_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49823554_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49823554_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49823554_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49823554_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49823554_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 49823554_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Cardiolipin antibody (tissue antibody) measurement 49823554_1 CDM 0302 RC 86147 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49823616_1 CDM 0250 RC 00409-3307-03 NDC J7608 HCPCS inpatient 1 UN 46.14 29.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 29.99 65 999999999 27.94 44.76 percent of total billed charges "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49823616_1 CDM 0250 RC 00409-3307-03 NDC J7608 HCPCS inpatient 1 UN 46.14 29.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 44.76 97 999999999 27.94 44.76 percent of total billed charges "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49823616_1 CDM 0250 RC 00409-3307-03 NDC J7608 HCPCS inpatient 1 UN 46.14 29.99 AETNA AETNA 36.45 79 999999999 27.94 44.76 percent of total billed charges "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49823616_1 CDM 0250 RC 00409-3307-03 NDC J7608 HCPCS inpatient 1 UN 46.14 29.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 35.99 78 999999999 27.94 44.76 percent of total billed charges "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49823616_1 CDM 0250 RC 00409-3307-03 NDC J7608 HCPCS inpatient 1 UN 46.14 29.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 31.84 69 999999999 27.94 44.76 percent of total billed charges "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49823616_1 CDM 0250 RC 00409-3307-03 NDC J7608 HCPCS inpatient 1 UN 46.14 29.99 SIHO - ALL PLANS SIHO - ALL PLANS 41.53 90 999999999 27.94 44.76 percent of total billed charges "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49823616_1 CDM 0250 RC 00409-3307-03 NDC J7608 HCPCS inpatient 1 UN 46.14 29.99 UMR - ALL PLANS UMR - ALL PLANS 32.3 70 999999999 27.94 44.76 percent of total billed charges "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49823616_1 CDM 0250 RC 00409-3307-03 NDC J7608 HCPCS inpatient 1 UN 46.14 29.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27.94 60.55 999999999 27.94 44.76 percent of total billed charges "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49823616_1 CDM 0250 RC 00409-3307-03 NDC J7608 HCPCS inpatient 1 UN 46.14 29.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 27.94 44.76 "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49823616_1 CDM 0250 RC 00409-3307-03 NDC J7608 HCPCS inpatient 1 UN 46.14 29.99 ANTHEM HMO ANTHEM HMO 999999999 27.94 44.76 "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49823616_1 CDM 0250 RC 00409-3307-03 NDC J7608 HCPCS inpatient 1 UN 46.14 29.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 27.94 44.76 "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49823616_1 CDM 0250 RC 00409-3307-03 NDC J7608 HCPCS inpatient 1 UN 46.14 29.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 31.19 67.6 999999999 27.94 44.76 percent of total billed charges "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49823616_1 CDM 0250 RC 00409-3307-03 NDC J7608 HCPCS inpatient 1 UN 46.14 29.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 27.94 44.76 "ACETYLCYSTEINE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, UNIT DOSE FORM, PER GRAM" 49823616_1 CDM 0250 RC 00409-3307-03 NDC J7608 HCPCS inpatient 1 UN 46.14 29.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 27.94 44.76 MRI scan of pelvis before and after contrast 49823976_1 CDM 0610 RC 72197 HCPCS inpatient 4326 2811.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 2811.9 65 999999999 2619.39 4196.22 percent of total billed charges MRI scan of pelvis before and after contrast 49823976_1 CDM 0610 RC 72197 HCPCS inpatient 4326 2811.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4196.22 97 999999999 2619.39 4196.22 percent of total billed charges MRI scan of pelvis before and after contrast 49823976_1 CDM 0610 RC 72197 HCPCS inpatient 4326 2811.9 AETNA AETNA 3417.54 79 999999999 2619.39 4196.22 percent of total billed charges MRI scan of pelvis before and after contrast 49823976_1 CDM 0610 RC 72197 HCPCS inpatient 4326 2811.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 3374.28 78 999999999 2619.39 4196.22 percent of total billed charges MRI scan of pelvis before and after contrast 49823976_1 CDM 0610 RC 72197 HCPCS inpatient 4326 2811.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 2984.94 69 999999999 2619.39 4196.22 percent of total billed charges MRI scan of pelvis before and after contrast 49823976_1 CDM 0610 RC 72197 HCPCS inpatient 4326 2811.9 SIHO - ALL PLANS SIHO - ALL PLANS 3893.4 90 999999999 2619.39 4196.22 percent of total billed charges MRI scan of pelvis before and after contrast 49823976_1 CDM 0610 RC 72197 HCPCS inpatient 4326 2811.9 UMR - ALL PLANS UMR - ALL PLANS 3028.2 70 999999999 2619.39 4196.22 percent of total billed charges MRI scan of pelvis before and after contrast 49823976_1 CDM 0610 RC 72197 HCPCS inpatient 4326 2811.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2619.39 60.55 999999999 2619.39 4196.22 percent of total billed charges MRI scan of pelvis before and after contrast 49823976_1 CDM 0610 RC 72197 HCPCS inpatient 4326 2811.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2619.39 4196.22 MRI scan of pelvis before and after contrast 49823976_1 CDM 0610 RC 72197 HCPCS inpatient 4326 2811.9 ANTHEM HMO ANTHEM HMO 999999999 2619.39 4196.22 MRI scan of pelvis before and after contrast 49823976_1 CDM 0610 RC 72197 HCPCS inpatient 4326 2811.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2619.39 4196.22 MRI scan of pelvis before and after contrast 49823976_1 CDM 0610 RC 72197 HCPCS inpatient 4326 2811.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 2924.38 67.6 999999999 2619.39 4196.22 percent of total billed charges MRI scan of pelvis before and after contrast 49823976_1 CDM 0610 RC 72197 HCPCS inpatient 4326 2811.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2619.39 4196.22 MRI scan of pelvis before and after contrast 49823976_1 CDM 0610 RC 72197 HCPCS inpatient 4326 2811.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 2619.39 4196.22 MRI scan of abdomen before and after contrast 49823977_1 CDM 0610 RC 74183 HCPCS inpatient 4374 2843.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 2843.1 65 999999999 2648.46 4242.78 percent of total billed charges MRI scan of abdomen before and after contrast 49823977_1 CDM 0610 RC 74183 HCPCS inpatient 4374 2843.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4242.78 97 999999999 2648.46 4242.78 percent of total billed charges MRI scan of abdomen before and after contrast 49823977_1 CDM 0610 RC 74183 HCPCS inpatient 4374 2843.1 AETNA AETNA 3455.46 79 999999999 2648.46 4242.78 percent of total billed charges MRI scan of abdomen before and after contrast 49823977_1 CDM 0610 RC 74183 HCPCS inpatient 4374 2843.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 3411.72 78 999999999 2648.46 4242.78 percent of total billed charges MRI scan of abdomen before and after contrast 49823977_1 CDM 0610 RC 74183 HCPCS inpatient 4374 2843.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 3018.06 69 999999999 2648.46 4242.78 percent of total billed charges MRI scan of abdomen before and after contrast 49823977_1 CDM 0610 RC 74183 HCPCS inpatient 4374 2843.1 SIHO - ALL PLANS SIHO - ALL PLANS 3936.6 90 999999999 2648.46 4242.78 percent of total billed charges MRI scan of abdomen before and after contrast 49823977_1 CDM 0610 RC 74183 HCPCS inpatient 4374 2843.1 UMR - ALL PLANS UMR - ALL PLANS 3061.8 70 999999999 2648.46 4242.78 percent of total billed charges MRI scan of abdomen before and after contrast 49823977_1 CDM 0610 RC 74183 HCPCS inpatient 4374 2843.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2648.46 60.55 999999999 2648.46 4242.78 percent of total billed charges MRI scan of abdomen before and after contrast 49823977_1 CDM 0610 RC 74183 HCPCS inpatient 4374 2843.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2648.46 4242.78 MRI scan of abdomen before and after contrast 49823977_1 CDM 0610 RC 74183 HCPCS inpatient 4374 2843.1 ANTHEM HMO ANTHEM HMO 999999999 2648.46 4242.78 MRI scan of abdomen before and after contrast 49823977_1 CDM 0610 RC 74183 HCPCS inpatient 4374 2843.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2648.46 4242.78 MRI scan of abdomen before and after contrast 49823977_1 CDM 0610 RC 74183 HCPCS inpatient 4374 2843.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 2956.82 67.6 999999999 2648.46 4242.78 percent of total billed charges MRI scan of abdomen before and after contrast 49823977_1 CDM 0610 RC 74183 HCPCS inpatient 4374 2843.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2648.46 4242.78 MRI scan of abdomen before and after contrast 49823977_1 CDM 0610 RC 74183 HCPCS inpatient 4374 2843.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 2648.46 4242.78 Rabies immune globulin for injection 49825081_1 CDM 0636 RC 13533-0318-05 NDC 90375 HCPCS inpatient 10 UN 3472.11 2256.87 SELF PAY DISCOUNT SELF PAY DISCOUNT 2256.87 65 999999999 2102.36 3367.95 percent of total billed charges Rabies immune globulin for injection 49825081_1 CDM 0636 RC 13533-0318-05 NDC 90375 HCPCS inpatient 10 UN 3472.11 2256.87 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3367.95 97 999999999 2102.36 3367.95 percent of total billed charges Rabies immune globulin for injection 49825081_1 CDM 0636 RC 13533-0318-05 NDC 90375 HCPCS inpatient 10 UN 3472.11 2256.87 AETNA AETNA 2742.97 79 999999999 2102.36 3367.95 percent of total billed charges Rabies immune globulin for injection 49825081_1 CDM 0636 RC 13533-0318-05 NDC 90375 HCPCS inpatient 10 UN 3472.11 2256.87 HUMANA - ALL PLANS HUMANA - ALL PLANS 2708.25 78 999999999 2102.36 3367.95 percent of total billed charges Rabies immune globulin for injection 49825081_1 CDM 0636 RC 13533-0318-05 NDC 90375 HCPCS inpatient 10 UN 3472.11 2256.87 ENCORE - ALL PLANS ENCORE - ALL PLANS 2395.76 69 999999999 2102.36 3367.95 percent of total billed charges Rabies immune globulin for injection 49825081_1 CDM 0636 RC 13533-0318-05 NDC 90375 HCPCS inpatient 10 UN 3472.11 2256.87 SIHO - ALL PLANS SIHO - ALL PLANS 3124.9 90 999999999 2102.36 3367.95 percent of total billed charges Rabies immune globulin for injection 49825081_1 CDM 0636 RC 13533-0318-05 NDC 90375 HCPCS inpatient 10 UN 3472.11 2256.87 UMR - ALL PLANS UMR - ALL PLANS 2430.48 70 999999999 2102.36 3367.95 percent of total billed charges Rabies immune globulin for injection 49825081_1 CDM 0636 RC 13533-0318-05 NDC 90375 HCPCS inpatient 10 UN 3472.11 2256.87 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2102.36 60.55 999999999 2102.36 3367.95 percent of total billed charges Rabies immune globulin for injection 49825081_1 CDM 0636 RC 13533-0318-05 NDC 90375 HCPCS inpatient 10 UN 3472.11 2256.87 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2102.36 3367.95 Rabies immune globulin for injection 49825081_1 CDM 0636 RC 13533-0318-05 NDC 90375 HCPCS inpatient 10 UN 3472.11 2256.87 ANTHEM HMO ANTHEM HMO 999999999 2102.36 3367.95 Rabies immune globulin for injection 49825081_1 CDM 0636 RC 13533-0318-05 NDC 90375 HCPCS inpatient 10 UN 3472.11 2256.87 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2102.36 3367.95 Rabies immune globulin for injection 49825081_1 CDM 0636 RC 13533-0318-05 NDC 90375 HCPCS inpatient 10 UN 3472.11 2256.87 CIGNA - ALL PLANS CIGNA - ALL PLANS 2347.15 67.6 999999999 2102.36 3367.95 percent of total billed charges Rabies immune globulin for injection 49825081_1 CDM 0636 RC 13533-0318-05 NDC 90375 HCPCS inpatient 10 UN 3472.11 2256.87 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2102.36 3367.95 Rabies immune globulin for injection 49825081_1 CDM 0636 RC 13533-0318-05 NDC 90375 HCPCS inpatient 10 UN 3472.11 2256.87 UHC - ALL PLANS UHC - ALL PLANS 999999999 2102.36 3367.95 SUTURE PROLENE 2-0 8685H 49825198_1 CDM 0272 RC inpatient 25 16.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.25 65 999999999 15.14 24.25 percent of total billed charges SUTURE PROLENE 2-0 8685H 49825198_1 CDM 0272 RC inpatient 25 16.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.25 97 999999999 15.14 24.25 percent of total billed charges SUTURE PROLENE 2-0 8685H 49825198_1 CDM 0272 RC inpatient 25 16.25 AETNA AETNA 19.75 79 999999999 15.14 24.25 percent of total billed charges SUTURE PROLENE 2-0 8685H 49825198_1 CDM 0272 RC inpatient 25 16.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.5 78 999999999 15.14 24.25 percent of total billed charges SUTURE PROLENE 2-0 8685H 49825198_1 CDM 0272 RC inpatient 25 16.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.25 69 999999999 15.14 24.25 percent of total billed charges SUTURE PROLENE 2-0 8685H 49825198_1 CDM 0272 RC inpatient 25 16.25 SIHO - ALL PLANS SIHO - ALL PLANS 22.5 90 999999999 15.14 24.25 percent of total billed charges SUTURE PROLENE 2-0 8685H 49825198_1 CDM 0272 RC inpatient 25 16.25 UMR - ALL PLANS UMR - ALL PLANS 17.5 70 999999999 15.14 24.25 percent of total billed charges SUTURE PROLENE 2-0 8685H 49825198_1 CDM 0272 RC inpatient 25 16.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.14 60.55 999999999 15.14 24.25 percent of total billed charges SUTURE PROLENE 2-0 8685H 49825198_1 CDM 0272 RC inpatient 25 16.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.14 24.25 SUTURE PROLENE 2-0 8685H 49825198_1 CDM 0272 RC inpatient 25 16.25 ANTHEM HMO ANTHEM HMO 999999999 15.14 24.25 SUTURE PROLENE 2-0 8685H 49825198_1 CDM 0272 RC inpatient 25 16.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.14 24.25 SUTURE PROLENE 2-0 8685H 49825198_1 CDM 0272 RC inpatient 25 16.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.9 67.6 999999999 15.14 24.25 percent of total billed charges SUTURE PROLENE 2-0 8685H 49825198_1 CDM 0272 RC inpatient 25 16.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.14 24.25 SUTURE PROLENE 2-0 8685H 49825198_1 CDM 0272 RC inpatient 25 16.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.14 24.25 CIPROFLOXACIN HCL 500 MG TAB 49827881_1 CDM 0250 RC 00904-6378-61 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CIPROFLOXACIN HCL 500 MG TAB 49827881_1 CDM 0250 RC 00904-6378-61 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CIPROFLOXACIN HCL 500 MG TAB 49827881_1 CDM 0250 RC 00904-6378-61 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CIPROFLOXACIN HCL 500 MG TAB 49827881_1 CDM 0250 RC 00904-6378-61 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CIPROFLOXACIN HCL 500 MG TAB 49827881_1 CDM 0250 RC 00904-6378-61 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CIPROFLOXACIN HCL 500 MG TAB 49827881_1 CDM 0250 RC 00904-6378-61 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CIPROFLOXACIN HCL 500 MG TAB 49827881_1 CDM 0250 RC 00904-6378-61 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CIPROFLOXACIN HCL 500 MG TAB 49827881_1 CDM 0250 RC 00904-6378-61 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CIPROFLOXACIN HCL 500 MG TAB 49827881_1 CDM 0250 RC 00904-6378-61 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CIPROFLOXACIN HCL 500 MG TAB 49827881_1 CDM 0250 RC 00904-6378-61 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CIPROFLOXACIN HCL 500 MG TAB 49827881_1 CDM 0250 RC 00904-6378-61 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CIPROFLOXACIN HCL 500 MG TAB 49827881_1 CDM 0250 RC 00904-6378-61 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CIPROFLOXACIN HCL 500 MG TAB 49827881_1 CDM 0250 RC 00904-6378-61 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CIPROFLOXACIN HCL 500 MG TAB 49827881_1 CDM 0250 RC 00904-6378-61 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49831290_1 CDM 0250 RC 60505-6144-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.29 65 999999999 18.9 30.28 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49831290_1 CDM 0250 RC 60505-6144-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.28 97 999999999 18.9 30.28 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49831290_1 CDM 0250 RC 60505-6144-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 AETNA AETNA 24.66 79 999999999 18.9 30.28 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49831290_1 CDM 0250 RC 60505-6144-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.35 78 999999999 18.9 30.28 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49831290_1 CDM 0250 RC 60505-6144-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.54 69 999999999 18.9 30.28 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49831290_1 CDM 0250 RC 60505-6144-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 SIHO - ALL PLANS SIHO - ALL PLANS 28.1 90 999999999 18.9 30.28 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49831290_1 CDM 0250 RC 60505-6144-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 UMR - ALL PLANS UMR - ALL PLANS 21.85 70 999999999 18.9 30.28 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49831290_1 CDM 0250 RC 60505-6144-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.9 60.55 999999999 18.9 30.28 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49831290_1 CDM 0250 RC 60505-6144-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.9 30.28 "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49831290_1 CDM 0250 RC 60505-6144-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 ANTHEM HMO ANTHEM HMO 999999999 18.9 30.28 "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49831290_1 CDM 0250 RC 60505-6144-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.9 30.28 "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49831290_1 CDM 0250 RC 60505-6144-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.1 67.6 999999999 18.9 30.28 percent of total billed charges "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49831290_1 CDM 0250 RC 60505-6144-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.9 30.28 "INJECTION, CEFEPIME HYDROCHLORIDE, 500 MG" 49831290_1 CDM 0250 RC 60505-6144-04 NDC J0692 HCPCS inpatient 2 UN 31.22 20.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.9 30.28 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49831385_1 CDM 0250 RC 63323-0106-05 NDC J3475 HCPCS inpatient 4 UN 80.26 52.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.17 65 999999999 48.6 77.85 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49831385_1 CDM 0250 RC 63323-0106-05 NDC J3475 HCPCS inpatient 4 UN 80.26 52.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.85 97 999999999 48.6 77.85 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49831385_1 CDM 0250 RC 63323-0106-05 NDC J3475 HCPCS inpatient 4 UN 80.26 52.17 AETNA AETNA 63.41 79 999999999 48.6 77.85 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49831385_1 CDM 0250 RC 63323-0106-05 NDC J3475 HCPCS inpatient 4 UN 80.26 52.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.6 78 999999999 48.6 77.85 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49831385_1 CDM 0250 RC 63323-0106-05 NDC J3475 HCPCS inpatient 4 UN 80.26 52.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.38 69 999999999 48.6 77.85 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49831385_1 CDM 0250 RC 63323-0106-05 NDC J3475 HCPCS inpatient 4 UN 80.26 52.17 SIHO - ALL PLANS SIHO - ALL PLANS 72.23 90 999999999 48.6 77.85 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49831385_1 CDM 0250 RC 63323-0106-05 NDC J3475 HCPCS inpatient 4 UN 80.26 52.17 UMR - ALL PLANS UMR - ALL PLANS 56.18 70 999999999 48.6 77.85 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49831385_1 CDM 0250 RC 63323-0106-05 NDC J3475 HCPCS inpatient 4 UN 80.26 52.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.6 60.55 999999999 48.6 77.85 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49831385_1 CDM 0250 RC 63323-0106-05 NDC J3475 HCPCS inpatient 4 UN 80.26 52.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.6 77.85 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49831385_1 CDM 0250 RC 63323-0106-05 NDC J3475 HCPCS inpatient 4 UN 80.26 52.17 ANTHEM HMO ANTHEM HMO 999999999 48.6 77.85 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49831385_1 CDM 0250 RC 63323-0106-05 NDC J3475 HCPCS inpatient 4 UN 80.26 52.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.6 77.85 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49831385_1 CDM 0250 RC 63323-0106-05 NDC J3475 HCPCS inpatient 4 UN 80.26 52.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.26 67.6 999999999 48.6 77.85 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49831385_1 CDM 0250 RC 63323-0106-05 NDC J3475 HCPCS inpatient 4 UN 80.26 52.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.6 77.85 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49831385_1 CDM 0250 RC 63323-0106-05 NDC J3475 HCPCS inpatient 4 UN 80.26 52.17 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.6 77.85 PANTOPRAZOLE SOD DR 40 MG TAB 49831417_1 CDM 0250 RC 68084-0813-09 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges PANTOPRAZOLE SOD DR 40 MG TAB 49831417_1 CDM 0250 RC 68084-0813-09 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges PANTOPRAZOLE SOD DR 40 MG TAB 49831417_1 CDM 0250 RC 68084-0813-09 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges PANTOPRAZOLE SOD DR 40 MG TAB 49831417_1 CDM 0250 RC 68084-0813-09 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges PANTOPRAZOLE SOD DR 40 MG TAB 49831417_1 CDM 0250 RC 68084-0813-09 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges PANTOPRAZOLE SOD DR 40 MG TAB 49831417_1 CDM 0250 RC 68084-0813-09 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges PANTOPRAZOLE SOD DR 40 MG TAB 49831417_1 CDM 0250 RC 68084-0813-09 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges PANTOPRAZOLE SOD DR 40 MG TAB 49831417_1 CDM 0250 RC 68084-0813-09 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges PANTOPRAZOLE SOD DR 40 MG TAB 49831417_1 CDM 0250 RC 68084-0813-09 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 PANTOPRAZOLE SOD DR 40 MG TAB 49831417_1 CDM 0250 RC 68084-0813-09 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 PANTOPRAZOLE SOD DR 40 MG TAB 49831417_1 CDM 0250 RC 68084-0813-09 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 PANTOPRAZOLE SOD DR 40 MG TAB 49831417_1 CDM 0250 RC 68084-0813-09 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges PANTOPRAZOLE SOD DR 40 MG TAB 49831417_1 CDM 0250 RC 68084-0813-09 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 PANTOPRAZOLE SOD DR 40 MG TAB 49831417_1 CDM 0250 RC 68084-0813-09 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ATENOLOL 50 MG TABLET 49831903_1 CDM 0250 RC 00378-0231-01 NDC inpatient 4 UN 1.63 1.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.06 65 999999999 0.99 1.58 percent of total billed charges ATENOLOL 50 MG TABLET 49831903_1 CDM 0250 RC 00378-0231-01 NDC inpatient 4 UN 1.63 1.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.58 97 999999999 0.99 1.58 percent of total billed charges ATENOLOL 50 MG TABLET 49831903_1 CDM 0250 RC 00378-0231-01 NDC inpatient 4 UN 1.63 1.06 AETNA AETNA 1.29 79 999999999 0.99 1.58 percent of total billed charges ATENOLOL 50 MG TABLET 49831903_1 CDM 0250 RC 00378-0231-01 NDC inpatient 4 UN 1.63 1.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.27 78 999999999 0.99 1.58 percent of total billed charges ATENOLOL 50 MG TABLET 49831903_1 CDM 0250 RC 00378-0231-01 NDC inpatient 4 UN 1.63 1.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.12 69 999999999 0.99 1.58 percent of total billed charges ATENOLOL 50 MG TABLET 49831903_1 CDM 0250 RC 00378-0231-01 NDC inpatient 4 UN 1.63 1.06 SIHO - ALL PLANS SIHO - ALL PLANS 1.47 90 999999999 0.99 1.58 percent of total billed charges ATENOLOL 50 MG TABLET 49831903_1 CDM 0250 RC 00378-0231-01 NDC inpatient 4 UN 1.63 1.06 UMR - ALL PLANS UMR - ALL PLANS 1.14 70 999999999 0.99 1.58 percent of total billed charges ATENOLOL 50 MG TABLET 49831903_1 CDM 0250 RC 00378-0231-01 NDC inpatient 4 UN 1.63 1.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.99 60.55 999999999 0.99 1.58 percent of total billed charges ATENOLOL 50 MG TABLET 49831903_1 CDM 0250 RC 00378-0231-01 NDC inpatient 4 UN 1.63 1.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.99 1.58 ATENOLOL 50 MG TABLET 49831903_1 CDM 0250 RC 00378-0231-01 NDC inpatient 4 UN 1.63 1.06 ANTHEM HMO ANTHEM HMO 999999999 0.99 1.58 ATENOLOL 50 MG TABLET 49831903_1 CDM 0250 RC 00378-0231-01 NDC inpatient 4 UN 1.63 1.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.99 1.58 ATENOLOL 50 MG TABLET 49831903_1 CDM 0250 RC 00378-0231-01 NDC inpatient 4 UN 1.63 1.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.1 67.6 999999999 0.99 1.58 percent of total billed charges ATENOLOL 50 MG TABLET 49831903_1 CDM 0250 RC 00378-0231-01 NDC inpatient 4 UN 1.63 1.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.99 1.58 ATENOLOL 50 MG TABLET 49831903_1 CDM 0250 RC 00378-0231-01 NDC inpatient 4 UN 1.63 1.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.99 1.58 "Myelin basic protein (nerve protein) level, spinal fluid" 49832828_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges "Myelin basic protein (nerve protein) level, spinal fluid" 49832828_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges "Myelin basic protein (nerve protein) level, spinal fluid" 49832828_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges "Myelin basic protein (nerve protein) level, spinal fluid" 49832828_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges "Myelin basic protein (nerve protein) level, spinal fluid" 49832828_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges "Myelin basic protein (nerve protein) level, spinal fluid" 49832828_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges "Myelin basic protein (nerve protein) level, spinal fluid" 49832828_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges "Myelin basic protein (nerve protein) level, spinal fluid" 49832828_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges "Myelin basic protein (nerve protein) level, spinal fluid" 49832828_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 "Myelin basic protein (nerve protein) level, spinal fluid" 49832828_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 "Myelin basic protein (nerve protein) level, spinal fluid" 49832828_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 "Myelin basic protein (nerve protein) level, spinal fluid" 49832828_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges "Myelin basic protein (nerve protein) level, spinal fluid" 49832828_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 "Myelin basic protein (nerve protein) level, spinal fluid" 49832828_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 "Drugs or substances measurement, 1-3" 49835678_1 CDM 0301 RC 80375 HCPCS inpatient 521 338.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 338.65 65 999999999 315.47 505.37 percent of total billed charges "Drugs or substances measurement, 1-3" 49835678_1 CDM 0301 RC 80375 HCPCS inpatient 521 338.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 505.37 97 999999999 315.47 505.37 percent of total billed charges "Drugs or substances measurement, 1-3" 49835678_1 CDM 0301 RC 80375 HCPCS inpatient 521 338.65 AETNA AETNA 411.59 79 999999999 315.47 505.37 percent of total billed charges "Drugs or substances measurement, 1-3" 49835678_1 CDM 0301 RC 80375 HCPCS inpatient 521 338.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 406.38 78 999999999 315.47 505.37 percent of total billed charges "Drugs or substances measurement, 1-3" 49835678_1 CDM 0301 RC 80375 HCPCS inpatient 521 338.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 359.49 69 999999999 315.47 505.37 percent of total billed charges "Drugs or substances measurement, 1-3" 49835678_1 CDM 0301 RC 80375 HCPCS inpatient 521 338.65 SIHO - ALL PLANS SIHO - ALL PLANS 468.9 90 999999999 315.47 505.37 percent of total billed charges "Drugs or substances measurement, 1-3" 49835678_1 CDM 0301 RC 80375 HCPCS inpatient 521 338.65 UMR - ALL PLANS UMR - ALL PLANS 364.7 70 999999999 315.47 505.37 percent of total billed charges "Drugs or substances measurement, 1-3" 49835678_1 CDM 0301 RC 80375 HCPCS inpatient 521 338.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 315.47 60.55 999999999 315.47 505.37 percent of total billed charges "Drugs or substances measurement, 1-3" 49835678_1 CDM 0301 RC 80375 HCPCS inpatient 521 338.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 315.47 505.37 "Drugs or substances measurement, 1-3" 49835678_1 CDM 0301 RC 80375 HCPCS inpatient 521 338.65 ANTHEM HMO ANTHEM HMO 999999999 315.47 505.37 "Drugs or substances measurement, 1-3" 49835678_1 CDM 0301 RC 80375 HCPCS inpatient 521 338.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 315.47 505.37 "Drugs or substances measurement, 1-3" 49835678_1 CDM 0301 RC 80375 HCPCS inpatient 521 338.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 352.2 67.6 999999999 315.47 505.37 percent of total billed charges "Drugs or substances measurement, 1-3" 49835678_1 CDM 0301 RC 80375 HCPCS inpatient 521 338.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 315.47 505.37 "Drugs or substances measurement, 1-3" 49835678_1 CDM 0301 RC 80375 HCPCS inpatient 521 338.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 315.47 505.37 CEFUROXIME AXETIL 250 MG TAB 49837221_1 CDM 0250 RC 67877-0215-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CEFUROXIME AXETIL 250 MG TAB 49837221_1 CDM 0250 RC 67877-0215-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CEFUROXIME AXETIL 250 MG TAB 49837221_1 CDM 0250 RC 67877-0215-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CEFUROXIME AXETIL 250 MG TAB 49837221_1 CDM 0250 RC 67877-0215-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CEFUROXIME AXETIL 250 MG TAB 49837221_1 CDM 0250 RC 67877-0215-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CEFUROXIME AXETIL 250 MG TAB 49837221_1 CDM 0250 RC 67877-0215-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CEFUROXIME AXETIL 250 MG TAB 49837221_1 CDM 0250 RC 67877-0215-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CEFUROXIME AXETIL 250 MG TAB 49837221_1 CDM 0250 RC 67877-0215-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CEFUROXIME AXETIL 250 MG TAB 49837221_1 CDM 0250 RC 67877-0215-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CEFUROXIME AXETIL 250 MG TAB 49837221_1 CDM 0250 RC 67877-0215-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CEFUROXIME AXETIL 250 MG TAB 49837221_1 CDM 0250 RC 67877-0215-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CEFUROXIME AXETIL 250 MG TAB 49837221_1 CDM 0250 RC 67877-0215-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CEFUROXIME AXETIL 250 MG TAB 49837221_1 CDM 0250 RC 67877-0215-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CEFUROXIME AXETIL 250 MG TAB 49837221_1 CDM 0250 RC 67877-0215-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "Analysis of substance using immunoassay technique, multiple step method" 49837342_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49837342_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49837342_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49837342_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49837342_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49837342_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49837342_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49837342_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49837342_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49837342_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49837342_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49837342_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 49837342_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 49837342_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 49837350_1 CDM 0510 RC 36465 HCPCS inpatient 4407 2864.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 2864.55 65 999999999 2668.44 4274.79 percent of total billed charges Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 49837350_1 CDM 0510 RC 36465 HCPCS inpatient 4407 2864.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4274.79 97 999999999 2668.44 4274.79 percent of total billed charges Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 49837350_1 CDM 0510 RC 36465 HCPCS inpatient 4407 2864.55 AETNA AETNA 3481.53 79 999999999 2668.44 4274.79 percent of total billed charges Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 49837350_1 CDM 0510 RC 36465 HCPCS inpatient 4407 2864.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 3437.46 78 999999999 2668.44 4274.79 percent of total billed charges Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 49837350_1 CDM 0510 RC 36465 HCPCS inpatient 4407 2864.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 3040.83 69 999999999 2668.44 4274.79 percent of total billed charges Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 49837350_1 CDM 0510 RC 36465 HCPCS inpatient 4407 2864.55 SIHO - ALL PLANS SIHO - ALL PLANS 3966.3 90 999999999 2668.44 4274.79 percent of total billed charges Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 49837350_1 CDM 0510 RC 36465 HCPCS inpatient 4407 2864.55 UMR - ALL PLANS UMR - ALL PLANS 3084.9 70 999999999 2668.44 4274.79 percent of total billed charges Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 49837350_1 CDM 0510 RC 36465 HCPCS inpatient 4407 2864.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2668.44 60.55 999999999 2668.44 4274.79 percent of total billed charges Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 49837350_1 CDM 0510 RC 36465 HCPCS inpatient 4407 2864.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2668.44 4274.79 Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 49837350_1 CDM 0510 RC 36465 HCPCS inpatient 4407 2864.55 ANTHEM HMO ANTHEM HMO 999999999 2668.44 4274.79 Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 49837350_1 CDM 0510 RC 36465 HCPCS inpatient 4407 2864.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2668.44 4274.79 Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 49837350_1 CDM 0510 RC 36465 HCPCS inpatient 4407 2864.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 2979.13 67.6 999999999 2668.44 4274.79 percent of total billed charges Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 49837350_1 CDM 0510 RC 36465 HCPCS inpatient 4407 2864.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2668.44 4274.79 Injection of chemical agent into single incompetent vein of leg using ultrasound guidance 49837350_1 CDM 0510 RC 36465 HCPCS inpatient 4407 2864.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 2668.44 4274.79 Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 49837354_1 CDM 0510 RC 36466 HCPCS inpatient 4489 2917.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 2917.85 65 999999999 2718.09 4354.33 percent of total billed charges Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 49837354_1 CDM 0510 RC 36466 HCPCS inpatient 4489 2917.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4354.33 97 999999999 2718.09 4354.33 percent of total billed charges Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 49837354_1 CDM 0510 RC 36466 HCPCS inpatient 4489 2917.85 AETNA AETNA 3546.31 79 999999999 2718.09 4354.33 percent of total billed charges Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 49837354_1 CDM 0510 RC 36466 HCPCS inpatient 4489 2917.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 3501.42 78 999999999 2718.09 4354.33 percent of total billed charges Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 49837354_1 CDM 0510 RC 36466 HCPCS inpatient 4489 2917.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 3097.41 69 999999999 2718.09 4354.33 percent of total billed charges Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 49837354_1 CDM 0510 RC 36466 HCPCS inpatient 4489 2917.85 SIHO - ALL PLANS SIHO - ALL PLANS 4040.1 90 999999999 2718.09 4354.33 percent of total billed charges Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 49837354_1 CDM 0510 RC 36466 HCPCS inpatient 4489 2917.85 UMR - ALL PLANS UMR - ALL PLANS 3142.3 70 999999999 2718.09 4354.33 percent of total billed charges Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 49837354_1 CDM 0510 RC 36466 HCPCS inpatient 4489 2917.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2718.09 60.55 999999999 2718.09 4354.33 percent of total billed charges Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 49837354_1 CDM 0510 RC 36466 HCPCS inpatient 4489 2917.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2718.09 4354.33 Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 49837354_1 CDM 0510 RC 36466 HCPCS inpatient 4489 2917.85 ANTHEM HMO ANTHEM HMO 999999999 2718.09 4354.33 Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 49837354_1 CDM 0510 RC 36466 HCPCS inpatient 4489 2917.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2718.09 4354.33 Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 49837354_1 CDM 0510 RC 36466 HCPCS inpatient 4489 2917.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 3034.56 67.6 999999999 2718.09 4354.33 percent of total billed charges Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 49837354_1 CDM 0510 RC 36466 HCPCS inpatient 4489 2917.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2718.09 4354.33 Injection of chemical agent into multiple incompetent veins of same leg using ultrasound guidance 49837354_1 CDM 0510 RC 36466 HCPCS inpatient 4489 2917.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 2718.09 4354.33 Chemical destruction of first incompetent vein of arm or leg using imaging guidance 49837355_1 CDM 0510 RC 36482 HCPCS inpatient 8150 5297.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 5297.5 65 999999999 4934.83 7905.5 percent of total billed charges Chemical destruction of first incompetent vein of arm or leg using imaging guidance 49837355_1 CDM 0510 RC 36482 HCPCS inpatient 8150 5297.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7905.5 97 999999999 4934.83 7905.5 percent of total billed charges Chemical destruction of first incompetent vein of arm or leg using imaging guidance 49837355_1 CDM 0510 RC 36482 HCPCS inpatient 8150 5297.5 AETNA AETNA 6438.5 79 999999999 4934.83 7905.5 percent of total billed charges Chemical destruction of first incompetent vein of arm or leg using imaging guidance 49837355_1 CDM 0510 RC 36482 HCPCS inpatient 8150 5297.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 6357 78 999999999 4934.83 7905.5 percent of total billed charges Chemical destruction of first incompetent vein of arm or leg using imaging guidance 49837355_1 CDM 0510 RC 36482 HCPCS inpatient 8150 5297.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 5623.5 69 999999999 4934.83 7905.5 percent of total billed charges Chemical destruction of first incompetent vein of arm or leg using imaging guidance 49837355_1 CDM 0510 RC 36482 HCPCS inpatient 8150 5297.5 SIHO - ALL PLANS SIHO - ALL PLANS 7335 90 999999999 4934.83 7905.5 percent of total billed charges Chemical destruction of first incompetent vein of arm or leg using imaging guidance 49837355_1 CDM 0510 RC 36482 HCPCS inpatient 8150 5297.5 UMR - ALL PLANS UMR - ALL PLANS 5705 70 999999999 4934.83 7905.5 percent of total billed charges Chemical destruction of first incompetent vein of arm or leg using imaging guidance 49837355_1 CDM 0510 RC 36482 HCPCS inpatient 8150 5297.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4934.83 60.55 999999999 4934.83 7905.5 percent of total billed charges Chemical destruction of first incompetent vein of arm or leg using imaging guidance 49837355_1 CDM 0510 RC 36482 HCPCS inpatient 8150 5297.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4934.83 7905.5 Chemical destruction of first incompetent vein of arm or leg using imaging guidance 49837355_1 CDM 0510 RC 36482 HCPCS inpatient 8150 5297.5 ANTHEM HMO ANTHEM HMO 999999999 4934.83 7905.5 Chemical destruction of first incompetent vein of arm or leg using imaging guidance 49837355_1 CDM 0510 RC 36482 HCPCS inpatient 8150 5297.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4934.83 7905.5 Chemical destruction of first incompetent vein of arm or leg using imaging guidance 49837355_1 CDM 0510 RC 36482 HCPCS inpatient 8150 5297.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 5509.4 67.6 999999999 4934.83 7905.5 percent of total billed charges Chemical destruction of first incompetent vein of arm or leg using imaging guidance 49837355_1 CDM 0510 RC 36482 HCPCS inpatient 8150 5297.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4934.83 7905.5 Chemical destruction of first incompetent vein of arm or leg using imaging guidance 49837355_1 CDM 0510 RC 36482 HCPCS inpatient 8150 5297.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 4934.83 7905.5 Chemical destruction of subsequent incompetent veins of arm or leg using imaging guidance 49837356_1 CDM 0510 RC 36483 HCPCS inpatient 4074 2648.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 2648.1 65 999999999 2466.81 3951.78 percent of total billed charges Chemical destruction of subsequent incompetent veins of arm or leg using imaging guidance 49837356_1 CDM 0510 RC 36483 HCPCS inpatient 4074 2648.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3951.78 97 999999999 2466.81 3951.78 percent of total billed charges Chemical destruction of subsequent incompetent veins of arm or leg using imaging guidance 49837356_1 CDM 0510 RC 36483 HCPCS inpatient 4074 2648.1 AETNA AETNA 3218.46 79 999999999 2466.81 3951.78 percent of total billed charges Chemical destruction of subsequent incompetent veins of arm or leg using imaging guidance 49837356_1 CDM 0510 RC 36483 HCPCS inpatient 4074 2648.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 3177.72 78 999999999 2466.81 3951.78 percent of total billed charges Chemical destruction of subsequent incompetent veins of arm or leg using imaging guidance 49837356_1 CDM 0510 RC 36483 HCPCS inpatient 4074 2648.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 2811.06 69 999999999 2466.81 3951.78 percent of total billed charges Chemical destruction of subsequent incompetent veins of arm or leg using imaging guidance 49837356_1 CDM 0510 RC 36483 HCPCS inpatient 4074 2648.1 SIHO - ALL PLANS SIHO - ALL PLANS 3666.6 90 999999999 2466.81 3951.78 percent of total billed charges Chemical destruction of subsequent incompetent veins of arm or leg using imaging guidance 49837356_1 CDM 0510 RC 36483 HCPCS inpatient 4074 2648.1 UMR - ALL PLANS UMR - ALL PLANS 2851.8 70 999999999 2466.81 3951.78 percent of total billed charges Chemical destruction of subsequent incompetent veins of arm or leg using imaging guidance 49837356_1 CDM 0510 RC 36483 HCPCS inpatient 4074 2648.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2466.81 60.55 999999999 2466.81 3951.78 percent of total billed charges Chemical destruction of subsequent incompetent veins of arm or leg using imaging guidance 49837356_1 CDM 0510 RC 36483 HCPCS inpatient 4074 2648.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2466.81 3951.78 Chemical destruction of subsequent incompetent veins of arm or leg using imaging guidance 49837356_1 CDM 0510 RC 36483 HCPCS inpatient 4074 2648.1 ANTHEM HMO ANTHEM HMO 999999999 2466.81 3951.78 Chemical destruction of subsequent incompetent veins of arm or leg using imaging guidance 49837356_1 CDM 0510 RC 36483 HCPCS inpatient 4074 2648.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2466.81 3951.78 Chemical destruction of subsequent incompetent veins of arm or leg using imaging guidance 49837356_1 CDM 0510 RC 36483 HCPCS inpatient 4074 2648.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 2754.02 67.6 999999999 2466.81 3951.78 percent of total billed charges Chemical destruction of subsequent incompetent veins of arm or leg using imaging guidance 49837356_1 CDM 0510 RC 36483 HCPCS inpatient 4074 2648.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2466.81 3951.78 Chemical destruction of subsequent incompetent veins of arm or leg using imaging guidance 49837356_1 CDM 0510 RC 36483 HCPCS inpatient 4074 2648.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 2466.81 3951.78 UNCLASSIFIED DRUGS 49837357_1 CDM 0636 RC J3490 HCPCS inpatient 241 156.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 156.65 65 999999999 145.93 233.77 percent of total billed charges UNCLASSIFIED DRUGS 49837357_1 CDM 0636 RC J3490 HCPCS inpatient 241 156.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 233.77 97 999999999 145.93 233.77 percent of total billed charges UNCLASSIFIED DRUGS 49837357_1 CDM 0636 RC J3490 HCPCS inpatient 241 156.65 AETNA AETNA 190.39 79 999999999 145.93 233.77 percent of total billed charges UNCLASSIFIED DRUGS 49837357_1 CDM 0636 RC J3490 HCPCS inpatient 241 156.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.98 78 999999999 145.93 233.77 percent of total billed charges UNCLASSIFIED DRUGS 49837357_1 CDM 0636 RC J3490 HCPCS inpatient 241 156.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 166.29 69 999999999 145.93 233.77 percent of total billed charges UNCLASSIFIED DRUGS 49837357_1 CDM 0636 RC J3490 HCPCS inpatient 241 156.65 SIHO - ALL PLANS SIHO - ALL PLANS 216.9 90 999999999 145.93 233.77 percent of total billed charges UNCLASSIFIED DRUGS 49837357_1 CDM 0636 RC J3490 HCPCS inpatient 241 156.65 UMR - ALL PLANS UMR - ALL PLANS 168.7 70 999999999 145.93 233.77 percent of total billed charges UNCLASSIFIED DRUGS 49837357_1 CDM 0636 RC J3490 HCPCS inpatient 241 156.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.93 60.55 999999999 145.93 233.77 percent of total billed charges UNCLASSIFIED DRUGS 49837357_1 CDM 0636 RC J3490 HCPCS inpatient 241 156.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.93 233.77 UNCLASSIFIED DRUGS 49837357_1 CDM 0636 RC J3490 HCPCS inpatient 241 156.65 ANTHEM HMO ANTHEM HMO 999999999 145.93 233.77 UNCLASSIFIED DRUGS 49837357_1 CDM 0636 RC J3490 HCPCS inpatient 241 156.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.93 233.77 UNCLASSIFIED DRUGS 49837357_1 CDM 0636 RC J3490 HCPCS inpatient 241 156.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.92 67.6 999999999 145.93 233.77 percent of total billed charges UNCLASSIFIED DRUGS 49837357_1 CDM 0636 RC J3490 HCPCS inpatient 241 156.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.93 233.77 UNCLASSIFIED DRUGS 49837357_1 CDM 0636 RC J3490 HCPCS inpatient 241 156.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.93 233.77 Analysis for antibody to West Nile virus 49837503_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.6 65 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 49837503_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.88 97 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 49837503_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 AETNA AETNA 161.16 79 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 49837503_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.12 78 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 49837503_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.76 69 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 49837503_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 SIHO - ALL PLANS SIHO - ALL PLANS 183.6 90 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 49837503_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 UMR - ALL PLANS UMR - ALL PLANS 142.8 70 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 49837503_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.52 60.55 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 49837503_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.52 197.88 Analysis for antibody to West Nile virus 49837503_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 ANTHEM HMO ANTHEM HMO 999999999 123.52 197.88 Analysis for antibody to West Nile virus 49837503_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.52 197.88 Analysis for antibody to West Nile virus 49837503_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.9 67.6 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 49837503_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.52 197.88 Analysis for antibody to West Nile virus 49837503_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.52 197.88 Analysis for antibody (IgM) to West Nile virus 49837504_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 AETNA AETNA 163.53 79 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 49837504_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 134.55 65 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 49837504_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 200.79 97 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 49837504_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 161.46 78 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 49837504_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.83 69 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 49837504_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 SIHO - ALL PLANS SIHO - ALL PLANS 186.3 90 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 49837504_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 UMR - ALL PLANS UMR - ALL PLANS 144.9 70 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 49837504_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 125.34 60.55 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 49837504_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 125.34 200.79 Analysis for antibody (IgM) to West Nile virus 49837504_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ANTHEM HMO ANTHEM HMO 999999999 125.34 200.79 Analysis for antibody (IgM) to West Nile virus 49837504_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 125.34 200.79 Analysis for antibody (IgM) to West Nile virus 49837504_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.93 67.6 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 49837504_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 125.34 200.79 Analysis for antibody (IgM) to West Nile virus 49837504_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 125.34 200.79 Analysis for antibody to Herpes simplex virus 49837505_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 49837505_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 49837505_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 49837505_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 49837505_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 49837505_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 49837505_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 49837505_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 49837505_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 49837505_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 49837505_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 49837505_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 49837505_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 49837505_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 49837506_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 49837506_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 49837506_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 49837506_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 49837506_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 49837506_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 49837506_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 49837506_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 49837506_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 49837506_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 49837506_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 49837506_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 49837506_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 49837506_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 Analysis for antibody to Rubeola (measles virus) 49837507_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49837507_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49837507_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49837507_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49837507_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49837507_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49837507_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49837507_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49837507_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 Analysis for antibody to Rubeola (measles virus) 49837507_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 Analysis for antibody to Rubeola (measles virus) 49837507_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 Analysis for antibody to Rubeola (measles virus) 49837507_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49837507_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 Analysis for antibody to Rubeola (measles virus) 49837507_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 Analysis for antibody to Rubeola (measles virus) 49837508_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49837508_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49837508_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49837508_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49837508_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49837508_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49837508_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49837508_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49837508_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 Analysis for antibody to Rubeola (measles virus) 49837508_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 Analysis for antibody to Rubeola (measles virus) 49837508_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 Analysis for antibody to Rubeola (measles virus) 49837508_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 49837508_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 Analysis for antibody to Rubeola (measles virus) 49837508_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 Analysis for antibody to mumps virus 49837509_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 49837509_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 49837509_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 49837509_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 49837509_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 49837509_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 49837509_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 49837509_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 49837509_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 Analysis for antibody to mumps virus 49837509_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 Analysis for antibody to mumps virus 49837509_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 Analysis for antibody to mumps virus 49837509_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 49837509_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 Analysis for antibody to mumps virus 49837509_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 Analysis for antibody to mumps virus 49837510_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 49837510_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 49837510_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 49837510_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 49837510_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 49837510_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 49837510_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 49837510_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 49837510_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 Analysis for antibody to mumps virus 49837510_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 Analysis for antibody to mumps virus 49837510_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 Analysis for antibody to mumps virus 49837510_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges Analysis for antibody to mumps virus 49837510_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 Analysis for antibody to mumps virus 49837510_1 CDM 0301 RC 86735 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 Analysis for antibody to varicella-zoster virus (chicken pox) 49837511_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 49837511_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 49837511_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 49837511_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 49837511_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 49837511_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 49837511_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 49837511_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 49837511_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 49837511_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 49837511_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 49837511_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 49837511_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 49837511_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 49837512_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 49837512_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 49837512_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 49837512_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 49837512_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 49837512_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 49837512_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 49837512_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 49837512_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 49837512_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 49837512_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 49837512_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 49837512_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 49837512_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 "Enzyme activity measurement, nonradioactive substrate" 49837518_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 AETNA AETNA 193.55 79 999999999 148.35 237.65 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49837518_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 159.25 65 999999999 148.35 237.65 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49837518_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 237.65 97 999999999 148.35 237.65 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49837518_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 191.1 78 999999999 148.35 237.65 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49837518_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 169.05 69 999999999 148.35 237.65 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49837518_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 SIHO - ALL PLANS SIHO - ALL PLANS 220.5 90 999999999 148.35 237.65 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49837518_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 UMR - ALL PLANS UMR - ALL PLANS 171.5 70 999999999 148.35 237.65 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49837518_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 148.35 60.55 999999999 148.35 237.65 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49837518_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 148.35 237.65 "Enzyme activity measurement, nonradioactive substrate" 49837518_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 ANTHEM HMO ANTHEM HMO 999999999 148.35 237.65 "Enzyme activity measurement, nonradioactive substrate" 49837518_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 148.35 237.65 "Enzyme activity measurement, nonradioactive substrate" 49837518_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 165.62 67.6 999999999 148.35 237.65 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49837518_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 148.35 237.65 "Enzyme activity measurement, nonradioactive substrate" 49837518_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 148.35 237.65 NITROGLYCERIN 0.4 MG TABLET SL 49837873_1 CDM 0250 RC 68462-0639-45 NDC inpatient 1 UN 27.44 17.84 AETNA AETNA 21.68 79 999999999 16.61 26.62 percent of total billed charges NITROGLYCERIN 0.4 MG TABLET SL 49837873_1 CDM 0250 RC 68462-0639-45 NDC inpatient 1 UN 27.44 17.84 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.84 65 999999999 16.61 26.62 percent of total billed charges NITROGLYCERIN 0.4 MG TABLET SL 49837873_1 CDM 0250 RC 68462-0639-45 NDC inpatient 1 UN 27.44 17.84 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26.62 97 999999999 16.61 26.62 percent of total billed charges NITROGLYCERIN 0.4 MG TABLET SL 49837873_1 CDM 0250 RC 68462-0639-45 NDC inpatient 1 UN 27.44 17.84 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.4 78 999999999 16.61 26.62 percent of total billed charges NITROGLYCERIN 0.4 MG TABLET SL 49837873_1 CDM 0250 RC 68462-0639-45 NDC inpatient 1 UN 27.44 17.84 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.93 69 999999999 16.61 26.62 percent of total billed charges NITROGLYCERIN 0.4 MG TABLET SL 49837873_1 CDM 0250 RC 68462-0639-45 NDC inpatient 1 UN 27.44 17.84 SIHO - ALL PLANS SIHO - ALL PLANS 24.7 90 999999999 16.61 26.62 percent of total billed charges NITROGLYCERIN 0.4 MG TABLET SL 49837873_1 CDM 0250 RC 68462-0639-45 NDC inpatient 1 UN 27.44 17.84 UMR - ALL PLANS UMR - ALL PLANS 19.21 70 999999999 16.61 26.62 percent of total billed charges NITROGLYCERIN 0.4 MG TABLET SL 49837873_1 CDM 0250 RC 68462-0639-45 NDC inpatient 1 UN 27.44 17.84 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.61 60.55 999999999 16.61 26.62 percent of total billed charges NITROGLYCERIN 0.4 MG TABLET SL 49837873_1 CDM 0250 RC 68462-0639-45 NDC inpatient 1 UN 27.44 17.84 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.61 26.62 NITROGLYCERIN 0.4 MG TABLET SL 49837873_1 CDM 0250 RC 68462-0639-45 NDC inpatient 1 UN 27.44 17.84 ANTHEM HMO ANTHEM HMO 999999999 16.61 26.62 NITROGLYCERIN 0.4 MG TABLET SL 49837873_1 CDM 0250 RC 68462-0639-45 NDC inpatient 1 UN 27.44 17.84 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.61 26.62 NITROGLYCERIN 0.4 MG TABLET SL 49837873_1 CDM 0250 RC 68462-0639-45 NDC inpatient 1 UN 27.44 17.84 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.55 67.6 999999999 16.61 26.62 percent of total billed charges NITROGLYCERIN 0.4 MG TABLET SL 49837873_1 CDM 0250 RC 68462-0639-45 NDC inpatient 1 UN 27.44 17.84 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.61 26.62 NITROGLYCERIN 0.4 MG TABLET SL 49837873_1 CDM 0250 RC 68462-0639-45 NDC inpatient 1 UN 27.44 17.84 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.61 26.62 X-SURGE CURVED SCISSOR TIP 590-005-001 49839199_1 CDM 0272 RC inpatient 238 154.7 AETNA AETNA 188.02 79 999999999 144.11 230.86 percent of total billed charges X-SURGE CURVED SCISSOR TIP 590-005-001 49839199_1 CDM 0272 RC inpatient 238 154.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.7 65 999999999 144.11 230.86 percent of total billed charges X-SURGE CURVED SCISSOR TIP 590-005-001 49839199_1 CDM 0272 RC inpatient 238 154.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 230.86 97 999999999 144.11 230.86 percent of total billed charges X-SURGE CURVED SCISSOR TIP 590-005-001 49839199_1 CDM 0272 RC inpatient 238 154.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 185.64 78 999999999 144.11 230.86 percent of total billed charges X-SURGE CURVED SCISSOR TIP 590-005-001 49839199_1 CDM 0272 RC inpatient 238 154.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.22 69 999999999 144.11 230.86 percent of total billed charges X-SURGE CURVED SCISSOR TIP 590-005-001 49839199_1 CDM 0272 RC inpatient 238 154.7 SIHO - ALL PLANS SIHO - ALL PLANS 214.2 90 999999999 144.11 230.86 percent of total billed charges X-SURGE CURVED SCISSOR TIP 590-005-001 49839199_1 CDM 0272 RC inpatient 238 154.7 UMR - ALL PLANS UMR - ALL PLANS 166.6 70 999999999 144.11 230.86 percent of total billed charges X-SURGE CURVED SCISSOR TIP 590-005-001 49839199_1 CDM 0272 RC inpatient 238 154.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.11 60.55 999999999 144.11 230.86 percent of total billed charges X-SURGE CURVED SCISSOR TIP 590-005-001 49839199_1 CDM 0272 RC inpatient 238 154.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.11 230.86 X-SURGE CURVED SCISSOR TIP 590-005-001 49839199_1 CDM 0272 RC inpatient 238 154.7 ANTHEM HMO ANTHEM HMO 999999999 144.11 230.86 X-SURGE CURVED SCISSOR TIP 590-005-001 49839199_1 CDM 0272 RC inpatient 238 154.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.11 230.86 X-SURGE CURVED SCISSOR TIP 590-005-001 49839199_1 CDM 0272 RC inpatient 238 154.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.89 67.6 999999999 144.11 230.86 percent of total billed charges X-SURGE CURVED SCISSOR TIP 590-005-001 49839199_1 CDM 0272 RC inpatient 238 154.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.11 230.86 X-SURGE CURVED SCISSOR TIP 590-005-001 49839199_1 CDM 0272 RC inpatient 238 154.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.11 230.86 PROMETHAZINE 25 MG SUPPOSITORY 49842718_1 CDM 0250 RC 51672-5297-01 NDC inpatient 1 UN 29.94 19.46 AETNA AETNA 23.65 79 999999999 18.13 29.04 percent of total billed charges PROMETHAZINE 25 MG SUPPOSITORY 49842718_1 CDM 0250 RC 51672-5297-01 NDC inpatient 1 UN 29.94 19.46 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.46 65 999999999 18.13 29.04 percent of total billed charges PROMETHAZINE 25 MG SUPPOSITORY 49842718_1 CDM 0250 RC 51672-5297-01 NDC inpatient 1 UN 29.94 19.46 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.04 97 999999999 18.13 29.04 percent of total billed charges PROMETHAZINE 25 MG SUPPOSITORY 49842718_1 CDM 0250 RC 51672-5297-01 NDC inpatient 1 UN 29.94 19.46 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.35 78 999999999 18.13 29.04 percent of total billed charges PROMETHAZINE 25 MG SUPPOSITORY 49842718_1 CDM 0250 RC 51672-5297-01 NDC inpatient 1 UN 29.94 19.46 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.66 69 999999999 18.13 29.04 percent of total billed charges PROMETHAZINE 25 MG SUPPOSITORY 49842718_1 CDM 0250 RC 51672-5297-01 NDC inpatient 1 UN 29.94 19.46 SIHO - ALL PLANS SIHO - ALL PLANS 26.95 90 999999999 18.13 29.04 percent of total billed charges PROMETHAZINE 25 MG SUPPOSITORY 49842718_1 CDM 0250 RC 51672-5297-01 NDC inpatient 1 UN 29.94 19.46 UMR - ALL PLANS UMR - ALL PLANS 20.96 70 999999999 18.13 29.04 percent of total billed charges PROMETHAZINE 25 MG SUPPOSITORY 49842718_1 CDM 0250 RC 51672-5297-01 NDC inpatient 1 UN 29.94 19.46 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.13 60.55 999999999 18.13 29.04 percent of total billed charges PROMETHAZINE 25 MG SUPPOSITORY 49842718_1 CDM 0250 RC 51672-5297-01 NDC inpatient 1 UN 29.94 19.46 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.13 29.04 PROMETHAZINE 25 MG SUPPOSITORY 49842718_1 CDM 0250 RC 51672-5297-01 NDC inpatient 1 UN 29.94 19.46 ANTHEM HMO ANTHEM HMO 999999999 18.13 29.04 PROMETHAZINE 25 MG SUPPOSITORY 49842718_1 CDM 0250 RC 51672-5297-01 NDC inpatient 1 UN 29.94 19.46 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.13 29.04 PROMETHAZINE 25 MG SUPPOSITORY 49842718_1 CDM 0250 RC 51672-5297-01 NDC inpatient 1 UN 29.94 19.46 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.24 67.6 999999999 18.13 29.04 percent of total billed charges PROMETHAZINE 25 MG SUPPOSITORY 49842718_1 CDM 0250 RC 51672-5297-01 NDC inpatient 1 UN 29.94 19.46 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.13 29.04 PROMETHAZINE 25 MG SUPPOSITORY 49842718_1 CDM 0250 RC 51672-5297-01 NDC inpatient 1 UN 29.94 19.46 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.13 29.04 METOLAZONE 2.5 MG TABLET 49842836_1 CDM 0250 RC 00185-5050-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges METOLAZONE 2.5 MG TABLET 49842836_1 CDM 0250 RC 00185-5050-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges METOLAZONE 2.5 MG TABLET 49842836_1 CDM 0250 RC 00185-5050-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges METOLAZONE 2.5 MG TABLET 49842836_1 CDM 0250 RC 00185-5050-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges METOLAZONE 2.5 MG TABLET 49842836_1 CDM 0250 RC 00185-5050-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges METOLAZONE 2.5 MG TABLET 49842836_1 CDM 0250 RC 00185-5050-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges METOLAZONE 2.5 MG TABLET 49842836_1 CDM 0250 RC 00185-5050-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges METOLAZONE 2.5 MG TABLET 49842836_1 CDM 0250 RC 00185-5050-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges METOLAZONE 2.5 MG TABLET 49842836_1 CDM 0250 RC 00185-5050-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 METOLAZONE 2.5 MG TABLET 49842836_1 CDM 0250 RC 00185-5050-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 METOLAZONE 2.5 MG TABLET 49842836_1 CDM 0250 RC 00185-5050-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 METOLAZONE 2.5 MG TABLET 49842836_1 CDM 0250 RC 00185-5050-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges METOLAZONE 2.5 MG TABLET 49842836_1 CDM 0250 RC 00185-5050-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 METOLAZONE 2.5 MG TABLET 49842836_1 CDM 0250 RC 00185-5050-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "METHOTREXATE; ORAL, 2.5 MG" 49842840_1 CDM 0636 RC 00054-4550-15 NDC J8610 HCPCS inpatient 1 UN 8.92 5.8 AETNA AETNA 7.05 79 999999999 5.4 8.65 percent of total billed charges "METHOTREXATE; ORAL, 2.5 MG" 49842840_1 CDM 0636 RC 00054-4550-15 NDC J8610 HCPCS inpatient 1 UN 8.92 5.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.8 65 999999999 5.4 8.65 percent of total billed charges "METHOTREXATE; ORAL, 2.5 MG" 49842840_1 CDM 0636 RC 00054-4550-15 NDC J8610 HCPCS inpatient 1 UN 8.92 5.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.65 97 999999999 5.4 8.65 percent of total billed charges "METHOTREXATE; ORAL, 2.5 MG" 49842840_1 CDM 0636 RC 00054-4550-15 NDC J8610 HCPCS inpatient 1 UN 8.92 5.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.96 78 999999999 5.4 8.65 percent of total billed charges "METHOTREXATE; ORAL, 2.5 MG" 49842840_1 CDM 0636 RC 00054-4550-15 NDC J8610 HCPCS inpatient 1 UN 8.92 5.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.15 69 999999999 5.4 8.65 percent of total billed charges "METHOTREXATE; ORAL, 2.5 MG" 49842840_1 CDM 0636 RC 00054-4550-15 NDC J8610 HCPCS inpatient 1 UN 8.92 5.8 SIHO - ALL PLANS SIHO - ALL PLANS 8.03 90 999999999 5.4 8.65 percent of total billed charges "METHOTREXATE; ORAL, 2.5 MG" 49842840_1 CDM 0636 RC 00054-4550-15 NDC J8610 HCPCS inpatient 1 UN 8.92 5.8 UMR - ALL PLANS UMR - ALL PLANS 6.24 70 999999999 5.4 8.65 percent of total billed charges "METHOTREXATE; ORAL, 2.5 MG" 49842840_1 CDM 0636 RC 00054-4550-15 NDC J8610 HCPCS inpatient 1 UN 8.92 5.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.4 60.55 999999999 5.4 8.65 percent of total billed charges "METHOTREXATE; ORAL, 2.5 MG" 49842840_1 CDM 0636 RC 00054-4550-15 NDC J8610 HCPCS inpatient 1 UN 8.92 5.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.4 8.65 "METHOTREXATE; ORAL, 2.5 MG" 49842840_1 CDM 0636 RC 00054-4550-15 NDC J8610 HCPCS inpatient 1 UN 8.92 5.8 ANTHEM HMO ANTHEM HMO 999999999 5.4 8.65 "METHOTREXATE; ORAL, 2.5 MG" 49842840_1 CDM 0636 RC 00054-4550-15 NDC J8610 HCPCS inpatient 1 UN 8.92 5.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.4 8.65 "METHOTREXATE; ORAL, 2.5 MG" 49842840_1 CDM 0636 RC 00054-4550-15 NDC J8610 HCPCS inpatient 1 UN 8.92 5.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.03 67.6 999999999 5.4 8.65 percent of total billed charges "METHOTREXATE; ORAL, 2.5 MG" 49842840_1 CDM 0636 RC 00054-4550-15 NDC J8610 HCPCS inpatient 1 UN 8.92 5.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.4 8.65 "METHOTREXATE; ORAL, 2.5 MG" 49842840_1 CDM 0636 RC 00054-4550-15 NDC J8610 HCPCS inpatient 1 UN 8.92 5.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.4 8.65 "Fungal culture, yeast" 49843047_1 CDM 0306 RC 87106 HCPCS inpatient 295 191.75 AETNA AETNA 233.05 79 999999999 178.62 286.15 percent of total billed charges "Fungal culture, yeast" 49843047_1 CDM 0306 RC 87106 HCPCS inpatient 295 191.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 191.75 65 999999999 178.62 286.15 percent of total billed charges "Fungal culture, yeast" 49843047_1 CDM 0306 RC 87106 HCPCS inpatient 295 191.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 286.15 97 999999999 178.62 286.15 percent of total billed charges "Fungal culture, yeast" 49843047_1 CDM 0306 RC 87106 HCPCS inpatient 295 191.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 230.1 78 999999999 178.62 286.15 percent of total billed charges "Fungal culture, yeast" 49843047_1 CDM 0306 RC 87106 HCPCS inpatient 295 191.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 203.55 69 999999999 178.62 286.15 percent of total billed charges "Fungal culture, yeast" 49843047_1 CDM 0306 RC 87106 HCPCS inpatient 295 191.75 SIHO - ALL PLANS SIHO - ALL PLANS 265.5 90 999999999 178.62 286.15 percent of total billed charges "Fungal culture, yeast" 49843047_1 CDM 0306 RC 87106 HCPCS inpatient 295 191.75 UMR - ALL PLANS UMR - ALL PLANS 206.5 70 999999999 178.62 286.15 percent of total billed charges "Fungal culture, yeast" 49843047_1 CDM 0306 RC 87106 HCPCS inpatient 295 191.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 178.62 60.55 999999999 178.62 286.15 percent of total billed charges "Fungal culture, yeast" 49843047_1 CDM 0306 RC 87106 HCPCS inpatient 295 191.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 178.62 286.15 "Fungal culture, yeast" 49843047_1 CDM 0306 RC 87106 HCPCS inpatient 295 191.75 ANTHEM HMO ANTHEM HMO 999999999 178.62 286.15 "Fungal culture, yeast" 49843047_1 CDM 0306 RC 87106 HCPCS inpatient 295 191.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 178.62 286.15 "Fungal culture, yeast" 49843047_1 CDM 0306 RC 87106 HCPCS inpatient 295 191.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 199.42 67.6 999999999 178.62 286.15 percent of total billed charges "Fungal culture, yeast" 49843047_1 CDM 0306 RC 87106 HCPCS inpatient 295 191.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 178.62 286.15 "Fungal culture, yeast" 49843047_1 CDM 0306 RC 87106 HCPCS inpatient 295 191.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 178.62 286.15 CLEARFAST PREOP DRINK 49847028_1 CDM 0636 RC inpatient 51 33.15 AETNA AETNA 40.29 79 999999999 30.88 49.47 percent of total billed charges CLEARFAST PREOP DRINK 49847028_1 CDM 0636 RC inpatient 51 33.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 33.15 65 999999999 30.88 49.47 percent of total billed charges CLEARFAST PREOP DRINK 49847028_1 CDM 0636 RC inpatient 51 33.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 49.47 97 999999999 30.88 49.47 percent of total billed charges CLEARFAST PREOP DRINK 49847028_1 CDM 0636 RC inpatient 51 33.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 39.78 78 999999999 30.88 49.47 percent of total billed charges CLEARFAST PREOP DRINK 49847028_1 CDM 0636 RC inpatient 51 33.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 35.19 69 999999999 30.88 49.47 percent of total billed charges CLEARFAST PREOP DRINK 49847028_1 CDM 0636 RC inpatient 51 33.15 SIHO - ALL PLANS SIHO - ALL PLANS 45.9 90 999999999 30.88 49.47 percent of total billed charges CLEARFAST PREOP DRINK 49847028_1 CDM 0636 RC inpatient 51 33.15 UMR - ALL PLANS UMR - ALL PLANS 35.7 70 999999999 30.88 49.47 percent of total billed charges CLEARFAST PREOP DRINK 49847028_1 CDM 0636 RC inpatient 51 33.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.88 60.55 999999999 30.88 49.47 percent of total billed charges CLEARFAST PREOP DRINK 49847028_1 CDM 0636 RC inpatient 51 33.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.88 49.47 CLEARFAST PREOP DRINK 49847028_1 CDM 0636 RC inpatient 51 33.15 ANTHEM HMO ANTHEM HMO 999999999 30.88 49.47 CLEARFAST PREOP DRINK 49847028_1 CDM 0636 RC inpatient 51 33.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.88 49.47 CLEARFAST PREOP DRINK 49847028_1 CDM 0636 RC inpatient 51 33.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 34.48 67.6 999999999 30.88 49.47 percent of total billed charges CLEARFAST PREOP DRINK 49847028_1 CDM 0636 RC inpatient 51 33.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.88 49.47 CLEARFAST PREOP DRINK 49847028_1 CDM 0636 RC inpatient 51 33.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.88 49.47 CLOTH SKIN PREP CHLORHEXIDINE GLUCONATE 49847029_1 CDM 0272 RC inpatient 22 14.3 AETNA AETNA 17.38 79 999999999 13.32 21.34 percent of total billed charges CLOTH SKIN PREP CHLORHEXIDINE GLUCONATE 49847029_1 CDM 0272 RC inpatient 22 14.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.3 65 999999999 13.32 21.34 percent of total billed charges CLOTH SKIN PREP CHLORHEXIDINE GLUCONATE 49847029_1 CDM 0272 RC inpatient 22 14.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21.34 97 999999999 13.32 21.34 percent of total billed charges CLOTH SKIN PREP CHLORHEXIDINE GLUCONATE 49847029_1 CDM 0272 RC inpatient 22 14.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.16 78 999999999 13.32 21.34 percent of total billed charges CLOTH SKIN PREP CHLORHEXIDINE GLUCONATE 49847029_1 CDM 0272 RC inpatient 22 14.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.18 69 999999999 13.32 21.34 percent of total billed charges CLOTH SKIN PREP CHLORHEXIDINE GLUCONATE 49847029_1 CDM 0272 RC inpatient 22 14.3 SIHO - ALL PLANS SIHO - ALL PLANS 19.8 90 999999999 13.32 21.34 percent of total billed charges CLOTH SKIN PREP CHLORHEXIDINE GLUCONATE 49847029_1 CDM 0272 RC inpatient 22 14.3 UMR - ALL PLANS UMR - ALL PLANS 15.4 70 999999999 13.32 21.34 percent of total billed charges CLOTH SKIN PREP CHLORHEXIDINE GLUCONATE 49847029_1 CDM 0272 RC inpatient 22 14.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.32 60.55 999999999 13.32 21.34 percent of total billed charges CLOTH SKIN PREP CHLORHEXIDINE GLUCONATE 49847029_1 CDM 0272 RC inpatient 22 14.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.32 21.34 CLOTH SKIN PREP CHLORHEXIDINE GLUCONATE 49847029_1 CDM 0272 RC inpatient 22 14.3 ANTHEM HMO ANTHEM HMO 999999999 13.32 21.34 CLOTH SKIN PREP CHLORHEXIDINE GLUCONATE 49847029_1 CDM 0272 RC inpatient 22 14.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.32 21.34 CLOTH SKIN PREP CHLORHEXIDINE GLUCONATE 49847029_1 CDM 0272 RC inpatient 22 14.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.87 67.6 999999999 13.32 21.34 percent of total billed charges CLOTH SKIN PREP CHLORHEXIDINE GLUCONATE 49847029_1 CDM 0272 RC inpatient 22 14.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.32 21.34 CLOTH SKIN PREP CHLORHEXIDINE GLUCONATE 49847029_1 CDM 0272 RC inpatient 22 14.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.32 21.34 BAG SPECIMEN RETRIEVAL MEDIUM 10MM MIN ORDER 3 BOXES 49847218_1 CDM 0272 RC inpatient 476 309.4 AETNA AETNA 376.04 79 999999999 288.22 461.72 percent of total billed charges BAG SPECIMEN RETRIEVAL MEDIUM 10MM MIN ORDER 3 BOXES 49847218_1 CDM 0272 RC inpatient 476 309.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 309.4 65 999999999 288.22 461.72 percent of total billed charges BAG SPECIMEN RETRIEVAL MEDIUM 10MM MIN ORDER 3 BOXES 49847218_1 CDM 0272 RC inpatient 476 309.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 461.72 97 999999999 288.22 461.72 percent of total billed charges BAG SPECIMEN RETRIEVAL MEDIUM 10MM MIN ORDER 3 BOXES 49847218_1 CDM 0272 RC inpatient 476 309.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 371.28 78 999999999 288.22 461.72 percent of total billed charges BAG SPECIMEN RETRIEVAL MEDIUM 10MM MIN ORDER 3 BOXES 49847218_1 CDM 0272 RC inpatient 476 309.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 328.44 69 999999999 288.22 461.72 percent of total billed charges BAG SPECIMEN RETRIEVAL MEDIUM 10MM MIN ORDER 3 BOXES 49847218_1 CDM 0272 RC inpatient 476 309.4 SIHO - ALL PLANS SIHO - ALL PLANS 428.4 90 999999999 288.22 461.72 percent of total billed charges BAG SPECIMEN RETRIEVAL MEDIUM 10MM MIN ORDER 3 BOXES 49847218_1 CDM 0272 RC inpatient 476 309.4 UMR - ALL PLANS UMR - ALL PLANS 333.2 70 999999999 288.22 461.72 percent of total billed charges BAG SPECIMEN RETRIEVAL MEDIUM 10MM MIN ORDER 3 BOXES 49847218_1 CDM 0272 RC inpatient 476 309.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 288.22 60.55 999999999 288.22 461.72 percent of total billed charges BAG SPECIMEN RETRIEVAL MEDIUM 10MM MIN ORDER 3 BOXES 49847218_1 CDM 0272 RC inpatient 476 309.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 288.22 461.72 BAG SPECIMEN RETRIEVAL MEDIUM 10MM MIN ORDER 3 BOXES 49847218_1 CDM 0272 RC inpatient 476 309.4 ANTHEM HMO ANTHEM HMO 999999999 288.22 461.72 BAG SPECIMEN RETRIEVAL MEDIUM 10MM MIN ORDER 3 BOXES 49847218_1 CDM 0272 RC inpatient 476 309.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 288.22 461.72 BAG SPECIMEN RETRIEVAL MEDIUM 10MM MIN ORDER 3 BOXES 49847218_1 CDM 0272 RC inpatient 476 309.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 321.78 67.6 999999999 288.22 461.72 percent of total billed charges BAG SPECIMEN RETRIEVAL MEDIUM 10MM MIN ORDER 3 BOXES 49847218_1 CDM 0272 RC inpatient 476 309.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 288.22 461.72 BAG SPECIMEN RETRIEVAL MEDIUM 10MM MIN ORDER 3 BOXES 49847218_1 CDM 0272 RC inpatient 476 309.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 288.22 461.72 FAMOTIDINE 20 MG TABLET 49847329_1 CDM 0250 RC 50268-0303-15 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges FAMOTIDINE 20 MG TABLET 49847329_1 CDM 0250 RC 50268-0303-15 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges FAMOTIDINE 20 MG TABLET 49847329_1 CDM 0250 RC 50268-0303-15 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges FAMOTIDINE 20 MG TABLET 49847329_1 CDM 0250 RC 50268-0303-15 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges FAMOTIDINE 20 MG TABLET 49847329_1 CDM 0250 RC 50268-0303-15 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges FAMOTIDINE 20 MG TABLET 49847329_1 CDM 0250 RC 50268-0303-15 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges FAMOTIDINE 20 MG TABLET 49847329_1 CDM 0250 RC 50268-0303-15 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges FAMOTIDINE 20 MG TABLET 49847329_1 CDM 0250 RC 50268-0303-15 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges FAMOTIDINE 20 MG TABLET 49847329_1 CDM 0250 RC 50268-0303-15 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 FAMOTIDINE 20 MG TABLET 49847329_1 CDM 0250 RC 50268-0303-15 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 FAMOTIDINE 20 MG TABLET 49847329_1 CDM 0250 RC 50268-0303-15 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 FAMOTIDINE 20 MG TABLET 49847329_1 CDM 0250 RC 50268-0303-15 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges FAMOTIDINE 20 MG TABLET 49847329_1 CDM 0250 RC 50268-0303-15 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 FAMOTIDINE 20 MG TABLET 49847329_1 CDM 0250 RC 50268-0303-15 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49848963_1 CDM 0250 RC 55513-0057-04 NDC J0881 HCPCS inpatient 25 UN 478.3 310.9 AETNA AETNA 377.86 79 999999999 289.61 463.95 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49848963_1 CDM 0250 RC 55513-0057-04 NDC J0881 HCPCS inpatient 25 UN 478.3 310.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 310.9 65 999999999 289.61 463.95 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49848963_1 CDM 0250 RC 55513-0057-04 NDC J0881 HCPCS inpatient 25 UN 478.3 310.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 463.95 97 999999999 289.61 463.95 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49848963_1 CDM 0250 RC 55513-0057-04 NDC J0881 HCPCS inpatient 25 UN 478.3 310.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 373.07 78 999999999 289.61 463.95 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49848963_1 CDM 0250 RC 55513-0057-04 NDC J0881 HCPCS inpatient 25 UN 478.3 310.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 330.03 69 999999999 289.61 463.95 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49848963_1 CDM 0250 RC 55513-0057-04 NDC J0881 HCPCS inpatient 25 UN 478.3 310.9 SIHO - ALL PLANS SIHO - ALL PLANS 430.47 90 999999999 289.61 463.95 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49848963_1 CDM 0250 RC 55513-0057-04 NDC J0881 HCPCS inpatient 25 UN 478.3 310.9 UMR - ALL PLANS UMR - ALL PLANS 334.81 70 999999999 289.61 463.95 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49848963_1 CDM 0250 RC 55513-0057-04 NDC J0881 HCPCS inpatient 25 UN 478.3 310.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 289.61 60.55 999999999 289.61 463.95 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49848963_1 CDM 0250 RC 55513-0057-04 NDC J0881 HCPCS inpatient 25 UN 478.3 310.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 289.61 463.95 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49848963_1 CDM 0250 RC 55513-0057-04 NDC J0881 HCPCS inpatient 25 UN 478.3 310.9 ANTHEM HMO ANTHEM HMO 999999999 289.61 463.95 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49848963_1 CDM 0250 RC 55513-0057-04 NDC J0881 HCPCS inpatient 25 UN 478.3 310.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 289.61 463.95 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49848963_1 CDM 0250 RC 55513-0057-04 NDC J0881 HCPCS inpatient 25 UN 478.3 310.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 323.33 67.6 999999999 289.61 463.95 percent of total billed charges "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49848963_1 CDM 0250 RC 55513-0057-04 NDC J0881 HCPCS inpatient 25 UN 478.3 310.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 289.61 463.95 "INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)" 49848963_1 CDM 0250 RC 55513-0057-04 NDC J0881 HCPCS inpatient 25 UN 478.3 310.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 289.61 463.95 "Enzyme activity measurement, nonradioactive substrate" 49849163_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 AETNA AETNA 193.55 79 999999999 148.35 237.65 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49849163_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 159.25 65 999999999 148.35 237.65 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49849163_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 237.65 97 999999999 148.35 237.65 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49849163_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 191.1 78 999999999 148.35 237.65 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49849163_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 169.05 69 999999999 148.35 237.65 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49849163_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 SIHO - ALL PLANS SIHO - ALL PLANS 220.5 90 999999999 148.35 237.65 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49849163_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 UMR - ALL PLANS UMR - ALL PLANS 171.5 70 999999999 148.35 237.65 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49849163_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 148.35 60.55 999999999 148.35 237.65 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49849163_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 148.35 237.65 "Enzyme activity measurement, nonradioactive substrate" 49849163_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 ANTHEM HMO ANTHEM HMO 999999999 148.35 237.65 "Enzyme activity measurement, nonradioactive substrate" 49849163_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 148.35 237.65 "Enzyme activity measurement, nonradioactive substrate" 49849163_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 165.62 67.6 999999999 148.35 237.65 percent of total billed charges "Enzyme activity measurement, nonradioactive substrate" 49849163_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 148.35 237.65 "Enzyme activity measurement, nonradioactive substrate" 49849163_1 CDM 0301 RC 82657 HCPCS inpatient 245 159.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 148.35 237.65 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49849931_1 CDM 0250 RC 00409-7332-20 NDC j0696 HCPCS inpatient 4 UN 25.75 16.74 AETNA AETNA 20.34 79 999999999 15.59 24.98 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49849931_1 CDM 0250 RC 00409-7332-20 NDC j0696 HCPCS inpatient 4 UN 25.75 16.74 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.74 65 999999999 15.59 24.98 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49849931_1 CDM 0250 RC 00409-7332-20 NDC j0696 HCPCS inpatient 4 UN 25.75 16.74 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.98 97 999999999 15.59 24.98 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49849931_1 CDM 0250 RC 00409-7332-20 NDC j0696 HCPCS inpatient 4 UN 25.75 16.74 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.09 78 999999999 15.59 24.98 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49849931_1 CDM 0250 RC 00409-7332-20 NDC j0696 HCPCS inpatient 4 UN 25.75 16.74 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.77 69 999999999 15.59 24.98 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49849931_1 CDM 0250 RC 00409-7332-20 NDC j0696 HCPCS inpatient 4 UN 25.75 16.74 SIHO - ALL PLANS SIHO - ALL PLANS 23.18 90 999999999 15.59 24.98 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49849931_1 CDM 0250 RC 00409-7332-20 NDC j0696 HCPCS inpatient 4 UN 25.75 16.74 UMR - ALL PLANS UMR - ALL PLANS 18.03 70 999999999 15.59 24.98 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49849931_1 CDM 0250 RC 00409-7332-20 NDC j0696 HCPCS inpatient 4 UN 25.75 16.74 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.59 60.55 999999999 15.59 24.98 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49849931_1 CDM 0250 RC 00409-7332-20 NDC j0696 HCPCS inpatient 4 UN 25.75 16.74 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.59 24.98 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49849931_1 CDM 0250 RC 00409-7332-20 NDC j0696 HCPCS inpatient 4 UN 25.75 16.74 ANTHEM HMO ANTHEM HMO 999999999 15.59 24.98 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49849931_1 CDM 0250 RC 00409-7332-20 NDC j0696 HCPCS inpatient 4 UN 25.75 16.74 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.59 24.98 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49849931_1 CDM 0250 RC 00409-7332-20 NDC j0696 HCPCS inpatient 4 UN 25.75 16.74 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.41 67.6 999999999 15.59 24.98 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49849931_1 CDM 0250 RC 00409-7332-20 NDC j0696 HCPCS inpatient 4 UN 25.75 16.74 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.59 24.98 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49849931_1 CDM 0250 RC 00409-7332-20 NDC j0696 HCPCS inpatient 4 UN 25.75 16.74 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.59 24.98 Insertion of stomach tube and aspiration of stomach contents 49850620_1 CDM 0450 RC 43753 HCPCS inpatient 705 458.25 AETNA AETNA 556.95 79 999999999 426.88 683.85 percent of total billed charges Insertion of stomach tube and aspiration of stomach contents 49850620_1 CDM 0450 RC 43753 HCPCS inpatient 705 458.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 458.25 65 999999999 426.88 683.85 percent of total billed charges Insertion of stomach tube and aspiration of stomach contents 49850620_1 CDM 0450 RC 43753 HCPCS inpatient 705 458.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 683.85 97 999999999 426.88 683.85 percent of total billed charges Insertion of stomach tube and aspiration of stomach contents 49850620_1 CDM 0450 RC 43753 HCPCS inpatient 705 458.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 549.9 78 999999999 426.88 683.85 percent of total billed charges Insertion of stomach tube and aspiration of stomach contents 49850620_1 CDM 0450 RC 43753 HCPCS inpatient 705 458.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 486.45 69 999999999 426.88 683.85 percent of total billed charges Insertion of stomach tube and aspiration of stomach contents 49850620_1 CDM 0450 RC 43753 HCPCS inpatient 705 458.25 SIHO - ALL PLANS SIHO - ALL PLANS 634.5 90 999999999 426.88 683.85 percent of total billed charges Insertion of stomach tube and aspiration of stomach contents 49850620_1 CDM 0450 RC 43753 HCPCS inpatient 705 458.25 UMR - ALL PLANS UMR - ALL PLANS 493.5 70 999999999 426.88 683.85 percent of total billed charges Insertion of stomach tube and aspiration of stomach contents 49850620_1 CDM 0450 RC 43753 HCPCS inpatient 705 458.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 426.88 60.55 999999999 426.88 683.85 percent of total billed charges Insertion of stomach tube and aspiration of stomach contents 49850620_1 CDM 0450 RC 43753 HCPCS inpatient 705 458.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 426.88 683.85 Insertion of stomach tube and aspiration of stomach contents 49850620_1 CDM 0450 RC 43753 HCPCS inpatient 705 458.25 ANTHEM HMO ANTHEM HMO 999999999 426.88 683.85 Insertion of stomach tube and aspiration of stomach contents 49850620_1 CDM 0450 RC 43753 HCPCS inpatient 705 458.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 426.88 683.85 Insertion of stomach tube and aspiration of stomach contents 49850620_1 CDM 0450 RC 43753 HCPCS inpatient 705 458.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 476.58 67.6 999999999 426.88 683.85 percent of total billed charges Insertion of stomach tube and aspiration of stomach contents 49850620_1 CDM 0450 RC 43753 HCPCS inpatient 705 458.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 426.88 683.85 Insertion of stomach tube and aspiration of stomach contents 49850620_1 CDM 0450 RC 43753 HCPCS inpatient 705 458.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 426.88 683.85 Red blood cell antibody screening test 49851063_1 CDM 0302 RC 86940 HCPCS inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges Red blood cell antibody screening test 49851063_1 CDM 0302 RC 86940 HCPCS inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges Red blood cell antibody screening test 49851063_1 CDM 0302 RC 86940 HCPCS inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges Red blood cell antibody screening test 49851063_1 CDM 0302 RC 86940 HCPCS inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges Red blood cell antibody screening test 49851063_1 CDM 0302 RC 86940 HCPCS inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges Red blood cell antibody screening test 49851063_1 CDM 0302 RC 86940 HCPCS inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges Red blood cell antibody screening test 49851063_1 CDM 0302 RC 86940 HCPCS inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges Red blood cell antibody screening test 49851063_1 CDM 0302 RC 86940 HCPCS inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges Red blood cell antibody screening test 49851063_1 CDM 0302 RC 86940 HCPCS inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 Red blood cell antibody screening test 49851063_1 CDM 0302 RC 86940 HCPCS inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 Red blood cell antibody screening test 49851063_1 CDM 0302 RC 86940 HCPCS inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 Red blood cell antibody screening test 49851063_1 CDM 0302 RC 86940 HCPCS inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges Red blood cell antibody screening test 49851063_1 CDM 0302 RC 86940 HCPCS inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 Red blood cell antibody screening test 49851063_1 CDM 0302 RC 86940 HCPCS inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 SPACEMAKER PRO ACCESS DISSECTO - SMBTTOVLX 49851690_1 CDM 0272 RC inpatient 3321 2158.65 AETNA AETNA 2623.59 79 999999999 2010.87 3221.37 percent of total billed charges SPACEMAKER PRO ACCESS DISSECTO - SMBTTOVLX 49851690_1 CDM 0272 RC inpatient 3321 2158.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 2158.65 65 999999999 2010.87 3221.37 percent of total billed charges SPACEMAKER PRO ACCESS DISSECTO - SMBTTOVLX 49851690_1 CDM 0272 RC inpatient 3321 2158.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3221.37 97 999999999 2010.87 3221.37 percent of total billed charges SPACEMAKER PRO ACCESS DISSECTO - SMBTTOVLX 49851690_1 CDM 0272 RC inpatient 3321 2158.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2291.49 69 999999999 2010.87 3221.37 percent of total billed charges SPACEMAKER PRO ACCESS DISSECTO - SMBTTOVLX 49851690_1 CDM 0272 RC inpatient 3321 2158.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2590.38 78 999999999 2010.87 3221.37 percent of total billed charges SPACEMAKER PRO ACCESS DISSECTO - SMBTTOVLX 49851690_1 CDM 0272 RC inpatient 3321 2158.65 SIHO - ALL PLANS SIHO - ALL PLANS 2988.9 90 999999999 2010.87 3221.37 percent of total billed charges SPACEMAKER PRO ACCESS DISSECTO - SMBTTOVLX 49851690_1 CDM 0272 RC inpatient 3321 2158.65 UMR - ALL PLANS UMR - ALL PLANS 2324.7 70 999999999 2010.87 3221.37 percent of total billed charges SPACEMAKER PRO ACCESS DISSECTO - SMBTTOVLX 49851690_1 CDM 0272 RC inpatient 3321 2158.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2010.87 60.55 999999999 2010.87 3221.37 percent of total billed charges SPACEMAKER PRO ACCESS DISSECTO - SMBTTOVLX 49851690_1 CDM 0272 RC inpatient 3321 2158.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2010.87 3221.37 SPACEMAKER PRO ACCESS DISSECTO - SMBTTOVLX 49851690_1 CDM 0272 RC inpatient 3321 2158.65 ANTHEM HMO ANTHEM HMO 999999999 2010.87 3221.37 SPACEMAKER PRO ACCESS DISSECTO - SMBTTOVLX 49851690_1 CDM 0272 RC inpatient 3321 2158.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2010.87 3221.37 SPACEMAKER PRO ACCESS DISSECTO - SMBTTOVLX 49851690_1 CDM 0272 RC inpatient 3321 2158.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2245 67.6 999999999 2010.87 3221.37 percent of total billed charges SPACEMAKER PRO ACCESS DISSECTO - SMBTTOVLX 49851690_1 CDM 0272 RC inpatient 3321 2158.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2010.87 3221.37 SPACEMAKER PRO ACCESS DISSECTO - SMBTTOVLX 49851690_1 CDM 0272 RC inpatient 3321 2158.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 2010.87 3221.37 "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" 49853754_1 CDM 0301 RC 80335 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" 49853754_1 CDM 0301 RC 80335 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" 49853754_1 CDM 0301 RC 80335 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" 49853754_1 CDM 0301 RC 80335 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" 49853754_1 CDM 0301 RC 80335 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" 49853754_1 CDM 0301 RC 80335 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" 49853754_1 CDM 0301 RC 80335 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" 49853754_1 CDM 0301 RC 80335 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" 49853754_1 CDM 0301 RC 80335 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" 49853754_1 CDM 0301 RC 80335 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" 49853754_1 CDM 0301 RC 80335 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" 49853754_1 CDM 0301 RC 80335 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" 49853754_1 CDM 0301 RC 80335 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 "Antidepressants levels, 1 or 2 (tricyclic and other cyclicals)" 49853754_1 CDM 0301 RC 80335 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 "Testing for presence of drug, by chemistry analyzers" 49853768_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49853768_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49853768_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49853768_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49853768_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49853768_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49853768_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49853768_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49853768_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49853768_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49853768_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49853768_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 49853768_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 49853768_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 Urine porphobilinogen (metabolism substance) level 49853841_1 CDM 0301 RC 84110 HCPCS inpatient 130 84.5 AETNA AETNA 102.7 79 999999999 78.72 126.1 percent of total billed charges Urine porphobilinogen (metabolism substance) level 49853841_1 CDM 0301 RC 84110 HCPCS inpatient 130 84.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 84.5 65 999999999 78.72 126.1 percent of total billed charges Urine porphobilinogen (metabolism substance) level 49853841_1 CDM 0301 RC 84110 HCPCS inpatient 130 84.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 126.1 97 999999999 78.72 126.1 percent of total billed charges Urine porphobilinogen (metabolism substance) level 49853841_1 CDM 0301 RC 84110 HCPCS inpatient 130 84.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.7 69 999999999 78.72 126.1 percent of total billed charges Urine porphobilinogen (metabolism substance) level 49853841_1 CDM 0301 RC 84110 HCPCS inpatient 130 84.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 101.4 78 999999999 78.72 126.1 percent of total billed charges Urine porphobilinogen (metabolism substance) level 49853841_1 CDM 0301 RC 84110 HCPCS inpatient 130 84.5 SIHO - ALL PLANS SIHO - ALL PLANS 117 90 999999999 78.72 126.1 percent of total billed charges Urine porphobilinogen (metabolism substance) level 49853841_1 CDM 0301 RC 84110 HCPCS inpatient 130 84.5 UMR - ALL PLANS UMR - ALL PLANS 91 70 999999999 78.72 126.1 percent of total billed charges Urine porphobilinogen (metabolism substance) level 49853841_1 CDM 0301 RC 84110 HCPCS inpatient 130 84.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.72 60.55 999999999 78.72 126.1 percent of total billed charges Urine porphobilinogen (metabolism substance) level 49853841_1 CDM 0301 RC 84110 HCPCS inpatient 130 84.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.72 126.1 Urine porphobilinogen (metabolism substance) level 49853841_1 CDM 0301 RC 84110 HCPCS inpatient 130 84.5 ANTHEM HMO ANTHEM HMO 999999999 78.72 126.1 Urine porphobilinogen (metabolism substance) level 49853841_1 CDM 0301 RC 84110 HCPCS inpatient 130 84.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.72 126.1 Urine porphobilinogen (metabolism substance) level 49853841_1 CDM 0301 RC 84110 HCPCS inpatient 130 84.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.88 67.6 999999999 78.72 126.1 percent of total billed charges Urine porphobilinogen (metabolism substance) level 49853841_1 CDM 0301 RC 84110 HCPCS inpatient 130 84.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.72 126.1 Urine porphobilinogen (metabolism substance) level 49853841_1 CDM 0301 RC 84110 HCPCS inpatient 130 84.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.72 126.1 Microsatellite instability analysis 49853909_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 AETNA AETNA 1024.63 79 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 49853909_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 843.05 65 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 49853909_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1258.09 97 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 49853909_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 894.93 69 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 49853909_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1011.66 78 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 49853909_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 SIHO - ALL PLANS SIHO - ALL PLANS 1167.3 90 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 49853909_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 UMR - ALL PLANS UMR - ALL PLANS 907.9 70 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 49853909_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 785.33 60.55 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 49853909_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 785.33 1258.09 Microsatellite instability analysis 49853909_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 ANTHEM HMO ANTHEM HMO 999999999 785.33 1258.09 Microsatellite instability analysis 49853909_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 785.33 1258.09 Microsatellite instability analysis 49853909_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 876.77 67.6 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 49853909_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 785.33 1258.09 Microsatellite instability analysis 49853909_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 785.33 1258.09 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49854104_1 CDM 0250 RC 00409-7338-20 NDC J0696 HCPCS inpatient 2 UN 4.01 2.61 AETNA AETNA 3.17 79 999999999 2.43 3.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49854104_1 CDM 0250 RC 00409-7338-20 NDC J0696 HCPCS inpatient 2 UN 4.01 2.61 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.61 65 999999999 2.43 3.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49854104_1 CDM 0250 RC 00409-7338-20 NDC J0696 HCPCS inpatient 2 UN 4.01 2.61 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.89 97 999999999 2.43 3.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49854104_1 CDM 0250 RC 00409-7338-20 NDC J0696 HCPCS inpatient 2 UN 4.01 2.61 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.77 69 999999999 2.43 3.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49854104_1 CDM 0250 RC 00409-7338-20 NDC J0696 HCPCS inpatient 2 UN 4.01 2.61 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.13 78 999999999 2.43 3.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49854104_1 CDM 0250 RC 00409-7338-20 NDC J0696 HCPCS inpatient 2 UN 4.01 2.61 SIHO - ALL PLANS SIHO - ALL PLANS 3.61 90 999999999 2.43 3.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49854104_1 CDM 0250 RC 00409-7338-20 NDC J0696 HCPCS inpatient 2 UN 4.01 2.61 UMR - ALL PLANS UMR - ALL PLANS 2.81 70 999999999 2.43 3.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49854104_1 CDM 0250 RC 00409-7338-20 NDC J0696 HCPCS inpatient 2 UN 4.01 2.61 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.43 60.55 999999999 2.43 3.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49854104_1 CDM 0250 RC 00409-7338-20 NDC J0696 HCPCS inpatient 2 UN 4.01 2.61 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.43 3.89 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49854104_1 CDM 0250 RC 00409-7338-20 NDC J0696 HCPCS inpatient 2 UN 4.01 2.61 ANTHEM HMO ANTHEM HMO 999999999 2.43 3.89 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49854104_1 CDM 0250 RC 00409-7338-20 NDC J0696 HCPCS inpatient 2 UN 4.01 2.61 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.43 3.89 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49854104_1 CDM 0250 RC 00409-7338-20 NDC J0696 HCPCS inpatient 2 UN 4.01 2.61 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.71 67.6 999999999 2.43 3.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49854104_1 CDM 0250 RC 00409-7338-20 NDC J0696 HCPCS inpatient 2 UN 4.01 2.61 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.43 3.89 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49854104_1 CDM 0250 RC 00409-7338-20 NDC J0696 HCPCS inpatient 2 UN 4.01 2.61 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.43 3.89 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854107_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854107_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854107_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854107_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854107_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854107_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854107_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854107_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854107_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854107_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854107_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854107_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854107_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854107_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854108_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854108_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854108_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854108_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854108_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854108_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854108_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854108_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854108_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854108_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854108_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854108_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854108_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854108_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854174_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854174_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854174_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854174_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854174_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854174_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854174_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854174_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854174_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854174_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854174_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854174_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854174_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854174_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854175_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854175_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854175_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854175_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854175_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854175_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854175_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854175_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854175_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854175_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854175_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854175_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854175_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49854175_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgG) to allergic substance, each allergen" 49854176_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 AETNA AETNA 45.03 79 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49854176_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.05 65 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49854176_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.29 97 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49854176_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.33 69 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49854176_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.46 78 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49854176_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 SIHO - ALL PLANS SIHO - ALL PLANS 51.3 90 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49854176_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UMR - ALL PLANS UMR - ALL PLANS 39.9 70 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49854176_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.51 60.55 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49854176_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49854176_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM HMO ANTHEM HMO 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49854176_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49854176_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.53 67.6 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49854176_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49854176_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.51 55.29 Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 49854235_1 CDM 0310 RC 81445 HCPCS inpatient 1124 730.6 AETNA AETNA 887.96 79 999999999 680.58 1090.28 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 49854235_1 CDM 0310 RC 81445 HCPCS inpatient 1124 730.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 730.6 65 999999999 680.58 1090.28 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 49854235_1 CDM 0310 RC 81445 HCPCS inpatient 1124 730.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1090.28 97 999999999 680.58 1090.28 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 49854235_1 CDM 0310 RC 81445 HCPCS inpatient 1124 730.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 775.56 69 999999999 680.58 1090.28 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 49854235_1 CDM 0310 RC 81445 HCPCS inpatient 1124 730.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 876.72 78 999999999 680.58 1090.28 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 49854235_1 CDM 0310 RC 81445 HCPCS inpatient 1124 730.6 SIHO - ALL PLANS SIHO - ALL PLANS 1011.6 90 999999999 680.58 1090.28 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 49854235_1 CDM 0310 RC 81445 HCPCS inpatient 1124 730.6 UMR - ALL PLANS UMR - ALL PLANS 786.8 70 999999999 680.58 1090.28 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 49854235_1 CDM 0310 RC 81445 HCPCS inpatient 1124 730.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 680.58 60.55 999999999 680.58 1090.28 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 49854235_1 CDM 0310 RC 81445 HCPCS inpatient 1124 730.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 680.58 1090.28 Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 49854235_1 CDM 0310 RC 81445 HCPCS inpatient 1124 730.6 ANTHEM HMO ANTHEM HMO 999999999 680.58 1090.28 Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 49854235_1 CDM 0310 RC 81445 HCPCS inpatient 1124 730.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 680.58 1090.28 Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 49854235_1 CDM 0310 RC 81445 HCPCS inpatient 1124 730.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 759.82 67.6 999999999 680.58 1090.28 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 49854235_1 CDM 0310 RC 81445 HCPCS inpatient 1124 730.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 680.58 1090.28 Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 49854235_1 CDM 0310 RC 81445 HCPCS inpatient 1124 730.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 680.58 1090.28 "INJ PANTOPRAZOLE SODIUM, VIA" 49855575_1 CDM 0250 RC 00143-9284-10 NDC C9113 HCPCS inpatient 1 UN 31.29 20.34 AETNA AETNA 24.72 79 999999999 18.95 30.35 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 49855575_1 CDM 0250 RC 00143-9284-10 NDC C9113 HCPCS inpatient 1 UN 31.29 20.34 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.34 65 999999999 18.95 30.35 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 49855575_1 CDM 0250 RC 00143-9284-10 NDC C9113 HCPCS inpatient 1 UN 31.29 20.34 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.35 97 999999999 18.95 30.35 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 49855575_1 CDM 0250 RC 00143-9284-10 NDC C9113 HCPCS inpatient 1 UN 31.29 20.34 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.59 69 999999999 18.95 30.35 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 49855575_1 CDM 0250 RC 00143-9284-10 NDC C9113 HCPCS inpatient 1 UN 31.29 20.34 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.41 78 999999999 18.95 30.35 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 49855575_1 CDM 0250 RC 00143-9284-10 NDC C9113 HCPCS inpatient 1 UN 31.29 20.34 SIHO - ALL PLANS SIHO - ALL PLANS 28.16 90 999999999 18.95 30.35 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 49855575_1 CDM 0250 RC 00143-9284-10 NDC C9113 HCPCS inpatient 1 UN 31.29 20.34 UMR - ALL PLANS UMR - ALL PLANS 21.9 70 999999999 18.95 30.35 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 49855575_1 CDM 0250 RC 00143-9284-10 NDC C9113 HCPCS inpatient 1 UN 31.29 20.34 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.95 60.55 999999999 18.95 30.35 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 49855575_1 CDM 0250 RC 00143-9284-10 NDC C9113 HCPCS inpatient 1 UN 31.29 20.34 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.95 30.35 "INJ PANTOPRAZOLE SODIUM, VIA" 49855575_1 CDM 0250 RC 00143-9284-10 NDC C9113 HCPCS inpatient 1 UN 31.29 20.34 ANTHEM HMO ANTHEM HMO 999999999 18.95 30.35 "INJ PANTOPRAZOLE SODIUM, VIA" 49855575_1 CDM 0250 RC 00143-9284-10 NDC C9113 HCPCS inpatient 1 UN 31.29 20.34 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.95 30.35 "INJ PANTOPRAZOLE SODIUM, VIA" 49855575_1 CDM 0250 RC 00143-9284-10 NDC C9113 HCPCS inpatient 1 UN 31.29 20.34 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.15 67.6 999999999 18.95 30.35 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 49855575_1 CDM 0250 RC 00143-9284-10 NDC C9113 HCPCS inpatient 1 UN 31.29 20.34 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.95 30.35 "INJ PANTOPRAZOLE SODIUM, VIA" 49855575_1 CDM 0250 RC 00143-9284-10 NDC C9113 HCPCS inpatient 1 UN 31.29 20.34 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.95 30.35 "Special stained specimen slides to examine tissue, each additional procedure" 49855942_1 CDM 0310 RC 88341 HCPCS inpatient 383 248.95 AETNA AETNA 302.57 79 999999999 231.91 371.51 percent of total billed charges "Special stained specimen slides to examine tissue, each additional procedure" 49855942_1 CDM 0310 RC 88341 HCPCS inpatient 383 248.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 248.95 65 999999999 231.91 371.51 percent of total billed charges "Special stained specimen slides to examine tissue, each additional procedure" 49855942_1 CDM 0310 RC 88341 HCPCS inpatient 383 248.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 371.51 97 999999999 231.91 371.51 percent of total billed charges "Special stained specimen slides to examine tissue, each additional procedure" 49855942_1 CDM 0310 RC 88341 HCPCS inpatient 383 248.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 264.27 69 999999999 231.91 371.51 percent of total billed charges "Special stained specimen slides to examine tissue, each additional procedure" 49855942_1 CDM 0310 RC 88341 HCPCS inpatient 383 248.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 298.74 78 999999999 231.91 371.51 percent of total billed charges "Special stained specimen slides to examine tissue, each additional procedure" 49855942_1 CDM 0310 RC 88341 HCPCS inpatient 383 248.95 SIHO - ALL PLANS SIHO - ALL PLANS 344.7 90 999999999 231.91 371.51 percent of total billed charges "Special stained specimen slides to examine tissue, each additional procedure" 49855942_1 CDM 0310 RC 88341 HCPCS inpatient 383 248.95 UMR - ALL PLANS UMR - ALL PLANS 268.1 70 999999999 231.91 371.51 percent of total billed charges "Special stained specimen slides to examine tissue, each additional procedure" 49855942_1 CDM 0310 RC 88341 HCPCS inpatient 383 248.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 231.91 60.55 999999999 231.91 371.51 percent of total billed charges "Special stained specimen slides to examine tissue, each additional procedure" 49855942_1 CDM 0310 RC 88341 HCPCS inpatient 383 248.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 231.91 371.51 "Special stained specimen slides to examine tissue, each additional procedure" 49855942_1 CDM 0310 RC 88341 HCPCS inpatient 383 248.95 ANTHEM HMO ANTHEM HMO 999999999 231.91 371.51 "Special stained specimen slides to examine tissue, each additional procedure" 49855942_1 CDM 0310 RC 88341 HCPCS inpatient 383 248.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 231.91 371.51 "Special stained specimen slides to examine tissue, each additional procedure" 49855942_1 CDM 0310 RC 88341 HCPCS inpatient 383 248.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 258.91 67.6 999999999 231.91 371.51 percent of total billed charges "Special stained specimen slides to examine tissue, each additional procedure" 49855942_1 CDM 0310 RC 88341 HCPCS inpatient 383 248.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 231.91 371.51 "Special stained specimen slides to examine tissue, each additional procedure" 49855942_1 CDM 0310 RC 88341 HCPCS inpatient 383 248.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 231.91 371.51 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49857711_1 CDM 0250 RC 00409-7335-20 NDC J0696 HCPCS inpatient 8 UN 30.81 20.03 AETNA AETNA 24.34 79 999999999 18.66 29.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49857711_1 CDM 0250 RC 00409-7335-20 NDC J0696 HCPCS inpatient 8 UN 30.81 20.03 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.03 65 999999999 18.66 29.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49857711_1 CDM 0250 RC 00409-7335-20 NDC J0696 HCPCS inpatient 8 UN 30.81 20.03 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.89 97 999999999 18.66 29.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49857711_1 CDM 0250 RC 00409-7335-20 NDC J0696 HCPCS inpatient 8 UN 30.81 20.03 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.26 69 999999999 18.66 29.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49857711_1 CDM 0250 RC 00409-7335-20 NDC J0696 HCPCS inpatient 8 UN 30.81 20.03 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.03 78 999999999 18.66 29.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49857711_1 CDM 0250 RC 00409-7335-20 NDC J0696 HCPCS inpatient 8 UN 30.81 20.03 SIHO - ALL PLANS SIHO - ALL PLANS 27.73 90 999999999 18.66 29.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49857711_1 CDM 0250 RC 00409-7335-20 NDC J0696 HCPCS inpatient 8 UN 30.81 20.03 UMR - ALL PLANS UMR - ALL PLANS 21.57 70 999999999 18.66 29.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49857711_1 CDM 0250 RC 00409-7335-20 NDC J0696 HCPCS inpatient 8 UN 30.81 20.03 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.66 60.55 999999999 18.66 29.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49857711_1 CDM 0250 RC 00409-7335-20 NDC J0696 HCPCS inpatient 8 UN 30.81 20.03 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.66 29.89 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49857711_1 CDM 0250 RC 00409-7335-20 NDC J0696 HCPCS inpatient 8 UN 30.81 20.03 ANTHEM HMO ANTHEM HMO 999999999 18.66 29.89 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49857711_1 CDM 0250 RC 00409-7335-20 NDC J0696 HCPCS inpatient 8 UN 30.81 20.03 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.66 29.89 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49857711_1 CDM 0250 RC 00409-7335-20 NDC J0696 HCPCS inpatient 8 UN 30.81 20.03 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.83 67.6 999999999 18.66 29.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49857711_1 CDM 0250 RC 00409-7335-20 NDC J0696 HCPCS inpatient 8 UN 30.81 20.03 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.66 29.89 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49857711_1 CDM 0250 RC 00409-7335-20 NDC J0696 HCPCS inpatient 8 UN 30.81 20.03 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.66 29.89 "INJECTION, AZITHROMYCIN, 500 MG" 49857756_1 CDM 0250 RC 70860-0100-10 NDC J0456 HCPCS inpatient 1 UN 63.96 41.57 AETNA AETNA 50.53 79 999999999 38.73 62.04 percent of total billed charges "INJECTION, AZITHROMYCIN, 500 MG" 49857756_1 CDM 0250 RC 70860-0100-10 NDC J0456 HCPCS inpatient 1 UN 63.96 41.57 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.57 65 999999999 38.73 62.04 percent of total billed charges "INJECTION, AZITHROMYCIN, 500 MG" 49857756_1 CDM 0250 RC 70860-0100-10 NDC J0456 HCPCS inpatient 1 UN 63.96 41.57 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 62.04 97 999999999 38.73 62.04 percent of total billed charges "INJECTION, AZITHROMYCIN, 500 MG" 49857756_1 CDM 0250 RC 70860-0100-10 NDC J0456 HCPCS inpatient 1 UN 63.96 41.57 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.13 69 999999999 38.73 62.04 percent of total billed charges "INJECTION, AZITHROMYCIN, 500 MG" 49857756_1 CDM 0250 RC 70860-0100-10 NDC J0456 HCPCS inpatient 1 UN 63.96 41.57 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.89 78 999999999 38.73 62.04 percent of total billed charges "INJECTION, AZITHROMYCIN, 500 MG" 49857756_1 CDM 0250 RC 70860-0100-10 NDC J0456 HCPCS inpatient 1 UN 63.96 41.57 SIHO - ALL PLANS SIHO - ALL PLANS 57.56 90 999999999 38.73 62.04 percent of total billed charges "INJECTION, AZITHROMYCIN, 500 MG" 49857756_1 CDM 0250 RC 70860-0100-10 NDC J0456 HCPCS inpatient 1 UN 63.96 41.57 UMR - ALL PLANS UMR - ALL PLANS 44.77 70 999999999 38.73 62.04 percent of total billed charges "INJECTION, AZITHROMYCIN, 500 MG" 49857756_1 CDM 0250 RC 70860-0100-10 NDC J0456 HCPCS inpatient 1 UN 63.96 41.57 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.73 60.55 999999999 38.73 62.04 percent of total billed charges "INJECTION, AZITHROMYCIN, 500 MG" 49857756_1 CDM 0250 RC 70860-0100-10 NDC J0456 HCPCS inpatient 1 UN 63.96 41.57 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.73 62.04 "INJECTION, AZITHROMYCIN, 500 MG" 49857756_1 CDM 0250 RC 70860-0100-10 NDC J0456 HCPCS inpatient 1 UN 63.96 41.57 ANTHEM HMO ANTHEM HMO 999999999 38.73 62.04 "INJECTION, AZITHROMYCIN, 500 MG" 49857756_1 CDM 0250 RC 70860-0100-10 NDC J0456 HCPCS inpatient 1 UN 63.96 41.57 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.73 62.04 "INJECTION, AZITHROMYCIN, 500 MG" 49857756_1 CDM 0250 RC 70860-0100-10 NDC J0456 HCPCS inpatient 1 UN 63.96 41.57 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.24 67.6 999999999 38.73 62.04 percent of total billed charges "INJECTION, AZITHROMYCIN, 500 MG" 49857756_1 CDM 0250 RC 70860-0100-10 NDC J0456 HCPCS inpatient 1 UN 63.96 41.57 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.73 62.04 "INJECTION, AZITHROMYCIN, 500 MG" 49857756_1 CDM 0250 RC 70860-0100-10 NDC J0456 HCPCS inpatient 1 UN 63.96 41.57 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.73 62.04 NICOTINE 14 MG/24HR PATCH 49857758_1 CDM 0250 RC 00536-5895-88 NDC inpatient 1 UN 6.23 4.05 AETNA AETNA 4.92 79 999999999 3.77 6.04 percent of total billed charges NICOTINE 14 MG/24HR PATCH 49857758_1 CDM 0250 RC 00536-5895-88 NDC inpatient 1 UN 6.23 4.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.05 65 999999999 3.77 6.04 percent of total billed charges NICOTINE 14 MG/24HR PATCH 49857758_1 CDM 0250 RC 00536-5895-88 NDC inpatient 1 UN 6.23 4.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.04 97 999999999 3.77 6.04 percent of total billed charges NICOTINE 14 MG/24HR PATCH 49857758_1 CDM 0250 RC 00536-5895-88 NDC inpatient 1 UN 6.23 4.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.3 69 999999999 3.77 6.04 percent of total billed charges NICOTINE 14 MG/24HR PATCH 49857758_1 CDM 0250 RC 00536-5895-88 NDC inpatient 1 UN 6.23 4.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.86 78 999999999 3.77 6.04 percent of total billed charges NICOTINE 14 MG/24HR PATCH 49857758_1 CDM 0250 RC 00536-5895-88 NDC inpatient 1 UN 6.23 4.05 SIHO - ALL PLANS SIHO - ALL PLANS 5.61 90 999999999 3.77 6.04 percent of total billed charges NICOTINE 14 MG/24HR PATCH 49857758_1 CDM 0250 RC 00536-5895-88 NDC inpatient 1 UN 6.23 4.05 UMR - ALL PLANS UMR - ALL PLANS 4.36 70 999999999 3.77 6.04 percent of total billed charges NICOTINE 14 MG/24HR PATCH 49857758_1 CDM 0250 RC 00536-5895-88 NDC inpatient 1 UN 6.23 4.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.77 60.55 999999999 3.77 6.04 percent of total billed charges NICOTINE 14 MG/24HR PATCH 49857758_1 CDM 0250 RC 00536-5895-88 NDC inpatient 1 UN 6.23 4.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.77 6.04 NICOTINE 14 MG/24HR PATCH 49857758_1 CDM 0250 RC 00536-5895-88 NDC inpatient 1 UN 6.23 4.05 ANTHEM HMO ANTHEM HMO 999999999 3.77 6.04 NICOTINE 14 MG/24HR PATCH 49857758_1 CDM 0250 RC 00536-5895-88 NDC inpatient 1 UN 6.23 4.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.77 6.04 NICOTINE 14 MG/24HR PATCH 49857758_1 CDM 0250 RC 00536-5895-88 NDC inpatient 1 UN 6.23 4.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.21 67.6 999999999 3.77 6.04 percent of total billed charges NICOTINE 14 MG/24HR PATCH 49857758_1 CDM 0250 RC 00536-5895-88 NDC inpatient 1 UN 6.23 4.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.77 6.04 NICOTINE 14 MG/24HR PATCH 49857758_1 CDM 0250 RC 00536-5895-88 NDC inpatient 1 UN 6.23 4.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.77 6.04 NICOTINE 21 MG/24HR PATCH 49857760_1 CDM 0250 RC 00536-5896-88 NDC inpatient 1 UN 5.54 3.6 AETNA AETNA 4.38 79 999999999 3.35 5.37 percent of total billed charges NICOTINE 21 MG/24HR PATCH 49857760_1 CDM 0250 RC 00536-5896-88 NDC inpatient 1 UN 5.54 3.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.6 65 999999999 3.35 5.37 percent of total billed charges NICOTINE 21 MG/24HR PATCH 49857760_1 CDM 0250 RC 00536-5896-88 NDC inpatient 1 UN 5.54 3.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.37 97 999999999 3.35 5.37 percent of total billed charges NICOTINE 21 MG/24HR PATCH 49857760_1 CDM 0250 RC 00536-5896-88 NDC inpatient 1 UN 5.54 3.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.82 69 999999999 3.35 5.37 percent of total billed charges NICOTINE 21 MG/24HR PATCH 49857760_1 CDM 0250 RC 00536-5896-88 NDC inpatient 1 UN 5.54 3.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.32 78 999999999 3.35 5.37 percent of total billed charges NICOTINE 21 MG/24HR PATCH 49857760_1 CDM 0250 RC 00536-5896-88 NDC inpatient 1 UN 5.54 3.6 SIHO - ALL PLANS SIHO - ALL PLANS 4.99 90 999999999 3.35 5.37 percent of total billed charges NICOTINE 21 MG/24HR PATCH 49857760_1 CDM 0250 RC 00536-5896-88 NDC inpatient 1 UN 5.54 3.6 UMR - ALL PLANS UMR - ALL PLANS 3.88 70 999999999 3.35 5.37 percent of total billed charges NICOTINE 21 MG/24HR PATCH 49857760_1 CDM 0250 RC 00536-5896-88 NDC inpatient 1 UN 5.54 3.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.35 60.55 999999999 3.35 5.37 percent of total billed charges NICOTINE 21 MG/24HR PATCH 49857760_1 CDM 0250 RC 00536-5896-88 NDC inpatient 1 UN 5.54 3.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.35 5.37 NICOTINE 21 MG/24HR PATCH 49857760_1 CDM 0250 RC 00536-5896-88 NDC inpatient 1 UN 5.54 3.6 ANTHEM HMO ANTHEM HMO 999999999 3.35 5.37 NICOTINE 21 MG/24HR PATCH 49857760_1 CDM 0250 RC 00536-5896-88 NDC inpatient 1 UN 5.54 3.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.35 5.37 NICOTINE 21 MG/24HR PATCH 49857760_1 CDM 0250 RC 00536-5896-88 NDC inpatient 1 UN 5.54 3.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.75 67.6 999999999 3.35 5.37 percent of total billed charges NICOTINE 21 MG/24HR PATCH 49857760_1 CDM 0250 RC 00536-5896-88 NDC inpatient 1 UN 5.54 3.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.35 5.37 NICOTINE 21 MG/24HR PATCH 49857760_1 CDM 0250 RC 00536-5896-88 NDC inpatient 1 UN 5.54 3.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.35 5.37 "INJECTION, PACLITAXEL, 1 MG" 49857940_1 CDM 0636 RC 70860-0200-17 NDC J9267 HCPCS inpatient 100 UN 119.71 77.81 AETNA AETNA 94.57 79 999999999 72.48 116.12 percent of total billed charges "INJECTION, PACLITAXEL, 1 MG" 49857940_1 CDM 0636 RC 70860-0200-17 NDC J9267 HCPCS inpatient 100 UN 119.71 77.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.81 65 999999999 72.48 116.12 percent of total billed charges "INJECTION, PACLITAXEL, 1 MG" 49857940_1 CDM 0636 RC 70860-0200-17 NDC J9267 HCPCS inpatient 100 UN 119.71 77.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.12 97 999999999 72.48 116.12 percent of total billed charges "INJECTION, PACLITAXEL, 1 MG" 49857940_1 CDM 0636 RC 70860-0200-17 NDC J9267 HCPCS inpatient 100 UN 119.71 77.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.6 69 999999999 72.48 116.12 percent of total billed charges "INJECTION, PACLITAXEL, 1 MG" 49857940_1 CDM 0636 RC 70860-0200-17 NDC J9267 HCPCS inpatient 100 UN 119.71 77.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.37 78 999999999 72.48 116.12 percent of total billed charges "INJECTION, PACLITAXEL, 1 MG" 49857940_1 CDM 0636 RC 70860-0200-17 NDC J9267 HCPCS inpatient 100 UN 119.71 77.81 SIHO - ALL PLANS SIHO - ALL PLANS 107.74 90 999999999 72.48 116.12 percent of total billed charges "INJECTION, PACLITAXEL, 1 MG" 49857940_1 CDM 0636 RC 70860-0200-17 NDC J9267 HCPCS inpatient 100 UN 119.71 77.81 UMR - ALL PLANS UMR - ALL PLANS 83.8 70 999999999 72.48 116.12 percent of total billed charges "INJECTION, PACLITAXEL, 1 MG" 49857940_1 CDM 0636 RC 70860-0200-17 NDC J9267 HCPCS inpatient 100 UN 119.71 77.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.48 60.55 999999999 72.48 116.12 percent of total billed charges "INJECTION, PACLITAXEL, 1 MG" 49857940_1 CDM 0636 RC 70860-0200-17 NDC J9267 HCPCS inpatient 100 UN 119.71 77.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.48 116.12 "INJECTION, PACLITAXEL, 1 MG" 49857940_1 CDM 0636 RC 70860-0200-17 NDC J9267 HCPCS inpatient 100 UN 119.71 77.81 ANTHEM HMO ANTHEM HMO 999999999 72.48 116.12 "INJECTION, PACLITAXEL, 1 MG" 49857940_1 CDM 0636 RC 70860-0200-17 NDC J9267 HCPCS inpatient 100 UN 119.71 77.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.48 116.12 "INJECTION, PACLITAXEL, 1 MG" 49857940_1 CDM 0636 RC 70860-0200-17 NDC J9267 HCPCS inpatient 100 UN 119.71 77.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.92 67.6 999999999 72.48 116.12 percent of total billed charges "INJECTION, PACLITAXEL, 1 MG" 49857940_1 CDM 0636 RC 70860-0200-17 NDC J9267 HCPCS inpatient 100 UN 119.71 77.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.48 116.12 "INJECTION, PACLITAXEL, 1 MG" 49857940_1 CDM 0636 RC 70860-0200-17 NDC J9267 HCPCS inpatient 100 UN 119.71 77.81 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.48 116.12 "Pneumococcal vaccine, 23-valent" 49857976_1 CDM 0250 RC 00006-4837-03 NDC 90732 HCPCS inpatient 1 UN 147.91 96.14 AETNA AETNA 116.85 79 999999999 89.56 143.47 percent of total billed charges "Pneumococcal vaccine, 23-valent" 49857976_1 CDM 0250 RC 00006-4837-03 NDC 90732 HCPCS inpatient 1 UN 147.91 96.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 96.14 65 999999999 89.56 143.47 percent of total billed charges "Pneumococcal vaccine, 23-valent" 49857976_1 CDM 0250 RC 00006-4837-03 NDC 90732 HCPCS inpatient 1 UN 147.91 96.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 143.47 97 999999999 89.56 143.47 percent of total billed charges "Pneumococcal vaccine, 23-valent" 49857976_1 CDM 0250 RC 00006-4837-03 NDC 90732 HCPCS inpatient 1 UN 147.91 96.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 102.06 69 999999999 89.56 143.47 percent of total billed charges "Pneumococcal vaccine, 23-valent" 49857976_1 CDM 0250 RC 00006-4837-03 NDC 90732 HCPCS inpatient 1 UN 147.91 96.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 115.37 78 999999999 89.56 143.47 percent of total billed charges "Pneumococcal vaccine, 23-valent" 49857976_1 CDM 0250 RC 00006-4837-03 NDC 90732 HCPCS inpatient 1 UN 147.91 96.14 SIHO - ALL PLANS SIHO - ALL PLANS 133.12 90 999999999 89.56 143.47 percent of total billed charges "Pneumococcal vaccine, 23-valent" 49857976_1 CDM 0250 RC 00006-4837-03 NDC 90732 HCPCS inpatient 1 UN 147.91 96.14 UMR - ALL PLANS UMR - ALL PLANS 103.54 70 999999999 89.56 143.47 percent of total billed charges "Pneumococcal vaccine, 23-valent" 49857976_1 CDM 0250 RC 00006-4837-03 NDC 90732 HCPCS inpatient 1 UN 147.91 96.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 89.56 60.55 999999999 89.56 143.47 percent of total billed charges "Pneumococcal vaccine, 23-valent" 49857976_1 CDM 0250 RC 00006-4837-03 NDC 90732 HCPCS inpatient 1 UN 147.91 96.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 89.56 143.47 "Pneumococcal vaccine, 23-valent" 49857976_1 CDM 0250 RC 00006-4837-03 NDC 90732 HCPCS inpatient 1 UN 147.91 96.14 ANTHEM HMO ANTHEM HMO 999999999 89.56 143.47 "Pneumococcal vaccine, 23-valent" 49857976_1 CDM 0250 RC 00006-4837-03 NDC 90732 HCPCS inpatient 1 UN 147.91 96.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 89.56 143.47 "Pneumococcal vaccine, 23-valent" 49857976_1 CDM 0250 RC 00006-4837-03 NDC 90732 HCPCS inpatient 1 UN 147.91 96.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 99.99 67.6 999999999 89.56 143.47 percent of total billed charges "Pneumococcal vaccine, 23-valent" 49857976_1 CDM 0250 RC 00006-4837-03 NDC 90732 HCPCS inpatient 1 UN 147.91 96.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 89.56 143.47 "Pneumococcal vaccine, 23-valent" 49857976_1 CDM 0250 RC 00006-4837-03 NDC 90732 HCPCS inpatient 1 UN 147.91 96.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 89.56 143.47 "INJECTION, VEDOLIZUMAB, 1 MG" 49858134_1 CDM 0636 RC 64764-0300-20 NDC J3380 HCPCS inpatient 300 UN 32665.98 21232.89 AETNA AETNA 25806.12 79 999999999 19779.25 31686 percent of total billed charges "INJECTION, VEDOLIZUMAB, 1 MG" 49858134_1 CDM 0636 RC 64764-0300-20 NDC J3380 HCPCS inpatient 300 UN 32665.98 21232.89 SELF PAY DISCOUNT SELF PAY DISCOUNT 21232.89 65 999999999 19779.25 31686 percent of total billed charges "INJECTION, VEDOLIZUMAB, 1 MG" 49858134_1 CDM 0636 RC 64764-0300-20 NDC J3380 HCPCS inpatient 300 UN 32665.98 21232.89 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31686 97 999999999 19779.25 31686 percent of total billed charges "INJECTION, VEDOLIZUMAB, 1 MG" 49858134_1 CDM 0636 RC 64764-0300-20 NDC J3380 HCPCS inpatient 300 UN 32665.98 21232.89 ENCORE - ALL PLANS ENCORE - ALL PLANS 22539.53 69 999999999 19779.25 31686 percent of total billed charges "INJECTION, VEDOLIZUMAB, 1 MG" 49858134_1 CDM 0636 RC 64764-0300-20 NDC J3380 HCPCS inpatient 300 UN 32665.98 21232.89 HUMANA - ALL PLANS HUMANA - ALL PLANS 25479.46 78 999999999 19779.25 31686 percent of total billed charges "INJECTION, VEDOLIZUMAB, 1 MG" 49858134_1 CDM 0636 RC 64764-0300-20 NDC J3380 HCPCS inpatient 300 UN 32665.98 21232.89 SIHO - ALL PLANS SIHO - ALL PLANS 29399.38 90 999999999 19779.25 31686 percent of total billed charges "INJECTION, VEDOLIZUMAB, 1 MG" 49858134_1 CDM 0636 RC 64764-0300-20 NDC J3380 HCPCS inpatient 300 UN 32665.98 21232.89 UMR - ALL PLANS UMR - ALL PLANS 22866.19 70 999999999 19779.25 31686 percent of total billed charges "INJECTION, VEDOLIZUMAB, 1 MG" 49858134_1 CDM 0636 RC 64764-0300-20 NDC J3380 HCPCS inpatient 300 UN 32665.98 21232.89 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19779.25 60.55 999999999 19779.25 31686 percent of total billed charges "INJECTION, VEDOLIZUMAB, 1 MG" 49858134_1 CDM 0636 RC 64764-0300-20 NDC J3380 HCPCS inpatient 300 UN 32665.98 21232.89 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19779.25 31686 "INJECTION, VEDOLIZUMAB, 1 MG" 49858134_1 CDM 0636 RC 64764-0300-20 NDC J3380 HCPCS inpatient 300 UN 32665.98 21232.89 ANTHEM HMO ANTHEM HMO 999999999 19779.25 31686 "INJECTION, VEDOLIZUMAB, 1 MG" 49858134_1 CDM 0636 RC 64764-0300-20 NDC J3380 HCPCS inpatient 300 UN 32665.98 21232.89 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19779.25 31686 "INJECTION, VEDOLIZUMAB, 1 MG" 49858134_1 CDM 0636 RC 64764-0300-20 NDC J3380 HCPCS inpatient 300 UN 32665.98 21232.89 CIGNA - ALL PLANS CIGNA - ALL PLANS 22082.2 67.6 999999999 19779.25 31686 percent of total billed charges "INJECTION, VEDOLIZUMAB, 1 MG" 49858134_1 CDM 0636 RC 64764-0300-20 NDC J3380 HCPCS inpatient 300 UN 32665.98 21232.89 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19779.25 31686 "INJECTION, VEDOLIZUMAB, 1 MG" 49858134_1 CDM 0636 RC 64764-0300-20 NDC J3380 HCPCS inpatient 300 UN 32665.98 21232.89 UHC - ALL PLANS UHC - ALL PLANS 999999999 19779.25 31686 Aspiration of bone marrow sample for diagnosis 49858236_1 CDM 0510 RC 38220 HCPCS inpatient 5308.5 3450.53 AETNA AETNA 4193.72 79 999999999 3214.3 5149.25 percent of total billed charges Aspiration of bone marrow sample for diagnosis 49858236_1 CDM 0510 RC 38220 HCPCS inpatient 5308.5 3450.53 SELF PAY DISCOUNT SELF PAY DISCOUNT 3450.53 65 999999999 3214.3 5149.25 percent of total billed charges Aspiration of bone marrow sample for diagnosis 49858236_1 CDM 0510 RC 38220 HCPCS inpatient 5308.5 3450.53 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5149.25 97 999999999 3214.3 5149.25 percent of total billed charges Aspiration of bone marrow sample for diagnosis 49858236_1 CDM 0510 RC 38220 HCPCS inpatient 5308.5 3450.53 ENCORE - ALL PLANS ENCORE - ALL PLANS 3662.87 69 999999999 3214.3 5149.25 percent of total billed charges Aspiration of bone marrow sample for diagnosis 49858236_1 CDM 0510 RC 38220 HCPCS inpatient 5308.5 3450.53 HUMANA - ALL PLANS HUMANA - ALL PLANS 4140.63 78 999999999 3214.3 5149.25 percent of total billed charges Aspiration of bone marrow sample for diagnosis 49858236_1 CDM 0510 RC 38220 HCPCS inpatient 5308.5 3450.53 SIHO - ALL PLANS SIHO - ALL PLANS 4777.65 90 999999999 3214.3 5149.25 percent of total billed charges Aspiration of bone marrow sample for diagnosis 49858236_1 CDM 0510 RC 38220 HCPCS inpatient 5308.5 3450.53 UMR - ALL PLANS UMR - ALL PLANS 3715.95 70 999999999 3214.3 5149.25 percent of total billed charges Aspiration of bone marrow sample for diagnosis 49858236_1 CDM 0510 RC 38220 HCPCS inpatient 5308.5 3450.53 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3214.3 60.55 999999999 3214.3 5149.25 percent of total billed charges Aspiration of bone marrow sample for diagnosis 49858236_1 CDM 0510 RC 38220 HCPCS inpatient 5308.5 3450.53 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3214.3 5149.25 Aspiration of bone marrow sample for diagnosis 49858236_1 CDM 0510 RC 38220 HCPCS inpatient 5308.5 3450.53 ANTHEM HMO ANTHEM HMO 999999999 3214.3 5149.25 Aspiration of bone marrow sample for diagnosis 49858236_1 CDM 0510 RC 38220 HCPCS inpatient 5308.5 3450.53 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3214.3 5149.25 Aspiration of bone marrow sample for diagnosis 49858236_1 CDM 0510 RC 38220 HCPCS inpatient 5308.5 3450.53 CIGNA - ALL PLANS CIGNA - ALL PLANS 3588.55 67.6 999999999 3214.3 5149.25 percent of total billed charges Aspiration of bone marrow sample for diagnosis 49858236_1 CDM 0510 RC 38220 HCPCS inpatient 5308.5 3450.53 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3214.3 5149.25 Aspiration of bone marrow sample for diagnosis 49858236_1 CDM 0510 RC 38220 HCPCS inpatient 5308.5 3450.53 UHC - ALL PLANS UHC - ALL PLANS 999999999 3214.3 5149.25 Analysis for antibody (IgM) to West Nile virus 49862167_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 AETNA AETNA 163.53 79 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 49862167_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 134.55 65 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 49862167_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 200.79 97 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 49862167_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.83 69 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 49862167_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 161.46 78 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 49862167_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 SIHO - ALL PLANS SIHO - ALL PLANS 186.3 90 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 49862167_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 UMR - ALL PLANS UMR - ALL PLANS 144.9 70 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 49862167_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 125.34 60.55 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 49862167_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 125.34 200.79 Analysis for antibody (IgM) to West Nile virus 49862167_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ANTHEM HMO ANTHEM HMO 999999999 125.34 200.79 Analysis for antibody (IgM) to West Nile virus 49862167_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 125.34 200.79 Analysis for antibody (IgM) to West Nile virus 49862167_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.93 67.6 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 49862167_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 125.34 200.79 Analysis for antibody (IgM) to West Nile virus 49862167_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 125.34 200.79 Analysis for antibody to HIV -1 virus 49862179_1 CDM 0302 RC 86701 HCPCS inpatient 183 118.95 AETNA AETNA 144.57 79 999999999 110.81 177.51 percent of total billed charges Analysis for antibody to HIV -1 virus 49862179_1 CDM 0302 RC 86701 HCPCS inpatient 183 118.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.95 65 999999999 110.81 177.51 percent of total billed charges Analysis for antibody to HIV -1 virus 49862179_1 CDM 0302 RC 86701 HCPCS inpatient 183 118.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.51 97 999999999 110.81 177.51 percent of total billed charges Analysis for antibody to HIV -1 virus 49862179_1 CDM 0302 RC 86701 HCPCS inpatient 183 118.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.27 69 999999999 110.81 177.51 percent of total billed charges Analysis for antibody to HIV -1 virus 49862179_1 CDM 0302 RC 86701 HCPCS inpatient 183 118.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 142.74 78 999999999 110.81 177.51 percent of total billed charges Analysis for antibody to HIV -1 virus 49862179_1 CDM 0302 RC 86701 HCPCS inpatient 183 118.95 SIHO - ALL PLANS SIHO - ALL PLANS 164.7 90 999999999 110.81 177.51 percent of total billed charges Analysis for antibody to HIV -1 virus 49862179_1 CDM 0302 RC 86701 HCPCS inpatient 183 118.95 UMR - ALL PLANS UMR - ALL PLANS 128.1 70 999999999 110.81 177.51 percent of total billed charges Analysis for antibody to HIV -1 virus 49862179_1 CDM 0302 RC 86701 HCPCS inpatient 183 118.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.81 60.55 999999999 110.81 177.51 percent of total billed charges Analysis for antibody to HIV -1 virus 49862179_1 CDM 0302 RC 86701 HCPCS inpatient 183 118.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.81 177.51 Analysis for antibody to HIV -1 virus 49862179_1 CDM 0302 RC 86701 HCPCS inpatient 183 118.95 ANTHEM HMO ANTHEM HMO 999999999 110.81 177.51 Analysis for antibody to HIV -1 virus 49862179_1 CDM 0302 RC 86701 HCPCS inpatient 183 118.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.81 177.51 Analysis for antibody to HIV -1 virus 49862179_1 CDM 0302 RC 86701 HCPCS inpatient 183 118.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.71 67.6 999999999 110.81 177.51 percent of total billed charges Analysis for antibody to HIV -1 virus 49862179_1 CDM 0302 RC 86701 HCPCS inpatient 183 118.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.81 177.51 Analysis for antibody to HIV -1 virus 49862179_1 CDM 0302 RC 86701 HCPCS inpatient 183 118.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.81 177.51 Osteocalcin (bone protein) level 49862403_1 CDM 0301 RC 83937 HCPCS inpatient 273 177.45 AETNA AETNA 215.67 79 999999999 165.3 264.81 percent of total billed charges Osteocalcin (bone protein) level 49862403_1 CDM 0301 RC 83937 HCPCS inpatient 273 177.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 177.45 65 999999999 165.3 264.81 percent of total billed charges Osteocalcin (bone protein) level 49862403_1 CDM 0301 RC 83937 HCPCS inpatient 273 177.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 264.81 97 999999999 165.3 264.81 percent of total billed charges Osteocalcin (bone protein) level 49862403_1 CDM 0301 RC 83937 HCPCS inpatient 273 177.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 188.37 69 999999999 165.3 264.81 percent of total billed charges Osteocalcin (bone protein) level 49862403_1 CDM 0301 RC 83937 HCPCS inpatient 273 177.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 212.94 78 999999999 165.3 264.81 percent of total billed charges Osteocalcin (bone protein) level 49862403_1 CDM 0301 RC 83937 HCPCS inpatient 273 177.45 SIHO - ALL PLANS SIHO - ALL PLANS 245.7 90 999999999 165.3 264.81 percent of total billed charges Osteocalcin (bone protein) level 49862403_1 CDM 0301 RC 83937 HCPCS inpatient 273 177.45 UMR - ALL PLANS UMR - ALL PLANS 191.1 70 999999999 165.3 264.81 percent of total billed charges Osteocalcin (bone protein) level 49862403_1 CDM 0301 RC 83937 HCPCS inpatient 273 177.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.3 60.55 999999999 165.3 264.81 percent of total billed charges Osteocalcin (bone protein) level 49862403_1 CDM 0301 RC 83937 HCPCS inpatient 273 177.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.3 264.81 Osteocalcin (bone protein) level 49862403_1 CDM 0301 RC 83937 HCPCS inpatient 273 177.45 ANTHEM HMO ANTHEM HMO 999999999 165.3 264.81 Osteocalcin (bone protein) level 49862403_1 CDM 0301 RC 83937 HCPCS inpatient 273 177.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.3 264.81 Osteocalcin (bone protein) level 49862403_1 CDM 0301 RC 83937 HCPCS inpatient 273 177.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 184.55 67.6 999999999 165.3 264.81 percent of total billed charges Osteocalcin (bone protein) level 49862403_1 CDM 0301 RC 83937 HCPCS inpatient 273 177.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.3 264.81 Osteocalcin (bone protein) level 49862403_1 CDM 0301 RC 83937 HCPCS inpatient 273 177.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.3 264.81 ROPINIROLE HCL ER 2 MG TABLET 49862518_1 CDM 0250 RC 00228-3658-03 NDC inpatient 1 UN 2.52 1.64 AETNA AETNA 1.99 79 999999999 1.53 2.44 percent of total billed charges ROPINIROLE HCL ER 2 MG TABLET 49862518_1 CDM 0250 RC 00228-3658-03 NDC inpatient 1 UN 2.52 1.64 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.64 65 999999999 1.53 2.44 percent of total billed charges ROPINIROLE HCL ER 2 MG TABLET 49862518_1 CDM 0250 RC 00228-3658-03 NDC inpatient 1 UN 2.52 1.64 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.44 97 999999999 1.53 2.44 percent of total billed charges ROPINIROLE HCL ER 2 MG TABLET 49862518_1 CDM 0250 RC 00228-3658-03 NDC inpatient 1 UN 2.52 1.64 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.74 69 999999999 1.53 2.44 percent of total billed charges ROPINIROLE HCL ER 2 MG TABLET 49862518_1 CDM 0250 RC 00228-3658-03 NDC inpatient 1 UN 2.52 1.64 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.97 78 999999999 1.53 2.44 percent of total billed charges ROPINIROLE HCL ER 2 MG TABLET 49862518_1 CDM 0250 RC 00228-3658-03 NDC inpatient 1 UN 2.52 1.64 SIHO - ALL PLANS SIHO - ALL PLANS 2.27 90 999999999 1.53 2.44 percent of total billed charges ROPINIROLE HCL ER 2 MG TABLET 49862518_1 CDM 0250 RC 00228-3658-03 NDC inpatient 1 UN 2.52 1.64 UMR - ALL PLANS UMR - ALL PLANS 1.76 70 999999999 1.53 2.44 percent of total billed charges ROPINIROLE HCL ER 2 MG TABLET 49862518_1 CDM 0250 RC 00228-3658-03 NDC inpatient 1 UN 2.52 1.64 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.53 60.55 999999999 1.53 2.44 percent of total billed charges ROPINIROLE HCL ER 2 MG TABLET 49862518_1 CDM 0250 RC 00228-3658-03 NDC inpatient 1 UN 2.52 1.64 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.53 2.44 ROPINIROLE HCL ER 2 MG TABLET 49862518_1 CDM 0250 RC 00228-3658-03 NDC inpatient 1 UN 2.52 1.64 ANTHEM HMO ANTHEM HMO 999999999 1.53 2.44 ROPINIROLE HCL ER 2 MG TABLET 49862518_1 CDM 0250 RC 00228-3658-03 NDC inpatient 1 UN 2.52 1.64 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.53 2.44 ROPINIROLE HCL ER 2 MG TABLET 49862518_1 CDM 0250 RC 00228-3658-03 NDC inpatient 1 UN 2.52 1.64 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.7 67.6 999999999 1.53 2.44 percent of total billed charges ROPINIROLE HCL ER 2 MG TABLET 49862518_1 CDM 0250 RC 00228-3658-03 NDC inpatient 1 UN 2.52 1.64 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.53 2.44 ROPINIROLE HCL ER 2 MG TABLET 49862518_1 CDM 0250 RC 00228-3658-03 NDC inpatient 1 UN 2.52 1.64 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.53 2.44 "INJECTION, DECITABINE, 1 MG" 49862526_1 CDM 0636 RC 43598-0348-37 NDC J0894 HCPCS inpatient 50 UN 2498.96 1624.32 AETNA AETNA 1974.18 79 999999999 1513.12 2423.99 percent of total billed charges "INJECTION, DECITABINE, 1 MG" 49862526_1 CDM 0636 RC 43598-0348-37 NDC J0894 HCPCS inpatient 50 UN 2498.96 1624.32 SELF PAY DISCOUNT SELF PAY DISCOUNT 1624.32 65 999999999 1513.12 2423.99 percent of total billed charges "INJECTION, DECITABINE, 1 MG" 49862526_1 CDM 0636 RC 43598-0348-37 NDC J0894 HCPCS inpatient 50 UN 2498.96 1624.32 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2423.99 97 999999999 1513.12 2423.99 percent of total billed charges "INJECTION, DECITABINE, 1 MG" 49862526_1 CDM 0636 RC 43598-0348-37 NDC J0894 HCPCS inpatient 50 UN 2498.96 1624.32 ENCORE - ALL PLANS ENCORE - ALL PLANS 1724.28 69 999999999 1513.12 2423.99 percent of total billed charges "INJECTION, DECITABINE, 1 MG" 49862526_1 CDM 0636 RC 43598-0348-37 NDC J0894 HCPCS inpatient 50 UN 2498.96 1624.32 HUMANA - ALL PLANS HUMANA - ALL PLANS 1949.19 78 999999999 1513.12 2423.99 percent of total billed charges "INJECTION, DECITABINE, 1 MG" 49862526_1 CDM 0636 RC 43598-0348-37 NDC J0894 HCPCS inpatient 50 UN 2498.96 1624.32 SIHO - ALL PLANS SIHO - ALL PLANS 2249.06 90 999999999 1513.12 2423.99 percent of total billed charges "INJECTION, DECITABINE, 1 MG" 49862526_1 CDM 0636 RC 43598-0348-37 NDC J0894 HCPCS inpatient 50 UN 2498.96 1624.32 UMR - ALL PLANS UMR - ALL PLANS 1749.27 70 999999999 1513.12 2423.99 percent of total billed charges "INJECTION, DECITABINE, 1 MG" 49862526_1 CDM 0636 RC 43598-0348-37 NDC J0894 HCPCS inpatient 50 UN 2498.96 1624.32 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1513.12 60.55 999999999 1513.12 2423.99 percent of total billed charges "INJECTION, DECITABINE, 1 MG" 49862526_1 CDM 0636 RC 43598-0348-37 NDC J0894 HCPCS inpatient 50 UN 2498.96 1624.32 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1513.12 2423.99 "INJECTION, DECITABINE, 1 MG" 49862526_1 CDM 0636 RC 43598-0348-37 NDC J0894 HCPCS inpatient 50 UN 2498.96 1624.32 ANTHEM HMO ANTHEM HMO 999999999 1513.12 2423.99 "INJECTION, DECITABINE, 1 MG" 49862526_1 CDM 0636 RC 43598-0348-37 NDC J0894 HCPCS inpatient 50 UN 2498.96 1624.32 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1513.12 2423.99 "INJECTION, DECITABINE, 1 MG" 49862526_1 CDM 0636 RC 43598-0348-37 NDC J0894 HCPCS inpatient 50 UN 2498.96 1624.32 CIGNA - ALL PLANS CIGNA - ALL PLANS 1689.3 67.6 999999999 1513.12 2423.99 percent of total billed charges "INJECTION, DECITABINE, 1 MG" 49862526_1 CDM 0636 RC 43598-0348-37 NDC J0894 HCPCS inpatient 50 UN 2498.96 1624.32 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1513.12 2423.99 "INJECTION, DECITABINE, 1 MG" 49862526_1 CDM 0636 RC 43598-0348-37 NDC J0894 HCPCS inpatient 50 UN 2498.96 1624.32 UHC - ALL PLANS UHC - ALL PLANS 999999999 1513.12 2423.99 Amikacin (antibiotic) level 49862774_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 AETNA AETNA 251.22 79 999999999 192.55 308.46 percent of total billed charges Amikacin (antibiotic) level 49862774_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 206.7 65 999999999 192.55 308.46 percent of total billed charges Amikacin (antibiotic) level 49862774_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 308.46 97 999999999 192.55 308.46 percent of total billed charges Amikacin (antibiotic) level 49862774_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 219.42 69 999999999 192.55 308.46 percent of total billed charges Amikacin (antibiotic) level 49862774_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 248.04 78 999999999 192.55 308.46 percent of total billed charges Amikacin (antibiotic) level 49862774_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 SIHO - ALL PLANS SIHO - ALL PLANS 286.2 90 999999999 192.55 308.46 percent of total billed charges Amikacin (antibiotic) level 49862774_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 UMR - ALL PLANS UMR - ALL PLANS 222.6 70 999999999 192.55 308.46 percent of total billed charges Amikacin (antibiotic) level 49862774_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 192.55 60.55 999999999 192.55 308.46 percent of total billed charges Amikacin (antibiotic) level 49862774_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 192.55 308.46 Amikacin (antibiotic) level 49862774_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 ANTHEM HMO ANTHEM HMO 999999999 192.55 308.46 Amikacin (antibiotic) level 49862774_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 192.55 308.46 Amikacin (antibiotic) level 49862774_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 214.97 67.6 999999999 192.55 308.46 percent of total billed charges Amikacin (antibiotic) level 49862774_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 192.55 308.46 Amikacin (antibiotic) level 49862774_1 CDM 0301 RC 80150 HCPCS inpatient 318 206.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 192.55 308.46 BUSPIRONE HCL 5 MG TABLET 49869323_1 CDM 0250 RC 16729-0200-01 NDC inpatient 1 UN 1.18 0.77 AETNA AETNA 0.93 79 999999999 0.71 1.14 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 49869323_1 CDM 0250 RC 16729-0200-01 NDC inpatient 1 UN 1.18 0.77 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.77 65 999999999 0.71 1.14 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 49869323_1 CDM 0250 RC 16729-0200-01 NDC inpatient 1 UN 1.18 0.77 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.14 97 999999999 0.71 1.14 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 49869323_1 CDM 0250 RC 16729-0200-01 NDC inpatient 1 UN 1.18 0.77 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.81 69 999999999 0.71 1.14 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 49869323_1 CDM 0250 RC 16729-0200-01 NDC inpatient 1 UN 1.18 0.77 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.92 78 999999999 0.71 1.14 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 49869323_1 CDM 0250 RC 16729-0200-01 NDC inpatient 1 UN 1.18 0.77 SIHO - ALL PLANS SIHO - ALL PLANS 1.06 90 999999999 0.71 1.14 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 49869323_1 CDM 0250 RC 16729-0200-01 NDC inpatient 1 UN 1.18 0.77 UMR - ALL PLANS UMR - ALL PLANS 0.83 70 999999999 0.71 1.14 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 49869323_1 CDM 0250 RC 16729-0200-01 NDC inpatient 1 UN 1.18 0.77 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.71 60.55 999999999 0.71 1.14 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 49869323_1 CDM 0250 RC 16729-0200-01 NDC inpatient 1 UN 1.18 0.77 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.71 1.14 BUSPIRONE HCL 5 MG TABLET 49869323_1 CDM 0250 RC 16729-0200-01 NDC inpatient 1 UN 1.18 0.77 ANTHEM HMO ANTHEM HMO 999999999 0.71 1.14 BUSPIRONE HCL 5 MG TABLET 49869323_1 CDM 0250 RC 16729-0200-01 NDC inpatient 1 UN 1.18 0.77 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.71 1.14 BUSPIRONE HCL 5 MG TABLET 49869323_1 CDM 0250 RC 16729-0200-01 NDC inpatient 1 UN 1.18 0.77 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.8 67.6 999999999 0.71 1.14 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 49869323_1 CDM 0250 RC 16729-0200-01 NDC inpatient 1 UN 1.18 0.77 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.71 1.14 BUSPIRONE HCL 5 MG TABLET 49869323_1 CDM 0250 RC 16729-0200-01 NDC inpatient 1 UN 1.18 0.77 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.71 1.14 "INJECTION, ETOPOSIDE, 10 MG" 49869325_1 CDM 0636 RC 16729-0262-31 NDC J9181 HCPCS inpatient 10 UN 48.47 31.51 AETNA AETNA 38.29 79 999999999 29.35 47.02 percent of total billed charges "INJECTION, ETOPOSIDE, 10 MG" 49869325_1 CDM 0636 RC 16729-0262-31 NDC J9181 HCPCS inpatient 10 UN 48.47 31.51 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.51 65 999999999 29.35 47.02 percent of total billed charges "INJECTION, ETOPOSIDE, 10 MG" 49869325_1 CDM 0636 RC 16729-0262-31 NDC J9181 HCPCS inpatient 10 UN 48.47 31.51 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 47.02 97 999999999 29.35 47.02 percent of total billed charges "INJECTION, ETOPOSIDE, 10 MG" 49869325_1 CDM 0636 RC 16729-0262-31 NDC J9181 HCPCS inpatient 10 UN 48.47 31.51 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.44 69 999999999 29.35 47.02 percent of total billed charges "INJECTION, ETOPOSIDE, 10 MG" 49869325_1 CDM 0636 RC 16729-0262-31 NDC J9181 HCPCS inpatient 10 UN 48.47 31.51 HUMANA - ALL PLANS HUMANA - ALL PLANS 37.81 78 999999999 29.35 47.02 percent of total billed charges "INJECTION, ETOPOSIDE, 10 MG" 49869325_1 CDM 0636 RC 16729-0262-31 NDC J9181 HCPCS inpatient 10 UN 48.47 31.51 SIHO - ALL PLANS SIHO - ALL PLANS 43.62 90 999999999 29.35 47.02 percent of total billed charges "INJECTION, ETOPOSIDE, 10 MG" 49869325_1 CDM 0636 RC 16729-0262-31 NDC J9181 HCPCS inpatient 10 UN 48.47 31.51 UMR - ALL PLANS UMR - ALL PLANS 33.93 70 999999999 29.35 47.02 percent of total billed charges "INJECTION, ETOPOSIDE, 10 MG" 49869325_1 CDM 0636 RC 16729-0262-31 NDC J9181 HCPCS inpatient 10 UN 48.47 31.51 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.35 60.55 999999999 29.35 47.02 percent of total billed charges "INJECTION, ETOPOSIDE, 10 MG" 49869325_1 CDM 0636 RC 16729-0262-31 NDC J9181 HCPCS inpatient 10 UN 48.47 31.51 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.35 47.02 "INJECTION, ETOPOSIDE, 10 MG" 49869325_1 CDM 0636 RC 16729-0262-31 NDC J9181 HCPCS inpatient 10 UN 48.47 31.51 ANTHEM HMO ANTHEM HMO 999999999 29.35 47.02 "INJECTION, ETOPOSIDE, 10 MG" 49869325_1 CDM 0636 RC 16729-0262-31 NDC J9181 HCPCS inpatient 10 UN 48.47 31.51 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.35 47.02 "INJECTION, ETOPOSIDE, 10 MG" 49869325_1 CDM 0636 RC 16729-0262-31 NDC J9181 HCPCS inpatient 10 UN 48.47 31.51 CIGNA - ALL PLANS CIGNA - ALL PLANS 32.77 67.6 999999999 29.35 47.02 percent of total billed charges "INJECTION, ETOPOSIDE, 10 MG" 49869325_1 CDM 0636 RC 16729-0262-31 NDC J9181 HCPCS inpatient 10 UN 48.47 31.51 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.35 47.02 "INJECTION, ETOPOSIDE, 10 MG" 49869325_1 CDM 0636 RC 16729-0262-31 NDC J9181 HCPCS inpatient 10 UN 48.47 31.51 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.35 47.02 LIDOCAINE 50 MG/5 ML (1%) SYRG 49869500_1 CDM 0250 RC 69374-0985-05 NDC inpatient 1 UN 28.27 18.38 AETNA AETNA 22.33 79 999999999 17.12 27.42 percent of total billed charges LIDOCAINE 50 MG/5 ML (1%) SYRG 49869500_1 CDM 0250 RC 69374-0985-05 NDC inpatient 1 UN 28.27 18.38 SELF PAY DISCOUNT SELF PAY DISCOUNT 18.38 65 999999999 17.12 27.42 percent of total billed charges LIDOCAINE 50 MG/5 ML (1%) SYRG 49869500_1 CDM 0250 RC 69374-0985-05 NDC inpatient 1 UN 28.27 18.38 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 27.42 97 999999999 17.12 27.42 percent of total billed charges LIDOCAINE 50 MG/5 ML (1%) SYRG 49869500_1 CDM 0250 RC 69374-0985-05 NDC inpatient 1 UN 28.27 18.38 ENCORE - ALL PLANS ENCORE - ALL PLANS 19.51 69 999999999 17.12 27.42 percent of total billed charges LIDOCAINE 50 MG/5 ML (1%) SYRG 49869500_1 CDM 0250 RC 69374-0985-05 NDC inpatient 1 UN 28.27 18.38 HUMANA - ALL PLANS HUMANA - ALL PLANS 22.05 78 999999999 17.12 27.42 percent of total billed charges LIDOCAINE 50 MG/5 ML (1%) SYRG 49869500_1 CDM 0250 RC 69374-0985-05 NDC inpatient 1 UN 28.27 18.38 SIHO - ALL PLANS SIHO - ALL PLANS 25.44 90 999999999 17.12 27.42 percent of total billed charges LIDOCAINE 50 MG/5 ML (1%) SYRG 49869500_1 CDM 0250 RC 69374-0985-05 NDC inpatient 1 UN 28.27 18.38 UMR - ALL PLANS UMR - ALL PLANS 19.79 70 999999999 17.12 27.42 percent of total billed charges LIDOCAINE 50 MG/5 ML (1%) SYRG 49869500_1 CDM 0250 RC 69374-0985-05 NDC inpatient 1 UN 28.27 18.38 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17.12 60.55 999999999 17.12 27.42 percent of total billed charges LIDOCAINE 50 MG/5 ML (1%) SYRG 49869500_1 CDM 0250 RC 69374-0985-05 NDC inpatient 1 UN 28.27 18.38 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 17.12 27.42 LIDOCAINE 50 MG/5 ML (1%) SYRG 49869500_1 CDM 0250 RC 69374-0985-05 NDC inpatient 1 UN 28.27 18.38 ANTHEM HMO ANTHEM HMO 999999999 17.12 27.42 LIDOCAINE 50 MG/5 ML (1%) SYRG 49869500_1 CDM 0250 RC 69374-0985-05 NDC inpatient 1 UN 28.27 18.38 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 17.12 27.42 LIDOCAINE 50 MG/5 ML (1%) SYRG 49869500_1 CDM 0250 RC 69374-0985-05 NDC inpatient 1 UN 28.27 18.38 CIGNA - ALL PLANS CIGNA - ALL PLANS 19.11 67.6 999999999 17.12 27.42 percent of total billed charges LIDOCAINE 50 MG/5 ML (1%) SYRG 49869500_1 CDM 0250 RC 69374-0985-05 NDC inpatient 1 UN 28.27 18.38 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 17.12 27.42 LIDOCAINE 50 MG/5 ML (1%) SYRG 49869500_1 CDM 0250 RC 69374-0985-05 NDC inpatient 1 UN 28.27 18.38 UHC - ALL PLANS UHC - ALL PLANS 999999999 17.12 27.42 TRINTELLIX 20 MG TABLET 49869571_1 CDM 0250 RC 64764-0750-30 NDC inpatient 1 UN 60.11 39.07 AETNA AETNA 47.49 79 999999999 36.4 58.31 percent of total billed charges TRINTELLIX 20 MG TABLET 49869571_1 CDM 0250 RC 64764-0750-30 NDC inpatient 1 UN 60.11 39.07 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.07 65 999999999 36.4 58.31 percent of total billed charges TRINTELLIX 20 MG TABLET 49869571_1 CDM 0250 RC 64764-0750-30 NDC inpatient 1 UN 60.11 39.07 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.31 97 999999999 36.4 58.31 percent of total billed charges TRINTELLIX 20 MG TABLET 49869571_1 CDM 0250 RC 64764-0750-30 NDC inpatient 1 UN 60.11 39.07 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.48 69 999999999 36.4 58.31 percent of total billed charges TRINTELLIX 20 MG TABLET 49869571_1 CDM 0250 RC 64764-0750-30 NDC inpatient 1 UN 60.11 39.07 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.89 78 999999999 36.4 58.31 percent of total billed charges TRINTELLIX 20 MG TABLET 49869571_1 CDM 0250 RC 64764-0750-30 NDC inpatient 1 UN 60.11 39.07 SIHO - ALL PLANS SIHO - ALL PLANS 54.1 90 999999999 36.4 58.31 percent of total billed charges TRINTELLIX 20 MG TABLET 49869571_1 CDM 0250 RC 64764-0750-30 NDC inpatient 1 UN 60.11 39.07 UMR - ALL PLANS UMR - ALL PLANS 42.08 70 999999999 36.4 58.31 percent of total billed charges TRINTELLIX 20 MG TABLET 49869571_1 CDM 0250 RC 64764-0750-30 NDC inpatient 1 UN 60.11 39.07 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.4 60.55 999999999 36.4 58.31 percent of total billed charges TRINTELLIX 20 MG TABLET 49869571_1 CDM 0250 RC 64764-0750-30 NDC inpatient 1 UN 60.11 39.07 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.4 58.31 TRINTELLIX 20 MG TABLET 49869571_1 CDM 0250 RC 64764-0750-30 NDC inpatient 1 UN 60.11 39.07 ANTHEM HMO ANTHEM HMO 999999999 36.4 58.31 TRINTELLIX 20 MG TABLET 49869571_1 CDM 0250 RC 64764-0750-30 NDC inpatient 1 UN 60.11 39.07 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.4 58.31 TRINTELLIX 20 MG TABLET 49869571_1 CDM 0250 RC 64764-0750-30 NDC inpatient 1 UN 60.11 39.07 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.63 67.6 999999999 36.4 58.31 percent of total billed charges TRINTELLIX 20 MG TABLET 49869571_1 CDM 0250 RC 64764-0750-30 NDC inpatient 1 UN 60.11 39.07 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.4 58.31 TRINTELLIX 20 MG TABLET 49869571_1 CDM 0250 RC 64764-0750-30 NDC inpatient 1 UN 60.11 39.07 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.4 58.31 "Ketone bodies analysis, quantitative" 49869615_1 CDM 0301 RC 82010 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges "Ketone bodies analysis, quantitative" 49869615_1 CDM 0301 RC 82010 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges "Ketone bodies analysis, quantitative" 49869615_1 CDM 0301 RC 82010 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges "Ketone bodies analysis, quantitative" 49869615_1 CDM 0301 RC 82010 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges "Ketone bodies analysis, quantitative" 49869615_1 CDM 0301 RC 82010 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges "Ketone bodies analysis, quantitative" 49869615_1 CDM 0301 RC 82010 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges "Ketone bodies analysis, quantitative" 49869615_1 CDM 0301 RC 82010 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges "Ketone bodies analysis, quantitative" 49869615_1 CDM 0301 RC 82010 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges "Ketone bodies analysis, quantitative" 49869615_1 CDM 0301 RC 82010 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 "Ketone bodies analysis, quantitative" 49869615_1 CDM 0301 RC 82010 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 "Ketone bodies analysis, quantitative" 49869615_1 CDM 0301 RC 82010 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 "Ketone bodies analysis, quantitative" 49869615_1 CDM 0301 RC 82010 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges "Ketone bodies analysis, quantitative" 49869615_1 CDM 0301 RC 82010 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 "Ketone bodies analysis, quantitative" 49869615_1 CDM 0301 RC 82010 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 ISOPTO ATROPINE 1% EYE DROP 49869662_1 CDM 0250 RC 00065-0303-55 NDC inpatient 1 UN 112.68 73.24 AETNA AETNA 89.02 79 999999999 68.23 109.3 percent of total billed charges ISOPTO ATROPINE 1% EYE DROP 49869662_1 CDM 0250 RC 00065-0303-55 NDC inpatient 1 UN 112.68 73.24 SELF PAY DISCOUNT SELF PAY DISCOUNT 73.24 65 999999999 68.23 109.3 percent of total billed charges ISOPTO ATROPINE 1% EYE DROP 49869662_1 CDM 0250 RC 00065-0303-55 NDC inpatient 1 UN 112.68 73.24 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 109.3 97 999999999 68.23 109.3 percent of total billed charges ISOPTO ATROPINE 1% EYE DROP 49869662_1 CDM 0250 RC 00065-0303-55 NDC inpatient 1 UN 112.68 73.24 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.75 69 999999999 68.23 109.3 percent of total billed charges ISOPTO ATROPINE 1% EYE DROP 49869662_1 CDM 0250 RC 00065-0303-55 NDC inpatient 1 UN 112.68 73.24 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.89 78 999999999 68.23 109.3 percent of total billed charges ISOPTO ATROPINE 1% EYE DROP 49869662_1 CDM 0250 RC 00065-0303-55 NDC inpatient 1 UN 112.68 73.24 SIHO - ALL PLANS SIHO - ALL PLANS 101.41 90 999999999 68.23 109.3 percent of total billed charges ISOPTO ATROPINE 1% EYE DROP 49869662_1 CDM 0250 RC 00065-0303-55 NDC inpatient 1 UN 112.68 73.24 UMR - ALL PLANS UMR - ALL PLANS 78.88 70 999999999 68.23 109.3 percent of total billed charges ISOPTO ATROPINE 1% EYE DROP 49869662_1 CDM 0250 RC 00065-0303-55 NDC inpatient 1 UN 112.68 73.24 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 68.23 60.55 999999999 68.23 109.3 percent of total billed charges ISOPTO ATROPINE 1% EYE DROP 49869662_1 CDM 0250 RC 00065-0303-55 NDC inpatient 1 UN 112.68 73.24 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 68.23 109.3 ISOPTO ATROPINE 1% EYE DROP 49869662_1 CDM 0250 RC 00065-0303-55 NDC inpatient 1 UN 112.68 73.24 ANTHEM HMO ANTHEM HMO 999999999 68.23 109.3 ISOPTO ATROPINE 1% EYE DROP 49869662_1 CDM 0250 RC 00065-0303-55 NDC inpatient 1 UN 112.68 73.24 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 68.23 109.3 ISOPTO ATROPINE 1% EYE DROP 49869662_1 CDM 0250 RC 00065-0303-55 NDC inpatient 1 UN 112.68 73.24 CIGNA - ALL PLANS CIGNA - ALL PLANS 76.17 67.6 999999999 68.23 109.3 percent of total billed charges ISOPTO ATROPINE 1% EYE DROP 49869662_1 CDM 0250 RC 00065-0303-55 NDC inpatient 1 UN 112.68 73.24 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 68.23 109.3 ISOPTO ATROPINE 1% EYE DROP 49869662_1 CDM 0250 RC 00065-0303-55 NDC inpatient 1 UN 112.68 73.24 UHC - ALL PLANS UHC - ALL PLANS 999999999 68.23 109.3 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49869761_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 AETNA AETNA 202.24 79 999999999 155.01 248.32 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49869761_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 166.4 65 999999999 155.01 248.32 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49869761_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 248.32 97 999999999 155.01 248.32 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49869761_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 176.64 69 999999999 155.01 248.32 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49869761_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 199.68 78 999999999 155.01 248.32 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49869761_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 SIHO - ALL PLANS SIHO - ALL PLANS 230.4 90 999999999 155.01 248.32 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49869761_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 UMR - ALL PLANS UMR - ALL PLANS 179.2 70 999999999 155.01 248.32 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49869761_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.01 60.55 999999999 155.01 248.32 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49869761_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.01 248.32 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49869761_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 ANTHEM HMO ANTHEM HMO 999999999 155.01 248.32 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49869761_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.01 248.32 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49869761_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.06 67.6 999999999 155.01 248.32 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49869761_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.01 248.32 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49869761_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.01 248.32 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49869763_1 CDM 0302 RC 86971 HCPCS inpatient 412 267.8 AETNA AETNA 325.48 79 999999999 249.47 399.64 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49869763_1 CDM 0302 RC 86971 HCPCS inpatient 412 267.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 267.8 65 999999999 249.47 399.64 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49869763_1 CDM 0302 RC 86971 HCPCS inpatient 412 267.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 399.64 97 999999999 249.47 399.64 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49869763_1 CDM 0302 RC 86971 HCPCS inpatient 412 267.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 284.28 69 999999999 249.47 399.64 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49869763_1 CDM 0302 RC 86971 HCPCS inpatient 412 267.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 321.36 78 999999999 249.47 399.64 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49869763_1 CDM 0302 RC 86971 HCPCS inpatient 412 267.8 SIHO - ALL PLANS SIHO - ALL PLANS 370.8 90 999999999 249.47 399.64 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49869763_1 CDM 0302 RC 86971 HCPCS inpatient 412 267.8 UMR - ALL PLANS UMR - ALL PLANS 288.4 70 999999999 249.47 399.64 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49869763_1 CDM 0302 RC 86971 HCPCS inpatient 412 267.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 249.47 60.55 999999999 249.47 399.64 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49869763_1 CDM 0302 RC 86971 HCPCS inpatient 412 267.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 249.47 399.64 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49869763_1 CDM 0302 RC 86971 HCPCS inpatient 412 267.8 ANTHEM HMO ANTHEM HMO 999999999 249.47 399.64 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49869763_1 CDM 0302 RC 86971 HCPCS inpatient 412 267.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 249.47 399.64 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49869763_1 CDM 0302 RC 86971 HCPCS inpatient 412 267.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 278.51 67.6 999999999 249.47 399.64 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49869763_1 CDM 0302 RC 86971 HCPCS inpatient 412 267.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 249.47 399.64 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49869763_1 CDM 0302 RC 86971 HCPCS inpatient 412 267.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 249.47 399.64 ENTEREG 12 MG CAPSULE 49870443_1 CDM 0250 RC 67919-0020-10 NDC inpatient 1 UN 236.06 153.44 AETNA AETNA 186.49 79 999999999 142.93 228.98 percent of total billed charges ENTEREG 12 MG CAPSULE 49870443_1 CDM 0250 RC 67919-0020-10 NDC inpatient 1 UN 236.06 153.44 SELF PAY DISCOUNT SELF PAY DISCOUNT 153.44 65 999999999 142.93 228.98 percent of total billed charges ENTEREG 12 MG CAPSULE 49870443_1 CDM 0250 RC 67919-0020-10 NDC inpatient 1 UN 236.06 153.44 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 228.98 97 999999999 142.93 228.98 percent of total billed charges ENTEREG 12 MG CAPSULE 49870443_1 CDM 0250 RC 67919-0020-10 NDC inpatient 1 UN 236.06 153.44 ENCORE - ALL PLANS ENCORE - ALL PLANS 162.88 69 999999999 142.93 228.98 percent of total billed charges ENTEREG 12 MG CAPSULE 49870443_1 CDM 0250 RC 67919-0020-10 NDC inpatient 1 UN 236.06 153.44 HUMANA - ALL PLANS HUMANA - ALL PLANS 184.13 78 999999999 142.93 228.98 percent of total billed charges ENTEREG 12 MG CAPSULE 49870443_1 CDM 0250 RC 67919-0020-10 NDC inpatient 1 UN 236.06 153.44 SIHO - ALL PLANS SIHO - ALL PLANS 212.45 90 999999999 142.93 228.98 percent of total billed charges ENTEREG 12 MG CAPSULE 49870443_1 CDM 0250 RC 67919-0020-10 NDC inpatient 1 UN 236.06 153.44 UMR - ALL PLANS UMR - ALL PLANS 165.24 70 999999999 142.93 228.98 percent of total billed charges ENTEREG 12 MG CAPSULE 49870443_1 CDM 0250 RC 67919-0020-10 NDC inpatient 1 UN 236.06 153.44 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 142.93 60.55 999999999 142.93 228.98 percent of total billed charges ENTEREG 12 MG CAPSULE 49870443_1 CDM 0250 RC 67919-0020-10 NDC inpatient 1 UN 236.06 153.44 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 142.93 228.98 ENTEREG 12 MG CAPSULE 49870443_1 CDM 0250 RC 67919-0020-10 NDC inpatient 1 UN 236.06 153.44 ANTHEM HMO ANTHEM HMO 999999999 142.93 228.98 ENTEREG 12 MG CAPSULE 49870443_1 CDM 0250 RC 67919-0020-10 NDC inpatient 1 UN 236.06 153.44 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 142.93 228.98 ENTEREG 12 MG CAPSULE 49870443_1 CDM 0250 RC 67919-0020-10 NDC inpatient 1 UN 236.06 153.44 CIGNA - ALL PLANS CIGNA - ALL PLANS 159.58 67.6 999999999 142.93 228.98 percent of total billed charges ENTEREG 12 MG CAPSULE 49870443_1 CDM 0250 RC 67919-0020-10 NDC inpatient 1 UN 236.06 153.44 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 142.93 228.98 ENTEREG 12 MG CAPSULE 49870443_1 CDM 0250 RC 67919-0020-10 NDC inpatient 1 UN 236.06 153.44 UHC - ALL PLANS UHC - ALL PLANS 999999999 142.93 228.98 FENTANYL 50 MCG/HR PATCH 49870636_1 CDM 0250 RC 00406-9050-76 NDC inpatient 1 UN 12.72 8.27 AETNA AETNA 10.05 79 999999999 7.7 12.34 percent of total billed charges FENTANYL 50 MCG/HR PATCH 49870636_1 CDM 0250 RC 00406-9050-76 NDC inpatient 1 UN 12.72 8.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.27 65 999999999 7.7 12.34 percent of total billed charges FENTANYL 50 MCG/HR PATCH 49870636_1 CDM 0250 RC 00406-9050-76 NDC inpatient 1 UN 12.72 8.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.34 97 999999999 7.7 12.34 percent of total billed charges FENTANYL 50 MCG/HR PATCH 49870636_1 CDM 0250 RC 00406-9050-76 NDC inpatient 1 UN 12.72 8.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.78 69 999999999 7.7 12.34 percent of total billed charges FENTANYL 50 MCG/HR PATCH 49870636_1 CDM 0250 RC 00406-9050-76 NDC inpatient 1 UN 12.72 8.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.92 78 999999999 7.7 12.34 percent of total billed charges FENTANYL 50 MCG/HR PATCH 49870636_1 CDM 0250 RC 00406-9050-76 NDC inpatient 1 UN 12.72 8.27 SIHO - ALL PLANS SIHO - ALL PLANS 11.45 90 999999999 7.7 12.34 percent of total billed charges FENTANYL 50 MCG/HR PATCH 49870636_1 CDM 0250 RC 00406-9050-76 NDC inpatient 1 UN 12.72 8.27 UMR - ALL PLANS UMR - ALL PLANS 8.9 70 999999999 7.7 12.34 percent of total billed charges FENTANYL 50 MCG/HR PATCH 49870636_1 CDM 0250 RC 00406-9050-76 NDC inpatient 1 UN 12.72 8.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.7 60.55 999999999 7.7 12.34 percent of total billed charges FENTANYL 50 MCG/HR PATCH 49870636_1 CDM 0250 RC 00406-9050-76 NDC inpatient 1 UN 12.72 8.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.7 12.34 FENTANYL 50 MCG/HR PATCH 49870636_1 CDM 0250 RC 00406-9050-76 NDC inpatient 1 UN 12.72 8.27 ANTHEM HMO ANTHEM HMO 999999999 7.7 12.34 FENTANYL 50 MCG/HR PATCH 49870636_1 CDM 0250 RC 00406-9050-76 NDC inpatient 1 UN 12.72 8.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.7 12.34 FENTANYL 50 MCG/HR PATCH 49870636_1 CDM 0250 RC 00406-9050-76 NDC inpatient 1 UN 12.72 8.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.6 67.6 999999999 7.7 12.34 percent of total billed charges FENTANYL 50 MCG/HR PATCH 49870636_1 CDM 0250 RC 00406-9050-76 NDC inpatient 1 UN 12.72 8.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.7 12.34 FENTANYL 50 MCG/HR PATCH 49870636_1 CDM 0250 RC 00406-9050-76 NDC inpatient 1 UN 12.72 8.27 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.7 12.34 "INJECTION, HYDROXYZINE HCL, UP TO 25 MG" 49870638_1 CDM 0250 RC 00517-5601-25 NDC J3410 HCPCS inpatient 1 UN 84.43 54.88 AETNA AETNA 66.7 79 999999999 51.12 81.9 percent of total billed charges "INJECTION, HYDROXYZINE HCL, UP TO 25 MG" 49870638_1 CDM 0250 RC 00517-5601-25 NDC J3410 HCPCS inpatient 1 UN 84.43 54.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 54.88 65 999999999 51.12 81.9 percent of total billed charges "INJECTION, HYDROXYZINE HCL, UP TO 25 MG" 49870638_1 CDM 0250 RC 00517-5601-25 NDC J3410 HCPCS inpatient 1 UN 84.43 54.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 81.9 97 999999999 51.12 81.9 percent of total billed charges "INJECTION, HYDROXYZINE HCL, UP TO 25 MG" 49870638_1 CDM 0250 RC 00517-5601-25 NDC J3410 HCPCS inpatient 1 UN 84.43 54.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 58.26 69 999999999 51.12 81.9 percent of total billed charges "INJECTION, HYDROXYZINE HCL, UP TO 25 MG" 49870638_1 CDM 0250 RC 00517-5601-25 NDC J3410 HCPCS inpatient 1 UN 84.43 54.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 65.86 78 999999999 51.12 81.9 percent of total billed charges "INJECTION, HYDROXYZINE HCL, UP TO 25 MG" 49870638_1 CDM 0250 RC 00517-5601-25 NDC J3410 HCPCS inpatient 1 UN 84.43 54.88 SIHO - ALL PLANS SIHO - ALL PLANS 75.99 90 999999999 51.12 81.9 percent of total billed charges "INJECTION, HYDROXYZINE HCL, UP TO 25 MG" 49870638_1 CDM 0250 RC 00517-5601-25 NDC J3410 HCPCS inpatient 1 UN 84.43 54.88 UMR - ALL PLANS UMR - ALL PLANS 59.1 70 999999999 51.12 81.9 percent of total billed charges "INJECTION, HYDROXYZINE HCL, UP TO 25 MG" 49870638_1 CDM 0250 RC 00517-5601-25 NDC J3410 HCPCS inpatient 1 UN 84.43 54.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 51.12 60.55 999999999 51.12 81.9 percent of total billed charges "INJECTION, HYDROXYZINE HCL, UP TO 25 MG" 49870638_1 CDM 0250 RC 00517-5601-25 NDC J3410 HCPCS inpatient 1 UN 84.43 54.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 51.12 81.9 "INJECTION, HYDROXYZINE HCL, UP TO 25 MG" 49870638_1 CDM 0250 RC 00517-5601-25 NDC J3410 HCPCS inpatient 1 UN 84.43 54.88 ANTHEM HMO ANTHEM HMO 999999999 51.12 81.9 "INJECTION, HYDROXYZINE HCL, UP TO 25 MG" 49870638_1 CDM 0250 RC 00517-5601-25 NDC J3410 HCPCS inpatient 1 UN 84.43 54.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 51.12 81.9 "INJECTION, HYDROXYZINE HCL, UP TO 25 MG" 49870638_1 CDM 0250 RC 00517-5601-25 NDC J3410 HCPCS inpatient 1 UN 84.43 54.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 57.07 67.6 999999999 51.12 81.9 percent of total billed charges "INJECTION, HYDROXYZINE HCL, UP TO 25 MG" 49870638_1 CDM 0250 RC 00517-5601-25 NDC J3410 HCPCS inpatient 1 UN 84.43 54.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 51.12 81.9 "INJECTION, HYDROXYZINE HCL, UP TO 25 MG" 49870638_1 CDM 0250 RC 00517-5601-25 NDC J3410 HCPCS inpatient 1 UN 84.43 54.88 UHC - ALL PLANS UHC - ALL PLANS 999999999 51.12 81.9 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49873659_1 CDM 0250 RC 00409-7337-20 NDC J0696 HCPCS inpatient 1 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49873659_1 CDM 0250 RC 00409-7337-20 NDC J0696 HCPCS inpatient 1 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49873659_1 CDM 0250 RC 00409-7337-20 NDC J0696 HCPCS inpatient 1 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49873659_1 CDM 0250 RC 00409-7337-20 NDC J0696 HCPCS inpatient 1 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49873659_1 CDM 0250 RC 00409-7337-20 NDC J0696 HCPCS inpatient 1 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49873659_1 CDM 0250 RC 00409-7337-20 NDC J0696 HCPCS inpatient 1 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49873659_1 CDM 0250 RC 00409-7337-20 NDC J0696 HCPCS inpatient 1 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49873659_1 CDM 0250 RC 00409-7337-20 NDC J0696 HCPCS inpatient 1 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49873659_1 CDM 0250 RC 00409-7337-20 NDC J0696 HCPCS inpatient 1 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49873659_1 CDM 0250 RC 00409-7337-20 NDC J0696 HCPCS inpatient 1 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49873659_1 CDM 0250 RC 00409-7337-20 NDC J0696 HCPCS inpatient 1 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49873659_1 CDM 0250 RC 00409-7337-20 NDC J0696 HCPCS inpatient 1 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49873659_1 CDM 0250 RC 00409-7337-20 NDC J0696 HCPCS inpatient 1 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 49873659_1 CDM 0250 RC 00409-7337-20 NDC J0696 HCPCS inpatient 1 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 Stool lactoferrin (immune system protein) analysis 49873799_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges Stool lactoferrin (immune system protein) analysis 49873799_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges Stool lactoferrin (immune system protein) analysis 49873799_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges Stool lactoferrin (immune system protein) analysis 49873799_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges Stool lactoferrin (immune system protein) analysis 49873799_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges Stool lactoferrin (immune system protein) analysis 49873799_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges Stool lactoferrin (immune system protein) analysis 49873799_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges Stool lactoferrin (immune system protein) analysis 49873799_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges Stool lactoferrin (immune system protein) analysis 49873799_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 Stool lactoferrin (immune system protein) analysis 49873799_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 Stool lactoferrin (immune system protein) analysis 49873799_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 Stool lactoferrin (immune system protein) analysis 49873799_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges Stool lactoferrin (immune system protein) analysis 49873799_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 Stool lactoferrin (immune system protein) analysis 49873799_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 LISINOPRIL 20 MG TABLET 49873907_1 CDM 0250 RC 60687-0333-01 NDC inpatient 1 UN 1.34 0.87 AETNA AETNA 1.06 79 999999999 0.81 1.3 percent of total billed charges LISINOPRIL 20 MG TABLET 49873907_1 CDM 0250 RC 60687-0333-01 NDC inpatient 1 UN 1.34 0.87 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.87 65 999999999 0.81 1.3 percent of total billed charges LISINOPRIL 20 MG TABLET 49873907_1 CDM 0250 RC 60687-0333-01 NDC inpatient 1 UN 1.34 0.87 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.3 97 999999999 0.81 1.3 percent of total billed charges LISINOPRIL 20 MG TABLET 49873907_1 CDM 0250 RC 60687-0333-01 NDC inpatient 1 UN 1.34 0.87 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.92 69 999999999 0.81 1.3 percent of total billed charges LISINOPRIL 20 MG TABLET 49873907_1 CDM 0250 RC 60687-0333-01 NDC inpatient 1 UN 1.34 0.87 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.05 78 999999999 0.81 1.3 percent of total billed charges LISINOPRIL 20 MG TABLET 49873907_1 CDM 0250 RC 60687-0333-01 NDC inpatient 1 UN 1.34 0.87 SIHO - ALL PLANS SIHO - ALL PLANS 1.21 90 999999999 0.81 1.3 percent of total billed charges LISINOPRIL 20 MG TABLET 49873907_1 CDM 0250 RC 60687-0333-01 NDC inpatient 1 UN 1.34 0.87 UMR - ALL PLANS UMR - ALL PLANS 0.94 70 999999999 0.81 1.3 percent of total billed charges LISINOPRIL 20 MG TABLET 49873907_1 CDM 0250 RC 60687-0333-01 NDC inpatient 1 UN 1.34 0.87 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.81 60.55 999999999 0.81 1.3 percent of total billed charges LISINOPRIL 20 MG TABLET 49873907_1 CDM 0250 RC 60687-0333-01 NDC inpatient 1 UN 1.34 0.87 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.81 1.3 LISINOPRIL 20 MG TABLET 49873907_1 CDM 0250 RC 60687-0333-01 NDC inpatient 1 UN 1.34 0.87 ANTHEM HMO ANTHEM HMO 999999999 0.81 1.3 LISINOPRIL 20 MG TABLET 49873907_1 CDM 0250 RC 60687-0333-01 NDC inpatient 1 UN 1.34 0.87 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.81 1.3 LISINOPRIL 20 MG TABLET 49873907_1 CDM 0250 RC 60687-0333-01 NDC inpatient 1 UN 1.34 0.87 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.91 67.6 999999999 0.81 1.3 percent of total billed charges LISINOPRIL 20 MG TABLET 49873907_1 CDM 0250 RC 60687-0333-01 NDC inpatient 1 UN 1.34 0.87 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.81 1.3 LISINOPRIL 20 MG TABLET 49873907_1 CDM 0250 RC 60687-0333-01 NDC inpatient 1 UN 1.34 0.87 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.81 1.3 "CYANOCOBALAMIN 1,000 MCG/ML VL" 49876458_1 CDM 0250 RC 70069-0005-10 NDC inpatient 1 UN 29.08 18.9 AETNA AETNA 22.97 79 999999999 17.61 28.21 percent of total billed charges "CYANOCOBALAMIN 1,000 MCG/ML VL" 49876458_1 CDM 0250 RC 70069-0005-10 NDC inpatient 1 UN 29.08 18.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 18.9 65 999999999 17.61 28.21 percent of total billed charges "CYANOCOBALAMIN 1,000 MCG/ML VL" 49876458_1 CDM 0250 RC 70069-0005-10 NDC inpatient 1 UN 29.08 18.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 28.21 97 999999999 17.61 28.21 percent of total billed charges "CYANOCOBALAMIN 1,000 MCG/ML VL" 49876458_1 CDM 0250 RC 70069-0005-10 NDC inpatient 1 UN 29.08 18.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.07 69 999999999 17.61 28.21 percent of total billed charges "CYANOCOBALAMIN 1,000 MCG/ML VL" 49876458_1 CDM 0250 RC 70069-0005-10 NDC inpatient 1 UN 29.08 18.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 22.68 78 999999999 17.61 28.21 percent of total billed charges "CYANOCOBALAMIN 1,000 MCG/ML VL" 49876458_1 CDM 0250 RC 70069-0005-10 NDC inpatient 1 UN 29.08 18.9 SIHO - ALL PLANS SIHO - ALL PLANS 26.17 90 999999999 17.61 28.21 percent of total billed charges "CYANOCOBALAMIN 1,000 MCG/ML VL" 49876458_1 CDM 0250 RC 70069-0005-10 NDC inpatient 1 UN 29.08 18.9 UMR - ALL PLANS UMR - ALL PLANS 20.36 70 999999999 17.61 28.21 percent of total billed charges "CYANOCOBALAMIN 1,000 MCG/ML VL" 49876458_1 CDM 0250 RC 70069-0005-10 NDC inpatient 1 UN 29.08 18.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17.61 60.55 999999999 17.61 28.21 percent of total billed charges "CYANOCOBALAMIN 1,000 MCG/ML VL" 49876458_1 CDM 0250 RC 70069-0005-10 NDC inpatient 1 UN 29.08 18.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 17.61 28.21 "CYANOCOBALAMIN 1,000 MCG/ML VL" 49876458_1 CDM 0250 RC 70069-0005-10 NDC inpatient 1 UN 29.08 18.9 ANTHEM HMO ANTHEM HMO 999999999 17.61 28.21 "CYANOCOBALAMIN 1,000 MCG/ML VL" 49876458_1 CDM 0250 RC 70069-0005-10 NDC inpatient 1 UN 29.08 18.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 17.61 28.21 "CYANOCOBALAMIN 1,000 MCG/ML VL" 49876458_1 CDM 0250 RC 70069-0005-10 NDC inpatient 1 UN 29.08 18.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 19.66 67.6 999999999 17.61 28.21 percent of total billed charges "CYANOCOBALAMIN 1,000 MCG/ML VL" 49876458_1 CDM 0250 RC 70069-0005-10 NDC inpatient 1 UN 29.08 18.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 17.61 28.21 "CYANOCOBALAMIN 1,000 MCG/ML VL" 49876458_1 CDM 0250 RC 70069-0005-10 NDC inpatient 1 UN 29.08 18.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 17.61 28.21 "INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG" 49876465_1 CDM 0250 RC 69918-0899-10 NDC J2597 HCPCS inpatient 1 UN 184.86 120.16 AETNA AETNA 146.04 79 999999999 111.93 179.31 percent of total billed charges "INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG" 49876465_1 CDM 0250 RC 69918-0899-10 NDC J2597 HCPCS inpatient 1 UN 184.86 120.16 SELF PAY DISCOUNT SELF PAY DISCOUNT 120.16 65 999999999 111.93 179.31 percent of total billed charges "INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG" 49876465_1 CDM 0250 RC 69918-0899-10 NDC J2597 HCPCS inpatient 1 UN 184.86 120.16 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 179.31 97 999999999 111.93 179.31 percent of total billed charges "INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG" 49876465_1 CDM 0250 RC 69918-0899-10 NDC J2597 HCPCS inpatient 1 UN 184.86 120.16 ENCORE - ALL PLANS ENCORE - ALL PLANS 127.55 69 999999999 111.93 179.31 percent of total billed charges "INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG" 49876465_1 CDM 0250 RC 69918-0899-10 NDC J2597 HCPCS inpatient 1 UN 184.86 120.16 HUMANA - ALL PLANS HUMANA - ALL PLANS 144.19 78 999999999 111.93 179.31 percent of total billed charges "INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG" 49876465_1 CDM 0250 RC 69918-0899-10 NDC J2597 HCPCS inpatient 1 UN 184.86 120.16 SIHO - ALL PLANS SIHO - ALL PLANS 166.37 90 999999999 111.93 179.31 percent of total billed charges "INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG" 49876465_1 CDM 0250 RC 69918-0899-10 NDC J2597 HCPCS inpatient 1 UN 184.86 120.16 UMR - ALL PLANS UMR - ALL PLANS 129.4 70 999999999 111.93 179.31 percent of total billed charges "INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG" 49876465_1 CDM 0250 RC 69918-0899-10 NDC J2597 HCPCS inpatient 1 UN 184.86 120.16 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 111.93 60.55 999999999 111.93 179.31 percent of total billed charges "INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG" 49876465_1 CDM 0250 RC 69918-0899-10 NDC J2597 HCPCS inpatient 1 UN 184.86 120.16 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 111.93 179.31 "INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG" 49876465_1 CDM 0250 RC 69918-0899-10 NDC J2597 HCPCS inpatient 1 UN 184.86 120.16 ANTHEM HMO ANTHEM HMO 999999999 111.93 179.31 "INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG" 49876465_1 CDM 0250 RC 69918-0899-10 NDC J2597 HCPCS inpatient 1 UN 184.86 120.16 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 111.93 179.31 "INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG" 49876465_1 CDM 0250 RC 69918-0899-10 NDC J2597 HCPCS inpatient 1 UN 184.86 120.16 CIGNA - ALL PLANS CIGNA - ALL PLANS 124.97 67.6 999999999 111.93 179.31 percent of total billed charges "INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG" 49876465_1 CDM 0250 RC 69918-0899-10 NDC J2597 HCPCS inpatient 1 UN 184.86 120.16 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 111.93 179.31 "INJECTION, DESMOPRESSIN ACETATE, PER 1 MCG" 49876465_1 CDM 0250 RC 69918-0899-10 NDC J2597 HCPCS inpatient 1 UN 184.86 120.16 UHC - ALL PLANS UHC - ALL PLANS 999999999 111.93 179.31 "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 49879588_1 CDM 0306 RC 87556 HCPCS inpatient 464 301.6 AETNA AETNA 366.56 79 999999999 280.95 450.08 percent of total billed charges "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 49879588_1 CDM 0306 RC 87556 HCPCS inpatient 464 301.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 301.6 65 999999999 280.95 450.08 percent of total billed charges "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 49879588_1 CDM 0306 RC 87556 HCPCS inpatient 464 301.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 450.08 97 999999999 280.95 450.08 percent of total billed charges "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 49879588_1 CDM 0306 RC 87556 HCPCS inpatient 464 301.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 320.16 69 999999999 280.95 450.08 percent of total billed charges "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 49879588_1 CDM 0306 RC 87556 HCPCS inpatient 464 301.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 361.92 78 999999999 280.95 450.08 percent of total billed charges "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 49879588_1 CDM 0306 RC 87556 HCPCS inpatient 464 301.6 SIHO - ALL PLANS SIHO - ALL PLANS 417.6 90 999999999 280.95 450.08 percent of total billed charges "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 49879588_1 CDM 0306 RC 87556 HCPCS inpatient 464 301.6 UMR - ALL PLANS UMR - ALL PLANS 324.8 70 999999999 280.95 450.08 percent of total billed charges "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 49879588_1 CDM 0306 RC 87556 HCPCS inpatient 464 301.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 280.95 60.55 999999999 280.95 450.08 percent of total billed charges "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 49879588_1 CDM 0306 RC 87556 HCPCS inpatient 464 301.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 280.95 450.08 "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 49879588_1 CDM 0306 RC 87556 HCPCS inpatient 464 301.6 ANTHEM HMO ANTHEM HMO 999999999 280.95 450.08 "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 49879588_1 CDM 0306 RC 87556 HCPCS inpatient 464 301.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 280.95 450.08 "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 49879588_1 CDM 0306 RC 87556 HCPCS inpatient 464 301.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 313.66 67.6 999999999 280.95 450.08 percent of total billed charges "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 49879588_1 CDM 0306 RC 87556 HCPCS inpatient 464 301.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 280.95 450.08 "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 49879588_1 CDM 0306 RC 87556 HCPCS inpatient 464 301.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 280.95 450.08 NORTRIPTYLINE HCL 10 MG CAP 49879847_1 CDM 0250 RC 51672-4001-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges NORTRIPTYLINE HCL 10 MG CAP 49879847_1 CDM 0250 RC 51672-4001-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges NORTRIPTYLINE HCL 10 MG CAP 49879847_1 CDM 0250 RC 51672-4001-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges NORTRIPTYLINE HCL 10 MG CAP 49879847_1 CDM 0250 RC 51672-4001-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges NORTRIPTYLINE HCL 10 MG CAP 49879847_1 CDM 0250 RC 51672-4001-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges NORTRIPTYLINE HCL 10 MG CAP 49879847_1 CDM 0250 RC 51672-4001-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges NORTRIPTYLINE HCL 10 MG CAP 49879847_1 CDM 0250 RC 51672-4001-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges NORTRIPTYLINE HCL 10 MG CAP 49879847_1 CDM 0250 RC 51672-4001-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges NORTRIPTYLINE HCL 10 MG CAP 49879847_1 CDM 0250 RC 51672-4001-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 NORTRIPTYLINE HCL 10 MG CAP 49879847_1 CDM 0250 RC 51672-4001-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 NORTRIPTYLINE HCL 10 MG CAP 49879847_1 CDM 0250 RC 51672-4001-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 NORTRIPTYLINE HCL 10 MG CAP 49879847_1 CDM 0250 RC 51672-4001-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges NORTRIPTYLINE HCL 10 MG CAP 49879847_1 CDM 0250 RC 51672-4001-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 NORTRIPTYLINE HCL 10 MG CAP 49879847_1 CDM 0250 RC 51672-4001-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 SELEGILINE HCL 5 MG TABLET 49879853_1 CDM 0250 RC 60505-3438-03 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges SELEGILINE HCL 5 MG TABLET 49879853_1 CDM 0250 RC 60505-3438-03 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges SELEGILINE HCL 5 MG TABLET 49879853_1 CDM 0250 RC 60505-3438-03 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges SELEGILINE HCL 5 MG TABLET 49879853_1 CDM 0250 RC 60505-3438-03 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges SELEGILINE HCL 5 MG TABLET 49879853_1 CDM 0250 RC 60505-3438-03 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges SELEGILINE HCL 5 MG TABLET 49879853_1 CDM 0250 RC 60505-3438-03 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges SELEGILINE HCL 5 MG TABLET 49879853_1 CDM 0250 RC 60505-3438-03 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges SELEGILINE HCL 5 MG TABLET 49879853_1 CDM 0250 RC 60505-3438-03 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges SELEGILINE HCL 5 MG TABLET 49879853_1 CDM 0250 RC 60505-3438-03 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 SELEGILINE HCL 5 MG TABLET 49879853_1 CDM 0250 RC 60505-3438-03 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 SELEGILINE HCL 5 MG TABLET 49879853_1 CDM 0250 RC 60505-3438-03 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 SELEGILINE HCL 5 MG TABLET 49879853_1 CDM 0250 RC 60505-3438-03 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges SELEGILINE HCL 5 MG TABLET 49879853_1 CDM 0250 RC 60505-3438-03 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 SELEGILINE HCL 5 MG TABLET 49879853_1 CDM 0250 RC 60505-3438-03 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 PROPRANOLOL ER 80 MG CAPSULE 49879855_1 CDM 0250 RC 62559-0531-01 NDC inpatient 1 UN 1.18 0.77 AETNA AETNA 0.93 79 999999999 0.71 1.14 percent of total billed charges PROPRANOLOL ER 80 MG CAPSULE 49879855_1 CDM 0250 RC 62559-0531-01 NDC inpatient 1 UN 1.18 0.77 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.77 65 999999999 0.71 1.14 percent of total billed charges PROPRANOLOL ER 80 MG CAPSULE 49879855_1 CDM 0250 RC 62559-0531-01 NDC inpatient 1 UN 1.18 0.77 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.14 97 999999999 0.71 1.14 percent of total billed charges PROPRANOLOL ER 80 MG CAPSULE 49879855_1 CDM 0250 RC 62559-0531-01 NDC inpatient 1 UN 1.18 0.77 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.81 69 999999999 0.71 1.14 percent of total billed charges PROPRANOLOL ER 80 MG CAPSULE 49879855_1 CDM 0250 RC 62559-0531-01 NDC inpatient 1 UN 1.18 0.77 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.92 78 999999999 0.71 1.14 percent of total billed charges PROPRANOLOL ER 80 MG CAPSULE 49879855_1 CDM 0250 RC 62559-0531-01 NDC inpatient 1 UN 1.18 0.77 SIHO - ALL PLANS SIHO - ALL PLANS 1.06 90 999999999 0.71 1.14 percent of total billed charges PROPRANOLOL ER 80 MG CAPSULE 49879855_1 CDM 0250 RC 62559-0531-01 NDC inpatient 1 UN 1.18 0.77 UMR - ALL PLANS UMR - ALL PLANS 0.83 70 999999999 0.71 1.14 percent of total billed charges PROPRANOLOL ER 80 MG CAPSULE 49879855_1 CDM 0250 RC 62559-0531-01 NDC inpatient 1 UN 1.18 0.77 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.71 60.55 999999999 0.71 1.14 percent of total billed charges PROPRANOLOL ER 80 MG CAPSULE 49879855_1 CDM 0250 RC 62559-0531-01 NDC inpatient 1 UN 1.18 0.77 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.71 1.14 PROPRANOLOL ER 80 MG CAPSULE 49879855_1 CDM 0250 RC 62559-0531-01 NDC inpatient 1 UN 1.18 0.77 ANTHEM HMO ANTHEM HMO 999999999 0.71 1.14 PROPRANOLOL ER 80 MG CAPSULE 49879855_1 CDM 0250 RC 62559-0531-01 NDC inpatient 1 UN 1.18 0.77 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.71 1.14 PROPRANOLOL ER 80 MG CAPSULE 49879855_1 CDM 0250 RC 62559-0531-01 NDC inpatient 1 UN 1.18 0.77 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.8 67.6 999999999 0.71 1.14 percent of total billed charges PROPRANOLOL ER 80 MG CAPSULE 49879855_1 CDM 0250 RC 62559-0531-01 NDC inpatient 1 UN 1.18 0.77 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.71 1.14 PROPRANOLOL ER 80 MG CAPSULE 49879855_1 CDM 0250 RC 62559-0531-01 NDC inpatient 1 UN 1.18 0.77 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.71 1.14 LISINOPRIL 2.5 MG TABLET 49879860_1 CDM 0250 RC 68001-0332-00 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LISINOPRIL 2.5 MG TABLET 49879860_1 CDM 0250 RC 68001-0332-00 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LISINOPRIL 2.5 MG TABLET 49879860_1 CDM 0250 RC 68001-0332-00 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LISINOPRIL 2.5 MG TABLET 49879860_1 CDM 0250 RC 68001-0332-00 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LISINOPRIL 2.5 MG TABLET 49879860_1 CDM 0250 RC 68001-0332-00 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LISINOPRIL 2.5 MG TABLET 49879860_1 CDM 0250 RC 68001-0332-00 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LISINOPRIL 2.5 MG TABLET 49879860_1 CDM 0250 RC 68001-0332-00 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LISINOPRIL 2.5 MG TABLET 49879860_1 CDM 0250 RC 68001-0332-00 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LISINOPRIL 2.5 MG TABLET 49879860_1 CDM 0250 RC 68001-0332-00 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LISINOPRIL 2.5 MG TABLET 49879860_1 CDM 0250 RC 68001-0332-00 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LISINOPRIL 2.5 MG TABLET 49879860_1 CDM 0250 RC 68001-0332-00 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LISINOPRIL 2.5 MG TABLET 49879860_1 CDM 0250 RC 68001-0332-00 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges LISINOPRIL 2.5 MG TABLET 49879860_1 CDM 0250 RC 68001-0332-00 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LISINOPRIL 2.5 MG TABLET 49879860_1 CDM 0250 RC 68001-0332-00 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ENTACAPONE 200 MG TABLET 49879875_1 CDM 0250 RC 00781-5578-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ENTACAPONE 200 MG TABLET 49879875_1 CDM 0250 RC 00781-5578-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ENTACAPONE 200 MG TABLET 49879875_1 CDM 0250 RC 00781-5578-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ENTACAPONE 200 MG TABLET 49879875_1 CDM 0250 RC 00781-5578-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ENTACAPONE 200 MG TABLET 49879875_1 CDM 0250 RC 00781-5578-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ENTACAPONE 200 MG TABLET 49879875_1 CDM 0250 RC 00781-5578-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ENTACAPONE 200 MG TABLET 49879875_1 CDM 0250 RC 00781-5578-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ENTACAPONE 200 MG TABLET 49879875_1 CDM 0250 RC 00781-5578-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ENTACAPONE 200 MG TABLET 49879875_1 CDM 0250 RC 00781-5578-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ENTACAPONE 200 MG TABLET 49879875_1 CDM 0250 RC 00781-5578-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ENTACAPONE 200 MG TABLET 49879875_1 CDM 0250 RC 00781-5578-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ENTACAPONE 200 MG TABLET 49879875_1 CDM 0250 RC 00781-5578-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges ENTACAPONE 200 MG TABLET 49879875_1 CDM 0250 RC 00781-5578-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ENTACAPONE 200 MG TABLET 49879875_1 CDM 0250 RC 00781-5578-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CELECOXIB 100 MG CAPSULE 49879876_1 CDM 0250 RC 62332-0141-31 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CELECOXIB 100 MG CAPSULE 49879876_1 CDM 0250 RC 62332-0141-31 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CELECOXIB 100 MG CAPSULE 49879876_1 CDM 0250 RC 62332-0141-31 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CELECOXIB 100 MG CAPSULE 49879876_1 CDM 0250 RC 62332-0141-31 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CELECOXIB 100 MG CAPSULE 49879876_1 CDM 0250 RC 62332-0141-31 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CELECOXIB 100 MG CAPSULE 49879876_1 CDM 0250 RC 62332-0141-31 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CELECOXIB 100 MG CAPSULE 49879876_1 CDM 0250 RC 62332-0141-31 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CELECOXIB 100 MG CAPSULE 49879876_1 CDM 0250 RC 62332-0141-31 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CELECOXIB 100 MG CAPSULE 49879876_1 CDM 0250 RC 62332-0141-31 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CELECOXIB 100 MG CAPSULE 49879876_1 CDM 0250 RC 62332-0141-31 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CELECOXIB 100 MG CAPSULE 49879876_1 CDM 0250 RC 62332-0141-31 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CELECOXIB 100 MG CAPSULE 49879876_1 CDM 0250 RC 62332-0141-31 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CELECOXIB 100 MG CAPSULE 49879876_1 CDM 0250 RC 62332-0141-31 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CELECOXIB 100 MG CAPSULE 49879876_1 CDM 0250 RC 62332-0141-31 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 DUTASTERIDE 0.5 MG CAPSULE 49879880_1 CDM 0250 RC 42806-0549-30 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges DUTASTERIDE 0.5 MG CAPSULE 49879880_1 CDM 0250 RC 42806-0549-30 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges DUTASTERIDE 0.5 MG CAPSULE 49879880_1 CDM 0250 RC 42806-0549-30 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges DUTASTERIDE 0.5 MG CAPSULE 49879880_1 CDM 0250 RC 42806-0549-30 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges DUTASTERIDE 0.5 MG CAPSULE 49879880_1 CDM 0250 RC 42806-0549-30 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges DUTASTERIDE 0.5 MG CAPSULE 49879880_1 CDM 0250 RC 42806-0549-30 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges DUTASTERIDE 0.5 MG CAPSULE 49879880_1 CDM 0250 RC 42806-0549-30 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges DUTASTERIDE 0.5 MG CAPSULE 49879880_1 CDM 0250 RC 42806-0549-30 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges DUTASTERIDE 0.5 MG CAPSULE 49879880_1 CDM 0250 RC 42806-0549-30 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 DUTASTERIDE 0.5 MG CAPSULE 49879880_1 CDM 0250 RC 42806-0549-30 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 DUTASTERIDE 0.5 MG CAPSULE 49879880_1 CDM 0250 RC 42806-0549-30 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 DUTASTERIDE 0.5 MG CAPSULE 49879880_1 CDM 0250 RC 42806-0549-30 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges DUTASTERIDE 0.5 MG CAPSULE 49879880_1 CDM 0250 RC 42806-0549-30 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 DUTASTERIDE 0.5 MG CAPSULE 49879880_1 CDM 0250 RC 42806-0549-30 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 49880069_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 AETNA AETNA 822.39 79 999999999 630.33 1009.77 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 49880069_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 676.65 65 999999999 630.33 1009.77 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 49880069_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1009.77 97 999999999 630.33 1009.77 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 49880069_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 718.29 69 999999999 630.33 1009.77 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 49880069_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 811.98 78 999999999 630.33 1009.77 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 49880069_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 SIHO - ALL PLANS SIHO - ALL PLANS 936.9 90 999999999 630.33 1009.77 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 49880069_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 UMR - ALL PLANS UMR - ALL PLANS 728.7 70 999999999 630.33 1009.77 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 49880069_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 630.33 60.55 999999999 630.33 1009.77 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 49880069_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 630.33 1009.77 "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 49880069_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 ANTHEM HMO ANTHEM HMO 999999999 630.33 1009.77 "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 49880069_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 630.33 1009.77 "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 49880069_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 703.72 67.6 999999999 630.33 1009.77 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 49880069_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 630.33 1009.77 "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 49880069_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 630.33 1009.77 "Gene analysis ((platelet-derived growth factor receptor, alpha polypeptide) targeted sequence" 49880074_1 CDM 0310 RC 81314 HCPCS inpatient 1041 676.65 AETNA AETNA 822.39 79 999999999 630.33 1009.77 percent of total billed charges "Gene analysis ((platelet-derived growth factor receptor, alpha polypeptide) targeted sequence" 49880074_1 CDM 0310 RC 81314 HCPCS inpatient 1041 676.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 676.65 65 999999999 630.33 1009.77 percent of total billed charges "Gene analysis ((platelet-derived growth factor receptor, alpha polypeptide) targeted sequence" 49880074_1 CDM 0310 RC 81314 HCPCS inpatient 1041 676.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1009.77 97 999999999 630.33 1009.77 percent of total billed charges "Gene analysis ((platelet-derived growth factor receptor, alpha polypeptide) targeted sequence" 49880074_1 CDM 0310 RC 81314 HCPCS inpatient 1041 676.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 718.29 69 999999999 630.33 1009.77 percent of total billed charges "Gene analysis ((platelet-derived growth factor receptor, alpha polypeptide) targeted sequence" 49880074_1 CDM 0310 RC 81314 HCPCS inpatient 1041 676.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 811.98 78 999999999 630.33 1009.77 percent of total billed charges "Gene analysis ((platelet-derived growth factor receptor, alpha polypeptide) targeted sequence" 49880074_1 CDM 0310 RC 81314 HCPCS inpatient 1041 676.65 SIHO - ALL PLANS SIHO - ALL PLANS 936.9 90 999999999 630.33 1009.77 percent of total billed charges "Gene analysis ((platelet-derived growth factor receptor, alpha polypeptide) targeted sequence" 49880074_1 CDM 0310 RC 81314 HCPCS inpatient 1041 676.65 UMR - ALL PLANS UMR - ALL PLANS 728.7 70 999999999 630.33 1009.77 percent of total billed charges "Gene analysis ((platelet-derived growth factor receptor, alpha polypeptide) targeted sequence" 49880074_1 CDM 0310 RC 81314 HCPCS inpatient 1041 676.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 630.33 60.55 999999999 630.33 1009.77 percent of total billed charges "Gene analysis ((platelet-derived growth factor receptor, alpha polypeptide) targeted sequence" 49880074_1 CDM 0310 RC 81314 HCPCS inpatient 1041 676.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 630.33 1009.77 "Gene analysis ((platelet-derived growth factor receptor, alpha polypeptide) targeted sequence" 49880074_1 CDM 0310 RC 81314 HCPCS inpatient 1041 676.65 ANTHEM HMO ANTHEM HMO 999999999 630.33 1009.77 "Gene analysis ((platelet-derived growth factor receptor, alpha polypeptide) targeted sequence" 49880074_1 CDM 0310 RC 81314 HCPCS inpatient 1041 676.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 630.33 1009.77 "Gene analysis ((platelet-derived growth factor receptor, alpha polypeptide) targeted sequence" 49880074_1 CDM 0310 RC 81314 HCPCS inpatient 1041 676.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 703.72 67.6 999999999 630.33 1009.77 percent of total billed charges "Gene analysis ((platelet-derived growth factor receptor, alpha polypeptide) targeted sequence" 49880074_1 CDM 0310 RC 81314 HCPCS inpatient 1041 676.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 630.33 1009.77 "Gene analysis ((platelet-derived growth factor receptor, alpha polypeptide) targeted sequence" 49880074_1 CDM 0310 RC 81314 HCPCS inpatient 1041 676.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 630.33 1009.77 "Preparation of specimen, manual" 49880075_1 CDM 0310 RC 88381 HCPCS inpatient 292 189.8 AETNA AETNA 230.68 79 999999999 176.81 283.24 percent of total billed charges "Preparation of specimen, manual" 49880075_1 CDM 0310 RC 88381 HCPCS inpatient 292 189.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 189.8 65 999999999 176.81 283.24 percent of total billed charges "Preparation of specimen, manual" 49880075_1 CDM 0310 RC 88381 HCPCS inpatient 292 189.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 283.24 97 999999999 176.81 283.24 percent of total billed charges "Preparation of specimen, manual" 49880075_1 CDM 0310 RC 88381 HCPCS inpatient 292 189.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 201.48 69 999999999 176.81 283.24 percent of total billed charges "Preparation of specimen, manual" 49880075_1 CDM 0310 RC 88381 HCPCS inpatient 292 189.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 227.76 78 999999999 176.81 283.24 percent of total billed charges "Preparation of specimen, manual" 49880075_1 CDM 0310 RC 88381 HCPCS inpatient 292 189.8 SIHO - ALL PLANS SIHO - ALL PLANS 262.8 90 999999999 176.81 283.24 percent of total billed charges "Preparation of specimen, manual" 49880075_1 CDM 0310 RC 88381 HCPCS inpatient 292 189.8 UMR - ALL PLANS UMR - ALL PLANS 204.4 70 999999999 176.81 283.24 percent of total billed charges "Preparation of specimen, manual" 49880075_1 CDM 0310 RC 88381 HCPCS inpatient 292 189.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 176.81 60.55 999999999 176.81 283.24 percent of total billed charges "Preparation of specimen, manual" 49880075_1 CDM 0310 RC 88381 HCPCS inpatient 292 189.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 176.81 283.24 "Preparation of specimen, manual" 49880075_1 CDM 0310 RC 88381 HCPCS inpatient 292 189.8 ANTHEM HMO ANTHEM HMO 999999999 176.81 283.24 "Preparation of specimen, manual" 49880075_1 CDM 0310 RC 88381 HCPCS inpatient 292 189.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 176.81 283.24 "Preparation of specimen, manual" 49880075_1 CDM 0310 RC 88381 HCPCS inpatient 292 189.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 197.39 67.6 999999999 176.81 283.24 percent of total billed charges "Preparation of specimen, manual" 49880075_1 CDM 0310 RC 88381 HCPCS inpatient 292 189.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 176.81 283.24 "Preparation of specimen, manual" 49880075_1 CDM 0310 RC 88381 HCPCS inpatient 292 189.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 176.81 283.24 SODIUM CHLORIDE 0.9% VIAL 49880455_1 CDM 0250 RC 00409-4888-10 NDC inpatient 1 UN 17.59 11.43 AETNA AETNA 13.9 79 999999999 10.65 17.06 percent of total billed charges SODIUM CHLORIDE 0.9% VIAL 49880455_1 CDM 0250 RC 00409-4888-10 NDC inpatient 1 UN 17.59 11.43 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.43 65 999999999 10.65 17.06 percent of total billed charges SODIUM CHLORIDE 0.9% VIAL 49880455_1 CDM 0250 RC 00409-4888-10 NDC inpatient 1 UN 17.59 11.43 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.06 97 999999999 10.65 17.06 percent of total billed charges SODIUM CHLORIDE 0.9% VIAL 49880455_1 CDM 0250 RC 00409-4888-10 NDC inpatient 1 UN 17.59 11.43 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.14 69 999999999 10.65 17.06 percent of total billed charges SODIUM CHLORIDE 0.9% VIAL 49880455_1 CDM 0250 RC 00409-4888-10 NDC inpatient 1 UN 17.59 11.43 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.72 78 999999999 10.65 17.06 percent of total billed charges SODIUM CHLORIDE 0.9% VIAL 49880455_1 CDM 0250 RC 00409-4888-10 NDC inpatient 1 UN 17.59 11.43 SIHO - ALL PLANS SIHO - ALL PLANS 15.83 90 999999999 10.65 17.06 percent of total billed charges SODIUM CHLORIDE 0.9% VIAL 49880455_1 CDM 0250 RC 00409-4888-10 NDC inpatient 1 UN 17.59 11.43 UMR - ALL PLANS UMR - ALL PLANS 12.31 70 999999999 10.65 17.06 percent of total billed charges SODIUM CHLORIDE 0.9% VIAL 49880455_1 CDM 0250 RC 00409-4888-10 NDC inpatient 1 UN 17.59 11.43 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.65 60.55 999999999 10.65 17.06 percent of total billed charges SODIUM CHLORIDE 0.9% VIAL 49880455_1 CDM 0250 RC 00409-4888-10 NDC inpatient 1 UN 17.59 11.43 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.65 17.06 SODIUM CHLORIDE 0.9% VIAL 49880455_1 CDM 0250 RC 00409-4888-10 NDC inpatient 1 UN 17.59 11.43 ANTHEM HMO ANTHEM HMO 999999999 10.65 17.06 SODIUM CHLORIDE 0.9% VIAL 49880455_1 CDM 0250 RC 00409-4888-10 NDC inpatient 1 UN 17.59 11.43 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.65 17.06 SODIUM CHLORIDE 0.9% VIAL 49880455_1 CDM 0250 RC 00409-4888-10 NDC inpatient 1 UN 17.59 11.43 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.89 67.6 999999999 10.65 17.06 percent of total billed charges SODIUM CHLORIDE 0.9% VIAL 49880455_1 CDM 0250 RC 00409-4888-10 NDC inpatient 1 UN 17.59 11.43 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.65 17.06 SODIUM CHLORIDE 0.9% VIAL 49880455_1 CDM 0250 RC 00409-4888-10 NDC inpatient 1 UN 17.59 11.43 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.65 17.06 Selenium (vitamin) level 49883914_1 CDM 0301 RC 84255 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges Selenium (vitamin) level 49883914_1 CDM 0301 RC 84255 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges Selenium (vitamin) level 49883914_1 CDM 0301 RC 84255 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges Selenium (vitamin) level 49883914_1 CDM 0301 RC 84255 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges Selenium (vitamin) level 49883914_1 CDM 0301 RC 84255 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges Selenium (vitamin) level 49883914_1 CDM 0301 RC 84255 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges Selenium (vitamin) level 49883914_1 CDM 0301 RC 84255 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges Selenium (vitamin) level 49883914_1 CDM 0301 RC 84255 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges Selenium (vitamin) level 49883914_1 CDM 0301 RC 84255 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 Selenium (vitamin) level 49883914_1 CDM 0301 RC 84255 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 Selenium (vitamin) level 49883914_1 CDM 0301 RC 84255 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 Selenium (vitamin) level 49883914_1 CDM 0301 RC 84255 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges Selenium (vitamin) level 49883914_1 CDM 0301 RC 84255 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 Selenium (vitamin) level 49883914_1 CDM 0301 RC 84255 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 FENTANYL 75 MCG/HR PATCH 49883935_1 CDM 0250 RC 00406-9075-76 NDC inpatient 1 UN 20.56 13.36 AETNA AETNA 16.24 79 999999999 12.45 19.94 percent of total billed charges FENTANYL 75 MCG/HR PATCH 49883935_1 CDM 0250 RC 00406-9075-76 NDC inpatient 1 UN 20.56 13.36 SELF PAY DISCOUNT SELF PAY DISCOUNT 13.36 65 999999999 12.45 19.94 percent of total billed charges FENTANYL 75 MCG/HR PATCH 49883935_1 CDM 0250 RC 00406-9075-76 NDC inpatient 1 UN 20.56 13.36 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.94 97 999999999 12.45 19.94 percent of total billed charges FENTANYL 75 MCG/HR PATCH 49883935_1 CDM 0250 RC 00406-9075-76 NDC inpatient 1 UN 20.56 13.36 ENCORE - ALL PLANS ENCORE - ALL PLANS 14.19 69 999999999 12.45 19.94 percent of total billed charges FENTANYL 75 MCG/HR PATCH 49883935_1 CDM 0250 RC 00406-9075-76 NDC inpatient 1 UN 20.56 13.36 HUMANA - ALL PLANS HUMANA - ALL PLANS 16.04 78 999999999 12.45 19.94 percent of total billed charges FENTANYL 75 MCG/HR PATCH 49883935_1 CDM 0250 RC 00406-9075-76 NDC inpatient 1 UN 20.56 13.36 SIHO - ALL PLANS SIHO - ALL PLANS 18.5 90 999999999 12.45 19.94 percent of total billed charges FENTANYL 75 MCG/HR PATCH 49883935_1 CDM 0250 RC 00406-9075-76 NDC inpatient 1 UN 20.56 13.36 UMR - ALL PLANS UMR - ALL PLANS 14.39 70 999999999 12.45 19.94 percent of total billed charges FENTANYL 75 MCG/HR PATCH 49883935_1 CDM 0250 RC 00406-9075-76 NDC inpatient 1 UN 20.56 13.36 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.45 60.55 999999999 12.45 19.94 percent of total billed charges FENTANYL 75 MCG/HR PATCH 49883935_1 CDM 0250 RC 00406-9075-76 NDC inpatient 1 UN 20.56 13.36 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.45 19.94 FENTANYL 75 MCG/HR PATCH 49883935_1 CDM 0250 RC 00406-9075-76 NDC inpatient 1 UN 20.56 13.36 ANTHEM HMO ANTHEM HMO 999999999 12.45 19.94 FENTANYL 75 MCG/HR PATCH 49883935_1 CDM 0250 RC 00406-9075-76 NDC inpatient 1 UN 20.56 13.36 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.45 19.94 FENTANYL 75 MCG/HR PATCH 49883935_1 CDM 0250 RC 00406-9075-76 NDC inpatient 1 UN 20.56 13.36 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.9 67.6 999999999 12.45 19.94 percent of total billed charges FENTANYL 75 MCG/HR PATCH 49883935_1 CDM 0250 RC 00406-9075-76 NDC inpatient 1 UN 20.56 13.36 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.45 19.94 FENTANYL 75 MCG/HR PATCH 49883935_1 CDM 0250 RC 00406-9075-76 NDC inpatient 1 UN 20.56 13.36 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.45 19.94 CIPROFLOXACIN 200 MG/100ML-D5W 49902220_1 CDM 0250 RC 36000-0008-24 NDC inpatient 1 UN 56.64 36.82 AETNA AETNA 44.75 79 999999999 34.3 54.94 percent of total billed charges CIPROFLOXACIN 200 MG/100ML-D5W 49902220_1 CDM 0250 RC 36000-0008-24 NDC inpatient 1 UN 56.64 36.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 36.82 65 999999999 34.3 54.94 percent of total billed charges CIPROFLOXACIN 200 MG/100ML-D5W 49902220_1 CDM 0250 RC 36000-0008-24 NDC inpatient 1 UN 56.64 36.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 54.94 97 999999999 34.3 54.94 percent of total billed charges CIPROFLOXACIN 200 MG/100ML-D5W 49902220_1 CDM 0250 RC 36000-0008-24 NDC inpatient 1 UN 56.64 36.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.08 69 999999999 34.3 54.94 percent of total billed charges CIPROFLOXACIN 200 MG/100ML-D5W 49902220_1 CDM 0250 RC 36000-0008-24 NDC inpatient 1 UN 56.64 36.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.18 78 999999999 34.3 54.94 percent of total billed charges CIPROFLOXACIN 200 MG/100ML-D5W 49902220_1 CDM 0250 RC 36000-0008-24 NDC inpatient 1 UN 56.64 36.82 SIHO - ALL PLANS SIHO - ALL PLANS 50.98 90 999999999 34.3 54.94 percent of total billed charges CIPROFLOXACIN 200 MG/100ML-D5W 49902220_1 CDM 0250 RC 36000-0008-24 NDC inpatient 1 UN 56.64 36.82 UMR - ALL PLANS UMR - ALL PLANS 39.65 70 999999999 34.3 54.94 percent of total billed charges CIPROFLOXACIN 200 MG/100ML-D5W 49902220_1 CDM 0250 RC 36000-0008-24 NDC inpatient 1 UN 56.64 36.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.3 60.55 999999999 34.3 54.94 percent of total billed charges CIPROFLOXACIN 200 MG/100ML-D5W 49902220_1 CDM 0250 RC 36000-0008-24 NDC inpatient 1 UN 56.64 36.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.3 54.94 CIPROFLOXACIN 200 MG/100ML-D5W 49902220_1 CDM 0250 RC 36000-0008-24 NDC inpatient 1 UN 56.64 36.82 ANTHEM HMO ANTHEM HMO 999999999 34.3 54.94 CIPROFLOXACIN 200 MG/100ML-D5W 49902220_1 CDM 0250 RC 36000-0008-24 NDC inpatient 1 UN 56.64 36.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.3 54.94 CIPROFLOXACIN 200 MG/100ML-D5W 49902220_1 CDM 0250 RC 36000-0008-24 NDC inpatient 1 UN 56.64 36.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.29 67.6 999999999 34.3 54.94 percent of total billed charges CIPROFLOXACIN 200 MG/100ML-D5W 49902220_1 CDM 0250 RC 36000-0008-24 NDC inpatient 1 UN 56.64 36.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.3 54.94 CIPROFLOXACIN 200 MG/100ML-D5W 49902220_1 CDM 0250 RC 36000-0008-24 NDC inpatient 1 UN 56.64 36.82 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.3 54.94 DILTIAZEM 125 MG/25 ML VIAL 49902355_1 CDM 0250 RC 00641-6015-10 NDC inpatient 1 UN 30.66 19.93 AETNA AETNA 24.22 79 999999999 18.56 29.74 percent of total billed charges DILTIAZEM 125 MG/25 ML VIAL 49902355_1 CDM 0250 RC 00641-6015-10 NDC inpatient 1 UN 30.66 19.93 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.93 65 999999999 18.56 29.74 percent of total billed charges DILTIAZEM 125 MG/25 ML VIAL 49902355_1 CDM 0250 RC 00641-6015-10 NDC inpatient 1 UN 30.66 19.93 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.74 97 999999999 18.56 29.74 percent of total billed charges DILTIAZEM 125 MG/25 ML VIAL 49902355_1 CDM 0250 RC 00641-6015-10 NDC inpatient 1 UN 30.66 19.93 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.16 69 999999999 18.56 29.74 percent of total billed charges DILTIAZEM 125 MG/25 ML VIAL 49902355_1 CDM 0250 RC 00641-6015-10 NDC inpatient 1 UN 30.66 19.93 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.91 78 999999999 18.56 29.74 percent of total billed charges DILTIAZEM 125 MG/25 ML VIAL 49902355_1 CDM 0250 RC 00641-6015-10 NDC inpatient 1 UN 30.66 19.93 SIHO - ALL PLANS SIHO - ALL PLANS 27.59 90 999999999 18.56 29.74 percent of total billed charges DILTIAZEM 125 MG/25 ML VIAL 49902355_1 CDM 0250 RC 00641-6015-10 NDC inpatient 1 UN 30.66 19.93 UMR - ALL PLANS UMR - ALL PLANS 21.46 70 999999999 18.56 29.74 percent of total billed charges DILTIAZEM 125 MG/25 ML VIAL 49902355_1 CDM 0250 RC 00641-6015-10 NDC inpatient 1 UN 30.66 19.93 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.56 60.55 999999999 18.56 29.74 percent of total billed charges DILTIAZEM 125 MG/25 ML VIAL 49902355_1 CDM 0250 RC 00641-6015-10 NDC inpatient 1 UN 30.66 19.93 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.56 29.74 DILTIAZEM 125 MG/25 ML VIAL 49902355_1 CDM 0250 RC 00641-6015-10 NDC inpatient 1 UN 30.66 19.93 ANTHEM HMO ANTHEM HMO 999999999 18.56 29.74 DILTIAZEM 125 MG/25 ML VIAL 49902355_1 CDM 0250 RC 00641-6015-10 NDC inpatient 1 UN 30.66 19.93 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.56 29.74 DILTIAZEM 125 MG/25 ML VIAL 49902355_1 CDM 0250 RC 00641-6015-10 NDC inpatient 1 UN 30.66 19.93 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.73 67.6 999999999 18.56 29.74 percent of total billed charges DILTIAZEM 125 MG/25 ML VIAL 49902355_1 CDM 0250 RC 00641-6015-10 NDC inpatient 1 UN 30.66 19.93 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.56 29.74 DILTIAZEM 125 MG/25 ML VIAL 49902355_1 CDM 0250 RC 00641-6015-10 NDC inpatient 1 UN 30.66 19.93 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.56 29.74 DILTIAZEM 25 MG/5 ML VIAL 49902799_1 CDM 0250 RC 00641-6013-10 NDC inpatient 1 UN 15.75 10.24 AETNA AETNA 12.44 79 999999999 9.54 15.28 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 49902799_1 CDM 0250 RC 00641-6013-10 NDC inpatient 1 UN 15.75 10.24 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.24 65 999999999 9.54 15.28 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 49902799_1 CDM 0250 RC 00641-6013-10 NDC inpatient 1 UN 15.75 10.24 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15.28 97 999999999 9.54 15.28 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 49902799_1 CDM 0250 RC 00641-6013-10 NDC inpatient 1 UN 15.75 10.24 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.87 69 999999999 9.54 15.28 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 49902799_1 CDM 0250 RC 00641-6013-10 NDC inpatient 1 UN 15.75 10.24 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.29 78 999999999 9.54 15.28 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 49902799_1 CDM 0250 RC 00641-6013-10 NDC inpatient 1 UN 15.75 10.24 SIHO - ALL PLANS SIHO - ALL PLANS 14.18 90 999999999 9.54 15.28 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 49902799_1 CDM 0250 RC 00641-6013-10 NDC inpatient 1 UN 15.75 10.24 UMR - ALL PLANS UMR - ALL PLANS 11.03 70 999999999 9.54 15.28 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 49902799_1 CDM 0250 RC 00641-6013-10 NDC inpatient 1 UN 15.75 10.24 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.54 60.55 999999999 9.54 15.28 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 49902799_1 CDM 0250 RC 00641-6013-10 NDC inpatient 1 UN 15.75 10.24 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.54 15.28 DILTIAZEM 25 MG/5 ML VIAL 49902799_1 CDM 0250 RC 00641-6013-10 NDC inpatient 1 UN 15.75 10.24 ANTHEM HMO ANTHEM HMO 999999999 9.54 15.28 DILTIAZEM 25 MG/5 ML VIAL 49902799_1 CDM 0250 RC 00641-6013-10 NDC inpatient 1 UN 15.75 10.24 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.54 15.28 DILTIAZEM 25 MG/5 ML VIAL 49902799_1 CDM 0250 RC 00641-6013-10 NDC inpatient 1 UN 15.75 10.24 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.65 67.6 999999999 9.54 15.28 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 49902799_1 CDM 0250 RC 00641-6013-10 NDC inpatient 1 UN 15.75 10.24 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.54 15.28 DILTIAZEM 25 MG/5 ML VIAL 49902799_1 CDM 0250 RC 00641-6013-10 NDC inpatient 1 UN 15.75 10.24 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.54 15.28 Measurement of proteins associated with prostate cancer 49902818_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 AETNA AETNA 1613.97 79 999999999 1237.04 1981.71 percent of total billed charges Measurement of proteins associated with prostate cancer 49902818_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1327.95 65 999999999 1237.04 1981.71 percent of total billed charges Measurement of proteins associated with prostate cancer 49902818_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1981.71 97 999999999 1237.04 1981.71 percent of total billed charges Measurement of proteins associated with prostate cancer 49902818_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1409.67 69 999999999 1237.04 1981.71 percent of total billed charges Measurement of proteins associated with prostate cancer 49902818_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1593.54 78 999999999 1237.04 1981.71 percent of total billed charges Measurement of proteins associated with prostate cancer 49902818_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 SIHO - ALL PLANS SIHO - ALL PLANS 1838.7 90 999999999 1237.04 1981.71 percent of total billed charges Measurement of proteins associated with prostate cancer 49902818_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 UMR - ALL PLANS UMR - ALL PLANS 1430.1 70 999999999 1237.04 1981.71 percent of total billed charges Measurement of proteins associated with prostate cancer 49902818_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1237.04 60.55 999999999 1237.04 1981.71 percent of total billed charges Measurement of proteins associated with prostate cancer 49902818_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1237.04 1981.71 Measurement of proteins associated with prostate cancer 49902818_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 ANTHEM HMO ANTHEM HMO 999999999 1237.04 1981.71 Measurement of proteins associated with prostate cancer 49902818_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1237.04 1981.71 Measurement of proteins associated with prostate cancer 49902818_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1381.07 67.6 999999999 1237.04 1981.71 percent of total billed charges Measurement of proteins associated with prostate cancer 49902818_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1237.04 1981.71 Measurement of proteins associated with prostate cancer 49902818_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1237.04 1981.71 TOPIRAMATE 100 MG TABLET 49907267_1 CDM 0250 RC 69097-0124-03 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges TOPIRAMATE 100 MG TABLET 49907267_1 CDM 0250 RC 69097-0124-03 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges TOPIRAMATE 100 MG TABLET 49907267_1 CDM 0250 RC 69097-0124-03 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges TOPIRAMATE 100 MG TABLET 49907267_1 CDM 0250 RC 69097-0124-03 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges TOPIRAMATE 100 MG TABLET 49907267_1 CDM 0250 RC 69097-0124-03 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges TOPIRAMATE 100 MG TABLET 49907267_1 CDM 0250 RC 69097-0124-03 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges TOPIRAMATE 100 MG TABLET 49907267_1 CDM 0250 RC 69097-0124-03 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges TOPIRAMATE 100 MG TABLET 49907267_1 CDM 0250 RC 69097-0124-03 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges TOPIRAMATE 100 MG TABLET 49907267_1 CDM 0250 RC 69097-0124-03 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 TOPIRAMATE 100 MG TABLET 49907267_1 CDM 0250 RC 69097-0124-03 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 TOPIRAMATE 100 MG TABLET 49907267_1 CDM 0250 RC 69097-0124-03 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 TOPIRAMATE 100 MG TABLET 49907267_1 CDM 0250 RC 69097-0124-03 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges TOPIRAMATE 100 MG TABLET 49907267_1 CDM 0250 RC 69097-0124-03 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 TOPIRAMATE 100 MG TABLET 49907267_1 CDM 0250 RC 69097-0124-03 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 Cholinesterase (enzyme) level 49909451_1 CDM 0301 RC 82482 HCPCS inpatient 194 126.1 AETNA AETNA 153.26 79 999999999 117.47 188.18 percent of total billed charges Cholinesterase (enzyme) level 49909451_1 CDM 0301 RC 82482 HCPCS inpatient 194 126.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 126.1 65 999999999 117.47 188.18 percent of total billed charges Cholinesterase (enzyme) level 49909451_1 CDM 0301 RC 82482 HCPCS inpatient 194 126.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 188.18 97 999999999 117.47 188.18 percent of total billed charges Cholinesterase (enzyme) level 49909451_1 CDM 0301 RC 82482 HCPCS inpatient 194 126.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.86 69 999999999 117.47 188.18 percent of total billed charges Cholinesterase (enzyme) level 49909451_1 CDM 0301 RC 82482 HCPCS inpatient 194 126.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 151.32 78 999999999 117.47 188.18 percent of total billed charges Cholinesterase (enzyme) level 49909451_1 CDM 0301 RC 82482 HCPCS inpatient 194 126.1 SIHO - ALL PLANS SIHO - ALL PLANS 174.6 90 999999999 117.47 188.18 percent of total billed charges Cholinesterase (enzyme) level 49909451_1 CDM 0301 RC 82482 HCPCS inpatient 194 126.1 UMR - ALL PLANS UMR - ALL PLANS 135.8 70 999999999 117.47 188.18 percent of total billed charges Cholinesterase (enzyme) level 49909451_1 CDM 0301 RC 82482 HCPCS inpatient 194 126.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 117.47 60.55 999999999 117.47 188.18 percent of total billed charges Cholinesterase (enzyme) level 49909451_1 CDM 0301 RC 82482 HCPCS inpatient 194 126.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 117.47 188.18 Cholinesterase (enzyme) level 49909451_1 CDM 0301 RC 82482 HCPCS inpatient 194 126.1 ANTHEM HMO ANTHEM HMO 999999999 117.47 188.18 Cholinesterase (enzyme) level 49909451_1 CDM 0301 RC 82482 HCPCS inpatient 194 126.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 117.47 188.18 Cholinesterase (enzyme) level 49909451_1 CDM 0301 RC 82482 HCPCS inpatient 194 126.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 131.14 67.6 999999999 117.47 188.18 percent of total billed charges Cholinesterase (enzyme) level 49909451_1 CDM 0301 RC 82482 HCPCS inpatient 194 126.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 117.47 188.18 Cholinesterase (enzyme) level 49909451_1 CDM 0301 RC 82482 HCPCS inpatient 194 126.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 117.47 188.18 Insertion of temporary bladder tube 49910151_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 AETNA AETNA 188.02 79 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 49910151_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.7 65 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 49910151_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 230.86 97 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 49910151_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.22 69 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 49910151_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 185.64 78 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 49910151_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 SIHO - ALL PLANS SIHO - ALL PLANS 214.2 90 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 49910151_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 UMR - ALL PLANS UMR - ALL PLANS 166.6 70 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 49910151_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.11 60.55 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 49910151_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.11 230.86 Insertion of temporary bladder tube 49910151_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 ANTHEM HMO ANTHEM HMO 999999999 144.11 230.86 Insertion of temporary bladder tube 49910151_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.11 230.86 Insertion of temporary bladder tube 49910151_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.89 67.6 999999999 144.11 230.86 percent of total billed charges Insertion of temporary bladder tube 49910151_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.11 230.86 Insertion of temporary bladder tube 49910151_1 CDM 0272 RC 51701 HCPCS inpatient 238 154.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.11 230.86 CALCITONIN-SALMON 200 UNIT SPR 49911526_1 CDM 0250 RC 60505-0823-06 NDC inpatient 1 UN 256.72 166.87 AETNA AETNA 202.81 79 999999999 155.44 249.02 percent of total billed charges CALCITONIN-SALMON 200 UNIT SPR 49911526_1 CDM 0250 RC 60505-0823-06 NDC inpatient 1 UN 256.72 166.87 SELF PAY DISCOUNT SELF PAY DISCOUNT 166.87 65 999999999 155.44 249.02 percent of total billed charges CALCITONIN-SALMON 200 UNIT SPR 49911526_1 CDM 0250 RC 60505-0823-06 NDC inpatient 1 UN 256.72 166.87 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 249.02 97 999999999 155.44 249.02 percent of total billed charges CALCITONIN-SALMON 200 UNIT SPR 49911526_1 CDM 0250 RC 60505-0823-06 NDC inpatient 1 UN 256.72 166.87 ENCORE - ALL PLANS ENCORE - ALL PLANS 177.14 69 999999999 155.44 249.02 percent of total billed charges CALCITONIN-SALMON 200 UNIT SPR 49911526_1 CDM 0250 RC 60505-0823-06 NDC inpatient 1 UN 256.72 166.87 HUMANA - ALL PLANS HUMANA - ALL PLANS 200.24 78 999999999 155.44 249.02 percent of total billed charges CALCITONIN-SALMON 200 UNIT SPR 49911526_1 CDM 0250 RC 60505-0823-06 NDC inpatient 1 UN 256.72 166.87 SIHO - ALL PLANS SIHO - ALL PLANS 231.05 90 999999999 155.44 249.02 percent of total billed charges CALCITONIN-SALMON 200 UNIT SPR 49911526_1 CDM 0250 RC 60505-0823-06 NDC inpatient 1 UN 256.72 166.87 UMR - ALL PLANS UMR - ALL PLANS 179.7 70 999999999 155.44 249.02 percent of total billed charges CALCITONIN-SALMON 200 UNIT SPR 49911526_1 CDM 0250 RC 60505-0823-06 NDC inpatient 1 UN 256.72 166.87 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.44 60.55 999999999 155.44 249.02 percent of total billed charges CALCITONIN-SALMON 200 UNIT SPR 49911526_1 CDM 0250 RC 60505-0823-06 NDC inpatient 1 UN 256.72 166.87 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.44 249.02 CALCITONIN-SALMON 200 UNIT SPR 49911526_1 CDM 0250 RC 60505-0823-06 NDC inpatient 1 UN 256.72 166.87 ANTHEM HMO ANTHEM HMO 999999999 155.44 249.02 CALCITONIN-SALMON 200 UNIT SPR 49911526_1 CDM 0250 RC 60505-0823-06 NDC inpatient 1 UN 256.72 166.87 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.44 249.02 CALCITONIN-SALMON 200 UNIT SPR 49911526_1 CDM 0250 RC 60505-0823-06 NDC inpatient 1 UN 256.72 166.87 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.54 67.6 999999999 155.44 249.02 percent of total billed charges CALCITONIN-SALMON 200 UNIT SPR 49911526_1 CDM 0250 RC 60505-0823-06 NDC inpatient 1 UN 256.72 166.87 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.44 249.02 CALCITONIN-SALMON 200 UNIT SPR 49911526_1 CDM 0250 RC 60505-0823-06 NDC inpatient 1 UN 256.72 166.87 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.44 249.02 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 49912591_1 CDM 0301 RC 86665 HCPCS inpatient 177 115.05 AETNA AETNA 139.83 79 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 49912591_1 CDM 0301 RC 86665 HCPCS inpatient 177 115.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.05 65 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 49912591_1 CDM 0301 RC 86665 HCPCS inpatient 177 115.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 171.69 97 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 49912591_1 CDM 0301 RC 86665 HCPCS inpatient 177 115.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.13 69 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 49912591_1 CDM 0301 RC 86665 HCPCS inpatient 177 115.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.06 78 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 49912591_1 CDM 0301 RC 86665 HCPCS inpatient 177 115.05 SIHO - ALL PLANS SIHO - ALL PLANS 159.3 90 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 49912591_1 CDM 0301 RC 86665 HCPCS inpatient 177 115.05 UMR - ALL PLANS UMR - ALL PLANS 123.9 70 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 49912591_1 CDM 0301 RC 86665 HCPCS inpatient 177 115.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.17 60.55 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 49912591_1 CDM 0301 RC 86665 HCPCS inpatient 177 115.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 49912591_1 CDM 0301 RC 86665 HCPCS inpatient 177 115.05 ANTHEM HMO ANTHEM HMO 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 49912591_1 CDM 0301 RC 86665 HCPCS inpatient 177 115.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 49912591_1 CDM 0301 RC 86665 HCPCS inpatient 177 115.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 119.65 67.6 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 49912591_1 CDM 0301 RC 86665 HCPCS inpatient 177 115.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), viral capsid" 49912591_1 CDM 0301 RC 86665 HCPCS inpatient 177 115.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 49912592_1 CDM 0301 RC 86664 HCPCS inpatient 156 101.4 AETNA AETNA 123.24 79 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 49912592_1 CDM 0301 RC 86664 HCPCS inpatient 156 101.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.4 65 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 49912592_1 CDM 0301 RC 86664 HCPCS inpatient 156 101.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 151.32 97 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 49912592_1 CDM 0301 RC 86664 HCPCS inpatient 156 101.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.64 69 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 49912592_1 CDM 0301 RC 86664 HCPCS inpatient 156 101.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.68 78 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 49912592_1 CDM 0301 RC 86664 HCPCS inpatient 156 101.4 SIHO - ALL PLANS SIHO - ALL PLANS 140.4 90 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 49912592_1 CDM 0301 RC 86664 HCPCS inpatient 156 101.4 UMR - ALL PLANS UMR - ALL PLANS 109.2 70 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 49912592_1 CDM 0301 RC 86664 HCPCS inpatient 156 101.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.46 60.55 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 49912592_1 CDM 0301 RC 86664 HCPCS inpatient 156 101.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 49912592_1 CDM 0301 RC 86664 HCPCS inpatient 156 101.4 ANTHEM HMO ANTHEM HMO 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 49912592_1 CDM 0301 RC 86664 HCPCS inpatient 156 101.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 49912592_1 CDM 0301 RC 86664 HCPCS inpatient 156 101.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.46 67.6 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 49912592_1 CDM 0301 RC 86664 HCPCS inpatient 156 101.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), nuclear antigen" 49912592_1 CDM 0301 RC 86664 HCPCS inpatient 156 101.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.46 151.32 AMLODIPINE BESYLATE 5 MG TAB 49912755_1 CDM 0250 RC 00904-6370-61 NDC inpatient 1 UN 1.42 0.92 AETNA AETNA 1.12 79 999999999 0.86 1.38 percent of total billed charges AMLODIPINE BESYLATE 5 MG TAB 49912755_1 CDM 0250 RC 00904-6370-61 NDC inpatient 1 UN 1.42 0.92 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.92 65 999999999 0.86 1.38 percent of total billed charges AMLODIPINE BESYLATE 5 MG TAB 49912755_1 CDM 0250 RC 00904-6370-61 NDC inpatient 1 UN 1.42 0.92 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.38 97 999999999 0.86 1.38 percent of total billed charges AMLODIPINE BESYLATE 5 MG TAB 49912755_1 CDM 0250 RC 00904-6370-61 NDC inpatient 1 UN 1.42 0.92 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.98 69 999999999 0.86 1.38 percent of total billed charges AMLODIPINE BESYLATE 5 MG TAB 49912755_1 CDM 0250 RC 00904-6370-61 NDC inpatient 1 UN 1.42 0.92 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.11 78 999999999 0.86 1.38 percent of total billed charges AMLODIPINE BESYLATE 5 MG TAB 49912755_1 CDM 0250 RC 00904-6370-61 NDC inpatient 1 UN 1.42 0.92 SIHO - ALL PLANS SIHO - ALL PLANS 1.28 90 999999999 0.86 1.38 percent of total billed charges AMLODIPINE BESYLATE 5 MG TAB 49912755_1 CDM 0250 RC 00904-6370-61 NDC inpatient 1 UN 1.42 0.92 UMR - ALL PLANS UMR - ALL PLANS 0.99 70 999999999 0.86 1.38 percent of total billed charges AMLODIPINE BESYLATE 5 MG TAB 49912755_1 CDM 0250 RC 00904-6370-61 NDC inpatient 1 UN 1.42 0.92 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.86 60.55 999999999 0.86 1.38 percent of total billed charges AMLODIPINE BESYLATE 5 MG TAB 49912755_1 CDM 0250 RC 00904-6370-61 NDC inpatient 1 UN 1.42 0.92 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.86 1.38 AMLODIPINE BESYLATE 5 MG TAB 49912755_1 CDM 0250 RC 00904-6370-61 NDC inpatient 1 UN 1.42 0.92 ANTHEM HMO ANTHEM HMO 999999999 0.86 1.38 AMLODIPINE BESYLATE 5 MG TAB 49912755_1 CDM 0250 RC 00904-6370-61 NDC inpatient 1 UN 1.42 0.92 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.86 1.38 AMLODIPINE BESYLATE 5 MG TAB 49912755_1 CDM 0250 RC 00904-6370-61 NDC inpatient 1 UN 1.42 0.92 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.96 67.6 999999999 0.86 1.38 percent of total billed charges AMLODIPINE BESYLATE 5 MG TAB 49912755_1 CDM 0250 RC 00904-6370-61 NDC inpatient 1 UN 1.42 0.92 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.86 1.38 AMLODIPINE BESYLATE 5 MG TAB 49912755_1 CDM 0250 RC 00904-6370-61 NDC inpatient 1 UN 1.42 0.92 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.86 1.38 Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 49912950_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 49912950_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 49912950_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 49912950_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 49912950_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 49912950_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 49912950_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 49912950_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 49912950_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 49912950_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 49912950_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 49912950_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 49912950_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 49912950_1 CDM 0302 RC 87389 HCPCS inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 MONTELUKAST SOD 10 MG TABLET 49915561_1 CDM 0250 RC 68084-0875-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges MONTELUKAST SOD 10 MG TABLET 49915561_1 CDM 0250 RC 68084-0875-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges MONTELUKAST SOD 10 MG TABLET 49915561_1 CDM 0250 RC 68084-0875-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges MONTELUKAST SOD 10 MG TABLET 49915561_1 CDM 0250 RC 68084-0875-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges MONTELUKAST SOD 10 MG TABLET 49915561_1 CDM 0250 RC 68084-0875-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges MONTELUKAST SOD 10 MG TABLET 49915561_1 CDM 0250 RC 68084-0875-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges MONTELUKAST SOD 10 MG TABLET 49915561_1 CDM 0250 RC 68084-0875-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges MONTELUKAST SOD 10 MG TABLET 49915561_1 CDM 0250 RC 68084-0875-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges MONTELUKAST SOD 10 MG TABLET 49915561_1 CDM 0250 RC 68084-0875-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 MONTELUKAST SOD 10 MG TABLET 49915561_1 CDM 0250 RC 68084-0875-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 MONTELUKAST SOD 10 MG TABLET 49915561_1 CDM 0250 RC 68084-0875-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 MONTELUKAST SOD 10 MG TABLET 49915561_1 CDM 0250 RC 68084-0875-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges MONTELUKAST SOD 10 MG TABLET 49915561_1 CDM 0250 RC 68084-0875-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 MONTELUKAST SOD 10 MG TABLET 49915561_1 CDM 0250 RC 68084-0875-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 49925103_1 CDM 0450 RC 62270 HCPCS inpatient 936 608.4 AETNA AETNA 739.44 79 999999999 566.75 907.92 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 49925103_1 CDM 0450 RC 62270 HCPCS inpatient 936 608.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 608.4 65 999999999 566.75 907.92 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 49925103_1 CDM 0450 RC 62270 HCPCS inpatient 936 608.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 907.92 97 999999999 566.75 907.92 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 49925103_1 CDM 0450 RC 62270 HCPCS inpatient 936 608.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 645.84 69 999999999 566.75 907.92 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 49925103_1 CDM 0450 RC 62270 HCPCS inpatient 936 608.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 730.08 78 999999999 566.75 907.92 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 49925103_1 CDM 0450 RC 62270 HCPCS inpatient 936 608.4 SIHO - ALL PLANS SIHO - ALL PLANS 842.4 90 999999999 566.75 907.92 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 49925103_1 CDM 0450 RC 62270 HCPCS inpatient 936 608.4 UMR - ALL PLANS UMR - ALL PLANS 655.2 70 999999999 566.75 907.92 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 49925103_1 CDM 0450 RC 62270 HCPCS inpatient 936 608.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 566.75 60.55 999999999 566.75 907.92 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 49925103_1 CDM 0450 RC 62270 HCPCS inpatient 936 608.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 566.75 907.92 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 49925103_1 CDM 0450 RC 62270 HCPCS inpatient 936 608.4 ANTHEM HMO ANTHEM HMO 999999999 566.75 907.92 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 49925103_1 CDM 0450 RC 62270 HCPCS inpatient 936 608.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 566.75 907.92 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 49925103_1 CDM 0450 RC 62270 HCPCS inpatient 936 608.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 632.74 67.6 999999999 566.75 907.92 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 49925103_1 CDM 0450 RC 62270 HCPCS inpatient 936 608.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 566.75 907.92 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 49925103_1 CDM 0450 RC 62270 HCPCS inpatient 936 608.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 566.75 907.92 "Aspiration of abscess, blood, or cyst" 49925118_1 CDM 0450 RC 10160 HCPCS inpatient 511 332.15 AETNA AETNA 403.69 79 999999999 309.41 495.67 percent of total billed charges "Aspiration of abscess, blood, or cyst" 49925118_1 CDM 0450 RC 10160 HCPCS inpatient 511 332.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 332.15 65 999999999 309.41 495.67 percent of total billed charges "Aspiration of abscess, blood, or cyst" 49925118_1 CDM 0450 RC 10160 HCPCS inpatient 511 332.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 495.67 97 999999999 309.41 495.67 percent of total billed charges "Aspiration of abscess, blood, or cyst" 49925118_1 CDM 0450 RC 10160 HCPCS inpatient 511 332.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 352.59 69 999999999 309.41 495.67 percent of total billed charges "Aspiration of abscess, blood, or cyst" 49925118_1 CDM 0450 RC 10160 HCPCS inpatient 511 332.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 398.58 78 999999999 309.41 495.67 percent of total billed charges "Aspiration of abscess, blood, or cyst" 49925118_1 CDM 0450 RC 10160 HCPCS inpatient 511 332.15 SIHO - ALL PLANS SIHO - ALL PLANS 459.9 90 999999999 309.41 495.67 percent of total billed charges "Aspiration of abscess, blood, or cyst" 49925118_1 CDM 0450 RC 10160 HCPCS inpatient 511 332.15 UMR - ALL PLANS UMR - ALL PLANS 357.7 70 999999999 309.41 495.67 percent of total billed charges "Aspiration of abscess, blood, or cyst" 49925118_1 CDM 0450 RC 10160 HCPCS inpatient 511 332.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 309.41 60.55 999999999 309.41 495.67 percent of total billed charges "Aspiration of abscess, blood, or cyst" 49925118_1 CDM 0450 RC 10160 HCPCS inpatient 511 332.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 309.41 495.67 "Aspiration of abscess, blood, or cyst" 49925118_1 CDM 0450 RC 10160 HCPCS inpatient 511 332.15 ANTHEM HMO ANTHEM HMO 999999999 309.41 495.67 "Aspiration of abscess, blood, or cyst" 49925118_1 CDM 0450 RC 10160 HCPCS inpatient 511 332.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 309.41 495.67 "Aspiration of abscess, blood, or cyst" 49925118_1 CDM 0450 RC 10160 HCPCS inpatient 511 332.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 345.44 67.6 999999999 309.41 495.67 percent of total billed charges "Aspiration of abscess, blood, or cyst" 49925118_1 CDM 0450 RC 10160 HCPCS inpatient 511 332.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 309.41 495.67 "Aspiration of abscess, blood, or cyst" 49925118_1 CDM 0450 RC 10160 HCPCS inpatient 511 332.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 309.41 495.67 LIGASURE EXACT LF2019 49926049_1 CDM 0272 RC inpatient 4137 2689.05 AETNA AETNA 3268.23 79 999999999 2504.95 4012.89 percent of total billed charges LIGASURE EXACT LF2019 49926049_1 CDM 0272 RC inpatient 4137 2689.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 2689.05 65 999999999 2504.95 4012.89 percent of total billed charges LIGASURE EXACT LF2019 49926049_1 CDM 0272 RC inpatient 4137 2689.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4012.89 97 999999999 2504.95 4012.89 percent of total billed charges LIGASURE EXACT LF2019 49926049_1 CDM 0272 RC inpatient 4137 2689.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2854.53 69 999999999 2504.95 4012.89 percent of total billed charges LIGASURE EXACT LF2019 49926049_1 CDM 0272 RC inpatient 4137 2689.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 3226.86 78 999999999 2504.95 4012.89 percent of total billed charges LIGASURE EXACT LF2019 49926049_1 CDM 0272 RC inpatient 4137 2689.05 SIHO - ALL PLANS SIHO - ALL PLANS 3723.3 90 999999999 2504.95 4012.89 percent of total billed charges LIGASURE EXACT LF2019 49926049_1 CDM 0272 RC inpatient 4137 2689.05 UMR - ALL PLANS UMR - ALL PLANS 2895.9 70 999999999 2504.95 4012.89 percent of total billed charges LIGASURE EXACT LF2019 49926049_1 CDM 0272 RC inpatient 4137 2689.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2504.95 60.55 999999999 2504.95 4012.89 percent of total billed charges LIGASURE EXACT LF2019 49926049_1 CDM 0272 RC inpatient 4137 2689.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2504.95 4012.89 LIGASURE EXACT LF2019 49926049_1 CDM 0272 RC inpatient 4137 2689.05 ANTHEM HMO ANTHEM HMO 999999999 2504.95 4012.89 LIGASURE EXACT LF2019 49926049_1 CDM 0272 RC inpatient 4137 2689.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2504.95 4012.89 LIGASURE EXACT LF2019 49926049_1 CDM 0272 RC inpatient 4137 2689.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2796.61 67.6 999999999 2504.95 4012.89 percent of total billed charges LIGASURE EXACT LF2019 49926049_1 CDM 0272 RC inpatient 4137 2689.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2504.95 4012.89 LIGASURE EXACT LF2019 49926049_1 CDM 0272 RC inpatient 4137 2689.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 2504.95 4012.89 BIZACT BZ4212A 49926051_1 CDM 0270 RC inpatient 2340 1521 AETNA AETNA 1848.6 79 999999999 1416.87 2269.8 percent of total billed charges BIZACT BZ4212A 49926051_1 CDM 0270 RC inpatient 2340 1521 SELF PAY DISCOUNT SELF PAY DISCOUNT 1521 65 999999999 1416.87 2269.8 percent of total billed charges BIZACT BZ4212A 49926051_1 CDM 0270 RC inpatient 2340 1521 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2269.8 97 999999999 1416.87 2269.8 percent of total billed charges BIZACT BZ4212A 49926051_1 CDM 0270 RC inpatient 2340 1521 ENCORE - ALL PLANS ENCORE - ALL PLANS 1614.6 69 999999999 1416.87 2269.8 percent of total billed charges BIZACT BZ4212A 49926051_1 CDM 0270 RC inpatient 2340 1521 HUMANA - ALL PLANS HUMANA - ALL PLANS 1825.2 78 999999999 1416.87 2269.8 percent of total billed charges BIZACT BZ4212A 49926051_1 CDM 0270 RC inpatient 2340 1521 SIHO - ALL PLANS SIHO - ALL PLANS 2106 90 999999999 1416.87 2269.8 percent of total billed charges BIZACT BZ4212A 49926051_1 CDM 0270 RC inpatient 2340 1521 UMR - ALL PLANS UMR - ALL PLANS 1638 70 999999999 1416.87 2269.8 percent of total billed charges BIZACT BZ4212A 49926051_1 CDM 0270 RC inpatient 2340 1521 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1416.87 60.55 999999999 1416.87 2269.8 percent of total billed charges BIZACT BZ4212A 49926051_1 CDM 0270 RC inpatient 2340 1521 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1416.87 2269.8 BIZACT BZ4212A 49926051_1 CDM 0270 RC inpatient 2340 1521 ANTHEM HMO ANTHEM HMO 999999999 1416.87 2269.8 BIZACT BZ4212A 49926051_1 CDM 0270 RC inpatient 2340 1521 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1416.87 2269.8 BIZACT BZ4212A 49926051_1 CDM 0270 RC inpatient 2340 1521 CIGNA - ALL PLANS CIGNA - ALL PLANS 1581.84 67.6 999999999 1416.87 2269.8 percent of total billed charges BIZACT BZ4212A 49926051_1 CDM 0270 RC inpatient 2340 1521 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1416.87 2269.8 BIZACT BZ4212A 49926051_1 CDM 0270 RC inpatient 2340 1521 UHC - ALL PLANS UHC - ALL PLANS 999999999 1416.87 2269.8 EXTRACTOR EZ PMIXTCR 10/BX 49926162_1 CDM 0272 RC inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges EXTRACTOR EZ PMIXTCR 10/BX 49926162_1 CDM 0272 RC inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges EXTRACTOR EZ PMIXTCR 10/BX 49926162_1 CDM 0272 RC inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges EXTRACTOR EZ PMIXTCR 10/BX 49926162_1 CDM 0272 RC inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges EXTRACTOR EZ PMIXTCR 10/BX 49926162_1 CDM 0272 RC inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges EXTRACTOR EZ PMIXTCR 10/BX 49926162_1 CDM 0272 RC inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges EXTRACTOR EZ PMIXTCR 10/BX 49926162_1 CDM 0272 RC inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges EXTRACTOR EZ PMIXTCR 10/BX 49926162_1 CDM 0272 RC inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges EXTRACTOR EZ PMIXTCR 10/BX 49926162_1 CDM 0272 RC inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 EXTRACTOR EZ PMIXTCR 10/BX 49926162_1 CDM 0272 RC inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 EXTRACTOR EZ PMIXTCR 10/BX 49926162_1 CDM 0272 RC inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 EXTRACTOR EZ PMIXTCR 10/BX 49926162_1 CDM 0272 RC inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges EXTRACTOR EZ PMIXTCR 10/BX 49926162_1 CDM 0272 RC inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 EXTRACTOR EZ PMIXTCR 10/BX 49926162_1 CDM 0272 RC inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 HF BAND 12 DEGREE WA22521C 12/BX 49926742_1 CDM 0272 RC inpatient 3574 2323.1 AETNA AETNA 2823.46 79 999999999 2164.06 3466.78 percent of total billed charges HF BAND 12 DEGREE WA22521C 12/BX 49926742_1 CDM 0272 RC inpatient 3574 2323.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 2323.1 65 999999999 2164.06 3466.78 percent of total billed charges HF BAND 12 DEGREE WA22521C 12/BX 49926742_1 CDM 0272 RC inpatient 3574 2323.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3466.78 97 999999999 2164.06 3466.78 percent of total billed charges HF BAND 12 DEGREE WA22521C 12/BX 49926742_1 CDM 0272 RC inpatient 3574 2323.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 2466.06 69 999999999 2164.06 3466.78 percent of total billed charges HF BAND 12 DEGREE WA22521C 12/BX 49926742_1 CDM 0272 RC inpatient 3574 2323.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 2787.72 78 999999999 2164.06 3466.78 percent of total billed charges HF BAND 12 DEGREE WA22521C 12/BX 49926742_1 CDM 0272 RC inpatient 3574 2323.1 SIHO - ALL PLANS SIHO - ALL PLANS 3216.6 90 999999999 2164.06 3466.78 percent of total billed charges HF BAND 12 DEGREE WA22521C 12/BX 49926742_1 CDM 0272 RC inpatient 3574 2323.1 UMR - ALL PLANS UMR - ALL PLANS 2501.8 70 999999999 2164.06 3466.78 percent of total billed charges HF BAND 12 DEGREE WA22521C 12/BX 49926742_1 CDM 0272 RC inpatient 3574 2323.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2164.06 60.55 999999999 2164.06 3466.78 percent of total billed charges HF BAND 12 DEGREE WA22521C 12/BX 49926742_1 CDM 0272 RC inpatient 3574 2323.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2164.06 3466.78 HF BAND 12 DEGREE WA22521C 12/BX 49926742_1 CDM 0272 RC inpatient 3574 2323.1 ANTHEM HMO ANTHEM HMO 999999999 2164.06 3466.78 HF BAND 12 DEGREE WA22521C 12/BX 49926742_1 CDM 0272 RC inpatient 3574 2323.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2164.06 3466.78 HF BAND 12 DEGREE WA22521C 12/BX 49926742_1 CDM 0272 RC inpatient 3574 2323.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 2416.02 67.6 999999999 2164.06 3466.78 percent of total billed charges HF BAND 12 DEGREE WA22521C 12/BX 49926742_1 CDM 0272 RC inpatient 3574 2323.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2164.06 3466.78 HF BAND 12 DEGREE WA22521C 12/BX 49926742_1 CDM 0272 RC inpatient 3574 2323.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 2164.06 3466.78 HF LOOP LARGE WA22503D 12/BX 49926744_1 CDM 0272 RC inpatient 3313 2153.45 AETNA AETNA 2617.27 79 999999999 2006.02 3213.61 percent of total billed charges HF LOOP LARGE WA22503D 12/BX 49926744_1 CDM 0272 RC inpatient 3313 2153.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 2153.45 65 999999999 2006.02 3213.61 percent of total billed charges HF LOOP LARGE WA22503D 12/BX 49926744_1 CDM 0272 RC inpatient 3313 2153.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3213.61 97 999999999 2006.02 3213.61 percent of total billed charges HF LOOP LARGE WA22503D 12/BX 49926744_1 CDM 0272 RC inpatient 3313 2153.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 2285.97 69 999999999 2006.02 3213.61 percent of total billed charges HF LOOP LARGE WA22503D 12/BX 49926744_1 CDM 0272 RC inpatient 3313 2153.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 2584.14 78 999999999 2006.02 3213.61 percent of total billed charges HF LOOP LARGE WA22503D 12/BX 49926744_1 CDM 0272 RC inpatient 3313 2153.45 SIHO - ALL PLANS SIHO - ALL PLANS 2981.7 90 999999999 2006.02 3213.61 percent of total billed charges HF LOOP LARGE WA22503D 12/BX 49926744_1 CDM 0272 RC inpatient 3313 2153.45 UMR - ALL PLANS UMR - ALL PLANS 2319.1 70 999999999 2006.02 3213.61 percent of total billed charges HF LOOP LARGE WA22503D 12/BX 49926744_1 CDM 0272 RC inpatient 3313 2153.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2006.02 60.55 999999999 2006.02 3213.61 percent of total billed charges HF LOOP LARGE WA22503D 12/BX 49926744_1 CDM 0272 RC inpatient 3313 2153.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2006.02 3213.61 HF LOOP LARGE WA22503D 12/BX 49926744_1 CDM 0272 RC inpatient 3313 2153.45 ANTHEM HMO ANTHEM HMO 999999999 2006.02 3213.61 HF LOOP LARGE WA22503D 12/BX 49926744_1 CDM 0272 RC inpatient 3313 2153.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2006.02 3213.61 HF LOOP LARGE WA22503D 12/BX 49926744_1 CDM 0272 RC inpatient 3313 2153.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 2239.59 67.6 999999999 2006.02 3213.61 percent of total billed charges HF LOOP LARGE WA22503D 12/BX 49926744_1 CDM 0272 RC inpatient 3313 2153.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2006.02 3213.61 HF LOOP LARGE WA22503D 12/BX 49926744_1 CDM 0272 RC inpatient 3313 2153.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 2006.02 3213.61 HF BUTTON WA22557C 12/BX 49926745_1 CDM 0272 RC inpatient 3396 2207.4 AETNA AETNA 2682.84 79 999999999 2056.28 3294.12 percent of total billed charges HF BUTTON WA22557C 12/BX 49926745_1 CDM 0272 RC inpatient 3396 2207.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 2207.4 65 999999999 2056.28 3294.12 percent of total billed charges HF BUTTON WA22557C 12/BX 49926745_1 CDM 0272 RC inpatient 3396 2207.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3294.12 97 999999999 2056.28 3294.12 percent of total billed charges HF BUTTON WA22557C 12/BX 49926745_1 CDM 0272 RC inpatient 3396 2207.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 2343.24 69 999999999 2056.28 3294.12 percent of total billed charges HF BUTTON WA22557C 12/BX 49926745_1 CDM 0272 RC inpatient 3396 2207.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 2648.88 78 999999999 2056.28 3294.12 percent of total billed charges HF BUTTON WA22557C 12/BX 49926745_1 CDM 0272 RC inpatient 3396 2207.4 SIHO - ALL PLANS SIHO - ALL PLANS 3056.4 90 999999999 2056.28 3294.12 percent of total billed charges HF BUTTON WA22557C 12/BX 49926745_1 CDM 0272 RC inpatient 3396 2207.4 UMR - ALL PLANS UMR - ALL PLANS 2377.2 70 999999999 2056.28 3294.12 percent of total billed charges HF BUTTON WA22557C 12/BX 49926745_1 CDM 0272 RC inpatient 3396 2207.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2056.28 60.55 999999999 2056.28 3294.12 percent of total billed charges HF BUTTON WA22557C 12/BX 49926745_1 CDM 0272 RC inpatient 3396 2207.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2056.28 3294.12 HF BUTTON WA22557C 12/BX 49926745_1 CDM 0272 RC inpatient 3396 2207.4 ANTHEM HMO ANTHEM HMO 999999999 2056.28 3294.12 HF BUTTON WA22557C 12/BX 49926745_1 CDM 0272 RC inpatient 3396 2207.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2056.28 3294.12 HF BUTTON WA22557C 12/BX 49926745_1 CDM 0272 RC inpatient 3396 2207.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 2295.7 67.6 999999999 2056.28 3294.12 percent of total billed charges HF BUTTON WA22557C 12/BX 49926745_1 CDM 0272 RC inpatient 3396 2207.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2056.28 3294.12 HF BUTTON WA22557C 12/BX 49926745_1 CDM 0272 RC inpatient 3396 2207.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 2056.28 3294.12 HF BARREL 24-28FR A22266C 12/BX 49926746_1 CDM 0272 RC inpatient 898 583.7 AETNA AETNA 709.42 79 999999999 543.74 871.06 percent of total billed charges HF BARREL 24-28FR A22266C 12/BX 49926746_1 CDM 0272 RC inpatient 898 583.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 583.7 65 999999999 543.74 871.06 percent of total billed charges HF BARREL 24-28FR A22266C 12/BX 49926746_1 CDM 0272 RC inpatient 898 583.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 871.06 97 999999999 543.74 871.06 percent of total billed charges HF BARREL 24-28FR A22266C 12/BX 49926746_1 CDM 0272 RC inpatient 898 583.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 619.62 69 999999999 543.74 871.06 percent of total billed charges HF BARREL 24-28FR A22266C 12/BX 49926746_1 CDM 0272 RC inpatient 898 583.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 700.44 78 999999999 543.74 871.06 percent of total billed charges HF BARREL 24-28FR A22266C 12/BX 49926746_1 CDM 0272 RC inpatient 898 583.7 SIHO - ALL PLANS SIHO - ALL PLANS 808.2 90 999999999 543.74 871.06 percent of total billed charges HF BARREL 24-28FR A22266C 12/BX 49926746_1 CDM 0272 RC inpatient 898 583.7 UMR - ALL PLANS UMR - ALL PLANS 628.6 70 999999999 543.74 871.06 percent of total billed charges HF BARREL 24-28FR A22266C 12/BX 49926746_1 CDM 0272 RC inpatient 898 583.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 543.74 60.55 999999999 543.74 871.06 percent of total billed charges HF BARREL 24-28FR A22266C 12/BX 49926746_1 CDM 0272 RC inpatient 898 583.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 543.74 871.06 HF BARREL 24-28FR A22266C 12/BX 49926746_1 CDM 0272 RC inpatient 898 583.7 ANTHEM HMO ANTHEM HMO 999999999 543.74 871.06 HF BARREL 24-28FR A22266C 12/BX 49926746_1 CDM 0272 RC inpatient 898 583.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 543.74 871.06 HF BARREL 24-28FR A22266C 12/BX 49926746_1 CDM 0272 RC inpatient 898 583.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 607.05 67.6 999999999 543.74 871.06 percent of total billed charges HF BARREL 24-28FR A22266C 12/BX 49926746_1 CDM 0272 RC inpatient 898 583.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 543.74 871.06 HF BARREL 24-28FR A22266C 12/BX 49926746_1 CDM 0272 RC inpatient 898 583.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 543.74 871.06 KNIFE 24-28FR A22265C 12/BX 49926747_1 CDM 0272 RC inpatient 1352 878.8 AETNA AETNA 1068.08 79 999999999 818.64 1311.44 percent of total billed charges KNIFE 24-28FR A22265C 12/BX 49926747_1 CDM 0272 RC inpatient 1352 878.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 878.8 65 999999999 818.64 1311.44 percent of total billed charges KNIFE 24-28FR A22265C 12/BX 49926747_1 CDM 0272 RC inpatient 1352 878.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1311.44 97 999999999 818.64 1311.44 percent of total billed charges KNIFE 24-28FR A22265C 12/BX 49926747_1 CDM 0272 RC inpatient 1352 878.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 932.88 69 999999999 818.64 1311.44 percent of total billed charges KNIFE 24-28FR A22265C 12/BX 49926747_1 CDM 0272 RC inpatient 1352 878.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1054.56 78 999999999 818.64 1311.44 percent of total billed charges KNIFE 24-28FR A22265C 12/BX 49926747_1 CDM 0272 RC inpatient 1352 878.8 SIHO - ALL PLANS SIHO - ALL PLANS 1216.8 90 999999999 818.64 1311.44 percent of total billed charges KNIFE 24-28FR A22265C 12/BX 49926747_1 CDM 0272 RC inpatient 1352 878.8 UMR - ALL PLANS UMR - ALL PLANS 946.4 70 999999999 818.64 1311.44 percent of total billed charges KNIFE 24-28FR A22265C 12/BX 49926747_1 CDM 0272 RC inpatient 1352 878.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 818.64 60.55 999999999 818.64 1311.44 percent of total billed charges KNIFE 24-28FR A22265C 12/BX 49926747_1 CDM 0272 RC inpatient 1352 878.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 818.64 1311.44 KNIFE 24-28FR A22265C 12/BX 49926747_1 CDM 0272 RC inpatient 1352 878.8 ANTHEM HMO ANTHEM HMO 999999999 818.64 1311.44 KNIFE 24-28FR A22265C 12/BX 49926747_1 CDM 0272 RC inpatient 1352 878.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 818.64 1311.44 KNIFE 24-28FR A22265C 12/BX 49926747_1 CDM 0272 RC inpatient 1352 878.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 913.95 67.6 999999999 818.64 1311.44 percent of total billed charges KNIFE 24-28FR A22265C 12/BX 49926747_1 CDM 0272 RC inpatient 1352 878.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 818.64 1311.44 KNIFE 24-28FR A22265C 12/BX 49926747_1 CDM 0272 RC inpatient 1352 878.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 818.64 1311.44 SEMI-CIRCULAR BLADE A3558 49926748_1 CDM 0272 RC inpatient 1621 1053.65 AETNA AETNA 1280.59 79 999999999 981.52 1572.37 percent of total billed charges SEMI-CIRCULAR BLADE A3558 49926748_1 CDM 0272 RC inpatient 1621 1053.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1053.65 65 999999999 981.52 1572.37 percent of total billed charges SEMI-CIRCULAR BLADE A3558 49926748_1 CDM 0272 RC inpatient 1621 1053.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1572.37 97 999999999 981.52 1572.37 percent of total billed charges SEMI-CIRCULAR BLADE A3558 49926748_1 CDM 0272 RC inpatient 1621 1053.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1118.49 69 999999999 981.52 1572.37 percent of total billed charges SEMI-CIRCULAR BLADE A3558 49926748_1 CDM 0272 RC inpatient 1621 1053.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1264.38 78 999999999 981.52 1572.37 percent of total billed charges SEMI-CIRCULAR BLADE A3558 49926748_1 CDM 0272 RC inpatient 1621 1053.65 SIHO - ALL PLANS SIHO - ALL PLANS 1458.9 90 999999999 981.52 1572.37 percent of total billed charges SEMI-CIRCULAR BLADE A3558 49926748_1 CDM 0272 RC inpatient 1621 1053.65 UMR - ALL PLANS UMR - ALL PLANS 1134.7 70 999999999 981.52 1572.37 percent of total billed charges SEMI-CIRCULAR BLADE A3558 49926748_1 CDM 0272 RC inpatient 1621 1053.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 981.52 60.55 999999999 981.52 1572.37 percent of total billed charges SEMI-CIRCULAR BLADE A3558 49926748_1 CDM 0272 RC inpatient 1621 1053.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 981.52 1572.37 SEMI-CIRCULAR BLADE A3558 49926748_1 CDM 0272 RC inpatient 1621 1053.65 ANTHEM HMO ANTHEM HMO 999999999 981.52 1572.37 SEMI-CIRCULAR BLADE A3558 49926748_1 CDM 0272 RC inpatient 1621 1053.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 981.52 1572.37 SEMI-CIRCULAR BLADE A3558 49926748_1 CDM 0272 RC inpatient 1621 1053.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1095.8 67.6 999999999 981.52 1572.37 percent of total billed charges SEMI-CIRCULAR BLADE A3558 49926748_1 CDM 0272 RC inpatient 1621 1053.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 981.52 1572.37 SEMI-CIRCULAR BLADE A3558 49926748_1 CDM 0272 RC inpatient 1621 1053.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 981.52 1572.37 SERRATED BLADE A3557 49926761_1 CDM 0272 RC inpatient 1621 1053.65 AETNA AETNA 1280.59 79 999999999 981.52 1572.37 percent of total billed charges SERRATED BLADE A3557 49926761_1 CDM 0272 RC inpatient 1621 1053.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1053.65 65 999999999 981.52 1572.37 percent of total billed charges SERRATED BLADE A3557 49926761_1 CDM 0272 RC inpatient 1621 1053.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1572.37 97 999999999 981.52 1572.37 percent of total billed charges SERRATED BLADE A3557 49926761_1 CDM 0272 RC inpatient 1621 1053.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1118.49 69 999999999 981.52 1572.37 percent of total billed charges SERRATED BLADE A3557 49926761_1 CDM 0272 RC inpatient 1621 1053.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1264.38 78 999999999 981.52 1572.37 percent of total billed charges SERRATED BLADE A3557 49926761_1 CDM 0272 RC inpatient 1621 1053.65 SIHO - ALL PLANS SIHO - ALL PLANS 1458.9 90 999999999 981.52 1572.37 percent of total billed charges SERRATED BLADE A3557 49926761_1 CDM 0272 RC inpatient 1621 1053.65 UMR - ALL PLANS UMR - ALL PLANS 1134.7 70 999999999 981.52 1572.37 percent of total billed charges SERRATED BLADE A3557 49926761_1 CDM 0272 RC inpatient 1621 1053.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 981.52 60.55 999999999 981.52 1572.37 percent of total billed charges SERRATED BLADE A3557 49926761_1 CDM 0272 RC inpatient 1621 1053.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 981.52 1572.37 SERRATED BLADE A3557 49926761_1 CDM 0272 RC inpatient 1621 1053.65 ANTHEM HMO ANTHEM HMO 999999999 981.52 1572.37 SERRATED BLADE A3557 49926761_1 CDM 0272 RC inpatient 1621 1053.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 981.52 1572.37 SERRATED BLADE A3557 49926761_1 CDM 0272 RC inpatient 1621 1053.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1095.8 67.6 999999999 981.52 1572.37 percent of total billed charges SERRATED BLADE A3557 49926761_1 CDM 0272 RC inpatient 1621 1053.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 981.52 1572.37 SERRATED BLADE A3557 49926761_1 CDM 0272 RC inpatient 1621 1053.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 981.52 1572.37 Quantitation of therapeutic drug 49927649_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 49927649_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 49927649_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 49927649_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 49927649_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 49927649_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 49927649_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 49927649_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 49927649_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 Quantitation of therapeutic drug 49927649_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 Quantitation of therapeutic drug 49927649_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 Quantitation of therapeutic drug 49927649_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 49927649_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 Quantitation of therapeutic drug 49927649_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 AMOX-CLAV 400-57 MG/5 ML SUSP 49927675_1 CDM 0250 RC 65862-0534-50 NDC inpatient 1 UN 13.25 8.61 AETNA AETNA 10.47 79 999999999 8.02 12.85 percent of total billed charges AMOX-CLAV 400-57 MG/5 ML SUSP 49927675_1 CDM 0250 RC 65862-0534-50 NDC inpatient 1 UN 13.25 8.61 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.61 65 999999999 8.02 12.85 percent of total billed charges AMOX-CLAV 400-57 MG/5 ML SUSP 49927675_1 CDM 0250 RC 65862-0534-50 NDC inpatient 1 UN 13.25 8.61 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.85 97 999999999 8.02 12.85 percent of total billed charges AMOX-CLAV 400-57 MG/5 ML SUSP 49927675_1 CDM 0250 RC 65862-0534-50 NDC inpatient 1 UN 13.25 8.61 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.14 69 999999999 8.02 12.85 percent of total billed charges AMOX-CLAV 400-57 MG/5 ML SUSP 49927675_1 CDM 0250 RC 65862-0534-50 NDC inpatient 1 UN 13.25 8.61 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.34 78 999999999 8.02 12.85 percent of total billed charges AMOX-CLAV 400-57 MG/5 ML SUSP 49927675_1 CDM 0250 RC 65862-0534-50 NDC inpatient 1 UN 13.25 8.61 SIHO - ALL PLANS SIHO - ALL PLANS 11.93 90 999999999 8.02 12.85 percent of total billed charges AMOX-CLAV 400-57 MG/5 ML SUSP 49927675_1 CDM 0250 RC 65862-0534-50 NDC inpatient 1 UN 13.25 8.61 UMR - ALL PLANS UMR - ALL PLANS 9.28 70 999999999 8.02 12.85 percent of total billed charges AMOX-CLAV 400-57 MG/5 ML SUSP 49927675_1 CDM 0250 RC 65862-0534-50 NDC inpatient 1 UN 13.25 8.61 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.02 60.55 999999999 8.02 12.85 percent of total billed charges AMOX-CLAV 400-57 MG/5 ML SUSP 49927675_1 CDM 0250 RC 65862-0534-50 NDC inpatient 1 UN 13.25 8.61 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.02 12.85 AMOX-CLAV 400-57 MG/5 ML SUSP 49927675_1 CDM 0250 RC 65862-0534-50 NDC inpatient 1 UN 13.25 8.61 ANTHEM HMO ANTHEM HMO 999999999 8.02 12.85 AMOX-CLAV 400-57 MG/5 ML SUSP 49927675_1 CDM 0250 RC 65862-0534-50 NDC inpatient 1 UN 13.25 8.61 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.02 12.85 AMOX-CLAV 400-57 MG/5 ML SUSP 49927675_1 CDM 0250 RC 65862-0534-50 NDC inpatient 1 UN 13.25 8.61 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.96 67.6 999999999 8.02 12.85 percent of total billed charges AMOX-CLAV 400-57 MG/5 ML SUSP 49927675_1 CDM 0250 RC 65862-0534-50 NDC inpatient 1 UN 13.25 8.61 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.02 12.85 AMOX-CLAV 400-57 MG/5 ML SUSP 49927675_1 CDM 0250 RC 65862-0534-50 NDC inpatient 1 UN 13.25 8.61 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.02 12.85 "Detection test by immunoassay with direct visual observation for HIV-1 antigen, with HIV-1 and HIV-2 antibodies" 49927724_1 CDM 0306 RC 87806 HCPCS inpatient 169 109.85 AETNA AETNA 133.51 79 999999999 102.33 163.93 percent of total billed charges "Detection test by immunoassay with direct visual observation for HIV-1 antigen, with HIV-1 and HIV-2 antibodies" 49927724_1 CDM 0306 RC 87806 HCPCS inpatient 169 109.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.85 65 999999999 102.33 163.93 percent of total billed charges "Detection test by immunoassay with direct visual observation for HIV-1 antigen, with HIV-1 and HIV-2 antibodies" 49927724_1 CDM 0306 RC 87806 HCPCS inpatient 169 109.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 163.93 97 999999999 102.33 163.93 percent of total billed charges "Detection test by immunoassay with direct visual observation for HIV-1 antigen, with HIV-1 and HIV-2 antibodies" 49927724_1 CDM 0306 RC 87806 HCPCS inpatient 169 109.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 116.61 69 999999999 102.33 163.93 percent of total billed charges "Detection test by immunoassay with direct visual observation for HIV-1 antigen, with HIV-1 and HIV-2 antibodies" 49927724_1 CDM 0306 RC 87806 HCPCS inpatient 169 109.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.82 78 999999999 102.33 163.93 percent of total billed charges "Detection test by immunoassay with direct visual observation for HIV-1 antigen, with HIV-1 and HIV-2 antibodies" 49927724_1 CDM 0306 RC 87806 HCPCS inpatient 169 109.85 SIHO - ALL PLANS SIHO - ALL PLANS 152.1 90 999999999 102.33 163.93 percent of total billed charges "Detection test by immunoassay with direct visual observation for HIV-1 antigen, with HIV-1 and HIV-2 antibodies" 49927724_1 CDM 0306 RC 87806 HCPCS inpatient 169 109.85 UMR - ALL PLANS UMR - ALL PLANS 118.3 70 999999999 102.33 163.93 percent of total billed charges "Detection test by immunoassay with direct visual observation for HIV-1 antigen, with HIV-1 and HIV-2 antibodies" 49927724_1 CDM 0306 RC 87806 HCPCS inpatient 169 109.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.33 60.55 999999999 102.33 163.93 percent of total billed charges "Detection test by immunoassay with direct visual observation for HIV-1 antigen, with HIV-1 and HIV-2 antibodies" 49927724_1 CDM 0306 RC 87806 HCPCS inpatient 169 109.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.33 163.93 "Detection test by immunoassay with direct visual observation for HIV-1 antigen, with HIV-1 and HIV-2 antibodies" 49927724_1 CDM 0306 RC 87806 HCPCS inpatient 169 109.85 ANTHEM HMO ANTHEM HMO 999999999 102.33 163.93 "Detection test by immunoassay with direct visual observation for HIV-1 antigen, with HIV-1 and HIV-2 antibodies" 49927724_1 CDM 0306 RC 87806 HCPCS inpatient 169 109.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.33 163.93 "Detection test by immunoassay with direct visual observation for HIV-1 antigen, with HIV-1 and HIV-2 antibodies" 49927724_1 CDM 0306 RC 87806 HCPCS inpatient 169 109.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.24 67.6 999999999 102.33 163.93 percent of total billed charges "Detection test by immunoassay with direct visual observation for HIV-1 antigen, with HIV-1 and HIV-2 antibodies" 49927724_1 CDM 0306 RC 87806 HCPCS inpatient 169 109.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.33 163.93 "Detection test by immunoassay with direct visual observation for HIV-1 antigen, with HIV-1 and HIV-2 antibodies" 49927724_1 CDM 0306 RC 87806 HCPCS inpatient 169 109.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.33 163.93 PRADAXA 75 MG CAPSULE 49928473_1 CDM 0250 RC 00597-0355-56 NDC inpatient 1 UN 28.9 18.79 AETNA AETNA 22.83 79 999999999 17.5 28.03 percent of total billed charges PRADAXA 75 MG CAPSULE 49928473_1 CDM 0250 RC 00597-0355-56 NDC inpatient 1 UN 28.9 18.79 SELF PAY DISCOUNT SELF PAY DISCOUNT 18.79 65 999999999 17.5 28.03 percent of total billed charges PRADAXA 75 MG CAPSULE 49928473_1 CDM 0250 RC 00597-0355-56 NDC inpatient 1 UN 28.9 18.79 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 28.03 97 999999999 17.5 28.03 percent of total billed charges PRADAXA 75 MG CAPSULE 49928473_1 CDM 0250 RC 00597-0355-56 NDC inpatient 1 UN 28.9 18.79 ENCORE - ALL PLANS ENCORE - ALL PLANS 19.94 69 999999999 17.5 28.03 percent of total billed charges PRADAXA 75 MG CAPSULE 49928473_1 CDM 0250 RC 00597-0355-56 NDC inpatient 1 UN 28.9 18.79 HUMANA - ALL PLANS HUMANA - ALL PLANS 22.54 78 999999999 17.5 28.03 percent of total billed charges PRADAXA 75 MG CAPSULE 49928473_1 CDM 0250 RC 00597-0355-56 NDC inpatient 1 UN 28.9 18.79 SIHO - ALL PLANS SIHO - ALL PLANS 26.01 90 999999999 17.5 28.03 percent of total billed charges PRADAXA 75 MG CAPSULE 49928473_1 CDM 0250 RC 00597-0355-56 NDC inpatient 1 UN 28.9 18.79 UMR - ALL PLANS UMR - ALL PLANS 20.23 70 999999999 17.5 28.03 percent of total billed charges PRADAXA 75 MG CAPSULE 49928473_1 CDM 0250 RC 00597-0355-56 NDC inpatient 1 UN 28.9 18.79 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17.5 60.55 999999999 17.5 28.03 percent of total billed charges PRADAXA 75 MG CAPSULE 49928473_1 CDM 0250 RC 00597-0355-56 NDC inpatient 1 UN 28.9 18.79 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 17.5 28.03 PRADAXA 75 MG CAPSULE 49928473_1 CDM 0250 RC 00597-0355-56 NDC inpatient 1 UN 28.9 18.79 ANTHEM HMO ANTHEM HMO 999999999 17.5 28.03 PRADAXA 75 MG CAPSULE 49928473_1 CDM 0250 RC 00597-0355-56 NDC inpatient 1 UN 28.9 18.79 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 17.5 28.03 PRADAXA 75 MG CAPSULE 49928473_1 CDM 0250 RC 00597-0355-56 NDC inpatient 1 UN 28.9 18.79 CIGNA - ALL PLANS CIGNA - ALL PLANS 19.54 67.6 999999999 17.5 28.03 percent of total billed charges PRADAXA 75 MG CAPSULE 49928473_1 CDM 0250 RC 00597-0355-56 NDC inpatient 1 UN 28.9 18.79 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 17.5 28.03 PRADAXA 75 MG CAPSULE 49928473_1 CDM 0250 RC 00597-0355-56 NDC inpatient 1 UN 28.9 18.79 UHC - ALL PLANS UHC - ALL PLANS 999999999 17.5 28.03 ISOSORBIDE DINITRATE 10 MG TAB 49929491_1 CDM 0250 RC 68084-0082-01 NDC inpatient 1 UN 1.85 1.2 AETNA AETNA 1.46 79 999999999 1.12 1.79 percent of total billed charges ISOSORBIDE DINITRATE 10 MG TAB 49929491_1 CDM 0250 RC 68084-0082-01 NDC inpatient 1 UN 1.85 1.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.2 65 999999999 1.12 1.79 percent of total billed charges ISOSORBIDE DINITRATE 10 MG TAB 49929491_1 CDM 0250 RC 68084-0082-01 NDC inpatient 1 UN 1.85 1.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.79 97 999999999 1.12 1.79 percent of total billed charges ISOSORBIDE DINITRATE 10 MG TAB 49929491_1 CDM 0250 RC 68084-0082-01 NDC inpatient 1 UN 1.85 1.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.28 69 999999999 1.12 1.79 percent of total billed charges ISOSORBIDE DINITRATE 10 MG TAB 49929491_1 CDM 0250 RC 68084-0082-01 NDC inpatient 1 UN 1.85 1.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.44 78 999999999 1.12 1.79 percent of total billed charges ISOSORBIDE DINITRATE 10 MG TAB 49929491_1 CDM 0250 RC 68084-0082-01 NDC inpatient 1 UN 1.85 1.2 SIHO - ALL PLANS SIHO - ALL PLANS 1.67 90 999999999 1.12 1.79 percent of total billed charges ISOSORBIDE DINITRATE 10 MG TAB 49929491_1 CDM 0250 RC 68084-0082-01 NDC inpatient 1 UN 1.85 1.2 UMR - ALL PLANS UMR - ALL PLANS 1.3 70 999999999 1.12 1.79 percent of total billed charges ISOSORBIDE DINITRATE 10 MG TAB 49929491_1 CDM 0250 RC 68084-0082-01 NDC inpatient 1 UN 1.85 1.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.12 60.55 999999999 1.12 1.79 percent of total billed charges ISOSORBIDE DINITRATE 10 MG TAB 49929491_1 CDM 0250 RC 68084-0082-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.12 1.79 ISOSORBIDE DINITRATE 10 MG TAB 49929491_1 CDM 0250 RC 68084-0082-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM HMO ANTHEM HMO 999999999 1.12 1.79 ISOSORBIDE DINITRATE 10 MG TAB 49929491_1 CDM 0250 RC 68084-0082-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.12 1.79 ISOSORBIDE DINITRATE 10 MG TAB 49929491_1 CDM 0250 RC 68084-0082-01 NDC inpatient 1 UN 1.85 1.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.25 67.6 999999999 1.12 1.79 percent of total billed charges ISOSORBIDE DINITRATE 10 MG TAB 49929491_1 CDM 0250 RC 68084-0082-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.12 1.79 ISOSORBIDE DINITRATE 10 MG TAB 49929491_1 CDM 0250 RC 68084-0082-01 NDC inpatient 1 UN 1.85 1.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.12 1.79 ADVANCED EYE RELIEF EYE WASH 49931980_1 CDM 0250 RC 10119-0002-52 NDC inpatient 1 UN 7.22 4.69 AETNA AETNA 5.7 79 999999999 4.37 7 percent of total billed charges ADVANCED EYE RELIEF EYE WASH 49931980_1 CDM 0250 RC 10119-0002-52 NDC inpatient 1 UN 7.22 4.69 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.69 65 999999999 4.37 7 percent of total billed charges ADVANCED EYE RELIEF EYE WASH 49931980_1 CDM 0250 RC 10119-0002-52 NDC inpatient 1 UN 7.22 4.69 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7 97 999999999 4.37 7 percent of total billed charges ADVANCED EYE RELIEF EYE WASH 49931980_1 CDM 0250 RC 10119-0002-52 NDC inpatient 1 UN 7.22 4.69 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.98 69 999999999 4.37 7 percent of total billed charges ADVANCED EYE RELIEF EYE WASH 49931980_1 CDM 0250 RC 10119-0002-52 NDC inpatient 1 UN 7.22 4.69 HUMANA - ALL PLANS HUMANA - ALL PLANS 5.63 78 999999999 4.37 7 percent of total billed charges ADVANCED EYE RELIEF EYE WASH 49931980_1 CDM 0250 RC 10119-0002-52 NDC inpatient 1 UN 7.22 4.69 SIHO - ALL PLANS SIHO - ALL PLANS 6.5 90 999999999 4.37 7 percent of total billed charges ADVANCED EYE RELIEF EYE WASH 49931980_1 CDM 0250 RC 10119-0002-52 NDC inpatient 1 UN 7.22 4.69 UMR - ALL PLANS UMR - ALL PLANS 5.05 70 999999999 4.37 7 percent of total billed charges ADVANCED EYE RELIEF EYE WASH 49931980_1 CDM 0250 RC 10119-0002-52 NDC inpatient 1 UN 7.22 4.69 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.37 60.55 999999999 4.37 7 percent of total billed charges ADVANCED EYE RELIEF EYE WASH 49931980_1 CDM 0250 RC 10119-0002-52 NDC inpatient 1 UN 7.22 4.69 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.37 7 ADVANCED EYE RELIEF EYE WASH 49931980_1 CDM 0250 RC 10119-0002-52 NDC inpatient 1 UN 7.22 4.69 ANTHEM HMO ANTHEM HMO 999999999 4.37 7 ADVANCED EYE RELIEF EYE WASH 49931980_1 CDM 0250 RC 10119-0002-52 NDC inpatient 1 UN 7.22 4.69 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.37 7 ADVANCED EYE RELIEF EYE WASH 49931980_1 CDM 0250 RC 10119-0002-52 NDC inpatient 1 UN 7.22 4.69 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.88 67.6 999999999 4.37 7 percent of total billed charges ADVANCED EYE RELIEF EYE WASH 49931980_1 CDM 0250 RC 10119-0002-52 NDC inpatient 1 UN 7.22 4.69 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.37 7 ADVANCED EYE RELIEF EYE WASH 49931980_1 CDM 0250 RC 10119-0002-52 NDC inpatient 1 UN 7.22 4.69 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.37 7 VELTASSA 8.4 GM POWDER PACKET 49936330_1 CDM 0250 RC 53436-0084-04 NDC inpatient 1 UN 170.19 110.62 AETNA AETNA 134.45 79 999999999 103.05 165.08 percent of total billed charges VELTASSA 8.4 GM POWDER PACKET 49936330_1 CDM 0250 RC 53436-0084-04 NDC inpatient 1 UN 170.19 110.62 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.62 65 999999999 103.05 165.08 percent of total billed charges VELTASSA 8.4 GM POWDER PACKET 49936330_1 CDM 0250 RC 53436-0084-04 NDC inpatient 1 UN 170.19 110.62 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 165.08 97 999999999 103.05 165.08 percent of total billed charges VELTASSA 8.4 GM POWDER PACKET 49936330_1 CDM 0250 RC 53436-0084-04 NDC inpatient 1 UN 170.19 110.62 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.43 69 999999999 103.05 165.08 percent of total billed charges VELTASSA 8.4 GM POWDER PACKET 49936330_1 CDM 0250 RC 53436-0084-04 NDC inpatient 1 UN 170.19 110.62 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.75 78 999999999 103.05 165.08 percent of total billed charges VELTASSA 8.4 GM POWDER PACKET 49936330_1 CDM 0250 RC 53436-0084-04 NDC inpatient 1 UN 170.19 110.62 SIHO - ALL PLANS SIHO - ALL PLANS 153.17 90 999999999 103.05 165.08 percent of total billed charges VELTASSA 8.4 GM POWDER PACKET 49936330_1 CDM 0250 RC 53436-0084-04 NDC inpatient 1 UN 170.19 110.62 UMR - ALL PLANS UMR - ALL PLANS 119.13 70 999999999 103.05 165.08 percent of total billed charges VELTASSA 8.4 GM POWDER PACKET 49936330_1 CDM 0250 RC 53436-0084-04 NDC inpatient 1 UN 170.19 110.62 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 103.05 60.55 999999999 103.05 165.08 percent of total billed charges VELTASSA 8.4 GM POWDER PACKET 49936330_1 CDM 0250 RC 53436-0084-04 NDC inpatient 1 UN 170.19 110.62 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 103.05 165.08 VELTASSA 8.4 GM POWDER PACKET 49936330_1 CDM 0250 RC 53436-0084-04 NDC inpatient 1 UN 170.19 110.62 ANTHEM HMO ANTHEM HMO 999999999 103.05 165.08 VELTASSA 8.4 GM POWDER PACKET 49936330_1 CDM 0250 RC 53436-0084-04 NDC inpatient 1 UN 170.19 110.62 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 103.05 165.08 VELTASSA 8.4 GM POWDER PACKET 49936330_1 CDM 0250 RC 53436-0084-04 NDC inpatient 1 UN 170.19 110.62 CIGNA - ALL PLANS CIGNA - ALL PLANS 115.05 67.6 999999999 103.05 165.08 percent of total billed charges VELTASSA 8.4 GM POWDER PACKET 49936330_1 CDM 0250 RC 53436-0084-04 NDC inpatient 1 UN 170.19 110.62 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 103.05 165.08 VELTASSA 8.4 GM POWDER PACKET 49936330_1 CDM 0250 RC 53436-0084-04 NDC inpatient 1 UN 170.19 110.62 UHC - ALL PLANS UHC - ALL PLANS 999999999 103.05 165.08 "Measurement of antibody (IgE) to allergic substance, multiallergen screen" 49936384_1 CDM 0301 RC 86005 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, multiallergen screen" 49936384_1 CDM 0301 RC 86005 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, multiallergen screen" 49936384_1 CDM 0301 RC 86005 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, multiallergen screen" 49936384_1 CDM 0301 RC 86005 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, multiallergen screen" 49936384_1 CDM 0301 RC 86005 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, multiallergen screen" 49936384_1 CDM 0301 RC 86005 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, multiallergen screen" 49936384_1 CDM 0301 RC 86005 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, multiallergen screen" 49936384_1 CDM 0301 RC 86005 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, multiallergen screen" 49936384_1 CDM 0301 RC 86005 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 "Measurement of antibody (IgE) to allergic substance, multiallergen screen" 49936384_1 CDM 0301 RC 86005 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 "Measurement of antibody (IgE) to allergic substance, multiallergen screen" 49936384_1 CDM 0301 RC 86005 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 "Measurement of antibody (IgE) to allergic substance, multiallergen screen" 49936384_1 CDM 0301 RC 86005 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, multiallergen screen" 49936384_1 CDM 0301 RC 86005 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 "Measurement of antibody (IgE) to allergic substance, multiallergen screen" 49936384_1 CDM 0301 RC 86005 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 Gene rearrangement analysis (immunoglobulin kappa light chain locus) to detect abnormal clonal population 49937105_1 CDM 0310 RC 81264 HCPCS inpatient 521 338.65 AETNA AETNA 411.59 79 999999999 315.47 505.37 percent of total billed charges Gene rearrangement analysis (immunoglobulin kappa light chain locus) to detect abnormal clonal population 49937105_1 CDM 0310 RC 81264 HCPCS inpatient 521 338.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 338.65 65 999999999 315.47 505.37 percent of total billed charges Gene rearrangement analysis (immunoglobulin kappa light chain locus) to detect abnormal clonal population 49937105_1 CDM 0310 RC 81264 HCPCS inpatient 521 338.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 505.37 97 999999999 315.47 505.37 percent of total billed charges Gene rearrangement analysis (immunoglobulin kappa light chain locus) to detect abnormal clonal population 49937105_1 CDM 0310 RC 81264 HCPCS inpatient 521 338.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 359.49 69 999999999 315.47 505.37 percent of total billed charges Gene rearrangement analysis (immunoglobulin kappa light chain locus) to detect abnormal clonal population 49937105_1 CDM 0310 RC 81264 HCPCS inpatient 521 338.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 406.38 78 999999999 315.47 505.37 percent of total billed charges Gene rearrangement analysis (immunoglobulin kappa light chain locus) to detect abnormal clonal population 49937105_1 CDM 0310 RC 81264 HCPCS inpatient 521 338.65 SIHO - ALL PLANS SIHO - ALL PLANS 468.9 90 999999999 315.47 505.37 percent of total billed charges Gene rearrangement analysis (immunoglobulin kappa light chain locus) to detect abnormal clonal population 49937105_1 CDM 0310 RC 81264 HCPCS inpatient 521 338.65 UMR - ALL PLANS UMR - ALL PLANS 364.7 70 999999999 315.47 505.37 percent of total billed charges Gene rearrangement analysis (immunoglobulin kappa light chain locus) to detect abnormal clonal population 49937105_1 CDM 0310 RC 81264 HCPCS inpatient 521 338.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 315.47 60.55 999999999 315.47 505.37 percent of total billed charges Gene rearrangement analysis (immunoglobulin kappa light chain locus) to detect abnormal clonal population 49937105_1 CDM 0310 RC 81264 HCPCS inpatient 521 338.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 315.47 505.37 Gene rearrangement analysis (immunoglobulin kappa light chain locus) to detect abnormal clonal population 49937105_1 CDM 0310 RC 81264 HCPCS inpatient 521 338.65 ANTHEM HMO ANTHEM HMO 999999999 315.47 505.37 Gene rearrangement analysis (immunoglobulin kappa light chain locus) to detect abnormal clonal population 49937105_1 CDM 0310 RC 81264 HCPCS inpatient 521 338.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 315.47 505.37 Gene rearrangement analysis (immunoglobulin kappa light chain locus) to detect abnormal clonal population 49937105_1 CDM 0310 RC 81264 HCPCS inpatient 521 338.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 352.2 67.6 999999999 315.47 505.37 percent of total billed charges Gene rearrangement analysis (immunoglobulin kappa light chain locus) to detect abnormal clonal population 49937105_1 CDM 0310 RC 81264 HCPCS inpatient 521 338.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 315.47 505.37 Gene rearrangement analysis (immunoglobulin kappa light chain locus) to detect abnormal clonal population 49937105_1 CDM 0310 RC 81264 HCPCS inpatient 521 338.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 315.47 505.37 Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 49937107_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 AETNA AETNA 514.29 79 999999999 394.18 631.47 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 49937107_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 423.15 65 999999999 394.18 631.47 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 49937107_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 631.47 97 999999999 394.18 631.47 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 49937107_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 449.19 69 999999999 394.18 631.47 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 49937107_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 507.78 78 999999999 394.18 631.47 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 49937107_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 SIHO - ALL PLANS SIHO - ALL PLANS 585.9 90 999999999 394.18 631.47 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 49937107_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 UMR - ALL PLANS UMR - ALL PLANS 455.7 70 999999999 394.18 631.47 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 49937107_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 394.18 60.55 999999999 394.18 631.47 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 49937107_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 394.18 631.47 Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 49937107_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 ANTHEM HMO ANTHEM HMO 999999999 394.18 631.47 Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 49937107_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 394.18 631.47 Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 49937107_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 440.08 67.6 999999999 394.18 631.47 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 49937107_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 394.18 631.47 Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 49937107_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 394.18 631.47 Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 49937121_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 AETNA AETNA 546.68 79 999999999 419.01 671.24 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 49937121_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 449.8 65 999999999 419.01 671.24 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 49937121_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 671.24 97 999999999 419.01 671.24 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 49937121_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 477.48 69 999999999 419.01 671.24 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 49937121_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 539.76 78 999999999 419.01 671.24 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 49937121_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 SIHO - ALL PLANS SIHO - ALL PLANS 622.8 90 999999999 419.01 671.24 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 49937121_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 UMR - ALL PLANS UMR - ALL PLANS 484.4 70 999999999 419.01 671.24 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 49937121_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 419.01 60.55 999999999 419.01 671.24 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 49937121_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 419.01 671.24 Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 49937121_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 ANTHEM HMO ANTHEM HMO 999999999 419.01 671.24 Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 49937121_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 419.01 671.24 Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 49937121_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 467.79 67.6 999999999 419.01 671.24 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 49937121_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 419.01 671.24 Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 49937121_1 CDM 0301 RC 81220 HCPCS inpatient 692 449.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 419.01 671.24 BUMETANIDE 1 MG TABLET 49937201_1 CDM 0250 RC 42799-0120-01 NDC inpatient 1 UN 1.49 0.97 AETNA AETNA 1.18 79 999999999 0.9 1.45 percent of total billed charges BUMETANIDE 1 MG TABLET 49937201_1 CDM 0250 RC 42799-0120-01 NDC inpatient 1 UN 1.49 0.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.97 65 999999999 0.9 1.45 percent of total billed charges BUMETANIDE 1 MG TABLET 49937201_1 CDM 0250 RC 42799-0120-01 NDC inpatient 1 UN 1.49 0.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.45 97 999999999 0.9 1.45 percent of total billed charges BUMETANIDE 1 MG TABLET 49937201_1 CDM 0250 RC 42799-0120-01 NDC inpatient 1 UN 1.49 0.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.03 69 999999999 0.9 1.45 percent of total billed charges BUMETANIDE 1 MG TABLET 49937201_1 CDM 0250 RC 42799-0120-01 NDC inpatient 1 UN 1.49 0.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.16 78 999999999 0.9 1.45 percent of total billed charges BUMETANIDE 1 MG TABLET 49937201_1 CDM 0250 RC 42799-0120-01 NDC inpatient 1 UN 1.49 0.97 SIHO - ALL PLANS SIHO - ALL PLANS 1.34 90 999999999 0.9 1.45 percent of total billed charges BUMETANIDE 1 MG TABLET 49937201_1 CDM 0250 RC 42799-0120-01 NDC inpatient 1 UN 1.49 0.97 UMR - ALL PLANS UMR - ALL PLANS 1.04 70 999999999 0.9 1.45 percent of total billed charges BUMETANIDE 1 MG TABLET 49937201_1 CDM 0250 RC 42799-0120-01 NDC inpatient 1 UN 1.49 0.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.9 60.55 999999999 0.9 1.45 percent of total billed charges BUMETANIDE 1 MG TABLET 49937201_1 CDM 0250 RC 42799-0120-01 NDC inpatient 1 UN 1.49 0.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.9 1.45 BUMETANIDE 1 MG TABLET 49937201_1 CDM 0250 RC 42799-0120-01 NDC inpatient 1 UN 1.49 0.97 ANTHEM HMO ANTHEM HMO 999999999 0.9 1.45 BUMETANIDE 1 MG TABLET 49937201_1 CDM 0250 RC 42799-0120-01 NDC inpatient 1 UN 1.49 0.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.9 1.45 BUMETANIDE 1 MG TABLET 49937201_1 CDM 0250 RC 42799-0120-01 NDC inpatient 1 UN 1.49 0.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.01 67.6 999999999 0.9 1.45 percent of total billed charges BUMETANIDE 1 MG TABLET 49937201_1 CDM 0250 RC 42799-0120-01 NDC inpatient 1 UN 1.49 0.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.9 1.45 BUMETANIDE 1 MG TABLET 49937201_1 CDM 0250 RC 42799-0120-01 NDC inpatient 1 UN 1.49 0.97 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.9 1.45 RISPERIDONE 1 MG/ML SOLUTION 49937950_1 CDM 0250 RC 50458-0596-01 NDC inpatient 1 UN 60.75 39.49 AETNA AETNA 47.99 79 999999999 36.78 58.93 percent of total billed charges RISPERIDONE 1 MG/ML SOLUTION 49937950_1 CDM 0250 RC 50458-0596-01 NDC inpatient 1 UN 60.75 39.49 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.49 65 999999999 36.78 58.93 percent of total billed charges RISPERIDONE 1 MG/ML SOLUTION 49937950_1 CDM 0250 RC 50458-0596-01 NDC inpatient 1 UN 60.75 39.49 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.93 97 999999999 36.78 58.93 percent of total billed charges RISPERIDONE 1 MG/ML SOLUTION 49937950_1 CDM 0250 RC 50458-0596-01 NDC inpatient 1 UN 60.75 39.49 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.92 69 999999999 36.78 58.93 percent of total billed charges RISPERIDONE 1 MG/ML SOLUTION 49937950_1 CDM 0250 RC 50458-0596-01 NDC inpatient 1 UN 60.75 39.49 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.39 78 999999999 36.78 58.93 percent of total billed charges RISPERIDONE 1 MG/ML SOLUTION 49937950_1 CDM 0250 RC 50458-0596-01 NDC inpatient 1 UN 60.75 39.49 SIHO - ALL PLANS SIHO - ALL PLANS 54.68 90 999999999 36.78 58.93 percent of total billed charges RISPERIDONE 1 MG/ML SOLUTION 49937950_1 CDM 0250 RC 50458-0596-01 NDC inpatient 1 UN 60.75 39.49 UMR - ALL PLANS UMR - ALL PLANS 42.53 70 999999999 36.78 58.93 percent of total billed charges RISPERIDONE 1 MG/ML SOLUTION 49937950_1 CDM 0250 RC 50458-0596-01 NDC inpatient 1 UN 60.75 39.49 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.78 60.55 999999999 36.78 58.93 percent of total billed charges RISPERIDONE 1 MG/ML SOLUTION 49937950_1 CDM 0250 RC 50458-0596-01 NDC inpatient 1 UN 60.75 39.49 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.78 58.93 RISPERIDONE 1 MG/ML SOLUTION 49937950_1 CDM 0250 RC 50458-0596-01 NDC inpatient 1 UN 60.75 39.49 ANTHEM HMO ANTHEM HMO 999999999 36.78 58.93 RISPERIDONE 1 MG/ML SOLUTION 49937950_1 CDM 0250 RC 50458-0596-01 NDC inpatient 1 UN 60.75 39.49 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.78 58.93 RISPERIDONE 1 MG/ML SOLUTION 49937950_1 CDM 0250 RC 50458-0596-01 NDC inpatient 1 UN 60.75 39.49 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.07 67.6 999999999 36.78 58.93 percent of total billed charges RISPERIDONE 1 MG/ML SOLUTION 49937950_1 CDM 0250 RC 50458-0596-01 NDC inpatient 1 UN 60.75 39.49 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.78 58.93 RISPERIDONE 1 MG/ML SOLUTION 49937950_1 CDM 0250 RC 50458-0596-01 NDC inpatient 1 UN 60.75 39.49 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.78 58.93 "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940022_1 CDM 0310 RC 88361 HCPCS inpatient 391 254.15 AETNA AETNA 308.89 79 999999999 236.75 379.27 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940022_1 CDM 0310 RC 88361 HCPCS inpatient 391 254.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 254.15 65 999999999 236.75 379.27 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940022_1 CDM 0310 RC 88361 HCPCS inpatient 391 254.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 379.27 97 999999999 236.75 379.27 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940022_1 CDM 0310 RC 88361 HCPCS inpatient 391 254.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 269.79 69 999999999 236.75 379.27 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940022_1 CDM 0310 RC 88361 HCPCS inpatient 391 254.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 304.98 78 999999999 236.75 379.27 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940022_1 CDM 0310 RC 88361 HCPCS inpatient 391 254.15 SIHO - ALL PLANS SIHO - ALL PLANS 351.9 90 999999999 236.75 379.27 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940022_1 CDM 0310 RC 88361 HCPCS inpatient 391 254.15 UMR - ALL PLANS UMR - ALL PLANS 273.7 70 999999999 236.75 379.27 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940022_1 CDM 0310 RC 88361 HCPCS inpatient 391 254.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 236.75 60.55 999999999 236.75 379.27 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940022_1 CDM 0310 RC 88361 HCPCS inpatient 391 254.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 236.75 379.27 "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940022_1 CDM 0310 RC 88361 HCPCS inpatient 391 254.15 ANTHEM HMO ANTHEM HMO 999999999 236.75 379.27 "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940022_1 CDM 0310 RC 88361 HCPCS inpatient 391 254.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 236.75 379.27 "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940022_1 CDM 0310 RC 88361 HCPCS inpatient 391 254.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 264.32 67.6 999999999 236.75 379.27 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940022_1 CDM 0310 RC 88361 HCPCS inpatient 391 254.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 236.75 379.27 "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940022_1 CDM 0310 RC 88361 HCPCS inpatient 391 254.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 236.75 379.27 "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940023_1 CDM 0310 RC 88361 HCPCS inpatient 587 381.55 AETNA AETNA 463.73 79 999999999 355.43 569.39 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940023_1 CDM 0310 RC 88361 HCPCS inpatient 587 381.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 381.55 65 999999999 355.43 569.39 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940023_1 CDM 0310 RC 88361 HCPCS inpatient 587 381.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 569.39 97 999999999 355.43 569.39 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940023_1 CDM 0310 RC 88361 HCPCS inpatient 587 381.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 405.03 69 999999999 355.43 569.39 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940023_1 CDM 0310 RC 88361 HCPCS inpatient 587 381.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 457.86 78 999999999 355.43 569.39 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940023_1 CDM 0310 RC 88361 HCPCS inpatient 587 381.55 SIHO - ALL PLANS SIHO - ALL PLANS 528.3 90 999999999 355.43 569.39 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940023_1 CDM 0310 RC 88361 HCPCS inpatient 587 381.55 UMR - ALL PLANS UMR - ALL PLANS 410.9 70 999999999 355.43 569.39 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940023_1 CDM 0310 RC 88361 HCPCS inpatient 587 381.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 355.43 60.55 999999999 355.43 569.39 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940023_1 CDM 0310 RC 88361 HCPCS inpatient 587 381.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 355.43 569.39 "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940023_1 CDM 0310 RC 88361 HCPCS inpatient 587 381.55 ANTHEM HMO ANTHEM HMO 999999999 355.43 569.39 "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940023_1 CDM 0310 RC 88361 HCPCS inpatient 587 381.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 355.43 569.39 "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940023_1 CDM 0310 RC 88361 HCPCS inpatient 587 381.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 396.81 67.6 999999999 355.43 569.39 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940023_1 CDM 0310 RC 88361 HCPCS inpatient 587 381.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 355.43 569.39 "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940023_1 CDM 0310 RC 88361 HCPCS inpatient 587 381.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 355.43 569.39 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 49940024_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 AETNA AETNA 705.47 79 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 49940024_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 580.45 65 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 49940024_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 866.21 97 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 49940024_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 616.17 69 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 49940024_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 696.54 78 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 49940024_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 SIHO - ALL PLANS SIHO - ALL PLANS 803.7 90 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 49940024_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 UMR - ALL PLANS UMR - ALL PLANS 625.1 70 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 49940024_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 540.71 60.55 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 49940024_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 49940024_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM HMO ANTHEM HMO 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 49940024_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 49940024_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 603.67 67.6 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 49940024_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 49940024_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 540.71 866.21 "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940025_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 AETNA AETNA 616.99 79 999999999 472.9 757.57 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940025_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 507.65 65 999999999 472.9 757.57 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940025_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 757.57 97 999999999 472.9 757.57 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940025_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 538.89 69 999999999 472.9 757.57 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940025_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 609.18 78 999999999 472.9 757.57 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940025_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 SIHO - ALL PLANS SIHO - ALL PLANS 702.9 90 999999999 472.9 757.57 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940025_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 UMR - ALL PLANS UMR - ALL PLANS 546.7 70 999999999 472.9 757.57 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940025_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 472.9 60.55 999999999 472.9 757.57 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940025_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 472.9 757.57 "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940025_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 ANTHEM HMO ANTHEM HMO 999999999 472.9 757.57 "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940025_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 472.9 757.57 "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940025_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 527.96 67.6 999999999 472.9 757.57 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940025_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 472.9 757.57 "Microscopic genetic analysis of tumor, using computer-assisted technology" 49940025_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 472.9 757.57 "Measurement of antibody (IgG) to allergic substance, each allergen" 49940054_1 CDM 0301 RC 86001 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49940054_1 CDM 0301 RC 86001 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49940054_1 CDM 0301 RC 86001 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49940054_1 CDM 0301 RC 86001 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49940054_1 CDM 0301 RC 86001 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49940054_1 CDM 0301 RC 86001 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49940054_1 CDM 0301 RC 86001 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49940054_1 CDM 0301 RC 86001 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49940054_1 CDM 0301 RC 86001 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgG) to allergic substance, each allergen" 49940054_1 CDM 0301 RC 86001 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgG) to allergic substance, each allergen" 49940054_1 CDM 0301 RC 86001 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgG) to allergic substance, each allergen" 49940054_1 CDM 0301 RC 86001 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49940054_1 CDM 0301 RC 86001 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgG) to allergic substance, each allergen" 49940054_1 CDM 0301 RC 86001 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 CT scan of blood vessels of head with contrast 49940469_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 AETNA AETNA 2399.23 79 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 49940469_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1974.05 65 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 49940469_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2945.89 97 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 49940469_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2095.53 69 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 49940469_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 2368.86 78 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 49940469_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 SIHO - ALL PLANS SIHO - ALL PLANS 2733.3 90 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 49940469_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 UMR - ALL PLANS UMR - ALL PLANS 2125.9 70 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 49940469_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1838.9 60.55 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 49940469_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1838.9 2945.89 CT scan of blood vessels of head with contrast 49940469_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 ANTHEM HMO ANTHEM HMO 999999999 1838.9 2945.89 CT scan of blood vessels of head with contrast 49940469_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1838.9 2945.89 CT scan of blood vessels of head with contrast 49940469_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2053.01 67.6 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 49940469_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1838.9 2945.89 CT scan of blood vessels of head with contrast 49940469_1 CDM 0352 RC 70496 HCPCS inpatient 3037 1974.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1838.9 2945.89 USE JMH # 3006419 49942081_1 CDM 0271 RC inpatient 198 128.7 AETNA AETNA 156.42 79 999999999 119.89 192.06 percent of total billed charges USE JMH # 3006419 49942081_1 CDM 0271 RC inpatient 198 128.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.7 65 999999999 119.89 192.06 percent of total billed charges USE JMH # 3006419 49942081_1 CDM 0271 RC inpatient 198 128.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 192.06 97 999999999 119.89 192.06 percent of total billed charges USE JMH # 3006419 49942081_1 CDM 0271 RC inpatient 198 128.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 136.62 69 999999999 119.89 192.06 percent of total billed charges USE JMH # 3006419 49942081_1 CDM 0271 RC inpatient 198 128.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 154.44 78 999999999 119.89 192.06 percent of total billed charges USE JMH # 3006419 49942081_1 CDM 0271 RC inpatient 198 128.7 SIHO - ALL PLANS SIHO - ALL PLANS 178.2 90 999999999 119.89 192.06 percent of total billed charges USE JMH # 3006419 49942081_1 CDM 0271 RC inpatient 198 128.7 UMR - ALL PLANS UMR - ALL PLANS 138.6 70 999999999 119.89 192.06 percent of total billed charges USE JMH # 3006419 49942081_1 CDM 0271 RC inpatient 198 128.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.89 60.55 999999999 119.89 192.06 percent of total billed charges USE JMH # 3006419 49942081_1 CDM 0271 RC inpatient 198 128.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.89 192.06 USE JMH # 3006419 49942081_1 CDM 0271 RC inpatient 198 128.7 ANTHEM HMO ANTHEM HMO 999999999 119.89 192.06 USE JMH # 3006419 49942081_1 CDM 0271 RC inpatient 198 128.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.89 192.06 USE JMH # 3006419 49942081_1 CDM 0271 RC inpatient 198 128.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.85 67.6 999999999 119.89 192.06 percent of total billed charges USE JMH # 3006419 49942081_1 CDM 0271 RC inpatient 198 128.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.89 192.06 USE JMH # 3006419 49942081_1 CDM 0271 RC inpatient 198 128.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.89 192.06 60687-0346-01 - benzonatate 100 mg Cap [JOHN] 49943717_1 CDM 0250 RC 60687-0346-01 NDC inpatient 1 UN 1.87 1.22 AETNA AETNA 1.48 79 999999999 1.13 1.81 percent of total billed charges 60687-0346-01 - benzonatate 100 mg Cap [JOHN] 49943717_1 CDM 0250 RC 60687-0346-01 NDC inpatient 1 UN 1.87 1.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.22 65 999999999 1.13 1.81 percent of total billed charges 60687-0346-01 - benzonatate 100 mg Cap [JOHN] 49943717_1 CDM 0250 RC 60687-0346-01 NDC inpatient 1 UN 1.87 1.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.81 97 999999999 1.13 1.81 percent of total billed charges 60687-0346-01 - benzonatate 100 mg Cap [JOHN] 49943717_1 CDM 0250 RC 60687-0346-01 NDC inpatient 1 UN 1.87 1.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.29 69 999999999 1.13 1.81 percent of total billed charges 60687-0346-01 - benzonatate 100 mg Cap [JOHN] 49943717_1 CDM 0250 RC 60687-0346-01 NDC inpatient 1 UN 1.87 1.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.46 78 999999999 1.13 1.81 percent of total billed charges 60687-0346-01 - benzonatate 100 mg Cap [JOHN] 49943717_1 CDM 0250 RC 60687-0346-01 NDC inpatient 1 UN 1.87 1.22 SIHO - ALL PLANS SIHO - ALL PLANS 1.68 90 999999999 1.13 1.81 percent of total billed charges 60687-0346-01 - benzonatate 100 mg Cap [JOHN] 49943717_1 CDM 0250 RC 60687-0346-01 NDC inpatient 1 UN 1.87 1.22 UMR - ALL PLANS UMR - ALL PLANS 1.31 70 999999999 1.13 1.81 percent of total billed charges 60687-0346-01 - benzonatate 100 mg Cap [JOHN] 49943717_1 CDM 0250 RC 60687-0346-01 NDC inpatient 1 UN 1.87 1.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.13 60.55 999999999 1.13 1.81 percent of total billed charges 60687-0346-01 - benzonatate 100 mg Cap [JOHN] 49943717_1 CDM 0250 RC 60687-0346-01 NDC inpatient 1 UN 1.87 1.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.13 1.81 60687-0346-01 - benzonatate 100 mg Cap [JOHN] 49943717_1 CDM 0250 RC 60687-0346-01 NDC inpatient 1 UN 1.87 1.22 ANTHEM HMO ANTHEM HMO 999999999 1.13 1.81 60687-0346-01 - benzonatate 100 mg Cap [JOHN] 49943717_1 CDM 0250 RC 60687-0346-01 NDC inpatient 1 UN 1.87 1.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.13 1.81 60687-0346-01 - benzonatate 100 mg Cap [JOHN] 49943717_1 CDM 0250 RC 60687-0346-01 NDC inpatient 1 UN 1.87 1.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.26 67.6 999999999 1.13 1.81 percent of total billed charges 60687-0346-01 - benzonatate 100 mg Cap [JOHN] 49943717_1 CDM 0250 RC 60687-0346-01 NDC inpatient 1 UN 1.87 1.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.13 1.81 60687-0346-01 - benzonatate 100 mg Cap [JOHN] 49943717_1 CDM 0250 RC 60687-0346-01 NDC inpatient 1 UN 1.87 1.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.13 1.81 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49943732_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49943732_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49943732_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49943732_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49943732_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49943732_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49943732_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49943732_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49943732_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49943732_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49943732_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49943732_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49943732_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49943732_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 FENTANYL 25 MCG/HR PATCH 49944096_1 CDM 0250 RC 00406-9025-76 NDC inpatient 1 UN 8.19 5.32 AETNA AETNA 6.47 79 999999999 4.96 7.94 percent of total billed charges FENTANYL 25 MCG/HR PATCH 49944096_1 CDM 0250 RC 00406-9025-76 NDC inpatient 1 UN 8.19 5.32 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.32 65 999999999 4.96 7.94 percent of total billed charges FENTANYL 25 MCG/HR PATCH 49944096_1 CDM 0250 RC 00406-9025-76 NDC inpatient 1 UN 8.19 5.32 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7.94 97 999999999 4.96 7.94 percent of total billed charges FENTANYL 25 MCG/HR PATCH 49944096_1 CDM 0250 RC 00406-9025-76 NDC inpatient 1 UN 8.19 5.32 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.65 69 999999999 4.96 7.94 percent of total billed charges FENTANYL 25 MCG/HR PATCH 49944096_1 CDM 0250 RC 00406-9025-76 NDC inpatient 1 UN 8.19 5.32 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.39 78 999999999 4.96 7.94 percent of total billed charges FENTANYL 25 MCG/HR PATCH 49944096_1 CDM 0250 RC 00406-9025-76 NDC inpatient 1 UN 8.19 5.32 SIHO - ALL PLANS SIHO - ALL PLANS 7.37 90 999999999 4.96 7.94 percent of total billed charges FENTANYL 25 MCG/HR PATCH 49944096_1 CDM 0250 RC 00406-9025-76 NDC inpatient 1 UN 8.19 5.32 UMR - ALL PLANS UMR - ALL PLANS 5.73 70 999999999 4.96 7.94 percent of total billed charges FENTANYL 25 MCG/HR PATCH 49944096_1 CDM 0250 RC 00406-9025-76 NDC inpatient 1 UN 8.19 5.32 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.96 60.55 999999999 4.96 7.94 percent of total billed charges FENTANYL 25 MCG/HR PATCH 49944096_1 CDM 0250 RC 00406-9025-76 NDC inpatient 1 UN 8.19 5.32 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.96 7.94 FENTANYL 25 MCG/HR PATCH 49944096_1 CDM 0250 RC 00406-9025-76 NDC inpatient 1 UN 8.19 5.32 ANTHEM HMO ANTHEM HMO 999999999 4.96 7.94 FENTANYL 25 MCG/HR PATCH 49944096_1 CDM 0250 RC 00406-9025-76 NDC inpatient 1 UN 8.19 5.32 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.96 7.94 FENTANYL 25 MCG/HR PATCH 49944096_1 CDM 0250 RC 00406-9025-76 NDC inpatient 1 UN 8.19 5.32 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.54 67.6 999999999 4.96 7.94 percent of total billed charges FENTANYL 25 MCG/HR PATCH 49944096_1 CDM 0250 RC 00406-9025-76 NDC inpatient 1 UN 8.19 5.32 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.96 7.94 FENTANYL 25 MCG/HR PATCH 49944096_1 CDM 0250 RC 00406-9025-76 NDC inpatient 1 UN 8.19 5.32 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.96 7.94 FENTANYL 12 MCG/HR PATCH 49944099_1 CDM 0250 RC 00406-9012-76 NDC inpatient 1 UN 18.7 12.16 AETNA AETNA 14.77 79 999999999 11.32 18.14 percent of total billed charges FENTANYL 12 MCG/HR PATCH 49944099_1 CDM 0250 RC 00406-9012-76 NDC inpatient 1 UN 18.7 12.16 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.16 65 999999999 11.32 18.14 percent of total billed charges FENTANYL 12 MCG/HR PATCH 49944099_1 CDM 0250 RC 00406-9012-76 NDC inpatient 1 UN 18.7 12.16 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 18.14 97 999999999 11.32 18.14 percent of total billed charges FENTANYL 12 MCG/HR PATCH 49944099_1 CDM 0250 RC 00406-9012-76 NDC inpatient 1 UN 18.7 12.16 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.9 69 999999999 11.32 18.14 percent of total billed charges FENTANYL 12 MCG/HR PATCH 49944099_1 CDM 0250 RC 00406-9012-76 NDC inpatient 1 UN 18.7 12.16 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.59 78 999999999 11.32 18.14 percent of total billed charges FENTANYL 12 MCG/HR PATCH 49944099_1 CDM 0250 RC 00406-9012-76 NDC inpatient 1 UN 18.7 12.16 SIHO - ALL PLANS SIHO - ALL PLANS 16.83 90 999999999 11.32 18.14 percent of total billed charges FENTANYL 12 MCG/HR PATCH 49944099_1 CDM 0250 RC 00406-9012-76 NDC inpatient 1 UN 18.7 12.16 UMR - ALL PLANS UMR - ALL PLANS 13.09 70 999999999 11.32 18.14 percent of total billed charges FENTANYL 12 MCG/HR PATCH 49944099_1 CDM 0250 RC 00406-9012-76 NDC inpatient 1 UN 18.7 12.16 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.32 60.55 999999999 11.32 18.14 percent of total billed charges FENTANYL 12 MCG/HR PATCH 49944099_1 CDM 0250 RC 00406-9012-76 NDC inpatient 1 UN 18.7 12.16 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.32 18.14 FENTANYL 12 MCG/HR PATCH 49944099_1 CDM 0250 RC 00406-9012-76 NDC inpatient 1 UN 18.7 12.16 ANTHEM HMO ANTHEM HMO 999999999 11.32 18.14 FENTANYL 12 MCG/HR PATCH 49944099_1 CDM 0250 RC 00406-9012-76 NDC inpatient 1 UN 18.7 12.16 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.32 18.14 FENTANYL 12 MCG/HR PATCH 49944099_1 CDM 0250 RC 00406-9012-76 NDC inpatient 1 UN 18.7 12.16 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.64 67.6 999999999 11.32 18.14 percent of total billed charges FENTANYL 12 MCG/HR PATCH 49944099_1 CDM 0250 RC 00406-9012-76 NDC inpatient 1 UN 18.7 12.16 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.32 18.14 FENTANYL 12 MCG/HR PATCH 49944099_1 CDM 0250 RC 00406-9012-76 NDC inpatient 1 UN 18.7 12.16 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.32 18.14 "Measurement of antibody (IgG) to allergic substance, each allergen" 49944168_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 AETNA AETNA 45.03 79 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49944168_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.05 65 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49944168_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.29 97 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49944168_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.33 69 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49944168_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.46 78 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49944168_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 SIHO - ALL PLANS SIHO - ALL PLANS 51.3 90 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49944168_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UMR - ALL PLANS UMR - ALL PLANS 39.9 70 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49944168_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.51 60.55 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49944168_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49944168_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM HMO ANTHEM HMO 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49944168_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49944168_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.53 67.6 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49944168_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49944168_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49944361_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 AETNA AETNA 45.03 79 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49944361_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.05 65 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49944361_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.29 97 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49944361_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.33 69 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49944361_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.46 78 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49944361_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 SIHO - ALL PLANS SIHO - ALL PLANS 51.3 90 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49944361_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UMR - ALL PLANS UMR - ALL PLANS 39.9 70 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49944361_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.51 60.55 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49944361_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49944361_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM HMO ANTHEM HMO 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49944361_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49944361_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.53 67.6 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49944361_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49944361_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.51 55.29 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49944384_1 CDM 0302 RC 86970 HCPCS inpatient 240 156 AETNA AETNA 189.6 79 999999999 145.32 232.8 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49944384_1 CDM 0302 RC 86970 HCPCS inpatient 240 156 SELF PAY DISCOUNT SELF PAY DISCOUNT 156 65 999999999 145.32 232.8 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49944384_1 CDM 0302 RC 86970 HCPCS inpatient 240 156 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 232.8 97 999999999 145.32 232.8 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49944384_1 CDM 0302 RC 86970 HCPCS inpatient 240 156 ENCORE - ALL PLANS ENCORE - ALL PLANS 165.6 69 999999999 145.32 232.8 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49944384_1 CDM 0302 RC 86970 HCPCS inpatient 240 156 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.2 78 999999999 145.32 232.8 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49944384_1 CDM 0302 RC 86970 HCPCS inpatient 240 156 SIHO - ALL PLANS SIHO - ALL PLANS 216 90 999999999 145.32 232.8 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49944384_1 CDM 0302 RC 86970 HCPCS inpatient 240 156 UMR - ALL PLANS UMR - ALL PLANS 168 70 999999999 145.32 232.8 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49944384_1 CDM 0302 RC 86970 HCPCS inpatient 240 156 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.32 60.55 999999999 145.32 232.8 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49944384_1 CDM 0302 RC 86970 HCPCS inpatient 240 156 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.32 232.8 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49944384_1 CDM 0302 RC 86970 HCPCS inpatient 240 156 ANTHEM HMO ANTHEM HMO 999999999 145.32 232.8 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49944384_1 CDM 0302 RC 86970 HCPCS inpatient 240 156 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.32 232.8 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49944384_1 CDM 0302 RC 86970 HCPCS inpatient 240 156 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.24 67.6 999999999 145.32 232.8 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49944384_1 CDM 0302 RC 86970 HCPCS inpatient 240 156 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.32 232.8 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 49944384_1 CDM 0302 RC 86970 HCPCS inpatient 240 156 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.32 232.8 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49944388_1 CDM 0302 RC 86971 HCPCS inpatient 388 252.2 AETNA AETNA 306.52 79 999999999 234.93 376.36 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49944388_1 CDM 0302 RC 86971 HCPCS inpatient 388 252.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 252.2 65 999999999 234.93 376.36 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49944388_1 CDM 0302 RC 86971 HCPCS inpatient 388 252.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 376.36 97 999999999 234.93 376.36 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49944388_1 CDM 0302 RC 86971 HCPCS inpatient 388 252.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.72 69 999999999 234.93 376.36 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49944388_1 CDM 0302 RC 86971 HCPCS inpatient 388 252.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 302.64 78 999999999 234.93 376.36 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49944388_1 CDM 0302 RC 86971 HCPCS inpatient 388 252.2 SIHO - ALL PLANS SIHO - ALL PLANS 349.2 90 999999999 234.93 376.36 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49944388_1 CDM 0302 RC 86971 HCPCS inpatient 388 252.2 UMR - ALL PLANS UMR - ALL PLANS 271.6 70 999999999 234.93 376.36 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49944388_1 CDM 0302 RC 86971 HCPCS inpatient 388 252.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.93 60.55 999999999 234.93 376.36 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49944388_1 CDM 0302 RC 86971 HCPCS inpatient 388 252.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.93 376.36 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49944388_1 CDM 0302 RC 86971 HCPCS inpatient 388 252.2 ANTHEM HMO ANTHEM HMO 999999999 234.93 376.36 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49944388_1 CDM 0302 RC 86971 HCPCS inpatient 388 252.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.93 376.36 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49944388_1 CDM 0302 RC 86971 HCPCS inpatient 388 252.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 262.29 67.6 999999999 234.93 376.36 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49944388_1 CDM 0302 RC 86971 HCPCS inpatient 388 252.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.93 376.36 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with enzymes" 49944388_1 CDM 0302 RC 86971 HCPCS inpatient 388 252.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.93 376.36 Red blood cell antibody level 49944390_1 CDM 0302 RC 86886 HCPCS inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges Red blood cell antibody level 49944390_1 CDM 0302 RC 86886 HCPCS inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges Red blood cell antibody level 49944390_1 CDM 0302 RC 86886 HCPCS inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges Red blood cell antibody level 49944390_1 CDM 0302 RC 86886 HCPCS inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges Red blood cell antibody level 49944390_1 CDM 0302 RC 86886 HCPCS inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges Red blood cell antibody level 49944390_1 CDM 0302 RC 86886 HCPCS inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges Red blood cell antibody level 49944390_1 CDM 0302 RC 86886 HCPCS inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges Red blood cell antibody level 49944390_1 CDM 0302 RC 86886 HCPCS inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges Red blood cell antibody level 49944390_1 CDM 0302 RC 86886 HCPCS inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 Red blood cell antibody level 49944390_1 CDM 0302 RC 86886 HCPCS inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 Red blood cell antibody level 49944390_1 CDM 0302 RC 86886 HCPCS inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 Red blood cell antibody level 49944390_1 CDM 0302 RC 86886 HCPCS inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges Red blood cell antibody level 49944390_1 CDM 0302 RC 86886 HCPCS inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 Red blood cell antibody level 49944390_1 CDM 0302 RC 86886 HCPCS inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 "Measurement of antibody (IgG) to allergic substance, each allergen" 49945371_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 AETNA AETNA 45.03 79 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945371_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.05 65 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945371_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.29 97 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945371_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.33 69 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945371_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.46 78 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945371_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 SIHO - ALL PLANS SIHO - ALL PLANS 51.3 90 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945371_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UMR - ALL PLANS UMR - ALL PLANS 39.9 70 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945371_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.51 60.55 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945371_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49945371_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM HMO ANTHEM HMO 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49945371_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49945371_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.53 67.6 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945371_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49945371_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49945372_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 AETNA AETNA 45.03 79 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945372_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.05 65 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945372_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.29 97 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945372_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.33 69 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945372_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.46 78 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945372_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 SIHO - ALL PLANS SIHO - ALL PLANS 51.3 90 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945372_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UMR - ALL PLANS UMR - ALL PLANS 39.9 70 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945372_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.51 60.55 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945372_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49945372_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM HMO ANTHEM HMO 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49945372_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49945372_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.53 67.6 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945372_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49945372_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49945373_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 AETNA AETNA 45.03 79 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945373_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.05 65 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945373_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.29 97 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945373_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.33 69 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945373_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.46 78 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945373_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 SIHO - ALL PLANS SIHO - ALL PLANS 51.3 90 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945373_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UMR - ALL PLANS UMR - ALL PLANS 39.9 70 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945373_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.51 60.55 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945373_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49945373_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM HMO ANTHEM HMO 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49945373_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49945373_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.53 67.6 999999999 34.51 55.29 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49945373_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.51 55.29 "Measurement of antibody (IgG) to allergic substance, each allergen" 49945373_1 CDM 0301 RC 86001 HCPCS inpatient 57 37.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.51 55.29 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946378_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946378_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946378_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946378_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946378_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946378_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946378_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946378_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946378_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946378_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946378_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946378_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946378_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946378_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946380_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946380_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946380_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946380_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946380_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946380_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946380_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946380_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946380_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946380_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946380_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946380_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946380_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49946380_1 CDM 0302 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Detection test by immunoassay technique for other organism 49950231_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 49950231_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 49950231_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 49950231_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 49950231_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 49950231_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 49950231_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 49950231_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 49950231_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 Detection test by immunoassay technique for other organism 49950231_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 Detection test by immunoassay technique for other organism 49950231_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 Detection test by immunoassay technique for other organism 49950231_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 49950231_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 Detection test by immunoassay technique for other organism 49950231_1 CDM 0301 RC 87449 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 Hydroxyindolacetic acid (product of metabolism) level 49950233_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 AETNA AETNA 324.69 79 999999999 248.86 398.67 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 49950233_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 267.15 65 999999999 248.86 398.67 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 49950233_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 398.67 97 999999999 248.86 398.67 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 49950233_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 283.59 69 999999999 248.86 398.67 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 49950233_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 320.58 78 999999999 248.86 398.67 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 49950233_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 SIHO - ALL PLANS SIHO - ALL PLANS 369.9 90 999999999 248.86 398.67 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 49950233_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 UMR - ALL PLANS UMR - ALL PLANS 287.7 70 999999999 248.86 398.67 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 49950233_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 248.86 60.55 999999999 248.86 398.67 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 49950233_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 248.86 398.67 Hydroxyindolacetic acid (product of metabolism) level 49950233_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 ANTHEM HMO ANTHEM HMO 999999999 248.86 398.67 Hydroxyindolacetic acid (product of metabolism) level 49950233_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 248.86 398.67 Hydroxyindolacetic acid (product of metabolism) level 49950233_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 277.84 67.6 999999999 248.86 398.67 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 49950233_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 248.86 398.67 Hydroxyindolacetic acid (product of metabolism) level 49950233_1 CDM 0301 RC 83497 HCPCS inpatient 411 267.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 248.86 398.67 Catecholamines (organic nitrogen) level 49950274_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 49950274_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 49950274_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 49950274_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 49950274_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 49950274_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 49950274_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 49950274_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 49950274_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 Catecholamines (organic nitrogen) level 49950274_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 Catecholamines (organic nitrogen) level 49950274_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 Catecholamines (organic nitrogen) level 49950274_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 49950274_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 Catecholamines (organic nitrogen) level 49950274_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 PREDNISOLONE AC 1% EYE DROP 49950773_1 CDM 0250 RC 60758-0119-05 NDC inpatient 1 UN 71.8 46.67 AETNA AETNA 56.72 79 999999999 43.47 69.65 percent of total billed charges PREDNISOLONE AC 1% EYE DROP 49950773_1 CDM 0250 RC 60758-0119-05 NDC inpatient 1 UN 71.8 46.67 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.67 65 999999999 43.47 69.65 percent of total billed charges PREDNISOLONE AC 1% EYE DROP 49950773_1 CDM 0250 RC 60758-0119-05 NDC inpatient 1 UN 71.8 46.67 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.65 97 999999999 43.47 69.65 percent of total billed charges PREDNISOLONE AC 1% EYE DROP 49950773_1 CDM 0250 RC 60758-0119-05 NDC inpatient 1 UN 71.8 46.67 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.54 69 999999999 43.47 69.65 percent of total billed charges PREDNISOLONE AC 1% EYE DROP 49950773_1 CDM 0250 RC 60758-0119-05 NDC inpatient 1 UN 71.8 46.67 HUMANA - ALL PLANS HUMANA - ALL PLANS 56 78 999999999 43.47 69.65 percent of total billed charges PREDNISOLONE AC 1% EYE DROP 49950773_1 CDM 0250 RC 60758-0119-05 NDC inpatient 1 UN 71.8 46.67 SIHO - ALL PLANS SIHO - ALL PLANS 64.62 90 999999999 43.47 69.65 percent of total billed charges PREDNISOLONE AC 1% EYE DROP 49950773_1 CDM 0250 RC 60758-0119-05 NDC inpatient 1 UN 71.8 46.67 UMR - ALL PLANS UMR - ALL PLANS 50.26 70 999999999 43.47 69.65 percent of total billed charges PREDNISOLONE AC 1% EYE DROP 49950773_1 CDM 0250 RC 60758-0119-05 NDC inpatient 1 UN 71.8 46.67 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.47 60.55 999999999 43.47 69.65 percent of total billed charges PREDNISOLONE AC 1% EYE DROP 49950773_1 CDM 0250 RC 60758-0119-05 NDC inpatient 1 UN 71.8 46.67 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.47 69.65 PREDNISOLONE AC 1% EYE DROP 49950773_1 CDM 0250 RC 60758-0119-05 NDC inpatient 1 UN 71.8 46.67 ANTHEM HMO ANTHEM HMO 999999999 43.47 69.65 PREDNISOLONE AC 1% EYE DROP 49950773_1 CDM 0250 RC 60758-0119-05 NDC inpatient 1 UN 71.8 46.67 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.47 69.65 PREDNISOLONE AC 1% EYE DROP 49950773_1 CDM 0250 RC 60758-0119-05 NDC inpatient 1 UN 71.8 46.67 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.54 67.6 999999999 43.47 69.65 percent of total billed charges PREDNISOLONE AC 1% EYE DROP 49950773_1 CDM 0250 RC 60758-0119-05 NDC inpatient 1 UN 71.8 46.67 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.47 69.65 PREDNISOLONE AC 1% EYE DROP 49950773_1 CDM 0250 RC 60758-0119-05 NDC inpatient 1 UN 71.8 46.67 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.47 69.65 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49951121_1 CDM 0250 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49951121_1 CDM 0250 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49951121_1 CDM 0250 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49951121_1 CDM 0250 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49951121_1 CDM 0250 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49951121_1 CDM 0250 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49951121_1 CDM 0250 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49951121_1 CDM 0250 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49951121_1 CDM 0250 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49951121_1 CDM 0250 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49951121_1 CDM 0250 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49951121_1 CDM 0250 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49951121_1 CDM 0250 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 5% DEXTROSE/WATER (500 ML = 1 UNIT) 49951121_1 CDM 0250 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 RAPID RHINO UNILATERAL INFLATABLE EPISTAXIS DEVICE RR751 49952128_1 CDM 0272 RC inpatient 212 137.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 137.8 65 999999999 128.37 205.64 percent of total billed charges RAPID RHINO UNILATERAL INFLATABLE EPISTAXIS DEVICE RR751 49952128_1 CDM 0272 RC inpatient 212 137.8 AETNA AETNA 167.48 79 999999999 128.37 205.64 percent of total billed charges RAPID RHINO UNILATERAL INFLATABLE EPISTAXIS DEVICE RR751 49952128_1 CDM 0272 RC inpatient 212 137.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 205.64 97 999999999 128.37 205.64 percent of total billed charges RAPID RHINO UNILATERAL INFLATABLE EPISTAXIS DEVICE RR751 49952128_1 CDM 0272 RC inpatient 212 137.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 146.28 69 999999999 128.37 205.64 percent of total billed charges RAPID RHINO UNILATERAL INFLATABLE EPISTAXIS DEVICE RR751 49952128_1 CDM 0272 RC inpatient 212 137.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 165.36 78 999999999 128.37 205.64 percent of total billed charges RAPID RHINO UNILATERAL INFLATABLE EPISTAXIS DEVICE RR751 49952128_1 CDM 0272 RC inpatient 212 137.8 SIHO - ALL PLANS SIHO - ALL PLANS 190.8 90 999999999 128.37 205.64 percent of total billed charges RAPID RHINO UNILATERAL INFLATABLE EPISTAXIS DEVICE RR751 49952128_1 CDM 0272 RC inpatient 212 137.8 UMR - ALL PLANS UMR - ALL PLANS 148.4 70 999999999 128.37 205.64 percent of total billed charges RAPID RHINO UNILATERAL INFLATABLE EPISTAXIS DEVICE RR751 49952128_1 CDM 0272 RC inpatient 212 137.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 128.37 60.55 999999999 128.37 205.64 percent of total billed charges RAPID RHINO UNILATERAL INFLATABLE EPISTAXIS DEVICE RR751 49952128_1 CDM 0272 RC inpatient 212 137.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 128.37 205.64 RAPID RHINO UNILATERAL INFLATABLE EPISTAXIS DEVICE RR751 49952128_1 CDM 0272 RC inpatient 212 137.8 ANTHEM HMO ANTHEM HMO 999999999 128.37 205.64 RAPID RHINO UNILATERAL INFLATABLE EPISTAXIS DEVICE RR751 49952128_1 CDM 0272 RC inpatient 212 137.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 128.37 205.64 RAPID RHINO UNILATERAL INFLATABLE EPISTAXIS DEVICE RR751 49952128_1 CDM 0272 RC inpatient 212 137.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 143.31 67.6 999999999 128.37 205.64 percent of total billed charges RAPID RHINO UNILATERAL INFLATABLE EPISTAXIS DEVICE RR751 49952128_1 CDM 0272 RC inpatient 212 137.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 128.37 205.64 RAPID RHINO UNILATERAL INFLATABLE EPISTAXIS DEVICE RR751 49952128_1 CDM 0272 RC inpatient 212 137.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 128.37 205.64 "Blood glucose (sugar) tolerance test, 3 specimens" 49954242_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49954242_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49954242_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49954242_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49954242_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49954242_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49954242_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49954242_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49954242_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 49954242_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 49954242_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 49954242_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 49954242_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 49954242_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 HYDROCORTISONE 10 MG TABLET 49955697_1 CDM 0250 RC 42543-0141-01 NDC inpatient 1 UN 1.6 1.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.04 65 999999999 0.97 1.55 percent of total billed charges HYDROCORTISONE 10 MG TABLET 49955697_1 CDM 0250 RC 42543-0141-01 NDC inpatient 1 UN 1.6 1.04 AETNA AETNA 1.26 79 999999999 0.97 1.55 percent of total billed charges HYDROCORTISONE 10 MG TABLET 49955697_1 CDM 0250 RC 42543-0141-01 NDC inpatient 1 UN 1.6 1.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.55 97 999999999 0.97 1.55 percent of total billed charges HYDROCORTISONE 10 MG TABLET 49955697_1 CDM 0250 RC 42543-0141-01 NDC inpatient 1 UN 1.6 1.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.1 69 999999999 0.97 1.55 percent of total billed charges HYDROCORTISONE 10 MG TABLET 49955697_1 CDM 0250 RC 42543-0141-01 NDC inpatient 1 UN 1.6 1.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.25 78 999999999 0.97 1.55 percent of total billed charges HYDROCORTISONE 10 MG TABLET 49955697_1 CDM 0250 RC 42543-0141-01 NDC inpatient 1 UN 1.6 1.04 SIHO - ALL PLANS SIHO - ALL PLANS 1.44 90 999999999 0.97 1.55 percent of total billed charges HYDROCORTISONE 10 MG TABLET 49955697_1 CDM 0250 RC 42543-0141-01 NDC inpatient 1 UN 1.6 1.04 UMR - ALL PLANS UMR - ALL PLANS 1.12 70 999999999 0.97 1.55 percent of total billed charges HYDROCORTISONE 10 MG TABLET 49955697_1 CDM 0250 RC 42543-0141-01 NDC inpatient 1 UN 1.6 1.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.97 60.55 999999999 0.97 1.55 percent of total billed charges HYDROCORTISONE 10 MG TABLET 49955697_1 CDM 0250 RC 42543-0141-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.97 1.55 HYDROCORTISONE 10 MG TABLET 49955697_1 CDM 0250 RC 42543-0141-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM HMO ANTHEM HMO 999999999 0.97 1.55 HYDROCORTISONE 10 MG TABLET 49955697_1 CDM 0250 RC 42543-0141-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.97 1.55 HYDROCORTISONE 10 MG TABLET 49955697_1 CDM 0250 RC 42543-0141-01 NDC inpatient 1 UN 1.6 1.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.08 67.6 999999999 0.97 1.55 percent of total billed charges HYDROCORTISONE 10 MG TABLET 49955697_1 CDM 0250 RC 42543-0141-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.97 1.55 HYDROCORTISONE 10 MG TABLET 49955697_1 CDM 0250 RC 42543-0141-01 NDC inpatient 1 UN 1.6 1.04 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.97 1.55 WHC-CLOSURE KIT 49956229_1 CDM 0272 RC inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges WHC-CLOSURE KIT 49956229_1 CDM 0272 RC inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges WHC-CLOSURE KIT 49956229_1 CDM 0272 RC inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges WHC-CLOSURE KIT 49956229_1 CDM 0272 RC inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges WHC-CLOSURE KIT 49956229_1 CDM 0272 RC inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges WHC-CLOSURE KIT 49956229_1 CDM 0272 RC inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges WHC-CLOSURE KIT 49956229_1 CDM 0272 RC inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges WHC-CLOSURE KIT 49956229_1 CDM 0272 RC inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges WHC-CLOSURE KIT 49956229_1 CDM 0272 RC inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 WHC-CLOSURE KIT 49956229_1 CDM 0272 RC inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 WHC-CLOSURE KIT 49956229_1 CDM 0272 RC inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 WHC-CLOSURE KIT 49956229_1 CDM 0272 RC inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges WHC-CLOSURE KIT 49956229_1 CDM 0272 RC inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 WHC-CLOSURE KIT 49956229_1 CDM 0272 RC inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 WHC-Catheter Sheath 49956230_1 CDM 0272 RC inpatient 1139 740.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 740.35 65 999999999 689.66 1104.83 percent of total billed charges WHC-Catheter Sheath 49956230_1 CDM 0272 RC inpatient 1139 740.35 AETNA AETNA 899.81 79 999999999 689.66 1104.83 percent of total billed charges WHC-Catheter Sheath 49956230_1 CDM 0272 RC inpatient 1139 740.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1104.83 97 999999999 689.66 1104.83 percent of total billed charges WHC-Catheter Sheath 49956230_1 CDM 0272 RC inpatient 1139 740.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 785.91 69 999999999 689.66 1104.83 percent of total billed charges WHC-Catheter Sheath 49956230_1 CDM 0272 RC inpatient 1139 740.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 888.42 78 999999999 689.66 1104.83 percent of total billed charges WHC-Catheter Sheath 49956230_1 CDM 0272 RC inpatient 1139 740.35 SIHO - ALL PLANS SIHO - ALL PLANS 1025.1 90 999999999 689.66 1104.83 percent of total billed charges WHC-Catheter Sheath 49956230_1 CDM 0272 RC inpatient 1139 740.35 UMR - ALL PLANS UMR - ALL PLANS 797.3 70 999999999 689.66 1104.83 percent of total billed charges WHC-Catheter Sheath 49956230_1 CDM 0272 RC inpatient 1139 740.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 689.66 60.55 999999999 689.66 1104.83 percent of total billed charges WHC-Catheter Sheath 49956230_1 CDM 0272 RC inpatient 1139 740.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 689.66 1104.83 WHC-Catheter Sheath 49956230_1 CDM 0272 RC inpatient 1139 740.35 ANTHEM HMO ANTHEM HMO 999999999 689.66 1104.83 WHC-Catheter Sheath 49956230_1 CDM 0272 RC inpatient 1139 740.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 689.66 1104.83 WHC-Catheter Sheath 49956230_1 CDM 0272 RC inpatient 1139 740.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 769.96 67.6 999999999 689.66 1104.83 percent of total billed charges WHC-Catheter Sheath 49956230_1 CDM 0272 RC inpatient 1139 740.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 689.66 1104.83 WHC-Catheter Sheath 49956230_1 CDM 0272 RC inpatient 1139 740.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 689.66 1104.83 WHC-MICRO SHEATH 49956231_1 CDM 0272 RC inpatient 24 15.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 15.6 65 999999999 14.53 23.28 percent of total billed charges WHC-MICRO SHEATH 49956231_1 CDM 0272 RC inpatient 24 15.6 AETNA AETNA 18.96 79 999999999 14.53 23.28 percent of total billed charges WHC-MICRO SHEATH 49956231_1 CDM 0272 RC inpatient 24 15.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23.28 97 999999999 14.53 23.28 percent of total billed charges WHC-MICRO SHEATH 49956231_1 CDM 0272 RC inpatient 24 15.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 16.56 69 999999999 14.53 23.28 percent of total billed charges WHC-MICRO SHEATH 49956231_1 CDM 0272 RC inpatient 24 15.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 18.72 78 999999999 14.53 23.28 percent of total billed charges WHC-MICRO SHEATH 49956231_1 CDM 0272 RC inpatient 24 15.6 SIHO - ALL PLANS SIHO - ALL PLANS 21.6 90 999999999 14.53 23.28 percent of total billed charges WHC-MICRO SHEATH 49956231_1 CDM 0272 RC inpatient 24 15.6 UMR - ALL PLANS UMR - ALL PLANS 16.8 70 999999999 14.53 23.28 percent of total billed charges WHC-MICRO SHEATH 49956231_1 CDM 0272 RC inpatient 24 15.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.53 60.55 999999999 14.53 23.28 percent of total billed charges WHC-MICRO SHEATH 49956231_1 CDM 0272 RC inpatient 24 15.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.53 23.28 WHC-MICRO SHEATH 49956231_1 CDM 0272 RC inpatient 24 15.6 ANTHEM HMO ANTHEM HMO 999999999 14.53 23.28 WHC-MICRO SHEATH 49956231_1 CDM 0272 RC inpatient 24 15.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.53 23.28 WHC-MICRO SHEATH 49956231_1 CDM 0272 RC inpatient 24 15.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.22 67.6 999999999 14.53 23.28 percent of total billed charges WHC-MICRO SHEATH 49956231_1 CDM 0272 RC inpatient 24 15.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.53 23.28 WHC-MICRO SHEATH 49956231_1 CDM 0272 RC inpatient 24 15.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.53 23.28 THD KIT 800070-5 5/BX 49958666_1 CDM 0272 RC inpatient 3659 2378.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 2378.35 65 999999999 2215.52 3549.23 percent of total billed charges THD KIT 800070-5 5/BX 49958666_1 CDM 0272 RC inpatient 3659 2378.35 AETNA AETNA 2890.61 79 999999999 2215.52 3549.23 percent of total billed charges THD KIT 800070-5 5/BX 49958666_1 CDM 0272 RC inpatient 3659 2378.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3549.23 97 999999999 2215.52 3549.23 percent of total billed charges THD KIT 800070-5 5/BX 49958666_1 CDM 0272 RC inpatient 3659 2378.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 2524.71 69 999999999 2215.52 3549.23 percent of total billed charges THD KIT 800070-5 5/BX 49958666_1 CDM 0272 RC inpatient 3659 2378.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 2854.02 78 999999999 2215.52 3549.23 percent of total billed charges THD KIT 800070-5 5/BX 49958666_1 CDM 0272 RC inpatient 3659 2378.35 SIHO - ALL PLANS SIHO - ALL PLANS 3293.1 90 999999999 2215.52 3549.23 percent of total billed charges THD KIT 800070-5 5/BX 49958666_1 CDM 0272 RC inpatient 3659 2378.35 UMR - ALL PLANS UMR - ALL PLANS 2561.3 70 999999999 2215.52 3549.23 percent of total billed charges THD KIT 800070-5 5/BX 49958666_1 CDM 0272 RC inpatient 3659 2378.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2215.52 60.55 999999999 2215.52 3549.23 percent of total billed charges THD KIT 800070-5 5/BX 49958666_1 CDM 0272 RC inpatient 3659 2378.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2215.52 3549.23 THD KIT 800070-5 5/BX 49958666_1 CDM 0272 RC inpatient 3659 2378.35 ANTHEM HMO ANTHEM HMO 999999999 2215.52 3549.23 THD KIT 800070-5 5/BX 49958666_1 CDM 0272 RC inpatient 3659 2378.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2215.52 3549.23 THD KIT 800070-5 5/BX 49958666_1 CDM 0272 RC inpatient 3659 2378.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 2473.48 67.6 999999999 2215.52 3549.23 percent of total billed charges THD KIT 800070-5 5/BX 49958666_1 CDM 0272 RC inpatient 3659 2378.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2215.52 3549.23 THD KIT 800070-5 5/BX 49958666_1 CDM 0272 RC inpatient 3659 2378.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 2215.52 3549.23 BLUE RHINO PERCUTANEOUS TRACH TRAY G57716 49958667_1 CDM 0272 RC inpatient 3059 1988.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1988.35 65 999999999 1852.22 2967.23 percent of total billed charges BLUE RHINO PERCUTANEOUS TRACH TRAY G57716 49958667_1 CDM 0272 RC inpatient 3059 1988.35 AETNA AETNA 2416.61 79 999999999 1852.22 2967.23 percent of total billed charges BLUE RHINO PERCUTANEOUS TRACH TRAY G57716 49958667_1 CDM 0272 RC inpatient 3059 1988.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2967.23 97 999999999 1852.22 2967.23 percent of total billed charges BLUE RHINO PERCUTANEOUS TRACH TRAY G57716 49958667_1 CDM 0272 RC inpatient 3059 1988.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 2110.71 69 999999999 1852.22 2967.23 percent of total billed charges BLUE RHINO PERCUTANEOUS TRACH TRAY G57716 49958667_1 CDM 0272 RC inpatient 3059 1988.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 2386.02 78 999999999 1852.22 2967.23 percent of total billed charges BLUE RHINO PERCUTANEOUS TRACH TRAY G57716 49958667_1 CDM 0272 RC inpatient 3059 1988.35 SIHO - ALL PLANS SIHO - ALL PLANS 2753.1 90 999999999 1852.22 2967.23 percent of total billed charges BLUE RHINO PERCUTANEOUS TRACH TRAY G57716 49958667_1 CDM 0272 RC inpatient 3059 1988.35 UMR - ALL PLANS UMR - ALL PLANS 2141.3 70 999999999 1852.22 2967.23 percent of total billed charges BLUE RHINO PERCUTANEOUS TRACH TRAY G57716 49958667_1 CDM 0272 RC inpatient 3059 1988.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1852.22 60.55 999999999 1852.22 2967.23 percent of total billed charges BLUE RHINO PERCUTANEOUS TRACH TRAY G57716 49958667_1 CDM 0272 RC inpatient 3059 1988.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1852.22 2967.23 BLUE RHINO PERCUTANEOUS TRACH TRAY G57716 49958667_1 CDM 0272 RC inpatient 3059 1988.35 ANTHEM HMO ANTHEM HMO 999999999 1852.22 2967.23 BLUE RHINO PERCUTANEOUS TRACH TRAY G57716 49958667_1 CDM 0272 RC inpatient 3059 1988.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1852.22 2967.23 BLUE RHINO PERCUTANEOUS TRACH TRAY G57716 49958667_1 CDM 0272 RC inpatient 3059 1988.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 2067.88 67.6 999999999 1852.22 2967.23 percent of total billed charges BLUE RHINO PERCUTANEOUS TRACH TRAY G57716 49958667_1 CDM 0272 RC inpatient 3059 1988.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1852.22 2967.23 BLUE RHINO PERCUTANEOUS TRACH TRAY G57716 49958667_1 CDM 0272 RC inpatient 3059 1988.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1852.22 2967.23 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49958713_1 CDM 0278 RC C1713 HCPCS inpatient 1400 910 SELF PAY DISCOUNT SELF PAY DISCOUNT 910 65 999999999 847.7 1358 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49958713_1 CDM 0278 RC C1713 HCPCS inpatient 1400 910 AETNA AETNA 1106 79 999999999 847.7 1358 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49958713_1 CDM 0278 RC C1713 HCPCS inpatient 1400 910 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1358 97 999999999 847.7 1358 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49958713_1 CDM 0278 RC C1713 HCPCS inpatient 1400 910 ENCORE - ALL PLANS ENCORE - ALL PLANS 966 69 999999999 847.7 1358 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49958713_1 CDM 0278 RC C1713 HCPCS inpatient 1400 910 HUMANA - ALL PLANS HUMANA - ALL PLANS 1092 78 999999999 847.7 1358 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49958713_1 CDM 0278 RC C1713 HCPCS inpatient 1400 910 SIHO - ALL PLANS SIHO - ALL PLANS 1260 90 999999999 847.7 1358 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49958713_1 CDM 0278 RC C1713 HCPCS inpatient 1400 910 UMR - ALL PLANS UMR - ALL PLANS 980 70 999999999 847.7 1358 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49958713_1 CDM 0278 RC C1713 HCPCS inpatient 1400 910 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 847.7 60.55 999999999 847.7 1358 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49958713_1 CDM 0278 RC C1713 HCPCS inpatient 1400 910 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 847.7 1358 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49958713_1 CDM 0278 RC C1713 HCPCS inpatient 1400 910 ANTHEM HMO ANTHEM HMO 999999999 847.7 1358 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49958713_1 CDM 0278 RC C1713 HCPCS inpatient 1400 910 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 847.7 1358 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49958713_1 CDM 0278 RC C1713 HCPCS inpatient 1400 910 CIGNA - ALL PLANS CIGNA - ALL PLANS 946.4 67.6 999999999 847.7 1358 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49958713_1 CDM 0278 RC C1713 HCPCS inpatient 1400 910 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 847.7 1358 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 49958713_1 CDM 0278 RC C1713 HCPCS inpatient 1400 910 UHC - ALL PLANS UHC - ALL PLANS 999999999 847.7 1358 ALLOGEN 2ML ALLOGRAFT ALB-0200S 49959080_1 CDM 0278 RC inpatient 21606 14043.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 14043.9 65 999999999 13082.43 20957.82 percent of total billed charges ALLOGEN 2ML ALLOGRAFT ALB-0200S 49959080_1 CDM 0278 RC inpatient 21606 14043.9 AETNA AETNA 17068.74 79 999999999 13082.43 20957.82 percent of total billed charges ALLOGEN 2ML ALLOGRAFT ALB-0200S 49959080_1 CDM 0278 RC inpatient 21606 14043.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20957.82 97 999999999 13082.43 20957.82 percent of total billed charges ALLOGEN 2ML ALLOGRAFT ALB-0200S 49959080_1 CDM 0278 RC inpatient 21606 14043.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 14908.14 69 999999999 13082.43 20957.82 percent of total billed charges ALLOGEN 2ML ALLOGRAFT ALB-0200S 49959080_1 CDM 0278 RC inpatient 21606 14043.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 16852.68 78 999999999 13082.43 20957.82 percent of total billed charges ALLOGEN 2ML ALLOGRAFT ALB-0200S 49959080_1 CDM 0278 RC inpatient 21606 14043.9 SIHO - ALL PLANS SIHO - ALL PLANS 19445.4 90 999999999 13082.43 20957.82 percent of total billed charges ALLOGEN 2ML ALLOGRAFT ALB-0200S 49959080_1 CDM 0278 RC inpatient 21606 14043.9 UMR - ALL PLANS UMR - ALL PLANS 15124.2 70 999999999 13082.43 20957.82 percent of total billed charges ALLOGEN 2ML ALLOGRAFT ALB-0200S 49959080_1 CDM 0278 RC inpatient 21606 14043.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13082.43 60.55 999999999 13082.43 20957.82 percent of total billed charges ALLOGEN 2ML ALLOGRAFT ALB-0200S 49959080_1 CDM 0278 RC inpatient 21606 14043.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13082.43 20957.82 ALLOGEN 2ML ALLOGRAFT ALB-0200S 49959080_1 CDM 0278 RC inpatient 21606 14043.9 ANTHEM HMO ANTHEM HMO 999999999 13082.43 20957.82 ALLOGEN 2ML ALLOGRAFT ALB-0200S 49959080_1 CDM 0278 RC inpatient 21606 14043.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13082.43 20957.82 ALLOGEN 2ML ALLOGRAFT ALB-0200S 49959080_1 CDM 0278 RC inpatient 21606 14043.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 14605.66 67.6 999999999 13082.43 20957.82 percent of total billed charges ALLOGEN 2ML ALLOGRAFT ALB-0200S 49959080_1 CDM 0278 RC inpatient 21606 14043.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13082.43 20957.82 ALLOGEN 2ML ALLOGRAFT ALB-0200S 49959080_1 CDM 0278 RC inpatient 21606 14043.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 13082.43 20957.82 Application of Long Arm Splint add-on 49961006_1 CDM 0271 RC inpatient 257 167.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.05 65 999999999 155.61 249.29 percent of total billed charges Application of Long Arm Splint add-on 49961006_1 CDM 0271 RC inpatient 257 167.05 AETNA AETNA 203.03 79 999999999 155.61 249.29 percent of total billed charges Application of Long Arm Splint add-on 49961006_1 CDM 0271 RC inpatient 257 167.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 249.29 97 999999999 155.61 249.29 percent of total billed charges Application of Long Arm Splint add-on 49961006_1 CDM 0271 RC inpatient 257 167.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 177.33 69 999999999 155.61 249.29 percent of total billed charges Application of Long Arm Splint add-on 49961006_1 CDM 0271 RC inpatient 257 167.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 200.46 78 999999999 155.61 249.29 percent of total billed charges Application of Long Arm Splint add-on 49961006_1 CDM 0271 RC inpatient 257 167.05 SIHO - ALL PLANS SIHO - ALL PLANS 231.3 90 999999999 155.61 249.29 percent of total billed charges Application of Long Arm Splint add-on 49961006_1 CDM 0271 RC inpatient 257 167.05 UMR - ALL PLANS UMR - ALL PLANS 179.9 70 999999999 155.61 249.29 percent of total billed charges Application of Long Arm Splint add-on 49961006_1 CDM 0271 RC inpatient 257 167.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.61 60.55 999999999 155.61 249.29 percent of total billed charges Application of Long Arm Splint add-on 49961006_1 CDM 0271 RC inpatient 257 167.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.61 249.29 Application of Long Arm Splint add-on 49961006_1 CDM 0271 RC inpatient 257 167.05 ANTHEM HMO ANTHEM HMO 999999999 155.61 249.29 Application of Long Arm Splint add-on 49961006_1 CDM 0271 RC inpatient 257 167.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.61 249.29 Application of Long Arm Splint add-on 49961006_1 CDM 0271 RC inpatient 257 167.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.73 67.6 999999999 155.61 249.29 percent of total billed charges Application of Long Arm Splint add-on 49961006_1 CDM 0271 RC inpatient 257 167.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.61 249.29 Application of Long Arm Splint add-on 49961006_1 CDM 0271 RC inpatient 257 167.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.61 249.29 Application of Short Arm Splint add-on 49961007_1 CDM 0271 RC inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges Application of Short Arm Splint add-on 49961007_1 CDM 0271 RC inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges Application of Short Arm Splint add-on 49961007_1 CDM 0271 RC inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges Application of Short Arm Splint add-on 49961007_1 CDM 0271 RC inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges Application of Short Arm Splint add-on 49961007_1 CDM 0271 RC inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges Application of Short Arm Splint add-on 49961007_1 CDM 0271 RC inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges Application of Short Arm Splint add-on 49961007_1 CDM 0271 RC inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges Application of Short Arm Splint add-on 49961007_1 CDM 0271 RC inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges Application of Short Arm Splint add-on 49961007_1 CDM 0271 RC inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 Application of Short Arm Splint add-on 49961007_1 CDM 0271 RC inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 Application of Short Arm Splint add-on 49961007_1 CDM 0271 RC inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 Application of Short Arm Splint add-on 49961007_1 CDM 0271 RC inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges Application of Short Arm Splint add-on 49961007_1 CDM 0271 RC inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 Application of Short Arm Splint add-on 49961007_1 CDM 0271 RC inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 Application of Finger Splint add-on 49961008_1 CDM 0271 RC inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges Application of Finger Splint add-on 49961008_1 CDM 0271 RC inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges Application of Finger Splint add-on 49961008_1 CDM 0271 RC inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges Application of Finger Splint add-on 49961008_1 CDM 0271 RC inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges Application of Finger Splint add-on 49961008_1 CDM 0271 RC inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges Application of Finger Splint add-on 49961008_1 CDM 0271 RC inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges Application of Finger Splint add-on 49961008_1 CDM 0271 RC inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges Application of Finger Splint add-on 49961008_1 CDM 0271 RC inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges Application of Finger Splint add-on 49961008_1 CDM 0271 RC inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 Application of Finger Splint add-on 49961008_1 CDM 0271 RC inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 Application of Finger Splint add-on 49961008_1 CDM 0271 RC inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 Application of Finger Splint add-on 49961008_1 CDM 0271 RC inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges Application of Finger Splint add-on 49961008_1 CDM 0271 RC inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 Application of Finger Splint add-on 49961008_1 CDM 0271 RC inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 Application of Long Leg Splint add-on 49961009_1 CDM 0271 RC inpatient 295 191.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 191.75 65 999999999 178.62 286.15 percent of total billed charges Application of Long Leg Splint add-on 49961009_1 CDM 0271 RC inpatient 295 191.75 AETNA AETNA 233.05 79 999999999 178.62 286.15 percent of total billed charges Application of Long Leg Splint add-on 49961009_1 CDM 0271 RC inpatient 295 191.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 286.15 97 999999999 178.62 286.15 percent of total billed charges Application of Long Leg Splint add-on 49961009_1 CDM 0271 RC inpatient 295 191.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 203.55 69 999999999 178.62 286.15 percent of total billed charges Application of Long Leg Splint add-on 49961009_1 CDM 0271 RC inpatient 295 191.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 230.1 78 999999999 178.62 286.15 percent of total billed charges Application of Long Leg Splint add-on 49961009_1 CDM 0271 RC inpatient 295 191.75 SIHO - ALL PLANS SIHO - ALL PLANS 265.5 90 999999999 178.62 286.15 percent of total billed charges Application of Long Leg Splint add-on 49961009_1 CDM 0271 RC inpatient 295 191.75 UMR - ALL PLANS UMR - ALL PLANS 206.5 70 999999999 178.62 286.15 percent of total billed charges Application of Long Leg Splint add-on 49961009_1 CDM 0271 RC inpatient 295 191.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 178.62 60.55 999999999 178.62 286.15 percent of total billed charges Application of Long Leg Splint add-on 49961009_1 CDM 0271 RC inpatient 295 191.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 178.62 286.15 Application of Long Leg Splint add-on 49961009_1 CDM 0271 RC inpatient 295 191.75 ANTHEM HMO ANTHEM HMO 999999999 178.62 286.15 Application of Long Leg Splint add-on 49961009_1 CDM 0271 RC inpatient 295 191.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 178.62 286.15 Application of Long Leg Splint add-on 49961009_1 CDM 0271 RC inpatient 295 191.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 199.42 67.6 999999999 178.62 286.15 percent of total billed charges Application of Long Leg Splint add-on 49961009_1 CDM 0271 RC inpatient 295 191.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 178.62 286.15 Application of Long Leg Splint add-on 49961009_1 CDM 0271 RC inpatient 295 191.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 178.62 286.15 Application of Short Leg Splint add-on 49961010_1 CDM 0271 RC inpatient 243 157.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 157.95 65 999999999 147.14 235.71 percent of total billed charges Application of Short Leg Splint add-on 49961010_1 CDM 0271 RC inpatient 243 157.95 AETNA AETNA 191.97 79 999999999 147.14 235.71 percent of total billed charges Application of Short Leg Splint add-on 49961010_1 CDM 0271 RC inpatient 243 157.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 235.71 97 999999999 147.14 235.71 percent of total billed charges Application of Short Leg Splint add-on 49961010_1 CDM 0271 RC inpatient 243 157.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 167.67 69 999999999 147.14 235.71 percent of total billed charges Application of Short Leg Splint add-on 49961010_1 CDM 0271 RC inpatient 243 157.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 189.54 78 999999999 147.14 235.71 percent of total billed charges Application of Short Leg Splint add-on 49961010_1 CDM 0271 RC inpatient 243 157.95 SIHO - ALL PLANS SIHO - ALL PLANS 218.7 90 999999999 147.14 235.71 percent of total billed charges Application of Short Leg Splint add-on 49961010_1 CDM 0271 RC inpatient 243 157.95 UMR - ALL PLANS UMR - ALL PLANS 170.1 70 999999999 147.14 235.71 percent of total billed charges Application of Short Leg Splint add-on 49961010_1 CDM 0271 RC inpatient 243 157.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.14 60.55 999999999 147.14 235.71 percent of total billed charges Application of Short Leg Splint add-on 49961010_1 CDM 0271 RC inpatient 243 157.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.14 235.71 Application of Short Leg Splint add-on 49961010_1 CDM 0271 RC inpatient 243 157.95 ANTHEM HMO ANTHEM HMO 999999999 147.14 235.71 Application of Short Leg Splint add-on 49961010_1 CDM 0271 RC inpatient 243 157.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.14 235.71 Application of Short Leg Splint add-on 49961010_1 CDM 0271 RC inpatient 243 157.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.27 67.6 999999999 147.14 235.71 percent of total billed charges Application of Short Leg Splint add-on 49961010_1 CDM 0271 RC inpatient 243 157.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.14 235.71 Application of Short Leg Splint add-on 49961010_1 CDM 0271 RC inpatient 243 157.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.14 235.71 HYDROCHLOROTHIAZIDE 25 MG TAB 49961346_1 CDM 0250 RC 16729-0183-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges HYDROCHLOROTHIAZIDE 25 MG TAB 49961346_1 CDM 0250 RC 16729-0183-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges HYDROCHLOROTHIAZIDE 25 MG TAB 49961346_1 CDM 0250 RC 16729-0183-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges HYDROCHLOROTHIAZIDE 25 MG TAB 49961346_1 CDM 0250 RC 16729-0183-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges HYDROCHLOROTHIAZIDE 25 MG TAB 49961346_1 CDM 0250 RC 16729-0183-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges HYDROCHLOROTHIAZIDE 25 MG TAB 49961346_1 CDM 0250 RC 16729-0183-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges HYDROCHLOROTHIAZIDE 25 MG TAB 49961346_1 CDM 0250 RC 16729-0183-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges HYDROCHLOROTHIAZIDE 25 MG TAB 49961346_1 CDM 0250 RC 16729-0183-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges HYDROCHLOROTHIAZIDE 25 MG TAB 49961346_1 CDM 0250 RC 16729-0183-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 HYDROCHLOROTHIAZIDE 25 MG TAB 49961346_1 CDM 0250 RC 16729-0183-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 HYDROCHLOROTHIAZIDE 25 MG TAB 49961346_1 CDM 0250 RC 16729-0183-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 HYDROCHLOROTHIAZIDE 25 MG TAB 49961346_1 CDM 0250 RC 16729-0183-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges HYDROCHLOROTHIAZIDE 25 MG TAB 49961346_1 CDM 0250 RC 16729-0183-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 HYDROCHLOROTHIAZIDE 25 MG TAB 49961346_1 CDM 0250 RC 16729-0183-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 PYRIDOSTIGMINE BR 60 MG TABLET 49962593_1 CDM 0250 RC 68382-0659-06 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges PYRIDOSTIGMINE BR 60 MG TABLET 49962593_1 CDM 0250 RC 68382-0659-06 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges PYRIDOSTIGMINE BR 60 MG TABLET 49962593_1 CDM 0250 RC 68382-0659-06 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges PYRIDOSTIGMINE BR 60 MG TABLET 49962593_1 CDM 0250 RC 68382-0659-06 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges PYRIDOSTIGMINE BR 60 MG TABLET 49962593_1 CDM 0250 RC 68382-0659-06 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges PYRIDOSTIGMINE BR 60 MG TABLET 49962593_1 CDM 0250 RC 68382-0659-06 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges PYRIDOSTIGMINE BR 60 MG TABLET 49962593_1 CDM 0250 RC 68382-0659-06 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges PYRIDOSTIGMINE BR 60 MG TABLET 49962593_1 CDM 0250 RC 68382-0659-06 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges PYRIDOSTIGMINE BR 60 MG TABLET 49962593_1 CDM 0250 RC 68382-0659-06 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 PYRIDOSTIGMINE BR 60 MG TABLET 49962593_1 CDM 0250 RC 68382-0659-06 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 PYRIDOSTIGMINE BR 60 MG TABLET 49962593_1 CDM 0250 RC 68382-0659-06 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 PYRIDOSTIGMINE BR 60 MG TABLET 49962593_1 CDM 0250 RC 68382-0659-06 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges PYRIDOSTIGMINE BR 60 MG TABLET 49962593_1 CDM 0250 RC 68382-0659-06 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 PYRIDOSTIGMINE BR 60 MG TABLET 49962593_1 CDM 0250 RC 68382-0659-06 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 Analysis for antibody to aspergillus (fungus) 49963774_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963774_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963774_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963774_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963774_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963774_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963774_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963774_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963774_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 49963774_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 49963774_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 49963774_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963774_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 49963774_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 49963776_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963776_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963776_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963776_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963776_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963776_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963776_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963776_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963776_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 49963776_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 49963776_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 49963776_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963776_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 49963776_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 49963778_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963778_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963778_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963778_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963778_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963778_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963778_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963778_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963778_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 49963778_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 49963778_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 49963778_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges Analysis for antibody to aspergillus (fungus) 49963778_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 Analysis for antibody to aspergillus (fungus) 49963778_1 CDM 0301 RC 86606 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 Immunologic analysis for detection of antigen or antibody 49963780_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963780_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963780_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963780_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963780_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963780_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963780_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963780_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963780_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 49963780_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 49963780_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 49963780_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963780_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 49963780_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 49963782_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963782_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963782_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963782_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963782_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963782_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963782_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963782_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963782_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 49963782_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 49963782_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 49963782_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963782_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 49963782_1 CDM 0301 RC 86331 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 49963784_1 CDM 0300 RC 86331 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963784_1 CDM 0300 RC 86331 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963784_1 CDM 0300 RC 86331 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963784_1 CDM 0300 RC 86331 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963784_1 CDM 0300 RC 86331 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963784_1 CDM 0300 RC 86331 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963784_1 CDM 0300 RC 86331 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963784_1 CDM 0300 RC 86331 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963784_1 CDM 0300 RC 86331 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 49963784_1 CDM 0300 RC 86331 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 49963784_1 CDM 0300 RC 86331 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 49963784_1 CDM 0300 RC 86331 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Immunologic analysis for detection of antigen or antibody 49963784_1 CDM 0300 RC 86331 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Immunologic analysis for detection of antigen or antibody 49963784_1 CDM 0300 RC 86331 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963786_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963822_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963822_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963822_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963822_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963822_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963822_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963822_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963822_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963822_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963822_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963822_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963822_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963822_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49963822_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 Proinsulin (pancreatic hormone) level 49963824_1 CDM 0301 RC 84206 HCPCS inpatient 240 156 SELF PAY DISCOUNT SELF PAY DISCOUNT 156 65 999999999 145.32 232.8 percent of total billed charges Proinsulin (pancreatic hormone) level 49963824_1 CDM 0301 RC 84206 HCPCS inpatient 240 156 AETNA AETNA 189.6 79 999999999 145.32 232.8 percent of total billed charges Proinsulin (pancreatic hormone) level 49963824_1 CDM 0301 RC 84206 HCPCS inpatient 240 156 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 232.8 97 999999999 145.32 232.8 percent of total billed charges Proinsulin (pancreatic hormone) level 49963824_1 CDM 0301 RC 84206 HCPCS inpatient 240 156 ENCORE - ALL PLANS ENCORE - ALL PLANS 165.6 69 999999999 145.32 232.8 percent of total billed charges Proinsulin (pancreatic hormone) level 49963824_1 CDM 0301 RC 84206 HCPCS inpatient 240 156 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.2 78 999999999 145.32 232.8 percent of total billed charges Proinsulin (pancreatic hormone) level 49963824_1 CDM 0301 RC 84206 HCPCS inpatient 240 156 UMR - ALL PLANS UMR - ALL PLANS 168 70 999999999 145.32 232.8 percent of total billed charges Proinsulin (pancreatic hormone) level 49963824_1 CDM 0301 RC 84206 HCPCS inpatient 240 156 SIHO - ALL PLANS SIHO - ALL PLANS 216 90 999999999 145.32 232.8 percent of total billed charges Proinsulin (pancreatic hormone) level 49963824_1 CDM 0301 RC 84206 HCPCS inpatient 240 156 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.32 60.55 999999999 145.32 232.8 percent of total billed charges Proinsulin (pancreatic hormone) level 49963824_1 CDM 0301 RC 84206 HCPCS inpatient 240 156 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.32 232.8 Proinsulin (pancreatic hormone) level 49963824_1 CDM 0301 RC 84206 HCPCS inpatient 240 156 ANTHEM HMO ANTHEM HMO 999999999 145.32 232.8 Proinsulin (pancreatic hormone) level 49963824_1 CDM 0301 RC 84206 HCPCS inpatient 240 156 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.32 232.8 Proinsulin (pancreatic hormone) level 49963824_1 CDM 0301 RC 84206 HCPCS inpatient 240 156 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.24 67.6 999999999 145.32 232.8 percent of total billed charges Proinsulin (pancreatic hormone) level 49963824_1 CDM 0301 RC 84206 HCPCS inpatient 240 156 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.32 232.8 Proinsulin (pancreatic hormone) level 49963824_1 CDM 0301 RC 84206 HCPCS inpatient 240 156 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.32 232.8 Analysis for antibody to Brucella (bacteria) 49963827_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49963827_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49963827_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49963827_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49963827_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49963827_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49963827_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49963827_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49963827_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 49963827_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 49963827_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 49963827_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49963827_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 49963827_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 49963829_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49963829_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49963829_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49963829_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49963829_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49963829_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49963829_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49963829_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49963829_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 49963829_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 49963829_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 49963829_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49963829_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 49963829_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 42037-1047-88 - carbamide peroxide otic 6.5% 0.065 Soln 49963877_1 CDM 0250 RC 42037-1047-88 NDC inpatient 1 UN 8.82 5.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.73 65 999999999 5.34 8.56 percent of total billed charges 42037-1047-88 - carbamide peroxide otic 6.5% 0.065 Soln 49963877_1 CDM 0250 RC 42037-1047-88 NDC inpatient 1 UN 8.82 5.73 AETNA AETNA 6.97 79 999999999 5.34 8.56 percent of total billed charges 42037-1047-88 - carbamide peroxide otic 6.5% 0.065 Soln 49963877_1 CDM 0250 RC 42037-1047-88 NDC inpatient 1 UN 8.82 5.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.56 97 999999999 5.34 8.56 percent of total billed charges 42037-1047-88 - carbamide peroxide otic 6.5% 0.065 Soln 49963877_1 CDM 0250 RC 42037-1047-88 NDC inpatient 1 UN 8.82 5.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.09 69 999999999 5.34 8.56 percent of total billed charges 42037-1047-88 - carbamide peroxide otic 6.5% 0.065 Soln 49963877_1 CDM 0250 RC 42037-1047-88 NDC inpatient 1 UN 8.82 5.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.88 78 999999999 5.34 8.56 percent of total billed charges 42037-1047-88 - carbamide peroxide otic 6.5% 0.065 Soln 49963877_1 CDM 0250 RC 42037-1047-88 NDC inpatient 1 UN 8.82 5.73 UMR - ALL PLANS UMR - ALL PLANS 6.17 70 999999999 5.34 8.56 percent of total billed charges 42037-1047-88 - carbamide peroxide otic 6.5% 0.065 Soln 49963877_1 CDM 0250 RC 42037-1047-88 NDC inpatient 1 UN 8.82 5.73 SIHO - ALL PLANS SIHO - ALL PLANS 7.94 90 999999999 5.34 8.56 percent of total billed charges 42037-1047-88 - carbamide peroxide otic 6.5% 0.065 Soln 49963877_1 CDM 0250 RC 42037-1047-88 NDC inpatient 1 UN 8.82 5.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.34 60.55 999999999 5.34 8.56 percent of total billed charges 42037-1047-88 - carbamide peroxide otic 6.5% 0.065 Soln 49963877_1 CDM 0250 RC 42037-1047-88 NDC inpatient 1 UN 8.82 5.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.34 8.56 42037-1047-88 - carbamide peroxide otic 6.5% 0.065 Soln 49963877_1 CDM 0250 RC 42037-1047-88 NDC inpatient 1 UN 8.82 5.73 ANTHEM HMO ANTHEM HMO 999999999 5.34 8.56 42037-1047-88 - carbamide peroxide otic 6.5% 0.065 Soln 49963877_1 CDM 0250 RC 42037-1047-88 NDC inpatient 1 UN 8.82 5.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.34 8.56 42037-1047-88 - carbamide peroxide otic 6.5% 0.065 Soln 49963877_1 CDM 0250 RC 42037-1047-88 NDC inpatient 1 UN 8.82 5.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.96 67.6 999999999 5.34 8.56 percent of total billed charges 42037-1047-88 - carbamide peroxide otic 6.5% 0.065 Soln 49963877_1 CDM 0250 RC 42037-1047-88 NDC inpatient 1 UN 8.82 5.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.34 8.56 42037-1047-88 - carbamide peroxide otic 6.5% 0.065 Soln 49963877_1 CDM 0250 RC 42037-1047-88 NDC inpatient 1 UN 8.82 5.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.34 8.56 ARTIFICIAL TEARS DROPS 49963880_1 CDM 0250 RC 57896-0181-05 NDC inpatient 1 UN 2.93 1.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.9 65 999999999 1.77 2.84 percent of total billed charges ARTIFICIAL TEARS DROPS 49963880_1 CDM 0250 RC 57896-0181-05 NDC inpatient 1 UN 2.93 1.9 AETNA AETNA 2.31 79 999999999 1.77 2.84 percent of total billed charges ARTIFICIAL TEARS DROPS 49963880_1 CDM 0250 RC 57896-0181-05 NDC inpatient 1 UN 2.93 1.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.84 97 999999999 1.77 2.84 percent of total billed charges ARTIFICIAL TEARS DROPS 49963880_1 CDM 0250 RC 57896-0181-05 NDC inpatient 1 UN 2.93 1.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.02 69 999999999 1.77 2.84 percent of total billed charges ARTIFICIAL TEARS DROPS 49963880_1 CDM 0250 RC 57896-0181-05 NDC inpatient 1 UN 2.93 1.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.29 78 999999999 1.77 2.84 percent of total billed charges ARTIFICIAL TEARS DROPS 49963880_1 CDM 0250 RC 57896-0181-05 NDC inpatient 1 UN 2.93 1.9 UMR - ALL PLANS UMR - ALL PLANS 2.05 70 999999999 1.77 2.84 percent of total billed charges ARTIFICIAL TEARS DROPS 49963880_1 CDM 0250 RC 57896-0181-05 NDC inpatient 1 UN 2.93 1.9 SIHO - ALL PLANS SIHO - ALL PLANS 2.64 90 999999999 1.77 2.84 percent of total billed charges ARTIFICIAL TEARS DROPS 49963880_1 CDM 0250 RC 57896-0181-05 NDC inpatient 1 UN 2.93 1.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.77 60.55 999999999 1.77 2.84 percent of total billed charges ARTIFICIAL TEARS DROPS 49963880_1 CDM 0250 RC 57896-0181-05 NDC inpatient 1 UN 2.93 1.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.77 2.84 ARTIFICIAL TEARS DROPS 49963880_1 CDM 0250 RC 57896-0181-05 NDC inpatient 1 UN 2.93 1.9 ANTHEM HMO ANTHEM HMO 999999999 1.77 2.84 ARTIFICIAL TEARS DROPS 49963880_1 CDM 0250 RC 57896-0181-05 NDC inpatient 1 UN 2.93 1.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.77 2.84 ARTIFICIAL TEARS DROPS 49963880_1 CDM 0250 RC 57896-0181-05 NDC inpatient 1 UN 2.93 1.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.98 67.6 999999999 1.77 2.84 percent of total billed charges ARTIFICIAL TEARS DROPS 49963880_1 CDM 0250 RC 57896-0181-05 NDC inpatient 1 UN 2.93 1.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.77 2.84 ARTIFICIAL TEARS DROPS 49963880_1 CDM 0250 RC 57896-0181-05 NDC inpatient 1 UN 2.93 1.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.77 2.84 NALOXONE 0.4 MG/ML VIAL 49964266_1 CDM 0250 RC 70069-0071-10 NDC inpatient 1 UN 38.48 25.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 25.01 65 999999999 23.3 37.33 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 49964266_1 CDM 0250 RC 70069-0071-10 NDC inpatient 1 UN 38.48 25.01 AETNA AETNA 30.4 79 999999999 23.3 37.33 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 49964266_1 CDM 0250 RC 70069-0071-10 NDC inpatient 1 UN 38.48 25.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37.33 97 999999999 23.3 37.33 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 49964266_1 CDM 0250 RC 70069-0071-10 NDC inpatient 1 UN 38.48 25.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.55 69 999999999 23.3 37.33 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 49964266_1 CDM 0250 RC 70069-0071-10 NDC inpatient 1 UN 38.48 25.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 30.01 78 999999999 23.3 37.33 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 49964266_1 CDM 0250 RC 70069-0071-10 NDC inpatient 1 UN 38.48 25.01 UMR - ALL PLANS UMR - ALL PLANS 26.94 70 999999999 23.3 37.33 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 49964266_1 CDM 0250 RC 70069-0071-10 NDC inpatient 1 UN 38.48 25.01 SIHO - ALL PLANS SIHO - ALL PLANS 34.63 90 999999999 23.3 37.33 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 49964266_1 CDM 0250 RC 70069-0071-10 NDC inpatient 1 UN 38.48 25.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.3 60.55 999999999 23.3 37.33 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 49964266_1 CDM 0250 RC 70069-0071-10 NDC inpatient 1 UN 38.48 25.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.3 37.33 NALOXONE 0.4 MG/ML VIAL 49964266_1 CDM 0250 RC 70069-0071-10 NDC inpatient 1 UN 38.48 25.01 ANTHEM HMO ANTHEM HMO 999999999 23.3 37.33 NALOXONE 0.4 MG/ML VIAL 49964266_1 CDM 0250 RC 70069-0071-10 NDC inpatient 1 UN 38.48 25.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.3 37.33 NALOXONE 0.4 MG/ML VIAL 49964266_1 CDM 0250 RC 70069-0071-10 NDC inpatient 1 UN 38.48 25.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 26.01 67.6 999999999 23.3 37.33 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 49964266_1 CDM 0250 RC 70069-0071-10 NDC inpatient 1 UN 38.48 25.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.3 37.33 NALOXONE 0.4 MG/ML VIAL 49964266_1 CDM 0250 RC 70069-0071-10 NDC inpatient 1 UN 38.48 25.01 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.3 37.33 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964313_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964313_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964313_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964313_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964313_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964313_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964313_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964313_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964313_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964313_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964313_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964313_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964313_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964313_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964314_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964314_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964314_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964314_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964314_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964314_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964314_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964314_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964314_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964314_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964314_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964314_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964314_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964314_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964318_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964318_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964318_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964318_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964318_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964318_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964318_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964318_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964318_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964318_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964318_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964318_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964318_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964318_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 49964333_1 CDM 0302 RC 87633 HCPCS inpatient 827 537.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 537.55 65 999999999 500.75 802.19 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 49964333_1 CDM 0302 RC 87633 HCPCS inpatient 827 537.55 AETNA AETNA 653.33 79 999999999 500.75 802.19 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 49964333_1 CDM 0302 RC 87633 HCPCS inpatient 827 537.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 802.19 97 999999999 500.75 802.19 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 49964333_1 CDM 0302 RC 87633 HCPCS inpatient 827 537.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 570.63 69 999999999 500.75 802.19 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 49964333_1 CDM 0302 RC 87633 HCPCS inpatient 827 537.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 645.06 78 999999999 500.75 802.19 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 49964333_1 CDM 0302 RC 87633 HCPCS inpatient 827 537.55 UMR - ALL PLANS UMR - ALL PLANS 578.9 70 999999999 500.75 802.19 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 49964333_1 CDM 0302 RC 87633 HCPCS inpatient 827 537.55 SIHO - ALL PLANS SIHO - ALL PLANS 744.3 90 999999999 500.75 802.19 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 49964333_1 CDM 0302 RC 87633 HCPCS inpatient 827 537.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 500.75 60.55 999999999 500.75 802.19 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 49964333_1 CDM 0302 RC 87633 HCPCS inpatient 827 537.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 500.75 802.19 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 49964333_1 CDM 0302 RC 87633 HCPCS inpatient 827 537.55 ANTHEM HMO ANTHEM HMO 999999999 500.75 802.19 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 49964333_1 CDM 0302 RC 87633 HCPCS inpatient 827 537.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 500.75 802.19 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 49964333_1 CDM 0302 RC 87633 HCPCS inpatient 827 537.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 559.05 67.6 999999999 500.75 802.19 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 49964333_1 CDM 0302 RC 87633 HCPCS inpatient 827 537.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 500.75 802.19 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 49964333_1 CDM 0302 RC 87633 HCPCS inpatient 827 537.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 500.75 802.19 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964689_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964689_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964689_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964689_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964689_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964689_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964689_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964689_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964689_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964689_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964689_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964689_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964689_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964689_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964753_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964753_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964753_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964753_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964753_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964753_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964753_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964753_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964753_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964753_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964753_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964753_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964753_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964753_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964754_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964754_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964754_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964754_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964754_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964754_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964754_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964754_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964754_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964754_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964754_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964754_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964754_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964754_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964770_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964770_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964770_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964770_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964770_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964770_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964770_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964770_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964770_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964770_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964770_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964770_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964770_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964770_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964771_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964771_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964771_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964771_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964771_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964771_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964771_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964771_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964771_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964771_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964771_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964771_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964771_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964771_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964772_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964772_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964772_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964772_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964772_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964772_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964772_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964772_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964772_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964772_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964772_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964772_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964772_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49964772_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 HALOPERIDOL LAC 5 MG/ML VIAL 49964832_1 CDM 0250 RC 63323-0474-01 NDC inpatient 510 UN 19.91 12.94 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.94 65 999999999 12.06 19.31 percent of total billed charges HALOPERIDOL LAC 5 MG/ML VIAL 49964832_1 CDM 0250 RC 63323-0474-01 NDC inpatient 510 UN 19.91 12.94 AETNA AETNA 15.73 79 999999999 12.06 19.31 percent of total billed charges HALOPERIDOL LAC 5 MG/ML VIAL 49964832_1 CDM 0250 RC 63323-0474-01 NDC inpatient 510 UN 19.91 12.94 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.31 97 999999999 12.06 19.31 percent of total billed charges HALOPERIDOL LAC 5 MG/ML VIAL 49964832_1 CDM 0250 RC 63323-0474-01 NDC inpatient 510 UN 19.91 12.94 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.74 69 999999999 12.06 19.31 percent of total billed charges HALOPERIDOL LAC 5 MG/ML VIAL 49964832_1 CDM 0250 RC 63323-0474-01 NDC inpatient 510 UN 19.91 12.94 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.53 78 999999999 12.06 19.31 percent of total billed charges HALOPERIDOL LAC 5 MG/ML VIAL 49964832_1 CDM 0250 RC 63323-0474-01 NDC inpatient 510 UN 19.91 12.94 UMR - ALL PLANS UMR - ALL PLANS 13.94 70 999999999 12.06 19.31 percent of total billed charges HALOPERIDOL LAC 5 MG/ML VIAL 49964832_1 CDM 0250 RC 63323-0474-01 NDC inpatient 510 UN 19.91 12.94 SIHO - ALL PLANS SIHO - ALL PLANS 17.92 90 999999999 12.06 19.31 percent of total billed charges HALOPERIDOL LAC 5 MG/ML VIAL 49964832_1 CDM 0250 RC 63323-0474-01 NDC inpatient 510 UN 19.91 12.94 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.06 60.55 999999999 12.06 19.31 percent of total billed charges HALOPERIDOL LAC 5 MG/ML VIAL 49964832_1 CDM 0250 RC 63323-0474-01 NDC inpatient 510 UN 19.91 12.94 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.06 19.31 HALOPERIDOL LAC 5 MG/ML VIAL 49964832_1 CDM 0250 RC 63323-0474-01 NDC inpatient 510 UN 19.91 12.94 ANTHEM HMO ANTHEM HMO 999999999 12.06 19.31 HALOPERIDOL LAC 5 MG/ML VIAL 49964832_1 CDM 0250 RC 63323-0474-01 NDC inpatient 510 UN 19.91 12.94 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.06 19.31 HALOPERIDOL LAC 5 MG/ML VIAL 49964832_1 CDM 0250 RC 63323-0474-01 NDC inpatient 510 UN 19.91 12.94 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.46 67.6 999999999 12.06 19.31 percent of total billed charges HALOPERIDOL LAC 5 MG/ML VIAL 49964832_1 CDM 0250 RC 63323-0474-01 NDC inpatient 510 UN 19.91 12.94 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.06 19.31 HALOPERIDOL LAC 5 MG/ML VIAL 49964832_1 CDM 0250 RC 63323-0474-01 NDC inpatient 510 UN 19.91 12.94 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.06 19.31 LEFLUNOMIDE 20 MG TABLET 49964833_1 CDM 0250 RC 62332-0062-30 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LEFLUNOMIDE 20 MG TABLET 49964833_1 CDM 0250 RC 62332-0062-30 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LEFLUNOMIDE 20 MG TABLET 49964833_1 CDM 0250 RC 62332-0062-30 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LEFLUNOMIDE 20 MG TABLET 49964833_1 CDM 0250 RC 62332-0062-30 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LEFLUNOMIDE 20 MG TABLET 49964833_1 CDM 0250 RC 62332-0062-30 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LEFLUNOMIDE 20 MG TABLET 49964833_1 CDM 0250 RC 62332-0062-30 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LEFLUNOMIDE 20 MG TABLET 49964833_1 CDM 0250 RC 62332-0062-30 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LEFLUNOMIDE 20 MG TABLET 49964833_1 CDM 0250 RC 62332-0062-30 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LEFLUNOMIDE 20 MG TABLET 49964833_1 CDM 0250 RC 62332-0062-30 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LEFLUNOMIDE 20 MG TABLET 49964833_1 CDM 0250 RC 62332-0062-30 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LEFLUNOMIDE 20 MG TABLET 49964833_1 CDM 0250 RC 62332-0062-30 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LEFLUNOMIDE 20 MG TABLET 49964833_1 CDM 0250 RC 62332-0062-30 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges LEFLUNOMIDE 20 MG TABLET 49964833_1 CDM 0250 RC 62332-0062-30 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LEFLUNOMIDE 20 MG TABLET 49964833_1 CDM 0250 RC 62332-0062-30 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965002_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965002_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965002_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965002_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965002_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965002_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965002_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965002_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965002_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965002_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965002_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965002_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965002_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965002_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965003_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965003_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965003_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965003_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965003_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965003_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965003_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965003_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965003_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965003_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965003_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965003_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965003_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965003_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965004_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965004_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965004_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965004_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965004_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965004_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965004_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965004_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965004_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965004_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965004_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965004_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965004_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965004_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965005_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965005_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965005_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965005_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965005_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965005_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965005_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965005_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965005_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965005_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965005_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965005_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965005_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965005_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965006_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965006_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965006_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965006_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965006_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965006_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965006_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965006_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965006_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965006_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965006_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965006_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965006_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49965006_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965017_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.45 65 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965017_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 AETNA AETNA 41.87 79 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965017_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.41 97 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965017_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.57 69 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965017_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.34 78 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965017_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UMR - ALL PLANS UMR - ALL PLANS 37.1 70 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965017_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SIHO - ALL PLANS SIHO - ALL PLANS 47.7 90 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965017_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.09 60.55 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965017_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965017_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM HMO ANTHEM HMO 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965017_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965017_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.83 67.6 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965017_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965017_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965018_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.45 65 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965018_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 AETNA AETNA 41.87 79 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965018_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.41 97 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965018_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.57 69 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965018_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.34 78 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965018_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UMR - ALL PLANS UMR - ALL PLANS 37.1 70 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965018_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SIHO - ALL PLANS SIHO - ALL PLANS 47.7 90 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965018_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.09 60.55 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965018_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965018_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM HMO ANTHEM HMO 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965018_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965018_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.83 67.6 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965018_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965018_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965019_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.45 65 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965019_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 AETNA AETNA 41.87 79 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965019_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.41 97 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965019_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.57 69 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965019_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.34 78 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965019_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UMR - ALL PLANS UMR - ALL PLANS 37.1 70 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965019_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SIHO - ALL PLANS SIHO - ALL PLANS 47.7 90 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965019_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.09 60.55 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965019_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965019_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM HMO ANTHEM HMO 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965019_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965019_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.83 67.6 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965019_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965019_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965022_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.45 65 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965022_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 AETNA AETNA 41.87 79 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965022_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.41 97 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965022_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.57 69 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965022_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.34 78 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965022_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UMR - ALL PLANS UMR - ALL PLANS 37.1 70 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965022_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SIHO - ALL PLANS SIHO - ALL PLANS 47.7 90 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965022_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.09 60.55 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965022_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965022_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM HMO ANTHEM HMO 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965022_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965022_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.83 67.6 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965022_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965022_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965023_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.45 65 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965023_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 AETNA AETNA 41.87 79 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965023_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.41 97 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965023_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.57 69 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965023_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.34 78 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965023_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UMR - ALL PLANS UMR - ALL PLANS 37.1 70 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965023_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SIHO - ALL PLANS SIHO - ALL PLANS 47.7 90 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965023_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.09 60.55 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965023_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965023_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM HMO ANTHEM HMO 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965023_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965023_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.83 67.6 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49965023_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49965023_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.09 51.41 "INJECTION, METHOTREXATE SODIUM, 50 MG" 49967638_1 CDM 0636 RC 00143-9519-10 NDC J9260 HCPCS inpatient 1 UN 33.1 21.52 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.52 65 999999999 20.04 32.11 percent of total billed charges "INJECTION, METHOTREXATE SODIUM, 50 MG" 49967638_1 CDM 0636 RC 00143-9519-10 NDC J9260 HCPCS inpatient 1 UN 33.1 21.52 AETNA AETNA 26.15 79 999999999 20.04 32.11 percent of total billed charges "INJECTION, METHOTREXATE SODIUM, 50 MG" 49967638_1 CDM 0636 RC 00143-9519-10 NDC J9260 HCPCS inpatient 1 UN 33.1 21.52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.11 97 999999999 20.04 32.11 percent of total billed charges "INJECTION, METHOTREXATE SODIUM, 50 MG" 49967638_1 CDM 0636 RC 00143-9519-10 NDC J9260 HCPCS inpatient 1 UN 33.1 21.52 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.84 69 999999999 20.04 32.11 percent of total billed charges "INJECTION, METHOTREXATE SODIUM, 50 MG" 49967638_1 CDM 0636 RC 00143-9519-10 NDC J9260 HCPCS inpatient 1 UN 33.1 21.52 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.82 78 999999999 20.04 32.11 percent of total billed charges "INJECTION, METHOTREXATE SODIUM, 50 MG" 49967638_1 CDM 0636 RC 00143-9519-10 NDC J9260 HCPCS inpatient 1 UN 33.1 21.52 UMR - ALL PLANS UMR - ALL PLANS 23.17 70 999999999 20.04 32.11 percent of total billed charges "INJECTION, METHOTREXATE SODIUM, 50 MG" 49967638_1 CDM 0636 RC 00143-9519-10 NDC J9260 HCPCS inpatient 1 UN 33.1 21.52 SIHO - ALL PLANS SIHO - ALL PLANS 29.79 90 999999999 20.04 32.11 percent of total billed charges "INJECTION, METHOTREXATE SODIUM, 50 MG" 49967638_1 CDM 0636 RC 00143-9519-10 NDC J9260 HCPCS inpatient 1 UN 33.1 21.52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.04 60.55 999999999 20.04 32.11 percent of total billed charges "INJECTION, METHOTREXATE SODIUM, 50 MG" 49967638_1 CDM 0636 RC 00143-9519-10 NDC J9260 HCPCS inpatient 1 UN 33.1 21.52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.04 32.11 "INJECTION, METHOTREXATE SODIUM, 50 MG" 49967638_1 CDM 0636 RC 00143-9519-10 NDC J9260 HCPCS inpatient 1 UN 33.1 21.52 ANTHEM HMO ANTHEM HMO 999999999 20.04 32.11 "INJECTION, METHOTREXATE SODIUM, 50 MG" 49967638_1 CDM 0636 RC 00143-9519-10 NDC J9260 HCPCS inpatient 1 UN 33.1 21.52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.04 32.11 "INJECTION, METHOTREXATE SODIUM, 50 MG" 49967638_1 CDM 0636 RC 00143-9519-10 NDC J9260 HCPCS inpatient 1 UN 33.1 21.52 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.38 67.6 999999999 20.04 32.11 percent of total billed charges "INJECTION, METHOTREXATE SODIUM, 50 MG" 49967638_1 CDM 0636 RC 00143-9519-10 NDC J9260 HCPCS inpatient 1 UN 33.1 21.52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.04 32.11 "INJECTION, METHOTREXATE SODIUM, 50 MG" 49967638_1 CDM 0636 RC 00143-9519-10 NDC J9260 HCPCS inpatient 1 UN 33.1 21.52 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.04 32.11 Rabies immune globulin for injection 49968084_1 CDM 0636 RC 13533-0318-01 NDC 90375 HCPCS inpatient 2 UN 961.47 624.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 624.96 65 999999999 582.17 932.63 percent of total billed charges Rabies immune globulin for injection 49968084_1 CDM 0636 RC 13533-0318-01 NDC 90375 HCPCS inpatient 2 UN 961.47 624.96 AETNA AETNA 759.56 79 999999999 582.17 932.63 percent of total billed charges Rabies immune globulin for injection 49968084_1 CDM 0636 RC 13533-0318-01 NDC 90375 HCPCS inpatient 2 UN 961.47 624.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 932.63 97 999999999 582.17 932.63 percent of total billed charges Rabies immune globulin for injection 49968084_1 CDM 0636 RC 13533-0318-01 NDC 90375 HCPCS inpatient 2 UN 961.47 624.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 663.41 69 999999999 582.17 932.63 percent of total billed charges Rabies immune globulin for injection 49968084_1 CDM 0636 RC 13533-0318-01 NDC 90375 HCPCS inpatient 2 UN 961.47 624.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 749.95 78 999999999 582.17 932.63 percent of total billed charges Rabies immune globulin for injection 49968084_1 CDM 0636 RC 13533-0318-01 NDC 90375 HCPCS inpatient 2 UN 961.47 624.96 UMR - ALL PLANS UMR - ALL PLANS 673.03 70 999999999 582.17 932.63 percent of total billed charges Rabies immune globulin for injection 49968084_1 CDM 0636 RC 13533-0318-01 NDC 90375 HCPCS inpatient 2 UN 961.47 624.96 SIHO - ALL PLANS SIHO - ALL PLANS 865.32 90 999999999 582.17 932.63 percent of total billed charges Rabies immune globulin for injection 49968084_1 CDM 0636 RC 13533-0318-01 NDC 90375 HCPCS inpatient 2 UN 961.47 624.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 582.17 60.55 999999999 582.17 932.63 percent of total billed charges Rabies immune globulin for injection 49968084_1 CDM 0636 RC 13533-0318-01 NDC 90375 HCPCS inpatient 2 UN 961.47 624.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 582.17 932.63 Rabies immune globulin for injection 49968084_1 CDM 0636 RC 13533-0318-01 NDC 90375 HCPCS inpatient 2 UN 961.47 624.96 ANTHEM HMO ANTHEM HMO 999999999 582.17 932.63 Rabies immune globulin for injection 49968084_1 CDM 0636 RC 13533-0318-01 NDC 90375 HCPCS inpatient 2 UN 961.47 624.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 582.17 932.63 Rabies immune globulin for injection 49968084_1 CDM 0636 RC 13533-0318-01 NDC 90375 HCPCS inpatient 2 UN 961.47 624.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 649.95 67.6 999999999 582.17 932.63 percent of total billed charges Rabies immune globulin for injection 49968084_1 CDM 0636 RC 13533-0318-01 NDC 90375 HCPCS inpatient 2 UN 961.47 624.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 582.17 932.63 Rabies immune globulin for injection 49968084_1 CDM 0636 RC 13533-0318-01 NDC 90375 HCPCS inpatient 2 UN 961.47 624.96 UHC - ALL PLANS UHC - ALL PLANS 999999999 582.17 932.63 JOH WHC-CLOSURE KIT 49968728_1 CDM 0272 RC inpatient 253 164.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 164.45 65 999999999 153.19 245.41 percent of total billed charges JOH WHC-CLOSURE KIT 49968728_1 CDM 0272 RC inpatient 253 164.45 AETNA AETNA 199.87 79 999999999 153.19 245.41 percent of total billed charges JOH WHC-CLOSURE KIT 49968728_1 CDM 0272 RC inpatient 253 164.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 245.41 97 999999999 153.19 245.41 percent of total billed charges JOH WHC-CLOSURE KIT 49968728_1 CDM 0272 RC inpatient 253 164.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 174.57 69 999999999 153.19 245.41 percent of total billed charges JOH WHC-CLOSURE KIT 49968728_1 CDM 0272 RC inpatient 253 164.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 197.34 78 999999999 153.19 245.41 percent of total billed charges JOH WHC-CLOSURE KIT 49968728_1 CDM 0272 RC inpatient 253 164.45 UMR - ALL PLANS UMR - ALL PLANS 177.1 70 999999999 153.19 245.41 percent of total billed charges JOH WHC-CLOSURE KIT 49968728_1 CDM 0272 RC inpatient 253 164.45 SIHO - ALL PLANS SIHO - ALL PLANS 227.7 90 999999999 153.19 245.41 percent of total billed charges JOH WHC-CLOSURE KIT 49968728_1 CDM 0272 RC inpatient 253 164.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 153.19 60.55 999999999 153.19 245.41 percent of total billed charges JOH WHC-CLOSURE KIT 49968728_1 CDM 0272 RC inpatient 253 164.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 153.19 245.41 JOH WHC-CLOSURE KIT 49968728_1 CDM 0272 RC inpatient 253 164.45 ANTHEM HMO ANTHEM HMO 999999999 153.19 245.41 JOH WHC-CLOSURE KIT 49968728_1 CDM 0272 RC inpatient 253 164.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 153.19 245.41 JOH WHC-CLOSURE KIT 49968728_1 CDM 0272 RC inpatient 253 164.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 171.03 67.6 999999999 153.19 245.41 percent of total billed charges JOH WHC-CLOSURE KIT 49968728_1 CDM 0272 RC inpatient 253 164.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 153.19 245.41 JOH WHC-CLOSURE KIT 49968728_1 CDM 0272 RC inpatient 253 164.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 153.19 245.41 JOH WHC-Catheter Sheath 49968730_1 CDM 0272 RC inpatient 1154 750.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 750.1 65 999999999 698.75 1119.38 percent of total billed charges JOH WHC-Catheter Sheath 49968730_1 CDM 0272 RC inpatient 1154 750.1 AETNA AETNA 911.66 79 999999999 698.75 1119.38 percent of total billed charges JOH WHC-Catheter Sheath 49968730_1 CDM 0272 RC inpatient 1154 750.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1119.38 97 999999999 698.75 1119.38 percent of total billed charges JOH WHC-Catheter Sheath 49968730_1 CDM 0272 RC inpatient 1154 750.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 796.26 69 999999999 698.75 1119.38 percent of total billed charges JOH WHC-Catheter Sheath 49968730_1 CDM 0272 RC inpatient 1154 750.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 900.12 78 999999999 698.75 1119.38 percent of total billed charges JOH WHC-Catheter Sheath 49968730_1 CDM 0272 RC inpatient 1154 750.1 UMR - ALL PLANS UMR - ALL PLANS 807.8 70 999999999 698.75 1119.38 percent of total billed charges JOH WHC-Catheter Sheath 49968730_1 CDM 0272 RC inpatient 1154 750.1 SIHO - ALL PLANS SIHO - ALL PLANS 1038.6 90 999999999 698.75 1119.38 percent of total billed charges JOH WHC-Catheter Sheath 49968730_1 CDM 0272 RC inpatient 1154 750.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 698.75 60.55 999999999 698.75 1119.38 percent of total billed charges JOH WHC-Catheter Sheath 49968730_1 CDM 0272 RC inpatient 1154 750.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 698.75 1119.38 JOH WHC-Catheter Sheath 49968730_1 CDM 0272 RC inpatient 1154 750.1 ANTHEM HMO ANTHEM HMO 999999999 698.75 1119.38 JOH WHC-Catheter Sheath 49968730_1 CDM 0272 RC inpatient 1154 750.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 698.75 1119.38 JOH WHC-Catheter Sheath 49968730_1 CDM 0272 RC inpatient 1154 750.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 780.1 67.6 999999999 698.75 1119.38 percent of total billed charges JOH WHC-Catheter Sheath 49968730_1 CDM 0272 RC inpatient 1154 750.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 698.75 1119.38 JOH WHC-Catheter Sheath 49968730_1 CDM 0272 RC inpatient 1154 750.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 698.75 1119.38 JOH WHC-MICRO SHEATH 49968732_1 CDM 0272 RC inpatient 24 15.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 15.6 65 999999999 14.53 23.28 percent of total billed charges JOH WHC-MICRO SHEATH 49968732_1 CDM 0272 RC inpatient 24 15.6 AETNA AETNA 18.96 79 999999999 14.53 23.28 percent of total billed charges JOH WHC-MICRO SHEATH 49968732_1 CDM 0272 RC inpatient 24 15.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23.28 97 999999999 14.53 23.28 percent of total billed charges JOH WHC-MICRO SHEATH 49968732_1 CDM 0272 RC inpatient 24 15.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 16.56 69 999999999 14.53 23.28 percent of total billed charges JOH WHC-MICRO SHEATH 49968732_1 CDM 0272 RC inpatient 24 15.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 18.72 78 999999999 14.53 23.28 percent of total billed charges JOH WHC-MICRO SHEATH 49968732_1 CDM 0272 RC inpatient 24 15.6 UMR - ALL PLANS UMR - ALL PLANS 16.8 70 999999999 14.53 23.28 percent of total billed charges JOH WHC-MICRO SHEATH 49968732_1 CDM 0272 RC inpatient 24 15.6 SIHO - ALL PLANS SIHO - ALL PLANS 21.6 90 999999999 14.53 23.28 percent of total billed charges JOH WHC-MICRO SHEATH 49968732_1 CDM 0272 RC inpatient 24 15.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.53 60.55 999999999 14.53 23.28 percent of total billed charges JOH WHC-MICRO SHEATH 49968732_1 CDM 0272 RC inpatient 24 15.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.53 23.28 JOH WHC-MICRO SHEATH 49968732_1 CDM 0272 RC inpatient 24 15.6 ANTHEM HMO ANTHEM HMO 999999999 14.53 23.28 JOH WHC-MICRO SHEATH 49968732_1 CDM 0272 RC inpatient 24 15.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.53 23.28 JOH WHC-MICRO SHEATH 49968732_1 CDM 0272 RC inpatient 24 15.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.22 67.6 999999999 14.53 23.28 percent of total billed charges JOH WHC-MICRO SHEATH 49968732_1 CDM 0272 RC inpatient 24 15.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.53 23.28 JOH WHC-MICRO SHEATH 49968732_1 CDM 0272 RC inpatient 24 15.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.53 23.28 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968742_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.45 65 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968742_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 AETNA AETNA 41.87 79 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968742_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.41 97 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968742_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.57 69 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968742_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.34 78 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968742_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UMR - ALL PLANS UMR - ALL PLANS 37.1 70 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968742_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SIHO - ALL PLANS SIHO - ALL PLANS 47.7 90 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968742_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.09 60.55 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968742_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968742_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM HMO ANTHEM HMO 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968742_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968742_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.83 67.6 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968742_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968742_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968743_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.45 65 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968743_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 AETNA AETNA 41.87 79 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968743_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.41 97 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968743_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.57 69 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968743_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.34 78 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968743_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UMR - ALL PLANS UMR - ALL PLANS 37.1 70 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968743_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SIHO - ALL PLANS SIHO - ALL PLANS 47.7 90 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968743_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.09 60.55 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968743_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968743_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM HMO ANTHEM HMO 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968743_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968743_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.83 67.6 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968743_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968743_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968744_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.45 65 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968744_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 AETNA AETNA 41.87 79 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968744_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.41 97 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968744_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.57 69 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968744_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.34 78 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968744_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UMR - ALL PLANS UMR - ALL PLANS 37.1 70 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968744_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SIHO - ALL PLANS SIHO - ALL PLANS 47.7 90 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968744_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.09 60.55 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968744_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968744_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM HMO ANTHEM HMO 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968744_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968744_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.83 67.6 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968744_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968744_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968778_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.45 65 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968778_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 AETNA AETNA 41.87 79 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968778_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.41 97 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968778_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.57 69 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968778_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.34 78 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968778_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UMR - ALL PLANS UMR - ALL PLANS 37.1 70 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968778_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SIHO - ALL PLANS SIHO - ALL PLANS 47.7 90 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968778_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.09 60.55 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968778_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968778_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM HMO ANTHEM HMO 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968778_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968778_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.83 67.6 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968778_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968778_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968779_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.45 65 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968779_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 AETNA AETNA 41.87 79 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968779_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.41 97 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968779_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.57 69 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968779_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.34 78 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968779_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UMR - ALL PLANS UMR - ALL PLANS 37.1 70 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968779_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 SIHO - ALL PLANS SIHO - ALL PLANS 47.7 90 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968779_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.09 60.55 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968779_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968779_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM HMO ANTHEM HMO 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968779_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968779_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.83 67.6 999999999 32.09 51.41 percent of total billed charges "Measurement of antibody (IgG) to allergic substance, each allergen" 49968779_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.09 51.41 "Measurement of antibody (IgG) to allergic substance, each allergen" 49968779_1 CDM 0301 RC 86001 HCPCS inpatient 53 34.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.09 51.41 WIREGUIDE TSCF 35-80-5 49969652_1 CDM 0272 RC inpatient 14 9.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.1 65 999999999 8.48 13.58 percent of total billed charges WIREGUIDE TSCF 35-80-5 49969652_1 CDM 0272 RC inpatient 14 9.1 AETNA AETNA 11.06 79 999999999 8.48 13.58 percent of total billed charges WIREGUIDE TSCF 35-80-5 49969652_1 CDM 0272 RC inpatient 14 9.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13.58 97 999999999 8.48 13.58 percent of total billed charges WIREGUIDE TSCF 35-80-5 49969652_1 CDM 0272 RC inpatient 14 9.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.66 69 999999999 8.48 13.58 percent of total billed charges WIREGUIDE TSCF 35-80-5 49969652_1 CDM 0272 RC inpatient 14 9.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.92 78 999999999 8.48 13.58 percent of total billed charges WIREGUIDE TSCF 35-80-5 49969652_1 CDM 0272 RC inpatient 14 9.1 UMR - ALL PLANS UMR - ALL PLANS 9.8 70 999999999 8.48 13.58 percent of total billed charges WIREGUIDE TSCF 35-80-5 49969652_1 CDM 0272 RC inpatient 14 9.1 SIHO - ALL PLANS SIHO - ALL PLANS 12.6 90 999999999 8.48 13.58 percent of total billed charges WIREGUIDE TSCF 35-80-5 49969652_1 CDM 0272 RC inpatient 14 9.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.48 60.55 999999999 8.48 13.58 percent of total billed charges WIREGUIDE TSCF 35-80-5 49969652_1 CDM 0272 RC inpatient 14 9.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.48 13.58 WIREGUIDE TSCF 35-80-5 49969652_1 CDM 0272 RC inpatient 14 9.1 ANTHEM HMO ANTHEM HMO 999999999 8.48 13.58 WIREGUIDE TSCF 35-80-5 49969652_1 CDM 0272 RC inpatient 14 9.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.48 13.58 WIREGUIDE TSCF 35-80-5 49969652_1 CDM 0272 RC inpatient 14 9.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.46 67.6 999999999 8.48 13.58 percent of total billed charges WIREGUIDE TSCF 35-80-5 49969652_1 CDM 0272 RC inpatient 14 9.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.48 13.58 WIREGUIDE TSCF 35-80-5 49969652_1 CDM 0272 RC inpatient 14 9.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.48 13.58 DILTIAZEM 25 MG/5 ML VIAL 49971341_1 CDM 0250 RC 00641-9217-10 NDC inpatient 1 UN 16.96 11.02 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.02 65 999999999 10.27 16.45 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 49971341_1 CDM 0250 RC 00641-9217-10 NDC inpatient 1 UN 16.96 11.02 AETNA AETNA 13.4 79 999999999 10.27 16.45 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 49971341_1 CDM 0250 RC 00641-9217-10 NDC inpatient 1 UN 16.96 11.02 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16.45 97 999999999 10.27 16.45 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 49971341_1 CDM 0250 RC 00641-9217-10 NDC inpatient 1 UN 16.96 11.02 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.7 69 999999999 10.27 16.45 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 49971341_1 CDM 0250 RC 00641-9217-10 NDC inpatient 1 UN 16.96 11.02 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.23 78 999999999 10.27 16.45 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 49971341_1 CDM 0250 RC 00641-9217-10 NDC inpatient 1 UN 16.96 11.02 UMR - ALL PLANS UMR - ALL PLANS 11.87 70 999999999 10.27 16.45 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 49971341_1 CDM 0250 RC 00641-9217-10 NDC inpatient 1 UN 16.96 11.02 SIHO - ALL PLANS SIHO - ALL PLANS 15.26 90 999999999 10.27 16.45 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 49971341_1 CDM 0250 RC 00641-9217-10 NDC inpatient 1 UN 16.96 11.02 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.27 60.55 999999999 10.27 16.45 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 49971341_1 CDM 0250 RC 00641-9217-10 NDC inpatient 1 UN 16.96 11.02 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.27 16.45 DILTIAZEM 25 MG/5 ML VIAL 49971341_1 CDM 0250 RC 00641-9217-10 NDC inpatient 1 UN 16.96 11.02 ANTHEM HMO ANTHEM HMO 999999999 10.27 16.45 DILTIAZEM 25 MG/5 ML VIAL 49971341_1 CDM 0250 RC 00641-9217-10 NDC inpatient 1 UN 16.96 11.02 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.27 16.45 DILTIAZEM 25 MG/5 ML VIAL 49971341_1 CDM 0250 RC 00641-9217-10 NDC inpatient 1 UN 16.96 11.02 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.47 67.6 999999999 10.27 16.45 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 49971341_1 CDM 0250 RC 00641-9217-10 NDC inpatient 1 UN 16.96 11.02 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.27 16.45 DILTIAZEM 25 MG/5 ML VIAL 49971341_1 CDM 0250 RC 00641-9217-10 NDC inpatient 1 UN 16.96 11.02 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.27 16.45 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49971367_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49971367_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49971367_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49971367_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49971367_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49971367_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49971367_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49971367_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49971367_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49971367_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49971367_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49971367_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49971367_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 49971367_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 Magnesium level 49971529_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges Magnesium level 49971529_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges Magnesium level 49971529_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges Magnesium level 49971529_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges Magnesium level 49971529_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges Magnesium level 49971529_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges Magnesium level 49971529_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges Magnesium level 49971529_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges Magnesium level 49971529_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 Magnesium level 49971529_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 Magnesium level 49971529_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 Magnesium level 49971529_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges Magnesium level 49971529_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 Magnesium level 49971529_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 INVOKANA 100 MG TABLET 49973571_1 CDM 0250 RC 50458-0140-30 NDC inpatient 1 UN 36.27 23.58 SELF PAY DISCOUNT SELF PAY DISCOUNT 23.58 65 999999999 21.96 35.18 percent of total billed charges INVOKANA 100 MG TABLET 49973571_1 CDM 0250 RC 50458-0140-30 NDC inpatient 1 UN 36.27 23.58 AETNA AETNA 28.65 79 999999999 21.96 35.18 percent of total billed charges INVOKANA 100 MG TABLET 49973571_1 CDM 0250 RC 50458-0140-30 NDC inpatient 1 UN 36.27 23.58 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.18 97 999999999 21.96 35.18 percent of total billed charges INVOKANA 100 MG TABLET 49973571_1 CDM 0250 RC 50458-0140-30 NDC inpatient 1 UN 36.27 23.58 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.03 69 999999999 21.96 35.18 percent of total billed charges INVOKANA 100 MG TABLET 49973571_1 CDM 0250 RC 50458-0140-30 NDC inpatient 1 UN 36.27 23.58 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.29 78 999999999 21.96 35.18 percent of total billed charges INVOKANA 100 MG TABLET 49973571_1 CDM 0250 RC 50458-0140-30 NDC inpatient 1 UN 36.27 23.58 UMR - ALL PLANS UMR - ALL PLANS 25.39 70 999999999 21.96 35.18 percent of total billed charges INVOKANA 100 MG TABLET 49973571_1 CDM 0250 RC 50458-0140-30 NDC inpatient 1 UN 36.27 23.58 SIHO - ALL PLANS SIHO - ALL PLANS 32.64 90 999999999 21.96 35.18 percent of total billed charges INVOKANA 100 MG TABLET 49973571_1 CDM 0250 RC 50458-0140-30 NDC inpatient 1 UN 36.27 23.58 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.96 60.55 999999999 21.96 35.18 percent of total billed charges INVOKANA 100 MG TABLET 49973571_1 CDM 0250 RC 50458-0140-30 NDC inpatient 1 UN 36.27 23.58 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.96 35.18 INVOKANA 100 MG TABLET 49973571_1 CDM 0250 RC 50458-0140-30 NDC inpatient 1 UN 36.27 23.58 ANTHEM HMO ANTHEM HMO 999999999 21.96 35.18 INVOKANA 100 MG TABLET 49973571_1 CDM 0250 RC 50458-0140-30 NDC inpatient 1 UN 36.27 23.58 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.96 35.18 INVOKANA 100 MG TABLET 49973571_1 CDM 0250 RC 50458-0140-30 NDC inpatient 1 UN 36.27 23.58 CIGNA - ALL PLANS CIGNA - ALL PLANS 24.52 67.6 999999999 21.96 35.18 percent of total billed charges INVOKANA 100 MG TABLET 49973571_1 CDM 0250 RC 50458-0140-30 NDC inpatient 1 UN 36.27 23.58 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.96 35.18 INVOKANA 100 MG TABLET 49973571_1 CDM 0250 RC 50458-0140-30 NDC inpatient 1 UN 36.27 23.58 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.96 35.18 SOTALOL 80 MG TABLET 49973588_1 CDM 0250 RC 76385-0114-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges SOTALOL 80 MG TABLET 49973588_1 CDM 0250 RC 76385-0114-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges SOTALOL 80 MG TABLET 49973588_1 CDM 0250 RC 76385-0114-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges SOTALOL 80 MG TABLET 49973588_1 CDM 0250 RC 76385-0114-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges SOTALOL 80 MG TABLET 49973588_1 CDM 0250 RC 76385-0114-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges SOTALOL 80 MG TABLET 49973588_1 CDM 0250 RC 76385-0114-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges SOTALOL 80 MG TABLET 49973588_1 CDM 0250 RC 76385-0114-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges SOTALOL 80 MG TABLET 49973588_1 CDM 0250 RC 76385-0114-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges SOTALOL 80 MG TABLET 49973588_1 CDM 0250 RC 76385-0114-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 SOTALOL 80 MG TABLET 49973588_1 CDM 0250 RC 76385-0114-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 SOTALOL 80 MG TABLET 49973588_1 CDM 0250 RC 76385-0114-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 SOTALOL 80 MG TABLET 49973588_1 CDM 0250 RC 76385-0114-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges SOTALOL 80 MG TABLET 49973588_1 CDM 0250 RC 76385-0114-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 SOTALOL 80 MG TABLET 49973588_1 CDM 0250 RC 76385-0114-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 SSKI 1 GM/ML SOLUTION 49973593_1 CDM 0250 RC 71740-0112-30 NDC inpatient 1 UN 1689.07 1097.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1097.9 65 999999999 1022.73 1638.4 percent of total billed charges SSKI 1 GM/ML SOLUTION 49973593_1 CDM 0250 RC 71740-0112-30 NDC inpatient 1 UN 1689.07 1097.9 AETNA AETNA 1334.37 79 999999999 1022.73 1638.4 percent of total billed charges SSKI 1 GM/ML SOLUTION 49973593_1 CDM 0250 RC 71740-0112-30 NDC inpatient 1 UN 1689.07 1097.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1638.4 97 999999999 1022.73 1638.4 percent of total billed charges SSKI 1 GM/ML SOLUTION 49973593_1 CDM 0250 RC 71740-0112-30 NDC inpatient 1 UN 1689.07 1097.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1165.46 69 999999999 1022.73 1638.4 percent of total billed charges SSKI 1 GM/ML SOLUTION 49973593_1 CDM 0250 RC 71740-0112-30 NDC inpatient 1 UN 1689.07 1097.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1317.47 78 999999999 1022.73 1638.4 percent of total billed charges SSKI 1 GM/ML SOLUTION 49973593_1 CDM 0250 RC 71740-0112-30 NDC inpatient 1 UN 1689.07 1097.9 UMR - ALL PLANS UMR - ALL PLANS 1182.35 70 999999999 1022.73 1638.4 percent of total billed charges SSKI 1 GM/ML SOLUTION 49973593_1 CDM 0250 RC 71740-0112-30 NDC inpatient 1 UN 1689.07 1097.9 SIHO - ALL PLANS SIHO - ALL PLANS 1520.16 90 999999999 1022.73 1638.4 percent of total billed charges SSKI 1 GM/ML SOLUTION 49973593_1 CDM 0250 RC 71740-0112-30 NDC inpatient 1 UN 1689.07 1097.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1022.73 60.55 999999999 1022.73 1638.4 percent of total billed charges SSKI 1 GM/ML SOLUTION 49973593_1 CDM 0250 RC 71740-0112-30 NDC inpatient 1 UN 1689.07 1097.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1022.73 1638.4 SSKI 1 GM/ML SOLUTION 49973593_1 CDM 0250 RC 71740-0112-30 NDC inpatient 1 UN 1689.07 1097.9 ANTHEM HMO ANTHEM HMO 999999999 1022.73 1638.4 SSKI 1 GM/ML SOLUTION 49973593_1 CDM 0250 RC 71740-0112-30 NDC inpatient 1 UN 1689.07 1097.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1022.73 1638.4 SSKI 1 GM/ML SOLUTION 49973593_1 CDM 0250 RC 71740-0112-30 NDC inpatient 1 UN 1689.07 1097.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1141.81 67.6 999999999 1022.73 1638.4 percent of total billed charges SSKI 1 GM/ML SOLUTION 49973593_1 CDM 0250 RC 71740-0112-30 NDC inpatient 1 UN 1689.07 1097.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1022.73 1638.4 SSKI 1 GM/ML SOLUTION 49973593_1 CDM 0250 RC 71740-0112-30 NDC inpatient 1 UN 1689.07 1097.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1022.73 1638.4 TERAZOSIN 5 MG CAPSULE 49973611_1 CDM 0250 RC 59746-0385-06 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges TERAZOSIN 5 MG CAPSULE 49973611_1 CDM 0250 RC 59746-0385-06 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges TERAZOSIN 5 MG CAPSULE 49973611_1 CDM 0250 RC 59746-0385-06 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges TERAZOSIN 5 MG CAPSULE 49973611_1 CDM 0250 RC 59746-0385-06 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges TERAZOSIN 5 MG CAPSULE 49973611_1 CDM 0250 RC 59746-0385-06 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges TERAZOSIN 5 MG CAPSULE 49973611_1 CDM 0250 RC 59746-0385-06 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges TERAZOSIN 5 MG CAPSULE 49973611_1 CDM 0250 RC 59746-0385-06 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges TERAZOSIN 5 MG CAPSULE 49973611_1 CDM 0250 RC 59746-0385-06 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges TERAZOSIN 5 MG CAPSULE 49973611_1 CDM 0250 RC 59746-0385-06 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 TERAZOSIN 5 MG CAPSULE 49973611_1 CDM 0250 RC 59746-0385-06 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 TERAZOSIN 5 MG CAPSULE 49973611_1 CDM 0250 RC 59746-0385-06 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 TERAZOSIN 5 MG CAPSULE 49973611_1 CDM 0250 RC 59746-0385-06 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges TERAZOSIN 5 MG CAPSULE 49973611_1 CDM 0250 RC 59746-0385-06 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 TERAZOSIN 5 MG CAPSULE 49973611_1 CDM 0250 RC 59746-0385-06 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 MEMANTINE HCL ER 7 MG CAPSULE 49973623_1 CDM 0250 RC 65162-0782-03 NDC inpatient 1 UN 23.12 15.03 SELF PAY DISCOUNT SELF PAY DISCOUNT 15.03 65 999999999 14 22.43 percent of total billed charges MEMANTINE HCL ER 7 MG CAPSULE 49973623_1 CDM 0250 RC 65162-0782-03 NDC inpatient 1 UN 23.12 15.03 AETNA AETNA 18.26 79 999999999 14 22.43 percent of total billed charges MEMANTINE HCL ER 7 MG CAPSULE 49973623_1 CDM 0250 RC 65162-0782-03 NDC inpatient 1 UN 23.12 15.03 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22.43 97 999999999 14 22.43 percent of total billed charges MEMANTINE HCL ER 7 MG CAPSULE 49973623_1 CDM 0250 RC 65162-0782-03 NDC inpatient 1 UN 23.12 15.03 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.95 69 999999999 14 22.43 percent of total billed charges MEMANTINE HCL ER 7 MG CAPSULE 49973623_1 CDM 0250 RC 65162-0782-03 NDC inpatient 1 UN 23.12 15.03 HUMANA - ALL PLANS HUMANA - ALL PLANS 18.03 78 999999999 14 22.43 percent of total billed charges MEMANTINE HCL ER 7 MG CAPSULE 49973623_1 CDM 0250 RC 65162-0782-03 NDC inpatient 1 UN 23.12 15.03 UMR - ALL PLANS UMR - ALL PLANS 16.18 70 999999999 14 22.43 percent of total billed charges MEMANTINE HCL ER 7 MG CAPSULE 49973623_1 CDM 0250 RC 65162-0782-03 NDC inpatient 1 UN 23.12 15.03 SIHO - ALL PLANS SIHO - ALL PLANS 20.81 90 999999999 14 22.43 percent of total billed charges MEMANTINE HCL ER 7 MG CAPSULE 49973623_1 CDM 0250 RC 65162-0782-03 NDC inpatient 1 UN 23.12 15.03 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14 60.55 999999999 14 22.43 percent of total billed charges MEMANTINE HCL ER 7 MG CAPSULE 49973623_1 CDM 0250 RC 65162-0782-03 NDC inpatient 1 UN 23.12 15.03 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14 22.43 MEMANTINE HCL ER 7 MG CAPSULE 49973623_1 CDM 0250 RC 65162-0782-03 NDC inpatient 1 UN 23.12 15.03 ANTHEM HMO ANTHEM HMO 999999999 14 22.43 MEMANTINE HCL ER 7 MG CAPSULE 49973623_1 CDM 0250 RC 65162-0782-03 NDC inpatient 1 UN 23.12 15.03 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14 22.43 MEMANTINE HCL ER 7 MG CAPSULE 49973623_1 CDM 0250 RC 65162-0782-03 NDC inpatient 1 UN 23.12 15.03 CIGNA - ALL PLANS CIGNA - ALL PLANS 15.63 67.6 999999999 14 22.43 percent of total billed charges MEMANTINE HCL ER 7 MG CAPSULE 49973623_1 CDM 0250 RC 65162-0782-03 NDC inpatient 1 UN 23.12 15.03 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14 22.43 MEMANTINE HCL ER 7 MG CAPSULE 49973623_1 CDM 0250 RC 65162-0782-03 NDC inpatient 1 UN 23.12 15.03 UHC - ALL PLANS UHC - ALL PLANS 999999999 14 22.43 GLIPIZIDE 5 MG TABLET 49973624_1 CDM 0250 RC 60505-0141-00 NDC inpatient 1 UN 1.33 0.86 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.86 65 999999999 0.81 1.29 percent of total billed charges GLIPIZIDE 5 MG TABLET 49973624_1 CDM 0250 RC 60505-0141-00 NDC inpatient 1 UN 1.33 0.86 AETNA AETNA 1.05 79 999999999 0.81 1.29 percent of total billed charges GLIPIZIDE 5 MG TABLET 49973624_1 CDM 0250 RC 60505-0141-00 NDC inpatient 1 UN 1.33 0.86 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.29 97 999999999 0.81 1.29 percent of total billed charges GLIPIZIDE 5 MG TABLET 49973624_1 CDM 0250 RC 60505-0141-00 NDC inpatient 1 UN 1.33 0.86 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.92 69 999999999 0.81 1.29 percent of total billed charges GLIPIZIDE 5 MG TABLET 49973624_1 CDM 0250 RC 60505-0141-00 NDC inpatient 1 UN 1.33 0.86 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.04 78 999999999 0.81 1.29 percent of total billed charges GLIPIZIDE 5 MG TABLET 49973624_1 CDM 0250 RC 60505-0141-00 NDC inpatient 1 UN 1.33 0.86 UMR - ALL PLANS UMR - ALL PLANS 0.93 70 999999999 0.81 1.29 percent of total billed charges GLIPIZIDE 5 MG TABLET 49973624_1 CDM 0250 RC 60505-0141-00 NDC inpatient 1 UN 1.33 0.86 SIHO - ALL PLANS SIHO - ALL PLANS 1.2 90 999999999 0.81 1.29 percent of total billed charges GLIPIZIDE 5 MG TABLET 49973624_1 CDM 0250 RC 60505-0141-00 NDC inpatient 1 UN 1.33 0.86 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.81 60.55 999999999 0.81 1.29 percent of total billed charges GLIPIZIDE 5 MG TABLET 49973624_1 CDM 0250 RC 60505-0141-00 NDC inpatient 1 UN 1.33 0.86 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.81 1.29 GLIPIZIDE 5 MG TABLET 49973624_1 CDM 0250 RC 60505-0141-00 NDC inpatient 1 UN 1.33 0.86 ANTHEM HMO ANTHEM HMO 999999999 0.81 1.29 GLIPIZIDE 5 MG TABLET 49973624_1 CDM 0250 RC 60505-0141-00 NDC inpatient 1 UN 1.33 0.86 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.81 1.29 GLIPIZIDE 5 MG TABLET 49973624_1 CDM 0250 RC 60505-0141-00 NDC inpatient 1 UN 1.33 0.86 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.9 67.6 999999999 0.81 1.29 percent of total billed charges GLIPIZIDE 5 MG TABLET 49973624_1 CDM 0250 RC 60505-0141-00 NDC inpatient 1 UN 1.33 0.86 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.81 1.29 GLIPIZIDE 5 MG TABLET 49973624_1 CDM 0250 RC 60505-0141-00 NDC inpatient 1 UN 1.33 0.86 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.81 1.29 DOXAZOSIN MESYLATE 8 MG TAB 49973625_1 CDM 0250 RC 60505-0096-00 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges DOXAZOSIN MESYLATE 8 MG TAB 49973625_1 CDM 0250 RC 60505-0096-00 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges DOXAZOSIN MESYLATE 8 MG TAB 49973625_1 CDM 0250 RC 60505-0096-00 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges DOXAZOSIN MESYLATE 8 MG TAB 49973625_1 CDM 0250 RC 60505-0096-00 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges DOXAZOSIN MESYLATE 8 MG TAB 49973625_1 CDM 0250 RC 60505-0096-00 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges DOXAZOSIN MESYLATE 8 MG TAB 49973625_1 CDM 0250 RC 60505-0096-00 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges DOXAZOSIN MESYLATE 8 MG TAB 49973625_1 CDM 0250 RC 60505-0096-00 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges DOXAZOSIN MESYLATE 8 MG TAB 49973625_1 CDM 0250 RC 60505-0096-00 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges DOXAZOSIN MESYLATE 8 MG TAB 49973625_1 CDM 0250 RC 60505-0096-00 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 DOXAZOSIN MESYLATE 8 MG TAB 49973625_1 CDM 0250 RC 60505-0096-00 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 DOXAZOSIN MESYLATE 8 MG TAB 49973625_1 CDM 0250 RC 60505-0096-00 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 DOXAZOSIN MESYLATE 8 MG TAB 49973625_1 CDM 0250 RC 60505-0096-00 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges DOXAZOSIN MESYLATE 8 MG TAB 49973625_1 CDM 0250 RC 60505-0096-00 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 DOXAZOSIN MESYLATE 8 MG TAB 49973625_1 CDM 0250 RC 60505-0096-00 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 49974300_1 CDM 0636 RC 00409-0182-01 NDC J9201 HCPCS inpatient 10 UN 201.43 130.93 SELF PAY DISCOUNT SELF PAY DISCOUNT 130.93 65 999999999 121.97 195.39 percent of total billed charges "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 49974300_1 CDM 0636 RC 00409-0182-01 NDC J9201 HCPCS inpatient 10 UN 201.43 130.93 AETNA AETNA 159.13 79 999999999 121.97 195.39 percent of total billed charges "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 49974300_1 CDM 0636 RC 00409-0182-01 NDC J9201 HCPCS inpatient 10 UN 201.43 130.93 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 195.39 97 999999999 121.97 195.39 percent of total billed charges "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 49974300_1 CDM 0636 RC 00409-0182-01 NDC J9201 HCPCS inpatient 10 UN 201.43 130.93 ENCORE - ALL PLANS ENCORE - ALL PLANS 138.99 69 999999999 121.97 195.39 percent of total billed charges "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 49974300_1 CDM 0636 RC 00409-0182-01 NDC J9201 HCPCS inpatient 10 UN 201.43 130.93 HUMANA - ALL PLANS HUMANA - ALL PLANS 157.12 78 999999999 121.97 195.39 percent of total billed charges "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 49974300_1 CDM 0636 RC 00409-0182-01 NDC J9201 HCPCS inpatient 10 UN 201.43 130.93 UMR - ALL PLANS UMR - ALL PLANS 141 70 999999999 121.97 195.39 percent of total billed charges "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 49974300_1 CDM 0636 RC 00409-0182-01 NDC J9201 HCPCS inpatient 10 UN 201.43 130.93 SIHO - ALL PLANS SIHO - ALL PLANS 181.29 90 999999999 121.97 195.39 percent of total billed charges "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 49974300_1 CDM 0636 RC 00409-0182-01 NDC J9201 HCPCS inpatient 10 UN 201.43 130.93 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 121.97 60.55 999999999 121.97 195.39 percent of total billed charges "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 49974300_1 CDM 0636 RC 00409-0182-01 NDC J9201 HCPCS inpatient 10 UN 201.43 130.93 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 121.97 195.39 "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 49974300_1 CDM 0636 RC 00409-0182-01 NDC J9201 HCPCS inpatient 10 UN 201.43 130.93 ANTHEM HMO ANTHEM HMO 999999999 121.97 195.39 "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 49974300_1 CDM 0636 RC 00409-0182-01 NDC J9201 HCPCS inpatient 10 UN 201.43 130.93 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 121.97 195.39 "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 49974300_1 CDM 0636 RC 00409-0182-01 NDC J9201 HCPCS inpatient 10 UN 201.43 130.93 CIGNA - ALL PLANS CIGNA - ALL PLANS 136.17 67.6 999999999 121.97 195.39 percent of total billed charges "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 49974300_1 CDM 0636 RC 00409-0182-01 NDC J9201 HCPCS inpatient 10 UN 201.43 130.93 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 121.97 195.39 "INJECTION, GEMCITABINE HYDROCHLORIDE, NOT OTHERWISE SPECIFIED, 200 MG" 49974300_1 CDM 0636 RC 00409-0182-01 NDC J9201 HCPCS inpatient 10 UN 201.43 130.93 UHC - ALL PLANS UHC - ALL PLANS 999999999 121.97 195.39 GABAPENTIN 250 MG/5 ML SOLN 49975085_1 CDM 0250 RC 42192-0608-16 NDC inpatient 1 UN 1.82 1.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.18 65 999999999 1.1 1.77 percent of total billed charges GABAPENTIN 250 MG/5 ML SOLN 49975085_1 CDM 0250 RC 42192-0608-16 NDC inpatient 1 UN 1.82 1.18 AETNA AETNA 1.44 79 999999999 1.1 1.77 percent of total billed charges GABAPENTIN 250 MG/5 ML SOLN 49975085_1 CDM 0250 RC 42192-0608-16 NDC inpatient 1 UN 1.82 1.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.77 97 999999999 1.1 1.77 percent of total billed charges GABAPENTIN 250 MG/5 ML SOLN 49975085_1 CDM 0250 RC 42192-0608-16 NDC inpatient 1 UN 1.82 1.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.26 69 999999999 1.1 1.77 percent of total billed charges GABAPENTIN 250 MG/5 ML SOLN 49975085_1 CDM 0250 RC 42192-0608-16 NDC inpatient 1 UN 1.82 1.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.42 78 999999999 1.1 1.77 percent of total billed charges GABAPENTIN 250 MG/5 ML SOLN 49975085_1 CDM 0250 RC 42192-0608-16 NDC inpatient 1 UN 1.82 1.18 UMR - ALL PLANS UMR - ALL PLANS 1.27 70 999999999 1.1 1.77 percent of total billed charges GABAPENTIN 250 MG/5 ML SOLN 49975085_1 CDM 0250 RC 42192-0608-16 NDC inpatient 1 UN 1.82 1.18 SIHO - ALL PLANS SIHO - ALL PLANS 1.64 90 999999999 1.1 1.77 percent of total billed charges GABAPENTIN 250 MG/5 ML SOLN 49975085_1 CDM 0250 RC 42192-0608-16 NDC inpatient 1 UN 1.82 1.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.1 60.55 999999999 1.1 1.77 percent of total billed charges GABAPENTIN 250 MG/5 ML SOLN 49975085_1 CDM 0250 RC 42192-0608-16 NDC inpatient 1 UN 1.82 1.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.1 1.77 GABAPENTIN 250 MG/5 ML SOLN 49975085_1 CDM 0250 RC 42192-0608-16 NDC inpatient 1 UN 1.82 1.18 ANTHEM HMO ANTHEM HMO 999999999 1.1 1.77 GABAPENTIN 250 MG/5 ML SOLN 49975085_1 CDM 0250 RC 42192-0608-16 NDC inpatient 1 UN 1.82 1.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.1 1.77 GABAPENTIN 250 MG/5 ML SOLN 49975085_1 CDM 0250 RC 42192-0608-16 NDC inpatient 1 UN 1.82 1.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.23 67.6 999999999 1.1 1.77 percent of total billed charges GABAPENTIN 250 MG/5 ML SOLN 49975085_1 CDM 0250 RC 42192-0608-16 NDC inpatient 1 UN 1.82 1.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.1 1.77 GABAPENTIN 250 MG/5 ML SOLN 49975085_1 CDM 0250 RC 42192-0608-16 NDC inpatient 1 UN 1.82 1.18 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.1 1.77 ESG PLASMA LOOP MEDIUM WA22702S 49976000_1 CDM 0272 RC inpatient 3635 2362.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 2362.75 65 999999999 2200.99 3525.95 percent of total billed charges ESG PLASMA LOOP MEDIUM WA22702S 49976000_1 CDM 0272 RC inpatient 3635 2362.75 AETNA AETNA 2871.65 79 999999999 2200.99 3525.95 percent of total billed charges ESG PLASMA LOOP MEDIUM WA22702S 49976000_1 CDM 0272 RC inpatient 3635 2362.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3525.95 97 999999999 2200.99 3525.95 percent of total billed charges ESG PLASMA LOOP MEDIUM WA22702S 49976000_1 CDM 0272 RC inpatient 3635 2362.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 2508.15 69 999999999 2200.99 3525.95 percent of total billed charges ESG PLASMA LOOP MEDIUM WA22702S 49976000_1 CDM 0272 RC inpatient 3635 2362.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 2835.3 78 999999999 2200.99 3525.95 percent of total billed charges ESG PLASMA LOOP MEDIUM WA22702S 49976000_1 CDM 0272 RC inpatient 3635 2362.75 UMR - ALL PLANS UMR - ALL PLANS 2544.5 70 999999999 2200.99 3525.95 percent of total billed charges ESG PLASMA LOOP MEDIUM WA22702S 49976000_1 CDM 0272 RC inpatient 3635 2362.75 SIHO - ALL PLANS SIHO - ALL PLANS 3271.5 90 999999999 2200.99 3525.95 percent of total billed charges ESG PLASMA LOOP MEDIUM WA22702S 49976000_1 CDM 0272 RC inpatient 3635 2362.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2200.99 60.55 999999999 2200.99 3525.95 percent of total billed charges ESG PLASMA LOOP MEDIUM WA22702S 49976000_1 CDM 0272 RC inpatient 3635 2362.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2200.99 3525.95 ESG PLASMA LOOP MEDIUM WA22702S 49976000_1 CDM 0272 RC inpatient 3635 2362.75 ANTHEM HMO ANTHEM HMO 999999999 2200.99 3525.95 ESG PLASMA LOOP MEDIUM WA22702S 49976000_1 CDM 0272 RC inpatient 3635 2362.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2200.99 3525.95 ESG PLASMA LOOP MEDIUM WA22702S 49976000_1 CDM 0272 RC inpatient 3635 2362.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 2457.26 67.6 999999999 2200.99 3525.95 percent of total billed charges ESG PLASMA LOOP MEDIUM WA22702S 49976000_1 CDM 0272 RC inpatient 3635 2362.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2200.99 3525.95 ESG PLASMA LOOP MEDIUM WA22702S 49976000_1 CDM 0272 RC inpatient 3635 2362.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 2200.99 3525.95 ESG PLASMA OVAL BUTTON WA22766S 49976001_1 CDM 0272 RC inpatient 4194 2726.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 2726.1 65 999999999 2539.47 4068.18 percent of total billed charges ESG PLASMA OVAL BUTTON WA22766S 49976001_1 CDM 0272 RC inpatient 4194 2726.1 AETNA AETNA 3313.26 79 999999999 2539.47 4068.18 percent of total billed charges ESG PLASMA OVAL BUTTON WA22766S 49976001_1 CDM 0272 RC inpatient 4194 2726.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4068.18 97 999999999 2539.47 4068.18 percent of total billed charges ESG PLASMA OVAL BUTTON WA22766S 49976001_1 CDM 0272 RC inpatient 4194 2726.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 2893.86 69 999999999 2539.47 4068.18 percent of total billed charges ESG PLASMA OVAL BUTTON WA22766S 49976001_1 CDM 0272 RC inpatient 4194 2726.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 3271.32 78 999999999 2539.47 4068.18 percent of total billed charges ESG PLASMA OVAL BUTTON WA22766S 49976001_1 CDM 0272 RC inpatient 4194 2726.1 UMR - ALL PLANS UMR - ALL PLANS 2935.8 70 999999999 2539.47 4068.18 percent of total billed charges ESG PLASMA OVAL BUTTON WA22766S 49976001_1 CDM 0272 RC inpatient 4194 2726.1 SIHO - ALL PLANS SIHO - ALL PLANS 3774.6 90 999999999 2539.47 4068.18 percent of total billed charges ESG PLASMA OVAL BUTTON WA22766S 49976001_1 CDM 0272 RC inpatient 4194 2726.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2539.47 60.55 999999999 2539.47 4068.18 percent of total billed charges ESG PLASMA OVAL BUTTON WA22766S 49976001_1 CDM 0272 RC inpatient 4194 2726.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2539.47 4068.18 ESG PLASMA OVAL BUTTON WA22766S 49976001_1 CDM 0272 RC inpatient 4194 2726.1 ANTHEM HMO ANTHEM HMO 999999999 2539.47 4068.18 ESG PLASMA OVAL BUTTON WA22766S 49976001_1 CDM 0272 RC inpatient 4194 2726.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2539.47 4068.18 ESG PLASMA OVAL BUTTON WA22766S 49976001_1 CDM 0272 RC inpatient 4194 2726.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 2835.14 67.6 999999999 2539.47 4068.18 percent of total billed charges ESG PLASMA OVAL BUTTON WA22766S 49976001_1 CDM 0272 RC inpatient 4194 2726.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2539.47 4068.18 ESG PLASMA OVAL BUTTON WA22766S 49976001_1 CDM 0272 RC inpatient 4194 2726.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 2539.47 4068.18 ARTHROSCOPIC TUBING 350-800-006. 49976002_1 CDM 0272 RC inpatient 395 256.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 256.75 65 999999999 239.17 383.15 percent of total billed charges ARTHROSCOPIC TUBING 350-800-006. 49976002_1 CDM 0272 RC inpatient 395 256.75 AETNA AETNA 312.05 79 999999999 239.17 383.15 percent of total billed charges ARTHROSCOPIC TUBING 350-800-006. 49976002_1 CDM 0272 RC inpatient 395 256.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 383.15 97 999999999 239.17 383.15 percent of total billed charges ARTHROSCOPIC TUBING 350-800-006. 49976002_1 CDM 0272 RC inpatient 395 256.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 272.55 69 999999999 239.17 383.15 percent of total billed charges ARTHROSCOPIC TUBING 350-800-006. 49976002_1 CDM 0272 RC inpatient 395 256.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 308.1 78 999999999 239.17 383.15 percent of total billed charges ARTHROSCOPIC TUBING 350-800-006. 49976002_1 CDM 0272 RC inpatient 395 256.75 UMR - ALL PLANS UMR - ALL PLANS 276.5 70 999999999 239.17 383.15 percent of total billed charges ARTHROSCOPIC TUBING 350-800-006. 49976002_1 CDM 0272 RC inpatient 395 256.75 SIHO - ALL PLANS SIHO - ALL PLANS 355.5 90 999999999 239.17 383.15 percent of total billed charges ARTHROSCOPIC TUBING 350-800-006. 49976002_1 CDM 0272 RC inpatient 395 256.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 239.17 60.55 999999999 239.17 383.15 percent of total billed charges ARTHROSCOPIC TUBING 350-800-006. 49976002_1 CDM 0272 RC inpatient 395 256.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 239.17 383.15 ARTHROSCOPIC TUBING 350-800-006. 49976002_1 CDM 0272 RC inpatient 395 256.75 ANTHEM HMO ANTHEM HMO 999999999 239.17 383.15 ARTHROSCOPIC TUBING 350-800-006. 49976002_1 CDM 0272 RC inpatient 395 256.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 239.17 383.15 ARTHROSCOPIC TUBING 350-800-006. 49976002_1 CDM 0272 RC inpatient 395 256.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 267.02 67.6 999999999 239.17 383.15 percent of total billed charges ARTHROSCOPIC TUBING 350-800-006. 49976002_1 CDM 0272 RC inpatient 395 256.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 239.17 383.15 ARTHROSCOPIC TUBING 350-800-006. 49976002_1 CDM 0272 RC inpatient 395 256.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 239.17 383.15 JOINT DEVICE (IMPLANTABLE) 49976291_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 7688.85 65 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976291_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 AETNA AETNA 9344.91 79 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976291_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11474.13 97 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976291_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 8162.01 69 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976291_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 9226.62 78 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976291_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UMR - ALL PLANS UMR - ALL PLANS 8280.3 70 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976291_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 SIHO - ALL PLANS SIHO - ALL PLANS 10646.1 90 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976291_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7162.46 60.55 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976291_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976291_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM HMO ANTHEM HMO 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976291_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976291_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 7996.4 67.6 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976291_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976291_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976292_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 7688.85 65 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976292_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 AETNA AETNA 9344.91 79 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976292_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11474.13 97 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976292_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 8162.01 69 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976292_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 9226.62 78 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976292_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UMR - ALL PLANS UMR - ALL PLANS 8280.3 70 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976292_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 SIHO - ALL PLANS SIHO - ALL PLANS 10646.1 90 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976292_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7162.46 60.55 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976292_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976292_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM HMO ANTHEM HMO 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976292_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976292_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 7996.4 67.6 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976292_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976292_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976293_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 7688.85 65 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976293_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 AETNA AETNA 9344.91 79 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976293_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11474.13 97 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976293_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 8162.01 69 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976293_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 9226.62 78 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976293_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UMR - ALL PLANS UMR - ALL PLANS 8280.3 70 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976293_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 SIHO - ALL PLANS SIHO - ALL PLANS 10646.1 90 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976293_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7162.46 60.55 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976293_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976293_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM HMO ANTHEM HMO 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976293_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976293_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 7996.4 67.6 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976293_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976293_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976295_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 7688.85 65 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976295_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 AETNA AETNA 9344.91 79 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976295_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11474.13 97 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976295_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 8162.01 69 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976295_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 9226.62 78 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976295_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UMR - ALL PLANS UMR - ALL PLANS 8280.3 70 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976295_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 SIHO - ALL PLANS SIHO - ALL PLANS 10646.1 90 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976295_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7162.46 60.55 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976295_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976295_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM HMO ANTHEM HMO 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976295_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976295_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 7996.4 67.6 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976295_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976295_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976296_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 7688.85 65 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976296_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 AETNA AETNA 9344.91 79 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976296_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11474.13 97 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976296_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 8162.01 69 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976296_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 9226.62 78 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976296_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UMR - ALL PLANS UMR - ALL PLANS 8280.3 70 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976296_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 SIHO - ALL PLANS SIHO - ALL PLANS 10646.1 90 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976296_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7162.46 60.55 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976296_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976296_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM HMO ANTHEM HMO 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976296_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976296_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 7996.4 67.6 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49976296_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49976296_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 7162.46 11474.13 ANORO ELLIPTA 62.5-25 MCG INH 49977374_1 CDM 0250 RC 00173-0869-06 NDC inpatient 1 UN 140.37 91.24 SELF PAY DISCOUNT SELF PAY DISCOUNT 91.24 65 999999999 84.99 136.16 percent of total billed charges ANORO ELLIPTA 62.5-25 MCG INH 49977374_1 CDM 0250 RC 00173-0869-06 NDC inpatient 1 UN 140.37 91.24 AETNA AETNA 110.89 79 999999999 84.99 136.16 percent of total billed charges ANORO ELLIPTA 62.5-25 MCG INH 49977374_1 CDM 0250 RC 00173-0869-06 NDC inpatient 1 UN 140.37 91.24 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 136.16 97 999999999 84.99 136.16 percent of total billed charges ANORO ELLIPTA 62.5-25 MCG INH 49977374_1 CDM 0250 RC 00173-0869-06 NDC inpatient 1 UN 140.37 91.24 ENCORE - ALL PLANS ENCORE - ALL PLANS 96.86 69 999999999 84.99 136.16 percent of total billed charges ANORO ELLIPTA 62.5-25 MCG INH 49977374_1 CDM 0250 RC 00173-0869-06 NDC inpatient 1 UN 140.37 91.24 HUMANA - ALL PLANS HUMANA - ALL PLANS 109.49 78 999999999 84.99 136.16 percent of total billed charges ANORO ELLIPTA 62.5-25 MCG INH 49977374_1 CDM 0250 RC 00173-0869-06 NDC inpatient 1 UN 140.37 91.24 UMR - ALL PLANS UMR - ALL PLANS 98.26 70 999999999 84.99 136.16 percent of total billed charges ANORO ELLIPTA 62.5-25 MCG INH 49977374_1 CDM 0250 RC 00173-0869-06 NDC inpatient 1 UN 140.37 91.24 SIHO - ALL PLANS SIHO - ALL PLANS 126.33 90 999999999 84.99 136.16 percent of total billed charges ANORO ELLIPTA 62.5-25 MCG INH 49977374_1 CDM 0250 RC 00173-0869-06 NDC inpatient 1 UN 140.37 91.24 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 84.99 60.55 999999999 84.99 136.16 percent of total billed charges ANORO ELLIPTA 62.5-25 MCG INH 49977374_1 CDM 0250 RC 00173-0869-06 NDC inpatient 1 UN 140.37 91.24 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 84.99 136.16 ANORO ELLIPTA 62.5-25 MCG INH 49977374_1 CDM 0250 RC 00173-0869-06 NDC inpatient 1 UN 140.37 91.24 ANTHEM HMO ANTHEM HMO 999999999 84.99 136.16 ANORO ELLIPTA 62.5-25 MCG INH 49977374_1 CDM 0250 RC 00173-0869-06 NDC inpatient 1 UN 140.37 91.24 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 84.99 136.16 ANORO ELLIPTA 62.5-25 MCG INH 49977374_1 CDM 0250 RC 00173-0869-06 NDC inpatient 1 UN 140.37 91.24 CIGNA - ALL PLANS CIGNA - ALL PLANS 94.89 67.6 999999999 84.99 136.16 percent of total billed charges ANORO ELLIPTA 62.5-25 MCG INH 49977374_1 CDM 0250 RC 00173-0869-06 NDC inpatient 1 UN 140.37 91.24 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 84.99 136.16 ANORO ELLIPTA 62.5-25 MCG INH 49977374_1 CDM 0250 RC 00173-0869-06 NDC inpatient 1 UN 140.37 91.24 UHC - ALL PLANS UHC - ALL PLANS 999999999 84.99 136.16 CARVEDILOL 3.125 MG TABLET 49977531_1 CDM 0250 RC 00904-6300-61 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CARVEDILOL 3.125 MG TABLET 49977531_1 CDM 0250 RC 00904-6300-61 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CARVEDILOL 3.125 MG TABLET 49977531_1 CDM 0250 RC 00904-6300-61 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CARVEDILOL 3.125 MG TABLET 49977531_1 CDM 0250 RC 00904-6300-61 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CARVEDILOL 3.125 MG TABLET 49977531_1 CDM 0250 RC 00904-6300-61 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CARVEDILOL 3.125 MG TABLET 49977531_1 CDM 0250 RC 00904-6300-61 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CARVEDILOL 3.125 MG TABLET 49977531_1 CDM 0250 RC 00904-6300-61 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CARVEDILOL 3.125 MG TABLET 49977531_1 CDM 0250 RC 00904-6300-61 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CARVEDILOL 3.125 MG TABLET 49977531_1 CDM 0250 RC 00904-6300-61 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CARVEDILOL 3.125 MG TABLET 49977531_1 CDM 0250 RC 00904-6300-61 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CARVEDILOL 3.125 MG TABLET 49977531_1 CDM 0250 RC 00904-6300-61 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CARVEDILOL 3.125 MG TABLET 49977531_1 CDM 0250 RC 00904-6300-61 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CARVEDILOL 3.125 MG TABLET 49977531_1 CDM 0250 RC 00904-6300-61 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CARVEDILOL 3.125 MG TABLET 49977531_1 CDM 0250 RC 00904-6300-61 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "Preparation of specimen, manual" 49978746_1 CDM 0310 RC 88381 HCPCS inpatient 569 369.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 369.85 65 999999999 344.53 551.93 percent of total billed charges "Preparation of specimen, manual" 49978746_1 CDM 0310 RC 88381 HCPCS inpatient 569 369.85 AETNA AETNA 449.51 79 999999999 344.53 551.93 percent of total billed charges "Preparation of specimen, manual" 49978746_1 CDM 0310 RC 88381 HCPCS inpatient 569 369.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 551.93 97 999999999 344.53 551.93 percent of total billed charges "Preparation of specimen, manual" 49978746_1 CDM 0310 RC 88381 HCPCS inpatient 569 369.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 392.61 69 999999999 344.53 551.93 percent of total billed charges "Preparation of specimen, manual" 49978746_1 CDM 0310 RC 88381 HCPCS inpatient 569 369.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 443.82 78 999999999 344.53 551.93 percent of total billed charges "Preparation of specimen, manual" 49978746_1 CDM 0310 RC 88381 HCPCS inpatient 569 369.85 UMR - ALL PLANS UMR - ALL PLANS 398.3 70 999999999 344.53 551.93 percent of total billed charges "Preparation of specimen, manual" 49978746_1 CDM 0310 RC 88381 HCPCS inpatient 569 369.85 SIHO - ALL PLANS SIHO - ALL PLANS 512.1 90 999999999 344.53 551.93 percent of total billed charges "Preparation of specimen, manual" 49978746_1 CDM 0310 RC 88381 HCPCS inpatient 569 369.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 344.53 60.55 999999999 344.53 551.93 percent of total billed charges "Preparation of specimen, manual" 49978746_1 CDM 0310 RC 88381 HCPCS inpatient 569 369.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 344.53 551.93 "Preparation of specimen, manual" 49978746_1 CDM 0310 RC 88381 HCPCS inpatient 569 369.85 ANTHEM HMO ANTHEM HMO 999999999 344.53 551.93 "Preparation of specimen, manual" 49978746_1 CDM 0310 RC 88381 HCPCS inpatient 569 369.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 344.53 551.93 "Preparation of specimen, manual" 49978746_1 CDM 0310 RC 88381 HCPCS inpatient 569 369.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 384.64 67.6 999999999 344.53 551.93 percent of total billed charges "Preparation of specimen, manual" 49978746_1 CDM 0310 RC 88381 HCPCS inpatient 569 369.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 344.53 551.93 "Preparation of specimen, manual" 49978746_1 CDM 0310 RC 88381 HCPCS inpatient 569 369.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 344.53 551.93 Analysis for antibody to Brucella (bacteria) 49978817_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49978817_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49978817_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49978817_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49978817_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49978817_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49978817_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49978817_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49978817_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 49978817_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 49978817_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 49978817_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 49978817_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 49978817_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 "INJECTION, ERTAPENEM SODIUM, 500 MG" 49979359_1 CDM 0250 RC 55150-0282-20 NDC J1335 HCPCS inpatient 2 UN 269.54 175.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 175.2 65 999999999 163.21 261.45 percent of total billed charges "INJECTION, ERTAPENEM SODIUM, 500 MG" 49979359_1 CDM 0250 RC 55150-0282-20 NDC J1335 HCPCS inpatient 2 UN 269.54 175.2 AETNA AETNA 212.94 79 999999999 163.21 261.45 percent of total billed charges "INJECTION, ERTAPENEM SODIUM, 500 MG" 49979359_1 CDM 0250 RC 55150-0282-20 NDC J1335 HCPCS inpatient 2 UN 269.54 175.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 261.45 97 999999999 163.21 261.45 percent of total billed charges "INJECTION, ERTAPENEM SODIUM, 500 MG" 49979359_1 CDM 0250 RC 55150-0282-20 NDC J1335 HCPCS inpatient 2 UN 269.54 175.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 185.98 69 999999999 163.21 261.45 percent of total billed charges "INJECTION, ERTAPENEM SODIUM, 500 MG" 49979359_1 CDM 0250 RC 55150-0282-20 NDC J1335 HCPCS inpatient 2 UN 269.54 175.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 210.24 78 999999999 163.21 261.45 percent of total billed charges "INJECTION, ERTAPENEM SODIUM, 500 MG" 49979359_1 CDM 0250 RC 55150-0282-20 NDC J1335 HCPCS inpatient 2 UN 269.54 175.2 UMR - ALL PLANS UMR - ALL PLANS 188.68 70 999999999 163.21 261.45 percent of total billed charges "INJECTION, ERTAPENEM SODIUM, 500 MG" 49979359_1 CDM 0250 RC 55150-0282-20 NDC J1335 HCPCS inpatient 2 UN 269.54 175.2 SIHO - ALL PLANS SIHO - ALL PLANS 242.59 90 999999999 163.21 261.45 percent of total billed charges "INJECTION, ERTAPENEM SODIUM, 500 MG" 49979359_1 CDM 0250 RC 55150-0282-20 NDC J1335 HCPCS inpatient 2 UN 269.54 175.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 163.21 60.55 999999999 163.21 261.45 percent of total billed charges "INJECTION, ERTAPENEM SODIUM, 500 MG" 49979359_1 CDM 0250 RC 55150-0282-20 NDC J1335 HCPCS inpatient 2 UN 269.54 175.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 163.21 261.45 "INJECTION, ERTAPENEM SODIUM, 500 MG" 49979359_1 CDM 0250 RC 55150-0282-20 NDC J1335 HCPCS inpatient 2 UN 269.54 175.2 ANTHEM HMO ANTHEM HMO 999999999 163.21 261.45 "INJECTION, ERTAPENEM SODIUM, 500 MG" 49979359_1 CDM 0250 RC 55150-0282-20 NDC J1335 HCPCS inpatient 2 UN 269.54 175.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 163.21 261.45 "INJECTION, ERTAPENEM SODIUM, 500 MG" 49979359_1 CDM 0250 RC 55150-0282-20 NDC J1335 HCPCS inpatient 2 UN 269.54 175.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 182.21 67.6 999999999 163.21 261.45 percent of total billed charges "INJECTION, ERTAPENEM SODIUM, 500 MG" 49979359_1 CDM 0250 RC 55150-0282-20 NDC J1335 HCPCS inpatient 2 UN 269.54 175.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 163.21 261.45 "INJECTION, ERTAPENEM SODIUM, 500 MG" 49979359_1 CDM 0250 RC 55150-0282-20 NDC J1335 HCPCS inpatient 2 UN 269.54 175.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 163.21 261.45 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49980165_1 CDM 0258 RC 63323-0106-10 NDC J3475 HCPCS inpatient 80 UN 49.69 32.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.3 65 999999999 30.09 48.2 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49980165_1 CDM 0258 RC 63323-0106-10 NDC J3475 HCPCS inpatient 80 UN 49.69 32.3 AETNA AETNA 39.26 79 999999999 30.09 48.2 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49980165_1 CDM 0258 RC 63323-0106-10 NDC J3475 HCPCS inpatient 80 UN 49.69 32.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.2 97 999999999 30.09 48.2 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49980165_1 CDM 0258 RC 63323-0106-10 NDC J3475 HCPCS inpatient 80 UN 49.69 32.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.29 69 999999999 30.09 48.2 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49980165_1 CDM 0258 RC 63323-0106-10 NDC J3475 HCPCS inpatient 80 UN 49.69 32.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 38.76 78 999999999 30.09 48.2 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49980165_1 CDM 0258 RC 63323-0106-10 NDC J3475 HCPCS inpatient 80 UN 49.69 32.3 UMR - ALL PLANS UMR - ALL PLANS 34.78 70 999999999 30.09 48.2 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49980165_1 CDM 0258 RC 63323-0106-10 NDC J3475 HCPCS inpatient 80 UN 49.69 32.3 SIHO - ALL PLANS SIHO - ALL PLANS 44.72 90 999999999 30.09 48.2 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49980165_1 CDM 0258 RC 63323-0106-10 NDC J3475 HCPCS inpatient 80 UN 49.69 32.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.09 60.55 999999999 30.09 48.2 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49980165_1 CDM 0258 RC 63323-0106-10 NDC J3475 HCPCS inpatient 80 UN 49.69 32.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.09 48.2 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49980165_1 CDM 0258 RC 63323-0106-10 NDC J3475 HCPCS inpatient 80 UN 49.69 32.3 ANTHEM HMO ANTHEM HMO 999999999 30.09 48.2 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49980165_1 CDM 0258 RC 63323-0106-10 NDC J3475 HCPCS inpatient 80 UN 49.69 32.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.09 48.2 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49980165_1 CDM 0258 RC 63323-0106-10 NDC J3475 HCPCS inpatient 80 UN 49.69 32.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.59 67.6 999999999 30.09 48.2 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49980165_1 CDM 0258 RC 63323-0106-10 NDC J3475 HCPCS inpatient 80 UN 49.69 32.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.09 48.2 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49980165_1 CDM 0258 RC 63323-0106-10 NDC J3475 HCPCS inpatient 80 UN 49.69 32.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.09 48.2 NIFEDIPINE 10 MG CAPSULE 49980168_1 CDM 0250 RC 69315-0211-01 NDC inpatient 1 UN 1.61 1.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.05 65 999999999 0.97 1.56 percent of total billed charges NIFEDIPINE 10 MG CAPSULE 49980168_1 CDM 0250 RC 69315-0211-01 NDC inpatient 1 UN 1.61 1.05 AETNA AETNA 1.27 79 999999999 0.97 1.56 percent of total billed charges NIFEDIPINE 10 MG CAPSULE 49980168_1 CDM 0250 RC 69315-0211-01 NDC inpatient 1 UN 1.61 1.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.56 97 999999999 0.97 1.56 percent of total billed charges NIFEDIPINE 10 MG CAPSULE 49980168_1 CDM 0250 RC 69315-0211-01 NDC inpatient 1 UN 1.61 1.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.11 69 999999999 0.97 1.56 percent of total billed charges NIFEDIPINE 10 MG CAPSULE 49980168_1 CDM 0250 RC 69315-0211-01 NDC inpatient 1 UN 1.61 1.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.26 78 999999999 0.97 1.56 percent of total billed charges NIFEDIPINE 10 MG CAPSULE 49980168_1 CDM 0250 RC 69315-0211-01 NDC inpatient 1 UN 1.61 1.05 UMR - ALL PLANS UMR - ALL PLANS 1.13 70 999999999 0.97 1.56 percent of total billed charges NIFEDIPINE 10 MG CAPSULE 49980168_1 CDM 0250 RC 69315-0211-01 NDC inpatient 1 UN 1.61 1.05 SIHO - ALL PLANS SIHO - ALL PLANS 1.45 90 999999999 0.97 1.56 percent of total billed charges NIFEDIPINE 10 MG CAPSULE 49980168_1 CDM 0250 RC 69315-0211-01 NDC inpatient 1 UN 1.61 1.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.97 60.55 999999999 0.97 1.56 percent of total billed charges NIFEDIPINE 10 MG CAPSULE 49980168_1 CDM 0250 RC 69315-0211-01 NDC inpatient 1 UN 1.61 1.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.97 1.56 NIFEDIPINE 10 MG CAPSULE 49980168_1 CDM 0250 RC 69315-0211-01 NDC inpatient 1 UN 1.61 1.05 ANTHEM HMO ANTHEM HMO 999999999 0.97 1.56 NIFEDIPINE 10 MG CAPSULE 49980168_1 CDM 0250 RC 69315-0211-01 NDC inpatient 1 UN 1.61 1.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.97 1.56 NIFEDIPINE 10 MG CAPSULE 49980168_1 CDM 0250 RC 69315-0211-01 NDC inpatient 1 UN 1.61 1.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.09 67.6 999999999 0.97 1.56 percent of total billed charges NIFEDIPINE 10 MG CAPSULE 49980168_1 CDM 0250 RC 69315-0211-01 NDC inpatient 1 UN 1.61 1.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.97 1.56 NIFEDIPINE 10 MG CAPSULE 49980168_1 CDM 0250 RC 69315-0211-01 NDC inpatient 1 UN 1.61 1.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.97 1.56 AFRIN 0.05% NASAL SPRAY 49984216_1 CDM 0250 RC 11523-1167-06 NDC inpatient 1 UN 21.14 13.74 SELF PAY DISCOUNT SELF PAY DISCOUNT 13.74 65 999999999 12.8 20.51 percent of total billed charges AFRIN 0.05% NASAL SPRAY 49984216_1 CDM 0250 RC 11523-1167-06 NDC inpatient 1 UN 21.14 13.74 AETNA AETNA 16.7 79 999999999 12.8 20.51 percent of total billed charges AFRIN 0.05% NASAL SPRAY 49984216_1 CDM 0250 RC 11523-1167-06 NDC inpatient 1 UN 21.14 13.74 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20.51 97 999999999 12.8 20.51 percent of total billed charges AFRIN 0.05% NASAL SPRAY 49984216_1 CDM 0250 RC 11523-1167-06 NDC inpatient 1 UN 21.14 13.74 ENCORE - ALL PLANS ENCORE - ALL PLANS 14.59 69 999999999 12.8 20.51 percent of total billed charges AFRIN 0.05% NASAL SPRAY 49984216_1 CDM 0250 RC 11523-1167-06 NDC inpatient 1 UN 21.14 13.74 HUMANA - ALL PLANS HUMANA - ALL PLANS 16.49 78 999999999 12.8 20.51 percent of total billed charges AFRIN 0.05% NASAL SPRAY 49984216_1 CDM 0250 RC 11523-1167-06 NDC inpatient 1 UN 21.14 13.74 UMR - ALL PLANS UMR - ALL PLANS 14.8 70 999999999 12.8 20.51 percent of total billed charges AFRIN 0.05% NASAL SPRAY 49984216_1 CDM 0250 RC 11523-1167-06 NDC inpatient 1 UN 21.14 13.74 SIHO - ALL PLANS SIHO - ALL PLANS 19.03 90 999999999 12.8 20.51 percent of total billed charges AFRIN 0.05% NASAL SPRAY 49984216_1 CDM 0250 RC 11523-1167-06 NDC inpatient 1 UN 21.14 13.74 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.8 60.55 999999999 12.8 20.51 percent of total billed charges AFRIN 0.05% NASAL SPRAY 49984216_1 CDM 0250 RC 11523-1167-06 NDC inpatient 1 UN 21.14 13.74 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.8 20.51 AFRIN 0.05% NASAL SPRAY 49984216_1 CDM 0250 RC 11523-1167-06 NDC inpatient 1 UN 21.14 13.74 ANTHEM HMO ANTHEM HMO 999999999 12.8 20.51 AFRIN 0.05% NASAL SPRAY 49984216_1 CDM 0250 RC 11523-1167-06 NDC inpatient 1 UN 21.14 13.74 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.8 20.51 AFRIN 0.05% NASAL SPRAY 49984216_1 CDM 0250 RC 11523-1167-06 NDC inpatient 1 UN 21.14 13.74 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.29 67.6 999999999 12.8 20.51 percent of total billed charges AFRIN 0.05% NASAL SPRAY 49984216_1 CDM 0250 RC 11523-1167-06 NDC inpatient 1 UN 21.14 13.74 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.8 20.51 AFRIN 0.05% NASAL SPRAY 49984216_1 CDM 0250 RC 11523-1167-06 NDC inpatient 1 UN 21.14 13.74 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.8 20.51 PROPRANOLOL ER 60 MG CAPSULE 49984651_1 CDM 0250 RC 62559-0530-01 NDC inpatient 1 UN 1.2 0.78 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.78 65 999999999 0.73 1.16 percent of total billed charges PROPRANOLOL ER 60 MG CAPSULE 49984651_1 CDM 0250 RC 62559-0530-01 NDC inpatient 1 UN 1.2 0.78 AETNA AETNA 0.95 79 999999999 0.73 1.16 percent of total billed charges PROPRANOLOL ER 60 MG CAPSULE 49984651_1 CDM 0250 RC 62559-0530-01 NDC inpatient 1 UN 1.2 0.78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.16 97 999999999 0.73 1.16 percent of total billed charges PROPRANOLOL ER 60 MG CAPSULE 49984651_1 CDM 0250 RC 62559-0530-01 NDC inpatient 1 UN 1.2 0.78 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.83 69 999999999 0.73 1.16 percent of total billed charges PROPRANOLOL ER 60 MG CAPSULE 49984651_1 CDM 0250 RC 62559-0530-01 NDC inpatient 1 UN 1.2 0.78 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.94 78 999999999 0.73 1.16 percent of total billed charges PROPRANOLOL ER 60 MG CAPSULE 49984651_1 CDM 0250 RC 62559-0530-01 NDC inpatient 1 UN 1.2 0.78 UMR - ALL PLANS UMR - ALL PLANS 0.84 70 999999999 0.73 1.16 percent of total billed charges PROPRANOLOL ER 60 MG CAPSULE 49984651_1 CDM 0250 RC 62559-0530-01 NDC inpatient 1 UN 1.2 0.78 SIHO - ALL PLANS SIHO - ALL PLANS 1.08 90 999999999 0.73 1.16 percent of total billed charges PROPRANOLOL ER 60 MG CAPSULE 49984651_1 CDM 0250 RC 62559-0530-01 NDC inpatient 1 UN 1.2 0.78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.73 60.55 999999999 0.73 1.16 percent of total billed charges PROPRANOLOL ER 60 MG CAPSULE 49984651_1 CDM 0250 RC 62559-0530-01 NDC inpatient 1 UN 1.2 0.78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.73 1.16 PROPRANOLOL ER 60 MG CAPSULE 49984651_1 CDM 0250 RC 62559-0530-01 NDC inpatient 1 UN 1.2 0.78 ANTHEM HMO ANTHEM HMO 999999999 0.73 1.16 PROPRANOLOL ER 60 MG CAPSULE 49984651_1 CDM 0250 RC 62559-0530-01 NDC inpatient 1 UN 1.2 0.78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.73 1.16 PROPRANOLOL ER 60 MG CAPSULE 49984651_1 CDM 0250 RC 62559-0530-01 NDC inpatient 1 UN 1.2 0.78 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.81 67.6 999999999 0.73 1.16 percent of total billed charges PROPRANOLOL ER 60 MG CAPSULE 49984651_1 CDM 0250 RC 62559-0530-01 NDC inpatient 1 UN 1.2 0.78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.73 1.16 PROPRANOLOL ER 60 MG CAPSULE 49984651_1 CDM 0250 RC 62559-0530-01 NDC inpatient 1 UN 1.2 0.78 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.73 1.16 JOINT DEVICE (IMPLANTABLE) 49985559_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 7688.85 65 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985559_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 AETNA AETNA 9344.91 79 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985559_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11474.13 97 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985559_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 8162.01 69 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985559_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 9226.62 78 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985559_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UMR - ALL PLANS UMR - ALL PLANS 8280.3 70 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985559_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 SIHO - ALL PLANS SIHO - ALL PLANS 10646.1 90 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985559_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7162.46 60.55 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985559_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49985559_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM HMO ANTHEM HMO 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49985559_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49985559_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 7996.4 67.6 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985559_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49985559_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49985560_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 7688.85 65 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985560_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 AETNA AETNA 9344.91 79 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985560_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11474.13 97 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985560_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 8162.01 69 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985560_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 9226.62 78 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985560_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UMR - ALL PLANS UMR - ALL PLANS 8280.3 70 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985560_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 SIHO - ALL PLANS SIHO - ALL PLANS 10646.1 90 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985560_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7162.46 60.55 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985560_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49985560_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM HMO ANTHEM HMO 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49985560_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49985560_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 7996.4 67.6 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985560_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49985560_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49985561_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 7688.85 65 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985561_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 AETNA AETNA 9344.91 79 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985561_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11474.13 97 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985561_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 8162.01 69 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985561_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 9226.62 78 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985561_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UMR - ALL PLANS UMR - ALL PLANS 8280.3 70 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985561_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 SIHO - ALL PLANS SIHO - ALL PLANS 10646.1 90 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985561_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7162.46 60.55 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985561_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49985561_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM HMO ANTHEM HMO 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49985561_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49985561_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 7996.4 67.6 999999999 7162.46 11474.13 percent of total billed charges JOINT DEVICE (IMPLANTABLE) 49985561_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7162.46 11474.13 JOINT DEVICE (IMPLANTABLE) 49985561_1 CDM 0278 RC C1776 HCPCS inpatient 11829 7688.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 7162.46 11474.13 TRACH SIZE 8 UNCUFFED W/INNER CANNULA 8CFN 49986551_1 CDM 0272 RC inpatient 193 125.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 125.45 65 999999999 116.86 187.21 percent of total billed charges TRACH SIZE 8 UNCUFFED W/INNER CANNULA 8CFN 49986551_1 CDM 0272 RC inpatient 193 125.45 AETNA AETNA 152.47 79 999999999 116.86 187.21 percent of total billed charges TRACH SIZE 8 UNCUFFED W/INNER CANNULA 8CFN 49986551_1 CDM 0272 RC inpatient 193 125.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 187.21 97 999999999 116.86 187.21 percent of total billed charges TRACH SIZE 8 UNCUFFED W/INNER CANNULA 8CFN 49986551_1 CDM 0272 RC inpatient 193 125.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.17 69 999999999 116.86 187.21 percent of total billed charges TRACH SIZE 8 UNCUFFED W/INNER CANNULA 8CFN 49986551_1 CDM 0272 RC inpatient 193 125.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 150.54 78 999999999 116.86 187.21 percent of total billed charges TRACH SIZE 8 UNCUFFED W/INNER CANNULA 8CFN 49986551_1 CDM 0272 RC inpatient 193 125.45 UMR - ALL PLANS UMR - ALL PLANS 135.1 70 999999999 116.86 187.21 percent of total billed charges TRACH SIZE 8 UNCUFFED W/INNER CANNULA 8CFN 49986551_1 CDM 0272 RC inpatient 193 125.45 SIHO - ALL PLANS SIHO - ALL PLANS 173.7 90 999999999 116.86 187.21 percent of total billed charges TRACH SIZE 8 UNCUFFED W/INNER CANNULA 8CFN 49986551_1 CDM 0272 RC inpatient 193 125.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.86 60.55 999999999 116.86 187.21 percent of total billed charges TRACH SIZE 8 UNCUFFED W/INNER CANNULA 8CFN 49986551_1 CDM 0272 RC inpatient 193 125.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.86 187.21 TRACH SIZE 8 UNCUFFED W/INNER CANNULA 8CFN 49986551_1 CDM 0272 RC inpatient 193 125.45 ANTHEM HMO ANTHEM HMO 999999999 116.86 187.21 TRACH SIZE 8 UNCUFFED W/INNER CANNULA 8CFN 49986551_1 CDM 0272 RC inpatient 193 125.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.86 187.21 TRACH SIZE 8 UNCUFFED W/INNER CANNULA 8CFN 49986551_1 CDM 0272 RC inpatient 193 125.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 130.47 67.6 999999999 116.86 187.21 percent of total billed charges TRACH SIZE 8 UNCUFFED W/INNER CANNULA 8CFN 49986551_1 CDM 0272 RC inpatient 193 125.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.86 187.21 TRACH SIZE 8 UNCUFFED W/INNER CANNULA 8CFN 49986551_1 CDM 0272 RC inpatient 193 125.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.86 187.21 SUTURE VICRYL 2-0 CT 1 COATED UNDYED BRAIDED 36in 90cm J945H 49986855_1 CDM 0272 RC inpatient 36 23.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 23.4 65 999999999 21.8 34.92 percent of total billed charges SUTURE VICRYL 2-0 CT 1 COATED UNDYED BRAIDED 36in 90cm J945H 49986855_1 CDM 0272 RC inpatient 36 23.4 AETNA AETNA 28.44 79 999999999 21.8 34.92 percent of total billed charges SUTURE VICRYL 2-0 CT 1 COATED UNDYED BRAIDED 36in 90cm J945H 49986855_1 CDM 0272 RC inpatient 36 23.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34.92 97 999999999 21.8 34.92 percent of total billed charges SUTURE VICRYL 2-0 CT 1 COATED UNDYED BRAIDED 36in 90cm J945H 49986855_1 CDM 0272 RC inpatient 36 23.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.84 69 999999999 21.8 34.92 percent of total billed charges SUTURE VICRYL 2-0 CT 1 COATED UNDYED BRAIDED 36in 90cm J945H 49986855_1 CDM 0272 RC inpatient 36 23.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.08 78 999999999 21.8 34.92 percent of total billed charges SUTURE VICRYL 2-0 CT 1 COATED UNDYED BRAIDED 36in 90cm J945H 49986855_1 CDM 0272 RC inpatient 36 23.4 UMR - ALL PLANS UMR - ALL PLANS 25.2 70 999999999 21.8 34.92 percent of total billed charges SUTURE VICRYL 2-0 CT 1 COATED UNDYED BRAIDED 36in 90cm J945H 49986855_1 CDM 0272 RC inpatient 36 23.4 SIHO - ALL PLANS SIHO - ALL PLANS 32.4 90 999999999 21.8 34.92 percent of total billed charges SUTURE VICRYL 2-0 CT 1 COATED UNDYED BRAIDED 36in 90cm J945H 49986855_1 CDM 0272 RC inpatient 36 23.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.8 60.55 999999999 21.8 34.92 percent of total billed charges SUTURE VICRYL 2-0 CT 1 COATED UNDYED BRAIDED 36in 90cm J945H 49986855_1 CDM 0272 RC inpatient 36 23.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.8 34.92 SUTURE VICRYL 2-0 CT 1 COATED UNDYED BRAIDED 36in 90cm J945H 49986855_1 CDM 0272 RC inpatient 36 23.4 ANTHEM HMO ANTHEM HMO 999999999 21.8 34.92 SUTURE VICRYL 2-0 CT 1 COATED UNDYED BRAIDED 36in 90cm J945H 49986855_1 CDM 0272 RC inpatient 36 23.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.8 34.92 SUTURE VICRYL 2-0 CT 1 COATED UNDYED BRAIDED 36in 90cm J945H 49986855_1 CDM 0272 RC inpatient 36 23.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 24.34 67.6 999999999 21.8 34.92 percent of total billed charges SUTURE VICRYL 2-0 CT 1 COATED UNDYED BRAIDED 36in 90cm J945H 49986855_1 CDM 0272 RC inpatient 36 23.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.8 34.92 SUTURE VICRYL 2-0 CT 1 COATED UNDYED BRAIDED 36in 90cm J945H 49986855_1 CDM 0272 RC inpatient 36 23.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.8 34.92 "Methemoglobin (hemoglobin) analysis, quantitative" 49987491_1 CDM 0301 RC 83050 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "Methemoglobin (hemoglobin) analysis, quantitative" 49987491_1 CDM 0301 RC 83050 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "Methemoglobin (hemoglobin) analysis, quantitative" 49987491_1 CDM 0301 RC 83050 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "Methemoglobin (hemoglobin) analysis, quantitative" 49987491_1 CDM 0301 RC 83050 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "Methemoglobin (hemoglobin) analysis, quantitative" 49987491_1 CDM 0301 RC 83050 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "Methemoglobin (hemoglobin) analysis, quantitative" 49987491_1 CDM 0301 RC 83050 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "Methemoglobin (hemoglobin) analysis, quantitative" 49987491_1 CDM 0301 RC 83050 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "Methemoglobin (hemoglobin) analysis, quantitative" 49987491_1 CDM 0301 RC 83050 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "Methemoglobin (hemoglobin) analysis, quantitative" 49987491_1 CDM 0301 RC 83050 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "Methemoglobin (hemoglobin) analysis, quantitative" 49987491_1 CDM 0301 RC 83050 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "Methemoglobin (hemoglobin) analysis, quantitative" 49987491_1 CDM 0301 RC 83050 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "Methemoglobin (hemoglobin) analysis, quantitative" 49987491_1 CDM 0301 RC 83050 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges "Methemoglobin (hemoglobin) analysis, quantitative" 49987491_1 CDM 0301 RC 83050 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "Methemoglobin (hemoglobin) analysis, quantitative" 49987491_1 CDM 0301 RC 83050 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 "THERASKIN, PER SQUARE CENTIMETER" 49988763_1 CDM 0636 RC Q4121 HCPCS inpatient 2249 1461.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1461.85 65 999999999 1361.77 2181.53 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988763_1 CDM 0636 RC Q4121 HCPCS inpatient 2249 1461.85 AETNA AETNA 1776.71 79 999999999 1361.77 2181.53 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988763_1 CDM 0636 RC Q4121 HCPCS inpatient 2249 1461.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2181.53 97 999999999 1361.77 2181.53 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988763_1 CDM 0636 RC Q4121 HCPCS inpatient 2249 1461.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1551.81 69 999999999 1361.77 2181.53 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988763_1 CDM 0636 RC Q4121 HCPCS inpatient 2249 1461.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1754.22 78 999999999 1361.77 2181.53 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988763_1 CDM 0636 RC Q4121 HCPCS inpatient 2249 1461.85 UMR - ALL PLANS UMR - ALL PLANS 1574.3 70 999999999 1361.77 2181.53 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988763_1 CDM 0636 RC Q4121 HCPCS inpatient 2249 1461.85 SIHO - ALL PLANS SIHO - ALL PLANS 2024.1 90 999999999 1361.77 2181.53 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988763_1 CDM 0636 RC Q4121 HCPCS inpatient 2249 1461.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1361.77 60.55 999999999 1361.77 2181.53 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988763_1 CDM 0636 RC Q4121 HCPCS inpatient 2249 1461.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1361.77 2181.53 "THERASKIN, PER SQUARE CENTIMETER" 49988763_1 CDM 0636 RC Q4121 HCPCS inpatient 2249 1461.85 ANTHEM HMO ANTHEM HMO 999999999 1361.77 2181.53 "THERASKIN, PER SQUARE CENTIMETER" 49988763_1 CDM 0636 RC Q4121 HCPCS inpatient 2249 1461.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1361.77 2181.53 "THERASKIN, PER SQUARE CENTIMETER" 49988763_1 CDM 0636 RC Q4121 HCPCS inpatient 2249 1461.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1520.32 67.6 999999999 1361.77 2181.53 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988763_1 CDM 0636 RC Q4121 HCPCS inpatient 2249 1461.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1361.77 2181.53 "THERASKIN, PER SQUARE CENTIMETER" 49988763_1 CDM 0636 RC Q4121 HCPCS inpatient 2249 1461.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1361.77 2181.53 "THERASKIN, PER SQUARE CENTIMETER" 49988765_1 CDM 0636 RC Q4121 HCPCS inpatient 2553 1659.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1659.45 65 999999999 1545.84 2476.41 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988765_1 CDM 0636 RC Q4121 HCPCS inpatient 2553 1659.45 AETNA AETNA 2016.87 79 999999999 1545.84 2476.41 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988765_1 CDM 0636 RC Q4121 HCPCS inpatient 2553 1659.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2476.41 97 999999999 1545.84 2476.41 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988765_1 CDM 0636 RC Q4121 HCPCS inpatient 2553 1659.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1761.57 69 999999999 1545.84 2476.41 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988765_1 CDM 0636 RC Q4121 HCPCS inpatient 2553 1659.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1991.34 78 999999999 1545.84 2476.41 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988765_1 CDM 0636 RC Q4121 HCPCS inpatient 2553 1659.45 UMR - ALL PLANS UMR - ALL PLANS 1787.1 70 999999999 1545.84 2476.41 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988765_1 CDM 0636 RC Q4121 HCPCS inpatient 2553 1659.45 SIHO - ALL PLANS SIHO - ALL PLANS 2297.7 90 999999999 1545.84 2476.41 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988765_1 CDM 0636 RC Q4121 HCPCS inpatient 2553 1659.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1545.84 60.55 999999999 1545.84 2476.41 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988765_1 CDM 0636 RC Q4121 HCPCS inpatient 2553 1659.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1545.84 2476.41 "THERASKIN, PER SQUARE CENTIMETER" 49988765_1 CDM 0636 RC Q4121 HCPCS inpatient 2553 1659.45 ANTHEM HMO ANTHEM HMO 999999999 1545.84 2476.41 "THERASKIN, PER SQUARE CENTIMETER" 49988765_1 CDM 0636 RC Q4121 HCPCS inpatient 2553 1659.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1545.84 2476.41 "THERASKIN, PER SQUARE CENTIMETER" 49988765_1 CDM 0636 RC Q4121 HCPCS inpatient 2553 1659.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1725.83 67.6 999999999 1545.84 2476.41 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988765_1 CDM 0636 RC Q4121 HCPCS inpatient 2553 1659.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1545.84 2476.41 "THERASKIN, PER SQUARE CENTIMETER" 49988765_1 CDM 0636 RC Q4121 HCPCS inpatient 2553 1659.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1545.84 2476.41 "THERASKIN, PER SQUARE CENTIMETER" 49988766_1 CDM 0636 RC Q4121 HCPCS inpatient 3149 2046.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 2046.85 65 999999999 1906.72 3054.53 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988766_1 CDM 0636 RC Q4121 HCPCS inpatient 3149 2046.85 AETNA AETNA 2487.71 79 999999999 1906.72 3054.53 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988766_1 CDM 0636 RC Q4121 HCPCS inpatient 3149 2046.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3054.53 97 999999999 1906.72 3054.53 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988766_1 CDM 0636 RC Q4121 HCPCS inpatient 3149 2046.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 2172.81 69 999999999 1906.72 3054.53 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988766_1 CDM 0636 RC Q4121 HCPCS inpatient 3149 2046.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 2456.22 78 999999999 1906.72 3054.53 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988766_1 CDM 0636 RC Q4121 HCPCS inpatient 3149 2046.85 UMR - ALL PLANS UMR - ALL PLANS 2204.3 70 999999999 1906.72 3054.53 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988766_1 CDM 0636 RC Q4121 HCPCS inpatient 3149 2046.85 SIHO - ALL PLANS SIHO - ALL PLANS 2834.1 90 999999999 1906.72 3054.53 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988766_1 CDM 0636 RC Q4121 HCPCS inpatient 3149 2046.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1906.72 60.55 999999999 1906.72 3054.53 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988766_1 CDM 0636 RC Q4121 HCPCS inpatient 3149 2046.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1906.72 3054.53 "THERASKIN, PER SQUARE CENTIMETER" 49988766_1 CDM 0636 RC Q4121 HCPCS inpatient 3149 2046.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1906.72 3054.53 "THERASKIN, PER SQUARE CENTIMETER" 49988766_1 CDM 0636 RC Q4121 HCPCS inpatient 3149 2046.85 ANTHEM HMO ANTHEM HMO 999999999 1906.72 3054.53 "THERASKIN, PER SQUARE CENTIMETER" 49988766_1 CDM 0636 RC Q4121 HCPCS inpatient 3149 2046.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 2128.72 67.6 999999999 1906.72 3054.53 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988766_1 CDM 0636 RC Q4121 HCPCS inpatient 3149 2046.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1906.72 3054.53 "THERASKIN, PER SQUARE CENTIMETER" 49988766_1 CDM 0636 RC Q4121 HCPCS inpatient 3149 2046.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1906.72 3054.53 "THERASKIN, PER SQUARE CENTIMETER" 49988767_1 CDM 0636 RC Q4121 HCPCS inpatient 11151 7248.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 7248.15 65 999999999 6751.93 10816.47 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988767_1 CDM 0636 RC Q4121 HCPCS inpatient 11151 7248.15 AETNA AETNA 8809.29 79 999999999 6751.93 10816.47 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988767_1 CDM 0636 RC Q4121 HCPCS inpatient 11151 7248.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10816.47 97 999999999 6751.93 10816.47 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988767_1 CDM 0636 RC Q4121 HCPCS inpatient 11151 7248.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 7694.19 69 999999999 6751.93 10816.47 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988767_1 CDM 0636 RC Q4121 HCPCS inpatient 11151 7248.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 8697.78 78 999999999 6751.93 10816.47 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988767_1 CDM 0636 RC Q4121 HCPCS inpatient 11151 7248.15 UMR - ALL PLANS UMR - ALL PLANS 7805.7 70 999999999 6751.93 10816.47 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988767_1 CDM 0636 RC Q4121 HCPCS inpatient 11151 7248.15 SIHO - ALL PLANS SIHO - ALL PLANS 10035.9 90 999999999 6751.93 10816.47 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988767_1 CDM 0636 RC Q4121 HCPCS inpatient 11151 7248.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6751.93 60.55 999999999 6751.93 10816.47 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988767_1 CDM 0636 RC Q4121 HCPCS inpatient 11151 7248.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6751.93 10816.47 "THERASKIN, PER SQUARE CENTIMETER" 49988767_1 CDM 0636 RC Q4121 HCPCS inpatient 11151 7248.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6751.93 10816.47 "THERASKIN, PER SQUARE CENTIMETER" 49988767_1 CDM 0636 RC Q4121 HCPCS inpatient 11151 7248.15 ANTHEM HMO ANTHEM HMO 999999999 6751.93 10816.47 "THERASKIN, PER SQUARE CENTIMETER" 49988767_1 CDM 0636 RC Q4121 HCPCS inpatient 11151 7248.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 7538.08 67.6 999999999 6751.93 10816.47 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 49988767_1 CDM 0636 RC Q4121 HCPCS inpatient 11151 7248.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6751.93 10816.47 "THERASKIN, PER SQUARE CENTIMETER" 49988767_1 CDM 0636 RC Q4121 HCPCS inpatient 11151 7248.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 6751.93 10816.47 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988768_1 CDM 0636 RC Q4133 HCPCS inpatient 2675 1738.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1738.75 65 999999999 1619.71 2594.75 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988768_1 CDM 0636 RC Q4133 HCPCS inpatient 2675 1738.75 AETNA AETNA 2113.25 79 999999999 1619.71 2594.75 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988768_1 CDM 0636 RC Q4133 HCPCS inpatient 2675 1738.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2594.75 97 999999999 1619.71 2594.75 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988768_1 CDM 0636 RC Q4133 HCPCS inpatient 2675 1738.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1845.75 69 999999999 1619.71 2594.75 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988768_1 CDM 0636 RC Q4133 HCPCS inpatient 2675 1738.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 2086.5 78 999999999 1619.71 2594.75 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988768_1 CDM 0636 RC Q4133 HCPCS inpatient 2675 1738.75 UMR - ALL PLANS UMR - ALL PLANS 1872.5 70 999999999 1619.71 2594.75 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988768_1 CDM 0636 RC Q4133 HCPCS inpatient 2675 1738.75 SIHO - ALL PLANS SIHO - ALL PLANS 2407.5 90 999999999 1619.71 2594.75 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988768_1 CDM 0636 RC Q4133 HCPCS inpatient 2675 1738.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1619.71 60.55 999999999 1619.71 2594.75 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988768_1 CDM 0636 RC Q4133 HCPCS inpatient 2675 1738.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1619.71 2594.75 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988768_1 CDM 0636 RC Q4133 HCPCS inpatient 2675 1738.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1619.71 2594.75 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988768_1 CDM 0636 RC Q4133 HCPCS inpatient 2675 1738.75 ANTHEM HMO ANTHEM HMO 999999999 1619.71 2594.75 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988768_1 CDM 0636 RC Q4133 HCPCS inpatient 2675 1738.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1808.3 67.6 999999999 1619.71 2594.75 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988768_1 CDM 0636 RC Q4133 HCPCS inpatient 2675 1738.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1619.71 2594.75 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988768_1 CDM 0636 RC Q4133 HCPCS inpatient 2675 1738.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1619.71 2594.75 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988769_1 CDM 0636 RC Q4133 HCPCS inpatient 3039 1975.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1975.35 65 999999999 1840.11 2947.83 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988769_1 CDM 0636 RC Q4133 HCPCS inpatient 3039 1975.35 AETNA AETNA 2400.81 79 999999999 1840.11 2947.83 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988769_1 CDM 0636 RC Q4133 HCPCS inpatient 3039 1975.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2947.83 97 999999999 1840.11 2947.83 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988769_1 CDM 0636 RC Q4133 HCPCS inpatient 3039 1975.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 2096.91 69 999999999 1840.11 2947.83 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988769_1 CDM 0636 RC Q4133 HCPCS inpatient 3039 1975.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 2370.42 78 999999999 1840.11 2947.83 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988769_1 CDM 0636 RC Q4133 HCPCS inpatient 3039 1975.35 UMR - ALL PLANS UMR - ALL PLANS 2127.3 70 999999999 1840.11 2947.83 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988769_1 CDM 0636 RC Q4133 HCPCS inpatient 3039 1975.35 SIHO - ALL PLANS SIHO - ALL PLANS 2735.1 90 999999999 1840.11 2947.83 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988769_1 CDM 0636 RC Q4133 HCPCS inpatient 3039 1975.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1840.11 60.55 999999999 1840.11 2947.83 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988769_1 CDM 0636 RC Q4133 HCPCS inpatient 3039 1975.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1840.11 2947.83 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988769_1 CDM 0636 RC Q4133 HCPCS inpatient 3039 1975.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1840.11 2947.83 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988769_1 CDM 0636 RC Q4133 HCPCS inpatient 3039 1975.35 ANTHEM HMO ANTHEM HMO 999999999 1840.11 2947.83 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988769_1 CDM 0636 RC Q4133 HCPCS inpatient 3039 1975.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 2054.36 67.6 999999999 1840.11 2947.83 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988769_1 CDM 0636 RC Q4133 HCPCS inpatient 3039 1975.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1840.11 2947.83 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988769_1 CDM 0636 RC Q4133 HCPCS inpatient 3039 1975.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1840.11 2947.83 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988771_1 CDM 0278 RC Q4133 HCPCS inpatient 3282 2133.3 AETNA AETNA 2592.78 79 999999999 1987.25 3183.54 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988771_1 CDM 0278 RC Q4133 HCPCS inpatient 3282 2133.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 2133.3 65 999999999 1987.25 3183.54 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988771_1 CDM 0278 RC Q4133 HCPCS inpatient 3282 2133.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3183.54 97 999999999 1987.25 3183.54 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988771_1 CDM 0278 RC Q4133 HCPCS inpatient 3282 2133.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 2264.58 69 999999999 1987.25 3183.54 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988771_1 CDM 0278 RC Q4133 HCPCS inpatient 3282 2133.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 2559.96 78 999999999 1987.25 3183.54 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988771_1 CDM 0278 RC Q4133 HCPCS inpatient 3282 2133.3 UMR - ALL PLANS UMR - ALL PLANS 2297.4 70 999999999 1987.25 3183.54 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988771_1 CDM 0278 RC Q4133 HCPCS inpatient 3282 2133.3 SIHO - ALL PLANS SIHO - ALL PLANS 2953.8 90 999999999 1987.25 3183.54 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988771_1 CDM 0278 RC Q4133 HCPCS inpatient 3282 2133.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1987.25 60.55 999999999 1987.25 3183.54 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988771_1 CDM 0278 RC Q4133 HCPCS inpatient 3282 2133.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1987.25 3183.54 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988771_1 CDM 0278 RC Q4133 HCPCS inpatient 3282 2133.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1987.25 3183.54 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988771_1 CDM 0278 RC Q4133 HCPCS inpatient 3282 2133.3 ANTHEM HMO ANTHEM HMO 999999999 1987.25 3183.54 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988771_1 CDM 0278 RC Q4133 HCPCS inpatient 3282 2133.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 2218.63 67.6 999999999 1987.25 3183.54 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988771_1 CDM 0278 RC Q4133 HCPCS inpatient 3282 2133.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1987.25 3183.54 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988771_1 CDM 0278 RC Q4133 HCPCS inpatient 3282 2133.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1987.25 3183.54 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988772_1 CDM 0278 RC Q4133 HCPCS inpatient 7294 4741.1 AETNA AETNA 5762.26 79 999999999 4416.52 7075.18 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988772_1 CDM 0278 RC Q4133 HCPCS inpatient 7294 4741.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 4741.1 65 999999999 4416.52 7075.18 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988772_1 CDM 0278 RC Q4133 HCPCS inpatient 7294 4741.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7075.18 97 999999999 4416.52 7075.18 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988772_1 CDM 0278 RC Q4133 HCPCS inpatient 7294 4741.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 5032.86 69 999999999 4416.52 7075.18 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988772_1 CDM 0278 RC Q4133 HCPCS inpatient 7294 4741.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 5689.32 78 999999999 4416.52 7075.18 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988772_1 CDM 0278 RC Q4133 HCPCS inpatient 7294 4741.1 UMR - ALL PLANS UMR - ALL PLANS 5105.8 70 999999999 4416.52 7075.18 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988772_1 CDM 0278 RC Q4133 HCPCS inpatient 7294 4741.1 SIHO - ALL PLANS SIHO - ALL PLANS 6564.6 90 999999999 4416.52 7075.18 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988772_1 CDM 0278 RC Q4133 HCPCS inpatient 7294 4741.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4416.52 60.55 999999999 4416.52 7075.18 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988772_1 CDM 0278 RC Q4133 HCPCS inpatient 7294 4741.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4416.52 7075.18 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988772_1 CDM 0278 RC Q4133 HCPCS inpatient 7294 4741.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4416.52 7075.18 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988772_1 CDM 0278 RC Q4133 HCPCS inpatient 7294 4741.1 ANTHEM HMO ANTHEM HMO 999999999 4416.52 7075.18 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988772_1 CDM 0278 RC Q4133 HCPCS inpatient 7294 4741.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 4930.74 67.6 999999999 4416.52 7075.18 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988772_1 CDM 0278 RC Q4133 HCPCS inpatient 7294 4741.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4416.52 7075.18 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 49988772_1 CDM 0278 RC Q4133 HCPCS inpatient 7294 4741.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 4416.52 7075.18 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49989206_1 CDM 0250 RC 44567-0420-24 NDC J3475 HCPCS inpatient 4 UN 87.24 56.71 AETNA AETNA 68.92 79 999999999 52.82 84.62 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49989206_1 CDM 0250 RC 44567-0420-24 NDC J3475 HCPCS inpatient 4 UN 87.24 56.71 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.71 65 999999999 52.82 84.62 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49989206_1 CDM 0250 RC 44567-0420-24 NDC J3475 HCPCS inpatient 4 UN 87.24 56.71 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.62 97 999999999 52.82 84.62 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49989206_1 CDM 0250 RC 44567-0420-24 NDC J3475 HCPCS inpatient 4 UN 87.24 56.71 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.2 69 999999999 52.82 84.62 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49989206_1 CDM 0250 RC 44567-0420-24 NDC J3475 HCPCS inpatient 4 UN 87.24 56.71 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.05 78 999999999 52.82 84.62 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49989206_1 CDM 0250 RC 44567-0420-24 NDC J3475 HCPCS inpatient 4 UN 87.24 56.71 UMR - ALL PLANS UMR - ALL PLANS 61.07 70 999999999 52.82 84.62 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49989206_1 CDM 0250 RC 44567-0420-24 NDC J3475 HCPCS inpatient 4 UN 87.24 56.71 SIHO - ALL PLANS SIHO - ALL PLANS 78.52 90 999999999 52.82 84.62 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49989206_1 CDM 0250 RC 44567-0420-24 NDC J3475 HCPCS inpatient 4 UN 87.24 56.71 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.82 60.55 999999999 52.82 84.62 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49989206_1 CDM 0250 RC 44567-0420-24 NDC J3475 HCPCS inpatient 4 UN 87.24 56.71 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.82 84.62 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49989206_1 CDM 0250 RC 44567-0420-24 NDC J3475 HCPCS inpatient 4 UN 87.24 56.71 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.82 84.62 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49989206_1 CDM 0250 RC 44567-0420-24 NDC J3475 HCPCS inpatient 4 UN 87.24 56.71 ANTHEM HMO ANTHEM HMO 999999999 52.82 84.62 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49989206_1 CDM 0250 RC 44567-0420-24 NDC J3475 HCPCS inpatient 4 UN 87.24 56.71 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.97 67.6 999999999 52.82 84.62 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49989206_1 CDM 0250 RC 44567-0420-24 NDC J3475 HCPCS inpatient 4 UN 87.24 56.71 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.82 84.62 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 49989206_1 CDM 0250 RC 44567-0420-24 NDC J3475 HCPCS inpatient 4 UN 87.24 56.71 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.82 84.62 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49989246_1 CDM 0312 RC 81210 HCPCS inpatient 531 345.15 AETNA AETNA 419.49 79 999999999 321.52 515.07 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49989246_1 CDM 0312 RC 81210 HCPCS inpatient 531 345.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 345.15 65 999999999 321.52 515.07 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49989246_1 CDM 0312 RC 81210 HCPCS inpatient 531 345.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 515.07 97 999999999 321.52 515.07 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49989246_1 CDM 0312 RC 81210 HCPCS inpatient 531 345.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 366.39 69 999999999 321.52 515.07 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49989246_1 CDM 0312 RC 81210 HCPCS inpatient 531 345.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 414.18 78 999999999 321.52 515.07 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49989246_1 CDM 0312 RC 81210 HCPCS inpatient 531 345.15 UMR - ALL PLANS UMR - ALL PLANS 371.7 70 999999999 321.52 515.07 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49989246_1 CDM 0312 RC 81210 HCPCS inpatient 531 345.15 SIHO - ALL PLANS SIHO - ALL PLANS 477.9 90 999999999 321.52 515.07 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49989246_1 CDM 0312 RC 81210 HCPCS inpatient 531 345.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 321.52 60.55 999999999 321.52 515.07 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49989246_1 CDM 0312 RC 81210 HCPCS inpatient 531 345.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 321.52 515.07 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49989246_1 CDM 0312 RC 81210 HCPCS inpatient 531 345.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 321.52 515.07 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49989246_1 CDM 0312 RC 81210 HCPCS inpatient 531 345.15 ANTHEM HMO ANTHEM HMO 999999999 321.52 515.07 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49989246_1 CDM 0312 RC 81210 HCPCS inpatient 531 345.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 358.96 67.6 999999999 321.52 515.07 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49989246_1 CDM 0312 RC 81210 HCPCS inpatient 531 345.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 321.52 515.07 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 49989246_1 CDM 0312 RC 81210 HCPCS inpatient 531 345.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 321.52 515.07 Gene analysis for cancer (neuroblastoma) 49989248_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 AETNA AETNA 983.55 79 999999999 753.85 1207.65 percent of total billed charges Gene analysis for cancer (neuroblastoma) 49989248_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 809.25 65 999999999 753.85 1207.65 percent of total billed charges Gene analysis for cancer (neuroblastoma) 49989248_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1207.65 97 999999999 753.85 1207.65 percent of total billed charges Gene analysis for cancer (neuroblastoma) 49989248_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 859.05 69 999999999 753.85 1207.65 percent of total billed charges Gene analysis for cancer (neuroblastoma) 49989248_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 971.1 78 999999999 753.85 1207.65 percent of total billed charges Gene analysis for cancer (neuroblastoma) 49989248_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 UMR - ALL PLANS UMR - ALL PLANS 871.5 70 999999999 753.85 1207.65 percent of total billed charges Gene analysis for cancer (neuroblastoma) 49989248_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 SIHO - ALL PLANS SIHO - ALL PLANS 1120.5 90 999999999 753.85 1207.65 percent of total billed charges Gene analysis for cancer (neuroblastoma) 49989248_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 753.85 60.55 999999999 753.85 1207.65 percent of total billed charges Gene analysis for cancer (neuroblastoma) 49989248_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 753.85 1207.65 Gene analysis for cancer (neuroblastoma) 49989248_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 753.85 1207.65 Gene analysis for cancer (neuroblastoma) 49989248_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 ANTHEM HMO ANTHEM HMO 999999999 753.85 1207.65 Gene analysis for cancer (neuroblastoma) 49989248_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 841.62 67.6 999999999 753.85 1207.65 percent of total billed charges Gene analysis for cancer (neuroblastoma) 49989248_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 753.85 1207.65 Gene analysis for cancer (neuroblastoma) 49989248_1 CDM 0312 RC 81311 HCPCS inpatient 1245 809.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 753.85 1207.65 "Gene analysis (epidermal growth factor receptor), common variants" 49989250_1 CDM 0312 RC 81235 HCPCS inpatient 937 609.05 AETNA AETNA 740.23 79 999999999 567.35 908.89 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 49989250_1 CDM 0312 RC 81235 HCPCS inpatient 937 609.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 609.05 65 999999999 567.35 908.89 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 49989250_1 CDM 0312 RC 81235 HCPCS inpatient 937 609.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 908.89 97 999999999 567.35 908.89 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 49989250_1 CDM 0312 RC 81235 HCPCS inpatient 937 609.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 646.53 69 999999999 567.35 908.89 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 49989250_1 CDM 0312 RC 81235 HCPCS inpatient 937 609.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 730.86 78 999999999 567.35 908.89 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 49989250_1 CDM 0312 RC 81235 HCPCS inpatient 937 609.05 UMR - ALL PLANS UMR - ALL PLANS 655.9 70 999999999 567.35 908.89 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 49989250_1 CDM 0312 RC 81235 HCPCS inpatient 937 609.05 SIHO - ALL PLANS SIHO - ALL PLANS 843.3 90 999999999 567.35 908.89 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 49989250_1 CDM 0312 RC 81235 HCPCS inpatient 937 609.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 567.35 60.55 999999999 567.35 908.89 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 49989250_1 CDM 0312 RC 81235 HCPCS inpatient 937 609.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 567.35 908.89 "Gene analysis (epidermal growth factor receptor), common variants" 49989250_1 CDM 0312 RC 81235 HCPCS inpatient 937 609.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 567.35 908.89 "Gene analysis (epidermal growth factor receptor), common variants" 49989250_1 CDM 0312 RC 81235 HCPCS inpatient 937 609.05 ANTHEM HMO ANTHEM HMO 999999999 567.35 908.89 "Gene analysis (epidermal growth factor receptor), common variants" 49989250_1 CDM 0312 RC 81235 HCPCS inpatient 937 609.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 633.41 67.6 999999999 567.35 908.89 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 49989250_1 CDM 0312 RC 81235 HCPCS inpatient 937 609.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 567.35 908.89 "Gene analysis (epidermal growth factor receptor), common variants" 49989250_1 CDM 0312 RC 81235 HCPCS inpatient 937 609.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 567.35 908.89 12mm DISTRACTION PIN DP12TB 49989496_1 CDM 0278 RC inpatient 176 114.4 AETNA AETNA 139.04 79 999999999 106.57 170.72 percent of total billed charges 12mm DISTRACTION PIN DP12TB 49989496_1 CDM 0278 RC inpatient 176 114.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 114.4 65 999999999 106.57 170.72 percent of total billed charges 12mm DISTRACTION PIN DP12TB 49989496_1 CDM 0278 RC inpatient 176 114.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 170.72 97 999999999 106.57 170.72 percent of total billed charges 12mm DISTRACTION PIN DP12TB 49989496_1 CDM 0278 RC inpatient 176 114.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 121.44 69 999999999 106.57 170.72 percent of total billed charges 12mm DISTRACTION PIN DP12TB 49989496_1 CDM 0278 RC inpatient 176 114.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 137.28 78 999999999 106.57 170.72 percent of total billed charges 12mm DISTRACTION PIN DP12TB 49989496_1 CDM 0278 RC inpatient 176 114.4 UMR - ALL PLANS UMR - ALL PLANS 123.2 70 999999999 106.57 170.72 percent of total billed charges 12mm DISTRACTION PIN DP12TB 49989496_1 CDM 0278 RC inpatient 176 114.4 SIHO - ALL PLANS SIHO - ALL PLANS 158.4 90 999999999 106.57 170.72 percent of total billed charges 12mm DISTRACTION PIN DP12TB 49989496_1 CDM 0278 RC inpatient 176 114.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 106.57 60.55 999999999 106.57 170.72 percent of total billed charges 12mm DISTRACTION PIN DP12TB 49989496_1 CDM 0278 RC inpatient 176 114.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 106.57 170.72 12mm DISTRACTION PIN DP12TB 49989496_1 CDM 0278 RC inpatient 176 114.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 106.57 170.72 12mm DISTRACTION PIN DP12TB 49989496_1 CDM 0278 RC inpatient 176 114.4 ANTHEM HMO ANTHEM HMO 999999999 106.57 170.72 12mm DISTRACTION PIN DP12TB 49989496_1 CDM 0278 RC inpatient 176 114.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.98 67.6 999999999 106.57 170.72 percent of total billed charges 12mm DISTRACTION PIN DP12TB 49989496_1 CDM 0278 RC inpatient 176 114.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 106.57 170.72 12mm DISTRACTION PIN DP12TB 49989496_1 CDM 0278 RC inpatient 176 114.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 106.57 170.72 "SUTURE SILK 5-0 TF BLACK BRAIDED 18"" 45c N266H" 49989497_1 CDM 0272 RC inpatient 26 16.9 AETNA AETNA 20.54 79 999999999 15.74 25.22 percent of total billed charges "SUTURE SILK 5-0 TF BLACK BRAIDED 18"" 45c N266H" 49989497_1 CDM 0272 RC inpatient 26 16.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.9 65 999999999 15.74 25.22 percent of total billed charges "SUTURE SILK 5-0 TF BLACK BRAIDED 18"" 45c N266H" 49989497_1 CDM 0272 RC inpatient 26 16.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.22 97 999999999 15.74 25.22 percent of total billed charges "SUTURE SILK 5-0 TF BLACK BRAIDED 18"" 45c N266H" 49989497_1 CDM 0272 RC inpatient 26 16.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.94 69 999999999 15.74 25.22 percent of total billed charges "SUTURE SILK 5-0 TF BLACK BRAIDED 18"" 45c N266H" 49989497_1 CDM 0272 RC inpatient 26 16.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.28 78 999999999 15.74 25.22 percent of total billed charges "SUTURE SILK 5-0 TF BLACK BRAIDED 18"" 45c N266H" 49989497_1 CDM 0272 RC inpatient 26 16.9 UMR - ALL PLANS UMR - ALL PLANS 18.2 70 999999999 15.74 25.22 percent of total billed charges "SUTURE SILK 5-0 TF BLACK BRAIDED 18"" 45c N266H" 49989497_1 CDM 0272 RC inpatient 26 16.9 SIHO - ALL PLANS SIHO - ALL PLANS 23.4 90 999999999 15.74 25.22 percent of total billed charges "SUTURE SILK 5-0 TF BLACK BRAIDED 18"" 45c N266H" 49989497_1 CDM 0272 RC inpatient 26 16.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.74 60.55 999999999 15.74 25.22 percent of total billed charges "SUTURE SILK 5-0 TF BLACK BRAIDED 18"" 45c N266H" 49989497_1 CDM 0272 RC inpatient 26 16.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.74 25.22 "SUTURE SILK 5-0 TF BLACK BRAIDED 18"" 45c N266H" 49989497_1 CDM 0272 RC inpatient 26 16.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.74 25.22 "SUTURE SILK 5-0 TF BLACK BRAIDED 18"" 45c N266H" 49989497_1 CDM 0272 RC inpatient 26 16.9 ANTHEM HMO ANTHEM HMO 999999999 15.74 25.22 "SUTURE SILK 5-0 TF BLACK BRAIDED 18"" 45c N266H" 49989497_1 CDM 0272 RC inpatient 26 16.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.58 67.6 999999999 15.74 25.22 percent of total billed charges "SUTURE SILK 5-0 TF BLACK BRAIDED 18"" 45c N266H" 49989497_1 CDM 0272 RC inpatient 26 16.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.74 25.22 "SUTURE SILK 5-0 TF BLACK BRAIDED 18"" 45c N266H" 49989497_1 CDM 0272 RC inpatient 26 16.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.74 25.22 TOOL LEGEND 7.6cm 4mm DIAM WHEEL MC254 49989558_1 CDM 0272 RC inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges TOOL LEGEND 7.6cm 4mm DIAM WHEEL MC254 49989558_1 CDM 0272 RC inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges TOOL LEGEND 7.6cm 4mm DIAM WHEEL MC254 49989558_1 CDM 0272 RC inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges TOOL LEGEND 7.6cm 4mm DIAM WHEEL MC254 49989558_1 CDM 0272 RC inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges TOOL LEGEND 7.6cm 4mm DIAM WHEEL MC254 49989558_1 CDM 0272 RC inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges TOOL LEGEND 7.6cm 4mm DIAM WHEEL MC254 49989558_1 CDM 0272 RC inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges TOOL LEGEND 7.6cm 4mm DIAM WHEEL MC254 49989558_1 CDM 0272 RC inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges TOOL LEGEND 7.6cm 4mm DIAM WHEEL MC254 49989558_1 CDM 0272 RC inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges TOOL LEGEND 7.6cm 4mm DIAM WHEEL MC254 49989558_1 CDM 0272 RC inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 TOOL LEGEND 7.6cm 4mm DIAM WHEEL MC254 49989558_1 CDM 0272 RC inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 TOOL LEGEND 7.6cm 4mm DIAM WHEEL MC254 49989558_1 CDM 0272 RC inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 TOOL LEGEND 7.6cm 4mm DIAM WHEEL MC254 49989558_1 CDM 0272 RC inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges TOOL LEGEND 7.6cm 4mm DIAM WHEEL MC254 49989558_1 CDM 0272 RC inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 TOOL LEGEND 7.6cm 4mm DIAM WHEEL MC254 49989558_1 CDM 0272 RC inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 TOOL LEGEND 7.6 CM 3mm MC30 49989559_1 CDM 0270 RC inpatient 300 195 AETNA AETNA 237 79 999999999 181.65 291 percent of total billed charges TOOL LEGEND 7.6 CM 3mm MC30 49989559_1 CDM 0270 RC inpatient 300 195 SELF PAY DISCOUNT SELF PAY DISCOUNT 195 65 999999999 181.65 291 percent of total billed charges TOOL LEGEND 7.6 CM 3mm MC30 49989559_1 CDM 0270 RC inpatient 300 195 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291 97 999999999 181.65 291 percent of total billed charges TOOL LEGEND 7.6 CM 3mm MC30 49989559_1 CDM 0270 RC inpatient 300 195 ENCORE - ALL PLANS ENCORE - ALL PLANS 207 69 999999999 181.65 291 percent of total billed charges TOOL LEGEND 7.6 CM 3mm MC30 49989559_1 CDM 0270 RC inpatient 300 195 HUMANA - ALL PLANS HUMANA - ALL PLANS 234 78 999999999 181.65 291 percent of total billed charges TOOL LEGEND 7.6 CM 3mm MC30 49989559_1 CDM 0270 RC inpatient 300 195 UMR - ALL PLANS UMR - ALL PLANS 210 70 999999999 181.65 291 percent of total billed charges TOOL LEGEND 7.6 CM 3mm MC30 49989559_1 CDM 0270 RC inpatient 300 195 SIHO - ALL PLANS SIHO - ALL PLANS 270 90 999999999 181.65 291 percent of total billed charges TOOL LEGEND 7.6 CM 3mm MC30 49989559_1 CDM 0270 RC inpatient 300 195 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 181.65 60.55 999999999 181.65 291 percent of total billed charges TOOL LEGEND 7.6 CM 3mm MC30 49989559_1 CDM 0270 RC inpatient 300 195 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 181.65 291 TOOL LEGEND 7.6 CM 3mm MC30 49989559_1 CDM 0270 RC inpatient 300 195 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 181.65 291 TOOL LEGEND 7.6 CM 3mm MC30 49989559_1 CDM 0270 RC inpatient 300 195 ANTHEM HMO ANTHEM HMO 999999999 181.65 291 TOOL LEGEND 7.6 CM 3mm MC30 49989559_1 CDM 0270 RC inpatient 300 195 CIGNA - ALL PLANS CIGNA - ALL PLANS 202.8 67.6 999999999 181.65 291 percent of total billed charges TOOL LEGEND 7.6 CM 3mm MC30 49989559_1 CDM 0270 RC inpatient 300 195 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 181.65 291 TOOL LEGEND 7.6 CM 3mm MC30 49989559_1 CDM 0270 RC inpatient 300 195 UHC - ALL PLANS UHC - ALL PLANS 999999999 181.65 291 "Preparation of specimen, manual" 49991423_1 CDM 0312 RC 88381 HCPCS inpatient 244 158.6 AETNA AETNA 192.76 79 999999999 147.74 236.68 percent of total billed charges "Preparation of specimen, manual" 49991423_1 CDM 0312 RC 88381 HCPCS inpatient 244 158.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 158.6 65 999999999 147.74 236.68 percent of total billed charges "Preparation of specimen, manual" 49991423_1 CDM 0312 RC 88381 HCPCS inpatient 244 158.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 236.68 97 999999999 147.74 236.68 percent of total billed charges "Preparation of specimen, manual" 49991423_1 CDM 0312 RC 88381 HCPCS inpatient 244 158.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 168.36 69 999999999 147.74 236.68 percent of total billed charges "Preparation of specimen, manual" 49991423_1 CDM 0312 RC 88381 HCPCS inpatient 244 158.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 190.32 78 999999999 147.74 236.68 percent of total billed charges "Preparation of specimen, manual" 49991423_1 CDM 0312 RC 88381 HCPCS inpatient 244 158.6 UMR - ALL PLANS UMR - ALL PLANS 170.8 70 999999999 147.74 236.68 percent of total billed charges "Preparation of specimen, manual" 49991423_1 CDM 0312 RC 88381 HCPCS inpatient 244 158.6 SIHO - ALL PLANS SIHO - ALL PLANS 219.6 90 999999999 147.74 236.68 percent of total billed charges "Preparation of specimen, manual" 49991423_1 CDM 0312 RC 88381 HCPCS inpatient 244 158.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.74 60.55 999999999 147.74 236.68 percent of total billed charges "Preparation of specimen, manual" 49991423_1 CDM 0312 RC 88381 HCPCS inpatient 244 158.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.74 236.68 "Preparation of specimen, manual" 49991423_1 CDM 0312 RC 88381 HCPCS inpatient 244 158.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.74 236.68 "Preparation of specimen, manual" 49991423_1 CDM 0312 RC 88381 HCPCS inpatient 244 158.6 ANTHEM HMO ANTHEM HMO 999999999 147.74 236.68 "Preparation of specimen, manual" 49991423_1 CDM 0312 RC 88381 HCPCS inpatient 244 158.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.94 67.6 999999999 147.74 236.68 percent of total billed charges "Preparation of specimen, manual" 49991423_1 CDM 0312 RC 88381 HCPCS inpatient 244 158.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.74 236.68 "Preparation of specimen, manual" 49991423_1 CDM 0312 RC 88381 HCPCS inpatient 244 158.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.74 236.68 LEVETIRACETAM 500 MG TABLET 49993084_1 CDM 0250 RC 00904-6052-61 NDC inpatient 1 UN 1.54 1 AETNA AETNA 1.22 79 999999999 0.93 1.49 percent of total billed charges LEVETIRACETAM 500 MG TABLET 49993084_1 CDM 0250 RC 00904-6052-61 NDC inpatient 1 UN 1.54 1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1 65 999999999 0.93 1.49 percent of total billed charges LEVETIRACETAM 500 MG TABLET 49993084_1 CDM 0250 RC 00904-6052-61 NDC inpatient 1 UN 1.54 1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.49 97 999999999 0.93 1.49 percent of total billed charges LEVETIRACETAM 500 MG TABLET 49993084_1 CDM 0250 RC 00904-6052-61 NDC inpatient 1 UN 1.54 1 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.06 69 999999999 0.93 1.49 percent of total billed charges LEVETIRACETAM 500 MG TABLET 49993084_1 CDM 0250 RC 00904-6052-61 NDC inpatient 1 UN 1.54 1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.2 78 999999999 0.93 1.49 percent of total billed charges LEVETIRACETAM 500 MG TABLET 49993084_1 CDM 0250 RC 00904-6052-61 NDC inpatient 1 UN 1.54 1 UMR - ALL PLANS UMR - ALL PLANS 1.08 70 999999999 0.93 1.49 percent of total billed charges LEVETIRACETAM 500 MG TABLET 49993084_1 CDM 0250 RC 00904-6052-61 NDC inpatient 1 UN 1.54 1 SIHO - ALL PLANS SIHO - ALL PLANS 1.39 90 999999999 0.93 1.49 percent of total billed charges LEVETIRACETAM 500 MG TABLET 49993084_1 CDM 0250 RC 00904-6052-61 NDC inpatient 1 UN 1.54 1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.93 60.55 999999999 0.93 1.49 percent of total billed charges LEVETIRACETAM 500 MG TABLET 49993084_1 CDM 0250 RC 00904-6052-61 NDC inpatient 1 UN 1.54 1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.93 1.49 LEVETIRACETAM 500 MG TABLET 49993084_1 CDM 0250 RC 00904-6052-61 NDC inpatient 1 UN 1.54 1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.93 1.49 LEVETIRACETAM 500 MG TABLET 49993084_1 CDM 0250 RC 00904-6052-61 NDC inpatient 1 UN 1.54 1 ANTHEM HMO ANTHEM HMO 999999999 0.93 1.49 LEVETIRACETAM 500 MG TABLET 49993084_1 CDM 0250 RC 00904-6052-61 NDC inpatient 1 UN 1.54 1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.04 67.6 999999999 0.93 1.49 percent of total billed charges LEVETIRACETAM 500 MG TABLET 49993084_1 CDM 0250 RC 00904-6052-61 NDC inpatient 1 UN 1.54 1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.93 1.49 LEVETIRACETAM 500 MG TABLET 49993084_1 CDM 0250 RC 00904-6052-61 NDC inpatient 1 UN 1.54 1 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.93 1.49 CARBIDOPA-LEVO 25-100 MG ODT 49993144_1 CDM 0250 RC 47335-0187-88 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO 25-100 MG ODT 49993144_1 CDM 0250 RC 47335-0187-88 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO 25-100 MG ODT 49993144_1 CDM 0250 RC 47335-0187-88 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO 25-100 MG ODT 49993144_1 CDM 0250 RC 47335-0187-88 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO 25-100 MG ODT 49993144_1 CDM 0250 RC 47335-0187-88 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO 25-100 MG ODT 49993144_1 CDM 0250 RC 47335-0187-88 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO 25-100 MG ODT 49993144_1 CDM 0250 RC 47335-0187-88 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO 25-100 MG ODT 49993144_1 CDM 0250 RC 47335-0187-88 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO 25-100 MG ODT 49993144_1 CDM 0250 RC 47335-0187-88 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CARBIDOPA-LEVO 25-100 MG ODT 49993144_1 CDM 0250 RC 47335-0187-88 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CARBIDOPA-LEVO 25-100 MG ODT 49993144_1 CDM 0250 RC 47335-0187-88 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CARBIDOPA-LEVO 25-100 MG ODT 49993144_1 CDM 0250 RC 47335-0187-88 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CARBIDOPA-LEVO 25-100 MG ODT 49993144_1 CDM 0250 RC 47335-0187-88 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CARBIDOPA-LEVO 25-100 MG ODT 49993144_1 CDM 0250 RC 47335-0187-88 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 SERTRALINE HCL 50 MG TABLET 49994254_1 CDM 0250 RC 60687-0242-01 NDC inpatient 1 UN 1.58 1.03 AETNA AETNA 1.25 79 999999999 0.96 1.53 percent of total billed charges SERTRALINE HCL 50 MG TABLET 49994254_1 CDM 0250 RC 60687-0242-01 NDC inpatient 1 UN 1.58 1.03 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.03 65 999999999 0.96 1.53 percent of total billed charges SERTRALINE HCL 50 MG TABLET 49994254_1 CDM 0250 RC 60687-0242-01 NDC inpatient 1 UN 1.58 1.03 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.53 97 999999999 0.96 1.53 percent of total billed charges SERTRALINE HCL 50 MG TABLET 49994254_1 CDM 0250 RC 60687-0242-01 NDC inpatient 1 UN 1.58 1.03 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.09 69 999999999 0.96 1.53 percent of total billed charges SERTRALINE HCL 50 MG TABLET 49994254_1 CDM 0250 RC 60687-0242-01 NDC inpatient 1 UN 1.58 1.03 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.23 78 999999999 0.96 1.53 percent of total billed charges SERTRALINE HCL 50 MG TABLET 49994254_1 CDM 0250 RC 60687-0242-01 NDC inpatient 1 UN 1.58 1.03 UMR - ALL PLANS UMR - ALL PLANS 1.11 70 999999999 0.96 1.53 percent of total billed charges SERTRALINE HCL 50 MG TABLET 49994254_1 CDM 0250 RC 60687-0242-01 NDC inpatient 1 UN 1.58 1.03 SIHO - ALL PLANS SIHO - ALL PLANS 1.42 90 999999999 0.96 1.53 percent of total billed charges SERTRALINE HCL 50 MG TABLET 49994254_1 CDM 0250 RC 60687-0242-01 NDC inpatient 1 UN 1.58 1.03 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.96 60.55 999999999 0.96 1.53 percent of total billed charges SERTRALINE HCL 50 MG TABLET 49994254_1 CDM 0250 RC 60687-0242-01 NDC inpatient 1 UN 1.58 1.03 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.96 1.53 SERTRALINE HCL 50 MG TABLET 49994254_1 CDM 0250 RC 60687-0242-01 NDC inpatient 1 UN 1.58 1.03 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.96 1.53 SERTRALINE HCL 50 MG TABLET 49994254_1 CDM 0250 RC 60687-0242-01 NDC inpatient 1 UN 1.58 1.03 ANTHEM HMO ANTHEM HMO 999999999 0.96 1.53 SERTRALINE HCL 50 MG TABLET 49994254_1 CDM 0250 RC 60687-0242-01 NDC inpatient 1 UN 1.58 1.03 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.07 67.6 999999999 0.96 1.53 percent of total billed charges SERTRALINE HCL 50 MG TABLET 49994254_1 CDM 0250 RC 60687-0242-01 NDC inpatient 1 UN 1.58 1.03 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.96 1.53 SERTRALINE HCL 50 MG TABLET 49994254_1 CDM 0250 RC 60687-0242-01 NDC inpatient 1 UN 1.58 1.03 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.96 1.53 Natriuretic peptide (heart and blood vessel protein) level 49994434_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 AETNA AETNA 173.8 79 999999999 133.21 213.4 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 49994434_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 SELF PAY DISCOUNT SELF PAY DISCOUNT 143 65 999999999 133.21 213.4 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 49994434_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 213.4 97 999999999 133.21 213.4 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 49994434_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.8 69 999999999 133.21 213.4 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 49994434_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 HUMANA - ALL PLANS HUMANA - ALL PLANS 171.6 78 999999999 133.21 213.4 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 49994434_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 UMR - ALL PLANS UMR - ALL PLANS 154 70 999999999 133.21 213.4 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 49994434_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 SIHO - ALL PLANS SIHO - ALL PLANS 198 90 999999999 133.21 213.4 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 49994434_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 133.21 60.55 999999999 133.21 213.4 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 49994434_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 133.21 213.4 Natriuretic peptide (heart and blood vessel protein) level 49994434_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 133.21 213.4 Natriuretic peptide (heart and blood vessel protein) level 49994434_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 ANTHEM HMO ANTHEM HMO 999999999 133.21 213.4 Natriuretic peptide (heart and blood vessel protein) level 49994434_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.72 67.6 999999999 133.21 213.4 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 49994434_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 133.21 213.4 Natriuretic peptide (heart and blood vessel protein) level 49994434_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 UHC - ALL PLANS UHC - ALL PLANS 999999999 133.21 213.4 METOPROLOL SUCC ER 25 MG TAB 49994609_1 CDM 0250 RC 68001-0356-00 NDC inpatient 1 UN 1.93 1.25 AETNA AETNA 1.52 79 999999999 1.17 1.87 percent of total billed charges METOPROLOL SUCC ER 25 MG TAB 49994609_1 CDM 0250 RC 68001-0356-00 NDC inpatient 1 UN 1.93 1.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.25 65 999999999 1.17 1.87 percent of total billed charges METOPROLOL SUCC ER 25 MG TAB 49994609_1 CDM 0250 RC 68001-0356-00 NDC inpatient 1 UN 1.93 1.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.87 97 999999999 1.17 1.87 percent of total billed charges METOPROLOL SUCC ER 25 MG TAB 49994609_1 CDM 0250 RC 68001-0356-00 NDC inpatient 1 UN 1.93 1.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.33 69 999999999 1.17 1.87 percent of total billed charges METOPROLOL SUCC ER 25 MG TAB 49994609_1 CDM 0250 RC 68001-0356-00 NDC inpatient 1 UN 1.93 1.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.51 78 999999999 1.17 1.87 percent of total billed charges METOPROLOL SUCC ER 25 MG TAB 49994609_1 CDM 0250 RC 68001-0356-00 NDC inpatient 1 UN 1.93 1.25 UMR - ALL PLANS UMR - ALL PLANS 1.35 70 999999999 1.17 1.87 percent of total billed charges METOPROLOL SUCC ER 25 MG TAB 49994609_1 CDM 0250 RC 68001-0356-00 NDC inpatient 1 UN 1.93 1.25 SIHO - ALL PLANS SIHO - ALL PLANS 1.74 90 999999999 1.17 1.87 percent of total billed charges METOPROLOL SUCC ER 25 MG TAB 49994609_1 CDM 0250 RC 68001-0356-00 NDC inpatient 1 UN 1.93 1.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.17 60.55 999999999 1.17 1.87 percent of total billed charges METOPROLOL SUCC ER 25 MG TAB 49994609_1 CDM 0250 RC 68001-0356-00 NDC inpatient 1 UN 1.93 1.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.17 1.87 METOPROLOL SUCC ER 25 MG TAB 49994609_1 CDM 0250 RC 68001-0356-00 NDC inpatient 1 UN 1.93 1.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.17 1.87 METOPROLOL SUCC ER 25 MG TAB 49994609_1 CDM 0250 RC 68001-0356-00 NDC inpatient 1 UN 1.93 1.25 ANTHEM HMO ANTHEM HMO 999999999 1.17 1.87 METOPROLOL SUCC ER 25 MG TAB 49994609_1 CDM 0250 RC 68001-0356-00 NDC inpatient 1 UN 1.93 1.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.3 67.6 999999999 1.17 1.87 percent of total billed charges METOPROLOL SUCC ER 25 MG TAB 49994609_1 CDM 0250 RC 68001-0356-00 NDC inpatient 1 UN 1.93 1.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.17 1.87 METOPROLOL SUCC ER 25 MG TAB 49994609_1 CDM 0250 RC 68001-0356-00 NDC inpatient 1 UN 1.93 1.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.17 1.87 Gene analysis (thiopurine S-methyltransferase) for common variant 49994926_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 AETNA AETNA 768.67 79 999999999 589.15 943.81 percent of total billed charges Gene analysis (thiopurine S-methyltransferase) for common variant 49994926_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 632.45 65 999999999 589.15 943.81 percent of total billed charges Gene analysis (thiopurine S-methyltransferase) for common variant 49994926_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 943.81 97 999999999 589.15 943.81 percent of total billed charges Gene analysis (thiopurine S-methyltransferase) for common variant 49994926_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 671.37 69 999999999 589.15 943.81 percent of total billed charges Gene analysis (thiopurine S-methyltransferase) for common variant 49994926_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 758.94 78 999999999 589.15 943.81 percent of total billed charges Gene analysis (thiopurine S-methyltransferase) for common variant 49994926_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 UMR - ALL PLANS UMR - ALL PLANS 681.1 70 999999999 589.15 943.81 percent of total billed charges Gene analysis (thiopurine S-methyltransferase) for common variant 49994926_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 SIHO - ALL PLANS SIHO - ALL PLANS 875.7 90 999999999 589.15 943.81 percent of total billed charges Gene analysis (thiopurine S-methyltransferase) for common variant 49994926_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 589.15 60.55 999999999 589.15 943.81 percent of total billed charges Gene analysis (thiopurine S-methyltransferase) for common variant 49994926_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 589.15 943.81 Gene analysis (thiopurine S-methyltransferase) for common variant 49994926_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 589.15 943.81 Gene analysis (thiopurine S-methyltransferase) for common variant 49994926_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 ANTHEM HMO ANTHEM HMO 999999999 589.15 943.81 Gene analysis (thiopurine S-methyltransferase) for common variant 49994926_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 657.75 67.6 999999999 589.15 943.81 percent of total billed charges Gene analysis (thiopurine S-methyltransferase) for common variant 49994926_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 589.15 943.81 Gene analysis (thiopurine S-methyltransferase) for common variant 49994926_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 589.15 943.81 SPINAL PACK JOSP18G-01 49995295_1 CDM 0272 RC inpatient 1011 657.15 AETNA AETNA 798.69 79 999999999 612.16 980.67 percent of total billed charges SPINAL PACK JOSP18G-01 49995295_1 CDM 0272 RC inpatient 1011 657.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 657.15 65 999999999 612.16 980.67 percent of total billed charges SPINAL PACK JOSP18G-01 49995295_1 CDM 0272 RC inpatient 1011 657.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 980.67 97 999999999 612.16 980.67 percent of total billed charges SPINAL PACK JOSP18G-01 49995295_1 CDM 0272 RC inpatient 1011 657.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 697.59 69 999999999 612.16 980.67 percent of total billed charges SPINAL PACK JOSP18G-01 49995295_1 CDM 0272 RC inpatient 1011 657.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 788.58 78 999999999 612.16 980.67 percent of total billed charges SPINAL PACK JOSP18G-01 49995295_1 CDM 0272 RC inpatient 1011 657.15 UMR - ALL PLANS UMR - ALL PLANS 707.7 70 999999999 612.16 980.67 percent of total billed charges SPINAL PACK JOSP18G-01 49995295_1 CDM 0272 RC inpatient 1011 657.15 SIHO - ALL PLANS SIHO - ALL PLANS 909.9 90 999999999 612.16 980.67 percent of total billed charges SPINAL PACK JOSP18G-01 49995295_1 CDM 0272 RC inpatient 1011 657.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 612.16 60.55 999999999 612.16 980.67 percent of total billed charges SPINAL PACK JOSP18G-01 49995295_1 CDM 0272 RC inpatient 1011 657.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 612.16 980.67 SPINAL PACK JOSP18G-01 49995295_1 CDM 0272 RC inpatient 1011 657.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 612.16 980.67 SPINAL PACK JOSP18G-01 49995295_1 CDM 0272 RC inpatient 1011 657.15 ANTHEM HMO ANTHEM HMO 999999999 612.16 980.67 SPINAL PACK JOSP18G-01 49995295_1 CDM 0272 RC inpatient 1011 657.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 683.44 67.6 999999999 612.16 980.67 percent of total billed charges SPINAL PACK JOSP18G-01 49995295_1 CDM 0272 RC inpatient 1011 657.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 612.16 980.67 SPINAL PACK JOSP18G-01 49995295_1 CDM 0272 RC inpatient 1011 657.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 612.16 980.67 HR RESECTION ELECTRODE ANGLED A22231C 49996144_1 CDM 0272 RC inpatient 286 185.9 AETNA AETNA 225.94 79 999999999 173.17 277.42 percent of total billed charges HR RESECTION ELECTRODE ANGLED A22231C 49996144_1 CDM 0272 RC inpatient 286 185.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.9 65 999999999 173.17 277.42 percent of total billed charges HR RESECTION ELECTRODE ANGLED A22231C 49996144_1 CDM 0272 RC inpatient 286 185.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 277.42 97 999999999 173.17 277.42 percent of total billed charges HR RESECTION ELECTRODE ANGLED A22231C 49996144_1 CDM 0272 RC inpatient 286 185.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 197.34 69 999999999 173.17 277.42 percent of total billed charges HR RESECTION ELECTRODE ANGLED A22231C 49996144_1 CDM 0272 RC inpatient 286 185.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 223.08 78 999999999 173.17 277.42 percent of total billed charges HR RESECTION ELECTRODE ANGLED A22231C 49996144_1 CDM 0272 RC inpatient 286 185.9 UMR - ALL PLANS UMR - ALL PLANS 200.2 70 999999999 173.17 277.42 percent of total billed charges HR RESECTION ELECTRODE ANGLED A22231C 49996144_1 CDM 0272 RC inpatient 286 185.9 SIHO - ALL PLANS SIHO - ALL PLANS 257.4 90 999999999 173.17 277.42 percent of total billed charges HR RESECTION ELECTRODE ANGLED A22231C 49996144_1 CDM 0272 RC inpatient 286 185.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 173.17 60.55 999999999 173.17 277.42 percent of total billed charges HR RESECTION ELECTRODE ANGLED A22231C 49996144_1 CDM 0272 RC inpatient 286 185.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 173.17 277.42 HR RESECTION ELECTRODE ANGLED A22231C 49996144_1 CDM 0272 RC inpatient 286 185.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 173.17 277.42 HR RESECTION ELECTRODE ANGLED A22231C 49996144_1 CDM 0272 RC inpatient 286 185.9 ANTHEM HMO ANTHEM HMO 999999999 173.17 277.42 HR RESECTION ELECTRODE ANGLED A22231C 49996144_1 CDM 0272 RC inpatient 286 185.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 193.34 67.6 999999999 173.17 277.42 percent of total billed charges HR RESECTION ELECTRODE ANGLED A22231C 49996144_1 CDM 0272 RC inpatient 286 185.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 173.17 277.42 HR RESECTION ELECTRODE ANGLED A22231C 49996144_1 CDM 0272 RC inpatient 286 185.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 173.17 277.42 LATERA 24MM KIT LATSYS01 49996190_1 CDM 0270 RC inpatient 9269 6024.85 AETNA AETNA 7322.51 79 999999999 5612.38 8990.93 percent of total billed charges LATERA 24MM KIT LATSYS01 49996190_1 CDM 0270 RC inpatient 9269 6024.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 6024.85 65 999999999 5612.38 8990.93 percent of total billed charges LATERA 24MM KIT LATSYS01 49996190_1 CDM 0270 RC inpatient 9269 6024.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8990.93 97 999999999 5612.38 8990.93 percent of total billed charges LATERA 24MM KIT LATSYS01 49996190_1 CDM 0270 RC inpatient 9269 6024.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 6395.61 69 999999999 5612.38 8990.93 percent of total billed charges LATERA 24MM KIT LATSYS01 49996190_1 CDM 0270 RC inpatient 9269 6024.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 7229.82 78 999999999 5612.38 8990.93 percent of total billed charges LATERA 24MM KIT LATSYS01 49996190_1 CDM 0270 RC inpatient 9269 6024.85 UMR - ALL PLANS UMR - ALL PLANS 6488.3 70 999999999 5612.38 8990.93 percent of total billed charges LATERA 24MM KIT LATSYS01 49996190_1 CDM 0270 RC inpatient 9269 6024.85 SIHO - ALL PLANS SIHO - ALL PLANS 8342.1 90 999999999 5612.38 8990.93 percent of total billed charges LATERA 24MM KIT LATSYS01 49996190_1 CDM 0270 RC inpatient 9269 6024.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5612.38 60.55 999999999 5612.38 8990.93 percent of total billed charges LATERA 24MM KIT LATSYS01 49996190_1 CDM 0270 RC inpatient 9269 6024.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5612.38 8990.93 LATERA 24MM KIT LATSYS01 49996190_1 CDM 0270 RC inpatient 9269 6024.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5612.38 8990.93 LATERA 24MM KIT LATSYS01 49996190_1 CDM 0270 RC inpatient 9269 6024.85 ANTHEM HMO ANTHEM HMO 999999999 5612.38 8990.93 LATERA 24MM KIT LATSYS01 49996190_1 CDM 0270 RC inpatient 9269 6024.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 6265.84 67.6 999999999 5612.38 8990.93 percent of total billed charges LATERA 24MM KIT LATSYS01 49996190_1 CDM 0270 RC inpatient 9269 6024.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5612.38 8990.93 LATERA 24MM KIT LATSYS01 49996190_1 CDM 0270 RC inpatient 9269 6024.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 5612.38 8990.93 METOPROLOL SUCC ER 50 MG TAB 49998826_1 CDM 0250 RC 00527-2601-37 NDC inpatient 1 UN 1.61 1.05 AETNA AETNA 1.27 79 999999999 0.97 1.56 percent of total billed charges METOPROLOL SUCC ER 50 MG TAB 49998826_1 CDM 0250 RC 00527-2601-37 NDC inpatient 1 UN 1.61 1.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.05 65 999999999 0.97 1.56 percent of total billed charges METOPROLOL SUCC ER 50 MG TAB 49998826_1 CDM 0250 RC 00527-2601-37 NDC inpatient 1 UN 1.61 1.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.56 97 999999999 0.97 1.56 percent of total billed charges METOPROLOL SUCC ER 50 MG TAB 49998826_1 CDM 0250 RC 00527-2601-37 NDC inpatient 1 UN 1.61 1.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.11 69 999999999 0.97 1.56 percent of total billed charges METOPROLOL SUCC ER 50 MG TAB 49998826_1 CDM 0250 RC 00527-2601-37 NDC inpatient 1 UN 1.61 1.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.26 78 999999999 0.97 1.56 percent of total billed charges METOPROLOL SUCC ER 50 MG TAB 49998826_1 CDM 0250 RC 00527-2601-37 NDC inpatient 1 UN 1.61 1.05 UMR - ALL PLANS UMR - ALL PLANS 1.13 70 999999999 0.97 1.56 percent of total billed charges METOPROLOL SUCC ER 50 MG TAB 49998826_1 CDM 0250 RC 00527-2601-37 NDC inpatient 1 UN 1.61 1.05 SIHO - ALL PLANS SIHO - ALL PLANS 1.45 90 999999999 0.97 1.56 percent of total billed charges METOPROLOL SUCC ER 50 MG TAB 49998826_1 CDM 0250 RC 00527-2601-37 NDC inpatient 1 UN 1.61 1.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.97 60.55 999999999 0.97 1.56 percent of total billed charges METOPROLOL SUCC ER 50 MG TAB 49998826_1 CDM 0250 RC 00527-2601-37 NDC inpatient 1 UN 1.61 1.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.97 1.56 METOPROLOL SUCC ER 50 MG TAB 49998826_1 CDM 0250 RC 00527-2601-37 NDC inpatient 1 UN 1.61 1.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.97 1.56 METOPROLOL SUCC ER 50 MG TAB 49998826_1 CDM 0250 RC 00527-2601-37 NDC inpatient 1 UN 1.61 1.05 ANTHEM HMO ANTHEM HMO 999999999 0.97 1.56 METOPROLOL SUCC ER 50 MG TAB 49998826_1 CDM 0250 RC 00527-2601-37 NDC inpatient 1 UN 1.61 1.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.09 67.6 999999999 0.97 1.56 percent of total billed charges METOPROLOL SUCC ER 50 MG TAB 49998826_1 CDM 0250 RC 00527-2601-37 NDC inpatient 1 UN 1.61 1.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.97 1.56 METOPROLOL SUCC ER 50 MG TAB 49998826_1 CDM 0250 RC 00527-2601-37 NDC inpatient 1 UN 1.61 1.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.97 1.56 PIPERACIL-TAZOBACT 4.5 GM VIAL 49998836_1 CDM 0250 RC 00781-9214-95 NDC inpatient 1 UN 40.34 26.22 AETNA AETNA 31.87 79 999999999 24.43 39.13 percent of total billed charges PIPERACIL-TAZOBACT 4.5 GM VIAL 49998836_1 CDM 0250 RC 00781-9214-95 NDC inpatient 1 UN 40.34 26.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.22 65 999999999 24.43 39.13 percent of total billed charges PIPERACIL-TAZOBACT 4.5 GM VIAL 49998836_1 CDM 0250 RC 00781-9214-95 NDC inpatient 1 UN 40.34 26.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39.13 97 999999999 24.43 39.13 percent of total billed charges PIPERACIL-TAZOBACT 4.5 GM VIAL 49998836_1 CDM 0250 RC 00781-9214-95 NDC inpatient 1 UN 40.34 26.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 27.83 69 999999999 24.43 39.13 percent of total billed charges PIPERACIL-TAZOBACT 4.5 GM VIAL 49998836_1 CDM 0250 RC 00781-9214-95 NDC inpatient 1 UN 40.34 26.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.47 78 999999999 24.43 39.13 percent of total billed charges PIPERACIL-TAZOBACT 4.5 GM VIAL 49998836_1 CDM 0250 RC 00781-9214-95 NDC inpatient 1 UN 40.34 26.22 UMR - ALL PLANS UMR - ALL PLANS 28.24 70 999999999 24.43 39.13 percent of total billed charges PIPERACIL-TAZOBACT 4.5 GM VIAL 49998836_1 CDM 0250 RC 00781-9214-95 NDC inpatient 1 UN 40.34 26.22 SIHO - ALL PLANS SIHO - ALL PLANS 36.31 90 999999999 24.43 39.13 percent of total billed charges PIPERACIL-TAZOBACT 4.5 GM VIAL 49998836_1 CDM 0250 RC 00781-9214-95 NDC inpatient 1 UN 40.34 26.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.43 60.55 999999999 24.43 39.13 percent of total billed charges PIPERACIL-TAZOBACT 4.5 GM VIAL 49998836_1 CDM 0250 RC 00781-9214-95 NDC inpatient 1 UN 40.34 26.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.43 39.13 PIPERACIL-TAZOBACT 4.5 GM VIAL 49998836_1 CDM 0250 RC 00781-9214-95 NDC inpatient 1 UN 40.34 26.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.43 39.13 PIPERACIL-TAZOBACT 4.5 GM VIAL 49998836_1 CDM 0250 RC 00781-9214-95 NDC inpatient 1 UN 40.34 26.22 ANTHEM HMO ANTHEM HMO 999999999 24.43 39.13 PIPERACIL-TAZOBACT 4.5 GM VIAL 49998836_1 CDM 0250 RC 00781-9214-95 NDC inpatient 1 UN 40.34 26.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.27 67.6 999999999 24.43 39.13 percent of total billed charges PIPERACIL-TAZOBACT 4.5 GM VIAL 49998836_1 CDM 0250 RC 00781-9214-95 NDC inpatient 1 UN 40.34 26.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.43 39.13 PIPERACIL-TAZOBACT 4.5 GM VIAL 49998836_1 CDM 0250 RC 00781-9214-95 NDC inpatient 1 UN 40.34 26.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.43 39.13 12547-1716-25 - diphenhydramine-zinc acetate topical 1%-0.1% Cream 49998843_1 CDM 0250 RC 12547-1716-25 NDC inpatient 1 UN 6.26 4.07 AETNA AETNA 4.95 79 999999999 3.79 6.07 percent of total billed charges 12547-1716-25 - diphenhydramine-zinc acetate topical 1%-0.1% Cream 49998843_1 CDM 0250 RC 12547-1716-25 NDC inpatient 1 UN 6.26 4.07 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.07 65 999999999 3.79 6.07 percent of total billed charges 12547-1716-25 - diphenhydramine-zinc acetate topical 1%-0.1% Cream 49998843_1 CDM 0250 RC 12547-1716-25 NDC inpatient 1 UN 6.26 4.07 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.07 97 999999999 3.79 6.07 percent of total billed charges 12547-1716-25 - diphenhydramine-zinc acetate topical 1%-0.1% Cream 49998843_1 CDM 0250 RC 12547-1716-25 NDC inpatient 1 UN 6.26 4.07 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.32 69 999999999 3.79 6.07 percent of total billed charges 12547-1716-25 - diphenhydramine-zinc acetate topical 1%-0.1% Cream 49998843_1 CDM 0250 RC 12547-1716-25 NDC inpatient 1 UN 6.26 4.07 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.88 78 999999999 3.79 6.07 percent of total billed charges 12547-1716-25 - diphenhydramine-zinc acetate topical 1%-0.1% Cream 49998843_1 CDM 0250 RC 12547-1716-25 NDC inpatient 1 UN 6.26 4.07 UMR - ALL PLANS UMR - ALL PLANS 4.38 70 999999999 3.79 6.07 percent of total billed charges 12547-1716-25 - diphenhydramine-zinc acetate topical 1%-0.1% Cream 49998843_1 CDM 0250 RC 12547-1716-25 NDC inpatient 1 UN 6.26 4.07 SIHO - ALL PLANS SIHO - ALL PLANS 5.63 90 999999999 3.79 6.07 percent of total billed charges 12547-1716-25 - diphenhydramine-zinc acetate topical 1%-0.1% Cream 49998843_1 CDM 0250 RC 12547-1716-25 NDC inpatient 1 UN 6.26 4.07 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.79 60.55 999999999 3.79 6.07 percent of total billed charges 12547-1716-25 - diphenhydramine-zinc acetate topical 1%-0.1% Cream 49998843_1 CDM 0250 RC 12547-1716-25 NDC inpatient 1 UN 6.26 4.07 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.79 6.07 12547-1716-25 - diphenhydramine-zinc acetate topical 1%-0.1% Cream 49998843_1 CDM 0250 RC 12547-1716-25 NDC inpatient 1 UN 6.26 4.07 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.79 6.07 12547-1716-25 - diphenhydramine-zinc acetate topical 1%-0.1% Cream 49998843_1 CDM 0250 RC 12547-1716-25 NDC inpatient 1 UN 6.26 4.07 ANTHEM HMO ANTHEM HMO 999999999 3.79 6.07 12547-1716-25 - diphenhydramine-zinc acetate topical 1%-0.1% Cream 49998843_1 CDM 0250 RC 12547-1716-25 NDC inpatient 1 UN 6.26 4.07 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.23 67.6 999999999 3.79 6.07 percent of total billed charges 12547-1716-25 - diphenhydramine-zinc acetate topical 1%-0.1% Cream 49998843_1 CDM 0250 RC 12547-1716-25 NDC inpatient 1 UN 6.26 4.07 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.79 6.07 12547-1716-25 - diphenhydramine-zinc acetate topical 1%-0.1% Cream 49998843_1 CDM 0250 RC 12547-1716-25 NDC inpatient 1 UN 6.26 4.07 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.79 6.07 NEPTUNE 2 MANIFOLD 4 PORT 0702020000 49999309_1 CDM 0270 RC inpatient 160 104 AETNA AETNA 126.4 79 999999999 96.88 155.2 percent of total billed charges NEPTUNE 2 MANIFOLD 4 PORT 0702020000 49999309_1 CDM 0270 RC inpatient 160 104 SELF PAY DISCOUNT SELF PAY DISCOUNT 104 65 999999999 96.88 155.2 percent of total billed charges NEPTUNE 2 MANIFOLD 4 PORT 0702020000 49999309_1 CDM 0270 RC inpatient 160 104 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 155.2 97 999999999 96.88 155.2 percent of total billed charges NEPTUNE 2 MANIFOLD 4 PORT 0702020000 49999309_1 CDM 0270 RC inpatient 160 104 ENCORE - ALL PLANS ENCORE - ALL PLANS 110.4 69 999999999 96.88 155.2 percent of total billed charges NEPTUNE 2 MANIFOLD 4 PORT 0702020000 49999309_1 CDM 0270 RC inpatient 160 104 HUMANA - ALL PLANS HUMANA - ALL PLANS 124.8 78 999999999 96.88 155.2 percent of total billed charges NEPTUNE 2 MANIFOLD 4 PORT 0702020000 49999309_1 CDM 0270 RC inpatient 160 104 UMR - ALL PLANS UMR - ALL PLANS 112 70 999999999 96.88 155.2 percent of total billed charges NEPTUNE 2 MANIFOLD 4 PORT 0702020000 49999309_1 CDM 0270 RC inpatient 160 104 SIHO - ALL PLANS SIHO - ALL PLANS 144 90 999999999 96.88 155.2 percent of total billed charges NEPTUNE 2 MANIFOLD 4 PORT 0702020000 49999309_1 CDM 0270 RC inpatient 160 104 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 96.88 60.55 999999999 96.88 155.2 percent of total billed charges NEPTUNE 2 MANIFOLD 4 PORT 0702020000 49999309_1 CDM 0270 RC inpatient 160 104 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 96.88 155.2 NEPTUNE 2 MANIFOLD 4 PORT 0702020000 49999309_1 CDM 0270 RC inpatient 160 104 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 96.88 155.2 NEPTUNE 2 MANIFOLD 4 PORT 0702020000 49999309_1 CDM 0270 RC inpatient 160 104 ANTHEM HMO ANTHEM HMO 999999999 96.88 155.2 NEPTUNE 2 MANIFOLD 4 PORT 0702020000 49999309_1 CDM 0270 RC inpatient 160 104 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.16 67.6 999999999 96.88 155.2 percent of total billed charges NEPTUNE 2 MANIFOLD 4 PORT 0702020000 49999309_1 CDM 0270 RC inpatient 160 104 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 96.88 155.2 NEPTUNE 2 MANIFOLD 4 PORT 0702020000 49999309_1 CDM 0270 RC inpatient 160 104 UHC - ALL PLANS UHC - ALL PLANS 999999999 96.88 155.2 REINFORCED NEEDLE 50000803_1 CDM 0270 RC inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges REINFORCED NEEDLE 50000803_1 CDM 0270 RC inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges REINFORCED NEEDLE 50000803_1 CDM 0270 RC inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges REINFORCED NEEDLE 50000803_1 CDM 0270 RC inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges REINFORCED NEEDLE 50000803_1 CDM 0270 RC inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges REINFORCED NEEDLE 50000803_1 CDM 0270 RC inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges REINFORCED NEEDLE 50000803_1 CDM 0270 RC inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges REINFORCED NEEDLE 50000803_1 CDM 0270 RC inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges REINFORCED NEEDLE 50000803_1 CDM 0270 RC inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 REINFORCED NEEDLE 50000803_1 CDM 0270 RC inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 REINFORCED NEEDLE 50000803_1 CDM 0270 RC inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 REINFORCED NEEDLE 50000803_1 CDM 0270 RC inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges REINFORCED NEEDLE 50000803_1 CDM 0270 RC inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 REINFORCED NEEDLE 50000803_1 CDM 0270 RC inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 "CYGNUS, PER SQUARE CENTIMETER" 50000840_1 CDM 0278 RC Q4170 HCPCS inpatient 6122 3979.3 AETNA AETNA 4836.38 79 999999999 3706.87 5938.34 percent of total billed charges "CYGNUS, PER SQUARE CENTIMETER" 50000840_1 CDM 0278 RC Q4170 HCPCS inpatient 6122 3979.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 3979.3 65 999999999 3706.87 5938.34 percent of total billed charges "CYGNUS, PER SQUARE CENTIMETER" 50000840_1 CDM 0278 RC Q4170 HCPCS inpatient 6122 3979.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5938.34 97 999999999 3706.87 5938.34 percent of total billed charges "CYGNUS, PER SQUARE CENTIMETER" 50000840_1 CDM 0278 RC Q4170 HCPCS inpatient 6122 3979.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 4224.18 69 999999999 3706.87 5938.34 percent of total billed charges "CYGNUS, PER SQUARE CENTIMETER" 50000840_1 CDM 0278 RC Q4170 HCPCS inpatient 6122 3979.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 4775.16 78 999999999 3706.87 5938.34 percent of total billed charges "CYGNUS, PER SQUARE CENTIMETER" 50000840_1 CDM 0278 RC Q4170 HCPCS inpatient 6122 3979.3 UMR - ALL PLANS UMR - ALL PLANS 4285.4 70 999999999 3706.87 5938.34 percent of total billed charges "CYGNUS, PER SQUARE CENTIMETER" 50000840_1 CDM 0278 RC Q4170 HCPCS inpatient 6122 3979.3 SIHO - ALL PLANS SIHO - ALL PLANS 5509.8 90 999999999 3706.87 5938.34 percent of total billed charges "CYGNUS, PER SQUARE CENTIMETER" 50000840_1 CDM 0278 RC Q4170 HCPCS inpatient 6122 3979.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3706.87 60.55 999999999 3706.87 5938.34 percent of total billed charges "CYGNUS, PER SQUARE CENTIMETER" 50000840_1 CDM 0278 RC Q4170 HCPCS inpatient 6122 3979.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3706.87 5938.34 "CYGNUS, PER SQUARE CENTIMETER" 50000840_1 CDM 0278 RC Q4170 HCPCS inpatient 6122 3979.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3706.87 5938.34 "CYGNUS, PER SQUARE CENTIMETER" 50000840_1 CDM 0278 RC Q4170 HCPCS inpatient 6122 3979.3 ANTHEM HMO ANTHEM HMO 999999999 3706.87 5938.34 "CYGNUS, PER SQUARE CENTIMETER" 50000840_1 CDM 0278 RC Q4170 HCPCS inpatient 6122 3979.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 4138.47 67.6 999999999 3706.87 5938.34 percent of total billed charges "CYGNUS, PER SQUARE CENTIMETER" 50000840_1 CDM 0278 RC Q4170 HCPCS inpatient 6122 3979.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3706.87 5938.34 "CYGNUS, PER SQUARE CENTIMETER" 50000840_1 CDM 0278 RC Q4170 HCPCS inpatient 6122 3979.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 3706.87 5938.34 "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1 CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 AETNA AETNA 12214.98 79 999999999 9362.24 14998.14 percent of total billed charges "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1 CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 10050.3 65 999999999 9362.24 14998.14 percent of total billed charges "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1 CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14998.14 97 999999999 9362.24 14998.14 percent of total billed charges "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1 CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 10668.78 69 999999999 9362.24 14998.14 percent of total billed charges "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1 CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 12060.36 78 999999999 9362.24 14998.14 percent of total billed charges "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1 CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 UMR - ALL PLANS UMR - ALL PLANS 10823.4 70 999999999 9362.24 14998.14 percent of total billed charges "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1 CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 SIHO - ALL PLANS SIHO - ALL PLANS 13915.8 90 999999999 9362.24 14998.14 percent of total billed charges "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1 CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9362.24 60.55 999999999 9362.24 14998.14 percent of total billed charges "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1 CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9362.24 14998.14 "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1 CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9362.24 14998.14 "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1 CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 ANTHEM HMO ANTHEM HMO 999999999 9362.24 14998.14 "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1 CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 10452.31 67.6 999999999 9362.24 14998.14 percent of total billed charges "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1 CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9362.24 14998.14 "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1 CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 9362.24 14998.14 "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1{2} CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 AETNA AETNA 12214.98 79 999999999 9362.24 14998.14 percent of total billed charges "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1{2} CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 10050.3 65 999999999 9362.24 14998.14 percent of total billed charges "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1{2} CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14998.14 97 999999999 9362.24 14998.14 percent of total billed charges "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1{2} CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 10668.78 69 999999999 9362.24 14998.14 percent of total billed charges "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1{2} CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 12060.36 78 999999999 9362.24 14998.14 percent of total billed charges "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1{2} CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 UMR - ALL PLANS UMR - ALL PLANS 10823.4 70 999999999 9362.24 14998.14 percent of total billed charges "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1{2} CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 SIHO - ALL PLANS SIHO - ALL PLANS 13915.8 90 999999999 9362.24 14998.14 percent of total billed charges "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1{2} CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9362.24 60.55 999999999 9362.24 14998.14 percent of total billed charges "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1{2} CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9362.24 14998.14 "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1{2} CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9362.24 14998.14 "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1{2} CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 ANTHEM HMO ANTHEM HMO 999999999 9362.24 14998.14 "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1{2} CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 10452.31 67.6 999999999 9362.24 14998.14 percent of total billed charges "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1{2} CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9362.24 14998.14 "SKIN SUBSTITUTE, NOT OTHERWISE SPECIFIED" 50001027_1{2} CDM 0278 RC Q4100 HCPCS inpatient 15462 10050.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 9362.24 14998.14 DIGOXIN 500 MCG/2 ML AMPULE 50002882_1 CDM 0250 RC 00781-3059-95 NDC inpatient 1 UN 46.63 30.31 AETNA AETNA 36.84 79 999999999 28.23 45.23 percent of total billed charges DIGOXIN 500 MCG/2 ML AMPULE 50002882_1 CDM 0250 RC 00781-3059-95 NDC inpatient 1 UN 46.63 30.31 SELF PAY DISCOUNT SELF PAY DISCOUNT 30.31 65 999999999 28.23 45.23 percent of total billed charges DIGOXIN 500 MCG/2 ML AMPULE 50002882_1 CDM 0250 RC 00781-3059-95 NDC inpatient 1 UN 46.63 30.31 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 45.23 97 999999999 28.23 45.23 percent of total billed charges DIGOXIN 500 MCG/2 ML AMPULE 50002882_1 CDM 0250 RC 00781-3059-95 NDC inpatient 1 UN 46.63 30.31 ENCORE - ALL PLANS ENCORE - ALL PLANS 32.17 69 999999999 28.23 45.23 percent of total billed charges DIGOXIN 500 MCG/2 ML AMPULE 50002882_1 CDM 0250 RC 00781-3059-95 NDC inpatient 1 UN 46.63 30.31 HUMANA - ALL PLANS HUMANA - ALL PLANS 36.37 78 999999999 28.23 45.23 percent of total billed charges DIGOXIN 500 MCG/2 ML AMPULE 50002882_1 CDM 0250 RC 00781-3059-95 NDC inpatient 1 UN 46.63 30.31 UMR - ALL PLANS UMR - ALL PLANS 32.64 70 999999999 28.23 45.23 percent of total billed charges DIGOXIN 500 MCG/2 ML AMPULE 50002882_1 CDM 0250 RC 00781-3059-95 NDC inpatient 1 UN 46.63 30.31 SIHO - ALL PLANS SIHO - ALL PLANS 41.97 90 999999999 28.23 45.23 percent of total billed charges DIGOXIN 500 MCG/2 ML AMPULE 50002882_1 CDM 0250 RC 00781-3059-95 NDC inpatient 1 UN 46.63 30.31 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 28.23 60.55 999999999 28.23 45.23 percent of total billed charges DIGOXIN 500 MCG/2 ML AMPULE 50002882_1 CDM 0250 RC 00781-3059-95 NDC inpatient 1 UN 46.63 30.31 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 28.23 45.23 DIGOXIN 500 MCG/2 ML AMPULE 50002882_1 CDM 0250 RC 00781-3059-95 NDC inpatient 1 UN 46.63 30.31 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 28.23 45.23 DIGOXIN 500 MCG/2 ML AMPULE 50002882_1 CDM 0250 RC 00781-3059-95 NDC inpatient 1 UN 46.63 30.31 ANTHEM HMO ANTHEM HMO 999999999 28.23 45.23 DIGOXIN 500 MCG/2 ML AMPULE 50002882_1 CDM 0250 RC 00781-3059-95 NDC inpatient 1 UN 46.63 30.31 CIGNA - ALL PLANS CIGNA - ALL PLANS 31.52 67.6 999999999 28.23 45.23 percent of total billed charges DIGOXIN 500 MCG/2 ML AMPULE 50002882_1 CDM 0250 RC 00781-3059-95 NDC inpatient 1 UN 46.63 30.31 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 28.23 45.23 DIGOXIN 500 MCG/2 ML AMPULE 50002882_1 CDM 0250 RC 00781-3059-95 NDC inpatient 1 UN 46.63 30.31 UHC - ALL PLANS UHC - ALL PLANS 999999999 28.23 45.23 "Genetic sequencing localization, each multiplex procedure" 50002991_1 CDM 0312 RC 88366 HCPCS inpatient 893 580.45 AETNA AETNA 705.47 79 999999999 540.71 866.21 percent of total billed charges "Genetic sequencing localization, each multiplex procedure" 50002991_1 CDM 0312 RC 88366 HCPCS inpatient 893 580.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 580.45 65 999999999 540.71 866.21 percent of total billed charges "Genetic sequencing localization, each multiplex procedure" 50002991_1 CDM 0312 RC 88366 HCPCS inpatient 893 580.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 866.21 97 999999999 540.71 866.21 percent of total billed charges "Genetic sequencing localization, each multiplex procedure" 50002991_1 CDM 0312 RC 88366 HCPCS inpatient 893 580.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 616.17 69 999999999 540.71 866.21 percent of total billed charges "Genetic sequencing localization, each multiplex procedure" 50002991_1 CDM 0312 RC 88366 HCPCS inpatient 893 580.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 696.54 78 999999999 540.71 866.21 percent of total billed charges "Genetic sequencing localization, each multiplex procedure" 50002991_1 CDM 0312 RC 88366 HCPCS inpatient 893 580.45 UMR - ALL PLANS UMR - ALL PLANS 625.1 70 999999999 540.71 866.21 percent of total billed charges "Genetic sequencing localization, each multiplex procedure" 50002991_1 CDM 0312 RC 88366 HCPCS inpatient 893 580.45 SIHO - ALL PLANS SIHO - ALL PLANS 803.7 90 999999999 540.71 866.21 percent of total billed charges "Genetic sequencing localization, each multiplex procedure" 50002991_1 CDM 0312 RC 88366 HCPCS inpatient 893 580.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 540.71 60.55 999999999 540.71 866.21 percent of total billed charges "Genetic sequencing localization, each multiplex procedure" 50002991_1 CDM 0312 RC 88366 HCPCS inpatient 893 580.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 540.71 866.21 "Genetic sequencing localization, each multiplex procedure" 50002991_1 CDM 0312 RC 88366 HCPCS inpatient 893 580.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 540.71 866.21 "Genetic sequencing localization, each multiplex procedure" 50002991_1 CDM 0312 RC 88366 HCPCS inpatient 893 580.45 ANTHEM HMO ANTHEM HMO 999999999 540.71 866.21 "Genetic sequencing localization, each multiplex procedure" 50002991_1 CDM 0312 RC 88366 HCPCS inpatient 893 580.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 603.67 67.6 999999999 540.71 866.21 percent of total billed charges "Genetic sequencing localization, each multiplex procedure" 50002991_1 CDM 0312 RC 88366 HCPCS inpatient 893 580.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 540.71 866.21 "Genetic sequencing localization, each multiplex procedure" 50002991_1 CDM 0312 RC 88366 HCPCS inpatient 893 580.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 540.71 866.21 "Genetic sequencing localization, each multiplex procedure" 50003023_1 CDM 0310 RC 88366 HCPCS inpatient 938 609.7 AETNA AETNA 741.02 79 999999999 567.96 909.86 percent of total billed charges "Genetic sequencing localization, each multiplex procedure" 50003023_1 CDM 0310 RC 88366 HCPCS inpatient 938 609.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 609.7 65 999999999 567.96 909.86 percent of total billed charges "Genetic sequencing localization, each multiplex procedure" 50003023_1 CDM 0310 RC 88366 HCPCS inpatient 938 609.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 909.86 97 999999999 567.96 909.86 percent of total billed charges "Genetic sequencing localization, each multiplex procedure" 50003023_1 CDM 0310 RC 88366 HCPCS inpatient 938 609.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 647.22 69 999999999 567.96 909.86 percent of total billed charges "Genetic sequencing localization, each multiplex procedure" 50003023_1 CDM 0310 RC 88366 HCPCS inpatient 938 609.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 731.64 78 999999999 567.96 909.86 percent of total billed charges "Genetic sequencing localization, each multiplex procedure" 50003023_1 CDM 0310 RC 88366 HCPCS inpatient 938 609.7 UMR - ALL PLANS UMR - ALL PLANS 656.6 70 999999999 567.96 909.86 percent of total billed charges "Genetic sequencing localization, each multiplex procedure" 50003023_1 CDM 0310 RC 88366 HCPCS inpatient 938 609.7 SIHO - ALL PLANS SIHO - ALL PLANS 844.2 90 999999999 567.96 909.86 percent of total billed charges "Genetic sequencing localization, each multiplex procedure" 50003023_1 CDM 0310 RC 88366 HCPCS inpatient 938 609.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 567.96 60.55 999999999 567.96 909.86 percent of total billed charges "Genetic sequencing localization, each multiplex procedure" 50003023_1 CDM 0310 RC 88366 HCPCS inpatient 938 609.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 567.96 909.86 "Genetic sequencing localization, each multiplex procedure" 50003023_1 CDM 0310 RC 88366 HCPCS inpatient 938 609.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 567.96 909.86 "Genetic sequencing localization, each multiplex procedure" 50003023_1 CDM 0310 RC 88366 HCPCS inpatient 938 609.7 ANTHEM HMO ANTHEM HMO 999999999 567.96 909.86 "Genetic sequencing localization, each multiplex procedure" 50003023_1 CDM 0310 RC 88366 HCPCS inpatient 938 609.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 634.09 67.6 999999999 567.96 909.86 percent of total billed charges "Genetic sequencing localization, each multiplex procedure" 50003023_1 CDM 0310 RC 88366 HCPCS inpatient 938 609.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 567.96 909.86 "Genetic sequencing localization, each multiplex procedure" 50003023_1 CDM 0310 RC 88366 HCPCS inpatient 938 609.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 567.96 909.86 SUTURE PROLENE 3-0 1 X 18in MONOFILAMENT PS-2 NEEDLE 8687H 50004434_1 CDM 0272 RC inpatient 55 35.75 AETNA AETNA 43.45 79 999999999 33.3 53.35 percent of total billed charges SUTURE PROLENE 3-0 1 X 18in MONOFILAMENT PS-2 NEEDLE 8687H 50004434_1 CDM 0272 RC inpatient 55 35.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 35.75 65 999999999 33.3 53.35 percent of total billed charges SUTURE PROLENE 3-0 1 X 18in MONOFILAMENT PS-2 NEEDLE 8687H 50004434_1 CDM 0272 RC inpatient 55 35.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 53.35 97 999999999 33.3 53.35 percent of total billed charges SUTURE PROLENE 3-0 1 X 18in MONOFILAMENT PS-2 NEEDLE 8687H 50004434_1 CDM 0272 RC inpatient 55 35.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 37.95 69 999999999 33.3 53.35 percent of total billed charges SUTURE PROLENE 3-0 1 X 18in MONOFILAMENT PS-2 NEEDLE 8687H 50004434_1 CDM 0272 RC inpatient 55 35.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 42.9 78 999999999 33.3 53.35 percent of total billed charges SUTURE PROLENE 3-0 1 X 18in MONOFILAMENT PS-2 NEEDLE 8687H 50004434_1 CDM 0272 RC inpatient 55 35.75 UMR - ALL PLANS UMR - ALL PLANS 38.5 70 999999999 33.3 53.35 percent of total billed charges SUTURE PROLENE 3-0 1 X 18in MONOFILAMENT PS-2 NEEDLE 8687H 50004434_1 CDM 0272 RC inpatient 55 35.75 SIHO - ALL PLANS SIHO - ALL PLANS 49.5 90 999999999 33.3 53.35 percent of total billed charges SUTURE PROLENE 3-0 1 X 18in MONOFILAMENT PS-2 NEEDLE 8687H 50004434_1 CDM 0272 RC inpatient 55 35.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33.3 60.55 999999999 33.3 53.35 percent of total billed charges SUTURE PROLENE 3-0 1 X 18in MONOFILAMENT PS-2 NEEDLE 8687H 50004434_1 CDM 0272 RC inpatient 55 35.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 33.3 53.35 SUTURE PROLENE 3-0 1 X 18in MONOFILAMENT PS-2 NEEDLE 8687H 50004434_1 CDM 0272 RC inpatient 55 35.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 33.3 53.35 SUTURE PROLENE 3-0 1 X 18in MONOFILAMENT PS-2 NEEDLE 8687H 50004434_1 CDM 0272 RC inpatient 55 35.75 ANTHEM HMO ANTHEM HMO 999999999 33.3 53.35 SUTURE PROLENE 3-0 1 X 18in MONOFILAMENT PS-2 NEEDLE 8687H 50004434_1 CDM 0272 RC inpatient 55 35.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 37.18 67.6 999999999 33.3 53.35 percent of total billed charges SUTURE PROLENE 3-0 1 X 18in MONOFILAMENT PS-2 NEEDLE 8687H 50004434_1 CDM 0272 RC inpatient 55 35.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 33.3 53.35 SUTURE PROLENE 3-0 1 X 18in MONOFILAMENT PS-2 NEEDLE 8687H 50004434_1 CDM 0272 RC inpatient 55 35.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 33.3 53.35 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50005275_1 CDM 0250 RC 63323-0064-03 NDC J3475 HCPCS inpatient 2 UN 15.23 9.9 AETNA AETNA 12.03 79 999999999 9.22 14.77 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50005275_1 CDM 0250 RC 63323-0064-03 NDC J3475 HCPCS inpatient 2 UN 15.23 9.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.9 65 999999999 9.22 14.77 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50005275_1 CDM 0250 RC 63323-0064-03 NDC J3475 HCPCS inpatient 2 UN 15.23 9.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14.77 97 999999999 9.22 14.77 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50005275_1 CDM 0250 RC 63323-0064-03 NDC J3475 HCPCS inpatient 2 UN 15.23 9.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.51 69 999999999 9.22 14.77 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50005275_1 CDM 0250 RC 63323-0064-03 NDC J3475 HCPCS inpatient 2 UN 15.23 9.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.88 78 999999999 9.22 14.77 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50005275_1 CDM 0250 RC 63323-0064-03 NDC J3475 HCPCS inpatient 2 UN 15.23 9.9 UMR - ALL PLANS UMR - ALL PLANS 10.66 70 999999999 9.22 14.77 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50005275_1 CDM 0250 RC 63323-0064-03 NDC J3475 HCPCS inpatient 2 UN 15.23 9.9 SIHO - ALL PLANS SIHO - ALL PLANS 13.71 90 999999999 9.22 14.77 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50005275_1 CDM 0250 RC 63323-0064-03 NDC J3475 HCPCS inpatient 2 UN 15.23 9.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.22 60.55 999999999 9.22 14.77 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50005275_1 CDM 0250 RC 63323-0064-03 NDC J3475 HCPCS inpatient 2 UN 15.23 9.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.22 14.77 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50005275_1 CDM 0250 RC 63323-0064-03 NDC J3475 HCPCS inpatient 2 UN 15.23 9.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.22 14.77 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50005275_1 CDM 0250 RC 63323-0064-03 NDC J3475 HCPCS inpatient 2 UN 15.23 9.9 ANTHEM HMO ANTHEM HMO 999999999 9.22 14.77 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50005275_1 CDM 0250 RC 63323-0064-03 NDC J3475 HCPCS inpatient 2 UN 15.23 9.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.3 67.6 999999999 9.22 14.77 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50005275_1 CDM 0250 RC 63323-0064-03 NDC J3475 HCPCS inpatient 2 UN 15.23 9.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.22 14.77 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50005275_1 CDM 0250 RC 63323-0064-03 NDC J3475 HCPCS inpatient 2 UN 15.23 9.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.22 14.77 "Microscopic genetic analysis of tumor, manual" 50005375_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 AETNA AETNA 422.65 79 999999999 323.94 518.95 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50005375_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 347.75 65 999999999 323.94 518.95 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50005375_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 518.95 97 999999999 323.94 518.95 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50005375_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 369.15 69 999999999 323.94 518.95 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50005375_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 417.3 78 999999999 323.94 518.95 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50005375_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 UMR - ALL PLANS UMR - ALL PLANS 374.5 70 999999999 323.94 518.95 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50005375_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 SIHO - ALL PLANS SIHO - ALL PLANS 481.5 90 999999999 323.94 518.95 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50005375_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 323.94 60.55 999999999 323.94 518.95 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50005375_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 323.94 518.95 "Microscopic genetic analysis of tumor, manual" 50005375_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 323.94 518.95 "Microscopic genetic analysis of tumor, manual" 50005375_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 ANTHEM HMO ANTHEM HMO 999999999 323.94 518.95 "Microscopic genetic analysis of tumor, manual" 50005375_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 361.66 67.6 999999999 323.94 518.95 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50005375_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 323.94 518.95 "Microscopic genetic analysis of tumor, manual" 50005375_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 323.94 518.95 "Microscopic genetic analysis of tumor, manual" 50005376_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 AETNA AETNA 422.65 79 999999999 323.94 518.95 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50005376_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 347.75 65 999999999 323.94 518.95 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50005376_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 518.95 97 999999999 323.94 518.95 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50005376_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 369.15 69 999999999 323.94 518.95 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50005376_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 417.3 78 999999999 323.94 518.95 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50005376_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 UMR - ALL PLANS UMR - ALL PLANS 374.5 70 999999999 323.94 518.95 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50005376_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 SIHO - ALL PLANS SIHO - ALL PLANS 481.5 90 999999999 323.94 518.95 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50005376_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 323.94 60.55 999999999 323.94 518.95 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50005376_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 323.94 518.95 "Microscopic genetic analysis of tumor, manual" 50005376_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 323.94 518.95 "Microscopic genetic analysis of tumor, manual" 50005376_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 ANTHEM HMO ANTHEM HMO 999999999 323.94 518.95 "Microscopic genetic analysis of tumor, manual" 50005376_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 361.66 67.6 999999999 323.94 518.95 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50005376_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 323.94 518.95 "Microscopic genetic analysis of tumor, manual" 50005376_1 CDM 0312 RC 88360 HCPCS inpatient 535 347.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 323.94 518.95 "CYCLOPHOSPHAMIDE, 100 MG" 50009382_1 CDM 0636 RC 00781-3233-94 NDC J9070 HCPCS inpatient 5 UN 1174.33 763.31 AETNA AETNA 927.72 79 999999999 711.06 1139.1 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50009382_1 CDM 0636 RC 00781-3233-94 NDC J9070 HCPCS inpatient 5 UN 1174.33 763.31 SELF PAY DISCOUNT SELF PAY DISCOUNT 763.31 65 999999999 711.06 1139.1 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50009382_1 CDM 0636 RC 00781-3233-94 NDC J9070 HCPCS inpatient 5 UN 1174.33 763.31 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1139.1 97 999999999 711.06 1139.1 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50009382_1 CDM 0636 RC 00781-3233-94 NDC J9070 HCPCS inpatient 5 UN 1174.33 763.31 ENCORE - ALL PLANS ENCORE - ALL PLANS 810.29 69 999999999 711.06 1139.1 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50009382_1 CDM 0636 RC 00781-3233-94 NDC J9070 HCPCS inpatient 5 UN 1174.33 763.31 HUMANA - ALL PLANS HUMANA - ALL PLANS 915.98 78 999999999 711.06 1139.1 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50009382_1 CDM 0636 RC 00781-3233-94 NDC J9070 HCPCS inpatient 5 UN 1174.33 763.31 UMR - ALL PLANS UMR - ALL PLANS 822.03 70 999999999 711.06 1139.1 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50009382_1 CDM 0636 RC 00781-3233-94 NDC J9070 HCPCS inpatient 5 UN 1174.33 763.31 SIHO - ALL PLANS SIHO - ALL PLANS 1056.9 90 999999999 711.06 1139.1 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50009382_1 CDM 0636 RC 00781-3233-94 NDC J9070 HCPCS inpatient 5 UN 1174.33 763.31 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 711.06 60.55 999999999 711.06 1139.1 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50009382_1 CDM 0636 RC 00781-3233-94 NDC J9070 HCPCS inpatient 5 UN 1174.33 763.31 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 711.06 1139.1 "CYCLOPHOSPHAMIDE, 100 MG" 50009382_1 CDM 0636 RC 00781-3233-94 NDC J9070 HCPCS inpatient 5 UN 1174.33 763.31 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 711.06 1139.1 "CYCLOPHOSPHAMIDE, 100 MG" 50009382_1 CDM 0636 RC 00781-3233-94 NDC J9070 HCPCS inpatient 5 UN 1174.33 763.31 ANTHEM HMO ANTHEM HMO 999999999 711.06 1139.1 "CYCLOPHOSPHAMIDE, 100 MG" 50009382_1 CDM 0636 RC 00781-3233-94 NDC J9070 HCPCS inpatient 5 UN 1174.33 763.31 CIGNA - ALL PLANS CIGNA - ALL PLANS 793.85 67.6 999999999 711.06 1139.1 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50009382_1 CDM 0636 RC 00781-3233-94 NDC J9070 HCPCS inpatient 5 UN 1174.33 763.31 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 711.06 1139.1 "CYCLOPHOSPHAMIDE, 100 MG" 50009382_1 CDM 0636 RC 00781-3233-94 NDC J9070 HCPCS inpatient 5 UN 1174.33 763.31 UHC - ALL PLANS UHC - ALL PLANS 999999999 711.06 1139.1 "Preparation of specimen, manual" 50009444_1 CDM 0310 RC 88381 HCPCS inpatient 244 158.6 AETNA AETNA 192.76 79 999999999 147.74 236.68 percent of total billed charges "Preparation of specimen, manual" 50009444_1 CDM 0310 RC 88381 HCPCS inpatient 244 158.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 158.6 65 999999999 147.74 236.68 percent of total billed charges "Preparation of specimen, manual" 50009444_1 CDM 0310 RC 88381 HCPCS inpatient 244 158.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 236.68 97 999999999 147.74 236.68 percent of total billed charges "Preparation of specimen, manual" 50009444_1 CDM 0310 RC 88381 HCPCS inpatient 244 158.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 168.36 69 999999999 147.74 236.68 percent of total billed charges "Preparation of specimen, manual" 50009444_1 CDM 0310 RC 88381 HCPCS inpatient 244 158.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 190.32 78 999999999 147.74 236.68 percent of total billed charges "Preparation of specimen, manual" 50009444_1 CDM 0310 RC 88381 HCPCS inpatient 244 158.6 UMR - ALL PLANS UMR - ALL PLANS 170.8 70 999999999 147.74 236.68 percent of total billed charges "Preparation of specimen, manual" 50009444_1 CDM 0310 RC 88381 HCPCS inpatient 244 158.6 SIHO - ALL PLANS SIHO - ALL PLANS 219.6 90 999999999 147.74 236.68 percent of total billed charges "Preparation of specimen, manual" 50009444_1 CDM 0310 RC 88381 HCPCS inpatient 244 158.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.74 60.55 999999999 147.74 236.68 percent of total billed charges "Preparation of specimen, manual" 50009444_1 CDM 0310 RC 88381 HCPCS inpatient 244 158.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.74 236.68 "Preparation of specimen, manual" 50009444_1 CDM 0310 RC 88381 HCPCS inpatient 244 158.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.74 236.68 "Preparation of specimen, manual" 50009444_1 CDM 0310 RC 88381 HCPCS inpatient 244 158.6 ANTHEM HMO ANTHEM HMO 999999999 147.74 236.68 "Preparation of specimen, manual" 50009444_1 CDM 0310 RC 88381 HCPCS inpatient 244 158.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.94 67.6 999999999 147.74 236.68 percent of total billed charges "Preparation of specimen, manual" 50009444_1 CDM 0310 RC 88381 HCPCS inpatient 244 158.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.74 236.68 "Preparation of specimen, manual" 50009444_1 CDM 0310 RC 88381 HCPCS inpatient 244 158.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.74 236.68 KETOROLAC 0.5% OPHTH SOLUTION 50010059_1 CDM 0250 RC 60505-1003-01 NDC inpatient 1 UN 17.8 11.57 AETNA AETNA 14.06 79 999999999 10.78 17.27 percent of total billed charges KETOROLAC 0.5% OPHTH SOLUTION 50010059_1 CDM 0250 RC 60505-1003-01 NDC inpatient 1 UN 17.8 11.57 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.57 65 999999999 10.78 17.27 percent of total billed charges KETOROLAC 0.5% OPHTH SOLUTION 50010059_1 CDM 0250 RC 60505-1003-01 NDC inpatient 1 UN 17.8 11.57 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.27 97 999999999 10.78 17.27 percent of total billed charges KETOROLAC 0.5% OPHTH SOLUTION 50010059_1 CDM 0250 RC 60505-1003-01 NDC inpatient 1 UN 17.8 11.57 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.28 69 999999999 10.78 17.27 percent of total billed charges KETOROLAC 0.5% OPHTH SOLUTION 50010059_1 CDM 0250 RC 60505-1003-01 NDC inpatient 1 UN 17.8 11.57 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.88 78 999999999 10.78 17.27 percent of total billed charges KETOROLAC 0.5% OPHTH SOLUTION 50010059_1 CDM 0250 RC 60505-1003-01 NDC inpatient 1 UN 17.8 11.57 UMR - ALL PLANS UMR - ALL PLANS 12.46 70 999999999 10.78 17.27 percent of total billed charges KETOROLAC 0.5% OPHTH SOLUTION 50010059_1 CDM 0250 RC 60505-1003-01 NDC inpatient 1 UN 17.8 11.57 SIHO - ALL PLANS SIHO - ALL PLANS 16.02 90 999999999 10.78 17.27 percent of total billed charges KETOROLAC 0.5% OPHTH SOLUTION 50010059_1 CDM 0250 RC 60505-1003-01 NDC inpatient 1 UN 17.8 11.57 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.78 60.55 999999999 10.78 17.27 percent of total billed charges KETOROLAC 0.5% OPHTH SOLUTION 50010059_1 CDM 0250 RC 60505-1003-01 NDC inpatient 1 UN 17.8 11.57 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.78 17.27 KETOROLAC 0.5% OPHTH SOLUTION 50010059_1 CDM 0250 RC 60505-1003-01 NDC inpatient 1 UN 17.8 11.57 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.78 17.27 KETOROLAC 0.5% OPHTH SOLUTION 50010059_1 CDM 0250 RC 60505-1003-01 NDC inpatient 1 UN 17.8 11.57 ANTHEM HMO ANTHEM HMO 999999999 10.78 17.27 KETOROLAC 0.5% OPHTH SOLUTION 50010059_1 CDM 0250 RC 60505-1003-01 NDC inpatient 1 UN 17.8 11.57 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.03 67.6 999999999 10.78 17.27 percent of total billed charges KETOROLAC 0.5% OPHTH SOLUTION 50010059_1 CDM 0250 RC 60505-1003-01 NDC inpatient 1 UN 17.8 11.57 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.78 17.27 KETOROLAC 0.5% OPHTH SOLUTION 50010059_1 CDM 0250 RC 60505-1003-01 NDC inpatient 1 UN 17.8 11.57 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.78 17.27 SUTURE PDS II 2-0 SH VIOLET MONOFILAMENT 27in 70cm Z317H 50011859_1 CDM 0272 RC inpatient 26 16.9 AETNA AETNA 20.54 79 999999999 15.74 25.22 percent of total billed charges SUTURE PDS II 2-0 SH VIOLET MONOFILAMENT 27in 70cm Z317H 50011859_1 CDM 0272 RC inpatient 26 16.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.9 65 999999999 15.74 25.22 percent of total billed charges SUTURE PDS II 2-0 SH VIOLET MONOFILAMENT 27in 70cm Z317H 50011859_1 CDM 0272 RC inpatient 26 16.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.22 97 999999999 15.74 25.22 percent of total billed charges SUTURE PDS II 2-0 SH VIOLET MONOFILAMENT 27in 70cm Z317H 50011859_1 CDM 0272 RC inpatient 26 16.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.94 69 999999999 15.74 25.22 percent of total billed charges SUTURE PDS II 2-0 SH VIOLET MONOFILAMENT 27in 70cm Z317H 50011859_1 CDM 0272 RC inpatient 26 16.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.28 78 999999999 15.74 25.22 percent of total billed charges SUTURE PDS II 2-0 SH VIOLET MONOFILAMENT 27in 70cm Z317H 50011859_1 CDM 0272 RC inpatient 26 16.9 UMR - ALL PLANS UMR - ALL PLANS 18.2 70 999999999 15.74 25.22 percent of total billed charges SUTURE PDS II 2-0 SH VIOLET MONOFILAMENT 27in 70cm Z317H 50011859_1 CDM 0272 RC inpatient 26 16.9 SIHO - ALL PLANS SIHO - ALL PLANS 23.4 90 999999999 15.74 25.22 percent of total billed charges SUTURE PDS II 2-0 SH VIOLET MONOFILAMENT 27in 70cm Z317H 50011859_1 CDM 0272 RC inpatient 26 16.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.74 60.55 999999999 15.74 25.22 percent of total billed charges SUTURE PDS II 2-0 SH VIOLET MONOFILAMENT 27in 70cm Z317H 50011859_1 CDM 0272 RC inpatient 26 16.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.74 25.22 SUTURE PDS II 2-0 SH VIOLET MONOFILAMENT 27in 70cm Z317H 50011859_1 CDM 0272 RC inpatient 26 16.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.74 25.22 SUTURE PDS II 2-0 SH VIOLET MONOFILAMENT 27in 70cm Z317H 50011859_1 CDM 0272 RC inpatient 26 16.9 ANTHEM HMO ANTHEM HMO 999999999 15.74 25.22 SUTURE PDS II 2-0 SH VIOLET MONOFILAMENT 27in 70cm Z317H 50011859_1 CDM 0272 RC inpatient 26 16.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.58 67.6 999999999 15.74 25.22 percent of total billed charges SUTURE PDS II 2-0 SH VIOLET MONOFILAMENT 27in 70cm Z317H 50011859_1 CDM 0272 RC inpatient 26 16.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.74 25.22 SUTURE PDS II 2-0 SH VIOLET MONOFILAMENT 27in 70cm Z317H 50011859_1 CDM 0272 RC inpatient 26 16.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.74 25.22 SUTURE VICRYL PLUS 2-0 V-34 UNDYED BRAIDED 36in VCP917H 50011860_1 CDM 0272 RC inpatient 30 19.5 AETNA AETNA 23.7 79 999999999 18.17 29.1 percent of total billed charges SUTURE VICRYL PLUS 2-0 V-34 UNDYED BRAIDED 36in VCP917H 50011860_1 CDM 0272 RC inpatient 30 19.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.5 65 999999999 18.17 29.1 percent of total billed charges SUTURE VICRYL PLUS 2-0 V-34 UNDYED BRAIDED 36in VCP917H 50011860_1 CDM 0272 RC inpatient 30 19.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.1 97 999999999 18.17 29.1 percent of total billed charges SUTURE VICRYL PLUS 2-0 V-34 UNDYED BRAIDED 36in VCP917H 50011860_1 CDM 0272 RC inpatient 30 19.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.7 69 999999999 18.17 29.1 percent of total billed charges SUTURE VICRYL PLUS 2-0 V-34 UNDYED BRAIDED 36in VCP917H 50011860_1 CDM 0272 RC inpatient 30 19.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.4 78 999999999 18.17 29.1 percent of total billed charges SUTURE VICRYL PLUS 2-0 V-34 UNDYED BRAIDED 36in VCP917H 50011860_1 CDM 0272 RC inpatient 30 19.5 UMR - ALL PLANS UMR - ALL PLANS 21 70 999999999 18.17 29.1 percent of total billed charges SUTURE VICRYL PLUS 2-0 V-34 UNDYED BRAIDED 36in VCP917H 50011860_1 CDM 0272 RC inpatient 30 19.5 SIHO - ALL PLANS SIHO - ALL PLANS 27 90 999999999 18.17 29.1 percent of total billed charges SUTURE VICRYL PLUS 2-0 V-34 UNDYED BRAIDED 36in VCP917H 50011860_1 CDM 0272 RC inpatient 30 19.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.17 60.55 999999999 18.17 29.1 percent of total billed charges SUTURE VICRYL PLUS 2-0 V-34 UNDYED BRAIDED 36in VCP917H 50011860_1 CDM 0272 RC inpatient 30 19.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.17 29.1 SUTURE VICRYL PLUS 2-0 V-34 UNDYED BRAIDED 36in VCP917H 50011860_1 CDM 0272 RC inpatient 30 19.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.17 29.1 SUTURE VICRYL PLUS 2-0 V-34 UNDYED BRAIDED 36in VCP917H 50011860_1 CDM 0272 RC inpatient 30 19.5 ANTHEM HMO ANTHEM HMO 999999999 18.17 29.1 SUTURE VICRYL PLUS 2-0 V-34 UNDYED BRAIDED 36in VCP917H 50011860_1 CDM 0272 RC inpatient 30 19.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.28 67.6 999999999 18.17 29.1 percent of total billed charges SUTURE VICRYL PLUS 2-0 V-34 UNDYED BRAIDED 36in VCP917H 50011860_1 CDM 0272 RC inpatient 30 19.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.17 29.1 SUTURE VICRYL PLUS 2-0 V-34 UNDYED BRAIDED 36in VCP917H 50011860_1 CDM 0272 RC inpatient 30 19.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.17 29.1 SUTURE VICRYL 3-0 SH COATED UNDYED BRAIDED 27in 70 J416H 50011861_1 CDM 0272 RC inpatient 17 11.05 AETNA AETNA 13.43 79 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL 3-0 SH COATED UNDYED BRAIDED 27in 70 J416H 50011861_1 CDM 0272 RC inpatient 17 11.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.05 65 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL 3-0 SH COATED UNDYED BRAIDED 27in 70 J416H 50011861_1 CDM 0272 RC inpatient 17 11.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16.49 97 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL 3-0 SH COATED UNDYED BRAIDED 27in 70 J416H 50011861_1 CDM 0272 RC inpatient 17 11.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.73 69 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL 3-0 SH COATED UNDYED BRAIDED 27in 70 J416H 50011861_1 CDM 0272 RC inpatient 17 11.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.26 78 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL 3-0 SH COATED UNDYED BRAIDED 27in 70 J416H 50011861_1 CDM 0272 RC inpatient 17 11.05 UMR - ALL PLANS UMR - ALL PLANS 11.9 70 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL 3-0 SH COATED UNDYED BRAIDED 27in 70 J416H 50011861_1 CDM 0272 RC inpatient 17 11.05 SIHO - ALL PLANS SIHO - ALL PLANS 15.3 90 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL 3-0 SH COATED UNDYED BRAIDED 27in 70 J416H 50011861_1 CDM 0272 RC inpatient 17 11.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.29 60.55 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL 3-0 SH COATED UNDYED BRAIDED 27in 70 J416H 50011861_1 CDM 0272 RC inpatient 17 11.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.29 16.49 SUTURE VICRYL 3-0 SH COATED UNDYED BRAIDED 27in 70 J416H 50011861_1 CDM 0272 RC inpatient 17 11.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.29 16.49 SUTURE VICRYL 3-0 SH COATED UNDYED BRAIDED 27in 70 J416H 50011861_1 CDM 0272 RC inpatient 17 11.05 ANTHEM HMO ANTHEM HMO 999999999 10.29 16.49 SUTURE VICRYL 3-0 SH COATED UNDYED BRAIDED 27in 70 J416H 50011861_1 CDM 0272 RC inpatient 17 11.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.49 67.6 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL 3-0 SH COATED UNDYED BRAIDED 27in 70 J416H 50011861_1 CDM 0272 RC inpatient 17 11.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.29 16.49 SUTURE VICRYL 3-0 SH COATED UNDYED BRAIDED 27in 70 J416H 50011861_1 CDM 0272 RC inpatient 17 11.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.29 16.49 SUTURE VICRYL 4-0 SH NEEDLE COATED UNDYED BRAIDED 27in J415H 50011862_1 CDM 0272 RC inpatient 17 11.05 AETNA AETNA 13.43 79 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL 4-0 SH NEEDLE COATED UNDYED BRAIDED 27in J415H 50011862_1 CDM 0272 RC inpatient 17 11.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.05 65 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL 4-0 SH NEEDLE COATED UNDYED BRAIDED 27in J415H 50011862_1 CDM 0272 RC inpatient 17 11.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16.49 97 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL 4-0 SH NEEDLE COATED UNDYED BRAIDED 27in J415H 50011862_1 CDM 0272 RC inpatient 17 11.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.73 69 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL 4-0 SH NEEDLE COATED UNDYED BRAIDED 27in J415H 50011862_1 CDM 0272 RC inpatient 17 11.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.26 78 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL 4-0 SH NEEDLE COATED UNDYED BRAIDED 27in J415H 50011862_1 CDM 0272 RC inpatient 17 11.05 UMR - ALL PLANS UMR - ALL PLANS 11.9 70 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL 4-0 SH NEEDLE COATED UNDYED BRAIDED 27in J415H 50011862_1 CDM 0272 RC inpatient 17 11.05 SIHO - ALL PLANS SIHO - ALL PLANS 15.3 90 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL 4-0 SH NEEDLE COATED UNDYED BRAIDED 27in J415H 50011862_1 CDM 0272 RC inpatient 17 11.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.29 60.55 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL 4-0 SH NEEDLE COATED UNDYED BRAIDED 27in J415H 50011862_1 CDM 0272 RC inpatient 17 11.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.29 16.49 SUTURE VICRYL 4-0 SH NEEDLE COATED UNDYED BRAIDED 27in J415H 50011862_1 CDM 0272 RC inpatient 17 11.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.29 16.49 SUTURE VICRYL 4-0 SH NEEDLE COATED UNDYED BRAIDED 27in J415H 50011862_1 CDM 0272 RC inpatient 17 11.05 ANTHEM HMO ANTHEM HMO 999999999 10.29 16.49 SUTURE VICRYL 4-0 SH NEEDLE COATED UNDYED BRAIDED 27in J415H 50011862_1 CDM 0272 RC inpatient 17 11.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.49 67.6 999999999 10.29 16.49 percent of total billed charges SUTURE VICRYL 4-0 SH NEEDLE COATED UNDYED BRAIDED 27in J415H 50011862_1 CDM 0272 RC inpatient 17 11.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.29 16.49 SUTURE VICRYL 4-0 SH NEEDLE COATED UNDYED BRAIDED 27in J415H 50011862_1 CDM 0272 RC inpatient 17 11.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.29 16.49 "PATIENT PROGRAMMER, NEUROSTIMULATOR" 50012082_1 CDM 0278 RC C1787 HCPCS inpatient 10666 6932.9 AETNA AETNA 8426.14 79 999999999 6458.26 10346.02 percent of total billed charges "PATIENT PROGRAMMER, NEUROSTIMULATOR" 50012082_1 CDM 0278 RC C1787 HCPCS inpatient 10666 6932.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 6932.9 65 999999999 6458.26 10346.02 percent of total billed charges "PATIENT PROGRAMMER, NEUROSTIMULATOR" 50012082_1 CDM 0278 RC C1787 HCPCS inpatient 10666 6932.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10346.02 97 999999999 6458.26 10346.02 percent of total billed charges "PATIENT PROGRAMMER, NEUROSTIMULATOR" 50012082_1 CDM 0278 RC C1787 HCPCS inpatient 10666 6932.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 7359.54 69 999999999 6458.26 10346.02 percent of total billed charges "PATIENT PROGRAMMER, NEUROSTIMULATOR" 50012082_1 CDM 0278 RC C1787 HCPCS inpatient 10666 6932.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 8319.48 78 999999999 6458.26 10346.02 percent of total billed charges "PATIENT PROGRAMMER, NEUROSTIMULATOR" 50012082_1 CDM 0278 RC C1787 HCPCS inpatient 10666 6932.9 UMR - ALL PLANS UMR - ALL PLANS 7466.2 70 999999999 6458.26 10346.02 percent of total billed charges "PATIENT PROGRAMMER, NEUROSTIMULATOR" 50012082_1 CDM 0278 RC C1787 HCPCS inpatient 10666 6932.9 SIHO - ALL PLANS SIHO - ALL PLANS 9599.4 90 999999999 6458.26 10346.02 percent of total billed charges "PATIENT PROGRAMMER, NEUROSTIMULATOR" 50012082_1 CDM 0278 RC C1787 HCPCS inpatient 10666 6932.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6458.26 60.55 999999999 6458.26 10346.02 percent of total billed charges "PATIENT PROGRAMMER, NEUROSTIMULATOR" 50012082_1 CDM 0278 RC C1787 HCPCS inpatient 10666 6932.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6458.26 10346.02 "PATIENT PROGRAMMER, NEUROSTIMULATOR" 50012082_1 CDM 0278 RC C1787 HCPCS inpatient 10666 6932.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6458.26 10346.02 "PATIENT PROGRAMMER, NEUROSTIMULATOR" 50012082_1 CDM 0278 RC C1787 HCPCS inpatient 10666 6932.9 ANTHEM HMO ANTHEM HMO 999999999 6458.26 10346.02 "PATIENT PROGRAMMER, NEUROSTIMULATOR" 50012082_1 CDM 0278 RC C1787 HCPCS inpatient 10666 6932.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 7210.22 67.6 999999999 6458.26 10346.02 percent of total billed charges "PATIENT PROGRAMMER, NEUROSTIMULATOR" 50012082_1 CDM 0278 RC C1787 HCPCS inpatient 10666 6932.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6458.26 10346.02 "PATIENT PROGRAMMER, NEUROSTIMULATOR" 50012082_1 CDM 0278 RC C1787 HCPCS inpatient 10666 6932.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 6458.26 10346.02 POLYETHYLENE GLYCOL 3350 POWD 50016910_1 CDM 0250 RC 69784-0180-14 NDC inpatient 1 UN 2.22 1.44 AETNA AETNA 1.75 79 999999999 1.34 2.15 percent of total billed charges POLYETHYLENE GLYCOL 3350 POWD 50016910_1 CDM 0250 RC 69784-0180-14 NDC inpatient 1 UN 2.22 1.44 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.44 65 999999999 1.34 2.15 percent of total billed charges POLYETHYLENE GLYCOL 3350 POWD 50016910_1 CDM 0250 RC 69784-0180-14 NDC inpatient 1 UN 2.22 1.44 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.15 97 999999999 1.34 2.15 percent of total billed charges POLYETHYLENE GLYCOL 3350 POWD 50016910_1 CDM 0250 RC 69784-0180-14 NDC inpatient 1 UN 2.22 1.44 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.53 69 999999999 1.34 2.15 percent of total billed charges POLYETHYLENE GLYCOL 3350 POWD 50016910_1 CDM 0250 RC 69784-0180-14 NDC inpatient 1 UN 2.22 1.44 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.73 78 999999999 1.34 2.15 percent of total billed charges POLYETHYLENE GLYCOL 3350 POWD 50016910_1 CDM 0250 RC 69784-0180-14 NDC inpatient 1 UN 2.22 1.44 UMR - ALL PLANS UMR - ALL PLANS 1.55 70 999999999 1.34 2.15 percent of total billed charges POLYETHYLENE GLYCOL 3350 POWD 50016910_1 CDM 0250 RC 69784-0180-14 NDC inpatient 1 UN 2.22 1.44 SIHO - ALL PLANS SIHO - ALL PLANS 2 90 999999999 1.34 2.15 percent of total billed charges POLYETHYLENE GLYCOL 3350 POWD 50016910_1 CDM 0250 RC 69784-0180-14 NDC inpatient 1 UN 2.22 1.44 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.34 60.55 999999999 1.34 2.15 percent of total billed charges POLYETHYLENE GLYCOL 3350 POWD 50016910_1 CDM 0250 RC 69784-0180-14 NDC inpatient 1 UN 2.22 1.44 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.34 2.15 POLYETHYLENE GLYCOL 3350 POWD 50016910_1 CDM 0250 RC 69784-0180-14 NDC inpatient 1 UN 2.22 1.44 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.34 2.15 POLYETHYLENE GLYCOL 3350 POWD 50016910_1 CDM 0250 RC 69784-0180-14 NDC inpatient 1 UN 2.22 1.44 ANTHEM HMO ANTHEM HMO 999999999 1.34 2.15 POLYETHYLENE GLYCOL 3350 POWD 50016910_1 CDM 0250 RC 69784-0180-14 NDC inpatient 1 UN 2.22 1.44 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.5 67.6 999999999 1.34 2.15 percent of total billed charges POLYETHYLENE GLYCOL 3350 POWD 50016910_1 CDM 0250 RC 69784-0180-14 NDC inpatient 1 UN 2.22 1.44 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.34 2.15 POLYETHYLENE GLYCOL 3350 POWD 50016910_1 CDM 0250 RC 69784-0180-14 NDC inpatient 1 UN 2.22 1.44 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.34 2.15 LEVOTHYROXINE 88 MCG TABLET 50016933_1 CDM 0250 RC 42292-0038-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 88 MCG TABLET 50016933_1 CDM 0250 RC 42292-0038-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 88 MCG TABLET 50016933_1 CDM 0250 RC 42292-0038-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 88 MCG TABLET 50016933_1 CDM 0250 RC 42292-0038-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 88 MCG TABLET 50016933_1 CDM 0250 RC 42292-0038-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 88 MCG TABLET 50016933_1 CDM 0250 RC 42292-0038-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 88 MCG TABLET 50016933_1 CDM 0250 RC 42292-0038-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 88 MCG TABLET 50016933_1 CDM 0250 RC 42292-0038-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 88 MCG TABLET 50016933_1 CDM 0250 RC 42292-0038-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LEVOTHYROXINE 88 MCG TABLET 50016933_1 CDM 0250 RC 42292-0038-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 88 MCG TABLET 50016933_1 CDM 0250 RC 42292-0038-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LEVOTHYROXINE 88 MCG TABLET 50016933_1 CDM 0250 RC 42292-0038-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 88 MCG TABLET 50016933_1 CDM 0250 RC 42292-0038-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 88 MCG TABLET 50016933_1 CDM 0250 RC 42292-0038-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 MECLIZINE 12.5 MG CAPLET 50016936_1 CDM 0250 RC 69618-0027-01 NDC inpatient 1 UN 1.56 1.01 AETNA AETNA 1.23 79 999999999 0.94 1.51 percent of total billed charges MECLIZINE 12.5 MG CAPLET 50016936_1 CDM 0250 RC 69618-0027-01 NDC inpatient 1 UN 1.56 1.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.01 65 999999999 0.94 1.51 percent of total billed charges MECLIZINE 12.5 MG CAPLET 50016936_1 CDM 0250 RC 69618-0027-01 NDC inpatient 1 UN 1.56 1.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.51 97 999999999 0.94 1.51 percent of total billed charges MECLIZINE 12.5 MG CAPLET 50016936_1 CDM 0250 RC 69618-0027-01 NDC inpatient 1 UN 1.56 1.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.08 69 999999999 0.94 1.51 percent of total billed charges MECLIZINE 12.5 MG CAPLET 50016936_1 CDM 0250 RC 69618-0027-01 NDC inpatient 1 UN 1.56 1.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.22 78 999999999 0.94 1.51 percent of total billed charges MECLIZINE 12.5 MG CAPLET 50016936_1 CDM 0250 RC 69618-0027-01 NDC inpatient 1 UN 1.56 1.01 UMR - ALL PLANS UMR - ALL PLANS 1.09 70 999999999 0.94 1.51 percent of total billed charges MECLIZINE 12.5 MG CAPLET 50016936_1 CDM 0250 RC 69618-0027-01 NDC inpatient 1 UN 1.56 1.01 SIHO - ALL PLANS SIHO - ALL PLANS 1.4 90 999999999 0.94 1.51 percent of total billed charges MECLIZINE 12.5 MG CAPLET 50016936_1 CDM 0250 RC 69618-0027-01 NDC inpatient 1 UN 1.56 1.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.94 60.55 999999999 0.94 1.51 percent of total billed charges MECLIZINE 12.5 MG CAPLET 50016936_1 CDM 0250 RC 69618-0027-01 NDC inpatient 1 UN 1.56 1.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.94 1.51 MECLIZINE 12.5 MG CAPLET 50016936_1 CDM 0250 RC 69618-0027-01 NDC inpatient 1 UN 1.56 1.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.94 1.51 MECLIZINE 12.5 MG CAPLET 50016936_1 CDM 0250 RC 69618-0027-01 NDC inpatient 1 UN 1.56 1.01 ANTHEM HMO ANTHEM HMO 999999999 0.94 1.51 MECLIZINE 12.5 MG CAPLET 50016936_1 CDM 0250 RC 69618-0027-01 NDC inpatient 1 UN 1.56 1.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.05 67.6 999999999 0.94 1.51 percent of total billed charges MECLIZINE 12.5 MG CAPLET 50016936_1 CDM 0250 RC 69618-0027-01 NDC inpatient 1 UN 1.56 1.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.94 1.51 MECLIZINE 12.5 MG CAPLET 50016936_1 CDM 0250 RC 69618-0027-01 NDC inpatient 1 UN 1.56 1.01 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.94 1.51 LEVOTHYROXINE 100 MCG TABLET 50027262_1 CDM 0250 RC 51079-0442-20 NDC inpatient 1 UN 2.14 1.39 AETNA AETNA 1.69 79 999999999 1.3 2.08 percent of total billed charges LEVOTHYROXINE 100 MCG TABLET 50027262_1 CDM 0250 RC 51079-0442-20 NDC inpatient 1 UN 2.14 1.39 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.39 65 999999999 1.3 2.08 percent of total billed charges LEVOTHYROXINE 100 MCG TABLET 50027262_1 CDM 0250 RC 51079-0442-20 NDC inpatient 1 UN 2.14 1.39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.08 97 999999999 1.3 2.08 percent of total billed charges LEVOTHYROXINE 100 MCG TABLET 50027262_1 CDM 0250 RC 51079-0442-20 NDC inpatient 1 UN 2.14 1.39 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.48 69 999999999 1.3 2.08 percent of total billed charges LEVOTHYROXINE 100 MCG TABLET 50027262_1 CDM 0250 RC 51079-0442-20 NDC inpatient 1 UN 2.14 1.39 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.67 78 999999999 1.3 2.08 percent of total billed charges LEVOTHYROXINE 100 MCG TABLET 50027262_1 CDM 0250 RC 51079-0442-20 NDC inpatient 1 UN 2.14 1.39 UMR - ALL PLANS UMR - ALL PLANS 1.5 70 999999999 1.3 2.08 percent of total billed charges LEVOTHYROXINE 100 MCG TABLET 50027262_1 CDM 0250 RC 51079-0442-20 NDC inpatient 1 UN 2.14 1.39 SIHO - ALL PLANS SIHO - ALL PLANS 1.93 90 999999999 1.3 2.08 percent of total billed charges LEVOTHYROXINE 100 MCG TABLET 50027262_1 CDM 0250 RC 51079-0442-20 NDC inpatient 1 UN 2.14 1.39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.3 60.55 999999999 1.3 2.08 percent of total billed charges LEVOTHYROXINE 100 MCG TABLET 50027262_1 CDM 0250 RC 51079-0442-20 NDC inpatient 1 UN 2.14 1.39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.3 2.08 LEVOTHYROXINE 100 MCG TABLET 50027262_1 CDM 0250 RC 51079-0442-20 NDC inpatient 1 UN 2.14 1.39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.3 2.08 LEVOTHYROXINE 100 MCG TABLET 50027262_1 CDM 0250 RC 51079-0442-20 NDC inpatient 1 UN 2.14 1.39 ANTHEM HMO ANTHEM HMO 999999999 1.3 2.08 LEVOTHYROXINE 100 MCG TABLET 50027262_1 CDM 0250 RC 51079-0442-20 NDC inpatient 1 UN 2.14 1.39 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.45 67.6 999999999 1.3 2.08 percent of total billed charges LEVOTHYROXINE 100 MCG TABLET 50027262_1 CDM 0250 RC 51079-0442-20 NDC inpatient 1 UN 2.14 1.39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.3 2.08 LEVOTHYROXINE 100 MCG TABLET 50027262_1 CDM 0250 RC 51079-0442-20 NDC inpatient 1 UN 2.14 1.39 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.3 2.08 "Microscopic genetic analysis of tumor, using computer-assisted technology" 50031477_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 AETNA AETNA 616.99 79 999999999 472.9 757.57 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 50031477_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 507.65 65 999999999 472.9 757.57 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 50031477_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 757.57 97 999999999 472.9 757.57 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 50031477_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 538.89 69 999999999 472.9 757.57 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 50031477_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 609.18 78 999999999 472.9 757.57 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 50031477_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 UMR - ALL PLANS UMR - ALL PLANS 546.7 70 999999999 472.9 757.57 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 50031477_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 SIHO - ALL PLANS SIHO - ALL PLANS 702.9 90 999999999 472.9 757.57 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 50031477_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 472.9 60.55 999999999 472.9 757.57 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 50031477_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 472.9 757.57 "Microscopic genetic analysis of tumor, using computer-assisted technology" 50031477_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 472.9 757.57 "Microscopic genetic analysis of tumor, using computer-assisted technology" 50031477_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 ANTHEM HMO ANTHEM HMO 999999999 472.9 757.57 "Microscopic genetic analysis of tumor, using computer-assisted technology" 50031477_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 527.96 67.6 999999999 472.9 757.57 percent of total billed charges "Microscopic genetic analysis of tumor, using computer-assisted technology" 50031477_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 472.9 757.57 "Microscopic genetic analysis of tumor, using computer-assisted technology" 50031477_1 CDM 0310 RC 88361 HCPCS inpatient 781 507.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 472.9 757.57 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50031728_1 CDM 0636 RC 70860-0210-51 NDC J3489 HCPCS inpatient 4 UN 92.32 60.01 AETNA AETNA 72.93 79 999999999 55.9 89.55 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50031728_1 CDM 0636 RC 70860-0210-51 NDC J3489 HCPCS inpatient 4 UN 92.32 60.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 60.01 65 999999999 55.9 89.55 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50031728_1 CDM 0636 RC 70860-0210-51 NDC J3489 HCPCS inpatient 4 UN 92.32 60.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.55 97 999999999 55.9 89.55 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50031728_1 CDM 0636 RC 70860-0210-51 NDC J3489 HCPCS inpatient 4 UN 92.32 60.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.7 69 999999999 55.9 89.55 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50031728_1 CDM 0636 RC 70860-0210-51 NDC J3489 HCPCS inpatient 4 UN 92.32 60.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 72.01 78 999999999 55.9 89.55 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50031728_1 CDM 0636 RC 70860-0210-51 NDC J3489 HCPCS inpatient 4 UN 92.32 60.01 UMR - ALL PLANS UMR - ALL PLANS 64.62 70 999999999 55.9 89.55 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50031728_1 CDM 0636 RC 70860-0210-51 NDC J3489 HCPCS inpatient 4 UN 92.32 60.01 SIHO - ALL PLANS SIHO - ALL PLANS 83.09 90 999999999 55.9 89.55 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50031728_1 CDM 0636 RC 70860-0210-51 NDC J3489 HCPCS inpatient 4 UN 92.32 60.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.9 60.55 999999999 55.9 89.55 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50031728_1 CDM 0636 RC 70860-0210-51 NDC J3489 HCPCS inpatient 4 UN 92.32 60.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.9 89.55 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50031728_1 CDM 0636 RC 70860-0210-51 NDC J3489 HCPCS inpatient 4 UN 92.32 60.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.9 89.55 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50031728_1 CDM 0636 RC 70860-0210-51 NDC J3489 HCPCS inpatient 4 UN 92.32 60.01 ANTHEM HMO ANTHEM HMO 999999999 55.9 89.55 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50031728_1 CDM 0636 RC 70860-0210-51 NDC J3489 HCPCS inpatient 4 UN 92.32 60.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.41 67.6 999999999 55.9 89.55 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50031728_1 CDM 0636 RC 70860-0210-51 NDC J3489 HCPCS inpatient 4 UN 92.32 60.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.9 89.55 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50031728_1 CDM 0636 RC 70860-0210-51 NDC J3489 HCPCS inpatient 4 UN 92.32 60.01 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.9 89.55 MEPERIDINE 25 MG/ML VIAL 50031829_1 CDM 0250 RC 00641-6052-25 NDC inpatient 1 UN 27.35 17.78 AETNA AETNA 21.61 79 999999999 16.56 26.53 percent of total billed charges MEPERIDINE 25 MG/ML VIAL 50031829_1 CDM 0250 RC 00641-6052-25 NDC inpatient 1 UN 27.35 17.78 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.78 65 999999999 16.56 26.53 percent of total billed charges MEPERIDINE 25 MG/ML VIAL 50031829_1 CDM 0250 RC 00641-6052-25 NDC inpatient 1 UN 27.35 17.78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26.53 97 999999999 16.56 26.53 percent of total billed charges MEPERIDINE 25 MG/ML VIAL 50031829_1 CDM 0250 RC 00641-6052-25 NDC inpatient 1 UN 27.35 17.78 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.87 69 999999999 16.56 26.53 percent of total billed charges MEPERIDINE 25 MG/ML VIAL 50031829_1 CDM 0250 RC 00641-6052-25 NDC inpatient 1 UN 27.35 17.78 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.33 78 999999999 16.56 26.53 percent of total billed charges MEPERIDINE 25 MG/ML VIAL 50031829_1 CDM 0250 RC 00641-6052-25 NDC inpatient 1 UN 27.35 17.78 UMR - ALL PLANS UMR - ALL PLANS 19.15 70 999999999 16.56 26.53 percent of total billed charges MEPERIDINE 25 MG/ML VIAL 50031829_1 CDM 0250 RC 00641-6052-25 NDC inpatient 1 UN 27.35 17.78 SIHO - ALL PLANS SIHO - ALL PLANS 24.62 90 999999999 16.56 26.53 percent of total billed charges MEPERIDINE 25 MG/ML VIAL 50031829_1 CDM 0250 RC 00641-6052-25 NDC inpatient 1 UN 27.35 17.78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.56 60.55 999999999 16.56 26.53 percent of total billed charges MEPERIDINE 25 MG/ML VIAL 50031829_1 CDM 0250 RC 00641-6052-25 NDC inpatient 1 UN 27.35 17.78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.56 26.53 MEPERIDINE 25 MG/ML VIAL 50031829_1 CDM 0250 RC 00641-6052-25 NDC inpatient 1 UN 27.35 17.78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.56 26.53 MEPERIDINE 25 MG/ML VIAL 50031829_1 CDM 0250 RC 00641-6052-25 NDC inpatient 1 UN 27.35 17.78 ANTHEM HMO ANTHEM HMO 999999999 16.56 26.53 MEPERIDINE 25 MG/ML VIAL 50031829_1 CDM 0250 RC 00641-6052-25 NDC inpatient 1 UN 27.35 17.78 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.49 67.6 999999999 16.56 26.53 percent of total billed charges MEPERIDINE 25 MG/ML VIAL 50031829_1 CDM 0250 RC 00641-6052-25 NDC inpatient 1 UN 27.35 17.78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.56 26.53 MEPERIDINE 25 MG/ML VIAL 50031829_1 CDM 0250 RC 00641-6052-25 NDC inpatient 1 UN 27.35 17.78 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.56 26.53 CIRCUIT ADULT VAPOTHERM 50044756_1 CDM 0410 RC inpatient 471 306.15 AETNA AETNA 372.09 79 999999999 285.19 456.87 percent of total billed charges CIRCUIT ADULT VAPOTHERM 50044756_1 CDM 0410 RC inpatient 471 306.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 306.15 65 999999999 285.19 456.87 percent of total billed charges CIRCUIT ADULT VAPOTHERM 50044756_1 CDM 0410 RC inpatient 471 306.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 456.87 97 999999999 285.19 456.87 percent of total billed charges CIRCUIT ADULT VAPOTHERM 50044756_1 CDM 0410 RC inpatient 471 306.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 324.99 69 999999999 285.19 456.87 percent of total billed charges CIRCUIT ADULT VAPOTHERM 50044756_1 CDM 0410 RC inpatient 471 306.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 367.38 78 999999999 285.19 456.87 percent of total billed charges CIRCUIT ADULT VAPOTHERM 50044756_1 CDM 0410 RC inpatient 471 306.15 UMR - ALL PLANS UMR - ALL PLANS 329.7 70 999999999 285.19 456.87 percent of total billed charges CIRCUIT ADULT VAPOTHERM 50044756_1 CDM 0410 RC inpatient 471 306.15 SIHO - ALL PLANS SIHO - ALL PLANS 423.9 90 999999999 285.19 456.87 percent of total billed charges CIRCUIT ADULT VAPOTHERM 50044756_1 CDM 0410 RC inpatient 471 306.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 285.19 60.55 999999999 285.19 456.87 percent of total billed charges CIRCUIT ADULT VAPOTHERM 50044756_1 CDM 0410 RC inpatient 471 306.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 285.19 456.87 CIRCUIT ADULT VAPOTHERM 50044756_1 CDM 0410 RC inpatient 471 306.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 285.19 456.87 CIRCUIT ADULT VAPOTHERM 50044756_1 CDM 0410 RC inpatient 471 306.15 ANTHEM HMO ANTHEM HMO 999999999 285.19 456.87 CIRCUIT ADULT VAPOTHERM 50044756_1 CDM 0410 RC inpatient 471 306.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 318.4 67.6 999999999 285.19 456.87 percent of total billed charges CIRCUIT ADULT VAPOTHERM 50044756_1 CDM 0410 RC inpatient 471 306.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 285.19 456.87 CIRCUIT ADULT VAPOTHERM 50044756_1 CDM 0410 RC inpatient 471 306.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 285.19 456.87 ATORVASTATIN 80 MG TABLET 50046085_1 CDM 0250 RC 51079-0211-03 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 80 MG TABLET 50046085_1 CDM 0250 RC 51079-0211-03 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 80 MG TABLET 50046085_1 CDM 0250 RC 51079-0211-03 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 80 MG TABLET 50046085_1 CDM 0250 RC 51079-0211-03 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 80 MG TABLET 50046085_1 CDM 0250 RC 51079-0211-03 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 80 MG TABLET 50046085_1 CDM 0250 RC 51079-0211-03 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 80 MG TABLET 50046085_1 CDM 0250 RC 51079-0211-03 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 80 MG TABLET 50046085_1 CDM 0250 RC 51079-0211-03 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 80 MG TABLET 50046085_1 CDM 0250 RC 51079-0211-03 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ATORVASTATIN 80 MG TABLET 50046085_1 CDM 0250 RC 51079-0211-03 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ATORVASTATIN 80 MG TABLET 50046085_1 CDM 0250 RC 51079-0211-03 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ATORVASTATIN 80 MG TABLET 50046085_1 CDM 0250 RC 51079-0211-03 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 80 MG TABLET 50046085_1 CDM 0250 RC 51079-0211-03 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ATORVASTATIN 80 MG TABLET 50046085_1 CDM 0250 RC 51079-0211-03 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CARVEDILOL 25 MG TABLET 50047256_1 CDM 0250 RC 00904-6303-61 NDC inpatient 1 UN 1.98 1.29 AETNA AETNA 1.56 79 999999999 1.2 1.92 percent of total billed charges CARVEDILOL 25 MG TABLET 50047256_1 CDM 0250 RC 00904-6303-61 NDC inpatient 1 UN 1.98 1.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.29 65 999999999 1.2 1.92 percent of total billed charges CARVEDILOL 25 MG TABLET 50047256_1 CDM 0250 RC 00904-6303-61 NDC inpatient 1 UN 1.98 1.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.92 97 999999999 1.2 1.92 percent of total billed charges CARVEDILOL 25 MG TABLET 50047256_1 CDM 0250 RC 00904-6303-61 NDC inpatient 1 UN 1.98 1.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.37 69 999999999 1.2 1.92 percent of total billed charges CARVEDILOL 25 MG TABLET 50047256_1 CDM 0250 RC 00904-6303-61 NDC inpatient 1 UN 1.98 1.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.54 78 999999999 1.2 1.92 percent of total billed charges CARVEDILOL 25 MG TABLET 50047256_1 CDM 0250 RC 00904-6303-61 NDC inpatient 1 UN 1.98 1.29 UMR - ALL PLANS UMR - ALL PLANS 1.39 70 999999999 1.2 1.92 percent of total billed charges CARVEDILOL 25 MG TABLET 50047256_1 CDM 0250 RC 00904-6303-61 NDC inpatient 1 UN 1.98 1.29 SIHO - ALL PLANS SIHO - ALL PLANS 1.78 90 999999999 1.2 1.92 percent of total billed charges CARVEDILOL 25 MG TABLET 50047256_1 CDM 0250 RC 00904-6303-61 NDC inpatient 1 UN 1.98 1.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.2 60.55 999999999 1.2 1.92 percent of total billed charges CARVEDILOL 25 MG TABLET 50047256_1 CDM 0250 RC 00904-6303-61 NDC inpatient 1 UN 1.98 1.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.2 1.92 CARVEDILOL 25 MG TABLET 50047256_1 CDM 0250 RC 00904-6303-61 NDC inpatient 1 UN 1.98 1.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.2 1.92 CARVEDILOL 25 MG TABLET 50047256_1 CDM 0250 RC 00904-6303-61 NDC inpatient 1 UN 1.98 1.29 ANTHEM HMO ANTHEM HMO 999999999 1.2 1.92 CARVEDILOL 25 MG TABLET 50047256_1 CDM 0250 RC 00904-6303-61 NDC inpatient 1 UN 1.98 1.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.34 67.6 999999999 1.2 1.92 percent of total billed charges CARVEDILOL 25 MG TABLET 50047256_1 CDM 0250 RC 00904-6303-61 NDC inpatient 1 UN 1.98 1.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.2 1.92 CARVEDILOL 25 MG TABLET 50047256_1 CDM 0250 RC 00904-6303-61 NDC inpatient 1 UN 1.98 1.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.2 1.92 "EVENT RECORDER, CARDIAC (IMPLANTABLE)" 50048437_1 CDM 0278 RC C1764 HCPCS inpatient 27323 17759.95 AETNA AETNA 21585.17 79 999999999 16544.08 26503.31 percent of total billed charges "EVENT RECORDER, CARDIAC (IMPLANTABLE)" 50048437_1 CDM 0278 RC C1764 HCPCS inpatient 27323 17759.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 17759.95 65 999999999 16544.08 26503.31 percent of total billed charges "EVENT RECORDER, CARDIAC (IMPLANTABLE)" 50048437_1 CDM 0278 RC C1764 HCPCS inpatient 27323 17759.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26503.31 97 999999999 16544.08 26503.31 percent of total billed charges "EVENT RECORDER, CARDIAC (IMPLANTABLE)" 50048437_1 CDM 0278 RC C1764 HCPCS inpatient 27323 17759.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 18852.87 69 999999999 16544.08 26503.31 percent of total billed charges "EVENT RECORDER, CARDIAC (IMPLANTABLE)" 50048437_1 CDM 0278 RC C1764 HCPCS inpatient 27323 17759.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 21311.94 78 999999999 16544.08 26503.31 percent of total billed charges "EVENT RECORDER, CARDIAC (IMPLANTABLE)" 50048437_1 CDM 0278 RC C1764 HCPCS inpatient 27323 17759.95 UMR - ALL PLANS UMR - ALL PLANS 19126.1 70 999999999 16544.08 26503.31 percent of total billed charges "EVENT RECORDER, CARDIAC (IMPLANTABLE)" 50048437_1 CDM 0278 RC C1764 HCPCS inpatient 27323 17759.95 SIHO - ALL PLANS SIHO - ALL PLANS 24590.7 90 999999999 16544.08 26503.31 percent of total billed charges "EVENT RECORDER, CARDIAC (IMPLANTABLE)" 50048437_1 CDM 0278 RC C1764 HCPCS inpatient 27323 17759.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16544.08 60.55 999999999 16544.08 26503.31 percent of total billed charges "EVENT RECORDER, CARDIAC (IMPLANTABLE)" 50048437_1 CDM 0278 RC C1764 HCPCS inpatient 27323 17759.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16544.08 26503.31 "EVENT RECORDER, CARDIAC (IMPLANTABLE)" 50048437_1 CDM 0278 RC C1764 HCPCS inpatient 27323 17759.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16544.08 26503.31 "EVENT RECORDER, CARDIAC (IMPLANTABLE)" 50048437_1 CDM 0278 RC C1764 HCPCS inpatient 27323 17759.95 ANTHEM HMO ANTHEM HMO 999999999 16544.08 26503.31 "EVENT RECORDER, CARDIAC (IMPLANTABLE)" 50048437_1 CDM 0278 RC C1764 HCPCS inpatient 27323 17759.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 18470.35 67.6 999999999 16544.08 26503.31 percent of total billed charges "EVENT RECORDER, CARDIAC (IMPLANTABLE)" 50048437_1 CDM 0278 RC C1764 HCPCS inpatient 27323 17759.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16544.08 26503.31 "EVENT RECORDER, CARDIAC (IMPLANTABLE)" 50048437_1 CDM 0278 RC C1764 HCPCS inpatient 27323 17759.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 16544.08 26503.31 BUSPIRONE HCL 5 MG TABLET 50053279_1 CDM 0250 RC 64380-0741-06 NDC inpatient 1 UN 1.88 1.22 AETNA AETNA 1.49 79 999999999 1.14 1.82 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 50053279_1 CDM 0250 RC 64380-0741-06 NDC inpatient 1 UN 1.88 1.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.22 65 999999999 1.14 1.82 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 50053279_1 CDM 0250 RC 64380-0741-06 NDC inpatient 1 UN 1.88 1.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.82 97 999999999 1.14 1.82 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 50053279_1 CDM 0250 RC 64380-0741-06 NDC inpatient 1 UN 1.88 1.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.3 69 999999999 1.14 1.82 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 50053279_1 CDM 0250 RC 64380-0741-06 NDC inpatient 1 UN 1.88 1.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.47 78 999999999 1.14 1.82 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 50053279_1 CDM 0250 RC 64380-0741-06 NDC inpatient 1 UN 1.88 1.22 UMR - ALL PLANS UMR - ALL PLANS 1.32 70 999999999 1.14 1.82 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 50053279_1 CDM 0250 RC 64380-0741-06 NDC inpatient 1 UN 1.88 1.22 SIHO - ALL PLANS SIHO - ALL PLANS 1.69 90 999999999 1.14 1.82 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 50053279_1 CDM 0250 RC 64380-0741-06 NDC inpatient 1 UN 1.88 1.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.14 60.55 999999999 1.14 1.82 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 50053279_1 CDM 0250 RC 64380-0741-06 NDC inpatient 1 UN 1.88 1.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.14 1.82 BUSPIRONE HCL 5 MG TABLET 50053279_1 CDM 0250 RC 64380-0741-06 NDC inpatient 1 UN 1.88 1.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.14 1.82 BUSPIRONE HCL 5 MG TABLET 50053279_1 CDM 0250 RC 64380-0741-06 NDC inpatient 1 UN 1.88 1.22 ANTHEM HMO ANTHEM HMO 999999999 1.14 1.82 BUSPIRONE HCL 5 MG TABLET 50053279_1 CDM 0250 RC 64380-0741-06 NDC inpatient 1 UN 1.88 1.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.27 67.6 999999999 1.14 1.82 percent of total billed charges BUSPIRONE HCL 5 MG TABLET 50053279_1 CDM 0250 RC 64380-0741-06 NDC inpatient 1 UN 1.88 1.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.14 1.82 BUSPIRONE HCL 5 MG TABLET 50053279_1 CDM 0250 RC 64380-0741-06 NDC inpatient 1 UN 1.88 1.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.14 1.82 Fetal hemoglobin analysis 50053333_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 AETNA AETNA 38.71 79 999999999 29.67 47.53 percent of total billed charges Fetal hemoglobin analysis 50053333_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.85 65 999999999 29.67 47.53 percent of total billed charges Fetal hemoglobin analysis 50053333_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 47.53 97 999999999 29.67 47.53 percent of total billed charges Fetal hemoglobin analysis 50053333_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.81 69 999999999 29.67 47.53 percent of total billed charges Fetal hemoglobin analysis 50053333_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 38.22 78 999999999 29.67 47.53 percent of total billed charges Fetal hemoglobin analysis 50053333_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 UMR - ALL PLANS UMR - ALL PLANS 34.3 70 999999999 29.67 47.53 percent of total billed charges Fetal hemoglobin analysis 50053333_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 SIHO - ALL PLANS SIHO - ALL PLANS 44.1 90 999999999 29.67 47.53 percent of total billed charges Fetal hemoglobin analysis 50053333_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.67 60.55 999999999 29.67 47.53 percent of total billed charges Fetal hemoglobin analysis 50053333_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.67 47.53 Fetal hemoglobin analysis 50053333_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.67 47.53 Fetal hemoglobin analysis 50053333_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 ANTHEM HMO ANTHEM HMO 999999999 29.67 47.53 Fetal hemoglobin analysis 50053333_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.12 67.6 999999999 29.67 47.53 percent of total billed charges Fetal hemoglobin analysis 50053333_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.67 47.53 Fetal hemoglobin analysis 50053333_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.67 47.53 Analysis for antibody to Rubella (German measles virus) 50053341_1 CDM 0301 RC 86762 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 50053341_1 CDM 0301 RC 86762 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 50053341_1 CDM 0301 RC 86762 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 50053341_1 CDM 0301 RC 86762 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 50053341_1 CDM 0301 RC 86762 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 50053341_1 CDM 0301 RC 86762 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 50053341_1 CDM 0301 RC 86762 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 50053341_1 CDM 0301 RC 86762 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 50053341_1 CDM 0301 RC 86762 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 Analysis for antibody to Rubella (German measles virus) 50053341_1 CDM 0301 RC 86762 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 Analysis for antibody to Rubella (German measles virus) 50053341_1 CDM 0301 RC 86762 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 Analysis for antibody to Rubella (German measles virus) 50053341_1 CDM 0301 RC 86762 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 50053341_1 CDM 0301 RC 86762 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 Analysis for antibody to Rubella (German measles virus) 50053341_1 CDM 0301 RC 86762 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 Analysis for antibody to Rubeola (measles virus) 50053342_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50053342_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50053342_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50053342_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50053342_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50053342_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50053342_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50053342_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50053342_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 Analysis for antibody to Rubeola (measles virus) 50053342_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 Analysis for antibody to Rubeola (measles virus) 50053342_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 Analysis for antibody to Rubeola (measles virus) 50053342_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50053342_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 Analysis for antibody to Rubeola (measles virus) 50053342_1 CDM 0301 RC 86765 HCPCS inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 50055961_1 CDM 0278 RC C1713 HCPCS inpatient 11 7.15 AETNA AETNA 8.69 79 999999999 6.66 10.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 50055961_1 CDM 0278 RC C1713 HCPCS inpatient 11 7.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.15 65 999999999 6.66 10.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 50055961_1 CDM 0278 RC C1713 HCPCS inpatient 11 7.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10.67 97 999999999 6.66 10.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 50055961_1 CDM 0278 RC C1713 HCPCS inpatient 11 7.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.59 69 999999999 6.66 10.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 50055961_1 CDM 0278 RC C1713 HCPCS inpatient 11 7.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 8.58 78 999999999 6.66 10.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 50055961_1 CDM 0278 RC C1713 HCPCS inpatient 11 7.15 UMR - ALL PLANS UMR - ALL PLANS 7.7 70 999999999 6.66 10.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 50055961_1 CDM 0278 RC C1713 HCPCS inpatient 11 7.15 SIHO - ALL PLANS SIHO - ALL PLANS 9.9 90 999999999 6.66 10.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 50055961_1 CDM 0278 RC C1713 HCPCS inpatient 11 7.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.66 60.55 999999999 6.66 10.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 50055961_1 CDM 0278 RC C1713 HCPCS inpatient 11 7.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.66 10.67 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 50055961_1 CDM 0278 RC C1713 HCPCS inpatient 11 7.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.66 10.67 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 50055961_1 CDM 0278 RC C1713 HCPCS inpatient 11 7.15 ANTHEM HMO ANTHEM HMO 999999999 6.66 10.67 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 50055961_1 CDM 0278 RC C1713 HCPCS inpatient 11 7.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 7.44 67.6 999999999 6.66 10.67 percent of total billed charges ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 50055961_1 CDM 0278 RC C1713 HCPCS inpatient 11 7.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.66 10.67 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) 50055961_1 CDM 0278 RC C1713 HCPCS inpatient 11 7.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.66 10.67 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057322_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057322_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057322_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057322_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057322_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057322_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057322_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057322_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057322_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057322_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057322_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057322_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057322_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057322_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057347_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057347_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057347_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057347_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057347_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057347_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057347_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057347_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057347_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057347_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057347_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057347_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057347_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50057347_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 DICLOFENAC SODIUM 1% GEL 50057384_1 CDM 0250 RC 69097-0524-44 NDC inpatient 1 UN 46.78 30.41 AETNA AETNA 36.96 79 999999999 28.33 45.38 percent of total billed charges DICLOFENAC SODIUM 1% GEL 50057384_1 CDM 0250 RC 69097-0524-44 NDC inpatient 1 UN 46.78 30.41 SELF PAY DISCOUNT SELF PAY DISCOUNT 30.41 65 999999999 28.33 45.38 percent of total billed charges DICLOFENAC SODIUM 1% GEL 50057384_1 CDM 0250 RC 69097-0524-44 NDC inpatient 1 UN 46.78 30.41 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 45.38 97 999999999 28.33 45.38 percent of total billed charges DICLOFENAC SODIUM 1% GEL 50057384_1 CDM 0250 RC 69097-0524-44 NDC inpatient 1 UN 46.78 30.41 ENCORE - ALL PLANS ENCORE - ALL PLANS 32.28 69 999999999 28.33 45.38 percent of total billed charges DICLOFENAC SODIUM 1% GEL 50057384_1 CDM 0250 RC 69097-0524-44 NDC inpatient 1 UN 46.78 30.41 HUMANA - ALL PLANS HUMANA - ALL PLANS 36.49 78 999999999 28.33 45.38 percent of total billed charges DICLOFENAC SODIUM 1% GEL 50057384_1 CDM 0250 RC 69097-0524-44 NDC inpatient 1 UN 46.78 30.41 UMR - ALL PLANS UMR - ALL PLANS 32.75 70 999999999 28.33 45.38 percent of total billed charges DICLOFENAC SODIUM 1% GEL 50057384_1 CDM 0250 RC 69097-0524-44 NDC inpatient 1 UN 46.78 30.41 SIHO - ALL PLANS SIHO - ALL PLANS 42.1 90 999999999 28.33 45.38 percent of total billed charges DICLOFENAC SODIUM 1% GEL 50057384_1 CDM 0250 RC 69097-0524-44 NDC inpatient 1 UN 46.78 30.41 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 28.33 60.55 999999999 28.33 45.38 percent of total billed charges DICLOFENAC SODIUM 1% GEL 50057384_1 CDM 0250 RC 69097-0524-44 NDC inpatient 1 UN 46.78 30.41 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 28.33 45.38 DICLOFENAC SODIUM 1% GEL 50057384_1 CDM 0250 RC 69097-0524-44 NDC inpatient 1 UN 46.78 30.41 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 28.33 45.38 DICLOFENAC SODIUM 1% GEL 50057384_1 CDM 0250 RC 69097-0524-44 NDC inpatient 1 UN 46.78 30.41 ANTHEM HMO ANTHEM HMO 999999999 28.33 45.38 DICLOFENAC SODIUM 1% GEL 50057384_1 CDM 0250 RC 69097-0524-44 NDC inpatient 1 UN 46.78 30.41 CIGNA - ALL PLANS CIGNA - ALL PLANS 31.62 67.6 999999999 28.33 45.38 percent of total billed charges DICLOFENAC SODIUM 1% GEL 50057384_1 CDM 0250 RC 69097-0524-44 NDC inpatient 1 UN 46.78 30.41 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 28.33 45.38 DICLOFENAC SODIUM 1% GEL 50057384_1 CDM 0250 RC 69097-0524-44 NDC inpatient 1 UN 46.78 30.41 UHC - ALL PLANS UHC - ALL PLANS 999999999 28.33 45.38 MEMANTINE HCL ER 28 MG CAPSULE 50059266_1 CDM 0250 RC 65162-0785-03 NDC inpatient 1 UN 9.32 6.06 AETNA AETNA 7.36 79 999999999 5.64 9.04 percent of total billed charges MEMANTINE HCL ER 28 MG CAPSULE 50059266_1 CDM 0250 RC 65162-0785-03 NDC inpatient 1 UN 9.32 6.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.06 65 999999999 5.64 9.04 percent of total billed charges MEMANTINE HCL ER 28 MG CAPSULE 50059266_1 CDM 0250 RC 65162-0785-03 NDC inpatient 1 UN 9.32 6.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.04 97 999999999 5.64 9.04 percent of total billed charges MEMANTINE HCL ER 28 MG CAPSULE 50059266_1 CDM 0250 RC 65162-0785-03 NDC inpatient 1 UN 9.32 6.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.43 69 999999999 5.64 9.04 percent of total billed charges MEMANTINE HCL ER 28 MG CAPSULE 50059266_1 CDM 0250 RC 65162-0785-03 NDC inpatient 1 UN 9.32 6.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.27 78 999999999 5.64 9.04 percent of total billed charges MEMANTINE HCL ER 28 MG CAPSULE 50059266_1 CDM 0250 RC 65162-0785-03 NDC inpatient 1 UN 9.32 6.06 UMR - ALL PLANS UMR - ALL PLANS 6.52 70 999999999 5.64 9.04 percent of total billed charges MEMANTINE HCL ER 28 MG CAPSULE 50059266_1 CDM 0250 RC 65162-0785-03 NDC inpatient 1 UN 9.32 6.06 SIHO - ALL PLANS SIHO - ALL PLANS 8.39 90 999999999 5.64 9.04 percent of total billed charges MEMANTINE HCL ER 28 MG CAPSULE 50059266_1 CDM 0250 RC 65162-0785-03 NDC inpatient 1 UN 9.32 6.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.64 60.55 999999999 5.64 9.04 percent of total billed charges MEMANTINE HCL ER 28 MG CAPSULE 50059266_1 CDM 0250 RC 65162-0785-03 NDC inpatient 1 UN 9.32 6.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.64 9.04 MEMANTINE HCL ER 28 MG CAPSULE 50059266_1 CDM 0250 RC 65162-0785-03 NDC inpatient 1 UN 9.32 6.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.64 9.04 MEMANTINE HCL ER 28 MG CAPSULE 50059266_1 CDM 0250 RC 65162-0785-03 NDC inpatient 1 UN 9.32 6.06 ANTHEM HMO ANTHEM HMO 999999999 5.64 9.04 MEMANTINE HCL ER 28 MG CAPSULE 50059266_1 CDM 0250 RC 65162-0785-03 NDC inpatient 1 UN 9.32 6.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.3 67.6 999999999 5.64 9.04 percent of total billed charges MEMANTINE HCL ER 28 MG CAPSULE 50059266_1 CDM 0250 RC 65162-0785-03 NDC inpatient 1 UN 9.32 6.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.64 9.04 MEMANTINE HCL ER 28 MG CAPSULE 50059266_1 CDM 0250 RC 65162-0785-03 NDC inpatient 1 UN 9.32 6.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.64 9.04 CLOBETASOL 0.05% SOLUTION 50059267_1 CDM 0250 RC 00472-0402-25 NDC inpatient 1 UN 84.6 54.99 AETNA AETNA 66.83 79 999999999 51.23 82.06 percent of total billed charges CLOBETASOL 0.05% SOLUTION 50059267_1 CDM 0250 RC 00472-0402-25 NDC inpatient 1 UN 84.6 54.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 54.99 65 999999999 51.23 82.06 percent of total billed charges CLOBETASOL 0.05% SOLUTION 50059267_1 CDM 0250 RC 00472-0402-25 NDC inpatient 1 UN 84.6 54.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 82.06 97 999999999 51.23 82.06 percent of total billed charges CLOBETASOL 0.05% SOLUTION 50059267_1 CDM 0250 RC 00472-0402-25 NDC inpatient 1 UN 84.6 54.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 58.37 69 999999999 51.23 82.06 percent of total billed charges CLOBETASOL 0.05% SOLUTION 50059267_1 CDM 0250 RC 00472-0402-25 NDC inpatient 1 UN 84.6 54.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 65.99 78 999999999 51.23 82.06 percent of total billed charges CLOBETASOL 0.05% SOLUTION 50059267_1 CDM 0250 RC 00472-0402-25 NDC inpatient 1 UN 84.6 54.99 UMR - ALL PLANS UMR - ALL PLANS 59.22 70 999999999 51.23 82.06 percent of total billed charges CLOBETASOL 0.05% SOLUTION 50059267_1 CDM 0250 RC 00472-0402-25 NDC inpatient 1 UN 84.6 54.99 SIHO - ALL PLANS SIHO - ALL PLANS 76.14 90 999999999 51.23 82.06 percent of total billed charges CLOBETASOL 0.05% SOLUTION 50059267_1 CDM 0250 RC 00472-0402-25 NDC inpatient 1 UN 84.6 54.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 51.23 60.55 999999999 51.23 82.06 percent of total billed charges CLOBETASOL 0.05% SOLUTION 50059267_1 CDM 0250 RC 00472-0402-25 NDC inpatient 1 UN 84.6 54.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 51.23 82.06 CLOBETASOL 0.05% SOLUTION 50059267_1 CDM 0250 RC 00472-0402-25 NDC inpatient 1 UN 84.6 54.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 51.23 82.06 CLOBETASOL 0.05% SOLUTION 50059267_1 CDM 0250 RC 00472-0402-25 NDC inpatient 1 UN 84.6 54.99 ANTHEM HMO ANTHEM HMO 999999999 51.23 82.06 CLOBETASOL 0.05% SOLUTION 50059267_1 CDM 0250 RC 00472-0402-25 NDC inpatient 1 UN 84.6 54.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 57.19 67.6 999999999 51.23 82.06 percent of total billed charges CLOBETASOL 0.05% SOLUTION 50059267_1 CDM 0250 RC 00472-0402-25 NDC inpatient 1 UN 84.6 54.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 51.23 82.06 CLOBETASOL 0.05% SOLUTION 50059267_1 CDM 0250 RC 00472-0402-25 NDC inpatient 1 UN 84.6 54.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 51.23 82.06 "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area 50.0 sq cm or less" 50059457_1 CDM 0510 RC 97607 HCPCS inpatient 1243 807.95 AETNA AETNA 981.97 79 999999999 752.64 1205.71 percent of total billed charges "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area 50.0 sq cm or less" 50059457_1 CDM 0510 RC 97607 HCPCS inpatient 1243 807.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 807.95 65 999999999 752.64 1205.71 percent of total billed charges "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area 50.0 sq cm or less" 50059457_1 CDM 0510 RC 97607 HCPCS inpatient 1243 807.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1205.71 97 999999999 752.64 1205.71 percent of total billed charges "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area 50.0 sq cm or less" 50059457_1 CDM 0510 RC 97607 HCPCS inpatient 1243 807.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 857.67 69 999999999 752.64 1205.71 percent of total billed charges "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area 50.0 sq cm or less" 50059457_1 CDM 0510 RC 97607 HCPCS inpatient 1243 807.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 969.54 78 999999999 752.64 1205.71 percent of total billed charges "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area 50.0 sq cm or less" 50059457_1 CDM 0510 RC 97607 HCPCS inpatient 1243 807.95 UMR - ALL PLANS UMR - ALL PLANS 870.1 70 999999999 752.64 1205.71 percent of total billed charges "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area 50.0 sq cm or less" 50059457_1 CDM 0510 RC 97607 HCPCS inpatient 1243 807.95 SIHO - ALL PLANS SIHO - ALL PLANS 1118.7 90 999999999 752.64 1205.71 percent of total billed charges "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area 50.0 sq cm or less" 50059457_1 CDM 0510 RC 97607 HCPCS inpatient 1243 807.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 752.64 60.55 999999999 752.64 1205.71 percent of total billed charges "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area 50.0 sq cm or less" 50059457_1 CDM 0510 RC 97607 HCPCS inpatient 1243 807.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 752.64 1205.71 "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area 50.0 sq cm or less" 50059457_1 CDM 0510 RC 97607 HCPCS inpatient 1243 807.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 752.64 1205.71 "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area 50.0 sq cm or less" 50059457_1 CDM 0510 RC 97607 HCPCS inpatient 1243 807.95 ANTHEM HMO ANTHEM HMO 999999999 752.64 1205.71 "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area 50.0 sq cm or less" 50059457_1 CDM 0510 RC 97607 HCPCS inpatient 1243 807.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 840.27 67.6 999999999 752.64 1205.71 percent of total billed charges "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area 50.0 sq cm or less" 50059457_1 CDM 0510 RC 97607 HCPCS inpatient 1243 807.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 752.64 1205.71 "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area 50.0 sq cm or less" 50059457_1 CDM 0510 RC 97607 HCPCS inpatient 1243 807.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 752.64 1205.71 "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area more than 50.0 sq cm" 50059458_1 CDM 0510 RC 97608 HCPCS inpatient 1279 831.35 AETNA AETNA 1010.41 79 999999999 774.43 1240.63 percent of total billed charges "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area more than 50.0 sq cm" 50059458_1 CDM 0510 RC 97608 HCPCS inpatient 1279 831.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 831.35 65 999999999 774.43 1240.63 percent of total billed charges "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area more than 50.0 sq cm" 50059458_1 CDM 0510 RC 97608 HCPCS inpatient 1279 831.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1240.63 97 999999999 774.43 1240.63 percent of total billed charges "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area more than 50.0 sq cm" 50059458_1 CDM 0510 RC 97608 HCPCS inpatient 1279 831.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 882.51 69 999999999 774.43 1240.63 percent of total billed charges "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area more than 50.0 sq cm" 50059458_1 CDM 0510 RC 97608 HCPCS inpatient 1279 831.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 997.62 78 999999999 774.43 1240.63 percent of total billed charges "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area more than 50.0 sq cm" 50059458_1 CDM 0510 RC 97608 HCPCS inpatient 1279 831.35 UMR - ALL PLANS UMR - ALL PLANS 895.3 70 999999999 774.43 1240.63 percent of total billed charges "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area more than 50.0 sq cm" 50059458_1 CDM 0510 RC 97608 HCPCS inpatient 1279 831.35 SIHO - ALL PLANS SIHO - ALL PLANS 1151.1 90 999999999 774.43 1240.63 percent of total billed charges "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area more than 50.0 sq cm" 50059458_1 CDM 0510 RC 97608 HCPCS inpatient 1279 831.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 774.43 60.55 999999999 774.43 1240.63 percent of total billed charges "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area more than 50.0 sq cm" 50059458_1 CDM 0510 RC 97608 HCPCS inpatient 1279 831.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 774.43 1240.63 "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area more than 50.0 sq cm" 50059458_1 CDM 0510 RC 97608 HCPCS inpatient 1279 831.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 774.43 1240.63 "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area more than 50.0 sq cm" 50059458_1 CDM 0510 RC 97608 HCPCS inpatient 1279 831.35 ANTHEM HMO ANTHEM HMO 999999999 774.43 1240.63 "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area more than 50.0 sq cm" 50059458_1 CDM 0510 RC 97608 HCPCS inpatient 1279 831.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 864.6 67.6 999999999 774.43 1240.63 percent of total billed charges "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area more than 50.0 sq cm" 50059458_1 CDM 0510 RC 97608 HCPCS inpatient 1279 831.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 774.43 1240.63 "Therapy procedure using a special bandage, vacuum pump and disposable medical equipment, surface area more than 50.0 sq cm" 50059458_1 CDM 0510 RC 97608 HCPCS inpatient 1279 831.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 774.43 1240.63 "Biopsy of related skin growth, first growth" 50059459_1 CDM 0510 RC 11102 HCPCS inpatient 1261 819.65 AETNA AETNA 996.19 79 999999999 763.54 1223.17 percent of total billed charges "Biopsy of related skin growth, first growth" 50059459_1 CDM 0510 RC 11102 HCPCS inpatient 1261 819.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 819.65 65 999999999 763.54 1223.17 percent of total billed charges "Biopsy of related skin growth, first growth" 50059459_1 CDM 0510 RC 11102 HCPCS inpatient 1261 819.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1223.17 97 999999999 763.54 1223.17 percent of total billed charges "Biopsy of related skin growth, first growth" 50059459_1 CDM 0510 RC 11102 HCPCS inpatient 1261 819.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 870.09 69 999999999 763.54 1223.17 percent of total billed charges "Biopsy of related skin growth, first growth" 50059459_1 CDM 0510 RC 11102 HCPCS inpatient 1261 819.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 983.58 78 999999999 763.54 1223.17 percent of total billed charges "Biopsy of related skin growth, first growth" 50059459_1 CDM 0510 RC 11102 HCPCS inpatient 1261 819.65 UMR - ALL PLANS UMR - ALL PLANS 882.7 70 999999999 763.54 1223.17 percent of total billed charges "Biopsy of related skin growth, first growth" 50059459_1 CDM 0510 RC 11102 HCPCS inpatient 1261 819.65 SIHO - ALL PLANS SIHO - ALL PLANS 1134.9 90 999999999 763.54 1223.17 percent of total billed charges "Biopsy of related skin growth, first growth" 50059459_1 CDM 0510 RC 11102 HCPCS inpatient 1261 819.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 763.54 60.55 999999999 763.54 1223.17 percent of total billed charges "Biopsy of related skin growth, first growth" 50059459_1 CDM 0510 RC 11102 HCPCS inpatient 1261 819.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 763.54 1223.17 "Biopsy of related skin growth, first growth" 50059459_1 CDM 0510 RC 11102 HCPCS inpatient 1261 819.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 763.54 1223.17 "Biopsy of related skin growth, first growth" 50059459_1 CDM 0510 RC 11102 HCPCS inpatient 1261 819.65 ANTHEM HMO ANTHEM HMO 999999999 763.54 1223.17 "Biopsy of related skin growth, first growth" 50059459_1 CDM 0510 RC 11102 HCPCS inpatient 1261 819.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 852.44 67.6 999999999 763.54 1223.17 percent of total billed charges "Biopsy of related skin growth, first growth" 50059459_1 CDM 0510 RC 11102 HCPCS inpatient 1261 819.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 763.54 1223.17 "Biopsy of related skin growth, first growth" 50059459_1 CDM 0510 RC 11102 HCPCS inpatient 1261 819.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 763.54 1223.17 "Biopsy of related skin growth, each additional growth" 50059460_1 CDM 0510 RC 11103 HCPCS inpatient 644 418.6 AETNA AETNA 508.76 79 999999999 389.94 624.68 percent of total billed charges "Biopsy of related skin growth, each additional growth" 50059460_1 CDM 0510 RC 11103 HCPCS inpatient 644 418.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 418.6 65 999999999 389.94 624.68 percent of total billed charges "Biopsy of related skin growth, each additional growth" 50059460_1 CDM 0510 RC 11103 HCPCS inpatient 644 418.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 624.68 97 999999999 389.94 624.68 percent of total billed charges "Biopsy of related skin growth, each additional growth" 50059460_1 CDM 0510 RC 11103 HCPCS inpatient 644 418.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 444.36 69 999999999 389.94 624.68 percent of total billed charges "Biopsy of related skin growth, each additional growth" 50059460_1 CDM 0510 RC 11103 HCPCS inpatient 644 418.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 502.32 78 999999999 389.94 624.68 percent of total billed charges "Biopsy of related skin growth, each additional growth" 50059460_1 CDM 0510 RC 11103 HCPCS inpatient 644 418.6 UMR - ALL PLANS UMR - ALL PLANS 450.8 70 999999999 389.94 624.68 percent of total billed charges "Biopsy of related skin growth, each additional growth" 50059460_1 CDM 0510 RC 11103 HCPCS inpatient 644 418.6 SIHO - ALL PLANS SIHO - ALL PLANS 579.6 90 999999999 389.94 624.68 percent of total billed charges "Biopsy of related skin growth, each additional growth" 50059460_1 CDM 0510 RC 11103 HCPCS inpatient 644 418.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 389.94 60.55 999999999 389.94 624.68 percent of total billed charges "Biopsy of related skin growth, each additional growth" 50059460_1 CDM 0510 RC 11103 HCPCS inpatient 644 418.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 389.94 624.68 "Biopsy of related skin growth, each additional growth" 50059460_1 CDM 0510 RC 11103 HCPCS inpatient 644 418.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 389.94 624.68 "Biopsy of related skin growth, each additional growth" 50059460_1 CDM 0510 RC 11103 HCPCS inpatient 644 418.6 ANTHEM HMO ANTHEM HMO 999999999 389.94 624.68 "Biopsy of related skin growth, each additional growth" 50059460_1 CDM 0510 RC 11103 HCPCS inpatient 644 418.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 435.34 67.6 999999999 389.94 624.68 percent of total billed charges "Biopsy of related skin growth, each additional growth" 50059460_1 CDM 0510 RC 11103 HCPCS inpatient 644 418.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 389.94 624.68 "Biopsy of related skin growth, each additional growth" 50059460_1 CDM 0510 RC 11103 HCPCS inpatient 644 418.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 389.94 624.68 "Punch biopsy, first skin growth" 50059461_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 AETNA AETNA 1043.59 79 999999999 799.87 1281.37 percent of total billed charges "Punch biopsy, first skin growth" 50059461_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 858.65 65 999999999 799.87 1281.37 percent of total billed charges "Punch biopsy, first skin growth" 50059461_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1281.37 97 999999999 799.87 1281.37 percent of total billed charges "Punch biopsy, first skin growth" 50059461_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 911.49 69 999999999 799.87 1281.37 percent of total billed charges "Punch biopsy, first skin growth" 50059461_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1030.38 78 999999999 799.87 1281.37 percent of total billed charges "Punch biopsy, first skin growth" 50059461_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 UMR - ALL PLANS UMR - ALL PLANS 924.7 70 999999999 799.87 1281.37 percent of total billed charges "Punch biopsy, first skin growth" 50059461_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 SIHO - ALL PLANS SIHO - ALL PLANS 1188.9 90 999999999 799.87 1281.37 percent of total billed charges "Punch biopsy, first skin growth" 50059461_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 799.87 60.55 999999999 799.87 1281.37 percent of total billed charges "Punch biopsy, first skin growth" 50059461_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 799.87 1281.37 "Punch biopsy, first skin growth" 50059461_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 799.87 1281.37 "Punch biopsy, first skin growth" 50059461_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 ANTHEM HMO ANTHEM HMO 999999999 799.87 1281.37 "Punch biopsy, first skin growth" 50059461_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 893 67.6 999999999 799.87 1281.37 percent of total billed charges "Punch biopsy, first skin growth" 50059461_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 799.87 1281.37 "Punch biopsy, first skin growth" 50059461_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 799.87 1281.37 "Punch biopsy, each additional skin growth" 50059462_1 CDM 0510 RC 11105 HCPCS inpatient 644 418.6 AETNA AETNA 508.76 79 999999999 389.94 624.68 percent of total billed charges "Punch biopsy, each additional skin growth" 50059462_1 CDM 0510 RC 11105 HCPCS inpatient 644 418.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 418.6 65 999999999 389.94 624.68 percent of total billed charges "Punch biopsy, each additional skin growth" 50059462_1 CDM 0510 RC 11105 HCPCS inpatient 644 418.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 624.68 97 999999999 389.94 624.68 percent of total billed charges "Punch biopsy, each additional skin growth" 50059462_1 CDM 0510 RC 11105 HCPCS inpatient 644 418.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 444.36 69 999999999 389.94 624.68 percent of total billed charges "Punch biopsy, each additional skin growth" 50059462_1 CDM 0510 RC 11105 HCPCS inpatient 644 418.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 502.32 78 999999999 389.94 624.68 percent of total billed charges "Punch biopsy, each additional skin growth" 50059462_1 CDM 0510 RC 11105 HCPCS inpatient 644 418.6 UMR - ALL PLANS UMR - ALL PLANS 450.8 70 999999999 389.94 624.68 percent of total billed charges "Punch biopsy, each additional skin growth" 50059462_1 CDM 0510 RC 11105 HCPCS inpatient 644 418.6 SIHO - ALL PLANS SIHO - ALL PLANS 579.6 90 999999999 389.94 624.68 percent of total billed charges "Punch biopsy, each additional skin growth" 50059462_1 CDM 0510 RC 11105 HCPCS inpatient 644 418.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 389.94 60.55 999999999 389.94 624.68 percent of total billed charges "Punch biopsy, each additional skin growth" 50059462_1 CDM 0510 RC 11105 HCPCS inpatient 644 418.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 389.94 624.68 "Punch biopsy, each additional skin growth" 50059462_1 CDM 0510 RC 11105 HCPCS inpatient 644 418.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 389.94 624.68 "Punch biopsy, each additional skin growth" 50059462_1 CDM 0510 RC 11105 HCPCS inpatient 644 418.6 ANTHEM HMO ANTHEM HMO 999999999 389.94 624.68 "Punch biopsy, each additional skin growth" 50059462_1 CDM 0510 RC 11105 HCPCS inpatient 644 418.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 435.34 67.6 999999999 389.94 624.68 percent of total billed charges "Punch biopsy, each additional skin growth" 50059462_1 CDM 0510 RC 11105 HCPCS inpatient 644 418.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 389.94 624.68 "Punch biopsy, each additional skin growth" 50059462_1 CDM 0510 RC 11105 HCPCS inpatient 644 418.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 389.94 624.68 "Incision biopsy, first skin growth" 50059463_1 CDM 0510 RC 11106 HCPCS inpatient 1146 744.9 AETNA AETNA 905.34 79 999999999 693.9 1111.62 percent of total billed charges "Incision biopsy, first skin growth" 50059463_1 CDM 0510 RC 11106 HCPCS inpatient 1146 744.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 744.9 65 999999999 693.9 1111.62 percent of total billed charges "Incision biopsy, first skin growth" 50059463_1 CDM 0510 RC 11106 HCPCS inpatient 1146 744.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1111.62 97 999999999 693.9 1111.62 percent of total billed charges "Incision biopsy, first skin growth" 50059463_1 CDM 0510 RC 11106 HCPCS inpatient 1146 744.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 790.74 69 999999999 693.9 1111.62 percent of total billed charges "Incision biopsy, first skin growth" 50059463_1 CDM 0510 RC 11106 HCPCS inpatient 1146 744.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 893.88 78 999999999 693.9 1111.62 percent of total billed charges "Incision biopsy, first skin growth" 50059463_1 CDM 0510 RC 11106 HCPCS inpatient 1146 744.9 UMR - ALL PLANS UMR - ALL PLANS 802.2 70 999999999 693.9 1111.62 percent of total billed charges "Incision biopsy, first skin growth" 50059463_1 CDM 0510 RC 11106 HCPCS inpatient 1146 744.9 SIHO - ALL PLANS SIHO - ALL PLANS 1031.4 90 999999999 693.9 1111.62 percent of total billed charges "Incision biopsy, first skin growth" 50059463_1 CDM 0510 RC 11106 HCPCS inpatient 1146 744.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 693.9 60.55 999999999 693.9 1111.62 percent of total billed charges "Incision biopsy, first skin growth" 50059463_1 CDM 0510 RC 11106 HCPCS inpatient 1146 744.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 693.9 1111.62 "Incision biopsy, first skin growth" 50059463_1 CDM 0510 RC 11106 HCPCS inpatient 1146 744.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 693.9 1111.62 "Incision biopsy, first skin growth" 50059463_1 CDM 0510 RC 11106 HCPCS inpatient 1146 744.9 ANTHEM HMO ANTHEM HMO 999999999 693.9 1111.62 "Incision biopsy, first skin growth" 50059463_1 CDM 0510 RC 11106 HCPCS inpatient 1146 744.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 774.7 67.6 999999999 693.9 1111.62 percent of total billed charges "Incision biopsy, first skin growth" 50059463_1 CDM 0510 RC 11106 HCPCS inpatient 1146 744.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 693.9 1111.62 "Incision biopsy, first skin growth" 50059463_1 CDM 0510 RC 11106 HCPCS inpatient 1146 744.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 693.9 1111.62 "Incision biopsy, each additional skin growth" 50059464_1 CDM 0510 RC 11107 HCPCS inpatient 1146 744.9 AETNA AETNA 905.34 79 999999999 693.9 1111.62 percent of total billed charges "Incision biopsy, each additional skin growth" 50059464_1 CDM 0510 RC 11107 HCPCS inpatient 1146 744.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 744.9 65 999999999 693.9 1111.62 percent of total billed charges "Incision biopsy, each additional skin growth" 50059464_1 CDM 0510 RC 11107 HCPCS inpatient 1146 744.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1111.62 97 999999999 693.9 1111.62 percent of total billed charges "Incision biopsy, each additional skin growth" 50059464_1 CDM 0510 RC 11107 HCPCS inpatient 1146 744.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 790.74 69 999999999 693.9 1111.62 percent of total billed charges "Incision biopsy, each additional skin growth" 50059464_1 CDM 0510 RC 11107 HCPCS inpatient 1146 744.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 893.88 78 999999999 693.9 1111.62 percent of total billed charges "Incision biopsy, each additional skin growth" 50059464_1 CDM 0510 RC 11107 HCPCS inpatient 1146 744.9 UMR - ALL PLANS UMR - ALL PLANS 802.2 70 999999999 693.9 1111.62 percent of total billed charges "Incision biopsy, each additional skin growth" 50059464_1 CDM 0510 RC 11107 HCPCS inpatient 1146 744.9 SIHO - ALL PLANS SIHO - ALL PLANS 1031.4 90 999999999 693.9 1111.62 percent of total billed charges "Incision biopsy, each additional skin growth" 50059464_1 CDM 0510 RC 11107 HCPCS inpatient 1146 744.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 693.9 60.55 999999999 693.9 1111.62 percent of total billed charges "Incision biopsy, each additional skin growth" 50059464_1 CDM 0510 RC 11107 HCPCS inpatient 1146 744.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 693.9 1111.62 "Incision biopsy, each additional skin growth" 50059464_1 CDM 0510 RC 11107 HCPCS inpatient 1146 744.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 693.9 1111.62 "Incision biopsy, each additional skin growth" 50059464_1 CDM 0510 RC 11107 HCPCS inpatient 1146 744.9 ANTHEM HMO ANTHEM HMO 999999999 693.9 1111.62 "Incision biopsy, each additional skin growth" 50059464_1 CDM 0510 RC 11107 HCPCS inpatient 1146 744.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 774.7 67.6 999999999 693.9 1111.62 percent of total billed charges "Incision biopsy, each additional skin growth" 50059464_1 CDM 0510 RC 11107 HCPCS inpatient 1146 744.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 693.9 1111.62 "Incision biopsy, each additional skin growth" 50059464_1 CDM 0510 RC 11107 HCPCS inpatient 1146 744.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 693.9 1111.62 "INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG" 50059517_1 CDM 0636 RC 00078-0825-81 NDC J2353 HCPCS inpatient 30 UN 25207.67 16384.99 AETNA AETNA 19914.06 79 999999999 15263.24 24451.44 percent of total billed charges "INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG" 50059517_1 CDM 0636 RC 00078-0825-81 NDC J2353 HCPCS inpatient 30 UN 25207.67 16384.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 16384.99 65 999999999 15263.24 24451.44 percent of total billed charges "INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG" 50059517_1 CDM 0636 RC 00078-0825-81 NDC J2353 HCPCS inpatient 30 UN 25207.67 16384.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24451.44 97 999999999 15263.24 24451.44 percent of total billed charges "INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG" 50059517_1 CDM 0636 RC 00078-0825-81 NDC J2353 HCPCS inpatient 30 UN 25207.67 16384.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 17393.29 69 999999999 15263.24 24451.44 percent of total billed charges "INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG" 50059517_1 CDM 0636 RC 00078-0825-81 NDC J2353 HCPCS inpatient 30 UN 25207.67 16384.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 19661.98 78 999999999 15263.24 24451.44 percent of total billed charges "INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG" 50059517_1 CDM 0636 RC 00078-0825-81 NDC J2353 HCPCS inpatient 30 UN 25207.67 16384.99 UMR - ALL PLANS UMR - ALL PLANS 17645.37 70 999999999 15263.24 24451.44 percent of total billed charges "INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG" 50059517_1 CDM 0636 RC 00078-0825-81 NDC J2353 HCPCS inpatient 30 UN 25207.67 16384.99 SIHO - ALL PLANS SIHO - ALL PLANS 22686.9 90 999999999 15263.24 24451.44 percent of total billed charges "INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG" 50059517_1 CDM 0636 RC 00078-0825-81 NDC J2353 HCPCS inpatient 30 UN 25207.67 16384.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15263.24 60.55 999999999 15263.24 24451.44 percent of total billed charges "INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG" 50059517_1 CDM 0636 RC 00078-0825-81 NDC J2353 HCPCS inpatient 30 UN 25207.67 16384.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15263.24 24451.44 "INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG" 50059517_1 CDM 0636 RC 00078-0825-81 NDC J2353 HCPCS inpatient 30 UN 25207.67 16384.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15263.24 24451.44 "INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG" 50059517_1 CDM 0636 RC 00078-0825-81 NDC J2353 HCPCS inpatient 30 UN 25207.67 16384.99 ANTHEM HMO ANTHEM HMO 999999999 15263.24 24451.44 "INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG" 50059517_1 CDM 0636 RC 00078-0825-81 NDC J2353 HCPCS inpatient 30 UN 25207.67 16384.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 17040.38 67.6 999999999 15263.24 24451.44 percent of total billed charges "INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG" 50059517_1 CDM 0636 RC 00078-0825-81 NDC J2353 HCPCS inpatient 30 UN 25207.67 16384.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15263.24 24451.44 "INJECTION, OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 MG" 50059517_1 CDM 0636 RC 00078-0825-81 NDC J2353 HCPCS inpatient 30 UN 25207.67 16384.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 15263.24 24451.44 IBUPROFEN 800 MG TABLET 50061468_1 CDM 0250 RC 00904-5855-61 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 800 MG TABLET 50061468_1 CDM 0250 RC 00904-5855-61 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 800 MG TABLET 50061468_1 CDM 0250 RC 00904-5855-61 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 800 MG TABLET 50061468_1 CDM 0250 RC 00904-5855-61 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 800 MG TABLET 50061468_1 CDM 0250 RC 00904-5855-61 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 800 MG TABLET 50061468_1 CDM 0250 RC 00904-5855-61 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 800 MG TABLET 50061468_1 CDM 0250 RC 00904-5855-61 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 800 MG TABLET 50061468_1 CDM 0250 RC 00904-5855-61 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 800 MG TABLET 50061468_1 CDM 0250 RC 00904-5855-61 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 IBUPROFEN 800 MG TABLET 50061468_1 CDM 0250 RC 00904-5855-61 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 IBUPROFEN 800 MG TABLET 50061468_1 CDM 0250 RC 00904-5855-61 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 IBUPROFEN 800 MG TABLET 50061468_1 CDM 0250 RC 00904-5855-61 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 800 MG TABLET 50061468_1 CDM 0250 RC 00904-5855-61 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 IBUPROFEN 800 MG TABLET 50061468_1 CDM 0250 RC 00904-5855-61 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 Alcohols levels 50069600_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50069600_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50069600_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50069600_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50069600_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50069600_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50069600_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50069600_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50069600_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 Alcohols levels 50069600_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 Alcohols levels 50069600_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 Alcohols levels 50069600_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50069600_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 Alcohols levels 50069600_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 "INJECTION, LEVETIRACETAM, 10 MG" 50070031_1 CDM 0250 RC 55150-0177-05 NDC J1953 HCPCS inpatient 1 UN 25.33 16.46 AETNA AETNA 20.01 79 999999999 15.34 24.57 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50070031_1 CDM 0250 RC 55150-0177-05 NDC J1953 HCPCS inpatient 1 UN 25.33 16.46 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.46 65 999999999 15.34 24.57 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50070031_1 CDM 0250 RC 55150-0177-05 NDC J1953 HCPCS inpatient 1 UN 25.33 16.46 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.57 97 999999999 15.34 24.57 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50070031_1 CDM 0250 RC 55150-0177-05 NDC J1953 HCPCS inpatient 1 UN 25.33 16.46 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.48 69 999999999 15.34 24.57 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50070031_1 CDM 0250 RC 55150-0177-05 NDC J1953 HCPCS inpatient 1 UN 25.33 16.46 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.76 78 999999999 15.34 24.57 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50070031_1 CDM 0250 RC 55150-0177-05 NDC J1953 HCPCS inpatient 1 UN 25.33 16.46 UMR - ALL PLANS UMR - ALL PLANS 17.73 70 999999999 15.34 24.57 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50070031_1 CDM 0250 RC 55150-0177-05 NDC J1953 HCPCS inpatient 1 UN 25.33 16.46 SIHO - ALL PLANS SIHO - ALL PLANS 22.8 90 999999999 15.34 24.57 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50070031_1 CDM 0250 RC 55150-0177-05 NDC J1953 HCPCS inpatient 1 UN 25.33 16.46 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.34 60.55 999999999 15.34 24.57 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50070031_1 CDM 0250 RC 55150-0177-05 NDC J1953 HCPCS inpatient 1 UN 25.33 16.46 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.34 24.57 "INJECTION, LEVETIRACETAM, 10 MG" 50070031_1 CDM 0250 RC 55150-0177-05 NDC J1953 HCPCS inpatient 1 UN 25.33 16.46 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.34 24.57 "INJECTION, LEVETIRACETAM, 10 MG" 50070031_1 CDM 0250 RC 55150-0177-05 NDC J1953 HCPCS inpatient 1 UN 25.33 16.46 ANTHEM HMO ANTHEM HMO 999999999 15.34 24.57 "INJECTION, LEVETIRACETAM, 10 MG" 50070031_1 CDM 0250 RC 55150-0177-05 NDC J1953 HCPCS inpatient 1 UN 25.33 16.46 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.12 67.6 999999999 15.34 24.57 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50070031_1 CDM 0250 RC 55150-0177-05 NDC J1953 HCPCS inpatient 1 UN 25.33 16.46 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.34 24.57 "INJECTION, LEVETIRACETAM, 10 MG" 50070031_1 CDM 0250 RC 55150-0177-05 NDC J1953 HCPCS inpatient 1 UN 25.33 16.46 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.34 24.57 NAPROXEN SODIUM 550 MG TAB 50071347_1 CDM 0250 RC 68462-0179-01 NDC inpatient 2 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges NAPROXEN SODIUM 550 MG TAB 50071347_1 CDM 0250 RC 68462-0179-01 NDC inpatient 2 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges NAPROXEN SODIUM 550 MG TAB 50071347_1 CDM 0250 RC 68462-0179-01 NDC inpatient 2 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges NAPROXEN SODIUM 550 MG TAB 50071347_1 CDM 0250 RC 68462-0179-01 NDC inpatient 2 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges NAPROXEN SODIUM 550 MG TAB 50071347_1 CDM 0250 RC 68462-0179-01 NDC inpatient 2 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges NAPROXEN SODIUM 550 MG TAB 50071347_1 CDM 0250 RC 68462-0179-01 NDC inpatient 2 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges NAPROXEN SODIUM 550 MG TAB 50071347_1 CDM 0250 RC 68462-0179-01 NDC inpatient 2 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges NAPROXEN SODIUM 550 MG TAB 50071347_1 CDM 0250 RC 68462-0179-01 NDC inpatient 2 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges NAPROXEN SODIUM 550 MG TAB 50071347_1 CDM 0250 RC 68462-0179-01 NDC inpatient 2 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 NAPROXEN SODIUM 550 MG TAB 50071347_1 CDM 0250 RC 68462-0179-01 NDC inpatient 2 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 NAPROXEN SODIUM 550 MG TAB 50071347_1 CDM 0250 RC 68462-0179-01 NDC inpatient 2 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 NAPROXEN SODIUM 550 MG TAB 50071347_1 CDM 0250 RC 68462-0179-01 NDC inpatient 2 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges NAPROXEN SODIUM 550 MG TAB 50071347_1 CDM 0250 RC 68462-0179-01 NDC inpatient 2 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 NAPROXEN SODIUM 550 MG TAB 50071347_1 CDM 0250 RC 68462-0179-01 NDC inpatient 2 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "LIDOCAINE 2%-EPI 1:200,000" 50071774_1 CDM 0250 RC 00409-3183-01 NDC inpatient 1 UN 31.54 20.5 AETNA AETNA 24.92 79 999999999 19.1 30.59 percent of total billed charges "LIDOCAINE 2%-EPI 1:200,000" 50071774_1 CDM 0250 RC 00409-3183-01 NDC inpatient 1 UN 31.54 20.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.5 65 999999999 19.1 30.59 percent of total billed charges "LIDOCAINE 2%-EPI 1:200,000" 50071774_1 CDM 0250 RC 00409-3183-01 NDC inpatient 1 UN 31.54 20.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.59 97 999999999 19.1 30.59 percent of total billed charges "LIDOCAINE 2%-EPI 1:200,000" 50071774_1 CDM 0250 RC 00409-3183-01 NDC inpatient 1 UN 31.54 20.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.76 69 999999999 19.1 30.59 percent of total billed charges "LIDOCAINE 2%-EPI 1:200,000" 50071774_1 CDM 0250 RC 00409-3183-01 NDC inpatient 1 UN 31.54 20.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.6 78 999999999 19.1 30.59 percent of total billed charges "LIDOCAINE 2%-EPI 1:200,000" 50071774_1 CDM 0250 RC 00409-3183-01 NDC inpatient 1 UN 31.54 20.5 UMR - ALL PLANS UMR - ALL PLANS 22.08 70 999999999 19.1 30.59 percent of total billed charges "LIDOCAINE 2%-EPI 1:200,000" 50071774_1 CDM 0250 RC 00409-3183-01 NDC inpatient 1 UN 31.54 20.5 SIHO - ALL PLANS SIHO - ALL PLANS 28.39 90 999999999 19.1 30.59 percent of total billed charges "LIDOCAINE 2%-EPI 1:200,000" 50071774_1 CDM 0250 RC 00409-3183-01 NDC inpatient 1 UN 31.54 20.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.1 60.55 999999999 19.1 30.59 percent of total billed charges "LIDOCAINE 2%-EPI 1:200,000" 50071774_1 CDM 0250 RC 00409-3183-01 NDC inpatient 1 UN 31.54 20.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.1 30.59 "LIDOCAINE 2%-EPI 1:200,000" 50071774_1 CDM 0250 RC 00409-3183-01 NDC inpatient 1 UN 31.54 20.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.1 30.59 "LIDOCAINE 2%-EPI 1:200,000" 50071774_1 CDM 0250 RC 00409-3183-01 NDC inpatient 1 UN 31.54 20.5 ANTHEM HMO ANTHEM HMO 999999999 19.1 30.59 "LIDOCAINE 2%-EPI 1:200,000" 50071774_1 CDM 0250 RC 00409-3183-01 NDC inpatient 1 UN 31.54 20.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.32 67.6 999999999 19.1 30.59 percent of total billed charges "LIDOCAINE 2%-EPI 1:200,000" 50071774_1 CDM 0250 RC 00409-3183-01 NDC inpatient 1 UN 31.54 20.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.1 30.59 "LIDOCAINE 2%-EPI 1:200,000" 50071774_1 CDM 0250 RC 00409-3183-01 NDC inpatient 1 UN 31.54 20.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.1 30.59 NALOXONE 0.4 MG/ML VIAL 50071779_1 CDM 0250 RC 67457-0292-02 NDC inpatient 1 UN 38.56 25.06 AETNA AETNA 30.46 79 999999999 23.35 37.4 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 50071779_1 CDM 0250 RC 67457-0292-02 NDC inpatient 1 UN 38.56 25.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 25.06 65 999999999 23.35 37.4 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 50071779_1 CDM 0250 RC 67457-0292-02 NDC inpatient 1 UN 38.56 25.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37.4 97 999999999 23.35 37.4 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 50071779_1 CDM 0250 RC 67457-0292-02 NDC inpatient 1 UN 38.56 25.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.61 69 999999999 23.35 37.4 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 50071779_1 CDM 0250 RC 67457-0292-02 NDC inpatient 1 UN 38.56 25.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 30.08 78 999999999 23.35 37.4 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 50071779_1 CDM 0250 RC 67457-0292-02 NDC inpatient 1 UN 38.56 25.06 UMR - ALL PLANS UMR - ALL PLANS 26.99 70 999999999 23.35 37.4 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 50071779_1 CDM 0250 RC 67457-0292-02 NDC inpatient 1 UN 38.56 25.06 SIHO - ALL PLANS SIHO - ALL PLANS 34.7 90 999999999 23.35 37.4 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 50071779_1 CDM 0250 RC 67457-0292-02 NDC inpatient 1 UN 38.56 25.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.35 60.55 999999999 23.35 37.4 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 50071779_1 CDM 0250 RC 67457-0292-02 NDC inpatient 1 UN 38.56 25.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.35 37.4 NALOXONE 0.4 MG/ML VIAL 50071779_1 CDM 0250 RC 67457-0292-02 NDC inpatient 1 UN 38.56 25.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.35 37.4 NALOXONE 0.4 MG/ML VIAL 50071779_1 CDM 0250 RC 67457-0292-02 NDC inpatient 1 UN 38.56 25.06 ANTHEM HMO ANTHEM HMO 999999999 23.35 37.4 NALOXONE 0.4 MG/ML VIAL 50071779_1 CDM 0250 RC 67457-0292-02 NDC inpatient 1 UN 38.56 25.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 26.07 67.6 999999999 23.35 37.4 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 50071779_1 CDM 0250 RC 67457-0292-02 NDC inpatient 1 UN 38.56 25.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.35 37.4 NALOXONE 0.4 MG/ML VIAL 50071779_1 CDM 0250 RC 67457-0292-02 NDC inpatient 1 UN 38.56 25.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.35 37.4 Insertion of heart rhythm monitor under skin 50072070_1 CDM 0361 RC 33285 HCPCS inpatient 20250 13162.5 AETNA AETNA 15997.5 79 999999999 12261.38 19642.5 percent of total billed charges Insertion of heart rhythm monitor under skin 50072070_1 CDM 0361 RC 33285 HCPCS inpatient 20250 13162.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 13162.5 65 999999999 12261.38 19642.5 percent of total billed charges Insertion of heart rhythm monitor under skin 50072070_1 CDM 0361 RC 33285 HCPCS inpatient 20250 13162.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19642.5 97 999999999 12261.38 19642.5 percent of total billed charges Insertion of heart rhythm monitor under skin 50072070_1 CDM 0361 RC 33285 HCPCS inpatient 20250 13162.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 13972.5 69 999999999 12261.38 19642.5 percent of total billed charges Insertion of heart rhythm monitor under skin 50072070_1 CDM 0361 RC 33285 HCPCS inpatient 20250 13162.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 15795 78 999999999 12261.38 19642.5 percent of total billed charges Insertion of heart rhythm monitor under skin 50072070_1 CDM 0361 RC 33285 HCPCS inpatient 20250 13162.5 UMR - ALL PLANS UMR - ALL PLANS 14175 70 999999999 12261.38 19642.5 percent of total billed charges Insertion of heart rhythm monitor under skin 50072070_1 CDM 0361 RC 33285 HCPCS inpatient 20250 13162.5 SIHO - ALL PLANS SIHO - ALL PLANS 18225 90 999999999 12261.38 19642.5 percent of total billed charges Insertion of heart rhythm monitor under skin 50072070_1 CDM 0361 RC 33285 HCPCS inpatient 20250 13162.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12261.38 60.55 999999999 12261.38 19642.5 percent of total billed charges Insertion of heart rhythm monitor under skin 50072070_1 CDM 0361 RC 33285 HCPCS inpatient 20250 13162.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12261.38 19642.5 Insertion of heart rhythm monitor under skin 50072070_1 CDM 0361 RC 33285 HCPCS inpatient 20250 13162.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12261.38 19642.5 Insertion of heart rhythm monitor under skin 50072070_1 CDM 0361 RC 33285 HCPCS inpatient 20250 13162.5 ANTHEM HMO ANTHEM HMO 999999999 12261.38 19642.5 Insertion of heart rhythm monitor under skin 50072070_1 CDM 0361 RC 33285 HCPCS inpatient 20250 13162.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 13689 67.6 999999999 12261.38 19642.5 percent of total billed charges Insertion of heart rhythm monitor under skin 50072070_1 CDM 0361 RC 33285 HCPCS inpatient 20250 13162.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12261.38 19642.5 Insertion of heart rhythm monitor under skin 50072070_1 CDM 0361 RC 33285 HCPCS inpatient 20250 13162.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 12261.38 19642.5 Removal of heart rhythm monitor from under the skin 50072071_1 CDM 0361 RC 33286 HCPCS inpatient 1585 1030.25 AETNA AETNA 1252.15 79 999999999 959.72 1537.45 percent of total billed charges Removal of heart rhythm monitor from under the skin 50072071_1 CDM 0361 RC 33286 HCPCS inpatient 1585 1030.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1030.25 65 999999999 959.72 1537.45 percent of total billed charges Removal of heart rhythm monitor from under the skin 50072071_1 CDM 0361 RC 33286 HCPCS inpatient 1585 1030.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1537.45 97 999999999 959.72 1537.45 percent of total billed charges Removal of heart rhythm monitor from under the skin 50072071_1 CDM 0361 RC 33286 HCPCS inpatient 1585 1030.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1093.65 69 999999999 959.72 1537.45 percent of total billed charges Removal of heart rhythm monitor from under the skin 50072071_1 CDM 0361 RC 33286 HCPCS inpatient 1585 1030.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1236.3 78 999999999 959.72 1537.45 percent of total billed charges Removal of heart rhythm monitor from under the skin 50072071_1 CDM 0361 RC 33286 HCPCS inpatient 1585 1030.25 UMR - ALL PLANS UMR - ALL PLANS 1109.5 70 999999999 959.72 1537.45 percent of total billed charges Removal of heart rhythm monitor from under the skin 50072071_1 CDM 0361 RC 33286 HCPCS inpatient 1585 1030.25 SIHO - ALL PLANS SIHO - ALL PLANS 1426.5 90 999999999 959.72 1537.45 percent of total billed charges Removal of heart rhythm monitor from under the skin 50072071_1 CDM 0361 RC 33286 HCPCS inpatient 1585 1030.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 959.72 60.55 999999999 959.72 1537.45 percent of total billed charges Removal of heart rhythm monitor from under the skin 50072071_1 CDM 0361 RC 33286 HCPCS inpatient 1585 1030.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 959.72 1537.45 Removal of heart rhythm monitor from under the skin 50072071_1 CDM 0361 RC 33286 HCPCS inpatient 1585 1030.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 959.72 1537.45 Removal of heart rhythm monitor from under the skin 50072071_1 CDM 0361 RC 33286 HCPCS inpatient 1585 1030.25 ANTHEM HMO ANTHEM HMO 999999999 959.72 1537.45 Removal of heart rhythm monitor from under the skin 50072071_1 CDM 0361 RC 33286 HCPCS inpatient 1585 1030.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1071.46 67.6 999999999 959.72 1537.45 percent of total billed charges Removal of heart rhythm monitor from under the skin 50072071_1 CDM 0361 RC 33286 HCPCS inpatient 1585 1030.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 959.72 1537.45 Removal of heart rhythm monitor from under the skin 50072071_1 CDM 0361 RC 33286 HCPCS inpatient 1585 1030.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 959.72 1537.45 Programming of cardiac rhythm monitor system 50072072_1 CDM 0361 RC 93285 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges Programming of cardiac rhythm monitor system 50072072_1 CDM 0361 RC 93285 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges Programming of cardiac rhythm monitor system 50072072_1 CDM 0361 RC 93285 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges Programming of cardiac rhythm monitor system 50072072_1 CDM 0361 RC 93285 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges Programming of cardiac rhythm monitor system 50072072_1 CDM 0361 RC 93285 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges Programming of cardiac rhythm monitor system 50072072_1 CDM 0361 RC 93285 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges Programming of cardiac rhythm monitor system 50072072_1 CDM 0361 RC 93285 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges Programming of cardiac rhythm monitor system 50072072_1 CDM 0361 RC 93285 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges Programming of cardiac rhythm monitor system 50072072_1 CDM 0361 RC 93285 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 Programming of cardiac rhythm monitor system 50072072_1 CDM 0361 RC 93285 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 Programming of cardiac rhythm monitor system 50072072_1 CDM 0361 RC 93285 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 Programming of cardiac rhythm monitor system 50072072_1 CDM 0361 RC 93285 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges Programming of cardiac rhythm monitor system 50072072_1 CDM 0361 RC 93285 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 Programming of cardiac rhythm monitor system 50072072_1 CDM 0361 RC 93285 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 Evaluation of cardiac rhythm monitor system 50072073_1 CDM 0361 RC 93291 HCPCS inpatient 48 31.2 AETNA AETNA 37.92 79 999999999 29.06 46.56 percent of total billed charges Evaluation of cardiac rhythm monitor system 50072073_1 CDM 0361 RC 93291 HCPCS inpatient 48 31.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.2 65 999999999 29.06 46.56 percent of total billed charges Evaluation of cardiac rhythm monitor system 50072073_1 CDM 0361 RC 93291 HCPCS inpatient 48 31.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 46.56 97 999999999 29.06 46.56 percent of total billed charges Evaluation of cardiac rhythm monitor system 50072073_1 CDM 0361 RC 93291 HCPCS inpatient 48 31.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.12 69 999999999 29.06 46.56 percent of total billed charges Evaluation of cardiac rhythm monitor system 50072073_1 CDM 0361 RC 93291 HCPCS inpatient 48 31.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 37.44 78 999999999 29.06 46.56 percent of total billed charges Evaluation of cardiac rhythm monitor system 50072073_1 CDM 0361 RC 93291 HCPCS inpatient 48 31.2 UMR - ALL PLANS UMR - ALL PLANS 33.6 70 999999999 29.06 46.56 percent of total billed charges Evaluation of cardiac rhythm monitor system 50072073_1 CDM 0361 RC 93291 HCPCS inpatient 48 31.2 SIHO - ALL PLANS SIHO - ALL PLANS 43.2 90 999999999 29.06 46.56 percent of total billed charges Evaluation of cardiac rhythm monitor system 50072073_1 CDM 0361 RC 93291 HCPCS inpatient 48 31.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.06 60.55 999999999 29.06 46.56 percent of total billed charges Evaluation of cardiac rhythm monitor system 50072073_1 CDM 0361 RC 93291 HCPCS inpatient 48 31.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.06 46.56 Evaluation of cardiac rhythm monitor system 50072073_1 CDM 0361 RC 93291 HCPCS inpatient 48 31.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.06 46.56 Evaluation of cardiac rhythm monitor system 50072073_1 CDM 0361 RC 93291 HCPCS inpatient 48 31.2 ANTHEM HMO ANTHEM HMO 999999999 29.06 46.56 Evaluation of cardiac rhythm monitor system 50072073_1 CDM 0361 RC 93291 HCPCS inpatient 48 31.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 32.45 67.6 999999999 29.06 46.56 percent of total billed charges Evaluation of cardiac rhythm monitor system 50072073_1 CDM 0361 RC 93291 HCPCS inpatient 48 31.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.06 46.56 Evaluation of cardiac rhythm monitor system 50072073_1 CDM 0361 RC 93291 HCPCS inpatient 48 31.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.06 46.56 "INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR PHYSIOLOGIC MONITOR SYSTEM OR SUBCUTANEOUS CARDIAC RHYTHM MONITOR SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORT AND DISTRIBUTION OF RESULTS" 50072074_1 CDM 0361 RC 93299 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges "INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR PHYSIOLOGIC MONITOR SYSTEM OR SUBCUTANEOUS CARDIAC RHYTHM MONITOR SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORT AND DISTRIBUTION OF RESULTS" 50072074_1 CDM 0361 RC 93299 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges "INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR PHYSIOLOGIC MONITOR SYSTEM OR SUBCUTANEOUS CARDIAC RHYTHM MONITOR SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORT AND DISTRIBUTION OF RESULTS" 50072074_1 CDM 0361 RC 93299 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges "INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR PHYSIOLOGIC MONITOR SYSTEM OR SUBCUTANEOUS CARDIAC RHYTHM MONITOR SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORT AND DISTRIBUTION OF RESULTS" 50072074_1 CDM 0361 RC 93299 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges "INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR PHYSIOLOGIC MONITOR SYSTEM OR SUBCUTANEOUS CARDIAC RHYTHM MONITOR SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORT AND DISTRIBUTION OF RESULTS" 50072074_1 CDM 0361 RC 93299 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges "INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR PHYSIOLOGIC MONITOR SYSTEM OR SUBCUTANEOUS CARDIAC RHYTHM MONITOR SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORT AND DISTRIBUTION OF RESULTS" 50072074_1 CDM 0361 RC 93299 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges "INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR PHYSIOLOGIC MONITOR SYSTEM OR SUBCUTANEOUS CARDIAC RHYTHM MONITOR SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORT AND DISTRIBUTION OF RESULTS" 50072074_1 CDM 0361 RC 93299 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges "INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR PHYSIOLOGIC MONITOR SYSTEM OR SUBCUTANEOUS CARDIAC RHYTHM MONITOR SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORT AND DISTRIBUTION OF RESULTS" 50072074_1 CDM 0361 RC 93299 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges "INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR PHYSIOLOGIC MONITOR SYSTEM OR SUBCUTANEOUS CARDIAC RHYTHM MONITOR SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORT AND DISTRIBUTION OF RESULTS" 50072074_1 CDM 0361 RC 93299 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 "INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR PHYSIOLOGIC MONITOR SYSTEM OR SUBCUTANEOUS CARDIAC RHYTHM MONITOR SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORT AND DISTRIBUTION OF RESULTS" 50072074_1 CDM 0361 RC 93299 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 "INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR PHYSIOLOGIC MONITOR SYSTEM OR SUBCUTANEOUS CARDIAC RHYTHM MONITOR SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORT AND DISTRIBUTION OF RESULTS" 50072074_1 CDM 0361 RC 93299 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 "INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR PHYSIOLOGIC MONITOR SYSTEM OR SUBCUTANEOUS CARDIAC RHYTHM MONITOR SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORT AND DISTRIBUTION OF RESULTS" 50072074_1 CDM 0361 RC 93299 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges "INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR PHYSIOLOGIC MONITOR SYSTEM OR SUBCUTANEOUS CARDIAC RHYTHM MONITOR SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORT AND DISTRIBUTION OF RESULTS" 50072074_1 CDM 0361 RC 93299 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 "INTERROGATION DEVICE EVALUATION(S), (REMOTE) UP TO 30 DAYS; IMPLANTABLE CARDIOVASCULAR PHYSIOLOGIC MONITOR SYSTEM OR SUBCUTANEOUS CARDIAC RHYTHM MONITOR SYSTEM, REMOTE DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AND TECHNICIAN REVIEW, TECHNICAL SUPPORT AND DISTRIBUTION OF RESULTS" 50072074_1 CDM 0361 RC 93299 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 "DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF LESS THAN 50 ML PER HOUR" 50072102_1 CDM 0272 RC A4306 HCPCS inpatient 5590 3633.5 AETNA AETNA 4416.1 79 999999999 3384.75 5422.3 percent of total billed charges "DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF LESS THAN 50 ML PER HOUR" 50072102_1 CDM 0272 RC A4306 HCPCS inpatient 5590 3633.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 3633.5 65 999999999 3384.75 5422.3 percent of total billed charges "DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF LESS THAN 50 ML PER HOUR" 50072102_1 CDM 0272 RC A4306 HCPCS inpatient 5590 3633.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5422.3 97 999999999 3384.75 5422.3 percent of total billed charges "DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF LESS THAN 50 ML PER HOUR" 50072102_1 CDM 0272 RC A4306 HCPCS inpatient 5590 3633.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 3857.1 69 999999999 3384.75 5422.3 percent of total billed charges "DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF LESS THAN 50 ML PER HOUR" 50072102_1 CDM 0272 RC A4306 HCPCS inpatient 5590 3633.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 4360.2 78 999999999 3384.75 5422.3 percent of total billed charges "DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF LESS THAN 50 ML PER HOUR" 50072102_1 CDM 0272 RC A4306 HCPCS inpatient 5590 3633.5 UMR - ALL PLANS UMR - ALL PLANS 3913 70 999999999 3384.75 5422.3 percent of total billed charges "DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF LESS THAN 50 ML PER HOUR" 50072102_1 CDM 0272 RC A4306 HCPCS inpatient 5590 3633.5 SIHO - ALL PLANS SIHO - ALL PLANS 5031 90 999999999 3384.75 5422.3 percent of total billed charges "DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF LESS THAN 50 ML PER HOUR" 50072102_1 CDM 0272 RC A4306 HCPCS inpatient 5590 3633.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3384.75 60.55 999999999 3384.75 5422.3 percent of total billed charges "DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF LESS THAN 50 ML PER HOUR" 50072102_1 CDM 0272 RC A4306 HCPCS inpatient 5590 3633.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3384.75 5422.3 "DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF LESS THAN 50 ML PER HOUR" 50072102_1 CDM 0272 RC A4306 HCPCS inpatient 5590 3633.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3384.75 5422.3 "DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF LESS THAN 50 ML PER HOUR" 50072102_1 CDM 0272 RC A4306 HCPCS inpatient 5590 3633.5 ANTHEM HMO ANTHEM HMO 999999999 3384.75 5422.3 "DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF LESS THAN 50 ML PER HOUR" 50072102_1 CDM 0272 RC A4306 HCPCS inpatient 5590 3633.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 3778.84 67.6 999999999 3384.75 5422.3 percent of total billed charges "DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF LESS THAN 50 ML PER HOUR" 50072102_1 CDM 0272 RC A4306 HCPCS inpatient 5590 3633.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3384.75 5422.3 "DISPOSABLE DRUG DELIVERY SYSTEM, FLOW RATE OF LESS THAN 50 ML PER HOUR" 50072102_1 CDM 0272 RC A4306 HCPCS inpatient 5590 3633.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 3384.75 5422.3 TRACH TUBE PED CUFFLESS 3.5PED 50076033_1 CDM 0272 RC inpatient 170 110.5 AETNA AETNA 134.3 79 999999999 102.94 164.9 percent of total billed charges TRACH TUBE PED CUFFLESS 3.5PED 50076033_1 CDM 0272 RC inpatient 170 110.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.5 65 999999999 102.94 164.9 percent of total billed charges TRACH TUBE PED CUFFLESS 3.5PED 50076033_1 CDM 0272 RC inpatient 170 110.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.9 97 999999999 102.94 164.9 percent of total billed charges TRACH TUBE PED CUFFLESS 3.5PED 50076033_1 CDM 0272 RC inpatient 170 110.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.3 69 999999999 102.94 164.9 percent of total billed charges TRACH TUBE PED CUFFLESS 3.5PED 50076033_1 CDM 0272 RC inpatient 170 110.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.6 78 999999999 102.94 164.9 percent of total billed charges TRACH TUBE PED CUFFLESS 3.5PED 50076033_1 CDM 0272 RC inpatient 170 110.5 UMR - ALL PLANS UMR - ALL PLANS 119 70 999999999 102.94 164.9 percent of total billed charges TRACH TUBE PED CUFFLESS 3.5PED 50076033_1 CDM 0272 RC inpatient 170 110.5 SIHO - ALL PLANS SIHO - ALL PLANS 153 90 999999999 102.94 164.9 percent of total billed charges TRACH TUBE PED CUFFLESS 3.5PED 50076033_1 CDM 0272 RC inpatient 170 110.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.94 60.55 999999999 102.94 164.9 percent of total billed charges TRACH TUBE PED CUFFLESS 3.5PED 50076033_1 CDM 0272 RC inpatient 170 110.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.94 164.9 TRACH TUBE PED CUFFLESS 3.5PED 50076033_1 CDM 0272 RC inpatient 170 110.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.94 164.9 TRACH TUBE PED CUFFLESS 3.5PED 50076033_1 CDM 0272 RC inpatient 170 110.5 ANTHEM HMO ANTHEM HMO 999999999 102.94 164.9 TRACH TUBE PED CUFFLESS 3.5PED 50076033_1 CDM 0272 RC inpatient 170 110.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.92 67.6 999999999 102.94 164.9 percent of total billed charges TRACH TUBE PED CUFFLESS 3.5PED 50076033_1 CDM 0272 RC inpatient 170 110.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.94 164.9 TRACH TUBE PED CUFFLESS 3.5PED 50076033_1 CDM 0272 RC inpatient 170 110.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.94 164.9 TUBE TRACH PEDIATRIC SIZE 4 CUFFED SHILEY 4.0PCF 50076034_1 CDM 0272 RC inpatient 234 152.1 AETNA AETNA 184.86 79 999999999 141.69 226.98 percent of total billed charges TUBE TRACH PEDIATRIC SIZE 4 CUFFED SHILEY 4.0PCF 50076034_1 CDM 0272 RC inpatient 234 152.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 152.1 65 999999999 141.69 226.98 percent of total billed charges TUBE TRACH PEDIATRIC SIZE 4 CUFFED SHILEY 4.0PCF 50076034_1 CDM 0272 RC inpatient 234 152.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 226.98 97 999999999 141.69 226.98 percent of total billed charges TUBE TRACH PEDIATRIC SIZE 4 CUFFED SHILEY 4.0PCF 50076034_1 CDM 0272 RC inpatient 234 152.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 161.46 69 999999999 141.69 226.98 percent of total billed charges TUBE TRACH PEDIATRIC SIZE 4 CUFFED SHILEY 4.0PCF 50076034_1 CDM 0272 RC inpatient 234 152.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 182.52 78 999999999 141.69 226.98 percent of total billed charges TUBE TRACH PEDIATRIC SIZE 4 CUFFED SHILEY 4.0PCF 50076034_1 CDM 0272 RC inpatient 234 152.1 UMR - ALL PLANS UMR - ALL PLANS 163.8 70 999999999 141.69 226.98 percent of total billed charges TUBE TRACH PEDIATRIC SIZE 4 CUFFED SHILEY 4.0PCF 50076034_1 CDM 0272 RC inpatient 234 152.1 SIHO - ALL PLANS SIHO - ALL PLANS 210.6 90 999999999 141.69 226.98 percent of total billed charges TUBE TRACH PEDIATRIC SIZE 4 CUFFED SHILEY 4.0PCF 50076034_1 CDM 0272 RC inpatient 234 152.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 141.69 60.55 999999999 141.69 226.98 percent of total billed charges TUBE TRACH PEDIATRIC SIZE 4 CUFFED SHILEY 4.0PCF 50076034_1 CDM 0272 RC inpatient 234 152.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 141.69 226.98 TUBE TRACH PEDIATRIC SIZE 4 CUFFED SHILEY 4.0PCF 50076034_1 CDM 0272 RC inpatient 234 152.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 141.69 226.98 TUBE TRACH PEDIATRIC SIZE 4 CUFFED SHILEY 4.0PCF 50076034_1 CDM 0272 RC inpatient 234 152.1 ANTHEM HMO ANTHEM HMO 999999999 141.69 226.98 TUBE TRACH PEDIATRIC SIZE 4 CUFFED SHILEY 4.0PCF 50076034_1 CDM 0272 RC inpatient 234 152.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 158.18 67.6 999999999 141.69 226.98 percent of total billed charges TUBE TRACH PEDIATRIC SIZE 4 CUFFED SHILEY 4.0PCF 50076034_1 CDM 0272 RC inpatient 234 152.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 141.69 226.98 TUBE TRACH PEDIATRIC SIZE 4 CUFFED SHILEY 4.0PCF 50076034_1 CDM 0272 RC inpatient 234 152.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 141.69 226.98 CANNULA DILATOR STERILE 15mm W/RADIALLY EXPANDABLE SLEEVE VERSA STEP PLUS VS101015P 50076103_1 CDM 0272 RC inpatient 525 341.25 AETNA AETNA 414.75 79 999999999 317.89 509.25 percent of total billed charges CANNULA DILATOR STERILE 15mm W/RADIALLY EXPANDABLE SLEEVE VERSA STEP PLUS VS101015P 50076103_1 CDM 0272 RC inpatient 525 341.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 341.25 65 999999999 317.89 509.25 percent of total billed charges CANNULA DILATOR STERILE 15mm W/RADIALLY EXPANDABLE SLEEVE VERSA STEP PLUS VS101015P 50076103_1 CDM 0272 RC inpatient 525 341.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 509.25 97 999999999 317.89 509.25 percent of total billed charges CANNULA DILATOR STERILE 15mm W/RADIALLY EXPANDABLE SLEEVE VERSA STEP PLUS VS101015P 50076103_1 CDM 0272 RC inpatient 525 341.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 362.25 69 999999999 317.89 509.25 percent of total billed charges CANNULA DILATOR STERILE 15mm W/RADIALLY EXPANDABLE SLEEVE VERSA STEP PLUS VS101015P 50076103_1 CDM 0272 RC inpatient 525 341.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 409.5 78 999999999 317.89 509.25 percent of total billed charges CANNULA DILATOR STERILE 15mm W/RADIALLY EXPANDABLE SLEEVE VERSA STEP PLUS VS101015P 50076103_1 CDM 0272 RC inpatient 525 341.25 UMR - ALL PLANS UMR - ALL PLANS 367.5 70 999999999 317.89 509.25 percent of total billed charges CANNULA DILATOR STERILE 15mm W/RADIALLY EXPANDABLE SLEEVE VERSA STEP PLUS VS101015P 50076103_1 CDM 0272 RC inpatient 525 341.25 SIHO - ALL PLANS SIHO - ALL PLANS 472.5 90 999999999 317.89 509.25 percent of total billed charges CANNULA DILATOR STERILE 15mm W/RADIALLY EXPANDABLE SLEEVE VERSA STEP PLUS VS101015P 50076103_1 CDM 0272 RC inpatient 525 341.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 317.89 60.55 999999999 317.89 509.25 percent of total billed charges CANNULA DILATOR STERILE 15mm W/RADIALLY EXPANDABLE SLEEVE VERSA STEP PLUS VS101015P 50076103_1 CDM 0272 RC inpatient 525 341.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 317.89 509.25 CANNULA DILATOR STERILE 15mm W/RADIALLY EXPANDABLE SLEEVE VERSA STEP PLUS VS101015P 50076103_1 CDM 0272 RC inpatient 525 341.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 317.89 509.25 CANNULA DILATOR STERILE 15mm W/RADIALLY EXPANDABLE SLEEVE VERSA STEP PLUS VS101015P 50076103_1 CDM 0272 RC inpatient 525 341.25 ANTHEM HMO ANTHEM HMO 999999999 317.89 509.25 CANNULA DILATOR STERILE 15mm W/RADIALLY EXPANDABLE SLEEVE VERSA STEP PLUS VS101015P 50076103_1 CDM 0272 RC inpatient 525 341.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 354.9 67.6 999999999 317.89 509.25 percent of total billed charges CANNULA DILATOR STERILE 15mm W/RADIALLY EXPANDABLE SLEEVE VERSA STEP PLUS VS101015P 50076103_1 CDM 0272 RC inpatient 525 341.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 317.89 509.25 CANNULA DILATOR STERILE 15mm W/RADIALLY EXPANDABLE SLEEVE VERSA STEP PLUS VS101015P 50076103_1 CDM 0272 RC inpatient 525 341.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 317.89 509.25 ESG PLASMA LOOP LARGE WA22703S 50076957_1 CDM 0272 RC inpatient 3378 2195.7 AETNA AETNA 2668.62 79 999999999 2045.38 3276.66 percent of total billed charges ESG PLASMA LOOP LARGE WA22703S 50076957_1 CDM 0272 RC inpatient 3378 2195.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 2195.7 65 999999999 2045.38 3276.66 percent of total billed charges ESG PLASMA LOOP LARGE WA22703S 50076957_1 CDM 0272 RC inpatient 3378 2195.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3276.66 97 999999999 2045.38 3276.66 percent of total billed charges ESG PLASMA LOOP LARGE WA22703S 50076957_1 CDM 0272 RC inpatient 3378 2195.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 2330.82 69 999999999 2045.38 3276.66 percent of total billed charges ESG PLASMA LOOP LARGE WA22703S 50076957_1 CDM 0272 RC inpatient 3378 2195.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 2634.84 78 999999999 2045.38 3276.66 percent of total billed charges ESG PLASMA LOOP LARGE WA22703S 50076957_1 CDM 0272 RC inpatient 3378 2195.7 UMR - ALL PLANS UMR - ALL PLANS 2364.6 70 999999999 2045.38 3276.66 percent of total billed charges ESG PLASMA LOOP LARGE WA22703S 50076957_1 CDM 0272 RC inpatient 3378 2195.7 SIHO - ALL PLANS SIHO - ALL PLANS 3040.2 90 999999999 2045.38 3276.66 percent of total billed charges ESG PLASMA LOOP LARGE WA22703S 50076957_1 CDM 0272 RC inpatient 3378 2195.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2045.38 60.55 999999999 2045.38 3276.66 percent of total billed charges ESG PLASMA LOOP LARGE WA22703S 50076957_1 CDM 0272 RC inpatient 3378 2195.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2045.38 3276.66 ESG PLASMA LOOP LARGE WA22703S 50076957_1 CDM 0272 RC inpatient 3378 2195.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2045.38 3276.66 ESG PLASMA LOOP LARGE WA22703S 50076957_1 CDM 0272 RC inpatient 3378 2195.7 ANTHEM HMO ANTHEM HMO 999999999 2045.38 3276.66 ESG PLASMA LOOP LARGE WA22703S 50076957_1 CDM 0272 RC inpatient 3378 2195.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 2283.53 67.6 999999999 2045.38 3276.66 percent of total billed charges ESG PLASMA LOOP LARGE WA22703S 50076957_1 CDM 0272 RC inpatient 3378 2195.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2045.38 3276.66 ESG PLASMA LOOP LARGE WA22703S 50076957_1 CDM 0272 RC inpatient 3378 2195.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 2045.38 3276.66 DRAPE BRACHIAL 50077205_1 CDM 0272 RC inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges DRAPE BRACHIAL 50077205_1 CDM 0272 RC inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges DRAPE BRACHIAL 50077205_1 CDM 0272 RC inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges DRAPE BRACHIAL 50077205_1 CDM 0272 RC inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges DRAPE BRACHIAL 50077205_1 CDM 0272 RC inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges DRAPE BRACHIAL 50077205_1 CDM 0272 RC inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges DRAPE BRACHIAL 50077205_1 CDM 0272 RC inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges DRAPE BRACHIAL 50077205_1 CDM 0272 RC inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges DRAPE BRACHIAL 50077205_1 CDM 0272 RC inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 DRAPE BRACHIAL 50077205_1 CDM 0272 RC inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 DRAPE BRACHIAL 50077205_1 CDM 0272 RC inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 DRAPE BRACHIAL 50077205_1 CDM 0272 RC inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges DRAPE BRACHIAL 50077205_1 CDM 0272 RC inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 DRAPE BRACHIAL 50077205_1 CDM 0272 RC inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 CEFDINIR 300 MG CAPSULE 50077268_1 CDM 0250 RC 68001-0362-06 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CEFDINIR 300 MG CAPSULE 50077268_1 CDM 0250 RC 68001-0362-06 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CEFDINIR 300 MG CAPSULE 50077268_1 CDM 0250 RC 68001-0362-06 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CEFDINIR 300 MG CAPSULE 50077268_1 CDM 0250 RC 68001-0362-06 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CEFDINIR 300 MG CAPSULE 50077268_1 CDM 0250 RC 68001-0362-06 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CEFDINIR 300 MG CAPSULE 50077268_1 CDM 0250 RC 68001-0362-06 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CEFDINIR 300 MG CAPSULE 50077268_1 CDM 0250 RC 68001-0362-06 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CEFDINIR 300 MG CAPSULE 50077268_1 CDM 0250 RC 68001-0362-06 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CEFDINIR 300 MG CAPSULE 50077268_1 CDM 0250 RC 68001-0362-06 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CEFDINIR 300 MG CAPSULE 50077268_1 CDM 0250 RC 68001-0362-06 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CEFDINIR 300 MG CAPSULE 50077268_1 CDM 0250 RC 68001-0362-06 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CEFDINIR 300 MG CAPSULE 50077268_1 CDM 0250 RC 68001-0362-06 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CEFDINIR 300 MG CAPSULE 50077268_1 CDM 0250 RC 68001-0362-06 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CEFDINIR 300 MG CAPSULE 50077268_1 CDM 0250 RC 68001-0362-06 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50079289_1 CDM 0250 RC 63323-0593-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 AETNA AETNA 459.91 79 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50079289_1 CDM 0250 RC 63323-0593-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 SELF PAY DISCOUNT SELF PAY DISCOUNT 378.41 65 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50079289_1 CDM 0250 RC 63323-0593-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 564.7 97 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50079289_1 CDM 0250 RC 63323-0593-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 ENCORE - ALL PLANS ENCORE - ALL PLANS 401.7 69 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50079289_1 CDM 0250 RC 63323-0593-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 HUMANA - ALL PLANS HUMANA - ALL PLANS 454.09 78 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50079289_1 CDM 0250 RC 63323-0593-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 UMR - ALL PLANS UMR - ALL PLANS 407.52 70 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50079289_1 CDM 0250 RC 63323-0593-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 SIHO - ALL PLANS SIHO - ALL PLANS 523.95 90 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50079289_1 CDM 0250 RC 63323-0593-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 352.5 60.55 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50079289_1 CDM 0250 RC 63323-0593-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 352.5 564.7 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50079289_1 CDM 0250 RC 63323-0593-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 352.5 564.7 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50079289_1 CDM 0250 RC 63323-0593-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 ANTHEM HMO ANTHEM HMO 999999999 352.5 564.7 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50079289_1 CDM 0250 RC 63323-0593-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 CIGNA - ALL PLANS CIGNA - ALL PLANS 393.55 67.6 999999999 352.5 564.7 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50079289_1 CDM 0250 RC 63323-0593-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 352.5 564.7 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50079289_1 CDM 0250 RC 63323-0593-03 NDC J1610 HCPCS inpatient 1 UN 582.17 378.41 UHC - ALL PLANS UHC - ALL PLANS 999999999 352.5 564.7 OCTREOTIDE ACET 100 MCG/ML VL 50079816_1 CDM 0250 RC 63323-0376-01 NDC inpatient 1 UN 24.15 15.7 AETNA AETNA 19.08 79 999999999 14.62 23.43 percent of total billed charges OCTREOTIDE ACET 100 MCG/ML VL 50079816_1 CDM 0250 RC 63323-0376-01 NDC inpatient 1 UN 24.15 15.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 15.7 65 999999999 14.62 23.43 percent of total billed charges OCTREOTIDE ACET 100 MCG/ML VL 50079816_1 CDM 0250 RC 63323-0376-01 NDC inpatient 1 UN 24.15 15.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23.43 97 999999999 14.62 23.43 percent of total billed charges OCTREOTIDE ACET 100 MCG/ML VL 50079816_1 CDM 0250 RC 63323-0376-01 NDC inpatient 1 UN 24.15 15.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 16.66 69 999999999 14.62 23.43 percent of total billed charges OCTREOTIDE ACET 100 MCG/ML VL 50079816_1 CDM 0250 RC 63323-0376-01 NDC inpatient 1 UN 24.15 15.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 18.84 78 999999999 14.62 23.43 percent of total billed charges OCTREOTIDE ACET 100 MCG/ML VL 50079816_1 CDM 0250 RC 63323-0376-01 NDC inpatient 1 UN 24.15 15.7 UMR - ALL PLANS UMR - ALL PLANS 16.91 70 999999999 14.62 23.43 percent of total billed charges OCTREOTIDE ACET 100 MCG/ML VL 50079816_1 CDM 0250 RC 63323-0376-01 NDC inpatient 1 UN 24.15 15.7 SIHO - ALL PLANS SIHO - ALL PLANS 21.74 90 999999999 14.62 23.43 percent of total billed charges OCTREOTIDE ACET 100 MCG/ML VL 50079816_1 CDM 0250 RC 63323-0376-01 NDC inpatient 1 UN 24.15 15.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.62 60.55 999999999 14.62 23.43 percent of total billed charges OCTREOTIDE ACET 100 MCG/ML VL 50079816_1 CDM 0250 RC 63323-0376-01 NDC inpatient 1 UN 24.15 15.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.62 23.43 OCTREOTIDE ACET 100 MCG/ML VL 50079816_1 CDM 0250 RC 63323-0376-01 NDC inpatient 1 UN 24.15 15.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.62 23.43 OCTREOTIDE ACET 100 MCG/ML VL 50079816_1 CDM 0250 RC 63323-0376-01 NDC inpatient 1 UN 24.15 15.7 ANTHEM HMO ANTHEM HMO 999999999 14.62 23.43 OCTREOTIDE ACET 100 MCG/ML VL 50079816_1 CDM 0250 RC 63323-0376-01 NDC inpatient 1 UN 24.15 15.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.33 67.6 999999999 14.62 23.43 percent of total billed charges OCTREOTIDE ACET 100 MCG/ML VL 50079816_1 CDM 0250 RC 63323-0376-01 NDC inpatient 1 UN 24.15 15.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.62 23.43 OCTREOTIDE ACET 100 MCG/ML VL 50079816_1 CDM 0250 RC 63323-0376-01 NDC inpatient 1 UN 24.15 15.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.62 23.43 LEVOTHYROXINE 100 MCG VIAL 50079821_1 CDM 0250 RC 70860-0451-10 NDC inpatient 1 UN 373.83 242.99 AETNA AETNA 295.33 79 999999999 226.35 362.62 percent of total billed charges LEVOTHYROXINE 100 MCG VIAL 50079821_1 CDM 0250 RC 70860-0451-10 NDC inpatient 1 UN 373.83 242.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 242.99 65 999999999 226.35 362.62 percent of total billed charges LEVOTHYROXINE 100 MCG VIAL 50079821_1 CDM 0250 RC 70860-0451-10 NDC inpatient 1 UN 373.83 242.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 362.62 97 999999999 226.35 362.62 percent of total billed charges LEVOTHYROXINE 100 MCG VIAL 50079821_1 CDM 0250 RC 70860-0451-10 NDC inpatient 1 UN 373.83 242.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 257.94 69 999999999 226.35 362.62 percent of total billed charges LEVOTHYROXINE 100 MCG VIAL 50079821_1 CDM 0250 RC 70860-0451-10 NDC inpatient 1 UN 373.83 242.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 291.59 78 999999999 226.35 362.62 percent of total billed charges LEVOTHYROXINE 100 MCG VIAL 50079821_1 CDM 0250 RC 70860-0451-10 NDC inpatient 1 UN 373.83 242.99 UMR - ALL PLANS UMR - ALL PLANS 261.68 70 999999999 226.35 362.62 percent of total billed charges LEVOTHYROXINE 100 MCG VIAL 50079821_1 CDM 0250 RC 70860-0451-10 NDC inpatient 1 UN 373.83 242.99 SIHO - ALL PLANS SIHO - ALL PLANS 336.45 90 999999999 226.35 362.62 percent of total billed charges LEVOTHYROXINE 100 MCG VIAL 50079821_1 CDM 0250 RC 70860-0451-10 NDC inpatient 1 UN 373.83 242.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 226.35 60.55 999999999 226.35 362.62 percent of total billed charges LEVOTHYROXINE 100 MCG VIAL 50079821_1 CDM 0250 RC 70860-0451-10 NDC inpatient 1 UN 373.83 242.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 226.35 362.62 LEVOTHYROXINE 100 MCG VIAL 50079821_1 CDM 0250 RC 70860-0451-10 NDC inpatient 1 UN 373.83 242.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 226.35 362.62 LEVOTHYROXINE 100 MCG VIAL 50079821_1 CDM 0250 RC 70860-0451-10 NDC inpatient 1 UN 373.83 242.99 ANTHEM HMO ANTHEM HMO 999999999 226.35 362.62 LEVOTHYROXINE 100 MCG VIAL 50079821_1 CDM 0250 RC 70860-0451-10 NDC inpatient 1 UN 373.83 242.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 252.71 67.6 999999999 226.35 362.62 percent of total billed charges LEVOTHYROXINE 100 MCG VIAL 50079821_1 CDM 0250 RC 70860-0451-10 NDC inpatient 1 UN 373.83 242.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 226.35 362.62 LEVOTHYROXINE 100 MCG VIAL 50079821_1 CDM 0250 RC 70860-0451-10 NDC inpatient 1 UN 373.83 242.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 226.35 362.62 BRIDION 500 MG/5 ML VIAL 50083392_1 CDM 0250 RC 00006-5425-15 NDC inpatient 1 UN 991.14 644.24 AETNA AETNA 783 79 999999999 600.14 961.41 percent of total billed charges BRIDION 500 MG/5 ML VIAL 50083392_1 CDM 0250 RC 00006-5425-15 NDC inpatient 1 UN 991.14 644.24 SELF PAY DISCOUNT SELF PAY DISCOUNT 644.24 65 999999999 600.14 961.41 percent of total billed charges BRIDION 500 MG/5 ML VIAL 50083392_1 CDM 0250 RC 00006-5425-15 NDC inpatient 1 UN 991.14 644.24 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 961.41 97 999999999 600.14 961.41 percent of total billed charges BRIDION 500 MG/5 ML VIAL 50083392_1 CDM 0250 RC 00006-5425-15 NDC inpatient 1 UN 991.14 644.24 ENCORE - ALL PLANS ENCORE - ALL PLANS 683.89 69 999999999 600.14 961.41 percent of total billed charges BRIDION 500 MG/5 ML VIAL 50083392_1 CDM 0250 RC 00006-5425-15 NDC inpatient 1 UN 991.14 644.24 HUMANA - ALL PLANS HUMANA - ALL PLANS 773.09 78 999999999 600.14 961.41 percent of total billed charges BRIDION 500 MG/5 ML VIAL 50083392_1 CDM 0250 RC 00006-5425-15 NDC inpatient 1 UN 991.14 644.24 UMR - ALL PLANS UMR - ALL PLANS 693.8 70 999999999 600.14 961.41 percent of total billed charges BRIDION 500 MG/5 ML VIAL 50083392_1 CDM 0250 RC 00006-5425-15 NDC inpatient 1 UN 991.14 644.24 SIHO - ALL PLANS SIHO - ALL PLANS 892.03 90 999999999 600.14 961.41 percent of total billed charges BRIDION 500 MG/5 ML VIAL 50083392_1 CDM 0250 RC 00006-5425-15 NDC inpatient 1 UN 991.14 644.24 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 600.14 60.55 999999999 600.14 961.41 percent of total billed charges BRIDION 500 MG/5 ML VIAL 50083392_1 CDM 0250 RC 00006-5425-15 NDC inpatient 1 UN 991.14 644.24 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 600.14 961.41 BRIDION 500 MG/5 ML VIAL 50083392_1 CDM 0250 RC 00006-5425-15 NDC inpatient 1 UN 991.14 644.24 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 600.14 961.41 BRIDION 500 MG/5 ML VIAL 50083392_1 CDM 0250 RC 00006-5425-15 NDC inpatient 1 UN 991.14 644.24 ANTHEM HMO ANTHEM HMO 999999999 600.14 961.41 BRIDION 500 MG/5 ML VIAL 50083392_1 CDM 0250 RC 00006-5425-15 NDC inpatient 1 UN 991.14 644.24 CIGNA - ALL PLANS CIGNA - ALL PLANS 670.01 67.6 999999999 600.14 961.41 percent of total billed charges BRIDION 500 MG/5 ML VIAL 50083392_1 CDM 0250 RC 00006-5425-15 NDC inpatient 1 UN 991.14 644.24 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 600.14 961.41 BRIDION 500 MG/5 ML VIAL 50083392_1 CDM 0250 RC 00006-5425-15 NDC inpatient 1 UN 991.14 644.24 UHC - ALL PLANS UHC - ALL PLANS 999999999 600.14 961.41 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50083396_1 CDM 0250 RC 55150-0198-30 NDC J2795 HCPCS inpatient 150 UN 38.58 25.08 AETNA AETNA 30.48 79 999999999 23.36 37.42 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50083396_1 CDM 0250 RC 55150-0198-30 NDC J2795 HCPCS inpatient 150 UN 38.58 25.08 SELF PAY DISCOUNT SELF PAY DISCOUNT 25.08 65 999999999 23.36 37.42 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50083396_1 CDM 0250 RC 55150-0198-30 NDC J2795 HCPCS inpatient 150 UN 38.58 25.08 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37.42 97 999999999 23.36 37.42 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50083396_1 CDM 0250 RC 55150-0198-30 NDC J2795 HCPCS inpatient 150 UN 38.58 25.08 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.62 69 999999999 23.36 37.42 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50083396_1 CDM 0250 RC 55150-0198-30 NDC J2795 HCPCS inpatient 150 UN 38.58 25.08 HUMANA - ALL PLANS HUMANA - ALL PLANS 30.09 78 999999999 23.36 37.42 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50083396_1 CDM 0250 RC 55150-0198-30 NDC J2795 HCPCS inpatient 150 UN 38.58 25.08 UMR - ALL PLANS UMR - ALL PLANS 27.01 70 999999999 23.36 37.42 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50083396_1 CDM 0250 RC 55150-0198-30 NDC J2795 HCPCS inpatient 150 UN 38.58 25.08 SIHO - ALL PLANS SIHO - ALL PLANS 34.72 90 999999999 23.36 37.42 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50083396_1 CDM 0250 RC 55150-0198-30 NDC J2795 HCPCS inpatient 150 UN 38.58 25.08 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.36 60.55 999999999 23.36 37.42 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50083396_1 CDM 0250 RC 55150-0198-30 NDC J2795 HCPCS inpatient 150 UN 38.58 25.08 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.36 37.42 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50083396_1 CDM 0250 RC 55150-0198-30 NDC J2795 HCPCS inpatient 150 UN 38.58 25.08 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.36 37.42 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50083396_1 CDM 0250 RC 55150-0198-30 NDC J2795 HCPCS inpatient 150 UN 38.58 25.08 ANTHEM HMO ANTHEM HMO 999999999 23.36 37.42 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50083396_1 CDM 0250 RC 55150-0198-30 NDC J2795 HCPCS inpatient 150 UN 38.58 25.08 CIGNA - ALL PLANS CIGNA - ALL PLANS 26.08 67.6 999999999 23.36 37.42 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50083396_1 CDM 0250 RC 55150-0198-30 NDC J2795 HCPCS inpatient 150 UN 38.58 25.08 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.36 37.42 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50083396_1 CDM 0250 RC 55150-0198-30 NDC J2795 HCPCS inpatient 150 UN 38.58 25.08 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.36 37.42 "Phosphatase (enzyme) measurement, acid, total" 50085466_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 AETNA AETNA 234.63 79 999999999 179.83 288.09 percent of total billed charges "Phosphatase (enzyme) measurement, acid, total" 50085466_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 193.05 65 999999999 179.83 288.09 percent of total billed charges "Phosphatase (enzyme) measurement, acid, total" 50085466_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 288.09 97 999999999 179.83 288.09 percent of total billed charges "Phosphatase (enzyme) measurement, acid, total" 50085466_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 204.93 69 999999999 179.83 288.09 percent of total billed charges "Phosphatase (enzyme) measurement, acid, total" 50085466_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 231.66 78 999999999 179.83 288.09 percent of total billed charges "Phosphatase (enzyme) measurement, acid, total" 50085466_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 UMR - ALL PLANS UMR - ALL PLANS 207.9 70 999999999 179.83 288.09 percent of total billed charges "Phosphatase (enzyme) measurement, acid, total" 50085466_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 SIHO - ALL PLANS SIHO - ALL PLANS 267.3 90 999999999 179.83 288.09 percent of total billed charges "Phosphatase (enzyme) measurement, acid, total" 50085466_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 179.83 60.55 999999999 179.83 288.09 percent of total billed charges "Phosphatase (enzyme) measurement, acid, total" 50085466_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 179.83 288.09 "Phosphatase (enzyme) measurement, acid, total" 50085466_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 179.83 288.09 "Phosphatase (enzyme) measurement, acid, total" 50085466_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 ANTHEM HMO ANTHEM HMO 999999999 179.83 288.09 "Phosphatase (enzyme) measurement, acid, total" 50085466_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 200.77 67.6 999999999 179.83 288.09 percent of total billed charges "Phosphatase (enzyme) measurement, acid, total" 50085466_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 179.83 288.09 "Phosphatase (enzyme) measurement, acid, total" 50085466_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 179.83 288.09 METOPROLOL SUCC ER 100 MG TAB 50087297_1 CDM 0250 RC 68001-0358-00 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 100 MG TAB 50087297_1 CDM 0250 RC 68001-0358-00 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 100 MG TAB 50087297_1 CDM 0250 RC 68001-0358-00 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 100 MG TAB 50087297_1 CDM 0250 RC 68001-0358-00 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 100 MG TAB 50087297_1 CDM 0250 RC 68001-0358-00 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 100 MG TAB 50087297_1 CDM 0250 RC 68001-0358-00 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 100 MG TAB 50087297_1 CDM 0250 RC 68001-0358-00 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 100 MG TAB 50087297_1 CDM 0250 RC 68001-0358-00 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 100 MG TAB 50087297_1 CDM 0250 RC 68001-0358-00 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 METOPROLOL SUCC ER 100 MG TAB 50087297_1 CDM 0250 RC 68001-0358-00 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 METOPROLOL SUCC ER 100 MG TAB 50087297_1 CDM 0250 RC 68001-0358-00 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 METOPROLOL SUCC ER 100 MG TAB 50087297_1 CDM 0250 RC 68001-0358-00 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 100 MG TAB 50087297_1 CDM 0250 RC 68001-0358-00 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 METOPROLOL SUCC ER 100 MG TAB 50087297_1 CDM 0250 RC 68001-0358-00 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CALCIUM ACETATE 667 MG CAPSULE 50089282_1 CDM 0250 RC 00054-0088-13 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CALCIUM ACETATE 667 MG CAPSULE 50089282_1 CDM 0250 RC 00054-0088-13 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CALCIUM ACETATE 667 MG CAPSULE 50089282_1 CDM 0250 RC 00054-0088-13 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CALCIUM ACETATE 667 MG CAPSULE 50089282_1 CDM 0250 RC 00054-0088-13 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CALCIUM ACETATE 667 MG CAPSULE 50089282_1 CDM 0250 RC 00054-0088-13 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CALCIUM ACETATE 667 MG CAPSULE 50089282_1 CDM 0250 RC 00054-0088-13 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CALCIUM ACETATE 667 MG CAPSULE 50089282_1 CDM 0250 RC 00054-0088-13 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CALCIUM ACETATE 667 MG CAPSULE 50089282_1 CDM 0250 RC 00054-0088-13 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CALCIUM ACETATE 667 MG CAPSULE 50089282_1 CDM 0250 RC 00054-0088-13 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CALCIUM ACETATE 667 MG CAPSULE 50089282_1 CDM 0250 RC 00054-0088-13 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CALCIUM ACETATE 667 MG CAPSULE 50089282_1 CDM 0250 RC 00054-0088-13 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CALCIUM ACETATE 667 MG CAPSULE 50089282_1 CDM 0250 RC 00054-0088-13 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CALCIUM ACETATE 667 MG CAPSULE 50089282_1 CDM 0250 RC 00054-0088-13 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CALCIUM ACETATE 667 MG CAPSULE 50089282_1 CDM 0250 RC 00054-0088-13 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 LEVOTHYROXINE 125 MCG TABLET 50091279_1 CDM 0250 RC 69238-1836-01 NDC inpatient 1 UN 1.77 1.15 AETNA AETNA 1.4 79 999999999 1.07 1.72 percent of total billed charges LEVOTHYROXINE 125 MCG TABLET 50091279_1 CDM 0250 RC 69238-1836-01 NDC inpatient 1 UN 1.77 1.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.15 65 999999999 1.07 1.72 percent of total billed charges LEVOTHYROXINE 125 MCG TABLET 50091279_1 CDM 0250 RC 69238-1836-01 NDC inpatient 1 UN 1.77 1.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.72 97 999999999 1.07 1.72 percent of total billed charges LEVOTHYROXINE 125 MCG TABLET 50091279_1 CDM 0250 RC 69238-1836-01 NDC inpatient 1 UN 1.77 1.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.22 69 999999999 1.07 1.72 percent of total billed charges LEVOTHYROXINE 125 MCG TABLET 50091279_1 CDM 0250 RC 69238-1836-01 NDC inpatient 1 UN 1.77 1.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.38 78 999999999 1.07 1.72 percent of total billed charges LEVOTHYROXINE 125 MCG TABLET 50091279_1 CDM 0250 RC 69238-1836-01 NDC inpatient 1 UN 1.77 1.15 UMR - ALL PLANS UMR - ALL PLANS 1.24 70 999999999 1.07 1.72 percent of total billed charges LEVOTHYROXINE 125 MCG TABLET 50091279_1 CDM 0250 RC 69238-1836-01 NDC inpatient 1 UN 1.77 1.15 SIHO - ALL PLANS SIHO - ALL PLANS 1.59 90 999999999 1.07 1.72 percent of total billed charges LEVOTHYROXINE 125 MCG TABLET 50091279_1 CDM 0250 RC 69238-1836-01 NDC inpatient 1 UN 1.77 1.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.07 60.55 999999999 1.07 1.72 percent of total billed charges LEVOTHYROXINE 125 MCG TABLET 50091279_1 CDM 0250 RC 69238-1836-01 NDC inpatient 1 UN 1.77 1.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.07 1.72 LEVOTHYROXINE 125 MCG TABLET 50091279_1 CDM 0250 RC 69238-1836-01 NDC inpatient 1 UN 1.77 1.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.07 1.72 LEVOTHYROXINE 125 MCG TABLET 50091279_1 CDM 0250 RC 69238-1836-01 NDC inpatient 1 UN 1.77 1.15 ANTHEM HMO ANTHEM HMO 999999999 1.07 1.72 LEVOTHYROXINE 125 MCG TABLET 50091279_1 CDM 0250 RC 69238-1836-01 NDC inpatient 1 UN 1.77 1.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.2 67.6 999999999 1.07 1.72 percent of total billed charges LEVOTHYROXINE 125 MCG TABLET 50091279_1 CDM 0250 RC 69238-1836-01 NDC inpatient 1 UN 1.77 1.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.07 1.72 LEVOTHYROXINE 125 MCG TABLET 50091279_1 CDM 0250 RC 69238-1836-01 NDC inpatient 1 UN 1.77 1.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.07 1.72 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091529_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091529_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091529_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091529_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091529_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091529_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091529_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091529_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091529_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091529_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091529_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091529_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091529_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091529_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091530_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091530_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091530_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091530_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091530_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091530_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091530_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091530_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091530_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091530_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091530_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091530_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091530_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091530_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091531_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091531_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091531_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091531_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091531_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091531_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091531_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091531_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091531_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091531_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091531_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091531_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091531_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091531_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091532_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091532_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091532_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091532_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091532_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091532_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091532_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091532_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091532_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091532_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091532_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091532_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091532_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, IRRADIATED, EACH UNIT" 50091532_1 CDM 0390 RC P9037 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091533_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 AETNA AETNA 1316.14 79 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091533_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1082.9 65 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091533_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1616.02 97 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091533_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1149.54 69 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091533_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1299.48 78 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091533_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 UMR - ALL PLANS UMR - ALL PLANS 1166.2 70 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091533_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 SIHO - ALL PLANS SIHO - ALL PLANS 1499.4 90 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091533_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1008.76 60.55 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091533_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091533_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091533_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM HMO ANTHEM HMO 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091533_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1126.22 67.6 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091533_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091533_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091534_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 AETNA AETNA 1316.14 79 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091534_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1082.9 65 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091534_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1616.02 97 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091534_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1149.54 69 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091534_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1299.48 78 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091534_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 UMR - ALL PLANS UMR - ALL PLANS 1166.2 70 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091534_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 SIHO - ALL PLANS SIHO - ALL PLANS 1499.4 90 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091534_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1008.76 60.55 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091534_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091534_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091534_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM HMO ANTHEM HMO 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091534_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1126.22 67.6 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091534_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091534_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091535_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 AETNA AETNA 1316.14 79 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091535_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1082.9 65 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091535_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1616.02 97 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091535_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1149.54 69 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091535_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1299.48 78 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091535_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 UMR - ALL PLANS UMR - ALL PLANS 1166.2 70 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091535_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 SIHO - ALL PLANS SIHO - ALL PLANS 1499.4 90 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091535_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1008.76 60.55 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091535_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091535_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091535_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM HMO ANTHEM HMO 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091535_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1126.22 67.6 999999999 1008.76 1616.02 percent of total billed charges "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091535_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1008.76 1616.02 "PLATELETS, PHERESIS, LEUKOCYTES REDUCED, EACH UNIT" 50091535_1 CDM 0390 RC P9035 HCPCS inpatient 1666 1082.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1008.76 1616.02 SODIUM CHLORIDE 0.9% INHAL VL 50091658_1 CDM 0250 RC 00487-9301-03 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges SODIUM CHLORIDE 0.9% INHAL VL 50091658_1 CDM 0250 RC 00487-9301-03 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges SODIUM CHLORIDE 0.9% INHAL VL 50091658_1 CDM 0250 RC 00487-9301-03 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges SODIUM CHLORIDE 0.9% INHAL VL 50091658_1 CDM 0250 RC 00487-9301-03 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges SODIUM CHLORIDE 0.9% INHAL VL 50091658_1 CDM 0250 RC 00487-9301-03 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges SODIUM CHLORIDE 0.9% INHAL VL 50091658_1 CDM 0250 RC 00487-9301-03 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges SODIUM CHLORIDE 0.9% INHAL VL 50091658_1 CDM 0250 RC 00487-9301-03 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges SODIUM CHLORIDE 0.9% INHAL VL 50091658_1 CDM 0250 RC 00487-9301-03 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges SODIUM CHLORIDE 0.9% INHAL VL 50091658_1 CDM 0250 RC 00487-9301-03 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 SODIUM CHLORIDE 0.9% INHAL VL 50091658_1 CDM 0250 RC 00487-9301-03 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 SODIUM CHLORIDE 0.9% INHAL VL 50091658_1 CDM 0250 RC 00487-9301-03 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 SODIUM CHLORIDE 0.9% INHAL VL 50091658_1 CDM 0250 RC 00487-9301-03 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges SODIUM CHLORIDE 0.9% INHAL VL 50091658_1 CDM 0250 RC 00487-9301-03 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 SODIUM CHLORIDE 0.9% INHAL VL 50091658_1 CDM 0250 RC 00487-9301-03 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 LISINOPRIL 10 MG TABLET 50091802_1 CDM 0250 RC 60687-0325-01 NDC inpatient 1 UN 1.78 1.16 AETNA AETNA 1.41 79 999999999 1.08 1.73 percent of total billed charges LISINOPRIL 10 MG TABLET 50091802_1 CDM 0250 RC 60687-0325-01 NDC inpatient 1 UN 1.78 1.16 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.16 65 999999999 1.08 1.73 percent of total billed charges LISINOPRIL 10 MG TABLET 50091802_1 CDM 0250 RC 60687-0325-01 NDC inpatient 1 UN 1.78 1.16 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.73 97 999999999 1.08 1.73 percent of total billed charges LISINOPRIL 10 MG TABLET 50091802_1 CDM 0250 RC 60687-0325-01 NDC inpatient 1 UN 1.78 1.16 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.23 69 999999999 1.08 1.73 percent of total billed charges LISINOPRIL 10 MG TABLET 50091802_1 CDM 0250 RC 60687-0325-01 NDC inpatient 1 UN 1.78 1.16 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.39 78 999999999 1.08 1.73 percent of total billed charges LISINOPRIL 10 MG TABLET 50091802_1 CDM 0250 RC 60687-0325-01 NDC inpatient 1 UN 1.78 1.16 UMR - ALL PLANS UMR - ALL PLANS 1.25 70 999999999 1.08 1.73 percent of total billed charges LISINOPRIL 10 MG TABLET 50091802_1 CDM 0250 RC 60687-0325-01 NDC inpatient 1 UN 1.78 1.16 SIHO - ALL PLANS SIHO - ALL PLANS 1.6 90 999999999 1.08 1.73 percent of total billed charges LISINOPRIL 10 MG TABLET 50091802_1 CDM 0250 RC 60687-0325-01 NDC inpatient 1 UN 1.78 1.16 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.08 60.55 999999999 1.08 1.73 percent of total billed charges LISINOPRIL 10 MG TABLET 50091802_1 CDM 0250 RC 60687-0325-01 NDC inpatient 1 UN 1.78 1.16 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.08 1.73 LISINOPRIL 10 MG TABLET 50091802_1 CDM 0250 RC 60687-0325-01 NDC inpatient 1 UN 1.78 1.16 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.08 1.73 LISINOPRIL 10 MG TABLET 50091802_1 CDM 0250 RC 60687-0325-01 NDC inpatient 1 UN 1.78 1.16 ANTHEM HMO ANTHEM HMO 999999999 1.08 1.73 LISINOPRIL 10 MG TABLET 50091802_1 CDM 0250 RC 60687-0325-01 NDC inpatient 1 UN 1.78 1.16 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.2 67.6 999999999 1.08 1.73 percent of total billed charges LISINOPRIL 10 MG TABLET 50091802_1 CDM 0250 RC 60687-0325-01 NDC inpatient 1 UN 1.78 1.16 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.08 1.73 LISINOPRIL 10 MG TABLET 50091802_1 CDM 0250 RC 60687-0325-01 NDC inpatient 1 UN 1.78 1.16 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.08 1.73 DALIRESP 500 MCG TABLET 50097356_1 CDM 0250 RC 00310-0095-30 NDC inpatient 1 UN 55.7 36.21 AETNA AETNA 44 79 999999999 33.73 54.03 percent of total billed charges DALIRESP 500 MCG TABLET 50097356_1 CDM 0250 RC 00310-0095-30 NDC inpatient 1 UN 55.7 36.21 SELF PAY DISCOUNT SELF PAY DISCOUNT 36.21 65 999999999 33.73 54.03 percent of total billed charges DALIRESP 500 MCG TABLET 50097356_1 CDM 0250 RC 00310-0095-30 NDC inpatient 1 UN 55.7 36.21 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 54.03 97 999999999 33.73 54.03 percent of total billed charges DALIRESP 500 MCG TABLET 50097356_1 CDM 0250 RC 00310-0095-30 NDC inpatient 1 UN 55.7 36.21 ENCORE - ALL PLANS ENCORE - ALL PLANS 38.43 69 999999999 33.73 54.03 percent of total billed charges DALIRESP 500 MCG TABLET 50097356_1 CDM 0250 RC 00310-0095-30 NDC inpatient 1 UN 55.7 36.21 HUMANA - ALL PLANS HUMANA - ALL PLANS 43.45 78 999999999 33.73 54.03 percent of total billed charges DALIRESP 500 MCG TABLET 50097356_1 CDM 0250 RC 00310-0095-30 NDC inpatient 1 UN 55.7 36.21 UMR - ALL PLANS UMR - ALL PLANS 38.99 70 999999999 33.73 54.03 percent of total billed charges DALIRESP 500 MCG TABLET 50097356_1 CDM 0250 RC 00310-0095-30 NDC inpatient 1 UN 55.7 36.21 SIHO - ALL PLANS SIHO - ALL PLANS 50.13 90 999999999 33.73 54.03 percent of total billed charges DALIRESP 500 MCG TABLET 50097356_1 CDM 0250 RC 00310-0095-30 NDC inpatient 1 UN 55.7 36.21 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33.73 60.55 999999999 33.73 54.03 percent of total billed charges DALIRESP 500 MCG TABLET 50097356_1 CDM 0250 RC 00310-0095-30 NDC inpatient 1 UN 55.7 36.21 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 33.73 54.03 DALIRESP 500 MCG TABLET 50097356_1 CDM 0250 RC 00310-0095-30 NDC inpatient 1 UN 55.7 36.21 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 33.73 54.03 DALIRESP 500 MCG TABLET 50097356_1 CDM 0250 RC 00310-0095-30 NDC inpatient 1 UN 55.7 36.21 ANTHEM HMO ANTHEM HMO 999999999 33.73 54.03 DALIRESP 500 MCG TABLET 50097356_1 CDM 0250 RC 00310-0095-30 NDC inpatient 1 UN 55.7 36.21 CIGNA - ALL PLANS CIGNA - ALL PLANS 37.65 67.6 999999999 33.73 54.03 percent of total billed charges DALIRESP 500 MCG TABLET 50097356_1 CDM 0250 RC 00310-0095-30 NDC inpatient 1 UN 55.7 36.21 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 33.73 54.03 DALIRESP 500 MCG TABLET 50097356_1 CDM 0250 RC 00310-0095-30 NDC inpatient 1 UN 55.7 36.21 UHC - ALL PLANS UHC - ALL PLANS 999999999 33.73 54.03 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50097362_1 CDM 0250 RC 00409-7333-49 NDC J0696 HCPCS inpatient 4 UN 69 44.85 AETNA AETNA 54.51 79 999999999 41.78 66.93 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50097362_1 CDM 0250 RC 00409-7333-49 NDC J0696 HCPCS inpatient 4 UN 69 44.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.85 65 999999999 41.78 66.93 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50097362_1 CDM 0250 RC 00409-7333-49 NDC J0696 HCPCS inpatient 4 UN 69 44.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 66.93 97 999999999 41.78 66.93 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50097362_1 CDM 0250 RC 00409-7333-49 NDC J0696 HCPCS inpatient 4 UN 69 44.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 47.61 69 999999999 41.78 66.93 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50097362_1 CDM 0250 RC 00409-7333-49 NDC J0696 HCPCS inpatient 4 UN 69 44.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.82 78 999999999 41.78 66.93 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50097362_1 CDM 0250 RC 00409-7333-49 NDC J0696 HCPCS inpatient 4 UN 69 44.85 UMR - ALL PLANS UMR - ALL PLANS 48.3 70 999999999 41.78 66.93 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50097362_1 CDM 0250 RC 00409-7333-49 NDC J0696 HCPCS inpatient 4 UN 69 44.85 SIHO - ALL PLANS SIHO - ALL PLANS 62.1 90 999999999 41.78 66.93 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50097362_1 CDM 0250 RC 00409-7333-49 NDC J0696 HCPCS inpatient 4 UN 69 44.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.78 60.55 999999999 41.78 66.93 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50097362_1 CDM 0250 RC 00409-7333-49 NDC J0696 HCPCS inpatient 4 UN 69 44.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.78 66.93 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50097362_1 CDM 0250 RC 00409-7333-49 NDC J0696 HCPCS inpatient 4 UN 69 44.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.78 66.93 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50097362_1 CDM 0250 RC 00409-7333-49 NDC J0696 HCPCS inpatient 4 UN 69 44.85 ANTHEM HMO ANTHEM HMO 999999999 41.78 66.93 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50097362_1 CDM 0250 RC 00409-7333-49 NDC J0696 HCPCS inpatient 4 UN 69 44.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 46.64 67.6 999999999 41.78 66.93 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50097362_1 CDM 0250 RC 00409-7333-49 NDC J0696 HCPCS inpatient 4 UN 69 44.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.78 66.93 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50097362_1 CDM 0250 RC 00409-7333-49 NDC J0696 HCPCS inpatient 4 UN 69 44.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.78 66.93 MUCINEX DM ER 600-30 MG TABLET 50101296_1 CDM 0250 RC 63824-0056-32 NDC inpatient 1 UN 2.01 1.31 AETNA AETNA 1.59 79 999999999 1.22 1.95 percent of total billed charges MUCINEX DM ER 600-30 MG TABLET 50101296_1 CDM 0250 RC 63824-0056-32 NDC inpatient 1 UN 2.01 1.31 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.31 65 999999999 1.22 1.95 percent of total billed charges MUCINEX DM ER 600-30 MG TABLET 50101296_1 CDM 0250 RC 63824-0056-32 NDC inpatient 1 UN 2.01 1.31 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.95 97 999999999 1.22 1.95 percent of total billed charges MUCINEX DM ER 600-30 MG TABLET 50101296_1 CDM 0250 RC 63824-0056-32 NDC inpatient 1 UN 2.01 1.31 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.39 69 999999999 1.22 1.95 percent of total billed charges MUCINEX DM ER 600-30 MG TABLET 50101296_1 CDM 0250 RC 63824-0056-32 NDC inpatient 1 UN 2.01 1.31 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.57 78 999999999 1.22 1.95 percent of total billed charges MUCINEX DM ER 600-30 MG TABLET 50101296_1 CDM 0250 RC 63824-0056-32 NDC inpatient 1 UN 2.01 1.31 UMR - ALL PLANS UMR - ALL PLANS 1.41 70 999999999 1.22 1.95 percent of total billed charges MUCINEX DM ER 600-30 MG TABLET 50101296_1 CDM 0250 RC 63824-0056-32 NDC inpatient 1 UN 2.01 1.31 SIHO - ALL PLANS SIHO - ALL PLANS 1.81 90 999999999 1.22 1.95 percent of total billed charges MUCINEX DM ER 600-30 MG TABLET 50101296_1 CDM 0250 RC 63824-0056-32 NDC inpatient 1 UN 2.01 1.31 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.22 60.55 999999999 1.22 1.95 percent of total billed charges MUCINEX DM ER 600-30 MG TABLET 50101296_1 CDM 0250 RC 63824-0056-32 NDC inpatient 1 UN 2.01 1.31 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.22 1.95 MUCINEX DM ER 600-30 MG TABLET 50101296_1 CDM 0250 RC 63824-0056-32 NDC inpatient 1 UN 2.01 1.31 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.22 1.95 MUCINEX DM ER 600-30 MG TABLET 50101296_1 CDM 0250 RC 63824-0056-32 NDC inpatient 1 UN 2.01 1.31 ANTHEM HMO ANTHEM HMO 999999999 1.22 1.95 MUCINEX DM ER 600-30 MG TABLET 50101296_1 CDM 0250 RC 63824-0056-32 NDC inpatient 1 UN 2.01 1.31 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.36 67.6 999999999 1.22 1.95 percent of total billed charges MUCINEX DM ER 600-30 MG TABLET 50101296_1 CDM 0250 RC 63824-0056-32 NDC inpatient 1 UN 2.01 1.31 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.22 1.95 MUCINEX DM ER 600-30 MG TABLET 50101296_1 CDM 0250 RC 63824-0056-32 NDC inpatient 1 UN 2.01 1.31 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.22 1.95 "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50105460_1 CDM 0636 RC 63323-0711-00 NDC J0640 HCPCS inpatient 10 UN 269.46 175.15 AETNA AETNA 212.87 79 999999999 163.16 261.38 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50105460_1 CDM 0636 RC 63323-0711-00 NDC J0640 HCPCS inpatient 10 UN 269.46 175.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 175.15 65 999999999 163.16 261.38 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50105460_1 CDM 0636 RC 63323-0711-00 NDC J0640 HCPCS inpatient 10 UN 269.46 175.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 261.38 97 999999999 163.16 261.38 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50105460_1 CDM 0636 RC 63323-0711-00 NDC J0640 HCPCS inpatient 10 UN 269.46 175.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 185.93 69 999999999 163.16 261.38 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50105460_1 CDM 0636 RC 63323-0711-00 NDC J0640 HCPCS inpatient 10 UN 269.46 175.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 210.18 78 999999999 163.16 261.38 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50105460_1 CDM 0636 RC 63323-0711-00 NDC J0640 HCPCS inpatient 10 UN 269.46 175.15 UMR - ALL PLANS UMR - ALL PLANS 188.62 70 999999999 163.16 261.38 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50105460_1 CDM 0636 RC 63323-0711-00 NDC J0640 HCPCS inpatient 10 UN 269.46 175.15 SIHO - ALL PLANS SIHO - ALL PLANS 242.51 90 999999999 163.16 261.38 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50105460_1 CDM 0636 RC 63323-0711-00 NDC J0640 HCPCS inpatient 10 UN 269.46 175.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 163.16 60.55 999999999 163.16 261.38 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50105460_1 CDM 0636 RC 63323-0711-00 NDC J0640 HCPCS inpatient 10 UN 269.46 175.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 163.16 261.38 "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50105460_1 CDM 0636 RC 63323-0711-00 NDC J0640 HCPCS inpatient 10 UN 269.46 175.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 163.16 261.38 "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50105460_1 CDM 0636 RC 63323-0711-00 NDC J0640 HCPCS inpatient 10 UN 269.46 175.15 ANTHEM HMO ANTHEM HMO 999999999 163.16 261.38 "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50105460_1 CDM 0636 RC 63323-0711-00 NDC J0640 HCPCS inpatient 10 UN 269.46 175.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 182.16 67.6 999999999 163.16 261.38 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50105460_1 CDM 0636 RC 63323-0711-00 NDC J0640 HCPCS inpatient 10 UN 269.46 175.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 163.16 261.38 "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50105460_1 CDM 0636 RC 63323-0711-00 NDC J0640 HCPCS inpatient 10 UN 269.46 175.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 163.16 261.38 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50107366_1 CDM 0250 RC 67457-0420-10 NDC J1100 HCPCS inpatient 100 UN 25.38 16.5 AETNA AETNA 20.05 79 999999999 15.37 24.62 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50107366_1 CDM 0250 RC 67457-0420-10 NDC J1100 HCPCS inpatient 100 UN 25.38 16.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.5 65 999999999 15.37 24.62 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50107366_1 CDM 0250 RC 67457-0420-10 NDC J1100 HCPCS inpatient 100 UN 25.38 16.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.62 97 999999999 15.37 24.62 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50107366_1 CDM 0250 RC 67457-0420-10 NDC J1100 HCPCS inpatient 100 UN 25.38 16.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.51 69 999999999 15.37 24.62 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50107366_1 CDM 0250 RC 67457-0420-10 NDC J1100 HCPCS inpatient 100 UN 25.38 16.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.8 78 999999999 15.37 24.62 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50107366_1 CDM 0250 RC 67457-0420-10 NDC J1100 HCPCS inpatient 100 UN 25.38 16.5 UMR - ALL PLANS UMR - ALL PLANS 17.77 70 999999999 15.37 24.62 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50107366_1 CDM 0250 RC 67457-0420-10 NDC J1100 HCPCS inpatient 100 UN 25.38 16.5 SIHO - ALL PLANS SIHO - ALL PLANS 22.84 90 999999999 15.37 24.62 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50107366_1 CDM 0250 RC 67457-0420-10 NDC J1100 HCPCS inpatient 100 UN 25.38 16.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.37 60.55 999999999 15.37 24.62 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50107366_1 CDM 0250 RC 67457-0420-10 NDC J1100 HCPCS inpatient 100 UN 25.38 16.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.37 24.62 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50107366_1 CDM 0250 RC 67457-0420-10 NDC J1100 HCPCS inpatient 100 UN 25.38 16.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.37 24.62 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50107366_1 CDM 0250 RC 67457-0420-10 NDC J1100 HCPCS inpatient 100 UN 25.38 16.5 ANTHEM HMO ANTHEM HMO 999999999 15.37 24.62 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50107366_1 CDM 0250 RC 67457-0420-10 NDC J1100 HCPCS inpatient 100 UN 25.38 16.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.16 67.6 999999999 15.37 24.62 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50107366_1 CDM 0250 RC 67457-0420-10 NDC J1100 HCPCS inpatient 100 UN 25.38 16.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.37 24.62 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50107366_1 CDM 0250 RC 67457-0420-10 NDC J1100 HCPCS inpatient 100 UN 25.38 16.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.37 24.62 ACETYLCYSTEINE 6 GRAM/30 ML VL 50107374_1 CDM 0250 RC 25021-0812-30 NDC inpatient 1 UN 172.31 112 AETNA AETNA 136.12 79 999999999 104.33 167.14 percent of total billed charges ACETYLCYSTEINE 6 GRAM/30 ML VL 50107374_1 CDM 0250 RC 25021-0812-30 NDC inpatient 1 UN 172.31 112 SELF PAY DISCOUNT SELF PAY DISCOUNT 112 65 999999999 104.33 167.14 percent of total billed charges ACETYLCYSTEINE 6 GRAM/30 ML VL 50107374_1 CDM 0250 RC 25021-0812-30 NDC inpatient 1 UN 172.31 112 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 167.14 97 999999999 104.33 167.14 percent of total billed charges ACETYLCYSTEINE 6 GRAM/30 ML VL 50107374_1 CDM 0250 RC 25021-0812-30 NDC inpatient 1 UN 172.31 112 ENCORE - ALL PLANS ENCORE - ALL PLANS 118.89 69 999999999 104.33 167.14 percent of total billed charges ACETYLCYSTEINE 6 GRAM/30 ML VL 50107374_1 CDM 0250 RC 25021-0812-30 NDC inpatient 1 UN 172.31 112 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.4 78 999999999 104.33 167.14 percent of total billed charges ACETYLCYSTEINE 6 GRAM/30 ML VL 50107374_1 CDM 0250 RC 25021-0812-30 NDC inpatient 1 UN 172.31 112 UMR - ALL PLANS UMR - ALL PLANS 120.62 70 999999999 104.33 167.14 percent of total billed charges ACETYLCYSTEINE 6 GRAM/30 ML VL 50107374_1 CDM 0250 RC 25021-0812-30 NDC inpatient 1 UN 172.31 112 SIHO - ALL PLANS SIHO - ALL PLANS 155.08 90 999999999 104.33 167.14 percent of total billed charges ACETYLCYSTEINE 6 GRAM/30 ML VL 50107374_1 CDM 0250 RC 25021-0812-30 NDC inpatient 1 UN 172.31 112 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.33 60.55 999999999 104.33 167.14 percent of total billed charges ACETYLCYSTEINE 6 GRAM/30 ML VL 50107374_1 CDM 0250 RC 25021-0812-30 NDC inpatient 1 UN 172.31 112 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.33 167.14 ACETYLCYSTEINE 6 GRAM/30 ML VL 50107374_1 CDM 0250 RC 25021-0812-30 NDC inpatient 1 UN 172.31 112 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.33 167.14 ACETYLCYSTEINE 6 GRAM/30 ML VL 50107374_1 CDM 0250 RC 25021-0812-30 NDC inpatient 1 UN 172.31 112 ANTHEM HMO ANTHEM HMO 999999999 104.33 167.14 ACETYLCYSTEINE 6 GRAM/30 ML VL 50107374_1 CDM 0250 RC 25021-0812-30 NDC inpatient 1 UN 172.31 112 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.48 67.6 999999999 104.33 167.14 percent of total billed charges ACETYLCYSTEINE 6 GRAM/30 ML VL 50107374_1 CDM 0250 RC 25021-0812-30 NDC inpatient 1 UN 172.31 112 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.33 167.14 ACETYLCYSTEINE 6 GRAM/30 ML VL 50107374_1 CDM 0250 RC 25021-0812-30 NDC inpatient 1 UN 172.31 112 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.33 167.14 SULFATRIM PEDIATRIC SUSPENSION 50107376_1 CDM 0250 RC 00121-0854-16 NDC inpatient 1 UN 3.23 2.1 AETNA AETNA 2.55 79 999999999 1.96 3.13 percent of total billed charges SULFATRIM PEDIATRIC SUSPENSION 50107376_1 CDM 0250 RC 00121-0854-16 NDC inpatient 1 UN 3.23 2.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.1 65 999999999 1.96 3.13 percent of total billed charges SULFATRIM PEDIATRIC SUSPENSION 50107376_1 CDM 0250 RC 00121-0854-16 NDC inpatient 1 UN 3.23 2.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.13 97 999999999 1.96 3.13 percent of total billed charges SULFATRIM PEDIATRIC SUSPENSION 50107376_1 CDM 0250 RC 00121-0854-16 NDC inpatient 1 UN 3.23 2.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.23 69 999999999 1.96 3.13 percent of total billed charges SULFATRIM PEDIATRIC SUSPENSION 50107376_1 CDM 0250 RC 00121-0854-16 NDC inpatient 1 UN 3.23 2.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.52 78 999999999 1.96 3.13 percent of total billed charges SULFATRIM PEDIATRIC SUSPENSION 50107376_1 CDM 0250 RC 00121-0854-16 NDC inpatient 1 UN 3.23 2.1 UMR - ALL PLANS UMR - ALL PLANS 2.26 70 999999999 1.96 3.13 percent of total billed charges SULFATRIM PEDIATRIC SUSPENSION 50107376_1 CDM 0250 RC 00121-0854-16 NDC inpatient 1 UN 3.23 2.1 SIHO - ALL PLANS SIHO - ALL PLANS 2.91 90 999999999 1.96 3.13 percent of total billed charges SULFATRIM PEDIATRIC SUSPENSION 50107376_1 CDM 0250 RC 00121-0854-16 NDC inpatient 1 UN 3.23 2.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.96 60.55 999999999 1.96 3.13 percent of total billed charges SULFATRIM PEDIATRIC SUSPENSION 50107376_1 CDM 0250 RC 00121-0854-16 NDC inpatient 1 UN 3.23 2.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.96 3.13 SULFATRIM PEDIATRIC SUSPENSION 50107376_1 CDM 0250 RC 00121-0854-16 NDC inpatient 1 UN 3.23 2.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.96 3.13 SULFATRIM PEDIATRIC SUSPENSION 50107376_1 CDM 0250 RC 00121-0854-16 NDC inpatient 1 UN 3.23 2.1 ANTHEM HMO ANTHEM HMO 999999999 1.96 3.13 SULFATRIM PEDIATRIC SUSPENSION 50107376_1 CDM 0250 RC 00121-0854-16 NDC inpatient 1 UN 3.23 2.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.18 67.6 999999999 1.96 3.13 percent of total billed charges SULFATRIM PEDIATRIC SUSPENSION 50107376_1 CDM 0250 RC 00121-0854-16 NDC inpatient 1 UN 3.23 2.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.96 3.13 SULFATRIM PEDIATRIC SUSPENSION 50107376_1 CDM 0250 RC 00121-0854-16 NDC inpatient 1 UN 3.23 2.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.96 3.13 NITROGLYCERIN 0.2 MG/HR PATCH 50107377_1 CDM 0250 RC 68382-0309-30 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges NITROGLYCERIN 0.2 MG/HR PATCH 50107377_1 CDM 0250 RC 68382-0309-30 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges NITROGLYCERIN 0.2 MG/HR PATCH 50107377_1 CDM 0250 RC 68382-0309-30 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges NITROGLYCERIN 0.2 MG/HR PATCH 50107377_1 CDM 0250 RC 68382-0309-30 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges NITROGLYCERIN 0.2 MG/HR PATCH 50107377_1 CDM 0250 RC 68382-0309-30 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges NITROGLYCERIN 0.2 MG/HR PATCH 50107377_1 CDM 0250 RC 68382-0309-30 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges NITROGLYCERIN 0.2 MG/HR PATCH 50107377_1 CDM 0250 RC 68382-0309-30 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges NITROGLYCERIN 0.2 MG/HR PATCH 50107377_1 CDM 0250 RC 68382-0309-30 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges NITROGLYCERIN 0.2 MG/HR PATCH 50107377_1 CDM 0250 RC 68382-0309-30 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 NITROGLYCERIN 0.2 MG/HR PATCH 50107377_1 CDM 0250 RC 68382-0309-30 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 NITROGLYCERIN 0.2 MG/HR PATCH 50107377_1 CDM 0250 RC 68382-0309-30 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 NITROGLYCERIN 0.2 MG/HR PATCH 50107377_1 CDM 0250 RC 68382-0309-30 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges NITROGLYCERIN 0.2 MG/HR PATCH 50107377_1 CDM 0250 RC 68382-0309-30 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 NITROGLYCERIN 0.2 MG/HR PATCH 50107377_1 CDM 0250 RC 68382-0309-30 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 SULFAMETHOXAZOLE-TMP SS TABLET 50107379_1 CDM 0250 RC 65862-0419-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges SULFAMETHOXAZOLE-TMP SS TABLET 50107379_1 CDM 0250 RC 65862-0419-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges SULFAMETHOXAZOLE-TMP SS TABLET 50107379_1 CDM 0250 RC 65862-0419-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges SULFAMETHOXAZOLE-TMP SS TABLET 50107379_1 CDM 0250 RC 65862-0419-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges SULFAMETHOXAZOLE-TMP SS TABLET 50107379_1 CDM 0250 RC 65862-0419-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges SULFAMETHOXAZOLE-TMP SS TABLET 50107379_1 CDM 0250 RC 65862-0419-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges SULFAMETHOXAZOLE-TMP SS TABLET 50107379_1 CDM 0250 RC 65862-0419-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges SULFAMETHOXAZOLE-TMP SS TABLET 50107379_1 CDM 0250 RC 65862-0419-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges SULFAMETHOXAZOLE-TMP SS TABLET 50107379_1 CDM 0250 RC 65862-0419-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 SULFAMETHOXAZOLE-TMP SS TABLET 50107379_1 CDM 0250 RC 65862-0419-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 SULFAMETHOXAZOLE-TMP SS TABLET 50107379_1 CDM 0250 RC 65862-0419-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 SULFAMETHOXAZOLE-TMP SS TABLET 50107379_1 CDM 0250 RC 65862-0419-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges SULFAMETHOXAZOLE-TMP SS TABLET 50107379_1 CDM 0250 RC 65862-0419-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 SULFAMETHOXAZOLE-TMP SS TABLET 50107379_1 CDM 0250 RC 65862-0419-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 68001-0142-00 - ramipril 2.5 mg Cap[JOHN] 50107380_1 CDM 0250 RC 68001-0142-00 NDC inpatient 1 UN 1.29 0.84 AETNA AETNA 1.02 79 999999999 0.78 1.25 percent of total billed charges 68001-0142-00 - ramipril 2.5 mg Cap[JOHN] 50107380_1 CDM 0250 RC 68001-0142-00 NDC inpatient 1 UN 1.29 0.84 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.84 65 999999999 0.78 1.25 percent of total billed charges 68001-0142-00 - ramipril 2.5 mg Cap[JOHN] 50107380_1 CDM 0250 RC 68001-0142-00 NDC inpatient 1 UN 1.29 0.84 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.25 97 999999999 0.78 1.25 percent of total billed charges 68001-0142-00 - ramipril 2.5 mg Cap[JOHN] 50107380_1 CDM 0250 RC 68001-0142-00 NDC inpatient 1 UN 1.29 0.84 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.89 69 999999999 0.78 1.25 percent of total billed charges 68001-0142-00 - ramipril 2.5 mg Cap[JOHN] 50107380_1 CDM 0250 RC 68001-0142-00 NDC inpatient 1 UN 1.29 0.84 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.01 78 999999999 0.78 1.25 percent of total billed charges 68001-0142-00 - ramipril 2.5 mg Cap[JOHN] 50107380_1 CDM 0250 RC 68001-0142-00 NDC inpatient 1 UN 1.29 0.84 UMR - ALL PLANS UMR - ALL PLANS 0.9 70 999999999 0.78 1.25 percent of total billed charges 68001-0142-00 - ramipril 2.5 mg Cap[JOHN] 50107380_1 CDM 0250 RC 68001-0142-00 NDC inpatient 1 UN 1.29 0.84 SIHO - ALL PLANS SIHO - ALL PLANS 1.16 90 999999999 0.78 1.25 percent of total billed charges 68001-0142-00 - ramipril 2.5 mg Cap[JOHN] 50107380_1 CDM 0250 RC 68001-0142-00 NDC inpatient 1 UN 1.29 0.84 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.78 60.55 999999999 0.78 1.25 percent of total billed charges 68001-0142-00 - ramipril 2.5 mg Cap[JOHN] 50107380_1 CDM 0250 RC 68001-0142-00 NDC inpatient 1 UN 1.29 0.84 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.78 1.25 68001-0142-00 - ramipril 2.5 mg Cap[JOHN] 50107380_1 CDM 0250 RC 68001-0142-00 NDC inpatient 1 UN 1.29 0.84 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.78 1.25 68001-0142-00 - ramipril 2.5 mg Cap[JOHN] 50107380_1 CDM 0250 RC 68001-0142-00 NDC inpatient 1 UN 1.29 0.84 ANTHEM HMO ANTHEM HMO 999999999 0.78 1.25 68001-0142-00 - ramipril 2.5 mg Cap[JOHN] 50107380_1 CDM 0250 RC 68001-0142-00 NDC inpatient 1 UN 1.29 0.84 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.87 67.6 999999999 0.78 1.25 percent of total billed charges 68001-0142-00 - ramipril 2.5 mg Cap[JOHN] 50107380_1 CDM 0250 RC 68001-0142-00 NDC inpatient 1 UN 1.29 0.84 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.78 1.25 68001-0142-00 - ramipril 2.5 mg Cap[JOHN] 50107380_1 CDM 0250 RC 68001-0142-00 NDC inpatient 1 UN 1.29 0.84 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.78 1.25 ENALAPRIL MALEATE 10 MG TAB 50107385_1 CDM 0250 RC 51672-4039-01 NDC inpatient 1 UN 1.6 1.04 AETNA AETNA 1.26 79 999999999 0.97 1.55 percent of total billed charges ENALAPRIL MALEATE 10 MG TAB 50107385_1 CDM 0250 RC 51672-4039-01 NDC inpatient 1 UN 1.6 1.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.04 65 999999999 0.97 1.55 percent of total billed charges ENALAPRIL MALEATE 10 MG TAB 50107385_1 CDM 0250 RC 51672-4039-01 NDC inpatient 1 UN 1.6 1.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.55 97 999999999 0.97 1.55 percent of total billed charges ENALAPRIL MALEATE 10 MG TAB 50107385_1 CDM 0250 RC 51672-4039-01 NDC inpatient 1 UN 1.6 1.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.1 69 999999999 0.97 1.55 percent of total billed charges ENALAPRIL MALEATE 10 MG TAB 50107385_1 CDM 0250 RC 51672-4039-01 NDC inpatient 1 UN 1.6 1.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.25 78 999999999 0.97 1.55 percent of total billed charges ENALAPRIL MALEATE 10 MG TAB 50107385_1 CDM 0250 RC 51672-4039-01 NDC inpatient 1 UN 1.6 1.04 UMR - ALL PLANS UMR - ALL PLANS 1.12 70 999999999 0.97 1.55 percent of total billed charges ENALAPRIL MALEATE 10 MG TAB 50107385_1 CDM 0250 RC 51672-4039-01 NDC inpatient 1 UN 1.6 1.04 SIHO - ALL PLANS SIHO - ALL PLANS 1.44 90 999999999 0.97 1.55 percent of total billed charges ENALAPRIL MALEATE 10 MG TAB 50107385_1 CDM 0250 RC 51672-4039-01 NDC inpatient 1 UN 1.6 1.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.97 60.55 999999999 0.97 1.55 percent of total billed charges ENALAPRIL MALEATE 10 MG TAB 50107385_1 CDM 0250 RC 51672-4039-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.97 1.55 ENALAPRIL MALEATE 10 MG TAB 50107385_1 CDM 0250 RC 51672-4039-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.97 1.55 ENALAPRIL MALEATE 10 MG TAB 50107385_1 CDM 0250 RC 51672-4039-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM HMO ANTHEM HMO 999999999 0.97 1.55 ENALAPRIL MALEATE 10 MG TAB 50107385_1 CDM 0250 RC 51672-4039-01 NDC inpatient 1 UN 1.6 1.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.08 67.6 999999999 0.97 1.55 percent of total billed charges ENALAPRIL MALEATE 10 MG TAB 50107385_1 CDM 0250 RC 51672-4039-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.97 1.55 ENALAPRIL MALEATE 10 MG TAB 50107385_1 CDM 0250 RC 51672-4039-01 NDC inpatient 1 UN 1.6 1.04 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.97 1.55 INDOMETHACIN 25 MG CAPSULE 50107387_1 CDM 0250 RC 31722-0542-01 NDC inpatient 1 UN 1.33 0.86 AETNA AETNA 1.05 79 999999999 0.81 1.29 percent of total billed charges INDOMETHACIN 25 MG CAPSULE 50107387_1 CDM 0250 RC 31722-0542-01 NDC inpatient 1 UN 1.33 0.86 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.86 65 999999999 0.81 1.29 percent of total billed charges INDOMETHACIN 25 MG CAPSULE 50107387_1 CDM 0250 RC 31722-0542-01 NDC inpatient 1 UN 1.33 0.86 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.29 97 999999999 0.81 1.29 percent of total billed charges INDOMETHACIN 25 MG CAPSULE 50107387_1 CDM 0250 RC 31722-0542-01 NDC inpatient 1 UN 1.33 0.86 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.92 69 999999999 0.81 1.29 percent of total billed charges INDOMETHACIN 25 MG CAPSULE 50107387_1 CDM 0250 RC 31722-0542-01 NDC inpatient 1 UN 1.33 0.86 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.04 78 999999999 0.81 1.29 percent of total billed charges INDOMETHACIN 25 MG CAPSULE 50107387_1 CDM 0250 RC 31722-0542-01 NDC inpatient 1 UN 1.33 0.86 UMR - ALL PLANS UMR - ALL PLANS 0.93 70 999999999 0.81 1.29 percent of total billed charges INDOMETHACIN 25 MG CAPSULE 50107387_1 CDM 0250 RC 31722-0542-01 NDC inpatient 1 UN 1.33 0.86 SIHO - ALL PLANS SIHO - ALL PLANS 1.2 90 999999999 0.81 1.29 percent of total billed charges INDOMETHACIN 25 MG CAPSULE 50107387_1 CDM 0250 RC 31722-0542-01 NDC inpatient 1 UN 1.33 0.86 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.81 60.55 999999999 0.81 1.29 percent of total billed charges INDOMETHACIN 25 MG CAPSULE 50107387_1 CDM 0250 RC 31722-0542-01 NDC inpatient 1 UN 1.33 0.86 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.81 1.29 INDOMETHACIN 25 MG CAPSULE 50107387_1 CDM 0250 RC 31722-0542-01 NDC inpatient 1 UN 1.33 0.86 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.81 1.29 INDOMETHACIN 25 MG CAPSULE 50107387_1 CDM 0250 RC 31722-0542-01 NDC inpatient 1 UN 1.33 0.86 ANTHEM HMO ANTHEM HMO 999999999 0.81 1.29 INDOMETHACIN 25 MG CAPSULE 50107387_1 CDM 0250 RC 31722-0542-01 NDC inpatient 1 UN 1.33 0.86 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.9 67.6 999999999 0.81 1.29 percent of total billed charges INDOMETHACIN 25 MG CAPSULE 50107387_1 CDM 0250 RC 31722-0542-01 NDC inpatient 1 UN 1.33 0.86 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.81 1.29 INDOMETHACIN 25 MG CAPSULE 50107387_1 CDM 0250 RC 31722-0542-01 NDC inpatient 1 UN 1.33 0.86 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.81 1.29 MICONAZOLE 7 CREAM 50107388_1 CDM 0250 RC 24385-0590-29 NDC inpatient 1 UN 15.27 9.93 AETNA AETNA 12.06 79 999999999 9.25 14.81 percent of total billed charges MICONAZOLE 7 CREAM 50107388_1 CDM 0250 RC 24385-0590-29 NDC inpatient 1 UN 15.27 9.93 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.93 65 999999999 9.25 14.81 percent of total billed charges MICONAZOLE 7 CREAM 50107388_1 CDM 0250 RC 24385-0590-29 NDC inpatient 1 UN 15.27 9.93 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14.81 97 999999999 9.25 14.81 percent of total billed charges MICONAZOLE 7 CREAM 50107388_1 CDM 0250 RC 24385-0590-29 NDC inpatient 1 UN 15.27 9.93 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.54 69 999999999 9.25 14.81 percent of total billed charges MICONAZOLE 7 CREAM 50107388_1 CDM 0250 RC 24385-0590-29 NDC inpatient 1 UN 15.27 9.93 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.91 78 999999999 9.25 14.81 percent of total billed charges MICONAZOLE 7 CREAM 50107388_1 CDM 0250 RC 24385-0590-29 NDC inpatient 1 UN 15.27 9.93 UMR - ALL PLANS UMR - ALL PLANS 10.69 70 999999999 9.25 14.81 percent of total billed charges MICONAZOLE 7 CREAM 50107388_1 CDM 0250 RC 24385-0590-29 NDC inpatient 1 UN 15.27 9.93 SIHO - ALL PLANS SIHO - ALL PLANS 13.74 90 999999999 9.25 14.81 percent of total billed charges MICONAZOLE 7 CREAM 50107388_1 CDM 0250 RC 24385-0590-29 NDC inpatient 1 UN 15.27 9.93 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.25 60.55 999999999 9.25 14.81 percent of total billed charges MICONAZOLE 7 CREAM 50107388_1 CDM 0250 RC 24385-0590-29 NDC inpatient 1 UN 15.27 9.93 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.25 14.81 MICONAZOLE 7 CREAM 50107388_1 CDM 0250 RC 24385-0590-29 NDC inpatient 1 UN 15.27 9.93 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.25 14.81 MICONAZOLE 7 CREAM 50107388_1 CDM 0250 RC 24385-0590-29 NDC inpatient 1 UN 15.27 9.93 ANTHEM HMO ANTHEM HMO 999999999 9.25 14.81 MICONAZOLE 7 CREAM 50107388_1 CDM 0250 RC 24385-0590-29 NDC inpatient 1 UN 15.27 9.93 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.32 67.6 999999999 9.25 14.81 percent of total billed charges MICONAZOLE 7 CREAM 50107388_1 CDM 0250 RC 24385-0590-29 NDC inpatient 1 UN 15.27 9.93 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.25 14.81 MICONAZOLE 7 CREAM 50107388_1 CDM 0250 RC 24385-0590-29 NDC inpatient 1 UN 15.27 9.93 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.25 14.81 BUSPIRONE HCL 10 MG TABLET 50111269_1 CDM 0250 RC 64380-0742-06 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges BUSPIRONE HCL 10 MG TABLET 50111269_1 CDM 0250 RC 64380-0742-06 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges BUSPIRONE HCL 10 MG TABLET 50111269_1 CDM 0250 RC 64380-0742-06 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges BUSPIRONE HCL 10 MG TABLET 50111269_1 CDM 0250 RC 64380-0742-06 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges BUSPIRONE HCL 10 MG TABLET 50111269_1 CDM 0250 RC 64380-0742-06 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges BUSPIRONE HCL 10 MG TABLET 50111269_1 CDM 0250 RC 64380-0742-06 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges BUSPIRONE HCL 10 MG TABLET 50111269_1 CDM 0250 RC 64380-0742-06 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges BUSPIRONE HCL 10 MG TABLET 50111269_1 CDM 0250 RC 64380-0742-06 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges BUSPIRONE HCL 10 MG TABLET 50111269_1 CDM 0250 RC 64380-0742-06 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 BUSPIRONE HCL 10 MG TABLET 50111269_1 CDM 0250 RC 64380-0742-06 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 BUSPIRONE HCL 10 MG TABLET 50111269_1 CDM 0250 RC 64380-0742-06 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 BUSPIRONE HCL 10 MG TABLET 50111269_1 CDM 0250 RC 64380-0742-06 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges BUSPIRONE HCL 10 MG TABLET 50111269_1 CDM 0250 RC 64380-0742-06 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 BUSPIRONE HCL 10 MG TABLET 50111269_1 CDM 0250 RC 64380-0742-06 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "61924-0174-04 - emollients, Top Crm 113 gm [JOHN]" 50111270_1 CDM 0250 RC 61924-0174-04 NDC inpatient 1 UN 14.28 9.28 AETNA AETNA 11.28 79 999999999 8.65 13.85 percent of total billed charges "61924-0174-04 - emollients, Top Crm 113 gm [JOHN]" 50111270_1 CDM 0250 RC 61924-0174-04 NDC inpatient 1 UN 14.28 9.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.28 65 999999999 8.65 13.85 percent of total billed charges "61924-0174-04 - emollients, Top Crm 113 gm [JOHN]" 50111270_1 CDM 0250 RC 61924-0174-04 NDC inpatient 1 UN 14.28 9.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13.85 97 999999999 8.65 13.85 percent of total billed charges "61924-0174-04 - emollients, Top Crm 113 gm [JOHN]" 50111270_1 CDM 0250 RC 61924-0174-04 NDC inpatient 1 UN 14.28 9.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.85 69 999999999 8.65 13.85 percent of total billed charges "61924-0174-04 - emollients, Top Crm 113 gm [JOHN]" 50111270_1 CDM 0250 RC 61924-0174-04 NDC inpatient 1 UN 14.28 9.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.14 78 999999999 8.65 13.85 percent of total billed charges "61924-0174-04 - emollients, Top Crm 113 gm [JOHN]" 50111270_1 CDM 0250 RC 61924-0174-04 NDC inpatient 1 UN 14.28 9.28 UMR - ALL PLANS UMR - ALL PLANS 10 70 999999999 8.65 13.85 percent of total billed charges "61924-0174-04 - emollients, Top Crm 113 gm [JOHN]" 50111270_1 CDM 0250 RC 61924-0174-04 NDC inpatient 1 UN 14.28 9.28 SIHO - ALL PLANS SIHO - ALL PLANS 12.85 90 999999999 8.65 13.85 percent of total billed charges "61924-0174-04 - emollients, Top Crm 113 gm [JOHN]" 50111270_1 CDM 0250 RC 61924-0174-04 NDC inpatient 1 UN 14.28 9.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.65 60.55 999999999 8.65 13.85 percent of total billed charges "61924-0174-04 - emollients, Top Crm 113 gm [JOHN]" 50111270_1 CDM 0250 RC 61924-0174-04 NDC inpatient 1 UN 14.28 9.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.65 13.85 "61924-0174-04 - emollients, Top Crm 113 gm [JOHN]" 50111270_1 CDM 0250 RC 61924-0174-04 NDC inpatient 1 UN 14.28 9.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.65 13.85 "61924-0174-04 - emollients, Top Crm 113 gm [JOHN]" 50111270_1 CDM 0250 RC 61924-0174-04 NDC inpatient 1 UN 14.28 9.28 ANTHEM HMO ANTHEM HMO 999999999 8.65 13.85 "61924-0174-04 - emollients, Top Crm 113 gm [JOHN]" 50111270_1 CDM 0250 RC 61924-0174-04 NDC inpatient 1 UN 14.28 9.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.65 67.6 999999999 8.65 13.85 percent of total billed charges "61924-0174-04 - emollients, Top Crm 113 gm [JOHN]" 50111270_1 CDM 0250 RC 61924-0174-04 NDC inpatient 1 UN 14.28 9.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.65 13.85 "61924-0174-04 - emollients, Top Crm 113 gm [JOHN]" 50111270_1 CDM 0250 RC 61924-0174-04 NDC inpatient 1 UN 14.28 9.28 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.65 13.85 "Microscopic genetic analysis of tumor, manual" 50111483_1 CDM 0312 RC 88360 HCPCS inpatient 317 206.05 AETNA AETNA 250.43 79 999999999 191.94 307.49 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50111483_1 CDM 0312 RC 88360 HCPCS inpatient 317 206.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 206.05 65 999999999 191.94 307.49 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50111483_1 CDM 0312 RC 88360 HCPCS inpatient 317 206.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 307.49 97 999999999 191.94 307.49 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50111483_1 CDM 0312 RC 88360 HCPCS inpatient 317 206.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 218.73 69 999999999 191.94 307.49 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50111483_1 CDM 0312 RC 88360 HCPCS inpatient 317 206.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 247.26 78 999999999 191.94 307.49 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50111483_1 CDM 0312 RC 88360 HCPCS inpatient 317 206.05 UMR - ALL PLANS UMR - ALL PLANS 221.9 70 999999999 191.94 307.49 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50111483_1 CDM 0312 RC 88360 HCPCS inpatient 317 206.05 SIHO - ALL PLANS SIHO - ALL PLANS 285.3 90 999999999 191.94 307.49 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50111483_1 CDM 0312 RC 88360 HCPCS inpatient 317 206.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 191.94 60.55 999999999 191.94 307.49 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50111483_1 CDM 0312 RC 88360 HCPCS inpatient 317 206.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 191.94 307.49 "Microscopic genetic analysis of tumor, manual" 50111483_1 CDM 0312 RC 88360 HCPCS inpatient 317 206.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 191.94 307.49 "Microscopic genetic analysis of tumor, manual" 50111483_1 CDM 0312 RC 88360 HCPCS inpatient 317 206.05 ANTHEM HMO ANTHEM HMO 999999999 191.94 307.49 "Microscopic genetic analysis of tumor, manual" 50111483_1 CDM 0312 RC 88360 HCPCS inpatient 317 206.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 214.29 67.6 999999999 191.94 307.49 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50111483_1 CDM 0312 RC 88360 HCPCS inpatient 317 206.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 191.94 307.49 "Microscopic genetic analysis of tumor, manual" 50111483_1 CDM 0312 RC 88360 HCPCS inpatient 317 206.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 191.94 307.49 Carotene level 50113391_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges Carotene level 50113391_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges Carotene level 50113391_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges Carotene level 50113391_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges Carotene level 50113391_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges Carotene level 50113391_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges Carotene level 50113391_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges Carotene level 50113391_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges Carotene level 50113391_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 Carotene level 50113391_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 Carotene level 50113391_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 Carotene level 50113391_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges Carotene level 50113391_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 Carotene level 50113391_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 Renin (kidney enzyme) level 50115469_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 AETNA AETNA 285.98 79 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 50115469_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 235.3 65 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 50115469_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 351.14 97 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 50115469_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 249.78 69 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 50115469_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 282.36 78 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 50115469_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 UMR - ALL PLANS UMR - ALL PLANS 253.4 70 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 50115469_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 SIHO - ALL PLANS SIHO - ALL PLANS 325.8 90 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 50115469_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 219.19 60.55 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 50115469_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 219.19 351.14 Renin (kidney enzyme) level 50115469_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 219.19 351.14 Renin (kidney enzyme) level 50115469_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 ANTHEM HMO ANTHEM HMO 999999999 219.19 351.14 Renin (kidney enzyme) level 50115469_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 244.71 67.6 999999999 219.19 351.14 percent of total billed charges Renin (kidney enzyme) level 50115469_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 219.19 351.14 Renin (kidney enzyme) level 50115469_1 CDM 0301 RC 84244 HCPCS inpatient 362 235.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 219.19 351.14 "Clotting factor X assessment test, diluted" 50115478_1 CDM 0301 RC 85613 HCPCS inpatient 125 81.25 AETNA AETNA 98.75 79 999999999 75.69 121.25 percent of total billed charges "Clotting factor X assessment test, diluted" 50115478_1 CDM 0301 RC 85613 HCPCS inpatient 125 81.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.25 65 999999999 75.69 121.25 percent of total billed charges "Clotting factor X assessment test, diluted" 50115478_1 CDM 0301 RC 85613 HCPCS inpatient 125 81.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 121.25 97 999999999 75.69 121.25 percent of total billed charges "Clotting factor X assessment test, diluted" 50115478_1 CDM 0301 RC 85613 HCPCS inpatient 125 81.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.25 69 999999999 75.69 121.25 percent of total billed charges "Clotting factor X assessment test, diluted" 50115478_1 CDM 0301 RC 85613 HCPCS inpatient 125 81.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.5 78 999999999 75.69 121.25 percent of total billed charges "Clotting factor X assessment test, diluted" 50115478_1 CDM 0301 RC 85613 HCPCS inpatient 125 81.25 UMR - ALL PLANS UMR - ALL PLANS 87.5 70 999999999 75.69 121.25 percent of total billed charges "Clotting factor X assessment test, diluted" 50115478_1 CDM 0301 RC 85613 HCPCS inpatient 125 81.25 SIHO - ALL PLANS SIHO - ALL PLANS 112.5 90 999999999 75.69 121.25 percent of total billed charges "Clotting factor X assessment test, diluted" 50115478_1 CDM 0301 RC 85613 HCPCS inpatient 125 81.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.69 60.55 999999999 75.69 121.25 percent of total billed charges "Clotting factor X assessment test, diluted" 50115478_1 CDM 0301 RC 85613 HCPCS inpatient 125 81.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.69 121.25 "Clotting factor X assessment test, diluted" 50115478_1 CDM 0301 RC 85613 HCPCS inpatient 125 81.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.69 121.25 "Clotting factor X assessment test, diluted" 50115478_1 CDM 0301 RC 85613 HCPCS inpatient 125 81.25 ANTHEM HMO ANTHEM HMO 999999999 75.69 121.25 "Clotting factor X assessment test, diluted" 50115478_1 CDM 0301 RC 85613 HCPCS inpatient 125 81.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.5 67.6 999999999 75.69 121.25 percent of total billed charges "Clotting factor X assessment test, diluted" 50115478_1 CDM 0301 RC 85613 HCPCS inpatient 125 81.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.69 121.25 "Clotting factor X assessment test, diluted" 50115478_1 CDM 0301 RC 85613 HCPCS inpatient 125 81.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.69 121.25 HYDROCODONE-ACETAMIN 10-325 MG 50116559_1 CDM 0250 RC 60687-0418-01 NDC inpatient 1 UN 1.98 1.29 AETNA AETNA 1.56 79 999999999 1.2 1.92 percent of total billed charges HYDROCODONE-ACETAMIN 10-325 MG 50116559_1 CDM 0250 RC 60687-0418-01 NDC inpatient 1 UN 1.98 1.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.29 65 999999999 1.2 1.92 percent of total billed charges HYDROCODONE-ACETAMIN 10-325 MG 50116559_1 CDM 0250 RC 60687-0418-01 NDC inpatient 1 UN 1.98 1.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.92 97 999999999 1.2 1.92 percent of total billed charges HYDROCODONE-ACETAMIN 10-325 MG 50116559_1 CDM 0250 RC 60687-0418-01 NDC inpatient 1 UN 1.98 1.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.37 69 999999999 1.2 1.92 percent of total billed charges HYDROCODONE-ACETAMIN 10-325 MG 50116559_1 CDM 0250 RC 60687-0418-01 NDC inpatient 1 UN 1.98 1.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.54 78 999999999 1.2 1.92 percent of total billed charges HYDROCODONE-ACETAMIN 10-325 MG 50116559_1 CDM 0250 RC 60687-0418-01 NDC inpatient 1 UN 1.98 1.29 UMR - ALL PLANS UMR - ALL PLANS 1.39 70 999999999 1.2 1.92 percent of total billed charges HYDROCODONE-ACETAMIN 10-325 MG 50116559_1 CDM 0250 RC 60687-0418-01 NDC inpatient 1 UN 1.98 1.29 SIHO - ALL PLANS SIHO - ALL PLANS 1.78 90 999999999 1.2 1.92 percent of total billed charges HYDROCODONE-ACETAMIN 10-325 MG 50116559_1 CDM 0250 RC 60687-0418-01 NDC inpatient 1 UN 1.98 1.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.2 60.55 999999999 1.2 1.92 percent of total billed charges HYDROCODONE-ACETAMIN 10-325 MG 50116559_1 CDM 0250 RC 60687-0418-01 NDC inpatient 1 UN 1.98 1.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.2 1.92 HYDROCODONE-ACETAMIN 10-325 MG 50116559_1 CDM 0250 RC 60687-0418-01 NDC inpatient 1 UN 1.98 1.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.2 1.92 HYDROCODONE-ACETAMIN 10-325 MG 50116559_1 CDM 0250 RC 60687-0418-01 NDC inpatient 1 UN 1.98 1.29 ANTHEM HMO ANTHEM HMO 999999999 1.2 1.92 HYDROCODONE-ACETAMIN 10-325 MG 50116559_1 CDM 0250 RC 60687-0418-01 NDC inpatient 1 UN 1.98 1.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.34 67.6 999999999 1.2 1.92 percent of total billed charges HYDROCODONE-ACETAMIN 10-325 MG 50116559_1 CDM 0250 RC 60687-0418-01 NDC inpatient 1 UN 1.98 1.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.2 1.92 HYDROCODONE-ACETAMIN 10-325 MG 50116559_1 CDM 0250 RC 60687-0418-01 NDC inpatient 1 UN 1.98 1.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.2 1.92 PIPERACIL-TAZOBACT 3.375 GM VL 50118268_1 CDM 0250 RC 55150-0120-30 NDC inpatient 2 UN 32.41 21.07 AETNA AETNA 25.6 79 999999999 19.62 31.44 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50118268_1 CDM 0250 RC 55150-0120-30 NDC inpatient 2 UN 32.41 21.07 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.07 65 999999999 19.62 31.44 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50118268_1 CDM 0250 RC 55150-0120-30 NDC inpatient 2 UN 32.41 21.07 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31.44 97 999999999 19.62 31.44 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50118268_1 CDM 0250 RC 55150-0120-30 NDC inpatient 2 UN 32.41 21.07 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.36 69 999999999 19.62 31.44 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50118268_1 CDM 0250 RC 55150-0120-30 NDC inpatient 2 UN 32.41 21.07 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.28 78 999999999 19.62 31.44 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50118268_1 CDM 0250 RC 55150-0120-30 NDC inpatient 2 UN 32.41 21.07 UMR - ALL PLANS UMR - ALL PLANS 22.69 70 999999999 19.62 31.44 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50118268_1 CDM 0250 RC 55150-0120-30 NDC inpatient 2 UN 32.41 21.07 SIHO - ALL PLANS SIHO - ALL PLANS 29.17 90 999999999 19.62 31.44 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50118268_1 CDM 0250 RC 55150-0120-30 NDC inpatient 2 UN 32.41 21.07 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.62 60.55 999999999 19.62 31.44 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50118268_1 CDM 0250 RC 55150-0120-30 NDC inpatient 2 UN 32.41 21.07 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.62 31.44 PIPERACIL-TAZOBACT 3.375 GM VL 50118268_1 CDM 0250 RC 55150-0120-30 NDC inpatient 2 UN 32.41 21.07 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.62 31.44 PIPERACIL-TAZOBACT 3.375 GM VL 50118268_1 CDM 0250 RC 55150-0120-30 NDC inpatient 2 UN 32.41 21.07 ANTHEM HMO ANTHEM HMO 999999999 19.62 31.44 PIPERACIL-TAZOBACT 3.375 GM VL 50118268_1 CDM 0250 RC 55150-0120-30 NDC inpatient 2 UN 32.41 21.07 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.91 67.6 999999999 19.62 31.44 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50118268_1 CDM 0250 RC 55150-0120-30 NDC inpatient 2 UN 32.41 21.07 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.62 31.44 PIPERACIL-TAZOBACT 3.375 GM VL 50118268_1 CDM 0250 RC 55150-0120-30 NDC inpatient 2 UN 32.41 21.07 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.62 31.44 CALCITRIOL 0.25 MCG CAPSULE 50121264_1 CDM 0250 RC 69452-0207-13 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CALCITRIOL 0.25 MCG CAPSULE 50121264_1 CDM 0250 RC 69452-0207-13 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CALCITRIOL 0.25 MCG CAPSULE 50121264_1 CDM 0250 RC 69452-0207-13 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CALCITRIOL 0.25 MCG CAPSULE 50121264_1 CDM 0250 RC 69452-0207-13 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CALCITRIOL 0.25 MCG CAPSULE 50121264_1 CDM 0250 RC 69452-0207-13 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CALCITRIOL 0.25 MCG CAPSULE 50121264_1 CDM 0250 RC 69452-0207-13 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CALCITRIOL 0.25 MCG CAPSULE 50121264_1 CDM 0250 RC 69452-0207-13 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CALCITRIOL 0.25 MCG CAPSULE 50121264_1 CDM 0250 RC 69452-0207-13 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CALCITRIOL 0.25 MCG CAPSULE 50121264_1 CDM 0250 RC 69452-0207-13 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CALCITRIOL 0.25 MCG CAPSULE 50121264_1 CDM 0250 RC 69452-0207-13 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CALCITRIOL 0.25 MCG CAPSULE 50121264_1 CDM 0250 RC 69452-0207-13 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CALCITRIOL 0.25 MCG CAPSULE 50121264_1 CDM 0250 RC 69452-0207-13 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CALCITRIOL 0.25 MCG CAPSULE 50121264_1 CDM 0250 RC 69452-0207-13 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CALCITRIOL 0.25 MCG CAPSULE 50121264_1 CDM 0250 RC 69452-0207-13 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 LAMOTRIGINE ER 100 MG TABLET 50121265_1 CDM 0250 RC 52817-0242-30 NDC inpatient 1 UN 8.59 5.58 AETNA AETNA 6.79 79 999999999 5.2 8.33 percent of total billed charges LAMOTRIGINE ER 100 MG TABLET 50121265_1 CDM 0250 RC 52817-0242-30 NDC inpatient 1 UN 8.59 5.58 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.58 65 999999999 5.2 8.33 percent of total billed charges LAMOTRIGINE ER 100 MG TABLET 50121265_1 CDM 0250 RC 52817-0242-30 NDC inpatient 1 UN 8.59 5.58 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.33 97 999999999 5.2 8.33 percent of total billed charges LAMOTRIGINE ER 100 MG TABLET 50121265_1 CDM 0250 RC 52817-0242-30 NDC inpatient 1 UN 8.59 5.58 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.93 69 999999999 5.2 8.33 percent of total billed charges LAMOTRIGINE ER 100 MG TABLET 50121265_1 CDM 0250 RC 52817-0242-30 NDC inpatient 1 UN 8.59 5.58 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.7 78 999999999 5.2 8.33 percent of total billed charges LAMOTRIGINE ER 100 MG TABLET 50121265_1 CDM 0250 RC 52817-0242-30 NDC inpatient 1 UN 8.59 5.58 UMR - ALL PLANS UMR - ALL PLANS 6.01 70 999999999 5.2 8.33 percent of total billed charges LAMOTRIGINE ER 100 MG TABLET 50121265_1 CDM 0250 RC 52817-0242-30 NDC inpatient 1 UN 8.59 5.58 SIHO - ALL PLANS SIHO - ALL PLANS 7.73 90 999999999 5.2 8.33 percent of total billed charges LAMOTRIGINE ER 100 MG TABLET 50121265_1 CDM 0250 RC 52817-0242-30 NDC inpatient 1 UN 8.59 5.58 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.2 60.55 999999999 5.2 8.33 percent of total billed charges LAMOTRIGINE ER 100 MG TABLET 50121265_1 CDM 0250 RC 52817-0242-30 NDC inpatient 1 UN 8.59 5.58 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.2 8.33 LAMOTRIGINE ER 100 MG TABLET 50121265_1 CDM 0250 RC 52817-0242-30 NDC inpatient 1 UN 8.59 5.58 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.2 8.33 LAMOTRIGINE ER 100 MG TABLET 50121265_1 CDM 0250 RC 52817-0242-30 NDC inpatient 1 UN 8.59 5.58 ANTHEM HMO ANTHEM HMO 999999999 5.2 8.33 LAMOTRIGINE ER 100 MG TABLET 50121265_1 CDM 0250 RC 52817-0242-30 NDC inpatient 1 UN 8.59 5.58 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.81 67.6 999999999 5.2 8.33 percent of total billed charges LAMOTRIGINE ER 100 MG TABLET 50121265_1 CDM 0250 RC 52817-0242-30 NDC inpatient 1 UN 8.59 5.58 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.2 8.33 LAMOTRIGINE ER 100 MG TABLET 50121265_1 CDM 0250 RC 52817-0242-30 NDC inpatient 1 UN 8.59 5.58 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.2 8.33 TRIAMCINOLONE ACET 40 MG/ML VL 50127336_1 CDM 0250 RC 70121-1651-05 NDC inpatient 1 UN 36.17 23.51 AETNA AETNA 28.57 79 999999999 21.9 35.08 percent of total billed charges TRIAMCINOLONE ACET 40 MG/ML VL 50127336_1 CDM 0250 RC 70121-1651-05 NDC inpatient 1 UN 36.17 23.51 SELF PAY DISCOUNT SELF PAY DISCOUNT 23.51 65 999999999 21.9 35.08 percent of total billed charges TRIAMCINOLONE ACET 40 MG/ML VL 50127336_1 CDM 0250 RC 70121-1651-05 NDC inpatient 1 UN 36.17 23.51 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.08 97 999999999 21.9 35.08 percent of total billed charges TRIAMCINOLONE ACET 40 MG/ML VL 50127336_1 CDM 0250 RC 70121-1651-05 NDC inpatient 1 UN 36.17 23.51 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.96 69 999999999 21.9 35.08 percent of total billed charges TRIAMCINOLONE ACET 40 MG/ML VL 50127336_1 CDM 0250 RC 70121-1651-05 NDC inpatient 1 UN 36.17 23.51 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.21 78 999999999 21.9 35.08 percent of total billed charges TRIAMCINOLONE ACET 40 MG/ML VL 50127336_1 CDM 0250 RC 70121-1651-05 NDC inpatient 1 UN 36.17 23.51 UMR - ALL PLANS UMR - ALL PLANS 25.32 70 999999999 21.9 35.08 percent of total billed charges TRIAMCINOLONE ACET 40 MG/ML VL 50127336_1 CDM 0250 RC 70121-1651-05 NDC inpatient 1 UN 36.17 23.51 SIHO - ALL PLANS SIHO - ALL PLANS 32.55 90 999999999 21.9 35.08 percent of total billed charges TRIAMCINOLONE ACET 40 MG/ML VL 50127336_1 CDM 0250 RC 70121-1651-05 NDC inpatient 1 UN 36.17 23.51 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.9 60.55 999999999 21.9 35.08 percent of total billed charges TRIAMCINOLONE ACET 40 MG/ML VL 50127336_1 CDM 0250 RC 70121-1651-05 NDC inpatient 1 UN 36.17 23.51 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.9 35.08 TRIAMCINOLONE ACET 40 MG/ML VL 50127336_1 CDM 0250 RC 70121-1651-05 NDC inpatient 1 UN 36.17 23.51 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.9 35.08 TRIAMCINOLONE ACET 40 MG/ML VL 50127336_1 CDM 0250 RC 70121-1651-05 NDC inpatient 1 UN 36.17 23.51 ANTHEM HMO ANTHEM HMO 999999999 21.9 35.08 TRIAMCINOLONE ACET 40 MG/ML VL 50127336_1 CDM 0250 RC 70121-1651-05 NDC inpatient 1 UN 36.17 23.51 CIGNA - ALL PLANS CIGNA - ALL PLANS 24.45 67.6 999999999 21.9 35.08 percent of total billed charges TRIAMCINOLONE ACET 40 MG/ML VL 50127336_1 CDM 0250 RC 70121-1651-05 NDC inpatient 1 UN 36.17 23.51 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.9 35.08 TRIAMCINOLONE ACET 40 MG/ML VL 50127336_1 CDM 0250 RC 70121-1651-05 NDC inpatient 1 UN 36.17 23.51 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.9 35.08 POTASSIUM CL 10% (20 MEQ/15ML) 50127519_1 CDM 0250 RC 60687-0341-71 NDC inpatient 1 UN 27.77 18.05 AETNA AETNA 21.94 79 999999999 16.81 26.94 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50127519_1 CDM 0250 RC 60687-0341-71 NDC inpatient 1 UN 27.77 18.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 18.05 65 999999999 16.81 26.94 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50127519_1 CDM 0250 RC 60687-0341-71 NDC inpatient 1 UN 27.77 18.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26.94 97 999999999 16.81 26.94 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50127519_1 CDM 0250 RC 60687-0341-71 NDC inpatient 1 UN 27.77 18.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 19.16 69 999999999 16.81 26.94 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50127519_1 CDM 0250 RC 60687-0341-71 NDC inpatient 1 UN 27.77 18.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.66 78 999999999 16.81 26.94 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50127519_1 CDM 0250 RC 60687-0341-71 NDC inpatient 1 UN 27.77 18.05 UMR - ALL PLANS UMR - ALL PLANS 19.44 70 999999999 16.81 26.94 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50127519_1 CDM 0250 RC 60687-0341-71 NDC inpatient 1 UN 27.77 18.05 SIHO - ALL PLANS SIHO - ALL PLANS 24.99 90 999999999 16.81 26.94 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50127519_1 CDM 0250 RC 60687-0341-71 NDC inpatient 1 UN 27.77 18.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.81 60.55 999999999 16.81 26.94 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50127519_1 CDM 0250 RC 60687-0341-71 NDC inpatient 1 UN 27.77 18.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.81 26.94 POTASSIUM CL 10% (20 MEQ/15ML) 50127519_1 CDM 0250 RC 60687-0341-71 NDC inpatient 1 UN 27.77 18.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.81 26.94 POTASSIUM CL 10% (20 MEQ/15ML) 50127519_1 CDM 0250 RC 60687-0341-71 NDC inpatient 1 UN 27.77 18.05 ANTHEM HMO ANTHEM HMO 999999999 16.81 26.94 POTASSIUM CL 10% (20 MEQ/15ML) 50127519_1 CDM 0250 RC 60687-0341-71 NDC inpatient 1 UN 27.77 18.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.77 67.6 999999999 16.81 26.94 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50127519_1 CDM 0250 RC 60687-0341-71 NDC inpatient 1 UN 27.77 18.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.81 26.94 POTASSIUM CL 10% (20 MEQ/15ML) 50127519_1 CDM 0250 RC 60687-0341-71 NDC inpatient 1 UN 27.77 18.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.81 26.94 "INJECTION, IPILIMUMAB, 1 MG" 50131986_1 CDM 0636 RC 00003-2328-22 NDC J9228 HCPCS inpatient 200 UN 138394.95 89956.72 AETNA AETNA 109332.01 79 999999999 83798.14 134243.1 percent of total billed charges "INJECTION, IPILIMUMAB, 1 MG" 50131986_1 CDM 0636 RC 00003-2328-22 NDC J9228 HCPCS inpatient 200 UN 138394.95 89956.72 SELF PAY DISCOUNT SELF PAY DISCOUNT 89956.72 65 999999999 83798.14 134243.1 percent of total billed charges "INJECTION, IPILIMUMAB, 1 MG" 50131986_1 CDM 0636 RC 00003-2328-22 NDC J9228 HCPCS inpatient 200 UN 138394.95 89956.72 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 134243.1 97 999999999 83798.14 134243.1 percent of total billed charges "INJECTION, IPILIMUMAB, 1 MG" 50131986_1 CDM 0636 RC 00003-2328-22 NDC J9228 HCPCS inpatient 200 UN 138394.95 89956.72 ENCORE - ALL PLANS ENCORE - ALL PLANS 95492.52 69 999999999 83798.14 134243.1 percent of total billed charges "INJECTION, IPILIMUMAB, 1 MG" 50131986_1 CDM 0636 RC 00003-2328-22 NDC J9228 HCPCS inpatient 200 UN 138394.95 89956.72 HUMANA - ALL PLANS HUMANA - ALL PLANS 107948.06 78 999999999 83798.14 134243.1 percent of total billed charges "INJECTION, IPILIMUMAB, 1 MG" 50131986_1 CDM 0636 RC 00003-2328-22 NDC J9228 HCPCS inpatient 200 UN 138394.95 89956.72 UMR - ALL PLANS UMR - ALL PLANS 96876.47 70 999999999 83798.14 134243.1 percent of total billed charges "INJECTION, IPILIMUMAB, 1 MG" 50131986_1 CDM 0636 RC 00003-2328-22 NDC J9228 HCPCS inpatient 200 UN 138394.95 89956.72 SIHO - ALL PLANS SIHO - ALL PLANS 124555.46 90 999999999 83798.14 134243.1 percent of total billed charges "INJECTION, IPILIMUMAB, 1 MG" 50131986_1 CDM 0636 RC 00003-2328-22 NDC J9228 HCPCS inpatient 200 UN 138394.95 89956.72 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 83798.14 60.55 999999999 83798.14 134243.1 percent of total billed charges "INJECTION, IPILIMUMAB, 1 MG" 50131986_1 CDM 0636 RC 00003-2328-22 NDC J9228 HCPCS inpatient 200 UN 138394.95 89956.72 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 83798.14 134243.1 "INJECTION, IPILIMUMAB, 1 MG" 50131986_1 CDM 0636 RC 00003-2328-22 NDC J9228 HCPCS inpatient 200 UN 138394.95 89956.72 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 83798.14 134243.1 "INJECTION, IPILIMUMAB, 1 MG" 50131986_1 CDM 0636 RC 00003-2328-22 NDC J9228 HCPCS inpatient 200 UN 138394.95 89956.72 ANTHEM HMO ANTHEM HMO 999999999 83798.14 134243.1 "INJECTION, IPILIMUMAB, 1 MG" 50131986_1 CDM 0636 RC 00003-2328-22 NDC J9228 HCPCS inpatient 200 UN 138394.95 89956.72 CIGNA - ALL PLANS CIGNA - ALL PLANS 93554.99 67.6 999999999 83798.14 134243.1 percent of total billed charges "INJECTION, IPILIMUMAB, 1 MG" 50131986_1 CDM 0636 RC 00003-2328-22 NDC J9228 HCPCS inpatient 200 UN 138394.95 89956.72 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 83798.14 134243.1 "INJECTION, IPILIMUMAB, 1 MG" 50131986_1 CDM 0636 RC 00003-2328-22 NDC J9228 HCPCS inpatient 200 UN 138394.95 89956.72 UHC - ALL PLANS UHC - ALL PLANS 999999999 83798.14 134243.1 LINZESS 72 MCG CAPSULE 50133354_1 CDM 0250 RC 00456-1203-30 NDC inpatient 1 UN 65.03 42.27 AETNA AETNA 51.37 79 999999999 39.38 63.08 percent of total billed charges LINZESS 72 MCG CAPSULE 50133354_1 CDM 0250 RC 00456-1203-30 NDC inpatient 1 UN 65.03 42.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.27 65 999999999 39.38 63.08 percent of total billed charges LINZESS 72 MCG CAPSULE 50133354_1 CDM 0250 RC 00456-1203-30 NDC inpatient 1 UN 65.03 42.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 63.08 97 999999999 39.38 63.08 percent of total billed charges LINZESS 72 MCG CAPSULE 50133354_1 CDM 0250 RC 00456-1203-30 NDC inpatient 1 UN 65.03 42.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.87 69 999999999 39.38 63.08 percent of total billed charges LINZESS 72 MCG CAPSULE 50133354_1 CDM 0250 RC 00456-1203-30 NDC inpatient 1 UN 65.03 42.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 50.72 78 999999999 39.38 63.08 percent of total billed charges LINZESS 72 MCG CAPSULE 50133354_1 CDM 0250 RC 00456-1203-30 NDC inpatient 1 UN 65.03 42.27 UMR - ALL PLANS UMR - ALL PLANS 45.52 70 999999999 39.38 63.08 percent of total billed charges LINZESS 72 MCG CAPSULE 50133354_1 CDM 0250 RC 00456-1203-30 NDC inpatient 1 UN 65.03 42.27 SIHO - ALL PLANS SIHO - ALL PLANS 58.53 90 999999999 39.38 63.08 percent of total billed charges LINZESS 72 MCG CAPSULE 50133354_1 CDM 0250 RC 00456-1203-30 NDC inpatient 1 UN 65.03 42.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.38 60.55 999999999 39.38 63.08 percent of total billed charges LINZESS 72 MCG CAPSULE 50133354_1 CDM 0250 RC 00456-1203-30 NDC inpatient 1 UN 65.03 42.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.38 63.08 LINZESS 72 MCG CAPSULE 50133354_1 CDM 0250 RC 00456-1203-30 NDC inpatient 1 UN 65.03 42.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.38 63.08 LINZESS 72 MCG CAPSULE 50133354_1 CDM 0250 RC 00456-1203-30 NDC inpatient 1 UN 65.03 42.27 ANTHEM HMO ANTHEM HMO 999999999 39.38 63.08 LINZESS 72 MCG CAPSULE 50133354_1 CDM 0250 RC 00456-1203-30 NDC inpatient 1 UN 65.03 42.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.96 67.6 999999999 39.38 63.08 percent of total billed charges LINZESS 72 MCG CAPSULE 50133354_1 CDM 0250 RC 00456-1203-30 NDC inpatient 1 UN 65.03 42.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.38 63.08 LINZESS 72 MCG CAPSULE 50133354_1 CDM 0250 RC 00456-1203-30 NDC inpatient 1 UN 65.03 42.27 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.38 63.08 NICOTINE 7 MG/24HR PATCH 50133508_1 CDM 0250 RC 46122-0354-74 NDC inpatient 1 UN 4.83 3.14 AETNA AETNA 3.82 79 999999999 2.92 4.69 percent of total billed charges NICOTINE 7 MG/24HR PATCH 50133508_1 CDM 0250 RC 46122-0354-74 NDC inpatient 1 UN 4.83 3.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.14 65 999999999 2.92 4.69 percent of total billed charges NICOTINE 7 MG/24HR PATCH 50133508_1 CDM 0250 RC 46122-0354-74 NDC inpatient 1 UN 4.83 3.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4.69 97 999999999 2.92 4.69 percent of total billed charges NICOTINE 7 MG/24HR PATCH 50133508_1 CDM 0250 RC 46122-0354-74 NDC inpatient 1 UN 4.83 3.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.33 69 999999999 2.92 4.69 percent of total billed charges NICOTINE 7 MG/24HR PATCH 50133508_1 CDM 0250 RC 46122-0354-74 NDC inpatient 1 UN 4.83 3.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.77 78 999999999 2.92 4.69 percent of total billed charges NICOTINE 7 MG/24HR PATCH 50133508_1 CDM 0250 RC 46122-0354-74 NDC inpatient 1 UN 4.83 3.14 UMR - ALL PLANS UMR - ALL PLANS 3.38 70 999999999 2.92 4.69 percent of total billed charges NICOTINE 7 MG/24HR PATCH 50133508_1 CDM 0250 RC 46122-0354-74 NDC inpatient 1 UN 4.83 3.14 SIHO - ALL PLANS SIHO - ALL PLANS 4.35 90 999999999 2.92 4.69 percent of total billed charges NICOTINE 7 MG/24HR PATCH 50133508_1 CDM 0250 RC 46122-0354-74 NDC inpatient 1 UN 4.83 3.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.92 60.55 999999999 2.92 4.69 percent of total billed charges NICOTINE 7 MG/24HR PATCH 50133508_1 CDM 0250 RC 46122-0354-74 NDC inpatient 1 UN 4.83 3.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.92 4.69 NICOTINE 7 MG/24HR PATCH 50133508_1 CDM 0250 RC 46122-0354-74 NDC inpatient 1 UN 4.83 3.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.92 4.69 NICOTINE 7 MG/24HR PATCH 50133508_1 CDM 0250 RC 46122-0354-74 NDC inpatient 1 UN 4.83 3.14 ANTHEM HMO ANTHEM HMO 999999999 2.92 4.69 NICOTINE 7 MG/24HR PATCH 50133508_1 CDM 0250 RC 46122-0354-74 NDC inpatient 1 UN 4.83 3.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.27 67.6 999999999 2.92 4.69 percent of total billed charges NICOTINE 7 MG/24HR PATCH 50133508_1 CDM 0250 RC 46122-0354-74 NDC inpatient 1 UN 4.83 3.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.92 4.69 NICOTINE 7 MG/24HR PATCH 50133508_1 CDM 0250 RC 46122-0354-74 NDC inpatient 1 UN 4.83 3.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.92 4.69 OXYCODONE HCL (IR) 10 MG TAB 50133510_1 CDM 0250 RC 68084-0968-01 NDC inpatient 1 UN 2.06 1.34 AETNA AETNA 1.63 79 999999999 1.25 2 percent of total billed charges OXYCODONE HCL (IR) 10 MG TAB 50133510_1 CDM 0250 RC 68084-0968-01 NDC inpatient 1 UN 2.06 1.34 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.34 65 999999999 1.25 2 percent of total billed charges OXYCODONE HCL (IR) 10 MG TAB 50133510_1 CDM 0250 RC 68084-0968-01 NDC inpatient 1 UN 2.06 1.34 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2 97 999999999 1.25 2 percent of total billed charges OXYCODONE HCL (IR) 10 MG TAB 50133510_1 CDM 0250 RC 68084-0968-01 NDC inpatient 1 UN 2.06 1.34 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.42 69 999999999 1.25 2 percent of total billed charges OXYCODONE HCL (IR) 10 MG TAB 50133510_1 CDM 0250 RC 68084-0968-01 NDC inpatient 1 UN 2.06 1.34 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.61 78 999999999 1.25 2 percent of total billed charges OXYCODONE HCL (IR) 10 MG TAB 50133510_1 CDM 0250 RC 68084-0968-01 NDC inpatient 1 UN 2.06 1.34 UMR - ALL PLANS UMR - ALL PLANS 1.44 70 999999999 1.25 2 percent of total billed charges OXYCODONE HCL (IR) 10 MG TAB 50133510_1 CDM 0250 RC 68084-0968-01 NDC inpatient 1 UN 2.06 1.34 SIHO - ALL PLANS SIHO - ALL PLANS 1.85 90 999999999 1.25 2 percent of total billed charges OXYCODONE HCL (IR) 10 MG TAB 50133510_1 CDM 0250 RC 68084-0968-01 NDC inpatient 1 UN 2.06 1.34 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.25 60.55 999999999 1.25 2 percent of total billed charges OXYCODONE HCL (IR) 10 MG TAB 50133510_1 CDM 0250 RC 68084-0968-01 NDC inpatient 1 UN 2.06 1.34 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.25 2 OXYCODONE HCL (IR) 10 MG TAB 50133510_1 CDM 0250 RC 68084-0968-01 NDC inpatient 1 UN 2.06 1.34 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.25 2 OXYCODONE HCL (IR) 10 MG TAB 50133510_1 CDM 0250 RC 68084-0968-01 NDC inpatient 1 UN 2.06 1.34 ANTHEM HMO ANTHEM HMO 999999999 1.25 2 OXYCODONE HCL (IR) 10 MG TAB 50133510_1 CDM 0250 RC 68084-0968-01 NDC inpatient 1 UN 2.06 1.34 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.39 67.6 999999999 1.25 2 percent of total billed charges OXYCODONE HCL (IR) 10 MG TAB 50133510_1 CDM 0250 RC 68084-0968-01 NDC inpatient 1 UN 2.06 1.34 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.25 2 OXYCODONE HCL (IR) 10 MG TAB 50133510_1 CDM 0250 RC 68084-0968-01 NDC inpatient 1 UN 2.06 1.34 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.25 2 PIPERACIL-TAZOBACT 4.5 GM VIAL 50143276_1 CDM 0250 RC 55150-0121-50 NDC inpatient 1 UN 37.81 24.58 AETNA AETNA 29.87 79 999999999 22.89 36.68 percent of total billed charges PIPERACIL-TAZOBACT 4.5 GM VIAL 50143276_1 CDM 0250 RC 55150-0121-50 NDC inpatient 1 UN 37.81 24.58 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.58 65 999999999 22.89 36.68 percent of total billed charges PIPERACIL-TAZOBACT 4.5 GM VIAL 50143276_1 CDM 0250 RC 55150-0121-50 NDC inpatient 1 UN 37.81 24.58 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 36.68 97 999999999 22.89 36.68 percent of total billed charges PIPERACIL-TAZOBACT 4.5 GM VIAL 50143276_1 CDM 0250 RC 55150-0121-50 NDC inpatient 1 UN 37.81 24.58 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.09 69 999999999 22.89 36.68 percent of total billed charges PIPERACIL-TAZOBACT 4.5 GM VIAL 50143276_1 CDM 0250 RC 55150-0121-50 NDC inpatient 1 UN 37.81 24.58 HUMANA - ALL PLANS HUMANA - ALL PLANS 29.49 78 999999999 22.89 36.68 percent of total billed charges PIPERACIL-TAZOBACT 4.5 GM VIAL 50143276_1 CDM 0250 RC 55150-0121-50 NDC inpatient 1 UN 37.81 24.58 UMR - ALL PLANS UMR - ALL PLANS 26.47 70 999999999 22.89 36.68 percent of total billed charges PIPERACIL-TAZOBACT 4.5 GM VIAL 50143276_1 CDM 0250 RC 55150-0121-50 NDC inpatient 1 UN 37.81 24.58 SIHO - ALL PLANS SIHO - ALL PLANS 34.03 90 999999999 22.89 36.68 percent of total billed charges PIPERACIL-TAZOBACT 4.5 GM VIAL 50143276_1 CDM 0250 RC 55150-0121-50 NDC inpatient 1 UN 37.81 24.58 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.89 60.55 999999999 22.89 36.68 percent of total billed charges PIPERACIL-TAZOBACT 4.5 GM VIAL 50143276_1 CDM 0250 RC 55150-0121-50 NDC inpatient 1 UN 37.81 24.58 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.89 36.68 PIPERACIL-TAZOBACT 4.5 GM VIAL 50143276_1 CDM 0250 RC 55150-0121-50 NDC inpatient 1 UN 37.81 24.58 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.89 36.68 PIPERACIL-TAZOBACT 4.5 GM VIAL 50143276_1 CDM 0250 RC 55150-0121-50 NDC inpatient 1 UN 37.81 24.58 ANTHEM HMO ANTHEM HMO 999999999 22.89 36.68 PIPERACIL-TAZOBACT 4.5 GM VIAL 50143276_1 CDM 0250 RC 55150-0121-50 NDC inpatient 1 UN 37.81 24.58 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.56 67.6 999999999 22.89 36.68 percent of total billed charges PIPERACIL-TAZOBACT 4.5 GM VIAL 50143276_1 CDM 0250 RC 55150-0121-50 NDC inpatient 1 UN 37.81 24.58 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.89 36.68 PIPERACIL-TAZOBACT 4.5 GM VIAL 50143276_1 CDM 0250 RC 55150-0121-50 NDC inpatient 1 UN 37.81 24.58 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.89 36.68 "Pap test, automated thin layer preparation; automated system and manual rescreening" 50147266_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 50147266_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 50147266_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 50147266_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 50147266_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 50147266_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 50147266_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 50147266_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 50147266_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 50147266_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 50147266_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 50147266_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges "Pap test, automated thin layer preparation; automated system and manual rescreening" 50147266_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 "Pap test, automated thin layer preparation; automated system and manual rescreening" 50147266_1 CDM 0311 RC 88175 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50147516_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 AETNA AETNA 698.36 79 999999999 535.26 857.48 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50147516_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 574.6 65 999999999 535.26 857.48 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50147516_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 857.48 97 999999999 535.26 857.48 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50147516_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 609.96 69 999999999 535.26 857.48 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50147516_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 689.52 78 999999999 535.26 857.48 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50147516_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 UMR - ALL PLANS UMR - ALL PLANS 618.8 70 999999999 535.26 857.48 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50147516_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 SIHO - ALL PLANS SIHO - ALL PLANS 795.6 90 999999999 535.26 857.48 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50147516_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 535.26 60.55 999999999 535.26 857.48 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50147516_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 535.26 857.48 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50147516_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 535.26 857.48 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50147516_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 ANTHEM HMO ANTHEM HMO 999999999 535.26 857.48 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50147516_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 597.58 67.6 999999999 535.26 857.48 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50147516_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 535.26 857.48 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50147516_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 535.26 857.48 "Identification of organisms by genetic analysis, amplified probe technique" 50147559_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147559_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147559_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147559_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147559_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147559_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147559_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147559_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147559_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147559_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147559_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147559_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147559_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147559_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147561_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147561_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147561_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147561_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147561_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147561_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147561_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147561_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147561_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147561_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147561_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147561_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147561_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147561_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147563_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147563_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147563_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147563_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147563_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147563_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147563_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147563_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147563_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147563_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147563_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147563_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147563_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147563_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147565_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147565_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147565_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147565_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147565_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147565_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147565_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147565_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147565_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147565_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147565_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147565_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147565_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147565_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147567_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147567_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147567_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147567_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147567_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147567_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147567_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147567_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147567_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147567_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147567_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147567_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147567_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147567_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147569_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147569_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147569_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147569_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147569_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147569_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147569_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147569_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147569_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147569_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147569_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147569_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147569_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147569_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147571_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147571_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147571_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147571_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147571_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147571_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147571_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147571_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147571_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147571_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147571_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147571_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147571_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147571_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147573_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147573_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147573_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147573_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147573_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147573_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147573_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147573_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147573_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147573_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147573_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147573_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147573_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147573_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147575_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147575_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147575_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147575_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147575_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147575_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147575_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147575_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147575_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147575_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147575_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147575_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147575_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147575_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147577_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147577_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147577_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147577_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147577_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147577_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147577_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147577_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147577_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147577_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147577_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147577_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147577_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147577_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147580_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147580_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147580_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147580_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147580_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147580_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147580_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147580_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147580_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147580_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147580_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147580_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147580_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147580_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147587_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147587_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147587_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147587_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147587_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147587_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147587_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147587_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147587_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147587_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147587_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147587_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147587_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147587_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147589_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147589_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147589_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147589_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147589_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147589_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147589_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147589_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147589_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147589_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147589_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147589_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147589_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147589_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147591_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147591_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147591_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147591_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147591_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147591_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147591_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147591_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147591_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147591_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147591_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147591_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147591_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147591_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147593_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147593_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147593_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147593_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147593_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147593_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147593_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147593_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147593_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147593_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147593_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147593_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147593_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147593_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147595_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147595_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147595_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147595_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147595_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147595_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147595_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147595_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147595_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147595_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147595_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147595_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147595_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147595_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147597_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147597_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147597_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147597_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147597_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147597_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147597_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147597_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147597_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147597_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147597_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147597_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147597_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147597_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147599_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147599_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147599_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147599_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147599_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147599_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147599_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147599_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147599_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147599_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147599_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147599_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147599_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147599_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147605_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147605_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147605_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147605_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147605_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147605_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147605_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147605_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147605_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147605_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147605_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147605_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147605_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147605_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147609_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147609_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147609_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147609_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147609_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147609_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147609_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147609_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147609_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147609_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147609_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147609_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147609_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147609_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147615_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147615_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147615_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147615_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147615_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147615_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147615_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147615_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147615_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147615_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147615_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147615_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147615_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147615_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147617_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147617_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147617_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147617_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147617_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147617_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147617_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147617_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147617_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147617_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147617_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147617_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50147617_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50147617_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 LEVOTHYROXINE 75 MCG TABLET 50156219_1 CDM 0250 RC 69238-1832-01 NDC inpatient 4 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 75 MCG TABLET 50156219_1 CDM 0250 RC 69238-1832-01 NDC inpatient 4 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 75 MCG TABLET 50156219_1 CDM 0250 RC 69238-1832-01 NDC inpatient 4 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 75 MCG TABLET 50156219_1 CDM 0250 RC 69238-1832-01 NDC inpatient 4 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 75 MCG TABLET 50156219_1 CDM 0250 RC 69238-1832-01 NDC inpatient 4 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 75 MCG TABLET 50156219_1 CDM 0250 RC 69238-1832-01 NDC inpatient 4 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 75 MCG TABLET 50156219_1 CDM 0250 RC 69238-1832-01 NDC inpatient 4 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 75 MCG TABLET 50156219_1 CDM 0250 RC 69238-1832-01 NDC inpatient 4 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 75 MCG TABLET 50156219_1 CDM 0250 RC 69238-1832-01 NDC inpatient 4 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LEVOTHYROXINE 75 MCG TABLET 50156219_1 CDM 0250 RC 69238-1832-01 NDC inpatient 4 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 75 MCG TABLET 50156219_1 CDM 0250 RC 69238-1832-01 NDC inpatient 4 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LEVOTHYROXINE 75 MCG TABLET 50156219_1 CDM 0250 RC 69238-1832-01 NDC inpatient 4 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 75 MCG TABLET 50156219_1 CDM 0250 RC 69238-1832-01 NDC inpatient 4 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 75 MCG TABLET 50156219_1 CDM 0250 RC 69238-1832-01 NDC inpatient 4 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 DONEPEZIL HCL 5 MG TABLET 50157273_1 CDM 0250 RC 60687-0292-01 NDC inpatient 1 UN 1.17 0.76 AETNA AETNA 0.92 79 999999999 0.71 1.13 percent of total billed charges DONEPEZIL HCL 5 MG TABLET 50157273_1 CDM 0250 RC 60687-0292-01 NDC inpatient 1 UN 1.17 0.76 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.76 65 999999999 0.71 1.13 percent of total billed charges DONEPEZIL HCL 5 MG TABLET 50157273_1 CDM 0250 RC 60687-0292-01 NDC inpatient 1 UN 1.17 0.76 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.13 97 999999999 0.71 1.13 percent of total billed charges DONEPEZIL HCL 5 MG TABLET 50157273_1 CDM 0250 RC 60687-0292-01 NDC inpatient 1 UN 1.17 0.76 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.81 69 999999999 0.71 1.13 percent of total billed charges DONEPEZIL HCL 5 MG TABLET 50157273_1 CDM 0250 RC 60687-0292-01 NDC inpatient 1 UN 1.17 0.76 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.91 78 999999999 0.71 1.13 percent of total billed charges DONEPEZIL HCL 5 MG TABLET 50157273_1 CDM 0250 RC 60687-0292-01 NDC inpatient 1 UN 1.17 0.76 SIHO - ALL PLANS SIHO - ALL PLANS 1.05 90 999999999 0.71 1.13 percent of total billed charges DONEPEZIL HCL 5 MG TABLET 50157273_1 CDM 0250 RC 60687-0292-01 NDC inpatient 1 UN 1.17 0.76 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.71 60.55 999999999 0.71 1.13 percent of total billed charges DONEPEZIL HCL 5 MG TABLET 50157273_1 CDM 0250 RC 60687-0292-01 NDC inpatient 1 UN 1.17 0.76 UMR - ALL PLANS UMR - ALL PLANS 0.82 70 999999999 0.71 1.13 percent of total billed charges DONEPEZIL HCL 5 MG TABLET 50157273_1 CDM 0250 RC 60687-0292-01 NDC inpatient 1 UN 1.17 0.76 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.71 1.13 DONEPEZIL HCL 5 MG TABLET 50157273_1 CDM 0250 RC 60687-0292-01 NDC inpatient 1 UN 1.17 0.76 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.71 1.13 DONEPEZIL HCL 5 MG TABLET 50157273_1 CDM 0250 RC 60687-0292-01 NDC inpatient 1 UN 1.17 0.76 ANTHEM HMO ANTHEM HMO 999999999 0.71 1.13 DONEPEZIL HCL 5 MG TABLET 50157273_1 CDM 0250 RC 60687-0292-01 NDC inpatient 1 UN 1.17 0.76 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.79 67.6 999999999 0.71 1.13 percent of total billed charges DONEPEZIL HCL 5 MG TABLET 50157273_1 CDM 0250 RC 60687-0292-01 NDC inpatient 1 UN 1.17 0.76 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.71 1.13 DONEPEZIL HCL 5 MG TABLET 50157273_1 CDM 0250 RC 60687-0292-01 NDC inpatient 1 UN 1.17 0.76 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.71 1.13 TRAZODONE 50 MG TABLET 50161289_1 CDM 0250 RC 60687-0443-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges TRAZODONE 50 MG TABLET 50161289_1 CDM 0250 RC 60687-0443-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges TRAZODONE 50 MG TABLET 50161289_1 CDM 0250 RC 60687-0443-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges TRAZODONE 50 MG TABLET 50161289_1 CDM 0250 RC 60687-0443-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges TRAZODONE 50 MG TABLET 50161289_1 CDM 0250 RC 60687-0443-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges TRAZODONE 50 MG TABLET 50161289_1 CDM 0250 RC 60687-0443-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges TRAZODONE 50 MG TABLET 50161289_1 CDM 0250 RC 60687-0443-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges TRAZODONE 50 MG TABLET 50161289_1 CDM 0250 RC 60687-0443-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges TRAZODONE 50 MG TABLET 50161289_1 CDM 0250 RC 60687-0443-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 TRAZODONE 50 MG TABLET 50161289_1 CDM 0250 RC 60687-0443-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 TRAZODONE 50 MG TABLET 50161289_1 CDM 0250 RC 60687-0443-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 TRAZODONE 50 MG TABLET 50161289_1 CDM 0250 RC 60687-0443-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges TRAZODONE 50 MG TABLET 50161289_1 CDM 0250 RC 60687-0443-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 TRAZODONE 50 MG TABLET 50161289_1 CDM 0250 RC 60687-0443-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CIPROFLOXACIN 0.3% EYE DROP 50161994_1 CDM 0250 RC 69315-0308-05 NDC inpatient 1 UN 27.41 17.82 AETNA AETNA 21.65 79 999999999 16.6 26.59 percent of total billed charges CIPROFLOXACIN 0.3% EYE DROP 50161994_1 CDM 0250 RC 69315-0308-05 NDC inpatient 1 UN 27.41 17.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.82 65 999999999 16.6 26.59 percent of total billed charges CIPROFLOXACIN 0.3% EYE DROP 50161994_1 CDM 0250 RC 69315-0308-05 NDC inpatient 1 UN 27.41 17.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26.59 97 999999999 16.6 26.59 percent of total billed charges CIPROFLOXACIN 0.3% EYE DROP 50161994_1 CDM 0250 RC 69315-0308-05 NDC inpatient 1 UN 27.41 17.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.91 69 999999999 16.6 26.59 percent of total billed charges CIPROFLOXACIN 0.3% EYE DROP 50161994_1 CDM 0250 RC 69315-0308-05 NDC inpatient 1 UN 27.41 17.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.38 78 999999999 16.6 26.59 percent of total billed charges CIPROFLOXACIN 0.3% EYE DROP 50161994_1 CDM 0250 RC 69315-0308-05 NDC inpatient 1 UN 27.41 17.82 SIHO - ALL PLANS SIHO - ALL PLANS 24.67 90 999999999 16.6 26.59 percent of total billed charges CIPROFLOXACIN 0.3% EYE DROP 50161994_1 CDM 0250 RC 69315-0308-05 NDC inpatient 1 UN 27.41 17.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.6 60.55 999999999 16.6 26.59 percent of total billed charges CIPROFLOXACIN 0.3% EYE DROP 50161994_1 CDM 0250 RC 69315-0308-05 NDC inpatient 1 UN 27.41 17.82 UMR - ALL PLANS UMR - ALL PLANS 19.19 70 999999999 16.6 26.59 percent of total billed charges CIPROFLOXACIN 0.3% EYE DROP 50161994_1 CDM 0250 RC 69315-0308-05 NDC inpatient 1 UN 27.41 17.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.6 26.59 CIPROFLOXACIN 0.3% EYE DROP 50161994_1 CDM 0250 RC 69315-0308-05 NDC inpatient 1 UN 27.41 17.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.6 26.59 CIPROFLOXACIN 0.3% EYE DROP 50161994_1 CDM 0250 RC 69315-0308-05 NDC inpatient 1 UN 27.41 17.82 ANTHEM HMO ANTHEM HMO 999999999 16.6 26.59 CIPROFLOXACIN 0.3% EYE DROP 50161994_1 CDM 0250 RC 69315-0308-05 NDC inpatient 1 UN 27.41 17.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.53 67.6 999999999 16.6 26.59 percent of total billed charges CIPROFLOXACIN 0.3% EYE DROP 50161994_1 CDM 0250 RC 69315-0308-05 NDC inpatient 1 UN 27.41 17.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.6 26.59 CIPROFLOXACIN 0.3% EYE DROP 50161994_1 CDM 0250 RC 69315-0308-05 NDC inpatient 1 UN 27.41 17.82 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.6 26.59 SALINE 0.45% SOLN-EXCEL CON 50161995_1 CDM 0250 RC 00264-7802-00 NDC inpatient 1 UN 65.91 42.84 AETNA AETNA 52.07 79 999999999 39.91 63.93 percent of total billed charges SALINE 0.45% SOLN-EXCEL CON 50161995_1 CDM 0250 RC 00264-7802-00 NDC inpatient 1 UN 65.91 42.84 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.84 65 999999999 39.91 63.93 percent of total billed charges SALINE 0.45% SOLN-EXCEL CON 50161995_1 CDM 0250 RC 00264-7802-00 NDC inpatient 1 UN 65.91 42.84 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 63.93 97 999999999 39.91 63.93 percent of total billed charges SALINE 0.45% SOLN-EXCEL CON 50161995_1 CDM 0250 RC 00264-7802-00 NDC inpatient 1 UN 65.91 42.84 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.48 69 999999999 39.91 63.93 percent of total billed charges SALINE 0.45% SOLN-EXCEL CON 50161995_1 CDM 0250 RC 00264-7802-00 NDC inpatient 1 UN 65.91 42.84 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.41 78 999999999 39.91 63.93 percent of total billed charges SALINE 0.45% SOLN-EXCEL CON 50161995_1 CDM 0250 RC 00264-7802-00 NDC inpatient 1 UN 65.91 42.84 SIHO - ALL PLANS SIHO - ALL PLANS 59.32 90 999999999 39.91 63.93 percent of total billed charges SALINE 0.45% SOLN-EXCEL CON 50161995_1 CDM 0250 RC 00264-7802-00 NDC inpatient 1 UN 65.91 42.84 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.91 60.55 999999999 39.91 63.93 percent of total billed charges SALINE 0.45% SOLN-EXCEL CON 50161995_1 CDM 0250 RC 00264-7802-00 NDC inpatient 1 UN 65.91 42.84 UMR - ALL PLANS UMR - ALL PLANS 46.14 70 999999999 39.91 63.93 percent of total billed charges SALINE 0.45% SOLN-EXCEL CON 50161995_1 CDM 0250 RC 00264-7802-00 NDC inpatient 1 UN 65.91 42.84 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.91 63.93 SALINE 0.45% SOLN-EXCEL CON 50161995_1 CDM 0250 RC 00264-7802-00 NDC inpatient 1 UN 65.91 42.84 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.91 63.93 SALINE 0.45% SOLN-EXCEL CON 50161995_1 CDM 0250 RC 00264-7802-00 NDC inpatient 1 UN 65.91 42.84 ANTHEM HMO ANTHEM HMO 999999999 39.91 63.93 SALINE 0.45% SOLN-EXCEL CON 50161995_1 CDM 0250 RC 00264-7802-00 NDC inpatient 1 UN 65.91 42.84 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.56 67.6 999999999 39.91 63.93 percent of total billed charges SALINE 0.45% SOLN-EXCEL CON 50161995_1 CDM 0250 RC 00264-7802-00 NDC inpatient 1 UN 65.91 42.84 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.91 63.93 SALINE 0.45% SOLN-EXCEL CON 50161995_1 CDM 0250 RC 00264-7802-00 NDC inpatient 1 UN 65.91 42.84 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.91 63.93 "Chromosome analysis for genetic defects, count 5 cells" 50162081_1 CDM 0301 RC 88261 HCPCS inpatient 615 399.75 AETNA AETNA 485.85 79 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 5 cells" 50162081_1 CDM 0301 RC 88261 HCPCS inpatient 615 399.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 399.75 65 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 5 cells" 50162081_1 CDM 0301 RC 88261 HCPCS inpatient 615 399.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 596.55 97 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 5 cells" 50162081_1 CDM 0301 RC 88261 HCPCS inpatient 615 399.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 424.35 69 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 5 cells" 50162081_1 CDM 0301 RC 88261 HCPCS inpatient 615 399.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 479.7 78 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 5 cells" 50162081_1 CDM 0301 RC 88261 HCPCS inpatient 615 399.75 SIHO - ALL PLANS SIHO - ALL PLANS 553.5 90 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 5 cells" 50162081_1 CDM 0301 RC 88261 HCPCS inpatient 615 399.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 372.38 60.55 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 5 cells" 50162081_1 CDM 0301 RC 88261 HCPCS inpatient 615 399.75 UMR - ALL PLANS UMR - ALL PLANS 430.5 70 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 5 cells" 50162081_1 CDM 0301 RC 88261 HCPCS inpatient 615 399.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 5 cells" 50162081_1 CDM 0301 RC 88261 HCPCS inpatient 615 399.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 5 cells" 50162081_1 CDM 0301 RC 88261 HCPCS inpatient 615 399.75 ANTHEM HMO ANTHEM HMO 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 5 cells" 50162081_1 CDM 0301 RC 88261 HCPCS inpatient 615 399.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 415.74 67.6 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 5 cells" 50162081_1 CDM 0301 RC 88261 HCPCS inpatient 615 399.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 5 cells" 50162081_1 CDM 0301 RC 88261 HCPCS inpatient 615 399.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 372.38 596.55 "Chromosome analysis for genetic defects, additional cells counted, each study" 50162082_1 CDM 0301 RC 88285 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges "Chromosome analysis for genetic defects, additional cells counted, each study" 50162082_1 CDM 0301 RC 88285 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges "Chromosome analysis for genetic defects, additional cells counted, each study" 50162082_1 CDM 0301 RC 88285 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges "Chromosome analysis for genetic defects, additional cells counted, each study" 50162082_1 CDM 0301 RC 88285 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges "Chromosome analysis for genetic defects, additional cells counted, each study" 50162082_1 CDM 0301 RC 88285 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges "Chromosome analysis for genetic defects, additional cells counted, each study" 50162082_1 CDM 0301 RC 88285 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges "Chromosome analysis for genetic defects, additional cells counted, each study" 50162082_1 CDM 0301 RC 88285 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges "Chromosome analysis for genetic defects, additional cells counted, each study" 50162082_1 CDM 0301 RC 88285 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges "Chromosome analysis for genetic defects, additional cells counted, each study" 50162082_1 CDM 0301 RC 88285 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 "Chromosome analysis for genetic defects, additional cells counted, each study" 50162082_1 CDM 0301 RC 88285 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 "Chromosome analysis for genetic defects, additional cells counted, each study" 50162082_1 CDM 0301 RC 88285 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 "Chromosome analysis for genetic defects, additional cells counted, each study" 50162082_1 CDM 0301 RC 88285 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges "Chromosome analysis for genetic defects, additional cells counted, each study" 50162082_1 CDM 0301 RC 88285 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 "Chromosome analysis for genetic defects, additional cells counted, each study" 50162082_1 CDM 0301 RC 88285 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 Evaluation of heart function using tilt table 50163586_1 CDM 0480 RC 93660 HCPCS inpatient 1238 804.7 AETNA AETNA 978.02 79 999999999 749.61 1200.86 percent of total billed charges Evaluation of heart function using tilt table 50163586_1 CDM 0480 RC 93660 HCPCS inpatient 1238 804.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 804.7 65 999999999 749.61 1200.86 percent of total billed charges Evaluation of heart function using tilt table 50163586_1 CDM 0480 RC 93660 HCPCS inpatient 1238 804.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1200.86 97 999999999 749.61 1200.86 percent of total billed charges Evaluation of heart function using tilt table 50163586_1 CDM 0480 RC 93660 HCPCS inpatient 1238 804.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 854.22 69 999999999 749.61 1200.86 percent of total billed charges Evaluation of heart function using tilt table 50163586_1 CDM 0480 RC 93660 HCPCS inpatient 1238 804.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 965.64 78 999999999 749.61 1200.86 percent of total billed charges Evaluation of heart function using tilt table 50163586_1 CDM 0480 RC 93660 HCPCS inpatient 1238 804.7 SIHO - ALL PLANS SIHO - ALL PLANS 1114.2 90 999999999 749.61 1200.86 percent of total billed charges Evaluation of heart function using tilt table 50163586_1 CDM 0480 RC 93660 HCPCS inpatient 1238 804.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 749.61 60.55 999999999 749.61 1200.86 percent of total billed charges Evaluation of heart function using tilt table 50163586_1 CDM 0480 RC 93660 HCPCS inpatient 1238 804.7 UMR - ALL PLANS UMR - ALL PLANS 866.6 70 999999999 749.61 1200.86 percent of total billed charges Evaluation of heart function using tilt table 50163586_1 CDM 0480 RC 93660 HCPCS inpatient 1238 804.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 749.61 1200.86 Evaluation of heart function using tilt table 50163586_1 CDM 0480 RC 93660 HCPCS inpatient 1238 804.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 749.61 1200.86 Evaluation of heart function using tilt table 50163586_1 CDM 0480 RC 93660 HCPCS inpatient 1238 804.7 ANTHEM HMO ANTHEM HMO 999999999 749.61 1200.86 Evaluation of heart function using tilt table 50163586_1 CDM 0480 RC 93660 HCPCS inpatient 1238 804.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 836.89 67.6 999999999 749.61 1200.86 percent of total billed charges Evaluation of heart function using tilt table 50163586_1 CDM 0480 RC 93660 HCPCS inpatient 1238 804.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 749.61 1200.86 Evaluation of heart function using tilt table 50163586_1 CDM 0480 RC 93660 HCPCS inpatient 1238 804.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 749.61 1200.86 Measurement of total estradiol (hormone) 50163702_1 CDM 0301 RC 82670 HCPCS inpatient 289 187.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 187.85 65 999999999 174.99 280.33 percent of total billed charges Measurement of total estradiol (hormone) 50163702_1 CDM 0301 RC 82670 HCPCS inpatient 289 187.85 AETNA AETNA 228.31 79 999999999 174.99 280.33 percent of total billed charges Measurement of total estradiol (hormone) 50163702_1 CDM 0301 RC 82670 HCPCS inpatient 289 187.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 280.33 97 999999999 174.99 280.33 percent of total billed charges Measurement of total estradiol (hormone) 50163702_1 CDM 0301 RC 82670 HCPCS inpatient 289 187.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 199.41 69 999999999 174.99 280.33 percent of total billed charges Measurement of total estradiol (hormone) 50163702_1 CDM 0301 RC 82670 HCPCS inpatient 289 187.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 225.42 78 999999999 174.99 280.33 percent of total billed charges Measurement of total estradiol (hormone) 50163702_1 CDM 0301 RC 82670 HCPCS inpatient 289 187.85 SIHO - ALL PLANS SIHO - ALL PLANS 260.1 90 999999999 174.99 280.33 percent of total billed charges Measurement of total estradiol (hormone) 50163702_1 CDM 0301 RC 82670 HCPCS inpatient 289 187.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 174.99 60.55 999999999 174.99 280.33 percent of total billed charges Measurement of total estradiol (hormone) 50163702_1 CDM 0301 RC 82670 HCPCS inpatient 289 187.85 UMR - ALL PLANS UMR - ALL PLANS 202.3 70 999999999 174.99 280.33 percent of total billed charges Measurement of total estradiol (hormone) 50163702_1 CDM 0301 RC 82670 HCPCS inpatient 289 187.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 174.99 280.33 Measurement of total estradiol (hormone) 50163702_1 CDM 0301 RC 82670 HCPCS inpatient 289 187.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 174.99 280.33 Measurement of total estradiol (hormone) 50163702_1 CDM 0301 RC 82670 HCPCS inpatient 289 187.85 ANTHEM HMO ANTHEM HMO 999999999 174.99 280.33 Measurement of total estradiol (hormone) 50163702_1 CDM 0301 RC 82670 HCPCS inpatient 289 187.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 195.36 67.6 999999999 174.99 280.33 percent of total billed charges Measurement of total estradiol (hormone) 50163702_1 CDM 0301 RC 82670 HCPCS inpatient 289 187.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 174.99 280.33 Measurement of total estradiol (hormone) 50163702_1 CDM 0301 RC 82670 HCPCS inpatient 289 187.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 174.99 280.33 "NYSTOP 100,000 UNIT/GM POWDER" 50163740_1 CDM 0250 RC 00574-2008-15 NDC inpatient 1 UN 16.91 10.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.99 65 999999999 10.24 16.4 percent of total billed charges "NYSTOP 100,000 UNIT/GM POWDER" 50163740_1 CDM 0250 RC 00574-2008-15 NDC inpatient 1 UN 16.91 10.99 AETNA AETNA 13.36 79 999999999 10.24 16.4 percent of total billed charges "NYSTOP 100,000 UNIT/GM POWDER" 50163740_1 CDM 0250 RC 00574-2008-15 NDC inpatient 1 UN 16.91 10.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16.4 97 999999999 10.24 16.4 percent of total billed charges "NYSTOP 100,000 UNIT/GM POWDER" 50163740_1 CDM 0250 RC 00574-2008-15 NDC inpatient 1 UN 16.91 10.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.67 69 999999999 10.24 16.4 percent of total billed charges "NYSTOP 100,000 UNIT/GM POWDER" 50163740_1 CDM 0250 RC 00574-2008-15 NDC inpatient 1 UN 16.91 10.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.19 78 999999999 10.24 16.4 percent of total billed charges "NYSTOP 100,000 UNIT/GM POWDER" 50163740_1 CDM 0250 RC 00574-2008-15 NDC inpatient 1 UN 16.91 10.99 SIHO - ALL PLANS SIHO - ALL PLANS 15.22 90 999999999 10.24 16.4 percent of total billed charges "NYSTOP 100,000 UNIT/GM POWDER" 50163740_1 CDM 0250 RC 00574-2008-15 NDC inpatient 1 UN 16.91 10.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.24 60.55 999999999 10.24 16.4 percent of total billed charges "NYSTOP 100,000 UNIT/GM POWDER" 50163740_1 CDM 0250 RC 00574-2008-15 NDC inpatient 1 UN 16.91 10.99 UMR - ALL PLANS UMR - ALL PLANS 11.84 70 999999999 10.24 16.4 percent of total billed charges "NYSTOP 100,000 UNIT/GM POWDER" 50163740_1 CDM 0250 RC 00574-2008-15 NDC inpatient 1 UN 16.91 10.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.24 16.4 "NYSTOP 100,000 UNIT/GM POWDER" 50163740_1 CDM 0250 RC 00574-2008-15 NDC inpatient 1 UN 16.91 10.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.24 16.4 "NYSTOP 100,000 UNIT/GM POWDER" 50163740_1 CDM 0250 RC 00574-2008-15 NDC inpatient 1 UN 16.91 10.99 ANTHEM HMO ANTHEM HMO 999999999 10.24 16.4 "NYSTOP 100,000 UNIT/GM POWDER" 50163740_1 CDM 0250 RC 00574-2008-15 NDC inpatient 1 UN 16.91 10.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.43 67.6 999999999 10.24 16.4 percent of total billed charges "NYSTOP 100,000 UNIT/GM POWDER" 50163740_1 CDM 0250 RC 00574-2008-15 NDC inpatient 1 UN 16.91 10.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.24 16.4 "NYSTOP 100,000 UNIT/GM POWDER" 50163740_1 CDM 0250 RC 00574-2008-15 NDC inpatient 1 UN 16.91 10.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.24 16.4 OLOPATADINE HCL 0.1% EYE DROPS 50163741_1 CDM 0250 RC 60505-0575-01 NDC inpatient 1 UN 92.68 60.24 SELF PAY DISCOUNT SELF PAY DISCOUNT 60.24 65 999999999 56.12 89.9 percent of total billed charges OLOPATADINE HCL 0.1% EYE DROPS 50163741_1 CDM 0250 RC 60505-0575-01 NDC inpatient 1 UN 92.68 60.24 AETNA AETNA 73.22 79 999999999 56.12 89.9 percent of total billed charges OLOPATADINE HCL 0.1% EYE DROPS 50163741_1 CDM 0250 RC 60505-0575-01 NDC inpatient 1 UN 92.68 60.24 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.9 97 999999999 56.12 89.9 percent of total billed charges OLOPATADINE HCL 0.1% EYE DROPS 50163741_1 CDM 0250 RC 60505-0575-01 NDC inpatient 1 UN 92.68 60.24 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.95 69 999999999 56.12 89.9 percent of total billed charges OLOPATADINE HCL 0.1% EYE DROPS 50163741_1 CDM 0250 RC 60505-0575-01 NDC inpatient 1 UN 92.68 60.24 HUMANA - ALL PLANS HUMANA - ALL PLANS 72.29 78 999999999 56.12 89.9 percent of total billed charges OLOPATADINE HCL 0.1% EYE DROPS 50163741_1 CDM 0250 RC 60505-0575-01 NDC inpatient 1 UN 92.68 60.24 SIHO - ALL PLANS SIHO - ALL PLANS 83.41 90 999999999 56.12 89.9 percent of total billed charges OLOPATADINE HCL 0.1% EYE DROPS 50163741_1 CDM 0250 RC 60505-0575-01 NDC inpatient 1 UN 92.68 60.24 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.12 60.55 999999999 56.12 89.9 percent of total billed charges OLOPATADINE HCL 0.1% EYE DROPS 50163741_1 CDM 0250 RC 60505-0575-01 NDC inpatient 1 UN 92.68 60.24 UMR - ALL PLANS UMR - ALL PLANS 64.88 70 999999999 56.12 89.9 percent of total billed charges OLOPATADINE HCL 0.1% EYE DROPS 50163741_1 CDM 0250 RC 60505-0575-01 NDC inpatient 1 UN 92.68 60.24 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.12 89.9 OLOPATADINE HCL 0.1% EYE DROPS 50163741_1 CDM 0250 RC 60505-0575-01 NDC inpatient 1 UN 92.68 60.24 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.12 89.9 OLOPATADINE HCL 0.1% EYE DROPS 50163741_1 CDM 0250 RC 60505-0575-01 NDC inpatient 1 UN 92.68 60.24 ANTHEM HMO ANTHEM HMO 999999999 56.12 89.9 OLOPATADINE HCL 0.1% EYE DROPS 50163741_1 CDM 0250 RC 60505-0575-01 NDC inpatient 1 UN 92.68 60.24 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.65 67.6 999999999 56.12 89.9 percent of total billed charges OLOPATADINE HCL 0.1% EYE DROPS 50163741_1 CDM 0250 RC 60505-0575-01 NDC inpatient 1 UN 92.68 60.24 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.12 89.9 OLOPATADINE HCL 0.1% EYE DROPS 50163741_1 CDM 0250 RC 60505-0575-01 NDC inpatient 1 UN 92.68 60.24 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.12 89.9 Test for detecting nucleic acid of organism causing infection of central nervous system 50163754_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 406.9 65 999999999 379.04 607.22 percent of total billed charges Test for detecting nucleic acid of organism causing infection of central nervous system 50163754_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 AETNA AETNA 494.54 79 999999999 379.04 607.22 percent of total billed charges Test for detecting nucleic acid of organism causing infection of central nervous system 50163754_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 607.22 97 999999999 379.04 607.22 percent of total billed charges Test for detecting nucleic acid of organism causing infection of central nervous system 50163754_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 431.94 69 999999999 379.04 607.22 percent of total billed charges Test for detecting nucleic acid of organism causing infection of central nervous system 50163754_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 488.28 78 999999999 379.04 607.22 percent of total billed charges Test for detecting nucleic acid of organism causing infection of central nervous system 50163754_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 SIHO - ALL PLANS SIHO - ALL PLANS 563.4 90 999999999 379.04 607.22 percent of total billed charges Test for detecting nucleic acid of organism causing infection of central nervous system 50163754_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 379.04 60.55 999999999 379.04 607.22 percent of total billed charges Test for detecting nucleic acid of organism causing infection of central nervous system 50163754_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 UMR - ALL PLANS UMR - ALL PLANS 438.2 70 999999999 379.04 607.22 percent of total billed charges Test for detecting nucleic acid of organism causing infection of central nervous system 50163754_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 379.04 607.22 Test for detecting nucleic acid of organism causing infection of central nervous system 50163754_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 379.04 607.22 Test for detecting nucleic acid of organism causing infection of central nervous system 50163754_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 ANTHEM HMO ANTHEM HMO 999999999 379.04 607.22 Test for detecting nucleic acid of organism causing infection of central nervous system 50163754_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 423.18 67.6 999999999 379.04 607.22 percent of total billed charges Test for detecting nucleic acid of organism causing infection of central nervous system 50163754_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 379.04 607.22 Test for detecting nucleic acid of organism causing infection of central nervous system 50163754_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 379.04 607.22 CARVEDILOL 12.5 MG TABLET 50165304_1 CDM 0250 RC 00904-6302-61 NDC inpatient 5 UN 1.96 1.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.27 65 999999999 1.19 1.9 percent of total billed charges CARVEDILOL 12.5 MG TABLET 50165304_1 CDM 0250 RC 00904-6302-61 NDC inpatient 5 UN 1.96 1.27 AETNA AETNA 1.55 79 999999999 1.19 1.9 percent of total billed charges CARVEDILOL 12.5 MG TABLET 50165304_1 CDM 0250 RC 00904-6302-61 NDC inpatient 5 UN 1.96 1.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.9 97 999999999 1.19 1.9 percent of total billed charges CARVEDILOL 12.5 MG TABLET 50165304_1 CDM 0250 RC 00904-6302-61 NDC inpatient 5 UN 1.96 1.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.35 69 999999999 1.19 1.9 percent of total billed charges CARVEDILOL 12.5 MG TABLET 50165304_1 CDM 0250 RC 00904-6302-61 NDC inpatient 5 UN 1.96 1.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.53 78 999999999 1.19 1.9 percent of total billed charges CARVEDILOL 12.5 MG TABLET 50165304_1 CDM 0250 RC 00904-6302-61 NDC inpatient 5 UN 1.96 1.27 SIHO - ALL PLANS SIHO - ALL PLANS 1.76 90 999999999 1.19 1.9 percent of total billed charges CARVEDILOL 12.5 MG TABLET 50165304_1 CDM 0250 RC 00904-6302-61 NDC inpatient 5 UN 1.96 1.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.19 60.55 999999999 1.19 1.9 percent of total billed charges CARVEDILOL 12.5 MG TABLET 50165304_1 CDM 0250 RC 00904-6302-61 NDC inpatient 5 UN 1.96 1.27 UMR - ALL PLANS UMR - ALL PLANS 1.37 70 999999999 1.19 1.9 percent of total billed charges CARVEDILOL 12.5 MG TABLET 50165304_1 CDM 0250 RC 00904-6302-61 NDC inpatient 5 UN 1.96 1.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.19 1.9 CARVEDILOL 12.5 MG TABLET 50165304_1 CDM 0250 RC 00904-6302-61 NDC inpatient 5 UN 1.96 1.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.19 1.9 CARVEDILOL 12.5 MG TABLET 50165304_1 CDM 0250 RC 00904-6302-61 NDC inpatient 5 UN 1.96 1.27 ANTHEM HMO ANTHEM HMO 999999999 1.19 1.9 CARVEDILOL 12.5 MG TABLET 50165304_1 CDM 0250 RC 00904-6302-61 NDC inpatient 5 UN 1.96 1.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.33 67.6 999999999 1.19 1.9 percent of total billed charges CARVEDILOL 12.5 MG TABLET 50165304_1 CDM 0250 RC 00904-6302-61 NDC inpatient 5 UN 1.96 1.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.19 1.9 CARVEDILOL 12.5 MG TABLET 50165304_1 CDM 0250 RC 00904-6302-61 NDC inpatient 5 UN 1.96 1.27 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.19 1.9 Analysis for antibody to Candida (yeast) 50165436_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165436_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165436_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165436_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165436_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165436_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165436_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165436_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165436_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 Analysis for antibody to Candida (yeast) 50165436_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 Analysis for antibody to Candida (yeast) 50165436_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 Analysis for antibody to Candida (yeast) 50165436_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165436_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 Analysis for antibody to Candida (yeast) 50165436_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 Analysis for antibody to Candida (yeast) 50165438_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165438_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165438_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165438_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165438_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165438_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165438_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165438_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165438_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 Analysis for antibody to Candida (yeast) 50165438_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 Analysis for antibody to Candida (yeast) 50165438_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 Analysis for antibody to Candida (yeast) 50165438_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165438_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 Analysis for antibody to Candida (yeast) 50165438_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 Analysis for antibody to Candida (yeast) 50165440_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165440_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165440_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165440_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165440_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165440_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165440_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165440_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165440_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 Analysis for antibody to Candida (yeast) 50165440_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 Analysis for antibody to Candida (yeast) 50165440_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 Analysis for antibody to Candida (yeast) 50165440_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges Analysis for antibody to Candida (yeast) 50165440_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 Analysis for antibody to Candida (yeast) 50165440_1 CDM 0301 RC 86628 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 "Testing for presence of drug, by chemistry analyzers" 50165545_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.6 65 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50165545_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 AETNA AETNA 161.16 79 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50165545_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.88 97 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50165545_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.76 69 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50165545_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.12 78 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50165545_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 SIHO - ALL PLANS SIHO - ALL PLANS 183.6 90 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50165545_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.52 60.55 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50165545_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 UMR - ALL PLANS UMR - ALL PLANS 142.8 70 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50165545_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.52 197.88 "Testing for presence of drug, by chemistry analyzers" 50165545_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.52 197.88 "Testing for presence of drug, by chemistry analyzers" 50165545_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 ANTHEM HMO ANTHEM HMO 999999999 123.52 197.88 "Testing for presence of drug, by chemistry analyzers" 50165545_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.9 67.6 999999999 123.52 197.88 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50165545_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.52 197.88 "Testing for presence of drug, by chemistry analyzers" 50165545_1 CDM 0301 RC 80307 HCPCS inpatient 204 132.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.52 197.88 DIVALPROEX SOD ER 500 MG TAB 50166045_1 CDM 0250 RC 65862-0595-01 NDC inpatient 1 UN 1.55 1.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.01 65 999999999 0.94 1.5 percent of total billed charges DIVALPROEX SOD ER 500 MG TAB 50166045_1 CDM 0250 RC 65862-0595-01 NDC inpatient 1 UN 1.55 1.01 AETNA AETNA 1.22 79 999999999 0.94 1.5 percent of total billed charges DIVALPROEX SOD ER 500 MG TAB 50166045_1 CDM 0250 RC 65862-0595-01 NDC inpatient 1 UN 1.55 1.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.5 97 999999999 0.94 1.5 percent of total billed charges DIVALPROEX SOD ER 500 MG TAB 50166045_1 CDM 0250 RC 65862-0595-01 NDC inpatient 1 UN 1.55 1.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.07 69 999999999 0.94 1.5 percent of total billed charges DIVALPROEX SOD ER 500 MG TAB 50166045_1 CDM 0250 RC 65862-0595-01 NDC inpatient 1 UN 1.55 1.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.21 78 999999999 0.94 1.5 percent of total billed charges DIVALPROEX SOD ER 500 MG TAB 50166045_1 CDM 0250 RC 65862-0595-01 NDC inpatient 1 UN 1.55 1.01 SIHO - ALL PLANS SIHO - ALL PLANS 1.4 90 999999999 0.94 1.5 percent of total billed charges DIVALPROEX SOD ER 500 MG TAB 50166045_1 CDM 0250 RC 65862-0595-01 NDC inpatient 1 UN 1.55 1.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.94 60.55 999999999 0.94 1.5 percent of total billed charges DIVALPROEX SOD ER 500 MG TAB 50166045_1 CDM 0250 RC 65862-0595-01 NDC inpatient 1 UN 1.55 1.01 UMR - ALL PLANS UMR - ALL PLANS 1.09 70 999999999 0.94 1.5 percent of total billed charges DIVALPROEX SOD ER 500 MG TAB 50166045_1 CDM 0250 RC 65862-0595-01 NDC inpatient 1 UN 1.55 1.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.94 1.5 DIVALPROEX SOD ER 500 MG TAB 50166045_1 CDM 0250 RC 65862-0595-01 NDC inpatient 1 UN 1.55 1.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.94 1.5 DIVALPROEX SOD ER 500 MG TAB 50166045_1 CDM 0250 RC 65862-0595-01 NDC inpatient 1 UN 1.55 1.01 ANTHEM HMO ANTHEM HMO 999999999 0.94 1.5 DIVALPROEX SOD ER 500 MG TAB 50166045_1 CDM 0250 RC 65862-0595-01 NDC inpatient 1 UN 1.55 1.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.05 67.6 999999999 0.94 1.5 percent of total billed charges DIVALPROEX SOD ER 500 MG TAB 50166045_1 CDM 0250 RC 65862-0595-01 NDC inpatient 1 UN 1.55 1.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.94 1.5 DIVALPROEX SOD ER 500 MG TAB 50166045_1 CDM 0250 RC 65862-0595-01 NDC inpatient 1 UN 1.55 1.01 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.94 1.5 "CHLORPROMAZINE HYDROCHLORIDE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50166050_1 CDM 0250 RC 69238-1056-01 NDC Q0161 HCPCS inpatient 1 UN 13.02 8.46 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.46 65 999999999 7.88 12.63 percent of total billed charges "CHLORPROMAZINE HYDROCHLORIDE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50166050_1 CDM 0250 RC 69238-1056-01 NDC Q0161 HCPCS inpatient 1 UN 13.02 8.46 AETNA AETNA 10.29 79 999999999 7.88 12.63 percent of total billed charges "CHLORPROMAZINE HYDROCHLORIDE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50166050_1 CDM 0250 RC 69238-1056-01 NDC Q0161 HCPCS inpatient 1 UN 13.02 8.46 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.63 97 999999999 7.88 12.63 percent of total billed charges "CHLORPROMAZINE HYDROCHLORIDE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50166050_1 CDM 0250 RC 69238-1056-01 NDC Q0161 HCPCS inpatient 1 UN 13.02 8.46 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.98 69 999999999 7.88 12.63 percent of total billed charges "CHLORPROMAZINE HYDROCHLORIDE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50166050_1 CDM 0250 RC 69238-1056-01 NDC Q0161 HCPCS inpatient 1 UN 13.02 8.46 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.16 78 999999999 7.88 12.63 percent of total billed charges "CHLORPROMAZINE HYDROCHLORIDE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50166050_1 CDM 0250 RC 69238-1056-01 NDC Q0161 HCPCS inpatient 1 UN 13.02 8.46 SIHO - ALL PLANS SIHO - ALL PLANS 11.72 90 999999999 7.88 12.63 percent of total billed charges "CHLORPROMAZINE HYDROCHLORIDE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50166050_1 CDM 0250 RC 69238-1056-01 NDC Q0161 HCPCS inpatient 1 UN 13.02 8.46 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.88 60.55 999999999 7.88 12.63 percent of total billed charges "CHLORPROMAZINE HYDROCHLORIDE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50166050_1 CDM 0250 RC 69238-1056-01 NDC Q0161 HCPCS inpatient 1 UN 13.02 8.46 UMR - ALL PLANS UMR - ALL PLANS 9.11 70 999999999 7.88 12.63 percent of total billed charges "CHLORPROMAZINE HYDROCHLORIDE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50166050_1 CDM 0250 RC 69238-1056-01 NDC Q0161 HCPCS inpatient 1 UN 13.02 8.46 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.88 12.63 "CHLORPROMAZINE HYDROCHLORIDE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50166050_1 CDM 0250 RC 69238-1056-01 NDC Q0161 HCPCS inpatient 1 UN 13.02 8.46 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.88 12.63 "CHLORPROMAZINE HYDROCHLORIDE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50166050_1 CDM 0250 RC 69238-1056-01 NDC Q0161 HCPCS inpatient 1 UN 13.02 8.46 ANTHEM HMO ANTHEM HMO 999999999 7.88 12.63 "CHLORPROMAZINE HYDROCHLORIDE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50166050_1 CDM 0250 RC 69238-1056-01 NDC Q0161 HCPCS inpatient 1 UN 13.02 8.46 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.8 67.6 999999999 7.88 12.63 percent of total billed charges "CHLORPROMAZINE HYDROCHLORIDE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50166050_1 CDM 0250 RC 69238-1056-01 NDC Q0161 HCPCS inpatient 1 UN 13.02 8.46 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.88 12.63 "CHLORPROMAZINE HYDROCHLORIDE, 5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50166050_1 CDM 0250 RC 69238-1056-01 NDC Q0161 HCPCS inpatient 1 UN 13.02 8.46 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.88 12.63 FLUDROCORTISONE 0.1 MG TABLET 50166051_1 CDM 0250 RC 00115-7033-01 NDC inpatient 1 UN 2.1 1.37 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.37 65 999999999 1.27 2.04 percent of total billed charges FLUDROCORTISONE 0.1 MG TABLET 50166051_1 CDM 0250 RC 00115-7033-01 NDC inpatient 1 UN 2.1 1.37 AETNA AETNA 1.66 79 999999999 1.27 2.04 percent of total billed charges FLUDROCORTISONE 0.1 MG TABLET 50166051_1 CDM 0250 RC 00115-7033-01 NDC inpatient 1 UN 2.1 1.37 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.04 97 999999999 1.27 2.04 percent of total billed charges FLUDROCORTISONE 0.1 MG TABLET 50166051_1 CDM 0250 RC 00115-7033-01 NDC inpatient 1 UN 2.1 1.37 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.45 69 999999999 1.27 2.04 percent of total billed charges FLUDROCORTISONE 0.1 MG TABLET 50166051_1 CDM 0250 RC 00115-7033-01 NDC inpatient 1 UN 2.1 1.37 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.64 78 999999999 1.27 2.04 percent of total billed charges FLUDROCORTISONE 0.1 MG TABLET 50166051_1 CDM 0250 RC 00115-7033-01 NDC inpatient 1 UN 2.1 1.37 SIHO - ALL PLANS SIHO - ALL PLANS 1.89 90 999999999 1.27 2.04 percent of total billed charges FLUDROCORTISONE 0.1 MG TABLET 50166051_1 CDM 0250 RC 00115-7033-01 NDC inpatient 1 UN 2.1 1.37 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.27 60.55 999999999 1.27 2.04 percent of total billed charges FLUDROCORTISONE 0.1 MG TABLET 50166051_1 CDM 0250 RC 00115-7033-01 NDC inpatient 1 UN 2.1 1.37 UMR - ALL PLANS UMR - ALL PLANS 1.47 70 999999999 1.27 2.04 percent of total billed charges FLUDROCORTISONE 0.1 MG TABLET 50166051_1 CDM 0250 RC 00115-7033-01 NDC inpatient 1 UN 2.1 1.37 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.27 2.04 FLUDROCORTISONE 0.1 MG TABLET 50166051_1 CDM 0250 RC 00115-7033-01 NDC inpatient 1 UN 2.1 1.37 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.27 2.04 FLUDROCORTISONE 0.1 MG TABLET 50166051_1 CDM 0250 RC 00115-7033-01 NDC inpatient 1 UN 2.1 1.37 ANTHEM HMO ANTHEM HMO 999999999 1.27 2.04 FLUDROCORTISONE 0.1 MG TABLET 50166051_1 CDM 0250 RC 00115-7033-01 NDC inpatient 1 UN 2.1 1.37 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.42 67.6 999999999 1.27 2.04 percent of total billed charges FLUDROCORTISONE 0.1 MG TABLET 50166051_1 CDM 0250 RC 00115-7033-01 NDC inpatient 1 UN 2.1 1.37 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.27 2.04 FLUDROCORTISONE 0.1 MG TABLET 50166051_1 CDM 0250 RC 00115-7033-01 NDC inpatient 1 UN 2.1 1.37 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.27 2.04 "Analysis of substance using immunoassay technique, multiple step method" 50172496_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50172496_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50172496_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50172496_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50172496_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50172496_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50172496_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50172496_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50172496_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 50172496_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 50172496_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 50172496_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50172496_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 50172496_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 VERAPAMIL ER 180 MG TABLET 50173404_1 CDM 0250 RC 68462-0293-05 NDC inpatient 1 UN 1.67 1.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.09 65 999999999 1.01 1.62 percent of total billed charges VERAPAMIL ER 180 MG TABLET 50173404_1 CDM 0250 RC 68462-0293-05 NDC inpatient 1 UN 1.67 1.09 AETNA AETNA 1.32 79 999999999 1.01 1.62 percent of total billed charges VERAPAMIL ER 180 MG TABLET 50173404_1 CDM 0250 RC 68462-0293-05 NDC inpatient 1 UN 1.67 1.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.62 97 999999999 1.01 1.62 percent of total billed charges VERAPAMIL ER 180 MG TABLET 50173404_1 CDM 0250 RC 68462-0293-05 NDC inpatient 1 UN 1.67 1.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.15 69 999999999 1.01 1.62 percent of total billed charges VERAPAMIL ER 180 MG TABLET 50173404_1 CDM 0250 RC 68462-0293-05 NDC inpatient 1 UN 1.67 1.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.3 78 999999999 1.01 1.62 percent of total billed charges VERAPAMIL ER 180 MG TABLET 50173404_1 CDM 0250 RC 68462-0293-05 NDC inpatient 1 UN 1.67 1.09 SIHO - ALL PLANS SIHO - ALL PLANS 1.5 90 999999999 1.01 1.62 percent of total billed charges VERAPAMIL ER 180 MG TABLET 50173404_1 CDM 0250 RC 68462-0293-05 NDC inpatient 1 UN 1.67 1.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.01 60.55 999999999 1.01 1.62 percent of total billed charges VERAPAMIL ER 180 MG TABLET 50173404_1 CDM 0250 RC 68462-0293-05 NDC inpatient 1 UN 1.67 1.09 UMR - ALL PLANS UMR - ALL PLANS 1.17 70 999999999 1.01 1.62 percent of total billed charges VERAPAMIL ER 180 MG TABLET 50173404_1 CDM 0250 RC 68462-0293-05 NDC inpatient 1 UN 1.67 1.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.01 1.62 VERAPAMIL ER 180 MG TABLET 50173404_1 CDM 0250 RC 68462-0293-05 NDC inpatient 1 UN 1.67 1.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.01 1.62 VERAPAMIL ER 180 MG TABLET 50173404_1 CDM 0250 RC 68462-0293-05 NDC inpatient 1 UN 1.67 1.09 ANTHEM HMO ANTHEM HMO 999999999 1.01 1.62 VERAPAMIL ER 180 MG TABLET 50173404_1 CDM 0250 RC 68462-0293-05 NDC inpatient 1 UN 1.67 1.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.13 67.6 999999999 1.01 1.62 percent of total billed charges VERAPAMIL ER 180 MG TABLET 50173404_1 CDM 0250 RC 68462-0293-05 NDC inpatient 1 UN 1.67 1.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.01 1.62 VERAPAMIL ER 180 MG TABLET 50173404_1 CDM 0250 RC 68462-0293-05 NDC inpatient 1 UN 1.67 1.09 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.01 1.62 AMMONIUM LACTATE 12% CREAM 50177479_1 CDM 0250 RC 00904-5983-48 NDC inpatient 1 UN 18.7 12.16 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.16 65 999999999 11.32 18.14 percent of total billed charges AMMONIUM LACTATE 12% CREAM 50177479_1 CDM 0250 RC 00904-5983-48 NDC inpatient 1 UN 18.7 12.16 AETNA AETNA 14.77 79 999999999 11.32 18.14 percent of total billed charges AMMONIUM LACTATE 12% CREAM 50177479_1 CDM 0250 RC 00904-5983-48 NDC inpatient 1 UN 18.7 12.16 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 18.14 97 999999999 11.32 18.14 percent of total billed charges AMMONIUM LACTATE 12% CREAM 50177479_1 CDM 0250 RC 00904-5983-48 NDC inpatient 1 UN 18.7 12.16 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.9 69 999999999 11.32 18.14 percent of total billed charges AMMONIUM LACTATE 12% CREAM 50177479_1 CDM 0250 RC 00904-5983-48 NDC inpatient 1 UN 18.7 12.16 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.59 78 999999999 11.32 18.14 percent of total billed charges AMMONIUM LACTATE 12% CREAM 50177479_1 CDM 0250 RC 00904-5983-48 NDC inpatient 1 UN 18.7 12.16 SIHO - ALL PLANS SIHO - ALL PLANS 16.83 90 999999999 11.32 18.14 percent of total billed charges AMMONIUM LACTATE 12% CREAM 50177479_1 CDM 0250 RC 00904-5983-48 NDC inpatient 1 UN 18.7 12.16 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.32 60.55 999999999 11.32 18.14 percent of total billed charges AMMONIUM LACTATE 12% CREAM 50177479_1 CDM 0250 RC 00904-5983-48 NDC inpatient 1 UN 18.7 12.16 UMR - ALL PLANS UMR - ALL PLANS 13.09 70 999999999 11.32 18.14 percent of total billed charges AMMONIUM LACTATE 12% CREAM 50177479_1 CDM 0250 RC 00904-5983-48 NDC inpatient 1 UN 18.7 12.16 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.32 18.14 AMMONIUM LACTATE 12% CREAM 50177479_1 CDM 0250 RC 00904-5983-48 NDC inpatient 1 UN 18.7 12.16 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.32 18.14 AMMONIUM LACTATE 12% CREAM 50177479_1 CDM 0250 RC 00904-5983-48 NDC inpatient 1 UN 18.7 12.16 ANTHEM HMO ANTHEM HMO 999999999 11.32 18.14 AMMONIUM LACTATE 12% CREAM 50177479_1 CDM 0250 RC 00904-5983-48 NDC inpatient 1 UN 18.7 12.16 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.64 67.6 999999999 11.32 18.14 percent of total billed charges AMMONIUM LACTATE 12% CREAM 50177479_1 CDM 0250 RC 00904-5983-48 NDC inpatient 1 UN 18.7 12.16 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.32 18.14 AMMONIUM LACTATE 12% CREAM 50177479_1 CDM 0250 RC 00904-5983-48 NDC inpatient 1 UN 18.7 12.16 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.32 18.14 00904-6726-02 - mineral oil/petrolatum/phenylephrine topical 14%-74.9%-0.25% Oin[JOHN] 50177497_1 CDM 0250 RC 00904-6726-02 NDC inpatient 1 UN 4.58 2.98 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.98 65 999999999 2.77 4.44 percent of total billed charges 00904-6726-02 - mineral oil/petrolatum/phenylephrine topical 14%-74.9%-0.25% Oin[JOHN] 50177497_1 CDM 0250 RC 00904-6726-02 NDC inpatient 1 UN 4.58 2.98 AETNA AETNA 3.62 79 999999999 2.77 4.44 percent of total billed charges 00904-6726-02 - mineral oil/petrolatum/phenylephrine topical 14%-74.9%-0.25% Oin[JOHN] 50177497_1 CDM 0250 RC 00904-6726-02 NDC inpatient 1 UN 4.58 2.98 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4.44 97 999999999 2.77 4.44 percent of total billed charges 00904-6726-02 - mineral oil/petrolatum/phenylephrine topical 14%-74.9%-0.25% Oin[JOHN] 50177497_1 CDM 0250 RC 00904-6726-02 NDC inpatient 1 UN 4.58 2.98 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.16 69 999999999 2.77 4.44 percent of total billed charges 00904-6726-02 - mineral oil/petrolatum/phenylephrine topical 14%-74.9%-0.25% Oin[JOHN] 50177497_1 CDM 0250 RC 00904-6726-02 NDC inpatient 1 UN 4.58 2.98 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.57 78 999999999 2.77 4.44 percent of total billed charges 00904-6726-02 - mineral oil/petrolatum/phenylephrine topical 14%-74.9%-0.25% Oin[JOHN] 50177497_1 CDM 0250 RC 00904-6726-02 NDC inpatient 1 UN 4.58 2.98 SIHO - ALL PLANS SIHO - ALL PLANS 4.12 90 999999999 2.77 4.44 percent of total billed charges 00904-6726-02 - mineral oil/petrolatum/phenylephrine topical 14%-74.9%-0.25% Oin[JOHN] 50177497_1 CDM 0250 RC 00904-6726-02 NDC inpatient 1 UN 4.58 2.98 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.77 60.55 999999999 2.77 4.44 percent of total billed charges 00904-6726-02 - mineral oil/petrolatum/phenylephrine topical 14%-74.9%-0.25% Oin[JOHN] 50177497_1 CDM 0250 RC 00904-6726-02 NDC inpatient 1 UN 4.58 2.98 UMR - ALL PLANS UMR - ALL PLANS 3.21 70 999999999 2.77 4.44 percent of total billed charges 00904-6726-02 - mineral oil/petrolatum/phenylephrine topical 14%-74.9%-0.25% Oin[JOHN] 50177497_1 CDM 0250 RC 00904-6726-02 NDC inpatient 1 UN 4.58 2.98 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.77 4.44 00904-6726-02 - mineral oil/petrolatum/phenylephrine topical 14%-74.9%-0.25% Oin[JOHN] 50177497_1 CDM 0250 RC 00904-6726-02 NDC inpatient 1 UN 4.58 2.98 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.77 4.44 00904-6726-02 - mineral oil/petrolatum/phenylephrine topical 14%-74.9%-0.25% Oin[JOHN] 50177497_1 CDM 0250 RC 00904-6726-02 NDC inpatient 1 UN 4.58 2.98 ANTHEM HMO ANTHEM HMO 999999999 2.77 4.44 00904-6726-02 - mineral oil/petrolatum/phenylephrine topical 14%-74.9%-0.25% Oin[JOHN] 50177497_1 CDM 0250 RC 00904-6726-02 NDC inpatient 1 UN 4.58 2.98 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.1 67.6 999999999 2.77 4.44 percent of total billed charges 00904-6726-02 - mineral oil/petrolatum/phenylephrine topical 14%-74.9%-0.25% Oin[JOHN] 50177497_1 CDM 0250 RC 00904-6726-02 NDC inpatient 1 UN 4.58 2.98 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.77 4.44 00904-6726-02 - mineral oil/petrolatum/phenylephrine topical 14%-74.9%-0.25% Oin[JOHN] 50177497_1 CDM 0250 RC 00904-6726-02 NDC inpatient 1 UN 4.58 2.98 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.77 4.44 EZETIMIBE 10 MG TABLET 50177758_1 CDM 0250 RC 67877-0490-30 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges EZETIMIBE 10 MG TABLET 50177758_1 CDM 0250 RC 67877-0490-30 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges EZETIMIBE 10 MG TABLET 50177758_1 CDM 0250 RC 67877-0490-30 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges EZETIMIBE 10 MG TABLET 50177758_1 CDM 0250 RC 67877-0490-30 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges EZETIMIBE 10 MG TABLET 50177758_1 CDM 0250 RC 67877-0490-30 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges EZETIMIBE 10 MG TABLET 50177758_1 CDM 0250 RC 67877-0490-30 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges EZETIMIBE 10 MG TABLET 50177758_1 CDM 0250 RC 67877-0490-30 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges EZETIMIBE 10 MG TABLET 50177758_1 CDM 0250 RC 67877-0490-30 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges EZETIMIBE 10 MG TABLET 50177758_1 CDM 0250 RC 67877-0490-30 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 EZETIMIBE 10 MG TABLET 50177758_1 CDM 0250 RC 67877-0490-30 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 EZETIMIBE 10 MG TABLET 50177758_1 CDM 0250 RC 67877-0490-30 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 EZETIMIBE 10 MG TABLET 50177758_1 CDM 0250 RC 67877-0490-30 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges EZETIMIBE 10 MG TABLET 50177758_1 CDM 0250 RC 67877-0490-30 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 EZETIMIBE 10 MG TABLET 50177758_1 CDM 0250 RC 67877-0490-30 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 SORE THROAT 1.4% SPRAY 50177768_1 CDM 0250 RC 46122-0265-30 NDC inpatient 1 UN 6.41 4.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.17 65 999999999 3.88 6.22 percent of total billed charges SORE THROAT 1.4% SPRAY 50177768_1 CDM 0250 RC 46122-0265-30 NDC inpatient 1 UN 6.41 4.17 AETNA AETNA 5.06 79 999999999 3.88 6.22 percent of total billed charges SORE THROAT 1.4% SPRAY 50177768_1 CDM 0250 RC 46122-0265-30 NDC inpatient 1 UN 6.41 4.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.22 97 999999999 3.88 6.22 percent of total billed charges SORE THROAT 1.4% SPRAY 50177768_1 CDM 0250 RC 46122-0265-30 NDC inpatient 1 UN 6.41 4.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.42 69 999999999 3.88 6.22 percent of total billed charges SORE THROAT 1.4% SPRAY 50177768_1 CDM 0250 RC 46122-0265-30 NDC inpatient 1 UN 6.41 4.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 5 78 999999999 3.88 6.22 percent of total billed charges SORE THROAT 1.4% SPRAY 50177768_1 CDM 0250 RC 46122-0265-30 NDC inpatient 1 UN 6.41 4.17 SIHO - ALL PLANS SIHO - ALL PLANS 5.77 90 999999999 3.88 6.22 percent of total billed charges SORE THROAT 1.4% SPRAY 50177768_1 CDM 0250 RC 46122-0265-30 NDC inpatient 1 UN 6.41 4.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.88 60.55 999999999 3.88 6.22 percent of total billed charges SORE THROAT 1.4% SPRAY 50177768_1 CDM 0250 RC 46122-0265-30 NDC inpatient 1 UN 6.41 4.17 UMR - ALL PLANS UMR - ALL PLANS 4.49 70 999999999 3.88 6.22 percent of total billed charges SORE THROAT 1.4% SPRAY 50177768_1 CDM 0250 RC 46122-0265-30 NDC inpatient 1 UN 6.41 4.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.88 6.22 SORE THROAT 1.4% SPRAY 50177768_1 CDM 0250 RC 46122-0265-30 NDC inpatient 1 UN 6.41 4.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.88 6.22 SORE THROAT 1.4% SPRAY 50177768_1 CDM 0250 RC 46122-0265-30 NDC inpatient 1 UN 6.41 4.17 ANTHEM HMO ANTHEM HMO 999999999 3.88 6.22 SORE THROAT 1.4% SPRAY 50177768_1 CDM 0250 RC 46122-0265-30 NDC inpatient 1 UN 6.41 4.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.33 67.6 999999999 3.88 6.22 percent of total billed charges SORE THROAT 1.4% SPRAY 50177768_1 CDM 0250 RC 46122-0265-30 NDC inpatient 1 UN 6.41 4.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.88 6.22 SORE THROAT 1.4% SPRAY 50177768_1 CDM 0250 RC 46122-0265-30 NDC inpatient 1 UN 6.41 4.17 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.88 6.22 "Special stained specimen slides to examine tissue, initial procedure" 50179605_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 230.75 65 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 50179605_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 AETNA AETNA 280.45 79 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 50179605_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 344.35 97 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 50179605_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 244.95 69 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 50179605_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 276.9 78 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 50179605_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 SIHO - ALL PLANS SIHO - ALL PLANS 319.5 90 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 50179605_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 214.95 60.55 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 50179605_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UMR - ALL PLANS UMR - ALL PLANS 248.5 70 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 50179605_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 50179605_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 50179605_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM HMO ANTHEM HMO 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 50179605_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 239.98 67.6 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 50179605_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 50179605_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 214.95 344.35 SPIRONOLACTONE 25 MG TABLET 50183320_1 CDM 0250 RC 60687-0465-01 NDC inpatient 1 UN 1.41 0.92 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.92 65 999999999 0.85 1.37 percent of total billed charges SPIRONOLACTONE 25 MG TABLET 50183320_1 CDM 0250 RC 60687-0465-01 NDC inpatient 1 UN 1.41 0.92 AETNA AETNA 1.11 79 999999999 0.85 1.37 percent of total billed charges SPIRONOLACTONE 25 MG TABLET 50183320_1 CDM 0250 RC 60687-0465-01 NDC inpatient 1 UN 1.41 0.92 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.37 97 999999999 0.85 1.37 percent of total billed charges SPIRONOLACTONE 25 MG TABLET 50183320_1 CDM 0250 RC 60687-0465-01 NDC inpatient 1 UN 1.41 0.92 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.97 69 999999999 0.85 1.37 percent of total billed charges SPIRONOLACTONE 25 MG TABLET 50183320_1 CDM 0250 RC 60687-0465-01 NDC inpatient 1 UN 1.41 0.92 SIHO - ALL PLANS SIHO - ALL PLANS 1.27 90 999999999 0.85 1.37 percent of total billed charges SPIRONOLACTONE 25 MG TABLET 50183320_1 CDM 0250 RC 60687-0465-01 NDC inpatient 1 UN 1.41 0.92 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.1 78 999999999 0.85 1.37 percent of total billed charges SPIRONOLACTONE 25 MG TABLET 50183320_1 CDM 0250 RC 60687-0465-01 NDC inpatient 1 UN 1.41 0.92 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.85 60.55 999999999 0.85 1.37 percent of total billed charges SPIRONOLACTONE 25 MG TABLET 50183320_1 CDM 0250 RC 60687-0465-01 NDC inpatient 1 UN 1.41 0.92 UMR - ALL PLANS UMR - ALL PLANS 0.99 70 999999999 0.85 1.37 percent of total billed charges SPIRONOLACTONE 25 MG TABLET 50183320_1 CDM 0250 RC 60687-0465-01 NDC inpatient 1 UN 1.41 0.92 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.85 1.37 SPIRONOLACTONE 25 MG TABLET 50183320_1 CDM 0250 RC 60687-0465-01 NDC inpatient 1 UN 1.41 0.92 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.85 1.37 SPIRONOLACTONE 25 MG TABLET 50183320_1 CDM 0250 RC 60687-0465-01 NDC inpatient 1 UN 1.41 0.92 ANTHEM HMO ANTHEM HMO 999999999 0.85 1.37 SPIRONOLACTONE 25 MG TABLET 50183320_1 CDM 0250 RC 60687-0465-01 NDC inpatient 1 UN 1.41 0.92 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.95 67.6 999999999 0.85 1.37 percent of total billed charges SPIRONOLACTONE 25 MG TABLET 50183320_1 CDM 0250 RC 60687-0465-01 NDC inpatient 1 UN 1.41 0.92 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.85 1.37 SPIRONOLACTONE 25 MG TABLET 50183320_1 CDM 0250 RC 60687-0465-01 NDC inpatient 1 UN 1.41 0.92 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.85 1.37 ACETAMINOPHEN 650 MG SUPPOS 50183321_1 CDM 0250 RC 45802-0730-33 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ACETAMINOPHEN 650 MG SUPPOS 50183321_1 CDM 0250 RC 45802-0730-33 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ACETAMINOPHEN 650 MG SUPPOS 50183321_1 CDM 0250 RC 45802-0730-33 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ACETAMINOPHEN 650 MG SUPPOS 50183321_1 CDM 0250 RC 45802-0730-33 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ACETAMINOPHEN 650 MG SUPPOS 50183321_1 CDM 0250 RC 45802-0730-33 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ACETAMINOPHEN 650 MG SUPPOS 50183321_1 CDM 0250 RC 45802-0730-33 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ACETAMINOPHEN 650 MG SUPPOS 50183321_1 CDM 0250 RC 45802-0730-33 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ACETAMINOPHEN 650 MG SUPPOS 50183321_1 CDM 0250 RC 45802-0730-33 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ACETAMINOPHEN 650 MG SUPPOS 50183321_1 CDM 0250 RC 45802-0730-33 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ACETAMINOPHEN 650 MG SUPPOS 50183321_1 CDM 0250 RC 45802-0730-33 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ACETAMINOPHEN 650 MG SUPPOS 50183321_1 CDM 0250 RC 45802-0730-33 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ACETAMINOPHEN 650 MG SUPPOS 50183321_1 CDM 0250 RC 45802-0730-33 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges ACETAMINOPHEN 650 MG SUPPOS 50183321_1 CDM 0250 RC 45802-0730-33 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ACETAMINOPHEN 650 MG SUPPOS 50183321_1 CDM 0250 RC 45802-0730-33 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 LEVOTHYROXINE 50 MCG TABLET 50183322_1 CDM 0250 RC 69238-1831-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 50 MCG TABLET 50183322_1 CDM 0250 RC 69238-1831-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 50 MCG TABLET 50183322_1 CDM 0250 RC 69238-1831-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 50 MCG TABLET 50183322_1 CDM 0250 RC 69238-1831-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 50 MCG TABLET 50183322_1 CDM 0250 RC 69238-1831-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 50 MCG TABLET 50183322_1 CDM 0250 RC 69238-1831-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 50 MCG TABLET 50183322_1 CDM 0250 RC 69238-1831-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 50 MCG TABLET 50183322_1 CDM 0250 RC 69238-1831-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 50 MCG TABLET 50183322_1 CDM 0250 RC 69238-1831-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LEVOTHYROXINE 50 MCG TABLET 50183322_1 CDM 0250 RC 69238-1831-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 50 MCG TABLET 50183322_1 CDM 0250 RC 69238-1831-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LEVOTHYROXINE 50 MCG TABLET 50183322_1 CDM 0250 RC 69238-1831-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 50 MCG TABLET 50183322_1 CDM 0250 RC 69238-1831-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 50 MCG TABLET 50183322_1 CDM 0250 RC 69238-1831-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 Molecular pathology procedure level 6 genetic analysis 50184386_1 CDM 0310 RC 81405 HCPCS inpatient 1364 886.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 886.6 65 999999999 825.9 1323.08 percent of total billed charges Molecular pathology procedure level 6 genetic analysis 50184386_1 CDM 0310 RC 81405 HCPCS inpatient 1364 886.6 AETNA AETNA 1077.56 79 999999999 825.9 1323.08 percent of total billed charges Molecular pathology procedure level 6 genetic analysis 50184386_1 CDM 0310 RC 81405 HCPCS inpatient 1364 886.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1323.08 97 999999999 825.9 1323.08 percent of total billed charges Molecular pathology procedure level 6 genetic analysis 50184386_1 CDM 0310 RC 81405 HCPCS inpatient 1364 886.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 941.16 69 999999999 825.9 1323.08 percent of total billed charges Molecular pathology procedure level 6 genetic analysis 50184386_1 CDM 0310 RC 81405 HCPCS inpatient 1364 886.6 SIHO - ALL PLANS SIHO - ALL PLANS 1227.6 90 999999999 825.9 1323.08 percent of total billed charges Molecular pathology procedure level 6 genetic analysis 50184386_1 CDM 0310 RC 81405 HCPCS inpatient 1364 886.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1063.92 78 999999999 825.9 1323.08 percent of total billed charges Molecular pathology procedure level 6 genetic analysis 50184386_1 CDM 0310 RC 81405 HCPCS inpatient 1364 886.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 825.9 60.55 999999999 825.9 1323.08 percent of total billed charges Molecular pathology procedure level 6 genetic analysis 50184386_1 CDM 0310 RC 81405 HCPCS inpatient 1364 886.6 UMR - ALL PLANS UMR - ALL PLANS 954.8 70 999999999 825.9 1323.08 percent of total billed charges Molecular pathology procedure level 6 genetic analysis 50184386_1 CDM 0310 RC 81405 HCPCS inpatient 1364 886.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 825.9 1323.08 Molecular pathology procedure level 6 genetic analysis 50184386_1 CDM 0310 RC 81405 HCPCS inpatient 1364 886.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 825.9 1323.08 Molecular pathology procedure level 6 genetic analysis 50184386_1 CDM 0310 RC 81405 HCPCS inpatient 1364 886.6 ANTHEM HMO ANTHEM HMO 999999999 825.9 1323.08 Molecular pathology procedure level 6 genetic analysis 50184386_1 CDM 0310 RC 81405 HCPCS inpatient 1364 886.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 922.06 67.6 999999999 825.9 1323.08 percent of total billed charges Molecular pathology procedure level 6 genetic analysis 50184386_1 CDM 0310 RC 81405 HCPCS inpatient 1364 886.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 825.9 1323.08 Molecular pathology procedure level 6 genetic analysis 50184386_1 CDM 0310 RC 81405 HCPCS inpatient 1364 886.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 825.9 1323.08 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50184418_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 553.8 65 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50184418_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 AETNA AETNA 673.08 79 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50184418_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 826.44 97 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50184418_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 587.88 69 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50184418_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 SIHO - ALL PLANS SIHO - ALL PLANS 766.8 90 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50184418_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 664.56 78 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50184418_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 515.89 60.55 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50184418_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 UMR - ALL PLANS UMR - ALL PLANS 596.4 70 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50184418_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50184418_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50184418_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM HMO ANTHEM HMO 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50184418_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 575.95 67.6 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50184418_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50184418_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 515.89 826.44 63739-0684-10 - ibuprofen 600 mg Tab[JOHN] 50185276_1 CDM 0250 RC 63739-0684-10 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 63739-0684-10 - ibuprofen 600 mg Tab[JOHN] 50185276_1 CDM 0250 RC 63739-0684-10 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 63739-0684-10 - ibuprofen 600 mg Tab[JOHN] 50185276_1 CDM 0250 RC 63739-0684-10 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 63739-0684-10 - ibuprofen 600 mg Tab[JOHN] 50185276_1 CDM 0250 RC 63739-0684-10 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 63739-0684-10 - ibuprofen 600 mg Tab[JOHN] 50185276_1 CDM 0250 RC 63739-0684-10 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 63739-0684-10 - ibuprofen 600 mg Tab[JOHN] 50185276_1 CDM 0250 RC 63739-0684-10 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 63739-0684-10 - ibuprofen 600 mg Tab[JOHN] 50185276_1 CDM 0250 RC 63739-0684-10 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 63739-0684-10 - ibuprofen 600 mg Tab[JOHN] 50185276_1 CDM 0250 RC 63739-0684-10 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 63739-0684-10 - ibuprofen 600 mg Tab[JOHN] 50185276_1 CDM 0250 RC 63739-0684-10 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 63739-0684-10 - ibuprofen 600 mg Tab[JOHN] 50185276_1 CDM 0250 RC 63739-0684-10 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 63739-0684-10 - ibuprofen 600 mg Tab[JOHN] 50185276_1 CDM 0250 RC 63739-0684-10 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 63739-0684-10 - ibuprofen 600 mg Tab[JOHN] 50185276_1 CDM 0250 RC 63739-0684-10 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 63739-0684-10 - ibuprofen 600 mg Tab[JOHN] 50185276_1 CDM 0250 RC 63739-0684-10 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 63739-0684-10 - ibuprofen 600 mg Tab[JOHN] 50185276_1 CDM 0250 RC 63739-0684-10 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "00023-6110-01 - pancrelipase 10,000 units-32,000 units-42,000 units Cap" 50185289_1 CDM 0250 RC 00023-6110-01 NDC inpatient 1 UN 14.88 9.67 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.67 65 999999999 9.01 14.43 percent of total billed charges "00023-6110-01 - pancrelipase 10,000 units-32,000 units-42,000 units Cap" 50185289_1 CDM 0250 RC 00023-6110-01 NDC inpatient 1 UN 14.88 9.67 AETNA AETNA 11.76 79 999999999 9.01 14.43 percent of total billed charges "00023-6110-01 - pancrelipase 10,000 units-32,000 units-42,000 units Cap" 50185289_1 CDM 0250 RC 00023-6110-01 NDC inpatient 1 UN 14.88 9.67 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14.43 97 999999999 9.01 14.43 percent of total billed charges "00023-6110-01 - pancrelipase 10,000 units-32,000 units-42,000 units Cap" 50185289_1 CDM 0250 RC 00023-6110-01 NDC inpatient 1 UN 14.88 9.67 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.27 69 999999999 9.01 14.43 percent of total billed charges "00023-6110-01 - pancrelipase 10,000 units-32,000 units-42,000 units Cap" 50185289_1 CDM 0250 RC 00023-6110-01 NDC inpatient 1 UN 14.88 9.67 SIHO - ALL PLANS SIHO - ALL PLANS 13.39 90 999999999 9.01 14.43 percent of total billed charges "00023-6110-01 - pancrelipase 10,000 units-32,000 units-42,000 units Cap" 50185289_1 CDM 0250 RC 00023-6110-01 NDC inpatient 1 UN 14.88 9.67 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.61 78 999999999 9.01 14.43 percent of total billed charges "00023-6110-01 - pancrelipase 10,000 units-32,000 units-42,000 units Cap" 50185289_1 CDM 0250 RC 00023-6110-01 NDC inpatient 1 UN 14.88 9.67 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.01 60.55 999999999 9.01 14.43 percent of total billed charges "00023-6110-01 - pancrelipase 10,000 units-32,000 units-42,000 units Cap" 50185289_1 CDM 0250 RC 00023-6110-01 NDC inpatient 1 UN 14.88 9.67 UMR - ALL PLANS UMR - ALL PLANS 10.42 70 999999999 9.01 14.43 percent of total billed charges "00023-6110-01 - pancrelipase 10,000 units-32,000 units-42,000 units Cap" 50185289_1 CDM 0250 RC 00023-6110-01 NDC inpatient 1 UN 14.88 9.67 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.01 14.43 "00023-6110-01 - pancrelipase 10,000 units-32,000 units-42,000 units Cap" 50185289_1 CDM 0250 RC 00023-6110-01 NDC inpatient 1 UN 14.88 9.67 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.01 14.43 "00023-6110-01 - pancrelipase 10,000 units-32,000 units-42,000 units Cap" 50185289_1 CDM 0250 RC 00023-6110-01 NDC inpatient 1 UN 14.88 9.67 ANTHEM HMO ANTHEM HMO 999999999 9.01 14.43 "00023-6110-01 - pancrelipase 10,000 units-32,000 units-42,000 units Cap" 50185289_1 CDM 0250 RC 00023-6110-01 NDC inpatient 1 UN 14.88 9.67 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.06 67.6 999999999 9.01 14.43 percent of total billed charges "00023-6110-01 - pancrelipase 10,000 units-32,000 units-42,000 units Cap" 50185289_1 CDM 0250 RC 00023-6110-01 NDC inpatient 1 UN 14.88 9.67 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.01 14.43 "00023-6110-01 - pancrelipase 10,000 units-32,000 units-42,000 units Cap" 50185289_1 CDM 0250 RC 00023-6110-01 NDC inpatient 1 UN 14.88 9.67 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.01 14.43 "Microscopic genetic analysis of tumor, manual" 50185317_1 CDM 0310 RC 88360 HCPCS inpatient 852 553.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 553.8 65 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50185317_1 CDM 0310 RC 88360 HCPCS inpatient 852 553.8 AETNA AETNA 673.08 79 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50185317_1 CDM 0310 RC 88360 HCPCS inpatient 852 553.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 826.44 97 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50185317_1 CDM 0310 RC 88360 HCPCS inpatient 852 553.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 587.88 69 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50185317_1 CDM 0310 RC 88360 HCPCS inpatient 852 553.8 SIHO - ALL PLANS SIHO - ALL PLANS 766.8 90 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50185317_1 CDM 0310 RC 88360 HCPCS inpatient 852 553.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 664.56 78 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50185317_1 CDM 0310 RC 88360 HCPCS inpatient 852 553.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 515.89 60.55 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50185317_1 CDM 0310 RC 88360 HCPCS inpatient 852 553.8 UMR - ALL PLANS UMR - ALL PLANS 596.4 70 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50185317_1 CDM 0310 RC 88360 HCPCS inpatient 852 553.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 515.89 826.44 "Microscopic genetic analysis of tumor, manual" 50185317_1 CDM 0310 RC 88360 HCPCS inpatient 852 553.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 515.89 826.44 "Microscopic genetic analysis of tumor, manual" 50185317_1 CDM 0310 RC 88360 HCPCS inpatient 852 553.8 ANTHEM HMO ANTHEM HMO 999999999 515.89 826.44 "Microscopic genetic analysis of tumor, manual" 50185317_1 CDM 0310 RC 88360 HCPCS inpatient 852 553.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 575.95 67.6 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 50185317_1 CDM 0310 RC 88360 HCPCS inpatient 852 553.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 515.89 826.44 "Microscopic genetic analysis of tumor, manual" 50185317_1 CDM 0310 RC 88360 HCPCS inpatient 852 553.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 515.89 826.44 LIDOCAINE HCL 2% VIAL 50187299_1 CDM 0250 RC 55150-0255-20 NDC inpatient 1 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges LIDOCAINE HCL 2% VIAL 50187299_1 CDM 0250 RC 55150-0255-20 NDC inpatient 1 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges LIDOCAINE HCL 2% VIAL 50187299_1 CDM 0250 RC 55150-0255-20 NDC inpatient 1 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges LIDOCAINE HCL 2% VIAL 50187299_1 CDM 0250 RC 55150-0255-20 NDC inpatient 1 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges LIDOCAINE HCL 2% VIAL 50187299_1 CDM 0250 RC 55150-0255-20 NDC inpatient 1 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges LIDOCAINE HCL 2% VIAL 50187299_1 CDM 0250 RC 55150-0255-20 NDC inpatient 1 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges LIDOCAINE HCL 2% VIAL 50187299_1 CDM 0250 RC 55150-0255-20 NDC inpatient 1 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges LIDOCAINE HCL 2% VIAL 50187299_1 CDM 0250 RC 55150-0255-20 NDC inpatient 1 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges LIDOCAINE HCL 2% VIAL 50187299_1 CDM 0250 RC 55150-0255-20 NDC inpatient 1 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 LIDOCAINE HCL 2% VIAL 50187299_1 CDM 0250 RC 55150-0255-20 NDC inpatient 1 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 LIDOCAINE HCL 2% VIAL 50187299_1 CDM 0250 RC 55150-0255-20 NDC inpatient 1 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 LIDOCAINE HCL 2% VIAL 50187299_1 CDM 0250 RC 55150-0255-20 NDC inpatient 1 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges LIDOCAINE HCL 2% VIAL 50187299_1 CDM 0250 RC 55150-0255-20 NDC inpatient 1 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 LIDOCAINE HCL 2% VIAL 50187299_1 CDM 0250 RC 55150-0255-20 NDC inpatient 1 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 MORPHINE SULF ER 60 MG TABLET 50187303_1 CDM 0250 RC 00406-8380-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges MORPHINE SULF ER 60 MG TABLET 50187303_1 CDM 0250 RC 00406-8380-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges MORPHINE SULF ER 60 MG TABLET 50187303_1 CDM 0250 RC 00406-8380-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges MORPHINE SULF ER 60 MG TABLET 50187303_1 CDM 0250 RC 00406-8380-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges MORPHINE SULF ER 60 MG TABLET 50187303_1 CDM 0250 RC 00406-8380-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges MORPHINE SULF ER 60 MG TABLET 50187303_1 CDM 0250 RC 00406-8380-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges MORPHINE SULF ER 60 MG TABLET 50187303_1 CDM 0250 RC 00406-8380-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges MORPHINE SULF ER 60 MG TABLET 50187303_1 CDM 0250 RC 00406-8380-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges MORPHINE SULF ER 60 MG TABLET 50187303_1 CDM 0250 RC 00406-8380-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 MORPHINE SULF ER 60 MG TABLET 50187303_1 CDM 0250 RC 00406-8380-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 MORPHINE SULF ER 60 MG TABLET 50187303_1 CDM 0250 RC 00406-8380-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 MORPHINE SULF ER 60 MG TABLET 50187303_1 CDM 0250 RC 00406-8380-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges MORPHINE SULF ER 60 MG TABLET 50187303_1 CDM 0250 RC 00406-8380-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 MORPHINE SULF ER 60 MG TABLET 50187303_1 CDM 0250 RC 00406-8380-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 DIAZEPAM 10 MG/2 ML SYRINGE 50187625_1 CDM 0250 RC 69339-0136-32 NDC inpatient 1 UN 98.24 63.86 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.86 65 999999999 59.48 95.29 percent of total billed charges DIAZEPAM 10 MG/2 ML SYRINGE 50187625_1 CDM 0250 RC 69339-0136-32 NDC inpatient 1 UN 98.24 63.86 AETNA AETNA 77.61 79 999999999 59.48 95.29 percent of total billed charges DIAZEPAM 10 MG/2 ML SYRINGE 50187625_1 CDM 0250 RC 69339-0136-32 NDC inpatient 1 UN 98.24 63.86 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.29 97 999999999 59.48 95.29 percent of total billed charges DIAZEPAM 10 MG/2 ML SYRINGE 50187625_1 CDM 0250 RC 69339-0136-32 NDC inpatient 1 UN 98.24 63.86 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.79 69 999999999 59.48 95.29 percent of total billed charges DIAZEPAM 10 MG/2 ML SYRINGE 50187625_1 CDM 0250 RC 69339-0136-32 NDC inpatient 1 UN 98.24 63.86 SIHO - ALL PLANS SIHO - ALL PLANS 88.42 90 999999999 59.48 95.29 percent of total billed charges DIAZEPAM 10 MG/2 ML SYRINGE 50187625_1 CDM 0250 RC 69339-0136-32 NDC inpatient 1 UN 98.24 63.86 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.63 78 999999999 59.48 95.29 percent of total billed charges DIAZEPAM 10 MG/2 ML SYRINGE 50187625_1 CDM 0250 RC 69339-0136-32 NDC inpatient 1 UN 98.24 63.86 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.48 60.55 999999999 59.48 95.29 percent of total billed charges DIAZEPAM 10 MG/2 ML SYRINGE 50187625_1 CDM 0250 RC 69339-0136-32 NDC inpatient 1 UN 98.24 63.86 UMR - ALL PLANS UMR - ALL PLANS 68.77 70 999999999 59.48 95.29 percent of total billed charges DIAZEPAM 10 MG/2 ML SYRINGE 50187625_1 CDM 0250 RC 69339-0136-32 NDC inpatient 1 UN 98.24 63.86 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.48 95.29 DIAZEPAM 10 MG/2 ML SYRINGE 50187625_1 CDM 0250 RC 69339-0136-32 NDC inpatient 1 UN 98.24 63.86 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.48 95.29 DIAZEPAM 10 MG/2 ML SYRINGE 50187625_1 CDM 0250 RC 69339-0136-32 NDC inpatient 1 UN 98.24 63.86 ANTHEM HMO ANTHEM HMO 999999999 59.48 95.29 DIAZEPAM 10 MG/2 ML SYRINGE 50187625_1 CDM 0250 RC 69339-0136-32 NDC inpatient 1 UN 98.24 63.86 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.41 67.6 999999999 59.48 95.29 percent of total billed charges DIAZEPAM 10 MG/2 ML SYRINGE 50187625_1 CDM 0250 RC 69339-0136-32 NDC inpatient 1 UN 98.24 63.86 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.48 95.29 DIAZEPAM 10 MG/2 ML SYRINGE 50187625_1 CDM 0250 RC 69339-0136-32 NDC inpatient 1 UN 98.24 63.86 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.48 95.29 SODIUM CHLORIDE 0.9% SOLUTION 50193451_1 CDM 0250 RC 00264-1800-31 NDC inpatient 1 UN 61.02 39.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.66 65 999999999 36.95 59.19 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50193451_1 CDM 0250 RC 00264-1800-31 NDC inpatient 1 UN 61.02 39.66 AETNA AETNA 48.21 79 999999999 36.95 59.19 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50193451_1 CDM 0250 RC 00264-1800-31 NDC inpatient 1 UN 61.02 39.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59.19 97 999999999 36.95 59.19 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50193451_1 CDM 0250 RC 00264-1800-31 NDC inpatient 1 UN 61.02 39.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.1 69 999999999 36.95 59.19 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50193451_1 CDM 0250 RC 00264-1800-31 NDC inpatient 1 UN 61.02 39.66 SIHO - ALL PLANS SIHO - ALL PLANS 54.92 90 999999999 36.95 59.19 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50193451_1 CDM 0250 RC 00264-1800-31 NDC inpatient 1 UN 61.02 39.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.6 78 999999999 36.95 59.19 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50193451_1 CDM 0250 RC 00264-1800-31 NDC inpatient 1 UN 61.02 39.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.95 60.55 999999999 36.95 59.19 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50193451_1 CDM 0250 RC 00264-1800-31 NDC inpatient 1 UN 61.02 39.66 UMR - ALL PLANS UMR - ALL PLANS 42.71 70 999999999 36.95 59.19 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50193451_1 CDM 0250 RC 00264-1800-31 NDC inpatient 1 UN 61.02 39.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.95 59.19 SODIUM CHLORIDE 0.9% SOLUTION 50193451_1 CDM 0250 RC 00264-1800-31 NDC inpatient 1 UN 61.02 39.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.95 59.19 SODIUM CHLORIDE 0.9% SOLUTION 50193451_1 CDM 0250 RC 00264-1800-31 NDC inpatient 1 UN 61.02 39.66 ANTHEM HMO ANTHEM HMO 999999999 36.95 59.19 SODIUM CHLORIDE 0.9% SOLUTION 50193451_1 CDM 0250 RC 00264-1800-31 NDC inpatient 1 UN 61.02 39.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.25 67.6 999999999 36.95 59.19 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50193451_1 CDM 0250 RC 00264-1800-31 NDC inpatient 1 UN 61.02 39.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.95 59.19 SODIUM CHLORIDE 0.9% SOLUTION 50193451_1 CDM 0250 RC 00264-1800-31 NDC inpatient 1 UN 61.02 39.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.95 59.19 SODIUM CHLORIDE 0.9% SOLUTION 50193452_1 CDM 0250 RC 00264-1800-32 NDC inpatient 1 UN 58.79 38.21 SELF PAY DISCOUNT SELF PAY DISCOUNT 38.21 65 999999999 35.6 57.03 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50193452_1 CDM 0250 RC 00264-1800-32 NDC inpatient 1 UN 58.79 38.21 AETNA AETNA 46.44 79 999999999 35.6 57.03 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50193452_1 CDM 0250 RC 00264-1800-32 NDC inpatient 1 UN 58.79 38.21 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 57.03 97 999999999 35.6 57.03 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50193452_1 CDM 0250 RC 00264-1800-32 NDC inpatient 1 UN 58.79 38.21 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.57 69 999999999 35.6 57.03 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50193452_1 CDM 0250 RC 00264-1800-32 NDC inpatient 1 UN 58.79 38.21 SIHO - ALL PLANS SIHO - ALL PLANS 52.91 90 999999999 35.6 57.03 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50193452_1 CDM 0250 RC 00264-1800-32 NDC inpatient 1 UN 58.79 38.21 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.86 78 999999999 35.6 57.03 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50193452_1 CDM 0250 RC 00264-1800-32 NDC inpatient 1 UN 58.79 38.21 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.6 60.55 999999999 35.6 57.03 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50193452_1 CDM 0250 RC 00264-1800-32 NDC inpatient 1 UN 58.79 38.21 UMR - ALL PLANS UMR - ALL PLANS 41.15 70 999999999 35.6 57.03 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50193452_1 CDM 0250 RC 00264-1800-32 NDC inpatient 1 UN 58.79 38.21 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.6 57.03 SODIUM CHLORIDE 0.9% SOLUTION 50193452_1 CDM 0250 RC 00264-1800-32 NDC inpatient 1 UN 58.79 38.21 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.6 57.03 SODIUM CHLORIDE 0.9% SOLUTION 50193452_1 CDM 0250 RC 00264-1800-32 NDC inpatient 1 UN 58.79 38.21 ANTHEM HMO ANTHEM HMO 999999999 35.6 57.03 SODIUM CHLORIDE 0.9% SOLUTION 50193452_1 CDM 0250 RC 00264-1800-32 NDC inpatient 1 UN 58.79 38.21 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.74 67.6 999999999 35.6 57.03 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50193452_1 CDM 0250 RC 00264-1800-32 NDC inpatient 1 UN 58.79 38.21 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.6 57.03 SODIUM CHLORIDE 0.9% SOLUTION 50193452_1 CDM 0250 RC 00264-1800-32 NDC inpatient 1 UN 58.79 38.21 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.6 57.03 DEXTROSE 5%-WATER IV SOLN 50193453_1 CDM 0250 RC 00264-1510-31 NDC inpatient 1 UN 60.84 39.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.55 65 999999999 36.84 59.01 percent of total billed charges DEXTROSE 5%-WATER IV SOLN 50193453_1 CDM 0250 RC 00264-1510-31 NDC inpatient 1 UN 60.84 39.55 AETNA AETNA 48.06 79 999999999 36.84 59.01 percent of total billed charges DEXTROSE 5%-WATER IV SOLN 50193453_1 CDM 0250 RC 00264-1510-31 NDC inpatient 1 UN 60.84 39.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59.01 97 999999999 36.84 59.01 percent of total billed charges DEXTROSE 5%-WATER IV SOLN 50193453_1 CDM 0250 RC 00264-1510-31 NDC inpatient 1 UN 60.84 39.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.98 69 999999999 36.84 59.01 percent of total billed charges DEXTROSE 5%-WATER IV SOLN 50193453_1 CDM 0250 RC 00264-1510-31 NDC inpatient 1 UN 60.84 39.55 SIHO - ALL PLANS SIHO - ALL PLANS 54.76 90 999999999 36.84 59.01 percent of total billed charges DEXTROSE 5%-WATER IV SOLN 50193453_1 CDM 0250 RC 00264-1510-31 NDC inpatient 1 UN 60.84 39.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.46 78 999999999 36.84 59.01 percent of total billed charges DEXTROSE 5%-WATER IV SOLN 50193453_1 CDM 0250 RC 00264-1510-31 NDC inpatient 1 UN 60.84 39.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.84 60.55 999999999 36.84 59.01 percent of total billed charges DEXTROSE 5%-WATER IV SOLN 50193453_1 CDM 0250 RC 00264-1510-31 NDC inpatient 1 UN 60.84 39.55 UMR - ALL PLANS UMR - ALL PLANS 42.59 70 999999999 36.84 59.01 percent of total billed charges DEXTROSE 5%-WATER IV SOLN 50193453_1 CDM 0250 RC 00264-1510-31 NDC inpatient 1 UN 60.84 39.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.84 59.01 DEXTROSE 5%-WATER IV SOLN 50193453_1 CDM 0250 RC 00264-1510-31 NDC inpatient 1 UN 60.84 39.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.84 59.01 DEXTROSE 5%-WATER IV SOLN 50193453_1 CDM 0250 RC 00264-1510-31 NDC inpatient 1 UN 60.84 39.55 ANTHEM HMO ANTHEM HMO 999999999 36.84 59.01 DEXTROSE 5%-WATER IV SOLN 50193453_1 CDM 0250 RC 00264-1510-31 NDC inpatient 1 UN 60.84 39.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.13 67.6 999999999 36.84 59.01 percent of total billed charges DEXTROSE 5%-WATER IV SOLN 50193453_1 CDM 0250 RC 00264-1510-31 NDC inpatient 1 UN 60.84 39.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.84 59.01 DEXTROSE 5%-WATER IV SOLN 50193453_1 CDM 0250 RC 00264-1510-31 NDC inpatient 1 UN 60.84 39.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.84 59.01 "Identification of organisms by genetic analysis, amplified probe technique" 50195342_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195342_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195342_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195342_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195342_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195342_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195342_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195342_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195342_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195342_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195342_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195342_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195342_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195342_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195344_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195344_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195344_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195344_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195344_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195344_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195344_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195344_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195344_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195344_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195344_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195344_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195344_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195344_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195346_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195346_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195346_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195346_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195346_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195346_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195346_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195346_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195346_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195346_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195346_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195346_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195346_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195346_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195348_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195348_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195348_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195348_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195348_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195348_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195348_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195348_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195348_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195348_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195348_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195348_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195348_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195348_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195350_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195350_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195350_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195350_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195350_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195350_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195350_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195350_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195350_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195350_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195350_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195350_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195350_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195350_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195352_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195352_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195352_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195352_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195352_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195352_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195352_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195352_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195352_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195352_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195352_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195352_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195352_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195352_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195354_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195354_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195354_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195354_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195354_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195354_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195354_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195354_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195354_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195354_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195354_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195354_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195354_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195354_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195356_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195356_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195356_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195356_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195356_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195356_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195356_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195356_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195356_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195356_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195356_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195356_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195356_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195356_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195358_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195358_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195358_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195358_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195358_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195358_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195358_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195358_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195358_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195358_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195358_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195358_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195358_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195358_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195360_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195360_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195360_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195360_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195360_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195360_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195360_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195360_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195360_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195360_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195360_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195360_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195360_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195360_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195362_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195362_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195362_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195362_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195362_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195362_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195362_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195362_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195362_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195362_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195362_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195362_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195362_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195362_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195364_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195364_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195364_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195364_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195364_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195364_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195364_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195364_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195364_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195364_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195364_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195364_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195364_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195364_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195366_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195366_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195366_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195366_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195366_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195366_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195366_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195366_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195366_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195366_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195366_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195366_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195366_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195366_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195368_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195368_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195368_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195368_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195368_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195368_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195368_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195368_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195368_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195368_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195368_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195368_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195368_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195368_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195370_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195370_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195370_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195370_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195370_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195370_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195370_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195370_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195370_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195370_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195370_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195370_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195370_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195370_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195385_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195385_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195385_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195385_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195385_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195385_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195385_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195385_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195385_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195385_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195385_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195385_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195385_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195385_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195387_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195387_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195387_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195387_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195387_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195387_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195387_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195387_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195387_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195387_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195387_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195387_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195387_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195387_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195389_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195389_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195389_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195389_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195389_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195389_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195389_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195389_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195389_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195389_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195389_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195389_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195389_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195389_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195391_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195391_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195391_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195391_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195391_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195391_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195391_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195391_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195391_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195391_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195391_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195391_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195391_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195391_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195393_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195393_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195393_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195393_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195393_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195393_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195393_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195393_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195393_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195393_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195393_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195393_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195393_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195393_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195395_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195395_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195395_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195395_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195395_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195395_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195395_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195395_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195395_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195395_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195395_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195395_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50195395_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50195395_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201156_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 553.8 65 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201156_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 AETNA AETNA 673.08 79 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201156_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 826.44 97 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201156_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 587.88 69 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201156_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 664.56 78 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201156_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 SIHO - ALL PLANS SIHO - ALL PLANS 766.8 90 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201156_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 515.89 60.55 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201156_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 UMR - ALL PLANS UMR - ALL PLANS 596.4 70 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201156_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201156_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201156_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM HMO ANTHEM HMO 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201156_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 575.95 67.6 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201156_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201156_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201157_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 553.8 65 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201157_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 AETNA AETNA 673.08 79 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201157_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 826.44 97 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201157_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 587.88 69 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201157_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 664.56 78 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201157_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 SIHO - ALL PLANS SIHO - ALL PLANS 766.8 90 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201157_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 515.89 60.55 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201157_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 UMR - ALL PLANS UMR - ALL PLANS 596.4 70 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201157_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201157_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201157_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM HMO ANTHEM HMO 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201157_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 575.95 67.6 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201157_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 50201157_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 515.89 826.44 "Identification of organisms by genetic analysis, amplified probe technique" 50201172_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50201172_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50201172_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50201172_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50201172_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50201172_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50201172_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50201172_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50201172_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50201172_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50201172_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50201172_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 50201172_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Identification of organisms by genetic analysis, amplified probe technique" 50201172_1 CDM 0306 RC 87150 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50203783_1 CDM 0250 RC 00378-2045-01 NDC J7507 HCPCS inpatient 1 UN 1.99 1.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.29 65 999999999 1.2 1.93 percent of total billed charges "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50203783_1 CDM 0250 RC 00378-2045-01 NDC J7507 HCPCS inpatient 1 UN 1.99 1.29 AETNA AETNA 1.57 79 999999999 1.2 1.93 percent of total billed charges "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50203783_1 CDM 0250 RC 00378-2045-01 NDC J7507 HCPCS inpatient 1 UN 1.99 1.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.93 97 999999999 1.2 1.93 percent of total billed charges "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50203783_1 CDM 0250 RC 00378-2045-01 NDC J7507 HCPCS inpatient 1 UN 1.99 1.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.37 69 999999999 1.2 1.93 percent of total billed charges "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50203783_1 CDM 0250 RC 00378-2045-01 NDC J7507 HCPCS inpatient 1 UN 1.99 1.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.55 78 999999999 1.2 1.93 percent of total billed charges "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50203783_1 CDM 0250 RC 00378-2045-01 NDC J7507 HCPCS inpatient 1 UN 1.99 1.29 SIHO - ALL PLANS SIHO - ALL PLANS 1.79 90 999999999 1.2 1.93 percent of total billed charges "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50203783_1 CDM 0250 RC 00378-2045-01 NDC J7507 HCPCS inpatient 1 UN 1.99 1.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.2 60.55 999999999 1.2 1.93 percent of total billed charges "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50203783_1 CDM 0250 RC 00378-2045-01 NDC J7507 HCPCS inpatient 1 UN 1.99 1.29 UMR - ALL PLANS UMR - ALL PLANS 1.39 70 999999999 1.2 1.93 percent of total billed charges "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50203783_1 CDM 0250 RC 00378-2045-01 NDC J7507 HCPCS inpatient 1 UN 1.99 1.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.2 1.93 "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50203783_1 CDM 0250 RC 00378-2045-01 NDC J7507 HCPCS inpatient 1 UN 1.99 1.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.2 1.93 "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50203783_1 CDM 0250 RC 00378-2045-01 NDC J7507 HCPCS inpatient 1 UN 1.99 1.29 ANTHEM HMO ANTHEM HMO 999999999 1.2 1.93 "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50203783_1 CDM 0250 RC 00378-2045-01 NDC J7507 HCPCS inpatient 1 UN 1.99 1.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.2 1.93 percent of total billed charges "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50203783_1 CDM 0250 RC 00378-2045-01 NDC J7507 HCPCS inpatient 1 UN 1.99 1.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.2 1.93 "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50203783_1 CDM 0250 RC 00378-2045-01 NDC J7507 HCPCS inpatient 1 UN 1.99 1.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.2 1.93 00904-6342-61 - metoprolol 100 mg Tab[JOHN] 50206030_1 CDM 0250 RC 00904-6342-61 NDC inpatient 1 UN 1.85 1.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.2 65 999999999 1.12 1.79 percent of total billed charges 00904-6342-61 - metoprolol 100 mg Tab[JOHN] 50206030_1 CDM 0250 RC 00904-6342-61 NDC inpatient 1 UN 1.85 1.2 AETNA AETNA 1.46 79 999999999 1.12 1.79 percent of total billed charges 00904-6342-61 - metoprolol 100 mg Tab[JOHN] 50206030_1 CDM 0250 RC 00904-6342-61 NDC inpatient 1 UN 1.85 1.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.79 97 999999999 1.12 1.79 percent of total billed charges 00904-6342-61 - metoprolol 100 mg Tab[JOHN] 50206030_1 CDM 0250 RC 00904-6342-61 NDC inpatient 1 UN 1.85 1.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.28 69 999999999 1.12 1.79 percent of total billed charges 00904-6342-61 - metoprolol 100 mg Tab[JOHN] 50206030_1 CDM 0250 RC 00904-6342-61 NDC inpatient 1 UN 1.85 1.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.44 78 999999999 1.12 1.79 percent of total billed charges 00904-6342-61 - metoprolol 100 mg Tab[JOHN] 50206030_1 CDM 0250 RC 00904-6342-61 NDC inpatient 1 UN 1.85 1.2 SIHO - ALL PLANS SIHO - ALL PLANS 1.67 90 999999999 1.12 1.79 percent of total billed charges 00904-6342-61 - metoprolol 100 mg Tab[JOHN] 50206030_1 CDM 0250 RC 00904-6342-61 NDC inpatient 1 UN 1.85 1.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.12 60.55 999999999 1.12 1.79 percent of total billed charges 00904-6342-61 - metoprolol 100 mg Tab[JOHN] 50206030_1 CDM 0250 RC 00904-6342-61 NDC inpatient 1 UN 1.85 1.2 UMR - ALL PLANS UMR - ALL PLANS 1.3 70 999999999 1.12 1.79 percent of total billed charges 00904-6342-61 - metoprolol 100 mg Tab[JOHN] 50206030_1 CDM 0250 RC 00904-6342-61 NDC inpatient 1 UN 1.85 1.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.12 1.79 00904-6342-61 - metoprolol 100 mg Tab[JOHN] 50206030_1 CDM 0250 RC 00904-6342-61 NDC inpatient 1 UN 1.85 1.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.12 1.79 00904-6342-61 - metoprolol 100 mg Tab[JOHN] 50206030_1 CDM 0250 RC 00904-6342-61 NDC inpatient 1 UN 1.85 1.2 ANTHEM HMO ANTHEM HMO 999999999 1.12 1.79 00904-6342-61 - metoprolol 100 mg Tab[JOHN] 50206030_1 CDM 0250 RC 00904-6342-61 NDC inpatient 1 UN 1.85 1.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.25 67.6 999999999 1.12 1.79 percent of total billed charges 00904-6342-61 - metoprolol 100 mg Tab[JOHN] 50206030_1 CDM 0250 RC 00904-6342-61 NDC inpatient 1 UN 1.85 1.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.12 1.79 00904-6342-61 - metoprolol 100 mg Tab[JOHN] 50206030_1 CDM 0250 RC 00904-6342-61 NDC inpatient 1 UN 1.85 1.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.12 1.79 ETOMIDATE 20 MG/10 ML VIAL 50209304_1 CDM 0250 RC 00143-9310-10 NDC inpatient 1 UN 29 18.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 18.85 65 999999999 17.56 28.13 percent of total billed charges ETOMIDATE 20 MG/10 ML VIAL 50209304_1 CDM 0250 RC 00143-9310-10 NDC inpatient 1 UN 29 18.85 AETNA AETNA 22.91 79 999999999 17.56 28.13 percent of total billed charges ETOMIDATE 20 MG/10 ML VIAL 50209304_1 CDM 0250 RC 00143-9310-10 NDC inpatient 1 UN 29 18.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 28.13 97 999999999 17.56 28.13 percent of total billed charges ETOMIDATE 20 MG/10 ML VIAL 50209304_1 CDM 0250 RC 00143-9310-10 NDC inpatient 1 UN 29 18.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.01 69 999999999 17.56 28.13 percent of total billed charges ETOMIDATE 20 MG/10 ML VIAL 50209304_1 CDM 0250 RC 00143-9310-10 NDC inpatient 1 UN 29 18.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 22.62 78 999999999 17.56 28.13 percent of total billed charges ETOMIDATE 20 MG/10 ML VIAL 50209304_1 CDM 0250 RC 00143-9310-10 NDC inpatient 1 UN 29 18.85 SIHO - ALL PLANS SIHO - ALL PLANS 26.1 90 999999999 17.56 28.13 percent of total billed charges ETOMIDATE 20 MG/10 ML VIAL 50209304_1 CDM 0250 RC 00143-9310-10 NDC inpatient 1 UN 29 18.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17.56 60.55 999999999 17.56 28.13 percent of total billed charges ETOMIDATE 20 MG/10 ML VIAL 50209304_1 CDM 0250 RC 00143-9310-10 NDC inpatient 1 UN 29 18.85 UMR - ALL PLANS UMR - ALL PLANS 20.3 70 999999999 17.56 28.13 percent of total billed charges ETOMIDATE 20 MG/10 ML VIAL 50209304_1 CDM 0250 RC 00143-9310-10 NDC inpatient 1 UN 29 18.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 17.56 28.13 ETOMIDATE 20 MG/10 ML VIAL 50209304_1 CDM 0250 RC 00143-9310-10 NDC inpatient 1 UN 29 18.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 17.56 28.13 ETOMIDATE 20 MG/10 ML VIAL 50209304_1 CDM 0250 RC 00143-9310-10 NDC inpatient 1 UN 29 18.85 ANTHEM HMO ANTHEM HMO 999999999 17.56 28.13 ETOMIDATE 20 MG/10 ML VIAL 50209304_1 CDM 0250 RC 00143-9310-10 NDC inpatient 1 UN 29 18.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 19.6 67.6 999999999 17.56 28.13 percent of total billed charges ETOMIDATE 20 MG/10 ML VIAL 50209304_1 CDM 0250 RC 00143-9310-10 NDC inpatient 1 UN 29 18.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 17.56 28.13 ETOMIDATE 20 MG/10 ML VIAL 50209304_1 CDM 0250 RC 00143-9310-10 NDC inpatient 1 UN 29 18.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 17.56 28.13 "Removal of fingernails or toenails, 1-5 nails" 50210864_1 CDM 0510 RC 11720 HCPCS inpatient 141 91.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 91.65 65 999999999 85.38 136.77 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 50210864_1 CDM 0510 RC 11720 HCPCS inpatient 141 91.65 AETNA AETNA 111.39 79 999999999 85.38 136.77 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 50210864_1 CDM 0510 RC 11720 HCPCS inpatient 141 91.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 136.77 97 999999999 85.38 136.77 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 50210864_1 CDM 0510 RC 11720 HCPCS inpatient 141 91.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.29 69 999999999 85.38 136.77 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 50210864_1 CDM 0510 RC 11720 HCPCS inpatient 141 91.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 109.98 78 999999999 85.38 136.77 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 50210864_1 CDM 0510 RC 11720 HCPCS inpatient 141 91.65 SIHO - ALL PLANS SIHO - ALL PLANS 126.9 90 999999999 85.38 136.77 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 50210864_1 CDM 0510 RC 11720 HCPCS inpatient 141 91.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.38 60.55 999999999 85.38 136.77 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 50210864_1 CDM 0510 RC 11720 HCPCS inpatient 141 91.65 UMR - ALL PLANS UMR - ALL PLANS 98.7 70 999999999 85.38 136.77 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 50210864_1 CDM 0510 RC 11720 HCPCS inpatient 141 91.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.38 136.77 "Removal of fingernails or toenails, 1-5 nails" 50210864_1 CDM 0510 RC 11720 HCPCS inpatient 141 91.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.38 136.77 "Removal of fingernails or toenails, 1-5 nails" 50210864_1 CDM 0510 RC 11720 HCPCS inpatient 141 91.65 ANTHEM HMO ANTHEM HMO 999999999 85.38 136.77 "Removal of fingernails or toenails, 1-5 nails" 50210864_1 CDM 0510 RC 11720 HCPCS inpatient 141 91.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.32 67.6 999999999 85.38 136.77 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 50210864_1 CDM 0510 RC 11720 HCPCS inpatient 141 91.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.38 136.77 "Removal of fingernails or toenails, 1-5 nails" 50210864_1 CDM 0510 RC 11720 HCPCS inpatient 141 91.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.38 136.77 "Removal of fingernails or toenails, 6 or more nails" 50210869_1 CDM 0510 RC 11721 HCPCS inpatient 154 100.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.1 65 999999999 93.25 149.38 percent of total billed charges "Removal of fingernails or toenails, 6 or more nails" 50210869_1 CDM 0510 RC 11721 HCPCS inpatient 154 100.1 AETNA AETNA 121.66 79 999999999 93.25 149.38 percent of total billed charges "Removal of fingernails or toenails, 6 or more nails" 50210869_1 CDM 0510 RC 11721 HCPCS inpatient 154 100.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 149.38 97 999999999 93.25 149.38 percent of total billed charges "Removal of fingernails or toenails, 6 or more nails" 50210869_1 CDM 0510 RC 11721 HCPCS inpatient 154 100.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.26 69 999999999 93.25 149.38 percent of total billed charges "Removal of fingernails or toenails, 6 or more nails" 50210869_1 CDM 0510 RC 11721 HCPCS inpatient 154 100.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.12 78 999999999 93.25 149.38 percent of total billed charges "Removal of fingernails or toenails, 6 or more nails" 50210869_1 CDM 0510 RC 11721 HCPCS inpatient 154 100.1 SIHO - ALL PLANS SIHO - ALL PLANS 138.6 90 999999999 93.25 149.38 percent of total billed charges "Removal of fingernails or toenails, 6 or more nails" 50210869_1 CDM 0510 RC 11721 HCPCS inpatient 154 100.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.25 60.55 999999999 93.25 149.38 percent of total billed charges "Removal of fingernails or toenails, 6 or more nails" 50210869_1 CDM 0510 RC 11721 HCPCS inpatient 154 100.1 UMR - ALL PLANS UMR - ALL PLANS 107.8 70 999999999 93.25 149.38 percent of total billed charges "Removal of fingernails or toenails, 6 or more nails" 50210869_1 CDM 0510 RC 11721 HCPCS inpatient 154 100.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.25 149.38 "Removal of fingernails or toenails, 6 or more nails" 50210869_1 CDM 0510 RC 11721 HCPCS inpatient 154 100.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.25 149.38 "Removal of fingernails or toenails, 6 or more nails" 50210869_1 CDM 0510 RC 11721 HCPCS inpatient 154 100.1 ANTHEM HMO ANTHEM HMO 999999999 93.25 149.38 "Removal of fingernails or toenails, 6 or more nails" 50210869_1 CDM 0510 RC 11721 HCPCS inpatient 154 100.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.1 67.6 999999999 93.25 149.38 percent of total billed charges "Removal of fingernails or toenails, 6 or more nails" 50210869_1 CDM 0510 RC 11721 HCPCS inpatient 154 100.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.25 149.38 "Removal of fingernails or toenails, 6 or more nails" 50210869_1 CDM 0510 RC 11721 HCPCS inpatient 154 100.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.25 149.38 "INJECTION, TERBUTALINE SULFATE, UP TO 1 MG" 50211156_1 CDM 0250 RC 00143-9746-10 NDC J3105 HCPCS inpatient 1 UN 25.7 16.71 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.71 65 999999999 15.56 24.93 percent of total billed charges "INJECTION, TERBUTALINE SULFATE, UP TO 1 MG" 50211156_1 CDM 0250 RC 00143-9746-10 NDC J3105 HCPCS inpatient 1 UN 25.7 16.71 AETNA AETNA 20.3 79 999999999 15.56 24.93 percent of total billed charges "INJECTION, TERBUTALINE SULFATE, UP TO 1 MG" 50211156_1 CDM 0250 RC 00143-9746-10 NDC J3105 HCPCS inpatient 1 UN 25.7 16.71 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.93 97 999999999 15.56 24.93 percent of total billed charges "INJECTION, TERBUTALINE SULFATE, UP TO 1 MG" 50211156_1 CDM 0250 RC 00143-9746-10 NDC J3105 HCPCS inpatient 1 UN 25.7 16.71 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.73 69 999999999 15.56 24.93 percent of total billed charges "INJECTION, TERBUTALINE SULFATE, UP TO 1 MG" 50211156_1 CDM 0250 RC 00143-9746-10 NDC J3105 HCPCS inpatient 1 UN 25.7 16.71 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.05 78 999999999 15.56 24.93 percent of total billed charges "INJECTION, TERBUTALINE SULFATE, UP TO 1 MG" 50211156_1 CDM 0250 RC 00143-9746-10 NDC J3105 HCPCS inpatient 1 UN 25.7 16.71 SIHO - ALL PLANS SIHO - ALL PLANS 23.13 90 999999999 15.56 24.93 percent of total billed charges "INJECTION, TERBUTALINE SULFATE, UP TO 1 MG" 50211156_1 CDM 0250 RC 00143-9746-10 NDC J3105 HCPCS inpatient 1 UN 25.7 16.71 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.56 60.55 999999999 15.56 24.93 percent of total billed charges "INJECTION, TERBUTALINE SULFATE, UP TO 1 MG" 50211156_1 CDM 0250 RC 00143-9746-10 NDC J3105 HCPCS inpatient 1 UN 25.7 16.71 UMR - ALL PLANS UMR - ALL PLANS 17.99 70 999999999 15.56 24.93 percent of total billed charges "INJECTION, TERBUTALINE SULFATE, UP TO 1 MG" 50211156_1 CDM 0250 RC 00143-9746-10 NDC J3105 HCPCS inpatient 1 UN 25.7 16.71 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.56 24.93 "INJECTION, TERBUTALINE SULFATE, UP TO 1 MG" 50211156_1 CDM 0250 RC 00143-9746-10 NDC J3105 HCPCS inpatient 1 UN 25.7 16.71 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.56 24.93 "INJECTION, TERBUTALINE SULFATE, UP TO 1 MG" 50211156_1 CDM 0250 RC 00143-9746-10 NDC J3105 HCPCS inpatient 1 UN 25.7 16.71 ANTHEM HMO ANTHEM HMO 999999999 15.56 24.93 "INJECTION, TERBUTALINE SULFATE, UP TO 1 MG" 50211156_1 CDM 0250 RC 00143-9746-10 NDC J3105 HCPCS inpatient 1 UN 25.7 16.71 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.37 67.6 999999999 15.56 24.93 percent of total billed charges "INJECTION, TERBUTALINE SULFATE, UP TO 1 MG" 50211156_1 CDM 0250 RC 00143-9746-10 NDC J3105 HCPCS inpatient 1 UN 25.7 16.71 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.56 24.93 "INJECTION, TERBUTALINE SULFATE, UP TO 1 MG" 50211156_1 CDM 0250 RC 00143-9746-10 NDC J3105 HCPCS inpatient 1 UN 25.7 16.71 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.56 24.93 "VITAMIN D2 1.25MG(50,000 UNIT)" 50211157_1 CDM 0250 RC 69452-0151-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges "VITAMIN D2 1.25MG(50,000 UNIT)" 50211157_1 CDM 0250 RC 69452-0151-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges "VITAMIN D2 1.25MG(50,000 UNIT)" 50211157_1 CDM 0250 RC 69452-0151-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges "VITAMIN D2 1.25MG(50,000 UNIT)" 50211157_1 CDM 0250 RC 69452-0151-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges "VITAMIN D2 1.25MG(50,000 UNIT)" 50211157_1 CDM 0250 RC 69452-0151-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges "VITAMIN D2 1.25MG(50,000 UNIT)" 50211157_1 CDM 0250 RC 69452-0151-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges "VITAMIN D2 1.25MG(50,000 UNIT)" 50211157_1 CDM 0250 RC 69452-0151-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges "VITAMIN D2 1.25MG(50,000 UNIT)" 50211157_1 CDM 0250 RC 69452-0151-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges "VITAMIN D2 1.25MG(50,000 UNIT)" 50211157_1 CDM 0250 RC 69452-0151-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 "VITAMIN D2 1.25MG(50,000 UNIT)" 50211157_1 CDM 0250 RC 69452-0151-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 "VITAMIN D2 1.25MG(50,000 UNIT)" 50211157_1 CDM 0250 RC 69452-0151-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 "VITAMIN D2 1.25MG(50,000 UNIT)" 50211157_1 CDM 0250 RC 69452-0151-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "VITAMIN D2 1.25MG(50,000 UNIT)" 50211157_1 CDM 0250 RC 69452-0151-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 "VITAMIN D2 1.25MG(50,000 UNIT)" 50211157_1 CDM 0250 RC 69452-0151-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 VERAPAMIL ER 240 MG TABLET 50211158_1 CDM 0250 RC 68462-0260-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges VERAPAMIL ER 240 MG TABLET 50211158_1 CDM 0250 RC 68462-0260-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges VERAPAMIL ER 240 MG TABLET 50211158_1 CDM 0250 RC 68462-0260-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges VERAPAMIL ER 240 MG TABLET 50211158_1 CDM 0250 RC 68462-0260-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges VERAPAMIL ER 240 MG TABLET 50211158_1 CDM 0250 RC 68462-0260-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges VERAPAMIL ER 240 MG TABLET 50211158_1 CDM 0250 RC 68462-0260-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges VERAPAMIL ER 240 MG TABLET 50211158_1 CDM 0250 RC 68462-0260-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges VERAPAMIL ER 240 MG TABLET 50211158_1 CDM 0250 RC 68462-0260-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges VERAPAMIL ER 240 MG TABLET 50211158_1 CDM 0250 RC 68462-0260-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 VERAPAMIL ER 240 MG TABLET 50211158_1 CDM 0250 RC 68462-0260-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 VERAPAMIL ER 240 MG TABLET 50211158_1 CDM 0250 RC 68462-0260-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 VERAPAMIL ER 240 MG TABLET 50211158_1 CDM 0250 RC 68462-0260-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges VERAPAMIL ER 240 MG TABLET 50211158_1 CDM 0250 RC 68462-0260-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 VERAPAMIL ER 240 MG TABLET 50211158_1 CDM 0250 RC 68462-0260-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 PRAVASTATIN SODIUM 20 MG TAB 50211159_1 CDM 0250 RC 00093-7201-98 NDC inpatient 1 UN 1.25 0.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.81 65 999999999 0.76 1.21 percent of total billed charges PRAVASTATIN SODIUM 20 MG TAB 50211159_1 CDM 0250 RC 00093-7201-98 NDC inpatient 1 UN 1.25 0.81 AETNA AETNA 0.99 79 999999999 0.76 1.21 percent of total billed charges PRAVASTATIN SODIUM 20 MG TAB 50211159_1 CDM 0250 RC 00093-7201-98 NDC inpatient 1 UN 1.25 0.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.21 97 999999999 0.76 1.21 percent of total billed charges PRAVASTATIN SODIUM 20 MG TAB 50211159_1 CDM 0250 RC 00093-7201-98 NDC inpatient 1 UN 1.25 0.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.86 69 999999999 0.76 1.21 percent of total billed charges PRAVASTATIN SODIUM 20 MG TAB 50211159_1 CDM 0250 RC 00093-7201-98 NDC inpatient 1 UN 1.25 0.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.98 78 999999999 0.76 1.21 percent of total billed charges PRAVASTATIN SODIUM 20 MG TAB 50211159_1 CDM 0250 RC 00093-7201-98 NDC inpatient 1 UN 1.25 0.81 SIHO - ALL PLANS SIHO - ALL PLANS 1.13 90 999999999 0.76 1.21 percent of total billed charges PRAVASTATIN SODIUM 20 MG TAB 50211159_1 CDM 0250 RC 00093-7201-98 NDC inpatient 1 UN 1.25 0.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.76 60.55 999999999 0.76 1.21 percent of total billed charges PRAVASTATIN SODIUM 20 MG TAB 50211159_1 CDM 0250 RC 00093-7201-98 NDC inpatient 1 UN 1.25 0.81 UMR - ALL PLANS UMR - ALL PLANS 0.88 70 999999999 0.76 1.21 percent of total billed charges PRAVASTATIN SODIUM 20 MG TAB 50211159_1 CDM 0250 RC 00093-7201-98 NDC inpatient 1 UN 1.25 0.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.76 1.21 PRAVASTATIN SODIUM 20 MG TAB 50211159_1 CDM 0250 RC 00093-7201-98 NDC inpatient 1 UN 1.25 0.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.76 1.21 PRAVASTATIN SODIUM 20 MG TAB 50211159_1 CDM 0250 RC 00093-7201-98 NDC inpatient 1 UN 1.25 0.81 ANTHEM HMO ANTHEM HMO 999999999 0.76 1.21 PRAVASTATIN SODIUM 20 MG TAB 50211159_1 CDM 0250 RC 00093-7201-98 NDC inpatient 1 UN 1.25 0.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.85 67.6 999999999 0.76 1.21 percent of total billed charges PRAVASTATIN SODIUM 20 MG TAB 50211159_1 CDM 0250 RC 00093-7201-98 NDC inpatient 1 UN 1.25 0.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.76 1.21 PRAVASTATIN SODIUM 20 MG TAB 50211159_1 CDM 0250 RC 00093-7201-98 NDC inpatient 1 UN 1.25 0.81 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.76 1.21 NALBUPHINE 10 MG/ML AMPUL 50213325_1 CDM 0250 RC 00409-1463-49 NDC inpatient 1 UN 35.19 22.87 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.87 65 999999999 21.31 34.13 percent of total billed charges NALBUPHINE 10 MG/ML AMPUL 50213325_1 CDM 0250 RC 00409-1463-49 NDC inpatient 1 UN 35.19 22.87 AETNA AETNA 27.8 79 999999999 21.31 34.13 percent of total billed charges NALBUPHINE 10 MG/ML AMPUL 50213325_1 CDM 0250 RC 00409-1463-49 NDC inpatient 1 UN 35.19 22.87 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34.13 97 999999999 21.31 34.13 percent of total billed charges NALBUPHINE 10 MG/ML AMPUL 50213325_1 CDM 0250 RC 00409-1463-49 NDC inpatient 1 UN 35.19 22.87 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.28 69 999999999 21.31 34.13 percent of total billed charges NALBUPHINE 10 MG/ML AMPUL 50213325_1 CDM 0250 RC 00409-1463-49 NDC inpatient 1 UN 35.19 22.87 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.45 78 999999999 21.31 34.13 percent of total billed charges NALBUPHINE 10 MG/ML AMPUL 50213325_1 CDM 0250 RC 00409-1463-49 NDC inpatient 1 UN 35.19 22.87 SIHO - ALL PLANS SIHO - ALL PLANS 31.67 90 999999999 21.31 34.13 percent of total billed charges NALBUPHINE 10 MG/ML AMPUL 50213325_1 CDM 0250 RC 00409-1463-49 NDC inpatient 1 UN 35.19 22.87 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.31 60.55 999999999 21.31 34.13 percent of total billed charges NALBUPHINE 10 MG/ML AMPUL 50213325_1 CDM 0250 RC 00409-1463-49 NDC inpatient 1 UN 35.19 22.87 UMR - ALL PLANS UMR - ALL PLANS 24.63 70 999999999 21.31 34.13 percent of total billed charges NALBUPHINE 10 MG/ML AMPUL 50213325_1 CDM 0250 RC 00409-1463-49 NDC inpatient 1 UN 35.19 22.87 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.31 34.13 NALBUPHINE 10 MG/ML AMPUL 50213325_1 CDM 0250 RC 00409-1463-49 NDC inpatient 1 UN 35.19 22.87 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.31 34.13 NALBUPHINE 10 MG/ML AMPUL 50213325_1 CDM 0250 RC 00409-1463-49 NDC inpatient 1 UN 35.19 22.87 ANTHEM HMO ANTHEM HMO 999999999 21.31 34.13 NALBUPHINE 10 MG/ML AMPUL 50213325_1 CDM 0250 RC 00409-1463-49 NDC inpatient 1 UN 35.19 22.87 CIGNA - ALL PLANS CIGNA - ALL PLANS 23.79 67.6 999999999 21.31 34.13 percent of total billed charges NALBUPHINE 10 MG/ML AMPUL 50213325_1 CDM 0250 RC 00409-1463-49 NDC inpatient 1 UN 35.19 22.87 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.31 34.13 NALBUPHINE 10 MG/ML AMPUL 50213325_1 CDM 0250 RC 00409-1463-49 NDC inpatient 1 UN 35.19 22.87 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.31 34.13 NITROGLYCERIN 400 MCG SPRAY 50217552_1 CDM 0250 RC 45802-0210-01 NDC inpatient 1 UN 178.74 116.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 116.18 65 999999999 108.23 173.38 percent of total billed charges NITROGLYCERIN 400 MCG SPRAY 50217552_1 CDM 0250 RC 45802-0210-01 NDC inpatient 1 UN 178.74 116.18 AETNA AETNA 141.2 79 999999999 108.23 173.38 percent of total billed charges NITROGLYCERIN 400 MCG SPRAY 50217552_1 CDM 0250 RC 45802-0210-01 NDC inpatient 1 UN 178.74 116.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 173.38 97 999999999 108.23 173.38 percent of total billed charges NITROGLYCERIN 400 MCG SPRAY 50217552_1 CDM 0250 RC 45802-0210-01 NDC inpatient 1 UN 178.74 116.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 123.33 69 999999999 108.23 173.38 percent of total billed charges NITROGLYCERIN 400 MCG SPRAY 50217552_1 CDM 0250 RC 45802-0210-01 NDC inpatient 1 UN 178.74 116.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 139.42 78 999999999 108.23 173.38 percent of total billed charges NITROGLYCERIN 400 MCG SPRAY 50217552_1 CDM 0250 RC 45802-0210-01 NDC inpatient 1 UN 178.74 116.18 SIHO - ALL PLANS SIHO - ALL PLANS 160.87 90 999999999 108.23 173.38 percent of total billed charges NITROGLYCERIN 400 MCG SPRAY 50217552_1 CDM 0250 RC 45802-0210-01 NDC inpatient 1 UN 178.74 116.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.23 60.55 999999999 108.23 173.38 percent of total billed charges NITROGLYCERIN 400 MCG SPRAY 50217552_1 CDM 0250 RC 45802-0210-01 NDC inpatient 1 UN 178.74 116.18 UMR - ALL PLANS UMR - ALL PLANS 125.12 70 999999999 108.23 173.38 percent of total billed charges NITROGLYCERIN 400 MCG SPRAY 50217552_1 CDM 0250 RC 45802-0210-01 NDC inpatient 1 UN 178.74 116.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.23 173.38 NITROGLYCERIN 400 MCG SPRAY 50217552_1 CDM 0250 RC 45802-0210-01 NDC inpatient 1 UN 178.74 116.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.23 173.38 NITROGLYCERIN 400 MCG SPRAY 50217552_1 CDM 0250 RC 45802-0210-01 NDC inpatient 1 UN 178.74 116.18 ANTHEM HMO ANTHEM HMO 999999999 108.23 173.38 NITROGLYCERIN 400 MCG SPRAY 50217552_1 CDM 0250 RC 45802-0210-01 NDC inpatient 1 UN 178.74 116.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.83 67.6 999999999 108.23 173.38 percent of total billed charges NITROGLYCERIN 400 MCG SPRAY 50217552_1 CDM 0250 RC 45802-0210-01 NDC inpatient 1 UN 178.74 116.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.23 173.38 NITROGLYCERIN 400 MCG SPRAY 50217552_1 CDM 0250 RC 45802-0210-01 NDC inpatient 1 UN 178.74 116.18 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.23 173.38 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219455_1 CDM 0636 RC Q4133 HCPCS inpatient 3311 2152.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 2152.15 65 999999999 2004.81 3211.67 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219455_1 CDM 0636 RC Q4133 HCPCS inpatient 3311 2152.15 AETNA AETNA 2615.69 79 999999999 2004.81 3211.67 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219455_1 CDM 0636 RC Q4133 HCPCS inpatient 3311 2152.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3211.67 97 999999999 2004.81 3211.67 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219455_1 CDM 0636 RC Q4133 HCPCS inpatient 3311 2152.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 2284.59 69 999999999 2004.81 3211.67 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219455_1 CDM 0636 RC Q4133 HCPCS inpatient 3311 2152.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 2582.58 78 999999999 2004.81 3211.67 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219455_1 CDM 0636 RC Q4133 HCPCS inpatient 3311 2152.15 SIHO - ALL PLANS SIHO - ALL PLANS 2979.9 90 999999999 2004.81 3211.67 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219455_1 CDM 0636 RC Q4133 HCPCS inpatient 3311 2152.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2004.81 60.55 999999999 2004.81 3211.67 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219455_1 CDM 0636 RC Q4133 HCPCS inpatient 3311 2152.15 UMR - ALL PLANS UMR - ALL PLANS 2317.7 70 999999999 2004.81 3211.67 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219455_1 CDM 0636 RC Q4133 HCPCS inpatient 3311 2152.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2004.81 3211.67 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219455_1 CDM 0636 RC Q4133 HCPCS inpatient 3311 2152.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2004.81 3211.67 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219455_1 CDM 0636 RC Q4133 HCPCS inpatient 3311 2152.15 ANTHEM HMO ANTHEM HMO 999999999 2004.81 3211.67 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219455_1 CDM 0636 RC Q4133 HCPCS inpatient 3311 2152.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 2238.24 67.6 999999999 2004.81 3211.67 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219455_1 CDM 0636 RC Q4133 HCPCS inpatient 3311 2152.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2004.81 3211.67 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219455_1 CDM 0636 RC Q4133 HCPCS inpatient 3311 2152.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 2004.81 3211.67 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219456_1 CDM 0636 RC Q4133 HCPCS inpatient 4547 2955.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 2955.55 65 999999999 2753.21 4410.59 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219456_1 CDM 0636 RC Q4133 HCPCS inpatient 4547 2955.55 AETNA AETNA 3592.13 79 999999999 2753.21 4410.59 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219456_1 CDM 0636 RC Q4133 HCPCS inpatient 4547 2955.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4410.59 97 999999999 2753.21 4410.59 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219456_1 CDM 0636 RC Q4133 HCPCS inpatient 4547 2955.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 3137.43 69 999999999 2753.21 4410.59 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219456_1 CDM 0636 RC Q4133 HCPCS inpatient 4547 2955.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 3546.66 78 999999999 2753.21 4410.59 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219456_1 CDM 0636 RC Q4133 HCPCS inpatient 4547 2955.55 SIHO - ALL PLANS SIHO - ALL PLANS 4092.3 90 999999999 2753.21 4410.59 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219456_1 CDM 0636 RC Q4133 HCPCS inpatient 4547 2955.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2753.21 60.55 999999999 2753.21 4410.59 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219456_1 CDM 0636 RC Q4133 HCPCS inpatient 4547 2955.55 UMR - ALL PLANS UMR - ALL PLANS 3182.9 70 999999999 2753.21 4410.59 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219456_1 CDM 0636 RC Q4133 HCPCS inpatient 4547 2955.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2753.21 4410.59 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219456_1 CDM 0636 RC Q4133 HCPCS inpatient 4547 2955.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2753.21 4410.59 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219456_1 CDM 0636 RC Q4133 HCPCS inpatient 4547 2955.55 ANTHEM HMO ANTHEM HMO 999999999 2753.21 4410.59 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219456_1 CDM 0636 RC Q4133 HCPCS inpatient 4547 2955.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 3073.77 67.6 999999999 2753.21 4410.59 percent of total billed charges "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219456_1 CDM 0636 RC Q4133 HCPCS inpatient 4547 2955.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2753.21 4410.59 "GRAFIX PRIME, GRAFIXPL PRIME, STRAVIX AND STRAVIXPL, PER SQUARE CENTIMETER" 50219456_1 CDM 0636 RC Q4133 HCPCS inpatient 4547 2955.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 2753.21 4410.59 "PURAPLY AM, PER SQUARE CENTIMETER" 50219457_1 CDM 0636 RC Q4196 HCPCS inpatient 2501 1625.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1625.65 65 999999999 1514.36 2425.97 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219457_1 CDM 0636 RC Q4196 HCPCS inpatient 2501 1625.65 AETNA AETNA 1975.79 79 999999999 1514.36 2425.97 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219457_1 CDM 0636 RC Q4196 HCPCS inpatient 2501 1625.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2425.97 97 999999999 1514.36 2425.97 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219457_1 CDM 0636 RC Q4196 HCPCS inpatient 2501 1625.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1725.69 69 999999999 1514.36 2425.97 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219457_1 CDM 0636 RC Q4196 HCPCS inpatient 2501 1625.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1950.78 78 999999999 1514.36 2425.97 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219457_1 CDM 0636 RC Q4196 HCPCS inpatient 2501 1625.65 SIHO - ALL PLANS SIHO - ALL PLANS 2250.9 90 999999999 1514.36 2425.97 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219457_1 CDM 0636 RC Q4196 HCPCS inpatient 2501 1625.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1514.36 60.55 999999999 1514.36 2425.97 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219457_1 CDM 0636 RC Q4196 HCPCS inpatient 2501 1625.65 UMR - ALL PLANS UMR - ALL PLANS 1750.7 70 999999999 1514.36 2425.97 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219457_1 CDM 0636 RC Q4196 HCPCS inpatient 2501 1625.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1514.36 2425.97 "PURAPLY AM, PER SQUARE CENTIMETER" 50219457_1 CDM 0636 RC Q4196 HCPCS inpatient 2501 1625.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1514.36 2425.97 "PURAPLY AM, PER SQUARE CENTIMETER" 50219457_1 CDM 0636 RC Q4196 HCPCS inpatient 2501 1625.65 ANTHEM HMO ANTHEM HMO 999999999 1514.36 2425.97 "PURAPLY AM, PER SQUARE CENTIMETER" 50219457_1 CDM 0636 RC Q4196 HCPCS inpatient 2501 1625.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1690.68 67.6 999999999 1514.36 2425.97 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219457_1 CDM 0636 RC Q4196 HCPCS inpatient 2501 1625.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1514.36 2425.97 "PURAPLY AM, PER SQUARE CENTIMETER" 50219457_1 CDM 0636 RC Q4196 HCPCS inpatient 2501 1625.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1514.36 2425.97 "PURAPLY AM, PER SQUARE CENTIMETER" 50219459_1 CDM 0636 RC Q4196 HCPCS inpatient 3978 2585.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 2585.7 65 999999999 2408.68 3858.66 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219459_1 CDM 0636 RC Q4196 HCPCS inpatient 3978 2585.7 AETNA AETNA 3142.62 79 999999999 2408.68 3858.66 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219459_1 CDM 0636 RC Q4196 HCPCS inpatient 3978 2585.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3858.66 97 999999999 2408.68 3858.66 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219459_1 CDM 0636 RC Q4196 HCPCS inpatient 3978 2585.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 2744.82 69 999999999 2408.68 3858.66 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219459_1 CDM 0636 RC Q4196 HCPCS inpatient 3978 2585.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 3102.84 78 999999999 2408.68 3858.66 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219459_1 CDM 0636 RC Q4196 HCPCS inpatient 3978 2585.7 SIHO - ALL PLANS SIHO - ALL PLANS 3580.2 90 999999999 2408.68 3858.66 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219459_1 CDM 0636 RC Q4196 HCPCS inpatient 3978 2585.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2408.68 60.55 999999999 2408.68 3858.66 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219459_1 CDM 0636 RC Q4196 HCPCS inpatient 3978 2585.7 UMR - ALL PLANS UMR - ALL PLANS 2784.6 70 999999999 2408.68 3858.66 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219459_1 CDM 0636 RC Q4196 HCPCS inpatient 3978 2585.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2408.68 3858.66 "PURAPLY AM, PER SQUARE CENTIMETER" 50219459_1 CDM 0636 RC Q4196 HCPCS inpatient 3978 2585.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2408.68 3858.66 "PURAPLY AM, PER SQUARE CENTIMETER" 50219459_1 CDM 0636 RC Q4196 HCPCS inpatient 3978 2585.7 ANTHEM HMO ANTHEM HMO 999999999 2408.68 3858.66 "PURAPLY AM, PER SQUARE CENTIMETER" 50219459_1 CDM 0636 RC Q4196 HCPCS inpatient 3978 2585.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 2689.13 67.6 999999999 2408.68 3858.66 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219459_1 CDM 0636 RC Q4196 HCPCS inpatient 3978 2585.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2408.68 3858.66 "PURAPLY AM, PER SQUARE CENTIMETER" 50219459_1 CDM 0636 RC Q4196 HCPCS inpatient 3978 2585.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 2408.68 3858.66 "PURAPLY AM, PER SQUARE CENTIMETER" 50219460_1 CDM 0636 RC Q4196 HCPCS inpatient 5114 3324.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 3324.1 65 999999999 3096.53 4960.58 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219460_1 CDM 0636 RC Q4196 HCPCS inpatient 5114 3324.1 AETNA AETNA 4040.06 79 999999999 3096.53 4960.58 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219460_1 CDM 0636 RC Q4196 HCPCS inpatient 5114 3324.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4960.58 97 999999999 3096.53 4960.58 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219460_1 CDM 0636 RC Q4196 HCPCS inpatient 5114 3324.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 3528.66 69 999999999 3096.53 4960.58 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219460_1 CDM 0636 RC Q4196 HCPCS inpatient 5114 3324.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 3988.92 78 999999999 3096.53 4960.58 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219460_1 CDM 0636 RC Q4196 HCPCS inpatient 5114 3324.1 SIHO - ALL PLANS SIHO - ALL PLANS 4602.6 90 999999999 3096.53 4960.58 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219460_1 CDM 0636 RC Q4196 HCPCS inpatient 5114 3324.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3096.53 60.55 999999999 3096.53 4960.58 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219460_1 CDM 0636 RC Q4196 HCPCS inpatient 5114 3324.1 UMR - ALL PLANS UMR - ALL PLANS 3579.8 70 999999999 3096.53 4960.58 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219460_1 CDM 0636 RC Q4196 HCPCS inpatient 5114 3324.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3096.53 4960.58 "PURAPLY AM, PER SQUARE CENTIMETER" 50219460_1 CDM 0636 RC Q4196 HCPCS inpatient 5114 3324.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3096.53 4960.58 "PURAPLY AM, PER SQUARE CENTIMETER" 50219460_1 CDM 0636 RC Q4196 HCPCS inpatient 5114 3324.1 ANTHEM HMO ANTHEM HMO 999999999 3096.53 4960.58 "PURAPLY AM, PER SQUARE CENTIMETER" 50219460_1 CDM 0636 RC Q4196 HCPCS inpatient 5114 3324.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 3457.06 67.6 999999999 3096.53 4960.58 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219460_1 CDM 0636 RC Q4196 HCPCS inpatient 5114 3324.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3096.53 4960.58 "PURAPLY AM, PER SQUARE CENTIMETER" 50219460_1 CDM 0636 RC Q4196 HCPCS inpatient 5114 3324.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 3096.53 4960.58 "PURAPLY AM, PER SQUARE CENTIMETER" 50219461_1 CDM 0636 RC Q4196 HCPCS inpatient 15863 10310.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 10310.95 65 999999999 9605.05 15387.11 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219461_1 CDM 0636 RC Q4196 HCPCS inpatient 15863 10310.95 AETNA AETNA 12531.77 79 999999999 9605.05 15387.11 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219461_1 CDM 0636 RC Q4196 HCPCS inpatient 15863 10310.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15387.11 97 999999999 9605.05 15387.11 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219461_1 CDM 0636 RC Q4196 HCPCS inpatient 15863 10310.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 10945.47 69 999999999 9605.05 15387.11 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219461_1 CDM 0636 RC Q4196 HCPCS inpatient 15863 10310.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 12373.14 78 999999999 9605.05 15387.11 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219461_1 CDM 0636 RC Q4196 HCPCS inpatient 15863 10310.95 SIHO - ALL PLANS SIHO - ALL PLANS 14276.7 90 999999999 9605.05 15387.11 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219461_1 CDM 0636 RC Q4196 HCPCS inpatient 15863 10310.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9605.05 60.55 999999999 9605.05 15387.11 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219461_1 CDM 0636 RC Q4196 HCPCS inpatient 15863 10310.95 UMR - ALL PLANS UMR - ALL PLANS 11104.1 70 999999999 9605.05 15387.11 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219461_1 CDM 0636 RC Q4196 HCPCS inpatient 15863 10310.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9605.05 15387.11 "PURAPLY AM, PER SQUARE CENTIMETER" 50219461_1 CDM 0636 RC Q4196 HCPCS inpatient 15863 10310.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9605.05 15387.11 "PURAPLY AM, PER SQUARE CENTIMETER" 50219461_1 CDM 0636 RC Q4196 HCPCS inpatient 15863 10310.95 ANTHEM HMO ANTHEM HMO 999999999 9605.05 15387.11 "PURAPLY AM, PER SQUARE CENTIMETER" 50219461_1 CDM 0636 RC Q4196 HCPCS inpatient 15863 10310.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 10723.39 67.6 999999999 9605.05 15387.11 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219461_1 CDM 0636 RC Q4196 HCPCS inpatient 15863 10310.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9605.05 15387.11 "PURAPLY AM, PER SQUARE CENTIMETER" 50219461_1 CDM 0636 RC Q4196 HCPCS inpatient 15863 10310.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 9605.05 15387.11 "PURAPLY AM, PER SQUARE CENTIMETER" 50219462_1 CDM 0636 RC Q4196 HCPCS inpatient 30631 19910.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 19910.15 65 999999999 18547.07 29712.07 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219462_1 CDM 0636 RC Q4196 HCPCS inpatient 30631 19910.15 AETNA AETNA 24198.49 79 999999999 18547.07 29712.07 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219462_1 CDM 0636 RC Q4196 HCPCS inpatient 30631 19910.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29712.07 97 999999999 18547.07 29712.07 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219462_1 CDM 0636 RC Q4196 HCPCS inpatient 30631 19910.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 21135.39 69 999999999 18547.07 29712.07 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219462_1 CDM 0636 RC Q4196 HCPCS inpatient 30631 19910.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 23892.18 78 999999999 18547.07 29712.07 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219462_1 CDM 0636 RC Q4196 HCPCS inpatient 30631 19910.15 SIHO - ALL PLANS SIHO - ALL PLANS 27567.9 90 999999999 18547.07 29712.07 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219462_1 CDM 0636 RC Q4196 HCPCS inpatient 30631 19910.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18547.07 60.55 999999999 18547.07 29712.07 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219462_1 CDM 0636 RC Q4196 HCPCS inpatient 30631 19910.15 UMR - ALL PLANS UMR - ALL PLANS 21441.7 70 999999999 18547.07 29712.07 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219462_1 CDM 0636 RC Q4196 HCPCS inpatient 30631 19910.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18547.07 29712.07 "PURAPLY AM, PER SQUARE CENTIMETER" 50219462_1 CDM 0636 RC Q4196 HCPCS inpatient 30631 19910.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18547.07 29712.07 "PURAPLY AM, PER SQUARE CENTIMETER" 50219462_1 CDM 0636 RC Q4196 HCPCS inpatient 30631 19910.15 ANTHEM HMO ANTHEM HMO 999999999 18547.07 29712.07 "PURAPLY AM, PER SQUARE CENTIMETER" 50219462_1 CDM 0636 RC Q4196 HCPCS inpatient 30631 19910.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 20706.56 67.6 999999999 18547.07 29712.07 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219462_1 CDM 0636 RC Q4196 HCPCS inpatient 30631 19910.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18547.07 29712.07 "PURAPLY AM, PER SQUARE CENTIMETER" 50219462_1 CDM 0636 RC Q4196 HCPCS inpatient 30631 19910.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 18547.07 29712.07 "PURAPLY AM, PER SQUARE CENTIMETER" 50219463_1 CDM 0636 RC Q4196 HCPCS inpatient 75605 49143.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 49143.25 65 999999999 45778.83 73336.85 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219463_1 CDM 0636 RC Q4196 HCPCS inpatient 75605 49143.25 AETNA AETNA 59727.95 79 999999999 45778.83 73336.85 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219463_1 CDM 0636 RC Q4196 HCPCS inpatient 75605 49143.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73336.85 97 999999999 45778.83 73336.85 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219463_1 CDM 0636 RC Q4196 HCPCS inpatient 75605 49143.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 52167.45 69 999999999 45778.83 73336.85 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219463_1 CDM 0636 RC Q4196 HCPCS inpatient 75605 49143.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 58971.9 78 999999999 45778.83 73336.85 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219463_1 CDM 0636 RC Q4196 HCPCS inpatient 75605 49143.25 SIHO - ALL PLANS SIHO - ALL PLANS 68044.5 90 999999999 45778.83 73336.85 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219463_1 CDM 0636 RC Q4196 HCPCS inpatient 75605 49143.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45778.83 60.55 999999999 45778.83 73336.85 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219463_1 CDM 0636 RC Q4196 HCPCS inpatient 75605 49143.25 UMR - ALL PLANS UMR - ALL PLANS 52923.5 70 999999999 45778.83 73336.85 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219463_1 CDM 0636 RC Q4196 HCPCS inpatient 75605 49143.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45778.83 73336.85 "PURAPLY AM, PER SQUARE CENTIMETER" 50219463_1 CDM 0636 RC Q4196 HCPCS inpatient 75605 49143.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45778.83 73336.85 "PURAPLY AM, PER SQUARE CENTIMETER" 50219463_1 CDM 0636 RC Q4196 HCPCS inpatient 75605 49143.25 ANTHEM HMO ANTHEM HMO 999999999 45778.83 73336.85 "PURAPLY AM, PER SQUARE CENTIMETER" 50219463_1 CDM 0636 RC Q4196 HCPCS inpatient 75605 49143.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 51108.98 67.6 999999999 45778.83 73336.85 percent of total billed charges "PURAPLY AM, PER SQUARE CENTIMETER" 50219463_1 CDM 0636 RC Q4196 HCPCS inpatient 75605 49143.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45778.83 73336.85 "PURAPLY AM, PER SQUARE CENTIMETER" 50219463_1 CDM 0636 RC Q4196 HCPCS inpatient 75605 49143.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 45778.83 73336.85 ANECTINE 200 MG/10 ML VIAL 50219517_1 CDM 0250 RC 00781-9053-95 NDC inpatient 1 UN 66.88 43.47 SELF PAY DISCOUNT SELF PAY DISCOUNT 43.47 65 999999999 40.5 64.87 percent of total billed charges ANECTINE 200 MG/10 ML VIAL 50219517_1 CDM 0250 RC 00781-9053-95 NDC inpatient 1 UN 66.88 43.47 AETNA AETNA 52.84 79 999999999 40.5 64.87 percent of total billed charges ANECTINE 200 MG/10 ML VIAL 50219517_1 CDM 0250 RC 00781-9053-95 NDC inpatient 1 UN 66.88 43.47 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.87 97 999999999 40.5 64.87 percent of total billed charges ANECTINE 200 MG/10 ML VIAL 50219517_1 CDM 0250 RC 00781-9053-95 NDC inpatient 1 UN 66.88 43.47 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.15 69 999999999 40.5 64.87 percent of total billed charges ANECTINE 200 MG/10 ML VIAL 50219517_1 CDM 0250 RC 00781-9053-95 NDC inpatient 1 UN 66.88 43.47 HUMANA - ALL PLANS HUMANA - ALL PLANS 52.17 78 999999999 40.5 64.87 percent of total billed charges ANECTINE 200 MG/10 ML VIAL 50219517_1 CDM 0250 RC 00781-9053-95 NDC inpatient 1 UN 66.88 43.47 SIHO - ALL PLANS SIHO - ALL PLANS 60.19 90 999999999 40.5 64.87 percent of total billed charges ANECTINE 200 MG/10 ML VIAL 50219517_1 CDM 0250 RC 00781-9053-95 NDC inpatient 1 UN 66.88 43.47 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 40.5 60.55 999999999 40.5 64.87 percent of total billed charges ANECTINE 200 MG/10 ML VIAL 50219517_1 CDM 0250 RC 00781-9053-95 NDC inpatient 1 UN 66.88 43.47 UMR - ALL PLANS UMR - ALL PLANS 46.82 70 999999999 40.5 64.87 percent of total billed charges ANECTINE 200 MG/10 ML VIAL 50219517_1 CDM 0250 RC 00781-9053-95 NDC inpatient 1 UN 66.88 43.47 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 40.5 64.87 ANECTINE 200 MG/10 ML VIAL 50219517_1 CDM 0250 RC 00781-9053-95 NDC inpatient 1 UN 66.88 43.47 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 40.5 64.87 ANECTINE 200 MG/10 ML VIAL 50219517_1 CDM 0250 RC 00781-9053-95 NDC inpatient 1 UN 66.88 43.47 ANTHEM HMO ANTHEM HMO 999999999 40.5 64.87 ANECTINE 200 MG/10 ML VIAL 50219517_1 CDM 0250 RC 00781-9053-95 NDC inpatient 1 UN 66.88 43.47 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.21 67.6 999999999 40.5 64.87 percent of total billed charges ANECTINE 200 MG/10 ML VIAL 50219517_1 CDM 0250 RC 00781-9053-95 NDC inpatient 1 UN 66.88 43.47 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 40.5 64.87 ANECTINE 200 MG/10 ML VIAL 50219517_1 CDM 0250 RC 00781-9053-95 NDC inpatient 1 UN 66.88 43.47 UHC - ALL PLANS UHC - ALL PLANS 999999999 40.5 64.87 BUPIVACAINE 0.5% VIAL 50223319_1 CDM 0250 RC 00409-1163-01 NDC inpatient 1 UN 30.24 19.66 AETNA AETNA 23.89 79 999999999 18.31 29.33 percent of total billed charges BUPIVACAINE 0.5% VIAL 50223319_1 CDM 0250 RC 00409-1163-01 NDC inpatient 1 UN 30.24 19.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.66 65 999999999 18.31 29.33 percent of total billed charges BUPIVACAINE 0.5% VIAL 50223319_1 CDM 0250 RC 00409-1163-01 NDC inpatient 1 UN 30.24 19.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.33 97 999999999 18.31 29.33 percent of total billed charges BUPIVACAINE 0.5% VIAL 50223319_1 CDM 0250 RC 00409-1163-01 NDC inpatient 1 UN 30.24 19.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.87 69 999999999 18.31 29.33 percent of total billed charges BUPIVACAINE 0.5% VIAL 50223319_1 CDM 0250 RC 00409-1163-01 NDC inpatient 1 UN 30.24 19.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.59 78 999999999 18.31 29.33 percent of total billed charges BUPIVACAINE 0.5% VIAL 50223319_1 CDM 0250 RC 00409-1163-01 NDC inpatient 1 UN 30.24 19.66 SIHO - ALL PLANS SIHO - ALL PLANS 27.22 90 999999999 18.31 29.33 percent of total billed charges BUPIVACAINE 0.5% VIAL 50223319_1 CDM 0250 RC 00409-1163-01 NDC inpatient 1 UN 30.24 19.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.31 60.55 999999999 18.31 29.33 percent of total billed charges BUPIVACAINE 0.5% VIAL 50223319_1 CDM 0250 RC 00409-1163-01 NDC inpatient 1 UN 30.24 19.66 UMR - ALL PLANS UMR - ALL PLANS 21.17 70 999999999 18.31 29.33 percent of total billed charges BUPIVACAINE 0.5% VIAL 50223319_1 CDM 0250 RC 00409-1163-01 NDC inpatient 1 UN 30.24 19.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.31 29.33 BUPIVACAINE 0.5% VIAL 50223319_1 CDM 0250 RC 00409-1163-01 NDC inpatient 1 UN 30.24 19.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.31 29.33 BUPIVACAINE 0.5% VIAL 50223319_1 CDM 0250 RC 00409-1163-01 NDC inpatient 1 UN 30.24 19.66 ANTHEM HMO ANTHEM HMO 999999999 18.31 29.33 BUPIVACAINE 0.5% VIAL 50223319_1 CDM 0250 RC 00409-1163-01 NDC inpatient 1 UN 30.24 19.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.44 67.6 999999999 18.31 29.33 percent of total billed charges BUPIVACAINE 0.5% VIAL 50223319_1 CDM 0250 RC 00409-1163-01 NDC inpatient 1 UN 30.24 19.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.31 29.33 BUPIVACAINE 0.5% VIAL 50223319_1 CDM 0250 RC 00409-1163-01 NDC inpatient 1 UN 30.24 19.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.31 29.33 Methylation analysis (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) 50225398_1 CDM 0310 RC 81331 HCPCS inpatient 608 395.2 AETNA AETNA 480.32 79 999999999 368.14 589.76 percent of total billed charges Methylation analysis (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) 50225398_1 CDM 0310 RC 81331 HCPCS inpatient 608 395.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 395.2 65 999999999 368.14 589.76 percent of total billed charges Methylation analysis (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) 50225398_1 CDM 0310 RC 81331 HCPCS inpatient 608 395.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 589.76 97 999999999 368.14 589.76 percent of total billed charges Methylation analysis (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) 50225398_1 CDM 0310 RC 81331 HCPCS inpatient 608 395.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 419.52 69 999999999 368.14 589.76 percent of total billed charges Methylation analysis (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) 50225398_1 CDM 0310 RC 81331 HCPCS inpatient 608 395.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 474.24 78 999999999 368.14 589.76 percent of total billed charges Methylation analysis (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) 50225398_1 CDM 0310 RC 81331 HCPCS inpatient 608 395.2 SIHO - ALL PLANS SIHO - ALL PLANS 547.2 90 999999999 368.14 589.76 percent of total billed charges Methylation analysis (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) 50225398_1 CDM 0310 RC 81331 HCPCS inpatient 608 395.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 368.14 60.55 999999999 368.14 589.76 percent of total billed charges Methylation analysis (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) 50225398_1 CDM 0310 RC 81331 HCPCS inpatient 608 395.2 UMR - ALL PLANS UMR - ALL PLANS 425.6 70 999999999 368.14 589.76 percent of total billed charges Methylation analysis (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) 50225398_1 CDM 0310 RC 81331 HCPCS inpatient 608 395.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 368.14 589.76 Methylation analysis (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) 50225398_1 CDM 0310 RC 81331 HCPCS inpatient 608 395.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 368.14 589.76 Methylation analysis (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) 50225398_1 CDM 0310 RC 81331 HCPCS inpatient 608 395.2 ANTHEM HMO ANTHEM HMO 999999999 368.14 589.76 Methylation analysis (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) 50225398_1 CDM 0310 RC 81331 HCPCS inpatient 608 395.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 411.01 67.6 999999999 368.14 589.76 percent of total billed charges Methylation analysis (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) 50225398_1 CDM 0310 RC 81331 HCPCS inpatient 608 395.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 368.14 589.76 Methylation analysis (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) 50225398_1 CDM 0310 RC 81331 HCPCS inpatient 608 395.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 368.14 589.76 Heart rhythm recording of continous external EKG over 8-15 days 50231352_1 CDM 0480 RC 93246 HCPCS inpatient 321 208.65 AETNA AETNA 253.59 79 999999999 194.37 311.37 percent of total billed charges Heart rhythm recording of continous external EKG over 8-15 days 50231352_1 CDM 0480 RC 93246 HCPCS inpatient 321 208.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 208.65 65 999999999 194.37 311.37 percent of total billed charges Heart rhythm recording of continous external EKG over 8-15 days 50231352_1 CDM 0480 RC 93246 HCPCS inpatient 321 208.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 311.37 97 999999999 194.37 311.37 percent of total billed charges Heart rhythm recording of continous external EKG over 8-15 days 50231352_1 CDM 0480 RC 93246 HCPCS inpatient 321 208.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 221.49 69 999999999 194.37 311.37 percent of total billed charges Heart rhythm recording of continous external EKG over 8-15 days 50231352_1 CDM 0480 RC 93246 HCPCS inpatient 321 208.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 250.38 78 999999999 194.37 311.37 percent of total billed charges Heart rhythm recording of continous external EKG over 8-15 days 50231352_1 CDM 0480 RC 93246 HCPCS inpatient 321 208.65 SIHO - ALL PLANS SIHO - ALL PLANS 288.9 90 999999999 194.37 311.37 percent of total billed charges Heart rhythm recording of continous external EKG over 8-15 days 50231352_1 CDM 0480 RC 93246 HCPCS inpatient 321 208.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 194.37 60.55 999999999 194.37 311.37 percent of total billed charges Heart rhythm recording of continous external EKG over 8-15 days 50231352_1 CDM 0480 RC 93246 HCPCS inpatient 321 208.65 UMR - ALL PLANS UMR - ALL PLANS 224.7 70 999999999 194.37 311.37 percent of total billed charges Heart rhythm recording of continous external EKG over 8-15 days 50231352_1 CDM 0480 RC 93246 HCPCS inpatient 321 208.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 194.37 311.37 Heart rhythm recording of continous external EKG over 8-15 days 50231352_1 CDM 0480 RC 93246 HCPCS inpatient 321 208.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 194.37 311.37 Heart rhythm recording of continous external EKG over 8-15 days 50231352_1 CDM 0480 RC 93246 HCPCS inpatient 321 208.65 ANTHEM HMO ANTHEM HMO 999999999 194.37 311.37 Heart rhythm recording of continous external EKG over 8-15 days 50231352_1 CDM 0480 RC 93246 HCPCS inpatient 321 208.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 217 67.6 999999999 194.37 311.37 percent of total billed charges Heart rhythm recording of continous external EKG over 8-15 days 50231352_1 CDM 0480 RC 93246 HCPCS inpatient 321 208.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 194.37 311.37 Heart rhythm recording of continous external EKG over 8-15 days 50231352_1 CDM 0480 RC 93246 HCPCS inpatient 321 208.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 194.37 311.37 "INJECTION, FLUOROURACIL, 500 MG" 50231391_1 CDM 0636 RC 63323-0117-69 NDC J9190 HCPCS inpatient 10 UN 119.49 77.67 AETNA AETNA 94.4 79 999999999 72.35 115.91 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50231391_1 CDM 0636 RC 63323-0117-69 NDC J9190 HCPCS inpatient 10 UN 119.49 77.67 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.67 65 999999999 72.35 115.91 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50231391_1 CDM 0636 RC 63323-0117-69 NDC J9190 HCPCS inpatient 10 UN 119.49 77.67 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.91 97 999999999 72.35 115.91 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50231391_1 CDM 0636 RC 63323-0117-69 NDC J9190 HCPCS inpatient 10 UN 119.49 77.67 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.45 69 999999999 72.35 115.91 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50231391_1 CDM 0636 RC 63323-0117-69 NDC J9190 HCPCS inpatient 10 UN 119.49 77.67 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.2 78 999999999 72.35 115.91 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50231391_1 CDM 0636 RC 63323-0117-69 NDC J9190 HCPCS inpatient 10 UN 119.49 77.67 SIHO - ALL PLANS SIHO - ALL PLANS 107.54 90 999999999 72.35 115.91 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50231391_1 CDM 0636 RC 63323-0117-69 NDC J9190 HCPCS inpatient 10 UN 119.49 77.67 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.35 60.55 999999999 72.35 115.91 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50231391_1 CDM 0636 RC 63323-0117-69 NDC J9190 HCPCS inpatient 10 UN 119.49 77.67 UMR - ALL PLANS UMR - ALL PLANS 83.64 70 999999999 72.35 115.91 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50231391_1 CDM 0636 RC 63323-0117-69 NDC J9190 HCPCS inpatient 10 UN 119.49 77.67 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.35 115.91 "INJECTION, FLUOROURACIL, 500 MG" 50231391_1 CDM 0636 RC 63323-0117-69 NDC J9190 HCPCS inpatient 10 UN 119.49 77.67 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.35 115.91 "INJECTION, FLUOROURACIL, 500 MG" 50231391_1 CDM 0636 RC 63323-0117-69 NDC J9190 HCPCS inpatient 10 UN 119.49 77.67 ANTHEM HMO ANTHEM HMO 999999999 72.35 115.91 "INJECTION, FLUOROURACIL, 500 MG" 50231391_1 CDM 0636 RC 63323-0117-69 NDC J9190 HCPCS inpatient 10 UN 119.49 77.67 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.78 67.6 999999999 72.35 115.91 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50231391_1 CDM 0636 RC 63323-0117-69 NDC J9190 HCPCS inpatient 10 UN 119.49 77.67 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.35 115.91 "INJECTION, FLUOROURACIL, 500 MG" 50231391_1 CDM 0636 RC 63323-0117-69 NDC J9190 HCPCS inpatient 10 UN 119.49 77.67 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.35 115.91 LACTATED RINGERS INJECTION 50235341_1 CDM 0250 RC 00264-7750-10 NDC inpatient 1 UN 62.81 40.83 AETNA AETNA 49.62 79 999999999 38.03 60.93 percent of total billed charges LACTATED RINGERS INJECTION 50235341_1 CDM 0250 RC 00264-7750-10 NDC inpatient 1 UN 62.81 40.83 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.83 65 999999999 38.03 60.93 percent of total billed charges LACTATED RINGERS INJECTION 50235341_1 CDM 0250 RC 00264-7750-10 NDC inpatient 1 UN 62.81 40.83 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 60.93 97 999999999 38.03 60.93 percent of total billed charges LACTATED RINGERS INJECTION 50235341_1 CDM 0250 RC 00264-7750-10 NDC inpatient 1 UN 62.81 40.83 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.34 69 999999999 38.03 60.93 percent of total billed charges LACTATED RINGERS INJECTION 50235341_1 CDM 0250 RC 00264-7750-10 NDC inpatient 1 UN 62.81 40.83 HUMANA - ALL PLANS HUMANA - ALL PLANS 48.99 78 999999999 38.03 60.93 percent of total billed charges LACTATED RINGERS INJECTION 50235341_1 CDM 0250 RC 00264-7750-10 NDC inpatient 1 UN 62.81 40.83 SIHO - ALL PLANS SIHO - ALL PLANS 56.53 90 999999999 38.03 60.93 percent of total billed charges LACTATED RINGERS INJECTION 50235341_1 CDM 0250 RC 00264-7750-10 NDC inpatient 1 UN 62.81 40.83 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.03 60.55 999999999 38.03 60.93 percent of total billed charges LACTATED RINGERS INJECTION 50235341_1 CDM 0250 RC 00264-7750-10 NDC inpatient 1 UN 62.81 40.83 UMR - ALL PLANS UMR - ALL PLANS 43.97 70 999999999 38.03 60.93 percent of total billed charges LACTATED RINGERS INJECTION 50235341_1 CDM 0250 RC 00264-7750-10 NDC inpatient 1 UN 62.81 40.83 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.03 60.93 LACTATED RINGERS INJECTION 50235341_1 CDM 0250 RC 00264-7750-10 NDC inpatient 1 UN 62.81 40.83 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.03 60.93 LACTATED RINGERS INJECTION 50235341_1 CDM 0250 RC 00264-7750-10 NDC inpatient 1 UN 62.81 40.83 ANTHEM HMO ANTHEM HMO 999999999 38.03 60.93 LACTATED RINGERS INJECTION 50235341_1 CDM 0250 RC 00264-7750-10 NDC inpatient 1 UN 62.81 40.83 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.46 67.6 999999999 38.03 60.93 percent of total billed charges LACTATED RINGERS INJECTION 50235341_1 CDM 0250 RC 00264-7750-10 NDC inpatient 1 UN 62.81 40.83 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.03 60.93 LACTATED RINGERS INJECTION 50235341_1 CDM 0250 RC 00264-7750-10 NDC inpatient 1 UN 62.81 40.83 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.03 60.93 SODIUM CHLORIDE 1 GM TABLET 50241417_1 CDM 0250 RC 00223-1760-01 NDC inpatient 1 UN 1.87 1.22 AETNA AETNA 1.48 79 999999999 1.13 1.81 percent of total billed charges SODIUM CHLORIDE 1 GM TABLET 50241417_1 CDM 0250 RC 00223-1760-01 NDC inpatient 1 UN 1.87 1.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.22 65 999999999 1.13 1.81 percent of total billed charges SODIUM CHLORIDE 1 GM TABLET 50241417_1 CDM 0250 RC 00223-1760-01 NDC inpatient 1 UN 1.87 1.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.81 97 999999999 1.13 1.81 percent of total billed charges SODIUM CHLORIDE 1 GM TABLET 50241417_1 CDM 0250 RC 00223-1760-01 NDC inpatient 1 UN 1.87 1.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.29 69 999999999 1.13 1.81 percent of total billed charges SODIUM CHLORIDE 1 GM TABLET 50241417_1 CDM 0250 RC 00223-1760-01 NDC inpatient 1 UN 1.87 1.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.46 78 999999999 1.13 1.81 percent of total billed charges SODIUM CHLORIDE 1 GM TABLET 50241417_1 CDM 0250 RC 00223-1760-01 NDC inpatient 1 UN 1.87 1.22 SIHO - ALL PLANS SIHO - ALL PLANS 1.68 90 999999999 1.13 1.81 percent of total billed charges SODIUM CHLORIDE 1 GM TABLET 50241417_1 CDM 0250 RC 00223-1760-01 NDC inpatient 1 UN 1.87 1.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.13 60.55 999999999 1.13 1.81 percent of total billed charges SODIUM CHLORIDE 1 GM TABLET 50241417_1 CDM 0250 RC 00223-1760-01 NDC inpatient 1 UN 1.87 1.22 UMR - ALL PLANS UMR - ALL PLANS 1.31 70 999999999 1.13 1.81 percent of total billed charges SODIUM CHLORIDE 1 GM TABLET 50241417_1 CDM 0250 RC 00223-1760-01 NDC inpatient 1 UN 1.87 1.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.13 1.81 SODIUM CHLORIDE 1 GM TABLET 50241417_1 CDM 0250 RC 00223-1760-01 NDC inpatient 1 UN 1.87 1.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.13 1.81 SODIUM CHLORIDE 1 GM TABLET 50241417_1 CDM 0250 RC 00223-1760-01 NDC inpatient 1 UN 1.87 1.22 ANTHEM HMO ANTHEM HMO 999999999 1.13 1.81 SODIUM CHLORIDE 1 GM TABLET 50241417_1 CDM 0250 RC 00223-1760-01 NDC inpatient 1 UN 1.87 1.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.26 67.6 999999999 1.13 1.81 percent of total billed charges SODIUM CHLORIDE 1 GM TABLET 50241417_1 CDM 0250 RC 00223-1760-01 NDC inpatient 1 UN 1.87 1.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.13 1.81 SODIUM CHLORIDE 1 GM TABLET 50241417_1 CDM 0250 RC 00223-1760-01 NDC inpatient 1 UN 1.87 1.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.13 1.81 "Removal of bone, each additional 20.0 sq cm or less" 50245721_1 CDM 0510 RC 11047 HCPCS inpatient 441 286.65 AETNA AETNA 348.39 79 999999999 267.03 427.77 percent of total billed charges "Removal of bone, each additional 20.0 sq cm or less" 50245721_1 CDM 0510 RC 11047 HCPCS inpatient 441 286.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 286.65 65 999999999 267.03 427.77 percent of total billed charges "Removal of bone, each additional 20.0 sq cm or less" 50245721_1 CDM 0510 RC 11047 HCPCS inpatient 441 286.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 427.77 97 999999999 267.03 427.77 percent of total billed charges "Removal of bone, each additional 20.0 sq cm or less" 50245721_1 CDM 0510 RC 11047 HCPCS inpatient 441 286.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 304.29 69 999999999 267.03 427.77 percent of total billed charges "Removal of bone, each additional 20.0 sq cm or less" 50245721_1 CDM 0510 RC 11047 HCPCS inpatient 441 286.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 343.98 78 999999999 267.03 427.77 percent of total billed charges "Removal of bone, each additional 20.0 sq cm or less" 50245721_1 CDM 0510 RC 11047 HCPCS inpatient 441 286.65 SIHO - ALL PLANS SIHO - ALL PLANS 396.9 90 999999999 267.03 427.77 percent of total billed charges "Removal of bone, each additional 20.0 sq cm or less" 50245721_1 CDM 0510 RC 11047 HCPCS inpatient 441 286.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 267.03 60.55 999999999 267.03 427.77 percent of total billed charges "Removal of bone, each additional 20.0 sq cm or less" 50245721_1 CDM 0510 RC 11047 HCPCS inpatient 441 286.65 UMR - ALL PLANS UMR - ALL PLANS 308.7 70 999999999 267.03 427.77 percent of total billed charges "Removal of bone, each additional 20.0 sq cm or less" 50245721_1 CDM 0510 RC 11047 HCPCS inpatient 441 286.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 267.03 427.77 "Removal of bone, each additional 20.0 sq cm or less" 50245721_1 CDM 0510 RC 11047 HCPCS inpatient 441 286.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 267.03 427.77 "Removal of bone, each additional 20.0 sq cm or less" 50245721_1 CDM 0510 RC 11047 HCPCS inpatient 441 286.65 ANTHEM HMO ANTHEM HMO 999999999 267.03 427.77 "Removal of bone, each additional 20.0 sq cm or less" 50245721_1 CDM 0510 RC 11047 HCPCS inpatient 441 286.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 298.12 67.6 999999999 267.03 427.77 percent of total billed charges "Removal of bone, each additional 20.0 sq cm or less" 50245721_1 CDM 0510 RC 11047 HCPCS inpatient 441 286.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 267.03 427.77 "Removal of bone, each additional 20.0 sq cm or less" 50245721_1 CDM 0510 RC 11047 HCPCS inpatient 441 286.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 267.03 427.77 60687-0214-01 - methadone 5 mg Tab[JOHN] 50253598_1 CDM 0250 RC 60687-0214-01 NDC inpatient 1 UN 1.12 0.73 AETNA AETNA 0.88 79 999999999 0.68 1.09 percent of total billed charges 60687-0214-01 - methadone 5 mg Tab[JOHN] 50253598_1 CDM 0250 RC 60687-0214-01 NDC inpatient 1 UN 1.12 0.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.73 65 999999999 0.68 1.09 percent of total billed charges 60687-0214-01 - methadone 5 mg Tab[JOHN] 50253598_1 CDM 0250 RC 60687-0214-01 NDC inpatient 1 UN 1.12 0.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.09 97 999999999 0.68 1.09 percent of total billed charges 60687-0214-01 - methadone 5 mg Tab[JOHN] 50253598_1 CDM 0250 RC 60687-0214-01 NDC inpatient 1 UN 1.12 0.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.77 69 999999999 0.68 1.09 percent of total billed charges 60687-0214-01 - methadone 5 mg Tab[JOHN] 50253598_1 CDM 0250 RC 60687-0214-01 NDC inpatient 1 UN 1.12 0.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.87 78 999999999 0.68 1.09 percent of total billed charges 60687-0214-01 - methadone 5 mg Tab[JOHN] 50253598_1 CDM 0250 RC 60687-0214-01 NDC inpatient 1 UN 1.12 0.73 SIHO - ALL PLANS SIHO - ALL PLANS 1.01 90 999999999 0.68 1.09 percent of total billed charges 60687-0214-01 - methadone 5 mg Tab[JOHN] 50253598_1 CDM 0250 RC 60687-0214-01 NDC inpatient 1 UN 1.12 0.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.68 60.55 999999999 0.68 1.09 percent of total billed charges 60687-0214-01 - methadone 5 mg Tab[JOHN] 50253598_1 CDM 0250 RC 60687-0214-01 NDC inpatient 1 UN 1.12 0.73 UMR - ALL PLANS UMR - ALL PLANS 0.78 70 999999999 0.68 1.09 percent of total billed charges 60687-0214-01 - methadone 5 mg Tab[JOHN] 50253598_1 CDM 0250 RC 60687-0214-01 NDC inpatient 1 UN 1.12 0.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.68 1.09 60687-0214-01 - methadone 5 mg Tab[JOHN] 50253598_1 CDM 0250 RC 60687-0214-01 NDC inpatient 1 UN 1.12 0.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.68 1.09 60687-0214-01 - methadone 5 mg Tab[JOHN] 50253598_1 CDM 0250 RC 60687-0214-01 NDC inpatient 1 UN 1.12 0.73 ANTHEM HMO ANTHEM HMO 999999999 0.68 1.09 60687-0214-01 - methadone 5 mg Tab[JOHN] 50253598_1 CDM 0250 RC 60687-0214-01 NDC inpatient 1 UN 1.12 0.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.76 67.6 999999999 0.68 1.09 percent of total billed charges 60687-0214-01 - methadone 5 mg Tab[JOHN] 50253598_1 CDM 0250 RC 60687-0214-01 NDC inpatient 1 UN 1.12 0.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.68 1.09 60687-0214-01 - methadone 5 mg Tab[JOHN] 50253598_1 CDM 0250 RC 60687-0214-01 NDC inpatient 1 UN 1.12 0.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.68 1.09 AMIODARONE HCL 100 MG TABLET 50259631_1 CDM 0250 RC 51862-0240-30 NDC inpatient 1 UN 12.41 8.07 AETNA AETNA 9.8 79 999999999 7.51 12.04 percent of total billed charges AMIODARONE HCL 100 MG TABLET 50259631_1 CDM 0250 RC 51862-0240-30 NDC inpatient 1 UN 12.41 8.07 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.07 65 999999999 7.51 12.04 percent of total billed charges AMIODARONE HCL 100 MG TABLET 50259631_1 CDM 0250 RC 51862-0240-30 NDC inpatient 1 UN 12.41 8.07 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.04 97 999999999 7.51 12.04 percent of total billed charges AMIODARONE HCL 100 MG TABLET 50259631_1 CDM 0250 RC 51862-0240-30 NDC inpatient 1 UN 12.41 8.07 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.56 69 999999999 7.51 12.04 percent of total billed charges AMIODARONE HCL 100 MG TABLET 50259631_1 CDM 0250 RC 51862-0240-30 NDC inpatient 1 UN 12.41 8.07 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.68 78 999999999 7.51 12.04 percent of total billed charges AMIODARONE HCL 100 MG TABLET 50259631_1 CDM 0250 RC 51862-0240-30 NDC inpatient 1 UN 12.41 8.07 SIHO - ALL PLANS SIHO - ALL PLANS 11.17 90 999999999 7.51 12.04 percent of total billed charges AMIODARONE HCL 100 MG TABLET 50259631_1 CDM 0250 RC 51862-0240-30 NDC inpatient 1 UN 12.41 8.07 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.51 60.55 999999999 7.51 12.04 percent of total billed charges AMIODARONE HCL 100 MG TABLET 50259631_1 CDM 0250 RC 51862-0240-30 NDC inpatient 1 UN 12.41 8.07 UMR - ALL PLANS UMR - ALL PLANS 8.69 70 999999999 7.51 12.04 percent of total billed charges AMIODARONE HCL 100 MG TABLET 50259631_1 CDM 0250 RC 51862-0240-30 NDC inpatient 1 UN 12.41 8.07 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.51 12.04 AMIODARONE HCL 100 MG TABLET 50259631_1 CDM 0250 RC 51862-0240-30 NDC inpatient 1 UN 12.41 8.07 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.51 12.04 AMIODARONE HCL 100 MG TABLET 50259631_1 CDM 0250 RC 51862-0240-30 NDC inpatient 1 UN 12.41 8.07 ANTHEM HMO ANTHEM HMO 999999999 7.51 12.04 AMIODARONE HCL 100 MG TABLET 50259631_1 CDM 0250 RC 51862-0240-30 NDC inpatient 1 UN 12.41 8.07 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.39 67.6 999999999 7.51 12.04 percent of total billed charges AMIODARONE HCL 100 MG TABLET 50259631_1 CDM 0250 RC 51862-0240-30 NDC inpatient 1 UN 12.41 8.07 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.51 12.04 AMIODARONE HCL 100 MG TABLET 50259631_1 CDM 0250 RC 51862-0240-30 NDC inpatient 1 UN 12.41 8.07 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.51 12.04 00904-7809-61 - cyclobenzaprine 10 mg Tab[JOHN} 50259633_1 CDM 0250 RC 00904-7809-61 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges 00904-7809-61 - cyclobenzaprine 10 mg Tab[JOHN} 50259633_1 CDM 0250 RC 00904-7809-61 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges 00904-7809-61 - cyclobenzaprine 10 mg Tab[JOHN} 50259633_1 CDM 0250 RC 00904-7809-61 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges 00904-7809-61 - cyclobenzaprine 10 mg Tab[JOHN} 50259633_1 CDM 0250 RC 00904-7809-61 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges 00904-7809-61 - cyclobenzaprine 10 mg Tab[JOHN} 50259633_1 CDM 0250 RC 00904-7809-61 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges 00904-7809-61 - cyclobenzaprine 10 mg Tab[JOHN} 50259633_1 CDM 0250 RC 00904-7809-61 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges 00904-7809-61 - cyclobenzaprine 10 mg Tab[JOHN} 50259633_1 CDM 0250 RC 00904-7809-61 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges 00904-7809-61 - cyclobenzaprine 10 mg Tab[JOHN} 50259633_1 CDM 0250 RC 00904-7809-61 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges 00904-7809-61 - cyclobenzaprine 10 mg Tab[JOHN} 50259633_1 CDM 0250 RC 00904-7809-61 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 00904-7809-61 - cyclobenzaprine 10 mg Tab[JOHN} 50259633_1 CDM 0250 RC 00904-7809-61 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 00904-7809-61 - cyclobenzaprine 10 mg Tab[JOHN} 50259633_1 CDM 0250 RC 00904-7809-61 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 00904-7809-61 - cyclobenzaprine 10 mg Tab[JOHN} 50259633_1 CDM 0250 RC 00904-7809-61 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges 00904-7809-61 - cyclobenzaprine 10 mg Tab[JOHN} 50259633_1 CDM 0250 RC 00904-7809-61 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 00904-7809-61 - cyclobenzaprine 10 mg Tab[JOHN} 50259633_1 CDM 0250 RC 00904-7809-61 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CLINDAMYCIN 300 MG/50 ML-D5W 50261628_1 CDM 0250 RC 00338-3410-24 NDC inpatient 1 UN 64.04 41.63 AETNA AETNA 50.59 79 999999999 38.78 62.12 percent of total billed charges CLINDAMYCIN 300 MG/50 ML-D5W 50261628_1 CDM 0250 RC 00338-3410-24 NDC inpatient 1 UN 64.04 41.63 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.63 65 999999999 38.78 62.12 percent of total billed charges CLINDAMYCIN 300 MG/50 ML-D5W 50261628_1 CDM 0250 RC 00338-3410-24 NDC inpatient 1 UN 64.04 41.63 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 62.12 97 999999999 38.78 62.12 percent of total billed charges CLINDAMYCIN 300 MG/50 ML-D5W 50261628_1 CDM 0250 RC 00338-3410-24 NDC inpatient 1 UN 64.04 41.63 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.19 69 999999999 38.78 62.12 percent of total billed charges CLINDAMYCIN 300 MG/50 ML-D5W 50261628_1 CDM 0250 RC 00338-3410-24 NDC inpatient 1 UN 64.04 41.63 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.95 78 999999999 38.78 62.12 percent of total billed charges CLINDAMYCIN 300 MG/50 ML-D5W 50261628_1 CDM 0250 RC 00338-3410-24 NDC inpatient 1 UN 64.04 41.63 SIHO - ALL PLANS SIHO - ALL PLANS 57.64 90 999999999 38.78 62.12 percent of total billed charges CLINDAMYCIN 300 MG/50 ML-D5W 50261628_1 CDM 0250 RC 00338-3410-24 NDC inpatient 1 UN 64.04 41.63 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.78 60.55 999999999 38.78 62.12 percent of total billed charges CLINDAMYCIN 300 MG/50 ML-D5W 50261628_1 CDM 0250 RC 00338-3410-24 NDC inpatient 1 UN 64.04 41.63 UMR - ALL PLANS UMR - ALL PLANS 44.83 70 999999999 38.78 62.12 percent of total billed charges CLINDAMYCIN 300 MG/50 ML-D5W 50261628_1 CDM 0250 RC 00338-3410-24 NDC inpatient 1 UN 64.04 41.63 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.78 62.12 CLINDAMYCIN 300 MG/50 ML-D5W 50261628_1 CDM 0250 RC 00338-3410-24 NDC inpatient 1 UN 64.04 41.63 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.78 62.12 CLINDAMYCIN 300 MG/50 ML-D5W 50261628_1 CDM 0250 RC 00338-3410-24 NDC inpatient 1 UN 64.04 41.63 ANTHEM HMO ANTHEM HMO 999999999 38.78 62.12 CLINDAMYCIN 300 MG/50 ML-D5W 50261628_1 CDM 0250 RC 00338-3410-24 NDC inpatient 1 UN 64.04 41.63 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.29 67.6 999999999 38.78 62.12 percent of total billed charges CLINDAMYCIN 300 MG/50 ML-D5W 50261628_1 CDM 0250 RC 00338-3410-24 NDC inpatient 1 UN 64.04 41.63 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.78 62.12 CLINDAMYCIN 300 MG/50 ML-D5W 50261628_1 CDM 0250 RC 00338-3410-24 NDC inpatient 1 UN 64.04 41.63 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.78 62.12 "INJECTION, LEVETIRACETAM, 10 MG" 50261629_1 CDM 0250 RC 43598-0755-10 NDC J1953 HCPCS inpatient 50 UN 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50261629_1 CDM 0250 RC 43598-0755-10 NDC J1953 HCPCS inpatient 50 UN 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50261629_1 CDM 0250 RC 43598-0755-10 NDC J1953 HCPCS inpatient 50 UN 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50261629_1 CDM 0250 RC 43598-0755-10 NDC J1953 HCPCS inpatient 50 UN 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50261629_1 CDM 0250 RC 43598-0755-10 NDC J1953 HCPCS inpatient 50 UN 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50261629_1 CDM 0250 RC 43598-0755-10 NDC J1953 HCPCS inpatient 50 UN 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50261629_1 CDM 0250 RC 43598-0755-10 NDC J1953 HCPCS inpatient 50 UN 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50261629_1 CDM 0250 RC 43598-0755-10 NDC J1953 HCPCS inpatient 50 UN 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50261629_1 CDM 0250 RC 43598-0755-10 NDC J1953 HCPCS inpatient 50 UN 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 "INJECTION, LEVETIRACETAM, 10 MG" 50261629_1 CDM 0250 RC 43598-0755-10 NDC J1953 HCPCS inpatient 50 UN 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 "INJECTION, LEVETIRACETAM, 10 MG" 50261629_1 CDM 0250 RC 43598-0755-10 NDC J1953 HCPCS inpatient 50 UN 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 "INJECTION, LEVETIRACETAM, 10 MG" 50261629_1 CDM 0250 RC 43598-0755-10 NDC J1953 HCPCS inpatient 50 UN 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50261629_1 CDM 0250 RC 43598-0755-10 NDC J1953 HCPCS inpatient 50 UN 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 "INJECTION, LEVETIRACETAM, 10 MG" 50261629_1 CDM 0250 RC 43598-0755-10 NDC J1953 HCPCS inpatient 50 UN 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 TRINTELLIX 5 MG TABLET 50265573_1 CDM 0250 RC 64764-0720-30 NDC inpatient 1 UN 59.19 38.47 AETNA AETNA 46.76 79 999999999 35.84 57.41 percent of total billed charges TRINTELLIX 5 MG TABLET 50265573_1 CDM 0250 RC 64764-0720-30 NDC inpatient 1 UN 59.19 38.47 SELF PAY DISCOUNT SELF PAY DISCOUNT 38.47 65 999999999 35.84 57.41 percent of total billed charges TRINTELLIX 5 MG TABLET 50265573_1 CDM 0250 RC 64764-0720-30 NDC inpatient 1 UN 59.19 38.47 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 57.41 97 999999999 35.84 57.41 percent of total billed charges TRINTELLIX 5 MG TABLET 50265573_1 CDM 0250 RC 64764-0720-30 NDC inpatient 1 UN 59.19 38.47 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.84 69 999999999 35.84 57.41 percent of total billed charges TRINTELLIX 5 MG TABLET 50265573_1 CDM 0250 RC 64764-0720-30 NDC inpatient 1 UN 59.19 38.47 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.17 78 999999999 35.84 57.41 percent of total billed charges TRINTELLIX 5 MG TABLET 50265573_1 CDM 0250 RC 64764-0720-30 NDC inpatient 1 UN 59.19 38.47 SIHO - ALL PLANS SIHO - ALL PLANS 53.27 90 999999999 35.84 57.41 percent of total billed charges TRINTELLIX 5 MG TABLET 50265573_1 CDM 0250 RC 64764-0720-30 NDC inpatient 1 UN 59.19 38.47 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.84 60.55 999999999 35.84 57.41 percent of total billed charges TRINTELLIX 5 MG TABLET 50265573_1 CDM 0250 RC 64764-0720-30 NDC inpatient 1 UN 59.19 38.47 UMR - ALL PLANS UMR - ALL PLANS 41.43 70 999999999 35.84 57.41 percent of total billed charges TRINTELLIX 5 MG TABLET 50265573_1 CDM 0250 RC 64764-0720-30 NDC inpatient 1 UN 59.19 38.47 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.84 57.41 TRINTELLIX 5 MG TABLET 50265573_1 CDM 0250 RC 64764-0720-30 NDC inpatient 1 UN 59.19 38.47 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.84 57.41 TRINTELLIX 5 MG TABLET 50265573_1 CDM 0250 RC 64764-0720-30 NDC inpatient 1 UN 59.19 38.47 ANTHEM HMO ANTHEM HMO 999999999 35.84 57.41 TRINTELLIX 5 MG TABLET 50265573_1 CDM 0250 RC 64764-0720-30 NDC inpatient 1 UN 59.19 38.47 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.01 67.6 999999999 35.84 57.41 percent of total billed charges TRINTELLIX 5 MG TABLET 50265573_1 CDM 0250 RC 64764-0720-30 NDC inpatient 1 UN 59.19 38.47 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.84 57.41 TRINTELLIX 5 MG TABLET 50265573_1 CDM 0250 RC 64764-0720-30 NDC inpatient 1 UN 59.19 38.47 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.84 57.41 DOXYCYCLINE HYCLATE 100 MG VL 50265590_1 CDM 0250 RC 67457-0437-10 NDC inpatient 1 UN 94.23 61.25 AETNA AETNA 74.44 79 999999999 57.06 91.4 percent of total billed charges DOXYCYCLINE HYCLATE 100 MG VL 50265590_1 CDM 0250 RC 67457-0437-10 NDC inpatient 1 UN 94.23 61.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.25 65 999999999 57.06 91.4 percent of total billed charges DOXYCYCLINE HYCLATE 100 MG VL 50265590_1 CDM 0250 RC 67457-0437-10 NDC inpatient 1 UN 94.23 61.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.4 97 999999999 57.06 91.4 percent of total billed charges DOXYCYCLINE HYCLATE 100 MG VL 50265590_1 CDM 0250 RC 67457-0437-10 NDC inpatient 1 UN 94.23 61.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 65.02 69 999999999 57.06 91.4 percent of total billed charges DOXYCYCLINE HYCLATE 100 MG VL 50265590_1 CDM 0250 RC 67457-0437-10 NDC inpatient 1 UN 94.23 61.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.5 78 999999999 57.06 91.4 percent of total billed charges DOXYCYCLINE HYCLATE 100 MG VL 50265590_1 CDM 0250 RC 67457-0437-10 NDC inpatient 1 UN 94.23 61.25 SIHO - ALL PLANS SIHO - ALL PLANS 84.81 90 999999999 57.06 91.4 percent of total billed charges DOXYCYCLINE HYCLATE 100 MG VL 50265590_1 CDM 0250 RC 67457-0437-10 NDC inpatient 1 UN 94.23 61.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 57.06 60.55 999999999 57.06 91.4 percent of total billed charges DOXYCYCLINE HYCLATE 100 MG VL 50265590_1 CDM 0250 RC 67457-0437-10 NDC inpatient 1 UN 94.23 61.25 UMR - ALL PLANS UMR - ALL PLANS 65.96 70 999999999 57.06 91.4 percent of total billed charges DOXYCYCLINE HYCLATE 100 MG VL 50265590_1 CDM 0250 RC 67457-0437-10 NDC inpatient 1 UN 94.23 61.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 57.06 91.4 DOXYCYCLINE HYCLATE 100 MG VL 50265590_1 CDM 0250 RC 67457-0437-10 NDC inpatient 1 UN 94.23 61.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 57.06 91.4 DOXYCYCLINE HYCLATE 100 MG VL 50265590_1 CDM 0250 RC 67457-0437-10 NDC inpatient 1 UN 94.23 61.25 ANTHEM HMO ANTHEM HMO 999999999 57.06 91.4 DOXYCYCLINE HYCLATE 100 MG VL 50265590_1 CDM 0250 RC 67457-0437-10 NDC inpatient 1 UN 94.23 61.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.7 67.6 999999999 57.06 91.4 percent of total billed charges DOXYCYCLINE HYCLATE 100 MG VL 50265590_1 CDM 0250 RC 67457-0437-10 NDC inpatient 1 UN 94.23 61.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 57.06 91.4 DOXYCYCLINE HYCLATE 100 MG VL 50265590_1 CDM 0250 RC 67457-0437-10 NDC inpatient 1 UN 94.23 61.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 57.06 91.4 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 50267610_1 CDM 0258 RC 00264-7610-00 NDC J7042 HCPCS inpatient 1 UN 65.53 42.59 AETNA AETNA 51.77 79 999999999 39.68 63.56 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 50267610_1 CDM 0258 RC 00264-7610-00 NDC J7042 HCPCS inpatient 1 UN 65.53 42.59 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.59 65 999999999 39.68 63.56 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 50267610_1 CDM 0258 RC 00264-7610-00 NDC J7042 HCPCS inpatient 1 UN 65.53 42.59 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 63.56 97 999999999 39.68 63.56 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 50267610_1 CDM 0258 RC 00264-7610-00 NDC J7042 HCPCS inpatient 1 UN 65.53 42.59 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.22 69 999999999 39.68 63.56 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 50267610_1 CDM 0258 RC 00264-7610-00 NDC J7042 HCPCS inpatient 1 UN 65.53 42.59 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.11 78 999999999 39.68 63.56 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 50267610_1 CDM 0258 RC 00264-7610-00 NDC J7042 HCPCS inpatient 1 UN 65.53 42.59 SIHO - ALL PLANS SIHO - ALL PLANS 58.98 90 999999999 39.68 63.56 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 50267610_1 CDM 0258 RC 00264-7610-00 NDC J7042 HCPCS inpatient 1 UN 65.53 42.59 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.68 60.55 999999999 39.68 63.56 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 50267610_1 CDM 0258 RC 00264-7610-00 NDC J7042 HCPCS inpatient 1 UN 65.53 42.59 UMR - ALL PLANS UMR - ALL PLANS 45.87 70 999999999 39.68 63.56 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 50267610_1 CDM 0258 RC 00264-7610-00 NDC J7042 HCPCS inpatient 1 UN 65.53 42.59 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.68 63.56 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 50267610_1 CDM 0258 RC 00264-7610-00 NDC J7042 HCPCS inpatient 1 UN 65.53 42.59 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.68 63.56 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 50267610_1 CDM 0258 RC 00264-7610-00 NDC J7042 HCPCS inpatient 1 UN 65.53 42.59 ANTHEM HMO ANTHEM HMO 999999999 39.68 63.56 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 50267610_1 CDM 0258 RC 00264-7610-00 NDC J7042 HCPCS inpatient 1 UN 65.53 42.59 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.3 67.6 999999999 39.68 63.56 percent of total billed charges 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 50267610_1 CDM 0258 RC 00264-7610-00 NDC J7042 HCPCS inpatient 1 UN 65.53 42.59 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.68 63.56 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) 50267610_1 CDM 0258 RC 00264-7610-00 NDC J7042 HCPCS inpatient 1 UN 65.53 42.59 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.68 63.56 MODAFINIL 200 MG TABLET 50267611_1 CDM 0250 RC 60505-2527-03 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges MODAFINIL 200 MG TABLET 50267611_1 CDM 0250 RC 60505-2527-03 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges MODAFINIL 200 MG TABLET 50267611_1 CDM 0250 RC 60505-2527-03 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges MODAFINIL 200 MG TABLET 50267611_1 CDM 0250 RC 60505-2527-03 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges MODAFINIL 200 MG TABLET 50267611_1 CDM 0250 RC 60505-2527-03 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges MODAFINIL 200 MG TABLET 50267611_1 CDM 0250 RC 60505-2527-03 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges MODAFINIL 200 MG TABLET 50267611_1 CDM 0250 RC 60505-2527-03 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges MODAFINIL 200 MG TABLET 50267611_1 CDM 0250 RC 60505-2527-03 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges MODAFINIL 200 MG TABLET 50267611_1 CDM 0250 RC 60505-2527-03 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 MODAFINIL 200 MG TABLET 50267611_1 CDM 0250 RC 60505-2527-03 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 MODAFINIL 200 MG TABLET 50267611_1 CDM 0250 RC 60505-2527-03 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 MODAFINIL 200 MG TABLET 50267611_1 CDM 0250 RC 60505-2527-03 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges MODAFINIL 200 MG TABLET 50267611_1 CDM 0250 RC 60505-2527-03 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 MODAFINIL 200 MG TABLET 50267611_1 CDM 0250 RC 60505-2527-03 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 PERIVIEW FLEX PERIPHERAL FNA NEEDLE NA-403D-2021 50271726_1 CDM 0272 RC inpatient 1692 1099.8 AETNA AETNA 1336.68 79 999999999 1024.51 1641.24 percent of total billed charges PERIVIEW FLEX PERIPHERAL FNA NEEDLE NA-403D-2021 50271726_1 CDM 0272 RC inpatient 1692 1099.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1099.8 65 999999999 1024.51 1641.24 percent of total billed charges PERIVIEW FLEX PERIPHERAL FNA NEEDLE NA-403D-2021 50271726_1 CDM 0272 RC inpatient 1692 1099.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1641.24 97 999999999 1024.51 1641.24 percent of total billed charges PERIVIEW FLEX PERIPHERAL FNA NEEDLE NA-403D-2021 50271726_1 CDM 0272 RC inpatient 1692 1099.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1167.48 69 999999999 1024.51 1641.24 percent of total billed charges PERIVIEW FLEX PERIPHERAL FNA NEEDLE NA-403D-2021 50271726_1 CDM 0272 RC inpatient 1692 1099.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1319.76 78 999999999 1024.51 1641.24 percent of total billed charges PERIVIEW FLEX PERIPHERAL FNA NEEDLE NA-403D-2021 50271726_1 CDM 0272 RC inpatient 1692 1099.8 SIHO - ALL PLANS SIHO - ALL PLANS 1522.8 90 999999999 1024.51 1641.24 percent of total billed charges PERIVIEW FLEX PERIPHERAL FNA NEEDLE NA-403D-2021 50271726_1 CDM 0272 RC inpatient 1692 1099.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1024.51 60.55 999999999 1024.51 1641.24 percent of total billed charges PERIVIEW FLEX PERIPHERAL FNA NEEDLE NA-403D-2021 50271726_1 CDM 0272 RC inpatient 1692 1099.8 UMR - ALL PLANS UMR - ALL PLANS 1184.4 70 999999999 1024.51 1641.24 percent of total billed charges PERIVIEW FLEX PERIPHERAL FNA NEEDLE NA-403D-2021 50271726_1 CDM 0272 RC inpatient 1692 1099.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1024.51 1641.24 PERIVIEW FLEX PERIPHERAL FNA NEEDLE NA-403D-2021 50271726_1 CDM 0272 RC inpatient 1692 1099.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1024.51 1641.24 PERIVIEW FLEX PERIPHERAL FNA NEEDLE NA-403D-2021 50271726_1 CDM 0272 RC inpatient 1692 1099.8 ANTHEM HMO ANTHEM HMO 999999999 1024.51 1641.24 PERIVIEW FLEX PERIPHERAL FNA NEEDLE NA-403D-2021 50271726_1 CDM 0272 RC inpatient 1692 1099.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1143.79 67.6 999999999 1024.51 1641.24 percent of total billed charges PERIVIEW FLEX PERIPHERAL FNA NEEDLE NA-403D-2021 50271726_1 CDM 0272 RC inpatient 1692 1099.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1024.51 1641.24 PERIVIEW FLEX PERIPHERAL FNA NEEDLE NA-403D-2021 50271726_1 CDM 0272 RC inpatient 1692 1099.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1024.51 1641.24 ***BLANKET PER MEGAN PALMER - 09/19/2023*** GUIDE SHEATH KIT FOR EBUS K-201 50271727_1 CDM 0272 RC inpatient 832 540.8 AETNA AETNA 657.28 79 999999999 503.78 807.04 percent of total billed charges ***BLANKET PER MEGAN PALMER - 09/19/2023*** GUIDE SHEATH KIT FOR EBUS K-201 50271727_1 CDM 0272 RC inpatient 832 540.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 540.8 65 999999999 503.78 807.04 percent of total billed charges ***BLANKET PER MEGAN PALMER - 09/19/2023*** GUIDE SHEATH KIT FOR EBUS K-201 50271727_1 CDM 0272 RC inpatient 832 540.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 807.04 97 999999999 503.78 807.04 percent of total billed charges ***BLANKET PER MEGAN PALMER - 09/19/2023*** GUIDE SHEATH KIT FOR EBUS K-201 50271727_1 CDM 0272 RC inpatient 832 540.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 574.08 69 999999999 503.78 807.04 percent of total billed charges ***BLANKET PER MEGAN PALMER - 09/19/2023*** GUIDE SHEATH KIT FOR EBUS K-201 50271727_1 CDM 0272 RC inpatient 832 540.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 648.96 78 999999999 503.78 807.04 percent of total billed charges ***BLANKET PER MEGAN PALMER - 09/19/2023*** GUIDE SHEATH KIT FOR EBUS K-201 50271727_1 CDM 0272 RC inpatient 832 540.8 SIHO - ALL PLANS SIHO - ALL PLANS 748.8 90 999999999 503.78 807.04 percent of total billed charges ***BLANKET PER MEGAN PALMER - 09/19/2023*** GUIDE SHEATH KIT FOR EBUS K-201 50271727_1 CDM 0272 RC inpatient 832 540.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 503.78 60.55 999999999 503.78 807.04 percent of total billed charges ***BLANKET PER MEGAN PALMER - 09/19/2023*** GUIDE SHEATH KIT FOR EBUS K-201 50271727_1 CDM 0272 RC inpatient 832 540.8 UMR - ALL PLANS UMR - ALL PLANS 582.4 70 999999999 503.78 807.04 percent of total billed charges ***BLANKET PER MEGAN PALMER - 09/19/2023*** GUIDE SHEATH KIT FOR EBUS K-201 50271727_1 CDM 0272 RC inpatient 832 540.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 503.78 807.04 ***BLANKET PER MEGAN PALMER - 09/19/2023*** GUIDE SHEATH KIT FOR EBUS K-201 50271727_1 CDM 0272 RC inpatient 832 540.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 503.78 807.04 ***BLANKET PER MEGAN PALMER - 09/19/2023*** GUIDE SHEATH KIT FOR EBUS K-201 50271727_1 CDM 0272 RC inpatient 832 540.8 ANTHEM HMO ANTHEM HMO 999999999 503.78 807.04 ***BLANKET PER MEGAN PALMER - 09/19/2023*** GUIDE SHEATH KIT FOR EBUS K-201 50271727_1 CDM 0272 RC inpatient 832 540.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 562.43 67.6 999999999 503.78 807.04 percent of total billed charges ***BLANKET PER MEGAN PALMER - 09/19/2023*** GUIDE SHEATH KIT FOR EBUS K-201 50271727_1 CDM 0272 RC inpatient 832 540.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 503.78 807.04 ***BLANKET PER MEGAN PALMER - 09/19/2023*** GUIDE SHEATH KIT FOR EBUS K-201 50271727_1 CDM 0272 RC inpatient 832 540.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 503.78 807.04 EBUS BALLOON MAJ-1351 50271728_1 CDM 0272 RC inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges EBUS BALLOON MAJ-1351 50271728_1 CDM 0272 RC inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges EBUS BALLOON MAJ-1351 50271728_1 CDM 0272 RC inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges EBUS BALLOON MAJ-1351 50271728_1 CDM 0272 RC inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges EBUS BALLOON MAJ-1351 50271728_1 CDM 0272 RC inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges EBUS BALLOON MAJ-1351 50271728_1 CDM 0272 RC inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges EBUS BALLOON MAJ-1351 50271728_1 CDM 0272 RC inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges EBUS BALLOON MAJ-1351 50271728_1 CDM 0272 RC inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges EBUS BALLOON MAJ-1351 50271728_1 CDM 0272 RC inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 EBUS BALLOON MAJ-1351 50271728_1 CDM 0272 RC inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 EBUS BALLOON MAJ-1351 50271728_1 CDM 0272 RC inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 EBUS BALLOON MAJ-1351 50271728_1 CDM 0272 RC inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges EBUS BALLOON MAJ-1351 50271728_1 CDM 0272 RC inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 EBUS BALLOON MAJ-1351 50271728_1 CDM 0272 RC inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 DISCONTINED BY MEGAN PALMER EBUS NEEDLE BIOPSY ADAPTER MAJ-1414 50271729_1 CDM 0272 RC inpatient 51 33.15 AETNA AETNA 40.29 79 999999999 30.88 49.47 percent of total billed charges DISCONTINED BY MEGAN PALMER EBUS NEEDLE BIOPSY ADAPTER MAJ-1414 50271729_1 CDM 0272 RC inpatient 51 33.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 33.15 65 999999999 30.88 49.47 percent of total billed charges DISCONTINED BY MEGAN PALMER EBUS NEEDLE BIOPSY ADAPTER MAJ-1414 50271729_1 CDM 0272 RC inpatient 51 33.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 49.47 97 999999999 30.88 49.47 percent of total billed charges DISCONTINED BY MEGAN PALMER EBUS NEEDLE BIOPSY ADAPTER MAJ-1414 50271729_1 CDM 0272 RC inpatient 51 33.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 35.19 69 999999999 30.88 49.47 percent of total billed charges DISCONTINED BY MEGAN PALMER EBUS NEEDLE BIOPSY ADAPTER MAJ-1414 50271729_1 CDM 0272 RC inpatient 51 33.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 39.78 78 999999999 30.88 49.47 percent of total billed charges DISCONTINED BY MEGAN PALMER EBUS NEEDLE BIOPSY ADAPTER MAJ-1414 50271729_1 CDM 0272 RC inpatient 51 33.15 SIHO - ALL PLANS SIHO - ALL PLANS 45.9 90 999999999 30.88 49.47 percent of total billed charges DISCONTINED BY MEGAN PALMER EBUS NEEDLE BIOPSY ADAPTER MAJ-1414 50271729_1 CDM 0272 RC inpatient 51 33.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.88 60.55 999999999 30.88 49.47 percent of total billed charges DISCONTINED BY MEGAN PALMER EBUS NEEDLE BIOPSY ADAPTER MAJ-1414 50271729_1 CDM 0272 RC inpatient 51 33.15 UMR - ALL PLANS UMR - ALL PLANS 35.7 70 999999999 30.88 49.47 percent of total billed charges DISCONTINED BY MEGAN PALMER EBUS NEEDLE BIOPSY ADAPTER MAJ-1414 50271729_1 CDM 0272 RC inpatient 51 33.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.88 49.47 DISCONTINED BY MEGAN PALMER EBUS NEEDLE BIOPSY ADAPTER MAJ-1414 50271729_1 CDM 0272 RC inpatient 51 33.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.88 49.47 DISCONTINED BY MEGAN PALMER EBUS NEEDLE BIOPSY ADAPTER MAJ-1414 50271729_1 CDM 0272 RC inpatient 51 33.15 ANTHEM HMO ANTHEM HMO 999999999 30.88 49.47 DISCONTINED BY MEGAN PALMER EBUS NEEDLE BIOPSY ADAPTER MAJ-1414 50271729_1 CDM 0272 RC inpatient 51 33.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 34.48 67.6 999999999 30.88 49.47 percent of total billed charges DISCONTINED BY MEGAN PALMER EBUS NEEDLE BIOPSY ADAPTER MAJ-1414 50271729_1 CDM 0272 RC inpatient 51 33.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.88 49.47 DISCONTINED BY MEGAN PALMER EBUS NEEDLE BIOPSY ADAPTER MAJ-1414 50271729_1 CDM 0272 RC inpatient 51 33.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.88 49.47 19g EBUS NEEDLE NA-U403SX-4019 50271762_1 CDM 0272 RC inpatient 2060 1339 AETNA AETNA 1627.4 79 999999999 1247.33 1998.2 percent of total billed charges 19g EBUS NEEDLE NA-U403SX-4019 50271762_1 CDM 0272 RC inpatient 2060 1339 SELF PAY DISCOUNT SELF PAY DISCOUNT 1339 65 999999999 1247.33 1998.2 percent of total billed charges 19g EBUS NEEDLE NA-U403SX-4019 50271762_1 CDM 0272 RC inpatient 2060 1339 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1998.2 97 999999999 1247.33 1998.2 percent of total billed charges 19g EBUS NEEDLE NA-U403SX-4019 50271762_1 CDM 0272 RC inpatient 2060 1339 ENCORE - ALL PLANS ENCORE - ALL PLANS 1421.4 69 999999999 1247.33 1998.2 percent of total billed charges 19g EBUS NEEDLE NA-U403SX-4019 50271762_1 CDM 0272 RC inpatient 2060 1339 HUMANA - ALL PLANS HUMANA - ALL PLANS 1606.8 78 999999999 1247.33 1998.2 percent of total billed charges 19g EBUS NEEDLE NA-U403SX-4019 50271762_1 CDM 0272 RC inpatient 2060 1339 SIHO - ALL PLANS SIHO - ALL PLANS 1854 90 999999999 1247.33 1998.2 percent of total billed charges 19g EBUS NEEDLE NA-U403SX-4019 50271762_1 CDM 0272 RC inpatient 2060 1339 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1247.33 60.55 999999999 1247.33 1998.2 percent of total billed charges 19g EBUS NEEDLE NA-U403SX-4019 50271762_1 CDM 0272 RC inpatient 2060 1339 UMR - ALL PLANS UMR - ALL PLANS 1442 70 999999999 1247.33 1998.2 percent of total billed charges 19g EBUS NEEDLE NA-U403SX-4019 50271762_1 CDM 0272 RC inpatient 2060 1339 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1247.33 1998.2 19g EBUS NEEDLE NA-U403SX-4019 50271762_1 CDM 0272 RC inpatient 2060 1339 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1247.33 1998.2 19g EBUS NEEDLE NA-U403SX-4019 50271762_1 CDM 0272 RC inpatient 2060 1339 ANTHEM HMO ANTHEM HMO 999999999 1247.33 1998.2 19g EBUS NEEDLE NA-U403SX-4019 50271762_1 CDM 0272 RC inpatient 2060 1339 CIGNA - ALL PLANS CIGNA - ALL PLANS 1392.56 67.6 999999999 1247.33 1998.2 percent of total billed charges 19g EBUS NEEDLE NA-U403SX-4019 50271762_1 CDM 0272 RC inpatient 2060 1339 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1247.33 1998.2 19g EBUS NEEDLE NA-U403SX-4019 50271762_1 CDM 0272 RC inpatient 2060 1339 UHC - ALL PLANS UHC - ALL PLANS 999999999 1247.33 1998.2 DISCONTINUED BY MEGAN PALMER 21g EBUS NEEDLE NA-U401SX-4021-A 50271763_1 CDM 0272 RC inpatient 1465 952.25 AETNA AETNA 1157.35 79 999999999 887.06 1421.05 percent of total billed charges DISCONTINUED BY MEGAN PALMER 21g EBUS NEEDLE NA-U401SX-4021-A 50271763_1 CDM 0272 RC inpatient 1465 952.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 952.25 65 999999999 887.06 1421.05 percent of total billed charges DISCONTINUED BY MEGAN PALMER 21g EBUS NEEDLE NA-U401SX-4021-A 50271763_1 CDM 0272 RC inpatient 1465 952.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1421.05 97 999999999 887.06 1421.05 percent of total billed charges DISCONTINUED BY MEGAN PALMER 21g EBUS NEEDLE NA-U401SX-4021-A 50271763_1 CDM 0272 RC inpatient 1465 952.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1010.85 69 999999999 887.06 1421.05 percent of total billed charges DISCONTINUED BY MEGAN PALMER 21g EBUS NEEDLE NA-U401SX-4021-A 50271763_1 CDM 0272 RC inpatient 1465 952.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1142.7 78 999999999 887.06 1421.05 percent of total billed charges DISCONTINUED BY MEGAN PALMER 21g EBUS NEEDLE NA-U401SX-4021-A 50271763_1 CDM 0272 RC inpatient 1465 952.25 SIHO - ALL PLANS SIHO - ALL PLANS 1318.5 90 999999999 887.06 1421.05 percent of total billed charges DISCONTINUED BY MEGAN PALMER 21g EBUS NEEDLE NA-U401SX-4021-A 50271763_1 CDM 0272 RC inpatient 1465 952.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 887.06 60.55 999999999 887.06 1421.05 percent of total billed charges DISCONTINUED BY MEGAN PALMER 21g EBUS NEEDLE NA-U401SX-4021-A 50271763_1 CDM 0272 RC inpatient 1465 952.25 UMR - ALL PLANS UMR - ALL PLANS 1025.5 70 999999999 887.06 1421.05 percent of total billed charges DISCONTINUED BY MEGAN PALMER 21g EBUS NEEDLE NA-U401SX-4021-A 50271763_1 CDM 0272 RC inpatient 1465 952.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 887.06 1421.05 DISCONTINUED BY MEGAN PALMER 21g EBUS NEEDLE NA-U401SX-4021-A 50271763_1 CDM 0272 RC inpatient 1465 952.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 887.06 1421.05 DISCONTINUED BY MEGAN PALMER 21g EBUS NEEDLE NA-U401SX-4021-A 50271763_1 CDM 0272 RC inpatient 1465 952.25 ANTHEM HMO ANTHEM HMO 999999999 887.06 1421.05 DISCONTINUED BY MEGAN PALMER 21g EBUS NEEDLE NA-U401SX-4021-A 50271763_1 CDM 0272 RC inpatient 1465 952.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 990.34 67.6 999999999 887.06 1421.05 percent of total billed charges DISCONTINUED BY MEGAN PALMER 21g EBUS NEEDLE NA-U401SX-4021-A 50271763_1 CDM 0272 RC inpatient 1465 952.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 887.06 1421.05 DISCONTINUED BY MEGAN PALMER 21g EBUS NEEDLE NA-U401SX-4021-A 50271763_1 CDM 0272 RC inpatient 1465 952.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 887.06 1421.05 22g EBUS NEEDLE NA-U401SX-4022-A 50271764_1 CDM 0272 RC inpatient 1465 952.25 AETNA AETNA 1157.35 79 999999999 887.06 1421.05 percent of total billed charges 22g EBUS NEEDLE NA-U401SX-4022-A 50271764_1 CDM 0272 RC inpatient 1465 952.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 952.25 65 999999999 887.06 1421.05 percent of total billed charges 22g EBUS NEEDLE NA-U401SX-4022-A 50271764_1 CDM 0272 RC inpatient 1465 952.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1421.05 97 999999999 887.06 1421.05 percent of total billed charges 22g EBUS NEEDLE NA-U401SX-4022-A 50271764_1 CDM 0272 RC inpatient 1465 952.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1010.85 69 999999999 887.06 1421.05 percent of total billed charges 22g EBUS NEEDLE NA-U401SX-4022-A 50271764_1 CDM 0272 RC inpatient 1465 952.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1142.7 78 999999999 887.06 1421.05 percent of total billed charges 22g EBUS NEEDLE NA-U401SX-4022-A 50271764_1 CDM 0272 RC inpatient 1465 952.25 SIHO - ALL PLANS SIHO - ALL PLANS 1318.5 90 999999999 887.06 1421.05 percent of total billed charges 22g EBUS NEEDLE NA-U401SX-4022-A 50271764_1 CDM 0272 RC inpatient 1465 952.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 887.06 60.55 999999999 887.06 1421.05 percent of total billed charges 22g EBUS NEEDLE NA-U401SX-4022-A 50271764_1 CDM 0272 RC inpatient 1465 952.25 UMR - ALL PLANS UMR - ALL PLANS 1025.5 70 999999999 887.06 1421.05 percent of total billed charges 22g EBUS NEEDLE NA-U401SX-4022-A 50271764_1 CDM 0272 RC inpatient 1465 952.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 887.06 1421.05 22g EBUS NEEDLE NA-U401SX-4022-A 50271764_1 CDM 0272 RC inpatient 1465 952.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 887.06 1421.05 22g EBUS NEEDLE NA-U401SX-4022-A 50271764_1 CDM 0272 RC inpatient 1465 952.25 ANTHEM HMO ANTHEM HMO 999999999 887.06 1421.05 22g EBUS NEEDLE NA-U401SX-4022-A 50271764_1 CDM 0272 RC inpatient 1465 952.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 990.34 67.6 999999999 887.06 1421.05 percent of total billed charges 22g EBUS NEEDLE NA-U401SX-4022-A 50271764_1 CDM 0272 RC inpatient 1465 952.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 887.06 1421.05 22g EBUS NEEDLE NA-U401SX-4022-A 50271764_1 CDM 0272 RC inpatient 1465 952.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 887.06 1421.05 HEPARIN 50 UNITS/5 ML (10/ML) 50279570_1 CDM 0250 RC 63807-0500-55 NDC inpatient 1 UN 19.95 12.97 AETNA AETNA 15.76 79 999999999 12.08 19.35 percent of total billed charges HEPARIN 50 UNITS/5 ML (10/ML) 50279570_1 CDM 0250 RC 63807-0500-55 NDC inpatient 1 UN 19.95 12.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.97 65 999999999 12.08 19.35 percent of total billed charges HEPARIN 50 UNITS/5 ML (10/ML) 50279570_1 CDM 0250 RC 63807-0500-55 NDC inpatient 1 UN 19.95 12.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.35 97 999999999 12.08 19.35 percent of total billed charges HEPARIN 50 UNITS/5 ML (10/ML) 50279570_1 CDM 0250 RC 63807-0500-55 NDC inpatient 1 UN 19.95 12.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.77 69 999999999 12.08 19.35 percent of total billed charges HEPARIN 50 UNITS/5 ML (10/ML) 50279570_1 CDM 0250 RC 63807-0500-55 NDC inpatient 1 UN 19.95 12.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.56 78 999999999 12.08 19.35 percent of total billed charges HEPARIN 50 UNITS/5 ML (10/ML) 50279570_1 CDM 0250 RC 63807-0500-55 NDC inpatient 1 UN 19.95 12.97 SIHO - ALL PLANS SIHO - ALL PLANS 17.96 90 999999999 12.08 19.35 percent of total billed charges HEPARIN 50 UNITS/5 ML (10/ML) 50279570_1 CDM 0250 RC 63807-0500-55 NDC inpatient 1 UN 19.95 12.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.08 60.55 999999999 12.08 19.35 percent of total billed charges HEPARIN 50 UNITS/5 ML (10/ML) 50279570_1 CDM 0250 RC 63807-0500-55 NDC inpatient 1 UN 19.95 12.97 UMR - ALL PLANS UMR - ALL PLANS 13.97 70 999999999 12.08 19.35 percent of total billed charges HEPARIN 50 UNITS/5 ML (10/ML) 50279570_1 CDM 0250 RC 63807-0500-55 NDC inpatient 1 UN 19.95 12.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.08 19.35 HEPARIN 50 UNITS/5 ML (10/ML) 50279570_1 CDM 0250 RC 63807-0500-55 NDC inpatient 1 UN 19.95 12.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.08 19.35 HEPARIN 50 UNITS/5 ML (10/ML) 50279570_1 CDM 0250 RC 63807-0500-55 NDC inpatient 1 UN 19.95 12.97 ANTHEM HMO ANTHEM HMO 999999999 12.08 19.35 HEPARIN 50 UNITS/5 ML (10/ML) 50279570_1 CDM 0250 RC 63807-0500-55 NDC inpatient 1 UN 19.95 12.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.49 67.6 999999999 12.08 19.35 percent of total billed charges HEPARIN 50 UNITS/5 ML (10/ML) 50279570_1 CDM 0250 RC 63807-0500-55 NDC inpatient 1 UN 19.95 12.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.08 19.35 HEPARIN 50 UNITS/5 ML (10/ML) 50279570_1 CDM 0250 RC 63807-0500-55 NDC inpatient 1 UN 19.95 12.97 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.08 19.35 HYDROCODONE-ACETAMIN 7.5-325 50284611_1 CDM 0250 RC 60687-0407-01 NDC inpatient 1 UN 1.85 1.2 AETNA AETNA 1.46 79 999999999 1.12 1.79 percent of total billed charges HYDROCODONE-ACETAMIN 7.5-325 50284611_1 CDM 0250 RC 60687-0407-01 NDC inpatient 1 UN 1.85 1.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.2 65 999999999 1.12 1.79 percent of total billed charges HYDROCODONE-ACETAMIN 7.5-325 50284611_1 CDM 0250 RC 60687-0407-01 NDC inpatient 1 UN 1.85 1.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.79 97 999999999 1.12 1.79 percent of total billed charges HYDROCODONE-ACETAMIN 7.5-325 50284611_1 CDM 0250 RC 60687-0407-01 NDC inpatient 1 UN 1.85 1.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.28 69 999999999 1.12 1.79 percent of total billed charges HYDROCODONE-ACETAMIN 7.5-325 50284611_1 CDM 0250 RC 60687-0407-01 NDC inpatient 1 UN 1.85 1.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.44 78 999999999 1.12 1.79 percent of total billed charges HYDROCODONE-ACETAMIN 7.5-325 50284611_1 CDM 0250 RC 60687-0407-01 NDC inpatient 1 UN 1.85 1.2 SIHO - ALL PLANS SIHO - ALL PLANS 1.67 90 999999999 1.12 1.79 percent of total billed charges HYDROCODONE-ACETAMIN 7.5-325 50284611_1 CDM 0250 RC 60687-0407-01 NDC inpatient 1 UN 1.85 1.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.12 60.55 999999999 1.12 1.79 percent of total billed charges HYDROCODONE-ACETAMIN 7.5-325 50284611_1 CDM 0250 RC 60687-0407-01 NDC inpatient 1 UN 1.85 1.2 UMR - ALL PLANS UMR - ALL PLANS 1.3 70 999999999 1.12 1.79 percent of total billed charges HYDROCODONE-ACETAMIN 7.5-325 50284611_1 CDM 0250 RC 60687-0407-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.12 1.79 HYDROCODONE-ACETAMIN 7.5-325 50284611_1 CDM 0250 RC 60687-0407-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.12 1.79 HYDROCODONE-ACETAMIN 7.5-325 50284611_1 CDM 0250 RC 60687-0407-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM HMO ANTHEM HMO 999999999 1.12 1.79 HYDROCODONE-ACETAMIN 7.5-325 50284611_1 CDM 0250 RC 60687-0407-01 NDC inpatient 1 UN 1.85 1.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.25 67.6 999999999 1.12 1.79 percent of total billed charges HYDROCODONE-ACETAMIN 7.5-325 50284611_1 CDM 0250 RC 60687-0407-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.12 1.79 HYDROCODONE-ACETAMIN 7.5-325 50284611_1 CDM 0250 RC 60687-0407-01 NDC inpatient 1 UN 1.85 1.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.12 1.79 "INJECTION, PALONOSETRON HCL, 25 MCG" 50284613_1 CDM 0250 RC 69543-0371-10 NDC J2469 HCPCS inpatient 10 UN 82.34 53.52 AETNA AETNA 65.05 79 999999999 49.86 79.87 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50284613_1 CDM 0250 RC 69543-0371-10 NDC J2469 HCPCS inpatient 10 UN 82.34 53.52 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.52 65 999999999 49.86 79.87 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50284613_1 CDM 0250 RC 69543-0371-10 NDC J2469 HCPCS inpatient 10 UN 82.34 53.52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.87 97 999999999 49.86 79.87 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50284613_1 CDM 0250 RC 69543-0371-10 NDC J2469 HCPCS inpatient 10 UN 82.34 53.52 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.81 69 999999999 49.86 79.87 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50284613_1 CDM 0250 RC 69543-0371-10 NDC J2469 HCPCS inpatient 10 UN 82.34 53.52 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.23 78 999999999 49.86 79.87 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50284613_1 CDM 0250 RC 69543-0371-10 NDC J2469 HCPCS inpatient 10 UN 82.34 53.52 SIHO - ALL PLANS SIHO - ALL PLANS 74.11 90 999999999 49.86 79.87 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50284613_1 CDM 0250 RC 69543-0371-10 NDC J2469 HCPCS inpatient 10 UN 82.34 53.52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.86 60.55 999999999 49.86 79.87 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50284613_1 CDM 0250 RC 69543-0371-10 NDC J2469 HCPCS inpatient 10 UN 82.34 53.52 UMR - ALL PLANS UMR - ALL PLANS 57.64 70 999999999 49.86 79.87 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50284613_1 CDM 0250 RC 69543-0371-10 NDC J2469 HCPCS inpatient 10 UN 82.34 53.52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.86 79.87 "INJECTION, PALONOSETRON HCL, 25 MCG" 50284613_1 CDM 0250 RC 69543-0371-10 NDC J2469 HCPCS inpatient 10 UN 82.34 53.52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.86 79.87 "INJECTION, PALONOSETRON HCL, 25 MCG" 50284613_1 CDM 0250 RC 69543-0371-10 NDC J2469 HCPCS inpatient 10 UN 82.34 53.52 ANTHEM HMO ANTHEM HMO 999999999 49.86 79.87 "INJECTION, PALONOSETRON HCL, 25 MCG" 50284613_1 CDM 0250 RC 69543-0371-10 NDC J2469 HCPCS inpatient 10 UN 82.34 53.52 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.66 67.6 999999999 49.86 79.87 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50284613_1 CDM 0250 RC 69543-0371-10 NDC J2469 HCPCS inpatient 10 UN 82.34 53.52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.86 79.87 "INJECTION, PALONOSETRON HCL, 25 MCG" 50284613_1 CDM 0250 RC 69543-0371-10 NDC J2469 HCPCS inpatient 10 UN 82.34 53.52 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.86 79.87 "INJECTION, FLUOROURACIL, 500 MG" 50285096_1 CDM 0636 RC 16729-0276-38 NDC J9190 HCPCS inpatient 10 UN 235.25 152.91 AETNA AETNA 185.85 79 999999999 142.44 228.19 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50285096_1 CDM 0636 RC 16729-0276-38 NDC J9190 HCPCS inpatient 10 UN 235.25 152.91 SELF PAY DISCOUNT SELF PAY DISCOUNT 152.91 65 999999999 142.44 228.19 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50285096_1 CDM 0636 RC 16729-0276-38 NDC J9190 HCPCS inpatient 10 UN 235.25 152.91 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 228.19 97 999999999 142.44 228.19 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50285096_1 CDM 0636 RC 16729-0276-38 NDC J9190 HCPCS inpatient 10 UN 235.25 152.91 ENCORE - ALL PLANS ENCORE - ALL PLANS 162.32 69 999999999 142.44 228.19 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50285096_1 CDM 0636 RC 16729-0276-38 NDC J9190 HCPCS inpatient 10 UN 235.25 152.91 HUMANA - ALL PLANS HUMANA - ALL PLANS 183.5 78 999999999 142.44 228.19 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50285096_1 CDM 0636 RC 16729-0276-38 NDC J9190 HCPCS inpatient 10 UN 235.25 152.91 SIHO - ALL PLANS SIHO - ALL PLANS 211.73 90 999999999 142.44 228.19 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50285096_1 CDM 0636 RC 16729-0276-38 NDC J9190 HCPCS inpatient 10 UN 235.25 152.91 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 142.44 60.55 999999999 142.44 228.19 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50285096_1 CDM 0636 RC 16729-0276-38 NDC J9190 HCPCS inpatient 10 UN 235.25 152.91 UMR - ALL PLANS UMR - ALL PLANS 164.68 70 999999999 142.44 228.19 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50285096_1 CDM 0636 RC 16729-0276-38 NDC J9190 HCPCS inpatient 10 UN 235.25 152.91 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 142.44 228.19 "INJECTION, FLUOROURACIL, 500 MG" 50285096_1 CDM 0636 RC 16729-0276-38 NDC J9190 HCPCS inpatient 10 UN 235.25 152.91 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 142.44 228.19 "INJECTION, FLUOROURACIL, 500 MG" 50285096_1 CDM 0636 RC 16729-0276-38 NDC J9190 HCPCS inpatient 10 UN 235.25 152.91 ANTHEM HMO ANTHEM HMO 999999999 142.44 228.19 "INJECTION, FLUOROURACIL, 500 MG" 50285096_1 CDM 0636 RC 16729-0276-38 NDC J9190 HCPCS inpatient 10 UN 235.25 152.91 CIGNA - ALL PLANS CIGNA - ALL PLANS 159.03 67.6 999999999 142.44 228.19 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50285096_1 CDM 0636 RC 16729-0276-38 NDC J9190 HCPCS inpatient 10 UN 235.25 152.91 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 142.44 228.19 "INJECTION, FLUOROURACIL, 500 MG" 50285096_1 CDM 0636 RC 16729-0276-38 NDC J9190 HCPCS inpatient 10 UN 235.25 152.91 UHC - ALL PLANS UHC - ALL PLANS 999999999 142.44 228.19 SCOPOLAMINE 1 MG/3 DAY PATCH 50287656_1 CDM 0250 RC 00378-6470-97 NDC inpatient 1 UN 56.4 36.66 AETNA AETNA 44.56 79 999999999 34.15 54.71 percent of total billed charges SCOPOLAMINE 1 MG/3 DAY PATCH 50287656_1 CDM 0250 RC 00378-6470-97 NDC inpatient 1 UN 56.4 36.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 36.66 65 999999999 34.15 54.71 percent of total billed charges SCOPOLAMINE 1 MG/3 DAY PATCH 50287656_1 CDM 0250 RC 00378-6470-97 NDC inpatient 1 UN 56.4 36.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 54.71 97 999999999 34.15 54.71 percent of total billed charges SCOPOLAMINE 1 MG/3 DAY PATCH 50287656_1 CDM 0250 RC 00378-6470-97 NDC inpatient 1 UN 56.4 36.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 38.92 69 999999999 34.15 54.71 percent of total billed charges SCOPOLAMINE 1 MG/3 DAY PATCH 50287656_1 CDM 0250 RC 00378-6470-97 NDC inpatient 1 UN 56.4 36.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 43.99 78 999999999 34.15 54.71 percent of total billed charges SCOPOLAMINE 1 MG/3 DAY PATCH 50287656_1 CDM 0250 RC 00378-6470-97 NDC inpatient 1 UN 56.4 36.66 SIHO - ALL PLANS SIHO - ALL PLANS 50.76 90 999999999 34.15 54.71 percent of total billed charges SCOPOLAMINE 1 MG/3 DAY PATCH 50287656_1 CDM 0250 RC 00378-6470-97 NDC inpatient 1 UN 56.4 36.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.15 60.55 999999999 34.15 54.71 percent of total billed charges SCOPOLAMINE 1 MG/3 DAY PATCH 50287656_1 CDM 0250 RC 00378-6470-97 NDC inpatient 1 UN 56.4 36.66 UMR - ALL PLANS UMR - ALL PLANS 39.48 70 999999999 34.15 54.71 percent of total billed charges SCOPOLAMINE 1 MG/3 DAY PATCH 50287656_1 CDM 0250 RC 00378-6470-97 NDC inpatient 1 UN 56.4 36.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.15 54.71 SCOPOLAMINE 1 MG/3 DAY PATCH 50287656_1 CDM 0250 RC 00378-6470-97 NDC inpatient 1 UN 56.4 36.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.15 54.71 SCOPOLAMINE 1 MG/3 DAY PATCH 50287656_1 CDM 0250 RC 00378-6470-97 NDC inpatient 1 UN 56.4 36.66 ANTHEM HMO ANTHEM HMO 999999999 34.15 54.71 SCOPOLAMINE 1 MG/3 DAY PATCH 50287656_1 CDM 0250 RC 00378-6470-97 NDC inpatient 1 UN 56.4 36.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.13 67.6 999999999 34.15 54.71 percent of total billed charges SCOPOLAMINE 1 MG/3 DAY PATCH 50287656_1 CDM 0250 RC 00378-6470-97 NDC inpatient 1 UN 56.4 36.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.15 54.71 SCOPOLAMINE 1 MG/3 DAY PATCH 50287656_1 CDM 0250 RC 00378-6470-97 NDC inpatient 1 UN 56.4 36.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.15 54.71 "INJECTION, DURVALUMAB, 10 MG" 50291575_1 CDM 0636 RC 00310-4611-50 NDC J9173 HCPCS inpatient 50 UN 17719.91 11517.94 AETNA AETNA 13998.73 79 999999999 10729.41 17188.31 percent of total billed charges "INJECTION, DURVALUMAB, 10 MG" 50291575_1 CDM 0636 RC 00310-4611-50 NDC J9173 HCPCS inpatient 50 UN 17719.91 11517.94 SELF PAY DISCOUNT SELF PAY DISCOUNT 11517.94 65 999999999 10729.41 17188.31 percent of total billed charges "INJECTION, DURVALUMAB, 10 MG" 50291575_1 CDM 0636 RC 00310-4611-50 NDC J9173 HCPCS inpatient 50 UN 17719.91 11517.94 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17188.31 97 999999999 10729.41 17188.31 percent of total billed charges "INJECTION, DURVALUMAB, 10 MG" 50291575_1 CDM 0636 RC 00310-4611-50 NDC J9173 HCPCS inpatient 50 UN 17719.91 11517.94 ENCORE - ALL PLANS ENCORE - ALL PLANS 12226.74 69 999999999 10729.41 17188.31 percent of total billed charges "INJECTION, DURVALUMAB, 10 MG" 50291575_1 CDM 0636 RC 00310-4611-50 NDC J9173 HCPCS inpatient 50 UN 17719.91 11517.94 HUMANA - ALL PLANS HUMANA - ALL PLANS 13821.53 78 999999999 10729.41 17188.31 percent of total billed charges "INJECTION, DURVALUMAB, 10 MG" 50291575_1 CDM 0636 RC 00310-4611-50 NDC J9173 HCPCS inpatient 50 UN 17719.91 11517.94 SIHO - ALL PLANS SIHO - ALL PLANS 15947.92 90 999999999 10729.41 17188.31 percent of total billed charges "INJECTION, DURVALUMAB, 10 MG" 50291575_1 CDM 0636 RC 00310-4611-50 NDC J9173 HCPCS inpatient 50 UN 17719.91 11517.94 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10729.41 60.55 999999999 10729.41 17188.31 percent of total billed charges "INJECTION, DURVALUMAB, 10 MG" 50291575_1 CDM 0636 RC 00310-4611-50 NDC J9173 HCPCS inpatient 50 UN 17719.91 11517.94 UMR - ALL PLANS UMR - ALL PLANS 12403.94 70 999999999 10729.41 17188.31 percent of total billed charges "INJECTION, DURVALUMAB, 10 MG" 50291575_1 CDM 0636 RC 00310-4611-50 NDC J9173 HCPCS inpatient 50 UN 17719.91 11517.94 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10729.41 17188.31 "INJECTION, DURVALUMAB, 10 MG" 50291575_1 CDM 0636 RC 00310-4611-50 NDC J9173 HCPCS inpatient 50 UN 17719.91 11517.94 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10729.41 17188.31 "INJECTION, DURVALUMAB, 10 MG" 50291575_1 CDM 0636 RC 00310-4611-50 NDC J9173 HCPCS inpatient 50 UN 17719.91 11517.94 ANTHEM HMO ANTHEM HMO 999999999 10729.41 17188.31 "INJECTION, DURVALUMAB, 10 MG" 50291575_1 CDM 0636 RC 00310-4611-50 NDC J9173 HCPCS inpatient 50 UN 17719.91 11517.94 CIGNA - ALL PLANS CIGNA - ALL PLANS 11978.66 67.6 999999999 10729.41 17188.31 percent of total billed charges "INJECTION, DURVALUMAB, 10 MG" 50291575_1 CDM 0636 RC 00310-4611-50 NDC J9173 HCPCS inpatient 50 UN 17719.91 11517.94 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10729.41 17188.31 "INJECTION, DURVALUMAB, 10 MG" 50291575_1 CDM 0636 RC 00310-4611-50 NDC J9173 HCPCS inpatient 50 UN 17719.91 11517.94 UHC - ALL PLANS UHC - ALL PLANS 999999999 10729.41 17188.31 "INJECTION, DURVALUMAB, 10 MG" 50291576_1 CDM 0636 RC 00310-4500-12 NDC J9173 HCPCS inpatient 12 UN 4269.75 2775.34 AETNA AETNA 3373.1 79 999999999 2585.33 4141.66 percent of total billed charges "INJECTION, DURVALUMAB, 10 MG" 50291576_1 CDM 0636 RC 00310-4500-12 NDC J9173 HCPCS inpatient 12 UN 4269.75 2775.34 SELF PAY DISCOUNT SELF PAY DISCOUNT 2775.34 65 999999999 2585.33 4141.66 percent of total billed charges "INJECTION, DURVALUMAB, 10 MG" 50291576_1 CDM 0636 RC 00310-4500-12 NDC J9173 HCPCS inpatient 12 UN 4269.75 2775.34 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4141.66 97 999999999 2585.33 4141.66 percent of total billed charges "INJECTION, DURVALUMAB, 10 MG" 50291576_1 CDM 0636 RC 00310-4500-12 NDC J9173 HCPCS inpatient 12 UN 4269.75 2775.34 ENCORE - ALL PLANS ENCORE - ALL PLANS 2946.13 69 999999999 2585.33 4141.66 percent of total billed charges "INJECTION, DURVALUMAB, 10 MG" 50291576_1 CDM 0636 RC 00310-4500-12 NDC J9173 HCPCS inpatient 12 UN 4269.75 2775.34 HUMANA - ALL PLANS HUMANA - ALL PLANS 3330.41 78 999999999 2585.33 4141.66 percent of total billed charges "INJECTION, DURVALUMAB, 10 MG" 50291576_1 CDM 0636 RC 00310-4500-12 NDC J9173 HCPCS inpatient 12 UN 4269.75 2775.34 SIHO - ALL PLANS SIHO - ALL PLANS 3842.78 90 999999999 2585.33 4141.66 percent of total billed charges "INJECTION, DURVALUMAB, 10 MG" 50291576_1 CDM 0636 RC 00310-4500-12 NDC J9173 HCPCS inpatient 12 UN 4269.75 2775.34 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2585.33 60.55 999999999 2585.33 4141.66 percent of total billed charges "INJECTION, DURVALUMAB, 10 MG" 50291576_1 CDM 0636 RC 00310-4500-12 NDC J9173 HCPCS inpatient 12 UN 4269.75 2775.34 UMR - ALL PLANS UMR - ALL PLANS 2988.83 70 999999999 2585.33 4141.66 percent of total billed charges "INJECTION, DURVALUMAB, 10 MG" 50291576_1 CDM 0636 RC 00310-4500-12 NDC J9173 HCPCS inpatient 12 UN 4269.75 2775.34 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2585.33 4141.66 "INJECTION, DURVALUMAB, 10 MG" 50291576_1 CDM 0636 RC 00310-4500-12 NDC J9173 HCPCS inpatient 12 UN 4269.75 2775.34 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2585.33 4141.66 "INJECTION, DURVALUMAB, 10 MG" 50291576_1 CDM 0636 RC 00310-4500-12 NDC J9173 HCPCS inpatient 12 UN 4269.75 2775.34 ANTHEM HMO ANTHEM HMO 999999999 2585.33 4141.66 "INJECTION, DURVALUMAB, 10 MG" 50291576_1 CDM 0636 RC 00310-4500-12 NDC J9173 HCPCS inpatient 12 UN 4269.75 2775.34 CIGNA - ALL PLANS CIGNA - ALL PLANS 2886.35 67.6 999999999 2585.33 4141.66 percent of total billed charges "INJECTION, DURVALUMAB, 10 MG" 50291576_1 CDM 0636 RC 00310-4500-12 NDC J9173 HCPCS inpatient 12 UN 4269.75 2775.34 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2585.33 4141.66 "INJECTION, DURVALUMAB, 10 MG" 50291576_1 CDM 0636 RC 00310-4500-12 NDC J9173 HCPCS inpatient 12 UN 4269.75 2775.34 UHC - ALL PLANS UHC - ALL PLANS 999999999 2585.33 4141.66 SODIUM CHLORIDE 0.9% SOL-EXCEL 50292023_1 CDM 0250 RC 00264-7800-00 NDC inpatient 1 UN 57.88 37.62 AETNA AETNA 45.73 79 999999999 35.05 56.14 percent of total billed charges SODIUM CHLORIDE 0.9% SOL-EXCEL 50292023_1 CDM 0250 RC 00264-7800-00 NDC inpatient 1 UN 57.88 37.62 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.62 65 999999999 35.05 56.14 percent of total billed charges SODIUM CHLORIDE 0.9% SOL-EXCEL 50292023_1 CDM 0250 RC 00264-7800-00 NDC inpatient 1 UN 57.88 37.62 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.14 97 999999999 35.05 56.14 percent of total billed charges SODIUM CHLORIDE 0.9% SOL-EXCEL 50292023_1 CDM 0250 RC 00264-7800-00 NDC inpatient 1 UN 57.88 37.62 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.94 69 999999999 35.05 56.14 percent of total billed charges SODIUM CHLORIDE 0.9% SOL-EXCEL 50292023_1 CDM 0250 RC 00264-7800-00 NDC inpatient 1 UN 57.88 37.62 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.15 78 999999999 35.05 56.14 percent of total billed charges SODIUM CHLORIDE 0.9% SOL-EXCEL 50292023_1 CDM 0250 RC 00264-7800-00 NDC inpatient 1 UN 57.88 37.62 SIHO - ALL PLANS SIHO - ALL PLANS 52.09 90 999999999 35.05 56.14 percent of total billed charges SODIUM CHLORIDE 0.9% SOL-EXCEL 50292023_1 CDM 0250 RC 00264-7800-00 NDC inpatient 1 UN 57.88 37.62 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.05 60.55 999999999 35.05 56.14 percent of total billed charges SODIUM CHLORIDE 0.9% SOL-EXCEL 50292023_1 CDM 0250 RC 00264-7800-00 NDC inpatient 1 UN 57.88 37.62 UMR - ALL PLANS UMR - ALL PLANS 40.52 70 999999999 35.05 56.14 percent of total billed charges SODIUM CHLORIDE 0.9% SOL-EXCEL 50292023_1 CDM 0250 RC 00264-7800-00 NDC inpatient 1 UN 57.88 37.62 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.05 56.14 SODIUM CHLORIDE 0.9% SOL-EXCEL 50292023_1 CDM 0250 RC 00264-7800-00 NDC inpatient 1 UN 57.88 37.62 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.05 56.14 SODIUM CHLORIDE 0.9% SOL-EXCEL 50292023_1 CDM 0250 RC 00264-7800-00 NDC inpatient 1 UN 57.88 37.62 ANTHEM HMO ANTHEM HMO 999999999 35.05 56.14 SODIUM CHLORIDE 0.9% SOL-EXCEL 50292023_1 CDM 0250 RC 00264-7800-00 NDC inpatient 1 UN 57.88 37.62 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.13 67.6 999999999 35.05 56.14 percent of total billed charges SODIUM CHLORIDE 0.9% SOL-EXCEL 50292023_1 CDM 0250 RC 00264-7800-00 NDC inpatient 1 UN 57.88 37.62 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.05 56.14 SODIUM CHLORIDE 0.9% SOL-EXCEL 50292023_1 CDM 0250 RC 00264-7800-00 NDC inpatient 1 UN 57.88 37.62 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.05 56.14 "Benzodiazepines levels, 1-12" 50294339_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 AETNA AETNA 92.43 79 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294339_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 76.05 65 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294339_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 113.49 97 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294339_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.73 69 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294339_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 91.26 78 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294339_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 SIHO - ALL PLANS SIHO - ALL PLANS 105.3 90 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294339_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 70.84 60.55 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294339_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 UMR - ALL PLANS UMR - ALL PLANS 81.9 70 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294339_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 70.84 113.49 "Benzodiazepines levels, 1-12" 50294339_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 70.84 113.49 "Benzodiazepines levels, 1-12" 50294339_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 ANTHEM HMO ANTHEM HMO 999999999 70.84 113.49 "Benzodiazepines levels, 1-12" 50294339_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 79.09 67.6 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294339_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 70.84 113.49 "Benzodiazepines levels, 1-12" 50294339_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 70.84 113.49 "Testing for presence of drug, by chemistry analyzers" 50294345_1 CDM 0301 RC 80307 HCPCS inpatient 170 110.5 AETNA AETNA 134.3 79 999999999 102.94 164.9 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50294345_1 CDM 0301 RC 80307 HCPCS inpatient 170 110.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.5 65 999999999 102.94 164.9 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50294345_1 CDM 0301 RC 80307 HCPCS inpatient 170 110.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.9 97 999999999 102.94 164.9 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50294345_1 CDM 0301 RC 80307 HCPCS inpatient 170 110.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.3 69 999999999 102.94 164.9 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50294345_1 CDM 0301 RC 80307 HCPCS inpatient 170 110.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.6 78 999999999 102.94 164.9 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50294345_1 CDM 0301 RC 80307 HCPCS inpatient 170 110.5 SIHO - ALL PLANS SIHO - ALL PLANS 153 90 999999999 102.94 164.9 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50294345_1 CDM 0301 RC 80307 HCPCS inpatient 170 110.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.94 60.55 999999999 102.94 164.9 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50294345_1 CDM 0301 RC 80307 HCPCS inpatient 170 110.5 UMR - ALL PLANS UMR - ALL PLANS 119 70 999999999 102.94 164.9 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50294345_1 CDM 0301 RC 80307 HCPCS inpatient 170 110.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.94 164.9 "Testing for presence of drug, by chemistry analyzers" 50294345_1 CDM 0301 RC 80307 HCPCS inpatient 170 110.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.94 164.9 "Testing for presence of drug, by chemistry analyzers" 50294345_1 CDM 0301 RC 80307 HCPCS inpatient 170 110.5 ANTHEM HMO ANTHEM HMO 999999999 102.94 164.9 "Testing for presence of drug, by chemistry analyzers" 50294345_1 CDM 0301 RC 80307 HCPCS inpatient 170 110.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.92 67.6 999999999 102.94 164.9 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50294345_1 CDM 0301 RC 80307 HCPCS inpatient 170 110.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.94 164.9 "Testing for presence of drug, by chemistry analyzers" 50294345_1 CDM 0301 RC 80307 HCPCS inpatient 170 110.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.94 164.9 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50294352_1 CDM 0301 RC 83704 HCPCS inpatient 255 165.75 AETNA AETNA 201.45 79 999999999 154.4 247.35 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50294352_1 CDM 0301 RC 83704 HCPCS inpatient 255 165.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 165.75 65 999999999 154.4 247.35 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50294352_1 CDM 0301 RC 83704 HCPCS inpatient 255 165.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 247.35 97 999999999 154.4 247.35 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50294352_1 CDM 0301 RC 83704 HCPCS inpatient 255 165.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 175.95 69 999999999 154.4 247.35 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50294352_1 CDM 0301 RC 83704 HCPCS inpatient 255 165.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 198.9 78 999999999 154.4 247.35 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50294352_1 CDM 0301 RC 83704 HCPCS inpatient 255 165.75 SIHO - ALL PLANS SIHO - ALL PLANS 229.5 90 999999999 154.4 247.35 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50294352_1 CDM 0301 RC 83704 HCPCS inpatient 255 165.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 154.4 60.55 999999999 154.4 247.35 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50294352_1 CDM 0301 RC 83704 HCPCS inpatient 255 165.75 UMR - ALL PLANS UMR - ALL PLANS 178.5 70 999999999 154.4 247.35 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50294352_1 CDM 0301 RC 83704 HCPCS inpatient 255 165.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 154.4 247.35 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50294352_1 CDM 0301 RC 83704 HCPCS inpatient 255 165.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 154.4 247.35 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50294352_1 CDM 0301 RC 83704 HCPCS inpatient 255 165.75 ANTHEM HMO ANTHEM HMO 999999999 154.4 247.35 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50294352_1 CDM 0301 RC 83704 HCPCS inpatient 255 165.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 172.38 67.6 999999999 154.4 247.35 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50294352_1 CDM 0301 RC 83704 HCPCS inpatient 255 165.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 154.4 247.35 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50294352_1 CDM 0301 RC 83704 HCPCS inpatient 255 165.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 154.4 247.35 Buprenorphine level 50294384_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 50294384_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 50294384_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 50294384_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 50294384_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 50294384_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 50294384_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 50294384_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 50294384_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 Buprenorphine level 50294384_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 Buprenorphine level 50294384_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 Buprenorphine level 50294384_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 50294384_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 Buprenorphine level 50294384_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 Detection test by immunoassay technique for other organism 50294388_1 CDM 0301 RC 87449 HCPCS inpatient 209 135.85 AETNA AETNA 165.11 79 999999999 126.55 202.73 percent of total billed charges Detection test by immunoassay technique for other organism 50294388_1 CDM 0301 RC 87449 HCPCS inpatient 209 135.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 135.85 65 999999999 126.55 202.73 percent of total billed charges Detection test by immunoassay technique for other organism 50294388_1 CDM 0301 RC 87449 HCPCS inpatient 209 135.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 202.73 97 999999999 126.55 202.73 percent of total billed charges Detection test by immunoassay technique for other organism 50294388_1 CDM 0301 RC 87449 HCPCS inpatient 209 135.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 144.21 69 999999999 126.55 202.73 percent of total billed charges Detection test by immunoassay technique for other organism 50294388_1 CDM 0301 RC 87449 HCPCS inpatient 209 135.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 163.02 78 999999999 126.55 202.73 percent of total billed charges Detection test by immunoassay technique for other organism 50294388_1 CDM 0301 RC 87449 HCPCS inpatient 209 135.85 SIHO - ALL PLANS SIHO - ALL PLANS 188.1 90 999999999 126.55 202.73 percent of total billed charges Detection test by immunoassay technique for other organism 50294388_1 CDM 0301 RC 87449 HCPCS inpatient 209 135.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 126.55 60.55 999999999 126.55 202.73 percent of total billed charges Detection test by immunoassay technique for other organism 50294388_1 CDM 0301 RC 87449 HCPCS inpatient 209 135.85 UMR - ALL PLANS UMR - ALL PLANS 146.3 70 999999999 126.55 202.73 percent of total billed charges Detection test by immunoassay technique for other organism 50294388_1 CDM 0301 RC 87449 HCPCS inpatient 209 135.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 126.55 202.73 Detection test by immunoassay technique for other organism 50294388_1 CDM 0301 RC 87449 HCPCS inpatient 209 135.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 126.55 202.73 Detection test by immunoassay technique for other organism 50294388_1 CDM 0301 RC 87449 HCPCS inpatient 209 135.85 ANTHEM HMO ANTHEM HMO 999999999 126.55 202.73 Detection test by immunoassay technique for other organism 50294388_1 CDM 0301 RC 87449 HCPCS inpatient 209 135.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 141.28 67.6 999999999 126.55 202.73 percent of total billed charges Detection test by immunoassay technique for other organism 50294388_1 CDM 0301 RC 87449 HCPCS inpatient 209 135.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 126.55 202.73 Detection test by immunoassay technique for other organism 50294388_1 CDM 0301 RC 87449 HCPCS inpatient 209 135.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 126.55 202.73 "Benzodiazepines levels, 1-12" 50294409_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 AETNA AETNA 92.43 79 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294409_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 76.05 65 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294409_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 113.49 97 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294409_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.73 69 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294409_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 91.26 78 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294409_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 SIHO - ALL PLANS SIHO - ALL PLANS 105.3 90 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294409_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 70.84 60.55 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294409_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 UMR - ALL PLANS UMR - ALL PLANS 81.9 70 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294409_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 70.84 113.49 "Benzodiazepines levels, 1-12" 50294409_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 70.84 113.49 "Benzodiazepines levels, 1-12" 50294409_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 ANTHEM HMO ANTHEM HMO 999999999 70.84 113.49 "Benzodiazepines levels, 1-12" 50294409_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 79.09 67.6 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294409_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 70.84 113.49 "Benzodiazepines levels, 1-12" 50294409_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 70.84 113.49 "Benzodiazepines levels, 1-12" 50294410_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 AETNA AETNA 92.43 79 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294410_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 76.05 65 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294410_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 113.49 97 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294410_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.73 69 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294410_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 91.26 78 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294410_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 SIHO - ALL PLANS SIHO - ALL PLANS 105.3 90 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294410_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 70.84 60.55 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294410_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 UMR - ALL PLANS UMR - ALL PLANS 81.9 70 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294410_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 70.84 113.49 "Benzodiazepines levels, 1-12" 50294410_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 70.84 113.49 "Benzodiazepines levels, 1-12" 50294410_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 ANTHEM HMO ANTHEM HMO 999999999 70.84 113.49 "Benzodiazepines levels, 1-12" 50294410_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 79.09 67.6 999999999 70.84 113.49 percent of total billed charges "Benzodiazepines levels, 1-12" 50294410_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 70.84 113.49 "Benzodiazepines levels, 1-12" 50294410_1 CDM 0301 RC 80346 HCPCS inpatient 117 76.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 70.84 113.49 Creatinine level to test for kidney function or muscle injury 50294433_1 CDM 0301 RC 82570 HCPCS inpatient 167 108.55 AETNA AETNA 131.93 79 999999999 101.12 161.99 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50294433_1 CDM 0301 RC 82570 HCPCS inpatient 167 108.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 108.55 65 999999999 101.12 161.99 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50294433_1 CDM 0301 RC 82570 HCPCS inpatient 167 108.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.99 97 999999999 101.12 161.99 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50294433_1 CDM 0301 RC 82570 HCPCS inpatient 167 108.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.23 69 999999999 101.12 161.99 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50294433_1 CDM 0301 RC 82570 HCPCS inpatient 167 108.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 130.26 78 999999999 101.12 161.99 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50294433_1 CDM 0301 RC 82570 HCPCS inpatient 167 108.55 SIHO - ALL PLANS SIHO - ALL PLANS 150.3 90 999999999 101.12 161.99 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50294433_1 CDM 0301 RC 82570 HCPCS inpatient 167 108.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.12 60.55 999999999 101.12 161.99 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50294433_1 CDM 0301 RC 82570 HCPCS inpatient 167 108.55 UMR - ALL PLANS UMR - ALL PLANS 116.9 70 999999999 101.12 161.99 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50294433_1 CDM 0301 RC 82570 HCPCS inpatient 167 108.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.12 161.99 Creatinine level to test for kidney function or muscle injury 50294433_1 CDM 0301 RC 82570 HCPCS inpatient 167 108.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.12 161.99 Creatinine level to test for kidney function or muscle injury 50294433_1 CDM 0301 RC 82570 HCPCS inpatient 167 108.55 ANTHEM HMO ANTHEM HMO 999999999 101.12 161.99 Creatinine level to test for kidney function or muscle injury 50294433_1 CDM 0301 RC 82570 HCPCS inpatient 167 108.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.89 67.6 999999999 101.12 161.99 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50294433_1 CDM 0301 RC 82570 HCPCS inpatient 167 108.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.12 161.99 Creatinine level to test for kidney function or muscle injury 50294433_1 CDM 0301 RC 82570 HCPCS inpatient 167 108.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.12 161.99 "Analysis for antibody, Treponema pallidum" 50294506_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50294506_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50294506_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50294506_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50294506_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50294506_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50294506_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50294506_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50294506_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 "Analysis for antibody, Treponema pallidum" 50294506_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 "Analysis for antibody, Treponema pallidum" 50294506_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 "Analysis for antibody, Treponema pallidum" 50294506_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50294506_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 "Analysis for antibody, Treponema pallidum" 50294506_1 CDM 0302 RC 86780 HCPCS inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 TORSEMIDE 20 MG TABLET 50296493_1 CDM 0250 RC 50111-0917-01 NDC inpatient 1 UN 1.03 0.67 AETNA AETNA 0.81 79 999999999 0.62 1 percent of total billed charges TORSEMIDE 20 MG TABLET 50296493_1 CDM 0250 RC 50111-0917-01 NDC inpatient 1 UN 1.03 0.67 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.67 65 999999999 0.62 1 percent of total billed charges TORSEMIDE 20 MG TABLET 50296493_1 CDM 0250 RC 50111-0917-01 NDC inpatient 1 UN 1.03 0.67 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1 97 999999999 0.62 1 percent of total billed charges TORSEMIDE 20 MG TABLET 50296493_1 CDM 0250 RC 50111-0917-01 NDC inpatient 1 UN 1.03 0.67 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.71 69 999999999 0.62 1 percent of total billed charges TORSEMIDE 20 MG TABLET 50296493_1 CDM 0250 RC 50111-0917-01 NDC inpatient 1 UN 1.03 0.67 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.8 78 999999999 0.62 1 percent of total billed charges TORSEMIDE 20 MG TABLET 50296493_1 CDM 0250 RC 50111-0917-01 NDC inpatient 1 UN 1.03 0.67 SIHO - ALL PLANS SIHO - ALL PLANS 0.93 90 999999999 0.62 1 percent of total billed charges TORSEMIDE 20 MG TABLET 50296493_1 CDM 0250 RC 50111-0917-01 NDC inpatient 1 UN 1.03 0.67 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.62 60.55 999999999 0.62 1 percent of total billed charges TORSEMIDE 20 MG TABLET 50296493_1 CDM 0250 RC 50111-0917-01 NDC inpatient 1 UN 1.03 0.67 UMR - ALL PLANS UMR - ALL PLANS 0.72 70 999999999 0.62 1 percent of total billed charges TORSEMIDE 20 MG TABLET 50296493_1 CDM 0250 RC 50111-0917-01 NDC inpatient 1 UN 1.03 0.67 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.62 1 TORSEMIDE 20 MG TABLET 50296493_1 CDM 0250 RC 50111-0917-01 NDC inpatient 1 UN 1.03 0.67 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.62 1 TORSEMIDE 20 MG TABLET 50296493_1 CDM 0250 RC 50111-0917-01 NDC inpatient 1 UN 1.03 0.67 ANTHEM HMO ANTHEM HMO 999999999 0.62 1 TORSEMIDE 20 MG TABLET 50296493_1 CDM 0250 RC 50111-0917-01 NDC inpatient 1 UN 1.03 0.67 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.7 67.6 999999999 0.62 1 percent of total billed charges TORSEMIDE 20 MG TABLET 50296493_1 CDM 0250 RC 50111-0917-01 NDC inpatient 1 UN 1.03 0.67 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.62 1 TORSEMIDE 20 MG TABLET 50296493_1 CDM 0250 RC 50111-0917-01 NDC inpatient 1 UN 1.03 0.67 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.62 1 VENLAFAXINE HCL ER 37.5 MG CAP 50296496_1 CDM 0250 RC 65862-0527-30 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges VENLAFAXINE HCL ER 37.5 MG CAP 50296496_1 CDM 0250 RC 65862-0527-30 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges VENLAFAXINE HCL ER 37.5 MG CAP 50296496_1 CDM 0250 RC 65862-0527-30 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges VENLAFAXINE HCL ER 37.5 MG CAP 50296496_1 CDM 0250 RC 65862-0527-30 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges VENLAFAXINE HCL ER 37.5 MG CAP 50296496_1 CDM 0250 RC 65862-0527-30 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges VENLAFAXINE HCL ER 37.5 MG CAP 50296496_1 CDM 0250 RC 65862-0527-30 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges VENLAFAXINE HCL ER 37.5 MG CAP 50296496_1 CDM 0250 RC 65862-0527-30 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges VENLAFAXINE HCL ER 37.5 MG CAP 50296496_1 CDM 0250 RC 65862-0527-30 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges VENLAFAXINE HCL ER 37.5 MG CAP 50296496_1 CDM 0250 RC 65862-0527-30 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 VENLAFAXINE HCL ER 37.5 MG CAP 50296496_1 CDM 0250 RC 65862-0527-30 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 VENLAFAXINE HCL ER 37.5 MG CAP 50296496_1 CDM 0250 RC 65862-0527-30 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 VENLAFAXINE HCL ER 37.5 MG CAP 50296496_1 CDM 0250 RC 65862-0527-30 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges VENLAFAXINE HCL ER 37.5 MG CAP 50296496_1 CDM 0250 RC 65862-0527-30 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 VENLAFAXINE HCL ER 37.5 MG CAP 50296496_1 CDM 0250 RC 65862-0527-30 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 LABETALOL HCL 100 MG TABLET 50297103_1 CDM 0250 RC 68001-0381-00 NDC inpatient 1 UN 1.49 0.97 AETNA AETNA 1.18 79 999999999 0.9 1.45 percent of total billed charges LABETALOL HCL 100 MG TABLET 50297103_1 CDM 0250 RC 68001-0381-00 NDC inpatient 1 UN 1.49 0.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.97 65 999999999 0.9 1.45 percent of total billed charges LABETALOL HCL 100 MG TABLET 50297103_1 CDM 0250 RC 68001-0381-00 NDC inpatient 1 UN 1.49 0.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.45 97 999999999 0.9 1.45 percent of total billed charges LABETALOL HCL 100 MG TABLET 50297103_1 CDM 0250 RC 68001-0381-00 NDC inpatient 1 UN 1.49 0.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.03 69 999999999 0.9 1.45 percent of total billed charges LABETALOL HCL 100 MG TABLET 50297103_1 CDM 0250 RC 68001-0381-00 NDC inpatient 1 UN 1.49 0.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.16 78 999999999 0.9 1.45 percent of total billed charges LABETALOL HCL 100 MG TABLET 50297103_1 CDM 0250 RC 68001-0381-00 NDC inpatient 1 UN 1.49 0.97 SIHO - ALL PLANS SIHO - ALL PLANS 1.34 90 999999999 0.9 1.45 percent of total billed charges LABETALOL HCL 100 MG TABLET 50297103_1 CDM 0250 RC 68001-0381-00 NDC inpatient 1 UN 1.49 0.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.9 60.55 999999999 0.9 1.45 percent of total billed charges LABETALOL HCL 100 MG TABLET 50297103_1 CDM 0250 RC 68001-0381-00 NDC inpatient 1 UN 1.49 0.97 UMR - ALL PLANS UMR - ALL PLANS 1.04 70 999999999 0.9 1.45 percent of total billed charges LABETALOL HCL 100 MG TABLET 50297103_1 CDM 0250 RC 68001-0381-00 NDC inpatient 1 UN 1.49 0.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.9 1.45 LABETALOL HCL 100 MG TABLET 50297103_1 CDM 0250 RC 68001-0381-00 NDC inpatient 1 UN 1.49 0.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.9 1.45 LABETALOL HCL 100 MG TABLET 50297103_1 CDM 0250 RC 68001-0381-00 NDC inpatient 1 UN 1.49 0.97 ANTHEM HMO ANTHEM HMO 999999999 0.9 1.45 LABETALOL HCL 100 MG TABLET 50297103_1 CDM 0250 RC 68001-0381-00 NDC inpatient 1 UN 1.49 0.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.01 67.6 999999999 0.9 1.45 percent of total billed charges LABETALOL HCL 100 MG TABLET 50297103_1 CDM 0250 RC 68001-0381-00 NDC inpatient 1 UN 1.49 0.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.9 1.45 LABETALOL HCL 100 MG TABLET 50297103_1 CDM 0250 RC 68001-0381-00 NDC inpatient 1 UN 1.49 0.97 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.9 1.45 KLOR-CON M20 TABLET 50297356_1 CDM 0250 RC 00245-5319-01 NDC inpatient 1 UN 1.54 1 AETNA AETNA 1.22 79 999999999 0.93 1.49 percent of total billed charges KLOR-CON M20 TABLET 50297356_1 CDM 0250 RC 00245-5319-01 NDC inpatient 1 UN 1.54 1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1 65 999999999 0.93 1.49 percent of total billed charges KLOR-CON M20 TABLET 50297356_1 CDM 0250 RC 00245-5319-01 NDC inpatient 1 UN 1.54 1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.49 97 999999999 0.93 1.49 percent of total billed charges KLOR-CON M20 TABLET 50297356_1 CDM 0250 RC 00245-5319-01 NDC inpatient 1 UN 1.54 1 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.06 69 999999999 0.93 1.49 percent of total billed charges KLOR-CON M20 TABLET 50297356_1 CDM 0250 RC 00245-5319-01 NDC inpatient 1 UN 1.54 1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.2 78 999999999 0.93 1.49 percent of total billed charges KLOR-CON M20 TABLET 50297356_1 CDM 0250 RC 00245-5319-01 NDC inpatient 1 UN 1.54 1 SIHO - ALL PLANS SIHO - ALL PLANS 1.39 90 999999999 0.93 1.49 percent of total billed charges KLOR-CON M20 TABLET 50297356_1 CDM 0250 RC 00245-5319-01 NDC inpatient 1 UN 1.54 1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.93 60.55 999999999 0.93 1.49 percent of total billed charges KLOR-CON M20 TABLET 50297356_1 CDM 0250 RC 00245-5319-01 NDC inpatient 1 UN 1.54 1 UMR - ALL PLANS UMR - ALL PLANS 1.08 70 999999999 0.93 1.49 percent of total billed charges KLOR-CON M20 TABLET 50297356_1 CDM 0250 RC 00245-5319-01 NDC inpatient 1 UN 1.54 1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.93 1.49 KLOR-CON M20 TABLET 50297356_1 CDM 0250 RC 00245-5319-01 NDC inpatient 1 UN 1.54 1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.93 1.49 KLOR-CON M20 TABLET 50297356_1 CDM 0250 RC 00245-5319-01 NDC inpatient 1 UN 1.54 1 ANTHEM HMO ANTHEM HMO 999999999 0.93 1.49 KLOR-CON M20 TABLET 50297356_1 CDM 0250 RC 00245-5319-01 NDC inpatient 1 UN 1.54 1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.04 67.6 999999999 0.93 1.49 percent of total billed charges KLOR-CON M20 TABLET 50297356_1 CDM 0250 RC 00245-5319-01 NDC inpatient 1 UN 1.54 1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.93 1.49 KLOR-CON M20 TABLET 50297356_1 CDM 0250 RC 00245-5319-01 NDC inpatient 1 UN 1.54 1 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.93 1.49 CARVEDILOL 6.25 MG TABLET 50300377_1 CDM 0250 RC 00904-6301-61 NDC inpatient 1 UN 1.93 1.25 AETNA AETNA 1.52 79 999999999 1.17 1.87 percent of total billed charges CARVEDILOL 6.25 MG TABLET 50300377_1 CDM 0250 RC 00904-6301-61 NDC inpatient 1 UN 1.93 1.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.25 65 999999999 1.17 1.87 percent of total billed charges CARVEDILOL 6.25 MG TABLET 50300377_1 CDM 0250 RC 00904-6301-61 NDC inpatient 1 UN 1.93 1.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.87 97 999999999 1.17 1.87 percent of total billed charges CARVEDILOL 6.25 MG TABLET 50300377_1 CDM 0250 RC 00904-6301-61 NDC inpatient 1 UN 1.93 1.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.33 69 999999999 1.17 1.87 percent of total billed charges CARVEDILOL 6.25 MG TABLET 50300377_1 CDM 0250 RC 00904-6301-61 NDC inpatient 1 UN 1.93 1.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.51 78 999999999 1.17 1.87 percent of total billed charges CARVEDILOL 6.25 MG TABLET 50300377_1 CDM 0250 RC 00904-6301-61 NDC inpatient 1 UN 1.93 1.25 SIHO - ALL PLANS SIHO - ALL PLANS 1.74 90 999999999 1.17 1.87 percent of total billed charges CARVEDILOL 6.25 MG TABLET 50300377_1 CDM 0250 RC 00904-6301-61 NDC inpatient 1 UN 1.93 1.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.17 60.55 999999999 1.17 1.87 percent of total billed charges CARVEDILOL 6.25 MG TABLET 50300377_1 CDM 0250 RC 00904-6301-61 NDC inpatient 1 UN 1.93 1.25 UMR - ALL PLANS UMR - ALL PLANS 1.35 70 999999999 1.17 1.87 percent of total billed charges CARVEDILOL 6.25 MG TABLET 50300377_1 CDM 0250 RC 00904-6301-61 NDC inpatient 1 UN 1.93 1.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.17 1.87 CARVEDILOL 6.25 MG TABLET 50300377_1 CDM 0250 RC 00904-6301-61 NDC inpatient 1 UN 1.93 1.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.17 1.87 CARVEDILOL 6.25 MG TABLET 50300377_1 CDM 0250 RC 00904-6301-61 NDC inpatient 1 UN 1.93 1.25 ANTHEM HMO ANTHEM HMO 999999999 1.17 1.87 CARVEDILOL 6.25 MG TABLET 50300377_1 CDM 0250 RC 00904-6301-61 NDC inpatient 1 UN 1.93 1.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.3 67.6 999999999 1.17 1.87 percent of total billed charges CARVEDILOL 6.25 MG TABLET 50300377_1 CDM 0250 RC 00904-6301-61 NDC inpatient 1 UN 1.93 1.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.17 1.87 CARVEDILOL 6.25 MG TABLET 50300377_1 CDM 0250 RC 00904-6301-61 NDC inpatient 1 UN 1.93 1.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.17 1.87 "Testing for presence of drug, by chemistry analyzers" 50301064_1 CDM 0301 RC 80307 HCPCS inpatient 251 163.15 AETNA AETNA 198.29 79 999999999 151.98 243.47 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50301064_1 CDM 0301 RC 80307 HCPCS inpatient 251 163.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.15 65 999999999 151.98 243.47 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50301064_1 CDM 0301 RC 80307 HCPCS inpatient 251 163.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 243.47 97 999999999 151.98 243.47 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50301064_1 CDM 0301 RC 80307 HCPCS inpatient 251 163.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.19 69 999999999 151.98 243.47 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50301064_1 CDM 0301 RC 80307 HCPCS inpatient 251 163.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 195.78 78 999999999 151.98 243.47 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50301064_1 CDM 0301 RC 80307 HCPCS inpatient 251 163.15 SIHO - ALL PLANS SIHO - ALL PLANS 225.9 90 999999999 151.98 243.47 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50301064_1 CDM 0301 RC 80307 HCPCS inpatient 251 163.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.98 60.55 999999999 151.98 243.47 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50301064_1 CDM 0301 RC 80307 HCPCS inpatient 251 163.15 UMR - ALL PLANS UMR - ALL PLANS 175.7 70 999999999 151.98 243.47 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50301064_1 CDM 0301 RC 80307 HCPCS inpatient 251 163.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.98 243.47 "Testing for presence of drug, by chemistry analyzers" 50301064_1 CDM 0301 RC 80307 HCPCS inpatient 251 163.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.98 243.47 "Testing for presence of drug, by chemistry analyzers" 50301064_1 CDM 0301 RC 80307 HCPCS inpatient 251 163.15 ANTHEM HMO ANTHEM HMO 999999999 151.98 243.47 "Testing for presence of drug, by chemistry analyzers" 50301064_1 CDM 0301 RC 80307 HCPCS inpatient 251 163.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 169.68 67.6 999999999 151.98 243.47 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50301064_1 CDM 0301 RC 80307 HCPCS inpatient 251 163.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.98 243.47 "Testing for presence of drug, by chemistry analyzers" 50301064_1 CDM 0301 RC 80307 HCPCS inpatient 251 163.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.98 243.47 TOPIRAMATE 25 MG TABLET 50301220_1 CDM 0250 RC 68382-0138-14 NDC inpatient 1 UN 1.52 0.99 AETNA AETNA 1.2 79 999999999 0.92 1.47 percent of total billed charges TOPIRAMATE 25 MG TABLET 50301220_1 CDM 0250 RC 68382-0138-14 NDC inpatient 1 UN 1.52 0.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.99 65 999999999 0.92 1.47 percent of total billed charges TOPIRAMATE 25 MG TABLET 50301220_1 CDM 0250 RC 68382-0138-14 NDC inpatient 1 UN 1.52 0.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.47 97 999999999 0.92 1.47 percent of total billed charges TOPIRAMATE 25 MG TABLET 50301220_1 CDM 0250 RC 68382-0138-14 NDC inpatient 1 UN 1.52 0.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.05 69 999999999 0.92 1.47 percent of total billed charges TOPIRAMATE 25 MG TABLET 50301220_1 CDM 0250 RC 68382-0138-14 NDC inpatient 1 UN 1.52 0.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.19 78 999999999 0.92 1.47 percent of total billed charges TOPIRAMATE 25 MG TABLET 50301220_1 CDM 0250 RC 68382-0138-14 NDC inpatient 1 UN 1.52 0.99 SIHO - ALL PLANS SIHO - ALL PLANS 1.37 90 999999999 0.92 1.47 percent of total billed charges TOPIRAMATE 25 MG TABLET 50301220_1 CDM 0250 RC 68382-0138-14 NDC inpatient 1 UN 1.52 0.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.92 60.55 999999999 0.92 1.47 percent of total billed charges TOPIRAMATE 25 MG TABLET 50301220_1 CDM 0250 RC 68382-0138-14 NDC inpatient 1 UN 1.52 0.99 UMR - ALL PLANS UMR - ALL PLANS 1.06 70 999999999 0.92 1.47 percent of total billed charges TOPIRAMATE 25 MG TABLET 50301220_1 CDM 0250 RC 68382-0138-14 NDC inpatient 1 UN 1.52 0.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.92 1.47 TOPIRAMATE 25 MG TABLET 50301220_1 CDM 0250 RC 68382-0138-14 NDC inpatient 1 UN 1.52 0.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.92 1.47 TOPIRAMATE 25 MG TABLET 50301220_1 CDM 0250 RC 68382-0138-14 NDC inpatient 1 UN 1.52 0.99 ANTHEM HMO ANTHEM HMO 999999999 0.92 1.47 TOPIRAMATE 25 MG TABLET 50301220_1 CDM 0250 RC 68382-0138-14 NDC inpatient 1 UN 1.52 0.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.03 67.6 999999999 0.92 1.47 percent of total billed charges TOPIRAMATE 25 MG TABLET 50301220_1 CDM 0250 RC 68382-0138-14 NDC inpatient 1 UN 1.52 0.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.92 1.47 TOPIRAMATE 25 MG TABLET 50301220_1 CDM 0250 RC 68382-0138-14 NDC inpatient 1 UN 1.52 0.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.92 1.47 "Bacterial culture, any other source except urine, blood or stool, aerobic" 50301226_1 CDM 0301 RC 87070 HCPCS inpatient 122 79.3 AETNA AETNA 96.38 79 999999999 73.87 118.34 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 50301226_1 CDM 0301 RC 87070 HCPCS inpatient 122 79.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.3 65 999999999 73.87 118.34 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 50301226_1 CDM 0301 RC 87070 HCPCS inpatient 122 79.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 118.34 97 999999999 73.87 118.34 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 50301226_1 CDM 0301 RC 87070 HCPCS inpatient 122 79.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.18 69 999999999 73.87 118.34 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 50301226_1 CDM 0301 RC 87070 HCPCS inpatient 122 79.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.16 78 999999999 73.87 118.34 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 50301226_1 CDM 0301 RC 87070 HCPCS inpatient 122 79.3 SIHO - ALL PLANS SIHO - ALL PLANS 109.8 90 999999999 73.87 118.34 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 50301226_1 CDM 0301 RC 87070 HCPCS inpatient 122 79.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.87 60.55 999999999 73.87 118.34 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 50301226_1 CDM 0301 RC 87070 HCPCS inpatient 122 79.3 UMR - ALL PLANS UMR - ALL PLANS 85.4 70 999999999 73.87 118.34 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 50301226_1 CDM 0301 RC 87070 HCPCS inpatient 122 79.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.87 118.34 "Bacterial culture, any other source except urine, blood or stool, aerobic" 50301226_1 CDM 0301 RC 87070 HCPCS inpatient 122 79.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.87 118.34 "Bacterial culture, any other source except urine, blood or stool, aerobic" 50301226_1 CDM 0301 RC 87070 HCPCS inpatient 122 79.3 ANTHEM HMO ANTHEM HMO 999999999 73.87 118.34 "Bacterial culture, any other source except urine, blood or stool, aerobic" 50301226_1 CDM 0301 RC 87070 HCPCS inpatient 122 79.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 82.47 67.6 999999999 73.87 118.34 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 50301226_1 CDM 0301 RC 87070 HCPCS inpatient 122 79.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.87 118.34 "Bacterial culture, any other source except urine, blood or stool, aerobic" 50301226_1 CDM 0301 RC 87070 HCPCS inpatient 122 79.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.87 118.34 Hepatitis C antibody measurement 50302510_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Hepatitis C antibody measurement 50302510_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Hepatitis C antibody measurement 50302510_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Hepatitis C antibody measurement 50302510_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Hepatitis C antibody measurement 50302510_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Hepatitis C antibody measurement 50302510_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Hepatitis C antibody measurement 50302510_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Hepatitis C antibody measurement 50302510_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Hepatitis C antibody measurement 50302510_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Hepatitis C antibody measurement 50302510_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Hepatitis C antibody measurement 50302510_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Hepatitis C antibody measurement 50302510_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges Hepatitis C antibody measurement 50302510_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Hepatitis C antibody measurement 50302510_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 FOREIGN BODY GRASPING FORCEP 3-NAIL FG-54D 50304143_1 CDM 0272 RC inpatient 1467 953.55 AETNA AETNA 1158.93 79 999999999 888.27 1422.99 percent of total billed charges FOREIGN BODY GRASPING FORCEP 3-NAIL FG-54D 50304143_1 CDM 0272 RC inpatient 1467 953.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 953.55 65 999999999 888.27 1422.99 percent of total billed charges FOREIGN BODY GRASPING FORCEP 3-NAIL FG-54D 50304143_1 CDM 0272 RC inpatient 1467 953.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1422.99 97 999999999 888.27 1422.99 percent of total billed charges FOREIGN BODY GRASPING FORCEP 3-NAIL FG-54D 50304143_1 CDM 0272 RC inpatient 1467 953.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1012.23 69 999999999 888.27 1422.99 percent of total billed charges FOREIGN BODY GRASPING FORCEP 3-NAIL FG-54D 50304143_1 CDM 0272 RC inpatient 1467 953.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1144.26 78 999999999 888.27 1422.99 percent of total billed charges FOREIGN BODY GRASPING FORCEP 3-NAIL FG-54D 50304143_1 CDM 0272 RC inpatient 1467 953.55 SIHO - ALL PLANS SIHO - ALL PLANS 1320.3 90 999999999 888.27 1422.99 percent of total billed charges FOREIGN BODY GRASPING FORCEP 3-NAIL FG-54D 50304143_1 CDM 0272 RC inpatient 1467 953.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 888.27 60.55 999999999 888.27 1422.99 percent of total billed charges FOREIGN BODY GRASPING FORCEP 3-NAIL FG-54D 50304143_1 CDM 0272 RC inpatient 1467 953.55 UMR - ALL PLANS UMR - ALL PLANS 1026.9 70 999999999 888.27 1422.99 percent of total billed charges FOREIGN BODY GRASPING FORCEP 3-NAIL FG-54D 50304143_1 CDM 0272 RC inpatient 1467 953.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 888.27 1422.99 FOREIGN BODY GRASPING FORCEP 3-NAIL FG-54D 50304143_1 CDM 0272 RC inpatient 1467 953.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 888.27 1422.99 FOREIGN BODY GRASPING FORCEP 3-NAIL FG-54D 50304143_1 CDM 0272 RC inpatient 1467 953.55 ANTHEM HMO ANTHEM HMO 999999999 888.27 1422.99 FOREIGN BODY GRASPING FORCEP 3-NAIL FG-54D 50304143_1 CDM 0272 RC inpatient 1467 953.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 991.69 67.6 999999999 888.27 1422.99 percent of total billed charges FOREIGN BODY GRASPING FORCEP 3-NAIL FG-54D 50304143_1 CDM 0272 RC inpatient 1467 953.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 888.27 1422.99 FOREIGN BODY GRASPING FORCEP 3-NAIL FG-54D 50304143_1 CDM 0272 RC inpatient 1467 953.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 888.27 1422.99 FOREIGN BODY GRASPING FORCEP 3DR 50304144_1 CDM 0272 RC inpatient 1400 910 AETNA AETNA 1106 79 999999999 847.7 1358 percent of total billed charges FOREIGN BODY GRASPING FORCEP 3DR 50304144_1 CDM 0272 RC inpatient 1400 910 SELF PAY DISCOUNT SELF PAY DISCOUNT 910 65 999999999 847.7 1358 percent of total billed charges FOREIGN BODY GRASPING FORCEP 3DR 50304144_1 CDM 0272 RC inpatient 1400 910 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1358 97 999999999 847.7 1358 percent of total billed charges FOREIGN BODY GRASPING FORCEP 3DR 50304144_1 CDM 0272 RC inpatient 1400 910 ENCORE - ALL PLANS ENCORE - ALL PLANS 966 69 999999999 847.7 1358 percent of total billed charges FOREIGN BODY GRASPING FORCEP 3DR 50304144_1 CDM 0272 RC inpatient 1400 910 HUMANA - ALL PLANS HUMANA - ALL PLANS 1092 78 999999999 847.7 1358 percent of total billed charges FOREIGN BODY GRASPING FORCEP 3DR 50304144_1 CDM 0272 RC inpatient 1400 910 SIHO - ALL PLANS SIHO - ALL PLANS 1260 90 999999999 847.7 1358 percent of total billed charges FOREIGN BODY GRASPING FORCEP 3DR 50304144_1 CDM 0272 RC inpatient 1400 910 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 847.7 60.55 999999999 847.7 1358 percent of total billed charges FOREIGN BODY GRASPING FORCEP 3DR 50304144_1 CDM 0272 RC inpatient 1400 910 UMR - ALL PLANS UMR - ALL PLANS 980 70 999999999 847.7 1358 percent of total billed charges FOREIGN BODY GRASPING FORCEP 3DR 50304144_1 CDM 0272 RC inpatient 1400 910 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 847.7 1358 FOREIGN BODY GRASPING FORCEP 3DR 50304144_1 CDM 0272 RC inpatient 1400 910 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 847.7 1358 FOREIGN BODY GRASPING FORCEP 3DR 50304144_1 CDM 0272 RC inpatient 1400 910 ANTHEM HMO ANTHEM HMO 999999999 847.7 1358 FOREIGN BODY GRASPING FORCEP 3DR 50304144_1 CDM 0272 RC inpatient 1400 910 CIGNA - ALL PLANS CIGNA - ALL PLANS 946.4 67.6 999999999 847.7 1358 percent of total billed charges FOREIGN BODY GRASPING FORCEP 3DR 50304144_1 CDM 0272 RC inpatient 1400 910 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 847.7 1358 FOREIGN BODY GRASPING FORCEP 3DR 50304144_1 CDM 0272 RC inpatient 1400 910 UHC - ALL PLANS UHC - ALL PLANS 999999999 847.7 1358 CYTOLOGY BRUSH 2mm 50304145_1 CDM 0272 RC inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges CYTOLOGY BRUSH 2mm 50304145_1 CDM 0272 RC inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges CYTOLOGY BRUSH 2mm 50304145_1 CDM 0272 RC inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges CYTOLOGY BRUSH 2mm 50304145_1 CDM 0272 RC inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges CYTOLOGY BRUSH 2mm 50304145_1 CDM 0272 RC inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges CYTOLOGY BRUSH 2mm 50304145_1 CDM 0272 RC inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges CYTOLOGY BRUSH 2mm 50304145_1 CDM 0272 RC inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges CYTOLOGY BRUSH 2mm 50304145_1 CDM 0272 RC inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges CYTOLOGY BRUSH 2mm 50304145_1 CDM 0272 RC inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 CYTOLOGY BRUSH 2mm 50304145_1 CDM 0272 RC inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 CYTOLOGY BRUSH 2mm 50304145_1 CDM 0272 RC inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 CYTOLOGY BRUSH 2mm 50304145_1 CDM 0272 RC inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges CYTOLOGY BRUSH 2mm 50304145_1 CDM 0272 RC inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 CYTOLOGY BRUSH 2mm 50304145_1 CDM 0272 RC inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 ALLIGATOR BIOPSY FORCEPS 2mm 50304146_1 CDM 0272 RC inpatient 190 123.5 AETNA AETNA 150.1 79 999999999 115.05 184.3 percent of total billed charges ALLIGATOR BIOPSY FORCEPS 2mm 50304146_1 CDM 0272 RC inpatient 190 123.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 123.5 65 999999999 115.05 184.3 percent of total billed charges ALLIGATOR BIOPSY FORCEPS 2mm 50304146_1 CDM 0272 RC inpatient 190 123.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 184.3 97 999999999 115.05 184.3 percent of total billed charges ALLIGATOR BIOPSY FORCEPS 2mm 50304146_1 CDM 0272 RC inpatient 190 123.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 131.1 69 999999999 115.05 184.3 percent of total billed charges ALLIGATOR BIOPSY FORCEPS 2mm 50304146_1 CDM 0272 RC inpatient 190 123.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 148.2 78 999999999 115.05 184.3 percent of total billed charges ALLIGATOR BIOPSY FORCEPS 2mm 50304146_1 CDM 0272 RC inpatient 190 123.5 SIHO - ALL PLANS SIHO - ALL PLANS 171 90 999999999 115.05 184.3 percent of total billed charges ALLIGATOR BIOPSY FORCEPS 2mm 50304146_1 CDM 0272 RC inpatient 190 123.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 115.05 60.55 999999999 115.05 184.3 percent of total billed charges ALLIGATOR BIOPSY FORCEPS 2mm 50304146_1 CDM 0272 RC inpatient 190 123.5 UMR - ALL PLANS UMR - ALL PLANS 133 70 999999999 115.05 184.3 percent of total billed charges ALLIGATOR BIOPSY FORCEPS 2mm 50304146_1 CDM 0272 RC inpatient 190 123.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 115.05 184.3 ALLIGATOR BIOPSY FORCEPS 2mm 50304146_1 CDM 0272 RC inpatient 190 123.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 115.05 184.3 ALLIGATOR BIOPSY FORCEPS 2mm 50304146_1 CDM 0272 RC inpatient 190 123.5 ANTHEM HMO ANTHEM HMO 999999999 115.05 184.3 ALLIGATOR BIOPSY FORCEPS 2mm 50304146_1 CDM 0272 RC inpatient 190 123.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 128.44 67.6 999999999 115.05 184.3 percent of total billed charges ALLIGATOR BIOPSY FORCEPS 2mm 50304146_1 CDM 0272 RC inpatient 190 123.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 115.05 184.3 ALLIGATOR BIOPSY FORCEPS 2mm 50304146_1 CDM 0272 RC inpatient 190 123.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 115.05 184.3 "BONE MARROW BIOPSY SYSTEM COMPREHENSIVE TRAY 11GA X 4.0"" 9458-VC-006" 50304668_1 CDM 0272 RC inpatient 1013 658.45 AETNA AETNA 800.27 79 999999999 613.37 982.61 percent of total billed charges "BONE MARROW BIOPSY SYSTEM COMPREHENSIVE TRAY 11GA X 4.0"" 9458-VC-006" 50304668_1 CDM 0272 RC inpatient 1013 658.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 658.45 65 999999999 613.37 982.61 percent of total billed charges "BONE MARROW BIOPSY SYSTEM COMPREHENSIVE TRAY 11GA X 4.0"" 9458-VC-006" 50304668_1 CDM 0272 RC inpatient 1013 658.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 982.61 97 999999999 613.37 982.61 percent of total billed charges "BONE MARROW BIOPSY SYSTEM COMPREHENSIVE TRAY 11GA X 4.0"" 9458-VC-006" 50304668_1 CDM 0272 RC inpatient 1013 658.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 698.97 69 999999999 613.37 982.61 percent of total billed charges "BONE MARROW BIOPSY SYSTEM COMPREHENSIVE TRAY 11GA X 4.0"" 9458-VC-006" 50304668_1 CDM 0272 RC inpatient 1013 658.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 790.14 78 999999999 613.37 982.61 percent of total billed charges "BONE MARROW BIOPSY SYSTEM COMPREHENSIVE TRAY 11GA X 4.0"" 9458-VC-006" 50304668_1 CDM 0272 RC inpatient 1013 658.45 SIHO - ALL PLANS SIHO - ALL PLANS 911.7 90 999999999 613.37 982.61 percent of total billed charges "BONE MARROW BIOPSY SYSTEM COMPREHENSIVE TRAY 11GA X 4.0"" 9458-VC-006" 50304668_1 CDM 0272 RC inpatient 1013 658.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 613.37 60.55 999999999 613.37 982.61 percent of total billed charges "BONE MARROW BIOPSY SYSTEM COMPREHENSIVE TRAY 11GA X 4.0"" 9458-VC-006" 50304668_1 CDM 0272 RC inpatient 1013 658.45 UMR - ALL PLANS UMR - ALL PLANS 709.1 70 999999999 613.37 982.61 percent of total billed charges "BONE MARROW BIOPSY SYSTEM COMPREHENSIVE TRAY 11GA X 4.0"" 9458-VC-006" 50304668_1 CDM 0272 RC inpatient 1013 658.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 613.37 982.61 "BONE MARROW BIOPSY SYSTEM COMPREHENSIVE TRAY 11GA X 4.0"" 9458-VC-006" 50304668_1 CDM 0272 RC inpatient 1013 658.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 613.37 982.61 "BONE MARROW BIOPSY SYSTEM COMPREHENSIVE TRAY 11GA X 4.0"" 9458-VC-006" 50304668_1 CDM 0272 RC inpatient 1013 658.45 ANTHEM HMO ANTHEM HMO 999999999 613.37 982.61 "BONE MARROW BIOPSY SYSTEM COMPREHENSIVE TRAY 11GA X 4.0"" 9458-VC-006" 50304668_1 CDM 0272 RC inpatient 1013 658.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 684.79 67.6 999999999 613.37 982.61 percent of total billed charges "BONE MARROW BIOPSY SYSTEM COMPREHENSIVE TRAY 11GA X 4.0"" 9458-VC-006" 50304668_1 CDM 0272 RC inpatient 1013 658.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 613.37 982.61 "BONE MARROW BIOPSY SYSTEM COMPREHENSIVE TRAY 11GA X 4.0"" 9458-VC-006" 50304668_1 CDM 0272 RC inpatient 1013 658.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 613.37 982.61 BACITRACIN ZN 500 UNIT/GM OINT 50305900_1 CDM 0250 RC 24385-0060-03 NDC inpatient 1 UN 5.43 3.53 AETNA AETNA 4.29 79 999999999 3.29 5.27 percent of total billed charges BACITRACIN ZN 500 UNIT/GM OINT 50305900_1 CDM 0250 RC 24385-0060-03 NDC inpatient 1 UN 5.43 3.53 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.53 65 999999999 3.29 5.27 percent of total billed charges BACITRACIN ZN 500 UNIT/GM OINT 50305900_1 CDM 0250 RC 24385-0060-03 NDC inpatient 1 UN 5.43 3.53 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.27 97 999999999 3.29 5.27 percent of total billed charges BACITRACIN ZN 500 UNIT/GM OINT 50305900_1 CDM 0250 RC 24385-0060-03 NDC inpatient 1 UN 5.43 3.53 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.75 69 999999999 3.29 5.27 percent of total billed charges BACITRACIN ZN 500 UNIT/GM OINT 50305900_1 CDM 0250 RC 24385-0060-03 NDC inpatient 1 UN 5.43 3.53 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.24 78 999999999 3.29 5.27 percent of total billed charges BACITRACIN ZN 500 UNIT/GM OINT 50305900_1 CDM 0250 RC 24385-0060-03 NDC inpatient 1 UN 5.43 3.53 SIHO - ALL PLANS SIHO - ALL PLANS 4.89 90 999999999 3.29 5.27 percent of total billed charges BACITRACIN ZN 500 UNIT/GM OINT 50305900_1 CDM 0250 RC 24385-0060-03 NDC inpatient 1 UN 5.43 3.53 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.29 60.55 999999999 3.29 5.27 percent of total billed charges BACITRACIN ZN 500 UNIT/GM OINT 50305900_1 CDM 0250 RC 24385-0060-03 NDC inpatient 1 UN 5.43 3.53 UMR - ALL PLANS UMR - ALL PLANS 3.8 70 999999999 3.29 5.27 percent of total billed charges BACITRACIN ZN 500 UNIT/GM OINT 50305900_1 CDM 0250 RC 24385-0060-03 NDC inpatient 1 UN 5.43 3.53 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.29 5.27 BACITRACIN ZN 500 UNIT/GM OINT 50305900_1 CDM 0250 RC 24385-0060-03 NDC inpatient 1 UN 5.43 3.53 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.29 5.27 BACITRACIN ZN 500 UNIT/GM OINT 50305900_1 CDM 0250 RC 24385-0060-03 NDC inpatient 1 UN 5.43 3.53 ANTHEM HMO ANTHEM HMO 999999999 3.29 5.27 BACITRACIN ZN 500 UNIT/GM OINT 50305900_1 CDM 0250 RC 24385-0060-03 NDC inpatient 1 UN 5.43 3.53 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.67 67.6 999999999 3.29 5.27 percent of total billed charges BACITRACIN ZN 500 UNIT/GM OINT 50305900_1 CDM 0250 RC 24385-0060-03 NDC inpatient 1 UN 5.43 3.53 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.29 5.27 BACITRACIN ZN 500 UNIT/GM OINT 50305900_1 CDM 0250 RC 24385-0060-03 NDC inpatient 1 UN 5.43 3.53 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.29 5.27 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50308132_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 AETNA AETNA 698.36 79 999999999 535.26 857.48 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50308132_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 574.6 65 999999999 535.26 857.48 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50308132_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 857.48 97 999999999 535.26 857.48 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50308132_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 609.96 69 999999999 535.26 857.48 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50308132_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 689.52 78 999999999 535.26 857.48 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50308132_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 SIHO - ALL PLANS SIHO - ALL PLANS 795.6 90 999999999 535.26 857.48 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50308132_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 535.26 60.55 999999999 535.26 857.48 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50308132_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 UMR - ALL PLANS UMR - ALL PLANS 618.8 70 999999999 535.26 857.48 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50308132_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 535.26 857.48 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50308132_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 535.26 857.48 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50308132_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 ANTHEM HMO ANTHEM HMO 999999999 535.26 857.48 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50308132_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 597.58 67.6 999999999 535.26 857.48 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50308132_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 535.26 857.48 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50308132_1 CDM 0306 RC 87633 HCPCS inpatient 884 574.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 535.26 857.48 METHYLPREDNISOLONE SS 1 GM VL 50308441_1 CDM 0250 RC 63323-0265-30 NDC inpatient 1 UN 73.11 47.52 AETNA AETNA 57.76 79 999999999 44.27 70.92 percent of total billed charges METHYLPREDNISOLONE SS 1 GM VL 50308441_1 CDM 0250 RC 63323-0265-30 NDC inpatient 1 UN 73.11 47.52 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.52 65 999999999 44.27 70.92 percent of total billed charges METHYLPREDNISOLONE SS 1 GM VL 50308441_1 CDM 0250 RC 63323-0265-30 NDC inpatient 1 UN 73.11 47.52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.92 97 999999999 44.27 70.92 percent of total billed charges METHYLPREDNISOLONE SS 1 GM VL 50308441_1 CDM 0250 RC 63323-0265-30 NDC inpatient 1 UN 73.11 47.52 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.45 69 999999999 44.27 70.92 percent of total billed charges METHYLPREDNISOLONE SS 1 GM VL 50308441_1 CDM 0250 RC 63323-0265-30 NDC inpatient 1 UN 73.11 47.52 HUMANA - ALL PLANS HUMANA - ALL PLANS 57.03 78 999999999 44.27 70.92 percent of total billed charges METHYLPREDNISOLONE SS 1 GM VL 50308441_1 CDM 0250 RC 63323-0265-30 NDC inpatient 1 UN 73.11 47.52 SIHO - ALL PLANS SIHO - ALL PLANS 65.8 90 999999999 44.27 70.92 percent of total billed charges METHYLPREDNISOLONE SS 1 GM VL 50308441_1 CDM 0250 RC 63323-0265-30 NDC inpatient 1 UN 73.11 47.52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.27 60.55 999999999 44.27 70.92 percent of total billed charges METHYLPREDNISOLONE SS 1 GM VL 50308441_1 CDM 0250 RC 63323-0265-30 NDC inpatient 1 UN 73.11 47.52 UMR - ALL PLANS UMR - ALL PLANS 51.18 70 999999999 44.27 70.92 percent of total billed charges METHYLPREDNISOLONE SS 1 GM VL 50308441_1 CDM 0250 RC 63323-0265-30 NDC inpatient 1 UN 73.11 47.52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.27 70.92 METHYLPREDNISOLONE SS 1 GM VL 50308441_1 CDM 0250 RC 63323-0265-30 NDC inpatient 1 UN 73.11 47.52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.27 70.92 METHYLPREDNISOLONE SS 1 GM VL 50308441_1 CDM 0250 RC 63323-0265-30 NDC inpatient 1 UN 73.11 47.52 ANTHEM HMO ANTHEM HMO 999999999 44.27 70.92 METHYLPREDNISOLONE SS 1 GM VL 50308441_1 CDM 0250 RC 63323-0265-30 NDC inpatient 1 UN 73.11 47.52 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.42 67.6 999999999 44.27 70.92 percent of total billed charges METHYLPREDNISOLONE SS 1 GM VL 50308441_1 CDM 0250 RC 63323-0265-30 NDC inpatient 1 UN 73.11 47.52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.27 70.92 METHYLPREDNISOLONE SS 1 GM VL 50308441_1 CDM 0250 RC 63323-0265-30 NDC inpatient 1 UN 73.11 47.52 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.27 70.92 PIPERACIL-TAZOBACT 3.375 GM VL 50308866_1 CDM 0250 RC 00781-9213-95 NDC inpatient 4 UN 35.23 22.9 AETNA AETNA 27.83 79 999999999 21.33 34.17 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50308866_1 CDM 0250 RC 00781-9213-95 NDC inpatient 4 UN 35.23 22.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.9 65 999999999 21.33 34.17 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50308866_1 CDM 0250 RC 00781-9213-95 NDC inpatient 4 UN 35.23 22.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34.17 97 999999999 21.33 34.17 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50308866_1 CDM 0250 RC 00781-9213-95 NDC inpatient 4 UN 35.23 22.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.31 69 999999999 21.33 34.17 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50308866_1 CDM 0250 RC 00781-9213-95 NDC inpatient 4 UN 35.23 22.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.48 78 999999999 21.33 34.17 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50308866_1 CDM 0250 RC 00781-9213-95 NDC inpatient 4 UN 35.23 22.9 SIHO - ALL PLANS SIHO - ALL PLANS 31.71 90 999999999 21.33 34.17 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50308866_1 CDM 0250 RC 00781-9213-95 NDC inpatient 4 UN 35.23 22.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.33 60.55 999999999 21.33 34.17 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50308866_1 CDM 0250 RC 00781-9213-95 NDC inpatient 4 UN 35.23 22.9 UMR - ALL PLANS UMR - ALL PLANS 24.66 70 999999999 21.33 34.17 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50308866_1 CDM 0250 RC 00781-9213-95 NDC inpatient 4 UN 35.23 22.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.33 34.17 PIPERACIL-TAZOBACT 3.375 GM VL 50308866_1 CDM 0250 RC 00781-9213-95 NDC inpatient 4 UN 35.23 22.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.33 34.17 PIPERACIL-TAZOBACT 3.375 GM VL 50308866_1 CDM 0250 RC 00781-9213-95 NDC inpatient 4 UN 35.23 22.9 ANTHEM HMO ANTHEM HMO 999999999 21.33 34.17 PIPERACIL-TAZOBACT 3.375 GM VL 50308866_1 CDM 0250 RC 00781-9213-95 NDC inpatient 4 UN 35.23 22.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 23.82 67.6 999999999 21.33 34.17 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50308866_1 CDM 0250 RC 00781-9213-95 NDC inpatient 4 UN 35.23 22.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.33 34.17 PIPERACIL-TAZOBACT 3.375 GM VL 50308866_1 CDM 0250 RC 00781-9213-95 NDC inpatient 4 UN 35.23 22.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.33 34.17 ENULOSE 10 GM/15 ML SOLUTION 50318201_1 CDM 0250 RC 45963-0438-64 NDC inpatient 1 UN 22.17 14.41 AETNA AETNA 17.51 79 999999999 13.42 21.5 percent of total billed charges ENULOSE 10 GM/15 ML SOLUTION 50318201_1 CDM 0250 RC 45963-0438-64 NDC inpatient 1 UN 22.17 14.41 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.41 65 999999999 13.42 21.5 percent of total billed charges ENULOSE 10 GM/15 ML SOLUTION 50318201_1 CDM 0250 RC 45963-0438-64 NDC inpatient 1 UN 22.17 14.41 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21.5 97 999999999 13.42 21.5 percent of total billed charges ENULOSE 10 GM/15 ML SOLUTION 50318201_1 CDM 0250 RC 45963-0438-64 NDC inpatient 1 UN 22.17 14.41 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.3 69 999999999 13.42 21.5 percent of total billed charges ENULOSE 10 GM/15 ML SOLUTION 50318201_1 CDM 0250 RC 45963-0438-64 NDC inpatient 1 UN 22.17 14.41 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.29 78 999999999 13.42 21.5 percent of total billed charges ENULOSE 10 GM/15 ML SOLUTION 50318201_1 CDM 0250 RC 45963-0438-64 NDC inpatient 1 UN 22.17 14.41 SIHO - ALL PLANS SIHO - ALL PLANS 19.95 90 999999999 13.42 21.5 percent of total billed charges ENULOSE 10 GM/15 ML SOLUTION 50318201_1 CDM 0250 RC 45963-0438-64 NDC inpatient 1 UN 22.17 14.41 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.42 60.55 999999999 13.42 21.5 percent of total billed charges ENULOSE 10 GM/15 ML SOLUTION 50318201_1 CDM 0250 RC 45963-0438-64 NDC inpatient 1 UN 22.17 14.41 UMR - ALL PLANS UMR - ALL PLANS 15.52 70 999999999 13.42 21.5 percent of total billed charges ENULOSE 10 GM/15 ML SOLUTION 50318201_1 CDM 0250 RC 45963-0438-64 NDC inpatient 1 UN 22.17 14.41 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.42 21.5 ENULOSE 10 GM/15 ML SOLUTION 50318201_1 CDM 0250 RC 45963-0438-64 NDC inpatient 1 UN 22.17 14.41 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.42 21.5 ENULOSE 10 GM/15 ML SOLUTION 50318201_1 CDM 0250 RC 45963-0438-64 NDC inpatient 1 UN 22.17 14.41 ANTHEM HMO ANTHEM HMO 999999999 13.42 21.5 ENULOSE 10 GM/15 ML SOLUTION 50318201_1 CDM 0250 RC 45963-0438-64 NDC inpatient 1 UN 22.17 14.41 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.99 67.6 999999999 13.42 21.5 percent of total billed charges ENULOSE 10 GM/15 ML SOLUTION 50318201_1 CDM 0250 RC 45963-0438-64 NDC inpatient 1 UN 22.17 14.41 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.42 21.5 ENULOSE 10 GM/15 ML SOLUTION 50318201_1 CDM 0250 RC 45963-0438-64 NDC inpatient 1 UN 22.17 14.41 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.42 21.5 MYXREDLIN 100 UNIT/100 ML BAG 50318257_1 CDM 0250 RC 00338-0126-12 NDC inpatient 1 UN 141.87 92.22 AETNA AETNA 112.08 79 999999999 85.9 137.61 percent of total billed charges MYXREDLIN 100 UNIT/100 ML BAG 50318257_1 CDM 0250 RC 00338-0126-12 NDC inpatient 1 UN 141.87 92.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.22 65 999999999 85.9 137.61 percent of total billed charges MYXREDLIN 100 UNIT/100 ML BAG 50318257_1 CDM 0250 RC 00338-0126-12 NDC inpatient 1 UN 141.87 92.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.61 97 999999999 85.9 137.61 percent of total billed charges MYXREDLIN 100 UNIT/100 ML BAG 50318257_1 CDM 0250 RC 00338-0126-12 NDC inpatient 1 UN 141.87 92.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.89 69 999999999 85.9 137.61 percent of total billed charges MYXREDLIN 100 UNIT/100 ML BAG 50318257_1 CDM 0250 RC 00338-0126-12 NDC inpatient 1 UN 141.87 92.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.66 78 999999999 85.9 137.61 percent of total billed charges MYXREDLIN 100 UNIT/100 ML BAG 50318257_1 CDM 0250 RC 00338-0126-12 NDC inpatient 1 UN 141.87 92.22 SIHO - ALL PLANS SIHO - ALL PLANS 127.68 90 999999999 85.9 137.61 percent of total billed charges MYXREDLIN 100 UNIT/100 ML BAG 50318257_1 CDM 0250 RC 00338-0126-12 NDC inpatient 1 UN 141.87 92.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.9 60.55 999999999 85.9 137.61 percent of total billed charges MYXREDLIN 100 UNIT/100 ML BAG 50318257_1 CDM 0250 RC 00338-0126-12 NDC inpatient 1 UN 141.87 92.22 UMR - ALL PLANS UMR - ALL PLANS 99.31 70 999999999 85.9 137.61 percent of total billed charges MYXREDLIN 100 UNIT/100 ML BAG 50318257_1 CDM 0250 RC 00338-0126-12 NDC inpatient 1 UN 141.87 92.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.9 137.61 MYXREDLIN 100 UNIT/100 ML BAG 50318257_1 CDM 0250 RC 00338-0126-12 NDC inpatient 1 UN 141.87 92.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.9 137.61 MYXREDLIN 100 UNIT/100 ML BAG 50318257_1 CDM 0250 RC 00338-0126-12 NDC inpatient 1 UN 141.87 92.22 ANTHEM HMO ANTHEM HMO 999999999 85.9 137.61 MYXREDLIN 100 UNIT/100 ML BAG 50318257_1 CDM 0250 RC 00338-0126-12 NDC inpatient 1 UN 141.87 92.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.9 67.6 999999999 85.9 137.61 percent of total billed charges MYXREDLIN 100 UNIT/100 ML BAG 50318257_1 CDM 0250 RC 00338-0126-12 NDC inpatient 1 UN 141.87 92.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.9 137.61 MYXREDLIN 100 UNIT/100 ML BAG 50318257_1 CDM 0250 RC 00338-0126-12 NDC inpatient 1 UN 141.87 92.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.9 137.61 LEVOTHYROXINE 175 MCG TABLET 50318271_1 CDM 0250 RC 69238-1839-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 175 MCG TABLET 50318271_1 CDM 0250 RC 69238-1839-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 175 MCG TABLET 50318271_1 CDM 0250 RC 69238-1839-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 175 MCG TABLET 50318271_1 CDM 0250 RC 69238-1839-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 175 MCG TABLET 50318271_1 CDM 0250 RC 69238-1839-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 175 MCG TABLET 50318271_1 CDM 0250 RC 69238-1839-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 175 MCG TABLET 50318271_1 CDM 0250 RC 69238-1839-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 175 MCG TABLET 50318271_1 CDM 0250 RC 69238-1839-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 175 MCG TABLET 50318271_1 CDM 0250 RC 69238-1839-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LEVOTHYROXINE 175 MCG TABLET 50318271_1 CDM 0250 RC 69238-1839-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 175 MCG TABLET 50318271_1 CDM 0250 RC 69238-1839-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LEVOTHYROXINE 175 MCG TABLET 50318271_1 CDM 0250 RC 69238-1839-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 175 MCG TABLET 50318271_1 CDM 0250 RC 69238-1839-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 175 MCG TABLET 50318271_1 CDM 0250 RC 69238-1839-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 FUROSEMIDE 20 MG/2 ML VIAL 50318304_1 CDM 0250 RC 55150-0322-25 NDC inpatient 1 UN 17.5 11.38 AETNA AETNA 13.83 79 999999999 10.6 16.98 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 50318304_1 CDM 0250 RC 55150-0322-25 NDC inpatient 1 UN 17.5 11.38 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.38 65 999999999 10.6 16.98 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 50318304_1 CDM 0250 RC 55150-0322-25 NDC inpatient 1 UN 17.5 11.38 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16.98 97 999999999 10.6 16.98 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 50318304_1 CDM 0250 RC 55150-0322-25 NDC inpatient 1 UN 17.5 11.38 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.08 69 999999999 10.6 16.98 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 50318304_1 CDM 0250 RC 55150-0322-25 NDC inpatient 1 UN 17.5 11.38 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.65 78 999999999 10.6 16.98 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 50318304_1 CDM 0250 RC 55150-0322-25 NDC inpatient 1 UN 17.5 11.38 SIHO - ALL PLANS SIHO - ALL PLANS 15.75 90 999999999 10.6 16.98 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 50318304_1 CDM 0250 RC 55150-0322-25 NDC inpatient 1 UN 17.5 11.38 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.6 60.55 999999999 10.6 16.98 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 50318304_1 CDM 0250 RC 55150-0322-25 NDC inpatient 1 UN 17.5 11.38 UMR - ALL PLANS UMR - ALL PLANS 12.25 70 999999999 10.6 16.98 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 50318304_1 CDM 0250 RC 55150-0322-25 NDC inpatient 1 UN 17.5 11.38 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.6 16.98 FUROSEMIDE 20 MG/2 ML VIAL 50318304_1 CDM 0250 RC 55150-0322-25 NDC inpatient 1 UN 17.5 11.38 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.6 16.98 FUROSEMIDE 20 MG/2 ML VIAL 50318304_1 CDM 0250 RC 55150-0322-25 NDC inpatient 1 UN 17.5 11.38 ANTHEM HMO ANTHEM HMO 999999999 10.6 16.98 FUROSEMIDE 20 MG/2 ML VIAL 50318304_1 CDM 0250 RC 55150-0322-25 NDC inpatient 1 UN 17.5 11.38 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.83 67.6 999999999 10.6 16.98 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 50318304_1 CDM 0250 RC 55150-0322-25 NDC inpatient 1 UN 17.5 11.38 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.6 16.98 FUROSEMIDE 20 MG/2 ML VIAL 50318304_1 CDM 0250 RC 55150-0322-25 NDC inpatient 1 UN 17.5 11.38 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.6 16.98 TOLTERODINE TART ER 2 MG CAP 50318323_1 CDM 0250 RC 00093-7163-56 NDC inpatient 1 UN 8.82 5.73 AETNA AETNA 6.97 79 999999999 5.34 8.56 percent of total billed charges TOLTERODINE TART ER 2 MG CAP 50318323_1 CDM 0250 RC 00093-7163-56 NDC inpatient 1 UN 8.82 5.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.73 65 999999999 5.34 8.56 percent of total billed charges TOLTERODINE TART ER 2 MG CAP 50318323_1 CDM 0250 RC 00093-7163-56 NDC inpatient 1 UN 8.82 5.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.56 97 999999999 5.34 8.56 percent of total billed charges TOLTERODINE TART ER 2 MG CAP 50318323_1 CDM 0250 RC 00093-7163-56 NDC inpatient 1 UN 8.82 5.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.09 69 999999999 5.34 8.56 percent of total billed charges TOLTERODINE TART ER 2 MG CAP 50318323_1 CDM 0250 RC 00093-7163-56 NDC inpatient 1 UN 8.82 5.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.88 78 999999999 5.34 8.56 percent of total billed charges TOLTERODINE TART ER 2 MG CAP 50318323_1 CDM 0250 RC 00093-7163-56 NDC inpatient 1 UN 8.82 5.73 SIHO - ALL PLANS SIHO - ALL PLANS 7.94 90 999999999 5.34 8.56 percent of total billed charges TOLTERODINE TART ER 2 MG CAP 50318323_1 CDM 0250 RC 00093-7163-56 NDC inpatient 1 UN 8.82 5.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.34 60.55 999999999 5.34 8.56 percent of total billed charges TOLTERODINE TART ER 2 MG CAP 50318323_1 CDM 0250 RC 00093-7163-56 NDC inpatient 1 UN 8.82 5.73 UMR - ALL PLANS UMR - ALL PLANS 6.17 70 999999999 5.34 8.56 percent of total billed charges TOLTERODINE TART ER 2 MG CAP 50318323_1 CDM 0250 RC 00093-7163-56 NDC inpatient 1 UN 8.82 5.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.34 8.56 TOLTERODINE TART ER 2 MG CAP 50318323_1 CDM 0250 RC 00093-7163-56 NDC inpatient 1 UN 8.82 5.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.34 8.56 TOLTERODINE TART ER 2 MG CAP 50318323_1 CDM 0250 RC 00093-7163-56 NDC inpatient 1 UN 8.82 5.73 ANTHEM HMO ANTHEM HMO 999999999 5.34 8.56 TOLTERODINE TART ER 2 MG CAP 50318323_1 CDM 0250 RC 00093-7163-56 NDC inpatient 1 UN 8.82 5.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.96 67.6 999999999 5.34 8.56 percent of total billed charges TOLTERODINE TART ER 2 MG CAP 50318323_1 CDM 0250 RC 00093-7163-56 NDC inpatient 1 UN 8.82 5.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.34 8.56 TOLTERODINE TART ER 2 MG CAP 50318323_1 CDM 0250 RC 00093-7163-56 NDC inpatient 1 UN 8.82 5.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.34 8.56 ISOSORBIDE DINITRATE 5 MG TAB 50318326_1 CDM 0250 RC 68001-0373-00 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE DINITRATE 5 MG TAB 50318326_1 CDM 0250 RC 68001-0373-00 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE DINITRATE 5 MG TAB 50318326_1 CDM 0250 RC 68001-0373-00 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE DINITRATE 5 MG TAB 50318326_1 CDM 0250 RC 68001-0373-00 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE DINITRATE 5 MG TAB 50318326_1 CDM 0250 RC 68001-0373-00 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE DINITRATE 5 MG TAB 50318326_1 CDM 0250 RC 68001-0373-00 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE DINITRATE 5 MG TAB 50318326_1 CDM 0250 RC 68001-0373-00 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE DINITRATE 5 MG TAB 50318326_1 CDM 0250 RC 68001-0373-00 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE DINITRATE 5 MG TAB 50318326_1 CDM 0250 RC 68001-0373-00 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ISOSORBIDE DINITRATE 5 MG TAB 50318326_1 CDM 0250 RC 68001-0373-00 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ISOSORBIDE DINITRATE 5 MG TAB 50318326_1 CDM 0250 RC 68001-0373-00 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ISOSORBIDE DINITRATE 5 MG TAB 50318326_1 CDM 0250 RC 68001-0373-00 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges ISOSORBIDE DINITRATE 5 MG TAB 50318326_1 CDM 0250 RC 68001-0373-00 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ISOSORBIDE DINITRATE 5 MG TAB 50318326_1 CDM 0250 RC 68001-0373-00 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 LAMOTRIGINE 25 MG TABLET 50318349_1 CDM 0250 RC 29300-0111-01 NDC inpatient 1 UN 1.17 0.76 AETNA AETNA 0.92 79 999999999 0.71 1.13 percent of total billed charges LAMOTRIGINE 25 MG TABLET 50318349_1 CDM 0250 RC 29300-0111-01 NDC inpatient 1 UN 1.17 0.76 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.76 65 999999999 0.71 1.13 percent of total billed charges LAMOTRIGINE 25 MG TABLET 50318349_1 CDM 0250 RC 29300-0111-01 NDC inpatient 1 UN 1.17 0.76 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.13 97 999999999 0.71 1.13 percent of total billed charges LAMOTRIGINE 25 MG TABLET 50318349_1 CDM 0250 RC 29300-0111-01 NDC inpatient 1 UN 1.17 0.76 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.81 69 999999999 0.71 1.13 percent of total billed charges LAMOTRIGINE 25 MG TABLET 50318349_1 CDM 0250 RC 29300-0111-01 NDC inpatient 1 UN 1.17 0.76 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.91 78 999999999 0.71 1.13 percent of total billed charges LAMOTRIGINE 25 MG TABLET 50318349_1 CDM 0250 RC 29300-0111-01 NDC inpatient 1 UN 1.17 0.76 SIHO - ALL PLANS SIHO - ALL PLANS 1.05 90 999999999 0.71 1.13 percent of total billed charges LAMOTRIGINE 25 MG TABLET 50318349_1 CDM 0250 RC 29300-0111-01 NDC inpatient 1 UN 1.17 0.76 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.71 60.55 999999999 0.71 1.13 percent of total billed charges LAMOTRIGINE 25 MG TABLET 50318349_1 CDM 0250 RC 29300-0111-01 NDC inpatient 1 UN 1.17 0.76 UMR - ALL PLANS UMR - ALL PLANS 0.82 70 999999999 0.71 1.13 percent of total billed charges LAMOTRIGINE 25 MG TABLET 50318349_1 CDM 0250 RC 29300-0111-01 NDC inpatient 1 UN 1.17 0.76 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.71 1.13 LAMOTRIGINE 25 MG TABLET 50318349_1 CDM 0250 RC 29300-0111-01 NDC inpatient 1 UN 1.17 0.76 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.71 1.13 LAMOTRIGINE 25 MG TABLET 50318349_1 CDM 0250 RC 29300-0111-01 NDC inpatient 1 UN 1.17 0.76 ANTHEM HMO ANTHEM HMO 999999999 0.71 1.13 LAMOTRIGINE 25 MG TABLET 50318349_1 CDM 0250 RC 29300-0111-01 NDC inpatient 1 UN 1.17 0.76 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.79 67.6 999999999 0.71 1.13 percent of total billed charges LAMOTRIGINE 25 MG TABLET 50318349_1 CDM 0250 RC 29300-0111-01 NDC inpatient 1 UN 1.17 0.76 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.71 1.13 LAMOTRIGINE 25 MG TABLET 50318349_1 CDM 0250 RC 29300-0111-01 NDC inpatient 1 UN 1.17 0.76 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.71 1.13 ALBUTEROL SULF 2 MG/5 ML SYRUP 50318651_1 CDM 0250 RC 00472-0825-16 NDC inpatient 1 UN 111.31 72.35 AETNA AETNA 87.93 79 999999999 67.4 107.97 percent of total billed charges ALBUTEROL SULF 2 MG/5 ML SYRUP 50318651_1 CDM 0250 RC 00472-0825-16 NDC inpatient 1 UN 111.31 72.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.35 65 999999999 67.4 107.97 percent of total billed charges ALBUTEROL SULF 2 MG/5 ML SYRUP 50318651_1 CDM 0250 RC 00472-0825-16 NDC inpatient 1 UN 111.31 72.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 107.97 97 999999999 67.4 107.97 percent of total billed charges ALBUTEROL SULF 2 MG/5 ML SYRUP 50318651_1 CDM 0250 RC 00472-0825-16 NDC inpatient 1 UN 111.31 72.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 76.8 69 999999999 67.4 107.97 percent of total billed charges ALBUTEROL SULF 2 MG/5 ML SYRUP 50318651_1 CDM 0250 RC 00472-0825-16 NDC inpatient 1 UN 111.31 72.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 86.82 78 999999999 67.4 107.97 percent of total billed charges ALBUTEROL SULF 2 MG/5 ML SYRUP 50318651_1 CDM 0250 RC 00472-0825-16 NDC inpatient 1 UN 111.31 72.35 SIHO - ALL PLANS SIHO - ALL PLANS 100.18 90 999999999 67.4 107.97 percent of total billed charges ALBUTEROL SULF 2 MG/5 ML SYRUP 50318651_1 CDM 0250 RC 00472-0825-16 NDC inpatient 1 UN 111.31 72.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.4 60.55 999999999 67.4 107.97 percent of total billed charges ALBUTEROL SULF 2 MG/5 ML SYRUP 50318651_1 CDM 0250 RC 00472-0825-16 NDC inpatient 1 UN 111.31 72.35 UMR - ALL PLANS UMR - ALL PLANS 77.92 70 999999999 67.4 107.97 percent of total billed charges ALBUTEROL SULF 2 MG/5 ML SYRUP 50318651_1 CDM 0250 RC 00472-0825-16 NDC inpatient 1 UN 111.31 72.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.4 107.97 ALBUTEROL SULF 2 MG/5 ML SYRUP 50318651_1 CDM 0250 RC 00472-0825-16 NDC inpatient 1 UN 111.31 72.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.4 107.97 ALBUTEROL SULF 2 MG/5 ML SYRUP 50318651_1 CDM 0250 RC 00472-0825-16 NDC inpatient 1 UN 111.31 72.35 ANTHEM HMO ANTHEM HMO 999999999 67.4 107.97 ALBUTEROL SULF 2 MG/5 ML SYRUP 50318651_1 CDM 0250 RC 00472-0825-16 NDC inpatient 1 UN 111.31 72.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.25 67.6 999999999 67.4 107.97 percent of total billed charges ALBUTEROL SULF 2 MG/5 ML SYRUP 50318651_1 CDM 0250 RC 00472-0825-16 NDC inpatient 1 UN 111.31 72.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.4 107.97 ALBUTEROL SULF 2 MG/5 ML SYRUP 50318651_1 CDM 0250 RC 00472-0825-16 NDC inpatient 1 UN 111.31 72.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.4 107.97 METRONIDAZOLE VAGINAL 0.75% GL 50318656_1 CDM 0250 RC 68682-0455-70 NDC inpatient 1 UN 387.41 251.82 AETNA AETNA 306.05 79 999999999 234.58 375.79 percent of total billed charges METRONIDAZOLE VAGINAL 0.75% GL 50318656_1 CDM 0250 RC 68682-0455-70 NDC inpatient 1 UN 387.41 251.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 251.82 65 999999999 234.58 375.79 percent of total billed charges METRONIDAZOLE VAGINAL 0.75% GL 50318656_1 CDM 0250 RC 68682-0455-70 NDC inpatient 1 UN 387.41 251.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 375.79 97 999999999 234.58 375.79 percent of total billed charges METRONIDAZOLE VAGINAL 0.75% GL 50318656_1 CDM 0250 RC 68682-0455-70 NDC inpatient 1 UN 387.41 251.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 267.31 69 999999999 234.58 375.79 percent of total billed charges METRONIDAZOLE VAGINAL 0.75% GL 50318656_1 CDM 0250 RC 68682-0455-70 NDC inpatient 1 UN 387.41 251.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 302.18 78 999999999 234.58 375.79 percent of total billed charges METRONIDAZOLE VAGINAL 0.75% GL 50318656_1 CDM 0250 RC 68682-0455-70 NDC inpatient 1 UN 387.41 251.82 SIHO - ALL PLANS SIHO - ALL PLANS 348.67 90 999999999 234.58 375.79 percent of total billed charges METRONIDAZOLE VAGINAL 0.75% GL 50318656_1 CDM 0250 RC 68682-0455-70 NDC inpatient 1 UN 387.41 251.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 234.58 60.55 999999999 234.58 375.79 percent of total billed charges METRONIDAZOLE VAGINAL 0.75% GL 50318656_1 CDM 0250 RC 68682-0455-70 NDC inpatient 1 UN 387.41 251.82 UMR - ALL PLANS UMR - ALL PLANS 271.19 70 999999999 234.58 375.79 percent of total billed charges METRONIDAZOLE VAGINAL 0.75% GL 50318656_1 CDM 0250 RC 68682-0455-70 NDC inpatient 1 UN 387.41 251.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 234.58 375.79 METRONIDAZOLE VAGINAL 0.75% GL 50318656_1 CDM 0250 RC 68682-0455-70 NDC inpatient 1 UN 387.41 251.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 234.58 375.79 METRONIDAZOLE VAGINAL 0.75% GL 50318656_1 CDM 0250 RC 68682-0455-70 NDC inpatient 1 UN 387.41 251.82 ANTHEM HMO ANTHEM HMO 999999999 234.58 375.79 METRONIDAZOLE VAGINAL 0.75% GL 50318656_1 CDM 0250 RC 68682-0455-70 NDC inpatient 1 UN 387.41 251.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 261.89 67.6 999999999 234.58 375.79 percent of total billed charges METRONIDAZOLE VAGINAL 0.75% GL 50318656_1 CDM 0250 RC 68682-0455-70 NDC inpatient 1 UN 387.41 251.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 234.58 375.79 METRONIDAZOLE VAGINAL 0.75% GL 50318656_1 CDM 0250 RC 68682-0455-70 NDC inpatient 1 UN 387.41 251.82 UHC - ALL PLANS UHC - ALL PLANS 999999999 234.58 375.79 NOREPINEPHRINE 4 MG/4 ML VIAL 50318671_1 CDM 0250 RC 00143-9318-10 NDC inpatient 1 UN 90.24 58.66 AETNA AETNA 71.29 79 999999999 54.64 87.53 percent of total billed charges NOREPINEPHRINE 4 MG/4 ML VIAL 50318671_1 CDM 0250 RC 00143-9318-10 NDC inpatient 1 UN 90.24 58.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.66 65 999999999 54.64 87.53 percent of total billed charges NOREPINEPHRINE 4 MG/4 ML VIAL 50318671_1 CDM 0250 RC 00143-9318-10 NDC inpatient 1 UN 90.24 58.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.53 97 999999999 54.64 87.53 percent of total billed charges NOREPINEPHRINE 4 MG/4 ML VIAL 50318671_1 CDM 0250 RC 00143-9318-10 NDC inpatient 1 UN 90.24 58.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.27 69 999999999 54.64 87.53 percent of total billed charges NOREPINEPHRINE 4 MG/4 ML VIAL 50318671_1 CDM 0250 RC 00143-9318-10 NDC inpatient 1 UN 90.24 58.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.39 78 999999999 54.64 87.53 percent of total billed charges NOREPINEPHRINE 4 MG/4 ML VIAL 50318671_1 CDM 0250 RC 00143-9318-10 NDC inpatient 1 UN 90.24 58.66 SIHO - ALL PLANS SIHO - ALL PLANS 81.22 90 999999999 54.64 87.53 percent of total billed charges NOREPINEPHRINE 4 MG/4 ML VIAL 50318671_1 CDM 0250 RC 00143-9318-10 NDC inpatient 1 UN 90.24 58.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.64 60.55 999999999 54.64 87.53 percent of total billed charges NOREPINEPHRINE 4 MG/4 ML VIAL 50318671_1 CDM 0250 RC 00143-9318-10 NDC inpatient 1 UN 90.24 58.66 UMR - ALL PLANS UMR - ALL PLANS 63.17 70 999999999 54.64 87.53 percent of total billed charges NOREPINEPHRINE 4 MG/4 ML VIAL 50318671_1 CDM 0250 RC 00143-9318-10 NDC inpatient 1 UN 90.24 58.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.64 87.53 NOREPINEPHRINE 4 MG/4 ML VIAL 50318671_1 CDM 0250 RC 00143-9318-10 NDC inpatient 1 UN 90.24 58.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.64 87.53 NOREPINEPHRINE 4 MG/4 ML VIAL 50318671_1 CDM 0250 RC 00143-9318-10 NDC inpatient 1 UN 90.24 58.66 ANTHEM HMO ANTHEM HMO 999999999 54.64 87.53 NOREPINEPHRINE 4 MG/4 ML VIAL 50318671_1 CDM 0250 RC 00143-9318-10 NDC inpatient 1 UN 90.24 58.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.64 87.53 NOREPINEPHRINE 4 MG/4 ML VIAL 50318671_1 CDM 0250 RC 00143-9318-10 NDC inpatient 1 UN 90.24 58.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 61 67.6 999999999 54.64 87.53 percent of total billed charges NOREPINEPHRINE 4 MG/4 ML VIAL 50318671_1 CDM 0250 RC 00143-9318-10 NDC inpatient 1 UN 90.24 58.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.64 87.53 IBUPROFEN 400 MG TABLET 50318678_1 CDM 0250 RC 60687-0446-01 NDC inpatient 300 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 400 MG TABLET 50318678_1 CDM 0250 RC 60687-0446-01 NDC inpatient 300 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 400 MG TABLET 50318678_1 CDM 0250 RC 60687-0446-01 NDC inpatient 300 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 400 MG TABLET 50318678_1 CDM 0250 RC 60687-0446-01 NDC inpatient 300 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 400 MG TABLET 50318678_1 CDM 0250 RC 60687-0446-01 NDC inpatient 300 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 400 MG TABLET 50318678_1 CDM 0250 RC 60687-0446-01 NDC inpatient 300 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 400 MG TABLET 50318678_1 CDM 0250 RC 60687-0446-01 NDC inpatient 300 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 400 MG TABLET 50318678_1 CDM 0250 RC 60687-0446-01 NDC inpatient 300 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 400 MG TABLET 50318678_1 CDM 0250 RC 60687-0446-01 NDC inpatient 300 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 IBUPROFEN 400 MG TABLET 50318678_1 CDM 0250 RC 60687-0446-01 NDC inpatient 300 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 IBUPROFEN 400 MG TABLET 50318678_1 CDM 0250 RC 60687-0446-01 NDC inpatient 300 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 IBUPROFEN 400 MG TABLET 50318678_1 CDM 0250 RC 60687-0446-01 NDC inpatient 300 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 IBUPROFEN 400 MG TABLET 50318678_1 CDM 0250 RC 60687-0446-01 NDC inpatient 300 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 400 MG TABLET 50318678_1 CDM 0250 RC 60687-0446-01 NDC inpatient 300 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 DRONABINOL 2.5 MG CAPSULE 50318855_1 CDM 0250 RC 42858-0867-06 NDC inpatient 1 UN 6.7 4.36 AETNA AETNA 5.29 79 999999999 4.06 6.5 percent of total billed charges DRONABINOL 2.5 MG CAPSULE 50318855_1 CDM 0250 RC 42858-0867-06 NDC inpatient 1 UN 6.7 4.36 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.36 65 999999999 4.06 6.5 percent of total billed charges DRONABINOL 2.5 MG CAPSULE 50318855_1 CDM 0250 RC 42858-0867-06 NDC inpatient 1 UN 6.7 4.36 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.5 97 999999999 4.06 6.5 percent of total billed charges DRONABINOL 2.5 MG CAPSULE 50318855_1 CDM 0250 RC 42858-0867-06 NDC inpatient 1 UN 6.7 4.36 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.62 69 999999999 4.06 6.5 percent of total billed charges DRONABINOL 2.5 MG CAPSULE 50318855_1 CDM 0250 RC 42858-0867-06 NDC inpatient 1 UN 6.7 4.36 HUMANA - ALL PLANS HUMANA - ALL PLANS 5.23 78 999999999 4.06 6.5 percent of total billed charges DRONABINOL 2.5 MG CAPSULE 50318855_1 CDM 0250 RC 42858-0867-06 NDC inpatient 1 UN 6.7 4.36 SIHO - ALL PLANS SIHO - ALL PLANS 6.03 90 999999999 4.06 6.5 percent of total billed charges DRONABINOL 2.5 MG CAPSULE 50318855_1 CDM 0250 RC 42858-0867-06 NDC inpatient 1 UN 6.7 4.36 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.06 60.55 999999999 4.06 6.5 percent of total billed charges DRONABINOL 2.5 MG CAPSULE 50318855_1 CDM 0250 RC 42858-0867-06 NDC inpatient 1 UN 6.7 4.36 UMR - ALL PLANS UMR - ALL PLANS 4.69 70 999999999 4.06 6.5 percent of total billed charges DRONABINOL 2.5 MG CAPSULE 50318855_1 CDM 0250 RC 42858-0867-06 NDC inpatient 1 UN 6.7 4.36 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.06 6.5 DRONABINOL 2.5 MG CAPSULE 50318855_1 CDM 0250 RC 42858-0867-06 NDC inpatient 1 UN 6.7 4.36 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.06 6.5 DRONABINOL 2.5 MG CAPSULE 50318855_1 CDM 0250 RC 42858-0867-06 NDC inpatient 1 UN 6.7 4.36 ANTHEM HMO ANTHEM HMO 999999999 4.06 6.5 DRONABINOL 2.5 MG CAPSULE 50318855_1 CDM 0250 RC 42858-0867-06 NDC inpatient 1 UN 6.7 4.36 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.06 6.5 DRONABINOL 2.5 MG CAPSULE 50318855_1 CDM 0250 RC 42858-0867-06 NDC inpatient 1 UN 6.7 4.36 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.53 67.6 999999999 4.06 6.5 percent of total billed charges DRONABINOL 2.5 MG CAPSULE 50318855_1 CDM 0250 RC 42858-0867-06 NDC inpatient 1 UN 6.7 4.36 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.06 6.5 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50318857_1 CDM 0258 RC 00264-1510-32 NDC J7060 HCPCS inpatient 1 UN 61.04 39.68 AETNA AETNA 48.22 79 999999999 36.96 59.21 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50318857_1 CDM 0258 RC 00264-1510-32 NDC J7060 HCPCS inpatient 1 UN 61.04 39.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.68 65 999999999 36.96 59.21 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50318857_1 CDM 0258 RC 00264-1510-32 NDC J7060 HCPCS inpatient 1 UN 61.04 39.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59.21 97 999999999 36.96 59.21 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50318857_1 CDM 0258 RC 00264-1510-32 NDC J7060 HCPCS inpatient 1 UN 61.04 39.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.12 69 999999999 36.96 59.21 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50318857_1 CDM 0258 RC 00264-1510-32 NDC J7060 HCPCS inpatient 1 UN 61.04 39.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.61 78 999999999 36.96 59.21 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50318857_1 CDM 0258 RC 00264-1510-32 NDC J7060 HCPCS inpatient 1 UN 61.04 39.68 SIHO - ALL PLANS SIHO - ALL PLANS 54.94 90 999999999 36.96 59.21 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50318857_1 CDM 0258 RC 00264-1510-32 NDC J7060 HCPCS inpatient 1 UN 61.04 39.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.96 60.55 999999999 36.96 59.21 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50318857_1 CDM 0258 RC 00264-1510-32 NDC J7060 HCPCS inpatient 1 UN 61.04 39.68 UMR - ALL PLANS UMR - ALL PLANS 42.73 70 999999999 36.96 59.21 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50318857_1 CDM 0258 RC 00264-1510-32 NDC J7060 HCPCS inpatient 1 UN 61.04 39.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.96 59.21 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50318857_1 CDM 0258 RC 00264-1510-32 NDC J7060 HCPCS inpatient 1 UN 61.04 39.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.96 59.21 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50318857_1 CDM 0258 RC 00264-1510-32 NDC J7060 HCPCS inpatient 1 UN 61.04 39.68 ANTHEM HMO ANTHEM HMO 999999999 36.96 59.21 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50318857_1 CDM 0258 RC 00264-1510-32 NDC J7060 HCPCS inpatient 1 UN 61.04 39.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.96 59.21 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50318857_1 CDM 0258 RC 00264-1510-32 NDC J7060 HCPCS inpatient 1 UN 61.04 39.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.26 67.6 999999999 36.96 59.21 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50318857_1 CDM 0258 RC 00264-1510-32 NDC J7060 HCPCS inpatient 1 UN 61.04 39.68 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.96 59.21 DICYCLOMINE 20 MG/2 ML AMPUL 50319179_1 CDM 0250 RC 17478-0015-02 NDC inpatient 1 UN 193.66 125.88 AETNA AETNA 152.99 79 999999999 117.26 187.85 percent of total billed charges DICYCLOMINE 20 MG/2 ML AMPUL 50319179_1 CDM 0250 RC 17478-0015-02 NDC inpatient 1 UN 193.66 125.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 125.88 65 999999999 117.26 187.85 percent of total billed charges DICYCLOMINE 20 MG/2 ML AMPUL 50319179_1 CDM 0250 RC 17478-0015-02 NDC inpatient 1 UN 193.66 125.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 187.85 97 999999999 117.26 187.85 percent of total billed charges DICYCLOMINE 20 MG/2 ML AMPUL 50319179_1 CDM 0250 RC 17478-0015-02 NDC inpatient 1 UN 193.66 125.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.63 69 999999999 117.26 187.85 percent of total billed charges DICYCLOMINE 20 MG/2 ML AMPUL 50319179_1 CDM 0250 RC 17478-0015-02 NDC inpatient 1 UN 193.66 125.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 151.05 78 999999999 117.26 187.85 percent of total billed charges DICYCLOMINE 20 MG/2 ML AMPUL 50319179_1 CDM 0250 RC 17478-0015-02 NDC inpatient 1 UN 193.66 125.88 SIHO - ALL PLANS SIHO - ALL PLANS 174.29 90 999999999 117.26 187.85 percent of total billed charges DICYCLOMINE 20 MG/2 ML AMPUL 50319179_1 CDM 0250 RC 17478-0015-02 NDC inpatient 1 UN 193.66 125.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 117.26 60.55 999999999 117.26 187.85 percent of total billed charges DICYCLOMINE 20 MG/2 ML AMPUL 50319179_1 CDM 0250 RC 17478-0015-02 NDC inpatient 1 UN 193.66 125.88 UMR - ALL PLANS UMR - ALL PLANS 135.56 70 999999999 117.26 187.85 percent of total billed charges DICYCLOMINE 20 MG/2 ML AMPUL 50319179_1 CDM 0250 RC 17478-0015-02 NDC inpatient 1 UN 193.66 125.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 117.26 187.85 DICYCLOMINE 20 MG/2 ML AMPUL 50319179_1 CDM 0250 RC 17478-0015-02 NDC inpatient 1 UN 193.66 125.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 117.26 187.85 DICYCLOMINE 20 MG/2 ML AMPUL 50319179_1 CDM 0250 RC 17478-0015-02 NDC inpatient 1 UN 193.66 125.88 ANTHEM HMO ANTHEM HMO 999999999 117.26 187.85 DICYCLOMINE 20 MG/2 ML AMPUL 50319179_1 CDM 0250 RC 17478-0015-02 NDC inpatient 1 UN 193.66 125.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 117.26 187.85 DICYCLOMINE 20 MG/2 ML AMPUL 50319179_1 CDM 0250 RC 17478-0015-02 NDC inpatient 1 UN 193.66 125.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 130.91 67.6 999999999 117.26 187.85 percent of total billed charges DICYCLOMINE 20 MG/2 ML AMPUL 50319179_1 CDM 0250 RC 17478-0015-02 NDC inpatient 1 UN 193.66 125.88 UHC - ALL PLANS UHC - ALL PLANS 999999999 117.26 187.85 Analysis for antibody to protozoa (parasite) 50323847_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 AETNA AETNA 152.47 79 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to protozoa (parasite) 50323847_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 125.45 65 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to protozoa (parasite) 50323847_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 187.21 97 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to protozoa (parasite) 50323847_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.17 69 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to protozoa (parasite) 50323847_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 150.54 78 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to protozoa (parasite) 50323847_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 SIHO - ALL PLANS SIHO - ALL PLANS 173.7 90 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to protozoa (parasite) 50323847_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.86 60.55 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to protozoa (parasite) 50323847_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 UMR - ALL PLANS UMR - ALL PLANS 135.1 70 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to protozoa (parasite) 50323847_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.86 187.21 Analysis for antibody to protozoa (parasite) 50323847_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.86 187.21 Analysis for antibody to protozoa (parasite) 50323847_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 ANTHEM HMO ANTHEM HMO 999999999 116.86 187.21 Analysis for antibody to protozoa (parasite) 50323847_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.86 187.21 Analysis for antibody to protozoa (parasite) 50323847_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 130.47 67.6 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to protozoa (parasite) 50323847_1 CDM 0301 RC 86753 HCPCS inpatient 193 125.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.86 187.21 PREGABALIN 50 MG CAPSULE 50324270_1 CDM 0250 RC 60687-0484-01 NDC inpatient 1 UN 1.47 0.96 AETNA AETNA 1.16 79 999999999 0.89 1.43 percent of total billed charges PREGABALIN 50 MG CAPSULE 50324270_1 CDM 0250 RC 60687-0484-01 NDC inpatient 1 UN 1.47 0.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.96 65 999999999 0.89 1.43 percent of total billed charges PREGABALIN 50 MG CAPSULE 50324270_1 CDM 0250 RC 60687-0484-01 NDC inpatient 1 UN 1.47 0.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.43 97 999999999 0.89 1.43 percent of total billed charges PREGABALIN 50 MG CAPSULE 50324270_1 CDM 0250 RC 60687-0484-01 NDC inpatient 1 UN 1.47 0.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.01 69 999999999 0.89 1.43 percent of total billed charges PREGABALIN 50 MG CAPSULE 50324270_1 CDM 0250 RC 60687-0484-01 NDC inpatient 1 UN 1.47 0.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.15 78 999999999 0.89 1.43 percent of total billed charges PREGABALIN 50 MG CAPSULE 50324270_1 CDM 0250 RC 60687-0484-01 NDC inpatient 1 UN 1.47 0.96 SIHO - ALL PLANS SIHO - ALL PLANS 1.32 90 999999999 0.89 1.43 percent of total billed charges PREGABALIN 50 MG CAPSULE 50324270_1 CDM 0250 RC 60687-0484-01 NDC inpatient 1 UN 1.47 0.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.89 60.55 999999999 0.89 1.43 percent of total billed charges PREGABALIN 50 MG CAPSULE 50324270_1 CDM 0250 RC 60687-0484-01 NDC inpatient 1 UN 1.47 0.96 UMR - ALL PLANS UMR - ALL PLANS 1.03 70 999999999 0.89 1.43 percent of total billed charges PREGABALIN 50 MG CAPSULE 50324270_1 CDM 0250 RC 60687-0484-01 NDC inpatient 1 UN 1.47 0.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.89 1.43 PREGABALIN 50 MG CAPSULE 50324270_1 CDM 0250 RC 60687-0484-01 NDC inpatient 1 UN 1.47 0.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.89 1.43 PREGABALIN 50 MG CAPSULE 50324270_1 CDM 0250 RC 60687-0484-01 NDC inpatient 1 UN 1.47 0.96 ANTHEM HMO ANTHEM HMO 999999999 0.89 1.43 PREGABALIN 50 MG CAPSULE 50324270_1 CDM 0250 RC 60687-0484-01 NDC inpatient 1 UN 1.47 0.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.89 1.43 PREGABALIN 50 MG CAPSULE 50324270_1 CDM 0250 RC 60687-0484-01 NDC inpatient 1 UN 1.47 0.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.99 67.6 999999999 0.89 1.43 percent of total billed charges PREGABALIN 50 MG CAPSULE 50324270_1 CDM 0250 RC 60687-0484-01 NDC inpatient 1 UN 1.47 0.96 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.89 1.43 NIFEDIPINE ER 30 MG TABLET 50325158_1 CDM 0250 RC 50268-0597-15 NDC inpatient 1 UN 3.11 2.02 AETNA AETNA 2.46 79 999999999 1.88 3.02 percent of total billed charges NIFEDIPINE ER 30 MG TABLET 50325158_1 CDM 0250 RC 50268-0597-15 NDC inpatient 1 UN 3.11 2.02 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.02 65 999999999 1.88 3.02 percent of total billed charges NIFEDIPINE ER 30 MG TABLET 50325158_1 CDM 0250 RC 50268-0597-15 NDC inpatient 1 UN 3.11 2.02 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.02 97 999999999 1.88 3.02 percent of total billed charges NIFEDIPINE ER 30 MG TABLET 50325158_1 CDM 0250 RC 50268-0597-15 NDC inpatient 1 UN 3.11 2.02 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.15 69 999999999 1.88 3.02 percent of total billed charges NIFEDIPINE ER 30 MG TABLET 50325158_1 CDM 0250 RC 50268-0597-15 NDC inpatient 1 UN 3.11 2.02 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.43 78 999999999 1.88 3.02 percent of total billed charges NIFEDIPINE ER 30 MG TABLET 50325158_1 CDM 0250 RC 50268-0597-15 NDC inpatient 1 UN 3.11 2.02 SIHO - ALL PLANS SIHO - ALL PLANS 2.8 90 999999999 1.88 3.02 percent of total billed charges NIFEDIPINE ER 30 MG TABLET 50325158_1 CDM 0250 RC 50268-0597-15 NDC inpatient 1 UN 3.11 2.02 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.88 60.55 999999999 1.88 3.02 percent of total billed charges NIFEDIPINE ER 30 MG TABLET 50325158_1 CDM 0250 RC 50268-0597-15 NDC inpatient 1 UN 3.11 2.02 UMR - ALL PLANS UMR - ALL PLANS 2.18 70 999999999 1.88 3.02 percent of total billed charges NIFEDIPINE ER 30 MG TABLET 50325158_1 CDM 0250 RC 50268-0597-15 NDC inpatient 1 UN 3.11 2.02 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.88 3.02 NIFEDIPINE ER 30 MG TABLET 50325158_1 CDM 0250 RC 50268-0597-15 NDC inpatient 1 UN 3.11 2.02 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.88 3.02 NIFEDIPINE ER 30 MG TABLET 50325158_1 CDM 0250 RC 50268-0597-15 NDC inpatient 1 UN 3.11 2.02 ANTHEM HMO ANTHEM HMO 999999999 1.88 3.02 NIFEDIPINE ER 30 MG TABLET 50325158_1 CDM 0250 RC 50268-0597-15 NDC inpatient 1 UN 3.11 2.02 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.88 3.02 NIFEDIPINE ER 30 MG TABLET 50325158_1 CDM 0250 RC 50268-0597-15 NDC inpatient 1 UN 3.11 2.02 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.1 67.6 999999999 1.88 3.02 percent of total billed charges NIFEDIPINE ER 30 MG TABLET 50325158_1 CDM 0250 RC 50268-0597-15 NDC inpatient 1 UN 3.11 2.02 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.88 3.02 NICOTINE 14 MG/24HR PATCH 50325221_1 CDM 0250 RC 46122-0352-74 NDC inpatient 510 UN 4.83 3.14 AETNA AETNA 3.82 79 999999999 2.92 4.69 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50325221_1 CDM 0250 RC 46122-0352-74 NDC inpatient 510 UN 4.83 3.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.14 65 999999999 2.92 4.69 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50325221_1 CDM 0250 RC 46122-0352-74 NDC inpatient 510 UN 4.83 3.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4.69 97 999999999 2.92 4.69 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50325221_1 CDM 0250 RC 46122-0352-74 NDC inpatient 510 UN 4.83 3.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.33 69 999999999 2.92 4.69 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50325221_1 CDM 0250 RC 46122-0352-74 NDC inpatient 510 UN 4.83 3.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.77 78 999999999 2.92 4.69 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50325221_1 CDM 0250 RC 46122-0352-74 NDC inpatient 510 UN 4.83 3.14 SIHO - ALL PLANS SIHO - ALL PLANS 4.35 90 999999999 2.92 4.69 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50325221_1 CDM 0250 RC 46122-0352-74 NDC inpatient 510 UN 4.83 3.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.92 60.55 999999999 2.92 4.69 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50325221_1 CDM 0250 RC 46122-0352-74 NDC inpatient 510 UN 4.83 3.14 UMR - ALL PLANS UMR - ALL PLANS 3.38 70 999999999 2.92 4.69 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50325221_1 CDM 0250 RC 46122-0352-74 NDC inpatient 510 UN 4.83 3.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.92 4.69 NICOTINE 14 MG/24HR PATCH 50325221_1 CDM 0250 RC 46122-0352-74 NDC inpatient 510 UN 4.83 3.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.92 4.69 NICOTINE 14 MG/24HR PATCH 50325221_1 CDM 0250 RC 46122-0352-74 NDC inpatient 510 UN 4.83 3.14 ANTHEM HMO ANTHEM HMO 999999999 2.92 4.69 NICOTINE 14 MG/24HR PATCH 50325221_1 CDM 0250 RC 46122-0352-74 NDC inpatient 510 UN 4.83 3.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.92 4.69 NICOTINE 14 MG/24HR PATCH 50325221_1 CDM 0250 RC 46122-0352-74 NDC inpatient 510 UN 4.83 3.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.27 67.6 999999999 2.92 4.69 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50325221_1 CDM 0250 RC 46122-0352-74 NDC inpatient 510 UN 4.83 3.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.92 4.69 "Detection test by nucleic acid for organism, amplified probe technique" 50328155_1 CDM 0301 RC 87798 HCPCS inpatient 108 70.2 AETNA AETNA 85.32 79 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50328155_1 CDM 0301 RC 87798 HCPCS inpatient 108 70.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.2 65 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50328155_1 CDM 0301 RC 87798 HCPCS inpatient 108 70.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 104.76 97 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50328155_1 CDM 0301 RC 87798 HCPCS inpatient 108 70.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 74.52 69 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50328155_1 CDM 0301 RC 87798 HCPCS inpatient 108 70.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 84.24 78 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50328155_1 CDM 0301 RC 87798 HCPCS inpatient 108 70.2 SIHO - ALL PLANS SIHO - ALL PLANS 97.2 90 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50328155_1 CDM 0301 RC 87798 HCPCS inpatient 108 70.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 65.39 60.55 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50328155_1 CDM 0301 RC 87798 HCPCS inpatient 108 70.2 UMR - ALL PLANS UMR - ALL PLANS 75.6 70 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50328155_1 CDM 0301 RC 87798 HCPCS inpatient 108 70.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 65.39 104.76 "Detection test by nucleic acid for organism, amplified probe technique" 50328155_1 CDM 0301 RC 87798 HCPCS inpatient 108 70.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 65.39 104.76 "Detection test by nucleic acid for organism, amplified probe technique" 50328155_1 CDM 0301 RC 87798 HCPCS inpatient 108 70.2 ANTHEM HMO ANTHEM HMO 999999999 65.39 104.76 "Detection test by nucleic acid for organism, amplified probe technique" 50328155_1 CDM 0301 RC 87798 HCPCS inpatient 108 70.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 65.39 104.76 "Detection test by nucleic acid for organism, amplified probe technique" 50328155_1 CDM 0301 RC 87798 HCPCS inpatient 108 70.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.01 67.6 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50328155_1 CDM 0301 RC 87798 HCPCS inpatient 108 70.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 65.39 104.76 Analysis for antibody to Bartonella (bacteria) 50328235_1 CDM 0301 RC 86611 HCPCS inpatient 332 215.8 AETNA AETNA 262.28 79 999999999 201.03 322.04 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 50328235_1 CDM 0301 RC 86611 HCPCS inpatient 332 215.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 215.8 65 999999999 201.03 322.04 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 50328235_1 CDM 0301 RC 86611 HCPCS inpatient 332 215.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 322.04 97 999999999 201.03 322.04 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 50328235_1 CDM 0301 RC 86611 HCPCS inpatient 332 215.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 229.08 69 999999999 201.03 322.04 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 50328235_1 CDM 0301 RC 86611 HCPCS inpatient 332 215.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 258.96 78 999999999 201.03 322.04 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 50328235_1 CDM 0301 RC 86611 HCPCS inpatient 332 215.8 SIHO - ALL PLANS SIHO - ALL PLANS 298.8 90 999999999 201.03 322.04 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 50328235_1 CDM 0301 RC 86611 HCPCS inpatient 332 215.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 201.03 60.55 999999999 201.03 322.04 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 50328235_1 CDM 0301 RC 86611 HCPCS inpatient 332 215.8 UMR - ALL PLANS UMR - ALL PLANS 232.4 70 999999999 201.03 322.04 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 50328235_1 CDM 0301 RC 86611 HCPCS inpatient 332 215.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 201.03 322.04 Analysis for antibody to Bartonella (bacteria) 50328235_1 CDM 0301 RC 86611 HCPCS inpatient 332 215.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 201.03 322.04 Analysis for antibody to Bartonella (bacteria) 50328235_1 CDM 0301 RC 86611 HCPCS inpatient 332 215.8 ANTHEM HMO ANTHEM HMO 999999999 201.03 322.04 Analysis for antibody to Bartonella (bacteria) 50328235_1 CDM 0301 RC 86611 HCPCS inpatient 332 215.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 201.03 322.04 Analysis for antibody to Bartonella (bacteria) 50328235_1 CDM 0301 RC 86611 HCPCS inpatient 332 215.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 224.43 67.6 999999999 201.03 322.04 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 50328235_1 CDM 0301 RC 86611 HCPCS inpatient 332 215.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 201.03 322.04 "MYCOPHENOLIC ACID, ORAL, 180 MG" 50328649_1 CDM 0250 RC 16729-0189-29 NDC J7518 HCPCS inpatient 2 UN 4.77 3.1 AETNA AETNA 3.77 79 999999999 2.89 4.63 percent of total billed charges "MYCOPHENOLIC ACID, ORAL, 180 MG" 50328649_1 CDM 0250 RC 16729-0189-29 NDC J7518 HCPCS inpatient 2 UN 4.77 3.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.1 65 999999999 2.89 4.63 percent of total billed charges "MYCOPHENOLIC ACID, ORAL, 180 MG" 50328649_1 CDM 0250 RC 16729-0189-29 NDC J7518 HCPCS inpatient 2 UN 4.77 3.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4.63 97 999999999 2.89 4.63 percent of total billed charges "MYCOPHENOLIC ACID, ORAL, 180 MG" 50328649_1 CDM 0250 RC 16729-0189-29 NDC J7518 HCPCS inpatient 2 UN 4.77 3.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.29 69 999999999 2.89 4.63 percent of total billed charges "MYCOPHENOLIC ACID, ORAL, 180 MG" 50328649_1 CDM 0250 RC 16729-0189-29 NDC J7518 HCPCS inpatient 2 UN 4.77 3.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.72 78 999999999 2.89 4.63 percent of total billed charges "MYCOPHENOLIC ACID, ORAL, 180 MG" 50328649_1 CDM 0250 RC 16729-0189-29 NDC J7518 HCPCS inpatient 2 UN 4.77 3.1 SIHO - ALL PLANS SIHO - ALL PLANS 4.29 90 999999999 2.89 4.63 percent of total billed charges "MYCOPHENOLIC ACID, ORAL, 180 MG" 50328649_1 CDM 0250 RC 16729-0189-29 NDC J7518 HCPCS inpatient 2 UN 4.77 3.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.89 60.55 999999999 2.89 4.63 percent of total billed charges "MYCOPHENOLIC ACID, ORAL, 180 MG" 50328649_1 CDM 0250 RC 16729-0189-29 NDC J7518 HCPCS inpatient 2 UN 4.77 3.1 UMR - ALL PLANS UMR - ALL PLANS 3.34 70 999999999 2.89 4.63 percent of total billed charges "MYCOPHENOLIC ACID, ORAL, 180 MG" 50328649_1 CDM 0250 RC 16729-0189-29 NDC J7518 HCPCS inpatient 2 UN 4.77 3.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.89 4.63 "MYCOPHENOLIC ACID, ORAL, 180 MG" 50328649_1 CDM 0250 RC 16729-0189-29 NDC J7518 HCPCS inpatient 2 UN 4.77 3.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.89 4.63 "MYCOPHENOLIC ACID, ORAL, 180 MG" 50328649_1 CDM 0250 RC 16729-0189-29 NDC J7518 HCPCS inpatient 2 UN 4.77 3.1 ANTHEM HMO ANTHEM HMO 999999999 2.89 4.63 "MYCOPHENOLIC ACID, ORAL, 180 MG" 50328649_1 CDM 0250 RC 16729-0189-29 NDC J7518 HCPCS inpatient 2 UN 4.77 3.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.89 4.63 "MYCOPHENOLIC ACID, ORAL, 180 MG" 50328649_1 CDM 0250 RC 16729-0189-29 NDC J7518 HCPCS inpatient 2 UN 4.77 3.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.22 67.6 999999999 2.89 4.63 percent of total billed charges "MYCOPHENOLIC ACID, ORAL, 180 MG" 50328649_1 CDM 0250 RC 16729-0189-29 NDC J7518 HCPCS inpatient 2 UN 4.77 3.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.89 4.63 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50328662_1 CDM 0250 RC 67457-0423-12 NDC J1100 HCPCS inpatient 4 UN 10.47 6.81 AETNA AETNA 8.27 79 999999999 6.34 10.16 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50328662_1 CDM 0250 RC 67457-0423-12 NDC J1100 HCPCS inpatient 4 UN 10.47 6.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.81 65 999999999 6.34 10.16 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50328662_1 CDM 0250 RC 67457-0423-12 NDC J1100 HCPCS inpatient 4 UN 10.47 6.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10.16 97 999999999 6.34 10.16 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50328662_1 CDM 0250 RC 67457-0423-12 NDC J1100 HCPCS inpatient 4 UN 10.47 6.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.22 69 999999999 6.34 10.16 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50328662_1 CDM 0250 RC 67457-0423-12 NDC J1100 HCPCS inpatient 4 UN 10.47 6.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 8.17 78 999999999 6.34 10.16 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50328662_1 CDM 0250 RC 67457-0423-12 NDC J1100 HCPCS inpatient 4 UN 10.47 6.81 SIHO - ALL PLANS SIHO - ALL PLANS 9.42 90 999999999 6.34 10.16 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50328662_1 CDM 0250 RC 67457-0423-12 NDC J1100 HCPCS inpatient 4 UN 10.47 6.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.34 60.55 999999999 6.34 10.16 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50328662_1 CDM 0250 RC 67457-0423-12 NDC J1100 HCPCS inpatient 4 UN 10.47 6.81 UMR - ALL PLANS UMR - ALL PLANS 7.33 70 999999999 6.34 10.16 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50328662_1 CDM 0250 RC 67457-0423-12 NDC J1100 HCPCS inpatient 4 UN 10.47 6.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.34 10.16 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50328662_1 CDM 0250 RC 67457-0423-12 NDC J1100 HCPCS inpatient 4 UN 10.47 6.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.34 10.16 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50328662_1 CDM 0250 RC 67457-0423-12 NDC J1100 HCPCS inpatient 4 UN 10.47 6.81 ANTHEM HMO ANTHEM HMO 999999999 6.34 10.16 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50328662_1 CDM 0250 RC 67457-0423-12 NDC J1100 HCPCS inpatient 4 UN 10.47 6.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.34 10.16 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50328662_1 CDM 0250 RC 67457-0423-12 NDC J1100 HCPCS inpatient 4 UN 10.47 6.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 7.08 67.6 999999999 6.34 10.16 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 50328662_1 CDM 0250 RC 67457-0423-12 NDC J1100 HCPCS inpatient 4 UN 10.47 6.81 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.34 10.16 CHLORDIAZEPOXIDE 10 MG CAPSULE 50329652_1 CDM 0250 RC 00555-0033-02 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 10 MG CAPSULE 50329652_1 CDM 0250 RC 00555-0033-02 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 10 MG CAPSULE 50329652_1 CDM 0250 RC 00555-0033-02 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 10 MG CAPSULE 50329652_1 CDM 0250 RC 00555-0033-02 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 10 MG CAPSULE 50329652_1 CDM 0250 RC 00555-0033-02 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 10 MG CAPSULE 50329652_1 CDM 0250 RC 00555-0033-02 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 10 MG CAPSULE 50329652_1 CDM 0250 RC 00555-0033-02 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 10 MG CAPSULE 50329652_1 CDM 0250 RC 00555-0033-02 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 10 MG CAPSULE 50329652_1 CDM 0250 RC 00555-0033-02 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CHLORDIAZEPOXIDE 10 MG CAPSULE 50329652_1 CDM 0250 RC 00555-0033-02 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CHLORDIAZEPOXIDE 10 MG CAPSULE 50329652_1 CDM 0250 RC 00555-0033-02 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CHLORDIAZEPOXIDE 10 MG CAPSULE 50329652_1 CDM 0250 RC 00555-0033-02 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CHLORDIAZEPOXIDE 10 MG CAPSULE 50329652_1 CDM 0250 RC 00555-0033-02 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CHLORDIAZEPOXIDE 10 MG CAPSULE 50329652_1 CDM 0250 RC 00555-0033-02 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50331518_1 CDM 0250 RC 76045-0009-06 NDC J1170 HCPCS inpatient 1 UN 38.26 24.87 AETNA AETNA 30.23 79 999999999 23.17 37.11 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50331518_1 CDM 0250 RC 76045-0009-06 NDC J1170 HCPCS inpatient 1 UN 38.26 24.87 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.87 65 999999999 23.17 37.11 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50331518_1 CDM 0250 RC 76045-0009-06 NDC J1170 HCPCS inpatient 1 UN 38.26 24.87 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37.11 97 999999999 23.17 37.11 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50331518_1 CDM 0250 RC 76045-0009-06 NDC J1170 HCPCS inpatient 1 UN 38.26 24.87 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.4 69 999999999 23.17 37.11 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50331518_1 CDM 0250 RC 76045-0009-06 NDC J1170 HCPCS inpatient 1 UN 38.26 24.87 HUMANA - ALL PLANS HUMANA - ALL PLANS 29.84 78 999999999 23.17 37.11 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50331518_1 CDM 0250 RC 76045-0009-06 NDC J1170 HCPCS inpatient 1 UN 38.26 24.87 SIHO - ALL PLANS SIHO - ALL PLANS 34.43 90 999999999 23.17 37.11 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50331518_1 CDM 0250 RC 76045-0009-06 NDC J1170 HCPCS inpatient 1 UN 38.26 24.87 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.17 60.55 999999999 23.17 37.11 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50331518_1 CDM 0250 RC 76045-0009-06 NDC J1170 HCPCS inpatient 1 UN 38.26 24.87 UMR - ALL PLANS UMR - ALL PLANS 26.78 70 999999999 23.17 37.11 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50331518_1 CDM 0250 RC 76045-0009-06 NDC J1170 HCPCS inpatient 1 UN 38.26 24.87 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.17 37.11 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50331518_1 CDM 0250 RC 76045-0009-06 NDC J1170 HCPCS inpatient 1 UN 38.26 24.87 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.17 37.11 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50331518_1 CDM 0250 RC 76045-0009-06 NDC J1170 HCPCS inpatient 1 UN 38.26 24.87 ANTHEM HMO ANTHEM HMO 999999999 23.17 37.11 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50331518_1 CDM 0250 RC 76045-0009-06 NDC J1170 HCPCS inpatient 1 UN 38.26 24.87 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.17 37.11 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50331518_1 CDM 0250 RC 76045-0009-06 NDC J1170 HCPCS inpatient 1 UN 38.26 24.87 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.86 67.6 999999999 23.17 37.11 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50331518_1 CDM 0250 RC 76045-0009-06 NDC J1170 HCPCS inpatient 1 UN 38.26 24.87 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.17 37.11 "Chromosome analysis for genetic defects, analyze 20-25 cells" 50334854_1 CDM 0300 RC 88264 HCPCS inpatient 487 316.55 AETNA AETNA 384.73 79 999999999 294.88 472.39 percent of total billed charges "Chromosome analysis for genetic defects, analyze 20-25 cells" 50334854_1 CDM 0300 RC 88264 HCPCS inpatient 487 316.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 316.55 65 999999999 294.88 472.39 percent of total billed charges "Chromosome analysis for genetic defects, analyze 20-25 cells" 50334854_1 CDM 0300 RC 88264 HCPCS inpatient 487 316.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 472.39 97 999999999 294.88 472.39 percent of total billed charges "Chromosome analysis for genetic defects, analyze 20-25 cells" 50334854_1 CDM 0300 RC 88264 HCPCS inpatient 487 316.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 336.03 69 999999999 294.88 472.39 percent of total billed charges "Chromosome analysis for genetic defects, analyze 20-25 cells" 50334854_1 CDM 0300 RC 88264 HCPCS inpatient 487 316.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 379.86 78 999999999 294.88 472.39 percent of total billed charges "Chromosome analysis for genetic defects, analyze 20-25 cells" 50334854_1 CDM 0300 RC 88264 HCPCS inpatient 487 316.55 SIHO - ALL PLANS SIHO - ALL PLANS 438.3 90 999999999 294.88 472.39 percent of total billed charges "Chromosome analysis for genetic defects, analyze 20-25 cells" 50334854_1 CDM 0300 RC 88264 HCPCS inpatient 487 316.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 294.88 60.55 999999999 294.88 472.39 percent of total billed charges "Chromosome analysis for genetic defects, analyze 20-25 cells" 50334854_1 CDM 0300 RC 88264 HCPCS inpatient 487 316.55 UMR - ALL PLANS UMR - ALL PLANS 340.9 70 999999999 294.88 472.39 percent of total billed charges "Chromosome analysis for genetic defects, analyze 20-25 cells" 50334854_1 CDM 0300 RC 88264 HCPCS inpatient 487 316.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 294.88 472.39 "Chromosome analysis for genetic defects, analyze 20-25 cells" 50334854_1 CDM 0300 RC 88264 HCPCS inpatient 487 316.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 294.88 472.39 "Chromosome analysis for genetic defects, analyze 20-25 cells" 50334854_1 CDM 0300 RC 88264 HCPCS inpatient 487 316.55 ANTHEM HMO ANTHEM HMO 999999999 294.88 472.39 "Chromosome analysis for genetic defects, analyze 20-25 cells" 50334854_1 CDM 0300 RC 88264 HCPCS inpatient 487 316.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 294.88 472.39 "Chromosome analysis for genetic defects, analyze 20-25 cells" 50334854_1 CDM 0300 RC 88264 HCPCS inpatient 487 316.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 329.21 67.6 999999999 294.88 472.39 percent of total billed charges "Chromosome analysis for genetic defects, analyze 20-25 cells" 50334854_1 CDM 0300 RC 88264 HCPCS inpatient 487 316.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 294.88 472.39 Measurement of substance using immunoassay technique 50335131_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 AETNA AETNA 78.21 79 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 50335131_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 64.35 65 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 50335131_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 96.03 97 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 50335131_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 68.31 69 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 50335131_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 77.22 78 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 50335131_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 SIHO - ALL PLANS SIHO - ALL PLANS 89.1 90 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 50335131_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.94 60.55 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 50335131_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 UMR - ALL PLANS UMR - ALL PLANS 69.3 70 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 50335131_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.94 96.03 Measurement of substance using immunoassay technique 50335131_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.94 96.03 Measurement of substance using immunoassay technique 50335131_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM HMO ANTHEM HMO 999999999 59.94 96.03 Measurement of substance using immunoassay technique 50335131_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.94 96.03 Measurement of substance using immunoassay technique 50335131_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.92 67.6 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 50335131_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.94 96.03 "DACARBAZINE, 100 MG" 50335163_1 CDM 0636 RC 63323-0128-20 NDC J9130 HCPCS inpatient 2 UN 39.22 25.49 AETNA AETNA 30.98 79 999999999 23.75 38.04 percent of total billed charges "DACARBAZINE, 100 MG" 50335163_1 CDM 0636 RC 63323-0128-20 NDC J9130 HCPCS inpatient 2 UN 39.22 25.49 SELF PAY DISCOUNT SELF PAY DISCOUNT 25.49 65 999999999 23.75 38.04 percent of total billed charges "DACARBAZINE, 100 MG" 50335163_1 CDM 0636 RC 63323-0128-20 NDC J9130 HCPCS inpatient 2 UN 39.22 25.49 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 38.04 97 999999999 23.75 38.04 percent of total billed charges "DACARBAZINE, 100 MG" 50335163_1 CDM 0636 RC 63323-0128-20 NDC J9130 HCPCS inpatient 2 UN 39.22 25.49 ENCORE - ALL PLANS ENCORE - ALL PLANS 27.06 69 999999999 23.75 38.04 percent of total billed charges "DACARBAZINE, 100 MG" 50335163_1 CDM 0636 RC 63323-0128-20 NDC J9130 HCPCS inpatient 2 UN 39.22 25.49 HUMANA - ALL PLANS HUMANA - ALL PLANS 30.59 78 999999999 23.75 38.04 percent of total billed charges "DACARBAZINE, 100 MG" 50335163_1 CDM 0636 RC 63323-0128-20 NDC J9130 HCPCS inpatient 2 UN 39.22 25.49 SIHO - ALL PLANS SIHO - ALL PLANS 35.3 90 999999999 23.75 38.04 percent of total billed charges "DACARBAZINE, 100 MG" 50335163_1 CDM 0636 RC 63323-0128-20 NDC J9130 HCPCS inpatient 2 UN 39.22 25.49 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.75 60.55 999999999 23.75 38.04 percent of total billed charges "DACARBAZINE, 100 MG" 50335163_1 CDM 0636 RC 63323-0128-20 NDC J9130 HCPCS inpatient 2 UN 39.22 25.49 UMR - ALL PLANS UMR - ALL PLANS 27.45 70 999999999 23.75 38.04 percent of total billed charges "DACARBAZINE, 100 MG" 50335163_1 CDM 0636 RC 63323-0128-20 NDC J9130 HCPCS inpatient 2 UN 39.22 25.49 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.75 38.04 "DACARBAZINE, 100 MG" 50335163_1 CDM 0636 RC 63323-0128-20 NDC J9130 HCPCS inpatient 2 UN 39.22 25.49 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.75 38.04 "DACARBAZINE, 100 MG" 50335163_1 CDM 0636 RC 63323-0128-20 NDC J9130 HCPCS inpatient 2 UN 39.22 25.49 ANTHEM HMO ANTHEM HMO 999999999 23.75 38.04 "DACARBAZINE, 100 MG" 50335163_1 CDM 0636 RC 63323-0128-20 NDC J9130 HCPCS inpatient 2 UN 39.22 25.49 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.75 38.04 "DACARBAZINE, 100 MG" 50335163_1 CDM 0636 RC 63323-0128-20 NDC J9130 HCPCS inpatient 2 UN 39.22 25.49 CIGNA - ALL PLANS CIGNA - ALL PLANS 26.51 67.6 999999999 23.75 38.04 percent of total billed charges "DACARBAZINE, 100 MG" 50335163_1 CDM 0636 RC 63323-0128-20 NDC J9130 HCPCS inpatient 2 UN 39.22 25.49 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.75 38.04 Molecular pathology procedure 50335507_1 CDM 0302 RC 81479 HCPCS inpatient 393 255.45 AETNA AETNA 310.47 79 999999999 237.96 381.21 percent of total billed charges Molecular pathology procedure 50335507_1 CDM 0302 RC 81479 HCPCS inpatient 393 255.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 255.45 65 999999999 237.96 381.21 percent of total billed charges Molecular pathology procedure 50335507_1 CDM 0302 RC 81479 HCPCS inpatient 393 255.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 381.21 97 999999999 237.96 381.21 percent of total billed charges Molecular pathology procedure 50335507_1 CDM 0302 RC 81479 HCPCS inpatient 393 255.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 271.17 69 999999999 237.96 381.21 percent of total billed charges Molecular pathology procedure 50335507_1 CDM 0302 RC 81479 HCPCS inpatient 393 255.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 306.54 78 999999999 237.96 381.21 percent of total billed charges Molecular pathology procedure 50335507_1 CDM 0302 RC 81479 HCPCS inpatient 393 255.45 SIHO - ALL PLANS SIHO - ALL PLANS 353.7 90 999999999 237.96 381.21 percent of total billed charges Molecular pathology procedure 50335507_1 CDM 0302 RC 81479 HCPCS inpatient 393 255.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 237.96 60.55 999999999 237.96 381.21 percent of total billed charges Molecular pathology procedure 50335507_1 CDM 0302 RC 81479 HCPCS inpatient 393 255.45 UMR - ALL PLANS UMR - ALL PLANS 275.1 70 999999999 237.96 381.21 percent of total billed charges Molecular pathology procedure 50335507_1 CDM 0302 RC 81479 HCPCS inpatient 393 255.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 237.96 381.21 Molecular pathology procedure 50335507_1 CDM 0302 RC 81479 HCPCS inpatient 393 255.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 237.96 381.21 Molecular pathology procedure 50335507_1 CDM 0302 RC 81479 HCPCS inpatient 393 255.45 ANTHEM HMO ANTHEM HMO 999999999 237.96 381.21 Molecular pathology procedure 50335507_1 CDM 0302 RC 81479 HCPCS inpatient 393 255.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 237.96 381.21 Molecular pathology procedure 50335507_1 CDM 0302 RC 81479 HCPCS inpatient 393 255.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 265.67 67.6 999999999 237.96 381.21 percent of total billed charges Molecular pathology procedure 50335507_1 CDM 0302 RC 81479 HCPCS inpatient 393 255.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 237.96 381.21 LEVOFLOXACIN 750 MG TABLET 50337301_1 CDM 0250 RC 65862-0538-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 750 MG TABLET 50337301_1 CDM 0250 RC 65862-0538-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 750 MG TABLET 50337301_1 CDM 0250 RC 65862-0538-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 750 MG TABLET 50337301_1 CDM 0250 RC 65862-0538-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 750 MG TABLET 50337301_1 CDM 0250 RC 65862-0538-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 750 MG TABLET 50337301_1 CDM 0250 RC 65862-0538-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 750 MG TABLET 50337301_1 CDM 0250 RC 65862-0538-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 750 MG TABLET 50337301_1 CDM 0250 RC 65862-0538-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 750 MG TABLET 50337301_1 CDM 0250 RC 65862-0538-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LEVOFLOXACIN 750 MG TABLET 50337301_1 CDM 0250 RC 65862-0538-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LEVOFLOXACIN 750 MG TABLET 50337301_1 CDM 0250 RC 65862-0538-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LEVOFLOXACIN 750 MG TABLET 50337301_1 CDM 0250 RC 65862-0538-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LEVOFLOXACIN 750 MG TABLET 50337301_1 CDM 0250 RC 65862-0538-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 750 MG TABLET 50337301_1 CDM 0250 RC 65862-0538-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 Application of hot or cold packs 50342563_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 50342563_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 50342563_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 50342563_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 50342563_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 50342563_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 50342563_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 50342563_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 50342563_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 Application of hot or cold packs 50342563_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 Application of hot or cold packs 50342563_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 Application of hot or cold packs 50342563_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 Application of hot or cold packs 50342563_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 50342563_1 CDM 0430 RC 97010 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 Application of blood vessel compression device 50342567_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 50342567_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 50342567_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 50342567_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 50342567_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 50342567_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 50342567_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 50342567_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 50342567_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 Application of blood vessel compression device 50342567_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 Application of blood vessel compression device 50342567_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 Application of blood vessel compression device 50342567_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 Application of blood vessel compression device 50342567_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges Application of blood vessel compression device 50342567_1 CDM 0430 RC 97016 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 Application of hot wax bath 50342569_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 AETNA AETNA 144.57 79 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 50342569_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.95 65 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 50342569_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.51 97 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 50342569_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.27 69 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 50342569_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 142.74 78 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 50342569_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 SIHO - ALL PLANS SIHO - ALL PLANS 164.7 90 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 50342569_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.81 60.55 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 50342569_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 UMR - ALL PLANS UMR - ALL PLANS 128.1 70 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 50342569_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.81 177.51 Application of hot wax bath 50342569_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.81 177.51 Application of hot wax bath 50342569_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 ANTHEM HMO ANTHEM HMO 999999999 110.81 177.51 Application of hot wax bath 50342569_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.81 177.51 Application of hot wax bath 50342569_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.71 67.6 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 50342569_1 CDM 0430 RC 97018 HCPCS inpatient 183 118.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.81 177.51 Application of whirlpool therapy 50342571_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 50342571_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 50342571_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 50342571_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 50342571_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 50342571_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 50342571_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 50342571_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 50342571_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 Application of whirlpool therapy 50342571_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 Application of whirlpool therapy 50342571_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 Application of whirlpool therapy 50342571_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 Application of whirlpool therapy 50342571_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 50342571_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 Therapy procedure in a group setting 50342589_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 50342589_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 50342589_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 50342589_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 50342589_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 50342589_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 50342589_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 50342589_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 50342589_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 Therapy procedure in a group setting 50342589_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 Therapy procedure in a group setting 50342589_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 Therapy procedure in a group setting 50342589_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 Therapy procedure in a group setting 50342589_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 50342589_1 CDM 0430 RC 97150 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 "Application of electrical stimulation with therapist present, each 15 minutes" 50342595_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 AETNA AETNA 158.79 79 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 50342595_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 130.65 65 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 50342595_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 194.97 97 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 50342595_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 138.69 69 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 50342595_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 156.78 78 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 50342595_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 SIHO - ALL PLANS SIHO - ALL PLANS 180.9 90 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 50342595_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 121.71 60.55 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 50342595_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 UMR - ALL PLANS UMR - ALL PLANS 140.7 70 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 50342595_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 121.71 194.97 "Application of electrical stimulation with therapist present, each 15 minutes" 50342595_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 121.71 194.97 "Application of electrical stimulation with therapist present, each 15 minutes" 50342595_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 ANTHEM HMO ANTHEM HMO 999999999 121.71 194.97 "Application of electrical stimulation with therapist present, each 15 minutes" 50342595_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 121.71 194.97 "Application of electrical stimulation with therapist present, each 15 minutes" 50342595_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 135.88 67.6 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 50342595_1 CDM 0430 RC 97032 HCPCS inpatient 201 130.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 121.71 194.97 "Application of medication using electrical current, each 15 minutes" 50342597_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 AETNA AETNA 170.64 79 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 50342597_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 140.4 65 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 50342597_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 209.52 97 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 50342597_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 149.04 69 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 50342597_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 168.48 78 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 50342597_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 SIHO - ALL PLANS SIHO - ALL PLANS 194.4 90 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 50342597_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 130.79 60.55 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 50342597_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 UMR - ALL PLANS UMR - ALL PLANS 151.2 70 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 50342597_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 50342597_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 50342597_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 ANTHEM HMO ANTHEM HMO 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 50342597_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 50342597_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 146.02 67.6 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 50342597_1 CDM 0430 RC 97033 HCPCS inpatient 216 140.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 130.79 209.52 "Application of hot and cold baths, each 15 minutes" 50342599_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 50342599_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 50342599_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 50342599_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 50342599_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 50342599_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 50342599_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 50342599_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 50342599_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 50342599_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 50342599_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 50342599_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 50342599_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 50342599_1 CDM 0430 RC 97034 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 "Application of ultrasound, each 15 minutes" 50342601_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 50342601_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 50342601_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 50342601_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 50342601_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 50342601_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 50342601_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 50342601_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 50342601_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 "Application of ultrasound, each 15 minutes" 50342601_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 "Application of ultrasound, each 15 minutes" 50342601_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 "Application of ultrasound, each 15 minutes" 50342601_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 "Application of ultrasound, each 15 minutes" 50342601_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 50342601_1 CDM 0430 RC 97035 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342603_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342603_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342603_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342603_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342603_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342603_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342603_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342603_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342603_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342603_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342603_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342603_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342603_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342603_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342605_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342605_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342605_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342605_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342605_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342605_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342605_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342605_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342605_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342605_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342605_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342605_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342605_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342605_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 "Therapy procedure using massage, each 15 minutes" 50342607_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 50342607_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 50342607_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 50342607_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 50342607_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 50342607_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 50342607_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 50342607_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 50342607_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 50342607_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 50342607_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 50342607_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 50342607_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 50342607_1 CDM 0430 RC 97124 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 "Therapy procedure using manual technique, each 15 minutes" 50342609_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 50342609_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 50342609_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 50342609_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 50342609_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 50342609_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 50342609_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 50342609_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 50342609_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 "Therapy procedure using manual technique, each 15 minutes" 50342609_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 "Therapy procedure using manual technique, each 15 minutes" 50342609_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 "Therapy procedure using manual technique, each 15 minutes" 50342609_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 "Therapy procedure using manual technique, each 15 minutes" 50342609_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 50342609_1 CDM 0430 RC 97140 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 Therapy procedure using functional activities 50342611_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 50342611_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 50342611_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 50342611_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 50342611_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 50342611_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 50342611_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 50342611_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 50342611_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 Therapy procedure using functional activities 50342611_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 Therapy procedure using functional activities 50342611_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 Therapy procedure using functional activities 50342611_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 Therapy procedure using functional activities 50342611_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges Therapy procedure using functional activities 50342611_1 CDM 0430 RC 97530 HCPCS inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 "Training for self-care or home management, each 15 minutes" 50342617_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 AETNA AETNA 157.21 79 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 50342617_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 129.35 65 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 50342617_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 193.03 97 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 50342617_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 137.31 69 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 50342617_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 SIHO - ALL PLANS SIHO - ALL PLANS 179.1 90 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 50342617_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 155.22 78 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 50342617_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 120.49 60.55 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 50342617_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 UMR - ALL PLANS UMR - ALL PLANS 139.3 70 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 50342617_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 120.49 193.03 "Training for self-care or home management, each 15 minutes" 50342617_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 120.49 193.03 "Training for self-care or home management, each 15 minutes" 50342617_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 ANTHEM HMO ANTHEM HMO 999999999 120.49 193.03 "Training for self-care or home management, each 15 minutes" 50342617_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 120.49 193.03 "Training for self-care or home management, each 15 minutes" 50342617_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 134.52 67.6 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 50342617_1 CDM 0430 RC 97535 HCPCS inpatient 199 129.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 120.49 193.03 "Evaluation for wheelchair, each 15 minutes" 50342621_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 50342621_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 50342621_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 50342621_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 50342621_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 50342621_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 50342621_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 50342621_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 50342621_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 50342621_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 50342621_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 50342621_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 50342621_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 50342621_1 CDM 0430 RC 97542 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 "Evaluation for work hardening or conditioning, initial 2 hours" 50342623_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 AETNA AETNA 464.52 79 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 50342623_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 382.2 65 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 50342623_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 570.36 97 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 50342623_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 405.72 69 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 50342623_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 SIHO - ALL PLANS SIHO - ALL PLANS 529.2 90 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 50342623_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 458.64 78 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 50342623_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 356.03 60.55 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 50342623_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 UMR - ALL PLANS UMR - ALL PLANS 411.6 70 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 50342623_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 50342623_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 50342623_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 ANTHEM HMO ANTHEM HMO 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 50342623_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 50342623_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 397.49 67.6 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 50342623_1 CDM 0430 RC 97545 HCPCS inpatient 588 382.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, each additional hour" 50342625_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 AETNA AETNA 237.79 79 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 50342625_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 195.65 65 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 50342625_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291.97 97 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 50342625_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 207.69 69 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 50342625_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 SIHO - ALL PLANS SIHO - ALL PLANS 270.9 90 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 50342625_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 234.78 78 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 50342625_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.26 60.55 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 50342625_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 UMR - ALL PLANS UMR - ALL PLANS 210.7 70 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 50342625_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 50342625_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 50342625_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 ANTHEM HMO ANTHEM HMO 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 50342625_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 50342625_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 203.48 67.6 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 50342625_1 CDM 0430 RC 97546 HCPCS inpatient 301 195.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.26 291.97 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342627_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342627_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342627_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342627_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342627_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342627_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342627_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342627_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342627_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342627_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342627_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342627_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342627_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342627_1 CDM 0430 RC 97760 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 Application of hot or cold packs 50342637_1 CDM 0420 RC 97010 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 50342637_1 CDM 0420 RC 97010 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 50342637_1 CDM 0420 RC 97010 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 50342637_1 CDM 0420 RC 97010 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 50342637_1 CDM 0420 RC 97010 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 50342637_1 CDM 0420 RC 97010 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 50342637_1 CDM 0420 RC 97010 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 50342637_1 CDM 0420 RC 97010 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 50342637_1 CDM 0420 RC 97010 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 Application of hot or cold packs 50342637_1 CDM 0420 RC 97010 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 Application of hot or cold packs 50342637_1 CDM 0420 RC 97010 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 Application of hot or cold packs 50342637_1 CDM 0420 RC 97010 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 Application of hot or cold packs 50342637_1 CDM 0420 RC 97010 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges Application of hot or cold packs 50342637_1 CDM 0420 RC 97010 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 Application of mechanical traction 50342639_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 AETNA AETNA 168.27 79 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 50342639_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 138.45 65 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 50342639_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 206.61 97 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 50342639_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 146.97 69 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 50342639_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 SIHO - ALL PLANS SIHO - ALL PLANS 191.7 90 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 50342639_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 166.14 78 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 50342639_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 128.97 60.55 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 50342639_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 UMR - ALL PLANS UMR - ALL PLANS 149.1 70 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 50342639_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 128.97 206.61 Application of mechanical traction 50342639_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 128.97 206.61 Application of mechanical traction 50342639_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 ANTHEM HMO ANTHEM HMO 999999999 128.97 206.61 Application of mechanical traction 50342639_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 128.97 206.61 Application of mechanical traction 50342639_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 143.99 67.6 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 50342639_1 CDM 0420 RC 97012 HCPCS inpatient 213 138.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 128.97 206.61 "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 50342641_1 CDM 0420 RC G0283 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 50342641_1 CDM 0420 RC G0283 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 50342641_1 CDM 0420 RC G0283 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 50342641_1 CDM 0420 RC G0283 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 50342641_1 CDM 0420 RC G0283 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 50342641_1 CDM 0420 RC G0283 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 50342641_1 CDM 0420 RC G0283 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 50342641_1 CDM 0420 RC G0283 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 50342641_1 CDM 0420 RC G0283 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 50342641_1 CDM 0420 RC G0283 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 50342641_1 CDM 0420 RC G0283 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 50342641_1 CDM 0420 RC G0283 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 50342641_1 CDM 0420 RC G0283 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges "ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE" 50342641_1 CDM 0420 RC G0283 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 Application of hot wax bath 50342645_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 AETNA AETNA 144.57 79 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 50342645_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.95 65 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 50342645_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.51 97 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 50342645_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.27 69 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 50342645_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 SIHO - ALL PLANS SIHO - ALL PLANS 164.7 90 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 50342645_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 142.74 78 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 50342645_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.81 60.55 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 50342645_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 UMR - ALL PLANS UMR - ALL PLANS 128.1 70 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 50342645_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.81 177.51 Application of hot wax bath 50342645_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.81 177.51 Application of hot wax bath 50342645_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 ANTHEM HMO ANTHEM HMO 999999999 110.81 177.51 Application of hot wax bath 50342645_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.81 177.51 Application of hot wax bath 50342645_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.71 67.6 999999999 110.81 177.51 percent of total billed charges Application of hot wax bath 50342645_1 CDM 0420 RC 97018 HCPCS inpatient 183 118.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.81 177.51 Application of whirlpool therapy 50342647_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 50342647_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 50342647_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 50342647_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 50342647_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 50342647_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 50342647_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 50342647_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 50342647_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 Application of whirlpool therapy 50342647_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 Application of whirlpool therapy 50342647_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 Application of whirlpool therapy 50342647_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 Application of whirlpool therapy 50342647_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 50342647_1 CDM 0420 RC 97022 HCPCS inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 Biofeedback training 50342649_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 AETNA AETNA 245.69 79 999999999 188.31 301.67 percent of total billed charges Biofeedback training 50342649_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 202.15 65 999999999 188.31 301.67 percent of total billed charges Biofeedback training 50342649_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 301.67 97 999999999 188.31 301.67 percent of total billed charges Biofeedback training 50342649_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 214.59 69 999999999 188.31 301.67 percent of total billed charges Biofeedback training 50342649_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 SIHO - ALL PLANS SIHO - ALL PLANS 279.9 90 999999999 188.31 301.67 percent of total billed charges Biofeedback training 50342649_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 242.58 78 999999999 188.31 301.67 percent of total billed charges Biofeedback training 50342649_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 188.31 60.55 999999999 188.31 301.67 percent of total billed charges Biofeedback training 50342649_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 UMR - ALL PLANS UMR - ALL PLANS 217.7 70 999999999 188.31 301.67 percent of total billed charges Biofeedback training 50342649_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 188.31 301.67 Biofeedback training 50342649_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 188.31 301.67 Biofeedback training 50342649_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 ANTHEM HMO ANTHEM HMO 999999999 188.31 301.67 Biofeedback training 50342649_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 188.31 301.67 Biofeedback training 50342649_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 210.24 67.6 999999999 188.31 301.67 percent of total billed charges Biofeedback training 50342649_1 CDM 0420 RC 90901 HCPCS inpatient 311 202.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 188.31 301.67 Therapy procedure in a group setting 50342665_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 50342665_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 50342665_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 50342665_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 50342665_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 50342665_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 50342665_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 50342665_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 50342665_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 Therapy procedure in a group setting 50342665_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 Therapy procedure in a group setting 50342665_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 Therapy procedure in a group setting 50342665_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 Therapy procedure in a group setting 50342665_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 50342665_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 "Application of medication using electrical current, each 15 minutes" 50342671_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 AETNA AETNA 170.64 79 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 50342671_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 140.4 65 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 50342671_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 209.52 97 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 50342671_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 149.04 69 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 50342671_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 SIHO - ALL PLANS SIHO - ALL PLANS 194.4 90 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 50342671_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 168.48 78 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 50342671_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 130.79 60.55 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 50342671_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 UMR - ALL PLANS UMR - ALL PLANS 151.2 70 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 50342671_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 50342671_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 50342671_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 ANTHEM HMO ANTHEM HMO 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 50342671_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 50342671_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 146.02 67.6 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 50342671_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 130.79 209.52 "Application of hot and cold baths, each 15 minutes" 50342673_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 50342673_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 50342673_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 50342673_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 50342673_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 50342673_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 50342673_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 50342673_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 50342673_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 50342673_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 50342673_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 50342673_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 "Application of hot and cold baths, each 15 minutes" 50342673_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges "Application of hot and cold baths, each 15 minutes" 50342673_1 CDM 0420 RC 97034 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 "Application of ultrasound, each 15 minutes" 50342675_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 50342675_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 50342675_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 50342675_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 50342675_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 50342675_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 50342675_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 50342675_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 50342675_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 "Application of ultrasound, each 15 minutes" 50342675_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 "Application of ultrasound, each 15 minutes" 50342675_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 "Application of ultrasound, each 15 minutes" 50342675_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 "Application of ultrasound, each 15 minutes" 50342675_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 50342675_1 CDM 0420 RC 97035 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342677_1 CDM 0420 RC 97110 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342677_1 CDM 0420 RC 97110 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342677_1 CDM 0420 RC 97110 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342677_1 CDM 0420 RC 97110 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342677_1 CDM 0420 RC 97110 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342677_1 CDM 0420 RC 97110 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342677_1 CDM 0420 RC 97110 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342677_1 CDM 0420 RC 97110 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342677_1 CDM 0420 RC 97110 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342677_1 CDM 0420 RC 97110 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342677_1 CDM 0420 RC 97110 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342677_1 CDM 0420 RC 97110 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342677_1 CDM 0420 RC 97110 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 50342677_1 CDM 0420 RC 97110 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 "Therapy procedure for walking training, each 15 minutes" 50342683_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 50342683_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 50342683_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 50342683_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 50342683_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 50342683_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 50342683_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 50342683_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 50342683_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 "Therapy procedure for walking training, each 15 minutes" 50342683_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 "Therapy procedure for walking training, each 15 minutes" 50342683_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 "Therapy procedure for walking training, each 15 minutes" 50342683_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 "Therapy procedure for walking training, each 15 minutes" 50342683_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 50342683_1 CDM 0420 RC 97116 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 "Therapy procedure using massage, each 15 minutes" 50342685_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 50342685_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 50342685_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 50342685_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 50342685_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 50342685_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 50342685_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 50342685_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 50342685_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 50342685_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 50342685_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 50342685_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 "Therapy procedure using massage, each 15 minutes" 50342685_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using massage, each 15 minutes" 50342685_1 CDM 0420 RC 97124 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 "Therapy procedure using manual technique, each 15 minutes" 50342687_1 CDM 0420 RC 97140 HCPCS inpatient 177 115.05 AETNA AETNA 139.83 79 999999999 107.17 171.69 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 50342687_1 CDM 0420 RC 97140 HCPCS inpatient 177 115.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.05 65 999999999 107.17 171.69 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 50342687_1 CDM 0420 RC 97140 HCPCS inpatient 177 115.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 171.69 97 999999999 107.17 171.69 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 50342687_1 CDM 0420 RC 97140 HCPCS inpatient 177 115.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.13 69 999999999 107.17 171.69 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 50342687_1 CDM 0420 RC 97140 HCPCS inpatient 177 115.05 SIHO - ALL PLANS SIHO - ALL PLANS 159.3 90 999999999 107.17 171.69 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 50342687_1 CDM 0420 RC 97140 HCPCS inpatient 177 115.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.06 78 999999999 107.17 171.69 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 50342687_1 CDM 0420 RC 97140 HCPCS inpatient 177 115.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.17 60.55 999999999 107.17 171.69 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 50342687_1 CDM 0420 RC 97140 HCPCS inpatient 177 115.05 UMR - ALL PLANS UMR - ALL PLANS 123.9 70 999999999 107.17 171.69 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 50342687_1 CDM 0420 RC 97140 HCPCS inpatient 177 115.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.17 171.69 "Therapy procedure using manual technique, each 15 minutes" 50342687_1 CDM 0420 RC 97140 HCPCS inpatient 177 115.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.17 171.69 "Therapy procedure using manual technique, each 15 minutes" 50342687_1 CDM 0420 RC 97140 HCPCS inpatient 177 115.05 ANTHEM HMO ANTHEM HMO 999999999 107.17 171.69 "Therapy procedure using manual technique, each 15 minutes" 50342687_1 CDM 0420 RC 97140 HCPCS inpatient 177 115.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.17 171.69 "Therapy procedure using manual technique, each 15 minutes" 50342687_1 CDM 0420 RC 97140 HCPCS inpatient 177 115.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 119.65 67.6 999999999 107.17 171.69 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 50342687_1 CDM 0420 RC 97140 HCPCS inpatient 177 115.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.17 171.69 Therapy procedure using functional activities 50342689_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 AETNA AETNA 133.51 79 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 50342689_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.85 65 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 50342689_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 163.93 97 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 50342689_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 116.61 69 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 50342689_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 SIHO - ALL PLANS SIHO - ALL PLANS 152.1 90 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 50342689_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.82 78 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 50342689_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.33 60.55 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 50342689_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 UMR - ALL PLANS UMR - ALL PLANS 118.3 70 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 50342689_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.33 163.93 Therapy procedure using functional activities 50342689_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.33 163.93 Therapy procedure using functional activities 50342689_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 ANTHEM HMO ANTHEM HMO 999999999 102.33 163.93 Therapy procedure using functional activities 50342689_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.33 163.93 Therapy procedure using functional activities 50342689_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.24 67.6 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 50342689_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.33 163.93 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342691_1 CDM 0420 RC 97112 HCPCS inpatient 169 109.85 AETNA AETNA 133.51 79 999999999 102.33 163.93 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342691_1 CDM 0420 RC 97112 HCPCS inpatient 169 109.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.85 65 999999999 102.33 163.93 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342691_1 CDM 0420 RC 97112 HCPCS inpatient 169 109.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 163.93 97 999999999 102.33 163.93 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342691_1 CDM 0420 RC 97112 HCPCS inpatient 169 109.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 116.61 69 999999999 102.33 163.93 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342691_1 CDM 0420 RC 97112 HCPCS inpatient 169 109.85 SIHO - ALL PLANS SIHO - ALL PLANS 152.1 90 999999999 102.33 163.93 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342691_1 CDM 0420 RC 97112 HCPCS inpatient 169 109.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.82 78 999999999 102.33 163.93 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342691_1 CDM 0420 RC 97112 HCPCS inpatient 169 109.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.33 60.55 999999999 102.33 163.93 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342691_1 CDM 0420 RC 97112 HCPCS inpatient 169 109.85 UMR - ALL PLANS UMR - ALL PLANS 118.3 70 999999999 102.33 163.93 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342691_1 CDM 0420 RC 97112 HCPCS inpatient 169 109.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.33 163.93 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342691_1 CDM 0420 RC 97112 HCPCS inpatient 169 109.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.33 163.93 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342691_1 CDM 0420 RC 97112 HCPCS inpatient 169 109.85 ANTHEM HMO ANTHEM HMO 999999999 102.33 163.93 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342691_1 CDM 0420 RC 97112 HCPCS inpatient 169 109.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.33 163.93 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342691_1 CDM 0420 RC 97112 HCPCS inpatient 169 109.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.24 67.6 999999999 102.33 163.93 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 50342691_1 CDM 0420 RC 97112 HCPCS inpatient 169 109.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.33 163.93 "Training for self-care or home management, each 15 minutes" 50342695_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 AETNA AETNA 157.21 79 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 50342695_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 129.35 65 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 50342695_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 193.03 97 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 50342695_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 137.31 69 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 50342695_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 SIHO - ALL PLANS SIHO - ALL PLANS 179.1 90 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 50342695_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 155.22 78 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 50342695_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 120.49 60.55 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 50342695_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 UMR - ALL PLANS UMR - ALL PLANS 139.3 70 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 50342695_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 120.49 193.03 "Training for self-care or home management, each 15 minutes" 50342695_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 120.49 193.03 "Training for self-care or home management, each 15 minutes" 50342695_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 ANTHEM HMO ANTHEM HMO 999999999 120.49 193.03 "Training for self-care or home management, each 15 minutes" 50342695_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 120.49 193.03 "Training for self-care or home management, each 15 minutes" 50342695_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 134.52 67.6 999999999 120.49 193.03 percent of total billed charges "Training for self-care or home management, each 15 minutes" 50342695_1 CDM 0420 RC 97535 HCPCS inpatient 199 129.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 120.49 193.03 "Evaluation for wheelchair, each 15 minutes" 50342699_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 50342699_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 50342699_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 50342699_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 50342699_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 50342699_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 50342699_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 50342699_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 50342699_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 50342699_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 50342699_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 50342699_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 50342699_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 50342699_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 "Evaluation for work hardening or conditioning, initial 2 hours" 50342701_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 AETNA AETNA 464.52 79 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 50342701_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 382.2 65 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 50342701_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 570.36 97 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 50342701_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 405.72 69 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 50342701_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 SIHO - ALL PLANS SIHO - ALL PLANS 529.2 90 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 50342701_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 458.64 78 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 50342701_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 356.03 60.55 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 50342701_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 UMR - ALL PLANS UMR - ALL PLANS 411.6 70 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 50342701_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 50342701_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 50342701_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 ANTHEM HMO ANTHEM HMO 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 50342701_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, initial 2 hours" 50342701_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 397.49 67.6 999999999 356.03 570.36 percent of total billed charges "Evaluation for work hardening or conditioning, initial 2 hours" 50342701_1 CDM 0420 RC 97545 HCPCS inpatient 588 382.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 356.03 570.36 "Evaluation for work hardening or conditioning, each additional hour" 50342703_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 AETNA AETNA 237.79 79 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 50342703_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 195.65 65 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 50342703_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291.97 97 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 50342703_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 207.69 69 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 50342703_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 SIHO - ALL PLANS SIHO - ALL PLANS 270.9 90 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 50342703_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 234.78 78 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 50342703_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.26 60.55 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 50342703_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 UMR - ALL PLANS UMR - ALL PLANS 210.7 70 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 50342703_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 50342703_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 50342703_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 ANTHEM HMO ANTHEM HMO 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 50342703_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.26 291.97 "Evaluation for work hardening or conditioning, each additional hour" 50342703_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 203.48 67.6 999999999 182.26 291.97 percent of total billed charges "Evaluation for work hardening or conditioning, each additional hour" 50342703_1 CDM 0420 RC 97546 HCPCS inpatient 301 195.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.26 291.97 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342705_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342705_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342705_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342705_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342705_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342705_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342705_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342705_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342705_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342705_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342705_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342705_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342705_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges "Training in the use of orthopedic device for arm, leg and/or trunk, each 15 minutes" 50342705_1 CDM 0420 RC 97760 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 "INJECTION, LEVETIRACETAM, 10 MG" 50348108_1 CDM 0250 RC 43598-0757-10 NDC J1953 HCPCS inpatient 100 UN 48.39 31.45 AETNA AETNA 38.23 79 999999999 29.3 46.94 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50348108_1 CDM 0250 RC 43598-0757-10 NDC J1953 HCPCS inpatient 100 UN 48.39 31.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.45 65 999999999 29.3 46.94 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50348108_1 CDM 0250 RC 43598-0757-10 NDC J1953 HCPCS inpatient 100 UN 48.39 31.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 46.94 97 999999999 29.3 46.94 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50348108_1 CDM 0250 RC 43598-0757-10 NDC J1953 HCPCS inpatient 100 UN 48.39 31.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.39 69 999999999 29.3 46.94 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50348108_1 CDM 0250 RC 43598-0757-10 NDC J1953 HCPCS inpatient 100 UN 48.39 31.45 SIHO - ALL PLANS SIHO - ALL PLANS 43.55 90 999999999 29.3 46.94 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50348108_1 CDM 0250 RC 43598-0757-10 NDC J1953 HCPCS inpatient 100 UN 48.39 31.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 37.74 78 999999999 29.3 46.94 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50348108_1 CDM 0250 RC 43598-0757-10 NDC J1953 HCPCS inpatient 100 UN 48.39 31.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.3 60.55 999999999 29.3 46.94 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50348108_1 CDM 0250 RC 43598-0757-10 NDC J1953 HCPCS inpatient 100 UN 48.39 31.45 UMR - ALL PLANS UMR - ALL PLANS 33.87 70 999999999 29.3 46.94 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50348108_1 CDM 0250 RC 43598-0757-10 NDC J1953 HCPCS inpatient 100 UN 48.39 31.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.3 46.94 "INJECTION, LEVETIRACETAM, 10 MG" 50348108_1 CDM 0250 RC 43598-0757-10 NDC J1953 HCPCS inpatient 100 UN 48.39 31.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.3 46.94 "INJECTION, LEVETIRACETAM, 10 MG" 50348108_1 CDM 0250 RC 43598-0757-10 NDC J1953 HCPCS inpatient 100 UN 48.39 31.45 ANTHEM HMO ANTHEM HMO 999999999 29.3 46.94 "INJECTION, LEVETIRACETAM, 10 MG" 50348108_1 CDM 0250 RC 43598-0757-10 NDC J1953 HCPCS inpatient 100 UN 48.39 31.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.3 46.94 "INJECTION, LEVETIRACETAM, 10 MG" 50348108_1 CDM 0250 RC 43598-0757-10 NDC J1953 HCPCS inpatient 100 UN 48.39 31.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 32.71 67.6 999999999 29.3 46.94 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50348108_1 CDM 0250 RC 43598-0757-10 NDC J1953 HCPCS inpatient 100 UN 48.39 31.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.3 46.94 "INJECTION, LEVETIRACETAM, 10 MG" 50348117_1 CDM 0250 RC 43598-0759-10 NDC J1953 HCPCS inpatient 150 UN 31.82 20.68 AETNA AETNA 25.14 79 999999999 19.27 30.87 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50348117_1 CDM 0250 RC 43598-0759-10 NDC J1953 HCPCS inpatient 150 UN 31.82 20.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.68 65 999999999 19.27 30.87 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50348117_1 CDM 0250 RC 43598-0759-10 NDC J1953 HCPCS inpatient 150 UN 31.82 20.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.87 97 999999999 19.27 30.87 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50348117_1 CDM 0250 RC 43598-0759-10 NDC J1953 HCPCS inpatient 150 UN 31.82 20.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.96 69 999999999 19.27 30.87 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50348117_1 CDM 0250 RC 43598-0759-10 NDC J1953 HCPCS inpatient 150 UN 31.82 20.68 SIHO - ALL PLANS SIHO - ALL PLANS 28.64 90 999999999 19.27 30.87 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50348117_1 CDM 0250 RC 43598-0759-10 NDC J1953 HCPCS inpatient 150 UN 31.82 20.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.82 78 999999999 19.27 30.87 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50348117_1 CDM 0250 RC 43598-0759-10 NDC J1953 HCPCS inpatient 150 UN 31.82 20.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.27 60.55 999999999 19.27 30.87 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50348117_1 CDM 0250 RC 43598-0759-10 NDC J1953 HCPCS inpatient 150 UN 31.82 20.68 UMR - ALL PLANS UMR - ALL PLANS 22.27 70 999999999 19.27 30.87 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50348117_1 CDM 0250 RC 43598-0759-10 NDC J1953 HCPCS inpatient 150 UN 31.82 20.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.27 30.87 "INJECTION, LEVETIRACETAM, 10 MG" 50348117_1 CDM 0250 RC 43598-0759-10 NDC J1953 HCPCS inpatient 150 UN 31.82 20.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.27 30.87 "INJECTION, LEVETIRACETAM, 10 MG" 50348117_1 CDM 0250 RC 43598-0759-10 NDC J1953 HCPCS inpatient 150 UN 31.82 20.68 ANTHEM HMO ANTHEM HMO 999999999 19.27 30.87 "INJECTION, LEVETIRACETAM, 10 MG" 50348117_1 CDM 0250 RC 43598-0759-10 NDC J1953 HCPCS inpatient 150 UN 31.82 20.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.27 30.87 "INJECTION, LEVETIRACETAM, 10 MG" 50348117_1 CDM 0250 RC 43598-0759-10 NDC J1953 HCPCS inpatient 150 UN 31.82 20.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.51 67.6 999999999 19.27 30.87 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50348117_1 CDM 0250 RC 43598-0759-10 NDC J1953 HCPCS inpatient 150 UN 31.82 20.68 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.27 30.87 "INJECTION, PALONOSETRON HCL, 25 MCG" 50348546_1 CDM 0250 RC 55150-0186-05 NDC J2469 HCPCS inpatient 10 UN 60.38 39.25 AETNA AETNA 47.7 79 999999999 36.56 58.57 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50348546_1 CDM 0250 RC 55150-0186-05 NDC J2469 HCPCS inpatient 10 UN 60.38 39.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.25 65 999999999 36.56 58.57 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50348546_1 CDM 0250 RC 55150-0186-05 NDC J2469 HCPCS inpatient 10 UN 60.38 39.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.57 97 999999999 36.56 58.57 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50348546_1 CDM 0250 RC 55150-0186-05 NDC J2469 HCPCS inpatient 10 UN 60.38 39.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.66 69 999999999 36.56 58.57 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50348546_1 CDM 0250 RC 55150-0186-05 NDC J2469 HCPCS inpatient 10 UN 60.38 39.25 SIHO - ALL PLANS SIHO - ALL PLANS 54.34 90 999999999 36.56 58.57 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50348546_1 CDM 0250 RC 55150-0186-05 NDC J2469 HCPCS inpatient 10 UN 60.38 39.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.1 78 999999999 36.56 58.57 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50348546_1 CDM 0250 RC 55150-0186-05 NDC J2469 HCPCS inpatient 10 UN 60.38 39.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.56 60.55 999999999 36.56 58.57 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50348546_1 CDM 0250 RC 55150-0186-05 NDC J2469 HCPCS inpatient 10 UN 60.38 39.25 UMR - ALL PLANS UMR - ALL PLANS 42.27 70 999999999 36.56 58.57 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50348546_1 CDM 0250 RC 55150-0186-05 NDC J2469 HCPCS inpatient 10 UN 60.38 39.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.56 58.57 "INJECTION, PALONOSETRON HCL, 25 MCG" 50348546_1 CDM 0250 RC 55150-0186-05 NDC J2469 HCPCS inpatient 10 UN 60.38 39.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.56 58.57 "INJECTION, PALONOSETRON HCL, 25 MCG" 50348546_1 CDM 0250 RC 55150-0186-05 NDC J2469 HCPCS inpatient 10 UN 60.38 39.25 ANTHEM HMO ANTHEM HMO 999999999 36.56 58.57 "INJECTION, PALONOSETRON HCL, 25 MCG" 50348546_1 CDM 0250 RC 55150-0186-05 NDC J2469 HCPCS inpatient 10 UN 60.38 39.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.56 58.57 "INJECTION, PALONOSETRON HCL, 25 MCG" 50348546_1 CDM 0250 RC 55150-0186-05 NDC J2469 HCPCS inpatient 10 UN 60.38 39.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.82 67.6 999999999 36.56 58.57 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50348546_1 CDM 0250 RC 55150-0186-05 NDC J2469 HCPCS inpatient 10 UN 60.38 39.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.56 58.57 IBUPROFEN 600 MG TABLET 50348548_1 CDM 0250 RC 00904-5854-61 NDC inpatient 5 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 600 MG TABLET 50348548_1 CDM 0250 RC 00904-5854-61 NDC inpatient 5 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 600 MG TABLET 50348548_1 CDM 0250 RC 00904-5854-61 NDC inpatient 5 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 600 MG TABLET 50348548_1 CDM 0250 RC 00904-5854-61 NDC inpatient 5 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 600 MG TABLET 50348548_1 CDM 0250 RC 00904-5854-61 NDC inpatient 5 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 600 MG TABLET 50348548_1 CDM 0250 RC 00904-5854-61 NDC inpatient 5 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 600 MG TABLET 50348548_1 CDM 0250 RC 00904-5854-61 NDC inpatient 5 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 600 MG TABLET 50348548_1 CDM 0250 RC 00904-5854-61 NDC inpatient 5 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 600 MG TABLET 50348548_1 CDM 0250 RC 00904-5854-61 NDC inpatient 5 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 IBUPROFEN 600 MG TABLET 50348548_1 CDM 0250 RC 00904-5854-61 NDC inpatient 5 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 IBUPROFEN 600 MG TABLET 50348548_1 CDM 0250 RC 00904-5854-61 NDC inpatient 5 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 IBUPROFEN 600 MG TABLET 50348548_1 CDM 0250 RC 00904-5854-61 NDC inpatient 5 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 IBUPROFEN 600 MG TABLET 50348548_1 CDM 0250 RC 00904-5854-61 NDC inpatient 5 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 600 MG TABLET 50348548_1 CDM 0250 RC 00904-5854-61 NDC inpatient 5 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 NICOTINE 21 MG/24HR PATCH 50348553_1 CDM 0250 RC 46122-0353-74 NDC inpatient 1 UN 5.11 3.32 AETNA AETNA 4.04 79 999999999 3.09 4.96 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50348553_1 CDM 0250 RC 46122-0353-74 NDC inpatient 1 UN 5.11 3.32 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.32 65 999999999 3.09 4.96 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50348553_1 CDM 0250 RC 46122-0353-74 NDC inpatient 1 UN 5.11 3.32 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4.96 97 999999999 3.09 4.96 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50348553_1 CDM 0250 RC 46122-0353-74 NDC inpatient 1 UN 5.11 3.32 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.53 69 999999999 3.09 4.96 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50348553_1 CDM 0250 RC 46122-0353-74 NDC inpatient 1 UN 5.11 3.32 SIHO - ALL PLANS SIHO - ALL PLANS 4.6 90 999999999 3.09 4.96 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50348553_1 CDM 0250 RC 46122-0353-74 NDC inpatient 1 UN 5.11 3.32 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.99 78 999999999 3.09 4.96 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50348553_1 CDM 0250 RC 46122-0353-74 NDC inpatient 1 UN 5.11 3.32 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.09 60.55 999999999 3.09 4.96 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50348553_1 CDM 0250 RC 46122-0353-74 NDC inpatient 1 UN 5.11 3.32 UMR - ALL PLANS UMR - ALL PLANS 3.58 70 999999999 3.09 4.96 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50348553_1 CDM 0250 RC 46122-0353-74 NDC inpatient 1 UN 5.11 3.32 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.09 4.96 NICOTINE 21 MG/24HR PATCH 50348553_1 CDM 0250 RC 46122-0353-74 NDC inpatient 1 UN 5.11 3.32 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.09 4.96 NICOTINE 21 MG/24HR PATCH 50348553_1 CDM 0250 RC 46122-0353-74 NDC inpatient 1 UN 5.11 3.32 ANTHEM HMO ANTHEM HMO 999999999 3.09 4.96 NICOTINE 21 MG/24HR PATCH 50348553_1 CDM 0250 RC 46122-0353-74 NDC inpatient 1 UN 5.11 3.32 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.09 4.96 NICOTINE 21 MG/24HR PATCH 50348553_1 CDM 0250 RC 46122-0353-74 NDC inpatient 1 UN 5.11 3.32 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.45 67.6 999999999 3.09 4.96 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50348553_1 CDM 0250 RC 46122-0353-74 NDC inpatient 1 UN 5.11 3.32 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.09 4.96 DICYCLOMINE 20 MG TABLET 50348713_1 CDM 0250 RC 60687-0380-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 20 MG TABLET 50348713_1 CDM 0250 RC 60687-0380-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 20 MG TABLET 50348713_1 CDM 0250 RC 60687-0380-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 20 MG TABLET 50348713_1 CDM 0250 RC 60687-0380-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 20 MG TABLET 50348713_1 CDM 0250 RC 60687-0380-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 20 MG TABLET 50348713_1 CDM 0250 RC 60687-0380-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 20 MG TABLET 50348713_1 CDM 0250 RC 60687-0380-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 20 MG TABLET 50348713_1 CDM 0250 RC 60687-0380-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 20 MG TABLET 50348713_1 CDM 0250 RC 60687-0380-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 DICYCLOMINE 20 MG TABLET 50348713_1 CDM 0250 RC 60687-0380-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 DICYCLOMINE 20 MG TABLET 50348713_1 CDM 0250 RC 60687-0380-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 DICYCLOMINE 20 MG TABLET 50348713_1 CDM 0250 RC 60687-0380-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 DICYCLOMINE 20 MG TABLET 50348713_1 CDM 0250 RC 60687-0380-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 20 MG TABLET 50348713_1 CDM 0250 RC 60687-0380-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 MESALAMINE DR 400 MG CAPSULE 50348715_1 CDM 0250 RC 00093-5907-86 NDC inpatient 1 UN 7.84 5.1 AETNA AETNA 6.19 79 999999999 4.75 7.6 percent of total billed charges MESALAMINE DR 400 MG CAPSULE 50348715_1 CDM 0250 RC 00093-5907-86 NDC inpatient 1 UN 7.84 5.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.1 65 999999999 4.75 7.6 percent of total billed charges MESALAMINE DR 400 MG CAPSULE 50348715_1 CDM 0250 RC 00093-5907-86 NDC inpatient 1 UN 7.84 5.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7.6 97 999999999 4.75 7.6 percent of total billed charges MESALAMINE DR 400 MG CAPSULE 50348715_1 CDM 0250 RC 00093-5907-86 NDC inpatient 1 UN 7.84 5.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.41 69 999999999 4.75 7.6 percent of total billed charges MESALAMINE DR 400 MG CAPSULE 50348715_1 CDM 0250 RC 00093-5907-86 NDC inpatient 1 UN 7.84 5.1 SIHO - ALL PLANS SIHO - ALL PLANS 7.06 90 999999999 4.75 7.6 percent of total billed charges MESALAMINE DR 400 MG CAPSULE 50348715_1 CDM 0250 RC 00093-5907-86 NDC inpatient 1 UN 7.84 5.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.12 78 999999999 4.75 7.6 percent of total billed charges MESALAMINE DR 400 MG CAPSULE 50348715_1 CDM 0250 RC 00093-5907-86 NDC inpatient 1 UN 7.84 5.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.75 60.55 999999999 4.75 7.6 percent of total billed charges MESALAMINE DR 400 MG CAPSULE 50348715_1 CDM 0250 RC 00093-5907-86 NDC inpatient 1 UN 7.84 5.1 UMR - ALL PLANS UMR - ALL PLANS 5.49 70 999999999 4.75 7.6 percent of total billed charges MESALAMINE DR 400 MG CAPSULE 50348715_1 CDM 0250 RC 00093-5907-86 NDC inpatient 1 UN 7.84 5.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.75 7.6 MESALAMINE DR 400 MG CAPSULE 50348715_1 CDM 0250 RC 00093-5907-86 NDC inpatient 1 UN 7.84 5.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.75 7.6 MESALAMINE DR 400 MG CAPSULE 50348715_1 CDM 0250 RC 00093-5907-86 NDC inpatient 1 UN 7.84 5.1 ANTHEM HMO ANTHEM HMO 999999999 4.75 7.6 MESALAMINE DR 400 MG CAPSULE 50348715_1 CDM 0250 RC 00093-5907-86 NDC inpatient 1 UN 7.84 5.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.75 7.6 MESALAMINE DR 400 MG CAPSULE 50348715_1 CDM 0250 RC 00093-5907-86 NDC inpatient 1 UN 7.84 5.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.3 67.6 999999999 4.75 7.6 percent of total billed charges MESALAMINE DR 400 MG CAPSULE 50348715_1 CDM 0250 RC 00093-5907-86 NDC inpatient 1 UN 7.84 5.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.75 7.6 GLYCOPYRROLATE 1 MG/5 ML VIAL 50348721_1 CDM 0250 RC 55150-0294-05 NDC inpatient 1 UN 57.19 37.17 AETNA AETNA 45.18 79 999999999 34.63 55.47 percent of total billed charges GLYCOPYRROLATE 1 MG/5 ML VIAL 50348721_1 CDM 0250 RC 55150-0294-05 NDC inpatient 1 UN 57.19 37.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.17 65 999999999 34.63 55.47 percent of total billed charges GLYCOPYRROLATE 1 MG/5 ML VIAL 50348721_1 CDM 0250 RC 55150-0294-05 NDC inpatient 1 UN 57.19 37.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.47 97 999999999 34.63 55.47 percent of total billed charges GLYCOPYRROLATE 1 MG/5 ML VIAL 50348721_1 CDM 0250 RC 55150-0294-05 NDC inpatient 1 UN 57.19 37.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.46 69 999999999 34.63 55.47 percent of total billed charges GLYCOPYRROLATE 1 MG/5 ML VIAL 50348721_1 CDM 0250 RC 55150-0294-05 NDC inpatient 1 UN 57.19 37.17 SIHO - ALL PLANS SIHO - ALL PLANS 51.47 90 999999999 34.63 55.47 percent of total billed charges GLYCOPYRROLATE 1 MG/5 ML VIAL 50348721_1 CDM 0250 RC 55150-0294-05 NDC inpatient 1 UN 57.19 37.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.61 78 999999999 34.63 55.47 percent of total billed charges GLYCOPYRROLATE 1 MG/5 ML VIAL 50348721_1 CDM 0250 RC 55150-0294-05 NDC inpatient 1 UN 57.19 37.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.63 60.55 999999999 34.63 55.47 percent of total billed charges GLYCOPYRROLATE 1 MG/5 ML VIAL 50348721_1 CDM 0250 RC 55150-0294-05 NDC inpatient 1 UN 57.19 37.17 UMR - ALL PLANS UMR - ALL PLANS 40.03 70 999999999 34.63 55.47 percent of total billed charges GLYCOPYRROLATE 1 MG/5 ML VIAL 50348721_1 CDM 0250 RC 55150-0294-05 NDC inpatient 1 UN 57.19 37.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.63 55.47 GLYCOPYRROLATE 1 MG/5 ML VIAL 50348721_1 CDM 0250 RC 55150-0294-05 NDC inpatient 1 UN 57.19 37.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.63 55.47 GLYCOPYRROLATE 1 MG/5 ML VIAL 50348721_1 CDM 0250 RC 55150-0294-05 NDC inpatient 1 UN 57.19 37.17 ANTHEM HMO ANTHEM HMO 999999999 34.63 55.47 GLYCOPYRROLATE 1 MG/5 ML VIAL 50348721_1 CDM 0250 RC 55150-0294-05 NDC inpatient 1 UN 57.19 37.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.63 55.47 GLYCOPYRROLATE 1 MG/5 ML VIAL 50348721_1 CDM 0250 RC 55150-0294-05 NDC inpatient 1 UN 57.19 37.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.66 67.6 999999999 34.63 55.47 percent of total billed charges GLYCOPYRROLATE 1 MG/5 ML VIAL 50348721_1 CDM 0250 RC 55150-0294-05 NDC inpatient 1 UN 57.19 37.17 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.63 55.47 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 50348738_1 CDM 0250 RC 71288-0006-30 NDC J0295 HCPCS inpatient 2 UN 56.34 36.62 AETNA AETNA 44.51 79 999999999 34.11 54.65 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 50348738_1 CDM 0250 RC 71288-0006-30 NDC J0295 HCPCS inpatient 2 UN 56.34 36.62 SELF PAY DISCOUNT SELF PAY DISCOUNT 36.62 65 999999999 34.11 54.65 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 50348738_1 CDM 0250 RC 71288-0006-30 NDC J0295 HCPCS inpatient 2 UN 56.34 36.62 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 54.65 97 999999999 34.11 54.65 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 50348738_1 CDM 0250 RC 71288-0006-30 NDC J0295 HCPCS inpatient 2 UN 56.34 36.62 ENCORE - ALL PLANS ENCORE - ALL PLANS 38.87 69 999999999 34.11 54.65 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 50348738_1 CDM 0250 RC 71288-0006-30 NDC J0295 HCPCS inpatient 2 UN 56.34 36.62 SIHO - ALL PLANS SIHO - ALL PLANS 50.71 90 999999999 34.11 54.65 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 50348738_1 CDM 0250 RC 71288-0006-30 NDC J0295 HCPCS inpatient 2 UN 56.34 36.62 HUMANA - ALL PLANS HUMANA - ALL PLANS 43.95 78 999999999 34.11 54.65 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 50348738_1 CDM 0250 RC 71288-0006-30 NDC J0295 HCPCS inpatient 2 UN 56.34 36.62 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.11 60.55 999999999 34.11 54.65 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 50348738_1 CDM 0250 RC 71288-0006-30 NDC J0295 HCPCS inpatient 2 UN 56.34 36.62 UMR - ALL PLANS UMR - ALL PLANS 39.44 70 999999999 34.11 54.65 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 50348738_1 CDM 0250 RC 71288-0006-30 NDC J0295 HCPCS inpatient 2 UN 56.34 36.62 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.11 54.65 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 50348738_1 CDM 0250 RC 71288-0006-30 NDC J0295 HCPCS inpatient 2 UN 56.34 36.62 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.11 54.65 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 50348738_1 CDM 0250 RC 71288-0006-30 NDC J0295 HCPCS inpatient 2 UN 56.34 36.62 ANTHEM HMO ANTHEM HMO 999999999 34.11 54.65 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 50348738_1 CDM 0250 RC 71288-0006-30 NDC J0295 HCPCS inpatient 2 UN 56.34 36.62 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.11 54.65 "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 50348738_1 CDM 0250 RC 71288-0006-30 NDC J0295 HCPCS inpatient 2 UN 56.34 36.62 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.09 67.6 999999999 34.11 54.65 percent of total billed charges "INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM" 50348738_1 CDM 0250 RC 71288-0006-30 NDC J0295 HCPCS inpatient 2 UN 56.34 36.62 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.11 54.65 "INJECTION, IRON DEXTRAN, 50 MG" 50348744_1 CDM 0250 RC 00023-6082-10 NDC J1750 HCPCS inpatient 2 UN 139 90.35 AETNA AETNA 109.81 79 999999999 84.16 134.83 percent of total billed charges "INJECTION, IRON DEXTRAN, 50 MG" 50348744_1 CDM 0250 RC 00023-6082-10 NDC J1750 HCPCS inpatient 2 UN 139 90.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 90.35 65 999999999 84.16 134.83 percent of total billed charges "INJECTION, IRON DEXTRAN, 50 MG" 50348744_1 CDM 0250 RC 00023-6082-10 NDC J1750 HCPCS inpatient 2 UN 139 90.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 134.83 97 999999999 84.16 134.83 percent of total billed charges "INJECTION, IRON DEXTRAN, 50 MG" 50348744_1 CDM 0250 RC 00023-6082-10 NDC J1750 HCPCS inpatient 2 UN 139 90.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.91 69 999999999 84.16 134.83 percent of total billed charges "INJECTION, IRON DEXTRAN, 50 MG" 50348744_1 CDM 0250 RC 00023-6082-10 NDC J1750 HCPCS inpatient 2 UN 139 90.35 SIHO - ALL PLANS SIHO - ALL PLANS 125.1 90 999999999 84.16 134.83 percent of total billed charges "INJECTION, IRON DEXTRAN, 50 MG" 50348744_1 CDM 0250 RC 00023-6082-10 NDC J1750 HCPCS inpatient 2 UN 139 90.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 108.42 78 999999999 84.16 134.83 percent of total billed charges "INJECTION, IRON DEXTRAN, 50 MG" 50348744_1 CDM 0250 RC 00023-6082-10 NDC J1750 HCPCS inpatient 2 UN 139 90.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 84.16 60.55 999999999 84.16 134.83 percent of total billed charges "INJECTION, IRON DEXTRAN, 50 MG" 50348744_1 CDM 0250 RC 00023-6082-10 NDC J1750 HCPCS inpatient 2 UN 139 90.35 UMR - ALL PLANS UMR - ALL PLANS 97.3 70 999999999 84.16 134.83 percent of total billed charges "INJECTION, IRON DEXTRAN, 50 MG" 50348744_1 CDM 0250 RC 00023-6082-10 NDC J1750 HCPCS inpatient 2 UN 139 90.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 84.16 134.83 "INJECTION, IRON DEXTRAN, 50 MG" 50348744_1 CDM 0250 RC 00023-6082-10 NDC J1750 HCPCS inpatient 2 UN 139 90.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 84.16 134.83 "INJECTION, IRON DEXTRAN, 50 MG" 50348744_1 CDM 0250 RC 00023-6082-10 NDC J1750 HCPCS inpatient 2 UN 139 90.35 ANTHEM HMO ANTHEM HMO 999999999 84.16 134.83 "INJECTION, IRON DEXTRAN, 50 MG" 50348744_1 CDM 0250 RC 00023-6082-10 NDC J1750 HCPCS inpatient 2 UN 139 90.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 84.16 134.83 "INJECTION, IRON DEXTRAN, 50 MG" 50348744_1 CDM 0250 RC 00023-6082-10 NDC J1750 HCPCS inpatient 2 UN 139 90.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.96 67.6 999999999 84.16 134.83 percent of total billed charges "INJECTION, IRON DEXTRAN, 50 MG" 50348744_1 CDM 0250 RC 00023-6082-10 NDC J1750 HCPCS inpatient 2 UN 139 90.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 84.16 134.83 METOPROLOL SUCC ER 200 MG TAB 50348751_1 CDM 0250 RC 68382-0567-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 200 MG TAB 50348751_1 CDM 0250 RC 68382-0567-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 200 MG TAB 50348751_1 CDM 0250 RC 68382-0567-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 200 MG TAB 50348751_1 CDM 0250 RC 68382-0567-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 200 MG TAB 50348751_1 CDM 0250 RC 68382-0567-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 200 MG TAB 50348751_1 CDM 0250 RC 68382-0567-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 200 MG TAB 50348751_1 CDM 0250 RC 68382-0567-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 200 MG TAB 50348751_1 CDM 0250 RC 68382-0567-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 200 MG TAB 50348751_1 CDM 0250 RC 68382-0567-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 METOPROLOL SUCC ER 200 MG TAB 50348751_1 CDM 0250 RC 68382-0567-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 METOPROLOL SUCC ER 200 MG TAB 50348751_1 CDM 0250 RC 68382-0567-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 METOPROLOL SUCC ER 200 MG TAB 50348751_1 CDM 0250 RC 68382-0567-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 METOPROLOL SUCC ER 200 MG TAB 50348751_1 CDM 0250 RC 68382-0567-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 200 MG TAB 50348751_1 CDM 0250 RC 68382-0567-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 NITROFURANTOIN MCR 50 MG CAP 50348760_1 CDM 0250 RC 68001-0385-00 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges NITROFURANTOIN MCR 50 MG CAP 50348760_1 CDM 0250 RC 68001-0385-00 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges NITROFURANTOIN MCR 50 MG CAP 50348760_1 CDM 0250 RC 68001-0385-00 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges NITROFURANTOIN MCR 50 MG CAP 50348760_1 CDM 0250 RC 68001-0385-00 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges NITROFURANTOIN MCR 50 MG CAP 50348760_1 CDM 0250 RC 68001-0385-00 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges NITROFURANTOIN MCR 50 MG CAP 50348760_1 CDM 0250 RC 68001-0385-00 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges NITROFURANTOIN MCR 50 MG CAP 50348760_1 CDM 0250 RC 68001-0385-00 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges NITROFURANTOIN MCR 50 MG CAP 50348760_1 CDM 0250 RC 68001-0385-00 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges NITROFURANTOIN MCR 50 MG CAP 50348760_1 CDM 0250 RC 68001-0385-00 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 NITROFURANTOIN MCR 50 MG CAP 50348760_1 CDM 0250 RC 68001-0385-00 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 NITROFURANTOIN MCR 50 MG CAP 50348760_1 CDM 0250 RC 68001-0385-00 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 NITROFURANTOIN MCR 50 MG CAP 50348760_1 CDM 0250 RC 68001-0385-00 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 NITROFURANTOIN MCR 50 MG CAP 50348760_1 CDM 0250 RC 68001-0385-00 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges NITROFURANTOIN MCR 50 MG CAP 50348760_1 CDM 0250 RC 68001-0385-00 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 PHENAZOPYRIDINE 200 MG TAB 50348761_1 CDM 0250 RC 69367-0163-04 NDC inpatient 1 UN 1.98 1.29 AETNA AETNA 1.56 79 999999999 1.2 1.92 percent of total billed charges PHENAZOPYRIDINE 200 MG TAB 50348761_1 CDM 0250 RC 69367-0163-04 NDC inpatient 1 UN 1.98 1.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.29 65 999999999 1.2 1.92 percent of total billed charges PHENAZOPYRIDINE 200 MG TAB 50348761_1 CDM 0250 RC 69367-0163-04 NDC inpatient 1 UN 1.98 1.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.92 97 999999999 1.2 1.92 percent of total billed charges PHENAZOPYRIDINE 200 MG TAB 50348761_1 CDM 0250 RC 69367-0163-04 NDC inpatient 1 UN 1.98 1.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.37 69 999999999 1.2 1.92 percent of total billed charges PHENAZOPYRIDINE 200 MG TAB 50348761_1 CDM 0250 RC 69367-0163-04 NDC inpatient 1 UN 1.98 1.29 SIHO - ALL PLANS SIHO - ALL PLANS 1.78 90 999999999 1.2 1.92 percent of total billed charges PHENAZOPYRIDINE 200 MG TAB 50348761_1 CDM 0250 RC 69367-0163-04 NDC inpatient 1 UN 1.98 1.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.54 78 999999999 1.2 1.92 percent of total billed charges PHENAZOPYRIDINE 200 MG TAB 50348761_1 CDM 0250 RC 69367-0163-04 NDC inpatient 1 UN 1.98 1.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.2 60.55 999999999 1.2 1.92 percent of total billed charges PHENAZOPYRIDINE 200 MG TAB 50348761_1 CDM 0250 RC 69367-0163-04 NDC inpatient 1 UN 1.98 1.29 UMR - ALL PLANS UMR - ALL PLANS 1.39 70 999999999 1.2 1.92 percent of total billed charges PHENAZOPYRIDINE 200 MG TAB 50348761_1 CDM 0250 RC 69367-0163-04 NDC inpatient 1 UN 1.98 1.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.2 1.92 PHENAZOPYRIDINE 200 MG TAB 50348761_1 CDM 0250 RC 69367-0163-04 NDC inpatient 1 UN 1.98 1.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.2 1.92 PHENAZOPYRIDINE 200 MG TAB 50348761_1 CDM 0250 RC 69367-0163-04 NDC inpatient 1 UN 1.98 1.29 ANTHEM HMO ANTHEM HMO 999999999 1.2 1.92 PHENAZOPYRIDINE 200 MG TAB 50348761_1 CDM 0250 RC 69367-0163-04 NDC inpatient 1 UN 1.98 1.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.2 1.92 PHENAZOPYRIDINE 200 MG TAB 50348761_1 CDM 0250 RC 69367-0163-04 NDC inpatient 1 UN 1.98 1.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.34 67.6 999999999 1.2 1.92 percent of total billed charges PHENAZOPYRIDINE 200 MG TAB 50348761_1 CDM 0250 RC 69367-0163-04 NDC inpatient 1 UN 1.98 1.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.2 1.92 METOLAZONE 5 MG TABLET 50348770_1 CDM 0250 RC 00185-0055-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges METOLAZONE 5 MG TABLET 50348770_1 CDM 0250 RC 00185-0055-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges METOLAZONE 5 MG TABLET 50348770_1 CDM 0250 RC 00185-0055-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges METOLAZONE 5 MG TABLET 50348770_1 CDM 0250 RC 00185-0055-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges METOLAZONE 5 MG TABLET 50348770_1 CDM 0250 RC 00185-0055-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges METOLAZONE 5 MG TABLET 50348770_1 CDM 0250 RC 00185-0055-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges METOLAZONE 5 MG TABLET 50348770_1 CDM 0250 RC 00185-0055-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges METOLAZONE 5 MG TABLET 50348770_1 CDM 0250 RC 00185-0055-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges METOLAZONE 5 MG TABLET 50348770_1 CDM 0250 RC 00185-0055-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 METOLAZONE 5 MG TABLET 50348770_1 CDM 0250 RC 00185-0055-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 METOLAZONE 5 MG TABLET 50348770_1 CDM 0250 RC 00185-0055-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 METOLAZONE 5 MG TABLET 50348770_1 CDM 0250 RC 00185-0055-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 METOLAZONE 5 MG TABLET 50348770_1 CDM 0250 RC 00185-0055-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges METOLAZONE 5 MG TABLET 50348770_1 CDM 0250 RC 00185-0055-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 OLANZAPINE 2.5 MG TABLET 50348771_1 CDM 0250 RC 69543-0380-30 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges OLANZAPINE 2.5 MG TABLET 50348771_1 CDM 0250 RC 69543-0380-30 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges OLANZAPINE 2.5 MG TABLET 50348771_1 CDM 0250 RC 69543-0380-30 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges OLANZAPINE 2.5 MG TABLET 50348771_1 CDM 0250 RC 69543-0380-30 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges OLANZAPINE 2.5 MG TABLET 50348771_1 CDM 0250 RC 69543-0380-30 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges OLANZAPINE 2.5 MG TABLET 50348771_1 CDM 0250 RC 69543-0380-30 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges OLANZAPINE 2.5 MG TABLET 50348771_1 CDM 0250 RC 69543-0380-30 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges OLANZAPINE 2.5 MG TABLET 50348771_1 CDM 0250 RC 69543-0380-30 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges OLANZAPINE 2.5 MG TABLET 50348771_1 CDM 0250 RC 69543-0380-30 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 OLANZAPINE 2.5 MG TABLET 50348771_1 CDM 0250 RC 69543-0380-30 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 OLANZAPINE 2.5 MG TABLET 50348771_1 CDM 0250 RC 69543-0380-30 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 OLANZAPINE 2.5 MG TABLET 50348771_1 CDM 0250 RC 69543-0380-30 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 OLANZAPINE 2.5 MG TABLET 50348771_1 CDM 0250 RC 69543-0380-30 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges OLANZAPINE 2.5 MG TABLET 50348771_1 CDM 0250 RC 69543-0380-30 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ENOXAPARIN 40 MG/0.4 ML SYR 50348772_1 CDM 0250 RC 63323-0535-98 NDC inpatient 1 UN 36.48 23.71 SELF PAY DISCOUNT SELF PAY DISCOUNT 23.71 65 999999999 22.09 35.39 percent of total billed charges ENOXAPARIN 40 MG/0.4 ML SYR 50348772_1 CDM 0250 RC 63323-0535-98 NDC inpatient 1 UN 36.48 23.71 AETNA AETNA 28.82 79 999999999 22.09 35.39 percent of total billed charges ENOXAPARIN 40 MG/0.4 ML SYR 50348772_1 CDM 0250 RC 63323-0535-98 NDC inpatient 1 UN 36.48 23.71 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.39 97 999999999 22.09 35.39 percent of total billed charges ENOXAPARIN 40 MG/0.4 ML SYR 50348772_1 CDM 0250 RC 63323-0535-98 NDC inpatient 1 UN 36.48 23.71 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.17 69 999999999 22.09 35.39 percent of total billed charges ENOXAPARIN 40 MG/0.4 ML SYR 50348772_1 CDM 0250 RC 63323-0535-98 NDC inpatient 1 UN 36.48 23.71 SIHO - ALL PLANS SIHO - ALL PLANS 32.83 90 999999999 22.09 35.39 percent of total billed charges ENOXAPARIN 40 MG/0.4 ML SYR 50348772_1 CDM 0250 RC 63323-0535-98 NDC inpatient 1 UN 36.48 23.71 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.45 78 999999999 22.09 35.39 percent of total billed charges ENOXAPARIN 40 MG/0.4 ML SYR 50348772_1 CDM 0250 RC 63323-0535-98 NDC inpatient 1 UN 36.48 23.71 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.09 60.55 999999999 22.09 35.39 percent of total billed charges ENOXAPARIN 40 MG/0.4 ML SYR 50348772_1 CDM 0250 RC 63323-0535-98 NDC inpatient 1 UN 36.48 23.71 UMR - ALL PLANS UMR - ALL PLANS 25.54 70 999999999 22.09 35.39 percent of total billed charges ENOXAPARIN 40 MG/0.4 ML SYR 50348772_1 CDM 0250 RC 63323-0535-98 NDC inpatient 1 UN 36.48 23.71 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.09 35.39 ENOXAPARIN 40 MG/0.4 ML SYR 50348772_1 CDM 0250 RC 63323-0535-98 NDC inpatient 1 UN 36.48 23.71 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.09 35.39 ENOXAPARIN 40 MG/0.4 ML SYR 50348772_1 CDM 0250 RC 63323-0535-98 NDC inpatient 1 UN 36.48 23.71 ANTHEM HMO ANTHEM HMO 999999999 22.09 35.39 ENOXAPARIN 40 MG/0.4 ML SYR 50348772_1 CDM 0250 RC 63323-0535-98 NDC inpatient 1 UN 36.48 23.71 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.09 35.39 ENOXAPARIN 40 MG/0.4 ML SYR 50348772_1 CDM 0250 RC 63323-0535-98 NDC inpatient 1 UN 36.48 23.71 CIGNA - ALL PLANS CIGNA - ALL PLANS 24.66 67.6 999999999 22.09 35.39 percent of total billed charges ENOXAPARIN 40 MG/0.4 ML SYR 50348772_1 CDM 0250 RC 63323-0535-98 NDC inpatient 1 UN 36.48 23.71 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.09 35.39 Drainage of blood or fluid accumulation 50348797_1 CDM 0510 RC 10140 HCPCS inpatient 4599 2989.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 2989.35 65 999999999 2784.69 4461.03 percent of total billed charges Drainage of blood or fluid accumulation 50348797_1 CDM 0510 RC 10140 HCPCS inpatient 4599 2989.35 AETNA AETNA 3633.21 79 999999999 2784.69 4461.03 percent of total billed charges Drainage of blood or fluid accumulation 50348797_1 CDM 0510 RC 10140 HCPCS inpatient 4599 2989.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4461.03 97 999999999 2784.69 4461.03 percent of total billed charges Drainage of blood or fluid accumulation 50348797_1 CDM 0510 RC 10140 HCPCS inpatient 4599 2989.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 3173.31 69 999999999 2784.69 4461.03 percent of total billed charges Drainage of blood or fluid accumulation 50348797_1 CDM 0510 RC 10140 HCPCS inpatient 4599 2989.35 SIHO - ALL PLANS SIHO - ALL PLANS 4139.1 90 999999999 2784.69 4461.03 percent of total billed charges Drainage of blood or fluid accumulation 50348797_1 CDM 0510 RC 10140 HCPCS inpatient 4599 2989.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 3587.22 78 999999999 2784.69 4461.03 percent of total billed charges Drainage of blood or fluid accumulation 50348797_1 CDM 0510 RC 10140 HCPCS inpatient 4599 2989.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2784.69 60.55 999999999 2784.69 4461.03 percent of total billed charges Drainage of blood or fluid accumulation 50348797_1 CDM 0510 RC 10140 HCPCS inpatient 4599 2989.35 UMR - ALL PLANS UMR - ALL PLANS 3219.3 70 999999999 2784.69 4461.03 percent of total billed charges Drainage of blood or fluid accumulation 50348797_1 CDM 0510 RC 10140 HCPCS inpatient 4599 2989.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2784.69 4461.03 Drainage of blood or fluid accumulation 50348797_1 CDM 0510 RC 10140 HCPCS inpatient 4599 2989.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2784.69 4461.03 Drainage of blood or fluid accumulation 50348797_1 CDM 0510 RC 10140 HCPCS inpatient 4599 2989.35 ANTHEM HMO ANTHEM HMO 999999999 2784.69 4461.03 Drainage of blood or fluid accumulation 50348797_1 CDM 0510 RC 10140 HCPCS inpatient 4599 2989.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2784.69 4461.03 Drainage of blood or fluid accumulation 50348797_1 CDM 0510 RC 10140 HCPCS inpatient 4599 2989.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 3108.92 67.6 999999999 2784.69 4461.03 percent of total billed charges Drainage of blood or fluid accumulation 50348797_1 CDM 0510 RC 10140 HCPCS inpatient 4599 2989.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 2784.69 4461.03 LEVOTHYROXINE 112 MCG TABLET 50348861_1 CDM 0250 RC 60687-0508-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 112 MCG TABLET 50348861_1 CDM 0250 RC 60687-0508-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 112 MCG TABLET 50348861_1 CDM 0250 RC 60687-0508-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 112 MCG TABLET 50348861_1 CDM 0250 RC 60687-0508-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 112 MCG TABLET 50348861_1 CDM 0250 RC 60687-0508-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 112 MCG TABLET 50348861_1 CDM 0250 RC 60687-0508-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 112 MCG TABLET 50348861_1 CDM 0250 RC 60687-0508-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 112 MCG TABLET 50348861_1 CDM 0250 RC 60687-0508-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 112 MCG TABLET 50348861_1 CDM 0250 RC 60687-0508-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LEVOTHYROXINE 112 MCG TABLET 50348861_1 CDM 0250 RC 60687-0508-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 112 MCG TABLET 50348861_1 CDM 0250 RC 60687-0508-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LEVOTHYROXINE 112 MCG TABLET 50348861_1 CDM 0250 RC 60687-0508-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 112 MCG TABLET 50348861_1 CDM 0250 RC 60687-0508-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 112 MCG TABLET 50348861_1 CDM 0250 RC 60687-0508-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 Molecular pathology procedure level 5 50348903_1 CDM 0310 RC 81404 HCPCS inpatient 1459 948.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 948.35 65 999999999 883.42 1415.23 percent of total billed charges Molecular pathology procedure level 5 50348903_1 CDM 0310 RC 81404 HCPCS inpatient 1459 948.35 AETNA AETNA 1152.61 79 999999999 883.42 1415.23 percent of total billed charges Molecular pathology procedure level 5 50348903_1 CDM 0310 RC 81404 HCPCS inpatient 1459 948.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1415.23 97 999999999 883.42 1415.23 percent of total billed charges Molecular pathology procedure level 5 50348903_1 CDM 0310 RC 81404 HCPCS inpatient 1459 948.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1006.71 69 999999999 883.42 1415.23 percent of total billed charges Molecular pathology procedure level 5 50348903_1 CDM 0310 RC 81404 HCPCS inpatient 1459 948.35 SIHO - ALL PLANS SIHO - ALL PLANS 1313.1 90 999999999 883.42 1415.23 percent of total billed charges Molecular pathology procedure level 5 50348903_1 CDM 0310 RC 81404 HCPCS inpatient 1459 948.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1138.02 78 999999999 883.42 1415.23 percent of total billed charges Molecular pathology procedure level 5 50348903_1 CDM 0310 RC 81404 HCPCS inpatient 1459 948.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 883.42 60.55 999999999 883.42 1415.23 percent of total billed charges Molecular pathology procedure level 5 50348903_1 CDM 0310 RC 81404 HCPCS inpatient 1459 948.35 UMR - ALL PLANS UMR - ALL PLANS 1021.3 70 999999999 883.42 1415.23 percent of total billed charges Molecular pathology procedure level 5 50348903_1 CDM 0310 RC 81404 HCPCS inpatient 1459 948.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 883.42 1415.23 Molecular pathology procedure level 5 50348903_1 CDM 0310 RC 81404 HCPCS inpatient 1459 948.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 883.42 1415.23 Molecular pathology procedure level 5 50348903_1 CDM 0310 RC 81404 HCPCS inpatient 1459 948.35 ANTHEM HMO ANTHEM HMO 999999999 883.42 1415.23 Molecular pathology procedure level 5 50348903_1 CDM 0310 RC 81404 HCPCS inpatient 1459 948.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 883.42 1415.23 Molecular pathology procedure level 5 50348903_1 CDM 0310 RC 81404 HCPCS inpatient 1459 948.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 986.28 67.6 999999999 883.42 1415.23 percent of total billed charges Molecular pathology procedure level 5 50348903_1 CDM 0310 RC 81404 HCPCS inpatient 1459 948.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 883.42 1415.23 Application of mechanical traction 50349031_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 138.45 65 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 50349031_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 AETNA AETNA 168.27 79 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 50349031_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 206.61 97 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 50349031_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 146.97 69 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 50349031_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 SIHO - ALL PLANS SIHO - ALL PLANS 191.7 90 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 50349031_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 166.14 78 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 50349031_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 128.97 60.55 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 50349031_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 UMR - ALL PLANS UMR - ALL PLANS 149.1 70 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 50349031_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 128.97 206.61 Application of mechanical traction 50349031_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 128.97 206.61 Application of mechanical traction 50349031_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 ANTHEM HMO ANTHEM HMO 999999999 128.97 206.61 Application of mechanical traction 50349031_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 128.97 206.61 Application of mechanical traction 50349031_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 143.99 67.6 999999999 128.97 206.61 percent of total billed charges Application of mechanical traction 50349031_1 CDM 0430 RC 97012 HCPCS inpatient 213 138.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 128.97 206.61 "Testing for presence of drug, by chemistry analyzers" 50349088_1 CDM 0301 RC 80307 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50349088_1 CDM 0301 RC 80307 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50349088_1 CDM 0301 RC 80307 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50349088_1 CDM 0301 RC 80307 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50349088_1 CDM 0301 RC 80307 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50349088_1 CDM 0301 RC 80307 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50349088_1 CDM 0301 RC 80307 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50349088_1 CDM 0301 RC 80307 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50349088_1 CDM 0301 RC 80307 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 "Testing for presence of drug, by chemistry analyzers" 50349088_1 CDM 0301 RC 80307 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 "Testing for presence of drug, by chemistry analyzers" 50349088_1 CDM 0301 RC 80307 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 "Testing for presence of drug, by chemistry analyzers" 50349088_1 CDM 0301 RC 80307 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 "Testing for presence of drug, by chemistry analyzers" 50349088_1 CDM 0301 RC 80307 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50349088_1 CDM 0301 RC 80307 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 HEALTHYLAX POWDER PACKET 50351390_1 CDM 0250 RC 60687-0431-98 NDC inpatient 1 UN 1.57 1.02 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.02 65 999999999 0.95 1.52 percent of total billed charges HEALTHYLAX POWDER PACKET 50351390_1 CDM 0250 RC 60687-0431-98 NDC inpatient 1 UN 1.57 1.02 AETNA AETNA 1.24 79 999999999 0.95 1.52 percent of total billed charges HEALTHYLAX POWDER PACKET 50351390_1 CDM 0250 RC 60687-0431-98 NDC inpatient 1 UN 1.57 1.02 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.52 97 999999999 0.95 1.52 percent of total billed charges HEALTHYLAX POWDER PACKET 50351390_1 CDM 0250 RC 60687-0431-98 NDC inpatient 1 UN 1.57 1.02 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.08 69 999999999 0.95 1.52 percent of total billed charges HEALTHYLAX POWDER PACKET 50351390_1 CDM 0250 RC 60687-0431-98 NDC inpatient 1 UN 1.57 1.02 SIHO - ALL PLANS SIHO - ALL PLANS 1.41 90 999999999 0.95 1.52 percent of total billed charges HEALTHYLAX POWDER PACKET 50351390_1 CDM 0250 RC 60687-0431-98 NDC inpatient 1 UN 1.57 1.02 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.22 78 999999999 0.95 1.52 percent of total billed charges HEALTHYLAX POWDER PACKET 50351390_1 CDM 0250 RC 60687-0431-98 NDC inpatient 1 UN 1.57 1.02 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.95 60.55 999999999 0.95 1.52 percent of total billed charges HEALTHYLAX POWDER PACKET 50351390_1 CDM 0250 RC 60687-0431-98 NDC inpatient 1 UN 1.57 1.02 UMR - ALL PLANS UMR - ALL PLANS 1.1 70 999999999 0.95 1.52 percent of total billed charges HEALTHYLAX POWDER PACKET 50351390_1 CDM 0250 RC 60687-0431-98 NDC inpatient 1 UN 1.57 1.02 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.95 1.52 HEALTHYLAX POWDER PACKET 50351390_1 CDM 0250 RC 60687-0431-98 NDC inpatient 1 UN 1.57 1.02 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.95 1.52 HEALTHYLAX POWDER PACKET 50351390_1 CDM 0250 RC 60687-0431-98 NDC inpatient 1 UN 1.57 1.02 ANTHEM HMO ANTHEM HMO 999999999 0.95 1.52 HEALTHYLAX POWDER PACKET 50351390_1 CDM 0250 RC 60687-0431-98 NDC inpatient 1 UN 1.57 1.02 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.95 1.52 HEALTHYLAX POWDER PACKET 50351390_1 CDM 0250 RC 60687-0431-98 NDC inpatient 1 UN 1.57 1.02 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.06 67.6 999999999 0.95 1.52 percent of total billed charges HEALTHYLAX POWDER PACKET 50351390_1 CDM 0250 RC 60687-0431-98 NDC inpatient 1 UN 1.57 1.02 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.95 1.52 ACETAMINOPHEN 325 MG/10.15 ML 50351404_1 CDM 0250 RC 66689-0055-99 NDC inpatient 1 UN 3.07 2 SELF PAY DISCOUNT SELF PAY DISCOUNT 2 65 999999999 1.86 2.98 percent of total billed charges ACETAMINOPHEN 325 MG/10.15 ML 50351404_1 CDM 0250 RC 66689-0055-99 NDC inpatient 1 UN 3.07 2 AETNA AETNA 2.43 79 999999999 1.86 2.98 percent of total billed charges ACETAMINOPHEN 325 MG/10.15 ML 50351404_1 CDM 0250 RC 66689-0055-99 NDC inpatient 1 UN 3.07 2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.98 97 999999999 1.86 2.98 percent of total billed charges ACETAMINOPHEN 325 MG/10.15 ML 50351404_1 CDM 0250 RC 66689-0055-99 NDC inpatient 1 UN 3.07 2 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.12 69 999999999 1.86 2.98 percent of total billed charges ACETAMINOPHEN 325 MG/10.15 ML 50351404_1 CDM 0250 RC 66689-0055-99 NDC inpatient 1 UN 3.07 2 SIHO - ALL PLANS SIHO - ALL PLANS 2.76 90 999999999 1.86 2.98 percent of total billed charges ACETAMINOPHEN 325 MG/10.15 ML 50351404_1 CDM 0250 RC 66689-0055-99 NDC inpatient 1 UN 3.07 2 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.39 78 999999999 1.86 2.98 percent of total billed charges ACETAMINOPHEN 325 MG/10.15 ML 50351404_1 CDM 0250 RC 66689-0055-99 NDC inpatient 1 UN 3.07 2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.86 60.55 999999999 1.86 2.98 percent of total billed charges ACETAMINOPHEN 325 MG/10.15 ML 50351404_1 CDM 0250 RC 66689-0055-99 NDC inpatient 1 UN 3.07 2 UMR - ALL PLANS UMR - ALL PLANS 2.15 70 999999999 1.86 2.98 percent of total billed charges ACETAMINOPHEN 325 MG/10.15 ML 50351404_1 CDM 0250 RC 66689-0055-99 NDC inpatient 1 UN 3.07 2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.86 2.98 ACETAMINOPHEN 325 MG/10.15 ML 50351404_1 CDM 0250 RC 66689-0055-99 NDC inpatient 1 UN 3.07 2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.86 2.98 ACETAMINOPHEN 325 MG/10.15 ML 50351404_1 CDM 0250 RC 66689-0055-99 NDC inpatient 1 UN 3.07 2 ANTHEM HMO ANTHEM HMO 999999999 1.86 2.98 ACETAMINOPHEN 325 MG/10.15 ML 50351404_1 CDM 0250 RC 66689-0055-99 NDC inpatient 1 UN 3.07 2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.86 2.98 ACETAMINOPHEN 325 MG/10.15 ML 50351404_1 CDM 0250 RC 66689-0055-99 NDC inpatient 1 UN 3.07 2 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.08 67.6 999999999 1.86 2.98 percent of total billed charges ACETAMINOPHEN 325 MG/10.15 ML 50351404_1 CDM 0250 RC 66689-0055-99 NDC inpatient 1 UN 3.07 2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.86 2.98 INSYTE AUTO 20G X 1.88 381437 50352305_1 CDM 0270 RC inpatient 13 8.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.45 65 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20G X 1.88 381437 50352305_1 CDM 0270 RC inpatient 13 8.45 AETNA AETNA 10.27 79 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20G X 1.88 381437 50352305_1 CDM 0270 RC inpatient 13 8.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.61 97 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20G X 1.88 381437 50352305_1 CDM 0270 RC inpatient 13 8.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.97 69 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20G X 1.88 381437 50352305_1 CDM 0270 RC inpatient 13 8.45 SIHO - ALL PLANS SIHO - ALL PLANS 11.7 90 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20G X 1.88 381437 50352305_1 CDM 0270 RC inpatient 13 8.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.14 78 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20G X 1.88 381437 50352305_1 CDM 0270 RC inpatient 13 8.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.87 60.55 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20G X 1.88 381437 50352305_1 CDM 0270 RC inpatient 13 8.45 UMR - ALL PLANS UMR - ALL PLANS 9.1 70 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20G X 1.88 381437 50352305_1 CDM 0270 RC inpatient 13 8.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.87 12.61 INSYTE AUTO 20G X 1.88 381437 50352305_1 CDM 0270 RC inpatient 13 8.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.87 12.61 INSYTE AUTO 20G X 1.88 381437 50352305_1 CDM 0270 RC inpatient 13 8.45 ANTHEM HMO ANTHEM HMO 999999999 7.87 12.61 INSYTE AUTO 20G X 1.88 381437 50352305_1 CDM 0270 RC inpatient 13 8.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.87 12.61 INSYTE AUTO 20G X 1.88 381437 50352305_1 CDM 0270 RC inpatient 13 8.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.79 67.6 999999999 7.87 12.61 percent of total billed charges INSYTE AUTO 20G X 1.88 381437 50352305_1 CDM 0270 RC inpatient 13 8.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.87 12.61 CLOTRIMAZOLE 10 MG TROCHE 50354443_1 CDM 0250 RC 00054-4146-22 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CLOTRIMAZOLE 10 MG TROCHE 50354443_1 CDM 0250 RC 00054-4146-22 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CLOTRIMAZOLE 10 MG TROCHE 50354443_1 CDM 0250 RC 00054-4146-22 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CLOTRIMAZOLE 10 MG TROCHE 50354443_1 CDM 0250 RC 00054-4146-22 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CLOTRIMAZOLE 10 MG TROCHE 50354443_1 CDM 0250 RC 00054-4146-22 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CLOTRIMAZOLE 10 MG TROCHE 50354443_1 CDM 0250 RC 00054-4146-22 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CLOTRIMAZOLE 10 MG TROCHE 50354443_1 CDM 0250 RC 00054-4146-22 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CLOTRIMAZOLE 10 MG TROCHE 50354443_1 CDM 0250 RC 00054-4146-22 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CLOTRIMAZOLE 10 MG TROCHE 50354443_1 CDM 0250 RC 00054-4146-22 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CLOTRIMAZOLE 10 MG TROCHE 50354443_1 CDM 0250 RC 00054-4146-22 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CLOTRIMAZOLE 10 MG TROCHE 50354443_1 CDM 0250 RC 00054-4146-22 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CLOTRIMAZOLE 10 MG TROCHE 50354443_1 CDM 0250 RC 00054-4146-22 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CLOTRIMAZOLE 10 MG TROCHE 50354443_1 CDM 0250 RC 00054-4146-22 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CLOTRIMAZOLE 10 MG TROCHE 50354443_1 CDM 0250 RC 00054-4146-22 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 STERILE WATER FOR INJECTION 50354444_1 CDM 0250 RC 00264-7850-00 NDC inpatient 1 UN 66.91 43.49 SELF PAY DISCOUNT SELF PAY DISCOUNT 43.49 65 999999999 40.51 64.9 percent of total billed charges STERILE WATER FOR INJECTION 50354444_1 CDM 0250 RC 00264-7850-00 NDC inpatient 1 UN 66.91 43.49 AETNA AETNA 52.86 79 999999999 40.51 64.9 percent of total billed charges STERILE WATER FOR INJECTION 50354444_1 CDM 0250 RC 00264-7850-00 NDC inpatient 1 UN 66.91 43.49 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.9 97 999999999 40.51 64.9 percent of total billed charges STERILE WATER FOR INJECTION 50354444_1 CDM 0250 RC 00264-7850-00 NDC inpatient 1 UN 66.91 43.49 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.17 69 999999999 40.51 64.9 percent of total billed charges STERILE WATER FOR INJECTION 50354444_1 CDM 0250 RC 00264-7850-00 NDC inpatient 1 UN 66.91 43.49 SIHO - ALL PLANS SIHO - ALL PLANS 60.22 90 999999999 40.51 64.9 percent of total billed charges STERILE WATER FOR INJECTION 50354444_1 CDM 0250 RC 00264-7850-00 NDC inpatient 1 UN 66.91 43.49 HUMANA - ALL PLANS HUMANA - ALL PLANS 52.19 78 999999999 40.51 64.9 percent of total billed charges STERILE WATER FOR INJECTION 50354444_1 CDM 0250 RC 00264-7850-00 NDC inpatient 1 UN 66.91 43.49 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 40.51 60.55 999999999 40.51 64.9 percent of total billed charges STERILE WATER FOR INJECTION 50354444_1 CDM 0250 RC 00264-7850-00 NDC inpatient 1 UN 66.91 43.49 UMR - ALL PLANS UMR - ALL PLANS 46.84 70 999999999 40.51 64.9 percent of total billed charges STERILE WATER FOR INJECTION 50354444_1 CDM 0250 RC 00264-7850-00 NDC inpatient 1 UN 66.91 43.49 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 40.51 64.9 STERILE WATER FOR INJECTION 50354444_1 CDM 0250 RC 00264-7850-00 NDC inpatient 1 UN 66.91 43.49 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 40.51 64.9 STERILE WATER FOR INJECTION 50354444_1 CDM 0250 RC 00264-7850-00 NDC inpatient 1 UN 66.91 43.49 ANTHEM HMO ANTHEM HMO 999999999 40.51 64.9 STERILE WATER FOR INJECTION 50354444_1 CDM 0250 RC 00264-7850-00 NDC inpatient 1 UN 66.91 43.49 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 40.51 64.9 STERILE WATER FOR INJECTION 50354444_1 CDM 0250 RC 00264-7850-00 NDC inpatient 1 UN 66.91 43.49 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.23 67.6 999999999 40.51 64.9 percent of total billed charges STERILE WATER FOR INJECTION 50354444_1 CDM 0250 RC 00264-7850-00 NDC inpatient 1 UN 66.91 43.49 UHC - ALL PLANS UHC - ALL PLANS 999999999 40.51 64.9 "Therapy procedure for a range of mental processes, initial 15 minutes" 50354875_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354875_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354875_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354875_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354875_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354875_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354875_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354875_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354875_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, initial 15 minutes" 50354875_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, initial 15 minutes" 50354875_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, initial 15 minutes" 50354875_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, initial 15 minutes" 50354875_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354875_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, initial 15 minutes" 50354877_1 CDM 0440 RC 97129 HCPCS inpatient 411 267.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 267.15 65 999999999 248.86 398.67 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354877_1 CDM 0440 RC 97129 HCPCS inpatient 411 267.15 AETNA AETNA 324.69 79 999999999 248.86 398.67 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354877_1 CDM 0440 RC 97129 HCPCS inpatient 411 267.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 398.67 97 999999999 248.86 398.67 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354877_1 CDM 0440 RC 97129 HCPCS inpatient 411 267.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 283.59 69 999999999 248.86 398.67 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354877_1 CDM 0440 RC 97129 HCPCS inpatient 411 267.15 SIHO - ALL PLANS SIHO - ALL PLANS 369.9 90 999999999 248.86 398.67 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354877_1 CDM 0440 RC 97129 HCPCS inpatient 411 267.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 320.58 78 999999999 248.86 398.67 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354877_1 CDM 0440 RC 97129 HCPCS inpatient 411 267.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 248.86 60.55 999999999 248.86 398.67 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354877_1 CDM 0440 RC 97129 HCPCS inpatient 411 267.15 UMR - ALL PLANS UMR - ALL PLANS 287.7 70 999999999 248.86 398.67 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354877_1 CDM 0440 RC 97129 HCPCS inpatient 411 267.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 248.86 398.67 "Therapy procedure for a range of mental processes, initial 15 minutes" 50354877_1 CDM 0440 RC 97129 HCPCS inpatient 411 267.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 248.86 398.67 "Therapy procedure for a range of mental processes, initial 15 minutes" 50354877_1 CDM 0440 RC 97129 HCPCS inpatient 411 267.15 ANTHEM HMO ANTHEM HMO 999999999 248.86 398.67 "Therapy procedure for a range of mental processes, initial 15 minutes" 50354877_1 CDM 0440 RC 97129 HCPCS inpatient 411 267.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 248.86 398.67 "Therapy procedure for a range of mental processes, initial 15 minutes" 50354877_1 CDM 0440 RC 97129 HCPCS inpatient 411 267.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 277.84 67.6 999999999 248.86 398.67 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354877_1 CDM 0440 RC 97129 HCPCS inpatient 411 267.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 248.86 398.67 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354879_1 CDM 0440 RC 97130 HCPCS inpatient 411 267.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 267.15 65 999999999 248.86 398.67 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354879_1 CDM 0440 RC 97130 HCPCS inpatient 411 267.15 AETNA AETNA 324.69 79 999999999 248.86 398.67 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354879_1 CDM 0440 RC 97130 HCPCS inpatient 411 267.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 398.67 97 999999999 248.86 398.67 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354879_1 CDM 0440 RC 97130 HCPCS inpatient 411 267.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 283.59 69 999999999 248.86 398.67 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354879_1 CDM 0440 RC 97130 HCPCS inpatient 411 267.15 SIHO - ALL PLANS SIHO - ALL PLANS 369.9 90 999999999 248.86 398.67 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354879_1 CDM 0440 RC 97130 HCPCS inpatient 411 267.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 320.58 78 999999999 248.86 398.67 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354879_1 CDM 0440 RC 97130 HCPCS inpatient 411 267.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 248.86 60.55 999999999 248.86 398.67 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354879_1 CDM 0440 RC 97130 HCPCS inpatient 411 267.15 UMR - ALL PLANS UMR - ALL PLANS 287.7 70 999999999 248.86 398.67 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354879_1 CDM 0440 RC 97130 HCPCS inpatient 411 267.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 248.86 398.67 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354879_1 CDM 0440 RC 97130 HCPCS inpatient 411 267.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 248.86 398.67 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354879_1 CDM 0440 RC 97130 HCPCS inpatient 411 267.15 ANTHEM HMO ANTHEM HMO 999999999 248.86 398.67 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354879_1 CDM 0440 RC 97130 HCPCS inpatient 411 267.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 248.86 398.67 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354879_1 CDM 0440 RC 97130 HCPCS inpatient 411 267.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 277.84 67.6 999999999 248.86 398.67 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354879_1 CDM 0440 RC 97130 HCPCS inpatient 411 267.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 248.86 398.67 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354881_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354881_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354881_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354881_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354881_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354881_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354881_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354881_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354881_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354881_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354881_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354881_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354881_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354881_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, initial 15 minutes" 50354925_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354925_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354925_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354925_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354925_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354925_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354925_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354925_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354925_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, initial 15 minutes" 50354925_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, initial 15 minutes" 50354925_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, initial 15 minutes" 50354925_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, initial 15 minutes" 50354925_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50354925_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354929_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354929_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354929_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354929_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354929_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354929_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354929_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354929_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354929_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354929_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354929_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354929_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354929_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50354929_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 LORAZEPAM 0.5 MG TABLET 50356227_1 CDM 0250 RC 00904-6007-61 NDC inpatient 1 UN 1.99 1.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.29 65 999999999 1.2 1.93 percent of total billed charges LORAZEPAM 0.5 MG TABLET 50356227_1 CDM 0250 RC 00904-6007-61 NDC inpatient 1 UN 1.99 1.29 AETNA AETNA 1.57 79 999999999 1.2 1.93 percent of total billed charges LORAZEPAM 0.5 MG TABLET 50356227_1 CDM 0250 RC 00904-6007-61 NDC inpatient 1 UN 1.99 1.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.93 97 999999999 1.2 1.93 percent of total billed charges LORAZEPAM 0.5 MG TABLET 50356227_1 CDM 0250 RC 00904-6007-61 NDC inpatient 1 UN 1.99 1.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.37 69 999999999 1.2 1.93 percent of total billed charges LORAZEPAM 0.5 MG TABLET 50356227_1 CDM 0250 RC 00904-6007-61 NDC inpatient 1 UN 1.99 1.29 SIHO - ALL PLANS SIHO - ALL PLANS 1.79 90 999999999 1.2 1.93 percent of total billed charges LORAZEPAM 0.5 MG TABLET 50356227_1 CDM 0250 RC 00904-6007-61 NDC inpatient 1 UN 1.99 1.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.55 78 999999999 1.2 1.93 percent of total billed charges LORAZEPAM 0.5 MG TABLET 50356227_1 CDM 0250 RC 00904-6007-61 NDC inpatient 1 UN 1.99 1.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.2 60.55 999999999 1.2 1.93 percent of total billed charges LORAZEPAM 0.5 MG TABLET 50356227_1 CDM 0250 RC 00904-6007-61 NDC inpatient 1 UN 1.99 1.29 UMR - ALL PLANS UMR - ALL PLANS 1.39 70 999999999 1.2 1.93 percent of total billed charges LORAZEPAM 0.5 MG TABLET 50356227_1 CDM 0250 RC 00904-6007-61 NDC inpatient 1 UN 1.99 1.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.2 1.93 LORAZEPAM 0.5 MG TABLET 50356227_1 CDM 0250 RC 00904-6007-61 NDC inpatient 1 UN 1.99 1.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.2 1.93 LORAZEPAM 0.5 MG TABLET 50356227_1 CDM 0250 RC 00904-6007-61 NDC inpatient 1 UN 1.99 1.29 ANTHEM HMO ANTHEM HMO 999999999 1.2 1.93 LORAZEPAM 0.5 MG TABLET 50356227_1 CDM 0250 RC 00904-6007-61 NDC inpatient 1 UN 1.99 1.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.2 1.93 LORAZEPAM 0.5 MG TABLET 50356227_1 CDM 0250 RC 00904-6007-61 NDC inpatient 1 UN 1.99 1.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.2 1.93 percent of total billed charges LORAZEPAM 0.5 MG TABLET 50356227_1 CDM 0250 RC 00904-6007-61 NDC inpatient 1 UN 1.99 1.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.2 1.93 "INJECTION, VANCOMYCIN HCL, 500 MG" 50356454_1 CDM 0250 RC 67457-0823-99 NDC J3370 HCPCS inpatient 3 UN 99.64 64.77 SELF PAY DISCOUNT SELF PAY DISCOUNT 64.77 65 999999999 60.33 96.65 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50356454_1 CDM 0250 RC 67457-0823-99 NDC J3370 HCPCS inpatient 3 UN 99.64 64.77 AETNA AETNA 78.72 79 999999999 60.33 96.65 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50356454_1 CDM 0250 RC 67457-0823-99 NDC J3370 HCPCS inpatient 3 UN 99.64 64.77 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 96.65 97 999999999 60.33 96.65 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50356454_1 CDM 0250 RC 67457-0823-99 NDC J3370 HCPCS inpatient 3 UN 99.64 64.77 ENCORE - ALL PLANS ENCORE - ALL PLANS 68.75 69 999999999 60.33 96.65 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50356454_1 CDM 0250 RC 67457-0823-99 NDC J3370 HCPCS inpatient 3 UN 99.64 64.77 SIHO - ALL PLANS SIHO - ALL PLANS 89.68 90 999999999 60.33 96.65 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50356454_1 CDM 0250 RC 67457-0823-99 NDC J3370 HCPCS inpatient 3 UN 99.64 64.77 HUMANA - ALL PLANS HUMANA - ALL PLANS 77.72 78 999999999 60.33 96.65 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50356454_1 CDM 0250 RC 67457-0823-99 NDC J3370 HCPCS inpatient 3 UN 99.64 64.77 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.33 60.55 999999999 60.33 96.65 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50356454_1 CDM 0250 RC 67457-0823-99 NDC J3370 HCPCS inpatient 3 UN 99.64 64.77 UMR - ALL PLANS UMR - ALL PLANS 69.75 70 999999999 60.33 96.65 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50356454_1 CDM 0250 RC 67457-0823-99 NDC J3370 HCPCS inpatient 3 UN 99.64 64.77 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.33 96.65 "INJECTION, VANCOMYCIN HCL, 500 MG" 50356454_1 CDM 0250 RC 67457-0823-99 NDC J3370 HCPCS inpatient 3 UN 99.64 64.77 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.33 96.65 "INJECTION, VANCOMYCIN HCL, 500 MG" 50356454_1 CDM 0250 RC 67457-0823-99 NDC J3370 HCPCS inpatient 3 UN 99.64 64.77 ANTHEM HMO ANTHEM HMO 999999999 60.33 96.65 "INJECTION, VANCOMYCIN HCL, 500 MG" 50356454_1 CDM 0250 RC 67457-0823-99 NDC J3370 HCPCS inpatient 3 UN 99.64 64.77 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.33 96.65 "INJECTION, VANCOMYCIN HCL, 500 MG" 50356454_1 CDM 0250 RC 67457-0823-99 NDC J3370 HCPCS inpatient 3 UN 99.64 64.77 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.36 67.6 999999999 60.33 96.65 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50356454_1 CDM 0250 RC 67457-0823-99 NDC J3370 HCPCS inpatient 3 UN 99.64 64.77 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.33 96.65 "INJECTION, VANCOMYCIN HCL, 500 MG" 50356458_1 CDM 0250 RC 67457-0824-99 NDC J3370 HCPCS inpatient 3 UN 127.39 82.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 82.8 65 999999999 77.13 123.57 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50356458_1 CDM 0250 RC 67457-0824-99 NDC J3370 HCPCS inpatient 3 UN 127.39 82.8 AETNA AETNA 100.64 79 999999999 77.13 123.57 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50356458_1 CDM 0250 RC 67457-0824-99 NDC J3370 HCPCS inpatient 3 UN 127.39 82.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 123.57 97 999999999 77.13 123.57 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50356458_1 CDM 0250 RC 67457-0824-99 NDC J3370 HCPCS inpatient 3 UN 127.39 82.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 87.9 69 999999999 77.13 123.57 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50356458_1 CDM 0250 RC 67457-0824-99 NDC J3370 HCPCS inpatient 3 UN 127.39 82.8 SIHO - ALL PLANS SIHO - ALL PLANS 114.65 90 999999999 77.13 123.57 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50356458_1 CDM 0250 RC 67457-0824-99 NDC J3370 HCPCS inpatient 3 UN 127.39 82.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 99.36 78 999999999 77.13 123.57 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50356458_1 CDM 0250 RC 67457-0824-99 NDC J3370 HCPCS inpatient 3 UN 127.39 82.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 77.13 60.55 999999999 77.13 123.57 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50356458_1 CDM 0250 RC 67457-0824-99 NDC J3370 HCPCS inpatient 3 UN 127.39 82.8 UMR - ALL PLANS UMR - ALL PLANS 89.17 70 999999999 77.13 123.57 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50356458_1 CDM 0250 RC 67457-0824-99 NDC J3370 HCPCS inpatient 3 UN 127.39 82.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 77.13 123.57 "INJECTION, VANCOMYCIN HCL, 500 MG" 50356458_1 CDM 0250 RC 67457-0824-99 NDC J3370 HCPCS inpatient 3 UN 127.39 82.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 77.13 123.57 "INJECTION, VANCOMYCIN HCL, 500 MG" 50356458_1 CDM 0250 RC 67457-0824-99 NDC J3370 HCPCS inpatient 3 UN 127.39 82.8 ANTHEM HMO ANTHEM HMO 999999999 77.13 123.57 "INJECTION, VANCOMYCIN HCL, 500 MG" 50356458_1 CDM 0250 RC 67457-0824-99 NDC J3370 HCPCS inpatient 3 UN 127.39 82.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 77.13 123.57 "INJECTION, VANCOMYCIN HCL, 500 MG" 50356458_1 CDM 0250 RC 67457-0824-99 NDC J3370 HCPCS inpatient 3 UN 127.39 82.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 86.12 67.6 999999999 77.13 123.57 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50356458_1 CDM 0250 RC 67457-0824-99 NDC J3370 HCPCS inpatient 3 UN 127.39 82.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 77.13 123.57 Hemoglobin measurement 50356461_1 CDM 0305 RC 88738 HCPCS inpatient 104 67.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 67.6 65 999999999 62.97 100.88 percent of total billed charges Hemoglobin measurement 50356461_1 CDM 0305 RC 88738 HCPCS inpatient 104 67.6 AETNA AETNA 82.16 79 999999999 62.97 100.88 percent of total billed charges Hemoglobin measurement 50356461_1 CDM 0305 RC 88738 HCPCS inpatient 104 67.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 100.88 97 999999999 62.97 100.88 percent of total billed charges Hemoglobin measurement 50356461_1 CDM 0305 RC 88738 HCPCS inpatient 104 67.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.76 69 999999999 62.97 100.88 percent of total billed charges Hemoglobin measurement 50356461_1 CDM 0305 RC 88738 HCPCS inpatient 104 67.6 SIHO - ALL PLANS SIHO - ALL PLANS 93.6 90 999999999 62.97 100.88 percent of total billed charges Hemoglobin measurement 50356461_1 CDM 0305 RC 88738 HCPCS inpatient 104 67.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.12 78 999999999 62.97 100.88 percent of total billed charges Hemoglobin measurement 50356461_1 CDM 0305 RC 88738 HCPCS inpatient 104 67.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.97 60.55 999999999 62.97 100.88 percent of total billed charges Hemoglobin measurement 50356461_1 CDM 0305 RC 88738 HCPCS inpatient 104 67.6 UMR - ALL PLANS UMR - ALL PLANS 72.8 70 999999999 62.97 100.88 percent of total billed charges Hemoglobin measurement 50356461_1 CDM 0305 RC 88738 HCPCS inpatient 104 67.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.97 100.88 Hemoglobin measurement 50356461_1 CDM 0305 RC 88738 HCPCS inpatient 104 67.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.97 100.88 Hemoglobin measurement 50356461_1 CDM 0305 RC 88738 HCPCS inpatient 104 67.6 ANTHEM HMO ANTHEM HMO 999999999 62.97 100.88 Hemoglobin measurement 50356461_1 CDM 0305 RC 88738 HCPCS inpatient 104 67.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.97 100.88 Hemoglobin measurement 50356461_1 CDM 0305 RC 88738 HCPCS inpatient 104 67.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.3 67.6 999999999 62.97 100.88 percent of total billed charges Hemoglobin measurement 50356461_1 CDM 0305 RC 88738 HCPCS inpatient 104 67.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.97 100.88 PRECEDEX 400 MCG/100 ML BOTTLE 50356496_1 CDM 0250 RC 00409-1660-10 NDC inpatient 1 UN 225.88 146.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 146.82 65 999999999 136.77 219.1 percent of total billed charges PRECEDEX 400 MCG/100 ML BOTTLE 50356496_1 CDM 0250 RC 00409-1660-10 NDC inpatient 1 UN 225.88 146.82 AETNA AETNA 178.45 79 999999999 136.77 219.1 percent of total billed charges PRECEDEX 400 MCG/100 ML BOTTLE 50356496_1 CDM 0250 RC 00409-1660-10 NDC inpatient 1 UN 225.88 146.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 219.1 97 999999999 136.77 219.1 percent of total billed charges PRECEDEX 400 MCG/100 ML BOTTLE 50356496_1 CDM 0250 RC 00409-1660-10 NDC inpatient 1 UN 225.88 146.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 155.86 69 999999999 136.77 219.1 percent of total billed charges PRECEDEX 400 MCG/100 ML BOTTLE 50356496_1 CDM 0250 RC 00409-1660-10 NDC inpatient 1 UN 225.88 146.82 SIHO - ALL PLANS SIHO - ALL PLANS 203.29 90 999999999 136.77 219.1 percent of total billed charges PRECEDEX 400 MCG/100 ML BOTTLE 50356496_1 CDM 0250 RC 00409-1660-10 NDC inpatient 1 UN 225.88 146.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 176.19 78 999999999 136.77 219.1 percent of total billed charges PRECEDEX 400 MCG/100 ML BOTTLE 50356496_1 CDM 0250 RC 00409-1660-10 NDC inpatient 1 UN 225.88 146.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 136.77 60.55 999999999 136.77 219.1 percent of total billed charges PRECEDEX 400 MCG/100 ML BOTTLE 50356496_1 CDM 0250 RC 00409-1660-10 NDC inpatient 1 UN 225.88 146.82 UMR - ALL PLANS UMR - ALL PLANS 158.12 70 999999999 136.77 219.1 percent of total billed charges PRECEDEX 400 MCG/100 ML BOTTLE 50356496_1 CDM 0250 RC 00409-1660-10 NDC inpatient 1 UN 225.88 146.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 136.77 219.1 PRECEDEX 400 MCG/100 ML BOTTLE 50356496_1 CDM 0250 RC 00409-1660-10 NDC inpatient 1 UN 225.88 146.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 136.77 219.1 PRECEDEX 400 MCG/100 ML BOTTLE 50356496_1 CDM 0250 RC 00409-1660-10 NDC inpatient 1 UN 225.88 146.82 ANTHEM HMO ANTHEM HMO 999999999 136.77 219.1 PRECEDEX 400 MCG/100 ML BOTTLE 50356496_1 CDM 0250 RC 00409-1660-10 NDC inpatient 1 UN 225.88 146.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 136.77 219.1 PRECEDEX 400 MCG/100 ML BOTTLE 50356496_1 CDM 0250 RC 00409-1660-10 NDC inpatient 1 UN 225.88 146.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 152.69 67.6 999999999 136.77 219.1 percent of total billed charges PRECEDEX 400 MCG/100 ML BOTTLE 50356496_1 CDM 0250 RC 00409-1660-10 NDC inpatient 1 UN 225.88 146.82 UHC - ALL PLANS UHC - ALL PLANS 999999999 136.77 219.1 "Analysis of substance using immunoassay technique, multiple step method" 50356742_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50356742_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50356742_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50356742_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50356742_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50356742_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50356742_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50356742_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50356742_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50356742_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50356742_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50356742_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50356742_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50356742_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 "INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG" 50356767_1 CDM 0636 RC 00143-9547-01 NDC J9000 HCPCS inpatient 5 UN 94.06 61.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.14 65 999999999 56.95 91.24 percent of total billed charges "INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG" 50356767_1 CDM 0636 RC 00143-9547-01 NDC J9000 HCPCS inpatient 5 UN 94.06 61.14 AETNA AETNA 74.31 79 999999999 56.95 91.24 percent of total billed charges "INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG" 50356767_1 CDM 0636 RC 00143-9547-01 NDC J9000 HCPCS inpatient 5 UN 94.06 61.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.24 97 999999999 56.95 91.24 percent of total billed charges "INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG" 50356767_1 CDM 0636 RC 00143-9547-01 NDC J9000 HCPCS inpatient 5 UN 94.06 61.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.9 69 999999999 56.95 91.24 percent of total billed charges "INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG" 50356767_1 CDM 0636 RC 00143-9547-01 NDC J9000 HCPCS inpatient 5 UN 94.06 61.14 SIHO - ALL PLANS SIHO - ALL PLANS 84.65 90 999999999 56.95 91.24 percent of total billed charges "INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG" 50356767_1 CDM 0636 RC 00143-9547-01 NDC J9000 HCPCS inpatient 5 UN 94.06 61.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.37 78 999999999 56.95 91.24 percent of total billed charges "INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG" 50356767_1 CDM 0636 RC 00143-9547-01 NDC J9000 HCPCS inpatient 5 UN 94.06 61.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.95 60.55 999999999 56.95 91.24 percent of total billed charges "INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG" 50356767_1 CDM 0636 RC 00143-9547-01 NDC J9000 HCPCS inpatient 5 UN 94.06 61.14 UMR - ALL PLANS UMR - ALL PLANS 65.84 70 999999999 56.95 91.24 percent of total billed charges "INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG" 50356767_1 CDM 0636 RC 00143-9547-01 NDC J9000 HCPCS inpatient 5 UN 94.06 61.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.95 91.24 "INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG" 50356767_1 CDM 0636 RC 00143-9547-01 NDC J9000 HCPCS inpatient 5 UN 94.06 61.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.95 91.24 "INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG" 50356767_1 CDM 0636 RC 00143-9547-01 NDC J9000 HCPCS inpatient 5 UN 94.06 61.14 ANTHEM HMO ANTHEM HMO 999999999 56.95 91.24 "INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG" 50356767_1 CDM 0636 RC 00143-9547-01 NDC J9000 HCPCS inpatient 5 UN 94.06 61.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.95 91.24 "INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG" 50356767_1 CDM 0636 RC 00143-9547-01 NDC J9000 HCPCS inpatient 5 UN 94.06 61.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.58 67.6 999999999 56.95 91.24 percent of total billed charges "INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG" 50356767_1 CDM 0636 RC 00143-9547-01 NDC J9000 HCPCS inpatient 5 UN 94.06 61.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.95 91.24 "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50356818_1 CDM 0250 RC 17478-0953-02 NDC J0153 HCPCS inpatient 6 UN 24.54 15.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 15.95 65 999999999 14.86 23.8 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50356818_1 CDM 0250 RC 17478-0953-02 NDC J0153 HCPCS inpatient 6 UN 24.54 15.95 AETNA AETNA 19.39 79 999999999 14.86 23.8 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50356818_1 CDM 0250 RC 17478-0953-02 NDC J0153 HCPCS inpatient 6 UN 24.54 15.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23.8 97 999999999 14.86 23.8 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50356818_1 CDM 0250 RC 17478-0953-02 NDC J0153 HCPCS inpatient 6 UN 24.54 15.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 16.93 69 999999999 14.86 23.8 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50356818_1 CDM 0250 RC 17478-0953-02 NDC J0153 HCPCS inpatient 6 UN 24.54 15.95 SIHO - ALL PLANS SIHO - ALL PLANS 22.09 90 999999999 14.86 23.8 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50356818_1 CDM 0250 RC 17478-0953-02 NDC J0153 HCPCS inpatient 6 UN 24.54 15.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.14 78 999999999 14.86 23.8 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50356818_1 CDM 0250 RC 17478-0953-02 NDC J0153 HCPCS inpatient 6 UN 24.54 15.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.86 60.55 999999999 14.86 23.8 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50356818_1 CDM 0250 RC 17478-0953-02 NDC J0153 HCPCS inpatient 6 UN 24.54 15.95 UMR - ALL PLANS UMR - ALL PLANS 17.18 70 999999999 14.86 23.8 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50356818_1 CDM 0250 RC 17478-0953-02 NDC J0153 HCPCS inpatient 6 UN 24.54 15.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.86 23.8 "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50356818_1 CDM 0250 RC 17478-0953-02 NDC J0153 HCPCS inpatient 6 UN 24.54 15.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.86 23.8 "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50356818_1 CDM 0250 RC 17478-0953-02 NDC J0153 HCPCS inpatient 6 UN 24.54 15.95 ANTHEM HMO ANTHEM HMO 999999999 14.86 23.8 "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50356818_1 CDM 0250 RC 17478-0953-02 NDC J0153 HCPCS inpatient 6 UN 24.54 15.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.86 23.8 "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50356818_1 CDM 0250 RC 17478-0953-02 NDC J0153 HCPCS inpatient 6 UN 24.54 15.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.59 67.6 999999999 14.86 23.8 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50356818_1 CDM 0250 RC 17478-0953-02 NDC J0153 HCPCS inpatient 6 UN 24.54 15.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.86 23.8 TRAVOPROST 0.004% EYE DROP 50368846_1 CDM 0250 RC 00378-9651-32 NDC inpatient 1 UN 211.97 137.78 SELF PAY DISCOUNT SELF PAY DISCOUNT 137.78 65 999999999 128.35 205.61 percent of total billed charges TRAVOPROST 0.004% EYE DROP 50368846_1 CDM 0250 RC 00378-9651-32 NDC inpatient 1 UN 211.97 137.78 AETNA AETNA 167.46 79 999999999 128.35 205.61 percent of total billed charges TRAVOPROST 0.004% EYE DROP 50368846_1 CDM 0250 RC 00378-9651-32 NDC inpatient 1 UN 211.97 137.78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 205.61 97 999999999 128.35 205.61 percent of total billed charges TRAVOPROST 0.004% EYE DROP 50368846_1 CDM 0250 RC 00378-9651-32 NDC inpatient 1 UN 211.97 137.78 ENCORE - ALL PLANS ENCORE - ALL PLANS 146.26 69 999999999 128.35 205.61 percent of total billed charges TRAVOPROST 0.004% EYE DROP 50368846_1 CDM 0250 RC 00378-9651-32 NDC inpatient 1 UN 211.97 137.78 SIHO - ALL PLANS SIHO - ALL PLANS 190.77 90 999999999 128.35 205.61 percent of total billed charges TRAVOPROST 0.004% EYE DROP 50368846_1 CDM 0250 RC 00378-9651-32 NDC inpatient 1 UN 211.97 137.78 HUMANA - ALL PLANS HUMANA - ALL PLANS 165.34 78 999999999 128.35 205.61 percent of total billed charges TRAVOPROST 0.004% EYE DROP 50368846_1 CDM 0250 RC 00378-9651-32 NDC inpatient 1 UN 211.97 137.78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 128.35 60.55 999999999 128.35 205.61 percent of total billed charges TRAVOPROST 0.004% EYE DROP 50368846_1 CDM 0250 RC 00378-9651-32 NDC inpatient 1 UN 211.97 137.78 UMR - ALL PLANS UMR - ALL PLANS 148.38 70 999999999 128.35 205.61 percent of total billed charges TRAVOPROST 0.004% EYE DROP 50368846_1 CDM 0250 RC 00378-9651-32 NDC inpatient 1 UN 211.97 137.78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 128.35 205.61 TRAVOPROST 0.004% EYE DROP 50368846_1 CDM 0250 RC 00378-9651-32 NDC inpatient 1 UN 211.97 137.78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 128.35 205.61 TRAVOPROST 0.004% EYE DROP 50368846_1 CDM 0250 RC 00378-9651-32 NDC inpatient 1 UN 211.97 137.78 ANTHEM HMO ANTHEM HMO 999999999 128.35 205.61 TRAVOPROST 0.004% EYE DROP 50368846_1 CDM 0250 RC 00378-9651-32 NDC inpatient 1 UN 211.97 137.78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 128.35 205.61 TRAVOPROST 0.004% EYE DROP 50368846_1 CDM 0250 RC 00378-9651-32 NDC inpatient 1 UN 211.97 137.78 CIGNA - ALL PLANS CIGNA - ALL PLANS 143.29 67.6 999999999 128.35 205.61 percent of total billed charges TRAVOPROST 0.004% EYE DROP 50368846_1 CDM 0250 RC 00378-9651-32 NDC inpatient 1 UN 211.97 137.78 UHC - ALL PLANS UHC - ALL PLANS 999999999 128.35 205.61 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50369860_1 CDM 0258 RC 00264-7510-00 NDC J7060 HCPCS inpatient 1 UN 66.42 43.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 43.17 65 999999999 40.22 64.43 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50369860_1 CDM 0258 RC 00264-7510-00 NDC J7060 HCPCS inpatient 1 UN 66.42 43.17 AETNA AETNA 52.47 79 999999999 40.22 64.43 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50369860_1 CDM 0258 RC 00264-7510-00 NDC J7060 HCPCS inpatient 1 UN 66.42 43.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.43 97 999999999 40.22 64.43 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50369860_1 CDM 0258 RC 00264-7510-00 NDC J7060 HCPCS inpatient 1 UN 66.42 43.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.83 69 999999999 40.22 64.43 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50369860_1 CDM 0258 RC 00264-7510-00 NDC J7060 HCPCS inpatient 1 UN 66.42 43.17 SIHO - ALL PLANS SIHO - ALL PLANS 59.78 90 999999999 40.22 64.43 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50369860_1 CDM 0258 RC 00264-7510-00 NDC J7060 HCPCS inpatient 1 UN 66.42 43.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.81 78 999999999 40.22 64.43 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50369860_1 CDM 0258 RC 00264-7510-00 NDC J7060 HCPCS inpatient 1 UN 66.42 43.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 40.22 60.55 999999999 40.22 64.43 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50369860_1 CDM 0258 RC 00264-7510-00 NDC J7060 HCPCS inpatient 1 UN 66.42 43.17 UMR - ALL PLANS UMR - ALL PLANS 46.49 70 999999999 40.22 64.43 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50369860_1 CDM 0258 RC 00264-7510-00 NDC J7060 HCPCS inpatient 1 UN 66.42 43.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 40.22 64.43 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50369860_1 CDM 0258 RC 00264-7510-00 NDC J7060 HCPCS inpatient 1 UN 66.42 43.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 40.22 64.43 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50369860_1 CDM 0258 RC 00264-7510-00 NDC J7060 HCPCS inpatient 1 UN 66.42 43.17 ANTHEM HMO ANTHEM HMO 999999999 40.22 64.43 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50369860_1 CDM 0258 RC 00264-7510-00 NDC J7060 HCPCS inpatient 1 UN 66.42 43.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 40.22 64.43 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50369860_1 CDM 0258 RC 00264-7510-00 NDC J7060 HCPCS inpatient 1 UN 66.42 43.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.9 67.6 999999999 40.22 64.43 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50369860_1 CDM 0258 RC 00264-7510-00 NDC J7060 HCPCS inpatient 1 UN 66.42 43.17 UHC - ALL PLANS UHC - ALL PLANS 999999999 40.22 64.43 ALPRAZOLAM 0.5 MG TABLET 50369870_1 CDM 0250 RC 59762-3720-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ALPRAZOLAM 0.5 MG TABLET 50369870_1 CDM 0250 RC 59762-3720-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ALPRAZOLAM 0.5 MG TABLET 50369870_1 CDM 0250 RC 59762-3720-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ALPRAZOLAM 0.5 MG TABLET 50369870_1 CDM 0250 RC 59762-3720-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ALPRAZOLAM 0.5 MG TABLET 50369870_1 CDM 0250 RC 59762-3720-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ALPRAZOLAM 0.5 MG TABLET 50369870_1 CDM 0250 RC 59762-3720-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ALPRAZOLAM 0.5 MG TABLET 50369870_1 CDM 0250 RC 59762-3720-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ALPRAZOLAM 0.5 MG TABLET 50369870_1 CDM 0250 RC 59762-3720-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ALPRAZOLAM 0.5 MG TABLET 50369870_1 CDM 0250 RC 59762-3720-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ALPRAZOLAM 0.5 MG TABLET 50369870_1 CDM 0250 RC 59762-3720-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ALPRAZOLAM 0.5 MG TABLET 50369870_1 CDM 0250 RC 59762-3720-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ALPRAZOLAM 0.5 MG TABLET 50369870_1 CDM 0250 RC 59762-3720-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ALPRAZOLAM 0.5 MG TABLET 50369870_1 CDM 0250 RC 59762-3720-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges ALPRAZOLAM 0.5 MG TABLET 50369870_1 CDM 0250 RC 59762-3720-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CLINDAMYCIN 600 MG/50 ML-D5W 50370203_1 CDM 0250 RC 00338-3612-24 NDC inpatient 1 UN 72.23 46.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.95 65 999999999 43.74 70.06 percent of total billed charges CLINDAMYCIN 600 MG/50 ML-D5W 50370203_1 CDM 0250 RC 00338-3612-24 NDC inpatient 1 UN 72.23 46.95 AETNA AETNA 57.06 79 999999999 43.74 70.06 percent of total billed charges CLINDAMYCIN 600 MG/50 ML-D5W 50370203_1 CDM 0250 RC 00338-3612-24 NDC inpatient 1 UN 72.23 46.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.06 97 999999999 43.74 70.06 percent of total billed charges CLINDAMYCIN 600 MG/50 ML-D5W 50370203_1 CDM 0250 RC 00338-3612-24 NDC inpatient 1 UN 72.23 46.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.84 69 999999999 43.74 70.06 percent of total billed charges CLINDAMYCIN 600 MG/50 ML-D5W 50370203_1 CDM 0250 RC 00338-3612-24 NDC inpatient 1 UN 72.23 46.95 SIHO - ALL PLANS SIHO - ALL PLANS 65.01 90 999999999 43.74 70.06 percent of total billed charges CLINDAMYCIN 600 MG/50 ML-D5W 50370203_1 CDM 0250 RC 00338-3612-24 NDC inpatient 1 UN 72.23 46.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.34 78 999999999 43.74 70.06 percent of total billed charges CLINDAMYCIN 600 MG/50 ML-D5W 50370203_1 CDM 0250 RC 00338-3612-24 NDC inpatient 1 UN 72.23 46.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.74 60.55 999999999 43.74 70.06 percent of total billed charges CLINDAMYCIN 600 MG/50 ML-D5W 50370203_1 CDM 0250 RC 00338-3612-24 NDC inpatient 1 UN 72.23 46.95 UMR - ALL PLANS UMR - ALL PLANS 50.56 70 999999999 43.74 70.06 percent of total billed charges CLINDAMYCIN 600 MG/50 ML-D5W 50370203_1 CDM 0250 RC 00338-3612-24 NDC inpatient 1 UN 72.23 46.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.74 70.06 CLINDAMYCIN 600 MG/50 ML-D5W 50370203_1 CDM 0250 RC 00338-3612-24 NDC inpatient 1 UN 72.23 46.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.74 70.06 CLINDAMYCIN 600 MG/50 ML-D5W 50370203_1 CDM 0250 RC 00338-3612-24 NDC inpatient 1 UN 72.23 46.95 ANTHEM HMO ANTHEM HMO 999999999 43.74 70.06 CLINDAMYCIN 600 MG/50 ML-D5W 50370203_1 CDM 0250 RC 00338-3612-24 NDC inpatient 1 UN 72.23 46.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.74 70.06 CLINDAMYCIN 600 MG/50 ML-D5W 50370203_1 CDM 0250 RC 00338-3612-24 NDC inpatient 1 UN 72.23 46.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.83 67.6 999999999 43.74 70.06 percent of total billed charges CLINDAMYCIN 600 MG/50 ML-D5W 50370203_1 CDM 0250 RC 00338-3612-24 NDC inpatient 1 UN 72.23 46.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.74 70.06 Tissue culture to identify white blood cell disorders 50370658_1 CDM 0301 RC 88230 HCPCS inpatient 255 165.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 165.75 65 999999999 154.4 247.35 percent of total billed charges Tissue culture to identify white blood cell disorders 50370658_1 CDM 0301 RC 88230 HCPCS inpatient 255 165.75 AETNA AETNA 201.45 79 999999999 154.4 247.35 percent of total billed charges Tissue culture to identify white blood cell disorders 50370658_1 CDM 0301 RC 88230 HCPCS inpatient 255 165.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 247.35 97 999999999 154.4 247.35 percent of total billed charges Tissue culture to identify white blood cell disorders 50370658_1 CDM 0301 RC 88230 HCPCS inpatient 255 165.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 175.95 69 999999999 154.4 247.35 percent of total billed charges Tissue culture to identify white blood cell disorders 50370658_1 CDM 0301 RC 88230 HCPCS inpatient 255 165.75 SIHO - ALL PLANS SIHO - ALL PLANS 229.5 90 999999999 154.4 247.35 percent of total billed charges Tissue culture to identify white blood cell disorders 50370658_1 CDM 0301 RC 88230 HCPCS inpatient 255 165.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 198.9 78 999999999 154.4 247.35 percent of total billed charges Tissue culture to identify white blood cell disorders 50370658_1 CDM 0301 RC 88230 HCPCS inpatient 255 165.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 154.4 60.55 999999999 154.4 247.35 percent of total billed charges Tissue culture to identify white blood cell disorders 50370658_1 CDM 0301 RC 88230 HCPCS inpatient 255 165.75 UMR - ALL PLANS UMR - ALL PLANS 178.5 70 999999999 154.4 247.35 percent of total billed charges Tissue culture to identify white blood cell disorders 50370658_1 CDM 0301 RC 88230 HCPCS inpatient 255 165.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 154.4 247.35 Tissue culture to identify white blood cell disorders 50370658_1 CDM 0301 RC 88230 HCPCS inpatient 255 165.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 154.4 247.35 Tissue culture to identify white blood cell disorders 50370658_1 CDM 0301 RC 88230 HCPCS inpatient 255 165.75 ANTHEM HMO ANTHEM HMO 999999999 154.4 247.35 Tissue culture to identify white blood cell disorders 50370658_1 CDM 0301 RC 88230 HCPCS inpatient 255 165.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 154.4 247.35 Tissue culture to identify white blood cell disorders 50370658_1 CDM 0301 RC 88230 HCPCS inpatient 255 165.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 172.38 67.6 999999999 154.4 247.35 percent of total billed charges Tissue culture to identify white blood cell disorders 50370658_1 CDM 0301 RC 88230 HCPCS inpatient 255 165.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 154.4 247.35 "Chromosome analysis for genetic defects, additional high resolution study" 50370659_1 CDM 0301 RC 88289 HCPCS inpatient 64 41.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.6 65 999999999 38.75 62.08 percent of total billed charges "Chromosome analysis for genetic defects, additional high resolution study" 50370659_1 CDM 0301 RC 88289 HCPCS inpatient 64 41.6 AETNA AETNA 50.56 79 999999999 38.75 62.08 percent of total billed charges "Chromosome analysis for genetic defects, additional high resolution study" 50370659_1 CDM 0301 RC 88289 HCPCS inpatient 64 41.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 62.08 97 999999999 38.75 62.08 percent of total billed charges "Chromosome analysis for genetic defects, additional high resolution study" 50370659_1 CDM 0301 RC 88289 HCPCS inpatient 64 41.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.16 69 999999999 38.75 62.08 percent of total billed charges "Chromosome analysis for genetic defects, additional high resolution study" 50370659_1 CDM 0301 RC 88289 HCPCS inpatient 64 41.6 SIHO - ALL PLANS SIHO - ALL PLANS 57.6 90 999999999 38.75 62.08 percent of total billed charges "Chromosome analysis for genetic defects, additional high resolution study" 50370659_1 CDM 0301 RC 88289 HCPCS inpatient 64 41.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.92 78 999999999 38.75 62.08 percent of total billed charges "Chromosome analysis for genetic defects, additional high resolution study" 50370659_1 CDM 0301 RC 88289 HCPCS inpatient 64 41.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.75 60.55 999999999 38.75 62.08 percent of total billed charges "Chromosome analysis for genetic defects, additional high resolution study" 50370659_1 CDM 0301 RC 88289 HCPCS inpatient 64 41.6 UMR - ALL PLANS UMR - ALL PLANS 44.8 70 999999999 38.75 62.08 percent of total billed charges "Chromosome analysis for genetic defects, additional high resolution study" 50370659_1 CDM 0301 RC 88289 HCPCS inpatient 64 41.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.75 62.08 "Chromosome analysis for genetic defects, additional high resolution study" 50370659_1 CDM 0301 RC 88289 HCPCS inpatient 64 41.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.75 62.08 "Chromosome analysis for genetic defects, additional high resolution study" 50370659_1 CDM 0301 RC 88289 HCPCS inpatient 64 41.6 ANTHEM HMO ANTHEM HMO 999999999 38.75 62.08 "Chromosome analysis for genetic defects, additional high resolution study" 50370659_1 CDM 0301 RC 88289 HCPCS inpatient 64 41.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.75 62.08 "Chromosome analysis for genetic defects, additional high resolution study" 50370659_1 CDM 0301 RC 88289 HCPCS inpatient 64 41.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.26 67.6 999999999 38.75 62.08 percent of total billed charges "Chromosome analysis for genetic defects, additional high resolution study" 50370659_1 CDM 0301 RC 88289 HCPCS inpatient 64 41.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.75 62.08 "INJECTION, DAPTOMYCIN, 1 MG" 50371089_1 CDM 0250 RC 16729-0435-05 NDC J0878 HCPCS inpatient 500 UN 251.97 163.78 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.78 65 999999999 152.57 244.41 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 50371089_1 CDM 0250 RC 16729-0435-05 NDC J0878 HCPCS inpatient 500 UN 251.97 163.78 AETNA AETNA 199.06 79 999999999 152.57 244.41 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 50371089_1 CDM 0250 RC 16729-0435-05 NDC J0878 HCPCS inpatient 500 UN 251.97 163.78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.41 97 999999999 152.57 244.41 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 50371089_1 CDM 0250 RC 16729-0435-05 NDC J0878 HCPCS inpatient 500 UN 251.97 163.78 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.86 69 999999999 152.57 244.41 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 50371089_1 CDM 0250 RC 16729-0435-05 NDC J0878 HCPCS inpatient 500 UN 251.97 163.78 SIHO - ALL PLANS SIHO - ALL PLANS 226.77 90 999999999 152.57 244.41 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 50371089_1 CDM 0250 RC 16729-0435-05 NDC J0878 HCPCS inpatient 500 UN 251.97 163.78 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.54 78 999999999 152.57 244.41 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 50371089_1 CDM 0250 RC 16729-0435-05 NDC J0878 HCPCS inpatient 500 UN 251.97 163.78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.57 60.55 999999999 152.57 244.41 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 50371089_1 CDM 0250 RC 16729-0435-05 NDC J0878 HCPCS inpatient 500 UN 251.97 163.78 UMR - ALL PLANS UMR - ALL PLANS 176.38 70 999999999 152.57 244.41 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 50371089_1 CDM 0250 RC 16729-0435-05 NDC J0878 HCPCS inpatient 500 UN 251.97 163.78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.57 244.41 "INJECTION, DAPTOMYCIN, 1 MG" 50371089_1 CDM 0250 RC 16729-0435-05 NDC J0878 HCPCS inpatient 500 UN 251.97 163.78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.57 244.41 "INJECTION, DAPTOMYCIN, 1 MG" 50371089_1 CDM 0250 RC 16729-0435-05 NDC J0878 HCPCS inpatient 500 UN 251.97 163.78 ANTHEM HMO ANTHEM HMO 999999999 152.57 244.41 "INJECTION, DAPTOMYCIN, 1 MG" 50371089_1 CDM 0250 RC 16729-0435-05 NDC J0878 HCPCS inpatient 500 UN 251.97 163.78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.57 244.41 "INJECTION, DAPTOMYCIN, 1 MG" 50371089_1 CDM 0250 RC 16729-0435-05 NDC J0878 HCPCS inpatient 500 UN 251.97 163.78 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.33 67.6 999999999 152.57 244.41 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 50371089_1 CDM 0250 RC 16729-0435-05 NDC J0878 HCPCS inpatient 500 UN 251.97 163.78 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.57 244.41 ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER SYSTEM 20g X 8cm EDC-00820-B 50372896_1 CDM 0272 RC inpatient 457 297.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 297.05 65 999999999 276.71 443.29 percent of total billed charges ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER SYSTEM 20g X 8cm EDC-00820-B 50372896_1 CDM 0272 RC inpatient 457 297.05 AETNA AETNA 361.03 79 999999999 276.71 443.29 percent of total billed charges ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER SYSTEM 20g X 8cm EDC-00820-B 50372896_1 CDM 0272 RC inpatient 457 297.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 443.29 97 999999999 276.71 443.29 percent of total billed charges ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER SYSTEM 20g X 8cm EDC-00820-B 50372896_1 CDM 0272 RC inpatient 457 297.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 315.33 69 999999999 276.71 443.29 percent of total billed charges ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER SYSTEM 20g X 8cm EDC-00820-B 50372896_1 CDM 0272 RC inpatient 457 297.05 SIHO - ALL PLANS SIHO - ALL PLANS 411.3 90 999999999 276.71 443.29 percent of total billed charges ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER SYSTEM 20g X 8cm EDC-00820-B 50372896_1 CDM 0272 RC inpatient 457 297.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 356.46 78 999999999 276.71 443.29 percent of total billed charges ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER SYSTEM 20g X 8cm EDC-00820-B 50372896_1 CDM 0272 RC inpatient 457 297.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 276.71 60.55 999999999 276.71 443.29 percent of total billed charges ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER SYSTEM 20g X 8cm EDC-00820-B 50372896_1 CDM 0272 RC inpatient 457 297.05 UMR - ALL PLANS UMR - ALL PLANS 319.9 70 999999999 276.71 443.29 percent of total billed charges ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER SYSTEM 20g X 8cm EDC-00820-B 50372896_1 CDM 0272 RC inpatient 457 297.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 276.71 443.29 ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER SYSTEM 20g X 8cm EDC-00820-B 50372896_1 CDM 0272 RC inpatient 457 297.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 276.71 443.29 ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER SYSTEM 20g X 8cm EDC-00820-B 50372896_1 CDM 0272 RC inpatient 457 297.05 ANTHEM HMO ANTHEM HMO 999999999 276.71 443.29 ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER SYSTEM 20g X 8cm EDC-00820-B 50372896_1 CDM 0272 RC inpatient 457 297.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 276.71 443.29 ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER SYSTEM 20g X 8cm EDC-00820-B 50372896_1 CDM 0272 RC inpatient 457 297.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 308.93 67.6 999999999 276.71 443.29 percent of total billed charges ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER SYSTEM 20g X 8cm EDC-00820-B 50372896_1 CDM 0272 RC inpatient 457 297.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 276.71 443.29 "RINGERS LACTATE INFUSION, UP TO 1000 CC" 50374541_1 CDM 0258 RC 00264-7751-00 NDC J7120 HCPCS inpatient 1 UN 66.34 43.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 43.12 65 999999999 40.17 64.35 percent of total billed charges "RINGERS LACTATE INFUSION, UP TO 1000 CC" 50374541_1 CDM 0258 RC 00264-7751-00 NDC J7120 HCPCS inpatient 1 UN 66.34 43.12 AETNA AETNA 52.41 79 999999999 40.17 64.35 percent of total billed charges "RINGERS LACTATE INFUSION, UP TO 1000 CC" 50374541_1 CDM 0258 RC 00264-7751-00 NDC J7120 HCPCS inpatient 1 UN 66.34 43.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.35 97 999999999 40.17 64.35 percent of total billed charges "RINGERS LACTATE INFUSION, UP TO 1000 CC" 50374541_1 CDM 0258 RC 00264-7751-00 NDC J7120 HCPCS inpatient 1 UN 66.34 43.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.77 69 999999999 40.17 64.35 percent of total billed charges "RINGERS LACTATE INFUSION, UP TO 1000 CC" 50374541_1 CDM 0258 RC 00264-7751-00 NDC J7120 HCPCS inpatient 1 UN 66.34 43.12 SIHO - ALL PLANS SIHO - ALL PLANS 59.71 90 999999999 40.17 64.35 percent of total billed charges "RINGERS LACTATE INFUSION, UP TO 1000 CC" 50374541_1 CDM 0258 RC 00264-7751-00 NDC J7120 HCPCS inpatient 1 UN 66.34 43.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.75 78 999999999 40.17 64.35 percent of total billed charges "RINGERS LACTATE INFUSION, UP TO 1000 CC" 50374541_1 CDM 0258 RC 00264-7751-00 NDC J7120 HCPCS inpatient 1 UN 66.34 43.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 40.17 60.55 999999999 40.17 64.35 percent of total billed charges "RINGERS LACTATE INFUSION, UP TO 1000 CC" 50374541_1 CDM 0258 RC 00264-7751-00 NDC J7120 HCPCS inpatient 1 UN 66.34 43.12 UMR - ALL PLANS UMR - ALL PLANS 46.44 70 999999999 40.17 64.35 percent of total billed charges "RINGERS LACTATE INFUSION, UP TO 1000 CC" 50374541_1 CDM 0258 RC 00264-7751-00 NDC J7120 HCPCS inpatient 1 UN 66.34 43.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 40.17 64.35 "RINGERS LACTATE INFUSION, UP TO 1000 CC" 50374541_1 CDM 0258 RC 00264-7751-00 NDC J7120 HCPCS inpatient 1 UN 66.34 43.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 40.17 64.35 "RINGERS LACTATE INFUSION, UP TO 1000 CC" 50374541_1 CDM 0258 RC 00264-7751-00 NDC J7120 HCPCS inpatient 1 UN 66.34 43.12 ANTHEM HMO ANTHEM HMO 999999999 40.17 64.35 "RINGERS LACTATE INFUSION, UP TO 1000 CC" 50374541_1 CDM 0258 RC 00264-7751-00 NDC J7120 HCPCS inpatient 1 UN 66.34 43.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 40.17 64.35 "RINGERS LACTATE INFUSION, UP TO 1000 CC" 50374541_1 CDM 0258 RC 00264-7751-00 NDC J7120 HCPCS inpatient 1 UN 66.34 43.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.85 67.6 999999999 40.17 64.35 percent of total billed charges "RINGERS LACTATE INFUSION, UP TO 1000 CC" 50374541_1 CDM 0258 RC 00264-7751-00 NDC J7120 HCPCS inpatient 1 UN 66.34 43.12 UHC - ALL PLANS UHC - ALL PLANS 999999999 40.17 64.35 KCL 20 MEQ IN D5W-LACT RINGER 50375052_1 CDM 0250 RC 00338-0811-04 NDC inpatient 2 UN 74.8 48.62 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.62 65 999999999 45.29 72.56 percent of total billed charges KCL 20 MEQ IN D5W-LACT RINGER 50375052_1 CDM 0250 RC 00338-0811-04 NDC inpatient 2 UN 74.8 48.62 AETNA AETNA 59.09 79 999999999 45.29 72.56 percent of total billed charges KCL 20 MEQ IN D5W-LACT RINGER 50375052_1 CDM 0250 RC 00338-0811-04 NDC inpatient 2 UN 74.8 48.62 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.56 97 999999999 45.29 72.56 percent of total billed charges KCL 20 MEQ IN D5W-LACT RINGER 50375052_1 CDM 0250 RC 00338-0811-04 NDC inpatient 2 UN 74.8 48.62 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.61 69 999999999 45.29 72.56 percent of total billed charges KCL 20 MEQ IN D5W-LACT RINGER 50375052_1 CDM 0250 RC 00338-0811-04 NDC inpatient 2 UN 74.8 48.62 SIHO - ALL PLANS SIHO - ALL PLANS 67.32 90 999999999 45.29 72.56 percent of total billed charges KCL 20 MEQ IN D5W-LACT RINGER 50375052_1 CDM 0250 RC 00338-0811-04 NDC inpatient 2 UN 74.8 48.62 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.34 78 999999999 45.29 72.56 percent of total billed charges KCL 20 MEQ IN D5W-LACT RINGER 50375052_1 CDM 0250 RC 00338-0811-04 NDC inpatient 2 UN 74.8 48.62 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.29 60.55 999999999 45.29 72.56 percent of total billed charges KCL 20 MEQ IN D5W-LACT RINGER 50375052_1 CDM 0250 RC 00338-0811-04 NDC inpatient 2 UN 74.8 48.62 UMR - ALL PLANS UMR - ALL PLANS 52.36 70 999999999 45.29 72.56 percent of total billed charges KCL 20 MEQ IN D5W-LACT RINGER 50375052_1 CDM 0250 RC 00338-0811-04 NDC inpatient 2 UN 74.8 48.62 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.29 72.56 KCL 20 MEQ IN D5W-LACT RINGER 50375052_1 CDM 0250 RC 00338-0811-04 NDC inpatient 2 UN 74.8 48.62 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.29 72.56 KCL 20 MEQ IN D5W-LACT RINGER 50375052_1 CDM 0250 RC 00338-0811-04 NDC inpatient 2 UN 74.8 48.62 ANTHEM HMO ANTHEM HMO 999999999 45.29 72.56 KCL 20 MEQ IN D5W-LACT RINGER 50375052_1 CDM 0250 RC 00338-0811-04 NDC inpatient 2 UN 74.8 48.62 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.29 72.56 KCL 20 MEQ IN D5W-LACT RINGER 50375052_1 CDM 0250 RC 00338-0811-04 NDC inpatient 2 UN 74.8 48.62 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.56 67.6 999999999 45.29 72.56 percent of total billed charges KCL 20 MEQ IN D5W-LACT RINGER 50375052_1 CDM 0250 RC 00338-0811-04 NDC inpatient 2 UN 74.8 48.62 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.29 72.56 Local - Monitored Anesthesia Care 5037518_1 CDM 0370 RC inpatient 280.88 182.57 SELF PAY DISCOUNT SELF PAY DISCOUNT 182.57 65 999999999 170.07 272.45 percent of total billed charges Local - Monitored Anesthesia Care 5037518_1 CDM 0370 RC inpatient 280.88 182.57 AETNA AETNA 221.9 79 999999999 170.07 272.45 percent of total billed charges Local - Monitored Anesthesia Care 5037518_1 CDM 0370 RC inpatient 280.88 182.57 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 272.45 97 999999999 170.07 272.45 percent of total billed charges Local - Monitored Anesthesia Care 5037518_1 CDM 0370 RC inpatient 280.88 182.57 ENCORE - ALL PLANS ENCORE - ALL PLANS 193.81 69 999999999 170.07 272.45 percent of total billed charges Local - Monitored Anesthesia Care 5037518_1 CDM 0370 RC inpatient 280.88 182.57 SIHO - ALL PLANS SIHO - ALL PLANS 252.79 90 999999999 170.07 272.45 percent of total billed charges Local - Monitored Anesthesia Care 5037518_1 CDM 0370 RC inpatient 280.88 182.57 HUMANA - ALL PLANS HUMANA - ALL PLANS 219.09 78 999999999 170.07 272.45 percent of total billed charges Local - Monitored Anesthesia Care 5037518_1 CDM 0370 RC inpatient 280.88 182.57 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 170.07 60.55 999999999 170.07 272.45 percent of total billed charges Local - Monitored Anesthesia Care 5037518_1 CDM 0370 RC inpatient 280.88 182.57 UMR - ALL PLANS UMR - ALL PLANS 196.62 70 999999999 170.07 272.45 percent of total billed charges Local - Monitored Anesthesia Care 5037518_1 CDM 0370 RC inpatient 280.88 182.57 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 170.07 272.45 Local - Monitored Anesthesia Care 5037518_1 CDM 0370 RC inpatient 280.88 182.57 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 170.07 272.45 Local - Monitored Anesthesia Care 5037518_1 CDM 0370 RC inpatient 280.88 182.57 ANTHEM HMO ANTHEM HMO 999999999 170.07 272.45 Local - Monitored Anesthesia Care 5037518_1 CDM 0370 RC inpatient 280.88 182.57 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 170.07 272.45 Local - Monitored Anesthesia Care 5037518_1 CDM 0370 RC inpatient 280.88 182.57 CIGNA - ALL PLANS CIGNA - ALL PLANS 189.87 67.6 999999999 170.07 272.45 percent of total billed charges Local - Monitored Anesthesia Care 5037518_1 CDM 0370 RC inpatient 280.88 182.57 UHC - ALL PLANS UHC - ALL PLANS 999999999 170.07 272.45 VALACYCLOVIR HCL 500 MG TABLET 50375250_1 CDM 0250 RC 00378-4275-93 NDC inpatient 1 UN 1.33 0.86 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.86 65 999999999 0.81 1.29 percent of total billed charges VALACYCLOVIR HCL 500 MG TABLET 50375250_1 CDM 0250 RC 00378-4275-93 NDC inpatient 1 UN 1.33 0.86 AETNA AETNA 1.05 79 999999999 0.81 1.29 percent of total billed charges VALACYCLOVIR HCL 500 MG TABLET 50375250_1 CDM 0250 RC 00378-4275-93 NDC inpatient 1 UN 1.33 0.86 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.29 97 999999999 0.81 1.29 percent of total billed charges VALACYCLOVIR HCL 500 MG TABLET 50375250_1 CDM 0250 RC 00378-4275-93 NDC inpatient 1 UN 1.33 0.86 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.92 69 999999999 0.81 1.29 percent of total billed charges VALACYCLOVIR HCL 500 MG TABLET 50375250_1 CDM 0250 RC 00378-4275-93 NDC inpatient 1 UN 1.33 0.86 SIHO - ALL PLANS SIHO - ALL PLANS 1.2 90 999999999 0.81 1.29 percent of total billed charges VALACYCLOVIR HCL 500 MG TABLET 50375250_1 CDM 0250 RC 00378-4275-93 NDC inpatient 1 UN 1.33 0.86 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.04 78 999999999 0.81 1.29 percent of total billed charges VALACYCLOVIR HCL 500 MG TABLET 50375250_1 CDM 0250 RC 00378-4275-93 NDC inpatient 1 UN 1.33 0.86 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.81 60.55 999999999 0.81 1.29 percent of total billed charges VALACYCLOVIR HCL 500 MG TABLET 50375250_1 CDM 0250 RC 00378-4275-93 NDC inpatient 1 UN 1.33 0.86 UMR - ALL PLANS UMR - ALL PLANS 0.93 70 999999999 0.81 1.29 percent of total billed charges VALACYCLOVIR HCL 500 MG TABLET 50375250_1 CDM 0250 RC 00378-4275-93 NDC inpatient 1 UN 1.33 0.86 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.81 1.29 VALACYCLOVIR HCL 500 MG TABLET 50375250_1 CDM 0250 RC 00378-4275-93 NDC inpatient 1 UN 1.33 0.86 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.81 1.29 VALACYCLOVIR HCL 500 MG TABLET 50375250_1 CDM 0250 RC 00378-4275-93 NDC inpatient 1 UN 1.33 0.86 ANTHEM HMO ANTHEM HMO 999999999 0.81 1.29 VALACYCLOVIR HCL 500 MG TABLET 50375250_1 CDM 0250 RC 00378-4275-93 NDC inpatient 1 UN 1.33 0.86 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.81 1.29 VALACYCLOVIR HCL 500 MG TABLET 50375250_1 CDM 0250 RC 00378-4275-93 NDC inpatient 1 UN 1.33 0.86 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.9 67.6 999999999 0.81 1.29 percent of total billed charges VALACYCLOVIR HCL 500 MG TABLET 50375250_1 CDM 0250 RC 00378-4275-93 NDC inpatient 1 UN 1.33 0.86 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.81 1.29 LABETALOL HCL 100 MG/20 ML VL 50375444_1 CDM 0250 RC 00409-2267-20 NDC inpatient 1 UN 28.8 18.72 SELF PAY DISCOUNT SELF PAY DISCOUNT 18.72 65 999999999 17.44 27.94 percent of total billed charges LABETALOL HCL 100 MG/20 ML VL 50375444_1 CDM 0250 RC 00409-2267-20 NDC inpatient 1 UN 28.8 18.72 AETNA AETNA 22.75 79 999999999 17.44 27.94 percent of total billed charges LABETALOL HCL 100 MG/20 ML VL 50375444_1 CDM 0250 RC 00409-2267-20 NDC inpatient 1 UN 28.8 18.72 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 27.94 97 999999999 17.44 27.94 percent of total billed charges LABETALOL HCL 100 MG/20 ML VL 50375444_1 CDM 0250 RC 00409-2267-20 NDC inpatient 1 UN 28.8 18.72 ENCORE - ALL PLANS ENCORE - ALL PLANS 19.87 69 999999999 17.44 27.94 percent of total billed charges LABETALOL HCL 100 MG/20 ML VL 50375444_1 CDM 0250 RC 00409-2267-20 NDC inpatient 1 UN 28.8 18.72 SIHO - ALL PLANS SIHO - ALL PLANS 25.92 90 999999999 17.44 27.94 percent of total billed charges LABETALOL HCL 100 MG/20 ML VL 50375444_1 CDM 0250 RC 00409-2267-20 NDC inpatient 1 UN 28.8 18.72 HUMANA - ALL PLANS HUMANA - ALL PLANS 22.46 78 999999999 17.44 27.94 percent of total billed charges LABETALOL HCL 100 MG/20 ML VL 50375444_1 CDM 0250 RC 00409-2267-20 NDC inpatient 1 UN 28.8 18.72 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17.44 60.55 999999999 17.44 27.94 percent of total billed charges LABETALOL HCL 100 MG/20 ML VL 50375444_1 CDM 0250 RC 00409-2267-20 NDC inpatient 1 UN 28.8 18.72 UMR - ALL PLANS UMR - ALL PLANS 20.16 70 999999999 17.44 27.94 percent of total billed charges LABETALOL HCL 100 MG/20 ML VL 50375444_1 CDM 0250 RC 00409-2267-20 NDC inpatient 1 UN 28.8 18.72 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 17.44 27.94 LABETALOL HCL 100 MG/20 ML VL 50375444_1 CDM 0250 RC 00409-2267-20 NDC inpatient 1 UN 28.8 18.72 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 17.44 27.94 LABETALOL HCL 100 MG/20 ML VL 50375444_1 CDM 0250 RC 00409-2267-20 NDC inpatient 1 UN 28.8 18.72 ANTHEM HMO ANTHEM HMO 999999999 17.44 27.94 LABETALOL HCL 100 MG/20 ML VL 50375444_1 CDM 0250 RC 00409-2267-20 NDC inpatient 1 UN 28.8 18.72 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 17.44 27.94 LABETALOL HCL 100 MG/20 ML VL 50375444_1 CDM 0250 RC 00409-2267-20 NDC inpatient 1 UN 28.8 18.72 CIGNA - ALL PLANS CIGNA - ALL PLANS 19.47 67.6 999999999 17.44 27.94 percent of total billed charges LABETALOL HCL 100 MG/20 ML VL 50375444_1 CDM 0250 RC 00409-2267-20 NDC inpatient 1 UN 28.8 18.72 UHC - ALL PLANS UHC - ALL PLANS 999999999 17.44 27.94 Opiates levels 50376199_1 CDM 0301 RC 80361 HCPCS inpatient 179 116.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 116.35 65 999999999 108.38 173.63 percent of total billed charges Opiates levels 50376199_1 CDM 0301 RC 80361 HCPCS inpatient 179 116.35 AETNA AETNA 141.41 79 999999999 108.38 173.63 percent of total billed charges Opiates levels 50376199_1 CDM 0301 RC 80361 HCPCS inpatient 179 116.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 173.63 97 999999999 108.38 173.63 percent of total billed charges Opiates levels 50376199_1 CDM 0301 RC 80361 HCPCS inpatient 179 116.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 123.51 69 999999999 108.38 173.63 percent of total billed charges Opiates levels 50376199_1 CDM 0301 RC 80361 HCPCS inpatient 179 116.35 SIHO - ALL PLANS SIHO - ALL PLANS 161.1 90 999999999 108.38 173.63 percent of total billed charges Opiates levels 50376199_1 CDM 0301 RC 80361 HCPCS inpatient 179 116.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 139.62 78 999999999 108.38 173.63 percent of total billed charges Opiates levels 50376199_1 CDM 0301 RC 80361 HCPCS inpatient 179 116.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.38 60.55 999999999 108.38 173.63 percent of total billed charges Opiates levels 50376199_1 CDM 0301 RC 80361 HCPCS inpatient 179 116.35 UMR - ALL PLANS UMR - ALL PLANS 125.3 70 999999999 108.38 173.63 percent of total billed charges Opiates levels 50376199_1 CDM 0301 RC 80361 HCPCS inpatient 179 116.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.38 173.63 Opiates levels 50376199_1 CDM 0301 RC 80361 HCPCS inpatient 179 116.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.38 173.63 Opiates levels 50376199_1 CDM 0301 RC 80361 HCPCS inpatient 179 116.35 ANTHEM HMO ANTHEM HMO 999999999 108.38 173.63 Opiates levels 50376199_1 CDM 0301 RC 80361 HCPCS inpatient 179 116.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.38 173.63 Opiates levels 50376199_1 CDM 0301 RC 80361 HCPCS inpatient 179 116.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 121 67.6 999999999 108.38 173.63 percent of total billed charges Opiates levels 50376199_1 CDM 0301 RC 80361 HCPCS inpatient 179 116.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.38 173.63 Oxycodone levels 50376208_1 CDM 0301 RC 80365 HCPCS inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges Oxycodone levels 50376208_1 CDM 0301 RC 80365 HCPCS inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges Oxycodone levels 50376208_1 CDM 0301 RC 80365 HCPCS inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges Oxycodone levels 50376208_1 CDM 0301 RC 80365 HCPCS inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges Oxycodone levels 50376208_1 CDM 0301 RC 80365 HCPCS inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges Oxycodone levels 50376208_1 CDM 0301 RC 80365 HCPCS inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges Oxycodone levels 50376208_1 CDM 0301 RC 80365 HCPCS inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges Oxycodone levels 50376208_1 CDM 0301 RC 80365 HCPCS inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges Oxycodone levels 50376208_1 CDM 0301 RC 80365 HCPCS inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 Oxycodone levels 50376208_1 CDM 0301 RC 80365 HCPCS inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 Oxycodone levels 50376208_1 CDM 0301 RC 80365 HCPCS inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 Oxycodone levels 50376208_1 CDM 0301 RC 80365 HCPCS inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 Oxycodone levels 50376208_1 CDM 0301 RC 80365 HCPCS inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges Oxycodone levels 50376208_1 CDM 0301 RC 80365 HCPCS inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 IRBESARTAN 300 MG TABLET 50376966_1 CDM 0250 RC 33342-0049-07 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges IRBESARTAN 300 MG TABLET 50376966_1 CDM 0250 RC 33342-0049-07 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges IRBESARTAN 300 MG TABLET 50376966_1 CDM 0250 RC 33342-0049-07 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges IRBESARTAN 300 MG TABLET 50376966_1 CDM 0250 RC 33342-0049-07 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges IRBESARTAN 300 MG TABLET 50376966_1 CDM 0250 RC 33342-0049-07 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges IRBESARTAN 300 MG TABLET 50376966_1 CDM 0250 RC 33342-0049-07 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges IRBESARTAN 300 MG TABLET 50376966_1 CDM 0250 RC 33342-0049-07 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges IRBESARTAN 300 MG TABLET 50376966_1 CDM 0250 RC 33342-0049-07 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges IRBESARTAN 300 MG TABLET 50376966_1 CDM 0250 RC 33342-0049-07 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 IRBESARTAN 300 MG TABLET 50376966_1 CDM 0250 RC 33342-0049-07 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 IRBESARTAN 300 MG TABLET 50376966_1 CDM 0250 RC 33342-0049-07 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 IRBESARTAN 300 MG TABLET 50376966_1 CDM 0250 RC 33342-0049-07 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 IRBESARTAN 300 MG TABLET 50376966_1 CDM 0250 RC 33342-0049-07 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges IRBESARTAN 300 MG TABLET 50376966_1 CDM 0250 RC 33342-0049-07 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 Removal of growth in soft tissue of ear canal 50379547_1 CDM 0450 RC 69145 HCPCS inpatient 752 488.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 488.8 65 999999999 455.34 729.44 percent of total billed charges Removal of growth in soft tissue of ear canal 50379547_1 CDM 0450 RC 69145 HCPCS inpatient 752 488.8 AETNA AETNA 594.08 79 999999999 455.34 729.44 percent of total billed charges Removal of growth in soft tissue of ear canal 50379547_1 CDM 0450 RC 69145 HCPCS inpatient 752 488.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 729.44 97 999999999 455.34 729.44 percent of total billed charges Removal of growth in soft tissue of ear canal 50379547_1 CDM 0450 RC 69145 HCPCS inpatient 752 488.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 518.88 69 999999999 455.34 729.44 percent of total billed charges Removal of growth in soft tissue of ear canal 50379547_1 CDM 0450 RC 69145 HCPCS inpatient 752 488.8 SIHO - ALL PLANS SIHO - ALL PLANS 676.8 90 999999999 455.34 729.44 percent of total billed charges Removal of growth in soft tissue of ear canal 50379547_1 CDM 0450 RC 69145 HCPCS inpatient 752 488.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 586.56 78 999999999 455.34 729.44 percent of total billed charges Removal of growth in soft tissue of ear canal 50379547_1 CDM 0450 RC 69145 HCPCS inpatient 752 488.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 455.34 60.55 999999999 455.34 729.44 percent of total billed charges Removal of growth in soft tissue of ear canal 50379547_1 CDM 0450 RC 69145 HCPCS inpatient 752 488.8 UMR - ALL PLANS UMR - ALL PLANS 526.4 70 999999999 455.34 729.44 percent of total billed charges Removal of growth in soft tissue of ear canal 50379547_1 CDM 0450 RC 69145 HCPCS inpatient 752 488.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 455.34 729.44 Removal of growth in soft tissue of ear canal 50379547_1 CDM 0450 RC 69145 HCPCS inpatient 752 488.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 455.34 729.44 Removal of growth in soft tissue of ear canal 50379547_1 CDM 0450 RC 69145 HCPCS inpatient 752 488.8 ANTHEM HMO ANTHEM HMO 999999999 455.34 729.44 Removal of growth in soft tissue of ear canal 50379547_1 CDM 0450 RC 69145 HCPCS inpatient 752 488.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 455.34 729.44 Removal of growth in soft tissue of ear canal 50379547_1 CDM 0450 RC 69145 HCPCS inpatient 752 488.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 508.35 67.6 999999999 455.34 729.44 percent of total billed charges Removal of growth in soft tissue of ear canal 50379547_1 CDM 0450 RC 69145 HCPCS inpatient 752 488.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 455.34 729.44 Natriuretic peptide (heart and blood vessel protein) level 50379695_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 SELF PAY DISCOUNT SELF PAY DISCOUNT 143 65 999999999 133.21 213.4 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 50379695_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 AETNA AETNA 173.8 79 999999999 133.21 213.4 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 50379695_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 213.4 97 999999999 133.21 213.4 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 50379695_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.8 69 999999999 133.21 213.4 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 50379695_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 SIHO - ALL PLANS SIHO - ALL PLANS 198 90 999999999 133.21 213.4 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 50379695_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 HUMANA - ALL PLANS HUMANA - ALL PLANS 171.6 78 999999999 133.21 213.4 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 50379695_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 133.21 60.55 999999999 133.21 213.4 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 50379695_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 UMR - ALL PLANS UMR - ALL PLANS 154 70 999999999 133.21 213.4 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 50379695_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 133.21 213.4 Natriuretic peptide (heart and blood vessel protein) level 50379695_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 133.21 213.4 Natriuretic peptide (heart and blood vessel protein) level 50379695_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 ANTHEM HMO ANTHEM HMO 999999999 133.21 213.4 Natriuretic peptide (heart and blood vessel protein) level 50379695_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 133.21 213.4 Natriuretic peptide (heart and blood vessel protein) level 50379695_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.72 67.6 999999999 133.21 213.4 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 50379695_1 CDM 0301 RC 83880 HCPCS inpatient 220 143 UHC - ALL PLANS UHC - ALL PLANS 999999999 133.21 213.4 METHYLERGONOVINE 0.2 MG TABLET 50379760_1 CDM 0250 RC 60687-0410-94 NDC inpatient 1 UN 195.92 127.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 127.35 65 999999999 118.63 190.04 percent of total billed charges METHYLERGONOVINE 0.2 MG TABLET 50379760_1 CDM 0250 RC 60687-0410-94 NDC inpatient 1 UN 195.92 127.35 AETNA AETNA 154.78 79 999999999 118.63 190.04 percent of total billed charges METHYLERGONOVINE 0.2 MG TABLET 50379760_1 CDM 0250 RC 60687-0410-94 NDC inpatient 1 UN 195.92 127.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 190.04 97 999999999 118.63 190.04 percent of total billed charges METHYLERGONOVINE 0.2 MG TABLET 50379760_1 CDM 0250 RC 60687-0410-94 NDC inpatient 1 UN 195.92 127.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 135.18 69 999999999 118.63 190.04 percent of total billed charges METHYLERGONOVINE 0.2 MG TABLET 50379760_1 CDM 0250 RC 60687-0410-94 NDC inpatient 1 UN 195.92 127.35 SIHO - ALL PLANS SIHO - ALL PLANS 176.33 90 999999999 118.63 190.04 percent of total billed charges METHYLERGONOVINE 0.2 MG TABLET 50379760_1 CDM 0250 RC 60687-0410-94 NDC inpatient 1 UN 195.92 127.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 152.82 78 999999999 118.63 190.04 percent of total billed charges METHYLERGONOVINE 0.2 MG TABLET 50379760_1 CDM 0250 RC 60687-0410-94 NDC inpatient 1 UN 195.92 127.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 118.63 60.55 999999999 118.63 190.04 percent of total billed charges METHYLERGONOVINE 0.2 MG TABLET 50379760_1 CDM 0250 RC 60687-0410-94 NDC inpatient 1 UN 195.92 127.35 UMR - ALL PLANS UMR - ALL PLANS 137.14 70 999999999 118.63 190.04 percent of total billed charges METHYLERGONOVINE 0.2 MG TABLET 50379760_1 CDM 0250 RC 60687-0410-94 NDC inpatient 1 UN 195.92 127.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 118.63 190.04 METHYLERGONOVINE 0.2 MG TABLET 50379760_1 CDM 0250 RC 60687-0410-94 NDC inpatient 1 UN 195.92 127.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 118.63 190.04 METHYLERGONOVINE 0.2 MG TABLET 50379760_1 CDM 0250 RC 60687-0410-94 NDC inpatient 1 UN 195.92 127.35 ANTHEM HMO ANTHEM HMO 999999999 118.63 190.04 METHYLERGONOVINE 0.2 MG TABLET 50379760_1 CDM 0250 RC 60687-0410-94 NDC inpatient 1 UN 195.92 127.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 118.63 190.04 METHYLERGONOVINE 0.2 MG TABLET 50379760_1 CDM 0250 RC 60687-0410-94 NDC inpatient 1 UN 195.92 127.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 132.44 67.6 999999999 118.63 190.04 percent of total billed charges METHYLERGONOVINE 0.2 MG TABLET 50379760_1 CDM 0250 RC 60687-0410-94 NDC inpatient 1 UN 195.92 127.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 118.63 190.04 DEXTROSE 10%-WATER IV SOLUTION 50380072_1 CDM 0250 RC 00264-7520-10 NDC inpatient 1 UN 47.96 31.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.17 65 999999999 29.04 46.52 percent of total billed charges DEXTROSE 10%-WATER IV SOLUTION 50380072_1 CDM 0250 RC 00264-7520-10 NDC inpatient 1 UN 47.96 31.17 AETNA AETNA 37.89 79 999999999 29.04 46.52 percent of total billed charges DEXTROSE 10%-WATER IV SOLUTION 50380072_1 CDM 0250 RC 00264-7520-10 NDC inpatient 1 UN 47.96 31.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 46.52 97 999999999 29.04 46.52 percent of total billed charges DEXTROSE 10%-WATER IV SOLUTION 50380072_1 CDM 0250 RC 00264-7520-10 NDC inpatient 1 UN 47.96 31.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.09 69 999999999 29.04 46.52 percent of total billed charges DEXTROSE 10%-WATER IV SOLUTION 50380072_1 CDM 0250 RC 00264-7520-10 NDC inpatient 1 UN 47.96 31.17 SIHO - ALL PLANS SIHO - ALL PLANS 43.16 90 999999999 29.04 46.52 percent of total billed charges DEXTROSE 10%-WATER IV SOLUTION 50380072_1 CDM 0250 RC 00264-7520-10 NDC inpatient 1 UN 47.96 31.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 37.41 78 999999999 29.04 46.52 percent of total billed charges DEXTROSE 10%-WATER IV SOLUTION 50380072_1 CDM 0250 RC 00264-7520-10 NDC inpatient 1 UN 47.96 31.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.04 60.55 999999999 29.04 46.52 percent of total billed charges DEXTROSE 10%-WATER IV SOLUTION 50380072_1 CDM 0250 RC 00264-7520-10 NDC inpatient 1 UN 47.96 31.17 UMR - ALL PLANS UMR - ALL PLANS 33.57 70 999999999 29.04 46.52 percent of total billed charges DEXTROSE 10%-WATER IV SOLUTION 50380072_1 CDM 0250 RC 00264-7520-10 NDC inpatient 1 UN 47.96 31.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.04 46.52 DEXTROSE 10%-WATER IV SOLUTION 50380072_1 CDM 0250 RC 00264-7520-10 NDC inpatient 1 UN 47.96 31.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.04 46.52 DEXTROSE 10%-WATER IV SOLUTION 50380072_1 CDM 0250 RC 00264-7520-10 NDC inpatient 1 UN 47.96 31.17 ANTHEM HMO ANTHEM HMO 999999999 29.04 46.52 DEXTROSE 10%-WATER IV SOLUTION 50380072_1 CDM 0250 RC 00264-7520-10 NDC inpatient 1 UN 47.96 31.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.04 46.52 DEXTROSE 10%-WATER IV SOLUTION 50380072_1 CDM 0250 RC 00264-7520-10 NDC inpatient 1 UN 47.96 31.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 32.42 67.6 999999999 29.04 46.52 percent of total billed charges DEXTROSE 10%-WATER IV SOLUTION 50380072_1 CDM 0250 RC 00264-7520-10 NDC inpatient 1 UN 47.96 31.17 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.04 46.52 "INJECTION, PROPOFOL, 10 MG" 50381056_1 CDM 0250 RC 43598-0265-58 NDC J2704 HCPCS inpatient 20 UN 24.71 16.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.06 65 999999999 14.96 23.97 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50381056_1 CDM 0250 RC 43598-0265-58 NDC J2704 HCPCS inpatient 20 UN 24.71 16.06 AETNA AETNA 19.52 79 999999999 14.96 23.97 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50381056_1 CDM 0250 RC 43598-0265-58 NDC J2704 HCPCS inpatient 20 UN 24.71 16.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23.97 97 999999999 14.96 23.97 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50381056_1 CDM 0250 RC 43598-0265-58 NDC J2704 HCPCS inpatient 20 UN 24.71 16.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.05 69 999999999 14.96 23.97 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50381056_1 CDM 0250 RC 43598-0265-58 NDC J2704 HCPCS inpatient 20 UN 24.71 16.06 SIHO - ALL PLANS SIHO - ALL PLANS 22.24 90 999999999 14.96 23.97 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50381056_1 CDM 0250 RC 43598-0265-58 NDC J2704 HCPCS inpatient 20 UN 24.71 16.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.27 78 999999999 14.96 23.97 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50381056_1 CDM 0250 RC 43598-0265-58 NDC J2704 HCPCS inpatient 20 UN 24.71 16.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.96 60.55 999999999 14.96 23.97 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50381056_1 CDM 0250 RC 43598-0265-58 NDC J2704 HCPCS inpatient 20 UN 24.71 16.06 UMR - ALL PLANS UMR - ALL PLANS 17.3 70 999999999 14.96 23.97 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50381056_1 CDM 0250 RC 43598-0265-58 NDC J2704 HCPCS inpatient 20 UN 24.71 16.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.96 23.97 "INJECTION, PROPOFOL, 10 MG" 50381056_1 CDM 0250 RC 43598-0265-58 NDC J2704 HCPCS inpatient 20 UN 24.71 16.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.96 23.97 "INJECTION, PROPOFOL, 10 MG" 50381056_1 CDM 0250 RC 43598-0265-58 NDC J2704 HCPCS inpatient 20 UN 24.71 16.06 ANTHEM HMO ANTHEM HMO 999999999 14.96 23.97 "INJECTION, PROPOFOL, 10 MG" 50381056_1 CDM 0250 RC 43598-0265-58 NDC J2704 HCPCS inpatient 20 UN 24.71 16.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.96 23.97 "INJECTION, PROPOFOL, 10 MG" 50381056_1 CDM 0250 RC 43598-0265-58 NDC J2704 HCPCS inpatient 20 UN 24.71 16.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.7 67.6 999999999 14.96 23.97 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50381056_1 CDM 0250 RC 43598-0265-58 NDC J2704 HCPCS inpatient 20 UN 24.71 16.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.96 23.97 "BUPRENORPHINE, ORAL, 1 MG" 50381498_1 CDM 0250 RC 00054-0176-13 NDC J0571 HCPCS inpatient 1 UN 5.57 3.62 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.62 65 999999999 3.37 5.4 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50381498_1 CDM 0250 RC 00054-0176-13 NDC J0571 HCPCS inpatient 1 UN 5.57 3.62 AETNA AETNA 4.4 79 999999999 3.37 5.4 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50381498_1 CDM 0250 RC 00054-0176-13 NDC J0571 HCPCS inpatient 1 UN 5.57 3.62 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.4 97 999999999 3.37 5.4 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50381498_1 CDM 0250 RC 00054-0176-13 NDC J0571 HCPCS inpatient 1 UN 5.57 3.62 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.84 69 999999999 3.37 5.4 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50381498_1 CDM 0250 RC 00054-0176-13 NDC J0571 HCPCS inpatient 1 UN 5.57 3.62 SIHO - ALL PLANS SIHO - ALL PLANS 5.01 90 999999999 3.37 5.4 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50381498_1 CDM 0250 RC 00054-0176-13 NDC J0571 HCPCS inpatient 1 UN 5.57 3.62 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.34 78 999999999 3.37 5.4 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50381498_1 CDM 0250 RC 00054-0176-13 NDC J0571 HCPCS inpatient 1 UN 5.57 3.62 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.37 60.55 999999999 3.37 5.4 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50381498_1 CDM 0250 RC 00054-0176-13 NDC J0571 HCPCS inpatient 1 UN 5.57 3.62 UMR - ALL PLANS UMR - ALL PLANS 3.9 70 999999999 3.37 5.4 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50381498_1 CDM 0250 RC 00054-0176-13 NDC J0571 HCPCS inpatient 1 UN 5.57 3.62 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.37 5.4 "BUPRENORPHINE, ORAL, 1 MG" 50381498_1 CDM 0250 RC 00054-0176-13 NDC J0571 HCPCS inpatient 1 UN 5.57 3.62 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.37 5.4 "BUPRENORPHINE, ORAL, 1 MG" 50381498_1 CDM 0250 RC 00054-0176-13 NDC J0571 HCPCS inpatient 1 UN 5.57 3.62 ANTHEM HMO ANTHEM HMO 999999999 3.37 5.4 "BUPRENORPHINE, ORAL, 1 MG" 50381498_1 CDM 0250 RC 00054-0176-13 NDC J0571 HCPCS inpatient 1 UN 5.57 3.62 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.37 5.4 "BUPRENORPHINE, ORAL, 1 MG" 50381498_1 CDM 0250 RC 00054-0176-13 NDC J0571 HCPCS inpatient 1 UN 5.57 3.62 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.77 67.6 999999999 3.37 5.4 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50381498_1 CDM 0250 RC 00054-0176-13 NDC J0571 HCPCS inpatient 1 UN 5.57 3.62 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.37 5.4 "BUPRENORPHINE, ORAL, 1 MG" 50381506_1 CDM 0250 RC 62756-0460-83 NDC J0571 HCPCS inpatient 1 UN 5.05 3.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.28 65 999999999 3.06 4.9 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50381506_1 CDM 0250 RC 62756-0460-83 NDC J0571 HCPCS inpatient 1 UN 5.05 3.28 AETNA AETNA 3.99 79 999999999 3.06 4.9 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50381506_1 CDM 0250 RC 62756-0460-83 NDC J0571 HCPCS inpatient 1 UN 5.05 3.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4.9 97 999999999 3.06 4.9 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50381506_1 CDM 0250 RC 62756-0460-83 NDC J0571 HCPCS inpatient 1 UN 5.05 3.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.48 69 999999999 3.06 4.9 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50381506_1 CDM 0250 RC 62756-0460-83 NDC J0571 HCPCS inpatient 1 UN 5.05 3.28 SIHO - ALL PLANS SIHO - ALL PLANS 4.55 90 999999999 3.06 4.9 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50381506_1 CDM 0250 RC 62756-0460-83 NDC J0571 HCPCS inpatient 1 UN 5.05 3.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.94 78 999999999 3.06 4.9 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50381506_1 CDM 0250 RC 62756-0460-83 NDC J0571 HCPCS inpatient 1 UN 5.05 3.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.06 60.55 999999999 3.06 4.9 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50381506_1 CDM 0250 RC 62756-0460-83 NDC J0571 HCPCS inpatient 1 UN 5.05 3.28 UMR - ALL PLANS UMR - ALL PLANS 3.54 70 999999999 3.06 4.9 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50381506_1 CDM 0250 RC 62756-0460-83 NDC J0571 HCPCS inpatient 1 UN 5.05 3.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.06 4.9 "BUPRENORPHINE, ORAL, 1 MG" 50381506_1 CDM 0250 RC 62756-0460-83 NDC J0571 HCPCS inpatient 1 UN 5.05 3.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.06 4.9 "BUPRENORPHINE, ORAL, 1 MG" 50381506_1 CDM 0250 RC 62756-0460-83 NDC J0571 HCPCS inpatient 1 UN 5.05 3.28 ANTHEM HMO ANTHEM HMO 999999999 3.06 4.9 "BUPRENORPHINE, ORAL, 1 MG" 50381506_1 CDM 0250 RC 62756-0460-83 NDC J0571 HCPCS inpatient 1 UN 5.05 3.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.06 4.9 "BUPRENORPHINE, ORAL, 1 MG" 50381506_1 CDM 0250 RC 62756-0460-83 NDC J0571 HCPCS inpatient 1 UN 5.05 3.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.41 67.6 999999999 3.06 4.9 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50381506_1 CDM 0250 RC 62756-0460-83 NDC J0571 HCPCS inpatient 1 UN 5.05 3.28 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.06 4.9 "Preparation of skin graft site of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 50382462_1 CDM 0361 RC 15004 HCPCS inpatient 1174 763.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 763.1 65 999999999 710.86 1138.78 percent of total billed charges "Preparation of skin graft site of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 50382462_1 CDM 0361 RC 15004 HCPCS inpatient 1174 763.1 AETNA AETNA 927.46 79 999999999 710.86 1138.78 percent of total billed charges "Preparation of skin graft site of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 50382462_1 CDM 0361 RC 15004 HCPCS inpatient 1174 763.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1138.78 97 999999999 710.86 1138.78 percent of total billed charges "Preparation of skin graft site of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 50382462_1 CDM 0361 RC 15004 HCPCS inpatient 1174 763.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 810.06 69 999999999 710.86 1138.78 percent of total billed charges "Preparation of skin graft site of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 50382462_1 CDM 0361 RC 15004 HCPCS inpatient 1174 763.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 915.72 78 999999999 710.86 1138.78 percent of total billed charges "Preparation of skin graft site of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 50382462_1 CDM 0361 RC 15004 HCPCS inpatient 1174 763.1 SIHO - ALL PLANS SIHO - ALL PLANS 1056.6 90 999999999 710.86 1138.78 percent of total billed charges "Preparation of skin graft site of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 50382462_1 CDM 0361 RC 15004 HCPCS inpatient 1174 763.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 710.86 60.55 999999999 710.86 1138.78 percent of total billed charges "Preparation of skin graft site of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 50382462_1 CDM 0361 RC 15004 HCPCS inpatient 1174 763.1 UMR - ALL PLANS UMR - ALL PLANS 821.8 70 999999999 710.86 1138.78 percent of total billed charges "Preparation of skin graft site of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 50382462_1 CDM 0361 RC 15004 HCPCS inpatient 1174 763.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 710.86 1138.78 "Preparation of skin graft site of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 50382462_1 CDM 0361 RC 15004 HCPCS inpatient 1174 763.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 710.86 1138.78 "Preparation of skin graft site of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 50382462_1 CDM 0361 RC 15004 HCPCS inpatient 1174 763.1 ANTHEM HMO ANTHEM HMO 999999999 710.86 1138.78 "Preparation of skin graft site of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 50382462_1 CDM 0361 RC 15004 HCPCS inpatient 1174 763.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 710.86 1138.78 "Preparation of skin graft site of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 50382462_1 CDM 0361 RC 15004 HCPCS inpatient 1174 763.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 793.62 67.6 999999999 710.86 1138.78 percent of total billed charges "Preparation of skin graft site of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 100.0 sq cm or 1% body area for infants and children, or less" 50382462_1 CDM 0361 RC 15004 HCPCS inpatient 1174 763.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 710.86 1138.78 00869-4206-10 - mineral oil 100% Liq[JOHN] 50382525_1 CDM 0250 RC 00869-4206-10 NDC inpatient 1 UN 8.29 5.39 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.39 65 999999999 5.02 8.04 percent of total billed charges 00869-4206-10 - mineral oil 100% Liq[JOHN] 50382525_1 CDM 0250 RC 00869-4206-10 NDC inpatient 1 UN 8.29 5.39 AETNA AETNA 6.55 79 999999999 5.02 8.04 percent of total billed charges 00869-4206-10 - mineral oil 100% Liq[JOHN] 50382525_1 CDM 0250 RC 00869-4206-10 NDC inpatient 1 UN 8.29 5.39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.04 97 999999999 5.02 8.04 percent of total billed charges 00869-4206-10 - mineral oil 100% Liq[JOHN] 50382525_1 CDM 0250 RC 00869-4206-10 NDC inpatient 1 UN 8.29 5.39 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.72 69 999999999 5.02 8.04 percent of total billed charges 00869-4206-10 - mineral oil 100% Liq[JOHN] 50382525_1 CDM 0250 RC 00869-4206-10 NDC inpatient 1 UN 8.29 5.39 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.47 78 999999999 5.02 8.04 percent of total billed charges 00869-4206-10 - mineral oil 100% Liq[JOHN] 50382525_1 CDM 0250 RC 00869-4206-10 NDC inpatient 1 UN 8.29 5.39 SIHO - ALL PLANS SIHO - ALL PLANS 7.46 90 999999999 5.02 8.04 percent of total billed charges 00869-4206-10 - mineral oil 100% Liq[JOHN] 50382525_1 CDM 0250 RC 00869-4206-10 NDC inpatient 1 UN 8.29 5.39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.02 60.55 999999999 5.02 8.04 percent of total billed charges 00869-4206-10 - mineral oil 100% Liq[JOHN] 50382525_1 CDM 0250 RC 00869-4206-10 NDC inpatient 1 UN 8.29 5.39 UMR - ALL PLANS UMR - ALL PLANS 5.8 70 999999999 5.02 8.04 percent of total billed charges 00869-4206-10 - mineral oil 100% Liq[JOHN] 50382525_1 CDM 0250 RC 00869-4206-10 NDC inpatient 1 UN 8.29 5.39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.02 8.04 00869-4206-10 - mineral oil 100% Liq[JOHN] 50382525_1 CDM 0250 RC 00869-4206-10 NDC inpatient 1 UN 8.29 5.39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.02 8.04 00869-4206-10 - mineral oil 100% Liq[JOHN] 50382525_1 CDM 0250 RC 00869-4206-10 NDC inpatient 1 UN 8.29 5.39 ANTHEM HMO ANTHEM HMO 999999999 5.02 8.04 00869-4206-10 - mineral oil 100% Liq[JOHN] 50382525_1 CDM 0250 RC 00869-4206-10 NDC inpatient 1 UN 8.29 5.39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.02 8.04 00869-4206-10 - mineral oil 100% Liq[JOHN] 50382525_1 CDM 0250 RC 00869-4206-10 NDC inpatient 1 UN 8.29 5.39 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.6 67.6 999999999 5.02 8.04 percent of total billed charges 00869-4206-10 - mineral oil 100% Liq[JOHN] 50382525_1 CDM 0250 RC 00869-4206-10 NDC inpatient 1 UN 8.29 5.39 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.02 8.04 POTASSIUM CL 20 MEQ/100 ML SOL 50383197_1 CDM 0250 RC 00990-7075-26 NDC inpatient 1 UN 49.13 31.93 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.93 65 999999999 29.75 47.66 percent of total billed charges POTASSIUM CL 20 MEQ/100 ML SOL 50383197_1 CDM 0250 RC 00990-7075-26 NDC inpatient 1 UN 49.13 31.93 AETNA AETNA 38.81 79 999999999 29.75 47.66 percent of total billed charges POTASSIUM CL 20 MEQ/100 ML SOL 50383197_1 CDM 0250 RC 00990-7075-26 NDC inpatient 1 UN 49.13 31.93 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 47.66 97 999999999 29.75 47.66 percent of total billed charges POTASSIUM CL 20 MEQ/100 ML SOL 50383197_1 CDM 0250 RC 00990-7075-26 NDC inpatient 1 UN 49.13 31.93 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.9 69 999999999 29.75 47.66 percent of total billed charges POTASSIUM CL 20 MEQ/100 ML SOL 50383197_1 CDM 0250 RC 00990-7075-26 NDC inpatient 1 UN 49.13 31.93 HUMANA - ALL PLANS HUMANA - ALL PLANS 38.32 78 999999999 29.75 47.66 percent of total billed charges POTASSIUM CL 20 MEQ/100 ML SOL 50383197_1 CDM 0250 RC 00990-7075-26 NDC inpatient 1 UN 49.13 31.93 SIHO - ALL PLANS SIHO - ALL PLANS 44.22 90 999999999 29.75 47.66 percent of total billed charges POTASSIUM CL 20 MEQ/100 ML SOL 50383197_1 CDM 0250 RC 00990-7075-26 NDC inpatient 1 UN 49.13 31.93 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.75 60.55 999999999 29.75 47.66 percent of total billed charges POTASSIUM CL 20 MEQ/100 ML SOL 50383197_1 CDM 0250 RC 00990-7075-26 NDC inpatient 1 UN 49.13 31.93 UMR - ALL PLANS UMR - ALL PLANS 34.39 70 999999999 29.75 47.66 percent of total billed charges POTASSIUM CL 20 MEQ/100 ML SOL 50383197_1 CDM 0250 RC 00990-7075-26 NDC inpatient 1 UN 49.13 31.93 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.75 47.66 POTASSIUM CL 20 MEQ/100 ML SOL 50383197_1 CDM 0250 RC 00990-7075-26 NDC inpatient 1 UN 49.13 31.93 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.75 47.66 POTASSIUM CL 20 MEQ/100 ML SOL 50383197_1 CDM 0250 RC 00990-7075-26 NDC inpatient 1 UN 49.13 31.93 ANTHEM HMO ANTHEM HMO 999999999 29.75 47.66 POTASSIUM CL 20 MEQ/100 ML SOL 50383197_1 CDM 0250 RC 00990-7075-26 NDC inpatient 1 UN 49.13 31.93 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.75 47.66 POTASSIUM CL 20 MEQ/100 ML SOL 50383197_1 CDM 0250 RC 00990-7075-26 NDC inpatient 1 UN 49.13 31.93 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.21 67.6 999999999 29.75 47.66 percent of total billed charges POTASSIUM CL 20 MEQ/100 ML SOL 50383197_1 CDM 0250 RC 00990-7075-26 NDC inpatient 1 UN 49.13 31.93 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.75 47.66 TRAZODONE 100 MG TABLET 50383198_1 CDM 0250 RC 60687-0454-01 NDC inpatient 1 UN 1.73 1.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.12 65 999999999 1.05 1.68 percent of total billed charges TRAZODONE 100 MG TABLET 50383198_1 CDM 0250 RC 60687-0454-01 NDC inpatient 1 UN 1.73 1.12 AETNA AETNA 1.37 79 999999999 1.05 1.68 percent of total billed charges TRAZODONE 100 MG TABLET 50383198_1 CDM 0250 RC 60687-0454-01 NDC inpatient 1 UN 1.73 1.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.68 97 999999999 1.05 1.68 percent of total billed charges TRAZODONE 100 MG TABLET 50383198_1 CDM 0250 RC 60687-0454-01 NDC inpatient 1 UN 1.73 1.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.19 69 999999999 1.05 1.68 percent of total billed charges TRAZODONE 100 MG TABLET 50383198_1 CDM 0250 RC 60687-0454-01 NDC inpatient 1 UN 1.73 1.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.35 78 999999999 1.05 1.68 percent of total billed charges TRAZODONE 100 MG TABLET 50383198_1 CDM 0250 RC 60687-0454-01 NDC inpatient 1 UN 1.73 1.12 SIHO - ALL PLANS SIHO - ALL PLANS 1.56 90 999999999 1.05 1.68 percent of total billed charges TRAZODONE 100 MG TABLET 50383198_1 CDM 0250 RC 60687-0454-01 NDC inpatient 1 UN 1.73 1.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.05 60.55 999999999 1.05 1.68 percent of total billed charges TRAZODONE 100 MG TABLET 50383198_1 CDM 0250 RC 60687-0454-01 NDC inpatient 1 UN 1.73 1.12 UMR - ALL PLANS UMR - ALL PLANS 1.21 70 999999999 1.05 1.68 percent of total billed charges TRAZODONE 100 MG TABLET 50383198_1 CDM 0250 RC 60687-0454-01 NDC inpatient 1 UN 1.73 1.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.05 1.68 TRAZODONE 100 MG TABLET 50383198_1 CDM 0250 RC 60687-0454-01 NDC inpatient 1 UN 1.73 1.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.05 1.68 TRAZODONE 100 MG TABLET 50383198_1 CDM 0250 RC 60687-0454-01 NDC inpatient 1 UN 1.73 1.12 ANTHEM HMO ANTHEM HMO 999999999 1.05 1.68 TRAZODONE 100 MG TABLET 50383198_1 CDM 0250 RC 60687-0454-01 NDC inpatient 1 UN 1.73 1.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.05 1.68 TRAZODONE 100 MG TABLET 50383198_1 CDM 0250 RC 60687-0454-01 NDC inpatient 1 UN 1.73 1.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.17 67.6 999999999 1.05 1.68 percent of total billed charges TRAZODONE 100 MG TABLET 50383198_1 CDM 0250 RC 60687-0454-01 NDC inpatient 1 UN 1.73 1.12 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.05 1.68 LIDOCAINE HCL 1% VIAL 50383199_1 CDM 0250 RC 00409-4276-02 NDC inpatient 100 UN 32.42 21.07 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.07 65 999999999 19.63 31.45 percent of total billed charges LIDOCAINE HCL 1% VIAL 50383199_1 CDM 0250 RC 00409-4276-02 NDC inpatient 100 UN 32.42 21.07 AETNA AETNA 25.61 79 999999999 19.63 31.45 percent of total billed charges LIDOCAINE HCL 1% VIAL 50383199_1 CDM 0250 RC 00409-4276-02 NDC inpatient 100 UN 32.42 21.07 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31.45 97 999999999 19.63 31.45 percent of total billed charges LIDOCAINE HCL 1% VIAL 50383199_1 CDM 0250 RC 00409-4276-02 NDC inpatient 100 UN 32.42 21.07 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.37 69 999999999 19.63 31.45 percent of total billed charges LIDOCAINE HCL 1% VIAL 50383199_1 CDM 0250 RC 00409-4276-02 NDC inpatient 100 UN 32.42 21.07 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.29 78 999999999 19.63 31.45 percent of total billed charges LIDOCAINE HCL 1% VIAL 50383199_1 CDM 0250 RC 00409-4276-02 NDC inpatient 100 UN 32.42 21.07 SIHO - ALL PLANS SIHO - ALL PLANS 29.18 90 999999999 19.63 31.45 percent of total billed charges LIDOCAINE HCL 1% VIAL 50383199_1 CDM 0250 RC 00409-4276-02 NDC inpatient 100 UN 32.42 21.07 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.63 60.55 999999999 19.63 31.45 percent of total billed charges LIDOCAINE HCL 1% VIAL 50383199_1 CDM 0250 RC 00409-4276-02 NDC inpatient 100 UN 32.42 21.07 UMR - ALL PLANS UMR - ALL PLANS 22.69 70 999999999 19.63 31.45 percent of total billed charges LIDOCAINE HCL 1% VIAL 50383199_1 CDM 0250 RC 00409-4276-02 NDC inpatient 100 UN 32.42 21.07 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.63 31.45 LIDOCAINE HCL 1% VIAL 50383199_1 CDM 0250 RC 00409-4276-02 NDC inpatient 100 UN 32.42 21.07 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.63 31.45 LIDOCAINE HCL 1% VIAL 50383199_1 CDM 0250 RC 00409-4276-02 NDC inpatient 100 UN 32.42 21.07 ANTHEM HMO ANTHEM HMO 999999999 19.63 31.45 LIDOCAINE HCL 1% VIAL 50383199_1 CDM 0250 RC 00409-4276-02 NDC inpatient 100 UN 32.42 21.07 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.63 31.45 LIDOCAINE HCL 1% VIAL 50383199_1 CDM 0250 RC 00409-4276-02 NDC inpatient 100 UN 32.42 21.07 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.92 67.6 999999999 19.63 31.45 percent of total billed charges LIDOCAINE HCL 1% VIAL 50383199_1 CDM 0250 RC 00409-4276-02 NDC inpatient 100 UN 32.42 21.07 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.63 31.45 ACYCLOVIR 5% OINTMENT 50383201_1 CDM 0250 RC 68382-0992-01 NDC inpatient 1 UN 86.73 56.37 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.37 65 999999999 52.52 84.13 percent of total billed charges ACYCLOVIR 5% OINTMENT 50383201_1 CDM 0250 RC 68382-0992-01 NDC inpatient 1 UN 86.73 56.37 AETNA AETNA 68.52 79 999999999 52.52 84.13 percent of total billed charges ACYCLOVIR 5% OINTMENT 50383201_1 CDM 0250 RC 68382-0992-01 NDC inpatient 1 UN 86.73 56.37 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.13 97 999999999 52.52 84.13 percent of total billed charges ACYCLOVIR 5% OINTMENT 50383201_1 CDM 0250 RC 68382-0992-01 NDC inpatient 1 UN 86.73 56.37 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.84 69 999999999 52.52 84.13 percent of total billed charges ACYCLOVIR 5% OINTMENT 50383201_1 CDM 0250 RC 68382-0992-01 NDC inpatient 1 UN 86.73 56.37 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.65 78 999999999 52.52 84.13 percent of total billed charges ACYCLOVIR 5% OINTMENT 50383201_1 CDM 0250 RC 68382-0992-01 NDC inpatient 1 UN 86.73 56.37 SIHO - ALL PLANS SIHO - ALL PLANS 78.06 90 999999999 52.52 84.13 percent of total billed charges ACYCLOVIR 5% OINTMENT 50383201_1 CDM 0250 RC 68382-0992-01 NDC inpatient 1 UN 86.73 56.37 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.52 60.55 999999999 52.52 84.13 percent of total billed charges ACYCLOVIR 5% OINTMENT 50383201_1 CDM 0250 RC 68382-0992-01 NDC inpatient 1 UN 86.73 56.37 UMR - ALL PLANS UMR - ALL PLANS 60.71 70 999999999 52.52 84.13 percent of total billed charges ACYCLOVIR 5% OINTMENT 50383201_1 CDM 0250 RC 68382-0992-01 NDC inpatient 1 UN 86.73 56.37 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.52 84.13 ACYCLOVIR 5% OINTMENT 50383201_1 CDM 0250 RC 68382-0992-01 NDC inpatient 1 UN 86.73 56.37 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.52 84.13 ACYCLOVIR 5% OINTMENT 50383201_1 CDM 0250 RC 68382-0992-01 NDC inpatient 1 UN 86.73 56.37 ANTHEM HMO ANTHEM HMO 999999999 52.52 84.13 ACYCLOVIR 5% OINTMENT 50383201_1 CDM 0250 RC 68382-0992-01 NDC inpatient 1 UN 86.73 56.37 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.52 84.13 ACYCLOVIR 5% OINTMENT 50383201_1 CDM 0250 RC 68382-0992-01 NDC inpatient 1 UN 86.73 56.37 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.63 67.6 999999999 52.52 84.13 percent of total billed charges ACYCLOVIR 5% OINTMENT 50383201_1 CDM 0250 RC 68382-0992-01 NDC inpatient 1 UN 86.73 56.37 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.52 84.13 "Therapy procedure for a range of mental processes, initial 15 minutes" 50385581_1 CDM 0440 RC 97129 HCPCS inpatient 374 243.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 243.1 65 999999999 226.46 362.78 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50385581_1 CDM 0440 RC 97129 HCPCS inpatient 374 243.1 AETNA AETNA 295.46 79 999999999 226.46 362.78 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50385581_1 CDM 0440 RC 97129 HCPCS inpatient 374 243.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 362.78 97 999999999 226.46 362.78 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50385581_1 CDM 0440 RC 97129 HCPCS inpatient 374 243.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 258.06 69 999999999 226.46 362.78 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50385581_1 CDM 0440 RC 97129 HCPCS inpatient 374 243.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 291.72 78 999999999 226.46 362.78 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50385581_1 CDM 0440 RC 97129 HCPCS inpatient 374 243.1 SIHO - ALL PLANS SIHO - ALL PLANS 336.6 90 999999999 226.46 362.78 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50385581_1 CDM 0440 RC 97129 HCPCS inpatient 374 243.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 226.46 60.55 999999999 226.46 362.78 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50385581_1 CDM 0440 RC 97129 HCPCS inpatient 374 243.1 UMR - ALL PLANS UMR - ALL PLANS 261.8 70 999999999 226.46 362.78 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50385581_1 CDM 0440 RC 97129 HCPCS inpatient 374 243.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 226.46 362.78 "Therapy procedure for a range of mental processes, initial 15 minutes" 50385581_1 CDM 0440 RC 97129 HCPCS inpatient 374 243.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 226.46 362.78 "Therapy procedure for a range of mental processes, initial 15 minutes" 50385581_1 CDM 0440 RC 97129 HCPCS inpatient 374 243.1 ANTHEM HMO ANTHEM HMO 999999999 226.46 362.78 "Therapy procedure for a range of mental processes, initial 15 minutes" 50385581_1 CDM 0440 RC 97129 HCPCS inpatient 374 243.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 226.46 362.78 "Therapy procedure for a range of mental processes, initial 15 minutes" 50385581_1 CDM 0440 RC 97129 HCPCS inpatient 374 243.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 252.82 67.6 999999999 226.46 362.78 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50385581_1 CDM 0440 RC 97129 HCPCS inpatient 374 243.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 226.46 362.78 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50385582_1 CDM 0440 RC 97130 HCPCS inpatient 374 243.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 243.1 65 999999999 226.46 362.78 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50385582_1 CDM 0440 RC 97130 HCPCS inpatient 374 243.1 AETNA AETNA 295.46 79 999999999 226.46 362.78 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50385582_1 CDM 0440 RC 97130 HCPCS inpatient 374 243.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 362.78 97 999999999 226.46 362.78 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50385582_1 CDM 0440 RC 97130 HCPCS inpatient 374 243.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 258.06 69 999999999 226.46 362.78 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50385582_1 CDM 0440 RC 97130 HCPCS inpatient 374 243.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 291.72 78 999999999 226.46 362.78 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50385582_1 CDM 0440 RC 97130 HCPCS inpatient 374 243.1 SIHO - ALL PLANS SIHO - ALL PLANS 336.6 90 999999999 226.46 362.78 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50385582_1 CDM 0440 RC 97130 HCPCS inpatient 374 243.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 226.46 60.55 999999999 226.46 362.78 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50385582_1 CDM 0440 RC 97130 HCPCS inpatient 374 243.1 UMR - ALL PLANS UMR - ALL PLANS 261.8 70 999999999 226.46 362.78 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50385582_1 CDM 0440 RC 97130 HCPCS inpatient 374 243.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 226.46 362.78 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50385582_1 CDM 0440 RC 97130 HCPCS inpatient 374 243.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 226.46 362.78 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50385582_1 CDM 0440 RC 97130 HCPCS inpatient 374 243.1 ANTHEM HMO ANTHEM HMO 999999999 226.46 362.78 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50385582_1 CDM 0440 RC 97130 HCPCS inpatient 374 243.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 226.46 362.78 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50385582_1 CDM 0440 RC 97130 HCPCS inpatient 374 243.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 252.82 67.6 999999999 226.46 362.78 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50385582_1 CDM 0440 RC 97130 HCPCS inpatient 374 243.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 226.46 362.78 Anticoagulant management of patient taking warfarin 50385697_1 CDM 0510 RC 93793 HCPCS inpatient 31 20.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.15 65 999999999 18.77 30.07 percent of total billed charges Anticoagulant management of patient taking warfarin 50385697_1 CDM 0510 RC 93793 HCPCS inpatient 31 20.15 AETNA AETNA 24.49 79 999999999 18.77 30.07 percent of total billed charges Anticoagulant management of patient taking warfarin 50385697_1 CDM 0510 RC 93793 HCPCS inpatient 31 20.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.07 97 999999999 18.77 30.07 percent of total billed charges Anticoagulant management of patient taking warfarin 50385697_1 CDM 0510 RC 93793 HCPCS inpatient 31 20.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.39 69 999999999 18.77 30.07 percent of total billed charges Anticoagulant management of patient taking warfarin 50385697_1 CDM 0510 RC 93793 HCPCS inpatient 31 20.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.18 78 999999999 18.77 30.07 percent of total billed charges Anticoagulant management of patient taking warfarin 50385697_1 CDM 0510 RC 93793 HCPCS inpatient 31 20.15 SIHO - ALL PLANS SIHO - ALL PLANS 27.9 90 999999999 18.77 30.07 percent of total billed charges Anticoagulant management of patient taking warfarin 50385697_1 CDM 0510 RC 93793 HCPCS inpatient 31 20.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.77 60.55 999999999 18.77 30.07 percent of total billed charges Anticoagulant management of patient taking warfarin 50385697_1 CDM 0510 RC 93793 HCPCS inpatient 31 20.15 UMR - ALL PLANS UMR - ALL PLANS 21.7 70 999999999 18.77 30.07 percent of total billed charges Anticoagulant management of patient taking warfarin 50385697_1 CDM 0510 RC 93793 HCPCS inpatient 31 20.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.77 30.07 Anticoagulant management of patient taking warfarin 50385697_1 CDM 0510 RC 93793 HCPCS inpatient 31 20.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.77 30.07 Anticoagulant management of patient taking warfarin 50385697_1 CDM 0510 RC 93793 HCPCS inpatient 31 20.15 ANTHEM HMO ANTHEM HMO 999999999 18.77 30.07 Anticoagulant management of patient taking warfarin 50385697_1 CDM 0510 RC 93793 HCPCS inpatient 31 20.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.77 30.07 Anticoagulant management of patient taking warfarin 50385697_1 CDM 0510 RC 93793 HCPCS inpatient 31 20.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.96 67.6 999999999 18.77 30.07 percent of total billed charges Anticoagulant management of patient taking warfarin 50385697_1 CDM 0510 RC 93793 HCPCS inpatient 31 20.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.77 30.07 "INJECTION, PEGFILGRASTIM, EXCLUDES BIOSIMILAR, 0.5 MG" 50385814_1 CDM 0650 RC 55513-0192-01 NDC J2506 HCPCS inpatient 1 UN 17655.37 11475.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 11475.99 65 999999999 10690.33 17125.71 percent of total billed charges "INJECTION, PEGFILGRASTIM, EXCLUDES BIOSIMILAR, 0.5 MG" 50385814_1 CDM 0650 RC 55513-0192-01 NDC J2506 HCPCS inpatient 1 UN 17655.37 11475.99 AETNA AETNA 13947.74 79 999999999 10690.33 17125.71 percent of total billed charges "INJECTION, PEGFILGRASTIM, EXCLUDES BIOSIMILAR, 0.5 MG" 50385814_1 CDM 0650 RC 55513-0192-01 NDC J2506 HCPCS inpatient 1 UN 17655.37 11475.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17125.71 97 999999999 10690.33 17125.71 percent of total billed charges "INJECTION, PEGFILGRASTIM, EXCLUDES BIOSIMILAR, 0.5 MG" 50385814_1 CDM 0650 RC 55513-0192-01 NDC J2506 HCPCS inpatient 1 UN 17655.37 11475.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 12182.21 69 999999999 10690.33 17125.71 percent of total billed charges "INJECTION, PEGFILGRASTIM, EXCLUDES BIOSIMILAR, 0.5 MG" 50385814_1 CDM 0650 RC 55513-0192-01 NDC J2506 HCPCS inpatient 1 UN 17655.37 11475.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 13771.19 78 999999999 10690.33 17125.71 percent of total billed charges "INJECTION, PEGFILGRASTIM, EXCLUDES BIOSIMILAR, 0.5 MG" 50385814_1 CDM 0650 RC 55513-0192-01 NDC J2506 HCPCS inpatient 1 UN 17655.37 11475.99 SIHO - ALL PLANS SIHO - ALL PLANS 15889.83 90 999999999 10690.33 17125.71 percent of total billed charges "INJECTION, PEGFILGRASTIM, EXCLUDES BIOSIMILAR, 0.5 MG" 50385814_1 CDM 0650 RC 55513-0192-01 NDC J2506 HCPCS inpatient 1 UN 17655.37 11475.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10690.33 60.55 999999999 10690.33 17125.71 percent of total billed charges "INJECTION, PEGFILGRASTIM, EXCLUDES BIOSIMILAR, 0.5 MG" 50385814_1 CDM 0650 RC 55513-0192-01 NDC J2506 HCPCS inpatient 1 UN 17655.37 11475.99 UMR - ALL PLANS UMR - ALL PLANS 12358.76 70 999999999 10690.33 17125.71 percent of total billed charges "INJECTION, PEGFILGRASTIM, EXCLUDES BIOSIMILAR, 0.5 MG" 50385814_1 CDM 0650 RC 55513-0192-01 NDC J2506 HCPCS inpatient 1 UN 17655.37 11475.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10690.33 17125.71 "INJECTION, PEGFILGRASTIM, EXCLUDES BIOSIMILAR, 0.5 MG" 50385814_1 CDM 0650 RC 55513-0192-01 NDC J2506 HCPCS inpatient 1 UN 17655.37 11475.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10690.33 17125.71 "INJECTION, PEGFILGRASTIM, EXCLUDES BIOSIMILAR, 0.5 MG" 50385814_1 CDM 0650 RC 55513-0192-01 NDC J2506 HCPCS inpatient 1 UN 17655.37 11475.99 ANTHEM HMO ANTHEM HMO 999999999 10690.33 17125.71 "INJECTION, PEGFILGRASTIM, EXCLUDES BIOSIMILAR, 0.5 MG" 50385814_1 CDM 0650 RC 55513-0192-01 NDC J2506 HCPCS inpatient 1 UN 17655.37 11475.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10690.33 17125.71 "INJECTION, PEGFILGRASTIM, EXCLUDES BIOSIMILAR, 0.5 MG" 50385814_1 CDM 0650 RC 55513-0192-01 NDC J2506 HCPCS inpatient 1 UN 17655.37 11475.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 11935.03 67.6 999999999 10690.33 17125.71 percent of total billed charges "INJECTION, PEGFILGRASTIM, EXCLUDES BIOSIMILAR, 0.5 MG" 50385814_1 CDM 0650 RC 55513-0192-01 NDC J2506 HCPCS inpatient 1 UN 17655.37 11475.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 10690.33 17125.71 BRIMONIDINE 0.2% EYE DROP 50386156_1 CDM 0250 RC 70069-0231-01 NDC inpatient 1 UN 7.25 4.71 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.71 65 999999999 4.39 7.03 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 50386156_1 CDM 0250 RC 70069-0231-01 NDC inpatient 1 UN 7.25 4.71 AETNA AETNA 5.73 79 999999999 4.39 7.03 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 50386156_1 CDM 0250 RC 70069-0231-01 NDC inpatient 1 UN 7.25 4.71 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7.03 97 999999999 4.39 7.03 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 50386156_1 CDM 0250 RC 70069-0231-01 NDC inpatient 1 UN 7.25 4.71 ENCORE - ALL PLANS ENCORE - ALL PLANS 5 69 999999999 4.39 7.03 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 50386156_1 CDM 0250 RC 70069-0231-01 NDC inpatient 1 UN 7.25 4.71 HUMANA - ALL PLANS HUMANA - ALL PLANS 5.66 78 999999999 4.39 7.03 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 50386156_1 CDM 0250 RC 70069-0231-01 NDC inpatient 1 UN 7.25 4.71 SIHO - ALL PLANS SIHO - ALL PLANS 6.53 90 999999999 4.39 7.03 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 50386156_1 CDM 0250 RC 70069-0231-01 NDC inpatient 1 UN 7.25 4.71 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.39 60.55 999999999 4.39 7.03 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 50386156_1 CDM 0250 RC 70069-0231-01 NDC inpatient 1 UN 7.25 4.71 UMR - ALL PLANS UMR - ALL PLANS 5.08 70 999999999 4.39 7.03 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 50386156_1 CDM 0250 RC 70069-0231-01 NDC inpatient 1 UN 7.25 4.71 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.39 7.03 BRIMONIDINE 0.2% EYE DROP 50386156_1 CDM 0250 RC 70069-0231-01 NDC inpatient 1 UN 7.25 4.71 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.39 7.03 BRIMONIDINE 0.2% EYE DROP 50386156_1 CDM 0250 RC 70069-0231-01 NDC inpatient 1 UN 7.25 4.71 ANTHEM HMO ANTHEM HMO 999999999 4.39 7.03 BRIMONIDINE 0.2% EYE DROP 50386156_1 CDM 0250 RC 70069-0231-01 NDC inpatient 1 UN 7.25 4.71 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.39 7.03 BRIMONIDINE 0.2% EYE DROP 50386156_1 CDM 0250 RC 70069-0231-01 NDC inpatient 1 UN 7.25 4.71 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.9 67.6 999999999 4.39 7.03 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 50386156_1 CDM 0250 RC 70069-0231-01 NDC inpatient 1 UN 7.25 4.71 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.39 7.03 "INJECTION, PROPOFOL, 10 MG" 50386158_1 CDM 0250 RC 43598-0548-21 NDC J2704 HCPCS inpatient 50 UN 110.6 71.89 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.89 65 999999999 66.97 107.28 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50386158_1 CDM 0250 RC 43598-0548-21 NDC J2704 HCPCS inpatient 50 UN 110.6 71.89 AETNA AETNA 87.37 79 999999999 66.97 107.28 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50386158_1 CDM 0250 RC 43598-0548-21 NDC J2704 HCPCS inpatient 50 UN 110.6 71.89 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 107.28 97 999999999 66.97 107.28 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50386158_1 CDM 0250 RC 43598-0548-21 NDC J2704 HCPCS inpatient 50 UN 110.6 71.89 ENCORE - ALL PLANS ENCORE - ALL PLANS 76.31 69 999999999 66.97 107.28 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50386158_1 CDM 0250 RC 43598-0548-21 NDC J2704 HCPCS inpatient 50 UN 110.6 71.89 HUMANA - ALL PLANS HUMANA - ALL PLANS 86.27 78 999999999 66.97 107.28 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50386158_1 CDM 0250 RC 43598-0548-21 NDC J2704 HCPCS inpatient 50 UN 110.6 71.89 SIHO - ALL PLANS SIHO - ALL PLANS 99.54 90 999999999 66.97 107.28 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50386158_1 CDM 0250 RC 43598-0548-21 NDC J2704 HCPCS inpatient 50 UN 110.6 71.89 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.97 60.55 999999999 66.97 107.28 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50386158_1 CDM 0250 RC 43598-0548-21 NDC J2704 HCPCS inpatient 50 UN 110.6 71.89 UMR - ALL PLANS UMR - ALL PLANS 77.42 70 999999999 66.97 107.28 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50386158_1 CDM 0250 RC 43598-0548-21 NDC J2704 HCPCS inpatient 50 UN 110.6 71.89 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.97 107.28 "INJECTION, PROPOFOL, 10 MG" 50386158_1 CDM 0250 RC 43598-0548-21 NDC J2704 HCPCS inpatient 50 UN 110.6 71.89 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.97 107.28 "INJECTION, PROPOFOL, 10 MG" 50386158_1 CDM 0250 RC 43598-0548-21 NDC J2704 HCPCS inpatient 50 UN 110.6 71.89 ANTHEM HMO ANTHEM HMO 999999999 66.97 107.28 "INJECTION, PROPOFOL, 10 MG" 50386158_1 CDM 0250 RC 43598-0548-21 NDC J2704 HCPCS inpatient 50 UN 110.6 71.89 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.97 107.28 "INJECTION, PROPOFOL, 10 MG" 50386158_1 CDM 0250 RC 43598-0548-21 NDC J2704 HCPCS inpatient 50 UN 110.6 71.89 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.77 67.6 999999999 66.97 107.28 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50386158_1 CDM 0250 RC 43598-0548-21 NDC J2704 HCPCS inpatient 50 UN 110.6 71.89 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.97 107.28 "Therapy procedure for a range of mental processes, initial 15 minutes" 50386195_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50386195_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50386195_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50386195_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50386195_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50386195_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50386195_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50386195_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50386195_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, initial 15 minutes" 50386195_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, initial 15 minutes" 50386195_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, initial 15 minutes" 50386195_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, initial 15 minutes" 50386195_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, initial 15 minutes" 50386195_1 CDM 0430 RC 97129 HCPCS inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50386196_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50386196_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50386196_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50386196_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50386196_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50386196_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50386196_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50386196_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50386196_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50386196_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50386196_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50386196_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 "Therapy procedure for a range of mental processes, each additional 15 minutes" 50386196_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges "Therapy procedure for a range of mental processes, each additional 15 minutes" 50386196_1 CDM 0430 RC 97130 HCPCS inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 PREGABALIN 75 MG CAPSULE 50388853_1 CDM 0250 RC 60687-0495-01 NDC inpatient 1 UN 1.49 0.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.97 65 999999999 0.9 1.45 percent of total billed charges PREGABALIN 75 MG CAPSULE 50388853_1 CDM 0250 RC 60687-0495-01 NDC inpatient 1 UN 1.49 0.97 AETNA AETNA 1.18 79 999999999 0.9 1.45 percent of total billed charges PREGABALIN 75 MG CAPSULE 50388853_1 CDM 0250 RC 60687-0495-01 NDC inpatient 1 UN 1.49 0.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.45 97 999999999 0.9 1.45 percent of total billed charges PREGABALIN 75 MG CAPSULE 50388853_1 CDM 0250 RC 60687-0495-01 NDC inpatient 1 UN 1.49 0.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.03 69 999999999 0.9 1.45 percent of total billed charges PREGABALIN 75 MG CAPSULE 50388853_1 CDM 0250 RC 60687-0495-01 NDC inpatient 1 UN 1.49 0.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.16 78 999999999 0.9 1.45 percent of total billed charges PREGABALIN 75 MG CAPSULE 50388853_1 CDM 0250 RC 60687-0495-01 NDC inpatient 1 UN 1.49 0.97 SIHO - ALL PLANS SIHO - ALL PLANS 1.34 90 999999999 0.9 1.45 percent of total billed charges PREGABALIN 75 MG CAPSULE 50388853_1 CDM 0250 RC 60687-0495-01 NDC inpatient 1 UN 1.49 0.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.9 60.55 999999999 0.9 1.45 percent of total billed charges PREGABALIN 75 MG CAPSULE 50388853_1 CDM 0250 RC 60687-0495-01 NDC inpatient 1 UN 1.49 0.97 UMR - ALL PLANS UMR - ALL PLANS 1.04 70 999999999 0.9 1.45 percent of total billed charges PREGABALIN 75 MG CAPSULE 50388853_1 CDM 0250 RC 60687-0495-01 NDC inpatient 1 UN 1.49 0.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.9 1.45 PREGABALIN 75 MG CAPSULE 50388853_1 CDM 0250 RC 60687-0495-01 NDC inpatient 1 UN 1.49 0.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.9 1.45 PREGABALIN 75 MG CAPSULE 50388853_1 CDM 0250 RC 60687-0495-01 NDC inpatient 1 UN 1.49 0.97 ANTHEM HMO ANTHEM HMO 999999999 0.9 1.45 PREGABALIN 75 MG CAPSULE 50388853_1 CDM 0250 RC 60687-0495-01 NDC inpatient 1 UN 1.49 0.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.9 1.45 PREGABALIN 75 MG CAPSULE 50388853_1 CDM 0250 RC 60687-0495-01 NDC inpatient 1 UN 1.49 0.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.01 67.6 999999999 0.9 1.45 percent of total billed charges PREGABALIN 75 MG CAPSULE 50388853_1 CDM 0250 RC 60687-0495-01 NDC inpatient 1 UN 1.49 0.97 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.9 1.45 PHENOBARBITAL 32.4 MG TABLET 50389251_1 CDM 0250 RC 00904-6575-61 NDC inpatient 510 UN 1.72 1.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.12 65 999999999 1.04 1.67 percent of total billed charges PHENOBARBITAL 32.4 MG TABLET 50389251_1 CDM 0250 RC 00904-6575-61 NDC inpatient 510 UN 1.72 1.12 AETNA AETNA 1.36 79 999999999 1.04 1.67 percent of total billed charges PHENOBARBITAL 32.4 MG TABLET 50389251_1 CDM 0250 RC 00904-6575-61 NDC inpatient 510 UN 1.72 1.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.67 97 999999999 1.04 1.67 percent of total billed charges PHENOBARBITAL 32.4 MG TABLET 50389251_1 CDM 0250 RC 00904-6575-61 NDC inpatient 510 UN 1.72 1.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.19 69 999999999 1.04 1.67 percent of total billed charges PHENOBARBITAL 32.4 MG TABLET 50389251_1 CDM 0250 RC 00904-6575-61 NDC inpatient 510 UN 1.72 1.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.34 78 999999999 1.04 1.67 percent of total billed charges PHENOBARBITAL 32.4 MG TABLET 50389251_1 CDM 0250 RC 00904-6575-61 NDC inpatient 510 UN 1.72 1.12 SIHO - ALL PLANS SIHO - ALL PLANS 1.55 90 999999999 1.04 1.67 percent of total billed charges PHENOBARBITAL 32.4 MG TABLET 50389251_1 CDM 0250 RC 00904-6575-61 NDC inpatient 510 UN 1.72 1.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.04 60.55 999999999 1.04 1.67 percent of total billed charges PHENOBARBITAL 32.4 MG TABLET 50389251_1 CDM 0250 RC 00904-6575-61 NDC inpatient 510 UN 1.72 1.12 UMR - ALL PLANS UMR - ALL PLANS 1.2 70 999999999 1.04 1.67 percent of total billed charges PHENOBARBITAL 32.4 MG TABLET 50389251_1 CDM 0250 RC 00904-6575-61 NDC inpatient 510 UN 1.72 1.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.04 1.67 PHENOBARBITAL 32.4 MG TABLET 50389251_1 CDM 0250 RC 00904-6575-61 NDC inpatient 510 UN 1.72 1.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.04 1.67 PHENOBARBITAL 32.4 MG TABLET 50389251_1 CDM 0250 RC 00904-6575-61 NDC inpatient 510 UN 1.72 1.12 ANTHEM HMO ANTHEM HMO 999999999 1.04 1.67 PHENOBARBITAL 32.4 MG TABLET 50389251_1 CDM 0250 RC 00904-6575-61 NDC inpatient 510 UN 1.72 1.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.04 1.67 PHENOBARBITAL 32.4 MG TABLET 50389251_1 CDM 0250 RC 00904-6575-61 NDC inpatient 510 UN 1.72 1.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.16 67.6 999999999 1.04 1.67 percent of total billed charges PHENOBARBITAL 32.4 MG TABLET 50389251_1 CDM 0250 RC 00904-6575-61 NDC inpatient 510 UN 1.72 1.12 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.04 1.67 "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 50393658_1 CDM 0250 RC 59730-4203-01 NDC J1571 HCPCS inpatient 10 UN 95.01 61.76 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.76 65 999999999 57.53 92.16 percent of total billed charges "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 50393658_1 CDM 0250 RC 59730-4203-01 NDC J1571 HCPCS inpatient 10 UN 95.01 61.76 AETNA AETNA 75.06 79 999999999 57.53 92.16 percent of total billed charges "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 50393658_1 CDM 0250 RC 59730-4203-01 NDC J1571 HCPCS inpatient 10 UN 95.01 61.76 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 92.16 97 999999999 57.53 92.16 percent of total billed charges "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 50393658_1 CDM 0250 RC 59730-4203-01 NDC J1571 HCPCS inpatient 10 UN 95.01 61.76 ENCORE - ALL PLANS ENCORE - ALL PLANS 65.56 69 999999999 57.53 92.16 percent of total billed charges "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 50393658_1 CDM 0250 RC 59730-4203-01 NDC J1571 HCPCS inpatient 10 UN 95.01 61.76 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.11 78 999999999 57.53 92.16 percent of total billed charges "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 50393658_1 CDM 0250 RC 59730-4203-01 NDC J1571 HCPCS inpatient 10 UN 95.01 61.76 SIHO - ALL PLANS SIHO - ALL PLANS 85.51 90 999999999 57.53 92.16 percent of total billed charges "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 50393658_1 CDM 0250 RC 59730-4203-01 NDC J1571 HCPCS inpatient 10 UN 95.01 61.76 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 57.53 60.55 999999999 57.53 92.16 percent of total billed charges "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 50393658_1 CDM 0250 RC 59730-4203-01 NDC J1571 HCPCS inpatient 10 UN 95.01 61.76 UMR - ALL PLANS UMR - ALL PLANS 66.51 70 999999999 57.53 92.16 percent of total billed charges "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 50393658_1 CDM 0250 RC 59730-4203-01 NDC J1571 HCPCS inpatient 10 UN 95.01 61.76 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 57.53 92.16 "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 50393658_1 CDM 0250 RC 59730-4203-01 NDC J1571 HCPCS inpatient 10 UN 95.01 61.76 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 57.53 92.16 "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 50393658_1 CDM 0250 RC 59730-4203-01 NDC J1571 HCPCS inpatient 10 UN 95.01 61.76 ANTHEM HMO ANTHEM HMO 999999999 57.53 92.16 "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 50393658_1 CDM 0250 RC 59730-4203-01 NDC J1571 HCPCS inpatient 10 UN 95.01 61.76 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 57.53 92.16 "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 50393658_1 CDM 0250 RC 59730-4203-01 NDC J1571 HCPCS inpatient 10 UN 95.01 61.76 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.23 67.6 999999999 57.53 92.16 percent of total billed charges "INJECTION, HEPATITIS B IMMUNE GLOBULIN (HEPAGAM B), INTRAMUSCULAR, 0.5 ML" 50393658_1 CDM 0250 RC 59730-4203-01 NDC J1571 HCPCS inpatient 10 UN 95.01 61.76 UHC - ALL PLANS UHC - ALL PLANS 999999999 57.53 92.16 PROPARACAINE 0.5% EYE DROPS 50393765_1 CDM 0250 RC 61314-0016-01 NDC inpatient 1 UN 126.59 82.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 82.28 65 999999999 76.65 122.79 percent of total billed charges PROPARACAINE 0.5% EYE DROPS 50393765_1 CDM 0250 RC 61314-0016-01 NDC inpatient 1 UN 126.59 82.28 AETNA AETNA 100.01 79 999999999 76.65 122.79 percent of total billed charges PROPARACAINE 0.5% EYE DROPS 50393765_1 CDM 0250 RC 61314-0016-01 NDC inpatient 1 UN 126.59 82.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 122.79 97 999999999 76.65 122.79 percent of total billed charges PROPARACAINE 0.5% EYE DROPS 50393765_1 CDM 0250 RC 61314-0016-01 NDC inpatient 1 UN 126.59 82.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 87.35 69 999999999 76.65 122.79 percent of total billed charges PROPARACAINE 0.5% EYE DROPS 50393765_1 CDM 0250 RC 61314-0016-01 NDC inpatient 1 UN 126.59 82.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 98.74 78 999999999 76.65 122.79 percent of total billed charges PROPARACAINE 0.5% EYE DROPS 50393765_1 CDM 0250 RC 61314-0016-01 NDC inpatient 1 UN 126.59 82.28 SIHO - ALL PLANS SIHO - ALL PLANS 113.93 90 999999999 76.65 122.79 percent of total billed charges PROPARACAINE 0.5% EYE DROPS 50393765_1 CDM 0250 RC 61314-0016-01 NDC inpatient 1 UN 126.59 82.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.65 60.55 999999999 76.65 122.79 percent of total billed charges PROPARACAINE 0.5% EYE DROPS 50393765_1 CDM 0250 RC 61314-0016-01 NDC inpatient 1 UN 126.59 82.28 UMR - ALL PLANS UMR - ALL PLANS 88.61 70 999999999 76.65 122.79 percent of total billed charges PROPARACAINE 0.5% EYE DROPS 50393765_1 CDM 0250 RC 61314-0016-01 NDC inpatient 1 UN 126.59 82.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.65 122.79 PROPARACAINE 0.5% EYE DROPS 50393765_1 CDM 0250 RC 61314-0016-01 NDC inpatient 1 UN 126.59 82.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.65 122.79 PROPARACAINE 0.5% EYE DROPS 50393765_1 CDM 0250 RC 61314-0016-01 NDC inpatient 1 UN 126.59 82.28 ANTHEM HMO ANTHEM HMO 999999999 76.65 122.79 PROPARACAINE 0.5% EYE DROPS 50393765_1 CDM 0250 RC 61314-0016-01 NDC inpatient 1 UN 126.59 82.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.65 122.79 PROPARACAINE 0.5% EYE DROPS 50393765_1 CDM 0250 RC 61314-0016-01 NDC inpatient 1 UN 126.59 82.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.57 67.6 999999999 76.65 122.79 percent of total billed charges PROPARACAINE 0.5% EYE DROPS 50393765_1 CDM 0250 RC 61314-0016-01 NDC inpatient 1 UN 126.59 82.28 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.65 122.79 PRASUGREL 10 MG TABLET 50394649_1 CDM 0250 RC 60505-4643-03 NDC inpatient 1 UN 1.71 1.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.11 65 999999999 1.04 1.66 percent of total billed charges PRASUGREL 10 MG TABLET 50394649_1 CDM 0250 RC 60505-4643-03 NDC inpatient 1 UN 1.71 1.11 AETNA AETNA 1.35 79 999999999 1.04 1.66 percent of total billed charges PRASUGREL 10 MG TABLET 50394649_1 CDM 0250 RC 60505-4643-03 NDC inpatient 1 UN 1.71 1.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.66 97 999999999 1.04 1.66 percent of total billed charges PRASUGREL 10 MG TABLET 50394649_1 CDM 0250 RC 60505-4643-03 NDC inpatient 1 UN 1.71 1.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.18 69 999999999 1.04 1.66 percent of total billed charges PRASUGREL 10 MG TABLET 50394649_1 CDM 0250 RC 60505-4643-03 NDC inpatient 1 UN 1.71 1.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.33 78 999999999 1.04 1.66 percent of total billed charges PRASUGREL 10 MG TABLET 50394649_1 CDM 0250 RC 60505-4643-03 NDC inpatient 1 UN 1.71 1.11 SIHO - ALL PLANS SIHO - ALL PLANS 1.54 90 999999999 1.04 1.66 percent of total billed charges PRASUGREL 10 MG TABLET 50394649_1 CDM 0250 RC 60505-4643-03 NDC inpatient 1 UN 1.71 1.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.04 60.55 999999999 1.04 1.66 percent of total billed charges PRASUGREL 10 MG TABLET 50394649_1 CDM 0250 RC 60505-4643-03 NDC inpatient 1 UN 1.71 1.11 UMR - ALL PLANS UMR - ALL PLANS 1.2 70 999999999 1.04 1.66 percent of total billed charges PRASUGREL 10 MG TABLET 50394649_1 CDM 0250 RC 60505-4643-03 NDC inpatient 1 UN 1.71 1.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.04 1.66 PRASUGREL 10 MG TABLET 50394649_1 CDM 0250 RC 60505-4643-03 NDC inpatient 1 UN 1.71 1.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.04 1.66 PRASUGREL 10 MG TABLET 50394649_1 CDM 0250 RC 60505-4643-03 NDC inpatient 1 UN 1.71 1.11 ANTHEM HMO ANTHEM HMO 999999999 1.04 1.66 PRASUGREL 10 MG TABLET 50394649_1 CDM 0250 RC 60505-4643-03 NDC inpatient 1 UN 1.71 1.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.04 1.66 PRASUGREL 10 MG TABLET 50394649_1 CDM 0250 RC 60505-4643-03 NDC inpatient 1 UN 1.71 1.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.16 67.6 999999999 1.04 1.66 percent of total billed charges PRASUGREL 10 MG TABLET 50394649_1 CDM 0250 RC 60505-4643-03 NDC inpatient 1 UN 1.71 1.11 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.04 1.66 ALPRAZOLAM 0.25 MG TABLET 50395944_1 CDM 0250 RC 00228-2027-10 NDC inpatient 1 UN 1.59 1.03 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.03 65 999999999 0.96 1.54 percent of total billed charges ALPRAZOLAM 0.25 MG TABLET 50395944_1 CDM 0250 RC 00228-2027-10 NDC inpatient 1 UN 1.59 1.03 AETNA AETNA 1.26 79 999999999 0.96 1.54 percent of total billed charges ALPRAZOLAM 0.25 MG TABLET 50395944_1 CDM 0250 RC 00228-2027-10 NDC inpatient 1 UN 1.59 1.03 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.54 97 999999999 0.96 1.54 percent of total billed charges ALPRAZOLAM 0.25 MG TABLET 50395944_1 CDM 0250 RC 00228-2027-10 NDC inpatient 1 UN 1.59 1.03 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.1 69 999999999 0.96 1.54 percent of total billed charges ALPRAZOLAM 0.25 MG TABLET 50395944_1 CDM 0250 RC 00228-2027-10 NDC inpatient 1 UN 1.59 1.03 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.24 78 999999999 0.96 1.54 percent of total billed charges ALPRAZOLAM 0.25 MG TABLET 50395944_1 CDM 0250 RC 00228-2027-10 NDC inpatient 1 UN 1.59 1.03 SIHO - ALL PLANS SIHO - ALL PLANS 1.43 90 999999999 0.96 1.54 percent of total billed charges ALPRAZOLAM 0.25 MG TABLET 50395944_1 CDM 0250 RC 00228-2027-10 NDC inpatient 1 UN 1.59 1.03 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.96 60.55 999999999 0.96 1.54 percent of total billed charges ALPRAZOLAM 0.25 MG TABLET 50395944_1 CDM 0250 RC 00228-2027-10 NDC inpatient 1 UN 1.59 1.03 UMR - ALL PLANS UMR - ALL PLANS 1.11 70 999999999 0.96 1.54 percent of total billed charges ALPRAZOLAM 0.25 MG TABLET 50395944_1 CDM 0250 RC 00228-2027-10 NDC inpatient 1 UN 1.59 1.03 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.96 1.54 ALPRAZOLAM 0.25 MG TABLET 50395944_1 CDM 0250 RC 00228-2027-10 NDC inpatient 1 UN 1.59 1.03 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.96 1.54 ALPRAZOLAM 0.25 MG TABLET 50395944_1 CDM 0250 RC 00228-2027-10 NDC inpatient 1 UN 1.59 1.03 ANTHEM HMO ANTHEM HMO 999999999 0.96 1.54 ALPRAZOLAM 0.25 MG TABLET 50395944_1 CDM 0250 RC 00228-2027-10 NDC inpatient 1 UN 1.59 1.03 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.96 1.54 ALPRAZOLAM 0.25 MG TABLET 50395944_1 CDM 0250 RC 00228-2027-10 NDC inpatient 1 UN 1.59 1.03 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.07 67.6 999999999 0.96 1.54 percent of total billed charges ALPRAZOLAM 0.25 MG TABLET 50395944_1 CDM 0250 RC 00228-2027-10 NDC inpatient 1 UN 1.59 1.03 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.96 1.54 DRONABINOL 2.5 MG CAPSULE 50397388_1 CDM 0250 RC 60687-0375-01 NDC inpatient 1 UN 15.15 9.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.85 65 999999999 9.17 14.7 percent of total billed charges DRONABINOL 2.5 MG CAPSULE 50397388_1 CDM 0250 RC 60687-0375-01 NDC inpatient 1 UN 15.15 9.85 AETNA AETNA 11.97 79 999999999 9.17 14.7 percent of total billed charges DRONABINOL 2.5 MG CAPSULE 50397388_1 CDM 0250 RC 60687-0375-01 NDC inpatient 1 UN 15.15 9.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14.7 97 999999999 9.17 14.7 percent of total billed charges DRONABINOL 2.5 MG CAPSULE 50397388_1 CDM 0250 RC 60687-0375-01 NDC inpatient 1 UN 15.15 9.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.45 69 999999999 9.17 14.7 percent of total billed charges DRONABINOL 2.5 MG CAPSULE 50397388_1 CDM 0250 RC 60687-0375-01 NDC inpatient 1 UN 15.15 9.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.82 78 999999999 9.17 14.7 percent of total billed charges DRONABINOL 2.5 MG CAPSULE 50397388_1 CDM 0250 RC 60687-0375-01 NDC inpatient 1 UN 15.15 9.85 SIHO - ALL PLANS SIHO - ALL PLANS 13.64 90 999999999 9.17 14.7 percent of total billed charges DRONABINOL 2.5 MG CAPSULE 50397388_1 CDM 0250 RC 60687-0375-01 NDC inpatient 1 UN 15.15 9.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.17 60.55 999999999 9.17 14.7 percent of total billed charges DRONABINOL 2.5 MG CAPSULE 50397388_1 CDM 0250 RC 60687-0375-01 NDC inpatient 1 UN 15.15 9.85 UMR - ALL PLANS UMR - ALL PLANS 10.61 70 999999999 9.17 14.7 percent of total billed charges DRONABINOL 2.5 MG CAPSULE 50397388_1 CDM 0250 RC 60687-0375-01 NDC inpatient 1 UN 15.15 9.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.17 14.7 DRONABINOL 2.5 MG CAPSULE 50397388_1 CDM 0250 RC 60687-0375-01 NDC inpatient 1 UN 15.15 9.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.17 14.7 DRONABINOL 2.5 MG CAPSULE 50397388_1 CDM 0250 RC 60687-0375-01 NDC inpatient 1 UN 15.15 9.85 ANTHEM HMO ANTHEM HMO 999999999 9.17 14.7 DRONABINOL 2.5 MG CAPSULE 50397388_1 CDM 0250 RC 60687-0375-01 NDC inpatient 1 UN 15.15 9.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.17 14.7 DRONABINOL 2.5 MG CAPSULE 50397388_1 CDM 0250 RC 60687-0375-01 NDC inpatient 1 UN 15.15 9.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.24 67.6 999999999 9.17 14.7 percent of total billed charges DRONABINOL 2.5 MG CAPSULE 50397388_1 CDM 0250 RC 60687-0375-01 NDC inpatient 1 UN 15.15 9.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.17 14.7 TUBE GASTROSTOMY 16fr M00582060 50397552_1 CDM 0272 RC inpatient 169.91 110.44 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.44 65 999999999 102.88 164.81 percent of total billed charges TUBE GASTROSTOMY 16fr M00582060 50397552_1 CDM 0272 RC inpatient 169.91 110.44 AETNA AETNA 134.23 79 999999999 102.88 164.81 percent of total billed charges TUBE GASTROSTOMY 16fr M00582060 50397552_1 CDM 0272 RC inpatient 169.91 110.44 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.81 97 999999999 102.88 164.81 percent of total billed charges TUBE GASTROSTOMY 16fr M00582060 50397552_1 CDM 0272 RC inpatient 169.91 110.44 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.24 69 999999999 102.88 164.81 percent of total billed charges TUBE GASTROSTOMY 16fr M00582060 50397552_1 CDM 0272 RC inpatient 169.91 110.44 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.53 78 999999999 102.88 164.81 percent of total billed charges TUBE GASTROSTOMY 16fr M00582060 50397552_1 CDM 0272 RC inpatient 169.91 110.44 SIHO - ALL PLANS SIHO - ALL PLANS 152.92 90 999999999 102.88 164.81 percent of total billed charges TUBE GASTROSTOMY 16fr M00582060 50397552_1 CDM 0272 RC inpatient 169.91 110.44 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.88 60.55 999999999 102.88 164.81 percent of total billed charges TUBE GASTROSTOMY 16fr M00582060 50397552_1 CDM 0272 RC inpatient 169.91 110.44 UMR - ALL PLANS UMR - ALL PLANS 118.94 70 999999999 102.88 164.81 percent of total billed charges TUBE GASTROSTOMY 16fr M00582060 50397552_1 CDM 0272 RC inpatient 169.91 110.44 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.88 164.81 TUBE GASTROSTOMY 16fr M00582060 50397552_1 CDM 0272 RC inpatient 169.91 110.44 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.88 164.81 TUBE GASTROSTOMY 16fr M00582060 50397552_1 CDM 0272 RC inpatient 169.91 110.44 ANTHEM HMO ANTHEM HMO 999999999 102.88 164.81 TUBE GASTROSTOMY 16fr M00582060 50397552_1 CDM 0272 RC inpatient 169.91 110.44 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.88 164.81 TUBE GASTROSTOMY 16fr M00582060 50397552_1 CDM 0272 RC inpatient 169.91 110.44 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.86 67.6 999999999 102.88 164.81 percent of total billed charges TUBE GASTROSTOMY 16fr M00582060 50397552_1 CDM 0272 RC inpatient 169.91 110.44 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.88 164.81 ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER 22ga X 8cm EDC-00822-B 50397937_1 CDM 0272 RC inpatient 435 282.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 282.75 65 999999999 263.39 421.95 percent of total billed charges ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER 22ga X 8cm EDC-00822-B 50397937_1 CDM 0272 RC inpatient 435 282.75 AETNA AETNA 343.65 79 999999999 263.39 421.95 percent of total billed charges ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER 22ga X 8cm EDC-00822-B 50397937_1 CDM 0272 RC inpatient 435 282.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 421.95 97 999999999 263.39 421.95 percent of total billed charges ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER 22ga X 8cm EDC-00822-B 50397937_1 CDM 0272 RC inpatient 435 282.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 300.15 69 999999999 263.39 421.95 percent of total billed charges ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER 22ga X 8cm EDC-00822-B 50397937_1 CDM 0272 RC inpatient 435 282.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 339.3 78 999999999 263.39 421.95 percent of total billed charges ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER 22ga X 8cm EDC-00822-B 50397937_1 CDM 0272 RC inpatient 435 282.75 SIHO - ALL PLANS SIHO - ALL PLANS 391.5 90 999999999 263.39 421.95 percent of total billed charges ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER 22ga X 8cm EDC-00822-B 50397937_1 CDM 0272 RC inpatient 435 282.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 263.39 60.55 999999999 263.39 421.95 percent of total billed charges ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER 22ga X 8cm EDC-00822-B 50397937_1 CDM 0272 RC inpatient 435 282.75 UMR - ALL PLANS UMR - ALL PLANS 304.5 70 999999999 263.39 421.95 percent of total billed charges ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER 22ga X 8cm EDC-00822-B 50397937_1 CDM 0272 RC inpatient 435 282.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 263.39 421.95 ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER 22ga X 8cm EDC-00822-B 50397937_1 CDM 0272 RC inpatient 435 282.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 263.39 421.95 ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER 22ga X 8cm EDC-00822-B 50397937_1 CDM 0272 RC inpatient 435 282.75 ANTHEM HMO ANTHEM HMO 999999999 263.39 421.95 ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER 22ga X 8cm EDC-00822-B 50397937_1 CDM 0272 RC inpatient 435 282.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 263.39 421.95 ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER 22ga X 8cm EDC-00822-B 50397937_1 CDM 0272 RC inpatient 435 282.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 294.06 67.6 999999999 263.39 421.95 percent of total billed charges ENDURANCE EXTENDED DWELL PERIPHERAL CATHETER 22ga X 8cm EDC-00822-B 50397937_1 CDM 0272 RC inpatient 435 282.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 263.39 421.95 ARTIFICIAL TEARS EYE OINTMENT 50399652_1 CDM 0250 RC 17478-0062-35 NDC inpatient 1 UN 13.82 8.98 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.98 65 999999999 8.37 13.41 percent of total billed charges ARTIFICIAL TEARS EYE OINTMENT 50399652_1 CDM 0250 RC 17478-0062-35 NDC inpatient 1 UN 13.82 8.98 AETNA AETNA 10.92 79 999999999 8.37 13.41 percent of total billed charges ARTIFICIAL TEARS EYE OINTMENT 50399652_1 CDM 0250 RC 17478-0062-35 NDC inpatient 1 UN 13.82 8.98 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13.41 97 999999999 8.37 13.41 percent of total billed charges ARTIFICIAL TEARS EYE OINTMENT 50399652_1 CDM 0250 RC 17478-0062-35 NDC inpatient 1 UN 13.82 8.98 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.54 69 999999999 8.37 13.41 percent of total billed charges ARTIFICIAL TEARS EYE OINTMENT 50399652_1 CDM 0250 RC 17478-0062-35 NDC inpatient 1 UN 13.82 8.98 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.78 78 999999999 8.37 13.41 percent of total billed charges ARTIFICIAL TEARS EYE OINTMENT 50399652_1 CDM 0250 RC 17478-0062-35 NDC inpatient 1 UN 13.82 8.98 SIHO - ALL PLANS SIHO - ALL PLANS 12.44 90 999999999 8.37 13.41 percent of total billed charges ARTIFICIAL TEARS EYE OINTMENT 50399652_1 CDM 0250 RC 17478-0062-35 NDC inpatient 1 UN 13.82 8.98 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.37 60.55 999999999 8.37 13.41 percent of total billed charges ARTIFICIAL TEARS EYE OINTMENT 50399652_1 CDM 0250 RC 17478-0062-35 NDC inpatient 1 UN 13.82 8.98 UMR - ALL PLANS UMR - ALL PLANS 9.67 70 999999999 8.37 13.41 percent of total billed charges ARTIFICIAL TEARS EYE OINTMENT 50399652_1 CDM 0250 RC 17478-0062-35 NDC inpatient 1 UN 13.82 8.98 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.37 13.41 ARTIFICIAL TEARS EYE OINTMENT 50399652_1 CDM 0250 RC 17478-0062-35 NDC inpatient 1 UN 13.82 8.98 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.37 13.41 ARTIFICIAL TEARS EYE OINTMENT 50399652_1 CDM 0250 RC 17478-0062-35 NDC inpatient 1 UN 13.82 8.98 ANTHEM HMO ANTHEM HMO 999999999 8.37 13.41 ARTIFICIAL TEARS EYE OINTMENT 50399652_1 CDM 0250 RC 17478-0062-35 NDC inpatient 1 UN 13.82 8.98 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.37 13.41 ARTIFICIAL TEARS EYE OINTMENT 50399652_1 CDM 0250 RC 17478-0062-35 NDC inpatient 1 UN 13.82 8.98 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.34 67.6 999999999 8.37 13.41 percent of total billed charges ARTIFICIAL TEARS EYE OINTMENT 50399652_1 CDM 0250 RC 17478-0062-35 NDC inpatient 1 UN 13.82 8.98 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.37 13.41 CICLOPIROX 0.77% CREAM 50399654_1 CDM 0250 RC 68462-0297-35 NDC inpatient 1 UN 16.15 10.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.5 65 999999999 9.78 15.67 percent of total billed charges CICLOPIROX 0.77% CREAM 50399654_1 CDM 0250 RC 68462-0297-35 NDC inpatient 1 UN 16.15 10.5 AETNA AETNA 12.76 79 999999999 9.78 15.67 percent of total billed charges CICLOPIROX 0.77% CREAM 50399654_1 CDM 0250 RC 68462-0297-35 NDC inpatient 1 UN 16.15 10.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15.67 97 999999999 9.78 15.67 percent of total billed charges CICLOPIROX 0.77% CREAM 50399654_1 CDM 0250 RC 68462-0297-35 NDC inpatient 1 UN 16.15 10.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.14 69 999999999 9.78 15.67 percent of total billed charges CICLOPIROX 0.77% CREAM 50399654_1 CDM 0250 RC 68462-0297-35 NDC inpatient 1 UN 16.15 10.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.6 78 999999999 9.78 15.67 percent of total billed charges CICLOPIROX 0.77% CREAM 50399654_1 CDM 0250 RC 68462-0297-35 NDC inpatient 1 UN 16.15 10.5 SIHO - ALL PLANS SIHO - ALL PLANS 14.54 90 999999999 9.78 15.67 percent of total billed charges CICLOPIROX 0.77% CREAM 50399654_1 CDM 0250 RC 68462-0297-35 NDC inpatient 1 UN 16.15 10.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.78 60.55 999999999 9.78 15.67 percent of total billed charges CICLOPIROX 0.77% CREAM 50399654_1 CDM 0250 RC 68462-0297-35 NDC inpatient 1 UN 16.15 10.5 UMR - ALL PLANS UMR - ALL PLANS 11.31 70 999999999 9.78 15.67 percent of total billed charges CICLOPIROX 0.77% CREAM 50399654_1 CDM 0250 RC 68462-0297-35 NDC inpatient 1 UN 16.15 10.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.78 15.67 CICLOPIROX 0.77% CREAM 50399654_1 CDM 0250 RC 68462-0297-35 NDC inpatient 1 UN 16.15 10.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.78 15.67 CICLOPIROX 0.77% CREAM 50399654_1 CDM 0250 RC 68462-0297-35 NDC inpatient 1 UN 16.15 10.5 ANTHEM HMO ANTHEM HMO 999999999 9.78 15.67 CICLOPIROX 0.77% CREAM 50399654_1 CDM 0250 RC 68462-0297-35 NDC inpatient 1 UN 16.15 10.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.78 15.67 CICLOPIROX 0.77% CREAM 50399654_1 CDM 0250 RC 68462-0297-35 NDC inpatient 1 UN 16.15 10.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.92 67.6 999999999 9.78 15.67 percent of total billed charges CICLOPIROX 0.77% CREAM 50399654_1 CDM 0250 RC 68462-0297-35 NDC inpatient 1 UN 16.15 10.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.78 15.67 "BACITRACIN 50,000 UNIT VIAL" 50399979_1 CDM 0250 RC 70594-0026-04 NDC inpatient 1 UN 33.29 21.64 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.64 65 999999999 20.16 32.29 percent of total billed charges "BACITRACIN 50,000 UNIT VIAL" 50399979_1 CDM 0250 RC 70594-0026-04 NDC inpatient 1 UN 33.29 21.64 AETNA AETNA 26.3 79 999999999 20.16 32.29 percent of total billed charges "BACITRACIN 50,000 UNIT VIAL" 50399979_1 CDM 0250 RC 70594-0026-04 NDC inpatient 1 UN 33.29 21.64 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.29 97 999999999 20.16 32.29 percent of total billed charges "BACITRACIN 50,000 UNIT VIAL" 50399979_1 CDM 0250 RC 70594-0026-04 NDC inpatient 1 UN 33.29 21.64 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.97 69 999999999 20.16 32.29 percent of total billed charges "BACITRACIN 50,000 UNIT VIAL" 50399979_1 CDM 0250 RC 70594-0026-04 NDC inpatient 1 UN 33.29 21.64 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.97 78 999999999 20.16 32.29 percent of total billed charges "BACITRACIN 50,000 UNIT VIAL" 50399979_1 CDM 0250 RC 70594-0026-04 NDC inpatient 1 UN 33.29 21.64 SIHO - ALL PLANS SIHO - ALL PLANS 29.96 90 999999999 20.16 32.29 percent of total billed charges "BACITRACIN 50,000 UNIT VIAL" 50399979_1 CDM 0250 RC 70594-0026-04 NDC inpatient 1 UN 33.29 21.64 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.16 60.55 999999999 20.16 32.29 percent of total billed charges "BACITRACIN 50,000 UNIT VIAL" 50399979_1 CDM 0250 RC 70594-0026-04 NDC inpatient 1 UN 33.29 21.64 UMR - ALL PLANS UMR - ALL PLANS 23.3 70 999999999 20.16 32.29 percent of total billed charges "BACITRACIN 50,000 UNIT VIAL" 50399979_1 CDM 0250 RC 70594-0026-04 NDC inpatient 1 UN 33.29 21.64 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.16 32.29 "BACITRACIN 50,000 UNIT VIAL" 50399979_1 CDM 0250 RC 70594-0026-04 NDC inpatient 1 UN 33.29 21.64 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.16 32.29 "BACITRACIN 50,000 UNIT VIAL" 50399979_1 CDM 0250 RC 70594-0026-04 NDC inpatient 1 UN 33.29 21.64 ANTHEM HMO ANTHEM HMO 999999999 20.16 32.29 "BACITRACIN 50,000 UNIT VIAL" 50399979_1 CDM 0250 RC 70594-0026-04 NDC inpatient 1 UN 33.29 21.64 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.16 32.29 "BACITRACIN 50,000 UNIT VIAL" 50399979_1 CDM 0250 RC 70594-0026-04 NDC inpatient 1 UN 33.29 21.64 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.5 67.6 999999999 20.16 32.29 percent of total billed charges "BACITRACIN 50,000 UNIT VIAL" 50399979_1 CDM 0250 RC 70594-0026-04 NDC inpatient 1 UN 33.29 21.64 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.16 32.29 MEMANTINE HCL ER 7 MG CAPSULE 50399980_1 CDM 0250 RC 00904-6734-61 NDC inpatient 1 UN 7.71 5.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.01 65 999999999 4.67 7.48 percent of total billed charges MEMANTINE HCL ER 7 MG CAPSULE 50399980_1 CDM 0250 RC 00904-6734-61 NDC inpatient 1 UN 7.71 5.01 AETNA AETNA 6.09 79 999999999 4.67 7.48 percent of total billed charges MEMANTINE HCL ER 7 MG CAPSULE 50399980_1 CDM 0250 RC 00904-6734-61 NDC inpatient 1 UN 7.71 5.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7.48 97 999999999 4.67 7.48 percent of total billed charges MEMANTINE HCL ER 7 MG CAPSULE 50399980_1 CDM 0250 RC 00904-6734-61 NDC inpatient 1 UN 7.71 5.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.32 69 999999999 4.67 7.48 percent of total billed charges MEMANTINE HCL ER 7 MG CAPSULE 50399980_1 CDM 0250 RC 00904-6734-61 NDC inpatient 1 UN 7.71 5.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.01 78 999999999 4.67 7.48 percent of total billed charges MEMANTINE HCL ER 7 MG CAPSULE 50399980_1 CDM 0250 RC 00904-6734-61 NDC inpatient 1 UN 7.71 5.01 SIHO - ALL PLANS SIHO - ALL PLANS 6.94 90 999999999 4.67 7.48 percent of total billed charges MEMANTINE HCL ER 7 MG CAPSULE 50399980_1 CDM 0250 RC 00904-6734-61 NDC inpatient 1 UN 7.71 5.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.67 60.55 999999999 4.67 7.48 percent of total billed charges MEMANTINE HCL ER 7 MG CAPSULE 50399980_1 CDM 0250 RC 00904-6734-61 NDC inpatient 1 UN 7.71 5.01 UMR - ALL PLANS UMR - ALL PLANS 5.4 70 999999999 4.67 7.48 percent of total billed charges MEMANTINE HCL ER 7 MG CAPSULE 50399980_1 CDM 0250 RC 00904-6734-61 NDC inpatient 1 UN 7.71 5.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.67 7.48 MEMANTINE HCL ER 7 MG CAPSULE 50399980_1 CDM 0250 RC 00904-6734-61 NDC inpatient 1 UN 7.71 5.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.67 7.48 MEMANTINE HCL ER 7 MG CAPSULE 50399980_1 CDM 0250 RC 00904-6734-61 NDC inpatient 1 UN 7.71 5.01 ANTHEM HMO ANTHEM HMO 999999999 4.67 7.48 MEMANTINE HCL ER 7 MG CAPSULE 50399980_1 CDM 0250 RC 00904-6734-61 NDC inpatient 1 UN 7.71 5.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.67 7.48 MEMANTINE HCL ER 7 MG CAPSULE 50399980_1 CDM 0250 RC 00904-6734-61 NDC inpatient 1 UN 7.71 5.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.21 67.6 999999999 4.67 7.48 percent of total billed charges MEMANTINE HCL ER 7 MG CAPSULE 50399980_1 CDM 0250 RC 00904-6734-61 NDC inpatient 1 UN 7.71 5.01 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.67 7.48 "Clotting factor II prothrombin, measurement" 50400917_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 258.05 65 999999999 240.38 385.09 percent of total billed charges "Clotting factor II prothrombin, measurement" 50400917_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 AETNA AETNA 313.63 79 999999999 240.38 385.09 percent of total billed charges "Clotting factor II prothrombin, measurement" 50400917_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 385.09 97 999999999 240.38 385.09 percent of total billed charges "Clotting factor II prothrombin, measurement" 50400917_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 273.93 69 999999999 240.38 385.09 percent of total billed charges "Clotting factor II prothrombin, measurement" 50400917_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 309.66 78 999999999 240.38 385.09 percent of total billed charges "Clotting factor II prothrombin, measurement" 50400917_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 SIHO - ALL PLANS SIHO - ALL PLANS 357.3 90 999999999 240.38 385.09 percent of total billed charges "Clotting factor II prothrombin, measurement" 50400917_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 240.38 60.55 999999999 240.38 385.09 percent of total billed charges "Clotting factor II prothrombin, measurement" 50400917_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 UMR - ALL PLANS UMR - ALL PLANS 277.9 70 999999999 240.38 385.09 percent of total billed charges "Clotting factor II prothrombin, measurement" 50400917_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 240.38 385.09 "Clotting factor II prothrombin, measurement" 50400917_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 240.38 385.09 "Clotting factor II prothrombin, measurement" 50400917_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 ANTHEM HMO ANTHEM HMO 999999999 240.38 385.09 "Clotting factor II prothrombin, measurement" 50400917_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 240.38 385.09 "Clotting factor II prothrombin, measurement" 50400917_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 268.37 67.6 999999999 240.38 385.09 percent of total billed charges "Clotting factor II prothrombin, measurement" 50400917_1 CDM 0301 RC 85210 HCPCS inpatient 397 258.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 240.38 385.09 "INJECTION, PROPOFOL, 10 MG" 50400934_1 CDM 0250 RC 43598-0549-10 NDC J2704 HCPCS inpatient 100 UN 84.08 54.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 54.65 65 999999999 50.91 81.56 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50400934_1 CDM 0250 RC 43598-0549-10 NDC J2704 HCPCS inpatient 100 UN 84.08 54.65 AETNA AETNA 66.42 79 999999999 50.91 81.56 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50400934_1 CDM 0250 RC 43598-0549-10 NDC J2704 HCPCS inpatient 100 UN 84.08 54.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 81.56 97 999999999 50.91 81.56 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50400934_1 CDM 0250 RC 43598-0549-10 NDC J2704 HCPCS inpatient 100 UN 84.08 54.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 58.02 69 999999999 50.91 81.56 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50400934_1 CDM 0250 RC 43598-0549-10 NDC J2704 HCPCS inpatient 100 UN 84.08 54.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 65.58 78 999999999 50.91 81.56 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50400934_1 CDM 0250 RC 43598-0549-10 NDC J2704 HCPCS inpatient 100 UN 84.08 54.65 SIHO - ALL PLANS SIHO - ALL PLANS 75.67 90 999999999 50.91 81.56 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50400934_1 CDM 0250 RC 43598-0549-10 NDC J2704 HCPCS inpatient 100 UN 84.08 54.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.91 60.55 999999999 50.91 81.56 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50400934_1 CDM 0250 RC 43598-0549-10 NDC J2704 HCPCS inpatient 100 UN 84.08 54.65 UMR - ALL PLANS UMR - ALL PLANS 58.86 70 999999999 50.91 81.56 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50400934_1 CDM 0250 RC 43598-0549-10 NDC J2704 HCPCS inpatient 100 UN 84.08 54.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.91 81.56 "INJECTION, PROPOFOL, 10 MG" 50400934_1 CDM 0250 RC 43598-0549-10 NDC J2704 HCPCS inpatient 100 UN 84.08 54.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.91 81.56 "INJECTION, PROPOFOL, 10 MG" 50400934_1 CDM 0250 RC 43598-0549-10 NDC J2704 HCPCS inpatient 100 UN 84.08 54.65 ANTHEM HMO ANTHEM HMO 999999999 50.91 81.56 "INJECTION, PROPOFOL, 10 MG" 50400934_1 CDM 0250 RC 43598-0549-10 NDC J2704 HCPCS inpatient 100 UN 84.08 54.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.91 81.56 "INJECTION, PROPOFOL, 10 MG" 50400934_1 CDM 0250 RC 43598-0549-10 NDC J2704 HCPCS inpatient 100 UN 84.08 54.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.84 67.6 999999999 50.91 81.56 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50400934_1 CDM 0250 RC 43598-0549-10 NDC J2704 HCPCS inpatient 100 UN 84.08 54.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.91 81.56 KCL 20 MEQ/L-D5W-0.9% NACL 50401359_1 CDM 0258 RC 00264-7652-00 NDC inpatient 1 UN 70.43 45.78 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.78 65 999999999 42.65 68.32 percent of total billed charges KCL 20 MEQ/L-D5W-0.9% NACL 50401359_1 CDM 0258 RC 00264-7652-00 NDC inpatient 1 UN 70.43 45.78 AETNA AETNA 55.64 79 999999999 42.65 68.32 percent of total billed charges KCL 20 MEQ/L-D5W-0.9% NACL 50401359_1 CDM 0258 RC 00264-7652-00 NDC inpatient 1 UN 70.43 45.78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 68.32 97 999999999 42.65 68.32 percent of total billed charges KCL 20 MEQ/L-D5W-0.9% NACL 50401359_1 CDM 0258 RC 00264-7652-00 NDC inpatient 1 UN 70.43 45.78 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.6 69 999999999 42.65 68.32 percent of total billed charges KCL 20 MEQ/L-D5W-0.9% NACL 50401359_1 CDM 0258 RC 00264-7652-00 NDC inpatient 1 UN 70.43 45.78 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.94 78 999999999 42.65 68.32 percent of total billed charges KCL 20 MEQ/L-D5W-0.9% NACL 50401359_1 CDM 0258 RC 00264-7652-00 NDC inpatient 1 UN 70.43 45.78 SIHO - ALL PLANS SIHO - ALL PLANS 63.39 90 999999999 42.65 68.32 percent of total billed charges KCL 20 MEQ/L-D5W-0.9% NACL 50401359_1 CDM 0258 RC 00264-7652-00 NDC inpatient 1 UN 70.43 45.78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.65 60.55 999999999 42.65 68.32 percent of total billed charges KCL 20 MEQ/L-D5W-0.9% NACL 50401359_1 CDM 0258 RC 00264-7652-00 NDC inpatient 1 UN 70.43 45.78 UMR - ALL PLANS UMR - ALL PLANS 49.3 70 999999999 42.65 68.32 percent of total billed charges KCL 20 MEQ/L-D5W-0.9% NACL 50401359_1 CDM 0258 RC 00264-7652-00 NDC inpatient 1 UN 70.43 45.78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.65 68.32 KCL 20 MEQ/L-D5W-0.9% NACL 50401359_1 CDM 0258 RC 00264-7652-00 NDC inpatient 1 UN 70.43 45.78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.65 68.32 KCL 20 MEQ/L-D5W-0.9% NACL 50401359_1 CDM 0258 RC 00264-7652-00 NDC inpatient 1 UN 70.43 45.78 ANTHEM HMO ANTHEM HMO 999999999 42.65 68.32 KCL 20 MEQ/L-D5W-0.9% NACL 50401359_1 CDM 0258 RC 00264-7652-00 NDC inpatient 1 UN 70.43 45.78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.65 68.32 KCL 20 MEQ/L-D5W-0.9% NACL 50401359_1 CDM 0258 RC 00264-7652-00 NDC inpatient 1 UN 70.43 45.78 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.61 67.6 999999999 42.65 68.32 percent of total billed charges KCL 20 MEQ/L-D5W-0.9% NACL 50401359_1 CDM 0258 RC 00264-7652-00 NDC inpatient 1 UN 70.43 45.78 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.65 68.32 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50401389_1 CDM 0258 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 65.11 42.32 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.32 65 999999999 39.42 63.16 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50401389_1 CDM 0258 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 65.11 42.32 AETNA AETNA 51.44 79 999999999 39.42 63.16 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50401389_1 CDM 0258 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 65.11 42.32 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 63.16 97 999999999 39.42 63.16 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50401389_1 CDM 0258 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 65.11 42.32 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.93 69 999999999 39.42 63.16 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50401389_1 CDM 0258 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 65.11 42.32 HUMANA - ALL PLANS HUMANA - ALL PLANS 50.79 78 999999999 39.42 63.16 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50401389_1 CDM 0258 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 65.11 42.32 SIHO - ALL PLANS SIHO - ALL PLANS 58.6 90 999999999 39.42 63.16 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50401389_1 CDM 0258 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 65.11 42.32 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.42 60.55 999999999 39.42 63.16 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50401389_1 CDM 0258 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 65.11 42.32 UMR - ALL PLANS UMR - ALL PLANS 45.58 70 999999999 39.42 63.16 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50401389_1 CDM 0258 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 65.11 42.32 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.42 63.16 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50401389_1 CDM 0258 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 65.11 42.32 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.42 63.16 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50401389_1 CDM 0258 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 65.11 42.32 ANTHEM HMO ANTHEM HMO 999999999 39.42 63.16 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50401389_1 CDM 0258 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 65.11 42.32 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.42 63.16 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50401389_1 CDM 0258 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 65.11 42.32 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.01 67.6 999999999 39.42 63.16 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50401389_1 CDM 0258 RC 00264-7510-10 NDC J7060 HCPCS inpatient 1 UN 65.11 42.32 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.42 63.16 FEVERALL 325 MG SUPPOSITORY 50401486_1 CDM 0250 RC 51672-2116-02 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges FEVERALL 325 MG SUPPOSITORY 50401486_1 CDM 0250 RC 51672-2116-02 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges FEVERALL 325 MG SUPPOSITORY 50401486_1 CDM 0250 RC 51672-2116-02 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges FEVERALL 325 MG SUPPOSITORY 50401486_1 CDM 0250 RC 51672-2116-02 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges FEVERALL 325 MG SUPPOSITORY 50401486_1 CDM 0250 RC 51672-2116-02 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges FEVERALL 325 MG SUPPOSITORY 50401486_1 CDM 0250 RC 51672-2116-02 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges FEVERALL 325 MG SUPPOSITORY 50401486_1 CDM 0250 RC 51672-2116-02 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges FEVERALL 325 MG SUPPOSITORY 50401486_1 CDM 0250 RC 51672-2116-02 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges FEVERALL 325 MG SUPPOSITORY 50401486_1 CDM 0250 RC 51672-2116-02 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 FEVERALL 325 MG SUPPOSITORY 50401486_1 CDM 0250 RC 51672-2116-02 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 FEVERALL 325 MG SUPPOSITORY 50401486_1 CDM 0250 RC 51672-2116-02 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 FEVERALL 325 MG SUPPOSITORY 50401486_1 CDM 0250 RC 51672-2116-02 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 FEVERALL 325 MG SUPPOSITORY 50401486_1 CDM 0250 RC 51672-2116-02 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges FEVERALL 325 MG SUPPOSITORY 50401486_1 CDM 0250 RC 51672-2116-02 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 50401487_1 CDM 0250 RC 67457-0640-02 NDC J0780 HCPCS inpatient 1 UN 39.59 25.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 25.73 65 999999999 23.97 38.4 percent of total billed charges "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 50401487_1 CDM 0250 RC 67457-0640-02 NDC J0780 HCPCS inpatient 1 UN 39.59 25.73 AETNA AETNA 31.28 79 999999999 23.97 38.4 percent of total billed charges "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 50401487_1 CDM 0250 RC 67457-0640-02 NDC J0780 HCPCS inpatient 1 UN 39.59 25.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 38.4 97 999999999 23.97 38.4 percent of total billed charges "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 50401487_1 CDM 0250 RC 67457-0640-02 NDC J0780 HCPCS inpatient 1 UN 39.59 25.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 27.32 69 999999999 23.97 38.4 percent of total billed charges "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 50401487_1 CDM 0250 RC 67457-0640-02 NDC J0780 HCPCS inpatient 1 UN 39.59 25.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 30.88 78 999999999 23.97 38.4 percent of total billed charges "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 50401487_1 CDM 0250 RC 67457-0640-02 NDC J0780 HCPCS inpatient 1 UN 39.59 25.73 SIHO - ALL PLANS SIHO - ALL PLANS 35.63 90 999999999 23.97 38.4 percent of total billed charges "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 50401487_1 CDM 0250 RC 67457-0640-02 NDC J0780 HCPCS inpatient 1 UN 39.59 25.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.97 60.55 999999999 23.97 38.4 percent of total billed charges "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 50401487_1 CDM 0250 RC 67457-0640-02 NDC J0780 HCPCS inpatient 1 UN 39.59 25.73 UMR - ALL PLANS UMR - ALL PLANS 27.71 70 999999999 23.97 38.4 percent of total billed charges "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 50401487_1 CDM 0250 RC 67457-0640-02 NDC J0780 HCPCS inpatient 1 UN 39.59 25.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.97 38.4 "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 50401487_1 CDM 0250 RC 67457-0640-02 NDC J0780 HCPCS inpatient 1 UN 39.59 25.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.97 38.4 "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 50401487_1 CDM 0250 RC 67457-0640-02 NDC J0780 HCPCS inpatient 1 UN 39.59 25.73 ANTHEM HMO ANTHEM HMO 999999999 23.97 38.4 "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 50401487_1 CDM 0250 RC 67457-0640-02 NDC J0780 HCPCS inpatient 1 UN 39.59 25.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.97 38.4 "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 50401487_1 CDM 0250 RC 67457-0640-02 NDC J0780 HCPCS inpatient 1 UN 39.59 25.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 26.76 67.6 999999999 23.97 38.4 percent of total billed charges "INJECTION, PROCHLORPERAZINE, UP TO 10 MG" 50401487_1 CDM 0250 RC 67457-0640-02 NDC J0780 HCPCS inpatient 1 UN 39.59 25.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.97 38.4 LEVOTHYROXINE 150 MCG TABLET 50401565_1 CDM 0250 RC 60687-0530-01 NDC inpatient 1 UN 1.72 1.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.12 65 999999999 1.04 1.67 percent of total billed charges LEVOTHYROXINE 150 MCG TABLET 50401565_1 CDM 0250 RC 60687-0530-01 NDC inpatient 1 UN 1.72 1.12 AETNA AETNA 1.36 79 999999999 1.04 1.67 percent of total billed charges LEVOTHYROXINE 150 MCG TABLET 50401565_1 CDM 0250 RC 60687-0530-01 NDC inpatient 1 UN 1.72 1.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.67 97 999999999 1.04 1.67 percent of total billed charges LEVOTHYROXINE 150 MCG TABLET 50401565_1 CDM 0250 RC 60687-0530-01 NDC inpatient 1 UN 1.72 1.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.19 69 999999999 1.04 1.67 percent of total billed charges LEVOTHYROXINE 150 MCG TABLET 50401565_1 CDM 0250 RC 60687-0530-01 NDC inpatient 1 UN 1.72 1.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.34 78 999999999 1.04 1.67 percent of total billed charges LEVOTHYROXINE 150 MCG TABLET 50401565_1 CDM 0250 RC 60687-0530-01 NDC inpatient 1 UN 1.72 1.12 SIHO - ALL PLANS SIHO - ALL PLANS 1.55 90 999999999 1.04 1.67 percent of total billed charges LEVOTHYROXINE 150 MCG TABLET 50401565_1 CDM 0250 RC 60687-0530-01 NDC inpatient 1 UN 1.72 1.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.04 60.55 999999999 1.04 1.67 percent of total billed charges LEVOTHYROXINE 150 MCG TABLET 50401565_1 CDM 0250 RC 60687-0530-01 NDC inpatient 1 UN 1.72 1.12 UMR - ALL PLANS UMR - ALL PLANS 1.2 70 999999999 1.04 1.67 percent of total billed charges LEVOTHYROXINE 150 MCG TABLET 50401565_1 CDM 0250 RC 60687-0530-01 NDC inpatient 1 UN 1.72 1.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.04 1.67 LEVOTHYROXINE 150 MCG TABLET 50401565_1 CDM 0250 RC 60687-0530-01 NDC inpatient 1 UN 1.72 1.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.04 1.67 LEVOTHYROXINE 150 MCG TABLET 50401565_1 CDM 0250 RC 60687-0530-01 NDC inpatient 1 UN 1.72 1.12 ANTHEM HMO ANTHEM HMO 999999999 1.04 1.67 LEVOTHYROXINE 150 MCG TABLET 50401565_1 CDM 0250 RC 60687-0530-01 NDC inpatient 1 UN 1.72 1.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.04 1.67 LEVOTHYROXINE 150 MCG TABLET 50401565_1 CDM 0250 RC 60687-0530-01 NDC inpatient 1 UN 1.72 1.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.16 67.6 999999999 1.04 1.67 percent of total billed charges LEVOTHYROXINE 150 MCG TABLET 50401565_1 CDM 0250 RC 60687-0530-01 NDC inpatient 1 UN 1.72 1.12 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.04 1.67 LINEZOLID 600 MG TABLET 50401569_1 CDM 0250 RC 60687-0309-21 NDC inpatient 1 UN 9.5 6.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.18 65 999999999 5.75 9.22 percent of total billed charges LINEZOLID 600 MG TABLET 50401569_1 CDM 0250 RC 60687-0309-21 NDC inpatient 1 UN 9.5 6.18 AETNA AETNA 7.51 79 999999999 5.75 9.22 percent of total billed charges LINEZOLID 600 MG TABLET 50401569_1 CDM 0250 RC 60687-0309-21 NDC inpatient 1 UN 9.5 6.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.22 97 999999999 5.75 9.22 percent of total billed charges LINEZOLID 600 MG TABLET 50401569_1 CDM 0250 RC 60687-0309-21 NDC inpatient 1 UN 9.5 6.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.56 69 999999999 5.75 9.22 percent of total billed charges LINEZOLID 600 MG TABLET 50401569_1 CDM 0250 RC 60687-0309-21 NDC inpatient 1 UN 9.5 6.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.41 78 999999999 5.75 9.22 percent of total billed charges LINEZOLID 600 MG TABLET 50401569_1 CDM 0250 RC 60687-0309-21 NDC inpatient 1 UN 9.5 6.18 SIHO - ALL PLANS SIHO - ALL PLANS 8.55 90 999999999 5.75 9.22 percent of total billed charges LINEZOLID 600 MG TABLET 50401569_1 CDM 0250 RC 60687-0309-21 NDC inpatient 1 UN 9.5 6.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.75 60.55 999999999 5.75 9.22 percent of total billed charges LINEZOLID 600 MG TABLET 50401569_1 CDM 0250 RC 60687-0309-21 NDC inpatient 1 UN 9.5 6.18 UMR - ALL PLANS UMR - ALL PLANS 6.65 70 999999999 5.75 9.22 percent of total billed charges LINEZOLID 600 MG TABLET 50401569_1 CDM 0250 RC 60687-0309-21 NDC inpatient 1 UN 9.5 6.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.75 9.22 LINEZOLID 600 MG TABLET 50401569_1 CDM 0250 RC 60687-0309-21 NDC inpatient 1 UN 9.5 6.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.75 9.22 LINEZOLID 600 MG TABLET 50401569_1 CDM 0250 RC 60687-0309-21 NDC inpatient 1 UN 9.5 6.18 ANTHEM HMO ANTHEM HMO 999999999 5.75 9.22 LINEZOLID 600 MG TABLET 50401569_1 CDM 0250 RC 60687-0309-21 NDC inpatient 1 UN 9.5 6.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.75 9.22 LINEZOLID 600 MG TABLET 50401569_1 CDM 0250 RC 60687-0309-21 NDC inpatient 1 UN 9.5 6.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.42 67.6 999999999 5.75 9.22 percent of total billed charges LINEZOLID 600 MG TABLET 50401569_1 CDM 0250 RC 60687-0309-21 NDC inpatient 1 UN 9.5 6.18 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.75 9.22 MISOPROSTOL 100 MCG TABLET 50401571_1 CDM 0250 RC 68084-0040-01 NDC inpatient 1 UN 6.44 4.19 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.19 65 999999999 3.9 6.25 percent of total billed charges MISOPROSTOL 100 MCG TABLET 50401571_1 CDM 0250 RC 68084-0040-01 NDC inpatient 1 UN 6.44 4.19 AETNA AETNA 5.09 79 999999999 3.9 6.25 percent of total billed charges MISOPROSTOL 100 MCG TABLET 50401571_1 CDM 0250 RC 68084-0040-01 NDC inpatient 1 UN 6.44 4.19 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.25 97 999999999 3.9 6.25 percent of total billed charges MISOPROSTOL 100 MCG TABLET 50401571_1 CDM 0250 RC 68084-0040-01 NDC inpatient 1 UN 6.44 4.19 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.44 69 999999999 3.9 6.25 percent of total billed charges MISOPROSTOL 100 MCG TABLET 50401571_1 CDM 0250 RC 68084-0040-01 NDC inpatient 1 UN 6.44 4.19 HUMANA - ALL PLANS HUMANA - ALL PLANS 5.02 78 999999999 3.9 6.25 percent of total billed charges MISOPROSTOL 100 MCG TABLET 50401571_1 CDM 0250 RC 68084-0040-01 NDC inpatient 1 UN 6.44 4.19 SIHO - ALL PLANS SIHO - ALL PLANS 5.8 90 999999999 3.9 6.25 percent of total billed charges MISOPROSTOL 100 MCG TABLET 50401571_1 CDM 0250 RC 68084-0040-01 NDC inpatient 1 UN 6.44 4.19 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.9 60.55 999999999 3.9 6.25 percent of total billed charges MISOPROSTOL 100 MCG TABLET 50401571_1 CDM 0250 RC 68084-0040-01 NDC inpatient 1 UN 6.44 4.19 UMR - ALL PLANS UMR - ALL PLANS 4.51 70 999999999 3.9 6.25 percent of total billed charges MISOPROSTOL 100 MCG TABLET 50401571_1 CDM 0250 RC 68084-0040-01 NDC inpatient 1 UN 6.44 4.19 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.9 6.25 MISOPROSTOL 100 MCG TABLET 50401571_1 CDM 0250 RC 68084-0040-01 NDC inpatient 1 UN 6.44 4.19 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.9 6.25 MISOPROSTOL 100 MCG TABLET 50401571_1 CDM 0250 RC 68084-0040-01 NDC inpatient 1 UN 6.44 4.19 ANTHEM HMO ANTHEM HMO 999999999 3.9 6.25 MISOPROSTOL 100 MCG TABLET 50401571_1 CDM 0250 RC 68084-0040-01 NDC inpatient 1 UN 6.44 4.19 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.9 6.25 MISOPROSTOL 100 MCG TABLET 50401571_1 CDM 0250 RC 68084-0040-01 NDC inpatient 1 UN 6.44 4.19 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.35 67.6 999999999 3.9 6.25 percent of total billed charges MISOPROSTOL 100 MCG TABLET 50401571_1 CDM 0250 RC 68084-0040-01 NDC inpatient 1 UN 6.44 4.19 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.9 6.25 DAPSONE 25 MG TABLET 50401572_1 CDM 0250 RC 13925-0504-30 NDC inpatient 1 UN 7.03 4.57 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.57 65 999999999 4.26 6.82 percent of total billed charges DAPSONE 25 MG TABLET 50401572_1 CDM 0250 RC 13925-0504-30 NDC inpatient 1 UN 7.03 4.57 AETNA AETNA 5.55 79 999999999 4.26 6.82 percent of total billed charges DAPSONE 25 MG TABLET 50401572_1 CDM 0250 RC 13925-0504-30 NDC inpatient 1 UN 7.03 4.57 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.82 97 999999999 4.26 6.82 percent of total billed charges DAPSONE 25 MG TABLET 50401572_1 CDM 0250 RC 13925-0504-30 NDC inpatient 1 UN 7.03 4.57 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.85 69 999999999 4.26 6.82 percent of total billed charges DAPSONE 25 MG TABLET 50401572_1 CDM 0250 RC 13925-0504-30 NDC inpatient 1 UN 7.03 4.57 HUMANA - ALL PLANS HUMANA - ALL PLANS 5.48 78 999999999 4.26 6.82 percent of total billed charges DAPSONE 25 MG TABLET 50401572_1 CDM 0250 RC 13925-0504-30 NDC inpatient 1 UN 7.03 4.57 SIHO - ALL PLANS SIHO - ALL PLANS 6.33 90 999999999 4.26 6.82 percent of total billed charges DAPSONE 25 MG TABLET 50401572_1 CDM 0250 RC 13925-0504-30 NDC inpatient 1 UN 7.03 4.57 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.26 60.55 999999999 4.26 6.82 percent of total billed charges DAPSONE 25 MG TABLET 50401572_1 CDM 0250 RC 13925-0504-30 NDC inpatient 1 UN 7.03 4.57 UMR - ALL PLANS UMR - ALL PLANS 4.92 70 999999999 4.26 6.82 percent of total billed charges DAPSONE 25 MG TABLET 50401572_1 CDM 0250 RC 13925-0504-30 NDC inpatient 1 UN 7.03 4.57 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.26 6.82 DAPSONE 25 MG TABLET 50401572_1 CDM 0250 RC 13925-0504-30 NDC inpatient 1 UN 7.03 4.57 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.26 6.82 DAPSONE 25 MG TABLET 50401572_1 CDM 0250 RC 13925-0504-30 NDC inpatient 1 UN 7.03 4.57 ANTHEM HMO ANTHEM HMO 999999999 4.26 6.82 DAPSONE 25 MG TABLET 50401572_1 CDM 0250 RC 13925-0504-30 NDC inpatient 1 UN 7.03 4.57 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.26 6.82 DAPSONE 25 MG TABLET 50401572_1 CDM 0250 RC 13925-0504-30 NDC inpatient 1 UN 7.03 4.57 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.75 67.6 999999999 4.26 6.82 percent of total billed charges DAPSONE 25 MG TABLET 50401572_1 CDM 0250 RC 13925-0504-30 NDC inpatient 1 UN 7.03 4.57 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.26 6.82 RIVASTIGMINE 1.5 MG CAPSULE 50401575_1 CDM 0250 RC 51991-0793-06 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 1.5 MG CAPSULE 50401575_1 CDM 0250 RC 51991-0793-06 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 1.5 MG CAPSULE 50401575_1 CDM 0250 RC 51991-0793-06 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 1.5 MG CAPSULE 50401575_1 CDM 0250 RC 51991-0793-06 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 1.5 MG CAPSULE 50401575_1 CDM 0250 RC 51991-0793-06 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 1.5 MG CAPSULE 50401575_1 CDM 0250 RC 51991-0793-06 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 1.5 MG CAPSULE 50401575_1 CDM 0250 RC 51991-0793-06 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 1.5 MG CAPSULE 50401575_1 CDM 0250 RC 51991-0793-06 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 1.5 MG CAPSULE 50401575_1 CDM 0250 RC 51991-0793-06 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 RIVASTIGMINE 1.5 MG CAPSULE 50401575_1 CDM 0250 RC 51991-0793-06 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 RIVASTIGMINE 1.5 MG CAPSULE 50401575_1 CDM 0250 RC 51991-0793-06 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 RIVASTIGMINE 1.5 MG CAPSULE 50401575_1 CDM 0250 RC 51991-0793-06 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 RIVASTIGMINE 1.5 MG CAPSULE 50401575_1 CDM 0250 RC 51991-0793-06 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 1.5 MG CAPSULE 50401575_1 CDM 0250 RC 51991-0793-06 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 KLOR-CON-EF 25 MEQ TAB EFF 50401576_1 CDM 0250 RC 00245-5326-30 NDC inpatient 1 UN 4.91 3.19 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.19 65 999999999 2.97 4.76 percent of total billed charges KLOR-CON-EF 25 MEQ TAB EFF 50401576_1 CDM 0250 RC 00245-5326-30 NDC inpatient 1 UN 4.91 3.19 AETNA AETNA 3.88 79 999999999 2.97 4.76 percent of total billed charges KLOR-CON-EF 25 MEQ TAB EFF 50401576_1 CDM 0250 RC 00245-5326-30 NDC inpatient 1 UN 4.91 3.19 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4.76 97 999999999 2.97 4.76 percent of total billed charges KLOR-CON-EF 25 MEQ TAB EFF 50401576_1 CDM 0250 RC 00245-5326-30 NDC inpatient 1 UN 4.91 3.19 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.39 69 999999999 2.97 4.76 percent of total billed charges KLOR-CON-EF 25 MEQ TAB EFF 50401576_1 CDM 0250 RC 00245-5326-30 NDC inpatient 1 UN 4.91 3.19 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.83 78 999999999 2.97 4.76 percent of total billed charges KLOR-CON-EF 25 MEQ TAB EFF 50401576_1 CDM 0250 RC 00245-5326-30 NDC inpatient 1 UN 4.91 3.19 SIHO - ALL PLANS SIHO - ALL PLANS 4.42 90 999999999 2.97 4.76 percent of total billed charges KLOR-CON-EF 25 MEQ TAB EFF 50401576_1 CDM 0250 RC 00245-5326-30 NDC inpatient 1 UN 4.91 3.19 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.97 60.55 999999999 2.97 4.76 percent of total billed charges KLOR-CON-EF 25 MEQ TAB EFF 50401576_1 CDM 0250 RC 00245-5326-30 NDC inpatient 1 UN 4.91 3.19 UMR - ALL PLANS UMR - ALL PLANS 3.44 70 999999999 2.97 4.76 percent of total billed charges KLOR-CON-EF 25 MEQ TAB EFF 50401576_1 CDM 0250 RC 00245-5326-30 NDC inpatient 1 UN 4.91 3.19 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.97 4.76 KLOR-CON-EF 25 MEQ TAB EFF 50401576_1 CDM 0250 RC 00245-5326-30 NDC inpatient 1 UN 4.91 3.19 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.97 4.76 KLOR-CON-EF 25 MEQ TAB EFF 50401576_1 CDM 0250 RC 00245-5326-30 NDC inpatient 1 UN 4.91 3.19 ANTHEM HMO ANTHEM HMO 999999999 2.97 4.76 KLOR-CON-EF 25 MEQ TAB EFF 50401576_1 CDM 0250 RC 00245-5326-30 NDC inpatient 1 UN 4.91 3.19 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.97 4.76 KLOR-CON-EF 25 MEQ TAB EFF 50401576_1 CDM 0250 RC 00245-5326-30 NDC inpatient 1 UN 4.91 3.19 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.32 67.6 999999999 2.97 4.76 percent of total billed charges KLOR-CON-EF 25 MEQ TAB EFF 50401576_1 CDM 0250 RC 00245-5326-30 NDC inpatient 1 UN 4.91 3.19 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.97 4.76 JANTOVEN 7.5 MG TABLET 50403250_1 CDM 0250 RC 00832-1218-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges JANTOVEN 7.5 MG TABLET 50403250_1 CDM 0250 RC 00832-1218-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges JANTOVEN 7.5 MG TABLET 50403250_1 CDM 0250 RC 00832-1218-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges JANTOVEN 7.5 MG TABLET 50403250_1 CDM 0250 RC 00832-1218-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges JANTOVEN 7.5 MG TABLET 50403250_1 CDM 0250 RC 00832-1218-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges JANTOVEN 7.5 MG TABLET 50403250_1 CDM 0250 RC 00832-1218-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges JANTOVEN 7.5 MG TABLET 50403250_1 CDM 0250 RC 00832-1218-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges JANTOVEN 7.5 MG TABLET 50403250_1 CDM 0250 RC 00832-1218-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges JANTOVEN 7.5 MG TABLET 50403250_1 CDM 0250 RC 00832-1218-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 JANTOVEN 7.5 MG TABLET 50403250_1 CDM 0250 RC 00832-1218-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 JANTOVEN 7.5 MG TABLET 50403250_1 CDM 0250 RC 00832-1218-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 JANTOVEN 7.5 MG TABLET 50403250_1 CDM 0250 RC 00832-1218-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 JANTOVEN 7.5 MG TABLET 50403250_1 CDM 0250 RC 00832-1218-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges JANTOVEN 7.5 MG TABLET 50403250_1 CDM 0250 RC 00832-1218-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 JANTOVEN 5 MG TABLET 50403251_1 CDM 0250 RC 00832-1216-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges JANTOVEN 5 MG TABLET 50403251_1 CDM 0250 RC 00832-1216-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges JANTOVEN 5 MG TABLET 50403251_1 CDM 0250 RC 00832-1216-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges JANTOVEN 5 MG TABLET 50403251_1 CDM 0250 RC 00832-1216-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges JANTOVEN 5 MG TABLET 50403251_1 CDM 0250 RC 00832-1216-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges JANTOVEN 5 MG TABLET 50403251_1 CDM 0250 RC 00832-1216-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges JANTOVEN 5 MG TABLET 50403251_1 CDM 0250 RC 00832-1216-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges JANTOVEN 5 MG TABLET 50403251_1 CDM 0250 RC 00832-1216-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges JANTOVEN 5 MG TABLET 50403251_1 CDM 0250 RC 00832-1216-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 JANTOVEN 5 MG TABLET 50403251_1 CDM 0250 RC 00832-1216-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 JANTOVEN 5 MG TABLET 50403251_1 CDM 0250 RC 00832-1216-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 JANTOVEN 5 MG TABLET 50403251_1 CDM 0250 RC 00832-1216-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 JANTOVEN 5 MG TABLET 50403251_1 CDM 0250 RC 00832-1216-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges JANTOVEN 5 MG TABLET 50403251_1 CDM 0250 RC 00832-1216-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "DERMAGRAFT, PER SQUARE CENTIMETER" 50405691_1 CDM 0636 RC Q4106 HCPCS inpatient 4062 2640.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 2640.3 65 999999999 2459.54 3940.14 percent of total billed charges "DERMAGRAFT, PER SQUARE CENTIMETER" 50405691_1 CDM 0636 RC Q4106 HCPCS inpatient 4062 2640.3 AETNA AETNA 3208.98 79 999999999 2459.54 3940.14 percent of total billed charges "DERMAGRAFT, PER SQUARE CENTIMETER" 50405691_1 CDM 0636 RC Q4106 HCPCS inpatient 4062 2640.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3940.14 97 999999999 2459.54 3940.14 percent of total billed charges "DERMAGRAFT, PER SQUARE CENTIMETER" 50405691_1 CDM 0636 RC Q4106 HCPCS inpatient 4062 2640.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 2802.78 69 999999999 2459.54 3940.14 percent of total billed charges "DERMAGRAFT, PER SQUARE CENTIMETER" 50405691_1 CDM 0636 RC Q4106 HCPCS inpatient 4062 2640.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 3168.36 78 999999999 2459.54 3940.14 percent of total billed charges "DERMAGRAFT, PER SQUARE CENTIMETER" 50405691_1 CDM 0636 RC Q4106 HCPCS inpatient 4062 2640.3 SIHO - ALL PLANS SIHO - ALL PLANS 3655.8 90 999999999 2459.54 3940.14 percent of total billed charges "DERMAGRAFT, PER SQUARE CENTIMETER" 50405691_1 CDM 0636 RC Q4106 HCPCS inpatient 4062 2640.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2459.54 60.55 999999999 2459.54 3940.14 percent of total billed charges "DERMAGRAFT, PER SQUARE CENTIMETER" 50405691_1 CDM 0636 RC Q4106 HCPCS inpatient 4062 2640.3 UMR - ALL PLANS UMR - ALL PLANS 2843.4 70 999999999 2459.54 3940.14 percent of total billed charges "DERMAGRAFT, PER SQUARE CENTIMETER" 50405691_1 CDM 0636 RC Q4106 HCPCS inpatient 4062 2640.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2459.54 3940.14 "DERMAGRAFT, PER SQUARE CENTIMETER" 50405691_1 CDM 0636 RC Q4106 HCPCS inpatient 4062 2640.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2459.54 3940.14 "DERMAGRAFT, PER SQUARE CENTIMETER" 50405691_1 CDM 0636 RC Q4106 HCPCS inpatient 4062 2640.3 ANTHEM HMO ANTHEM HMO 999999999 2459.54 3940.14 "DERMAGRAFT, PER SQUARE CENTIMETER" 50405691_1 CDM 0636 RC Q4106 HCPCS inpatient 4062 2640.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2459.54 3940.14 "DERMAGRAFT, PER SQUARE CENTIMETER" 50405691_1 CDM 0636 RC Q4106 HCPCS inpatient 4062 2640.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 2745.91 67.6 999999999 2459.54 3940.14 percent of total billed charges "DERMAGRAFT, PER SQUARE CENTIMETER" 50405691_1 CDM 0636 RC Q4106 HCPCS inpatient 4062 2640.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 2459.54 3940.14 "INJECTION, FOSAPREPITANT, 1 MG" 50406099_1 CDM 0250 RC 70860-0780-10 NDC J1453 HCPCS inpatient 150 UN 203.21 132.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.09 65 999999999 123.04 197.11 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50406099_1 CDM 0250 RC 70860-0780-10 NDC J1453 HCPCS inpatient 150 UN 203.21 132.09 AETNA AETNA 160.54 79 999999999 123.04 197.11 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50406099_1 CDM 0250 RC 70860-0780-10 NDC J1453 HCPCS inpatient 150 UN 203.21 132.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.11 97 999999999 123.04 197.11 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50406099_1 CDM 0250 RC 70860-0780-10 NDC J1453 HCPCS inpatient 150 UN 203.21 132.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.21 69 999999999 123.04 197.11 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50406099_1 CDM 0250 RC 70860-0780-10 NDC J1453 HCPCS inpatient 150 UN 203.21 132.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 158.5 78 999999999 123.04 197.11 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50406099_1 CDM 0250 RC 70860-0780-10 NDC J1453 HCPCS inpatient 150 UN 203.21 132.09 SIHO - ALL PLANS SIHO - ALL PLANS 182.89 90 999999999 123.04 197.11 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50406099_1 CDM 0250 RC 70860-0780-10 NDC J1453 HCPCS inpatient 150 UN 203.21 132.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.04 60.55 999999999 123.04 197.11 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50406099_1 CDM 0250 RC 70860-0780-10 NDC J1453 HCPCS inpatient 150 UN 203.21 132.09 UMR - ALL PLANS UMR - ALL PLANS 142.25 70 999999999 123.04 197.11 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50406099_1 CDM 0250 RC 70860-0780-10 NDC J1453 HCPCS inpatient 150 UN 203.21 132.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.04 197.11 "INJECTION, FOSAPREPITANT, 1 MG" 50406099_1 CDM 0250 RC 70860-0780-10 NDC J1453 HCPCS inpatient 150 UN 203.21 132.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.04 197.11 "INJECTION, FOSAPREPITANT, 1 MG" 50406099_1 CDM 0250 RC 70860-0780-10 NDC J1453 HCPCS inpatient 150 UN 203.21 132.09 ANTHEM HMO ANTHEM HMO 999999999 123.04 197.11 "INJECTION, FOSAPREPITANT, 1 MG" 50406099_1 CDM 0250 RC 70860-0780-10 NDC J1453 HCPCS inpatient 150 UN 203.21 132.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.04 197.11 "INJECTION, FOSAPREPITANT, 1 MG" 50406099_1 CDM 0250 RC 70860-0780-10 NDC J1453 HCPCS inpatient 150 UN 203.21 132.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.37 67.6 999999999 123.04 197.11 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50406099_1 CDM 0250 RC 70860-0780-10 NDC J1453 HCPCS inpatient 150 UN 203.21 132.09 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.04 197.11 LORAZEPAM 1 MG TABLET 50406305_1 CDM 0250 RC 00904-6008-61 NDC inpatient 1 UN 1.89 1.23 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.23 65 999999999 1.14 1.83 percent of total billed charges LORAZEPAM 1 MG TABLET 50406305_1 CDM 0250 RC 00904-6008-61 NDC inpatient 1 UN 1.89 1.23 AETNA AETNA 1.49 79 999999999 1.14 1.83 percent of total billed charges LORAZEPAM 1 MG TABLET 50406305_1 CDM 0250 RC 00904-6008-61 NDC inpatient 1 UN 1.89 1.23 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.83 97 999999999 1.14 1.83 percent of total billed charges LORAZEPAM 1 MG TABLET 50406305_1 CDM 0250 RC 00904-6008-61 NDC inpatient 1 UN 1.89 1.23 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.3 69 999999999 1.14 1.83 percent of total billed charges LORAZEPAM 1 MG TABLET 50406305_1 CDM 0250 RC 00904-6008-61 NDC inpatient 1 UN 1.89 1.23 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.47 78 999999999 1.14 1.83 percent of total billed charges LORAZEPAM 1 MG TABLET 50406305_1 CDM 0250 RC 00904-6008-61 NDC inpatient 1 UN 1.89 1.23 SIHO - ALL PLANS SIHO - ALL PLANS 1.7 90 999999999 1.14 1.83 percent of total billed charges LORAZEPAM 1 MG TABLET 50406305_1 CDM 0250 RC 00904-6008-61 NDC inpatient 1 UN 1.89 1.23 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.14 60.55 999999999 1.14 1.83 percent of total billed charges LORAZEPAM 1 MG TABLET 50406305_1 CDM 0250 RC 00904-6008-61 NDC inpatient 1 UN 1.89 1.23 UMR - ALL PLANS UMR - ALL PLANS 1.32 70 999999999 1.14 1.83 percent of total billed charges LORAZEPAM 1 MG TABLET 50406305_1 CDM 0250 RC 00904-6008-61 NDC inpatient 1 UN 1.89 1.23 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.14 1.83 LORAZEPAM 1 MG TABLET 50406305_1 CDM 0250 RC 00904-6008-61 NDC inpatient 1 UN 1.89 1.23 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.14 1.83 LORAZEPAM 1 MG TABLET 50406305_1 CDM 0250 RC 00904-6008-61 NDC inpatient 1 UN 1.89 1.23 ANTHEM HMO ANTHEM HMO 999999999 1.14 1.83 LORAZEPAM 1 MG TABLET 50406305_1 CDM 0250 RC 00904-6008-61 NDC inpatient 1 UN 1.89 1.23 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.14 1.83 LORAZEPAM 1 MG TABLET 50406305_1 CDM 0250 RC 00904-6008-61 NDC inpatient 1 UN 1.89 1.23 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.28 67.6 999999999 1.14 1.83 percent of total billed charges LORAZEPAM 1 MG TABLET 50406305_1 CDM 0250 RC 00904-6008-61 NDC inpatient 1 UN 1.89 1.23 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.14 1.83 TEMAZEPAM 15 MG CAPSULE 50406308_1 CDM 0250 RC 00228-2076-10 NDC inpatient 1 UN 1.33 0.86 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.86 65 999999999 0.81 1.29 percent of total billed charges TEMAZEPAM 15 MG CAPSULE 50406308_1 CDM 0250 RC 00228-2076-10 NDC inpatient 1 UN 1.33 0.86 AETNA AETNA 1.05 79 999999999 0.81 1.29 percent of total billed charges TEMAZEPAM 15 MG CAPSULE 50406308_1 CDM 0250 RC 00228-2076-10 NDC inpatient 1 UN 1.33 0.86 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.29 97 999999999 0.81 1.29 percent of total billed charges TEMAZEPAM 15 MG CAPSULE 50406308_1 CDM 0250 RC 00228-2076-10 NDC inpatient 1 UN 1.33 0.86 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.92 69 999999999 0.81 1.29 percent of total billed charges TEMAZEPAM 15 MG CAPSULE 50406308_1 CDM 0250 RC 00228-2076-10 NDC inpatient 1 UN 1.33 0.86 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.04 78 999999999 0.81 1.29 percent of total billed charges TEMAZEPAM 15 MG CAPSULE 50406308_1 CDM 0250 RC 00228-2076-10 NDC inpatient 1 UN 1.33 0.86 SIHO - ALL PLANS SIHO - ALL PLANS 1.2 90 999999999 0.81 1.29 percent of total billed charges TEMAZEPAM 15 MG CAPSULE 50406308_1 CDM 0250 RC 00228-2076-10 NDC inpatient 1 UN 1.33 0.86 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.81 60.55 999999999 0.81 1.29 percent of total billed charges TEMAZEPAM 15 MG CAPSULE 50406308_1 CDM 0250 RC 00228-2076-10 NDC inpatient 1 UN 1.33 0.86 UMR - ALL PLANS UMR - ALL PLANS 0.93 70 999999999 0.81 1.29 percent of total billed charges TEMAZEPAM 15 MG CAPSULE 50406308_1 CDM 0250 RC 00228-2076-10 NDC inpatient 1 UN 1.33 0.86 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.81 1.29 TEMAZEPAM 15 MG CAPSULE 50406308_1 CDM 0250 RC 00228-2076-10 NDC inpatient 1 UN 1.33 0.86 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.81 1.29 TEMAZEPAM 15 MG CAPSULE 50406308_1 CDM 0250 RC 00228-2076-10 NDC inpatient 1 UN 1.33 0.86 ANTHEM HMO ANTHEM HMO 999999999 0.81 1.29 TEMAZEPAM 15 MG CAPSULE 50406308_1 CDM 0250 RC 00228-2076-10 NDC inpatient 1 UN 1.33 0.86 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.81 1.29 TEMAZEPAM 15 MG CAPSULE 50406308_1 CDM 0250 RC 00228-2076-10 NDC inpatient 1 UN 1.33 0.86 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.9 67.6 999999999 0.81 1.29 percent of total billed charges TEMAZEPAM 15 MG CAPSULE 50406308_1 CDM 0250 RC 00228-2076-10 NDC inpatient 1 UN 1.33 0.86 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.81 1.29 "INJECTION, FONDAPARINUX SODIUM, 0.5 MG" 50406315_1 CDM 0250 RC 55150-0230-10 NDC J1652 HCPCS inpatient 5 UN 66.05 42.93 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.93 65 999999999 39.99 64.07 percent of total billed charges "INJECTION, FONDAPARINUX SODIUM, 0.5 MG" 50406315_1 CDM 0250 RC 55150-0230-10 NDC J1652 HCPCS inpatient 5 UN 66.05 42.93 AETNA AETNA 52.18 79 999999999 39.99 64.07 percent of total billed charges "INJECTION, FONDAPARINUX SODIUM, 0.5 MG" 50406315_1 CDM 0250 RC 55150-0230-10 NDC J1652 HCPCS inpatient 5 UN 66.05 42.93 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.07 97 999999999 39.99 64.07 percent of total billed charges "INJECTION, FONDAPARINUX SODIUM, 0.5 MG" 50406315_1 CDM 0250 RC 55150-0230-10 NDC J1652 HCPCS inpatient 5 UN 66.05 42.93 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.57 69 999999999 39.99 64.07 percent of total billed charges "INJECTION, FONDAPARINUX SODIUM, 0.5 MG" 50406315_1 CDM 0250 RC 55150-0230-10 NDC J1652 HCPCS inpatient 5 UN 66.05 42.93 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.52 78 999999999 39.99 64.07 percent of total billed charges "INJECTION, FONDAPARINUX SODIUM, 0.5 MG" 50406315_1 CDM 0250 RC 55150-0230-10 NDC J1652 HCPCS inpatient 5 UN 66.05 42.93 SIHO - ALL PLANS SIHO - ALL PLANS 59.45 90 999999999 39.99 64.07 percent of total billed charges "INJECTION, FONDAPARINUX SODIUM, 0.5 MG" 50406315_1 CDM 0250 RC 55150-0230-10 NDC J1652 HCPCS inpatient 5 UN 66.05 42.93 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.99 60.55 999999999 39.99 64.07 percent of total billed charges "INJECTION, FONDAPARINUX SODIUM, 0.5 MG" 50406315_1 CDM 0250 RC 55150-0230-10 NDC J1652 HCPCS inpatient 5 UN 66.05 42.93 UMR - ALL PLANS UMR - ALL PLANS 46.24 70 999999999 39.99 64.07 percent of total billed charges "INJECTION, FONDAPARINUX SODIUM, 0.5 MG" 50406315_1 CDM 0250 RC 55150-0230-10 NDC J1652 HCPCS inpatient 5 UN 66.05 42.93 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.99 64.07 "INJECTION, FONDAPARINUX SODIUM, 0.5 MG" 50406315_1 CDM 0250 RC 55150-0230-10 NDC J1652 HCPCS inpatient 5 UN 66.05 42.93 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.99 64.07 "INJECTION, FONDAPARINUX SODIUM, 0.5 MG" 50406315_1 CDM 0250 RC 55150-0230-10 NDC J1652 HCPCS inpatient 5 UN 66.05 42.93 ANTHEM HMO ANTHEM HMO 999999999 39.99 64.07 "INJECTION, FONDAPARINUX SODIUM, 0.5 MG" 50406315_1 CDM 0250 RC 55150-0230-10 NDC J1652 HCPCS inpatient 5 UN 66.05 42.93 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.99 64.07 "INJECTION, FONDAPARINUX SODIUM, 0.5 MG" 50406315_1 CDM 0250 RC 55150-0230-10 NDC J1652 HCPCS inpatient 5 UN 66.05 42.93 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.65 67.6 999999999 39.99 64.07 percent of total billed charges "INJECTION, FONDAPARINUX SODIUM, 0.5 MG" 50406315_1 CDM 0250 RC 55150-0230-10 NDC J1652 HCPCS inpatient 5 UN 66.05 42.93 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.99 64.07 "INJECTION, VANCOMYCIN HCL, 500 MG" 50406745_1 CDM 0250 RC 63323-0203-20 NDC J3370 HCPCS inpatient 2 UN 62.26 40.47 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.47 65 999999999 37.7 60.39 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50406745_1 CDM 0250 RC 63323-0203-20 NDC J3370 HCPCS inpatient 2 UN 62.26 40.47 AETNA AETNA 49.19 79 999999999 37.7 60.39 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50406745_1 CDM 0250 RC 63323-0203-20 NDC J3370 HCPCS inpatient 2 UN 62.26 40.47 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 60.39 97 999999999 37.7 60.39 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50406745_1 CDM 0250 RC 63323-0203-20 NDC J3370 HCPCS inpatient 2 UN 62.26 40.47 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.96 69 999999999 37.7 60.39 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50406745_1 CDM 0250 RC 63323-0203-20 NDC J3370 HCPCS inpatient 2 UN 62.26 40.47 HUMANA - ALL PLANS HUMANA - ALL PLANS 48.56 78 999999999 37.7 60.39 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50406745_1 CDM 0250 RC 63323-0203-20 NDC J3370 HCPCS inpatient 2 UN 62.26 40.47 SIHO - ALL PLANS SIHO - ALL PLANS 56.03 90 999999999 37.7 60.39 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50406745_1 CDM 0250 RC 63323-0203-20 NDC J3370 HCPCS inpatient 2 UN 62.26 40.47 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 37.7 60.55 999999999 37.7 60.39 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50406745_1 CDM 0250 RC 63323-0203-20 NDC J3370 HCPCS inpatient 2 UN 62.26 40.47 UMR - ALL PLANS UMR - ALL PLANS 43.58 70 999999999 37.7 60.39 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50406745_1 CDM 0250 RC 63323-0203-20 NDC J3370 HCPCS inpatient 2 UN 62.26 40.47 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 37.7 60.39 "INJECTION, VANCOMYCIN HCL, 500 MG" 50406745_1 CDM 0250 RC 63323-0203-20 NDC J3370 HCPCS inpatient 2 UN 62.26 40.47 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 37.7 60.39 "INJECTION, VANCOMYCIN HCL, 500 MG" 50406745_1 CDM 0250 RC 63323-0203-20 NDC J3370 HCPCS inpatient 2 UN 62.26 40.47 ANTHEM HMO ANTHEM HMO 999999999 37.7 60.39 "INJECTION, VANCOMYCIN HCL, 500 MG" 50406745_1 CDM 0250 RC 63323-0203-20 NDC J3370 HCPCS inpatient 2 UN 62.26 40.47 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 37.7 60.39 "INJECTION, VANCOMYCIN HCL, 500 MG" 50406745_1 CDM 0250 RC 63323-0203-20 NDC J3370 HCPCS inpatient 2 UN 62.26 40.47 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.09 67.6 999999999 37.7 60.39 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50406745_1 CDM 0250 RC 63323-0203-20 NDC J3370 HCPCS inpatient 2 UN 62.26 40.47 UHC - ALL PLANS UHC - ALL PLANS 999999999 37.7 60.39 ENOXAPARIN 30 MG/0.3 ML SYR 50406934_1 CDM 0250 RC 63323-0533-93 NDC inpatient 1 UN 31.18 20.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.27 65 999999999 18.88 30.24 percent of total billed charges ENOXAPARIN 30 MG/0.3 ML SYR 50406934_1 CDM 0250 RC 63323-0533-93 NDC inpatient 1 UN 31.18 20.27 AETNA AETNA 24.63 79 999999999 18.88 30.24 percent of total billed charges ENOXAPARIN 30 MG/0.3 ML SYR 50406934_1 CDM 0250 RC 63323-0533-93 NDC inpatient 1 UN 31.18 20.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.24 97 999999999 18.88 30.24 percent of total billed charges ENOXAPARIN 30 MG/0.3 ML SYR 50406934_1 CDM 0250 RC 63323-0533-93 NDC inpatient 1 UN 31.18 20.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.51 69 999999999 18.88 30.24 percent of total billed charges ENOXAPARIN 30 MG/0.3 ML SYR 50406934_1 CDM 0250 RC 63323-0533-93 NDC inpatient 1 UN 31.18 20.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.32 78 999999999 18.88 30.24 percent of total billed charges ENOXAPARIN 30 MG/0.3 ML SYR 50406934_1 CDM 0250 RC 63323-0533-93 NDC inpatient 1 UN 31.18 20.27 SIHO - ALL PLANS SIHO - ALL PLANS 28.06 90 999999999 18.88 30.24 percent of total billed charges ENOXAPARIN 30 MG/0.3 ML SYR 50406934_1 CDM 0250 RC 63323-0533-93 NDC inpatient 1 UN 31.18 20.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.88 60.55 999999999 18.88 30.24 percent of total billed charges ENOXAPARIN 30 MG/0.3 ML SYR 50406934_1 CDM 0250 RC 63323-0533-93 NDC inpatient 1 UN 31.18 20.27 UMR - ALL PLANS UMR - ALL PLANS 21.83 70 999999999 18.88 30.24 percent of total billed charges ENOXAPARIN 30 MG/0.3 ML SYR 50406934_1 CDM 0250 RC 63323-0533-93 NDC inpatient 1 UN 31.18 20.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.88 30.24 ENOXAPARIN 30 MG/0.3 ML SYR 50406934_1 CDM 0250 RC 63323-0533-93 NDC inpatient 1 UN 31.18 20.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.88 30.24 ENOXAPARIN 30 MG/0.3 ML SYR 50406934_1 CDM 0250 RC 63323-0533-93 NDC inpatient 1 UN 31.18 20.27 ANTHEM HMO ANTHEM HMO 999999999 18.88 30.24 ENOXAPARIN 30 MG/0.3 ML SYR 50406934_1 CDM 0250 RC 63323-0533-93 NDC inpatient 1 UN 31.18 20.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.88 30.24 ENOXAPARIN 30 MG/0.3 ML SYR 50406934_1 CDM 0250 RC 63323-0533-93 NDC inpatient 1 UN 31.18 20.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.08 67.6 999999999 18.88 30.24 percent of total billed charges ENOXAPARIN 30 MG/0.3 ML SYR 50406934_1 CDM 0250 RC 63323-0533-93 NDC inpatient 1 UN 31.18 20.27 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.88 30.24 FIRVANQ 50 MG/ML SOLUTION 50407474_1 CDM 0250 RC 65628-0016-05 NDC inpatient 1 UN 558.17 362.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 362.81 65 999999999 337.97 541.42 percent of total billed charges FIRVANQ 50 MG/ML SOLUTION 50407474_1 CDM 0250 RC 65628-0016-05 NDC inpatient 1 UN 558.17 362.81 AETNA AETNA 440.95 79 999999999 337.97 541.42 percent of total billed charges FIRVANQ 50 MG/ML SOLUTION 50407474_1 CDM 0250 RC 65628-0016-05 NDC inpatient 1 UN 558.17 362.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 541.42 97 999999999 337.97 541.42 percent of total billed charges FIRVANQ 50 MG/ML SOLUTION 50407474_1 CDM 0250 RC 65628-0016-05 NDC inpatient 1 UN 558.17 362.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 385.14 69 999999999 337.97 541.42 percent of total billed charges FIRVANQ 50 MG/ML SOLUTION 50407474_1 CDM 0250 RC 65628-0016-05 NDC inpatient 1 UN 558.17 362.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 435.37 78 999999999 337.97 541.42 percent of total billed charges FIRVANQ 50 MG/ML SOLUTION 50407474_1 CDM 0250 RC 65628-0016-05 NDC inpatient 1 UN 558.17 362.81 SIHO - ALL PLANS SIHO - ALL PLANS 502.35 90 999999999 337.97 541.42 percent of total billed charges FIRVANQ 50 MG/ML SOLUTION 50407474_1 CDM 0250 RC 65628-0016-05 NDC inpatient 1 UN 558.17 362.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 337.97 60.55 999999999 337.97 541.42 percent of total billed charges FIRVANQ 50 MG/ML SOLUTION 50407474_1 CDM 0250 RC 65628-0016-05 NDC inpatient 1 UN 558.17 362.81 UMR - ALL PLANS UMR - ALL PLANS 390.72 70 999999999 337.97 541.42 percent of total billed charges FIRVANQ 50 MG/ML SOLUTION 50407474_1 CDM 0250 RC 65628-0016-05 NDC inpatient 1 UN 558.17 362.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 337.97 541.42 FIRVANQ 50 MG/ML SOLUTION 50407474_1 CDM 0250 RC 65628-0016-05 NDC inpatient 1 UN 558.17 362.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 337.97 541.42 FIRVANQ 50 MG/ML SOLUTION 50407474_1 CDM 0250 RC 65628-0016-05 NDC inpatient 1 UN 558.17 362.81 ANTHEM HMO ANTHEM HMO 999999999 337.97 541.42 FIRVANQ 50 MG/ML SOLUTION 50407474_1 CDM 0250 RC 65628-0016-05 NDC inpatient 1 UN 558.17 362.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 337.97 541.42 FIRVANQ 50 MG/ML SOLUTION 50407474_1 CDM 0250 RC 65628-0016-05 NDC inpatient 1 UN 558.17 362.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 377.32 67.6 999999999 337.97 541.42 percent of total billed charges FIRVANQ 50 MG/ML SOLUTION 50407474_1 CDM 0250 RC 65628-0016-05 NDC inpatient 1 UN 558.17 362.81 UHC - ALL PLANS UHC - ALL PLANS 999999999 337.97 541.42 PREDNISONE 20 MG TABLET 50407882_1 CDM 0250 RC 63739-0588-10 NDC inpatient 1 UN 1.71 1.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.11 65 999999999 1.04 1.66 percent of total billed charges PREDNISONE 20 MG TABLET 50407882_1 CDM 0250 RC 63739-0588-10 NDC inpatient 1 UN 1.71 1.11 AETNA AETNA 1.35 79 999999999 1.04 1.66 percent of total billed charges PREDNISONE 20 MG TABLET 50407882_1 CDM 0250 RC 63739-0588-10 NDC inpatient 1 UN 1.71 1.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.66 97 999999999 1.04 1.66 percent of total billed charges PREDNISONE 20 MG TABLET 50407882_1 CDM 0250 RC 63739-0588-10 NDC inpatient 1 UN 1.71 1.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.18 69 999999999 1.04 1.66 percent of total billed charges PREDNISONE 20 MG TABLET 50407882_1 CDM 0250 RC 63739-0588-10 NDC inpatient 1 UN 1.71 1.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.33 78 999999999 1.04 1.66 percent of total billed charges PREDNISONE 20 MG TABLET 50407882_1 CDM 0250 RC 63739-0588-10 NDC inpatient 1 UN 1.71 1.11 SIHO - ALL PLANS SIHO - ALL PLANS 1.54 90 999999999 1.04 1.66 percent of total billed charges PREDNISONE 20 MG TABLET 50407882_1 CDM 0250 RC 63739-0588-10 NDC inpatient 1 UN 1.71 1.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.04 60.55 999999999 1.04 1.66 percent of total billed charges PREDNISONE 20 MG TABLET 50407882_1 CDM 0250 RC 63739-0588-10 NDC inpatient 1 UN 1.71 1.11 UMR - ALL PLANS UMR - ALL PLANS 1.2 70 999999999 1.04 1.66 percent of total billed charges PREDNISONE 20 MG TABLET 50407882_1 CDM 0250 RC 63739-0588-10 NDC inpatient 1 UN 1.71 1.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.04 1.66 PREDNISONE 20 MG TABLET 50407882_1 CDM 0250 RC 63739-0588-10 NDC inpatient 1 UN 1.71 1.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.04 1.66 PREDNISONE 20 MG TABLET 50407882_1 CDM 0250 RC 63739-0588-10 NDC inpatient 1 UN 1.71 1.11 ANTHEM HMO ANTHEM HMO 999999999 1.04 1.66 PREDNISONE 20 MG TABLET 50407882_1 CDM 0250 RC 63739-0588-10 NDC inpatient 1 UN 1.71 1.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.04 1.66 PREDNISONE 20 MG TABLET 50407882_1 CDM 0250 RC 63739-0588-10 NDC inpatient 1 UN 1.71 1.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.16 67.6 999999999 1.04 1.66 percent of total billed charges PREDNISONE 20 MG TABLET 50407882_1 CDM 0250 RC 63739-0588-10 NDC inpatient 1 UN 1.71 1.11 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.04 1.66 "INJECTION, LEVETIRACETAM, 10 MG" 50408346_1 CDM 0250 RC 70860-0603-82 NDC J1953 HCPCS inpatient 100 UN 39.13 25.43 SELF PAY DISCOUNT SELF PAY DISCOUNT 25.43 65 999999999 23.69 37.96 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50408346_1 CDM 0250 RC 70860-0603-82 NDC J1953 HCPCS inpatient 100 UN 39.13 25.43 AETNA AETNA 30.91 79 999999999 23.69 37.96 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50408346_1 CDM 0250 RC 70860-0603-82 NDC J1953 HCPCS inpatient 100 UN 39.13 25.43 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37.96 97 999999999 23.69 37.96 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50408346_1 CDM 0250 RC 70860-0603-82 NDC J1953 HCPCS inpatient 100 UN 39.13 25.43 ENCORE - ALL PLANS ENCORE - ALL PLANS 27 69 999999999 23.69 37.96 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50408346_1 CDM 0250 RC 70860-0603-82 NDC J1953 HCPCS inpatient 100 UN 39.13 25.43 HUMANA - ALL PLANS HUMANA - ALL PLANS 30.52 78 999999999 23.69 37.96 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50408346_1 CDM 0250 RC 70860-0603-82 NDC J1953 HCPCS inpatient 100 UN 39.13 25.43 SIHO - ALL PLANS SIHO - ALL PLANS 35.22 90 999999999 23.69 37.96 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50408346_1 CDM 0250 RC 70860-0603-82 NDC J1953 HCPCS inpatient 100 UN 39.13 25.43 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.69 60.55 999999999 23.69 37.96 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50408346_1 CDM 0250 RC 70860-0603-82 NDC J1953 HCPCS inpatient 100 UN 39.13 25.43 UMR - ALL PLANS UMR - ALL PLANS 27.39 70 999999999 23.69 37.96 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50408346_1 CDM 0250 RC 70860-0603-82 NDC J1953 HCPCS inpatient 100 UN 39.13 25.43 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.69 37.96 "INJECTION, LEVETIRACETAM, 10 MG" 50408346_1 CDM 0250 RC 70860-0603-82 NDC J1953 HCPCS inpatient 100 UN 39.13 25.43 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.69 37.96 "INJECTION, LEVETIRACETAM, 10 MG" 50408346_1 CDM 0250 RC 70860-0603-82 NDC J1953 HCPCS inpatient 100 UN 39.13 25.43 ANTHEM HMO ANTHEM HMO 999999999 23.69 37.96 "INJECTION, LEVETIRACETAM, 10 MG" 50408346_1 CDM 0250 RC 70860-0603-82 NDC J1953 HCPCS inpatient 100 UN 39.13 25.43 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.69 37.96 "INJECTION, LEVETIRACETAM, 10 MG" 50408346_1 CDM 0250 RC 70860-0603-82 NDC J1953 HCPCS inpatient 100 UN 39.13 25.43 CIGNA - ALL PLANS CIGNA - ALL PLANS 26.45 67.6 999999999 23.69 37.96 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50408346_1 CDM 0250 RC 70860-0603-82 NDC J1953 HCPCS inpatient 100 UN 39.13 25.43 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.69 37.96 "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412184_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412184_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412184_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412184_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412184_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412184_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412184_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412184_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412184_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412184_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412184_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412184_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412184_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412184_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 AMLODIPINE BESYLATE 5 MG TAB 50412437_1 CDM 0250 RC 60687-0488-01 NDC inpatient 1 UN 1.38 0.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.9 65 999999999 0.84 1.34 percent of total billed charges AMLODIPINE BESYLATE 5 MG TAB 50412437_1 CDM 0250 RC 60687-0488-01 NDC inpatient 1 UN 1.38 0.9 AETNA AETNA 1.09 79 999999999 0.84 1.34 percent of total billed charges AMLODIPINE BESYLATE 5 MG TAB 50412437_1 CDM 0250 RC 60687-0488-01 NDC inpatient 1 UN 1.38 0.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.34 97 999999999 0.84 1.34 percent of total billed charges AMLODIPINE BESYLATE 5 MG TAB 50412437_1 CDM 0250 RC 60687-0488-01 NDC inpatient 1 UN 1.38 0.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.95 69 999999999 0.84 1.34 percent of total billed charges AMLODIPINE BESYLATE 5 MG TAB 50412437_1 CDM 0250 RC 60687-0488-01 NDC inpatient 1 UN 1.38 0.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.08 78 999999999 0.84 1.34 percent of total billed charges AMLODIPINE BESYLATE 5 MG TAB 50412437_1 CDM 0250 RC 60687-0488-01 NDC inpatient 1 UN 1.38 0.9 SIHO - ALL PLANS SIHO - ALL PLANS 1.24 90 999999999 0.84 1.34 percent of total billed charges AMLODIPINE BESYLATE 5 MG TAB 50412437_1 CDM 0250 RC 60687-0488-01 NDC inpatient 1 UN 1.38 0.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.84 60.55 999999999 0.84 1.34 percent of total billed charges AMLODIPINE BESYLATE 5 MG TAB 50412437_1 CDM 0250 RC 60687-0488-01 NDC inpatient 1 UN 1.38 0.9 UMR - ALL PLANS UMR - ALL PLANS 0.97 70 999999999 0.84 1.34 percent of total billed charges AMLODIPINE BESYLATE 5 MG TAB 50412437_1 CDM 0250 RC 60687-0488-01 NDC inpatient 1 UN 1.38 0.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.84 1.34 AMLODIPINE BESYLATE 5 MG TAB 50412437_1 CDM 0250 RC 60687-0488-01 NDC inpatient 1 UN 1.38 0.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.84 1.34 AMLODIPINE BESYLATE 5 MG TAB 50412437_1 CDM 0250 RC 60687-0488-01 NDC inpatient 1 UN 1.38 0.9 ANTHEM HMO ANTHEM HMO 999999999 0.84 1.34 AMLODIPINE BESYLATE 5 MG TAB 50412437_1 CDM 0250 RC 60687-0488-01 NDC inpatient 1 UN 1.38 0.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.84 1.34 AMLODIPINE BESYLATE 5 MG TAB 50412437_1 CDM 0250 RC 60687-0488-01 NDC inpatient 1 UN 1.38 0.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.93 67.6 999999999 0.84 1.34 percent of total billed charges AMLODIPINE BESYLATE 5 MG TAB 50412437_1 CDM 0250 RC 60687-0488-01 NDC inpatient 1 UN 1.38 0.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.84 1.34 "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412507_1 CDM 0301 RC U0002 HCPCS inpatient 163 105.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 105.95 65 999999999 98.7 158.11 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412507_1 CDM 0301 RC U0002 HCPCS inpatient 163 105.95 AETNA AETNA 128.77 79 999999999 98.7 158.11 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412507_1 CDM 0301 RC U0002 HCPCS inpatient 163 105.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 158.11 97 999999999 98.7 158.11 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412507_1 CDM 0301 RC U0002 HCPCS inpatient 163 105.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 112.47 69 999999999 98.7 158.11 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412507_1 CDM 0301 RC U0002 HCPCS inpatient 163 105.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.14 78 999999999 98.7 158.11 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412507_1 CDM 0301 RC U0002 HCPCS inpatient 163 105.95 SIHO - ALL PLANS SIHO - ALL PLANS 146.7 90 999999999 98.7 158.11 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412507_1 CDM 0301 RC U0002 HCPCS inpatient 163 105.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 98.7 60.55 999999999 98.7 158.11 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412507_1 CDM 0301 RC U0002 HCPCS inpatient 163 105.95 UMR - ALL PLANS UMR - ALL PLANS 114.1 70 999999999 98.7 158.11 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412507_1 CDM 0301 RC U0002 HCPCS inpatient 163 105.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 98.7 158.11 "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412507_1 CDM 0301 RC U0002 HCPCS inpatient 163 105.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 98.7 158.11 "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412507_1 CDM 0301 RC U0002 HCPCS inpatient 163 105.95 ANTHEM HMO ANTHEM HMO 999999999 98.7 158.11 "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412507_1 CDM 0301 RC U0002 HCPCS inpatient 163 105.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 98.7 158.11 "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412507_1 CDM 0301 RC U0002 HCPCS inpatient 163 105.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.19 67.6 999999999 98.7 158.11 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50412507_1 CDM 0301 RC U0002 HCPCS inpatient 163 105.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 98.7 158.11 "CREON DR 12,000 UNIT CAPSULE" 50412562_1 CDM 0259 RC 00032-1212-01 NDC inpatient 1 UN 14.49 9.42 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.42 65 999999999 8.77 14.06 percent of total billed charges "CREON DR 12,000 UNIT CAPSULE" 50412562_1 CDM 0259 RC 00032-1212-01 NDC inpatient 1 UN 14.49 9.42 AETNA AETNA 11.45 79 999999999 8.77 14.06 percent of total billed charges "CREON DR 12,000 UNIT CAPSULE" 50412562_1 CDM 0259 RC 00032-1212-01 NDC inpatient 1 UN 14.49 9.42 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14.06 97 999999999 8.77 14.06 percent of total billed charges "CREON DR 12,000 UNIT CAPSULE" 50412562_1 CDM 0259 RC 00032-1212-01 NDC inpatient 1 UN 14.49 9.42 ENCORE - ALL PLANS ENCORE - ALL PLANS 10 69 999999999 8.77 14.06 percent of total billed charges "CREON DR 12,000 UNIT CAPSULE" 50412562_1 CDM 0259 RC 00032-1212-01 NDC inpatient 1 UN 14.49 9.42 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.3 78 999999999 8.77 14.06 percent of total billed charges "CREON DR 12,000 UNIT CAPSULE" 50412562_1 CDM 0259 RC 00032-1212-01 NDC inpatient 1 UN 14.49 9.42 SIHO - ALL PLANS SIHO - ALL PLANS 13.04 90 999999999 8.77 14.06 percent of total billed charges "CREON DR 12,000 UNIT CAPSULE" 50412562_1 CDM 0259 RC 00032-1212-01 NDC inpatient 1 UN 14.49 9.42 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.77 60.55 999999999 8.77 14.06 percent of total billed charges "CREON DR 12,000 UNIT CAPSULE" 50412562_1 CDM 0259 RC 00032-1212-01 NDC inpatient 1 UN 14.49 9.42 UMR - ALL PLANS UMR - ALL PLANS 10.14 70 999999999 8.77 14.06 percent of total billed charges "CREON DR 12,000 UNIT CAPSULE" 50412562_1 CDM 0259 RC 00032-1212-01 NDC inpatient 1 UN 14.49 9.42 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.77 14.06 "CREON DR 12,000 UNIT CAPSULE" 50412562_1 CDM 0259 RC 00032-1212-01 NDC inpatient 1 UN 14.49 9.42 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.77 14.06 "CREON DR 12,000 UNIT CAPSULE" 50412562_1 CDM 0259 RC 00032-1212-01 NDC inpatient 1 UN 14.49 9.42 ANTHEM HMO ANTHEM HMO 999999999 8.77 14.06 "CREON DR 12,000 UNIT CAPSULE" 50412562_1 CDM 0259 RC 00032-1212-01 NDC inpatient 1 UN 14.49 9.42 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.77 14.06 "CREON DR 12,000 UNIT CAPSULE" 50412562_1 CDM 0259 RC 00032-1212-01 NDC inpatient 1 UN 14.49 9.42 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.8 67.6 999999999 8.77 14.06 percent of total billed charges "CREON DR 12,000 UNIT CAPSULE" 50412562_1 CDM 0259 RC 00032-1212-01 NDC inpatient 1 UN 14.49 9.42 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.77 14.06 "CREON DR 24,000 UNIT CAPSULE" 50412563_1 CDM 0259 RC 00032-1224-01 NDC inpatient 1 UN 29.48 19.16 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.16 65 999999999 17.85 28.6 percent of total billed charges "CREON DR 24,000 UNIT CAPSULE" 50412563_1 CDM 0259 RC 00032-1224-01 NDC inpatient 1 UN 29.48 19.16 AETNA AETNA 23.29 79 999999999 17.85 28.6 percent of total billed charges "CREON DR 24,000 UNIT CAPSULE" 50412563_1 CDM 0259 RC 00032-1224-01 NDC inpatient 1 UN 29.48 19.16 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 28.6 97 999999999 17.85 28.6 percent of total billed charges "CREON DR 24,000 UNIT CAPSULE" 50412563_1 CDM 0259 RC 00032-1224-01 NDC inpatient 1 UN 29.48 19.16 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.34 69 999999999 17.85 28.6 percent of total billed charges "CREON DR 24,000 UNIT CAPSULE" 50412563_1 CDM 0259 RC 00032-1224-01 NDC inpatient 1 UN 29.48 19.16 HUMANA - ALL PLANS HUMANA - ALL PLANS 22.99 78 999999999 17.85 28.6 percent of total billed charges "CREON DR 24,000 UNIT CAPSULE" 50412563_1 CDM 0259 RC 00032-1224-01 NDC inpatient 1 UN 29.48 19.16 SIHO - ALL PLANS SIHO - ALL PLANS 26.53 90 999999999 17.85 28.6 percent of total billed charges "CREON DR 24,000 UNIT CAPSULE" 50412563_1 CDM 0259 RC 00032-1224-01 NDC inpatient 1 UN 29.48 19.16 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17.85 60.55 999999999 17.85 28.6 percent of total billed charges "CREON DR 24,000 UNIT CAPSULE" 50412563_1 CDM 0259 RC 00032-1224-01 NDC inpatient 1 UN 29.48 19.16 UMR - ALL PLANS UMR - ALL PLANS 20.64 70 999999999 17.85 28.6 percent of total billed charges "CREON DR 24,000 UNIT CAPSULE" 50412563_1 CDM 0259 RC 00032-1224-01 NDC inpatient 1 UN 29.48 19.16 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 17.85 28.6 "CREON DR 24,000 UNIT CAPSULE" 50412563_1 CDM 0259 RC 00032-1224-01 NDC inpatient 1 UN 29.48 19.16 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 17.85 28.6 "CREON DR 24,000 UNIT CAPSULE" 50412563_1 CDM 0259 RC 00032-1224-01 NDC inpatient 1 UN 29.48 19.16 ANTHEM HMO ANTHEM HMO 999999999 17.85 28.6 "CREON DR 24,000 UNIT CAPSULE" 50412563_1 CDM 0259 RC 00032-1224-01 NDC inpatient 1 UN 29.48 19.16 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 17.85 28.6 "CREON DR 24,000 UNIT CAPSULE" 50412563_1 CDM 0259 RC 00032-1224-01 NDC inpatient 1 UN 29.48 19.16 CIGNA - ALL PLANS CIGNA - ALL PLANS 19.93 67.6 999999999 17.85 28.6 percent of total billed charges "CREON DR 24,000 UNIT CAPSULE" 50412563_1 CDM 0259 RC 00032-1224-01 NDC inpatient 1 UN 29.48 19.16 UHC - ALL PLANS UHC - ALL PLANS 999999999 17.85 28.6 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50412645_1 CDM 0636 RC 67457-0390-54 NDC J3489 HCPCS inpatient 4 UN 103.11 67.02 SELF PAY DISCOUNT SELF PAY DISCOUNT 67.02 65 999999999 62.43 100.02 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50412645_1 CDM 0636 RC 67457-0390-54 NDC J3489 HCPCS inpatient 4 UN 103.11 67.02 AETNA AETNA 81.46 79 999999999 62.43 100.02 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50412645_1 CDM 0636 RC 67457-0390-54 NDC J3489 HCPCS inpatient 4 UN 103.11 67.02 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 100.02 97 999999999 62.43 100.02 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50412645_1 CDM 0636 RC 67457-0390-54 NDC J3489 HCPCS inpatient 4 UN 103.11 67.02 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.15 69 999999999 62.43 100.02 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50412645_1 CDM 0636 RC 67457-0390-54 NDC J3489 HCPCS inpatient 4 UN 103.11 67.02 HUMANA - ALL PLANS HUMANA - ALL PLANS 80.43 78 999999999 62.43 100.02 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50412645_1 CDM 0636 RC 67457-0390-54 NDC J3489 HCPCS inpatient 4 UN 103.11 67.02 SIHO - ALL PLANS SIHO - ALL PLANS 92.8 90 999999999 62.43 100.02 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50412645_1 CDM 0636 RC 67457-0390-54 NDC J3489 HCPCS inpatient 4 UN 103.11 67.02 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.43 60.55 999999999 62.43 100.02 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50412645_1 CDM 0636 RC 67457-0390-54 NDC J3489 HCPCS inpatient 4 UN 103.11 67.02 UMR - ALL PLANS UMR - ALL PLANS 72.18 70 999999999 62.43 100.02 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50412645_1 CDM 0636 RC 67457-0390-54 NDC J3489 HCPCS inpatient 4 UN 103.11 67.02 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.43 100.02 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50412645_1 CDM 0636 RC 67457-0390-54 NDC J3489 HCPCS inpatient 4 UN 103.11 67.02 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.43 100.02 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50412645_1 CDM 0636 RC 67457-0390-54 NDC J3489 HCPCS inpatient 4 UN 103.11 67.02 ANTHEM HMO ANTHEM HMO 999999999 62.43 100.02 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50412645_1 CDM 0636 RC 67457-0390-54 NDC J3489 HCPCS inpatient 4 UN 103.11 67.02 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.43 100.02 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50412645_1 CDM 0636 RC 67457-0390-54 NDC J3489 HCPCS inpatient 4 UN 103.11 67.02 CIGNA - ALL PLANS CIGNA - ALL PLANS 69.7 67.6 999999999 62.43 100.02 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50412645_1 CDM 0636 RC 67457-0390-54 NDC J3489 HCPCS inpatient 4 UN 103.11 67.02 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.43 100.02 "INJECTION, IRINOTECAN, 20 MG" 50412654_1 CDM 0636 RC 00143-9701-01 NDC J9206 HCPCS inpatient 5 UN 72.15 46.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.9 65 999999999 43.69 69.99 percent of total billed charges "INJECTION, IRINOTECAN, 20 MG" 50412654_1 CDM 0636 RC 00143-9701-01 NDC J9206 HCPCS inpatient 5 UN 72.15 46.9 AETNA AETNA 57 79 999999999 43.69 69.99 percent of total billed charges "INJECTION, IRINOTECAN, 20 MG" 50412654_1 CDM 0636 RC 00143-9701-01 NDC J9206 HCPCS inpatient 5 UN 72.15 46.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.99 97 999999999 43.69 69.99 percent of total billed charges "INJECTION, IRINOTECAN, 20 MG" 50412654_1 CDM 0636 RC 00143-9701-01 NDC J9206 HCPCS inpatient 5 UN 72.15 46.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.78 69 999999999 43.69 69.99 percent of total billed charges "INJECTION, IRINOTECAN, 20 MG" 50412654_1 CDM 0636 RC 00143-9701-01 NDC J9206 HCPCS inpatient 5 UN 72.15 46.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.28 78 999999999 43.69 69.99 percent of total billed charges "INJECTION, IRINOTECAN, 20 MG" 50412654_1 CDM 0636 RC 00143-9701-01 NDC J9206 HCPCS inpatient 5 UN 72.15 46.9 SIHO - ALL PLANS SIHO - ALL PLANS 64.94 90 999999999 43.69 69.99 percent of total billed charges "INJECTION, IRINOTECAN, 20 MG" 50412654_1 CDM 0636 RC 00143-9701-01 NDC J9206 HCPCS inpatient 5 UN 72.15 46.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.69 60.55 999999999 43.69 69.99 percent of total billed charges "INJECTION, IRINOTECAN, 20 MG" 50412654_1 CDM 0636 RC 00143-9701-01 NDC J9206 HCPCS inpatient 5 UN 72.15 46.9 UMR - ALL PLANS UMR - ALL PLANS 50.51 70 999999999 43.69 69.99 percent of total billed charges "INJECTION, IRINOTECAN, 20 MG" 50412654_1 CDM 0636 RC 00143-9701-01 NDC J9206 HCPCS inpatient 5 UN 72.15 46.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.69 69.99 "INJECTION, IRINOTECAN, 20 MG" 50412654_1 CDM 0636 RC 00143-9701-01 NDC J9206 HCPCS inpatient 5 UN 72.15 46.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.69 69.99 "INJECTION, IRINOTECAN, 20 MG" 50412654_1 CDM 0636 RC 00143-9701-01 NDC J9206 HCPCS inpatient 5 UN 72.15 46.9 ANTHEM HMO ANTHEM HMO 999999999 43.69 69.99 "INJECTION, IRINOTECAN, 20 MG" 50412654_1 CDM 0636 RC 00143-9701-01 NDC J9206 HCPCS inpatient 5 UN 72.15 46.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.69 69.99 "INJECTION, IRINOTECAN, 20 MG" 50412654_1 CDM 0636 RC 00143-9701-01 NDC J9206 HCPCS inpatient 5 UN 72.15 46.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.77 67.6 999999999 43.69 69.99 percent of total billed charges "INJECTION, IRINOTECAN, 20 MG" 50412654_1 CDM 0636 RC 00143-9701-01 NDC J9206 HCPCS inpatient 5 UN 72.15 46.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.69 69.99 Repair of tendon on sole of foot 50412766_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 10749.05 65 999999999 10013.15 16040.89 percent of total billed charges Repair of tendon on sole of foot 50412766_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 AETNA AETNA 13064.23 79 999999999 10013.15 16040.89 percent of total billed charges Repair of tendon on sole of foot 50412766_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16040.89 97 999999999 10013.15 16040.89 percent of total billed charges Repair of tendon on sole of foot 50412766_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 11410.53 69 999999999 10013.15 16040.89 percent of total billed charges Repair of tendon on sole of foot 50412766_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 12898.86 78 999999999 10013.15 16040.89 percent of total billed charges Repair of tendon on sole of foot 50412766_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 SIHO - ALL PLANS SIHO - ALL PLANS 14883.3 90 999999999 10013.15 16040.89 percent of total billed charges Repair of tendon on sole of foot 50412766_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10013.15 60.55 999999999 10013.15 16040.89 percent of total billed charges Repair of tendon on sole of foot 50412766_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 UMR - ALL PLANS UMR - ALL PLANS 11575.9 70 999999999 10013.15 16040.89 percent of total billed charges Repair of tendon on sole of foot 50412766_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10013.15 16040.89 Repair of tendon on sole of foot 50412766_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10013.15 16040.89 Repair of tendon on sole of foot 50412766_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 ANTHEM HMO ANTHEM HMO 999999999 10013.15 16040.89 Repair of tendon on sole of foot 50412766_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10013.15 16040.89 Repair of tendon on sole of foot 50412766_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 11179.01 67.6 999999999 10013.15 16040.89 percent of total billed charges Repair of tendon on sole of foot 50412766_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 10013.15 16040.89 "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50412929_1 CDM 0250 RC 68001-0237-00 NDC J0735 HCPCS inpatient 1 UN 1.36 0.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.88 65 999999999 0.82 1.32 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50412929_1 CDM 0250 RC 68001-0237-00 NDC J0735 HCPCS inpatient 1 UN 1.36 0.88 AETNA AETNA 1.07 79 999999999 0.82 1.32 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50412929_1 CDM 0250 RC 68001-0237-00 NDC J0735 HCPCS inpatient 1 UN 1.36 0.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.32 97 999999999 0.82 1.32 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50412929_1 CDM 0250 RC 68001-0237-00 NDC J0735 HCPCS inpatient 1 UN 1.36 0.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.94 69 999999999 0.82 1.32 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50412929_1 CDM 0250 RC 68001-0237-00 NDC J0735 HCPCS inpatient 1 UN 1.36 0.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.06 78 999999999 0.82 1.32 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50412929_1 CDM 0250 RC 68001-0237-00 NDC J0735 HCPCS inpatient 1 UN 1.36 0.88 SIHO - ALL PLANS SIHO - ALL PLANS 1.22 90 999999999 0.82 1.32 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50412929_1 CDM 0250 RC 68001-0237-00 NDC J0735 HCPCS inpatient 1 UN 1.36 0.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.82 60.55 999999999 0.82 1.32 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50412929_1 CDM 0250 RC 68001-0237-00 NDC J0735 HCPCS inpatient 1 UN 1.36 0.88 UMR - ALL PLANS UMR - ALL PLANS 0.95 70 999999999 0.82 1.32 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50412929_1 CDM 0250 RC 68001-0237-00 NDC J0735 HCPCS inpatient 1 UN 1.36 0.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.82 1.32 "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50412929_1 CDM 0250 RC 68001-0237-00 NDC J0735 HCPCS inpatient 1 UN 1.36 0.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.82 1.32 "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50412929_1 CDM 0250 RC 68001-0237-00 NDC J0735 HCPCS inpatient 1 UN 1.36 0.88 ANTHEM HMO ANTHEM HMO 999999999 0.82 1.32 "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50412929_1 CDM 0250 RC 68001-0237-00 NDC J0735 HCPCS inpatient 1 UN 1.36 0.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.82 1.32 "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50412929_1 CDM 0250 RC 68001-0237-00 NDC J0735 HCPCS inpatient 1 UN 1.36 0.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.92 67.6 999999999 0.82 1.32 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50412929_1 CDM 0250 RC 68001-0237-00 NDC J0735 HCPCS inpatient 1 UN 1.36 0.88 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.82 1.32 52565-0007-07 - lidocaine-prilocaine topical 2.5%-2.5% Cre[JOHN] 50414268_1 CDM 0250 RC 52565-0007-07 NDC inpatient 1 UN 22.05 14.33 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.33 65 999999999 13.35 21.39 percent of total billed charges 52565-0007-07 - lidocaine-prilocaine topical 2.5%-2.5% Cre[JOHN] 50414268_1 CDM 0250 RC 52565-0007-07 NDC inpatient 1 UN 22.05 14.33 AETNA AETNA 17.42 79 999999999 13.35 21.39 percent of total billed charges 52565-0007-07 - lidocaine-prilocaine topical 2.5%-2.5% Cre[JOHN] 50414268_1 CDM 0250 RC 52565-0007-07 NDC inpatient 1 UN 22.05 14.33 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21.39 97 999999999 13.35 21.39 percent of total billed charges 52565-0007-07 - lidocaine-prilocaine topical 2.5%-2.5% Cre[JOHN] 50414268_1 CDM 0250 RC 52565-0007-07 NDC inpatient 1 UN 22.05 14.33 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.21 69 999999999 13.35 21.39 percent of total billed charges 52565-0007-07 - lidocaine-prilocaine topical 2.5%-2.5% Cre[JOHN] 50414268_1 CDM 0250 RC 52565-0007-07 NDC inpatient 1 UN 22.05 14.33 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.2 78 999999999 13.35 21.39 percent of total billed charges 52565-0007-07 - lidocaine-prilocaine topical 2.5%-2.5% Cre[JOHN] 50414268_1 CDM 0250 RC 52565-0007-07 NDC inpatient 1 UN 22.05 14.33 SIHO - ALL PLANS SIHO - ALL PLANS 19.85 90 999999999 13.35 21.39 percent of total billed charges 52565-0007-07 - lidocaine-prilocaine topical 2.5%-2.5% Cre[JOHN] 50414268_1 CDM 0250 RC 52565-0007-07 NDC inpatient 1 UN 22.05 14.33 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.35 60.55 999999999 13.35 21.39 percent of total billed charges 52565-0007-07 - lidocaine-prilocaine topical 2.5%-2.5% Cre[JOHN] 50414268_1 CDM 0250 RC 52565-0007-07 NDC inpatient 1 UN 22.05 14.33 UMR - ALL PLANS UMR - ALL PLANS 15.44 70 999999999 13.35 21.39 percent of total billed charges 52565-0007-07 - lidocaine-prilocaine topical 2.5%-2.5% Cre[JOHN] 50414268_1 CDM 0250 RC 52565-0007-07 NDC inpatient 1 UN 22.05 14.33 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.35 21.39 52565-0007-07 - lidocaine-prilocaine topical 2.5%-2.5% Cre[JOHN] 50414268_1 CDM 0250 RC 52565-0007-07 NDC inpatient 1 UN 22.05 14.33 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.35 21.39 52565-0007-07 - lidocaine-prilocaine topical 2.5%-2.5% Cre[JOHN] 50414268_1 CDM 0250 RC 52565-0007-07 NDC inpatient 1 UN 22.05 14.33 ANTHEM HMO ANTHEM HMO 999999999 13.35 21.39 52565-0007-07 - lidocaine-prilocaine topical 2.5%-2.5% Cre[JOHN] 50414268_1 CDM 0250 RC 52565-0007-07 NDC inpatient 1 UN 22.05 14.33 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.35 21.39 52565-0007-07 - lidocaine-prilocaine topical 2.5%-2.5% Cre[JOHN] 50414268_1 CDM 0250 RC 52565-0007-07 NDC inpatient 1 UN 22.05 14.33 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.91 67.6 999999999 13.35 21.39 percent of total billed charges 52565-0007-07 - lidocaine-prilocaine topical 2.5%-2.5% Cre[JOHN] 50414268_1 CDM 0250 RC 52565-0007-07 NDC inpatient 1 UN 22.05 14.33 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.35 21.39 TIMOLOL MALEATE 0.5% EYE DROPS 50414283_1 CDM 0250 RC 17478-0288-11 NDC inpatient 1 UN 10.99 7.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.14 65 999999999 6.65 10.66 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50414283_1 CDM 0250 RC 17478-0288-11 NDC inpatient 1 UN 10.99 7.14 AETNA AETNA 8.68 79 999999999 6.65 10.66 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50414283_1 CDM 0250 RC 17478-0288-11 NDC inpatient 1 UN 10.99 7.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10.66 97 999999999 6.65 10.66 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50414283_1 CDM 0250 RC 17478-0288-11 NDC inpatient 1 UN 10.99 7.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.58 69 999999999 6.65 10.66 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50414283_1 CDM 0250 RC 17478-0288-11 NDC inpatient 1 UN 10.99 7.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 8.57 78 999999999 6.65 10.66 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50414283_1 CDM 0250 RC 17478-0288-11 NDC inpatient 1 UN 10.99 7.14 SIHO - ALL PLANS SIHO - ALL PLANS 9.89 90 999999999 6.65 10.66 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50414283_1 CDM 0250 RC 17478-0288-11 NDC inpatient 1 UN 10.99 7.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.65 60.55 999999999 6.65 10.66 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50414283_1 CDM 0250 RC 17478-0288-11 NDC inpatient 1 UN 10.99 7.14 UMR - ALL PLANS UMR - ALL PLANS 7.69 70 999999999 6.65 10.66 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50414283_1 CDM 0250 RC 17478-0288-11 NDC inpatient 1 UN 10.99 7.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.65 10.66 TIMOLOL MALEATE 0.5% EYE DROPS 50414283_1 CDM 0250 RC 17478-0288-11 NDC inpatient 1 UN 10.99 7.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.65 10.66 TIMOLOL MALEATE 0.5% EYE DROPS 50414283_1 CDM 0250 RC 17478-0288-11 NDC inpatient 1 UN 10.99 7.14 ANTHEM HMO ANTHEM HMO 999999999 6.65 10.66 TIMOLOL MALEATE 0.5% EYE DROPS 50414283_1 CDM 0250 RC 17478-0288-11 NDC inpatient 1 UN 10.99 7.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.65 10.66 TIMOLOL MALEATE 0.5% EYE DROPS 50414283_1 CDM 0250 RC 17478-0288-11 NDC inpatient 1 UN 10.99 7.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 7.43 67.6 999999999 6.65 10.66 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50414283_1 CDM 0250 RC 17478-0288-11 NDC inpatient 1 UN 10.99 7.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.65 10.66 AZITHROMYCIN 500 MG TABLET 50415096_1 CDM 0250 RC 51224-0122-30 NDC inpatient 4 UN 2.54 1.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.65 65 999999999 1.54 2.46 percent of total billed charges AZITHROMYCIN 500 MG TABLET 50415096_1 CDM 0250 RC 51224-0122-30 NDC inpatient 4 UN 2.54 1.65 AETNA AETNA 2.01 79 999999999 1.54 2.46 percent of total billed charges AZITHROMYCIN 500 MG TABLET 50415096_1 CDM 0250 RC 51224-0122-30 NDC inpatient 4 UN 2.54 1.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.46 97 999999999 1.54 2.46 percent of total billed charges AZITHROMYCIN 500 MG TABLET 50415096_1 CDM 0250 RC 51224-0122-30 NDC inpatient 4 UN 2.54 1.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.75 69 999999999 1.54 2.46 percent of total billed charges AZITHROMYCIN 500 MG TABLET 50415096_1 CDM 0250 RC 51224-0122-30 NDC inpatient 4 UN 2.54 1.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.98 78 999999999 1.54 2.46 percent of total billed charges AZITHROMYCIN 500 MG TABLET 50415096_1 CDM 0250 RC 51224-0122-30 NDC inpatient 4 UN 2.54 1.65 SIHO - ALL PLANS SIHO - ALL PLANS 2.29 90 999999999 1.54 2.46 percent of total billed charges AZITHROMYCIN 500 MG TABLET 50415096_1 CDM 0250 RC 51224-0122-30 NDC inpatient 4 UN 2.54 1.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.54 60.55 999999999 1.54 2.46 percent of total billed charges AZITHROMYCIN 500 MG TABLET 50415096_1 CDM 0250 RC 51224-0122-30 NDC inpatient 4 UN 2.54 1.65 UMR - ALL PLANS UMR - ALL PLANS 1.78 70 999999999 1.54 2.46 percent of total billed charges AZITHROMYCIN 500 MG TABLET 50415096_1 CDM 0250 RC 51224-0122-30 NDC inpatient 4 UN 2.54 1.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.54 2.46 AZITHROMYCIN 500 MG TABLET 50415096_1 CDM 0250 RC 51224-0122-30 NDC inpatient 4 UN 2.54 1.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.54 2.46 AZITHROMYCIN 500 MG TABLET 50415096_1 CDM 0250 RC 51224-0122-30 NDC inpatient 4 UN 2.54 1.65 ANTHEM HMO ANTHEM HMO 999999999 1.54 2.46 AZITHROMYCIN 500 MG TABLET 50415096_1 CDM 0250 RC 51224-0122-30 NDC inpatient 4 UN 2.54 1.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.54 2.46 AZITHROMYCIN 500 MG TABLET 50415096_1 CDM 0250 RC 51224-0122-30 NDC inpatient 4 UN 2.54 1.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.72 67.6 999999999 1.54 2.46 percent of total billed charges AZITHROMYCIN 500 MG TABLET 50415096_1 CDM 0250 RC 51224-0122-30 NDC inpatient 4 UN 2.54 1.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.54 2.46 "INJECTION, VANCOMYCIN HCL, 500 MG" 50415098_1 CDM 0250 RC 70594-0044-02 NDC J3370 HCPCS inpatient 4 UN 164.9 107.19 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.19 65 999999999 99.85 159.95 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50415098_1 CDM 0250 RC 70594-0044-02 NDC J3370 HCPCS inpatient 4 UN 164.9 107.19 AETNA AETNA 130.27 79 999999999 99.85 159.95 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50415098_1 CDM 0250 RC 70594-0044-02 NDC J3370 HCPCS inpatient 4 UN 164.9 107.19 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.95 97 999999999 99.85 159.95 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50415098_1 CDM 0250 RC 70594-0044-02 NDC J3370 HCPCS inpatient 4 UN 164.9 107.19 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.78 69 999999999 99.85 159.95 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50415098_1 CDM 0250 RC 70594-0044-02 NDC J3370 HCPCS inpatient 4 UN 164.9 107.19 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.62 78 999999999 99.85 159.95 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50415098_1 CDM 0250 RC 70594-0044-02 NDC J3370 HCPCS inpatient 4 UN 164.9 107.19 SIHO - ALL PLANS SIHO - ALL PLANS 148.41 90 999999999 99.85 159.95 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50415098_1 CDM 0250 RC 70594-0044-02 NDC J3370 HCPCS inpatient 4 UN 164.9 107.19 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.85 60.55 999999999 99.85 159.95 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50415098_1 CDM 0250 RC 70594-0044-02 NDC J3370 HCPCS inpatient 4 UN 164.9 107.19 UMR - ALL PLANS UMR - ALL PLANS 115.43 70 999999999 99.85 159.95 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50415098_1 CDM 0250 RC 70594-0044-02 NDC J3370 HCPCS inpatient 4 UN 164.9 107.19 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.85 159.95 "INJECTION, VANCOMYCIN HCL, 500 MG" 50415098_1 CDM 0250 RC 70594-0044-02 NDC J3370 HCPCS inpatient 4 UN 164.9 107.19 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.85 159.95 "INJECTION, VANCOMYCIN HCL, 500 MG" 50415098_1 CDM 0250 RC 70594-0044-02 NDC J3370 HCPCS inpatient 4 UN 164.9 107.19 ANTHEM HMO ANTHEM HMO 999999999 99.85 159.95 "INJECTION, VANCOMYCIN HCL, 500 MG" 50415098_1 CDM 0250 RC 70594-0044-02 NDC J3370 HCPCS inpatient 4 UN 164.9 107.19 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.85 159.95 "INJECTION, VANCOMYCIN HCL, 500 MG" 50415098_1 CDM 0250 RC 70594-0044-02 NDC J3370 HCPCS inpatient 4 UN 164.9 107.19 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.47 67.6 999999999 99.85 159.95 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50415098_1 CDM 0250 RC 70594-0044-02 NDC J3370 HCPCS inpatient 4 UN 164.9 107.19 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.85 159.95 KCL 20 MEQ/L-D5W-0.45% NACL 50415222_1 CDM 0258 RC 00264-7635-00 NDC inpatient 1 UN 63.94 41.56 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.56 65 999999999 38.72 62.02 percent of total billed charges KCL 20 MEQ/L-D5W-0.45% NACL 50415222_1 CDM 0258 RC 00264-7635-00 NDC inpatient 1 UN 63.94 41.56 AETNA AETNA 50.51 79 999999999 38.72 62.02 percent of total billed charges KCL 20 MEQ/L-D5W-0.45% NACL 50415222_1 CDM 0258 RC 00264-7635-00 NDC inpatient 1 UN 63.94 41.56 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 62.02 97 999999999 38.72 62.02 percent of total billed charges KCL 20 MEQ/L-D5W-0.45% NACL 50415222_1 CDM 0258 RC 00264-7635-00 NDC inpatient 1 UN 63.94 41.56 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.12 69 999999999 38.72 62.02 percent of total billed charges KCL 20 MEQ/L-D5W-0.45% NACL 50415222_1 CDM 0258 RC 00264-7635-00 NDC inpatient 1 UN 63.94 41.56 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.87 78 999999999 38.72 62.02 percent of total billed charges KCL 20 MEQ/L-D5W-0.45% NACL 50415222_1 CDM 0258 RC 00264-7635-00 NDC inpatient 1 UN 63.94 41.56 SIHO - ALL PLANS SIHO - ALL PLANS 57.55 90 999999999 38.72 62.02 percent of total billed charges KCL 20 MEQ/L-D5W-0.45% NACL 50415222_1 CDM 0258 RC 00264-7635-00 NDC inpatient 1 UN 63.94 41.56 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.72 60.55 999999999 38.72 62.02 percent of total billed charges KCL 20 MEQ/L-D5W-0.45% NACL 50415222_1 CDM 0258 RC 00264-7635-00 NDC inpatient 1 UN 63.94 41.56 UMR - ALL PLANS UMR - ALL PLANS 44.76 70 999999999 38.72 62.02 percent of total billed charges KCL 20 MEQ/L-D5W-0.45% NACL 50415222_1 CDM 0258 RC 00264-7635-00 NDC inpatient 1 UN 63.94 41.56 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.72 62.02 KCL 20 MEQ/L-D5W-0.45% NACL 50415222_1 CDM 0258 RC 00264-7635-00 NDC inpatient 1 UN 63.94 41.56 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.72 62.02 KCL 20 MEQ/L-D5W-0.45% NACL 50415222_1 CDM 0258 RC 00264-7635-00 NDC inpatient 1 UN 63.94 41.56 ANTHEM HMO ANTHEM HMO 999999999 38.72 62.02 KCL 20 MEQ/L-D5W-0.45% NACL 50415222_1 CDM 0258 RC 00264-7635-00 NDC inpatient 1 UN 63.94 41.56 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.72 62.02 KCL 20 MEQ/L-D5W-0.45% NACL 50415222_1 CDM 0258 RC 00264-7635-00 NDC inpatient 1 UN 63.94 41.56 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.22 67.6 999999999 38.72 62.02 percent of total billed charges KCL 20 MEQ/L-D5W-0.45% NACL 50415222_1 CDM 0258 RC 00264-7635-00 NDC inpatient 1 UN 63.94 41.56 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.72 62.02 LEVOFLOXACIN 500 MG TABLET 50415265_1 CDM 0250 RC 65862-0537-50 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 500 MG TABLET 50415265_1 CDM 0250 RC 65862-0537-50 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 500 MG TABLET 50415265_1 CDM 0250 RC 65862-0537-50 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 500 MG TABLET 50415265_1 CDM 0250 RC 65862-0537-50 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 500 MG TABLET 50415265_1 CDM 0250 RC 65862-0537-50 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 500 MG TABLET 50415265_1 CDM 0250 RC 65862-0537-50 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 500 MG TABLET 50415265_1 CDM 0250 RC 65862-0537-50 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 500 MG TABLET 50415265_1 CDM 0250 RC 65862-0537-50 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LEVOFLOXACIN 500 MG TABLET 50415265_1 CDM 0250 RC 65862-0537-50 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LEVOFLOXACIN 500 MG TABLET 50415265_1 CDM 0250 RC 65862-0537-50 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LEVOFLOXACIN 500 MG TABLET 50415265_1 CDM 0250 RC 65862-0537-50 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LEVOFLOXACIN 500 MG TABLET 50415265_1 CDM 0250 RC 65862-0537-50 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LEVOFLOXACIN 500 MG TABLET 50415265_1 CDM 0250 RC 65862-0537-50 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 LEVOFLOXACIN 500 MG TABLET 50415265_1 CDM 0250 RC 65862-0537-50 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CLARITHROMYCIN 500 MG TABLET 50415267_1 CDM 0250 RC 65862-0226-60 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CLARITHROMYCIN 500 MG TABLET 50415267_1 CDM 0250 RC 65862-0226-60 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CLARITHROMYCIN 500 MG TABLET 50415267_1 CDM 0250 RC 65862-0226-60 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CLARITHROMYCIN 500 MG TABLET 50415267_1 CDM 0250 RC 65862-0226-60 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CLARITHROMYCIN 500 MG TABLET 50415267_1 CDM 0250 RC 65862-0226-60 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CLARITHROMYCIN 500 MG TABLET 50415267_1 CDM 0250 RC 65862-0226-60 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CLARITHROMYCIN 500 MG TABLET 50415267_1 CDM 0250 RC 65862-0226-60 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CLARITHROMYCIN 500 MG TABLET 50415267_1 CDM 0250 RC 65862-0226-60 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CLARITHROMYCIN 500 MG TABLET 50415267_1 CDM 0250 RC 65862-0226-60 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CLARITHROMYCIN 500 MG TABLET 50415267_1 CDM 0250 RC 65862-0226-60 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CLARITHROMYCIN 500 MG TABLET 50415267_1 CDM 0250 RC 65862-0226-60 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CLARITHROMYCIN 500 MG TABLET 50415267_1 CDM 0250 RC 65862-0226-60 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CLARITHROMYCIN 500 MG TABLET 50415267_1 CDM 0250 RC 65862-0226-60 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CLARITHROMYCIN 500 MG TABLET 50415267_1 CDM 0250 RC 65862-0226-60 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 3 MG CAPSULE 50415268_1 CDM 0250 RC 51991-0794-06 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 3 MG CAPSULE 50415268_1 CDM 0250 RC 51991-0794-06 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 3 MG CAPSULE 50415268_1 CDM 0250 RC 51991-0794-06 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 3 MG CAPSULE 50415268_1 CDM 0250 RC 51991-0794-06 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 3 MG CAPSULE 50415268_1 CDM 0250 RC 51991-0794-06 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 3 MG CAPSULE 50415268_1 CDM 0250 RC 51991-0794-06 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 3 MG CAPSULE 50415268_1 CDM 0250 RC 51991-0794-06 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 3 MG CAPSULE 50415268_1 CDM 0250 RC 51991-0794-06 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 3 MG CAPSULE 50415268_1 CDM 0250 RC 51991-0794-06 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 RIVASTIGMINE 3 MG CAPSULE 50415268_1 CDM 0250 RC 51991-0794-06 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 RIVASTIGMINE 3 MG CAPSULE 50415268_1 CDM 0250 RC 51991-0794-06 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 RIVASTIGMINE 3 MG CAPSULE 50415268_1 CDM 0250 RC 51991-0794-06 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 RIVASTIGMINE 3 MG CAPSULE 50415268_1 CDM 0250 RC 51991-0794-06 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 RIVASTIGMINE 3 MG CAPSULE 50415268_1 CDM 0250 RC 51991-0794-06 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CDC 2019 NOVEL CORONAVIRUS (2019-NCOV) REAL-TIME RT-PCR DIAGNOSTIC PANEL 50418035_1 CDM 0301 RC U0001 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges CDC 2019 NOVEL CORONAVIRUS (2019-NCOV) REAL-TIME RT-PCR DIAGNOSTIC PANEL 50418035_1 CDM 0301 RC U0001 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges CDC 2019 NOVEL CORONAVIRUS (2019-NCOV) REAL-TIME RT-PCR DIAGNOSTIC PANEL 50418035_1 CDM 0301 RC U0001 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges CDC 2019 NOVEL CORONAVIRUS (2019-NCOV) REAL-TIME RT-PCR DIAGNOSTIC PANEL 50418035_1 CDM 0301 RC U0001 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges CDC 2019 NOVEL CORONAVIRUS (2019-NCOV) REAL-TIME RT-PCR DIAGNOSTIC PANEL 50418035_1 CDM 0301 RC U0001 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges CDC 2019 NOVEL CORONAVIRUS (2019-NCOV) REAL-TIME RT-PCR DIAGNOSTIC PANEL 50418035_1 CDM 0301 RC U0001 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges CDC 2019 NOVEL CORONAVIRUS (2019-NCOV) REAL-TIME RT-PCR DIAGNOSTIC PANEL 50418035_1 CDM 0301 RC U0001 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges CDC 2019 NOVEL CORONAVIRUS (2019-NCOV) REAL-TIME RT-PCR DIAGNOSTIC PANEL 50418035_1 CDM 0301 RC U0001 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges CDC 2019 NOVEL CORONAVIRUS (2019-NCOV) REAL-TIME RT-PCR DIAGNOSTIC PANEL 50418035_1 CDM 0301 RC U0001 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 CDC 2019 NOVEL CORONAVIRUS (2019-NCOV) REAL-TIME RT-PCR DIAGNOSTIC PANEL 50418035_1 CDM 0301 RC U0001 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 CDC 2019 NOVEL CORONAVIRUS (2019-NCOV) REAL-TIME RT-PCR DIAGNOSTIC PANEL 50418035_1 CDM 0301 RC U0001 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 CDC 2019 NOVEL CORONAVIRUS (2019-NCOV) REAL-TIME RT-PCR DIAGNOSTIC PANEL 50418035_1 CDM 0301 RC U0001 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 CDC 2019 NOVEL CORONAVIRUS (2019-NCOV) REAL-TIME RT-PCR DIAGNOSTIC PANEL 50418035_1 CDM 0301 RC U0001 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 CDC 2019 NOVEL CORONAVIRUS (2019-NCOV) REAL-TIME RT-PCR DIAGNOSTIC PANEL 50418035_1 CDM 0301 RC U0001 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50418418_1 CDM 0302 RC 87635 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50418418_1 CDM 0302 RC 87635 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50418418_1 CDM 0302 RC 87635 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50418418_1 CDM 0302 RC 87635 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50418418_1 CDM 0302 RC 87635 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50418418_1 CDM 0302 RC 87635 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50418418_1 CDM 0302 RC 87635 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50418418_1 CDM 0302 RC 87635 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50418418_1 CDM 0302 RC 87635 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50418418_1 CDM 0302 RC 87635 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50418418_1 CDM 0302 RC 87635 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50418418_1 CDM 0302 RC 87635 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50418418_1 CDM 0302 RC 87635 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50418418_1 CDM 0302 RC 87635 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50423792_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50423792_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50423792_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50423792_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50423792_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50423792_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50423792_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50423792_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50423792_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50423792_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50423792_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50423792_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50423792_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 "2019-NCOV CORONAVIRUS, SARS-COV-2/2019-NCOV (COVID-19), ANY TECHNIQUE, MULTIPLE TYPES OR SUBTYPES (INCLUDES ALL TARGETS), NON-CDC" 50423792_1 CDM 0302 RC U0002 HCPCS inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50423836_1 CDM 0250 RC 00990-7983-61 NDC inpatient 1 UN 33.16 21.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.55 65 999999999 20.08 32.17 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50423836_1 CDM 0250 RC 00990-7983-61 NDC inpatient 1 UN 33.16 21.55 AETNA AETNA 26.2 79 999999999 20.08 32.17 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50423836_1 CDM 0250 RC 00990-7983-61 NDC inpatient 1 UN 33.16 21.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.17 97 999999999 20.08 32.17 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50423836_1 CDM 0250 RC 00990-7983-61 NDC inpatient 1 UN 33.16 21.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.88 69 999999999 20.08 32.17 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50423836_1 CDM 0250 RC 00990-7983-61 NDC inpatient 1 UN 33.16 21.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 25.86 78 999999999 20.08 32.17 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50423836_1 CDM 0250 RC 00990-7983-61 NDC inpatient 1 UN 33.16 21.55 SIHO - ALL PLANS SIHO - ALL PLANS 29.84 90 999999999 20.08 32.17 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50423836_1 CDM 0250 RC 00990-7983-61 NDC inpatient 1 UN 33.16 21.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.08 60.55 999999999 20.08 32.17 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50423836_1 CDM 0250 RC 00990-7983-61 NDC inpatient 1 UN 33.16 21.55 UMR - ALL PLANS UMR - ALL PLANS 23.21 70 999999999 20.08 32.17 percent of total billed charges SODIUM CHLORIDE 0.9% SOLUTION 50423836_1 CDM 0250 RC 00990-7983-61 NDC inpatient 1 UN 33.16 21.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.08 32.17 SODIUM CHLORIDE 0.9% SOLUTION 50423836_1 CDM 0250 RC 00990-7983-61 NDC inpatient 1 UN 33.16 21.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.08 32.17 SODIUM CHLORIDE 0.9% SOLUTION 50423836_1 CDM 0250 RC 00990-7983-61 NDC inpatient 1 UN 33.16 21.55 ANTHEM HMO ANTHEM HMO 999999999 20.08 32.17 SODIUM CHLORIDE 0.9% SOLUTION 50423836_1 CDM 0250 RC 00990-7983-61 NDC inpatient 1 UN 33.16 21.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.08 32.17 SODIUM CHLORIDE 0.9% SOLUTION 50423836_1 CDM 0250 RC 00990-7983-61 NDC inpatient 1 UN 33.16 21.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.08 32.17 SODIUM CHLORIDE 0.9% SOLUTION 50423836_1 CDM 0250 RC 00990-7983-61 NDC inpatient 1 UN 33.16 21.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.42 67.6 999999999 20.08 32.17 percent of total billed charges CEPHALEXIN 250 MG CAPSULE 50424659_1 CDM 0250 RC 65862-0018-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CEPHALEXIN 250 MG CAPSULE 50424659_1 CDM 0250 RC 65862-0018-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CEPHALEXIN 250 MG CAPSULE 50424659_1 CDM 0250 RC 65862-0018-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CEPHALEXIN 250 MG CAPSULE 50424659_1 CDM 0250 RC 65862-0018-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CEPHALEXIN 250 MG CAPSULE 50424659_1 CDM 0250 RC 65862-0018-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CEPHALEXIN 250 MG CAPSULE 50424659_1 CDM 0250 RC 65862-0018-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CEPHALEXIN 250 MG CAPSULE 50424659_1 CDM 0250 RC 65862-0018-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CEPHALEXIN 250 MG CAPSULE 50424659_1 CDM 0250 RC 65862-0018-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CEPHALEXIN 250 MG CAPSULE 50424659_1 CDM 0250 RC 65862-0018-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CEPHALEXIN 250 MG CAPSULE 50424659_1 CDM 0250 RC 65862-0018-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CEPHALEXIN 250 MG CAPSULE 50424659_1 CDM 0250 RC 65862-0018-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CEPHALEXIN 250 MG CAPSULE 50424659_1 CDM 0250 RC 65862-0018-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CEPHALEXIN 250 MG CAPSULE 50424659_1 CDM 0250 RC 65862-0018-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CEPHALEXIN 250 MG CAPSULE 50424659_1 CDM 0250 RC 65862-0018-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 50424660_1 CDM 0250 RC 62756-0129-44 NDC C9113 HCPCS inpatient 1 UN 29.82 19.38 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.38 65 999999999 18.06 28.93 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 50424660_1 CDM 0250 RC 62756-0129-44 NDC C9113 HCPCS inpatient 1 UN 29.82 19.38 AETNA AETNA 23.56 79 999999999 18.06 28.93 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 50424660_1 CDM 0250 RC 62756-0129-44 NDC C9113 HCPCS inpatient 1 UN 29.82 19.38 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 28.93 97 999999999 18.06 28.93 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 50424660_1 CDM 0250 RC 62756-0129-44 NDC C9113 HCPCS inpatient 1 UN 29.82 19.38 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.58 69 999999999 18.06 28.93 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 50424660_1 CDM 0250 RC 62756-0129-44 NDC C9113 HCPCS inpatient 1 UN 29.82 19.38 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.26 78 999999999 18.06 28.93 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 50424660_1 CDM 0250 RC 62756-0129-44 NDC C9113 HCPCS inpatient 1 UN 29.82 19.38 SIHO - ALL PLANS SIHO - ALL PLANS 26.84 90 999999999 18.06 28.93 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 50424660_1 CDM 0250 RC 62756-0129-44 NDC C9113 HCPCS inpatient 1 UN 29.82 19.38 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.06 60.55 999999999 18.06 28.93 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 50424660_1 CDM 0250 RC 62756-0129-44 NDC C9113 HCPCS inpatient 1 UN 29.82 19.38 UMR - ALL PLANS UMR - ALL PLANS 20.87 70 999999999 18.06 28.93 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 50424660_1 CDM 0250 RC 62756-0129-44 NDC C9113 HCPCS inpatient 1 UN 29.82 19.38 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.06 28.93 "INJ PANTOPRAZOLE SODIUM, VIA" 50424660_1 CDM 0250 RC 62756-0129-44 NDC C9113 HCPCS inpatient 1 UN 29.82 19.38 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.06 28.93 "INJ PANTOPRAZOLE SODIUM, VIA" 50424660_1 CDM 0250 RC 62756-0129-44 NDC C9113 HCPCS inpatient 1 UN 29.82 19.38 ANTHEM HMO ANTHEM HMO 999999999 18.06 28.93 "INJ PANTOPRAZOLE SODIUM, VIA" 50424660_1 CDM 0250 RC 62756-0129-44 NDC C9113 HCPCS inpatient 1 UN 29.82 19.38 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.06 28.93 "INJ PANTOPRAZOLE SODIUM, VIA" 50424660_1 CDM 0250 RC 62756-0129-44 NDC C9113 HCPCS inpatient 1 UN 29.82 19.38 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.06 28.93 "INJ PANTOPRAZOLE SODIUM, VIA" 50424660_1 CDM 0250 RC 62756-0129-44 NDC C9113 HCPCS inpatient 1 UN 29.82 19.38 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.16 67.6 999999999 18.06 28.93 percent of total billed charges BENZTROPINE MES 0.5 MG TAB 50424865_1 CDM 0250 RC 60687-0356-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges BENZTROPINE MES 0.5 MG TAB 50424865_1 CDM 0250 RC 60687-0356-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges BENZTROPINE MES 0.5 MG TAB 50424865_1 CDM 0250 RC 60687-0356-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges BENZTROPINE MES 0.5 MG TAB 50424865_1 CDM 0250 RC 60687-0356-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges BENZTROPINE MES 0.5 MG TAB 50424865_1 CDM 0250 RC 60687-0356-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges BENZTROPINE MES 0.5 MG TAB 50424865_1 CDM 0250 RC 60687-0356-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges BENZTROPINE MES 0.5 MG TAB 50424865_1 CDM 0250 RC 60687-0356-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges BENZTROPINE MES 0.5 MG TAB 50424865_1 CDM 0250 RC 60687-0356-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges BENZTROPINE MES 0.5 MG TAB 50424865_1 CDM 0250 RC 60687-0356-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 BENZTROPINE MES 0.5 MG TAB 50424865_1 CDM 0250 RC 60687-0356-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 BENZTROPINE MES 0.5 MG TAB 50424865_1 CDM 0250 RC 60687-0356-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 BENZTROPINE MES 0.5 MG TAB 50424865_1 CDM 0250 RC 60687-0356-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 BENZTROPINE MES 0.5 MG TAB 50424865_1 CDM 0250 RC 60687-0356-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 BENZTROPINE MES 0.5 MG TAB 50424865_1 CDM 0250 RC 60687-0356-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 50425591_1 CDM 0250 RC 00024-5926-05 NDC J1817 HCPCS inpatient 6 UN 74.15 48.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.2 65 999999999 44.9 71.93 percent of total billed charges "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 50425591_1 CDM 0250 RC 00024-5926-05 NDC J1817 HCPCS inpatient 6 UN 74.15 48.2 AETNA AETNA 58.58 79 999999999 44.9 71.93 percent of total billed charges "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 50425591_1 CDM 0250 RC 00024-5926-05 NDC J1817 HCPCS inpatient 6 UN 74.15 48.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 71.93 97 999999999 44.9 71.93 percent of total billed charges "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 50425591_1 CDM 0250 RC 00024-5926-05 NDC J1817 HCPCS inpatient 6 UN 74.15 48.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.16 69 999999999 44.9 71.93 percent of total billed charges "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 50425591_1 CDM 0250 RC 00024-5926-05 NDC J1817 HCPCS inpatient 6 UN 74.15 48.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 57.84 78 999999999 44.9 71.93 percent of total billed charges "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 50425591_1 CDM 0250 RC 00024-5926-05 NDC J1817 HCPCS inpatient 6 UN 74.15 48.2 SIHO - ALL PLANS SIHO - ALL PLANS 66.74 90 999999999 44.9 71.93 percent of total billed charges "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 50425591_1 CDM 0250 RC 00024-5926-05 NDC J1817 HCPCS inpatient 6 UN 74.15 48.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.9 60.55 999999999 44.9 71.93 percent of total billed charges "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 50425591_1 CDM 0250 RC 00024-5926-05 NDC J1817 HCPCS inpatient 6 UN 74.15 48.2 UMR - ALL PLANS UMR - ALL PLANS 51.91 70 999999999 44.9 71.93 percent of total billed charges "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 50425591_1 CDM 0250 RC 00024-5926-05 NDC J1817 HCPCS inpatient 6 UN 74.15 48.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.9 71.93 "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 50425591_1 CDM 0250 RC 00024-5926-05 NDC J1817 HCPCS inpatient 6 UN 74.15 48.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.9 71.93 "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 50425591_1 CDM 0250 RC 00024-5926-05 NDC J1817 HCPCS inpatient 6 UN 74.15 48.2 ANTHEM HMO ANTHEM HMO 999999999 44.9 71.93 "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 50425591_1 CDM 0250 RC 00024-5926-05 NDC J1817 HCPCS inpatient 6 UN 74.15 48.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.9 71.93 "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 50425591_1 CDM 0250 RC 00024-5926-05 NDC J1817 HCPCS inpatient 6 UN 74.15 48.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.9 71.93 "INSULIN FOR ADMINISTRATION THROUGH DME (I.E., INSULIN PUMP) PER 50 UNITS" 50425591_1 CDM 0250 RC 00024-5926-05 NDC J1817 HCPCS inpatient 6 UN 74.15 48.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.13 67.6 999999999 44.9 71.93 percent of total billed charges PHYTONADIONE 5 MG TABLET 50426293_1 CDM 0250 RC 69238-1051-03 NDC inpatient 1 UN 130.77 85 SELF PAY DISCOUNT SELF PAY DISCOUNT 85 65 999999999 79.18 126.85 percent of total billed charges PHYTONADIONE 5 MG TABLET 50426293_1 CDM 0250 RC 69238-1051-03 NDC inpatient 1 UN 130.77 85 AETNA AETNA 103.31 79 999999999 79.18 126.85 percent of total billed charges PHYTONADIONE 5 MG TABLET 50426293_1 CDM 0250 RC 69238-1051-03 NDC inpatient 1 UN 130.77 85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 126.85 97 999999999 79.18 126.85 percent of total billed charges PHYTONADIONE 5 MG TABLET 50426293_1 CDM 0250 RC 69238-1051-03 NDC inpatient 1 UN 130.77 85 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.23 69 999999999 79.18 126.85 percent of total billed charges PHYTONADIONE 5 MG TABLET 50426293_1 CDM 0250 RC 69238-1051-03 NDC inpatient 1 UN 130.77 85 HUMANA - ALL PLANS HUMANA - ALL PLANS 102 78 999999999 79.18 126.85 percent of total billed charges PHYTONADIONE 5 MG TABLET 50426293_1 CDM 0250 RC 69238-1051-03 NDC inpatient 1 UN 130.77 85 SIHO - ALL PLANS SIHO - ALL PLANS 117.69 90 999999999 79.18 126.85 percent of total billed charges PHYTONADIONE 5 MG TABLET 50426293_1 CDM 0250 RC 69238-1051-03 NDC inpatient 1 UN 130.77 85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.18 60.55 999999999 79.18 126.85 percent of total billed charges PHYTONADIONE 5 MG TABLET 50426293_1 CDM 0250 RC 69238-1051-03 NDC inpatient 1 UN 130.77 85 UMR - ALL PLANS UMR - ALL PLANS 91.54 70 999999999 79.18 126.85 percent of total billed charges PHYTONADIONE 5 MG TABLET 50426293_1 CDM 0250 RC 69238-1051-03 NDC inpatient 1 UN 130.77 85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.18 126.85 PHYTONADIONE 5 MG TABLET 50426293_1 CDM 0250 RC 69238-1051-03 NDC inpatient 1 UN 130.77 85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.18 126.85 PHYTONADIONE 5 MG TABLET 50426293_1 CDM 0250 RC 69238-1051-03 NDC inpatient 1 UN 130.77 85 ANTHEM HMO ANTHEM HMO 999999999 79.18 126.85 PHYTONADIONE 5 MG TABLET 50426293_1 CDM 0250 RC 69238-1051-03 NDC inpatient 1 UN 130.77 85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.18 126.85 PHYTONADIONE 5 MG TABLET 50426293_1 CDM 0250 RC 69238-1051-03 NDC inpatient 1 UN 130.77 85 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.18 126.85 PHYTONADIONE 5 MG TABLET 50426293_1 CDM 0250 RC 69238-1051-03 NDC inpatient 1 UN 130.77 85 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.4 67.6 999999999 79.18 126.85 percent of total billed charges INTRODUCER BOUGIE 15FR STRAIGHT TIP 9-0212-72 50429180_1 CDM 0272 RC inpatient 32 20.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.8 65 999999999 19.38 31.04 percent of total billed charges INTRODUCER BOUGIE 15FR STRAIGHT TIP 9-0212-72 50429180_1 CDM 0272 RC inpatient 32 20.8 AETNA AETNA 25.28 79 999999999 19.38 31.04 percent of total billed charges INTRODUCER BOUGIE 15FR STRAIGHT TIP 9-0212-72 50429180_1 CDM 0272 RC inpatient 32 20.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31.04 97 999999999 19.38 31.04 percent of total billed charges INTRODUCER BOUGIE 15FR STRAIGHT TIP 9-0212-72 50429180_1 CDM 0272 RC inpatient 32 20.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.08 69 999999999 19.38 31.04 percent of total billed charges INTRODUCER BOUGIE 15FR STRAIGHT TIP 9-0212-72 50429180_1 CDM 0272 RC inpatient 32 20.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.96 78 999999999 19.38 31.04 percent of total billed charges INTRODUCER BOUGIE 15FR STRAIGHT TIP 9-0212-72 50429180_1 CDM 0272 RC inpatient 32 20.8 SIHO - ALL PLANS SIHO - ALL PLANS 28.8 90 999999999 19.38 31.04 percent of total billed charges INTRODUCER BOUGIE 15FR STRAIGHT TIP 9-0212-72 50429180_1 CDM 0272 RC inpatient 32 20.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.38 60.55 999999999 19.38 31.04 percent of total billed charges INTRODUCER BOUGIE 15FR STRAIGHT TIP 9-0212-72 50429180_1 CDM 0272 RC inpatient 32 20.8 UMR - ALL PLANS UMR - ALL PLANS 22.4 70 999999999 19.38 31.04 percent of total billed charges INTRODUCER BOUGIE 15FR STRAIGHT TIP 9-0212-72 50429180_1 CDM 0272 RC inpatient 32 20.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.38 31.04 INTRODUCER BOUGIE 15FR STRAIGHT TIP 9-0212-72 50429180_1 CDM 0272 RC inpatient 32 20.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.38 31.04 INTRODUCER BOUGIE 15FR STRAIGHT TIP 9-0212-72 50429180_1 CDM 0272 RC inpatient 32 20.8 ANTHEM HMO ANTHEM HMO 999999999 19.38 31.04 INTRODUCER BOUGIE 15FR STRAIGHT TIP 9-0212-72 50429180_1 CDM 0272 RC inpatient 32 20.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.38 31.04 INTRODUCER BOUGIE 15FR STRAIGHT TIP 9-0212-72 50429180_1 CDM 0272 RC inpatient 32 20.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.38 31.04 INTRODUCER BOUGIE 15FR STRAIGHT TIP 9-0212-72 50429180_1 CDM 0272 RC inpatient 32 20.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.63 67.6 999999999 19.38 31.04 percent of total billed charges AMIODARONE HCL 200 MG TABLET 50430026_1 CDM 0250 RC 60687-0437-01 NDC inpatient 1 UN 1.6 1.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.04 65 999999999 0.97 1.55 percent of total billed charges AMIODARONE HCL 200 MG TABLET 50430026_1 CDM 0250 RC 60687-0437-01 NDC inpatient 1 UN 1.6 1.04 AETNA AETNA 1.26 79 999999999 0.97 1.55 percent of total billed charges AMIODARONE HCL 200 MG TABLET 50430026_1 CDM 0250 RC 60687-0437-01 NDC inpatient 1 UN 1.6 1.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.55 97 999999999 0.97 1.55 percent of total billed charges AMIODARONE HCL 200 MG TABLET 50430026_1 CDM 0250 RC 60687-0437-01 NDC inpatient 1 UN 1.6 1.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.1 69 999999999 0.97 1.55 percent of total billed charges AMIODARONE HCL 200 MG TABLET 50430026_1 CDM 0250 RC 60687-0437-01 NDC inpatient 1 UN 1.6 1.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.25 78 999999999 0.97 1.55 percent of total billed charges AMIODARONE HCL 200 MG TABLET 50430026_1 CDM 0250 RC 60687-0437-01 NDC inpatient 1 UN 1.6 1.04 SIHO - ALL PLANS SIHO - ALL PLANS 1.44 90 999999999 0.97 1.55 percent of total billed charges AMIODARONE HCL 200 MG TABLET 50430026_1 CDM 0250 RC 60687-0437-01 NDC inpatient 1 UN 1.6 1.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.97 60.55 999999999 0.97 1.55 percent of total billed charges AMIODARONE HCL 200 MG TABLET 50430026_1 CDM 0250 RC 60687-0437-01 NDC inpatient 1 UN 1.6 1.04 UMR - ALL PLANS UMR - ALL PLANS 1.12 70 999999999 0.97 1.55 percent of total billed charges AMIODARONE HCL 200 MG TABLET 50430026_1 CDM 0250 RC 60687-0437-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.97 1.55 AMIODARONE HCL 200 MG TABLET 50430026_1 CDM 0250 RC 60687-0437-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.97 1.55 AMIODARONE HCL 200 MG TABLET 50430026_1 CDM 0250 RC 60687-0437-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM HMO ANTHEM HMO 999999999 0.97 1.55 AMIODARONE HCL 200 MG TABLET 50430026_1 CDM 0250 RC 60687-0437-01 NDC inpatient 1 UN 1.6 1.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.97 1.55 AMIODARONE HCL 200 MG TABLET 50430026_1 CDM 0250 RC 60687-0437-01 NDC inpatient 1 UN 1.6 1.04 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.97 1.55 AMIODARONE HCL 200 MG TABLET 50430026_1 CDM 0250 RC 60687-0437-01 NDC inpatient 1 UN 1.6 1.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.08 67.6 999999999 0.97 1.55 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50430117_1 CDM 0300 RC 87635 HCPCS inpatient 163 105.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 105.95 65 999999999 98.7 158.11 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50430117_1 CDM 0300 RC 87635 HCPCS inpatient 163 105.95 AETNA AETNA 128.77 79 999999999 98.7 158.11 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50430117_1 CDM 0300 RC 87635 HCPCS inpatient 163 105.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 158.11 97 999999999 98.7 158.11 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50430117_1 CDM 0300 RC 87635 HCPCS inpatient 163 105.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 112.47 69 999999999 98.7 158.11 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50430117_1 CDM 0300 RC 87635 HCPCS inpatient 163 105.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.14 78 999999999 98.7 158.11 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50430117_1 CDM 0300 RC 87635 HCPCS inpatient 163 105.95 SIHO - ALL PLANS SIHO - ALL PLANS 146.7 90 999999999 98.7 158.11 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50430117_1 CDM 0300 RC 87635 HCPCS inpatient 163 105.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 98.7 60.55 999999999 98.7 158.11 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50430117_1 CDM 0300 RC 87635 HCPCS inpatient 163 105.95 UMR - ALL PLANS UMR - ALL PLANS 114.1 70 999999999 98.7 158.11 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50430117_1 CDM 0300 RC 87635 HCPCS inpatient 163 105.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 98.7 158.11 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50430117_1 CDM 0300 RC 87635 HCPCS inpatient 163 105.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 98.7 158.11 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50430117_1 CDM 0300 RC 87635 HCPCS inpatient 163 105.95 ANTHEM HMO ANTHEM HMO 999999999 98.7 158.11 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50430117_1 CDM 0300 RC 87635 HCPCS inpatient 163 105.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 98.7 158.11 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50430117_1 CDM 0300 RC 87635 HCPCS inpatient 163 105.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 98.7 158.11 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50430117_1 CDM 0300 RC 87635 HCPCS inpatient 163 105.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.19 67.6 999999999 98.7 158.11 percent of total billed charges SODIUM CHLORIDE 3% IV SOLN 50430373_1 CDM 0250 RC 63323-0530-75 NDC inpatient 1 UN 199.61 129.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 129.75 65 999999999 120.86 193.62 percent of total billed charges SODIUM CHLORIDE 3% IV SOLN 50430373_1 CDM 0250 RC 63323-0530-75 NDC inpatient 1 UN 199.61 129.75 AETNA AETNA 157.69 79 999999999 120.86 193.62 percent of total billed charges SODIUM CHLORIDE 3% IV SOLN 50430373_1 CDM 0250 RC 63323-0530-75 NDC inpatient 1 UN 199.61 129.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 193.62 97 999999999 120.86 193.62 percent of total billed charges SODIUM CHLORIDE 3% IV SOLN 50430373_1 CDM 0250 RC 63323-0530-75 NDC inpatient 1 UN 199.61 129.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 137.73 69 999999999 120.86 193.62 percent of total billed charges SODIUM CHLORIDE 3% IV SOLN 50430373_1 CDM 0250 RC 63323-0530-75 NDC inpatient 1 UN 199.61 129.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 155.7 78 999999999 120.86 193.62 percent of total billed charges SODIUM CHLORIDE 3% IV SOLN 50430373_1 CDM 0250 RC 63323-0530-75 NDC inpatient 1 UN 199.61 129.75 SIHO - ALL PLANS SIHO - ALL PLANS 179.65 90 999999999 120.86 193.62 percent of total billed charges SODIUM CHLORIDE 3% IV SOLN 50430373_1 CDM 0250 RC 63323-0530-75 NDC inpatient 1 UN 199.61 129.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 120.86 60.55 999999999 120.86 193.62 percent of total billed charges SODIUM CHLORIDE 3% IV SOLN 50430373_1 CDM 0250 RC 63323-0530-75 NDC inpatient 1 UN 199.61 129.75 UMR - ALL PLANS UMR - ALL PLANS 139.73 70 999999999 120.86 193.62 percent of total billed charges SODIUM CHLORIDE 3% IV SOLN 50430373_1 CDM 0250 RC 63323-0530-75 NDC inpatient 1 UN 199.61 129.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 120.86 193.62 SODIUM CHLORIDE 3% IV SOLN 50430373_1 CDM 0250 RC 63323-0530-75 NDC inpatient 1 UN 199.61 129.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 120.86 193.62 SODIUM CHLORIDE 3% IV SOLN 50430373_1 CDM 0250 RC 63323-0530-75 NDC inpatient 1 UN 199.61 129.75 ANTHEM HMO ANTHEM HMO 999999999 120.86 193.62 SODIUM CHLORIDE 3% IV SOLN 50430373_1 CDM 0250 RC 63323-0530-75 NDC inpatient 1 UN 199.61 129.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 120.86 193.62 SODIUM CHLORIDE 3% IV SOLN 50430373_1 CDM 0250 RC 63323-0530-75 NDC inpatient 1 UN 199.61 129.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 120.86 193.62 SODIUM CHLORIDE 3% IV SOLN 50430373_1 CDM 0250 RC 63323-0530-75 NDC inpatient 1 UN 199.61 129.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 134.94 67.6 999999999 120.86 193.62 percent of total billed charges Measurement of cold agglutinin (protein) to screen for infection or disease 50430521_1 CDM 0302 RC 86156 HCPCS inpatient 163 105.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 105.95 65 999999999 98.7 158.11 percent of total billed charges Measurement of cold agglutinin (protein) to screen for infection or disease 50430521_1 CDM 0302 RC 86156 HCPCS inpatient 163 105.95 AETNA AETNA 128.77 79 999999999 98.7 158.11 percent of total billed charges Measurement of cold agglutinin (protein) to screen for infection or disease 50430521_1 CDM 0302 RC 86156 HCPCS inpatient 163 105.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 158.11 97 999999999 98.7 158.11 percent of total billed charges Measurement of cold agglutinin (protein) to screen for infection or disease 50430521_1 CDM 0302 RC 86156 HCPCS inpatient 163 105.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 112.47 69 999999999 98.7 158.11 percent of total billed charges Measurement of cold agglutinin (protein) to screen for infection or disease 50430521_1 CDM 0302 RC 86156 HCPCS inpatient 163 105.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.14 78 999999999 98.7 158.11 percent of total billed charges Measurement of cold agglutinin (protein) to screen for infection or disease 50430521_1 CDM 0302 RC 86156 HCPCS inpatient 163 105.95 SIHO - ALL PLANS SIHO - ALL PLANS 146.7 90 999999999 98.7 158.11 percent of total billed charges Measurement of cold agglutinin (protein) to screen for infection or disease 50430521_1 CDM 0302 RC 86156 HCPCS inpatient 163 105.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 98.7 60.55 999999999 98.7 158.11 percent of total billed charges Measurement of cold agglutinin (protein) to screen for infection or disease 50430521_1 CDM 0302 RC 86156 HCPCS inpatient 163 105.95 UMR - ALL PLANS UMR - ALL PLANS 114.1 70 999999999 98.7 158.11 percent of total billed charges Measurement of cold agglutinin (protein) to screen for infection or disease 50430521_1 CDM 0302 RC 86156 HCPCS inpatient 163 105.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 98.7 158.11 Measurement of cold agglutinin (protein) to screen for infection or disease 50430521_1 CDM 0302 RC 86156 HCPCS inpatient 163 105.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 98.7 158.11 Measurement of cold agglutinin (protein) to screen for infection or disease 50430521_1 CDM 0302 RC 86156 HCPCS inpatient 163 105.95 ANTHEM HMO ANTHEM HMO 999999999 98.7 158.11 Measurement of cold agglutinin (protein) to screen for infection or disease 50430521_1 CDM 0302 RC 86156 HCPCS inpatient 163 105.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 98.7 158.11 Measurement of cold agglutinin (protein) to screen for infection or disease 50430521_1 CDM 0302 RC 86156 HCPCS inpatient 163 105.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 98.7 158.11 Measurement of cold agglutinin (protein) to screen for infection or disease 50430521_1 CDM 0302 RC 86156 HCPCS inpatient 163 105.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.19 67.6 999999999 98.7 158.11 percent of total billed charges Removal of spinal fluid with lower back spinal tap for diagnostic test using imaging guidance 50430754_1 CDM 0320 RC 62328 HCPCS inpatient 863 560.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 560.95 65 999999999 522.55 837.11 percent of total billed charges Removal of spinal fluid with lower back spinal tap for diagnostic test using imaging guidance 50430754_1 CDM 0320 RC 62328 HCPCS inpatient 863 560.95 AETNA AETNA 681.77 79 999999999 522.55 837.11 percent of total billed charges Removal of spinal fluid with lower back spinal tap for diagnostic test using imaging guidance 50430754_1 CDM 0320 RC 62328 HCPCS inpatient 863 560.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 837.11 97 999999999 522.55 837.11 percent of total billed charges Removal of spinal fluid with lower back spinal tap for diagnostic test using imaging guidance 50430754_1 CDM 0320 RC 62328 HCPCS inpatient 863 560.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 595.47 69 999999999 522.55 837.11 percent of total billed charges Removal of spinal fluid with lower back spinal tap for diagnostic test using imaging guidance 50430754_1 CDM 0320 RC 62328 HCPCS inpatient 863 560.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 673.14 78 999999999 522.55 837.11 percent of total billed charges Removal of spinal fluid with lower back spinal tap for diagnostic test using imaging guidance 50430754_1 CDM 0320 RC 62328 HCPCS inpatient 863 560.95 SIHO - ALL PLANS SIHO - ALL PLANS 776.7 90 999999999 522.55 837.11 percent of total billed charges Removal of spinal fluid with lower back spinal tap for diagnostic test using imaging guidance 50430754_1 CDM 0320 RC 62328 HCPCS inpatient 863 560.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 522.55 60.55 999999999 522.55 837.11 percent of total billed charges Removal of spinal fluid with lower back spinal tap for diagnostic test using imaging guidance 50430754_1 CDM 0320 RC 62328 HCPCS inpatient 863 560.95 UMR - ALL PLANS UMR - ALL PLANS 604.1 70 999999999 522.55 837.11 percent of total billed charges Removal of spinal fluid with lower back spinal tap for diagnostic test using imaging guidance 50430754_1 CDM 0320 RC 62328 HCPCS inpatient 863 560.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 522.55 837.11 Removal of spinal fluid with lower back spinal tap for diagnostic test using imaging guidance 50430754_1 CDM 0320 RC 62328 HCPCS inpatient 863 560.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 522.55 837.11 Removal of spinal fluid with lower back spinal tap for diagnostic test using imaging guidance 50430754_1 CDM 0320 RC 62328 HCPCS inpatient 863 560.95 ANTHEM HMO ANTHEM HMO 999999999 522.55 837.11 Removal of spinal fluid with lower back spinal tap for diagnostic test using imaging guidance 50430754_1 CDM 0320 RC 62328 HCPCS inpatient 863 560.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 522.55 837.11 Removal of spinal fluid with lower back spinal tap for diagnostic test using imaging guidance 50430754_1 CDM 0320 RC 62328 HCPCS inpatient 863 560.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 522.55 837.11 Removal of spinal fluid with lower back spinal tap for diagnostic test using imaging guidance 50430754_1 CDM 0320 RC 62328 HCPCS inpatient 863 560.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 583.39 67.6 999999999 522.55 837.11 percent of total billed charges CLOZAPINE 100 MG TABLET 50432336_1 CDM 0250 RC 60687-0415-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CLOZAPINE 100 MG TABLET 50432336_1 CDM 0250 RC 60687-0415-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CLOZAPINE 100 MG TABLET 50432336_1 CDM 0250 RC 60687-0415-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CLOZAPINE 100 MG TABLET 50432336_1 CDM 0250 RC 60687-0415-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CLOZAPINE 100 MG TABLET 50432336_1 CDM 0250 RC 60687-0415-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CLOZAPINE 100 MG TABLET 50432336_1 CDM 0250 RC 60687-0415-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CLOZAPINE 100 MG TABLET 50432336_1 CDM 0250 RC 60687-0415-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CLOZAPINE 100 MG TABLET 50432336_1 CDM 0250 RC 60687-0415-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CLOZAPINE 100 MG TABLET 50432336_1 CDM 0250 RC 60687-0415-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CLOZAPINE 100 MG TABLET 50432336_1 CDM 0250 RC 60687-0415-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CLOZAPINE 100 MG TABLET 50432336_1 CDM 0250 RC 60687-0415-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CLOZAPINE 100 MG TABLET 50432336_1 CDM 0250 RC 60687-0415-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CLOZAPINE 100 MG TABLET 50432336_1 CDM 0250 RC 60687-0415-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CLOZAPINE 100 MG TABLET 50432336_1 CDM 0250 RC 60687-0415-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges ENOXAPARIN 120 MG/0.8 ML SYR 50432338_1 CDM 0250 RC 00548-5606-00 NDC inpatient 1 UN 100.15 65.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.1 65 999999999 60.64 97.15 percent of total billed charges ENOXAPARIN 120 MG/0.8 ML SYR 50432338_1 CDM 0250 RC 00548-5606-00 NDC inpatient 1 UN 100.15 65.1 AETNA AETNA 79.12 79 999999999 60.64 97.15 percent of total billed charges ENOXAPARIN 120 MG/0.8 ML SYR 50432338_1 CDM 0250 RC 00548-5606-00 NDC inpatient 1 UN 100.15 65.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.15 97 999999999 60.64 97.15 percent of total billed charges ENOXAPARIN 120 MG/0.8 ML SYR 50432338_1 CDM 0250 RC 00548-5606-00 NDC inpatient 1 UN 100.15 65.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.1 69 999999999 60.64 97.15 percent of total billed charges ENOXAPARIN 120 MG/0.8 ML SYR 50432338_1 CDM 0250 RC 00548-5606-00 NDC inpatient 1 UN 100.15 65.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.12 78 999999999 60.64 97.15 percent of total billed charges ENOXAPARIN 120 MG/0.8 ML SYR 50432338_1 CDM 0250 RC 00548-5606-00 NDC inpatient 1 UN 100.15 65.1 SIHO - ALL PLANS SIHO - ALL PLANS 90.14 90 999999999 60.64 97.15 percent of total billed charges ENOXAPARIN 120 MG/0.8 ML SYR 50432338_1 CDM 0250 RC 00548-5606-00 NDC inpatient 1 UN 100.15 65.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.64 60.55 999999999 60.64 97.15 percent of total billed charges ENOXAPARIN 120 MG/0.8 ML SYR 50432338_1 CDM 0250 RC 00548-5606-00 NDC inpatient 1 UN 100.15 65.1 UMR - ALL PLANS UMR - ALL PLANS 70.11 70 999999999 60.64 97.15 percent of total billed charges ENOXAPARIN 120 MG/0.8 ML SYR 50432338_1 CDM 0250 RC 00548-5606-00 NDC inpatient 1 UN 100.15 65.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.64 97.15 ENOXAPARIN 120 MG/0.8 ML SYR 50432338_1 CDM 0250 RC 00548-5606-00 NDC inpatient 1 UN 100.15 65.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.64 97.15 ENOXAPARIN 120 MG/0.8 ML SYR 50432338_1 CDM 0250 RC 00548-5606-00 NDC inpatient 1 UN 100.15 65.1 ANTHEM HMO ANTHEM HMO 999999999 60.64 97.15 ENOXAPARIN 120 MG/0.8 ML SYR 50432338_1 CDM 0250 RC 00548-5606-00 NDC inpatient 1 UN 100.15 65.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.64 97.15 ENOXAPARIN 120 MG/0.8 ML SYR 50432338_1 CDM 0250 RC 00548-5606-00 NDC inpatient 1 UN 100.15 65.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.64 97.15 ENOXAPARIN 120 MG/0.8 ML SYR 50432338_1 CDM 0250 RC 00548-5606-00 NDC inpatient 1 UN 100.15 65.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.7 67.6 999999999 60.64 97.15 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50432763_1 CDM 0302 RC 87635 HCPCS inpatient 176 114.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 114.4 65 999999999 106.57 170.72 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50432763_1 CDM 0302 RC 87635 HCPCS inpatient 176 114.4 AETNA AETNA 139.04 79 999999999 106.57 170.72 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50432763_1 CDM 0302 RC 87635 HCPCS inpatient 176 114.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 170.72 97 999999999 106.57 170.72 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50432763_1 CDM 0302 RC 87635 HCPCS inpatient 176 114.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 121.44 69 999999999 106.57 170.72 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50432763_1 CDM 0302 RC 87635 HCPCS inpatient 176 114.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 137.28 78 999999999 106.57 170.72 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50432763_1 CDM 0302 RC 87635 HCPCS inpatient 176 114.4 SIHO - ALL PLANS SIHO - ALL PLANS 158.4 90 999999999 106.57 170.72 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50432763_1 CDM 0302 RC 87635 HCPCS inpatient 176 114.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 106.57 60.55 999999999 106.57 170.72 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50432763_1 CDM 0302 RC 87635 HCPCS inpatient 176 114.4 UMR - ALL PLANS UMR - ALL PLANS 123.2 70 999999999 106.57 170.72 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50432763_1 CDM 0302 RC 87635 HCPCS inpatient 176 114.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 106.57 170.72 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50432763_1 CDM 0302 RC 87635 HCPCS inpatient 176 114.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 106.57 170.72 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50432763_1 CDM 0302 RC 87635 HCPCS inpatient 176 114.4 ANTHEM HMO ANTHEM HMO 999999999 106.57 170.72 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50432763_1 CDM 0302 RC 87635 HCPCS inpatient 176 114.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 106.57 170.72 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50432763_1 CDM 0302 RC 87635 HCPCS inpatient 176 114.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 106.57 170.72 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50432763_1 CDM 0302 RC 87635 HCPCS inpatient 176 114.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.98 67.6 999999999 106.57 170.72 percent of total billed charges ARMODAFINIL 150 MG TABLET 50432939_1 CDM 0250 RC 65862-0806-30 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ARMODAFINIL 150 MG TABLET 50432939_1 CDM 0250 RC 65862-0806-30 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ARMODAFINIL 150 MG TABLET 50432939_1 CDM 0250 RC 65862-0806-30 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ARMODAFINIL 150 MG TABLET 50432939_1 CDM 0250 RC 65862-0806-30 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ARMODAFINIL 150 MG TABLET 50432939_1 CDM 0250 RC 65862-0806-30 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ARMODAFINIL 150 MG TABLET 50432939_1 CDM 0250 RC 65862-0806-30 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ARMODAFINIL 150 MG TABLET 50432939_1 CDM 0250 RC 65862-0806-30 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ARMODAFINIL 150 MG TABLET 50432939_1 CDM 0250 RC 65862-0806-30 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ARMODAFINIL 150 MG TABLET 50432939_1 CDM 0250 RC 65862-0806-30 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ARMODAFINIL 150 MG TABLET 50432939_1 CDM 0250 RC 65862-0806-30 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ARMODAFINIL 150 MG TABLET 50432939_1 CDM 0250 RC 65862-0806-30 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ARMODAFINIL 150 MG TABLET 50432939_1 CDM 0250 RC 65862-0806-30 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ARMODAFINIL 150 MG TABLET 50432939_1 CDM 0250 RC 65862-0806-30 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ARMODAFINIL 150 MG TABLET 50432939_1 CDM 0250 RC 65862-0806-30 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50432943_1 CDM 0250 RC 00703-8580-23 NDC J1650 HCPCS inpatient 10 UN 51.48 33.46 SELF PAY DISCOUNT SELF PAY DISCOUNT 33.46 65 999999999 31.17 49.94 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50432943_1 CDM 0250 RC 00703-8580-23 NDC J1650 HCPCS inpatient 10 UN 51.48 33.46 AETNA AETNA 40.67 79 999999999 31.17 49.94 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50432943_1 CDM 0250 RC 00703-8580-23 NDC J1650 HCPCS inpatient 10 UN 51.48 33.46 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 49.94 97 999999999 31.17 49.94 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50432943_1 CDM 0250 RC 00703-8580-23 NDC J1650 HCPCS inpatient 10 UN 51.48 33.46 ENCORE - ALL PLANS ENCORE - ALL PLANS 35.52 69 999999999 31.17 49.94 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50432943_1 CDM 0250 RC 00703-8580-23 NDC J1650 HCPCS inpatient 10 UN 51.48 33.46 HUMANA - ALL PLANS HUMANA - ALL PLANS 40.15 78 999999999 31.17 49.94 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50432943_1 CDM 0250 RC 00703-8580-23 NDC J1650 HCPCS inpatient 10 UN 51.48 33.46 SIHO - ALL PLANS SIHO - ALL PLANS 46.33 90 999999999 31.17 49.94 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50432943_1 CDM 0250 RC 00703-8580-23 NDC J1650 HCPCS inpatient 10 UN 51.48 33.46 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 31.17 60.55 999999999 31.17 49.94 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50432943_1 CDM 0250 RC 00703-8580-23 NDC J1650 HCPCS inpatient 10 UN 51.48 33.46 UMR - ALL PLANS UMR - ALL PLANS 36.04 70 999999999 31.17 49.94 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50432943_1 CDM 0250 RC 00703-8580-23 NDC J1650 HCPCS inpatient 10 UN 51.48 33.46 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 31.17 49.94 "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50432943_1 CDM 0250 RC 00703-8580-23 NDC J1650 HCPCS inpatient 10 UN 51.48 33.46 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 31.17 49.94 "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50432943_1 CDM 0250 RC 00703-8580-23 NDC J1650 HCPCS inpatient 10 UN 51.48 33.46 ANTHEM HMO ANTHEM HMO 999999999 31.17 49.94 "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50432943_1 CDM 0250 RC 00703-8580-23 NDC J1650 HCPCS inpatient 10 UN 51.48 33.46 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 31.17 49.94 "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50432943_1 CDM 0250 RC 00703-8580-23 NDC J1650 HCPCS inpatient 10 UN 51.48 33.46 UHC - ALL PLANS UHC - ALL PLANS 999999999 31.17 49.94 "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50432943_1 CDM 0250 RC 00703-8580-23 NDC J1650 HCPCS inpatient 10 UN 51.48 33.46 CIGNA - ALL PLANS CIGNA - ALL PLANS 34.8 67.6 999999999 31.17 49.94 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50432944_1 CDM 0250 RC 25021-0608-51 NDC J2704 HCPCS inpatient 100 UN 180.06 117.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.04 65 999999999 109.03 174.66 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50432944_1 CDM 0250 RC 25021-0608-51 NDC J2704 HCPCS inpatient 100 UN 180.06 117.04 AETNA AETNA 142.25 79 999999999 109.03 174.66 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50432944_1 CDM 0250 RC 25021-0608-51 NDC J2704 HCPCS inpatient 100 UN 180.06 117.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.66 97 999999999 109.03 174.66 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50432944_1 CDM 0250 RC 25021-0608-51 NDC J2704 HCPCS inpatient 100 UN 180.06 117.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.24 69 999999999 109.03 174.66 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50432944_1 CDM 0250 RC 25021-0608-51 NDC J2704 HCPCS inpatient 100 UN 180.06 117.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.45 78 999999999 109.03 174.66 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50432944_1 CDM 0250 RC 25021-0608-51 NDC J2704 HCPCS inpatient 100 UN 180.06 117.04 SIHO - ALL PLANS SIHO - ALL PLANS 162.05 90 999999999 109.03 174.66 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50432944_1 CDM 0250 RC 25021-0608-51 NDC J2704 HCPCS inpatient 100 UN 180.06 117.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.03 60.55 999999999 109.03 174.66 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50432944_1 CDM 0250 RC 25021-0608-51 NDC J2704 HCPCS inpatient 100 UN 180.06 117.04 UMR - ALL PLANS UMR - ALL PLANS 126.04 70 999999999 109.03 174.66 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50432944_1 CDM 0250 RC 25021-0608-51 NDC J2704 HCPCS inpatient 100 UN 180.06 117.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.03 174.66 "INJECTION, PROPOFOL, 10 MG" 50432944_1 CDM 0250 RC 25021-0608-51 NDC J2704 HCPCS inpatient 100 UN 180.06 117.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.03 174.66 "INJECTION, PROPOFOL, 10 MG" 50432944_1 CDM 0250 RC 25021-0608-51 NDC J2704 HCPCS inpatient 100 UN 180.06 117.04 ANTHEM HMO ANTHEM HMO 999999999 109.03 174.66 "INJECTION, PROPOFOL, 10 MG" 50432944_1 CDM 0250 RC 25021-0608-51 NDC J2704 HCPCS inpatient 100 UN 180.06 117.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.03 174.66 "INJECTION, PROPOFOL, 10 MG" 50432944_1 CDM 0250 RC 25021-0608-51 NDC J2704 HCPCS inpatient 100 UN 180.06 117.04 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.03 174.66 "INJECTION, PROPOFOL, 10 MG" 50432944_1 CDM 0250 RC 25021-0608-51 NDC J2704 HCPCS inpatient 100 UN 180.06 117.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.72 67.6 999999999 109.03 174.66 percent of total billed charges POTASSIUM CL ER 10 MEQ CAPSULE 50432977_1 CDM 0250 RC 00904-6930-61 NDC inpatient 1 UN 3.14 2.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.04 65 999999999 1.9 3.05 percent of total billed charges POTASSIUM CL ER 10 MEQ CAPSULE 50432977_1 CDM 0250 RC 00904-6930-61 NDC inpatient 1 UN 3.14 2.04 AETNA AETNA 2.48 79 999999999 1.9 3.05 percent of total billed charges POTASSIUM CL ER 10 MEQ CAPSULE 50432977_1 CDM 0250 RC 00904-6930-61 NDC inpatient 1 UN 3.14 2.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.05 97 999999999 1.9 3.05 percent of total billed charges POTASSIUM CL ER 10 MEQ CAPSULE 50432977_1 CDM 0250 RC 00904-6930-61 NDC inpatient 1 UN 3.14 2.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.17 69 999999999 1.9 3.05 percent of total billed charges POTASSIUM CL ER 10 MEQ CAPSULE 50432977_1 CDM 0250 RC 00904-6930-61 NDC inpatient 1 UN 3.14 2.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.45 78 999999999 1.9 3.05 percent of total billed charges POTASSIUM CL ER 10 MEQ CAPSULE 50432977_1 CDM 0250 RC 00904-6930-61 NDC inpatient 1 UN 3.14 2.04 SIHO - ALL PLANS SIHO - ALL PLANS 2.83 90 999999999 1.9 3.05 percent of total billed charges POTASSIUM CL ER 10 MEQ CAPSULE 50432977_1 CDM 0250 RC 00904-6930-61 NDC inpatient 1 UN 3.14 2.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.9 60.55 999999999 1.9 3.05 percent of total billed charges POTASSIUM CL ER 10 MEQ CAPSULE 50432977_1 CDM 0250 RC 00904-6930-61 NDC inpatient 1 UN 3.14 2.04 UMR - ALL PLANS UMR - ALL PLANS 2.2 70 999999999 1.9 3.05 percent of total billed charges POTASSIUM CL ER 10 MEQ CAPSULE 50432977_1 CDM 0250 RC 00904-6930-61 NDC inpatient 1 UN 3.14 2.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.9 3.05 POTASSIUM CL ER 10 MEQ CAPSULE 50432977_1 CDM 0250 RC 00904-6930-61 NDC inpatient 1 UN 3.14 2.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.9 3.05 POTASSIUM CL ER 10 MEQ CAPSULE 50432977_1 CDM 0250 RC 00904-6930-61 NDC inpatient 1 UN 3.14 2.04 ANTHEM HMO ANTHEM HMO 999999999 1.9 3.05 POTASSIUM CL ER 10 MEQ CAPSULE 50432977_1 CDM 0250 RC 00904-6930-61 NDC inpatient 1 UN 3.14 2.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.9 3.05 POTASSIUM CL ER 10 MEQ CAPSULE 50432977_1 CDM 0250 RC 00904-6930-61 NDC inpatient 1 UN 3.14 2.04 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.9 3.05 POTASSIUM CL ER 10 MEQ CAPSULE 50432977_1 CDM 0250 RC 00904-6930-61 NDC inpatient 1 UN 3.14 2.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.12 67.6 999999999 1.9 3.05 percent of total billed charges Barbiturates levels 50434041_1 CDM 0301 RC 80345 HCPCS inpatient 187 121.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 121.55 65 999999999 113.23 181.39 percent of total billed charges Barbiturates levels 50434041_1 CDM 0301 RC 80345 HCPCS inpatient 187 121.55 AETNA AETNA 147.73 79 999999999 113.23 181.39 percent of total billed charges Barbiturates levels 50434041_1 CDM 0301 RC 80345 HCPCS inpatient 187 121.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 181.39 97 999999999 113.23 181.39 percent of total billed charges Barbiturates levels 50434041_1 CDM 0301 RC 80345 HCPCS inpatient 187 121.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.03 69 999999999 113.23 181.39 percent of total billed charges Barbiturates levels 50434041_1 CDM 0301 RC 80345 HCPCS inpatient 187 121.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 145.86 78 999999999 113.23 181.39 percent of total billed charges Barbiturates levels 50434041_1 CDM 0301 RC 80345 HCPCS inpatient 187 121.55 SIHO - ALL PLANS SIHO - ALL PLANS 168.3 90 999999999 113.23 181.39 percent of total billed charges Barbiturates levels 50434041_1 CDM 0301 RC 80345 HCPCS inpatient 187 121.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.23 60.55 999999999 113.23 181.39 percent of total billed charges Barbiturates levels 50434041_1 CDM 0301 RC 80345 HCPCS inpatient 187 121.55 UMR - ALL PLANS UMR - ALL PLANS 130.9 70 999999999 113.23 181.39 percent of total billed charges Barbiturates levels 50434041_1 CDM 0301 RC 80345 HCPCS inpatient 187 121.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.23 181.39 Barbiturates levels 50434041_1 CDM 0301 RC 80345 HCPCS inpatient 187 121.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.23 181.39 Barbiturates levels 50434041_1 CDM 0301 RC 80345 HCPCS inpatient 187 121.55 ANTHEM HMO ANTHEM HMO 999999999 113.23 181.39 Barbiturates levels 50434041_1 CDM 0301 RC 80345 HCPCS inpatient 187 121.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.23 181.39 Barbiturates levels 50434041_1 CDM 0301 RC 80345 HCPCS inpatient 187 121.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.23 181.39 Barbiturates levels 50434041_1 CDM 0301 RC 80345 HCPCS inpatient 187 121.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 126.41 67.6 999999999 113.23 181.39 percent of total billed charges Buprenorphine level 50434042_1 CDM 0301 RC 80348 HCPCS inpatient 303 196.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 196.95 65 999999999 183.47 293.91 percent of total billed charges Buprenorphine level 50434042_1 CDM 0301 RC 80348 HCPCS inpatient 303 196.95 AETNA AETNA 239.37 79 999999999 183.47 293.91 percent of total billed charges Buprenorphine level 50434042_1 CDM 0301 RC 80348 HCPCS inpatient 303 196.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 293.91 97 999999999 183.47 293.91 percent of total billed charges Buprenorphine level 50434042_1 CDM 0301 RC 80348 HCPCS inpatient 303 196.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 209.07 69 999999999 183.47 293.91 percent of total billed charges Buprenorphine level 50434042_1 CDM 0301 RC 80348 HCPCS inpatient 303 196.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 236.34 78 999999999 183.47 293.91 percent of total billed charges Buprenorphine level 50434042_1 CDM 0301 RC 80348 HCPCS inpatient 303 196.95 SIHO - ALL PLANS SIHO - ALL PLANS 272.7 90 999999999 183.47 293.91 percent of total billed charges Buprenorphine level 50434042_1 CDM 0301 RC 80348 HCPCS inpatient 303 196.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 183.47 60.55 999999999 183.47 293.91 percent of total billed charges Buprenorphine level 50434042_1 CDM 0301 RC 80348 HCPCS inpatient 303 196.95 UMR - ALL PLANS UMR - ALL PLANS 212.1 70 999999999 183.47 293.91 percent of total billed charges Buprenorphine level 50434042_1 CDM 0301 RC 80348 HCPCS inpatient 303 196.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 183.47 293.91 Buprenorphine level 50434042_1 CDM 0301 RC 80348 HCPCS inpatient 303 196.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 183.47 293.91 Buprenorphine level 50434042_1 CDM 0301 RC 80348 HCPCS inpatient 303 196.95 ANTHEM HMO ANTHEM HMO 999999999 183.47 293.91 Buprenorphine level 50434042_1 CDM 0301 RC 80348 HCPCS inpatient 303 196.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 183.47 293.91 Buprenorphine level 50434042_1 CDM 0301 RC 80348 HCPCS inpatient 303 196.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 183.47 293.91 Buprenorphine level 50434042_1 CDM 0301 RC 80348 HCPCS inpatient 303 196.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 204.83 67.6 999999999 183.47 293.91 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50434043_1 CDM 0301 RC 82570 HCPCS inpatient 194 126.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 126.1 65 999999999 117.47 188.18 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50434043_1 CDM 0301 RC 82570 HCPCS inpatient 194 126.1 AETNA AETNA 153.26 79 999999999 117.47 188.18 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50434043_1 CDM 0301 RC 82570 HCPCS inpatient 194 126.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 188.18 97 999999999 117.47 188.18 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50434043_1 CDM 0301 RC 82570 HCPCS inpatient 194 126.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.86 69 999999999 117.47 188.18 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50434043_1 CDM 0301 RC 82570 HCPCS inpatient 194 126.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 151.32 78 999999999 117.47 188.18 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50434043_1 CDM 0301 RC 82570 HCPCS inpatient 194 126.1 SIHO - ALL PLANS SIHO - ALL PLANS 174.6 90 999999999 117.47 188.18 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50434043_1 CDM 0301 RC 82570 HCPCS inpatient 194 126.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 117.47 60.55 999999999 117.47 188.18 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50434043_1 CDM 0301 RC 82570 HCPCS inpatient 194 126.1 UMR - ALL PLANS UMR - ALL PLANS 135.8 70 999999999 117.47 188.18 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50434043_1 CDM 0301 RC 82570 HCPCS inpatient 194 126.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 117.47 188.18 Creatinine level to test for kidney function or muscle injury 50434043_1 CDM 0301 RC 82570 HCPCS inpatient 194 126.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 117.47 188.18 Creatinine level to test for kidney function or muscle injury 50434043_1 CDM 0301 RC 82570 HCPCS inpatient 194 126.1 ANTHEM HMO ANTHEM HMO 999999999 117.47 188.18 Creatinine level to test for kidney function or muscle injury 50434043_1 CDM 0301 RC 82570 HCPCS inpatient 194 126.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 117.47 188.18 Creatinine level to test for kidney function or muscle injury 50434043_1 CDM 0301 RC 82570 HCPCS inpatient 194 126.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 117.47 188.18 Creatinine level to test for kidney function or muscle injury 50434043_1 CDM 0301 RC 82570 HCPCS inpatient 194 126.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 131.14 67.6 999999999 117.47 188.18 percent of total billed charges Cocaine level 50434044_1 CDM 0301 RC 80353 HCPCS inpatient 413 268.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 268.45 65 999999999 250.07 400.61 percent of total billed charges Cocaine level 50434044_1 CDM 0301 RC 80353 HCPCS inpatient 413 268.45 AETNA AETNA 326.27 79 999999999 250.07 400.61 percent of total billed charges Cocaine level 50434044_1 CDM 0301 RC 80353 HCPCS inpatient 413 268.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 400.61 97 999999999 250.07 400.61 percent of total billed charges Cocaine level 50434044_1 CDM 0301 RC 80353 HCPCS inpatient 413 268.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 284.97 69 999999999 250.07 400.61 percent of total billed charges Cocaine level 50434044_1 CDM 0301 RC 80353 HCPCS inpatient 413 268.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 322.14 78 999999999 250.07 400.61 percent of total billed charges Cocaine level 50434044_1 CDM 0301 RC 80353 HCPCS inpatient 413 268.45 SIHO - ALL PLANS SIHO - ALL PLANS 371.7 90 999999999 250.07 400.61 percent of total billed charges Cocaine level 50434044_1 CDM 0301 RC 80353 HCPCS inpatient 413 268.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 250.07 60.55 999999999 250.07 400.61 percent of total billed charges Cocaine level 50434044_1 CDM 0301 RC 80353 HCPCS inpatient 413 268.45 UMR - ALL PLANS UMR - ALL PLANS 289.1 70 999999999 250.07 400.61 percent of total billed charges Cocaine level 50434044_1 CDM 0301 RC 80353 HCPCS inpatient 413 268.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 250.07 400.61 Cocaine level 50434044_1 CDM 0301 RC 80353 HCPCS inpatient 413 268.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 250.07 400.61 Cocaine level 50434044_1 CDM 0301 RC 80353 HCPCS inpatient 413 268.45 ANTHEM HMO ANTHEM HMO 999999999 250.07 400.61 Cocaine level 50434044_1 CDM 0301 RC 80353 HCPCS inpatient 413 268.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 250.07 400.61 Cocaine level 50434044_1 CDM 0301 RC 80353 HCPCS inpatient 413 268.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 250.07 400.61 Cocaine level 50434044_1 CDM 0301 RC 80353 HCPCS inpatient 413 268.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 279.19 67.6 999999999 250.07 400.61 percent of total billed charges "Alcohols levels, 1 or 2" 50434045_1 CDM 0301 RC 80321 HCPCS inpatient 199 129.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 129.35 65 999999999 120.49 193.03 percent of total billed charges "Alcohols levels, 1 or 2" 50434045_1 CDM 0301 RC 80321 HCPCS inpatient 199 129.35 AETNA AETNA 157.21 79 999999999 120.49 193.03 percent of total billed charges "Alcohols levels, 1 or 2" 50434045_1 CDM 0301 RC 80321 HCPCS inpatient 199 129.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 193.03 97 999999999 120.49 193.03 percent of total billed charges "Alcohols levels, 1 or 2" 50434045_1 CDM 0301 RC 80321 HCPCS inpatient 199 129.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 137.31 69 999999999 120.49 193.03 percent of total billed charges "Alcohols levels, 1 or 2" 50434045_1 CDM 0301 RC 80321 HCPCS inpatient 199 129.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 155.22 78 999999999 120.49 193.03 percent of total billed charges "Alcohols levels, 1 or 2" 50434045_1 CDM 0301 RC 80321 HCPCS inpatient 199 129.35 SIHO - ALL PLANS SIHO - ALL PLANS 179.1 90 999999999 120.49 193.03 percent of total billed charges "Alcohols levels, 1 or 2" 50434045_1 CDM 0301 RC 80321 HCPCS inpatient 199 129.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 120.49 60.55 999999999 120.49 193.03 percent of total billed charges "Alcohols levels, 1 or 2" 50434045_1 CDM 0301 RC 80321 HCPCS inpatient 199 129.35 UMR - ALL PLANS UMR - ALL PLANS 139.3 70 999999999 120.49 193.03 percent of total billed charges "Alcohols levels, 1 or 2" 50434045_1 CDM 0301 RC 80321 HCPCS inpatient 199 129.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 120.49 193.03 "Alcohols levels, 1 or 2" 50434045_1 CDM 0301 RC 80321 HCPCS inpatient 199 129.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 120.49 193.03 "Alcohols levels, 1 or 2" 50434045_1 CDM 0301 RC 80321 HCPCS inpatient 199 129.35 ANTHEM HMO ANTHEM HMO 999999999 120.49 193.03 "Alcohols levels, 1 or 2" 50434045_1 CDM 0301 RC 80321 HCPCS inpatient 199 129.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 120.49 193.03 "Alcohols levels, 1 or 2" 50434045_1 CDM 0301 RC 80321 HCPCS inpatient 199 129.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 120.49 193.03 "Alcohols levels, 1 or 2" 50434045_1 CDM 0301 RC 80321 HCPCS inpatient 199 129.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 134.52 67.6 999999999 120.49 193.03 percent of total billed charges Oxycodone levels 50434046_1 CDM 0301 RC 80365 HCPCS inpatient 127 82.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 82.55 65 999999999 76.9 123.19 percent of total billed charges Oxycodone levels 50434046_1 CDM 0301 RC 80365 HCPCS inpatient 127 82.55 AETNA AETNA 100.33 79 999999999 76.9 123.19 percent of total billed charges Oxycodone levels 50434046_1 CDM 0301 RC 80365 HCPCS inpatient 127 82.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 123.19 97 999999999 76.9 123.19 percent of total billed charges Oxycodone levels 50434046_1 CDM 0301 RC 80365 HCPCS inpatient 127 82.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 87.63 69 999999999 76.9 123.19 percent of total billed charges Oxycodone levels 50434046_1 CDM 0301 RC 80365 HCPCS inpatient 127 82.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 99.06 78 999999999 76.9 123.19 percent of total billed charges Oxycodone levels 50434046_1 CDM 0301 RC 80365 HCPCS inpatient 127 82.55 SIHO - ALL PLANS SIHO - ALL PLANS 114.3 90 999999999 76.9 123.19 percent of total billed charges Oxycodone levels 50434046_1 CDM 0301 RC 80365 HCPCS inpatient 127 82.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.9 60.55 999999999 76.9 123.19 percent of total billed charges Oxycodone levels 50434046_1 CDM 0301 RC 80365 HCPCS inpatient 127 82.55 UMR - ALL PLANS UMR - ALL PLANS 88.9 70 999999999 76.9 123.19 percent of total billed charges Oxycodone levels 50434046_1 CDM 0301 RC 80365 HCPCS inpatient 127 82.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.9 123.19 Oxycodone levels 50434046_1 CDM 0301 RC 80365 HCPCS inpatient 127 82.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.9 123.19 Oxycodone levels 50434046_1 CDM 0301 RC 80365 HCPCS inpatient 127 82.55 ANTHEM HMO ANTHEM HMO 999999999 76.9 123.19 Oxycodone levels 50434046_1 CDM 0301 RC 80365 HCPCS inpatient 127 82.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.9 123.19 Oxycodone levels 50434046_1 CDM 0301 RC 80365 HCPCS inpatient 127 82.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.9 123.19 Oxycodone levels 50434046_1 CDM 0301 RC 80365 HCPCS inpatient 127 82.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.85 67.6 999999999 76.9 123.19 percent of total billed charges Urine vanillylmandelic acid 50434047_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 235.3 65 999999999 219.19 351.14 percent of total billed charges Urine vanillylmandelic acid 50434047_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 AETNA AETNA 285.98 79 999999999 219.19 351.14 percent of total billed charges Urine vanillylmandelic acid 50434047_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 351.14 97 999999999 219.19 351.14 percent of total billed charges Urine vanillylmandelic acid 50434047_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 249.78 69 999999999 219.19 351.14 percent of total billed charges Urine vanillylmandelic acid 50434047_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 282.36 78 999999999 219.19 351.14 percent of total billed charges Urine vanillylmandelic acid 50434047_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 SIHO - ALL PLANS SIHO - ALL PLANS 325.8 90 999999999 219.19 351.14 percent of total billed charges Urine vanillylmandelic acid 50434047_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 219.19 60.55 999999999 219.19 351.14 percent of total billed charges Urine vanillylmandelic acid 50434047_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 UMR - ALL PLANS UMR - ALL PLANS 253.4 70 999999999 219.19 351.14 percent of total billed charges Urine vanillylmandelic acid 50434047_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 219.19 351.14 Urine vanillylmandelic acid 50434047_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 219.19 351.14 Urine vanillylmandelic acid 50434047_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 ANTHEM HMO ANTHEM HMO 999999999 219.19 351.14 Urine vanillylmandelic acid 50434047_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 219.19 351.14 Urine vanillylmandelic acid 50434047_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 219.19 351.14 Urine vanillylmandelic acid 50434047_1 CDM 0301 RC 84585 HCPCS inpatient 362 235.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 244.71 67.6 999999999 219.19 351.14 percent of total billed charges DRUG SCREEN CLASS LIST A 50434048_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges DRUG SCREEN CLASS LIST A 50434048_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges DRUG SCREEN CLASS LIST A 50434048_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges DRUG SCREEN CLASS LIST A 50434048_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges DRUG SCREEN CLASS LIST A 50434048_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges DRUG SCREEN CLASS LIST A 50434048_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges DRUG SCREEN CLASS LIST A 50434048_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges DRUG SCREEN CLASS LIST A 50434048_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges DRUG SCREEN CLASS LIST A 50434048_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 DRUG SCREEN CLASS LIST A 50434048_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 DRUG SCREEN CLASS LIST A 50434048_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 DRUG SCREEN CLASS LIST A 50434048_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 DRUG SCREEN CLASS LIST A 50434048_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 DRUG SCREEN CLASS LIST A 50434048_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges DRUG SCREEN CLASS LIST A 50434049_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges DRUG SCREEN CLASS LIST A 50434049_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges DRUG SCREEN CLASS LIST A 50434049_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges DRUG SCREEN CLASS LIST A 50434049_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges DRUG SCREEN CLASS LIST A 50434049_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges DRUG SCREEN CLASS LIST A 50434049_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges DRUG SCREEN CLASS LIST A 50434049_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges DRUG SCREEN CLASS LIST A 50434049_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges DRUG SCREEN CLASS LIST A 50434049_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 DRUG SCREEN CLASS LIST A 50434049_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 DRUG SCREEN CLASS LIST A 50434049_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 DRUG SCREEN CLASS LIST A 50434049_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 DRUG SCREEN CLASS LIST A 50434049_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 DRUG SCREEN CLASS LIST A 50434049_1 CDM 0301 RC 80301 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Dihydroxyvitamin D, 1, 25 level" 50434050_1 CDM 0301 RC 82652 HCPCS inpatient 327 212.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 212.55 65 999999999 198 317.19 percent of total billed charges "Dihydroxyvitamin D, 1, 25 level" 50434050_1 CDM 0301 RC 82652 HCPCS inpatient 327 212.55 AETNA AETNA 258.33 79 999999999 198 317.19 percent of total billed charges "Dihydroxyvitamin D, 1, 25 level" 50434050_1 CDM 0301 RC 82652 HCPCS inpatient 327 212.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 317.19 97 999999999 198 317.19 percent of total billed charges "Dihydroxyvitamin D, 1, 25 level" 50434050_1 CDM 0301 RC 82652 HCPCS inpatient 327 212.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 225.63 69 999999999 198 317.19 percent of total billed charges "Dihydroxyvitamin D, 1, 25 level" 50434050_1 CDM 0301 RC 82652 HCPCS inpatient 327 212.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.06 78 999999999 198 317.19 percent of total billed charges "Dihydroxyvitamin D, 1, 25 level" 50434050_1 CDM 0301 RC 82652 HCPCS inpatient 327 212.55 SIHO - ALL PLANS SIHO - ALL PLANS 294.3 90 999999999 198 317.19 percent of total billed charges "Dihydroxyvitamin D, 1, 25 level" 50434050_1 CDM 0301 RC 82652 HCPCS inpatient 327 212.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198 60.55 999999999 198 317.19 percent of total billed charges "Dihydroxyvitamin D, 1, 25 level" 50434050_1 CDM 0301 RC 82652 HCPCS inpatient 327 212.55 UMR - ALL PLANS UMR - ALL PLANS 228.9 70 999999999 198 317.19 percent of total billed charges "Dihydroxyvitamin D, 1, 25 level" 50434050_1 CDM 0301 RC 82652 HCPCS inpatient 327 212.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198 317.19 "Dihydroxyvitamin D, 1, 25 level" 50434050_1 CDM 0301 RC 82652 HCPCS inpatient 327 212.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198 317.19 "Dihydroxyvitamin D, 1, 25 level" 50434050_1 CDM 0301 RC 82652 HCPCS inpatient 327 212.55 ANTHEM HMO ANTHEM HMO 999999999 198 317.19 "Dihydroxyvitamin D, 1, 25 level" 50434050_1 CDM 0301 RC 82652 HCPCS inpatient 327 212.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198 317.19 "Dihydroxyvitamin D, 1, 25 level" 50434050_1 CDM 0301 RC 82652 HCPCS inpatient 327 212.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 198 317.19 "Dihydroxyvitamin D, 1, 25 level" 50434050_1 CDM 0301 RC 82652 HCPCS inpatient 327 212.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.05 67.6 999999999 198 317.19 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50434051_1 CDM 0301 RC 83498 HCPCS inpatient 251 163.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.15 65 999999999 151.98 243.47 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50434051_1 CDM 0301 RC 83498 HCPCS inpatient 251 163.15 AETNA AETNA 198.29 79 999999999 151.98 243.47 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50434051_1 CDM 0301 RC 83498 HCPCS inpatient 251 163.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 243.47 97 999999999 151.98 243.47 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50434051_1 CDM 0301 RC 83498 HCPCS inpatient 251 163.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.19 69 999999999 151.98 243.47 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50434051_1 CDM 0301 RC 83498 HCPCS inpatient 251 163.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 195.78 78 999999999 151.98 243.47 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50434051_1 CDM 0301 RC 83498 HCPCS inpatient 251 163.15 SIHO - ALL PLANS SIHO - ALL PLANS 225.9 90 999999999 151.98 243.47 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50434051_1 CDM 0301 RC 83498 HCPCS inpatient 251 163.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.98 60.55 999999999 151.98 243.47 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50434051_1 CDM 0301 RC 83498 HCPCS inpatient 251 163.15 UMR - ALL PLANS UMR - ALL PLANS 175.7 70 999999999 151.98 243.47 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50434051_1 CDM 0301 RC 83498 HCPCS inpatient 251 163.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.98 243.47 "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50434051_1 CDM 0301 RC 83498 HCPCS inpatient 251 163.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.98 243.47 "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50434051_1 CDM 0301 RC 83498 HCPCS inpatient 251 163.15 ANTHEM HMO ANTHEM HMO 999999999 151.98 243.47 "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50434051_1 CDM 0301 RC 83498 HCPCS inpatient 251 163.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.98 243.47 "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50434051_1 CDM 0301 RC 83498 HCPCS inpatient 251 163.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.98 243.47 "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50434051_1 CDM 0301 RC 83498 HCPCS inpatient 251 163.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 169.68 67.6 999999999 151.98 243.47 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 50434052_1 CDM 0301 RC 83497 HCPCS inpatient 384 249.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 249.6 65 999999999 232.51 372.48 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 50434052_1 CDM 0301 RC 83497 HCPCS inpatient 384 249.6 AETNA AETNA 303.36 79 999999999 232.51 372.48 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 50434052_1 CDM 0301 RC 83497 HCPCS inpatient 384 249.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 372.48 97 999999999 232.51 372.48 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 50434052_1 CDM 0301 RC 83497 HCPCS inpatient 384 249.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 264.96 69 999999999 232.51 372.48 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 50434052_1 CDM 0301 RC 83497 HCPCS inpatient 384 249.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 299.52 78 999999999 232.51 372.48 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 50434052_1 CDM 0301 RC 83497 HCPCS inpatient 384 249.6 SIHO - ALL PLANS SIHO - ALL PLANS 345.6 90 999999999 232.51 372.48 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 50434052_1 CDM 0301 RC 83497 HCPCS inpatient 384 249.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 232.51 60.55 999999999 232.51 372.48 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 50434052_1 CDM 0301 RC 83497 HCPCS inpatient 384 249.6 UMR - ALL PLANS UMR - ALL PLANS 268.8 70 999999999 232.51 372.48 percent of total billed charges Hydroxyindolacetic acid (product of metabolism) level 50434052_1 CDM 0301 RC 83497 HCPCS inpatient 384 249.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 232.51 372.48 Hydroxyindolacetic acid (product of metabolism) level 50434052_1 CDM 0301 RC 83497 HCPCS inpatient 384 249.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 232.51 372.48 Hydroxyindolacetic acid (product of metabolism) level 50434052_1 CDM 0301 RC 83497 HCPCS inpatient 384 249.6 ANTHEM HMO ANTHEM HMO 999999999 232.51 372.48 Hydroxyindolacetic acid (product of metabolism) level 50434052_1 CDM 0301 RC 83497 HCPCS inpatient 384 249.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 232.51 372.48 Hydroxyindolacetic acid (product of metabolism) level 50434052_1 CDM 0301 RC 83497 HCPCS inpatient 384 249.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 232.51 372.48 Hydroxyindolacetic acid (product of metabolism) level 50434052_1 CDM 0301 RC 83497 HCPCS inpatient 384 249.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 259.58 67.6 999999999 232.51 372.48 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 50434053_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.7 65 999999999 119.89 192.06 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 50434053_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 AETNA AETNA 156.42 79 999999999 119.89 192.06 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 50434053_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 192.06 97 999999999 119.89 192.06 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 50434053_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 136.62 69 999999999 119.89 192.06 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 50434053_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 154.44 78 999999999 119.89 192.06 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 50434053_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 SIHO - ALL PLANS SIHO - ALL PLANS 178.2 90 999999999 119.89 192.06 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 50434053_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.89 60.55 999999999 119.89 192.06 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 50434053_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 UMR - ALL PLANS UMR - ALL PLANS 138.6 70 999999999 119.89 192.06 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 50434053_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.89 192.06 Angiotensin l - converting enzyme (ACE) level 50434053_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.89 192.06 Angiotensin l - converting enzyme (ACE) level 50434053_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 ANTHEM HMO ANTHEM HMO 999999999 119.89 192.06 Angiotensin l - converting enzyme (ACE) level 50434053_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.89 192.06 Angiotensin l - converting enzyme (ACE) level 50434053_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.89 192.06 Angiotensin l - converting enzyme (ACE) level 50434053_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.85 67.6 999999999 119.89 192.06 percent of total billed charges Adrenocorticotropic hormone (ACTH) level 50434054_1 CDM 0301 RC 82024 HCPCS inpatient 293 190.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 190.45 65 999999999 177.41 284.21 percent of total billed charges Adrenocorticotropic hormone (ACTH) level 50434054_1 CDM 0301 RC 82024 HCPCS inpatient 293 190.45 AETNA AETNA 231.47 79 999999999 177.41 284.21 percent of total billed charges Adrenocorticotropic hormone (ACTH) level 50434054_1 CDM 0301 RC 82024 HCPCS inpatient 293 190.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 284.21 97 999999999 177.41 284.21 percent of total billed charges Adrenocorticotropic hormone (ACTH) level 50434054_1 CDM 0301 RC 82024 HCPCS inpatient 293 190.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 202.17 69 999999999 177.41 284.21 percent of total billed charges Adrenocorticotropic hormone (ACTH) level 50434054_1 CDM 0301 RC 82024 HCPCS inpatient 293 190.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 228.54 78 999999999 177.41 284.21 percent of total billed charges Adrenocorticotropic hormone (ACTH) level 50434054_1 CDM 0301 RC 82024 HCPCS inpatient 293 190.45 SIHO - ALL PLANS SIHO - ALL PLANS 263.7 90 999999999 177.41 284.21 percent of total billed charges Adrenocorticotropic hormone (ACTH) level 50434054_1 CDM 0301 RC 82024 HCPCS inpatient 293 190.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 177.41 60.55 999999999 177.41 284.21 percent of total billed charges Adrenocorticotropic hormone (ACTH) level 50434054_1 CDM 0301 RC 82024 HCPCS inpatient 293 190.45 UMR - ALL PLANS UMR - ALL PLANS 205.1 70 999999999 177.41 284.21 percent of total billed charges Adrenocorticotropic hormone (ACTH) level 50434054_1 CDM 0301 RC 82024 HCPCS inpatient 293 190.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 177.41 284.21 Adrenocorticotropic hormone (ACTH) level 50434054_1 CDM 0301 RC 82024 HCPCS inpatient 293 190.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 177.41 284.21 Adrenocorticotropic hormone (ACTH) level 50434054_1 CDM 0301 RC 82024 HCPCS inpatient 293 190.45 ANTHEM HMO ANTHEM HMO 999999999 177.41 284.21 Adrenocorticotropic hormone (ACTH) level 50434054_1 CDM 0301 RC 82024 HCPCS inpatient 293 190.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 177.41 284.21 Adrenocorticotropic hormone (ACTH) level 50434054_1 CDM 0301 RC 82024 HCPCS inpatient 293 190.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 177.41 284.21 Adrenocorticotropic hormone (ACTH) level 50434054_1 CDM 0301 RC 82024 HCPCS inpatient 293 190.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 198.07 67.6 999999999 177.41 284.21 percent of total billed charges Fetal hemoglobin analysis 50434055_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.85 65 999999999 29.67 47.53 percent of total billed charges Fetal hemoglobin analysis 50434055_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 AETNA AETNA 38.71 79 999999999 29.67 47.53 percent of total billed charges Fetal hemoglobin analysis 50434055_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 47.53 97 999999999 29.67 47.53 percent of total billed charges Fetal hemoglobin analysis 50434055_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.81 69 999999999 29.67 47.53 percent of total billed charges Fetal hemoglobin analysis 50434055_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 38.22 78 999999999 29.67 47.53 percent of total billed charges Fetal hemoglobin analysis 50434055_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 SIHO - ALL PLANS SIHO - ALL PLANS 44.1 90 999999999 29.67 47.53 percent of total billed charges Fetal hemoglobin analysis 50434055_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.67 60.55 999999999 29.67 47.53 percent of total billed charges Fetal hemoglobin analysis 50434055_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 UMR - ALL PLANS UMR - ALL PLANS 34.3 70 999999999 29.67 47.53 percent of total billed charges Fetal hemoglobin analysis 50434055_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.67 47.53 Fetal hemoglobin analysis 50434055_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.67 47.53 Fetal hemoglobin analysis 50434055_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 ANTHEM HMO ANTHEM HMO 999999999 29.67 47.53 Fetal hemoglobin analysis 50434055_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.67 47.53 Fetal hemoglobin analysis 50434055_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.67 47.53 Fetal hemoglobin analysis 50434055_1 CDM 0301 RC 83033 HCPCS inpatient 49 31.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.12 67.6 999999999 29.67 47.53 percent of total billed charges Culture for acid-fast bacilli 50434056_1 CDM 0306 RC 87116 HCPCS inpatient 204 132.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.6 65 999999999 123.52 197.88 percent of total billed charges Culture for acid-fast bacilli 50434056_1 CDM 0306 RC 87116 HCPCS inpatient 204 132.6 AETNA AETNA 161.16 79 999999999 123.52 197.88 percent of total billed charges Culture for acid-fast bacilli 50434056_1 CDM 0306 RC 87116 HCPCS inpatient 204 132.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.88 97 999999999 123.52 197.88 percent of total billed charges Culture for acid-fast bacilli 50434056_1 CDM 0306 RC 87116 HCPCS inpatient 204 132.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.76 69 999999999 123.52 197.88 percent of total billed charges Culture for acid-fast bacilli 50434056_1 CDM 0306 RC 87116 HCPCS inpatient 204 132.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.12 78 999999999 123.52 197.88 percent of total billed charges Culture for acid-fast bacilli 50434056_1 CDM 0306 RC 87116 HCPCS inpatient 204 132.6 SIHO - ALL PLANS SIHO - ALL PLANS 183.6 90 999999999 123.52 197.88 percent of total billed charges Culture for acid-fast bacilli 50434056_1 CDM 0306 RC 87116 HCPCS inpatient 204 132.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.52 60.55 999999999 123.52 197.88 percent of total billed charges Culture for acid-fast bacilli 50434056_1 CDM 0306 RC 87116 HCPCS inpatient 204 132.6 UMR - ALL PLANS UMR - ALL PLANS 142.8 70 999999999 123.52 197.88 percent of total billed charges Culture for acid-fast bacilli 50434056_1 CDM 0306 RC 87116 HCPCS inpatient 204 132.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.52 197.88 Culture for acid-fast bacilli 50434056_1 CDM 0306 RC 87116 HCPCS inpatient 204 132.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.52 197.88 Culture for acid-fast bacilli 50434056_1 CDM 0306 RC 87116 HCPCS inpatient 204 132.6 ANTHEM HMO ANTHEM HMO 999999999 123.52 197.88 Culture for acid-fast bacilli 50434056_1 CDM 0306 RC 87116 HCPCS inpatient 204 132.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.52 197.88 Culture for acid-fast bacilli 50434056_1 CDM 0306 RC 87116 HCPCS inpatient 204 132.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.52 197.88 Culture for acid-fast bacilli 50434056_1 CDM 0306 RC 87116 HCPCS inpatient 204 132.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.9 67.6 999999999 123.52 197.88 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50434057_1 CDM 0301 RC 82105 HCPCS inpatient 111 72.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.15 65 999999999 67.21 107.67 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50434057_1 CDM 0301 RC 82105 HCPCS inpatient 111 72.15 AETNA AETNA 87.69 79 999999999 67.21 107.67 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50434057_1 CDM 0301 RC 82105 HCPCS inpatient 111 72.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 107.67 97 999999999 67.21 107.67 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50434057_1 CDM 0301 RC 82105 HCPCS inpatient 111 72.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 76.59 69 999999999 67.21 107.67 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50434057_1 CDM 0301 RC 82105 HCPCS inpatient 111 72.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 86.58 78 999999999 67.21 107.67 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50434057_1 CDM 0301 RC 82105 HCPCS inpatient 111 72.15 SIHO - ALL PLANS SIHO - ALL PLANS 99.9 90 999999999 67.21 107.67 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50434057_1 CDM 0301 RC 82105 HCPCS inpatient 111 72.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.21 60.55 999999999 67.21 107.67 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50434057_1 CDM 0301 RC 82105 HCPCS inpatient 111 72.15 UMR - ALL PLANS UMR - ALL PLANS 77.7 70 999999999 67.21 107.67 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50434057_1 CDM 0301 RC 82105 HCPCS inpatient 111 72.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.21 107.67 "Alpha-fetoprotein (AFP) level, serum" 50434057_1 CDM 0301 RC 82105 HCPCS inpatient 111 72.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.21 107.67 "Alpha-fetoprotein (AFP) level, serum" 50434057_1 CDM 0301 RC 82105 HCPCS inpatient 111 72.15 ANTHEM HMO ANTHEM HMO 999999999 67.21 107.67 "Alpha-fetoprotein (AFP) level, serum" 50434057_1 CDM 0301 RC 82105 HCPCS inpatient 111 72.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.21 107.67 "Alpha-fetoprotein (AFP) level, serum" 50434057_1 CDM 0301 RC 82105 HCPCS inpatient 111 72.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.21 107.67 "Alpha-fetoprotein (AFP) level, serum" 50434057_1 CDM 0301 RC 82105 HCPCS inpatient 111 72.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.04 67.6 999999999 67.21 107.67 percent of total billed charges Aldolase (enzyme) level 50434058_1 CDM 0301 RC 82085 HCPCS inpatient 198 128.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.7 65 999999999 119.89 192.06 percent of total billed charges Aldolase (enzyme) level 50434058_1 CDM 0301 RC 82085 HCPCS inpatient 198 128.7 AETNA AETNA 156.42 79 999999999 119.89 192.06 percent of total billed charges Aldolase (enzyme) level 50434058_1 CDM 0301 RC 82085 HCPCS inpatient 198 128.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 192.06 97 999999999 119.89 192.06 percent of total billed charges Aldolase (enzyme) level 50434058_1 CDM 0301 RC 82085 HCPCS inpatient 198 128.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 136.62 69 999999999 119.89 192.06 percent of total billed charges Aldolase (enzyme) level 50434058_1 CDM 0301 RC 82085 HCPCS inpatient 198 128.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 154.44 78 999999999 119.89 192.06 percent of total billed charges Aldolase (enzyme) level 50434058_1 CDM 0301 RC 82085 HCPCS inpatient 198 128.7 SIHO - ALL PLANS SIHO - ALL PLANS 178.2 90 999999999 119.89 192.06 percent of total billed charges Aldolase (enzyme) level 50434058_1 CDM 0301 RC 82085 HCPCS inpatient 198 128.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.89 60.55 999999999 119.89 192.06 percent of total billed charges Aldolase (enzyme) level 50434058_1 CDM 0301 RC 82085 HCPCS inpatient 198 128.7 UMR - ALL PLANS UMR - ALL PLANS 138.6 70 999999999 119.89 192.06 percent of total billed charges Aldolase (enzyme) level 50434058_1 CDM 0301 RC 82085 HCPCS inpatient 198 128.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.89 192.06 Aldolase (enzyme) level 50434058_1 CDM 0301 RC 82085 HCPCS inpatient 198 128.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.89 192.06 Aldolase (enzyme) level 50434058_1 CDM 0301 RC 82085 HCPCS inpatient 198 128.7 ANTHEM HMO ANTHEM HMO 999999999 119.89 192.06 Aldolase (enzyme) level 50434058_1 CDM 0301 RC 82085 HCPCS inpatient 198 128.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.89 192.06 Aldolase (enzyme) level 50434058_1 CDM 0301 RC 82085 HCPCS inpatient 198 128.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.89 192.06 Aldolase (enzyme) level 50434058_1 CDM 0301 RC 82085 HCPCS inpatient 198 128.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.85 67.6 999999999 119.89 192.06 percent of total billed charges Aldosterone hormone level 50434059_1 CDM 0301 RC 82088 HCPCS inpatient 185 120.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 120.25 65 999999999 112.02 179.45 percent of total billed charges Aldosterone hormone level 50434059_1 CDM 0301 RC 82088 HCPCS inpatient 185 120.25 AETNA AETNA 146.15 79 999999999 112.02 179.45 percent of total billed charges Aldosterone hormone level 50434059_1 CDM 0301 RC 82088 HCPCS inpatient 185 120.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 179.45 97 999999999 112.02 179.45 percent of total billed charges Aldosterone hormone level 50434059_1 CDM 0301 RC 82088 HCPCS inpatient 185 120.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 127.65 69 999999999 112.02 179.45 percent of total billed charges Aldosterone hormone level 50434059_1 CDM 0301 RC 82088 HCPCS inpatient 185 120.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 144.3 78 999999999 112.02 179.45 percent of total billed charges Aldosterone hormone level 50434059_1 CDM 0301 RC 82088 HCPCS inpatient 185 120.25 SIHO - ALL PLANS SIHO - ALL PLANS 166.5 90 999999999 112.02 179.45 percent of total billed charges Aldosterone hormone level 50434059_1 CDM 0301 RC 82088 HCPCS inpatient 185 120.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 112.02 60.55 999999999 112.02 179.45 percent of total billed charges Aldosterone hormone level 50434059_1 CDM 0301 RC 82088 HCPCS inpatient 185 120.25 UMR - ALL PLANS UMR - ALL PLANS 129.5 70 999999999 112.02 179.45 percent of total billed charges Aldosterone hormone level 50434059_1 CDM 0301 RC 82088 HCPCS inpatient 185 120.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 112.02 179.45 Aldosterone hormone level 50434059_1 CDM 0301 RC 82088 HCPCS inpatient 185 120.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 112.02 179.45 Aldosterone hormone level 50434059_1 CDM 0301 RC 82088 HCPCS inpatient 185 120.25 ANTHEM HMO ANTHEM HMO 999999999 112.02 179.45 Aldosterone hormone level 50434059_1 CDM 0301 RC 82088 HCPCS inpatient 185 120.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 112.02 179.45 Aldosterone hormone level 50434059_1 CDM 0301 RC 82088 HCPCS inpatient 185 120.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 112.02 179.45 Aldosterone hormone level 50434059_1 CDM 0301 RC 82088 HCPCS inpatient 185 120.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 125.06 67.6 999999999 112.02 179.45 percent of total billed charges "Phosphatase (enzyme) level, alkaline" 50434060_1 CDM 0301 RC 84075 HCPCS inpatient 96 62.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.4 65 999999999 58.13 93.12 percent of total billed charges "Phosphatase (enzyme) level, alkaline" 50434060_1 CDM 0301 RC 84075 HCPCS inpatient 96 62.4 AETNA AETNA 75.84 79 999999999 58.13 93.12 percent of total billed charges "Phosphatase (enzyme) level, alkaline" 50434060_1 CDM 0301 RC 84075 HCPCS inpatient 96 62.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.12 97 999999999 58.13 93.12 percent of total billed charges "Phosphatase (enzyme) level, alkaline" 50434060_1 CDM 0301 RC 84075 HCPCS inpatient 96 62.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.24 69 999999999 58.13 93.12 percent of total billed charges "Phosphatase (enzyme) level, alkaline" 50434060_1 CDM 0301 RC 84075 HCPCS inpatient 96 62.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.88 78 999999999 58.13 93.12 percent of total billed charges "Phosphatase (enzyme) level, alkaline" 50434060_1 CDM 0301 RC 84075 HCPCS inpatient 96 62.4 SIHO - ALL PLANS SIHO - ALL PLANS 86.4 90 999999999 58.13 93.12 percent of total billed charges "Phosphatase (enzyme) level, alkaline" 50434060_1 CDM 0301 RC 84075 HCPCS inpatient 96 62.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.13 60.55 999999999 58.13 93.12 percent of total billed charges "Phosphatase (enzyme) level, alkaline" 50434060_1 CDM 0301 RC 84075 HCPCS inpatient 96 62.4 UMR - ALL PLANS UMR - ALL PLANS 67.2 70 999999999 58.13 93.12 percent of total billed charges "Phosphatase (enzyme) level, alkaline" 50434060_1 CDM 0301 RC 84075 HCPCS inpatient 96 62.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.13 93.12 "Phosphatase (enzyme) level, alkaline" 50434060_1 CDM 0301 RC 84075 HCPCS inpatient 96 62.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.13 93.12 "Phosphatase (enzyme) level, alkaline" 50434060_1 CDM 0301 RC 84075 HCPCS inpatient 96 62.4 ANTHEM HMO ANTHEM HMO 999999999 58.13 93.12 "Phosphatase (enzyme) level, alkaline" 50434060_1 CDM 0301 RC 84075 HCPCS inpatient 96 62.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.13 93.12 "Phosphatase (enzyme) level, alkaline" 50434060_1 CDM 0301 RC 84075 HCPCS inpatient 96 62.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.13 93.12 "Phosphatase (enzyme) level, alkaline" 50434060_1 CDM 0301 RC 84075 HCPCS inpatient 96 62.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.9 67.6 999999999 58.13 93.12 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434061_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434061_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434061_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434061_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434061_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434061_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434061_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434061_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434061_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434061_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434061_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434061_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434061_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434061_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434062_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434062_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434062_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434062_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434062_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434062_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434062_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434062_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434062_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434062_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434062_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434062_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434062_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434062_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434063_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434063_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434063_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434063_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434063_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434063_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434063_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434063_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434063_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434063_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434063_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434063_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434063_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434063_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434064_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434064_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434064_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434064_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434064_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434064_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434064_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434064_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434064_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434064_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434064_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434064_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434064_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434064_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434065_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434065_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434065_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434065_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434065_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434065_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434065_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434065_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434065_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434065_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434065_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434065_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434065_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434065_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434066_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434066_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434066_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434066_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434066_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434066_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434066_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434066_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434066_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434066_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434066_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434066_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434066_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434066_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434067_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434067_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434067_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434067_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434067_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434067_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434067_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434067_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434067_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434067_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434067_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434067_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434067_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434067_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434068_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434068_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434068_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434068_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434068_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434068_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434068_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434068_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434068_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434068_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434068_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434068_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434068_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434068_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434069_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434069_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434069_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434069_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434069_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434069_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434069_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434069_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434069_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434069_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434069_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434069_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434069_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434069_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434070_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434070_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434070_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434070_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434070_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434070_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434070_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434070_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434070_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434070_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434070_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434070_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434070_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434070_1 CDM 0302 RC 86008 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434071_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434071_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434071_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434071_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434071_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434071_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434071_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434071_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434071_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434071_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434071_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434071_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434071_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434071_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434072_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434072_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434072_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434072_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434072_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434072_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434072_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434072_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434072_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434072_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434072_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434072_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434072_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434072_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434073_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434073_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434073_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434073_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434073_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434073_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434073_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434073_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434073_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434073_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434073_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434073_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434073_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434073_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434074_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434074_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434074_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434074_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434074_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434074_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434074_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434074_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434074_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434074_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434074_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434074_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434074_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434074_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434075_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434075_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434075_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434075_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434075_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434075_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434075_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434075_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434075_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434075_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434075_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434075_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434075_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434075_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434076_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434076_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434076_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434076_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434076_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434076_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434076_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434076_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434076_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434076_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434076_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434076_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434076_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434076_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434077_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434077_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434077_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434077_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434077_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434077_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434077_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434077_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434077_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434077_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434077_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434077_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434077_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434077_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434078_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434078_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434078_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434078_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434078_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434078_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434078_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434078_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434078_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434078_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434078_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434078_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434078_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434078_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434079_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434079_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434079_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434079_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434079_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434079_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434079_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434079_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434079_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434079_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434079_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434079_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434079_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434079_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434080_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434080_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434080_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434080_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434080_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434080_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434080_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434080_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434080_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434080_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434080_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434080_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434080_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434080_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434081_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434081_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434081_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434081_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434081_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434081_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434081_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434081_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434081_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434081_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434081_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434081_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434081_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434081_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434082_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434082_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434082_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434082_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434082_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434082_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434082_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434082_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434082_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434082_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434082_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434082_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434082_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434082_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434083_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434083_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434083_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434083_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434083_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434083_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434083_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434083_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434083_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434083_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434083_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434083_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434083_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434083_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434084_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434084_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434084_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434084_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434084_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434084_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434084_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434084_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434084_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434084_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434084_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434084_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434084_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434084_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434085_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434085_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434085_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434085_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434085_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434085_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434085_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434085_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434085_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434085_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434085_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434085_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434085_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434085_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434086_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434086_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434086_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434086_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434086_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434086_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434086_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434086_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434086_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434086_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434086_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434086_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434086_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434086_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434087_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434087_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434087_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434087_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434087_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434087_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434087_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434087_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434087_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434087_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434087_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434087_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434087_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434087_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434088_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434088_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434088_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434088_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434088_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434088_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434088_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434088_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434088_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434088_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434088_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434088_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434088_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434088_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434089_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434089_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434089_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434089_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434089_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434089_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434089_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434089_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434089_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434089_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434089_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434089_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434089_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434089_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434090_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434090_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434090_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434090_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434090_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434090_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434090_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434090_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434090_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434090_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434090_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434090_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434090_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434090_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434091_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434091_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434091_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434091_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434091_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434091_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434091_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434091_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434091_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434091_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434091_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434091_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434091_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434091_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434092_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434092_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434092_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434092_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434092_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434092_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434092_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434092_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434092_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434092_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434092_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434092_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434092_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434092_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434093_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434093_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434093_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434093_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434093_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434093_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434093_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434093_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434093_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434093_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434093_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434093_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434093_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434093_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434094_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434094_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434094_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434094_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434094_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434094_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434094_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434094_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434094_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434094_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434094_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434094_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434094_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434094_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434095_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434095_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434095_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434095_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434095_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434095_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434095_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434095_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434095_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434095_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434095_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434095_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434095_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434095_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434096_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434096_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434096_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434096_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434096_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434096_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434096_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434096_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434096_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434096_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434096_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434096_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434096_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434096_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434097_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434097_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434097_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434097_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434097_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434097_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434097_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434097_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434097_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434097_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434097_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434097_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434097_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434097_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434098_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434098_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434098_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434098_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434098_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434098_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434098_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434098_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434098_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434098_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434098_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434098_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434098_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434098_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434099_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434099_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434099_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434099_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434099_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434099_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434099_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434099_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434099_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434099_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434099_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434099_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434099_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434099_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434100_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434100_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434100_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434100_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434100_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434100_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434100_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434100_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434100_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434100_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434100_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434100_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434100_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434100_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434101_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434101_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434101_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434101_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434101_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434101_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434101_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434101_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434101_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434101_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434101_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434101_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434101_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434101_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434102_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434102_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434102_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434102_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434102_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434102_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434102_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434102_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434102_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434102_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434102_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434102_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434102_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434102_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434103_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434103_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434103_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434103_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434103_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434103_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434103_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434103_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434103_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434103_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434103_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434103_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434103_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434103_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434104_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434104_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434104_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434104_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434104_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434104_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434104_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434104_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434104_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434104_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434104_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434104_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434104_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434104_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434105_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434105_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434105_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434105_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434105_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434105_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434105_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434105_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434105_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434105_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434105_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434105_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434105_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434105_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434106_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434106_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434106_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434106_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434106_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434106_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434106_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434106_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434106_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434106_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434106_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434106_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434106_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434106_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434107_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434107_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434107_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434107_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434107_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434107_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434107_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434107_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434107_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434107_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434107_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434107_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434107_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434107_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434108_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434108_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434108_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434108_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434108_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434108_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434108_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434108_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434108_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434108_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434108_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434108_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434108_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434108_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434109_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434109_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434109_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434109_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434109_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434109_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434109_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434109_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434109_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434109_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434109_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434109_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434109_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434109_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434110_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434110_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434110_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434110_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434110_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434110_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434110_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434110_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434110_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434110_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434110_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434110_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434110_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434110_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434111_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434111_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434111_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434111_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434111_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434111_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434111_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434111_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434111_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434111_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434111_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434111_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434111_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434111_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434112_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434112_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434112_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434112_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434112_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434112_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434112_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434112_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434112_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434112_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434112_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434112_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434112_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434112_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434113_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434113_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434113_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434113_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434113_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434113_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434113_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434113_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434113_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434113_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434113_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434113_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434113_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434113_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434114_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434114_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434114_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434114_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434114_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434114_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434114_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434114_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434114_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434114_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434114_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434114_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434114_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434114_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434115_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434115_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434115_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434115_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434115_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434115_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434115_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434115_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434115_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434115_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434115_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434115_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434115_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434115_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434116_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434116_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434116_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434116_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434116_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434116_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434116_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434116_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434116_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434116_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434116_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434116_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434116_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434116_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434117_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434117_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434117_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434117_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434117_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434117_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434117_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434117_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434117_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434117_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434117_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434117_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434117_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434117_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434118_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434118_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434118_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434118_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434118_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434118_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434118_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434118_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434118_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434118_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434118_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434118_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434118_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434118_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434119_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434119_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434119_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434119_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434119_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434119_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434119_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434119_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434119_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434119_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434119_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434119_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434119_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434119_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434120_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434120_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434120_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434120_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434120_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434120_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434120_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434120_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434120_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434120_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434120_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434120_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434120_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434120_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434121_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434121_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434121_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434121_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434121_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434121_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434121_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434121_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434121_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434121_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434121_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434121_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434121_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434121_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434122_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434122_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434122_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434122_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434122_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434122_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434122_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434122_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434122_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434122_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434122_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434122_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434122_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434122_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434123_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434123_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434123_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434123_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434123_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434123_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434123_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434123_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434123_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434123_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434123_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434123_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434123_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434123_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434124_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434124_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434124_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434124_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434124_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434124_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434124_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434124_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434124_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434124_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434124_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434124_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434124_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434124_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434125_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434125_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434125_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434125_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434125_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434125_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434125_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434125_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434125_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434125_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434125_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434125_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434125_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434125_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434126_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434126_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434126_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434126_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434126_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434126_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434126_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434126_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434126_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434126_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434126_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434126_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434126_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434126_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434127_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434127_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434127_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434127_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434127_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434127_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434127_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434127_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434127_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434127_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434127_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434127_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434127_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434127_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434128_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434128_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434128_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434128_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434128_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434128_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434128_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434128_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434128_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434128_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434128_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434128_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434128_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434128_1 CDM 0302 RC 86003 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434129_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434129_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434129_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434129_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434129_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434129_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434129_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434129_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434129_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434129_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434129_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434129_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434129_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434129_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434130_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434130_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434130_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434130_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434130_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434130_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434130_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434130_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434130_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434130_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434130_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434130_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434130_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434130_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434131_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434131_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434131_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434131_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434131_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434131_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434131_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434131_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434131_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434131_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434131_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434131_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434131_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434131_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434132_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434132_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434132_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434132_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434132_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434132_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434132_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434132_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434132_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434132_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434132_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434132_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434132_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434132_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434133_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434133_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434133_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434133_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434133_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434133_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434133_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434133_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434133_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434133_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434133_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434133_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434133_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434133_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434134_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434134_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434134_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434134_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434134_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434134_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434134_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434134_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434134_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434134_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434134_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434134_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434134_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434134_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434135_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434135_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434135_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434135_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434135_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434135_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434135_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434135_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434135_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434135_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434135_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434135_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434135_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434135_1 CDM 0302 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434136_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434136_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434136_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434136_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434136_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434136_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434136_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434136_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434136_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434136_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434136_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434136_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434136_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434136_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434137_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434137_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434137_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434137_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434137_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434137_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434137_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434137_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434137_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434137_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434137_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434137_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434137_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434137_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434138_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434138_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434138_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434138_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434138_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434138_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434138_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434138_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434138_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434138_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434138_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434138_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434138_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434138_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434139_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434139_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434139_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434139_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434139_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434139_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434139_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434139_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434139_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434139_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434139_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434139_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434139_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434139_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434140_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434140_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434140_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434140_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434140_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434140_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434140_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434140_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434140_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434140_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434140_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434140_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434140_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50434140_1 CDM 0302 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 50434141_1 CDM 0301 RC 82103 HCPCS inpatient 147 95.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 95.55 65 999999999 89.01 142.59 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 50434141_1 CDM 0301 RC 82103 HCPCS inpatient 147 95.55 AETNA AETNA 116.13 79 999999999 89.01 142.59 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 50434141_1 CDM 0301 RC 82103 HCPCS inpatient 147 95.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 142.59 97 999999999 89.01 142.59 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 50434141_1 CDM 0301 RC 82103 HCPCS inpatient 147 95.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 101.43 69 999999999 89.01 142.59 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 50434141_1 CDM 0301 RC 82103 HCPCS inpatient 147 95.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 114.66 78 999999999 89.01 142.59 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 50434141_1 CDM 0301 RC 82103 HCPCS inpatient 147 95.55 SIHO - ALL PLANS SIHO - ALL PLANS 132.3 90 999999999 89.01 142.59 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 50434141_1 CDM 0301 RC 82103 HCPCS inpatient 147 95.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 89.01 60.55 999999999 89.01 142.59 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 50434141_1 CDM 0301 RC 82103 HCPCS inpatient 147 95.55 UMR - ALL PLANS UMR - ALL PLANS 102.9 70 999999999 89.01 142.59 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 50434141_1 CDM 0301 RC 82103 HCPCS inpatient 147 95.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 89.01 142.59 "Alpha-1-antitrypsin (protein) blood test, total" 50434141_1 CDM 0301 RC 82103 HCPCS inpatient 147 95.55 ANTHEM HMO ANTHEM HMO 999999999 89.01 142.59 "Alpha-1-antitrypsin (protein) blood test, total" 50434141_1 CDM 0301 RC 82103 HCPCS inpatient 147 95.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 89.01 142.59 "Alpha-1-antitrypsin (protein) blood test, total" 50434141_1 CDM 0301 RC 82103 HCPCS inpatient 147 95.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 89.01 142.59 "Alpha-1-antitrypsin (protein) blood test, total" 50434141_1 CDM 0301 RC 82103 HCPCS inpatient 147 95.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 89.01 142.59 "Alpha-1-antitrypsin (protein) blood test, total" 50434141_1 CDM 0301 RC 82103 HCPCS inpatient 147 95.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 99.37 67.6 999999999 89.01 142.59 percent of total billed charges Quantitation of therapeutic drug 50434142_1 CDM 0301 RC 80299 HCPCS inpatient 568 369.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 369.2 65 999999999 343.92 550.96 percent of total billed charges Quantitation of therapeutic drug 50434142_1 CDM 0301 RC 80299 HCPCS inpatient 568 369.2 AETNA AETNA 448.72 79 999999999 343.92 550.96 percent of total billed charges Quantitation of therapeutic drug 50434142_1 CDM 0301 RC 80299 HCPCS inpatient 568 369.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 550.96 97 999999999 343.92 550.96 percent of total billed charges Quantitation of therapeutic drug 50434142_1 CDM 0301 RC 80299 HCPCS inpatient 568 369.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 391.92 69 999999999 343.92 550.96 percent of total billed charges Quantitation of therapeutic drug 50434142_1 CDM 0301 RC 80299 HCPCS inpatient 568 369.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 443.04 78 999999999 343.92 550.96 percent of total billed charges Quantitation of therapeutic drug 50434142_1 CDM 0301 RC 80299 HCPCS inpatient 568 369.2 SIHO - ALL PLANS SIHO - ALL PLANS 511.2 90 999999999 343.92 550.96 percent of total billed charges Quantitation of therapeutic drug 50434142_1 CDM 0301 RC 80299 HCPCS inpatient 568 369.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 343.92 60.55 999999999 343.92 550.96 percent of total billed charges Quantitation of therapeutic drug 50434142_1 CDM 0301 RC 80299 HCPCS inpatient 568 369.2 UMR - ALL PLANS UMR - ALL PLANS 397.6 70 999999999 343.92 550.96 percent of total billed charges Quantitation of therapeutic drug 50434142_1 CDM 0301 RC 80299 HCPCS inpatient 568 369.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 343.92 550.96 Quantitation of therapeutic drug 50434142_1 CDM 0301 RC 80299 HCPCS inpatient 568 369.2 ANTHEM HMO ANTHEM HMO 999999999 343.92 550.96 Quantitation of therapeutic drug 50434142_1 CDM 0301 RC 80299 HCPCS inpatient 568 369.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 343.92 550.96 Quantitation of therapeutic drug 50434142_1 CDM 0301 RC 80299 HCPCS inpatient 568 369.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 343.92 550.96 Quantitation of therapeutic drug 50434142_1 CDM 0301 RC 80299 HCPCS inpatient 568 369.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 343.92 550.96 Quantitation of therapeutic drug 50434142_1 CDM 0301 RC 80299 HCPCS inpatient 568 369.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 383.97 67.6 999999999 343.92 550.96 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50434144_1 CDM 0301 RC 86039 HCPCS inpatient 84 54.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 54.6 65 999999999 50.86 81.48 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50434144_1 CDM 0301 RC 86039 HCPCS inpatient 84 54.6 AETNA AETNA 66.36 79 999999999 50.86 81.48 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50434144_1 CDM 0301 RC 86039 HCPCS inpatient 84 54.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 81.48 97 999999999 50.86 81.48 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50434144_1 CDM 0301 RC 86039 HCPCS inpatient 84 54.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.96 69 999999999 50.86 81.48 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50434144_1 CDM 0301 RC 86039 HCPCS inpatient 84 54.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 65.52 78 999999999 50.86 81.48 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50434144_1 CDM 0301 RC 86039 HCPCS inpatient 84 54.6 SIHO - ALL PLANS SIHO - ALL PLANS 75.6 90 999999999 50.86 81.48 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50434144_1 CDM 0301 RC 86039 HCPCS inpatient 84 54.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.86 60.55 999999999 50.86 81.48 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50434144_1 CDM 0301 RC 86039 HCPCS inpatient 84 54.6 UMR - ALL PLANS UMR - ALL PLANS 58.8 70 999999999 50.86 81.48 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50434144_1 CDM 0301 RC 86039 HCPCS inpatient 84 54.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.86 81.48 "Measurement of antibody for assessment of autoimmune disorder, titer" 50434144_1 CDM 0301 RC 86039 HCPCS inpatient 84 54.6 ANTHEM HMO ANTHEM HMO 999999999 50.86 81.48 "Measurement of antibody for assessment of autoimmune disorder, titer" 50434144_1 CDM 0301 RC 86039 HCPCS inpatient 84 54.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.86 81.48 "Measurement of antibody for assessment of autoimmune disorder, titer" 50434144_1 CDM 0301 RC 86039 HCPCS inpatient 84 54.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.86 81.48 "Measurement of antibody for assessment of autoimmune disorder, titer" 50434144_1 CDM 0301 RC 86039 HCPCS inpatient 84 54.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.86 81.48 "Measurement of antibody for assessment of autoimmune disorder, titer" 50434144_1 CDM 0301 RC 86039 HCPCS inpatient 84 54.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.78 67.6 999999999 50.86 81.48 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50434145_1 CDM 0301 RC 86039 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50434145_1 CDM 0301 RC 86039 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50434145_1 CDM 0301 RC 86039 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50434145_1 CDM 0301 RC 86039 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50434145_1 CDM 0301 RC 86039 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50434145_1 CDM 0301 RC 86039 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50434145_1 CDM 0301 RC 86039 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50434145_1 CDM 0301 RC 86039 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50434145_1 CDM 0301 RC 86039 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 "Measurement of antibody for assessment of autoimmune disorder, titer" 50434145_1 CDM 0301 RC 86039 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 "Measurement of antibody for assessment of autoimmune disorder, titer" 50434145_1 CDM 0301 RC 86039 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 "Measurement of antibody for assessment of autoimmune disorder, titer" 50434145_1 CDM 0301 RC 86039 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 "Measurement of antibody for assessment of autoimmune disorder, titer" 50434145_1 CDM 0301 RC 86039 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 "Measurement of antibody for assessment of autoimmune disorder, titer" 50434145_1 CDM 0301 RC 86039 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 50434146_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 50434146_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 50434146_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 50434146_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 50434146_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 50434146_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 50434146_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 50434146_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 50434146_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 50434146_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 50434146_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 50434146_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 50434146_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 Analysis for antibody to Ehrlichia (bacteria transmitted by ticks) 50434146_1 CDM 0301 RC 86666 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges Screening test for antibody to noninfectious agent 50434147_1 CDM 0302 RC 86255 HCPCS inpatient 113 73.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 73.45 65 999999999 68.42 109.61 percent of total billed charges Screening test for antibody to noninfectious agent 50434147_1 CDM 0302 RC 86255 HCPCS inpatient 113 73.45 AETNA AETNA 89.27 79 999999999 68.42 109.61 percent of total billed charges Screening test for antibody to noninfectious agent 50434147_1 CDM 0302 RC 86255 HCPCS inpatient 113 73.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 109.61 97 999999999 68.42 109.61 percent of total billed charges Screening test for antibody to noninfectious agent 50434147_1 CDM 0302 RC 86255 HCPCS inpatient 113 73.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.14 78 999999999 68.42 109.61 percent of total billed charges Screening test for antibody to noninfectious agent 50434147_1 CDM 0302 RC 86255 HCPCS inpatient 113 73.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.97 69 999999999 68.42 109.61 percent of total billed charges Screening test for antibody to noninfectious agent 50434147_1 CDM 0302 RC 86255 HCPCS inpatient 113 73.45 SIHO - ALL PLANS SIHO - ALL PLANS 101.7 90 999999999 68.42 109.61 percent of total billed charges Screening test for antibody to noninfectious agent 50434147_1 CDM 0302 RC 86255 HCPCS inpatient 113 73.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 68.42 60.55 999999999 68.42 109.61 percent of total billed charges Screening test for antibody to noninfectious agent 50434147_1 CDM 0302 RC 86255 HCPCS inpatient 113 73.45 UMR - ALL PLANS UMR - ALL PLANS 79.1 70 999999999 68.42 109.61 percent of total billed charges Screening test for antibody to noninfectious agent 50434147_1 CDM 0302 RC 86255 HCPCS inpatient 113 73.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 68.42 109.61 Screening test for antibody to noninfectious agent 50434147_1 CDM 0302 RC 86255 HCPCS inpatient 113 73.45 ANTHEM HMO ANTHEM HMO 999999999 68.42 109.61 Screening test for antibody to noninfectious agent 50434147_1 CDM 0302 RC 86255 HCPCS inpatient 113 73.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 68.42 109.61 Screening test for antibody to noninfectious agent 50434147_1 CDM 0302 RC 86255 HCPCS inpatient 113 73.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 68.42 109.61 Screening test for antibody to noninfectious agent 50434147_1 CDM 0302 RC 86255 HCPCS inpatient 113 73.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 68.42 109.61 Screening test for antibody to noninfectious agent 50434147_1 CDM 0302 RC 86255 HCPCS inpatient 113 73.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 76.39 67.6 999999999 68.42 109.61 percent of total billed charges Androstenedione (hormone) level 50434148_1 CDM 0301 RC 82157 HCPCS inpatient 268 174.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 174.2 65 999999999 162.27 259.96 percent of total billed charges Androstenedione (hormone) level 50434148_1 CDM 0301 RC 82157 HCPCS inpatient 268 174.2 AETNA AETNA 211.72 79 999999999 162.27 259.96 percent of total billed charges Androstenedione (hormone) level 50434148_1 CDM 0301 RC 82157 HCPCS inpatient 268 174.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 259.96 97 999999999 162.27 259.96 percent of total billed charges Androstenedione (hormone) level 50434148_1 CDM 0301 RC 82157 HCPCS inpatient 268 174.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 209.04 78 999999999 162.27 259.96 percent of total billed charges Androstenedione (hormone) level 50434148_1 CDM 0301 RC 82157 HCPCS inpatient 268 174.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.92 69 999999999 162.27 259.96 percent of total billed charges Androstenedione (hormone) level 50434148_1 CDM 0301 RC 82157 HCPCS inpatient 268 174.2 SIHO - ALL PLANS SIHO - ALL PLANS 241.2 90 999999999 162.27 259.96 percent of total billed charges Androstenedione (hormone) level 50434148_1 CDM 0301 RC 82157 HCPCS inpatient 268 174.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 162.27 60.55 999999999 162.27 259.96 percent of total billed charges Androstenedione (hormone) level 50434148_1 CDM 0301 RC 82157 HCPCS inpatient 268 174.2 UMR - ALL PLANS UMR - ALL PLANS 187.6 70 999999999 162.27 259.96 percent of total billed charges Androstenedione (hormone) level 50434148_1 CDM 0301 RC 82157 HCPCS inpatient 268 174.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 162.27 259.96 Androstenedione (hormone) level 50434148_1 CDM 0301 RC 82157 HCPCS inpatient 268 174.2 ANTHEM HMO ANTHEM HMO 999999999 162.27 259.96 Androstenedione (hormone) level 50434148_1 CDM 0301 RC 82157 HCPCS inpatient 268 174.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 162.27 259.96 Androstenedione (hormone) level 50434148_1 CDM 0301 RC 82157 HCPCS inpatient 268 174.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 162.27 259.96 Androstenedione (hormone) level 50434148_1 CDM 0301 RC 82157 HCPCS inpatient 268 174.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 162.27 259.96 Androstenedione (hormone) level 50434148_1 CDM 0301 RC 82157 HCPCS inpatient 268 174.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 181.17 67.6 999999999 162.27 259.96 percent of total billed charges Measurement of antibody for rheumatoid arthritis assessment 50434149_1 CDM 0302 RC 86200 HCPCS inpatient 151 98.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.15 65 999999999 91.43 146.47 percent of total billed charges Measurement of antibody for rheumatoid arthritis assessment 50434149_1 CDM 0302 RC 86200 HCPCS inpatient 151 98.15 AETNA AETNA 119.29 79 999999999 91.43 146.47 percent of total billed charges Measurement of antibody for rheumatoid arthritis assessment 50434149_1 CDM 0302 RC 86200 HCPCS inpatient 151 98.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 146.47 97 999999999 91.43 146.47 percent of total billed charges Measurement of antibody for rheumatoid arthritis assessment 50434149_1 CDM 0302 RC 86200 HCPCS inpatient 151 98.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 117.78 78 999999999 91.43 146.47 percent of total billed charges Measurement of antibody for rheumatoid arthritis assessment 50434149_1 CDM 0302 RC 86200 HCPCS inpatient 151 98.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.19 69 999999999 91.43 146.47 percent of total billed charges Measurement of antibody for rheumatoid arthritis assessment 50434149_1 CDM 0302 RC 86200 HCPCS inpatient 151 98.15 SIHO - ALL PLANS SIHO - ALL PLANS 135.9 90 999999999 91.43 146.47 percent of total billed charges Measurement of antibody for rheumatoid arthritis assessment 50434149_1 CDM 0302 RC 86200 HCPCS inpatient 151 98.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 91.43 60.55 999999999 91.43 146.47 percent of total billed charges Measurement of antibody for rheumatoid arthritis assessment 50434149_1 CDM 0302 RC 86200 HCPCS inpatient 151 98.15 UMR - ALL PLANS UMR - ALL PLANS 105.7 70 999999999 91.43 146.47 percent of total billed charges Measurement of antibody for rheumatoid arthritis assessment 50434149_1 CDM 0302 RC 86200 HCPCS inpatient 151 98.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 91.43 146.47 Measurement of antibody for rheumatoid arthritis assessment 50434149_1 CDM 0302 RC 86200 HCPCS inpatient 151 98.15 ANTHEM HMO ANTHEM HMO 999999999 91.43 146.47 Measurement of antibody for rheumatoid arthritis assessment 50434149_1 CDM 0302 RC 86200 HCPCS inpatient 151 98.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 91.43 146.47 Measurement of antibody for rheumatoid arthritis assessment 50434149_1 CDM 0302 RC 86200 HCPCS inpatient 151 98.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 91.43 146.47 Measurement of antibody for rheumatoid arthritis assessment 50434149_1 CDM 0302 RC 86200 HCPCS inpatient 151 98.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 91.43 146.47 Measurement of antibody for rheumatoid arthritis assessment 50434149_1 CDM 0302 RC 86200 HCPCS inpatient 151 98.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.08 67.6 999999999 91.43 146.47 percent of total billed charges Measurement of substance using immunoassay technique 50434150_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 130.65 65 999999999 121.71 194.97 percent of total billed charges Measurement of substance using immunoassay technique 50434150_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 AETNA AETNA 158.79 79 999999999 121.71 194.97 percent of total billed charges Measurement of substance using immunoassay technique 50434150_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 194.97 97 999999999 121.71 194.97 percent of total billed charges Measurement of substance using immunoassay technique 50434150_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 156.78 78 999999999 121.71 194.97 percent of total billed charges Measurement of substance using immunoassay technique 50434150_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 138.69 69 999999999 121.71 194.97 percent of total billed charges Measurement of substance using immunoassay technique 50434150_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 SIHO - ALL PLANS SIHO - ALL PLANS 180.9 90 999999999 121.71 194.97 percent of total billed charges Measurement of substance using immunoassay technique 50434150_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 121.71 60.55 999999999 121.71 194.97 percent of total billed charges Measurement of substance using immunoassay technique 50434150_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 UMR - ALL PLANS UMR - ALL PLANS 140.7 70 999999999 121.71 194.97 percent of total billed charges Measurement of substance using immunoassay technique 50434150_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 121.71 194.97 Measurement of substance using immunoassay technique 50434150_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 ANTHEM HMO ANTHEM HMO 999999999 121.71 194.97 Measurement of substance using immunoassay technique 50434150_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 121.71 194.97 Measurement of substance using immunoassay technique 50434150_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 121.71 194.97 Measurement of substance using immunoassay technique 50434150_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 121.71 194.97 Measurement of substance using immunoassay technique 50434150_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 135.88 67.6 999999999 121.71 194.97 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 50434151_1 CDM 0302 RC 86800 HCPCS inpatient 158 102.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.7 65 999999999 95.67 153.26 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 50434151_1 CDM 0302 RC 86800 HCPCS inpatient 158 102.7 AETNA AETNA 124.82 79 999999999 95.67 153.26 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 50434151_1 CDM 0302 RC 86800 HCPCS inpatient 158 102.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 153.26 97 999999999 95.67 153.26 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 50434151_1 CDM 0302 RC 86800 HCPCS inpatient 158 102.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 123.24 78 999999999 95.67 153.26 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 50434151_1 CDM 0302 RC 86800 HCPCS inpatient 158 102.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 109.02 69 999999999 95.67 153.26 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 50434151_1 CDM 0302 RC 86800 HCPCS inpatient 158 102.7 SIHO - ALL PLANS SIHO - ALL PLANS 142.2 90 999999999 95.67 153.26 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 50434151_1 CDM 0302 RC 86800 HCPCS inpatient 158 102.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.67 60.55 999999999 95.67 153.26 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 50434151_1 CDM 0302 RC 86800 HCPCS inpatient 158 102.7 UMR - ALL PLANS UMR - ALL PLANS 110.6 70 999999999 95.67 153.26 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 50434151_1 CDM 0302 RC 86800 HCPCS inpatient 158 102.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.67 153.26 Thyroglobulin (thyroid protein) antibody measurement 50434151_1 CDM 0302 RC 86800 HCPCS inpatient 158 102.7 ANTHEM HMO ANTHEM HMO 999999999 95.67 153.26 Thyroglobulin (thyroid protein) antibody measurement 50434151_1 CDM 0302 RC 86800 HCPCS inpatient 158 102.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.67 153.26 Thyroglobulin (thyroid protein) antibody measurement 50434151_1 CDM 0302 RC 86800 HCPCS inpatient 158 102.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.67 153.26 Thyroglobulin (thyroid protein) antibody measurement 50434151_1 CDM 0302 RC 86800 HCPCS inpatient 158 102.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.67 153.26 Thyroglobulin (thyroid protein) antibody measurement 50434151_1 CDM 0302 RC 86800 HCPCS inpatient 158 102.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.81 67.6 999999999 95.67 153.26 percent of total billed charges Apolipoprotein level 50434152_1 CDM 0301 RC 82172 HCPCS inpatient 410 266.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 266.5 65 999999999 248.26 397.7 percent of total billed charges Apolipoprotein level 50434152_1 CDM 0301 RC 82172 HCPCS inpatient 410 266.5 AETNA AETNA 323.9 79 999999999 248.26 397.7 percent of total billed charges Apolipoprotein level 50434152_1 CDM 0301 RC 82172 HCPCS inpatient 410 266.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 397.7 97 999999999 248.26 397.7 percent of total billed charges Apolipoprotein level 50434152_1 CDM 0301 RC 82172 HCPCS inpatient 410 266.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 319.8 78 999999999 248.26 397.7 percent of total billed charges Apolipoprotein level 50434152_1 CDM 0301 RC 82172 HCPCS inpatient 410 266.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 282.9 69 999999999 248.26 397.7 percent of total billed charges Apolipoprotein level 50434152_1 CDM 0301 RC 82172 HCPCS inpatient 410 266.5 SIHO - ALL PLANS SIHO - ALL PLANS 369 90 999999999 248.26 397.7 percent of total billed charges Apolipoprotein level 50434152_1 CDM 0301 RC 82172 HCPCS inpatient 410 266.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 248.26 60.55 999999999 248.26 397.7 percent of total billed charges Apolipoprotein level 50434152_1 CDM 0301 RC 82172 HCPCS inpatient 410 266.5 UMR - ALL PLANS UMR - ALL PLANS 287 70 999999999 248.26 397.7 percent of total billed charges Apolipoprotein level 50434152_1 CDM 0301 RC 82172 HCPCS inpatient 410 266.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 248.26 397.7 Apolipoprotein level 50434152_1 CDM 0301 RC 82172 HCPCS inpatient 410 266.5 ANTHEM HMO ANTHEM HMO 999999999 248.26 397.7 Apolipoprotein level 50434152_1 CDM 0301 RC 82172 HCPCS inpatient 410 266.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 248.26 397.7 Apolipoprotein level 50434152_1 CDM 0301 RC 82172 HCPCS inpatient 410 266.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 248.26 397.7 Apolipoprotein level 50434152_1 CDM 0301 RC 82172 HCPCS inpatient 410 266.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 248.26 397.7 Apolipoprotein level 50434152_1 CDM 0301 RC 82172 HCPCS inpatient 410 266.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 277.16 67.6 999999999 248.26 397.7 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434153_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.7 65 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434153_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 AETNA AETNA 61.62 79 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434153_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 75.66 97 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434153_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.84 78 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434153_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.82 69 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434153_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 SIHO - ALL PLANS SIHO - ALL PLANS 70.2 90 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434153_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.23 60.55 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434153_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 UMR - ALL PLANS UMR - ALL PLANS 54.6 70 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434153_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.23 75.66 Analysis for antibody to Coccidioides (bacteria) 50434153_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 ANTHEM HMO ANTHEM HMO 999999999 47.23 75.66 Analysis for antibody to Coccidioides (bacteria) 50434153_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.23 75.66 Analysis for antibody to Coccidioides (bacteria) 50434153_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.23 75.66 Analysis for antibody to Coccidioides (bacteria) 50434153_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.23 75.66 Analysis for antibody to Coccidioides (bacteria) 50434153_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.73 67.6 999999999 47.23 75.66 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 50434154_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 309.4 65 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 50434154_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 AETNA AETNA 376.04 79 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 50434154_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 461.72 97 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 50434154_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 371.28 78 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 50434154_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 328.44 69 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 50434154_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 SIHO - ALL PLANS SIHO - ALL PLANS 428.4 90 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 50434154_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 288.22 60.55 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 50434154_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 UMR - ALL PLANS UMR - ALL PLANS 333.2 70 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 50434154_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 288.22 461.72 Translocation analysis (BCR/ABL1) major breakpoint 50434154_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 ANTHEM HMO ANTHEM HMO 999999999 288.22 461.72 Translocation analysis (BCR/ABL1) major breakpoint 50434154_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 288.22 461.72 Translocation analysis (BCR/ABL1) major breakpoint 50434154_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 288.22 461.72 Translocation analysis (BCR/ABL1) major breakpoint 50434154_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 288.22 461.72 Translocation analysis (BCR/ABL1) major breakpoint 50434154_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 321.78 67.6 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 50434155_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 309.4 65 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 50434155_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 AETNA AETNA 376.04 79 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 50434155_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 461.72 97 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 50434155_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 371.28 78 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 50434155_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 328.44 69 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 50434155_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 SIHO - ALL PLANS SIHO - ALL PLANS 428.4 90 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 50434155_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 288.22 60.55 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 50434155_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 UMR - ALL PLANS UMR - ALL PLANS 333.2 70 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) major breakpoint 50434155_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 288.22 461.72 Translocation analysis (BCR/ABL1) major breakpoint 50434155_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 ANTHEM HMO ANTHEM HMO 999999999 288.22 461.72 Translocation analysis (BCR/ABL1) major breakpoint 50434155_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 288.22 461.72 Translocation analysis (BCR/ABL1) major breakpoint 50434155_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 288.22 461.72 Translocation analysis (BCR/ABL1) major breakpoint 50434155_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 288.22 461.72 Translocation analysis (BCR/ABL1) major breakpoint 50434155_1 CDM 0301 RC 81206 HCPCS inpatient 476 309.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 321.78 67.6 999999999 288.22 461.72 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434156_1 CDM 0301 RC 86146 HCPCS inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434156_1 CDM 0301 RC 86146 HCPCS inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434156_1 CDM 0301 RC 86146 HCPCS inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434156_1 CDM 0301 RC 86146 HCPCS inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434156_1 CDM 0301 RC 86146 HCPCS inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434156_1 CDM 0301 RC 86146 HCPCS inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434156_1 CDM 0301 RC 86146 HCPCS inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434156_1 CDM 0301 RC 86146 HCPCS inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434156_1 CDM 0301 RC 86146 HCPCS inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434156_1 CDM 0301 RC 86146 HCPCS inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434156_1 CDM 0301 RC 86146 HCPCS inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434156_1 CDM 0301 RC 86146 HCPCS inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434156_1 CDM 0301 RC 86146 HCPCS inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434156_1 CDM 0301 RC 86146 HCPCS inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434157_1 CDM 0301 RC 86146 HCPCS inpatient 121 78.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 78.65 65 999999999 73.27 117.37 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434157_1 CDM 0301 RC 86146 HCPCS inpatient 121 78.65 AETNA AETNA 95.59 79 999999999 73.27 117.37 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434157_1 CDM 0301 RC 86146 HCPCS inpatient 121 78.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 117.37 97 999999999 73.27 117.37 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434157_1 CDM 0301 RC 86146 HCPCS inpatient 121 78.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 94.38 78 999999999 73.27 117.37 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434157_1 CDM 0301 RC 86146 HCPCS inpatient 121 78.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 83.49 69 999999999 73.27 117.37 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434157_1 CDM 0301 RC 86146 HCPCS inpatient 121 78.65 SIHO - ALL PLANS SIHO - ALL PLANS 108.9 90 999999999 73.27 117.37 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434157_1 CDM 0301 RC 86146 HCPCS inpatient 121 78.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.27 60.55 999999999 73.27 117.37 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434157_1 CDM 0301 RC 86146 HCPCS inpatient 121 78.65 UMR - ALL PLANS UMR - ALL PLANS 84.7 70 999999999 73.27 117.37 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434157_1 CDM 0301 RC 86146 HCPCS inpatient 121 78.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.27 117.37 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434157_1 CDM 0301 RC 86146 HCPCS inpatient 121 78.65 ANTHEM HMO ANTHEM HMO 999999999 73.27 117.37 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434157_1 CDM 0301 RC 86146 HCPCS inpatient 121 78.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.27 117.37 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434157_1 CDM 0301 RC 86146 HCPCS inpatient 121 78.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.27 117.37 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434157_1 CDM 0301 RC 86146 HCPCS inpatient 121 78.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.27 117.37 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50434157_1 CDM 0301 RC 86146 HCPCS inpatient 121 78.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.8 67.6 999999999 73.27 117.37 percent of total billed charges Beta-2 microglobulin (protein) level 50434158_1 CDM 0301 RC 82232 HCPCS inpatient 189 122.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.85 65 999999999 114.44 183.33 percent of total billed charges Beta-2 microglobulin (protein) level 50434158_1 CDM 0301 RC 82232 HCPCS inpatient 189 122.85 AETNA AETNA 149.31 79 999999999 114.44 183.33 percent of total billed charges Beta-2 microglobulin (protein) level 50434158_1 CDM 0301 RC 82232 HCPCS inpatient 189 122.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 183.33 97 999999999 114.44 183.33 percent of total billed charges Beta-2 microglobulin (protein) level 50434158_1 CDM 0301 RC 82232 HCPCS inpatient 189 122.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 147.42 78 999999999 114.44 183.33 percent of total billed charges Beta-2 microglobulin (protein) level 50434158_1 CDM 0301 RC 82232 HCPCS inpatient 189 122.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 130.41 69 999999999 114.44 183.33 percent of total billed charges Beta-2 microglobulin (protein) level 50434158_1 CDM 0301 RC 82232 HCPCS inpatient 189 122.85 SIHO - ALL PLANS SIHO - ALL PLANS 170.1 90 999999999 114.44 183.33 percent of total billed charges Beta-2 microglobulin (protein) level 50434158_1 CDM 0301 RC 82232 HCPCS inpatient 189 122.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 114.44 60.55 999999999 114.44 183.33 percent of total billed charges Beta-2 microglobulin (protein) level 50434158_1 CDM 0301 RC 82232 HCPCS inpatient 189 122.85 UMR - ALL PLANS UMR - ALL PLANS 132.3 70 999999999 114.44 183.33 percent of total billed charges Beta-2 microglobulin (protein) level 50434158_1 CDM 0301 RC 82232 HCPCS inpatient 189 122.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 114.44 183.33 Beta-2 microglobulin (protein) level 50434158_1 CDM 0301 RC 82232 HCPCS inpatient 189 122.85 ANTHEM HMO ANTHEM HMO 999999999 114.44 183.33 Beta-2 microglobulin (protein) level 50434158_1 CDM 0301 RC 82232 HCPCS inpatient 189 122.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 114.44 183.33 Beta-2 microglobulin (protein) level 50434158_1 CDM 0301 RC 82232 HCPCS inpatient 189 122.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 114.44 183.33 Beta-2 microglobulin (protein) level 50434158_1 CDM 0301 RC 82232 HCPCS inpatient 189 122.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 114.44 183.33 Beta-2 microglobulin (protein) level 50434158_1 CDM 0301 RC 82232 HCPCS inpatient 189 122.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.76 67.6 999999999 114.44 183.33 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 50434159_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 50434159_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 50434159_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 50434159_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 50434159_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 50434159_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 50434159_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 50434159_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 50434159_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 "Immunologic analysis technique on body fluid, other fluids with concentration" 50434159_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 "Immunologic analysis technique on body fluid, other fluids with concentration" 50434159_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 "Immunologic analysis technique on body fluid, other fluids with concentration" 50434159_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 "Immunologic analysis technique on body fluid, other fluids with concentration" 50434159_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 "Immunologic analysis technique on body fluid, other fluids with concentration" 50434159_1 CDM 0301 RC 86335 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges Mass spectrometry (laboratory testing method) 50434160_1 CDM 0301 RC 83789 HCPCS inpatient 381 247.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 247.65 65 999999999 230.7 369.57 percent of total billed charges Mass spectrometry (laboratory testing method) 50434160_1 CDM 0301 RC 83789 HCPCS inpatient 381 247.65 AETNA AETNA 300.99 79 999999999 230.7 369.57 percent of total billed charges Mass spectrometry (laboratory testing method) 50434160_1 CDM 0301 RC 83789 HCPCS inpatient 381 247.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 369.57 97 999999999 230.7 369.57 percent of total billed charges Mass spectrometry (laboratory testing method) 50434160_1 CDM 0301 RC 83789 HCPCS inpatient 381 247.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 297.18 78 999999999 230.7 369.57 percent of total billed charges Mass spectrometry (laboratory testing method) 50434160_1 CDM 0301 RC 83789 HCPCS inpatient 381 247.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 262.89 69 999999999 230.7 369.57 percent of total billed charges Mass spectrometry (laboratory testing method) 50434160_1 CDM 0301 RC 83789 HCPCS inpatient 381 247.65 SIHO - ALL PLANS SIHO - ALL PLANS 342.9 90 999999999 230.7 369.57 percent of total billed charges Mass spectrometry (laboratory testing method) 50434160_1 CDM 0301 RC 83789 HCPCS inpatient 381 247.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 230.7 60.55 999999999 230.7 369.57 percent of total billed charges Mass spectrometry (laboratory testing method) 50434160_1 CDM 0301 RC 83789 HCPCS inpatient 381 247.65 UMR - ALL PLANS UMR - ALL PLANS 266.7 70 999999999 230.7 369.57 percent of total billed charges Mass spectrometry (laboratory testing method) 50434160_1 CDM 0301 RC 83789 HCPCS inpatient 381 247.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 230.7 369.57 Mass spectrometry (laboratory testing method) 50434160_1 CDM 0301 RC 83789 HCPCS inpatient 381 247.65 ANTHEM HMO ANTHEM HMO 999999999 230.7 369.57 Mass spectrometry (laboratory testing method) 50434160_1 CDM 0301 RC 83789 HCPCS inpatient 381 247.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 230.7 369.57 Mass spectrometry (laboratory testing method) 50434160_1 CDM 0301 RC 83789 HCPCS inpatient 381 247.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 230.7 369.57 Mass spectrometry (laboratory testing method) 50434160_1 CDM 0301 RC 83789 HCPCS inpatient 381 247.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 230.7 369.57 Mass spectrometry (laboratory testing method) 50434160_1 CDM 0301 RC 83789 HCPCS inpatient 381 247.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 257.56 67.6 999999999 230.7 369.57 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434161_1 CDM 0301 RC 86635 HCPCS inpatient 60 39 SELF PAY DISCOUNT SELF PAY DISCOUNT 39 65 999999999 36.33 58.2 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434161_1 CDM 0301 RC 86635 HCPCS inpatient 60 39 AETNA AETNA 47.4 79 999999999 36.33 58.2 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434161_1 CDM 0301 RC 86635 HCPCS inpatient 60 39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.2 97 999999999 36.33 58.2 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434161_1 CDM 0301 RC 86635 HCPCS inpatient 60 39 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.8 78 999999999 36.33 58.2 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434161_1 CDM 0301 RC 86635 HCPCS inpatient 60 39 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.4 69 999999999 36.33 58.2 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434161_1 CDM 0301 RC 86635 HCPCS inpatient 60 39 SIHO - ALL PLANS SIHO - ALL PLANS 54 90 999999999 36.33 58.2 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434161_1 CDM 0301 RC 86635 HCPCS inpatient 60 39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.33 60.55 999999999 36.33 58.2 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434161_1 CDM 0301 RC 86635 HCPCS inpatient 60 39 UMR - ALL PLANS UMR - ALL PLANS 42 70 999999999 36.33 58.2 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434161_1 CDM 0301 RC 86635 HCPCS inpatient 60 39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.33 58.2 Analysis for antibody to Coccidioides (bacteria) 50434161_1 CDM 0301 RC 86635 HCPCS inpatient 60 39 ANTHEM HMO ANTHEM HMO 999999999 36.33 58.2 Analysis for antibody to Coccidioides (bacteria) 50434161_1 CDM 0301 RC 86635 HCPCS inpatient 60 39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.33 58.2 Analysis for antibody to Coccidioides (bacteria) 50434161_1 CDM 0301 RC 86635 HCPCS inpatient 60 39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.33 58.2 Analysis for antibody to Coccidioides (bacteria) 50434161_1 CDM 0301 RC 86635 HCPCS inpatient 60 39 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.33 58.2 Analysis for antibody to Coccidioides (bacteria) 50434161_1 CDM 0301 RC 86635 HCPCS inpatient 60 39 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.56 67.6 999999999 36.33 58.2 percent of total billed charges Detection test by immunoassay technique for other organism 50434162_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.3 65 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 50434162_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 AETNA AETNA 143.78 79 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 50434162_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 176.54 97 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 50434162_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.96 78 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 50434162_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 125.58 69 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 50434162_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 SIHO - ALL PLANS SIHO - ALL PLANS 163.8 90 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 50434162_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.2 60.55 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 50434162_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 UMR - ALL PLANS UMR - ALL PLANS 127.4 70 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 50434162_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.2 176.54 Detection test by immunoassay technique for other organism 50434162_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 ANTHEM HMO ANTHEM HMO 999999999 110.2 176.54 Detection test by immunoassay technique for other organism 50434162_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.2 176.54 Detection test by immunoassay technique for other organism 50434162_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.2 176.54 Detection test by immunoassay technique for other organism 50434162_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.2 176.54 Detection test by immunoassay technique for other organism 50434162_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.03 67.6 999999999 110.2 176.54 percent of total billed charges Analysis for antibody to Brucella (bacteria) 50434163_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 50434163_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 50434163_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 50434163_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 50434163_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 50434163_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 50434163_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 50434163_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 50434163_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 50434163_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 50434163_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 50434163_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 50434163_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 50434163_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50434164_1 CDM 0302 RC 86160 HCPCS inpatient 166 107.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.9 65 999999999 100.51 161.02 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50434164_1 CDM 0302 RC 86160 HCPCS inpatient 166 107.9 AETNA AETNA 131.14 79 999999999 100.51 161.02 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50434164_1 CDM 0302 RC 86160 HCPCS inpatient 166 107.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.02 97 999999999 100.51 161.02 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50434164_1 CDM 0302 RC 86160 HCPCS inpatient 166 107.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 129.48 78 999999999 100.51 161.02 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50434164_1 CDM 0302 RC 86160 HCPCS inpatient 166 107.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 114.54 69 999999999 100.51 161.02 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50434164_1 CDM 0302 RC 86160 HCPCS inpatient 166 107.9 SIHO - ALL PLANS SIHO - ALL PLANS 149.4 90 999999999 100.51 161.02 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50434164_1 CDM 0302 RC 86160 HCPCS inpatient 166 107.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 100.51 60.55 999999999 100.51 161.02 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50434164_1 CDM 0302 RC 86160 HCPCS inpatient 166 107.9 UMR - ALL PLANS UMR - ALL PLANS 116.2 70 999999999 100.51 161.02 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50434164_1 CDM 0302 RC 86160 HCPCS inpatient 166 107.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 100.51 161.02 "Measurement of complement (immune system proteins), antigen," 50434164_1 CDM 0302 RC 86160 HCPCS inpatient 166 107.9 ANTHEM HMO ANTHEM HMO 999999999 100.51 161.02 "Measurement of complement (immune system proteins), antigen," 50434164_1 CDM 0302 RC 86160 HCPCS inpatient 166 107.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 100.51 161.02 "Measurement of complement (immune system proteins), antigen," 50434164_1 CDM 0302 RC 86160 HCPCS inpatient 166 107.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 100.51 161.02 "Measurement of complement (immune system proteins), antigen," 50434164_1 CDM 0302 RC 86160 HCPCS inpatient 166 107.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 100.51 161.02 "Measurement of complement (immune system proteins), antigen," 50434164_1 CDM 0302 RC 86160 HCPCS inpatient 166 107.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.22 67.6 999999999 100.51 161.02 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 50434165_1 CDM 0302 RC 86304 HCPCS inpatient 299 194.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 194.35 65 999999999 181.04 290.03 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 50434165_1 CDM 0302 RC 86304 HCPCS inpatient 299 194.35 AETNA AETNA 236.21 79 999999999 181.04 290.03 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 50434165_1 CDM 0302 RC 86304 HCPCS inpatient 299 194.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 290.03 97 999999999 181.04 290.03 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 50434165_1 CDM 0302 RC 86304 HCPCS inpatient 299 194.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 233.22 78 999999999 181.04 290.03 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 50434165_1 CDM 0302 RC 86304 HCPCS inpatient 299 194.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 206.31 69 999999999 181.04 290.03 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 50434165_1 CDM 0302 RC 86304 HCPCS inpatient 299 194.35 SIHO - ALL PLANS SIHO - ALL PLANS 269.1 90 999999999 181.04 290.03 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 50434165_1 CDM 0302 RC 86304 HCPCS inpatient 299 194.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 181.04 60.55 999999999 181.04 290.03 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 50434165_1 CDM 0302 RC 86304 HCPCS inpatient 299 194.35 UMR - ALL PLANS UMR - ALL PLANS 209.3 70 999999999 181.04 290.03 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 50434165_1 CDM 0302 RC 86304 HCPCS inpatient 299 194.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 181.04 290.03 "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 50434165_1 CDM 0302 RC 86304 HCPCS inpatient 299 194.35 ANTHEM HMO ANTHEM HMO 999999999 181.04 290.03 "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 50434165_1 CDM 0302 RC 86304 HCPCS inpatient 299 194.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 181.04 290.03 "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 50434165_1 CDM 0302 RC 86304 HCPCS inpatient 299 194.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 181.04 290.03 "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 50434165_1 CDM 0302 RC 86304 HCPCS inpatient 299 194.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 181.04 290.03 "Immunologic analysis for detection of tumor antigen, quantitative; CA 125" 50434165_1 CDM 0302 RC 86304 HCPCS inpatient 299 194.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 202.12 67.6 999999999 181.04 290.03 percent of total billed charges Cadmium level 50434166_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Cadmium level 50434166_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Cadmium level 50434166_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Cadmium level 50434166_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Cadmium level 50434166_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Cadmium level 50434166_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Cadmium level 50434166_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Cadmium level 50434166_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Cadmium level 50434166_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Cadmium level 50434166_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Cadmium level 50434166_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Cadmium level 50434166_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Cadmium level 50434166_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Cadmium level 50434166_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges "Calcium level, ionized" 50434167_1 CDM 0301 RC 82330 HCPCS inpatient 336 218.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 218.4 65 999999999 203.45 325.92 percent of total billed charges "Calcium level, ionized" 50434167_1 CDM 0301 RC 82330 HCPCS inpatient 336 218.4 AETNA AETNA 265.44 79 999999999 203.45 325.92 percent of total billed charges "Calcium level, ionized" 50434167_1 CDM 0301 RC 82330 HCPCS inpatient 336 218.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 325.92 97 999999999 203.45 325.92 percent of total billed charges "Calcium level, ionized" 50434167_1 CDM 0301 RC 82330 HCPCS inpatient 336 218.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 262.08 78 999999999 203.45 325.92 percent of total billed charges "Calcium level, ionized" 50434167_1 CDM 0301 RC 82330 HCPCS inpatient 336 218.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 231.84 69 999999999 203.45 325.92 percent of total billed charges "Calcium level, ionized" 50434167_1 CDM 0301 RC 82330 HCPCS inpatient 336 218.4 SIHO - ALL PLANS SIHO - ALL PLANS 302.4 90 999999999 203.45 325.92 percent of total billed charges "Calcium level, ionized" 50434167_1 CDM 0301 RC 82330 HCPCS inpatient 336 218.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 203.45 60.55 999999999 203.45 325.92 percent of total billed charges "Calcium level, ionized" 50434167_1 CDM 0301 RC 82330 HCPCS inpatient 336 218.4 UMR - ALL PLANS UMR - ALL PLANS 235.2 70 999999999 203.45 325.92 percent of total billed charges "Calcium level, ionized" 50434167_1 CDM 0301 RC 82330 HCPCS inpatient 336 218.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 203.45 325.92 "Calcium level, ionized" 50434167_1 CDM 0301 RC 82330 HCPCS inpatient 336 218.4 ANTHEM HMO ANTHEM HMO 999999999 203.45 325.92 "Calcium level, ionized" 50434167_1 CDM 0301 RC 82330 HCPCS inpatient 336 218.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 203.45 325.92 "Calcium level, ionized" 50434167_1 CDM 0301 RC 82330 HCPCS inpatient 336 218.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 203.45 325.92 "Calcium level, ionized" 50434167_1 CDM 0301 RC 82330 HCPCS inpatient 336 218.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 203.45 325.92 "Calcium level, ionized" 50434167_1 CDM 0301 RC 82330 HCPCS inpatient 336 218.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 227.14 67.6 999999999 203.45 325.92 percent of total billed charges "Cannabinoids levels, natural" 50434169_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 50434169_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 50434169_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 50434169_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 50434169_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 50434169_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 50434169_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 50434169_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges "Cannabinoids levels, natural" 50434169_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 "Cannabinoids levels, natural" 50434169_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 "Cannabinoids levels, natural" 50434169_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 "Cannabinoids levels, natural" 50434169_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 "Cannabinoids levels, natural" 50434169_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 "Cannabinoids levels, natural" 50434169_1 CDM 0301 RC 80349 HCPCS inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges Carbohydrate deficient transferrin (protein) level 50434170_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges Carbohydrate deficient transferrin (protein) level 50434170_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges Carbohydrate deficient transferrin (protein) level 50434170_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges Carbohydrate deficient transferrin (protein) level 50434170_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges Carbohydrate deficient transferrin (protein) level 50434170_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges Carbohydrate deficient transferrin (protein) level 50434170_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges Carbohydrate deficient transferrin (protein) level 50434170_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges Carbohydrate deficient transferrin (protein) level 50434170_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges Carbohydrate deficient transferrin (protein) level 50434170_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 Carbohydrate deficient transferrin (protein) level 50434170_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 Carbohydrate deficient transferrin (protein) level 50434170_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 Carbohydrate deficient transferrin (protein) level 50434170_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 Carbohydrate deficient transferrin (protein) level 50434170_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 Carbohydrate deficient transferrin (protein) level 50434170_1 CDM 0301 RC 82373 HCPCS inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges Carboxyhemoglobin (protein) level 50434171_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 146.25 65 999999999 136.24 218.25 percent of total billed charges Carboxyhemoglobin (protein) level 50434171_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 AETNA AETNA 177.75 79 999999999 136.24 218.25 percent of total billed charges Carboxyhemoglobin (protein) level 50434171_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 218.25 97 999999999 136.24 218.25 percent of total billed charges Carboxyhemoglobin (protein) level 50434171_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 175.5 78 999999999 136.24 218.25 percent of total billed charges Carboxyhemoglobin (protein) level 50434171_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 155.25 69 999999999 136.24 218.25 percent of total billed charges Carboxyhemoglobin (protein) level 50434171_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 SIHO - ALL PLANS SIHO - ALL PLANS 202.5 90 999999999 136.24 218.25 percent of total billed charges Carboxyhemoglobin (protein) level 50434171_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 136.24 60.55 999999999 136.24 218.25 percent of total billed charges Carboxyhemoglobin (protein) level 50434171_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 UMR - ALL PLANS UMR - ALL PLANS 157.5 70 999999999 136.24 218.25 percent of total billed charges Carboxyhemoglobin (protein) level 50434171_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 136.24 218.25 Carboxyhemoglobin (protein) level 50434171_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 ANTHEM HMO ANTHEM HMO 999999999 136.24 218.25 Carboxyhemoglobin (protein) level 50434171_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 136.24 218.25 Carboxyhemoglobin (protein) level 50434171_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 136.24 218.25 Carboxyhemoglobin (protein) level 50434171_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 136.24 218.25 Carboxyhemoglobin (protein) level 50434171_1 CDM 0301 RC 82375 HCPCS inpatient 225 146.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 152.1 67.6 999999999 136.24 218.25 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434172_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 75.4 65 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434172_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 AETNA AETNA 91.64 79 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434172_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 112.52 97 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434172_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 90.48 78 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434172_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.04 69 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434172_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 SIHO - ALL PLANS SIHO - ALL PLANS 104.4 90 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434172_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 70.24 60.55 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434172_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 UMR - ALL PLANS UMR - ALL PLANS 81.2 70 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434172_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 70.24 112.52 Cardiolipin antibody (tissue antibody) measurement 50434172_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 ANTHEM HMO ANTHEM HMO 999999999 70.24 112.52 Cardiolipin antibody (tissue antibody) measurement 50434172_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 70.24 112.52 Cardiolipin antibody (tissue antibody) measurement 50434172_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 70.24 112.52 Cardiolipin antibody (tissue antibody) measurement 50434172_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 70.24 112.52 Cardiolipin antibody (tissue antibody) measurement 50434172_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 78.42 67.6 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434173_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 75.4 65 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434173_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 AETNA AETNA 91.64 79 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434173_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 112.52 97 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434173_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 90.48 78 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434173_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.04 69 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434173_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 SIHO - ALL PLANS SIHO - ALL PLANS 104.4 90 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434173_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 70.24 60.55 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434173_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 UMR - ALL PLANS UMR - ALL PLANS 81.2 70 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434173_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 70.24 112.52 Cardiolipin antibody (tissue antibody) measurement 50434173_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 ANTHEM HMO ANTHEM HMO 999999999 70.24 112.52 Cardiolipin antibody (tissue antibody) measurement 50434173_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 70.24 112.52 Cardiolipin antibody (tissue antibody) measurement 50434173_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 70.24 112.52 Cardiolipin antibody (tissue antibody) measurement 50434173_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 70.24 112.52 Cardiolipin antibody (tissue antibody) measurement 50434173_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 78.42 67.6 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434174_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 75.4 65 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434174_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 AETNA AETNA 91.64 79 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434174_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 112.52 97 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434174_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 90.48 78 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434174_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.04 69 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434174_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 SIHO - ALL PLANS SIHO - ALL PLANS 104.4 90 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434174_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 70.24 60.55 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434174_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 UMR - ALL PLANS UMR - ALL PLANS 81.2 70 999999999 70.24 112.52 percent of total billed charges Cardiolipin antibody (tissue antibody) measurement 50434174_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 70.24 112.52 Cardiolipin antibody (tissue antibody) measurement 50434174_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 ANTHEM HMO ANTHEM HMO 999999999 70.24 112.52 Cardiolipin antibody (tissue antibody) measurement 50434174_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 70.24 112.52 Cardiolipin antibody (tissue antibody) measurement 50434174_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 70.24 112.52 Cardiolipin antibody (tissue antibody) measurement 50434174_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 70.24 112.52 Cardiolipin antibody (tissue antibody) measurement 50434174_1 CDM 0302 RC 86147 HCPCS inpatient 116 75.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 78.42 67.6 999999999 70.24 112.52 percent of total billed charges Carotene level 50434175_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges Carotene level 50434175_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges Carotene level 50434175_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges Carotene level 50434175_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges Carotene level 50434175_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges Carotene level 50434175_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges Carotene level 50434175_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges Carotene level 50434175_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges Carotene level 50434175_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 Carotene level 50434175_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 Carotene level 50434175_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 Carotene level 50434175_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 Carotene level 50434175_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 Carotene level 50434175_1 CDM 0301 RC 82380 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges Catecholamines (organic nitrogen) level 50434176_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 50434176_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 50434176_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 50434176_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 50434176_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 50434176_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 50434176_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 50434176_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges Catecholamines (organic nitrogen) level 50434176_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 Catecholamines (organic nitrogen) level 50434176_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 Catecholamines (organic nitrogen) level 50434176_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 Catecholamines (organic nitrogen) level 50434176_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 Catecholamines (organic nitrogen) level 50434176_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 Catecholamines (organic nitrogen) level 50434176_1 CDM 0301 RC 82384 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges Carcinoembryonic antigen (CEA) protein level 50434177_1 CDM 0301 RC 82378 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges Carcinoembryonic antigen (CEA) protein level 50434177_1 CDM 0301 RC 82378 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges Carcinoembryonic antigen (CEA) protein level 50434177_1 CDM 0301 RC 82378 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges Carcinoembryonic antigen (CEA) protein level 50434177_1 CDM 0301 RC 82378 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges Carcinoembryonic antigen (CEA) protein level 50434177_1 CDM 0301 RC 82378 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges Carcinoembryonic antigen (CEA) protein level 50434177_1 CDM 0301 RC 82378 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges Carcinoembryonic antigen (CEA) protein level 50434177_1 CDM 0301 RC 82378 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges Carcinoembryonic antigen (CEA) protein level 50434177_1 CDM 0301 RC 82378 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges Carcinoembryonic antigen (CEA) protein level 50434177_1 CDM 0301 RC 82378 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 Carcinoembryonic antigen (CEA) protein level 50434177_1 CDM 0301 RC 82378 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 Carcinoembryonic antigen (CEA) protein level 50434177_1 CDM 0301 RC 82378 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 Carcinoembryonic antigen (CEA) protein level 50434177_1 CDM 0301 RC 82378 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 Carcinoembryonic antigen (CEA) protein level 50434177_1 CDM 0301 RC 82378 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 Carcinoembryonic antigen (CEA) protein level 50434177_1 CDM 0301 RC 82378 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434178_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 104.65 65 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434178_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 AETNA AETNA 127.19 79 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434178_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 156.17 97 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434178_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 125.58 78 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434178_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 111.09 69 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434178_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 SIHO - ALL PLANS SIHO - ALL PLANS 144.9 90 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434178_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 97.49 60.55 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434178_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 UMR - ALL PLANS UMR - ALL PLANS 112.7 70 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434178_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 97.49 156.17 Gammaglobulin (immune system protein) measurement 50434178_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 ANTHEM HMO ANTHEM HMO 999999999 97.49 156.17 Gammaglobulin (immune system protein) measurement 50434178_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 97.49 156.17 Gammaglobulin (immune system protein) measurement 50434178_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 97.49 156.17 Gammaglobulin (immune system protein) measurement 50434178_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 97.49 156.17 Gammaglobulin (immune system protein) measurement 50434178_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.84 67.6 999999999 97.49 156.17 percent of total billed charges Ceruloplasmin (protein) level 50434179_1 CDM 0301 RC 82390 HCPCS inpatient 121 78.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 78.65 65 999999999 73.27 117.37 percent of total billed charges Ceruloplasmin (protein) level 50434179_1 CDM 0301 RC 82390 HCPCS inpatient 121 78.65 AETNA AETNA 95.59 79 999999999 73.27 117.37 percent of total billed charges Ceruloplasmin (protein) level 50434179_1 CDM 0301 RC 82390 HCPCS inpatient 121 78.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 117.37 97 999999999 73.27 117.37 percent of total billed charges Ceruloplasmin (protein) level 50434179_1 CDM 0301 RC 82390 HCPCS inpatient 121 78.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 94.38 78 999999999 73.27 117.37 percent of total billed charges Ceruloplasmin (protein) level 50434179_1 CDM 0301 RC 82390 HCPCS inpatient 121 78.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 83.49 69 999999999 73.27 117.37 percent of total billed charges Ceruloplasmin (protein) level 50434179_1 CDM 0301 RC 82390 HCPCS inpatient 121 78.65 SIHO - ALL PLANS SIHO - ALL PLANS 108.9 90 999999999 73.27 117.37 percent of total billed charges Ceruloplasmin (protein) level 50434179_1 CDM 0301 RC 82390 HCPCS inpatient 121 78.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.27 60.55 999999999 73.27 117.37 percent of total billed charges Ceruloplasmin (protein) level 50434179_1 CDM 0301 RC 82390 HCPCS inpatient 121 78.65 UMR - ALL PLANS UMR - ALL PLANS 84.7 70 999999999 73.27 117.37 percent of total billed charges Ceruloplasmin (protein) level 50434179_1 CDM 0301 RC 82390 HCPCS inpatient 121 78.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.27 117.37 Ceruloplasmin (protein) level 50434179_1 CDM 0301 RC 82390 HCPCS inpatient 121 78.65 ANTHEM HMO ANTHEM HMO 999999999 73.27 117.37 Ceruloplasmin (protein) level 50434179_1 CDM 0301 RC 82390 HCPCS inpatient 121 78.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.27 117.37 Ceruloplasmin (protein) level 50434179_1 CDM 0301 RC 82390 HCPCS inpatient 121 78.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.27 117.37 Ceruloplasmin (protein) level 50434179_1 CDM 0301 RC 82390 HCPCS inpatient 121 78.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.27 117.37 Ceruloplasmin (protein) level 50434179_1 CDM 0301 RC 82390 HCPCS inpatient 121 78.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.8 67.6 999999999 73.27 117.37 percent of total billed charges Culture for chlamydia 50434180_1 CDM 0301 RC 87110 HCPCS inpatient 107 69.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 69.55 65 999999999 64.79 103.79 percent of total billed charges Culture for chlamydia 50434180_1 CDM 0301 RC 87110 HCPCS inpatient 107 69.55 AETNA AETNA 84.53 79 999999999 64.79 103.79 percent of total billed charges Culture for chlamydia 50434180_1 CDM 0301 RC 87110 HCPCS inpatient 107 69.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 103.79 97 999999999 64.79 103.79 percent of total billed charges Culture for chlamydia 50434180_1 CDM 0301 RC 87110 HCPCS inpatient 107 69.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 83.46 78 999999999 64.79 103.79 percent of total billed charges Culture for chlamydia 50434180_1 CDM 0301 RC 87110 HCPCS inpatient 107 69.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.83 69 999999999 64.79 103.79 percent of total billed charges Culture for chlamydia 50434180_1 CDM 0301 RC 87110 HCPCS inpatient 107 69.55 SIHO - ALL PLANS SIHO - ALL PLANS 96.3 90 999999999 64.79 103.79 percent of total billed charges Culture for chlamydia 50434180_1 CDM 0301 RC 87110 HCPCS inpatient 107 69.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.79 60.55 999999999 64.79 103.79 percent of total billed charges Culture for chlamydia 50434180_1 CDM 0301 RC 87110 HCPCS inpatient 107 69.55 UMR - ALL PLANS UMR - ALL PLANS 74.9 70 999999999 64.79 103.79 percent of total billed charges Culture for chlamydia 50434180_1 CDM 0301 RC 87110 HCPCS inpatient 107 69.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.79 103.79 Culture for chlamydia 50434180_1 CDM 0301 RC 87110 HCPCS inpatient 107 69.55 ANTHEM HMO ANTHEM HMO 999999999 64.79 103.79 Culture for chlamydia 50434180_1 CDM 0301 RC 87110 HCPCS inpatient 107 69.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.79 103.79 Culture for chlamydia 50434180_1 CDM 0301 RC 87110 HCPCS inpatient 107 69.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.79 103.79 Culture for chlamydia 50434180_1 CDM 0301 RC 87110 HCPCS inpatient 107 69.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.79 103.79 Culture for chlamydia 50434180_1 CDM 0301 RC 87110 HCPCS inpatient 107 69.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 72.33 67.6 999999999 64.79 103.79 percent of total billed charges Analysis for detection of tumor marker 50434181_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 124.8 65 999999999 116.26 186.24 percent of total billed charges Analysis for detection of tumor marker 50434181_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 AETNA AETNA 151.68 79 999999999 116.26 186.24 percent of total billed charges Analysis for detection of tumor marker 50434181_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 186.24 97 999999999 116.26 186.24 percent of total billed charges Analysis for detection of tumor marker 50434181_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 149.76 78 999999999 116.26 186.24 percent of total billed charges Analysis for detection of tumor marker 50434181_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 132.48 69 999999999 116.26 186.24 percent of total billed charges Analysis for detection of tumor marker 50434181_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 SIHO - ALL PLANS SIHO - ALL PLANS 172.8 90 999999999 116.26 186.24 percent of total billed charges Analysis for detection of tumor marker 50434181_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.26 60.55 999999999 116.26 186.24 percent of total billed charges Analysis for detection of tumor marker 50434181_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 UMR - ALL PLANS UMR - ALL PLANS 134.4 70 999999999 116.26 186.24 percent of total billed charges Analysis for detection of tumor marker 50434181_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.26 186.24 Analysis for detection of tumor marker 50434181_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 ANTHEM HMO ANTHEM HMO 999999999 116.26 186.24 Analysis for detection of tumor marker 50434181_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.26 186.24 Analysis for detection of tumor marker 50434181_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.26 186.24 Analysis for detection of tumor marker 50434181_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.26 186.24 Analysis for detection of tumor marker 50434181_1 CDM 0301 RC 86316 HCPCS inpatient 192 124.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 129.79 67.6 999999999 116.26 186.24 percent of total billed charges Citrate level 50434182_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.9 65 999999999 173.17 277.42 percent of total billed charges Citrate level 50434182_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 AETNA AETNA 225.94 79 999999999 173.17 277.42 percent of total billed charges Citrate level 50434182_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 277.42 97 999999999 173.17 277.42 percent of total billed charges Citrate level 50434182_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 223.08 78 999999999 173.17 277.42 percent of total billed charges Citrate level 50434182_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 197.34 69 999999999 173.17 277.42 percent of total billed charges Citrate level 50434182_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 SIHO - ALL PLANS SIHO - ALL PLANS 257.4 90 999999999 173.17 277.42 percent of total billed charges Citrate level 50434182_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 173.17 60.55 999999999 173.17 277.42 percent of total billed charges Citrate level 50434182_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 UMR - ALL PLANS UMR - ALL PLANS 200.2 70 999999999 173.17 277.42 percent of total billed charges Citrate level 50434182_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 173.17 277.42 Citrate level 50434182_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 ANTHEM HMO ANTHEM HMO 999999999 173.17 277.42 Citrate level 50434182_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 173.17 277.42 Citrate level 50434182_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 173.17 277.42 Citrate level 50434182_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 173.17 277.42 Citrate level 50434182_1 CDM 0301 RC 82507 HCPCS inpatient 286 185.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 193.34 67.6 999999999 173.17 277.42 percent of total billed charges "Benzodiazepines levels, 1-12" 50434183_1 CDM 0301 RC 80346 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges "Benzodiazepines levels, 1-12" 50434183_1 CDM 0301 RC 80346 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges "Benzodiazepines levels, 1-12" 50434183_1 CDM 0301 RC 80346 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges "Benzodiazepines levels, 1-12" 50434183_1 CDM 0301 RC 80346 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges "Benzodiazepines levels, 1-12" 50434183_1 CDM 0301 RC 80346 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges "Benzodiazepines levels, 1-12" 50434183_1 CDM 0301 RC 80346 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges "Benzodiazepines levels, 1-12" 50434183_1 CDM 0301 RC 80346 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges "Benzodiazepines levels, 1-12" 50434183_1 CDM 0301 RC 80346 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges "Benzodiazepines levels, 1-12" 50434183_1 CDM 0301 RC 80346 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 "Benzodiazepines levels, 1-12" 50434183_1 CDM 0301 RC 80346 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 "Benzodiazepines levels, 1-12" 50434183_1 CDM 0301 RC 80346 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 "Benzodiazepines levels, 1-12" 50434183_1 CDM 0301 RC 80346 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 "Benzodiazepines levels, 1-12" 50434183_1 CDM 0301 RC 80346 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 "Benzodiazepines levels, 1-12" 50434183_1 CDM 0301 RC 80346 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges Clozapine level 50434184_1 CDM 0301 RC 80159 HCPCS inpatient 256 166.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 166.4 65 999999999 155.01 248.32 percent of total billed charges Clozapine level 50434184_1 CDM 0301 RC 80159 HCPCS inpatient 256 166.4 AETNA AETNA 202.24 79 999999999 155.01 248.32 percent of total billed charges Clozapine level 50434184_1 CDM 0301 RC 80159 HCPCS inpatient 256 166.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 248.32 97 999999999 155.01 248.32 percent of total billed charges Clozapine level 50434184_1 CDM 0301 RC 80159 HCPCS inpatient 256 166.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 199.68 78 999999999 155.01 248.32 percent of total billed charges Clozapine level 50434184_1 CDM 0301 RC 80159 HCPCS inpatient 256 166.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 176.64 69 999999999 155.01 248.32 percent of total billed charges Clozapine level 50434184_1 CDM 0301 RC 80159 HCPCS inpatient 256 166.4 SIHO - ALL PLANS SIHO - ALL PLANS 230.4 90 999999999 155.01 248.32 percent of total billed charges Clozapine level 50434184_1 CDM 0301 RC 80159 HCPCS inpatient 256 166.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.01 60.55 999999999 155.01 248.32 percent of total billed charges Clozapine level 50434184_1 CDM 0301 RC 80159 HCPCS inpatient 256 166.4 UMR - ALL PLANS UMR - ALL PLANS 179.2 70 999999999 155.01 248.32 percent of total billed charges Clozapine level 50434184_1 CDM 0301 RC 80159 HCPCS inpatient 256 166.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.01 248.32 Clozapine level 50434184_1 CDM 0301 RC 80159 HCPCS inpatient 256 166.4 ANTHEM HMO ANTHEM HMO 999999999 155.01 248.32 Clozapine level 50434184_1 CDM 0301 RC 80159 HCPCS inpatient 256 166.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.01 248.32 Clozapine level 50434184_1 CDM 0301 RC 80159 HCPCS inpatient 256 166.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.01 248.32 Clozapine level 50434184_1 CDM 0301 RC 80159 HCPCS inpatient 256 166.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.01 248.32 Clozapine level 50434184_1 CDM 0301 RC 80159 HCPCS inpatient 256 166.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.06 67.6 999999999 155.01 248.32 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434185_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.7 65 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434185_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 AETNA AETNA 61.62 79 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434185_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 75.66 97 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434185_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.84 78 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434185_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.82 69 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434185_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 SIHO - ALL PLANS SIHO - ALL PLANS 70.2 90 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434185_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.23 60.55 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434185_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 UMR - ALL PLANS UMR - ALL PLANS 54.6 70 999999999 47.23 75.66 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434185_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.23 75.66 Analysis for antibody to Coccidioides (bacteria) 50434185_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 ANTHEM HMO ANTHEM HMO 999999999 47.23 75.66 Analysis for antibody to Coccidioides (bacteria) 50434185_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.23 75.66 Analysis for antibody to Coccidioides (bacteria) 50434185_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.23 75.66 Analysis for antibody to Coccidioides (bacteria) 50434185_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.23 75.66 Analysis for antibody to Coccidioides (bacteria) 50434185_1 CDM 0302 RC 86635 HCPCS inpatient 78 50.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.73 67.6 999999999 47.23 75.66 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50434186_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50434186_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50434186_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50434186_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50434186_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50434186_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50434186_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50434186_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50434186_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 50434186_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 50434186_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 50434186_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 50434186_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 50434186_1 CDM 0302 RC 86160 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges Copper level 50434187_1 CDM 0301 RC 82525 HCPCS inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges Copper level 50434187_1 CDM 0301 RC 82525 HCPCS inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges Copper level 50434187_1 CDM 0301 RC 82525 HCPCS inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges Copper level 50434187_1 CDM 0301 RC 82525 HCPCS inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges Copper level 50434187_1 CDM 0301 RC 82525 HCPCS inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges Copper level 50434187_1 CDM 0301 RC 82525 HCPCS inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges Copper level 50434187_1 CDM 0301 RC 82525 HCPCS inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges Copper level 50434187_1 CDM 0301 RC 82525 HCPCS inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges Copper level 50434187_1 CDM 0301 RC 82525 HCPCS inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 Copper level 50434187_1 CDM 0301 RC 82525 HCPCS inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 Copper level 50434187_1 CDM 0301 RC 82525 HCPCS inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 Copper level 50434187_1 CDM 0301 RC 82525 HCPCS inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 Copper level 50434187_1 CDM 0301 RC 82525 HCPCS inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 Copper level 50434187_1 CDM 0301 RC 82525 HCPCS inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges "Cortisol (hormone) measurement, free" 50434188_1 CDM 0301 RC 82530 HCPCS inpatient 422 274.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 274.3 65 999999999 255.52 409.34 percent of total billed charges "Cortisol (hormone) measurement, free" 50434188_1 CDM 0301 RC 82530 HCPCS inpatient 422 274.3 AETNA AETNA 333.38 79 999999999 255.52 409.34 percent of total billed charges "Cortisol (hormone) measurement, free" 50434188_1 CDM 0301 RC 82530 HCPCS inpatient 422 274.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 409.34 97 999999999 255.52 409.34 percent of total billed charges "Cortisol (hormone) measurement, free" 50434188_1 CDM 0301 RC 82530 HCPCS inpatient 422 274.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 329.16 78 999999999 255.52 409.34 percent of total billed charges "Cortisol (hormone) measurement, free" 50434188_1 CDM 0301 RC 82530 HCPCS inpatient 422 274.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 291.18 69 999999999 255.52 409.34 percent of total billed charges "Cortisol (hormone) measurement, free" 50434188_1 CDM 0301 RC 82530 HCPCS inpatient 422 274.3 SIHO - ALL PLANS SIHO - ALL PLANS 379.8 90 999999999 255.52 409.34 percent of total billed charges "Cortisol (hormone) measurement, free" 50434188_1 CDM 0301 RC 82530 HCPCS inpatient 422 274.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 255.52 60.55 999999999 255.52 409.34 percent of total billed charges "Cortisol (hormone) measurement, free" 50434188_1 CDM 0301 RC 82530 HCPCS inpatient 422 274.3 UMR - ALL PLANS UMR - ALL PLANS 295.4 70 999999999 255.52 409.34 percent of total billed charges "Cortisol (hormone) measurement, free" 50434188_1 CDM 0301 RC 82530 HCPCS inpatient 422 274.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 255.52 409.34 "Cortisol (hormone) measurement, free" 50434188_1 CDM 0301 RC 82530 HCPCS inpatient 422 274.3 ANTHEM HMO ANTHEM HMO 999999999 255.52 409.34 "Cortisol (hormone) measurement, free" 50434188_1 CDM 0301 RC 82530 HCPCS inpatient 422 274.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 255.52 409.34 "Cortisol (hormone) measurement, free" 50434188_1 CDM 0301 RC 82530 HCPCS inpatient 422 274.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 255.52 409.34 "Cortisol (hormone) measurement, free" 50434188_1 CDM 0301 RC 82530 HCPCS inpatient 422 274.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 255.52 409.34 "Cortisol (hormone) measurement, free" 50434188_1 CDM 0301 RC 82530 HCPCS inpatient 422 274.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 285.27 67.6 999999999 255.52 409.34 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 50434189_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 50434189_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 50434189_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 50434189_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 50434189_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 50434189_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 50434189_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 50434189_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges "Creatine kinase (cardiac enzyme) level, total" 50434189_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 "Creatine kinase (cardiac enzyme) level, total" 50434189_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 "Creatine kinase (cardiac enzyme) level, total" 50434189_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 "Creatine kinase (cardiac enzyme) level, total" 50434189_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 "Creatine kinase (cardiac enzyme) level, total" 50434189_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 "Creatine kinase (cardiac enzyme) level, total" 50434189_1 CDM 0301 RC 82550 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges Blood creatinine level 50434190_1 CDM 0301 RC 82565 HCPCS inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges Blood creatinine level 50434190_1 CDM 0301 RC 82565 HCPCS inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges Blood creatinine level 50434190_1 CDM 0301 RC 82565 HCPCS inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges Blood creatinine level 50434190_1 CDM 0301 RC 82565 HCPCS inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges Blood creatinine level 50434190_1 CDM 0301 RC 82565 HCPCS inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges Blood creatinine level 50434190_1 CDM 0301 RC 82565 HCPCS inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges Blood creatinine level 50434190_1 CDM 0301 RC 82565 HCPCS inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges Blood creatinine level 50434190_1 CDM 0301 RC 82565 HCPCS inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges Blood creatinine level 50434190_1 CDM 0301 RC 82565 HCPCS inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 Blood creatinine level 50434190_1 CDM 0301 RC 82565 HCPCS inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 Blood creatinine level 50434190_1 CDM 0301 RC 82565 HCPCS inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 Blood creatinine level 50434190_1 CDM 0301 RC 82565 HCPCS inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 Blood creatinine level 50434190_1 CDM 0301 RC 82565 HCPCS inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 Blood creatinine level 50434190_1 CDM 0301 RC 82565 HCPCS inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges Cryoglobulin (protein) measurement 50434191_1 CDM 0301 RC 82595 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges Cryoglobulin (protein) measurement 50434191_1 CDM 0301 RC 82595 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges Cryoglobulin (protein) measurement 50434191_1 CDM 0301 RC 82595 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges Cryoglobulin (protein) measurement 50434191_1 CDM 0301 RC 82595 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges Cryoglobulin (protein) measurement 50434191_1 CDM 0301 RC 82595 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges Cryoglobulin (protein) measurement 50434191_1 CDM 0301 RC 82595 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges Cryoglobulin (protein) measurement 50434191_1 CDM 0301 RC 82595 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges Cryoglobulin (protein) measurement 50434191_1 CDM 0301 RC 82595 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges Cryoglobulin (protein) measurement 50434191_1 CDM 0301 RC 82595 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 Cryoglobulin (protein) measurement 50434191_1 CDM 0301 RC 82595 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 Cryoglobulin (protein) measurement 50434191_1 CDM 0301 RC 82595 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 Cryoglobulin (protein) measurement 50434191_1 CDM 0301 RC 82595 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 Cryoglobulin (protein) measurement 50434191_1 CDM 0301 RC 82595 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 Cryoglobulin (protein) measurement 50434191_1 CDM 0301 RC 82595 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges Cyclosporine level 50434192_1 CDM 0300 RC 80158 HCPCS inpatient 229 148.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 148.85 65 999999999 138.66 222.13 percent of total billed charges Cyclosporine level 50434192_1 CDM 0300 RC 80158 HCPCS inpatient 229 148.85 AETNA AETNA 180.91 79 999999999 138.66 222.13 percent of total billed charges Cyclosporine level 50434192_1 CDM 0300 RC 80158 HCPCS inpatient 229 148.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 222.13 97 999999999 138.66 222.13 percent of total billed charges Cyclosporine level 50434192_1 CDM 0300 RC 80158 HCPCS inpatient 229 148.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 178.62 78 999999999 138.66 222.13 percent of total billed charges Cyclosporine level 50434192_1 CDM 0300 RC 80158 HCPCS inpatient 229 148.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 158.01 69 999999999 138.66 222.13 percent of total billed charges Cyclosporine level 50434192_1 CDM 0300 RC 80158 HCPCS inpatient 229 148.85 SIHO - ALL PLANS SIHO - ALL PLANS 206.1 90 999999999 138.66 222.13 percent of total billed charges Cyclosporine level 50434192_1 CDM 0300 RC 80158 HCPCS inpatient 229 148.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 138.66 60.55 999999999 138.66 222.13 percent of total billed charges Cyclosporine level 50434192_1 CDM 0300 RC 80158 HCPCS inpatient 229 148.85 UMR - ALL PLANS UMR - ALL PLANS 160.3 70 999999999 138.66 222.13 percent of total billed charges Cyclosporine level 50434192_1 CDM 0300 RC 80158 HCPCS inpatient 229 148.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 138.66 222.13 Cyclosporine level 50434192_1 CDM 0300 RC 80158 HCPCS inpatient 229 148.85 ANTHEM HMO ANTHEM HMO 999999999 138.66 222.13 Cyclosporine level 50434192_1 CDM 0300 RC 80158 HCPCS inpatient 229 148.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 138.66 222.13 Cyclosporine level 50434192_1 CDM 0300 RC 80158 HCPCS inpatient 229 148.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 138.66 222.13 Cyclosporine level 50434192_1 CDM 0300 RC 80158 HCPCS inpatient 229 148.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 138.66 222.13 Cyclosporine level 50434192_1 CDM 0300 RC 80158 HCPCS inpatient 229 148.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 154.8 67.6 999999999 138.66 222.13 percent of total billed charges Cystatin C (enzyme inhibitor) level 50434193_1 CDM 0301 RC 82610 HCPCS inpatient 202 131.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 131.3 65 999999999 122.31 195.94 percent of total billed charges Cystatin C (enzyme inhibitor) level 50434193_1 CDM 0301 RC 82610 HCPCS inpatient 202 131.3 AETNA AETNA 159.58 79 999999999 122.31 195.94 percent of total billed charges Cystatin C (enzyme inhibitor) level 50434193_1 CDM 0301 RC 82610 HCPCS inpatient 202 131.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 195.94 97 999999999 122.31 195.94 percent of total billed charges Cystatin C (enzyme inhibitor) level 50434193_1 CDM 0301 RC 82610 HCPCS inpatient 202 131.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 157.56 78 999999999 122.31 195.94 percent of total billed charges Cystatin C (enzyme inhibitor) level 50434193_1 CDM 0301 RC 82610 HCPCS inpatient 202 131.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 139.38 69 999999999 122.31 195.94 percent of total billed charges Cystatin C (enzyme inhibitor) level 50434193_1 CDM 0301 RC 82610 HCPCS inpatient 202 131.3 SIHO - ALL PLANS SIHO - ALL PLANS 181.8 90 999999999 122.31 195.94 percent of total billed charges Cystatin C (enzyme inhibitor) level 50434193_1 CDM 0301 RC 82610 HCPCS inpatient 202 131.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 122.31 60.55 999999999 122.31 195.94 percent of total billed charges Cystatin C (enzyme inhibitor) level 50434193_1 CDM 0301 RC 82610 HCPCS inpatient 202 131.3 UMR - ALL PLANS UMR - ALL PLANS 141.4 70 999999999 122.31 195.94 percent of total billed charges Cystatin C (enzyme inhibitor) level 50434193_1 CDM 0301 RC 82610 HCPCS inpatient 202 131.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 122.31 195.94 Cystatin C (enzyme inhibitor) level 50434193_1 CDM 0301 RC 82610 HCPCS inpatient 202 131.3 ANTHEM HMO ANTHEM HMO 999999999 122.31 195.94 Cystatin C (enzyme inhibitor) level 50434193_1 CDM 0301 RC 82610 HCPCS inpatient 202 131.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 122.31 195.94 Cystatin C (enzyme inhibitor) level 50434193_1 CDM 0301 RC 82610 HCPCS inpatient 202 131.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 122.31 195.94 Cystatin C (enzyme inhibitor) level 50434193_1 CDM 0301 RC 82610 HCPCS inpatient 202 131.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 122.31 195.94 Cystatin C (enzyme inhibitor) level 50434193_1 CDM 0301 RC 82610 HCPCS inpatient 202 131.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 136.55 67.6 999999999 122.31 195.94 percent of total billed charges Macroscopic examination (visual inspection) of parasite 50434194_1 CDM 0301 RC 87169 HCPCS inpatient 57 37.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.05 65 999999999 34.51 55.29 percent of total billed charges Macroscopic examination (visual inspection) of parasite 50434194_1 CDM 0301 RC 87169 HCPCS inpatient 57 37.05 AETNA AETNA 45.03 79 999999999 34.51 55.29 percent of total billed charges Macroscopic examination (visual inspection) of parasite 50434194_1 CDM 0301 RC 87169 HCPCS inpatient 57 37.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.29 97 999999999 34.51 55.29 percent of total billed charges Macroscopic examination (visual inspection) of parasite 50434194_1 CDM 0301 RC 87169 HCPCS inpatient 57 37.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.46 78 999999999 34.51 55.29 percent of total billed charges Macroscopic examination (visual inspection) of parasite 50434194_1 CDM 0301 RC 87169 HCPCS inpatient 57 37.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.33 69 999999999 34.51 55.29 percent of total billed charges Macroscopic examination (visual inspection) of parasite 50434194_1 CDM 0301 RC 87169 HCPCS inpatient 57 37.05 SIHO - ALL PLANS SIHO - ALL PLANS 51.3 90 999999999 34.51 55.29 percent of total billed charges Macroscopic examination (visual inspection) of parasite 50434194_1 CDM 0301 RC 87169 HCPCS inpatient 57 37.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.51 60.55 999999999 34.51 55.29 percent of total billed charges Macroscopic examination (visual inspection) of parasite 50434194_1 CDM 0301 RC 87169 HCPCS inpatient 57 37.05 UMR - ALL PLANS UMR - ALL PLANS 39.9 70 999999999 34.51 55.29 percent of total billed charges Macroscopic examination (visual inspection) of parasite 50434194_1 CDM 0301 RC 87169 HCPCS inpatient 57 37.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.51 55.29 Macroscopic examination (visual inspection) of parasite 50434194_1 CDM 0301 RC 87169 HCPCS inpatient 57 37.05 ANTHEM HMO ANTHEM HMO 999999999 34.51 55.29 Macroscopic examination (visual inspection) of parasite 50434194_1 CDM 0301 RC 87169 HCPCS inpatient 57 37.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.51 55.29 Macroscopic examination (visual inspection) of parasite 50434194_1 CDM 0301 RC 87169 HCPCS inpatient 57 37.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.51 55.29 Macroscopic examination (visual inspection) of parasite 50434194_1 CDM 0301 RC 87169 HCPCS inpatient 57 37.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.51 55.29 Macroscopic examination (visual inspection) of parasite 50434194_1 CDM 0301 RC 87169 HCPCS inpatient 57 37.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.53 67.6 999999999 34.51 55.29 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434195_1 CDM 0301 RC 80307 HCPCS inpatient 78 50.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.7 65 999999999 47.23 75.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434195_1 CDM 0301 RC 80307 HCPCS inpatient 78 50.7 AETNA AETNA 61.62 79 999999999 47.23 75.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434195_1 CDM 0301 RC 80307 HCPCS inpatient 78 50.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 75.66 97 999999999 47.23 75.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434195_1 CDM 0301 RC 80307 HCPCS inpatient 78 50.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.84 78 999999999 47.23 75.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434195_1 CDM 0301 RC 80307 HCPCS inpatient 78 50.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.82 69 999999999 47.23 75.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434195_1 CDM 0301 RC 80307 HCPCS inpatient 78 50.7 SIHO - ALL PLANS SIHO - ALL PLANS 70.2 90 999999999 47.23 75.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434195_1 CDM 0301 RC 80307 HCPCS inpatient 78 50.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.23 60.55 999999999 47.23 75.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434195_1 CDM 0301 RC 80307 HCPCS inpatient 78 50.7 UMR - ALL PLANS UMR - ALL PLANS 54.6 70 999999999 47.23 75.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434195_1 CDM 0301 RC 80307 HCPCS inpatient 78 50.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.23 75.66 "Testing for presence of drug, by chemistry analyzers" 50434195_1 CDM 0301 RC 80307 HCPCS inpatient 78 50.7 ANTHEM HMO ANTHEM HMO 999999999 47.23 75.66 "Testing for presence of drug, by chemistry analyzers" 50434195_1 CDM 0301 RC 80307 HCPCS inpatient 78 50.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.23 75.66 "Testing for presence of drug, by chemistry analyzers" 50434195_1 CDM 0301 RC 80307 HCPCS inpatient 78 50.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.23 75.66 "Testing for presence of drug, by chemistry analyzers" 50434195_1 CDM 0301 RC 80307 HCPCS inpatient 78 50.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.23 75.66 "Testing for presence of drug, by chemistry analyzers" 50434195_1 CDM 0301 RC 80307 HCPCS inpatient 78 50.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.73 67.6 999999999 47.23 75.66 percent of total billed charges Androstenedione (hormone) level 50434196_1 CDM 0301 RC 82157 HCPCS inpatient 265 172.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 172.25 65 999999999 160.46 257.05 percent of total billed charges Androstenedione (hormone) level 50434196_1 CDM 0301 RC 82157 HCPCS inpatient 265 172.25 AETNA AETNA 209.35 79 999999999 160.46 257.05 percent of total billed charges Androstenedione (hormone) level 50434196_1 CDM 0301 RC 82157 HCPCS inpatient 265 172.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 257.05 97 999999999 160.46 257.05 percent of total billed charges Androstenedione (hormone) level 50434196_1 CDM 0301 RC 82157 HCPCS inpatient 265 172.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 206.7 78 999999999 160.46 257.05 percent of total billed charges Androstenedione (hormone) level 50434196_1 CDM 0301 RC 82157 HCPCS inpatient 265 172.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 182.85 69 999999999 160.46 257.05 percent of total billed charges Androstenedione (hormone) level 50434196_1 CDM 0301 RC 82157 HCPCS inpatient 265 172.25 SIHO - ALL PLANS SIHO - ALL PLANS 238.5 90 999999999 160.46 257.05 percent of total billed charges Androstenedione (hormone) level 50434196_1 CDM 0301 RC 82157 HCPCS inpatient 265 172.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 160.46 60.55 999999999 160.46 257.05 percent of total billed charges Androstenedione (hormone) level 50434196_1 CDM 0301 RC 82157 HCPCS inpatient 265 172.25 UMR - ALL PLANS UMR - ALL PLANS 185.5 70 999999999 160.46 257.05 percent of total billed charges Androstenedione (hormone) level 50434196_1 CDM 0301 RC 82157 HCPCS inpatient 265 172.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 160.46 257.05 Androstenedione (hormone) level 50434196_1 CDM 0301 RC 82157 HCPCS inpatient 265 172.25 ANTHEM HMO ANTHEM HMO 999999999 160.46 257.05 Androstenedione (hormone) level 50434196_1 CDM 0301 RC 82157 HCPCS inpatient 265 172.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 160.46 257.05 Androstenedione (hormone) level 50434196_1 CDM 0301 RC 82157 HCPCS inpatient 265 172.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 160.46 257.05 Androstenedione (hormone) level 50434196_1 CDM 0301 RC 82157 HCPCS inpatient 265 172.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 160.46 257.05 Androstenedione (hormone) level 50434196_1 CDM 0301 RC 82157 HCPCS inpatient 265 172.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 179.14 67.6 999999999 160.46 257.05 percent of total billed charges Dehydroepiandrosterone (DHEA-S) hormone level 50434197_1 CDM 0301 RC 82627 HCPCS inpatient 251 163.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.15 65 999999999 151.98 243.47 percent of total billed charges Dehydroepiandrosterone (DHEA-S) hormone level 50434197_1 CDM 0301 RC 82627 HCPCS inpatient 251 163.15 AETNA AETNA 198.29 79 999999999 151.98 243.47 percent of total billed charges Dehydroepiandrosterone (DHEA-S) hormone level 50434197_1 CDM 0301 RC 82627 HCPCS inpatient 251 163.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 243.47 97 999999999 151.98 243.47 percent of total billed charges Dehydroepiandrosterone (DHEA-S) hormone level 50434197_1 CDM 0301 RC 82627 HCPCS inpatient 251 163.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 195.78 78 999999999 151.98 243.47 percent of total billed charges Dehydroepiandrosterone (DHEA-S) hormone level 50434197_1 CDM 0301 RC 82627 HCPCS inpatient 251 163.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.19 69 999999999 151.98 243.47 percent of total billed charges Dehydroepiandrosterone (DHEA-S) hormone level 50434197_1 CDM 0301 RC 82627 HCPCS inpatient 251 163.15 SIHO - ALL PLANS SIHO - ALL PLANS 225.9 90 999999999 151.98 243.47 percent of total billed charges Dehydroepiandrosterone (DHEA-S) hormone level 50434197_1 CDM 0301 RC 82627 HCPCS inpatient 251 163.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.98 60.55 999999999 151.98 243.47 percent of total billed charges Dehydroepiandrosterone (DHEA-S) hormone level 50434197_1 CDM 0301 RC 82627 HCPCS inpatient 251 163.15 UMR - ALL PLANS UMR - ALL PLANS 175.7 70 999999999 151.98 243.47 percent of total billed charges Dehydroepiandrosterone (DHEA-S) hormone level 50434197_1 CDM 0301 RC 82627 HCPCS inpatient 251 163.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.98 243.47 Dehydroepiandrosterone (DHEA-S) hormone level 50434197_1 CDM 0301 RC 82627 HCPCS inpatient 251 163.15 ANTHEM HMO ANTHEM HMO 999999999 151.98 243.47 Dehydroepiandrosterone (DHEA-S) hormone level 50434197_1 CDM 0301 RC 82627 HCPCS inpatient 251 163.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.98 243.47 Dehydroepiandrosterone (DHEA-S) hormone level 50434197_1 CDM 0301 RC 82627 HCPCS inpatient 251 163.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.98 243.47 Dehydroepiandrosterone (DHEA-S) hormone level 50434197_1 CDM 0301 RC 82627 HCPCS inpatient 251 163.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.98 243.47 Dehydroepiandrosterone (DHEA-S) hormone level 50434197_1 CDM 0301 RC 82627 HCPCS inpatient 251 163.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 169.68 67.6 999999999 151.98 243.47 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434198_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434198_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434198_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434198_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434198_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434198_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434198_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434198_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434198_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 "Testing for presence of drug, by chemistry analyzers" 50434198_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 "Testing for presence of drug, by chemistry analyzers" 50434198_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 "Testing for presence of drug, by chemistry analyzers" 50434198_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 "Testing for presence of drug, by chemistry analyzers" 50434198_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 "Testing for presence of drug, by chemistry analyzers" 50434198_1 CDM 0301 RC 80307 HCPCS inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434199_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434199_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434199_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434199_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434199_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434199_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434199_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434199_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434199_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 50434199_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 50434199_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 50434199_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 50434199_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Testing for presence of drug, by chemistry analyzers" 50434199_1 CDM 0301 RC 80307 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434200_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.4 65 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434200_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 AETNA AETNA 123.24 79 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434200_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 151.32 97 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434200_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.68 78 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434200_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.64 69 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434200_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 SIHO - ALL PLANS SIHO - ALL PLANS 140.4 90 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434200_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.46 60.55 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434200_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 UMR - ALL PLANS UMR - ALL PLANS 109.2 70 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434200_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434200_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 ANTHEM HMO ANTHEM HMO 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434200_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434200_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434200_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434200_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.46 67.6 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434201_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.4 65 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434201_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 AETNA AETNA 123.24 79 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434201_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 151.32 97 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434201_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.68 78 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434201_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.64 69 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434201_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 SIHO - ALL PLANS SIHO - ALL PLANS 140.4 90 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434201_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.46 60.55 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434201_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 UMR - ALL PLANS UMR - ALL PLANS 109.2 70 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434201_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434201_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 ANTHEM HMO ANTHEM HMO 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434201_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434201_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434201_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.46 151.32 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434201_1 CDM 0302 RC 86663 HCPCS inpatient 156 101.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.46 67.6 999999999 94.46 151.32 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434202_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.05 65 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434202_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 AETNA AETNA 139.83 79 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434202_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 171.69 97 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434202_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.06 78 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434202_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.13 69 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434202_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 SIHO - ALL PLANS SIHO - ALL PLANS 159.3 90 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434202_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.17 60.55 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434202_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 UMR - ALL PLANS UMR - ALL PLANS 123.9 70 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434202_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434202_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 ANTHEM HMO ANTHEM HMO 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434202_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434202_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434202_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434202_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 119.65 67.6 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434203_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.05 65 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434203_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 AETNA AETNA 139.83 79 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434203_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 171.69 97 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434203_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.06 78 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434203_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.13 69 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434203_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 SIHO - ALL PLANS SIHO - ALL PLANS 159.3 90 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434203_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.17 60.55 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434203_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 UMR - ALL PLANS UMR - ALL PLANS 123.9 70 999999999 107.17 171.69 percent of total billed charges "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434203_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434203_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 ANTHEM HMO ANTHEM HMO 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434203_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434203_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434203_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.17 171.69 "Analysis for antibody to Epstein-Barr virus (mononucleosis virus), early antigen" 50434203_1 CDM 0302 RC 86663 HCPCS inpatient 177 115.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 119.65 67.6 999999999 107.17 171.69 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434204_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434204_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434204_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434204_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434204_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434204_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434204_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434204_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434204_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50434204_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50434204_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50434204_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50434204_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50434204_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434205_1 CDM 0302 RC 86235 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434205_1 CDM 0302 RC 86235 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434205_1 CDM 0302 RC 86235 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434205_1 CDM 0302 RC 86235 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434205_1 CDM 0302 RC 86235 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434205_1 CDM 0302 RC 86235 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434205_1 CDM 0302 RC 86235 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434205_1 CDM 0302 RC 86235 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434205_1 CDM 0302 RC 86235 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 "Measurement of antibody for assessment of autoimmune disorder, any method" 50434205_1 CDM 0302 RC 86235 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 "Measurement of antibody for assessment of autoimmune disorder, any method" 50434205_1 CDM 0302 RC 86235 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 "Measurement of antibody for assessment of autoimmune disorder, any method" 50434205_1 CDM 0302 RC 86235 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 "Measurement of antibody for assessment of autoimmune disorder, any method" 50434205_1 CDM 0302 RC 86235 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 "Measurement of antibody for assessment of autoimmune disorder, any method" 50434205_1 CDM 0302 RC 86235 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434206_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434206_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434206_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434206_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434206_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434206_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434206_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434206_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50434206_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50434206_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50434206_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50434206_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50434206_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50434206_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges Erythropoietin (protein) level 50434207_1 CDM 0301 RC 82668 HCPCS inpatient 169 109.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.85 65 999999999 102.33 163.93 percent of total billed charges Erythropoietin (protein) level 50434207_1 CDM 0301 RC 82668 HCPCS inpatient 169 109.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 163.93 97 999999999 102.33 163.93 percent of total billed charges Erythropoietin (protein) level 50434207_1 CDM 0301 RC 82668 HCPCS inpatient 169 109.85 AETNA AETNA 133.51 79 999999999 102.33 163.93 percent of total billed charges Erythropoietin (protein) level 50434207_1 CDM 0301 RC 82668 HCPCS inpatient 169 109.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.82 78 999999999 102.33 163.93 percent of total billed charges Erythropoietin (protein) level 50434207_1 CDM 0301 RC 82668 HCPCS inpatient 169 109.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 116.61 69 999999999 102.33 163.93 percent of total billed charges Erythropoietin (protein) level 50434207_1 CDM 0301 RC 82668 HCPCS inpatient 169 109.85 SIHO - ALL PLANS SIHO - ALL PLANS 152.1 90 999999999 102.33 163.93 percent of total billed charges Erythropoietin (protein) level 50434207_1 CDM 0301 RC 82668 HCPCS inpatient 169 109.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.33 60.55 999999999 102.33 163.93 percent of total billed charges Erythropoietin (protein) level 50434207_1 CDM 0301 RC 82668 HCPCS inpatient 169 109.85 UMR - ALL PLANS UMR - ALL PLANS 118.3 70 999999999 102.33 163.93 percent of total billed charges Erythropoietin (protein) level 50434207_1 CDM 0301 RC 82668 HCPCS inpatient 169 109.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.33 163.93 Erythropoietin (protein) level 50434207_1 CDM 0301 RC 82668 HCPCS inpatient 169 109.85 ANTHEM HMO ANTHEM HMO 999999999 102.33 163.93 Erythropoietin (protein) level 50434207_1 CDM 0301 RC 82668 HCPCS inpatient 169 109.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.33 163.93 Erythropoietin (protein) level 50434207_1 CDM 0301 RC 82668 HCPCS inpatient 169 109.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.33 163.93 Erythropoietin (protein) level 50434207_1 CDM 0301 RC 82668 HCPCS inpatient 169 109.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.33 163.93 Erythropoietin (protein) level 50434207_1 CDM 0301 RC 82668 HCPCS inpatient 169 109.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.24 67.6 999999999 102.33 163.93 percent of total billed charges Measurement of total estradiol (hormone) 50434208_1 CDM 0301 RC 82670 HCPCS inpatient 317 206.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 206.05 65 999999999 191.94 307.49 percent of total billed charges Measurement of total estradiol (hormone) 50434208_1 CDM 0301 RC 82670 HCPCS inpatient 317 206.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 307.49 97 999999999 191.94 307.49 percent of total billed charges Measurement of total estradiol (hormone) 50434208_1 CDM 0301 RC 82670 HCPCS inpatient 317 206.05 AETNA AETNA 250.43 79 999999999 191.94 307.49 percent of total billed charges Measurement of total estradiol (hormone) 50434208_1 CDM 0301 RC 82670 HCPCS inpatient 317 206.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 247.26 78 999999999 191.94 307.49 percent of total billed charges Measurement of total estradiol (hormone) 50434208_1 CDM 0301 RC 82670 HCPCS inpatient 317 206.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 218.73 69 999999999 191.94 307.49 percent of total billed charges Measurement of total estradiol (hormone) 50434208_1 CDM 0301 RC 82670 HCPCS inpatient 317 206.05 SIHO - ALL PLANS SIHO - ALL PLANS 285.3 90 999999999 191.94 307.49 percent of total billed charges Measurement of total estradiol (hormone) 50434208_1 CDM 0301 RC 82670 HCPCS inpatient 317 206.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 191.94 60.55 999999999 191.94 307.49 percent of total billed charges Measurement of total estradiol (hormone) 50434208_1 CDM 0301 RC 82670 HCPCS inpatient 317 206.05 UMR - ALL PLANS UMR - ALL PLANS 221.9 70 999999999 191.94 307.49 percent of total billed charges Measurement of total estradiol (hormone) 50434208_1 CDM 0301 RC 82670 HCPCS inpatient 317 206.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 191.94 307.49 Measurement of total estradiol (hormone) 50434208_1 CDM 0301 RC 82670 HCPCS inpatient 317 206.05 ANTHEM HMO ANTHEM HMO 999999999 191.94 307.49 Measurement of total estradiol (hormone) 50434208_1 CDM 0301 RC 82670 HCPCS inpatient 317 206.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 191.94 307.49 Measurement of total estradiol (hormone) 50434208_1 CDM 0301 RC 82670 HCPCS inpatient 317 206.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 191.94 307.49 Measurement of total estradiol (hormone) 50434208_1 CDM 0301 RC 82670 HCPCS inpatient 317 206.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 191.94 307.49 Measurement of total estradiol (hormone) 50434208_1 CDM 0301 RC 82670 HCPCS inpatient 317 206.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 214.29 67.6 999999999 191.94 307.49 percent of total billed charges Estriol (hormone) level 50434209_1 CDM 0301 RC 82677 HCPCS inpatient 198 128.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.7 65 999999999 119.89 192.06 percent of total billed charges Estriol (hormone) level 50434209_1 CDM 0301 RC 82677 HCPCS inpatient 198 128.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 192.06 97 999999999 119.89 192.06 percent of total billed charges Estriol (hormone) level 50434209_1 CDM 0301 RC 82677 HCPCS inpatient 198 128.7 AETNA AETNA 156.42 79 999999999 119.89 192.06 percent of total billed charges Estriol (hormone) level 50434209_1 CDM 0301 RC 82677 HCPCS inpatient 198 128.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 154.44 78 999999999 119.89 192.06 percent of total billed charges Estriol (hormone) level 50434209_1 CDM 0301 RC 82677 HCPCS inpatient 198 128.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 136.62 69 999999999 119.89 192.06 percent of total billed charges Estriol (hormone) level 50434209_1 CDM 0301 RC 82677 HCPCS inpatient 198 128.7 SIHO - ALL PLANS SIHO - ALL PLANS 178.2 90 999999999 119.89 192.06 percent of total billed charges Estriol (hormone) level 50434209_1 CDM 0301 RC 82677 HCPCS inpatient 198 128.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.89 60.55 999999999 119.89 192.06 percent of total billed charges Estriol (hormone) level 50434209_1 CDM 0301 RC 82677 HCPCS inpatient 198 128.7 UMR - ALL PLANS UMR - ALL PLANS 138.6 70 999999999 119.89 192.06 percent of total billed charges Estriol (hormone) level 50434209_1 CDM 0301 RC 82677 HCPCS inpatient 198 128.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.89 192.06 Estriol (hormone) level 50434209_1 CDM 0301 RC 82677 HCPCS inpatient 198 128.7 ANTHEM HMO ANTHEM HMO 999999999 119.89 192.06 Estriol (hormone) level 50434209_1 CDM 0301 RC 82677 HCPCS inpatient 198 128.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.89 192.06 Estriol (hormone) level 50434209_1 CDM 0301 RC 82677 HCPCS inpatient 198 128.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.89 192.06 Estriol (hormone) level 50434209_1 CDM 0301 RC 82677 HCPCS inpatient 198 128.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.89 192.06 Estriol (hormone) level 50434209_1 CDM 0301 RC 82677 HCPCS inpatient 198 128.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.85 67.6 999999999 119.89 192.06 percent of total billed charges "Estrogen analysis, fractionated" 50434210_1 CDM 0301 RC 82671 HCPCS inpatient 469 304.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 304.85 65 999999999 283.98 454.93 percent of total billed charges "Estrogen analysis, fractionated" 50434210_1 CDM 0301 RC 82671 HCPCS inpatient 469 304.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 454.93 97 999999999 283.98 454.93 percent of total billed charges "Estrogen analysis, fractionated" 50434210_1 CDM 0301 RC 82671 HCPCS inpatient 469 304.85 AETNA AETNA 370.51 79 999999999 283.98 454.93 percent of total billed charges "Estrogen analysis, fractionated" 50434210_1 CDM 0301 RC 82671 HCPCS inpatient 469 304.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 365.82 78 999999999 283.98 454.93 percent of total billed charges "Estrogen analysis, fractionated" 50434210_1 CDM 0301 RC 82671 HCPCS inpatient 469 304.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 323.61 69 999999999 283.98 454.93 percent of total billed charges "Estrogen analysis, fractionated" 50434210_1 CDM 0301 RC 82671 HCPCS inpatient 469 304.85 SIHO - ALL PLANS SIHO - ALL PLANS 422.1 90 999999999 283.98 454.93 percent of total billed charges "Estrogen analysis, fractionated" 50434210_1 CDM 0301 RC 82671 HCPCS inpatient 469 304.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 283.98 60.55 999999999 283.98 454.93 percent of total billed charges "Estrogen analysis, fractionated" 50434210_1 CDM 0301 RC 82671 HCPCS inpatient 469 304.85 UMR - ALL PLANS UMR - ALL PLANS 328.3 70 999999999 283.98 454.93 percent of total billed charges "Estrogen analysis, fractionated" 50434210_1 CDM 0301 RC 82671 HCPCS inpatient 469 304.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 283.98 454.93 "Estrogen analysis, fractionated" 50434210_1 CDM 0301 RC 82671 HCPCS inpatient 469 304.85 ANTHEM HMO ANTHEM HMO 999999999 283.98 454.93 "Estrogen analysis, fractionated" 50434210_1 CDM 0301 RC 82671 HCPCS inpatient 469 304.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 283.98 454.93 "Estrogen analysis, fractionated" 50434210_1 CDM 0301 RC 82671 HCPCS inpatient 469 304.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 283.98 454.93 "Estrogen analysis, fractionated" 50434210_1 CDM 0301 RC 82671 HCPCS inpatient 469 304.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 283.98 454.93 "Estrogen analysis, fractionated" 50434210_1 CDM 0301 RC 82671 HCPCS inpatient 469 304.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 317.04 67.6 999999999 283.98 454.93 percent of total billed charges Ethosuximide level 50434211_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 SELF PAY DISCOUNT SELF PAY DISCOUNT 104 65 999999999 96.88 155.2 percent of total billed charges Ethosuximide level 50434211_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 155.2 97 999999999 96.88 155.2 percent of total billed charges Ethosuximide level 50434211_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 AETNA AETNA 126.4 79 999999999 96.88 155.2 percent of total billed charges Ethosuximide level 50434211_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 HUMANA - ALL PLANS HUMANA - ALL PLANS 124.8 78 999999999 96.88 155.2 percent of total billed charges Ethosuximide level 50434211_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 ENCORE - ALL PLANS ENCORE - ALL PLANS 110.4 69 999999999 96.88 155.2 percent of total billed charges Ethosuximide level 50434211_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 SIHO - ALL PLANS SIHO - ALL PLANS 144 90 999999999 96.88 155.2 percent of total billed charges Ethosuximide level 50434211_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 96.88 60.55 999999999 96.88 155.2 percent of total billed charges Ethosuximide level 50434211_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 UMR - ALL PLANS UMR - ALL PLANS 112 70 999999999 96.88 155.2 percent of total billed charges Ethosuximide level 50434211_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 96.88 155.2 Ethosuximide level 50434211_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 ANTHEM HMO ANTHEM HMO 999999999 96.88 155.2 Ethosuximide level 50434211_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 96.88 155.2 Ethosuximide level 50434211_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 96.88 155.2 Ethosuximide level 50434211_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 UHC - ALL PLANS UHC - ALL PLANS 999999999 96.88 155.2 Ethosuximide level 50434211_1 CDM 0301 RC 80168 HCPCS inpatient 160 104 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.16 67.6 999999999 96.88 155.2 percent of total billed charges Ethylene glycol (antifreeze) measurement 50434212_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 156.65 65 999999999 145.93 233.77 percent of total billed charges Ethylene glycol (antifreeze) measurement 50434212_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 233.77 97 999999999 145.93 233.77 percent of total billed charges Ethylene glycol (antifreeze) measurement 50434212_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 AETNA AETNA 190.39 79 999999999 145.93 233.77 percent of total billed charges Ethylene glycol (antifreeze) measurement 50434212_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.98 78 999999999 145.93 233.77 percent of total billed charges Ethylene glycol (antifreeze) measurement 50434212_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 166.29 69 999999999 145.93 233.77 percent of total billed charges Ethylene glycol (antifreeze) measurement 50434212_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 SIHO - ALL PLANS SIHO - ALL PLANS 216.9 90 999999999 145.93 233.77 percent of total billed charges Ethylene glycol (antifreeze) measurement 50434212_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.93 60.55 999999999 145.93 233.77 percent of total billed charges Ethylene glycol (antifreeze) measurement 50434212_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 UMR - ALL PLANS UMR - ALL PLANS 168.7 70 999999999 145.93 233.77 percent of total billed charges Ethylene glycol (antifreeze) measurement 50434212_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.93 233.77 Ethylene glycol (antifreeze) measurement 50434212_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 ANTHEM HMO ANTHEM HMO 999999999 145.93 233.77 Ethylene glycol (antifreeze) measurement 50434212_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.93 233.77 Ethylene glycol (antifreeze) measurement 50434212_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.93 233.77 Ethylene glycol (antifreeze) measurement 50434212_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.93 233.77 Ethylene glycol (antifreeze) measurement 50434212_1 CDM 0301 RC 82693 HCPCS inpatient 241 156.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.92 67.6 999999999 145.93 233.77 percent of total billed charges "Stool fat or lipids analysis, qualitative" 50434213_1 CDM 0301 RC 82705 HCPCS inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges "Stool fat or lipids analysis, qualitative" 50434213_1 CDM 0301 RC 82705 HCPCS inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges "Stool fat or lipids analysis, qualitative" 50434213_1 CDM 0301 RC 82705 HCPCS inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges "Stool fat or lipids analysis, qualitative" 50434213_1 CDM 0301 RC 82705 HCPCS inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges "Stool fat or lipids analysis, qualitative" 50434213_1 CDM 0301 RC 82705 HCPCS inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges "Stool fat or lipids analysis, qualitative" 50434213_1 CDM 0301 RC 82705 HCPCS inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges "Stool fat or lipids analysis, qualitative" 50434213_1 CDM 0301 RC 82705 HCPCS inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges "Stool fat or lipids analysis, qualitative" 50434213_1 CDM 0301 RC 82705 HCPCS inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges "Stool fat or lipids analysis, qualitative" 50434213_1 CDM 0301 RC 82705 HCPCS inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 "Stool fat or lipids analysis, qualitative" 50434213_1 CDM 0301 RC 82705 HCPCS inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 "Stool fat or lipids analysis, qualitative" 50434213_1 CDM 0301 RC 82705 HCPCS inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 "Stool fat or lipids analysis, qualitative" 50434213_1 CDM 0301 RC 82705 HCPCS inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 "Stool fat or lipids analysis, qualitative" 50434213_1 CDM 0301 RC 82705 HCPCS inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 "Stool fat or lipids analysis, qualitative" 50434213_1 CDM 0301 RC 82705 HCPCS inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges Fibrinogen (factor 1) activity measurement 50434214_1 CDM 0300 RC 85384 HCPCS inpatient 343 222.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 222.95 65 999999999 207.69 332.71 percent of total billed charges Fibrinogen (factor 1) activity measurement 50434214_1 CDM 0300 RC 85384 HCPCS inpatient 343 222.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 332.71 97 999999999 207.69 332.71 percent of total billed charges Fibrinogen (factor 1) activity measurement 50434214_1 CDM 0300 RC 85384 HCPCS inpatient 343 222.95 AETNA AETNA 270.97 79 999999999 207.69 332.71 percent of total billed charges Fibrinogen (factor 1) activity measurement 50434214_1 CDM 0300 RC 85384 HCPCS inpatient 343 222.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 267.54 78 999999999 207.69 332.71 percent of total billed charges Fibrinogen (factor 1) activity measurement 50434214_1 CDM 0300 RC 85384 HCPCS inpatient 343 222.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 236.67 69 999999999 207.69 332.71 percent of total billed charges Fibrinogen (factor 1) activity measurement 50434214_1 CDM 0300 RC 85384 HCPCS inpatient 343 222.95 SIHO - ALL PLANS SIHO - ALL PLANS 308.7 90 999999999 207.69 332.71 percent of total billed charges Fibrinogen (factor 1) activity measurement 50434214_1 CDM 0300 RC 85384 HCPCS inpatient 343 222.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 207.69 60.55 999999999 207.69 332.71 percent of total billed charges Fibrinogen (factor 1) activity measurement 50434214_1 CDM 0300 RC 85384 HCPCS inpatient 343 222.95 UMR - ALL PLANS UMR - ALL PLANS 240.1 70 999999999 207.69 332.71 percent of total billed charges Fibrinogen (factor 1) activity measurement 50434214_1 CDM 0300 RC 85384 HCPCS inpatient 343 222.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 207.69 332.71 Fibrinogen (factor 1) activity measurement 50434214_1 CDM 0300 RC 85384 HCPCS inpatient 343 222.95 ANTHEM HMO ANTHEM HMO 999999999 207.69 332.71 Fibrinogen (factor 1) activity measurement 50434214_1 CDM 0300 RC 85384 HCPCS inpatient 343 222.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 207.69 332.71 Fibrinogen (factor 1) activity measurement 50434214_1 CDM 0300 RC 85384 HCPCS inpatient 343 222.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 207.69 332.71 Fibrinogen (factor 1) activity measurement 50434214_1 CDM 0300 RC 85384 HCPCS inpatient 343 222.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 207.69 332.71 Fibrinogen (factor 1) activity measurement 50434214_1 CDM 0300 RC 85384 HCPCS inpatient 343 222.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 231.87 67.6 999999999 207.69 332.71 percent of total billed charges "Folic acid level, serum" 50434215_1 CDM 0301 RC 82746 HCPCS inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges "Folic acid level, serum" 50434215_1 CDM 0301 RC 82746 HCPCS inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges "Folic acid level, serum" 50434215_1 CDM 0301 RC 82746 HCPCS inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges "Folic acid level, serum" 50434215_1 CDM 0301 RC 82746 HCPCS inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges "Folic acid level, serum" 50434215_1 CDM 0301 RC 82746 HCPCS inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges "Folic acid level, serum" 50434215_1 CDM 0301 RC 82746 HCPCS inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges "Folic acid level, serum" 50434215_1 CDM 0301 RC 82746 HCPCS inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges "Folic acid level, serum" 50434215_1 CDM 0301 RC 82746 HCPCS inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges "Folic acid level, serum" 50434215_1 CDM 0301 RC 82746 HCPCS inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 "Folic acid level, serum" 50434215_1 CDM 0301 RC 82746 HCPCS inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 "Folic acid level, serum" 50434215_1 CDM 0301 RC 82746 HCPCS inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 "Folic acid level, serum" 50434215_1 CDM 0301 RC 82746 HCPCS inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 "Folic acid level, serum" 50434215_1 CDM 0301 RC 82746 HCPCS inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 "Folic acid level, serum" 50434215_1 CDM 0301 RC 82746 HCPCS inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges "Nephelometry, test method using light" 50434216_1 CDM 0301 RC 83883 HCPCS inpatient 148 96.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 96.2 65 999999999 89.61 143.56 percent of total billed charges "Nephelometry, test method using light" 50434216_1 CDM 0301 RC 83883 HCPCS inpatient 148 96.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 143.56 97 999999999 89.61 143.56 percent of total billed charges "Nephelometry, test method using light" 50434216_1 CDM 0301 RC 83883 HCPCS inpatient 148 96.2 AETNA AETNA 116.92 79 999999999 89.61 143.56 percent of total billed charges "Nephelometry, test method using light" 50434216_1 CDM 0301 RC 83883 HCPCS inpatient 148 96.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 115.44 78 999999999 89.61 143.56 percent of total billed charges "Nephelometry, test method using light" 50434216_1 CDM 0301 RC 83883 HCPCS inpatient 148 96.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 102.12 69 999999999 89.61 143.56 percent of total billed charges "Nephelometry, test method using light" 50434216_1 CDM 0301 RC 83883 HCPCS inpatient 148 96.2 SIHO - ALL PLANS SIHO - ALL PLANS 133.2 90 999999999 89.61 143.56 percent of total billed charges "Nephelometry, test method using light" 50434216_1 CDM 0301 RC 83883 HCPCS inpatient 148 96.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 89.61 60.55 999999999 89.61 143.56 percent of total billed charges "Nephelometry, test method using light" 50434216_1 CDM 0301 RC 83883 HCPCS inpatient 148 96.2 UMR - ALL PLANS UMR - ALL PLANS 103.6 70 999999999 89.61 143.56 percent of total billed charges "Nephelometry, test method using light" 50434216_1 CDM 0301 RC 83883 HCPCS inpatient 148 96.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 89.61 143.56 "Nephelometry, test method using light" 50434216_1 CDM 0301 RC 83883 HCPCS inpatient 148 96.2 ANTHEM HMO ANTHEM HMO 999999999 89.61 143.56 "Nephelometry, test method using light" 50434216_1 CDM 0301 RC 83883 HCPCS inpatient 148 96.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 89.61 143.56 "Nephelometry, test method using light" 50434216_1 CDM 0301 RC 83883 HCPCS inpatient 148 96.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 89.61 143.56 "Nephelometry, test method using light" 50434216_1 CDM 0301 RC 83883 HCPCS inpatient 148 96.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 89.61 143.56 "Nephelometry, test method using light" 50434216_1 CDM 0301 RC 83883 HCPCS inpatient 148 96.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 100.05 67.6 999999999 89.61 143.56 percent of total billed charges "Nephelometry, test method using light" 50434217_1 CDM 0301 RC 83883 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges "Nephelometry, test method using light" 50434217_1 CDM 0301 RC 83883 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges "Nephelometry, test method using light" 50434217_1 CDM 0301 RC 83883 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges "Nephelometry, test method using light" 50434217_1 CDM 0301 RC 83883 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges "Nephelometry, test method using light" 50434217_1 CDM 0301 RC 83883 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges "Nephelometry, test method using light" 50434217_1 CDM 0301 RC 83883 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges "Nephelometry, test method using light" 50434217_1 CDM 0301 RC 83883 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges "Nephelometry, test method using light" 50434217_1 CDM 0301 RC 83883 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges "Nephelometry, test method using light" 50434217_1 CDM 0301 RC 83883 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 "Nephelometry, test method using light" 50434217_1 CDM 0301 RC 83883 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 "Nephelometry, test method using light" 50434217_1 CDM 0301 RC 83883 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 "Nephelometry, test method using light" 50434217_1 CDM 0301 RC 83883 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 "Nephelometry, test method using light" 50434217_1 CDM 0301 RC 83883 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 "Nephelometry, test method using light" 50434217_1 CDM 0301 RC 83883 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges Gene analysis (coagulation factor V) Leiden variant 50434218_1 CDM 0301 RC 81241 HCPCS inpatient 603 391.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 391.95 65 999999999 365.12 584.91 percent of total billed charges Gene analysis (coagulation factor V) Leiden variant 50434218_1 CDM 0301 RC 81241 HCPCS inpatient 603 391.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 584.91 97 999999999 365.12 584.91 percent of total billed charges Gene analysis (coagulation factor V) Leiden variant 50434218_1 CDM 0301 RC 81241 HCPCS inpatient 603 391.95 AETNA AETNA 476.37 79 999999999 365.12 584.91 percent of total billed charges Gene analysis (coagulation factor V) Leiden variant 50434218_1 CDM 0301 RC 81241 HCPCS inpatient 603 391.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 470.34 78 999999999 365.12 584.91 percent of total billed charges Gene analysis (coagulation factor V) Leiden variant 50434218_1 CDM 0301 RC 81241 HCPCS inpatient 603 391.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 416.07 69 999999999 365.12 584.91 percent of total billed charges Gene analysis (coagulation factor V) Leiden variant 50434218_1 CDM 0301 RC 81241 HCPCS inpatient 603 391.95 SIHO - ALL PLANS SIHO - ALL PLANS 542.7 90 999999999 365.12 584.91 percent of total billed charges Gene analysis (coagulation factor V) Leiden variant 50434218_1 CDM 0301 RC 81241 HCPCS inpatient 603 391.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 365.12 60.55 999999999 365.12 584.91 percent of total billed charges Gene analysis (coagulation factor V) Leiden variant 50434218_1 CDM 0301 RC 81241 HCPCS inpatient 603 391.95 UMR - ALL PLANS UMR - ALL PLANS 422.1 70 999999999 365.12 584.91 percent of total billed charges Gene analysis (coagulation factor V) Leiden variant 50434218_1 CDM 0301 RC 81241 HCPCS inpatient 603 391.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 365.12 584.91 Gene analysis (coagulation factor V) Leiden variant 50434218_1 CDM 0301 RC 81241 HCPCS inpatient 603 391.95 ANTHEM HMO ANTHEM HMO 999999999 365.12 584.91 Gene analysis (coagulation factor V) Leiden variant 50434218_1 CDM 0301 RC 81241 HCPCS inpatient 603 391.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 365.12 584.91 Gene analysis (coagulation factor V) Leiden variant 50434218_1 CDM 0301 RC 81241 HCPCS inpatient 603 391.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 365.12 584.91 Gene analysis (coagulation factor V) Leiden variant 50434218_1 CDM 0301 RC 81241 HCPCS inpatient 603 391.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 365.12 584.91 Gene analysis (coagulation factor V) Leiden variant 50434218_1 CDM 0301 RC 81241 HCPCS inpatient 603 391.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 407.63 67.6 999999999 365.12 584.91 percent of total billed charges G6PD (enzyme) level 50434219_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges G6PD (enzyme) level 50434219_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges G6PD (enzyme) level 50434219_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges G6PD (enzyme) level 50434219_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges G6PD (enzyme) level 50434219_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges G6PD (enzyme) level 50434219_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges G6PD (enzyme) level 50434219_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges G6PD (enzyme) level 50434219_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges G6PD (enzyme) level 50434219_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 G6PD (enzyme) level 50434219_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 G6PD (enzyme) level 50434219_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 G6PD (enzyme) level 50434219_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 G6PD (enzyme) level 50434219_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 G6PD (enzyme) level 50434219_1 CDM 0301 RC 82955 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges Gabapentin level 50434220_1 CDM 0301 RC 80171 HCPCS inpatient 256 166.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 166.4 65 999999999 155.01 248.32 percent of total billed charges Gabapentin level 50434220_1 CDM 0301 RC 80171 HCPCS inpatient 256 166.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 248.32 97 999999999 155.01 248.32 percent of total billed charges Gabapentin level 50434220_1 CDM 0301 RC 80171 HCPCS inpatient 256 166.4 AETNA AETNA 202.24 79 999999999 155.01 248.32 percent of total billed charges Gabapentin level 50434220_1 CDM 0301 RC 80171 HCPCS inpatient 256 166.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 199.68 78 999999999 155.01 248.32 percent of total billed charges Gabapentin level 50434220_1 CDM 0301 RC 80171 HCPCS inpatient 256 166.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 176.64 69 999999999 155.01 248.32 percent of total billed charges Gabapentin level 50434220_1 CDM 0301 RC 80171 HCPCS inpatient 256 166.4 SIHO - ALL PLANS SIHO - ALL PLANS 230.4 90 999999999 155.01 248.32 percent of total billed charges Gabapentin level 50434220_1 CDM 0301 RC 80171 HCPCS inpatient 256 166.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.01 60.55 999999999 155.01 248.32 percent of total billed charges Gabapentin level 50434220_1 CDM 0301 RC 80171 HCPCS inpatient 256 166.4 UMR - ALL PLANS UMR - ALL PLANS 179.2 70 999999999 155.01 248.32 percent of total billed charges Gabapentin level 50434220_1 CDM 0301 RC 80171 HCPCS inpatient 256 166.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.01 248.32 Gabapentin level 50434220_1 CDM 0301 RC 80171 HCPCS inpatient 256 166.4 ANTHEM HMO ANTHEM HMO 999999999 155.01 248.32 Gabapentin level 50434220_1 CDM 0301 RC 80171 HCPCS inpatient 256 166.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.01 248.32 Gabapentin level 50434220_1 CDM 0301 RC 80171 HCPCS inpatient 256 166.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.01 248.32 Gabapentin level 50434220_1 CDM 0301 RC 80171 HCPCS inpatient 256 166.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.01 248.32 Gabapentin level 50434220_1 CDM 0301 RC 80171 HCPCS inpatient 256 166.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.06 67.6 999999999 155.01 248.32 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434221_1 CDM 0301 RC 83519 HCPCS inpatient 331 215.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 215.15 65 999999999 200.42 321.07 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434221_1 CDM 0301 RC 83519 HCPCS inpatient 331 215.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 321.07 97 999999999 200.42 321.07 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434221_1 CDM 0301 RC 83519 HCPCS inpatient 331 215.15 AETNA AETNA 261.49 79 999999999 200.42 321.07 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434221_1 CDM 0301 RC 83519 HCPCS inpatient 331 215.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 258.18 78 999999999 200.42 321.07 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434221_1 CDM 0301 RC 83519 HCPCS inpatient 331 215.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 228.39 69 999999999 200.42 321.07 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434221_1 CDM 0301 RC 83519 HCPCS inpatient 331 215.15 SIHO - ALL PLANS SIHO - ALL PLANS 297.9 90 999999999 200.42 321.07 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434221_1 CDM 0301 RC 83519 HCPCS inpatient 331 215.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 200.42 60.55 999999999 200.42 321.07 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434221_1 CDM 0301 RC 83519 HCPCS inpatient 331 215.15 UMR - ALL PLANS UMR - ALL PLANS 231.7 70 999999999 200.42 321.07 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434221_1 CDM 0301 RC 83519 HCPCS inpatient 331 215.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 200.42 321.07 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434221_1 CDM 0301 RC 83519 HCPCS inpatient 331 215.15 ANTHEM HMO ANTHEM HMO 999999999 200.42 321.07 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434221_1 CDM 0301 RC 83519 HCPCS inpatient 331 215.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 200.42 321.07 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434221_1 CDM 0301 RC 83519 HCPCS inpatient 331 215.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 200.42 321.07 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434221_1 CDM 0301 RC 83519 HCPCS inpatient 331 215.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 200.42 321.07 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434221_1 CDM 0301 RC 83519 HCPCS inpatient 331 215.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 223.76 67.6 999999999 200.42 321.07 percent of total billed charges Gastrin (GI tract hormone) level 50434222_1 CDM 0301 RC 82941 HCPCS inpatient 326 211.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 211.9 65 999999999 197.39 316.22 percent of total billed charges Gastrin (GI tract hormone) level 50434222_1 CDM 0301 RC 82941 HCPCS inpatient 326 211.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 316.22 97 999999999 197.39 316.22 percent of total billed charges Gastrin (GI tract hormone) level 50434222_1 CDM 0301 RC 82941 HCPCS inpatient 326 211.9 AETNA AETNA 257.54 79 999999999 197.39 316.22 percent of total billed charges Gastrin (GI tract hormone) level 50434222_1 CDM 0301 RC 82941 HCPCS inpatient 326 211.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 254.28 78 999999999 197.39 316.22 percent of total billed charges Gastrin (GI tract hormone) level 50434222_1 CDM 0301 RC 82941 HCPCS inpatient 326 211.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 224.94 69 999999999 197.39 316.22 percent of total billed charges Gastrin (GI tract hormone) level 50434222_1 CDM 0301 RC 82941 HCPCS inpatient 326 211.9 SIHO - ALL PLANS SIHO - ALL PLANS 293.4 90 999999999 197.39 316.22 percent of total billed charges Gastrin (GI tract hormone) level 50434222_1 CDM 0301 RC 82941 HCPCS inpatient 326 211.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 197.39 60.55 999999999 197.39 316.22 percent of total billed charges Gastrin (GI tract hormone) level 50434222_1 CDM 0301 RC 82941 HCPCS inpatient 326 211.9 UMR - ALL PLANS UMR - ALL PLANS 228.2 70 999999999 197.39 316.22 percent of total billed charges Gastrin (GI tract hormone) level 50434222_1 CDM 0301 RC 82941 HCPCS inpatient 326 211.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 197.39 316.22 Gastrin (GI tract hormone) level 50434222_1 CDM 0301 RC 82941 HCPCS inpatient 326 211.9 ANTHEM HMO ANTHEM HMO 999999999 197.39 316.22 Gastrin (GI tract hormone) level 50434222_1 CDM 0301 RC 82941 HCPCS inpatient 326 211.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 197.39 316.22 Gastrin (GI tract hormone) level 50434222_1 CDM 0301 RC 82941 HCPCS inpatient 326 211.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 197.39 316.22 Gastrin (GI tract hormone) level 50434222_1 CDM 0301 RC 82941 HCPCS inpatient 326 211.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 197.39 316.22 Gastrin (GI tract hormone) level 50434222_1 CDM 0301 RC 82941 HCPCS inpatient 326 211.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 220.38 67.6 999999999 197.39 316.22 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434223_1 CDM 0301 RC 83516 HCPCS inpatient 298 193.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 193.7 65 999999999 180.44 289.06 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434223_1 CDM 0301 RC 83516 HCPCS inpatient 298 193.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 289.06 97 999999999 180.44 289.06 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434223_1 CDM 0301 RC 83516 HCPCS inpatient 298 193.7 AETNA AETNA 235.42 79 999999999 180.44 289.06 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434223_1 CDM 0301 RC 83516 HCPCS inpatient 298 193.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 232.44 78 999999999 180.44 289.06 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434223_1 CDM 0301 RC 83516 HCPCS inpatient 298 193.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 205.62 69 999999999 180.44 289.06 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434223_1 CDM 0301 RC 83516 HCPCS inpatient 298 193.7 SIHO - ALL PLANS SIHO - ALL PLANS 268.2 90 999999999 180.44 289.06 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434223_1 CDM 0301 RC 83516 HCPCS inpatient 298 193.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 180.44 60.55 999999999 180.44 289.06 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434223_1 CDM 0301 RC 83516 HCPCS inpatient 298 193.7 UMR - ALL PLANS UMR - ALL PLANS 208.6 70 999999999 180.44 289.06 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434223_1 CDM 0301 RC 83516 HCPCS inpatient 298 193.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 180.44 289.06 "Analysis of substance using immunoassay technique, multiple step method" 50434223_1 CDM 0301 RC 83516 HCPCS inpatient 298 193.7 ANTHEM HMO ANTHEM HMO 999999999 180.44 289.06 "Analysis of substance using immunoassay technique, multiple step method" 50434223_1 CDM 0301 RC 83516 HCPCS inpatient 298 193.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 180.44 289.06 "Analysis of substance using immunoassay technique, multiple step method" 50434223_1 CDM 0301 RC 83516 HCPCS inpatient 298 193.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 180.44 289.06 "Analysis of substance using immunoassay technique, multiple step method" 50434223_1 CDM 0301 RC 83516 HCPCS inpatient 298 193.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 180.44 289.06 "Analysis of substance using immunoassay technique, multiple step method" 50434223_1 CDM 0301 RC 83516 HCPCS inpatient 298 193.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 201.45 67.6 999999999 180.44 289.06 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434224_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434224_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434224_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434224_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434224_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434224_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434224_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434224_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434224_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50434224_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50434224_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50434224_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50434224_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50434224_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434225_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434225_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434225_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434225_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434225_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434225_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434225_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434225_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434225_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50434225_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50434225_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50434225_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50434225_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50434225_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges Breath test analysis for helicobacter pylori 50434226_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 193.05 65 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 50434226_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 288.09 97 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 50434226_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 AETNA AETNA 234.63 79 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 50434226_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 231.66 78 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 50434226_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 204.93 69 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 50434226_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 SIHO - ALL PLANS SIHO - ALL PLANS 267.3 90 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 50434226_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 179.83 60.55 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 50434226_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 UMR - ALL PLANS UMR - ALL PLANS 207.9 70 999999999 179.83 288.09 percent of total billed charges Breath test analysis for helicobacter pylori 50434226_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 179.83 288.09 Breath test analysis for helicobacter pylori 50434226_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 ANTHEM HMO ANTHEM HMO 999999999 179.83 288.09 Breath test analysis for helicobacter pylori 50434226_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 179.83 288.09 Breath test analysis for helicobacter pylori 50434226_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 179.83 288.09 Breath test analysis for helicobacter pylori 50434226_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 179.83 288.09 Breath test analysis for helicobacter pylori 50434226_1 CDM 0301 RC 83013 HCPCS inpatient 297 193.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 200.77 67.6 999999999 179.83 288.09 percent of total billed charges Haptoglobin (serum protein) level 50434227_1 CDM 0301 RC 83010 HCPCS inpatient 195 126.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 126.75 65 999999999 118.07 189.15 percent of total billed charges Haptoglobin (serum protein) level 50434227_1 CDM 0301 RC 83010 HCPCS inpatient 195 126.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 189.15 97 999999999 118.07 189.15 percent of total billed charges Haptoglobin (serum protein) level 50434227_1 CDM 0301 RC 83010 HCPCS inpatient 195 126.75 AETNA AETNA 154.05 79 999999999 118.07 189.15 percent of total billed charges Haptoglobin (serum protein) level 50434227_1 CDM 0301 RC 83010 HCPCS inpatient 195 126.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 152.1 78 999999999 118.07 189.15 percent of total billed charges Haptoglobin (serum protein) level 50434227_1 CDM 0301 RC 83010 HCPCS inpatient 195 126.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 134.55 69 999999999 118.07 189.15 percent of total billed charges Haptoglobin (serum protein) level 50434227_1 CDM 0301 RC 83010 HCPCS inpatient 195 126.75 SIHO - ALL PLANS SIHO - ALL PLANS 175.5 90 999999999 118.07 189.15 percent of total billed charges Haptoglobin (serum protein) level 50434227_1 CDM 0301 RC 83010 HCPCS inpatient 195 126.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 118.07 60.55 999999999 118.07 189.15 percent of total billed charges Haptoglobin (serum protein) level 50434227_1 CDM 0301 RC 83010 HCPCS inpatient 195 126.75 UMR - ALL PLANS UMR - ALL PLANS 136.5 70 999999999 118.07 189.15 percent of total billed charges Haptoglobin (serum protein) level 50434227_1 CDM 0301 RC 83010 HCPCS inpatient 195 126.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 118.07 189.15 Haptoglobin (serum protein) level 50434227_1 CDM 0301 RC 83010 HCPCS inpatient 195 126.75 ANTHEM HMO ANTHEM HMO 999999999 118.07 189.15 Haptoglobin (serum protein) level 50434227_1 CDM 0301 RC 83010 HCPCS inpatient 195 126.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 118.07 189.15 Haptoglobin (serum protein) level 50434227_1 CDM 0301 RC 83010 HCPCS inpatient 195 126.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 118.07 189.15 Haptoglobin (serum protein) level 50434227_1 CDM 0301 RC 83010 HCPCS inpatient 195 126.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 118.07 189.15 Haptoglobin (serum protein) level 50434227_1 CDM 0301 RC 83010 HCPCS inpatient 195 126.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 131.82 67.6 999999999 118.07 189.15 percent of total billed charges Hepatitis B core antibody measurement 50434228_1 CDM 0301 RC 86704 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges Hepatitis B core antibody measurement 50434228_1 CDM 0301 RC 86704 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges Hepatitis B core antibody measurement 50434228_1 CDM 0301 RC 86704 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges Hepatitis B core antibody measurement 50434228_1 CDM 0301 RC 86704 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges Hepatitis B core antibody measurement 50434228_1 CDM 0301 RC 86704 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges Hepatitis B core antibody measurement 50434228_1 CDM 0301 RC 86704 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges Hepatitis B core antibody measurement 50434228_1 CDM 0301 RC 86704 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges Hepatitis B core antibody measurement 50434228_1 CDM 0301 RC 86704 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges Hepatitis B core antibody measurement 50434228_1 CDM 0301 RC 86704 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 Hepatitis B core antibody measurement 50434228_1 CDM 0301 RC 86704 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 Hepatitis B core antibody measurement 50434228_1 CDM 0301 RC 86704 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 Hepatitis B core antibody measurement 50434228_1 CDM 0301 RC 86704 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 Hepatitis B core antibody measurement 50434228_1 CDM 0301 RC 86704 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 Hepatitis B core antibody measurement 50434228_1 CDM 0301 RC 86704 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges Hepatitis Be antibody measurement 50434229_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.95 65 999999999 110.81 177.51 percent of total billed charges Hepatitis Be antibody measurement 50434229_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.51 97 999999999 110.81 177.51 percent of total billed charges Hepatitis Be antibody measurement 50434229_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 AETNA AETNA 144.57 79 999999999 110.81 177.51 percent of total billed charges Hepatitis Be antibody measurement 50434229_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 142.74 78 999999999 110.81 177.51 percent of total billed charges Hepatitis Be antibody measurement 50434229_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.27 69 999999999 110.81 177.51 percent of total billed charges Hepatitis Be antibody measurement 50434229_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 SIHO - ALL PLANS SIHO - ALL PLANS 164.7 90 999999999 110.81 177.51 percent of total billed charges Hepatitis Be antibody measurement 50434229_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.81 60.55 999999999 110.81 177.51 percent of total billed charges Hepatitis Be antibody measurement 50434229_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 UMR - ALL PLANS UMR - ALL PLANS 128.1 70 999999999 110.81 177.51 percent of total billed charges Hepatitis Be antibody measurement 50434229_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.81 177.51 Hepatitis Be antibody measurement 50434229_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 ANTHEM HMO ANTHEM HMO 999999999 110.81 177.51 Hepatitis Be antibody measurement 50434229_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.81 177.51 Hepatitis Be antibody measurement 50434229_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.81 177.51 Hepatitis Be antibody measurement 50434229_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.81 177.51 Hepatitis Be antibody measurement 50434229_1 CDM 0301 RC 86707 HCPCS inpatient 183 118.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.71 67.6 999999999 110.81 177.51 percent of total billed charges Hepatitis B surface antibody measurement 50434230_1 CDM 0302 RC 86706 HCPCS inpatient 148 96.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 96.2 65 999999999 89.61 143.56 percent of total billed charges Hepatitis B surface antibody measurement 50434230_1 CDM 0302 RC 86706 HCPCS inpatient 148 96.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 143.56 97 999999999 89.61 143.56 percent of total billed charges Hepatitis B surface antibody measurement 50434230_1 CDM 0302 RC 86706 HCPCS inpatient 148 96.2 AETNA AETNA 116.92 79 999999999 89.61 143.56 percent of total billed charges Hepatitis B surface antibody measurement 50434230_1 CDM 0302 RC 86706 HCPCS inpatient 148 96.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 115.44 78 999999999 89.61 143.56 percent of total billed charges Hepatitis B surface antibody measurement 50434230_1 CDM 0302 RC 86706 HCPCS inpatient 148 96.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 102.12 69 999999999 89.61 143.56 percent of total billed charges Hepatitis B surface antibody measurement 50434230_1 CDM 0302 RC 86706 HCPCS inpatient 148 96.2 SIHO - ALL PLANS SIHO - ALL PLANS 133.2 90 999999999 89.61 143.56 percent of total billed charges Hepatitis B surface antibody measurement 50434230_1 CDM 0302 RC 86706 HCPCS inpatient 148 96.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 89.61 60.55 999999999 89.61 143.56 percent of total billed charges Hepatitis B surface antibody measurement 50434230_1 CDM 0302 RC 86706 HCPCS inpatient 148 96.2 UMR - ALL PLANS UMR - ALL PLANS 103.6 70 999999999 89.61 143.56 percent of total billed charges Hepatitis B surface antibody measurement 50434230_1 CDM 0302 RC 86706 HCPCS inpatient 148 96.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 89.61 143.56 Hepatitis B surface antibody measurement 50434230_1 CDM 0302 RC 86706 HCPCS inpatient 148 96.2 ANTHEM HMO ANTHEM HMO 999999999 89.61 143.56 Hepatitis B surface antibody measurement 50434230_1 CDM 0302 RC 86706 HCPCS inpatient 148 96.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 89.61 143.56 Hepatitis B surface antibody measurement 50434230_1 CDM 0302 RC 86706 HCPCS inpatient 148 96.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 89.61 143.56 Hepatitis B surface antibody measurement 50434230_1 CDM 0302 RC 86706 HCPCS inpatient 148 96.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 89.61 143.56 Hepatitis B surface antibody measurement 50434230_1 CDM 0302 RC 86706 HCPCS inpatient 148 96.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 100.05 67.6 999999999 89.61 143.56 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 50434231_1 CDM 0306 RC 87340 HCPCS inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 50434231_1 CDM 0306 RC 87340 HCPCS inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 50434231_1 CDM 0306 RC 87340 HCPCS inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 50434231_1 CDM 0306 RC 87340 HCPCS inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 50434231_1 CDM 0306 RC 87340 HCPCS inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 50434231_1 CDM 0306 RC 87340 HCPCS inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 50434231_1 CDM 0306 RC 87340 HCPCS inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 50434231_1 CDM 0306 RC 87340 HCPCS inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 50434231_1 CDM 0306 RC 87340 HCPCS inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 Detection test by immunoassay technique for hepatitis B surface antigen 50434231_1 CDM 0306 RC 87340 HCPCS inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 Detection test by immunoassay technique for hepatitis B surface antigen 50434231_1 CDM 0306 RC 87340 HCPCS inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 Detection test by immunoassay technique for hepatitis B surface antigen 50434231_1 CDM 0306 RC 87340 HCPCS inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 Detection test by immunoassay technique for hepatitis B surface antigen 50434231_1 CDM 0306 RC 87340 HCPCS inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 Detection test by immunoassay technique for hepatitis B surface antigen 50434231_1 CDM 0306 RC 87340 HCPCS inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges Hepatitis C antibody measurement 50434232_1 CDM 0302 RC 86803 HCPCS inpatient 116 75.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 75.4 65 999999999 70.24 112.52 percent of total billed charges Hepatitis C antibody measurement 50434232_1 CDM 0302 RC 86803 HCPCS inpatient 116 75.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 112.52 97 999999999 70.24 112.52 percent of total billed charges Hepatitis C antibody measurement 50434232_1 CDM 0302 RC 86803 HCPCS inpatient 116 75.4 AETNA AETNA 91.64 79 999999999 70.24 112.52 percent of total billed charges Hepatitis C antibody measurement 50434232_1 CDM 0302 RC 86803 HCPCS inpatient 116 75.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 90.48 78 999999999 70.24 112.52 percent of total billed charges Hepatitis C antibody measurement 50434232_1 CDM 0302 RC 86803 HCPCS inpatient 116 75.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.04 69 999999999 70.24 112.52 percent of total billed charges Hepatitis C antibody measurement 50434232_1 CDM 0302 RC 86803 HCPCS inpatient 116 75.4 SIHO - ALL PLANS SIHO - ALL PLANS 104.4 90 999999999 70.24 112.52 percent of total billed charges Hepatitis C antibody measurement 50434232_1 CDM 0302 RC 86803 HCPCS inpatient 116 75.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 70.24 60.55 999999999 70.24 112.52 percent of total billed charges Hepatitis C antibody measurement 50434232_1 CDM 0302 RC 86803 HCPCS inpatient 116 75.4 UMR - ALL PLANS UMR - ALL PLANS 81.2 70 999999999 70.24 112.52 percent of total billed charges Hepatitis C antibody measurement 50434232_1 CDM 0302 RC 86803 HCPCS inpatient 116 75.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 70.24 112.52 Hepatitis C antibody measurement 50434232_1 CDM 0302 RC 86803 HCPCS inpatient 116 75.4 ANTHEM HMO ANTHEM HMO 999999999 70.24 112.52 Hepatitis C antibody measurement 50434232_1 CDM 0302 RC 86803 HCPCS inpatient 116 75.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 70.24 112.52 Hepatitis C antibody measurement 50434232_1 CDM 0302 RC 86803 HCPCS inpatient 116 75.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 70.24 112.52 Hepatitis C antibody measurement 50434232_1 CDM 0302 RC 86803 HCPCS inpatient 116 75.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 70.24 112.52 Hepatitis C antibody measurement 50434232_1 CDM 0302 RC 86803 HCPCS inpatient 116 75.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 78.42 67.6 999999999 70.24 112.52 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 50434233_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.15 65 999999999 151.98 243.47 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 50434233_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 243.47 97 999999999 151.98 243.47 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 50434233_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 AETNA AETNA 198.29 79 999999999 151.98 243.47 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 50434233_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 195.78 78 999999999 151.98 243.47 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 50434233_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.19 69 999999999 151.98 243.47 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 50434233_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 SIHO - ALL PLANS SIHO - ALL PLANS 225.9 90 999999999 151.98 243.47 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 50434233_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.98 60.55 999999999 151.98 243.47 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 50434233_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 UMR - ALL PLANS UMR - ALL PLANS 175.7 70 999999999 151.98 243.47 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 50434233_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.98 243.47 "Detection test by nucleic acid for Hepatitis C virus, quantification" 50434233_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 ANTHEM HMO ANTHEM HMO 999999999 151.98 243.47 "Detection test by nucleic acid for Hepatitis C virus, quantification" 50434233_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.98 243.47 "Detection test by nucleic acid for Hepatitis C virus, quantification" 50434233_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.98 243.47 "Detection test by nucleic acid for Hepatitis C virus, quantification" 50434233_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.98 243.47 "Detection test by nucleic acid for Hepatitis C virus, quantification" 50434233_1 CDM 0306 RC 87522 HCPCS inpatient 251 163.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 169.68 67.6 999999999 151.98 243.47 percent of total billed charges Acute hepatitis panel 50434234_1 CDM 0301 RC 80074 HCPCS inpatient 318 206.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 206.7 65 999999999 192.55 308.46 percent of total billed charges Acute hepatitis panel 50434234_1 CDM 0301 RC 80074 HCPCS inpatient 318 206.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 308.46 97 999999999 192.55 308.46 percent of total billed charges Acute hepatitis panel 50434234_1 CDM 0301 RC 80074 HCPCS inpatient 318 206.7 AETNA AETNA 251.22 79 999999999 192.55 308.46 percent of total billed charges Acute hepatitis panel 50434234_1 CDM 0301 RC 80074 HCPCS inpatient 318 206.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 248.04 78 999999999 192.55 308.46 percent of total billed charges Acute hepatitis panel 50434234_1 CDM 0301 RC 80074 HCPCS inpatient 318 206.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 219.42 69 999999999 192.55 308.46 percent of total billed charges Acute hepatitis panel 50434234_1 CDM 0301 RC 80074 HCPCS inpatient 318 206.7 SIHO - ALL PLANS SIHO - ALL PLANS 286.2 90 999999999 192.55 308.46 percent of total billed charges Acute hepatitis panel 50434234_1 CDM 0301 RC 80074 HCPCS inpatient 318 206.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 192.55 60.55 999999999 192.55 308.46 percent of total billed charges Acute hepatitis panel 50434234_1 CDM 0301 RC 80074 HCPCS inpatient 318 206.7 UMR - ALL PLANS UMR - ALL PLANS 222.6 70 999999999 192.55 308.46 percent of total billed charges Acute hepatitis panel 50434234_1 CDM 0301 RC 80074 HCPCS inpatient 318 206.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 192.55 308.46 Acute hepatitis panel 50434234_1 CDM 0301 RC 80074 HCPCS inpatient 318 206.7 ANTHEM HMO ANTHEM HMO 999999999 192.55 308.46 Acute hepatitis panel 50434234_1 CDM 0301 RC 80074 HCPCS inpatient 318 206.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 192.55 308.46 Acute hepatitis panel 50434234_1 CDM 0301 RC 80074 HCPCS inpatient 318 206.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 192.55 308.46 Acute hepatitis panel 50434234_1 CDM 0301 RC 80074 HCPCS inpatient 318 206.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 192.55 308.46 Acute hepatitis panel 50434234_1 CDM 0301 RC 80074 HCPCS inpatient 318 206.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 214.97 67.6 999999999 192.55 308.46 percent of total billed charges Gene analysis (hemochromatosis) common variants 50434235_1 CDM 0301 RC 81256 HCPCS inpatient 715 464.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 464.75 65 999999999 432.93 693.55 percent of total billed charges Gene analysis (hemochromatosis) common variants 50434235_1 CDM 0301 RC 81256 HCPCS inpatient 715 464.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 693.55 97 999999999 432.93 693.55 percent of total billed charges Gene analysis (hemochromatosis) common variants 50434235_1 CDM 0301 RC 81256 HCPCS inpatient 715 464.75 AETNA AETNA 564.85 79 999999999 432.93 693.55 percent of total billed charges Gene analysis (hemochromatosis) common variants 50434235_1 CDM 0301 RC 81256 HCPCS inpatient 715 464.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 557.7 78 999999999 432.93 693.55 percent of total billed charges Gene analysis (hemochromatosis) common variants 50434235_1 CDM 0301 RC 81256 HCPCS inpatient 715 464.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 493.35 69 999999999 432.93 693.55 percent of total billed charges Gene analysis (hemochromatosis) common variants 50434235_1 CDM 0301 RC 81256 HCPCS inpatient 715 464.75 SIHO - ALL PLANS SIHO - ALL PLANS 643.5 90 999999999 432.93 693.55 percent of total billed charges Gene analysis (hemochromatosis) common variants 50434235_1 CDM 0301 RC 81256 HCPCS inpatient 715 464.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 432.93 60.55 999999999 432.93 693.55 percent of total billed charges Gene analysis (hemochromatosis) common variants 50434235_1 CDM 0301 RC 81256 HCPCS inpatient 715 464.75 UMR - ALL PLANS UMR - ALL PLANS 500.5 70 999999999 432.93 693.55 percent of total billed charges Gene analysis (hemochromatosis) common variants 50434235_1 CDM 0301 RC 81256 HCPCS inpatient 715 464.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 432.93 693.55 Gene analysis (hemochromatosis) common variants 50434235_1 CDM 0301 RC 81256 HCPCS inpatient 715 464.75 ANTHEM HMO ANTHEM HMO 999999999 432.93 693.55 Gene analysis (hemochromatosis) common variants 50434235_1 CDM 0301 RC 81256 HCPCS inpatient 715 464.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 432.93 693.55 Gene analysis (hemochromatosis) common variants 50434235_1 CDM 0301 RC 81256 HCPCS inpatient 715 464.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 432.93 693.55 Gene analysis (hemochromatosis) common variants 50434235_1 CDM 0301 RC 81256 HCPCS inpatient 715 464.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 432.93 693.55 Gene analysis (hemochromatosis) common variants 50434235_1 CDM 0301 RC 81256 HCPCS inpatient 715 464.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 483.34 67.6 999999999 432.93 693.55 percent of total billed charges Hemoglobin A1C level 50434236_1 CDM 0301 RC 83036 HCPCS inpatient 193 125.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 125.45 65 999999999 116.86 187.21 percent of total billed charges Hemoglobin A1C level 50434236_1 CDM 0301 RC 83036 HCPCS inpatient 193 125.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 187.21 97 999999999 116.86 187.21 percent of total billed charges Hemoglobin A1C level 50434236_1 CDM 0301 RC 83036 HCPCS inpatient 193 125.45 AETNA AETNA 152.47 79 999999999 116.86 187.21 percent of total billed charges Hemoglobin A1C level 50434236_1 CDM 0301 RC 83036 HCPCS inpatient 193 125.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 150.54 78 999999999 116.86 187.21 percent of total billed charges Hemoglobin A1C level 50434236_1 CDM 0301 RC 83036 HCPCS inpatient 193 125.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.17 69 999999999 116.86 187.21 percent of total billed charges Hemoglobin A1C level 50434236_1 CDM 0301 RC 83036 HCPCS inpatient 193 125.45 SIHO - ALL PLANS SIHO - ALL PLANS 173.7 90 999999999 116.86 187.21 percent of total billed charges Hemoglobin A1C level 50434236_1 CDM 0301 RC 83036 HCPCS inpatient 193 125.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.86 60.55 999999999 116.86 187.21 percent of total billed charges Hemoglobin A1C level 50434236_1 CDM 0301 RC 83036 HCPCS inpatient 193 125.45 UMR - ALL PLANS UMR - ALL PLANS 135.1 70 999999999 116.86 187.21 percent of total billed charges Hemoglobin A1C level 50434236_1 CDM 0301 RC 83036 HCPCS inpatient 193 125.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.86 187.21 Hemoglobin A1C level 50434236_1 CDM 0301 RC 83036 HCPCS inpatient 193 125.45 ANTHEM HMO ANTHEM HMO 999999999 116.86 187.21 Hemoglobin A1C level 50434236_1 CDM 0301 RC 83036 HCPCS inpatient 193 125.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.86 187.21 Hemoglobin A1C level 50434236_1 CDM 0301 RC 83036 HCPCS inpatient 193 125.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.86 187.21 Hemoglobin A1C level 50434236_1 CDM 0301 RC 83036 HCPCS inpatient 193 125.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.86 187.21 Hemoglobin A1C level 50434236_1 CDM 0301 RC 83036 HCPCS inpatient 193 125.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 130.47 67.6 999999999 116.86 187.21 percent of total billed charges Red blood cell sickling measurement 50434237_1 CDM 0305 RC 85660 HCPCS inpatient 84 54.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 54.6 65 999999999 50.86 81.48 percent of total billed charges Red blood cell sickling measurement 50434237_1 CDM 0305 RC 85660 HCPCS inpatient 84 54.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 81.48 97 999999999 50.86 81.48 percent of total billed charges Red blood cell sickling measurement 50434237_1 CDM 0305 RC 85660 HCPCS inpatient 84 54.6 AETNA AETNA 66.36 79 999999999 50.86 81.48 percent of total billed charges Red blood cell sickling measurement 50434237_1 CDM 0305 RC 85660 HCPCS inpatient 84 54.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 65.52 78 999999999 50.86 81.48 percent of total billed charges Red blood cell sickling measurement 50434237_1 CDM 0305 RC 85660 HCPCS inpatient 84 54.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.96 69 999999999 50.86 81.48 percent of total billed charges Red blood cell sickling measurement 50434237_1 CDM 0305 RC 85660 HCPCS inpatient 84 54.6 SIHO - ALL PLANS SIHO - ALL PLANS 75.6 90 999999999 50.86 81.48 percent of total billed charges Red blood cell sickling measurement 50434237_1 CDM 0305 RC 85660 HCPCS inpatient 84 54.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.86 60.55 999999999 50.86 81.48 percent of total billed charges Red blood cell sickling measurement 50434237_1 CDM 0305 RC 85660 HCPCS inpatient 84 54.6 UMR - ALL PLANS UMR - ALL PLANS 58.8 70 999999999 50.86 81.48 percent of total billed charges Red blood cell sickling measurement 50434237_1 CDM 0305 RC 85660 HCPCS inpatient 84 54.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.86 81.48 Red blood cell sickling measurement 50434237_1 CDM 0305 RC 85660 HCPCS inpatient 84 54.6 ANTHEM HMO ANTHEM HMO 999999999 50.86 81.48 Red blood cell sickling measurement 50434237_1 CDM 0305 RC 85660 HCPCS inpatient 84 54.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.86 81.48 Red blood cell sickling measurement 50434237_1 CDM 0305 RC 85660 HCPCS inpatient 84 54.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.86 81.48 Red blood cell sickling measurement 50434237_1 CDM 0305 RC 85660 HCPCS inpatient 84 54.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.86 81.48 Red blood cell sickling measurement 50434237_1 CDM 0305 RC 85660 HCPCS inpatient 84 54.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.78 67.6 999999999 50.86 81.48 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434238_1 CDM 0301 RC 86635 HCPCS inpatient 361 234.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 234.65 65 999999999 218.59 350.17 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434238_1 CDM 0301 RC 86635 HCPCS inpatient 361 234.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 350.17 97 999999999 218.59 350.17 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434238_1 CDM 0301 RC 86635 HCPCS inpatient 361 234.65 AETNA AETNA 285.19 79 999999999 218.59 350.17 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434238_1 CDM 0301 RC 86635 HCPCS inpatient 361 234.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 281.58 78 999999999 218.59 350.17 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434238_1 CDM 0301 RC 86635 HCPCS inpatient 361 234.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 249.09 69 999999999 218.59 350.17 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434238_1 CDM 0301 RC 86635 HCPCS inpatient 361 234.65 SIHO - ALL PLANS SIHO - ALL PLANS 324.9 90 999999999 218.59 350.17 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434238_1 CDM 0301 RC 86635 HCPCS inpatient 361 234.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 218.59 60.55 999999999 218.59 350.17 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434238_1 CDM 0301 RC 86635 HCPCS inpatient 361 234.65 UMR - ALL PLANS UMR - ALL PLANS 252.7 70 999999999 218.59 350.17 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50434238_1 CDM 0301 RC 86635 HCPCS inpatient 361 234.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 218.59 350.17 Analysis for antibody to Coccidioides (bacteria) 50434238_1 CDM 0301 RC 86635 HCPCS inpatient 361 234.65 ANTHEM HMO ANTHEM HMO 999999999 218.59 350.17 Analysis for antibody to Coccidioides (bacteria) 50434238_1 CDM 0301 RC 86635 HCPCS inpatient 361 234.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 218.59 350.17 Analysis for antibody to Coccidioides (bacteria) 50434238_1 CDM 0301 RC 86635 HCPCS inpatient 361 234.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 218.59 350.17 Analysis for antibody to Coccidioides (bacteria) 50434238_1 CDM 0301 RC 86635 HCPCS inpatient 361 234.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 218.59 350.17 Analysis for antibody to Coccidioides (bacteria) 50434238_1 CDM 0301 RC 86635 HCPCS inpatient 361 234.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 244.04 67.6 999999999 218.59 350.17 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50434239_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 272.35 65 999999999 253.7 406.43 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50434239_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 406.43 97 999999999 253.7 406.43 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50434239_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 AETNA AETNA 331.01 79 999999999 253.7 406.43 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50434239_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 326.82 78 999999999 253.7 406.43 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50434239_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 289.11 69 999999999 253.7 406.43 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50434239_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 SIHO - ALL PLANS SIHO - ALL PLANS 377.1 90 999999999 253.7 406.43 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50434239_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 253.7 60.55 999999999 253.7 406.43 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50434239_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 UMR - ALL PLANS UMR - ALL PLANS 293.3 70 999999999 253.7 406.43 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50434239_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 253.7 406.43 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50434239_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 ANTHEM HMO ANTHEM HMO 999999999 253.7 406.43 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50434239_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 253.7 406.43 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50434239_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 253.7 406.43 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50434239_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 253.7 406.43 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50434239_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 283.24 67.6 999999999 253.7 406.43 percent of total billed charges Homocysteine (amino acid) level 50434240_1 CDM 0301 RC 83090 HCPCS inpatient 245 159.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 159.25 65 999999999 148.35 237.65 percent of total billed charges Homocysteine (amino acid) level 50434240_1 CDM 0301 RC 83090 HCPCS inpatient 245 159.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 237.65 97 999999999 148.35 237.65 percent of total billed charges Homocysteine (amino acid) level 50434240_1 CDM 0301 RC 83090 HCPCS inpatient 245 159.25 AETNA AETNA 193.55 79 999999999 148.35 237.65 percent of total billed charges Homocysteine (amino acid) level 50434240_1 CDM 0301 RC 83090 HCPCS inpatient 245 159.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 191.1 78 999999999 148.35 237.65 percent of total billed charges Homocysteine (amino acid) level 50434240_1 CDM 0301 RC 83090 HCPCS inpatient 245 159.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 169.05 69 999999999 148.35 237.65 percent of total billed charges Homocysteine (amino acid) level 50434240_1 CDM 0301 RC 83090 HCPCS inpatient 245 159.25 SIHO - ALL PLANS SIHO - ALL PLANS 220.5 90 999999999 148.35 237.65 percent of total billed charges Homocysteine (amino acid) level 50434240_1 CDM 0301 RC 83090 HCPCS inpatient 245 159.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 148.35 60.55 999999999 148.35 237.65 percent of total billed charges Homocysteine (amino acid) level 50434240_1 CDM 0301 RC 83090 HCPCS inpatient 245 159.25 UMR - ALL PLANS UMR - ALL PLANS 171.5 70 999999999 148.35 237.65 percent of total billed charges Homocysteine (amino acid) level 50434240_1 CDM 0301 RC 83090 HCPCS inpatient 245 159.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 148.35 237.65 Homocysteine (amino acid) level 50434240_1 CDM 0301 RC 83090 HCPCS inpatient 245 159.25 ANTHEM HMO ANTHEM HMO 999999999 148.35 237.65 Homocysteine (amino acid) level 50434240_1 CDM 0301 RC 83090 HCPCS inpatient 245 159.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 148.35 237.65 Homocysteine (amino acid) level 50434240_1 CDM 0301 RC 83090 HCPCS inpatient 245 159.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 148.35 237.65 Homocysteine (amino acid) level 50434240_1 CDM 0301 RC 83090 HCPCS inpatient 245 159.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 148.35 237.65 Homocysteine (amino acid) level 50434240_1 CDM 0301 RC 83090 HCPCS inpatient 245 159.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 165.62 67.6 999999999 148.35 237.65 percent of total billed charges Analysis for antibody to Herpes simplex virus 50434241_1 CDM 0301 RC 86694 HCPCS inpatient 140 91 SELF PAY DISCOUNT SELF PAY DISCOUNT 91 65 999999999 84.77 135.8 percent of total billed charges Analysis for antibody to Herpes simplex virus 50434241_1 CDM 0301 RC 86694 HCPCS inpatient 140 91 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 135.8 97 999999999 84.77 135.8 percent of total billed charges Analysis for antibody to Herpes simplex virus 50434241_1 CDM 0301 RC 86694 HCPCS inpatient 140 91 AETNA AETNA 110.6 79 999999999 84.77 135.8 percent of total billed charges Analysis for antibody to Herpes simplex virus 50434241_1 CDM 0301 RC 86694 HCPCS inpatient 140 91 HUMANA - ALL PLANS HUMANA - ALL PLANS 109.2 78 999999999 84.77 135.8 percent of total billed charges Analysis for antibody to Herpes simplex virus 50434241_1 CDM 0301 RC 86694 HCPCS inpatient 140 91 ENCORE - ALL PLANS ENCORE - ALL PLANS 96.6 69 999999999 84.77 135.8 percent of total billed charges Analysis for antibody to Herpes simplex virus 50434241_1 CDM 0301 RC 86694 HCPCS inpatient 140 91 SIHO - ALL PLANS SIHO - ALL PLANS 126 90 999999999 84.77 135.8 percent of total billed charges Analysis for antibody to Herpes simplex virus 50434241_1 CDM 0301 RC 86694 HCPCS inpatient 140 91 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 84.77 60.55 999999999 84.77 135.8 percent of total billed charges Analysis for antibody to Herpes simplex virus 50434241_1 CDM 0301 RC 86694 HCPCS inpatient 140 91 UMR - ALL PLANS UMR - ALL PLANS 98 70 999999999 84.77 135.8 percent of total billed charges Analysis for antibody to Herpes simplex virus 50434241_1 CDM 0301 RC 86694 HCPCS inpatient 140 91 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 84.77 135.8 Analysis for antibody to Herpes simplex virus 50434241_1 CDM 0301 RC 86694 HCPCS inpatient 140 91 ANTHEM HMO ANTHEM HMO 999999999 84.77 135.8 Analysis for antibody to Herpes simplex virus 50434241_1 CDM 0301 RC 86694 HCPCS inpatient 140 91 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 84.77 135.8 Analysis for antibody to Herpes simplex virus 50434241_1 CDM 0301 RC 86694 HCPCS inpatient 140 91 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 84.77 135.8 Analysis for antibody to Herpes simplex virus 50434241_1 CDM 0301 RC 86694 HCPCS inpatient 140 91 UHC - ALL PLANS UHC - ALL PLANS 999999999 84.77 135.8 Analysis for antibody to Herpes simplex virus 50434241_1 CDM 0301 RC 86694 HCPCS inpatient 140 91 CIGNA - ALL PLANS CIGNA - ALL PLANS 94.64 67.6 999999999 84.77 135.8 percent of total billed charges Analysis for antibody to Herpes simplex virus 50434242_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50434242_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50434242_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50434242_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50434242_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50434242_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50434242_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50434242_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50434242_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50434242_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50434242_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50434242_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50434242_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50434242_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434243_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 110.5 65 999999999 102.94 164.9 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434243_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 164.9 97 999999999 102.94 164.9 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434243_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 AETNA AETNA 134.3 79 999999999 102.94 164.9 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434243_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 132.6 78 999999999 102.94 164.9 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434243_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 117.3 69 999999999 102.94 164.9 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434243_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 SIHO - ALL PLANS SIHO - ALL PLANS 153 90 999999999 102.94 164.9 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434243_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.94 60.55 999999999 102.94 164.9 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434243_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 UMR - ALL PLANS UMR - ALL PLANS 119 70 999999999 102.94 164.9 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50434243_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.94 164.9 "Analysis of substance using immunoassay technique, multiple step method" 50434243_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 ANTHEM HMO ANTHEM HMO 999999999 102.94 164.9 "Analysis of substance using immunoassay technique, multiple step method" 50434243_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.94 164.9 "Analysis of substance using immunoassay technique, multiple step method" 50434243_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.94 164.9 "Analysis of substance using immunoassay technique, multiple step method" 50434243_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.94 164.9 "Analysis of substance using immunoassay technique, multiple step method" 50434243_1 CDM 0301 RC 83516 HCPCS inpatient 170 110.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.92 67.6 999999999 102.94 164.9 percent of total billed charges Arsenic level 50434244_1 CDM 0301 RC 82175 HCPCS inpatient 106 68.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.9 65 999999999 64.18 102.82 percent of total billed charges Arsenic level 50434244_1 CDM 0301 RC 82175 HCPCS inpatient 106 68.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 102.82 97 999999999 64.18 102.82 percent of total billed charges Arsenic level 50434244_1 CDM 0301 RC 82175 HCPCS inpatient 106 68.9 AETNA AETNA 83.74 79 999999999 64.18 102.82 percent of total billed charges Arsenic level 50434244_1 CDM 0301 RC 82175 HCPCS inpatient 106 68.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 82.68 78 999999999 64.18 102.82 percent of total billed charges Arsenic level 50434244_1 CDM 0301 RC 82175 HCPCS inpatient 106 68.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.14 69 999999999 64.18 102.82 percent of total billed charges Arsenic level 50434244_1 CDM 0301 RC 82175 HCPCS inpatient 106 68.9 SIHO - ALL PLANS SIHO - ALL PLANS 95.4 90 999999999 64.18 102.82 percent of total billed charges Arsenic level 50434244_1 CDM 0301 RC 82175 HCPCS inpatient 106 68.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.18 60.55 999999999 64.18 102.82 percent of total billed charges Arsenic level 50434244_1 CDM 0301 RC 82175 HCPCS inpatient 106 68.9 UMR - ALL PLANS UMR - ALL PLANS 74.2 70 999999999 64.18 102.82 percent of total billed charges Arsenic level 50434244_1 CDM 0301 RC 82175 HCPCS inpatient 106 68.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.18 102.82 Arsenic level 50434244_1 CDM 0301 RC 82175 HCPCS inpatient 106 68.9 ANTHEM HMO ANTHEM HMO 999999999 64.18 102.82 Arsenic level 50434244_1 CDM 0301 RC 82175 HCPCS inpatient 106 68.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.18 102.82 Arsenic level 50434244_1 CDM 0301 RC 82175 HCPCS inpatient 106 68.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.18 102.82 Arsenic level 50434244_1 CDM 0301 RC 82175 HCPCS inpatient 106 68.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.18 102.82 Arsenic level 50434244_1 CDM 0301 RC 82175 HCPCS inpatient 106 68.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 71.66 67.6 999999999 64.18 102.82 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434245_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.7 65 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434245_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 153.26 97 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434245_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 AETNA AETNA 124.82 79 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434245_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 123.24 78 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434245_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 109.02 69 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434245_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 SIHO - ALL PLANS SIHO - ALL PLANS 142.2 90 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434245_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.67 60.55 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434245_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 UMR - ALL PLANS UMR - ALL PLANS 110.6 70 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434245_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50434245_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ANTHEM HMO ANTHEM HMO 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50434245_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50434245_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50434245_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50434245_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.81 67.6 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434246_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.7 65 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434246_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 153.26 97 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434246_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 AETNA AETNA 124.82 79 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434246_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 123.24 78 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434246_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 109.02 69 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434246_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 SIHO - ALL PLANS SIHO - ALL PLANS 142.2 90 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434246_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.67 60.55 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434246_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 UMR - ALL PLANS UMR - ALL PLANS 110.6 70 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434246_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50434246_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ANTHEM HMO ANTHEM HMO 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50434246_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50434246_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50434246_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50434246_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.81 67.6 999999999 95.67 153.26 percent of total billed charges IgE (immune system protein) level 50434247_1 CDM 0301 RC 82785 HCPCS inpatient 254 165.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 165.1 65 999999999 153.8 246.38 percent of total billed charges IgE (immune system protein) level 50434247_1 CDM 0301 RC 82785 HCPCS inpatient 254 165.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 246.38 97 999999999 153.8 246.38 percent of total billed charges IgE (immune system protein) level 50434247_1 CDM 0301 RC 82785 HCPCS inpatient 254 165.1 AETNA AETNA 200.66 79 999999999 153.8 246.38 percent of total billed charges IgE (immune system protein) level 50434247_1 CDM 0301 RC 82785 HCPCS inpatient 254 165.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 198.12 78 999999999 153.8 246.38 percent of total billed charges IgE (immune system protein) level 50434247_1 CDM 0301 RC 82785 HCPCS inpatient 254 165.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 175.26 69 999999999 153.8 246.38 percent of total billed charges IgE (immune system protein) level 50434247_1 CDM 0301 RC 82785 HCPCS inpatient 254 165.1 SIHO - ALL PLANS SIHO - ALL PLANS 228.6 90 999999999 153.8 246.38 percent of total billed charges IgE (immune system protein) level 50434247_1 CDM 0301 RC 82785 HCPCS inpatient 254 165.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 153.8 60.55 999999999 153.8 246.38 percent of total billed charges IgE (immune system protein) level 50434247_1 CDM 0301 RC 82785 HCPCS inpatient 254 165.1 UMR - ALL PLANS UMR - ALL PLANS 177.8 70 999999999 153.8 246.38 percent of total billed charges IgE (immune system protein) level 50434247_1 CDM 0301 RC 82785 HCPCS inpatient 254 165.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 153.8 246.38 IgE (immune system protein) level 50434247_1 CDM 0301 RC 82785 HCPCS inpatient 254 165.1 ANTHEM HMO ANTHEM HMO 999999999 153.8 246.38 IgE (immune system protein) level 50434247_1 CDM 0301 RC 82785 HCPCS inpatient 254 165.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 153.8 246.38 IgE (immune system protein) level 50434247_1 CDM 0301 RC 82785 HCPCS inpatient 254 165.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 153.8 246.38 IgE (immune system protein) level 50434247_1 CDM 0301 RC 82785 HCPCS inpatient 254 165.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 153.8 246.38 IgE (immune system protein) level 50434247_1 CDM 0301 RC 82785 HCPCS inpatient 254 165.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 171.7 67.6 999999999 153.8 246.38 percent of total billed charges Somatomedin (growth factor) level 50434248_1 CDM 0301 RC 84305 HCPCS inpatient 281 182.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 182.65 65 999999999 170.15 272.57 percent of total billed charges Somatomedin (growth factor) level 50434248_1 CDM 0301 RC 84305 HCPCS inpatient 281 182.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 272.57 97 999999999 170.15 272.57 percent of total billed charges Somatomedin (growth factor) level 50434248_1 CDM 0301 RC 84305 HCPCS inpatient 281 182.65 AETNA AETNA 221.99 79 999999999 170.15 272.57 percent of total billed charges Somatomedin (growth factor) level 50434248_1 CDM 0301 RC 84305 HCPCS inpatient 281 182.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 219.18 78 999999999 170.15 272.57 percent of total billed charges Somatomedin (growth factor) level 50434248_1 CDM 0301 RC 84305 HCPCS inpatient 281 182.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 193.89 69 999999999 170.15 272.57 percent of total billed charges Somatomedin (growth factor) level 50434248_1 CDM 0301 RC 84305 HCPCS inpatient 281 182.65 SIHO - ALL PLANS SIHO - ALL PLANS 252.9 90 999999999 170.15 272.57 percent of total billed charges Somatomedin (growth factor) level 50434248_1 CDM 0301 RC 84305 HCPCS inpatient 281 182.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 170.15 60.55 999999999 170.15 272.57 percent of total billed charges Somatomedin (growth factor) level 50434248_1 CDM 0301 RC 84305 HCPCS inpatient 281 182.65 UMR - ALL PLANS UMR - ALL PLANS 196.7 70 999999999 170.15 272.57 percent of total billed charges Somatomedin (growth factor) level 50434248_1 CDM 0301 RC 84305 HCPCS inpatient 281 182.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 170.15 272.57 Somatomedin (growth factor) level 50434248_1 CDM 0301 RC 84305 HCPCS inpatient 281 182.65 ANTHEM HMO ANTHEM HMO 999999999 170.15 272.57 Somatomedin (growth factor) level 50434248_1 CDM 0301 RC 84305 HCPCS inpatient 281 182.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 170.15 272.57 Somatomedin (growth factor) level 50434248_1 CDM 0301 RC 84305 HCPCS inpatient 281 182.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 170.15 272.57 Somatomedin (growth factor) level 50434248_1 CDM 0301 RC 84305 HCPCS inpatient 281 182.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 170.15 272.57 Somatomedin (growth factor) level 50434248_1 CDM 0301 RC 84305 HCPCS inpatient 281 182.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 189.96 67.6 999999999 170.15 272.57 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50434249_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50434249_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50434249_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50434249_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50434249_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50434249_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50434249_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50434249_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50434249_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50434249_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50434249_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50434249_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50434249_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50434249_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434250_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 104.65 65 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434250_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 156.17 97 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434250_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 AETNA AETNA 127.19 79 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434250_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 125.58 78 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434250_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 111.09 69 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434250_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 SIHO - ALL PLANS SIHO - ALL PLANS 144.9 90 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434250_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 97.49 60.55 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434250_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 UMR - ALL PLANS UMR - ALL PLANS 112.7 70 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50434250_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 97.49 156.17 Gammaglobulin (immune system protein) measurement 50434250_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 ANTHEM HMO ANTHEM HMO 999999999 97.49 156.17 Gammaglobulin (immune system protein) measurement 50434250_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 97.49 156.17 Gammaglobulin (immune system protein) measurement 50434250_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 97.49 156.17 Gammaglobulin (immune system protein) measurement 50434250_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 97.49 156.17 Gammaglobulin (immune system protein) measurement 50434250_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.84 67.6 999999999 97.49 156.17 percent of total billed charges "Insulin measurement, free" 50434251_1 CDM 0301 RC 83527 HCPCS inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges "Insulin measurement, free" 50434251_1 CDM 0301 RC 83527 HCPCS inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges "Insulin measurement, free" 50434251_1 CDM 0301 RC 83527 HCPCS inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges "Insulin measurement, free" 50434251_1 CDM 0301 RC 83527 HCPCS inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges "Insulin measurement, free" 50434251_1 CDM 0301 RC 83527 HCPCS inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges "Insulin measurement, free" 50434251_1 CDM 0301 RC 83527 HCPCS inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges "Insulin measurement, free" 50434251_1 CDM 0301 RC 83527 HCPCS inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges "Insulin measurement, free" 50434251_1 CDM 0301 RC 83527 HCPCS inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges "Insulin measurement, free" 50434251_1 CDM 0301 RC 83527 HCPCS inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 "Insulin measurement, free" 50434251_1 CDM 0301 RC 83527 HCPCS inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 "Insulin measurement, free" 50434251_1 CDM 0301 RC 83527 HCPCS inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 "Insulin measurement, free" 50434251_1 CDM 0301 RC 83527 HCPCS inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 "Insulin measurement, free" 50434251_1 CDM 0301 RC 83527 HCPCS inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 "Insulin measurement, free" 50434251_1 CDM 0301 RC 83527 HCPCS inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges "Insulin measurement, total" 50434252_1 CDM 0301 RC 83525 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges "Insulin measurement, total" 50434252_1 CDM 0301 RC 83525 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges "Insulin measurement, total" 50434252_1 CDM 0301 RC 83525 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges "Insulin measurement, total" 50434252_1 CDM 0301 RC 83525 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges "Insulin measurement, total" 50434252_1 CDM 0301 RC 83525 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges "Insulin measurement, total" 50434252_1 CDM 0301 RC 83525 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges "Insulin measurement, total" 50434252_1 CDM 0301 RC 83525 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges "Insulin measurement, total" 50434252_1 CDM 0301 RC 83525 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges "Insulin measurement, total" 50434252_1 CDM 0301 RC 83525 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 "Insulin measurement, total" 50434252_1 CDM 0301 RC 83525 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 "Insulin measurement, total" 50434252_1 CDM 0301 RC 83525 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 "Insulin measurement, total" 50434252_1 CDM 0301 RC 83525 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 "Insulin measurement, total" 50434252_1 CDM 0301 RC 83525 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 "Insulin measurement, total" 50434252_1 CDM 0301 RC 83525 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 50434253_1 CDM 0301 RC 82397 HCPCS inpatient 332 215.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 215.8 65 999999999 201.03 322.04 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 50434253_1 CDM 0301 RC 82397 HCPCS inpatient 332 215.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 322.04 97 999999999 201.03 322.04 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 50434253_1 CDM 0301 RC 82397 HCPCS inpatient 332 215.8 AETNA AETNA 262.28 79 999999999 201.03 322.04 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 50434253_1 CDM 0301 RC 82397 HCPCS inpatient 332 215.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 258.96 78 999999999 201.03 322.04 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 50434253_1 CDM 0301 RC 82397 HCPCS inpatient 332 215.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 229.08 69 999999999 201.03 322.04 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 50434253_1 CDM 0301 RC 82397 HCPCS inpatient 332 215.8 SIHO - ALL PLANS SIHO - ALL PLANS 298.8 90 999999999 201.03 322.04 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 50434253_1 CDM 0301 RC 82397 HCPCS inpatient 332 215.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 201.03 60.55 999999999 201.03 322.04 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 50434253_1 CDM 0301 RC 82397 HCPCS inpatient 332 215.8 UMR - ALL PLANS UMR - ALL PLANS 232.4 70 999999999 201.03 322.04 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 50434253_1 CDM 0301 RC 82397 HCPCS inpatient 332 215.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 201.03 322.04 Analysis using chemiluminescent technique (light and chemical )reaction 50434253_1 CDM 0301 RC 82397 HCPCS inpatient 332 215.8 ANTHEM HMO ANTHEM HMO 999999999 201.03 322.04 Analysis using chemiluminescent technique (light and chemical )reaction 50434253_1 CDM 0301 RC 82397 HCPCS inpatient 332 215.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 201.03 322.04 Analysis using chemiluminescent technique (light and chemical )reaction 50434253_1 CDM 0301 RC 82397 HCPCS inpatient 332 215.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 201.03 322.04 Analysis using chemiluminescent technique (light and chemical )reaction 50434253_1 CDM 0301 RC 82397 HCPCS inpatient 332 215.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 201.03 322.04 Analysis using chemiluminescent technique (light and chemical )reaction 50434253_1 CDM 0301 RC 82397 HCPCS inpatient 332 215.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 224.43 67.6 999999999 201.03 322.04 percent of total billed charges Heavy metal level 50434254_1 CDM 0301 RC 83018 HCPCS inpatient 381 247.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 247.65 65 999999999 230.7 369.57 percent of total billed charges Heavy metal level 50434254_1 CDM 0301 RC 83018 HCPCS inpatient 381 247.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 369.57 97 999999999 230.7 369.57 percent of total billed charges Heavy metal level 50434254_1 CDM 0301 RC 83018 HCPCS inpatient 381 247.65 AETNA AETNA 300.99 79 999999999 230.7 369.57 percent of total billed charges Heavy metal level 50434254_1 CDM 0301 RC 83018 HCPCS inpatient 381 247.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 297.18 78 999999999 230.7 369.57 percent of total billed charges Heavy metal level 50434254_1 CDM 0301 RC 83018 HCPCS inpatient 381 247.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 262.89 69 999999999 230.7 369.57 percent of total billed charges Heavy metal level 50434254_1 CDM 0301 RC 83018 HCPCS inpatient 381 247.65 SIHO - ALL PLANS SIHO - ALL PLANS 342.9 90 999999999 230.7 369.57 percent of total billed charges Heavy metal level 50434254_1 CDM 0301 RC 83018 HCPCS inpatient 381 247.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 230.7 60.55 999999999 230.7 369.57 percent of total billed charges Heavy metal level 50434254_1 CDM 0301 RC 83018 HCPCS inpatient 381 247.65 UMR - ALL PLANS UMR - ALL PLANS 266.7 70 999999999 230.7 369.57 percent of total billed charges Heavy metal level 50434254_1 CDM 0301 RC 83018 HCPCS inpatient 381 247.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 230.7 369.57 Heavy metal level 50434254_1 CDM 0301 RC 83018 HCPCS inpatient 381 247.65 ANTHEM HMO ANTHEM HMO 999999999 230.7 369.57 Heavy metal level 50434254_1 CDM 0301 RC 83018 HCPCS inpatient 381 247.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 230.7 369.57 Heavy metal level 50434254_1 CDM 0301 RC 83018 HCPCS inpatient 381 247.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 230.7 369.57 Heavy metal level 50434254_1 CDM 0301 RC 83018 HCPCS inpatient 381 247.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 230.7 369.57 Heavy metal level 50434254_1 CDM 0301 RC 83018 HCPCS inpatient 381 247.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 257.56 67.6 999999999 230.7 369.57 percent of total billed charges Immunologic analysis technique on body fluid 50434255_1 CDM 0301 RC 86325 HCPCS inpatient 74 48.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.1 65 999999999 44.81 71.78 percent of total billed charges Immunologic analysis technique on body fluid 50434255_1 CDM 0301 RC 86325 HCPCS inpatient 74 48.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 71.78 97 999999999 44.81 71.78 percent of total billed charges Immunologic analysis technique on body fluid 50434255_1 CDM 0301 RC 86325 HCPCS inpatient 74 48.1 AETNA AETNA 58.46 79 999999999 44.81 71.78 percent of total billed charges Immunologic analysis technique on body fluid 50434255_1 CDM 0301 RC 86325 HCPCS inpatient 74 48.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 57.72 78 999999999 44.81 71.78 percent of total billed charges Immunologic analysis technique on body fluid 50434255_1 CDM 0301 RC 86325 HCPCS inpatient 74 48.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.06 69 999999999 44.81 71.78 percent of total billed charges Immunologic analysis technique on body fluid 50434255_1 CDM 0301 RC 86325 HCPCS inpatient 74 48.1 SIHO - ALL PLANS SIHO - ALL PLANS 66.6 90 999999999 44.81 71.78 percent of total billed charges Immunologic analysis technique on body fluid 50434255_1 CDM 0301 RC 86325 HCPCS inpatient 74 48.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.81 60.55 999999999 44.81 71.78 percent of total billed charges Immunologic analysis technique on body fluid 50434255_1 CDM 0301 RC 86325 HCPCS inpatient 74 48.1 UMR - ALL PLANS UMR - ALL PLANS 51.8 70 999999999 44.81 71.78 percent of total billed charges Immunologic analysis technique on body fluid 50434255_1 CDM 0301 RC 86325 HCPCS inpatient 74 48.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.81 71.78 Immunologic analysis technique on body fluid 50434255_1 CDM 0301 RC 86325 HCPCS inpatient 74 48.1 ANTHEM HMO ANTHEM HMO 999999999 44.81 71.78 Immunologic analysis technique on body fluid 50434255_1 CDM 0301 RC 86325 HCPCS inpatient 74 48.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.81 71.78 Immunologic analysis technique on body fluid 50434255_1 CDM 0301 RC 86325 HCPCS inpatient 74 48.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.81 71.78 Immunologic analysis technique on body fluid 50434255_1 CDM 0301 RC 86325 HCPCS inpatient 74 48.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.81 71.78 Immunologic analysis technique on body fluid 50434255_1 CDM 0301 RC 86325 HCPCS inpatient 74 48.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.02 67.6 999999999 44.81 71.78 percent of total billed charges Gene analysis (Janus kinase 2) variant 50434256_1 CDM 0301 RC 81270 HCPCS inpatient 1020 663 SELF PAY DISCOUNT SELF PAY DISCOUNT 663 65 999999999 617.61 989.4 percent of total billed charges Gene analysis (Janus kinase 2) variant 50434256_1 CDM 0301 RC 81270 HCPCS inpatient 1020 663 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 989.4 97 999999999 617.61 989.4 percent of total billed charges Gene analysis (Janus kinase 2) variant 50434256_1 CDM 0301 RC 81270 HCPCS inpatient 1020 663 AETNA AETNA 805.8 79 999999999 617.61 989.4 percent of total billed charges Gene analysis (Janus kinase 2) variant 50434256_1 CDM 0301 RC 81270 HCPCS inpatient 1020 663 HUMANA - ALL PLANS HUMANA - ALL PLANS 795.6 78 999999999 617.61 989.4 percent of total billed charges Gene analysis (Janus kinase 2) variant 50434256_1 CDM 0301 RC 81270 HCPCS inpatient 1020 663 ENCORE - ALL PLANS ENCORE - ALL PLANS 703.8 69 999999999 617.61 989.4 percent of total billed charges Gene analysis (Janus kinase 2) variant 50434256_1 CDM 0301 RC 81270 HCPCS inpatient 1020 663 SIHO - ALL PLANS SIHO - ALL PLANS 918 90 999999999 617.61 989.4 percent of total billed charges Gene analysis (Janus kinase 2) variant 50434256_1 CDM 0301 RC 81270 HCPCS inpatient 1020 663 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 617.61 60.55 999999999 617.61 989.4 percent of total billed charges Gene analysis (Janus kinase 2) variant 50434256_1 CDM 0301 RC 81270 HCPCS inpatient 1020 663 UMR - ALL PLANS UMR - ALL PLANS 714 70 999999999 617.61 989.4 percent of total billed charges Gene analysis (Janus kinase 2) variant 50434256_1 CDM 0301 RC 81270 HCPCS inpatient 1020 663 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 617.61 989.4 Gene analysis (Janus kinase 2) variant 50434256_1 CDM 0301 RC 81270 HCPCS inpatient 1020 663 ANTHEM HMO ANTHEM HMO 999999999 617.61 989.4 Gene analysis (Janus kinase 2) variant 50434256_1 CDM 0301 RC 81270 HCPCS inpatient 1020 663 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 617.61 989.4 Gene analysis (Janus kinase 2) variant 50434256_1 CDM 0301 RC 81270 HCPCS inpatient 1020 663 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 617.61 989.4 Gene analysis (Janus kinase 2) variant 50434256_1 CDM 0301 RC 81270 HCPCS inpatient 1020 663 UHC - ALL PLANS UHC - ALL PLANS 999999999 617.61 989.4 Gene analysis (Janus kinase 2) variant 50434256_1 CDM 0301 RC 81270 HCPCS inpatient 1020 663 CIGNA - ALL PLANS CIGNA - ALL PLANS 689.52 67.6 999999999 617.61 989.4 percent of total billed charges Levetiracetam level 50434257_1 CDM 0301 RC 80177 HCPCS inpatient 296 192.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 192.4 65 999999999 179.23 287.12 percent of total billed charges Levetiracetam level 50434257_1 CDM 0301 RC 80177 HCPCS inpatient 296 192.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 287.12 97 999999999 179.23 287.12 percent of total billed charges Levetiracetam level 50434257_1 CDM 0301 RC 80177 HCPCS inpatient 296 192.4 AETNA AETNA 233.84 79 999999999 179.23 287.12 percent of total billed charges Levetiracetam level 50434257_1 CDM 0301 RC 80177 HCPCS inpatient 296 192.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 230.88 78 999999999 179.23 287.12 percent of total billed charges Levetiracetam level 50434257_1 CDM 0301 RC 80177 HCPCS inpatient 296 192.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 204.24 69 999999999 179.23 287.12 percent of total billed charges Levetiracetam level 50434257_1 CDM 0301 RC 80177 HCPCS inpatient 296 192.4 SIHO - ALL PLANS SIHO - ALL PLANS 266.4 90 999999999 179.23 287.12 percent of total billed charges Levetiracetam level 50434257_1 CDM 0301 RC 80177 HCPCS inpatient 296 192.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 179.23 60.55 999999999 179.23 287.12 percent of total billed charges Levetiracetam level 50434257_1 CDM 0301 RC 80177 HCPCS inpatient 296 192.4 UMR - ALL PLANS UMR - ALL PLANS 207.2 70 999999999 179.23 287.12 percent of total billed charges Levetiracetam level 50434257_1 CDM 0301 RC 80177 HCPCS inpatient 296 192.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 179.23 287.12 Levetiracetam level 50434257_1 CDM 0301 RC 80177 HCPCS inpatient 296 192.4 ANTHEM HMO ANTHEM HMO 999999999 179.23 287.12 Levetiracetam level 50434257_1 CDM 0301 RC 80177 HCPCS inpatient 296 192.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 179.23 287.12 Levetiracetam level 50434257_1 CDM 0301 RC 80177 HCPCS inpatient 296 192.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 179.23 287.12 Levetiracetam level 50434257_1 CDM 0301 RC 80177 HCPCS inpatient 296 192.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 179.23 287.12 Levetiracetam level 50434257_1 CDM 0301 RC 80177 HCPCS inpatient 296 192.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 200.1 67.6 999999999 179.23 287.12 percent of total billed charges "Amphetamines levels, 3 or 4" 50434258_1 CDM 0301 RC 80325 HCPCS inpatient 256 166.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 166.4 65 999999999 155.01 248.32 percent of total billed charges "Amphetamines levels, 3 or 4" 50434258_1 CDM 0301 RC 80325 HCPCS inpatient 256 166.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 248.32 97 999999999 155.01 248.32 percent of total billed charges "Amphetamines levels, 3 or 4" 50434258_1 CDM 0301 RC 80325 HCPCS inpatient 256 166.4 AETNA AETNA 202.24 79 999999999 155.01 248.32 percent of total billed charges "Amphetamines levels, 3 or 4" 50434258_1 CDM 0301 RC 80325 HCPCS inpatient 256 166.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 199.68 78 999999999 155.01 248.32 percent of total billed charges "Amphetamines levels, 3 or 4" 50434258_1 CDM 0301 RC 80325 HCPCS inpatient 256 166.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 176.64 69 999999999 155.01 248.32 percent of total billed charges "Amphetamines levels, 3 or 4" 50434258_1 CDM 0301 RC 80325 HCPCS inpatient 256 166.4 SIHO - ALL PLANS SIHO - ALL PLANS 230.4 90 999999999 155.01 248.32 percent of total billed charges "Amphetamines levels, 3 or 4" 50434258_1 CDM 0301 RC 80325 HCPCS inpatient 256 166.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.01 60.55 999999999 155.01 248.32 percent of total billed charges "Amphetamines levels, 3 or 4" 50434258_1 CDM 0301 RC 80325 HCPCS inpatient 256 166.4 UMR - ALL PLANS UMR - ALL PLANS 179.2 70 999999999 155.01 248.32 percent of total billed charges "Amphetamines levels, 3 or 4" 50434258_1 CDM 0301 RC 80325 HCPCS inpatient 256 166.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.01 248.32 "Amphetamines levels, 3 or 4" 50434258_1 CDM 0301 RC 80325 HCPCS inpatient 256 166.4 ANTHEM HMO ANTHEM HMO 999999999 155.01 248.32 "Amphetamines levels, 3 or 4" 50434258_1 CDM 0301 RC 80325 HCPCS inpatient 256 166.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.01 248.32 "Amphetamines levels, 3 or 4" 50434258_1 CDM 0301 RC 80325 HCPCS inpatient 256 166.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.01 248.32 "Amphetamines levels, 3 or 4" 50434258_1 CDM 0301 RC 80325 HCPCS inpatient 256 166.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.01 248.32 "Amphetamines levels, 3 or 4" 50434258_1 CDM 0301 RC 80325 HCPCS inpatient 256 166.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.06 67.6 999999999 155.01 248.32 percent of total billed charges Stool lactoferrin (immune system protein) analysis 50434259_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges Stool lactoferrin (immune system protein) analysis 50434259_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges Stool lactoferrin (immune system protein) analysis 50434259_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges Stool lactoferrin (immune system protein) analysis 50434259_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges Stool lactoferrin (immune system protein) analysis 50434259_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges Stool lactoferrin (immune system protein) analysis 50434259_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges Stool lactoferrin (immune system protein) analysis 50434259_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges Stool lactoferrin (immune system protein) analysis 50434259_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges Stool lactoferrin (immune system protein) analysis 50434259_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 Stool lactoferrin (immune system protein) analysis 50434259_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 Stool lactoferrin (immune system protein) analysis 50434259_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 Stool lactoferrin (immune system protein) analysis 50434259_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 Stool lactoferrin (immune system protein) analysis 50434259_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 Stool lactoferrin (immune system protein) analysis 50434259_1 CDM 0301 RC 83630 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges Lamotrigine level 50434260_1 CDM 0301 RC 80175 HCPCS inpatient 256 166.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 166.4 65 999999999 155.01 248.32 percent of total billed charges Lamotrigine level 50434260_1 CDM 0301 RC 80175 HCPCS inpatient 256 166.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 248.32 97 999999999 155.01 248.32 percent of total billed charges Lamotrigine level 50434260_1 CDM 0301 RC 80175 HCPCS inpatient 256 166.4 AETNA AETNA 202.24 79 999999999 155.01 248.32 percent of total billed charges Lamotrigine level 50434260_1 CDM 0301 RC 80175 HCPCS inpatient 256 166.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 199.68 78 999999999 155.01 248.32 percent of total billed charges Lamotrigine level 50434260_1 CDM 0301 RC 80175 HCPCS inpatient 256 166.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 176.64 69 999999999 155.01 248.32 percent of total billed charges Lamotrigine level 50434260_1 CDM 0301 RC 80175 HCPCS inpatient 256 166.4 SIHO - ALL PLANS SIHO - ALL PLANS 230.4 90 999999999 155.01 248.32 percent of total billed charges Lamotrigine level 50434260_1 CDM 0301 RC 80175 HCPCS inpatient 256 166.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.01 60.55 999999999 155.01 248.32 percent of total billed charges Lamotrigine level 50434260_1 CDM 0301 RC 80175 HCPCS inpatient 256 166.4 UMR - ALL PLANS UMR - ALL PLANS 179.2 70 999999999 155.01 248.32 percent of total billed charges Lamotrigine level 50434260_1 CDM 0301 RC 80175 HCPCS inpatient 256 166.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.01 248.32 Lamotrigine level 50434260_1 CDM 0301 RC 80175 HCPCS inpatient 256 166.4 ANTHEM HMO ANTHEM HMO 999999999 155.01 248.32 Lamotrigine level 50434260_1 CDM 0301 RC 80175 HCPCS inpatient 256 166.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.01 248.32 Lamotrigine level 50434260_1 CDM 0301 RC 80175 HCPCS inpatient 256 166.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.01 248.32 Lamotrigine level 50434260_1 CDM 0301 RC 80175 HCPCS inpatient 256 166.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.01 248.32 Lamotrigine level 50434260_1 CDM 0301 RC 80175 HCPCS inpatient 256 166.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.06 67.6 999999999 155.01 248.32 percent of total billed charges LDL cholesterol level 50434261_1 CDM 0301 RC 83721 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges LDL cholesterol level 50434261_1 CDM 0301 RC 83721 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges LDL cholesterol level 50434261_1 CDM 0301 RC 83721 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges LDL cholesterol level 50434261_1 CDM 0301 RC 83721 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges LDL cholesterol level 50434261_1 CDM 0301 RC 83721 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges LDL cholesterol level 50434261_1 CDM 0301 RC 83721 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges LDL cholesterol level 50434261_1 CDM 0301 RC 83721 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges LDL cholesterol level 50434261_1 CDM 0301 RC 83721 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges LDL cholesterol level 50434261_1 CDM 0301 RC 83721 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 LDL cholesterol level 50434261_1 CDM 0301 RC 83721 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 LDL cholesterol level 50434261_1 CDM 0301 RC 83721 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 LDL cholesterol level 50434261_1 CDM 0301 RC 83721 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 LDL cholesterol level 50434261_1 CDM 0301 RC 83721 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 LDL cholesterol level 50434261_1 CDM 0301 RC 83721 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Lead level 50434262_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 140.4 65 999999999 130.79 209.52 percent of total billed charges Lead level 50434262_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 209.52 97 999999999 130.79 209.52 percent of total billed charges Lead level 50434262_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 AETNA AETNA 170.64 79 999999999 130.79 209.52 percent of total billed charges Lead level 50434262_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 168.48 78 999999999 130.79 209.52 percent of total billed charges Lead level 50434262_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 149.04 69 999999999 130.79 209.52 percent of total billed charges Lead level 50434262_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 SIHO - ALL PLANS SIHO - ALL PLANS 194.4 90 999999999 130.79 209.52 percent of total billed charges Lead level 50434262_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 130.79 60.55 999999999 130.79 209.52 percent of total billed charges Lead level 50434262_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 UMR - ALL PLANS UMR - ALL PLANS 151.2 70 999999999 130.79 209.52 percent of total billed charges Lead level 50434262_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 130.79 209.52 Lead level 50434262_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ANTHEM HMO ANTHEM HMO 999999999 130.79 209.52 Lead level 50434262_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 130.79 209.52 Lead level 50434262_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 130.79 209.52 Lead level 50434262_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 130.79 209.52 Lead level 50434262_1 CDM 0301 RC 83655 HCPCS inpatient 216 140.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 146.02 67.6 999999999 130.79 209.52 percent of total billed charges Detection test by immunofluorescent technique for legionella pneumophila (water borne bacteria) 50434263_1 CDM 0301 RC 87278 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges Detection test by immunofluorescent technique for legionella pneumophila (water borne bacteria) 50434263_1 CDM 0301 RC 87278 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges Detection test by immunofluorescent technique for legionella pneumophila (water borne bacteria) 50434263_1 CDM 0301 RC 87278 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges Detection test by immunofluorescent technique for legionella pneumophila (water borne bacteria) 50434263_1 CDM 0301 RC 87278 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges Detection test by immunofluorescent technique for legionella pneumophila (water borne bacteria) 50434263_1 CDM 0301 RC 87278 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges Detection test by immunofluorescent technique for legionella pneumophila (water borne bacteria) 50434263_1 CDM 0301 RC 87278 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges Detection test by immunofluorescent technique for legionella pneumophila (water borne bacteria) 50434263_1 CDM 0301 RC 87278 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges Detection test by immunofluorescent technique for legionella pneumophila (water borne bacteria) 50434263_1 CDM 0301 RC 87278 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges Detection test by immunofluorescent technique for legionella pneumophila (water borne bacteria) 50434263_1 CDM 0301 RC 87278 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 Detection test by immunofluorescent technique for legionella pneumophila (water borne bacteria) 50434263_1 CDM 0301 RC 87278 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 Detection test by immunofluorescent technique for legionella pneumophila (water borne bacteria) 50434263_1 CDM 0301 RC 87278 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 Detection test by immunofluorescent technique for legionella pneumophila (water borne bacteria) 50434263_1 CDM 0301 RC 87278 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 Detection test by immunofluorescent technique for legionella pneumophila (water borne bacteria) 50434263_1 CDM 0301 RC 87278 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 Detection test by immunofluorescent technique for legionella pneumophila (water borne bacteria) 50434263_1 CDM 0301 RC 87278 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges Screening test for pathogenic organisms 50434264_1 CDM 0301 RC 87081 HCPCS inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges Screening test for pathogenic organisms 50434264_1 CDM 0301 RC 87081 HCPCS inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges Screening test for pathogenic organisms 50434264_1 CDM 0301 RC 87081 HCPCS inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges Screening test for pathogenic organisms 50434264_1 CDM 0301 RC 87081 HCPCS inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges Screening test for pathogenic organisms 50434264_1 CDM 0301 RC 87081 HCPCS inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges Screening test for pathogenic organisms 50434264_1 CDM 0301 RC 87081 HCPCS inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges Screening test for pathogenic organisms 50434264_1 CDM 0301 RC 87081 HCPCS inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges Screening test for pathogenic organisms 50434264_1 CDM 0301 RC 87081 HCPCS inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges Screening test for pathogenic organisms 50434264_1 CDM 0301 RC 87081 HCPCS inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 Screening test for pathogenic organisms 50434264_1 CDM 0301 RC 87081 HCPCS inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 Screening test for pathogenic organisms 50434264_1 CDM 0301 RC 87081 HCPCS inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 Screening test for pathogenic organisms 50434264_1 CDM 0301 RC 87081 HCPCS inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 Screening test for pathogenic organisms 50434264_1 CDM 0301 RC 87081 HCPCS inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 Screening test for pathogenic organisms 50434264_1 CDM 0301 RC 87081 HCPCS inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 50434265_1 CDM 0311 RC 88184 HCPCS inpatient 928 603.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 603.2 65 999999999 561.9 900.16 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 50434265_1 CDM 0311 RC 88184 HCPCS inpatient 928 603.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 900.16 97 999999999 561.9 900.16 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 50434265_1 CDM 0311 RC 88184 HCPCS inpatient 928 603.2 AETNA AETNA 733.12 79 999999999 561.9 900.16 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 50434265_1 CDM 0311 RC 88184 HCPCS inpatient 928 603.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 723.84 78 999999999 561.9 900.16 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 50434265_1 CDM 0311 RC 88184 HCPCS inpatient 928 603.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 640.32 69 999999999 561.9 900.16 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 50434265_1 CDM 0311 RC 88184 HCPCS inpatient 928 603.2 SIHO - ALL PLANS SIHO - ALL PLANS 835.2 90 999999999 561.9 900.16 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 50434265_1 CDM 0311 RC 88184 HCPCS inpatient 928 603.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 561.9 60.55 999999999 561.9 900.16 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 50434265_1 CDM 0311 RC 88184 HCPCS inpatient 928 603.2 UMR - ALL PLANS UMR - ALL PLANS 649.6 70 999999999 561.9 900.16 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 50434265_1 CDM 0311 RC 88184 HCPCS inpatient 928 603.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 561.9 900.16 "Flow cytometry technique for DNA or cell analysis, first marker" 50434265_1 CDM 0311 RC 88184 HCPCS inpatient 928 603.2 ANTHEM HMO ANTHEM HMO 999999999 561.9 900.16 "Flow cytometry technique for DNA or cell analysis, first marker" 50434265_1 CDM 0311 RC 88184 HCPCS inpatient 928 603.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 561.9 900.16 "Flow cytometry technique for DNA or cell analysis, first marker" 50434265_1 CDM 0311 RC 88184 HCPCS inpatient 928 603.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 561.9 900.16 "Flow cytometry technique for DNA or cell analysis, first marker" 50434265_1 CDM 0311 RC 88184 HCPCS inpatient 928 603.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 561.9 900.16 "Flow cytometry technique for DNA or cell analysis, first marker" 50434265_1 CDM 0311 RC 88184 HCPCS inpatient 928 603.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 627.33 67.6 999999999 561.9 900.16 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50434266_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50434266_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50434266_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50434266_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50434266_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50434266_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50434266_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50434266_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50434266_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 50434266_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 50434266_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 50434266_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 50434266_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 50434266_1 CDM 0302 RC 80061 HCPCS inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50434267_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50434267_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50434267_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50434267_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50434267_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50434267_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50434267_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50434267_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50434267_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 50434267_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 50434267_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 50434267_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 50434267_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 "Blood test, lipids (cholesterol and triglycerides)" 50434267_1 CDM 0301 RC 80061 HCPCS inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges Lipoprotein (A) level 50434268_1 CDM 0301 RC 83695 HCPCS inpatient 307 199.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 199.55 65 999999999 185.89 297.79 percent of total billed charges Lipoprotein (A) level 50434268_1 CDM 0301 RC 83695 HCPCS inpatient 307 199.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 297.79 97 999999999 185.89 297.79 percent of total billed charges Lipoprotein (A) level 50434268_1 CDM 0301 RC 83695 HCPCS inpatient 307 199.55 AETNA AETNA 242.53 79 999999999 185.89 297.79 percent of total billed charges Lipoprotein (A) level 50434268_1 CDM 0301 RC 83695 HCPCS inpatient 307 199.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 239.46 78 999999999 185.89 297.79 percent of total billed charges Lipoprotein (A) level 50434268_1 CDM 0301 RC 83695 HCPCS inpatient 307 199.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 211.83 69 999999999 185.89 297.79 percent of total billed charges Lipoprotein (A) level 50434268_1 CDM 0301 RC 83695 HCPCS inpatient 307 199.55 SIHO - ALL PLANS SIHO - ALL PLANS 276.3 90 999999999 185.89 297.79 percent of total billed charges Lipoprotein (A) level 50434268_1 CDM 0301 RC 83695 HCPCS inpatient 307 199.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 185.89 60.55 999999999 185.89 297.79 percent of total billed charges Lipoprotein (A) level 50434268_1 CDM 0301 RC 83695 HCPCS inpatient 307 199.55 UMR - ALL PLANS UMR - ALL PLANS 214.9 70 999999999 185.89 297.79 percent of total billed charges Lipoprotein (A) level 50434268_1 CDM 0301 RC 83695 HCPCS inpatient 307 199.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 185.89 297.79 Lipoprotein (A) level 50434268_1 CDM 0301 RC 83695 HCPCS inpatient 307 199.55 ANTHEM HMO ANTHEM HMO 999999999 185.89 297.79 Lipoprotein (A) level 50434268_1 CDM 0301 RC 83695 HCPCS inpatient 307 199.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 185.89 297.79 Lipoprotein (A) level 50434268_1 CDM 0301 RC 83695 HCPCS inpatient 307 199.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 185.89 297.79 Lipoprotein (A) level 50434268_1 CDM 0301 RC 83695 HCPCS inpatient 307 199.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 185.89 297.79 Lipoprotein (A) level 50434268_1 CDM 0301 RC 83695 HCPCS inpatient 307 199.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 207.53 67.6 999999999 185.89 297.79 percent of total billed charges Multianalyte assay procedure with algorithmic analysis 50434269_1 CDM 0301 RC 81599 HCPCS inpatient 633 411.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 411.45 65 999999999 383.28 614.01 percent of total billed charges Multianalyte assay procedure with algorithmic analysis 50434269_1 CDM 0301 RC 81599 HCPCS inpatient 633 411.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 614.01 97 999999999 383.28 614.01 percent of total billed charges Multianalyte assay procedure with algorithmic analysis 50434269_1 CDM 0301 RC 81599 HCPCS inpatient 633 411.45 AETNA AETNA 500.07 79 999999999 383.28 614.01 percent of total billed charges Multianalyte assay procedure with algorithmic analysis 50434269_1 CDM 0301 RC 81599 HCPCS inpatient 633 411.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 493.74 78 999999999 383.28 614.01 percent of total billed charges Multianalyte assay procedure with algorithmic analysis 50434269_1 CDM 0301 RC 81599 HCPCS inpatient 633 411.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 436.77 69 999999999 383.28 614.01 percent of total billed charges Multianalyte assay procedure with algorithmic analysis 50434269_1 CDM 0301 RC 81599 HCPCS inpatient 633 411.45 SIHO - ALL PLANS SIHO - ALL PLANS 569.7 90 999999999 383.28 614.01 percent of total billed charges Multianalyte assay procedure with algorithmic analysis 50434269_1 CDM 0301 RC 81599 HCPCS inpatient 633 411.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 383.28 60.55 999999999 383.28 614.01 percent of total billed charges Multianalyte assay procedure with algorithmic analysis 50434269_1 CDM 0301 RC 81599 HCPCS inpatient 633 411.45 UMR - ALL PLANS UMR - ALL PLANS 443.1 70 999999999 383.28 614.01 percent of total billed charges Multianalyte assay procedure with algorithmic analysis 50434269_1 CDM 0301 RC 81599 HCPCS inpatient 633 411.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 383.28 614.01 Multianalyte assay procedure with algorithmic analysis 50434269_1 CDM 0301 RC 81599 HCPCS inpatient 633 411.45 ANTHEM HMO ANTHEM HMO 999999999 383.28 614.01 Multianalyte assay procedure with algorithmic analysis 50434269_1 CDM 0301 RC 81599 HCPCS inpatient 633 411.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 383.28 614.01 Multianalyte assay procedure with algorithmic analysis 50434269_1 CDM 0301 RC 81599 HCPCS inpatient 633 411.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 383.28 614.01 Multianalyte assay procedure with algorithmic analysis 50434269_1 CDM 0301 RC 81599 HCPCS inpatient 633 411.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 383.28 614.01 Multianalyte assay procedure with algorithmic analysis 50434269_1 CDM 0301 RC 81599 HCPCS inpatient 633 411.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 427.91 67.6 999999999 383.28 614.01 percent of total billed charges Microsomal antibodies (autoantibody) measurement 50434270_1 CDM 0301 RC 86376 HCPCS inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges Microsomal antibodies (autoantibody) measurement 50434270_1 CDM 0301 RC 86376 HCPCS inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges Microsomal antibodies (autoantibody) measurement 50434270_1 CDM 0301 RC 86376 HCPCS inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges Microsomal antibodies (autoantibody) measurement 50434270_1 CDM 0301 RC 86376 HCPCS inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges Microsomal antibodies (autoantibody) measurement 50434270_1 CDM 0301 RC 86376 HCPCS inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges Microsomal antibodies (autoantibody) measurement 50434270_1 CDM 0301 RC 86376 HCPCS inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges Microsomal antibodies (autoantibody) measurement 50434270_1 CDM 0301 RC 86376 HCPCS inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges Microsomal antibodies (autoantibody) measurement 50434270_1 CDM 0301 RC 86376 HCPCS inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges Microsomal antibodies (autoantibody) measurement 50434270_1 CDM 0301 RC 86376 HCPCS inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 Microsomal antibodies (autoantibody) measurement 50434270_1 CDM 0301 RC 86376 HCPCS inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 Microsomal antibodies (autoantibody) measurement 50434270_1 CDM 0301 RC 86376 HCPCS inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 Microsomal antibodies (autoantibody) measurement 50434270_1 CDM 0301 RC 86376 HCPCS inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 Microsomal antibodies (autoantibody) measurement 50434270_1 CDM 0301 RC 86376 HCPCS inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 Microsomal antibodies (autoantibody) measurement 50434270_1 CDM 0301 RC 86376 HCPCS inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50434271_1 CDM 0302 RC 86618 HCPCS inpatient 128 83.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 83.2 65 999999999 77.5 124.16 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50434271_1 CDM 0302 RC 86618 HCPCS inpatient 128 83.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 124.16 97 999999999 77.5 124.16 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50434271_1 CDM 0302 RC 86618 HCPCS inpatient 128 83.2 AETNA AETNA 101.12 79 999999999 77.5 124.16 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50434271_1 CDM 0302 RC 86618 HCPCS inpatient 128 83.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 99.84 78 999999999 77.5 124.16 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50434271_1 CDM 0302 RC 86618 HCPCS inpatient 128 83.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 88.32 69 999999999 77.5 124.16 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50434271_1 CDM 0302 RC 86618 HCPCS inpatient 128 83.2 SIHO - ALL PLANS SIHO - ALL PLANS 115.2 90 999999999 77.5 124.16 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50434271_1 CDM 0302 RC 86618 HCPCS inpatient 128 83.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 77.5 60.55 999999999 77.5 124.16 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50434271_1 CDM 0302 RC 86618 HCPCS inpatient 128 83.2 UMR - ALL PLANS UMR - ALL PLANS 89.6 70 999999999 77.5 124.16 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50434271_1 CDM 0302 RC 86618 HCPCS inpatient 128 83.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 77.5 124.16 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50434271_1 CDM 0302 RC 86618 HCPCS inpatient 128 83.2 ANTHEM HMO ANTHEM HMO 999999999 77.5 124.16 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50434271_1 CDM 0302 RC 86618 HCPCS inpatient 128 83.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 77.5 124.16 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50434271_1 CDM 0302 RC 86618 HCPCS inpatient 128 83.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 77.5 124.16 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50434271_1 CDM 0302 RC 86618 HCPCS inpatient 128 83.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 77.5 124.16 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50434271_1 CDM 0302 RC 86618 HCPCS inpatient 128 83.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 86.53 67.6 999999999 77.5 124.16 percent of total billed charges White blood cell enzyme activity measurement 50434272_1 CDM 0301 RC 85549 HCPCS inpatient 232 150.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 150.8 65 999999999 140.48 225.04 percent of total billed charges White blood cell enzyme activity measurement 50434272_1 CDM 0301 RC 85549 HCPCS inpatient 232 150.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 225.04 97 999999999 140.48 225.04 percent of total billed charges White blood cell enzyme activity measurement 50434272_1 CDM 0301 RC 85549 HCPCS inpatient 232 150.8 AETNA AETNA 183.28 79 999999999 140.48 225.04 percent of total billed charges White blood cell enzyme activity measurement 50434272_1 CDM 0301 RC 85549 HCPCS inpatient 232 150.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 180.96 78 999999999 140.48 225.04 percent of total billed charges White blood cell enzyme activity measurement 50434272_1 CDM 0301 RC 85549 HCPCS inpatient 232 150.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 160.08 69 999999999 140.48 225.04 percent of total billed charges White blood cell enzyme activity measurement 50434272_1 CDM 0301 RC 85549 HCPCS inpatient 232 150.8 SIHO - ALL PLANS SIHO - ALL PLANS 208.8 90 999999999 140.48 225.04 percent of total billed charges White blood cell enzyme activity measurement 50434272_1 CDM 0301 RC 85549 HCPCS inpatient 232 150.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 140.48 60.55 999999999 140.48 225.04 percent of total billed charges White blood cell enzyme activity measurement 50434272_1 CDM 0301 RC 85549 HCPCS inpatient 232 150.8 UMR - ALL PLANS UMR - ALL PLANS 162.4 70 999999999 140.48 225.04 percent of total billed charges White blood cell enzyme activity measurement 50434272_1 CDM 0301 RC 85549 HCPCS inpatient 232 150.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 140.48 225.04 White blood cell enzyme activity measurement 50434272_1 CDM 0301 RC 85549 HCPCS inpatient 232 150.8 ANTHEM HMO ANTHEM HMO 999999999 140.48 225.04 White blood cell enzyme activity measurement 50434272_1 CDM 0301 RC 85549 HCPCS inpatient 232 150.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 140.48 225.04 White blood cell enzyme activity measurement 50434272_1 CDM 0301 RC 85549 HCPCS inpatient 232 150.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 140.48 225.04 White blood cell enzyme activity measurement 50434272_1 CDM 0301 RC 85549 HCPCS inpatient 232 150.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 140.48 225.04 White blood cell enzyme activity measurement 50434272_1 CDM 0301 RC 85549 HCPCS inpatient 232 150.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 156.83 67.6 999999999 140.48 225.04 percent of total billed charges Magnesium level 50434273_1 CDM 0301 RC 83735 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Magnesium level 50434273_1 CDM 0301 RC 83735 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Magnesium level 50434273_1 CDM 0301 RC 83735 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Magnesium level 50434273_1 CDM 0301 RC 83735 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Magnesium level 50434273_1 CDM 0301 RC 83735 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Magnesium level 50434273_1 CDM 0301 RC 83735 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Magnesium level 50434273_1 CDM 0301 RC 83735 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Magnesium level 50434273_1 CDM 0301 RC 83735 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Magnesium level 50434273_1 CDM 0301 RC 83735 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Magnesium level 50434273_1 CDM 0301 RC 83735 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Magnesium level 50434273_1 CDM 0301 RC 83735 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Magnesium level 50434273_1 CDM 0301 RC 83735 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Magnesium level 50434273_1 CDM 0301 RC 83735 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Magnesium level 50434273_1 CDM 0301 RC 83735 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50434274_1 CDM 0301 RC 82105 HCPCS inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50434274_1 CDM 0301 RC 82105 HCPCS inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50434274_1 CDM 0301 RC 82105 HCPCS inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50434274_1 CDM 0301 RC 82105 HCPCS inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50434274_1 CDM 0301 RC 82105 HCPCS inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50434274_1 CDM 0301 RC 82105 HCPCS inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50434274_1 CDM 0301 RC 82105 HCPCS inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50434274_1 CDM 0301 RC 82105 HCPCS inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50434274_1 CDM 0301 RC 82105 HCPCS inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 "Alpha-fetoprotein (AFP) level, serum" 50434274_1 CDM 0301 RC 82105 HCPCS inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 "Alpha-fetoprotein (AFP) level, serum" 50434274_1 CDM 0301 RC 82105 HCPCS inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 "Alpha-fetoprotein (AFP) level, serum" 50434274_1 CDM 0301 RC 82105 HCPCS inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 "Alpha-fetoprotein (AFP) level, serum" 50434274_1 CDM 0301 RC 82105 HCPCS inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 "Alpha-fetoprotein (AFP) level, serum" 50434274_1 CDM 0301 RC 82105 HCPCS inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50434275_1 CDM 0301 RC 86765 HCPCS inpatient 165 107.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.25 65 999999999 99.91 160.05 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50434275_1 CDM 0301 RC 86765 HCPCS inpatient 165 107.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 160.05 97 999999999 99.91 160.05 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50434275_1 CDM 0301 RC 86765 HCPCS inpatient 165 107.25 AETNA AETNA 130.35 79 999999999 99.91 160.05 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50434275_1 CDM 0301 RC 86765 HCPCS inpatient 165 107.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.7 78 999999999 99.91 160.05 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50434275_1 CDM 0301 RC 86765 HCPCS inpatient 165 107.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.85 69 999999999 99.91 160.05 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50434275_1 CDM 0301 RC 86765 HCPCS inpatient 165 107.25 SIHO - ALL PLANS SIHO - ALL PLANS 148.5 90 999999999 99.91 160.05 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50434275_1 CDM 0301 RC 86765 HCPCS inpatient 165 107.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.91 60.55 999999999 99.91 160.05 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50434275_1 CDM 0301 RC 86765 HCPCS inpatient 165 107.25 UMR - ALL PLANS UMR - ALL PLANS 115.5 70 999999999 99.91 160.05 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50434275_1 CDM 0301 RC 86765 HCPCS inpatient 165 107.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.91 160.05 Analysis for antibody to Rubeola (measles virus) 50434275_1 CDM 0301 RC 86765 HCPCS inpatient 165 107.25 ANTHEM HMO ANTHEM HMO 999999999 99.91 160.05 Analysis for antibody to Rubeola (measles virus) 50434275_1 CDM 0301 RC 86765 HCPCS inpatient 165 107.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.91 160.05 Analysis for antibody to Rubeola (measles virus) 50434275_1 CDM 0301 RC 86765 HCPCS inpatient 165 107.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.91 160.05 Analysis for antibody to Rubeola (measles virus) 50434275_1 CDM 0301 RC 86765 HCPCS inpatient 165 107.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.91 160.05 Analysis for antibody to Rubeola (measles virus) 50434275_1 CDM 0301 RC 86765 HCPCS inpatient 165 107.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.54 67.6 999999999 99.91 160.05 percent of total billed charges Mercury level 50434276_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 SELF PAY DISCOUNT SELF PAY DISCOUNT 156 65 999999999 145.32 232.8 percent of total billed charges Mercury level 50434276_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 232.8 97 999999999 145.32 232.8 percent of total billed charges Mercury level 50434276_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 AETNA AETNA 189.6 79 999999999 145.32 232.8 percent of total billed charges Mercury level 50434276_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.2 78 999999999 145.32 232.8 percent of total billed charges Mercury level 50434276_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 ENCORE - ALL PLANS ENCORE - ALL PLANS 165.6 69 999999999 145.32 232.8 percent of total billed charges Mercury level 50434276_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 SIHO - ALL PLANS SIHO - ALL PLANS 216 90 999999999 145.32 232.8 percent of total billed charges Mercury level 50434276_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.32 60.55 999999999 145.32 232.8 percent of total billed charges Mercury level 50434276_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 UMR - ALL PLANS UMR - ALL PLANS 168 70 999999999 145.32 232.8 percent of total billed charges Mercury level 50434276_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.32 232.8 Mercury level 50434276_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 ANTHEM HMO ANTHEM HMO 999999999 145.32 232.8 Mercury level 50434276_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.32 232.8 Mercury level 50434276_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.32 232.8 Mercury level 50434276_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.32 232.8 Mercury level 50434276_1 CDM 0301 RC 83825 HCPCS inpatient 240 156 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.24 67.6 999999999 145.32 232.8 percent of total billed charges Metanephrines level 50434277_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 SELF PAY DISCOUNT SELF PAY DISCOUNT 169 65 999999999 157.43 252.2 percent of total billed charges Metanephrines level 50434277_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 252.2 97 999999999 157.43 252.2 percent of total billed charges Metanephrines level 50434277_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 AETNA AETNA 205.4 79 999999999 157.43 252.2 percent of total billed charges Metanephrines level 50434277_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 HUMANA - ALL PLANS HUMANA - ALL PLANS 202.8 78 999999999 157.43 252.2 percent of total billed charges Metanephrines level 50434277_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 ENCORE - ALL PLANS ENCORE - ALL PLANS 179.4 69 999999999 157.43 252.2 percent of total billed charges Metanephrines level 50434277_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 SIHO - ALL PLANS SIHO - ALL PLANS 234 90 999999999 157.43 252.2 percent of total billed charges Metanephrines level 50434277_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 157.43 60.55 999999999 157.43 252.2 percent of total billed charges Metanephrines level 50434277_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 UMR - ALL PLANS UMR - ALL PLANS 182 70 999999999 157.43 252.2 percent of total billed charges Metanephrines level 50434277_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 157.43 252.2 Metanephrines level 50434277_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 ANTHEM HMO ANTHEM HMO 999999999 157.43 252.2 Metanephrines level 50434277_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 157.43 252.2 Metanephrines level 50434277_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 157.43 252.2 Metanephrines level 50434277_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 UHC - ALL PLANS UHC - ALL PLANS 999999999 157.43 252.2 Metanephrines level 50434277_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 CIGNA - ALL PLANS CIGNA - ALL PLANS 175.76 67.6 999999999 157.43 252.2 percent of total billed charges Alcohols levels 50434278_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50434278_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50434278_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50434278_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50434278_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50434278_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50434278_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50434278_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50434278_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 Alcohols levels 50434278_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 Alcohols levels 50434278_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 Alcohols levels 50434278_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 Alcohols levels 50434278_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 Alcohols levels 50434278_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges Organic acid level 50434279_1 CDM 0301 RC 83921 HCPCS inpatient 262 170.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.3 65 999999999 158.64 254.14 percent of total billed charges Organic acid level 50434279_1 CDM 0301 RC 83921 HCPCS inpatient 262 170.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 254.14 97 999999999 158.64 254.14 percent of total billed charges Organic acid level 50434279_1 CDM 0301 RC 83921 HCPCS inpatient 262 170.3 AETNA AETNA 206.98 79 999999999 158.64 254.14 percent of total billed charges Organic acid level 50434279_1 CDM 0301 RC 83921 HCPCS inpatient 262 170.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 204.36 78 999999999 158.64 254.14 percent of total billed charges Organic acid level 50434279_1 CDM 0301 RC 83921 HCPCS inpatient 262 170.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.78 69 999999999 158.64 254.14 percent of total billed charges Organic acid level 50434279_1 CDM 0301 RC 83921 HCPCS inpatient 262 170.3 SIHO - ALL PLANS SIHO - ALL PLANS 235.8 90 999999999 158.64 254.14 percent of total billed charges Organic acid level 50434279_1 CDM 0301 RC 83921 HCPCS inpatient 262 170.3 UMR - ALL PLANS UMR - ALL PLANS 183.4 70 999999999 158.64 254.14 percent of total billed charges Organic acid level 50434279_1 CDM 0301 RC 83921 HCPCS inpatient 262 170.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.64 60.55 999999999 158.64 254.14 percent of total billed charges Organic acid level 50434279_1 CDM 0301 RC 83921 HCPCS inpatient 262 170.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.64 254.14 Organic acid level 50434279_1 CDM 0301 RC 83921 HCPCS inpatient 262 170.3 ANTHEM HMO ANTHEM HMO 999999999 158.64 254.14 Organic acid level 50434279_1 CDM 0301 RC 83921 HCPCS inpatient 262 170.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.64 254.14 Organic acid level 50434279_1 CDM 0301 RC 83921 HCPCS inpatient 262 170.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.64 254.14 Organic acid level 50434279_1 CDM 0301 RC 83921 HCPCS inpatient 262 170.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.64 254.14 Organic acid level 50434279_1 CDM 0301 RC 83921 HCPCS inpatient 262 170.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.11 67.6 999999999 158.64 254.14 percent of total billed charges "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 50434280_1 CDM 0301 RC 81291 HCPCS inpatient 700 455 SELF PAY DISCOUNT SELF PAY DISCOUNT 455 65 999999999 423.85 679 percent of total billed charges "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 50434280_1 CDM 0301 RC 81291 HCPCS inpatient 700 455 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 679 97 999999999 423.85 679 percent of total billed charges "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 50434280_1 CDM 0301 RC 81291 HCPCS inpatient 700 455 AETNA AETNA 553 79 999999999 423.85 679 percent of total billed charges "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 50434280_1 CDM 0301 RC 81291 HCPCS inpatient 700 455 HUMANA - ALL PLANS HUMANA - ALL PLANS 546 78 999999999 423.85 679 percent of total billed charges "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 50434280_1 CDM 0301 RC 81291 HCPCS inpatient 700 455 ENCORE - ALL PLANS ENCORE - ALL PLANS 483 69 999999999 423.85 679 percent of total billed charges "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 50434280_1 CDM 0301 RC 81291 HCPCS inpatient 700 455 SIHO - ALL PLANS SIHO - ALL PLANS 630 90 999999999 423.85 679 percent of total billed charges "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 50434280_1 CDM 0301 RC 81291 HCPCS inpatient 700 455 UMR - ALL PLANS UMR - ALL PLANS 490 70 999999999 423.85 679 percent of total billed charges "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 50434280_1 CDM 0301 RC 81291 HCPCS inpatient 700 455 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 423.85 60.55 999999999 423.85 679 percent of total billed charges "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 50434280_1 CDM 0301 RC 81291 HCPCS inpatient 700 455 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 423.85 679 "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 50434280_1 CDM 0301 RC 81291 HCPCS inpatient 700 455 ANTHEM HMO ANTHEM HMO 999999999 423.85 679 "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 50434280_1 CDM 0301 RC 81291 HCPCS inpatient 700 455 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 423.85 679 "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 50434280_1 CDM 0301 RC 81291 HCPCS inpatient 700 455 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 423.85 679 "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 50434280_1 CDM 0301 RC 81291 HCPCS inpatient 700 455 UHC - ALL PLANS UHC - ALL PLANS 999999999 423.85 679 "Gene analysis (5, 10-methylenetetrahydrofolate reductase) common variants" 50434280_1 CDM 0301 RC 81291 HCPCS inpatient 700 455 CIGNA - ALL PLANS CIGNA - ALL PLANS 473.2 67.6 999999999 423.85 679 percent of total billed charges Analysis for antibody to mumps virus 50434281_1 CDM 0302 RC 86735 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to mumps virus 50434281_1 CDM 0302 RC 86735 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to mumps virus 50434281_1 CDM 0302 RC 86735 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to mumps virus 50434281_1 CDM 0302 RC 86735 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to mumps virus 50434281_1 CDM 0302 RC 86735 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to mumps virus 50434281_1 CDM 0302 RC 86735 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to mumps virus 50434281_1 CDM 0302 RC 86735 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to mumps virus 50434281_1 CDM 0302 RC 86735 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to mumps virus 50434281_1 CDM 0302 RC 86735 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 Analysis for antibody to mumps virus 50434281_1 CDM 0302 RC 86735 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 Analysis for antibody to mumps virus 50434281_1 CDM 0302 RC 86735 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 Analysis for antibody to mumps virus 50434281_1 CDM 0302 RC 86735 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 Analysis for antibody to mumps virus 50434281_1 CDM 0302 RC 86735 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 Analysis for antibody to mumps virus 50434281_1 CDM 0302 RC 86735 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges Myoglobin (muscle protein) level 50434282_1 CDM 0301 RC 83874 HCPCS inpatient 297 193.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 193.05 65 999999999 179.83 288.09 percent of total billed charges Myoglobin (muscle protein) level 50434282_1 CDM 0301 RC 83874 HCPCS inpatient 297 193.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 288.09 97 999999999 179.83 288.09 percent of total billed charges Myoglobin (muscle protein) level 50434282_1 CDM 0301 RC 83874 HCPCS inpatient 297 193.05 AETNA AETNA 234.63 79 999999999 179.83 288.09 percent of total billed charges Myoglobin (muscle protein) level 50434282_1 CDM 0301 RC 83874 HCPCS inpatient 297 193.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 231.66 78 999999999 179.83 288.09 percent of total billed charges Myoglobin (muscle protein) level 50434282_1 CDM 0301 RC 83874 HCPCS inpatient 297 193.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 204.93 69 999999999 179.83 288.09 percent of total billed charges Myoglobin (muscle protein) level 50434282_1 CDM 0301 RC 83874 HCPCS inpatient 297 193.05 SIHO - ALL PLANS SIHO - ALL PLANS 267.3 90 999999999 179.83 288.09 percent of total billed charges Myoglobin (muscle protein) level 50434282_1 CDM 0301 RC 83874 HCPCS inpatient 297 193.05 UMR - ALL PLANS UMR - ALL PLANS 207.9 70 999999999 179.83 288.09 percent of total billed charges Myoglobin (muscle protein) level 50434282_1 CDM 0301 RC 83874 HCPCS inpatient 297 193.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 179.83 60.55 999999999 179.83 288.09 percent of total billed charges Myoglobin (muscle protein) level 50434282_1 CDM 0301 RC 83874 HCPCS inpatient 297 193.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 179.83 288.09 Myoglobin (muscle protein) level 50434282_1 CDM 0301 RC 83874 HCPCS inpatient 297 193.05 ANTHEM HMO ANTHEM HMO 999999999 179.83 288.09 Myoglobin (muscle protein) level 50434282_1 CDM 0301 RC 83874 HCPCS inpatient 297 193.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 179.83 288.09 Myoglobin (muscle protein) level 50434282_1 CDM 0301 RC 83874 HCPCS inpatient 297 193.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 179.83 288.09 Myoglobin (muscle protein) level 50434282_1 CDM 0301 RC 83874 HCPCS inpatient 297 193.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 179.83 288.09 Myoglobin (muscle protein) level 50434282_1 CDM 0301 RC 83874 HCPCS inpatient 297 193.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 200.77 67.6 999999999 179.83 288.09 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 50434283_1 CDM 0301 RC 86225 HCPCS inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 50434283_1 CDM 0301 RC 86225 HCPCS inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 50434283_1 CDM 0301 RC 86225 HCPCS inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 50434283_1 CDM 0301 RC 86225 HCPCS inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 50434283_1 CDM 0301 RC 86225 HCPCS inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 50434283_1 CDM 0301 RC 86225 HCPCS inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 50434283_1 CDM 0301 RC 86225 HCPCS inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 50434283_1 CDM 0301 RC 86225 HCPCS inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges "Measurement of DNA antibody, native or double stranded" 50434283_1 CDM 0301 RC 86225 HCPCS inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 "Measurement of DNA antibody, native or double stranded" 50434283_1 CDM 0301 RC 86225 HCPCS inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 "Measurement of DNA antibody, native or double stranded" 50434283_1 CDM 0301 RC 86225 HCPCS inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 "Measurement of DNA antibody, native or double stranded" 50434283_1 CDM 0301 RC 86225 HCPCS inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 "Measurement of DNA antibody, native or double stranded" 50434283_1 CDM 0301 RC 86225 HCPCS inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 "Measurement of DNA antibody, native or double stranded" 50434283_1 CDM 0301 RC 86225 HCPCS inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges Alkaloids levels 50434284_1 CDM 0301 RC 80323 HCPCS inpatient 166 107.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.9 65 999999999 100.51 161.02 percent of total billed charges Alkaloids levels 50434284_1 CDM 0301 RC 80323 HCPCS inpatient 166 107.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.02 97 999999999 100.51 161.02 percent of total billed charges Alkaloids levels 50434284_1 CDM 0301 RC 80323 HCPCS inpatient 166 107.9 AETNA AETNA 131.14 79 999999999 100.51 161.02 percent of total billed charges Alkaloids levels 50434284_1 CDM 0301 RC 80323 HCPCS inpatient 166 107.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 129.48 78 999999999 100.51 161.02 percent of total billed charges Alkaloids levels 50434284_1 CDM 0301 RC 80323 HCPCS inpatient 166 107.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 114.54 69 999999999 100.51 161.02 percent of total billed charges Alkaloids levels 50434284_1 CDM 0301 RC 80323 HCPCS inpatient 166 107.9 SIHO - ALL PLANS SIHO - ALL PLANS 149.4 90 999999999 100.51 161.02 percent of total billed charges Alkaloids levels 50434284_1 CDM 0301 RC 80323 HCPCS inpatient 166 107.9 UMR - ALL PLANS UMR - ALL PLANS 116.2 70 999999999 100.51 161.02 percent of total billed charges Alkaloids levels 50434284_1 CDM 0301 RC 80323 HCPCS inpatient 166 107.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 100.51 60.55 999999999 100.51 161.02 percent of total billed charges Alkaloids levels 50434284_1 CDM 0301 RC 80323 HCPCS inpatient 166 107.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 100.51 161.02 Alkaloids levels 50434284_1 CDM 0301 RC 80323 HCPCS inpatient 166 107.9 ANTHEM HMO ANTHEM HMO 999999999 100.51 161.02 Alkaloids levels 50434284_1 CDM 0301 RC 80323 HCPCS inpatient 166 107.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 100.51 161.02 Alkaloids levels 50434284_1 CDM 0301 RC 80323 HCPCS inpatient 166 107.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 100.51 161.02 Alkaloids levels 50434284_1 CDM 0301 RC 80323 HCPCS inpatient 166 107.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 100.51 161.02 Alkaloids levels 50434284_1 CDM 0301 RC 80323 HCPCS inpatient 166 107.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.22 67.6 999999999 100.51 161.02 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434285_1 CDM 0301 RC 80307 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434285_1 CDM 0301 RC 80307 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434285_1 CDM 0301 RC 80307 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434285_1 CDM 0301 RC 80307 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434285_1 CDM 0301 RC 80307 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434285_1 CDM 0301 RC 80307 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434285_1 CDM 0301 RC 80307 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434285_1 CDM 0301 RC 80307 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434285_1 CDM 0301 RC 80307 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 "Testing for presence of drug, by chemistry analyzers" 50434285_1 CDM 0301 RC 80307 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 "Testing for presence of drug, by chemistry analyzers" 50434285_1 CDM 0301 RC 80307 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 "Testing for presence of drug, by chemistry analyzers" 50434285_1 CDM 0301 RC 80307 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 "Testing for presence of drug, by chemistry analyzers" 50434285_1 CDM 0301 RC 80307 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 "Testing for presence of drug, by chemistry analyzers" 50434285_1 CDM 0301 RC 80307 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 50434286_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 50434286_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 50434286_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 50434286_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 50434286_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 50434286_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 50434286_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 50434286_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 50434286_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 "Collagen cross links test, (urine test to evaluate bone health)" 50434286_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 "Collagen cross links test, (urine test to evaluate bone health)" 50434286_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 "Collagen cross links test, (urine test to evaluate bone health)" 50434286_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 "Collagen cross links test, (urine test to evaluate bone health)" 50434286_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 "Collagen cross links test, (urine test to evaluate bone health)" 50434286_1 CDM 0301 RC 82523 HCPCS inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges Urine osmolality (concentration) measurement 50434288_1 CDM 0301 RC 83935 HCPCS inpatient 156 101.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.4 65 999999999 94.46 151.32 percent of total billed charges Urine osmolality (concentration) measurement 50434288_1 CDM 0301 RC 83935 HCPCS inpatient 156 101.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 151.32 97 999999999 94.46 151.32 percent of total billed charges Urine osmolality (concentration) measurement 50434288_1 CDM 0301 RC 83935 HCPCS inpatient 156 101.4 AETNA AETNA 123.24 79 999999999 94.46 151.32 percent of total billed charges Urine osmolality (concentration) measurement 50434288_1 CDM 0301 RC 83935 HCPCS inpatient 156 101.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.68 78 999999999 94.46 151.32 percent of total billed charges Urine osmolality (concentration) measurement 50434288_1 CDM 0301 RC 83935 HCPCS inpatient 156 101.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.64 69 999999999 94.46 151.32 percent of total billed charges Urine osmolality (concentration) measurement 50434288_1 CDM 0301 RC 83935 HCPCS inpatient 156 101.4 SIHO - ALL PLANS SIHO - ALL PLANS 140.4 90 999999999 94.46 151.32 percent of total billed charges Urine osmolality (concentration) measurement 50434288_1 CDM 0301 RC 83935 HCPCS inpatient 156 101.4 UMR - ALL PLANS UMR - ALL PLANS 109.2 70 999999999 94.46 151.32 percent of total billed charges Urine osmolality (concentration) measurement 50434288_1 CDM 0301 RC 83935 HCPCS inpatient 156 101.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.46 60.55 999999999 94.46 151.32 percent of total billed charges Urine osmolality (concentration) measurement 50434288_1 CDM 0301 RC 83935 HCPCS inpatient 156 101.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.46 151.32 Urine osmolality (concentration) measurement 50434288_1 CDM 0301 RC 83935 HCPCS inpatient 156 101.4 ANTHEM HMO ANTHEM HMO 999999999 94.46 151.32 Urine osmolality (concentration) measurement 50434288_1 CDM 0301 RC 83935 HCPCS inpatient 156 101.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.46 151.32 Urine osmolality (concentration) measurement 50434288_1 CDM 0301 RC 83935 HCPCS inpatient 156 101.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.46 151.32 Urine osmolality (concentration) measurement 50434288_1 CDM 0301 RC 83935 HCPCS inpatient 156 101.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.46 151.32 Urine osmolality (concentration) measurement 50434288_1 CDM 0301 RC 83935 HCPCS inpatient 156 101.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.46 67.6 999999999 94.46 151.32 percent of total billed charges Oxalate level 50434289_1 CDM 0301 RC 83945 HCPCS inpatient 338 219.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 219.7 65 999999999 204.66 327.86 percent of total billed charges Oxalate level 50434289_1 CDM 0301 RC 83945 HCPCS inpatient 338 219.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 327.86 97 999999999 204.66 327.86 percent of total billed charges Oxalate level 50434289_1 CDM 0301 RC 83945 HCPCS inpatient 338 219.7 AETNA AETNA 267.02 79 999999999 204.66 327.86 percent of total billed charges Oxalate level 50434289_1 CDM 0301 RC 83945 HCPCS inpatient 338 219.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 263.64 78 999999999 204.66 327.86 percent of total billed charges Oxalate level 50434289_1 CDM 0301 RC 83945 HCPCS inpatient 338 219.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 233.22 69 999999999 204.66 327.86 percent of total billed charges Oxalate level 50434289_1 CDM 0301 RC 83945 HCPCS inpatient 338 219.7 SIHO - ALL PLANS SIHO - ALL PLANS 304.2 90 999999999 204.66 327.86 percent of total billed charges Oxalate level 50434289_1 CDM 0301 RC 83945 HCPCS inpatient 338 219.7 UMR - ALL PLANS UMR - ALL PLANS 236.6 70 999999999 204.66 327.86 percent of total billed charges Oxalate level 50434289_1 CDM 0301 RC 83945 HCPCS inpatient 338 219.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 204.66 60.55 999999999 204.66 327.86 percent of total billed charges Oxalate level 50434289_1 CDM 0301 RC 83945 HCPCS inpatient 338 219.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 204.66 327.86 Oxalate level 50434289_1 CDM 0301 RC 83945 HCPCS inpatient 338 219.7 ANTHEM HMO ANTHEM HMO 999999999 204.66 327.86 Oxalate level 50434289_1 CDM 0301 RC 83945 HCPCS inpatient 338 219.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 204.66 327.86 Oxalate level 50434289_1 CDM 0301 RC 83945 HCPCS inpatient 338 219.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 204.66 327.86 Oxalate level 50434289_1 CDM 0301 RC 83945 HCPCS inpatient 338 219.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 204.66 327.86 Oxalate level 50434289_1 CDM 0301 RC 83945 HCPCS inpatient 338 219.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 228.49 67.6 999999999 204.66 327.86 percent of total billed charges Oxcarbazepine level 50434290_1 CDM 0301 RC 80183 HCPCS inpatient 301 195.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 195.65 65 999999999 182.26 291.97 percent of total billed charges Oxcarbazepine level 50434290_1 CDM 0301 RC 80183 HCPCS inpatient 301 195.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291.97 97 999999999 182.26 291.97 percent of total billed charges Oxcarbazepine level 50434290_1 CDM 0301 RC 80183 HCPCS inpatient 301 195.65 AETNA AETNA 237.79 79 999999999 182.26 291.97 percent of total billed charges Oxcarbazepine level 50434290_1 CDM 0301 RC 80183 HCPCS inpatient 301 195.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 234.78 78 999999999 182.26 291.97 percent of total billed charges Oxcarbazepine level 50434290_1 CDM 0301 RC 80183 HCPCS inpatient 301 195.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 207.69 69 999999999 182.26 291.97 percent of total billed charges Oxcarbazepine level 50434290_1 CDM 0301 RC 80183 HCPCS inpatient 301 195.65 SIHO - ALL PLANS SIHO - ALL PLANS 270.9 90 999999999 182.26 291.97 percent of total billed charges Oxcarbazepine level 50434290_1 CDM 0301 RC 80183 HCPCS inpatient 301 195.65 UMR - ALL PLANS UMR - ALL PLANS 210.7 70 999999999 182.26 291.97 percent of total billed charges Oxcarbazepine level 50434290_1 CDM 0301 RC 80183 HCPCS inpatient 301 195.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.26 60.55 999999999 182.26 291.97 percent of total billed charges Oxcarbazepine level 50434290_1 CDM 0301 RC 80183 HCPCS inpatient 301 195.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.26 291.97 Oxcarbazepine level 50434290_1 CDM 0301 RC 80183 HCPCS inpatient 301 195.65 ANTHEM HMO ANTHEM HMO 999999999 182.26 291.97 Oxcarbazepine level 50434290_1 CDM 0301 RC 80183 HCPCS inpatient 301 195.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.26 291.97 Oxcarbazepine level 50434290_1 CDM 0301 RC 80183 HCPCS inpatient 301 195.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.26 291.97 Oxcarbazepine level 50434290_1 CDM 0301 RC 80183 HCPCS inpatient 301 195.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.26 291.97 Oxcarbazepine level 50434290_1 CDM 0301 RC 80183 HCPCS inpatient 301 195.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 203.48 67.6 999999999 182.26 291.97 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434291_1 CDM 0301 RC 80307 HCPCS inpatient 220 143 SELF PAY DISCOUNT SELF PAY DISCOUNT 143 65 999999999 133.21 213.4 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434291_1 CDM 0301 RC 80307 HCPCS inpatient 220 143 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 213.4 97 999999999 133.21 213.4 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434291_1 CDM 0301 RC 80307 HCPCS inpatient 220 143 AETNA AETNA 173.8 79 999999999 133.21 213.4 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434291_1 CDM 0301 RC 80307 HCPCS inpatient 220 143 HUMANA - ALL PLANS HUMANA - ALL PLANS 171.6 78 999999999 133.21 213.4 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434291_1 CDM 0301 RC 80307 HCPCS inpatient 220 143 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.8 69 999999999 133.21 213.4 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434291_1 CDM 0301 RC 80307 HCPCS inpatient 220 143 SIHO - ALL PLANS SIHO - ALL PLANS 198 90 999999999 133.21 213.4 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434291_1 CDM 0301 RC 80307 HCPCS inpatient 220 143 UMR - ALL PLANS UMR - ALL PLANS 154 70 999999999 133.21 213.4 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434291_1 CDM 0301 RC 80307 HCPCS inpatient 220 143 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 133.21 60.55 999999999 133.21 213.4 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50434291_1 CDM 0301 RC 80307 HCPCS inpatient 220 143 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 133.21 213.4 "Testing for presence of drug, by chemistry analyzers" 50434291_1 CDM 0301 RC 80307 HCPCS inpatient 220 143 ANTHEM HMO ANTHEM HMO 999999999 133.21 213.4 "Testing for presence of drug, by chemistry analyzers" 50434291_1 CDM 0301 RC 80307 HCPCS inpatient 220 143 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 133.21 213.4 "Testing for presence of drug, by chemistry analyzers" 50434291_1 CDM 0301 RC 80307 HCPCS inpatient 220 143 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 133.21 213.4 "Testing for presence of drug, by chemistry analyzers" 50434291_1 CDM 0301 RC 80307 HCPCS inpatient 220 143 UHC - ALL PLANS UHC - ALL PLANS 999999999 133.21 213.4 "Testing for presence of drug, by chemistry analyzers" 50434291_1 CDM 0301 RC 80307 HCPCS inpatient 220 143 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.72 67.6 999999999 133.21 213.4 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434292_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 195.65 65 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434292_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291.97 97 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434292_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 AETNA AETNA 237.79 79 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434292_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 234.78 78 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434292_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 207.69 69 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434292_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 SIHO - ALL PLANS SIHO - ALL PLANS 270.9 90 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434292_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 UMR - ALL PLANS UMR - ALL PLANS 210.7 70 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434292_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.26 60.55 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434292_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434292_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM HMO ANTHEM HMO 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434292_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434292_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434292_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50434292_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 203.48 67.6 999999999 182.26 291.97 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 50434293_1 CDM 0301 RC 88184 HCPCS inpatient 478 310.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 310.7 65 999999999 289.43 463.66 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 50434293_1 CDM 0301 RC 88184 HCPCS inpatient 478 310.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 463.66 97 999999999 289.43 463.66 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 50434293_1 CDM 0301 RC 88184 HCPCS inpatient 478 310.7 AETNA AETNA 377.62 79 999999999 289.43 463.66 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 50434293_1 CDM 0301 RC 88184 HCPCS inpatient 478 310.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 372.84 78 999999999 289.43 463.66 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 50434293_1 CDM 0301 RC 88184 HCPCS inpatient 478 310.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 329.82 69 999999999 289.43 463.66 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 50434293_1 CDM 0301 RC 88184 HCPCS inpatient 478 310.7 SIHO - ALL PLANS SIHO - ALL PLANS 430.2 90 999999999 289.43 463.66 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 50434293_1 CDM 0301 RC 88184 HCPCS inpatient 478 310.7 UMR - ALL PLANS UMR - ALL PLANS 334.6 70 999999999 289.43 463.66 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 50434293_1 CDM 0301 RC 88184 HCPCS inpatient 478 310.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 289.43 60.55 999999999 289.43 463.66 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, first marker" 50434293_1 CDM 0301 RC 88184 HCPCS inpatient 478 310.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 289.43 463.66 "Flow cytometry technique for DNA or cell analysis, first marker" 50434293_1 CDM 0301 RC 88184 HCPCS inpatient 478 310.7 ANTHEM HMO ANTHEM HMO 999999999 289.43 463.66 "Flow cytometry technique for DNA or cell analysis, first marker" 50434293_1 CDM 0301 RC 88184 HCPCS inpatient 478 310.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 289.43 463.66 "Flow cytometry technique for DNA or cell analysis, first marker" 50434293_1 CDM 0301 RC 88184 HCPCS inpatient 478 310.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 289.43 463.66 "Flow cytometry technique for DNA or cell analysis, first marker" 50434293_1 CDM 0301 RC 88184 HCPCS inpatient 478 310.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 289.43 463.66 "Flow cytometry technique for DNA or cell analysis, first marker" 50434293_1 CDM 0301 RC 88184 HCPCS inpatient 478 310.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 323.13 67.6 999999999 289.43 463.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434294_1 CDM 0301 RC 86008 HCPCS inpatient 84 54.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 54.6 65 999999999 50.86 81.48 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434294_1 CDM 0301 RC 86008 HCPCS inpatient 84 54.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 81.48 97 999999999 50.86 81.48 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434294_1 CDM 0301 RC 86008 HCPCS inpatient 84 54.6 AETNA AETNA 66.36 79 999999999 50.86 81.48 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434294_1 CDM 0301 RC 86008 HCPCS inpatient 84 54.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 65.52 78 999999999 50.86 81.48 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434294_1 CDM 0301 RC 86008 HCPCS inpatient 84 54.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.96 69 999999999 50.86 81.48 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434294_1 CDM 0301 RC 86008 HCPCS inpatient 84 54.6 SIHO - ALL PLANS SIHO - ALL PLANS 75.6 90 999999999 50.86 81.48 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434294_1 CDM 0301 RC 86008 HCPCS inpatient 84 54.6 UMR - ALL PLANS UMR - ALL PLANS 58.8 70 999999999 50.86 81.48 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434294_1 CDM 0301 RC 86008 HCPCS inpatient 84 54.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.86 60.55 999999999 50.86 81.48 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434294_1 CDM 0301 RC 86008 HCPCS inpatient 84 54.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.86 81.48 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434294_1 CDM 0301 RC 86008 HCPCS inpatient 84 54.6 ANTHEM HMO ANTHEM HMO 999999999 50.86 81.48 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434294_1 CDM 0301 RC 86008 HCPCS inpatient 84 54.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.86 81.48 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434294_1 CDM 0301 RC 86008 HCPCS inpatient 84 54.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.86 81.48 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434294_1 CDM 0301 RC 86008 HCPCS inpatient 84 54.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.86 81.48 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50434294_1 CDM 0301 RC 86008 HCPCS inpatient 84 54.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.78 67.6 999999999 50.86 81.48 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 50434295_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.75 65 999999999 57.52 92.15 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 50434295_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 92.15 97 999999999 57.52 92.15 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 50434295_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 AETNA AETNA 75.05 79 999999999 57.52 92.15 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 50434295_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.1 78 999999999 57.52 92.15 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 50434295_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 65.55 69 999999999 57.52 92.15 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 50434295_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 SIHO - ALL PLANS SIHO - ALL PLANS 85.5 90 999999999 57.52 92.15 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 50434295_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 UMR - ALL PLANS UMR - ALL PLANS 66.5 70 999999999 57.52 92.15 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 50434295_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 57.52 60.55 999999999 57.52 92.15 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 50434295_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 57.52 92.15 Phospholipid antibody (autoimmune antibody) measurement 50434295_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 ANTHEM HMO ANTHEM HMO 999999999 57.52 92.15 Phospholipid antibody (autoimmune antibody) measurement 50434295_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 57.52 92.15 Phospholipid antibody (autoimmune antibody) measurement 50434295_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 57.52 92.15 Phospholipid antibody (autoimmune antibody) measurement 50434295_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 57.52 92.15 Phospholipid antibody (autoimmune antibody) measurement 50434295_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.22 67.6 999999999 57.52 92.15 percent of total billed charges Platelet aggregation function test 50434296_1 CDM 0305 RC 85576 HCPCS inpatient 536 348.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 348.4 65 999999999 324.55 519.92 percent of total billed charges Platelet aggregation function test 50434296_1 CDM 0305 RC 85576 HCPCS inpatient 536 348.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 519.92 97 999999999 324.55 519.92 percent of total billed charges Platelet aggregation function test 50434296_1 CDM 0305 RC 85576 HCPCS inpatient 536 348.4 AETNA AETNA 423.44 79 999999999 324.55 519.92 percent of total billed charges Platelet aggregation function test 50434296_1 CDM 0305 RC 85576 HCPCS inpatient 536 348.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 418.08 78 999999999 324.55 519.92 percent of total billed charges Platelet aggregation function test 50434296_1 CDM 0305 RC 85576 HCPCS inpatient 536 348.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 369.84 69 999999999 324.55 519.92 percent of total billed charges Platelet aggregation function test 50434296_1 CDM 0305 RC 85576 HCPCS inpatient 536 348.4 SIHO - ALL PLANS SIHO - ALL PLANS 482.4 90 999999999 324.55 519.92 percent of total billed charges Platelet aggregation function test 50434296_1 CDM 0305 RC 85576 HCPCS inpatient 536 348.4 UMR - ALL PLANS UMR - ALL PLANS 375.2 70 999999999 324.55 519.92 percent of total billed charges Platelet aggregation function test 50434296_1 CDM 0305 RC 85576 HCPCS inpatient 536 348.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 324.55 60.55 999999999 324.55 519.92 percent of total billed charges Platelet aggregation function test 50434296_1 CDM 0305 RC 85576 HCPCS inpatient 536 348.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 324.55 519.92 Platelet aggregation function test 50434296_1 CDM 0305 RC 85576 HCPCS inpatient 536 348.4 ANTHEM HMO ANTHEM HMO 999999999 324.55 519.92 Platelet aggregation function test 50434296_1 CDM 0305 RC 85576 HCPCS inpatient 536 348.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 324.55 519.92 Platelet aggregation function test 50434296_1 CDM 0305 RC 85576 HCPCS inpatient 536 348.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 324.55 519.92 Platelet aggregation function test 50434296_1 CDM 0305 RC 85576 HCPCS inpatient 536 348.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 324.55 519.92 Platelet aggregation function test 50434296_1 CDM 0305 RC 85576 HCPCS inpatient 536 348.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 362.34 67.6 999999999 324.55 519.92 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434297_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.1 65 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434297_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 71.78 97 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434297_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 AETNA AETNA 58.46 79 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434297_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 57.72 78 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434297_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.06 69 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434297_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 SIHO - ALL PLANS SIHO - ALL PLANS 66.6 90 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434297_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 UMR - ALL PLANS UMR - ALL PLANS 51.8 70 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434297_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.81 60.55 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434297_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 50434297_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 ANTHEM HMO ANTHEM HMO 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 50434297_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 50434297_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 50434297_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 50434297_1 CDM 0301 RC 86317 HCPCS inpatient 74 48.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.02 67.6 999999999 44.81 71.78 percent of total billed charges Pregnenolone (reproductive hormone) level 50434298_1 CDM 0301 RC 84140 HCPCS inpatient 475 308.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 308.75 65 999999999 287.61 460.75 percent of total billed charges Pregnenolone (reproductive hormone) level 50434298_1 CDM 0301 RC 84140 HCPCS inpatient 475 308.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 460.75 97 999999999 287.61 460.75 percent of total billed charges Pregnenolone (reproductive hormone) level 50434298_1 CDM 0301 RC 84140 HCPCS inpatient 475 308.75 AETNA AETNA 375.25 79 999999999 287.61 460.75 percent of total billed charges Pregnenolone (reproductive hormone) level 50434298_1 CDM 0301 RC 84140 HCPCS inpatient 475 308.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 370.5 78 999999999 287.61 460.75 percent of total billed charges Pregnenolone (reproductive hormone) level 50434298_1 CDM 0301 RC 84140 HCPCS inpatient 475 308.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 327.75 69 999999999 287.61 460.75 percent of total billed charges Pregnenolone (reproductive hormone) level 50434298_1 CDM 0301 RC 84140 HCPCS inpatient 475 308.75 SIHO - ALL PLANS SIHO - ALL PLANS 427.5 90 999999999 287.61 460.75 percent of total billed charges Pregnenolone (reproductive hormone) level 50434298_1 CDM 0301 RC 84140 HCPCS inpatient 475 308.75 UMR - ALL PLANS UMR - ALL PLANS 332.5 70 999999999 287.61 460.75 percent of total billed charges Pregnenolone (reproductive hormone) level 50434298_1 CDM 0301 RC 84140 HCPCS inpatient 475 308.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 287.61 60.55 999999999 287.61 460.75 percent of total billed charges Pregnenolone (reproductive hormone) level 50434298_1 CDM 0301 RC 84140 HCPCS inpatient 475 308.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 287.61 460.75 Pregnenolone (reproductive hormone) level 50434298_1 CDM 0301 RC 84140 HCPCS inpatient 475 308.75 ANTHEM HMO ANTHEM HMO 999999999 287.61 460.75 Pregnenolone (reproductive hormone) level 50434298_1 CDM 0301 RC 84140 HCPCS inpatient 475 308.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 287.61 460.75 Pregnenolone (reproductive hormone) level 50434298_1 CDM 0301 RC 84140 HCPCS inpatient 475 308.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 287.61 460.75 Pregnenolone (reproductive hormone) level 50434298_1 CDM 0301 RC 84140 HCPCS inpatient 475 308.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 287.61 460.75 Pregnenolone (reproductive hormone) level 50434298_1 CDM 0301 RC 84140 HCPCS inpatient 475 308.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 321.1 67.6 999999999 287.61 460.75 percent of total billed charges Primidone level 50434299_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.9 65 999999999 100.51 161.02 percent of total billed charges Primidone level 50434299_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.02 97 999999999 100.51 161.02 percent of total billed charges Primidone level 50434299_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 AETNA AETNA 131.14 79 999999999 100.51 161.02 percent of total billed charges Primidone level 50434299_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 129.48 78 999999999 100.51 161.02 percent of total billed charges Primidone level 50434299_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 114.54 69 999999999 100.51 161.02 percent of total billed charges Primidone level 50434299_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 SIHO - ALL PLANS SIHO - ALL PLANS 149.4 90 999999999 100.51 161.02 percent of total billed charges Primidone level 50434299_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 UMR - ALL PLANS UMR - ALL PLANS 116.2 70 999999999 100.51 161.02 percent of total billed charges Primidone level 50434299_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 100.51 60.55 999999999 100.51 161.02 percent of total billed charges Primidone level 50434299_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 100.51 161.02 Primidone level 50434299_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 ANTHEM HMO ANTHEM HMO 999999999 100.51 161.02 Primidone level 50434299_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 100.51 161.02 Primidone level 50434299_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 100.51 161.02 Primidone level 50434299_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 100.51 161.02 Primidone level 50434299_1 CDM 0301 RC 80188 HCPCS inpatient 166 107.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.22 67.6 999999999 100.51 161.02 percent of total billed charges Progesterone (reproductive hormone) level 50434300_1 CDM 0301 RC 84144 HCPCS inpatient 288 187.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 187.2 65 999999999 174.38 279.36 percent of total billed charges Progesterone (reproductive hormone) level 50434300_1 CDM 0301 RC 84144 HCPCS inpatient 288 187.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 279.36 97 999999999 174.38 279.36 percent of total billed charges Progesterone (reproductive hormone) level 50434300_1 CDM 0301 RC 84144 HCPCS inpatient 288 187.2 AETNA AETNA 227.52 79 999999999 174.38 279.36 percent of total billed charges Progesterone (reproductive hormone) level 50434300_1 CDM 0301 RC 84144 HCPCS inpatient 288 187.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 224.64 78 999999999 174.38 279.36 percent of total billed charges Progesterone (reproductive hormone) level 50434300_1 CDM 0301 RC 84144 HCPCS inpatient 288 187.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 198.72 69 999999999 174.38 279.36 percent of total billed charges Progesterone (reproductive hormone) level 50434300_1 CDM 0301 RC 84144 HCPCS inpatient 288 187.2 SIHO - ALL PLANS SIHO - ALL PLANS 259.2 90 999999999 174.38 279.36 percent of total billed charges Progesterone (reproductive hormone) level 50434300_1 CDM 0301 RC 84144 HCPCS inpatient 288 187.2 UMR - ALL PLANS UMR - ALL PLANS 201.6 70 999999999 174.38 279.36 percent of total billed charges Progesterone (reproductive hormone) level 50434300_1 CDM 0301 RC 84144 HCPCS inpatient 288 187.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 174.38 60.55 999999999 174.38 279.36 percent of total billed charges Progesterone (reproductive hormone) level 50434300_1 CDM 0301 RC 84144 HCPCS inpatient 288 187.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 174.38 279.36 Progesterone (reproductive hormone) level 50434300_1 CDM 0301 RC 84144 HCPCS inpatient 288 187.2 ANTHEM HMO ANTHEM HMO 999999999 174.38 279.36 Progesterone (reproductive hormone) level 50434300_1 CDM 0301 RC 84144 HCPCS inpatient 288 187.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 174.38 279.36 Progesterone (reproductive hormone) level 50434300_1 CDM 0301 RC 84144 HCPCS inpatient 288 187.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 174.38 279.36 Progesterone (reproductive hormone) level 50434300_1 CDM 0301 RC 84144 HCPCS inpatient 288 187.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 174.38 279.36 Progesterone (reproductive hormone) level 50434300_1 CDM 0301 RC 84144 HCPCS inpatient 288 187.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 194.69 67.6 999999999 174.38 279.36 percent of total billed charges Proinsulin (pancreatic hormone) level 50434301_1 CDM 0301 RC 84206 HCPCS inpatient 260 169 SELF PAY DISCOUNT SELF PAY DISCOUNT 169 65 999999999 157.43 252.2 percent of total billed charges Proinsulin (pancreatic hormone) level 50434301_1 CDM 0301 RC 84206 HCPCS inpatient 260 169 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 252.2 97 999999999 157.43 252.2 percent of total billed charges Proinsulin (pancreatic hormone) level 50434301_1 CDM 0301 RC 84206 HCPCS inpatient 260 169 AETNA AETNA 205.4 79 999999999 157.43 252.2 percent of total billed charges Proinsulin (pancreatic hormone) level 50434301_1 CDM 0301 RC 84206 HCPCS inpatient 260 169 HUMANA - ALL PLANS HUMANA - ALL PLANS 202.8 78 999999999 157.43 252.2 percent of total billed charges Proinsulin (pancreatic hormone) level 50434301_1 CDM 0301 RC 84206 HCPCS inpatient 260 169 ENCORE - ALL PLANS ENCORE - ALL PLANS 179.4 69 999999999 157.43 252.2 percent of total billed charges Proinsulin (pancreatic hormone) level 50434301_1 CDM 0301 RC 84206 HCPCS inpatient 260 169 SIHO - ALL PLANS SIHO - ALL PLANS 234 90 999999999 157.43 252.2 percent of total billed charges Proinsulin (pancreatic hormone) level 50434301_1 CDM 0301 RC 84206 HCPCS inpatient 260 169 UMR - ALL PLANS UMR - ALL PLANS 182 70 999999999 157.43 252.2 percent of total billed charges Proinsulin (pancreatic hormone) level 50434301_1 CDM 0301 RC 84206 HCPCS inpatient 260 169 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 157.43 60.55 999999999 157.43 252.2 percent of total billed charges Proinsulin (pancreatic hormone) level 50434301_1 CDM 0301 RC 84206 HCPCS inpatient 260 169 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 157.43 252.2 Proinsulin (pancreatic hormone) level 50434301_1 CDM 0301 RC 84206 HCPCS inpatient 260 169 ANTHEM HMO ANTHEM HMO 999999999 157.43 252.2 Proinsulin (pancreatic hormone) level 50434301_1 CDM 0301 RC 84206 HCPCS inpatient 260 169 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 157.43 252.2 Proinsulin (pancreatic hormone) level 50434301_1 CDM 0301 RC 84206 HCPCS inpatient 260 169 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 157.43 252.2 Proinsulin (pancreatic hormone) level 50434301_1 CDM 0301 RC 84206 HCPCS inpatient 260 169 UHC - ALL PLANS UHC - ALL PLANS 999999999 157.43 252.2 Proinsulin (pancreatic hormone) level 50434301_1 CDM 0301 RC 84206 HCPCS inpatient 260 169 CIGNA - ALL PLANS CIGNA - ALL PLANS 175.76 67.6 999999999 157.43 252.2 percent of total billed charges Measurement of proteins associated with prostate cancer 50434302_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1327.95 65 999999999 1237.04 1981.71 percent of total billed charges Measurement of proteins associated with prostate cancer 50434302_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1981.71 97 999999999 1237.04 1981.71 percent of total billed charges Measurement of proteins associated with prostate cancer 50434302_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 AETNA AETNA 1613.97 79 999999999 1237.04 1981.71 percent of total billed charges Measurement of proteins associated with prostate cancer 50434302_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1593.54 78 999999999 1237.04 1981.71 percent of total billed charges Measurement of proteins associated with prostate cancer 50434302_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1409.67 69 999999999 1237.04 1981.71 percent of total billed charges Measurement of proteins associated with prostate cancer 50434302_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 SIHO - ALL PLANS SIHO - ALL PLANS 1838.7 90 999999999 1237.04 1981.71 percent of total billed charges Measurement of proteins associated with prostate cancer 50434302_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 UMR - ALL PLANS UMR - ALL PLANS 1430.1 70 999999999 1237.04 1981.71 percent of total billed charges Measurement of proteins associated with prostate cancer 50434302_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1237.04 60.55 999999999 1237.04 1981.71 percent of total billed charges Measurement of proteins associated with prostate cancer 50434302_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1237.04 1981.71 Measurement of proteins associated with prostate cancer 50434302_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 ANTHEM HMO ANTHEM HMO 999999999 1237.04 1981.71 Measurement of proteins associated with prostate cancer 50434302_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1237.04 1981.71 Measurement of proteins associated with prostate cancer 50434302_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1237.04 1981.71 Measurement of proteins associated with prostate cancer 50434302_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1237.04 1981.71 Measurement of proteins associated with prostate cancer 50434302_1 CDM 0301 RC 81539 HCPCS inpatient 2043 1327.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1381.07 67.6 999999999 1237.04 1981.71 percent of total billed charges "Phosphatase (enzyme) measurement, acid, total" 50434303_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 193.05 65 999999999 179.83 288.09 percent of total billed charges "Phosphatase (enzyme) measurement, acid, total" 50434303_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 288.09 97 999999999 179.83 288.09 percent of total billed charges "Phosphatase (enzyme) measurement, acid, total" 50434303_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 AETNA AETNA 234.63 79 999999999 179.83 288.09 percent of total billed charges "Phosphatase (enzyme) measurement, acid, total" 50434303_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 231.66 78 999999999 179.83 288.09 percent of total billed charges "Phosphatase (enzyme) measurement, acid, total" 50434303_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 204.93 69 999999999 179.83 288.09 percent of total billed charges "Phosphatase (enzyme) measurement, acid, total" 50434303_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 SIHO - ALL PLANS SIHO - ALL PLANS 267.3 90 999999999 179.83 288.09 percent of total billed charges "Phosphatase (enzyme) measurement, acid, total" 50434303_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 UMR - ALL PLANS UMR - ALL PLANS 207.9 70 999999999 179.83 288.09 percent of total billed charges "Phosphatase (enzyme) measurement, acid, total" 50434303_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 179.83 60.55 999999999 179.83 288.09 percent of total billed charges "Phosphatase (enzyme) measurement, acid, total" 50434303_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 179.83 288.09 "Phosphatase (enzyme) measurement, acid, total" 50434303_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 ANTHEM HMO ANTHEM HMO 999999999 179.83 288.09 "Phosphatase (enzyme) measurement, acid, total" 50434303_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 179.83 288.09 "Phosphatase (enzyme) measurement, acid, total" 50434303_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 179.83 288.09 "Phosphatase (enzyme) measurement, acid, total" 50434303_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 179.83 288.09 "Phosphatase (enzyme) measurement, acid, total" 50434303_1 CDM 0301 RC 84060 HCPCS inpatient 297 193.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 200.77 67.6 999999999 179.83 288.09 percent of total billed charges "Protein C, (clotting inhibitor) activity" 50434304_1 CDM 0301 RC 85302 HCPCS inpatient 342 222.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 222.3 65 999999999 207.08 331.74 percent of total billed charges "Protein C, (clotting inhibitor) activity" 50434304_1 CDM 0301 RC 85302 HCPCS inpatient 342 222.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 331.74 97 999999999 207.08 331.74 percent of total billed charges "Protein C, (clotting inhibitor) activity" 50434304_1 CDM 0301 RC 85302 HCPCS inpatient 342 222.3 AETNA AETNA 270.18 79 999999999 207.08 331.74 percent of total billed charges "Protein C, (clotting inhibitor) activity" 50434304_1 CDM 0301 RC 85302 HCPCS inpatient 342 222.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 266.76 78 999999999 207.08 331.74 percent of total billed charges "Protein C, (clotting inhibitor) activity" 50434304_1 CDM 0301 RC 85302 HCPCS inpatient 342 222.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 235.98 69 999999999 207.08 331.74 percent of total billed charges "Protein C, (clotting inhibitor) activity" 50434304_1 CDM 0301 RC 85302 HCPCS inpatient 342 222.3 SIHO - ALL PLANS SIHO - ALL PLANS 307.8 90 999999999 207.08 331.74 percent of total billed charges "Protein C, (clotting inhibitor) activity" 50434304_1 CDM 0301 RC 85302 HCPCS inpatient 342 222.3 UMR - ALL PLANS UMR - ALL PLANS 239.4 70 999999999 207.08 331.74 percent of total billed charges "Protein C, (clotting inhibitor) activity" 50434304_1 CDM 0301 RC 85302 HCPCS inpatient 342 222.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 207.08 60.55 999999999 207.08 331.74 percent of total billed charges "Protein C, (clotting inhibitor) activity" 50434304_1 CDM 0301 RC 85302 HCPCS inpatient 342 222.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 207.08 331.74 "Protein C, (clotting inhibitor) activity" 50434304_1 CDM 0301 RC 85302 HCPCS inpatient 342 222.3 ANTHEM HMO ANTHEM HMO 999999999 207.08 331.74 "Protein C, (clotting inhibitor) activity" 50434304_1 CDM 0301 RC 85302 HCPCS inpatient 342 222.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 207.08 331.74 "Protein C, (clotting inhibitor) activity" 50434304_1 CDM 0301 RC 85302 HCPCS inpatient 342 222.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 207.08 331.74 "Protein C, (clotting inhibitor) activity" 50434304_1 CDM 0301 RC 85302 HCPCS inpatient 342 222.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 207.08 331.74 "Protein C, (clotting inhibitor) activity" 50434304_1 CDM 0301 RC 85302 HCPCS inpatient 342 222.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 231.19 67.6 999999999 207.08 331.74 percent of total billed charges "Total protein level, blood" 50434305_1 CDM 0301 RC 84155 HCPCS inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges "Total protein level, blood" 50434305_1 CDM 0301 RC 84155 HCPCS inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges "Total protein level, blood" 50434305_1 CDM 0301 RC 84155 HCPCS inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges "Total protein level, blood" 50434305_1 CDM 0301 RC 84155 HCPCS inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges "Total protein level, blood" 50434305_1 CDM 0301 RC 84155 HCPCS inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges "Total protein level, blood" 50434305_1 CDM 0301 RC 84155 HCPCS inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges "Total protein level, blood" 50434305_1 CDM 0301 RC 84155 HCPCS inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges "Total protein level, blood" 50434305_1 CDM 0301 RC 84155 HCPCS inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges "Total protein level, blood" 50434305_1 CDM 0301 RC 84155 HCPCS inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 "Total protein level, blood" 50434305_1 CDM 0301 RC 84155 HCPCS inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 "Total protein level, blood" 50434305_1 CDM 0301 RC 84155 HCPCS inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 "Total protein level, blood" 50434305_1 CDM 0301 RC 84155 HCPCS inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 "Total protein level, blood" 50434305_1 CDM 0301 RC 84155 HCPCS inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 "Total protein level, blood" 50434305_1 CDM 0301 RC 84155 HCPCS inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges "Protein measurement, body fluid" 50434306_1 CDM 0301 RC 84166 HCPCS inpatient 144 93.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 93.6 65 999999999 87.19 139.68 percent of total billed charges "Protein measurement, body fluid" 50434306_1 CDM 0301 RC 84166 HCPCS inpatient 144 93.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 139.68 97 999999999 87.19 139.68 percent of total billed charges "Protein measurement, body fluid" 50434306_1 CDM 0301 RC 84166 HCPCS inpatient 144 93.6 AETNA AETNA 113.76 79 999999999 87.19 139.68 percent of total billed charges "Protein measurement, body fluid" 50434306_1 CDM 0301 RC 84166 HCPCS inpatient 144 93.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 112.32 78 999999999 87.19 139.68 percent of total billed charges "Protein measurement, body fluid" 50434306_1 CDM 0301 RC 84166 HCPCS inpatient 144 93.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 99.36 69 999999999 87.19 139.68 percent of total billed charges "Protein measurement, body fluid" 50434306_1 CDM 0301 RC 84166 HCPCS inpatient 144 93.6 SIHO - ALL PLANS SIHO - ALL PLANS 129.6 90 999999999 87.19 139.68 percent of total billed charges "Protein measurement, body fluid" 50434306_1 CDM 0301 RC 84166 HCPCS inpatient 144 93.6 UMR - ALL PLANS UMR - ALL PLANS 100.8 70 999999999 87.19 139.68 percent of total billed charges "Protein measurement, body fluid" 50434306_1 CDM 0301 RC 84166 HCPCS inpatient 144 93.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.19 60.55 999999999 87.19 139.68 percent of total billed charges "Protein measurement, body fluid" 50434306_1 CDM 0301 RC 84166 HCPCS inpatient 144 93.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.19 139.68 "Protein measurement, body fluid" 50434306_1 CDM 0301 RC 84166 HCPCS inpatient 144 93.6 ANTHEM HMO ANTHEM HMO 999999999 87.19 139.68 "Protein measurement, body fluid" 50434306_1 CDM 0301 RC 84166 HCPCS inpatient 144 93.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.19 139.68 "Protein measurement, body fluid" 50434306_1 CDM 0301 RC 84166 HCPCS inpatient 144 93.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.19 139.68 "Protein measurement, body fluid" 50434306_1 CDM 0301 RC 84166 HCPCS inpatient 144 93.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.19 139.68 "Protein measurement, body fluid" 50434306_1 CDM 0301 RC 84166 HCPCS inpatient 144 93.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 97.34 67.6 999999999 87.19 139.68 percent of total billed charges "Electrophoresis, laboratory testing technique" 50434307_1 CDM 0301 RC 82664 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges "Electrophoresis, laboratory testing technique" 50434307_1 CDM 0301 RC 82664 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges "Electrophoresis, laboratory testing technique" 50434307_1 CDM 0301 RC 82664 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges "Electrophoresis, laboratory testing technique" 50434307_1 CDM 0301 RC 82664 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges "Electrophoresis, laboratory testing technique" 50434307_1 CDM 0301 RC 82664 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges "Electrophoresis, laboratory testing technique" 50434307_1 CDM 0301 RC 82664 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges "Electrophoresis, laboratory testing technique" 50434307_1 CDM 0301 RC 82664 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges "Electrophoresis, laboratory testing technique" 50434307_1 CDM 0301 RC 82664 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges "Electrophoresis, laboratory testing technique" 50434307_1 CDM 0301 RC 82664 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 "Electrophoresis, laboratory testing technique" 50434307_1 CDM 0301 RC 82664 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 "Electrophoresis, laboratory testing technique" 50434307_1 CDM 0301 RC 82664 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 "Electrophoresis, laboratory testing technique" 50434307_1 CDM 0301 RC 82664 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 "Electrophoresis, laboratory testing technique" 50434307_1 CDM 0301 RC 82664 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 "Electrophoresis, laboratory testing technique" 50434307_1 CDM 0301 RC 82664 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges Protein S (clotting inhibitor) level 50434308_1 CDM 0301 RC 85305 HCPCS inpatient 347 225.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 225.55 65 999999999 210.11 336.59 percent of total billed charges Protein S (clotting inhibitor) level 50434308_1 CDM 0301 RC 85305 HCPCS inpatient 347 225.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 336.59 97 999999999 210.11 336.59 percent of total billed charges Protein S (clotting inhibitor) level 50434308_1 CDM 0301 RC 85305 HCPCS inpatient 347 225.55 AETNA AETNA 274.13 79 999999999 210.11 336.59 percent of total billed charges Protein S (clotting inhibitor) level 50434308_1 CDM 0301 RC 85305 HCPCS inpatient 347 225.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 270.66 78 999999999 210.11 336.59 percent of total billed charges Protein S (clotting inhibitor) level 50434308_1 CDM 0301 RC 85305 HCPCS inpatient 347 225.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 239.43 69 999999999 210.11 336.59 percent of total billed charges Protein S (clotting inhibitor) level 50434308_1 CDM 0301 RC 85305 HCPCS inpatient 347 225.55 SIHO - ALL PLANS SIHO - ALL PLANS 312.3 90 999999999 210.11 336.59 percent of total billed charges Protein S (clotting inhibitor) level 50434308_1 CDM 0301 RC 85305 HCPCS inpatient 347 225.55 UMR - ALL PLANS UMR - ALL PLANS 242.9 70 999999999 210.11 336.59 percent of total billed charges Protein S (clotting inhibitor) level 50434308_1 CDM 0301 RC 85305 HCPCS inpatient 347 225.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 210.11 60.55 999999999 210.11 336.59 percent of total billed charges Protein S (clotting inhibitor) level 50434308_1 CDM 0301 RC 85305 HCPCS inpatient 347 225.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 210.11 336.59 Protein S (clotting inhibitor) level 50434308_1 CDM 0301 RC 85305 HCPCS inpatient 347 225.55 ANTHEM HMO ANTHEM HMO 999999999 210.11 336.59 Protein S (clotting inhibitor) level 50434308_1 CDM 0301 RC 85305 HCPCS inpatient 347 225.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 210.11 336.59 Protein S (clotting inhibitor) level 50434308_1 CDM 0301 RC 85305 HCPCS inpatient 347 225.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 210.11 336.59 Protein S (clotting inhibitor) level 50434308_1 CDM 0301 RC 85305 HCPCS inpatient 347 225.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 210.11 336.59 Protein S (clotting inhibitor) level 50434308_1 CDM 0301 RC 85305 HCPCS inpatient 347 225.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 234.57 67.6 999999999 210.11 336.59 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 50434309_1 CDM 0301 RC 84154 HCPCS inpatient 288 187.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 187.2 65 999999999 174.38 279.36 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 50434309_1 CDM 0301 RC 84154 HCPCS inpatient 288 187.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 279.36 97 999999999 174.38 279.36 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 50434309_1 CDM 0301 RC 84154 HCPCS inpatient 288 187.2 AETNA AETNA 227.52 79 999999999 174.38 279.36 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 50434309_1 CDM 0301 RC 84154 HCPCS inpatient 288 187.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 224.64 78 999999999 174.38 279.36 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 50434309_1 CDM 0301 RC 84154 HCPCS inpatient 288 187.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 198.72 69 999999999 174.38 279.36 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 50434309_1 CDM 0301 RC 84154 HCPCS inpatient 288 187.2 SIHO - ALL PLANS SIHO - ALL PLANS 259.2 90 999999999 174.38 279.36 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 50434309_1 CDM 0301 RC 84154 HCPCS inpatient 288 187.2 UMR - ALL PLANS UMR - ALL PLANS 201.6 70 999999999 174.38 279.36 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 50434309_1 CDM 0301 RC 84154 HCPCS inpatient 288 187.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 174.38 60.55 999999999 174.38 279.36 percent of total billed charges "PSA (prostate specific antigen) measurement, free" 50434309_1 CDM 0301 RC 84154 HCPCS inpatient 288 187.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 174.38 279.36 "PSA (prostate specific antigen) measurement, free" 50434309_1 CDM 0301 RC 84154 HCPCS inpatient 288 187.2 ANTHEM HMO ANTHEM HMO 999999999 174.38 279.36 "PSA (prostate specific antigen) measurement, free" 50434309_1 CDM 0301 RC 84154 HCPCS inpatient 288 187.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 174.38 279.36 "PSA (prostate specific antigen) measurement, free" 50434309_1 CDM 0301 RC 84154 HCPCS inpatient 288 187.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 174.38 279.36 "PSA (prostate specific antigen) measurement, free" 50434309_1 CDM 0301 RC 84154 HCPCS inpatient 288 187.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 174.38 279.36 "PSA (prostate specific antigen) measurement, free" 50434309_1 CDM 0301 RC 84154 HCPCS inpatient 288 187.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 194.69 67.6 999999999 174.38 279.36 percent of total billed charges "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 50434310_1 CDM 0301 RC 82480 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 50434310_1 CDM 0301 RC 82480 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 50434310_1 CDM 0301 RC 82480 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 50434310_1 CDM 0301 RC 82480 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 50434310_1 CDM 0301 RC 82480 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 50434310_1 CDM 0301 RC 82480 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 50434310_1 CDM 0301 RC 82480 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 50434310_1 CDM 0301 RC 82480 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 50434310_1 CDM 0301 RC 82480 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 50434310_1 CDM 0301 RC 82480 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 50434310_1 CDM 0301 RC 82480 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 50434310_1 CDM 0301 RC 82480 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 50434310_1 CDM 0301 RC 82480 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 "Cholinesterase (enzyme) level, to test for exposure to chemical or liver disease" 50434310_1 CDM 0301 RC 82480 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges "Gene analysis (prothrombin, coagulation factor II) A variant" 50434311_1 CDM 0301 RC 81240 HCPCS inpatient 560 364 SELF PAY DISCOUNT SELF PAY DISCOUNT 364 65 999999999 339.08 543.2 percent of total billed charges "Gene analysis (prothrombin, coagulation factor II) A variant" 50434311_1 CDM 0301 RC 81240 HCPCS inpatient 560 364 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 543.2 97 999999999 339.08 543.2 percent of total billed charges "Gene analysis (prothrombin, coagulation factor II) A variant" 50434311_1 CDM 0301 RC 81240 HCPCS inpatient 560 364 AETNA AETNA 442.4 79 999999999 339.08 543.2 percent of total billed charges "Gene analysis (prothrombin, coagulation factor II) A variant" 50434311_1 CDM 0301 RC 81240 HCPCS inpatient 560 364 HUMANA - ALL PLANS HUMANA - ALL PLANS 436.8 78 999999999 339.08 543.2 percent of total billed charges "Gene analysis (prothrombin, coagulation factor II) A variant" 50434311_1 CDM 0301 RC 81240 HCPCS inpatient 560 364 ENCORE - ALL PLANS ENCORE - ALL PLANS 386.4 69 999999999 339.08 543.2 percent of total billed charges "Gene analysis (prothrombin, coagulation factor II) A variant" 50434311_1 CDM 0301 RC 81240 HCPCS inpatient 560 364 SIHO - ALL PLANS SIHO - ALL PLANS 504 90 999999999 339.08 543.2 percent of total billed charges "Gene analysis (prothrombin, coagulation factor II) A variant" 50434311_1 CDM 0301 RC 81240 HCPCS inpatient 560 364 UMR - ALL PLANS UMR - ALL PLANS 392 70 999999999 339.08 543.2 percent of total billed charges "Gene analysis (prothrombin, coagulation factor II) A variant" 50434311_1 CDM 0301 RC 81240 HCPCS inpatient 560 364 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 339.08 60.55 999999999 339.08 543.2 percent of total billed charges "Gene analysis (prothrombin, coagulation factor II) A variant" 50434311_1 CDM 0301 RC 81240 HCPCS inpatient 560 364 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 339.08 543.2 "Gene analysis (prothrombin, coagulation factor II) A variant" 50434311_1 CDM 0301 RC 81240 HCPCS inpatient 560 364 ANTHEM HMO ANTHEM HMO 999999999 339.08 543.2 "Gene analysis (prothrombin, coagulation factor II) A variant" 50434311_1 CDM 0301 RC 81240 HCPCS inpatient 560 364 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 339.08 543.2 "Gene analysis (prothrombin, coagulation factor II) A variant" 50434311_1 CDM 0301 RC 81240 HCPCS inpatient 560 364 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 339.08 543.2 "Gene analysis (prothrombin, coagulation factor II) A variant" 50434311_1 CDM 0301 RC 81240 HCPCS inpatient 560 364 UHC - ALL PLANS UHC - ALL PLANS 999999999 339.08 543.2 "Gene analysis (prothrombin, coagulation factor II) A variant" 50434311_1 CDM 0301 RC 81240 HCPCS inpatient 560 364 CIGNA - ALL PLANS CIGNA - ALL PLANS 378.56 67.6 999999999 339.08 543.2 percent of total billed charges Estriol (hormone) level 50434312_1 CDM 0301 RC 82677 HCPCS inpatient 194 126.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 126.1 65 999999999 117.47 188.18 percent of total billed charges Estriol (hormone) level 50434312_1 CDM 0301 RC 82677 HCPCS inpatient 194 126.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 188.18 97 999999999 117.47 188.18 percent of total billed charges Estriol (hormone) level 50434312_1 CDM 0301 RC 82677 HCPCS inpatient 194 126.1 AETNA AETNA 153.26 79 999999999 117.47 188.18 percent of total billed charges Estriol (hormone) level 50434312_1 CDM 0301 RC 82677 HCPCS inpatient 194 126.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 151.32 78 999999999 117.47 188.18 percent of total billed charges Estriol (hormone) level 50434312_1 CDM 0301 RC 82677 HCPCS inpatient 194 126.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.86 69 999999999 117.47 188.18 percent of total billed charges Estriol (hormone) level 50434312_1 CDM 0301 RC 82677 HCPCS inpatient 194 126.1 SIHO - ALL PLANS SIHO - ALL PLANS 174.6 90 999999999 117.47 188.18 percent of total billed charges Estriol (hormone) level 50434312_1 CDM 0301 RC 82677 HCPCS inpatient 194 126.1 UMR - ALL PLANS UMR - ALL PLANS 135.8 70 999999999 117.47 188.18 percent of total billed charges Estriol (hormone) level 50434312_1 CDM 0301 RC 82677 HCPCS inpatient 194 126.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 117.47 60.55 999999999 117.47 188.18 percent of total billed charges Estriol (hormone) level 50434312_1 CDM 0301 RC 82677 HCPCS inpatient 194 126.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 117.47 188.18 Estriol (hormone) level 50434312_1 CDM 0301 RC 82677 HCPCS inpatient 194 126.1 ANTHEM HMO ANTHEM HMO 999999999 117.47 188.18 Estriol (hormone) level 50434312_1 CDM 0301 RC 82677 HCPCS inpatient 194 126.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 117.47 188.18 Estriol (hormone) level 50434312_1 CDM 0301 RC 82677 HCPCS inpatient 194 126.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 117.47 188.18 Estriol (hormone) level 50434312_1 CDM 0301 RC 82677 HCPCS inpatient 194 126.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 117.47 188.18 Estriol (hormone) level 50434312_1 CDM 0301 RC 82677 HCPCS inpatient 194 126.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 131.14 67.6 999999999 117.47 188.18 percent of total billed charges "Tuberculosis test, gamma interferon" 50434313_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges "Tuberculosis test, gamma interferon" 50434313_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges "Tuberculosis test, gamma interferon" 50434313_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges "Tuberculosis test, gamma interferon" 50434313_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges "Tuberculosis test, gamma interferon" 50434313_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges "Tuberculosis test, gamma interferon" 50434313_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges "Tuberculosis test, gamma interferon" 50434313_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges "Tuberculosis test, gamma interferon" 50434313_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges "Tuberculosis test, gamma interferon" 50434313_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 "Tuberculosis test, gamma interferon" 50434313_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 "Tuberculosis test, gamma interferon" 50434313_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 "Tuberculosis test, gamma interferon" 50434313_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 "Tuberculosis test, gamma interferon" 50434313_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 "Tuberculosis test, gamma interferon" 50434313_1 CDM 0302 RC 86480 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges Renin (kidney enzyme) level 50434314_1 CDM 0301 RC 84244 HCPCS inpatient 398 258.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 258.7 65 999999999 240.99 386.06 percent of total billed charges Renin (kidney enzyme) level 50434314_1 CDM 0301 RC 84244 HCPCS inpatient 398 258.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 386.06 97 999999999 240.99 386.06 percent of total billed charges Renin (kidney enzyme) level 50434314_1 CDM 0301 RC 84244 HCPCS inpatient 398 258.7 AETNA AETNA 314.42 79 999999999 240.99 386.06 percent of total billed charges Renin (kidney enzyme) level 50434314_1 CDM 0301 RC 84244 HCPCS inpatient 398 258.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 310.44 78 999999999 240.99 386.06 percent of total billed charges Renin (kidney enzyme) level 50434314_1 CDM 0301 RC 84244 HCPCS inpatient 398 258.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 274.62 69 999999999 240.99 386.06 percent of total billed charges Renin (kidney enzyme) level 50434314_1 CDM 0301 RC 84244 HCPCS inpatient 398 258.7 SIHO - ALL PLANS SIHO - ALL PLANS 358.2 90 999999999 240.99 386.06 percent of total billed charges Renin (kidney enzyme) level 50434314_1 CDM 0301 RC 84244 HCPCS inpatient 398 258.7 UMR - ALL PLANS UMR - ALL PLANS 278.6 70 999999999 240.99 386.06 percent of total billed charges Renin (kidney enzyme) level 50434314_1 CDM 0301 RC 84244 HCPCS inpatient 398 258.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 240.99 60.55 999999999 240.99 386.06 percent of total billed charges Renin (kidney enzyme) level 50434314_1 CDM 0301 RC 84244 HCPCS inpatient 398 258.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 240.99 386.06 Renin (kidney enzyme) level 50434314_1 CDM 0301 RC 84244 HCPCS inpatient 398 258.7 ANTHEM HMO ANTHEM HMO 999999999 240.99 386.06 Renin (kidney enzyme) level 50434314_1 CDM 0301 RC 84244 HCPCS inpatient 398 258.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 240.99 386.06 Renin (kidney enzyme) level 50434314_1 CDM 0301 RC 84244 HCPCS inpatient 398 258.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 240.99 386.06 Renin (kidney enzyme) level 50434314_1 CDM 0301 RC 84244 HCPCS inpatient 398 258.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 240.99 386.06 Renin (kidney enzyme) level 50434314_1 CDM 0301 RC 84244 HCPCS inpatient 398 258.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 269.05 67.6 999999999 240.99 386.06 percent of total billed charges "Antipsychotics levels, 1-3" 50434315_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges "Antipsychotics levels, 1-3" 50434315_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges "Antipsychotics levels, 1-3" 50434315_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges "Antipsychotics levels, 1-3" 50434315_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges "Antipsychotics levels, 1-3" 50434315_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges "Antipsychotics levels, 1-3" 50434315_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges "Antipsychotics levels, 1-3" 50434315_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges "Antipsychotics levels, 1-3" 50434315_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges "Antipsychotics levels, 1-3" 50434315_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 "Antipsychotics levels, 1-3" 50434315_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 "Antipsychotics levels, 1-3" 50434315_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 "Antipsychotics levels, 1-3" 50434315_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 "Antipsychotics levels, 1-3" 50434315_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 "Antipsychotics levels, 1-3" 50434315_1 CDM 0301 RC 80342 HCPCS inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 50434316_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 50434316_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 50434316_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 50434316_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 50434316_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 50434316_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 50434316_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 50434316_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 50434316_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 Analysis for antibody to Rickettsia (bacteria) 50434316_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 Analysis for antibody to Rickettsia (bacteria) 50434316_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 Analysis for antibody to Rickettsia (bacteria) 50434316_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 Analysis for antibody to Rickettsia (bacteria) 50434316_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 Analysis for antibody to Rickettsia (bacteria) 50434316_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434317_1 CDM 0302 RC 86317 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434317_1 CDM 0302 RC 86317 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434317_1 CDM 0302 RC 86317 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434317_1 CDM 0302 RC 86317 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434317_1 CDM 0302 RC 86317 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434317_1 CDM 0302 RC 86317 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434317_1 CDM 0302 RC 86317 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434317_1 CDM 0302 RC 86317 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434317_1 CDM 0302 RC 86317 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 "Detection of infectious agent antibody, quantitative" 50434317_1 CDM 0302 RC 86317 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 "Detection of infectious agent antibody, quantitative" 50434317_1 CDM 0302 RC 86317 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 "Detection of infectious agent antibody, quantitative" 50434317_1 CDM 0302 RC 86317 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 "Detection of infectious agent antibody, quantitative" 50434317_1 CDM 0302 RC 86317 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 "Detection of infectious agent antibody, quantitative" 50434317_1 CDM 0302 RC 86317 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Selenium (vitamin) level 50434318_1 CDM 0301 RC 84255 HCPCS inpatient 196 127.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 127.4 65 999999999 118.68 190.12 percent of total billed charges Selenium (vitamin) level 50434318_1 CDM 0301 RC 84255 HCPCS inpatient 196 127.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 190.12 97 999999999 118.68 190.12 percent of total billed charges Selenium (vitamin) level 50434318_1 CDM 0301 RC 84255 HCPCS inpatient 196 127.4 AETNA AETNA 154.84 79 999999999 118.68 190.12 percent of total billed charges Selenium (vitamin) level 50434318_1 CDM 0301 RC 84255 HCPCS inpatient 196 127.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 152.88 78 999999999 118.68 190.12 percent of total billed charges Selenium (vitamin) level 50434318_1 CDM 0301 RC 84255 HCPCS inpatient 196 127.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 135.24 69 999999999 118.68 190.12 percent of total billed charges Selenium (vitamin) level 50434318_1 CDM 0301 RC 84255 HCPCS inpatient 196 127.4 SIHO - ALL PLANS SIHO - ALL PLANS 176.4 90 999999999 118.68 190.12 percent of total billed charges Selenium (vitamin) level 50434318_1 CDM 0301 RC 84255 HCPCS inpatient 196 127.4 UMR - ALL PLANS UMR - ALL PLANS 137.2 70 999999999 118.68 190.12 percent of total billed charges Selenium (vitamin) level 50434318_1 CDM 0301 RC 84255 HCPCS inpatient 196 127.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 118.68 60.55 999999999 118.68 190.12 percent of total billed charges Selenium (vitamin) level 50434318_1 CDM 0301 RC 84255 HCPCS inpatient 196 127.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 118.68 190.12 Selenium (vitamin) level 50434318_1 CDM 0301 RC 84255 HCPCS inpatient 196 127.4 ANTHEM HMO ANTHEM HMO 999999999 118.68 190.12 Selenium (vitamin) level 50434318_1 CDM 0301 RC 84255 HCPCS inpatient 196 127.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 118.68 190.12 Selenium (vitamin) level 50434318_1 CDM 0301 RC 84255 HCPCS inpatient 196 127.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 118.68 190.12 Selenium (vitamin) level 50434318_1 CDM 0301 RC 84255 HCPCS inpatient 196 127.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 118.68 190.12 Selenium (vitamin) level 50434318_1 CDM 0301 RC 84255 HCPCS inpatient 196 127.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 132.5 67.6 999999999 118.68 190.12 percent of total billed charges Serotonin (hormone) level 50434319_1 CDM 0301 RC 84260 HCPCS inpatient 308 200.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 200.2 65 999999999 186.49 298.76 percent of total billed charges Serotonin (hormone) level 50434319_1 CDM 0301 RC 84260 HCPCS inpatient 308 200.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 298.76 97 999999999 186.49 298.76 percent of total billed charges Serotonin (hormone) level 50434319_1 CDM 0301 RC 84260 HCPCS inpatient 308 200.2 AETNA AETNA 243.32 79 999999999 186.49 298.76 percent of total billed charges Serotonin (hormone) level 50434319_1 CDM 0301 RC 84260 HCPCS inpatient 308 200.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 240.24 78 999999999 186.49 298.76 percent of total billed charges Serotonin (hormone) level 50434319_1 CDM 0301 RC 84260 HCPCS inpatient 308 200.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 212.52 69 999999999 186.49 298.76 percent of total billed charges Serotonin (hormone) level 50434319_1 CDM 0301 RC 84260 HCPCS inpatient 308 200.2 SIHO - ALL PLANS SIHO - ALL PLANS 277.2 90 999999999 186.49 298.76 percent of total billed charges Serotonin (hormone) level 50434319_1 CDM 0301 RC 84260 HCPCS inpatient 308 200.2 UMR - ALL PLANS UMR - ALL PLANS 215.6 70 999999999 186.49 298.76 percent of total billed charges Serotonin (hormone) level 50434319_1 CDM 0301 RC 84260 HCPCS inpatient 308 200.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 186.49 60.55 999999999 186.49 298.76 percent of total billed charges Serotonin (hormone) level 50434319_1 CDM 0301 RC 84260 HCPCS inpatient 308 200.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 186.49 298.76 Serotonin (hormone) level 50434319_1 CDM 0301 RC 84260 HCPCS inpatient 308 200.2 ANTHEM HMO ANTHEM HMO 999999999 186.49 298.76 Serotonin (hormone) level 50434319_1 CDM 0301 RC 84260 HCPCS inpatient 308 200.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 186.49 298.76 Serotonin (hormone) level 50434319_1 CDM 0301 RC 84260 HCPCS inpatient 308 200.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 186.49 298.76 Serotonin (hormone) level 50434319_1 CDM 0301 RC 84260 HCPCS inpatient 308 200.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 186.49 298.76 Serotonin (hormone) level 50434319_1 CDM 0301 RC 84260 HCPCS inpatient 308 200.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 208.21 67.6 999999999 186.49 298.76 percent of total billed charges Sex hormone binding globulin (protein) level 50434320_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.4 65 999999999 94.46 151.32 percent of total billed charges Sex hormone binding globulin (protein) level 50434320_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 151.32 97 999999999 94.46 151.32 percent of total billed charges Sex hormone binding globulin (protein) level 50434320_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 AETNA AETNA 123.24 79 999999999 94.46 151.32 percent of total billed charges Sex hormone binding globulin (protein) level 50434320_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.68 78 999999999 94.46 151.32 percent of total billed charges Sex hormone binding globulin (protein) level 50434320_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.64 69 999999999 94.46 151.32 percent of total billed charges Sex hormone binding globulin (protein) level 50434320_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 SIHO - ALL PLANS SIHO - ALL PLANS 140.4 90 999999999 94.46 151.32 percent of total billed charges Sex hormone binding globulin (protein) level 50434320_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 UMR - ALL PLANS UMR - ALL PLANS 109.2 70 999999999 94.46 151.32 percent of total billed charges Sex hormone binding globulin (protein) level 50434320_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.46 60.55 999999999 94.46 151.32 percent of total billed charges Sex hormone binding globulin (protein) level 50434320_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.46 151.32 Sex hormone binding globulin (protein) level 50434320_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 ANTHEM HMO ANTHEM HMO 999999999 94.46 151.32 Sex hormone binding globulin (protein) level 50434320_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.46 151.32 Sex hormone binding globulin (protein) level 50434320_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.46 151.32 Sex hormone binding globulin (protein) level 50434320_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.46 151.32 Sex hormone binding globulin (protein) level 50434320_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.46 67.6 999999999 94.46 151.32 percent of total billed charges Sirolimus level 50434321_1 CDM 0301 RC 80195 HCPCS inpatient 231 150.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 150.15 65 999999999 139.87 224.07 percent of total billed charges Sirolimus level 50434321_1 CDM 0301 RC 80195 HCPCS inpatient 231 150.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 224.07 97 999999999 139.87 224.07 percent of total billed charges Sirolimus level 50434321_1 CDM 0301 RC 80195 HCPCS inpatient 231 150.15 AETNA AETNA 182.49 79 999999999 139.87 224.07 percent of total billed charges Sirolimus level 50434321_1 CDM 0301 RC 80195 HCPCS inpatient 231 150.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 180.18 78 999999999 139.87 224.07 percent of total billed charges Sirolimus level 50434321_1 CDM 0301 RC 80195 HCPCS inpatient 231 150.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 159.39 69 999999999 139.87 224.07 percent of total billed charges Sirolimus level 50434321_1 CDM 0301 RC 80195 HCPCS inpatient 231 150.15 SIHO - ALL PLANS SIHO - ALL PLANS 207.9 90 999999999 139.87 224.07 percent of total billed charges Sirolimus level 50434321_1 CDM 0301 RC 80195 HCPCS inpatient 231 150.15 UMR - ALL PLANS UMR - ALL PLANS 161.7 70 999999999 139.87 224.07 percent of total billed charges Sirolimus level 50434321_1 CDM 0301 RC 80195 HCPCS inpatient 231 150.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 139.87 60.55 999999999 139.87 224.07 percent of total billed charges Sirolimus level 50434321_1 CDM 0301 RC 80195 HCPCS inpatient 231 150.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 139.87 224.07 Sirolimus level 50434321_1 CDM 0301 RC 80195 HCPCS inpatient 231 150.15 ANTHEM HMO ANTHEM HMO 999999999 139.87 224.07 Sirolimus level 50434321_1 CDM 0301 RC 80195 HCPCS inpatient 231 150.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 139.87 224.07 Sirolimus level 50434321_1 CDM 0301 RC 80195 HCPCS inpatient 231 150.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 139.87 224.07 Sirolimus level 50434321_1 CDM 0301 RC 80195 HCPCS inpatient 231 150.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 139.87 224.07 Sirolimus level 50434321_1 CDM 0301 RC 80195 HCPCS inpatient 231 150.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 156.16 67.6 999999999 139.87 224.07 percent of total billed charges Chemical receptor analysis 50434322_1 CDM 0301 RC 84238 HCPCS inpatient 290 188.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 188.5 65 999999999 175.6 281.3 percent of total billed charges Chemical receptor analysis 50434322_1 CDM 0301 RC 84238 HCPCS inpatient 290 188.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 281.3 97 999999999 175.6 281.3 percent of total billed charges Chemical receptor analysis 50434322_1 CDM 0301 RC 84238 HCPCS inpatient 290 188.5 AETNA AETNA 229.1 79 999999999 175.6 281.3 percent of total billed charges Chemical receptor analysis 50434322_1 CDM 0301 RC 84238 HCPCS inpatient 290 188.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 226.2 78 999999999 175.6 281.3 percent of total billed charges Chemical receptor analysis 50434322_1 CDM 0301 RC 84238 HCPCS inpatient 290 188.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 200.1 69 999999999 175.6 281.3 percent of total billed charges Chemical receptor analysis 50434322_1 CDM 0301 RC 84238 HCPCS inpatient 290 188.5 SIHO - ALL PLANS SIHO - ALL PLANS 261 90 999999999 175.6 281.3 percent of total billed charges Chemical receptor analysis 50434322_1 CDM 0301 RC 84238 HCPCS inpatient 290 188.5 UMR - ALL PLANS UMR - ALL PLANS 203 70 999999999 175.6 281.3 percent of total billed charges Chemical receptor analysis 50434322_1 CDM 0301 RC 84238 HCPCS inpatient 290 188.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 175.6 60.55 999999999 175.6 281.3 percent of total billed charges Chemical receptor analysis 50434322_1 CDM 0301 RC 84238 HCPCS inpatient 290 188.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 175.6 281.3 Chemical receptor analysis 50434322_1 CDM 0301 RC 84238 HCPCS inpatient 290 188.5 ANTHEM HMO ANTHEM HMO 999999999 175.6 281.3 Chemical receptor analysis 50434322_1 CDM 0301 RC 84238 HCPCS inpatient 290 188.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 175.6 281.3 Chemical receptor analysis 50434322_1 CDM 0301 RC 84238 HCPCS inpatient 290 188.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 175.6 281.3 Chemical receptor analysis 50434322_1 CDM 0301 RC 84238 HCPCS inpatient 290 188.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 175.6 281.3 Chemical receptor analysis 50434322_1 CDM 0301 RC 84238 HCPCS inpatient 290 188.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 196.04 67.6 999999999 175.6 281.3 percent of total billed charges Infrared analysis of stone 50434323_1 CDM 0301 RC 82365 HCPCS inpatient 193 125.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 125.45 65 999999999 116.86 187.21 percent of total billed charges Infrared analysis of stone 50434323_1 CDM 0301 RC 82365 HCPCS inpatient 193 125.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 187.21 97 999999999 116.86 187.21 percent of total billed charges Infrared analysis of stone 50434323_1 CDM 0301 RC 82365 HCPCS inpatient 193 125.45 AETNA AETNA 152.47 79 999999999 116.86 187.21 percent of total billed charges Infrared analysis of stone 50434323_1 CDM 0301 RC 82365 HCPCS inpatient 193 125.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 150.54 78 999999999 116.86 187.21 percent of total billed charges Infrared analysis of stone 50434323_1 CDM 0301 RC 82365 HCPCS inpatient 193 125.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.17 69 999999999 116.86 187.21 percent of total billed charges Infrared analysis of stone 50434323_1 CDM 0301 RC 82365 HCPCS inpatient 193 125.45 SIHO - ALL PLANS SIHO - ALL PLANS 173.7 90 999999999 116.86 187.21 percent of total billed charges Infrared analysis of stone 50434323_1 CDM 0301 RC 82365 HCPCS inpatient 193 125.45 UMR - ALL PLANS UMR - ALL PLANS 135.1 70 999999999 116.86 187.21 percent of total billed charges Infrared analysis of stone 50434323_1 CDM 0301 RC 82365 HCPCS inpatient 193 125.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.86 60.55 999999999 116.86 187.21 percent of total billed charges Infrared analysis of stone 50434323_1 CDM 0301 RC 82365 HCPCS inpatient 193 125.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.86 187.21 Infrared analysis of stone 50434323_1 CDM 0301 RC 82365 HCPCS inpatient 193 125.45 ANTHEM HMO ANTHEM HMO 999999999 116.86 187.21 Infrared analysis of stone 50434323_1 CDM 0301 RC 82365 HCPCS inpatient 193 125.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.86 187.21 Infrared analysis of stone 50434323_1 CDM 0301 RC 82365 HCPCS inpatient 193 125.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.86 187.21 Infrared analysis of stone 50434323_1 CDM 0301 RC 82365 HCPCS inpatient 193 125.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.86 187.21 Infrared analysis of stone 50434323_1 CDM 0301 RC 82365 HCPCS inpatient 193 125.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 130.47 67.6 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to helminth (intestinal worm) 50434324_1 CDM 0301 RC 86682 HCPCS inpatient 261 169.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 169.65 65 999999999 158.04 253.17 percent of total billed charges Analysis for antibody to helminth (intestinal worm) 50434324_1 CDM 0301 RC 86682 HCPCS inpatient 261 169.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 253.17 97 999999999 158.04 253.17 percent of total billed charges Analysis for antibody to helminth (intestinal worm) 50434324_1 CDM 0301 RC 86682 HCPCS inpatient 261 169.65 AETNA AETNA 206.19 79 999999999 158.04 253.17 percent of total billed charges Analysis for antibody to helminth (intestinal worm) 50434324_1 CDM 0301 RC 86682 HCPCS inpatient 261 169.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 203.58 78 999999999 158.04 253.17 percent of total billed charges Analysis for antibody to helminth (intestinal worm) 50434324_1 CDM 0301 RC 86682 HCPCS inpatient 261 169.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.09 69 999999999 158.04 253.17 percent of total billed charges Analysis for antibody to helminth (intestinal worm) 50434324_1 CDM 0301 RC 86682 HCPCS inpatient 261 169.65 SIHO - ALL PLANS SIHO - ALL PLANS 234.9 90 999999999 158.04 253.17 percent of total billed charges Analysis for antibody to helminth (intestinal worm) 50434324_1 CDM 0301 RC 86682 HCPCS inpatient 261 169.65 UMR - ALL PLANS UMR - ALL PLANS 182.7 70 999999999 158.04 253.17 percent of total billed charges Analysis for antibody to helminth (intestinal worm) 50434324_1 CDM 0301 RC 86682 HCPCS inpatient 261 169.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.04 60.55 999999999 158.04 253.17 percent of total billed charges Analysis for antibody to helminth (intestinal worm) 50434324_1 CDM 0301 RC 86682 HCPCS inpatient 261 169.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.04 253.17 Analysis for antibody to helminth (intestinal worm) 50434324_1 CDM 0301 RC 86682 HCPCS inpatient 261 169.65 ANTHEM HMO ANTHEM HMO 999999999 158.04 253.17 Analysis for antibody to helminth (intestinal worm) 50434324_1 CDM 0301 RC 86682 HCPCS inpatient 261 169.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.04 253.17 Analysis for antibody to helminth (intestinal worm) 50434324_1 CDM 0301 RC 86682 HCPCS inpatient 261 169.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.04 253.17 Analysis for antibody to helminth (intestinal worm) 50434324_1 CDM 0301 RC 86682 HCPCS inpatient 261 169.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.04 253.17 Analysis for antibody to helminth (intestinal worm) 50434324_1 CDM 0301 RC 86682 HCPCS inpatient 261 169.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 176.44 67.6 999999999 158.04 253.17 percent of total billed charges "Thyroid hormone, T3 measurement, free" 50434325_1 CDM 0301 RC 84481 HCPCS inpatient 311 202.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 202.15 65 999999999 188.31 301.67 percent of total billed charges "Thyroid hormone, T3 measurement, free" 50434325_1 CDM 0301 RC 84481 HCPCS inpatient 311 202.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 301.67 97 999999999 188.31 301.67 percent of total billed charges "Thyroid hormone, T3 measurement, free" 50434325_1 CDM 0301 RC 84481 HCPCS inpatient 311 202.15 AETNA AETNA 245.69 79 999999999 188.31 301.67 percent of total billed charges "Thyroid hormone, T3 measurement, free" 50434325_1 CDM 0301 RC 84481 HCPCS inpatient 311 202.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 242.58 78 999999999 188.31 301.67 percent of total billed charges "Thyroid hormone, T3 measurement, free" 50434325_1 CDM 0301 RC 84481 HCPCS inpatient 311 202.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 214.59 69 999999999 188.31 301.67 percent of total billed charges "Thyroid hormone, T3 measurement, free" 50434325_1 CDM 0301 RC 84481 HCPCS inpatient 311 202.15 SIHO - ALL PLANS SIHO - ALL PLANS 279.9 90 999999999 188.31 301.67 percent of total billed charges "Thyroid hormone, T3 measurement, free" 50434325_1 CDM 0301 RC 84481 HCPCS inpatient 311 202.15 UMR - ALL PLANS UMR - ALL PLANS 217.7 70 999999999 188.31 301.67 percent of total billed charges "Thyroid hormone, T3 measurement, free" 50434325_1 CDM 0301 RC 84481 HCPCS inpatient 311 202.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 188.31 60.55 999999999 188.31 301.67 percent of total billed charges "Thyroid hormone, T3 measurement, free" 50434325_1 CDM 0301 RC 84481 HCPCS inpatient 311 202.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 188.31 301.67 "Thyroid hormone, T3 measurement, free" 50434325_1 CDM 0301 RC 84481 HCPCS inpatient 311 202.15 ANTHEM HMO ANTHEM HMO 999999999 188.31 301.67 "Thyroid hormone, T3 measurement, free" 50434325_1 CDM 0301 RC 84481 HCPCS inpatient 311 202.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 188.31 301.67 "Thyroid hormone, T3 measurement, free" 50434325_1 CDM 0301 RC 84481 HCPCS inpatient 311 202.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 188.31 301.67 "Thyroid hormone, T3 measurement, free" 50434325_1 CDM 0301 RC 84481 HCPCS inpatient 311 202.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 188.31 301.67 "Thyroid hormone, T3 measurement, free" 50434325_1 CDM 0301 RC 84481 HCPCS inpatient 311 202.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 210.24 67.6 999999999 188.31 301.67 percent of total billed charges "Thyroid hormone, T3 measurement, reverse" 50434326_1 CDM 0301 RC 84482 HCPCS inpatient 337 219.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 219.05 65 999999999 204.05 326.89 percent of total billed charges "Thyroid hormone, T3 measurement, reverse" 50434326_1 CDM 0301 RC 84482 HCPCS inpatient 337 219.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 326.89 97 999999999 204.05 326.89 percent of total billed charges "Thyroid hormone, T3 measurement, reverse" 50434326_1 CDM 0301 RC 84482 HCPCS inpatient 337 219.05 AETNA AETNA 266.23 79 999999999 204.05 326.89 percent of total billed charges "Thyroid hormone, T3 measurement, reverse" 50434326_1 CDM 0301 RC 84482 HCPCS inpatient 337 219.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 262.86 78 999999999 204.05 326.89 percent of total billed charges "Thyroid hormone, T3 measurement, reverse" 50434326_1 CDM 0301 RC 84482 HCPCS inpatient 337 219.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 232.53 69 999999999 204.05 326.89 percent of total billed charges "Thyroid hormone, T3 measurement, reverse" 50434326_1 CDM 0301 RC 84482 HCPCS inpatient 337 219.05 SIHO - ALL PLANS SIHO - ALL PLANS 303.3 90 999999999 204.05 326.89 percent of total billed charges "Thyroid hormone, T3 measurement, reverse" 50434326_1 CDM 0301 RC 84482 HCPCS inpatient 337 219.05 UMR - ALL PLANS UMR - ALL PLANS 235.9 70 999999999 204.05 326.89 percent of total billed charges "Thyroid hormone, T3 measurement, reverse" 50434326_1 CDM 0301 RC 84482 HCPCS inpatient 337 219.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 204.05 60.55 999999999 204.05 326.89 percent of total billed charges "Thyroid hormone, T3 measurement, reverse" 50434326_1 CDM 0301 RC 84482 HCPCS inpatient 337 219.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 204.05 326.89 "Thyroid hormone, T3 measurement, reverse" 50434326_1 CDM 0301 RC 84482 HCPCS inpatient 337 219.05 ANTHEM HMO ANTHEM HMO 999999999 204.05 326.89 "Thyroid hormone, T3 measurement, reverse" 50434326_1 CDM 0301 RC 84482 HCPCS inpatient 337 219.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 204.05 326.89 "Thyroid hormone, T3 measurement, reverse" 50434326_1 CDM 0301 RC 84482 HCPCS inpatient 337 219.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 204.05 326.89 "Thyroid hormone, T3 measurement, reverse" 50434326_1 CDM 0301 RC 84482 HCPCS inpatient 337 219.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 204.05 326.89 "Thyroid hormone, T3 measurement, reverse" 50434326_1 CDM 0301 RC 84482 HCPCS inpatient 337 219.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 227.81 67.6 999999999 204.05 326.89 percent of total billed charges "Thyroid hormone, T3 measurement, total" 50434327_1 CDM 0301 RC 84480 HCPCS inpatient 391 254.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 254.15 65 999999999 236.75 379.27 percent of total billed charges "Thyroid hormone, T3 measurement, total" 50434327_1 CDM 0301 RC 84480 HCPCS inpatient 391 254.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 379.27 97 999999999 236.75 379.27 percent of total billed charges "Thyroid hormone, T3 measurement, total" 50434327_1 CDM 0301 RC 84480 HCPCS inpatient 391 254.15 AETNA AETNA 308.89 79 999999999 236.75 379.27 percent of total billed charges "Thyroid hormone, T3 measurement, total" 50434327_1 CDM 0301 RC 84480 HCPCS inpatient 391 254.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 304.98 78 999999999 236.75 379.27 percent of total billed charges "Thyroid hormone, T3 measurement, total" 50434327_1 CDM 0301 RC 84480 HCPCS inpatient 391 254.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 269.79 69 999999999 236.75 379.27 percent of total billed charges "Thyroid hormone, T3 measurement, total" 50434327_1 CDM 0301 RC 84480 HCPCS inpatient 391 254.15 SIHO - ALL PLANS SIHO - ALL PLANS 351.9 90 999999999 236.75 379.27 percent of total billed charges "Thyroid hormone, T3 measurement, total" 50434327_1 CDM 0301 RC 84480 HCPCS inpatient 391 254.15 UMR - ALL PLANS UMR - ALL PLANS 273.7 70 999999999 236.75 379.27 percent of total billed charges "Thyroid hormone, T3 measurement, total" 50434327_1 CDM 0301 RC 84480 HCPCS inpatient 391 254.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 236.75 60.55 999999999 236.75 379.27 percent of total billed charges "Thyroid hormone, T3 measurement, total" 50434327_1 CDM 0301 RC 84480 HCPCS inpatient 391 254.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 236.75 379.27 "Thyroid hormone, T3 measurement, total" 50434327_1 CDM 0301 RC 84480 HCPCS inpatient 391 254.15 ANTHEM HMO ANTHEM HMO 999999999 236.75 379.27 "Thyroid hormone, T3 measurement, total" 50434327_1 CDM 0301 RC 84480 HCPCS inpatient 391 254.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 236.75 379.27 "Thyroid hormone, T3 measurement, total" 50434327_1 CDM 0301 RC 84480 HCPCS inpatient 391 254.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 236.75 379.27 "Thyroid hormone, T3 measurement, total" 50434327_1 CDM 0301 RC 84480 HCPCS inpatient 391 254.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 236.75 379.27 "Thyroid hormone, T3 measurement, total" 50434327_1 CDM 0301 RC 84480 HCPCS inpatient 391 254.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 264.32 67.6 999999999 236.75 379.27 percent of total billed charges Thyroid hormone evaluation 50434328_1 CDM 0301 RC 84479 HCPCS inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges Thyroid hormone evaluation 50434328_1 CDM 0301 RC 84479 HCPCS inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges Thyroid hormone evaluation 50434328_1 CDM 0301 RC 84479 HCPCS inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges Thyroid hormone evaluation 50434328_1 CDM 0301 RC 84479 HCPCS inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges Thyroid hormone evaluation 50434328_1 CDM 0301 RC 84479 HCPCS inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges Thyroid hormone evaluation 50434328_1 CDM 0301 RC 84479 HCPCS inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges Thyroid hormone evaluation 50434328_1 CDM 0301 RC 84479 HCPCS inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges Thyroid hormone evaluation 50434328_1 CDM 0301 RC 84479 HCPCS inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges Thyroid hormone evaluation 50434328_1 CDM 0301 RC 84479 HCPCS inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 Thyroid hormone evaluation 50434328_1 CDM 0301 RC 84479 HCPCS inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 Thyroid hormone evaluation 50434328_1 CDM 0301 RC 84479 HCPCS inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 Thyroid hormone evaluation 50434328_1 CDM 0301 RC 84479 HCPCS inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 Thyroid hormone evaluation 50434328_1 CDM 0301 RC 84479 HCPCS inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 Thyroid hormone evaluation 50434328_1 CDM 0301 RC 84479 HCPCS inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges Sex hormone binding globulin (protein) level 50434329_1 CDM 0301 RC 84270 HCPCS inpatient 154 100.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.1 65 999999999 93.25 149.38 percent of total billed charges Sex hormone binding globulin (protein) level 50434329_1 CDM 0301 RC 84270 HCPCS inpatient 154 100.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 149.38 97 999999999 93.25 149.38 percent of total billed charges Sex hormone binding globulin (protein) level 50434329_1 CDM 0301 RC 84270 HCPCS inpatient 154 100.1 AETNA AETNA 121.66 79 999999999 93.25 149.38 percent of total billed charges Sex hormone binding globulin (protein) level 50434329_1 CDM 0301 RC 84270 HCPCS inpatient 154 100.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.12 78 999999999 93.25 149.38 percent of total billed charges Sex hormone binding globulin (protein) level 50434329_1 CDM 0301 RC 84270 HCPCS inpatient 154 100.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.26 69 999999999 93.25 149.38 percent of total billed charges Sex hormone binding globulin (protein) level 50434329_1 CDM 0301 RC 84270 HCPCS inpatient 154 100.1 SIHO - ALL PLANS SIHO - ALL PLANS 138.6 90 999999999 93.25 149.38 percent of total billed charges Sex hormone binding globulin (protein) level 50434329_1 CDM 0301 RC 84270 HCPCS inpatient 154 100.1 UMR - ALL PLANS UMR - ALL PLANS 107.8 70 999999999 93.25 149.38 percent of total billed charges Sex hormone binding globulin (protein) level 50434329_1 CDM 0301 RC 84270 HCPCS inpatient 154 100.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.25 60.55 999999999 93.25 149.38 percent of total billed charges Sex hormone binding globulin (protein) level 50434329_1 CDM 0301 RC 84270 HCPCS inpatient 154 100.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.25 149.38 Sex hormone binding globulin (protein) level 50434329_1 CDM 0301 RC 84270 HCPCS inpatient 154 100.1 ANTHEM HMO ANTHEM HMO 999999999 93.25 149.38 Sex hormone binding globulin (protein) level 50434329_1 CDM 0301 RC 84270 HCPCS inpatient 154 100.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.25 149.38 Sex hormone binding globulin (protein) level 50434329_1 CDM 0301 RC 84270 HCPCS inpatient 154 100.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.25 149.38 Sex hormone binding globulin (protein) level 50434329_1 CDM 0301 RC 84270 HCPCS inpatient 154 100.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.25 149.38 Sex hormone binding globulin (protein) level 50434329_1 CDM 0301 RC 84270 HCPCS inpatient 154 100.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.1 67.6 999999999 93.25 149.38 percent of total billed charges Evaluation of thiopurine S-methyltransferase (TPMT) 50434330_1 CDM 0301 RC 84433 HCPCS inpatient 326 211.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 211.9 65 999999999 197.39 316.22 percent of total billed charges Evaluation of thiopurine S-methyltransferase (TPMT) 50434330_1 CDM 0301 RC 84433 HCPCS inpatient 326 211.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 316.22 97 999999999 197.39 316.22 percent of total billed charges Evaluation of thiopurine S-methyltransferase (TPMT) 50434330_1 CDM 0301 RC 84433 HCPCS inpatient 326 211.9 AETNA AETNA 257.54 79 999999999 197.39 316.22 percent of total billed charges Evaluation of thiopurine S-methyltransferase (TPMT) 50434330_1 CDM 0301 RC 84433 HCPCS inpatient 326 211.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 254.28 78 999999999 197.39 316.22 percent of total billed charges Evaluation of thiopurine S-methyltransferase (TPMT) 50434330_1 CDM 0301 RC 84433 HCPCS inpatient 326 211.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 224.94 69 999999999 197.39 316.22 percent of total billed charges Evaluation of thiopurine S-methyltransferase (TPMT) 50434330_1 CDM 0301 RC 84433 HCPCS inpatient 326 211.9 SIHO - ALL PLANS SIHO - ALL PLANS 293.4 90 999999999 197.39 316.22 percent of total billed charges Evaluation of thiopurine S-methyltransferase (TPMT) 50434330_1 CDM 0301 RC 84433 HCPCS inpatient 326 211.9 UMR - ALL PLANS UMR - ALL PLANS 228.2 70 999999999 197.39 316.22 percent of total billed charges Evaluation of thiopurine S-methyltransferase (TPMT) 50434330_1 CDM 0301 RC 84433 HCPCS inpatient 326 211.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 197.39 60.55 999999999 197.39 316.22 percent of total billed charges Evaluation of thiopurine S-methyltransferase (TPMT) 50434330_1 CDM 0301 RC 84433 HCPCS inpatient 326 211.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 197.39 316.22 Evaluation of thiopurine S-methyltransferase (TPMT) 50434330_1 CDM 0301 RC 84433 HCPCS inpatient 326 211.9 ANTHEM HMO ANTHEM HMO 999999999 197.39 316.22 Evaluation of thiopurine S-methyltransferase (TPMT) 50434330_1 CDM 0301 RC 84433 HCPCS inpatient 326 211.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 197.39 316.22 Evaluation of thiopurine S-methyltransferase (TPMT) 50434330_1 CDM 0301 RC 84433 HCPCS inpatient 326 211.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 197.39 316.22 Evaluation of thiopurine S-methyltransferase (TPMT) 50434330_1 CDM 0301 RC 84433 HCPCS inpatient 326 211.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 197.39 316.22 Evaluation of thiopurine S-methyltransferase (TPMT) 50434330_1 CDM 0301 RC 84433 HCPCS inpatient 326 211.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 220.38 67.6 999999999 197.39 316.22 percent of total billed charges Thyroid stimulating immune globulins (thyroid related protein) level 50434331_1 CDM 0301 RC 84445 HCPCS inpatient 445 289.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 289.25 65 999999999 269.45 431.65 percent of total billed charges Thyroid stimulating immune globulins (thyroid related protein) level 50434331_1 CDM 0301 RC 84445 HCPCS inpatient 445 289.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 431.65 97 999999999 269.45 431.65 percent of total billed charges Thyroid stimulating immune globulins (thyroid related protein) level 50434331_1 CDM 0301 RC 84445 HCPCS inpatient 445 289.25 AETNA AETNA 351.55 79 999999999 269.45 431.65 percent of total billed charges Thyroid stimulating immune globulins (thyroid related protein) level 50434331_1 CDM 0301 RC 84445 HCPCS inpatient 445 289.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 347.1 78 999999999 269.45 431.65 percent of total billed charges Thyroid stimulating immune globulins (thyroid related protein) level 50434331_1 CDM 0301 RC 84445 HCPCS inpatient 445 289.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 307.05 69 999999999 269.45 431.65 percent of total billed charges Thyroid stimulating immune globulins (thyroid related protein) level 50434331_1 CDM 0301 RC 84445 HCPCS inpatient 445 289.25 SIHO - ALL PLANS SIHO - ALL PLANS 400.5 90 999999999 269.45 431.65 percent of total billed charges Thyroid stimulating immune globulins (thyroid related protein) level 50434331_1 CDM 0301 RC 84445 HCPCS inpatient 445 289.25 UMR - ALL PLANS UMR - ALL PLANS 311.5 70 999999999 269.45 431.65 percent of total billed charges Thyroid stimulating immune globulins (thyroid related protein) level 50434331_1 CDM 0301 RC 84445 HCPCS inpatient 445 289.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 269.45 60.55 999999999 269.45 431.65 percent of total billed charges Thyroid stimulating immune globulins (thyroid related protein) level 50434331_1 CDM 0301 RC 84445 HCPCS inpatient 445 289.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 269.45 431.65 Thyroid stimulating immune globulins (thyroid related protein) level 50434331_1 CDM 0301 RC 84445 HCPCS inpatient 445 289.25 ANTHEM HMO ANTHEM HMO 999999999 269.45 431.65 Thyroid stimulating immune globulins (thyroid related protein) level 50434331_1 CDM 0301 RC 84445 HCPCS inpatient 445 289.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 269.45 431.65 Thyroid stimulating immune globulins (thyroid related protein) level 50434331_1 CDM 0301 RC 84445 HCPCS inpatient 445 289.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 269.45 431.65 Thyroid stimulating immune globulins (thyroid related protein) level 50434331_1 CDM 0301 RC 84445 HCPCS inpatient 445 289.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 269.45 431.65 Thyroid stimulating immune globulins (thyroid related protein) level 50434331_1 CDM 0301 RC 84445 HCPCS inpatient 445 289.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 300.82 67.6 999999999 269.45 431.65 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50434332_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50434332_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50434332_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50434332_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50434332_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50434332_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50434332_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50434332_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 50434332_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 Creatinine level to test for kidney function or muscle injury 50434332_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 Creatinine level to test for kidney function or muscle injury 50434332_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 Creatinine level to test for kidney function or muscle injury 50434332_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 Creatinine level to test for kidney function or muscle injury 50434332_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 Creatinine level to test for kidney function or muscle injury 50434332_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges Topiramate level 50434333_1 CDM 0300 RC 80201 HCPCS inpatient 193 125.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 125.45 65 999999999 116.86 187.21 percent of total billed charges Topiramate level 50434333_1 CDM 0300 RC 80201 HCPCS inpatient 193 125.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 187.21 97 999999999 116.86 187.21 percent of total billed charges Topiramate level 50434333_1 CDM 0300 RC 80201 HCPCS inpatient 193 125.45 AETNA AETNA 152.47 79 999999999 116.86 187.21 percent of total billed charges Topiramate level 50434333_1 CDM 0300 RC 80201 HCPCS inpatient 193 125.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 150.54 78 999999999 116.86 187.21 percent of total billed charges Topiramate level 50434333_1 CDM 0300 RC 80201 HCPCS inpatient 193 125.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.17 69 999999999 116.86 187.21 percent of total billed charges Topiramate level 50434333_1 CDM 0300 RC 80201 HCPCS inpatient 193 125.45 SIHO - ALL PLANS SIHO - ALL PLANS 173.7 90 999999999 116.86 187.21 percent of total billed charges Topiramate level 50434333_1 CDM 0300 RC 80201 HCPCS inpatient 193 125.45 UMR - ALL PLANS UMR - ALL PLANS 135.1 70 999999999 116.86 187.21 percent of total billed charges Topiramate level 50434333_1 CDM 0300 RC 80201 HCPCS inpatient 193 125.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.86 60.55 999999999 116.86 187.21 percent of total billed charges Topiramate level 50434333_1 CDM 0300 RC 80201 HCPCS inpatient 193 125.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.86 187.21 Topiramate level 50434333_1 CDM 0300 RC 80201 HCPCS inpatient 193 125.45 ANTHEM HMO ANTHEM HMO 999999999 116.86 187.21 Topiramate level 50434333_1 CDM 0300 RC 80201 HCPCS inpatient 193 125.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.86 187.21 Topiramate level 50434333_1 CDM 0300 RC 80201 HCPCS inpatient 193 125.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.86 187.21 Topiramate level 50434333_1 CDM 0300 RC 80201 HCPCS inpatient 193 125.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.86 187.21 Topiramate level 50434333_1 CDM 0300 RC 80201 HCPCS inpatient 193 125.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 130.47 67.6 999999999 116.86 187.21 percent of total billed charges Analysis for antibody to Toxoplasma (parasite) 50434334_1 CDM 0301 RC 86777 HCPCS inpatient 117 76.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 76.05 65 999999999 70.84 113.49 percent of total billed charges Analysis for antibody to Toxoplasma (parasite) 50434334_1 CDM 0301 RC 86777 HCPCS inpatient 117 76.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 113.49 97 999999999 70.84 113.49 percent of total billed charges Analysis for antibody to Toxoplasma (parasite) 50434334_1 CDM 0301 RC 86777 HCPCS inpatient 117 76.05 AETNA AETNA 92.43 79 999999999 70.84 113.49 percent of total billed charges Analysis for antibody to Toxoplasma (parasite) 50434334_1 CDM 0301 RC 86777 HCPCS inpatient 117 76.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 91.26 78 999999999 70.84 113.49 percent of total billed charges Analysis for antibody to Toxoplasma (parasite) 50434334_1 CDM 0301 RC 86777 HCPCS inpatient 117 76.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.73 69 999999999 70.84 113.49 percent of total billed charges Analysis for antibody to Toxoplasma (parasite) 50434334_1 CDM 0301 RC 86777 HCPCS inpatient 117 76.05 SIHO - ALL PLANS SIHO - ALL PLANS 105.3 90 999999999 70.84 113.49 percent of total billed charges Analysis for antibody to Toxoplasma (parasite) 50434334_1 CDM 0301 RC 86777 HCPCS inpatient 117 76.05 UMR - ALL PLANS UMR - ALL PLANS 81.9 70 999999999 70.84 113.49 percent of total billed charges Analysis for antibody to Toxoplasma (parasite) 50434334_1 CDM 0301 RC 86777 HCPCS inpatient 117 76.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 70.84 60.55 999999999 70.84 113.49 percent of total billed charges Analysis for antibody to Toxoplasma (parasite) 50434334_1 CDM 0301 RC 86777 HCPCS inpatient 117 76.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 70.84 113.49 Analysis for antibody to Toxoplasma (parasite) 50434334_1 CDM 0301 RC 86777 HCPCS inpatient 117 76.05 ANTHEM HMO ANTHEM HMO 999999999 70.84 113.49 Analysis for antibody to Toxoplasma (parasite) 50434334_1 CDM 0301 RC 86777 HCPCS inpatient 117 76.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 70.84 113.49 Analysis for antibody to Toxoplasma (parasite) 50434334_1 CDM 0301 RC 86777 HCPCS inpatient 117 76.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 70.84 113.49 Analysis for antibody to Toxoplasma (parasite) 50434334_1 CDM 0301 RC 86777 HCPCS inpatient 117 76.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 70.84 113.49 Analysis for antibody to Toxoplasma (parasite) 50434334_1 CDM 0301 RC 86777 HCPCS inpatient 117 76.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 79.09 67.6 999999999 70.84 113.49 percent of total billed charges Analysis for antibody (IgM) to Toxoplasma (parasite) 50434335_1 CDM 0302 RC 86778 HCPCS inpatient 205 133.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.25 65 999999999 124.13 198.85 percent of total billed charges Analysis for antibody (IgM) to Toxoplasma (parasite) 50434335_1 CDM 0302 RC 86778 HCPCS inpatient 205 133.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 198.85 97 999999999 124.13 198.85 percent of total billed charges Analysis for antibody (IgM) to Toxoplasma (parasite) 50434335_1 CDM 0302 RC 86778 HCPCS inpatient 205 133.25 AETNA AETNA 161.95 79 999999999 124.13 198.85 percent of total billed charges Analysis for antibody (IgM) to Toxoplasma (parasite) 50434335_1 CDM 0302 RC 86778 HCPCS inpatient 205 133.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.9 78 999999999 124.13 198.85 percent of total billed charges Analysis for antibody (IgM) to Toxoplasma (parasite) 50434335_1 CDM 0302 RC 86778 HCPCS inpatient 205 133.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 141.45 69 999999999 124.13 198.85 percent of total billed charges Analysis for antibody (IgM) to Toxoplasma (parasite) 50434335_1 CDM 0302 RC 86778 HCPCS inpatient 205 133.25 SIHO - ALL PLANS SIHO - ALL PLANS 184.5 90 999999999 124.13 198.85 percent of total billed charges Analysis for antibody (IgM) to Toxoplasma (parasite) 50434335_1 CDM 0302 RC 86778 HCPCS inpatient 205 133.25 UMR - ALL PLANS UMR - ALL PLANS 143.5 70 999999999 124.13 198.85 percent of total billed charges Analysis for antibody (IgM) to Toxoplasma (parasite) 50434335_1 CDM 0302 RC 86778 HCPCS inpatient 205 133.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.13 60.55 999999999 124.13 198.85 percent of total billed charges Analysis for antibody (IgM) to Toxoplasma (parasite) 50434335_1 CDM 0302 RC 86778 HCPCS inpatient 205 133.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.13 198.85 Analysis for antibody (IgM) to Toxoplasma (parasite) 50434335_1 CDM 0302 RC 86778 HCPCS inpatient 205 133.25 ANTHEM HMO ANTHEM HMO 999999999 124.13 198.85 Analysis for antibody (IgM) to Toxoplasma (parasite) 50434335_1 CDM 0302 RC 86778 HCPCS inpatient 205 133.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.13 198.85 Analysis for antibody (IgM) to Toxoplasma (parasite) 50434335_1 CDM 0302 RC 86778 HCPCS inpatient 205 133.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.13 198.85 Analysis for antibody (IgM) to Toxoplasma (parasite) 50434335_1 CDM 0302 RC 86778 HCPCS inpatient 205 133.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.13 198.85 Analysis for antibody (IgM) to Toxoplasma (parasite) 50434335_1 CDM 0302 RC 86778 HCPCS inpatient 205 133.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 138.58 67.6 999999999 124.13 198.85 percent of total billed charges Gene analysis (thiopurine S-methyltransferase) for common variant 50434336_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 632.45 65 999999999 589.15 943.81 percent of total billed charges Gene analysis (thiopurine S-methyltransferase) for common variant 50434336_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 943.81 97 999999999 589.15 943.81 percent of total billed charges Gene analysis (thiopurine S-methyltransferase) for common variant 50434336_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 AETNA AETNA 768.67 79 999999999 589.15 943.81 percent of total billed charges Gene analysis (thiopurine S-methyltransferase) for common variant 50434336_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 758.94 78 999999999 589.15 943.81 percent of total billed charges Gene analysis (thiopurine S-methyltransferase) for common variant 50434336_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 671.37 69 999999999 589.15 943.81 percent of total billed charges Gene analysis (thiopurine S-methyltransferase) for common variant 50434336_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 SIHO - ALL PLANS SIHO - ALL PLANS 875.7 90 999999999 589.15 943.81 percent of total billed charges Gene analysis (thiopurine S-methyltransferase) for common variant 50434336_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 UMR - ALL PLANS UMR - ALL PLANS 681.1 70 999999999 589.15 943.81 percent of total billed charges Gene analysis (thiopurine S-methyltransferase) for common variant 50434336_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 589.15 60.55 999999999 589.15 943.81 percent of total billed charges Gene analysis (thiopurine S-methyltransferase) for common variant 50434336_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 589.15 943.81 Gene analysis (thiopurine S-methyltransferase) for common variant 50434336_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 ANTHEM HMO ANTHEM HMO 999999999 589.15 943.81 Gene analysis (thiopurine S-methyltransferase) for common variant 50434336_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 589.15 943.81 Gene analysis (thiopurine S-methyltransferase) for common variant 50434336_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 589.15 943.81 Gene analysis (thiopurine S-methyltransferase) for common variant 50434336_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 589.15 943.81 Gene analysis (thiopurine S-methyltransferase) for common variant 50434336_1 CDM 0301 RC 81335 HCPCS inpatient 973 632.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 657.75 67.6 999999999 589.15 943.81 percent of total billed charges Microsomal antibodies (autoantibody) measurement 50434337_1 CDM 0302 RC 86376 HCPCS inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges Microsomal antibodies (autoantibody) measurement 50434337_1 CDM 0302 RC 86376 HCPCS inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges Microsomal antibodies (autoantibody) measurement 50434337_1 CDM 0302 RC 86376 HCPCS inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges Microsomal antibodies (autoantibody) measurement 50434337_1 CDM 0302 RC 86376 HCPCS inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges Microsomal antibodies (autoantibody) measurement 50434337_1 CDM 0302 RC 86376 HCPCS inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges Microsomal antibodies (autoantibody) measurement 50434337_1 CDM 0302 RC 86376 HCPCS inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges Microsomal antibodies (autoantibody) measurement 50434337_1 CDM 0302 RC 86376 HCPCS inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges Microsomal antibodies (autoantibody) measurement 50434337_1 CDM 0302 RC 86376 HCPCS inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges Microsomal antibodies (autoantibody) measurement 50434337_1 CDM 0302 RC 86376 HCPCS inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 Microsomal antibodies (autoantibody) measurement 50434337_1 CDM 0302 RC 86376 HCPCS inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 Microsomal antibodies (autoantibody) measurement 50434337_1 CDM 0302 RC 86376 HCPCS inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 Microsomal antibodies (autoantibody) measurement 50434337_1 CDM 0302 RC 86376 HCPCS inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 Microsomal antibodies (autoantibody) measurement 50434337_1 CDM 0302 RC 86376 HCPCS inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 Microsomal antibodies (autoantibody) measurement 50434337_1 CDM 0302 RC 86376 HCPCS inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges Analysis of cell function and analysis for genetic marker 50434338_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 234.65 65 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 50434338_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 350.17 97 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 50434338_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 AETNA AETNA 285.19 79 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 50434338_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 281.58 78 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 50434338_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 249.09 69 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 50434338_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 SIHO - ALL PLANS SIHO - ALL PLANS 324.9 90 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 50434338_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 UMR - ALL PLANS UMR - ALL PLANS 252.7 70 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 50434338_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 218.59 60.55 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 50434338_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 218.59 350.17 Analysis of cell function and analysis for genetic marker 50434338_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 ANTHEM HMO ANTHEM HMO 999999999 218.59 350.17 Analysis of cell function and analysis for genetic marker 50434338_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 218.59 350.17 Analysis of cell function and analysis for genetic marker 50434338_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 218.59 350.17 Analysis of cell function and analysis for genetic marker 50434338_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 218.59 350.17 Analysis of cell function and analysis for genetic marker 50434338_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 244.04 67.6 999999999 218.59 350.17 percent of total billed charges "Valproic acid level, total" 50434339_1 CDM 0301 RC 80164 HCPCS inpatient 127 82.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 82.55 65 999999999 76.9 123.19 percent of total billed charges "Valproic acid level, total" 50434339_1 CDM 0301 RC 80164 HCPCS inpatient 127 82.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 123.19 97 999999999 76.9 123.19 percent of total billed charges "Valproic acid level, total" 50434339_1 CDM 0301 RC 80164 HCPCS inpatient 127 82.55 AETNA AETNA 100.33 79 999999999 76.9 123.19 percent of total billed charges "Valproic acid level, total" 50434339_1 CDM 0301 RC 80164 HCPCS inpatient 127 82.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 99.06 78 999999999 76.9 123.19 percent of total billed charges "Valproic acid level, total" 50434339_1 CDM 0301 RC 80164 HCPCS inpatient 127 82.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 87.63 69 999999999 76.9 123.19 percent of total billed charges "Valproic acid level, total" 50434339_1 CDM 0301 RC 80164 HCPCS inpatient 127 82.55 SIHO - ALL PLANS SIHO - ALL PLANS 114.3 90 999999999 76.9 123.19 percent of total billed charges "Valproic acid level, total" 50434339_1 CDM 0301 RC 80164 HCPCS inpatient 127 82.55 UMR - ALL PLANS UMR - ALL PLANS 88.9 70 999999999 76.9 123.19 percent of total billed charges "Valproic acid level, total" 50434339_1 CDM 0301 RC 80164 HCPCS inpatient 127 82.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.9 60.55 999999999 76.9 123.19 percent of total billed charges "Valproic acid level, total" 50434339_1 CDM 0301 RC 80164 HCPCS inpatient 127 82.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.9 123.19 "Valproic acid level, total" 50434339_1 CDM 0301 RC 80164 HCPCS inpatient 127 82.55 ANTHEM HMO ANTHEM HMO 999999999 76.9 123.19 "Valproic acid level, total" 50434339_1 CDM 0301 RC 80164 HCPCS inpatient 127 82.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.9 123.19 "Valproic acid level, total" 50434339_1 CDM 0301 RC 80164 HCPCS inpatient 127 82.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.9 123.19 "Valproic acid level, total" 50434339_1 CDM 0301 RC 80164 HCPCS inpatient 127 82.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.9 123.19 "Valproic acid level, total" 50434339_1 CDM 0301 RC 80164 HCPCS inpatient 127 82.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.85 67.6 999999999 76.9 123.19 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434340_1 CDM 0302 RC 86317 HCPCS inpatient 85 55.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.25 65 999999999 51.47 82.45 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434340_1 CDM 0302 RC 86317 HCPCS inpatient 85 55.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 82.45 97 999999999 51.47 82.45 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434340_1 CDM 0302 RC 86317 HCPCS inpatient 85 55.25 AETNA AETNA 67.15 79 999999999 51.47 82.45 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434340_1 CDM 0302 RC 86317 HCPCS inpatient 85 55.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 66.3 78 999999999 51.47 82.45 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434340_1 CDM 0302 RC 86317 HCPCS inpatient 85 55.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 58.65 69 999999999 51.47 82.45 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434340_1 CDM 0302 RC 86317 HCPCS inpatient 85 55.25 SIHO - ALL PLANS SIHO - ALL PLANS 76.5 90 999999999 51.47 82.45 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434340_1 CDM 0302 RC 86317 HCPCS inpatient 85 55.25 UMR - ALL PLANS UMR - ALL PLANS 59.5 70 999999999 51.47 82.45 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434340_1 CDM 0302 RC 86317 HCPCS inpatient 85 55.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 51.47 60.55 999999999 51.47 82.45 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50434340_1 CDM 0302 RC 86317 HCPCS inpatient 85 55.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 51.47 82.45 "Detection of infectious agent antibody, quantitative" 50434340_1 CDM 0302 RC 86317 HCPCS inpatient 85 55.25 ANTHEM HMO ANTHEM HMO 999999999 51.47 82.45 "Detection of infectious agent antibody, quantitative" 50434340_1 CDM 0302 RC 86317 HCPCS inpatient 85 55.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 51.47 82.45 "Detection of infectious agent antibody, quantitative" 50434340_1 CDM 0302 RC 86317 HCPCS inpatient 85 55.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 51.47 82.45 "Detection of infectious agent antibody, quantitative" 50434340_1 CDM 0302 RC 86317 HCPCS inpatient 85 55.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 51.47 82.45 "Detection of infectious agent antibody, quantitative" 50434340_1 CDM 0302 RC 86317 HCPCS inpatient 85 55.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 57.46 67.6 999999999 51.47 82.45 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50434341_1 CDM 0302 RC 86787 HCPCS inpatient 95 61.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.75 65 999999999 57.52 92.15 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50434341_1 CDM 0302 RC 86787 HCPCS inpatient 95 61.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 92.15 97 999999999 57.52 92.15 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50434341_1 CDM 0302 RC 86787 HCPCS inpatient 95 61.75 AETNA AETNA 75.05 79 999999999 57.52 92.15 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50434341_1 CDM 0302 RC 86787 HCPCS inpatient 95 61.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.1 78 999999999 57.52 92.15 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50434341_1 CDM 0302 RC 86787 HCPCS inpatient 95 61.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 65.55 69 999999999 57.52 92.15 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50434341_1 CDM 0302 RC 86787 HCPCS inpatient 95 61.75 SIHO - ALL PLANS SIHO - ALL PLANS 85.5 90 999999999 57.52 92.15 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50434341_1 CDM 0302 RC 86787 HCPCS inpatient 95 61.75 UMR - ALL PLANS UMR - ALL PLANS 66.5 70 999999999 57.52 92.15 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50434341_1 CDM 0302 RC 86787 HCPCS inpatient 95 61.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 57.52 60.55 999999999 57.52 92.15 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50434341_1 CDM 0302 RC 86787 HCPCS inpatient 95 61.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 57.52 92.15 Analysis for antibody to varicella-zoster virus (chicken pox) 50434341_1 CDM 0302 RC 86787 HCPCS inpatient 95 61.75 ANTHEM HMO ANTHEM HMO 999999999 57.52 92.15 Analysis for antibody to varicella-zoster virus (chicken pox) 50434341_1 CDM 0302 RC 86787 HCPCS inpatient 95 61.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 57.52 92.15 Analysis for antibody to varicella-zoster virus (chicken pox) 50434341_1 CDM 0302 RC 86787 HCPCS inpatient 95 61.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 57.52 92.15 Analysis for antibody to varicella-zoster virus (chicken pox) 50434341_1 CDM 0302 RC 86787 HCPCS inpatient 95 61.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 57.52 92.15 Analysis for antibody to varicella-zoster virus (chicken pox) 50434341_1 CDM 0302 RC 86787 HCPCS inpatient 95 61.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.22 67.6 999999999 57.52 92.15 percent of total billed charges Vitamin A level 50434342_1 CDM 0301 RC 84590 HCPCS inpatient 187 121.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 121.55 65 999999999 113.23 181.39 percent of total billed charges Vitamin A level 50434342_1 CDM 0301 RC 84590 HCPCS inpatient 187 121.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 181.39 97 999999999 113.23 181.39 percent of total billed charges Vitamin A level 50434342_1 CDM 0301 RC 84590 HCPCS inpatient 187 121.55 AETNA AETNA 147.73 79 999999999 113.23 181.39 percent of total billed charges Vitamin A level 50434342_1 CDM 0301 RC 84590 HCPCS inpatient 187 121.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 145.86 78 999999999 113.23 181.39 percent of total billed charges Vitamin A level 50434342_1 CDM 0301 RC 84590 HCPCS inpatient 187 121.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.03 69 999999999 113.23 181.39 percent of total billed charges Vitamin A level 50434342_1 CDM 0301 RC 84590 HCPCS inpatient 187 121.55 SIHO - ALL PLANS SIHO - ALL PLANS 168.3 90 999999999 113.23 181.39 percent of total billed charges Vitamin A level 50434342_1 CDM 0301 RC 84590 HCPCS inpatient 187 121.55 UMR - ALL PLANS UMR - ALL PLANS 130.9 70 999999999 113.23 181.39 percent of total billed charges Vitamin A level 50434342_1 CDM 0301 RC 84590 HCPCS inpatient 187 121.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.23 60.55 999999999 113.23 181.39 percent of total billed charges Vitamin A level 50434342_1 CDM 0301 RC 84590 HCPCS inpatient 187 121.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.23 181.39 Vitamin A level 50434342_1 CDM 0301 RC 84590 HCPCS inpatient 187 121.55 ANTHEM HMO ANTHEM HMO 999999999 113.23 181.39 Vitamin A level 50434342_1 CDM 0301 RC 84590 HCPCS inpatient 187 121.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.23 181.39 Vitamin A level 50434342_1 CDM 0301 RC 84590 HCPCS inpatient 187 121.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.23 181.39 Vitamin A level 50434342_1 CDM 0301 RC 84590 HCPCS inpatient 187 121.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.23 181.39 Vitamin A level 50434342_1 CDM 0301 RC 84590 HCPCS inpatient 187 121.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 126.41 67.6 999999999 113.23 181.39 percent of total billed charges Vitamin B-1 (thiamine) level 50434343_1 CDM 0301 RC 84425 HCPCS inpatient 261 169.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 169.65 65 999999999 158.04 253.17 percent of total billed charges Vitamin B-1 (thiamine) level 50434343_1 CDM 0301 RC 84425 HCPCS inpatient 261 169.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 253.17 97 999999999 158.04 253.17 percent of total billed charges Vitamin B-1 (thiamine) level 50434343_1 CDM 0301 RC 84425 HCPCS inpatient 261 169.65 AETNA AETNA 206.19 79 999999999 158.04 253.17 percent of total billed charges Vitamin B-1 (thiamine) level 50434343_1 CDM 0301 RC 84425 HCPCS inpatient 261 169.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 203.58 78 999999999 158.04 253.17 percent of total billed charges Vitamin B-1 (thiamine) level 50434343_1 CDM 0301 RC 84425 HCPCS inpatient 261 169.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.09 69 999999999 158.04 253.17 percent of total billed charges Vitamin B-1 (thiamine) level 50434343_1 CDM 0301 RC 84425 HCPCS inpatient 261 169.65 SIHO - ALL PLANS SIHO - ALL PLANS 234.9 90 999999999 158.04 253.17 percent of total billed charges Vitamin B-1 (thiamine) level 50434343_1 CDM 0301 RC 84425 HCPCS inpatient 261 169.65 UMR - ALL PLANS UMR - ALL PLANS 182.7 70 999999999 158.04 253.17 percent of total billed charges Vitamin B-1 (thiamine) level 50434343_1 CDM 0301 RC 84425 HCPCS inpatient 261 169.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.04 60.55 999999999 158.04 253.17 percent of total billed charges Vitamin B-1 (thiamine) level 50434343_1 CDM 0301 RC 84425 HCPCS inpatient 261 169.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.04 253.17 Vitamin B-1 (thiamine) level 50434343_1 CDM 0301 RC 84425 HCPCS inpatient 261 169.65 ANTHEM HMO ANTHEM HMO 999999999 158.04 253.17 Vitamin B-1 (thiamine) level 50434343_1 CDM 0301 RC 84425 HCPCS inpatient 261 169.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.04 253.17 Vitamin B-1 (thiamine) level 50434343_1 CDM 0301 RC 84425 HCPCS inpatient 261 169.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.04 253.17 Vitamin B-1 (thiamine) level 50434343_1 CDM 0301 RC 84425 HCPCS inpatient 261 169.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.04 253.17 Vitamin B-1 (thiamine) level 50434343_1 CDM 0301 RC 84425 HCPCS inpatient 261 169.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 176.44 67.6 999999999 158.04 253.17 percent of total billed charges Vitamin B-6 level 50434344_1 CDM 0301 RC 84207 HCPCS inpatient 258 167.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.7 65 999999999 156.22 250.26 percent of total billed charges Vitamin B-6 level 50434344_1 CDM 0301 RC 84207 HCPCS inpatient 258 167.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 250.26 97 999999999 156.22 250.26 percent of total billed charges Vitamin B-6 level 50434344_1 CDM 0301 RC 84207 HCPCS inpatient 258 167.7 AETNA AETNA 203.82 79 999999999 156.22 250.26 percent of total billed charges Vitamin B-6 level 50434344_1 CDM 0301 RC 84207 HCPCS inpatient 258 167.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 201.24 78 999999999 156.22 250.26 percent of total billed charges Vitamin B-6 level 50434344_1 CDM 0301 RC 84207 HCPCS inpatient 258 167.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 178.02 69 999999999 156.22 250.26 percent of total billed charges Vitamin B-6 level 50434344_1 CDM 0301 RC 84207 HCPCS inpatient 258 167.7 SIHO - ALL PLANS SIHO - ALL PLANS 232.2 90 999999999 156.22 250.26 percent of total billed charges Vitamin B-6 level 50434344_1 CDM 0301 RC 84207 HCPCS inpatient 258 167.7 UMR - ALL PLANS UMR - ALL PLANS 180.6 70 999999999 156.22 250.26 percent of total billed charges Vitamin B-6 level 50434344_1 CDM 0301 RC 84207 HCPCS inpatient 258 167.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 156.22 60.55 999999999 156.22 250.26 percent of total billed charges Vitamin B-6 level 50434344_1 CDM 0301 RC 84207 HCPCS inpatient 258 167.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 156.22 250.26 Vitamin B-6 level 50434344_1 CDM 0301 RC 84207 HCPCS inpatient 258 167.7 ANTHEM HMO ANTHEM HMO 999999999 156.22 250.26 Vitamin B-6 level 50434344_1 CDM 0301 RC 84207 HCPCS inpatient 258 167.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 156.22 250.26 Vitamin B-6 level 50434344_1 CDM 0301 RC 84207 HCPCS inpatient 258 167.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 156.22 250.26 Vitamin B-6 level 50434344_1 CDM 0301 RC 84207 HCPCS inpatient 258 167.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 156.22 250.26 Vitamin B-6 level 50434344_1 CDM 0301 RC 84207 HCPCS inpatient 258 167.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 174.41 67.6 999999999 156.22 250.26 percent of total billed charges "Ascorbic acid (Vitamin C) level, blood" 50434345_1 CDM 0301 RC 82180 HCPCS inpatient 205 133.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.25 65 999999999 124.13 198.85 percent of total billed charges "Ascorbic acid (Vitamin C) level, blood" 50434345_1 CDM 0301 RC 82180 HCPCS inpatient 205 133.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 198.85 97 999999999 124.13 198.85 percent of total billed charges "Ascorbic acid (Vitamin C) level, blood" 50434345_1 CDM 0301 RC 82180 HCPCS inpatient 205 133.25 AETNA AETNA 161.95 79 999999999 124.13 198.85 percent of total billed charges "Ascorbic acid (Vitamin C) level, blood" 50434345_1 CDM 0301 RC 82180 HCPCS inpatient 205 133.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.9 78 999999999 124.13 198.85 percent of total billed charges "Ascorbic acid (Vitamin C) level, blood" 50434345_1 CDM 0301 RC 82180 HCPCS inpatient 205 133.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 141.45 69 999999999 124.13 198.85 percent of total billed charges "Ascorbic acid (Vitamin C) level, blood" 50434345_1 CDM 0301 RC 82180 HCPCS inpatient 205 133.25 SIHO - ALL PLANS SIHO - ALL PLANS 184.5 90 999999999 124.13 198.85 percent of total billed charges "Ascorbic acid (Vitamin C) level, blood" 50434345_1 CDM 0301 RC 82180 HCPCS inpatient 205 133.25 UMR - ALL PLANS UMR - ALL PLANS 143.5 70 999999999 124.13 198.85 percent of total billed charges "Ascorbic acid (Vitamin C) level, blood" 50434345_1 CDM 0301 RC 82180 HCPCS inpatient 205 133.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.13 60.55 999999999 124.13 198.85 percent of total billed charges "Ascorbic acid (Vitamin C) level, blood" 50434345_1 CDM 0301 RC 82180 HCPCS inpatient 205 133.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.13 198.85 "Ascorbic acid (Vitamin C) level, blood" 50434345_1 CDM 0301 RC 82180 HCPCS inpatient 205 133.25 ANTHEM HMO ANTHEM HMO 999999999 124.13 198.85 "Ascorbic acid (Vitamin C) level, blood" 50434345_1 CDM 0301 RC 82180 HCPCS inpatient 205 133.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.13 198.85 "Ascorbic acid (Vitamin C) level, blood" 50434345_1 CDM 0301 RC 82180 HCPCS inpatient 205 133.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.13 198.85 "Ascorbic acid (Vitamin C) level, blood" 50434345_1 CDM 0301 RC 82180 HCPCS inpatient 205 133.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.13 198.85 "Ascorbic acid (Vitamin C) level, blood" 50434345_1 CDM 0301 RC 82180 HCPCS inpatient 205 133.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 138.58 67.6 999999999 124.13 198.85 percent of total billed charges Vitamin D-3 level 50434346_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges Vitamin D-3 level 50434346_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges Vitamin D-3 level 50434346_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges Vitamin D-3 level 50434346_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges Vitamin D-3 level 50434346_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges Vitamin D-3 level 50434346_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges Vitamin D-3 level 50434346_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges Vitamin D-3 level 50434346_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges Vitamin D-3 level 50434346_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 Vitamin D-3 level 50434346_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 Vitamin D-3 level 50434346_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 Vitamin D-3 level 50434346_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 Vitamin D-3 level 50434346_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 Vitamin D-3 level 50434346_1 CDM 0301 RC 82306 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges Vitamin D-3 level 50434347_1 CDM 0301 RC 82306 HCPCS inpatient 78 50.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.7 65 999999999 47.23 75.66 percent of total billed charges Vitamin D-3 level 50434347_1 CDM 0301 RC 82306 HCPCS inpatient 78 50.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 75.66 97 999999999 47.23 75.66 percent of total billed charges Vitamin D-3 level 50434347_1 CDM 0301 RC 82306 HCPCS inpatient 78 50.7 AETNA AETNA 61.62 79 999999999 47.23 75.66 percent of total billed charges Vitamin D-3 level 50434347_1 CDM 0301 RC 82306 HCPCS inpatient 78 50.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.84 78 999999999 47.23 75.66 percent of total billed charges Vitamin D-3 level 50434347_1 CDM 0301 RC 82306 HCPCS inpatient 78 50.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.82 69 999999999 47.23 75.66 percent of total billed charges Vitamin D-3 level 50434347_1 CDM 0301 RC 82306 HCPCS inpatient 78 50.7 SIHO - ALL PLANS SIHO - ALL PLANS 70.2 90 999999999 47.23 75.66 percent of total billed charges Vitamin D-3 level 50434347_1 CDM 0301 RC 82306 HCPCS inpatient 78 50.7 UMR - ALL PLANS UMR - ALL PLANS 54.6 70 999999999 47.23 75.66 percent of total billed charges Vitamin D-3 level 50434347_1 CDM 0301 RC 82306 HCPCS inpatient 78 50.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.23 60.55 999999999 47.23 75.66 percent of total billed charges Vitamin D-3 level 50434347_1 CDM 0301 RC 82306 HCPCS inpatient 78 50.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.23 75.66 Vitamin D-3 level 50434347_1 CDM 0301 RC 82306 HCPCS inpatient 78 50.7 ANTHEM HMO ANTHEM HMO 999999999 47.23 75.66 Vitamin D-3 level 50434347_1 CDM 0301 RC 82306 HCPCS inpatient 78 50.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.23 75.66 Vitamin D-3 level 50434347_1 CDM 0301 RC 82306 HCPCS inpatient 78 50.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.23 75.66 Vitamin D-3 level 50434347_1 CDM 0301 RC 82306 HCPCS inpatient 78 50.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.23 75.66 Vitamin D-3 level 50434347_1 CDM 0301 RC 82306 HCPCS inpatient 78 50.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.73 67.6 999999999 47.23 75.66 percent of total billed charges Vitamin E level 50434348_1 CDM 0301 RC 84446 HCPCS inpatient 188 122.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.2 65 999999999 113.83 182.36 percent of total billed charges Vitamin E level 50434348_1 CDM 0301 RC 84446 HCPCS inpatient 188 122.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 182.36 97 999999999 113.83 182.36 percent of total billed charges Vitamin E level 50434348_1 CDM 0301 RC 84446 HCPCS inpatient 188 122.2 AETNA AETNA 148.52 79 999999999 113.83 182.36 percent of total billed charges Vitamin E level 50434348_1 CDM 0301 RC 84446 HCPCS inpatient 188 122.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 146.64 78 999999999 113.83 182.36 percent of total billed charges Vitamin E level 50434348_1 CDM 0301 RC 84446 HCPCS inpatient 188 122.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.72 69 999999999 113.83 182.36 percent of total billed charges Vitamin E level 50434348_1 CDM 0301 RC 84446 HCPCS inpatient 188 122.2 SIHO - ALL PLANS SIHO - ALL PLANS 169.2 90 999999999 113.83 182.36 percent of total billed charges Vitamin E level 50434348_1 CDM 0301 RC 84446 HCPCS inpatient 188 122.2 UMR - ALL PLANS UMR - ALL PLANS 131.6 70 999999999 113.83 182.36 percent of total billed charges Vitamin E level 50434348_1 CDM 0301 RC 84446 HCPCS inpatient 188 122.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.83 60.55 999999999 113.83 182.36 percent of total billed charges Vitamin E level 50434348_1 CDM 0301 RC 84446 HCPCS inpatient 188 122.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.83 182.36 Vitamin E level 50434348_1 CDM 0301 RC 84446 HCPCS inpatient 188 122.2 ANTHEM HMO ANTHEM HMO 999999999 113.83 182.36 Vitamin E level 50434348_1 CDM 0301 RC 84446 HCPCS inpatient 188 122.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.83 182.36 Vitamin E level 50434348_1 CDM 0301 RC 84446 HCPCS inpatient 188 122.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.83 182.36 Vitamin E level 50434348_1 CDM 0301 RC 84446 HCPCS inpatient 188 122.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.83 182.36 Vitamin E level 50434348_1 CDM 0301 RC 84446 HCPCS inpatient 188 122.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.09 67.6 999999999 113.83 182.36 percent of total billed charges Very long chain fatty acids level 50434349_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 303.55 65 999999999 282.77 452.99 percent of total billed charges Very long chain fatty acids level 50434349_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 452.99 97 999999999 282.77 452.99 percent of total billed charges Very long chain fatty acids level 50434349_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 AETNA AETNA 368.93 79 999999999 282.77 452.99 percent of total billed charges Very long chain fatty acids level 50434349_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 364.26 78 999999999 282.77 452.99 percent of total billed charges Very long chain fatty acids level 50434349_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 322.23 69 999999999 282.77 452.99 percent of total billed charges Very long chain fatty acids level 50434349_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 SIHO - ALL PLANS SIHO - ALL PLANS 420.3 90 999999999 282.77 452.99 percent of total billed charges Very long chain fatty acids level 50434349_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 UMR - ALL PLANS UMR - ALL PLANS 326.9 70 999999999 282.77 452.99 percent of total billed charges Very long chain fatty acids level 50434349_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 282.77 60.55 999999999 282.77 452.99 percent of total billed charges Very long chain fatty acids level 50434349_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 282.77 452.99 Very long chain fatty acids level 50434349_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 ANTHEM HMO ANTHEM HMO 999999999 282.77 452.99 Very long chain fatty acids level 50434349_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 282.77 452.99 Very long chain fatty acids level 50434349_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 282.77 452.99 Very long chain fatty acids level 50434349_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 282.77 452.99 Very long chain fatty acids level 50434349_1 CDM 0301 RC 82726 HCPCS inpatient 467 303.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 315.69 67.6 999999999 282.77 452.99 percent of total billed charges Volatile chemical measurement 50434350_1 CDM 0301 RC 84600 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Volatile chemical measurement 50434350_1 CDM 0301 RC 84600 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Volatile chemical measurement 50434350_1 CDM 0301 RC 84600 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Volatile chemical measurement 50434350_1 CDM 0301 RC 84600 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Volatile chemical measurement 50434350_1 CDM 0301 RC 84600 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Volatile chemical measurement 50434350_1 CDM 0301 RC 84600 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Volatile chemical measurement 50434350_1 CDM 0301 RC 84600 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Volatile chemical measurement 50434350_1 CDM 0301 RC 84600 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Volatile chemical measurement 50434350_1 CDM 0301 RC 84600 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Volatile chemical measurement 50434350_1 CDM 0301 RC 84600 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Volatile chemical measurement 50434350_1 CDM 0301 RC 84600 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Volatile chemical measurement 50434350_1 CDM 0301 RC 84600 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Volatile chemical measurement 50434350_1 CDM 0301 RC 84600 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Volatile chemical measurement 50434350_1 CDM 0301 RC 84600 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Clotting factor VIII (VW factor) antigen 50434351_1 CDM 0301 RC 85246 HCPCS inpatient 184 119.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 119.6 65 999999999 111.41 178.48 percent of total billed charges Clotting factor VIII (VW factor) antigen 50434351_1 CDM 0301 RC 85246 HCPCS inpatient 184 119.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 178.48 97 999999999 111.41 178.48 percent of total billed charges Clotting factor VIII (VW factor) antigen 50434351_1 CDM 0301 RC 85246 HCPCS inpatient 184 119.6 AETNA AETNA 145.36 79 999999999 111.41 178.48 percent of total billed charges Clotting factor VIII (VW factor) antigen 50434351_1 CDM 0301 RC 85246 HCPCS inpatient 184 119.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 143.52 78 999999999 111.41 178.48 percent of total billed charges Clotting factor VIII (VW factor) antigen 50434351_1 CDM 0301 RC 85246 HCPCS inpatient 184 119.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.96 69 999999999 111.41 178.48 percent of total billed charges Clotting factor VIII (VW factor) antigen 50434351_1 CDM 0301 RC 85246 HCPCS inpatient 184 119.6 SIHO - ALL PLANS SIHO - ALL PLANS 165.6 90 999999999 111.41 178.48 percent of total billed charges Clotting factor VIII (VW factor) antigen 50434351_1 CDM 0301 RC 85246 HCPCS inpatient 184 119.6 UMR - ALL PLANS UMR - ALL PLANS 128.8 70 999999999 111.41 178.48 percent of total billed charges Clotting factor VIII (VW factor) antigen 50434351_1 CDM 0301 RC 85246 HCPCS inpatient 184 119.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 111.41 60.55 999999999 111.41 178.48 percent of total billed charges Clotting factor VIII (VW factor) antigen 50434351_1 CDM 0301 RC 85246 HCPCS inpatient 184 119.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 111.41 178.48 Clotting factor VIII (VW factor) antigen 50434351_1 CDM 0301 RC 85246 HCPCS inpatient 184 119.6 ANTHEM HMO ANTHEM HMO 999999999 111.41 178.48 Clotting factor VIII (VW factor) antigen 50434351_1 CDM 0301 RC 85246 HCPCS inpatient 184 119.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 111.41 178.48 Clotting factor VIII (VW factor) antigen 50434351_1 CDM 0301 RC 85246 HCPCS inpatient 184 119.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 111.41 178.48 Clotting factor VIII (VW factor) antigen 50434351_1 CDM 0301 RC 85246 HCPCS inpatient 184 119.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 111.41 178.48 Clotting factor VIII (VW factor) antigen 50434351_1 CDM 0301 RC 85246 HCPCS inpatient 184 119.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 124.38 67.6 999999999 111.41 178.48 percent of total billed charges Clotting factor VIII (von Willebrand factor) measurement 50434352_1 CDM 0301 RC 85247 HCPCS inpatient 238 154.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.7 65 999999999 144.11 230.86 percent of total billed charges Clotting factor VIII (von Willebrand factor) measurement 50434352_1 CDM 0301 RC 85247 HCPCS inpatient 238 154.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 230.86 97 999999999 144.11 230.86 percent of total billed charges Clotting factor VIII (von Willebrand factor) measurement 50434352_1 CDM 0301 RC 85247 HCPCS inpatient 238 154.7 AETNA AETNA 188.02 79 999999999 144.11 230.86 percent of total billed charges Clotting factor VIII (von Willebrand factor) measurement 50434352_1 CDM 0301 RC 85247 HCPCS inpatient 238 154.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 185.64 78 999999999 144.11 230.86 percent of total billed charges Clotting factor VIII (von Willebrand factor) measurement 50434352_1 CDM 0301 RC 85247 HCPCS inpatient 238 154.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.22 69 999999999 144.11 230.86 percent of total billed charges Clotting factor VIII (von Willebrand factor) measurement 50434352_1 CDM 0301 RC 85247 HCPCS inpatient 238 154.7 SIHO - ALL PLANS SIHO - ALL PLANS 214.2 90 999999999 144.11 230.86 percent of total billed charges Clotting factor VIII (von Willebrand factor) measurement 50434352_1 CDM 0301 RC 85247 HCPCS inpatient 238 154.7 UMR - ALL PLANS UMR - ALL PLANS 166.6 70 999999999 144.11 230.86 percent of total billed charges Clotting factor VIII (von Willebrand factor) measurement 50434352_1 CDM 0301 RC 85247 HCPCS inpatient 238 154.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.11 60.55 999999999 144.11 230.86 percent of total billed charges Clotting factor VIII (von Willebrand factor) measurement 50434352_1 CDM 0301 RC 85247 HCPCS inpatient 238 154.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.11 230.86 Clotting factor VIII (von Willebrand factor) measurement 50434352_1 CDM 0301 RC 85247 HCPCS inpatient 238 154.7 ANTHEM HMO ANTHEM HMO 999999999 144.11 230.86 Clotting factor VIII (von Willebrand factor) measurement 50434352_1 CDM 0301 RC 85247 HCPCS inpatient 238 154.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.11 230.86 Clotting factor VIII (von Willebrand factor) measurement 50434352_1 CDM 0301 RC 85247 HCPCS inpatient 238 154.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.11 230.86 Clotting factor VIII (von Willebrand factor) measurement 50434352_1 CDM 0301 RC 85247 HCPCS inpatient 238 154.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.11 230.86 Clotting factor VIII (von Willebrand factor) measurement 50434352_1 CDM 0301 RC 85247 HCPCS inpatient 238 154.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.89 67.6 999999999 144.11 230.86 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50434353_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50434353_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50434353_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50434353_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50434353_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50434353_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50434353_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50434353_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50434353_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 50434353_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 50434353_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 50434353_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 50434353_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 50434353_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to West Nile virus 50434354_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.6 65 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 50434354_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.88 97 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 50434354_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 AETNA AETNA 161.16 79 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 50434354_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.12 78 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 50434354_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.76 69 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 50434354_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 SIHO - ALL PLANS SIHO - ALL PLANS 183.6 90 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 50434354_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 UMR - ALL PLANS UMR - ALL PLANS 142.8 70 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 50434354_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.52 60.55 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 50434354_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.52 197.88 Analysis for antibody to West Nile virus 50434354_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 ANTHEM HMO ANTHEM HMO 999999999 123.52 197.88 Analysis for antibody to West Nile virus 50434354_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.52 197.88 Analysis for antibody to West Nile virus 50434354_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.52 197.88 Analysis for antibody to West Nile virus 50434354_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.52 197.88 Analysis for antibody to West Nile virus 50434354_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.9 67.6 999999999 123.52 197.88 percent of total billed charges Protoporphyrin (metabolism substance) level 50434355_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 137.15 65 999999999 127.76 204.67 percent of total billed charges Protoporphyrin (metabolism substance) level 50434355_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 204.67 97 999999999 127.76 204.67 percent of total billed charges Protoporphyrin (metabolism substance) level 50434355_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 AETNA AETNA 166.69 79 999999999 127.76 204.67 percent of total billed charges Protoporphyrin (metabolism substance) level 50434355_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 164.58 78 999999999 127.76 204.67 percent of total billed charges Protoporphyrin (metabolism substance) level 50434355_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 145.59 69 999999999 127.76 204.67 percent of total billed charges Protoporphyrin (metabolism substance) level 50434355_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 SIHO - ALL PLANS SIHO - ALL PLANS 189.9 90 999999999 127.76 204.67 percent of total billed charges Protoporphyrin (metabolism substance) level 50434355_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 UMR - ALL PLANS UMR - ALL PLANS 147.7 70 999999999 127.76 204.67 percent of total billed charges Protoporphyrin (metabolism substance) level 50434355_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.76 60.55 999999999 127.76 204.67 percent of total billed charges Protoporphyrin (metabolism substance) level 50434355_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.76 204.67 Protoporphyrin (metabolism substance) level 50434355_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 ANTHEM HMO ANTHEM HMO 999999999 127.76 204.67 Protoporphyrin (metabolism substance) level 50434355_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.76 204.67 Protoporphyrin (metabolism substance) level 50434355_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.76 204.67 Protoporphyrin (metabolism substance) level 50434355_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.76 204.67 Protoporphyrin (metabolism substance) level 50434355_1 CDM 0301 RC 84202 HCPCS inpatient 211 137.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 142.64 67.6 999999999 127.76 204.67 percent of total billed charges Zinc level 50434356_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 129.35 65 999999999 120.49 193.03 percent of total billed charges Zinc level 50434356_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 193.03 97 999999999 120.49 193.03 percent of total billed charges Zinc level 50434356_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 AETNA AETNA 157.21 79 999999999 120.49 193.03 percent of total billed charges Zinc level 50434356_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 155.22 78 999999999 120.49 193.03 percent of total billed charges Zinc level 50434356_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 137.31 69 999999999 120.49 193.03 percent of total billed charges Zinc level 50434356_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 SIHO - ALL PLANS SIHO - ALL PLANS 179.1 90 999999999 120.49 193.03 percent of total billed charges Zinc level 50434356_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 UMR - ALL PLANS UMR - ALL PLANS 139.3 70 999999999 120.49 193.03 percent of total billed charges Zinc level 50434356_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 120.49 60.55 999999999 120.49 193.03 percent of total billed charges Zinc level 50434356_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 120.49 193.03 Zinc level 50434356_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 ANTHEM HMO ANTHEM HMO 999999999 120.49 193.03 Zinc level 50434356_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 120.49 193.03 Zinc level 50434356_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 120.49 193.03 Zinc level 50434356_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 120.49 193.03 Zinc level 50434356_1 CDM 0301 RC 84630 HCPCS inpatient 199 129.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 134.52 67.6 999999999 120.49 193.03 percent of total billed charges Zonisamide level 50434357_1 CDM 0301 RC 80203 HCPCS inpatient 297 193.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 193.05 65 999999999 179.83 288.09 percent of total billed charges Zonisamide level 50434357_1 CDM 0301 RC 80203 HCPCS inpatient 297 193.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 288.09 97 999999999 179.83 288.09 percent of total billed charges Zonisamide level 50434357_1 CDM 0301 RC 80203 HCPCS inpatient 297 193.05 AETNA AETNA 234.63 79 999999999 179.83 288.09 percent of total billed charges Zonisamide level 50434357_1 CDM 0301 RC 80203 HCPCS inpatient 297 193.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 231.66 78 999999999 179.83 288.09 percent of total billed charges Zonisamide level 50434357_1 CDM 0301 RC 80203 HCPCS inpatient 297 193.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 204.93 69 999999999 179.83 288.09 percent of total billed charges Zonisamide level 50434357_1 CDM 0301 RC 80203 HCPCS inpatient 297 193.05 SIHO - ALL PLANS SIHO - ALL PLANS 267.3 90 999999999 179.83 288.09 percent of total billed charges Zonisamide level 50434357_1 CDM 0301 RC 80203 HCPCS inpatient 297 193.05 UMR - ALL PLANS UMR - ALL PLANS 207.9 70 999999999 179.83 288.09 percent of total billed charges Zonisamide level 50434357_1 CDM 0301 RC 80203 HCPCS inpatient 297 193.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 179.83 60.55 999999999 179.83 288.09 percent of total billed charges Zonisamide level 50434357_1 CDM 0301 RC 80203 HCPCS inpatient 297 193.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 179.83 288.09 Zonisamide level 50434357_1 CDM 0301 RC 80203 HCPCS inpatient 297 193.05 ANTHEM HMO ANTHEM HMO 999999999 179.83 288.09 Zonisamide level 50434357_1 CDM 0301 RC 80203 HCPCS inpatient 297 193.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 179.83 288.09 Zonisamide level 50434357_1 CDM 0301 RC 80203 HCPCS inpatient 297 193.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 179.83 288.09 Zonisamide level 50434357_1 CDM 0301 RC 80203 HCPCS inpatient 297 193.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 179.83 288.09 Zonisamide level 50434357_1 CDM 0301 RC 80203 HCPCS inpatient 297 193.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 200.77 67.6 999999999 179.83 288.09 percent of total billed charges "Amphetamines levels, 1 or 2" 50435014_1 CDM 0301 RC 80324 HCPCS inpatient 166 107.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.9 65 999999999 100.51 161.02 percent of total billed charges "Amphetamines levels, 1 or 2" 50435014_1 CDM 0301 RC 80324 HCPCS inpatient 166 107.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.02 97 999999999 100.51 161.02 percent of total billed charges "Amphetamines levels, 1 or 2" 50435014_1 CDM 0301 RC 80324 HCPCS inpatient 166 107.9 AETNA AETNA 131.14 79 999999999 100.51 161.02 percent of total billed charges "Amphetamines levels, 1 or 2" 50435014_1 CDM 0301 RC 80324 HCPCS inpatient 166 107.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 129.48 78 999999999 100.51 161.02 percent of total billed charges "Amphetamines levels, 1 or 2" 50435014_1 CDM 0301 RC 80324 HCPCS inpatient 166 107.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 114.54 69 999999999 100.51 161.02 percent of total billed charges "Amphetamines levels, 1 or 2" 50435014_1 CDM 0301 RC 80324 HCPCS inpatient 166 107.9 SIHO - ALL PLANS SIHO - ALL PLANS 149.4 90 999999999 100.51 161.02 percent of total billed charges "Amphetamines levels, 1 or 2" 50435014_1 CDM 0301 RC 80324 HCPCS inpatient 166 107.9 UMR - ALL PLANS UMR - ALL PLANS 116.2 70 999999999 100.51 161.02 percent of total billed charges "Amphetamines levels, 1 or 2" 50435014_1 CDM 0301 RC 80324 HCPCS inpatient 166 107.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 100.51 60.55 999999999 100.51 161.02 percent of total billed charges "Amphetamines levels, 1 or 2" 50435014_1 CDM 0301 RC 80324 HCPCS inpatient 166 107.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 100.51 161.02 "Amphetamines levels, 1 or 2" 50435014_1 CDM 0301 RC 80324 HCPCS inpatient 166 107.9 ANTHEM HMO ANTHEM HMO 999999999 100.51 161.02 "Amphetamines levels, 1 or 2" 50435014_1 CDM 0301 RC 80324 HCPCS inpatient 166 107.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 100.51 161.02 "Amphetamines levels, 1 or 2" 50435014_1 CDM 0301 RC 80324 HCPCS inpatient 166 107.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 100.51 161.02 "Amphetamines levels, 1 or 2" 50435014_1 CDM 0301 RC 80324 HCPCS inpatient 166 107.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 100.51 161.02 "Amphetamines levels, 1 or 2" 50435014_1 CDM 0301 RC 80324 HCPCS inpatient 166 107.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.22 67.6 999999999 100.51 161.02 percent of total billed charges Methylenedioxyamphetamines levels 50435017_1 CDM 0301 RC 80359 HCPCS inpatient 166 107.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.9 65 999999999 100.51 161.02 percent of total billed charges Methylenedioxyamphetamines levels 50435017_1 CDM 0301 RC 80359 HCPCS inpatient 166 107.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.02 97 999999999 100.51 161.02 percent of total billed charges Methylenedioxyamphetamines levels 50435017_1 CDM 0301 RC 80359 HCPCS inpatient 166 107.9 AETNA AETNA 131.14 79 999999999 100.51 161.02 percent of total billed charges Methylenedioxyamphetamines levels 50435017_1 CDM 0301 RC 80359 HCPCS inpatient 166 107.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 129.48 78 999999999 100.51 161.02 percent of total billed charges Methylenedioxyamphetamines levels 50435017_1 CDM 0301 RC 80359 HCPCS inpatient 166 107.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 114.54 69 999999999 100.51 161.02 percent of total billed charges Methylenedioxyamphetamines levels 50435017_1 CDM 0301 RC 80359 HCPCS inpatient 166 107.9 SIHO - ALL PLANS SIHO - ALL PLANS 149.4 90 999999999 100.51 161.02 percent of total billed charges Methylenedioxyamphetamines levels 50435017_1 CDM 0301 RC 80359 HCPCS inpatient 166 107.9 UMR - ALL PLANS UMR - ALL PLANS 116.2 70 999999999 100.51 161.02 percent of total billed charges Methylenedioxyamphetamines levels 50435017_1 CDM 0301 RC 80359 HCPCS inpatient 166 107.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 100.51 60.55 999999999 100.51 161.02 percent of total billed charges Methylenedioxyamphetamines levels 50435017_1 CDM 0301 RC 80359 HCPCS inpatient 166 107.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 100.51 161.02 Methylenedioxyamphetamines levels 50435017_1 CDM 0301 RC 80359 HCPCS inpatient 166 107.9 ANTHEM HMO ANTHEM HMO 999999999 100.51 161.02 Methylenedioxyamphetamines levels 50435017_1 CDM 0301 RC 80359 HCPCS inpatient 166 107.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 100.51 161.02 Methylenedioxyamphetamines levels 50435017_1 CDM 0301 RC 80359 HCPCS inpatient 166 107.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 100.51 161.02 Methylenedioxyamphetamines levels 50435017_1 CDM 0301 RC 80359 HCPCS inpatient 166 107.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 100.51 161.02 Methylenedioxyamphetamines levels 50435017_1 CDM 0301 RC 80359 HCPCS inpatient 166 107.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.22 67.6 999999999 100.51 161.02 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50435835_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50435835_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50435835_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50435835_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50435835_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50435835_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50435835_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50435835_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50435835_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50435835_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50435835_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50435835_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50435835_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50435835_1 CDM 0306 RC 87491 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50435836_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50435836_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50435836_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50435836_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50435836_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50435836_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50435836_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50435836_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50435836_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50435836_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50435836_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50435836_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50435836_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50435836_1 CDM 0306 RC 87591 HCPCS inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges HYDRALAZINE 20 MG/ML VIAL 50435858_1 CDM 0250 RC 67457-0291-01 NDC inpatient 1 UN 33.93 22.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.05 65 999999999 20.54 32.91 percent of total billed charges HYDRALAZINE 20 MG/ML VIAL 50435858_1 CDM 0250 RC 67457-0291-01 NDC inpatient 1 UN 33.93 22.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.91 97 999999999 20.54 32.91 percent of total billed charges HYDRALAZINE 20 MG/ML VIAL 50435858_1 CDM 0250 RC 67457-0291-01 NDC inpatient 1 UN 33.93 22.05 AETNA AETNA 26.8 79 999999999 20.54 32.91 percent of total billed charges HYDRALAZINE 20 MG/ML VIAL 50435858_1 CDM 0250 RC 67457-0291-01 NDC inpatient 1 UN 33.93 22.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 26.47 78 999999999 20.54 32.91 percent of total billed charges HYDRALAZINE 20 MG/ML VIAL 50435858_1 CDM 0250 RC 67457-0291-01 NDC inpatient 1 UN 33.93 22.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 23.41 69 999999999 20.54 32.91 percent of total billed charges HYDRALAZINE 20 MG/ML VIAL 50435858_1 CDM 0250 RC 67457-0291-01 NDC inpatient 1 UN 33.93 22.05 SIHO - ALL PLANS SIHO - ALL PLANS 30.54 90 999999999 20.54 32.91 percent of total billed charges HYDRALAZINE 20 MG/ML VIAL 50435858_1 CDM 0250 RC 67457-0291-01 NDC inpatient 1 UN 33.93 22.05 UMR - ALL PLANS UMR - ALL PLANS 23.75 70 999999999 20.54 32.91 percent of total billed charges HYDRALAZINE 20 MG/ML VIAL 50435858_1 CDM 0250 RC 67457-0291-01 NDC inpatient 1 UN 33.93 22.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.54 60.55 999999999 20.54 32.91 percent of total billed charges HYDRALAZINE 20 MG/ML VIAL 50435858_1 CDM 0250 RC 67457-0291-01 NDC inpatient 1 UN 33.93 22.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.54 32.91 HYDRALAZINE 20 MG/ML VIAL 50435858_1 CDM 0250 RC 67457-0291-01 NDC inpatient 1 UN 33.93 22.05 ANTHEM HMO ANTHEM HMO 999999999 20.54 32.91 HYDRALAZINE 20 MG/ML VIAL 50435858_1 CDM 0250 RC 67457-0291-01 NDC inpatient 1 UN 33.93 22.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.54 32.91 HYDRALAZINE 20 MG/ML VIAL 50435858_1 CDM 0250 RC 67457-0291-01 NDC inpatient 1 UN 33.93 22.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.54 32.91 HYDRALAZINE 20 MG/ML VIAL 50435858_1 CDM 0250 RC 67457-0291-01 NDC inpatient 1 UN 33.93 22.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.54 32.91 HYDRALAZINE 20 MG/ML VIAL 50435858_1 CDM 0250 RC 67457-0291-01 NDC inpatient 1 UN 33.93 22.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.94 67.6 999999999 20.54 32.91 percent of total billed charges TRIFLURIDINE 1% EYE DROPS 50436000_1 CDM 0250 RC 61314-0044-75 NDC inpatient 1 UN 234.95 152.72 SELF PAY DISCOUNT SELF PAY DISCOUNT 152.72 65 999999999 142.26 227.9 percent of total billed charges TRIFLURIDINE 1% EYE DROPS 50436000_1 CDM 0250 RC 61314-0044-75 NDC inpatient 1 UN 234.95 152.72 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 227.9 97 999999999 142.26 227.9 percent of total billed charges TRIFLURIDINE 1% EYE DROPS 50436000_1 CDM 0250 RC 61314-0044-75 NDC inpatient 1 UN 234.95 152.72 AETNA AETNA 185.61 79 999999999 142.26 227.9 percent of total billed charges TRIFLURIDINE 1% EYE DROPS 50436000_1 CDM 0250 RC 61314-0044-75 NDC inpatient 1 UN 234.95 152.72 HUMANA - ALL PLANS HUMANA - ALL PLANS 183.26 78 999999999 142.26 227.9 percent of total billed charges TRIFLURIDINE 1% EYE DROPS 50436000_1 CDM 0250 RC 61314-0044-75 NDC inpatient 1 UN 234.95 152.72 ENCORE - ALL PLANS ENCORE - ALL PLANS 162.12 69 999999999 142.26 227.9 percent of total billed charges TRIFLURIDINE 1% EYE DROPS 50436000_1 CDM 0250 RC 61314-0044-75 NDC inpatient 1 UN 234.95 152.72 SIHO - ALL PLANS SIHO - ALL PLANS 211.46 90 999999999 142.26 227.9 percent of total billed charges TRIFLURIDINE 1% EYE DROPS 50436000_1 CDM 0250 RC 61314-0044-75 NDC inpatient 1 UN 234.95 152.72 UMR - ALL PLANS UMR - ALL PLANS 164.47 70 999999999 142.26 227.9 percent of total billed charges TRIFLURIDINE 1% EYE DROPS 50436000_1 CDM 0250 RC 61314-0044-75 NDC inpatient 1 UN 234.95 152.72 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 142.26 60.55 999999999 142.26 227.9 percent of total billed charges TRIFLURIDINE 1% EYE DROPS 50436000_1 CDM 0250 RC 61314-0044-75 NDC inpatient 1 UN 234.95 152.72 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 142.26 227.9 TRIFLURIDINE 1% EYE DROPS 50436000_1 CDM 0250 RC 61314-0044-75 NDC inpatient 1 UN 234.95 152.72 ANTHEM HMO ANTHEM HMO 999999999 142.26 227.9 TRIFLURIDINE 1% EYE DROPS 50436000_1 CDM 0250 RC 61314-0044-75 NDC inpatient 1 UN 234.95 152.72 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 142.26 227.9 TRIFLURIDINE 1% EYE DROPS 50436000_1 CDM 0250 RC 61314-0044-75 NDC inpatient 1 UN 234.95 152.72 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 142.26 227.9 TRIFLURIDINE 1% EYE DROPS 50436000_1 CDM 0250 RC 61314-0044-75 NDC inpatient 1 UN 234.95 152.72 UHC - ALL PLANS UHC - ALL PLANS 999999999 142.26 227.9 TRIFLURIDINE 1% EYE DROPS 50436000_1 CDM 0250 RC 61314-0044-75 NDC inpatient 1 UN 234.95 152.72 CIGNA - ALL PLANS CIGNA - ALL PLANS 158.83 67.6 999999999 142.26 227.9 percent of total billed charges PENICILLIN GK 5 MILLION UNIT 50436874_1 CDM 0250 RC 44567-0311-10 NDC inpatient 1 UN 41.02 26.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.66 65 999999999 24.84 39.79 percent of total billed charges PENICILLIN GK 5 MILLION UNIT 50436874_1 CDM 0250 RC 44567-0311-10 NDC inpatient 1 UN 41.02 26.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39.79 97 999999999 24.84 39.79 percent of total billed charges PENICILLIN GK 5 MILLION UNIT 50436874_1 CDM 0250 RC 44567-0311-10 NDC inpatient 1 UN 41.02 26.66 AETNA AETNA 32.41 79 999999999 24.84 39.79 percent of total billed charges PENICILLIN GK 5 MILLION UNIT 50436874_1 CDM 0250 RC 44567-0311-10 NDC inpatient 1 UN 41.02 26.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 32 78 999999999 24.84 39.79 percent of total billed charges PENICILLIN GK 5 MILLION UNIT 50436874_1 CDM 0250 RC 44567-0311-10 NDC inpatient 1 UN 41.02 26.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.3 69 999999999 24.84 39.79 percent of total billed charges PENICILLIN GK 5 MILLION UNIT 50436874_1 CDM 0250 RC 44567-0311-10 NDC inpatient 1 UN 41.02 26.66 SIHO - ALL PLANS SIHO - ALL PLANS 36.92 90 999999999 24.84 39.79 percent of total billed charges PENICILLIN GK 5 MILLION UNIT 50436874_1 CDM 0250 RC 44567-0311-10 NDC inpatient 1 UN 41.02 26.66 UMR - ALL PLANS UMR - ALL PLANS 28.71 70 999999999 24.84 39.79 percent of total billed charges PENICILLIN GK 5 MILLION UNIT 50436874_1 CDM 0250 RC 44567-0311-10 NDC inpatient 1 UN 41.02 26.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.84 60.55 999999999 24.84 39.79 percent of total billed charges PENICILLIN GK 5 MILLION UNIT 50436874_1 CDM 0250 RC 44567-0311-10 NDC inpatient 1 UN 41.02 26.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.84 39.79 PENICILLIN GK 5 MILLION UNIT 50436874_1 CDM 0250 RC 44567-0311-10 NDC inpatient 1 UN 41.02 26.66 ANTHEM HMO ANTHEM HMO 999999999 24.84 39.79 PENICILLIN GK 5 MILLION UNIT 50436874_1 CDM 0250 RC 44567-0311-10 NDC inpatient 1 UN 41.02 26.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.84 39.79 PENICILLIN GK 5 MILLION UNIT 50436874_1 CDM 0250 RC 44567-0311-10 NDC inpatient 1 UN 41.02 26.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.84 39.79 PENICILLIN GK 5 MILLION UNIT 50436874_1 CDM 0250 RC 44567-0311-10 NDC inpatient 1 UN 41.02 26.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.84 39.79 PENICILLIN GK 5 MILLION UNIT 50436874_1 CDM 0250 RC 44567-0311-10 NDC inpatient 1 UN 41.02 26.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.73 67.6 999999999 24.84 39.79 percent of total billed charges Opiates levels 50438202_1 CDM 0301 RC 80361 HCPCS inpatient 207 134.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 134.55 65 999999999 125.34 200.79 percent of total billed charges Opiates levels 50438202_1 CDM 0301 RC 80361 HCPCS inpatient 207 134.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 200.79 97 999999999 125.34 200.79 percent of total billed charges Opiates levels 50438202_1 CDM 0301 RC 80361 HCPCS inpatient 207 134.55 AETNA AETNA 163.53 79 999999999 125.34 200.79 percent of total billed charges Opiates levels 50438202_1 CDM 0301 RC 80361 HCPCS inpatient 207 134.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 161.46 78 999999999 125.34 200.79 percent of total billed charges Opiates levels 50438202_1 CDM 0301 RC 80361 HCPCS inpatient 207 134.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.83 69 999999999 125.34 200.79 percent of total billed charges Opiates levels 50438202_1 CDM 0301 RC 80361 HCPCS inpatient 207 134.55 SIHO - ALL PLANS SIHO - ALL PLANS 186.3 90 999999999 125.34 200.79 percent of total billed charges Opiates levels 50438202_1 CDM 0301 RC 80361 HCPCS inpatient 207 134.55 UMR - ALL PLANS UMR - ALL PLANS 144.9 70 999999999 125.34 200.79 percent of total billed charges Opiates levels 50438202_1 CDM 0301 RC 80361 HCPCS inpatient 207 134.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 125.34 60.55 999999999 125.34 200.79 percent of total billed charges Opiates levels 50438202_1 CDM 0301 RC 80361 HCPCS inpatient 207 134.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 125.34 200.79 Opiates levels 50438202_1 CDM 0301 RC 80361 HCPCS inpatient 207 134.55 ANTHEM HMO ANTHEM HMO 999999999 125.34 200.79 Opiates levels 50438202_1 CDM 0301 RC 80361 HCPCS inpatient 207 134.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 125.34 200.79 Opiates levels 50438202_1 CDM 0301 RC 80361 HCPCS inpatient 207 134.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 125.34 200.79 Opiates levels 50438202_1 CDM 0301 RC 80361 HCPCS inpatient 207 134.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 125.34 200.79 Opiates levels 50438202_1 CDM 0301 RC 80361 HCPCS inpatient 207 134.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.93 67.6 999999999 125.34 200.79 percent of total billed charges Oxycodone levels 50438220_1 CDM 0301 RC 80365 HCPCS inpatient 130 84.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 84.5 65 999999999 78.72 126.1 percent of total billed charges Oxycodone levels 50438220_1 CDM 0301 RC 80365 HCPCS inpatient 130 84.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 126.1 97 999999999 78.72 126.1 percent of total billed charges Oxycodone levels 50438220_1 CDM 0301 RC 80365 HCPCS inpatient 130 84.5 AETNA AETNA 102.7 79 999999999 78.72 126.1 percent of total billed charges Oxycodone levels 50438220_1 CDM 0301 RC 80365 HCPCS inpatient 130 84.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 101.4 78 999999999 78.72 126.1 percent of total billed charges Oxycodone levels 50438220_1 CDM 0301 RC 80365 HCPCS inpatient 130 84.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.7 69 999999999 78.72 126.1 percent of total billed charges Oxycodone levels 50438220_1 CDM 0301 RC 80365 HCPCS inpatient 130 84.5 SIHO - ALL PLANS SIHO - ALL PLANS 117 90 999999999 78.72 126.1 percent of total billed charges Oxycodone levels 50438220_1 CDM 0301 RC 80365 HCPCS inpatient 130 84.5 UMR - ALL PLANS UMR - ALL PLANS 91 70 999999999 78.72 126.1 percent of total billed charges Oxycodone levels 50438220_1 CDM 0301 RC 80365 HCPCS inpatient 130 84.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.72 60.55 999999999 78.72 126.1 percent of total billed charges Oxycodone levels 50438220_1 CDM 0301 RC 80365 HCPCS inpatient 130 84.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.72 126.1 Oxycodone levels 50438220_1 CDM 0301 RC 80365 HCPCS inpatient 130 84.5 ANTHEM HMO ANTHEM HMO 999999999 78.72 126.1 Oxycodone levels 50438220_1 CDM 0301 RC 80365 HCPCS inpatient 130 84.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.72 126.1 Oxycodone levels 50438220_1 CDM 0301 RC 80365 HCPCS inpatient 130 84.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.72 126.1 Oxycodone levels 50438220_1 CDM 0301 RC 80365 HCPCS inpatient 130 84.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.72 126.1 Oxycodone levels 50438220_1 CDM 0301 RC 80365 HCPCS inpatient 130 84.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.88 67.6 999999999 78.72 126.1 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439139_1 CDM 0360 RC inpatient 351 228.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 228.15 65 999999999 212.53 340.47 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439139_1 CDM 0360 RC inpatient 351 228.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 340.47 97 999999999 212.53 340.47 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439139_1 CDM 0360 RC inpatient 351 228.15 AETNA AETNA 277.29 79 999999999 212.53 340.47 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439139_1 CDM 0360 RC inpatient 351 228.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 273.78 78 999999999 212.53 340.47 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439139_1 CDM 0360 RC inpatient 351 228.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 242.19 69 999999999 212.53 340.47 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439139_1 CDM 0360 RC inpatient 351 228.15 SIHO - ALL PLANS SIHO - ALL PLANS 315.9 90 999999999 212.53 340.47 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439139_1 CDM 0360 RC inpatient 351 228.15 UMR - ALL PLANS UMR - ALL PLANS 245.7 70 999999999 212.53 340.47 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439139_1 CDM 0360 RC inpatient 351 228.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 212.53 60.55 999999999 212.53 340.47 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439139_1 CDM 0360 RC inpatient 351 228.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 212.53 340.47 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439139_1 CDM 0360 RC inpatient 351 228.15 ANTHEM HMO ANTHEM HMO 999999999 212.53 340.47 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439139_1 CDM 0360 RC inpatient 351 228.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 212.53 340.47 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439139_1 CDM 0360 RC inpatient 351 228.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 212.53 340.47 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439139_1 CDM 0360 RC inpatient 351 228.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 212.53 340.47 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439139_1 CDM 0360 RC inpatient 351 228.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 237.28 67.6 999999999 212.53 340.47 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439142_1 CDM 0360 RC inpatient 923 599.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 599.95 65 999999999 558.88 895.31 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439142_1 CDM 0360 RC inpatient 923 599.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 895.31 97 999999999 558.88 895.31 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439142_1 CDM 0360 RC inpatient 923 599.95 AETNA AETNA 729.17 79 999999999 558.88 895.31 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439142_1 CDM 0360 RC inpatient 923 599.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 719.94 78 999999999 558.88 895.31 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439142_1 CDM 0360 RC inpatient 923 599.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 636.87 69 999999999 558.88 895.31 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439142_1 CDM 0360 RC inpatient 923 599.95 SIHO - ALL PLANS SIHO - ALL PLANS 830.7 90 999999999 558.88 895.31 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439142_1 CDM 0360 RC inpatient 923 599.95 UMR - ALL PLANS UMR - ALL PLANS 646.1 70 999999999 558.88 895.31 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439142_1 CDM 0360 RC inpatient 923 599.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 558.88 60.55 999999999 558.88 895.31 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439142_1 CDM 0360 RC inpatient 923 599.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 558.88 895.31 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439142_1 CDM 0360 RC inpatient 923 599.95 ANTHEM HMO ANTHEM HMO 999999999 558.88 895.31 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439142_1 CDM 0360 RC inpatient 923 599.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 558.88 895.31 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439142_1 CDM 0360 RC inpatient 923 599.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 558.88 895.31 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439142_1 CDM 0360 RC inpatient 923 599.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 558.88 895.31 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439142_1 CDM 0360 RC inpatient 923 599.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 623.95 67.6 999999999 558.88 895.31 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439143_1 CDM 0360 RC inpatient 383 248.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 248.95 65 999999999 231.91 371.51 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439143_1 CDM 0360 RC inpatient 383 248.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 371.51 97 999999999 231.91 371.51 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439143_1 CDM 0360 RC inpatient 383 248.95 AETNA AETNA 302.57 79 999999999 231.91 371.51 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439143_1 CDM 0360 RC inpatient 383 248.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 298.74 78 999999999 231.91 371.51 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439143_1 CDM 0360 RC inpatient 383 248.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 264.27 69 999999999 231.91 371.51 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439143_1 CDM 0360 RC inpatient 383 248.95 SIHO - ALL PLANS SIHO - ALL PLANS 344.7 90 999999999 231.91 371.51 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439143_1 CDM 0360 RC inpatient 383 248.95 UMR - ALL PLANS UMR - ALL PLANS 268.1 70 999999999 231.91 371.51 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439143_1 CDM 0360 RC inpatient 383 248.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 231.91 60.55 999999999 231.91 371.51 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439143_1 CDM 0360 RC inpatient 383 248.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 231.91 371.51 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439143_1 CDM 0360 RC inpatient 383 248.95 ANTHEM HMO ANTHEM HMO 999999999 231.91 371.51 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439143_1 CDM 0360 RC inpatient 383 248.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 231.91 371.51 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439143_1 CDM 0360 RC inpatient 383 248.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 231.91 371.51 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439143_1 CDM 0360 RC inpatient 383 248.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 231.91 371.51 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439143_1 CDM 0360 RC inpatient 383 248.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 258.91 67.6 999999999 231.91 371.51 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439144_1 CDM 0360 RC inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439144_1 CDM 0360 RC inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439144_1 CDM 0360 RC inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439144_1 CDM 0360 RC inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439144_1 CDM 0360 RC inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439144_1 CDM 0360 RC inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439144_1 CDM 0360 RC inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439144_1 CDM 0360 RC inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439144_1 CDM 0360 RC inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439144_1 CDM 0360 RC inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439144_1 CDM 0360 RC inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439144_1 CDM 0360 RC inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439144_1 CDM 0360 RC inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439144_1 CDM 0360 RC inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges VAPR WAND UNIT 50439145_1 CDM 0272 RC inpatient 319 207.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 207.35 65 999999999 193.15 309.43 percent of total billed charges VAPR WAND UNIT 50439145_1 CDM 0272 RC inpatient 319 207.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 309.43 97 999999999 193.15 309.43 percent of total billed charges VAPR WAND UNIT 50439145_1 CDM 0272 RC inpatient 319 207.35 AETNA AETNA 252.01 79 999999999 193.15 309.43 percent of total billed charges VAPR WAND UNIT 50439145_1 CDM 0272 RC inpatient 319 207.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 248.82 78 999999999 193.15 309.43 percent of total billed charges VAPR WAND UNIT 50439145_1 CDM 0272 RC inpatient 319 207.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 220.11 69 999999999 193.15 309.43 percent of total billed charges VAPR WAND UNIT 50439145_1 CDM 0272 RC inpatient 319 207.35 SIHO - ALL PLANS SIHO - ALL PLANS 287.1 90 999999999 193.15 309.43 percent of total billed charges VAPR WAND UNIT 50439145_1 CDM 0272 RC inpatient 319 207.35 UMR - ALL PLANS UMR - ALL PLANS 223.3 70 999999999 193.15 309.43 percent of total billed charges VAPR WAND UNIT 50439145_1 CDM 0272 RC inpatient 319 207.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 193.15 60.55 999999999 193.15 309.43 percent of total billed charges VAPR WAND UNIT 50439145_1 CDM 0272 RC inpatient 319 207.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 193.15 309.43 VAPR WAND UNIT 50439145_1 CDM 0272 RC inpatient 319 207.35 ANTHEM HMO ANTHEM HMO 999999999 193.15 309.43 VAPR WAND UNIT 50439145_1 CDM 0272 RC inpatient 319 207.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 193.15 309.43 VAPR WAND UNIT 50439145_1 CDM 0272 RC inpatient 319 207.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 193.15 309.43 VAPR WAND UNIT 50439145_1 CDM 0272 RC inpatient 319 207.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 193.15 309.43 VAPR WAND UNIT 50439145_1 CDM 0272 RC inpatient 319 207.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 215.64 67.6 999999999 193.15 309.43 percent of total billed charges ARTHROSCOPY SHAVER 50439146_1 CDM 0272 RC inpatient 121 78.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 78.65 65 999999999 73.27 117.37 percent of total billed charges ARTHROSCOPY SHAVER 50439146_1 CDM 0272 RC inpatient 121 78.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 117.37 97 999999999 73.27 117.37 percent of total billed charges ARTHROSCOPY SHAVER 50439146_1 CDM 0272 RC inpatient 121 78.65 AETNA AETNA 95.59 79 999999999 73.27 117.37 percent of total billed charges ARTHROSCOPY SHAVER 50439146_1 CDM 0272 RC inpatient 121 78.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 94.38 78 999999999 73.27 117.37 percent of total billed charges ARTHROSCOPY SHAVER 50439146_1 CDM 0272 RC inpatient 121 78.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 83.49 69 999999999 73.27 117.37 percent of total billed charges ARTHROSCOPY SHAVER 50439146_1 CDM 0272 RC inpatient 121 78.65 SIHO - ALL PLANS SIHO - ALL PLANS 108.9 90 999999999 73.27 117.37 percent of total billed charges ARTHROSCOPY SHAVER 50439146_1 CDM 0272 RC inpatient 121 78.65 UMR - ALL PLANS UMR - ALL PLANS 84.7 70 999999999 73.27 117.37 percent of total billed charges ARTHROSCOPY SHAVER 50439146_1 CDM 0272 RC inpatient 121 78.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.27 60.55 999999999 73.27 117.37 percent of total billed charges ARTHROSCOPY SHAVER 50439146_1 CDM 0272 RC inpatient 121 78.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.27 117.37 ARTHROSCOPY SHAVER 50439146_1 CDM 0272 RC inpatient 121 78.65 ANTHEM HMO ANTHEM HMO 999999999 73.27 117.37 ARTHROSCOPY SHAVER 50439146_1 CDM 0272 RC inpatient 121 78.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.27 117.37 ARTHROSCOPY SHAVER 50439146_1 CDM 0272 RC inpatient 121 78.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.27 117.37 ARTHROSCOPY SHAVER 50439146_1 CDM 0272 RC inpatient 121 78.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.27 117.37 ARTHROSCOPY SHAVER 50439146_1 CDM 0272 RC inpatient 121 78.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.8 67.6 999999999 73.27 117.37 percent of total billed charges MICRODEBRIDER 50439147_1 CDM 0272 RC inpatient 319 207.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 207.35 65 999999999 193.15 309.43 percent of total billed charges MICRODEBRIDER 50439147_1 CDM 0272 RC inpatient 319 207.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 309.43 97 999999999 193.15 309.43 percent of total billed charges MICRODEBRIDER 50439147_1 CDM 0272 RC inpatient 319 207.35 AETNA AETNA 252.01 79 999999999 193.15 309.43 percent of total billed charges MICRODEBRIDER 50439147_1 CDM 0272 RC inpatient 319 207.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 248.82 78 999999999 193.15 309.43 percent of total billed charges MICRODEBRIDER 50439147_1 CDM 0272 RC inpatient 319 207.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 220.11 69 999999999 193.15 309.43 percent of total billed charges MICRODEBRIDER 50439147_1 CDM 0272 RC inpatient 319 207.35 SIHO - ALL PLANS SIHO - ALL PLANS 287.1 90 999999999 193.15 309.43 percent of total billed charges MICRODEBRIDER 50439147_1 CDM 0272 RC inpatient 319 207.35 UMR - ALL PLANS UMR - ALL PLANS 223.3 70 999999999 193.15 309.43 percent of total billed charges MICRODEBRIDER 50439147_1 CDM 0272 RC inpatient 319 207.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 193.15 60.55 999999999 193.15 309.43 percent of total billed charges MICRODEBRIDER 50439147_1 CDM 0272 RC inpatient 319 207.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 193.15 309.43 MICRODEBRIDER 50439147_1 CDM 0272 RC inpatient 319 207.35 ANTHEM HMO ANTHEM HMO 999999999 193.15 309.43 MICRODEBRIDER 50439147_1 CDM 0272 RC inpatient 319 207.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 193.15 309.43 MICRODEBRIDER 50439147_1 CDM 0272 RC inpatient 319 207.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 193.15 309.43 MICRODEBRIDER 50439147_1 CDM 0272 RC inpatient 319 207.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 193.15 309.43 MICRODEBRIDER 50439147_1 CDM 0272 RC inpatient 319 207.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 215.64 67.6 999999999 193.15 309.43 percent of total billed charges DAVINCI-ROBOT 50439148_1 CDM 0272 RC inpatient 3242 2107.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 2107.3 65 999999999 1963.03 3144.74 percent of total billed charges DAVINCI-ROBOT 50439148_1 CDM 0272 RC inpatient 3242 2107.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3144.74 97 999999999 1963.03 3144.74 percent of total billed charges DAVINCI-ROBOT 50439148_1 CDM 0272 RC inpatient 3242 2107.3 AETNA AETNA 2561.18 79 999999999 1963.03 3144.74 percent of total billed charges DAVINCI-ROBOT 50439148_1 CDM 0272 RC inpatient 3242 2107.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 2528.76 78 999999999 1963.03 3144.74 percent of total billed charges DAVINCI-ROBOT 50439148_1 CDM 0272 RC inpatient 3242 2107.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 2236.98 69 999999999 1963.03 3144.74 percent of total billed charges DAVINCI-ROBOT 50439148_1 CDM 0272 RC inpatient 3242 2107.3 SIHO - ALL PLANS SIHO - ALL PLANS 2917.8 90 999999999 1963.03 3144.74 percent of total billed charges DAVINCI-ROBOT 50439148_1 CDM 0272 RC inpatient 3242 2107.3 UMR - ALL PLANS UMR - ALL PLANS 2269.4 70 999999999 1963.03 3144.74 percent of total billed charges DAVINCI-ROBOT 50439148_1 CDM 0272 RC inpatient 3242 2107.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1963.03 60.55 999999999 1963.03 3144.74 percent of total billed charges DAVINCI-ROBOT 50439148_1 CDM 0272 RC inpatient 3242 2107.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1963.03 3144.74 DAVINCI-ROBOT 50439148_1 CDM 0272 RC inpatient 3242 2107.3 ANTHEM HMO ANTHEM HMO 999999999 1963.03 3144.74 DAVINCI-ROBOT 50439148_1 CDM 0272 RC inpatient 3242 2107.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1963.03 3144.74 DAVINCI-ROBOT 50439148_1 CDM 0272 RC inpatient 3242 2107.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1963.03 3144.74 DAVINCI-ROBOT 50439148_1 CDM 0272 RC inpatient 3242 2107.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1963.03 3144.74 DAVINCI-ROBOT 50439148_1 CDM 0272 RC inpatient 3242 2107.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 2191.59 67.6 999999999 1963.03 3144.74 percent of total billed charges INSUFFLATOR 50439149_1 CDM 0272 RC inpatient 129 83.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 83.85 65 999999999 78.11 125.13 percent of total billed charges INSUFFLATOR 50439149_1 CDM 0272 RC inpatient 129 83.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 125.13 97 999999999 78.11 125.13 percent of total billed charges INSUFFLATOR 50439149_1 CDM 0272 RC inpatient 129 83.85 AETNA AETNA 101.91 79 999999999 78.11 125.13 percent of total billed charges INSUFFLATOR 50439149_1 CDM 0272 RC inpatient 129 83.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 100.62 78 999999999 78.11 125.13 percent of total billed charges INSUFFLATOR 50439149_1 CDM 0272 RC inpatient 129 83.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.01 69 999999999 78.11 125.13 percent of total billed charges INSUFFLATOR 50439149_1 CDM 0272 RC inpatient 129 83.85 SIHO - ALL PLANS SIHO - ALL PLANS 116.1 90 999999999 78.11 125.13 percent of total billed charges INSUFFLATOR 50439149_1 CDM 0272 RC inpatient 129 83.85 UMR - ALL PLANS UMR - ALL PLANS 90.3 70 999999999 78.11 125.13 percent of total billed charges INSUFFLATOR 50439149_1 CDM 0272 RC inpatient 129 83.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.11 60.55 999999999 78.11 125.13 percent of total billed charges INSUFFLATOR 50439149_1 CDM 0272 RC inpatient 129 83.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.11 125.13 INSUFFLATOR 50439149_1 CDM 0272 RC inpatient 129 83.85 ANTHEM HMO ANTHEM HMO 999999999 78.11 125.13 INSUFFLATOR 50439149_1 CDM 0272 RC inpatient 129 83.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.11 125.13 INSUFFLATOR 50439149_1 CDM 0272 RC inpatient 129 83.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.11 125.13 INSUFFLATOR 50439149_1 CDM 0272 RC inpatient 129 83.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.11 125.13 INSUFFLATOR 50439149_1 CDM 0272 RC inpatient 129 83.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.2 67.6 999999999 78.11 125.13 percent of total billed charges LASERS 50439150_1 CDM 0272 RC inpatient 1624 1055.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1055.6 65 999999999 983.33 1575.28 percent of total billed charges LASERS 50439150_1 CDM 0272 RC inpatient 1624 1055.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1575.28 97 999999999 983.33 1575.28 percent of total billed charges LASERS 50439150_1 CDM 0272 RC inpatient 1624 1055.6 AETNA AETNA 1282.96 79 999999999 983.33 1575.28 percent of total billed charges LASERS 50439150_1 CDM 0272 RC inpatient 1624 1055.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1266.72 78 999999999 983.33 1575.28 percent of total billed charges LASERS 50439150_1 CDM 0272 RC inpatient 1624 1055.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1120.56 69 999999999 983.33 1575.28 percent of total billed charges LASERS 50439150_1 CDM 0272 RC inpatient 1624 1055.6 SIHO - ALL PLANS SIHO - ALL PLANS 1461.6 90 999999999 983.33 1575.28 percent of total billed charges LASERS 50439150_1 CDM 0272 RC inpatient 1624 1055.6 UMR - ALL PLANS UMR - ALL PLANS 1136.8 70 999999999 983.33 1575.28 percent of total billed charges LASERS 50439150_1 CDM 0272 RC inpatient 1624 1055.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 983.33 60.55 999999999 983.33 1575.28 percent of total billed charges LASERS 50439150_1 CDM 0272 RC inpatient 1624 1055.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 983.33 1575.28 LASERS 50439150_1 CDM 0272 RC inpatient 1624 1055.6 ANTHEM HMO ANTHEM HMO 999999999 983.33 1575.28 LASERS 50439150_1 CDM 0272 RC inpatient 1624 1055.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 983.33 1575.28 LASERS 50439150_1 CDM 0272 RC inpatient 1624 1055.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 983.33 1575.28 LASERS 50439150_1 CDM 0272 RC inpatient 1624 1055.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 983.33 1575.28 LASERS 50439150_1 CDM 0272 RC inpatient 1624 1055.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1097.82 67.6 999999999 983.33 1575.28 percent of total billed charges MICROSCOPES 50439151_1 CDM 0272 RC inpatient 441 286.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 286.65 65 999999999 267.03 427.77 percent of total billed charges MICROSCOPES 50439151_1 CDM 0272 RC inpatient 441 286.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 427.77 97 999999999 267.03 427.77 percent of total billed charges MICROSCOPES 50439151_1 CDM 0272 RC inpatient 441 286.65 AETNA AETNA 348.39 79 999999999 267.03 427.77 percent of total billed charges MICROSCOPES 50439151_1 CDM 0272 RC inpatient 441 286.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 343.98 78 999999999 267.03 427.77 percent of total billed charges MICROSCOPES 50439151_1 CDM 0272 RC inpatient 441 286.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 304.29 69 999999999 267.03 427.77 percent of total billed charges MICROSCOPES 50439151_1 CDM 0272 RC inpatient 441 286.65 SIHO - ALL PLANS SIHO - ALL PLANS 396.9 90 999999999 267.03 427.77 percent of total billed charges MICROSCOPES 50439151_1 CDM 0272 RC inpatient 441 286.65 UMR - ALL PLANS UMR - ALL PLANS 308.7 70 999999999 267.03 427.77 percent of total billed charges MICROSCOPES 50439151_1 CDM 0272 RC inpatient 441 286.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 267.03 60.55 999999999 267.03 427.77 percent of total billed charges MICROSCOPES 50439151_1 CDM 0272 RC inpatient 441 286.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 267.03 427.77 MICROSCOPES 50439151_1 CDM 0272 RC inpatient 441 286.65 ANTHEM HMO ANTHEM HMO 999999999 267.03 427.77 MICROSCOPES 50439151_1 CDM 0272 RC inpatient 441 286.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 267.03 427.77 MICROSCOPES 50439151_1 CDM 0272 RC inpatient 441 286.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 267.03 427.77 MICROSCOPES 50439151_1 CDM 0272 RC inpatient 441 286.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 267.03 427.77 MICROSCOPES 50439151_1 CDM 0272 RC inpatient 441 286.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 298.12 67.6 999999999 267.03 427.77 percent of total billed charges PHACO 50439152_1 CDM 0272 RC inpatient 695 451.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 451.75 65 999999999 420.82 674.15 percent of total billed charges PHACO 50439152_1 CDM 0272 RC inpatient 695 451.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 674.15 97 999999999 420.82 674.15 percent of total billed charges PHACO 50439152_1 CDM 0272 RC inpatient 695 451.75 AETNA AETNA 549.05 79 999999999 420.82 674.15 percent of total billed charges PHACO 50439152_1 CDM 0272 RC inpatient 695 451.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 542.1 78 999999999 420.82 674.15 percent of total billed charges PHACO 50439152_1 CDM 0272 RC inpatient 695 451.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 479.55 69 999999999 420.82 674.15 percent of total billed charges PHACO 50439152_1 CDM 0272 RC inpatient 695 451.75 SIHO - ALL PLANS SIHO - ALL PLANS 625.5 90 999999999 420.82 674.15 percent of total billed charges PHACO 50439152_1 CDM 0272 RC inpatient 695 451.75 UMR - ALL PLANS UMR - ALL PLANS 486.5 70 999999999 420.82 674.15 percent of total billed charges PHACO 50439152_1 CDM 0272 RC inpatient 695 451.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 420.82 60.55 999999999 420.82 674.15 percent of total billed charges PHACO 50439152_1 CDM 0272 RC inpatient 695 451.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 420.82 674.15 PHACO 50439152_1 CDM 0272 RC inpatient 695 451.75 ANTHEM HMO ANTHEM HMO 999999999 420.82 674.15 PHACO 50439152_1 CDM 0272 RC inpatient 695 451.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 420.82 674.15 PHACO 50439152_1 CDM 0272 RC inpatient 695 451.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 420.82 674.15 PHACO 50439152_1 CDM 0272 RC inpatient 695 451.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 420.82 674.15 PHACO 50439152_1 CDM 0272 RC inpatient 695 451.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 469.82 67.6 999999999 420.82 674.15 percent of total billed charges SCOPES 50439153_1 CDM 0272 RC inpatient 396 257.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 257.4 65 999999999 239.78 384.12 percent of total billed charges SCOPES 50439153_1 CDM 0272 RC inpatient 396 257.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 384.12 97 999999999 239.78 384.12 percent of total billed charges SCOPES 50439153_1 CDM 0272 RC inpatient 396 257.4 AETNA AETNA 312.84 79 999999999 239.78 384.12 percent of total billed charges SCOPES 50439153_1 CDM 0272 RC inpatient 396 257.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 308.88 78 999999999 239.78 384.12 percent of total billed charges SCOPES 50439153_1 CDM 0272 RC inpatient 396 257.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 273.24 69 999999999 239.78 384.12 percent of total billed charges SCOPES 50439153_1 CDM 0272 RC inpatient 396 257.4 SIHO - ALL PLANS SIHO - ALL PLANS 356.4 90 999999999 239.78 384.12 percent of total billed charges SCOPES 50439153_1 CDM 0272 RC inpatient 396 257.4 UMR - ALL PLANS UMR - ALL PLANS 277.2 70 999999999 239.78 384.12 percent of total billed charges SCOPES 50439153_1 CDM 0272 RC inpatient 396 257.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 239.78 60.55 999999999 239.78 384.12 percent of total billed charges SCOPES 50439153_1 CDM 0272 RC inpatient 396 257.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 239.78 384.12 SCOPES 50439153_1 CDM 0272 RC inpatient 396 257.4 ANTHEM HMO ANTHEM HMO 999999999 239.78 384.12 SCOPES 50439153_1 CDM 0272 RC inpatient 396 257.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 239.78 384.12 SCOPES 50439153_1 CDM 0272 RC inpatient 396 257.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 239.78 384.12 SCOPES 50439153_1 CDM 0272 RC inpatient 396 257.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 239.78 384.12 SCOPES 50439153_1 CDM 0272 RC inpatient 396 257.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 267.7 67.6 999999999 239.78 384.12 percent of total billed charges VENTILATOR IN SURGERY CHARGE 50439154_1 CDM 0370 RC inpatient 237 154.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.05 65 999999999 143.5 229.89 percent of total billed charges VENTILATOR IN SURGERY CHARGE 50439154_1 CDM 0370 RC inpatient 237 154.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 229.89 97 999999999 143.5 229.89 percent of total billed charges VENTILATOR IN SURGERY CHARGE 50439154_1 CDM 0370 RC inpatient 237 154.05 AETNA AETNA 187.23 79 999999999 143.5 229.89 percent of total billed charges VENTILATOR IN SURGERY CHARGE 50439154_1 CDM 0370 RC inpatient 237 154.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 184.86 78 999999999 143.5 229.89 percent of total billed charges VENTILATOR IN SURGERY CHARGE 50439154_1 CDM 0370 RC inpatient 237 154.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 163.53 69 999999999 143.5 229.89 percent of total billed charges VENTILATOR IN SURGERY CHARGE 50439154_1 CDM 0370 RC inpatient 237 154.05 SIHO - ALL PLANS SIHO - ALL PLANS 213.3 90 999999999 143.5 229.89 percent of total billed charges VENTILATOR IN SURGERY CHARGE 50439154_1 CDM 0370 RC inpatient 237 154.05 UMR - ALL PLANS UMR - ALL PLANS 165.9 70 999999999 143.5 229.89 percent of total billed charges VENTILATOR IN SURGERY CHARGE 50439154_1 CDM 0370 RC inpatient 237 154.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 143.5 60.55 999999999 143.5 229.89 percent of total billed charges VENTILATOR IN SURGERY CHARGE 50439154_1 CDM 0370 RC inpatient 237 154.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 143.5 229.89 VENTILATOR IN SURGERY CHARGE 50439154_1 CDM 0370 RC inpatient 237 154.05 ANTHEM HMO ANTHEM HMO 999999999 143.5 229.89 VENTILATOR IN SURGERY CHARGE 50439154_1 CDM 0370 RC inpatient 237 154.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 143.5 229.89 VENTILATOR IN SURGERY CHARGE 50439154_1 CDM 0370 RC inpatient 237 154.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 143.5 229.89 VENTILATOR IN SURGERY CHARGE 50439154_1 CDM 0370 RC inpatient 237 154.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 143.5 229.89 VENTILATOR IN SURGERY CHARGE 50439154_1 CDM 0370 RC inpatient 237 154.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.21 67.6 999999999 143.5 229.89 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439155_1 CDM 0360 RC inpatient 1020 663 SELF PAY DISCOUNT SELF PAY DISCOUNT 663 65 999999999 617.61 989.4 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439155_1 CDM 0360 RC inpatient 1020 663 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 989.4 97 999999999 617.61 989.4 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439155_1 CDM 0360 RC inpatient 1020 663 AETNA AETNA 805.8 79 999999999 617.61 989.4 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439155_1 CDM 0360 RC inpatient 1020 663 HUMANA - ALL PLANS HUMANA - ALL PLANS 795.6 78 999999999 617.61 989.4 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439155_1 CDM 0360 RC inpatient 1020 663 ENCORE - ALL PLANS ENCORE - ALL PLANS 703.8 69 999999999 617.61 989.4 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439155_1 CDM 0360 RC inpatient 1020 663 SIHO - ALL PLANS SIHO - ALL PLANS 918 90 999999999 617.61 989.4 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439155_1 CDM 0360 RC inpatient 1020 663 UMR - ALL PLANS UMR - ALL PLANS 714 70 999999999 617.61 989.4 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439155_1 CDM 0360 RC inpatient 1020 663 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 617.61 60.55 999999999 617.61 989.4 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439155_1 CDM 0360 RC inpatient 1020 663 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 617.61 989.4 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439155_1 CDM 0360 RC inpatient 1020 663 ANTHEM HMO ANTHEM HMO 999999999 617.61 989.4 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439155_1 CDM 0360 RC inpatient 1020 663 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 617.61 989.4 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439155_1 CDM 0360 RC inpatient 1020 663 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 617.61 989.4 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439155_1 CDM 0360 RC inpatient 1020 663 UHC - ALL PLANS UHC - ALL PLANS 999999999 617.61 989.4 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439155_1 CDM 0360 RC inpatient 1020 663 CIGNA - ALL PLANS CIGNA - ALL PLANS 689.52 67.6 999999999 617.61 989.4 percent of total billed charges GENERAL ANESTHESIA PER 15 MINUTES 50439156_1 CDM 0370 RC inpatient 535 347.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 347.75 65 999999999 323.94 518.95 percent of total billed charges GENERAL ANESTHESIA PER 15 MINUTES 50439156_1 CDM 0370 RC inpatient 535 347.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 518.95 97 999999999 323.94 518.95 percent of total billed charges GENERAL ANESTHESIA PER 15 MINUTES 50439156_1 CDM 0370 RC inpatient 535 347.75 AETNA AETNA 422.65 79 999999999 323.94 518.95 percent of total billed charges GENERAL ANESTHESIA PER 15 MINUTES 50439156_1 CDM 0370 RC inpatient 535 347.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 417.3 78 999999999 323.94 518.95 percent of total billed charges GENERAL ANESTHESIA PER 15 MINUTES 50439156_1 CDM 0370 RC inpatient 535 347.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 369.15 69 999999999 323.94 518.95 percent of total billed charges GENERAL ANESTHESIA PER 15 MINUTES 50439156_1 CDM 0370 RC inpatient 535 347.75 SIHO - ALL PLANS SIHO - ALL PLANS 481.5 90 999999999 323.94 518.95 percent of total billed charges GENERAL ANESTHESIA PER 15 MINUTES 50439156_1 CDM 0370 RC inpatient 535 347.75 UMR - ALL PLANS UMR - ALL PLANS 374.5 70 999999999 323.94 518.95 percent of total billed charges GENERAL ANESTHESIA PER 15 MINUTES 50439156_1 CDM 0370 RC inpatient 535 347.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 323.94 60.55 999999999 323.94 518.95 percent of total billed charges GENERAL ANESTHESIA PER 15 MINUTES 50439156_1 CDM 0370 RC inpatient 535 347.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 323.94 518.95 GENERAL ANESTHESIA PER 15 MINUTES 50439156_1 CDM 0370 RC inpatient 535 347.75 ANTHEM HMO ANTHEM HMO 999999999 323.94 518.95 GENERAL ANESTHESIA PER 15 MINUTES 50439156_1 CDM 0370 RC inpatient 535 347.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 323.94 518.95 GENERAL ANESTHESIA PER 15 MINUTES 50439156_1 CDM 0370 RC inpatient 535 347.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 323.94 518.95 GENERAL ANESTHESIA PER 15 MINUTES 50439156_1 CDM 0370 RC inpatient 535 347.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 323.94 518.95 GENERAL ANESTHESIA PER 15 MINUTES 50439156_1 CDM 0370 RC inpatient 535 347.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 361.66 67.6 999999999 323.94 518.95 percent of total billed charges MAC ANESTHESIA FIRST 30 MINUTES 50439157_1 CDM 0370 RC inpatient 713 463.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 463.45 65 999999999 431.72 691.61 percent of total billed charges MAC ANESTHESIA FIRST 30 MINUTES 50439157_1 CDM 0370 RC inpatient 713 463.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 691.61 97 999999999 431.72 691.61 percent of total billed charges MAC ANESTHESIA FIRST 30 MINUTES 50439157_1 CDM 0370 RC inpatient 713 463.45 AETNA AETNA 563.27 79 999999999 431.72 691.61 percent of total billed charges MAC ANESTHESIA FIRST 30 MINUTES 50439157_1 CDM 0370 RC inpatient 713 463.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 556.14 78 999999999 431.72 691.61 percent of total billed charges MAC ANESTHESIA FIRST 30 MINUTES 50439157_1 CDM 0370 RC inpatient 713 463.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 491.97 69 999999999 431.72 691.61 percent of total billed charges MAC ANESTHESIA FIRST 30 MINUTES 50439157_1 CDM 0370 RC inpatient 713 463.45 SIHO - ALL PLANS SIHO - ALL PLANS 641.7 90 999999999 431.72 691.61 percent of total billed charges MAC ANESTHESIA FIRST 30 MINUTES 50439157_1 CDM 0370 RC inpatient 713 463.45 UMR - ALL PLANS UMR - ALL PLANS 499.1 70 999999999 431.72 691.61 percent of total billed charges MAC ANESTHESIA FIRST 30 MINUTES 50439157_1 CDM 0370 RC inpatient 713 463.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 431.72 60.55 999999999 431.72 691.61 percent of total billed charges MAC ANESTHESIA FIRST 30 MINUTES 50439157_1 CDM 0370 RC inpatient 713 463.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 431.72 691.61 MAC ANESTHESIA FIRST 30 MINUTES 50439157_1 CDM 0370 RC inpatient 713 463.45 ANTHEM HMO ANTHEM HMO 999999999 431.72 691.61 MAC ANESTHESIA FIRST 30 MINUTES 50439157_1 CDM 0370 RC inpatient 713 463.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 431.72 691.61 MAC ANESTHESIA FIRST 30 MINUTES 50439157_1 CDM 0370 RC inpatient 713 463.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 431.72 691.61 MAC ANESTHESIA FIRST 30 MINUTES 50439157_1 CDM 0370 RC inpatient 713 463.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 431.72 691.61 MAC ANESTHESIA FIRST 30 MINUTES 50439157_1 CDM 0370 RC inpatient 713 463.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 481.99 67.6 999999999 431.72 691.61 percent of total billed charges MAC ANESTHESIA ADDITIONAL 15 MINUTES 50439158_1 CDM 0370 RC inpatient 248 161.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.2 65 999999999 150.16 240.56 percent of total billed charges MAC ANESTHESIA ADDITIONAL 15 MINUTES 50439158_1 CDM 0370 RC inpatient 248 161.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 240.56 97 999999999 150.16 240.56 percent of total billed charges MAC ANESTHESIA ADDITIONAL 15 MINUTES 50439158_1 CDM 0370 RC inpatient 248 161.2 AETNA AETNA 195.92 79 999999999 150.16 240.56 percent of total billed charges MAC ANESTHESIA ADDITIONAL 15 MINUTES 50439158_1 CDM 0370 RC inpatient 248 161.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 193.44 78 999999999 150.16 240.56 percent of total billed charges MAC ANESTHESIA ADDITIONAL 15 MINUTES 50439158_1 CDM 0370 RC inpatient 248 161.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.12 69 999999999 150.16 240.56 percent of total billed charges MAC ANESTHESIA ADDITIONAL 15 MINUTES 50439158_1 CDM 0370 RC inpatient 248 161.2 SIHO - ALL PLANS SIHO - ALL PLANS 223.2 90 999999999 150.16 240.56 percent of total billed charges MAC ANESTHESIA ADDITIONAL 15 MINUTES 50439158_1 CDM 0370 RC inpatient 248 161.2 UMR - ALL PLANS UMR - ALL PLANS 173.6 70 999999999 150.16 240.56 percent of total billed charges MAC ANESTHESIA ADDITIONAL 15 MINUTES 50439158_1 CDM 0370 RC inpatient 248 161.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.16 60.55 999999999 150.16 240.56 percent of total billed charges MAC ANESTHESIA ADDITIONAL 15 MINUTES 50439158_1 CDM 0370 RC inpatient 248 161.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.16 240.56 MAC ANESTHESIA ADDITIONAL 15 MINUTES 50439158_1 CDM 0370 RC inpatient 248 161.2 ANTHEM HMO ANTHEM HMO 999999999 150.16 240.56 MAC ANESTHESIA ADDITIONAL 15 MINUTES 50439158_1 CDM 0370 RC inpatient 248 161.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.16 240.56 MAC ANESTHESIA ADDITIONAL 15 MINUTES 50439158_1 CDM 0370 RC inpatient 248 161.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.16 240.56 MAC ANESTHESIA ADDITIONAL 15 MINUTES 50439158_1 CDM 0370 RC inpatient 248 161.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.16 240.56 MAC ANESTHESIA ADDITIONAL 15 MINUTES 50439158_1 CDM 0370 RC inpatient 248 161.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 167.65 67.6 999999999 150.16 240.56 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439159_1 CDM 0360 RC inpatient 580 377 SELF PAY DISCOUNT SELF PAY DISCOUNT 377 65 999999999 351.19 562.6 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439159_1 CDM 0360 RC inpatient 580 377 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 562.6 97 999999999 351.19 562.6 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439159_1 CDM 0360 RC inpatient 580 377 AETNA AETNA 458.2 79 999999999 351.19 562.6 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439159_1 CDM 0360 RC inpatient 580 377 HUMANA - ALL PLANS HUMANA - ALL PLANS 452.4 78 999999999 351.19 562.6 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439159_1 CDM 0360 RC inpatient 580 377 ENCORE - ALL PLANS ENCORE - ALL PLANS 400.2 69 999999999 351.19 562.6 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439159_1 CDM 0360 RC inpatient 580 377 SIHO - ALL PLANS SIHO - ALL PLANS 522 90 999999999 351.19 562.6 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439159_1 CDM 0360 RC inpatient 580 377 UMR - ALL PLANS UMR - ALL PLANS 406 70 999999999 351.19 562.6 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439159_1 CDM 0360 RC inpatient 580 377 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 351.19 60.55 999999999 351.19 562.6 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439159_1 CDM 0360 RC inpatient 580 377 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 351.19 562.6 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439159_1 CDM 0360 RC inpatient 580 377 ANTHEM HMO ANTHEM HMO 999999999 351.19 562.6 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439159_1 CDM 0360 RC inpatient 580 377 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 351.19 562.6 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439159_1 CDM 0360 RC inpatient 580 377 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 351.19 562.6 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439159_1 CDM 0360 RC inpatient 580 377 UHC - ALL PLANS UHC - ALL PLANS 999999999 351.19 562.6 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 50439159_1 CDM 0360 RC inpatient 580 377 CIGNA - ALL PLANS CIGNA - ALL PLANS 392.08 67.6 999999999 351.19 562.6 percent of total billed charges ANESTHESIA GAS FLAT FEE 50439160_1 CDM 0370 RC inpatient 165 107.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.25 65 999999999 99.91 160.05 percent of total billed charges ANESTHESIA GAS FLAT FEE 50439160_1 CDM 0370 RC inpatient 165 107.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 160.05 97 999999999 99.91 160.05 percent of total billed charges ANESTHESIA GAS FLAT FEE 50439160_1 CDM 0370 RC inpatient 165 107.25 AETNA AETNA 130.35 79 999999999 99.91 160.05 percent of total billed charges ANESTHESIA GAS FLAT FEE 50439160_1 CDM 0370 RC inpatient 165 107.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.7 78 999999999 99.91 160.05 percent of total billed charges ANESTHESIA GAS FLAT FEE 50439160_1 CDM 0370 RC inpatient 165 107.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.85 69 999999999 99.91 160.05 percent of total billed charges ANESTHESIA GAS FLAT FEE 50439160_1 CDM 0370 RC inpatient 165 107.25 SIHO - ALL PLANS SIHO - ALL PLANS 148.5 90 999999999 99.91 160.05 percent of total billed charges ANESTHESIA GAS FLAT FEE 50439160_1 CDM 0370 RC inpatient 165 107.25 UMR - ALL PLANS UMR - ALL PLANS 115.5 70 999999999 99.91 160.05 percent of total billed charges ANESTHESIA GAS FLAT FEE 50439160_1 CDM 0370 RC inpatient 165 107.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.91 60.55 999999999 99.91 160.05 percent of total billed charges ANESTHESIA GAS FLAT FEE 50439160_1 CDM 0370 RC inpatient 165 107.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.91 160.05 ANESTHESIA GAS FLAT FEE 50439160_1 CDM 0370 RC inpatient 165 107.25 ANTHEM HMO ANTHEM HMO 999999999 99.91 160.05 ANESTHESIA GAS FLAT FEE 50439160_1 CDM 0370 RC inpatient 165 107.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.91 160.05 ANESTHESIA GAS FLAT FEE 50439160_1 CDM 0370 RC inpatient 165 107.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.91 160.05 ANESTHESIA GAS FLAT FEE 50439160_1 CDM 0370 RC inpatient 165 107.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.91 160.05 ANESTHESIA GAS FLAT FEE 50439160_1 CDM 0370 RC inpatient 165 107.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.54 67.6 999999999 99.91 160.05 percent of total billed charges DIGOXIN 250 MCG TABLET 50443497_1 CDM 0250 RC 00143-1241-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges DIGOXIN 250 MCG TABLET 50443497_1 CDM 0250 RC 00143-1241-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges DIGOXIN 250 MCG TABLET 50443497_1 CDM 0250 RC 00143-1241-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges DIGOXIN 250 MCG TABLET 50443497_1 CDM 0250 RC 00143-1241-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges DIGOXIN 250 MCG TABLET 50443497_1 CDM 0250 RC 00143-1241-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges DIGOXIN 250 MCG TABLET 50443497_1 CDM 0250 RC 00143-1241-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges DIGOXIN 250 MCG TABLET 50443497_1 CDM 0250 RC 00143-1241-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges DIGOXIN 250 MCG TABLET 50443497_1 CDM 0250 RC 00143-1241-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges DIGOXIN 250 MCG TABLET 50443497_1 CDM 0250 RC 00143-1241-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 DIGOXIN 250 MCG TABLET 50443497_1 CDM 0250 RC 00143-1241-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 DIGOXIN 250 MCG TABLET 50443497_1 CDM 0250 RC 00143-1241-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 DIGOXIN 250 MCG TABLET 50443497_1 CDM 0250 RC 00143-1241-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 DIGOXIN 250 MCG TABLET 50443497_1 CDM 0250 RC 00143-1241-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 DIGOXIN 250 MCG TABLET 50443497_1 CDM 0250 RC 00143-1241-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "INJECTION, ARGATROBAN, 1 MG (FOR NON-ESRD USE)" 50448167_1 CDM 0250 RC 63323-0526-03 NDC J0883 HCPCS inpatient 250 UN 1033.83 671.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 671.99 65 999999999 625.98 1002.82 percent of total billed charges "INJECTION, ARGATROBAN, 1 MG (FOR NON-ESRD USE)" 50448167_1 CDM 0250 RC 63323-0526-03 NDC J0883 HCPCS inpatient 250 UN 1033.83 671.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1002.82 97 999999999 625.98 1002.82 percent of total billed charges "INJECTION, ARGATROBAN, 1 MG (FOR NON-ESRD USE)" 50448167_1 CDM 0250 RC 63323-0526-03 NDC J0883 HCPCS inpatient 250 UN 1033.83 671.99 AETNA AETNA 816.73 79 999999999 625.98 1002.82 percent of total billed charges "INJECTION, ARGATROBAN, 1 MG (FOR NON-ESRD USE)" 50448167_1 CDM 0250 RC 63323-0526-03 NDC J0883 HCPCS inpatient 250 UN 1033.83 671.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 806.39 78 999999999 625.98 1002.82 percent of total billed charges "INJECTION, ARGATROBAN, 1 MG (FOR NON-ESRD USE)" 50448167_1 CDM 0250 RC 63323-0526-03 NDC J0883 HCPCS inpatient 250 UN 1033.83 671.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 713.34 69 999999999 625.98 1002.82 percent of total billed charges "INJECTION, ARGATROBAN, 1 MG (FOR NON-ESRD USE)" 50448167_1 CDM 0250 RC 63323-0526-03 NDC J0883 HCPCS inpatient 250 UN 1033.83 671.99 UMR - ALL PLANS UMR - ALL PLANS 723.68 70 999999999 625.98 1002.82 percent of total billed charges "INJECTION, ARGATROBAN, 1 MG (FOR NON-ESRD USE)" 50448167_1 CDM 0250 RC 63323-0526-03 NDC J0883 HCPCS inpatient 250 UN 1033.83 671.99 SIHO - ALL PLANS SIHO - ALL PLANS 930.45 90 999999999 625.98 1002.82 percent of total billed charges "INJECTION, ARGATROBAN, 1 MG (FOR NON-ESRD USE)" 50448167_1 CDM 0250 RC 63323-0526-03 NDC J0883 HCPCS inpatient 250 UN 1033.83 671.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 625.98 60.55 999999999 625.98 1002.82 percent of total billed charges "INJECTION, ARGATROBAN, 1 MG (FOR NON-ESRD USE)" 50448167_1 CDM 0250 RC 63323-0526-03 NDC J0883 HCPCS inpatient 250 UN 1033.83 671.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 625.98 1002.82 "INJECTION, ARGATROBAN, 1 MG (FOR NON-ESRD USE)" 50448167_1 CDM 0250 RC 63323-0526-03 NDC J0883 HCPCS inpatient 250 UN 1033.83 671.99 ANTHEM HMO ANTHEM HMO 999999999 625.98 1002.82 "INJECTION, ARGATROBAN, 1 MG (FOR NON-ESRD USE)" 50448167_1 CDM 0250 RC 63323-0526-03 NDC J0883 HCPCS inpatient 250 UN 1033.83 671.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 625.98 1002.82 "INJECTION, ARGATROBAN, 1 MG (FOR NON-ESRD USE)" 50448167_1 CDM 0250 RC 63323-0526-03 NDC J0883 HCPCS inpatient 250 UN 1033.83 671.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 625.98 1002.82 "INJECTION, ARGATROBAN, 1 MG (FOR NON-ESRD USE)" 50448167_1 CDM 0250 RC 63323-0526-03 NDC J0883 HCPCS inpatient 250 UN 1033.83 671.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 625.98 1002.82 "INJECTION, ARGATROBAN, 1 MG (FOR NON-ESRD USE)" 50448167_1 CDM 0250 RC 63323-0526-03 NDC J0883 HCPCS inpatient 250 UN 1033.83 671.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 698.87 67.6 999999999 625.98 1002.82 percent of total billed charges DORZOLAMIDE-TIMOLOL EYE DROPS 50448168_1 CDM 0250 RC 70069-0051-01 NDC inpatient 1 UN 69.85 45.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.4 65 999999999 42.29 67.75 percent of total billed charges DORZOLAMIDE-TIMOLOL EYE DROPS 50448168_1 CDM 0250 RC 70069-0051-01 NDC inpatient 1 UN 69.85 45.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.75 97 999999999 42.29 67.75 percent of total billed charges DORZOLAMIDE-TIMOLOL EYE DROPS 50448168_1 CDM 0250 RC 70069-0051-01 NDC inpatient 1 UN 69.85 45.4 AETNA AETNA 55.18 79 999999999 42.29 67.75 percent of total billed charges DORZOLAMIDE-TIMOLOL EYE DROPS 50448168_1 CDM 0250 RC 70069-0051-01 NDC inpatient 1 UN 69.85 45.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.48 78 999999999 42.29 67.75 percent of total billed charges DORZOLAMIDE-TIMOLOL EYE DROPS 50448168_1 CDM 0250 RC 70069-0051-01 NDC inpatient 1 UN 69.85 45.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.2 69 999999999 42.29 67.75 percent of total billed charges DORZOLAMIDE-TIMOLOL EYE DROPS 50448168_1 CDM 0250 RC 70069-0051-01 NDC inpatient 1 UN 69.85 45.4 UMR - ALL PLANS UMR - ALL PLANS 48.9 70 999999999 42.29 67.75 percent of total billed charges DORZOLAMIDE-TIMOLOL EYE DROPS 50448168_1 CDM 0250 RC 70069-0051-01 NDC inpatient 1 UN 69.85 45.4 SIHO - ALL PLANS SIHO - ALL PLANS 62.87 90 999999999 42.29 67.75 percent of total billed charges DORZOLAMIDE-TIMOLOL EYE DROPS 50448168_1 CDM 0250 RC 70069-0051-01 NDC inpatient 1 UN 69.85 45.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.29 60.55 999999999 42.29 67.75 percent of total billed charges DORZOLAMIDE-TIMOLOL EYE DROPS 50448168_1 CDM 0250 RC 70069-0051-01 NDC inpatient 1 UN 69.85 45.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.29 67.75 DORZOLAMIDE-TIMOLOL EYE DROPS 50448168_1 CDM 0250 RC 70069-0051-01 NDC inpatient 1 UN 69.85 45.4 ANTHEM HMO ANTHEM HMO 999999999 42.29 67.75 DORZOLAMIDE-TIMOLOL EYE DROPS 50448168_1 CDM 0250 RC 70069-0051-01 NDC inpatient 1 UN 69.85 45.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.29 67.75 DORZOLAMIDE-TIMOLOL EYE DROPS 50448168_1 CDM 0250 RC 70069-0051-01 NDC inpatient 1 UN 69.85 45.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.29 67.75 DORZOLAMIDE-TIMOLOL EYE DROPS 50448168_1 CDM 0250 RC 70069-0051-01 NDC inpatient 1 UN 69.85 45.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.29 67.75 DORZOLAMIDE-TIMOLOL EYE DROPS 50448168_1 CDM 0250 RC 70069-0051-01 NDC inpatient 1 UN 69.85 45.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.22 67.6 999999999 42.29 67.75 percent of total billed charges RAPID RHINO 5.5CM RR530 50451555_1 CDM 0272 RC inpatient 194 126.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 126.1 65 999999999 117.47 188.18 percent of total billed charges RAPID RHINO 5.5CM RR530 50451555_1 CDM 0272 RC inpatient 194 126.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 188.18 97 999999999 117.47 188.18 percent of total billed charges RAPID RHINO 5.5CM RR530 50451555_1 CDM 0272 RC inpatient 194 126.1 AETNA AETNA 153.26 79 999999999 117.47 188.18 percent of total billed charges RAPID RHINO 5.5CM RR530 50451555_1 CDM 0272 RC inpatient 194 126.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 151.32 78 999999999 117.47 188.18 percent of total billed charges RAPID RHINO 5.5CM RR530 50451555_1 CDM 0272 RC inpatient 194 126.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.86 69 999999999 117.47 188.18 percent of total billed charges RAPID RHINO 5.5CM RR530 50451555_1 CDM 0272 RC inpatient 194 126.1 UMR - ALL PLANS UMR - ALL PLANS 135.8 70 999999999 117.47 188.18 percent of total billed charges RAPID RHINO 5.5CM RR530 50451555_1 CDM 0272 RC inpatient 194 126.1 SIHO - ALL PLANS SIHO - ALL PLANS 174.6 90 999999999 117.47 188.18 percent of total billed charges RAPID RHINO 5.5CM RR530 50451555_1 CDM 0272 RC inpatient 194 126.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 117.47 60.55 999999999 117.47 188.18 percent of total billed charges RAPID RHINO 5.5CM RR530 50451555_1 CDM 0272 RC inpatient 194 126.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 117.47 188.18 RAPID RHINO 5.5CM RR530 50451555_1 CDM 0272 RC inpatient 194 126.1 ANTHEM HMO ANTHEM HMO 999999999 117.47 188.18 RAPID RHINO 5.5CM RR530 50451555_1 CDM 0272 RC inpatient 194 126.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 117.47 188.18 RAPID RHINO 5.5CM RR530 50451555_1 CDM 0272 RC inpatient 194 126.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 117.47 188.18 RAPID RHINO 5.5CM RR530 50451555_1 CDM 0272 RC inpatient 194 126.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 117.47 188.18 RAPID RHINO 5.5CM RR530 50451555_1 CDM 0272 RC inpatient 194 126.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 131.14 67.6 999999999 117.47 188.18 percent of total billed charges RAPID RHINO 5.5CM ANTERIOR AIRWAY RR 551 50451556_1 CDM 0272 RC inpatient 209 135.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 135.85 65 999999999 126.55 202.73 percent of total billed charges RAPID RHINO 5.5CM ANTERIOR AIRWAY RR 551 50451556_1 CDM 0272 RC inpatient 209 135.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 202.73 97 999999999 126.55 202.73 percent of total billed charges RAPID RHINO 5.5CM ANTERIOR AIRWAY RR 551 50451556_1 CDM 0272 RC inpatient 209 135.85 AETNA AETNA 165.11 79 999999999 126.55 202.73 percent of total billed charges RAPID RHINO 5.5CM ANTERIOR AIRWAY RR 551 50451556_1 CDM 0272 RC inpatient 209 135.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 163.02 78 999999999 126.55 202.73 percent of total billed charges RAPID RHINO 5.5CM ANTERIOR AIRWAY RR 551 50451556_1 CDM 0272 RC inpatient 209 135.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 144.21 69 999999999 126.55 202.73 percent of total billed charges RAPID RHINO 5.5CM ANTERIOR AIRWAY RR 551 50451556_1 CDM 0272 RC inpatient 209 135.85 UMR - ALL PLANS UMR - ALL PLANS 146.3 70 999999999 126.55 202.73 percent of total billed charges RAPID RHINO 5.5CM ANTERIOR AIRWAY RR 551 50451556_1 CDM 0272 RC inpatient 209 135.85 SIHO - ALL PLANS SIHO - ALL PLANS 188.1 90 999999999 126.55 202.73 percent of total billed charges RAPID RHINO 5.5CM ANTERIOR AIRWAY RR 551 50451556_1 CDM 0272 RC inpatient 209 135.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 126.55 60.55 999999999 126.55 202.73 percent of total billed charges RAPID RHINO 5.5CM ANTERIOR AIRWAY RR 551 50451556_1 CDM 0272 RC inpatient 209 135.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 126.55 202.73 RAPID RHINO 5.5CM ANTERIOR AIRWAY RR 551 50451556_1 CDM 0272 RC inpatient 209 135.85 ANTHEM HMO ANTHEM HMO 999999999 126.55 202.73 RAPID RHINO 5.5CM ANTERIOR AIRWAY RR 551 50451556_1 CDM 0272 RC inpatient 209 135.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 126.55 202.73 RAPID RHINO 5.5CM ANTERIOR AIRWAY RR 551 50451556_1 CDM 0272 RC inpatient 209 135.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 126.55 202.73 RAPID RHINO 5.5CM ANTERIOR AIRWAY RR 551 50451556_1 CDM 0272 RC inpatient 209 135.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 126.55 202.73 RAPID RHINO 5.5CM ANTERIOR AIRWAY RR 551 50451556_1 CDM 0272 RC inpatient 209 135.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 141.28 67.6 999999999 126.55 202.73 percent of total billed charges SODIUM BICARBONATE 4.2% VIAL 50453947_1 CDM 0250 RC 00409-5555-02 NDC inpatient 1 UN 35.62 23.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 23.15 65 999999999 21.57 34.55 percent of total billed charges SODIUM BICARBONATE 4.2% VIAL 50453947_1 CDM 0250 RC 00409-5555-02 NDC inpatient 1 UN 35.62 23.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34.55 97 999999999 21.57 34.55 percent of total billed charges SODIUM BICARBONATE 4.2% VIAL 50453947_1 CDM 0250 RC 00409-5555-02 NDC inpatient 1 UN 35.62 23.15 AETNA AETNA 28.14 79 999999999 21.57 34.55 percent of total billed charges SODIUM BICARBONATE 4.2% VIAL 50453947_1 CDM 0250 RC 00409-5555-02 NDC inpatient 1 UN 35.62 23.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.78 78 999999999 21.57 34.55 percent of total billed charges SODIUM BICARBONATE 4.2% VIAL 50453947_1 CDM 0250 RC 00409-5555-02 NDC inpatient 1 UN 35.62 23.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.58 69 999999999 21.57 34.55 percent of total billed charges SODIUM BICARBONATE 4.2% VIAL 50453947_1 CDM 0250 RC 00409-5555-02 NDC inpatient 1 UN 35.62 23.15 UMR - ALL PLANS UMR - ALL PLANS 24.93 70 999999999 21.57 34.55 percent of total billed charges SODIUM BICARBONATE 4.2% VIAL 50453947_1 CDM 0250 RC 00409-5555-02 NDC inpatient 1 UN 35.62 23.15 SIHO - ALL PLANS SIHO - ALL PLANS 32.06 90 999999999 21.57 34.55 percent of total billed charges SODIUM BICARBONATE 4.2% VIAL 50453947_1 CDM 0250 RC 00409-5555-02 NDC inpatient 1 UN 35.62 23.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.57 60.55 999999999 21.57 34.55 percent of total billed charges SODIUM BICARBONATE 4.2% VIAL 50453947_1 CDM 0250 RC 00409-5555-02 NDC inpatient 1 UN 35.62 23.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.57 34.55 SODIUM BICARBONATE 4.2% VIAL 50453947_1 CDM 0250 RC 00409-5555-02 NDC inpatient 1 UN 35.62 23.15 ANTHEM HMO ANTHEM HMO 999999999 21.57 34.55 SODIUM BICARBONATE 4.2% VIAL 50453947_1 CDM 0250 RC 00409-5555-02 NDC inpatient 1 UN 35.62 23.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.57 34.55 SODIUM BICARBONATE 4.2% VIAL 50453947_1 CDM 0250 RC 00409-5555-02 NDC inpatient 1 UN 35.62 23.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.57 34.55 SODIUM BICARBONATE 4.2% VIAL 50453947_1 CDM 0250 RC 00409-5555-02 NDC inpatient 1 UN 35.62 23.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.57 34.55 SODIUM BICARBONATE 4.2% VIAL 50453947_1 CDM 0250 RC 00409-5555-02 NDC inpatient 1 UN 35.62 23.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 24.08 67.6 999999999 21.57 34.55 percent of total billed charges ACID REDUCER 10 MG TABLET 50454062_1 CDM 0250 RC 46122-0394-75 NDC inpatient 1 UN 1.24 0.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.81 65 999999999 0.75 1.2 percent of total billed charges ACID REDUCER 10 MG TABLET 50454062_1 CDM 0250 RC 46122-0394-75 NDC inpatient 1 UN 1.24 0.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.2 97 999999999 0.75 1.2 percent of total billed charges ACID REDUCER 10 MG TABLET 50454062_1 CDM 0250 RC 46122-0394-75 NDC inpatient 1 UN 1.24 0.81 AETNA AETNA 0.98 79 999999999 0.75 1.2 percent of total billed charges ACID REDUCER 10 MG TABLET 50454062_1 CDM 0250 RC 46122-0394-75 NDC inpatient 1 UN 1.24 0.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.97 78 999999999 0.75 1.2 percent of total billed charges ACID REDUCER 10 MG TABLET 50454062_1 CDM 0250 RC 46122-0394-75 NDC inpatient 1 UN 1.24 0.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.86 69 999999999 0.75 1.2 percent of total billed charges ACID REDUCER 10 MG TABLET 50454062_1 CDM 0250 RC 46122-0394-75 NDC inpatient 1 UN 1.24 0.81 UMR - ALL PLANS UMR - ALL PLANS 0.87 70 999999999 0.75 1.2 percent of total billed charges ACID REDUCER 10 MG TABLET 50454062_1 CDM 0250 RC 46122-0394-75 NDC inpatient 1 UN 1.24 0.81 SIHO - ALL PLANS SIHO - ALL PLANS 1.12 90 999999999 0.75 1.2 percent of total billed charges ACID REDUCER 10 MG TABLET 50454062_1 CDM 0250 RC 46122-0394-75 NDC inpatient 1 UN 1.24 0.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.75 60.55 999999999 0.75 1.2 percent of total billed charges ACID REDUCER 10 MG TABLET 50454062_1 CDM 0250 RC 46122-0394-75 NDC inpatient 1 UN 1.24 0.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.75 1.2 ACID REDUCER 10 MG TABLET 50454062_1 CDM 0250 RC 46122-0394-75 NDC inpatient 1 UN 1.24 0.81 ANTHEM HMO ANTHEM HMO 999999999 0.75 1.2 ACID REDUCER 10 MG TABLET 50454062_1 CDM 0250 RC 46122-0394-75 NDC inpatient 1 UN 1.24 0.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.75 1.2 ACID REDUCER 10 MG TABLET 50454062_1 CDM 0250 RC 46122-0394-75 NDC inpatient 1 UN 1.24 0.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.75 1.2 ACID REDUCER 10 MG TABLET 50454062_1 CDM 0250 RC 46122-0394-75 NDC inpatient 1 UN 1.24 0.81 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.75 1.2 ACID REDUCER 10 MG TABLET 50454062_1 CDM 0250 RC 46122-0394-75 NDC inpatient 1 UN 1.24 0.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.84 67.6 999999999 0.75 1.2 percent of total billed charges 61958-9998-99 - Miscellaneous MAR Items - Powder 50454246_1 CDM 0250 RC 61958-9998-99 NDC inpatient 1 UN 2459.93 1598.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1598.95 65 999999999 1489.49 2386.13 percent of total billed charges 61958-9998-99 - Miscellaneous MAR Items - Powder 50454246_1 CDM 0250 RC 61958-9998-99 NDC inpatient 1 UN 2459.93 1598.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2386.13 97 999999999 1489.49 2386.13 percent of total billed charges 61958-9998-99 - Miscellaneous MAR Items - Powder 50454246_1 CDM 0250 RC 61958-9998-99 NDC inpatient 1 UN 2459.93 1598.95 AETNA AETNA 1943.34 79 999999999 1489.49 2386.13 percent of total billed charges 61958-9998-99 - Miscellaneous MAR Items - Powder 50454246_1 CDM 0250 RC 61958-9998-99 NDC inpatient 1 UN 2459.93 1598.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1918.75 78 999999999 1489.49 2386.13 percent of total billed charges 61958-9998-99 - Miscellaneous MAR Items - Powder 50454246_1 CDM 0250 RC 61958-9998-99 NDC inpatient 1 UN 2459.93 1598.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1697.35 69 999999999 1489.49 2386.13 percent of total billed charges 61958-9998-99 - Miscellaneous MAR Items - Powder 50454246_1 CDM 0250 RC 61958-9998-99 NDC inpatient 1 UN 2459.93 1598.95 UMR - ALL PLANS UMR - ALL PLANS 1721.95 70 999999999 1489.49 2386.13 percent of total billed charges 61958-9998-99 - Miscellaneous MAR Items - Powder 50454246_1 CDM 0250 RC 61958-9998-99 NDC inpatient 1 UN 2459.93 1598.95 SIHO - ALL PLANS SIHO - ALL PLANS 2213.94 90 999999999 1489.49 2386.13 percent of total billed charges 61958-9998-99 - Miscellaneous MAR Items - Powder 50454246_1 CDM 0250 RC 61958-9998-99 NDC inpatient 1 UN 2459.93 1598.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1489.49 60.55 999999999 1489.49 2386.13 percent of total billed charges 61958-9998-99 - Miscellaneous MAR Items - Powder 50454246_1 CDM 0250 RC 61958-9998-99 NDC inpatient 1 UN 2459.93 1598.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1489.49 2386.13 61958-9998-99 - Miscellaneous MAR Items - Powder 50454246_1 CDM 0250 RC 61958-9998-99 NDC inpatient 1 UN 2459.93 1598.95 ANTHEM HMO ANTHEM HMO 999999999 1489.49 2386.13 61958-9998-99 - Miscellaneous MAR Items - Powder 50454246_1 CDM 0250 RC 61958-9998-99 NDC inpatient 1 UN 2459.93 1598.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1489.49 2386.13 61958-9998-99 - Miscellaneous MAR Items - Powder 50454246_1 CDM 0250 RC 61958-9998-99 NDC inpatient 1 UN 2459.93 1598.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1489.49 2386.13 61958-9998-99 - Miscellaneous MAR Items - Powder 50454246_1 CDM 0250 RC 61958-9998-99 NDC inpatient 1 UN 2459.93 1598.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1489.49 2386.13 61958-9998-99 - Miscellaneous MAR Items - Powder 50454246_1 CDM 0250 RC 61958-9998-99 NDC inpatient 1 UN 2459.93 1598.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1662.91 67.6 999999999 1489.49 2386.13 percent of total billed charges Measure of severe acute respiratory syndrome coronavirus 2 (Covid-19) antibody 50454345_1 CDM 0301 RC 86769 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges Measure of severe acute respiratory syndrome coronavirus 2 (Covid-19) antibody 50454345_1 CDM 0301 RC 86769 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges Measure of severe acute respiratory syndrome coronavirus 2 (Covid-19) antibody 50454345_1 CDM 0301 RC 86769 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges Measure of severe acute respiratory syndrome coronavirus 2 (Covid-19) antibody 50454345_1 CDM 0301 RC 86769 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges Measure of severe acute respiratory syndrome coronavirus 2 (Covid-19) antibody 50454345_1 CDM 0301 RC 86769 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges Measure of severe acute respiratory syndrome coronavirus 2 (Covid-19) antibody 50454345_1 CDM 0301 RC 86769 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges Measure of severe acute respiratory syndrome coronavirus 2 (Covid-19) antibody 50454345_1 CDM 0301 RC 86769 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges Measure of severe acute respiratory syndrome coronavirus 2 (Covid-19) antibody 50454345_1 CDM 0301 RC 86769 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges Measure of severe acute respiratory syndrome coronavirus 2 (Covid-19) antibody 50454345_1 CDM 0301 RC 86769 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 Measure of severe acute respiratory syndrome coronavirus 2 (Covid-19) antibody 50454345_1 CDM 0301 RC 86769 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 Measure of severe acute respiratory syndrome coronavirus 2 (Covid-19) antibody 50454345_1 CDM 0301 RC 86769 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 Measure of severe acute respiratory syndrome coronavirus 2 (Covid-19) antibody 50454345_1 CDM 0301 RC 86769 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 Measure of severe acute respiratory syndrome coronavirus 2 (Covid-19) antibody 50454345_1 CDM 0301 RC 86769 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 Measure of severe acute respiratory syndrome coronavirus 2 (Covid-19) antibody 50454345_1 CDM 0301 RC 86769 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges DIAZEPAM 2 MG TABLET 50454524_1 CDM 0250 RC 00172-3925-60 NDC inpatient 1 UN 1.7 1.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.11 65 999999999 1.03 1.65 percent of total billed charges DIAZEPAM 2 MG TABLET 50454524_1 CDM 0250 RC 00172-3925-60 NDC inpatient 1 UN 1.7 1.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.65 97 999999999 1.03 1.65 percent of total billed charges DIAZEPAM 2 MG TABLET 50454524_1 CDM 0250 RC 00172-3925-60 NDC inpatient 1 UN 1.7 1.11 AETNA AETNA 1.34 79 999999999 1.03 1.65 percent of total billed charges DIAZEPAM 2 MG TABLET 50454524_1 CDM 0250 RC 00172-3925-60 NDC inpatient 1 UN 1.7 1.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.33 78 999999999 1.03 1.65 percent of total billed charges DIAZEPAM 2 MG TABLET 50454524_1 CDM 0250 RC 00172-3925-60 NDC inpatient 1 UN 1.7 1.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.17 69 999999999 1.03 1.65 percent of total billed charges DIAZEPAM 2 MG TABLET 50454524_1 CDM 0250 RC 00172-3925-60 NDC inpatient 1 UN 1.7 1.11 UMR - ALL PLANS UMR - ALL PLANS 1.19 70 999999999 1.03 1.65 percent of total billed charges DIAZEPAM 2 MG TABLET 50454524_1 CDM 0250 RC 00172-3925-60 NDC inpatient 1 UN 1.7 1.11 SIHO - ALL PLANS SIHO - ALL PLANS 1.53 90 999999999 1.03 1.65 percent of total billed charges DIAZEPAM 2 MG TABLET 50454524_1 CDM 0250 RC 00172-3925-60 NDC inpatient 1 UN 1.7 1.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.03 60.55 999999999 1.03 1.65 percent of total billed charges DIAZEPAM 2 MG TABLET 50454524_1 CDM 0250 RC 00172-3925-60 NDC inpatient 1 UN 1.7 1.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.03 1.65 DIAZEPAM 2 MG TABLET 50454524_1 CDM 0250 RC 00172-3925-60 NDC inpatient 1 UN 1.7 1.11 ANTHEM HMO ANTHEM HMO 999999999 1.03 1.65 DIAZEPAM 2 MG TABLET 50454524_1 CDM 0250 RC 00172-3925-60 NDC inpatient 1 UN 1.7 1.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.03 1.65 DIAZEPAM 2 MG TABLET 50454524_1 CDM 0250 RC 00172-3925-60 NDC inpatient 1 UN 1.7 1.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.03 1.65 DIAZEPAM 2 MG TABLET 50454524_1 CDM 0250 RC 00172-3925-60 NDC inpatient 1 UN 1.7 1.11 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.03 1.65 DIAZEPAM 2 MG TABLET 50454524_1 CDM 0250 RC 00172-3925-60 NDC inpatient 1 UN 1.7 1.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.15 67.6 999999999 1.03 1.65 percent of total billed charges BUPIVACAIN 0.75%-DEXTROS 8.25% 50454526_1 CDM 0250 RC 36000-0092-10 NDC inpatient 1 UN 6.68 4.34 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.34 65 999999999 4.04 6.48 percent of total billed charges BUPIVACAIN 0.75%-DEXTROS 8.25% 50454526_1 CDM 0250 RC 36000-0092-10 NDC inpatient 1 UN 6.68 4.34 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.48 97 999999999 4.04 6.48 percent of total billed charges BUPIVACAIN 0.75%-DEXTROS 8.25% 50454526_1 CDM 0250 RC 36000-0092-10 NDC inpatient 1 UN 6.68 4.34 AETNA AETNA 5.28 79 999999999 4.04 6.48 percent of total billed charges BUPIVACAIN 0.75%-DEXTROS 8.25% 50454526_1 CDM 0250 RC 36000-0092-10 NDC inpatient 1 UN 6.68 4.34 HUMANA - ALL PLANS HUMANA - ALL PLANS 5.21 78 999999999 4.04 6.48 percent of total billed charges BUPIVACAIN 0.75%-DEXTROS 8.25% 50454526_1 CDM 0250 RC 36000-0092-10 NDC inpatient 1 UN 6.68 4.34 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.61 69 999999999 4.04 6.48 percent of total billed charges BUPIVACAIN 0.75%-DEXTROS 8.25% 50454526_1 CDM 0250 RC 36000-0092-10 NDC inpatient 1 UN 6.68 4.34 UMR - ALL PLANS UMR - ALL PLANS 4.68 70 999999999 4.04 6.48 percent of total billed charges BUPIVACAIN 0.75%-DEXTROS 8.25% 50454526_1 CDM 0250 RC 36000-0092-10 NDC inpatient 1 UN 6.68 4.34 SIHO - ALL PLANS SIHO - ALL PLANS 6.01 90 999999999 4.04 6.48 percent of total billed charges BUPIVACAIN 0.75%-DEXTROS 8.25% 50454526_1 CDM 0250 RC 36000-0092-10 NDC inpatient 1 UN 6.68 4.34 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.04 60.55 999999999 4.04 6.48 percent of total billed charges BUPIVACAIN 0.75%-DEXTROS 8.25% 50454526_1 CDM 0250 RC 36000-0092-10 NDC inpatient 1 UN 6.68 4.34 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.04 6.48 BUPIVACAIN 0.75%-DEXTROS 8.25% 50454526_1 CDM 0250 RC 36000-0092-10 NDC inpatient 1 UN 6.68 4.34 ANTHEM HMO ANTHEM HMO 999999999 4.04 6.48 BUPIVACAIN 0.75%-DEXTROS 8.25% 50454526_1 CDM 0250 RC 36000-0092-10 NDC inpatient 1 UN 6.68 4.34 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.04 6.48 BUPIVACAIN 0.75%-DEXTROS 8.25% 50454526_1 CDM 0250 RC 36000-0092-10 NDC inpatient 1 UN 6.68 4.34 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.04 6.48 BUPIVACAIN 0.75%-DEXTROS 8.25% 50454526_1 CDM 0250 RC 36000-0092-10 NDC inpatient 1 UN 6.68 4.34 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.04 6.48 BUPIVACAIN 0.75%-DEXTROS 8.25% 50454526_1 CDM 0250 RC 36000-0092-10 NDC inpatient 1 UN 6.68 4.34 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.52 67.6 999999999 4.04 6.48 percent of total billed charges Closed treatment of dislocated wrist bones with manipulation 50454817_1 CDM 0450 RC 25660 HCPCS inpatient 652 423.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 423.8 65 999999999 394.79 632.44 percent of total billed charges Closed treatment of dislocated wrist bones with manipulation 50454817_1 CDM 0450 RC 25660 HCPCS inpatient 652 423.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 632.44 97 999999999 394.79 632.44 percent of total billed charges Closed treatment of dislocated wrist bones with manipulation 50454817_1 CDM 0450 RC 25660 HCPCS inpatient 652 423.8 AETNA AETNA 515.08 79 999999999 394.79 632.44 percent of total billed charges Closed treatment of dislocated wrist bones with manipulation 50454817_1 CDM 0450 RC 25660 HCPCS inpatient 652 423.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 508.56 78 999999999 394.79 632.44 percent of total billed charges Closed treatment of dislocated wrist bones with manipulation 50454817_1 CDM 0450 RC 25660 HCPCS inpatient 652 423.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 449.88 69 999999999 394.79 632.44 percent of total billed charges Closed treatment of dislocated wrist bones with manipulation 50454817_1 CDM 0450 RC 25660 HCPCS inpatient 652 423.8 UMR - ALL PLANS UMR - ALL PLANS 456.4 70 999999999 394.79 632.44 percent of total billed charges Closed treatment of dislocated wrist bones with manipulation 50454817_1 CDM 0450 RC 25660 HCPCS inpatient 652 423.8 SIHO - ALL PLANS SIHO - ALL PLANS 586.8 90 999999999 394.79 632.44 percent of total billed charges Closed treatment of dislocated wrist bones with manipulation 50454817_1 CDM 0450 RC 25660 HCPCS inpatient 652 423.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 394.79 60.55 999999999 394.79 632.44 percent of total billed charges Closed treatment of dislocated wrist bones with manipulation 50454817_1 CDM 0450 RC 25660 HCPCS inpatient 652 423.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 394.79 632.44 Closed treatment of dislocated wrist bones with manipulation 50454817_1 CDM 0450 RC 25660 HCPCS inpatient 652 423.8 ANTHEM HMO ANTHEM HMO 999999999 394.79 632.44 Closed treatment of dislocated wrist bones with manipulation 50454817_1 CDM 0450 RC 25660 HCPCS inpatient 652 423.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 394.79 632.44 Closed treatment of dislocated wrist bones with manipulation 50454817_1 CDM 0450 RC 25660 HCPCS inpatient 652 423.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 394.79 632.44 Closed treatment of dislocated wrist bones with manipulation 50454817_1 CDM 0450 RC 25660 HCPCS inpatient 652 423.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 394.79 632.44 Closed treatment of dislocated wrist bones with manipulation 50454817_1 CDM 0450 RC 25660 HCPCS inpatient 652 423.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 440.75 67.6 999999999 394.79 632.44 percent of total billed charges "HOSPITAL OUTPATIENT CLINIC VISIT SPECIMEN COLLECTION FOR SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), ANY SPECIMEN SOURCE" 50454938_1 CDM 0300 RC C9803 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "HOSPITAL OUTPATIENT CLINIC VISIT SPECIMEN COLLECTION FOR SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), ANY SPECIMEN SOURCE" 50454938_1 CDM 0300 RC C9803 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "HOSPITAL OUTPATIENT CLINIC VISIT SPECIMEN COLLECTION FOR SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), ANY SPECIMEN SOURCE" 50454938_1 CDM 0300 RC C9803 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "HOSPITAL OUTPATIENT CLINIC VISIT SPECIMEN COLLECTION FOR SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), ANY SPECIMEN SOURCE" 50454938_1 CDM 0300 RC C9803 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "HOSPITAL OUTPATIENT CLINIC VISIT SPECIMEN COLLECTION FOR SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), ANY SPECIMEN SOURCE" 50454938_1 CDM 0300 RC C9803 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "HOSPITAL OUTPATIENT CLINIC VISIT SPECIMEN COLLECTION FOR SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), ANY SPECIMEN SOURCE" 50454938_1 CDM 0300 RC C9803 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "HOSPITAL OUTPATIENT CLINIC VISIT SPECIMEN COLLECTION FOR SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), ANY SPECIMEN SOURCE" 50454938_1 CDM 0300 RC C9803 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "HOSPITAL OUTPATIENT CLINIC VISIT SPECIMEN COLLECTION FOR SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), ANY SPECIMEN SOURCE" 50454938_1 CDM 0300 RC C9803 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "HOSPITAL OUTPATIENT CLINIC VISIT SPECIMEN COLLECTION FOR SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), ANY SPECIMEN SOURCE" 50454938_1 CDM 0300 RC C9803 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "HOSPITAL OUTPATIENT CLINIC VISIT SPECIMEN COLLECTION FOR SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), ANY SPECIMEN SOURCE" 50454938_1 CDM 0300 RC C9803 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "HOSPITAL OUTPATIENT CLINIC VISIT SPECIMEN COLLECTION FOR SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), ANY SPECIMEN SOURCE" 50454938_1 CDM 0300 RC C9803 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "HOSPITAL OUTPATIENT CLINIC VISIT SPECIMEN COLLECTION FOR SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), ANY SPECIMEN SOURCE" 50454938_1 CDM 0300 RC C9803 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "HOSPITAL OUTPATIENT CLINIC VISIT SPECIMEN COLLECTION FOR SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), ANY SPECIMEN SOURCE" 50454938_1 CDM 0300 RC C9803 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "HOSPITAL OUTPATIENT CLINIC VISIT SPECIMEN COLLECTION FOR SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS 2 (SARS-COV-2) (CORONAVIRUS DISEASE [COVID-19]), ANY SPECIMEN SOURCE" 50454938_1 CDM 0300 RC C9803 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "PROTHROMBIN COMPLEX CONCENTRATE (HUMAN), KCENTRA, PER I.U. OF FACTOR IX ACTIVITY" 50455469_1 CDM 0636 RC 63833-0387-02 NDC J7168 HCPCS inpatient 1 UN 3971.76 2581.64 SELF PAY DISCOUNT SELF PAY DISCOUNT 2581.64 65 999999999 2404.9 3852.61 percent of total billed charges "PROTHROMBIN COMPLEX CONCENTRATE (HUMAN), KCENTRA, PER I.U. OF FACTOR IX ACTIVITY" 50455469_1 CDM 0636 RC 63833-0387-02 NDC J7168 HCPCS inpatient 1 UN 3971.76 2581.64 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3852.61 97 999999999 2404.9 3852.61 percent of total billed charges "PROTHROMBIN COMPLEX CONCENTRATE (HUMAN), KCENTRA, PER I.U. OF FACTOR IX ACTIVITY" 50455469_1 CDM 0636 RC 63833-0387-02 NDC J7168 HCPCS inpatient 1 UN 3971.76 2581.64 AETNA AETNA 3137.69 79 999999999 2404.9 3852.61 percent of total billed charges "PROTHROMBIN COMPLEX CONCENTRATE (HUMAN), KCENTRA, PER I.U. OF FACTOR IX ACTIVITY" 50455469_1 CDM 0636 RC 63833-0387-02 NDC J7168 HCPCS inpatient 1 UN 3971.76 2581.64 HUMANA - ALL PLANS HUMANA - ALL PLANS 3097.97 78 999999999 2404.9 3852.61 percent of total billed charges "PROTHROMBIN COMPLEX CONCENTRATE (HUMAN), KCENTRA, PER I.U. OF FACTOR IX ACTIVITY" 50455469_1 CDM 0636 RC 63833-0387-02 NDC J7168 HCPCS inpatient 1 UN 3971.76 2581.64 ENCORE - ALL PLANS ENCORE - ALL PLANS 2740.51 69 999999999 2404.9 3852.61 percent of total billed charges "PROTHROMBIN COMPLEX CONCENTRATE (HUMAN), KCENTRA, PER I.U. OF FACTOR IX ACTIVITY" 50455469_1 CDM 0636 RC 63833-0387-02 NDC J7168 HCPCS inpatient 1 UN 3971.76 2581.64 UMR - ALL PLANS UMR - ALL PLANS 2780.23 70 999999999 2404.9 3852.61 percent of total billed charges "PROTHROMBIN COMPLEX CONCENTRATE (HUMAN), KCENTRA, PER I.U. OF FACTOR IX ACTIVITY" 50455469_1 CDM 0636 RC 63833-0387-02 NDC J7168 HCPCS inpatient 1 UN 3971.76 2581.64 SIHO - ALL PLANS SIHO - ALL PLANS 3574.58 90 999999999 2404.9 3852.61 percent of total billed charges "PROTHROMBIN COMPLEX CONCENTRATE (HUMAN), KCENTRA, PER I.U. OF FACTOR IX ACTIVITY" 50455469_1 CDM 0636 RC 63833-0387-02 NDC J7168 HCPCS inpatient 1 UN 3971.76 2581.64 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2404.9 60.55 999999999 2404.9 3852.61 percent of total billed charges "PROTHROMBIN COMPLEX CONCENTRATE (HUMAN), KCENTRA, PER I.U. OF FACTOR IX ACTIVITY" 50455469_1 CDM 0636 RC 63833-0387-02 NDC J7168 HCPCS inpatient 1 UN 3971.76 2581.64 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2404.9 3852.61 "PROTHROMBIN COMPLEX CONCENTRATE (HUMAN), KCENTRA, PER I.U. OF FACTOR IX ACTIVITY" 50455469_1 CDM 0636 RC 63833-0387-02 NDC J7168 HCPCS inpatient 1 UN 3971.76 2581.64 ANTHEM HMO ANTHEM HMO 999999999 2404.9 3852.61 "PROTHROMBIN COMPLEX CONCENTRATE (HUMAN), KCENTRA, PER I.U. OF FACTOR IX ACTIVITY" 50455469_1 CDM 0636 RC 63833-0387-02 NDC J7168 HCPCS inpatient 1 UN 3971.76 2581.64 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2404.9 3852.61 "PROTHROMBIN COMPLEX CONCENTRATE (HUMAN), KCENTRA, PER I.U. OF FACTOR IX ACTIVITY" 50455469_1 CDM 0636 RC 63833-0387-02 NDC J7168 HCPCS inpatient 1 UN 3971.76 2581.64 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2404.9 3852.61 "PROTHROMBIN COMPLEX CONCENTRATE (HUMAN), KCENTRA, PER I.U. OF FACTOR IX ACTIVITY" 50455469_1 CDM 0636 RC 63833-0387-02 NDC J7168 HCPCS inpatient 1 UN 3971.76 2581.64 UHC - ALL PLANS UHC - ALL PLANS 999999999 2404.9 3852.61 "PROTHROMBIN COMPLEX CONCENTRATE (HUMAN), KCENTRA, PER I.U. OF FACTOR IX ACTIVITY" 50455469_1 CDM 0636 RC 63833-0387-02 NDC J7168 HCPCS inpatient 1 UN 3971.76 2581.64 CIGNA - ALL PLANS CIGNA - ALL PLANS 2684.91 67.6 999999999 2404.9 3852.61 percent of total billed charges "INJECTION, FULVESTRANT, 25 MG" 50457766_1 CDM 0636 RC 70860-0211-74 NDC J9395 HCPCS inpatient 10 UN 1742.05 1132.33 SELF PAY DISCOUNT SELF PAY DISCOUNT 1132.33 65 999999999 1054.81 1689.79 percent of total billed charges "INJECTION, FULVESTRANT, 25 MG" 50457766_1 CDM 0636 RC 70860-0211-74 NDC J9395 HCPCS inpatient 10 UN 1742.05 1132.33 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1689.79 97 999999999 1054.81 1689.79 percent of total billed charges "INJECTION, FULVESTRANT, 25 MG" 50457766_1 CDM 0636 RC 70860-0211-74 NDC J9395 HCPCS inpatient 10 UN 1742.05 1132.33 AETNA AETNA 1376.22 79 999999999 1054.81 1689.79 percent of total billed charges "INJECTION, FULVESTRANT, 25 MG" 50457766_1 CDM 0636 RC 70860-0211-74 NDC J9395 HCPCS inpatient 10 UN 1742.05 1132.33 HUMANA - ALL PLANS HUMANA - ALL PLANS 1358.8 78 999999999 1054.81 1689.79 percent of total billed charges "INJECTION, FULVESTRANT, 25 MG" 50457766_1 CDM 0636 RC 70860-0211-74 NDC J9395 HCPCS inpatient 10 UN 1742.05 1132.33 ENCORE - ALL PLANS ENCORE - ALL PLANS 1202.01 69 999999999 1054.81 1689.79 percent of total billed charges "INJECTION, FULVESTRANT, 25 MG" 50457766_1 CDM 0636 RC 70860-0211-74 NDC J9395 HCPCS inpatient 10 UN 1742.05 1132.33 UMR - ALL PLANS UMR - ALL PLANS 1219.44 70 999999999 1054.81 1689.79 percent of total billed charges "INJECTION, FULVESTRANT, 25 MG" 50457766_1 CDM 0636 RC 70860-0211-74 NDC J9395 HCPCS inpatient 10 UN 1742.05 1132.33 SIHO - ALL PLANS SIHO - ALL PLANS 1567.85 90 999999999 1054.81 1689.79 percent of total billed charges "INJECTION, FULVESTRANT, 25 MG" 50457766_1 CDM 0636 RC 70860-0211-74 NDC J9395 HCPCS inpatient 10 UN 1742.05 1132.33 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1054.81 60.55 999999999 1054.81 1689.79 percent of total billed charges "INJECTION, FULVESTRANT, 25 MG" 50457766_1 CDM 0636 RC 70860-0211-74 NDC J9395 HCPCS inpatient 10 UN 1742.05 1132.33 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1054.81 1689.79 "INJECTION, FULVESTRANT, 25 MG" 50457766_1 CDM 0636 RC 70860-0211-74 NDC J9395 HCPCS inpatient 10 UN 1742.05 1132.33 ANTHEM HMO ANTHEM HMO 999999999 1054.81 1689.79 "INJECTION, FULVESTRANT, 25 MG" 50457766_1 CDM 0636 RC 70860-0211-74 NDC J9395 HCPCS inpatient 10 UN 1742.05 1132.33 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1054.81 1689.79 "INJECTION, FULVESTRANT, 25 MG" 50457766_1 CDM 0636 RC 70860-0211-74 NDC J9395 HCPCS inpatient 10 UN 1742.05 1132.33 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1054.81 1689.79 "INJECTION, FULVESTRANT, 25 MG" 50457766_1 CDM 0636 RC 70860-0211-74 NDC J9395 HCPCS inpatient 10 UN 1742.05 1132.33 UHC - ALL PLANS UHC - ALL PLANS 999999999 1054.81 1689.79 "INJECTION, FULVESTRANT, 25 MG" 50457766_1 CDM 0636 RC 70860-0211-74 NDC J9395 HCPCS inpatient 10 UN 1742.05 1132.33 CIGNA - ALL PLANS CIGNA - ALL PLANS 1177.63 67.6 999999999 1054.81 1689.79 percent of total billed charges RANOLAZINE ER 500 MG TABLET 50458190_1 CDM 0250 RC 27241-0125-02 NDC inpatient 1 UN 1.5 0.98 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.98 65 999999999 0.91 1.46 percent of total billed charges RANOLAZINE ER 500 MG TABLET 50458190_1 CDM 0250 RC 27241-0125-02 NDC inpatient 1 UN 1.5 0.98 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.46 97 999999999 0.91 1.46 percent of total billed charges RANOLAZINE ER 500 MG TABLET 50458190_1 CDM 0250 RC 27241-0125-02 NDC inpatient 1 UN 1.5 0.98 AETNA AETNA 1.19 79 999999999 0.91 1.46 percent of total billed charges RANOLAZINE ER 500 MG TABLET 50458190_1 CDM 0250 RC 27241-0125-02 NDC inpatient 1 UN 1.5 0.98 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.17 78 999999999 0.91 1.46 percent of total billed charges RANOLAZINE ER 500 MG TABLET 50458190_1 CDM 0250 RC 27241-0125-02 NDC inpatient 1 UN 1.5 0.98 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.04 69 999999999 0.91 1.46 percent of total billed charges RANOLAZINE ER 500 MG TABLET 50458190_1 CDM 0250 RC 27241-0125-02 NDC inpatient 1 UN 1.5 0.98 UMR - ALL PLANS UMR - ALL PLANS 1.05 70 999999999 0.91 1.46 percent of total billed charges RANOLAZINE ER 500 MG TABLET 50458190_1 CDM 0250 RC 27241-0125-02 NDC inpatient 1 UN 1.5 0.98 SIHO - ALL PLANS SIHO - ALL PLANS 1.35 90 999999999 0.91 1.46 percent of total billed charges RANOLAZINE ER 500 MG TABLET 50458190_1 CDM 0250 RC 27241-0125-02 NDC inpatient 1 UN 1.5 0.98 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.91 60.55 999999999 0.91 1.46 percent of total billed charges RANOLAZINE ER 500 MG TABLET 50458190_1 CDM 0250 RC 27241-0125-02 NDC inpatient 1 UN 1.5 0.98 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.91 1.46 RANOLAZINE ER 500 MG TABLET 50458190_1 CDM 0250 RC 27241-0125-02 NDC inpatient 1 UN 1.5 0.98 ANTHEM HMO ANTHEM HMO 999999999 0.91 1.46 RANOLAZINE ER 500 MG TABLET 50458190_1 CDM 0250 RC 27241-0125-02 NDC inpatient 1 UN 1.5 0.98 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.91 1.46 RANOLAZINE ER 500 MG TABLET 50458190_1 CDM 0250 RC 27241-0125-02 NDC inpatient 1 UN 1.5 0.98 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.91 1.46 RANOLAZINE ER 500 MG TABLET 50458190_1 CDM 0250 RC 27241-0125-02 NDC inpatient 1 UN 1.5 0.98 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.91 1.46 RANOLAZINE ER 500 MG TABLET 50458190_1 CDM 0250 RC 27241-0125-02 NDC inpatient 1 UN 1.5 0.98 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.01 67.6 999999999 0.91 1.46 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50459346_1 CDM 0250 RC 70860-0602-82 NDC J1953 HCPCS inpatient 50 UN 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50459346_1 CDM 0250 RC 70860-0602-82 NDC J1953 HCPCS inpatient 50 UN 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50459346_1 CDM 0250 RC 70860-0602-82 NDC J1953 HCPCS inpatient 50 UN 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50459346_1 CDM 0250 RC 70860-0602-82 NDC J1953 HCPCS inpatient 50 UN 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50459346_1 CDM 0250 RC 70860-0602-82 NDC J1953 HCPCS inpatient 50 UN 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50459346_1 CDM 0250 RC 70860-0602-82 NDC J1953 HCPCS inpatient 50 UN 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50459346_1 CDM 0250 RC 70860-0602-82 NDC J1953 HCPCS inpatient 50 UN 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50459346_1 CDM 0250 RC 70860-0602-82 NDC J1953 HCPCS inpatient 50 UN 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges "INJECTION, LEVETIRACETAM, 10 MG" 50459346_1 CDM 0250 RC 70860-0602-82 NDC J1953 HCPCS inpatient 50 UN 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 "INJECTION, LEVETIRACETAM, 10 MG" 50459346_1 CDM 0250 RC 70860-0602-82 NDC J1953 HCPCS inpatient 50 UN 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 "INJECTION, LEVETIRACETAM, 10 MG" 50459346_1 CDM 0250 RC 70860-0602-82 NDC J1953 HCPCS inpatient 50 UN 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 "INJECTION, LEVETIRACETAM, 10 MG" 50459346_1 CDM 0250 RC 70860-0602-82 NDC J1953 HCPCS inpatient 50 UN 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 "INJECTION, LEVETIRACETAM, 10 MG" 50459346_1 CDM 0250 RC 70860-0602-82 NDC J1953 HCPCS inpatient 50 UN 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 "INJECTION, LEVETIRACETAM, 10 MG" 50459346_1 CDM 0250 RC 70860-0602-82 NDC J1953 HCPCS inpatient 50 UN 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges ANASTROZOLE 1 MG TABLET 50462519_1 CDM 0250 RC 00904-6195-46 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ANASTROZOLE 1 MG TABLET 50462519_1 CDM 0250 RC 00904-6195-46 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ANASTROZOLE 1 MG TABLET 50462519_1 CDM 0250 RC 00904-6195-46 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ANASTROZOLE 1 MG TABLET 50462519_1 CDM 0250 RC 00904-6195-46 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ANASTROZOLE 1 MG TABLET 50462519_1 CDM 0250 RC 00904-6195-46 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ANASTROZOLE 1 MG TABLET 50462519_1 CDM 0250 RC 00904-6195-46 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ANASTROZOLE 1 MG TABLET 50462519_1 CDM 0250 RC 00904-6195-46 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ANASTROZOLE 1 MG TABLET 50462519_1 CDM 0250 RC 00904-6195-46 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ANASTROZOLE 1 MG TABLET 50462519_1 CDM 0250 RC 00904-6195-46 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ANASTROZOLE 1 MG TABLET 50462519_1 CDM 0250 RC 00904-6195-46 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ANASTROZOLE 1 MG TABLET 50462519_1 CDM 0250 RC 00904-6195-46 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ANASTROZOLE 1 MG TABLET 50462519_1 CDM 0250 RC 00904-6195-46 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ANASTROZOLE 1 MG TABLET 50462519_1 CDM 0250 RC 00904-6195-46 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ANASTROZOLE 1 MG TABLET 50462519_1 CDM 0250 RC 00904-6195-46 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges HUMULIN N 100 UNIT/ML VIAL 50463229_1 CDM 0250 RC 00002-8315-01 NDC inpatient 1 UN 1.06 0.69 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.69 65 999999999 0.64 1.03 percent of total billed charges HUMULIN N 100 UNIT/ML VIAL 50463229_1 CDM 0250 RC 00002-8315-01 NDC inpatient 1 UN 1.06 0.69 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.03 97 999999999 0.64 1.03 percent of total billed charges HUMULIN N 100 UNIT/ML VIAL 50463229_1 CDM 0250 RC 00002-8315-01 NDC inpatient 1 UN 1.06 0.69 AETNA AETNA 0.84 79 999999999 0.64 1.03 percent of total billed charges HUMULIN N 100 UNIT/ML VIAL 50463229_1 CDM 0250 RC 00002-8315-01 NDC inpatient 1 UN 1.06 0.69 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.83 78 999999999 0.64 1.03 percent of total billed charges HUMULIN N 100 UNIT/ML VIAL 50463229_1 CDM 0250 RC 00002-8315-01 NDC inpatient 1 UN 1.06 0.69 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.73 69 999999999 0.64 1.03 percent of total billed charges HUMULIN N 100 UNIT/ML VIAL 50463229_1 CDM 0250 RC 00002-8315-01 NDC inpatient 1 UN 1.06 0.69 UMR - ALL PLANS UMR - ALL PLANS 0.74 70 999999999 0.64 1.03 percent of total billed charges HUMULIN N 100 UNIT/ML VIAL 50463229_1 CDM 0250 RC 00002-8315-01 NDC inpatient 1 UN 1.06 0.69 SIHO - ALL PLANS SIHO - ALL PLANS 0.95 90 999999999 0.64 1.03 percent of total billed charges HUMULIN N 100 UNIT/ML VIAL 50463229_1 CDM 0250 RC 00002-8315-01 NDC inpatient 1 UN 1.06 0.69 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.64 60.55 999999999 0.64 1.03 percent of total billed charges HUMULIN N 100 UNIT/ML VIAL 50463229_1 CDM 0250 RC 00002-8315-01 NDC inpatient 1 UN 1.06 0.69 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.64 1.03 HUMULIN N 100 UNIT/ML VIAL 50463229_1 CDM 0250 RC 00002-8315-01 NDC inpatient 1 UN 1.06 0.69 ANTHEM HMO ANTHEM HMO 999999999 0.64 1.03 HUMULIN N 100 UNIT/ML VIAL 50463229_1 CDM 0250 RC 00002-8315-01 NDC inpatient 1 UN 1.06 0.69 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.64 1.03 HUMULIN N 100 UNIT/ML VIAL 50463229_1 CDM 0250 RC 00002-8315-01 NDC inpatient 1 UN 1.06 0.69 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.64 1.03 HUMULIN N 100 UNIT/ML VIAL 50463229_1 CDM 0250 RC 00002-8315-01 NDC inpatient 1 UN 1.06 0.69 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.64 1.03 HUMULIN N 100 UNIT/ML VIAL 50463229_1 CDM 0250 RC 00002-8315-01 NDC inpatient 1 UN 1.06 0.69 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.72 67.6 999999999 0.64 1.03 percent of total billed charges OXYCODONE HCL (IR) 15 MG TAB 50464097_1 CDM 0250 RC 68084-0975-01 NDC inpatient 1 UN 2.11 1.37 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.37 65 999999999 1.28 2.05 percent of total billed charges OXYCODONE HCL (IR) 15 MG TAB 50464097_1 CDM 0250 RC 68084-0975-01 NDC inpatient 1 UN 2.11 1.37 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.05 97 999999999 1.28 2.05 percent of total billed charges OXYCODONE HCL (IR) 15 MG TAB 50464097_1 CDM 0250 RC 68084-0975-01 NDC inpatient 1 UN 2.11 1.37 AETNA AETNA 1.67 79 999999999 1.28 2.05 percent of total billed charges OXYCODONE HCL (IR) 15 MG TAB 50464097_1 CDM 0250 RC 68084-0975-01 NDC inpatient 1 UN 2.11 1.37 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.65 78 999999999 1.28 2.05 percent of total billed charges OXYCODONE HCL (IR) 15 MG TAB 50464097_1 CDM 0250 RC 68084-0975-01 NDC inpatient 1 UN 2.11 1.37 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.46 69 999999999 1.28 2.05 percent of total billed charges OXYCODONE HCL (IR) 15 MG TAB 50464097_1 CDM 0250 RC 68084-0975-01 NDC inpatient 1 UN 2.11 1.37 UMR - ALL PLANS UMR - ALL PLANS 1.48 70 999999999 1.28 2.05 percent of total billed charges OXYCODONE HCL (IR) 15 MG TAB 50464097_1 CDM 0250 RC 68084-0975-01 NDC inpatient 1 UN 2.11 1.37 SIHO - ALL PLANS SIHO - ALL PLANS 1.9 90 999999999 1.28 2.05 percent of total billed charges OXYCODONE HCL (IR) 15 MG TAB 50464097_1 CDM 0250 RC 68084-0975-01 NDC inpatient 1 UN 2.11 1.37 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.28 60.55 999999999 1.28 2.05 percent of total billed charges OXYCODONE HCL (IR) 15 MG TAB 50464097_1 CDM 0250 RC 68084-0975-01 NDC inpatient 1 UN 2.11 1.37 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.28 2.05 OXYCODONE HCL (IR) 15 MG TAB 50464097_1 CDM 0250 RC 68084-0975-01 NDC inpatient 1 UN 2.11 1.37 ANTHEM HMO ANTHEM HMO 999999999 1.28 2.05 OXYCODONE HCL (IR) 15 MG TAB 50464097_1 CDM 0250 RC 68084-0975-01 NDC inpatient 1 UN 2.11 1.37 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.28 2.05 OXYCODONE HCL (IR) 15 MG TAB 50464097_1 CDM 0250 RC 68084-0975-01 NDC inpatient 1 UN 2.11 1.37 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.28 2.05 OXYCODONE HCL (IR) 15 MG TAB 50464097_1 CDM 0250 RC 68084-0975-01 NDC inpatient 1 UN 2.11 1.37 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.28 2.05 OXYCODONE HCL (IR) 15 MG TAB 50464097_1 CDM 0250 RC 68084-0975-01 NDC inpatient 1 UN 2.11 1.37 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.43 67.6 999999999 1.28 2.05 percent of total billed charges "BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 6 MG, BUT LESS THAN OR EQUAL TO 10 MG BUPRENORPHINE" 50464946_1 CDM 0250 RC 43598-0582-30 NDC J0574 HCPCS inpatient 1 UN 16.92 11 SELF PAY DISCOUNT SELF PAY DISCOUNT 11 65 999999999 10.25 16.41 percent of total billed charges "BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 6 MG, BUT LESS THAN OR EQUAL TO 10 MG BUPRENORPHINE" 50464946_1 CDM 0250 RC 43598-0582-30 NDC J0574 HCPCS inpatient 1 UN 16.92 11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16.41 97 999999999 10.25 16.41 percent of total billed charges "BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 6 MG, BUT LESS THAN OR EQUAL TO 10 MG BUPRENORPHINE" 50464946_1 CDM 0250 RC 43598-0582-30 NDC J0574 HCPCS inpatient 1 UN 16.92 11 AETNA AETNA 13.37 79 999999999 10.25 16.41 percent of total billed charges "BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 6 MG, BUT LESS THAN OR EQUAL TO 10 MG BUPRENORPHINE" 50464946_1 CDM 0250 RC 43598-0582-30 NDC J0574 HCPCS inpatient 1 UN 16.92 11 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.2 78 999999999 10.25 16.41 percent of total billed charges "BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 6 MG, BUT LESS THAN OR EQUAL TO 10 MG BUPRENORPHINE" 50464946_1 CDM 0250 RC 43598-0582-30 NDC J0574 HCPCS inpatient 1 UN 16.92 11 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.67 69 999999999 10.25 16.41 percent of total billed charges "BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 6 MG, BUT LESS THAN OR EQUAL TO 10 MG BUPRENORPHINE" 50464946_1 CDM 0250 RC 43598-0582-30 NDC J0574 HCPCS inpatient 1 UN 16.92 11 UMR - ALL PLANS UMR - ALL PLANS 11.84 70 999999999 10.25 16.41 percent of total billed charges "BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 6 MG, BUT LESS THAN OR EQUAL TO 10 MG BUPRENORPHINE" 50464946_1 CDM 0250 RC 43598-0582-30 NDC J0574 HCPCS inpatient 1 UN 16.92 11 SIHO - ALL PLANS SIHO - ALL PLANS 15.23 90 999999999 10.25 16.41 percent of total billed charges "BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 6 MG, BUT LESS THAN OR EQUAL TO 10 MG BUPRENORPHINE" 50464946_1 CDM 0250 RC 43598-0582-30 NDC J0574 HCPCS inpatient 1 UN 16.92 11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.25 60.55 999999999 10.25 16.41 percent of total billed charges "BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 6 MG, BUT LESS THAN OR EQUAL TO 10 MG BUPRENORPHINE" 50464946_1 CDM 0250 RC 43598-0582-30 NDC J0574 HCPCS inpatient 1 UN 16.92 11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.25 16.41 "BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 6 MG, BUT LESS THAN OR EQUAL TO 10 MG BUPRENORPHINE" 50464946_1 CDM 0250 RC 43598-0582-30 NDC J0574 HCPCS inpatient 1 UN 16.92 11 ANTHEM HMO ANTHEM HMO 999999999 10.25 16.41 "BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 6 MG, BUT LESS THAN OR EQUAL TO 10 MG BUPRENORPHINE" 50464946_1 CDM 0250 RC 43598-0582-30 NDC J0574 HCPCS inpatient 1 UN 16.92 11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.25 16.41 "BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 6 MG, BUT LESS THAN OR EQUAL TO 10 MG BUPRENORPHINE" 50464946_1 CDM 0250 RC 43598-0582-30 NDC J0574 HCPCS inpatient 1 UN 16.92 11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.25 16.41 "BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 6 MG, BUT LESS THAN OR EQUAL TO 10 MG BUPRENORPHINE" 50464946_1 CDM 0250 RC 43598-0582-30 NDC J0574 HCPCS inpatient 1 UN 16.92 11 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.25 16.41 "BUPRENORPHINE/NALOXONE, ORAL, GREATER THAN 6 MG, BUT LESS THAN OR EQUAL TO 10 MG BUPRENORPHINE" 50464946_1 CDM 0250 RC 43598-0582-30 NDC J0574 HCPCS inpatient 1 UN 16.92 11 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.44 67.6 999999999 10.25 16.41 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 50465236_1 CDM 0306 RC 87517 HCPCS inpatient 359 233.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 233.35 65 999999999 217.37 348.23 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 50465236_1 CDM 0306 RC 87517 HCPCS inpatient 359 233.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 348.23 97 999999999 217.37 348.23 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 50465236_1 CDM 0306 RC 87517 HCPCS inpatient 359 233.35 AETNA AETNA 283.61 79 999999999 217.37 348.23 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 50465236_1 CDM 0306 RC 87517 HCPCS inpatient 359 233.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 280.02 78 999999999 217.37 348.23 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 50465236_1 CDM 0306 RC 87517 HCPCS inpatient 359 233.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 247.71 69 999999999 217.37 348.23 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 50465236_1 CDM 0306 RC 87517 HCPCS inpatient 359 233.35 UMR - ALL PLANS UMR - ALL PLANS 251.3 70 999999999 217.37 348.23 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 50465236_1 CDM 0306 RC 87517 HCPCS inpatient 359 233.35 SIHO - ALL PLANS SIHO - ALL PLANS 323.1 90 999999999 217.37 348.23 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 50465236_1 CDM 0306 RC 87517 HCPCS inpatient 359 233.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 217.37 60.55 999999999 217.37 348.23 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 50465236_1 CDM 0306 RC 87517 HCPCS inpatient 359 233.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 217.37 348.23 "Detection test by nucleic acid for Hepatitis B virus, quantification" 50465236_1 CDM 0306 RC 87517 HCPCS inpatient 359 233.35 ANTHEM HMO ANTHEM HMO 999999999 217.37 348.23 "Detection test by nucleic acid for Hepatitis B virus, quantification" 50465236_1 CDM 0306 RC 87517 HCPCS inpatient 359 233.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 217.37 348.23 "Detection test by nucleic acid for Hepatitis B virus, quantification" 50465236_1 CDM 0306 RC 87517 HCPCS inpatient 359 233.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 217.37 348.23 "Detection test by nucleic acid for Hepatitis B virus, quantification" 50465236_1 CDM 0306 RC 87517 HCPCS inpatient 359 233.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 217.37 348.23 "Detection test by nucleic acid for Hepatitis B virus, quantification" 50465236_1 CDM 0306 RC 87517 HCPCS inpatient 359 233.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 242.68 67.6 999999999 217.37 348.23 percent of total billed charges OXCARBAZEPINE 300 MG/5 ML SUSP 50465457_1 CDM 0250 RC 65162-0649-78 NDC inpatient 1 UN 736.68 478.84 SELF PAY DISCOUNT SELF PAY DISCOUNT 478.84 65 999999999 446.06 714.58 percent of total billed charges OXCARBAZEPINE 300 MG/5 ML SUSP 50465457_1 CDM 0250 RC 65162-0649-78 NDC inpatient 1 UN 736.68 478.84 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 714.58 97 999999999 446.06 714.58 percent of total billed charges OXCARBAZEPINE 300 MG/5 ML SUSP 50465457_1 CDM 0250 RC 65162-0649-78 NDC inpatient 1 UN 736.68 478.84 AETNA AETNA 581.98 79 999999999 446.06 714.58 percent of total billed charges OXCARBAZEPINE 300 MG/5 ML SUSP 50465457_1 CDM 0250 RC 65162-0649-78 NDC inpatient 1 UN 736.68 478.84 HUMANA - ALL PLANS HUMANA - ALL PLANS 574.61 78 999999999 446.06 714.58 percent of total billed charges OXCARBAZEPINE 300 MG/5 ML SUSP 50465457_1 CDM 0250 RC 65162-0649-78 NDC inpatient 1 UN 736.68 478.84 ENCORE - ALL PLANS ENCORE - ALL PLANS 508.31 69 999999999 446.06 714.58 percent of total billed charges OXCARBAZEPINE 300 MG/5 ML SUSP 50465457_1 CDM 0250 RC 65162-0649-78 NDC inpatient 1 UN 736.68 478.84 UMR - ALL PLANS UMR - ALL PLANS 515.68 70 999999999 446.06 714.58 percent of total billed charges OXCARBAZEPINE 300 MG/5 ML SUSP 50465457_1 CDM 0250 RC 65162-0649-78 NDC inpatient 1 UN 736.68 478.84 SIHO - ALL PLANS SIHO - ALL PLANS 663.01 90 999999999 446.06 714.58 percent of total billed charges OXCARBAZEPINE 300 MG/5 ML SUSP 50465457_1 CDM 0250 RC 65162-0649-78 NDC inpatient 1 UN 736.68 478.84 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 446.06 60.55 999999999 446.06 714.58 percent of total billed charges OXCARBAZEPINE 300 MG/5 ML SUSP 50465457_1 CDM 0250 RC 65162-0649-78 NDC inpatient 1 UN 736.68 478.84 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 446.06 714.58 OXCARBAZEPINE 300 MG/5 ML SUSP 50465457_1 CDM 0250 RC 65162-0649-78 NDC inpatient 1 UN 736.68 478.84 ANTHEM HMO ANTHEM HMO 999999999 446.06 714.58 OXCARBAZEPINE 300 MG/5 ML SUSP 50465457_1 CDM 0250 RC 65162-0649-78 NDC inpatient 1 UN 736.68 478.84 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 446.06 714.58 OXCARBAZEPINE 300 MG/5 ML SUSP 50465457_1 CDM 0250 RC 65162-0649-78 NDC inpatient 1 UN 736.68 478.84 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 446.06 714.58 OXCARBAZEPINE 300 MG/5 ML SUSP 50465457_1 CDM 0250 RC 65162-0649-78 NDC inpatient 1 UN 736.68 478.84 UHC - ALL PLANS UHC - ALL PLANS 999999999 446.06 714.58 OXCARBAZEPINE 300 MG/5 ML SUSP 50465457_1 CDM 0250 RC 65162-0649-78 NDC inpatient 1 UN 736.68 478.84 CIGNA - ALL PLANS CIGNA - ALL PLANS 498 67.6 999999999 446.06 714.58 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50465466_1 CDM 0250 RC 68001-0247-17 NDC Q0162 HCPCS inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50465466_1 CDM 0250 RC 68001-0247-17 NDC Q0162 HCPCS inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50465466_1 CDM 0250 RC 68001-0247-17 NDC Q0162 HCPCS inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50465466_1 CDM 0250 RC 68001-0247-17 NDC Q0162 HCPCS inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50465466_1 CDM 0250 RC 68001-0247-17 NDC Q0162 HCPCS inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50465466_1 CDM 0250 RC 68001-0247-17 NDC Q0162 HCPCS inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50465466_1 CDM 0250 RC 68001-0247-17 NDC Q0162 HCPCS inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50465466_1 CDM 0250 RC 68001-0247-17 NDC Q0162 HCPCS inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50465466_1 CDM 0250 RC 68001-0247-17 NDC Q0162 HCPCS inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50465466_1 CDM 0250 RC 68001-0247-17 NDC Q0162 HCPCS inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50465466_1 CDM 0250 RC 68001-0247-17 NDC Q0162 HCPCS inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50465466_1 CDM 0250 RC 68001-0247-17 NDC Q0162 HCPCS inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50465466_1 CDM 0250 RC 68001-0247-17 NDC Q0162 HCPCS inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "ONDANSETRON 1 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50465466_1 CDM 0250 RC 68001-0247-17 NDC Q0162 HCPCS inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CLINDAMYCIN PH 300 MG/2 ML VL 50468802_1 CDM 0250 RC 72611-0634-25 NDC inpatient 1 UN 14.25 9.26 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.26 65 999999999 8.63 13.82 percent of total billed charges CLINDAMYCIN PH 300 MG/2 ML VL 50468802_1 CDM 0250 RC 72611-0634-25 NDC inpatient 1 UN 14.25 9.26 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13.82 97 999999999 8.63 13.82 percent of total billed charges CLINDAMYCIN PH 300 MG/2 ML VL 50468802_1 CDM 0250 RC 72611-0634-25 NDC inpatient 1 UN 14.25 9.26 AETNA AETNA 11.26 79 999999999 8.63 13.82 percent of total billed charges CLINDAMYCIN PH 300 MG/2 ML VL 50468802_1 CDM 0250 RC 72611-0634-25 NDC inpatient 1 UN 14.25 9.26 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.12 78 999999999 8.63 13.82 percent of total billed charges CLINDAMYCIN PH 300 MG/2 ML VL 50468802_1 CDM 0250 RC 72611-0634-25 NDC inpatient 1 UN 14.25 9.26 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.83 69 999999999 8.63 13.82 percent of total billed charges CLINDAMYCIN PH 300 MG/2 ML VL 50468802_1 CDM 0250 RC 72611-0634-25 NDC inpatient 1 UN 14.25 9.26 UMR - ALL PLANS UMR - ALL PLANS 9.98 70 999999999 8.63 13.82 percent of total billed charges CLINDAMYCIN PH 300 MG/2 ML VL 50468802_1 CDM 0250 RC 72611-0634-25 NDC inpatient 1 UN 14.25 9.26 SIHO - ALL PLANS SIHO - ALL PLANS 12.83 90 999999999 8.63 13.82 percent of total billed charges CLINDAMYCIN PH 300 MG/2 ML VL 50468802_1 CDM 0250 RC 72611-0634-25 NDC inpatient 1 UN 14.25 9.26 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.63 60.55 999999999 8.63 13.82 percent of total billed charges CLINDAMYCIN PH 300 MG/2 ML VL 50468802_1 CDM 0250 RC 72611-0634-25 NDC inpatient 1 UN 14.25 9.26 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.63 13.82 CLINDAMYCIN PH 300 MG/2 ML VL 50468802_1 CDM 0250 RC 72611-0634-25 NDC inpatient 1 UN 14.25 9.26 ANTHEM HMO ANTHEM HMO 999999999 8.63 13.82 CLINDAMYCIN PH 300 MG/2 ML VL 50468802_1 CDM 0250 RC 72611-0634-25 NDC inpatient 1 UN 14.25 9.26 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.63 13.82 CLINDAMYCIN PH 300 MG/2 ML VL 50468802_1 CDM 0250 RC 72611-0634-25 NDC inpatient 1 UN 14.25 9.26 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.63 13.82 CLINDAMYCIN PH 300 MG/2 ML VL 50468802_1 CDM 0250 RC 72611-0634-25 NDC inpatient 1 UN 14.25 9.26 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.63 13.82 CLINDAMYCIN PH 300 MG/2 ML VL 50468802_1 CDM 0250 RC 72611-0634-25 NDC inpatient 1 UN 14.25 9.26 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.63 67.6 999999999 8.63 13.82 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50468839_1 CDM 0250 RC 44567-0620-24 NDC J0610 HCPCS inpatient 5 UN 87.47 56.86 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.86 65 999999999 52.96 84.85 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50468839_1 CDM 0250 RC 44567-0620-24 NDC J0610 HCPCS inpatient 5 UN 87.47 56.86 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.85 97 999999999 52.96 84.85 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50468839_1 CDM 0250 RC 44567-0620-24 NDC J0610 HCPCS inpatient 5 UN 87.47 56.86 AETNA AETNA 69.1 79 999999999 52.96 84.85 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50468839_1 CDM 0250 RC 44567-0620-24 NDC J0610 HCPCS inpatient 5 UN 87.47 56.86 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.23 78 999999999 52.96 84.85 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50468839_1 CDM 0250 RC 44567-0620-24 NDC J0610 HCPCS inpatient 5 UN 87.47 56.86 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.35 69 999999999 52.96 84.85 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50468839_1 CDM 0250 RC 44567-0620-24 NDC J0610 HCPCS inpatient 5 UN 87.47 56.86 UMR - ALL PLANS UMR - ALL PLANS 61.23 70 999999999 52.96 84.85 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50468839_1 CDM 0250 RC 44567-0620-24 NDC J0610 HCPCS inpatient 5 UN 87.47 56.86 SIHO - ALL PLANS SIHO - ALL PLANS 78.72 90 999999999 52.96 84.85 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50468839_1 CDM 0250 RC 44567-0620-24 NDC J0610 HCPCS inpatient 5 UN 87.47 56.86 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.96 60.55 999999999 52.96 84.85 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50468839_1 CDM 0250 RC 44567-0620-24 NDC J0610 HCPCS inpatient 5 UN 87.47 56.86 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.96 84.85 "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50468839_1 CDM 0250 RC 44567-0620-24 NDC J0610 HCPCS inpatient 5 UN 87.47 56.86 ANTHEM HMO ANTHEM HMO 999999999 52.96 84.85 "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50468839_1 CDM 0250 RC 44567-0620-24 NDC J0610 HCPCS inpatient 5 UN 87.47 56.86 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.96 84.85 "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50468839_1 CDM 0250 RC 44567-0620-24 NDC J0610 HCPCS inpatient 5 UN 87.47 56.86 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.96 84.85 "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50468839_1 CDM 0250 RC 44567-0620-24 NDC J0610 HCPCS inpatient 5 UN 87.47 56.86 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.96 84.85 "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50468839_1 CDM 0250 RC 44567-0620-24 NDC J0610 HCPCS inpatient 5 UN 87.47 56.86 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.13 67.6 999999999 52.96 84.85 percent of total billed charges MIDODRINE HCL 2.5 MG TABLET 50469119_1 CDM 0250 RC 60687-0387-01 NDC inpatient 1 UN 2.47 1.61 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.61 65 999999999 1.5 2.4 percent of total billed charges MIDODRINE HCL 2.5 MG TABLET 50469119_1 CDM 0250 RC 60687-0387-01 NDC inpatient 1 UN 2.47 1.61 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.4 97 999999999 1.5 2.4 percent of total billed charges MIDODRINE HCL 2.5 MG TABLET 50469119_1 CDM 0250 RC 60687-0387-01 NDC inpatient 1 UN 2.47 1.61 AETNA AETNA 1.95 79 999999999 1.5 2.4 percent of total billed charges MIDODRINE HCL 2.5 MG TABLET 50469119_1 CDM 0250 RC 60687-0387-01 NDC inpatient 1 UN 2.47 1.61 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.93 78 999999999 1.5 2.4 percent of total billed charges MIDODRINE HCL 2.5 MG TABLET 50469119_1 CDM 0250 RC 60687-0387-01 NDC inpatient 1 UN 2.47 1.61 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.7 69 999999999 1.5 2.4 percent of total billed charges MIDODRINE HCL 2.5 MG TABLET 50469119_1 CDM 0250 RC 60687-0387-01 NDC inpatient 1 UN 2.47 1.61 UMR - ALL PLANS UMR - ALL PLANS 1.73 70 999999999 1.5 2.4 percent of total billed charges MIDODRINE HCL 2.5 MG TABLET 50469119_1 CDM 0250 RC 60687-0387-01 NDC inpatient 1 UN 2.47 1.61 SIHO - ALL PLANS SIHO - ALL PLANS 2.22 90 999999999 1.5 2.4 percent of total billed charges MIDODRINE HCL 2.5 MG TABLET 50469119_1 CDM 0250 RC 60687-0387-01 NDC inpatient 1 UN 2.47 1.61 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.5 60.55 999999999 1.5 2.4 percent of total billed charges MIDODRINE HCL 2.5 MG TABLET 50469119_1 CDM 0250 RC 60687-0387-01 NDC inpatient 1 UN 2.47 1.61 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.5 2.4 MIDODRINE HCL 2.5 MG TABLET 50469119_1 CDM 0250 RC 60687-0387-01 NDC inpatient 1 UN 2.47 1.61 ANTHEM HMO ANTHEM HMO 999999999 1.5 2.4 MIDODRINE HCL 2.5 MG TABLET 50469119_1 CDM 0250 RC 60687-0387-01 NDC inpatient 1 UN 2.47 1.61 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.5 2.4 MIDODRINE HCL 2.5 MG TABLET 50469119_1 CDM 0250 RC 60687-0387-01 NDC inpatient 1 UN 2.47 1.61 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.5 2.4 MIDODRINE HCL 2.5 MG TABLET 50469119_1 CDM 0250 RC 60687-0387-01 NDC inpatient 1 UN 2.47 1.61 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.5 2.4 MIDODRINE HCL 2.5 MG TABLET 50469119_1 CDM 0250 RC 60687-0387-01 NDC inpatient 1 UN 2.47 1.61 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.67 67.6 999999999 1.5 2.4 percent of total billed charges BFLEX 5.0 BRONCHOSCOPE 0570-0375 50469661_1 CDM 0272 RC inpatient 1394 906.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 906.1 65 999999999 844.07 1352.18 percent of total billed charges BFLEX 5.0 BRONCHOSCOPE 0570-0375 50469661_1 CDM 0272 RC inpatient 1394 906.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1352.18 97 999999999 844.07 1352.18 percent of total billed charges BFLEX 5.0 BRONCHOSCOPE 0570-0375 50469661_1 CDM 0272 RC inpatient 1394 906.1 AETNA AETNA 1101.26 79 999999999 844.07 1352.18 percent of total billed charges BFLEX 5.0 BRONCHOSCOPE 0570-0375 50469661_1 CDM 0272 RC inpatient 1394 906.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1087.32 78 999999999 844.07 1352.18 percent of total billed charges BFLEX 5.0 BRONCHOSCOPE 0570-0375 50469661_1 CDM 0272 RC inpatient 1394 906.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 961.86 69 999999999 844.07 1352.18 percent of total billed charges BFLEX 5.0 BRONCHOSCOPE 0570-0375 50469661_1 CDM 0272 RC inpatient 1394 906.1 UMR - ALL PLANS UMR - ALL PLANS 975.8 70 999999999 844.07 1352.18 percent of total billed charges BFLEX 5.0 BRONCHOSCOPE 0570-0375 50469661_1 CDM 0272 RC inpatient 1394 906.1 SIHO - ALL PLANS SIHO - ALL PLANS 1254.6 90 999999999 844.07 1352.18 percent of total billed charges BFLEX 5.0 BRONCHOSCOPE 0570-0375 50469661_1 CDM 0272 RC inpatient 1394 906.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 844.07 60.55 999999999 844.07 1352.18 percent of total billed charges BFLEX 5.0 BRONCHOSCOPE 0570-0375 50469661_1 CDM 0272 RC inpatient 1394 906.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 844.07 1352.18 BFLEX 5.0 BRONCHOSCOPE 0570-0375 50469661_1 CDM 0272 RC inpatient 1394 906.1 ANTHEM HMO ANTHEM HMO 999999999 844.07 1352.18 BFLEX 5.0 BRONCHOSCOPE 0570-0375 50469661_1 CDM 0272 RC inpatient 1394 906.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 844.07 1352.18 BFLEX 5.0 BRONCHOSCOPE 0570-0375 50469661_1 CDM 0272 RC inpatient 1394 906.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 844.07 1352.18 BFLEX 5.0 BRONCHOSCOPE 0570-0375 50469661_1 CDM 0272 RC inpatient 1394 906.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 844.07 1352.18 BFLEX 5.0 BRONCHOSCOPE 0570-0375 50469661_1 CDM 0272 RC inpatient 1394 906.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 942.34 67.6 999999999 844.07 1352.18 percent of total billed charges METFORMIN HCL ER 500 MG TABLET 50471546_1 CDM 0250 RC 62756-0142-01 NDC inpatient 1 UN 1.22 0.79 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.79 65 999999999 0.74 1.18 percent of total billed charges METFORMIN HCL ER 500 MG TABLET 50471546_1 CDM 0250 RC 62756-0142-01 NDC inpatient 1 UN 1.22 0.79 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.18 97 999999999 0.74 1.18 percent of total billed charges METFORMIN HCL ER 500 MG TABLET 50471546_1 CDM 0250 RC 62756-0142-01 NDC inpatient 1 UN 1.22 0.79 AETNA AETNA 0.96 79 999999999 0.74 1.18 percent of total billed charges METFORMIN HCL ER 500 MG TABLET 50471546_1 CDM 0250 RC 62756-0142-01 NDC inpatient 1 UN 1.22 0.79 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.95 78 999999999 0.74 1.18 percent of total billed charges METFORMIN HCL ER 500 MG TABLET 50471546_1 CDM 0250 RC 62756-0142-01 NDC inpatient 1 UN 1.22 0.79 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.84 69 999999999 0.74 1.18 percent of total billed charges METFORMIN HCL ER 500 MG TABLET 50471546_1 CDM 0250 RC 62756-0142-01 NDC inpatient 1 UN 1.22 0.79 UMR - ALL PLANS UMR - ALL PLANS 0.85 70 999999999 0.74 1.18 percent of total billed charges METFORMIN HCL ER 500 MG TABLET 50471546_1 CDM 0250 RC 62756-0142-01 NDC inpatient 1 UN 1.22 0.79 SIHO - ALL PLANS SIHO - ALL PLANS 1.1 90 999999999 0.74 1.18 percent of total billed charges METFORMIN HCL ER 500 MG TABLET 50471546_1 CDM 0250 RC 62756-0142-01 NDC inpatient 1 UN 1.22 0.79 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.74 60.55 999999999 0.74 1.18 percent of total billed charges METFORMIN HCL ER 500 MG TABLET 50471546_1 CDM 0250 RC 62756-0142-01 NDC inpatient 1 UN 1.22 0.79 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.74 1.18 METFORMIN HCL ER 500 MG TABLET 50471546_1 CDM 0250 RC 62756-0142-01 NDC inpatient 1 UN 1.22 0.79 ANTHEM HMO ANTHEM HMO 999999999 0.74 1.18 METFORMIN HCL ER 500 MG TABLET 50471546_1 CDM 0250 RC 62756-0142-01 NDC inpatient 1 UN 1.22 0.79 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.74 1.18 METFORMIN HCL ER 500 MG TABLET 50471546_1 CDM 0250 RC 62756-0142-01 NDC inpatient 1 UN 1.22 0.79 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.74 1.18 METFORMIN HCL ER 500 MG TABLET 50471546_1 CDM 0250 RC 62756-0142-01 NDC inpatient 1 UN 1.22 0.79 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.74 1.18 METFORMIN HCL ER 500 MG TABLET 50471546_1 CDM 0250 RC 62756-0142-01 NDC inpatient 1 UN 1.22 0.79 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.82 67.6 999999999 0.74 1.18 percent of total billed charges KCL 40 MEQ/L-D5W-0.9% NACL 50471549_1 CDM 0250 RC 00990-7109-09 NDC inpatient 1 UN 64 41.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.6 65 999999999 38.75 62.08 percent of total billed charges KCL 40 MEQ/L-D5W-0.9% NACL 50471549_1 CDM 0250 RC 00990-7109-09 NDC inpatient 1 UN 64 41.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 62.08 97 999999999 38.75 62.08 percent of total billed charges KCL 40 MEQ/L-D5W-0.9% NACL 50471549_1 CDM 0250 RC 00990-7109-09 NDC inpatient 1 UN 64 41.6 AETNA AETNA 50.56 79 999999999 38.75 62.08 percent of total billed charges KCL 40 MEQ/L-D5W-0.9% NACL 50471549_1 CDM 0250 RC 00990-7109-09 NDC inpatient 1 UN 64 41.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.92 78 999999999 38.75 62.08 percent of total billed charges KCL 40 MEQ/L-D5W-0.9% NACL 50471549_1 CDM 0250 RC 00990-7109-09 NDC inpatient 1 UN 64 41.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.16 69 999999999 38.75 62.08 percent of total billed charges KCL 40 MEQ/L-D5W-0.9% NACL 50471549_1 CDM 0250 RC 00990-7109-09 NDC inpatient 1 UN 64 41.6 UMR - ALL PLANS UMR - ALL PLANS 44.8 70 999999999 38.75 62.08 percent of total billed charges KCL 40 MEQ/L-D5W-0.9% NACL 50471549_1 CDM 0250 RC 00990-7109-09 NDC inpatient 1 UN 64 41.6 SIHO - ALL PLANS SIHO - ALL PLANS 57.6 90 999999999 38.75 62.08 percent of total billed charges KCL 40 MEQ/L-D5W-0.9% NACL 50471549_1 CDM 0250 RC 00990-7109-09 NDC inpatient 1 UN 64 41.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.75 60.55 999999999 38.75 62.08 percent of total billed charges KCL 40 MEQ/L-D5W-0.9% NACL 50471549_1 CDM 0250 RC 00990-7109-09 NDC inpatient 1 UN 64 41.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.75 62.08 KCL 40 MEQ/L-D5W-0.9% NACL 50471549_1 CDM 0250 RC 00990-7109-09 NDC inpatient 1 UN 64 41.6 ANTHEM HMO ANTHEM HMO 999999999 38.75 62.08 KCL 40 MEQ/L-D5W-0.9% NACL 50471549_1 CDM 0250 RC 00990-7109-09 NDC inpatient 1 UN 64 41.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.75 62.08 KCL 40 MEQ/L-D5W-0.9% NACL 50471549_1 CDM 0250 RC 00990-7109-09 NDC inpatient 1 UN 64 41.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.75 62.08 KCL 40 MEQ/L-D5W-0.9% NACL 50471549_1 CDM 0250 RC 00990-7109-09 NDC inpatient 1 UN 64 41.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.75 62.08 KCL 40 MEQ/L-D5W-0.9% NACL 50471549_1 CDM 0250 RC 00990-7109-09 NDC inpatient 1 UN 64 41.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.26 67.6 999999999 38.75 62.08 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50471553_1 CDM 0636 RC 70860-0802-82 NDC J3489 HCPCS inpatient 5 UN 207.12 134.63 SELF PAY DISCOUNT SELF PAY DISCOUNT 134.63 65 999999999 125.41 200.91 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50471553_1 CDM 0636 RC 70860-0802-82 NDC J3489 HCPCS inpatient 5 UN 207.12 134.63 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 200.91 97 999999999 125.41 200.91 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50471553_1 CDM 0636 RC 70860-0802-82 NDC J3489 HCPCS inpatient 5 UN 207.12 134.63 AETNA AETNA 163.62 79 999999999 125.41 200.91 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50471553_1 CDM 0636 RC 70860-0802-82 NDC J3489 HCPCS inpatient 5 UN 207.12 134.63 HUMANA - ALL PLANS HUMANA - ALL PLANS 161.55 78 999999999 125.41 200.91 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50471553_1 CDM 0636 RC 70860-0802-82 NDC J3489 HCPCS inpatient 5 UN 207.12 134.63 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.91 69 999999999 125.41 200.91 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50471553_1 CDM 0636 RC 70860-0802-82 NDC J3489 HCPCS inpatient 5 UN 207.12 134.63 UMR - ALL PLANS UMR - ALL PLANS 144.98 70 999999999 125.41 200.91 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50471553_1 CDM 0636 RC 70860-0802-82 NDC J3489 HCPCS inpatient 5 UN 207.12 134.63 SIHO - ALL PLANS SIHO - ALL PLANS 186.41 90 999999999 125.41 200.91 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50471553_1 CDM 0636 RC 70860-0802-82 NDC J3489 HCPCS inpatient 5 UN 207.12 134.63 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 125.41 60.55 999999999 125.41 200.91 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50471553_1 CDM 0636 RC 70860-0802-82 NDC J3489 HCPCS inpatient 5 UN 207.12 134.63 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 125.41 200.91 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50471553_1 CDM 0636 RC 70860-0802-82 NDC J3489 HCPCS inpatient 5 UN 207.12 134.63 ANTHEM HMO ANTHEM HMO 999999999 125.41 200.91 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50471553_1 CDM 0636 RC 70860-0802-82 NDC J3489 HCPCS inpatient 5 UN 207.12 134.63 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 125.41 200.91 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50471553_1 CDM 0636 RC 70860-0802-82 NDC J3489 HCPCS inpatient 5 UN 207.12 134.63 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 125.41 200.91 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50471553_1 CDM 0636 RC 70860-0802-82 NDC J3489 HCPCS inpatient 5 UN 207.12 134.63 UHC - ALL PLANS UHC - ALL PLANS 999999999 125.41 200.91 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50471553_1 CDM 0636 RC 70860-0802-82 NDC J3489 HCPCS inpatient 5 UN 207.12 134.63 CIGNA - ALL PLANS CIGNA - ALL PLANS 140.01 67.6 999999999 125.41 200.91 percent of total billed charges CINACALCET HCL 30 MG TABLET 50472021_1 CDM 0250 RC 67877-0503-30 NDC inpatient 1 UN 25.23 16.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.4 65 999999999 15.28 24.47 percent of total billed charges CINACALCET HCL 30 MG TABLET 50472021_1 CDM 0250 RC 67877-0503-30 NDC inpatient 1 UN 25.23 16.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.47 97 999999999 15.28 24.47 percent of total billed charges CINACALCET HCL 30 MG TABLET 50472021_1 CDM 0250 RC 67877-0503-30 NDC inpatient 1 UN 25.23 16.4 AETNA AETNA 19.93 79 999999999 15.28 24.47 percent of total billed charges CINACALCET HCL 30 MG TABLET 50472021_1 CDM 0250 RC 67877-0503-30 NDC inpatient 1 UN 25.23 16.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.68 78 999999999 15.28 24.47 percent of total billed charges CINACALCET HCL 30 MG TABLET 50472021_1 CDM 0250 RC 67877-0503-30 NDC inpatient 1 UN 25.23 16.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.41 69 999999999 15.28 24.47 percent of total billed charges CINACALCET HCL 30 MG TABLET 50472021_1 CDM 0250 RC 67877-0503-30 NDC inpatient 1 UN 25.23 16.4 UMR - ALL PLANS UMR - ALL PLANS 17.66 70 999999999 15.28 24.47 percent of total billed charges CINACALCET HCL 30 MG TABLET 50472021_1 CDM 0250 RC 67877-0503-30 NDC inpatient 1 UN 25.23 16.4 SIHO - ALL PLANS SIHO - ALL PLANS 22.71 90 999999999 15.28 24.47 percent of total billed charges CINACALCET HCL 30 MG TABLET 50472021_1 CDM 0250 RC 67877-0503-30 NDC inpatient 1 UN 25.23 16.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.28 60.55 999999999 15.28 24.47 percent of total billed charges CINACALCET HCL 30 MG TABLET 50472021_1 CDM 0250 RC 67877-0503-30 NDC inpatient 1 UN 25.23 16.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.28 24.47 CINACALCET HCL 30 MG TABLET 50472021_1 CDM 0250 RC 67877-0503-30 NDC inpatient 1 UN 25.23 16.4 ANTHEM HMO ANTHEM HMO 999999999 15.28 24.47 CINACALCET HCL 30 MG TABLET 50472021_1 CDM 0250 RC 67877-0503-30 NDC inpatient 1 UN 25.23 16.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.28 24.47 CINACALCET HCL 30 MG TABLET 50472021_1 CDM 0250 RC 67877-0503-30 NDC inpatient 1 UN 25.23 16.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.28 24.47 CINACALCET HCL 30 MG TABLET 50472021_1 CDM 0250 RC 67877-0503-30 NDC inpatient 1 UN 25.23 16.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.28 24.47 CINACALCET HCL 30 MG TABLET 50472021_1 CDM 0250 RC 67877-0503-30 NDC inpatient 1 UN 25.23 16.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.06 67.6 999999999 15.28 24.47 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 50472048_1 CDM 0636 RC Q4121 HCPCS inpatient 2516 1635.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1635.4 65 999999999 1523.44 2440.52 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 50472048_1 CDM 0636 RC Q4121 HCPCS inpatient 2516 1635.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2440.52 97 999999999 1523.44 2440.52 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 50472048_1 CDM 0636 RC Q4121 HCPCS inpatient 2516 1635.4 AETNA AETNA 1987.64 79 999999999 1523.44 2440.52 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 50472048_1 CDM 0636 RC Q4121 HCPCS inpatient 2516 1635.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1962.48 78 999999999 1523.44 2440.52 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 50472048_1 CDM 0636 RC Q4121 HCPCS inpatient 2516 1635.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1736.04 69 999999999 1523.44 2440.52 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 50472048_1 CDM 0636 RC Q4121 HCPCS inpatient 2516 1635.4 UMR - ALL PLANS UMR - ALL PLANS 1761.2 70 999999999 1523.44 2440.52 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 50472048_1 CDM 0636 RC Q4121 HCPCS inpatient 2516 1635.4 SIHO - ALL PLANS SIHO - ALL PLANS 2264.4 90 999999999 1523.44 2440.52 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 50472048_1 CDM 0636 RC Q4121 HCPCS inpatient 2516 1635.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1523.44 60.55 999999999 1523.44 2440.52 percent of total billed charges "THERASKIN, PER SQUARE CENTIMETER" 50472048_1 CDM 0636 RC Q4121 HCPCS inpatient 2516 1635.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1523.44 2440.52 "THERASKIN, PER SQUARE CENTIMETER" 50472048_1 CDM 0636 RC Q4121 HCPCS inpatient 2516 1635.4 ANTHEM HMO ANTHEM HMO 999999999 1523.44 2440.52 "THERASKIN, PER SQUARE CENTIMETER" 50472048_1 CDM 0636 RC Q4121 HCPCS inpatient 2516 1635.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1523.44 2440.52 "THERASKIN, PER SQUARE CENTIMETER" 50472048_1 CDM 0636 RC Q4121 HCPCS inpatient 2516 1635.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1523.44 2440.52 "THERASKIN, PER SQUARE CENTIMETER" 50472048_1 CDM 0636 RC Q4121 HCPCS inpatient 2516 1635.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1523.44 2440.52 "THERASKIN, PER SQUARE CENTIMETER" 50472048_1 CDM 0636 RC Q4121 HCPCS inpatient 2516 1635.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1700.82 67.6 999999999 1523.44 2440.52 percent of total billed charges METHOCARBAMOL 500 MG TABLET 50472064_1 CDM 0250 RC 70010-0754-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges METHOCARBAMOL 500 MG TABLET 50472064_1 CDM 0250 RC 70010-0754-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges METHOCARBAMOL 500 MG TABLET 50472064_1 CDM 0250 RC 70010-0754-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges METHOCARBAMOL 500 MG TABLET 50472064_1 CDM 0250 RC 70010-0754-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges METHOCARBAMOL 500 MG TABLET 50472064_1 CDM 0250 RC 70010-0754-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges METHOCARBAMOL 500 MG TABLET 50472064_1 CDM 0250 RC 70010-0754-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges METHOCARBAMOL 500 MG TABLET 50472064_1 CDM 0250 RC 70010-0754-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges METHOCARBAMOL 500 MG TABLET 50472064_1 CDM 0250 RC 70010-0754-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges METHOCARBAMOL 500 MG TABLET 50472064_1 CDM 0250 RC 70010-0754-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 METHOCARBAMOL 500 MG TABLET 50472064_1 CDM 0250 RC 70010-0754-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 METHOCARBAMOL 500 MG TABLET 50472064_1 CDM 0250 RC 70010-0754-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 METHOCARBAMOL 500 MG TABLET 50472064_1 CDM 0250 RC 70010-0754-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 METHOCARBAMOL 500 MG TABLET 50472064_1 CDM 0250 RC 70010-0754-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 METHOCARBAMOL 500 MG TABLET 50472064_1 CDM 0250 RC 70010-0754-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges TRAZODONE 150 MG TABLET 50472065_1 CDM 0250 RC 68382-0807-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges TRAZODONE 150 MG TABLET 50472065_1 CDM 0250 RC 68382-0807-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges TRAZODONE 150 MG TABLET 50472065_1 CDM 0250 RC 68382-0807-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges TRAZODONE 150 MG TABLET 50472065_1 CDM 0250 RC 68382-0807-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges TRAZODONE 150 MG TABLET 50472065_1 CDM 0250 RC 68382-0807-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges TRAZODONE 150 MG TABLET 50472065_1 CDM 0250 RC 68382-0807-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges TRAZODONE 150 MG TABLET 50472065_1 CDM 0250 RC 68382-0807-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges TRAZODONE 150 MG TABLET 50472065_1 CDM 0250 RC 68382-0807-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges TRAZODONE 150 MG TABLET 50472065_1 CDM 0250 RC 68382-0807-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 TRAZODONE 150 MG TABLET 50472065_1 CDM 0250 RC 68382-0807-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 TRAZODONE 150 MG TABLET 50472065_1 CDM 0250 RC 68382-0807-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 TRAZODONE 150 MG TABLET 50472065_1 CDM 0250 RC 68382-0807-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 TRAZODONE 150 MG TABLET 50472065_1 CDM 0250 RC 68382-0807-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 TRAZODONE 150 MG TABLET 50472065_1 CDM 0250 RC 68382-0807-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges WARFARIN SODIUM 10 MG TABLET 50472067_1 CDM 0250 RC 65162-0769-10 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges WARFARIN SODIUM 10 MG TABLET 50472067_1 CDM 0250 RC 65162-0769-10 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges WARFARIN SODIUM 10 MG TABLET 50472067_1 CDM 0250 RC 65162-0769-10 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges WARFARIN SODIUM 10 MG TABLET 50472067_1 CDM 0250 RC 65162-0769-10 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges WARFARIN SODIUM 10 MG TABLET 50472067_1 CDM 0250 RC 65162-0769-10 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges WARFARIN SODIUM 10 MG TABLET 50472067_1 CDM 0250 RC 65162-0769-10 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges WARFARIN SODIUM 10 MG TABLET 50472067_1 CDM 0250 RC 65162-0769-10 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges WARFARIN SODIUM 10 MG TABLET 50472067_1 CDM 0250 RC 65162-0769-10 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges WARFARIN SODIUM 10 MG TABLET 50472067_1 CDM 0250 RC 65162-0769-10 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 WARFARIN SODIUM 10 MG TABLET 50472067_1 CDM 0250 RC 65162-0769-10 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 WARFARIN SODIUM 10 MG TABLET 50472067_1 CDM 0250 RC 65162-0769-10 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 WARFARIN SODIUM 10 MG TABLET 50472067_1 CDM 0250 RC 65162-0769-10 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 WARFARIN SODIUM 10 MG TABLET 50472067_1 CDM 0250 RC 65162-0769-10 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 WARFARIN SODIUM 10 MG TABLET 50472067_1 CDM 0250 RC 65162-0769-10 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges AMLODIPINE BESYLATE 2.5 MG TAB 50472073_1 CDM 0250 RC 67877-0197-90 NDC inpatient 1 UN 1.69 1.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.1 65 999999999 1.02 1.64 percent of total billed charges AMLODIPINE BESYLATE 2.5 MG TAB 50472073_1 CDM 0250 RC 67877-0197-90 NDC inpatient 1 UN 1.69 1.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.64 97 999999999 1.02 1.64 percent of total billed charges AMLODIPINE BESYLATE 2.5 MG TAB 50472073_1 CDM 0250 RC 67877-0197-90 NDC inpatient 1 UN 1.69 1.1 AETNA AETNA 1.34 79 999999999 1.02 1.64 percent of total billed charges AMLODIPINE BESYLATE 2.5 MG TAB 50472073_1 CDM 0250 RC 67877-0197-90 NDC inpatient 1 UN 1.69 1.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.32 78 999999999 1.02 1.64 percent of total billed charges AMLODIPINE BESYLATE 2.5 MG TAB 50472073_1 CDM 0250 RC 67877-0197-90 NDC inpatient 1 UN 1.69 1.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.17 69 999999999 1.02 1.64 percent of total billed charges AMLODIPINE BESYLATE 2.5 MG TAB 50472073_1 CDM 0250 RC 67877-0197-90 NDC inpatient 1 UN 1.69 1.1 UMR - ALL PLANS UMR - ALL PLANS 1.18 70 999999999 1.02 1.64 percent of total billed charges AMLODIPINE BESYLATE 2.5 MG TAB 50472073_1 CDM 0250 RC 67877-0197-90 NDC inpatient 1 UN 1.69 1.1 SIHO - ALL PLANS SIHO - ALL PLANS 1.52 90 999999999 1.02 1.64 percent of total billed charges AMLODIPINE BESYLATE 2.5 MG TAB 50472073_1 CDM 0250 RC 67877-0197-90 NDC inpatient 1 UN 1.69 1.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.02 60.55 999999999 1.02 1.64 percent of total billed charges AMLODIPINE BESYLATE 2.5 MG TAB 50472073_1 CDM 0250 RC 67877-0197-90 NDC inpatient 1 UN 1.69 1.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.02 1.64 AMLODIPINE BESYLATE 2.5 MG TAB 50472073_1 CDM 0250 RC 67877-0197-90 NDC inpatient 1 UN 1.69 1.1 ANTHEM HMO ANTHEM HMO 999999999 1.02 1.64 AMLODIPINE BESYLATE 2.5 MG TAB 50472073_1 CDM 0250 RC 67877-0197-90 NDC inpatient 1 UN 1.69 1.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.02 1.64 AMLODIPINE BESYLATE 2.5 MG TAB 50472073_1 CDM 0250 RC 67877-0197-90 NDC inpatient 1 UN 1.69 1.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.02 1.64 AMLODIPINE BESYLATE 2.5 MG TAB 50472073_1 CDM 0250 RC 67877-0197-90 NDC inpatient 1 UN 1.69 1.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.02 1.64 AMLODIPINE BESYLATE 2.5 MG TAB 50472073_1 CDM 0250 RC 67877-0197-90 NDC inpatient 1 UN 1.69 1.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.14 67.6 999999999 1.02 1.64 percent of total billed charges Biotinidase (enzyme) level 50472710_1 CDM 0301 RC 82261 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges Biotinidase (enzyme) level 50472710_1 CDM 0301 RC 82261 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges Biotinidase (enzyme) level 50472710_1 CDM 0301 RC 82261 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges Biotinidase (enzyme) level 50472710_1 CDM 0301 RC 82261 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges Biotinidase (enzyme) level 50472710_1 CDM 0301 RC 82261 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges Biotinidase (enzyme) level 50472710_1 CDM 0301 RC 82261 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges Biotinidase (enzyme) level 50472710_1 CDM 0301 RC 82261 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges Biotinidase (enzyme) level 50472710_1 CDM 0301 RC 82261 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges Biotinidase (enzyme) level 50472710_1 CDM 0301 RC 82261 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 Biotinidase (enzyme) level 50472710_1 CDM 0301 RC 82261 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 Biotinidase (enzyme) level 50472710_1 CDM 0301 RC 82261 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 Biotinidase (enzyme) level 50472710_1 CDM 0301 RC 82261 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 Biotinidase (enzyme) level 50472710_1 CDM 0301 RC 82261 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 Biotinidase (enzyme) level 50472710_1 CDM 0301 RC 82261 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50472711_1 CDM 0301 RC 83498 HCPCS inpatient 213 138.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 138.45 65 999999999 128.97 206.61 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50472711_1 CDM 0301 RC 83498 HCPCS inpatient 213 138.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 206.61 97 999999999 128.97 206.61 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50472711_1 CDM 0301 RC 83498 HCPCS inpatient 213 138.45 AETNA AETNA 168.27 79 999999999 128.97 206.61 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50472711_1 CDM 0301 RC 83498 HCPCS inpatient 213 138.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 166.14 78 999999999 128.97 206.61 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50472711_1 CDM 0301 RC 83498 HCPCS inpatient 213 138.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 146.97 69 999999999 128.97 206.61 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50472711_1 CDM 0301 RC 83498 HCPCS inpatient 213 138.45 UMR - ALL PLANS UMR - ALL PLANS 149.1 70 999999999 128.97 206.61 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50472711_1 CDM 0301 RC 83498 HCPCS inpatient 213 138.45 SIHO - ALL PLANS SIHO - ALL PLANS 191.7 90 999999999 128.97 206.61 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50472711_1 CDM 0301 RC 83498 HCPCS inpatient 213 138.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 128.97 60.55 999999999 128.97 206.61 percent of total billed charges "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50472711_1 CDM 0301 RC 83498 HCPCS inpatient 213 138.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 128.97 206.61 "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50472711_1 CDM 0301 RC 83498 HCPCS inpatient 213 138.45 ANTHEM HMO ANTHEM HMO 999999999 128.97 206.61 "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50472711_1 CDM 0301 RC 83498 HCPCS inpatient 213 138.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 128.97 206.61 "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50472711_1 CDM 0301 RC 83498 HCPCS inpatient 213 138.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 128.97 206.61 "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50472711_1 CDM 0301 RC 83498 HCPCS inpatient 213 138.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 128.97 206.61 "Hydroxyprogesterone, 17-D (synthetic hormone) level" 50472711_1 CDM 0301 RC 83498 HCPCS inpatient 213 138.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 143.99 67.6 999999999 128.97 206.61 percent of total billed charges Galactose-1-phosphate uridyl transferase screening test 50472712_1 CDM 0301 RC 82776 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges Galactose-1-phosphate uridyl transferase screening test 50472712_1 CDM 0301 RC 82776 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges Galactose-1-phosphate uridyl transferase screening test 50472712_1 CDM 0301 RC 82776 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges Galactose-1-phosphate uridyl transferase screening test 50472712_1 CDM 0301 RC 82776 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges Galactose-1-phosphate uridyl transferase screening test 50472712_1 CDM 0301 RC 82776 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges Galactose-1-phosphate uridyl transferase screening test 50472712_1 CDM 0301 RC 82776 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges Galactose-1-phosphate uridyl transferase screening test 50472712_1 CDM 0301 RC 82776 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges Galactose-1-phosphate uridyl transferase screening test 50472712_1 CDM 0301 RC 82776 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges Galactose-1-phosphate uridyl transferase screening test 50472712_1 CDM 0301 RC 82776 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 Galactose-1-phosphate uridyl transferase screening test 50472712_1 CDM 0301 RC 82776 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 Galactose-1-phosphate uridyl transferase screening test 50472712_1 CDM 0301 RC 82776 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 Galactose-1-phosphate uridyl transferase screening test 50472712_1 CDM 0301 RC 82776 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 Galactose-1-phosphate uridyl transferase screening test 50472712_1 CDM 0301 RC 82776 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 Galactose-1-phosphate uridyl transferase screening test 50472712_1 CDM 0301 RC 82776 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges Galactose (carbohydrate) level 50472713_1 CDM 0301 RC 82760 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges Galactose (carbohydrate) level 50472713_1 CDM 0301 RC 82760 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges Galactose (carbohydrate) level 50472713_1 CDM 0301 RC 82760 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges Galactose (carbohydrate) level 50472713_1 CDM 0301 RC 82760 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges Galactose (carbohydrate) level 50472713_1 CDM 0301 RC 82760 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges Galactose (carbohydrate) level 50472713_1 CDM 0301 RC 82760 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges Galactose (carbohydrate) level 50472713_1 CDM 0301 RC 82760 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges Galactose (carbohydrate) level 50472713_1 CDM 0301 RC 82760 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges Galactose (carbohydrate) level 50472713_1 CDM 0301 RC 82760 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 Galactose (carbohydrate) level 50472713_1 CDM 0301 RC 82760 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 Galactose (carbohydrate) level 50472713_1 CDM 0301 RC 82760 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 Galactose (carbohydrate) level 50472713_1 CDM 0301 RC 82760 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 Galactose (carbohydrate) level 50472713_1 CDM 0301 RC 82760 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 Galactose (carbohydrate) level 50472713_1 CDM 0301 RC 82760 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges "Hemoglobin analysis and measurement, electrophoresis" 50472714_1 CDM 0301 RC 83020 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges "Hemoglobin analysis and measurement, electrophoresis" 50472714_1 CDM 0301 RC 83020 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges "Hemoglobin analysis and measurement, electrophoresis" 50472714_1 CDM 0301 RC 83020 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges "Hemoglobin analysis and measurement, electrophoresis" 50472714_1 CDM 0301 RC 83020 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges "Hemoglobin analysis and measurement, electrophoresis" 50472714_1 CDM 0301 RC 83020 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges "Hemoglobin analysis and measurement, electrophoresis" 50472714_1 CDM 0301 RC 83020 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges "Hemoglobin analysis and measurement, electrophoresis" 50472714_1 CDM 0301 RC 83020 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges "Hemoglobin analysis and measurement, electrophoresis" 50472714_1 CDM 0301 RC 83020 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges "Hemoglobin analysis and measurement, electrophoresis" 50472714_1 CDM 0301 RC 83020 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 "Hemoglobin analysis and measurement, electrophoresis" 50472714_1 CDM 0301 RC 83020 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 "Hemoglobin analysis and measurement, electrophoresis" 50472714_1 CDM 0301 RC 83020 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 "Hemoglobin analysis and measurement, electrophoresis" 50472714_1 CDM 0301 RC 83020 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 "Hemoglobin analysis and measurement, electrophoresis" 50472714_1 CDM 0301 RC 83020 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 "Hemoglobin analysis and measurement, electrophoresis" 50472714_1 CDM 0301 RC 83020 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges "Amino acid analysis, multiple amino acids, qualitative, each specimen" 50472715_1 CDM 0301 RC 82128 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges "Amino acid analysis, multiple amino acids, qualitative, each specimen" 50472715_1 CDM 0301 RC 82128 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges "Amino acid analysis, multiple amino acids, qualitative, each specimen" 50472715_1 CDM 0301 RC 82128 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges "Amino acid analysis, multiple amino acids, qualitative, each specimen" 50472715_1 CDM 0301 RC 82128 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges "Amino acid analysis, multiple amino acids, qualitative, each specimen" 50472715_1 CDM 0301 RC 82128 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges "Amino acid analysis, multiple amino acids, qualitative, each specimen" 50472715_1 CDM 0301 RC 82128 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges "Amino acid analysis, multiple amino acids, qualitative, each specimen" 50472715_1 CDM 0301 RC 82128 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges "Amino acid analysis, multiple amino acids, qualitative, each specimen" 50472715_1 CDM 0301 RC 82128 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges "Amino acid analysis, multiple amino acids, qualitative, each specimen" 50472715_1 CDM 0301 RC 82128 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 "Amino acid analysis, multiple amino acids, qualitative, each specimen" 50472715_1 CDM 0301 RC 82128 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 "Amino acid analysis, multiple amino acids, qualitative, each specimen" 50472715_1 CDM 0301 RC 82128 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 "Amino acid analysis, multiple amino acids, qualitative, each specimen" 50472715_1 CDM 0301 RC 82128 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 "Amino acid analysis, multiple amino acids, qualitative, each specimen" 50472715_1 CDM 0301 RC 82128 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 "Amino acid analysis, multiple amino acids, qualitative, each specimen" 50472715_1 CDM 0301 RC 82128 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges Chemical analysis for genetic disorder 50472716_1 CDM 0301 RC 82016 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges Chemical analysis for genetic disorder 50472716_1 CDM 0301 RC 82016 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges Chemical analysis for genetic disorder 50472716_1 CDM 0301 RC 82016 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges Chemical analysis for genetic disorder 50472716_1 CDM 0301 RC 82016 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges Chemical analysis for genetic disorder 50472716_1 CDM 0301 RC 82016 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges Chemical analysis for genetic disorder 50472716_1 CDM 0301 RC 82016 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges Chemical analysis for genetic disorder 50472716_1 CDM 0301 RC 82016 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges Chemical analysis for genetic disorder 50472716_1 CDM 0301 RC 82016 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges Chemical analysis for genetic disorder 50472716_1 CDM 0301 RC 82016 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 Chemical analysis for genetic disorder 50472716_1 CDM 0301 RC 82016 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 Chemical analysis for genetic disorder 50472716_1 CDM 0301 RC 82016 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 Chemical analysis for genetic disorder 50472716_1 CDM 0301 RC 82016 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 Chemical analysis for genetic disorder 50472716_1 CDM 0301 RC 82016 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 Chemical analysis for genetic disorder 50472716_1 CDM 0301 RC 82016 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50472717_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50472717_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50472717_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50472717_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50472717_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50472717_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50472717_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50472717_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50472717_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 "Analysis of substance using immunoassay technique, multiple step method" 50472717_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 "Analysis of substance using immunoassay technique, multiple step method" 50472717_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 "Analysis of substance using immunoassay technique, multiple step method" 50472717_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 "Analysis of substance using immunoassay technique, multiple step method" 50472717_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 "Analysis of substance using immunoassay technique, multiple step method" 50472717_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges Mass spectrometry (laboratory testing method) 50472718_1 CDM 0301 RC 83789 HCPCS inpatient 324 210.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 210.6 65 999999999 196.18 314.28 percent of total billed charges Mass spectrometry (laboratory testing method) 50472718_1 CDM 0301 RC 83789 HCPCS inpatient 324 210.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 314.28 97 999999999 196.18 314.28 percent of total billed charges Mass spectrometry (laboratory testing method) 50472718_1 CDM 0301 RC 83789 HCPCS inpatient 324 210.6 AETNA AETNA 255.96 79 999999999 196.18 314.28 percent of total billed charges Mass spectrometry (laboratory testing method) 50472718_1 CDM 0301 RC 83789 HCPCS inpatient 324 210.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 252.72 78 999999999 196.18 314.28 percent of total billed charges Mass spectrometry (laboratory testing method) 50472718_1 CDM 0301 RC 83789 HCPCS inpatient 324 210.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 223.56 69 999999999 196.18 314.28 percent of total billed charges Mass spectrometry (laboratory testing method) 50472718_1 CDM 0301 RC 83789 HCPCS inpatient 324 210.6 UMR - ALL PLANS UMR - ALL PLANS 226.8 70 999999999 196.18 314.28 percent of total billed charges Mass spectrometry (laboratory testing method) 50472718_1 CDM 0301 RC 83789 HCPCS inpatient 324 210.6 SIHO - ALL PLANS SIHO - ALL PLANS 291.6 90 999999999 196.18 314.28 percent of total billed charges Mass spectrometry (laboratory testing method) 50472718_1 CDM 0301 RC 83789 HCPCS inpatient 324 210.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 196.18 60.55 999999999 196.18 314.28 percent of total billed charges Mass spectrometry (laboratory testing method) 50472718_1 CDM 0301 RC 83789 HCPCS inpatient 324 210.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 196.18 314.28 Mass spectrometry (laboratory testing method) 50472718_1 CDM 0301 RC 83789 HCPCS inpatient 324 210.6 ANTHEM HMO ANTHEM HMO 999999999 196.18 314.28 Mass spectrometry (laboratory testing method) 50472718_1 CDM 0301 RC 83789 HCPCS inpatient 324 210.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 196.18 314.28 Mass spectrometry (laboratory testing method) 50472718_1 CDM 0301 RC 83789 HCPCS inpatient 324 210.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 196.18 314.28 Mass spectrometry (laboratory testing method) 50472718_1 CDM 0301 RC 83789 HCPCS inpatient 324 210.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 196.18 314.28 Mass spectrometry (laboratory testing method) 50472718_1 CDM 0301 RC 83789 HCPCS inpatient 324 210.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 219.02 67.6 999999999 196.18 314.28 percent of total billed charges LEVOTHYROXINE 137 MCG TABLET 50473198_1 CDM 0250 RC 68180-0972-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 137 MCG TABLET 50473198_1 CDM 0250 RC 68180-0972-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 137 MCG TABLET 50473198_1 CDM 0250 RC 68180-0972-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 137 MCG TABLET 50473198_1 CDM 0250 RC 68180-0972-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 137 MCG TABLET 50473198_1 CDM 0250 RC 68180-0972-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 137 MCG TABLET 50473198_1 CDM 0250 RC 68180-0972-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 137 MCG TABLET 50473198_1 CDM 0250 RC 68180-0972-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 137 MCG TABLET 50473198_1 CDM 0250 RC 68180-0972-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 137 MCG TABLET 50473198_1 CDM 0250 RC 68180-0972-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LEVOTHYROXINE 137 MCG TABLET 50473198_1 CDM 0250 RC 68180-0972-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LEVOTHYROXINE 137 MCG TABLET 50473198_1 CDM 0250 RC 68180-0972-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 137 MCG TABLET 50473198_1 CDM 0250 RC 68180-0972-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 137 MCG TABLET 50473198_1 CDM 0250 RC 68180-0972-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 LEVOTHYROXINE 137 MCG TABLET 50473198_1 CDM 0250 RC 68180-0972-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474757_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474757_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474757_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474757_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474757_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474757_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474757_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474757_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474757_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474757_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474757_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474757_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474757_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474757_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474758_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474758_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474758_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474758_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474758_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474758_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474758_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474758_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474758_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474758_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474758_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474758_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474758_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474758_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474760_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474760_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474760_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474760_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474760_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474760_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474760_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474760_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474760_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474760_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474760_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474760_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474760_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474760_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474761_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474761_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474761_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474761_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474761_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474761_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474761_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474761_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474761_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474761_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474761_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474761_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474761_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474761_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474762_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474762_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474762_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474762_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474762_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474762_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474762_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474762_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474762_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474762_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474762_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474762_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474762_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474762_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474763_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474763_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474763_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474763_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474763_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474763_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474763_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474763_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474763_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474763_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474763_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474763_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474763_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474763_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474765_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474765_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474765_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474765_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474765_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474765_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474765_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474765_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474765_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474765_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474765_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474765_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474765_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474765_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474766_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474766_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474766_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474766_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474766_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474766_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474766_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474766_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50474766_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474766_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474766_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474766_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474766_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50474766_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges 51552-1345-01 - epinephrine/lidocaine/tetracaine topical 180 mg-4000 mg-500 mg/100 mL Sol 50475142_1 CDM 0250 RC 51552-1345-01 NDC inpatient 1 UN 267.19 173.67 SELF PAY DISCOUNT SELF PAY DISCOUNT 173.67 65 999999999 161.78 259.17 percent of total billed charges 51552-1345-01 - epinephrine/lidocaine/tetracaine topical 180 mg-4000 mg-500 mg/100 mL Sol 50475142_1 CDM 0250 RC 51552-1345-01 NDC inpatient 1 UN 267.19 173.67 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 259.17 97 999999999 161.78 259.17 percent of total billed charges 51552-1345-01 - epinephrine/lidocaine/tetracaine topical 180 mg-4000 mg-500 mg/100 mL Sol 50475142_1 CDM 0250 RC 51552-1345-01 NDC inpatient 1 UN 267.19 173.67 AETNA AETNA 211.08 79 999999999 161.78 259.17 percent of total billed charges 51552-1345-01 - epinephrine/lidocaine/tetracaine topical 180 mg-4000 mg-500 mg/100 mL Sol 50475142_1 CDM 0250 RC 51552-1345-01 NDC inpatient 1 UN 267.19 173.67 HUMANA - ALL PLANS HUMANA - ALL PLANS 208.41 78 999999999 161.78 259.17 percent of total billed charges 51552-1345-01 - epinephrine/lidocaine/tetracaine topical 180 mg-4000 mg-500 mg/100 mL Sol 50475142_1 CDM 0250 RC 51552-1345-01 NDC inpatient 1 UN 267.19 173.67 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.36 69 999999999 161.78 259.17 percent of total billed charges 51552-1345-01 - epinephrine/lidocaine/tetracaine topical 180 mg-4000 mg-500 mg/100 mL Sol 50475142_1 CDM 0250 RC 51552-1345-01 NDC inpatient 1 UN 267.19 173.67 UMR - ALL PLANS UMR - ALL PLANS 187.03 70 999999999 161.78 259.17 percent of total billed charges 51552-1345-01 - epinephrine/lidocaine/tetracaine topical 180 mg-4000 mg-500 mg/100 mL Sol 50475142_1 CDM 0250 RC 51552-1345-01 NDC inpatient 1 UN 267.19 173.67 SIHO - ALL PLANS SIHO - ALL PLANS 240.47 90 999999999 161.78 259.17 percent of total billed charges 51552-1345-01 - epinephrine/lidocaine/tetracaine topical 180 mg-4000 mg-500 mg/100 mL Sol 50475142_1 CDM 0250 RC 51552-1345-01 NDC inpatient 1 UN 267.19 173.67 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 161.78 60.55 999999999 161.78 259.17 percent of total billed charges 51552-1345-01 - epinephrine/lidocaine/tetracaine topical 180 mg-4000 mg-500 mg/100 mL Sol 50475142_1 CDM 0250 RC 51552-1345-01 NDC inpatient 1 UN 267.19 173.67 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 161.78 259.17 51552-1345-01 - epinephrine/lidocaine/tetracaine topical 180 mg-4000 mg-500 mg/100 mL Sol 50475142_1 CDM 0250 RC 51552-1345-01 NDC inpatient 1 UN 267.19 173.67 ANTHEM HMO ANTHEM HMO 999999999 161.78 259.17 51552-1345-01 - epinephrine/lidocaine/tetracaine topical 180 mg-4000 mg-500 mg/100 mL Sol 50475142_1 CDM 0250 RC 51552-1345-01 NDC inpatient 1 UN 267.19 173.67 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 161.78 259.17 51552-1345-01 - epinephrine/lidocaine/tetracaine topical 180 mg-4000 mg-500 mg/100 mL Sol 50475142_1 CDM 0250 RC 51552-1345-01 NDC inpatient 1 UN 267.19 173.67 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 161.78 259.17 51552-1345-01 - epinephrine/lidocaine/tetracaine topical 180 mg-4000 mg-500 mg/100 mL Sol 50475142_1 CDM 0250 RC 51552-1345-01 NDC inpatient 1 UN 267.19 173.67 UHC - ALL PLANS UHC - ALL PLANS 999999999 161.78 259.17 51552-1345-01 - epinephrine/lidocaine/tetracaine topical 180 mg-4000 mg-500 mg/100 mL Sol 50475142_1 CDM 0250 RC 51552-1345-01 NDC inpatient 1 UN 267.19 173.67 CIGNA - ALL PLANS CIGNA - ALL PLANS 180.62 67.6 999999999 161.78 259.17 percent of total billed charges DORZOLAMIDE HCL 2% EYE DROPS 50475219_1 CDM 0250 RC 42571-0141-26 NDC inpatient 1 UN 25.58 16.63 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.63 65 999999999 15.49 24.81 percent of total billed charges DORZOLAMIDE HCL 2% EYE DROPS 50475219_1 CDM 0250 RC 42571-0141-26 NDC inpatient 1 UN 25.58 16.63 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.81 97 999999999 15.49 24.81 percent of total billed charges DORZOLAMIDE HCL 2% EYE DROPS 50475219_1 CDM 0250 RC 42571-0141-26 NDC inpatient 1 UN 25.58 16.63 AETNA AETNA 20.21 79 999999999 15.49 24.81 percent of total billed charges DORZOLAMIDE HCL 2% EYE DROPS 50475219_1 CDM 0250 RC 42571-0141-26 NDC inpatient 1 UN 25.58 16.63 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.95 78 999999999 15.49 24.81 percent of total billed charges DORZOLAMIDE HCL 2% EYE DROPS 50475219_1 CDM 0250 RC 42571-0141-26 NDC inpatient 1 UN 25.58 16.63 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.65 69 999999999 15.49 24.81 percent of total billed charges DORZOLAMIDE HCL 2% EYE DROPS 50475219_1 CDM 0250 RC 42571-0141-26 NDC inpatient 1 UN 25.58 16.63 UMR - ALL PLANS UMR - ALL PLANS 17.91 70 999999999 15.49 24.81 percent of total billed charges DORZOLAMIDE HCL 2% EYE DROPS 50475219_1 CDM 0250 RC 42571-0141-26 NDC inpatient 1 UN 25.58 16.63 SIHO - ALL PLANS SIHO - ALL PLANS 23.02 90 999999999 15.49 24.81 percent of total billed charges DORZOLAMIDE HCL 2% EYE DROPS 50475219_1 CDM 0250 RC 42571-0141-26 NDC inpatient 1 UN 25.58 16.63 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.49 60.55 999999999 15.49 24.81 percent of total billed charges DORZOLAMIDE HCL 2% EYE DROPS 50475219_1 CDM 0250 RC 42571-0141-26 NDC inpatient 1 UN 25.58 16.63 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.49 24.81 DORZOLAMIDE HCL 2% EYE DROPS 50475219_1 CDM 0250 RC 42571-0141-26 NDC inpatient 1 UN 25.58 16.63 ANTHEM HMO ANTHEM HMO 999999999 15.49 24.81 DORZOLAMIDE HCL 2% EYE DROPS 50475219_1 CDM 0250 RC 42571-0141-26 NDC inpatient 1 UN 25.58 16.63 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.49 24.81 DORZOLAMIDE HCL 2% EYE DROPS 50475219_1 CDM 0250 RC 42571-0141-26 NDC inpatient 1 UN 25.58 16.63 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.49 24.81 DORZOLAMIDE HCL 2% EYE DROPS 50475219_1 CDM 0250 RC 42571-0141-26 NDC inpatient 1 UN 25.58 16.63 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.49 24.81 DORZOLAMIDE HCL 2% EYE DROPS 50475219_1 CDM 0250 RC 42571-0141-26 NDC inpatient 1 UN 25.58 16.63 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.29 67.6 999999999 15.49 24.81 percent of total billed charges COLCHICINE 0.6 MG TABLET 50475220_1 CDM 0250 RC 60687-0389-21 NDC inpatient 1 UN 16.92 11 SELF PAY DISCOUNT SELF PAY DISCOUNT 11 65 999999999 10.25 16.41 percent of total billed charges COLCHICINE 0.6 MG TABLET 50475220_1 CDM 0250 RC 60687-0389-21 NDC inpatient 1 UN 16.92 11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16.41 97 999999999 10.25 16.41 percent of total billed charges COLCHICINE 0.6 MG TABLET 50475220_1 CDM 0250 RC 60687-0389-21 NDC inpatient 1 UN 16.92 11 AETNA AETNA 13.37 79 999999999 10.25 16.41 percent of total billed charges COLCHICINE 0.6 MG TABLET 50475220_1 CDM 0250 RC 60687-0389-21 NDC inpatient 1 UN 16.92 11 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.2 78 999999999 10.25 16.41 percent of total billed charges COLCHICINE 0.6 MG TABLET 50475220_1 CDM 0250 RC 60687-0389-21 NDC inpatient 1 UN 16.92 11 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.67 69 999999999 10.25 16.41 percent of total billed charges COLCHICINE 0.6 MG TABLET 50475220_1 CDM 0250 RC 60687-0389-21 NDC inpatient 1 UN 16.92 11 UMR - ALL PLANS UMR - ALL PLANS 11.84 70 999999999 10.25 16.41 percent of total billed charges COLCHICINE 0.6 MG TABLET 50475220_1 CDM 0250 RC 60687-0389-21 NDC inpatient 1 UN 16.92 11 SIHO - ALL PLANS SIHO - ALL PLANS 15.23 90 999999999 10.25 16.41 percent of total billed charges COLCHICINE 0.6 MG TABLET 50475220_1 CDM 0250 RC 60687-0389-21 NDC inpatient 1 UN 16.92 11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.25 60.55 999999999 10.25 16.41 percent of total billed charges COLCHICINE 0.6 MG TABLET 50475220_1 CDM 0250 RC 60687-0389-21 NDC inpatient 1 UN 16.92 11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.25 16.41 COLCHICINE 0.6 MG TABLET 50475220_1 CDM 0250 RC 60687-0389-21 NDC inpatient 1 UN 16.92 11 ANTHEM HMO ANTHEM HMO 999999999 10.25 16.41 COLCHICINE 0.6 MG TABLET 50475220_1 CDM 0250 RC 60687-0389-21 NDC inpatient 1 UN 16.92 11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.25 16.41 COLCHICINE 0.6 MG TABLET 50475220_1 CDM 0250 RC 60687-0389-21 NDC inpatient 1 UN 16.92 11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.25 16.41 COLCHICINE 0.6 MG TABLET 50475220_1 CDM 0250 RC 60687-0389-21 NDC inpatient 1 UN 16.92 11 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.25 16.41 COLCHICINE 0.6 MG TABLET 50475220_1 CDM 0250 RC 60687-0389-21 NDC inpatient 1 UN 16.92 11 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.44 67.6 999999999 10.25 16.41 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 50477674_1 CDM 0250 RC 70069-0232-01 NDC inpatient 1 UN 4.1 2.67 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.67 65 999999999 2.48 3.98 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 50477674_1 CDM 0250 RC 70069-0232-01 NDC inpatient 1 UN 4.1 2.67 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.98 97 999999999 2.48 3.98 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 50477674_1 CDM 0250 RC 70069-0232-01 NDC inpatient 1 UN 4.1 2.67 AETNA AETNA 3.24 79 999999999 2.48 3.98 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 50477674_1 CDM 0250 RC 70069-0232-01 NDC inpatient 1 UN 4.1 2.67 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.2 78 999999999 2.48 3.98 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 50477674_1 CDM 0250 RC 70069-0232-01 NDC inpatient 1 UN 4.1 2.67 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.83 69 999999999 2.48 3.98 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 50477674_1 CDM 0250 RC 70069-0232-01 NDC inpatient 1 UN 4.1 2.67 UMR - ALL PLANS UMR - ALL PLANS 2.87 70 999999999 2.48 3.98 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 50477674_1 CDM 0250 RC 70069-0232-01 NDC inpatient 1 UN 4.1 2.67 SIHO - ALL PLANS SIHO - ALL PLANS 3.69 90 999999999 2.48 3.98 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 50477674_1 CDM 0250 RC 70069-0232-01 NDC inpatient 1 UN 4.1 2.67 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.48 60.55 999999999 2.48 3.98 percent of total billed charges BRIMONIDINE 0.2% EYE DROP 50477674_1 CDM 0250 RC 70069-0232-01 NDC inpatient 1 UN 4.1 2.67 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.48 3.98 BRIMONIDINE 0.2% EYE DROP 50477674_1 CDM 0250 RC 70069-0232-01 NDC inpatient 1 UN 4.1 2.67 ANTHEM HMO ANTHEM HMO 999999999 2.48 3.98 BRIMONIDINE 0.2% EYE DROP 50477674_1 CDM 0250 RC 70069-0232-01 NDC inpatient 1 UN 4.1 2.67 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.48 3.98 BRIMONIDINE 0.2% EYE DROP 50477674_1 CDM 0250 RC 70069-0232-01 NDC inpatient 1 UN 4.1 2.67 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.48 3.98 BRIMONIDINE 0.2% EYE DROP 50477674_1 CDM 0250 RC 70069-0232-01 NDC inpatient 1 UN 4.1 2.67 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.48 3.98 BRIMONIDINE 0.2% EYE DROP 50477674_1 CDM 0250 RC 70069-0232-01 NDC inpatient 1 UN 4.1 2.67 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.77 67.6 999999999 2.48 3.98 percent of total billed charges ARIPIPRAZOLE 2 MG TABLET 50479355_1 CDM 0250 RC 65862-0661-30 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 2 MG TABLET 50479355_1 CDM 0250 RC 65862-0661-30 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 2 MG TABLET 50479355_1 CDM 0250 RC 65862-0661-30 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 2 MG TABLET 50479355_1 CDM 0250 RC 65862-0661-30 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 2 MG TABLET 50479355_1 CDM 0250 RC 65862-0661-30 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 2 MG TABLET 50479355_1 CDM 0250 RC 65862-0661-30 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 2 MG TABLET 50479355_1 CDM 0250 RC 65862-0661-30 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 2 MG TABLET 50479355_1 CDM 0250 RC 65862-0661-30 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ARIPIPRAZOLE 2 MG TABLET 50479355_1 CDM 0250 RC 65862-0661-30 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ARIPIPRAZOLE 2 MG TABLET 50479355_1 CDM 0250 RC 65862-0661-30 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ARIPIPRAZOLE 2 MG TABLET 50479355_1 CDM 0250 RC 65862-0661-30 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ARIPIPRAZOLE 2 MG TABLET 50479355_1 CDM 0250 RC 65862-0661-30 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ARIPIPRAZOLE 2 MG TABLET 50479355_1 CDM 0250 RC 65862-0661-30 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ARIPIPRAZOLE 2 MG TABLET 50479355_1 CDM 0250 RC 65862-0661-30 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges MEDROXYPROGESTERONE 10 MG TAB 50479356_1 CDM 0250 RC 59762-0056-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges MEDROXYPROGESTERONE 10 MG TAB 50479356_1 CDM 0250 RC 59762-0056-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges MEDROXYPROGESTERONE 10 MG TAB 50479356_1 CDM 0250 RC 59762-0056-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges MEDROXYPROGESTERONE 10 MG TAB 50479356_1 CDM 0250 RC 59762-0056-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges MEDROXYPROGESTERONE 10 MG TAB 50479356_1 CDM 0250 RC 59762-0056-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges MEDROXYPROGESTERONE 10 MG TAB 50479356_1 CDM 0250 RC 59762-0056-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges MEDROXYPROGESTERONE 10 MG TAB 50479356_1 CDM 0250 RC 59762-0056-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges MEDROXYPROGESTERONE 10 MG TAB 50479356_1 CDM 0250 RC 59762-0056-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges MEDROXYPROGESTERONE 10 MG TAB 50479356_1 CDM 0250 RC 59762-0056-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 MEDROXYPROGESTERONE 10 MG TAB 50479356_1 CDM 0250 RC 59762-0056-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 MEDROXYPROGESTERONE 10 MG TAB 50479356_1 CDM 0250 RC 59762-0056-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 MEDROXYPROGESTERONE 10 MG TAB 50479356_1 CDM 0250 RC 59762-0056-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 MEDROXYPROGESTERONE 10 MG TAB 50479356_1 CDM 0250 RC 59762-0056-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 MEDROXYPROGESTERONE 10 MG TAB 50479356_1 CDM 0250 RC 59762-0056-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 50482725_1 CDM 0301 RC 81207 HCPCS inpatient 476 309.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 309.4 65 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 50482725_1 CDM 0301 RC 81207 HCPCS inpatient 476 309.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 461.72 97 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 50482725_1 CDM 0301 RC 81207 HCPCS inpatient 476 309.4 AETNA AETNA 376.04 79 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 50482725_1 CDM 0301 RC 81207 HCPCS inpatient 476 309.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 371.28 78 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 50482725_1 CDM 0301 RC 81207 HCPCS inpatient 476 309.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 328.44 69 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 50482725_1 CDM 0301 RC 81207 HCPCS inpatient 476 309.4 UMR - ALL PLANS UMR - ALL PLANS 333.2 70 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 50482725_1 CDM 0301 RC 81207 HCPCS inpatient 476 309.4 SIHO - ALL PLANS SIHO - ALL PLANS 428.4 90 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 50482725_1 CDM 0301 RC 81207 HCPCS inpatient 476 309.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 288.22 60.55 999999999 288.22 461.72 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 50482725_1 CDM 0301 RC 81207 HCPCS inpatient 476 309.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 288.22 461.72 Translocation analysis (BCR/ABL1) minor breakpoint 50482725_1 CDM 0301 RC 81207 HCPCS inpatient 476 309.4 ANTHEM HMO ANTHEM HMO 999999999 288.22 461.72 Translocation analysis (BCR/ABL1) minor breakpoint 50482725_1 CDM 0301 RC 81207 HCPCS inpatient 476 309.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 288.22 461.72 Translocation analysis (BCR/ABL1) minor breakpoint 50482725_1 CDM 0301 RC 81207 HCPCS inpatient 476 309.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 288.22 461.72 Translocation analysis (BCR/ABL1) minor breakpoint 50482725_1 CDM 0301 RC 81207 HCPCS inpatient 476 309.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 288.22 461.72 Translocation analysis (BCR/ABL1) minor breakpoint 50482725_1 CDM 0301 RC 81207 HCPCS inpatient 476 309.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 321.78 67.6 999999999 288.22 461.72 percent of total billed charges Screening test for antibody to noninfectious agent 50482726_1 CDM 0302 RC 86255 HCPCS inpatient 98 63.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.7 65 999999999 59.34 95.06 percent of total billed charges Screening test for antibody to noninfectious agent 50482726_1 CDM 0302 RC 86255 HCPCS inpatient 98 63.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.06 97 999999999 59.34 95.06 percent of total billed charges Screening test for antibody to noninfectious agent 50482726_1 CDM 0302 RC 86255 HCPCS inpatient 98 63.7 AETNA AETNA 77.42 79 999999999 59.34 95.06 percent of total billed charges Screening test for antibody to noninfectious agent 50482726_1 CDM 0302 RC 86255 HCPCS inpatient 98 63.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.44 78 999999999 59.34 95.06 percent of total billed charges Screening test for antibody to noninfectious agent 50482726_1 CDM 0302 RC 86255 HCPCS inpatient 98 63.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.62 69 999999999 59.34 95.06 percent of total billed charges Screening test for antibody to noninfectious agent 50482726_1 CDM 0302 RC 86255 HCPCS inpatient 98 63.7 UMR - ALL PLANS UMR - ALL PLANS 68.6 70 999999999 59.34 95.06 percent of total billed charges Screening test for antibody to noninfectious agent 50482726_1 CDM 0302 RC 86255 HCPCS inpatient 98 63.7 SIHO - ALL PLANS SIHO - ALL PLANS 88.2 90 999999999 59.34 95.06 percent of total billed charges Screening test for antibody to noninfectious agent 50482726_1 CDM 0302 RC 86255 HCPCS inpatient 98 63.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.34 60.55 999999999 59.34 95.06 percent of total billed charges Screening test for antibody to noninfectious agent 50482726_1 CDM 0302 RC 86255 HCPCS inpatient 98 63.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.34 95.06 Screening test for antibody to noninfectious agent 50482726_1 CDM 0302 RC 86255 HCPCS inpatient 98 63.7 ANTHEM HMO ANTHEM HMO 999999999 59.34 95.06 Screening test for antibody to noninfectious agent 50482726_1 CDM 0302 RC 86255 HCPCS inpatient 98 63.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.34 95.06 Screening test for antibody to noninfectious agent 50482726_1 CDM 0302 RC 86255 HCPCS inpatient 98 63.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.34 95.06 Screening test for antibody to noninfectious agent 50482726_1 CDM 0302 RC 86255 HCPCS inpatient 98 63.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.34 95.06 Screening test for antibody to noninfectious agent 50482726_1 CDM 0302 RC 86255 HCPCS inpatient 98 63.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.25 67.6 999999999 59.34 95.06 percent of total billed charges Analysis for antibody to Herpes simplex virus 50482727_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50482727_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50482727_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50482727_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50482727_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50482727_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50482727_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50482727_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50482727_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50482727_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50482727_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50482727_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50482727_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50482727_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges Cadmium level 50482728_1 CDM 0301 RC 82300 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges Cadmium level 50482728_1 CDM 0301 RC 82300 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges Cadmium level 50482728_1 CDM 0301 RC 82300 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges Cadmium level 50482728_1 CDM 0301 RC 82300 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges Cadmium level 50482728_1 CDM 0301 RC 82300 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges Cadmium level 50482728_1 CDM 0301 RC 82300 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges Cadmium level 50482728_1 CDM 0301 RC 82300 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges Cadmium level 50482728_1 CDM 0301 RC 82300 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges Cadmium level 50482728_1 CDM 0301 RC 82300 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 Cadmium level 50482728_1 CDM 0301 RC 82300 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 Cadmium level 50482728_1 CDM 0301 RC 82300 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 Cadmium level 50482728_1 CDM 0301 RC 82300 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 Cadmium level 50482728_1 CDM 0301 RC 82300 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 Cadmium level 50482728_1 CDM 0301 RC 82300 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges Copper level 50482729_1 CDM 0301 RC 82525 HCPCS inpatient 156 101.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.4 65 999999999 94.46 151.32 percent of total billed charges Copper level 50482729_1 CDM 0301 RC 82525 HCPCS inpatient 156 101.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 151.32 97 999999999 94.46 151.32 percent of total billed charges Copper level 50482729_1 CDM 0301 RC 82525 HCPCS inpatient 156 101.4 AETNA AETNA 123.24 79 999999999 94.46 151.32 percent of total billed charges Copper level 50482729_1 CDM 0301 RC 82525 HCPCS inpatient 156 101.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.68 78 999999999 94.46 151.32 percent of total billed charges Copper level 50482729_1 CDM 0301 RC 82525 HCPCS inpatient 156 101.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.64 69 999999999 94.46 151.32 percent of total billed charges Copper level 50482729_1 CDM 0301 RC 82525 HCPCS inpatient 156 101.4 UMR - ALL PLANS UMR - ALL PLANS 109.2 70 999999999 94.46 151.32 percent of total billed charges Copper level 50482729_1 CDM 0301 RC 82525 HCPCS inpatient 156 101.4 SIHO - ALL PLANS SIHO - ALL PLANS 140.4 90 999999999 94.46 151.32 percent of total billed charges Copper level 50482729_1 CDM 0301 RC 82525 HCPCS inpatient 156 101.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.46 60.55 999999999 94.46 151.32 percent of total billed charges Copper level 50482729_1 CDM 0301 RC 82525 HCPCS inpatient 156 101.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.46 151.32 Copper level 50482729_1 CDM 0301 RC 82525 HCPCS inpatient 156 101.4 ANTHEM HMO ANTHEM HMO 999999999 94.46 151.32 Copper level 50482729_1 CDM 0301 RC 82525 HCPCS inpatient 156 101.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.46 151.32 Copper level 50482729_1 CDM 0301 RC 82525 HCPCS inpatient 156 101.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.46 151.32 Copper level 50482729_1 CDM 0301 RC 82525 HCPCS inpatient 156 101.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.46 151.32 Copper level 50482729_1 CDM 0301 RC 82525 HCPCS inpatient 156 101.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.46 67.6 999999999 94.46 151.32 percent of total billed charges Mercury level 50482730_1 CDM 0301 RC 83825 HCPCS inpatient 224 145.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 145.6 65 999999999 135.63 217.28 percent of total billed charges Mercury level 50482730_1 CDM 0301 RC 83825 HCPCS inpatient 224 145.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 217.28 97 999999999 135.63 217.28 percent of total billed charges Mercury level 50482730_1 CDM 0301 RC 83825 HCPCS inpatient 224 145.6 AETNA AETNA 176.96 79 999999999 135.63 217.28 percent of total billed charges Mercury level 50482730_1 CDM 0301 RC 83825 HCPCS inpatient 224 145.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 174.72 78 999999999 135.63 217.28 percent of total billed charges Mercury level 50482730_1 CDM 0301 RC 83825 HCPCS inpatient 224 145.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 154.56 69 999999999 135.63 217.28 percent of total billed charges Mercury level 50482730_1 CDM 0301 RC 83825 HCPCS inpatient 224 145.6 UMR - ALL PLANS UMR - ALL PLANS 156.8 70 999999999 135.63 217.28 percent of total billed charges Mercury level 50482730_1 CDM 0301 RC 83825 HCPCS inpatient 224 145.6 SIHO - ALL PLANS SIHO - ALL PLANS 201.6 90 999999999 135.63 217.28 percent of total billed charges Mercury level 50482730_1 CDM 0301 RC 83825 HCPCS inpatient 224 145.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 135.63 60.55 999999999 135.63 217.28 percent of total billed charges Mercury level 50482730_1 CDM 0301 RC 83825 HCPCS inpatient 224 145.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 135.63 217.28 Mercury level 50482730_1 CDM 0301 RC 83825 HCPCS inpatient 224 145.6 ANTHEM HMO ANTHEM HMO 999999999 135.63 217.28 Mercury level 50482730_1 CDM 0301 RC 83825 HCPCS inpatient 224 145.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 135.63 217.28 Mercury level 50482730_1 CDM 0301 RC 83825 HCPCS inpatient 224 145.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 135.63 217.28 Mercury level 50482730_1 CDM 0301 RC 83825 HCPCS inpatient 224 145.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 135.63 217.28 Mercury level 50482730_1 CDM 0301 RC 83825 HCPCS inpatient 224 145.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 151.42 67.6 999999999 135.63 217.28 percent of total billed charges Zinc level 50482731_1 CDM 0301 RC 84630 HCPCS inpatient 169 109.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.85 65 999999999 102.33 163.93 percent of total billed charges Zinc level 50482731_1 CDM 0301 RC 84630 HCPCS inpatient 169 109.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 163.93 97 999999999 102.33 163.93 percent of total billed charges Zinc level 50482731_1 CDM 0301 RC 84630 HCPCS inpatient 169 109.85 AETNA AETNA 133.51 79 999999999 102.33 163.93 percent of total billed charges Zinc level 50482731_1 CDM 0301 RC 84630 HCPCS inpatient 169 109.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.82 78 999999999 102.33 163.93 percent of total billed charges Zinc level 50482731_1 CDM 0301 RC 84630 HCPCS inpatient 169 109.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 116.61 69 999999999 102.33 163.93 percent of total billed charges Zinc level 50482731_1 CDM 0301 RC 84630 HCPCS inpatient 169 109.85 UMR - ALL PLANS UMR - ALL PLANS 118.3 70 999999999 102.33 163.93 percent of total billed charges Zinc level 50482731_1 CDM 0301 RC 84630 HCPCS inpatient 169 109.85 SIHO - ALL PLANS SIHO - ALL PLANS 152.1 90 999999999 102.33 163.93 percent of total billed charges Zinc level 50482731_1 CDM 0301 RC 84630 HCPCS inpatient 169 109.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.33 60.55 999999999 102.33 163.93 percent of total billed charges Zinc level 50482731_1 CDM 0301 RC 84630 HCPCS inpatient 169 109.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.33 163.93 Zinc level 50482731_1 CDM 0301 RC 84630 HCPCS inpatient 169 109.85 ANTHEM HMO ANTHEM HMO 999999999 102.33 163.93 Zinc level 50482731_1 CDM 0301 RC 84630 HCPCS inpatient 169 109.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.33 163.93 Zinc level 50482731_1 CDM 0301 RC 84630 HCPCS inpatient 169 109.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.33 163.93 Zinc level 50482731_1 CDM 0301 RC 84630 HCPCS inpatient 169 109.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.33 163.93 Zinc level 50482731_1 CDM 0301 RC 84630 HCPCS inpatient 169 109.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.24 67.6 999999999 102.33 163.93 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50482732_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50482732_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50482732_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50482732_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50482732_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50482732_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50482732_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50482732_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50482732_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50482732_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50482732_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50482732_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50482732_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Gammaglobulin (immune system protein) measurement, immunoglobulin subclasses" 50482732_1 CDM 0301 RC 82787 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges Gammaglobulin (immune system protein) measurement 50482733_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 104.65 65 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50482733_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 156.17 97 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50482733_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 AETNA AETNA 127.19 79 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50482733_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 125.58 78 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50482733_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 111.09 69 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50482733_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 UMR - ALL PLANS UMR - ALL PLANS 112.7 70 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50482733_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 SIHO - ALL PLANS SIHO - ALL PLANS 144.9 90 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50482733_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 97.49 60.55 999999999 97.49 156.17 percent of total billed charges Gammaglobulin (immune system protein) measurement 50482733_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 97.49 156.17 Gammaglobulin (immune system protein) measurement 50482733_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 ANTHEM HMO ANTHEM HMO 999999999 97.49 156.17 Gammaglobulin (immune system protein) measurement 50482733_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 97.49 156.17 Gammaglobulin (immune system protein) measurement 50482733_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 97.49 156.17 Gammaglobulin (immune system protein) measurement 50482733_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 97.49 156.17 Gammaglobulin (immune system protein) measurement 50482733_1 CDM 0301 RC 82784 HCPCS inpatient 161 104.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.84 67.6 999999999 97.49 156.17 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50482734_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 174.2 65 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50482734_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 259.96 97 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50482734_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 AETNA AETNA 211.72 79 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50482734_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 209.04 78 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50482734_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.92 69 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50482734_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 UMR - ALL PLANS UMR - ALL PLANS 187.6 70 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50482734_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 SIHO - ALL PLANS SIHO - ALL PLANS 241.2 90 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50482734_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 162.27 60.55 999999999 162.27 259.96 percent of total billed charges "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50482734_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 162.27 259.96 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50482734_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 ANTHEM HMO ANTHEM HMO 999999999 162.27 259.96 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50482734_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 162.27 259.96 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50482734_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 162.27 259.96 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50482734_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 162.27 259.96 "Lipoprotein level, quantitation of lipoprotein particle number(s)" 50482734_1 CDM 0301 RC 83704 HCPCS inpatient 268 174.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 181.17 67.6 999999999 162.27 259.96 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50482735_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 195.65 65 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50482735_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291.97 97 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50482735_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 AETNA AETNA 237.79 79 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50482735_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 234.78 78 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50482735_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 207.69 69 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50482735_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 UMR - ALL PLANS UMR - ALL PLANS 210.7 70 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50482735_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 SIHO - ALL PLANS SIHO - ALL PLANS 270.9 90 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50482735_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.26 60.55 999999999 182.26 291.97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50482735_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50482735_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM HMO ANTHEM HMO 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50482735_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50482735_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50482735_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.26 291.97 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50482735_1 CDM 0301 RC 83519 HCPCS inpatient 301 195.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 203.48 67.6 999999999 182.26 291.97 percent of total billed charges Measurement of substance using immunoassay technique 50482736_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.95 65 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 50482736_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.51 97 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 50482736_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 AETNA AETNA 144.57 79 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 50482736_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 142.74 78 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 50482736_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.27 69 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 50482736_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 UMR - ALL PLANS UMR - ALL PLANS 128.1 70 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 50482736_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 SIHO - ALL PLANS SIHO - ALL PLANS 164.7 90 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 50482736_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.81 60.55 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 50482736_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.81 177.51 Measurement of substance using immunoassay technique 50482736_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM HMO ANTHEM HMO 999999999 110.81 177.51 Measurement of substance using immunoassay technique 50482736_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.81 177.51 Measurement of substance using immunoassay technique 50482736_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.81 177.51 Measurement of substance using immunoassay technique 50482736_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.81 177.51 Measurement of substance using immunoassay technique 50482736_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.71 67.6 999999999 110.81 177.51 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 50482737_1 CDM 0301 RC 88185 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 50482737_1 CDM 0301 RC 88185 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 50482737_1 CDM 0301 RC 88185 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 50482737_1 CDM 0301 RC 88185 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 50482737_1 CDM 0301 RC 88185 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 50482737_1 CDM 0301 RC 88185 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 50482737_1 CDM 0301 RC 88185 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 50482737_1 CDM 0301 RC 88185 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 50482737_1 CDM 0301 RC 88185 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Flow cytometry technique for DNA or cell analysis, each additional marker" 50482737_1 CDM 0301 RC 88185 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Flow cytometry technique for DNA or cell analysis, each additional marker" 50482737_1 CDM 0301 RC 88185 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Flow cytometry technique for DNA or cell analysis, each additional marker" 50482737_1 CDM 0301 RC 88185 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Flow cytometry technique for DNA or cell analysis, each additional marker" 50482737_1 CDM 0301 RC 88185 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Flow cytometry technique for DNA or cell analysis, each additional marker" 50482737_1 CDM 0301 RC 88185 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Protein measurement, serum" 50482738_1 CDM 0301 RC 84165 HCPCS inpatient 242 157.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 157.3 65 999999999 146.53 234.74 percent of total billed charges "Protein measurement, serum" 50482738_1 CDM 0301 RC 84165 HCPCS inpatient 242 157.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 234.74 97 999999999 146.53 234.74 percent of total billed charges "Protein measurement, serum" 50482738_1 CDM 0301 RC 84165 HCPCS inpatient 242 157.3 AETNA AETNA 191.18 79 999999999 146.53 234.74 percent of total billed charges "Protein measurement, serum" 50482738_1 CDM 0301 RC 84165 HCPCS inpatient 242 157.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 188.76 78 999999999 146.53 234.74 percent of total billed charges "Protein measurement, serum" 50482738_1 CDM 0301 RC 84165 HCPCS inpatient 242 157.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 166.98 69 999999999 146.53 234.74 percent of total billed charges "Protein measurement, serum" 50482738_1 CDM 0301 RC 84165 HCPCS inpatient 242 157.3 UMR - ALL PLANS UMR - ALL PLANS 169.4 70 999999999 146.53 234.74 percent of total billed charges "Protein measurement, serum" 50482738_1 CDM 0301 RC 84165 HCPCS inpatient 242 157.3 SIHO - ALL PLANS SIHO - ALL PLANS 217.8 90 999999999 146.53 234.74 percent of total billed charges "Protein measurement, serum" 50482738_1 CDM 0301 RC 84165 HCPCS inpatient 242 157.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 146.53 60.55 999999999 146.53 234.74 percent of total billed charges "Protein measurement, serum" 50482738_1 CDM 0301 RC 84165 HCPCS inpatient 242 157.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 146.53 234.74 "Protein measurement, serum" 50482738_1 CDM 0301 RC 84165 HCPCS inpatient 242 157.3 ANTHEM HMO ANTHEM HMO 999999999 146.53 234.74 "Protein measurement, serum" 50482738_1 CDM 0301 RC 84165 HCPCS inpatient 242 157.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 146.53 234.74 "Protein measurement, serum" 50482738_1 CDM 0301 RC 84165 HCPCS inpatient 242 157.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 146.53 234.74 "Protein measurement, serum" 50482738_1 CDM 0301 RC 84165 HCPCS inpatient 242 157.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 146.53 234.74 "Protein measurement, serum" 50482738_1 CDM 0301 RC 84165 HCPCS inpatient 242 157.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 163.59 67.6 999999999 146.53 234.74 percent of total billed charges "Total protein level, urine" 50482739_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 50482739_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 50482739_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 50482739_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 50482739_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 50482739_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 50482739_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 50482739_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 50482739_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 "Total protein level, urine" 50482739_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 "Total protein level, urine" 50482739_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 "Total protein level, urine" 50482739_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 "Total protein level, urine" 50482739_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 "Total protein level, urine" 50482739_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 50482740_1 CDM 0301 RC 84153 HCPCS inpatient 306 198.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 198.9 65 999999999 185.28 296.82 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 50482740_1 CDM 0301 RC 84153 HCPCS inpatient 306 198.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 296.82 97 999999999 185.28 296.82 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 50482740_1 CDM 0301 RC 84153 HCPCS inpatient 306 198.9 AETNA AETNA 241.74 79 999999999 185.28 296.82 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 50482740_1 CDM 0301 RC 84153 HCPCS inpatient 306 198.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 238.68 78 999999999 185.28 296.82 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 50482740_1 CDM 0301 RC 84153 HCPCS inpatient 306 198.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 211.14 69 999999999 185.28 296.82 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 50482740_1 CDM 0301 RC 84153 HCPCS inpatient 306 198.9 UMR - ALL PLANS UMR - ALL PLANS 214.2 70 999999999 185.28 296.82 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 50482740_1 CDM 0301 RC 84153 HCPCS inpatient 306 198.9 SIHO - ALL PLANS SIHO - ALL PLANS 275.4 90 999999999 185.28 296.82 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 50482740_1 CDM 0301 RC 84153 HCPCS inpatient 306 198.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 185.28 60.55 999999999 185.28 296.82 percent of total billed charges "PSA (prostate specific antigen) measurement, total" 50482740_1 CDM 0301 RC 84153 HCPCS inpatient 306 198.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 185.28 296.82 "PSA (prostate specific antigen) measurement, total" 50482740_1 CDM 0301 RC 84153 HCPCS inpatient 306 198.9 ANTHEM HMO ANTHEM HMO 999999999 185.28 296.82 "PSA (prostate specific antigen) measurement, total" 50482740_1 CDM 0301 RC 84153 HCPCS inpatient 306 198.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 185.28 296.82 "PSA (prostate specific antigen) measurement, total" 50482740_1 CDM 0301 RC 84153 HCPCS inpatient 306 198.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 185.28 296.82 "PSA (prostate specific antigen) measurement, total" 50482740_1 CDM 0301 RC 84153 HCPCS inpatient 306 198.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 185.28 296.82 "PSA (prostate specific antigen) measurement, total" 50482740_1 CDM 0301 RC 84153 HCPCS inpatient 306 198.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 206.86 67.6 999999999 185.28 296.82 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 50482741_1 CDM 0302 RC 86336 HCPCS inpatient 237 154.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.05 65 999999999 143.5 229.89 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 50482741_1 CDM 0302 RC 86336 HCPCS inpatient 237 154.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 229.89 97 999999999 143.5 229.89 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 50482741_1 CDM 0302 RC 86336 HCPCS inpatient 237 154.05 AETNA AETNA 187.23 79 999999999 143.5 229.89 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 50482741_1 CDM 0302 RC 86336 HCPCS inpatient 237 154.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 184.86 78 999999999 143.5 229.89 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 50482741_1 CDM 0302 RC 86336 HCPCS inpatient 237 154.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 163.53 69 999999999 143.5 229.89 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 50482741_1 CDM 0302 RC 86336 HCPCS inpatient 237 154.05 UMR - ALL PLANS UMR - ALL PLANS 165.9 70 999999999 143.5 229.89 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 50482741_1 CDM 0302 RC 86336 HCPCS inpatient 237 154.05 SIHO - ALL PLANS SIHO - ALL PLANS 213.3 90 999999999 143.5 229.89 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 50482741_1 CDM 0302 RC 86336 HCPCS inpatient 237 154.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 143.5 60.55 999999999 143.5 229.89 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 50482741_1 CDM 0302 RC 86336 HCPCS inpatient 237 154.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 143.5 229.89 Inhibin A (reproductive organ hormone) measurement 50482741_1 CDM 0302 RC 86336 HCPCS inpatient 237 154.05 ANTHEM HMO ANTHEM HMO 999999999 143.5 229.89 Inhibin A (reproductive organ hormone) measurement 50482741_1 CDM 0302 RC 86336 HCPCS inpatient 237 154.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 143.5 229.89 Inhibin A (reproductive organ hormone) measurement 50482741_1 CDM 0302 RC 86336 HCPCS inpatient 237 154.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 143.5 229.89 Inhibin A (reproductive organ hormone) measurement 50482741_1 CDM 0302 RC 86336 HCPCS inpatient 237 154.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 143.5 229.89 Inhibin A (reproductive organ hormone) measurement 50482741_1 CDM 0302 RC 86336 HCPCS inpatient 237 154.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.21 67.6 999999999 143.5 229.89 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50482743_1 CDM 0301 RC 82105 HCPCS inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50482743_1 CDM 0301 RC 82105 HCPCS inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50482743_1 CDM 0301 RC 82105 HCPCS inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50482743_1 CDM 0301 RC 82105 HCPCS inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50482743_1 CDM 0301 RC 82105 HCPCS inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50482743_1 CDM 0301 RC 82105 HCPCS inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50482743_1 CDM 0301 RC 82105 HCPCS inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50482743_1 CDM 0301 RC 82105 HCPCS inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges "Alpha-fetoprotein (AFP) level, serum" 50482743_1 CDM 0301 RC 82105 HCPCS inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 "Alpha-fetoprotein (AFP) level, serum" 50482743_1 CDM 0301 RC 82105 HCPCS inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 "Alpha-fetoprotein (AFP) level, serum" 50482743_1 CDM 0301 RC 82105 HCPCS inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 "Alpha-fetoprotein (AFP) level, serum" 50482743_1 CDM 0301 RC 82105 HCPCS inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 "Alpha-fetoprotein (AFP) level, serum" 50482743_1 CDM 0301 RC 82105 HCPCS inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 "Alpha-fetoprotein (AFP) level, serum" 50482743_1 CDM 0301 RC 82105 HCPCS inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges "Testosterone (hormone) level, total" 50482744_1 CDM 0301 RC 84403 HCPCS inpatient 135 87.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 87.75 65 999999999 81.74 130.95 percent of total billed charges "Testosterone (hormone) level, total" 50482744_1 CDM 0301 RC 84403 HCPCS inpatient 135 87.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 130.95 97 999999999 81.74 130.95 percent of total billed charges "Testosterone (hormone) level, total" 50482744_1 CDM 0301 RC 84403 HCPCS inpatient 135 87.75 AETNA AETNA 106.65 79 999999999 81.74 130.95 percent of total billed charges "Testosterone (hormone) level, total" 50482744_1 CDM 0301 RC 84403 HCPCS inpatient 135 87.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 105.3 78 999999999 81.74 130.95 percent of total billed charges "Testosterone (hormone) level, total" 50482744_1 CDM 0301 RC 84403 HCPCS inpatient 135 87.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.15 69 999999999 81.74 130.95 percent of total billed charges "Testosterone (hormone) level, total" 50482744_1 CDM 0301 RC 84403 HCPCS inpatient 135 87.75 UMR - ALL PLANS UMR - ALL PLANS 94.5 70 999999999 81.74 130.95 percent of total billed charges "Testosterone (hormone) level, total" 50482744_1 CDM 0301 RC 84403 HCPCS inpatient 135 87.75 SIHO - ALL PLANS SIHO - ALL PLANS 121.5 90 999999999 81.74 130.95 percent of total billed charges "Testosterone (hormone) level, total" 50482744_1 CDM 0301 RC 84403 HCPCS inpatient 135 87.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 81.74 60.55 999999999 81.74 130.95 percent of total billed charges "Testosterone (hormone) level, total" 50482744_1 CDM 0301 RC 84403 HCPCS inpatient 135 87.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 81.74 130.95 "Testosterone (hormone) level, total" 50482744_1 CDM 0301 RC 84403 HCPCS inpatient 135 87.75 ANTHEM HMO ANTHEM HMO 999999999 81.74 130.95 "Testosterone (hormone) level, total" 50482744_1 CDM 0301 RC 84403 HCPCS inpatient 135 87.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 81.74 130.95 "Testosterone (hormone) level, total" 50482744_1 CDM 0301 RC 84403 HCPCS inpatient 135 87.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 81.74 130.95 "Testosterone (hormone) level, total" 50482744_1 CDM 0301 RC 84403 HCPCS inpatient 135 87.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 81.74 130.95 "Testosterone (hormone) level, total" 50482744_1 CDM 0301 RC 84403 HCPCS inpatient 135 87.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.26 67.6 999999999 81.74 130.95 percent of total billed charges Gene analysis (nudix hydrolase 15) for common variants 50482745_1 CDM 0301 RC 81306 HCPCS inpatient 695 451.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 451.75 65 999999999 420.82 674.15 percent of total billed charges Gene analysis (nudix hydrolase 15) for common variants 50482745_1 CDM 0301 RC 81306 HCPCS inpatient 695 451.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 674.15 97 999999999 420.82 674.15 percent of total billed charges Gene analysis (nudix hydrolase 15) for common variants 50482745_1 CDM 0301 RC 81306 HCPCS inpatient 695 451.75 AETNA AETNA 549.05 79 999999999 420.82 674.15 percent of total billed charges Gene analysis (nudix hydrolase 15) for common variants 50482745_1 CDM 0301 RC 81306 HCPCS inpatient 695 451.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 542.1 78 999999999 420.82 674.15 percent of total billed charges Gene analysis (nudix hydrolase 15) for common variants 50482745_1 CDM 0301 RC 81306 HCPCS inpatient 695 451.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 479.55 69 999999999 420.82 674.15 percent of total billed charges Gene analysis (nudix hydrolase 15) for common variants 50482745_1 CDM 0301 RC 81306 HCPCS inpatient 695 451.75 UMR - ALL PLANS UMR - ALL PLANS 486.5 70 999999999 420.82 674.15 percent of total billed charges Gene analysis (nudix hydrolase 15) for common variants 50482745_1 CDM 0301 RC 81306 HCPCS inpatient 695 451.75 SIHO - ALL PLANS SIHO - ALL PLANS 625.5 90 999999999 420.82 674.15 percent of total billed charges Gene analysis (nudix hydrolase 15) for common variants 50482745_1 CDM 0301 RC 81306 HCPCS inpatient 695 451.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 420.82 60.55 999999999 420.82 674.15 percent of total billed charges Gene analysis (nudix hydrolase 15) for common variants 50482745_1 CDM 0301 RC 81306 HCPCS inpatient 695 451.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 420.82 674.15 Gene analysis (nudix hydrolase 15) for common variants 50482745_1 CDM 0301 RC 81306 HCPCS inpatient 695 451.75 ANTHEM HMO ANTHEM HMO 999999999 420.82 674.15 Gene analysis (nudix hydrolase 15) for common variants 50482745_1 CDM 0301 RC 81306 HCPCS inpatient 695 451.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 420.82 674.15 Gene analysis (nudix hydrolase 15) for common variants 50482745_1 CDM 0301 RC 81306 HCPCS inpatient 695 451.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 420.82 674.15 Gene analysis (nudix hydrolase 15) for common variants 50482745_1 CDM 0301 RC 81306 HCPCS inpatient 695 451.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 420.82 674.15 Gene analysis (nudix hydrolase 15) for common variants 50482745_1 CDM 0301 RC 81306 HCPCS inpatient 695 451.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 469.82 67.6 999999999 420.82 674.15 percent of total billed charges "Valproic acid level, free" 50482746_1 CDM 0301 RC 80165 HCPCS inpatient 60 39 SELF PAY DISCOUNT SELF PAY DISCOUNT 39 65 999999999 36.33 58.2 percent of total billed charges "Valproic acid level, free" 50482746_1 CDM 0301 RC 80165 HCPCS inpatient 60 39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.2 97 999999999 36.33 58.2 percent of total billed charges "Valproic acid level, free" 50482746_1 CDM 0301 RC 80165 HCPCS inpatient 60 39 AETNA AETNA 47.4 79 999999999 36.33 58.2 percent of total billed charges "Valproic acid level, free" 50482746_1 CDM 0301 RC 80165 HCPCS inpatient 60 39 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.8 78 999999999 36.33 58.2 percent of total billed charges "Valproic acid level, free" 50482746_1 CDM 0301 RC 80165 HCPCS inpatient 60 39 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.4 69 999999999 36.33 58.2 percent of total billed charges "Valproic acid level, free" 50482746_1 CDM 0301 RC 80165 HCPCS inpatient 60 39 UMR - ALL PLANS UMR - ALL PLANS 42 70 999999999 36.33 58.2 percent of total billed charges "Valproic acid level, free" 50482746_1 CDM 0301 RC 80165 HCPCS inpatient 60 39 SIHO - ALL PLANS SIHO - ALL PLANS 54 90 999999999 36.33 58.2 percent of total billed charges "Valproic acid level, free" 50482746_1 CDM 0301 RC 80165 HCPCS inpatient 60 39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.33 60.55 999999999 36.33 58.2 percent of total billed charges "Valproic acid level, free" 50482746_1 CDM 0301 RC 80165 HCPCS inpatient 60 39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.33 58.2 "Valproic acid level, free" 50482746_1 CDM 0301 RC 80165 HCPCS inpatient 60 39 ANTHEM HMO ANTHEM HMO 999999999 36.33 58.2 "Valproic acid level, free" 50482746_1 CDM 0301 RC 80165 HCPCS inpatient 60 39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.33 58.2 "Valproic acid level, free" 50482746_1 CDM 0301 RC 80165 HCPCS inpatient 60 39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.33 58.2 "Valproic acid level, free" 50482746_1 CDM 0301 RC 80165 HCPCS inpatient 60 39 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.33 58.2 "Valproic acid level, free" 50482746_1 CDM 0301 RC 80165 HCPCS inpatient 60 39 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.56 67.6 999999999 36.33 58.2 percent of total billed charges METRONIDAZOLE 250 MG TABLET 50483372_1 CDM 0250 RC 60687-0526-01 NDC inpatient 1 UN 1.01 0.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.66 65 999999999 0.61 0.98 percent of total billed charges METRONIDAZOLE 250 MG TABLET 50483372_1 CDM 0250 RC 60687-0526-01 NDC inpatient 1 UN 1.01 0.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 0.98 97 999999999 0.61 0.98 percent of total billed charges METRONIDAZOLE 250 MG TABLET 50483372_1 CDM 0250 RC 60687-0526-01 NDC inpatient 1 UN 1.01 0.66 AETNA AETNA 0.8 79 999999999 0.61 0.98 percent of total billed charges METRONIDAZOLE 250 MG TABLET 50483372_1 CDM 0250 RC 60687-0526-01 NDC inpatient 1 UN 1.01 0.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.79 78 999999999 0.61 0.98 percent of total billed charges METRONIDAZOLE 250 MG TABLET 50483372_1 CDM 0250 RC 60687-0526-01 NDC inpatient 1 UN 1.01 0.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.7 69 999999999 0.61 0.98 percent of total billed charges METRONIDAZOLE 250 MG TABLET 50483372_1 CDM 0250 RC 60687-0526-01 NDC inpatient 1 UN 1.01 0.66 UMR - ALL PLANS UMR - ALL PLANS 0.71 70 999999999 0.61 0.98 percent of total billed charges METRONIDAZOLE 250 MG TABLET 50483372_1 CDM 0250 RC 60687-0526-01 NDC inpatient 1 UN 1.01 0.66 SIHO - ALL PLANS SIHO - ALL PLANS 0.91 90 999999999 0.61 0.98 percent of total billed charges METRONIDAZOLE 250 MG TABLET 50483372_1 CDM 0250 RC 60687-0526-01 NDC inpatient 1 UN 1.01 0.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.61 60.55 999999999 0.61 0.98 percent of total billed charges METRONIDAZOLE 250 MG TABLET 50483372_1 CDM 0250 RC 60687-0526-01 NDC inpatient 1 UN 1.01 0.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.61 0.98 METRONIDAZOLE 250 MG TABLET 50483372_1 CDM 0250 RC 60687-0526-01 NDC inpatient 1 UN 1.01 0.66 ANTHEM HMO ANTHEM HMO 999999999 0.61 0.98 METRONIDAZOLE 250 MG TABLET 50483372_1 CDM 0250 RC 60687-0526-01 NDC inpatient 1 UN 1.01 0.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.61 0.98 METRONIDAZOLE 250 MG TABLET 50483372_1 CDM 0250 RC 60687-0526-01 NDC inpatient 1 UN 1.01 0.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.61 0.98 METRONIDAZOLE 250 MG TABLET 50483372_1 CDM 0250 RC 60687-0526-01 NDC inpatient 1 UN 1.01 0.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.61 0.98 METRONIDAZOLE 250 MG TABLET 50483372_1 CDM 0250 RC 60687-0526-01 NDC inpatient 1 UN 1.01 0.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.68 67.6 999999999 0.61 0.98 percent of total billed charges "INJECTION, LINEZOLID, 200 MG" 50483387_1 CDM 0250 RC 63323-0713-13 NDC J2020 HCPCS inpatient 1 UN 143.51 93.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 93.28 65 999999999 86.9 139.2 percent of total billed charges "INJECTION, LINEZOLID, 200 MG" 50483387_1 CDM 0250 RC 63323-0713-13 NDC J2020 HCPCS inpatient 1 UN 143.51 93.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 139.2 97 999999999 86.9 139.2 percent of total billed charges "INJECTION, LINEZOLID, 200 MG" 50483387_1 CDM 0250 RC 63323-0713-13 NDC J2020 HCPCS inpatient 1 UN 143.51 93.28 AETNA AETNA 113.37 79 999999999 86.9 139.2 percent of total billed charges "INJECTION, LINEZOLID, 200 MG" 50483387_1 CDM 0250 RC 63323-0713-13 NDC J2020 HCPCS inpatient 1 UN 143.51 93.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.94 78 999999999 86.9 139.2 percent of total billed charges "INJECTION, LINEZOLID, 200 MG" 50483387_1 CDM 0250 RC 63323-0713-13 NDC J2020 HCPCS inpatient 1 UN 143.51 93.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 99.02 69 999999999 86.9 139.2 percent of total billed charges "INJECTION, LINEZOLID, 200 MG" 50483387_1 CDM 0250 RC 63323-0713-13 NDC J2020 HCPCS inpatient 1 UN 143.51 93.28 UMR - ALL PLANS UMR - ALL PLANS 100.46 70 999999999 86.9 139.2 percent of total billed charges "INJECTION, LINEZOLID, 200 MG" 50483387_1 CDM 0250 RC 63323-0713-13 NDC J2020 HCPCS inpatient 1 UN 143.51 93.28 SIHO - ALL PLANS SIHO - ALL PLANS 129.16 90 999999999 86.9 139.2 percent of total billed charges "INJECTION, LINEZOLID, 200 MG" 50483387_1 CDM 0250 RC 63323-0713-13 NDC J2020 HCPCS inpatient 1 UN 143.51 93.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.9 60.55 999999999 86.9 139.2 percent of total billed charges "INJECTION, LINEZOLID, 200 MG" 50483387_1 CDM 0250 RC 63323-0713-13 NDC J2020 HCPCS inpatient 1 UN 143.51 93.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.9 139.2 "INJECTION, LINEZOLID, 200 MG" 50483387_1 CDM 0250 RC 63323-0713-13 NDC J2020 HCPCS inpatient 1 UN 143.51 93.28 ANTHEM HMO ANTHEM HMO 999999999 86.9 139.2 "INJECTION, LINEZOLID, 200 MG" 50483387_1 CDM 0250 RC 63323-0713-13 NDC J2020 HCPCS inpatient 1 UN 143.51 93.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.9 139.2 "INJECTION, LINEZOLID, 200 MG" 50483387_1 CDM 0250 RC 63323-0713-13 NDC J2020 HCPCS inpatient 1 UN 143.51 93.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.9 139.2 "INJECTION, LINEZOLID, 200 MG" 50483387_1 CDM 0250 RC 63323-0713-13 NDC J2020 HCPCS inpatient 1 UN 143.51 93.28 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.9 139.2 "INJECTION, LINEZOLID, 200 MG" 50483387_1 CDM 0250 RC 63323-0713-13 NDC J2020 HCPCS inpatient 1 UN 143.51 93.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 97.01 67.6 999999999 86.9 139.2 percent of total billed charges ENOXAPARIN 40 MG/0.4 ML SYR 50483715_1 CDM 0250 RC 71288-0410-83 NDC inpatient 10 UN 34.07 22.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.15 65 999999999 20.63 33.05 percent of total billed charges ENOXAPARIN 40 MG/0.4 ML SYR 50483715_1 CDM 0250 RC 71288-0410-83 NDC inpatient 10 UN 34.07 22.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33.05 97 999999999 20.63 33.05 percent of total billed charges ENOXAPARIN 40 MG/0.4 ML SYR 50483715_1 CDM 0250 RC 71288-0410-83 NDC inpatient 10 UN 34.07 22.15 AETNA AETNA 26.92 79 999999999 20.63 33.05 percent of total billed charges ENOXAPARIN 40 MG/0.4 ML SYR 50483715_1 CDM 0250 RC 71288-0410-83 NDC inpatient 10 UN 34.07 22.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 26.57 78 999999999 20.63 33.05 percent of total billed charges ENOXAPARIN 40 MG/0.4 ML SYR 50483715_1 CDM 0250 RC 71288-0410-83 NDC inpatient 10 UN 34.07 22.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 23.51 69 999999999 20.63 33.05 percent of total billed charges ENOXAPARIN 40 MG/0.4 ML SYR 50483715_1 CDM 0250 RC 71288-0410-83 NDC inpatient 10 UN 34.07 22.15 UMR - ALL PLANS UMR - ALL PLANS 23.85 70 999999999 20.63 33.05 percent of total billed charges ENOXAPARIN 40 MG/0.4 ML SYR 50483715_1 CDM 0250 RC 71288-0410-83 NDC inpatient 10 UN 34.07 22.15 SIHO - ALL PLANS SIHO - ALL PLANS 30.66 90 999999999 20.63 33.05 percent of total billed charges ENOXAPARIN 40 MG/0.4 ML SYR 50483715_1 CDM 0250 RC 71288-0410-83 NDC inpatient 10 UN 34.07 22.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.63 60.55 999999999 20.63 33.05 percent of total billed charges ENOXAPARIN 40 MG/0.4 ML SYR 50483715_1 CDM 0250 RC 71288-0410-83 NDC inpatient 10 UN 34.07 22.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.63 33.05 ENOXAPARIN 40 MG/0.4 ML SYR 50483715_1 CDM 0250 RC 71288-0410-83 NDC inpatient 10 UN 34.07 22.15 ANTHEM HMO ANTHEM HMO 999999999 20.63 33.05 ENOXAPARIN 40 MG/0.4 ML SYR 50483715_1 CDM 0250 RC 71288-0410-83 NDC inpatient 10 UN 34.07 22.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.63 33.05 ENOXAPARIN 40 MG/0.4 ML SYR 50483715_1 CDM 0250 RC 71288-0410-83 NDC inpatient 10 UN 34.07 22.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.63 33.05 ENOXAPARIN 40 MG/0.4 ML SYR 50483715_1 CDM 0250 RC 71288-0410-83 NDC inpatient 10 UN 34.07 22.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.63 33.05 ENOXAPARIN 40 MG/0.4 ML SYR 50483715_1 CDM 0250 RC 71288-0410-83 NDC inpatient 10 UN 34.07 22.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 23.03 67.6 999999999 20.63 33.05 percent of total billed charges AZELASTINE 0.1% (137 MCG) SPRY 50483809_1 CDM 0250 RC 60505-0833-05 NDC inpatient 1 UN 48.12 31.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.28 65 999999999 29.14 46.68 percent of total billed charges AZELASTINE 0.1% (137 MCG) SPRY 50483809_1 CDM 0250 RC 60505-0833-05 NDC inpatient 1 UN 48.12 31.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 46.68 97 999999999 29.14 46.68 percent of total billed charges AZELASTINE 0.1% (137 MCG) SPRY 50483809_1 CDM 0250 RC 60505-0833-05 NDC inpatient 1 UN 48.12 31.28 AETNA AETNA 38.01 79 999999999 29.14 46.68 percent of total billed charges AZELASTINE 0.1% (137 MCG) SPRY 50483809_1 CDM 0250 RC 60505-0833-05 NDC inpatient 1 UN 48.12 31.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 37.53 78 999999999 29.14 46.68 percent of total billed charges AZELASTINE 0.1% (137 MCG) SPRY 50483809_1 CDM 0250 RC 60505-0833-05 NDC inpatient 1 UN 48.12 31.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.2 69 999999999 29.14 46.68 percent of total billed charges AZELASTINE 0.1% (137 MCG) SPRY 50483809_1 CDM 0250 RC 60505-0833-05 NDC inpatient 1 UN 48.12 31.28 UMR - ALL PLANS UMR - ALL PLANS 33.68 70 999999999 29.14 46.68 percent of total billed charges AZELASTINE 0.1% (137 MCG) SPRY 50483809_1 CDM 0250 RC 60505-0833-05 NDC inpatient 1 UN 48.12 31.28 SIHO - ALL PLANS SIHO - ALL PLANS 43.31 90 999999999 29.14 46.68 percent of total billed charges AZELASTINE 0.1% (137 MCG) SPRY 50483809_1 CDM 0250 RC 60505-0833-05 NDC inpatient 1 UN 48.12 31.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.14 60.55 999999999 29.14 46.68 percent of total billed charges AZELASTINE 0.1% (137 MCG) SPRY 50483809_1 CDM 0250 RC 60505-0833-05 NDC inpatient 1 UN 48.12 31.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.14 46.68 AZELASTINE 0.1% (137 MCG) SPRY 50483809_1 CDM 0250 RC 60505-0833-05 NDC inpatient 1 UN 48.12 31.28 ANTHEM HMO ANTHEM HMO 999999999 29.14 46.68 AZELASTINE 0.1% (137 MCG) SPRY 50483809_1 CDM 0250 RC 60505-0833-05 NDC inpatient 1 UN 48.12 31.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.14 46.68 AZELASTINE 0.1% (137 MCG) SPRY 50483809_1 CDM 0250 RC 60505-0833-05 NDC inpatient 1 UN 48.12 31.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.14 46.68 AZELASTINE 0.1% (137 MCG) SPRY 50483809_1 CDM 0250 RC 60505-0833-05 NDC inpatient 1 UN 48.12 31.28 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.14 46.68 AZELASTINE 0.1% (137 MCG) SPRY 50483809_1 CDM 0250 RC 60505-0833-05 NDC inpatient 1 UN 48.12 31.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 32.53 67.6 999999999 29.14 46.68 percent of total billed charges Placement of device in muscle to monitor fluid pressure 50483978_1 CDM 0450 RC 20950 HCPCS inpatient 1652 1073.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1073.8 65 999999999 1000.29 1602.44 percent of total billed charges Placement of device in muscle to monitor fluid pressure 50483978_1 CDM 0450 RC 20950 HCPCS inpatient 1652 1073.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1602.44 97 999999999 1000.29 1602.44 percent of total billed charges Placement of device in muscle to monitor fluid pressure 50483978_1 CDM 0450 RC 20950 HCPCS inpatient 1652 1073.8 AETNA AETNA 1305.08 79 999999999 1000.29 1602.44 percent of total billed charges Placement of device in muscle to monitor fluid pressure 50483978_1 CDM 0450 RC 20950 HCPCS inpatient 1652 1073.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1288.56 78 999999999 1000.29 1602.44 percent of total billed charges Placement of device in muscle to monitor fluid pressure 50483978_1 CDM 0450 RC 20950 HCPCS inpatient 1652 1073.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1139.88 69 999999999 1000.29 1602.44 percent of total billed charges Placement of device in muscle to monitor fluid pressure 50483978_1 CDM 0450 RC 20950 HCPCS inpatient 1652 1073.8 UMR - ALL PLANS UMR - ALL PLANS 1156.4 70 999999999 1000.29 1602.44 percent of total billed charges Placement of device in muscle to monitor fluid pressure 50483978_1 CDM 0450 RC 20950 HCPCS inpatient 1652 1073.8 SIHO - ALL PLANS SIHO - ALL PLANS 1486.8 90 999999999 1000.29 1602.44 percent of total billed charges Placement of device in muscle to monitor fluid pressure 50483978_1 CDM 0450 RC 20950 HCPCS inpatient 1652 1073.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1000.29 60.55 999999999 1000.29 1602.44 percent of total billed charges Placement of device in muscle to monitor fluid pressure 50483978_1 CDM 0450 RC 20950 HCPCS inpatient 1652 1073.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1000.29 1602.44 Placement of device in muscle to monitor fluid pressure 50483978_1 CDM 0450 RC 20950 HCPCS inpatient 1652 1073.8 ANTHEM HMO ANTHEM HMO 999999999 1000.29 1602.44 Placement of device in muscle to monitor fluid pressure 50483978_1 CDM 0450 RC 20950 HCPCS inpatient 1652 1073.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1000.29 1602.44 Placement of device in muscle to monitor fluid pressure 50483978_1 CDM 0450 RC 20950 HCPCS inpatient 1652 1073.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1000.29 1602.44 Placement of device in muscle to monitor fluid pressure 50483978_1 CDM 0450 RC 20950 HCPCS inpatient 1652 1073.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1000.29 1602.44 Placement of device in muscle to monitor fluid pressure 50483978_1 CDM 0450 RC 20950 HCPCS inpatient 1652 1073.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1116.75 67.6 999999999 1000.29 1602.44 percent of total billed charges BETHANECHOL 25 MG TABLET 50484990_1 CDM 0250 RC 00832-0512-00 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges BETHANECHOL 25 MG TABLET 50484990_1 CDM 0250 RC 00832-0512-00 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges BETHANECHOL 25 MG TABLET 50484990_1 CDM 0250 RC 00832-0512-00 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges BETHANECHOL 25 MG TABLET 50484990_1 CDM 0250 RC 00832-0512-00 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges BETHANECHOL 25 MG TABLET 50484990_1 CDM 0250 RC 00832-0512-00 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges BETHANECHOL 25 MG TABLET 50484990_1 CDM 0250 RC 00832-0512-00 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges BETHANECHOL 25 MG TABLET 50484990_1 CDM 0250 RC 00832-0512-00 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges BETHANECHOL 25 MG TABLET 50484990_1 CDM 0250 RC 00832-0512-00 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges BETHANECHOL 25 MG TABLET 50484990_1 CDM 0250 RC 00832-0512-00 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 BETHANECHOL 25 MG TABLET 50484990_1 CDM 0250 RC 00832-0512-00 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 BETHANECHOL 25 MG TABLET 50484990_1 CDM 0250 RC 00832-0512-00 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 BETHANECHOL 25 MG TABLET 50484990_1 CDM 0250 RC 00832-0512-00 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 BETHANECHOL 25 MG TABLET 50484990_1 CDM 0250 RC 00832-0512-00 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 BETHANECHOL 25 MG TABLET 50484990_1 CDM 0250 RC 00832-0512-00 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges METHYLPREDNISOLONE 80 MG/ML VL 50484991_1 CDM 0250 RC 00703-0051-04 NDC inpatient 10 UN 58.35 37.93 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.93 65 999999999 35.33 56.6 percent of total billed charges METHYLPREDNISOLONE 80 MG/ML VL 50484991_1 CDM 0250 RC 00703-0051-04 NDC inpatient 10 UN 58.35 37.93 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.6 97 999999999 35.33 56.6 percent of total billed charges METHYLPREDNISOLONE 80 MG/ML VL 50484991_1 CDM 0250 RC 00703-0051-04 NDC inpatient 10 UN 58.35 37.93 AETNA AETNA 46.1 79 999999999 35.33 56.6 percent of total billed charges METHYLPREDNISOLONE 80 MG/ML VL 50484991_1 CDM 0250 RC 00703-0051-04 NDC inpatient 10 UN 58.35 37.93 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.51 78 999999999 35.33 56.6 percent of total billed charges METHYLPREDNISOLONE 80 MG/ML VL 50484991_1 CDM 0250 RC 00703-0051-04 NDC inpatient 10 UN 58.35 37.93 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.26 69 999999999 35.33 56.6 percent of total billed charges METHYLPREDNISOLONE 80 MG/ML VL 50484991_1 CDM 0250 RC 00703-0051-04 NDC inpatient 10 UN 58.35 37.93 UMR - ALL PLANS UMR - ALL PLANS 40.85 70 999999999 35.33 56.6 percent of total billed charges METHYLPREDNISOLONE 80 MG/ML VL 50484991_1 CDM 0250 RC 00703-0051-04 NDC inpatient 10 UN 58.35 37.93 SIHO - ALL PLANS SIHO - ALL PLANS 52.52 90 999999999 35.33 56.6 percent of total billed charges METHYLPREDNISOLONE 80 MG/ML VL 50484991_1 CDM 0250 RC 00703-0051-04 NDC inpatient 10 UN 58.35 37.93 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.33 60.55 999999999 35.33 56.6 percent of total billed charges METHYLPREDNISOLONE 80 MG/ML VL 50484991_1 CDM 0250 RC 00703-0051-04 NDC inpatient 10 UN 58.35 37.93 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.33 56.6 METHYLPREDNISOLONE 80 MG/ML VL 50484991_1 CDM 0250 RC 00703-0051-04 NDC inpatient 10 UN 58.35 37.93 ANTHEM HMO ANTHEM HMO 999999999 35.33 56.6 METHYLPREDNISOLONE 80 MG/ML VL 50484991_1 CDM 0250 RC 00703-0051-04 NDC inpatient 10 UN 58.35 37.93 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.33 56.6 METHYLPREDNISOLONE 80 MG/ML VL 50484991_1 CDM 0250 RC 00703-0051-04 NDC inpatient 10 UN 58.35 37.93 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.33 56.6 METHYLPREDNISOLONE 80 MG/ML VL 50484991_1 CDM 0250 RC 00703-0051-04 NDC inpatient 10 UN 58.35 37.93 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.33 56.6 METHYLPREDNISOLONE 80 MG/ML VL 50484991_1 CDM 0250 RC 00703-0051-04 NDC inpatient 10 UN 58.35 37.93 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.44 67.6 999999999 35.33 56.6 percent of total billed charges PROPAFENONE HCL 150 MG TABLET 50484992_1 CDM 0250 RC 62559-0230-01 NDC inpatient 10 UN 1.87 1.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.22 65 999999999 1.13 1.81 percent of total billed charges PROPAFENONE HCL 150 MG TABLET 50484992_1 CDM 0250 RC 62559-0230-01 NDC inpatient 10 UN 1.87 1.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.81 97 999999999 1.13 1.81 percent of total billed charges PROPAFENONE HCL 150 MG TABLET 50484992_1 CDM 0250 RC 62559-0230-01 NDC inpatient 10 UN 1.87 1.22 AETNA AETNA 1.48 79 999999999 1.13 1.81 percent of total billed charges PROPAFENONE HCL 150 MG TABLET 50484992_1 CDM 0250 RC 62559-0230-01 NDC inpatient 10 UN 1.87 1.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.46 78 999999999 1.13 1.81 percent of total billed charges PROPAFENONE HCL 150 MG TABLET 50484992_1 CDM 0250 RC 62559-0230-01 NDC inpatient 10 UN 1.87 1.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.29 69 999999999 1.13 1.81 percent of total billed charges PROPAFENONE HCL 150 MG TABLET 50484992_1 CDM 0250 RC 62559-0230-01 NDC inpatient 10 UN 1.87 1.22 UMR - ALL PLANS UMR - ALL PLANS 1.31 70 999999999 1.13 1.81 percent of total billed charges PROPAFENONE HCL 150 MG TABLET 50484992_1 CDM 0250 RC 62559-0230-01 NDC inpatient 10 UN 1.87 1.22 SIHO - ALL PLANS SIHO - ALL PLANS 1.68 90 999999999 1.13 1.81 percent of total billed charges PROPAFENONE HCL 150 MG TABLET 50484992_1 CDM 0250 RC 62559-0230-01 NDC inpatient 10 UN 1.87 1.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.13 60.55 999999999 1.13 1.81 percent of total billed charges PROPAFENONE HCL 150 MG TABLET 50484992_1 CDM 0250 RC 62559-0230-01 NDC inpatient 10 UN 1.87 1.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.13 1.81 PROPAFENONE HCL 150 MG TABLET 50484992_1 CDM 0250 RC 62559-0230-01 NDC inpatient 10 UN 1.87 1.22 ANTHEM HMO ANTHEM HMO 999999999 1.13 1.81 PROPAFENONE HCL 150 MG TABLET 50484992_1 CDM 0250 RC 62559-0230-01 NDC inpatient 10 UN 1.87 1.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.13 1.81 PROPAFENONE HCL 150 MG TABLET 50484992_1 CDM 0250 RC 62559-0230-01 NDC inpatient 10 UN 1.87 1.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.13 1.81 PROPAFENONE HCL 150 MG TABLET 50484992_1 CDM 0250 RC 62559-0230-01 NDC inpatient 10 UN 1.87 1.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.13 1.81 PROPAFENONE HCL 150 MG TABLET 50484992_1 CDM 0250 RC 62559-0230-01 NDC inpatient 10 UN 1.87 1.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.26 67.6 999999999 1.13 1.81 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50487201_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 176.8 65 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50487201_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 263.84 97 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50487201_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 AETNA AETNA 214.88 79 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50487201_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 212.16 78 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50487201_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 187.68 69 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50487201_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 UMR - ALL PLANS UMR - ALL PLANS 190.4 70 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50487201_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 SIHO - ALL PLANS SIHO - ALL PLANS 244.8 90 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50487201_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 164.7 60.55 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50487201_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 164.7 263.84 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50487201_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 ANTHEM HMO ANTHEM HMO 999999999 164.7 263.84 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50487201_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 164.7 263.84 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50487201_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 164.7 263.84 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50487201_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 164.7 263.84 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50487201_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 183.87 67.6 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487203_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 50487203_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 50487203_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 50487203_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 50487203_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 50487203_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 50487203_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 50487203_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 50487203_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Screening test for antibody to noninfectious agent 50487203_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Screening test for antibody to noninfectious agent 50487203_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Screening test for antibody to noninfectious agent 50487203_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Screening test for antibody to noninfectious agent 50487203_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Screening test for antibody to noninfectious agent 50487203_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges "Amphetamines levels, 3 or 4" 50487205_1 CDM 0301 RC 80325 HCPCS inpatient 118 76.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 76.7 65 999999999 71.45 114.46 percent of total billed charges "Amphetamines levels, 3 or 4" 50487205_1 CDM 0301 RC 80325 HCPCS inpatient 118 76.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 114.46 97 999999999 71.45 114.46 percent of total billed charges "Amphetamines levels, 3 or 4" 50487205_1 CDM 0301 RC 80325 HCPCS inpatient 118 76.7 AETNA AETNA 93.22 79 999999999 71.45 114.46 percent of total billed charges "Amphetamines levels, 3 or 4" 50487205_1 CDM 0301 RC 80325 HCPCS inpatient 118 76.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.04 78 999999999 71.45 114.46 percent of total billed charges "Amphetamines levels, 3 or 4" 50487205_1 CDM 0301 RC 80325 HCPCS inpatient 118 76.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 81.42 69 999999999 71.45 114.46 percent of total billed charges "Amphetamines levels, 3 or 4" 50487205_1 CDM 0301 RC 80325 HCPCS inpatient 118 76.7 UMR - ALL PLANS UMR - ALL PLANS 82.6 70 999999999 71.45 114.46 percent of total billed charges "Amphetamines levels, 3 or 4" 50487205_1 CDM 0301 RC 80325 HCPCS inpatient 118 76.7 SIHO - ALL PLANS SIHO - ALL PLANS 106.2 90 999999999 71.45 114.46 percent of total billed charges "Amphetamines levels, 3 or 4" 50487205_1 CDM 0301 RC 80325 HCPCS inpatient 118 76.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 71.45 60.55 999999999 71.45 114.46 percent of total billed charges "Amphetamines levels, 3 or 4" 50487205_1 CDM 0301 RC 80325 HCPCS inpatient 118 76.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 71.45 114.46 "Amphetamines levels, 3 or 4" 50487205_1 CDM 0301 RC 80325 HCPCS inpatient 118 76.7 ANTHEM HMO ANTHEM HMO 999999999 71.45 114.46 "Amphetamines levels, 3 or 4" 50487205_1 CDM 0301 RC 80325 HCPCS inpatient 118 76.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 71.45 114.46 "Amphetamines levels, 3 or 4" 50487205_1 CDM 0301 RC 80325 HCPCS inpatient 118 76.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 71.45 114.46 "Amphetamines levels, 3 or 4" 50487205_1 CDM 0301 RC 80325 HCPCS inpatient 118 76.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 71.45 114.46 "Amphetamines levels, 3 or 4" 50487205_1 CDM 0301 RC 80325 HCPCS inpatient 118 76.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 79.77 67.6 999999999 71.45 114.46 percent of total billed charges Screening test for antibody to noninfectious agent 50487207_1 CDM 0301 RC 86255 HCPCS inpatient 295 191.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 191.75 65 999999999 178.62 286.15 percent of total billed charges Screening test for antibody to noninfectious agent 50487207_1 CDM 0301 RC 86255 HCPCS inpatient 295 191.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 286.15 97 999999999 178.62 286.15 percent of total billed charges Screening test for antibody to noninfectious agent 50487207_1 CDM 0301 RC 86255 HCPCS inpatient 295 191.75 AETNA AETNA 233.05 79 999999999 178.62 286.15 percent of total billed charges Screening test for antibody to noninfectious agent 50487207_1 CDM 0301 RC 86255 HCPCS inpatient 295 191.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 230.1 78 999999999 178.62 286.15 percent of total billed charges Screening test for antibody to noninfectious agent 50487207_1 CDM 0301 RC 86255 HCPCS inpatient 295 191.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 203.55 69 999999999 178.62 286.15 percent of total billed charges Screening test for antibody to noninfectious agent 50487207_1 CDM 0301 RC 86255 HCPCS inpatient 295 191.75 UMR - ALL PLANS UMR - ALL PLANS 206.5 70 999999999 178.62 286.15 percent of total billed charges Screening test for antibody to noninfectious agent 50487207_1 CDM 0301 RC 86255 HCPCS inpatient 295 191.75 SIHO - ALL PLANS SIHO - ALL PLANS 265.5 90 999999999 178.62 286.15 percent of total billed charges Screening test for antibody to noninfectious agent 50487207_1 CDM 0301 RC 86255 HCPCS inpatient 295 191.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 178.62 60.55 999999999 178.62 286.15 percent of total billed charges Screening test for antibody to noninfectious agent 50487207_1 CDM 0301 RC 86255 HCPCS inpatient 295 191.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 178.62 286.15 Screening test for antibody to noninfectious agent 50487207_1 CDM 0301 RC 86255 HCPCS inpatient 295 191.75 ANTHEM HMO ANTHEM HMO 999999999 178.62 286.15 Screening test for antibody to noninfectious agent 50487207_1 CDM 0301 RC 86255 HCPCS inpatient 295 191.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 178.62 286.15 Screening test for antibody to noninfectious agent 50487207_1 CDM 0301 RC 86255 HCPCS inpatient 295 191.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 178.62 286.15 Screening test for antibody to noninfectious agent 50487207_1 CDM 0301 RC 86255 HCPCS inpatient 295 191.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 178.62 286.15 Screening test for antibody to noninfectious agent 50487207_1 CDM 0301 RC 86255 HCPCS inpatient 295 191.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 199.42 67.6 999999999 178.62 286.15 percent of total billed charges Arsenic level 50487210_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 73.45 65 999999999 68.42 109.61 percent of total billed charges Arsenic level 50487210_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 109.61 97 999999999 68.42 109.61 percent of total billed charges Arsenic level 50487210_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 AETNA AETNA 89.27 79 999999999 68.42 109.61 percent of total billed charges Arsenic level 50487210_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.14 78 999999999 68.42 109.61 percent of total billed charges Arsenic level 50487210_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.97 69 999999999 68.42 109.61 percent of total billed charges Arsenic level 50487210_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 UMR - ALL PLANS UMR - ALL PLANS 79.1 70 999999999 68.42 109.61 percent of total billed charges Arsenic level 50487210_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 SIHO - ALL PLANS SIHO - ALL PLANS 101.7 90 999999999 68.42 109.61 percent of total billed charges Arsenic level 50487210_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 68.42 60.55 999999999 68.42 109.61 percent of total billed charges Arsenic level 50487210_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 68.42 109.61 Arsenic level 50487210_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 ANTHEM HMO ANTHEM HMO 999999999 68.42 109.61 Arsenic level 50487210_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 68.42 109.61 Arsenic level 50487210_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 68.42 109.61 Arsenic level 50487210_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 68.42 109.61 Arsenic level 50487210_1 CDM 0301 RC 82175 HCPCS inpatient 113 73.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 76.39 67.6 999999999 68.42 109.61 percent of total billed charges "Benzodiazepines levels, 1-12" 50487211_1 CDM 0301 RC 80346 HCPCS inpatient 294 191.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 191.1 65 999999999 178.02 285.18 percent of total billed charges "Benzodiazepines levels, 1-12" 50487211_1 CDM 0301 RC 80346 HCPCS inpatient 294 191.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 285.18 97 999999999 178.02 285.18 percent of total billed charges "Benzodiazepines levels, 1-12" 50487211_1 CDM 0301 RC 80346 HCPCS inpatient 294 191.1 AETNA AETNA 232.26 79 999999999 178.02 285.18 percent of total billed charges "Benzodiazepines levels, 1-12" 50487211_1 CDM 0301 RC 80346 HCPCS inpatient 294 191.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 229.32 78 999999999 178.02 285.18 percent of total billed charges "Benzodiazepines levels, 1-12" 50487211_1 CDM 0301 RC 80346 HCPCS inpatient 294 191.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 202.86 69 999999999 178.02 285.18 percent of total billed charges "Benzodiazepines levels, 1-12" 50487211_1 CDM 0301 RC 80346 HCPCS inpatient 294 191.1 UMR - ALL PLANS UMR - ALL PLANS 205.8 70 999999999 178.02 285.18 percent of total billed charges "Benzodiazepines levels, 1-12" 50487211_1 CDM 0301 RC 80346 HCPCS inpatient 294 191.1 SIHO - ALL PLANS SIHO - ALL PLANS 264.6 90 999999999 178.02 285.18 percent of total billed charges "Benzodiazepines levels, 1-12" 50487211_1 CDM 0301 RC 80346 HCPCS inpatient 294 191.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 178.02 60.55 999999999 178.02 285.18 percent of total billed charges "Benzodiazepines levels, 1-12" 50487211_1 CDM 0301 RC 80346 HCPCS inpatient 294 191.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 178.02 285.18 "Benzodiazepines levels, 1-12" 50487211_1 CDM 0301 RC 80346 HCPCS inpatient 294 191.1 ANTHEM HMO ANTHEM HMO 999999999 178.02 285.18 "Benzodiazepines levels, 1-12" 50487211_1 CDM 0301 RC 80346 HCPCS inpatient 294 191.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 178.02 285.18 "Benzodiazepines levels, 1-12" 50487211_1 CDM 0301 RC 80346 HCPCS inpatient 294 191.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 178.02 285.18 "Benzodiazepines levels, 1-12" 50487211_1 CDM 0301 RC 80346 HCPCS inpatient 294 191.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 178.02 285.18 "Benzodiazepines levels, 1-12" 50487211_1 CDM 0301 RC 80346 HCPCS inpatient 294 191.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 198.74 67.6 999999999 178.02 285.18 percent of total billed charges Screening test for antibody to noninfectious agent 50487213_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 176.8 65 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487213_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 263.84 97 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487213_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 AETNA AETNA 214.88 79 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487213_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 212.16 78 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487213_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 187.68 69 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487213_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 UMR - ALL PLANS UMR - ALL PLANS 190.4 70 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487213_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 SIHO - ALL PLANS SIHO - ALL PLANS 244.8 90 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487213_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 164.7 60.55 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487213_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487213_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM HMO ANTHEM HMO 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487213_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487213_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487213_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487213_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 183.87 67.6 999999999 164.7 263.84 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487214_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487214_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487214_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487214_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487214_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487214_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487214_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487214_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487214_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 50487214_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 50487214_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 50487214_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 50487214_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 50487214_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges Screening test for antibody to noninfectious agent 50487215_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 176.8 65 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487215_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 263.84 97 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487215_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 AETNA AETNA 214.88 79 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487215_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 212.16 78 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487215_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 187.68 69 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487215_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 UMR - ALL PLANS UMR - ALL PLANS 190.4 70 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487215_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 SIHO - ALL PLANS SIHO - ALL PLANS 244.8 90 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487215_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 164.7 60.55 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487215_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487215_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM HMO ANTHEM HMO 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487215_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487215_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487215_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487215_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 183.87 67.6 999999999 164.7 263.84 percent of total billed charges Measurement of antibody to noninfectious agent 50487220_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.4 65 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50487220_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.12 97 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50487220_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 AETNA AETNA 75.84 79 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50487220_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.88 78 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50487220_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.24 69 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50487220_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 UMR - ALL PLANS UMR - ALL PLANS 67.2 70 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50487220_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 SIHO - ALL PLANS SIHO - ALL PLANS 86.4 90 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50487220_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.13 60.55 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50487220_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.13 93.12 Measurement of antibody to noninfectious agent 50487220_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ANTHEM HMO ANTHEM HMO 999999999 58.13 93.12 Measurement of antibody to noninfectious agent 50487220_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.13 93.12 Measurement of antibody to noninfectious agent 50487220_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.13 93.12 Measurement of antibody to noninfectious agent 50487220_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.13 93.12 Measurement of antibody to noninfectious agent 50487220_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.9 67.6 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50487221_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.4 65 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50487221_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.12 97 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50487221_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 AETNA AETNA 75.84 79 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50487221_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.88 78 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50487221_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.24 69 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50487221_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 UMR - ALL PLANS UMR - ALL PLANS 67.2 70 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50487221_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 SIHO - ALL PLANS SIHO - ALL PLANS 86.4 90 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50487221_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.13 60.55 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50487221_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.13 93.12 Measurement of antibody to noninfectious agent 50487221_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ANTHEM HMO ANTHEM HMO 999999999 58.13 93.12 Measurement of antibody to noninfectious agent 50487221_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.13 93.12 Measurement of antibody to noninfectious agent 50487221_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.13 93.12 Measurement of antibody to noninfectious agent 50487221_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.13 93.12 Measurement of antibody to noninfectious agent 50487221_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.9 67.6 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50487222_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487222_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487222_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487222_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487222_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487222_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487222_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487222_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487222_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487222_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487222_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487222_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487222_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487222_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges "Alcohols levels, 1 or 2" 50487223_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 119.6 65 999999999 111.41 178.48 percent of total billed charges "Alcohols levels, 1 or 2" 50487223_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 178.48 97 999999999 111.41 178.48 percent of total billed charges "Alcohols levels, 1 or 2" 50487223_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 AETNA AETNA 145.36 79 999999999 111.41 178.48 percent of total billed charges "Alcohols levels, 1 or 2" 50487223_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 143.52 78 999999999 111.41 178.48 percent of total billed charges "Alcohols levels, 1 or 2" 50487223_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.96 69 999999999 111.41 178.48 percent of total billed charges "Alcohols levels, 1 or 2" 50487223_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 UMR - ALL PLANS UMR - ALL PLANS 128.8 70 999999999 111.41 178.48 percent of total billed charges "Alcohols levels, 1 or 2" 50487223_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 SIHO - ALL PLANS SIHO - ALL PLANS 165.6 90 999999999 111.41 178.48 percent of total billed charges "Alcohols levels, 1 or 2" 50487223_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 111.41 60.55 999999999 111.41 178.48 percent of total billed charges "Alcohols levels, 1 or 2" 50487223_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 111.41 178.48 "Alcohols levels, 1 or 2" 50487223_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 ANTHEM HMO ANTHEM HMO 999999999 111.41 178.48 "Alcohols levels, 1 or 2" 50487223_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 111.41 178.48 "Alcohols levels, 1 or 2" 50487223_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 111.41 178.48 "Alcohols levels, 1 or 2" 50487223_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 111.41 178.48 "Alcohols levels, 1 or 2" 50487223_1 CDM 0301 RC 80321 HCPCS inpatient 184 119.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 124.38 67.6 999999999 111.41 178.48 percent of total billed charges Fentanyl level 50487224_1 CDM 0301 RC 80354 HCPCS inpatient 261 169.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 169.65 65 999999999 158.04 253.17 percent of total billed charges Fentanyl level 50487224_1 CDM 0301 RC 80354 HCPCS inpatient 261 169.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 253.17 97 999999999 158.04 253.17 percent of total billed charges Fentanyl level 50487224_1 CDM 0301 RC 80354 HCPCS inpatient 261 169.65 AETNA AETNA 206.19 79 999999999 158.04 253.17 percent of total billed charges Fentanyl level 50487224_1 CDM 0301 RC 80354 HCPCS inpatient 261 169.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 203.58 78 999999999 158.04 253.17 percent of total billed charges Fentanyl level 50487224_1 CDM 0301 RC 80354 HCPCS inpatient 261 169.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.09 69 999999999 158.04 253.17 percent of total billed charges Fentanyl level 50487224_1 CDM 0301 RC 80354 HCPCS inpatient 261 169.65 UMR - ALL PLANS UMR - ALL PLANS 182.7 70 999999999 158.04 253.17 percent of total billed charges Fentanyl level 50487224_1 CDM 0301 RC 80354 HCPCS inpatient 261 169.65 SIHO - ALL PLANS SIHO - ALL PLANS 234.9 90 999999999 158.04 253.17 percent of total billed charges Fentanyl level 50487224_1 CDM 0301 RC 80354 HCPCS inpatient 261 169.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.04 60.55 999999999 158.04 253.17 percent of total billed charges Fentanyl level 50487224_1 CDM 0301 RC 80354 HCPCS inpatient 261 169.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.04 253.17 Fentanyl level 50487224_1 CDM 0301 RC 80354 HCPCS inpatient 261 169.65 ANTHEM HMO ANTHEM HMO 999999999 158.04 253.17 Fentanyl level 50487224_1 CDM 0301 RC 80354 HCPCS inpatient 261 169.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.04 253.17 Fentanyl level 50487224_1 CDM 0301 RC 80354 HCPCS inpatient 261 169.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.04 253.17 Fentanyl level 50487224_1 CDM 0301 RC 80354 HCPCS inpatient 261 169.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.04 253.17 Fentanyl level 50487224_1 CDM 0301 RC 80354 HCPCS inpatient 261 169.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 176.44 67.6 999999999 158.04 253.17 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487225_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487225_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487225_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487225_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487225_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487225_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487225_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487225_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487225_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487225_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487225_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487225_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487225_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487225_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges Screening test for antibody to noninfectious agent 50487226_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 176.8 65 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487226_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 263.84 97 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487226_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 AETNA AETNA 214.88 79 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487226_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 212.16 78 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487226_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 187.68 69 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487226_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 UMR - ALL PLANS UMR - ALL PLANS 190.4 70 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487226_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 SIHO - ALL PLANS SIHO - ALL PLANS 244.8 90 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487226_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 164.7 60.55 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487226_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487226_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM HMO ANTHEM HMO 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487226_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487226_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487226_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487226_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 183.87 67.6 999999999 164.7 263.84 percent of total billed charges Measurement of antibody to noninfectious agent 50487227_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487227_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487227_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487227_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487227_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487227_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487227_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487227_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487227_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487227_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487227_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487227_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487227_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487227_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Islet cell (pancreas) antibody measurement 50487228_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 232.05 65 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 50487228_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 346.29 97 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 50487228_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 AETNA AETNA 282.03 79 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 50487228_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 278.46 78 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 50487228_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 246.33 69 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 50487228_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 UMR - ALL PLANS UMR - ALL PLANS 249.9 70 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 50487228_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 SIHO - ALL PLANS SIHO - ALL PLANS 321.3 90 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 50487228_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 216.16 60.55 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 50487228_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 216.16 346.29 Islet cell (pancreas) antibody measurement 50487228_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 ANTHEM HMO ANTHEM HMO 999999999 216.16 346.29 Islet cell (pancreas) antibody measurement 50487228_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 216.16 346.29 Islet cell (pancreas) antibody measurement 50487228_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 216.16 346.29 Islet cell (pancreas) antibody measurement 50487228_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 216.16 346.29 Islet cell (pancreas) antibody measurement 50487228_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 241.33 67.6 999999999 216.16 346.29 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 50487231_1 CDM 0301 RC 87522 HCPCS inpatient 268 174.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 174.2 65 999999999 162.27 259.96 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 50487231_1 CDM 0301 RC 87522 HCPCS inpatient 268 174.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 259.96 97 999999999 162.27 259.96 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 50487231_1 CDM 0301 RC 87522 HCPCS inpatient 268 174.2 AETNA AETNA 211.72 79 999999999 162.27 259.96 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 50487231_1 CDM 0301 RC 87522 HCPCS inpatient 268 174.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 209.04 78 999999999 162.27 259.96 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 50487231_1 CDM 0301 RC 87522 HCPCS inpatient 268 174.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.92 69 999999999 162.27 259.96 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 50487231_1 CDM 0301 RC 87522 HCPCS inpatient 268 174.2 UMR - ALL PLANS UMR - ALL PLANS 187.6 70 999999999 162.27 259.96 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 50487231_1 CDM 0301 RC 87522 HCPCS inpatient 268 174.2 SIHO - ALL PLANS SIHO - ALL PLANS 241.2 90 999999999 162.27 259.96 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 50487231_1 CDM 0301 RC 87522 HCPCS inpatient 268 174.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 162.27 60.55 999999999 162.27 259.96 percent of total billed charges "Detection test by nucleic acid for Hepatitis C virus, quantification" 50487231_1 CDM 0301 RC 87522 HCPCS inpatient 268 174.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 162.27 259.96 "Detection test by nucleic acid for Hepatitis C virus, quantification" 50487231_1 CDM 0301 RC 87522 HCPCS inpatient 268 174.2 ANTHEM HMO ANTHEM HMO 999999999 162.27 259.96 "Detection test by nucleic acid for Hepatitis C virus, quantification" 50487231_1 CDM 0301 RC 87522 HCPCS inpatient 268 174.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 162.27 259.96 "Detection test by nucleic acid for Hepatitis C virus, quantification" 50487231_1 CDM 0301 RC 87522 HCPCS inpatient 268 174.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 162.27 259.96 "Detection test by nucleic acid for Hepatitis C virus, quantification" 50487231_1 CDM 0301 RC 87522 HCPCS inpatient 268 174.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 162.27 259.96 "Detection test by nucleic acid for Hepatitis C virus, quantification" 50487231_1 CDM 0301 RC 87522 HCPCS inpatient 268 174.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 181.17 67.6 999999999 162.27 259.96 percent of total billed charges "Hemoglobin analysis and measurement, electrophoresis" 50487232_1 CDM 0301 RC 83020 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Hemoglobin analysis and measurement, electrophoresis" 50487232_1 CDM 0301 RC 83020 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Hemoglobin analysis and measurement, electrophoresis" 50487232_1 CDM 0301 RC 83020 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Hemoglobin analysis and measurement, electrophoresis" 50487232_1 CDM 0301 RC 83020 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Hemoglobin analysis and measurement, electrophoresis" 50487232_1 CDM 0301 RC 83020 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Hemoglobin analysis and measurement, electrophoresis" 50487232_1 CDM 0301 RC 83020 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Hemoglobin analysis and measurement, electrophoresis" 50487232_1 CDM 0301 RC 83020 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Hemoglobin analysis and measurement, electrophoresis" 50487232_1 CDM 0301 RC 83020 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Hemoglobin analysis and measurement, electrophoresis" 50487232_1 CDM 0301 RC 83020 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Hemoglobin analysis and measurement, electrophoresis" 50487232_1 CDM 0301 RC 83020 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Hemoglobin analysis and measurement, electrophoresis" 50487232_1 CDM 0301 RC 83020 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Hemoglobin analysis and measurement, electrophoresis" 50487232_1 CDM 0301 RC 83020 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Hemoglobin analysis and measurement, electrophoresis" 50487232_1 CDM 0301 RC 83020 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Hemoglobin analysis and measurement, electrophoresis" 50487232_1 CDM 0301 RC 83020 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges Measurement of antibody to noninfectious agent 50487233_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487233_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487233_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487233_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487233_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487233_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487233_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487233_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487233_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487233_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487233_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487233_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487233_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487233_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 50487234_1 CDM 0301 RC 87556 HCPCS inpatient 464 301.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 301.6 65 999999999 280.95 450.08 percent of total billed charges "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 50487234_1 CDM 0301 RC 87556 HCPCS inpatient 464 301.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 450.08 97 999999999 280.95 450.08 percent of total billed charges "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 50487234_1 CDM 0301 RC 87556 HCPCS inpatient 464 301.6 AETNA AETNA 366.56 79 999999999 280.95 450.08 percent of total billed charges "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 50487234_1 CDM 0301 RC 87556 HCPCS inpatient 464 301.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 361.92 78 999999999 280.95 450.08 percent of total billed charges "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 50487234_1 CDM 0301 RC 87556 HCPCS inpatient 464 301.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 320.16 69 999999999 280.95 450.08 percent of total billed charges "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 50487234_1 CDM 0301 RC 87556 HCPCS inpatient 464 301.6 UMR - ALL PLANS UMR - ALL PLANS 324.8 70 999999999 280.95 450.08 percent of total billed charges "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 50487234_1 CDM 0301 RC 87556 HCPCS inpatient 464 301.6 SIHO - ALL PLANS SIHO - ALL PLANS 417.6 90 999999999 280.95 450.08 percent of total billed charges "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 50487234_1 CDM 0301 RC 87556 HCPCS inpatient 464 301.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 280.95 60.55 999999999 280.95 450.08 percent of total billed charges "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 50487234_1 CDM 0301 RC 87556 HCPCS inpatient 464 301.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 280.95 450.08 "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 50487234_1 CDM 0301 RC 87556 HCPCS inpatient 464 301.6 ANTHEM HMO ANTHEM HMO 999999999 280.95 450.08 "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 50487234_1 CDM 0301 RC 87556 HCPCS inpatient 464 301.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 280.95 450.08 "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 50487234_1 CDM 0301 RC 87556 HCPCS inpatient 464 301.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 280.95 450.08 "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 50487234_1 CDM 0301 RC 87556 HCPCS inpatient 464 301.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 280.95 450.08 "Detection test by nucleic acid for Mycobacteria tuberculosis (TB bacteria), amplified probe technique" 50487234_1 CDM 0301 RC 87556 HCPCS inpatient 464 301.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 313.66 67.6 999999999 280.95 450.08 percent of total billed charges Methadone level 50487236_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 137.15 65 999999999 127.76 204.67 percent of total billed charges Methadone level 50487236_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 204.67 97 999999999 127.76 204.67 percent of total billed charges Methadone level 50487236_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 AETNA AETNA 166.69 79 999999999 127.76 204.67 percent of total billed charges Methadone level 50487236_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 164.58 78 999999999 127.76 204.67 percent of total billed charges Methadone level 50487236_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 145.59 69 999999999 127.76 204.67 percent of total billed charges Methadone level 50487236_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 UMR - ALL PLANS UMR - ALL PLANS 147.7 70 999999999 127.76 204.67 percent of total billed charges Methadone level 50487236_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 SIHO - ALL PLANS SIHO - ALL PLANS 189.9 90 999999999 127.76 204.67 percent of total billed charges Methadone level 50487236_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.76 60.55 999999999 127.76 204.67 percent of total billed charges Methadone level 50487236_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.76 204.67 Methadone level 50487236_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ANTHEM HMO ANTHEM HMO 999999999 127.76 204.67 Methadone level 50487236_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.76 204.67 Methadone level 50487236_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.76 204.67 Methadone level 50487236_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.76 204.67 Methadone level 50487236_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 142.64 67.6 999999999 127.76 204.67 percent of total billed charges Screening test for antibody to noninfectious agent 50487237_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 50487237_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 50487237_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 50487237_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 50487237_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 50487237_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 50487237_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 50487237_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 50487237_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 50487237_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 50487237_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 50487237_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 50487237_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 50487237_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges Measurement of antibody to noninfectious agent 50487238_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487238_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487238_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487238_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487238_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487238_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487238_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487238_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487238_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487238_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487238_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487238_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487238_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487238_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487239_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487239_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487239_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487239_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487239_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487239_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487239_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487239_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50487239_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487239_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487239_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487239_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487239_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50487239_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 50487240_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 176.8 65 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487240_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 263.84 97 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487240_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 AETNA AETNA 214.88 79 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487240_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 212.16 78 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487240_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 187.68 69 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487240_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 UMR - ALL PLANS UMR - ALL PLANS 190.4 70 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487240_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 SIHO - ALL PLANS SIHO - ALL PLANS 244.8 90 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487240_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 164.7 60.55 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 50487240_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487240_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM HMO ANTHEM HMO 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487240_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487240_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487240_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 50487240_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 183.87 67.6 999999999 164.7 263.84 percent of total billed charges PCP drug level 50487242_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges PCP drug level 50487242_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges PCP drug level 50487242_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges PCP drug level 50487242_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges PCP drug level 50487242_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges PCP drug level 50487242_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges PCP drug level 50487242_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges PCP drug level 50487242_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges PCP drug level 50487242_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 PCP drug level 50487242_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 PCP drug level 50487242_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 PCP drug level 50487242_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 PCP drug level 50487242_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 PCP drug level 50487242_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487243_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487243_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487243_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487243_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487243_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487243_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487243_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487243_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487243_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487243_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487243_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487243_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487243_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487243_1 CDM 0301 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges Propoxyphene level 50487244_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.2 65 999999999 113.83 182.36 percent of total billed charges Propoxyphene level 50487244_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 182.36 97 999999999 113.83 182.36 percent of total billed charges Propoxyphene level 50487244_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 AETNA AETNA 148.52 79 999999999 113.83 182.36 percent of total billed charges Propoxyphene level 50487244_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 146.64 78 999999999 113.83 182.36 percent of total billed charges Propoxyphene level 50487244_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.72 69 999999999 113.83 182.36 percent of total billed charges Propoxyphene level 50487244_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 UMR - ALL PLANS UMR - ALL PLANS 131.6 70 999999999 113.83 182.36 percent of total billed charges Propoxyphene level 50487244_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 SIHO - ALL PLANS SIHO - ALL PLANS 169.2 90 999999999 113.83 182.36 percent of total billed charges Propoxyphene level 50487244_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.83 60.55 999999999 113.83 182.36 percent of total billed charges Propoxyphene level 50487244_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.83 182.36 Propoxyphene level 50487244_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 ANTHEM HMO ANTHEM HMO 999999999 113.83 182.36 Propoxyphene level 50487244_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.83 182.36 Propoxyphene level 50487244_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.83 182.36 Propoxyphene level 50487244_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.83 182.36 Propoxyphene level 50487244_1 CDM 0301 RC 80367 HCPCS inpatient 188 122.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.09 67.6 999999999 113.83 182.36 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487245_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487245_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487245_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487245_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487245_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487245_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487245_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487245_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487245_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 "Analysis of substance using immunoassay technique, multiple step method" 50487245_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 "Analysis of substance using immunoassay technique, multiple step method" 50487245_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 "Analysis of substance using immunoassay technique, multiple step method" 50487245_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 "Analysis of substance using immunoassay technique, multiple step method" 50487245_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 "Analysis of substance using immunoassay technique, multiple step method" 50487245_1 CDM 0301 RC 83516 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487246_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487246_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487246_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487246_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487246_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487246_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487246_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487246_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487246_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487246_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487246_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487246_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487246_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487246_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487247_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487247_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487247_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487247_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487247_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487247_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487247_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487247_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487247_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487247_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487247_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487247_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487247_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487247_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487248_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487248_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487248_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487248_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487248_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487248_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487248_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487248_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487248_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487248_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487248_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487248_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487248_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487248_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487249_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487249_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487249_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487249_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487249_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487249_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487249_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487249_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487249_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487249_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487249_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487249_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487249_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487249_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487250_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487250_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487250_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487250_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487250_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487250_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487250_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487250_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50487250_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487250_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487250_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487250_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487250_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50487250_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges Tramadol level 50487251_1 CDM 0301 RC 80373 HCPCS inpatient 307 199.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 199.55 65 999999999 185.89 297.79 percent of total billed charges Tramadol level 50487251_1 CDM 0301 RC 80373 HCPCS inpatient 307 199.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 297.79 97 999999999 185.89 297.79 percent of total billed charges Tramadol level 50487251_1 CDM 0301 RC 80373 HCPCS inpatient 307 199.55 AETNA AETNA 242.53 79 999999999 185.89 297.79 percent of total billed charges Tramadol level 50487251_1 CDM 0301 RC 80373 HCPCS inpatient 307 199.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 239.46 78 999999999 185.89 297.79 percent of total billed charges Tramadol level 50487251_1 CDM 0301 RC 80373 HCPCS inpatient 307 199.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 211.83 69 999999999 185.89 297.79 percent of total billed charges Tramadol level 50487251_1 CDM 0301 RC 80373 HCPCS inpatient 307 199.55 UMR - ALL PLANS UMR - ALL PLANS 214.9 70 999999999 185.89 297.79 percent of total billed charges Tramadol level 50487251_1 CDM 0301 RC 80373 HCPCS inpatient 307 199.55 SIHO - ALL PLANS SIHO - ALL PLANS 276.3 90 999999999 185.89 297.79 percent of total billed charges Tramadol level 50487251_1 CDM 0301 RC 80373 HCPCS inpatient 307 199.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 185.89 60.55 999999999 185.89 297.79 percent of total billed charges Tramadol level 50487251_1 CDM 0301 RC 80373 HCPCS inpatient 307 199.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 185.89 297.79 Tramadol level 50487251_1 CDM 0301 RC 80373 HCPCS inpatient 307 199.55 ANTHEM HMO ANTHEM HMO 999999999 185.89 297.79 Tramadol level 50487251_1 CDM 0301 RC 80373 HCPCS inpatient 307 199.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 185.89 297.79 Tramadol level 50487251_1 CDM 0301 RC 80373 HCPCS inpatient 307 199.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 185.89 297.79 Tramadol level 50487251_1 CDM 0301 RC 80373 HCPCS inpatient 307 199.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 185.89 297.79 Tramadol level 50487251_1 CDM 0301 RC 80373 HCPCS inpatient 307 199.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 207.53 67.6 999999999 185.89 297.79 percent of total billed charges "Cannabinoids levels, natural" 50487252_1 CDM 0301 RC 80349 HCPCS inpatient 301 195.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 195.65 65 999999999 182.26 291.97 percent of total billed charges "Cannabinoids levels, natural" 50487252_1 CDM 0301 RC 80349 HCPCS inpatient 301 195.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291.97 97 999999999 182.26 291.97 percent of total billed charges "Cannabinoids levels, natural" 50487252_1 CDM 0301 RC 80349 HCPCS inpatient 301 195.65 AETNA AETNA 237.79 79 999999999 182.26 291.97 percent of total billed charges "Cannabinoids levels, natural" 50487252_1 CDM 0301 RC 80349 HCPCS inpatient 301 195.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 234.78 78 999999999 182.26 291.97 percent of total billed charges "Cannabinoids levels, natural" 50487252_1 CDM 0301 RC 80349 HCPCS inpatient 301 195.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 207.69 69 999999999 182.26 291.97 percent of total billed charges "Cannabinoids levels, natural" 50487252_1 CDM 0301 RC 80349 HCPCS inpatient 301 195.65 UMR - ALL PLANS UMR - ALL PLANS 210.7 70 999999999 182.26 291.97 percent of total billed charges "Cannabinoids levels, natural" 50487252_1 CDM 0301 RC 80349 HCPCS inpatient 301 195.65 SIHO - ALL PLANS SIHO - ALL PLANS 270.9 90 999999999 182.26 291.97 percent of total billed charges "Cannabinoids levels, natural" 50487252_1 CDM 0301 RC 80349 HCPCS inpatient 301 195.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.26 60.55 999999999 182.26 291.97 percent of total billed charges "Cannabinoids levels, natural" 50487252_1 CDM 0301 RC 80349 HCPCS inpatient 301 195.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.26 291.97 "Cannabinoids levels, natural" 50487252_1 CDM 0301 RC 80349 HCPCS inpatient 301 195.65 ANTHEM HMO ANTHEM HMO 999999999 182.26 291.97 "Cannabinoids levels, natural" 50487252_1 CDM 0301 RC 80349 HCPCS inpatient 301 195.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.26 291.97 "Cannabinoids levels, natural" 50487252_1 CDM 0301 RC 80349 HCPCS inpatient 301 195.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.26 291.97 "Cannabinoids levels, natural" 50487252_1 CDM 0301 RC 80349 HCPCS inpatient 301 195.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.26 291.97 "Cannabinoids levels, natural" 50487252_1 CDM 0301 RC 80349 HCPCS inpatient 301 195.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 203.48 67.6 999999999 182.26 291.97 percent of total billed charges Tramadol level 50487253_1 CDM 0301 RC 80373 HCPCS inpatient 303 196.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 196.95 65 999999999 183.47 293.91 percent of total billed charges Tramadol level 50487253_1 CDM 0301 RC 80373 HCPCS inpatient 303 196.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 293.91 97 999999999 183.47 293.91 percent of total billed charges Tramadol level 50487253_1 CDM 0301 RC 80373 HCPCS inpatient 303 196.95 AETNA AETNA 239.37 79 999999999 183.47 293.91 percent of total billed charges Tramadol level 50487253_1 CDM 0301 RC 80373 HCPCS inpatient 303 196.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 236.34 78 999999999 183.47 293.91 percent of total billed charges Tramadol level 50487253_1 CDM 0301 RC 80373 HCPCS inpatient 303 196.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 209.07 69 999999999 183.47 293.91 percent of total billed charges Tramadol level 50487253_1 CDM 0301 RC 80373 HCPCS inpatient 303 196.95 UMR - ALL PLANS UMR - ALL PLANS 212.1 70 999999999 183.47 293.91 percent of total billed charges Tramadol level 50487253_1 CDM 0301 RC 80373 HCPCS inpatient 303 196.95 SIHO - ALL PLANS SIHO - ALL PLANS 272.7 90 999999999 183.47 293.91 percent of total billed charges Tramadol level 50487253_1 CDM 0301 RC 80373 HCPCS inpatient 303 196.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 183.47 60.55 999999999 183.47 293.91 percent of total billed charges Tramadol level 50487253_1 CDM 0301 RC 80373 HCPCS inpatient 303 196.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 183.47 293.91 Tramadol level 50487253_1 CDM 0301 RC 80373 HCPCS inpatient 303 196.95 ANTHEM HMO ANTHEM HMO 999999999 183.47 293.91 Tramadol level 50487253_1 CDM 0301 RC 80373 HCPCS inpatient 303 196.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 183.47 293.91 Tramadol level 50487253_1 CDM 0301 RC 80373 HCPCS inpatient 303 196.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 183.47 293.91 Tramadol level 50487253_1 CDM 0301 RC 80373 HCPCS inpatient 303 196.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 183.47 293.91 Tramadol level 50487253_1 CDM 0301 RC 80373 HCPCS inpatient 303 196.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 204.83 67.6 999999999 183.47 293.91 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487254_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487254_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487254_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487254_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487254_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487254_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487254_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487254_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487254_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50487254_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50487254_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50487254_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50487254_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50487254_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487255_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487255_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487255_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487255_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487255_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487255_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487255_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487255_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50487255_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50487255_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50487255_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50487255_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50487255_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50487255_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges Sedative hypnotics (non-benzodiazepines) levels 50487256_1 CDM 0301 RC 80368 HCPCS inpatient 200 130 SELF PAY DISCOUNT SELF PAY DISCOUNT 130 65 999999999 121.1 194 percent of total billed charges Sedative hypnotics (non-benzodiazepines) levels 50487256_1 CDM 0301 RC 80368 HCPCS inpatient 200 130 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 194 97 999999999 121.1 194 percent of total billed charges Sedative hypnotics (non-benzodiazepines) levels 50487256_1 CDM 0301 RC 80368 HCPCS inpatient 200 130 AETNA AETNA 158 79 999999999 121.1 194 percent of total billed charges Sedative hypnotics (non-benzodiazepines) levels 50487256_1 CDM 0301 RC 80368 HCPCS inpatient 200 130 HUMANA - ALL PLANS HUMANA - ALL PLANS 156 78 999999999 121.1 194 percent of total billed charges Sedative hypnotics (non-benzodiazepines) levels 50487256_1 CDM 0301 RC 80368 HCPCS inpatient 200 130 ENCORE - ALL PLANS ENCORE - ALL PLANS 138 69 999999999 121.1 194 percent of total billed charges Sedative hypnotics (non-benzodiazepines) levels 50487256_1 CDM 0301 RC 80368 HCPCS inpatient 200 130 UMR - ALL PLANS UMR - ALL PLANS 140 70 999999999 121.1 194 percent of total billed charges Sedative hypnotics (non-benzodiazepines) levels 50487256_1 CDM 0301 RC 80368 HCPCS inpatient 200 130 SIHO - ALL PLANS SIHO - ALL PLANS 180 90 999999999 121.1 194 percent of total billed charges Sedative hypnotics (non-benzodiazepines) levels 50487256_1 CDM 0301 RC 80368 HCPCS inpatient 200 130 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 121.1 60.55 999999999 121.1 194 percent of total billed charges Sedative hypnotics (non-benzodiazepines) levels 50487256_1 CDM 0301 RC 80368 HCPCS inpatient 200 130 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 121.1 194 Sedative hypnotics (non-benzodiazepines) levels 50487256_1 CDM 0301 RC 80368 HCPCS inpatient 200 130 ANTHEM HMO ANTHEM HMO 999999999 121.1 194 Sedative hypnotics (non-benzodiazepines) levels 50487256_1 CDM 0301 RC 80368 HCPCS inpatient 200 130 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 121.1 194 Sedative hypnotics (non-benzodiazepines) levels 50487256_1 CDM 0301 RC 80368 HCPCS inpatient 200 130 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 121.1 194 Sedative hypnotics (non-benzodiazepines) levels 50487256_1 CDM 0301 RC 80368 HCPCS inpatient 200 130 UHC - ALL PLANS UHC - ALL PLANS 999999999 121.1 194 Sedative hypnotics (non-benzodiazepines) levels 50487256_1 CDM 0301 RC 80368 HCPCS inpatient 200 130 CIGNA - ALL PLANS CIGNA - ALL PLANS 135.2 67.6 999999999 121.1 194 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50488392_1 CDM 0301 RC 80307 HCPCS inpatient 67 43.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 43.55 65 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50488392_1 CDM 0301 RC 80307 HCPCS inpatient 67 43.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.99 97 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50488392_1 CDM 0301 RC 80307 HCPCS inpatient 67 43.55 AETNA AETNA 52.93 79 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50488392_1 CDM 0301 RC 80307 HCPCS inpatient 67 43.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 52.26 78 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50488392_1 CDM 0301 RC 80307 HCPCS inpatient 67 43.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.23 69 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50488392_1 CDM 0301 RC 80307 HCPCS inpatient 67 43.55 UMR - ALL PLANS UMR - ALL PLANS 46.9 70 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50488392_1 CDM 0301 RC 80307 HCPCS inpatient 67 43.55 SIHO - ALL PLANS SIHO - ALL PLANS 60.3 90 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50488392_1 CDM 0301 RC 80307 HCPCS inpatient 67 43.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 40.57 60.55 999999999 40.57 64.99 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50488392_1 CDM 0301 RC 80307 HCPCS inpatient 67 43.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 40.57 64.99 "Testing for presence of drug, by chemistry analyzers" 50488392_1 CDM 0301 RC 80307 HCPCS inpatient 67 43.55 ANTHEM HMO ANTHEM HMO 999999999 40.57 64.99 "Testing for presence of drug, by chemistry analyzers" 50488392_1 CDM 0301 RC 80307 HCPCS inpatient 67 43.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 40.57 64.99 "Testing for presence of drug, by chemistry analyzers" 50488392_1 CDM 0301 RC 80307 HCPCS inpatient 67 43.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 40.57 64.99 "Testing for presence of drug, by chemistry analyzers" 50488392_1 CDM 0301 RC 80307 HCPCS inpatient 67 43.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 40.57 64.99 "Testing for presence of drug, by chemistry analyzers" 50488392_1 CDM 0301 RC 80307 HCPCS inpatient 67 43.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.29 67.6 999999999 40.57 64.99 percent of total billed charges DICYCLOMINE 10 MG CAPSULE 50489043_1 CDM 0250 RC 00378-1610-01 NDC inpatient 1 UN 1.84 1.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.2 65 999999999 1.11 1.78 percent of total billed charges DICYCLOMINE 10 MG CAPSULE 50489043_1 CDM 0250 RC 00378-1610-01 NDC inpatient 1 UN 1.84 1.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.78 97 999999999 1.11 1.78 percent of total billed charges DICYCLOMINE 10 MG CAPSULE 50489043_1 CDM 0250 RC 00378-1610-01 NDC inpatient 1 UN 1.84 1.2 AETNA AETNA 1.45 79 999999999 1.11 1.78 percent of total billed charges DICYCLOMINE 10 MG CAPSULE 50489043_1 CDM 0250 RC 00378-1610-01 NDC inpatient 1 UN 1.84 1.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.44 78 999999999 1.11 1.78 percent of total billed charges DICYCLOMINE 10 MG CAPSULE 50489043_1 CDM 0250 RC 00378-1610-01 NDC inpatient 1 UN 1.84 1.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.27 69 999999999 1.11 1.78 percent of total billed charges DICYCLOMINE 10 MG CAPSULE 50489043_1 CDM 0250 RC 00378-1610-01 NDC inpatient 1 UN 1.84 1.2 UMR - ALL PLANS UMR - ALL PLANS 1.29 70 999999999 1.11 1.78 percent of total billed charges DICYCLOMINE 10 MG CAPSULE 50489043_1 CDM 0250 RC 00378-1610-01 NDC inpatient 1 UN 1.84 1.2 SIHO - ALL PLANS SIHO - ALL PLANS 1.66 90 999999999 1.11 1.78 percent of total billed charges DICYCLOMINE 10 MG CAPSULE 50489043_1 CDM 0250 RC 00378-1610-01 NDC inpatient 1 UN 1.84 1.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.11 60.55 999999999 1.11 1.78 percent of total billed charges DICYCLOMINE 10 MG CAPSULE 50489043_1 CDM 0250 RC 00378-1610-01 NDC inpatient 1 UN 1.84 1.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.11 1.78 DICYCLOMINE 10 MG CAPSULE 50489043_1 CDM 0250 RC 00378-1610-01 NDC inpatient 1 UN 1.84 1.2 ANTHEM HMO ANTHEM HMO 999999999 1.11 1.78 DICYCLOMINE 10 MG CAPSULE 50489043_1 CDM 0250 RC 00378-1610-01 NDC inpatient 1 UN 1.84 1.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.11 1.78 DICYCLOMINE 10 MG CAPSULE 50489043_1 CDM 0250 RC 00378-1610-01 NDC inpatient 1 UN 1.84 1.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.11 1.78 DICYCLOMINE 10 MG CAPSULE 50489043_1 CDM 0250 RC 00378-1610-01 NDC inpatient 1 UN 1.84 1.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.11 1.78 DICYCLOMINE 10 MG CAPSULE 50489043_1 CDM 0250 RC 00378-1610-01 NDC inpatient 1 UN 1.84 1.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.24 67.6 999999999 1.11 1.78 percent of total billed charges NITROGLYCERIN 0.4 MG/HR PATCH 50489890_1 CDM 0250 RC 68382-0310-30 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges NITROGLYCERIN 0.4 MG/HR PATCH 50489890_1 CDM 0250 RC 68382-0310-30 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges NITROGLYCERIN 0.4 MG/HR PATCH 50489890_1 CDM 0250 RC 68382-0310-30 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges NITROGLYCERIN 0.4 MG/HR PATCH 50489890_1 CDM 0250 RC 68382-0310-30 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges NITROGLYCERIN 0.4 MG/HR PATCH 50489890_1 CDM 0250 RC 68382-0310-30 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges NITROGLYCERIN 0.4 MG/HR PATCH 50489890_1 CDM 0250 RC 68382-0310-30 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges NITROGLYCERIN 0.4 MG/HR PATCH 50489890_1 CDM 0250 RC 68382-0310-30 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges NITROGLYCERIN 0.4 MG/HR PATCH 50489890_1 CDM 0250 RC 68382-0310-30 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges NITROGLYCERIN 0.4 MG/HR PATCH 50489890_1 CDM 0250 RC 68382-0310-30 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 NITROGLYCERIN 0.4 MG/HR PATCH 50489890_1 CDM 0250 RC 68382-0310-30 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 NITROGLYCERIN 0.4 MG/HR PATCH 50489890_1 CDM 0250 RC 68382-0310-30 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 NITROGLYCERIN 0.4 MG/HR PATCH 50489890_1 CDM 0250 RC 68382-0310-30 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 NITROGLYCERIN 0.4 MG/HR PATCH 50489890_1 CDM 0250 RC 68382-0310-30 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 NITROGLYCERIN 0.4 MG/HR PATCH 50489890_1 CDM 0250 RC 68382-0310-30 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges NICOTINE 2 MG CHEWING GUM 50489891_1 CDM 0250 RC 00536-3029-34 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges NICOTINE 2 MG CHEWING GUM 50489891_1 CDM 0250 RC 00536-3029-34 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges NICOTINE 2 MG CHEWING GUM 50489891_1 CDM 0250 RC 00536-3029-34 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges NICOTINE 2 MG CHEWING GUM 50489891_1 CDM 0250 RC 00536-3029-34 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges NICOTINE 2 MG CHEWING GUM 50489891_1 CDM 0250 RC 00536-3029-34 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges NICOTINE 2 MG CHEWING GUM 50489891_1 CDM 0250 RC 00536-3029-34 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges NICOTINE 2 MG CHEWING GUM 50489891_1 CDM 0250 RC 00536-3029-34 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges NICOTINE 2 MG CHEWING GUM 50489891_1 CDM 0250 RC 00536-3029-34 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges NICOTINE 2 MG CHEWING GUM 50489891_1 CDM 0250 RC 00536-3029-34 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 NICOTINE 2 MG CHEWING GUM 50489891_1 CDM 0250 RC 00536-3029-34 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 NICOTINE 2 MG CHEWING GUM 50489891_1 CDM 0250 RC 00536-3029-34 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 NICOTINE 2 MG CHEWING GUM 50489891_1 CDM 0250 RC 00536-3029-34 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 NICOTINE 2 MG CHEWING GUM 50489891_1 CDM 0250 RC 00536-3029-34 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 NICOTINE 2 MG CHEWING GUM 50489891_1 CDM 0250 RC 00536-3029-34 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges HYDROCORTISONE 2.5% CREAM 50489893_1 CDM 0250 RC 62559-0431-30 NDC inpatient 1 UN 55.53 36.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 36.09 65 999999999 33.62 53.86 percent of total billed charges HYDROCORTISONE 2.5% CREAM 50489893_1 CDM 0250 RC 62559-0431-30 NDC inpatient 1 UN 55.53 36.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 53.86 97 999999999 33.62 53.86 percent of total billed charges HYDROCORTISONE 2.5% CREAM 50489893_1 CDM 0250 RC 62559-0431-30 NDC inpatient 1 UN 55.53 36.09 AETNA AETNA 43.87 79 999999999 33.62 53.86 percent of total billed charges HYDROCORTISONE 2.5% CREAM 50489893_1 CDM 0250 RC 62559-0431-30 NDC inpatient 1 UN 55.53 36.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 43.31 78 999999999 33.62 53.86 percent of total billed charges HYDROCORTISONE 2.5% CREAM 50489893_1 CDM 0250 RC 62559-0431-30 NDC inpatient 1 UN 55.53 36.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 38.32 69 999999999 33.62 53.86 percent of total billed charges HYDROCORTISONE 2.5% CREAM 50489893_1 CDM 0250 RC 62559-0431-30 NDC inpatient 1 UN 55.53 36.09 UMR - ALL PLANS UMR - ALL PLANS 38.87 70 999999999 33.62 53.86 percent of total billed charges HYDROCORTISONE 2.5% CREAM 50489893_1 CDM 0250 RC 62559-0431-30 NDC inpatient 1 UN 55.53 36.09 SIHO - ALL PLANS SIHO - ALL PLANS 49.98 90 999999999 33.62 53.86 percent of total billed charges HYDROCORTISONE 2.5% CREAM 50489893_1 CDM 0250 RC 62559-0431-30 NDC inpatient 1 UN 55.53 36.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33.62 60.55 999999999 33.62 53.86 percent of total billed charges HYDROCORTISONE 2.5% CREAM 50489893_1 CDM 0250 RC 62559-0431-30 NDC inpatient 1 UN 55.53 36.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 33.62 53.86 HYDROCORTISONE 2.5% CREAM 50489893_1 CDM 0250 RC 62559-0431-30 NDC inpatient 1 UN 55.53 36.09 ANTHEM HMO ANTHEM HMO 999999999 33.62 53.86 HYDROCORTISONE 2.5% CREAM 50489893_1 CDM 0250 RC 62559-0431-30 NDC inpatient 1 UN 55.53 36.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 33.62 53.86 HYDROCORTISONE 2.5% CREAM 50489893_1 CDM 0250 RC 62559-0431-30 NDC inpatient 1 UN 55.53 36.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 33.62 53.86 HYDROCORTISONE 2.5% CREAM 50489893_1 CDM 0250 RC 62559-0431-30 NDC inpatient 1 UN 55.53 36.09 UHC - ALL PLANS UHC - ALL PLANS 999999999 33.62 53.86 HYDROCORTISONE 2.5% CREAM 50489893_1 CDM 0250 RC 62559-0431-30 NDC inpatient 1 UN 55.53 36.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 37.54 67.6 999999999 33.62 53.86 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 50491305_1 CDM 0360 RC 20604 HCPCS inpatient 743 482.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 482.95 65 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 50491305_1 CDM 0360 RC 20604 HCPCS inpatient 743 482.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 720.71 97 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 50491305_1 CDM 0360 RC 20604 HCPCS inpatient 743 482.95 AETNA AETNA 586.97 79 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 50491305_1 CDM 0360 RC 20604 HCPCS inpatient 743 482.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 579.54 78 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 50491305_1 CDM 0360 RC 20604 HCPCS inpatient 743 482.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 512.67 69 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 50491305_1 CDM 0360 RC 20604 HCPCS inpatient 743 482.95 UMR - ALL PLANS UMR - ALL PLANS 520.1 70 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 50491305_1 CDM 0360 RC 20604 HCPCS inpatient 743 482.95 SIHO - ALL PLANS SIHO - ALL PLANS 668.7 90 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 50491305_1 CDM 0360 RC 20604 HCPCS inpatient 743 482.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 449.89 60.55 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 50491305_1 CDM 0360 RC 20604 HCPCS inpatient 743 482.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 449.89 720.71 Aspiration and/or injection of fluid from small joint using ultrasound guidance 50491305_1 CDM 0360 RC 20604 HCPCS inpatient 743 482.95 ANTHEM HMO ANTHEM HMO 999999999 449.89 720.71 Aspiration and/or injection of fluid from small joint using ultrasound guidance 50491305_1 CDM 0360 RC 20604 HCPCS inpatient 743 482.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 449.89 720.71 Aspiration and/or injection of fluid from small joint using ultrasound guidance 50491305_1 CDM 0360 RC 20604 HCPCS inpatient 743 482.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 449.89 720.71 Aspiration and/or injection of fluid from small joint using ultrasound guidance 50491305_1 CDM 0360 RC 20604 HCPCS inpatient 743 482.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 449.89 720.71 Aspiration and/or injection of fluid from small joint using ultrasound guidance 50491305_1 CDM 0360 RC 20604 HCPCS inpatient 743 482.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 502.27 67.6 999999999 449.89 720.71 percent of total billed charges Aspiration and/or injection of fluid large joint using ultrasound guidance 50491306_1 CDM 0360 RC 20611 HCPCS inpatient 631 410.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 410.15 65 999999999 382.07 612.07 percent of total billed charges Aspiration and/or injection of fluid large joint using ultrasound guidance 50491306_1 CDM 0360 RC 20611 HCPCS inpatient 631 410.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 612.07 97 999999999 382.07 612.07 percent of total billed charges Aspiration and/or injection of fluid large joint using ultrasound guidance 50491306_1 CDM 0360 RC 20611 HCPCS inpatient 631 410.15 AETNA AETNA 498.49 79 999999999 382.07 612.07 percent of total billed charges Aspiration and/or injection of fluid large joint using ultrasound guidance 50491306_1 CDM 0360 RC 20611 HCPCS inpatient 631 410.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 492.18 78 999999999 382.07 612.07 percent of total billed charges Aspiration and/or injection of fluid large joint using ultrasound guidance 50491306_1 CDM 0360 RC 20611 HCPCS inpatient 631 410.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 435.39 69 999999999 382.07 612.07 percent of total billed charges Aspiration and/or injection of fluid large joint using ultrasound guidance 50491306_1 CDM 0360 RC 20611 HCPCS inpatient 631 410.15 UMR - ALL PLANS UMR - ALL PLANS 441.7 70 999999999 382.07 612.07 percent of total billed charges Aspiration and/or injection of fluid large joint using ultrasound guidance 50491306_1 CDM 0360 RC 20611 HCPCS inpatient 631 410.15 SIHO - ALL PLANS SIHO - ALL PLANS 567.9 90 999999999 382.07 612.07 percent of total billed charges Aspiration and/or injection of fluid large joint using ultrasound guidance 50491306_1 CDM 0360 RC 20611 HCPCS inpatient 631 410.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 382.07 60.55 999999999 382.07 612.07 percent of total billed charges Aspiration and/or injection of fluid large joint using ultrasound guidance 50491306_1 CDM 0360 RC 20611 HCPCS inpatient 631 410.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 382.07 612.07 Aspiration and/or injection of fluid large joint using ultrasound guidance 50491306_1 CDM 0360 RC 20611 HCPCS inpatient 631 410.15 ANTHEM HMO ANTHEM HMO 999999999 382.07 612.07 Aspiration and/or injection of fluid large joint using ultrasound guidance 50491306_1 CDM 0360 RC 20611 HCPCS inpatient 631 410.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 382.07 612.07 Aspiration and/or injection of fluid large joint using ultrasound guidance 50491306_1 CDM 0360 RC 20611 HCPCS inpatient 631 410.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 382.07 612.07 Aspiration and/or injection of fluid large joint using ultrasound guidance 50491306_1 CDM 0360 RC 20611 HCPCS inpatient 631 410.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 382.07 612.07 Aspiration and/or injection of fluid large joint using ultrasound guidance 50491306_1 CDM 0360 RC 20611 HCPCS inpatient 631 410.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 426.56 67.6 999999999 382.07 612.07 percent of total billed charges Analysis for antibody to Brucella (bacteria) 50491440_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 50491440_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 50491440_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 50491440_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 50491440_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 50491440_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 50491440_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 50491440_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges Analysis for antibody to Brucella (bacteria) 50491440_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 50491440_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 50491440_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 50491440_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 50491440_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 Analysis for antibody to Brucella (bacteria) 50491440_1 CDM 0301 RC 86622 HCPCS inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50491441_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50491441_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50491441_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50491441_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50491441_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50491441_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50491441_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50491441_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50491441_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50491441_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50491441_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50491441_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50491441_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50491441_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 50491442_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 50491442_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 50491442_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 50491442_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 50491442_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 50491442_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 50491442_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 50491442_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges Analysis for antibody to Rickettsia (bacteria) 50491442_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 Analysis for antibody to Rickettsia (bacteria) 50491442_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 Analysis for antibody to Rickettsia (bacteria) 50491442_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 Analysis for antibody to Rickettsia (bacteria) 50491442_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 Analysis for antibody to Rickettsia (bacteria) 50491442_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 Analysis for antibody to Rickettsia (bacteria) 50491442_1 CDM 0301 RC 86757 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges Methylenedioxyamphetamines levels 50491813_1 CDM 0301 RC 80359 HCPCS inpatient 155 100.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.75 65 999999999 93.85 150.35 percent of total billed charges Methylenedioxyamphetamines levels 50491813_1 CDM 0301 RC 80359 HCPCS inpatient 155 100.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 150.35 97 999999999 93.85 150.35 percent of total billed charges Methylenedioxyamphetamines levels 50491813_1 CDM 0301 RC 80359 HCPCS inpatient 155 100.75 AETNA AETNA 122.45 79 999999999 93.85 150.35 percent of total billed charges Methylenedioxyamphetamines levels 50491813_1 CDM 0301 RC 80359 HCPCS inpatient 155 100.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.9 78 999999999 93.85 150.35 percent of total billed charges Methylenedioxyamphetamines levels 50491813_1 CDM 0301 RC 80359 HCPCS inpatient 155 100.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.95 69 999999999 93.85 150.35 percent of total billed charges Methylenedioxyamphetamines levels 50491813_1 CDM 0301 RC 80359 HCPCS inpatient 155 100.75 UMR - ALL PLANS UMR - ALL PLANS 108.5 70 999999999 93.85 150.35 percent of total billed charges Methylenedioxyamphetamines levels 50491813_1 CDM 0301 RC 80359 HCPCS inpatient 155 100.75 SIHO - ALL PLANS SIHO - ALL PLANS 139.5 90 999999999 93.85 150.35 percent of total billed charges Methylenedioxyamphetamines levels 50491813_1 CDM 0301 RC 80359 HCPCS inpatient 155 100.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.85 60.55 999999999 93.85 150.35 percent of total billed charges Methylenedioxyamphetamines levels 50491813_1 CDM 0301 RC 80359 HCPCS inpatient 155 100.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.85 150.35 Methylenedioxyamphetamines levels 50491813_1 CDM 0301 RC 80359 HCPCS inpatient 155 100.75 ANTHEM HMO ANTHEM HMO 999999999 93.85 150.35 Methylenedioxyamphetamines levels 50491813_1 CDM 0301 RC 80359 HCPCS inpatient 155 100.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.85 150.35 Methylenedioxyamphetamines levels 50491813_1 CDM 0301 RC 80359 HCPCS inpatient 155 100.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.85 150.35 Methylenedioxyamphetamines levels 50491813_1 CDM 0301 RC 80359 HCPCS inpatient 155 100.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.85 150.35 Methylenedioxyamphetamines levels 50491813_1 CDM 0301 RC 80359 HCPCS inpatient 155 100.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.78 67.6 999999999 93.85 150.35 percent of total billed charges SAW BLADE SAGITTAL DUAL CUT - 19.5mm X 41mm X 0.38mm EXTRA LONG 5400-003-254 184142 50492338_1 CDM 0272 RC inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges SAW BLADE SAGITTAL DUAL CUT - 19.5mm X 41mm X 0.38mm EXTRA LONG 5400-003-254 184142 50492338_1 CDM 0272 RC inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges SAW BLADE SAGITTAL DUAL CUT - 19.5mm X 41mm X 0.38mm EXTRA LONG 5400-003-254 184142 50492338_1 CDM 0272 RC inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges SAW BLADE SAGITTAL DUAL CUT - 19.5mm X 41mm X 0.38mm EXTRA LONG 5400-003-254 184142 50492338_1 CDM 0272 RC inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges SAW BLADE SAGITTAL DUAL CUT - 19.5mm X 41mm X 0.38mm EXTRA LONG 5400-003-254 184142 50492338_1 CDM 0272 RC inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges SAW BLADE SAGITTAL DUAL CUT - 19.5mm X 41mm X 0.38mm EXTRA LONG 5400-003-254 184142 50492338_1 CDM 0272 RC inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges SAW BLADE SAGITTAL DUAL CUT - 19.5mm X 41mm X 0.38mm EXTRA LONG 5400-003-254 184142 50492338_1 CDM 0272 RC inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges SAW BLADE SAGITTAL DUAL CUT - 19.5mm X 41mm X 0.38mm EXTRA LONG 5400-003-254 184142 50492338_1 CDM 0272 RC inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges SAW BLADE SAGITTAL DUAL CUT - 19.5mm X 41mm X 0.38mm EXTRA LONG 5400-003-254 184142 50492338_1 CDM 0272 RC inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 SAW BLADE SAGITTAL DUAL CUT - 19.5mm X 41mm X 0.38mm EXTRA LONG 5400-003-254 184142 50492338_1 CDM 0272 RC inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 SAW BLADE SAGITTAL DUAL CUT - 19.5mm X 41mm X 0.38mm EXTRA LONG 5400-003-254 184142 50492338_1 CDM 0272 RC inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 SAW BLADE SAGITTAL DUAL CUT - 19.5mm X 41mm X 0.38mm EXTRA LONG 5400-003-254 184142 50492338_1 CDM 0272 RC inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 SAW BLADE SAGITTAL DUAL CUT - 19.5mm X 41mm X 0.38mm EXTRA LONG 5400-003-254 184142 50492338_1 CDM 0272 RC inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 SAW BLADE SAGITTAL DUAL CUT - 19.5mm X 41mm X 0.38mm EXTRA LONG 5400-003-254 184142 50492338_1 CDM 0272 RC inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50492356_1 CDM 0302 RC 87635 HCPCS inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50492356_1 CDM 0302 RC 87635 HCPCS inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50492356_1 CDM 0302 RC 87635 HCPCS inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50492356_1 CDM 0302 RC 87635 HCPCS inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50492356_1 CDM 0302 RC 87635 HCPCS inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50492356_1 CDM 0302 RC 87635 HCPCS inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50492356_1 CDM 0302 RC 87635 HCPCS inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50492356_1 CDM 0302 RC 87635 HCPCS inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50492356_1 CDM 0302 RC 87635 HCPCS inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50492356_1 CDM 0302 RC 87635 HCPCS inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50492356_1 CDM 0302 RC 87635 HCPCS inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50492356_1 CDM 0302 RC 87635 HCPCS inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50492356_1 CDM 0302 RC 87635 HCPCS inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50492356_1 CDM 0302 RC 87635 HCPCS inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50492357_1 CDM 0301 RC 86780 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50492357_1 CDM 0301 RC 86780 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50492357_1 CDM 0301 RC 86780 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50492357_1 CDM 0301 RC 86780 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50492357_1 CDM 0301 RC 86780 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50492357_1 CDM 0301 RC 86780 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50492357_1 CDM 0301 RC 86780 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50492357_1 CDM 0301 RC 86780 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50492357_1 CDM 0301 RC 86780 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 "Analysis for antibody, Treponema pallidum" 50492357_1 CDM 0301 RC 86780 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 "Analysis for antibody, Treponema pallidum" 50492357_1 CDM 0301 RC 86780 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 "Analysis for antibody, Treponema pallidum" 50492357_1 CDM 0301 RC 86780 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 "Analysis for antibody, Treponema pallidum" 50492357_1 CDM 0301 RC 86780 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 "Analysis for antibody, Treponema pallidum" 50492357_1 CDM 0301 RC 86780 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges Analysis for antibody to HIV -1 virus 50492358_1 CDM 0301 RC 86701 HCPCS inpatient 183 118.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.95 65 999999999 110.81 177.51 percent of total billed charges Analysis for antibody to HIV -1 virus 50492358_1 CDM 0301 RC 86701 HCPCS inpatient 183 118.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.51 97 999999999 110.81 177.51 percent of total billed charges Analysis for antibody to HIV -1 virus 50492358_1 CDM 0301 RC 86701 HCPCS inpatient 183 118.95 AETNA AETNA 144.57 79 999999999 110.81 177.51 percent of total billed charges Analysis for antibody to HIV -1 virus 50492358_1 CDM 0301 RC 86701 HCPCS inpatient 183 118.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 142.74 78 999999999 110.81 177.51 percent of total billed charges Analysis for antibody to HIV -1 virus 50492358_1 CDM 0301 RC 86701 HCPCS inpatient 183 118.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.27 69 999999999 110.81 177.51 percent of total billed charges Analysis for antibody to HIV -1 virus 50492358_1 CDM 0301 RC 86701 HCPCS inpatient 183 118.95 UMR - ALL PLANS UMR - ALL PLANS 128.1 70 999999999 110.81 177.51 percent of total billed charges Analysis for antibody to HIV -1 virus 50492358_1 CDM 0301 RC 86701 HCPCS inpatient 183 118.95 SIHO - ALL PLANS SIHO - ALL PLANS 164.7 90 999999999 110.81 177.51 percent of total billed charges Analysis for antibody to HIV -1 virus 50492358_1 CDM 0301 RC 86701 HCPCS inpatient 183 118.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.81 60.55 999999999 110.81 177.51 percent of total billed charges Analysis for antibody to HIV -1 virus 50492358_1 CDM 0301 RC 86701 HCPCS inpatient 183 118.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.81 177.51 Analysis for antibody to HIV -1 virus 50492358_1 CDM 0301 RC 86701 HCPCS inpatient 183 118.95 ANTHEM HMO ANTHEM HMO 999999999 110.81 177.51 Analysis for antibody to HIV -1 virus 50492358_1 CDM 0301 RC 86701 HCPCS inpatient 183 118.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.81 177.51 Analysis for antibody to HIV -1 virus 50492358_1 CDM 0301 RC 86701 HCPCS inpatient 183 118.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.81 177.51 Analysis for antibody to HIV -1 virus 50492358_1 CDM 0301 RC 86701 HCPCS inpatient 183 118.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.81 177.51 Analysis for antibody to HIV -1 virus 50492358_1 CDM 0301 RC 86701 HCPCS inpatient 183 118.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.71 67.6 999999999 110.81 177.51 percent of total billed charges MELATONIN 5 MG TABLET 50494478_1 CDM 0250 RC 50268-0533-15 NDC inpatient 1 UN 1.61 1.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.05 65 999999999 0.97 1.56 percent of total billed charges MELATONIN 5 MG TABLET 50494478_1 CDM 0250 RC 50268-0533-15 NDC inpatient 1 UN 1.61 1.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.56 97 999999999 0.97 1.56 percent of total billed charges MELATONIN 5 MG TABLET 50494478_1 CDM 0250 RC 50268-0533-15 NDC inpatient 1 UN 1.61 1.05 AETNA AETNA 1.27 79 999999999 0.97 1.56 percent of total billed charges MELATONIN 5 MG TABLET 50494478_1 CDM 0250 RC 50268-0533-15 NDC inpatient 1 UN 1.61 1.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.26 78 999999999 0.97 1.56 percent of total billed charges MELATONIN 5 MG TABLET 50494478_1 CDM 0250 RC 50268-0533-15 NDC inpatient 1 UN 1.61 1.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.11 69 999999999 0.97 1.56 percent of total billed charges MELATONIN 5 MG TABLET 50494478_1 CDM 0250 RC 50268-0533-15 NDC inpatient 1 UN 1.61 1.05 UMR - ALL PLANS UMR - ALL PLANS 1.13 70 999999999 0.97 1.56 percent of total billed charges MELATONIN 5 MG TABLET 50494478_1 CDM 0250 RC 50268-0533-15 NDC inpatient 1 UN 1.61 1.05 SIHO - ALL PLANS SIHO - ALL PLANS 1.45 90 999999999 0.97 1.56 percent of total billed charges MELATONIN 5 MG TABLET 50494478_1 CDM 0250 RC 50268-0533-15 NDC inpatient 1 UN 1.61 1.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.97 60.55 999999999 0.97 1.56 percent of total billed charges MELATONIN 5 MG TABLET 50494478_1 CDM 0250 RC 50268-0533-15 NDC inpatient 1 UN 1.61 1.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.97 1.56 MELATONIN 5 MG TABLET 50494478_1 CDM 0250 RC 50268-0533-15 NDC inpatient 1 UN 1.61 1.05 ANTHEM HMO ANTHEM HMO 999999999 0.97 1.56 MELATONIN 5 MG TABLET 50494478_1 CDM 0250 RC 50268-0533-15 NDC inpatient 1 UN 1.61 1.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.97 1.56 MELATONIN 5 MG TABLET 50494478_1 CDM 0250 RC 50268-0533-15 NDC inpatient 1 UN 1.61 1.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.97 1.56 MELATONIN 5 MG TABLET 50494478_1 CDM 0250 RC 50268-0533-15 NDC inpatient 1 UN 1.61 1.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.97 1.56 MELATONIN 5 MG TABLET 50494478_1 CDM 0250 RC 50268-0533-15 NDC inpatient 1 UN 1.61 1.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.09 67.6 999999999 0.97 1.56 percent of total billed charges Incision to lengthen toe tendon 50494644_1 CDM 0510 RC 28232 HCPCS inpatient 2986 1940.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1940.9 65 999999999 1808.02 2896.42 percent of total billed charges Incision to lengthen toe tendon 50494644_1 CDM 0510 RC 28232 HCPCS inpatient 2986 1940.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2896.42 97 999999999 1808.02 2896.42 percent of total billed charges Incision to lengthen toe tendon 50494644_1 CDM 0510 RC 28232 HCPCS inpatient 2986 1940.9 AETNA AETNA 2358.94 79 999999999 1808.02 2896.42 percent of total billed charges Incision to lengthen toe tendon 50494644_1 CDM 0510 RC 28232 HCPCS inpatient 2986 1940.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 2329.08 78 999999999 1808.02 2896.42 percent of total billed charges Incision to lengthen toe tendon 50494644_1 CDM 0510 RC 28232 HCPCS inpatient 2986 1940.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 2060.34 69 999999999 1808.02 2896.42 percent of total billed charges Incision to lengthen toe tendon 50494644_1 CDM 0510 RC 28232 HCPCS inpatient 2986 1940.9 UMR - ALL PLANS UMR - ALL PLANS 2090.2 70 999999999 1808.02 2896.42 percent of total billed charges Incision to lengthen toe tendon 50494644_1 CDM 0510 RC 28232 HCPCS inpatient 2986 1940.9 SIHO - ALL PLANS SIHO - ALL PLANS 2687.4 90 999999999 1808.02 2896.42 percent of total billed charges Incision to lengthen toe tendon 50494644_1 CDM 0510 RC 28232 HCPCS inpatient 2986 1940.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1808.02 60.55 999999999 1808.02 2896.42 percent of total billed charges Incision to lengthen toe tendon 50494644_1 CDM 0510 RC 28232 HCPCS inpatient 2986 1940.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1808.02 2896.42 Incision to lengthen toe tendon 50494644_1 CDM 0510 RC 28232 HCPCS inpatient 2986 1940.9 ANTHEM HMO ANTHEM HMO 999999999 1808.02 2896.42 Incision to lengthen toe tendon 50494644_1 CDM 0510 RC 28232 HCPCS inpatient 2986 1940.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1808.02 2896.42 Incision to lengthen toe tendon 50494644_1 CDM 0510 RC 28232 HCPCS inpatient 2986 1940.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1808.02 2896.42 Incision to lengthen toe tendon 50494644_1 CDM 0510 RC 28232 HCPCS inpatient 2986 1940.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1808.02 2896.42 Incision to lengthen toe tendon 50494644_1 CDM 0510 RC 28232 HCPCS inpatient 2986 1940.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 2018.54 67.6 999999999 1808.02 2896.42 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 50495612_1 CDM 0360 RC 20606 HCPCS inpatient 729 473.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 473.85 65 999999999 441.41 707.13 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 50495612_1 CDM 0360 RC 20606 HCPCS inpatient 729 473.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 707.13 97 999999999 441.41 707.13 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 50495612_1 CDM 0360 RC 20606 HCPCS inpatient 729 473.85 AETNA AETNA 575.91 79 999999999 441.41 707.13 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 50495612_1 CDM 0360 RC 20606 HCPCS inpatient 729 473.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 568.62 78 999999999 441.41 707.13 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 50495612_1 CDM 0360 RC 20606 HCPCS inpatient 729 473.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 503.01 69 999999999 441.41 707.13 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 50495612_1 CDM 0360 RC 20606 HCPCS inpatient 729 473.85 UMR - ALL PLANS UMR - ALL PLANS 510.3 70 999999999 441.41 707.13 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 50495612_1 CDM 0360 RC 20606 HCPCS inpatient 729 473.85 SIHO - ALL PLANS SIHO - ALL PLANS 656.1 90 999999999 441.41 707.13 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 50495612_1 CDM 0360 RC 20606 HCPCS inpatient 729 473.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 441.41 60.55 999999999 441.41 707.13 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 50495612_1 CDM 0360 RC 20606 HCPCS inpatient 729 473.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 441.41 707.13 Aspiration and/or injection of fluid from medium joint using ultrasound guidance 50495612_1 CDM 0360 RC 20606 HCPCS inpatient 729 473.85 ANTHEM HMO ANTHEM HMO 999999999 441.41 707.13 Aspiration and/or injection of fluid from medium joint using ultrasound guidance 50495612_1 CDM 0360 RC 20606 HCPCS inpatient 729 473.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 441.41 707.13 Aspiration and/or injection of fluid from medium joint using ultrasound guidance 50495612_1 CDM 0360 RC 20606 HCPCS inpatient 729 473.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 441.41 707.13 Aspiration and/or injection of fluid from medium joint using ultrasound guidance 50495612_1 CDM 0360 RC 20606 HCPCS inpatient 729 473.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 441.41 707.13 Aspiration and/or injection of fluid from medium joint using ultrasound guidance 50495612_1 CDM 0360 RC 20606 HCPCS inpatient 729 473.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 492.8 67.6 999999999 441.41 707.13 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50495866_1 CDM 0250 RC 25021-0671-66 NDC J2795 HCPCS inpatient 200 UN 130.43 84.78 SELF PAY DISCOUNT SELF PAY DISCOUNT 84.78 65 999999999 78.98 126.52 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50495866_1 CDM 0250 RC 25021-0671-66 NDC J2795 HCPCS inpatient 200 UN 130.43 84.78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 126.52 97 999999999 78.98 126.52 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50495866_1 CDM 0250 RC 25021-0671-66 NDC J2795 HCPCS inpatient 200 UN 130.43 84.78 AETNA AETNA 103.04 79 999999999 78.98 126.52 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50495866_1 CDM 0250 RC 25021-0671-66 NDC J2795 HCPCS inpatient 200 UN 130.43 84.78 HUMANA - ALL PLANS HUMANA - ALL PLANS 101.74 78 999999999 78.98 126.52 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50495866_1 CDM 0250 RC 25021-0671-66 NDC J2795 HCPCS inpatient 200 UN 130.43 84.78 ENCORE - ALL PLANS ENCORE - ALL PLANS 90 69 999999999 78.98 126.52 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50495866_1 CDM 0250 RC 25021-0671-66 NDC J2795 HCPCS inpatient 200 UN 130.43 84.78 UMR - ALL PLANS UMR - ALL PLANS 91.3 70 999999999 78.98 126.52 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50495866_1 CDM 0250 RC 25021-0671-66 NDC J2795 HCPCS inpatient 200 UN 130.43 84.78 SIHO - ALL PLANS SIHO - ALL PLANS 117.39 90 999999999 78.98 126.52 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50495866_1 CDM 0250 RC 25021-0671-66 NDC J2795 HCPCS inpatient 200 UN 130.43 84.78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.98 60.55 999999999 78.98 126.52 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50495866_1 CDM 0250 RC 25021-0671-66 NDC J2795 HCPCS inpatient 200 UN 130.43 84.78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.98 126.52 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50495866_1 CDM 0250 RC 25021-0671-66 NDC J2795 HCPCS inpatient 200 UN 130.43 84.78 ANTHEM HMO ANTHEM HMO 999999999 78.98 126.52 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50495866_1 CDM 0250 RC 25021-0671-66 NDC J2795 HCPCS inpatient 200 UN 130.43 84.78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.98 126.52 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50495866_1 CDM 0250 RC 25021-0671-66 NDC J2795 HCPCS inpatient 200 UN 130.43 84.78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.98 126.52 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50495866_1 CDM 0250 RC 25021-0671-66 NDC J2795 HCPCS inpatient 200 UN 130.43 84.78 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.98 126.52 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50495866_1 CDM 0250 RC 25021-0671-66 NDC J2795 HCPCS inpatient 200 UN 130.43 84.78 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.17 67.6 999999999 78.98 126.52 percent of total billed charges SODIUM CHLORIDE 0.45% SOLN 50511291_1 CDM 0250 RC 63323-0626-10 NDC inpatient 1 UN 60.45 39.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.29 65 999999999 36.6 58.64 percent of total billed charges SODIUM CHLORIDE 0.45% SOLN 50511291_1 CDM 0250 RC 63323-0626-10 NDC inpatient 1 UN 60.45 39.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.64 97 999999999 36.6 58.64 percent of total billed charges SODIUM CHLORIDE 0.45% SOLN 50511291_1 CDM 0250 RC 63323-0626-10 NDC inpatient 1 UN 60.45 39.29 AETNA AETNA 47.76 79 999999999 36.6 58.64 percent of total billed charges SODIUM CHLORIDE 0.45% SOLN 50511291_1 CDM 0250 RC 63323-0626-10 NDC inpatient 1 UN 60.45 39.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.15 78 999999999 36.6 58.64 percent of total billed charges SODIUM CHLORIDE 0.45% SOLN 50511291_1 CDM 0250 RC 63323-0626-10 NDC inpatient 1 UN 60.45 39.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.71 69 999999999 36.6 58.64 percent of total billed charges SODIUM CHLORIDE 0.45% SOLN 50511291_1 CDM 0250 RC 63323-0626-10 NDC inpatient 1 UN 60.45 39.29 UMR - ALL PLANS UMR - ALL PLANS 42.32 70 999999999 36.6 58.64 percent of total billed charges SODIUM CHLORIDE 0.45% SOLN 50511291_1 CDM 0250 RC 63323-0626-10 NDC inpatient 1 UN 60.45 39.29 SIHO - ALL PLANS SIHO - ALL PLANS 54.41 90 999999999 36.6 58.64 percent of total billed charges SODIUM CHLORIDE 0.45% SOLN 50511291_1 CDM 0250 RC 63323-0626-10 NDC inpatient 1 UN 60.45 39.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.6 60.55 999999999 36.6 58.64 percent of total billed charges SODIUM CHLORIDE 0.45% SOLN 50511291_1 CDM 0250 RC 63323-0626-10 NDC inpatient 1 UN 60.45 39.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.6 58.64 SODIUM CHLORIDE 0.45% SOLN 50511291_1 CDM 0250 RC 63323-0626-10 NDC inpatient 1 UN 60.45 39.29 ANTHEM HMO ANTHEM HMO 999999999 36.6 58.64 SODIUM CHLORIDE 0.45% SOLN 50511291_1 CDM 0250 RC 63323-0626-10 NDC inpatient 1 UN 60.45 39.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.6 58.64 SODIUM CHLORIDE 0.45% SOLN 50511291_1 CDM 0250 RC 63323-0626-10 NDC inpatient 1 UN 60.45 39.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.6 58.64 SODIUM CHLORIDE 0.45% SOLN 50511291_1 CDM 0250 RC 63323-0626-10 NDC inpatient 1 UN 60.45 39.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.6 58.64 SODIUM CHLORIDE 0.45% SOLN 50511291_1 CDM 0250 RC 63323-0626-10 NDC inpatient 1 UN 60.45 39.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.86 67.6 999999999 36.6 58.64 percent of total billed charges FLUTICASONE PROP 50 MCG SPRAY 50511316_1 CDM 0250 RC 60432-0264-15 NDC inpatient 1 UN 15.39 10 SELF PAY DISCOUNT SELF PAY DISCOUNT 10 65 999999999 9.32 14.93 percent of total billed charges FLUTICASONE PROP 50 MCG SPRAY 50511316_1 CDM 0250 RC 60432-0264-15 NDC inpatient 1 UN 15.39 10 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14.93 97 999999999 9.32 14.93 percent of total billed charges FLUTICASONE PROP 50 MCG SPRAY 50511316_1 CDM 0250 RC 60432-0264-15 NDC inpatient 1 UN 15.39 10 AETNA AETNA 12.16 79 999999999 9.32 14.93 percent of total billed charges FLUTICASONE PROP 50 MCG SPRAY 50511316_1 CDM 0250 RC 60432-0264-15 NDC inpatient 1 UN 15.39 10 HUMANA - ALL PLANS HUMANA - ALL PLANS 12 78 999999999 9.32 14.93 percent of total billed charges FLUTICASONE PROP 50 MCG SPRAY 50511316_1 CDM 0250 RC 60432-0264-15 NDC inpatient 1 UN 15.39 10 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.62 69 999999999 9.32 14.93 percent of total billed charges FLUTICASONE PROP 50 MCG SPRAY 50511316_1 CDM 0250 RC 60432-0264-15 NDC inpatient 1 UN 15.39 10 UMR - ALL PLANS UMR - ALL PLANS 10.77 70 999999999 9.32 14.93 percent of total billed charges FLUTICASONE PROP 50 MCG SPRAY 50511316_1 CDM 0250 RC 60432-0264-15 NDC inpatient 1 UN 15.39 10 SIHO - ALL PLANS SIHO - ALL PLANS 13.85 90 999999999 9.32 14.93 percent of total billed charges FLUTICASONE PROP 50 MCG SPRAY 50511316_1 CDM 0250 RC 60432-0264-15 NDC inpatient 1 UN 15.39 10 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.32 60.55 999999999 9.32 14.93 percent of total billed charges FLUTICASONE PROP 50 MCG SPRAY 50511316_1 CDM 0250 RC 60432-0264-15 NDC inpatient 1 UN 15.39 10 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.32 14.93 FLUTICASONE PROP 50 MCG SPRAY 50511316_1 CDM 0250 RC 60432-0264-15 NDC inpatient 1 UN 15.39 10 ANTHEM HMO ANTHEM HMO 999999999 9.32 14.93 FLUTICASONE PROP 50 MCG SPRAY 50511316_1 CDM 0250 RC 60432-0264-15 NDC inpatient 1 UN 15.39 10 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.32 14.93 FLUTICASONE PROP 50 MCG SPRAY 50511316_1 CDM 0250 RC 60432-0264-15 NDC inpatient 1 UN 15.39 10 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.32 14.93 FLUTICASONE PROP 50 MCG SPRAY 50511316_1 CDM 0250 RC 60432-0264-15 NDC inpatient 1 UN 15.39 10 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.32 14.93 FLUTICASONE PROP 50 MCG SPRAY 50511316_1 CDM 0250 RC 60432-0264-15 NDC inpatient 1 UN 15.39 10 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.4 67.6 999999999 9.32 14.93 percent of total billed charges CALCIUM CHLORIDE 1 GM/10ML SYR 50511317_1 CDM 0250 RC 00409-1631-10 NDC inpatient 1 UN 45.71 29.71 SELF PAY DISCOUNT SELF PAY DISCOUNT 29.71 65 999999999 27.68 44.34 percent of total billed charges CALCIUM CHLORIDE 1 GM/10ML SYR 50511317_1 CDM 0250 RC 00409-1631-10 NDC inpatient 1 UN 45.71 29.71 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 44.34 97 999999999 27.68 44.34 percent of total billed charges CALCIUM CHLORIDE 1 GM/10ML SYR 50511317_1 CDM 0250 RC 00409-1631-10 NDC inpatient 1 UN 45.71 29.71 AETNA AETNA 36.11 79 999999999 27.68 44.34 percent of total billed charges CALCIUM CHLORIDE 1 GM/10ML SYR 50511317_1 CDM 0250 RC 00409-1631-10 NDC inpatient 1 UN 45.71 29.71 HUMANA - ALL PLANS HUMANA - ALL PLANS 35.65 78 999999999 27.68 44.34 percent of total billed charges CALCIUM CHLORIDE 1 GM/10ML SYR 50511317_1 CDM 0250 RC 00409-1631-10 NDC inpatient 1 UN 45.71 29.71 ENCORE - ALL PLANS ENCORE - ALL PLANS 31.54 69 999999999 27.68 44.34 percent of total billed charges CALCIUM CHLORIDE 1 GM/10ML SYR 50511317_1 CDM 0250 RC 00409-1631-10 NDC inpatient 1 UN 45.71 29.71 UMR - ALL PLANS UMR - ALL PLANS 32 70 999999999 27.68 44.34 percent of total billed charges CALCIUM CHLORIDE 1 GM/10ML SYR 50511317_1 CDM 0250 RC 00409-1631-10 NDC inpatient 1 UN 45.71 29.71 SIHO - ALL PLANS SIHO - ALL PLANS 41.14 90 999999999 27.68 44.34 percent of total billed charges CALCIUM CHLORIDE 1 GM/10ML SYR 50511317_1 CDM 0250 RC 00409-1631-10 NDC inpatient 1 UN 45.71 29.71 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27.68 60.55 999999999 27.68 44.34 percent of total billed charges CALCIUM CHLORIDE 1 GM/10ML SYR 50511317_1 CDM 0250 RC 00409-1631-10 NDC inpatient 1 UN 45.71 29.71 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 27.68 44.34 CALCIUM CHLORIDE 1 GM/10ML SYR 50511317_1 CDM 0250 RC 00409-1631-10 NDC inpatient 1 UN 45.71 29.71 ANTHEM HMO ANTHEM HMO 999999999 27.68 44.34 CALCIUM CHLORIDE 1 GM/10ML SYR 50511317_1 CDM 0250 RC 00409-1631-10 NDC inpatient 1 UN 45.71 29.71 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 27.68 44.34 CALCIUM CHLORIDE 1 GM/10ML SYR 50511317_1 CDM 0250 RC 00409-1631-10 NDC inpatient 1 UN 45.71 29.71 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 27.68 44.34 CALCIUM CHLORIDE 1 GM/10ML SYR 50511317_1 CDM 0250 RC 00409-1631-10 NDC inpatient 1 UN 45.71 29.71 UHC - ALL PLANS UHC - ALL PLANS 999999999 27.68 44.34 CALCIUM CHLORIDE 1 GM/10ML SYR 50511317_1 CDM 0250 RC 00409-1631-10 NDC inpatient 1 UN 45.71 29.71 CIGNA - ALL PLANS CIGNA - ALL PLANS 30.9 67.6 999999999 27.68 44.34 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50511321_1 CDM 0250 RC 64679-0056-01 NDC inpatient 1 UN 35.58 23.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 23.13 65 999999999 21.54 34.51 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50511321_1 CDM 0250 RC 64679-0056-01 NDC inpatient 1 UN 35.58 23.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34.51 97 999999999 21.54 34.51 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50511321_1 CDM 0250 RC 64679-0056-01 NDC inpatient 1 UN 35.58 23.13 AETNA AETNA 28.11 79 999999999 21.54 34.51 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50511321_1 CDM 0250 RC 64679-0056-01 NDC inpatient 1 UN 35.58 23.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 27.75 78 999999999 21.54 34.51 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50511321_1 CDM 0250 RC 64679-0056-01 NDC inpatient 1 UN 35.58 23.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 24.55 69 999999999 21.54 34.51 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50511321_1 CDM 0250 RC 64679-0056-01 NDC inpatient 1 UN 35.58 23.13 UMR - ALL PLANS UMR - ALL PLANS 24.91 70 999999999 21.54 34.51 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50511321_1 CDM 0250 RC 64679-0056-01 NDC inpatient 1 UN 35.58 23.13 SIHO - ALL PLANS SIHO - ALL PLANS 32.02 90 999999999 21.54 34.51 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50511321_1 CDM 0250 RC 64679-0056-01 NDC inpatient 1 UN 35.58 23.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21.54 60.55 999999999 21.54 34.51 percent of total billed charges PIPERACIL-TAZOBACT 3.375 GM VL 50511321_1 CDM 0250 RC 64679-0056-01 NDC inpatient 1 UN 35.58 23.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 21.54 34.51 PIPERACIL-TAZOBACT 3.375 GM VL 50511321_1 CDM 0250 RC 64679-0056-01 NDC inpatient 1 UN 35.58 23.13 ANTHEM HMO ANTHEM HMO 999999999 21.54 34.51 PIPERACIL-TAZOBACT 3.375 GM VL 50511321_1 CDM 0250 RC 64679-0056-01 NDC inpatient 1 UN 35.58 23.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 21.54 34.51 PIPERACIL-TAZOBACT 3.375 GM VL 50511321_1 CDM 0250 RC 64679-0056-01 NDC inpatient 1 UN 35.58 23.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 21.54 34.51 PIPERACIL-TAZOBACT 3.375 GM VL 50511321_1 CDM 0250 RC 64679-0056-01 NDC inpatient 1 UN 35.58 23.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 21.54 34.51 PIPERACIL-TAZOBACT 3.375 GM VL 50511321_1 CDM 0250 RC 64679-0056-01 NDC inpatient 1 UN 35.58 23.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 24.05 67.6 999999999 21.54 34.51 percent of total billed charges "Smoking and tobacco use intensive counseling, 4-10 minutes" 50511972_1 CDM 0510 RC 99406 HCPCS inpatient 84 54.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 54.6 65 999999999 50.86 81.48 percent of total billed charges "Smoking and tobacco use intensive counseling, 4-10 minutes" 50511972_1 CDM 0510 RC 99406 HCPCS inpatient 84 54.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 81.48 97 999999999 50.86 81.48 percent of total billed charges "Smoking and tobacco use intensive counseling, 4-10 minutes" 50511972_1 CDM 0510 RC 99406 HCPCS inpatient 84 54.6 AETNA AETNA 66.36 79 999999999 50.86 81.48 percent of total billed charges "Smoking and tobacco use intensive counseling, 4-10 minutes" 50511972_1 CDM 0510 RC 99406 HCPCS inpatient 84 54.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 65.52 78 999999999 50.86 81.48 percent of total billed charges "Smoking and tobacco use intensive counseling, 4-10 minutes" 50511972_1 CDM 0510 RC 99406 HCPCS inpatient 84 54.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.96 69 999999999 50.86 81.48 percent of total billed charges "Smoking and tobacco use intensive counseling, 4-10 minutes" 50511972_1 CDM 0510 RC 99406 HCPCS inpatient 84 54.6 UMR - ALL PLANS UMR - ALL PLANS 58.8 70 999999999 50.86 81.48 percent of total billed charges "Smoking and tobacco use intensive counseling, 4-10 minutes" 50511972_1 CDM 0510 RC 99406 HCPCS inpatient 84 54.6 SIHO - ALL PLANS SIHO - ALL PLANS 75.6 90 999999999 50.86 81.48 percent of total billed charges "Smoking and tobacco use intensive counseling, 4-10 minutes" 50511972_1 CDM 0510 RC 99406 HCPCS inpatient 84 54.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.86 60.55 999999999 50.86 81.48 percent of total billed charges "Smoking and tobacco use intensive counseling, 4-10 minutes" 50511972_1 CDM 0510 RC 99406 HCPCS inpatient 84 54.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.86 81.48 "Smoking and tobacco use intensive counseling, 4-10 minutes" 50511972_1 CDM 0510 RC 99406 HCPCS inpatient 84 54.6 ANTHEM HMO ANTHEM HMO 999999999 50.86 81.48 "Smoking and tobacco use intensive counseling, 4-10 minutes" 50511972_1 CDM 0510 RC 99406 HCPCS inpatient 84 54.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.86 81.48 "Smoking and tobacco use intensive counseling, 4-10 minutes" 50511972_1 CDM 0510 RC 99406 HCPCS inpatient 84 54.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.86 81.48 "Smoking and tobacco use intensive counseling, 4-10 minutes" 50511972_1 CDM 0510 RC 99406 HCPCS inpatient 84 54.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.86 81.48 "Smoking and tobacco use intensive counseling, 4-10 minutes" 50511972_1 CDM 0510 RC 99406 HCPCS inpatient 84 54.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.78 67.6 999999999 50.86 81.48 percent of total billed charges "Smoking and tobacco use intensive counseling, more than 10 minutes" 50511973_1 CDM 0510 RC 99407 HCPCS inpatient 84 54.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 54.6 65 999999999 50.86 81.48 percent of total billed charges "Smoking and tobacco use intensive counseling, more than 10 minutes" 50511973_1 CDM 0510 RC 99407 HCPCS inpatient 84 54.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 81.48 97 999999999 50.86 81.48 percent of total billed charges "Smoking and tobacco use intensive counseling, more than 10 minutes" 50511973_1 CDM 0510 RC 99407 HCPCS inpatient 84 54.6 AETNA AETNA 66.36 79 999999999 50.86 81.48 percent of total billed charges "Smoking and tobacco use intensive counseling, more than 10 minutes" 50511973_1 CDM 0510 RC 99407 HCPCS inpatient 84 54.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 65.52 78 999999999 50.86 81.48 percent of total billed charges "Smoking and tobacco use intensive counseling, more than 10 minutes" 50511973_1 CDM 0510 RC 99407 HCPCS inpatient 84 54.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.96 69 999999999 50.86 81.48 percent of total billed charges "Smoking and tobacco use intensive counseling, more than 10 minutes" 50511973_1 CDM 0510 RC 99407 HCPCS inpatient 84 54.6 UMR - ALL PLANS UMR - ALL PLANS 58.8 70 999999999 50.86 81.48 percent of total billed charges "Smoking and tobacco use intensive counseling, more than 10 minutes" 50511973_1 CDM 0510 RC 99407 HCPCS inpatient 84 54.6 SIHO - ALL PLANS SIHO - ALL PLANS 75.6 90 999999999 50.86 81.48 percent of total billed charges "Smoking and tobacco use intensive counseling, more than 10 minutes" 50511973_1 CDM 0510 RC 99407 HCPCS inpatient 84 54.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.86 60.55 999999999 50.86 81.48 percent of total billed charges "Smoking and tobacco use intensive counseling, more than 10 minutes" 50511973_1 CDM 0510 RC 99407 HCPCS inpatient 84 54.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.86 81.48 "Smoking and tobacco use intensive counseling, more than 10 minutes" 50511973_1 CDM 0510 RC 99407 HCPCS inpatient 84 54.6 ANTHEM HMO ANTHEM HMO 999999999 50.86 81.48 "Smoking and tobacco use intensive counseling, more than 10 minutes" 50511973_1 CDM 0510 RC 99407 HCPCS inpatient 84 54.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.86 81.48 "Smoking and tobacco use intensive counseling, more than 10 minutes" 50511973_1 CDM 0510 RC 99407 HCPCS inpatient 84 54.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.86 81.48 "Smoking and tobacco use intensive counseling, more than 10 minutes" 50511973_1 CDM 0510 RC 99407 HCPCS inpatient 84 54.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.86 81.48 "Smoking and tobacco use intensive counseling, more than 10 minutes" 50511973_1 CDM 0510 RC 99407 HCPCS inpatient 84 54.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.78 67.6 999999999 50.86 81.48 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 50512101_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.75 65 999999999 57.52 92.15 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 50512101_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 92.15 97 999999999 57.52 92.15 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 50512101_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 AETNA AETNA 75.05 79 999999999 57.52 92.15 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 50512101_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.1 78 999999999 57.52 92.15 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 50512101_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 65.55 69 999999999 57.52 92.15 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 50512101_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 UMR - ALL PLANS UMR - ALL PLANS 66.5 70 999999999 57.52 92.15 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 50512101_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 SIHO - ALL PLANS SIHO - ALL PLANS 85.5 90 999999999 57.52 92.15 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 50512101_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 57.52 60.55 999999999 57.52 92.15 percent of total billed charges Phospholipid antibody (autoimmune antibody) measurement 50512101_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 57.52 92.15 Phospholipid antibody (autoimmune antibody) measurement 50512101_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 ANTHEM HMO ANTHEM HMO 999999999 57.52 92.15 Phospholipid antibody (autoimmune antibody) measurement 50512101_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 57.52 92.15 Phospholipid antibody (autoimmune antibody) measurement 50512101_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 57.52 92.15 Phospholipid antibody (autoimmune antibody) measurement 50512101_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 57.52 92.15 Phospholipid antibody (autoimmune antibody) measurement 50512101_1 CDM 0301 RC 86148 HCPCS inpatient 95 61.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.22 67.6 999999999 57.52 92.15 percent of total billed charges Gammaglobulin (immune system protein) measurement 50512102_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.7 65 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50512102_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 153.26 97 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50512102_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 AETNA AETNA 124.82 79 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50512102_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 123.24 78 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50512102_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 109.02 69 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50512102_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 UMR - ALL PLANS UMR - ALL PLANS 110.6 70 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50512102_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 SIHO - ALL PLANS SIHO - ALL PLANS 142.2 90 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50512102_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.67 60.55 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50512102_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50512102_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ANTHEM HMO ANTHEM HMO 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50512102_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50512102_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50512102_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50512102_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.81 67.6 999999999 95.67 153.26 percent of total billed charges CIPROFLOX-DEXAMETH OTIC SUSP 50514124_1 CDM 0250 RC 43598-0326-75 NDC inpatient 1 UN 192.15 124.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 124.9 65 999999999 116.35 186.39 percent of total billed charges CIPROFLOX-DEXAMETH OTIC SUSP 50514124_1 CDM 0250 RC 43598-0326-75 NDC inpatient 1 UN 192.15 124.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 186.39 97 999999999 116.35 186.39 percent of total billed charges CIPROFLOX-DEXAMETH OTIC SUSP 50514124_1 CDM 0250 RC 43598-0326-75 NDC inpatient 1 UN 192.15 124.9 AETNA AETNA 151.8 79 999999999 116.35 186.39 percent of total billed charges CIPROFLOX-DEXAMETH OTIC SUSP 50514124_1 CDM 0250 RC 43598-0326-75 NDC inpatient 1 UN 192.15 124.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 149.88 78 999999999 116.35 186.39 percent of total billed charges CIPROFLOX-DEXAMETH OTIC SUSP 50514124_1 CDM 0250 RC 43598-0326-75 NDC inpatient 1 UN 192.15 124.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 132.58 69 999999999 116.35 186.39 percent of total billed charges CIPROFLOX-DEXAMETH OTIC SUSP 50514124_1 CDM 0250 RC 43598-0326-75 NDC inpatient 1 UN 192.15 124.9 UMR - ALL PLANS UMR - ALL PLANS 134.51 70 999999999 116.35 186.39 percent of total billed charges CIPROFLOX-DEXAMETH OTIC SUSP 50514124_1 CDM 0250 RC 43598-0326-75 NDC inpatient 1 UN 192.15 124.9 SIHO - ALL PLANS SIHO - ALL PLANS 172.94 90 999999999 116.35 186.39 percent of total billed charges CIPROFLOX-DEXAMETH OTIC SUSP 50514124_1 CDM 0250 RC 43598-0326-75 NDC inpatient 1 UN 192.15 124.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.35 60.55 999999999 116.35 186.39 percent of total billed charges CIPROFLOX-DEXAMETH OTIC SUSP 50514124_1 CDM 0250 RC 43598-0326-75 NDC inpatient 1 UN 192.15 124.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.35 186.39 CIPROFLOX-DEXAMETH OTIC SUSP 50514124_1 CDM 0250 RC 43598-0326-75 NDC inpatient 1 UN 192.15 124.9 ANTHEM HMO ANTHEM HMO 999999999 116.35 186.39 CIPROFLOX-DEXAMETH OTIC SUSP 50514124_1 CDM 0250 RC 43598-0326-75 NDC inpatient 1 UN 192.15 124.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.35 186.39 CIPROFLOX-DEXAMETH OTIC SUSP 50514124_1 CDM 0250 RC 43598-0326-75 NDC inpatient 1 UN 192.15 124.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.35 186.39 CIPROFLOX-DEXAMETH OTIC SUSP 50514124_1 CDM 0250 RC 43598-0326-75 NDC inpatient 1 UN 192.15 124.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.35 186.39 CIPROFLOX-DEXAMETH OTIC SUSP 50514124_1 CDM 0250 RC 43598-0326-75 NDC inpatient 1 UN 192.15 124.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 129.89 67.6 999999999 116.35 186.39 percent of total billed charges Analysis for antibody to Herpes simplex virus 50514283_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50514283_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50514283_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50514283_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50514283_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50514283_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50514283_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50514283_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50514283_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50514283_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50514283_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50514283_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50514283_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50514283_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50514284_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50514284_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50514284_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50514284_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50514284_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50514284_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50514284_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50514284_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50514284_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50514284_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50514284_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50514284_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50514284_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50514284_1 CDM 0301 RC 86694 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50514294_1 CDM 0250 RC 17478-0288-12 NDC inpatient 1 UN 11.97 7.78 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.78 65 999999999 7.25 11.61 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50514294_1 CDM 0250 RC 17478-0288-12 NDC inpatient 1 UN 11.97 7.78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11.61 97 999999999 7.25 11.61 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50514294_1 CDM 0250 RC 17478-0288-12 NDC inpatient 1 UN 11.97 7.78 AETNA AETNA 9.46 79 999999999 7.25 11.61 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50514294_1 CDM 0250 RC 17478-0288-12 NDC inpatient 1 UN 11.97 7.78 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.34 78 999999999 7.25 11.61 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50514294_1 CDM 0250 RC 17478-0288-12 NDC inpatient 1 UN 11.97 7.78 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.26 69 999999999 7.25 11.61 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50514294_1 CDM 0250 RC 17478-0288-12 NDC inpatient 1 UN 11.97 7.78 UMR - ALL PLANS UMR - ALL PLANS 8.38 70 999999999 7.25 11.61 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50514294_1 CDM 0250 RC 17478-0288-12 NDC inpatient 1 UN 11.97 7.78 SIHO - ALL PLANS SIHO - ALL PLANS 10.77 90 999999999 7.25 11.61 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50514294_1 CDM 0250 RC 17478-0288-12 NDC inpatient 1 UN 11.97 7.78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.25 60.55 999999999 7.25 11.61 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50514294_1 CDM 0250 RC 17478-0288-12 NDC inpatient 1 UN 11.97 7.78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.25 11.61 TIMOLOL MALEATE 0.5% EYE DROPS 50514294_1 CDM 0250 RC 17478-0288-12 NDC inpatient 1 UN 11.97 7.78 ANTHEM HMO ANTHEM HMO 999999999 7.25 11.61 TIMOLOL MALEATE 0.5% EYE DROPS 50514294_1 CDM 0250 RC 17478-0288-12 NDC inpatient 1 UN 11.97 7.78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.25 11.61 TIMOLOL MALEATE 0.5% EYE DROPS 50514294_1 CDM 0250 RC 17478-0288-12 NDC inpatient 1 UN 11.97 7.78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.25 11.61 TIMOLOL MALEATE 0.5% EYE DROPS 50514294_1 CDM 0250 RC 17478-0288-12 NDC inpatient 1 UN 11.97 7.78 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.09 67.6 999999999 7.25 11.61 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50514294_1 CDM 0250 RC 17478-0288-12 NDC inpatient 1 UN 11.97 7.78 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.25 11.61 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50514301_1 CDM 0301 RC 86618 HCPCS inpatient 151 98.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.15 65 999999999 91.43 146.47 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50514301_1 CDM 0301 RC 86618 HCPCS inpatient 151 98.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 146.47 97 999999999 91.43 146.47 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50514301_1 CDM 0301 RC 86618 HCPCS inpatient 151 98.15 AETNA AETNA 119.29 79 999999999 91.43 146.47 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50514301_1 CDM 0301 RC 86618 HCPCS inpatient 151 98.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 117.78 78 999999999 91.43 146.47 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50514301_1 CDM 0301 RC 86618 HCPCS inpatient 151 98.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.19 69 999999999 91.43 146.47 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50514301_1 CDM 0301 RC 86618 HCPCS inpatient 151 98.15 UMR - ALL PLANS UMR - ALL PLANS 105.7 70 999999999 91.43 146.47 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50514301_1 CDM 0301 RC 86618 HCPCS inpatient 151 98.15 SIHO - ALL PLANS SIHO - ALL PLANS 135.9 90 999999999 91.43 146.47 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50514301_1 CDM 0301 RC 86618 HCPCS inpatient 151 98.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 91.43 60.55 999999999 91.43 146.47 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50514301_1 CDM 0301 RC 86618 HCPCS inpatient 151 98.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 91.43 146.47 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50514301_1 CDM 0301 RC 86618 HCPCS inpatient 151 98.15 ANTHEM HMO ANTHEM HMO 999999999 91.43 146.47 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50514301_1 CDM 0301 RC 86618 HCPCS inpatient 151 98.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 91.43 146.47 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50514301_1 CDM 0301 RC 86618 HCPCS inpatient 151 98.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 91.43 146.47 Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50514301_1 CDM 0301 RC 86618 HCPCS inpatient 151 98.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.08 67.6 999999999 91.43 146.47 percent of total billed charges Analysis for antibody Borrelia burgdorferi (Lyme disease bacteria) 50514301_1 CDM 0301 RC 86618 HCPCS inpatient 151 98.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 91.43 146.47 "Blood test, lipids (cholesterol and triglycerides)" 50514302_1 CDM 0301 RC 80061 HCPCS inpatient 186 120.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 120.9 65 999999999 112.62 180.42 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50514302_1 CDM 0301 RC 80061 HCPCS inpatient 186 120.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 180.42 97 999999999 112.62 180.42 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50514302_1 CDM 0301 RC 80061 HCPCS inpatient 186 120.9 AETNA AETNA 146.94 79 999999999 112.62 180.42 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50514302_1 CDM 0301 RC 80061 HCPCS inpatient 186 120.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 145.08 78 999999999 112.62 180.42 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50514302_1 CDM 0301 RC 80061 HCPCS inpatient 186 120.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 128.34 69 999999999 112.62 180.42 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50514302_1 CDM 0301 RC 80061 HCPCS inpatient 186 120.9 UMR - ALL PLANS UMR - ALL PLANS 130.2 70 999999999 112.62 180.42 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50514302_1 CDM 0301 RC 80061 HCPCS inpatient 186 120.9 SIHO - ALL PLANS SIHO - ALL PLANS 167.4 90 999999999 112.62 180.42 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50514302_1 CDM 0301 RC 80061 HCPCS inpatient 186 120.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 112.62 60.55 999999999 112.62 180.42 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50514302_1 CDM 0301 RC 80061 HCPCS inpatient 186 120.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 112.62 180.42 "Blood test, lipids (cholesterol and triglycerides)" 50514302_1 CDM 0301 RC 80061 HCPCS inpatient 186 120.9 ANTHEM HMO ANTHEM HMO 999999999 112.62 180.42 "Blood test, lipids (cholesterol and triglycerides)" 50514302_1 CDM 0301 RC 80061 HCPCS inpatient 186 120.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 112.62 180.42 "Blood test, lipids (cholesterol and triglycerides)" 50514302_1 CDM 0301 RC 80061 HCPCS inpatient 186 120.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 112.62 180.42 "Blood test, lipids (cholesterol and triglycerides)" 50514302_1 CDM 0301 RC 80061 HCPCS inpatient 186 120.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 125.74 67.6 999999999 112.62 180.42 percent of total billed charges "Blood test, lipids (cholesterol and triglycerides)" 50514302_1 CDM 0301 RC 80061 HCPCS inpatient 186 120.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 112.62 180.42 "Detection test by nucleic acid for organism, amplified probe technique" 50514303_1 CDM 0301 RC 87798 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50514303_1 CDM 0301 RC 87798 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50514303_1 CDM 0301 RC 87798 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50514303_1 CDM 0301 RC 87798 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50514303_1 CDM 0301 RC 87798 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50514303_1 CDM 0301 RC 87798 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50514303_1 CDM 0301 RC 87798 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50514303_1 CDM 0301 RC 87798 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50514303_1 CDM 0301 RC 87798 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 "Detection test by nucleic acid for organism, amplified probe technique" 50514303_1 CDM 0301 RC 87798 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 "Detection test by nucleic acid for organism, amplified probe technique" 50514303_1 CDM 0301 RC 87798 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 "Detection test by nucleic acid for organism, amplified probe technique" 50514303_1 CDM 0301 RC 87798 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 "Detection test by nucleic acid for organism, amplified probe technique" 50514303_1 CDM 0301 RC 87798 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50514303_1 CDM 0301 RC 87798 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 "Collagen cross links test, (urine test to evaluate bone health)" 50514304_1 CDM 0301 RC 82523 HCPCS inpatient 205 133.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.25 65 999999999 124.13 198.85 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 50514304_1 CDM 0301 RC 82523 HCPCS inpatient 205 133.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 198.85 97 999999999 124.13 198.85 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 50514304_1 CDM 0301 RC 82523 HCPCS inpatient 205 133.25 AETNA AETNA 161.95 79 999999999 124.13 198.85 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 50514304_1 CDM 0301 RC 82523 HCPCS inpatient 205 133.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.9 78 999999999 124.13 198.85 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 50514304_1 CDM 0301 RC 82523 HCPCS inpatient 205 133.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 141.45 69 999999999 124.13 198.85 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 50514304_1 CDM 0301 RC 82523 HCPCS inpatient 205 133.25 UMR - ALL PLANS UMR - ALL PLANS 143.5 70 999999999 124.13 198.85 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 50514304_1 CDM 0301 RC 82523 HCPCS inpatient 205 133.25 SIHO - ALL PLANS SIHO - ALL PLANS 184.5 90 999999999 124.13 198.85 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 50514304_1 CDM 0301 RC 82523 HCPCS inpatient 205 133.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.13 60.55 999999999 124.13 198.85 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 50514304_1 CDM 0301 RC 82523 HCPCS inpatient 205 133.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.13 198.85 "Collagen cross links test, (urine test to evaluate bone health)" 50514304_1 CDM 0301 RC 82523 HCPCS inpatient 205 133.25 ANTHEM HMO ANTHEM HMO 999999999 124.13 198.85 "Collagen cross links test, (urine test to evaluate bone health)" 50514304_1 CDM 0301 RC 82523 HCPCS inpatient 205 133.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.13 198.85 "Collagen cross links test, (urine test to evaluate bone health)" 50514304_1 CDM 0301 RC 82523 HCPCS inpatient 205 133.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.13 198.85 "Collagen cross links test, (urine test to evaluate bone health)" 50514304_1 CDM 0301 RC 82523 HCPCS inpatient 205 133.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 138.58 67.6 999999999 124.13 198.85 percent of total billed charges "Collagen cross links test, (urine test to evaluate bone health)" 50514304_1 CDM 0301 RC 82523 HCPCS inpatient 205 133.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.13 198.85 "Protein measurement, immunological probe for band identification" 50514308_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 113.75 65 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514308_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 169.75 97 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514308_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 AETNA AETNA 138.25 79 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514308_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 136.5 78 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514308_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 120.75 69 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514308_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 UMR - ALL PLANS UMR - ALL PLANS 122.5 70 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514308_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 SIHO - ALL PLANS SIHO - ALL PLANS 157.5 90 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514308_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 105.96 60.55 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514308_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 105.96 169.75 "Protein measurement, immunological probe for band identification" 50514308_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ANTHEM HMO ANTHEM HMO 999999999 105.96 169.75 "Protein measurement, immunological probe for band identification" 50514308_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 105.96 169.75 "Protein measurement, immunological probe for band identification" 50514308_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 105.96 169.75 "Protein measurement, immunological probe for band identification" 50514308_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.3 67.6 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514308_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 105.96 169.75 Measurement of antibody to noninfectious agent 50514309_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50514309_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50514309_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50514309_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50514309_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50514309_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50514309_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50514309_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50514309_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50514309_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50514309_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50514309_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50514309_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50514309_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Islet cell (pancreas) antibody measurement 50514310_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 232.05 65 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 50514310_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 346.29 97 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 50514310_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 AETNA AETNA 282.03 79 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 50514310_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 278.46 78 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 50514310_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 246.33 69 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 50514310_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 UMR - ALL PLANS UMR - ALL PLANS 249.9 70 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 50514310_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 SIHO - ALL PLANS SIHO - ALL PLANS 321.3 90 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 50514310_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 216.16 60.55 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 50514310_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 216.16 346.29 Islet cell (pancreas) antibody measurement 50514310_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 ANTHEM HMO ANTHEM HMO 999999999 216.16 346.29 Islet cell (pancreas) antibody measurement 50514310_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 216.16 346.29 Islet cell (pancreas) antibody measurement 50514310_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 216.16 346.29 Islet cell (pancreas) antibody measurement 50514310_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 241.33 67.6 999999999 216.16 346.29 percent of total billed charges Islet cell (pancreas) antibody measurement 50514310_1 CDM 0301 RC 86341 HCPCS inpatient 357 232.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 216.16 346.29 "Protein measurement, immunological probe for band identification" 50514311_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 113.75 65 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514311_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 169.75 97 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514311_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 AETNA AETNA 138.25 79 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514311_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 136.5 78 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514311_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 120.75 69 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514311_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 UMR - ALL PLANS UMR - ALL PLANS 122.5 70 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514311_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 SIHO - ALL PLANS SIHO - ALL PLANS 157.5 90 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514311_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 105.96 60.55 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514311_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 105.96 169.75 "Protein measurement, immunological probe for band identification" 50514311_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ANTHEM HMO ANTHEM HMO 999999999 105.96 169.75 "Protein measurement, immunological probe for band identification" 50514311_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 105.96 169.75 "Protein measurement, immunological probe for band identification" 50514311_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 105.96 169.75 "Protein measurement, immunological probe for band identification" 50514311_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.3 67.6 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514311_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 105.96 169.75 Measurement of antibody to noninfectious agent 50514312_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50514312_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50514312_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50514312_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50514312_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50514312_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50514312_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50514312_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50514312_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50514312_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50514312_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50514312_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Measurement of antibody to noninfectious agent 50514312_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Measurement of antibody to noninfectious agent 50514312_1 CDM 0301 RC 86256 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 "Protein measurement, immunological probe for band identification" 50514313_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 113.75 65 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514313_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 169.75 97 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514313_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 AETNA AETNA 138.25 79 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514313_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 136.5 78 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514313_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 120.75 69 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514313_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 UMR - ALL PLANS UMR - ALL PLANS 122.5 70 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514313_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 SIHO - ALL PLANS SIHO - ALL PLANS 157.5 90 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514313_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 105.96 60.55 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514313_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 105.96 169.75 "Protein measurement, immunological probe for band identification" 50514313_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ANTHEM HMO ANTHEM HMO 999999999 105.96 169.75 "Protein measurement, immunological probe for band identification" 50514313_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 105.96 169.75 "Protein measurement, immunological probe for band identification" 50514313_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 105.96 169.75 "Protein measurement, immunological probe for band identification" 50514313_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.3 67.6 999999999 105.96 169.75 percent of total billed charges "Protein measurement, immunological probe for band identification" 50514313_1 CDM 0301 RC 84182 HCPCS inpatient 175 113.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 105.96 169.75 MIDAZOLAM HCL 10 MG/2 ML VIAL 50514333_1 CDM 0250 RC 00641-6063-25 NDC inpatient 1 UN 47.79 31.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.06 65 999999999 28.94 46.36 percent of total billed charges MIDAZOLAM HCL 10 MG/2 ML VIAL 50514333_1 CDM 0250 RC 00641-6063-25 NDC inpatient 1 UN 47.79 31.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 46.36 97 999999999 28.94 46.36 percent of total billed charges MIDAZOLAM HCL 10 MG/2 ML VIAL 50514333_1 CDM 0250 RC 00641-6063-25 NDC inpatient 1 UN 47.79 31.06 AETNA AETNA 37.75 79 999999999 28.94 46.36 percent of total billed charges MIDAZOLAM HCL 10 MG/2 ML VIAL 50514333_1 CDM 0250 RC 00641-6063-25 NDC inpatient 1 UN 47.79 31.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 37.28 78 999999999 28.94 46.36 percent of total billed charges MIDAZOLAM HCL 10 MG/2 ML VIAL 50514333_1 CDM 0250 RC 00641-6063-25 NDC inpatient 1 UN 47.79 31.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 32.98 69 999999999 28.94 46.36 percent of total billed charges MIDAZOLAM HCL 10 MG/2 ML VIAL 50514333_1 CDM 0250 RC 00641-6063-25 NDC inpatient 1 UN 47.79 31.06 UMR - ALL PLANS UMR - ALL PLANS 33.45 70 999999999 28.94 46.36 percent of total billed charges MIDAZOLAM HCL 10 MG/2 ML VIAL 50514333_1 CDM 0250 RC 00641-6063-25 NDC inpatient 1 UN 47.79 31.06 SIHO - ALL PLANS SIHO - ALL PLANS 43.01 90 999999999 28.94 46.36 percent of total billed charges MIDAZOLAM HCL 10 MG/2 ML VIAL 50514333_1 CDM 0250 RC 00641-6063-25 NDC inpatient 1 UN 47.79 31.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 28.94 60.55 999999999 28.94 46.36 percent of total billed charges MIDAZOLAM HCL 10 MG/2 ML VIAL 50514333_1 CDM 0250 RC 00641-6063-25 NDC inpatient 1 UN 47.79 31.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 28.94 46.36 MIDAZOLAM HCL 10 MG/2 ML VIAL 50514333_1 CDM 0250 RC 00641-6063-25 NDC inpatient 1 UN 47.79 31.06 ANTHEM HMO ANTHEM HMO 999999999 28.94 46.36 MIDAZOLAM HCL 10 MG/2 ML VIAL 50514333_1 CDM 0250 RC 00641-6063-25 NDC inpatient 1 UN 47.79 31.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 28.94 46.36 MIDAZOLAM HCL 10 MG/2 ML VIAL 50514333_1 CDM 0250 RC 00641-6063-25 NDC inpatient 1 UN 47.79 31.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 28.94 46.36 MIDAZOLAM HCL 10 MG/2 ML VIAL 50514333_1 CDM 0250 RC 00641-6063-25 NDC inpatient 1 UN 47.79 31.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 32.31 67.6 999999999 28.94 46.36 percent of total billed charges MIDAZOLAM HCL 10 MG/2 ML VIAL 50514333_1 CDM 0250 RC 00641-6063-25 NDC inpatient 1 UN 47.79 31.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 28.94 46.36 METHYLPREDNISOLONE 40 MG/ML VL 50514388_1 CDM 0250 RC 70121-1573-05 NDC inpatient 1 UN 38.74 25.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 25.18 65 999999999 23.46 37.58 percent of total billed charges METHYLPREDNISOLONE 40 MG/ML VL 50514388_1 CDM 0250 RC 70121-1573-05 NDC inpatient 1 UN 38.74 25.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37.58 97 999999999 23.46 37.58 percent of total billed charges METHYLPREDNISOLONE 40 MG/ML VL 50514388_1 CDM 0250 RC 70121-1573-05 NDC inpatient 1 UN 38.74 25.18 AETNA AETNA 30.6 79 999999999 23.46 37.58 percent of total billed charges METHYLPREDNISOLONE 40 MG/ML VL 50514388_1 CDM 0250 RC 70121-1573-05 NDC inpatient 1 UN 38.74 25.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 30.22 78 999999999 23.46 37.58 percent of total billed charges METHYLPREDNISOLONE 40 MG/ML VL 50514388_1 CDM 0250 RC 70121-1573-05 NDC inpatient 1 UN 38.74 25.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.73 69 999999999 23.46 37.58 percent of total billed charges METHYLPREDNISOLONE 40 MG/ML VL 50514388_1 CDM 0250 RC 70121-1573-05 NDC inpatient 1 UN 38.74 25.18 UMR - ALL PLANS UMR - ALL PLANS 27.12 70 999999999 23.46 37.58 percent of total billed charges METHYLPREDNISOLONE 40 MG/ML VL 50514388_1 CDM 0250 RC 70121-1573-05 NDC inpatient 1 UN 38.74 25.18 SIHO - ALL PLANS SIHO - ALL PLANS 34.87 90 999999999 23.46 37.58 percent of total billed charges METHYLPREDNISOLONE 40 MG/ML VL 50514388_1 CDM 0250 RC 70121-1573-05 NDC inpatient 1 UN 38.74 25.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.46 60.55 999999999 23.46 37.58 percent of total billed charges METHYLPREDNISOLONE 40 MG/ML VL 50514388_1 CDM 0250 RC 70121-1573-05 NDC inpatient 1 UN 38.74 25.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.46 37.58 METHYLPREDNISOLONE 40 MG/ML VL 50514388_1 CDM 0250 RC 70121-1573-05 NDC inpatient 1 UN 38.74 25.18 ANTHEM HMO ANTHEM HMO 999999999 23.46 37.58 METHYLPREDNISOLONE 40 MG/ML VL 50514388_1 CDM 0250 RC 70121-1573-05 NDC inpatient 1 UN 38.74 25.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.46 37.58 METHYLPREDNISOLONE 40 MG/ML VL 50514388_1 CDM 0250 RC 70121-1573-05 NDC inpatient 1 UN 38.74 25.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.46 37.58 METHYLPREDNISOLONE 40 MG/ML VL 50514388_1 CDM 0250 RC 70121-1573-05 NDC inpatient 1 UN 38.74 25.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 26.19 67.6 999999999 23.46 37.58 percent of total billed charges METHYLPREDNISOLONE 40 MG/ML VL 50514388_1 CDM 0250 RC 70121-1573-05 NDC inpatient 1 UN 38.74 25.18 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.46 37.58 "POTASSIUM CL 40 MEQ/1,000ML-NS" 50517435_1 CDM 0250 RC 00990-7116-09 NDC inpatient 1 UN 60.45 39.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.29 65 999999999 36.6 58.64 percent of total billed charges "POTASSIUM CL 40 MEQ/1,000ML-NS" 50517435_1 CDM 0250 RC 00990-7116-09 NDC inpatient 1 UN 60.45 39.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.64 97 999999999 36.6 58.64 percent of total billed charges "POTASSIUM CL 40 MEQ/1,000ML-NS" 50517435_1 CDM 0250 RC 00990-7116-09 NDC inpatient 1 UN 60.45 39.29 AETNA AETNA 47.76 79 999999999 36.6 58.64 percent of total billed charges "POTASSIUM CL 40 MEQ/1,000ML-NS" 50517435_1 CDM 0250 RC 00990-7116-09 NDC inpatient 1 UN 60.45 39.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.15 78 999999999 36.6 58.64 percent of total billed charges "POTASSIUM CL 40 MEQ/1,000ML-NS" 50517435_1 CDM 0250 RC 00990-7116-09 NDC inpatient 1 UN 60.45 39.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.71 69 999999999 36.6 58.64 percent of total billed charges "POTASSIUM CL 40 MEQ/1,000ML-NS" 50517435_1 CDM 0250 RC 00990-7116-09 NDC inpatient 1 UN 60.45 39.29 UMR - ALL PLANS UMR - ALL PLANS 42.32 70 999999999 36.6 58.64 percent of total billed charges "POTASSIUM CL 40 MEQ/1,000ML-NS" 50517435_1 CDM 0250 RC 00990-7116-09 NDC inpatient 1 UN 60.45 39.29 SIHO - ALL PLANS SIHO - ALL PLANS 54.41 90 999999999 36.6 58.64 percent of total billed charges "POTASSIUM CL 40 MEQ/1,000ML-NS" 50517435_1 CDM 0250 RC 00990-7116-09 NDC inpatient 1 UN 60.45 39.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.6 60.55 999999999 36.6 58.64 percent of total billed charges "POTASSIUM CL 40 MEQ/1,000ML-NS" 50517435_1 CDM 0250 RC 00990-7116-09 NDC inpatient 1 UN 60.45 39.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.6 58.64 "POTASSIUM CL 40 MEQ/1,000ML-NS" 50517435_1 CDM 0250 RC 00990-7116-09 NDC inpatient 1 UN 60.45 39.29 ANTHEM HMO ANTHEM HMO 999999999 36.6 58.64 "POTASSIUM CL 40 MEQ/1,000ML-NS" 50517435_1 CDM 0250 RC 00990-7116-09 NDC inpatient 1 UN 60.45 39.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.6 58.64 "POTASSIUM CL 40 MEQ/1,000ML-NS" 50517435_1 CDM 0250 RC 00990-7116-09 NDC inpatient 1 UN 60.45 39.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.6 58.64 "POTASSIUM CL 40 MEQ/1,000ML-NS" 50517435_1 CDM 0250 RC 00990-7116-09 NDC inpatient 1 UN 60.45 39.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.86 67.6 999999999 36.6 58.64 percent of total billed charges "POTASSIUM CL 40 MEQ/1,000ML-NS" 50517435_1 CDM 0250 RC 00990-7116-09 NDC inpatient 1 UN 60.45 39.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.6 58.64 FAMOTIDINE 20 MG TABLET 50520291_1 CDM 0250 RC 65862-0859-01 NDC inpatient 1 UN 1.8 1.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.17 65 999999999 1.09 1.75 percent of total billed charges FAMOTIDINE 20 MG TABLET 50520291_1 CDM 0250 RC 65862-0859-01 NDC inpatient 1 UN 1.8 1.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.75 97 999999999 1.09 1.75 percent of total billed charges FAMOTIDINE 20 MG TABLET 50520291_1 CDM 0250 RC 65862-0859-01 NDC inpatient 1 UN 1.8 1.17 AETNA AETNA 1.42 79 999999999 1.09 1.75 percent of total billed charges FAMOTIDINE 20 MG TABLET 50520291_1 CDM 0250 RC 65862-0859-01 NDC inpatient 1 UN 1.8 1.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.4 78 999999999 1.09 1.75 percent of total billed charges FAMOTIDINE 20 MG TABLET 50520291_1 CDM 0250 RC 65862-0859-01 NDC inpatient 1 UN 1.8 1.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.24 69 999999999 1.09 1.75 percent of total billed charges FAMOTIDINE 20 MG TABLET 50520291_1 CDM 0250 RC 65862-0859-01 NDC inpatient 1 UN 1.8 1.17 UMR - ALL PLANS UMR - ALL PLANS 1.26 70 999999999 1.09 1.75 percent of total billed charges FAMOTIDINE 20 MG TABLET 50520291_1 CDM 0250 RC 65862-0859-01 NDC inpatient 1 UN 1.8 1.17 SIHO - ALL PLANS SIHO - ALL PLANS 1.62 90 999999999 1.09 1.75 percent of total billed charges FAMOTIDINE 20 MG TABLET 50520291_1 CDM 0250 RC 65862-0859-01 NDC inpatient 1 UN 1.8 1.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.09 60.55 999999999 1.09 1.75 percent of total billed charges FAMOTIDINE 20 MG TABLET 50520291_1 CDM 0250 RC 65862-0859-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.09 1.75 FAMOTIDINE 20 MG TABLET 50520291_1 CDM 0250 RC 65862-0859-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM HMO ANTHEM HMO 999999999 1.09 1.75 FAMOTIDINE 20 MG TABLET 50520291_1 CDM 0250 RC 65862-0859-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.09 1.75 FAMOTIDINE 20 MG TABLET 50520291_1 CDM 0250 RC 65862-0859-01 NDC inpatient 1 UN 1.8 1.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.09 1.75 FAMOTIDINE 20 MG TABLET 50520291_1 CDM 0250 RC 65862-0859-01 NDC inpatient 1 UN 1.8 1.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.22 67.6 999999999 1.09 1.75 percent of total billed charges FAMOTIDINE 20 MG TABLET 50520291_1 CDM 0250 RC 65862-0859-01 NDC inpatient 1 UN 1.8 1.17 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.09 1.75 FAMOTIDINE 20 MG/2 ML VIAL 50520296_1 CDM 0250 RC 67457-0433-22 NDC inpatient 1 UN 19.71 12.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.81 65 999999999 11.93 19.12 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 50520296_1 CDM 0250 RC 67457-0433-22 NDC inpatient 1 UN 19.71 12.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.12 97 999999999 11.93 19.12 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 50520296_1 CDM 0250 RC 67457-0433-22 NDC inpatient 1 UN 19.71 12.81 AETNA AETNA 15.57 79 999999999 11.93 19.12 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 50520296_1 CDM 0250 RC 67457-0433-22 NDC inpatient 1 UN 19.71 12.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.37 78 999999999 11.93 19.12 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 50520296_1 CDM 0250 RC 67457-0433-22 NDC inpatient 1 UN 19.71 12.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.6 69 999999999 11.93 19.12 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 50520296_1 CDM 0250 RC 67457-0433-22 NDC inpatient 1 UN 19.71 12.81 UMR - ALL PLANS UMR - ALL PLANS 13.8 70 999999999 11.93 19.12 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 50520296_1 CDM 0250 RC 67457-0433-22 NDC inpatient 1 UN 19.71 12.81 SIHO - ALL PLANS SIHO - ALL PLANS 17.74 90 999999999 11.93 19.12 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 50520296_1 CDM 0250 RC 67457-0433-22 NDC inpatient 1 UN 19.71 12.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.93 60.55 999999999 11.93 19.12 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 50520296_1 CDM 0250 RC 67457-0433-22 NDC inpatient 1 UN 19.71 12.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.93 19.12 FAMOTIDINE 20 MG/2 ML VIAL 50520296_1 CDM 0250 RC 67457-0433-22 NDC inpatient 1 UN 19.71 12.81 ANTHEM HMO ANTHEM HMO 999999999 11.93 19.12 FAMOTIDINE 20 MG/2 ML VIAL 50520296_1 CDM 0250 RC 67457-0433-22 NDC inpatient 1 UN 19.71 12.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.93 19.12 FAMOTIDINE 20 MG/2 ML VIAL 50520296_1 CDM 0250 RC 67457-0433-22 NDC inpatient 1 UN 19.71 12.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.93 19.12 FAMOTIDINE 20 MG/2 ML VIAL 50520296_1 CDM 0250 RC 67457-0433-22 NDC inpatient 1 UN 19.71 12.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.32 67.6 999999999 11.93 19.12 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 50520296_1 CDM 0250 RC 67457-0433-22 NDC inpatient 1 UN 19.71 12.81 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.93 19.12 "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50521104_1 CDM 0250 RC 44567-0621-24 NDC J0610 HCPCS inpatient 10 UN 98.46 64 SELF PAY DISCOUNT SELF PAY DISCOUNT 64 65 999999999 59.62 95.51 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50521104_1 CDM 0250 RC 44567-0621-24 NDC J0610 HCPCS inpatient 10 UN 98.46 64 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.51 97 999999999 59.62 95.51 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50521104_1 CDM 0250 RC 44567-0621-24 NDC J0610 HCPCS inpatient 10 UN 98.46 64 AETNA AETNA 77.78 79 999999999 59.62 95.51 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50521104_1 CDM 0250 RC 44567-0621-24 NDC J0610 HCPCS inpatient 10 UN 98.46 64 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.8 78 999999999 59.62 95.51 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50521104_1 CDM 0250 RC 44567-0621-24 NDC J0610 HCPCS inpatient 10 UN 98.46 64 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.94 69 999999999 59.62 95.51 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50521104_1 CDM 0250 RC 44567-0621-24 NDC J0610 HCPCS inpatient 10 UN 98.46 64 UMR - ALL PLANS UMR - ALL PLANS 68.92 70 999999999 59.62 95.51 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50521104_1 CDM 0250 RC 44567-0621-24 NDC J0610 HCPCS inpatient 10 UN 98.46 64 SIHO - ALL PLANS SIHO - ALL PLANS 88.61 90 999999999 59.62 95.51 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50521104_1 CDM 0250 RC 44567-0621-24 NDC J0610 HCPCS inpatient 10 UN 98.46 64 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.62 60.55 999999999 59.62 95.51 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50521104_1 CDM 0250 RC 44567-0621-24 NDC J0610 HCPCS inpatient 10 UN 98.46 64 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.62 95.51 "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50521104_1 CDM 0250 RC 44567-0621-24 NDC J0610 HCPCS inpatient 10 UN 98.46 64 ANTHEM HMO ANTHEM HMO 999999999 59.62 95.51 "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50521104_1 CDM 0250 RC 44567-0621-24 NDC J0610 HCPCS inpatient 10 UN 98.46 64 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.62 95.51 "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50521104_1 CDM 0250 RC 44567-0621-24 NDC J0610 HCPCS inpatient 10 UN 98.46 64 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.62 95.51 "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50521104_1 CDM 0250 RC 44567-0621-24 NDC J0610 HCPCS inpatient 10 UN 98.46 64 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.56 67.6 999999999 59.62 95.51 percent of total billed charges "INJECTION, CALCIUM GLUCONATE (FRESENIUS KABI), PER 10 ML" 50521104_1 CDM 0250 RC 44567-0621-24 NDC J0610 HCPCS inpatient 10 UN 98.46 64 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.62 95.51 "INJECTION, VANCOMYCIN HCL, 500 MG" 50521325_1 CDM 0250 RC 70594-0043-02 NDC J3370 HCPCS inpatient 3 UN 136.87 88.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.97 65 999999999 82.87 132.76 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50521325_1 CDM 0250 RC 70594-0043-02 NDC J3370 HCPCS inpatient 3 UN 136.87 88.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.76 97 999999999 82.87 132.76 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50521325_1 CDM 0250 RC 70594-0043-02 NDC J3370 HCPCS inpatient 3 UN 136.87 88.97 AETNA AETNA 108.13 79 999999999 82.87 132.76 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50521325_1 CDM 0250 RC 70594-0043-02 NDC J3370 HCPCS inpatient 3 UN 136.87 88.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.76 78 999999999 82.87 132.76 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50521325_1 CDM 0250 RC 70594-0043-02 NDC J3370 HCPCS inpatient 3 UN 136.87 88.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.44 69 999999999 82.87 132.76 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50521325_1 CDM 0250 RC 70594-0043-02 NDC J3370 HCPCS inpatient 3 UN 136.87 88.97 UMR - ALL PLANS UMR - ALL PLANS 95.81 70 999999999 82.87 132.76 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50521325_1 CDM 0250 RC 70594-0043-02 NDC J3370 HCPCS inpatient 3 UN 136.87 88.97 SIHO - ALL PLANS SIHO - ALL PLANS 123.18 90 999999999 82.87 132.76 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50521325_1 CDM 0250 RC 70594-0043-02 NDC J3370 HCPCS inpatient 3 UN 136.87 88.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.87 60.55 999999999 82.87 132.76 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50521325_1 CDM 0250 RC 70594-0043-02 NDC J3370 HCPCS inpatient 3 UN 136.87 88.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.87 132.76 "INJECTION, VANCOMYCIN HCL, 500 MG" 50521325_1 CDM 0250 RC 70594-0043-02 NDC J3370 HCPCS inpatient 3 UN 136.87 88.97 ANTHEM HMO ANTHEM HMO 999999999 82.87 132.76 "INJECTION, VANCOMYCIN HCL, 500 MG" 50521325_1 CDM 0250 RC 70594-0043-02 NDC J3370 HCPCS inpatient 3 UN 136.87 88.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.87 132.76 "INJECTION, VANCOMYCIN HCL, 500 MG" 50521325_1 CDM 0250 RC 70594-0043-02 NDC J3370 HCPCS inpatient 3 UN 136.87 88.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.87 132.76 "INJECTION, VANCOMYCIN HCL, 500 MG" 50521325_1 CDM 0250 RC 70594-0043-02 NDC J3370 HCPCS inpatient 3 UN 136.87 88.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.52 67.6 999999999 82.87 132.76 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50521325_1 CDM 0250 RC 70594-0043-02 NDC J3370 HCPCS inpatient 3 UN 136.87 88.97 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.87 132.76 "INJECTION, VANCOMYCIN HCL, 500 MG" 50521329_1 CDM 0250 RC 70594-0042-03 NDC J3370 HCPCS inpatient 2 UN 107.88 70.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.12 65 999999999 65.32 104.64 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50521329_1 CDM 0250 RC 70594-0042-03 NDC J3370 HCPCS inpatient 2 UN 107.88 70.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 104.64 97 999999999 65.32 104.64 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50521329_1 CDM 0250 RC 70594-0042-03 NDC J3370 HCPCS inpatient 2 UN 107.88 70.12 AETNA AETNA 85.23 79 999999999 65.32 104.64 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50521329_1 CDM 0250 RC 70594-0042-03 NDC J3370 HCPCS inpatient 2 UN 107.88 70.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 84.15 78 999999999 65.32 104.64 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50521329_1 CDM 0250 RC 70594-0042-03 NDC J3370 HCPCS inpatient 2 UN 107.88 70.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 74.44 69 999999999 65.32 104.64 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50521329_1 CDM 0250 RC 70594-0042-03 NDC J3370 HCPCS inpatient 2 UN 107.88 70.12 UMR - ALL PLANS UMR - ALL PLANS 75.52 70 999999999 65.32 104.64 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50521329_1 CDM 0250 RC 70594-0042-03 NDC J3370 HCPCS inpatient 2 UN 107.88 70.12 SIHO - ALL PLANS SIHO - ALL PLANS 97.09 90 999999999 65.32 104.64 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50521329_1 CDM 0250 RC 70594-0042-03 NDC J3370 HCPCS inpatient 2 UN 107.88 70.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 65.32 60.55 999999999 65.32 104.64 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50521329_1 CDM 0250 RC 70594-0042-03 NDC J3370 HCPCS inpatient 2 UN 107.88 70.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 65.32 104.64 "INJECTION, VANCOMYCIN HCL, 500 MG" 50521329_1 CDM 0250 RC 70594-0042-03 NDC J3370 HCPCS inpatient 2 UN 107.88 70.12 ANTHEM HMO ANTHEM HMO 999999999 65.32 104.64 "INJECTION, VANCOMYCIN HCL, 500 MG" 50521329_1 CDM 0250 RC 70594-0042-03 NDC J3370 HCPCS inpatient 2 UN 107.88 70.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 65.32 104.64 "INJECTION, VANCOMYCIN HCL, 500 MG" 50521329_1 CDM 0250 RC 70594-0042-03 NDC J3370 HCPCS inpatient 2 UN 107.88 70.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 65.32 104.64 "INJECTION, VANCOMYCIN HCL, 500 MG" 50521329_1 CDM 0250 RC 70594-0042-03 NDC J3370 HCPCS inpatient 2 UN 107.88 70.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 72.93 67.6 999999999 65.32 104.64 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50521329_1 CDM 0250 RC 70594-0042-03 NDC J3370 HCPCS inpatient 2 UN 107.88 70.12 UHC - ALL PLANS UHC - ALL PLANS 999999999 65.32 104.64 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50521630_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 352.3 65 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50521630_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 525.74 97 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50521630_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 AETNA AETNA 428.18 79 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50521630_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 422.76 78 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50521630_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 373.98 69 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50521630_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 UMR - ALL PLANS UMR - ALL PLANS 379.4 70 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50521630_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 SIHO - ALL PLANS SIHO - ALL PLANS 487.8 90 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50521630_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 328.18 60.55 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50521630_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 328.18 525.74 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50521630_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 ANTHEM HMO ANTHEM HMO 999999999 328.18 525.74 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50521630_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 328.18 525.74 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50521630_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 328.18 525.74 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50521630_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 366.39 67.6 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50521630_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 328.18 525.74 DURAMORPH 5 MG/10 ML AMPUL 50521785_1 CDM 0250 RC 00641-6020-10 NDC inpatient 1 UN 142.5 92.63 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.63 65 999999999 86.28 138.23 percent of total billed charges DURAMORPH 5 MG/10 ML AMPUL 50521785_1 CDM 0250 RC 00641-6020-10 NDC inpatient 1 UN 142.5 92.63 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.23 97 999999999 86.28 138.23 percent of total billed charges DURAMORPH 5 MG/10 ML AMPUL 50521785_1 CDM 0250 RC 00641-6020-10 NDC inpatient 1 UN 142.5 92.63 AETNA AETNA 112.58 79 999999999 86.28 138.23 percent of total billed charges DURAMORPH 5 MG/10 ML AMPUL 50521785_1 CDM 0250 RC 00641-6020-10 NDC inpatient 1 UN 142.5 92.63 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.15 78 999999999 86.28 138.23 percent of total billed charges DURAMORPH 5 MG/10 ML AMPUL 50521785_1 CDM 0250 RC 00641-6020-10 NDC inpatient 1 UN 142.5 92.63 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.33 69 999999999 86.28 138.23 percent of total billed charges DURAMORPH 5 MG/10 ML AMPUL 50521785_1 CDM 0250 RC 00641-6020-10 NDC inpatient 1 UN 142.5 92.63 UMR - ALL PLANS UMR - ALL PLANS 99.75 70 999999999 86.28 138.23 percent of total billed charges DURAMORPH 5 MG/10 ML AMPUL 50521785_1 CDM 0250 RC 00641-6020-10 NDC inpatient 1 UN 142.5 92.63 SIHO - ALL PLANS SIHO - ALL PLANS 128.25 90 999999999 86.28 138.23 percent of total billed charges DURAMORPH 5 MG/10 ML AMPUL 50521785_1 CDM 0250 RC 00641-6020-10 NDC inpatient 1 UN 142.5 92.63 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.28 60.55 999999999 86.28 138.23 percent of total billed charges DURAMORPH 5 MG/10 ML AMPUL 50521785_1 CDM 0250 RC 00641-6020-10 NDC inpatient 1 UN 142.5 92.63 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.28 138.23 DURAMORPH 5 MG/10 ML AMPUL 50521785_1 CDM 0250 RC 00641-6020-10 NDC inpatient 1 UN 142.5 92.63 ANTHEM HMO ANTHEM HMO 999999999 86.28 138.23 DURAMORPH 5 MG/10 ML AMPUL 50521785_1 CDM 0250 RC 00641-6020-10 NDC inpatient 1 UN 142.5 92.63 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.28 138.23 DURAMORPH 5 MG/10 ML AMPUL 50521785_1 CDM 0250 RC 00641-6020-10 NDC inpatient 1 UN 142.5 92.63 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.28 138.23 DURAMORPH 5 MG/10 ML AMPUL 50521785_1 CDM 0250 RC 00641-6020-10 NDC inpatient 1 UN 142.5 92.63 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.33 67.6 999999999 86.28 138.23 percent of total billed charges DURAMORPH 5 MG/10 ML AMPUL 50521785_1 CDM 0250 RC 00641-6020-10 NDC inpatient 1 UN 142.5 92.63 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.28 138.23 "INJECTION, ENFORTUMAB VEDOTIN-EJFV, 0.25 MG" 50522647_1 CDM 0636 RC 51144-0030-01 NDC J9177 HCPCS inpatient 1 UN 15058.75 9788.19 SELF PAY DISCOUNT SELF PAY DISCOUNT 9788.19 65 999999999 9118.07 14606.99 percent of total billed charges "INJECTION, ENFORTUMAB VEDOTIN-EJFV, 0.25 MG" 50522647_1 CDM 0636 RC 51144-0030-01 NDC J9177 HCPCS inpatient 1 UN 15058.75 9788.19 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14606.99 97 999999999 9118.07 14606.99 percent of total billed charges "INJECTION, ENFORTUMAB VEDOTIN-EJFV, 0.25 MG" 50522647_1 CDM 0636 RC 51144-0030-01 NDC J9177 HCPCS inpatient 1 UN 15058.75 9788.19 AETNA AETNA 11896.41 79 999999999 9118.07 14606.99 percent of total billed charges "INJECTION, ENFORTUMAB VEDOTIN-EJFV, 0.25 MG" 50522647_1 CDM 0636 RC 51144-0030-01 NDC J9177 HCPCS inpatient 1 UN 15058.75 9788.19 HUMANA - ALL PLANS HUMANA - ALL PLANS 11745.83 78 999999999 9118.07 14606.99 percent of total billed charges "INJECTION, ENFORTUMAB VEDOTIN-EJFV, 0.25 MG" 50522647_1 CDM 0636 RC 51144-0030-01 NDC J9177 HCPCS inpatient 1 UN 15058.75 9788.19 ENCORE - ALL PLANS ENCORE - ALL PLANS 10390.54 69 999999999 9118.07 14606.99 percent of total billed charges "INJECTION, ENFORTUMAB VEDOTIN-EJFV, 0.25 MG" 50522647_1 CDM 0636 RC 51144-0030-01 NDC J9177 HCPCS inpatient 1 UN 15058.75 9788.19 UMR - ALL PLANS UMR - ALL PLANS 10541.13 70 999999999 9118.07 14606.99 percent of total billed charges "INJECTION, ENFORTUMAB VEDOTIN-EJFV, 0.25 MG" 50522647_1 CDM 0636 RC 51144-0030-01 NDC J9177 HCPCS inpatient 1 UN 15058.75 9788.19 SIHO - ALL PLANS SIHO - ALL PLANS 13552.88 90 999999999 9118.07 14606.99 percent of total billed charges "INJECTION, ENFORTUMAB VEDOTIN-EJFV, 0.25 MG" 50522647_1 CDM 0636 RC 51144-0030-01 NDC J9177 HCPCS inpatient 1 UN 15058.75 9788.19 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9118.07 60.55 999999999 9118.07 14606.99 percent of total billed charges "INJECTION, ENFORTUMAB VEDOTIN-EJFV, 0.25 MG" 50522647_1 CDM 0636 RC 51144-0030-01 NDC J9177 HCPCS inpatient 1 UN 15058.75 9788.19 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9118.07 14606.99 "INJECTION, ENFORTUMAB VEDOTIN-EJFV, 0.25 MG" 50522647_1 CDM 0636 RC 51144-0030-01 NDC J9177 HCPCS inpatient 1 UN 15058.75 9788.19 ANTHEM HMO ANTHEM HMO 999999999 9118.07 14606.99 "INJECTION, ENFORTUMAB VEDOTIN-EJFV, 0.25 MG" 50522647_1 CDM 0636 RC 51144-0030-01 NDC J9177 HCPCS inpatient 1 UN 15058.75 9788.19 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9118.07 14606.99 "INJECTION, ENFORTUMAB VEDOTIN-EJFV, 0.25 MG" 50522647_1 CDM 0636 RC 51144-0030-01 NDC J9177 HCPCS inpatient 1 UN 15058.75 9788.19 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9118.07 14606.99 "INJECTION, ENFORTUMAB VEDOTIN-EJFV, 0.25 MG" 50522647_1 CDM 0636 RC 51144-0030-01 NDC J9177 HCPCS inpatient 1 UN 15058.75 9788.19 CIGNA - ALL PLANS CIGNA - ALL PLANS 10179.72 67.6 999999999 9118.07 14606.99 percent of total billed charges "INJECTION, ENFORTUMAB VEDOTIN-EJFV, 0.25 MG" 50522647_1 CDM 0636 RC 51144-0030-01 NDC J9177 HCPCS inpatient 1 UN 15058.75 9788.19 UHC - ALL PLANS UHC - ALL PLANS 999999999 9118.07 14606.99 Reticulated (young) platelet measurement 50529175_1 CDM 0305 RC 85055 HCPCS inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges Reticulated (young) platelet measurement 50529175_1 CDM 0305 RC 85055 HCPCS inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges Reticulated (young) platelet measurement 50529175_1 CDM 0305 RC 85055 HCPCS inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges Reticulated (young) platelet measurement 50529175_1 CDM 0305 RC 85055 HCPCS inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges Reticulated (young) platelet measurement 50529175_1 CDM 0305 RC 85055 HCPCS inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges Reticulated (young) platelet measurement 50529175_1 CDM 0305 RC 85055 HCPCS inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges Reticulated (young) platelet measurement 50529175_1 CDM 0305 RC 85055 HCPCS inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges Reticulated (young) platelet measurement 50529175_1 CDM 0305 RC 85055 HCPCS inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges Reticulated (young) platelet measurement 50529175_1 CDM 0305 RC 85055 HCPCS inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 Reticulated (young) platelet measurement 50529175_1 CDM 0305 RC 85055 HCPCS inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 Reticulated (young) platelet measurement 50529175_1 CDM 0305 RC 85055 HCPCS inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 Reticulated (young) platelet measurement 50529175_1 CDM 0305 RC 85055 HCPCS inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 Reticulated (young) platelet measurement 50529175_1 CDM 0305 RC 85055 HCPCS inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges Reticulated (young) platelet measurement 50529175_1 CDM 0305 RC 85055 HCPCS inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 Syphilis detection test 50529409_1 CDM 0301 RC 86592 HCPCS inpatient 74 48.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.1 65 999999999 44.81 71.78 percent of total billed charges Syphilis detection test 50529409_1 CDM 0301 RC 86592 HCPCS inpatient 74 48.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 71.78 97 999999999 44.81 71.78 percent of total billed charges Syphilis detection test 50529409_1 CDM 0301 RC 86592 HCPCS inpatient 74 48.1 AETNA AETNA 58.46 79 999999999 44.81 71.78 percent of total billed charges Syphilis detection test 50529409_1 CDM 0301 RC 86592 HCPCS inpatient 74 48.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 57.72 78 999999999 44.81 71.78 percent of total billed charges Syphilis detection test 50529409_1 CDM 0301 RC 86592 HCPCS inpatient 74 48.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.06 69 999999999 44.81 71.78 percent of total billed charges Syphilis detection test 50529409_1 CDM 0301 RC 86592 HCPCS inpatient 74 48.1 UMR - ALL PLANS UMR - ALL PLANS 51.8 70 999999999 44.81 71.78 percent of total billed charges Syphilis detection test 50529409_1 CDM 0301 RC 86592 HCPCS inpatient 74 48.1 SIHO - ALL PLANS SIHO - ALL PLANS 66.6 90 999999999 44.81 71.78 percent of total billed charges Syphilis detection test 50529409_1 CDM 0301 RC 86592 HCPCS inpatient 74 48.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.81 60.55 999999999 44.81 71.78 percent of total billed charges Syphilis detection test 50529409_1 CDM 0301 RC 86592 HCPCS inpatient 74 48.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.81 71.78 Syphilis detection test 50529409_1 CDM 0301 RC 86592 HCPCS inpatient 74 48.1 ANTHEM HMO ANTHEM HMO 999999999 44.81 71.78 Syphilis detection test 50529409_1 CDM 0301 RC 86592 HCPCS inpatient 74 48.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.81 71.78 Syphilis detection test 50529409_1 CDM 0301 RC 86592 HCPCS inpatient 74 48.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.81 71.78 Syphilis detection test 50529409_1 CDM 0301 RC 86592 HCPCS inpatient 74 48.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.02 67.6 999999999 44.81 71.78 percent of total billed charges Syphilis detection test 50529409_1 CDM 0301 RC 86592 HCPCS inpatient 74 48.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.81 71.78 Syphilis test 50529466_1 CDM 0301 RC 86593 HCPCS inpatient 127 82.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 82.55 65 999999999 76.9 123.19 percent of total billed charges Syphilis test 50529466_1 CDM 0301 RC 86593 HCPCS inpatient 127 82.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 123.19 97 999999999 76.9 123.19 percent of total billed charges Syphilis test 50529466_1 CDM 0301 RC 86593 HCPCS inpatient 127 82.55 AETNA AETNA 100.33 79 999999999 76.9 123.19 percent of total billed charges Syphilis test 50529466_1 CDM 0301 RC 86593 HCPCS inpatient 127 82.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 99.06 78 999999999 76.9 123.19 percent of total billed charges Syphilis test 50529466_1 CDM 0301 RC 86593 HCPCS inpatient 127 82.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 87.63 69 999999999 76.9 123.19 percent of total billed charges Syphilis test 50529466_1 CDM 0301 RC 86593 HCPCS inpatient 127 82.55 UMR - ALL PLANS UMR - ALL PLANS 88.9 70 999999999 76.9 123.19 percent of total billed charges Syphilis test 50529466_1 CDM 0301 RC 86593 HCPCS inpatient 127 82.55 SIHO - ALL PLANS SIHO - ALL PLANS 114.3 90 999999999 76.9 123.19 percent of total billed charges Syphilis test 50529466_1 CDM 0301 RC 86593 HCPCS inpatient 127 82.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.9 60.55 999999999 76.9 123.19 percent of total billed charges Syphilis test 50529466_1 CDM 0301 RC 86593 HCPCS inpatient 127 82.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.9 123.19 Syphilis test 50529466_1 CDM 0301 RC 86593 HCPCS inpatient 127 82.55 ANTHEM HMO ANTHEM HMO 999999999 76.9 123.19 Syphilis test 50529466_1 CDM 0301 RC 86593 HCPCS inpatient 127 82.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.9 123.19 Syphilis test 50529466_1 CDM 0301 RC 86593 HCPCS inpatient 127 82.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.9 123.19 Syphilis test 50529466_1 CDM 0301 RC 86593 HCPCS inpatient 127 82.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.85 67.6 999999999 76.9 123.19 percent of total billed charges Syphilis test 50529466_1 CDM 0301 RC 86593 HCPCS inpatient 127 82.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.9 123.19 VACC AIIV4 NO PRSRV 0.5ML IM 50529558_1 CDM 0250 RC 70461-0120-03 NDC inpatient 1 UN 33.73 21.92 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.92 65 999999999 20.42 32.72 percent of total billed charges VACC AIIV4 NO PRSRV 0.5ML IM 50529558_1 CDM 0250 RC 70461-0120-03 NDC inpatient 1 UN 33.73 21.92 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.72 97 999999999 20.42 32.72 percent of total billed charges VACC AIIV4 NO PRSRV 0.5ML IM 50529558_1 CDM 0250 RC 70461-0120-03 NDC inpatient 1 UN 33.73 21.92 AETNA AETNA 26.65 79 999999999 20.42 32.72 percent of total billed charges VACC AIIV4 NO PRSRV 0.5ML IM 50529558_1 CDM 0250 RC 70461-0120-03 NDC inpatient 1 UN 33.73 21.92 HUMANA - ALL PLANS HUMANA - ALL PLANS 26.31 78 999999999 20.42 32.72 percent of total billed charges VACC AIIV4 NO PRSRV 0.5ML IM 50529558_1 CDM 0250 RC 70461-0120-03 NDC inpatient 1 UN 33.73 21.92 ENCORE - ALL PLANS ENCORE - ALL PLANS 23.27 69 999999999 20.42 32.72 percent of total billed charges VACC AIIV4 NO PRSRV 0.5ML IM 50529558_1 CDM 0250 RC 70461-0120-03 NDC inpatient 1 UN 33.73 21.92 UMR - ALL PLANS UMR - ALL PLANS 23.61 70 999999999 20.42 32.72 percent of total billed charges VACC AIIV4 NO PRSRV 0.5ML IM 50529558_1 CDM 0250 RC 70461-0120-03 NDC inpatient 1 UN 33.73 21.92 SIHO - ALL PLANS SIHO - ALL PLANS 30.36 90 999999999 20.42 32.72 percent of total billed charges VACC AIIV4 NO PRSRV 0.5ML IM 50529558_1 CDM 0250 RC 70461-0120-03 NDC inpatient 1 UN 33.73 21.92 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.42 60.55 999999999 20.42 32.72 percent of total billed charges VACC AIIV4 NO PRSRV 0.5ML IM 50529558_1 CDM 0250 RC 70461-0120-03 NDC inpatient 1 UN 33.73 21.92 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.42 32.72 VACC AIIV4 NO PRSRV 0.5ML IM 50529558_1 CDM 0250 RC 70461-0120-03 NDC inpatient 1 UN 33.73 21.92 ANTHEM HMO ANTHEM HMO 999999999 20.42 32.72 VACC AIIV4 NO PRSRV 0.5ML IM 50529558_1 CDM 0250 RC 70461-0120-03 NDC inpatient 1 UN 33.73 21.92 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.42 32.72 VACC AIIV4 NO PRSRV 0.5ML IM 50529558_1 CDM 0250 RC 70461-0120-03 NDC inpatient 1 UN 33.73 21.92 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.42 32.72 VACC AIIV4 NO PRSRV 0.5ML IM 50529558_1 CDM 0250 RC 70461-0120-03 NDC inpatient 1 UN 33.73 21.92 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.8 67.6 999999999 20.42 32.72 percent of total billed charges VACC AIIV4 NO PRSRV 0.5ML IM 50529558_1 CDM 0250 RC 70461-0120-03 NDC inpatient 1 UN 33.73 21.92 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.42 32.72 "Testosterone (hormone) level, free" 50536866_1 CDM 0301 RC 84402 HCPCS inpatient 141 91.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 91.65 65 999999999 85.38 136.77 percent of total billed charges "Testosterone (hormone) level, free" 50536866_1 CDM 0301 RC 84402 HCPCS inpatient 141 91.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 136.77 97 999999999 85.38 136.77 percent of total billed charges "Testosterone (hormone) level, free" 50536866_1 CDM 0301 RC 84402 HCPCS inpatient 141 91.65 AETNA AETNA 111.39 79 999999999 85.38 136.77 percent of total billed charges "Testosterone (hormone) level, free" 50536866_1 CDM 0301 RC 84402 HCPCS inpatient 141 91.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 109.98 78 999999999 85.38 136.77 percent of total billed charges "Testosterone (hormone) level, free" 50536866_1 CDM 0301 RC 84402 HCPCS inpatient 141 91.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.29 69 999999999 85.38 136.77 percent of total billed charges "Testosterone (hormone) level, free" 50536866_1 CDM 0301 RC 84402 HCPCS inpatient 141 91.65 UMR - ALL PLANS UMR - ALL PLANS 98.7 70 999999999 85.38 136.77 percent of total billed charges "Testosterone (hormone) level, free" 50536866_1 CDM 0301 RC 84402 HCPCS inpatient 141 91.65 SIHO - ALL PLANS SIHO - ALL PLANS 126.9 90 999999999 85.38 136.77 percent of total billed charges "Testosterone (hormone) level, free" 50536866_1 CDM 0301 RC 84402 HCPCS inpatient 141 91.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.38 60.55 999999999 85.38 136.77 percent of total billed charges "Testosterone (hormone) level, free" 50536866_1 CDM 0301 RC 84402 HCPCS inpatient 141 91.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.38 136.77 "Testosterone (hormone) level, free" 50536866_1 CDM 0301 RC 84402 HCPCS inpatient 141 91.65 ANTHEM HMO ANTHEM HMO 999999999 85.38 136.77 "Testosterone (hormone) level, free" 50536866_1 CDM 0301 RC 84402 HCPCS inpatient 141 91.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.38 136.77 "Testosterone (hormone) level, free" 50536866_1 CDM 0301 RC 84402 HCPCS inpatient 141 91.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.38 136.77 "Testosterone (hormone) level, free" 50536866_1 CDM 0301 RC 84402 HCPCS inpatient 141 91.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.32 67.6 999999999 85.38 136.77 percent of total billed charges "Testosterone (hormone) level, free" 50536866_1 CDM 0301 RC 84402 HCPCS inpatient 141 91.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.38 136.77 "Testosterone (hormone) level, total" 50536872_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges "Testosterone (hormone) level, total" 50536872_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges "Testosterone (hormone) level, total" 50536872_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges "Testosterone (hormone) level, total" 50536872_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges "Testosterone (hormone) level, total" 50536872_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges "Testosterone (hormone) level, total" 50536872_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges "Testosterone (hormone) level, total" 50536872_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges "Testosterone (hormone) level, total" 50536872_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges "Testosterone (hormone) level, total" 50536872_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 "Testosterone (hormone) level, total" 50536872_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 "Testosterone (hormone) level, total" 50536872_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 "Testosterone (hormone) level, total" 50536872_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 "Testosterone (hormone) level, total" 50536872_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges "Testosterone (hormone) level, total" 50536872_1 CDM 0301 RC 84403 HCPCS inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 Sex hormone binding globulin (protein) level 50536878_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.4 65 999999999 94.46 151.32 percent of total billed charges Sex hormone binding globulin (protein) level 50536878_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 151.32 97 999999999 94.46 151.32 percent of total billed charges Sex hormone binding globulin (protein) level 50536878_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 AETNA AETNA 123.24 79 999999999 94.46 151.32 percent of total billed charges Sex hormone binding globulin (protein) level 50536878_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.68 78 999999999 94.46 151.32 percent of total billed charges Sex hormone binding globulin (protein) level 50536878_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.64 69 999999999 94.46 151.32 percent of total billed charges Sex hormone binding globulin (protein) level 50536878_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 UMR - ALL PLANS UMR - ALL PLANS 109.2 70 999999999 94.46 151.32 percent of total billed charges Sex hormone binding globulin (protein) level 50536878_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 SIHO - ALL PLANS SIHO - ALL PLANS 140.4 90 999999999 94.46 151.32 percent of total billed charges Sex hormone binding globulin (protein) level 50536878_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.46 60.55 999999999 94.46 151.32 percent of total billed charges Sex hormone binding globulin (protein) level 50536878_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.46 151.32 Sex hormone binding globulin (protein) level 50536878_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 ANTHEM HMO ANTHEM HMO 999999999 94.46 151.32 Sex hormone binding globulin (protein) level 50536878_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.46 151.32 Sex hormone binding globulin (protein) level 50536878_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.46 151.32 Sex hormone binding globulin (protein) level 50536878_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.46 67.6 999999999 94.46 151.32 percent of total billed charges Sex hormone binding globulin (protein) level 50536878_1 CDM 0301 RC 84270 HCPCS inpatient 156 101.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.46 151.32 SULFAMETHOXAZOLE-TMP DS TABLET 50537028_1 CDM 0250 RC 60687-0531-01 NDC inpatient 1 UN 1.95 1.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.27 65 999999999 1.18 1.89 percent of total billed charges SULFAMETHOXAZOLE-TMP DS TABLET 50537028_1 CDM 0250 RC 60687-0531-01 NDC inpatient 1 UN 1.95 1.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.89 97 999999999 1.18 1.89 percent of total billed charges SULFAMETHOXAZOLE-TMP DS TABLET 50537028_1 CDM 0250 RC 60687-0531-01 NDC inpatient 1 UN 1.95 1.27 AETNA AETNA 1.54 79 999999999 1.18 1.89 percent of total billed charges SULFAMETHOXAZOLE-TMP DS TABLET 50537028_1 CDM 0250 RC 60687-0531-01 NDC inpatient 1 UN 1.95 1.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.52 78 999999999 1.18 1.89 percent of total billed charges SULFAMETHOXAZOLE-TMP DS TABLET 50537028_1 CDM 0250 RC 60687-0531-01 NDC inpatient 1 UN 1.95 1.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.35 69 999999999 1.18 1.89 percent of total billed charges SULFAMETHOXAZOLE-TMP DS TABLET 50537028_1 CDM 0250 RC 60687-0531-01 NDC inpatient 1 UN 1.95 1.27 UMR - ALL PLANS UMR - ALL PLANS 1.37 70 999999999 1.18 1.89 percent of total billed charges SULFAMETHOXAZOLE-TMP DS TABLET 50537028_1 CDM 0250 RC 60687-0531-01 NDC inpatient 1 UN 1.95 1.27 SIHO - ALL PLANS SIHO - ALL PLANS 1.76 90 999999999 1.18 1.89 percent of total billed charges SULFAMETHOXAZOLE-TMP DS TABLET 50537028_1 CDM 0250 RC 60687-0531-01 NDC inpatient 1 UN 1.95 1.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.18 60.55 999999999 1.18 1.89 percent of total billed charges SULFAMETHOXAZOLE-TMP DS TABLET 50537028_1 CDM 0250 RC 60687-0531-01 NDC inpatient 1 UN 1.95 1.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.18 1.89 SULFAMETHOXAZOLE-TMP DS TABLET 50537028_1 CDM 0250 RC 60687-0531-01 NDC inpatient 1 UN 1.95 1.27 ANTHEM HMO ANTHEM HMO 999999999 1.18 1.89 SULFAMETHOXAZOLE-TMP DS TABLET 50537028_1 CDM 0250 RC 60687-0531-01 NDC inpatient 1 UN 1.95 1.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.18 1.89 SULFAMETHOXAZOLE-TMP DS TABLET 50537028_1 CDM 0250 RC 60687-0531-01 NDC inpatient 1 UN 1.95 1.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.18 1.89 SULFAMETHOXAZOLE-TMP DS TABLET 50537028_1 CDM 0250 RC 60687-0531-01 NDC inpatient 1 UN 1.95 1.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.32 67.6 999999999 1.18 1.89 percent of total billed charges SULFAMETHOXAZOLE-TMP DS TABLET 50537028_1 CDM 0250 RC 60687-0531-01 NDC inpatient 1 UN 1.95 1.27 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.18 1.89 SODIUM NITROPRUSSIDE 50 MG/2ML 50537033_1 CDM 0250 RC 70069-0261-01 NDC inpatient 1 UN 85.6 55.64 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.64 65 999999999 51.83 83.03 percent of total billed charges SODIUM NITROPRUSSIDE 50 MG/2ML 50537033_1 CDM 0250 RC 70069-0261-01 NDC inpatient 1 UN 85.6 55.64 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.03 97 999999999 51.83 83.03 percent of total billed charges SODIUM NITROPRUSSIDE 50 MG/2ML 50537033_1 CDM 0250 RC 70069-0261-01 NDC inpatient 1 UN 85.6 55.64 AETNA AETNA 67.62 79 999999999 51.83 83.03 percent of total billed charges SODIUM NITROPRUSSIDE 50 MG/2ML 50537033_1 CDM 0250 RC 70069-0261-01 NDC inpatient 1 UN 85.6 55.64 HUMANA - ALL PLANS HUMANA - ALL PLANS 66.77 78 999999999 51.83 83.03 percent of total billed charges SODIUM NITROPRUSSIDE 50 MG/2ML 50537033_1 CDM 0250 RC 70069-0261-01 NDC inpatient 1 UN 85.6 55.64 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.06 69 999999999 51.83 83.03 percent of total billed charges SODIUM NITROPRUSSIDE 50 MG/2ML 50537033_1 CDM 0250 RC 70069-0261-01 NDC inpatient 1 UN 85.6 55.64 UMR - ALL PLANS UMR - ALL PLANS 59.92 70 999999999 51.83 83.03 percent of total billed charges SODIUM NITROPRUSSIDE 50 MG/2ML 50537033_1 CDM 0250 RC 70069-0261-01 NDC inpatient 1 UN 85.6 55.64 SIHO - ALL PLANS SIHO - ALL PLANS 77.04 90 999999999 51.83 83.03 percent of total billed charges SODIUM NITROPRUSSIDE 50 MG/2ML 50537033_1 CDM 0250 RC 70069-0261-01 NDC inpatient 1 UN 85.6 55.64 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 51.83 60.55 999999999 51.83 83.03 percent of total billed charges SODIUM NITROPRUSSIDE 50 MG/2ML 50537033_1 CDM 0250 RC 70069-0261-01 NDC inpatient 1 UN 85.6 55.64 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 51.83 83.03 SODIUM NITROPRUSSIDE 50 MG/2ML 50537033_1 CDM 0250 RC 70069-0261-01 NDC inpatient 1 UN 85.6 55.64 ANTHEM HMO ANTHEM HMO 999999999 51.83 83.03 SODIUM NITROPRUSSIDE 50 MG/2ML 50537033_1 CDM 0250 RC 70069-0261-01 NDC inpatient 1 UN 85.6 55.64 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 51.83 83.03 SODIUM NITROPRUSSIDE 50 MG/2ML 50537033_1 CDM 0250 RC 70069-0261-01 NDC inpatient 1 UN 85.6 55.64 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 51.83 83.03 SODIUM NITROPRUSSIDE 50 MG/2ML 50537033_1 CDM 0250 RC 70069-0261-01 NDC inpatient 1 UN 85.6 55.64 CIGNA - ALL PLANS CIGNA - ALL PLANS 57.87 67.6 999999999 51.83 83.03 percent of total billed charges SODIUM NITROPRUSSIDE 50 MG/2ML 50537033_1 CDM 0250 RC 70069-0261-01 NDC inpatient 1 UN 85.6 55.64 UHC - ALL PLANS UHC - ALL PLANS 999999999 51.83 83.03 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50537358_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 73.45 65 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50537358_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 109.61 97 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50537358_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 AETNA AETNA 89.27 79 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50537358_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.14 78 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50537358_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.97 69 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50537358_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 UMR - ALL PLANS UMR - ALL PLANS 79.1 70 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50537358_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 SIHO - ALL PLANS SIHO - ALL PLANS 101.7 90 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50537358_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 68.42 60.55 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50537358_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 68.42 109.61 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50537358_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 ANTHEM HMO ANTHEM HMO 999999999 68.42 109.61 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50537358_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 68.42 109.61 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50537358_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 68.42 109.61 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50537358_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 76.39 67.6 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50537358_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 68.42 109.61 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50537359_1 CDM 0306 RC 87491 HCPCS inpatient 108 70.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.2 65 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50537359_1 CDM 0306 RC 87491 HCPCS inpatient 108 70.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 104.76 97 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50537359_1 CDM 0306 RC 87491 HCPCS inpatient 108 70.2 AETNA AETNA 85.32 79 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50537359_1 CDM 0306 RC 87491 HCPCS inpatient 108 70.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 84.24 78 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50537359_1 CDM 0306 RC 87491 HCPCS inpatient 108 70.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 74.52 69 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50537359_1 CDM 0306 RC 87491 HCPCS inpatient 108 70.2 UMR - ALL PLANS UMR - ALL PLANS 75.6 70 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50537359_1 CDM 0306 RC 87491 HCPCS inpatient 108 70.2 SIHO - ALL PLANS SIHO - ALL PLANS 97.2 90 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50537359_1 CDM 0306 RC 87491 HCPCS inpatient 108 70.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 65.39 60.55 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50537359_1 CDM 0306 RC 87491 HCPCS inpatient 108 70.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 65.39 104.76 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50537359_1 CDM 0306 RC 87491 HCPCS inpatient 108 70.2 ANTHEM HMO ANTHEM HMO 999999999 65.39 104.76 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50537359_1 CDM 0306 RC 87491 HCPCS inpatient 108 70.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 65.39 104.76 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50537359_1 CDM 0306 RC 87491 HCPCS inpatient 108 70.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 65.39 104.76 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50537359_1 CDM 0306 RC 87491 HCPCS inpatient 108 70.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.01 67.6 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50537359_1 CDM 0306 RC 87491 HCPCS inpatient 108 70.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 65.39 104.76 "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537793_1 CDM 0636 RC 68982-0850-04 NDC J1568 HCPCS inpatient 40 UN 4143.94 2693.56 SELF PAY DISCOUNT SELF PAY DISCOUNT 2693.56 65 999999999 2509.16 4019.62 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537793_1 CDM 0636 RC 68982-0850-04 NDC J1568 HCPCS inpatient 40 UN 4143.94 2693.56 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4019.62 97 999999999 2509.16 4019.62 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537793_1 CDM 0636 RC 68982-0850-04 NDC J1568 HCPCS inpatient 40 UN 4143.94 2693.56 AETNA AETNA 3273.71 79 999999999 2509.16 4019.62 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537793_1 CDM 0636 RC 68982-0850-04 NDC J1568 HCPCS inpatient 40 UN 4143.94 2693.56 HUMANA - ALL PLANS HUMANA - ALL PLANS 3232.27 78 999999999 2509.16 4019.62 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537793_1 CDM 0636 RC 68982-0850-04 NDC J1568 HCPCS inpatient 40 UN 4143.94 2693.56 ENCORE - ALL PLANS ENCORE - ALL PLANS 2859.32 69 999999999 2509.16 4019.62 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537793_1 CDM 0636 RC 68982-0850-04 NDC J1568 HCPCS inpatient 40 UN 4143.94 2693.56 UMR - ALL PLANS UMR - ALL PLANS 2900.76 70 999999999 2509.16 4019.62 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537793_1 CDM 0636 RC 68982-0850-04 NDC J1568 HCPCS inpatient 40 UN 4143.94 2693.56 SIHO - ALL PLANS SIHO - ALL PLANS 3729.55 90 999999999 2509.16 4019.62 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537793_1 CDM 0636 RC 68982-0850-04 NDC J1568 HCPCS inpatient 40 UN 4143.94 2693.56 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2509.16 60.55 999999999 2509.16 4019.62 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537793_1 CDM 0636 RC 68982-0850-04 NDC J1568 HCPCS inpatient 40 UN 4143.94 2693.56 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2509.16 4019.62 "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537793_1 CDM 0636 RC 68982-0850-04 NDC J1568 HCPCS inpatient 40 UN 4143.94 2693.56 ANTHEM HMO ANTHEM HMO 999999999 2509.16 4019.62 "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537793_1 CDM 0636 RC 68982-0850-04 NDC J1568 HCPCS inpatient 40 UN 4143.94 2693.56 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2509.16 4019.62 "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537793_1 CDM 0636 RC 68982-0850-04 NDC J1568 HCPCS inpatient 40 UN 4143.94 2693.56 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2509.16 4019.62 "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537793_1 CDM 0636 RC 68982-0850-04 NDC J1568 HCPCS inpatient 40 UN 4143.94 2693.56 CIGNA - ALL PLANS CIGNA - ALL PLANS 2801.3 67.6 999999999 2509.16 4019.62 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537793_1 CDM 0636 RC 68982-0850-04 NDC J1568 HCPCS inpatient 40 UN 4143.94 2693.56 UHC - ALL PLANS UHC - ALL PLANS 999999999 2509.16 4019.62 "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537808_1 CDM 0636 RC 68982-0850-05 NDC J1568 HCPCS inpatient 60 UN 5873.8 3817.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 3817.97 65 999999999 3556.59 5697.59 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537808_1 CDM 0636 RC 68982-0850-05 NDC J1568 HCPCS inpatient 60 UN 5873.8 3817.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5697.59 97 999999999 3556.59 5697.59 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537808_1 CDM 0636 RC 68982-0850-05 NDC J1568 HCPCS inpatient 60 UN 5873.8 3817.97 AETNA AETNA 4640.3 79 999999999 3556.59 5697.59 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537808_1 CDM 0636 RC 68982-0850-05 NDC J1568 HCPCS inpatient 60 UN 5873.8 3817.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 4581.56 78 999999999 3556.59 5697.59 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537808_1 CDM 0636 RC 68982-0850-05 NDC J1568 HCPCS inpatient 60 UN 5873.8 3817.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 4052.92 69 999999999 3556.59 5697.59 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537808_1 CDM 0636 RC 68982-0850-05 NDC J1568 HCPCS inpatient 60 UN 5873.8 3817.97 UMR - ALL PLANS UMR - ALL PLANS 4111.66 70 999999999 3556.59 5697.59 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537808_1 CDM 0636 RC 68982-0850-05 NDC J1568 HCPCS inpatient 60 UN 5873.8 3817.97 SIHO - ALL PLANS SIHO - ALL PLANS 5286.42 90 999999999 3556.59 5697.59 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537808_1 CDM 0636 RC 68982-0850-05 NDC J1568 HCPCS inpatient 60 UN 5873.8 3817.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3556.59 60.55 999999999 3556.59 5697.59 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537808_1 CDM 0636 RC 68982-0850-05 NDC J1568 HCPCS inpatient 60 UN 5873.8 3817.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3556.59 5697.59 "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537808_1 CDM 0636 RC 68982-0850-05 NDC J1568 HCPCS inpatient 60 UN 5873.8 3817.97 ANTHEM HMO ANTHEM HMO 999999999 3556.59 5697.59 "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537808_1 CDM 0636 RC 68982-0850-05 NDC J1568 HCPCS inpatient 60 UN 5873.8 3817.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3556.59 5697.59 "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537808_1 CDM 0636 RC 68982-0850-05 NDC J1568 HCPCS inpatient 60 UN 5873.8 3817.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3556.59 5697.59 "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537808_1 CDM 0636 RC 68982-0850-05 NDC J1568 HCPCS inpatient 60 UN 5873.8 3817.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 3970.69 67.6 999999999 3556.59 5697.59 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), 500 MG" 50537808_1 CDM 0636 RC 68982-0850-05 NDC J1568 HCPCS inpatient 60 UN 5873.8 3817.97 UHC - ALL PLANS UHC - ALL PLANS 999999999 3556.59 5697.59 "4"" SMOOTH DOUBLE TROCAR 1600454" 50538207_1 CDM 0272 RC inpatient 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges "4"" SMOOTH DOUBLE TROCAR 1600454" 50538207_1 CDM 0272 RC inpatient 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges "4"" SMOOTH DOUBLE TROCAR 1600454" 50538207_1 CDM 0272 RC inpatient 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges "4"" SMOOTH DOUBLE TROCAR 1600454" 50538207_1 CDM 0272 RC inpatient 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges "4"" SMOOTH DOUBLE TROCAR 1600454" 50538207_1 CDM 0272 RC inpatient 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges "4"" SMOOTH DOUBLE TROCAR 1600454" 50538207_1 CDM 0272 RC inpatient 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges "4"" SMOOTH DOUBLE TROCAR 1600454" 50538207_1 CDM 0272 RC inpatient 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges "4"" SMOOTH DOUBLE TROCAR 1600454" 50538207_1 CDM 0272 RC inpatient 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges "4"" SMOOTH DOUBLE TROCAR 1600454" 50538207_1 CDM 0272 RC inpatient 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 "4"" SMOOTH DOUBLE TROCAR 1600454" 50538207_1 CDM 0272 RC inpatient 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 "4"" SMOOTH DOUBLE TROCAR 1600454" 50538207_1 CDM 0272 RC inpatient 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 "4"" SMOOTH DOUBLE TROCAR 1600454" 50538207_1 CDM 0272 RC inpatient 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 "4"" SMOOTH DOUBLE TROCAR 1600454" 50538207_1 CDM 0272 RC inpatient 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges "4"" SMOOTH DOUBLE TROCAR 1600454" 50538207_1 CDM 0272 RC inpatient 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 "4"" THREADED DOUBLE TROCAR K-WIRE 1600-1454T" 50538208_1 CDM 0278 RC inpatient 121 78.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 78.65 65 999999999 73.27 117.37 percent of total billed charges "4"" THREADED DOUBLE TROCAR K-WIRE 1600-1454T" 50538208_1 CDM 0278 RC inpatient 121 78.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 117.37 97 999999999 73.27 117.37 percent of total billed charges "4"" THREADED DOUBLE TROCAR K-WIRE 1600-1454T" 50538208_1 CDM 0278 RC inpatient 121 78.65 AETNA AETNA 95.59 79 999999999 73.27 117.37 percent of total billed charges "4"" THREADED DOUBLE TROCAR K-WIRE 1600-1454T" 50538208_1 CDM 0278 RC inpatient 121 78.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 94.38 78 999999999 73.27 117.37 percent of total billed charges "4"" THREADED DOUBLE TROCAR K-WIRE 1600-1454T" 50538208_1 CDM 0278 RC inpatient 121 78.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 83.49 69 999999999 73.27 117.37 percent of total billed charges "4"" THREADED DOUBLE TROCAR K-WIRE 1600-1454T" 50538208_1 CDM 0278 RC inpatient 121 78.65 UMR - ALL PLANS UMR - ALL PLANS 84.7 70 999999999 73.27 117.37 percent of total billed charges "4"" THREADED DOUBLE TROCAR K-WIRE 1600-1454T" 50538208_1 CDM 0278 RC inpatient 121 78.65 SIHO - ALL PLANS SIHO - ALL PLANS 108.9 90 999999999 73.27 117.37 percent of total billed charges "4"" THREADED DOUBLE TROCAR K-WIRE 1600-1454T" 50538208_1 CDM 0278 RC inpatient 121 78.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.27 60.55 999999999 73.27 117.37 percent of total billed charges "4"" THREADED DOUBLE TROCAR K-WIRE 1600-1454T" 50538208_1 CDM 0278 RC inpatient 121 78.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.27 117.37 "4"" THREADED DOUBLE TROCAR K-WIRE 1600-1454T" 50538208_1 CDM 0278 RC inpatient 121 78.65 ANTHEM HMO ANTHEM HMO 999999999 73.27 117.37 "4"" THREADED DOUBLE TROCAR K-WIRE 1600-1454T" 50538208_1 CDM 0278 RC inpatient 121 78.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.27 117.37 "4"" THREADED DOUBLE TROCAR K-WIRE 1600-1454T" 50538208_1 CDM 0278 RC inpatient 121 78.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.27 117.37 "4"" THREADED DOUBLE TROCAR K-WIRE 1600-1454T" 50538208_1 CDM 0278 RC inpatient 121 78.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.8 67.6 999999999 73.27 117.37 percent of total billed charges "4"" THREADED DOUBLE TROCAR K-WIRE 1600-1454T" 50538208_1 CDM 0278 RC inpatient 121 78.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.27 117.37 METOPROLOL SUCC ER 50 MG TAB 50540123_1 CDM 0250 RC 60687-0402-01 NDC inpatient 1 UN 1.85 1.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.2 65 999999999 1.12 1.79 percent of total billed charges METOPROLOL SUCC ER 50 MG TAB 50540123_1 CDM 0250 RC 60687-0402-01 NDC inpatient 1 UN 1.85 1.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.79 97 999999999 1.12 1.79 percent of total billed charges METOPROLOL SUCC ER 50 MG TAB 50540123_1 CDM 0250 RC 60687-0402-01 NDC inpatient 1 UN 1.85 1.2 AETNA AETNA 1.46 79 999999999 1.12 1.79 percent of total billed charges METOPROLOL SUCC ER 50 MG TAB 50540123_1 CDM 0250 RC 60687-0402-01 NDC inpatient 1 UN 1.85 1.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.44 78 999999999 1.12 1.79 percent of total billed charges METOPROLOL SUCC ER 50 MG TAB 50540123_1 CDM 0250 RC 60687-0402-01 NDC inpatient 1 UN 1.85 1.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.28 69 999999999 1.12 1.79 percent of total billed charges METOPROLOL SUCC ER 50 MG TAB 50540123_1 CDM 0250 RC 60687-0402-01 NDC inpatient 1 UN 1.85 1.2 UMR - ALL PLANS UMR - ALL PLANS 1.3 70 999999999 1.12 1.79 percent of total billed charges METOPROLOL SUCC ER 50 MG TAB 50540123_1 CDM 0250 RC 60687-0402-01 NDC inpatient 1 UN 1.85 1.2 SIHO - ALL PLANS SIHO - ALL PLANS 1.67 90 999999999 1.12 1.79 percent of total billed charges METOPROLOL SUCC ER 50 MG TAB 50540123_1 CDM 0250 RC 60687-0402-01 NDC inpatient 1 UN 1.85 1.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.12 60.55 999999999 1.12 1.79 percent of total billed charges METOPROLOL SUCC ER 50 MG TAB 50540123_1 CDM 0250 RC 60687-0402-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.12 1.79 METOPROLOL SUCC ER 50 MG TAB 50540123_1 CDM 0250 RC 60687-0402-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM HMO ANTHEM HMO 999999999 1.12 1.79 METOPROLOL SUCC ER 50 MG TAB 50540123_1 CDM 0250 RC 60687-0402-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.12 1.79 METOPROLOL SUCC ER 50 MG TAB 50540123_1 CDM 0250 RC 60687-0402-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.12 1.79 METOPROLOL SUCC ER 50 MG TAB 50540123_1 CDM 0250 RC 60687-0402-01 NDC inpatient 1 UN 1.85 1.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.25 67.6 999999999 1.12 1.79 percent of total billed charges METOPROLOL SUCC ER 50 MG TAB 50540123_1 CDM 0250 RC 60687-0402-01 NDC inpatient 1 UN 1.85 1.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.12 1.79 GABAPENTIN 600 MG TABLET 50540124_1 CDM 0250 RC 60687-0507-01 NDC inpatient 1 UN 1.86 1.21 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.21 65 999999999 1.13 1.8 percent of total billed charges GABAPENTIN 600 MG TABLET 50540124_1 CDM 0250 RC 60687-0507-01 NDC inpatient 1 UN 1.86 1.21 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.8 97 999999999 1.13 1.8 percent of total billed charges GABAPENTIN 600 MG TABLET 50540124_1 CDM 0250 RC 60687-0507-01 NDC inpatient 1 UN 1.86 1.21 AETNA AETNA 1.47 79 999999999 1.13 1.8 percent of total billed charges GABAPENTIN 600 MG TABLET 50540124_1 CDM 0250 RC 60687-0507-01 NDC inpatient 1 UN 1.86 1.21 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.45 78 999999999 1.13 1.8 percent of total billed charges GABAPENTIN 600 MG TABLET 50540124_1 CDM 0250 RC 60687-0507-01 NDC inpatient 1 UN 1.86 1.21 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.28 69 999999999 1.13 1.8 percent of total billed charges GABAPENTIN 600 MG TABLET 50540124_1 CDM 0250 RC 60687-0507-01 NDC inpatient 1 UN 1.86 1.21 UMR - ALL PLANS UMR - ALL PLANS 1.3 70 999999999 1.13 1.8 percent of total billed charges GABAPENTIN 600 MG TABLET 50540124_1 CDM 0250 RC 60687-0507-01 NDC inpatient 1 UN 1.86 1.21 SIHO - ALL PLANS SIHO - ALL PLANS 1.67 90 999999999 1.13 1.8 percent of total billed charges GABAPENTIN 600 MG TABLET 50540124_1 CDM 0250 RC 60687-0507-01 NDC inpatient 1 UN 1.86 1.21 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.13 60.55 999999999 1.13 1.8 percent of total billed charges GABAPENTIN 600 MG TABLET 50540124_1 CDM 0250 RC 60687-0507-01 NDC inpatient 1 UN 1.86 1.21 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.13 1.8 GABAPENTIN 600 MG TABLET 50540124_1 CDM 0250 RC 60687-0507-01 NDC inpatient 1 UN 1.86 1.21 ANTHEM HMO ANTHEM HMO 999999999 1.13 1.8 GABAPENTIN 600 MG TABLET 50540124_1 CDM 0250 RC 60687-0507-01 NDC inpatient 1 UN 1.86 1.21 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.13 1.8 GABAPENTIN 600 MG TABLET 50540124_1 CDM 0250 RC 60687-0507-01 NDC inpatient 1 UN 1.86 1.21 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.13 1.8 GABAPENTIN 600 MG TABLET 50540124_1 CDM 0250 RC 60687-0507-01 NDC inpatient 1 UN 1.86 1.21 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.26 67.6 999999999 1.13 1.8 percent of total billed charges GABAPENTIN 600 MG TABLET 50540124_1 CDM 0250 RC 60687-0507-01 NDC inpatient 1 UN 1.86 1.21 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.13 1.8 CLONIDINE 0.1 MG/DAY PATCH 50540125_1 CDM 0250 RC 00591-3508-04 NDC inpatient 1 UN 40.7 26.46 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.46 65 999999999 24.64 39.48 percent of total billed charges CLONIDINE 0.1 MG/DAY PATCH 50540125_1 CDM 0250 RC 00591-3508-04 NDC inpatient 1 UN 40.7 26.46 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39.48 97 999999999 24.64 39.48 percent of total billed charges CLONIDINE 0.1 MG/DAY PATCH 50540125_1 CDM 0250 RC 00591-3508-04 NDC inpatient 1 UN 40.7 26.46 AETNA AETNA 32.15 79 999999999 24.64 39.48 percent of total billed charges CLONIDINE 0.1 MG/DAY PATCH 50540125_1 CDM 0250 RC 00591-3508-04 NDC inpatient 1 UN 40.7 26.46 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.75 78 999999999 24.64 39.48 percent of total billed charges CLONIDINE 0.1 MG/DAY PATCH 50540125_1 CDM 0250 RC 00591-3508-04 NDC inpatient 1 UN 40.7 26.46 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.08 69 999999999 24.64 39.48 percent of total billed charges CLONIDINE 0.1 MG/DAY PATCH 50540125_1 CDM 0250 RC 00591-3508-04 NDC inpatient 1 UN 40.7 26.46 UMR - ALL PLANS UMR - ALL PLANS 28.49 70 999999999 24.64 39.48 percent of total billed charges CLONIDINE 0.1 MG/DAY PATCH 50540125_1 CDM 0250 RC 00591-3508-04 NDC inpatient 1 UN 40.7 26.46 SIHO - ALL PLANS SIHO - ALL PLANS 36.63 90 999999999 24.64 39.48 percent of total billed charges CLONIDINE 0.1 MG/DAY PATCH 50540125_1 CDM 0250 RC 00591-3508-04 NDC inpatient 1 UN 40.7 26.46 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.64 60.55 999999999 24.64 39.48 percent of total billed charges CLONIDINE 0.1 MG/DAY PATCH 50540125_1 CDM 0250 RC 00591-3508-04 NDC inpatient 1 UN 40.7 26.46 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.64 39.48 CLONIDINE 0.1 MG/DAY PATCH 50540125_1 CDM 0250 RC 00591-3508-04 NDC inpatient 1 UN 40.7 26.46 ANTHEM HMO ANTHEM HMO 999999999 24.64 39.48 CLONIDINE 0.1 MG/DAY PATCH 50540125_1 CDM 0250 RC 00591-3508-04 NDC inpatient 1 UN 40.7 26.46 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.64 39.48 CLONIDINE 0.1 MG/DAY PATCH 50540125_1 CDM 0250 RC 00591-3508-04 NDC inpatient 1 UN 40.7 26.46 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.64 39.48 CLONIDINE 0.1 MG/DAY PATCH 50540125_1 CDM 0250 RC 00591-3508-04 NDC inpatient 1 UN 40.7 26.46 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.51 67.6 999999999 24.64 39.48 percent of total billed charges CLONIDINE 0.1 MG/DAY PATCH 50540125_1 CDM 0250 RC 00591-3508-04 NDC inpatient 1 UN 40.7 26.46 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.64 39.48 "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 50540127_1 CDM 0636 RC 62935-0303-30 NDC J9217 HCPCS inpatient 4 UN 2273 1477.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1477.45 65 999999999 1376.3 2204.81 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 50540127_1 CDM 0636 RC 62935-0303-30 NDC J9217 HCPCS inpatient 4 UN 2273 1477.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2204.81 97 999999999 1376.3 2204.81 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 50540127_1 CDM 0636 RC 62935-0303-30 NDC J9217 HCPCS inpatient 4 UN 2273 1477.45 AETNA AETNA 1795.67 79 999999999 1376.3 2204.81 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 50540127_1 CDM 0636 RC 62935-0303-30 NDC J9217 HCPCS inpatient 4 UN 2273 1477.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1772.94 78 999999999 1376.3 2204.81 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 50540127_1 CDM 0636 RC 62935-0303-30 NDC J9217 HCPCS inpatient 4 UN 2273 1477.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1568.37 69 999999999 1376.3 2204.81 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 50540127_1 CDM 0636 RC 62935-0303-30 NDC J9217 HCPCS inpatient 4 UN 2273 1477.45 UMR - ALL PLANS UMR - ALL PLANS 1591.1 70 999999999 1376.3 2204.81 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 50540127_1 CDM 0636 RC 62935-0303-30 NDC J9217 HCPCS inpatient 4 UN 2273 1477.45 SIHO - ALL PLANS SIHO - ALL PLANS 2045.7 90 999999999 1376.3 2204.81 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 50540127_1 CDM 0636 RC 62935-0303-30 NDC J9217 HCPCS inpatient 4 UN 2273 1477.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1376.3 60.55 999999999 1376.3 2204.81 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 50540127_1 CDM 0636 RC 62935-0303-30 NDC J9217 HCPCS inpatient 4 UN 2273 1477.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1376.3 2204.81 "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 50540127_1 CDM 0636 RC 62935-0303-30 NDC J9217 HCPCS inpatient 4 UN 2273 1477.45 ANTHEM HMO ANTHEM HMO 999999999 1376.3 2204.81 "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 50540127_1 CDM 0636 RC 62935-0303-30 NDC J9217 HCPCS inpatient 4 UN 2273 1477.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1376.3 2204.81 "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 50540127_1 CDM 0636 RC 62935-0303-30 NDC J9217 HCPCS inpatient 4 UN 2273 1477.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1376.3 2204.81 "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 50540127_1 CDM 0636 RC 62935-0303-30 NDC J9217 HCPCS inpatient 4 UN 2273 1477.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1536.55 67.6 999999999 1376.3 2204.81 percent of total billed charges "LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG" 50540127_1 CDM 0636 RC 62935-0303-30 NDC J9217 HCPCS inpatient 4 UN 2273 1477.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1376.3 2204.81 SUCRALFATE 1 GM/10 ML SUSP CUP 50540254_1 CDM 0250 RC 68094-0043-61 NDC inpatient 1 UN 39.05 25.38 SELF PAY DISCOUNT SELF PAY DISCOUNT 25.38 65 999999999 23.64 37.88 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP CUP 50540254_1 CDM 0250 RC 68094-0043-61 NDC inpatient 1 UN 39.05 25.38 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37.88 97 999999999 23.64 37.88 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP CUP 50540254_1 CDM 0250 RC 68094-0043-61 NDC inpatient 1 UN 39.05 25.38 AETNA AETNA 30.85 79 999999999 23.64 37.88 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP CUP 50540254_1 CDM 0250 RC 68094-0043-61 NDC inpatient 1 UN 39.05 25.38 HUMANA - ALL PLANS HUMANA - ALL PLANS 30.46 78 999999999 23.64 37.88 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP CUP 50540254_1 CDM 0250 RC 68094-0043-61 NDC inpatient 1 UN 39.05 25.38 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.94 69 999999999 23.64 37.88 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP CUP 50540254_1 CDM 0250 RC 68094-0043-61 NDC inpatient 1 UN 39.05 25.38 UMR - ALL PLANS UMR - ALL PLANS 27.34 70 999999999 23.64 37.88 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP CUP 50540254_1 CDM 0250 RC 68094-0043-61 NDC inpatient 1 UN 39.05 25.38 SIHO - ALL PLANS SIHO - ALL PLANS 35.15 90 999999999 23.64 37.88 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP CUP 50540254_1 CDM 0250 RC 68094-0043-61 NDC inpatient 1 UN 39.05 25.38 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.64 60.55 999999999 23.64 37.88 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP CUP 50540254_1 CDM 0250 RC 68094-0043-61 NDC inpatient 1 UN 39.05 25.38 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.64 37.88 SUCRALFATE 1 GM/10 ML SUSP CUP 50540254_1 CDM 0250 RC 68094-0043-61 NDC inpatient 1 UN 39.05 25.38 ANTHEM HMO ANTHEM HMO 999999999 23.64 37.88 SUCRALFATE 1 GM/10 ML SUSP CUP 50540254_1 CDM 0250 RC 68094-0043-61 NDC inpatient 1 UN 39.05 25.38 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.64 37.88 SUCRALFATE 1 GM/10 ML SUSP CUP 50540254_1 CDM 0250 RC 68094-0043-61 NDC inpatient 1 UN 39.05 25.38 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.64 37.88 SUCRALFATE 1 GM/10 ML SUSP CUP 50540254_1 CDM 0250 RC 68094-0043-61 NDC inpatient 1 UN 39.05 25.38 CIGNA - ALL PLANS CIGNA - ALL PLANS 26.4 67.6 999999999 23.64 37.88 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP CUP 50540254_1 CDM 0250 RC 68094-0043-61 NDC inpatient 1 UN 39.05 25.38 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.64 37.88 CYCLOBENZAPRINE 10 MG TABLET 50542679_1 CDM 0250 RC 43547-0400-10 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CYCLOBENZAPRINE 10 MG TABLET 50542679_1 CDM 0250 RC 43547-0400-10 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CYCLOBENZAPRINE 10 MG TABLET 50542679_1 CDM 0250 RC 43547-0400-10 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CYCLOBENZAPRINE 10 MG TABLET 50542679_1 CDM 0250 RC 43547-0400-10 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CYCLOBENZAPRINE 10 MG TABLET 50542679_1 CDM 0250 RC 43547-0400-10 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CYCLOBENZAPRINE 10 MG TABLET 50542679_1 CDM 0250 RC 43547-0400-10 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CYCLOBENZAPRINE 10 MG TABLET 50542679_1 CDM 0250 RC 43547-0400-10 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CYCLOBENZAPRINE 10 MG TABLET 50542679_1 CDM 0250 RC 43547-0400-10 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CYCLOBENZAPRINE 10 MG TABLET 50542679_1 CDM 0250 RC 43547-0400-10 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CYCLOBENZAPRINE 10 MG TABLET 50542679_1 CDM 0250 RC 43547-0400-10 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CYCLOBENZAPRINE 10 MG TABLET 50542679_1 CDM 0250 RC 43547-0400-10 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CYCLOBENZAPRINE 10 MG TABLET 50542679_1 CDM 0250 RC 43547-0400-10 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CYCLOBENZAPRINE 10 MG TABLET 50542679_1 CDM 0250 RC 43547-0400-10 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CYCLOBENZAPRINE 10 MG TABLET 50542679_1 CDM 0250 RC 43547-0400-10 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 50543416_1 CDM 0250 RC 36000-0012-25 NDC J2405 HCPCS inpatient 4 UN 19.55 12.71 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.71 65 999999999 11.84 18.96 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 50543416_1 CDM 0250 RC 36000-0012-25 NDC J2405 HCPCS inpatient 4 UN 19.55 12.71 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 18.96 97 999999999 11.84 18.96 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 50543416_1 CDM 0250 RC 36000-0012-25 NDC J2405 HCPCS inpatient 4 UN 19.55 12.71 AETNA AETNA 15.44 79 999999999 11.84 18.96 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 50543416_1 CDM 0250 RC 36000-0012-25 NDC J2405 HCPCS inpatient 4 UN 19.55 12.71 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.25 78 999999999 11.84 18.96 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 50543416_1 CDM 0250 RC 36000-0012-25 NDC J2405 HCPCS inpatient 4 UN 19.55 12.71 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.49 69 999999999 11.84 18.96 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 50543416_1 CDM 0250 RC 36000-0012-25 NDC J2405 HCPCS inpatient 4 UN 19.55 12.71 UMR - ALL PLANS UMR - ALL PLANS 13.69 70 999999999 11.84 18.96 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 50543416_1 CDM 0250 RC 36000-0012-25 NDC J2405 HCPCS inpatient 4 UN 19.55 12.71 SIHO - ALL PLANS SIHO - ALL PLANS 17.6 90 999999999 11.84 18.96 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 50543416_1 CDM 0250 RC 36000-0012-25 NDC J2405 HCPCS inpatient 4 UN 19.55 12.71 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.84 60.55 999999999 11.84 18.96 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 50543416_1 CDM 0250 RC 36000-0012-25 NDC J2405 HCPCS inpatient 4 UN 19.55 12.71 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.84 18.96 "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 50543416_1 CDM 0250 RC 36000-0012-25 NDC J2405 HCPCS inpatient 4 UN 19.55 12.71 ANTHEM HMO ANTHEM HMO 999999999 11.84 18.96 "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 50543416_1 CDM 0250 RC 36000-0012-25 NDC J2405 HCPCS inpatient 4 UN 19.55 12.71 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.84 18.96 "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 50543416_1 CDM 0250 RC 36000-0012-25 NDC J2405 HCPCS inpatient 4 UN 19.55 12.71 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.84 18.96 "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 50543416_1 CDM 0250 RC 36000-0012-25 NDC J2405 HCPCS inpatient 4 UN 19.55 12.71 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.22 67.6 999999999 11.84 18.96 percent of total billed charges "INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG" 50543416_1 CDM 0250 RC 36000-0012-25 NDC J2405 HCPCS inpatient 4 UN 19.55 12.71 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.84 18.96 LEVOTHYROXINE 25 MCG TABLET 50543703_1 CDM 0250 RC 60687-0453-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 25 MCG TABLET 50543703_1 CDM 0250 RC 60687-0453-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 25 MCG TABLET 50543703_1 CDM 0250 RC 60687-0453-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 25 MCG TABLET 50543703_1 CDM 0250 RC 60687-0453-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 25 MCG TABLET 50543703_1 CDM 0250 RC 60687-0453-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 25 MCG TABLET 50543703_1 CDM 0250 RC 60687-0453-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 25 MCG TABLET 50543703_1 CDM 0250 RC 60687-0453-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 25 MCG TABLET 50543703_1 CDM 0250 RC 60687-0453-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 25 MCG TABLET 50543703_1 CDM 0250 RC 60687-0453-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LEVOTHYROXINE 25 MCG TABLET 50543703_1 CDM 0250 RC 60687-0453-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LEVOTHYROXINE 25 MCG TABLET 50543703_1 CDM 0250 RC 60687-0453-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 25 MCG TABLET 50543703_1 CDM 0250 RC 60687-0453-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 25 MCG TABLET 50543703_1 CDM 0250 RC 60687-0453-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 25 MCG TABLET 50543703_1 CDM 0250 RC 60687-0453-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 50543980_1 CDM 0301 RC 86300 HCPCS inpatient 270 175.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 175.5 65 999999999 163.49 261.9 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 50543980_1 CDM 0301 RC 86300 HCPCS inpatient 270 175.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 261.9 97 999999999 163.49 261.9 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 50543980_1 CDM 0301 RC 86300 HCPCS inpatient 270 175.5 AETNA AETNA 213.3 79 999999999 163.49 261.9 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 50543980_1 CDM 0301 RC 86300 HCPCS inpatient 270 175.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 210.6 78 999999999 163.49 261.9 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 50543980_1 CDM 0301 RC 86300 HCPCS inpatient 270 175.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 186.3 69 999999999 163.49 261.9 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 50543980_1 CDM 0301 RC 86300 HCPCS inpatient 270 175.5 UMR - ALL PLANS UMR - ALL PLANS 189 70 999999999 163.49 261.9 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 50543980_1 CDM 0301 RC 86300 HCPCS inpatient 270 175.5 SIHO - ALL PLANS SIHO - ALL PLANS 243 90 999999999 163.49 261.9 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 50543980_1 CDM 0301 RC 86300 HCPCS inpatient 270 175.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 163.49 60.55 999999999 163.49 261.9 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 50543980_1 CDM 0301 RC 86300 HCPCS inpatient 270 175.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 163.49 261.9 "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 50543980_1 CDM 0301 RC 86300 HCPCS inpatient 270 175.5 ANTHEM HMO ANTHEM HMO 999999999 163.49 261.9 "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 50543980_1 CDM 0301 RC 86300 HCPCS inpatient 270 175.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 163.49 261.9 "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 50543980_1 CDM 0301 RC 86300 HCPCS inpatient 270 175.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 163.49 261.9 "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 50543980_1 CDM 0301 RC 86300 HCPCS inpatient 270 175.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 182.52 67.6 999999999 163.49 261.9 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 15-3" 50543980_1 CDM 0301 RC 86300 HCPCS inpatient 270 175.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 163.49 261.9 "Measurement of complement (immune system proteins), antigen," 50543981_1 CDM 0301 RC 86160 HCPCS inpatient 166 107.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.9 65 999999999 100.51 161.02 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50543981_1 CDM 0301 RC 86160 HCPCS inpatient 166 107.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.02 97 999999999 100.51 161.02 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50543981_1 CDM 0301 RC 86160 HCPCS inpatient 166 107.9 AETNA AETNA 131.14 79 999999999 100.51 161.02 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50543981_1 CDM 0301 RC 86160 HCPCS inpatient 166 107.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 129.48 78 999999999 100.51 161.02 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50543981_1 CDM 0301 RC 86160 HCPCS inpatient 166 107.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 114.54 69 999999999 100.51 161.02 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50543981_1 CDM 0301 RC 86160 HCPCS inpatient 166 107.9 UMR - ALL PLANS UMR - ALL PLANS 116.2 70 999999999 100.51 161.02 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50543981_1 CDM 0301 RC 86160 HCPCS inpatient 166 107.9 SIHO - ALL PLANS SIHO - ALL PLANS 149.4 90 999999999 100.51 161.02 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50543981_1 CDM 0301 RC 86160 HCPCS inpatient 166 107.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 100.51 60.55 999999999 100.51 161.02 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50543981_1 CDM 0301 RC 86160 HCPCS inpatient 166 107.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 100.51 161.02 "Measurement of complement (immune system proteins), antigen," 50543981_1 CDM 0301 RC 86160 HCPCS inpatient 166 107.9 ANTHEM HMO ANTHEM HMO 999999999 100.51 161.02 "Measurement of complement (immune system proteins), antigen," 50543981_1 CDM 0301 RC 86160 HCPCS inpatient 166 107.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 100.51 161.02 "Measurement of complement (immune system proteins), antigen," 50543981_1 CDM 0301 RC 86160 HCPCS inpatient 166 107.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 100.51 161.02 "Measurement of complement (immune system proteins), antigen," 50543981_1 CDM 0301 RC 86160 HCPCS inpatient 166 107.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.22 67.6 999999999 100.51 161.02 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 50543981_1 CDM 0301 RC 86160 HCPCS inpatient 166 107.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 100.51 161.02 Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 50543982_1 CDM 0301 RC 81220 HCPCS inpatient 659 428.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 428.35 65 999999999 399.02 639.23 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 50543982_1 CDM 0301 RC 81220 HCPCS inpatient 659 428.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 639.23 97 999999999 399.02 639.23 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 50543982_1 CDM 0301 RC 81220 HCPCS inpatient 659 428.35 AETNA AETNA 520.61 79 999999999 399.02 639.23 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 50543982_1 CDM 0301 RC 81220 HCPCS inpatient 659 428.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 514.02 78 999999999 399.02 639.23 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 50543982_1 CDM 0301 RC 81220 HCPCS inpatient 659 428.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 454.71 69 999999999 399.02 639.23 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 50543982_1 CDM 0301 RC 81220 HCPCS inpatient 659 428.35 UMR - ALL PLANS UMR - ALL PLANS 461.3 70 999999999 399.02 639.23 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 50543982_1 CDM 0301 RC 81220 HCPCS inpatient 659 428.35 SIHO - ALL PLANS SIHO - ALL PLANS 593.1 90 999999999 399.02 639.23 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 50543982_1 CDM 0301 RC 81220 HCPCS inpatient 659 428.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 399.02 60.55 999999999 399.02 639.23 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 50543982_1 CDM 0301 RC 81220 HCPCS inpatient 659 428.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 399.02 639.23 Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 50543982_1 CDM 0301 RC 81220 HCPCS inpatient 659 428.35 ANTHEM HMO ANTHEM HMO 999999999 399.02 639.23 Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 50543982_1 CDM 0301 RC 81220 HCPCS inpatient 659 428.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 399.02 639.23 Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 50543982_1 CDM 0301 RC 81220 HCPCS inpatient 659 428.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 399.02 639.23 Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 50543982_1 CDM 0301 RC 81220 HCPCS inpatient 659 428.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 445.48 67.6 999999999 399.02 639.23 percent of total billed charges Gene analysis (cystic fibrosis transmembrane conductance regular) common variants 50543982_1 CDM 0301 RC 81220 HCPCS inpatient 659 428.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 399.02 639.23 "Folic acid level, RBC" 50543984_1 CDM 0301 RC 82747 HCPCS inpatient 227 147.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 147.55 65 999999999 137.45 220.19 percent of total billed charges "Folic acid level, RBC" 50543984_1 CDM 0301 RC 82747 HCPCS inpatient 227 147.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 220.19 97 999999999 137.45 220.19 percent of total billed charges "Folic acid level, RBC" 50543984_1 CDM 0301 RC 82747 HCPCS inpatient 227 147.55 AETNA AETNA 179.33 79 999999999 137.45 220.19 percent of total billed charges "Folic acid level, RBC" 50543984_1 CDM 0301 RC 82747 HCPCS inpatient 227 147.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 177.06 78 999999999 137.45 220.19 percent of total billed charges "Folic acid level, RBC" 50543984_1 CDM 0301 RC 82747 HCPCS inpatient 227 147.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 156.63 69 999999999 137.45 220.19 percent of total billed charges "Folic acid level, RBC" 50543984_1 CDM 0301 RC 82747 HCPCS inpatient 227 147.55 UMR - ALL PLANS UMR - ALL PLANS 158.9 70 999999999 137.45 220.19 percent of total billed charges "Folic acid level, RBC" 50543984_1 CDM 0301 RC 82747 HCPCS inpatient 227 147.55 SIHO - ALL PLANS SIHO - ALL PLANS 204.3 90 999999999 137.45 220.19 percent of total billed charges "Folic acid level, RBC" 50543984_1 CDM 0301 RC 82747 HCPCS inpatient 227 147.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 137.45 60.55 999999999 137.45 220.19 percent of total billed charges "Folic acid level, RBC" 50543984_1 CDM 0301 RC 82747 HCPCS inpatient 227 147.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 137.45 220.19 "Folic acid level, RBC" 50543984_1 CDM 0301 RC 82747 HCPCS inpatient 227 147.55 ANTHEM HMO ANTHEM HMO 999999999 137.45 220.19 "Folic acid level, RBC" 50543984_1 CDM 0301 RC 82747 HCPCS inpatient 227 147.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 137.45 220.19 "Folic acid level, RBC" 50543984_1 CDM 0301 RC 82747 HCPCS inpatient 227 147.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 137.45 220.19 "Folic acid level, RBC" 50543984_1 CDM 0301 RC 82747 HCPCS inpatient 227 147.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 153.45 67.6 999999999 137.45 220.19 percent of total billed charges "Folic acid level, RBC" 50543984_1 CDM 0301 RC 82747 HCPCS inpatient 227 147.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 137.45 220.19 Analysis for detection of tumor marker 50543985_1 CDM 0301 RC 86316 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges Analysis for detection of tumor marker 50543985_1 CDM 0301 RC 86316 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges Analysis for detection of tumor marker 50543985_1 CDM 0301 RC 86316 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges Analysis for detection of tumor marker 50543985_1 CDM 0301 RC 86316 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges Analysis for detection of tumor marker 50543985_1 CDM 0301 RC 86316 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges Analysis for detection of tumor marker 50543985_1 CDM 0301 RC 86316 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges Analysis for detection of tumor marker 50543985_1 CDM 0301 RC 86316 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges Analysis for detection of tumor marker 50543985_1 CDM 0301 RC 86316 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges Analysis for detection of tumor marker 50543985_1 CDM 0301 RC 86316 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 Analysis for detection of tumor marker 50543985_1 CDM 0301 RC 86316 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 Analysis for detection of tumor marker 50543985_1 CDM 0301 RC 86316 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 Analysis for detection of tumor marker 50543985_1 CDM 0301 RC 86316 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 Analysis for detection of tumor marker 50543985_1 CDM 0301 RC 86316 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges Analysis for detection of tumor marker 50543985_1 CDM 0301 RC 86316 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 Measurement of antibody to noninfectious agent 50543986_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.4 65 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50543986_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.12 97 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50543986_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 AETNA AETNA 75.84 79 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50543986_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.88 78 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50543986_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.24 69 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50543986_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 UMR - ALL PLANS UMR - ALL PLANS 67.2 70 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50543986_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 SIHO - ALL PLANS SIHO - ALL PLANS 86.4 90 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50543986_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.13 60.55 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50543986_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.13 93.12 Measurement of antibody to noninfectious agent 50543986_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ANTHEM HMO ANTHEM HMO 999999999 58.13 93.12 Measurement of antibody to noninfectious agent 50543986_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.13 93.12 Measurement of antibody to noninfectious agent 50543986_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.13 93.12 Measurement of antibody to noninfectious agent 50543986_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.9 67.6 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50543986_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.13 93.12 "Detection test by nucleic acid for organism, quantification" 50543987_1 CDM 0301 RC 87799 HCPCS inpatient 542 352.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 352.3 65 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50543987_1 CDM 0301 RC 87799 HCPCS inpatient 542 352.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 525.74 97 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50543987_1 CDM 0301 RC 87799 HCPCS inpatient 542 352.3 AETNA AETNA 428.18 79 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50543987_1 CDM 0301 RC 87799 HCPCS inpatient 542 352.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 422.76 78 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50543987_1 CDM 0301 RC 87799 HCPCS inpatient 542 352.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 373.98 69 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50543987_1 CDM 0301 RC 87799 HCPCS inpatient 542 352.3 UMR - ALL PLANS UMR - ALL PLANS 379.4 70 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50543987_1 CDM 0301 RC 87799 HCPCS inpatient 542 352.3 SIHO - ALL PLANS SIHO - ALL PLANS 487.8 90 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50543987_1 CDM 0301 RC 87799 HCPCS inpatient 542 352.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 328.18 60.55 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50543987_1 CDM 0301 RC 87799 HCPCS inpatient 542 352.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 50543987_1 CDM 0301 RC 87799 HCPCS inpatient 542 352.3 ANTHEM HMO ANTHEM HMO 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 50543987_1 CDM 0301 RC 87799 HCPCS inpatient 542 352.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 50543987_1 CDM 0301 RC 87799 HCPCS inpatient 542 352.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 50543987_1 CDM 0301 RC 87799 HCPCS inpatient 542 352.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 366.39 67.6 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50543987_1 CDM 0301 RC 87799 HCPCS inpatient 542 352.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 328.18 525.74 Measurement of antibody to noninfectious agent 50543988_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.4 65 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50543988_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.12 97 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50543988_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 AETNA AETNA 75.84 79 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50543988_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.88 78 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50543988_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.24 69 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50543988_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 UMR - ALL PLANS UMR - ALL PLANS 67.2 70 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50543988_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 SIHO - ALL PLANS SIHO - ALL PLANS 86.4 90 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50543988_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.13 60.55 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50543988_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.13 93.12 Measurement of antibody to noninfectious agent 50543988_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ANTHEM HMO ANTHEM HMO 999999999 58.13 93.12 Measurement of antibody to noninfectious agent 50543988_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.13 93.12 Measurement of antibody to noninfectious agent 50543988_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.13 93.12 Measurement of antibody to noninfectious agent 50543988_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.9 67.6 999999999 58.13 93.12 percent of total billed charges Measurement of antibody to noninfectious agent 50543988_1 CDM 0301 RC 86256 HCPCS inpatient 96 62.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.13 93.12 "Detection test for candida species (yeast), direct probe technique" 50543989_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50543989_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50543989_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50543989_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50543989_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50543989_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50543989_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50543989_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50543989_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 "Detection test for candida species (yeast), direct probe technique" 50543989_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 "Detection test for candida species (yeast), direct probe technique" 50543989_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 "Detection test for candida species (yeast), direct probe technique" 50543989_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 "Detection test for candida species (yeast), direct probe technique" 50543989_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50543989_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 Screening test for antibody to noninfectious agent 50543990_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 50543990_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 50543990_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 50543990_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 50543990_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 50543990_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 50543990_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 50543990_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 50543990_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Screening test for antibody to noninfectious agent 50543990_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Screening test for antibody to noninfectious agent 50543990_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Screening test for antibody to noninfectious agent 50543990_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Screening test for antibody to noninfectious agent 50543990_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Screening test for antibody to noninfectious agent 50543990_1 CDM 0301 RC 86255 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 50543991_1 CDM 0302 RC 87389 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 50543991_1 CDM 0302 RC 87389 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 50543991_1 CDM 0302 RC 87389 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 50543991_1 CDM 0302 RC 87389 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 50543991_1 CDM 0302 RC 87389 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 50543991_1 CDM 0302 RC 87389 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 50543991_1 CDM 0302 RC 87389 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 50543991_1 CDM 0302 RC 87389 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 50543991_1 CDM 0302 RC 87389 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 50543991_1 CDM 0302 RC 87389 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 50543991_1 CDM 0302 RC 87389 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 50543991_1 CDM 0302 RC 87389 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 50543991_1 CDM 0302 RC 87389 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges Detection test by immunoassay technique for HIV-1 antigen and HIV-1 and HIV-2 antibodies 50543991_1 CDM 0302 RC 87389 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 "Gonadotropin, chorionic (reproductive hormone) level" 50543992_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 SELF PAY DISCOUNT SELF PAY DISCOUNT 130 65 999999999 121.1 194 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 50543992_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 194 97 999999999 121.1 194 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 50543992_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 AETNA AETNA 158 79 999999999 121.1 194 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 50543992_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 HUMANA - ALL PLANS HUMANA - ALL PLANS 156 78 999999999 121.1 194 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 50543992_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 ENCORE - ALL PLANS ENCORE - ALL PLANS 138 69 999999999 121.1 194 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 50543992_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 UMR - ALL PLANS UMR - ALL PLANS 140 70 999999999 121.1 194 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 50543992_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 SIHO - ALL PLANS SIHO - ALL PLANS 180 90 999999999 121.1 194 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 50543992_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 121.1 60.55 999999999 121.1 194 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 50543992_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 121.1 194 "Gonadotropin, chorionic (reproductive hormone) level" 50543992_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 ANTHEM HMO ANTHEM HMO 999999999 121.1 194 "Gonadotropin, chorionic (reproductive hormone) level" 50543992_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 121.1 194 "Gonadotropin, chorionic (reproductive hormone) level" 50543992_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 121.1 194 "Gonadotropin, chorionic (reproductive hormone) level" 50543992_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 CIGNA - ALL PLANS CIGNA - ALL PLANS 135.2 67.6 999999999 121.1 194 percent of total billed charges "Gonadotropin, chorionic (reproductive hormone) level" 50543992_1 CDM 0301 RC 84702 HCPCS inpatient 200 130 UHC - ALL PLANS UHC - ALL PLANS 999999999 121.1 194 "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 50543993_1 CDM 0301 RC 86301 HCPCS inpatient 151 98.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.15 65 999999999 91.43 146.47 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 50543993_1 CDM 0301 RC 86301 HCPCS inpatient 151 98.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 146.47 97 999999999 91.43 146.47 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 50543993_1 CDM 0301 RC 86301 HCPCS inpatient 151 98.15 AETNA AETNA 119.29 79 999999999 91.43 146.47 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 50543993_1 CDM 0301 RC 86301 HCPCS inpatient 151 98.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 117.78 78 999999999 91.43 146.47 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 50543993_1 CDM 0301 RC 86301 HCPCS inpatient 151 98.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.19 69 999999999 91.43 146.47 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 50543993_1 CDM 0301 RC 86301 HCPCS inpatient 151 98.15 UMR - ALL PLANS UMR - ALL PLANS 105.7 70 999999999 91.43 146.47 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 50543993_1 CDM 0301 RC 86301 HCPCS inpatient 151 98.15 SIHO - ALL PLANS SIHO - ALL PLANS 135.9 90 999999999 91.43 146.47 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 50543993_1 CDM 0301 RC 86301 HCPCS inpatient 151 98.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 91.43 60.55 999999999 91.43 146.47 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 50543993_1 CDM 0301 RC 86301 HCPCS inpatient 151 98.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 91.43 146.47 "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 50543993_1 CDM 0301 RC 86301 HCPCS inpatient 151 98.15 ANTHEM HMO ANTHEM HMO 999999999 91.43 146.47 "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 50543993_1 CDM 0301 RC 86301 HCPCS inpatient 151 98.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 91.43 146.47 "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 50543993_1 CDM 0301 RC 86301 HCPCS inpatient 151 98.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 91.43 146.47 "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 50543993_1 CDM 0301 RC 86301 HCPCS inpatient 151 98.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.08 67.6 999999999 91.43 146.47 percent of total billed charges "Immunologic analysis for detection of tumor antigen, quantitative; CA 19-9" 50543993_1 CDM 0301 RC 86301 HCPCS inpatient 151 98.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 91.43 146.47 Human growth hormone level 50543994_1 CDM 0301 RC 83003 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges Human growth hormone level 50543994_1 CDM 0301 RC 83003 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges Human growth hormone level 50543994_1 CDM 0301 RC 83003 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges Human growth hormone level 50543994_1 CDM 0301 RC 83003 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges Human growth hormone level 50543994_1 CDM 0301 RC 83003 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges Human growth hormone level 50543994_1 CDM 0301 RC 83003 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges Human growth hormone level 50543994_1 CDM 0301 RC 83003 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges Human growth hormone level 50543994_1 CDM 0301 RC 83003 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges Human growth hormone level 50543994_1 CDM 0301 RC 83003 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 Human growth hormone level 50543994_1 CDM 0301 RC 83003 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 Human growth hormone level 50543994_1 CDM 0301 RC 83003 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 Human growth hormone level 50543994_1 CDM 0301 RC 83003 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 Human growth hormone level 50543994_1 CDM 0301 RC 83003 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges Human growth hormone level 50543994_1 CDM 0301 RC 83003 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 "Analysis for antibody, Treponema pallidum" 50543995_1 CDM 0301 RC 86780 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50543995_1 CDM 0301 RC 86780 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50543995_1 CDM 0301 RC 86780 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50543995_1 CDM 0301 RC 86780 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50543995_1 CDM 0301 RC 86780 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50543995_1 CDM 0301 RC 86780 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50543995_1 CDM 0301 RC 86780 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50543995_1 CDM 0301 RC 86780 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50543995_1 CDM 0301 RC 86780 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 "Analysis for antibody, Treponema pallidum" 50543995_1 CDM 0301 RC 86780 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 "Analysis for antibody, Treponema pallidum" 50543995_1 CDM 0301 RC 86780 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 "Analysis for antibody, Treponema pallidum" 50543995_1 CDM 0301 RC 86780 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 "Analysis for antibody, Treponema pallidum" 50543995_1 CDM 0301 RC 86780 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50543995_1 CDM 0301 RC 86780 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 "Analysis for antibody to Herpes simplex virus, type 1" 50543996_1 CDM 0302 RC 86695 HCPCS inpatient 141 91.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 91.65 65 999999999 85.38 136.77 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 50543996_1 CDM 0302 RC 86695 HCPCS inpatient 141 91.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 136.77 97 999999999 85.38 136.77 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 50543996_1 CDM 0302 RC 86695 HCPCS inpatient 141 91.65 AETNA AETNA 111.39 79 999999999 85.38 136.77 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 50543996_1 CDM 0302 RC 86695 HCPCS inpatient 141 91.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 109.98 78 999999999 85.38 136.77 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 50543996_1 CDM 0302 RC 86695 HCPCS inpatient 141 91.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.29 69 999999999 85.38 136.77 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 50543996_1 CDM 0302 RC 86695 HCPCS inpatient 141 91.65 UMR - ALL PLANS UMR - ALL PLANS 98.7 70 999999999 85.38 136.77 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 50543996_1 CDM 0302 RC 86695 HCPCS inpatient 141 91.65 SIHO - ALL PLANS SIHO - ALL PLANS 126.9 90 999999999 85.38 136.77 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 50543996_1 CDM 0302 RC 86695 HCPCS inpatient 141 91.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.38 60.55 999999999 85.38 136.77 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 50543996_1 CDM 0302 RC 86695 HCPCS inpatient 141 91.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.38 136.77 "Analysis for antibody to Herpes simplex virus, type 1" 50543996_1 CDM 0302 RC 86695 HCPCS inpatient 141 91.65 ANTHEM HMO ANTHEM HMO 999999999 85.38 136.77 "Analysis for antibody to Herpes simplex virus, type 1" 50543996_1 CDM 0302 RC 86695 HCPCS inpatient 141 91.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.38 136.77 "Analysis for antibody to Herpes simplex virus, type 1" 50543996_1 CDM 0302 RC 86695 HCPCS inpatient 141 91.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.38 136.77 "Analysis for antibody to Herpes simplex virus, type 1" 50543996_1 CDM 0302 RC 86695 HCPCS inpatient 141 91.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.32 67.6 999999999 85.38 136.77 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 1" 50543996_1 CDM 0302 RC 86695 HCPCS inpatient 141 91.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.38 136.77 Clotting factor VIII (VW factor) measurement 50543997_1 CDM 0305 RC 85245 HCPCS inpatient 165 107.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.25 65 999999999 99.91 160.05 percent of total billed charges Clotting factor VIII (VW factor) measurement 50543997_1 CDM 0305 RC 85245 HCPCS inpatient 165 107.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 160.05 97 999999999 99.91 160.05 percent of total billed charges Clotting factor VIII (VW factor) measurement 50543997_1 CDM 0305 RC 85245 HCPCS inpatient 165 107.25 AETNA AETNA 130.35 79 999999999 99.91 160.05 percent of total billed charges Clotting factor VIII (VW factor) measurement 50543997_1 CDM 0305 RC 85245 HCPCS inpatient 165 107.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.7 78 999999999 99.91 160.05 percent of total billed charges Clotting factor VIII (VW factor) measurement 50543997_1 CDM 0305 RC 85245 HCPCS inpatient 165 107.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.85 69 999999999 99.91 160.05 percent of total billed charges Clotting factor VIII (VW factor) measurement 50543997_1 CDM 0305 RC 85245 HCPCS inpatient 165 107.25 UMR - ALL PLANS UMR - ALL PLANS 115.5 70 999999999 99.91 160.05 percent of total billed charges Clotting factor VIII (VW factor) measurement 50543997_1 CDM 0305 RC 85245 HCPCS inpatient 165 107.25 SIHO - ALL PLANS SIHO - ALL PLANS 148.5 90 999999999 99.91 160.05 percent of total billed charges Clotting factor VIII (VW factor) measurement 50543997_1 CDM 0305 RC 85245 HCPCS inpatient 165 107.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.91 60.55 999999999 99.91 160.05 percent of total billed charges Clotting factor VIII (VW factor) measurement 50543997_1 CDM 0305 RC 85245 HCPCS inpatient 165 107.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.91 160.05 Clotting factor VIII (VW factor) measurement 50543997_1 CDM 0305 RC 85245 HCPCS inpatient 165 107.25 ANTHEM HMO ANTHEM HMO 999999999 99.91 160.05 Clotting factor VIII (VW factor) measurement 50543997_1 CDM 0305 RC 85245 HCPCS inpatient 165 107.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.91 160.05 Clotting factor VIII (VW factor) measurement 50543997_1 CDM 0305 RC 85245 HCPCS inpatient 165 107.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.91 160.05 Clotting factor VIII (VW factor) measurement 50543997_1 CDM 0305 RC 85245 HCPCS inpatient 165 107.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.54 67.6 999999999 99.91 160.05 percent of total billed charges Clotting factor VIII (VW factor) measurement 50543997_1 CDM 0305 RC 85245 HCPCS inpatient 165 107.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.91 160.05 Clotting factor VIII (AHG) measurement 50543998_1 CDM 0305 RC 85240 HCPCS inpatient 125 81.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.25 65 999999999 75.69 121.25 percent of total billed charges Clotting factor VIII (AHG) measurement 50543998_1 CDM 0305 RC 85240 HCPCS inpatient 125 81.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 121.25 97 999999999 75.69 121.25 percent of total billed charges Clotting factor VIII (AHG) measurement 50543998_1 CDM 0305 RC 85240 HCPCS inpatient 125 81.25 AETNA AETNA 98.75 79 999999999 75.69 121.25 percent of total billed charges Clotting factor VIII (AHG) measurement 50543998_1 CDM 0305 RC 85240 HCPCS inpatient 125 81.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.5 78 999999999 75.69 121.25 percent of total billed charges Clotting factor VIII (AHG) measurement 50543998_1 CDM 0305 RC 85240 HCPCS inpatient 125 81.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.25 69 999999999 75.69 121.25 percent of total billed charges Clotting factor VIII (AHG) measurement 50543998_1 CDM 0305 RC 85240 HCPCS inpatient 125 81.25 UMR - ALL PLANS UMR - ALL PLANS 87.5 70 999999999 75.69 121.25 percent of total billed charges Clotting factor VIII (AHG) measurement 50543998_1 CDM 0305 RC 85240 HCPCS inpatient 125 81.25 SIHO - ALL PLANS SIHO - ALL PLANS 112.5 90 999999999 75.69 121.25 percent of total billed charges Clotting factor VIII (AHG) measurement 50543998_1 CDM 0305 RC 85240 HCPCS inpatient 125 81.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.69 60.55 999999999 75.69 121.25 percent of total billed charges Clotting factor VIII (AHG) measurement 50543998_1 CDM 0305 RC 85240 HCPCS inpatient 125 81.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.69 121.25 Clotting factor VIII (AHG) measurement 50543998_1 CDM 0305 RC 85240 HCPCS inpatient 125 81.25 ANTHEM HMO ANTHEM HMO 999999999 75.69 121.25 Clotting factor VIII (AHG) measurement 50543998_1 CDM 0305 RC 85240 HCPCS inpatient 125 81.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.69 121.25 Clotting factor VIII (AHG) measurement 50543998_1 CDM 0305 RC 85240 HCPCS inpatient 125 81.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.69 121.25 Clotting factor VIII (AHG) measurement 50543998_1 CDM 0305 RC 85240 HCPCS inpatient 125 81.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.5 67.6 999999999 75.69 121.25 percent of total billed charges Clotting factor VIII (AHG) measurement 50543998_1 CDM 0305 RC 85240 HCPCS inpatient 125 81.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.69 121.25 "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 50543999_1 CDM 0302 RC 85460 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 50543999_1 CDM 0302 RC 85460 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 50543999_1 CDM 0302 RC 85460 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 50543999_1 CDM 0302 RC 85460 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 50543999_1 CDM 0302 RC 85460 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 50543999_1 CDM 0302 RC 85460 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 50543999_1 CDM 0302 RC 85460 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 50543999_1 CDM 0302 RC 85460 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 50543999_1 CDM 0302 RC 85460 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 50543999_1 CDM 0302 RC 85460 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 50543999_1 CDM 0302 RC 85460 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 50543999_1 CDM 0302 RC 85460 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 50543999_1 CDM 0302 RC 85460 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges "Fetal hemoglobin or red blood cells measurement for assessment of fetal-maternal circulation, differential lysis" 50543999_1 CDM 0302 RC 85460 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 ADH (antidiuretic hormone) level 50544000_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 226.85 65 999999999 211.32 338.53 percent of total billed charges ADH (antidiuretic hormone) level 50544000_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 338.53 97 999999999 211.32 338.53 percent of total billed charges ADH (antidiuretic hormone) level 50544000_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 AETNA AETNA 275.71 79 999999999 211.32 338.53 percent of total billed charges ADH (antidiuretic hormone) level 50544000_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 272.22 78 999999999 211.32 338.53 percent of total billed charges ADH (antidiuretic hormone) level 50544000_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 240.81 69 999999999 211.32 338.53 percent of total billed charges ADH (antidiuretic hormone) level 50544000_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 UMR - ALL PLANS UMR - ALL PLANS 244.3 70 999999999 211.32 338.53 percent of total billed charges ADH (antidiuretic hormone) level 50544000_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 SIHO - ALL PLANS SIHO - ALL PLANS 314.1 90 999999999 211.32 338.53 percent of total billed charges ADH (antidiuretic hormone) level 50544000_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 211.32 60.55 999999999 211.32 338.53 percent of total billed charges ADH (antidiuretic hormone) level 50544000_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 211.32 338.53 ADH (antidiuretic hormone) level 50544000_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 ANTHEM HMO ANTHEM HMO 999999999 211.32 338.53 ADH (antidiuretic hormone) level 50544000_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 211.32 338.53 ADH (antidiuretic hormone) level 50544000_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 211.32 338.53 ADH (antidiuretic hormone) level 50544000_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 235.92 67.6 999999999 211.32 338.53 percent of total billed charges ADH (antidiuretic hormone) level 50544000_1 CDM 0301 RC 84588 HCPCS inpatient 349 226.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 211.32 338.53 Tacrolimus level 50544001_1 CDM 0301 RC 80197 HCPCS inpatient 251 163.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.15 65 999999999 151.98 243.47 percent of total billed charges Tacrolimus level 50544001_1 CDM 0301 RC 80197 HCPCS inpatient 251 163.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 243.47 97 999999999 151.98 243.47 percent of total billed charges Tacrolimus level 50544001_1 CDM 0301 RC 80197 HCPCS inpatient 251 163.15 AETNA AETNA 198.29 79 999999999 151.98 243.47 percent of total billed charges Tacrolimus level 50544001_1 CDM 0301 RC 80197 HCPCS inpatient 251 163.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 195.78 78 999999999 151.98 243.47 percent of total billed charges Tacrolimus level 50544001_1 CDM 0301 RC 80197 HCPCS inpatient 251 163.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.19 69 999999999 151.98 243.47 percent of total billed charges Tacrolimus level 50544001_1 CDM 0301 RC 80197 HCPCS inpatient 251 163.15 UMR - ALL PLANS UMR - ALL PLANS 175.7 70 999999999 151.98 243.47 percent of total billed charges Tacrolimus level 50544001_1 CDM 0301 RC 80197 HCPCS inpatient 251 163.15 SIHO - ALL PLANS SIHO - ALL PLANS 225.9 90 999999999 151.98 243.47 percent of total billed charges Tacrolimus level 50544001_1 CDM 0301 RC 80197 HCPCS inpatient 251 163.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.98 60.55 999999999 151.98 243.47 percent of total billed charges Tacrolimus level 50544001_1 CDM 0301 RC 80197 HCPCS inpatient 251 163.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.98 243.47 Tacrolimus level 50544001_1 CDM 0301 RC 80197 HCPCS inpatient 251 163.15 ANTHEM HMO ANTHEM HMO 999999999 151.98 243.47 Tacrolimus level 50544001_1 CDM 0301 RC 80197 HCPCS inpatient 251 163.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.98 243.47 Tacrolimus level 50544001_1 CDM 0301 RC 80197 HCPCS inpatient 251 163.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.98 243.47 Tacrolimus level 50544001_1 CDM 0301 RC 80197 HCPCS inpatient 251 163.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 169.68 67.6 999999999 151.98 243.47 percent of total billed charges Tacrolimus level 50544001_1 CDM 0301 RC 80197 HCPCS inpatient 251 163.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.98 243.47 Screening test for antibody to noninfectious agent 50544002_1 CDM 0301 RC 86255 HCPCS inpatient 94 61.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.1 65 999999999 56.92 91.18 percent of total billed charges Screening test for antibody to noninfectious agent 50544002_1 CDM 0301 RC 86255 HCPCS inpatient 94 61.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.18 97 999999999 56.92 91.18 percent of total billed charges Screening test for antibody to noninfectious agent 50544002_1 CDM 0301 RC 86255 HCPCS inpatient 94 61.1 AETNA AETNA 74.26 79 999999999 56.92 91.18 percent of total billed charges Screening test for antibody to noninfectious agent 50544002_1 CDM 0301 RC 86255 HCPCS inpatient 94 61.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.32 78 999999999 56.92 91.18 percent of total billed charges Screening test for antibody to noninfectious agent 50544002_1 CDM 0301 RC 86255 HCPCS inpatient 94 61.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.86 69 999999999 56.92 91.18 percent of total billed charges Screening test for antibody to noninfectious agent 50544002_1 CDM 0301 RC 86255 HCPCS inpatient 94 61.1 UMR - ALL PLANS UMR - ALL PLANS 65.8 70 999999999 56.92 91.18 percent of total billed charges Screening test for antibody to noninfectious agent 50544002_1 CDM 0301 RC 86255 HCPCS inpatient 94 61.1 SIHO - ALL PLANS SIHO - ALL PLANS 84.6 90 999999999 56.92 91.18 percent of total billed charges Screening test for antibody to noninfectious agent 50544002_1 CDM 0301 RC 86255 HCPCS inpatient 94 61.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.92 60.55 999999999 56.92 91.18 percent of total billed charges Screening test for antibody to noninfectious agent 50544002_1 CDM 0301 RC 86255 HCPCS inpatient 94 61.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.92 91.18 Screening test for antibody to noninfectious agent 50544002_1 CDM 0301 RC 86255 HCPCS inpatient 94 61.1 ANTHEM HMO ANTHEM HMO 999999999 56.92 91.18 Screening test for antibody to noninfectious agent 50544002_1 CDM 0301 RC 86255 HCPCS inpatient 94 61.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.92 91.18 Screening test for antibody to noninfectious agent 50544002_1 CDM 0301 RC 86255 HCPCS inpatient 94 61.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.92 91.18 Screening test for antibody to noninfectious agent 50544002_1 CDM 0301 RC 86255 HCPCS inpatient 94 61.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.54 67.6 999999999 56.92 91.18 percent of total billed charges Screening test for antibody to noninfectious agent 50544002_1 CDM 0301 RC 86255 HCPCS inpatient 94 61.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.92 91.18 "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 50544003_1 CDM 0301 RC 87529 HCPCS inpatient 485 315.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 315.25 65 999999999 293.67 470.45 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 50544003_1 CDM 0301 RC 87529 HCPCS inpatient 485 315.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 470.45 97 999999999 293.67 470.45 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 50544003_1 CDM 0301 RC 87529 HCPCS inpatient 485 315.25 AETNA AETNA 383.15 79 999999999 293.67 470.45 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 50544003_1 CDM 0301 RC 87529 HCPCS inpatient 485 315.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 378.3 78 999999999 293.67 470.45 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 50544003_1 CDM 0301 RC 87529 HCPCS inpatient 485 315.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 334.65 69 999999999 293.67 470.45 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 50544003_1 CDM 0301 RC 87529 HCPCS inpatient 485 315.25 UMR - ALL PLANS UMR - ALL PLANS 339.5 70 999999999 293.67 470.45 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 50544003_1 CDM 0301 RC 87529 HCPCS inpatient 485 315.25 SIHO - ALL PLANS SIHO - ALL PLANS 436.5 90 999999999 293.67 470.45 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 50544003_1 CDM 0301 RC 87529 HCPCS inpatient 485 315.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 293.67 60.55 999999999 293.67 470.45 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 50544003_1 CDM 0301 RC 87529 HCPCS inpatient 485 315.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 293.67 470.45 "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 50544003_1 CDM 0301 RC 87529 HCPCS inpatient 485 315.25 ANTHEM HMO ANTHEM HMO 999999999 293.67 470.45 "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 50544003_1 CDM 0301 RC 87529 HCPCS inpatient 485 315.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 293.67 470.45 "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 50544003_1 CDM 0301 RC 87529 HCPCS inpatient 485 315.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 293.67 470.45 "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 50544003_1 CDM 0301 RC 87529 HCPCS inpatient 485 315.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 327.86 67.6 999999999 293.67 470.45 percent of total billed charges "Detection test by nucleic acid for herpes simplex virus, amplified probe technique" 50544003_1 CDM 0301 RC 87529 HCPCS inpatient 485 315.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 293.67 470.45 Stool calprotectin (protein) level 50544004_1 CDM 0301 RC 83993 HCPCS inpatient 512 332.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 332.8 65 999999999 310.02 496.64 percent of total billed charges Stool calprotectin (protein) level 50544004_1 CDM 0301 RC 83993 HCPCS inpatient 512 332.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 496.64 97 999999999 310.02 496.64 percent of total billed charges Stool calprotectin (protein) level 50544004_1 CDM 0301 RC 83993 HCPCS inpatient 512 332.8 AETNA AETNA 404.48 79 999999999 310.02 496.64 percent of total billed charges Stool calprotectin (protein) level 50544004_1 CDM 0301 RC 83993 HCPCS inpatient 512 332.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 353.28 69 999999999 310.02 496.64 percent of total billed charges Stool calprotectin (protein) level 50544004_1 CDM 0301 RC 83993 HCPCS inpatient 512 332.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 399.36 78 999999999 310.02 496.64 percent of total billed charges Stool calprotectin (protein) level 50544004_1 CDM 0301 RC 83993 HCPCS inpatient 512 332.8 UMR - ALL PLANS UMR - ALL PLANS 358.4 70 999999999 310.02 496.64 percent of total billed charges Stool calprotectin (protein) level 50544004_1 CDM 0301 RC 83993 HCPCS inpatient 512 332.8 SIHO - ALL PLANS SIHO - ALL PLANS 460.8 90 999999999 310.02 496.64 percent of total billed charges Stool calprotectin (protein) level 50544004_1 CDM 0301 RC 83993 HCPCS inpatient 512 332.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 310.02 60.55 999999999 310.02 496.64 percent of total billed charges Stool calprotectin (protein) level 50544004_1 CDM 0301 RC 83993 HCPCS inpatient 512 332.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 310.02 496.64 Stool calprotectin (protein) level 50544004_1 CDM 0301 RC 83993 HCPCS inpatient 512 332.8 ANTHEM HMO ANTHEM HMO 999999999 310.02 496.64 Stool calprotectin (protein) level 50544004_1 CDM 0301 RC 83993 HCPCS inpatient 512 332.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 310.02 496.64 Stool calprotectin (protein) level 50544004_1 CDM 0301 RC 83993 HCPCS inpatient 512 332.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 310.02 496.64 Stool calprotectin (protein) level 50544004_1 CDM 0301 RC 83993 HCPCS inpatient 512 332.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 346.11 67.6 999999999 310.02 496.64 percent of total billed charges Stool calprotectin (protein) level 50544004_1 CDM 0301 RC 83993 HCPCS inpatient 512 332.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 310.02 496.64 Screening test for presence of antibody 50544005_1 CDM 0301 RC 86403 HCPCS inpatient 125 81.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.25 65 999999999 75.69 121.25 percent of total billed charges Screening test for presence of antibody 50544005_1 CDM 0301 RC 86403 HCPCS inpatient 125 81.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 121.25 97 999999999 75.69 121.25 percent of total billed charges Screening test for presence of antibody 50544005_1 CDM 0301 RC 86403 HCPCS inpatient 125 81.25 AETNA AETNA 98.75 79 999999999 75.69 121.25 percent of total billed charges Screening test for presence of antibody 50544005_1 CDM 0301 RC 86403 HCPCS inpatient 125 81.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.25 69 999999999 75.69 121.25 percent of total billed charges Screening test for presence of antibody 50544005_1 CDM 0301 RC 86403 HCPCS inpatient 125 81.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.5 78 999999999 75.69 121.25 percent of total billed charges Screening test for presence of antibody 50544005_1 CDM 0301 RC 86403 HCPCS inpatient 125 81.25 UMR - ALL PLANS UMR - ALL PLANS 87.5 70 999999999 75.69 121.25 percent of total billed charges Screening test for presence of antibody 50544005_1 CDM 0301 RC 86403 HCPCS inpatient 125 81.25 SIHO - ALL PLANS SIHO - ALL PLANS 112.5 90 999999999 75.69 121.25 percent of total billed charges Screening test for presence of antibody 50544005_1 CDM 0301 RC 86403 HCPCS inpatient 125 81.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.69 60.55 999999999 75.69 121.25 percent of total billed charges Screening test for presence of antibody 50544005_1 CDM 0301 RC 86403 HCPCS inpatient 125 81.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.69 121.25 Screening test for presence of antibody 50544005_1 CDM 0301 RC 86403 HCPCS inpatient 125 81.25 ANTHEM HMO ANTHEM HMO 999999999 75.69 121.25 Screening test for presence of antibody 50544005_1 CDM 0301 RC 86403 HCPCS inpatient 125 81.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.69 121.25 Screening test for presence of antibody 50544005_1 CDM 0301 RC 86403 HCPCS inpatient 125 81.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.69 121.25 Screening test for presence of antibody 50544005_1 CDM 0301 RC 86403 HCPCS inpatient 125 81.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.5 67.6 999999999 75.69 121.25 percent of total billed charges Screening test for presence of antibody 50544005_1 CDM 0301 RC 86403 HCPCS inpatient 125 81.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.69 121.25 Fungal culture (mold or yeast) 50544006_1 CDM 0306 RC 87102 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges Fungal culture (mold or yeast) 50544006_1 CDM 0306 RC 87102 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges Fungal culture (mold or yeast) 50544006_1 CDM 0306 RC 87102 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges Fungal culture (mold or yeast) 50544006_1 CDM 0306 RC 87102 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges Fungal culture (mold or yeast) 50544006_1 CDM 0306 RC 87102 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges Fungal culture (mold or yeast) 50544006_1 CDM 0306 RC 87102 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges Fungal culture (mold or yeast) 50544006_1 CDM 0306 RC 87102 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges Fungal culture (mold or yeast) 50544006_1 CDM 0306 RC 87102 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges Fungal culture (mold or yeast) 50544006_1 CDM 0306 RC 87102 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 Fungal culture (mold or yeast) 50544006_1 CDM 0306 RC 87102 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 Fungal culture (mold or yeast) 50544006_1 CDM 0306 RC 87102 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 Fungal culture (mold or yeast) 50544006_1 CDM 0306 RC 87102 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 Fungal culture (mold or yeast) 50544006_1 CDM 0306 RC 87102 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges Fungal culture (mold or yeast) 50544006_1 CDM 0306 RC 87102 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 50544007_1 CDM 0306 RC 87498 HCPCS inpatient 338 219.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 219.7 65 999999999 204.66 327.86 percent of total billed charges "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 50544007_1 CDM 0306 RC 87498 HCPCS inpatient 338 219.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 327.86 97 999999999 204.66 327.86 percent of total billed charges "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 50544007_1 CDM 0306 RC 87498 HCPCS inpatient 338 219.7 AETNA AETNA 267.02 79 999999999 204.66 327.86 percent of total billed charges "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 50544007_1 CDM 0306 RC 87498 HCPCS inpatient 338 219.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 233.22 69 999999999 204.66 327.86 percent of total billed charges "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 50544007_1 CDM 0306 RC 87498 HCPCS inpatient 338 219.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 263.64 78 999999999 204.66 327.86 percent of total billed charges "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 50544007_1 CDM 0306 RC 87498 HCPCS inpatient 338 219.7 UMR - ALL PLANS UMR - ALL PLANS 236.6 70 999999999 204.66 327.86 percent of total billed charges "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 50544007_1 CDM 0306 RC 87498 HCPCS inpatient 338 219.7 SIHO - ALL PLANS SIHO - ALL PLANS 304.2 90 999999999 204.66 327.86 percent of total billed charges "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 50544007_1 CDM 0306 RC 87498 HCPCS inpatient 338 219.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 204.66 60.55 999999999 204.66 327.86 percent of total billed charges "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 50544007_1 CDM 0306 RC 87498 HCPCS inpatient 338 219.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 204.66 327.86 "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 50544007_1 CDM 0306 RC 87498 HCPCS inpatient 338 219.7 ANTHEM HMO ANTHEM HMO 999999999 204.66 327.86 "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 50544007_1 CDM 0306 RC 87498 HCPCS inpatient 338 219.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 204.66 327.86 "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 50544007_1 CDM 0306 RC 87498 HCPCS inpatient 338 219.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 204.66 327.86 "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 50544007_1 CDM 0306 RC 87498 HCPCS inpatient 338 219.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 228.49 67.6 999999999 204.66 327.86 percent of total billed charges "Detection test by nucleic acid for enterovirus (intestinal virus), amplified probe technique" 50544007_1 CDM 0306 RC 87498 HCPCS inpatient 338 219.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 204.66 327.86 Tissue culture inoculation for virus isolation 50544008_1 CDM 0302 RC 87252 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges Tissue culture inoculation for virus isolation 50544008_1 CDM 0302 RC 87252 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges Tissue culture inoculation for virus isolation 50544008_1 CDM 0302 RC 87252 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges Tissue culture inoculation for virus isolation 50544008_1 CDM 0302 RC 87252 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges Tissue culture inoculation for virus isolation 50544008_1 CDM 0302 RC 87252 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges Tissue culture inoculation for virus isolation 50544008_1 CDM 0302 RC 87252 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges Tissue culture inoculation for virus isolation 50544008_1 CDM 0302 RC 87252 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges Tissue culture inoculation for virus isolation 50544008_1 CDM 0302 RC 87252 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges Tissue culture inoculation for virus isolation 50544008_1 CDM 0302 RC 87252 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 Tissue culture inoculation for virus isolation 50544008_1 CDM 0302 RC 87252 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 Tissue culture inoculation for virus isolation 50544008_1 CDM 0302 RC 87252 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 Tissue culture inoculation for virus isolation 50544008_1 CDM 0302 RC 87252 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 Tissue culture inoculation for virus isolation 50544008_1 CDM 0302 RC 87252 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges Tissue culture inoculation for virus isolation 50544008_1 CDM 0302 RC 87252 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 Analysis for antibody to Herpes simplex virus 50544009_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50544009_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50544009_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50544009_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50544009_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50544009_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50544009_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50544009_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50544009_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50544009_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50544009_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50544009_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 Analysis for antibody to Herpes simplex virus 50544009_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges Analysis for antibody to Herpes simplex virus 50544009_1 CDM 0302 RC 86694 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 "Detection test by nucleic acid for organism, quantification" 50544010_1 CDM 0306 RC 87799 HCPCS inpatient 507 329.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 329.55 65 999999999 306.99 491.79 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50544010_1 CDM 0306 RC 87799 HCPCS inpatient 507 329.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 491.79 97 999999999 306.99 491.79 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50544010_1 CDM 0306 RC 87799 HCPCS inpatient 507 329.55 AETNA AETNA 400.53 79 999999999 306.99 491.79 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50544010_1 CDM 0306 RC 87799 HCPCS inpatient 507 329.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 349.83 69 999999999 306.99 491.79 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50544010_1 CDM 0306 RC 87799 HCPCS inpatient 507 329.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 395.46 78 999999999 306.99 491.79 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50544010_1 CDM 0306 RC 87799 HCPCS inpatient 507 329.55 UMR - ALL PLANS UMR - ALL PLANS 354.9 70 999999999 306.99 491.79 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50544010_1 CDM 0306 RC 87799 HCPCS inpatient 507 329.55 SIHO - ALL PLANS SIHO - ALL PLANS 456.3 90 999999999 306.99 491.79 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50544010_1 CDM 0306 RC 87799 HCPCS inpatient 507 329.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 306.99 60.55 999999999 306.99 491.79 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50544010_1 CDM 0306 RC 87799 HCPCS inpatient 507 329.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 306.99 491.79 "Detection test by nucleic acid for organism, quantification" 50544010_1 CDM 0306 RC 87799 HCPCS inpatient 507 329.55 ANTHEM HMO ANTHEM HMO 999999999 306.99 491.79 "Detection test by nucleic acid for organism, quantification" 50544010_1 CDM 0306 RC 87799 HCPCS inpatient 507 329.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 306.99 491.79 "Detection test by nucleic acid for organism, quantification" 50544010_1 CDM 0306 RC 87799 HCPCS inpatient 507 329.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 306.99 491.79 "Detection test by nucleic acid for organism, quantification" 50544010_1 CDM 0306 RC 87799 HCPCS inpatient 507 329.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 342.73 67.6 999999999 306.99 491.79 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50544010_1 CDM 0306 RC 87799 HCPCS inpatient 507 329.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 306.99 491.79 Sex hormone binding globulin (protein) level 50544063_1 CDM 0301 RC 84270 HCPCS inpatient 149 96.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 96.85 65 999999999 90.22 144.53 percent of total billed charges Sex hormone binding globulin (protein) level 50544063_1 CDM 0301 RC 84270 HCPCS inpatient 149 96.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 144.53 97 999999999 90.22 144.53 percent of total billed charges Sex hormone binding globulin (protein) level 50544063_1 CDM 0301 RC 84270 HCPCS inpatient 149 96.85 AETNA AETNA 117.71 79 999999999 90.22 144.53 percent of total billed charges Sex hormone binding globulin (protein) level 50544063_1 CDM 0301 RC 84270 HCPCS inpatient 149 96.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 102.81 69 999999999 90.22 144.53 percent of total billed charges Sex hormone binding globulin (protein) level 50544063_1 CDM 0301 RC 84270 HCPCS inpatient 149 96.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 116.22 78 999999999 90.22 144.53 percent of total billed charges Sex hormone binding globulin (protein) level 50544063_1 CDM 0301 RC 84270 HCPCS inpatient 149 96.85 UMR - ALL PLANS UMR - ALL PLANS 104.3 70 999999999 90.22 144.53 percent of total billed charges Sex hormone binding globulin (protein) level 50544063_1 CDM 0301 RC 84270 HCPCS inpatient 149 96.85 SIHO - ALL PLANS SIHO - ALL PLANS 134.1 90 999999999 90.22 144.53 percent of total billed charges Sex hormone binding globulin (protein) level 50544063_1 CDM 0301 RC 84270 HCPCS inpatient 149 96.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.22 60.55 999999999 90.22 144.53 percent of total billed charges Sex hormone binding globulin (protein) level 50544063_1 CDM 0301 RC 84270 HCPCS inpatient 149 96.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.22 144.53 Sex hormone binding globulin (protein) level 50544063_1 CDM 0301 RC 84270 HCPCS inpatient 149 96.85 ANTHEM HMO ANTHEM HMO 999999999 90.22 144.53 Sex hormone binding globulin (protein) level 50544063_1 CDM 0301 RC 84270 HCPCS inpatient 149 96.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.22 144.53 Sex hormone binding globulin (protein) level 50544063_1 CDM 0301 RC 84270 HCPCS inpatient 149 96.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.22 144.53 Sex hormone binding globulin (protein) level 50544063_1 CDM 0301 RC 84270 HCPCS inpatient 149 96.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 100.72 67.6 999999999 90.22 144.53 percent of total billed charges Sex hormone binding globulin (protein) level 50544063_1 CDM 0301 RC 84270 HCPCS inpatient 149 96.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.22 144.53 "Testosterone (hormone) level, total" 50544066_1 CDM 0301 RC 84403 HCPCS inpatient 130 84.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 84.5 65 999999999 78.72 126.1 percent of total billed charges "Testosterone (hormone) level, total" 50544066_1 CDM 0301 RC 84403 HCPCS inpatient 130 84.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 126.1 97 999999999 78.72 126.1 percent of total billed charges "Testosterone (hormone) level, total" 50544066_1 CDM 0301 RC 84403 HCPCS inpatient 130 84.5 AETNA AETNA 102.7 79 999999999 78.72 126.1 percent of total billed charges "Testosterone (hormone) level, total" 50544066_1 CDM 0301 RC 84403 HCPCS inpatient 130 84.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.7 69 999999999 78.72 126.1 percent of total billed charges "Testosterone (hormone) level, total" 50544066_1 CDM 0301 RC 84403 HCPCS inpatient 130 84.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 101.4 78 999999999 78.72 126.1 percent of total billed charges "Testosterone (hormone) level, total" 50544066_1 CDM 0301 RC 84403 HCPCS inpatient 130 84.5 UMR - ALL PLANS UMR - ALL PLANS 91 70 999999999 78.72 126.1 percent of total billed charges "Testosterone (hormone) level, total" 50544066_1 CDM 0301 RC 84403 HCPCS inpatient 130 84.5 SIHO - ALL PLANS SIHO - ALL PLANS 117 90 999999999 78.72 126.1 percent of total billed charges "Testosterone (hormone) level, total" 50544066_1 CDM 0301 RC 84403 HCPCS inpatient 130 84.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.72 60.55 999999999 78.72 126.1 percent of total billed charges "Testosterone (hormone) level, total" 50544066_1 CDM 0301 RC 84403 HCPCS inpatient 130 84.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.72 126.1 "Testosterone (hormone) level, total" 50544066_1 CDM 0301 RC 84403 HCPCS inpatient 130 84.5 ANTHEM HMO ANTHEM HMO 999999999 78.72 126.1 "Testosterone (hormone) level, total" 50544066_1 CDM 0301 RC 84403 HCPCS inpatient 130 84.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.72 126.1 "Testosterone (hormone) level, total" 50544066_1 CDM 0301 RC 84403 HCPCS inpatient 130 84.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.72 126.1 "Testosterone (hormone) level, total" 50544066_1 CDM 0301 RC 84403 HCPCS inpatient 130 84.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.88 67.6 999999999 78.72 126.1 percent of total billed charges "Testosterone (hormone) level, total" 50544066_1 CDM 0301 RC 84403 HCPCS inpatient 130 84.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.72 126.1 Analysis for antibody to HIV-2 virus 50546791_1 CDM 0301 RC 86702 HCPCS inpatient 123 79.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.95 65 999999999 74.48 119.31 percent of total billed charges Analysis for antibody to HIV-2 virus 50546791_1 CDM 0301 RC 86702 HCPCS inpatient 123 79.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 119.31 97 999999999 74.48 119.31 percent of total billed charges Analysis for antibody to HIV-2 virus 50546791_1 CDM 0301 RC 86702 HCPCS inpatient 123 79.95 AETNA AETNA 97.17 79 999999999 74.48 119.31 percent of total billed charges Analysis for antibody to HIV-2 virus 50546791_1 CDM 0301 RC 86702 HCPCS inpatient 123 79.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.87 69 999999999 74.48 119.31 percent of total billed charges Analysis for antibody to HIV-2 virus 50546791_1 CDM 0301 RC 86702 HCPCS inpatient 123 79.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.94 78 999999999 74.48 119.31 percent of total billed charges Analysis for antibody to HIV-2 virus 50546791_1 CDM 0301 RC 86702 HCPCS inpatient 123 79.95 UMR - ALL PLANS UMR - ALL PLANS 86.1 70 999999999 74.48 119.31 percent of total billed charges Analysis for antibody to HIV-2 virus 50546791_1 CDM 0301 RC 86702 HCPCS inpatient 123 79.95 SIHO - ALL PLANS SIHO - ALL PLANS 110.7 90 999999999 74.48 119.31 percent of total billed charges Analysis for antibody to HIV-2 virus 50546791_1 CDM 0301 RC 86702 HCPCS inpatient 123 79.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 74.48 60.55 999999999 74.48 119.31 percent of total billed charges Analysis for antibody to HIV-2 virus 50546791_1 CDM 0301 RC 86702 HCPCS inpatient 123 79.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 74.48 119.31 Analysis for antibody to HIV-2 virus 50546791_1 CDM 0301 RC 86702 HCPCS inpatient 123 79.95 ANTHEM HMO ANTHEM HMO 999999999 74.48 119.31 Analysis for antibody to HIV-2 virus 50546791_1 CDM 0301 RC 86702 HCPCS inpatient 123 79.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 74.48 119.31 Analysis for antibody to HIV-2 virus 50546791_1 CDM 0301 RC 86702 HCPCS inpatient 123 79.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 74.48 119.31 Analysis for antibody to HIV-2 virus 50546791_1 CDM 0301 RC 86702 HCPCS inpatient 123 79.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.15 67.6 999999999 74.48 119.31 percent of total billed charges Analysis for antibody to HIV-2 virus 50546791_1 CDM 0301 RC 86702 HCPCS inpatient 123 79.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 74.48 119.31 POTASSIUM CL 40 MEQ/100 ML SOL 50547663_1 CDM 0250 RC 00990-7077-26 NDC inpatient 1 UN 37.38 24.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.3 65 999999999 22.63 36.26 percent of total billed charges POTASSIUM CL 40 MEQ/100 ML SOL 50547663_1 CDM 0250 RC 00990-7077-26 NDC inpatient 1 UN 37.38 24.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 36.26 97 999999999 22.63 36.26 percent of total billed charges POTASSIUM CL 40 MEQ/100 ML SOL 50547663_1 CDM 0250 RC 00990-7077-26 NDC inpatient 1 UN 37.38 24.3 AETNA AETNA 29.53 79 999999999 22.63 36.26 percent of total billed charges POTASSIUM CL 40 MEQ/100 ML SOL 50547663_1 CDM 0250 RC 00990-7077-26 NDC inpatient 1 UN 37.38 24.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.79 69 999999999 22.63 36.26 percent of total billed charges POTASSIUM CL 40 MEQ/100 ML SOL 50547663_1 CDM 0250 RC 00990-7077-26 NDC inpatient 1 UN 37.38 24.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 29.16 78 999999999 22.63 36.26 percent of total billed charges POTASSIUM CL 40 MEQ/100 ML SOL 50547663_1 CDM 0250 RC 00990-7077-26 NDC inpatient 1 UN 37.38 24.3 UMR - ALL PLANS UMR - ALL PLANS 26.17 70 999999999 22.63 36.26 percent of total billed charges POTASSIUM CL 40 MEQ/100 ML SOL 50547663_1 CDM 0250 RC 00990-7077-26 NDC inpatient 1 UN 37.38 24.3 SIHO - ALL PLANS SIHO - ALL PLANS 33.64 90 999999999 22.63 36.26 percent of total billed charges POTASSIUM CL 40 MEQ/100 ML SOL 50547663_1 CDM 0250 RC 00990-7077-26 NDC inpatient 1 UN 37.38 24.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.63 60.55 999999999 22.63 36.26 percent of total billed charges POTASSIUM CL 40 MEQ/100 ML SOL 50547663_1 CDM 0250 RC 00990-7077-26 NDC inpatient 1 UN 37.38 24.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.63 36.26 POTASSIUM CL 40 MEQ/100 ML SOL 50547663_1 CDM 0250 RC 00990-7077-26 NDC inpatient 1 UN 37.38 24.3 ANTHEM HMO ANTHEM HMO 999999999 22.63 36.26 POTASSIUM CL 40 MEQ/100 ML SOL 50547663_1 CDM 0250 RC 00990-7077-26 NDC inpatient 1 UN 37.38 24.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.63 36.26 POTASSIUM CL 40 MEQ/100 ML SOL 50547663_1 CDM 0250 RC 00990-7077-26 NDC inpatient 1 UN 37.38 24.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.63 36.26 POTASSIUM CL 40 MEQ/100 ML SOL 50547663_1 CDM 0250 RC 00990-7077-26 NDC inpatient 1 UN 37.38 24.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.27 67.6 999999999 22.63 36.26 percent of total billed charges POTASSIUM CL 40 MEQ/100 ML SOL 50547663_1 CDM 0250 RC 00990-7077-26 NDC inpatient 1 UN 37.38 24.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.63 36.26 BETHANECHOL 10 MG TABLET 50550834_1 CDM 0250 RC 68084-0365-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges BETHANECHOL 10 MG TABLET 50550834_1 CDM 0250 RC 68084-0365-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges BETHANECHOL 10 MG TABLET 50550834_1 CDM 0250 RC 68084-0365-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges BETHANECHOL 10 MG TABLET 50550834_1 CDM 0250 RC 68084-0365-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges BETHANECHOL 10 MG TABLET 50550834_1 CDM 0250 RC 68084-0365-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges BETHANECHOL 10 MG TABLET 50550834_1 CDM 0250 RC 68084-0365-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges BETHANECHOL 10 MG TABLET 50550834_1 CDM 0250 RC 68084-0365-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges BETHANECHOL 10 MG TABLET 50550834_1 CDM 0250 RC 68084-0365-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges BETHANECHOL 10 MG TABLET 50550834_1 CDM 0250 RC 68084-0365-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 BETHANECHOL 10 MG TABLET 50550834_1 CDM 0250 RC 68084-0365-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 BETHANECHOL 10 MG TABLET 50550834_1 CDM 0250 RC 68084-0365-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 BETHANECHOL 10 MG TABLET 50550834_1 CDM 0250 RC 68084-0365-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 BETHANECHOL 10 MG TABLET 50550834_1 CDM 0250 RC 68084-0365-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges BETHANECHOL 10 MG TABLET 50550834_1 CDM 0250 RC 68084-0365-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 LEVALBUTEROL TAR HFA 45MCG INH 50550837_1 CDM 0250 RC 00591-2927-54 NDC inpatient 1 UN 78.27 50.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.88 65 999999999 47.39 75.92 percent of total billed charges LEVALBUTEROL TAR HFA 45MCG INH 50550837_1 CDM 0250 RC 00591-2927-54 NDC inpatient 1 UN 78.27 50.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 75.92 97 999999999 47.39 75.92 percent of total billed charges LEVALBUTEROL TAR HFA 45MCG INH 50550837_1 CDM 0250 RC 00591-2927-54 NDC inpatient 1 UN 78.27 50.88 AETNA AETNA 61.83 79 999999999 47.39 75.92 percent of total billed charges LEVALBUTEROL TAR HFA 45MCG INH 50550837_1 CDM 0250 RC 00591-2927-54 NDC inpatient 1 UN 78.27 50.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.01 69 999999999 47.39 75.92 percent of total billed charges LEVALBUTEROL TAR HFA 45MCG INH 50550837_1 CDM 0250 RC 00591-2927-54 NDC inpatient 1 UN 78.27 50.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.05 78 999999999 47.39 75.92 percent of total billed charges LEVALBUTEROL TAR HFA 45MCG INH 50550837_1 CDM 0250 RC 00591-2927-54 NDC inpatient 1 UN 78.27 50.88 SIHO - ALL PLANS SIHO - ALL PLANS 70.44 90 999999999 47.39 75.92 percent of total billed charges LEVALBUTEROL TAR HFA 45MCG INH 50550837_1 CDM 0250 RC 00591-2927-54 NDC inpatient 1 UN 78.27 50.88 UMR - ALL PLANS UMR - ALL PLANS 54.79 70 999999999 47.39 75.92 percent of total billed charges LEVALBUTEROL TAR HFA 45MCG INH 50550837_1 CDM 0250 RC 00591-2927-54 NDC inpatient 1 UN 78.27 50.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.39 60.55 999999999 47.39 75.92 percent of total billed charges LEVALBUTEROL TAR HFA 45MCG INH 50550837_1 CDM 0250 RC 00591-2927-54 NDC inpatient 1 UN 78.27 50.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.39 75.92 LEVALBUTEROL TAR HFA 45MCG INH 50550837_1 CDM 0250 RC 00591-2927-54 NDC inpatient 1 UN 78.27 50.88 ANTHEM HMO ANTHEM HMO 999999999 47.39 75.92 LEVALBUTEROL TAR HFA 45MCG INH 50550837_1 CDM 0250 RC 00591-2927-54 NDC inpatient 1 UN 78.27 50.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.39 75.92 LEVALBUTEROL TAR HFA 45MCG INH 50550837_1 CDM 0250 RC 00591-2927-54 NDC inpatient 1 UN 78.27 50.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.39 75.92 LEVALBUTEROL TAR HFA 45MCG INH 50550837_1 CDM 0250 RC 00591-2927-54 NDC inpatient 1 UN 78.27 50.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.91 67.6 999999999 47.39 75.92 percent of total billed charges LEVALBUTEROL TAR HFA 45MCG INH 50550837_1 CDM 0250 RC 00591-2927-54 NDC inpatient 1 UN 78.27 50.88 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.39 75.92 DIGOXIN 125 MCG TABLET 50550839_1 CDM 0250 RC 00143-1240-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges DIGOXIN 125 MCG TABLET 50550839_1 CDM 0250 RC 00143-1240-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges DIGOXIN 125 MCG TABLET 50550839_1 CDM 0250 RC 00143-1240-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges DIGOXIN 125 MCG TABLET 50550839_1 CDM 0250 RC 00143-1240-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges DIGOXIN 125 MCG TABLET 50550839_1 CDM 0250 RC 00143-1240-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges DIGOXIN 125 MCG TABLET 50550839_1 CDM 0250 RC 00143-1240-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges DIGOXIN 125 MCG TABLET 50550839_1 CDM 0250 RC 00143-1240-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges DIGOXIN 125 MCG TABLET 50550839_1 CDM 0250 RC 00143-1240-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges DIGOXIN 125 MCG TABLET 50550839_1 CDM 0250 RC 00143-1240-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 DIGOXIN 125 MCG TABLET 50550839_1 CDM 0250 RC 00143-1240-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 DIGOXIN 125 MCG TABLET 50550839_1 CDM 0250 RC 00143-1240-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 DIGOXIN 125 MCG TABLET 50550839_1 CDM 0250 RC 00143-1240-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 DIGOXIN 125 MCG TABLET 50550839_1 CDM 0250 RC 00143-1240-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges DIGOXIN 125 MCG TABLET 50550839_1 CDM 0250 RC 00143-1240-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 OLMESARTAN MEDOXOMIL 20 MG TAB 50550841_1 CDM 0250 RC 68462-0437-30 NDC inpatient 1 UN 1.5 0.98 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.98 65 999999999 0.91 1.46 percent of total billed charges OLMESARTAN MEDOXOMIL 20 MG TAB 50550841_1 CDM 0250 RC 68462-0437-30 NDC inpatient 1 UN 1.5 0.98 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.46 97 999999999 0.91 1.46 percent of total billed charges OLMESARTAN MEDOXOMIL 20 MG TAB 50550841_1 CDM 0250 RC 68462-0437-30 NDC inpatient 1 UN 1.5 0.98 AETNA AETNA 1.19 79 999999999 0.91 1.46 percent of total billed charges OLMESARTAN MEDOXOMIL 20 MG TAB 50550841_1 CDM 0250 RC 68462-0437-30 NDC inpatient 1 UN 1.5 0.98 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.04 69 999999999 0.91 1.46 percent of total billed charges OLMESARTAN MEDOXOMIL 20 MG TAB 50550841_1 CDM 0250 RC 68462-0437-30 NDC inpatient 1 UN 1.5 0.98 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.17 78 999999999 0.91 1.46 percent of total billed charges OLMESARTAN MEDOXOMIL 20 MG TAB 50550841_1 CDM 0250 RC 68462-0437-30 NDC inpatient 1 UN 1.5 0.98 SIHO - ALL PLANS SIHO - ALL PLANS 1.35 90 999999999 0.91 1.46 percent of total billed charges OLMESARTAN MEDOXOMIL 20 MG TAB 50550841_1 CDM 0250 RC 68462-0437-30 NDC inpatient 1 UN 1.5 0.98 UMR - ALL PLANS UMR - ALL PLANS 1.05 70 999999999 0.91 1.46 percent of total billed charges OLMESARTAN MEDOXOMIL 20 MG TAB 50550841_1 CDM 0250 RC 68462-0437-30 NDC inpatient 1 UN 1.5 0.98 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.91 60.55 999999999 0.91 1.46 percent of total billed charges OLMESARTAN MEDOXOMIL 20 MG TAB 50550841_1 CDM 0250 RC 68462-0437-30 NDC inpatient 1 UN 1.5 0.98 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.91 1.46 OLMESARTAN MEDOXOMIL 20 MG TAB 50550841_1 CDM 0250 RC 68462-0437-30 NDC inpatient 1 UN 1.5 0.98 ANTHEM HMO ANTHEM HMO 999999999 0.91 1.46 OLMESARTAN MEDOXOMIL 20 MG TAB 50550841_1 CDM 0250 RC 68462-0437-30 NDC inpatient 1 UN 1.5 0.98 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.91 1.46 OLMESARTAN MEDOXOMIL 20 MG TAB 50550841_1 CDM 0250 RC 68462-0437-30 NDC inpatient 1 UN 1.5 0.98 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.91 1.46 OLMESARTAN MEDOXOMIL 20 MG TAB 50550841_1 CDM 0250 RC 68462-0437-30 NDC inpatient 1 UN 1.5 0.98 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.01 67.6 999999999 0.91 1.46 percent of total billed charges OLMESARTAN MEDOXOMIL 20 MG TAB 50550841_1 CDM 0250 RC 68462-0437-30 NDC inpatient 1 UN 1.5 0.98 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.91 1.46 PRIMIDONE 250 MG TABLET 50550842_1 CDM 0250 RC 68084-0203-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges PRIMIDONE 250 MG TABLET 50550842_1 CDM 0250 RC 68084-0203-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges PRIMIDONE 250 MG TABLET 50550842_1 CDM 0250 RC 68084-0203-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges PRIMIDONE 250 MG TABLET 50550842_1 CDM 0250 RC 68084-0203-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges PRIMIDONE 250 MG TABLET 50550842_1 CDM 0250 RC 68084-0203-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges PRIMIDONE 250 MG TABLET 50550842_1 CDM 0250 RC 68084-0203-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges PRIMIDONE 250 MG TABLET 50550842_1 CDM 0250 RC 68084-0203-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges PRIMIDONE 250 MG TABLET 50550842_1 CDM 0250 RC 68084-0203-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges PRIMIDONE 250 MG TABLET 50550842_1 CDM 0250 RC 68084-0203-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 PRIMIDONE 250 MG TABLET 50550842_1 CDM 0250 RC 68084-0203-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 PRIMIDONE 250 MG TABLET 50550842_1 CDM 0250 RC 68084-0203-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 PRIMIDONE 250 MG TABLET 50550842_1 CDM 0250 RC 68084-0203-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 PRIMIDONE 250 MG TABLET 50550842_1 CDM 0250 RC 68084-0203-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges PRIMIDONE 250 MG TABLET 50550842_1 CDM 0250 RC 68084-0203-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ZIPRASIDONE HCL 20 MG CAPSULE 50550848_1 CDM 0250 RC 59762-2001-01 NDC inpatient 1 UN 3.05 1.98 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.98 65 999999999 1.85 2.96 percent of total billed charges ZIPRASIDONE HCL 20 MG CAPSULE 50550848_1 CDM 0250 RC 59762-2001-01 NDC inpatient 1 UN 3.05 1.98 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.96 97 999999999 1.85 2.96 percent of total billed charges ZIPRASIDONE HCL 20 MG CAPSULE 50550848_1 CDM 0250 RC 59762-2001-01 NDC inpatient 1 UN 3.05 1.98 AETNA AETNA 2.41 79 999999999 1.85 2.96 percent of total billed charges ZIPRASIDONE HCL 20 MG CAPSULE 50550848_1 CDM 0250 RC 59762-2001-01 NDC inpatient 1 UN 3.05 1.98 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.1 69 999999999 1.85 2.96 percent of total billed charges ZIPRASIDONE HCL 20 MG CAPSULE 50550848_1 CDM 0250 RC 59762-2001-01 NDC inpatient 1 UN 3.05 1.98 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.38 78 999999999 1.85 2.96 percent of total billed charges ZIPRASIDONE HCL 20 MG CAPSULE 50550848_1 CDM 0250 RC 59762-2001-01 NDC inpatient 1 UN 3.05 1.98 SIHO - ALL PLANS SIHO - ALL PLANS 2.75 90 999999999 1.85 2.96 percent of total billed charges ZIPRASIDONE HCL 20 MG CAPSULE 50550848_1 CDM 0250 RC 59762-2001-01 NDC inpatient 1 UN 3.05 1.98 UMR - ALL PLANS UMR - ALL PLANS 2.14 70 999999999 1.85 2.96 percent of total billed charges ZIPRASIDONE HCL 20 MG CAPSULE 50550848_1 CDM 0250 RC 59762-2001-01 NDC inpatient 1 UN 3.05 1.98 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.85 60.55 999999999 1.85 2.96 percent of total billed charges ZIPRASIDONE HCL 20 MG CAPSULE 50550848_1 CDM 0250 RC 59762-2001-01 NDC inpatient 1 UN 3.05 1.98 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.85 2.96 ZIPRASIDONE HCL 20 MG CAPSULE 50550848_1 CDM 0250 RC 59762-2001-01 NDC inpatient 1 UN 3.05 1.98 ANTHEM HMO ANTHEM HMO 999999999 1.85 2.96 ZIPRASIDONE HCL 20 MG CAPSULE 50550848_1 CDM 0250 RC 59762-2001-01 NDC inpatient 1 UN 3.05 1.98 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.85 2.96 ZIPRASIDONE HCL 20 MG CAPSULE 50550848_1 CDM 0250 RC 59762-2001-01 NDC inpatient 1 UN 3.05 1.98 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.85 2.96 ZIPRASIDONE HCL 20 MG CAPSULE 50550848_1 CDM 0250 RC 59762-2001-01 NDC inpatient 1 UN 3.05 1.98 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.06 67.6 999999999 1.85 2.96 percent of total billed charges ZIPRASIDONE HCL 20 MG CAPSULE 50550848_1 CDM 0250 RC 59762-2001-01 NDC inpatient 1 UN 3.05 1.98 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.85 2.96 DOFETILIDE 125 MCG CAPSULE 50550851_1 CDM 0250 RC 42794-0044-10 NDC inpatient 1 UN 4.32 2.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.81 65 999999999 2.62 4.19 percent of total billed charges DOFETILIDE 125 MCG CAPSULE 50550851_1 CDM 0250 RC 42794-0044-10 NDC inpatient 1 UN 4.32 2.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4.19 97 999999999 2.62 4.19 percent of total billed charges DOFETILIDE 125 MCG CAPSULE 50550851_1 CDM 0250 RC 42794-0044-10 NDC inpatient 1 UN 4.32 2.81 AETNA AETNA 3.41 79 999999999 2.62 4.19 percent of total billed charges DOFETILIDE 125 MCG CAPSULE 50550851_1 CDM 0250 RC 42794-0044-10 NDC inpatient 1 UN 4.32 2.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.98 69 999999999 2.62 4.19 percent of total billed charges DOFETILIDE 125 MCG CAPSULE 50550851_1 CDM 0250 RC 42794-0044-10 NDC inpatient 1 UN 4.32 2.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.37 78 999999999 2.62 4.19 percent of total billed charges DOFETILIDE 125 MCG CAPSULE 50550851_1 CDM 0250 RC 42794-0044-10 NDC inpatient 1 UN 4.32 2.81 SIHO - ALL PLANS SIHO - ALL PLANS 3.89 90 999999999 2.62 4.19 percent of total billed charges DOFETILIDE 125 MCG CAPSULE 50550851_1 CDM 0250 RC 42794-0044-10 NDC inpatient 1 UN 4.32 2.81 UMR - ALL PLANS UMR - ALL PLANS 3.02 70 999999999 2.62 4.19 percent of total billed charges DOFETILIDE 125 MCG CAPSULE 50550851_1 CDM 0250 RC 42794-0044-10 NDC inpatient 1 UN 4.32 2.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.62 60.55 999999999 2.62 4.19 percent of total billed charges DOFETILIDE 125 MCG CAPSULE 50550851_1 CDM 0250 RC 42794-0044-10 NDC inpatient 1 UN 4.32 2.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.62 4.19 DOFETILIDE 125 MCG CAPSULE 50550851_1 CDM 0250 RC 42794-0044-10 NDC inpatient 1 UN 4.32 2.81 ANTHEM HMO ANTHEM HMO 999999999 2.62 4.19 DOFETILIDE 125 MCG CAPSULE 50550851_1 CDM 0250 RC 42794-0044-10 NDC inpatient 1 UN 4.32 2.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.62 4.19 DOFETILIDE 125 MCG CAPSULE 50550851_1 CDM 0250 RC 42794-0044-10 NDC inpatient 1 UN 4.32 2.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.62 4.19 DOFETILIDE 125 MCG CAPSULE 50550851_1 CDM 0250 RC 42794-0044-10 NDC inpatient 1 UN 4.32 2.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.92 67.6 999999999 2.62 4.19 percent of total billed charges DOFETILIDE 125 MCG CAPSULE 50550851_1 CDM 0250 RC 42794-0044-10 NDC inpatient 1 UN 4.32 2.81 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.62 4.19 AMANTADINE 100 MG CAPSULE 50550854_1 CDM 0250 RC 68382-0512-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges AMANTADINE 100 MG CAPSULE 50550854_1 CDM 0250 RC 68382-0512-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges AMANTADINE 100 MG CAPSULE 50550854_1 CDM 0250 RC 68382-0512-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges AMANTADINE 100 MG CAPSULE 50550854_1 CDM 0250 RC 68382-0512-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges AMANTADINE 100 MG CAPSULE 50550854_1 CDM 0250 RC 68382-0512-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges AMANTADINE 100 MG CAPSULE 50550854_1 CDM 0250 RC 68382-0512-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges AMANTADINE 100 MG CAPSULE 50550854_1 CDM 0250 RC 68382-0512-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges AMANTADINE 100 MG CAPSULE 50550854_1 CDM 0250 RC 68382-0512-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges AMANTADINE 100 MG CAPSULE 50550854_1 CDM 0250 RC 68382-0512-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 AMANTADINE 100 MG CAPSULE 50550854_1 CDM 0250 RC 68382-0512-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 AMANTADINE 100 MG CAPSULE 50550854_1 CDM 0250 RC 68382-0512-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 AMANTADINE 100 MG CAPSULE 50550854_1 CDM 0250 RC 68382-0512-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 AMANTADINE 100 MG CAPSULE 50550854_1 CDM 0250 RC 68382-0512-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges AMANTADINE 100 MG CAPSULE 50550854_1 CDM 0250 RC 68382-0512-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50550856_1 CDM 0250 RC 64380-0725-06 NDC J7517 HCPCS inpatient 1 UN 1.9 1.24 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.24 65 999999999 1.15 1.84 percent of total billed charges "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50550856_1 CDM 0250 RC 64380-0725-06 NDC J7517 HCPCS inpatient 1 UN 1.9 1.24 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.84 97 999999999 1.15 1.84 percent of total billed charges "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50550856_1 CDM 0250 RC 64380-0725-06 NDC J7517 HCPCS inpatient 1 UN 1.9 1.24 AETNA AETNA 1.5 79 999999999 1.15 1.84 percent of total billed charges "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50550856_1 CDM 0250 RC 64380-0725-06 NDC J7517 HCPCS inpatient 1 UN 1.9 1.24 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.31 69 999999999 1.15 1.84 percent of total billed charges "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50550856_1 CDM 0250 RC 64380-0725-06 NDC J7517 HCPCS inpatient 1 UN 1.9 1.24 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.48 78 999999999 1.15 1.84 percent of total billed charges "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50550856_1 CDM 0250 RC 64380-0725-06 NDC J7517 HCPCS inpatient 1 UN 1.9 1.24 SIHO - ALL PLANS SIHO - ALL PLANS 1.71 90 999999999 1.15 1.84 percent of total billed charges "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50550856_1 CDM 0250 RC 64380-0725-06 NDC J7517 HCPCS inpatient 1 UN 1.9 1.24 UMR - ALL PLANS UMR - ALL PLANS 1.33 70 999999999 1.15 1.84 percent of total billed charges "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50550856_1 CDM 0250 RC 64380-0725-06 NDC J7517 HCPCS inpatient 1 UN 1.9 1.24 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.15 60.55 999999999 1.15 1.84 percent of total billed charges "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50550856_1 CDM 0250 RC 64380-0725-06 NDC J7517 HCPCS inpatient 1 UN 1.9 1.24 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.15 1.84 "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50550856_1 CDM 0250 RC 64380-0725-06 NDC J7517 HCPCS inpatient 1 UN 1.9 1.24 ANTHEM HMO ANTHEM HMO 999999999 1.15 1.84 "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50550856_1 CDM 0250 RC 64380-0725-06 NDC J7517 HCPCS inpatient 1 UN 1.9 1.24 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.15 1.84 "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50550856_1 CDM 0250 RC 64380-0725-06 NDC J7517 HCPCS inpatient 1 UN 1.9 1.24 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.15 1.84 "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50550856_1 CDM 0250 RC 64380-0725-06 NDC J7517 HCPCS inpatient 1 UN 1.9 1.24 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.28 67.6 999999999 1.15 1.84 percent of total billed charges "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50550856_1 CDM 0250 RC 64380-0725-06 NDC J7517 HCPCS inpatient 1 UN 1.9 1.24 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.15 1.84 "DEXAMETHASONE, ORAL, 0.25 MG" 50550863_1 CDM 0250 RC 00054-4183-25 NDC J8540 HCPCS inpatient 1 UN 2.07 1.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.35 65 999999999 1.25 2.01 percent of total billed charges "DEXAMETHASONE, ORAL, 0.25 MG" 50550863_1 CDM 0250 RC 00054-4183-25 NDC J8540 HCPCS inpatient 1 UN 2.07 1.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.01 97 999999999 1.25 2.01 percent of total billed charges "DEXAMETHASONE, ORAL, 0.25 MG" 50550863_1 CDM 0250 RC 00054-4183-25 NDC J8540 HCPCS inpatient 1 UN 2.07 1.35 AETNA AETNA 1.64 79 999999999 1.25 2.01 percent of total billed charges "DEXAMETHASONE, ORAL, 0.25 MG" 50550863_1 CDM 0250 RC 00054-4183-25 NDC J8540 HCPCS inpatient 1 UN 2.07 1.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.43 69 999999999 1.25 2.01 percent of total billed charges "DEXAMETHASONE, ORAL, 0.25 MG" 50550863_1 CDM 0250 RC 00054-4183-25 NDC J8540 HCPCS inpatient 1 UN 2.07 1.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.61 78 999999999 1.25 2.01 percent of total billed charges "DEXAMETHASONE, ORAL, 0.25 MG" 50550863_1 CDM 0250 RC 00054-4183-25 NDC J8540 HCPCS inpatient 1 UN 2.07 1.35 SIHO - ALL PLANS SIHO - ALL PLANS 1.86 90 999999999 1.25 2.01 percent of total billed charges "DEXAMETHASONE, ORAL, 0.25 MG" 50550863_1 CDM 0250 RC 00054-4183-25 NDC J8540 HCPCS inpatient 1 UN 2.07 1.35 UMR - ALL PLANS UMR - ALL PLANS 1.45 70 999999999 1.25 2.01 percent of total billed charges "DEXAMETHASONE, ORAL, 0.25 MG" 50550863_1 CDM 0250 RC 00054-4183-25 NDC J8540 HCPCS inpatient 1 UN 2.07 1.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.25 60.55 999999999 1.25 2.01 percent of total billed charges "DEXAMETHASONE, ORAL, 0.25 MG" 50550863_1 CDM 0250 RC 00054-4183-25 NDC J8540 HCPCS inpatient 1 UN 2.07 1.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.25 2.01 "DEXAMETHASONE, ORAL, 0.25 MG" 50550863_1 CDM 0250 RC 00054-4183-25 NDC J8540 HCPCS inpatient 1 UN 2.07 1.35 ANTHEM HMO ANTHEM HMO 999999999 1.25 2.01 "DEXAMETHASONE, ORAL, 0.25 MG" 50550863_1 CDM 0250 RC 00054-4183-25 NDC J8540 HCPCS inpatient 1 UN 2.07 1.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.25 2.01 "DEXAMETHASONE, ORAL, 0.25 MG" 50550863_1 CDM 0250 RC 00054-4183-25 NDC J8540 HCPCS inpatient 1 UN 2.07 1.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.25 2.01 "DEXAMETHASONE, ORAL, 0.25 MG" 50550863_1 CDM 0250 RC 00054-4183-25 NDC J8540 HCPCS inpatient 1 UN 2.07 1.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.4 67.6 999999999 1.25 2.01 percent of total billed charges "DEXAMETHASONE, ORAL, 0.25 MG" 50550863_1 CDM 0250 RC 00054-4183-25 NDC J8540 HCPCS inpatient 1 UN 2.07 1.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.25 2.01 GLYBURIDE 5 MG TABLET 50550865_1 CDM 0250 RC 23155-0058-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges GLYBURIDE 5 MG TABLET 50550865_1 CDM 0250 RC 23155-0058-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges GLYBURIDE 5 MG TABLET 50550865_1 CDM 0250 RC 23155-0058-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges GLYBURIDE 5 MG TABLET 50550865_1 CDM 0250 RC 23155-0058-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges GLYBURIDE 5 MG TABLET 50550865_1 CDM 0250 RC 23155-0058-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges GLYBURIDE 5 MG TABLET 50550865_1 CDM 0250 RC 23155-0058-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges GLYBURIDE 5 MG TABLET 50550865_1 CDM 0250 RC 23155-0058-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges GLYBURIDE 5 MG TABLET 50550865_1 CDM 0250 RC 23155-0058-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges GLYBURIDE 5 MG TABLET 50550865_1 CDM 0250 RC 23155-0058-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 GLYBURIDE 5 MG TABLET 50550865_1 CDM 0250 RC 23155-0058-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 GLYBURIDE 5 MG TABLET 50550865_1 CDM 0250 RC 23155-0058-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 GLYBURIDE 5 MG TABLET 50550865_1 CDM 0250 RC 23155-0058-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 GLYBURIDE 5 MG TABLET 50550865_1 CDM 0250 RC 23155-0058-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges GLYBURIDE 5 MG TABLET 50550865_1 CDM 0250 RC 23155-0058-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 Injection of anesthetic agent and/or steroid into other nerve or branch 50550966_1 CDM 0510 RC 64450 HCPCS inpatient 1577 1025.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1025.05 65 999999999 954.87 1529.69 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 50550966_1 CDM 0510 RC 64450 HCPCS inpatient 1577 1025.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1529.69 97 999999999 954.87 1529.69 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 50550966_1 CDM 0510 RC 64450 HCPCS inpatient 1577 1025.05 AETNA AETNA 1245.83 79 999999999 954.87 1529.69 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 50550966_1 CDM 0510 RC 64450 HCPCS inpatient 1577 1025.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1088.13 69 999999999 954.87 1529.69 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 50550966_1 CDM 0510 RC 64450 HCPCS inpatient 1577 1025.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1230.06 78 999999999 954.87 1529.69 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 50550966_1 CDM 0510 RC 64450 HCPCS inpatient 1577 1025.05 SIHO - ALL PLANS SIHO - ALL PLANS 1419.3 90 999999999 954.87 1529.69 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 50550966_1 CDM 0510 RC 64450 HCPCS inpatient 1577 1025.05 UMR - ALL PLANS UMR - ALL PLANS 1103.9 70 999999999 954.87 1529.69 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 50550966_1 CDM 0510 RC 64450 HCPCS inpatient 1577 1025.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 954.87 60.55 999999999 954.87 1529.69 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 50550966_1 CDM 0510 RC 64450 HCPCS inpatient 1577 1025.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 954.87 1529.69 Injection of anesthetic agent and/or steroid into other nerve or branch 50550966_1 CDM 0510 RC 64450 HCPCS inpatient 1577 1025.05 ANTHEM HMO ANTHEM HMO 999999999 954.87 1529.69 Injection of anesthetic agent and/or steroid into other nerve or branch 50550966_1 CDM 0510 RC 64450 HCPCS inpatient 1577 1025.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 954.87 1529.69 Injection of anesthetic agent and/or steroid into other nerve or branch 50550966_1 CDM 0510 RC 64450 HCPCS inpatient 1577 1025.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 954.87 1529.69 Injection of anesthetic agent and/or steroid into other nerve or branch 50550966_1 CDM 0510 RC 64450 HCPCS inpatient 1577 1025.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 954.87 1529.69 Injection of anesthetic agent and/or steroid into other nerve or branch 50550966_1 CDM 0510 RC 64450 HCPCS inpatient 1577 1025.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1066.05 67.6 999999999 954.87 1529.69 percent of total billed charges C-TQTS-1400 14FR THERAQUICK SET/CATH G05777 50552223_1 CDM 0272 RC inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges C-TQTS-1400 14FR THERAQUICK SET/CATH G05777 50552223_1 CDM 0272 RC inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges C-TQTS-1400 14FR THERAQUICK SET/CATH G05777 50552223_1 CDM 0272 RC inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges C-TQTS-1400 14FR THERAQUICK SET/CATH G05777 50552223_1 CDM 0272 RC inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges C-TQTS-1400 14FR THERAQUICK SET/CATH G05777 50552223_1 CDM 0272 RC inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges C-TQTS-1400 14FR THERAQUICK SET/CATH G05777 50552223_1 CDM 0272 RC inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges C-TQTS-1400 14FR THERAQUICK SET/CATH G05777 50552223_1 CDM 0272 RC inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges C-TQTS-1400 14FR THERAQUICK SET/CATH G05777 50552223_1 CDM 0272 RC inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges C-TQTS-1400 14FR THERAQUICK SET/CATH G05777 50552223_1 CDM 0272 RC inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 C-TQTS-1400 14FR THERAQUICK SET/CATH G05777 50552223_1 CDM 0272 RC inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 C-TQTS-1400 14FR THERAQUICK SET/CATH G05777 50552223_1 CDM 0272 RC inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 C-TQTS-1400 14FR THERAQUICK SET/CATH G05777 50552223_1 CDM 0272 RC inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 C-TQTS-1400 14FR THERAQUICK SET/CATH G05777 50552223_1 CDM 0272 RC inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 C-TQTS-1400 14FR THERAQUICK SET/CATH G05777 50552223_1 CDM 0272 RC inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges C-TQTSY-1200 20FR THERAQUICK TRAY/CATH G05463 50552224_1 CDM 0272 RC inpatient 889 577.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 577.85 65 999999999 538.29 862.33 percent of total billed charges C-TQTSY-1200 20FR THERAQUICK TRAY/CATH G05463 50552224_1 CDM 0272 RC inpatient 889 577.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 862.33 97 999999999 538.29 862.33 percent of total billed charges C-TQTSY-1200 20FR THERAQUICK TRAY/CATH G05463 50552224_1 CDM 0272 RC inpatient 889 577.85 AETNA AETNA 702.31 79 999999999 538.29 862.33 percent of total billed charges C-TQTSY-1200 20FR THERAQUICK TRAY/CATH G05463 50552224_1 CDM 0272 RC inpatient 889 577.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 613.41 69 999999999 538.29 862.33 percent of total billed charges C-TQTSY-1200 20FR THERAQUICK TRAY/CATH G05463 50552224_1 CDM 0272 RC inpatient 889 577.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 693.42 78 999999999 538.29 862.33 percent of total billed charges C-TQTSY-1200 20FR THERAQUICK TRAY/CATH G05463 50552224_1 CDM 0272 RC inpatient 889 577.85 SIHO - ALL PLANS SIHO - ALL PLANS 800.1 90 999999999 538.29 862.33 percent of total billed charges C-TQTSY-1200 20FR THERAQUICK TRAY/CATH G05463 50552224_1 CDM 0272 RC inpatient 889 577.85 UMR - ALL PLANS UMR - ALL PLANS 622.3 70 999999999 538.29 862.33 percent of total billed charges C-TQTSY-1200 20FR THERAQUICK TRAY/CATH G05463 50552224_1 CDM 0272 RC inpatient 889 577.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 538.29 60.55 999999999 538.29 862.33 percent of total billed charges C-TQTSY-1200 20FR THERAQUICK TRAY/CATH G05463 50552224_1 CDM 0272 RC inpatient 889 577.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 538.29 862.33 C-TQTSY-1200 20FR THERAQUICK TRAY/CATH G05463 50552224_1 CDM 0272 RC inpatient 889 577.85 ANTHEM HMO ANTHEM HMO 999999999 538.29 862.33 C-TQTSY-1200 20FR THERAQUICK TRAY/CATH G05463 50552224_1 CDM 0272 RC inpatient 889 577.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 538.29 862.33 C-TQTSY-1200 20FR THERAQUICK TRAY/CATH G05463 50552224_1 CDM 0272 RC inpatient 889 577.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 538.29 862.33 C-TQTSY-1200 20FR THERAQUICK TRAY/CATH G05463 50552224_1 CDM 0272 RC inpatient 889 577.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 538.29 862.33 C-TQTSY-1200 20FR THERAQUICK TRAY/CATH G05463 50552224_1 CDM 0272 RC inpatient 889 577.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 600.96 67.6 999999999 538.29 862.33 percent of total billed charges SPY DYE MINIMALLY INVASIVE SURGERY PP9036 50552272_1 CDM 0272 RC inpatient 524 340.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 340.6 65 999999999 317.28 508.28 percent of total billed charges SPY DYE MINIMALLY INVASIVE SURGERY PP9036 50552272_1 CDM 0272 RC inpatient 524 340.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 508.28 97 999999999 317.28 508.28 percent of total billed charges SPY DYE MINIMALLY INVASIVE SURGERY PP9036 50552272_1 CDM 0272 RC inpatient 524 340.6 AETNA AETNA 413.96 79 999999999 317.28 508.28 percent of total billed charges SPY DYE MINIMALLY INVASIVE SURGERY PP9036 50552272_1 CDM 0272 RC inpatient 524 340.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 361.56 69 999999999 317.28 508.28 percent of total billed charges SPY DYE MINIMALLY INVASIVE SURGERY PP9036 50552272_1 CDM 0272 RC inpatient 524 340.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 408.72 78 999999999 317.28 508.28 percent of total billed charges SPY DYE MINIMALLY INVASIVE SURGERY PP9036 50552272_1 CDM 0272 RC inpatient 524 340.6 SIHO - ALL PLANS SIHO - ALL PLANS 471.6 90 999999999 317.28 508.28 percent of total billed charges SPY DYE MINIMALLY INVASIVE SURGERY PP9036 50552272_1 CDM 0272 RC inpatient 524 340.6 UMR - ALL PLANS UMR - ALL PLANS 366.8 70 999999999 317.28 508.28 percent of total billed charges SPY DYE MINIMALLY INVASIVE SURGERY PP9036 50552272_1 CDM 0272 RC inpatient 524 340.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 317.28 60.55 999999999 317.28 508.28 percent of total billed charges SPY DYE MINIMALLY INVASIVE SURGERY PP9036 50552272_1 CDM 0272 RC inpatient 524 340.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 317.28 508.28 SPY DYE MINIMALLY INVASIVE SURGERY PP9036 50552272_1 CDM 0272 RC inpatient 524 340.6 ANTHEM HMO ANTHEM HMO 999999999 317.28 508.28 SPY DYE MINIMALLY INVASIVE SURGERY PP9036 50552272_1 CDM 0272 RC inpatient 524 340.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 317.28 508.28 SPY DYE MINIMALLY INVASIVE SURGERY PP9036 50552272_1 CDM 0272 RC inpatient 524 340.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 317.28 508.28 SPY DYE MINIMALLY INVASIVE SURGERY PP9036 50552272_1 CDM 0272 RC inpatient 524 340.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 317.28 508.28 SPY DYE MINIMALLY INVASIVE SURGERY PP9036 50552272_1 CDM 0272 RC inpatient 524 340.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 354.22 67.6 999999999 317.28 508.28 percent of total billed charges METHYLPREDNISOLONE 80 MG/ML VL 50556448_1 CDM 0250 RC 70121-1574-05 NDC inpatient 1 UN 74.8 48.62 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.62 65 999999999 45.29 72.56 percent of total billed charges METHYLPREDNISOLONE 80 MG/ML VL 50556448_1 CDM 0250 RC 70121-1574-05 NDC inpatient 1 UN 74.8 48.62 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.56 97 999999999 45.29 72.56 percent of total billed charges METHYLPREDNISOLONE 80 MG/ML VL 50556448_1 CDM 0250 RC 70121-1574-05 NDC inpatient 1 UN 74.8 48.62 AETNA AETNA 59.09 79 999999999 45.29 72.56 percent of total billed charges METHYLPREDNISOLONE 80 MG/ML VL 50556448_1 CDM 0250 RC 70121-1574-05 NDC inpatient 1 UN 74.8 48.62 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.61 69 999999999 45.29 72.56 percent of total billed charges METHYLPREDNISOLONE 80 MG/ML VL 50556448_1 CDM 0250 RC 70121-1574-05 NDC inpatient 1 UN 74.8 48.62 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.34 78 999999999 45.29 72.56 percent of total billed charges METHYLPREDNISOLONE 80 MG/ML VL 50556448_1 CDM 0250 RC 70121-1574-05 NDC inpatient 1 UN 74.8 48.62 SIHO - ALL PLANS SIHO - ALL PLANS 67.32 90 999999999 45.29 72.56 percent of total billed charges METHYLPREDNISOLONE 80 MG/ML VL 50556448_1 CDM 0250 RC 70121-1574-05 NDC inpatient 1 UN 74.8 48.62 UMR - ALL PLANS UMR - ALL PLANS 52.36 70 999999999 45.29 72.56 percent of total billed charges METHYLPREDNISOLONE 80 MG/ML VL 50556448_1 CDM 0250 RC 70121-1574-05 NDC inpatient 1 UN 74.8 48.62 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.29 60.55 999999999 45.29 72.56 percent of total billed charges METHYLPREDNISOLONE 80 MG/ML VL 50556448_1 CDM 0250 RC 70121-1574-05 NDC inpatient 1 UN 74.8 48.62 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.29 72.56 METHYLPREDNISOLONE 80 MG/ML VL 50556448_1 CDM 0250 RC 70121-1574-05 NDC inpatient 1 UN 74.8 48.62 ANTHEM HMO ANTHEM HMO 999999999 45.29 72.56 METHYLPREDNISOLONE 80 MG/ML VL 50556448_1 CDM 0250 RC 70121-1574-05 NDC inpatient 1 UN 74.8 48.62 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.29 72.56 METHYLPREDNISOLONE 80 MG/ML VL 50556448_1 CDM 0250 RC 70121-1574-05 NDC inpatient 1 UN 74.8 48.62 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.29 72.56 METHYLPREDNISOLONE 80 MG/ML VL 50556448_1 CDM 0250 RC 70121-1574-05 NDC inpatient 1 UN 74.8 48.62 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.29 72.56 METHYLPREDNISOLONE 80 MG/ML VL 50556448_1 CDM 0250 RC 70121-1574-05 NDC inpatient 1 UN 74.8 48.62 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.56 67.6 999999999 45.29 72.56 percent of total billed charges IBUPROFEN 800 MG TABLET 50556469_1 CDM 0250 RC 60687-0468-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 800 MG TABLET 50556469_1 CDM 0250 RC 60687-0468-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 800 MG TABLET 50556469_1 CDM 0250 RC 60687-0468-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 800 MG TABLET 50556469_1 CDM 0250 RC 60687-0468-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 800 MG TABLET 50556469_1 CDM 0250 RC 60687-0468-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 800 MG TABLET 50556469_1 CDM 0250 RC 60687-0468-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 800 MG TABLET 50556469_1 CDM 0250 RC 60687-0468-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 800 MG TABLET 50556469_1 CDM 0250 RC 60687-0468-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 800 MG TABLET 50556469_1 CDM 0250 RC 60687-0468-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 IBUPROFEN 800 MG TABLET 50556469_1 CDM 0250 RC 60687-0468-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 IBUPROFEN 800 MG TABLET 50556469_1 CDM 0250 RC 60687-0468-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 IBUPROFEN 800 MG TABLET 50556469_1 CDM 0250 RC 60687-0468-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 IBUPROFEN 800 MG TABLET 50556469_1 CDM 0250 RC 60687-0468-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 IBUPROFEN 800 MG TABLET 50556469_1 CDM 0250 RC 60687-0468-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges DILTIAZEM 24H ER(CD) 180 MG CP 50556471_1 CDM 0250 RC 60687-0206-01 NDC inpatient 1 UN 1.67 1.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.09 65 999999999 1.01 1.62 percent of total billed charges DILTIAZEM 24H ER(CD) 180 MG CP 50556471_1 CDM 0250 RC 60687-0206-01 NDC inpatient 1 UN 1.67 1.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.62 97 999999999 1.01 1.62 percent of total billed charges DILTIAZEM 24H ER(CD) 180 MG CP 50556471_1 CDM 0250 RC 60687-0206-01 NDC inpatient 1 UN 1.67 1.09 AETNA AETNA 1.32 79 999999999 1.01 1.62 percent of total billed charges DILTIAZEM 24H ER(CD) 180 MG CP 50556471_1 CDM 0250 RC 60687-0206-01 NDC inpatient 1 UN 1.67 1.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.15 69 999999999 1.01 1.62 percent of total billed charges DILTIAZEM 24H ER(CD) 180 MG CP 50556471_1 CDM 0250 RC 60687-0206-01 NDC inpatient 1 UN 1.67 1.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.3 78 999999999 1.01 1.62 percent of total billed charges DILTIAZEM 24H ER(CD) 180 MG CP 50556471_1 CDM 0250 RC 60687-0206-01 NDC inpatient 1 UN 1.67 1.09 SIHO - ALL PLANS SIHO - ALL PLANS 1.5 90 999999999 1.01 1.62 percent of total billed charges DILTIAZEM 24H ER(CD) 180 MG CP 50556471_1 CDM 0250 RC 60687-0206-01 NDC inpatient 1 UN 1.67 1.09 UMR - ALL PLANS UMR - ALL PLANS 1.17 70 999999999 1.01 1.62 percent of total billed charges DILTIAZEM 24H ER(CD) 180 MG CP 50556471_1 CDM 0250 RC 60687-0206-01 NDC inpatient 1 UN 1.67 1.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.01 60.55 999999999 1.01 1.62 percent of total billed charges DILTIAZEM 24H ER(CD) 180 MG CP 50556471_1 CDM 0250 RC 60687-0206-01 NDC inpatient 1 UN 1.67 1.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.01 1.62 DILTIAZEM 24H ER(CD) 180 MG CP 50556471_1 CDM 0250 RC 60687-0206-01 NDC inpatient 1 UN 1.67 1.09 ANTHEM HMO ANTHEM HMO 999999999 1.01 1.62 DILTIAZEM 24H ER(CD) 180 MG CP 50556471_1 CDM 0250 RC 60687-0206-01 NDC inpatient 1 UN 1.67 1.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.01 1.62 DILTIAZEM 24H ER(CD) 180 MG CP 50556471_1 CDM 0250 RC 60687-0206-01 NDC inpatient 1 UN 1.67 1.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.01 1.62 DILTIAZEM 24H ER(CD) 180 MG CP 50556471_1 CDM 0250 RC 60687-0206-01 NDC inpatient 1 UN 1.67 1.09 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.01 1.62 DILTIAZEM 24H ER(CD) 180 MG CP 50556471_1 CDM 0250 RC 60687-0206-01 NDC inpatient 1 UN 1.67 1.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.13 67.6 999999999 1.01 1.62 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50557641_1 CDM 0636 RC 68001-0266-32 NDC J9190 HCPCS inpatient 10 UN 278.76 181.19 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.19 65 999999999 168.79 270.4 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50557641_1 CDM 0636 RC 68001-0266-32 NDC J9190 HCPCS inpatient 10 UN 278.76 181.19 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.4 97 999999999 168.79 270.4 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50557641_1 CDM 0636 RC 68001-0266-32 NDC J9190 HCPCS inpatient 10 UN 278.76 181.19 AETNA AETNA 220.22 79 999999999 168.79 270.4 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50557641_1 CDM 0636 RC 68001-0266-32 NDC J9190 HCPCS inpatient 10 UN 278.76 181.19 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.34 69 999999999 168.79 270.4 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50557641_1 CDM 0636 RC 68001-0266-32 NDC J9190 HCPCS inpatient 10 UN 278.76 181.19 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.43 78 999999999 168.79 270.4 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50557641_1 CDM 0636 RC 68001-0266-32 NDC J9190 HCPCS inpatient 10 UN 278.76 181.19 SIHO - ALL PLANS SIHO - ALL PLANS 250.88 90 999999999 168.79 270.4 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50557641_1 CDM 0636 RC 68001-0266-32 NDC J9190 HCPCS inpatient 10 UN 278.76 181.19 UMR - ALL PLANS UMR - ALL PLANS 195.13 70 999999999 168.79 270.4 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50557641_1 CDM 0636 RC 68001-0266-32 NDC J9190 HCPCS inpatient 10 UN 278.76 181.19 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.79 60.55 999999999 168.79 270.4 percent of total billed charges "INJECTION, FLUOROURACIL, 500 MG" 50557641_1 CDM 0636 RC 68001-0266-32 NDC J9190 HCPCS inpatient 10 UN 278.76 181.19 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.79 270.4 "INJECTION, FLUOROURACIL, 500 MG" 50557641_1 CDM 0636 RC 68001-0266-32 NDC J9190 HCPCS inpatient 10 UN 278.76 181.19 ANTHEM HMO ANTHEM HMO 999999999 168.79 270.4 "INJECTION, FLUOROURACIL, 500 MG" 50557641_1 CDM 0636 RC 68001-0266-32 NDC J9190 HCPCS inpatient 10 UN 278.76 181.19 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.79 270.4 "INJECTION, FLUOROURACIL, 500 MG" 50557641_1 CDM 0636 RC 68001-0266-32 NDC J9190 HCPCS inpatient 10 UN 278.76 181.19 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.79 270.4 "INJECTION, FLUOROURACIL, 500 MG" 50557641_1 CDM 0636 RC 68001-0266-32 NDC J9190 HCPCS inpatient 10 UN 278.76 181.19 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.79 270.4 "INJECTION, FLUOROURACIL, 500 MG" 50557641_1 CDM 0636 RC 68001-0266-32 NDC J9190 HCPCS inpatient 10 UN 278.76 181.19 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.44 67.6 999999999 168.79 270.4 percent of total billed charges METHYLPREDNISOLONE SS 1 GM VL 50557643_1 CDM 0250 RC 00143-9851-01 NDC inpatient 1 UN 66.69 43.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 43.35 65 999999999 40.38 64.69 percent of total billed charges METHYLPREDNISOLONE SS 1 GM VL 50557643_1 CDM 0250 RC 00143-9851-01 NDC inpatient 1 UN 66.69 43.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.69 97 999999999 40.38 64.69 percent of total billed charges METHYLPREDNISOLONE SS 1 GM VL 50557643_1 CDM 0250 RC 00143-9851-01 NDC inpatient 1 UN 66.69 43.35 AETNA AETNA 52.69 79 999999999 40.38 64.69 percent of total billed charges METHYLPREDNISOLONE SS 1 GM VL 50557643_1 CDM 0250 RC 00143-9851-01 NDC inpatient 1 UN 66.69 43.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.02 69 999999999 40.38 64.69 percent of total billed charges METHYLPREDNISOLONE SS 1 GM VL 50557643_1 CDM 0250 RC 00143-9851-01 NDC inpatient 1 UN 66.69 43.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 52.02 78 999999999 40.38 64.69 percent of total billed charges METHYLPREDNISOLONE SS 1 GM VL 50557643_1 CDM 0250 RC 00143-9851-01 NDC inpatient 1 UN 66.69 43.35 SIHO - ALL PLANS SIHO - ALL PLANS 60.02 90 999999999 40.38 64.69 percent of total billed charges METHYLPREDNISOLONE SS 1 GM VL 50557643_1 CDM 0250 RC 00143-9851-01 NDC inpatient 1 UN 66.69 43.35 UMR - ALL PLANS UMR - ALL PLANS 46.68 70 999999999 40.38 64.69 percent of total billed charges METHYLPREDNISOLONE SS 1 GM VL 50557643_1 CDM 0250 RC 00143-9851-01 NDC inpatient 1 UN 66.69 43.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 40.38 60.55 999999999 40.38 64.69 percent of total billed charges METHYLPREDNISOLONE SS 1 GM VL 50557643_1 CDM 0250 RC 00143-9851-01 NDC inpatient 1 UN 66.69 43.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 40.38 64.69 METHYLPREDNISOLONE SS 1 GM VL 50557643_1 CDM 0250 RC 00143-9851-01 NDC inpatient 1 UN 66.69 43.35 ANTHEM HMO ANTHEM HMO 999999999 40.38 64.69 METHYLPREDNISOLONE SS 1 GM VL 50557643_1 CDM 0250 RC 00143-9851-01 NDC inpatient 1 UN 66.69 43.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 40.38 64.69 METHYLPREDNISOLONE SS 1 GM VL 50557643_1 CDM 0250 RC 00143-9851-01 NDC inpatient 1 UN 66.69 43.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 40.38 64.69 METHYLPREDNISOLONE SS 1 GM VL 50557643_1 CDM 0250 RC 00143-9851-01 NDC inpatient 1 UN 66.69 43.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 40.38 64.69 METHYLPREDNISOLONE SS 1 GM VL 50557643_1 CDM 0250 RC 00143-9851-01 NDC inpatient 1 UN 66.69 43.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.08 67.6 999999999 40.38 64.69 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558091_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.85 65 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558091_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 183.33 97 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558091_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 AETNA AETNA 149.31 79 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558091_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 130.41 69 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558091_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 147.42 78 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558091_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 SIHO - ALL PLANS SIHO - ALL PLANS 170.1 90 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558091_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 UMR - ALL PLANS UMR - ALL PLANS 132.3 70 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558091_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 114.44 60.55 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558091_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558091_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ANTHEM HMO ANTHEM HMO 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558091_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558091_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558091_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558091_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.76 67.6 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558092_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.85 65 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558092_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 183.33 97 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558092_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 AETNA AETNA 149.31 79 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558092_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 130.41 69 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558092_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 147.42 78 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558092_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 SIHO - ALL PLANS SIHO - ALL PLANS 170.1 90 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558092_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 UMR - ALL PLANS UMR - ALL PLANS 132.3 70 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558092_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 114.44 60.55 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558092_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558092_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ANTHEM HMO ANTHEM HMO 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558092_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558092_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558092_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558092_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.76 67.6 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558093_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.85 65 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558093_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 183.33 97 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558093_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 AETNA AETNA 149.31 79 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558093_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 130.41 69 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558093_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 147.42 78 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558093_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 SIHO - ALL PLANS SIHO - ALL PLANS 170.1 90 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558093_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 UMR - ALL PLANS UMR - ALL PLANS 132.3 70 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558093_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 114.44 60.55 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558093_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558093_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ANTHEM HMO ANTHEM HMO 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558093_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558093_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558093_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558093_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.76 67.6 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558094_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.85 65 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558094_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 183.33 97 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558094_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 AETNA AETNA 149.31 79 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558094_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 130.41 69 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558094_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 147.42 78 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558094_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 SIHO - ALL PLANS SIHO - ALL PLANS 170.1 90 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558094_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 UMR - ALL PLANS UMR - ALL PLANS 132.3 70 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558094_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 114.44 60.55 999999999 114.44 183.33 percent of total billed charges "Protein measurement, immunological probe for band identification" 50558094_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558094_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ANTHEM HMO ANTHEM HMO 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558094_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558094_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558094_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 114.44 183.33 "Protein measurement, immunological probe for band identification" 50558094_1 CDM 0301 RC 84182 HCPCS inpatient 189 122.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.76 67.6 999999999 114.44 183.33 percent of total billed charges DOXYCYCLINE MONO 100 MG CAP 50558117_1 CDM 0250 RC 68084-0743-21 NDC inpatient 1 UN 2.02 1.31 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.31 65 999999999 1.22 1.96 percent of total billed charges DOXYCYCLINE MONO 100 MG CAP 50558117_1 CDM 0250 RC 68084-0743-21 NDC inpatient 1 UN 2.02 1.31 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.96 97 999999999 1.22 1.96 percent of total billed charges DOXYCYCLINE MONO 100 MG CAP 50558117_1 CDM 0250 RC 68084-0743-21 NDC inpatient 1 UN 2.02 1.31 AETNA AETNA 1.6 79 999999999 1.22 1.96 percent of total billed charges DOXYCYCLINE MONO 100 MG CAP 50558117_1 CDM 0250 RC 68084-0743-21 NDC inpatient 1 UN 2.02 1.31 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.39 69 999999999 1.22 1.96 percent of total billed charges DOXYCYCLINE MONO 100 MG CAP 50558117_1 CDM 0250 RC 68084-0743-21 NDC inpatient 1 UN 2.02 1.31 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.58 78 999999999 1.22 1.96 percent of total billed charges DOXYCYCLINE MONO 100 MG CAP 50558117_1 CDM 0250 RC 68084-0743-21 NDC inpatient 1 UN 2.02 1.31 SIHO - ALL PLANS SIHO - ALL PLANS 1.82 90 999999999 1.22 1.96 percent of total billed charges DOXYCYCLINE MONO 100 MG CAP 50558117_1 CDM 0250 RC 68084-0743-21 NDC inpatient 1 UN 2.02 1.31 UMR - ALL PLANS UMR - ALL PLANS 1.41 70 999999999 1.22 1.96 percent of total billed charges DOXYCYCLINE MONO 100 MG CAP 50558117_1 CDM 0250 RC 68084-0743-21 NDC inpatient 1 UN 2.02 1.31 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.22 60.55 999999999 1.22 1.96 percent of total billed charges DOXYCYCLINE MONO 100 MG CAP 50558117_1 CDM 0250 RC 68084-0743-21 NDC inpatient 1 UN 2.02 1.31 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.22 1.96 DOXYCYCLINE MONO 100 MG CAP 50558117_1 CDM 0250 RC 68084-0743-21 NDC inpatient 1 UN 2.02 1.31 ANTHEM HMO ANTHEM HMO 999999999 1.22 1.96 DOXYCYCLINE MONO 100 MG CAP 50558117_1 CDM 0250 RC 68084-0743-21 NDC inpatient 1 UN 2.02 1.31 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.22 1.96 DOXYCYCLINE MONO 100 MG CAP 50558117_1 CDM 0250 RC 68084-0743-21 NDC inpatient 1 UN 2.02 1.31 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.22 1.96 DOXYCYCLINE MONO 100 MG CAP 50558117_1 CDM 0250 RC 68084-0743-21 NDC inpatient 1 UN 2.02 1.31 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.22 1.96 DOXYCYCLINE MONO 100 MG CAP 50558117_1 CDM 0250 RC 68084-0743-21 NDC inpatient 1 UN 2.02 1.31 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.37 67.6 999999999 1.22 1.96 percent of total billed charges "Respiratory infectious agent detection by RNA for severe acute respiratory syndrome coronavirus 2 (COVID 19), influenza A, influenza B, and respiratory syncytial virus, upper respiratory specimen, each reported as detected or not detected" 50558748_1 CDM 0306 RC 0241U HCPCS inpatient 313 203.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 203.45 65 999999999 189.52 303.61 percent of total billed charges "Respiratory infectious agent detection by RNA for severe acute respiratory syndrome coronavirus 2 (COVID 19), influenza A, influenza B, and respiratory syncytial virus, upper respiratory specimen, each reported as detected or not detected" 50558748_1 CDM 0306 RC 0241U HCPCS inpatient 313 203.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 303.61 97 999999999 189.52 303.61 percent of total billed charges "Respiratory infectious agent detection by RNA for severe acute respiratory syndrome coronavirus 2 (COVID 19), influenza A, influenza B, and respiratory syncytial virus, upper respiratory specimen, each reported as detected or not detected" 50558748_1 CDM 0306 RC 0241U HCPCS inpatient 313 203.45 AETNA AETNA 247.27 79 999999999 189.52 303.61 percent of total billed charges "Respiratory infectious agent detection by RNA for severe acute respiratory syndrome coronavirus 2 (COVID 19), influenza A, influenza B, and respiratory syncytial virus, upper respiratory specimen, each reported as detected or not detected" 50558748_1 CDM 0306 RC 0241U HCPCS inpatient 313 203.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 215.97 69 999999999 189.52 303.61 percent of total billed charges "Respiratory infectious agent detection by RNA for severe acute respiratory syndrome coronavirus 2 (COVID 19), influenza A, influenza B, and respiratory syncytial virus, upper respiratory specimen, each reported as detected or not detected" 50558748_1 CDM 0306 RC 0241U HCPCS inpatient 313 203.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 244.14 78 999999999 189.52 303.61 percent of total billed charges "Respiratory infectious agent detection by RNA for severe acute respiratory syndrome coronavirus 2 (COVID 19), influenza A, influenza B, and respiratory syncytial virus, upper respiratory specimen, each reported as detected or not detected" 50558748_1 CDM 0306 RC 0241U HCPCS inpatient 313 203.45 SIHO - ALL PLANS SIHO - ALL PLANS 281.7 90 999999999 189.52 303.61 percent of total billed charges "Respiratory infectious agent detection by RNA for severe acute respiratory syndrome coronavirus 2 (COVID 19), influenza A, influenza B, and respiratory syncytial virus, upper respiratory specimen, each reported as detected or not detected" 50558748_1 CDM 0306 RC 0241U HCPCS inpatient 313 203.45 UMR - ALL PLANS UMR - ALL PLANS 219.1 70 999999999 189.52 303.61 percent of total billed charges "Respiratory infectious agent detection by RNA for severe acute respiratory syndrome coronavirus 2 (COVID 19), influenza A, influenza B, and respiratory syncytial virus, upper respiratory specimen, each reported as detected or not detected" 50558748_1 CDM 0306 RC 0241U HCPCS inpatient 313 203.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 189.52 60.55 999999999 189.52 303.61 percent of total billed charges "Respiratory infectious agent detection by RNA for severe acute respiratory syndrome coronavirus 2 (COVID 19), influenza A, influenza B, and respiratory syncytial virus, upper respiratory specimen, each reported as detected or not detected" 50558748_1 CDM 0306 RC 0241U HCPCS inpatient 313 203.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 189.52 303.61 "Respiratory infectious agent detection by RNA for severe acute respiratory syndrome coronavirus 2 (COVID 19), influenza A, influenza B, and respiratory syncytial virus, upper respiratory specimen, each reported as detected or not detected" 50558748_1 CDM 0306 RC 0241U HCPCS inpatient 313 203.45 ANTHEM HMO ANTHEM HMO 999999999 189.52 303.61 "Respiratory infectious agent detection by RNA for severe acute respiratory syndrome coronavirus 2 (COVID 19), influenza A, influenza B, and respiratory syncytial virus, upper respiratory specimen, each reported as detected or not detected" 50558748_1 CDM 0306 RC 0241U HCPCS inpatient 313 203.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 189.52 303.61 "Respiratory infectious agent detection by RNA for severe acute respiratory syndrome coronavirus 2 (COVID 19), influenza A, influenza B, and respiratory syncytial virus, upper respiratory specimen, each reported as detected or not detected" 50558748_1 CDM 0306 RC 0241U HCPCS inpatient 313 203.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 189.52 303.61 "Respiratory infectious agent detection by RNA for severe acute respiratory syndrome coronavirus 2 (COVID 19), influenza A, influenza B, and respiratory syncytial virus, upper respiratory specimen, each reported as detected or not detected" 50558748_1 CDM 0306 RC 0241U HCPCS inpatient 313 203.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 189.52 303.61 "Respiratory infectious agent detection by RNA for severe acute respiratory syndrome coronavirus 2 (COVID 19), influenza A, influenza B, and respiratory syncytial virus, upper respiratory specimen, each reported as detected or not detected" 50558748_1 CDM 0306 RC 0241U HCPCS inpatient 313 203.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 211.59 67.6 999999999 189.52 303.61 percent of total billed charges RADIALUX LIGHTED RETRACTOR 50-101-1 50561057_1 CDM 0272 RC inpatient 2070 1345.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1345.5 65 999999999 1253.39 2007.9 percent of total billed charges RADIALUX LIGHTED RETRACTOR 50-101-1 50561057_1 CDM 0272 RC inpatient 2070 1345.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2007.9 97 999999999 1253.39 2007.9 percent of total billed charges RADIALUX LIGHTED RETRACTOR 50-101-1 50561057_1 CDM 0272 RC inpatient 2070 1345.5 AETNA AETNA 1635.3 79 999999999 1253.39 2007.9 percent of total billed charges RADIALUX LIGHTED RETRACTOR 50-101-1 50561057_1 CDM 0272 RC inpatient 2070 1345.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1428.3 69 999999999 1253.39 2007.9 percent of total billed charges RADIALUX LIGHTED RETRACTOR 50-101-1 50561057_1 CDM 0272 RC inpatient 2070 1345.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1614.6 78 999999999 1253.39 2007.9 percent of total billed charges RADIALUX LIGHTED RETRACTOR 50-101-1 50561057_1 CDM 0272 RC inpatient 2070 1345.5 SIHO - ALL PLANS SIHO - ALL PLANS 1863 90 999999999 1253.39 2007.9 percent of total billed charges RADIALUX LIGHTED RETRACTOR 50-101-1 50561057_1 CDM 0272 RC inpatient 2070 1345.5 UMR - ALL PLANS UMR - ALL PLANS 1449 70 999999999 1253.39 2007.9 percent of total billed charges RADIALUX LIGHTED RETRACTOR 50-101-1 50561057_1 CDM 0272 RC inpatient 2070 1345.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1253.39 60.55 999999999 1253.39 2007.9 percent of total billed charges RADIALUX LIGHTED RETRACTOR 50-101-1 50561057_1 CDM 0272 RC inpatient 2070 1345.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1253.39 2007.9 RADIALUX LIGHTED RETRACTOR 50-101-1 50561057_1 CDM 0272 RC inpatient 2070 1345.5 ANTHEM HMO ANTHEM HMO 999999999 1253.39 2007.9 RADIALUX LIGHTED RETRACTOR 50-101-1 50561057_1 CDM 0272 RC inpatient 2070 1345.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1253.39 2007.9 RADIALUX LIGHTED RETRACTOR 50-101-1 50561057_1 CDM 0272 RC inpatient 2070 1345.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1253.39 2007.9 RADIALUX LIGHTED RETRACTOR 50-101-1 50561057_1 CDM 0272 RC inpatient 2070 1345.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1253.39 2007.9 RADIALUX LIGHTED RETRACTOR 50-101-1 50561057_1 CDM 0272 RC inpatient 2070 1345.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1399.32 67.6 999999999 1253.39 2007.9 percent of total billed charges PLASMABLADEX 3.0S LIGHT DEVICE PS210-030S-LIGHT 50561058_1 CDM 0272 RC inpatient 2321 1508.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1508.65 65 999999999 1405.37 2251.37 percent of total billed charges PLASMABLADEX 3.0S LIGHT DEVICE PS210-030S-LIGHT 50561058_1 CDM 0272 RC inpatient 2321 1508.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2251.37 97 999999999 1405.37 2251.37 percent of total billed charges PLASMABLADEX 3.0S LIGHT DEVICE PS210-030S-LIGHT 50561058_1 CDM 0272 RC inpatient 2321 1508.65 AETNA AETNA 1833.59 79 999999999 1405.37 2251.37 percent of total billed charges PLASMABLADEX 3.0S LIGHT DEVICE PS210-030S-LIGHT 50561058_1 CDM 0272 RC inpatient 2321 1508.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1601.49 69 999999999 1405.37 2251.37 percent of total billed charges PLASMABLADEX 3.0S LIGHT DEVICE PS210-030S-LIGHT 50561058_1 CDM 0272 RC inpatient 2321 1508.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1810.38 78 999999999 1405.37 2251.37 percent of total billed charges PLASMABLADEX 3.0S LIGHT DEVICE PS210-030S-LIGHT 50561058_1 CDM 0272 RC inpatient 2321 1508.65 SIHO - ALL PLANS SIHO - ALL PLANS 2088.9 90 999999999 1405.37 2251.37 percent of total billed charges PLASMABLADEX 3.0S LIGHT DEVICE PS210-030S-LIGHT 50561058_1 CDM 0272 RC inpatient 2321 1508.65 UMR - ALL PLANS UMR - ALL PLANS 1624.7 70 999999999 1405.37 2251.37 percent of total billed charges PLASMABLADEX 3.0S LIGHT DEVICE PS210-030S-LIGHT 50561058_1 CDM 0272 RC inpatient 2321 1508.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1405.37 60.55 999999999 1405.37 2251.37 percent of total billed charges PLASMABLADEX 3.0S LIGHT DEVICE PS210-030S-LIGHT 50561058_1 CDM 0272 RC inpatient 2321 1508.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1405.37 2251.37 PLASMABLADEX 3.0S LIGHT DEVICE PS210-030S-LIGHT 50561058_1 CDM 0272 RC inpatient 2321 1508.65 ANTHEM HMO ANTHEM HMO 999999999 1405.37 2251.37 PLASMABLADEX 3.0S LIGHT DEVICE PS210-030S-LIGHT 50561058_1 CDM 0272 RC inpatient 2321 1508.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1405.37 2251.37 PLASMABLADEX 3.0S LIGHT DEVICE PS210-030S-LIGHT 50561058_1 CDM 0272 RC inpatient 2321 1508.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1405.37 2251.37 PLASMABLADEX 3.0S LIGHT DEVICE PS210-030S-LIGHT 50561058_1 CDM 0272 RC inpatient 2321 1508.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1405.37 2251.37 PLASMABLADEX 3.0S LIGHT DEVICE PS210-030S-LIGHT 50561058_1 CDM 0272 RC inpatient 2321 1508.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1569 67.6 999999999 1405.37 2251.37 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 50562127_1 CDM 0636 RC 55150-0332-01 NDC J9263 HCPCS inpatient 200 UN 96.25 62.56 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.56 65 999999999 58.28 93.36 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 50562127_1 CDM 0636 RC 55150-0332-01 NDC J9263 HCPCS inpatient 200 UN 96.25 62.56 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.36 97 999999999 58.28 93.36 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 50562127_1 CDM 0636 RC 55150-0332-01 NDC J9263 HCPCS inpatient 200 UN 96.25 62.56 AETNA AETNA 76.04 79 999999999 58.28 93.36 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 50562127_1 CDM 0636 RC 55150-0332-01 NDC J9263 HCPCS inpatient 200 UN 96.25 62.56 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.41 69 999999999 58.28 93.36 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 50562127_1 CDM 0636 RC 55150-0332-01 NDC J9263 HCPCS inpatient 200 UN 96.25 62.56 HUMANA - ALL PLANS HUMANA - ALL PLANS 75.08 78 999999999 58.28 93.36 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 50562127_1 CDM 0636 RC 55150-0332-01 NDC J9263 HCPCS inpatient 200 UN 96.25 62.56 SIHO - ALL PLANS SIHO - ALL PLANS 86.63 90 999999999 58.28 93.36 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 50562127_1 CDM 0636 RC 55150-0332-01 NDC J9263 HCPCS inpatient 200 UN 96.25 62.56 UMR - ALL PLANS UMR - ALL PLANS 67.38 70 999999999 58.28 93.36 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 50562127_1 CDM 0636 RC 55150-0332-01 NDC J9263 HCPCS inpatient 200 UN 96.25 62.56 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.28 60.55 999999999 58.28 93.36 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 50562127_1 CDM 0636 RC 55150-0332-01 NDC J9263 HCPCS inpatient 200 UN 96.25 62.56 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.28 93.36 "INJECTION, OXALIPLATIN, 0.5 MG" 50562127_1 CDM 0636 RC 55150-0332-01 NDC J9263 HCPCS inpatient 200 UN 96.25 62.56 ANTHEM HMO ANTHEM HMO 999999999 58.28 93.36 "INJECTION, OXALIPLATIN, 0.5 MG" 50562127_1 CDM 0636 RC 55150-0332-01 NDC J9263 HCPCS inpatient 200 UN 96.25 62.56 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.28 93.36 "INJECTION, OXALIPLATIN, 0.5 MG" 50562127_1 CDM 0636 RC 55150-0332-01 NDC J9263 HCPCS inpatient 200 UN 96.25 62.56 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.28 93.36 "INJECTION, OXALIPLATIN, 0.5 MG" 50562127_1 CDM 0636 RC 55150-0332-01 NDC J9263 HCPCS inpatient 200 UN 96.25 62.56 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.28 93.36 "INJECTION, OXALIPLATIN, 0.5 MG" 50562127_1 CDM 0636 RC 55150-0332-01 NDC J9263 HCPCS inpatient 200 UN 96.25 62.56 CIGNA - ALL PLANS CIGNA - ALL PLANS 65.07 67.6 999999999 58.28 93.36 percent of total billed charges LEVOTHYROXINE 50 MCG TABLET 50567792_1 CDM 0250 RC 60687-0464-01 NDC inpatient 2 UN 1.97 1.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.28 65 999999999 1.19 1.91 percent of total billed charges LEVOTHYROXINE 50 MCG TABLET 50567792_1 CDM 0250 RC 60687-0464-01 NDC inpatient 2 UN 1.97 1.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.91 97 999999999 1.19 1.91 percent of total billed charges LEVOTHYROXINE 50 MCG TABLET 50567792_1 CDM 0250 RC 60687-0464-01 NDC inpatient 2 UN 1.97 1.28 AETNA AETNA 1.56 79 999999999 1.19 1.91 percent of total billed charges LEVOTHYROXINE 50 MCG TABLET 50567792_1 CDM 0250 RC 60687-0464-01 NDC inpatient 2 UN 1.97 1.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.36 69 999999999 1.19 1.91 percent of total billed charges LEVOTHYROXINE 50 MCG TABLET 50567792_1 CDM 0250 RC 60687-0464-01 NDC inpatient 2 UN 1.97 1.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.54 78 999999999 1.19 1.91 percent of total billed charges LEVOTHYROXINE 50 MCG TABLET 50567792_1 CDM 0250 RC 60687-0464-01 NDC inpatient 2 UN 1.97 1.28 SIHO - ALL PLANS SIHO - ALL PLANS 1.77 90 999999999 1.19 1.91 percent of total billed charges LEVOTHYROXINE 50 MCG TABLET 50567792_1 CDM 0250 RC 60687-0464-01 NDC inpatient 2 UN 1.97 1.28 UMR - ALL PLANS UMR - ALL PLANS 1.38 70 999999999 1.19 1.91 percent of total billed charges LEVOTHYROXINE 50 MCG TABLET 50567792_1 CDM 0250 RC 60687-0464-01 NDC inpatient 2 UN 1.97 1.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.19 60.55 999999999 1.19 1.91 percent of total billed charges LEVOTHYROXINE 50 MCG TABLET 50567792_1 CDM 0250 RC 60687-0464-01 NDC inpatient 2 UN 1.97 1.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.19 1.91 LEVOTHYROXINE 50 MCG TABLET 50567792_1 CDM 0250 RC 60687-0464-01 NDC inpatient 2 UN 1.97 1.28 ANTHEM HMO ANTHEM HMO 999999999 1.19 1.91 LEVOTHYROXINE 50 MCG TABLET 50567792_1 CDM 0250 RC 60687-0464-01 NDC inpatient 2 UN 1.97 1.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.19 1.91 LEVOTHYROXINE 50 MCG TABLET 50567792_1 CDM 0250 RC 60687-0464-01 NDC inpatient 2 UN 1.97 1.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.19 1.91 LEVOTHYROXINE 50 MCG TABLET 50567792_1 CDM 0250 RC 60687-0464-01 NDC inpatient 2 UN 1.97 1.28 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.19 1.91 LEVOTHYROXINE 50 MCG TABLET 50567792_1 CDM 0250 RC 60687-0464-01 NDC inpatient 2 UN 1.97 1.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.33 67.6 999999999 1.19 1.91 percent of total billed charges NAPROXEN 250 MG TABLET 50567795_1 CDM 0250 RC 50268-0594-15 NDC inpatient 1 UN 1.14 0.74 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.74 65 999999999 0.69 1.11 percent of total billed charges NAPROXEN 250 MG TABLET 50567795_1 CDM 0250 RC 50268-0594-15 NDC inpatient 1 UN 1.14 0.74 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.11 97 999999999 0.69 1.11 percent of total billed charges NAPROXEN 250 MG TABLET 50567795_1 CDM 0250 RC 50268-0594-15 NDC inpatient 1 UN 1.14 0.74 AETNA AETNA 0.9 79 999999999 0.69 1.11 percent of total billed charges NAPROXEN 250 MG TABLET 50567795_1 CDM 0250 RC 50268-0594-15 NDC inpatient 1 UN 1.14 0.74 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.79 69 999999999 0.69 1.11 percent of total billed charges NAPROXEN 250 MG TABLET 50567795_1 CDM 0250 RC 50268-0594-15 NDC inpatient 1 UN 1.14 0.74 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.89 78 999999999 0.69 1.11 percent of total billed charges NAPROXEN 250 MG TABLET 50567795_1 CDM 0250 RC 50268-0594-15 NDC inpatient 1 UN 1.14 0.74 SIHO - ALL PLANS SIHO - ALL PLANS 1.03 90 999999999 0.69 1.11 percent of total billed charges NAPROXEN 250 MG TABLET 50567795_1 CDM 0250 RC 50268-0594-15 NDC inpatient 1 UN 1.14 0.74 UMR - ALL PLANS UMR - ALL PLANS 0.8 70 999999999 0.69 1.11 percent of total billed charges NAPROXEN 250 MG TABLET 50567795_1 CDM 0250 RC 50268-0594-15 NDC inpatient 1 UN 1.14 0.74 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.69 60.55 999999999 0.69 1.11 percent of total billed charges NAPROXEN 250 MG TABLET 50567795_1 CDM 0250 RC 50268-0594-15 NDC inpatient 1 UN 1.14 0.74 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.69 1.11 NAPROXEN 250 MG TABLET 50567795_1 CDM 0250 RC 50268-0594-15 NDC inpatient 1 UN 1.14 0.74 ANTHEM HMO ANTHEM HMO 999999999 0.69 1.11 NAPROXEN 250 MG TABLET 50567795_1 CDM 0250 RC 50268-0594-15 NDC inpatient 1 UN 1.14 0.74 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.69 1.11 NAPROXEN 250 MG TABLET 50567795_1 CDM 0250 RC 50268-0594-15 NDC inpatient 1 UN 1.14 0.74 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.69 1.11 NAPROXEN 250 MG TABLET 50567795_1 CDM 0250 RC 50268-0594-15 NDC inpatient 1 UN 1.14 0.74 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.69 1.11 NAPROXEN 250 MG TABLET 50567795_1 CDM 0250 RC 50268-0594-15 NDC inpatient 1 UN 1.14 0.74 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.77 67.6 999999999 0.69 1.11 percent of total billed charges METOPROLOL TART 5 MG/5 ML VIAL 50567821_1 CDM 0250 RC 72611-0740-10 NDC inpatient 1 UN 18.07 11.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.75 65 999999999 10.94 17.53 percent of total billed charges METOPROLOL TART 5 MG/5 ML VIAL 50567821_1 CDM 0250 RC 72611-0740-10 NDC inpatient 1 UN 18.07 11.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17.53 97 999999999 10.94 17.53 percent of total billed charges METOPROLOL TART 5 MG/5 ML VIAL 50567821_1 CDM 0250 RC 72611-0740-10 NDC inpatient 1 UN 18.07 11.75 AETNA AETNA 14.28 79 999999999 10.94 17.53 percent of total billed charges METOPROLOL TART 5 MG/5 ML VIAL 50567821_1 CDM 0250 RC 72611-0740-10 NDC inpatient 1 UN 18.07 11.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.47 69 999999999 10.94 17.53 percent of total billed charges METOPROLOL TART 5 MG/5 ML VIAL 50567821_1 CDM 0250 RC 72611-0740-10 NDC inpatient 1 UN 18.07 11.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.09 78 999999999 10.94 17.53 percent of total billed charges METOPROLOL TART 5 MG/5 ML VIAL 50567821_1 CDM 0250 RC 72611-0740-10 NDC inpatient 1 UN 18.07 11.75 SIHO - ALL PLANS SIHO - ALL PLANS 16.26 90 999999999 10.94 17.53 percent of total billed charges METOPROLOL TART 5 MG/5 ML VIAL 50567821_1 CDM 0250 RC 72611-0740-10 NDC inpatient 1 UN 18.07 11.75 UMR - ALL PLANS UMR - ALL PLANS 12.65 70 999999999 10.94 17.53 percent of total billed charges METOPROLOL TART 5 MG/5 ML VIAL 50567821_1 CDM 0250 RC 72611-0740-10 NDC inpatient 1 UN 18.07 11.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.94 60.55 999999999 10.94 17.53 percent of total billed charges METOPROLOL TART 5 MG/5 ML VIAL 50567821_1 CDM 0250 RC 72611-0740-10 NDC inpatient 1 UN 18.07 11.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.94 17.53 METOPROLOL TART 5 MG/5 ML VIAL 50567821_1 CDM 0250 RC 72611-0740-10 NDC inpatient 1 UN 18.07 11.75 ANTHEM HMO ANTHEM HMO 999999999 10.94 17.53 METOPROLOL TART 5 MG/5 ML VIAL 50567821_1 CDM 0250 RC 72611-0740-10 NDC inpatient 1 UN 18.07 11.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.94 17.53 METOPROLOL TART 5 MG/5 ML VIAL 50567821_1 CDM 0250 RC 72611-0740-10 NDC inpatient 1 UN 18.07 11.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.94 17.53 METOPROLOL TART 5 MG/5 ML VIAL 50567821_1 CDM 0250 RC 72611-0740-10 NDC inpatient 1 UN 18.07 11.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.94 17.53 METOPROLOL TART 5 MG/5 ML VIAL 50567821_1 CDM 0250 RC 72611-0740-10 NDC inpatient 1 UN 18.07 11.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.22 67.6 999999999 10.94 17.53 percent of total billed charges Molecular pathology procedure level 6 genetic analysis 50567845_1 CDM 0310 RC 81405 HCPCS inpatient 1459 948.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 948.35 65 999999999 883.42 1415.23 percent of total billed charges Molecular pathology procedure level 6 genetic analysis 50567845_1 CDM 0310 RC 81405 HCPCS inpatient 1459 948.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1415.23 97 999999999 883.42 1415.23 percent of total billed charges Molecular pathology procedure level 6 genetic analysis 50567845_1 CDM 0310 RC 81405 HCPCS inpatient 1459 948.35 AETNA AETNA 1152.61 79 999999999 883.42 1415.23 percent of total billed charges Molecular pathology procedure level 6 genetic analysis 50567845_1 CDM 0310 RC 81405 HCPCS inpatient 1459 948.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1006.71 69 999999999 883.42 1415.23 percent of total billed charges Molecular pathology procedure level 6 genetic analysis 50567845_1 CDM 0310 RC 81405 HCPCS inpatient 1459 948.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1138.02 78 999999999 883.42 1415.23 percent of total billed charges Molecular pathology procedure level 6 genetic analysis 50567845_1 CDM 0310 RC 81405 HCPCS inpatient 1459 948.35 SIHO - ALL PLANS SIHO - ALL PLANS 1313.1 90 999999999 883.42 1415.23 percent of total billed charges Molecular pathology procedure level 6 genetic analysis 50567845_1 CDM 0310 RC 81405 HCPCS inpatient 1459 948.35 UMR - ALL PLANS UMR - ALL PLANS 1021.3 70 999999999 883.42 1415.23 percent of total billed charges Molecular pathology procedure level 6 genetic analysis 50567845_1 CDM 0310 RC 81405 HCPCS inpatient 1459 948.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 883.42 60.55 999999999 883.42 1415.23 percent of total billed charges Molecular pathology procedure level 6 genetic analysis 50567845_1 CDM 0310 RC 81405 HCPCS inpatient 1459 948.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 883.42 1415.23 Molecular pathology procedure level 6 genetic analysis 50567845_1 CDM 0310 RC 81405 HCPCS inpatient 1459 948.35 ANTHEM HMO ANTHEM HMO 999999999 883.42 1415.23 Molecular pathology procedure level 6 genetic analysis 50567845_1 CDM 0310 RC 81405 HCPCS inpatient 1459 948.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 883.42 1415.23 Molecular pathology procedure level 6 genetic analysis 50567845_1 CDM 0310 RC 81405 HCPCS inpatient 1459 948.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 883.42 1415.23 Molecular pathology procedure level 6 genetic analysis 50567845_1 CDM 0310 RC 81405 HCPCS inpatient 1459 948.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 883.42 1415.23 Molecular pathology procedure level 6 genetic analysis 50567845_1 CDM 0310 RC 81405 HCPCS inpatient 1459 948.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 986.28 67.6 999999999 883.42 1415.23 percent of total billed charges BRIDION 200 MG/2 ML VIAL 50567925_1 CDM 0250 RC 00006-5423-12 NDC inpatient 1 UN 550.94 358.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 358.11 65 999999999 333.59 534.41 percent of total billed charges BRIDION 200 MG/2 ML VIAL 50567925_1 CDM 0250 RC 00006-5423-12 NDC inpatient 1 UN 550.94 358.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 534.41 97 999999999 333.59 534.41 percent of total billed charges BRIDION 200 MG/2 ML VIAL 50567925_1 CDM 0250 RC 00006-5423-12 NDC inpatient 1 UN 550.94 358.11 AETNA AETNA 435.24 79 999999999 333.59 534.41 percent of total billed charges BRIDION 200 MG/2 ML VIAL 50567925_1 CDM 0250 RC 00006-5423-12 NDC inpatient 1 UN 550.94 358.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 380.15 69 999999999 333.59 534.41 percent of total billed charges BRIDION 200 MG/2 ML VIAL 50567925_1 CDM 0250 RC 00006-5423-12 NDC inpatient 1 UN 550.94 358.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 429.73 78 999999999 333.59 534.41 percent of total billed charges BRIDION 200 MG/2 ML VIAL 50567925_1 CDM 0250 RC 00006-5423-12 NDC inpatient 1 UN 550.94 358.11 SIHO - ALL PLANS SIHO - ALL PLANS 495.85 90 999999999 333.59 534.41 percent of total billed charges BRIDION 200 MG/2 ML VIAL 50567925_1 CDM 0250 RC 00006-5423-12 NDC inpatient 1 UN 550.94 358.11 UMR - ALL PLANS UMR - ALL PLANS 385.66 70 999999999 333.59 534.41 percent of total billed charges BRIDION 200 MG/2 ML VIAL 50567925_1 CDM 0250 RC 00006-5423-12 NDC inpatient 1 UN 550.94 358.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 333.59 60.55 999999999 333.59 534.41 percent of total billed charges BRIDION 200 MG/2 ML VIAL 50567925_1 CDM 0250 RC 00006-5423-12 NDC inpatient 1 UN 550.94 358.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 333.59 534.41 BRIDION 200 MG/2 ML VIAL 50567925_1 CDM 0250 RC 00006-5423-12 NDC inpatient 1 UN 550.94 358.11 ANTHEM HMO ANTHEM HMO 999999999 333.59 534.41 BRIDION 200 MG/2 ML VIAL 50567925_1 CDM 0250 RC 00006-5423-12 NDC inpatient 1 UN 550.94 358.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 333.59 534.41 BRIDION 200 MG/2 ML VIAL 50567925_1 CDM 0250 RC 00006-5423-12 NDC inpatient 1 UN 550.94 358.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 333.59 534.41 BRIDION 200 MG/2 ML VIAL 50567925_1 CDM 0250 RC 00006-5423-12 NDC inpatient 1 UN 550.94 358.11 UHC - ALL PLANS UHC - ALL PLANS 999999999 333.59 534.41 BRIDION 200 MG/2 ML VIAL 50567925_1 CDM 0250 RC 00006-5423-12 NDC inpatient 1 UN 550.94 358.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 372.44 67.6 999999999 333.59 534.41 percent of total billed charges Stool lactoferrin (immune system protein) analysis 50568019_1 CDM 0305 RC 83630 HCPCS inpatient 64 41.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.6 65 999999999 38.75 62.08 percent of total billed charges Stool lactoferrin (immune system protein) analysis 50568019_1 CDM 0305 RC 83630 HCPCS inpatient 64 41.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 62.08 97 999999999 38.75 62.08 percent of total billed charges Stool lactoferrin (immune system protein) analysis 50568019_1 CDM 0305 RC 83630 HCPCS inpatient 64 41.6 AETNA AETNA 50.56 79 999999999 38.75 62.08 percent of total billed charges Stool lactoferrin (immune system protein) analysis 50568019_1 CDM 0305 RC 83630 HCPCS inpatient 64 41.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.16 69 999999999 38.75 62.08 percent of total billed charges Stool lactoferrin (immune system protein) analysis 50568019_1 CDM 0305 RC 83630 HCPCS inpatient 64 41.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.92 78 999999999 38.75 62.08 percent of total billed charges Stool lactoferrin (immune system protein) analysis 50568019_1 CDM 0305 RC 83630 HCPCS inpatient 64 41.6 SIHO - ALL PLANS SIHO - ALL PLANS 57.6 90 999999999 38.75 62.08 percent of total billed charges Stool lactoferrin (immune system protein) analysis 50568019_1 CDM 0305 RC 83630 HCPCS inpatient 64 41.6 UMR - ALL PLANS UMR - ALL PLANS 44.8 70 999999999 38.75 62.08 percent of total billed charges Stool lactoferrin (immune system protein) analysis 50568019_1 CDM 0305 RC 83630 HCPCS inpatient 64 41.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.75 60.55 999999999 38.75 62.08 percent of total billed charges Stool lactoferrin (immune system protein) analysis 50568019_1 CDM 0305 RC 83630 HCPCS inpatient 64 41.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.75 62.08 Stool lactoferrin (immune system protein) analysis 50568019_1 CDM 0305 RC 83630 HCPCS inpatient 64 41.6 ANTHEM HMO ANTHEM HMO 999999999 38.75 62.08 Stool lactoferrin (immune system protein) analysis 50568019_1 CDM 0305 RC 83630 HCPCS inpatient 64 41.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.75 62.08 Stool lactoferrin (immune system protein) analysis 50568019_1 CDM 0305 RC 83630 HCPCS inpatient 64 41.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.75 62.08 Stool lactoferrin (immune system protein) analysis 50568019_1 CDM 0305 RC 83630 HCPCS inpatient 64 41.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.75 62.08 Stool lactoferrin (immune system protein) analysis 50568019_1 CDM 0305 RC 83630 HCPCS inpatient 64 41.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.26 67.6 999999999 38.75 62.08 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50570730_1 CDM 0250 RC 70594-0057-02 NDC J3370 HCPCS inpatient 3 UN 287.52 186.89 SELF PAY DISCOUNT SELF PAY DISCOUNT 186.89 65 999999999 174.09 278.89 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50570730_1 CDM 0250 RC 70594-0057-02 NDC J3370 HCPCS inpatient 3 UN 287.52 186.89 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 278.89 97 999999999 174.09 278.89 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50570730_1 CDM 0250 RC 70594-0057-02 NDC J3370 HCPCS inpatient 3 UN 287.52 186.89 AETNA AETNA 227.14 79 999999999 174.09 278.89 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50570730_1 CDM 0250 RC 70594-0057-02 NDC J3370 HCPCS inpatient 3 UN 287.52 186.89 ENCORE - ALL PLANS ENCORE - ALL PLANS 198.39 69 999999999 174.09 278.89 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50570730_1 CDM 0250 RC 70594-0057-02 NDC J3370 HCPCS inpatient 3 UN 287.52 186.89 HUMANA - ALL PLANS HUMANA - ALL PLANS 224.27 78 999999999 174.09 278.89 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50570730_1 CDM 0250 RC 70594-0057-02 NDC J3370 HCPCS inpatient 3 UN 287.52 186.89 SIHO - ALL PLANS SIHO - ALL PLANS 258.77 90 999999999 174.09 278.89 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50570730_1 CDM 0250 RC 70594-0057-02 NDC J3370 HCPCS inpatient 3 UN 287.52 186.89 UMR - ALL PLANS UMR - ALL PLANS 201.26 70 999999999 174.09 278.89 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50570730_1 CDM 0250 RC 70594-0057-02 NDC J3370 HCPCS inpatient 3 UN 287.52 186.89 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 174.09 60.55 999999999 174.09 278.89 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50570730_1 CDM 0250 RC 70594-0057-02 NDC J3370 HCPCS inpatient 3 UN 287.52 186.89 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 174.09 278.89 "INJECTION, VANCOMYCIN HCL, 500 MG" 50570730_1 CDM 0250 RC 70594-0057-02 NDC J3370 HCPCS inpatient 3 UN 287.52 186.89 ANTHEM HMO ANTHEM HMO 999999999 174.09 278.89 "INJECTION, VANCOMYCIN HCL, 500 MG" 50570730_1 CDM 0250 RC 70594-0057-02 NDC J3370 HCPCS inpatient 3 UN 287.52 186.89 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 174.09 278.89 "INJECTION, VANCOMYCIN HCL, 500 MG" 50570730_1 CDM 0250 RC 70594-0057-02 NDC J3370 HCPCS inpatient 3 UN 287.52 186.89 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 174.09 278.89 "INJECTION, VANCOMYCIN HCL, 500 MG" 50570730_1 CDM 0250 RC 70594-0057-02 NDC J3370 HCPCS inpatient 3 UN 287.52 186.89 UHC - ALL PLANS UHC - ALL PLANS 999999999 174.09 278.89 "INJECTION, VANCOMYCIN HCL, 500 MG" 50570730_1 CDM 0250 RC 70594-0057-02 NDC J3370 HCPCS inpatient 3 UN 287.52 186.89 CIGNA - ALL PLANS CIGNA - ALL PLANS 194.36 67.6 999999999 174.09 278.89 percent of total billed charges BENAZEPRIL HCL 10 MG TABLET 50570819_1 CDM 0250 RC 50268-0110-15 NDC inpatient 1 UN 1.67 1.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.09 65 999999999 1.01 1.62 percent of total billed charges BENAZEPRIL HCL 10 MG TABLET 50570819_1 CDM 0250 RC 50268-0110-15 NDC inpatient 1 UN 1.67 1.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.62 97 999999999 1.01 1.62 percent of total billed charges BENAZEPRIL HCL 10 MG TABLET 50570819_1 CDM 0250 RC 50268-0110-15 NDC inpatient 1 UN 1.67 1.09 AETNA AETNA 1.32 79 999999999 1.01 1.62 percent of total billed charges BENAZEPRIL HCL 10 MG TABLET 50570819_1 CDM 0250 RC 50268-0110-15 NDC inpatient 1 UN 1.67 1.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.15 69 999999999 1.01 1.62 percent of total billed charges BENAZEPRIL HCL 10 MG TABLET 50570819_1 CDM 0250 RC 50268-0110-15 NDC inpatient 1 UN 1.67 1.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.3 78 999999999 1.01 1.62 percent of total billed charges BENAZEPRIL HCL 10 MG TABLET 50570819_1 CDM 0250 RC 50268-0110-15 NDC inpatient 1 UN 1.67 1.09 SIHO - ALL PLANS SIHO - ALL PLANS 1.5 90 999999999 1.01 1.62 percent of total billed charges BENAZEPRIL HCL 10 MG TABLET 50570819_1 CDM 0250 RC 50268-0110-15 NDC inpatient 1 UN 1.67 1.09 UMR - ALL PLANS UMR - ALL PLANS 1.17 70 999999999 1.01 1.62 percent of total billed charges BENAZEPRIL HCL 10 MG TABLET 50570819_1 CDM 0250 RC 50268-0110-15 NDC inpatient 1 UN 1.67 1.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.01 60.55 999999999 1.01 1.62 percent of total billed charges BENAZEPRIL HCL 10 MG TABLET 50570819_1 CDM 0250 RC 50268-0110-15 NDC inpatient 1 UN 1.67 1.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.01 1.62 BENAZEPRIL HCL 10 MG TABLET 50570819_1 CDM 0250 RC 50268-0110-15 NDC inpatient 1 UN 1.67 1.09 ANTHEM HMO ANTHEM HMO 999999999 1.01 1.62 BENAZEPRIL HCL 10 MG TABLET 50570819_1 CDM 0250 RC 50268-0110-15 NDC inpatient 1 UN 1.67 1.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.01 1.62 BENAZEPRIL HCL 10 MG TABLET 50570819_1 CDM 0250 RC 50268-0110-15 NDC inpatient 1 UN 1.67 1.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.01 1.62 BENAZEPRIL HCL 10 MG TABLET 50570819_1 CDM 0250 RC 50268-0110-15 NDC inpatient 1 UN 1.67 1.09 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.01 1.62 BENAZEPRIL HCL 10 MG TABLET 50570819_1 CDM 0250 RC 50268-0110-15 NDC inpatient 1 UN 1.67 1.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.13 67.6 999999999 1.01 1.62 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50571092_1 CDM 0255 RC J2795 HCPCS inpatient 53 34.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.45 65 999999999 32.09 51.41 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50571092_1 CDM 0255 RC J2795 HCPCS inpatient 53 34.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.41 97 999999999 32.09 51.41 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50571092_1 CDM 0255 RC J2795 HCPCS inpatient 53 34.45 AETNA AETNA 41.87 79 999999999 32.09 51.41 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50571092_1 CDM 0255 RC J2795 HCPCS inpatient 53 34.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.57 69 999999999 32.09 51.41 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50571092_1 CDM 0255 RC J2795 HCPCS inpatient 53 34.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.34 78 999999999 32.09 51.41 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50571092_1 CDM 0255 RC J2795 HCPCS inpatient 53 34.45 SIHO - ALL PLANS SIHO - ALL PLANS 47.7 90 999999999 32.09 51.41 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50571092_1 CDM 0255 RC J2795 HCPCS inpatient 53 34.45 UMR - ALL PLANS UMR - ALL PLANS 37.1 70 999999999 32.09 51.41 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50571092_1 CDM 0255 RC J2795 HCPCS inpatient 53 34.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.09 60.55 999999999 32.09 51.41 percent of total billed charges "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50571092_1 CDM 0255 RC J2795 HCPCS inpatient 53 34.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.09 51.41 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50571092_1 CDM 0255 RC J2795 HCPCS inpatient 53 34.45 ANTHEM HMO ANTHEM HMO 999999999 32.09 51.41 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50571092_1 CDM 0255 RC J2795 HCPCS inpatient 53 34.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.09 51.41 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50571092_1 CDM 0255 RC J2795 HCPCS inpatient 53 34.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.09 51.41 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50571092_1 CDM 0255 RC J2795 HCPCS inpatient 53 34.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.09 51.41 "INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 MG" 50571092_1 CDM 0255 RC J2795 HCPCS inpatient 53 34.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.83 67.6 999999999 32.09 51.41 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50571115_1 CDM 0250 RC 00781-3415-75 NDC J2469 HCPCS inpatient 10 UN 63.65 41.37 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.37 65 999999999 38.54 61.74 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50571115_1 CDM 0250 RC 00781-3415-75 NDC J2469 HCPCS inpatient 10 UN 63.65 41.37 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.74 97 999999999 38.54 61.74 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50571115_1 CDM 0250 RC 00781-3415-75 NDC J2469 HCPCS inpatient 10 UN 63.65 41.37 AETNA AETNA 50.28 79 999999999 38.54 61.74 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50571115_1 CDM 0250 RC 00781-3415-75 NDC J2469 HCPCS inpatient 10 UN 63.65 41.37 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.92 69 999999999 38.54 61.74 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50571115_1 CDM 0250 RC 00781-3415-75 NDC J2469 HCPCS inpatient 10 UN 63.65 41.37 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.65 78 999999999 38.54 61.74 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50571115_1 CDM 0250 RC 00781-3415-75 NDC J2469 HCPCS inpatient 10 UN 63.65 41.37 SIHO - ALL PLANS SIHO - ALL PLANS 57.29 90 999999999 38.54 61.74 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50571115_1 CDM 0250 RC 00781-3415-75 NDC J2469 HCPCS inpatient 10 UN 63.65 41.37 UMR - ALL PLANS UMR - ALL PLANS 44.56 70 999999999 38.54 61.74 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50571115_1 CDM 0250 RC 00781-3415-75 NDC J2469 HCPCS inpatient 10 UN 63.65 41.37 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.54 60.55 999999999 38.54 61.74 percent of total billed charges "INJECTION, PALONOSETRON HCL, 25 MCG" 50571115_1 CDM 0250 RC 00781-3415-75 NDC J2469 HCPCS inpatient 10 UN 63.65 41.37 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.54 61.74 "INJECTION, PALONOSETRON HCL, 25 MCG" 50571115_1 CDM 0250 RC 00781-3415-75 NDC J2469 HCPCS inpatient 10 UN 63.65 41.37 ANTHEM HMO ANTHEM HMO 999999999 38.54 61.74 "INJECTION, PALONOSETRON HCL, 25 MCG" 50571115_1 CDM 0250 RC 00781-3415-75 NDC J2469 HCPCS inpatient 10 UN 63.65 41.37 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.54 61.74 "INJECTION, PALONOSETRON HCL, 25 MCG" 50571115_1 CDM 0250 RC 00781-3415-75 NDC J2469 HCPCS inpatient 10 UN 63.65 41.37 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.54 61.74 "INJECTION, PALONOSETRON HCL, 25 MCG" 50571115_1 CDM 0250 RC 00781-3415-75 NDC J2469 HCPCS inpatient 10 UN 63.65 41.37 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.54 61.74 "INJECTION, PALONOSETRON HCL, 25 MCG" 50571115_1 CDM 0250 RC 00781-3415-75 NDC J2469 HCPCS inpatient 10 UN 63.65 41.37 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.03 67.6 999999999 38.54 61.74 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50571121_1 CDM 0250 RC 70594-0058-02 NDC J3370 HCPCS inpatient 4 UN 151.3 98.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.35 65 999999999 91.61 146.76 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50571121_1 CDM 0250 RC 70594-0058-02 NDC J3370 HCPCS inpatient 4 UN 151.3 98.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 146.76 97 999999999 91.61 146.76 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50571121_1 CDM 0250 RC 70594-0058-02 NDC J3370 HCPCS inpatient 4 UN 151.3 98.35 AETNA AETNA 119.53 79 999999999 91.61 146.76 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50571121_1 CDM 0250 RC 70594-0058-02 NDC J3370 HCPCS inpatient 4 UN 151.3 98.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.4 69 999999999 91.61 146.76 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50571121_1 CDM 0250 RC 70594-0058-02 NDC J3370 HCPCS inpatient 4 UN 151.3 98.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.01 78 999999999 91.61 146.76 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50571121_1 CDM 0250 RC 70594-0058-02 NDC J3370 HCPCS inpatient 4 UN 151.3 98.35 SIHO - ALL PLANS SIHO - ALL PLANS 136.17 90 999999999 91.61 146.76 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50571121_1 CDM 0250 RC 70594-0058-02 NDC J3370 HCPCS inpatient 4 UN 151.3 98.35 UMR - ALL PLANS UMR - ALL PLANS 105.91 70 999999999 91.61 146.76 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50571121_1 CDM 0250 RC 70594-0058-02 NDC J3370 HCPCS inpatient 4 UN 151.3 98.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 91.61 60.55 999999999 91.61 146.76 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50571121_1 CDM 0250 RC 70594-0058-02 NDC J3370 HCPCS inpatient 4 UN 151.3 98.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 91.61 146.76 "INJECTION, VANCOMYCIN HCL, 500 MG" 50571121_1 CDM 0250 RC 70594-0058-02 NDC J3370 HCPCS inpatient 4 UN 151.3 98.35 ANTHEM HMO ANTHEM HMO 999999999 91.61 146.76 "INJECTION, VANCOMYCIN HCL, 500 MG" 50571121_1 CDM 0250 RC 70594-0058-02 NDC J3370 HCPCS inpatient 4 UN 151.3 98.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 91.61 146.76 "INJECTION, VANCOMYCIN HCL, 500 MG" 50571121_1 CDM 0250 RC 70594-0058-02 NDC J3370 HCPCS inpatient 4 UN 151.3 98.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 91.61 146.76 "INJECTION, VANCOMYCIN HCL, 500 MG" 50571121_1 CDM 0250 RC 70594-0058-02 NDC J3370 HCPCS inpatient 4 UN 151.3 98.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 91.61 146.76 "INJECTION, VANCOMYCIN HCL, 500 MG" 50571121_1 CDM 0250 RC 70594-0058-02 NDC J3370 HCPCS inpatient 4 UN 151.3 98.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.28 67.6 999999999 91.61 146.76 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50572189_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50572189_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50572189_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50572189_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50572189_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50572189_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50572189_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50572189_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges Analysis for antibody to varicella-zoster virus (chicken pox) 50572189_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 50572189_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 50572189_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 50572189_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 50572189_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 Analysis for antibody to varicella-zoster virus (chicken pox) 50572189_1 CDM 0301 RC 86787 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges "Myelin basic protein (nerve protein) level, spinal fluid" 50572964_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges "Myelin basic protein (nerve protein) level, spinal fluid" 50572964_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges "Myelin basic protein (nerve protein) level, spinal fluid" 50572964_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges "Myelin basic protein (nerve protein) level, spinal fluid" 50572964_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges "Myelin basic protein (nerve protein) level, spinal fluid" 50572964_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges "Myelin basic protein (nerve protein) level, spinal fluid" 50572964_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges "Myelin basic protein (nerve protein) level, spinal fluid" 50572964_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges "Myelin basic protein (nerve protein) level, spinal fluid" 50572964_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges "Myelin basic protein (nerve protein) level, spinal fluid" 50572964_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 "Myelin basic protein (nerve protein) level, spinal fluid" 50572964_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 "Myelin basic protein (nerve protein) level, spinal fluid" 50572964_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 "Myelin basic protein (nerve protein) level, spinal fluid" 50572964_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 "Myelin basic protein (nerve protein) level, spinal fluid" 50572964_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 "Myelin basic protein (nerve protein) level, spinal fluid" 50572964_1 CDM 0301 RC 83873 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges LISINOPRIL 20 MG TABLET 50573132_1 CDM 0250 RC 00904-6799-61 NDC inpatient 1 UN 1.49 0.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.97 65 999999999 0.9 1.45 percent of total billed charges LISINOPRIL 20 MG TABLET 50573132_1 CDM 0250 RC 00904-6799-61 NDC inpatient 1 UN 1.49 0.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.45 97 999999999 0.9 1.45 percent of total billed charges LISINOPRIL 20 MG TABLET 50573132_1 CDM 0250 RC 00904-6799-61 NDC inpatient 1 UN 1.49 0.97 AETNA AETNA 1.18 79 999999999 0.9 1.45 percent of total billed charges LISINOPRIL 20 MG TABLET 50573132_1 CDM 0250 RC 00904-6799-61 NDC inpatient 1 UN 1.49 0.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.03 69 999999999 0.9 1.45 percent of total billed charges LISINOPRIL 20 MG TABLET 50573132_1 CDM 0250 RC 00904-6799-61 NDC inpatient 1 UN 1.49 0.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.16 78 999999999 0.9 1.45 percent of total billed charges LISINOPRIL 20 MG TABLET 50573132_1 CDM 0250 RC 00904-6799-61 NDC inpatient 1 UN 1.49 0.97 SIHO - ALL PLANS SIHO - ALL PLANS 1.34 90 999999999 0.9 1.45 percent of total billed charges LISINOPRIL 20 MG TABLET 50573132_1 CDM 0250 RC 00904-6799-61 NDC inpatient 1 UN 1.49 0.97 UMR - ALL PLANS UMR - ALL PLANS 1.04 70 999999999 0.9 1.45 percent of total billed charges LISINOPRIL 20 MG TABLET 50573132_1 CDM 0250 RC 00904-6799-61 NDC inpatient 1 UN 1.49 0.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.9 60.55 999999999 0.9 1.45 percent of total billed charges LISINOPRIL 20 MG TABLET 50573132_1 CDM 0250 RC 00904-6799-61 NDC inpatient 1 UN 1.49 0.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.9 1.45 LISINOPRIL 20 MG TABLET 50573132_1 CDM 0250 RC 00904-6799-61 NDC inpatient 1 UN 1.49 0.97 ANTHEM HMO ANTHEM HMO 999999999 0.9 1.45 LISINOPRIL 20 MG TABLET 50573132_1 CDM 0250 RC 00904-6799-61 NDC inpatient 1 UN 1.49 0.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.9 1.45 LISINOPRIL 20 MG TABLET 50573132_1 CDM 0250 RC 00904-6799-61 NDC inpatient 1 UN 1.49 0.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.9 1.45 LISINOPRIL 20 MG TABLET 50573132_1 CDM 0250 RC 00904-6799-61 NDC inpatient 1 UN 1.49 0.97 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.9 1.45 LISINOPRIL 20 MG TABLET 50573132_1 CDM 0250 RC 00904-6799-61 NDC inpatient 1 UN 1.49 0.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.01 67.6 999999999 0.9 1.45 percent of total billed charges MECLIZINE 12.5 MG TABLET 50573481_1 CDM 0250 RC 68084-0490-01 NDC inpatient 1 UN 1.52 0.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.99 65 999999999 0.92 1.47 percent of total billed charges MECLIZINE 12.5 MG TABLET 50573481_1 CDM 0250 RC 68084-0490-01 NDC inpatient 1 UN 1.52 0.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.47 97 999999999 0.92 1.47 percent of total billed charges MECLIZINE 12.5 MG TABLET 50573481_1 CDM 0250 RC 68084-0490-01 NDC inpatient 1 UN 1.52 0.99 AETNA AETNA 1.2 79 999999999 0.92 1.47 percent of total billed charges MECLIZINE 12.5 MG TABLET 50573481_1 CDM 0250 RC 68084-0490-01 NDC inpatient 1 UN 1.52 0.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.05 69 999999999 0.92 1.47 percent of total billed charges MECLIZINE 12.5 MG TABLET 50573481_1 CDM 0250 RC 68084-0490-01 NDC inpatient 1 UN 1.52 0.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.19 78 999999999 0.92 1.47 percent of total billed charges MECLIZINE 12.5 MG TABLET 50573481_1 CDM 0250 RC 68084-0490-01 NDC inpatient 1 UN 1.52 0.99 SIHO - ALL PLANS SIHO - ALL PLANS 1.37 90 999999999 0.92 1.47 percent of total billed charges MECLIZINE 12.5 MG TABLET 50573481_1 CDM 0250 RC 68084-0490-01 NDC inpatient 1 UN 1.52 0.99 UMR - ALL PLANS UMR - ALL PLANS 1.06 70 999999999 0.92 1.47 percent of total billed charges MECLIZINE 12.5 MG TABLET 50573481_1 CDM 0250 RC 68084-0490-01 NDC inpatient 1 UN 1.52 0.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.92 60.55 999999999 0.92 1.47 percent of total billed charges MECLIZINE 12.5 MG TABLET 50573481_1 CDM 0250 RC 68084-0490-01 NDC inpatient 1 UN 1.52 0.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.92 1.47 MECLIZINE 12.5 MG TABLET 50573481_1 CDM 0250 RC 68084-0490-01 NDC inpatient 1 UN 1.52 0.99 ANTHEM HMO ANTHEM HMO 999999999 0.92 1.47 MECLIZINE 12.5 MG TABLET 50573481_1 CDM 0250 RC 68084-0490-01 NDC inpatient 1 UN 1.52 0.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.92 1.47 MECLIZINE 12.5 MG TABLET 50573481_1 CDM 0250 RC 68084-0490-01 NDC inpatient 1 UN 1.52 0.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.92 1.47 MECLIZINE 12.5 MG TABLET 50573481_1 CDM 0250 RC 68084-0490-01 NDC inpatient 1 UN 1.52 0.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.92 1.47 MECLIZINE 12.5 MG TABLET 50573481_1 CDM 0250 RC 68084-0490-01 NDC inpatient 1 UN 1.52 0.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.03 67.6 999999999 0.92 1.47 percent of total billed charges ALBUTEROL HFA 90 MCG INHALER 50573627_1 CDM 0250 RC 69097-0142-60 NDC inpatient 1 UN 21.02 13.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 13.66 65 999999999 12.73 20.39 percent of total billed charges ALBUTEROL HFA 90 MCG INHALER 50573627_1 CDM 0250 RC 69097-0142-60 NDC inpatient 1 UN 21.02 13.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20.39 97 999999999 12.73 20.39 percent of total billed charges ALBUTEROL HFA 90 MCG INHALER 50573627_1 CDM 0250 RC 69097-0142-60 NDC inpatient 1 UN 21.02 13.66 AETNA AETNA 16.61 79 999999999 12.73 20.39 percent of total billed charges ALBUTEROL HFA 90 MCG INHALER 50573627_1 CDM 0250 RC 69097-0142-60 NDC inpatient 1 UN 21.02 13.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 14.5 69 999999999 12.73 20.39 percent of total billed charges ALBUTEROL HFA 90 MCG INHALER 50573627_1 CDM 0250 RC 69097-0142-60 NDC inpatient 1 UN 21.02 13.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 16.4 78 999999999 12.73 20.39 percent of total billed charges ALBUTEROL HFA 90 MCG INHALER 50573627_1 CDM 0250 RC 69097-0142-60 NDC inpatient 1 UN 21.02 13.66 SIHO - ALL PLANS SIHO - ALL PLANS 18.92 90 999999999 12.73 20.39 percent of total billed charges ALBUTEROL HFA 90 MCG INHALER 50573627_1 CDM 0250 RC 69097-0142-60 NDC inpatient 1 UN 21.02 13.66 UMR - ALL PLANS UMR - ALL PLANS 14.71 70 999999999 12.73 20.39 percent of total billed charges ALBUTEROL HFA 90 MCG INHALER 50573627_1 CDM 0250 RC 69097-0142-60 NDC inpatient 1 UN 21.02 13.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.73 60.55 999999999 12.73 20.39 percent of total billed charges ALBUTEROL HFA 90 MCG INHALER 50573627_1 CDM 0250 RC 69097-0142-60 NDC inpatient 1 UN 21.02 13.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.73 20.39 ALBUTEROL HFA 90 MCG INHALER 50573627_1 CDM 0250 RC 69097-0142-60 NDC inpatient 1 UN 21.02 13.66 ANTHEM HMO ANTHEM HMO 999999999 12.73 20.39 ALBUTEROL HFA 90 MCG INHALER 50573627_1 CDM 0250 RC 69097-0142-60 NDC inpatient 1 UN 21.02 13.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.73 20.39 ALBUTEROL HFA 90 MCG INHALER 50573627_1 CDM 0250 RC 69097-0142-60 NDC inpatient 1 UN 21.02 13.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.73 20.39 ALBUTEROL HFA 90 MCG INHALER 50573627_1 CDM 0250 RC 69097-0142-60 NDC inpatient 1 UN 21.02 13.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.73 20.39 ALBUTEROL HFA 90 MCG INHALER 50573627_1 CDM 0250 RC 69097-0142-60 NDC inpatient 1 UN 21.02 13.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.21 67.6 999999999 12.73 20.39 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50573676_1 CDM 0250 RC 70594-0056-03 NDC J3370 HCPCS inpatient 2 UN 93.1 60.52 SELF PAY DISCOUNT SELF PAY DISCOUNT 60.52 65 999999999 56.37 90.31 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50573676_1 CDM 0250 RC 70594-0056-03 NDC J3370 HCPCS inpatient 2 UN 93.1 60.52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 90.31 97 999999999 56.37 90.31 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50573676_1 CDM 0250 RC 70594-0056-03 NDC J3370 HCPCS inpatient 2 UN 93.1 60.52 AETNA AETNA 73.55 79 999999999 56.37 90.31 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50573676_1 CDM 0250 RC 70594-0056-03 NDC J3370 HCPCS inpatient 2 UN 93.1 60.52 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.24 69 999999999 56.37 90.31 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50573676_1 CDM 0250 RC 70594-0056-03 NDC J3370 HCPCS inpatient 2 UN 93.1 60.52 HUMANA - ALL PLANS HUMANA - ALL PLANS 72.62 78 999999999 56.37 90.31 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50573676_1 CDM 0250 RC 70594-0056-03 NDC J3370 HCPCS inpatient 2 UN 93.1 60.52 SIHO - ALL PLANS SIHO - ALL PLANS 83.79 90 999999999 56.37 90.31 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50573676_1 CDM 0250 RC 70594-0056-03 NDC J3370 HCPCS inpatient 2 UN 93.1 60.52 UMR - ALL PLANS UMR - ALL PLANS 65.17 70 999999999 56.37 90.31 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50573676_1 CDM 0250 RC 70594-0056-03 NDC J3370 HCPCS inpatient 2 UN 93.1 60.52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.37 60.55 999999999 56.37 90.31 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50573676_1 CDM 0250 RC 70594-0056-03 NDC J3370 HCPCS inpatient 2 UN 93.1 60.52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.37 90.31 "INJECTION, VANCOMYCIN HCL, 500 MG" 50573676_1 CDM 0250 RC 70594-0056-03 NDC J3370 HCPCS inpatient 2 UN 93.1 60.52 ANTHEM HMO ANTHEM HMO 999999999 56.37 90.31 "INJECTION, VANCOMYCIN HCL, 500 MG" 50573676_1 CDM 0250 RC 70594-0056-03 NDC J3370 HCPCS inpatient 2 UN 93.1 60.52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.37 90.31 "INJECTION, VANCOMYCIN HCL, 500 MG" 50573676_1 CDM 0250 RC 70594-0056-03 NDC J3370 HCPCS inpatient 2 UN 93.1 60.52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.37 90.31 "INJECTION, VANCOMYCIN HCL, 500 MG" 50573676_1 CDM 0250 RC 70594-0056-03 NDC J3370 HCPCS inpatient 2 UN 93.1 60.52 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.37 90.31 "INJECTION, VANCOMYCIN HCL, 500 MG" 50573676_1 CDM 0250 RC 70594-0056-03 NDC J3370 HCPCS inpatient 2 UN 93.1 60.52 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.94 67.6 999999999 56.37 90.31 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50573715_1 CDM 0258 RC 44567-0421-24 NDC J3475 HCPCS inpatient 8 UN 68.48 44.51 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.51 65 999999999 41.46 66.43 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50573715_1 CDM 0258 RC 44567-0421-24 NDC J3475 HCPCS inpatient 8 UN 68.48 44.51 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 66.43 97 999999999 41.46 66.43 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50573715_1 CDM 0258 RC 44567-0421-24 NDC J3475 HCPCS inpatient 8 UN 68.48 44.51 AETNA AETNA 54.1 79 999999999 41.46 66.43 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50573715_1 CDM 0258 RC 44567-0421-24 NDC J3475 HCPCS inpatient 8 UN 68.48 44.51 ENCORE - ALL PLANS ENCORE - ALL PLANS 47.25 69 999999999 41.46 66.43 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50573715_1 CDM 0258 RC 44567-0421-24 NDC J3475 HCPCS inpatient 8 UN 68.48 44.51 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.41 78 999999999 41.46 66.43 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50573715_1 CDM 0258 RC 44567-0421-24 NDC J3475 HCPCS inpatient 8 UN 68.48 44.51 SIHO - ALL PLANS SIHO - ALL PLANS 61.63 90 999999999 41.46 66.43 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50573715_1 CDM 0258 RC 44567-0421-24 NDC J3475 HCPCS inpatient 8 UN 68.48 44.51 UMR - ALL PLANS UMR - ALL PLANS 47.94 70 999999999 41.46 66.43 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50573715_1 CDM 0258 RC 44567-0421-24 NDC J3475 HCPCS inpatient 8 UN 68.48 44.51 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.46 60.55 999999999 41.46 66.43 percent of total billed charges "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50573715_1 CDM 0258 RC 44567-0421-24 NDC J3475 HCPCS inpatient 8 UN 68.48 44.51 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.46 66.43 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50573715_1 CDM 0258 RC 44567-0421-24 NDC J3475 HCPCS inpatient 8 UN 68.48 44.51 ANTHEM HMO ANTHEM HMO 999999999 41.46 66.43 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50573715_1 CDM 0258 RC 44567-0421-24 NDC J3475 HCPCS inpatient 8 UN 68.48 44.51 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.46 66.43 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50573715_1 CDM 0258 RC 44567-0421-24 NDC J3475 HCPCS inpatient 8 UN 68.48 44.51 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.46 66.43 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50573715_1 CDM 0258 RC 44567-0421-24 NDC J3475 HCPCS inpatient 8 UN 68.48 44.51 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.46 66.43 "INJECTION, MAGNESIUM SULFATE, PER 500 MG" 50573715_1 CDM 0258 RC 44567-0421-24 NDC J3475 HCPCS inpatient 8 UN 68.48 44.51 CIGNA - ALL PLANS CIGNA - ALL PLANS 46.29 67.6 999999999 41.46 66.43 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50573722_1 CDM 0301 RC 86635 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50573722_1 CDM 0301 RC 86635 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50573722_1 CDM 0301 RC 86635 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50573722_1 CDM 0301 RC 86635 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50573722_1 CDM 0301 RC 86635 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50573722_1 CDM 0301 RC 86635 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50573722_1 CDM 0301 RC 86635 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50573722_1 CDM 0301 RC 86635 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges Analysis for antibody to Coccidioides (bacteria) 50573722_1 CDM 0301 RC 86635 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 Analysis for antibody to Coccidioides (bacteria) 50573722_1 CDM 0301 RC 86635 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 Analysis for antibody to Coccidioides (bacteria) 50573722_1 CDM 0301 RC 86635 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 Analysis for antibody to Coccidioides (bacteria) 50573722_1 CDM 0301 RC 86635 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 Analysis for antibody to Coccidioides (bacteria) 50573722_1 CDM 0301 RC 86635 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 Analysis for antibody to Coccidioides (bacteria) 50573722_1 CDM 0301 RC 86635 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges Gammaglobulin (immune system protein) measurement 50573733_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges Gammaglobulin (immune system protein) measurement 50573733_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges Gammaglobulin (immune system protein) measurement 50573733_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges Gammaglobulin (immune system protein) measurement 50573733_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges Gammaglobulin (immune system protein) measurement 50573733_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges Gammaglobulin (immune system protein) measurement 50573733_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges Gammaglobulin (immune system protein) measurement 50573733_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges Gammaglobulin (immune system protein) measurement 50573733_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges Gammaglobulin (immune system protein) measurement 50573733_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 Gammaglobulin (immune system protein) measurement 50573733_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 Gammaglobulin (immune system protein) measurement 50573733_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 Gammaglobulin (immune system protein) measurement 50573733_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 Gammaglobulin (immune system protein) measurement 50573733_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 Gammaglobulin (immune system protein) measurement 50573733_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges "Influenza vaccine split virus, preservative free" 50574207_1 CDM 0250 RC 33332-0320-01 NDC 90662 HCPCS inpatient 1 UN 21.75 14.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.14 65 999999999 13.17 21.1 percent of total billed charges "Influenza vaccine split virus, preservative free" 50574207_1 CDM 0250 RC 33332-0320-01 NDC 90662 HCPCS inpatient 1 UN 21.75 14.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21.1 97 999999999 13.17 21.1 percent of total billed charges "Influenza vaccine split virus, preservative free" 50574207_1 CDM 0250 RC 33332-0320-01 NDC 90662 HCPCS inpatient 1 UN 21.75 14.14 AETNA AETNA 17.18 79 999999999 13.17 21.1 percent of total billed charges "Influenza vaccine split virus, preservative free" 50574207_1 CDM 0250 RC 33332-0320-01 NDC 90662 HCPCS inpatient 1 UN 21.75 14.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 16.97 78 999999999 13.17 21.1 percent of total billed charges "Influenza vaccine split virus, preservative free" 50574207_1 CDM 0250 RC 33332-0320-01 NDC 90662 HCPCS inpatient 1 UN 21.75 14.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.01 69 999999999 13.17 21.1 percent of total billed charges "Influenza vaccine split virus, preservative free" 50574207_1 CDM 0250 RC 33332-0320-01 NDC 90662 HCPCS inpatient 1 UN 21.75 14.14 SIHO - ALL PLANS SIHO - ALL PLANS 19.58 90 999999999 13.17 21.1 percent of total billed charges "Influenza vaccine split virus, preservative free" 50574207_1 CDM 0250 RC 33332-0320-01 NDC 90662 HCPCS inpatient 1 UN 21.75 14.14 UMR - ALL PLANS UMR - ALL PLANS 15.23 70 999999999 13.17 21.1 percent of total billed charges "Influenza vaccine split virus, preservative free" 50574207_1 CDM 0250 RC 33332-0320-01 NDC 90662 HCPCS inpatient 1 UN 21.75 14.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.17 60.55 999999999 13.17 21.1 percent of total billed charges "Influenza vaccine split virus, preservative free" 50574207_1 CDM 0250 RC 33332-0320-01 NDC 90662 HCPCS inpatient 1 UN 21.75 14.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.17 21.1 "Influenza vaccine split virus, preservative free" 50574207_1 CDM 0250 RC 33332-0320-01 NDC 90662 HCPCS inpatient 1 UN 21.75 14.14 ANTHEM HMO ANTHEM HMO 999999999 13.17 21.1 "Influenza vaccine split virus, preservative free" 50574207_1 CDM 0250 RC 33332-0320-01 NDC 90662 HCPCS inpatient 1 UN 21.75 14.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.17 21.1 "Influenza vaccine split virus, preservative free" 50574207_1 CDM 0250 RC 33332-0320-01 NDC 90662 HCPCS inpatient 1 UN 21.75 14.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.17 21.1 "Influenza vaccine split virus, preservative free" 50574207_1 CDM 0250 RC 33332-0320-01 NDC 90662 HCPCS inpatient 1 UN 21.75 14.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.17 21.1 "Influenza vaccine split virus, preservative free" 50574207_1 CDM 0250 RC 33332-0320-01 NDC 90662 HCPCS inpatient 1 UN 21.75 14.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.7 67.6 999999999 13.17 21.1 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50582663_1 CDM 0636 RC 50742-0520-05 NDC J9070 HCPCS inpatient 10 UN 1252.23 813.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 813.95 65 999999999 758.23 1214.66 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50582663_1 CDM 0636 RC 50742-0520-05 NDC J9070 HCPCS inpatient 10 UN 1252.23 813.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1214.66 97 999999999 758.23 1214.66 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50582663_1 CDM 0636 RC 50742-0520-05 NDC J9070 HCPCS inpatient 10 UN 1252.23 813.95 AETNA AETNA 989.26 79 999999999 758.23 1214.66 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50582663_1 CDM 0636 RC 50742-0520-05 NDC J9070 HCPCS inpatient 10 UN 1252.23 813.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 976.74 78 999999999 758.23 1214.66 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50582663_1 CDM 0636 RC 50742-0520-05 NDC J9070 HCPCS inpatient 10 UN 1252.23 813.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 864.04 69 999999999 758.23 1214.66 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50582663_1 CDM 0636 RC 50742-0520-05 NDC J9070 HCPCS inpatient 10 UN 1252.23 813.95 SIHO - ALL PLANS SIHO - ALL PLANS 1127.01 90 999999999 758.23 1214.66 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50582663_1 CDM 0636 RC 50742-0520-05 NDC J9070 HCPCS inpatient 10 UN 1252.23 813.95 UMR - ALL PLANS UMR - ALL PLANS 876.56 70 999999999 758.23 1214.66 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50582663_1 CDM 0636 RC 50742-0520-05 NDC J9070 HCPCS inpatient 10 UN 1252.23 813.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 758.23 60.55 999999999 758.23 1214.66 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50582663_1 CDM 0636 RC 50742-0520-05 NDC J9070 HCPCS inpatient 10 UN 1252.23 813.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 758.23 1214.66 "CYCLOPHOSPHAMIDE, 100 MG" 50582663_1 CDM 0636 RC 50742-0520-05 NDC J9070 HCPCS inpatient 10 UN 1252.23 813.95 ANTHEM HMO ANTHEM HMO 999999999 758.23 1214.66 "CYCLOPHOSPHAMIDE, 100 MG" 50582663_1 CDM 0636 RC 50742-0520-05 NDC J9070 HCPCS inpatient 10 UN 1252.23 813.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 758.23 1214.66 "CYCLOPHOSPHAMIDE, 100 MG" 50582663_1 CDM 0636 RC 50742-0520-05 NDC J9070 HCPCS inpatient 10 UN 1252.23 813.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 758.23 1214.66 "CYCLOPHOSPHAMIDE, 100 MG" 50582663_1 CDM 0636 RC 50742-0520-05 NDC J9070 HCPCS inpatient 10 UN 1252.23 813.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 758.23 1214.66 "CYCLOPHOSPHAMIDE, 100 MG" 50582663_1 CDM 0636 RC 50742-0520-05 NDC J9070 HCPCS inpatient 10 UN 1252.23 813.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 846.51 67.6 999999999 758.23 1214.66 percent of total billed charges 60687-0511-01 - hydrocortisone 10 mg Tab [JOHN] 50587716_1 CDM 0250 RC 60687-0511-01 NDC inpatient 1 UN 4.99 3.24 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.24 65 999999999 3.02 4.84 percent of total billed charges 60687-0511-01 - hydrocortisone 10 mg Tab [JOHN] 50587716_1 CDM 0250 RC 60687-0511-01 NDC inpatient 1 UN 4.99 3.24 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4.84 97 999999999 3.02 4.84 percent of total billed charges 60687-0511-01 - hydrocortisone 10 mg Tab [JOHN] 50587716_1 CDM 0250 RC 60687-0511-01 NDC inpatient 1 UN 4.99 3.24 AETNA AETNA 3.94 79 999999999 3.02 4.84 percent of total billed charges 60687-0511-01 - hydrocortisone 10 mg Tab [JOHN] 50587716_1 CDM 0250 RC 60687-0511-01 NDC inpatient 1 UN 4.99 3.24 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.89 78 999999999 3.02 4.84 percent of total billed charges 60687-0511-01 - hydrocortisone 10 mg Tab [JOHN] 50587716_1 CDM 0250 RC 60687-0511-01 NDC inpatient 1 UN 4.99 3.24 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.44 69 999999999 3.02 4.84 percent of total billed charges 60687-0511-01 - hydrocortisone 10 mg Tab [JOHN] 50587716_1 CDM 0250 RC 60687-0511-01 NDC inpatient 1 UN 4.99 3.24 SIHO - ALL PLANS SIHO - ALL PLANS 4.49 90 999999999 3.02 4.84 percent of total billed charges 60687-0511-01 - hydrocortisone 10 mg Tab [JOHN] 50587716_1 CDM 0250 RC 60687-0511-01 NDC inpatient 1 UN 4.99 3.24 UMR - ALL PLANS UMR - ALL PLANS 3.49 70 999999999 3.02 4.84 percent of total billed charges 60687-0511-01 - hydrocortisone 10 mg Tab [JOHN] 50587716_1 CDM 0250 RC 60687-0511-01 NDC inpatient 1 UN 4.99 3.24 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.02 60.55 999999999 3.02 4.84 percent of total billed charges 60687-0511-01 - hydrocortisone 10 mg Tab [JOHN] 50587716_1 CDM 0250 RC 60687-0511-01 NDC inpatient 1 UN 4.99 3.24 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.02 4.84 60687-0511-01 - hydrocortisone 10 mg Tab [JOHN] 50587716_1 CDM 0250 RC 60687-0511-01 NDC inpatient 1 UN 4.99 3.24 ANTHEM HMO ANTHEM HMO 999999999 3.02 4.84 60687-0511-01 - hydrocortisone 10 mg Tab [JOHN] 50587716_1 CDM 0250 RC 60687-0511-01 NDC inpatient 1 UN 4.99 3.24 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.02 4.84 60687-0511-01 - hydrocortisone 10 mg Tab [JOHN] 50587716_1 CDM 0250 RC 60687-0511-01 NDC inpatient 1 UN 4.99 3.24 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.02 4.84 60687-0511-01 - hydrocortisone 10 mg Tab [JOHN] 50587716_1 CDM 0250 RC 60687-0511-01 NDC inpatient 1 UN 4.99 3.24 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.02 4.84 60687-0511-01 - hydrocortisone 10 mg Tab [JOHN] 50587716_1 CDM 0250 RC 60687-0511-01 NDC inpatient 1 UN 4.99 3.24 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.37 67.6 999999999 3.02 4.84 percent of total billed charges CISATRACURIUM 20 MG/10 ML VIAL 50587932_1 CDM 0250 RC 71288-0714-11 NDC inpatient 1 UN 21.2 13.78 SELF PAY DISCOUNT SELF PAY DISCOUNT 13.78 65 999999999 12.84 20.56 percent of total billed charges CISATRACURIUM 20 MG/10 ML VIAL 50587932_1 CDM 0250 RC 71288-0714-11 NDC inpatient 1 UN 21.2 13.78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20.56 97 999999999 12.84 20.56 percent of total billed charges CISATRACURIUM 20 MG/10 ML VIAL 50587932_1 CDM 0250 RC 71288-0714-11 NDC inpatient 1 UN 21.2 13.78 AETNA AETNA 16.75 79 999999999 12.84 20.56 percent of total billed charges CISATRACURIUM 20 MG/10 ML VIAL 50587932_1 CDM 0250 RC 71288-0714-11 NDC inpatient 1 UN 21.2 13.78 HUMANA - ALL PLANS HUMANA - ALL PLANS 16.54 78 999999999 12.84 20.56 percent of total billed charges CISATRACURIUM 20 MG/10 ML VIAL 50587932_1 CDM 0250 RC 71288-0714-11 NDC inpatient 1 UN 21.2 13.78 ENCORE - ALL PLANS ENCORE - ALL PLANS 14.63 69 999999999 12.84 20.56 percent of total billed charges CISATRACURIUM 20 MG/10 ML VIAL 50587932_1 CDM 0250 RC 71288-0714-11 NDC inpatient 1 UN 21.2 13.78 SIHO - ALL PLANS SIHO - ALL PLANS 19.08 90 999999999 12.84 20.56 percent of total billed charges CISATRACURIUM 20 MG/10 ML VIAL 50587932_1 CDM 0250 RC 71288-0714-11 NDC inpatient 1 UN 21.2 13.78 UMR - ALL PLANS UMR - ALL PLANS 14.84 70 999999999 12.84 20.56 percent of total billed charges CISATRACURIUM 20 MG/10 ML VIAL 50587932_1 CDM 0250 RC 71288-0714-11 NDC inpatient 1 UN 21.2 13.78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.84 60.55 999999999 12.84 20.56 percent of total billed charges CISATRACURIUM 20 MG/10 ML VIAL 50587932_1 CDM 0250 RC 71288-0714-11 NDC inpatient 1 UN 21.2 13.78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.84 20.56 CISATRACURIUM 20 MG/10 ML VIAL 50587932_1 CDM 0250 RC 71288-0714-11 NDC inpatient 1 UN 21.2 13.78 ANTHEM HMO ANTHEM HMO 999999999 12.84 20.56 CISATRACURIUM 20 MG/10 ML VIAL 50587932_1 CDM 0250 RC 71288-0714-11 NDC inpatient 1 UN 21.2 13.78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.84 20.56 CISATRACURIUM 20 MG/10 ML VIAL 50587932_1 CDM 0250 RC 71288-0714-11 NDC inpatient 1 UN 21.2 13.78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.84 20.56 CISATRACURIUM 20 MG/10 ML VIAL 50587932_1 CDM 0250 RC 71288-0714-11 NDC inpatient 1 UN 21.2 13.78 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.84 20.56 CISATRACURIUM 20 MG/10 ML VIAL 50587932_1 CDM 0250 RC 71288-0714-11 NDC inpatient 1 UN 21.2 13.78 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.33 67.6 999999999 12.84 20.56 percent of total billed charges ENOXAPARIN 80 MG/0.8 ML SYR 50587934_1 CDM 0250 RC 71288-0410-87 NDC inpatient 1 UN 47.79 31.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.06 65 999999999 28.94 46.36 percent of total billed charges ENOXAPARIN 80 MG/0.8 ML SYR 50587934_1 CDM 0250 RC 71288-0410-87 NDC inpatient 1 UN 47.79 31.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 46.36 97 999999999 28.94 46.36 percent of total billed charges ENOXAPARIN 80 MG/0.8 ML SYR 50587934_1 CDM 0250 RC 71288-0410-87 NDC inpatient 1 UN 47.79 31.06 AETNA AETNA 37.75 79 999999999 28.94 46.36 percent of total billed charges ENOXAPARIN 80 MG/0.8 ML SYR 50587934_1 CDM 0250 RC 71288-0410-87 NDC inpatient 1 UN 47.79 31.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 37.28 78 999999999 28.94 46.36 percent of total billed charges ENOXAPARIN 80 MG/0.8 ML SYR 50587934_1 CDM 0250 RC 71288-0410-87 NDC inpatient 1 UN 47.79 31.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 32.98 69 999999999 28.94 46.36 percent of total billed charges ENOXAPARIN 80 MG/0.8 ML SYR 50587934_1 CDM 0250 RC 71288-0410-87 NDC inpatient 1 UN 47.79 31.06 SIHO - ALL PLANS SIHO - ALL PLANS 43.01 90 999999999 28.94 46.36 percent of total billed charges ENOXAPARIN 80 MG/0.8 ML SYR 50587934_1 CDM 0250 RC 71288-0410-87 NDC inpatient 1 UN 47.79 31.06 UMR - ALL PLANS UMR - ALL PLANS 33.45 70 999999999 28.94 46.36 percent of total billed charges ENOXAPARIN 80 MG/0.8 ML SYR 50587934_1 CDM 0250 RC 71288-0410-87 NDC inpatient 1 UN 47.79 31.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 28.94 60.55 999999999 28.94 46.36 percent of total billed charges ENOXAPARIN 80 MG/0.8 ML SYR 50587934_1 CDM 0250 RC 71288-0410-87 NDC inpatient 1 UN 47.79 31.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 28.94 46.36 ENOXAPARIN 80 MG/0.8 ML SYR 50587934_1 CDM 0250 RC 71288-0410-87 NDC inpatient 1 UN 47.79 31.06 ANTHEM HMO ANTHEM HMO 999999999 28.94 46.36 ENOXAPARIN 80 MG/0.8 ML SYR 50587934_1 CDM 0250 RC 71288-0410-87 NDC inpatient 1 UN 47.79 31.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 28.94 46.36 ENOXAPARIN 80 MG/0.8 ML SYR 50587934_1 CDM 0250 RC 71288-0410-87 NDC inpatient 1 UN 47.79 31.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 28.94 46.36 ENOXAPARIN 80 MG/0.8 ML SYR 50587934_1 CDM 0250 RC 71288-0410-87 NDC inpatient 1 UN 47.79 31.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 28.94 46.36 ENOXAPARIN 80 MG/0.8 ML SYR 50587934_1 CDM 0250 RC 71288-0410-87 NDC inpatient 1 UN 47.79 31.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 32.31 67.6 999999999 28.94 46.36 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 50588144_1 CDM 0250 RC 63323-0806-01 NDC J3010 HCPCS inpatient 1 UN 25.73 16.72 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.72 65 999999999 15.58 24.96 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 50588144_1 CDM 0250 RC 63323-0806-01 NDC J3010 HCPCS inpatient 1 UN 25.73 16.72 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.96 97 999999999 15.58 24.96 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 50588144_1 CDM 0250 RC 63323-0806-01 NDC J3010 HCPCS inpatient 1 UN 25.73 16.72 AETNA AETNA 20.33 79 999999999 15.58 24.96 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 50588144_1 CDM 0250 RC 63323-0806-01 NDC J3010 HCPCS inpatient 1 UN 25.73 16.72 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.07 78 999999999 15.58 24.96 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 50588144_1 CDM 0250 RC 63323-0806-01 NDC J3010 HCPCS inpatient 1 UN 25.73 16.72 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.75 69 999999999 15.58 24.96 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 50588144_1 CDM 0250 RC 63323-0806-01 NDC J3010 HCPCS inpatient 1 UN 25.73 16.72 SIHO - ALL PLANS SIHO - ALL PLANS 23.16 90 999999999 15.58 24.96 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 50588144_1 CDM 0250 RC 63323-0806-01 NDC J3010 HCPCS inpatient 1 UN 25.73 16.72 UMR - ALL PLANS UMR - ALL PLANS 18.01 70 999999999 15.58 24.96 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 50588144_1 CDM 0250 RC 63323-0806-01 NDC J3010 HCPCS inpatient 1 UN 25.73 16.72 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.58 60.55 999999999 15.58 24.96 percent of total billed charges "INJECTION, FENTANYL CITRATE, 0.1 MG" 50588144_1 CDM 0250 RC 63323-0806-01 NDC J3010 HCPCS inpatient 1 UN 25.73 16.72 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.58 24.96 "INJECTION, FENTANYL CITRATE, 0.1 MG" 50588144_1 CDM 0250 RC 63323-0806-01 NDC J3010 HCPCS inpatient 1 UN 25.73 16.72 ANTHEM HMO ANTHEM HMO 999999999 15.58 24.96 "INJECTION, FENTANYL CITRATE, 0.1 MG" 50588144_1 CDM 0250 RC 63323-0806-01 NDC J3010 HCPCS inpatient 1 UN 25.73 16.72 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.58 24.96 "INJECTION, FENTANYL CITRATE, 0.1 MG" 50588144_1 CDM 0250 RC 63323-0806-01 NDC J3010 HCPCS inpatient 1 UN 25.73 16.72 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.58 24.96 "INJECTION, FENTANYL CITRATE, 0.1 MG" 50588144_1 CDM 0250 RC 63323-0806-01 NDC J3010 HCPCS inpatient 1 UN 25.73 16.72 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.58 24.96 "INJECTION, FENTANYL CITRATE, 0.1 MG" 50588144_1 CDM 0250 RC 63323-0806-01 NDC J3010 HCPCS inpatient 1 UN 25.73 16.72 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.39 67.6 999999999 15.58 24.96 percent of total billed charges "INJECTION, BAMLANIVIMAB-XXXX, 700 MG" 50588148_1 CDM 0636 RC 00002-7910-01 NDC Q0239 HCPCS inpatient 1 UN 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges "INJECTION, BAMLANIVIMAB-XXXX, 700 MG" 50588148_1 CDM 0636 RC 00002-7910-01 NDC Q0239 HCPCS inpatient 1 UN 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges "INJECTION, BAMLANIVIMAB-XXXX, 700 MG" 50588148_1 CDM 0636 RC 00002-7910-01 NDC Q0239 HCPCS inpatient 1 UN 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges "INJECTION, BAMLANIVIMAB-XXXX, 700 MG" 50588148_1 CDM 0636 RC 00002-7910-01 NDC Q0239 HCPCS inpatient 1 UN 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges "INJECTION, BAMLANIVIMAB-XXXX, 700 MG" 50588148_1 CDM 0636 RC 00002-7910-01 NDC Q0239 HCPCS inpatient 1 UN 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges "INJECTION, BAMLANIVIMAB-XXXX, 700 MG" 50588148_1 CDM 0636 RC 00002-7910-01 NDC Q0239 HCPCS inpatient 1 UN 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges "INJECTION, BAMLANIVIMAB-XXXX, 700 MG" 50588148_1 CDM 0636 RC 00002-7910-01 NDC Q0239 HCPCS inpatient 1 UN 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges "INJECTION, BAMLANIVIMAB-XXXX, 700 MG" 50588148_1 CDM 0636 RC 00002-7910-01 NDC Q0239 HCPCS inpatient 1 UN 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges "INJECTION, BAMLANIVIMAB-XXXX, 700 MG" 50588148_1 CDM 0636 RC 00002-7910-01 NDC Q0239 HCPCS inpatient 1 UN 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 "INJECTION, BAMLANIVIMAB-XXXX, 700 MG" 50588148_1 CDM 0636 RC 00002-7910-01 NDC Q0239 HCPCS inpatient 1 UN 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 "INJECTION, BAMLANIVIMAB-XXXX, 700 MG" 50588148_1 CDM 0636 RC 00002-7910-01 NDC Q0239 HCPCS inpatient 1 UN 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 "INJECTION, BAMLANIVIMAB-XXXX, 700 MG" 50588148_1 CDM 0636 RC 00002-7910-01 NDC Q0239 HCPCS inpatient 1 UN 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 "INJECTION, BAMLANIVIMAB-XXXX, 700 MG" 50588148_1 CDM 0636 RC 00002-7910-01 NDC Q0239 HCPCS inpatient 1 UN 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 "INJECTION, BAMLANIVIMAB-XXXX, 700 MG" 50588148_1 CDM 0636 RC 00002-7910-01 NDC Q0239 HCPCS inpatient 1 UN 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges Measurement for Strep antibody (strep throat) 50588153_1 CDM 0301 RC 86060 HCPCS inpatient 177 115.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.05 65 999999999 107.17 171.69 percent of total billed charges Measurement for Strep antibody (strep throat) 50588153_1 CDM 0301 RC 86060 HCPCS inpatient 177 115.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 171.69 97 999999999 107.17 171.69 percent of total billed charges Measurement for Strep antibody (strep throat) 50588153_1 CDM 0301 RC 86060 HCPCS inpatient 177 115.05 AETNA AETNA 139.83 79 999999999 107.17 171.69 percent of total billed charges Measurement for Strep antibody (strep throat) 50588153_1 CDM 0301 RC 86060 HCPCS inpatient 177 115.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.06 78 999999999 107.17 171.69 percent of total billed charges Measurement for Strep antibody (strep throat) 50588153_1 CDM 0301 RC 86060 HCPCS inpatient 177 115.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.13 69 999999999 107.17 171.69 percent of total billed charges Measurement for Strep antibody (strep throat) 50588153_1 CDM 0301 RC 86060 HCPCS inpatient 177 115.05 SIHO - ALL PLANS SIHO - ALL PLANS 159.3 90 999999999 107.17 171.69 percent of total billed charges Measurement for Strep antibody (strep throat) 50588153_1 CDM 0301 RC 86060 HCPCS inpatient 177 115.05 UMR - ALL PLANS UMR - ALL PLANS 123.9 70 999999999 107.17 171.69 percent of total billed charges Measurement for Strep antibody (strep throat) 50588153_1 CDM 0301 RC 86060 HCPCS inpatient 177 115.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.17 60.55 999999999 107.17 171.69 percent of total billed charges Measurement for Strep antibody (strep throat) 50588153_1 CDM 0301 RC 86060 HCPCS inpatient 177 115.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.17 171.69 Measurement for Strep antibody (strep throat) 50588153_1 CDM 0301 RC 86060 HCPCS inpatient 177 115.05 ANTHEM HMO ANTHEM HMO 999999999 107.17 171.69 Measurement for Strep antibody (strep throat) 50588153_1 CDM 0301 RC 86060 HCPCS inpatient 177 115.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.17 171.69 Measurement for Strep antibody (strep throat) 50588153_1 CDM 0301 RC 86060 HCPCS inpatient 177 115.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.17 171.69 Measurement for Strep antibody (strep throat) 50588153_1 CDM 0301 RC 86060 HCPCS inpatient 177 115.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.17 171.69 Measurement for Strep antibody (strep throat) 50588153_1 CDM 0301 RC 86060 HCPCS inpatient 177 115.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 119.65 67.6 999999999 107.17 171.69 percent of total billed charges URSODIOL 250 MG TABLET 50592069_1 CDM 0250 RC 60687-0527-21 NDC inpatient 1 UN 7.72 5.02 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.02 65 999999999 4.67 7.49 percent of total billed charges URSODIOL 250 MG TABLET 50592069_1 CDM 0250 RC 60687-0527-21 NDC inpatient 1 UN 7.72 5.02 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7.49 97 999999999 4.67 7.49 percent of total billed charges URSODIOL 250 MG TABLET 50592069_1 CDM 0250 RC 60687-0527-21 NDC inpatient 1 UN 7.72 5.02 AETNA AETNA 6.1 79 999999999 4.67 7.49 percent of total billed charges URSODIOL 250 MG TABLET 50592069_1 CDM 0250 RC 60687-0527-21 NDC inpatient 1 UN 7.72 5.02 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.02 78 999999999 4.67 7.49 percent of total billed charges URSODIOL 250 MG TABLET 50592069_1 CDM 0250 RC 60687-0527-21 NDC inpatient 1 UN 7.72 5.02 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.33 69 999999999 4.67 7.49 percent of total billed charges URSODIOL 250 MG TABLET 50592069_1 CDM 0250 RC 60687-0527-21 NDC inpatient 1 UN 7.72 5.02 SIHO - ALL PLANS SIHO - ALL PLANS 6.95 90 999999999 4.67 7.49 percent of total billed charges URSODIOL 250 MG TABLET 50592069_1 CDM 0250 RC 60687-0527-21 NDC inpatient 1 UN 7.72 5.02 UMR - ALL PLANS UMR - ALL PLANS 5.4 70 999999999 4.67 7.49 percent of total billed charges URSODIOL 250 MG TABLET 50592069_1 CDM 0250 RC 60687-0527-21 NDC inpatient 1 UN 7.72 5.02 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.67 60.55 999999999 4.67 7.49 percent of total billed charges URSODIOL 250 MG TABLET 50592069_1 CDM 0250 RC 60687-0527-21 NDC inpatient 1 UN 7.72 5.02 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.67 7.49 URSODIOL 250 MG TABLET 50592069_1 CDM 0250 RC 60687-0527-21 NDC inpatient 1 UN 7.72 5.02 ANTHEM HMO ANTHEM HMO 999999999 4.67 7.49 URSODIOL 250 MG TABLET 50592069_1 CDM 0250 RC 60687-0527-21 NDC inpatient 1 UN 7.72 5.02 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.67 7.49 URSODIOL 250 MG TABLET 50592069_1 CDM 0250 RC 60687-0527-21 NDC inpatient 1 UN 7.72 5.02 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.67 7.49 URSODIOL 250 MG TABLET 50592069_1 CDM 0250 RC 60687-0527-21 NDC inpatient 1 UN 7.72 5.02 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.67 7.49 URSODIOL 250 MG TABLET 50592069_1 CDM 0250 RC 60687-0527-21 NDC inpatient 1 UN 7.72 5.02 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.22 67.6 999999999 4.67 7.49 percent of total billed charges COLESEVELAM 625 MG TABLET 50592071_1 CDM 0250 RC 60687-0385-25 NDC inpatient 1 UN 11.86 7.71 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.71 65 999999999 7.18 11.5 percent of total billed charges COLESEVELAM 625 MG TABLET 50592071_1 CDM 0250 RC 60687-0385-25 NDC inpatient 1 UN 11.86 7.71 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11.5 97 999999999 7.18 11.5 percent of total billed charges COLESEVELAM 625 MG TABLET 50592071_1 CDM 0250 RC 60687-0385-25 NDC inpatient 1 UN 11.86 7.71 AETNA AETNA 9.37 79 999999999 7.18 11.5 percent of total billed charges COLESEVELAM 625 MG TABLET 50592071_1 CDM 0250 RC 60687-0385-25 NDC inpatient 1 UN 11.86 7.71 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.25 78 999999999 7.18 11.5 percent of total billed charges COLESEVELAM 625 MG TABLET 50592071_1 CDM 0250 RC 60687-0385-25 NDC inpatient 1 UN 11.86 7.71 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.18 69 999999999 7.18 11.5 percent of total billed charges COLESEVELAM 625 MG TABLET 50592071_1 CDM 0250 RC 60687-0385-25 NDC inpatient 1 UN 11.86 7.71 SIHO - ALL PLANS SIHO - ALL PLANS 10.67 90 999999999 7.18 11.5 percent of total billed charges COLESEVELAM 625 MG TABLET 50592071_1 CDM 0250 RC 60687-0385-25 NDC inpatient 1 UN 11.86 7.71 UMR - ALL PLANS UMR - ALL PLANS 8.3 70 999999999 7.18 11.5 percent of total billed charges COLESEVELAM 625 MG TABLET 50592071_1 CDM 0250 RC 60687-0385-25 NDC inpatient 1 UN 11.86 7.71 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.18 60.55 999999999 7.18 11.5 percent of total billed charges COLESEVELAM 625 MG TABLET 50592071_1 CDM 0250 RC 60687-0385-25 NDC inpatient 1 UN 11.86 7.71 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.18 11.5 COLESEVELAM 625 MG TABLET 50592071_1 CDM 0250 RC 60687-0385-25 NDC inpatient 1 UN 11.86 7.71 ANTHEM HMO ANTHEM HMO 999999999 7.18 11.5 COLESEVELAM 625 MG TABLET 50592071_1 CDM 0250 RC 60687-0385-25 NDC inpatient 1 UN 11.86 7.71 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.18 11.5 COLESEVELAM 625 MG TABLET 50592071_1 CDM 0250 RC 60687-0385-25 NDC inpatient 1 UN 11.86 7.71 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.18 11.5 COLESEVELAM 625 MG TABLET 50592071_1 CDM 0250 RC 60687-0385-25 NDC inpatient 1 UN 11.86 7.71 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.18 11.5 COLESEVELAM 625 MG TABLET 50592071_1 CDM 0250 RC 60687-0385-25 NDC inpatient 1 UN 11.86 7.71 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.02 67.6 999999999 7.18 11.5 percent of total billed charges TRIAMTERENE-HCTZ 37.5-25 MG TB 50592072_1 CDM 0250 RC 68084-0750-25 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 37.5-25 MG TB 50592072_1 CDM 0250 RC 68084-0750-25 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 37.5-25 MG TB 50592072_1 CDM 0250 RC 68084-0750-25 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 37.5-25 MG TB 50592072_1 CDM 0250 RC 68084-0750-25 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 37.5-25 MG TB 50592072_1 CDM 0250 RC 68084-0750-25 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 37.5-25 MG TB 50592072_1 CDM 0250 RC 68084-0750-25 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 37.5-25 MG TB 50592072_1 CDM 0250 RC 68084-0750-25 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 37.5-25 MG TB 50592072_1 CDM 0250 RC 68084-0750-25 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 37.5-25 MG TB 50592072_1 CDM 0250 RC 68084-0750-25 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 TRIAMTERENE-HCTZ 37.5-25 MG TB 50592072_1 CDM 0250 RC 68084-0750-25 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 TRIAMTERENE-HCTZ 37.5-25 MG TB 50592072_1 CDM 0250 RC 68084-0750-25 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 TRIAMTERENE-HCTZ 37.5-25 MG TB 50592072_1 CDM 0250 RC 68084-0750-25 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 TRIAMTERENE-HCTZ 37.5-25 MG TB 50592072_1 CDM 0250 RC 68084-0750-25 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 TRIAMTERENE-HCTZ 37.5-25 MG TB 50592072_1 CDM 0250 RC 68084-0750-25 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges RAMIPRIL 10 MG CAPSULE 50592073_1 CDM 0250 RC 68001-0431-00 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges RAMIPRIL 10 MG CAPSULE 50592073_1 CDM 0250 RC 68001-0431-00 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges RAMIPRIL 10 MG CAPSULE 50592073_1 CDM 0250 RC 68001-0431-00 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges RAMIPRIL 10 MG CAPSULE 50592073_1 CDM 0250 RC 68001-0431-00 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges RAMIPRIL 10 MG CAPSULE 50592073_1 CDM 0250 RC 68001-0431-00 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges RAMIPRIL 10 MG CAPSULE 50592073_1 CDM 0250 RC 68001-0431-00 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges RAMIPRIL 10 MG CAPSULE 50592073_1 CDM 0250 RC 68001-0431-00 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges RAMIPRIL 10 MG CAPSULE 50592073_1 CDM 0250 RC 68001-0431-00 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges RAMIPRIL 10 MG CAPSULE 50592073_1 CDM 0250 RC 68001-0431-00 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 RAMIPRIL 10 MG CAPSULE 50592073_1 CDM 0250 RC 68001-0431-00 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 RAMIPRIL 10 MG CAPSULE 50592073_1 CDM 0250 RC 68001-0431-00 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 RAMIPRIL 10 MG CAPSULE 50592073_1 CDM 0250 RC 68001-0431-00 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 RAMIPRIL 10 MG CAPSULE 50592073_1 CDM 0250 RC 68001-0431-00 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 RAMIPRIL 10 MG CAPSULE 50592073_1 CDM 0250 RC 68001-0431-00 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges Analysis for antibody to parvovirus 50592079_1 CDM 0301 RC 86747 HCPCS inpatient 194 126.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 126.1 65 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 50592079_1 CDM 0301 RC 86747 HCPCS inpatient 194 126.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 188.18 97 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 50592079_1 CDM 0301 RC 86747 HCPCS inpatient 194 126.1 AETNA AETNA 153.26 79 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 50592079_1 CDM 0301 RC 86747 HCPCS inpatient 194 126.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 151.32 78 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 50592079_1 CDM 0301 RC 86747 HCPCS inpatient 194 126.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.86 69 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 50592079_1 CDM 0301 RC 86747 HCPCS inpatient 194 126.1 SIHO - ALL PLANS SIHO - ALL PLANS 174.6 90 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 50592079_1 CDM 0301 RC 86747 HCPCS inpatient 194 126.1 UMR - ALL PLANS UMR - ALL PLANS 135.8 70 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 50592079_1 CDM 0301 RC 86747 HCPCS inpatient 194 126.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 117.47 60.55 999999999 117.47 188.18 percent of total billed charges Analysis for antibody to parvovirus 50592079_1 CDM 0301 RC 86747 HCPCS inpatient 194 126.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 117.47 188.18 Analysis for antibody to parvovirus 50592079_1 CDM 0301 RC 86747 HCPCS inpatient 194 126.1 ANTHEM HMO ANTHEM HMO 999999999 117.47 188.18 Analysis for antibody to parvovirus 50592079_1 CDM 0301 RC 86747 HCPCS inpatient 194 126.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 117.47 188.18 Analysis for antibody to parvovirus 50592079_1 CDM 0301 RC 86747 HCPCS inpatient 194 126.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 117.47 188.18 Analysis for antibody to parvovirus 50592079_1 CDM 0301 RC 86747 HCPCS inpatient 194 126.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 117.47 188.18 Analysis for antibody to parvovirus 50592079_1 CDM 0301 RC 86747 HCPCS inpatient 194 126.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 131.14 67.6 999999999 117.47 188.18 percent of total billed charges "AZATHIOPRINE, ORAL, 50 MG" 50592094_1 CDM 0250 RC 68084-0229-01 NDC J7500 HCPCS inpatient 1 UN 1.87 1.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.22 65 999999999 1.13 1.81 percent of total billed charges "AZATHIOPRINE, ORAL, 50 MG" 50592094_1 CDM 0250 RC 68084-0229-01 NDC J7500 HCPCS inpatient 1 UN 1.87 1.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.81 97 999999999 1.13 1.81 percent of total billed charges "AZATHIOPRINE, ORAL, 50 MG" 50592094_1 CDM 0250 RC 68084-0229-01 NDC J7500 HCPCS inpatient 1 UN 1.87 1.22 AETNA AETNA 1.48 79 999999999 1.13 1.81 percent of total billed charges "AZATHIOPRINE, ORAL, 50 MG" 50592094_1 CDM 0250 RC 68084-0229-01 NDC J7500 HCPCS inpatient 1 UN 1.87 1.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.46 78 999999999 1.13 1.81 percent of total billed charges "AZATHIOPRINE, ORAL, 50 MG" 50592094_1 CDM 0250 RC 68084-0229-01 NDC J7500 HCPCS inpatient 1 UN 1.87 1.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.29 69 999999999 1.13 1.81 percent of total billed charges "AZATHIOPRINE, ORAL, 50 MG" 50592094_1 CDM 0250 RC 68084-0229-01 NDC J7500 HCPCS inpatient 1 UN 1.87 1.22 SIHO - ALL PLANS SIHO - ALL PLANS 1.68 90 999999999 1.13 1.81 percent of total billed charges "AZATHIOPRINE, ORAL, 50 MG" 50592094_1 CDM 0250 RC 68084-0229-01 NDC J7500 HCPCS inpatient 1 UN 1.87 1.22 UMR - ALL PLANS UMR - ALL PLANS 1.31 70 999999999 1.13 1.81 percent of total billed charges "AZATHIOPRINE, ORAL, 50 MG" 50592094_1 CDM 0250 RC 68084-0229-01 NDC J7500 HCPCS inpatient 1 UN 1.87 1.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.13 60.55 999999999 1.13 1.81 percent of total billed charges "AZATHIOPRINE, ORAL, 50 MG" 50592094_1 CDM 0250 RC 68084-0229-01 NDC J7500 HCPCS inpatient 1 UN 1.87 1.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.13 1.81 "AZATHIOPRINE, ORAL, 50 MG" 50592094_1 CDM 0250 RC 68084-0229-01 NDC J7500 HCPCS inpatient 1 UN 1.87 1.22 ANTHEM HMO ANTHEM HMO 999999999 1.13 1.81 "AZATHIOPRINE, ORAL, 50 MG" 50592094_1 CDM 0250 RC 68084-0229-01 NDC J7500 HCPCS inpatient 1 UN 1.87 1.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.13 1.81 "AZATHIOPRINE, ORAL, 50 MG" 50592094_1 CDM 0250 RC 68084-0229-01 NDC J7500 HCPCS inpatient 1 UN 1.87 1.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.13 1.81 "AZATHIOPRINE, ORAL, 50 MG" 50592094_1 CDM 0250 RC 68084-0229-01 NDC J7500 HCPCS inpatient 1 UN 1.87 1.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.13 1.81 "AZATHIOPRINE, ORAL, 50 MG" 50592094_1 CDM 0250 RC 68084-0229-01 NDC J7500 HCPCS inpatient 1 UN 1.87 1.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.26 67.6 999999999 1.13 1.81 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50592095_1 CDM 0250 RC 63323-0582-82 NDC J1610 HCPCS inpatient 1 UN 1078.14 700.79 SELF PAY DISCOUNT SELF PAY DISCOUNT 700.79 65 999999999 652.81 1045.8 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50592095_1 CDM 0250 RC 63323-0582-82 NDC J1610 HCPCS inpatient 1 UN 1078.14 700.79 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1045.8 97 999999999 652.81 1045.8 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50592095_1 CDM 0250 RC 63323-0582-82 NDC J1610 HCPCS inpatient 1 UN 1078.14 700.79 AETNA AETNA 851.73 79 999999999 652.81 1045.8 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50592095_1 CDM 0250 RC 63323-0582-82 NDC J1610 HCPCS inpatient 1 UN 1078.14 700.79 HUMANA - ALL PLANS HUMANA - ALL PLANS 840.95 78 999999999 652.81 1045.8 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50592095_1 CDM 0250 RC 63323-0582-82 NDC J1610 HCPCS inpatient 1 UN 1078.14 700.79 ENCORE - ALL PLANS ENCORE - ALL PLANS 743.92 69 999999999 652.81 1045.8 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50592095_1 CDM 0250 RC 63323-0582-82 NDC J1610 HCPCS inpatient 1 UN 1078.14 700.79 SIHO - ALL PLANS SIHO - ALL PLANS 970.33 90 999999999 652.81 1045.8 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50592095_1 CDM 0250 RC 63323-0582-82 NDC J1610 HCPCS inpatient 1 UN 1078.14 700.79 UMR - ALL PLANS UMR - ALL PLANS 754.7 70 999999999 652.81 1045.8 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50592095_1 CDM 0250 RC 63323-0582-82 NDC J1610 HCPCS inpatient 1 UN 1078.14 700.79 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 652.81 60.55 999999999 652.81 1045.8 percent of total billed charges "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50592095_1 CDM 0250 RC 63323-0582-82 NDC J1610 HCPCS inpatient 1 UN 1078.14 700.79 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 652.81 1045.8 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50592095_1 CDM 0250 RC 63323-0582-82 NDC J1610 HCPCS inpatient 1 UN 1078.14 700.79 ANTHEM HMO ANTHEM HMO 999999999 652.81 1045.8 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50592095_1 CDM 0250 RC 63323-0582-82 NDC J1610 HCPCS inpatient 1 UN 1078.14 700.79 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 652.81 1045.8 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50592095_1 CDM 0250 RC 63323-0582-82 NDC J1610 HCPCS inpatient 1 UN 1078.14 700.79 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 652.81 1045.8 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50592095_1 CDM 0250 RC 63323-0582-82 NDC J1610 HCPCS inpatient 1 UN 1078.14 700.79 UHC - ALL PLANS UHC - ALL PLANS 999999999 652.81 1045.8 "INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 MG" 50592095_1 CDM 0250 RC 63323-0582-82 NDC J1610 HCPCS inpatient 1 UN 1078.14 700.79 CIGNA - ALL PLANS CIGNA - ALL PLANS 728.82 67.6 999999999 652.81 1045.8 percent of total billed charges Injection of substance into middle or upper spine canal 50592610_1 CDM 0360 RC 62320 HCPCS inpatient 2171 1411.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1411.15 65 999999999 1314.54 2105.87 percent of total billed charges Injection of substance into middle or upper spine canal 50592610_1 CDM 0360 RC 62320 HCPCS inpatient 2171 1411.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2105.87 97 999999999 1314.54 2105.87 percent of total billed charges Injection of substance into middle or upper spine canal 50592610_1 CDM 0360 RC 62320 HCPCS inpatient 2171 1411.15 AETNA AETNA 1715.09 79 999999999 1314.54 2105.87 percent of total billed charges Injection of substance into middle or upper spine canal 50592610_1 CDM 0360 RC 62320 HCPCS inpatient 2171 1411.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1693.38 78 999999999 1314.54 2105.87 percent of total billed charges Injection of substance into middle or upper spine canal 50592610_1 CDM 0360 RC 62320 HCPCS inpatient 2171 1411.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1497.99 69 999999999 1314.54 2105.87 percent of total billed charges Injection of substance into middle or upper spine canal 50592610_1 CDM 0360 RC 62320 HCPCS inpatient 2171 1411.15 SIHO - ALL PLANS SIHO - ALL PLANS 1953.9 90 999999999 1314.54 2105.87 percent of total billed charges Injection of substance into middle or upper spine canal 50592610_1 CDM 0360 RC 62320 HCPCS inpatient 2171 1411.15 UMR - ALL PLANS UMR - ALL PLANS 1519.7 70 999999999 1314.54 2105.87 percent of total billed charges Injection of substance into middle or upper spine canal 50592610_1 CDM 0360 RC 62320 HCPCS inpatient 2171 1411.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1314.54 60.55 999999999 1314.54 2105.87 percent of total billed charges Injection of substance into middle or upper spine canal 50592610_1 CDM 0360 RC 62320 HCPCS inpatient 2171 1411.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1314.54 2105.87 Injection of substance into middle or upper spine canal 50592610_1 CDM 0360 RC 62320 HCPCS inpatient 2171 1411.15 ANTHEM HMO ANTHEM HMO 999999999 1314.54 2105.87 Injection of substance into middle or upper spine canal 50592610_1 CDM 0360 RC 62320 HCPCS inpatient 2171 1411.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1314.54 2105.87 Injection of substance into middle or upper spine canal 50592610_1 CDM 0360 RC 62320 HCPCS inpatient 2171 1411.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1314.54 2105.87 Injection of substance into middle or upper spine canal 50592610_1 CDM 0360 RC 62320 HCPCS inpatient 2171 1411.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1314.54 2105.87 Injection of substance into middle or upper spine canal 50592610_1 CDM 0360 RC 62320 HCPCS inpatient 2171 1411.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1467.6 67.6 999999999 1314.54 2105.87 percent of total billed charges Injection of substance into middle or upper spine canal using imaging guidance 50592611_1 CDM 0360 RC 62321 HCPCS inpatient 2388 1552.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1552.2 65 999999999 1445.93 2316.36 percent of total billed charges Injection of substance into middle or upper spine canal using imaging guidance 50592611_1 CDM 0360 RC 62321 HCPCS inpatient 2388 1552.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2316.36 97 999999999 1445.93 2316.36 percent of total billed charges Injection of substance into middle or upper spine canal using imaging guidance 50592611_1 CDM 0360 RC 62321 HCPCS inpatient 2388 1552.2 AETNA AETNA 1886.52 79 999999999 1445.93 2316.36 percent of total billed charges Injection of substance into middle or upper spine canal using imaging guidance 50592611_1 CDM 0360 RC 62321 HCPCS inpatient 2388 1552.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1862.64 78 999999999 1445.93 2316.36 percent of total billed charges Injection of substance into middle or upper spine canal using imaging guidance 50592611_1 CDM 0360 RC 62321 HCPCS inpatient 2388 1552.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1647.72 69 999999999 1445.93 2316.36 percent of total billed charges Injection of substance into middle or upper spine canal using imaging guidance 50592611_1 CDM 0360 RC 62321 HCPCS inpatient 2388 1552.2 SIHO - ALL PLANS SIHO - ALL PLANS 2149.2 90 999999999 1445.93 2316.36 percent of total billed charges Injection of substance into middle or upper spine canal using imaging guidance 50592611_1 CDM 0360 RC 62321 HCPCS inpatient 2388 1552.2 UMR - ALL PLANS UMR - ALL PLANS 1671.6 70 999999999 1445.93 2316.36 percent of total billed charges Injection of substance into middle or upper spine canal using imaging guidance 50592611_1 CDM 0360 RC 62321 HCPCS inpatient 2388 1552.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1445.93 60.55 999999999 1445.93 2316.36 percent of total billed charges Injection of substance into middle or upper spine canal using imaging guidance 50592611_1 CDM 0360 RC 62321 HCPCS inpatient 2388 1552.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1445.93 2316.36 Injection of substance into middle or upper spine canal using imaging guidance 50592611_1 CDM 0360 RC 62321 HCPCS inpatient 2388 1552.2 ANTHEM HMO ANTHEM HMO 999999999 1445.93 2316.36 Injection of substance into middle or upper spine canal using imaging guidance 50592611_1 CDM 0360 RC 62321 HCPCS inpatient 2388 1552.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1445.93 2316.36 Injection of substance into middle or upper spine canal using imaging guidance 50592611_1 CDM 0360 RC 62321 HCPCS inpatient 2388 1552.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1445.93 2316.36 Injection of substance into middle or upper spine canal using imaging guidance 50592611_1 CDM 0360 RC 62321 HCPCS inpatient 2388 1552.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1445.93 2316.36 Injection of substance into middle or upper spine canal using imaging guidance 50592611_1 CDM 0360 RC 62321 HCPCS inpatient 2388 1552.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1614.29 67.6 999999999 1445.93 2316.36 percent of total billed charges Injection of substance into lower spine canal 50592612_1 CDM 0360 RC 62322 HCPCS inpatient 2171 1411.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1411.15 65 999999999 1314.54 2105.87 percent of total billed charges Injection of substance into lower spine canal 50592612_1 CDM 0360 RC 62322 HCPCS inpatient 2171 1411.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2105.87 97 999999999 1314.54 2105.87 percent of total billed charges Injection of substance into lower spine canal 50592612_1 CDM 0360 RC 62322 HCPCS inpatient 2171 1411.15 AETNA AETNA 1715.09 79 999999999 1314.54 2105.87 percent of total billed charges Injection of substance into lower spine canal 50592612_1 CDM 0360 RC 62322 HCPCS inpatient 2171 1411.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1693.38 78 999999999 1314.54 2105.87 percent of total billed charges Injection of substance into lower spine canal 50592612_1 CDM 0360 RC 62322 HCPCS inpatient 2171 1411.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1497.99 69 999999999 1314.54 2105.87 percent of total billed charges Injection of substance into lower spine canal 50592612_1 CDM 0360 RC 62322 HCPCS inpatient 2171 1411.15 SIHO - ALL PLANS SIHO - ALL PLANS 1953.9 90 999999999 1314.54 2105.87 percent of total billed charges Injection of substance into lower spine canal 50592612_1 CDM 0360 RC 62322 HCPCS inpatient 2171 1411.15 UMR - ALL PLANS UMR - ALL PLANS 1519.7 70 999999999 1314.54 2105.87 percent of total billed charges Injection of substance into lower spine canal 50592612_1 CDM 0360 RC 62322 HCPCS inpatient 2171 1411.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1314.54 60.55 999999999 1314.54 2105.87 percent of total billed charges Injection of substance into lower spine canal 50592612_1 CDM 0360 RC 62322 HCPCS inpatient 2171 1411.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1314.54 2105.87 Injection of substance into lower spine canal 50592612_1 CDM 0360 RC 62322 HCPCS inpatient 2171 1411.15 ANTHEM HMO ANTHEM HMO 999999999 1314.54 2105.87 Injection of substance into lower spine canal 50592612_1 CDM 0360 RC 62322 HCPCS inpatient 2171 1411.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1314.54 2105.87 Injection of substance into lower spine canal 50592612_1 CDM 0360 RC 62322 HCPCS inpatient 2171 1411.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1314.54 2105.87 Injection of substance into lower spine canal 50592612_1 CDM 0360 RC 62322 HCPCS inpatient 2171 1411.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1314.54 2105.87 Injection of substance into lower spine canal 50592612_1 CDM 0360 RC 62322 HCPCS inpatient 2171 1411.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1467.6 67.6 999999999 1314.54 2105.87 percent of total billed charges Injection of substance into lower spine canal using imaging guidance 50592613_1 CDM 0360 RC 62323 HCPCS inpatient 2345 1524.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1524.25 65 999999999 1419.9 2274.65 percent of total billed charges Injection of substance into lower spine canal using imaging guidance 50592613_1 CDM 0360 RC 62323 HCPCS inpatient 2345 1524.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2274.65 97 999999999 1419.9 2274.65 percent of total billed charges Injection of substance into lower spine canal using imaging guidance 50592613_1 CDM 0360 RC 62323 HCPCS inpatient 2345 1524.25 AETNA AETNA 1852.55 79 999999999 1419.9 2274.65 percent of total billed charges Injection of substance into lower spine canal using imaging guidance 50592613_1 CDM 0360 RC 62323 HCPCS inpatient 2345 1524.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1829.1 78 999999999 1419.9 2274.65 percent of total billed charges Injection of substance into lower spine canal using imaging guidance 50592613_1 CDM 0360 RC 62323 HCPCS inpatient 2345 1524.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1618.05 69 999999999 1419.9 2274.65 percent of total billed charges Injection of substance into lower spine canal using imaging guidance 50592613_1 CDM 0360 RC 62323 HCPCS inpatient 2345 1524.25 SIHO - ALL PLANS SIHO - ALL PLANS 2110.5 90 999999999 1419.9 2274.65 percent of total billed charges Injection of substance into lower spine canal using imaging guidance 50592613_1 CDM 0360 RC 62323 HCPCS inpatient 2345 1524.25 UMR - ALL PLANS UMR - ALL PLANS 1641.5 70 999999999 1419.9 2274.65 percent of total billed charges Injection of substance into lower spine canal using imaging guidance 50592613_1 CDM 0360 RC 62323 HCPCS inpatient 2345 1524.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1419.9 60.55 999999999 1419.9 2274.65 percent of total billed charges Injection of substance into lower spine canal using imaging guidance 50592613_1 CDM 0360 RC 62323 HCPCS inpatient 2345 1524.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1419.9 2274.65 Injection of substance into lower spine canal using imaging guidance 50592613_1 CDM 0360 RC 62323 HCPCS inpatient 2345 1524.25 ANTHEM HMO ANTHEM HMO 999999999 1419.9 2274.65 Injection of substance into lower spine canal using imaging guidance 50592613_1 CDM 0360 RC 62323 HCPCS inpatient 2345 1524.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1419.9 2274.65 Injection of substance into lower spine canal using imaging guidance 50592613_1 CDM 0360 RC 62323 HCPCS inpatient 2345 1524.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1419.9 2274.65 Injection of substance into lower spine canal using imaging guidance 50592613_1 CDM 0360 RC 62323 HCPCS inpatient 2345 1524.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1419.9 2274.65 Injection of substance into lower spine canal using imaging guidance 50592613_1 CDM 0360 RC 62323 HCPCS inpatient 2345 1524.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1585.22 67.6 999999999 1419.9 2274.65 percent of total billed charges Injection of anesthetic agent and/or steroid into knee nerve branch using imaging guidance 50592614_1 CDM 0360 RC 64454 HCPCS inpatient 1925 1251.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1251.25 65 999999999 1165.59 1867.25 percent of total billed charges Injection of anesthetic agent and/or steroid into knee nerve branch using imaging guidance 50592614_1 CDM 0360 RC 64454 HCPCS inpatient 1925 1251.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1867.25 97 999999999 1165.59 1867.25 percent of total billed charges Injection of anesthetic agent and/or steroid into knee nerve branch using imaging guidance 50592614_1 CDM 0360 RC 64454 HCPCS inpatient 1925 1251.25 AETNA AETNA 1520.75 79 999999999 1165.59 1867.25 percent of total billed charges Injection of anesthetic agent and/or steroid into knee nerve branch using imaging guidance 50592614_1 CDM 0360 RC 64454 HCPCS inpatient 1925 1251.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1501.5 78 999999999 1165.59 1867.25 percent of total billed charges Injection of anesthetic agent and/or steroid into knee nerve branch using imaging guidance 50592614_1 CDM 0360 RC 64454 HCPCS inpatient 1925 1251.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1328.25 69 999999999 1165.59 1867.25 percent of total billed charges Injection of anesthetic agent and/or steroid into knee nerve branch using imaging guidance 50592614_1 CDM 0360 RC 64454 HCPCS inpatient 1925 1251.25 SIHO - ALL PLANS SIHO - ALL PLANS 1732.5 90 999999999 1165.59 1867.25 percent of total billed charges Injection of anesthetic agent and/or steroid into knee nerve branch using imaging guidance 50592614_1 CDM 0360 RC 64454 HCPCS inpatient 1925 1251.25 UMR - ALL PLANS UMR - ALL PLANS 1347.5 70 999999999 1165.59 1867.25 percent of total billed charges Injection of anesthetic agent and/or steroid into knee nerve branch using imaging guidance 50592614_1 CDM 0360 RC 64454 HCPCS inpatient 1925 1251.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1165.59 60.55 999999999 1165.59 1867.25 percent of total billed charges Injection of anesthetic agent and/or steroid into knee nerve branch using imaging guidance 50592614_1 CDM 0360 RC 64454 HCPCS inpatient 1925 1251.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1165.59 1867.25 Injection of anesthetic agent and/or steroid into knee nerve branch using imaging guidance 50592614_1 CDM 0360 RC 64454 HCPCS inpatient 1925 1251.25 ANTHEM HMO ANTHEM HMO 999999999 1165.59 1867.25 Injection of anesthetic agent and/or steroid into knee nerve branch using imaging guidance 50592614_1 CDM 0360 RC 64454 HCPCS inpatient 1925 1251.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1165.59 1867.25 Injection of anesthetic agent and/or steroid into knee nerve branch using imaging guidance 50592614_1 CDM 0360 RC 64454 HCPCS inpatient 1925 1251.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1165.59 1867.25 Injection of anesthetic agent and/or steroid into knee nerve branch using imaging guidance 50592614_1 CDM 0360 RC 64454 HCPCS inpatient 1925 1251.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1165.59 1867.25 Injection of anesthetic agent and/or steroid into knee nerve branch using imaging guidance 50592614_1 CDM 0360 RC 64454 HCPCS inpatient 1925 1251.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1301.3 67.6 999999999 1165.59 1867.25 percent of total billed charges Injection of anesthetic agent and/or steroid into rib nerve 50592615_1 CDM 0360 RC 64420 HCPCS inpatient 2388 1552.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1552.2 65 999999999 1445.93 2316.36 percent of total billed charges Injection of anesthetic agent and/or steroid into rib nerve 50592615_1 CDM 0360 RC 64420 HCPCS inpatient 2388 1552.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2316.36 97 999999999 1445.93 2316.36 percent of total billed charges Injection of anesthetic agent and/or steroid into rib nerve 50592615_1 CDM 0360 RC 64420 HCPCS inpatient 2388 1552.2 AETNA AETNA 1886.52 79 999999999 1445.93 2316.36 percent of total billed charges Injection of anesthetic agent and/or steroid into rib nerve 50592615_1 CDM 0360 RC 64420 HCPCS inpatient 2388 1552.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1862.64 78 999999999 1445.93 2316.36 percent of total billed charges Injection of anesthetic agent and/or steroid into rib nerve 50592615_1 CDM 0360 RC 64420 HCPCS inpatient 2388 1552.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1647.72 69 999999999 1445.93 2316.36 percent of total billed charges Injection of anesthetic agent and/or steroid into rib nerve 50592615_1 CDM 0360 RC 64420 HCPCS inpatient 2388 1552.2 SIHO - ALL PLANS SIHO - ALL PLANS 2149.2 90 999999999 1445.93 2316.36 percent of total billed charges Injection of anesthetic agent and/or steroid into rib nerve 50592615_1 CDM 0360 RC 64420 HCPCS inpatient 2388 1552.2 UMR - ALL PLANS UMR - ALL PLANS 1671.6 70 999999999 1445.93 2316.36 percent of total billed charges Injection of anesthetic agent and/or steroid into rib nerve 50592615_1 CDM 0360 RC 64420 HCPCS inpatient 2388 1552.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1445.93 60.55 999999999 1445.93 2316.36 percent of total billed charges Injection of anesthetic agent and/or steroid into rib nerve 50592615_1 CDM 0360 RC 64420 HCPCS inpatient 2388 1552.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1445.93 2316.36 Injection of anesthetic agent and/or steroid into rib nerve 50592615_1 CDM 0360 RC 64420 HCPCS inpatient 2388 1552.2 ANTHEM HMO ANTHEM HMO 999999999 1445.93 2316.36 Injection of anesthetic agent and/or steroid into rib nerve 50592615_1 CDM 0360 RC 64420 HCPCS inpatient 2388 1552.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1445.93 2316.36 Injection of anesthetic agent and/or steroid into rib nerve 50592615_1 CDM 0360 RC 64420 HCPCS inpatient 2388 1552.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1445.93 2316.36 Injection of anesthetic agent and/or steroid into rib nerve 50592615_1 CDM 0360 RC 64420 HCPCS inpatient 2388 1552.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1445.93 2316.36 Injection of anesthetic agent and/or steroid into rib nerve 50592615_1 CDM 0360 RC 64420 HCPCS inpatient 2388 1552.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1614.29 67.6 999999999 1445.93 2316.36 percent of total billed charges Injection of anesthetic agent and/or steroid into rib nerve 50592616_1 CDM 0360 RC 64420 HCPCS inpatient 606 393.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 393.9 65 999999999 366.93 587.82 percent of total billed charges Injection of anesthetic agent and/or steroid into rib nerve 50592616_1 CDM 0360 RC 64420 HCPCS inpatient 606 393.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 587.82 97 999999999 366.93 587.82 percent of total billed charges Injection of anesthetic agent and/or steroid into rib nerve 50592616_1 CDM 0360 RC 64420 HCPCS inpatient 606 393.9 AETNA AETNA 478.74 79 999999999 366.93 587.82 percent of total billed charges Injection of anesthetic agent and/or steroid into rib nerve 50592616_1 CDM 0360 RC 64420 HCPCS inpatient 606 393.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 472.68 78 999999999 366.93 587.82 percent of total billed charges Injection of anesthetic agent and/or steroid into rib nerve 50592616_1 CDM 0360 RC 64420 HCPCS inpatient 606 393.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 418.14 69 999999999 366.93 587.82 percent of total billed charges Injection of anesthetic agent and/or steroid into rib nerve 50592616_1 CDM 0360 RC 64420 HCPCS inpatient 606 393.9 SIHO - ALL PLANS SIHO - ALL PLANS 545.4 90 999999999 366.93 587.82 percent of total billed charges Injection of anesthetic agent and/or steroid into rib nerve 50592616_1 CDM 0360 RC 64420 HCPCS inpatient 606 393.9 UMR - ALL PLANS UMR - ALL PLANS 424.2 70 999999999 366.93 587.82 percent of total billed charges Injection of anesthetic agent and/or steroid into rib nerve 50592616_1 CDM 0360 RC 64420 HCPCS inpatient 606 393.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 366.93 60.55 999999999 366.93 587.82 percent of total billed charges Injection of anesthetic agent and/or steroid into rib nerve 50592616_1 CDM 0360 RC 64420 HCPCS inpatient 606 393.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 366.93 587.82 Injection of anesthetic agent and/or steroid into rib nerve 50592616_1 CDM 0360 RC 64420 HCPCS inpatient 606 393.9 ANTHEM HMO ANTHEM HMO 999999999 366.93 587.82 Injection of anesthetic agent and/or steroid into rib nerve 50592616_1 CDM 0360 RC 64420 HCPCS inpatient 606 393.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 366.93 587.82 Injection of anesthetic agent and/or steroid into rib nerve 50592616_1 CDM 0360 RC 64420 HCPCS inpatient 606 393.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 366.93 587.82 Injection of anesthetic agent and/or steroid into rib nerve 50592616_1 CDM 0360 RC 64420 HCPCS inpatient 606 393.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 366.93 587.82 Injection of anesthetic agent and/or steroid into rib nerve 50592616_1 CDM 0360 RC 64420 HCPCS inpatient 606 393.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 409.66 67.6 999999999 366.93 587.82 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, single level" 50592617_1 CDM 0360 RC 64490 HCPCS inpatient 3103 2016.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 2016.95 65 999999999 1878.87 3009.91 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, single level" 50592617_1 CDM 0360 RC 64490 HCPCS inpatient 3103 2016.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3009.91 97 999999999 1878.87 3009.91 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, single level" 50592617_1 CDM 0360 RC 64490 HCPCS inpatient 3103 2016.95 AETNA AETNA 2451.37 79 999999999 1878.87 3009.91 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, single level" 50592617_1 CDM 0360 RC 64490 HCPCS inpatient 3103 2016.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 2420.34 78 999999999 1878.87 3009.91 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, single level" 50592617_1 CDM 0360 RC 64490 HCPCS inpatient 3103 2016.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 2141.07 69 999999999 1878.87 3009.91 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, single level" 50592617_1 CDM 0360 RC 64490 HCPCS inpatient 3103 2016.95 SIHO - ALL PLANS SIHO - ALL PLANS 2792.7 90 999999999 1878.87 3009.91 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, single level" 50592617_1 CDM 0360 RC 64490 HCPCS inpatient 3103 2016.95 UMR - ALL PLANS UMR - ALL PLANS 2172.1 70 999999999 1878.87 3009.91 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, single level" 50592617_1 CDM 0360 RC 64490 HCPCS inpatient 3103 2016.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1878.87 60.55 999999999 1878.87 3009.91 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, single level" 50592617_1 CDM 0360 RC 64490 HCPCS inpatient 3103 2016.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1878.87 3009.91 "Injection of upper or middle spine facet joint using imaging guidance, single level" 50592617_1 CDM 0360 RC 64490 HCPCS inpatient 3103 2016.95 ANTHEM HMO ANTHEM HMO 999999999 1878.87 3009.91 "Injection of upper or middle spine facet joint using imaging guidance, single level" 50592617_1 CDM 0360 RC 64490 HCPCS inpatient 3103 2016.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1878.87 3009.91 "Injection of upper or middle spine facet joint using imaging guidance, single level" 50592617_1 CDM 0360 RC 64490 HCPCS inpatient 3103 2016.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1878.87 3009.91 "Injection of upper or middle spine facet joint using imaging guidance, single level" 50592617_1 CDM 0360 RC 64490 HCPCS inpatient 3103 2016.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1878.87 3009.91 "Injection of upper or middle spine facet joint using imaging guidance, single level" 50592617_1 CDM 0360 RC 64490 HCPCS inpatient 3103 2016.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 2097.63 67.6 999999999 1878.87 3009.91 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, single level" 50592620_1 CDM 0360 RC 64493 HCPCS inpatient 3061 1989.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1989.65 65 999999999 1853.44 2969.17 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, single level" 50592620_1 CDM 0360 RC 64493 HCPCS inpatient 3061 1989.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2969.17 97 999999999 1853.44 2969.17 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, single level" 50592620_1 CDM 0360 RC 64493 HCPCS inpatient 3061 1989.65 AETNA AETNA 2418.19 79 999999999 1853.44 2969.17 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, single level" 50592620_1 CDM 0360 RC 64493 HCPCS inpatient 3061 1989.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2387.58 78 999999999 1853.44 2969.17 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, single level" 50592620_1 CDM 0360 RC 64493 HCPCS inpatient 3061 1989.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2112.09 69 999999999 1853.44 2969.17 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, single level" 50592620_1 CDM 0360 RC 64493 HCPCS inpatient 3061 1989.65 SIHO - ALL PLANS SIHO - ALL PLANS 2754.9 90 999999999 1853.44 2969.17 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, single level" 50592620_1 CDM 0360 RC 64493 HCPCS inpatient 3061 1989.65 UMR - ALL PLANS UMR - ALL PLANS 2142.7 70 999999999 1853.44 2969.17 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, single level" 50592620_1 CDM 0360 RC 64493 HCPCS inpatient 3061 1989.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1853.44 60.55 999999999 1853.44 2969.17 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, single level" 50592620_1 CDM 0360 RC 64493 HCPCS inpatient 3061 1989.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1853.44 2969.17 "Injection of lower or sacral spine facet joint using imaging guidance, single level" 50592620_1 CDM 0360 RC 64493 HCPCS inpatient 3061 1989.65 ANTHEM HMO ANTHEM HMO 999999999 1853.44 2969.17 "Injection of lower or sacral spine facet joint using imaging guidance, single level" 50592620_1 CDM 0360 RC 64493 HCPCS inpatient 3061 1989.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1853.44 2969.17 "Injection of lower or sacral spine facet joint using imaging guidance, single level" 50592620_1 CDM 0360 RC 64493 HCPCS inpatient 3061 1989.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1853.44 2969.17 "Injection of lower or sacral spine facet joint using imaging guidance, single level" 50592620_1 CDM 0360 RC 64493 HCPCS inpatient 3061 1989.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1853.44 2969.17 "Injection of lower or sacral spine facet joint using imaging guidance, single level" 50592620_1 CDM 0360 RC 64493 HCPCS inpatient 3061 1989.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2069.24 67.6 999999999 1853.44 2969.17 percent of total billed charges Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 50592624_1 CDM 0360 RC 27096 HCPCS inpatient 1925 1251.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1251.25 65 999999999 1165.59 1867.25 percent of total billed charges Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 50592624_1 CDM 0360 RC 27096 HCPCS inpatient 1925 1251.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1867.25 97 999999999 1165.59 1867.25 percent of total billed charges Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 50592624_1 CDM 0360 RC 27096 HCPCS inpatient 1925 1251.25 AETNA AETNA 1520.75 79 999999999 1165.59 1867.25 percent of total billed charges Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 50592624_1 CDM 0360 RC 27096 HCPCS inpatient 1925 1251.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1501.5 78 999999999 1165.59 1867.25 percent of total billed charges Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 50592624_1 CDM 0360 RC 27096 HCPCS inpatient 1925 1251.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1328.25 69 999999999 1165.59 1867.25 percent of total billed charges Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 50592624_1 CDM 0360 RC 27096 HCPCS inpatient 1925 1251.25 SIHO - ALL PLANS SIHO - ALL PLANS 1732.5 90 999999999 1165.59 1867.25 percent of total billed charges Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 50592624_1 CDM 0360 RC 27096 HCPCS inpatient 1925 1251.25 UMR - ALL PLANS UMR - ALL PLANS 1347.5 70 999999999 1165.59 1867.25 percent of total billed charges Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 50592624_1 CDM 0360 RC 27096 HCPCS inpatient 1925 1251.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1165.59 60.55 999999999 1165.59 1867.25 percent of total billed charges Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 50592624_1 CDM 0360 RC 27096 HCPCS inpatient 1925 1251.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1165.59 1867.25 Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 50592624_1 CDM 0360 RC 27096 HCPCS inpatient 1925 1251.25 ANTHEM HMO ANTHEM HMO 999999999 1165.59 1867.25 Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 50592624_1 CDM 0360 RC 27096 HCPCS inpatient 1925 1251.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1165.59 1867.25 Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 50592624_1 CDM 0360 RC 27096 HCPCS inpatient 1925 1251.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1165.59 1867.25 Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 50592624_1 CDM 0360 RC 27096 HCPCS inpatient 1925 1251.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1165.59 1867.25 Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 50592624_1 CDM 0360 RC 27096 HCPCS inpatient 1925 1251.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1301.3 67.6 999999999 1165.59 1867.25 percent of total billed charges "Injection of anesthetic agent, trigeminal nerve bundle" 50592625_1 CDM 0360 RC 64505 HCPCS inpatient 910 591.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 591.5 65 999999999 551.01 882.7 percent of total billed charges "Injection of anesthetic agent, trigeminal nerve bundle" 50592625_1 CDM 0360 RC 64505 HCPCS inpatient 910 591.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 882.7 97 999999999 551.01 882.7 percent of total billed charges "Injection of anesthetic agent, trigeminal nerve bundle" 50592625_1 CDM 0360 RC 64505 HCPCS inpatient 910 591.5 AETNA AETNA 718.9 79 999999999 551.01 882.7 percent of total billed charges "Injection of anesthetic agent, trigeminal nerve bundle" 50592625_1 CDM 0360 RC 64505 HCPCS inpatient 910 591.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 709.8 78 999999999 551.01 882.7 percent of total billed charges "Injection of anesthetic agent, trigeminal nerve bundle" 50592625_1 CDM 0360 RC 64505 HCPCS inpatient 910 591.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 627.9 69 999999999 551.01 882.7 percent of total billed charges "Injection of anesthetic agent, trigeminal nerve bundle" 50592625_1 CDM 0360 RC 64505 HCPCS inpatient 910 591.5 SIHO - ALL PLANS SIHO - ALL PLANS 819 90 999999999 551.01 882.7 percent of total billed charges "Injection of anesthetic agent, trigeminal nerve bundle" 50592625_1 CDM 0360 RC 64505 HCPCS inpatient 910 591.5 UMR - ALL PLANS UMR - ALL PLANS 637 70 999999999 551.01 882.7 percent of total billed charges "Injection of anesthetic agent, trigeminal nerve bundle" 50592625_1 CDM 0360 RC 64505 HCPCS inpatient 910 591.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 551.01 60.55 999999999 551.01 882.7 percent of total billed charges "Injection of anesthetic agent, trigeminal nerve bundle" 50592625_1 CDM 0360 RC 64505 HCPCS inpatient 910 591.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 551.01 882.7 "Injection of anesthetic agent, trigeminal nerve bundle" 50592625_1 CDM 0360 RC 64505 HCPCS inpatient 910 591.5 ANTHEM HMO ANTHEM HMO 999999999 551.01 882.7 "Injection of anesthetic agent, trigeminal nerve bundle" 50592625_1 CDM 0360 RC 64505 HCPCS inpatient 910 591.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 551.01 882.7 "Injection of anesthetic agent, trigeminal nerve bundle" 50592625_1 CDM 0360 RC 64505 HCPCS inpatient 910 591.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 551.01 882.7 "Injection of anesthetic agent, trigeminal nerve bundle" 50592625_1 CDM 0360 RC 64505 HCPCS inpatient 910 591.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 551.01 882.7 "Injection of anesthetic agent, trigeminal nerve bundle" 50592625_1 CDM 0360 RC 64505 HCPCS inpatient 910 591.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 615.16 67.6 999999999 551.01 882.7 percent of total billed charges Injection of anesthetic agent into sympathetic nerve bundle 50592627_1 CDM 0360 RC 64510 HCPCS inpatient 2821 1833.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1833.65 65 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into sympathetic nerve bundle 50592627_1 CDM 0360 RC 64510 HCPCS inpatient 2821 1833.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2736.37 97 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into sympathetic nerve bundle 50592627_1 CDM 0360 RC 64510 HCPCS inpatient 2821 1833.65 AETNA AETNA 2228.59 79 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into sympathetic nerve bundle 50592627_1 CDM 0360 RC 64510 HCPCS inpatient 2821 1833.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2200.38 78 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into sympathetic nerve bundle 50592627_1 CDM 0360 RC 64510 HCPCS inpatient 2821 1833.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1946.49 69 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into sympathetic nerve bundle 50592627_1 CDM 0360 RC 64510 HCPCS inpatient 2821 1833.65 SIHO - ALL PLANS SIHO - ALL PLANS 2538.9 90 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into sympathetic nerve bundle 50592627_1 CDM 0360 RC 64510 HCPCS inpatient 2821 1833.65 UMR - ALL PLANS UMR - ALL PLANS 1974.7 70 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into sympathetic nerve bundle 50592627_1 CDM 0360 RC 64510 HCPCS inpatient 2821 1833.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1708.12 60.55 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into sympathetic nerve bundle 50592627_1 CDM 0360 RC 64510 HCPCS inpatient 2821 1833.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1708.12 2736.37 Injection of anesthetic agent into sympathetic nerve bundle 50592627_1 CDM 0360 RC 64510 HCPCS inpatient 2821 1833.65 ANTHEM HMO ANTHEM HMO 999999999 1708.12 2736.37 Injection of anesthetic agent into sympathetic nerve bundle 50592627_1 CDM 0360 RC 64510 HCPCS inpatient 2821 1833.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1708.12 2736.37 Injection of anesthetic agent into sympathetic nerve bundle 50592627_1 CDM 0360 RC 64510 HCPCS inpatient 2821 1833.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1708.12 2736.37 Injection of anesthetic agent into sympathetic nerve bundle 50592627_1 CDM 0360 RC 64510 HCPCS inpatient 2821 1833.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1708.12 2736.37 Injection of anesthetic agent into sympathetic nerve bundle 50592627_1 CDM 0360 RC 64510 HCPCS inpatient 2821 1833.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1907 67.6 999999999 1708.12 2736.37 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592629_1 CDM 0360 RC 64479 HCPCS inpatient 2821 1833.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1833.65 65 999999999 1708.12 2736.37 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592629_1 CDM 0360 RC 64479 HCPCS inpatient 2821 1833.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2736.37 97 999999999 1708.12 2736.37 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592629_1 CDM 0360 RC 64479 HCPCS inpatient 2821 1833.65 AETNA AETNA 2228.59 79 999999999 1708.12 2736.37 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592629_1 CDM 0360 RC 64479 HCPCS inpatient 2821 1833.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2200.38 78 999999999 1708.12 2736.37 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592629_1 CDM 0360 RC 64479 HCPCS inpatient 2821 1833.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1946.49 69 999999999 1708.12 2736.37 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592629_1 CDM 0360 RC 64479 HCPCS inpatient 2821 1833.65 SIHO - ALL PLANS SIHO - ALL PLANS 2538.9 90 999999999 1708.12 2736.37 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592629_1 CDM 0360 RC 64479 HCPCS inpatient 2821 1833.65 UMR - ALL PLANS UMR - ALL PLANS 1974.7 70 999999999 1708.12 2736.37 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592629_1 CDM 0360 RC 64479 HCPCS inpatient 2821 1833.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1708.12 60.55 999999999 1708.12 2736.37 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592629_1 CDM 0360 RC 64479 HCPCS inpatient 2821 1833.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1708.12 2736.37 "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592629_1 CDM 0360 RC 64479 HCPCS inpatient 2821 1833.65 ANTHEM HMO ANTHEM HMO 999999999 1708.12 2736.37 "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592629_1 CDM 0360 RC 64479 HCPCS inpatient 2821 1833.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1708.12 2736.37 "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592629_1 CDM 0360 RC 64479 HCPCS inpatient 2821 1833.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1708.12 2736.37 "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592629_1 CDM 0360 RC 64479 HCPCS inpatient 2821 1833.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1708.12 2736.37 "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592629_1 CDM 0360 RC 64479 HCPCS inpatient 2821 1833.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1907 67.6 999999999 1708.12 2736.37 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592630_1 CDM 0360 RC 64479 HCPCS inpatient 1881 1222.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1222.65 65 999999999 1138.95 1824.57 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592630_1 CDM 0360 RC 64479 HCPCS inpatient 1881 1222.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1824.57 97 999999999 1138.95 1824.57 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592630_1 CDM 0360 RC 64479 HCPCS inpatient 1881 1222.65 AETNA AETNA 1485.99 79 999999999 1138.95 1824.57 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592630_1 CDM 0360 RC 64479 HCPCS inpatient 1881 1222.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1467.18 78 999999999 1138.95 1824.57 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592630_1 CDM 0360 RC 64479 HCPCS inpatient 1881 1222.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1297.89 69 999999999 1138.95 1824.57 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592630_1 CDM 0360 RC 64479 HCPCS inpatient 1881 1222.65 SIHO - ALL PLANS SIHO - ALL PLANS 1692.9 90 999999999 1138.95 1824.57 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592630_1 CDM 0360 RC 64479 HCPCS inpatient 1881 1222.65 UMR - ALL PLANS UMR - ALL PLANS 1316.7 70 999999999 1138.95 1824.57 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592630_1 CDM 0360 RC 64479 HCPCS inpatient 1881 1222.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1138.95 60.55 999999999 1138.95 1824.57 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592630_1 CDM 0360 RC 64479 HCPCS inpatient 1881 1222.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1138.95 1824.57 "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592630_1 CDM 0360 RC 64479 HCPCS inpatient 1881 1222.65 ANTHEM HMO ANTHEM HMO 999999999 1138.95 1824.57 "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592630_1 CDM 0360 RC 64479 HCPCS inpatient 1881 1222.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1138.95 1824.57 "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592630_1 CDM 0360 RC 64479 HCPCS inpatient 1881 1222.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1138.95 1824.57 "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592630_1 CDM 0360 RC 64479 HCPCS inpatient 1881 1222.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1138.95 1824.57 "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, single level" 50592630_1 CDM 0360 RC 64479 HCPCS inpatient 1881 1222.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1271.56 67.6 999999999 1138.95 1824.57 percent of total billed charges "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, single level" 50592631_1 CDM 0360 RC 64483 HCPCS inpatient 2638 1714.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1714.7 65 999999999 1597.31 2558.86 percent of total billed charges "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, single level" 50592631_1 CDM 0360 RC 64483 HCPCS inpatient 2638 1714.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2558.86 97 999999999 1597.31 2558.86 percent of total billed charges "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, single level" 50592631_1 CDM 0360 RC 64483 HCPCS inpatient 2638 1714.7 AETNA AETNA 2084.02 79 999999999 1597.31 2558.86 percent of total billed charges "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, single level" 50592631_1 CDM 0360 RC 64483 HCPCS inpatient 2638 1714.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 2057.64 78 999999999 1597.31 2558.86 percent of total billed charges "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, single level" 50592631_1 CDM 0360 RC 64483 HCPCS inpatient 2638 1714.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1820.22 69 999999999 1597.31 2558.86 percent of total billed charges "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, single level" 50592631_1 CDM 0360 RC 64483 HCPCS inpatient 2638 1714.7 SIHO - ALL PLANS SIHO - ALL PLANS 2374.2 90 999999999 1597.31 2558.86 percent of total billed charges "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, single level" 50592631_1 CDM 0360 RC 64483 HCPCS inpatient 2638 1714.7 UMR - ALL PLANS UMR - ALL PLANS 1846.6 70 999999999 1597.31 2558.86 percent of total billed charges "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, single level" 50592631_1 CDM 0360 RC 64483 HCPCS inpatient 2638 1714.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1597.31 60.55 999999999 1597.31 2558.86 percent of total billed charges "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, single level" 50592631_1 CDM 0360 RC 64483 HCPCS inpatient 2638 1714.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1597.31 2558.86 "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, single level" 50592631_1 CDM 0360 RC 64483 HCPCS inpatient 2638 1714.7 ANTHEM HMO ANTHEM HMO 999999999 1597.31 2558.86 "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, single level" 50592631_1 CDM 0360 RC 64483 HCPCS inpatient 2638 1714.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1597.31 2558.86 "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, single level" 50592631_1 CDM 0360 RC 64483 HCPCS inpatient 2638 1714.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1597.31 2558.86 "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, single level" 50592631_1 CDM 0360 RC 64483 HCPCS inpatient 2638 1714.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 1597.31 2558.86 "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, single level" 50592631_1 CDM 0360 RC 64483 HCPCS inpatient 2638 1714.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1783.29 67.6 999999999 1597.31 2558.86 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592633_1 CDM 0360 RC 64633 HCPCS inpatient 2160 1404 SELF PAY DISCOUNT SELF PAY DISCOUNT 1404 65 999999999 1307.88 2095.2 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592633_1 CDM 0360 RC 64633 HCPCS inpatient 2160 1404 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2095.2 97 999999999 1307.88 2095.2 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592633_1 CDM 0360 RC 64633 HCPCS inpatient 2160 1404 AETNA AETNA 1706.4 79 999999999 1307.88 2095.2 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592633_1 CDM 0360 RC 64633 HCPCS inpatient 2160 1404 HUMANA - ALL PLANS HUMANA - ALL PLANS 1684.8 78 999999999 1307.88 2095.2 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592633_1 CDM 0360 RC 64633 HCPCS inpatient 2160 1404 ENCORE - ALL PLANS ENCORE - ALL PLANS 1490.4 69 999999999 1307.88 2095.2 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592633_1 CDM 0360 RC 64633 HCPCS inpatient 2160 1404 SIHO - ALL PLANS SIHO - ALL PLANS 1944 90 999999999 1307.88 2095.2 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592633_1 CDM 0360 RC 64633 HCPCS inpatient 2160 1404 UMR - ALL PLANS UMR - ALL PLANS 1512 70 999999999 1307.88 2095.2 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592633_1 CDM 0360 RC 64633 HCPCS inpatient 2160 1404 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1307.88 60.55 999999999 1307.88 2095.2 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592633_1 CDM 0360 RC 64633 HCPCS inpatient 2160 1404 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1307.88 2095.2 "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592633_1 CDM 0360 RC 64633 HCPCS inpatient 2160 1404 ANTHEM HMO ANTHEM HMO 999999999 1307.88 2095.2 "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592633_1 CDM 0360 RC 64633 HCPCS inpatient 2160 1404 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1307.88 2095.2 "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592633_1 CDM 0360 RC 64633 HCPCS inpatient 2160 1404 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1307.88 2095.2 "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592633_1 CDM 0360 RC 64633 HCPCS inpatient 2160 1404 UHC - ALL PLANS UHC - ALL PLANS 999999999 1307.88 2095.2 "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592633_1 CDM 0360 RC 64633 HCPCS inpatient 2160 1404 CIGNA - ALL PLANS CIGNA - ALL PLANS 1460.16 67.6 999999999 1307.88 2095.2 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592634_1 CDM 0360 RC 64633 HCPCS inpatient 1991 1294.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1294.15 65 999999999 1205.55 1931.27 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592634_1 CDM 0360 RC 64633 HCPCS inpatient 1991 1294.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1931.27 97 999999999 1205.55 1931.27 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592634_1 CDM 0360 RC 64633 HCPCS inpatient 1991 1294.15 AETNA AETNA 1572.89 79 999999999 1205.55 1931.27 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592634_1 CDM 0360 RC 64633 HCPCS inpatient 1991 1294.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1552.98 78 999999999 1205.55 1931.27 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592634_1 CDM 0360 RC 64633 HCPCS inpatient 1991 1294.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1373.79 69 999999999 1205.55 1931.27 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592634_1 CDM 0360 RC 64633 HCPCS inpatient 1991 1294.15 SIHO - ALL PLANS SIHO - ALL PLANS 1791.9 90 999999999 1205.55 1931.27 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592634_1 CDM 0360 RC 64633 HCPCS inpatient 1991 1294.15 UMR - ALL PLANS UMR - ALL PLANS 1393.7 70 999999999 1205.55 1931.27 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592634_1 CDM 0360 RC 64633 HCPCS inpatient 1991 1294.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1205.55 60.55 999999999 1205.55 1931.27 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592634_1 CDM 0360 RC 64633 HCPCS inpatient 1991 1294.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1205.55 1931.27 "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592634_1 CDM 0360 RC 64633 HCPCS inpatient 1991 1294.15 ANTHEM HMO ANTHEM HMO 999999999 1205.55 1931.27 "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592634_1 CDM 0360 RC 64633 HCPCS inpatient 1991 1294.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1205.55 1931.27 "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592634_1 CDM 0360 RC 64633 HCPCS inpatient 1991 1294.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1205.55 1931.27 "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592634_1 CDM 0360 RC 64633 HCPCS inpatient 1991 1294.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1205.55 1931.27 "Destruction of upper or middle spinal facet joint nerves using imaging guidance, single facet joint" 50592634_1 CDM 0360 RC 64633 HCPCS inpatient 1991 1294.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1345.92 67.6 999999999 1205.55 1931.27 percent of total billed charges "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, single facet joint" 50592635_1 CDM 0360 RC 64635 HCPCS inpatient 2160 1404 SELF PAY DISCOUNT SELF PAY DISCOUNT 1404 65 999999999 1307.88 2095.2 percent of total billed charges "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, single facet joint" 50592635_1 CDM 0360 RC 64635 HCPCS inpatient 2160 1404 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2095.2 97 999999999 1307.88 2095.2 percent of total billed charges "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, single facet joint" 50592635_1 CDM 0360 RC 64635 HCPCS inpatient 2160 1404 AETNA AETNA 1706.4 79 999999999 1307.88 2095.2 percent of total billed charges "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, single facet joint" 50592635_1 CDM 0360 RC 64635 HCPCS inpatient 2160 1404 HUMANA - ALL PLANS HUMANA - ALL PLANS 1684.8 78 999999999 1307.88 2095.2 percent of total billed charges "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, single facet joint" 50592635_1 CDM 0360 RC 64635 HCPCS inpatient 2160 1404 ENCORE - ALL PLANS ENCORE - ALL PLANS 1490.4 69 999999999 1307.88 2095.2 percent of total billed charges "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, single facet joint" 50592635_1 CDM 0360 RC 64635 HCPCS inpatient 2160 1404 SIHO - ALL PLANS SIHO - ALL PLANS 1944 90 999999999 1307.88 2095.2 percent of total billed charges "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, single facet joint" 50592635_1 CDM 0360 RC 64635 HCPCS inpatient 2160 1404 UMR - ALL PLANS UMR - ALL PLANS 1512 70 999999999 1307.88 2095.2 percent of total billed charges "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, single facet joint" 50592635_1 CDM 0360 RC 64635 HCPCS inpatient 2160 1404 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1307.88 60.55 999999999 1307.88 2095.2 percent of total billed charges "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, single facet joint" 50592635_1 CDM 0360 RC 64635 HCPCS inpatient 2160 1404 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1307.88 2095.2 "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, single facet joint" 50592635_1 CDM 0360 RC 64635 HCPCS inpatient 2160 1404 ANTHEM HMO ANTHEM HMO 999999999 1307.88 2095.2 "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, single facet joint" 50592635_1 CDM 0360 RC 64635 HCPCS inpatient 2160 1404 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1307.88 2095.2 "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, single facet joint" 50592635_1 CDM 0360 RC 64635 HCPCS inpatient 2160 1404 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1307.88 2095.2 "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, single facet joint" 50592635_1 CDM 0360 RC 64635 HCPCS inpatient 2160 1404 UHC - ALL PLANS UHC - ALL PLANS 999999999 1307.88 2095.2 "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, single facet joint" 50592635_1 CDM 0360 RC 64635 HCPCS inpatient 2160 1404 CIGNA - ALL PLANS CIGNA - ALL PLANS 1460.16 67.6 999999999 1307.88 2095.2 percent of total billed charges Destruction of peripheral nerve or branch 50592637_1 CDM 0360 RC 64640 HCPCS inpatient 1881 1222.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1222.65 65 999999999 1138.95 1824.57 percent of total billed charges Destruction of peripheral nerve or branch 50592637_1 CDM 0360 RC 64640 HCPCS inpatient 1881 1222.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1824.57 97 999999999 1138.95 1824.57 percent of total billed charges Destruction of peripheral nerve or branch 50592637_1 CDM 0360 RC 64640 HCPCS inpatient 1881 1222.65 AETNA AETNA 1485.99 79 999999999 1138.95 1824.57 percent of total billed charges Destruction of peripheral nerve or branch 50592637_1 CDM 0360 RC 64640 HCPCS inpatient 1881 1222.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1467.18 78 999999999 1138.95 1824.57 percent of total billed charges Destruction of peripheral nerve or branch 50592637_1 CDM 0360 RC 64640 HCPCS inpatient 1881 1222.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1297.89 69 999999999 1138.95 1824.57 percent of total billed charges Destruction of peripheral nerve or branch 50592637_1 CDM 0360 RC 64640 HCPCS inpatient 1881 1222.65 SIHO - ALL PLANS SIHO - ALL PLANS 1692.9 90 999999999 1138.95 1824.57 percent of total billed charges Destruction of peripheral nerve or branch 50592637_1 CDM 0360 RC 64640 HCPCS inpatient 1881 1222.65 UMR - ALL PLANS UMR - ALL PLANS 1316.7 70 999999999 1138.95 1824.57 percent of total billed charges Destruction of peripheral nerve or branch 50592637_1 CDM 0360 RC 64640 HCPCS inpatient 1881 1222.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1138.95 60.55 999999999 1138.95 1824.57 percent of total billed charges Destruction of peripheral nerve or branch 50592637_1 CDM 0360 RC 64640 HCPCS inpatient 1881 1222.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1138.95 1824.57 Destruction of peripheral nerve or branch 50592637_1 CDM 0360 RC 64640 HCPCS inpatient 1881 1222.65 ANTHEM HMO ANTHEM HMO 999999999 1138.95 1824.57 Destruction of peripheral nerve or branch 50592637_1 CDM 0360 RC 64640 HCPCS inpatient 1881 1222.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1138.95 1824.57 Destruction of peripheral nerve or branch 50592637_1 CDM 0360 RC 64640 HCPCS inpatient 1881 1222.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1138.95 1824.57 Destruction of peripheral nerve or branch 50592637_1 CDM 0360 RC 64640 HCPCS inpatient 1881 1222.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1138.95 1824.57 Destruction of peripheral nerve or branch 50592637_1 CDM 0360 RC 64640 HCPCS inpatient 1881 1222.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1271.56 67.6 999999999 1138.95 1824.57 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50592693_1 CDM 0250 RC 71288-0410-89 NDC J1650 HCPCS inpatient 10 UN 54.73 35.57 SELF PAY DISCOUNT SELF PAY DISCOUNT 35.57 65 999999999 33.14 53.09 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50592693_1 CDM 0250 RC 71288-0410-89 NDC J1650 HCPCS inpatient 10 UN 54.73 35.57 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 53.09 97 999999999 33.14 53.09 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50592693_1 CDM 0250 RC 71288-0410-89 NDC J1650 HCPCS inpatient 10 UN 54.73 35.57 AETNA AETNA 43.24 79 999999999 33.14 53.09 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50592693_1 CDM 0250 RC 71288-0410-89 NDC J1650 HCPCS inpatient 10 UN 54.73 35.57 HUMANA - ALL PLANS HUMANA - ALL PLANS 42.69 78 999999999 33.14 53.09 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50592693_1 CDM 0250 RC 71288-0410-89 NDC J1650 HCPCS inpatient 10 UN 54.73 35.57 ENCORE - ALL PLANS ENCORE - ALL PLANS 37.76 69 999999999 33.14 53.09 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50592693_1 CDM 0250 RC 71288-0410-89 NDC J1650 HCPCS inpatient 10 UN 54.73 35.57 SIHO - ALL PLANS SIHO - ALL PLANS 49.26 90 999999999 33.14 53.09 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50592693_1 CDM 0250 RC 71288-0410-89 NDC J1650 HCPCS inpatient 10 UN 54.73 35.57 UMR - ALL PLANS UMR - ALL PLANS 38.31 70 999999999 33.14 53.09 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50592693_1 CDM 0250 RC 71288-0410-89 NDC J1650 HCPCS inpatient 10 UN 54.73 35.57 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33.14 60.55 999999999 33.14 53.09 percent of total billed charges "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50592693_1 CDM 0250 RC 71288-0410-89 NDC J1650 HCPCS inpatient 10 UN 54.73 35.57 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 33.14 53.09 "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50592693_1 CDM 0250 RC 71288-0410-89 NDC J1650 HCPCS inpatient 10 UN 54.73 35.57 ANTHEM HMO ANTHEM HMO 999999999 33.14 53.09 "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50592693_1 CDM 0250 RC 71288-0410-89 NDC J1650 HCPCS inpatient 10 UN 54.73 35.57 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 33.14 53.09 "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50592693_1 CDM 0250 RC 71288-0410-89 NDC J1650 HCPCS inpatient 10 UN 54.73 35.57 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 33.14 53.09 "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50592693_1 CDM 0250 RC 71288-0410-89 NDC J1650 HCPCS inpatient 10 UN 54.73 35.57 UHC - ALL PLANS UHC - ALL PLANS 999999999 33.14 53.09 "INJECTION, ENOXAPARIN SODIUM, 10 MG" 50592693_1 CDM 0250 RC 71288-0410-89 NDC J1650 HCPCS inpatient 10 UN 54.73 35.57 CIGNA - ALL PLANS CIGNA - ALL PLANS 37 67.6 999999999 33.14 53.09 percent of total billed charges "HEPARIN 10,000 UNIT/10 ML VIAL" 50592894_1 CDM 0250 RC 63323-0540-67 NDC inpatient 1 UN 8.37 5.44 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.44 65 999999999 5.07 8.12 percent of total billed charges "HEPARIN 10,000 UNIT/10 ML VIAL" 50592894_1 CDM 0250 RC 63323-0540-67 NDC inpatient 1 UN 8.37 5.44 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.12 97 999999999 5.07 8.12 percent of total billed charges "HEPARIN 10,000 UNIT/10 ML VIAL" 50592894_1 CDM 0250 RC 63323-0540-67 NDC inpatient 1 UN 8.37 5.44 AETNA AETNA 6.61 79 999999999 5.07 8.12 percent of total billed charges "HEPARIN 10,000 UNIT/10 ML VIAL" 50592894_1 CDM 0250 RC 63323-0540-67 NDC inpatient 1 UN 8.37 5.44 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.53 78 999999999 5.07 8.12 percent of total billed charges "HEPARIN 10,000 UNIT/10 ML VIAL" 50592894_1 CDM 0250 RC 63323-0540-67 NDC inpatient 1 UN 8.37 5.44 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.78 69 999999999 5.07 8.12 percent of total billed charges "HEPARIN 10,000 UNIT/10 ML VIAL" 50592894_1 CDM 0250 RC 63323-0540-67 NDC inpatient 1 UN 8.37 5.44 SIHO - ALL PLANS SIHO - ALL PLANS 7.53 90 999999999 5.07 8.12 percent of total billed charges "HEPARIN 10,000 UNIT/10 ML VIAL" 50592894_1 CDM 0250 RC 63323-0540-67 NDC inpatient 1 UN 8.37 5.44 UMR - ALL PLANS UMR - ALL PLANS 5.86 70 999999999 5.07 8.12 percent of total billed charges "HEPARIN 10,000 UNIT/10 ML VIAL" 50592894_1 CDM 0250 RC 63323-0540-67 NDC inpatient 1 UN 8.37 5.44 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.07 60.55 999999999 5.07 8.12 percent of total billed charges "HEPARIN 10,000 UNIT/10 ML VIAL" 50592894_1 CDM 0250 RC 63323-0540-67 NDC inpatient 1 UN 8.37 5.44 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.07 8.12 "HEPARIN 10,000 UNIT/10 ML VIAL" 50592894_1 CDM 0250 RC 63323-0540-67 NDC inpatient 1 UN 8.37 5.44 ANTHEM HMO ANTHEM HMO 999999999 5.07 8.12 "HEPARIN 10,000 UNIT/10 ML VIAL" 50592894_1 CDM 0250 RC 63323-0540-67 NDC inpatient 1 UN 8.37 5.44 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.07 8.12 "HEPARIN 10,000 UNIT/10 ML VIAL" 50592894_1 CDM 0250 RC 63323-0540-67 NDC inpatient 1 UN 8.37 5.44 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.07 8.12 "HEPARIN 10,000 UNIT/10 ML VIAL" 50592894_1 CDM 0250 RC 63323-0540-67 NDC inpatient 1 UN 8.37 5.44 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.07 8.12 "HEPARIN 10,000 UNIT/10 ML VIAL" 50592894_1 CDM 0250 RC 63323-0540-67 NDC inpatient 1 UN 8.37 5.44 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.66 67.6 999999999 5.07 8.12 percent of total billed charges ENOXAPARIN 150 MG/ML SYRINGE 50592902_1 CDM 0250 RC 71288-0411-83 NDC inpatient 1 UN 72.06 46.84 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.84 65 999999999 43.63 69.9 percent of total billed charges ENOXAPARIN 150 MG/ML SYRINGE 50592902_1 CDM 0250 RC 71288-0411-83 NDC inpatient 1 UN 72.06 46.84 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.9 97 999999999 43.63 69.9 percent of total billed charges ENOXAPARIN 150 MG/ML SYRINGE 50592902_1 CDM 0250 RC 71288-0411-83 NDC inpatient 1 UN 72.06 46.84 AETNA AETNA 56.93 79 999999999 43.63 69.9 percent of total billed charges ENOXAPARIN 150 MG/ML SYRINGE 50592902_1 CDM 0250 RC 71288-0411-83 NDC inpatient 1 UN 72.06 46.84 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.21 78 999999999 43.63 69.9 percent of total billed charges ENOXAPARIN 150 MG/ML SYRINGE 50592902_1 CDM 0250 RC 71288-0411-83 NDC inpatient 1 UN 72.06 46.84 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.72 69 999999999 43.63 69.9 percent of total billed charges ENOXAPARIN 150 MG/ML SYRINGE 50592902_1 CDM 0250 RC 71288-0411-83 NDC inpatient 1 UN 72.06 46.84 SIHO - ALL PLANS SIHO - ALL PLANS 64.85 90 999999999 43.63 69.9 percent of total billed charges ENOXAPARIN 150 MG/ML SYRINGE 50592902_1 CDM 0250 RC 71288-0411-83 NDC inpatient 1 UN 72.06 46.84 UMR - ALL PLANS UMR - ALL PLANS 50.44 70 999999999 43.63 69.9 percent of total billed charges ENOXAPARIN 150 MG/ML SYRINGE 50592902_1 CDM 0250 RC 71288-0411-83 NDC inpatient 1 UN 72.06 46.84 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.63 60.55 999999999 43.63 69.9 percent of total billed charges ENOXAPARIN 150 MG/ML SYRINGE 50592902_1 CDM 0250 RC 71288-0411-83 NDC inpatient 1 UN 72.06 46.84 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.63 69.9 ENOXAPARIN 150 MG/ML SYRINGE 50592902_1 CDM 0250 RC 71288-0411-83 NDC inpatient 1 UN 72.06 46.84 ANTHEM HMO ANTHEM HMO 999999999 43.63 69.9 ENOXAPARIN 150 MG/ML SYRINGE 50592902_1 CDM 0250 RC 71288-0411-83 NDC inpatient 1 UN 72.06 46.84 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.63 69.9 ENOXAPARIN 150 MG/ML SYRINGE 50592902_1 CDM 0250 RC 71288-0411-83 NDC inpatient 1 UN 72.06 46.84 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.63 69.9 ENOXAPARIN 150 MG/ML SYRINGE 50592902_1 CDM 0250 RC 71288-0411-83 NDC inpatient 1 UN 72.06 46.84 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.63 69.9 ENOXAPARIN 150 MG/ML SYRINGE 50592902_1 CDM 0250 RC 71288-0411-83 NDC inpatient 1 UN 72.06 46.84 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.71 67.6 999999999 43.63 69.9 percent of total billed charges GABAPENTIN 400 MG CAPSULE 50592904_1 CDM 0250 RC 00904-6667-61 NDC inpatient 1 UN 1.32 0.86 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.86 65 999999999 0.8 1.28 percent of total billed charges GABAPENTIN 400 MG CAPSULE 50592904_1 CDM 0250 RC 00904-6667-61 NDC inpatient 1 UN 1.32 0.86 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.28 97 999999999 0.8 1.28 percent of total billed charges GABAPENTIN 400 MG CAPSULE 50592904_1 CDM 0250 RC 00904-6667-61 NDC inpatient 1 UN 1.32 0.86 AETNA AETNA 1.04 79 999999999 0.8 1.28 percent of total billed charges GABAPENTIN 400 MG CAPSULE 50592904_1 CDM 0250 RC 00904-6667-61 NDC inpatient 1 UN 1.32 0.86 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.03 78 999999999 0.8 1.28 percent of total billed charges GABAPENTIN 400 MG CAPSULE 50592904_1 CDM 0250 RC 00904-6667-61 NDC inpatient 1 UN 1.32 0.86 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.91 69 999999999 0.8 1.28 percent of total billed charges GABAPENTIN 400 MG CAPSULE 50592904_1 CDM 0250 RC 00904-6667-61 NDC inpatient 1 UN 1.32 0.86 SIHO - ALL PLANS SIHO - ALL PLANS 1.19 90 999999999 0.8 1.28 percent of total billed charges GABAPENTIN 400 MG CAPSULE 50592904_1 CDM 0250 RC 00904-6667-61 NDC inpatient 1 UN 1.32 0.86 UMR - ALL PLANS UMR - ALL PLANS 0.92 70 999999999 0.8 1.28 percent of total billed charges GABAPENTIN 400 MG CAPSULE 50592904_1 CDM 0250 RC 00904-6667-61 NDC inpatient 1 UN 1.32 0.86 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.8 60.55 999999999 0.8 1.28 percent of total billed charges GABAPENTIN 400 MG CAPSULE 50592904_1 CDM 0250 RC 00904-6667-61 NDC inpatient 1 UN 1.32 0.86 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.8 1.28 GABAPENTIN 400 MG CAPSULE 50592904_1 CDM 0250 RC 00904-6667-61 NDC inpatient 1 UN 1.32 0.86 ANTHEM HMO ANTHEM HMO 999999999 0.8 1.28 GABAPENTIN 400 MG CAPSULE 50592904_1 CDM 0250 RC 00904-6667-61 NDC inpatient 1 UN 1.32 0.86 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.8 1.28 GABAPENTIN 400 MG CAPSULE 50592904_1 CDM 0250 RC 00904-6667-61 NDC inpatient 1 UN 1.32 0.86 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.8 1.28 GABAPENTIN 400 MG CAPSULE 50592904_1 CDM 0250 RC 00904-6667-61 NDC inpatient 1 UN 1.32 0.86 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.8 1.28 GABAPENTIN 400 MG CAPSULE 50592904_1 CDM 0250 RC 00904-6667-61 NDC inpatient 1 UN 1.32 0.86 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.89 67.6 999999999 0.8 1.28 percent of total billed charges OLUMIANT 2 MG TABLET 50592954_1 CDM 0250 RC 00002-4182-30 NDC inpatient 1 UN 225 146.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 146.25 65 999999999 136.24 218.25 percent of total billed charges OLUMIANT 2 MG TABLET 50592954_1 CDM 0250 RC 00002-4182-30 NDC inpatient 1 UN 225 146.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 218.25 97 999999999 136.24 218.25 percent of total billed charges OLUMIANT 2 MG TABLET 50592954_1 CDM 0250 RC 00002-4182-30 NDC inpatient 1 UN 225 146.25 AETNA AETNA 177.75 79 999999999 136.24 218.25 percent of total billed charges OLUMIANT 2 MG TABLET 50592954_1 CDM 0250 RC 00002-4182-30 NDC inpatient 1 UN 225 146.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 175.5 78 999999999 136.24 218.25 percent of total billed charges OLUMIANT 2 MG TABLET 50592954_1 CDM 0250 RC 00002-4182-30 NDC inpatient 1 UN 225 146.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 155.25 69 999999999 136.24 218.25 percent of total billed charges OLUMIANT 2 MG TABLET 50592954_1 CDM 0250 RC 00002-4182-30 NDC inpatient 1 UN 225 146.25 SIHO - ALL PLANS SIHO - ALL PLANS 202.5 90 999999999 136.24 218.25 percent of total billed charges OLUMIANT 2 MG TABLET 50592954_1 CDM 0250 RC 00002-4182-30 NDC inpatient 1 UN 225 146.25 UMR - ALL PLANS UMR - ALL PLANS 157.5 70 999999999 136.24 218.25 percent of total billed charges OLUMIANT 2 MG TABLET 50592954_1 CDM 0250 RC 00002-4182-30 NDC inpatient 1 UN 225 146.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 136.24 60.55 999999999 136.24 218.25 percent of total billed charges OLUMIANT 2 MG TABLET 50592954_1 CDM 0250 RC 00002-4182-30 NDC inpatient 1 UN 225 146.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 136.24 218.25 OLUMIANT 2 MG TABLET 50592954_1 CDM 0250 RC 00002-4182-30 NDC inpatient 1 UN 225 146.25 ANTHEM HMO ANTHEM HMO 999999999 136.24 218.25 OLUMIANT 2 MG TABLET 50592954_1 CDM 0250 RC 00002-4182-30 NDC inpatient 1 UN 225 146.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 136.24 218.25 OLUMIANT 2 MG TABLET 50592954_1 CDM 0250 RC 00002-4182-30 NDC inpatient 1 UN 225 146.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 136.24 218.25 OLUMIANT 2 MG TABLET 50592954_1 CDM 0250 RC 00002-4182-30 NDC inpatient 1 UN 225 146.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 136.24 218.25 OLUMIANT 2 MG TABLET 50592954_1 CDM 0250 RC 00002-4182-30 NDC inpatient 1 UN 225 146.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 152.1 67.6 999999999 136.24 218.25 percent of total billed charges MELATONIN 5 MG TABLET 50593027_1 CDM 0250 RC 77333-0520-10 NDC inpatient 1 UN 1.68 1.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.09 65 999999999 1.02 1.63 percent of total billed charges MELATONIN 5 MG TABLET 50593027_1 CDM 0250 RC 77333-0520-10 NDC inpatient 1 UN 1.68 1.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.63 97 999999999 1.02 1.63 percent of total billed charges MELATONIN 5 MG TABLET 50593027_1 CDM 0250 RC 77333-0520-10 NDC inpatient 1 UN 1.68 1.09 AETNA AETNA 1.33 79 999999999 1.02 1.63 percent of total billed charges MELATONIN 5 MG TABLET 50593027_1 CDM 0250 RC 77333-0520-10 NDC inpatient 1 UN 1.68 1.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.31 78 999999999 1.02 1.63 percent of total billed charges MELATONIN 5 MG TABLET 50593027_1 CDM 0250 RC 77333-0520-10 NDC inpatient 1 UN 1.68 1.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.16 69 999999999 1.02 1.63 percent of total billed charges MELATONIN 5 MG TABLET 50593027_1 CDM 0250 RC 77333-0520-10 NDC inpatient 1 UN 1.68 1.09 SIHO - ALL PLANS SIHO - ALL PLANS 1.51 90 999999999 1.02 1.63 percent of total billed charges MELATONIN 5 MG TABLET 50593027_1 CDM 0250 RC 77333-0520-10 NDC inpatient 1 UN 1.68 1.09 UMR - ALL PLANS UMR - ALL PLANS 1.18 70 999999999 1.02 1.63 percent of total billed charges MELATONIN 5 MG TABLET 50593027_1 CDM 0250 RC 77333-0520-10 NDC inpatient 1 UN 1.68 1.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.02 60.55 999999999 1.02 1.63 percent of total billed charges MELATONIN 5 MG TABLET 50593027_1 CDM 0250 RC 77333-0520-10 NDC inpatient 1 UN 1.68 1.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.02 1.63 MELATONIN 5 MG TABLET 50593027_1 CDM 0250 RC 77333-0520-10 NDC inpatient 1 UN 1.68 1.09 ANTHEM HMO ANTHEM HMO 999999999 1.02 1.63 MELATONIN 5 MG TABLET 50593027_1 CDM 0250 RC 77333-0520-10 NDC inpatient 1 UN 1.68 1.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.02 1.63 MELATONIN 5 MG TABLET 50593027_1 CDM 0250 RC 77333-0520-10 NDC inpatient 1 UN 1.68 1.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.02 1.63 MELATONIN 5 MG TABLET 50593027_1 CDM 0250 RC 77333-0520-10 NDC inpatient 1 UN 1.68 1.09 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.02 1.63 MELATONIN 5 MG TABLET 50593027_1 CDM 0250 RC 77333-0520-10 NDC inpatient 1 UN 1.68 1.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.14 67.6 999999999 1.02 1.63 percent of total billed charges Detection test by immunoassay technique for severe acute respiratory syndrome coronavirus 50593073_1 CDM 0306 RC 87426 HCPCS inpatient 94 61.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.1 65 999999999 56.92 91.18 percent of total billed charges Detection test by immunoassay technique for severe acute respiratory syndrome coronavirus 50593073_1 CDM 0306 RC 87426 HCPCS inpatient 94 61.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.18 97 999999999 56.92 91.18 percent of total billed charges Detection test by immunoassay technique for severe acute respiratory syndrome coronavirus 50593073_1 CDM 0306 RC 87426 HCPCS inpatient 94 61.1 AETNA AETNA 74.26 79 999999999 56.92 91.18 percent of total billed charges Detection test by immunoassay technique for severe acute respiratory syndrome coronavirus 50593073_1 CDM 0306 RC 87426 HCPCS inpatient 94 61.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.32 78 999999999 56.92 91.18 percent of total billed charges Detection test by immunoassay technique for severe acute respiratory syndrome coronavirus 50593073_1 CDM 0306 RC 87426 HCPCS inpatient 94 61.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.86 69 999999999 56.92 91.18 percent of total billed charges Detection test by immunoassay technique for severe acute respiratory syndrome coronavirus 50593073_1 CDM 0306 RC 87426 HCPCS inpatient 94 61.1 SIHO - ALL PLANS SIHO - ALL PLANS 84.6 90 999999999 56.92 91.18 percent of total billed charges Detection test by immunoassay technique for severe acute respiratory syndrome coronavirus 50593073_1 CDM 0306 RC 87426 HCPCS inpatient 94 61.1 UMR - ALL PLANS UMR - ALL PLANS 65.8 70 999999999 56.92 91.18 percent of total billed charges Detection test by immunoassay technique for severe acute respiratory syndrome coronavirus 50593073_1 CDM 0306 RC 87426 HCPCS inpatient 94 61.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.92 60.55 999999999 56.92 91.18 percent of total billed charges Detection test by immunoassay technique for severe acute respiratory syndrome coronavirus 50593073_1 CDM 0306 RC 87426 HCPCS inpatient 94 61.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.92 91.18 Detection test by immunoassay technique for severe acute respiratory syndrome coronavirus 50593073_1 CDM 0306 RC 87426 HCPCS inpatient 94 61.1 ANTHEM HMO ANTHEM HMO 999999999 56.92 91.18 Detection test by immunoassay technique for severe acute respiratory syndrome coronavirus 50593073_1 CDM 0306 RC 87426 HCPCS inpatient 94 61.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.92 91.18 Detection test by immunoassay technique for severe acute respiratory syndrome coronavirus 50593073_1 CDM 0306 RC 87426 HCPCS inpatient 94 61.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.92 91.18 Detection test by immunoassay technique for severe acute respiratory syndrome coronavirus 50593073_1 CDM 0306 RC 87426 HCPCS inpatient 94 61.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.92 91.18 Detection test by immunoassay technique for severe acute respiratory syndrome coronavirus 50593073_1 CDM 0306 RC 87426 HCPCS inpatient 94 61.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.54 67.6 999999999 56.92 91.18 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 50593454_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 166.4 65 999999999 155.01 248.32 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 50593454_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 248.32 97 999999999 155.01 248.32 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 50593454_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 AETNA AETNA 202.24 79 999999999 155.01 248.32 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 50593454_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 199.68 78 999999999 155.01 248.32 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 50593454_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 176.64 69 999999999 155.01 248.32 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 50593454_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 SIHO - ALL PLANS SIHO - ALL PLANS 230.4 90 999999999 155.01 248.32 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 50593454_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 UMR - ALL PLANS UMR - ALL PLANS 179.2 70 999999999 155.01 248.32 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 50593454_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.01 60.55 999999999 155.01 248.32 percent of total billed charges "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 50593454_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.01 248.32 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 50593454_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 ANTHEM HMO ANTHEM HMO 999999999 155.01 248.32 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 50593454_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.01 248.32 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 50593454_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.01 248.32 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 50593454_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.01 248.32 "Pretreatment of red blood cells for use in red blood cells antibody analysis and measurement, incubation with chemical agents or drugs" 50593454_1 CDM 0302 RC 86970 HCPCS inpatient 256 166.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.06 67.6 999999999 155.01 248.32 percent of total billed charges "Pretreatment of serum for use in red blood cell antibody analysis and measurement, incubation with inhibitors" 50593488_1 CDM 0302 RC 86977 HCPCS inpatient 174 113.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 113.1 65 999999999 105.36 168.78 percent of total billed charges "Pretreatment of serum for use in red blood cell antibody analysis and measurement, incubation with inhibitors" 50593488_1 CDM 0302 RC 86977 HCPCS inpatient 174 113.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 168.78 97 999999999 105.36 168.78 percent of total billed charges "Pretreatment of serum for use in red blood cell antibody analysis and measurement, incubation with inhibitors" 50593488_1 CDM 0302 RC 86977 HCPCS inpatient 174 113.1 AETNA AETNA 137.46 79 999999999 105.36 168.78 percent of total billed charges "Pretreatment of serum for use in red blood cell antibody analysis and measurement, incubation with inhibitors" 50593488_1 CDM 0302 RC 86977 HCPCS inpatient 174 113.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 135.72 78 999999999 105.36 168.78 percent of total billed charges "Pretreatment of serum for use in red blood cell antibody analysis and measurement, incubation with inhibitors" 50593488_1 CDM 0302 RC 86977 HCPCS inpatient 174 113.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 120.06 69 999999999 105.36 168.78 percent of total billed charges "Pretreatment of serum for use in red blood cell antibody analysis and measurement, incubation with inhibitors" 50593488_1 CDM 0302 RC 86977 HCPCS inpatient 174 113.1 SIHO - ALL PLANS SIHO - ALL PLANS 156.6 90 999999999 105.36 168.78 percent of total billed charges "Pretreatment of serum for use in red blood cell antibody analysis and measurement, incubation with inhibitors" 50593488_1 CDM 0302 RC 86977 HCPCS inpatient 174 113.1 UMR - ALL PLANS UMR - ALL PLANS 121.8 70 999999999 105.36 168.78 percent of total billed charges "Pretreatment of serum for use in red blood cell antibody analysis and measurement, incubation with inhibitors" 50593488_1 CDM 0302 RC 86977 HCPCS inpatient 174 113.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 105.36 60.55 999999999 105.36 168.78 percent of total billed charges "Pretreatment of serum for use in red blood cell antibody analysis and measurement, incubation with inhibitors" 50593488_1 CDM 0302 RC 86977 HCPCS inpatient 174 113.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 105.36 168.78 "Pretreatment of serum for use in red blood cell antibody analysis and measurement, incubation with inhibitors" 50593488_1 CDM 0302 RC 86977 HCPCS inpatient 174 113.1 ANTHEM HMO ANTHEM HMO 999999999 105.36 168.78 "Pretreatment of serum for use in red blood cell antibody analysis and measurement, incubation with inhibitors" 50593488_1 CDM 0302 RC 86977 HCPCS inpatient 174 113.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 105.36 168.78 "Pretreatment of serum for use in red blood cell antibody analysis and measurement, incubation with inhibitors" 50593488_1 CDM 0302 RC 86977 HCPCS inpatient 174 113.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 105.36 168.78 "Pretreatment of serum for use in red blood cell antibody analysis and measurement, incubation with inhibitors" 50593488_1 CDM 0302 RC 86977 HCPCS inpatient 174 113.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 105.36 168.78 "Pretreatment of serum for use in red blood cell antibody analysis and measurement, incubation with inhibitors" 50593488_1 CDM 0302 RC 86977 HCPCS inpatient 174 113.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 117.62 67.6 999999999 105.36 168.78 percent of total billed charges MINI C-ARM DRAPE 110788 20/CS 50599440_1 CDM 0272 RC inpatient 60 39 SELF PAY DISCOUNT SELF PAY DISCOUNT 39 65 999999999 36.33 58.2 percent of total billed charges MINI C-ARM DRAPE 110788 20/CS 50599440_1 CDM 0272 RC inpatient 60 39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.2 97 999999999 36.33 58.2 percent of total billed charges MINI C-ARM DRAPE 110788 20/CS 50599440_1 CDM 0272 RC inpatient 60 39 AETNA AETNA 47.4 79 999999999 36.33 58.2 percent of total billed charges MINI C-ARM DRAPE 110788 20/CS 50599440_1 CDM 0272 RC inpatient 60 39 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.8 78 999999999 36.33 58.2 percent of total billed charges MINI C-ARM DRAPE 110788 20/CS 50599440_1 CDM 0272 RC inpatient 60 39 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.4 69 999999999 36.33 58.2 percent of total billed charges MINI C-ARM DRAPE 110788 20/CS 50599440_1 CDM 0272 RC inpatient 60 39 SIHO - ALL PLANS SIHO - ALL PLANS 54 90 999999999 36.33 58.2 percent of total billed charges MINI C-ARM DRAPE 110788 20/CS 50599440_1 CDM 0272 RC inpatient 60 39 UMR - ALL PLANS UMR - ALL PLANS 42 70 999999999 36.33 58.2 percent of total billed charges MINI C-ARM DRAPE 110788 20/CS 50599440_1 CDM 0272 RC inpatient 60 39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.33 60.55 999999999 36.33 58.2 percent of total billed charges MINI C-ARM DRAPE 110788 20/CS 50599440_1 CDM 0272 RC inpatient 60 39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.33 58.2 MINI C-ARM DRAPE 110788 20/CS 50599440_1 CDM 0272 RC inpatient 60 39 ANTHEM HMO ANTHEM HMO 999999999 36.33 58.2 MINI C-ARM DRAPE 110788 20/CS 50599440_1 CDM 0272 RC inpatient 60 39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.33 58.2 MINI C-ARM DRAPE 110788 20/CS 50599440_1 CDM 0272 RC inpatient 60 39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.33 58.2 MINI C-ARM DRAPE 110788 20/CS 50599440_1 CDM 0272 RC inpatient 60 39 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.33 58.2 MINI C-ARM DRAPE 110788 20/CS 50599440_1 CDM 0272 RC inpatient 60 39 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.56 67.6 999999999 36.33 58.2 percent of total billed charges SODIUM BICARB 8.4% SYRINGE 50600502_1 CDM 0250 RC 76329-3352-01 NDC inpatient 1 UN 52.06 33.84 SELF PAY DISCOUNT SELF PAY DISCOUNT 33.84 65 999999999 31.52 50.5 percent of total billed charges SODIUM BICARB 8.4% SYRINGE 50600502_1 CDM 0250 RC 76329-3352-01 NDC inpatient 1 UN 52.06 33.84 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 50.5 97 999999999 31.52 50.5 percent of total billed charges SODIUM BICARB 8.4% SYRINGE 50600502_1 CDM 0250 RC 76329-3352-01 NDC inpatient 1 UN 52.06 33.84 AETNA AETNA 41.13 79 999999999 31.52 50.5 percent of total billed charges SODIUM BICARB 8.4% SYRINGE 50600502_1 CDM 0250 RC 76329-3352-01 NDC inpatient 1 UN 52.06 33.84 HUMANA - ALL PLANS HUMANA - ALL PLANS 40.61 78 999999999 31.52 50.5 percent of total billed charges SODIUM BICARB 8.4% SYRINGE 50600502_1 CDM 0250 RC 76329-3352-01 NDC inpatient 1 UN 52.06 33.84 ENCORE - ALL PLANS ENCORE - ALL PLANS 35.92 69 999999999 31.52 50.5 percent of total billed charges SODIUM BICARB 8.4% SYRINGE 50600502_1 CDM 0250 RC 76329-3352-01 NDC inpatient 1 UN 52.06 33.84 SIHO - ALL PLANS SIHO - ALL PLANS 46.85 90 999999999 31.52 50.5 percent of total billed charges SODIUM BICARB 8.4% SYRINGE 50600502_1 CDM 0250 RC 76329-3352-01 NDC inpatient 1 UN 52.06 33.84 UMR - ALL PLANS UMR - ALL PLANS 36.44 70 999999999 31.52 50.5 percent of total billed charges SODIUM BICARB 8.4% SYRINGE 50600502_1 CDM 0250 RC 76329-3352-01 NDC inpatient 1 UN 52.06 33.84 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 31.52 60.55 999999999 31.52 50.5 percent of total billed charges SODIUM BICARB 8.4% SYRINGE 50600502_1 CDM 0250 RC 76329-3352-01 NDC inpatient 1 UN 52.06 33.84 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 31.52 50.5 SODIUM BICARB 8.4% SYRINGE 50600502_1 CDM 0250 RC 76329-3352-01 NDC inpatient 1 UN 52.06 33.84 ANTHEM HMO ANTHEM HMO 999999999 31.52 50.5 SODIUM BICARB 8.4% SYRINGE 50600502_1 CDM 0250 RC 76329-3352-01 NDC inpatient 1 UN 52.06 33.84 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 31.52 50.5 SODIUM BICARB 8.4% SYRINGE 50600502_1 CDM 0250 RC 76329-3352-01 NDC inpatient 1 UN 52.06 33.84 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 31.52 50.5 SODIUM BICARB 8.4% SYRINGE 50600502_1 CDM 0250 RC 76329-3352-01 NDC inpatient 1 UN 52.06 33.84 UHC - ALL PLANS UHC - ALL PLANS 999999999 31.52 50.5 SODIUM BICARB 8.4% SYRINGE 50600502_1 CDM 0250 RC 76329-3352-01 NDC inpatient 1 UN 52.06 33.84 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.19 67.6 999999999 31.52 50.5 percent of total billed charges KCL 40 MEQ/L-D5W-0.45% NACL 50600832_1 CDM 0258 RC 00990-7904-09 NDC inpatient 1 UN 57.7 37.51 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.51 65 999999999 34.94 55.97 percent of total billed charges KCL 40 MEQ/L-D5W-0.45% NACL 50600832_1 CDM 0258 RC 00990-7904-09 NDC inpatient 1 UN 57.7 37.51 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.97 97 999999999 34.94 55.97 percent of total billed charges KCL 40 MEQ/L-D5W-0.45% NACL 50600832_1 CDM 0258 RC 00990-7904-09 NDC inpatient 1 UN 57.7 37.51 AETNA AETNA 45.58 79 999999999 34.94 55.97 percent of total billed charges KCL 40 MEQ/L-D5W-0.45% NACL 50600832_1 CDM 0258 RC 00990-7904-09 NDC inpatient 1 UN 57.7 37.51 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.01 78 999999999 34.94 55.97 percent of total billed charges KCL 40 MEQ/L-D5W-0.45% NACL 50600832_1 CDM 0258 RC 00990-7904-09 NDC inpatient 1 UN 57.7 37.51 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.81 69 999999999 34.94 55.97 percent of total billed charges KCL 40 MEQ/L-D5W-0.45% NACL 50600832_1 CDM 0258 RC 00990-7904-09 NDC inpatient 1 UN 57.7 37.51 SIHO - ALL PLANS SIHO - ALL PLANS 51.93 90 999999999 34.94 55.97 percent of total billed charges KCL 40 MEQ/L-D5W-0.45% NACL 50600832_1 CDM 0258 RC 00990-7904-09 NDC inpatient 1 UN 57.7 37.51 UMR - ALL PLANS UMR - ALL PLANS 40.39 70 999999999 34.94 55.97 percent of total billed charges KCL 40 MEQ/L-D5W-0.45% NACL 50600832_1 CDM 0258 RC 00990-7904-09 NDC inpatient 1 UN 57.7 37.51 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.94 60.55 999999999 34.94 55.97 percent of total billed charges KCL 40 MEQ/L-D5W-0.45% NACL 50600832_1 CDM 0258 RC 00990-7904-09 NDC inpatient 1 UN 57.7 37.51 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.94 55.97 KCL 40 MEQ/L-D5W-0.45% NACL 50600832_1 CDM 0258 RC 00990-7904-09 NDC inpatient 1 UN 57.7 37.51 ANTHEM HMO ANTHEM HMO 999999999 34.94 55.97 KCL 40 MEQ/L-D5W-0.45% NACL 50600832_1 CDM 0258 RC 00990-7904-09 NDC inpatient 1 UN 57.7 37.51 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.94 55.97 KCL 40 MEQ/L-D5W-0.45% NACL 50600832_1 CDM 0258 RC 00990-7904-09 NDC inpatient 1 UN 57.7 37.51 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.94 55.97 KCL 40 MEQ/L-D5W-0.45% NACL 50600832_1 CDM 0258 RC 00990-7904-09 NDC inpatient 1 UN 57.7 37.51 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.94 55.97 KCL 40 MEQ/L-D5W-0.45% NACL 50600832_1 CDM 0258 RC 00990-7904-09 NDC inpatient 1 UN 57.7 37.51 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.01 67.6 999999999 34.94 55.97 percent of total billed charges SODIUM BICARB 8.4% ABBOJECT 50600939_1 CDM 0250 RC 00409-6637-14 NDC inpatient 4 UN 40.43 26.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.28 65 999999999 24.48 39.22 percent of total billed charges SODIUM BICARB 8.4% ABBOJECT 50600939_1 CDM 0250 RC 00409-6637-14 NDC inpatient 4 UN 40.43 26.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39.22 97 999999999 24.48 39.22 percent of total billed charges SODIUM BICARB 8.4% ABBOJECT 50600939_1 CDM 0250 RC 00409-6637-14 NDC inpatient 4 UN 40.43 26.28 AETNA AETNA 31.94 79 999999999 24.48 39.22 percent of total billed charges SODIUM BICARB 8.4% ABBOJECT 50600939_1 CDM 0250 RC 00409-6637-14 NDC inpatient 4 UN 40.43 26.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.54 78 999999999 24.48 39.22 percent of total billed charges SODIUM BICARB 8.4% ABBOJECT 50600939_1 CDM 0250 RC 00409-6637-14 NDC inpatient 4 UN 40.43 26.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 27.9 69 999999999 24.48 39.22 percent of total billed charges SODIUM BICARB 8.4% ABBOJECT 50600939_1 CDM 0250 RC 00409-6637-14 NDC inpatient 4 UN 40.43 26.28 SIHO - ALL PLANS SIHO - ALL PLANS 36.39 90 999999999 24.48 39.22 percent of total billed charges SODIUM BICARB 8.4% ABBOJECT 50600939_1 CDM 0250 RC 00409-6637-14 NDC inpatient 4 UN 40.43 26.28 UMR - ALL PLANS UMR - ALL PLANS 28.3 70 999999999 24.48 39.22 percent of total billed charges SODIUM BICARB 8.4% ABBOJECT 50600939_1 CDM 0250 RC 00409-6637-14 NDC inpatient 4 UN 40.43 26.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.48 60.55 999999999 24.48 39.22 percent of total billed charges SODIUM BICARB 8.4% ABBOJECT 50600939_1 CDM 0250 RC 00409-6637-14 NDC inpatient 4 UN 40.43 26.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.48 39.22 SODIUM BICARB 8.4% ABBOJECT 50600939_1 CDM 0250 RC 00409-6637-14 NDC inpatient 4 UN 40.43 26.28 ANTHEM HMO ANTHEM HMO 999999999 24.48 39.22 SODIUM BICARB 8.4% ABBOJECT 50600939_1 CDM 0250 RC 00409-6637-14 NDC inpatient 4 UN 40.43 26.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.48 39.22 SODIUM BICARB 8.4% ABBOJECT 50600939_1 CDM 0250 RC 00409-6637-14 NDC inpatient 4 UN 40.43 26.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.48 39.22 SODIUM BICARB 8.4% ABBOJECT 50600939_1 CDM 0250 RC 00409-6637-14 NDC inpatient 4 UN 40.43 26.28 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.48 39.22 SODIUM BICARB 8.4% ABBOJECT 50600939_1 CDM 0250 RC 00409-6637-14 NDC inpatient 4 UN 40.43 26.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.33 67.6 999999999 24.48 39.22 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50601331_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65 65 999999999 60.55 97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50601331_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97 97 999999999 60.55 97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50601331_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 AETNA AETNA 79 79 999999999 60.55 97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50601331_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78 78 999999999 60.55 97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50601331_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69 69 999999999 60.55 97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50601331_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 SIHO - ALL PLANS SIHO - ALL PLANS 90 90 999999999 60.55 97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50601331_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 UMR - ALL PLANS UMR - ALL PLANS 70 70 999999999 60.55 97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50601331_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.55 60.55 999999999 60.55 97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50601331_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.55 97 "Analysis of substance using immunoassay technique, multiple step method" 50601331_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 ANTHEM HMO ANTHEM HMO 999999999 60.55 97 "Analysis of substance using immunoassay technique, multiple step method" 50601331_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.55 97 "Analysis of substance using immunoassay technique, multiple step method" 50601331_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.55 97 "Analysis of substance using immunoassay technique, multiple step method" 50601331_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.55 97 "Analysis of substance using immunoassay technique, multiple step method" 50601331_1 CDM 0301 RC 83516 HCPCS inpatient 100 65 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.6 67.6 999999999 60.55 97 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601332_1 CDM 0301 RC 83519 HCPCS inpatient 299 194.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 194.35 65 999999999 181.04 290.03 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601332_1 CDM 0301 RC 83519 HCPCS inpatient 299 194.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 290.03 97 999999999 181.04 290.03 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601332_1 CDM 0301 RC 83519 HCPCS inpatient 299 194.35 AETNA AETNA 236.21 79 999999999 181.04 290.03 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601332_1 CDM 0301 RC 83519 HCPCS inpatient 299 194.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 233.22 78 999999999 181.04 290.03 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601332_1 CDM 0301 RC 83519 HCPCS inpatient 299 194.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 206.31 69 999999999 181.04 290.03 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601332_1 CDM 0301 RC 83519 HCPCS inpatient 299 194.35 SIHO - ALL PLANS SIHO - ALL PLANS 269.1 90 999999999 181.04 290.03 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601332_1 CDM 0301 RC 83519 HCPCS inpatient 299 194.35 UMR - ALL PLANS UMR - ALL PLANS 209.3 70 999999999 181.04 290.03 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601332_1 CDM 0301 RC 83519 HCPCS inpatient 299 194.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 181.04 60.55 999999999 181.04 290.03 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601332_1 CDM 0301 RC 83519 HCPCS inpatient 299 194.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 181.04 290.03 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601332_1 CDM 0301 RC 83519 HCPCS inpatient 299 194.35 ANTHEM HMO ANTHEM HMO 999999999 181.04 290.03 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601332_1 CDM 0301 RC 83519 HCPCS inpatient 299 194.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 181.04 290.03 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601332_1 CDM 0301 RC 83519 HCPCS inpatient 299 194.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 181.04 290.03 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601332_1 CDM 0301 RC 83519 HCPCS inpatient 299 194.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 181.04 290.03 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601332_1 CDM 0301 RC 83519 HCPCS inpatient 299 194.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 202.12 67.6 999999999 181.04 290.03 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50601333_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50601333_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50601333_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50601333_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50601333_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50601333_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50601333_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50601333_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50601333_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50601333_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50601333_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50601333_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50601333_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50601333_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges Chemical analysis using chromatography technique 50601393_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 169.65 65 999999999 158.04 253.17 percent of total billed charges Chemical analysis using chromatography technique 50601393_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 253.17 97 999999999 158.04 253.17 percent of total billed charges Chemical analysis using chromatography technique 50601393_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 AETNA AETNA 206.19 79 999999999 158.04 253.17 percent of total billed charges Chemical analysis using chromatography technique 50601393_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 203.58 78 999999999 158.04 253.17 percent of total billed charges Chemical analysis using chromatography technique 50601393_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.09 69 999999999 158.04 253.17 percent of total billed charges Chemical analysis using chromatography technique 50601393_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 SIHO - ALL PLANS SIHO - ALL PLANS 234.9 90 999999999 158.04 253.17 percent of total billed charges Chemical analysis using chromatography technique 50601393_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 UMR - ALL PLANS UMR - ALL PLANS 182.7 70 999999999 158.04 253.17 percent of total billed charges Chemical analysis using chromatography technique 50601393_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.04 60.55 999999999 158.04 253.17 percent of total billed charges Chemical analysis using chromatography technique 50601393_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.04 253.17 Chemical analysis using chromatography technique 50601393_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 ANTHEM HMO ANTHEM HMO 999999999 158.04 253.17 Chemical analysis using chromatography technique 50601393_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.04 253.17 Chemical analysis using chromatography technique 50601393_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.04 253.17 Chemical analysis using chromatography technique 50601393_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.04 253.17 Chemical analysis using chromatography technique 50601393_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 176.44 67.6 999999999 158.04 253.17 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601394_1 CDM 0301 RC 83519 HCPCS inpatient 937 609.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 609.05 65 999999999 567.35 908.89 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601394_1 CDM 0301 RC 83519 HCPCS inpatient 937 609.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 908.89 97 999999999 567.35 908.89 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601394_1 CDM 0301 RC 83519 HCPCS inpatient 937 609.05 AETNA AETNA 740.23 79 999999999 567.35 908.89 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601394_1 CDM 0301 RC 83519 HCPCS inpatient 937 609.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 730.86 78 999999999 567.35 908.89 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601394_1 CDM 0301 RC 83519 HCPCS inpatient 937 609.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 646.53 69 999999999 567.35 908.89 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601394_1 CDM 0301 RC 83519 HCPCS inpatient 937 609.05 SIHO - ALL PLANS SIHO - ALL PLANS 843.3 90 999999999 567.35 908.89 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601394_1 CDM 0301 RC 83519 HCPCS inpatient 937 609.05 UMR - ALL PLANS UMR - ALL PLANS 655.9 70 999999999 567.35 908.89 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601394_1 CDM 0301 RC 83519 HCPCS inpatient 937 609.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 567.35 60.55 999999999 567.35 908.89 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601394_1 CDM 0301 RC 83519 HCPCS inpatient 937 609.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 567.35 908.89 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601394_1 CDM 0301 RC 83519 HCPCS inpatient 937 609.05 ANTHEM HMO ANTHEM HMO 999999999 567.35 908.89 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601394_1 CDM 0301 RC 83519 HCPCS inpatient 937 609.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 567.35 908.89 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601394_1 CDM 0301 RC 83519 HCPCS inpatient 937 609.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 567.35 908.89 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601394_1 CDM 0301 RC 83519 HCPCS inpatient 937 609.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 567.35 908.89 "Measurement of substance using immunoassay technique, by radioimmunoassay" 50601394_1 CDM 0301 RC 83519 HCPCS inpatient 937 609.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 633.41 67.6 999999999 567.35 908.89 percent of total billed charges ENOXAPARIN 120 MG/0.8 ML SYR 50601737_1 CDM 0250 RC 71288-0411-81 NDC inpatient 1 UN 61.63 40.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.06 65 999999999 37.32 59.78 percent of total billed charges ENOXAPARIN 120 MG/0.8 ML SYR 50601737_1 CDM 0250 RC 71288-0411-81 NDC inpatient 1 UN 61.63 40.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59.78 97 999999999 37.32 59.78 percent of total billed charges ENOXAPARIN 120 MG/0.8 ML SYR 50601737_1 CDM 0250 RC 71288-0411-81 NDC inpatient 1 UN 61.63 40.06 AETNA AETNA 48.69 79 999999999 37.32 59.78 percent of total billed charges ENOXAPARIN 120 MG/0.8 ML SYR 50601737_1 CDM 0250 RC 71288-0411-81 NDC inpatient 1 UN 61.63 40.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 48.07 78 999999999 37.32 59.78 percent of total billed charges ENOXAPARIN 120 MG/0.8 ML SYR 50601737_1 CDM 0250 RC 71288-0411-81 NDC inpatient 1 UN 61.63 40.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.52 69 999999999 37.32 59.78 percent of total billed charges ENOXAPARIN 120 MG/0.8 ML SYR 50601737_1 CDM 0250 RC 71288-0411-81 NDC inpatient 1 UN 61.63 40.06 SIHO - ALL PLANS SIHO - ALL PLANS 55.47 90 999999999 37.32 59.78 percent of total billed charges ENOXAPARIN 120 MG/0.8 ML SYR 50601737_1 CDM 0250 RC 71288-0411-81 NDC inpatient 1 UN 61.63 40.06 UMR - ALL PLANS UMR - ALL PLANS 43.14 70 999999999 37.32 59.78 percent of total billed charges ENOXAPARIN 120 MG/0.8 ML SYR 50601737_1 CDM 0250 RC 71288-0411-81 NDC inpatient 1 UN 61.63 40.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 37.32 60.55 999999999 37.32 59.78 percent of total billed charges ENOXAPARIN 120 MG/0.8 ML SYR 50601737_1 CDM 0250 RC 71288-0411-81 NDC inpatient 1 UN 61.63 40.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 37.32 59.78 ENOXAPARIN 120 MG/0.8 ML SYR 50601737_1 CDM 0250 RC 71288-0411-81 NDC inpatient 1 UN 61.63 40.06 ANTHEM HMO ANTHEM HMO 999999999 37.32 59.78 ENOXAPARIN 120 MG/0.8 ML SYR 50601737_1 CDM 0250 RC 71288-0411-81 NDC inpatient 1 UN 61.63 40.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 37.32 59.78 ENOXAPARIN 120 MG/0.8 ML SYR 50601737_1 CDM 0250 RC 71288-0411-81 NDC inpatient 1 UN 61.63 40.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 37.32 59.78 ENOXAPARIN 120 MG/0.8 ML SYR 50601737_1 CDM 0250 RC 71288-0411-81 NDC inpatient 1 UN 61.63 40.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 37.32 59.78 ENOXAPARIN 120 MG/0.8 ML SYR 50601737_1 CDM 0250 RC 71288-0411-81 NDC inpatient 1 UN 61.63 40.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.66 67.6 999999999 37.32 59.78 percent of total billed charges VRAYLAR 3 MG CAPSULE 50601739_1 CDM 0250 RC 61874-0130-20 NDC inpatient 1 UN 181.7 118.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.11 65 999999999 110.02 176.25 percent of total billed charges VRAYLAR 3 MG CAPSULE 50601739_1 CDM 0250 RC 61874-0130-20 NDC inpatient 1 UN 181.7 118.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 176.25 97 999999999 110.02 176.25 percent of total billed charges VRAYLAR 3 MG CAPSULE 50601739_1 CDM 0250 RC 61874-0130-20 NDC inpatient 1 UN 181.7 118.11 AETNA AETNA 143.54 79 999999999 110.02 176.25 percent of total billed charges VRAYLAR 3 MG CAPSULE 50601739_1 CDM 0250 RC 61874-0130-20 NDC inpatient 1 UN 181.7 118.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.73 78 999999999 110.02 176.25 percent of total billed charges VRAYLAR 3 MG CAPSULE 50601739_1 CDM 0250 RC 61874-0130-20 NDC inpatient 1 UN 181.7 118.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 125.37 69 999999999 110.02 176.25 percent of total billed charges VRAYLAR 3 MG CAPSULE 50601739_1 CDM 0250 RC 61874-0130-20 NDC inpatient 1 UN 181.7 118.11 SIHO - ALL PLANS SIHO - ALL PLANS 163.53 90 999999999 110.02 176.25 percent of total billed charges VRAYLAR 3 MG CAPSULE 50601739_1 CDM 0250 RC 61874-0130-20 NDC inpatient 1 UN 181.7 118.11 UMR - ALL PLANS UMR - ALL PLANS 127.19 70 999999999 110.02 176.25 percent of total billed charges VRAYLAR 3 MG CAPSULE 50601739_1 CDM 0250 RC 61874-0130-20 NDC inpatient 1 UN 181.7 118.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.02 60.55 999999999 110.02 176.25 percent of total billed charges VRAYLAR 3 MG CAPSULE 50601739_1 CDM 0250 RC 61874-0130-20 NDC inpatient 1 UN 181.7 118.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.02 176.25 VRAYLAR 3 MG CAPSULE 50601739_1 CDM 0250 RC 61874-0130-20 NDC inpatient 1 UN 181.7 118.11 ANTHEM HMO ANTHEM HMO 999999999 110.02 176.25 VRAYLAR 3 MG CAPSULE 50601739_1 CDM 0250 RC 61874-0130-20 NDC inpatient 1 UN 181.7 118.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.02 176.25 VRAYLAR 3 MG CAPSULE 50601739_1 CDM 0250 RC 61874-0130-20 NDC inpatient 1 UN 181.7 118.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.02 176.25 VRAYLAR 3 MG CAPSULE 50601739_1 CDM 0250 RC 61874-0130-20 NDC inpatient 1 UN 181.7 118.11 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.02 176.25 VRAYLAR 3 MG CAPSULE 50601739_1 CDM 0250 RC 61874-0130-20 NDC inpatient 1 UN 181.7 118.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.83 67.6 999999999 110.02 176.25 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601997_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601997_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601997_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601997_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601997_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601997_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601997_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601997_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601997_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601997_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601997_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601997_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601997_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601997_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50601998_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50602574_1 CDM 0250 RC 63323-0434-00 NDC J0131 HCPCS inpatient 100 UN 207.79 135.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 135.06 65 999999999 125.82 201.56 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50602574_1 CDM 0250 RC 63323-0434-00 NDC J0131 HCPCS inpatient 100 UN 207.79 135.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 201.56 97 999999999 125.82 201.56 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50602574_1 CDM 0250 RC 63323-0434-00 NDC J0131 HCPCS inpatient 100 UN 207.79 135.06 AETNA AETNA 164.15 79 999999999 125.82 201.56 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50602574_1 CDM 0250 RC 63323-0434-00 NDC J0131 HCPCS inpatient 100 UN 207.79 135.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 162.08 78 999999999 125.82 201.56 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50602574_1 CDM 0250 RC 63323-0434-00 NDC J0131 HCPCS inpatient 100 UN 207.79 135.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 143.38 69 999999999 125.82 201.56 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50602574_1 CDM 0250 RC 63323-0434-00 NDC J0131 HCPCS inpatient 100 UN 207.79 135.06 SIHO - ALL PLANS SIHO - ALL PLANS 187.01 90 999999999 125.82 201.56 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50602574_1 CDM 0250 RC 63323-0434-00 NDC J0131 HCPCS inpatient 100 UN 207.79 135.06 UMR - ALL PLANS UMR - ALL PLANS 145.45 70 999999999 125.82 201.56 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50602574_1 CDM 0250 RC 63323-0434-00 NDC J0131 HCPCS inpatient 100 UN 207.79 135.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 125.82 60.55 999999999 125.82 201.56 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50602574_1 CDM 0250 RC 63323-0434-00 NDC J0131 HCPCS inpatient 100 UN 207.79 135.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 125.82 201.56 "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50602574_1 CDM 0250 RC 63323-0434-00 NDC J0131 HCPCS inpatient 100 UN 207.79 135.06 ANTHEM HMO ANTHEM HMO 999999999 125.82 201.56 "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50602574_1 CDM 0250 RC 63323-0434-00 NDC J0131 HCPCS inpatient 100 UN 207.79 135.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 125.82 201.56 "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50602574_1 CDM 0250 RC 63323-0434-00 NDC J0131 HCPCS inpatient 100 UN 207.79 135.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 125.82 201.56 "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50602574_1 CDM 0250 RC 63323-0434-00 NDC J0131 HCPCS inpatient 100 UN 207.79 135.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 125.82 201.56 "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50602574_1 CDM 0250 RC 63323-0434-00 NDC J0131 HCPCS inpatient 100 UN 207.79 135.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 140.47 67.6 999999999 125.82 201.56 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50603748_1 CDM 0250 RC 68001-0434-90 NDC inpatient 1 UN 5.45 3.54 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.54 65 999999999 3.3 5.29 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50603748_1 CDM 0250 RC 68001-0434-90 NDC inpatient 1 UN 5.45 3.54 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.29 97 999999999 3.3 5.29 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50603748_1 CDM 0250 RC 68001-0434-90 NDC inpatient 1 UN 5.45 3.54 AETNA AETNA 4.31 79 999999999 3.3 5.29 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50603748_1 CDM 0250 RC 68001-0434-90 NDC inpatient 1 UN 5.45 3.54 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.25 78 999999999 3.3 5.29 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50603748_1 CDM 0250 RC 68001-0434-90 NDC inpatient 1 UN 5.45 3.54 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.76 69 999999999 3.3 5.29 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50603748_1 CDM 0250 RC 68001-0434-90 NDC inpatient 1 UN 5.45 3.54 SIHO - ALL PLANS SIHO - ALL PLANS 4.91 90 999999999 3.3 5.29 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50603748_1 CDM 0250 RC 68001-0434-90 NDC inpatient 1 UN 5.45 3.54 UMR - ALL PLANS UMR - ALL PLANS 3.82 70 999999999 3.3 5.29 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50603748_1 CDM 0250 RC 68001-0434-90 NDC inpatient 1 UN 5.45 3.54 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.3 60.55 999999999 3.3 5.29 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50603748_1 CDM 0250 RC 68001-0434-90 NDC inpatient 1 UN 5.45 3.54 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.3 5.29 NICOTINE 21 MG/24HR PATCH 50603748_1 CDM 0250 RC 68001-0434-90 NDC inpatient 1 UN 5.45 3.54 ANTHEM HMO ANTHEM HMO 999999999 3.3 5.29 NICOTINE 21 MG/24HR PATCH 50603748_1 CDM 0250 RC 68001-0434-90 NDC inpatient 1 UN 5.45 3.54 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.3 5.29 NICOTINE 21 MG/24HR PATCH 50603748_1 CDM 0250 RC 68001-0434-90 NDC inpatient 1 UN 5.45 3.54 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.3 5.29 NICOTINE 21 MG/24HR PATCH 50603748_1 CDM 0250 RC 68001-0434-90 NDC inpatient 1 UN 5.45 3.54 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.3 5.29 NICOTINE 21 MG/24HR PATCH 50603748_1 CDM 0250 RC 68001-0434-90 NDC inpatient 1 UN 5.45 3.54 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.68 67.6 999999999 3.3 5.29 percent of total billed charges FLUCONAZOLE 50 MG TABLET 50603827_1 CDM 0250 RC 68462-0101-30 NDC inpatient 1 UN 2.97 1.93 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.93 65 999999999 1.8 2.88 percent of total billed charges FLUCONAZOLE 50 MG TABLET 50603827_1 CDM 0250 RC 68462-0101-30 NDC inpatient 1 UN 2.97 1.93 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.88 97 999999999 1.8 2.88 percent of total billed charges FLUCONAZOLE 50 MG TABLET 50603827_1 CDM 0250 RC 68462-0101-30 NDC inpatient 1 UN 2.97 1.93 AETNA AETNA 2.35 79 999999999 1.8 2.88 percent of total billed charges FLUCONAZOLE 50 MG TABLET 50603827_1 CDM 0250 RC 68462-0101-30 NDC inpatient 1 UN 2.97 1.93 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.32 78 999999999 1.8 2.88 percent of total billed charges FLUCONAZOLE 50 MG TABLET 50603827_1 CDM 0250 RC 68462-0101-30 NDC inpatient 1 UN 2.97 1.93 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.05 69 999999999 1.8 2.88 percent of total billed charges FLUCONAZOLE 50 MG TABLET 50603827_1 CDM 0250 RC 68462-0101-30 NDC inpatient 1 UN 2.97 1.93 SIHO - ALL PLANS SIHO - ALL PLANS 2.67 90 999999999 1.8 2.88 percent of total billed charges FLUCONAZOLE 50 MG TABLET 50603827_1 CDM 0250 RC 68462-0101-30 NDC inpatient 1 UN 2.97 1.93 UMR - ALL PLANS UMR - ALL PLANS 2.08 70 999999999 1.8 2.88 percent of total billed charges FLUCONAZOLE 50 MG TABLET 50603827_1 CDM 0250 RC 68462-0101-30 NDC inpatient 1 UN 2.97 1.93 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.8 60.55 999999999 1.8 2.88 percent of total billed charges FLUCONAZOLE 50 MG TABLET 50603827_1 CDM 0250 RC 68462-0101-30 NDC inpatient 1 UN 2.97 1.93 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.8 2.88 FLUCONAZOLE 50 MG TABLET 50603827_1 CDM 0250 RC 68462-0101-30 NDC inpatient 1 UN 2.97 1.93 ANTHEM HMO ANTHEM HMO 999999999 1.8 2.88 FLUCONAZOLE 50 MG TABLET 50603827_1 CDM 0250 RC 68462-0101-30 NDC inpatient 1 UN 2.97 1.93 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.8 2.88 FLUCONAZOLE 50 MG TABLET 50603827_1 CDM 0250 RC 68462-0101-30 NDC inpatient 1 UN 2.97 1.93 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.8 2.88 FLUCONAZOLE 50 MG TABLET 50603827_1 CDM 0250 RC 68462-0101-30 NDC inpatient 1 UN 2.97 1.93 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.8 2.88 FLUCONAZOLE 50 MG TABLET 50603827_1 CDM 0250 RC 68462-0101-30 NDC inpatient 1 UN 2.97 1.93 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.01 67.6 999999999 1.8 2.88 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50604091_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 73.45 65 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50604091_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 109.61 97 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50604091_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 AETNA AETNA 89.27 79 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50604091_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.14 78 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50604091_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.97 69 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50604091_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 SIHO - ALL PLANS SIHO - ALL PLANS 101.7 90 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50604091_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 UMR - ALL PLANS UMR - ALL PLANS 79.1 70 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50604091_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 68.42 60.55 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50604091_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 68.42 109.61 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50604091_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 ANTHEM HMO ANTHEM HMO 999999999 68.42 109.61 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50604091_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 68.42 109.61 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50604091_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 68.42 109.61 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50604091_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 68.42 109.61 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 50604091_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 76.39 67.6 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50604092_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 73.45 65 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50604092_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 109.61 97 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50604092_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 AETNA AETNA 89.27 79 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50604092_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.14 78 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50604092_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.97 69 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50604092_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 SIHO - ALL PLANS SIHO - ALL PLANS 101.7 90 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50604092_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 UMR - ALL PLANS UMR - ALL PLANS 79.1 70 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50604092_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 68.42 60.55 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50604092_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 68.42 109.61 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50604092_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 ANTHEM HMO ANTHEM HMO 999999999 68.42 109.61 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50604092_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 68.42 109.61 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50604092_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 68.42 109.61 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50604092_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 68.42 109.61 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 50604092_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 76.39 67.6 999999999 68.42 109.61 percent of total billed charges Detection of Mycoplasma genitalium by DNA or RNA probe 50604093_1 CDM 0306 RC 87563 HCPCS inpatient 107 69.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 69.55 65 999999999 64.79 103.79 percent of total billed charges Detection of Mycoplasma genitalium by DNA or RNA probe 50604093_1 CDM 0306 RC 87563 HCPCS inpatient 107 69.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 103.79 97 999999999 64.79 103.79 percent of total billed charges Detection of Mycoplasma genitalium by DNA or RNA probe 50604093_1 CDM 0306 RC 87563 HCPCS inpatient 107 69.55 AETNA AETNA 84.53 79 999999999 64.79 103.79 percent of total billed charges Detection of Mycoplasma genitalium by DNA or RNA probe 50604093_1 CDM 0306 RC 87563 HCPCS inpatient 107 69.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 83.46 78 999999999 64.79 103.79 percent of total billed charges Detection of Mycoplasma genitalium by DNA or RNA probe 50604093_1 CDM 0306 RC 87563 HCPCS inpatient 107 69.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.83 69 999999999 64.79 103.79 percent of total billed charges Detection of Mycoplasma genitalium by DNA or RNA probe 50604093_1 CDM 0306 RC 87563 HCPCS inpatient 107 69.55 SIHO - ALL PLANS SIHO - ALL PLANS 96.3 90 999999999 64.79 103.79 percent of total billed charges Detection of Mycoplasma genitalium by DNA or RNA probe 50604093_1 CDM 0306 RC 87563 HCPCS inpatient 107 69.55 UMR - ALL PLANS UMR - ALL PLANS 74.9 70 999999999 64.79 103.79 percent of total billed charges Detection of Mycoplasma genitalium by DNA or RNA probe 50604093_1 CDM 0306 RC 87563 HCPCS inpatient 107 69.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.79 60.55 999999999 64.79 103.79 percent of total billed charges Detection of Mycoplasma genitalium by DNA or RNA probe 50604093_1 CDM 0306 RC 87563 HCPCS inpatient 107 69.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.79 103.79 Detection of Mycoplasma genitalium by DNA or RNA probe 50604093_1 CDM 0306 RC 87563 HCPCS inpatient 107 69.55 ANTHEM HMO ANTHEM HMO 999999999 64.79 103.79 Detection of Mycoplasma genitalium by DNA or RNA probe 50604093_1 CDM 0306 RC 87563 HCPCS inpatient 107 69.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.79 103.79 Detection of Mycoplasma genitalium by DNA or RNA probe 50604093_1 CDM 0306 RC 87563 HCPCS inpatient 107 69.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.79 103.79 Detection of Mycoplasma genitalium by DNA or RNA probe 50604093_1 CDM 0306 RC 87563 HCPCS inpatient 107 69.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.79 103.79 Detection of Mycoplasma genitalium by DNA or RNA probe 50604093_1 CDM 0306 RC 87563 HCPCS inpatient 107 69.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 72.33 67.6 999999999 64.79 103.79 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50604094_1 CDM 0306 RC 87661 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50604094_1 CDM 0306 RC 87661 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50604094_1 CDM 0306 RC 87661 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50604094_1 CDM 0306 RC 87661 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50604094_1 CDM 0306 RC 87661 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50604094_1 CDM 0306 RC 87661 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50604094_1 CDM 0306 RC 87661 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50604094_1 CDM 0306 RC 87661 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50604094_1 CDM 0306 RC 87661 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50604094_1 CDM 0306 RC 87661 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50604094_1 CDM 0306 RC 87661 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50604094_1 CDM 0306 RC 87661 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50604094_1 CDM 0306 RC 87661 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50604094_1 CDM 0306 RC 87661 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50606119_1 CDM 0250 RC 16729-0240-03 NDC J1453 HCPCS inpatient 150 UN 171.43 111.43 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.43 65 999999999 103.8 166.29 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50606119_1 CDM 0250 RC 16729-0240-03 NDC J1453 HCPCS inpatient 150 UN 171.43 111.43 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 166.29 97 999999999 103.8 166.29 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50606119_1 CDM 0250 RC 16729-0240-03 NDC J1453 HCPCS inpatient 150 UN 171.43 111.43 AETNA AETNA 135.43 79 999999999 103.8 166.29 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50606119_1 CDM 0250 RC 16729-0240-03 NDC J1453 HCPCS inpatient 150 UN 171.43 111.43 HUMANA - ALL PLANS HUMANA - ALL PLANS 133.72 78 999999999 103.8 166.29 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50606119_1 CDM 0250 RC 16729-0240-03 NDC J1453 HCPCS inpatient 150 UN 171.43 111.43 ENCORE - ALL PLANS ENCORE - ALL PLANS 118.29 69 999999999 103.8 166.29 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50606119_1 CDM 0250 RC 16729-0240-03 NDC J1453 HCPCS inpatient 150 UN 171.43 111.43 SIHO - ALL PLANS SIHO - ALL PLANS 154.29 90 999999999 103.8 166.29 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50606119_1 CDM 0250 RC 16729-0240-03 NDC J1453 HCPCS inpatient 150 UN 171.43 111.43 UMR - ALL PLANS UMR - ALL PLANS 120 70 999999999 103.8 166.29 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50606119_1 CDM 0250 RC 16729-0240-03 NDC J1453 HCPCS inpatient 150 UN 171.43 111.43 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 103.8 60.55 999999999 103.8 166.29 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50606119_1 CDM 0250 RC 16729-0240-03 NDC J1453 HCPCS inpatient 150 UN 171.43 111.43 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 103.8 166.29 "INJECTION, FOSAPREPITANT, 1 MG" 50606119_1 CDM 0250 RC 16729-0240-03 NDC J1453 HCPCS inpatient 150 UN 171.43 111.43 ANTHEM HMO ANTHEM HMO 999999999 103.8 166.29 "INJECTION, FOSAPREPITANT, 1 MG" 50606119_1 CDM 0250 RC 16729-0240-03 NDC J1453 HCPCS inpatient 150 UN 171.43 111.43 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 103.8 166.29 "INJECTION, FOSAPREPITANT, 1 MG" 50606119_1 CDM 0250 RC 16729-0240-03 NDC J1453 HCPCS inpatient 150 UN 171.43 111.43 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 103.8 166.29 "INJECTION, FOSAPREPITANT, 1 MG" 50606119_1 CDM 0250 RC 16729-0240-03 NDC J1453 HCPCS inpatient 150 UN 171.43 111.43 UHC - ALL PLANS UHC - ALL PLANS 999999999 103.8 166.29 "INJECTION, FOSAPREPITANT, 1 MG" 50606119_1 CDM 0250 RC 16729-0240-03 NDC J1453 HCPCS inpatient 150 UN 171.43 111.43 CIGNA - ALL PLANS CIGNA - ALL PLANS 115.89 67.6 999999999 103.8 166.29 percent of total billed charges MINERAL OIL 30 ML CUP 50607417_1 CDM 0250 RC 48433-0202-30 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges MINERAL OIL 30 ML CUP 50607417_1 CDM 0250 RC 48433-0202-30 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges MINERAL OIL 30 ML CUP 50607417_1 CDM 0250 RC 48433-0202-30 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges MINERAL OIL 30 ML CUP 50607417_1 CDM 0250 RC 48433-0202-30 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges MINERAL OIL 30 ML CUP 50607417_1 CDM 0250 RC 48433-0202-30 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges MINERAL OIL 30 ML CUP 50607417_1 CDM 0250 RC 48433-0202-30 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges MINERAL OIL 30 ML CUP 50607417_1 CDM 0250 RC 48433-0202-30 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges MINERAL OIL 30 ML CUP 50607417_1 CDM 0250 RC 48433-0202-30 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges MINERAL OIL 30 ML CUP 50607417_1 CDM 0250 RC 48433-0202-30 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 MINERAL OIL 30 ML CUP 50607417_1 CDM 0250 RC 48433-0202-30 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 MINERAL OIL 30 ML CUP 50607417_1 CDM 0250 RC 48433-0202-30 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 MINERAL OIL 30 ML CUP 50607417_1 CDM 0250 RC 48433-0202-30 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 MINERAL OIL 30 ML CUP 50607417_1 CDM 0250 RC 48433-0202-30 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 MINERAL OIL 30 ML CUP 50607417_1 CDM 0250 RC 48433-0202-30 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges CELESTONE SOLUSPAN 30 MG/5 ML 50607420_1 CDM 0250 RC 00085-4320-01 NDC inpatient 1 UN 183.49 119.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 119.27 65 999999999 111.1 177.99 percent of total billed charges CELESTONE SOLUSPAN 30 MG/5 ML 50607420_1 CDM 0250 RC 00085-4320-01 NDC inpatient 1 UN 183.49 119.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.99 97 999999999 111.1 177.99 percent of total billed charges CELESTONE SOLUSPAN 30 MG/5 ML 50607420_1 CDM 0250 RC 00085-4320-01 NDC inpatient 1 UN 183.49 119.27 AETNA AETNA 144.96 79 999999999 111.1 177.99 percent of total billed charges CELESTONE SOLUSPAN 30 MG/5 ML 50607420_1 CDM 0250 RC 00085-4320-01 NDC inpatient 1 UN 183.49 119.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 143.12 78 999999999 111.1 177.99 percent of total billed charges CELESTONE SOLUSPAN 30 MG/5 ML 50607420_1 CDM 0250 RC 00085-4320-01 NDC inpatient 1 UN 183.49 119.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.61 69 999999999 111.1 177.99 percent of total billed charges CELESTONE SOLUSPAN 30 MG/5 ML 50607420_1 CDM 0250 RC 00085-4320-01 NDC inpatient 1 UN 183.49 119.27 SIHO - ALL PLANS SIHO - ALL PLANS 165.14 90 999999999 111.1 177.99 percent of total billed charges CELESTONE SOLUSPAN 30 MG/5 ML 50607420_1 CDM 0250 RC 00085-4320-01 NDC inpatient 1 UN 183.49 119.27 UMR - ALL PLANS UMR - ALL PLANS 128.44 70 999999999 111.1 177.99 percent of total billed charges CELESTONE SOLUSPAN 30 MG/5 ML 50607420_1 CDM 0250 RC 00085-4320-01 NDC inpatient 1 UN 183.49 119.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 111.1 60.55 999999999 111.1 177.99 percent of total billed charges CELESTONE SOLUSPAN 30 MG/5 ML 50607420_1 CDM 0250 RC 00085-4320-01 NDC inpatient 1 UN 183.49 119.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 111.1 177.99 CELESTONE SOLUSPAN 30 MG/5 ML 50607420_1 CDM 0250 RC 00085-4320-01 NDC inpatient 1 UN 183.49 119.27 ANTHEM HMO ANTHEM HMO 999999999 111.1 177.99 CELESTONE SOLUSPAN 30 MG/5 ML 50607420_1 CDM 0250 RC 00085-4320-01 NDC inpatient 1 UN 183.49 119.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 111.1 177.99 CELESTONE SOLUSPAN 30 MG/5 ML 50607420_1 CDM 0250 RC 00085-4320-01 NDC inpatient 1 UN 183.49 119.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 111.1 177.99 CELESTONE SOLUSPAN 30 MG/5 ML 50607420_1 CDM 0250 RC 00085-4320-01 NDC inpatient 1 UN 183.49 119.27 UHC - ALL PLANS UHC - ALL PLANS 999999999 111.1 177.99 CELESTONE SOLUSPAN 30 MG/5 ML 50607420_1 CDM 0250 RC 00085-4320-01 NDC inpatient 1 UN 183.49 119.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 124.04 67.6 999999999 111.1 177.99 percent of total billed charges Manganese (heavy metal) level 50607431_1 CDM 0301 RC 83785 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges Manganese (heavy metal) level 50607431_1 CDM 0301 RC 83785 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges Manganese (heavy metal) level 50607431_1 CDM 0301 RC 83785 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges Manganese (heavy metal) level 50607431_1 CDM 0301 RC 83785 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges Manganese (heavy metal) level 50607431_1 CDM 0301 RC 83785 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges Manganese (heavy metal) level 50607431_1 CDM 0301 RC 83785 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges Manganese (heavy metal) level 50607431_1 CDM 0301 RC 83785 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges Manganese (heavy metal) level 50607431_1 CDM 0301 RC 83785 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges Manganese (heavy metal) level 50607431_1 CDM 0301 RC 83785 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 Manganese (heavy metal) level 50607431_1 CDM 0301 RC 83785 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 Manganese (heavy metal) level 50607431_1 CDM 0301 RC 83785 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 Manganese (heavy metal) level 50607431_1 CDM 0301 RC 83785 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 Manganese (heavy metal) level 50607431_1 CDM 0301 RC 83785 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 Manganese (heavy metal) level 50607431_1 CDM 0301 RC 83785 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50607457_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 113.75 65 999999999 105.96 169.75 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50607457_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 169.75 97 999999999 105.96 169.75 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50607457_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 AETNA AETNA 138.25 79 999999999 105.96 169.75 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50607457_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 136.5 78 999999999 105.96 169.75 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50607457_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 120.75 69 999999999 105.96 169.75 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50607457_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 SIHO - ALL PLANS SIHO - ALL PLANS 157.5 90 999999999 105.96 169.75 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50607457_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 UMR - ALL PLANS UMR - ALL PLANS 122.5 70 999999999 105.96 169.75 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50607457_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 105.96 60.55 999999999 105.96 169.75 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50607457_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 105.96 169.75 "Analysis of substance using immunoassay technique, multiple step method" 50607457_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 ANTHEM HMO ANTHEM HMO 999999999 105.96 169.75 "Analysis of substance using immunoassay technique, multiple step method" 50607457_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 105.96 169.75 "Analysis of substance using immunoassay technique, multiple step method" 50607457_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 105.96 169.75 "Analysis of substance using immunoassay technique, multiple step method" 50607457_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 105.96 169.75 "Analysis of substance using immunoassay technique, multiple step method" 50607457_1 CDM 0301 RC 83516 HCPCS inpatient 175 113.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.3 67.6 999999999 105.96 169.75 percent of total billed charges Measurement of substance using immunoassay technique 50607504_1 CDM 0301 RC 83520 HCPCS inpatient 311 202.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 202.15 65 999999999 188.31 301.67 percent of total billed charges Measurement of substance using immunoassay technique 50607504_1 CDM 0301 RC 83520 HCPCS inpatient 311 202.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 301.67 97 999999999 188.31 301.67 percent of total billed charges Measurement of substance using immunoassay technique 50607504_1 CDM 0301 RC 83520 HCPCS inpatient 311 202.15 AETNA AETNA 245.69 79 999999999 188.31 301.67 percent of total billed charges Measurement of substance using immunoassay technique 50607504_1 CDM 0301 RC 83520 HCPCS inpatient 311 202.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 242.58 78 999999999 188.31 301.67 percent of total billed charges Measurement of substance using immunoassay technique 50607504_1 CDM 0301 RC 83520 HCPCS inpatient 311 202.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 214.59 69 999999999 188.31 301.67 percent of total billed charges Measurement of substance using immunoassay technique 50607504_1 CDM 0301 RC 83520 HCPCS inpatient 311 202.15 SIHO - ALL PLANS SIHO - ALL PLANS 279.9 90 999999999 188.31 301.67 percent of total billed charges Measurement of substance using immunoassay technique 50607504_1 CDM 0301 RC 83520 HCPCS inpatient 311 202.15 UMR - ALL PLANS UMR - ALL PLANS 217.7 70 999999999 188.31 301.67 percent of total billed charges Measurement of substance using immunoassay technique 50607504_1 CDM 0301 RC 83520 HCPCS inpatient 311 202.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 188.31 60.55 999999999 188.31 301.67 percent of total billed charges Measurement of substance using immunoassay technique 50607504_1 CDM 0301 RC 83520 HCPCS inpatient 311 202.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 188.31 301.67 Measurement of substance using immunoassay technique 50607504_1 CDM 0301 RC 83520 HCPCS inpatient 311 202.15 ANTHEM HMO ANTHEM HMO 999999999 188.31 301.67 Measurement of substance using immunoassay technique 50607504_1 CDM 0301 RC 83520 HCPCS inpatient 311 202.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 188.31 301.67 Measurement of substance using immunoassay technique 50607504_1 CDM 0301 RC 83520 HCPCS inpatient 311 202.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 188.31 301.67 Measurement of substance using immunoassay technique 50607504_1 CDM 0301 RC 83520 HCPCS inpatient 311 202.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 188.31 301.67 Measurement of substance using immunoassay technique 50607504_1 CDM 0301 RC 83520 HCPCS inpatient 311 202.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 210.24 67.6 999999999 188.31 301.67 percent of total billed charges PANTOPRAZOLE SOD DR 40 MG TAB 50607616_1 CDM 0250 RC 35573-0428-80 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges PANTOPRAZOLE SOD DR 40 MG TAB 50607616_1 CDM 0250 RC 35573-0428-80 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges PANTOPRAZOLE SOD DR 40 MG TAB 50607616_1 CDM 0250 RC 35573-0428-80 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges PANTOPRAZOLE SOD DR 40 MG TAB 50607616_1 CDM 0250 RC 35573-0428-80 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges PANTOPRAZOLE SOD DR 40 MG TAB 50607616_1 CDM 0250 RC 35573-0428-80 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges PANTOPRAZOLE SOD DR 40 MG TAB 50607616_1 CDM 0250 RC 35573-0428-80 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges PANTOPRAZOLE SOD DR 40 MG TAB 50607616_1 CDM 0250 RC 35573-0428-80 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges PANTOPRAZOLE SOD DR 40 MG TAB 50607616_1 CDM 0250 RC 35573-0428-80 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges PANTOPRAZOLE SOD DR 40 MG TAB 50607616_1 CDM 0250 RC 35573-0428-80 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 PANTOPRAZOLE SOD DR 40 MG TAB 50607616_1 CDM 0250 RC 35573-0428-80 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 PANTOPRAZOLE SOD DR 40 MG TAB 50607616_1 CDM 0250 RC 35573-0428-80 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 PANTOPRAZOLE SOD DR 40 MG TAB 50607616_1 CDM 0250 RC 35573-0428-80 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 PANTOPRAZOLE SOD DR 40 MG TAB 50607616_1 CDM 0250 RC 35573-0428-80 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 PANTOPRAZOLE SOD DR 40 MG TAB 50607616_1 CDM 0250 RC 35573-0428-80 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges Immune complex measurement 50607698_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 148.85 65 999999999 138.66 222.13 percent of total billed charges Immune complex measurement 50607698_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 222.13 97 999999999 138.66 222.13 percent of total billed charges Immune complex measurement 50607698_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 AETNA AETNA 180.91 79 999999999 138.66 222.13 percent of total billed charges Immune complex measurement 50607698_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 178.62 78 999999999 138.66 222.13 percent of total billed charges Immune complex measurement 50607698_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 158.01 69 999999999 138.66 222.13 percent of total billed charges Immune complex measurement 50607698_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 SIHO - ALL PLANS SIHO - ALL PLANS 206.1 90 999999999 138.66 222.13 percent of total billed charges Immune complex measurement 50607698_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 UMR - ALL PLANS UMR - ALL PLANS 160.3 70 999999999 138.66 222.13 percent of total billed charges Immune complex measurement 50607698_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 138.66 60.55 999999999 138.66 222.13 percent of total billed charges Immune complex measurement 50607698_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 138.66 222.13 Immune complex measurement 50607698_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 ANTHEM HMO ANTHEM HMO 999999999 138.66 222.13 Immune complex measurement 50607698_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 138.66 222.13 Immune complex measurement 50607698_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 138.66 222.13 Immune complex measurement 50607698_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 138.66 222.13 Immune complex measurement 50607698_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 154.8 67.6 999999999 138.66 222.13 percent of total billed charges Immune complex measurement 50607734_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 148.85 65 999999999 138.66 222.13 percent of total billed charges Immune complex measurement 50607734_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 222.13 97 999999999 138.66 222.13 percent of total billed charges Immune complex measurement 50607734_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 AETNA AETNA 180.91 79 999999999 138.66 222.13 percent of total billed charges Immune complex measurement 50607734_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 178.62 78 999999999 138.66 222.13 percent of total billed charges Immune complex measurement 50607734_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 158.01 69 999999999 138.66 222.13 percent of total billed charges Immune complex measurement 50607734_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 SIHO - ALL PLANS SIHO - ALL PLANS 206.1 90 999999999 138.66 222.13 percent of total billed charges Immune complex measurement 50607734_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 UMR - ALL PLANS UMR - ALL PLANS 160.3 70 999999999 138.66 222.13 percent of total billed charges Immune complex measurement 50607734_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 138.66 60.55 999999999 138.66 222.13 percent of total billed charges Immune complex measurement 50607734_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 138.66 222.13 Immune complex measurement 50607734_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 ANTHEM HMO ANTHEM HMO 999999999 138.66 222.13 Immune complex measurement 50607734_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 138.66 222.13 Immune complex measurement 50607734_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 138.66 222.13 Immune complex measurement 50607734_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 138.66 222.13 Immune complex measurement 50607734_1 CDM 0301 RC 86332 HCPCS inpatient 229 148.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 154.8 67.6 999999999 138.66 222.13 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50607754_1 CDM 0302 RC 86146 HCPCS inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50607754_1 CDM 0302 RC 86146 HCPCS inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50607754_1 CDM 0302 RC 86146 HCPCS inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50607754_1 CDM 0302 RC 86146 HCPCS inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50607754_1 CDM 0302 RC 86146 HCPCS inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50607754_1 CDM 0302 RC 86146 HCPCS inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50607754_1 CDM 0302 RC 86146 HCPCS inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50607754_1 CDM 0302 RC 86146 HCPCS inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50607754_1 CDM 0302 RC 86146 HCPCS inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50607754_1 CDM 0302 RC 86146 HCPCS inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50607754_1 CDM 0302 RC 86146 HCPCS inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50607754_1 CDM 0302 RC 86146 HCPCS inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50607754_1 CDM 0302 RC 86146 HCPCS inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 Beta 2 glycoprotein 1 antibody (autoantibody) measurement 50607754_1 CDM 0302 RC 86146 HCPCS inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 50607930_1 CDM 0250 RC 68084-0964-25 NDC inpatient 1 UN 9.5 6.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.18 65 999999999 5.75 9.22 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 50607930_1 CDM 0250 RC 68084-0964-25 NDC inpatient 1 UN 9.5 6.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.22 97 999999999 5.75 9.22 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 50607930_1 CDM 0250 RC 68084-0964-25 NDC inpatient 1 UN 9.5 6.18 AETNA AETNA 7.51 79 999999999 5.75 9.22 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 50607930_1 CDM 0250 RC 68084-0964-25 NDC inpatient 1 UN 9.5 6.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.41 78 999999999 5.75 9.22 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 50607930_1 CDM 0250 RC 68084-0964-25 NDC inpatient 1 UN 9.5 6.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.56 69 999999999 5.75 9.22 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 50607930_1 CDM 0250 RC 68084-0964-25 NDC inpatient 1 UN 9.5 6.18 SIHO - ALL PLANS SIHO - ALL PLANS 8.55 90 999999999 5.75 9.22 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 50607930_1 CDM 0250 RC 68084-0964-25 NDC inpatient 1 UN 9.5 6.18 UMR - ALL PLANS UMR - ALL PLANS 6.65 70 999999999 5.75 9.22 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 50607930_1 CDM 0250 RC 68084-0964-25 NDC inpatient 1 UN 9.5 6.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.75 60.55 999999999 5.75 9.22 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 50607930_1 CDM 0250 RC 68084-0964-25 NDC inpatient 1 UN 9.5 6.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.75 9.22 PROPYLTHIOURACIL 50 MG TABLET 50607930_1 CDM 0250 RC 68084-0964-25 NDC inpatient 1 UN 9.5 6.18 ANTHEM HMO ANTHEM HMO 999999999 5.75 9.22 PROPYLTHIOURACIL 50 MG TABLET 50607930_1 CDM 0250 RC 68084-0964-25 NDC inpatient 1 UN 9.5 6.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.75 9.22 PROPYLTHIOURACIL 50 MG TABLET 50607930_1 CDM 0250 RC 68084-0964-25 NDC inpatient 1 UN 9.5 6.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.75 9.22 PROPYLTHIOURACIL 50 MG TABLET 50607930_1 CDM 0250 RC 68084-0964-25 NDC inpatient 1 UN 9.5 6.18 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.75 9.22 PROPYLTHIOURACIL 50 MG TABLET 50607930_1 CDM 0250 RC 68084-0964-25 NDC inpatient 1 UN 9.5 6.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.42 67.6 999999999 5.75 9.22 percent of total billed charges TOLVAPTAN 15 MG TABLET 50607933_1 CDM 0250 RC 60505-4704-00 NDC inpatient 1 UN 1591.53 1034.49 SELF PAY DISCOUNT SELF PAY DISCOUNT 1034.49 65 999999999 963.67 1543.78 percent of total billed charges TOLVAPTAN 15 MG TABLET 50607933_1 CDM 0250 RC 60505-4704-00 NDC inpatient 1 UN 1591.53 1034.49 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1543.78 97 999999999 963.67 1543.78 percent of total billed charges TOLVAPTAN 15 MG TABLET 50607933_1 CDM 0250 RC 60505-4704-00 NDC inpatient 1 UN 1591.53 1034.49 AETNA AETNA 1257.31 79 999999999 963.67 1543.78 percent of total billed charges TOLVAPTAN 15 MG TABLET 50607933_1 CDM 0250 RC 60505-4704-00 NDC inpatient 1 UN 1591.53 1034.49 HUMANA - ALL PLANS HUMANA - ALL PLANS 1241.39 78 999999999 963.67 1543.78 percent of total billed charges TOLVAPTAN 15 MG TABLET 50607933_1 CDM 0250 RC 60505-4704-00 NDC inpatient 1 UN 1591.53 1034.49 ENCORE - ALL PLANS ENCORE - ALL PLANS 1098.16 69 999999999 963.67 1543.78 percent of total billed charges TOLVAPTAN 15 MG TABLET 50607933_1 CDM 0250 RC 60505-4704-00 NDC inpatient 1 UN 1591.53 1034.49 SIHO - ALL PLANS SIHO - ALL PLANS 1432.38 90 999999999 963.67 1543.78 percent of total billed charges TOLVAPTAN 15 MG TABLET 50607933_1 CDM 0250 RC 60505-4704-00 NDC inpatient 1 UN 1591.53 1034.49 UMR - ALL PLANS UMR - ALL PLANS 1114.07 70 999999999 963.67 1543.78 percent of total billed charges TOLVAPTAN 15 MG TABLET 50607933_1 CDM 0250 RC 60505-4704-00 NDC inpatient 1 UN 1591.53 1034.49 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 963.67 60.55 999999999 963.67 1543.78 percent of total billed charges TOLVAPTAN 15 MG TABLET 50607933_1 CDM 0250 RC 60505-4704-00 NDC inpatient 1 UN 1591.53 1034.49 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 963.67 1543.78 TOLVAPTAN 15 MG TABLET 50607933_1 CDM 0250 RC 60505-4704-00 NDC inpatient 1 UN 1591.53 1034.49 ANTHEM HMO ANTHEM HMO 999999999 963.67 1543.78 TOLVAPTAN 15 MG TABLET 50607933_1 CDM 0250 RC 60505-4704-00 NDC inpatient 1 UN 1591.53 1034.49 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 963.67 1543.78 TOLVAPTAN 15 MG TABLET 50607933_1 CDM 0250 RC 60505-4704-00 NDC inpatient 1 UN 1591.53 1034.49 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 963.67 1543.78 TOLVAPTAN 15 MG TABLET 50607933_1 CDM 0250 RC 60505-4704-00 NDC inpatient 1 UN 1591.53 1034.49 UHC - ALL PLANS UHC - ALL PLANS 999999999 963.67 1543.78 TOLVAPTAN 15 MG TABLET 50607933_1 CDM 0250 RC 60505-4704-00 NDC inpatient 1 UN 1591.53 1034.49 CIGNA - ALL PLANS CIGNA - ALL PLANS 1075.87 67.6 999999999 963.67 1543.78 percent of total billed charges ZIPRASIDONE 20 MG/ML VIAL 50607934_1 CDM 0250 RC 72266-0160-10 NDC inpatient 1 UN 93.87 61.02 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.02 65 999999999 56.84 91.05 percent of total billed charges ZIPRASIDONE 20 MG/ML VIAL 50607934_1 CDM 0250 RC 72266-0160-10 NDC inpatient 1 UN 93.87 61.02 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.05 97 999999999 56.84 91.05 percent of total billed charges ZIPRASIDONE 20 MG/ML VIAL 50607934_1 CDM 0250 RC 72266-0160-10 NDC inpatient 1 UN 93.87 61.02 AETNA AETNA 74.16 79 999999999 56.84 91.05 percent of total billed charges ZIPRASIDONE 20 MG/ML VIAL 50607934_1 CDM 0250 RC 72266-0160-10 NDC inpatient 1 UN 93.87 61.02 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.22 78 999999999 56.84 91.05 percent of total billed charges ZIPRASIDONE 20 MG/ML VIAL 50607934_1 CDM 0250 RC 72266-0160-10 NDC inpatient 1 UN 93.87 61.02 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.77 69 999999999 56.84 91.05 percent of total billed charges ZIPRASIDONE 20 MG/ML VIAL 50607934_1 CDM 0250 RC 72266-0160-10 NDC inpatient 1 UN 93.87 61.02 SIHO - ALL PLANS SIHO - ALL PLANS 84.48 90 999999999 56.84 91.05 percent of total billed charges ZIPRASIDONE 20 MG/ML VIAL 50607934_1 CDM 0250 RC 72266-0160-10 NDC inpatient 1 UN 93.87 61.02 UMR - ALL PLANS UMR - ALL PLANS 65.71 70 999999999 56.84 91.05 percent of total billed charges ZIPRASIDONE 20 MG/ML VIAL 50607934_1 CDM 0250 RC 72266-0160-10 NDC inpatient 1 UN 93.87 61.02 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.84 60.55 999999999 56.84 91.05 percent of total billed charges ZIPRASIDONE 20 MG/ML VIAL 50607934_1 CDM 0250 RC 72266-0160-10 NDC inpatient 1 UN 93.87 61.02 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.84 91.05 ZIPRASIDONE 20 MG/ML VIAL 50607934_1 CDM 0250 RC 72266-0160-10 NDC inpatient 1 UN 93.87 61.02 ANTHEM HMO ANTHEM HMO 999999999 56.84 91.05 ZIPRASIDONE 20 MG/ML VIAL 50607934_1 CDM 0250 RC 72266-0160-10 NDC inpatient 1 UN 93.87 61.02 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.84 91.05 ZIPRASIDONE 20 MG/ML VIAL 50607934_1 CDM 0250 RC 72266-0160-10 NDC inpatient 1 UN 93.87 61.02 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.84 91.05 ZIPRASIDONE 20 MG/ML VIAL 50607934_1 CDM 0250 RC 72266-0160-10 NDC inpatient 1 UN 93.87 61.02 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.84 91.05 ZIPRASIDONE 20 MG/ML VIAL 50607934_1 CDM 0250 RC 72266-0160-10 NDC inpatient 1 UN 93.87 61.02 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.46 67.6 999999999 56.84 91.05 percent of total billed charges DEXMEDETOMIDIN 400MCG/100ML-NS 50607935_1 CDM 0250 RC 00338-9557-12 NDC inpatient 1 UN 239.48 155.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 155.66 65 999999999 145.01 232.3 percent of total billed charges DEXMEDETOMIDIN 400MCG/100ML-NS 50607935_1 CDM 0250 RC 00338-9557-12 NDC inpatient 1 UN 239.48 155.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 232.3 97 999999999 145.01 232.3 percent of total billed charges DEXMEDETOMIDIN 400MCG/100ML-NS 50607935_1 CDM 0250 RC 00338-9557-12 NDC inpatient 1 UN 239.48 155.66 AETNA AETNA 189.19 79 999999999 145.01 232.3 percent of total billed charges DEXMEDETOMIDIN 400MCG/100ML-NS 50607935_1 CDM 0250 RC 00338-9557-12 NDC inpatient 1 UN 239.48 155.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 186.79 78 999999999 145.01 232.3 percent of total billed charges DEXMEDETOMIDIN 400MCG/100ML-NS 50607935_1 CDM 0250 RC 00338-9557-12 NDC inpatient 1 UN 239.48 155.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 165.24 69 999999999 145.01 232.3 percent of total billed charges DEXMEDETOMIDIN 400MCG/100ML-NS 50607935_1 CDM 0250 RC 00338-9557-12 NDC inpatient 1 UN 239.48 155.66 SIHO - ALL PLANS SIHO - ALL PLANS 215.53 90 999999999 145.01 232.3 percent of total billed charges DEXMEDETOMIDIN 400MCG/100ML-NS 50607935_1 CDM 0250 RC 00338-9557-12 NDC inpatient 1 UN 239.48 155.66 UMR - ALL PLANS UMR - ALL PLANS 167.64 70 999999999 145.01 232.3 percent of total billed charges DEXMEDETOMIDIN 400MCG/100ML-NS 50607935_1 CDM 0250 RC 00338-9557-12 NDC inpatient 1 UN 239.48 155.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.01 60.55 999999999 145.01 232.3 percent of total billed charges DEXMEDETOMIDIN 400MCG/100ML-NS 50607935_1 CDM 0250 RC 00338-9557-12 NDC inpatient 1 UN 239.48 155.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.01 232.3 DEXMEDETOMIDIN 400MCG/100ML-NS 50607935_1 CDM 0250 RC 00338-9557-12 NDC inpatient 1 UN 239.48 155.66 ANTHEM HMO ANTHEM HMO 999999999 145.01 232.3 DEXMEDETOMIDIN 400MCG/100ML-NS 50607935_1 CDM 0250 RC 00338-9557-12 NDC inpatient 1 UN 239.48 155.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.01 232.3 DEXMEDETOMIDIN 400MCG/100ML-NS 50607935_1 CDM 0250 RC 00338-9557-12 NDC inpatient 1 UN 239.48 155.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.01 232.3 DEXMEDETOMIDIN 400MCG/100ML-NS 50607935_1 CDM 0250 RC 00338-9557-12 NDC inpatient 1 UN 239.48 155.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.01 232.3 DEXMEDETOMIDIN 400MCG/100ML-NS 50607935_1 CDM 0250 RC 00338-9557-12 NDC inpatient 1 UN 239.48 155.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 161.89 67.6 999999999 145.01 232.3 percent of total billed charges LATANOPROST 0.005% EYE DROPS 50607995_1 CDM 0250 RC 70069-0421-01 NDC inpatient 1 UN 10.45 6.79 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.79 65 999999999 6.33 10.14 percent of total billed charges LATANOPROST 0.005% EYE DROPS 50607995_1 CDM 0250 RC 70069-0421-01 NDC inpatient 1 UN 10.45 6.79 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10.14 97 999999999 6.33 10.14 percent of total billed charges LATANOPROST 0.005% EYE DROPS 50607995_1 CDM 0250 RC 70069-0421-01 NDC inpatient 1 UN 10.45 6.79 AETNA AETNA 8.26 79 999999999 6.33 10.14 percent of total billed charges LATANOPROST 0.005% EYE DROPS 50607995_1 CDM 0250 RC 70069-0421-01 NDC inpatient 1 UN 10.45 6.79 HUMANA - ALL PLANS HUMANA - ALL PLANS 8.15 78 999999999 6.33 10.14 percent of total billed charges LATANOPROST 0.005% EYE DROPS 50607995_1 CDM 0250 RC 70069-0421-01 NDC inpatient 1 UN 10.45 6.79 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.21 69 999999999 6.33 10.14 percent of total billed charges LATANOPROST 0.005% EYE DROPS 50607995_1 CDM 0250 RC 70069-0421-01 NDC inpatient 1 UN 10.45 6.79 SIHO - ALL PLANS SIHO - ALL PLANS 9.41 90 999999999 6.33 10.14 percent of total billed charges LATANOPROST 0.005% EYE DROPS 50607995_1 CDM 0250 RC 70069-0421-01 NDC inpatient 1 UN 10.45 6.79 UMR - ALL PLANS UMR - ALL PLANS 7.32 70 999999999 6.33 10.14 percent of total billed charges LATANOPROST 0.005% EYE DROPS 50607995_1 CDM 0250 RC 70069-0421-01 NDC inpatient 1 UN 10.45 6.79 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.33 60.55 999999999 6.33 10.14 percent of total billed charges LATANOPROST 0.005% EYE DROPS 50607995_1 CDM 0250 RC 70069-0421-01 NDC inpatient 1 UN 10.45 6.79 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.33 10.14 LATANOPROST 0.005% EYE DROPS 50607995_1 CDM 0250 RC 70069-0421-01 NDC inpatient 1 UN 10.45 6.79 ANTHEM HMO ANTHEM HMO 999999999 6.33 10.14 LATANOPROST 0.005% EYE DROPS 50607995_1 CDM 0250 RC 70069-0421-01 NDC inpatient 1 UN 10.45 6.79 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.33 10.14 LATANOPROST 0.005% EYE DROPS 50607995_1 CDM 0250 RC 70069-0421-01 NDC inpatient 1 UN 10.45 6.79 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.33 10.14 LATANOPROST 0.005% EYE DROPS 50607995_1 CDM 0250 RC 70069-0421-01 NDC inpatient 1 UN 10.45 6.79 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.33 10.14 LATANOPROST 0.005% EYE DROPS 50607995_1 CDM 0250 RC 70069-0421-01 NDC inpatient 1 UN 10.45 6.79 CIGNA - ALL PLANS CIGNA - ALL PLANS 7.06 67.6 999999999 6.33 10.14 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 2" 50612218_1 CDM 0302 RC 86696 HCPCS inpatient 93 60.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 60.45 65 999999999 56.31 90.21 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 2" 50612218_1 CDM 0302 RC 86696 HCPCS inpatient 93 60.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 90.21 97 999999999 56.31 90.21 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 2" 50612218_1 CDM 0302 RC 86696 HCPCS inpatient 93 60.45 AETNA AETNA 73.47 79 999999999 56.31 90.21 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 2" 50612218_1 CDM 0302 RC 86696 HCPCS inpatient 93 60.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 72.54 78 999999999 56.31 90.21 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 2" 50612218_1 CDM 0302 RC 86696 HCPCS inpatient 93 60.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.17 69 999999999 56.31 90.21 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 2" 50612218_1 CDM 0302 RC 86696 HCPCS inpatient 93 60.45 SIHO - ALL PLANS SIHO - ALL PLANS 83.7 90 999999999 56.31 90.21 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 2" 50612218_1 CDM 0302 RC 86696 HCPCS inpatient 93 60.45 UMR - ALL PLANS UMR - ALL PLANS 65.1 70 999999999 56.31 90.21 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 2" 50612218_1 CDM 0302 RC 86696 HCPCS inpatient 93 60.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.31 60.55 999999999 56.31 90.21 percent of total billed charges "Analysis for antibody to Herpes simplex virus, type 2" 50612218_1 CDM 0302 RC 86696 HCPCS inpatient 93 60.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.31 90.21 "Analysis for antibody to Herpes simplex virus, type 2" 50612218_1 CDM 0302 RC 86696 HCPCS inpatient 93 60.45 ANTHEM HMO ANTHEM HMO 999999999 56.31 90.21 "Analysis for antibody to Herpes simplex virus, type 2" 50612218_1 CDM 0302 RC 86696 HCPCS inpatient 93 60.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.31 90.21 "Analysis for antibody to Herpes simplex virus, type 2" 50612218_1 CDM 0302 RC 86696 HCPCS inpatient 93 60.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.31 90.21 "Analysis for antibody to Herpes simplex virus, type 2" 50612218_1 CDM 0302 RC 86696 HCPCS inpatient 93 60.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.31 90.21 "Analysis for antibody to Herpes simplex virus, type 2" 50612218_1 CDM 0302 RC 86696 HCPCS inpatient 93 60.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.87 67.6 999999999 56.31 90.21 percent of total billed charges ARTHRICREAM 10% RUB 50612239_1 CDM 0250 RC 24385-0165-53 NDC inpatient 1 UN 3.15 2.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.05 65 999999999 1.91 3.06 percent of total billed charges ARTHRICREAM 10% RUB 50612239_1 CDM 0250 RC 24385-0165-53 NDC inpatient 1 UN 3.15 2.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.06 97 999999999 1.91 3.06 percent of total billed charges ARTHRICREAM 10% RUB 50612239_1 CDM 0250 RC 24385-0165-53 NDC inpatient 1 UN 3.15 2.05 AETNA AETNA 2.49 79 999999999 1.91 3.06 percent of total billed charges ARTHRICREAM 10% RUB 50612239_1 CDM 0250 RC 24385-0165-53 NDC inpatient 1 UN 3.15 2.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.46 78 999999999 1.91 3.06 percent of total billed charges ARTHRICREAM 10% RUB 50612239_1 CDM 0250 RC 24385-0165-53 NDC inpatient 1 UN 3.15 2.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.17 69 999999999 1.91 3.06 percent of total billed charges ARTHRICREAM 10% RUB 50612239_1 CDM 0250 RC 24385-0165-53 NDC inpatient 1 UN 3.15 2.05 SIHO - ALL PLANS SIHO - ALL PLANS 2.84 90 999999999 1.91 3.06 percent of total billed charges ARTHRICREAM 10% RUB 50612239_1 CDM 0250 RC 24385-0165-53 NDC inpatient 1 UN 3.15 2.05 UMR - ALL PLANS UMR - ALL PLANS 2.21 70 999999999 1.91 3.06 percent of total billed charges ARTHRICREAM 10% RUB 50612239_1 CDM 0250 RC 24385-0165-53 NDC inpatient 1 UN 3.15 2.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.91 60.55 999999999 1.91 3.06 percent of total billed charges ARTHRICREAM 10% RUB 50612239_1 CDM 0250 RC 24385-0165-53 NDC inpatient 1 UN 3.15 2.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.91 3.06 ARTHRICREAM 10% RUB 50612239_1 CDM 0250 RC 24385-0165-53 NDC inpatient 1 UN 3.15 2.05 ANTHEM HMO ANTHEM HMO 999999999 1.91 3.06 ARTHRICREAM 10% RUB 50612239_1 CDM 0250 RC 24385-0165-53 NDC inpatient 1 UN 3.15 2.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.91 3.06 ARTHRICREAM 10% RUB 50612239_1 CDM 0250 RC 24385-0165-53 NDC inpatient 1 UN 3.15 2.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.91 3.06 ARTHRICREAM 10% RUB 50612239_1 CDM 0250 RC 24385-0165-53 NDC inpatient 1 UN 3.15 2.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.91 3.06 ARTHRICREAM 10% RUB 50612239_1 CDM 0250 RC 24385-0165-53 NDC inpatient 1 UN 3.15 2.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.13 67.6 999999999 1.91 3.06 percent of total billed charges TIMOLOL MALEATE 0.25% EYE DROP 50612551_1 CDM 0250 RC 60758-0802-05 NDC inpatient 1 UN 6.63 4.31 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.31 65 999999999 4.01 6.43 percent of total billed charges TIMOLOL MALEATE 0.25% EYE DROP 50612551_1 CDM 0250 RC 60758-0802-05 NDC inpatient 1 UN 6.63 4.31 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.43 97 999999999 4.01 6.43 percent of total billed charges TIMOLOL MALEATE 0.25% EYE DROP 50612551_1 CDM 0250 RC 60758-0802-05 NDC inpatient 1 UN 6.63 4.31 AETNA AETNA 5.24 79 999999999 4.01 6.43 percent of total billed charges TIMOLOL MALEATE 0.25% EYE DROP 50612551_1 CDM 0250 RC 60758-0802-05 NDC inpatient 1 UN 6.63 4.31 HUMANA - ALL PLANS HUMANA - ALL PLANS 5.17 78 999999999 4.01 6.43 percent of total billed charges TIMOLOL MALEATE 0.25% EYE DROP 50612551_1 CDM 0250 RC 60758-0802-05 NDC inpatient 1 UN 6.63 4.31 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.57 69 999999999 4.01 6.43 percent of total billed charges TIMOLOL MALEATE 0.25% EYE DROP 50612551_1 CDM 0250 RC 60758-0802-05 NDC inpatient 1 UN 6.63 4.31 SIHO - ALL PLANS SIHO - ALL PLANS 5.97 90 999999999 4.01 6.43 percent of total billed charges TIMOLOL MALEATE 0.25% EYE DROP 50612551_1 CDM 0250 RC 60758-0802-05 NDC inpatient 1 UN 6.63 4.31 UMR - ALL PLANS UMR - ALL PLANS 4.64 70 999999999 4.01 6.43 percent of total billed charges TIMOLOL MALEATE 0.25% EYE DROP 50612551_1 CDM 0250 RC 60758-0802-05 NDC inpatient 1 UN 6.63 4.31 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.01 60.55 999999999 4.01 6.43 percent of total billed charges TIMOLOL MALEATE 0.25% EYE DROP 50612551_1 CDM 0250 RC 60758-0802-05 NDC inpatient 1 UN 6.63 4.31 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.01 6.43 TIMOLOL MALEATE 0.25% EYE DROP 50612551_1 CDM 0250 RC 60758-0802-05 NDC inpatient 1 UN 6.63 4.31 ANTHEM HMO ANTHEM HMO 999999999 4.01 6.43 TIMOLOL MALEATE 0.25% EYE DROP 50612551_1 CDM 0250 RC 60758-0802-05 NDC inpatient 1 UN 6.63 4.31 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.01 6.43 TIMOLOL MALEATE 0.25% EYE DROP 50612551_1 CDM 0250 RC 60758-0802-05 NDC inpatient 1 UN 6.63 4.31 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.01 6.43 TIMOLOL MALEATE 0.25% EYE DROP 50612551_1 CDM 0250 RC 60758-0802-05 NDC inpatient 1 UN 6.63 4.31 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.01 6.43 TIMOLOL MALEATE 0.25% EYE DROP 50612551_1 CDM 0250 RC 60758-0802-05 NDC inpatient 1 UN 6.63 4.31 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.48 67.6 999999999 4.01 6.43 percent of total billed charges Measurement of substance using immunoassay technique 50612596_1 CDM 0301 RC 83520 HCPCS inpatient 191 124.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 124.15 65 999999999 115.65 185.27 percent of total billed charges Measurement of substance using immunoassay technique 50612596_1 CDM 0301 RC 83520 HCPCS inpatient 191 124.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 185.27 97 999999999 115.65 185.27 percent of total billed charges Measurement of substance using immunoassay technique 50612596_1 CDM 0301 RC 83520 HCPCS inpatient 191 124.15 AETNA AETNA 150.89 79 999999999 115.65 185.27 percent of total billed charges Measurement of substance using immunoassay technique 50612596_1 CDM 0301 RC 83520 HCPCS inpatient 191 124.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 148.98 78 999999999 115.65 185.27 percent of total billed charges Measurement of substance using immunoassay technique 50612596_1 CDM 0301 RC 83520 HCPCS inpatient 191 124.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 131.79 69 999999999 115.65 185.27 percent of total billed charges Measurement of substance using immunoassay technique 50612596_1 CDM 0301 RC 83520 HCPCS inpatient 191 124.15 SIHO - ALL PLANS SIHO - ALL PLANS 171.9 90 999999999 115.65 185.27 percent of total billed charges Measurement of substance using immunoassay technique 50612596_1 CDM 0301 RC 83520 HCPCS inpatient 191 124.15 UMR - ALL PLANS UMR - ALL PLANS 133.7 70 999999999 115.65 185.27 percent of total billed charges Measurement of substance using immunoassay technique 50612596_1 CDM 0301 RC 83520 HCPCS inpatient 191 124.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 115.65 60.55 999999999 115.65 185.27 percent of total billed charges Measurement of substance using immunoassay technique 50612596_1 CDM 0301 RC 83520 HCPCS inpatient 191 124.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 115.65 185.27 Measurement of substance using immunoassay technique 50612596_1 CDM 0301 RC 83520 HCPCS inpatient 191 124.15 ANTHEM HMO ANTHEM HMO 999999999 115.65 185.27 Measurement of substance using immunoassay technique 50612596_1 CDM 0301 RC 83520 HCPCS inpatient 191 124.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 115.65 185.27 Measurement of substance using immunoassay technique 50612596_1 CDM 0301 RC 83520 HCPCS inpatient 191 124.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 115.65 185.27 Measurement of substance using immunoassay technique 50612596_1 CDM 0301 RC 83520 HCPCS inpatient 191 124.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 115.65 185.27 Measurement of substance using immunoassay technique 50612596_1 CDM 0301 RC 83520 HCPCS inpatient 191 124.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 129.12 67.6 999999999 115.65 185.27 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 50612597_1 CDM 0301 RC 87902 HCPCS inpatient 994 646.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 646.1 65 999999999 601.87 964.18 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 50612597_1 CDM 0301 RC 87902 HCPCS inpatient 994 646.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 964.18 97 999999999 601.87 964.18 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 50612597_1 CDM 0301 RC 87902 HCPCS inpatient 994 646.1 AETNA AETNA 785.26 79 999999999 601.87 964.18 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 50612597_1 CDM 0301 RC 87902 HCPCS inpatient 994 646.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 775.32 78 999999999 601.87 964.18 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 50612597_1 CDM 0301 RC 87902 HCPCS inpatient 994 646.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 685.86 69 999999999 601.87 964.18 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 50612597_1 CDM 0301 RC 87902 HCPCS inpatient 994 646.1 SIHO - ALL PLANS SIHO - ALL PLANS 894.6 90 999999999 601.87 964.18 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 50612597_1 CDM 0301 RC 87902 HCPCS inpatient 994 646.1 UMR - ALL PLANS UMR - ALL PLANS 695.8 70 999999999 601.87 964.18 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 50612597_1 CDM 0301 RC 87902 HCPCS inpatient 994 646.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 601.87 60.55 999999999 601.87 964.18 percent of total billed charges Analysis test by nucleic acid for Hepatitis C virus 50612597_1 CDM 0301 RC 87902 HCPCS inpatient 994 646.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 601.87 964.18 Analysis test by nucleic acid for Hepatitis C virus 50612597_1 CDM 0301 RC 87902 HCPCS inpatient 994 646.1 ANTHEM HMO ANTHEM HMO 999999999 601.87 964.18 Analysis test by nucleic acid for Hepatitis C virus 50612597_1 CDM 0301 RC 87902 HCPCS inpatient 994 646.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 601.87 964.18 Analysis test by nucleic acid for Hepatitis C virus 50612597_1 CDM 0301 RC 87902 HCPCS inpatient 994 646.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 601.87 964.18 Analysis test by nucleic acid for Hepatitis C virus 50612597_1 CDM 0301 RC 87902 HCPCS inpatient 994 646.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 601.87 964.18 Analysis test by nucleic acid for Hepatitis C virus 50612597_1 CDM 0301 RC 87902 HCPCS inpatient 994 646.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 671.94 67.6 999999999 601.87 964.18 percent of total billed charges Chemical analysis using chromatography technique 50612598_1 CDM 0301 RC 82542 HCPCS inpatient 289 187.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 187.85 65 999999999 174.99 280.33 percent of total billed charges Chemical analysis using chromatography technique 50612598_1 CDM 0301 RC 82542 HCPCS inpatient 289 187.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 280.33 97 999999999 174.99 280.33 percent of total billed charges Chemical analysis using chromatography technique 50612598_1 CDM 0301 RC 82542 HCPCS inpatient 289 187.85 AETNA AETNA 228.31 79 999999999 174.99 280.33 percent of total billed charges Chemical analysis using chromatography technique 50612598_1 CDM 0301 RC 82542 HCPCS inpatient 289 187.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 225.42 78 999999999 174.99 280.33 percent of total billed charges Chemical analysis using chromatography technique 50612598_1 CDM 0301 RC 82542 HCPCS inpatient 289 187.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 199.41 69 999999999 174.99 280.33 percent of total billed charges Chemical analysis using chromatography technique 50612598_1 CDM 0301 RC 82542 HCPCS inpatient 289 187.85 SIHO - ALL PLANS SIHO - ALL PLANS 260.1 90 999999999 174.99 280.33 percent of total billed charges Chemical analysis using chromatography technique 50612598_1 CDM 0301 RC 82542 HCPCS inpatient 289 187.85 UMR - ALL PLANS UMR - ALL PLANS 202.3 70 999999999 174.99 280.33 percent of total billed charges Chemical analysis using chromatography technique 50612598_1 CDM 0301 RC 82542 HCPCS inpatient 289 187.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 174.99 60.55 999999999 174.99 280.33 percent of total billed charges Chemical analysis using chromatography technique 50612598_1 CDM 0301 RC 82542 HCPCS inpatient 289 187.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 174.99 280.33 Chemical analysis using chromatography technique 50612598_1 CDM 0301 RC 82542 HCPCS inpatient 289 187.85 ANTHEM HMO ANTHEM HMO 999999999 174.99 280.33 Chemical analysis using chromatography technique 50612598_1 CDM 0301 RC 82542 HCPCS inpatient 289 187.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 174.99 280.33 Chemical analysis using chromatography technique 50612598_1 CDM 0301 RC 82542 HCPCS inpatient 289 187.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 174.99 280.33 Chemical analysis using chromatography technique 50612598_1 CDM 0301 RC 82542 HCPCS inpatient 289 187.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 174.99 280.33 Chemical analysis using chromatography technique 50612598_1 CDM 0301 RC 82542 HCPCS inpatient 289 187.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 195.36 67.6 999999999 174.99 280.33 percent of total billed charges Phospholipid test 50612599_1 CDM 0301 RC 85598 HCPCS inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges Phospholipid test 50612599_1 CDM 0301 RC 85598 HCPCS inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges Phospholipid test 50612599_1 CDM 0301 RC 85598 HCPCS inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges Phospholipid test 50612599_1 CDM 0301 RC 85598 HCPCS inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges Phospholipid test 50612599_1 CDM 0301 RC 85598 HCPCS inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges Phospholipid test 50612599_1 CDM 0301 RC 85598 HCPCS inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges Phospholipid test 50612599_1 CDM 0301 RC 85598 HCPCS inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges Phospholipid test 50612599_1 CDM 0301 RC 85598 HCPCS inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges Phospholipid test 50612599_1 CDM 0301 RC 85598 HCPCS inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 Phospholipid test 50612599_1 CDM 0301 RC 85598 HCPCS inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 Phospholipid test 50612599_1 CDM 0301 RC 85598 HCPCS inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 Phospholipid test 50612599_1 CDM 0301 RC 85598 HCPCS inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 Phospholipid test 50612599_1 CDM 0301 RC 85598 HCPCS inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 Phospholipid test 50612599_1 CDM 0301 RC 85598 HCPCS inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50612600_1 CDM 0301 RC 83516 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50612600_1 CDM 0301 RC 83516 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50612600_1 CDM 0301 RC 83516 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50612600_1 CDM 0301 RC 83516 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50612600_1 CDM 0301 RC 83516 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50612600_1 CDM 0301 RC 83516 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50612600_1 CDM 0301 RC 83516 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50612600_1 CDM 0301 RC 83516 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50612600_1 CDM 0301 RC 83516 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 "Analysis of substance using immunoassay technique, multiple step method" 50612600_1 CDM 0301 RC 83516 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 "Analysis of substance using immunoassay technique, multiple step method" 50612600_1 CDM 0301 RC 83516 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 "Analysis of substance using immunoassay technique, multiple step method" 50612600_1 CDM 0301 RC 83516 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 "Analysis of substance using immunoassay technique, multiple step method" 50612600_1 CDM 0301 RC 83516 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 "Analysis of substance using immunoassay technique, multiple step method" 50612600_1 CDM 0301 RC 83516 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50612720_1 CDM 0301 RC 80307 HCPCS inpatient 255 165.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 165.75 65 999999999 154.4 247.35 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50612720_1 CDM 0301 RC 80307 HCPCS inpatient 255 165.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 247.35 97 999999999 154.4 247.35 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50612720_1 CDM 0301 RC 80307 HCPCS inpatient 255 165.75 AETNA AETNA 201.45 79 999999999 154.4 247.35 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50612720_1 CDM 0301 RC 80307 HCPCS inpatient 255 165.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 198.9 78 999999999 154.4 247.35 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50612720_1 CDM 0301 RC 80307 HCPCS inpatient 255 165.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 175.95 69 999999999 154.4 247.35 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50612720_1 CDM 0301 RC 80307 HCPCS inpatient 255 165.75 SIHO - ALL PLANS SIHO - ALL PLANS 229.5 90 999999999 154.4 247.35 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50612720_1 CDM 0301 RC 80307 HCPCS inpatient 255 165.75 UMR - ALL PLANS UMR - ALL PLANS 178.5 70 999999999 154.4 247.35 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50612720_1 CDM 0301 RC 80307 HCPCS inpatient 255 165.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 154.4 60.55 999999999 154.4 247.35 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50612720_1 CDM 0301 RC 80307 HCPCS inpatient 255 165.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 154.4 247.35 "Testing for presence of drug, by chemistry analyzers" 50612720_1 CDM 0301 RC 80307 HCPCS inpatient 255 165.75 ANTHEM HMO ANTHEM HMO 999999999 154.4 247.35 "Testing for presence of drug, by chemistry analyzers" 50612720_1 CDM 0301 RC 80307 HCPCS inpatient 255 165.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 154.4 247.35 "Testing for presence of drug, by chemistry analyzers" 50612720_1 CDM 0301 RC 80307 HCPCS inpatient 255 165.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 154.4 247.35 "Testing for presence of drug, by chemistry analyzers" 50612720_1 CDM 0301 RC 80307 HCPCS inpatient 255 165.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 154.4 247.35 "Testing for presence of drug, by chemistry analyzers" 50612720_1 CDM 0301 RC 80307 HCPCS inpatient 255 165.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 172.38 67.6 999999999 154.4 247.35 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612723_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612723_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612723_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612723_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612723_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612723_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612723_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612723_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612723_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody for assessment of autoimmune disorder, any method" 50612723_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody for assessment of autoimmune disorder, any method" 50612723_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody for assessment of autoimmune disorder, any method" 50612723_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody for assessment of autoimmune disorder, any method" 50612723_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody for assessment of autoimmune disorder, any method" 50612723_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612865_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612865_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612865_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612865_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612865_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612865_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612865_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612865_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612865_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody for assessment of autoimmune disorder, any method" 50612865_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody for assessment of autoimmune disorder, any method" 50612865_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody for assessment of autoimmune disorder, any method" 50612865_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody for assessment of autoimmune disorder, any method" 50612865_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody for assessment of autoimmune disorder, any method" 50612865_1 CDM 0301 RC 86235 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612866_1 CDM 0301 RC 86235 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612866_1 CDM 0301 RC 86235 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612866_1 CDM 0301 RC 86235 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612866_1 CDM 0301 RC 86235 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612866_1 CDM 0301 RC 86235 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612866_1 CDM 0301 RC 86235 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612866_1 CDM 0301 RC 86235 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612866_1 CDM 0301 RC 86235 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50612866_1 CDM 0301 RC 86235 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 "Measurement of antibody for assessment of autoimmune disorder, any method" 50612866_1 CDM 0301 RC 86235 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 "Measurement of antibody for assessment of autoimmune disorder, any method" 50612866_1 CDM 0301 RC 86235 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 "Measurement of antibody for assessment of autoimmune disorder, any method" 50612866_1 CDM 0301 RC 86235 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 "Measurement of antibody for assessment of autoimmune disorder, any method" 50612866_1 CDM 0301 RC 86235 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 "Measurement of antibody for assessment of autoimmune disorder, any method" 50612866_1 CDM 0301 RC 86235 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50613233_1 CDM 0301 RC 86780 HCPCS inpatient 135 87.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 87.75 65 999999999 81.74 130.95 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50613233_1 CDM 0301 RC 86780 HCPCS inpatient 135 87.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 130.95 97 999999999 81.74 130.95 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50613233_1 CDM 0301 RC 86780 HCPCS inpatient 135 87.75 AETNA AETNA 106.65 79 999999999 81.74 130.95 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50613233_1 CDM 0301 RC 86780 HCPCS inpatient 135 87.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 105.3 78 999999999 81.74 130.95 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50613233_1 CDM 0301 RC 86780 HCPCS inpatient 135 87.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.15 69 999999999 81.74 130.95 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50613233_1 CDM 0301 RC 86780 HCPCS inpatient 135 87.75 SIHO - ALL PLANS SIHO - ALL PLANS 121.5 90 999999999 81.74 130.95 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50613233_1 CDM 0301 RC 86780 HCPCS inpatient 135 87.75 UMR - ALL PLANS UMR - ALL PLANS 94.5 70 999999999 81.74 130.95 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50613233_1 CDM 0301 RC 86780 HCPCS inpatient 135 87.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 81.74 60.55 999999999 81.74 130.95 percent of total billed charges "Analysis for antibody, Treponema pallidum" 50613233_1 CDM 0301 RC 86780 HCPCS inpatient 135 87.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 81.74 130.95 "Analysis for antibody, Treponema pallidum" 50613233_1 CDM 0301 RC 86780 HCPCS inpatient 135 87.75 ANTHEM HMO ANTHEM HMO 999999999 81.74 130.95 "Analysis for antibody, Treponema pallidum" 50613233_1 CDM 0301 RC 86780 HCPCS inpatient 135 87.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 81.74 130.95 "Analysis for antibody, Treponema pallidum" 50613233_1 CDM 0301 RC 86780 HCPCS inpatient 135 87.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 81.74 130.95 "Analysis for antibody, Treponema pallidum" 50613233_1 CDM 0301 RC 86780 HCPCS inpatient 135 87.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 81.74 130.95 "Analysis for antibody, Treponema pallidum" 50613233_1 CDM 0301 RC 86780 HCPCS inpatient 135 87.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.26 67.6 999999999 81.74 130.95 percent of total billed charges OLOPATADINE HCL 0.1% EYE DROPS 50613461_1 CDM 0250 RC 51293-0838-85 NDC inpatient 1 UN 14.23 9.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.25 65 999999999 8.62 13.8 percent of total billed charges OLOPATADINE HCL 0.1% EYE DROPS 50613461_1 CDM 0250 RC 51293-0838-85 NDC inpatient 1 UN 14.23 9.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13.8 97 999999999 8.62 13.8 percent of total billed charges OLOPATADINE HCL 0.1% EYE DROPS 50613461_1 CDM 0250 RC 51293-0838-85 NDC inpatient 1 UN 14.23 9.25 AETNA AETNA 11.24 79 999999999 8.62 13.8 percent of total billed charges OLOPATADINE HCL 0.1% EYE DROPS 50613461_1 CDM 0250 RC 51293-0838-85 NDC inpatient 1 UN 14.23 9.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.1 78 999999999 8.62 13.8 percent of total billed charges OLOPATADINE HCL 0.1% EYE DROPS 50613461_1 CDM 0250 RC 51293-0838-85 NDC inpatient 1 UN 14.23 9.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.82 69 999999999 8.62 13.8 percent of total billed charges OLOPATADINE HCL 0.1% EYE DROPS 50613461_1 CDM 0250 RC 51293-0838-85 NDC inpatient 1 UN 14.23 9.25 SIHO - ALL PLANS SIHO - ALL PLANS 12.81 90 999999999 8.62 13.8 percent of total billed charges OLOPATADINE HCL 0.1% EYE DROPS 50613461_1 CDM 0250 RC 51293-0838-85 NDC inpatient 1 UN 14.23 9.25 UMR - ALL PLANS UMR - ALL PLANS 9.96 70 999999999 8.62 13.8 percent of total billed charges OLOPATADINE HCL 0.1% EYE DROPS 50613461_1 CDM 0250 RC 51293-0838-85 NDC inpatient 1 UN 14.23 9.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.62 60.55 999999999 8.62 13.8 percent of total billed charges OLOPATADINE HCL 0.1% EYE DROPS 50613461_1 CDM 0250 RC 51293-0838-85 NDC inpatient 1 UN 14.23 9.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.62 13.8 OLOPATADINE HCL 0.1% EYE DROPS 50613461_1 CDM 0250 RC 51293-0838-85 NDC inpatient 1 UN 14.23 9.25 ANTHEM HMO ANTHEM HMO 999999999 8.62 13.8 OLOPATADINE HCL 0.1% EYE DROPS 50613461_1 CDM 0250 RC 51293-0838-85 NDC inpatient 1 UN 14.23 9.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.62 13.8 OLOPATADINE HCL 0.1% EYE DROPS 50613461_1 CDM 0250 RC 51293-0838-85 NDC inpatient 1 UN 14.23 9.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.62 13.8 OLOPATADINE HCL 0.1% EYE DROPS 50613461_1 CDM 0250 RC 51293-0838-85 NDC inpatient 1 UN 14.23 9.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.62 13.8 OLOPATADINE HCL 0.1% EYE DROPS 50613461_1 CDM 0250 RC 51293-0838-85 NDC inpatient 1 UN 14.23 9.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.62 67.6 999999999 8.62 13.8 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615569_1 CDM 0636 RC 61755-0026-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.13 65 999999999 7.57 12.13 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615569_1 CDM 0636 RC 61755-0026-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.13 97 999999999 7.57 12.13 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615569_1 CDM 0636 RC 61755-0026-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 AETNA AETNA 9.88 79 999999999 7.57 12.13 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615569_1 CDM 0636 RC 61755-0026-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.75 78 999999999 7.57 12.13 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615569_1 CDM 0636 RC 61755-0026-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.63 69 999999999 7.57 12.13 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615569_1 CDM 0636 RC 61755-0026-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 SIHO - ALL PLANS SIHO - ALL PLANS 11.25 90 999999999 7.57 12.13 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615569_1 CDM 0636 RC 61755-0026-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 UMR - ALL PLANS UMR - ALL PLANS 8.75 70 999999999 7.57 12.13 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615569_1 CDM 0636 RC 61755-0026-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.57 60.55 999999999 7.57 12.13 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615569_1 CDM 0636 RC 61755-0026-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.57 12.13 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615569_1 CDM 0636 RC 61755-0026-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 ANTHEM HMO ANTHEM HMO 999999999 7.57 12.13 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615569_1 CDM 0636 RC 61755-0026-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.57 12.13 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615569_1 CDM 0636 RC 61755-0026-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.57 12.13 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615569_1 CDM 0636 RC 61755-0026-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.57 12.13 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615569_1 CDM 0636 RC 61755-0026-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.45 67.6 999999999 7.57 12.13 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615571_1 CDM 0636 RC 61755-0027-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.13 65 999999999 7.57 12.13 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615571_1 CDM 0636 RC 61755-0027-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.13 97 999999999 7.57 12.13 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615571_1 CDM 0636 RC 61755-0027-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 AETNA AETNA 9.88 79 999999999 7.57 12.13 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615571_1 CDM 0636 RC 61755-0027-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.75 78 999999999 7.57 12.13 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615571_1 CDM 0636 RC 61755-0027-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.63 69 999999999 7.57 12.13 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615571_1 CDM 0636 RC 61755-0027-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 SIHO - ALL PLANS SIHO - ALL PLANS 11.25 90 999999999 7.57 12.13 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615571_1 CDM 0636 RC 61755-0027-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 UMR - ALL PLANS UMR - ALL PLANS 8.75 70 999999999 7.57 12.13 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615571_1 CDM 0636 RC 61755-0027-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.57 60.55 999999999 7.57 12.13 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615571_1 CDM 0636 RC 61755-0027-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.57 12.13 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615571_1 CDM 0636 RC 61755-0027-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 ANTHEM HMO ANTHEM HMO 999999999 7.57 12.13 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615571_1 CDM 0636 RC 61755-0027-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.57 12.13 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615571_1 CDM 0636 RC 61755-0027-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.57 12.13 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615571_1 CDM 0636 RC 61755-0027-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.57 12.13 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50615571_1 CDM 0636 RC 61755-0027-01 NDC Q0243 HCPCS inpatient 1 UN 12.5 8.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.45 67.6 999999999 7.57 12.13 percent of total billed charges PAROXETINE HCL 10 MG TABLET 50615685_1 CDM 0250 RC 50268-0640-15 NDC inpatient 1 UN 1.73 1.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.12 65 999999999 1.05 1.68 percent of total billed charges PAROXETINE HCL 10 MG TABLET 50615685_1 CDM 0250 RC 50268-0640-15 NDC inpatient 1 UN 1.73 1.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.68 97 999999999 1.05 1.68 percent of total billed charges PAROXETINE HCL 10 MG TABLET 50615685_1 CDM 0250 RC 50268-0640-15 NDC inpatient 1 UN 1.73 1.12 AETNA AETNA 1.37 79 999999999 1.05 1.68 percent of total billed charges PAROXETINE HCL 10 MG TABLET 50615685_1 CDM 0250 RC 50268-0640-15 NDC inpatient 1 UN 1.73 1.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.35 78 999999999 1.05 1.68 percent of total billed charges PAROXETINE HCL 10 MG TABLET 50615685_1 CDM 0250 RC 50268-0640-15 NDC inpatient 1 UN 1.73 1.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.19 69 999999999 1.05 1.68 percent of total billed charges PAROXETINE HCL 10 MG TABLET 50615685_1 CDM 0250 RC 50268-0640-15 NDC inpatient 1 UN 1.73 1.12 SIHO - ALL PLANS SIHO - ALL PLANS 1.56 90 999999999 1.05 1.68 percent of total billed charges PAROXETINE HCL 10 MG TABLET 50615685_1 CDM 0250 RC 50268-0640-15 NDC inpatient 1 UN 1.73 1.12 UMR - ALL PLANS UMR - ALL PLANS 1.21 70 999999999 1.05 1.68 percent of total billed charges PAROXETINE HCL 10 MG TABLET 50615685_1 CDM 0250 RC 50268-0640-15 NDC inpatient 1 UN 1.73 1.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.05 60.55 999999999 1.05 1.68 percent of total billed charges PAROXETINE HCL 10 MG TABLET 50615685_1 CDM 0250 RC 50268-0640-15 NDC inpatient 1 UN 1.73 1.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.05 1.68 PAROXETINE HCL 10 MG TABLET 50615685_1 CDM 0250 RC 50268-0640-15 NDC inpatient 1 UN 1.73 1.12 ANTHEM HMO ANTHEM HMO 999999999 1.05 1.68 PAROXETINE HCL 10 MG TABLET 50615685_1 CDM 0250 RC 50268-0640-15 NDC inpatient 1 UN 1.73 1.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.05 1.68 PAROXETINE HCL 10 MG TABLET 50615685_1 CDM 0250 RC 50268-0640-15 NDC inpatient 1 UN 1.73 1.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.05 1.68 PAROXETINE HCL 10 MG TABLET 50615685_1 CDM 0250 RC 50268-0640-15 NDC inpatient 1 UN 1.73 1.12 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.05 1.68 PAROXETINE HCL 10 MG TABLET 50615685_1 CDM 0250 RC 50268-0640-15 NDC inpatient 1 UN 1.73 1.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.17 67.6 999999999 1.05 1.68 percent of total billed charges MORPHINE SULF 10 MG/5 ML CUP 50615715_1 CDM 0250 RC 68094-0001-62 NDC inpatient 1 UN 28.74 18.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 18.68 65 999999999 17.4 27.88 percent of total billed charges MORPHINE SULF 10 MG/5 ML CUP 50615715_1 CDM 0250 RC 68094-0001-62 NDC inpatient 1 UN 28.74 18.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 27.88 97 999999999 17.4 27.88 percent of total billed charges MORPHINE SULF 10 MG/5 ML CUP 50615715_1 CDM 0250 RC 68094-0001-62 NDC inpatient 1 UN 28.74 18.68 AETNA AETNA 22.7 79 999999999 17.4 27.88 percent of total billed charges MORPHINE SULF 10 MG/5 ML CUP 50615715_1 CDM 0250 RC 68094-0001-62 NDC inpatient 1 UN 28.74 18.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 22.42 78 999999999 17.4 27.88 percent of total billed charges MORPHINE SULF 10 MG/5 ML CUP 50615715_1 CDM 0250 RC 68094-0001-62 NDC inpatient 1 UN 28.74 18.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 19.83 69 999999999 17.4 27.88 percent of total billed charges MORPHINE SULF 10 MG/5 ML CUP 50615715_1 CDM 0250 RC 68094-0001-62 NDC inpatient 1 UN 28.74 18.68 SIHO - ALL PLANS SIHO - ALL PLANS 25.87 90 999999999 17.4 27.88 percent of total billed charges MORPHINE SULF 10 MG/5 ML CUP 50615715_1 CDM 0250 RC 68094-0001-62 NDC inpatient 1 UN 28.74 18.68 UMR - ALL PLANS UMR - ALL PLANS 20.12 70 999999999 17.4 27.88 percent of total billed charges MORPHINE SULF 10 MG/5 ML CUP 50615715_1 CDM 0250 RC 68094-0001-62 NDC inpatient 1 UN 28.74 18.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17.4 60.55 999999999 17.4 27.88 percent of total billed charges MORPHINE SULF 10 MG/5 ML CUP 50615715_1 CDM 0250 RC 68094-0001-62 NDC inpatient 1 UN 28.74 18.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 17.4 27.88 MORPHINE SULF 10 MG/5 ML CUP 50615715_1 CDM 0250 RC 68094-0001-62 NDC inpatient 1 UN 28.74 18.68 ANTHEM HMO ANTHEM HMO 999999999 17.4 27.88 MORPHINE SULF 10 MG/5 ML CUP 50615715_1 CDM 0250 RC 68094-0001-62 NDC inpatient 1 UN 28.74 18.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 17.4 27.88 MORPHINE SULF 10 MG/5 ML CUP 50615715_1 CDM 0250 RC 68094-0001-62 NDC inpatient 1 UN 28.74 18.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 17.4 27.88 MORPHINE SULF 10 MG/5 ML CUP 50615715_1 CDM 0250 RC 68094-0001-62 NDC inpatient 1 UN 28.74 18.68 UHC - ALL PLANS UHC - ALL PLANS 999999999 17.4 27.88 MORPHINE SULF 10 MG/5 ML CUP 50615715_1 CDM 0250 RC 68094-0001-62 NDC inpatient 1 UN 28.74 18.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 19.43 67.6 999999999 17.4 27.88 percent of total billed charges NITROFURANTOIN MONO-MCR 100 MG 50615741_1 CDM 0250 RC 68001-0423-00 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges NITROFURANTOIN MONO-MCR 100 MG 50615741_1 CDM 0250 RC 68001-0423-00 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges NITROFURANTOIN MONO-MCR 100 MG 50615741_1 CDM 0250 RC 68001-0423-00 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges NITROFURANTOIN MONO-MCR 100 MG 50615741_1 CDM 0250 RC 68001-0423-00 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges NITROFURANTOIN MONO-MCR 100 MG 50615741_1 CDM 0250 RC 68001-0423-00 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges NITROFURANTOIN MONO-MCR 100 MG 50615741_1 CDM 0250 RC 68001-0423-00 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges NITROFURANTOIN MONO-MCR 100 MG 50615741_1 CDM 0250 RC 68001-0423-00 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges NITROFURANTOIN MONO-MCR 100 MG 50615741_1 CDM 0250 RC 68001-0423-00 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges NITROFURANTOIN MONO-MCR 100 MG 50615741_1 CDM 0250 RC 68001-0423-00 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 NITROFURANTOIN MONO-MCR 100 MG 50615741_1 CDM 0250 RC 68001-0423-00 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 NITROFURANTOIN MONO-MCR 100 MG 50615741_1 CDM 0250 RC 68001-0423-00 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 NITROFURANTOIN MONO-MCR 100 MG 50615741_1 CDM 0250 RC 68001-0423-00 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 NITROFURANTOIN MONO-MCR 100 MG 50615741_1 CDM 0250 RC 68001-0423-00 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 NITROFURANTOIN MONO-MCR 100 MG 50615741_1 CDM 0250 RC 68001-0423-00 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 600 MG TABLET 50615965_1 CDM 0250 RC 60687-0457-01 NDC inpatient 4 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 600 MG TABLET 50615965_1 CDM 0250 RC 60687-0457-01 NDC inpatient 4 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 600 MG TABLET 50615965_1 CDM 0250 RC 60687-0457-01 NDC inpatient 4 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 600 MG TABLET 50615965_1 CDM 0250 RC 60687-0457-01 NDC inpatient 4 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 600 MG TABLET 50615965_1 CDM 0250 RC 60687-0457-01 NDC inpatient 4 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 600 MG TABLET 50615965_1 CDM 0250 RC 60687-0457-01 NDC inpatient 4 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 600 MG TABLET 50615965_1 CDM 0250 RC 60687-0457-01 NDC inpatient 4 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 600 MG TABLET 50615965_1 CDM 0250 RC 60687-0457-01 NDC inpatient 4 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges IBUPROFEN 600 MG TABLET 50615965_1 CDM 0250 RC 60687-0457-01 NDC inpatient 4 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 IBUPROFEN 600 MG TABLET 50615965_1 CDM 0250 RC 60687-0457-01 NDC inpatient 4 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 IBUPROFEN 600 MG TABLET 50615965_1 CDM 0250 RC 60687-0457-01 NDC inpatient 4 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 IBUPROFEN 600 MG TABLET 50615965_1 CDM 0250 RC 60687-0457-01 NDC inpatient 4 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 IBUPROFEN 600 MG TABLET 50615965_1 CDM 0250 RC 60687-0457-01 NDC inpatient 4 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 IBUPROFEN 600 MG TABLET 50615965_1 CDM 0250 RC 60687-0457-01 NDC inpatient 4 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50615966_1 CDM 0250 RC 51079-0817-20 NDC J7507 HCPCS inpatient 1 UN 3.99 2.59 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.59 65 999999999 2.42 3.87 percent of total billed charges "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50615966_1 CDM 0250 RC 51079-0817-20 NDC J7507 HCPCS inpatient 1 UN 3.99 2.59 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.87 97 999999999 2.42 3.87 percent of total billed charges "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50615966_1 CDM 0250 RC 51079-0817-20 NDC J7507 HCPCS inpatient 1 UN 3.99 2.59 AETNA AETNA 3.15 79 999999999 2.42 3.87 percent of total billed charges "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50615966_1 CDM 0250 RC 51079-0817-20 NDC J7507 HCPCS inpatient 1 UN 3.99 2.59 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.11 78 999999999 2.42 3.87 percent of total billed charges "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50615966_1 CDM 0250 RC 51079-0817-20 NDC J7507 HCPCS inpatient 1 UN 3.99 2.59 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.75 69 999999999 2.42 3.87 percent of total billed charges "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50615966_1 CDM 0250 RC 51079-0817-20 NDC J7507 HCPCS inpatient 1 UN 3.99 2.59 SIHO - ALL PLANS SIHO - ALL PLANS 3.59 90 999999999 2.42 3.87 percent of total billed charges "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50615966_1 CDM 0250 RC 51079-0817-20 NDC J7507 HCPCS inpatient 1 UN 3.99 2.59 UMR - ALL PLANS UMR - ALL PLANS 2.79 70 999999999 2.42 3.87 percent of total billed charges "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50615966_1 CDM 0250 RC 51079-0817-20 NDC J7507 HCPCS inpatient 1 UN 3.99 2.59 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.42 60.55 999999999 2.42 3.87 percent of total billed charges "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50615966_1 CDM 0250 RC 51079-0817-20 NDC J7507 HCPCS inpatient 1 UN 3.99 2.59 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.42 3.87 "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50615966_1 CDM 0250 RC 51079-0817-20 NDC J7507 HCPCS inpatient 1 UN 3.99 2.59 ANTHEM HMO ANTHEM HMO 999999999 2.42 3.87 "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50615966_1 CDM 0250 RC 51079-0817-20 NDC J7507 HCPCS inpatient 1 UN 3.99 2.59 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.42 3.87 "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50615966_1 CDM 0250 RC 51079-0817-20 NDC J7507 HCPCS inpatient 1 UN 3.99 2.59 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.42 3.87 "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50615966_1 CDM 0250 RC 51079-0817-20 NDC J7507 HCPCS inpatient 1 UN 3.99 2.59 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.42 3.87 "TACROLIMUS, IMMEDIATE RELEASE, ORAL, 1 MG" 50615966_1 CDM 0250 RC 51079-0817-20 NDC J7507 HCPCS inpatient 1 UN 3.99 2.59 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.7 67.6 999999999 2.42 3.87 percent of total billed charges MONTELUKAST SOD 10 MG TABLET 50615972_1 CDM 0250 RC 00904-6808-61 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges MONTELUKAST SOD 10 MG TABLET 50615972_1 CDM 0250 RC 00904-6808-61 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges MONTELUKAST SOD 10 MG TABLET 50615972_1 CDM 0250 RC 00904-6808-61 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges MONTELUKAST SOD 10 MG TABLET 50615972_1 CDM 0250 RC 00904-6808-61 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges MONTELUKAST SOD 10 MG TABLET 50615972_1 CDM 0250 RC 00904-6808-61 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges MONTELUKAST SOD 10 MG TABLET 50615972_1 CDM 0250 RC 00904-6808-61 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges MONTELUKAST SOD 10 MG TABLET 50615972_1 CDM 0250 RC 00904-6808-61 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges MONTELUKAST SOD 10 MG TABLET 50615972_1 CDM 0250 RC 00904-6808-61 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges MONTELUKAST SOD 10 MG TABLET 50615972_1 CDM 0250 RC 00904-6808-61 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 MONTELUKAST SOD 10 MG TABLET 50615972_1 CDM 0250 RC 00904-6808-61 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 MONTELUKAST SOD 10 MG TABLET 50615972_1 CDM 0250 RC 00904-6808-61 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 MONTELUKAST SOD 10 MG TABLET 50615972_1 CDM 0250 RC 00904-6808-61 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 MONTELUKAST SOD 10 MG TABLET 50615972_1 CDM 0250 RC 00904-6808-61 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 MONTELUKAST SOD 10 MG TABLET 50615972_1 CDM 0250 RC 00904-6808-61 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 10 MG TABLET 50616630_1 CDM 0250 RC 60505-2578-09 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 10 MG TABLET 50616630_1 CDM 0250 RC 60505-2578-09 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 10 MG TABLET 50616630_1 CDM 0250 RC 60505-2578-09 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 10 MG TABLET 50616630_1 CDM 0250 RC 60505-2578-09 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 10 MG TABLET 50616630_1 CDM 0250 RC 60505-2578-09 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 10 MG TABLET 50616630_1 CDM 0250 RC 60505-2578-09 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 10 MG TABLET 50616630_1 CDM 0250 RC 60505-2578-09 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 10 MG TABLET 50616630_1 CDM 0250 RC 60505-2578-09 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 10 MG TABLET 50616630_1 CDM 0250 RC 60505-2578-09 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ATORVASTATIN 10 MG TABLET 50616630_1 CDM 0250 RC 60505-2578-09 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ATORVASTATIN 10 MG TABLET 50616630_1 CDM 0250 RC 60505-2578-09 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ATORVASTATIN 10 MG TABLET 50616630_1 CDM 0250 RC 60505-2578-09 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ATORVASTATIN 10 MG TABLET 50616630_1 CDM 0250 RC 60505-2578-09 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ATORVASTATIN 10 MG TABLET 50616630_1 CDM 0250 RC 60505-2578-09 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50616632_1 CDM 0250 RC 00143-9384-01 NDC J1453 HCPCS inpatient 150 UN 124.5 80.93 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.93 65 999999999 75.38 120.77 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50616632_1 CDM 0250 RC 00143-9384-01 NDC J1453 HCPCS inpatient 150 UN 124.5 80.93 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.77 97 999999999 75.38 120.77 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50616632_1 CDM 0250 RC 00143-9384-01 NDC J1453 HCPCS inpatient 150 UN 124.5 80.93 AETNA AETNA 98.36 79 999999999 75.38 120.77 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50616632_1 CDM 0250 RC 00143-9384-01 NDC J1453 HCPCS inpatient 150 UN 124.5 80.93 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.11 78 999999999 75.38 120.77 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50616632_1 CDM 0250 RC 00143-9384-01 NDC J1453 HCPCS inpatient 150 UN 124.5 80.93 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.91 69 999999999 75.38 120.77 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50616632_1 CDM 0250 RC 00143-9384-01 NDC J1453 HCPCS inpatient 150 UN 124.5 80.93 SIHO - ALL PLANS SIHO - ALL PLANS 112.05 90 999999999 75.38 120.77 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50616632_1 CDM 0250 RC 00143-9384-01 NDC J1453 HCPCS inpatient 150 UN 124.5 80.93 UMR - ALL PLANS UMR - ALL PLANS 87.15 70 999999999 75.38 120.77 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50616632_1 CDM 0250 RC 00143-9384-01 NDC J1453 HCPCS inpatient 150 UN 124.5 80.93 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.38 60.55 999999999 75.38 120.77 percent of total billed charges "INJECTION, FOSAPREPITANT, 1 MG" 50616632_1 CDM 0250 RC 00143-9384-01 NDC J1453 HCPCS inpatient 150 UN 124.5 80.93 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.38 120.77 "INJECTION, FOSAPREPITANT, 1 MG" 50616632_1 CDM 0250 RC 00143-9384-01 NDC J1453 HCPCS inpatient 150 UN 124.5 80.93 ANTHEM HMO ANTHEM HMO 999999999 75.38 120.77 "INJECTION, FOSAPREPITANT, 1 MG" 50616632_1 CDM 0250 RC 00143-9384-01 NDC J1453 HCPCS inpatient 150 UN 124.5 80.93 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.38 120.77 "INJECTION, FOSAPREPITANT, 1 MG" 50616632_1 CDM 0250 RC 00143-9384-01 NDC J1453 HCPCS inpatient 150 UN 124.5 80.93 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.38 120.77 "INJECTION, FOSAPREPITANT, 1 MG" 50616632_1 CDM 0250 RC 00143-9384-01 NDC J1453 HCPCS inpatient 150 UN 124.5 80.93 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.38 120.77 "INJECTION, FOSAPREPITANT, 1 MG" 50616632_1 CDM 0250 RC 00143-9384-01 NDC J1453 HCPCS inpatient 150 UN 124.5 80.93 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.16 67.6 999999999 75.38 120.77 percent of total billed charges "Tuberculosis test, gamma interferon" 50616844_1 CDM 0301 RC 86480 HCPCS inpatient 282 183.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 183.3 65 999999999 170.75 273.54 percent of total billed charges "Tuberculosis test, gamma interferon" 50616844_1 CDM 0301 RC 86480 HCPCS inpatient 282 183.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 273.54 97 999999999 170.75 273.54 percent of total billed charges "Tuberculosis test, gamma interferon" 50616844_1 CDM 0301 RC 86480 HCPCS inpatient 282 183.3 AETNA AETNA 222.78 79 999999999 170.75 273.54 percent of total billed charges "Tuberculosis test, gamma interferon" 50616844_1 CDM 0301 RC 86480 HCPCS inpatient 282 183.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 219.96 78 999999999 170.75 273.54 percent of total billed charges "Tuberculosis test, gamma interferon" 50616844_1 CDM 0301 RC 86480 HCPCS inpatient 282 183.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 194.58 69 999999999 170.75 273.54 percent of total billed charges "Tuberculosis test, gamma interferon" 50616844_1 CDM 0301 RC 86480 HCPCS inpatient 282 183.3 SIHO - ALL PLANS SIHO - ALL PLANS 253.8 90 999999999 170.75 273.54 percent of total billed charges "Tuberculosis test, gamma interferon" 50616844_1 CDM 0301 RC 86480 HCPCS inpatient 282 183.3 UMR - ALL PLANS UMR - ALL PLANS 197.4 70 999999999 170.75 273.54 percent of total billed charges "Tuberculosis test, gamma interferon" 50616844_1 CDM 0301 RC 86480 HCPCS inpatient 282 183.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 170.75 60.55 999999999 170.75 273.54 percent of total billed charges "Tuberculosis test, gamma interferon" 50616844_1 CDM 0301 RC 86480 HCPCS inpatient 282 183.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 170.75 273.54 "Tuberculosis test, gamma interferon" 50616844_1 CDM 0301 RC 86480 HCPCS inpatient 282 183.3 ANTHEM HMO ANTHEM HMO 999999999 170.75 273.54 "Tuberculosis test, gamma interferon" 50616844_1 CDM 0301 RC 86480 HCPCS inpatient 282 183.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 170.75 273.54 "Tuberculosis test, gamma interferon" 50616844_1 CDM 0301 RC 86480 HCPCS inpatient 282 183.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 170.75 273.54 "Tuberculosis test, gamma interferon" 50616844_1 CDM 0301 RC 86480 HCPCS inpatient 282 183.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 170.75 273.54 "Tuberculosis test, gamma interferon" 50616844_1 CDM 0301 RC 86480 HCPCS inpatient 282 183.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 190.63 67.6 999999999 170.75 273.54 percent of total billed charges "Clotting factor X assessment test, diluted" 50616907_1 CDM 0301 RC 85613 HCPCS inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges "Clotting factor X assessment test, diluted" 50616907_1 CDM 0301 RC 85613 HCPCS inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges "Clotting factor X assessment test, diluted" 50616907_1 CDM 0301 RC 85613 HCPCS inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges "Clotting factor X assessment test, diluted" 50616907_1 CDM 0301 RC 85613 HCPCS inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges "Clotting factor X assessment test, diluted" 50616907_1 CDM 0301 RC 85613 HCPCS inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges "Clotting factor X assessment test, diluted" 50616907_1 CDM 0301 RC 85613 HCPCS inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges "Clotting factor X assessment test, diluted" 50616907_1 CDM 0301 RC 85613 HCPCS inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges "Clotting factor X assessment test, diluted" 50616907_1 CDM 0301 RC 85613 HCPCS inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges "Clotting factor X assessment test, diluted" 50616907_1 CDM 0301 RC 85613 HCPCS inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 "Clotting factor X assessment test, diluted" 50616907_1 CDM 0301 RC 85613 HCPCS inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 "Clotting factor X assessment test, diluted" 50616907_1 CDM 0301 RC 85613 HCPCS inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 "Clotting factor X assessment test, diluted" 50616907_1 CDM 0301 RC 85613 HCPCS inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 "Clotting factor X assessment test, diluted" 50616907_1 CDM 0301 RC 85613 HCPCS inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 "Clotting factor X assessment test, diluted" 50616907_1 CDM 0301 RC 85613 HCPCS inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 50617303_1 CDM 0301 RC 83880 HCPCS inpatient 242 157.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 157.3 65 999999999 146.53 234.74 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 50617303_1 CDM 0301 RC 83880 HCPCS inpatient 242 157.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 234.74 97 999999999 146.53 234.74 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 50617303_1 CDM 0301 RC 83880 HCPCS inpatient 242 157.3 AETNA AETNA 191.18 79 999999999 146.53 234.74 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 50617303_1 CDM 0301 RC 83880 HCPCS inpatient 242 157.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 188.76 78 999999999 146.53 234.74 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 50617303_1 CDM 0301 RC 83880 HCPCS inpatient 242 157.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 166.98 69 999999999 146.53 234.74 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 50617303_1 CDM 0301 RC 83880 HCPCS inpatient 242 157.3 SIHO - ALL PLANS SIHO - ALL PLANS 217.8 90 999999999 146.53 234.74 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 50617303_1 CDM 0301 RC 83880 HCPCS inpatient 242 157.3 UMR - ALL PLANS UMR - ALL PLANS 169.4 70 999999999 146.53 234.74 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 50617303_1 CDM 0301 RC 83880 HCPCS inpatient 242 157.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 146.53 60.55 999999999 146.53 234.74 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 50617303_1 CDM 0301 RC 83880 HCPCS inpatient 242 157.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 146.53 234.74 Natriuretic peptide (heart and blood vessel protein) level 50617303_1 CDM 0301 RC 83880 HCPCS inpatient 242 157.3 ANTHEM HMO ANTHEM HMO 999999999 146.53 234.74 Natriuretic peptide (heart and blood vessel protein) level 50617303_1 CDM 0301 RC 83880 HCPCS inpatient 242 157.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 146.53 234.74 Natriuretic peptide (heart and blood vessel protein) level 50617303_1 CDM 0301 RC 83880 HCPCS inpatient 242 157.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 146.53 234.74 Natriuretic peptide (heart and blood vessel protein) level 50617303_1 CDM 0301 RC 83880 HCPCS inpatient 242 157.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 146.53 234.74 Natriuretic peptide (heart and blood vessel protein) level 50617303_1 CDM 0301 RC 83880 HCPCS inpatient 242 157.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 163.59 67.6 999999999 146.53 234.74 percent of total billed charges AMITRIPTYLINE HCL 10 MG TAB 50617418_1 CDM 0250 RC 16729-0171-01 NDC inpatient 1 UN 1.52 0.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.99 65 999999999 0.92 1.47 percent of total billed charges AMITRIPTYLINE HCL 10 MG TAB 50617418_1 CDM 0250 RC 16729-0171-01 NDC inpatient 1 UN 1.52 0.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.47 97 999999999 0.92 1.47 percent of total billed charges AMITRIPTYLINE HCL 10 MG TAB 50617418_1 CDM 0250 RC 16729-0171-01 NDC inpatient 1 UN 1.52 0.99 AETNA AETNA 1.2 79 999999999 0.92 1.47 percent of total billed charges AMITRIPTYLINE HCL 10 MG TAB 50617418_1 CDM 0250 RC 16729-0171-01 NDC inpatient 1 UN 1.52 0.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.19 78 999999999 0.92 1.47 percent of total billed charges AMITRIPTYLINE HCL 10 MG TAB 50617418_1 CDM 0250 RC 16729-0171-01 NDC inpatient 1 UN 1.52 0.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.05 69 999999999 0.92 1.47 percent of total billed charges AMITRIPTYLINE HCL 10 MG TAB 50617418_1 CDM 0250 RC 16729-0171-01 NDC inpatient 1 UN 1.52 0.99 SIHO - ALL PLANS SIHO - ALL PLANS 1.37 90 999999999 0.92 1.47 percent of total billed charges AMITRIPTYLINE HCL 10 MG TAB 50617418_1 CDM 0250 RC 16729-0171-01 NDC inpatient 1 UN 1.52 0.99 UMR - ALL PLANS UMR - ALL PLANS 1.06 70 999999999 0.92 1.47 percent of total billed charges AMITRIPTYLINE HCL 10 MG TAB 50617418_1 CDM 0250 RC 16729-0171-01 NDC inpatient 1 UN 1.52 0.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.92 60.55 999999999 0.92 1.47 percent of total billed charges AMITRIPTYLINE HCL 10 MG TAB 50617418_1 CDM 0250 RC 16729-0171-01 NDC inpatient 1 UN 1.52 0.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.92 1.47 AMITRIPTYLINE HCL 10 MG TAB 50617418_1 CDM 0250 RC 16729-0171-01 NDC inpatient 1 UN 1.52 0.99 ANTHEM HMO ANTHEM HMO 999999999 0.92 1.47 AMITRIPTYLINE HCL 10 MG TAB 50617418_1 CDM 0250 RC 16729-0171-01 NDC inpatient 1 UN 1.52 0.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.92 1.47 AMITRIPTYLINE HCL 10 MG TAB 50617418_1 CDM 0250 RC 16729-0171-01 NDC inpatient 1 UN 1.52 0.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.92 1.47 AMITRIPTYLINE HCL 10 MG TAB 50617418_1 CDM 0250 RC 16729-0171-01 NDC inpatient 1 UN 1.52 0.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.92 1.47 AMITRIPTYLINE HCL 10 MG TAB 50617418_1 CDM 0250 RC 16729-0171-01 NDC inpatient 1 UN 1.52 0.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.03 67.6 999999999 0.92 1.47 percent of total billed charges SPIRONOLACTONE 100 MG TABLET 50618220_1 CDM 0250 RC 60687-0487-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges SPIRONOLACTONE 100 MG TABLET 50618220_1 CDM 0250 RC 60687-0487-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges SPIRONOLACTONE 100 MG TABLET 50618220_1 CDM 0250 RC 60687-0487-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges SPIRONOLACTONE 100 MG TABLET 50618220_1 CDM 0250 RC 60687-0487-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges SPIRONOLACTONE 100 MG TABLET 50618220_1 CDM 0250 RC 60687-0487-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges SPIRONOLACTONE 100 MG TABLET 50618220_1 CDM 0250 RC 60687-0487-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges SPIRONOLACTONE 100 MG TABLET 50618220_1 CDM 0250 RC 60687-0487-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges SPIRONOLACTONE 100 MG TABLET 50618220_1 CDM 0250 RC 60687-0487-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges SPIRONOLACTONE 100 MG TABLET 50618220_1 CDM 0250 RC 60687-0487-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 SPIRONOLACTONE 100 MG TABLET 50618220_1 CDM 0250 RC 60687-0487-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 SPIRONOLACTONE 100 MG TABLET 50618220_1 CDM 0250 RC 60687-0487-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 SPIRONOLACTONE 100 MG TABLET 50618220_1 CDM 0250 RC 60687-0487-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 SPIRONOLACTONE 100 MG TABLET 50618220_1 CDM 0250 RC 60687-0487-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 SPIRONOLACTONE 100 MG TABLET 50618220_1 CDM 0250 RC 60687-0487-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges ZONISAMIDE 100 MG CAPSULE 50618221_1 CDM 0250 RC 60687-0230-01 NDC inpatient 1 UN 1.65 1.07 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.07 65 999999999 1 1.6 percent of total billed charges ZONISAMIDE 100 MG CAPSULE 50618221_1 CDM 0250 RC 60687-0230-01 NDC inpatient 1 UN 1.65 1.07 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.6 97 999999999 1 1.6 percent of total billed charges ZONISAMIDE 100 MG CAPSULE 50618221_1 CDM 0250 RC 60687-0230-01 NDC inpatient 1 UN 1.65 1.07 AETNA AETNA 1.3 79 999999999 1 1.6 percent of total billed charges ZONISAMIDE 100 MG CAPSULE 50618221_1 CDM 0250 RC 60687-0230-01 NDC inpatient 1 UN 1.65 1.07 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.29 78 999999999 1 1.6 percent of total billed charges ZONISAMIDE 100 MG CAPSULE 50618221_1 CDM 0250 RC 60687-0230-01 NDC inpatient 1 UN 1.65 1.07 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.14 69 999999999 1 1.6 percent of total billed charges ZONISAMIDE 100 MG CAPSULE 50618221_1 CDM 0250 RC 60687-0230-01 NDC inpatient 1 UN 1.65 1.07 SIHO - ALL PLANS SIHO - ALL PLANS 1.49 90 999999999 1 1.6 percent of total billed charges ZONISAMIDE 100 MG CAPSULE 50618221_1 CDM 0250 RC 60687-0230-01 NDC inpatient 1 UN 1.65 1.07 UMR - ALL PLANS UMR - ALL PLANS 1.16 70 999999999 1 1.6 percent of total billed charges ZONISAMIDE 100 MG CAPSULE 50618221_1 CDM 0250 RC 60687-0230-01 NDC inpatient 1 UN 1.65 1.07 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1 60.55 999999999 1 1.6 percent of total billed charges ZONISAMIDE 100 MG CAPSULE 50618221_1 CDM 0250 RC 60687-0230-01 NDC inpatient 1 UN 1.65 1.07 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1 1.6 ZONISAMIDE 100 MG CAPSULE 50618221_1 CDM 0250 RC 60687-0230-01 NDC inpatient 1 UN 1.65 1.07 ANTHEM HMO ANTHEM HMO 999999999 1 1.6 ZONISAMIDE 100 MG CAPSULE 50618221_1 CDM 0250 RC 60687-0230-01 NDC inpatient 1 UN 1.65 1.07 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1 1.6 ZONISAMIDE 100 MG CAPSULE 50618221_1 CDM 0250 RC 60687-0230-01 NDC inpatient 1 UN 1.65 1.07 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1 1.6 ZONISAMIDE 100 MG CAPSULE 50618221_1 CDM 0250 RC 60687-0230-01 NDC inpatient 1 UN 1.65 1.07 UHC - ALL PLANS UHC - ALL PLANS 999999999 1 1.6 ZONISAMIDE 100 MG CAPSULE 50618221_1 CDM 0250 RC 60687-0230-01 NDC inpatient 1 UN 1.65 1.07 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.12 67.6 999999999 1 1.6 percent of total billed charges 60687-0562-01 - dilTIAZem 30 mg Tab[JOHN] 50618226_1 CDM 0250 RC 60687-0562-01 NDC inpatient 1 UN 1.04 0.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.68 65 999999999 0.63 1.01 percent of total billed charges 60687-0562-01 - dilTIAZem 30 mg Tab[JOHN] 50618226_1 CDM 0250 RC 60687-0562-01 NDC inpatient 1 UN 1.04 0.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.01 97 999999999 0.63 1.01 percent of total billed charges 60687-0562-01 - dilTIAZem 30 mg Tab[JOHN] 50618226_1 CDM 0250 RC 60687-0562-01 NDC inpatient 1 UN 1.04 0.68 AETNA AETNA 0.82 79 999999999 0.63 1.01 percent of total billed charges 60687-0562-01 - dilTIAZem 30 mg Tab[JOHN] 50618226_1 CDM 0250 RC 60687-0562-01 NDC inpatient 1 UN 1.04 0.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.81 78 999999999 0.63 1.01 percent of total billed charges 60687-0562-01 - dilTIAZem 30 mg Tab[JOHN] 50618226_1 CDM 0250 RC 60687-0562-01 NDC inpatient 1 UN 1.04 0.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.72 69 999999999 0.63 1.01 percent of total billed charges 60687-0562-01 - dilTIAZem 30 mg Tab[JOHN] 50618226_1 CDM 0250 RC 60687-0562-01 NDC inpatient 1 UN 1.04 0.68 SIHO - ALL PLANS SIHO - ALL PLANS 0.94 90 999999999 0.63 1.01 percent of total billed charges 60687-0562-01 - dilTIAZem 30 mg Tab[JOHN] 50618226_1 CDM 0250 RC 60687-0562-01 NDC inpatient 1 UN 1.04 0.68 UMR - ALL PLANS UMR - ALL PLANS 0.73 70 999999999 0.63 1.01 percent of total billed charges 60687-0562-01 - dilTIAZem 30 mg Tab[JOHN] 50618226_1 CDM 0250 RC 60687-0562-01 NDC inpatient 1 UN 1.04 0.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.63 60.55 999999999 0.63 1.01 percent of total billed charges 60687-0562-01 - dilTIAZem 30 mg Tab[JOHN] 50618226_1 CDM 0250 RC 60687-0562-01 NDC inpatient 1 UN 1.04 0.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.63 1.01 60687-0562-01 - dilTIAZem 30 mg Tab[JOHN] 50618226_1 CDM 0250 RC 60687-0562-01 NDC inpatient 1 UN 1.04 0.68 ANTHEM HMO ANTHEM HMO 999999999 0.63 1.01 60687-0562-01 - dilTIAZem 30 mg Tab[JOHN] 50618226_1 CDM 0250 RC 60687-0562-01 NDC inpatient 1 UN 1.04 0.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.63 1.01 60687-0562-01 - dilTIAZem 30 mg Tab[JOHN] 50618226_1 CDM 0250 RC 60687-0562-01 NDC inpatient 1 UN 1.04 0.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.63 1.01 60687-0562-01 - dilTIAZem 30 mg Tab[JOHN] 50618226_1 CDM 0250 RC 60687-0562-01 NDC inpatient 1 UN 1.04 0.68 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.63 1.01 60687-0562-01 - dilTIAZem 30 mg Tab[JOHN] 50618226_1 CDM 0250 RC 60687-0562-01 NDC inpatient 1 UN 1.04 0.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.7 67.6 999999999 0.63 1.01 percent of total billed charges Miscellaneous Laboratory Test Outreach IU 50618678_1 CDM 0300 RC inpatient 265.68 172.69 SELF PAY DISCOUNT SELF PAY DISCOUNT 172.69 65 999999999 160.87 257.71 percent of total billed charges Miscellaneous Laboratory Test Outreach IU 50618678_1 CDM 0300 RC inpatient 265.68 172.69 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 257.71 97 999999999 160.87 257.71 percent of total billed charges Miscellaneous Laboratory Test Outreach IU 50618678_1 CDM 0300 RC inpatient 265.68 172.69 AETNA AETNA 209.89 79 999999999 160.87 257.71 percent of total billed charges Miscellaneous Laboratory Test Outreach IU 50618678_1 CDM 0300 RC inpatient 265.68 172.69 HUMANA - ALL PLANS HUMANA - ALL PLANS 207.23 78 999999999 160.87 257.71 percent of total billed charges Miscellaneous Laboratory Test Outreach IU 50618678_1 CDM 0300 RC inpatient 265.68 172.69 ENCORE - ALL PLANS ENCORE - ALL PLANS 183.32 69 999999999 160.87 257.71 percent of total billed charges Miscellaneous Laboratory Test Outreach IU 50618678_1 CDM 0300 RC inpatient 265.68 172.69 SIHO - ALL PLANS SIHO - ALL PLANS 239.11 90 999999999 160.87 257.71 percent of total billed charges Miscellaneous Laboratory Test Outreach IU 50618678_1 CDM 0300 RC inpatient 265.68 172.69 UMR - ALL PLANS UMR - ALL PLANS 185.98 70 999999999 160.87 257.71 percent of total billed charges Miscellaneous Laboratory Test Outreach IU 50618678_1 CDM 0300 RC inpatient 265.68 172.69 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 160.87 60.55 999999999 160.87 257.71 percent of total billed charges Miscellaneous Laboratory Test Outreach IU 50618678_1 CDM 0300 RC inpatient 265.68 172.69 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 160.87 257.71 Miscellaneous Laboratory Test Outreach IU 50618678_1 CDM 0300 RC inpatient 265.68 172.69 ANTHEM HMO ANTHEM HMO 999999999 160.87 257.71 Miscellaneous Laboratory Test Outreach IU 50618678_1 CDM 0300 RC inpatient 265.68 172.69 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 160.87 257.71 Miscellaneous Laboratory Test Outreach IU 50618678_1 CDM 0300 RC inpatient 265.68 172.69 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 160.87 257.71 Miscellaneous Laboratory Test Outreach IU 50618678_1 CDM 0300 RC inpatient 265.68 172.69 UHC - ALL PLANS UHC - ALL PLANS 999999999 160.87 257.71 Miscellaneous Laboratory Test Outreach IU 50618678_1 CDM 0300 RC inpatient 265.68 172.69 CIGNA - ALL PLANS CIGNA - ALL PLANS 179.6 67.6 999999999 160.87 257.71 percent of total billed charges ALLOPURINOL 300 MG TABLET 50619194_1 CDM 0250 RC 62584-0713-01 NDC inpatient 1 UN 1.85 1.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.2 65 999999999 1.12 1.79 percent of total billed charges ALLOPURINOL 300 MG TABLET 50619194_1 CDM 0250 RC 62584-0713-01 NDC inpatient 1 UN 1.85 1.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.79 97 999999999 1.12 1.79 percent of total billed charges ALLOPURINOL 300 MG TABLET 50619194_1 CDM 0250 RC 62584-0713-01 NDC inpatient 1 UN 1.85 1.2 AETNA AETNA 1.46 79 999999999 1.12 1.79 percent of total billed charges ALLOPURINOL 300 MG TABLET 50619194_1 CDM 0250 RC 62584-0713-01 NDC inpatient 1 UN 1.85 1.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.44 78 999999999 1.12 1.79 percent of total billed charges ALLOPURINOL 300 MG TABLET 50619194_1 CDM 0250 RC 62584-0713-01 NDC inpatient 1 UN 1.85 1.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.28 69 999999999 1.12 1.79 percent of total billed charges ALLOPURINOL 300 MG TABLET 50619194_1 CDM 0250 RC 62584-0713-01 NDC inpatient 1 UN 1.85 1.2 SIHO - ALL PLANS SIHO - ALL PLANS 1.67 90 999999999 1.12 1.79 percent of total billed charges ALLOPURINOL 300 MG TABLET 50619194_1 CDM 0250 RC 62584-0713-01 NDC inpatient 1 UN 1.85 1.2 UMR - ALL PLANS UMR - ALL PLANS 1.3 70 999999999 1.12 1.79 percent of total billed charges ALLOPURINOL 300 MG TABLET 50619194_1 CDM 0250 RC 62584-0713-01 NDC inpatient 1 UN 1.85 1.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.12 60.55 999999999 1.12 1.79 percent of total billed charges ALLOPURINOL 300 MG TABLET 50619194_1 CDM 0250 RC 62584-0713-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.12 1.79 ALLOPURINOL 300 MG TABLET 50619194_1 CDM 0250 RC 62584-0713-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM HMO ANTHEM HMO 999999999 1.12 1.79 ALLOPURINOL 300 MG TABLET 50619194_1 CDM 0250 RC 62584-0713-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.12 1.79 ALLOPURINOL 300 MG TABLET 50619194_1 CDM 0250 RC 62584-0713-01 NDC inpatient 1 UN 1.85 1.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.12 1.79 ALLOPURINOL 300 MG TABLET 50619194_1 CDM 0250 RC 62584-0713-01 NDC inpatient 1 UN 1.85 1.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.12 1.79 ALLOPURINOL 300 MG TABLET 50619194_1 CDM 0250 RC 62584-0713-01 NDC inpatient 1 UN 1.85 1.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.25 67.6 999999999 1.12 1.79 percent of total billed charges "TRANEXAMIC ACID 1,000 MG/10 ML" 50619443_1 CDM 0250 RC 23155-0166-41 NDC inpatient 1 UN 24.2 15.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 15.73 65 999999999 14.65 23.47 percent of total billed charges "TRANEXAMIC ACID 1,000 MG/10 ML" 50619443_1 CDM 0250 RC 23155-0166-41 NDC inpatient 1 UN 24.2 15.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23.47 97 999999999 14.65 23.47 percent of total billed charges "TRANEXAMIC ACID 1,000 MG/10 ML" 50619443_1 CDM 0250 RC 23155-0166-41 NDC inpatient 1 UN 24.2 15.73 AETNA AETNA 19.12 79 999999999 14.65 23.47 percent of total billed charges "TRANEXAMIC ACID 1,000 MG/10 ML" 50619443_1 CDM 0250 RC 23155-0166-41 NDC inpatient 1 UN 24.2 15.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 18.88 78 999999999 14.65 23.47 percent of total billed charges "TRANEXAMIC ACID 1,000 MG/10 ML" 50619443_1 CDM 0250 RC 23155-0166-41 NDC inpatient 1 UN 24.2 15.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 16.7 69 999999999 14.65 23.47 percent of total billed charges "TRANEXAMIC ACID 1,000 MG/10 ML" 50619443_1 CDM 0250 RC 23155-0166-41 NDC inpatient 1 UN 24.2 15.73 SIHO - ALL PLANS SIHO - ALL PLANS 21.78 90 999999999 14.65 23.47 percent of total billed charges "TRANEXAMIC ACID 1,000 MG/10 ML" 50619443_1 CDM 0250 RC 23155-0166-41 NDC inpatient 1 UN 24.2 15.73 UMR - ALL PLANS UMR - ALL PLANS 16.94 70 999999999 14.65 23.47 percent of total billed charges "TRANEXAMIC ACID 1,000 MG/10 ML" 50619443_1 CDM 0250 RC 23155-0166-41 NDC inpatient 1 UN 24.2 15.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.65 60.55 999999999 14.65 23.47 percent of total billed charges "TRANEXAMIC ACID 1,000 MG/10 ML" 50619443_1 CDM 0250 RC 23155-0166-41 NDC inpatient 1 UN 24.2 15.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.65 23.47 "TRANEXAMIC ACID 1,000 MG/10 ML" 50619443_1 CDM 0250 RC 23155-0166-41 NDC inpatient 1 UN 24.2 15.73 ANTHEM HMO ANTHEM HMO 999999999 14.65 23.47 "TRANEXAMIC ACID 1,000 MG/10 ML" 50619443_1 CDM 0250 RC 23155-0166-41 NDC inpatient 1 UN 24.2 15.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.65 23.47 "TRANEXAMIC ACID 1,000 MG/10 ML" 50619443_1 CDM 0250 RC 23155-0166-41 NDC inpatient 1 UN 24.2 15.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.65 23.47 "TRANEXAMIC ACID 1,000 MG/10 ML" 50619443_1 CDM 0250 RC 23155-0166-41 NDC inpatient 1 UN 24.2 15.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.65 23.47 "TRANEXAMIC ACID 1,000 MG/10 ML" 50619443_1 CDM 0250 RC 23155-0166-41 NDC inpatient 1 UN 24.2 15.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.36 67.6 999999999 14.65 23.47 percent of total billed charges "MOMETASONE FUROATE SINUS IMPLANT, 10 MICROGRAMS" 50620079_1 CDM 0636 RC J7401 HCPCS inpatient 6941 4511.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 4511.65 65 999999999 4202.78 6732.77 percent of total billed charges "MOMETASONE FUROATE SINUS IMPLANT, 10 MICROGRAMS" 50620079_1 CDM 0636 RC J7401 HCPCS inpatient 6941 4511.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6732.77 97 999999999 4202.78 6732.77 percent of total billed charges "MOMETASONE FUROATE SINUS IMPLANT, 10 MICROGRAMS" 50620079_1 CDM 0636 RC J7401 HCPCS inpatient 6941 4511.65 AETNA AETNA 5483.39 79 999999999 4202.78 6732.77 percent of total billed charges "MOMETASONE FUROATE SINUS IMPLANT, 10 MICROGRAMS" 50620079_1 CDM 0636 RC J7401 HCPCS inpatient 6941 4511.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 5413.98 78 999999999 4202.78 6732.77 percent of total billed charges "MOMETASONE FUROATE SINUS IMPLANT, 10 MICROGRAMS" 50620079_1 CDM 0636 RC J7401 HCPCS inpatient 6941 4511.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 4789.29 69 999999999 4202.78 6732.77 percent of total billed charges "MOMETASONE FUROATE SINUS IMPLANT, 10 MICROGRAMS" 50620079_1 CDM 0636 RC J7401 HCPCS inpatient 6941 4511.65 SIHO - ALL PLANS SIHO - ALL PLANS 6246.9 90 999999999 4202.78 6732.77 percent of total billed charges "MOMETASONE FUROATE SINUS IMPLANT, 10 MICROGRAMS" 50620079_1 CDM 0636 RC J7401 HCPCS inpatient 6941 4511.65 UMR - ALL PLANS UMR - ALL PLANS 4858.7 70 999999999 4202.78 6732.77 percent of total billed charges "MOMETASONE FUROATE SINUS IMPLANT, 10 MICROGRAMS" 50620079_1 CDM 0636 RC J7401 HCPCS inpatient 6941 4511.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4202.78 60.55 999999999 4202.78 6732.77 percent of total billed charges "MOMETASONE FUROATE SINUS IMPLANT, 10 MICROGRAMS" 50620079_1 CDM 0636 RC J7401 HCPCS inpatient 6941 4511.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4202.78 6732.77 "MOMETASONE FUROATE SINUS IMPLANT, 10 MICROGRAMS" 50620079_1 CDM 0636 RC J7401 HCPCS inpatient 6941 4511.65 ANTHEM HMO ANTHEM HMO 999999999 4202.78 6732.77 "MOMETASONE FUROATE SINUS IMPLANT, 10 MICROGRAMS" 50620079_1 CDM 0636 RC J7401 HCPCS inpatient 6941 4511.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4202.78 6732.77 "MOMETASONE FUROATE SINUS IMPLANT, 10 MICROGRAMS" 50620079_1 CDM 0636 RC J7401 HCPCS inpatient 6941 4511.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4202.78 6732.77 "MOMETASONE FUROATE SINUS IMPLANT, 10 MICROGRAMS" 50620079_1 CDM 0636 RC J7401 HCPCS inpatient 6941 4511.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 4202.78 6732.77 "MOMETASONE FUROATE SINUS IMPLANT, 10 MICROGRAMS" 50620079_1 CDM 0636 RC J7401 HCPCS inpatient 6941 4511.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 4692.12 67.6 999999999 4202.78 6732.77 percent of total billed charges FOSFOMYCIN 3 GM SACHET 50621584_1 CDM 0250 RC 70700-0268-94 NDC inpatient 1 UN 318.48 207.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 207.01 65 999999999 192.84 308.93 percent of total billed charges FOSFOMYCIN 3 GM SACHET 50621584_1 CDM 0250 RC 70700-0268-94 NDC inpatient 1 UN 318.48 207.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 308.93 97 999999999 192.84 308.93 percent of total billed charges FOSFOMYCIN 3 GM SACHET 50621584_1 CDM 0250 RC 70700-0268-94 NDC inpatient 1 UN 318.48 207.01 AETNA AETNA 251.6 79 999999999 192.84 308.93 percent of total billed charges FOSFOMYCIN 3 GM SACHET 50621584_1 CDM 0250 RC 70700-0268-94 NDC inpatient 1 UN 318.48 207.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 248.41 78 999999999 192.84 308.93 percent of total billed charges FOSFOMYCIN 3 GM SACHET 50621584_1 CDM 0250 RC 70700-0268-94 NDC inpatient 1 UN 318.48 207.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 219.75 69 999999999 192.84 308.93 percent of total billed charges FOSFOMYCIN 3 GM SACHET 50621584_1 CDM 0250 RC 70700-0268-94 NDC inpatient 1 UN 318.48 207.01 SIHO - ALL PLANS SIHO - ALL PLANS 286.63 90 999999999 192.84 308.93 percent of total billed charges FOSFOMYCIN 3 GM SACHET 50621584_1 CDM 0250 RC 70700-0268-94 NDC inpatient 1 UN 318.48 207.01 UMR - ALL PLANS UMR - ALL PLANS 222.94 70 999999999 192.84 308.93 percent of total billed charges FOSFOMYCIN 3 GM SACHET 50621584_1 CDM 0250 RC 70700-0268-94 NDC inpatient 1 UN 318.48 207.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 192.84 60.55 999999999 192.84 308.93 percent of total billed charges FOSFOMYCIN 3 GM SACHET 50621584_1 CDM 0250 RC 70700-0268-94 NDC inpatient 1 UN 318.48 207.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 192.84 308.93 FOSFOMYCIN 3 GM SACHET 50621584_1 CDM 0250 RC 70700-0268-94 NDC inpatient 1 UN 318.48 207.01 ANTHEM HMO ANTHEM HMO 999999999 192.84 308.93 FOSFOMYCIN 3 GM SACHET 50621584_1 CDM 0250 RC 70700-0268-94 NDC inpatient 1 UN 318.48 207.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 192.84 308.93 FOSFOMYCIN 3 GM SACHET 50621584_1 CDM 0250 RC 70700-0268-94 NDC inpatient 1 UN 318.48 207.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 192.84 308.93 FOSFOMYCIN 3 GM SACHET 50621584_1 CDM 0250 RC 70700-0268-94 NDC inpatient 1 UN 318.48 207.01 UHC - ALL PLANS UHC - ALL PLANS 999999999 192.84 308.93 FOSFOMYCIN 3 GM SACHET 50621584_1 CDM 0250 RC 70700-0268-94 NDC inpatient 1 UN 318.48 207.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 215.29 67.6 999999999 192.84 308.93 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50622217_1 CDM 0258 RC 00990-7922-09 NDC J7060 HCPCS inpatient 1 UN 61.1 39.72 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.72 65 999999999 37 59.27 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50622217_1 CDM 0258 RC 00990-7922-09 NDC J7060 HCPCS inpatient 1 UN 61.1 39.72 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59.27 97 999999999 37 59.27 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50622217_1 CDM 0258 RC 00990-7922-09 NDC J7060 HCPCS inpatient 1 UN 61.1 39.72 AETNA AETNA 48.27 79 999999999 37 59.27 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50622217_1 CDM 0258 RC 00990-7922-09 NDC J7060 HCPCS inpatient 1 UN 61.1 39.72 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.66 78 999999999 37 59.27 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50622217_1 CDM 0258 RC 00990-7922-09 NDC J7060 HCPCS inpatient 1 UN 61.1 39.72 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.16 69 999999999 37 59.27 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50622217_1 CDM 0258 RC 00990-7922-09 NDC J7060 HCPCS inpatient 1 UN 61.1 39.72 SIHO - ALL PLANS SIHO - ALL PLANS 54.99 90 999999999 37 59.27 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50622217_1 CDM 0258 RC 00990-7922-09 NDC J7060 HCPCS inpatient 1 UN 61.1 39.72 UMR - ALL PLANS UMR - ALL PLANS 42.77 70 999999999 37 59.27 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50622217_1 CDM 0258 RC 00990-7922-09 NDC J7060 HCPCS inpatient 1 UN 61.1 39.72 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 37 60.55 999999999 37 59.27 percent of total billed charges 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50622217_1 CDM 0258 RC 00990-7922-09 NDC J7060 HCPCS inpatient 1 UN 61.1 39.72 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 37 59.27 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50622217_1 CDM 0258 RC 00990-7922-09 NDC J7060 HCPCS inpatient 1 UN 61.1 39.72 ANTHEM HMO ANTHEM HMO 999999999 37 59.27 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50622217_1 CDM 0258 RC 00990-7922-09 NDC J7060 HCPCS inpatient 1 UN 61.1 39.72 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 37 59.27 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50622217_1 CDM 0258 RC 00990-7922-09 NDC J7060 HCPCS inpatient 1 UN 61.1 39.72 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 37 59.27 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50622217_1 CDM 0258 RC 00990-7922-09 NDC J7060 HCPCS inpatient 1 UN 61.1 39.72 UHC - ALL PLANS UHC - ALL PLANS 999999999 37 59.27 5% DEXTROSE/WATER (500 ML = 1 UNIT) 50622217_1 CDM 0258 RC 00990-7922-09 NDC J7060 HCPCS inpatient 1 UN 61.1 39.72 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.3 67.6 999999999 37 59.27 percent of total billed charges CT scan of heart structure with contrast 50622664_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 299.65 65 999999999 279.14 447.17 percent of total billed charges CT scan of heart structure with contrast 50622664_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 447.17 97 999999999 279.14 447.17 percent of total billed charges CT scan of heart structure with contrast 50622664_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 AETNA AETNA 364.19 79 999999999 279.14 447.17 percent of total billed charges CT scan of heart structure with contrast 50622664_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 359.58 78 999999999 279.14 447.17 percent of total billed charges CT scan of heart structure with contrast 50622664_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 318.09 69 999999999 279.14 447.17 percent of total billed charges CT scan of heart structure with contrast 50622664_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 SIHO - ALL PLANS SIHO - ALL PLANS 414.9 90 999999999 279.14 447.17 percent of total billed charges CT scan of heart structure with contrast 50622664_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 UMR - ALL PLANS UMR - ALL PLANS 322.7 70 999999999 279.14 447.17 percent of total billed charges CT scan of heart structure with contrast 50622664_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 279.14 60.55 999999999 279.14 447.17 percent of total billed charges CT scan of heart structure with contrast 50622664_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 279.14 447.17 CT scan of heart structure with contrast 50622664_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 ANTHEM HMO ANTHEM HMO 999999999 279.14 447.17 CT scan of heart structure with contrast 50622664_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 279.14 447.17 CT scan of heart structure with contrast 50622664_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 279.14 447.17 CT scan of heart structure with contrast 50622664_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 279.14 447.17 CT scan of heart structure with contrast 50622664_1 CDM 0350 RC 75572 HCPCS inpatient 461 299.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 311.64 67.6 999999999 279.14 447.17 percent of total billed charges "INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ" 50622752_1 CDM 0258 RC 00990-7905-09 NDC J3480 HCPCS inpatient 1 UN 57.79 37.56 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.56 65 999999999 34.99 56.06 percent of total billed charges "INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ" 50622752_1 CDM 0258 RC 00990-7905-09 NDC J3480 HCPCS inpatient 1 UN 57.79 37.56 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.06 97 999999999 34.99 56.06 percent of total billed charges "INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ" 50622752_1 CDM 0258 RC 00990-7905-09 NDC J3480 HCPCS inpatient 1 UN 57.79 37.56 AETNA AETNA 45.65 79 999999999 34.99 56.06 percent of total billed charges "INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ" 50622752_1 CDM 0258 RC 00990-7905-09 NDC J3480 HCPCS inpatient 1 UN 57.79 37.56 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.08 78 999999999 34.99 56.06 percent of total billed charges "INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ" 50622752_1 CDM 0258 RC 00990-7905-09 NDC J3480 HCPCS inpatient 1 UN 57.79 37.56 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.88 69 999999999 34.99 56.06 percent of total billed charges "INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ" 50622752_1 CDM 0258 RC 00990-7905-09 NDC J3480 HCPCS inpatient 1 UN 57.79 37.56 SIHO - ALL PLANS SIHO - ALL PLANS 52.01 90 999999999 34.99 56.06 percent of total billed charges "INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ" 50622752_1 CDM 0258 RC 00990-7905-09 NDC J3480 HCPCS inpatient 1 UN 57.79 37.56 UMR - ALL PLANS UMR - ALL PLANS 40.45 70 999999999 34.99 56.06 percent of total billed charges "INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ" 50622752_1 CDM 0258 RC 00990-7905-09 NDC J3480 HCPCS inpatient 1 UN 57.79 37.56 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.99 60.55 999999999 34.99 56.06 percent of total billed charges "INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ" 50622752_1 CDM 0258 RC 00990-7905-09 NDC J3480 HCPCS inpatient 1 UN 57.79 37.56 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.99 56.06 "INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ" 50622752_1 CDM 0258 RC 00990-7905-09 NDC J3480 HCPCS inpatient 1 UN 57.79 37.56 ANTHEM HMO ANTHEM HMO 999999999 34.99 56.06 "INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ" 50622752_1 CDM 0258 RC 00990-7905-09 NDC J3480 HCPCS inpatient 1 UN 57.79 37.56 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.99 56.06 "INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ" 50622752_1 CDM 0258 RC 00990-7905-09 NDC J3480 HCPCS inpatient 1 UN 57.79 37.56 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.99 56.06 "INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ" 50622752_1 CDM 0258 RC 00990-7905-09 NDC J3480 HCPCS inpatient 1 UN 57.79 37.56 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.99 56.06 "INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ" 50622752_1 CDM 0258 RC 00990-7905-09 NDC J3480 HCPCS inpatient 1 UN 57.79 37.56 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.07 67.6 999999999 34.99 56.06 percent of total billed charges BUMETANIDE 1 MG/4 ML VIAL 50622753_1 CDM 0250 RC 00409-1412-04 NDC inpatient 1 UN 15.44 10.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.04 65 999999999 9.35 14.98 percent of total billed charges BUMETANIDE 1 MG/4 ML VIAL 50622753_1 CDM 0250 RC 00409-1412-04 NDC inpatient 1 UN 15.44 10.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14.98 97 999999999 9.35 14.98 percent of total billed charges BUMETANIDE 1 MG/4 ML VIAL 50622753_1 CDM 0250 RC 00409-1412-04 NDC inpatient 1 UN 15.44 10.04 AETNA AETNA 12.2 79 999999999 9.35 14.98 percent of total billed charges BUMETANIDE 1 MG/4 ML VIAL 50622753_1 CDM 0250 RC 00409-1412-04 NDC inpatient 1 UN 15.44 10.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.04 78 999999999 9.35 14.98 percent of total billed charges BUMETANIDE 1 MG/4 ML VIAL 50622753_1 CDM 0250 RC 00409-1412-04 NDC inpatient 1 UN 15.44 10.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.65 69 999999999 9.35 14.98 percent of total billed charges BUMETANIDE 1 MG/4 ML VIAL 50622753_1 CDM 0250 RC 00409-1412-04 NDC inpatient 1 UN 15.44 10.04 SIHO - ALL PLANS SIHO - ALL PLANS 13.9 90 999999999 9.35 14.98 percent of total billed charges BUMETANIDE 1 MG/4 ML VIAL 50622753_1 CDM 0250 RC 00409-1412-04 NDC inpatient 1 UN 15.44 10.04 UMR - ALL PLANS UMR - ALL PLANS 10.81 70 999999999 9.35 14.98 percent of total billed charges BUMETANIDE 1 MG/4 ML VIAL 50622753_1 CDM 0250 RC 00409-1412-04 NDC inpatient 1 UN 15.44 10.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.35 60.55 999999999 9.35 14.98 percent of total billed charges BUMETANIDE 1 MG/4 ML VIAL 50622753_1 CDM 0250 RC 00409-1412-04 NDC inpatient 1 UN 15.44 10.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.35 14.98 BUMETANIDE 1 MG/4 ML VIAL 50622753_1 CDM 0250 RC 00409-1412-04 NDC inpatient 1 UN 15.44 10.04 ANTHEM HMO ANTHEM HMO 999999999 9.35 14.98 BUMETANIDE 1 MG/4 ML VIAL 50622753_1 CDM 0250 RC 00409-1412-04 NDC inpatient 1 UN 15.44 10.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.35 14.98 BUMETANIDE 1 MG/4 ML VIAL 50622753_1 CDM 0250 RC 00409-1412-04 NDC inpatient 1 UN 15.44 10.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.35 14.98 BUMETANIDE 1 MG/4 ML VIAL 50622753_1 CDM 0250 RC 00409-1412-04 NDC inpatient 1 UN 15.44 10.04 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.35 14.98 BUMETANIDE 1 MG/4 ML VIAL 50622753_1 CDM 0250 RC 00409-1412-04 NDC inpatient 1 UN 15.44 10.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.44 67.6 999999999 9.35 14.98 percent of total billed charges SILDENAFIL 20 MG TABLET 50622757_1 CDM 0250 RC 60687-0416-21 NDC inpatient 1 UN 2.35 1.53 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.53 65 999999999 1.42 2.28 percent of total billed charges SILDENAFIL 20 MG TABLET 50622757_1 CDM 0250 RC 60687-0416-21 NDC inpatient 1 UN 2.35 1.53 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.28 97 999999999 1.42 2.28 percent of total billed charges SILDENAFIL 20 MG TABLET 50622757_1 CDM 0250 RC 60687-0416-21 NDC inpatient 1 UN 2.35 1.53 AETNA AETNA 1.86 79 999999999 1.42 2.28 percent of total billed charges SILDENAFIL 20 MG TABLET 50622757_1 CDM 0250 RC 60687-0416-21 NDC inpatient 1 UN 2.35 1.53 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.83 78 999999999 1.42 2.28 percent of total billed charges SILDENAFIL 20 MG TABLET 50622757_1 CDM 0250 RC 60687-0416-21 NDC inpatient 1 UN 2.35 1.53 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.62 69 999999999 1.42 2.28 percent of total billed charges SILDENAFIL 20 MG TABLET 50622757_1 CDM 0250 RC 60687-0416-21 NDC inpatient 1 UN 2.35 1.53 SIHO - ALL PLANS SIHO - ALL PLANS 2.12 90 999999999 1.42 2.28 percent of total billed charges SILDENAFIL 20 MG TABLET 50622757_1 CDM 0250 RC 60687-0416-21 NDC inpatient 1 UN 2.35 1.53 UMR - ALL PLANS UMR - ALL PLANS 1.65 70 999999999 1.42 2.28 percent of total billed charges SILDENAFIL 20 MG TABLET 50622757_1 CDM 0250 RC 60687-0416-21 NDC inpatient 1 UN 2.35 1.53 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.42 60.55 999999999 1.42 2.28 percent of total billed charges SILDENAFIL 20 MG TABLET 50622757_1 CDM 0250 RC 60687-0416-21 NDC inpatient 1 UN 2.35 1.53 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.42 2.28 SILDENAFIL 20 MG TABLET 50622757_1 CDM 0250 RC 60687-0416-21 NDC inpatient 1 UN 2.35 1.53 ANTHEM HMO ANTHEM HMO 999999999 1.42 2.28 SILDENAFIL 20 MG TABLET 50622757_1 CDM 0250 RC 60687-0416-21 NDC inpatient 1 UN 2.35 1.53 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.42 2.28 SILDENAFIL 20 MG TABLET 50622757_1 CDM 0250 RC 60687-0416-21 NDC inpatient 1 UN 2.35 1.53 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.42 2.28 SILDENAFIL 20 MG TABLET 50622757_1 CDM 0250 RC 60687-0416-21 NDC inpatient 1 UN 2.35 1.53 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.42 2.28 SILDENAFIL 20 MG TABLET 50622757_1 CDM 0250 RC 60687-0416-21 NDC inpatient 1 UN 2.35 1.53 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.59 67.6 999999999 1.42 2.28 percent of total billed charges "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623330_1 CDM 0636 RC Q4102 HCPCS inpatient 1243 807.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 807.95 65 999999999 752.64 1205.71 percent of total billed charges "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623330_1 CDM 0636 RC Q4102 HCPCS inpatient 1243 807.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1205.71 97 999999999 752.64 1205.71 percent of total billed charges "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623330_1 CDM 0636 RC Q4102 HCPCS inpatient 1243 807.95 AETNA AETNA 981.97 79 999999999 752.64 1205.71 percent of total billed charges "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623330_1 CDM 0636 RC Q4102 HCPCS inpatient 1243 807.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 969.54 78 999999999 752.64 1205.71 percent of total billed charges "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623330_1 CDM 0636 RC Q4102 HCPCS inpatient 1243 807.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 857.67 69 999999999 752.64 1205.71 percent of total billed charges "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623330_1 CDM 0636 RC Q4102 HCPCS inpatient 1243 807.95 SIHO - ALL PLANS SIHO - ALL PLANS 1118.7 90 999999999 752.64 1205.71 percent of total billed charges "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623330_1 CDM 0636 RC Q4102 HCPCS inpatient 1243 807.95 UMR - ALL PLANS UMR - ALL PLANS 870.1 70 999999999 752.64 1205.71 percent of total billed charges "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623330_1 CDM 0636 RC Q4102 HCPCS inpatient 1243 807.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 752.64 60.55 999999999 752.64 1205.71 percent of total billed charges "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623330_1 CDM 0636 RC Q4102 HCPCS inpatient 1243 807.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 752.64 1205.71 "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623330_1 CDM 0636 RC Q4102 HCPCS inpatient 1243 807.95 ANTHEM HMO ANTHEM HMO 999999999 752.64 1205.71 "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623330_1 CDM 0636 RC Q4102 HCPCS inpatient 1243 807.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 752.64 1205.71 "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623330_1 CDM 0636 RC Q4102 HCPCS inpatient 1243 807.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 752.64 1205.71 "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623330_1 CDM 0636 RC Q4102 HCPCS inpatient 1243 807.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 752.64 1205.71 "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623330_1 CDM 0636 RC Q4102 HCPCS inpatient 1243 807.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 840.27 67.6 999999999 752.64 1205.71 percent of total billed charges "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623331_1 CDM 0636 RC Q4102 HCPCS inpatient 2483 1613.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1613.95 65 999999999 1503.46 2408.51 percent of total billed charges "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623331_1 CDM 0636 RC Q4102 HCPCS inpatient 2483 1613.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2408.51 97 999999999 1503.46 2408.51 percent of total billed charges "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623331_1 CDM 0636 RC Q4102 HCPCS inpatient 2483 1613.95 AETNA AETNA 1961.57 79 999999999 1503.46 2408.51 percent of total billed charges "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623331_1 CDM 0636 RC Q4102 HCPCS inpatient 2483 1613.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1936.74 78 999999999 1503.46 2408.51 percent of total billed charges "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623331_1 CDM 0636 RC Q4102 HCPCS inpatient 2483 1613.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1713.27 69 999999999 1503.46 2408.51 percent of total billed charges "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623331_1 CDM 0636 RC Q4102 HCPCS inpatient 2483 1613.95 SIHO - ALL PLANS SIHO - ALL PLANS 2234.7 90 999999999 1503.46 2408.51 percent of total billed charges "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623331_1 CDM 0636 RC Q4102 HCPCS inpatient 2483 1613.95 UMR - ALL PLANS UMR - ALL PLANS 1738.1 70 999999999 1503.46 2408.51 percent of total billed charges "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623331_1 CDM 0636 RC Q4102 HCPCS inpatient 2483 1613.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1503.46 60.55 999999999 1503.46 2408.51 percent of total billed charges "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623331_1 CDM 0636 RC Q4102 HCPCS inpatient 2483 1613.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1503.46 2408.51 "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623331_1 CDM 0636 RC Q4102 HCPCS inpatient 2483 1613.95 ANTHEM HMO ANTHEM HMO 999999999 1503.46 2408.51 "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623331_1 CDM 0636 RC Q4102 HCPCS inpatient 2483 1613.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1503.46 2408.51 "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623331_1 CDM 0636 RC Q4102 HCPCS inpatient 2483 1613.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1503.46 2408.51 "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623331_1 CDM 0636 RC Q4102 HCPCS inpatient 2483 1613.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1503.46 2408.51 "OASIS WOUND MATRIX, PER SQUARE CENTIMETER" 50623331_1 CDM 0636 RC Q4102 HCPCS inpatient 2483 1613.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1678.51 67.6 999999999 1503.46 2408.51 percent of total billed charges SUTURE O MAXON T-12 GREEN MONOFILAMENT AB. 27in 8886626761 50625970_1 CDM 0272 RC inpatient 41 26.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.65 65 999999999 24.83 39.77 percent of total billed charges SUTURE O MAXON T-12 GREEN MONOFILAMENT AB. 27in 8886626761 50625970_1 CDM 0272 RC inpatient 41 26.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39.77 97 999999999 24.83 39.77 percent of total billed charges SUTURE O MAXON T-12 GREEN MONOFILAMENT AB. 27in 8886626761 50625970_1 CDM 0272 RC inpatient 41 26.65 AETNA AETNA 32.39 79 999999999 24.83 39.77 percent of total billed charges SUTURE O MAXON T-12 GREEN MONOFILAMENT AB. 27in 8886626761 50625970_1 CDM 0272 RC inpatient 41 26.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.98 78 999999999 24.83 39.77 percent of total billed charges SUTURE O MAXON T-12 GREEN MONOFILAMENT AB. 27in 8886626761 50625970_1 CDM 0272 RC inpatient 41 26.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.29 69 999999999 24.83 39.77 percent of total billed charges SUTURE O MAXON T-12 GREEN MONOFILAMENT AB. 27in 8886626761 50625970_1 CDM 0272 RC inpatient 41 26.65 SIHO - ALL PLANS SIHO - ALL PLANS 36.9 90 999999999 24.83 39.77 percent of total billed charges SUTURE O MAXON T-12 GREEN MONOFILAMENT AB. 27in 8886626761 50625970_1 CDM 0272 RC inpatient 41 26.65 UMR - ALL PLANS UMR - ALL PLANS 28.7 70 999999999 24.83 39.77 percent of total billed charges SUTURE O MAXON T-12 GREEN MONOFILAMENT AB. 27in 8886626761 50625970_1 CDM 0272 RC inpatient 41 26.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.83 60.55 999999999 24.83 39.77 percent of total billed charges SUTURE O MAXON T-12 GREEN MONOFILAMENT AB. 27in 8886626761 50625970_1 CDM 0272 RC inpatient 41 26.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.83 39.77 SUTURE O MAXON T-12 GREEN MONOFILAMENT AB. 27in 8886626761 50625970_1 CDM 0272 RC inpatient 41 26.65 ANTHEM HMO ANTHEM HMO 999999999 24.83 39.77 SUTURE O MAXON T-12 GREEN MONOFILAMENT AB. 27in 8886626761 50625970_1 CDM 0272 RC inpatient 41 26.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.83 39.77 SUTURE O MAXON T-12 GREEN MONOFILAMENT AB. 27in 8886626761 50625970_1 CDM 0272 RC inpatient 41 26.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.83 39.77 SUTURE O MAXON T-12 GREEN MONOFILAMENT AB. 27in 8886626761 50625970_1 CDM 0272 RC inpatient 41 26.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.83 39.77 SUTURE O MAXON T-12 GREEN MONOFILAMENT AB. 27in 8886626761 50625970_1 CDM 0272 RC inpatient 41 26.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.72 67.6 999999999 24.83 39.77 percent of total billed charges SODIUM BICARB 4.2% ABBOJECT 50627902_1 CDM 0250 RC 00409-5534-14 NDC inpatient 1 UN 45.87 29.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 29.82 65 999999999 27.77 44.49 percent of total billed charges SODIUM BICARB 4.2% ABBOJECT 50627902_1 CDM 0250 RC 00409-5534-14 NDC inpatient 1 UN 45.87 29.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 44.49 97 999999999 27.77 44.49 percent of total billed charges SODIUM BICARB 4.2% ABBOJECT 50627902_1 CDM 0250 RC 00409-5534-14 NDC inpatient 1 UN 45.87 29.82 AETNA AETNA 36.24 79 999999999 27.77 44.49 percent of total billed charges SODIUM BICARB 4.2% ABBOJECT 50627902_1 CDM 0250 RC 00409-5534-14 NDC inpatient 1 UN 45.87 29.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 35.78 78 999999999 27.77 44.49 percent of total billed charges SODIUM BICARB 4.2% ABBOJECT 50627902_1 CDM 0250 RC 00409-5534-14 NDC inpatient 1 UN 45.87 29.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 31.65 69 999999999 27.77 44.49 percent of total billed charges SODIUM BICARB 4.2% ABBOJECT 50627902_1 CDM 0250 RC 00409-5534-14 NDC inpatient 1 UN 45.87 29.82 SIHO - ALL PLANS SIHO - ALL PLANS 41.28 90 999999999 27.77 44.49 percent of total billed charges SODIUM BICARB 4.2% ABBOJECT 50627902_1 CDM 0250 RC 00409-5534-14 NDC inpatient 1 UN 45.87 29.82 UMR - ALL PLANS UMR - ALL PLANS 32.11 70 999999999 27.77 44.49 percent of total billed charges SODIUM BICARB 4.2% ABBOJECT 50627902_1 CDM 0250 RC 00409-5534-14 NDC inpatient 1 UN 45.87 29.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27.77 60.55 999999999 27.77 44.49 percent of total billed charges SODIUM BICARB 4.2% ABBOJECT 50627902_1 CDM 0250 RC 00409-5534-14 NDC inpatient 1 UN 45.87 29.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 27.77 44.49 SODIUM BICARB 4.2% ABBOJECT 50627902_1 CDM 0250 RC 00409-5534-14 NDC inpatient 1 UN 45.87 29.82 ANTHEM HMO ANTHEM HMO 999999999 27.77 44.49 SODIUM BICARB 4.2% ABBOJECT 50627902_1 CDM 0250 RC 00409-5534-14 NDC inpatient 1 UN 45.87 29.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 27.77 44.49 SODIUM BICARB 4.2% ABBOJECT 50627902_1 CDM 0250 RC 00409-5534-14 NDC inpatient 1 UN 45.87 29.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 27.77 44.49 SODIUM BICARB 4.2% ABBOJECT 50627902_1 CDM 0250 RC 00409-5534-14 NDC inpatient 1 UN 45.87 29.82 UHC - ALL PLANS UHC - ALL PLANS 999999999 27.77 44.49 SODIUM BICARB 4.2% ABBOJECT 50627902_1 CDM 0250 RC 00409-5534-14 NDC inpatient 1 UN 45.87 29.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 31.01 67.6 999999999 27.77 44.49 percent of total billed charges Clotting factor XI (PTA) measurement 50628105_1 CDM 0305 RC 85270 HCPCS inpatient 464 301.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 301.6 65 999999999 280.95 450.08 percent of total billed charges Clotting factor XI (PTA) measurement 50628105_1 CDM 0305 RC 85270 HCPCS inpatient 464 301.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 450.08 97 999999999 280.95 450.08 percent of total billed charges Clotting factor XI (PTA) measurement 50628105_1 CDM 0305 RC 85270 HCPCS inpatient 464 301.6 AETNA AETNA 366.56 79 999999999 280.95 450.08 percent of total billed charges Clotting factor XI (PTA) measurement 50628105_1 CDM 0305 RC 85270 HCPCS inpatient 464 301.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 361.92 78 999999999 280.95 450.08 percent of total billed charges Clotting factor XI (PTA) measurement 50628105_1 CDM 0305 RC 85270 HCPCS inpatient 464 301.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 320.16 69 999999999 280.95 450.08 percent of total billed charges Clotting factor XI (PTA) measurement 50628105_1 CDM 0305 RC 85270 HCPCS inpatient 464 301.6 SIHO - ALL PLANS SIHO - ALL PLANS 417.6 90 999999999 280.95 450.08 percent of total billed charges Clotting factor XI (PTA) measurement 50628105_1 CDM 0305 RC 85270 HCPCS inpatient 464 301.6 UMR - ALL PLANS UMR - ALL PLANS 324.8 70 999999999 280.95 450.08 percent of total billed charges Clotting factor XI (PTA) measurement 50628105_1 CDM 0305 RC 85270 HCPCS inpatient 464 301.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 280.95 60.55 999999999 280.95 450.08 percent of total billed charges Clotting factor XI (PTA) measurement 50628105_1 CDM 0305 RC 85270 HCPCS inpatient 464 301.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 280.95 450.08 Clotting factor XI (PTA) measurement 50628105_1 CDM 0305 RC 85270 HCPCS inpatient 464 301.6 ANTHEM HMO ANTHEM HMO 999999999 280.95 450.08 Clotting factor XI (PTA) measurement 50628105_1 CDM 0305 RC 85270 HCPCS inpatient 464 301.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 280.95 450.08 Clotting factor XI (PTA) measurement 50628105_1 CDM 0305 RC 85270 HCPCS inpatient 464 301.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 280.95 450.08 Clotting factor XI (PTA) measurement 50628105_1 CDM 0305 RC 85270 HCPCS inpatient 464 301.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 280.95 450.08 Clotting factor XI (PTA) measurement 50628105_1 CDM 0305 RC 85270 HCPCS inpatient 464 301.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 313.66 67.6 999999999 280.95 450.08 percent of total billed charges DICLOFENAC SOD DR 75 MG TAB 50628343_1 CDM 0250 RC 68084-0333-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges DICLOFENAC SOD DR 75 MG TAB 50628343_1 CDM 0250 RC 68084-0333-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges DICLOFENAC SOD DR 75 MG TAB 50628343_1 CDM 0250 RC 68084-0333-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges DICLOFENAC SOD DR 75 MG TAB 50628343_1 CDM 0250 RC 68084-0333-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges DICLOFENAC SOD DR 75 MG TAB 50628343_1 CDM 0250 RC 68084-0333-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges DICLOFENAC SOD DR 75 MG TAB 50628343_1 CDM 0250 RC 68084-0333-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges DICLOFENAC SOD DR 75 MG TAB 50628343_1 CDM 0250 RC 68084-0333-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges DICLOFENAC SOD DR 75 MG TAB 50628343_1 CDM 0250 RC 68084-0333-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges DICLOFENAC SOD DR 75 MG TAB 50628343_1 CDM 0250 RC 68084-0333-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 DICLOFENAC SOD DR 75 MG TAB 50628343_1 CDM 0250 RC 68084-0333-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 DICLOFENAC SOD DR 75 MG TAB 50628343_1 CDM 0250 RC 68084-0333-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 DICLOFENAC SOD DR 75 MG TAB 50628343_1 CDM 0250 RC 68084-0333-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 DICLOFENAC SOD DR 75 MG TAB 50628343_1 CDM 0250 RC 68084-0333-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 DICLOFENAC SOD DR 75 MG TAB 50628343_1 CDM 0250 RC 68084-0333-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "INJECTION, OBINUTUZUMAB, 10 MG" 50628781_1 CDM 0636 RC 50242-0070-01 NDC J9301 HCPCS inpatient 100 UN 1731.87 1125.72 SELF PAY DISCOUNT SELF PAY DISCOUNT 1125.72 65 999999999 1048.65 1679.91 percent of total billed charges "INJECTION, OBINUTUZUMAB, 10 MG" 50628781_1 CDM 0636 RC 50242-0070-01 NDC J9301 HCPCS inpatient 100 UN 1731.87 1125.72 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1679.91 97 999999999 1048.65 1679.91 percent of total billed charges "INJECTION, OBINUTUZUMAB, 10 MG" 50628781_1 CDM 0636 RC 50242-0070-01 NDC J9301 HCPCS inpatient 100 UN 1731.87 1125.72 AETNA AETNA 1368.18 79 999999999 1048.65 1679.91 percent of total billed charges "INJECTION, OBINUTUZUMAB, 10 MG" 50628781_1 CDM 0636 RC 50242-0070-01 NDC J9301 HCPCS inpatient 100 UN 1731.87 1125.72 HUMANA - ALL PLANS HUMANA - ALL PLANS 1350.86 78 999999999 1048.65 1679.91 percent of total billed charges "INJECTION, OBINUTUZUMAB, 10 MG" 50628781_1 CDM 0636 RC 50242-0070-01 NDC J9301 HCPCS inpatient 100 UN 1731.87 1125.72 ENCORE - ALL PLANS ENCORE - ALL PLANS 1194.99 69 999999999 1048.65 1679.91 percent of total billed charges "INJECTION, OBINUTUZUMAB, 10 MG" 50628781_1 CDM 0636 RC 50242-0070-01 NDC J9301 HCPCS inpatient 100 UN 1731.87 1125.72 SIHO - ALL PLANS SIHO - ALL PLANS 1558.68 90 999999999 1048.65 1679.91 percent of total billed charges "INJECTION, OBINUTUZUMAB, 10 MG" 50628781_1 CDM 0636 RC 50242-0070-01 NDC J9301 HCPCS inpatient 100 UN 1731.87 1125.72 UMR - ALL PLANS UMR - ALL PLANS 1212.31 70 999999999 1048.65 1679.91 percent of total billed charges "INJECTION, OBINUTUZUMAB, 10 MG" 50628781_1 CDM 0636 RC 50242-0070-01 NDC J9301 HCPCS inpatient 100 UN 1731.87 1125.72 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1048.65 60.55 999999999 1048.65 1679.91 percent of total billed charges "INJECTION, OBINUTUZUMAB, 10 MG" 50628781_1 CDM 0636 RC 50242-0070-01 NDC J9301 HCPCS inpatient 100 UN 1731.87 1125.72 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1048.65 1679.91 "INJECTION, OBINUTUZUMAB, 10 MG" 50628781_1 CDM 0636 RC 50242-0070-01 NDC J9301 HCPCS inpatient 100 UN 1731.87 1125.72 ANTHEM HMO ANTHEM HMO 999999999 1048.65 1679.91 "INJECTION, OBINUTUZUMAB, 10 MG" 50628781_1 CDM 0636 RC 50242-0070-01 NDC J9301 HCPCS inpatient 100 UN 1731.87 1125.72 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1048.65 1679.91 "INJECTION, OBINUTUZUMAB, 10 MG" 50628781_1 CDM 0636 RC 50242-0070-01 NDC J9301 HCPCS inpatient 100 UN 1731.87 1125.72 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1048.65 1679.91 "INJECTION, OBINUTUZUMAB, 10 MG" 50628781_1 CDM 0636 RC 50242-0070-01 NDC J9301 HCPCS inpatient 100 UN 1731.87 1125.72 UHC - ALL PLANS UHC - ALL PLANS 999999999 1048.65 1679.91 "INJECTION, OBINUTUZUMAB, 10 MG" 50628781_1 CDM 0636 RC 50242-0070-01 NDC J9301 HCPCS inpatient 100 UN 1731.87 1125.72 CIGNA - ALL PLANS CIGNA - ALL PLANS 1170.74 67.6 999999999 1048.65 1679.91 percent of total billed charges Clotting factor XIII (fibrin stabilizing) screening test 50628791_1 CDM 0306 RC 85291 HCPCS inpatient 122 79.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.3 65 999999999 73.87 118.34 percent of total billed charges Clotting factor XIII (fibrin stabilizing) screening test 50628791_1 CDM 0306 RC 85291 HCPCS inpatient 122 79.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 118.34 97 999999999 73.87 118.34 percent of total billed charges Clotting factor XIII (fibrin stabilizing) screening test 50628791_1 CDM 0306 RC 85291 HCPCS inpatient 122 79.3 AETNA AETNA 96.38 79 999999999 73.87 118.34 percent of total billed charges Clotting factor XIII (fibrin stabilizing) screening test 50628791_1 CDM 0306 RC 85291 HCPCS inpatient 122 79.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.16 78 999999999 73.87 118.34 percent of total billed charges Clotting factor XIII (fibrin stabilizing) screening test 50628791_1 CDM 0306 RC 85291 HCPCS inpatient 122 79.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.18 69 999999999 73.87 118.34 percent of total billed charges Clotting factor XIII (fibrin stabilizing) screening test 50628791_1 CDM 0306 RC 85291 HCPCS inpatient 122 79.3 SIHO - ALL PLANS SIHO - ALL PLANS 109.8 90 999999999 73.87 118.34 percent of total billed charges Clotting factor XIII (fibrin stabilizing) screening test 50628791_1 CDM 0306 RC 85291 HCPCS inpatient 122 79.3 UMR - ALL PLANS UMR - ALL PLANS 85.4 70 999999999 73.87 118.34 percent of total billed charges Clotting factor XIII (fibrin stabilizing) screening test 50628791_1 CDM 0306 RC 85291 HCPCS inpatient 122 79.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.87 60.55 999999999 73.87 118.34 percent of total billed charges Clotting factor XIII (fibrin stabilizing) screening test 50628791_1 CDM 0306 RC 85291 HCPCS inpatient 122 79.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.87 118.34 Clotting factor XIII (fibrin stabilizing) screening test 50628791_1 CDM 0306 RC 85291 HCPCS inpatient 122 79.3 ANTHEM HMO ANTHEM HMO 999999999 73.87 118.34 Clotting factor XIII (fibrin stabilizing) screening test 50628791_1 CDM 0306 RC 85291 HCPCS inpatient 122 79.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.87 118.34 Clotting factor XIII (fibrin stabilizing) screening test 50628791_1 CDM 0306 RC 85291 HCPCS inpatient 122 79.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.87 118.34 Clotting factor XIII (fibrin stabilizing) screening test 50628791_1 CDM 0306 RC 85291 HCPCS inpatient 122 79.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.87 118.34 Clotting factor XIII (fibrin stabilizing) screening test 50628791_1 CDM 0306 RC 85291 HCPCS inpatient 122 79.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 82.47 67.6 999999999 73.87 118.34 percent of total billed charges Gammaglobulin (immune system protein) measurement 50628889_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.7 65 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50628889_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 153.26 97 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50628889_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 AETNA AETNA 124.82 79 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50628889_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 123.24 78 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50628889_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 109.02 69 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50628889_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 SIHO - ALL PLANS SIHO - ALL PLANS 142.2 90 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50628889_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 UMR - ALL PLANS UMR - ALL PLANS 110.6 70 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50628889_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.67 60.55 999999999 95.67 153.26 percent of total billed charges Gammaglobulin (immune system protein) measurement 50628889_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50628889_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ANTHEM HMO ANTHEM HMO 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50628889_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50628889_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50628889_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.67 153.26 Gammaglobulin (immune system protein) measurement 50628889_1 CDM 0301 RC 82784 HCPCS inpatient 158 102.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.81 67.6 999999999 95.67 153.26 percent of total billed charges Antithrombin III antigen (clotting inhibitor) activity 50628920_1 CDM 0305 RC 85300 HCPCS inpatient 257 167.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 167.05 65 999999999 155.61 249.29 percent of total billed charges Antithrombin III antigen (clotting inhibitor) activity 50628920_1 CDM 0305 RC 85300 HCPCS inpatient 257 167.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 249.29 97 999999999 155.61 249.29 percent of total billed charges Antithrombin III antigen (clotting inhibitor) activity 50628920_1 CDM 0305 RC 85300 HCPCS inpatient 257 167.05 AETNA AETNA 203.03 79 999999999 155.61 249.29 percent of total billed charges Antithrombin III antigen (clotting inhibitor) activity 50628920_1 CDM 0305 RC 85300 HCPCS inpatient 257 167.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 200.46 78 999999999 155.61 249.29 percent of total billed charges Antithrombin III antigen (clotting inhibitor) activity 50628920_1 CDM 0305 RC 85300 HCPCS inpatient 257 167.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 177.33 69 999999999 155.61 249.29 percent of total billed charges Antithrombin III antigen (clotting inhibitor) activity 50628920_1 CDM 0305 RC 85300 HCPCS inpatient 257 167.05 SIHO - ALL PLANS SIHO - ALL PLANS 231.3 90 999999999 155.61 249.29 percent of total billed charges Antithrombin III antigen (clotting inhibitor) activity 50628920_1 CDM 0305 RC 85300 HCPCS inpatient 257 167.05 UMR - ALL PLANS UMR - ALL PLANS 179.9 70 999999999 155.61 249.29 percent of total billed charges Antithrombin III antigen (clotting inhibitor) activity 50628920_1 CDM 0305 RC 85300 HCPCS inpatient 257 167.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.61 60.55 999999999 155.61 249.29 percent of total billed charges Antithrombin III antigen (clotting inhibitor) activity 50628920_1 CDM 0305 RC 85300 HCPCS inpatient 257 167.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.61 249.29 Antithrombin III antigen (clotting inhibitor) activity 50628920_1 CDM 0305 RC 85300 HCPCS inpatient 257 167.05 ANTHEM HMO ANTHEM HMO 999999999 155.61 249.29 Antithrombin III antigen (clotting inhibitor) activity 50628920_1 CDM 0305 RC 85300 HCPCS inpatient 257 167.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.61 249.29 Antithrombin III antigen (clotting inhibitor) activity 50628920_1 CDM 0305 RC 85300 HCPCS inpatient 257 167.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.61 249.29 Antithrombin III antigen (clotting inhibitor) activity 50628920_1 CDM 0305 RC 85300 HCPCS inpatient 257 167.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.61 249.29 Antithrombin III antigen (clotting inhibitor) activity 50628920_1 CDM 0305 RC 85300 HCPCS inpatient 257 167.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.73 67.6 999999999 155.61 249.29 percent of total billed charges SULFAMETHOXAZOLE-TMP IV VIAL 50629162_1 CDM 0250 RC 70069-0361-10 NDC inpatient 420 UN 14.11 9.17 AETNA AETNA 11.15 79 999999999 8.54 13.69 percent of total billed charges SULFAMETHOXAZOLE-TMP IV VIAL 50629162_1 CDM 0250 RC 70069-0361-10 NDC inpatient 420 UN 14.11 9.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.17 65 999999999 8.54 13.69 percent of total billed charges SULFAMETHOXAZOLE-TMP IV VIAL 50629162_1 CDM 0250 RC 70069-0361-10 NDC inpatient 420 UN 14.11 9.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13.69 97 999999999 8.54 13.69 percent of total billed charges SULFAMETHOXAZOLE-TMP IV VIAL 50629162_1 CDM 0250 RC 70069-0361-10 NDC inpatient 420 UN 14.11 9.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.01 78 999999999 8.54 13.69 percent of total billed charges SULFAMETHOXAZOLE-TMP IV VIAL 50629162_1 CDM 0250 RC 70069-0361-10 NDC inpatient 420 UN 14.11 9.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.74 69 999999999 8.54 13.69 percent of total billed charges SULFAMETHOXAZOLE-TMP IV VIAL 50629162_1 CDM 0250 RC 70069-0361-10 NDC inpatient 420 UN 14.11 9.17 SIHO - ALL PLANS SIHO - ALL PLANS 12.7 90 999999999 8.54 13.69 percent of total billed charges SULFAMETHOXAZOLE-TMP IV VIAL 50629162_1 CDM 0250 RC 70069-0361-10 NDC inpatient 420 UN 14.11 9.17 UMR - ALL PLANS UMR - ALL PLANS 9.88 70 999999999 8.54 13.69 percent of total billed charges SULFAMETHOXAZOLE-TMP IV VIAL 50629162_1 CDM 0250 RC 70069-0361-10 NDC inpatient 420 UN 14.11 9.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.54 60.55 999999999 8.54 13.69 percent of total billed charges SULFAMETHOXAZOLE-TMP IV VIAL 50629162_1 CDM 0250 RC 70069-0361-10 NDC inpatient 420 UN 14.11 9.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.54 13.69 SULFAMETHOXAZOLE-TMP IV VIAL 50629162_1 CDM 0250 RC 70069-0361-10 NDC inpatient 420 UN 14.11 9.17 ANTHEM HMO ANTHEM HMO 999999999 8.54 13.69 SULFAMETHOXAZOLE-TMP IV VIAL 50629162_1 CDM 0250 RC 70069-0361-10 NDC inpatient 420 UN 14.11 9.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.54 13.69 SULFAMETHOXAZOLE-TMP IV VIAL 50629162_1 CDM 0250 RC 70069-0361-10 NDC inpatient 420 UN 14.11 9.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.54 13.69 SULFAMETHOXAZOLE-TMP IV VIAL 50629162_1 CDM 0250 RC 70069-0361-10 NDC inpatient 420 UN 14.11 9.17 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.54 13.69 SULFAMETHOXAZOLE-TMP IV VIAL 50629162_1 CDM 0250 RC 70069-0361-10 NDC inpatient 420 UN 14.11 9.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.54 67.6 999999999 8.54 13.69 percent of total billed charges SUTURE 4-0 VICRYL PS-1 J682G 50636381_1 CDM 0272 RC inpatient 41 26.65 AETNA AETNA 32.39 79 999999999 24.83 39.77 percent of total billed charges SUTURE 4-0 VICRYL PS-1 J682G 50636381_1 CDM 0272 RC inpatient 41 26.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.65 65 999999999 24.83 39.77 percent of total billed charges SUTURE 4-0 VICRYL PS-1 J682G 50636381_1 CDM 0272 RC inpatient 41 26.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39.77 97 999999999 24.83 39.77 percent of total billed charges SUTURE 4-0 VICRYL PS-1 J682G 50636381_1 CDM 0272 RC inpatient 41 26.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.98 78 999999999 24.83 39.77 percent of total billed charges SUTURE 4-0 VICRYL PS-1 J682G 50636381_1 CDM 0272 RC inpatient 41 26.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.29 69 999999999 24.83 39.77 percent of total billed charges SUTURE 4-0 VICRYL PS-1 J682G 50636381_1 CDM 0272 RC inpatient 41 26.65 SIHO - ALL PLANS SIHO - ALL PLANS 36.9 90 999999999 24.83 39.77 percent of total billed charges SUTURE 4-0 VICRYL PS-1 J682G 50636381_1 CDM 0272 RC inpatient 41 26.65 UMR - ALL PLANS UMR - ALL PLANS 28.7 70 999999999 24.83 39.77 percent of total billed charges SUTURE 4-0 VICRYL PS-1 J682G 50636381_1 CDM 0272 RC inpatient 41 26.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.83 60.55 999999999 24.83 39.77 percent of total billed charges SUTURE 4-0 VICRYL PS-1 J682G 50636381_1 CDM 0272 RC inpatient 41 26.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.83 39.77 SUTURE 4-0 VICRYL PS-1 J682G 50636381_1 CDM 0272 RC inpatient 41 26.65 ANTHEM HMO ANTHEM HMO 999999999 24.83 39.77 SUTURE 4-0 VICRYL PS-1 J682G 50636381_1 CDM 0272 RC inpatient 41 26.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.83 39.77 SUTURE 4-0 VICRYL PS-1 J682G 50636381_1 CDM 0272 RC inpatient 41 26.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.83 39.77 SUTURE 4-0 VICRYL PS-1 J682G 50636381_1 CDM 0272 RC inpatient 41 26.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.83 39.77 SUTURE 4-0 VICRYL PS-1 J682G 50636381_1 CDM 0272 RC inpatient 41 26.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.72 67.6 999999999 24.83 39.77 percent of total billed charges SUTURE 2-0 PLAIN GUT CTX 872H 50636393_1 CDM 0272 RC inpatient 28 18.2 AETNA AETNA 22.12 79 999999999 16.95 27.16 percent of total billed charges SUTURE 2-0 PLAIN GUT CTX 872H 50636393_1 CDM 0272 RC inpatient 28 18.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 18.2 65 999999999 16.95 27.16 percent of total billed charges SUTURE 2-0 PLAIN GUT CTX 872H 50636393_1 CDM 0272 RC inpatient 28 18.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 27.16 97 999999999 16.95 27.16 percent of total billed charges SUTURE 2-0 PLAIN GUT CTX 872H 50636393_1 CDM 0272 RC inpatient 28 18.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.84 78 999999999 16.95 27.16 percent of total billed charges SUTURE 2-0 PLAIN GUT CTX 872H 50636393_1 CDM 0272 RC inpatient 28 18.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 19.32 69 999999999 16.95 27.16 percent of total billed charges SUTURE 2-0 PLAIN GUT CTX 872H 50636393_1 CDM 0272 RC inpatient 28 18.2 SIHO - ALL PLANS SIHO - ALL PLANS 25.2 90 999999999 16.95 27.16 percent of total billed charges SUTURE 2-0 PLAIN GUT CTX 872H 50636393_1 CDM 0272 RC inpatient 28 18.2 UMR - ALL PLANS UMR - ALL PLANS 19.6 70 999999999 16.95 27.16 percent of total billed charges SUTURE 2-0 PLAIN GUT CTX 872H 50636393_1 CDM 0272 RC inpatient 28 18.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.95 60.55 999999999 16.95 27.16 percent of total billed charges SUTURE 2-0 PLAIN GUT CTX 872H 50636393_1 CDM 0272 RC inpatient 28 18.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.95 27.16 SUTURE 2-0 PLAIN GUT CTX 872H 50636393_1 CDM 0272 RC inpatient 28 18.2 ANTHEM HMO ANTHEM HMO 999999999 16.95 27.16 SUTURE 2-0 PLAIN GUT CTX 872H 50636393_1 CDM 0272 RC inpatient 28 18.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.95 27.16 SUTURE 2-0 PLAIN GUT CTX 872H 50636393_1 CDM 0272 RC inpatient 28 18.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.95 27.16 SUTURE 2-0 PLAIN GUT CTX 872H 50636393_1 CDM 0272 RC inpatient 28 18.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.95 27.16 SUTURE 2-0 PLAIN GUT CTX 872H 50636393_1 CDM 0272 RC inpatient 28 18.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.93 67.6 999999999 16.95 27.16 percent of total billed charges ARISTA ABSORBABLE HEMOSTATIC 3g BX/5 SM0002-USA 50636942_1 CDM 0272 RC inpatient 669 434.85 AETNA AETNA 528.51 79 999999999 405.08 648.93 percent of total billed charges ARISTA ABSORBABLE HEMOSTATIC 3g BX/5 SM0002-USA 50636942_1 CDM 0272 RC inpatient 669 434.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 434.85 65 999999999 405.08 648.93 percent of total billed charges ARISTA ABSORBABLE HEMOSTATIC 3g BX/5 SM0002-USA 50636942_1 CDM 0272 RC inpatient 669 434.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 648.93 97 999999999 405.08 648.93 percent of total billed charges ARISTA ABSORBABLE HEMOSTATIC 3g BX/5 SM0002-USA 50636942_1 CDM 0272 RC inpatient 669 434.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 521.82 78 999999999 405.08 648.93 percent of total billed charges ARISTA ABSORBABLE HEMOSTATIC 3g BX/5 SM0002-USA 50636942_1 CDM 0272 RC inpatient 669 434.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 461.61 69 999999999 405.08 648.93 percent of total billed charges ARISTA ABSORBABLE HEMOSTATIC 3g BX/5 SM0002-USA 50636942_1 CDM 0272 RC inpatient 669 434.85 SIHO - ALL PLANS SIHO - ALL PLANS 602.1 90 999999999 405.08 648.93 percent of total billed charges ARISTA ABSORBABLE HEMOSTATIC 3g BX/5 SM0002-USA 50636942_1 CDM 0272 RC inpatient 669 434.85 UMR - ALL PLANS UMR - ALL PLANS 468.3 70 999999999 405.08 648.93 percent of total billed charges ARISTA ABSORBABLE HEMOSTATIC 3g BX/5 SM0002-USA 50636942_1 CDM 0272 RC inpatient 669 434.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 405.08 60.55 999999999 405.08 648.93 percent of total billed charges ARISTA ABSORBABLE HEMOSTATIC 3g BX/5 SM0002-USA 50636942_1 CDM 0272 RC inpatient 669 434.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 405.08 648.93 ARISTA ABSORBABLE HEMOSTATIC 3g BX/5 SM0002-USA 50636942_1 CDM 0272 RC inpatient 669 434.85 ANTHEM HMO ANTHEM HMO 999999999 405.08 648.93 ARISTA ABSORBABLE HEMOSTATIC 3g BX/5 SM0002-USA 50636942_1 CDM 0272 RC inpatient 669 434.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 405.08 648.93 ARISTA ABSORBABLE HEMOSTATIC 3g BX/5 SM0002-USA 50636942_1 CDM 0272 RC inpatient 669 434.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 405.08 648.93 ARISTA ABSORBABLE HEMOSTATIC 3g BX/5 SM0002-USA 50636942_1 CDM 0272 RC inpatient 669 434.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 405.08 648.93 ARISTA ABSORBABLE HEMOSTATIC 3g BX/5 SM0002-USA 50636942_1 CDM 0272 RC inpatient 669 434.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 452.24 67.6 999999999 405.08 648.93 percent of total billed charges ARISTA RIGID 38cm APPLICATOR TIP 10ea/BOX AM0010 50636943_1 CDM 0272 RC inpatient 348 226.2 AETNA AETNA 274.92 79 999999999 210.71 337.56 percent of total billed charges ARISTA RIGID 38cm APPLICATOR TIP 10ea/BOX AM0010 50636943_1 CDM 0272 RC inpatient 348 226.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 226.2 65 999999999 210.71 337.56 percent of total billed charges ARISTA RIGID 38cm APPLICATOR TIP 10ea/BOX AM0010 50636943_1 CDM 0272 RC inpatient 348 226.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 337.56 97 999999999 210.71 337.56 percent of total billed charges ARISTA RIGID 38cm APPLICATOR TIP 10ea/BOX AM0010 50636943_1 CDM 0272 RC inpatient 348 226.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 271.44 78 999999999 210.71 337.56 percent of total billed charges ARISTA RIGID 38cm APPLICATOR TIP 10ea/BOX AM0010 50636943_1 CDM 0272 RC inpatient 348 226.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 240.12 69 999999999 210.71 337.56 percent of total billed charges ARISTA RIGID 38cm APPLICATOR TIP 10ea/BOX AM0010 50636943_1 CDM 0272 RC inpatient 348 226.2 SIHO - ALL PLANS SIHO - ALL PLANS 313.2 90 999999999 210.71 337.56 percent of total billed charges ARISTA RIGID 38cm APPLICATOR TIP 10ea/BOX AM0010 50636943_1 CDM 0272 RC inpatient 348 226.2 UMR - ALL PLANS UMR - ALL PLANS 243.6 70 999999999 210.71 337.56 percent of total billed charges ARISTA RIGID 38cm APPLICATOR TIP 10ea/BOX AM0010 50636943_1 CDM 0272 RC inpatient 348 226.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 210.71 60.55 999999999 210.71 337.56 percent of total billed charges ARISTA RIGID 38cm APPLICATOR TIP 10ea/BOX AM0010 50636943_1 CDM 0272 RC inpatient 348 226.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 210.71 337.56 ARISTA RIGID 38cm APPLICATOR TIP 10ea/BOX AM0010 50636943_1 CDM 0272 RC inpatient 348 226.2 ANTHEM HMO ANTHEM HMO 999999999 210.71 337.56 ARISTA RIGID 38cm APPLICATOR TIP 10ea/BOX AM0010 50636943_1 CDM 0272 RC inpatient 348 226.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 210.71 337.56 ARISTA RIGID 38cm APPLICATOR TIP 10ea/BOX AM0010 50636943_1 CDM 0272 RC inpatient 348 226.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 210.71 337.56 ARISTA RIGID 38cm APPLICATOR TIP 10ea/BOX AM0010 50636943_1 CDM 0272 RC inpatient 348 226.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 210.71 337.56 ARISTA RIGID 38cm APPLICATOR TIP 10ea/BOX AM0010 50636943_1 CDM 0272 RC inpatient 348 226.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 235.25 67.6 999999999 210.71 337.56 percent of total billed charges FLUCONAZOLE-NACL 200 MG/100 ML 50637643_1 CDM 0250 RC 25021-0184-66 NDC inpatient 1 UN 213.29 138.64 AETNA AETNA 168.5 79 999999999 129.15 206.89 percent of total billed charges FLUCONAZOLE-NACL 200 MG/100 ML 50637643_1 CDM 0250 RC 25021-0184-66 NDC inpatient 1 UN 213.29 138.64 SELF PAY DISCOUNT SELF PAY DISCOUNT 138.64 65 999999999 129.15 206.89 percent of total billed charges FLUCONAZOLE-NACL 200 MG/100 ML 50637643_1 CDM 0250 RC 25021-0184-66 NDC inpatient 1 UN 213.29 138.64 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 206.89 97 999999999 129.15 206.89 percent of total billed charges FLUCONAZOLE-NACL 200 MG/100 ML 50637643_1 CDM 0250 RC 25021-0184-66 NDC inpatient 1 UN 213.29 138.64 HUMANA - ALL PLANS HUMANA - ALL PLANS 166.37 78 999999999 129.15 206.89 percent of total billed charges FLUCONAZOLE-NACL 200 MG/100 ML 50637643_1 CDM 0250 RC 25021-0184-66 NDC inpatient 1 UN 213.29 138.64 ENCORE - ALL PLANS ENCORE - ALL PLANS 147.17 69 999999999 129.15 206.89 percent of total billed charges FLUCONAZOLE-NACL 200 MG/100 ML 50637643_1 CDM 0250 RC 25021-0184-66 NDC inpatient 1 UN 213.29 138.64 SIHO - ALL PLANS SIHO - ALL PLANS 191.96 90 999999999 129.15 206.89 percent of total billed charges FLUCONAZOLE-NACL 200 MG/100 ML 50637643_1 CDM 0250 RC 25021-0184-66 NDC inpatient 1 UN 213.29 138.64 UMR - ALL PLANS UMR - ALL PLANS 149.3 70 999999999 129.15 206.89 percent of total billed charges FLUCONAZOLE-NACL 200 MG/100 ML 50637643_1 CDM 0250 RC 25021-0184-66 NDC inpatient 1 UN 213.29 138.64 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 129.15 60.55 999999999 129.15 206.89 percent of total billed charges FLUCONAZOLE-NACL 200 MG/100 ML 50637643_1 CDM 0250 RC 25021-0184-66 NDC inpatient 1 UN 213.29 138.64 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 129.15 206.89 FLUCONAZOLE-NACL 200 MG/100 ML 50637643_1 CDM 0250 RC 25021-0184-66 NDC inpatient 1 UN 213.29 138.64 ANTHEM HMO ANTHEM HMO 999999999 129.15 206.89 FLUCONAZOLE-NACL 200 MG/100 ML 50637643_1 CDM 0250 RC 25021-0184-66 NDC inpatient 1 UN 213.29 138.64 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 129.15 206.89 FLUCONAZOLE-NACL 200 MG/100 ML 50637643_1 CDM 0250 RC 25021-0184-66 NDC inpatient 1 UN 213.29 138.64 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 129.15 206.89 FLUCONAZOLE-NACL 200 MG/100 ML 50637643_1 CDM 0250 RC 25021-0184-66 NDC inpatient 1 UN 213.29 138.64 UHC - ALL PLANS UHC - ALL PLANS 999999999 129.15 206.89 FLUCONAZOLE-NACL 200 MG/100 ML 50637643_1 CDM 0250 RC 25021-0184-66 NDC inpatient 1 UN 213.29 138.64 CIGNA - ALL PLANS CIGNA - ALL PLANS 144.18 67.6 999999999 129.15 206.89 percent of total billed charges ARIPIPRAZOLE 10 MG TABLET 50637964_1 CDM 0250 RC 16729-0280-10 NDC inpatient 1 UN 1.68 1.09 AETNA AETNA 1.33 79 999999999 1.02 1.63 percent of total billed charges ARIPIPRAZOLE 10 MG TABLET 50637964_1 CDM 0250 RC 16729-0280-10 NDC inpatient 1 UN 1.68 1.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.09 65 999999999 1.02 1.63 percent of total billed charges ARIPIPRAZOLE 10 MG TABLET 50637964_1 CDM 0250 RC 16729-0280-10 NDC inpatient 1 UN 1.68 1.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.63 97 999999999 1.02 1.63 percent of total billed charges ARIPIPRAZOLE 10 MG TABLET 50637964_1 CDM 0250 RC 16729-0280-10 NDC inpatient 1 UN 1.68 1.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.31 78 999999999 1.02 1.63 percent of total billed charges ARIPIPRAZOLE 10 MG TABLET 50637964_1 CDM 0250 RC 16729-0280-10 NDC inpatient 1 UN 1.68 1.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.16 69 999999999 1.02 1.63 percent of total billed charges ARIPIPRAZOLE 10 MG TABLET 50637964_1 CDM 0250 RC 16729-0280-10 NDC inpatient 1 UN 1.68 1.09 SIHO - ALL PLANS SIHO - ALL PLANS 1.51 90 999999999 1.02 1.63 percent of total billed charges ARIPIPRAZOLE 10 MG TABLET 50637964_1 CDM 0250 RC 16729-0280-10 NDC inpatient 1 UN 1.68 1.09 UMR - ALL PLANS UMR - ALL PLANS 1.18 70 999999999 1.02 1.63 percent of total billed charges ARIPIPRAZOLE 10 MG TABLET 50637964_1 CDM 0250 RC 16729-0280-10 NDC inpatient 1 UN 1.68 1.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.02 60.55 999999999 1.02 1.63 percent of total billed charges ARIPIPRAZOLE 10 MG TABLET 50637964_1 CDM 0250 RC 16729-0280-10 NDC inpatient 1 UN 1.68 1.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.02 1.63 ARIPIPRAZOLE 10 MG TABLET 50637964_1 CDM 0250 RC 16729-0280-10 NDC inpatient 1 UN 1.68 1.09 ANTHEM HMO ANTHEM HMO 999999999 1.02 1.63 ARIPIPRAZOLE 10 MG TABLET 50637964_1 CDM 0250 RC 16729-0280-10 NDC inpatient 1 UN 1.68 1.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.02 1.63 ARIPIPRAZOLE 10 MG TABLET 50637964_1 CDM 0250 RC 16729-0280-10 NDC inpatient 1 UN 1.68 1.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.02 1.63 ARIPIPRAZOLE 10 MG TABLET 50637964_1 CDM 0250 RC 16729-0280-10 NDC inpatient 1 UN 1.68 1.09 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.02 1.63 ARIPIPRAZOLE 10 MG TABLET 50637964_1 CDM 0250 RC 16729-0280-10 NDC inpatient 1 UN 1.68 1.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.14 67.6 999999999 1.02 1.63 percent of total billed charges AMPICILLIN 500 MG VIAL 50637972_1 CDM 0250 RC 44567-0101-10 NDC inpatient 1 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges AMPICILLIN 500 MG VIAL 50637972_1 CDM 0250 RC 44567-0101-10 NDC inpatient 1 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges AMPICILLIN 500 MG VIAL 50637972_1 CDM 0250 RC 44567-0101-10 NDC inpatient 1 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges AMPICILLIN 500 MG VIAL 50637972_1 CDM 0250 RC 44567-0101-10 NDC inpatient 1 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges AMPICILLIN 500 MG VIAL 50637972_1 CDM 0250 RC 44567-0101-10 NDC inpatient 1 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges AMPICILLIN 500 MG VIAL 50637972_1 CDM 0250 RC 44567-0101-10 NDC inpatient 1 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges AMPICILLIN 500 MG VIAL 50637972_1 CDM 0250 RC 44567-0101-10 NDC inpatient 1 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges AMPICILLIN 500 MG VIAL 50637972_1 CDM 0250 RC 44567-0101-10 NDC inpatient 1 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges AMPICILLIN 500 MG VIAL 50637972_1 CDM 0250 RC 44567-0101-10 NDC inpatient 1 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 AMPICILLIN 500 MG VIAL 50637972_1 CDM 0250 RC 44567-0101-10 NDC inpatient 1 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 AMPICILLIN 500 MG VIAL 50637972_1 CDM 0250 RC 44567-0101-10 NDC inpatient 1 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 AMPICILLIN 500 MG VIAL 50637972_1 CDM 0250 RC 44567-0101-10 NDC inpatient 1 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 AMPICILLIN 500 MG VIAL 50637972_1 CDM 0250 RC 44567-0101-10 NDC inpatient 1 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 AMPICILLIN 500 MG VIAL 50637972_1 CDM 0250 RC 44567-0101-10 NDC inpatient 1 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges KETAMINE 500 MG/10 ML VIAL 50638568_1 CDM 0250 RC 00143-9508-10 NDC inpatient 1 UN 41.24 26.81 AETNA AETNA 32.58 79 999999999 24.97 40 percent of total billed charges KETAMINE 500 MG/10 ML VIAL 50638568_1 CDM 0250 RC 00143-9508-10 NDC inpatient 1 UN 41.24 26.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 26.81 65 999999999 24.97 40 percent of total billed charges KETAMINE 500 MG/10 ML VIAL 50638568_1 CDM 0250 RC 00143-9508-10 NDC inpatient 1 UN 41.24 26.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 40 97 999999999 24.97 40 percent of total billed charges KETAMINE 500 MG/10 ML VIAL 50638568_1 CDM 0250 RC 00143-9508-10 NDC inpatient 1 UN 41.24 26.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 32.17 78 999999999 24.97 40 percent of total billed charges KETAMINE 500 MG/10 ML VIAL 50638568_1 CDM 0250 RC 00143-9508-10 NDC inpatient 1 UN 41.24 26.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.46 69 999999999 24.97 40 percent of total billed charges KETAMINE 500 MG/10 ML VIAL 50638568_1 CDM 0250 RC 00143-9508-10 NDC inpatient 1 UN 41.24 26.81 SIHO - ALL PLANS SIHO - ALL PLANS 37.12 90 999999999 24.97 40 percent of total billed charges KETAMINE 500 MG/10 ML VIAL 50638568_1 CDM 0250 RC 00143-9508-10 NDC inpatient 1 UN 41.24 26.81 UMR - ALL PLANS UMR - ALL PLANS 28.87 70 999999999 24.97 40 percent of total billed charges KETAMINE 500 MG/10 ML VIAL 50638568_1 CDM 0250 RC 00143-9508-10 NDC inpatient 1 UN 41.24 26.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.97 60.55 999999999 24.97 40 percent of total billed charges KETAMINE 500 MG/10 ML VIAL 50638568_1 CDM 0250 RC 00143-9508-10 NDC inpatient 1 UN 41.24 26.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.97 40 KETAMINE 500 MG/10 ML VIAL 50638568_1 CDM 0250 RC 00143-9508-10 NDC inpatient 1 UN 41.24 26.81 ANTHEM HMO ANTHEM HMO 999999999 24.97 40 KETAMINE 500 MG/10 ML VIAL 50638568_1 CDM 0250 RC 00143-9508-10 NDC inpatient 1 UN 41.24 26.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.97 40 KETAMINE 500 MG/10 ML VIAL 50638568_1 CDM 0250 RC 00143-9508-10 NDC inpatient 1 UN 41.24 26.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.97 40 KETAMINE 500 MG/10 ML VIAL 50638568_1 CDM 0250 RC 00143-9508-10 NDC inpatient 1 UN 41.24 26.81 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.97 40 KETAMINE 500 MG/10 ML VIAL 50638568_1 CDM 0250 RC 00143-9508-10 NDC inpatient 1 UN 41.24 26.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.88 67.6 999999999 24.97 40 percent of total billed charges GABAPENTIN 300 MG CAPSULE 50638844_1 CDM 0250 RC 60687-0591-01 NDC inpatient 1 UN 1.87 1.22 AETNA AETNA 1.48 79 999999999 1.13 1.81 percent of total billed charges GABAPENTIN 300 MG CAPSULE 50638844_1 CDM 0250 RC 60687-0591-01 NDC inpatient 1 UN 1.87 1.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.22 65 999999999 1.13 1.81 percent of total billed charges GABAPENTIN 300 MG CAPSULE 50638844_1 CDM 0250 RC 60687-0591-01 NDC inpatient 1 UN 1.87 1.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.81 97 999999999 1.13 1.81 percent of total billed charges GABAPENTIN 300 MG CAPSULE 50638844_1 CDM 0250 RC 60687-0591-01 NDC inpatient 1 UN 1.87 1.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.46 78 999999999 1.13 1.81 percent of total billed charges GABAPENTIN 300 MG CAPSULE 50638844_1 CDM 0250 RC 60687-0591-01 NDC inpatient 1 UN 1.87 1.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.29 69 999999999 1.13 1.81 percent of total billed charges GABAPENTIN 300 MG CAPSULE 50638844_1 CDM 0250 RC 60687-0591-01 NDC inpatient 1 UN 1.87 1.22 SIHO - ALL PLANS SIHO - ALL PLANS 1.68 90 999999999 1.13 1.81 percent of total billed charges GABAPENTIN 300 MG CAPSULE 50638844_1 CDM 0250 RC 60687-0591-01 NDC inpatient 1 UN 1.87 1.22 UMR - ALL PLANS UMR - ALL PLANS 1.31 70 999999999 1.13 1.81 percent of total billed charges GABAPENTIN 300 MG CAPSULE 50638844_1 CDM 0250 RC 60687-0591-01 NDC inpatient 1 UN 1.87 1.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.13 60.55 999999999 1.13 1.81 percent of total billed charges GABAPENTIN 300 MG CAPSULE 50638844_1 CDM 0250 RC 60687-0591-01 NDC inpatient 1 UN 1.87 1.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.13 1.81 GABAPENTIN 300 MG CAPSULE 50638844_1 CDM 0250 RC 60687-0591-01 NDC inpatient 1 UN 1.87 1.22 ANTHEM HMO ANTHEM HMO 999999999 1.13 1.81 GABAPENTIN 300 MG CAPSULE 50638844_1 CDM 0250 RC 60687-0591-01 NDC inpatient 1 UN 1.87 1.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.13 1.81 GABAPENTIN 300 MG CAPSULE 50638844_1 CDM 0250 RC 60687-0591-01 NDC inpatient 1 UN 1.87 1.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.13 1.81 GABAPENTIN 300 MG CAPSULE 50638844_1 CDM 0250 RC 60687-0591-01 NDC inpatient 1 UN 1.87 1.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.13 1.81 GABAPENTIN 300 MG CAPSULE 50638844_1 CDM 0250 RC 60687-0591-01 NDC inpatient 1 UN 1.87 1.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.26 67.6 999999999 1.13 1.81 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 50639116_1 CDM 0250 RC 69097-0807-37 NDC J0878 HCPCS inpatient 500 UN 183.38 119.2 AETNA AETNA 144.87 79 999999999 111.04 177.88 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 50639116_1 CDM 0250 RC 69097-0807-37 NDC J0878 HCPCS inpatient 500 UN 183.38 119.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 119.2 65 999999999 111.04 177.88 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 50639116_1 CDM 0250 RC 69097-0807-37 NDC J0878 HCPCS inpatient 500 UN 183.38 119.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.88 97 999999999 111.04 177.88 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 50639116_1 CDM 0250 RC 69097-0807-37 NDC J0878 HCPCS inpatient 500 UN 183.38 119.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 143.04 78 999999999 111.04 177.88 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 50639116_1 CDM 0250 RC 69097-0807-37 NDC J0878 HCPCS inpatient 500 UN 183.38 119.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.53 69 999999999 111.04 177.88 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 50639116_1 CDM 0250 RC 69097-0807-37 NDC J0878 HCPCS inpatient 500 UN 183.38 119.2 SIHO - ALL PLANS SIHO - ALL PLANS 165.04 90 999999999 111.04 177.88 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 50639116_1 CDM 0250 RC 69097-0807-37 NDC J0878 HCPCS inpatient 500 UN 183.38 119.2 UMR - ALL PLANS UMR - ALL PLANS 128.37 70 999999999 111.04 177.88 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 50639116_1 CDM 0250 RC 69097-0807-37 NDC J0878 HCPCS inpatient 500 UN 183.38 119.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 111.04 60.55 999999999 111.04 177.88 percent of total billed charges "INJECTION, DAPTOMYCIN, 1 MG" 50639116_1 CDM 0250 RC 69097-0807-37 NDC J0878 HCPCS inpatient 500 UN 183.38 119.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 111.04 177.88 "INJECTION, DAPTOMYCIN, 1 MG" 50639116_1 CDM 0250 RC 69097-0807-37 NDC J0878 HCPCS inpatient 500 UN 183.38 119.2 ANTHEM HMO ANTHEM HMO 999999999 111.04 177.88 "INJECTION, DAPTOMYCIN, 1 MG" 50639116_1 CDM 0250 RC 69097-0807-37 NDC J0878 HCPCS inpatient 500 UN 183.38 119.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 111.04 177.88 "INJECTION, DAPTOMYCIN, 1 MG" 50639116_1 CDM 0250 RC 69097-0807-37 NDC J0878 HCPCS inpatient 500 UN 183.38 119.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 111.04 177.88 "INJECTION, DAPTOMYCIN, 1 MG" 50639116_1 CDM 0250 RC 69097-0807-37 NDC J0878 HCPCS inpatient 500 UN 183.38 119.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 111.04 177.88 "INJECTION, DAPTOMYCIN, 1 MG" 50639116_1 CDM 0250 RC 69097-0807-37 NDC J0878 HCPCS inpatient 500 UN 183.38 119.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.96 67.6 999999999 111.04 177.88 percent of total billed charges KCL 10 MEQ/L-D5W-0.45% NACL 50639437_1 CDM 0258 RC 00264-7634-00 NDC inpatient 1 UN 86.77 56.4 AETNA AETNA 68.55 79 999999999 52.54 84.17 percent of total billed charges KCL 10 MEQ/L-D5W-0.45% NACL 50639437_1 CDM 0258 RC 00264-7634-00 NDC inpatient 1 UN 86.77 56.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.4 65 999999999 52.54 84.17 percent of total billed charges KCL 10 MEQ/L-D5W-0.45% NACL 50639437_1 CDM 0258 RC 00264-7634-00 NDC inpatient 1 UN 86.77 56.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.17 97 999999999 52.54 84.17 percent of total billed charges KCL 10 MEQ/L-D5W-0.45% NACL 50639437_1 CDM 0258 RC 00264-7634-00 NDC inpatient 1 UN 86.77 56.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.68 78 999999999 52.54 84.17 percent of total billed charges KCL 10 MEQ/L-D5W-0.45% NACL 50639437_1 CDM 0258 RC 00264-7634-00 NDC inpatient 1 UN 86.77 56.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.87 69 999999999 52.54 84.17 percent of total billed charges KCL 10 MEQ/L-D5W-0.45% NACL 50639437_1 CDM 0258 RC 00264-7634-00 NDC inpatient 1 UN 86.77 56.4 SIHO - ALL PLANS SIHO - ALL PLANS 78.09 90 999999999 52.54 84.17 percent of total billed charges KCL 10 MEQ/L-D5W-0.45% NACL 50639437_1 CDM 0258 RC 00264-7634-00 NDC inpatient 1 UN 86.77 56.4 UMR - ALL PLANS UMR - ALL PLANS 60.74 70 999999999 52.54 84.17 percent of total billed charges KCL 10 MEQ/L-D5W-0.45% NACL 50639437_1 CDM 0258 RC 00264-7634-00 NDC inpatient 1 UN 86.77 56.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.54 60.55 999999999 52.54 84.17 percent of total billed charges KCL 10 MEQ/L-D5W-0.45% NACL 50639437_1 CDM 0258 RC 00264-7634-00 NDC inpatient 1 UN 86.77 56.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.54 84.17 KCL 10 MEQ/L-D5W-0.45% NACL 50639437_1 CDM 0258 RC 00264-7634-00 NDC inpatient 1 UN 86.77 56.4 ANTHEM HMO ANTHEM HMO 999999999 52.54 84.17 KCL 10 MEQ/L-D5W-0.45% NACL 50639437_1 CDM 0258 RC 00264-7634-00 NDC inpatient 1 UN 86.77 56.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.54 84.17 KCL 10 MEQ/L-D5W-0.45% NACL 50639437_1 CDM 0258 RC 00264-7634-00 NDC inpatient 1 UN 86.77 56.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.54 84.17 KCL 10 MEQ/L-D5W-0.45% NACL 50639437_1 CDM 0258 RC 00264-7634-00 NDC inpatient 1 UN 86.77 56.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.54 84.17 KCL 10 MEQ/L-D5W-0.45% NACL 50639437_1 CDM 0258 RC 00264-7634-00 NDC inpatient 1 UN 86.77 56.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.66 67.6 999999999 52.54 84.17 percent of total billed charges GABAPENTIN 100 MG CAPSULE 50639440_1 CDM 0250 RC 60687-0580-01 NDC inpatient 1 UN 1.78 1.16 AETNA AETNA 1.41 79 999999999 1.08 1.73 percent of total billed charges GABAPENTIN 100 MG CAPSULE 50639440_1 CDM 0250 RC 60687-0580-01 NDC inpatient 1 UN 1.78 1.16 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.16 65 999999999 1.08 1.73 percent of total billed charges GABAPENTIN 100 MG CAPSULE 50639440_1 CDM 0250 RC 60687-0580-01 NDC inpatient 1 UN 1.78 1.16 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.73 97 999999999 1.08 1.73 percent of total billed charges GABAPENTIN 100 MG CAPSULE 50639440_1 CDM 0250 RC 60687-0580-01 NDC inpatient 1 UN 1.78 1.16 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.39 78 999999999 1.08 1.73 percent of total billed charges GABAPENTIN 100 MG CAPSULE 50639440_1 CDM 0250 RC 60687-0580-01 NDC inpatient 1 UN 1.78 1.16 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.23 69 999999999 1.08 1.73 percent of total billed charges GABAPENTIN 100 MG CAPSULE 50639440_1 CDM 0250 RC 60687-0580-01 NDC inpatient 1 UN 1.78 1.16 SIHO - ALL PLANS SIHO - ALL PLANS 1.6 90 999999999 1.08 1.73 percent of total billed charges GABAPENTIN 100 MG CAPSULE 50639440_1 CDM 0250 RC 60687-0580-01 NDC inpatient 1 UN 1.78 1.16 UMR - ALL PLANS UMR - ALL PLANS 1.25 70 999999999 1.08 1.73 percent of total billed charges GABAPENTIN 100 MG CAPSULE 50639440_1 CDM 0250 RC 60687-0580-01 NDC inpatient 1 UN 1.78 1.16 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.08 60.55 999999999 1.08 1.73 percent of total billed charges GABAPENTIN 100 MG CAPSULE 50639440_1 CDM 0250 RC 60687-0580-01 NDC inpatient 1 UN 1.78 1.16 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.08 1.73 GABAPENTIN 100 MG CAPSULE 50639440_1 CDM 0250 RC 60687-0580-01 NDC inpatient 1 UN 1.78 1.16 ANTHEM HMO ANTHEM HMO 999999999 1.08 1.73 GABAPENTIN 100 MG CAPSULE 50639440_1 CDM 0250 RC 60687-0580-01 NDC inpatient 1 UN 1.78 1.16 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.08 1.73 GABAPENTIN 100 MG CAPSULE 50639440_1 CDM 0250 RC 60687-0580-01 NDC inpatient 1 UN 1.78 1.16 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.08 1.73 GABAPENTIN 100 MG CAPSULE 50639440_1 CDM 0250 RC 60687-0580-01 NDC inpatient 1 UN 1.78 1.16 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.08 1.73 GABAPENTIN 100 MG CAPSULE 50639440_1 CDM 0250 RC 60687-0580-01 NDC inpatient 1 UN 1.78 1.16 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.2 67.6 999999999 1.08 1.73 percent of total billed charges BUTALB-ACETAMIN-CAFF 50-325-40 50639494_1 CDM 0250 RC 13107-0075-01 NDC inpatient 1 UN 13.73 8.92 AETNA AETNA 10.85 79 999999999 8.31 13.32 percent of total billed charges BUTALB-ACETAMIN-CAFF 50-325-40 50639494_1 CDM 0250 RC 13107-0075-01 NDC inpatient 1 UN 13.73 8.92 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.92 65 999999999 8.31 13.32 percent of total billed charges BUTALB-ACETAMIN-CAFF 50-325-40 50639494_1 CDM 0250 RC 13107-0075-01 NDC inpatient 1 UN 13.73 8.92 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13.32 97 999999999 8.31 13.32 percent of total billed charges BUTALB-ACETAMIN-CAFF 50-325-40 50639494_1 CDM 0250 RC 13107-0075-01 NDC inpatient 1 UN 13.73 8.92 HUMANA - ALL PLANS HUMANA - ALL PLANS 10.71 78 999999999 8.31 13.32 percent of total billed charges BUTALB-ACETAMIN-CAFF 50-325-40 50639494_1 CDM 0250 RC 13107-0075-01 NDC inpatient 1 UN 13.73 8.92 ENCORE - ALL PLANS ENCORE - ALL PLANS 9.47 69 999999999 8.31 13.32 percent of total billed charges BUTALB-ACETAMIN-CAFF 50-325-40 50639494_1 CDM 0250 RC 13107-0075-01 NDC inpatient 1 UN 13.73 8.92 SIHO - ALL PLANS SIHO - ALL PLANS 12.36 90 999999999 8.31 13.32 percent of total billed charges BUTALB-ACETAMIN-CAFF 50-325-40 50639494_1 CDM 0250 RC 13107-0075-01 NDC inpatient 1 UN 13.73 8.92 UMR - ALL PLANS UMR - ALL PLANS 9.61 70 999999999 8.31 13.32 percent of total billed charges BUTALB-ACETAMIN-CAFF 50-325-40 50639494_1 CDM 0250 RC 13107-0075-01 NDC inpatient 1 UN 13.73 8.92 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.31 60.55 999999999 8.31 13.32 percent of total billed charges BUTALB-ACETAMIN-CAFF 50-325-40 50639494_1 CDM 0250 RC 13107-0075-01 NDC inpatient 1 UN 13.73 8.92 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.31 13.32 BUTALB-ACETAMIN-CAFF 50-325-40 50639494_1 CDM 0250 RC 13107-0075-01 NDC inpatient 1 UN 13.73 8.92 ANTHEM HMO ANTHEM HMO 999999999 8.31 13.32 BUTALB-ACETAMIN-CAFF 50-325-40 50639494_1 CDM 0250 RC 13107-0075-01 NDC inpatient 1 UN 13.73 8.92 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.31 13.32 BUTALB-ACETAMIN-CAFF 50-325-40 50639494_1 CDM 0250 RC 13107-0075-01 NDC inpatient 1 UN 13.73 8.92 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.31 13.32 BUTALB-ACETAMIN-CAFF 50-325-40 50639494_1 CDM 0250 RC 13107-0075-01 NDC inpatient 1 UN 13.73 8.92 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.31 13.32 BUTALB-ACETAMIN-CAFF 50-325-40 50639494_1 CDM 0250 RC 13107-0075-01 NDC inpatient 1 UN 13.73 8.92 CIGNA - ALL PLANS CIGNA - ALL PLANS 9.28 67.6 999999999 8.31 13.32 percent of total billed charges CLONAZEPAM 0.5 MG TABLET 50639495_1 CDM 0250 RC 60687-0544-01 NDC inpatient 1 UN 1.16 0.75 AETNA AETNA 0.92 79 999999999 0.7 1.13 percent of total billed charges CLONAZEPAM 0.5 MG TABLET 50639495_1 CDM 0250 RC 60687-0544-01 NDC inpatient 1 UN 1.16 0.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.75 65 999999999 0.7 1.13 percent of total billed charges CLONAZEPAM 0.5 MG TABLET 50639495_1 CDM 0250 RC 60687-0544-01 NDC inpatient 1 UN 1.16 0.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.13 97 999999999 0.7 1.13 percent of total billed charges CLONAZEPAM 0.5 MG TABLET 50639495_1 CDM 0250 RC 60687-0544-01 NDC inpatient 1 UN 1.16 0.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 0.9 78 999999999 0.7 1.13 percent of total billed charges CLONAZEPAM 0.5 MG TABLET 50639495_1 CDM 0250 RC 60687-0544-01 NDC inpatient 1 UN 1.16 0.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.8 69 999999999 0.7 1.13 percent of total billed charges CLONAZEPAM 0.5 MG TABLET 50639495_1 CDM 0250 RC 60687-0544-01 NDC inpatient 1 UN 1.16 0.75 SIHO - ALL PLANS SIHO - ALL PLANS 1.04 90 999999999 0.7 1.13 percent of total billed charges CLONAZEPAM 0.5 MG TABLET 50639495_1 CDM 0250 RC 60687-0544-01 NDC inpatient 1 UN 1.16 0.75 UMR - ALL PLANS UMR - ALL PLANS 0.81 70 999999999 0.7 1.13 percent of total billed charges CLONAZEPAM 0.5 MG TABLET 50639495_1 CDM 0250 RC 60687-0544-01 NDC inpatient 1 UN 1.16 0.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.7 60.55 999999999 0.7 1.13 percent of total billed charges CLONAZEPAM 0.5 MG TABLET 50639495_1 CDM 0250 RC 60687-0544-01 NDC inpatient 1 UN 1.16 0.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.7 1.13 CLONAZEPAM 0.5 MG TABLET 50639495_1 CDM 0250 RC 60687-0544-01 NDC inpatient 1 UN 1.16 0.75 ANTHEM HMO ANTHEM HMO 999999999 0.7 1.13 CLONAZEPAM 0.5 MG TABLET 50639495_1 CDM 0250 RC 60687-0544-01 NDC inpatient 1 UN 1.16 0.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.7 1.13 CLONAZEPAM 0.5 MG TABLET 50639495_1 CDM 0250 RC 60687-0544-01 NDC inpatient 1 UN 1.16 0.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.7 1.13 CLONAZEPAM 0.5 MG TABLET 50639495_1 CDM 0250 RC 60687-0544-01 NDC inpatient 1 UN 1.16 0.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.7 1.13 CLONAZEPAM 0.5 MG TABLET 50639495_1 CDM 0250 RC 60687-0544-01 NDC inpatient 1 UN 1.16 0.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.78 67.6 999999999 0.7 1.13 percent of total billed charges 00472-0735-14 - miconazole topical 2% Cre[JOHN] 50641596_1 CDM 0250 RC 00472-0735-14 NDC inpatient 1 UN 15.03 9.77 AETNA AETNA 11.87 79 999999999 9.1 14.58 percent of total billed charges 00472-0735-14 - miconazole topical 2% Cre[JOHN] 50641596_1 CDM 0250 RC 00472-0735-14 NDC inpatient 1 UN 15.03 9.77 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.77 65 999999999 9.1 14.58 percent of total billed charges 00472-0735-14 - miconazole topical 2% Cre[JOHN] 50641596_1 CDM 0250 RC 00472-0735-14 NDC inpatient 1 UN 15.03 9.77 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14.58 97 999999999 9.1 14.58 percent of total billed charges 00472-0735-14 - miconazole topical 2% Cre[JOHN] 50641596_1 CDM 0250 RC 00472-0735-14 NDC inpatient 1 UN 15.03 9.77 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.72 78 999999999 9.1 14.58 percent of total billed charges 00472-0735-14 - miconazole topical 2% Cre[JOHN] 50641596_1 CDM 0250 RC 00472-0735-14 NDC inpatient 1 UN 15.03 9.77 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.37 69 999999999 9.1 14.58 percent of total billed charges 00472-0735-14 - miconazole topical 2% Cre[JOHN] 50641596_1 CDM 0250 RC 00472-0735-14 NDC inpatient 1 UN 15.03 9.77 SIHO - ALL PLANS SIHO - ALL PLANS 13.53 90 999999999 9.1 14.58 percent of total billed charges 00472-0735-14 - miconazole topical 2% Cre[JOHN] 50641596_1 CDM 0250 RC 00472-0735-14 NDC inpatient 1 UN 15.03 9.77 UMR - ALL PLANS UMR - ALL PLANS 10.52 70 999999999 9.1 14.58 percent of total billed charges 00472-0735-14 - miconazole topical 2% Cre[JOHN] 50641596_1 CDM 0250 RC 00472-0735-14 NDC inpatient 1 UN 15.03 9.77 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.1 60.55 999999999 9.1 14.58 percent of total billed charges 00472-0735-14 - miconazole topical 2% Cre[JOHN] 50641596_1 CDM 0250 RC 00472-0735-14 NDC inpatient 1 UN 15.03 9.77 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.1 14.58 00472-0735-14 - miconazole topical 2% Cre[JOHN] 50641596_1 CDM 0250 RC 00472-0735-14 NDC inpatient 1 UN 15.03 9.77 ANTHEM HMO ANTHEM HMO 999999999 9.1 14.58 00472-0735-14 - miconazole topical 2% Cre[JOHN] 50641596_1 CDM 0250 RC 00472-0735-14 NDC inpatient 1 UN 15.03 9.77 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.1 14.58 00472-0735-14 - miconazole topical 2% Cre[JOHN] 50641596_1 CDM 0250 RC 00472-0735-14 NDC inpatient 1 UN 15.03 9.77 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.1 14.58 00472-0735-14 - miconazole topical 2% Cre[JOHN] 50641596_1 CDM 0250 RC 00472-0735-14 NDC inpatient 1 UN 15.03 9.77 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.1 14.58 00472-0735-14 - miconazole topical 2% Cre[JOHN] 50641596_1 CDM 0250 RC 00472-0735-14 NDC inpatient 1 UN 15.03 9.77 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.16 67.6 999999999 9.1 14.58 percent of total billed charges CLOTRIMAZOLE-BETAMETHASONE CRM 50641597_1 CDM 0250 RC 68462-0298-55 NDC inpatient 1 UN 48.94 31.81 AETNA AETNA 38.66 79 999999999 29.63 47.47 percent of total billed charges CLOTRIMAZOLE-BETAMETHASONE CRM 50641597_1 CDM 0250 RC 68462-0298-55 NDC inpatient 1 UN 48.94 31.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.81 65 999999999 29.63 47.47 percent of total billed charges CLOTRIMAZOLE-BETAMETHASONE CRM 50641597_1 CDM 0250 RC 68462-0298-55 NDC inpatient 1 UN 48.94 31.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 47.47 97 999999999 29.63 47.47 percent of total billed charges CLOTRIMAZOLE-BETAMETHASONE CRM 50641597_1 CDM 0250 RC 68462-0298-55 NDC inpatient 1 UN 48.94 31.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 38.17 78 999999999 29.63 47.47 percent of total billed charges CLOTRIMAZOLE-BETAMETHASONE CRM 50641597_1 CDM 0250 RC 68462-0298-55 NDC inpatient 1 UN 48.94 31.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.77 69 999999999 29.63 47.47 percent of total billed charges CLOTRIMAZOLE-BETAMETHASONE CRM 50641597_1 CDM 0250 RC 68462-0298-55 NDC inpatient 1 UN 48.94 31.81 SIHO - ALL PLANS SIHO - ALL PLANS 44.05 90 999999999 29.63 47.47 percent of total billed charges CLOTRIMAZOLE-BETAMETHASONE CRM 50641597_1 CDM 0250 RC 68462-0298-55 NDC inpatient 1 UN 48.94 31.81 UMR - ALL PLANS UMR - ALL PLANS 34.26 70 999999999 29.63 47.47 percent of total billed charges CLOTRIMAZOLE-BETAMETHASONE CRM 50641597_1 CDM 0250 RC 68462-0298-55 NDC inpatient 1 UN 48.94 31.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.63 60.55 999999999 29.63 47.47 percent of total billed charges CLOTRIMAZOLE-BETAMETHASONE CRM 50641597_1 CDM 0250 RC 68462-0298-55 NDC inpatient 1 UN 48.94 31.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.63 47.47 CLOTRIMAZOLE-BETAMETHASONE CRM 50641597_1 CDM 0250 RC 68462-0298-55 NDC inpatient 1 UN 48.94 31.81 ANTHEM HMO ANTHEM HMO 999999999 29.63 47.47 CLOTRIMAZOLE-BETAMETHASONE CRM 50641597_1 CDM 0250 RC 68462-0298-55 NDC inpatient 1 UN 48.94 31.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.63 47.47 CLOTRIMAZOLE-BETAMETHASONE CRM 50641597_1 CDM 0250 RC 68462-0298-55 NDC inpatient 1 UN 48.94 31.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.63 47.47 CLOTRIMAZOLE-BETAMETHASONE CRM 50641597_1 CDM 0250 RC 68462-0298-55 NDC inpatient 1 UN 48.94 31.81 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.63 47.47 CLOTRIMAZOLE-BETAMETHASONE CRM 50641597_1 CDM 0250 RC 68462-0298-55 NDC inpatient 1 UN 48.94 31.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.08 67.6 999999999 29.63 47.47 percent of total billed charges HALOPERIDOL 5 MG TABLET 50641598_1 CDM 0250 RC 00832-1540-11 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges HALOPERIDOL 5 MG TABLET 50641598_1 CDM 0250 RC 00832-1540-11 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges HALOPERIDOL 5 MG TABLET 50641598_1 CDM 0250 RC 00832-1540-11 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges HALOPERIDOL 5 MG TABLET 50641598_1 CDM 0250 RC 00832-1540-11 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges HALOPERIDOL 5 MG TABLET 50641598_1 CDM 0250 RC 00832-1540-11 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges HALOPERIDOL 5 MG TABLET 50641598_1 CDM 0250 RC 00832-1540-11 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges HALOPERIDOL 5 MG TABLET 50641598_1 CDM 0250 RC 00832-1540-11 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges HALOPERIDOL 5 MG TABLET 50641598_1 CDM 0250 RC 00832-1540-11 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges HALOPERIDOL 5 MG TABLET 50641598_1 CDM 0250 RC 00832-1540-11 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 HALOPERIDOL 5 MG TABLET 50641598_1 CDM 0250 RC 00832-1540-11 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 HALOPERIDOL 5 MG TABLET 50641598_1 CDM 0250 RC 00832-1540-11 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 HALOPERIDOL 5 MG TABLET 50641598_1 CDM 0250 RC 00832-1540-11 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 HALOPERIDOL 5 MG TABLET 50641598_1 CDM 0250 RC 00832-1540-11 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 HALOPERIDOL 5 MG TABLET 50641598_1 CDM 0250 RC 00832-1540-11 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges Tobramycin (antibiotic) level 50641601_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 AETNA AETNA 259.12 79 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 50641601_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 213.2 65 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 50641601_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 318.16 97 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 50641601_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.84 78 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 50641601_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 226.32 69 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 50641601_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 SIHO - ALL PLANS SIHO - ALL PLANS 295.2 90 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 50641601_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 UMR - ALL PLANS UMR - ALL PLANS 229.6 70 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 50641601_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198.6 60.55 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 50641601_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198.6 318.16 Tobramycin (antibiotic) level 50641601_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM HMO ANTHEM HMO 999999999 198.6 318.16 Tobramycin (antibiotic) level 50641601_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198.6 318.16 Tobramycin (antibiotic) level 50641601_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198.6 318.16 Tobramycin (antibiotic) level 50641601_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 198.6 318.16 Tobramycin (antibiotic) level 50641601_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.73 67.6 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 50641615_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 AETNA AETNA 259.12 79 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 50641615_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 213.2 65 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 50641615_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 318.16 97 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 50641615_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.84 78 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 50641615_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 226.32 69 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 50641615_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 SIHO - ALL PLANS SIHO - ALL PLANS 295.2 90 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 50641615_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 UMR - ALL PLANS UMR - ALL PLANS 229.6 70 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 50641615_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198.6 60.55 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 50641615_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198.6 318.16 Tobramycin (antibiotic) level 50641615_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM HMO ANTHEM HMO 999999999 198.6 318.16 Tobramycin (antibiotic) level 50641615_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198.6 318.16 Tobramycin (antibiotic) level 50641615_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198.6 318.16 Tobramycin (antibiotic) level 50641615_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 198.6 318.16 Tobramycin (antibiotic) level 50641615_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.73 67.6 999999999 198.6 318.16 percent of total billed charges CHILDREN IBUPROFEN 100 MG/5 ML 50642789_1 CDM 0250 RC 68001-0435-92 NDC inpatient 1 UN 16.53 10.74 AETNA AETNA 13.06 79 999999999 10.01 16.03 percent of total billed charges CHILDREN IBUPROFEN 100 MG/5 ML 50642789_1 CDM 0250 RC 68001-0435-92 NDC inpatient 1 UN 16.53 10.74 SELF PAY DISCOUNT SELF PAY DISCOUNT 10.74 65 999999999 10.01 16.03 percent of total billed charges CHILDREN IBUPROFEN 100 MG/5 ML 50642789_1 CDM 0250 RC 68001-0435-92 NDC inpatient 1 UN 16.53 10.74 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16.03 97 999999999 10.01 16.03 percent of total billed charges CHILDREN IBUPROFEN 100 MG/5 ML 50642789_1 CDM 0250 RC 68001-0435-92 NDC inpatient 1 UN 16.53 10.74 HUMANA - ALL PLANS HUMANA - ALL PLANS 12.89 78 999999999 10.01 16.03 percent of total billed charges CHILDREN IBUPROFEN 100 MG/5 ML 50642789_1 CDM 0250 RC 68001-0435-92 NDC inpatient 1 UN 16.53 10.74 ENCORE - ALL PLANS ENCORE - ALL PLANS 11.41 69 999999999 10.01 16.03 percent of total billed charges CHILDREN IBUPROFEN 100 MG/5 ML 50642789_1 CDM 0250 RC 68001-0435-92 NDC inpatient 1 UN 16.53 10.74 SIHO - ALL PLANS SIHO - ALL PLANS 14.88 90 999999999 10.01 16.03 percent of total billed charges CHILDREN IBUPROFEN 100 MG/5 ML 50642789_1 CDM 0250 RC 68001-0435-92 NDC inpatient 1 UN 16.53 10.74 UMR - ALL PLANS UMR - ALL PLANS 11.57 70 999999999 10.01 16.03 percent of total billed charges CHILDREN IBUPROFEN 100 MG/5 ML 50642789_1 CDM 0250 RC 68001-0435-92 NDC inpatient 1 UN 16.53 10.74 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.01 60.55 999999999 10.01 16.03 percent of total billed charges CHILDREN IBUPROFEN 100 MG/5 ML 50642789_1 CDM 0250 RC 68001-0435-92 NDC inpatient 1 UN 16.53 10.74 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.01 16.03 CHILDREN IBUPROFEN 100 MG/5 ML 50642789_1 CDM 0250 RC 68001-0435-92 NDC inpatient 1 UN 16.53 10.74 ANTHEM HMO ANTHEM HMO 999999999 10.01 16.03 CHILDREN IBUPROFEN 100 MG/5 ML 50642789_1 CDM 0250 RC 68001-0435-92 NDC inpatient 1 UN 16.53 10.74 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.01 16.03 CHILDREN IBUPROFEN 100 MG/5 ML 50642789_1 CDM 0250 RC 68001-0435-92 NDC inpatient 1 UN 16.53 10.74 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.01 16.03 CHILDREN IBUPROFEN 100 MG/5 ML 50642789_1 CDM 0250 RC 68001-0435-92 NDC inpatient 1 UN 16.53 10.74 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.01 16.03 CHILDREN IBUPROFEN 100 MG/5 ML 50642789_1 CDM 0250 RC 68001-0435-92 NDC inpatient 1 UN 16.53 10.74 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.17 67.6 999999999 10.01 16.03 percent of total billed charges Theophylline level 50643416_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 AETNA AETNA 184.86 79 999999999 141.69 226.98 percent of total billed charges Theophylline level 50643416_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 152.1 65 999999999 141.69 226.98 percent of total billed charges Theophylline level 50643416_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 226.98 97 999999999 141.69 226.98 percent of total billed charges Theophylline level 50643416_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 182.52 78 999999999 141.69 226.98 percent of total billed charges Theophylline level 50643416_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 161.46 69 999999999 141.69 226.98 percent of total billed charges Theophylline level 50643416_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 SIHO - ALL PLANS SIHO - ALL PLANS 210.6 90 999999999 141.69 226.98 percent of total billed charges Theophylline level 50643416_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 UMR - ALL PLANS UMR - ALL PLANS 163.8 70 999999999 141.69 226.98 percent of total billed charges Theophylline level 50643416_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 141.69 60.55 999999999 141.69 226.98 percent of total billed charges Theophylline level 50643416_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 141.69 226.98 Theophylline level 50643416_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 ANTHEM HMO ANTHEM HMO 999999999 141.69 226.98 Theophylline level 50643416_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 141.69 226.98 Theophylline level 50643416_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 141.69 226.98 Theophylline level 50643416_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 141.69 226.98 Theophylline level 50643416_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 158.18 67.6 999999999 141.69 226.98 percent of total billed charges Clotting factor XIII (fibrin stabilizing) measurement 50643522_1 CDM 0305 RC 85290 HCPCS inpatient 248 161.2 AETNA AETNA 195.92 79 999999999 150.16 240.56 percent of total billed charges Clotting factor XIII (fibrin stabilizing) measurement 50643522_1 CDM 0305 RC 85290 HCPCS inpatient 248 161.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.2 65 999999999 150.16 240.56 percent of total billed charges Clotting factor XIII (fibrin stabilizing) measurement 50643522_1 CDM 0305 RC 85290 HCPCS inpatient 248 161.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 240.56 97 999999999 150.16 240.56 percent of total billed charges Clotting factor XIII (fibrin stabilizing) measurement 50643522_1 CDM 0305 RC 85290 HCPCS inpatient 248 161.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 193.44 78 999999999 150.16 240.56 percent of total billed charges Clotting factor XIII (fibrin stabilizing) measurement 50643522_1 CDM 0305 RC 85290 HCPCS inpatient 248 161.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.12 69 999999999 150.16 240.56 percent of total billed charges Clotting factor XIII (fibrin stabilizing) measurement 50643522_1 CDM 0305 RC 85290 HCPCS inpatient 248 161.2 SIHO - ALL PLANS SIHO - ALL PLANS 223.2 90 999999999 150.16 240.56 percent of total billed charges Clotting factor XIII (fibrin stabilizing) measurement 50643522_1 CDM 0305 RC 85290 HCPCS inpatient 248 161.2 UMR - ALL PLANS UMR - ALL PLANS 173.6 70 999999999 150.16 240.56 percent of total billed charges Clotting factor XIII (fibrin stabilizing) measurement 50643522_1 CDM 0305 RC 85290 HCPCS inpatient 248 161.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.16 60.55 999999999 150.16 240.56 percent of total billed charges Clotting factor XIII (fibrin stabilizing) measurement 50643522_1 CDM 0305 RC 85290 HCPCS inpatient 248 161.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.16 240.56 Clotting factor XIII (fibrin stabilizing) measurement 50643522_1 CDM 0305 RC 85290 HCPCS inpatient 248 161.2 ANTHEM HMO ANTHEM HMO 999999999 150.16 240.56 Clotting factor XIII (fibrin stabilizing) measurement 50643522_1 CDM 0305 RC 85290 HCPCS inpatient 248 161.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.16 240.56 Clotting factor XIII (fibrin stabilizing) measurement 50643522_1 CDM 0305 RC 85290 HCPCS inpatient 248 161.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.16 240.56 Clotting factor XIII (fibrin stabilizing) measurement 50643522_1 CDM 0305 RC 85290 HCPCS inpatient 248 161.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.16 240.56 Clotting factor XIII (fibrin stabilizing) measurement 50643522_1 CDM 0305 RC 85290 HCPCS inpatient 248 161.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 167.65 67.6 999999999 150.16 240.56 percent of total billed charges "INJECTION, CEFTAZIDIME, PER 500 MG" 50646209_1 CDM 0250 RC 00264-3143-11 NDC J0713 HCPCS inpatient 2 UN 98.1 63.77 AETNA AETNA 77.5 79 999999999 59.4 95.16 percent of total billed charges "INJECTION, CEFTAZIDIME, PER 500 MG" 50646209_1 CDM 0250 RC 00264-3143-11 NDC J0713 HCPCS inpatient 2 UN 98.1 63.77 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.77 65 999999999 59.4 95.16 percent of total billed charges "INJECTION, CEFTAZIDIME, PER 500 MG" 50646209_1 CDM 0250 RC 00264-3143-11 NDC J0713 HCPCS inpatient 2 UN 98.1 63.77 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.16 97 999999999 59.4 95.16 percent of total billed charges "INJECTION, CEFTAZIDIME, PER 500 MG" 50646209_1 CDM 0250 RC 00264-3143-11 NDC J0713 HCPCS inpatient 2 UN 98.1 63.77 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.52 78 999999999 59.4 95.16 percent of total billed charges "INJECTION, CEFTAZIDIME, PER 500 MG" 50646209_1 CDM 0250 RC 00264-3143-11 NDC J0713 HCPCS inpatient 2 UN 98.1 63.77 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.69 69 999999999 59.4 95.16 percent of total billed charges "INJECTION, CEFTAZIDIME, PER 500 MG" 50646209_1 CDM 0250 RC 00264-3143-11 NDC J0713 HCPCS inpatient 2 UN 98.1 63.77 SIHO - ALL PLANS SIHO - ALL PLANS 88.29 90 999999999 59.4 95.16 percent of total billed charges "INJECTION, CEFTAZIDIME, PER 500 MG" 50646209_1 CDM 0250 RC 00264-3143-11 NDC J0713 HCPCS inpatient 2 UN 98.1 63.77 UMR - ALL PLANS UMR - ALL PLANS 68.67 70 999999999 59.4 95.16 percent of total billed charges "INJECTION, CEFTAZIDIME, PER 500 MG" 50646209_1 CDM 0250 RC 00264-3143-11 NDC J0713 HCPCS inpatient 2 UN 98.1 63.77 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.4 60.55 999999999 59.4 95.16 percent of total billed charges "INJECTION, CEFTAZIDIME, PER 500 MG" 50646209_1 CDM 0250 RC 00264-3143-11 NDC J0713 HCPCS inpatient 2 UN 98.1 63.77 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.4 95.16 "INJECTION, CEFTAZIDIME, PER 500 MG" 50646209_1 CDM 0250 RC 00264-3143-11 NDC J0713 HCPCS inpatient 2 UN 98.1 63.77 ANTHEM HMO ANTHEM HMO 999999999 59.4 95.16 "INJECTION, CEFTAZIDIME, PER 500 MG" 50646209_1 CDM 0250 RC 00264-3143-11 NDC J0713 HCPCS inpatient 2 UN 98.1 63.77 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.4 95.16 "INJECTION, CEFTAZIDIME, PER 500 MG" 50646209_1 CDM 0250 RC 00264-3143-11 NDC J0713 HCPCS inpatient 2 UN 98.1 63.77 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.4 95.16 "INJECTION, CEFTAZIDIME, PER 500 MG" 50646209_1 CDM 0250 RC 00264-3143-11 NDC J0713 HCPCS inpatient 2 UN 98.1 63.77 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.4 95.16 "INJECTION, CEFTAZIDIME, PER 500 MG" 50646209_1 CDM 0250 RC 00264-3143-11 NDC J0713 HCPCS inpatient 2 UN 98.1 63.77 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.32 67.6 999999999 59.4 95.16 percent of total billed charges Protein S (clotting inhibitor) measurement 50646396_1 CDM 0305 RC 85306 HCPCS inpatient 330 214.5 AETNA AETNA 260.7 79 999999999 199.82 320.1 percent of total billed charges Protein S (clotting inhibitor) measurement 50646396_1 CDM 0305 RC 85306 HCPCS inpatient 330 214.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 214.5 65 999999999 199.82 320.1 percent of total billed charges Protein S (clotting inhibitor) measurement 50646396_1 CDM 0305 RC 85306 HCPCS inpatient 330 214.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 320.1 97 999999999 199.82 320.1 percent of total billed charges Protein S (clotting inhibitor) measurement 50646396_1 CDM 0305 RC 85306 HCPCS inpatient 330 214.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 257.4 78 999999999 199.82 320.1 percent of total billed charges Protein S (clotting inhibitor) measurement 50646396_1 CDM 0305 RC 85306 HCPCS inpatient 330 214.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 227.7 69 999999999 199.82 320.1 percent of total billed charges Protein S (clotting inhibitor) measurement 50646396_1 CDM 0305 RC 85306 HCPCS inpatient 330 214.5 SIHO - ALL PLANS SIHO - ALL PLANS 297 90 999999999 199.82 320.1 percent of total billed charges Protein S (clotting inhibitor) measurement 50646396_1 CDM 0305 RC 85306 HCPCS inpatient 330 214.5 UMR - ALL PLANS UMR - ALL PLANS 231 70 999999999 199.82 320.1 percent of total billed charges Protein S (clotting inhibitor) measurement 50646396_1 CDM 0305 RC 85306 HCPCS inpatient 330 214.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 199.82 60.55 999999999 199.82 320.1 percent of total billed charges Protein S (clotting inhibitor) measurement 50646396_1 CDM 0305 RC 85306 HCPCS inpatient 330 214.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 199.82 320.1 Protein S (clotting inhibitor) measurement 50646396_1 CDM 0305 RC 85306 HCPCS inpatient 330 214.5 ANTHEM HMO ANTHEM HMO 999999999 199.82 320.1 Protein S (clotting inhibitor) measurement 50646396_1 CDM 0305 RC 85306 HCPCS inpatient 330 214.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 199.82 320.1 Protein S (clotting inhibitor) measurement 50646396_1 CDM 0305 RC 85306 HCPCS inpatient 330 214.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 199.82 320.1 Protein S (clotting inhibitor) measurement 50646396_1 CDM 0305 RC 85306 HCPCS inpatient 330 214.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 199.82 320.1 Protein S (clotting inhibitor) measurement 50646396_1 CDM 0305 RC 85306 HCPCS inpatient 330 214.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 223.08 67.6 999999999 199.82 320.1 percent of total billed charges RANOLAZINE ER 500 MG TABLET 50647003_1 CDM 0250 RC 60687-0549-21 NDC inpatient 1 UN 2.43 1.58 AETNA AETNA 1.92 79 999999999 1.47 2.36 percent of total billed charges RANOLAZINE ER 500 MG TABLET 50647003_1 CDM 0250 RC 60687-0549-21 NDC inpatient 1 UN 2.43 1.58 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.58 65 999999999 1.47 2.36 percent of total billed charges RANOLAZINE ER 500 MG TABLET 50647003_1 CDM 0250 RC 60687-0549-21 NDC inpatient 1 UN 2.43 1.58 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.36 97 999999999 1.47 2.36 percent of total billed charges RANOLAZINE ER 500 MG TABLET 50647003_1 CDM 0250 RC 60687-0549-21 NDC inpatient 1 UN 2.43 1.58 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.9 78 999999999 1.47 2.36 percent of total billed charges RANOLAZINE ER 500 MG TABLET 50647003_1 CDM 0250 RC 60687-0549-21 NDC inpatient 1 UN 2.43 1.58 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.68 69 999999999 1.47 2.36 percent of total billed charges RANOLAZINE ER 500 MG TABLET 50647003_1 CDM 0250 RC 60687-0549-21 NDC inpatient 1 UN 2.43 1.58 SIHO - ALL PLANS SIHO - ALL PLANS 2.19 90 999999999 1.47 2.36 percent of total billed charges RANOLAZINE ER 500 MG TABLET 50647003_1 CDM 0250 RC 60687-0549-21 NDC inpatient 1 UN 2.43 1.58 UMR - ALL PLANS UMR - ALL PLANS 1.7 70 999999999 1.47 2.36 percent of total billed charges RANOLAZINE ER 500 MG TABLET 50647003_1 CDM 0250 RC 60687-0549-21 NDC inpatient 1 UN 2.43 1.58 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.47 60.55 999999999 1.47 2.36 percent of total billed charges RANOLAZINE ER 500 MG TABLET 50647003_1 CDM 0250 RC 60687-0549-21 NDC inpatient 1 UN 2.43 1.58 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.47 2.36 RANOLAZINE ER 500 MG TABLET 50647003_1 CDM 0250 RC 60687-0549-21 NDC inpatient 1 UN 2.43 1.58 ANTHEM HMO ANTHEM HMO 999999999 1.47 2.36 RANOLAZINE ER 500 MG TABLET 50647003_1 CDM 0250 RC 60687-0549-21 NDC inpatient 1 UN 2.43 1.58 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.47 2.36 RANOLAZINE ER 500 MG TABLET 50647003_1 CDM 0250 RC 60687-0549-21 NDC inpatient 1 UN 2.43 1.58 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.47 2.36 RANOLAZINE ER 500 MG TABLET 50647003_1 CDM 0250 RC 60687-0549-21 NDC inpatient 1 UN 2.43 1.58 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.47 2.36 RANOLAZINE ER 500 MG TABLET 50647003_1 CDM 0250 RC 60687-0549-21 NDC inpatient 1 UN 2.43 1.58 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.64 67.6 999999999 1.47 2.36 percent of total billed charges Phenobarbital level 50647016_1 CDM 0301 RC 80184 HCPCS inpatient 238 154.7 AETNA AETNA 188.02 79 999999999 144.11 230.86 percent of total billed charges Phenobarbital level 50647016_1 CDM 0301 RC 80184 HCPCS inpatient 238 154.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.7 65 999999999 144.11 230.86 percent of total billed charges Phenobarbital level 50647016_1 CDM 0301 RC 80184 HCPCS inpatient 238 154.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 230.86 97 999999999 144.11 230.86 percent of total billed charges Phenobarbital level 50647016_1 CDM 0301 RC 80184 HCPCS inpatient 238 154.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 185.64 78 999999999 144.11 230.86 percent of total billed charges Phenobarbital level 50647016_1 CDM 0301 RC 80184 HCPCS inpatient 238 154.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.22 69 999999999 144.11 230.86 percent of total billed charges Phenobarbital level 50647016_1 CDM 0301 RC 80184 HCPCS inpatient 238 154.7 SIHO - ALL PLANS SIHO - ALL PLANS 214.2 90 999999999 144.11 230.86 percent of total billed charges Phenobarbital level 50647016_1 CDM 0301 RC 80184 HCPCS inpatient 238 154.7 UMR - ALL PLANS UMR - ALL PLANS 166.6 70 999999999 144.11 230.86 percent of total billed charges Phenobarbital level 50647016_1 CDM 0301 RC 80184 HCPCS inpatient 238 154.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.11 60.55 999999999 144.11 230.86 percent of total billed charges Phenobarbital level 50647016_1 CDM 0301 RC 80184 HCPCS inpatient 238 154.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.11 230.86 Phenobarbital level 50647016_1 CDM 0301 RC 80184 HCPCS inpatient 238 154.7 ANTHEM HMO ANTHEM HMO 999999999 144.11 230.86 Phenobarbital level 50647016_1 CDM 0301 RC 80184 HCPCS inpatient 238 154.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.11 230.86 Phenobarbital level 50647016_1 CDM 0301 RC 80184 HCPCS inpatient 238 154.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.11 230.86 Phenobarbital level 50647016_1 CDM 0301 RC 80184 HCPCS inpatient 238 154.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.11 230.86 Phenobarbital level 50647016_1 CDM 0301 RC 80184 HCPCS inpatient 238 154.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.89 67.6 999999999 144.11 230.86 percent of total billed charges C-peptide (protein) level 50647017_1 CDM 0301 RC 84681 HCPCS inpatient 379 246.35 AETNA AETNA 299.41 79 999999999 229.48 367.63 percent of total billed charges C-peptide (protein) level 50647017_1 CDM 0301 RC 84681 HCPCS inpatient 379 246.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 246.35 65 999999999 229.48 367.63 percent of total billed charges C-peptide (protein) level 50647017_1 CDM 0301 RC 84681 HCPCS inpatient 379 246.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 367.63 97 999999999 229.48 367.63 percent of total billed charges C-peptide (protein) level 50647017_1 CDM 0301 RC 84681 HCPCS inpatient 379 246.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 295.62 78 999999999 229.48 367.63 percent of total billed charges C-peptide (protein) level 50647017_1 CDM 0301 RC 84681 HCPCS inpatient 379 246.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 261.51 69 999999999 229.48 367.63 percent of total billed charges C-peptide (protein) level 50647017_1 CDM 0301 RC 84681 HCPCS inpatient 379 246.35 SIHO - ALL PLANS SIHO - ALL PLANS 341.1 90 999999999 229.48 367.63 percent of total billed charges C-peptide (protein) level 50647017_1 CDM 0301 RC 84681 HCPCS inpatient 379 246.35 UMR - ALL PLANS UMR - ALL PLANS 265.3 70 999999999 229.48 367.63 percent of total billed charges C-peptide (protein) level 50647017_1 CDM 0301 RC 84681 HCPCS inpatient 379 246.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 229.48 60.55 999999999 229.48 367.63 percent of total billed charges C-peptide (protein) level 50647017_1 CDM 0301 RC 84681 HCPCS inpatient 379 246.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 229.48 367.63 C-peptide (protein) level 50647017_1 CDM 0301 RC 84681 HCPCS inpatient 379 246.35 ANTHEM HMO ANTHEM HMO 999999999 229.48 367.63 C-peptide (protein) level 50647017_1 CDM 0301 RC 84681 HCPCS inpatient 379 246.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 229.48 367.63 C-peptide (protein) level 50647017_1 CDM 0301 RC 84681 HCPCS inpatient 379 246.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 229.48 367.63 C-peptide (protein) level 50647017_1 CDM 0301 RC 84681 HCPCS inpatient 379 246.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 229.48 367.63 C-peptide (protein) level 50647017_1 CDM 0301 RC 84681 HCPCS inpatient 379 246.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 256.2 67.6 999999999 229.48 367.63 percent of total billed charges Mini C-Arm 50649549_1 CDM 0272 RC inpatient 245 159.25 AETNA AETNA 193.55 79 999999999 148.35 237.65 percent of total billed charges Mini C-Arm 50649549_1 CDM 0272 RC inpatient 245 159.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 159.25 65 999999999 148.35 237.65 percent of total billed charges Mini C-Arm 50649549_1 CDM 0272 RC inpatient 245 159.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 237.65 97 999999999 148.35 237.65 percent of total billed charges Mini C-Arm 50649549_1 CDM 0272 RC inpatient 245 159.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 191.1 78 999999999 148.35 237.65 percent of total billed charges Mini C-Arm 50649549_1 CDM 0272 RC inpatient 245 159.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 169.05 69 999999999 148.35 237.65 percent of total billed charges Mini C-Arm 50649549_1 CDM 0272 RC inpatient 245 159.25 SIHO - ALL PLANS SIHO - ALL PLANS 220.5 90 999999999 148.35 237.65 percent of total billed charges Mini C-Arm 50649549_1 CDM 0272 RC inpatient 245 159.25 UMR - ALL PLANS UMR - ALL PLANS 171.5 70 999999999 148.35 237.65 percent of total billed charges Mini C-Arm 50649549_1 CDM 0272 RC inpatient 245 159.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 148.35 60.55 999999999 148.35 237.65 percent of total billed charges Mini C-Arm 50649549_1 CDM 0272 RC inpatient 245 159.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 148.35 237.65 Mini C-Arm 50649549_1 CDM 0272 RC inpatient 245 159.25 ANTHEM HMO ANTHEM HMO 999999999 148.35 237.65 Mini C-Arm 50649549_1 CDM 0272 RC inpatient 245 159.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 148.35 237.65 Mini C-Arm 50649549_1 CDM 0272 RC inpatient 245 159.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 148.35 237.65 Mini C-Arm 50649549_1 CDM 0272 RC inpatient 245 159.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 148.35 237.65 Mini C-Arm 50649549_1 CDM 0272 RC inpatient 245 159.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 165.62 67.6 999999999 148.35 237.65 percent of total billed charges OXYCODONE-ACETAMINOPHEN 10-325 50649899_1 CDM 0250 RC 00406-0523-62 NDC inpatient 1 UN 5.71 3.71 AETNA AETNA 4.51 79 999999999 3.46 5.54 percent of total billed charges OXYCODONE-ACETAMINOPHEN 10-325 50649899_1 CDM 0250 RC 00406-0523-62 NDC inpatient 1 UN 5.71 3.71 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.71 65 999999999 3.46 5.54 percent of total billed charges OXYCODONE-ACETAMINOPHEN 10-325 50649899_1 CDM 0250 RC 00406-0523-62 NDC inpatient 1 UN 5.71 3.71 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.54 97 999999999 3.46 5.54 percent of total billed charges OXYCODONE-ACETAMINOPHEN 10-325 50649899_1 CDM 0250 RC 00406-0523-62 NDC inpatient 1 UN 5.71 3.71 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.45 78 999999999 3.46 5.54 percent of total billed charges OXYCODONE-ACETAMINOPHEN 10-325 50649899_1 CDM 0250 RC 00406-0523-62 NDC inpatient 1 UN 5.71 3.71 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.94 69 999999999 3.46 5.54 percent of total billed charges OXYCODONE-ACETAMINOPHEN 10-325 50649899_1 CDM 0250 RC 00406-0523-62 NDC inpatient 1 UN 5.71 3.71 SIHO - ALL PLANS SIHO - ALL PLANS 5.14 90 999999999 3.46 5.54 percent of total billed charges OXYCODONE-ACETAMINOPHEN 10-325 50649899_1 CDM 0250 RC 00406-0523-62 NDC inpatient 1 UN 5.71 3.71 UMR - ALL PLANS UMR - ALL PLANS 4 70 999999999 3.46 5.54 percent of total billed charges OXYCODONE-ACETAMINOPHEN 10-325 50649899_1 CDM 0250 RC 00406-0523-62 NDC inpatient 1 UN 5.71 3.71 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.46 60.55 999999999 3.46 5.54 percent of total billed charges OXYCODONE-ACETAMINOPHEN 10-325 50649899_1 CDM 0250 RC 00406-0523-62 NDC inpatient 1 UN 5.71 3.71 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.46 5.54 OXYCODONE-ACETAMINOPHEN 10-325 50649899_1 CDM 0250 RC 00406-0523-62 NDC inpatient 1 UN 5.71 3.71 ANTHEM HMO ANTHEM HMO 999999999 3.46 5.54 OXYCODONE-ACETAMINOPHEN 10-325 50649899_1 CDM 0250 RC 00406-0523-62 NDC inpatient 1 UN 5.71 3.71 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.46 5.54 OXYCODONE-ACETAMINOPHEN 10-325 50649899_1 CDM 0250 RC 00406-0523-62 NDC inpatient 1 UN 5.71 3.71 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.46 5.54 OXYCODONE-ACETAMINOPHEN 10-325 50649899_1 CDM 0250 RC 00406-0523-62 NDC inpatient 1 UN 5.71 3.71 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.46 5.54 OXYCODONE-ACETAMINOPHEN 10-325 50649899_1 CDM 0250 RC 00406-0523-62 NDC inpatient 1 UN 5.71 3.71 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.86 67.6 999999999 3.46 5.54 percent of total billed charges HYDROCODONE-ACETAMN 7.5-325/15 50649901_1 CDM 0250 RC 60687-0417-71 NDC inpatient 1 UN 12.2 7.93 AETNA AETNA 9.64 79 999999999 7.39 11.83 percent of total billed charges HYDROCODONE-ACETAMN 7.5-325/15 50649901_1 CDM 0250 RC 60687-0417-71 NDC inpatient 1 UN 12.2 7.93 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.93 65 999999999 7.39 11.83 percent of total billed charges HYDROCODONE-ACETAMN 7.5-325/15 50649901_1 CDM 0250 RC 60687-0417-71 NDC inpatient 1 UN 12.2 7.93 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11.83 97 999999999 7.39 11.83 percent of total billed charges HYDROCODONE-ACETAMN 7.5-325/15 50649901_1 CDM 0250 RC 60687-0417-71 NDC inpatient 1 UN 12.2 7.93 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.52 78 999999999 7.39 11.83 percent of total billed charges HYDROCODONE-ACETAMN 7.5-325/15 50649901_1 CDM 0250 RC 60687-0417-71 NDC inpatient 1 UN 12.2 7.93 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.42 69 999999999 7.39 11.83 percent of total billed charges HYDROCODONE-ACETAMN 7.5-325/15 50649901_1 CDM 0250 RC 60687-0417-71 NDC inpatient 1 UN 12.2 7.93 SIHO - ALL PLANS SIHO - ALL PLANS 10.98 90 999999999 7.39 11.83 percent of total billed charges HYDROCODONE-ACETAMN 7.5-325/15 50649901_1 CDM 0250 RC 60687-0417-71 NDC inpatient 1 UN 12.2 7.93 UMR - ALL PLANS UMR - ALL PLANS 8.54 70 999999999 7.39 11.83 percent of total billed charges HYDROCODONE-ACETAMN 7.5-325/15 50649901_1 CDM 0250 RC 60687-0417-71 NDC inpatient 1 UN 12.2 7.93 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.39 60.55 999999999 7.39 11.83 percent of total billed charges HYDROCODONE-ACETAMN 7.5-325/15 50649901_1 CDM 0250 RC 60687-0417-71 NDC inpatient 1 UN 12.2 7.93 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.39 11.83 HYDROCODONE-ACETAMN 7.5-325/15 50649901_1 CDM 0250 RC 60687-0417-71 NDC inpatient 1 UN 12.2 7.93 ANTHEM HMO ANTHEM HMO 999999999 7.39 11.83 HYDROCODONE-ACETAMN 7.5-325/15 50649901_1 CDM 0250 RC 60687-0417-71 NDC inpatient 1 UN 12.2 7.93 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.39 11.83 HYDROCODONE-ACETAMN 7.5-325/15 50649901_1 CDM 0250 RC 60687-0417-71 NDC inpatient 1 UN 12.2 7.93 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.39 11.83 HYDROCODONE-ACETAMN 7.5-325/15 50649901_1 CDM 0250 RC 60687-0417-71 NDC inpatient 1 UN 12.2 7.93 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.39 11.83 HYDROCODONE-ACETAMN 7.5-325/15 50649901_1 CDM 0250 RC 60687-0417-71 NDC inpatient 1 UN 12.2 7.93 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.25 67.6 999999999 7.39 11.83 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50650002_1 CDM 0250 RC 72611-0719-25 NDC J1885 HCPCS inpatient 1 UN 18.77 12.2 AETNA AETNA 14.83 79 999999999 11.37 18.21 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50650002_1 CDM 0250 RC 72611-0719-25 NDC J1885 HCPCS inpatient 1 UN 18.77 12.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.2 65 999999999 11.37 18.21 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50650002_1 CDM 0250 RC 72611-0719-25 NDC J1885 HCPCS inpatient 1 UN 18.77 12.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 18.21 97 999999999 11.37 18.21 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50650002_1 CDM 0250 RC 72611-0719-25 NDC J1885 HCPCS inpatient 1 UN 18.77 12.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.64 78 999999999 11.37 18.21 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50650002_1 CDM 0250 RC 72611-0719-25 NDC J1885 HCPCS inpatient 1 UN 18.77 12.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.95 69 999999999 11.37 18.21 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50650002_1 CDM 0250 RC 72611-0719-25 NDC J1885 HCPCS inpatient 1 UN 18.77 12.2 SIHO - ALL PLANS SIHO - ALL PLANS 16.89 90 999999999 11.37 18.21 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50650002_1 CDM 0250 RC 72611-0719-25 NDC J1885 HCPCS inpatient 1 UN 18.77 12.2 UMR - ALL PLANS UMR - ALL PLANS 13.14 70 999999999 11.37 18.21 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50650002_1 CDM 0250 RC 72611-0719-25 NDC J1885 HCPCS inpatient 1 UN 18.77 12.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.37 60.55 999999999 11.37 18.21 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50650002_1 CDM 0250 RC 72611-0719-25 NDC J1885 HCPCS inpatient 1 UN 18.77 12.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.37 18.21 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50650002_1 CDM 0250 RC 72611-0719-25 NDC J1885 HCPCS inpatient 1 UN 18.77 12.2 ANTHEM HMO ANTHEM HMO 999999999 11.37 18.21 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50650002_1 CDM 0250 RC 72611-0719-25 NDC J1885 HCPCS inpatient 1 UN 18.77 12.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.37 18.21 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50650002_1 CDM 0250 RC 72611-0719-25 NDC J1885 HCPCS inpatient 1 UN 18.77 12.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.37 18.21 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50650002_1 CDM 0250 RC 72611-0719-25 NDC J1885 HCPCS inpatient 1 UN 18.77 12.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.37 18.21 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50650002_1 CDM 0250 RC 72611-0719-25 NDC J1885 HCPCS inpatient 1 UN 18.77 12.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.69 67.6 999999999 11.37 18.21 percent of total billed charges PANTOPRAZOLE DR 40 MG SUSP PKT 50650173_1 CDM 0250 RC 62756-0071-64 NDC inpatient 1 UN 53.36 34.68 AETNA AETNA 42.15 79 999999999 32.31 51.76 percent of total billed charges PANTOPRAZOLE DR 40 MG SUSP PKT 50650173_1 CDM 0250 RC 62756-0071-64 NDC inpatient 1 UN 53.36 34.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.68 65 999999999 32.31 51.76 percent of total billed charges PANTOPRAZOLE DR 40 MG SUSP PKT 50650173_1 CDM 0250 RC 62756-0071-64 NDC inpatient 1 UN 53.36 34.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.76 97 999999999 32.31 51.76 percent of total billed charges PANTOPRAZOLE DR 40 MG SUSP PKT 50650173_1 CDM 0250 RC 62756-0071-64 NDC inpatient 1 UN 53.36 34.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.62 78 999999999 32.31 51.76 percent of total billed charges PANTOPRAZOLE DR 40 MG SUSP PKT 50650173_1 CDM 0250 RC 62756-0071-64 NDC inpatient 1 UN 53.36 34.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.82 69 999999999 32.31 51.76 percent of total billed charges PANTOPRAZOLE DR 40 MG SUSP PKT 50650173_1 CDM 0250 RC 62756-0071-64 NDC inpatient 1 UN 53.36 34.68 SIHO - ALL PLANS SIHO - ALL PLANS 48.02 90 999999999 32.31 51.76 percent of total billed charges PANTOPRAZOLE DR 40 MG SUSP PKT 50650173_1 CDM 0250 RC 62756-0071-64 NDC inpatient 1 UN 53.36 34.68 UMR - ALL PLANS UMR - ALL PLANS 37.35 70 999999999 32.31 51.76 percent of total billed charges PANTOPRAZOLE DR 40 MG SUSP PKT 50650173_1 CDM 0250 RC 62756-0071-64 NDC inpatient 1 UN 53.36 34.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.31 60.55 999999999 32.31 51.76 percent of total billed charges PANTOPRAZOLE DR 40 MG SUSP PKT 50650173_1 CDM 0250 RC 62756-0071-64 NDC inpatient 1 UN 53.36 34.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.31 51.76 PANTOPRAZOLE DR 40 MG SUSP PKT 50650173_1 CDM 0250 RC 62756-0071-64 NDC inpatient 1 UN 53.36 34.68 ANTHEM HMO ANTHEM HMO 999999999 32.31 51.76 PANTOPRAZOLE DR 40 MG SUSP PKT 50650173_1 CDM 0250 RC 62756-0071-64 NDC inpatient 1 UN 53.36 34.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.31 51.76 PANTOPRAZOLE DR 40 MG SUSP PKT 50650173_1 CDM 0250 RC 62756-0071-64 NDC inpatient 1 UN 53.36 34.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.31 51.76 PANTOPRAZOLE DR 40 MG SUSP PKT 50650173_1 CDM 0250 RC 62756-0071-64 NDC inpatient 1 UN 53.36 34.68 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.31 51.76 PANTOPRAZOLE DR 40 MG SUSP PKT 50650173_1 CDM 0250 RC 62756-0071-64 NDC inpatient 1 UN 53.36 34.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 36.07 67.6 999999999 32.31 51.76 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 50650175_1 CDM 0250 RC 70860-0301-05 NDC inpatient 1 UN 31.16 20.25 AETNA AETNA 24.62 79 999999999 18.87 30.23 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 50650175_1 CDM 0250 RC 70860-0301-05 NDC inpatient 1 UN 31.16 20.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.25 65 999999999 18.87 30.23 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 50650175_1 CDM 0250 RC 70860-0301-05 NDC inpatient 1 UN 31.16 20.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.23 97 999999999 18.87 30.23 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 50650175_1 CDM 0250 RC 70860-0301-05 NDC inpatient 1 UN 31.16 20.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.3 78 999999999 18.87 30.23 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 50650175_1 CDM 0250 RC 70860-0301-05 NDC inpatient 1 UN 31.16 20.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.5 69 999999999 18.87 30.23 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 50650175_1 CDM 0250 RC 70860-0301-05 NDC inpatient 1 UN 31.16 20.25 SIHO - ALL PLANS SIHO - ALL PLANS 28.04 90 999999999 18.87 30.23 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 50650175_1 CDM 0250 RC 70860-0301-05 NDC inpatient 1 UN 31.16 20.25 UMR - ALL PLANS UMR - ALL PLANS 21.81 70 999999999 18.87 30.23 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 50650175_1 CDM 0250 RC 70860-0301-05 NDC inpatient 1 UN 31.16 20.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.87 60.55 999999999 18.87 30.23 percent of total billed charges DILTIAZEM 25 MG/5 ML VIAL 50650175_1 CDM 0250 RC 70860-0301-05 NDC inpatient 1 UN 31.16 20.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.87 30.23 DILTIAZEM 25 MG/5 ML VIAL 50650175_1 CDM 0250 RC 70860-0301-05 NDC inpatient 1 UN 31.16 20.25 ANTHEM HMO ANTHEM HMO 999999999 18.87 30.23 DILTIAZEM 25 MG/5 ML VIAL 50650175_1 CDM 0250 RC 70860-0301-05 NDC inpatient 1 UN 31.16 20.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.87 30.23 DILTIAZEM 25 MG/5 ML VIAL 50650175_1 CDM 0250 RC 70860-0301-05 NDC inpatient 1 UN 31.16 20.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.87 30.23 DILTIAZEM 25 MG/5 ML VIAL 50650175_1 CDM 0250 RC 70860-0301-05 NDC inpatient 1 UN 31.16 20.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.87 30.23 DILTIAZEM 25 MG/5 ML VIAL 50650175_1 CDM 0250 RC 70860-0301-05 NDC inpatient 1 UN 31.16 20.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.06 67.6 999999999 18.87 30.23 percent of total billed charges VANCOMYCIN HCL 250 MG CAPSULE 50650704_1 CDM 0250 RC 00121-0890-20 NDC inpatient 1 UN 8.53 5.54 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.54 65 999999999 5.16 8.27 percent of total billed charges VANCOMYCIN HCL 250 MG CAPSULE 50650704_1 CDM 0250 RC 00121-0890-20 NDC inpatient 1 UN 8.53 5.54 AETNA AETNA 6.74 79 999999999 5.16 8.27 percent of total billed charges VANCOMYCIN HCL 250 MG CAPSULE 50650704_1 CDM 0250 RC 00121-0890-20 NDC inpatient 1 UN 8.53 5.54 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.27 97 999999999 5.16 8.27 percent of total billed charges VANCOMYCIN HCL 250 MG CAPSULE 50650704_1 CDM 0250 RC 00121-0890-20 NDC inpatient 1 UN 8.53 5.54 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.65 78 999999999 5.16 8.27 percent of total billed charges VANCOMYCIN HCL 250 MG CAPSULE 50650704_1 CDM 0250 RC 00121-0890-20 NDC inpatient 1 UN 8.53 5.54 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.89 69 999999999 5.16 8.27 percent of total billed charges VANCOMYCIN HCL 250 MG CAPSULE 50650704_1 CDM 0250 RC 00121-0890-20 NDC inpatient 1 UN 8.53 5.54 SIHO - ALL PLANS SIHO - ALL PLANS 7.68 90 999999999 5.16 8.27 percent of total billed charges VANCOMYCIN HCL 250 MG CAPSULE 50650704_1 CDM 0250 RC 00121-0890-20 NDC inpatient 1 UN 8.53 5.54 UMR - ALL PLANS UMR - ALL PLANS 5.97 70 999999999 5.16 8.27 percent of total billed charges VANCOMYCIN HCL 250 MG CAPSULE 50650704_1 CDM 0250 RC 00121-0890-20 NDC inpatient 1 UN 8.53 5.54 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.16 60.55 999999999 5.16 8.27 percent of total billed charges VANCOMYCIN HCL 250 MG CAPSULE 50650704_1 CDM 0250 RC 00121-0890-20 NDC inpatient 1 UN 8.53 5.54 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.16 8.27 VANCOMYCIN HCL 250 MG CAPSULE 50650704_1 CDM 0250 RC 00121-0890-20 NDC inpatient 1 UN 8.53 5.54 ANTHEM HMO ANTHEM HMO 999999999 5.16 8.27 VANCOMYCIN HCL 250 MG CAPSULE 50650704_1 CDM 0250 RC 00121-0890-20 NDC inpatient 1 UN 8.53 5.54 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.16 8.27 VANCOMYCIN HCL 250 MG CAPSULE 50650704_1 CDM 0250 RC 00121-0890-20 NDC inpatient 1 UN 8.53 5.54 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.16 8.27 VANCOMYCIN HCL 250 MG CAPSULE 50650704_1 CDM 0250 RC 00121-0890-20 NDC inpatient 1 UN 8.53 5.54 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.16 8.27 VANCOMYCIN HCL 250 MG CAPSULE 50650704_1 CDM 0250 RC 00121-0890-20 NDC inpatient 1 UN 8.53 5.54 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.77 67.6 999999999 5.16 8.27 percent of total billed charges VANCOMYCIN HCL 125 MG CAPSULE 50650711_1 CDM 0250 RC 00121-0867-20 NDC inpatient 1 UN 9.14 5.94 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.94 65 999999999 5.53 8.87 percent of total billed charges VANCOMYCIN HCL 125 MG CAPSULE 50650711_1 CDM 0250 RC 00121-0867-20 NDC inpatient 1 UN 9.14 5.94 AETNA AETNA 7.22 79 999999999 5.53 8.87 percent of total billed charges VANCOMYCIN HCL 125 MG CAPSULE 50650711_1 CDM 0250 RC 00121-0867-20 NDC inpatient 1 UN 9.14 5.94 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.87 97 999999999 5.53 8.87 percent of total billed charges VANCOMYCIN HCL 125 MG CAPSULE 50650711_1 CDM 0250 RC 00121-0867-20 NDC inpatient 1 UN 9.14 5.94 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.13 78 999999999 5.53 8.87 percent of total billed charges VANCOMYCIN HCL 125 MG CAPSULE 50650711_1 CDM 0250 RC 00121-0867-20 NDC inpatient 1 UN 9.14 5.94 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.31 69 999999999 5.53 8.87 percent of total billed charges VANCOMYCIN HCL 125 MG CAPSULE 50650711_1 CDM 0250 RC 00121-0867-20 NDC inpatient 1 UN 9.14 5.94 SIHO - ALL PLANS SIHO - ALL PLANS 8.23 90 999999999 5.53 8.87 percent of total billed charges VANCOMYCIN HCL 125 MG CAPSULE 50650711_1 CDM 0250 RC 00121-0867-20 NDC inpatient 1 UN 9.14 5.94 UMR - ALL PLANS UMR - ALL PLANS 6.4 70 999999999 5.53 8.87 percent of total billed charges VANCOMYCIN HCL 125 MG CAPSULE 50650711_1 CDM 0250 RC 00121-0867-20 NDC inpatient 1 UN 9.14 5.94 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.53 60.55 999999999 5.53 8.87 percent of total billed charges VANCOMYCIN HCL 125 MG CAPSULE 50650711_1 CDM 0250 RC 00121-0867-20 NDC inpatient 1 UN 9.14 5.94 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.53 8.87 VANCOMYCIN HCL 125 MG CAPSULE 50650711_1 CDM 0250 RC 00121-0867-20 NDC inpatient 1 UN 9.14 5.94 ANTHEM HMO ANTHEM HMO 999999999 5.53 8.87 VANCOMYCIN HCL 125 MG CAPSULE 50650711_1 CDM 0250 RC 00121-0867-20 NDC inpatient 1 UN 9.14 5.94 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.53 8.87 VANCOMYCIN HCL 125 MG CAPSULE 50650711_1 CDM 0250 RC 00121-0867-20 NDC inpatient 1 UN 9.14 5.94 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.53 8.87 VANCOMYCIN HCL 125 MG CAPSULE 50650711_1 CDM 0250 RC 00121-0867-20 NDC inpatient 1 UN 9.14 5.94 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.53 8.87 VANCOMYCIN HCL 125 MG CAPSULE 50650711_1 CDM 0250 RC 00121-0867-20 NDC inpatient 1 UN 9.14 5.94 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.18 67.6 999999999 5.53 8.87 percent of total billed charges TIMOLOL 0.5% GEL-SOLUTION 50651077_1 CDM 0250 RC 62332-0546-05 NDC inpatient 1 UN 227.88 148.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 148.12 65 999999999 137.98 221.04 percent of total billed charges TIMOLOL 0.5% GEL-SOLUTION 50651077_1 CDM 0250 RC 62332-0546-05 NDC inpatient 1 UN 227.88 148.12 AETNA AETNA 180.03 79 999999999 137.98 221.04 percent of total billed charges TIMOLOL 0.5% GEL-SOLUTION 50651077_1 CDM 0250 RC 62332-0546-05 NDC inpatient 1 UN 227.88 148.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 221.04 97 999999999 137.98 221.04 percent of total billed charges TIMOLOL 0.5% GEL-SOLUTION 50651077_1 CDM 0250 RC 62332-0546-05 NDC inpatient 1 UN 227.88 148.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 177.75 78 999999999 137.98 221.04 percent of total billed charges TIMOLOL 0.5% GEL-SOLUTION 50651077_1 CDM 0250 RC 62332-0546-05 NDC inpatient 1 UN 227.88 148.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 157.24 69 999999999 137.98 221.04 percent of total billed charges TIMOLOL 0.5% GEL-SOLUTION 50651077_1 CDM 0250 RC 62332-0546-05 NDC inpatient 1 UN 227.88 148.12 SIHO - ALL PLANS SIHO - ALL PLANS 205.09 90 999999999 137.98 221.04 percent of total billed charges TIMOLOL 0.5% GEL-SOLUTION 50651077_1 CDM 0250 RC 62332-0546-05 NDC inpatient 1 UN 227.88 148.12 UMR - ALL PLANS UMR - ALL PLANS 159.52 70 999999999 137.98 221.04 percent of total billed charges TIMOLOL 0.5% GEL-SOLUTION 50651077_1 CDM 0250 RC 62332-0546-05 NDC inpatient 1 UN 227.88 148.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 137.98 60.55 999999999 137.98 221.04 percent of total billed charges TIMOLOL 0.5% GEL-SOLUTION 50651077_1 CDM 0250 RC 62332-0546-05 NDC inpatient 1 UN 227.88 148.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 137.98 221.04 TIMOLOL 0.5% GEL-SOLUTION 50651077_1 CDM 0250 RC 62332-0546-05 NDC inpatient 1 UN 227.88 148.12 ANTHEM HMO ANTHEM HMO 999999999 137.98 221.04 TIMOLOL 0.5% GEL-SOLUTION 50651077_1 CDM 0250 RC 62332-0546-05 NDC inpatient 1 UN 227.88 148.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 137.98 221.04 TIMOLOL 0.5% GEL-SOLUTION 50651077_1 CDM 0250 RC 62332-0546-05 NDC inpatient 1 UN 227.88 148.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 137.98 221.04 TIMOLOL 0.5% GEL-SOLUTION 50651077_1 CDM 0250 RC 62332-0546-05 NDC inpatient 1 UN 227.88 148.12 UHC - ALL PLANS UHC - ALL PLANS 999999999 137.98 221.04 TIMOLOL 0.5% GEL-SOLUTION 50651077_1 CDM 0250 RC 62332-0546-05 NDC inpatient 1 UN 227.88 148.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 154.05 67.6 999999999 137.98 221.04 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 50651300_1 CDM 0250 RC 00641-6132-25 NDC inpatient 1 UN 44.58 28.98 SELF PAY DISCOUNT SELF PAY DISCOUNT 28.98 65 999999999 26.99 43.24 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 50651300_1 CDM 0250 RC 00641-6132-25 NDC inpatient 1 UN 44.58 28.98 AETNA AETNA 35.22 79 999999999 26.99 43.24 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 50651300_1 CDM 0250 RC 00641-6132-25 NDC inpatient 1 UN 44.58 28.98 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 43.24 97 999999999 26.99 43.24 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 50651300_1 CDM 0250 RC 00641-6132-25 NDC inpatient 1 UN 44.58 28.98 HUMANA - ALL PLANS HUMANA - ALL PLANS 34.77 78 999999999 26.99 43.24 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 50651300_1 CDM 0250 RC 00641-6132-25 NDC inpatient 1 UN 44.58 28.98 ENCORE - ALL PLANS ENCORE - ALL PLANS 30.76 69 999999999 26.99 43.24 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 50651300_1 CDM 0250 RC 00641-6132-25 NDC inpatient 1 UN 44.58 28.98 SIHO - ALL PLANS SIHO - ALL PLANS 40.12 90 999999999 26.99 43.24 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 50651300_1 CDM 0250 RC 00641-6132-25 NDC inpatient 1 UN 44.58 28.98 UMR - ALL PLANS UMR - ALL PLANS 31.21 70 999999999 26.99 43.24 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 50651300_1 CDM 0250 RC 00641-6132-25 NDC inpatient 1 UN 44.58 28.98 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26.99 60.55 999999999 26.99 43.24 percent of total billed charges NALOXONE 0.4 MG/ML VIAL 50651300_1 CDM 0250 RC 00641-6132-25 NDC inpatient 1 UN 44.58 28.98 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26.99 43.24 NALOXONE 0.4 MG/ML VIAL 50651300_1 CDM 0250 RC 00641-6132-25 NDC inpatient 1 UN 44.58 28.98 ANTHEM HMO ANTHEM HMO 999999999 26.99 43.24 NALOXONE 0.4 MG/ML VIAL 50651300_1 CDM 0250 RC 00641-6132-25 NDC inpatient 1 UN 44.58 28.98 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26.99 43.24 NALOXONE 0.4 MG/ML VIAL 50651300_1 CDM 0250 RC 00641-6132-25 NDC inpatient 1 UN 44.58 28.98 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26.99 43.24 NALOXONE 0.4 MG/ML VIAL 50651300_1 CDM 0250 RC 00641-6132-25 NDC inpatient 1 UN 44.58 28.98 UHC - ALL PLANS UHC - ALL PLANS 999999999 26.99 43.24 NALOXONE 0.4 MG/ML VIAL 50651300_1 CDM 0250 RC 00641-6132-25 NDC inpatient 1 UN 44.58 28.98 CIGNA - ALL PLANS CIGNA - ALL PLANS 30.14 67.6 999999999 26.99 43.24 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 50651588_1 CDM 0311 RC 88185 HCPCS inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 50651588_1 CDM 0311 RC 88185 HCPCS inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 50651588_1 CDM 0311 RC 88185 HCPCS inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 50651588_1 CDM 0311 RC 88185 HCPCS inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 50651588_1 CDM 0311 RC 88185 HCPCS inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 50651588_1 CDM 0311 RC 88185 HCPCS inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 50651588_1 CDM 0311 RC 88185 HCPCS inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 50651588_1 CDM 0311 RC 88185 HCPCS inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 50651588_1 CDM 0311 RC 88185 HCPCS inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 "Flow cytometry technique for DNA or cell analysis, each additional marker" 50651588_1 CDM 0311 RC 88185 HCPCS inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 "Flow cytometry technique for DNA or cell analysis, each additional marker" 50651588_1 CDM 0311 RC 88185 HCPCS inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 "Flow cytometry technique for DNA or cell analysis, each additional marker" 50651588_1 CDM 0311 RC 88185 HCPCS inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 "Flow cytometry technique for DNA or cell analysis, each additional marker" 50651588_1 CDM 0311 RC 88185 HCPCS inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 "Flow cytometry technique for DNA or cell analysis, each additional marker" 50651588_1 CDM 0311 RC 88185 HCPCS inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50651832_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.7 65 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50651832_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 AETNA AETNA 61.62 79 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50651832_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 75.66 97 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50651832_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.84 78 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50651832_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.82 69 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50651832_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 SIHO - ALL PLANS SIHO - ALL PLANS 70.2 90 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50651832_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 UMR - ALL PLANS UMR - ALL PLANS 54.6 70 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50651832_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.23 60.55 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50651832_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.23 75.66 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50651832_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 ANTHEM HMO ANTHEM HMO 999999999 47.23 75.66 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50651832_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.23 75.66 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50651832_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.23 75.66 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50651832_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.23 75.66 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50651832_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.73 67.6 999999999 47.23 75.66 percent of total billed charges Measurement of Hepatitis A antibody 50652181_1 CDM 0301 RC 86708 HCPCS inpatient 127 82.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 82.55 65 999999999 76.9 123.19 percent of total billed charges Measurement of Hepatitis A antibody 50652181_1 CDM 0301 RC 86708 HCPCS inpatient 127 82.55 AETNA AETNA 100.33 79 999999999 76.9 123.19 percent of total billed charges Measurement of Hepatitis A antibody 50652181_1 CDM 0301 RC 86708 HCPCS inpatient 127 82.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 123.19 97 999999999 76.9 123.19 percent of total billed charges Measurement of Hepatitis A antibody 50652181_1 CDM 0301 RC 86708 HCPCS inpatient 127 82.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 99.06 78 999999999 76.9 123.19 percent of total billed charges Measurement of Hepatitis A antibody 50652181_1 CDM 0301 RC 86708 HCPCS inpatient 127 82.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 87.63 69 999999999 76.9 123.19 percent of total billed charges Measurement of Hepatitis A antibody 50652181_1 CDM 0301 RC 86708 HCPCS inpatient 127 82.55 SIHO - ALL PLANS SIHO - ALL PLANS 114.3 90 999999999 76.9 123.19 percent of total billed charges Measurement of Hepatitis A antibody 50652181_1 CDM 0301 RC 86708 HCPCS inpatient 127 82.55 UMR - ALL PLANS UMR - ALL PLANS 88.9 70 999999999 76.9 123.19 percent of total billed charges Measurement of Hepatitis A antibody 50652181_1 CDM 0301 RC 86708 HCPCS inpatient 127 82.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.9 60.55 999999999 76.9 123.19 percent of total billed charges Measurement of Hepatitis A antibody 50652181_1 CDM 0301 RC 86708 HCPCS inpatient 127 82.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.9 123.19 Measurement of Hepatitis A antibody 50652181_1 CDM 0301 RC 86708 HCPCS inpatient 127 82.55 ANTHEM HMO ANTHEM HMO 999999999 76.9 123.19 Measurement of Hepatitis A antibody 50652181_1 CDM 0301 RC 86708 HCPCS inpatient 127 82.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.9 123.19 Measurement of Hepatitis A antibody 50652181_1 CDM 0301 RC 86708 HCPCS inpatient 127 82.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.9 123.19 Measurement of Hepatitis A antibody 50652181_1 CDM 0301 RC 86708 HCPCS inpatient 127 82.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.9 123.19 Measurement of Hepatitis A antibody 50652181_1 CDM 0301 RC 86708 HCPCS inpatient 127 82.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.85 67.6 999999999 76.9 123.19 percent of total billed charges 73702-0106-15 - ePHEDrine 5 mg/mL Inj Sol 5 mL [JOHN] 50652230_1 CDM 0250 RC 73702-0106-15 NDC inpatient 1 UN 342.64 222.72 SELF PAY DISCOUNT SELF PAY DISCOUNT 222.72 65 999999999 207.47 332.36 percent of total billed charges 73702-0106-15 - ePHEDrine 5 mg/mL Inj Sol 5 mL [JOHN] 50652230_1 CDM 0250 RC 73702-0106-15 NDC inpatient 1 UN 342.64 222.72 AETNA AETNA 270.69 79 999999999 207.47 332.36 percent of total billed charges 73702-0106-15 - ePHEDrine 5 mg/mL Inj Sol 5 mL [JOHN] 50652230_1 CDM 0250 RC 73702-0106-15 NDC inpatient 1 UN 342.64 222.72 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 332.36 97 999999999 207.47 332.36 percent of total billed charges 73702-0106-15 - ePHEDrine 5 mg/mL Inj Sol 5 mL [JOHN] 50652230_1 CDM 0250 RC 73702-0106-15 NDC inpatient 1 UN 342.64 222.72 HUMANA - ALL PLANS HUMANA - ALL PLANS 267.26 78 999999999 207.47 332.36 percent of total billed charges 73702-0106-15 - ePHEDrine 5 mg/mL Inj Sol 5 mL [JOHN] 50652230_1 CDM 0250 RC 73702-0106-15 NDC inpatient 1 UN 342.64 222.72 ENCORE - ALL PLANS ENCORE - ALL PLANS 236.42 69 999999999 207.47 332.36 percent of total billed charges 73702-0106-15 - ePHEDrine 5 mg/mL Inj Sol 5 mL [JOHN] 50652230_1 CDM 0250 RC 73702-0106-15 NDC inpatient 1 UN 342.64 222.72 SIHO - ALL PLANS SIHO - ALL PLANS 308.38 90 999999999 207.47 332.36 percent of total billed charges 73702-0106-15 - ePHEDrine 5 mg/mL Inj Sol 5 mL [JOHN] 50652230_1 CDM 0250 RC 73702-0106-15 NDC inpatient 1 UN 342.64 222.72 UMR - ALL PLANS UMR - ALL PLANS 239.85 70 999999999 207.47 332.36 percent of total billed charges 73702-0106-15 - ePHEDrine 5 mg/mL Inj Sol 5 mL [JOHN] 50652230_1 CDM 0250 RC 73702-0106-15 NDC inpatient 1 UN 342.64 222.72 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 207.47 60.55 999999999 207.47 332.36 percent of total billed charges 73702-0106-15 - ePHEDrine 5 mg/mL Inj Sol 5 mL [JOHN] 50652230_1 CDM 0250 RC 73702-0106-15 NDC inpatient 1 UN 342.64 222.72 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 207.47 332.36 73702-0106-15 - ePHEDrine 5 mg/mL Inj Sol 5 mL [JOHN] 50652230_1 CDM 0250 RC 73702-0106-15 NDC inpatient 1 UN 342.64 222.72 ANTHEM HMO ANTHEM HMO 999999999 207.47 332.36 73702-0106-15 - ePHEDrine 5 mg/mL Inj Sol 5 mL [JOHN] 50652230_1 CDM 0250 RC 73702-0106-15 NDC inpatient 1 UN 342.64 222.72 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 207.47 332.36 73702-0106-15 - ePHEDrine 5 mg/mL Inj Sol 5 mL [JOHN] 50652230_1 CDM 0250 RC 73702-0106-15 NDC inpatient 1 UN 342.64 222.72 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 207.47 332.36 73702-0106-15 - ePHEDrine 5 mg/mL Inj Sol 5 mL [JOHN] 50652230_1 CDM 0250 RC 73702-0106-15 NDC inpatient 1 UN 342.64 222.72 UHC - ALL PLANS UHC - ALL PLANS 999999999 207.47 332.36 73702-0106-15 - ePHEDrine 5 mg/mL Inj Sol 5 mL [JOHN] 50652230_1 CDM 0250 RC 73702-0106-15 NDC inpatient 1 UN 342.64 222.72 CIGNA - ALL PLANS CIGNA - ALL PLANS 231.62 67.6 999999999 207.47 332.36 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 50652248_1 CDM 0250 RC 57664-0506-52 NDC inpatient 50 UN 1.39 0.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.9 65 999999999 0.84 1.35 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 50652248_1 CDM 0250 RC 57664-0506-52 NDC inpatient 50 UN 1.39 0.9 AETNA AETNA 1.1 79 999999999 0.84 1.35 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 50652248_1 CDM 0250 RC 57664-0506-52 NDC inpatient 50 UN 1.39 0.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.35 97 999999999 0.84 1.35 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 50652248_1 CDM 0250 RC 57664-0506-52 NDC inpatient 50 UN 1.39 0.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.08 78 999999999 0.84 1.35 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 50652248_1 CDM 0250 RC 57664-0506-52 NDC inpatient 50 UN 1.39 0.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.96 69 999999999 0.84 1.35 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 50652248_1 CDM 0250 RC 57664-0506-52 NDC inpatient 50 UN 1.39 0.9 SIHO - ALL PLANS SIHO - ALL PLANS 1.25 90 999999999 0.84 1.35 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 50652248_1 CDM 0250 RC 57664-0506-52 NDC inpatient 50 UN 1.39 0.9 UMR - ALL PLANS UMR - ALL PLANS 0.97 70 999999999 0.84 1.35 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 50652248_1 CDM 0250 RC 57664-0506-52 NDC inpatient 50 UN 1.39 0.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.84 60.55 999999999 0.84 1.35 percent of total billed charges METOPROLOL TARTRATE 25 MG TAB 50652248_1 CDM 0250 RC 57664-0506-52 NDC inpatient 50 UN 1.39 0.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.84 1.35 METOPROLOL TARTRATE 25 MG TAB 50652248_1 CDM 0250 RC 57664-0506-52 NDC inpatient 50 UN 1.39 0.9 ANTHEM HMO ANTHEM HMO 999999999 0.84 1.35 METOPROLOL TARTRATE 25 MG TAB 50652248_1 CDM 0250 RC 57664-0506-52 NDC inpatient 50 UN 1.39 0.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.84 1.35 METOPROLOL TARTRATE 25 MG TAB 50652248_1 CDM 0250 RC 57664-0506-52 NDC inpatient 50 UN 1.39 0.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.84 1.35 METOPROLOL TARTRATE 25 MG TAB 50652248_1 CDM 0250 RC 57664-0506-52 NDC inpatient 50 UN 1.39 0.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.84 1.35 METOPROLOL TARTRATE 25 MG TAB 50652248_1 CDM 0250 RC 57664-0506-52 NDC inpatient 50 UN 1.39 0.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.94 67.6 999999999 0.84 1.35 percent of total billed charges HYDRALAZINE 25 MG TABLET 50652464_1 CDM 0250 RC 00904-6441-61 NDC inpatient 1 UN 1.56 1.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.01 65 999999999 0.94 1.51 percent of total billed charges HYDRALAZINE 25 MG TABLET 50652464_1 CDM 0250 RC 00904-6441-61 NDC inpatient 1 UN 1.56 1.01 AETNA AETNA 1.23 79 999999999 0.94 1.51 percent of total billed charges HYDRALAZINE 25 MG TABLET 50652464_1 CDM 0250 RC 00904-6441-61 NDC inpatient 1 UN 1.56 1.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.51 97 999999999 0.94 1.51 percent of total billed charges HYDRALAZINE 25 MG TABLET 50652464_1 CDM 0250 RC 00904-6441-61 NDC inpatient 1 UN 1.56 1.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.22 78 999999999 0.94 1.51 percent of total billed charges HYDRALAZINE 25 MG TABLET 50652464_1 CDM 0250 RC 00904-6441-61 NDC inpatient 1 UN 1.56 1.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.08 69 999999999 0.94 1.51 percent of total billed charges HYDRALAZINE 25 MG TABLET 50652464_1 CDM 0250 RC 00904-6441-61 NDC inpatient 1 UN 1.56 1.01 SIHO - ALL PLANS SIHO - ALL PLANS 1.4 90 999999999 0.94 1.51 percent of total billed charges HYDRALAZINE 25 MG TABLET 50652464_1 CDM 0250 RC 00904-6441-61 NDC inpatient 1 UN 1.56 1.01 UMR - ALL PLANS UMR - ALL PLANS 1.09 70 999999999 0.94 1.51 percent of total billed charges HYDRALAZINE 25 MG TABLET 50652464_1 CDM 0250 RC 00904-6441-61 NDC inpatient 1 UN 1.56 1.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.94 60.55 999999999 0.94 1.51 percent of total billed charges HYDRALAZINE 25 MG TABLET 50652464_1 CDM 0250 RC 00904-6441-61 NDC inpatient 1 UN 1.56 1.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.94 1.51 HYDRALAZINE 25 MG TABLET 50652464_1 CDM 0250 RC 00904-6441-61 NDC inpatient 1 UN 1.56 1.01 ANTHEM HMO ANTHEM HMO 999999999 0.94 1.51 HYDRALAZINE 25 MG TABLET 50652464_1 CDM 0250 RC 00904-6441-61 NDC inpatient 1 UN 1.56 1.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.94 1.51 HYDRALAZINE 25 MG TABLET 50652464_1 CDM 0250 RC 00904-6441-61 NDC inpatient 1 UN 1.56 1.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.94 1.51 HYDRALAZINE 25 MG TABLET 50652464_1 CDM 0250 RC 00904-6441-61 NDC inpatient 1 UN 1.56 1.01 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.94 1.51 HYDRALAZINE 25 MG TABLET 50652464_1 CDM 0250 RC 00904-6441-61 NDC inpatient 1 UN 1.56 1.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.05 67.6 999999999 0.94 1.51 percent of total billed charges TRIAMTERENE-HCTZ 37.5-25 MG TB 50652703_1 CDM 0250 RC 68001-0387-00 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 37.5-25 MG TB 50652703_1 CDM 0250 RC 68001-0387-00 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 37.5-25 MG TB 50652703_1 CDM 0250 RC 68001-0387-00 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 37.5-25 MG TB 50652703_1 CDM 0250 RC 68001-0387-00 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 37.5-25 MG TB 50652703_1 CDM 0250 RC 68001-0387-00 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 37.5-25 MG TB 50652703_1 CDM 0250 RC 68001-0387-00 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 37.5-25 MG TB 50652703_1 CDM 0250 RC 68001-0387-00 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 37.5-25 MG TB 50652703_1 CDM 0250 RC 68001-0387-00 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges TRIAMTERENE-HCTZ 37.5-25 MG TB 50652703_1 CDM 0250 RC 68001-0387-00 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 TRIAMTERENE-HCTZ 37.5-25 MG TB 50652703_1 CDM 0250 RC 68001-0387-00 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 TRIAMTERENE-HCTZ 37.5-25 MG TB 50652703_1 CDM 0250 RC 68001-0387-00 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 TRIAMTERENE-HCTZ 37.5-25 MG TB 50652703_1 CDM 0250 RC 68001-0387-00 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 TRIAMTERENE-HCTZ 37.5-25 MG TB 50652703_1 CDM 0250 RC 68001-0387-00 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 TRIAMTERENE-HCTZ 37.5-25 MG TB 50652703_1 CDM 0250 RC 68001-0387-00 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652855_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.7 65 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652855_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 AETNA AETNA 61.62 79 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652855_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 75.66 97 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652855_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.84 78 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652855_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.82 69 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652855_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 SIHO - ALL PLANS SIHO - ALL PLANS 70.2 90 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652855_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 UMR - ALL PLANS UMR - ALL PLANS 54.6 70 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652855_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.23 60.55 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652855_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.23 75.66 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652855_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 ANTHEM HMO ANTHEM HMO 999999999 47.23 75.66 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652855_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.23 75.66 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652855_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.23 75.66 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652855_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.23 75.66 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652855_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.73 67.6 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652870_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.7 65 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652870_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 AETNA AETNA 61.62 79 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652870_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 75.66 97 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652870_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.84 78 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652870_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.82 69 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652870_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 SIHO - ALL PLANS SIHO - ALL PLANS 70.2 90 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652870_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 UMR - ALL PLANS UMR - ALL PLANS 54.6 70 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652870_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.23 60.55 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652870_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.23 75.66 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652870_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 ANTHEM HMO ANTHEM HMO 999999999 47.23 75.66 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652870_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.23 75.66 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652870_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.23 75.66 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652870_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.23 75.66 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652870_1 CDM 0301 RC 86003 HCPCS inpatient 78 50.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.73 67.6 999999999 47.23 75.66 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652900_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.15 65 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652900_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 AETNA AETNA 56.09 79 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652900_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 68.87 97 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652900_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 55.38 78 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652900_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.99 69 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652900_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 SIHO - ALL PLANS SIHO - ALL PLANS 63.9 90 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652900_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 UMR - ALL PLANS UMR - ALL PLANS 49.7 70 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652900_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.99 60.55 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652900_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.99 68.87 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652900_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 ANTHEM HMO ANTHEM HMO 999999999 42.99 68.87 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652900_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.99 68.87 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652900_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.99 68.87 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652900_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.99 68.87 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50652900_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 48 67.6 999999999 42.99 68.87 percent of total billed charges General Anesthesia each 15 minutes 50652999_1 CDM 0370 RC inpatient 561 364.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 364.65 65 999999999 339.69 544.17 percent of total billed charges General Anesthesia each 15 minutes 50652999_1 CDM 0370 RC inpatient 561 364.65 AETNA AETNA 443.19 79 999999999 339.69 544.17 percent of total billed charges General Anesthesia each 15 minutes 50652999_1 CDM 0370 RC inpatient 561 364.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 544.17 97 999999999 339.69 544.17 percent of total billed charges General Anesthesia each 15 minutes 50652999_1 CDM 0370 RC inpatient 561 364.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 437.58 78 999999999 339.69 544.17 percent of total billed charges General Anesthesia each 15 minutes 50652999_1 CDM 0370 RC inpatient 561 364.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 387.09 69 999999999 339.69 544.17 percent of total billed charges General Anesthesia each 15 minutes 50652999_1 CDM 0370 RC inpatient 561 364.65 SIHO - ALL PLANS SIHO - ALL PLANS 504.9 90 999999999 339.69 544.17 percent of total billed charges General Anesthesia each 15 minutes 50652999_1 CDM 0370 RC inpatient 561 364.65 UMR - ALL PLANS UMR - ALL PLANS 392.7 70 999999999 339.69 544.17 percent of total billed charges General Anesthesia each 15 minutes 50652999_1 CDM 0370 RC inpatient 561 364.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 339.69 60.55 999999999 339.69 544.17 percent of total billed charges General Anesthesia each 15 minutes 50652999_1 CDM 0370 RC inpatient 561 364.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 339.69 544.17 General Anesthesia each 15 minutes 50652999_1 CDM 0370 RC inpatient 561 364.65 ANTHEM HMO ANTHEM HMO 999999999 339.69 544.17 General Anesthesia each 15 minutes 50652999_1 CDM 0370 RC inpatient 561 364.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 339.69 544.17 General Anesthesia each 15 minutes 50652999_1 CDM 0370 RC inpatient 561 364.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 339.69 544.17 General Anesthesia each 15 minutes 50652999_1 CDM 0370 RC inpatient 561 364.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 339.69 544.17 General Anesthesia each 15 minutes 50652999_1 CDM 0370 RC inpatient 561 364.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 379.24 67.6 999999999 339.69 544.17 percent of total billed charges "NON-RETURNABLE AEROGEN ULTRA KIT, 10 AEROGEN ULTRA & AEROGEN SOLO NEBULIZERS 06-AG-AS7500-US" 50655090_1 CDM 0271 RC inpatient 599 389.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 389.35 65 999999999 362.69 581.03 percent of total billed charges "NON-RETURNABLE AEROGEN ULTRA KIT, 10 AEROGEN ULTRA & AEROGEN SOLO NEBULIZERS 06-AG-AS7500-US" 50655090_1 CDM 0271 RC inpatient 599 389.35 AETNA AETNA 473.21 79 999999999 362.69 581.03 percent of total billed charges "NON-RETURNABLE AEROGEN ULTRA KIT, 10 AEROGEN ULTRA & AEROGEN SOLO NEBULIZERS 06-AG-AS7500-US" 50655090_1 CDM 0271 RC inpatient 599 389.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 581.03 97 999999999 362.69 581.03 percent of total billed charges "NON-RETURNABLE AEROGEN ULTRA KIT, 10 AEROGEN ULTRA & AEROGEN SOLO NEBULIZERS 06-AG-AS7500-US" 50655090_1 CDM 0271 RC inpatient 599 389.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 467.22 78 999999999 362.69 581.03 percent of total billed charges "NON-RETURNABLE AEROGEN ULTRA KIT, 10 AEROGEN ULTRA & AEROGEN SOLO NEBULIZERS 06-AG-AS7500-US" 50655090_1 CDM 0271 RC inpatient 599 389.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 413.31 69 999999999 362.69 581.03 percent of total billed charges "NON-RETURNABLE AEROGEN ULTRA KIT, 10 AEROGEN ULTRA & AEROGEN SOLO NEBULIZERS 06-AG-AS7500-US" 50655090_1 CDM 0271 RC inpatient 599 389.35 SIHO - ALL PLANS SIHO - ALL PLANS 539.1 90 999999999 362.69 581.03 percent of total billed charges "NON-RETURNABLE AEROGEN ULTRA KIT, 10 AEROGEN ULTRA & AEROGEN SOLO NEBULIZERS 06-AG-AS7500-US" 50655090_1 CDM 0271 RC inpatient 599 389.35 UMR - ALL PLANS UMR - ALL PLANS 419.3 70 999999999 362.69 581.03 percent of total billed charges "NON-RETURNABLE AEROGEN ULTRA KIT, 10 AEROGEN ULTRA & AEROGEN SOLO NEBULIZERS 06-AG-AS7500-US" 50655090_1 CDM 0271 RC inpatient 599 389.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 362.69 60.55 999999999 362.69 581.03 percent of total billed charges "NON-RETURNABLE AEROGEN ULTRA KIT, 10 AEROGEN ULTRA & AEROGEN SOLO NEBULIZERS 06-AG-AS7500-US" 50655090_1 CDM 0271 RC inpatient 599 389.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 362.69 581.03 "NON-RETURNABLE AEROGEN ULTRA KIT, 10 AEROGEN ULTRA & AEROGEN SOLO NEBULIZERS 06-AG-AS7500-US" 50655090_1 CDM 0271 RC inpatient 599 389.35 ANTHEM HMO ANTHEM HMO 999999999 362.69 581.03 "NON-RETURNABLE AEROGEN ULTRA KIT, 10 AEROGEN ULTRA & AEROGEN SOLO NEBULIZERS 06-AG-AS7500-US" 50655090_1 CDM 0271 RC inpatient 599 389.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 362.69 581.03 "NON-RETURNABLE AEROGEN ULTRA KIT, 10 AEROGEN ULTRA & AEROGEN SOLO NEBULIZERS 06-AG-AS7500-US" 50655090_1 CDM 0271 RC inpatient 599 389.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 362.69 581.03 "NON-RETURNABLE AEROGEN ULTRA KIT, 10 AEROGEN ULTRA & AEROGEN SOLO NEBULIZERS 06-AG-AS7500-US" 50655090_1 CDM 0271 RC inpatient 599 389.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 362.69 581.03 "NON-RETURNABLE AEROGEN ULTRA KIT, 10 AEROGEN ULTRA & AEROGEN SOLO NEBULIZERS 06-AG-AS7500-US" 50655090_1 CDM 0271 RC inpatient 599 389.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 404.92 67.6 999999999 362.69 581.03 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50656209_1 CDM 0250 RC 00536-5895-53 NDC inpatient 1 UN 8.88 5.77 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.77 65 999999999 5.38 8.61 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50656209_1 CDM 0250 RC 00536-5895-53 NDC inpatient 1 UN 8.88 5.77 AETNA AETNA 7.02 79 999999999 5.38 8.61 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50656209_1 CDM 0250 RC 00536-5895-53 NDC inpatient 1 UN 8.88 5.77 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.61 97 999999999 5.38 8.61 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50656209_1 CDM 0250 RC 00536-5895-53 NDC inpatient 1 UN 8.88 5.77 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.93 78 999999999 5.38 8.61 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50656209_1 CDM 0250 RC 00536-5895-53 NDC inpatient 1 UN 8.88 5.77 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.13 69 999999999 5.38 8.61 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50656209_1 CDM 0250 RC 00536-5895-53 NDC inpatient 1 UN 8.88 5.77 SIHO - ALL PLANS SIHO - ALL PLANS 7.99 90 999999999 5.38 8.61 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50656209_1 CDM 0250 RC 00536-5895-53 NDC inpatient 1 UN 8.88 5.77 UMR - ALL PLANS UMR - ALL PLANS 6.22 70 999999999 5.38 8.61 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50656209_1 CDM 0250 RC 00536-5895-53 NDC inpatient 1 UN 8.88 5.77 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.38 60.55 999999999 5.38 8.61 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50656209_1 CDM 0250 RC 00536-5895-53 NDC inpatient 1 UN 8.88 5.77 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.38 8.61 NICOTINE 14 MG/24HR PATCH 50656209_1 CDM 0250 RC 00536-5895-53 NDC inpatient 1 UN 8.88 5.77 ANTHEM HMO ANTHEM HMO 999999999 5.38 8.61 NICOTINE 14 MG/24HR PATCH 50656209_1 CDM 0250 RC 00536-5895-53 NDC inpatient 1 UN 8.88 5.77 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.38 8.61 NICOTINE 14 MG/24HR PATCH 50656209_1 CDM 0250 RC 00536-5895-53 NDC inpatient 1 UN 8.88 5.77 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.38 8.61 NICOTINE 14 MG/24HR PATCH 50656209_1 CDM 0250 RC 00536-5895-53 NDC inpatient 1 UN 8.88 5.77 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.38 8.61 NICOTINE 14 MG/24HR PATCH 50656209_1 CDM 0250 RC 00536-5895-53 NDC inpatient 1 UN 8.88 5.77 CIGNA - ALL PLANS CIGNA - ALL PLANS 6 67.6 999999999 5.38 8.61 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50656231_1 CDM 0250 RC 00264-3153-11 NDC J0696 HCPCS inpatient 4 UN 111.23 72.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.3 65 999999999 67.35 107.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50656231_1 CDM 0250 RC 00264-3153-11 NDC J0696 HCPCS inpatient 4 UN 111.23 72.3 AETNA AETNA 87.87 79 999999999 67.35 107.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50656231_1 CDM 0250 RC 00264-3153-11 NDC J0696 HCPCS inpatient 4 UN 111.23 72.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 107.89 97 999999999 67.35 107.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50656231_1 CDM 0250 RC 00264-3153-11 NDC J0696 HCPCS inpatient 4 UN 111.23 72.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 86.76 78 999999999 67.35 107.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50656231_1 CDM 0250 RC 00264-3153-11 NDC J0696 HCPCS inpatient 4 UN 111.23 72.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 76.75 69 999999999 67.35 107.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50656231_1 CDM 0250 RC 00264-3153-11 NDC J0696 HCPCS inpatient 4 UN 111.23 72.3 SIHO - ALL PLANS SIHO - ALL PLANS 100.11 90 999999999 67.35 107.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50656231_1 CDM 0250 RC 00264-3153-11 NDC J0696 HCPCS inpatient 4 UN 111.23 72.3 UMR - ALL PLANS UMR - ALL PLANS 77.86 70 999999999 67.35 107.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50656231_1 CDM 0250 RC 00264-3153-11 NDC J0696 HCPCS inpatient 4 UN 111.23 72.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.35 60.55 999999999 67.35 107.89 percent of total billed charges "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50656231_1 CDM 0250 RC 00264-3153-11 NDC J0696 HCPCS inpatient 4 UN 111.23 72.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.35 107.89 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50656231_1 CDM 0250 RC 00264-3153-11 NDC J0696 HCPCS inpatient 4 UN 111.23 72.3 ANTHEM HMO ANTHEM HMO 999999999 67.35 107.89 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50656231_1 CDM 0250 RC 00264-3153-11 NDC J0696 HCPCS inpatient 4 UN 111.23 72.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.35 107.89 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50656231_1 CDM 0250 RC 00264-3153-11 NDC J0696 HCPCS inpatient 4 UN 111.23 72.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.35 107.89 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50656231_1 CDM 0250 RC 00264-3153-11 NDC J0696 HCPCS inpatient 4 UN 111.23 72.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.35 107.89 "INJECTION, CEFTRIAXONE SODIUM, PER 250 MG" 50656231_1 CDM 0250 RC 00264-3153-11 NDC J0696 HCPCS inpatient 4 UN 111.23 72.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.19 67.6 999999999 67.35 107.89 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656389_1 CDM 0306 RC 87660 HCPCS inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656389_1 CDM 0306 RC 87660 HCPCS inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656389_1 CDM 0306 RC 87660 HCPCS inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656389_1 CDM 0306 RC 87660 HCPCS inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656389_1 CDM 0306 RC 87660 HCPCS inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656389_1 CDM 0306 RC 87660 HCPCS inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656389_1 CDM 0306 RC 87660 HCPCS inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656389_1 CDM 0306 RC 87660 HCPCS inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656389_1 CDM 0306 RC 87660 HCPCS inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656389_1 CDM 0306 RC 87660 HCPCS inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656389_1 CDM 0306 RC 87660 HCPCS inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656389_1 CDM 0306 RC 87660 HCPCS inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656389_1 CDM 0306 RC 87660 HCPCS inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656389_1 CDM 0306 RC 87660 HCPCS inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656390_1 CDM 0306 RC 87660 HCPCS inpatient 97 63.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.05 65 999999999 58.73 94.09 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656390_1 CDM 0306 RC 87660 HCPCS inpatient 97 63.05 AETNA AETNA 76.63 79 999999999 58.73 94.09 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656390_1 CDM 0306 RC 87660 HCPCS inpatient 97 63.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 94.09 97 999999999 58.73 94.09 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656390_1 CDM 0306 RC 87660 HCPCS inpatient 97 63.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 75.66 78 999999999 58.73 94.09 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656390_1 CDM 0306 RC 87660 HCPCS inpatient 97 63.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.93 69 999999999 58.73 94.09 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656390_1 CDM 0306 RC 87660 HCPCS inpatient 97 63.05 SIHO - ALL PLANS SIHO - ALL PLANS 87.3 90 999999999 58.73 94.09 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656390_1 CDM 0306 RC 87660 HCPCS inpatient 97 63.05 UMR - ALL PLANS UMR - ALL PLANS 67.9 70 999999999 58.73 94.09 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656390_1 CDM 0306 RC 87660 HCPCS inpatient 97 63.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.73 60.55 999999999 58.73 94.09 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656390_1 CDM 0306 RC 87660 HCPCS inpatient 97 63.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.73 94.09 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656390_1 CDM 0306 RC 87660 HCPCS inpatient 97 63.05 ANTHEM HMO ANTHEM HMO 999999999 58.73 94.09 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656390_1 CDM 0306 RC 87660 HCPCS inpatient 97 63.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.73 94.09 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656390_1 CDM 0306 RC 87660 HCPCS inpatient 97 63.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.73 94.09 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656390_1 CDM 0306 RC 87660 HCPCS inpatient 97 63.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.73 94.09 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50656390_1 CDM 0306 RC 87660 HCPCS inpatient 97 63.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 65.57 67.6 999999999 58.73 94.09 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50656428_1 CDM 0306 RC 87510 HCPCS inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50656428_1 CDM 0306 RC 87510 HCPCS inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50656428_1 CDM 0306 RC 87510 HCPCS inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50656428_1 CDM 0306 RC 87510 HCPCS inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50656428_1 CDM 0306 RC 87510 HCPCS inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50656428_1 CDM 0306 RC 87510 HCPCS inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50656428_1 CDM 0306 RC 87510 HCPCS inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50656428_1 CDM 0306 RC 87510 HCPCS inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50656428_1 CDM 0306 RC 87510 HCPCS inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50656428_1 CDM 0306 RC 87510 HCPCS inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50656428_1 CDM 0306 RC 87510 HCPCS inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50656428_1 CDM 0306 RC 87510 HCPCS inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50656428_1 CDM 0306 RC 87510 HCPCS inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50656428_1 CDM 0306 RC 87510 HCPCS inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50656429_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50656429_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50656429_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50656429_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50656429_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50656429_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50656429_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50656429_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50656429_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 "Detection test for candida species (yeast), direct probe technique" 50656429_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 "Detection test for candida species (yeast), direct probe technique" 50656429_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 "Detection test for candida species (yeast), direct probe technique" 50656429_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 "Detection test for candida species (yeast), direct probe technique" 50656429_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 "Detection test for candida species (yeast), direct probe technique" 50656429_1 CDM 0306 RC 87480 HCPCS inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges Protein C antigen (clotting inhibitor) measurement 50656455_1 CDM 0305 RC 85303 HCPCS inpatient 288 187.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 187.2 65 999999999 174.38 279.36 percent of total billed charges Protein C antigen (clotting inhibitor) measurement 50656455_1 CDM 0305 RC 85303 HCPCS inpatient 288 187.2 AETNA AETNA 227.52 79 999999999 174.38 279.36 percent of total billed charges Protein C antigen (clotting inhibitor) measurement 50656455_1 CDM 0305 RC 85303 HCPCS inpatient 288 187.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 279.36 97 999999999 174.38 279.36 percent of total billed charges Protein C antigen (clotting inhibitor) measurement 50656455_1 CDM 0305 RC 85303 HCPCS inpatient 288 187.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 224.64 78 999999999 174.38 279.36 percent of total billed charges Protein C antigen (clotting inhibitor) measurement 50656455_1 CDM 0305 RC 85303 HCPCS inpatient 288 187.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 198.72 69 999999999 174.38 279.36 percent of total billed charges Protein C antigen (clotting inhibitor) measurement 50656455_1 CDM 0305 RC 85303 HCPCS inpatient 288 187.2 SIHO - ALL PLANS SIHO - ALL PLANS 259.2 90 999999999 174.38 279.36 percent of total billed charges Protein C antigen (clotting inhibitor) measurement 50656455_1 CDM 0305 RC 85303 HCPCS inpatient 288 187.2 UMR - ALL PLANS UMR - ALL PLANS 201.6 70 999999999 174.38 279.36 percent of total billed charges Protein C antigen (clotting inhibitor) measurement 50656455_1 CDM 0305 RC 85303 HCPCS inpatient 288 187.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 174.38 60.55 999999999 174.38 279.36 percent of total billed charges Protein C antigen (clotting inhibitor) measurement 50656455_1 CDM 0305 RC 85303 HCPCS inpatient 288 187.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 174.38 279.36 Protein C antigen (clotting inhibitor) measurement 50656455_1 CDM 0305 RC 85303 HCPCS inpatient 288 187.2 ANTHEM HMO ANTHEM HMO 999999999 174.38 279.36 Protein C antigen (clotting inhibitor) measurement 50656455_1 CDM 0305 RC 85303 HCPCS inpatient 288 187.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 174.38 279.36 Protein C antigen (clotting inhibitor) measurement 50656455_1 CDM 0305 RC 85303 HCPCS inpatient 288 187.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 174.38 279.36 Protein C antigen (clotting inhibitor) measurement 50656455_1 CDM 0305 RC 85303 HCPCS inpatient 288 187.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 174.38 279.36 Protein C antigen (clotting inhibitor) measurement 50656455_1 CDM 0305 RC 85303 HCPCS inpatient 288 187.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 194.69 67.6 999999999 174.38 279.36 percent of total billed charges LABETALOL HCL 300 MG TABLET 50656984_1 CDM 0250 RC 68001-0383-00 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LABETALOL HCL 300 MG TABLET 50656984_1 CDM 0250 RC 68001-0383-00 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LABETALOL HCL 300 MG TABLET 50656984_1 CDM 0250 RC 68001-0383-00 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LABETALOL HCL 300 MG TABLET 50656984_1 CDM 0250 RC 68001-0383-00 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LABETALOL HCL 300 MG TABLET 50656984_1 CDM 0250 RC 68001-0383-00 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LABETALOL HCL 300 MG TABLET 50656984_1 CDM 0250 RC 68001-0383-00 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LABETALOL HCL 300 MG TABLET 50656984_1 CDM 0250 RC 68001-0383-00 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LABETALOL HCL 300 MG TABLET 50656984_1 CDM 0250 RC 68001-0383-00 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LABETALOL HCL 300 MG TABLET 50656984_1 CDM 0250 RC 68001-0383-00 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LABETALOL HCL 300 MG TABLET 50656984_1 CDM 0250 RC 68001-0383-00 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LABETALOL HCL 300 MG TABLET 50656984_1 CDM 0250 RC 68001-0383-00 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LABETALOL HCL 300 MG TABLET 50656984_1 CDM 0250 RC 68001-0383-00 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LABETALOL HCL 300 MG TABLET 50656984_1 CDM 0250 RC 68001-0383-00 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 LABETALOL HCL 300 MG TABLET 50656984_1 CDM 0250 RC 68001-0383-00 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50656986_1 CDM 0250 RC 68001-0433-90 NDC inpatient 1 UN 5.67 3.69 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.69 65 999999999 3.43 5.5 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50656986_1 CDM 0250 RC 68001-0433-90 NDC inpatient 1 UN 5.67 3.69 AETNA AETNA 4.48 79 999999999 3.43 5.5 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50656986_1 CDM 0250 RC 68001-0433-90 NDC inpatient 1 UN 5.67 3.69 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.5 97 999999999 3.43 5.5 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50656986_1 CDM 0250 RC 68001-0433-90 NDC inpatient 1 UN 5.67 3.69 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.42 78 999999999 3.43 5.5 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50656986_1 CDM 0250 RC 68001-0433-90 NDC inpatient 1 UN 5.67 3.69 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.91 69 999999999 3.43 5.5 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50656986_1 CDM 0250 RC 68001-0433-90 NDC inpatient 1 UN 5.67 3.69 SIHO - ALL PLANS SIHO - ALL PLANS 5.1 90 999999999 3.43 5.5 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50656986_1 CDM 0250 RC 68001-0433-90 NDC inpatient 1 UN 5.67 3.69 UMR - ALL PLANS UMR - ALL PLANS 3.97 70 999999999 3.43 5.5 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50656986_1 CDM 0250 RC 68001-0433-90 NDC inpatient 1 UN 5.67 3.69 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.43 60.55 999999999 3.43 5.5 percent of total billed charges NICOTINE 14 MG/24HR PATCH 50656986_1 CDM 0250 RC 68001-0433-90 NDC inpatient 1 UN 5.67 3.69 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.43 5.5 NICOTINE 14 MG/24HR PATCH 50656986_1 CDM 0250 RC 68001-0433-90 NDC inpatient 1 UN 5.67 3.69 ANTHEM HMO ANTHEM HMO 999999999 3.43 5.5 NICOTINE 14 MG/24HR PATCH 50656986_1 CDM 0250 RC 68001-0433-90 NDC inpatient 1 UN 5.67 3.69 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.43 5.5 NICOTINE 14 MG/24HR PATCH 50656986_1 CDM 0250 RC 68001-0433-90 NDC inpatient 1 UN 5.67 3.69 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.43 5.5 NICOTINE 14 MG/24HR PATCH 50656986_1 CDM 0250 RC 68001-0433-90 NDC inpatient 1 UN 5.67 3.69 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.43 5.5 NICOTINE 14 MG/24HR PATCH 50656986_1 CDM 0250 RC 68001-0433-90 NDC inpatient 1 UN 5.67 3.69 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.83 67.6 999999999 3.43 5.5 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 50657123_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 128.7 65 999999999 119.89 192.06 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 50657123_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 AETNA AETNA 156.42 79 999999999 119.89 192.06 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 50657123_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 192.06 97 999999999 119.89 192.06 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 50657123_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 154.44 78 999999999 119.89 192.06 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 50657123_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 136.62 69 999999999 119.89 192.06 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 50657123_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 SIHO - ALL PLANS SIHO - ALL PLANS 178.2 90 999999999 119.89 192.06 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 50657123_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 UMR - ALL PLANS UMR - ALL PLANS 138.6 70 999999999 119.89 192.06 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 50657123_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 119.89 60.55 999999999 119.89 192.06 percent of total billed charges Angiotensin l - converting enzyme (ACE) level 50657123_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 119.89 192.06 Angiotensin l - converting enzyme (ACE) level 50657123_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 ANTHEM HMO ANTHEM HMO 999999999 119.89 192.06 Angiotensin l - converting enzyme (ACE) level 50657123_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 119.89 192.06 Angiotensin l - converting enzyme (ACE) level 50657123_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 119.89 192.06 Angiotensin l - converting enzyme (ACE) level 50657123_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 119.89 192.06 Angiotensin l - converting enzyme (ACE) level 50657123_1 CDM 0301 RC 82164 HCPCS inpatient 198 128.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 133.85 67.6 999999999 119.89 192.06 percent of total billed charges Metanephrines level 50657130_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 SELF PAY DISCOUNT SELF PAY DISCOUNT 169 65 999999999 157.43 252.2 percent of total billed charges Metanephrines level 50657130_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 AETNA AETNA 205.4 79 999999999 157.43 252.2 percent of total billed charges Metanephrines level 50657130_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 252.2 97 999999999 157.43 252.2 percent of total billed charges Metanephrines level 50657130_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 HUMANA - ALL PLANS HUMANA - ALL PLANS 202.8 78 999999999 157.43 252.2 percent of total billed charges Metanephrines level 50657130_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 ENCORE - ALL PLANS ENCORE - ALL PLANS 179.4 69 999999999 157.43 252.2 percent of total billed charges Metanephrines level 50657130_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 SIHO - ALL PLANS SIHO - ALL PLANS 234 90 999999999 157.43 252.2 percent of total billed charges Metanephrines level 50657130_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 UMR - ALL PLANS UMR - ALL PLANS 182 70 999999999 157.43 252.2 percent of total billed charges Metanephrines level 50657130_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 157.43 60.55 999999999 157.43 252.2 percent of total billed charges Metanephrines level 50657130_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 157.43 252.2 Metanephrines level 50657130_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 ANTHEM HMO ANTHEM HMO 999999999 157.43 252.2 Metanephrines level 50657130_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 157.43 252.2 Metanephrines level 50657130_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 157.43 252.2 Metanephrines level 50657130_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 UHC - ALL PLANS UHC - ALL PLANS 999999999 157.43 252.2 Metanephrines level 50657130_1 CDM 0301 RC 83835 HCPCS inpatient 260 169 CIGNA - ALL PLANS CIGNA - ALL PLANS 175.76 67.6 999999999 157.43 252.2 percent of total billed charges DICYCLOMINE 20 MG TABLET 50657271_1 CDM 0250 RC 00527-1282-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 20 MG TABLET 50657271_1 CDM 0250 RC 00527-1282-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 20 MG TABLET 50657271_1 CDM 0250 RC 00527-1282-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 20 MG TABLET 50657271_1 CDM 0250 RC 00527-1282-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 20 MG TABLET 50657271_1 CDM 0250 RC 00527-1282-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 20 MG TABLET 50657271_1 CDM 0250 RC 00527-1282-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 20 MG TABLET 50657271_1 CDM 0250 RC 00527-1282-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 20 MG TABLET 50657271_1 CDM 0250 RC 00527-1282-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 20 MG TABLET 50657271_1 CDM 0250 RC 00527-1282-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 DICYCLOMINE 20 MG TABLET 50657271_1 CDM 0250 RC 00527-1282-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 DICYCLOMINE 20 MG TABLET 50657271_1 CDM 0250 RC 00527-1282-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 DICYCLOMINE 20 MG TABLET 50657271_1 CDM 0250 RC 00527-1282-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 DICYCLOMINE 20 MG TABLET 50657271_1 CDM 0250 RC 00527-1282-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 DICYCLOMINE 20 MG TABLET 50657271_1 CDM 0250 RC 00527-1282-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "HEPARIN SOD 5,000 UNIT/ML VIAL" 50657439_1 CDM 0250 RC 63323-0262-26 NDC inpatient 1 UN 22.53 14.64 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.64 65 999999999 13.64 21.85 percent of total billed charges "HEPARIN SOD 5,000 UNIT/ML VIAL" 50657439_1 CDM 0250 RC 63323-0262-26 NDC inpatient 1 UN 22.53 14.64 AETNA AETNA 17.8 79 999999999 13.64 21.85 percent of total billed charges "HEPARIN SOD 5,000 UNIT/ML VIAL" 50657439_1 CDM 0250 RC 63323-0262-26 NDC inpatient 1 UN 22.53 14.64 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21.85 97 999999999 13.64 21.85 percent of total billed charges "HEPARIN SOD 5,000 UNIT/ML VIAL" 50657439_1 CDM 0250 RC 63323-0262-26 NDC inpatient 1 UN 22.53 14.64 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.57 78 999999999 13.64 21.85 percent of total billed charges "HEPARIN SOD 5,000 UNIT/ML VIAL" 50657439_1 CDM 0250 RC 63323-0262-26 NDC inpatient 1 UN 22.53 14.64 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.55 69 999999999 13.64 21.85 percent of total billed charges "HEPARIN SOD 5,000 UNIT/ML VIAL" 50657439_1 CDM 0250 RC 63323-0262-26 NDC inpatient 1 UN 22.53 14.64 SIHO - ALL PLANS SIHO - ALL PLANS 20.28 90 999999999 13.64 21.85 percent of total billed charges "HEPARIN SOD 5,000 UNIT/ML VIAL" 50657439_1 CDM 0250 RC 63323-0262-26 NDC inpatient 1 UN 22.53 14.64 UMR - ALL PLANS UMR - ALL PLANS 15.77 70 999999999 13.64 21.85 percent of total billed charges "HEPARIN SOD 5,000 UNIT/ML VIAL" 50657439_1 CDM 0250 RC 63323-0262-26 NDC inpatient 1 UN 22.53 14.64 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.64 60.55 999999999 13.64 21.85 percent of total billed charges "HEPARIN SOD 5,000 UNIT/ML VIAL" 50657439_1 CDM 0250 RC 63323-0262-26 NDC inpatient 1 UN 22.53 14.64 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.64 21.85 "HEPARIN SOD 5,000 UNIT/ML VIAL" 50657439_1 CDM 0250 RC 63323-0262-26 NDC inpatient 1 UN 22.53 14.64 ANTHEM HMO ANTHEM HMO 999999999 13.64 21.85 "HEPARIN SOD 5,000 UNIT/ML VIAL" 50657439_1 CDM 0250 RC 63323-0262-26 NDC inpatient 1 UN 22.53 14.64 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.64 21.85 "HEPARIN SOD 5,000 UNIT/ML VIAL" 50657439_1 CDM 0250 RC 63323-0262-26 NDC inpatient 1 UN 22.53 14.64 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.64 21.85 "HEPARIN SOD 5,000 UNIT/ML VIAL" 50657439_1 CDM 0250 RC 63323-0262-26 NDC inpatient 1 UN 22.53 14.64 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.64 21.85 "HEPARIN SOD 5,000 UNIT/ML VIAL" 50657439_1 CDM 0250 RC 63323-0262-26 NDC inpatient 1 UN 22.53 14.64 CIGNA - ALL PLANS CIGNA - ALL PLANS 15.23 67.6 999999999 13.64 21.85 percent of total billed charges "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 50657440_1 CDM 0250 RC 60687-0524-83 NDC J7633 HCPCS inpatient 1 UN 14.84 9.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.65 65 999999999 8.99 14.39 percent of total billed charges "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 50657440_1 CDM 0250 RC 60687-0524-83 NDC J7633 HCPCS inpatient 1 UN 14.84 9.65 AETNA AETNA 11.72 79 999999999 8.99 14.39 percent of total billed charges "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 50657440_1 CDM 0250 RC 60687-0524-83 NDC J7633 HCPCS inpatient 1 UN 14.84 9.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14.39 97 999999999 8.99 14.39 percent of total billed charges "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 50657440_1 CDM 0250 RC 60687-0524-83 NDC J7633 HCPCS inpatient 1 UN 14.84 9.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.58 78 999999999 8.99 14.39 percent of total billed charges "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 50657440_1 CDM 0250 RC 60687-0524-83 NDC J7633 HCPCS inpatient 1 UN 14.84 9.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.24 69 999999999 8.99 14.39 percent of total billed charges "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 50657440_1 CDM 0250 RC 60687-0524-83 NDC J7633 HCPCS inpatient 1 UN 14.84 9.65 SIHO - ALL PLANS SIHO - ALL PLANS 13.36 90 999999999 8.99 14.39 percent of total billed charges "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 50657440_1 CDM 0250 RC 60687-0524-83 NDC J7633 HCPCS inpatient 1 UN 14.84 9.65 UMR - ALL PLANS UMR - ALL PLANS 10.39 70 999999999 8.99 14.39 percent of total billed charges "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 50657440_1 CDM 0250 RC 60687-0524-83 NDC J7633 HCPCS inpatient 1 UN 14.84 9.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8.99 60.55 999999999 8.99 14.39 percent of total billed charges "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 50657440_1 CDM 0250 RC 60687-0524-83 NDC J7633 HCPCS inpatient 1 UN 14.84 9.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8.99 14.39 "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 50657440_1 CDM 0250 RC 60687-0524-83 NDC J7633 HCPCS inpatient 1 UN 14.84 9.65 ANTHEM HMO ANTHEM HMO 999999999 8.99 14.39 "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 50657440_1 CDM 0250 RC 60687-0524-83 NDC J7633 HCPCS inpatient 1 UN 14.84 9.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8.99 14.39 "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 50657440_1 CDM 0250 RC 60687-0524-83 NDC J7633 HCPCS inpatient 1 UN 14.84 9.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8.99 14.39 "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 50657440_1 CDM 0250 RC 60687-0524-83 NDC J7633 HCPCS inpatient 1 UN 14.84 9.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 8.99 14.39 "BUDESONIDE, INHALATION SOLUTION, FDA-APPROVED FINAL PRODUCT, NON-COMPOUNDED, ADMINISTERED THROUGH DME, CONCENTRATED FORM, PER 0.25 MILLIGRAM" 50657440_1 CDM 0250 RC 60687-0524-83 NDC J7633 HCPCS inpatient 1 UN 14.84 9.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.03 67.6 999999999 8.99 14.39 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 50657442_1 CDM 0636 RC 16729-0295-33 NDC J9045 HCPCS inpatient 3 UN 70.06 45.54 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.54 65 999999999 42.42 67.96 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 50657442_1 CDM 0636 RC 16729-0295-33 NDC J9045 HCPCS inpatient 3 UN 70.06 45.54 AETNA AETNA 55.35 79 999999999 42.42 67.96 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 50657442_1 CDM 0636 RC 16729-0295-33 NDC J9045 HCPCS inpatient 3 UN 70.06 45.54 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.96 97 999999999 42.42 67.96 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 50657442_1 CDM 0636 RC 16729-0295-33 NDC J9045 HCPCS inpatient 3 UN 70.06 45.54 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.65 78 999999999 42.42 67.96 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 50657442_1 CDM 0636 RC 16729-0295-33 NDC J9045 HCPCS inpatient 3 UN 70.06 45.54 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.34 69 999999999 42.42 67.96 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 50657442_1 CDM 0636 RC 16729-0295-33 NDC J9045 HCPCS inpatient 3 UN 70.06 45.54 SIHO - ALL PLANS SIHO - ALL PLANS 63.05 90 999999999 42.42 67.96 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 50657442_1 CDM 0636 RC 16729-0295-33 NDC J9045 HCPCS inpatient 3 UN 70.06 45.54 UMR - ALL PLANS UMR - ALL PLANS 49.04 70 999999999 42.42 67.96 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 50657442_1 CDM 0636 RC 16729-0295-33 NDC J9045 HCPCS inpatient 3 UN 70.06 45.54 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.42 60.55 999999999 42.42 67.96 percent of total billed charges "INJECTION, CARBOPLATIN, 50 MG" 50657442_1 CDM 0636 RC 16729-0295-33 NDC J9045 HCPCS inpatient 3 UN 70.06 45.54 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.42 67.96 "INJECTION, CARBOPLATIN, 50 MG" 50657442_1 CDM 0636 RC 16729-0295-33 NDC J9045 HCPCS inpatient 3 UN 70.06 45.54 ANTHEM HMO ANTHEM HMO 999999999 42.42 67.96 "INJECTION, CARBOPLATIN, 50 MG" 50657442_1 CDM 0636 RC 16729-0295-33 NDC J9045 HCPCS inpatient 3 UN 70.06 45.54 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.42 67.96 "INJECTION, CARBOPLATIN, 50 MG" 50657442_1 CDM 0636 RC 16729-0295-33 NDC J9045 HCPCS inpatient 3 UN 70.06 45.54 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.42 67.96 "INJECTION, CARBOPLATIN, 50 MG" 50657442_1 CDM 0636 RC 16729-0295-33 NDC J9045 HCPCS inpatient 3 UN 70.06 45.54 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.42 67.96 "INJECTION, CARBOPLATIN, 50 MG" 50657442_1 CDM 0636 RC 16729-0295-33 NDC J9045 HCPCS inpatient 3 UN 70.06 45.54 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.36 67.6 999999999 42.42 67.96 percent of total billed charges 00002-7950-01 - etesevimab 700 mg/20 mL IV Sol [JOHN] 50659614_1 CDM 0250 RC 00002-7950-01 NDC inpatient 100 UN 25 16.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.25 65 999999999 15.14 24.25 percent of total billed charges 00002-7950-01 - etesevimab 700 mg/20 mL IV Sol [JOHN] 50659614_1 CDM 0250 RC 00002-7950-01 NDC inpatient 100 UN 25 16.25 AETNA AETNA 19.75 79 999999999 15.14 24.25 percent of total billed charges 00002-7950-01 - etesevimab 700 mg/20 mL IV Sol [JOHN] 50659614_1 CDM 0250 RC 00002-7950-01 NDC inpatient 100 UN 25 16.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.25 97 999999999 15.14 24.25 percent of total billed charges 00002-7950-01 - etesevimab 700 mg/20 mL IV Sol [JOHN] 50659614_1 CDM 0250 RC 00002-7950-01 NDC inpatient 100 UN 25 16.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.5 78 999999999 15.14 24.25 percent of total billed charges 00002-7950-01 - etesevimab 700 mg/20 mL IV Sol [JOHN] 50659614_1 CDM 0250 RC 00002-7950-01 NDC inpatient 100 UN 25 16.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.25 69 999999999 15.14 24.25 percent of total billed charges 00002-7950-01 - etesevimab 700 mg/20 mL IV Sol [JOHN] 50659614_1 CDM 0250 RC 00002-7950-01 NDC inpatient 100 UN 25 16.25 SIHO - ALL PLANS SIHO - ALL PLANS 22.5 90 999999999 15.14 24.25 percent of total billed charges 00002-7950-01 - etesevimab 700 mg/20 mL IV Sol [JOHN] 50659614_1 CDM 0250 RC 00002-7950-01 NDC inpatient 100 UN 25 16.25 UMR - ALL PLANS UMR - ALL PLANS 17.5 70 999999999 15.14 24.25 percent of total billed charges 00002-7950-01 - etesevimab 700 mg/20 mL IV Sol [JOHN] 50659614_1 CDM 0250 RC 00002-7950-01 NDC inpatient 100 UN 25 16.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.14 60.55 999999999 15.14 24.25 percent of total billed charges 00002-7950-01 - etesevimab 700 mg/20 mL IV Sol [JOHN] 50659614_1 CDM 0250 RC 00002-7950-01 NDC inpatient 100 UN 25 16.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.14 24.25 00002-7950-01 - etesevimab 700 mg/20 mL IV Sol [JOHN] 50659614_1 CDM 0250 RC 00002-7950-01 NDC inpatient 100 UN 25 16.25 ANTHEM HMO ANTHEM HMO 999999999 15.14 24.25 00002-7950-01 - etesevimab 700 mg/20 mL IV Sol [JOHN] 50659614_1 CDM 0250 RC 00002-7950-01 NDC inpatient 100 UN 25 16.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.14 24.25 00002-7950-01 - etesevimab 700 mg/20 mL IV Sol [JOHN] 50659614_1 CDM 0250 RC 00002-7950-01 NDC inpatient 100 UN 25 16.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.14 24.25 00002-7950-01 - etesevimab 700 mg/20 mL IV Sol [JOHN] 50659614_1 CDM 0250 RC 00002-7950-01 NDC inpatient 100 UN 25 16.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.14 24.25 00002-7950-01 - etesevimab 700 mg/20 mL IV Sol [JOHN] 50659614_1 CDM 0250 RC 00002-7950-01 NDC inpatient 100 UN 25 16.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.9 67.6 999999999 15.14 24.25 percent of total billed charges TRAZODONE 150 MG TABLET 50659679_1 CDM 0250 RC 60687-0432-01 NDC inpatient 1 UN 1.76 1.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.14 65 999999999 1.07 1.71 percent of total billed charges TRAZODONE 150 MG TABLET 50659679_1 CDM 0250 RC 60687-0432-01 NDC inpatient 1 UN 1.76 1.14 AETNA AETNA 1.39 79 999999999 1.07 1.71 percent of total billed charges TRAZODONE 150 MG TABLET 50659679_1 CDM 0250 RC 60687-0432-01 NDC inpatient 1 UN 1.76 1.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.71 97 999999999 1.07 1.71 percent of total billed charges TRAZODONE 150 MG TABLET 50659679_1 CDM 0250 RC 60687-0432-01 NDC inpatient 1 UN 1.76 1.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.37 78 999999999 1.07 1.71 percent of total billed charges TRAZODONE 150 MG TABLET 50659679_1 CDM 0250 RC 60687-0432-01 NDC inpatient 1 UN 1.76 1.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.21 69 999999999 1.07 1.71 percent of total billed charges TRAZODONE 150 MG TABLET 50659679_1 CDM 0250 RC 60687-0432-01 NDC inpatient 1 UN 1.76 1.14 SIHO - ALL PLANS SIHO - ALL PLANS 1.58 90 999999999 1.07 1.71 percent of total billed charges TRAZODONE 150 MG TABLET 50659679_1 CDM 0250 RC 60687-0432-01 NDC inpatient 1 UN 1.76 1.14 UMR - ALL PLANS UMR - ALL PLANS 1.23 70 999999999 1.07 1.71 percent of total billed charges TRAZODONE 150 MG TABLET 50659679_1 CDM 0250 RC 60687-0432-01 NDC inpatient 1 UN 1.76 1.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.07 60.55 999999999 1.07 1.71 percent of total billed charges TRAZODONE 150 MG TABLET 50659679_1 CDM 0250 RC 60687-0432-01 NDC inpatient 1 UN 1.76 1.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.07 1.71 TRAZODONE 150 MG TABLET 50659679_1 CDM 0250 RC 60687-0432-01 NDC inpatient 1 UN 1.76 1.14 ANTHEM HMO ANTHEM HMO 999999999 1.07 1.71 TRAZODONE 150 MG TABLET 50659679_1 CDM 0250 RC 60687-0432-01 NDC inpatient 1 UN 1.76 1.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.07 1.71 TRAZODONE 150 MG TABLET 50659679_1 CDM 0250 RC 60687-0432-01 NDC inpatient 1 UN 1.76 1.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.07 1.71 TRAZODONE 150 MG TABLET 50659679_1 CDM 0250 RC 60687-0432-01 NDC inpatient 1 UN 1.76 1.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.07 1.71 TRAZODONE 150 MG TABLET 50659679_1 CDM 0250 RC 60687-0432-01 NDC inpatient 1 UN 1.76 1.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.19 67.6 999999999 1.07 1.71 percent of total billed charges NOREPINEPHR 8 MG/250-0.9% NACL 50659685_1 CDM 0250 RC 69374-0316-25 NDC inpatient 5 UN 232.88 151.37 SELF PAY DISCOUNT SELF PAY DISCOUNT 151.37 65 999999999 141.01 225.89 percent of total billed charges NOREPINEPHR 8 MG/250-0.9% NACL 50659685_1 CDM 0250 RC 69374-0316-25 NDC inpatient 5 UN 232.88 151.37 AETNA AETNA 183.98 79 999999999 141.01 225.89 percent of total billed charges NOREPINEPHR 8 MG/250-0.9% NACL 50659685_1 CDM 0250 RC 69374-0316-25 NDC inpatient 5 UN 232.88 151.37 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 225.89 97 999999999 141.01 225.89 percent of total billed charges NOREPINEPHR 8 MG/250-0.9% NACL 50659685_1 CDM 0250 RC 69374-0316-25 NDC inpatient 5 UN 232.88 151.37 HUMANA - ALL PLANS HUMANA - ALL PLANS 181.65 78 999999999 141.01 225.89 percent of total billed charges NOREPINEPHR 8 MG/250-0.9% NACL 50659685_1 CDM 0250 RC 69374-0316-25 NDC inpatient 5 UN 232.88 151.37 ENCORE - ALL PLANS ENCORE - ALL PLANS 160.69 69 999999999 141.01 225.89 percent of total billed charges NOREPINEPHR 8 MG/250-0.9% NACL 50659685_1 CDM 0250 RC 69374-0316-25 NDC inpatient 5 UN 232.88 151.37 SIHO - ALL PLANS SIHO - ALL PLANS 209.59 90 999999999 141.01 225.89 percent of total billed charges NOREPINEPHR 8 MG/250-0.9% NACL 50659685_1 CDM 0250 RC 69374-0316-25 NDC inpatient 5 UN 232.88 151.37 UMR - ALL PLANS UMR - ALL PLANS 163.02 70 999999999 141.01 225.89 percent of total billed charges NOREPINEPHR 8 MG/250-0.9% NACL 50659685_1 CDM 0250 RC 69374-0316-25 NDC inpatient 5 UN 232.88 151.37 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 141.01 60.55 999999999 141.01 225.89 percent of total billed charges NOREPINEPHR 8 MG/250-0.9% NACL 50659685_1 CDM 0250 RC 69374-0316-25 NDC inpatient 5 UN 232.88 151.37 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 141.01 225.89 NOREPINEPHR 8 MG/250-0.9% NACL 50659685_1 CDM 0250 RC 69374-0316-25 NDC inpatient 5 UN 232.88 151.37 ANTHEM HMO ANTHEM HMO 999999999 141.01 225.89 NOREPINEPHR 8 MG/250-0.9% NACL 50659685_1 CDM 0250 RC 69374-0316-25 NDC inpatient 5 UN 232.88 151.37 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 141.01 225.89 NOREPINEPHR 8 MG/250-0.9% NACL 50659685_1 CDM 0250 RC 69374-0316-25 NDC inpatient 5 UN 232.88 151.37 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 141.01 225.89 NOREPINEPHR 8 MG/250-0.9% NACL 50659685_1 CDM 0250 RC 69374-0316-25 NDC inpatient 5 UN 232.88 151.37 UHC - ALL PLANS UHC - ALL PLANS 999999999 141.01 225.89 NOREPINEPHR 8 MG/250-0.9% NACL 50659685_1 CDM 0250 RC 69374-0316-25 NDC inpatient 5 UN 232.88 151.37 CIGNA - ALL PLANS CIGNA - ALL PLANS 157.43 67.6 999999999 141.01 225.89 percent of total billed charges Islet cell (pancreas) antibody measurement 50659817_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 255.45 65 999999999 237.96 381.21 percent of total billed charges Islet cell (pancreas) antibody measurement 50659817_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 AETNA AETNA 310.47 79 999999999 237.96 381.21 percent of total billed charges Islet cell (pancreas) antibody measurement 50659817_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 381.21 97 999999999 237.96 381.21 percent of total billed charges Islet cell (pancreas) antibody measurement 50659817_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 306.54 78 999999999 237.96 381.21 percent of total billed charges Islet cell (pancreas) antibody measurement 50659817_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 271.17 69 999999999 237.96 381.21 percent of total billed charges Islet cell (pancreas) antibody measurement 50659817_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 SIHO - ALL PLANS SIHO - ALL PLANS 353.7 90 999999999 237.96 381.21 percent of total billed charges Islet cell (pancreas) antibody measurement 50659817_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 UMR - ALL PLANS UMR - ALL PLANS 275.1 70 999999999 237.96 381.21 percent of total billed charges Islet cell (pancreas) antibody measurement 50659817_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 237.96 60.55 999999999 237.96 381.21 percent of total billed charges Islet cell (pancreas) antibody measurement 50659817_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 237.96 381.21 Islet cell (pancreas) antibody measurement 50659817_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 ANTHEM HMO ANTHEM HMO 999999999 237.96 381.21 Islet cell (pancreas) antibody measurement 50659817_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 237.96 381.21 Islet cell (pancreas) antibody measurement 50659817_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 237.96 381.21 Islet cell (pancreas) antibody measurement 50659817_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 237.96 381.21 Islet cell (pancreas) antibody measurement 50659817_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 265.67 67.6 999999999 237.96 381.21 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50659835_1 CDM 0250 RC 60758-0801-10 NDC inpatient 1 UN 9.39 6.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.1 65 999999999 5.69 9.11 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50659835_1 CDM 0250 RC 60758-0801-10 NDC inpatient 1 UN 9.39 6.1 AETNA AETNA 7.42 79 999999999 5.69 9.11 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50659835_1 CDM 0250 RC 60758-0801-10 NDC inpatient 1 UN 9.39 6.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.11 97 999999999 5.69 9.11 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50659835_1 CDM 0250 RC 60758-0801-10 NDC inpatient 1 UN 9.39 6.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.32 78 999999999 5.69 9.11 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50659835_1 CDM 0250 RC 60758-0801-10 NDC inpatient 1 UN 9.39 6.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.48 69 999999999 5.69 9.11 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50659835_1 CDM 0250 RC 60758-0801-10 NDC inpatient 1 UN 9.39 6.1 SIHO - ALL PLANS SIHO - ALL PLANS 8.45 90 999999999 5.69 9.11 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50659835_1 CDM 0250 RC 60758-0801-10 NDC inpatient 1 UN 9.39 6.1 UMR - ALL PLANS UMR - ALL PLANS 6.57 70 999999999 5.69 9.11 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50659835_1 CDM 0250 RC 60758-0801-10 NDC inpatient 1 UN 9.39 6.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.69 60.55 999999999 5.69 9.11 percent of total billed charges TIMOLOL MALEATE 0.5% EYE DROPS 50659835_1 CDM 0250 RC 60758-0801-10 NDC inpatient 1 UN 9.39 6.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.69 9.11 TIMOLOL MALEATE 0.5% EYE DROPS 50659835_1 CDM 0250 RC 60758-0801-10 NDC inpatient 1 UN 9.39 6.1 ANTHEM HMO ANTHEM HMO 999999999 5.69 9.11 TIMOLOL MALEATE 0.5% EYE DROPS 50659835_1 CDM 0250 RC 60758-0801-10 NDC inpatient 1 UN 9.39 6.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.69 9.11 TIMOLOL MALEATE 0.5% EYE DROPS 50659835_1 CDM 0250 RC 60758-0801-10 NDC inpatient 1 UN 9.39 6.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.69 9.11 TIMOLOL MALEATE 0.5% EYE DROPS 50659835_1 CDM 0250 RC 60758-0801-10 NDC inpatient 1 UN 9.39 6.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.69 9.11 TIMOLOL MALEATE 0.5% EYE DROPS 50659835_1 CDM 0250 RC 60758-0801-10 NDC inpatient 1 UN 9.39 6.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.35 67.6 999999999 5.69 9.11 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50659837_1 CDM 0250 RC 67457-0855-02 NDC J0153 HCPCS inpatient 6 UN 25.15 16.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.35 65 999999999 15.23 24.4 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50659837_1 CDM 0250 RC 67457-0855-02 NDC J0153 HCPCS inpatient 6 UN 25.15 16.35 AETNA AETNA 19.87 79 999999999 15.23 24.4 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50659837_1 CDM 0250 RC 67457-0855-02 NDC J0153 HCPCS inpatient 6 UN 25.15 16.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.4 97 999999999 15.23 24.4 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50659837_1 CDM 0250 RC 67457-0855-02 NDC J0153 HCPCS inpatient 6 UN 25.15 16.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.62 78 999999999 15.23 24.4 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50659837_1 CDM 0250 RC 67457-0855-02 NDC J0153 HCPCS inpatient 6 UN 25.15 16.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.35 69 999999999 15.23 24.4 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50659837_1 CDM 0250 RC 67457-0855-02 NDC J0153 HCPCS inpatient 6 UN 25.15 16.35 SIHO - ALL PLANS SIHO - ALL PLANS 22.64 90 999999999 15.23 24.4 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50659837_1 CDM 0250 RC 67457-0855-02 NDC J0153 HCPCS inpatient 6 UN 25.15 16.35 UMR - ALL PLANS UMR - ALL PLANS 17.61 70 999999999 15.23 24.4 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50659837_1 CDM 0250 RC 67457-0855-02 NDC J0153 HCPCS inpatient 6 UN 25.15 16.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.23 60.55 999999999 15.23 24.4 percent of total billed charges "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50659837_1 CDM 0250 RC 67457-0855-02 NDC J0153 HCPCS inpatient 6 UN 25.15 16.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.23 24.4 "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50659837_1 CDM 0250 RC 67457-0855-02 NDC J0153 HCPCS inpatient 6 UN 25.15 16.35 ANTHEM HMO ANTHEM HMO 999999999 15.23 24.4 "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50659837_1 CDM 0250 RC 67457-0855-02 NDC J0153 HCPCS inpatient 6 UN 25.15 16.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.23 24.4 "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50659837_1 CDM 0250 RC 67457-0855-02 NDC J0153 HCPCS inpatient 6 UN 25.15 16.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.23 24.4 "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50659837_1 CDM 0250 RC 67457-0855-02 NDC J0153 HCPCS inpatient 6 UN 25.15 16.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.23 24.4 "INJECTION, ADENOSINE, 1 MG (NOT TO BE USED TO REPORT ANY ADENOSINE PHOSPHATE COMPOUNDS)" 50659837_1 CDM 0250 RC 67457-0855-02 NDC J0153 HCPCS inpatient 6 UN 25.15 16.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 17 67.6 999999999 15.23 24.4 percent of total billed charges ZOLPIDEM TARTRATE 10 MG TABLET 50660292_1 CDM 0250 RC 71093-0156-04 NDC inpatient 100 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ZOLPIDEM TARTRATE 10 MG TABLET 50660292_1 CDM 0250 RC 71093-0156-04 NDC inpatient 100 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ZOLPIDEM TARTRATE 10 MG TABLET 50660292_1 CDM 0250 RC 71093-0156-04 NDC inpatient 100 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ZOLPIDEM TARTRATE 10 MG TABLET 50660292_1 CDM 0250 RC 71093-0156-04 NDC inpatient 100 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ZOLPIDEM TARTRATE 10 MG TABLET 50660292_1 CDM 0250 RC 71093-0156-04 NDC inpatient 100 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ZOLPIDEM TARTRATE 10 MG TABLET 50660292_1 CDM 0250 RC 71093-0156-04 NDC inpatient 100 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ZOLPIDEM TARTRATE 10 MG TABLET 50660292_1 CDM 0250 RC 71093-0156-04 NDC inpatient 100 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ZOLPIDEM TARTRATE 10 MG TABLET 50660292_1 CDM 0250 RC 71093-0156-04 NDC inpatient 100 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ZOLPIDEM TARTRATE 10 MG TABLET 50660292_1 CDM 0250 RC 71093-0156-04 NDC inpatient 100 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ZOLPIDEM TARTRATE 10 MG TABLET 50660292_1 CDM 0250 RC 71093-0156-04 NDC inpatient 100 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ZOLPIDEM TARTRATE 10 MG TABLET 50660292_1 CDM 0250 RC 71093-0156-04 NDC inpatient 100 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ZOLPIDEM TARTRATE 10 MG TABLET 50660292_1 CDM 0250 RC 71093-0156-04 NDC inpatient 100 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ZOLPIDEM TARTRATE 10 MG TABLET 50660292_1 CDM 0250 RC 71093-0156-04 NDC inpatient 100 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ZOLPIDEM TARTRATE 10 MG TABLET 50660292_1 CDM 0250 RC 71093-0156-04 NDC inpatient 100 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50660344_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50660344_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50660344_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50660344_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50660344_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50660344_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50660344_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50660344_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50660344_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50660344_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50660344_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50660344_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50660344_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50660344_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50660384_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1116.7 65 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50660384_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 AETNA AETNA 1357.22 79 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50660384_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1666.46 97 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50660384_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1340.04 78 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50660384_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1185.42 69 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50660384_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 SIHO - ALL PLANS SIHO - ALL PLANS 1546.2 90 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50660384_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 UMR - ALL PLANS UMR - ALL PLANS 1202.6 70 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50660384_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1040.25 60.55 999999999 1040.25 1666.46 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50660384_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1040.25 1666.46 PLATE PATH RED/RAPID BAC TES 50660384_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 ANTHEM HMO ANTHEM HMO 999999999 1040.25 1666.46 PLATE PATH RED/RAPID BAC TES 50660384_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1040.25 1666.46 PLATE PATH RED/RAPID BAC TES 50660384_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1040.25 1666.46 PLATE PATH RED/RAPID BAC TES 50660384_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 1040.25 1666.46 PLATE PATH RED/RAPID BAC TES 50660384_1 CDM 0390 RC P9072 HCPCS inpatient 1718 1116.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1161.37 67.6 999999999 1040.25 1666.46 percent of total billed charges ATROPINE 1 MG/10 ML SYRINGE 50660440_1 CDM 0250 RC 76329-3340-01 NDC inpatient 1 UN 58.56 38.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 38.06 65 999999999 35.46 56.8 percent of total billed charges ATROPINE 1 MG/10 ML SYRINGE 50660440_1 CDM 0250 RC 76329-3340-01 NDC inpatient 1 UN 58.56 38.06 AETNA AETNA 46.26 79 999999999 35.46 56.8 percent of total billed charges ATROPINE 1 MG/10 ML SYRINGE 50660440_1 CDM 0250 RC 76329-3340-01 NDC inpatient 1 UN 58.56 38.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.8 97 999999999 35.46 56.8 percent of total billed charges ATROPINE 1 MG/10 ML SYRINGE 50660440_1 CDM 0250 RC 76329-3340-01 NDC inpatient 1 UN 58.56 38.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.68 78 999999999 35.46 56.8 percent of total billed charges ATROPINE 1 MG/10 ML SYRINGE 50660440_1 CDM 0250 RC 76329-3340-01 NDC inpatient 1 UN 58.56 38.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.41 69 999999999 35.46 56.8 percent of total billed charges ATROPINE 1 MG/10 ML SYRINGE 50660440_1 CDM 0250 RC 76329-3340-01 NDC inpatient 1 UN 58.56 38.06 SIHO - ALL PLANS SIHO - ALL PLANS 52.7 90 999999999 35.46 56.8 percent of total billed charges ATROPINE 1 MG/10 ML SYRINGE 50660440_1 CDM 0250 RC 76329-3340-01 NDC inpatient 1 UN 58.56 38.06 UMR - ALL PLANS UMR - ALL PLANS 40.99 70 999999999 35.46 56.8 percent of total billed charges ATROPINE 1 MG/10 ML SYRINGE 50660440_1 CDM 0250 RC 76329-3340-01 NDC inpatient 1 UN 58.56 38.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.46 60.55 999999999 35.46 56.8 percent of total billed charges ATROPINE 1 MG/10 ML SYRINGE 50660440_1 CDM 0250 RC 76329-3340-01 NDC inpatient 1 UN 58.56 38.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.46 56.8 ATROPINE 1 MG/10 ML SYRINGE 50660440_1 CDM 0250 RC 76329-3340-01 NDC inpatient 1 UN 58.56 38.06 ANTHEM HMO ANTHEM HMO 999999999 35.46 56.8 ATROPINE 1 MG/10 ML SYRINGE 50660440_1 CDM 0250 RC 76329-3340-01 NDC inpatient 1 UN 58.56 38.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.46 56.8 ATROPINE 1 MG/10 ML SYRINGE 50660440_1 CDM 0250 RC 76329-3340-01 NDC inpatient 1 UN 58.56 38.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.46 56.8 ATROPINE 1 MG/10 ML SYRINGE 50660440_1 CDM 0250 RC 76329-3340-01 NDC inpatient 1 UN 58.56 38.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.46 56.8 ATROPINE 1 MG/10 ML SYRINGE 50660440_1 CDM 0250 RC 76329-3340-01 NDC inpatient 1 UN 58.56 38.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.59 67.6 999999999 35.46 56.8 percent of total billed charges BOOT WEE WALKER PED S/M AL185003BB 50665338_1 CDM 0271 RC inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges BOOT WEE WALKER PED S/M AL185003BB 50665338_1 CDM 0271 RC inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges BOOT WEE WALKER PED S/M AL185003BB 50665338_1 CDM 0271 RC inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges BOOT WEE WALKER PED S/M AL185003BB 50665338_1 CDM 0271 RC inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges BOOT WEE WALKER PED S/M AL185003BB 50665338_1 CDM 0271 RC inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges BOOT WEE WALKER PED S/M AL185003BB 50665338_1 CDM 0271 RC inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges BOOT WEE WALKER PED S/M AL185003BB 50665338_1 CDM 0271 RC inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges BOOT WEE WALKER PED S/M AL185003BB 50665338_1 CDM 0271 RC inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges BOOT WEE WALKER PED S/M AL185003BB 50665338_1 CDM 0271 RC inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 BOOT WEE WALKER PED S/M AL185003BB 50665338_1 CDM 0271 RC inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 BOOT WEE WALKER PED S/M AL185003BB 50665338_1 CDM 0271 RC inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 BOOT WEE WALKER PED S/M AL185003BB 50665338_1 CDM 0271 RC inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 BOOT WEE WALKER PED S/M AL185003BB 50665338_1 CDM 0271 RC inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 BOOT WEE WALKER PED S/M AL185003BB 50665338_1 CDM 0271 RC inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges Insulin antibody measurement 50682145_1 CDM 0302 RC 86337 HCPCS inpatient 275 178.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.75 65 999999999 166.51 266.75 percent of total billed charges Insulin antibody measurement 50682145_1 CDM 0302 RC 86337 HCPCS inpatient 275 178.75 AETNA AETNA 217.25 79 999999999 166.51 266.75 percent of total billed charges Insulin antibody measurement 50682145_1 CDM 0302 RC 86337 HCPCS inpatient 275 178.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 266.75 97 999999999 166.51 266.75 percent of total billed charges Insulin antibody measurement 50682145_1 CDM 0302 RC 86337 HCPCS inpatient 275 178.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 214.5 78 999999999 166.51 266.75 percent of total billed charges Insulin antibody measurement 50682145_1 CDM 0302 RC 86337 HCPCS inpatient 275 178.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.75 69 999999999 166.51 266.75 percent of total billed charges Insulin antibody measurement 50682145_1 CDM 0302 RC 86337 HCPCS inpatient 275 178.75 SIHO - ALL PLANS SIHO - ALL PLANS 247.5 90 999999999 166.51 266.75 percent of total billed charges Insulin antibody measurement 50682145_1 CDM 0302 RC 86337 HCPCS inpatient 275 178.75 UMR - ALL PLANS UMR - ALL PLANS 192.5 70 999999999 166.51 266.75 percent of total billed charges Insulin antibody measurement 50682145_1 CDM 0302 RC 86337 HCPCS inpatient 275 178.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 166.51 60.55 999999999 166.51 266.75 percent of total billed charges Insulin antibody measurement 50682145_1 CDM 0302 RC 86337 HCPCS inpatient 275 178.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 166.51 266.75 Insulin antibody measurement 50682145_1 CDM 0302 RC 86337 HCPCS inpatient 275 178.75 ANTHEM HMO ANTHEM HMO 999999999 166.51 266.75 Insulin antibody measurement 50682145_1 CDM 0302 RC 86337 HCPCS inpatient 275 178.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 166.51 266.75 Insulin antibody measurement 50682145_1 CDM 0302 RC 86337 HCPCS inpatient 275 178.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 166.51 266.75 Insulin antibody measurement 50682145_1 CDM 0302 RC 86337 HCPCS inpatient 275 178.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 166.51 266.75 Insulin antibody measurement 50682145_1 CDM 0302 RC 86337 HCPCS inpatient 275 178.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.9 67.6 999999999 166.51 266.75 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 50682187_1 CDM 0510 RC 12001 HCPCS inpatient 659 428.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 428.35 65 999999999 399.02 639.23 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 50682187_1 CDM 0510 RC 12001 HCPCS inpatient 659 428.35 AETNA AETNA 520.61 79 999999999 399.02 639.23 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 50682187_1 CDM 0510 RC 12001 HCPCS inpatient 659 428.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 639.23 97 999999999 399.02 639.23 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 50682187_1 CDM 0510 RC 12001 HCPCS inpatient 659 428.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 514.02 78 999999999 399.02 639.23 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 50682187_1 CDM 0510 RC 12001 HCPCS inpatient 659 428.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 454.71 69 999999999 399.02 639.23 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 50682187_1 CDM 0510 RC 12001 HCPCS inpatient 659 428.35 SIHO - ALL PLANS SIHO - ALL PLANS 593.1 90 999999999 399.02 639.23 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 50682187_1 CDM 0510 RC 12001 HCPCS inpatient 659 428.35 UMR - ALL PLANS UMR - ALL PLANS 461.3 70 999999999 399.02 639.23 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 50682187_1 CDM 0510 RC 12001 HCPCS inpatient 659 428.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 399.02 60.55 999999999 399.02 639.23 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 50682187_1 CDM 0510 RC 12001 HCPCS inpatient 659 428.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 399.02 639.23 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 50682187_1 CDM 0510 RC 12001 HCPCS inpatient 659 428.35 ANTHEM HMO ANTHEM HMO 999999999 399.02 639.23 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 50682187_1 CDM 0510 RC 12001 HCPCS inpatient 659 428.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 399.02 639.23 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 50682187_1 CDM 0510 RC 12001 HCPCS inpatient 659 428.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 399.02 639.23 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 50682187_1 CDM 0510 RC 12001 HCPCS inpatient 659 428.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 399.02 639.23 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 50682187_1 CDM 0510 RC 12001 HCPCS inpatient 659 428.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 445.48 67.6 999999999 399.02 639.23 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50683374_1 CDM 0250 RC 00338-0072-25 NDC J1885 HCPCS inpatient 2 UN 20.2 13.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13.13 65 999999999 12.23 19.59 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50683374_1 CDM 0250 RC 00338-0072-25 NDC J1885 HCPCS inpatient 2 UN 20.2 13.13 AETNA AETNA 15.96 79 999999999 12.23 19.59 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50683374_1 CDM 0250 RC 00338-0072-25 NDC J1885 HCPCS inpatient 2 UN 20.2 13.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.59 97 999999999 12.23 19.59 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50683374_1 CDM 0250 RC 00338-0072-25 NDC J1885 HCPCS inpatient 2 UN 20.2 13.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.76 78 999999999 12.23 19.59 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50683374_1 CDM 0250 RC 00338-0072-25 NDC J1885 HCPCS inpatient 2 UN 20.2 13.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.94 69 999999999 12.23 19.59 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50683374_1 CDM 0250 RC 00338-0072-25 NDC J1885 HCPCS inpatient 2 UN 20.2 13.13 SIHO - ALL PLANS SIHO - ALL PLANS 18.18 90 999999999 12.23 19.59 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50683374_1 CDM 0250 RC 00338-0072-25 NDC J1885 HCPCS inpatient 2 UN 20.2 13.13 UMR - ALL PLANS UMR - ALL PLANS 14.14 70 999999999 12.23 19.59 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50683374_1 CDM 0250 RC 00338-0072-25 NDC J1885 HCPCS inpatient 2 UN 20.2 13.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.23 60.55 999999999 12.23 19.59 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50683374_1 CDM 0250 RC 00338-0072-25 NDC J1885 HCPCS inpatient 2 UN 20.2 13.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.23 19.59 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50683374_1 CDM 0250 RC 00338-0072-25 NDC J1885 HCPCS inpatient 2 UN 20.2 13.13 ANTHEM HMO ANTHEM HMO 999999999 12.23 19.59 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50683374_1 CDM 0250 RC 00338-0072-25 NDC J1885 HCPCS inpatient 2 UN 20.2 13.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.23 19.59 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50683374_1 CDM 0250 RC 00338-0072-25 NDC J1885 HCPCS inpatient 2 UN 20.2 13.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.23 19.59 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50683374_1 CDM 0250 RC 00338-0072-25 NDC J1885 HCPCS inpatient 2 UN 20.2 13.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.23 19.59 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50683374_1 CDM 0250 RC 00338-0072-25 NDC J1885 HCPCS inpatient 2 UN 20.2 13.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.66 67.6 999999999 12.23 19.59 percent of total billed charges "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50683380_1 CDM 0250 RC 00904-6461-61 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50683380_1 CDM 0250 RC 00904-6461-61 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50683380_1 CDM 0250 RC 00904-6461-61 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50683380_1 CDM 0250 RC 00904-6461-61 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50683380_1 CDM 0250 RC 00904-6461-61 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50683380_1 CDM 0250 RC 00904-6461-61 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50683380_1 CDM 0250 RC 00904-6461-61 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50683380_1 CDM 0250 RC 00904-6461-61 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50683380_1 CDM 0250 RC 00904-6461-61 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50683380_1 CDM 0250 RC 00904-6461-61 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50683380_1 CDM 0250 RC 00904-6461-61 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50683380_1 CDM 0250 RC 00904-6461-61 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50683380_1 CDM 0250 RC 00904-6461-61 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "PROMETHAZINE HYDROCHLORIDE, 12.5 MG, ORAL, FDA APPROVED PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT, NOT TO EXCEED A 48 HOUR DOSAGE REGIMEN" 50683380_1 CDM 0250 RC 00904-6461-61 NDC Q0169 HCPCS inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges ALPRAZOLAM 0.5 MG TABLET 50683387_1 CDM 0250 RC 51991-0705-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ALPRAZOLAM 0.5 MG TABLET 50683387_1 CDM 0250 RC 51991-0705-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ALPRAZOLAM 0.5 MG TABLET 50683387_1 CDM 0250 RC 51991-0705-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ALPRAZOLAM 0.5 MG TABLET 50683387_1 CDM 0250 RC 51991-0705-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ALPRAZOLAM 0.5 MG TABLET 50683387_1 CDM 0250 RC 51991-0705-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ALPRAZOLAM 0.5 MG TABLET 50683387_1 CDM 0250 RC 51991-0705-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ALPRAZOLAM 0.5 MG TABLET 50683387_1 CDM 0250 RC 51991-0705-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ALPRAZOLAM 0.5 MG TABLET 50683387_1 CDM 0250 RC 51991-0705-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ALPRAZOLAM 0.5 MG TABLET 50683387_1 CDM 0250 RC 51991-0705-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ALPRAZOLAM 0.5 MG TABLET 50683387_1 CDM 0250 RC 51991-0705-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ALPRAZOLAM 0.5 MG TABLET 50683387_1 CDM 0250 RC 51991-0705-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ALPRAZOLAM 0.5 MG TABLET 50683387_1 CDM 0250 RC 51991-0705-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ALPRAZOLAM 0.5 MG TABLET 50683387_1 CDM 0250 RC 51991-0705-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ALPRAZOLAM 0.5 MG TABLET 50683387_1 CDM 0250 RC 51991-0705-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 50683618_1 CDM 0250 RC 68084-0354-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 50683618_1 CDM 0250 RC 68084-0354-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 50683618_1 CDM 0250 RC 68084-0354-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 50683618_1 CDM 0250 RC 68084-0354-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 50683618_1 CDM 0250 RC 68084-0354-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 50683618_1 CDM 0250 RC 68084-0354-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 50683618_1 CDM 0250 RC 68084-0354-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 50683618_1 CDM 0250 RC 68084-0354-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges OXYCODONE HCL (IR) 5 MG TABLET 50683618_1 CDM 0250 RC 68084-0354-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 OXYCODONE HCL (IR) 5 MG TABLET 50683618_1 CDM 0250 RC 68084-0354-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 OXYCODONE HCL (IR) 5 MG TABLET 50683618_1 CDM 0250 RC 68084-0354-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 OXYCODONE HCL (IR) 5 MG TABLET 50683618_1 CDM 0250 RC 68084-0354-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 OXYCODONE HCL (IR) 5 MG TABLET 50683618_1 CDM 0250 RC 68084-0354-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 OXYCODONE HCL (IR) 5 MG TABLET 50683618_1 CDM 0250 RC 68084-0354-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges Alcohols levels 50683689_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50683689_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50683689_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50683689_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50683689_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50683689_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50683689_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50683689_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges Alcohols levels 50683689_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 Alcohols levels 50683689_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 Alcohols levels 50683689_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 Alcohols levels 50683689_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 Alcohols levels 50683689_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 Alcohols levels 50683689_1 CDM 0301 RC 80320 HCPCS inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges "INJECTION, ETOPOSIDE, 10 MG" 50683933_1 CDM 0636 RC 00143-9510-01 NDC J9181 HCPCS inpatient 10 UN 50.71 32.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.96 65 999999999 30.7 49.19 percent of total billed charges "INJECTION, ETOPOSIDE, 10 MG" 50683933_1 CDM 0636 RC 00143-9510-01 NDC J9181 HCPCS inpatient 10 UN 50.71 32.96 AETNA AETNA 40.06 79 999999999 30.7 49.19 percent of total billed charges "INJECTION, ETOPOSIDE, 10 MG" 50683933_1 CDM 0636 RC 00143-9510-01 NDC J9181 HCPCS inpatient 10 UN 50.71 32.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 49.19 97 999999999 30.7 49.19 percent of total billed charges "INJECTION, ETOPOSIDE, 10 MG" 50683933_1 CDM 0636 RC 00143-9510-01 NDC J9181 HCPCS inpatient 10 UN 50.71 32.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 39.55 78 999999999 30.7 49.19 percent of total billed charges "INJECTION, ETOPOSIDE, 10 MG" 50683933_1 CDM 0636 RC 00143-9510-01 NDC J9181 HCPCS inpatient 10 UN 50.71 32.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.99 69 999999999 30.7 49.19 percent of total billed charges "INJECTION, ETOPOSIDE, 10 MG" 50683933_1 CDM 0636 RC 00143-9510-01 NDC J9181 HCPCS inpatient 10 UN 50.71 32.96 SIHO - ALL PLANS SIHO - ALL PLANS 45.64 90 999999999 30.7 49.19 percent of total billed charges "INJECTION, ETOPOSIDE, 10 MG" 50683933_1 CDM 0636 RC 00143-9510-01 NDC J9181 HCPCS inpatient 10 UN 50.71 32.96 UMR - ALL PLANS UMR - ALL PLANS 35.5 70 999999999 30.7 49.19 percent of total billed charges "INJECTION, ETOPOSIDE, 10 MG" 50683933_1 CDM 0636 RC 00143-9510-01 NDC J9181 HCPCS inpatient 10 UN 50.71 32.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.7 60.55 999999999 30.7 49.19 percent of total billed charges "INJECTION, ETOPOSIDE, 10 MG" 50683933_1 CDM 0636 RC 00143-9510-01 NDC J9181 HCPCS inpatient 10 UN 50.71 32.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.7 49.19 "INJECTION, ETOPOSIDE, 10 MG" 50683933_1 CDM 0636 RC 00143-9510-01 NDC J9181 HCPCS inpatient 10 UN 50.71 32.96 ANTHEM HMO ANTHEM HMO 999999999 30.7 49.19 "INJECTION, ETOPOSIDE, 10 MG" 50683933_1 CDM 0636 RC 00143-9510-01 NDC J9181 HCPCS inpatient 10 UN 50.71 32.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.7 49.19 "INJECTION, ETOPOSIDE, 10 MG" 50683933_1 CDM 0636 RC 00143-9510-01 NDC J9181 HCPCS inpatient 10 UN 50.71 32.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.7 49.19 "INJECTION, ETOPOSIDE, 10 MG" 50683933_1 CDM 0636 RC 00143-9510-01 NDC J9181 HCPCS inpatient 10 UN 50.71 32.96 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.7 49.19 "INJECTION, ETOPOSIDE, 10 MG" 50683933_1 CDM 0636 RC 00143-9510-01 NDC J9181 HCPCS inpatient 10 UN 50.71 32.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 34.28 67.6 999999999 30.7 49.19 percent of total billed charges BACLOFEN 10 MG TABLET 50683934_1 CDM 0250 RC 70710-1285-01 NDC inpatient 1 UN 1.45 0.94 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.94 65 999999999 0.88 1.41 percent of total billed charges BACLOFEN 10 MG TABLET 50683934_1 CDM 0250 RC 70710-1285-01 NDC inpatient 1 UN 1.45 0.94 AETNA AETNA 1.15 79 999999999 0.88 1.41 percent of total billed charges BACLOFEN 10 MG TABLET 50683934_1 CDM 0250 RC 70710-1285-01 NDC inpatient 1 UN 1.45 0.94 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.41 97 999999999 0.88 1.41 percent of total billed charges BACLOFEN 10 MG TABLET 50683934_1 CDM 0250 RC 70710-1285-01 NDC inpatient 1 UN 1.45 0.94 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.13 78 999999999 0.88 1.41 percent of total billed charges BACLOFEN 10 MG TABLET 50683934_1 CDM 0250 RC 70710-1285-01 NDC inpatient 1 UN 1.45 0.94 ENCORE - ALL PLANS ENCORE - ALL PLANS 1 69 999999999 0.88 1.41 percent of total billed charges BACLOFEN 10 MG TABLET 50683934_1 CDM 0250 RC 70710-1285-01 NDC inpatient 1 UN 1.45 0.94 SIHO - ALL PLANS SIHO - ALL PLANS 1.31 90 999999999 0.88 1.41 percent of total billed charges BACLOFEN 10 MG TABLET 50683934_1 CDM 0250 RC 70710-1285-01 NDC inpatient 1 UN 1.45 0.94 UMR - ALL PLANS UMR - ALL PLANS 1.02 70 999999999 0.88 1.41 percent of total billed charges BACLOFEN 10 MG TABLET 50683934_1 CDM 0250 RC 70710-1285-01 NDC inpatient 1 UN 1.45 0.94 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.88 60.55 999999999 0.88 1.41 percent of total billed charges BACLOFEN 10 MG TABLET 50683934_1 CDM 0250 RC 70710-1285-01 NDC inpatient 1 UN 1.45 0.94 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.88 1.41 BACLOFEN 10 MG TABLET 50683934_1 CDM 0250 RC 70710-1285-01 NDC inpatient 1 UN 1.45 0.94 ANTHEM HMO ANTHEM HMO 999999999 0.88 1.41 BACLOFEN 10 MG TABLET 50683934_1 CDM 0250 RC 70710-1285-01 NDC inpatient 1 UN 1.45 0.94 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.88 1.41 BACLOFEN 10 MG TABLET 50683934_1 CDM 0250 RC 70710-1285-01 NDC inpatient 1 UN 1.45 0.94 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.88 1.41 BACLOFEN 10 MG TABLET 50683934_1 CDM 0250 RC 70710-1285-01 NDC inpatient 1 UN 1.45 0.94 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.88 1.41 BACLOFEN 10 MG TABLET 50683934_1 CDM 0250 RC 70710-1285-01 NDC inpatient 1 UN 1.45 0.94 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.98 67.6 999999999 0.88 1.41 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50683948_1 CDM 0636 RC 61755-0036-08 NDC Q0243 HCPCS inpatient 1 UN 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50683948_1 CDM 0636 RC 61755-0036-08 NDC Q0243 HCPCS inpatient 1 UN 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50683948_1 CDM 0636 RC 61755-0036-08 NDC Q0243 HCPCS inpatient 1 UN 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50683948_1 CDM 0636 RC 61755-0036-08 NDC Q0243 HCPCS inpatient 1 UN 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50683948_1 CDM 0636 RC 61755-0036-08 NDC Q0243 HCPCS inpatient 1 UN 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50683948_1 CDM 0636 RC 61755-0036-08 NDC Q0243 HCPCS inpatient 1 UN 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50683948_1 CDM 0636 RC 61755-0036-08 NDC Q0243 HCPCS inpatient 1 UN 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50683948_1 CDM 0636 RC 61755-0036-08 NDC Q0243 HCPCS inpatient 1 UN 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50683948_1 CDM 0636 RC 61755-0036-08 NDC Q0243 HCPCS inpatient 1 UN 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50683948_1 CDM 0636 RC 61755-0036-08 NDC Q0243 HCPCS inpatient 1 UN 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50683948_1 CDM 0636 RC 61755-0036-08 NDC Q0243 HCPCS inpatient 1 UN 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50683948_1 CDM 0636 RC 61755-0036-08 NDC Q0243 HCPCS inpatient 1 UN 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50683948_1 CDM 0636 RC 61755-0036-08 NDC Q0243 HCPCS inpatient 1 UN 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50683948_1 CDM 0636 RC 61755-0036-08 NDC Q0243 HCPCS inpatient 1 UN 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges Hepatitis B core antibody (IgM) measurement 50683983_1 CDM 0301 RC 86705 HCPCS inpatient 61 39.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.65 65 999999999 36.94 59.17 percent of total billed charges Hepatitis B core antibody (IgM) measurement 50683983_1 CDM 0301 RC 86705 HCPCS inpatient 61 39.65 AETNA AETNA 48.19 79 999999999 36.94 59.17 percent of total billed charges Hepatitis B core antibody (IgM) measurement 50683983_1 CDM 0301 RC 86705 HCPCS inpatient 61 39.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59.17 97 999999999 36.94 59.17 percent of total billed charges Hepatitis B core antibody (IgM) measurement 50683983_1 CDM 0301 RC 86705 HCPCS inpatient 61 39.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.58 78 999999999 36.94 59.17 percent of total billed charges Hepatitis B core antibody (IgM) measurement 50683983_1 CDM 0301 RC 86705 HCPCS inpatient 61 39.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.09 69 999999999 36.94 59.17 percent of total billed charges Hepatitis B core antibody (IgM) measurement 50683983_1 CDM 0301 RC 86705 HCPCS inpatient 61 39.65 SIHO - ALL PLANS SIHO - ALL PLANS 54.9 90 999999999 36.94 59.17 percent of total billed charges Hepatitis B core antibody (IgM) measurement 50683983_1 CDM 0301 RC 86705 HCPCS inpatient 61 39.65 UMR - ALL PLANS UMR - ALL PLANS 42.7 70 999999999 36.94 59.17 percent of total billed charges Hepatitis B core antibody (IgM) measurement 50683983_1 CDM 0301 RC 86705 HCPCS inpatient 61 39.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.94 60.55 999999999 36.94 59.17 percent of total billed charges Hepatitis B core antibody (IgM) measurement 50683983_1 CDM 0301 RC 86705 HCPCS inpatient 61 39.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.94 59.17 Hepatitis B core antibody (IgM) measurement 50683983_1 CDM 0301 RC 86705 HCPCS inpatient 61 39.65 ANTHEM HMO ANTHEM HMO 999999999 36.94 59.17 Hepatitis B core antibody (IgM) measurement 50683983_1 CDM 0301 RC 86705 HCPCS inpatient 61 39.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.94 59.17 Hepatitis B core antibody (IgM) measurement 50683983_1 CDM 0301 RC 86705 HCPCS inpatient 61 39.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.94 59.17 Hepatitis B core antibody (IgM) measurement 50683983_1 CDM 0301 RC 86705 HCPCS inpatient 61 39.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.94 59.17 Hepatitis B core antibody (IgM) measurement 50683983_1 CDM 0301 RC 86705 HCPCS inpatient 61 39.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.24 67.6 999999999 36.94 59.17 percent of total billed charges "Troponin (protein) analysis, quantitative" 50684284_1 CDM 0301 RC 84484 HCPCS inpatient 336 218.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 218.4 65 999999999 203.45 325.92 percent of total billed charges "Troponin (protein) analysis, quantitative" 50684284_1 CDM 0301 RC 84484 HCPCS inpatient 336 218.4 AETNA AETNA 265.44 79 999999999 203.45 325.92 percent of total billed charges "Troponin (protein) analysis, quantitative" 50684284_1 CDM 0301 RC 84484 HCPCS inpatient 336 218.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 325.92 97 999999999 203.45 325.92 percent of total billed charges "Troponin (protein) analysis, quantitative" 50684284_1 CDM 0301 RC 84484 HCPCS inpatient 336 218.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 262.08 78 999999999 203.45 325.92 percent of total billed charges "Troponin (protein) analysis, quantitative" 50684284_1 CDM 0301 RC 84484 HCPCS inpatient 336 218.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 231.84 69 999999999 203.45 325.92 percent of total billed charges "Troponin (protein) analysis, quantitative" 50684284_1 CDM 0301 RC 84484 HCPCS inpatient 336 218.4 SIHO - ALL PLANS SIHO - ALL PLANS 302.4 90 999999999 203.45 325.92 percent of total billed charges "Troponin (protein) analysis, quantitative" 50684284_1 CDM 0301 RC 84484 HCPCS inpatient 336 218.4 UMR - ALL PLANS UMR - ALL PLANS 235.2 70 999999999 203.45 325.92 percent of total billed charges "Troponin (protein) analysis, quantitative" 50684284_1 CDM 0301 RC 84484 HCPCS inpatient 336 218.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 203.45 60.55 999999999 203.45 325.92 percent of total billed charges "Troponin (protein) analysis, quantitative" 50684284_1 CDM 0301 RC 84484 HCPCS inpatient 336 218.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 203.45 325.92 "Troponin (protein) analysis, quantitative" 50684284_1 CDM 0301 RC 84484 HCPCS inpatient 336 218.4 ANTHEM HMO ANTHEM HMO 999999999 203.45 325.92 "Troponin (protein) analysis, quantitative" 50684284_1 CDM 0301 RC 84484 HCPCS inpatient 336 218.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 203.45 325.92 "Troponin (protein) analysis, quantitative" 50684284_1 CDM 0301 RC 84484 HCPCS inpatient 336 218.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 203.45 325.92 "Troponin (protein) analysis, quantitative" 50684284_1 CDM 0301 RC 84484 HCPCS inpatient 336 218.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 203.45 325.92 "Troponin (protein) analysis, quantitative" 50684284_1 CDM 0301 RC 84484 HCPCS inpatient 336 218.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 227.14 67.6 999999999 203.45 325.92 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50684313_1 CDM 0250 RC 63323-0161-12 NDC J1885 HCPCS inpatient 1 UN 17.42 11.32 SELF PAY DISCOUNT SELF PAY DISCOUNT 11.32 65 999999999 10.55 16.9 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50684313_1 CDM 0250 RC 63323-0161-12 NDC J1885 HCPCS inpatient 1 UN 17.42 11.32 AETNA AETNA 13.76 79 999999999 10.55 16.9 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50684313_1 CDM 0250 RC 63323-0161-12 NDC J1885 HCPCS inpatient 1 UN 17.42 11.32 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16.9 97 999999999 10.55 16.9 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50684313_1 CDM 0250 RC 63323-0161-12 NDC J1885 HCPCS inpatient 1 UN 17.42 11.32 HUMANA - ALL PLANS HUMANA - ALL PLANS 13.59 78 999999999 10.55 16.9 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50684313_1 CDM 0250 RC 63323-0161-12 NDC J1885 HCPCS inpatient 1 UN 17.42 11.32 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.02 69 999999999 10.55 16.9 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50684313_1 CDM 0250 RC 63323-0161-12 NDC J1885 HCPCS inpatient 1 UN 17.42 11.32 SIHO - ALL PLANS SIHO - ALL PLANS 15.68 90 999999999 10.55 16.9 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50684313_1 CDM 0250 RC 63323-0161-12 NDC J1885 HCPCS inpatient 1 UN 17.42 11.32 UMR - ALL PLANS UMR - ALL PLANS 12.19 70 999999999 10.55 16.9 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50684313_1 CDM 0250 RC 63323-0161-12 NDC J1885 HCPCS inpatient 1 UN 17.42 11.32 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10.55 60.55 999999999 10.55 16.9 percent of total billed charges "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50684313_1 CDM 0250 RC 63323-0161-12 NDC J1885 HCPCS inpatient 1 UN 17.42 11.32 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10.55 16.9 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50684313_1 CDM 0250 RC 63323-0161-12 NDC J1885 HCPCS inpatient 1 UN 17.42 11.32 ANTHEM HMO ANTHEM HMO 999999999 10.55 16.9 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50684313_1 CDM 0250 RC 63323-0161-12 NDC J1885 HCPCS inpatient 1 UN 17.42 11.32 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10.55 16.9 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50684313_1 CDM 0250 RC 63323-0161-12 NDC J1885 HCPCS inpatient 1 UN 17.42 11.32 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10.55 16.9 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50684313_1 CDM 0250 RC 63323-0161-12 NDC J1885 HCPCS inpatient 1 UN 17.42 11.32 UHC - ALL PLANS UHC - ALL PLANS 999999999 10.55 16.9 "INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG" 50684313_1 CDM 0250 RC 63323-0161-12 NDC J1885 HCPCS inpatient 1 UN 17.42 11.32 CIGNA - ALL PLANS CIGNA - ALL PLANS 11.78 67.6 999999999 10.55 16.9 percent of total billed charges "Coagulation function measurement, qualitative or semiquantitative" 50684338_1 CDM 0305 RC 85378 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges "Coagulation function measurement, qualitative or semiquantitative" 50684338_1 CDM 0305 RC 85378 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges "Coagulation function measurement, qualitative or semiquantitative" 50684338_1 CDM 0305 RC 85378 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges "Coagulation function measurement, qualitative or semiquantitative" 50684338_1 CDM 0305 RC 85378 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges "Coagulation function measurement, qualitative or semiquantitative" 50684338_1 CDM 0305 RC 85378 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges "Coagulation function measurement, qualitative or semiquantitative" 50684338_1 CDM 0305 RC 85378 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges "Coagulation function measurement, qualitative or semiquantitative" 50684338_1 CDM 0305 RC 85378 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges "Coagulation function measurement, qualitative or semiquantitative" 50684338_1 CDM 0305 RC 85378 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges "Coagulation function measurement, qualitative or semiquantitative" 50684338_1 CDM 0305 RC 85378 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 "Coagulation function measurement, qualitative or semiquantitative" 50684338_1 CDM 0305 RC 85378 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 "Coagulation function measurement, qualitative or semiquantitative" 50684338_1 CDM 0305 RC 85378 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 "Coagulation function measurement, qualitative or semiquantitative" 50684338_1 CDM 0305 RC 85378 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 "Coagulation function measurement, qualitative or semiquantitative" 50684338_1 CDM 0305 RC 85378 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 "Coagulation function measurement, qualitative or semiquantitative" 50684338_1 CDM 0305 RC 85378 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges "Blood test, clotting time" 50684656_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 50684656_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 50684656_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 50684656_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 50684656_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 50684656_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 50684656_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 50684656_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 50684656_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 "Blood test, clotting time" 50684656_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 "Blood test, clotting time" 50684656_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 "Blood test, clotting time" 50684656_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 "Blood test, clotting time" 50684656_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 "Blood test, clotting time" 50684656_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 50684669_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 50684669_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 50684669_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 50684669_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 50684669_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 50684669_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 50684669_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 50684669_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 50684669_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 "Coagulation assessment blood test, plasma or whole blood" 50684669_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 "Coagulation assessment blood test, plasma or whole blood" 50684669_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 "Coagulation assessment blood test, plasma or whole blood" 50684669_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 "Coagulation assessment blood test, plasma or whole blood" 50684669_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 "Coagulation assessment blood test, plasma or whole blood" 50684669_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges DIAZEPAM 5 MG TABLET 50684854_1 CDM 0250 RC 00378-0345-01 NDC inpatient 1 UN 1.76 1.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.14 65 999999999 1.07 1.71 percent of total billed charges DIAZEPAM 5 MG TABLET 50684854_1 CDM 0250 RC 00378-0345-01 NDC inpatient 1 UN 1.76 1.14 AETNA AETNA 1.39 79 999999999 1.07 1.71 percent of total billed charges DIAZEPAM 5 MG TABLET 50684854_1 CDM 0250 RC 00378-0345-01 NDC inpatient 1 UN 1.76 1.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.71 97 999999999 1.07 1.71 percent of total billed charges DIAZEPAM 5 MG TABLET 50684854_1 CDM 0250 RC 00378-0345-01 NDC inpatient 1 UN 1.76 1.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.37 78 999999999 1.07 1.71 percent of total billed charges DIAZEPAM 5 MG TABLET 50684854_1 CDM 0250 RC 00378-0345-01 NDC inpatient 1 UN 1.76 1.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.21 69 999999999 1.07 1.71 percent of total billed charges DIAZEPAM 5 MG TABLET 50684854_1 CDM 0250 RC 00378-0345-01 NDC inpatient 1 UN 1.76 1.14 SIHO - ALL PLANS SIHO - ALL PLANS 1.58 90 999999999 1.07 1.71 percent of total billed charges DIAZEPAM 5 MG TABLET 50684854_1 CDM 0250 RC 00378-0345-01 NDC inpatient 1 UN 1.76 1.14 UMR - ALL PLANS UMR - ALL PLANS 1.23 70 999999999 1.07 1.71 percent of total billed charges DIAZEPAM 5 MG TABLET 50684854_1 CDM 0250 RC 00378-0345-01 NDC inpatient 1 UN 1.76 1.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.07 60.55 999999999 1.07 1.71 percent of total billed charges DIAZEPAM 5 MG TABLET 50684854_1 CDM 0250 RC 00378-0345-01 NDC inpatient 1 UN 1.76 1.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.07 1.71 DIAZEPAM 5 MG TABLET 50684854_1 CDM 0250 RC 00378-0345-01 NDC inpatient 1 UN 1.76 1.14 ANTHEM HMO ANTHEM HMO 999999999 1.07 1.71 DIAZEPAM 5 MG TABLET 50684854_1 CDM 0250 RC 00378-0345-01 NDC inpatient 1 UN 1.76 1.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.07 1.71 DIAZEPAM 5 MG TABLET 50684854_1 CDM 0250 RC 00378-0345-01 NDC inpatient 1 UN 1.76 1.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.07 1.71 DIAZEPAM 5 MG TABLET 50684854_1 CDM 0250 RC 00378-0345-01 NDC inpatient 1 UN 1.76 1.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.07 1.71 DIAZEPAM 5 MG TABLET 50684854_1 CDM 0250 RC 00378-0345-01 NDC inpatient 1 UN 1.76 1.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.19 67.6 999999999 1.07 1.71 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50685014_1 CDM 0250 RC 63323-0269-65 NDC J2704 HCPCS inpatient 100 UN 99.87 64.92 SELF PAY DISCOUNT SELF PAY DISCOUNT 64.92 65 999999999 60.47 96.87 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50685014_1 CDM 0250 RC 63323-0269-65 NDC J2704 HCPCS inpatient 100 UN 99.87 64.92 AETNA AETNA 78.9 79 999999999 60.47 96.87 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50685014_1 CDM 0250 RC 63323-0269-65 NDC J2704 HCPCS inpatient 100 UN 99.87 64.92 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 96.87 97 999999999 60.47 96.87 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50685014_1 CDM 0250 RC 63323-0269-65 NDC J2704 HCPCS inpatient 100 UN 99.87 64.92 HUMANA - ALL PLANS HUMANA - ALL PLANS 77.9 78 999999999 60.47 96.87 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50685014_1 CDM 0250 RC 63323-0269-65 NDC J2704 HCPCS inpatient 100 UN 99.87 64.92 ENCORE - ALL PLANS ENCORE - ALL PLANS 68.91 69 999999999 60.47 96.87 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50685014_1 CDM 0250 RC 63323-0269-65 NDC J2704 HCPCS inpatient 100 UN 99.87 64.92 SIHO - ALL PLANS SIHO - ALL PLANS 89.88 90 999999999 60.47 96.87 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50685014_1 CDM 0250 RC 63323-0269-65 NDC J2704 HCPCS inpatient 100 UN 99.87 64.92 UMR - ALL PLANS UMR - ALL PLANS 69.91 70 999999999 60.47 96.87 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50685014_1 CDM 0250 RC 63323-0269-65 NDC J2704 HCPCS inpatient 100 UN 99.87 64.92 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.47 60.55 999999999 60.47 96.87 percent of total billed charges "INJECTION, PROPOFOL, 10 MG" 50685014_1 CDM 0250 RC 63323-0269-65 NDC J2704 HCPCS inpatient 100 UN 99.87 64.92 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.47 96.87 "INJECTION, PROPOFOL, 10 MG" 50685014_1 CDM 0250 RC 63323-0269-65 NDC J2704 HCPCS inpatient 100 UN 99.87 64.92 ANTHEM HMO ANTHEM HMO 999999999 60.47 96.87 "INJECTION, PROPOFOL, 10 MG" 50685014_1 CDM 0250 RC 63323-0269-65 NDC J2704 HCPCS inpatient 100 UN 99.87 64.92 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.47 96.87 "INJECTION, PROPOFOL, 10 MG" 50685014_1 CDM 0250 RC 63323-0269-65 NDC J2704 HCPCS inpatient 100 UN 99.87 64.92 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.47 96.87 "INJECTION, PROPOFOL, 10 MG" 50685014_1 CDM 0250 RC 63323-0269-65 NDC J2704 HCPCS inpatient 100 UN 99.87 64.92 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.47 96.87 "INJECTION, PROPOFOL, 10 MG" 50685014_1 CDM 0250 RC 63323-0269-65 NDC J2704 HCPCS inpatient 100 UN 99.87 64.92 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.51 67.6 999999999 60.47 96.87 percent of total billed charges BENZONATATE 100 MG CAPSULE 50685556_1 CDM 0250 RC 42806-0714-01 NDC inpatient 1 UN 1.99 1.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.29 65 999999999 1.2 1.93 percent of total billed charges BENZONATATE 100 MG CAPSULE 50685556_1 CDM 0250 RC 42806-0714-01 NDC inpatient 1 UN 1.99 1.29 AETNA AETNA 1.57 79 999999999 1.2 1.93 percent of total billed charges BENZONATATE 100 MG CAPSULE 50685556_1 CDM 0250 RC 42806-0714-01 NDC inpatient 1 UN 1.99 1.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.93 97 999999999 1.2 1.93 percent of total billed charges BENZONATATE 100 MG CAPSULE 50685556_1 CDM 0250 RC 42806-0714-01 NDC inpatient 1 UN 1.99 1.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.55 78 999999999 1.2 1.93 percent of total billed charges BENZONATATE 100 MG CAPSULE 50685556_1 CDM 0250 RC 42806-0714-01 NDC inpatient 1 UN 1.99 1.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.37 69 999999999 1.2 1.93 percent of total billed charges BENZONATATE 100 MG CAPSULE 50685556_1 CDM 0250 RC 42806-0714-01 NDC inpatient 1 UN 1.99 1.29 SIHO - ALL PLANS SIHO - ALL PLANS 1.79 90 999999999 1.2 1.93 percent of total billed charges BENZONATATE 100 MG CAPSULE 50685556_1 CDM 0250 RC 42806-0714-01 NDC inpatient 1 UN 1.99 1.29 UMR - ALL PLANS UMR - ALL PLANS 1.39 70 999999999 1.2 1.93 percent of total billed charges BENZONATATE 100 MG CAPSULE 50685556_1 CDM 0250 RC 42806-0714-01 NDC inpatient 1 UN 1.99 1.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.2 60.55 999999999 1.2 1.93 percent of total billed charges BENZONATATE 100 MG CAPSULE 50685556_1 CDM 0250 RC 42806-0714-01 NDC inpatient 1 UN 1.99 1.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.2 1.93 BENZONATATE 100 MG CAPSULE 50685556_1 CDM 0250 RC 42806-0714-01 NDC inpatient 1 UN 1.99 1.29 ANTHEM HMO ANTHEM HMO 999999999 1.2 1.93 BENZONATATE 100 MG CAPSULE 50685556_1 CDM 0250 RC 42806-0714-01 NDC inpatient 1 UN 1.99 1.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.2 1.93 BENZONATATE 100 MG CAPSULE 50685556_1 CDM 0250 RC 42806-0714-01 NDC inpatient 1 UN 1.99 1.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.2 1.93 BENZONATATE 100 MG CAPSULE 50685556_1 CDM 0250 RC 42806-0714-01 NDC inpatient 1 UN 1.99 1.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.2 1.93 BENZONATATE 100 MG CAPSULE 50685556_1 CDM 0250 RC 42806-0714-01 NDC inpatient 1 UN 1.99 1.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.2 1.93 percent of total billed charges "CURVED SHARP CANNULA 10cm, 5mm, 20ga RFK-C10520S-P" 50685982_1 CDM 0272 RC inpatient 97 63.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.05 65 999999999 58.73 94.09 percent of total billed charges "CURVED SHARP CANNULA 10cm, 5mm, 20ga RFK-C10520S-P" 50685982_1 CDM 0272 RC inpatient 97 63.05 AETNA AETNA 76.63 79 999999999 58.73 94.09 percent of total billed charges "CURVED SHARP CANNULA 10cm, 5mm, 20ga RFK-C10520S-P" 50685982_1 CDM 0272 RC inpatient 97 63.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 94.09 97 999999999 58.73 94.09 percent of total billed charges "CURVED SHARP CANNULA 10cm, 5mm, 20ga RFK-C10520S-P" 50685982_1 CDM 0272 RC inpatient 97 63.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 75.66 78 999999999 58.73 94.09 percent of total billed charges "CURVED SHARP CANNULA 10cm, 5mm, 20ga RFK-C10520S-P" 50685982_1 CDM 0272 RC inpatient 97 63.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.93 69 999999999 58.73 94.09 percent of total billed charges "CURVED SHARP CANNULA 10cm, 5mm, 20ga RFK-C10520S-P" 50685982_1 CDM 0272 RC inpatient 97 63.05 SIHO - ALL PLANS SIHO - ALL PLANS 87.3 90 999999999 58.73 94.09 percent of total billed charges "CURVED SHARP CANNULA 10cm, 5mm, 20ga RFK-C10520S-P" 50685982_1 CDM 0272 RC inpatient 97 63.05 UMR - ALL PLANS UMR - ALL PLANS 67.9 70 999999999 58.73 94.09 percent of total billed charges "CURVED SHARP CANNULA 10cm, 5mm, 20ga RFK-C10520S-P" 50685982_1 CDM 0272 RC inpatient 97 63.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.73 60.55 999999999 58.73 94.09 percent of total billed charges "CURVED SHARP CANNULA 10cm, 5mm, 20ga RFK-C10520S-P" 50685982_1 CDM 0272 RC inpatient 97 63.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.73 94.09 "CURVED SHARP CANNULA 10cm, 5mm, 20ga RFK-C10520S-P" 50685982_1 CDM 0272 RC inpatient 97 63.05 ANTHEM HMO ANTHEM HMO 999999999 58.73 94.09 "CURVED SHARP CANNULA 10cm, 5mm, 20ga RFK-C10520S-P" 50685982_1 CDM 0272 RC inpatient 97 63.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.73 94.09 "CURVED SHARP CANNULA 10cm, 5mm, 20ga RFK-C10520S-P" 50685982_1 CDM 0272 RC inpatient 97 63.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.73 94.09 "CURVED SHARP CANNULA 10cm, 5mm, 20ga RFK-C10520S-P" 50685982_1 CDM 0272 RC inpatient 97 63.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.73 94.09 "CURVED SHARP CANNULA 10cm, 5mm, 20ga RFK-C10520S-P" 50685982_1 CDM 0272 RC inpatient 97 63.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 65.57 67.6 999999999 58.73 94.09 percent of total billed charges "RF CURVED SHARP CANNULA 10cm, 10mm, 20ga RFK-C101020VZ-P" 50686003_1 CDM 0272 RC inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 10cm, 10mm, 20ga RFK-C101020VZ-P" 50686003_1 CDM 0272 RC inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 10cm, 10mm, 20ga RFK-C101020VZ-P" 50686003_1 CDM 0272 RC inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 10cm, 10mm, 20ga RFK-C101020VZ-P" 50686003_1 CDM 0272 RC inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 10cm, 10mm, 20ga RFK-C101020VZ-P" 50686003_1 CDM 0272 RC inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 10cm, 10mm, 20ga RFK-C101020VZ-P" 50686003_1 CDM 0272 RC inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 10cm, 10mm, 20ga RFK-C101020VZ-P" 50686003_1 CDM 0272 RC inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 10cm, 10mm, 20ga RFK-C101020VZ-P" 50686003_1 CDM 0272 RC inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 10cm, 10mm, 20ga RFK-C101020VZ-P" 50686003_1 CDM 0272 RC inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 "RF CURVED SHARP CANNULA 10cm, 10mm, 20ga RFK-C101020VZ-P" 50686003_1 CDM 0272 RC inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 "RF CURVED SHARP CANNULA 10cm, 10mm, 20ga RFK-C101020VZ-P" 50686003_1 CDM 0272 RC inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 "RF CURVED SHARP CANNULA 10cm, 10mm, 20ga RFK-C101020VZ-P" 50686003_1 CDM 0272 RC inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 "RF CURVED SHARP CANNULA 10cm, 10mm, 20ga RFK-C101020VZ-P" 50686003_1 CDM 0272 RC inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 "RF CURVED SHARP CANNULA 10cm, 10mm, 20ga RFK-C101020VZ-P" 50686003_1 CDM 0272 RC inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 15cm, 10mm, 20g RFK-C151020VZ-P" 50686004_1 CDM 0272 RC inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 15cm, 10mm, 20g RFK-C151020VZ-P" 50686004_1 CDM 0272 RC inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 15cm, 10mm, 20g RFK-C151020VZ-P" 50686004_1 CDM 0272 RC inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 15cm, 10mm, 20g RFK-C151020VZ-P" 50686004_1 CDM 0272 RC inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 15cm, 10mm, 20g RFK-C151020VZ-P" 50686004_1 CDM 0272 RC inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 15cm, 10mm, 20g RFK-C151020VZ-P" 50686004_1 CDM 0272 RC inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 15cm, 10mm, 20g RFK-C151020VZ-P" 50686004_1 CDM 0272 RC inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 15cm, 10mm, 20g RFK-C151020VZ-P" 50686004_1 CDM 0272 RC inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 15cm, 10mm, 20g RFK-C151020VZ-P" 50686004_1 CDM 0272 RC inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 "RF CURVED SHARP CANNULA 15cm, 10mm, 20g RFK-C151020VZ-P" 50686004_1 CDM 0272 RC inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 "RF CURVED SHARP CANNULA 15cm, 10mm, 20g RFK-C151020VZ-P" 50686004_1 CDM 0272 RC inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 "RF CURVED SHARP CANNULA 15cm, 10mm, 20g RFK-C151020VZ-P" 50686004_1 CDM 0272 RC inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 "RF CURVED SHARP CANNULA 15cm, 10mm, 20g RFK-C151020VZ-P" 50686004_1 CDM 0272 RC inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 "RF CURVED SHARP CANNULA 15cm, 10mm, 20g RFK-C151020VZ-P" 50686004_1 CDM 0272 RC inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 15cm, 15mm, 20g RFK-C151520S-P" 50686125_1 CDM 0272 RC inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 15cm, 15mm, 20g RFK-C151520S-P" 50686125_1 CDM 0272 RC inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 15cm, 15mm, 20g RFK-C151520S-P" 50686125_1 CDM 0272 RC inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 15cm, 15mm, 20g RFK-C151520S-P" 50686125_1 CDM 0272 RC inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 15cm, 15mm, 20g RFK-C151520S-P" 50686125_1 CDM 0272 RC inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 15cm, 15mm, 20g RFK-C151520S-P" 50686125_1 CDM 0272 RC inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 15cm, 15mm, 20g RFK-C151520S-P" 50686125_1 CDM 0272 RC inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 15cm, 15mm, 20g RFK-C151520S-P" 50686125_1 CDM 0272 RC inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges "RF CURVED SHARP CANNULA 15cm, 15mm, 20g RFK-C151520S-P" 50686125_1 CDM 0272 RC inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 "RF CURVED SHARP CANNULA 15cm, 15mm, 20g RFK-C151520S-P" 50686125_1 CDM 0272 RC inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 "RF CURVED SHARP CANNULA 15cm, 15mm, 20g RFK-C151520S-P" 50686125_1 CDM 0272 RC inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 "RF CURVED SHARP CANNULA 15cm, 15mm, 20g RFK-C151520S-P" 50686125_1 CDM 0272 RC inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 "RF CURVED SHARP CANNULA 15cm, 15mm, 20g RFK-C151520S-P" 50686125_1 CDM 0272 RC inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 "RF CURVED SHARP CANNULA 15cm, 15mm, 20g RFK-C151520S-P" 50686125_1 CDM 0272 RC inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges RF ELECTRODE 15cm TCD-15-P 50686131_1 CDM 0272 RC inpatient 701 455.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 455.65 65 999999999 424.46 679.97 percent of total billed charges RF ELECTRODE 15cm TCD-15-P 50686131_1 CDM 0272 RC inpatient 701 455.65 AETNA AETNA 553.79 79 999999999 424.46 679.97 percent of total billed charges RF ELECTRODE 15cm TCD-15-P 50686131_1 CDM 0272 RC inpatient 701 455.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 679.97 97 999999999 424.46 679.97 percent of total billed charges RF ELECTRODE 15cm TCD-15-P 50686131_1 CDM 0272 RC inpatient 701 455.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 546.78 78 999999999 424.46 679.97 percent of total billed charges RF ELECTRODE 15cm TCD-15-P 50686131_1 CDM 0272 RC inpatient 701 455.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 483.69 69 999999999 424.46 679.97 percent of total billed charges RF ELECTRODE 15cm TCD-15-P 50686131_1 CDM 0272 RC inpatient 701 455.65 SIHO - ALL PLANS SIHO - ALL PLANS 630.9 90 999999999 424.46 679.97 percent of total billed charges RF ELECTRODE 15cm TCD-15-P 50686131_1 CDM 0272 RC inpatient 701 455.65 UMR - ALL PLANS UMR - ALL PLANS 490.7 70 999999999 424.46 679.97 percent of total billed charges RF ELECTRODE 15cm TCD-15-P 50686131_1 CDM 0272 RC inpatient 701 455.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 424.46 60.55 999999999 424.46 679.97 percent of total billed charges RF ELECTRODE 15cm TCD-15-P 50686131_1 CDM 0272 RC inpatient 701 455.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 424.46 679.97 RF ELECTRODE 15cm TCD-15-P 50686131_1 CDM 0272 RC inpatient 701 455.65 ANTHEM HMO ANTHEM HMO 999999999 424.46 679.97 RF ELECTRODE 15cm TCD-15-P 50686131_1 CDM 0272 RC inpatient 701 455.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 424.46 679.97 RF ELECTRODE 15cm TCD-15-P 50686131_1 CDM 0272 RC inpatient 701 455.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 424.46 679.97 RF ELECTRODE 15cm TCD-15-P 50686131_1 CDM 0272 RC inpatient 701 455.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 424.46 679.97 RF ELECTRODE 15cm TCD-15-P 50686131_1 CDM 0272 RC inpatient 701 455.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 473.88 67.6 999999999 424.46 679.97 percent of total billed charges RF ELECTRODE 10cm TCD-10-P 50686132_1 CDM 0272 RC inpatient 701 455.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 455.65 65 999999999 424.46 679.97 percent of total billed charges RF ELECTRODE 10cm TCD-10-P 50686132_1 CDM 0272 RC inpatient 701 455.65 AETNA AETNA 553.79 79 999999999 424.46 679.97 percent of total billed charges RF ELECTRODE 10cm TCD-10-P 50686132_1 CDM 0272 RC inpatient 701 455.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 679.97 97 999999999 424.46 679.97 percent of total billed charges RF ELECTRODE 10cm TCD-10-P 50686132_1 CDM 0272 RC inpatient 701 455.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 546.78 78 999999999 424.46 679.97 percent of total billed charges RF ELECTRODE 10cm TCD-10-P 50686132_1 CDM 0272 RC inpatient 701 455.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 483.69 69 999999999 424.46 679.97 percent of total billed charges RF ELECTRODE 10cm TCD-10-P 50686132_1 CDM 0272 RC inpatient 701 455.65 SIHO - ALL PLANS SIHO - ALL PLANS 630.9 90 999999999 424.46 679.97 percent of total billed charges RF ELECTRODE 10cm TCD-10-P 50686132_1 CDM 0272 RC inpatient 701 455.65 UMR - ALL PLANS UMR - ALL PLANS 490.7 70 999999999 424.46 679.97 percent of total billed charges RF ELECTRODE 10cm TCD-10-P 50686132_1 CDM 0272 RC inpatient 701 455.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 424.46 60.55 999999999 424.46 679.97 percent of total billed charges RF ELECTRODE 10cm TCD-10-P 50686132_1 CDM 0272 RC inpatient 701 455.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 424.46 679.97 RF ELECTRODE 10cm TCD-10-P 50686132_1 CDM 0272 RC inpatient 701 455.65 ANTHEM HMO ANTHEM HMO 999999999 424.46 679.97 RF ELECTRODE 10cm TCD-10-P 50686132_1 CDM 0272 RC inpatient 701 455.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 424.46 679.97 RF ELECTRODE 10cm TCD-10-P 50686132_1 CDM 0272 RC inpatient 701 455.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 424.46 679.97 RF ELECTRODE 10cm TCD-10-P 50686132_1 CDM 0272 RC inpatient 701 455.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 424.46 679.97 RF ELECTRODE 10cm TCD-10-P 50686132_1 CDM 0272 RC inpatient 701 455.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 473.88 67.6 999999999 424.46 679.97 percent of total billed charges "RF UNIFIED ELECTRODE 15cm, 10mm, 20g CUR-151020U-P" 50686133_1 CDM 0272 RC inpatient 452 293.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 293.8 65 999999999 273.69 438.44 percent of total billed charges "RF UNIFIED ELECTRODE 15cm, 10mm, 20g CUR-151020U-P" 50686133_1 CDM 0272 RC inpatient 452 293.8 AETNA AETNA 357.08 79 999999999 273.69 438.44 percent of total billed charges "RF UNIFIED ELECTRODE 15cm, 10mm, 20g CUR-151020U-P" 50686133_1 CDM 0272 RC inpatient 452 293.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 438.44 97 999999999 273.69 438.44 percent of total billed charges "RF UNIFIED ELECTRODE 15cm, 10mm, 20g CUR-151020U-P" 50686133_1 CDM 0272 RC inpatient 452 293.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 352.56 78 999999999 273.69 438.44 percent of total billed charges "RF UNIFIED ELECTRODE 15cm, 10mm, 20g CUR-151020U-P" 50686133_1 CDM 0272 RC inpatient 452 293.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 311.88 69 999999999 273.69 438.44 percent of total billed charges "RF UNIFIED ELECTRODE 15cm, 10mm, 20g CUR-151020U-P" 50686133_1 CDM 0272 RC inpatient 452 293.8 SIHO - ALL PLANS SIHO - ALL PLANS 406.8 90 999999999 273.69 438.44 percent of total billed charges "RF UNIFIED ELECTRODE 15cm, 10mm, 20g CUR-151020U-P" 50686133_1 CDM 0272 RC inpatient 452 293.8 UMR - ALL PLANS UMR - ALL PLANS 316.4 70 999999999 273.69 438.44 percent of total billed charges "RF UNIFIED ELECTRODE 15cm, 10mm, 20g CUR-151020U-P" 50686133_1 CDM 0272 RC inpatient 452 293.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 273.69 60.55 999999999 273.69 438.44 percent of total billed charges "RF UNIFIED ELECTRODE 15cm, 10mm, 20g CUR-151020U-P" 50686133_1 CDM 0272 RC inpatient 452 293.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 273.69 438.44 "RF UNIFIED ELECTRODE 15cm, 10mm, 20g CUR-151020U-P" 50686133_1 CDM 0272 RC inpatient 452 293.8 ANTHEM HMO ANTHEM HMO 999999999 273.69 438.44 "RF UNIFIED ELECTRODE 15cm, 10mm, 20g CUR-151020U-P" 50686133_1 CDM 0272 RC inpatient 452 293.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 273.69 438.44 "RF UNIFIED ELECTRODE 15cm, 10mm, 20g CUR-151020U-P" 50686133_1 CDM 0272 RC inpatient 452 293.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 273.69 438.44 "RF UNIFIED ELECTRODE 15cm, 10mm, 20g CUR-151020U-P" 50686133_1 CDM 0272 RC inpatient 452 293.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 273.69 438.44 "RF UNIFIED ELECTRODE 15cm, 10mm, 20g CUR-151020U-P" 50686133_1 CDM 0272 RC inpatient 452 293.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 305.55 67.6 999999999 273.69 438.44 percent of total billed charges "RF CC NEEDLE STRAIGHT TIP 10cm, 10mm, 20g CC101020-P" 50686134_1 CDM 0272 RC inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges "RF CC NEEDLE STRAIGHT TIP 10cm, 10mm, 20g CC101020-P" 50686134_1 CDM 0272 RC inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges "RF CC NEEDLE STRAIGHT TIP 10cm, 10mm, 20g CC101020-P" 50686134_1 CDM 0272 RC inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges "RF CC NEEDLE STRAIGHT TIP 10cm, 10mm, 20g CC101020-P" 50686134_1 CDM 0272 RC inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges "RF CC NEEDLE STRAIGHT TIP 10cm, 10mm, 20g CC101020-P" 50686134_1 CDM 0272 RC inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges "RF CC NEEDLE STRAIGHT TIP 10cm, 10mm, 20g CC101020-P" 50686134_1 CDM 0272 RC inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges "RF CC NEEDLE STRAIGHT TIP 10cm, 10mm, 20g CC101020-P" 50686134_1 CDM 0272 RC inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges "RF CC NEEDLE STRAIGHT TIP 10cm, 10mm, 20g CC101020-P" 50686134_1 CDM 0272 RC inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges "RF CC NEEDLE STRAIGHT TIP 10cm, 10mm, 20g CC101020-P" 50686134_1 CDM 0272 RC inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 "RF CC NEEDLE STRAIGHT TIP 10cm, 10mm, 20g CC101020-P" 50686134_1 CDM 0272 RC inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 "RF CC NEEDLE STRAIGHT TIP 10cm, 10mm, 20g CC101020-P" 50686134_1 CDM 0272 RC inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 "RF CC NEEDLE STRAIGHT TIP 10cm, 10mm, 20g CC101020-P" 50686134_1 CDM 0272 RC inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 "RF CC NEEDLE STRAIGHT TIP 10cm, 10mm, 20g CC101020-P" 50686134_1 CDM 0272 RC inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 "RF CC NEEDLE STRAIGHT TIP 10cm, 10mm, 20g CC101020-P" 50686134_1 CDM 0272 RC inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges "RF CC NEEDLE STRAIGHT TIP 15cm, 10mm, 20g CC151020-P" 50686135_1 CDM 0272 RC inpatient 104 67.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 67.6 65 999999999 62.97 100.88 percent of total billed charges "RF CC NEEDLE STRAIGHT TIP 15cm, 10mm, 20g CC151020-P" 50686135_1 CDM 0272 RC inpatient 104 67.6 AETNA AETNA 82.16 79 999999999 62.97 100.88 percent of total billed charges "RF CC NEEDLE STRAIGHT TIP 15cm, 10mm, 20g CC151020-P" 50686135_1 CDM 0272 RC inpatient 104 67.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 100.88 97 999999999 62.97 100.88 percent of total billed charges "RF CC NEEDLE STRAIGHT TIP 15cm, 10mm, 20g CC151020-P" 50686135_1 CDM 0272 RC inpatient 104 67.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.12 78 999999999 62.97 100.88 percent of total billed charges "RF CC NEEDLE STRAIGHT TIP 15cm, 10mm, 20g CC151020-P" 50686135_1 CDM 0272 RC inpatient 104 67.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.76 69 999999999 62.97 100.88 percent of total billed charges "RF CC NEEDLE STRAIGHT TIP 15cm, 10mm, 20g CC151020-P" 50686135_1 CDM 0272 RC inpatient 104 67.6 SIHO - ALL PLANS SIHO - ALL PLANS 93.6 90 999999999 62.97 100.88 percent of total billed charges "RF CC NEEDLE STRAIGHT TIP 15cm, 10mm, 20g CC151020-P" 50686135_1 CDM 0272 RC inpatient 104 67.6 UMR - ALL PLANS UMR - ALL PLANS 72.8 70 999999999 62.97 100.88 percent of total billed charges "RF CC NEEDLE STRAIGHT TIP 15cm, 10mm, 20g CC151020-P" 50686135_1 CDM 0272 RC inpatient 104 67.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.97 60.55 999999999 62.97 100.88 percent of total billed charges "RF CC NEEDLE STRAIGHT TIP 15cm, 10mm, 20g CC151020-P" 50686135_1 CDM 0272 RC inpatient 104 67.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.97 100.88 "RF CC NEEDLE STRAIGHT TIP 15cm, 10mm, 20g CC151020-P" 50686135_1 CDM 0272 RC inpatient 104 67.6 ANTHEM HMO ANTHEM HMO 999999999 62.97 100.88 "RF CC NEEDLE STRAIGHT TIP 15cm, 10mm, 20g CC151020-P" 50686135_1 CDM 0272 RC inpatient 104 67.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.97 100.88 "RF CC NEEDLE STRAIGHT TIP 15cm, 10mm, 20g CC151020-P" 50686135_1 CDM 0272 RC inpatient 104 67.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.97 100.88 "RF CC NEEDLE STRAIGHT TIP 15cm, 10mm, 20g CC151020-P" 50686135_1 CDM 0272 RC inpatient 104 67.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.97 100.88 "RF CC NEEDLE STRAIGHT TIP 15cm, 10mm, 20g CC151020-P" 50686135_1 CDM 0272 RC inpatient 104 67.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.3 67.6 999999999 62.97 100.88 percent of total billed charges DISPOSABLE GROUNDING PAD DGP-PM2-5 50686148_1 CDM 0272 RC inpatient 12 7.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 7.8 65 999999999 7.27 11.64 percent of total billed charges DISPOSABLE GROUNDING PAD DGP-PM2-5 50686148_1 CDM 0272 RC inpatient 12 7.8 AETNA AETNA 9.48 79 999999999 7.27 11.64 percent of total billed charges DISPOSABLE GROUNDING PAD DGP-PM2-5 50686148_1 CDM 0272 RC inpatient 12 7.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11.64 97 999999999 7.27 11.64 percent of total billed charges DISPOSABLE GROUNDING PAD DGP-PM2-5 50686148_1 CDM 0272 RC inpatient 12 7.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.36 78 999999999 7.27 11.64 percent of total billed charges DISPOSABLE GROUNDING PAD DGP-PM2-5 50686148_1 CDM 0272 RC inpatient 12 7.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.28 69 999999999 7.27 11.64 percent of total billed charges DISPOSABLE GROUNDING PAD DGP-PM2-5 50686148_1 CDM 0272 RC inpatient 12 7.8 SIHO - ALL PLANS SIHO - ALL PLANS 10.8 90 999999999 7.27 11.64 percent of total billed charges DISPOSABLE GROUNDING PAD DGP-PM2-5 50686148_1 CDM 0272 RC inpatient 12 7.8 UMR - ALL PLANS UMR - ALL PLANS 8.4 70 999999999 7.27 11.64 percent of total billed charges DISPOSABLE GROUNDING PAD DGP-PM2-5 50686148_1 CDM 0272 RC inpatient 12 7.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.27 60.55 999999999 7.27 11.64 percent of total billed charges DISPOSABLE GROUNDING PAD DGP-PM2-5 50686148_1 CDM 0272 RC inpatient 12 7.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.27 11.64 DISPOSABLE GROUNDING PAD DGP-PM2-5 50686148_1 CDM 0272 RC inpatient 12 7.8 ANTHEM HMO ANTHEM HMO 999999999 7.27 11.64 DISPOSABLE GROUNDING PAD DGP-PM2-5 50686148_1 CDM 0272 RC inpatient 12 7.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.27 11.64 DISPOSABLE GROUNDING PAD DGP-PM2-5 50686148_1 CDM 0272 RC inpatient 12 7.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.27 11.64 DISPOSABLE GROUNDING PAD DGP-PM2-5 50686148_1 CDM 0272 RC inpatient 12 7.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.27 11.64 DISPOSABLE GROUNDING PAD DGP-PM2-5 50686148_1 CDM 0272 RC inpatient 12 7.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.11 67.6 999999999 7.27 11.64 percent of total billed charges "RF UNIFIED ELECTRODE 10cm, 10mm, 20g CUR-101020U-P" 50686151_1 CDM 0272 RC inpatient 452 293.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 293.8 65 999999999 273.69 438.44 percent of total billed charges "RF UNIFIED ELECTRODE 10cm, 10mm, 20g CUR-101020U-P" 50686151_1 CDM 0272 RC inpatient 452 293.8 AETNA AETNA 357.08 79 999999999 273.69 438.44 percent of total billed charges "RF UNIFIED ELECTRODE 10cm, 10mm, 20g CUR-101020U-P" 50686151_1 CDM 0272 RC inpatient 452 293.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 438.44 97 999999999 273.69 438.44 percent of total billed charges "RF UNIFIED ELECTRODE 10cm, 10mm, 20g CUR-101020U-P" 50686151_1 CDM 0272 RC inpatient 452 293.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 352.56 78 999999999 273.69 438.44 percent of total billed charges "RF UNIFIED ELECTRODE 10cm, 10mm, 20g CUR-101020U-P" 50686151_1 CDM 0272 RC inpatient 452 293.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 311.88 69 999999999 273.69 438.44 percent of total billed charges "RF UNIFIED ELECTRODE 10cm, 10mm, 20g CUR-101020U-P" 50686151_1 CDM 0272 RC inpatient 452 293.8 SIHO - ALL PLANS SIHO - ALL PLANS 406.8 90 999999999 273.69 438.44 percent of total billed charges "RF UNIFIED ELECTRODE 10cm, 10mm, 20g CUR-101020U-P" 50686151_1 CDM 0272 RC inpatient 452 293.8 UMR - ALL PLANS UMR - ALL PLANS 316.4 70 999999999 273.69 438.44 percent of total billed charges "RF UNIFIED ELECTRODE 10cm, 10mm, 20g CUR-101020U-P" 50686151_1 CDM 0272 RC inpatient 452 293.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 273.69 60.55 999999999 273.69 438.44 percent of total billed charges "RF UNIFIED ELECTRODE 10cm, 10mm, 20g CUR-101020U-P" 50686151_1 CDM 0272 RC inpatient 452 293.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 273.69 438.44 "RF UNIFIED ELECTRODE 10cm, 10mm, 20g CUR-101020U-P" 50686151_1 CDM 0272 RC inpatient 452 293.8 ANTHEM HMO ANTHEM HMO 999999999 273.69 438.44 "RF UNIFIED ELECTRODE 10cm, 10mm, 20g CUR-101020U-P" 50686151_1 CDM 0272 RC inpatient 452 293.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 273.69 438.44 "RF UNIFIED ELECTRODE 10cm, 10mm, 20g CUR-101020U-P" 50686151_1 CDM 0272 RC inpatient 452 293.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 273.69 438.44 "RF UNIFIED ELECTRODE 10cm, 10mm, 20g CUR-101020U-P" 50686151_1 CDM 0272 RC inpatient 452 293.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 273.69 438.44 "RF UNIFIED ELECTRODE 10cm, 10mm, 20g CUR-101020U-P" 50686151_1 CDM 0272 RC inpatient 452 293.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 305.55 67.6 999999999 273.69 438.44 percent of total billed charges ATORVASTATIN 40 MG TABLET 50688770_1 CDM 0250 RC 51079-0210-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 40 MG TABLET 50688770_1 CDM 0250 RC 51079-0210-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 40 MG TABLET 50688770_1 CDM 0250 RC 51079-0210-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 40 MG TABLET 50688770_1 CDM 0250 RC 51079-0210-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 40 MG TABLET 50688770_1 CDM 0250 RC 51079-0210-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 40 MG TABLET 50688770_1 CDM 0250 RC 51079-0210-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 40 MG TABLET 50688770_1 CDM 0250 RC 51079-0210-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 40 MG TABLET 50688770_1 CDM 0250 RC 51079-0210-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges ATORVASTATIN 40 MG TABLET 50688770_1 CDM 0250 RC 51079-0210-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 ATORVASTATIN 40 MG TABLET 50688770_1 CDM 0250 RC 51079-0210-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 ATORVASTATIN 40 MG TABLET 50688770_1 CDM 0250 RC 51079-0210-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 ATORVASTATIN 40 MG TABLET 50688770_1 CDM 0250 RC 51079-0210-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 ATORVASTATIN 40 MG TABLET 50688770_1 CDM 0250 RC 51079-0210-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ATORVASTATIN 40 MG TABLET 50688770_1 CDM 0250 RC 51079-0210-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 50692477_1 CDM 0636 RC C5271 HCPCS inpatient 1446 939.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 939.9 65 999999999 875.55 1402.62 percent of total billed charges "APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 50692477_1 CDM 0636 RC C5271 HCPCS inpatient 1446 939.9 AETNA AETNA 1142.34 79 999999999 875.55 1402.62 percent of total billed charges "APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 50692477_1 CDM 0636 RC C5271 HCPCS inpatient 1446 939.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1402.62 97 999999999 875.55 1402.62 percent of total billed charges "APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 50692477_1 CDM 0636 RC C5271 HCPCS inpatient 1446 939.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1127.88 78 999999999 875.55 1402.62 percent of total billed charges "APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 50692477_1 CDM 0636 RC C5271 HCPCS inpatient 1446 939.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 997.74 69 999999999 875.55 1402.62 percent of total billed charges "APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 50692477_1 CDM 0636 RC C5271 HCPCS inpatient 1446 939.9 SIHO - ALL PLANS SIHO - ALL PLANS 1301.4 90 999999999 875.55 1402.62 percent of total billed charges "APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 50692477_1 CDM 0636 RC C5271 HCPCS inpatient 1446 939.9 UMR - ALL PLANS UMR - ALL PLANS 1012.2 70 999999999 875.55 1402.62 percent of total billed charges "APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 50692477_1 CDM 0636 RC C5271 HCPCS inpatient 1446 939.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 875.55 60.55 999999999 875.55 1402.62 percent of total billed charges "APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 50692477_1 CDM 0636 RC C5271 HCPCS inpatient 1446 939.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 875.55 1402.62 "APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 50692477_1 CDM 0636 RC C5271 HCPCS inpatient 1446 939.9 ANTHEM HMO ANTHEM HMO 999999999 875.55 1402.62 "APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 50692477_1 CDM 0636 RC C5271 HCPCS inpatient 1446 939.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 875.55 1402.62 "APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 50692477_1 CDM 0636 RC C5271 HCPCS inpatient 1446 939.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 875.55 1402.62 "APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 50692477_1 CDM 0636 RC C5271 HCPCS inpatient 1446 939.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 875.55 1402.62 "APPLICATION OF LOW COST SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA" 50692477_1 CDM 0636 RC C5271 HCPCS inpatient 1446 939.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 977.5 67.6 999999999 875.55 1402.62 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 50692532_1 CDM 0636 RC 16729-0332-05 NDC J9263 HCPCS inpatient 200 UN 79.44 51.64 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.64 65 999999999 48.1 77.06 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 50692532_1 CDM 0636 RC 16729-0332-05 NDC J9263 HCPCS inpatient 200 UN 79.44 51.64 AETNA AETNA 62.76 79 999999999 48.1 77.06 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 50692532_1 CDM 0636 RC 16729-0332-05 NDC J9263 HCPCS inpatient 200 UN 79.44 51.64 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.06 97 999999999 48.1 77.06 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 50692532_1 CDM 0636 RC 16729-0332-05 NDC J9263 HCPCS inpatient 200 UN 79.44 51.64 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.96 78 999999999 48.1 77.06 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 50692532_1 CDM 0636 RC 16729-0332-05 NDC J9263 HCPCS inpatient 200 UN 79.44 51.64 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.81 69 999999999 48.1 77.06 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 50692532_1 CDM 0636 RC 16729-0332-05 NDC J9263 HCPCS inpatient 200 UN 79.44 51.64 SIHO - ALL PLANS SIHO - ALL PLANS 71.5 90 999999999 48.1 77.06 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 50692532_1 CDM 0636 RC 16729-0332-05 NDC J9263 HCPCS inpatient 200 UN 79.44 51.64 UMR - ALL PLANS UMR - ALL PLANS 55.61 70 999999999 48.1 77.06 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 50692532_1 CDM 0636 RC 16729-0332-05 NDC J9263 HCPCS inpatient 200 UN 79.44 51.64 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.1 60.55 999999999 48.1 77.06 percent of total billed charges "INJECTION, OXALIPLATIN, 0.5 MG" 50692532_1 CDM 0636 RC 16729-0332-05 NDC J9263 HCPCS inpatient 200 UN 79.44 51.64 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.1 77.06 "INJECTION, OXALIPLATIN, 0.5 MG" 50692532_1 CDM 0636 RC 16729-0332-05 NDC J9263 HCPCS inpatient 200 UN 79.44 51.64 ANTHEM HMO ANTHEM HMO 999999999 48.1 77.06 "INJECTION, OXALIPLATIN, 0.5 MG" 50692532_1 CDM 0636 RC 16729-0332-05 NDC J9263 HCPCS inpatient 200 UN 79.44 51.64 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.1 77.06 "INJECTION, OXALIPLATIN, 0.5 MG" 50692532_1 CDM 0636 RC 16729-0332-05 NDC J9263 HCPCS inpatient 200 UN 79.44 51.64 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.1 77.06 "INJECTION, OXALIPLATIN, 0.5 MG" 50692532_1 CDM 0636 RC 16729-0332-05 NDC J9263 HCPCS inpatient 200 UN 79.44 51.64 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.1 77.06 "INJECTION, OXALIPLATIN, 0.5 MG" 50692532_1 CDM 0636 RC 16729-0332-05 NDC J9263 HCPCS inpatient 200 UN 79.44 51.64 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.7 67.6 999999999 48.1 77.06 percent of total billed charges SODIUM PHOSPHATE 45 MMOL/15 ML 50692633_1 CDM 0250 RC 00409-7391-72 NDC inpatient 2 UN 26.53 17.24 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.24 65 999999999 16.06 25.73 percent of total billed charges SODIUM PHOSPHATE 45 MMOL/15 ML 50692633_1 CDM 0250 RC 00409-7391-72 NDC inpatient 2 UN 26.53 17.24 AETNA AETNA 20.96 79 999999999 16.06 25.73 percent of total billed charges SODIUM PHOSPHATE 45 MMOL/15 ML 50692633_1 CDM 0250 RC 00409-7391-72 NDC inpatient 2 UN 26.53 17.24 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.73 97 999999999 16.06 25.73 percent of total billed charges SODIUM PHOSPHATE 45 MMOL/15 ML 50692633_1 CDM 0250 RC 00409-7391-72 NDC inpatient 2 UN 26.53 17.24 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.69 78 999999999 16.06 25.73 percent of total billed charges SODIUM PHOSPHATE 45 MMOL/15 ML 50692633_1 CDM 0250 RC 00409-7391-72 NDC inpatient 2 UN 26.53 17.24 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.31 69 999999999 16.06 25.73 percent of total billed charges SODIUM PHOSPHATE 45 MMOL/15 ML 50692633_1 CDM 0250 RC 00409-7391-72 NDC inpatient 2 UN 26.53 17.24 SIHO - ALL PLANS SIHO - ALL PLANS 23.88 90 999999999 16.06 25.73 percent of total billed charges SODIUM PHOSPHATE 45 MMOL/15 ML 50692633_1 CDM 0250 RC 00409-7391-72 NDC inpatient 2 UN 26.53 17.24 UMR - ALL PLANS UMR - ALL PLANS 18.57 70 999999999 16.06 25.73 percent of total billed charges SODIUM PHOSPHATE 45 MMOL/15 ML 50692633_1 CDM 0250 RC 00409-7391-72 NDC inpatient 2 UN 26.53 17.24 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.06 60.55 999999999 16.06 25.73 percent of total billed charges SODIUM PHOSPHATE 45 MMOL/15 ML 50692633_1 CDM 0250 RC 00409-7391-72 NDC inpatient 2 UN 26.53 17.24 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.06 25.73 SODIUM PHOSPHATE 45 MMOL/15 ML 50692633_1 CDM 0250 RC 00409-7391-72 NDC inpatient 2 UN 26.53 17.24 ANTHEM HMO ANTHEM HMO 999999999 16.06 25.73 SODIUM PHOSPHATE 45 MMOL/15 ML 50692633_1 CDM 0250 RC 00409-7391-72 NDC inpatient 2 UN 26.53 17.24 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.06 25.73 SODIUM PHOSPHATE 45 MMOL/15 ML 50692633_1 CDM 0250 RC 00409-7391-72 NDC inpatient 2 UN 26.53 17.24 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.06 25.73 SODIUM PHOSPHATE 45 MMOL/15 ML 50692633_1 CDM 0250 RC 00409-7391-72 NDC inpatient 2 UN 26.53 17.24 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.06 25.73 SODIUM PHOSPHATE 45 MMOL/15 ML 50692633_1 CDM 0250 RC 00409-7391-72 NDC inpatient 2 UN 26.53 17.24 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.93 67.6 999999999 16.06 25.73 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50694807_1 CDM 0301 RC 80307 HCPCS inpatient 221 143.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 143.65 65 999999999 133.82 214.37 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50694807_1 CDM 0301 RC 80307 HCPCS inpatient 221 143.65 AETNA AETNA 174.59 79 999999999 133.82 214.37 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50694807_1 CDM 0301 RC 80307 HCPCS inpatient 221 143.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 214.37 97 999999999 133.82 214.37 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50694807_1 CDM 0301 RC 80307 HCPCS inpatient 221 143.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 172.38 78 999999999 133.82 214.37 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50694807_1 CDM 0301 RC 80307 HCPCS inpatient 221 143.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 152.49 69 999999999 133.82 214.37 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50694807_1 CDM 0301 RC 80307 HCPCS inpatient 221 143.65 SIHO - ALL PLANS SIHO - ALL PLANS 198.9 90 999999999 133.82 214.37 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50694807_1 CDM 0301 RC 80307 HCPCS inpatient 221 143.65 UMR - ALL PLANS UMR - ALL PLANS 154.7 70 999999999 133.82 214.37 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50694807_1 CDM 0301 RC 80307 HCPCS inpatient 221 143.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 133.82 60.55 999999999 133.82 214.37 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 50694807_1 CDM 0301 RC 80307 HCPCS inpatient 221 143.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 133.82 214.37 "Testing for presence of drug, by chemistry analyzers" 50694807_1 CDM 0301 RC 80307 HCPCS inpatient 221 143.65 ANTHEM HMO ANTHEM HMO 999999999 133.82 214.37 "Testing for presence of drug, by chemistry analyzers" 50694807_1 CDM 0301 RC 80307 HCPCS inpatient 221 143.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 133.82 214.37 "Testing for presence of drug, by chemistry analyzers" 50694807_1 CDM 0301 RC 80307 HCPCS inpatient 221 143.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 133.82 214.37 "Testing for presence of drug, by chemistry analyzers" 50694807_1 CDM 0301 RC 80307 HCPCS inpatient 221 143.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 133.82 214.37 "Testing for presence of drug, by chemistry analyzers" 50694807_1 CDM 0301 RC 80307 HCPCS inpatient 221 143.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 149.4 67.6 999999999 133.82 214.37 percent of total billed charges Barbiturates levels 50694808_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 111.8 65 999999999 104.15 166.84 percent of total billed charges Barbiturates levels 50694808_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 AETNA AETNA 135.88 79 999999999 104.15 166.84 percent of total billed charges Barbiturates levels 50694808_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 166.84 97 999999999 104.15 166.84 percent of total billed charges Barbiturates levels 50694808_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 134.16 78 999999999 104.15 166.84 percent of total billed charges Barbiturates levels 50694808_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 118.68 69 999999999 104.15 166.84 percent of total billed charges Barbiturates levels 50694808_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 SIHO - ALL PLANS SIHO - ALL PLANS 154.8 90 999999999 104.15 166.84 percent of total billed charges Barbiturates levels 50694808_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 UMR - ALL PLANS UMR - ALL PLANS 120.4 70 999999999 104.15 166.84 percent of total billed charges Barbiturates levels 50694808_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 104.15 60.55 999999999 104.15 166.84 percent of total billed charges Barbiturates levels 50694808_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 104.15 166.84 Barbiturates levels 50694808_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 ANTHEM HMO ANTHEM HMO 999999999 104.15 166.84 Barbiturates levels 50694808_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 104.15 166.84 Barbiturates levels 50694808_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 104.15 166.84 Barbiturates levels 50694808_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 104.15 166.84 Barbiturates levels 50694808_1 CDM 0301 RC 80345 HCPCS inpatient 172 111.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 116.27 67.6 999999999 104.15 166.84 percent of total billed charges "Benzodiazepines levels, 1-12" 50694809_1 CDM 0301 RC 80346 HCPCS inpatient 314 204.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 204.1 65 999999999 190.13 304.58 percent of total billed charges "Benzodiazepines levels, 1-12" 50694809_1 CDM 0301 RC 80346 HCPCS inpatient 314 204.1 AETNA AETNA 248.06 79 999999999 190.13 304.58 percent of total billed charges "Benzodiazepines levels, 1-12" 50694809_1 CDM 0301 RC 80346 HCPCS inpatient 314 204.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 304.58 97 999999999 190.13 304.58 percent of total billed charges "Benzodiazepines levels, 1-12" 50694809_1 CDM 0301 RC 80346 HCPCS inpatient 314 204.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 244.92 78 999999999 190.13 304.58 percent of total billed charges "Benzodiazepines levels, 1-12" 50694809_1 CDM 0301 RC 80346 HCPCS inpatient 314 204.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 216.66 69 999999999 190.13 304.58 percent of total billed charges "Benzodiazepines levels, 1-12" 50694809_1 CDM 0301 RC 80346 HCPCS inpatient 314 204.1 SIHO - ALL PLANS SIHO - ALL PLANS 282.6 90 999999999 190.13 304.58 percent of total billed charges "Benzodiazepines levels, 1-12" 50694809_1 CDM 0301 RC 80346 HCPCS inpatient 314 204.1 UMR - ALL PLANS UMR - ALL PLANS 219.8 70 999999999 190.13 304.58 percent of total billed charges "Benzodiazepines levels, 1-12" 50694809_1 CDM 0301 RC 80346 HCPCS inpatient 314 204.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 190.13 60.55 999999999 190.13 304.58 percent of total billed charges "Benzodiazepines levels, 1-12" 50694809_1 CDM 0301 RC 80346 HCPCS inpatient 314 204.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 190.13 304.58 "Benzodiazepines levels, 1-12" 50694809_1 CDM 0301 RC 80346 HCPCS inpatient 314 204.1 ANTHEM HMO ANTHEM HMO 999999999 190.13 304.58 "Benzodiazepines levels, 1-12" 50694809_1 CDM 0301 RC 80346 HCPCS inpatient 314 204.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 190.13 304.58 "Benzodiazepines levels, 1-12" 50694809_1 CDM 0301 RC 80346 HCPCS inpatient 314 204.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 190.13 304.58 "Benzodiazepines levels, 1-12" 50694809_1 CDM 0301 RC 80346 HCPCS inpatient 314 204.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 190.13 304.58 "Benzodiazepines levels, 1-12" 50694809_1 CDM 0301 RC 80346 HCPCS inpatient 314 204.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 212.26 67.6 999999999 190.13 304.58 percent of total billed charges Buprenorphine level 50694810_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 181.35 65 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 50694810_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 AETNA AETNA 220.41 79 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 50694810_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 270.63 97 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 50694810_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 217.62 78 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 50694810_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 192.51 69 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 50694810_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 SIHO - ALL PLANS SIHO - ALL PLANS 251.1 90 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 50694810_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 UMR - ALL PLANS UMR - ALL PLANS 195.3 70 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 50694810_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 168.93 60.55 999999999 168.93 270.63 percent of total billed charges Buprenorphine level 50694810_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 168.93 270.63 Buprenorphine level 50694810_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 ANTHEM HMO ANTHEM HMO 999999999 168.93 270.63 Buprenorphine level 50694810_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 168.93 270.63 Buprenorphine level 50694810_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 168.93 270.63 Buprenorphine level 50694810_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 168.93 270.63 Buprenorphine level 50694810_1 CDM 0301 RC 80348 HCPCS inpatient 279 181.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 188.6 67.6 999999999 168.93 270.63 percent of total billed charges Cocaine level 50694811_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 287.3 65 999999999 267.63 428.74 percent of total billed charges Cocaine level 50694811_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 AETNA AETNA 349.18 79 999999999 267.63 428.74 percent of total billed charges Cocaine level 50694811_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 428.74 97 999999999 267.63 428.74 percent of total billed charges Cocaine level 50694811_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 344.76 78 999999999 267.63 428.74 percent of total billed charges Cocaine level 50694811_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 304.98 69 999999999 267.63 428.74 percent of total billed charges Cocaine level 50694811_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 SIHO - ALL PLANS SIHO - ALL PLANS 397.8 90 999999999 267.63 428.74 percent of total billed charges Cocaine level 50694811_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 UMR - ALL PLANS UMR - ALL PLANS 309.4 70 999999999 267.63 428.74 percent of total billed charges Cocaine level 50694811_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 267.63 60.55 999999999 267.63 428.74 percent of total billed charges Cocaine level 50694811_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 267.63 428.74 Cocaine level 50694811_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 ANTHEM HMO ANTHEM HMO 999999999 267.63 428.74 Cocaine level 50694811_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 267.63 428.74 Cocaine level 50694811_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 267.63 428.74 Cocaine level 50694811_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 267.63 428.74 Cocaine level 50694811_1 CDM 0301 RC 80353 HCPCS inpatient 442 287.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 298.79 67.6 999999999 267.63 428.74 percent of total billed charges Methadone level 50694812_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 137.15 65 999999999 127.76 204.67 percent of total billed charges Methadone level 50694812_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 AETNA AETNA 166.69 79 999999999 127.76 204.67 percent of total billed charges Methadone level 50694812_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 204.67 97 999999999 127.76 204.67 percent of total billed charges Methadone level 50694812_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 164.58 78 999999999 127.76 204.67 percent of total billed charges Methadone level 50694812_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 145.59 69 999999999 127.76 204.67 percent of total billed charges Methadone level 50694812_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 SIHO - ALL PLANS SIHO - ALL PLANS 189.9 90 999999999 127.76 204.67 percent of total billed charges Methadone level 50694812_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 UMR - ALL PLANS UMR - ALL PLANS 147.7 70 999999999 127.76 204.67 percent of total billed charges Methadone level 50694812_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.76 60.55 999999999 127.76 204.67 percent of total billed charges Methadone level 50694812_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.76 204.67 Methadone level 50694812_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ANTHEM HMO ANTHEM HMO 999999999 127.76 204.67 Methadone level 50694812_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.76 204.67 Methadone level 50694812_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.76 204.67 Methadone level 50694812_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.76 204.67 Methadone level 50694812_1 CDM 0301 RC 80358 HCPCS inpatient 211 137.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 142.64 67.6 999999999 127.76 204.67 percent of total billed charges PCP drug level 50694813_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges PCP drug level 50694813_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges PCP drug level 50694813_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges PCP drug level 50694813_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges PCP drug level 50694813_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges PCP drug level 50694813_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges PCP drug level 50694813_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges PCP drug level 50694813_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges PCP drug level 50694813_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 PCP drug level 50694813_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 PCP drug level 50694813_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 PCP drug level 50694813_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 PCP drug level 50694813_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 PCP drug level 50694813_1 CDM 0301 RC 83992 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50694928_1 CDM 0306 RC 87181 HCPCS inpatient 22 14.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.3 65 999999999 13.32 21.34 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50694928_1 CDM 0306 RC 87181 HCPCS inpatient 22 14.3 AETNA AETNA 17.38 79 999999999 13.32 21.34 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50694928_1 CDM 0306 RC 87181 HCPCS inpatient 22 14.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21.34 97 999999999 13.32 21.34 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50694928_1 CDM 0306 RC 87181 HCPCS inpatient 22 14.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.16 78 999999999 13.32 21.34 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50694928_1 CDM 0306 RC 87181 HCPCS inpatient 22 14.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.18 69 999999999 13.32 21.34 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50694928_1 CDM 0306 RC 87181 HCPCS inpatient 22 14.3 SIHO - ALL PLANS SIHO - ALL PLANS 19.8 90 999999999 13.32 21.34 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50694928_1 CDM 0306 RC 87181 HCPCS inpatient 22 14.3 UMR - ALL PLANS UMR - ALL PLANS 15.4 70 999999999 13.32 21.34 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50694928_1 CDM 0306 RC 87181 HCPCS inpatient 22 14.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.32 60.55 999999999 13.32 21.34 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50694928_1 CDM 0306 RC 87181 HCPCS inpatient 22 14.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.32 21.34 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50694928_1 CDM 0306 RC 87181 HCPCS inpatient 22 14.3 ANTHEM HMO ANTHEM HMO 999999999 13.32 21.34 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50694928_1 CDM 0306 RC 87181 HCPCS inpatient 22 14.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.32 21.34 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50694928_1 CDM 0306 RC 87181 HCPCS inpatient 22 14.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.32 21.34 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50694928_1 CDM 0306 RC 87181 HCPCS inpatient 22 14.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.32 21.34 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50694928_1 CDM 0306 RC 87181 HCPCS inpatient 22 14.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.87 67.6 999999999 13.32 21.34 percent of total billed charges DORZOLAMIDE-TIMOLOL EYE DROPS 50695262_1 CDM 0250 RC 61314-0030-02 NDC inpatient 1 UN 60.8 39.52 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.52 65 999999999 36.81 58.98 percent of total billed charges DORZOLAMIDE-TIMOLOL EYE DROPS 50695262_1 CDM 0250 RC 61314-0030-02 NDC inpatient 1 UN 60.8 39.52 AETNA AETNA 48.03 79 999999999 36.81 58.98 percent of total billed charges DORZOLAMIDE-TIMOLOL EYE DROPS 50695262_1 CDM 0250 RC 61314-0030-02 NDC inpatient 1 UN 60.8 39.52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.98 97 999999999 36.81 58.98 percent of total billed charges DORZOLAMIDE-TIMOLOL EYE DROPS 50695262_1 CDM 0250 RC 61314-0030-02 NDC inpatient 1 UN 60.8 39.52 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.42 78 999999999 36.81 58.98 percent of total billed charges DORZOLAMIDE-TIMOLOL EYE DROPS 50695262_1 CDM 0250 RC 61314-0030-02 NDC inpatient 1 UN 60.8 39.52 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.95 69 999999999 36.81 58.98 percent of total billed charges DORZOLAMIDE-TIMOLOL EYE DROPS 50695262_1 CDM 0250 RC 61314-0030-02 NDC inpatient 1 UN 60.8 39.52 SIHO - ALL PLANS SIHO - ALL PLANS 54.72 90 999999999 36.81 58.98 percent of total billed charges DORZOLAMIDE-TIMOLOL EYE DROPS 50695262_1 CDM 0250 RC 61314-0030-02 NDC inpatient 1 UN 60.8 39.52 UMR - ALL PLANS UMR - ALL PLANS 42.56 70 999999999 36.81 58.98 percent of total billed charges DORZOLAMIDE-TIMOLOL EYE DROPS 50695262_1 CDM 0250 RC 61314-0030-02 NDC inpatient 1 UN 60.8 39.52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.81 60.55 999999999 36.81 58.98 percent of total billed charges DORZOLAMIDE-TIMOLOL EYE DROPS 50695262_1 CDM 0250 RC 61314-0030-02 NDC inpatient 1 UN 60.8 39.52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.81 58.98 DORZOLAMIDE-TIMOLOL EYE DROPS 50695262_1 CDM 0250 RC 61314-0030-02 NDC inpatient 1 UN 60.8 39.52 ANTHEM HMO ANTHEM HMO 999999999 36.81 58.98 DORZOLAMIDE-TIMOLOL EYE DROPS 50695262_1 CDM 0250 RC 61314-0030-02 NDC inpatient 1 UN 60.8 39.52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.81 58.98 DORZOLAMIDE-TIMOLOL EYE DROPS 50695262_1 CDM 0250 RC 61314-0030-02 NDC inpatient 1 UN 60.8 39.52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.81 58.98 DORZOLAMIDE-TIMOLOL EYE DROPS 50695262_1 CDM 0250 RC 61314-0030-02 NDC inpatient 1 UN 60.8 39.52 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.81 58.98 DORZOLAMIDE-TIMOLOL EYE DROPS 50695262_1 CDM 0250 RC 61314-0030-02 NDC inpatient 1 UN 60.8 39.52 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.1 67.6 999999999 36.81 58.98 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50695264_1 CDM 0250 RC 68001-0434-91 NDC inpatient 1 UN 5.74 3.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.73 65 999999999 3.48 5.57 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50695264_1 CDM 0250 RC 68001-0434-91 NDC inpatient 1 UN 5.74 3.73 AETNA AETNA 4.53 79 999999999 3.48 5.57 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50695264_1 CDM 0250 RC 68001-0434-91 NDC inpatient 1 UN 5.74 3.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.57 97 999999999 3.48 5.57 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50695264_1 CDM 0250 RC 68001-0434-91 NDC inpatient 1 UN 5.74 3.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.48 78 999999999 3.48 5.57 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50695264_1 CDM 0250 RC 68001-0434-91 NDC inpatient 1 UN 5.74 3.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.96 69 999999999 3.48 5.57 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50695264_1 CDM 0250 RC 68001-0434-91 NDC inpatient 1 UN 5.74 3.73 SIHO - ALL PLANS SIHO - ALL PLANS 5.17 90 999999999 3.48 5.57 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50695264_1 CDM 0250 RC 68001-0434-91 NDC inpatient 1 UN 5.74 3.73 UMR - ALL PLANS UMR - ALL PLANS 4.02 70 999999999 3.48 5.57 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50695264_1 CDM 0250 RC 68001-0434-91 NDC inpatient 1 UN 5.74 3.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.48 60.55 999999999 3.48 5.57 percent of total billed charges NICOTINE 21 MG/24HR PATCH 50695264_1 CDM 0250 RC 68001-0434-91 NDC inpatient 1 UN 5.74 3.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.48 5.57 NICOTINE 21 MG/24HR PATCH 50695264_1 CDM 0250 RC 68001-0434-91 NDC inpatient 1 UN 5.74 3.73 ANTHEM HMO ANTHEM HMO 999999999 3.48 5.57 NICOTINE 21 MG/24HR PATCH 50695264_1 CDM 0250 RC 68001-0434-91 NDC inpatient 1 UN 5.74 3.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.48 5.57 NICOTINE 21 MG/24HR PATCH 50695264_1 CDM 0250 RC 68001-0434-91 NDC inpatient 1 UN 5.74 3.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.48 5.57 NICOTINE 21 MG/24HR PATCH 50695264_1 CDM 0250 RC 68001-0434-91 NDC inpatient 1 UN 5.74 3.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.48 5.57 NICOTINE 21 MG/24HR PATCH 50695264_1 CDM 0250 RC 68001-0434-91 NDC inpatient 1 UN 5.74 3.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.88 67.6 999999999 3.48 5.57 percent of total billed charges CLOPIDOGREL 75 MG TABLET 50695272_1 CDM 0250 RC 00904-6294-61 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges CLOPIDOGREL 75 MG TABLET 50695272_1 CDM 0250 RC 00904-6294-61 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges CLOPIDOGREL 75 MG TABLET 50695272_1 CDM 0250 RC 00904-6294-61 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges CLOPIDOGREL 75 MG TABLET 50695272_1 CDM 0250 RC 00904-6294-61 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges CLOPIDOGREL 75 MG TABLET 50695272_1 CDM 0250 RC 00904-6294-61 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges CLOPIDOGREL 75 MG TABLET 50695272_1 CDM 0250 RC 00904-6294-61 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges CLOPIDOGREL 75 MG TABLET 50695272_1 CDM 0250 RC 00904-6294-61 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges CLOPIDOGREL 75 MG TABLET 50695272_1 CDM 0250 RC 00904-6294-61 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges CLOPIDOGREL 75 MG TABLET 50695272_1 CDM 0250 RC 00904-6294-61 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 CLOPIDOGREL 75 MG TABLET 50695272_1 CDM 0250 RC 00904-6294-61 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 CLOPIDOGREL 75 MG TABLET 50695272_1 CDM 0250 RC 00904-6294-61 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 CLOPIDOGREL 75 MG TABLET 50695272_1 CDM 0250 RC 00904-6294-61 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 CLOPIDOGREL 75 MG TABLET 50695272_1 CDM 0250 RC 00904-6294-61 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 CLOPIDOGREL 75 MG TABLET 50695272_1 CDM 0250 RC 00904-6294-61 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges Islet cell (pancreas) antibody measurement 50695445_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 255.45 65 999999999 237.96 381.21 percent of total billed charges Islet cell (pancreas) antibody measurement 50695445_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 AETNA AETNA 310.47 79 999999999 237.96 381.21 percent of total billed charges Islet cell (pancreas) antibody measurement 50695445_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 381.21 97 999999999 237.96 381.21 percent of total billed charges Islet cell (pancreas) antibody measurement 50695445_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 306.54 78 999999999 237.96 381.21 percent of total billed charges Islet cell (pancreas) antibody measurement 50695445_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 271.17 69 999999999 237.96 381.21 percent of total billed charges Islet cell (pancreas) antibody measurement 50695445_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 SIHO - ALL PLANS SIHO - ALL PLANS 353.7 90 999999999 237.96 381.21 percent of total billed charges Islet cell (pancreas) antibody measurement 50695445_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 UMR - ALL PLANS UMR - ALL PLANS 275.1 70 999999999 237.96 381.21 percent of total billed charges Islet cell (pancreas) antibody measurement 50695445_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 237.96 60.55 999999999 237.96 381.21 percent of total billed charges Islet cell (pancreas) antibody measurement 50695445_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 237.96 381.21 Islet cell (pancreas) antibody measurement 50695445_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 ANTHEM HMO ANTHEM HMO 999999999 237.96 381.21 Islet cell (pancreas) antibody measurement 50695445_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 237.96 381.21 Islet cell (pancreas) antibody measurement 50695445_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 237.96 381.21 Islet cell (pancreas) antibody measurement 50695445_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 237.96 381.21 Islet cell (pancreas) antibody measurement 50695445_1 CDM 0302 RC 86341 HCPCS inpatient 393 255.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 265.67 67.6 999999999 237.96 381.21 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****SUTURE MAXON 40mm SIZE 0 GR60 GS-24 LOOP 1/2 KREIS GMM-56 50695911_1 CDM 0272 RC inpatient 108 70.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.2 65 999999999 65.39 104.76 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****SUTURE MAXON 40mm SIZE 0 GR60 GS-24 LOOP 1/2 KREIS GMM-56 50695911_1 CDM 0272 RC inpatient 108 70.2 AETNA AETNA 85.32 79 999999999 65.39 104.76 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****SUTURE MAXON 40mm SIZE 0 GR60 GS-24 LOOP 1/2 KREIS GMM-56 50695911_1 CDM 0272 RC inpatient 108 70.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 104.76 97 999999999 65.39 104.76 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****SUTURE MAXON 40mm SIZE 0 GR60 GS-24 LOOP 1/2 KREIS GMM-56 50695911_1 CDM 0272 RC inpatient 108 70.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 84.24 78 999999999 65.39 104.76 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****SUTURE MAXON 40mm SIZE 0 GR60 GS-24 LOOP 1/2 KREIS GMM-56 50695911_1 CDM 0272 RC inpatient 108 70.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 74.52 69 999999999 65.39 104.76 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****SUTURE MAXON 40mm SIZE 0 GR60 GS-24 LOOP 1/2 KREIS GMM-56 50695911_1 CDM 0272 RC inpatient 108 70.2 SIHO - ALL PLANS SIHO - ALL PLANS 97.2 90 999999999 65.39 104.76 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****SUTURE MAXON 40mm SIZE 0 GR60 GS-24 LOOP 1/2 KREIS GMM-56 50695911_1 CDM 0272 RC inpatient 108 70.2 UMR - ALL PLANS UMR - ALL PLANS 75.6 70 999999999 65.39 104.76 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****SUTURE MAXON 40mm SIZE 0 GR60 GS-24 LOOP 1/2 KREIS GMM-56 50695911_1 CDM 0272 RC inpatient 108 70.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 65.39 60.55 999999999 65.39 104.76 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****SUTURE MAXON 40mm SIZE 0 GR60 GS-24 LOOP 1/2 KREIS GMM-56 50695911_1 CDM 0272 RC inpatient 108 70.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 65.39 104.76 ****BLANKET PER MEGAN P. 05/01/2023****SUTURE MAXON 40mm SIZE 0 GR60 GS-24 LOOP 1/2 KREIS GMM-56 50695911_1 CDM 0272 RC inpatient 108 70.2 ANTHEM HMO ANTHEM HMO 999999999 65.39 104.76 ****BLANKET PER MEGAN P. 05/01/2023****SUTURE MAXON 40mm SIZE 0 GR60 GS-24 LOOP 1/2 KREIS GMM-56 50695911_1 CDM 0272 RC inpatient 108 70.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 65.39 104.76 ****BLANKET PER MEGAN P. 05/01/2023****SUTURE MAXON 40mm SIZE 0 GR60 GS-24 LOOP 1/2 KREIS GMM-56 50695911_1 CDM 0272 RC inpatient 108 70.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 65.39 104.76 ****BLANKET PER MEGAN P. 05/01/2023****SUTURE MAXON 40mm SIZE 0 GR60 GS-24 LOOP 1/2 KREIS GMM-56 50695911_1 CDM 0272 RC inpatient 108 70.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 65.39 104.76 ****BLANKET PER MEGAN P. 05/01/2023****SUTURE MAXON 40mm SIZE 0 GR60 GS-24 LOOP 1/2 KREIS GMM-56 50695911_1 CDM 0272 RC inpatient 108 70.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.01 67.6 999999999 65.39 104.76 percent of total billed charges "CYCLOSPORINE, ORAL, 25 MG" 50698021_1 CDM 0250 RC 60505-4630-03 NDC J7515 HCPCS inpatient 1 UN 1.38 0.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.9 65 999999999 0.84 1.34 percent of total billed charges "CYCLOSPORINE, ORAL, 25 MG" 50698021_1 CDM 0250 RC 60505-4630-03 NDC J7515 HCPCS inpatient 1 UN 1.38 0.9 AETNA AETNA 1.09 79 999999999 0.84 1.34 percent of total billed charges "CYCLOSPORINE, ORAL, 25 MG" 50698021_1 CDM 0250 RC 60505-4630-03 NDC J7515 HCPCS inpatient 1 UN 1.38 0.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.34 97 999999999 0.84 1.34 percent of total billed charges "CYCLOSPORINE, ORAL, 25 MG" 50698021_1 CDM 0250 RC 60505-4630-03 NDC J7515 HCPCS inpatient 1 UN 1.38 0.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.08 78 999999999 0.84 1.34 percent of total billed charges "CYCLOSPORINE, ORAL, 25 MG" 50698021_1 CDM 0250 RC 60505-4630-03 NDC J7515 HCPCS inpatient 1 UN 1.38 0.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.95 69 999999999 0.84 1.34 percent of total billed charges "CYCLOSPORINE, ORAL, 25 MG" 50698021_1 CDM 0250 RC 60505-4630-03 NDC J7515 HCPCS inpatient 1 UN 1.38 0.9 SIHO - ALL PLANS SIHO - ALL PLANS 1.24 90 999999999 0.84 1.34 percent of total billed charges "CYCLOSPORINE, ORAL, 25 MG" 50698021_1 CDM 0250 RC 60505-4630-03 NDC J7515 HCPCS inpatient 1 UN 1.38 0.9 UMR - ALL PLANS UMR - ALL PLANS 0.97 70 999999999 0.84 1.34 percent of total billed charges "CYCLOSPORINE, ORAL, 25 MG" 50698021_1 CDM 0250 RC 60505-4630-03 NDC J7515 HCPCS inpatient 1 UN 1.38 0.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.84 60.55 999999999 0.84 1.34 percent of total billed charges "CYCLOSPORINE, ORAL, 25 MG" 50698021_1 CDM 0250 RC 60505-4630-03 NDC J7515 HCPCS inpatient 1 UN 1.38 0.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.84 1.34 "CYCLOSPORINE, ORAL, 25 MG" 50698021_1 CDM 0250 RC 60505-4630-03 NDC J7515 HCPCS inpatient 1 UN 1.38 0.9 ANTHEM HMO ANTHEM HMO 999999999 0.84 1.34 "CYCLOSPORINE, ORAL, 25 MG" 50698021_1 CDM 0250 RC 60505-4630-03 NDC J7515 HCPCS inpatient 1 UN 1.38 0.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.84 1.34 "CYCLOSPORINE, ORAL, 25 MG" 50698021_1 CDM 0250 RC 60505-4630-03 NDC J7515 HCPCS inpatient 1 UN 1.38 0.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.84 1.34 "CYCLOSPORINE, ORAL, 25 MG" 50698021_1 CDM 0250 RC 60505-4630-03 NDC J7515 HCPCS inpatient 1 UN 1.38 0.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.84 1.34 "CYCLOSPORINE, ORAL, 25 MG" 50698021_1 CDM 0250 RC 60505-4630-03 NDC J7515 HCPCS inpatient 1 UN 1.38 0.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.93 67.6 999999999 0.84 1.34 percent of total billed charges Detection test by immunoassay technique for other organism 50698289_1 CDM 0306 RC 87449 HCPCS inpatient 157 102.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.05 65 999999999 95.06 152.29 percent of total billed charges Detection test by immunoassay technique for other organism 50698289_1 CDM 0306 RC 87449 HCPCS inpatient 157 102.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 152.29 97 999999999 95.06 152.29 percent of total billed charges Detection test by immunoassay technique for other organism 50698289_1 CDM 0306 RC 87449 HCPCS inpatient 157 102.05 AETNA AETNA 124.03 79 999999999 95.06 152.29 percent of total billed charges Detection test by immunoassay technique for other organism 50698289_1 CDM 0306 RC 87449 HCPCS inpatient 157 102.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 122.46 78 999999999 95.06 152.29 percent of total billed charges Detection test by immunoassay technique for other organism 50698289_1 CDM 0306 RC 87449 HCPCS inpatient 157 102.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 108.33 69 999999999 95.06 152.29 percent of total billed charges Detection test by immunoassay technique for other organism 50698289_1 CDM 0306 RC 87449 HCPCS inpatient 157 102.05 SIHO - ALL PLANS SIHO - ALL PLANS 141.3 90 999999999 95.06 152.29 percent of total billed charges Detection test by immunoassay technique for other organism 50698289_1 CDM 0306 RC 87449 HCPCS inpatient 157 102.05 UMR - ALL PLANS UMR - ALL PLANS 109.9 70 999999999 95.06 152.29 percent of total billed charges Detection test by immunoassay technique for other organism 50698289_1 CDM 0306 RC 87449 HCPCS inpatient 157 102.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.06 60.55 999999999 95.06 152.29 percent of total billed charges Detection test by immunoassay technique for other organism 50698289_1 CDM 0306 RC 87449 HCPCS inpatient 157 102.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.06 152.29 Detection test by immunoassay technique for other organism 50698289_1 CDM 0306 RC 87449 HCPCS inpatient 157 102.05 ANTHEM HMO ANTHEM HMO 999999999 95.06 152.29 Detection test by immunoassay technique for other organism 50698289_1 CDM 0306 RC 87449 HCPCS inpatient 157 102.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.06 152.29 Detection test by immunoassay technique for other organism 50698289_1 CDM 0306 RC 87449 HCPCS inpatient 157 102.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.06 152.29 Detection test by immunoassay technique for other organism 50698289_1 CDM 0306 RC 87449 HCPCS inpatient 157 102.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.06 152.29 Detection test by immunoassay technique for other organism 50698289_1 CDM 0306 RC 87449 HCPCS inpatient 157 102.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.13 67.6 999999999 95.06 152.29 percent of total billed charges ACETAZOLAMIDE SOD 500 MG VIAL 50698547_1 CDM 0250 RC 67457-0853-50 NDC inpatient 1 UN 176.27 114.58 SELF PAY DISCOUNT SELF PAY DISCOUNT 114.58 65 999999999 106.73 170.98 percent of total billed charges ACETAZOLAMIDE SOD 500 MG VIAL 50698547_1 CDM 0250 RC 67457-0853-50 NDC inpatient 1 UN 176.27 114.58 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 170.98 97 999999999 106.73 170.98 percent of total billed charges ACETAZOLAMIDE SOD 500 MG VIAL 50698547_1 CDM 0250 RC 67457-0853-50 NDC inpatient 1 UN 176.27 114.58 AETNA AETNA 139.25 79 999999999 106.73 170.98 percent of total billed charges ACETAZOLAMIDE SOD 500 MG VIAL 50698547_1 CDM 0250 RC 67457-0853-50 NDC inpatient 1 UN 176.27 114.58 HUMANA - ALL PLANS HUMANA - ALL PLANS 137.49 78 999999999 106.73 170.98 percent of total billed charges ACETAZOLAMIDE SOD 500 MG VIAL 50698547_1 CDM 0250 RC 67457-0853-50 NDC inpatient 1 UN 176.27 114.58 ENCORE - ALL PLANS ENCORE - ALL PLANS 121.63 69 999999999 106.73 170.98 percent of total billed charges ACETAZOLAMIDE SOD 500 MG VIAL 50698547_1 CDM 0250 RC 67457-0853-50 NDC inpatient 1 UN 176.27 114.58 SIHO - ALL PLANS SIHO - ALL PLANS 158.64 90 999999999 106.73 170.98 percent of total billed charges ACETAZOLAMIDE SOD 500 MG VIAL 50698547_1 CDM 0250 RC 67457-0853-50 NDC inpatient 1 UN 176.27 114.58 UMR - ALL PLANS UMR - ALL PLANS 123.39 70 999999999 106.73 170.98 percent of total billed charges ACETAZOLAMIDE SOD 500 MG VIAL 50698547_1 CDM 0250 RC 67457-0853-50 NDC inpatient 1 UN 176.27 114.58 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 106.73 60.55 999999999 106.73 170.98 percent of total billed charges ACETAZOLAMIDE SOD 500 MG VIAL 50698547_1 CDM 0250 RC 67457-0853-50 NDC inpatient 1 UN 176.27 114.58 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 106.73 170.98 ACETAZOLAMIDE SOD 500 MG VIAL 50698547_1 CDM 0250 RC 67457-0853-50 NDC inpatient 1 UN 176.27 114.58 ANTHEM HMO ANTHEM HMO 999999999 106.73 170.98 ACETAZOLAMIDE SOD 500 MG VIAL 50698547_1 CDM 0250 RC 67457-0853-50 NDC inpatient 1 UN 176.27 114.58 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 106.73 170.98 ACETAZOLAMIDE SOD 500 MG VIAL 50698547_1 CDM 0250 RC 67457-0853-50 NDC inpatient 1 UN 176.27 114.58 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 106.73 170.98 ACETAZOLAMIDE SOD 500 MG VIAL 50698547_1 CDM 0250 RC 67457-0853-50 NDC inpatient 1 UN 176.27 114.58 UHC - ALL PLANS UHC - ALL PLANS 999999999 106.73 170.98 ACETAZOLAMIDE SOD 500 MG VIAL 50698547_1 CDM 0250 RC 67457-0853-50 NDC inpatient 1 UN 176.27 114.58 CIGNA - ALL PLANS CIGNA - ALL PLANS 119.16 67.6 999999999 106.73 170.98 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50698766_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50698766_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50698766_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50698766_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50698766_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50698766_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50698766_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50698766_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50698766_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50698766_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50698766_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50698766_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50698766_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50698766_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges Chemical analysis using chromatography technique 50698767_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 169.65 65 999999999 158.04 253.17 percent of total billed charges Chemical analysis using chromatography technique 50698767_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 253.17 97 999999999 158.04 253.17 percent of total billed charges Chemical analysis using chromatography technique 50698767_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 AETNA AETNA 206.19 79 999999999 158.04 253.17 percent of total billed charges Chemical analysis using chromatography technique 50698767_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 203.58 78 999999999 158.04 253.17 percent of total billed charges Chemical analysis using chromatography technique 50698767_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.09 69 999999999 158.04 253.17 percent of total billed charges Chemical analysis using chromatography technique 50698767_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 SIHO - ALL PLANS SIHO - ALL PLANS 234.9 90 999999999 158.04 253.17 percent of total billed charges Chemical analysis using chromatography technique 50698767_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 UMR - ALL PLANS UMR - ALL PLANS 182.7 70 999999999 158.04 253.17 percent of total billed charges Chemical analysis using chromatography technique 50698767_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.04 60.55 999999999 158.04 253.17 percent of total billed charges Chemical analysis using chromatography technique 50698767_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.04 253.17 Chemical analysis using chromatography technique 50698767_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 ANTHEM HMO ANTHEM HMO 999999999 158.04 253.17 Chemical analysis using chromatography technique 50698767_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.04 253.17 Chemical analysis using chromatography technique 50698767_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.04 253.17 Chemical analysis using chromatography technique 50698767_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.04 253.17 Chemical analysis using chromatography technique 50698767_1 CDM 0301 RC 82542 HCPCS inpatient 261 169.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 176.44 67.6 999999999 158.04 253.17 percent of total billed charges LIDOCAINE 5% OINTMENT 50698861_1 CDM 0250 RC 68462-0418-20 NDC inpatient 1 UN 94.95 61.72 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.72 65 999999999 57.49 92.1 percent of total billed charges LIDOCAINE 5% OINTMENT 50698861_1 CDM 0250 RC 68462-0418-20 NDC inpatient 1 UN 94.95 61.72 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 92.1 97 999999999 57.49 92.1 percent of total billed charges LIDOCAINE 5% OINTMENT 50698861_1 CDM 0250 RC 68462-0418-20 NDC inpatient 1 UN 94.95 61.72 AETNA AETNA 75.01 79 999999999 57.49 92.1 percent of total billed charges LIDOCAINE 5% OINTMENT 50698861_1 CDM 0250 RC 68462-0418-20 NDC inpatient 1 UN 94.95 61.72 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.06 78 999999999 57.49 92.1 percent of total billed charges LIDOCAINE 5% OINTMENT 50698861_1 CDM 0250 RC 68462-0418-20 NDC inpatient 1 UN 94.95 61.72 ENCORE - ALL PLANS ENCORE - ALL PLANS 65.52 69 999999999 57.49 92.1 percent of total billed charges LIDOCAINE 5% OINTMENT 50698861_1 CDM 0250 RC 68462-0418-20 NDC inpatient 1 UN 94.95 61.72 SIHO - ALL PLANS SIHO - ALL PLANS 85.46 90 999999999 57.49 92.1 percent of total billed charges LIDOCAINE 5% OINTMENT 50698861_1 CDM 0250 RC 68462-0418-20 NDC inpatient 1 UN 94.95 61.72 UMR - ALL PLANS UMR - ALL PLANS 66.47 70 999999999 57.49 92.1 percent of total billed charges LIDOCAINE 5% OINTMENT 50698861_1 CDM 0250 RC 68462-0418-20 NDC inpatient 1 UN 94.95 61.72 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 57.49 60.55 999999999 57.49 92.1 percent of total billed charges LIDOCAINE 5% OINTMENT 50698861_1 CDM 0250 RC 68462-0418-20 NDC inpatient 1 UN 94.95 61.72 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 57.49 92.1 LIDOCAINE 5% OINTMENT 50698861_1 CDM 0250 RC 68462-0418-20 NDC inpatient 1 UN 94.95 61.72 ANTHEM HMO ANTHEM HMO 999999999 57.49 92.1 LIDOCAINE 5% OINTMENT 50698861_1 CDM 0250 RC 68462-0418-20 NDC inpatient 1 UN 94.95 61.72 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 57.49 92.1 LIDOCAINE 5% OINTMENT 50698861_1 CDM 0250 RC 68462-0418-20 NDC inpatient 1 UN 94.95 61.72 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 57.49 92.1 LIDOCAINE 5% OINTMENT 50698861_1 CDM 0250 RC 68462-0418-20 NDC inpatient 1 UN 94.95 61.72 UHC - ALL PLANS UHC - ALL PLANS 999999999 57.49 92.1 LIDOCAINE 5% OINTMENT 50698861_1 CDM 0250 RC 68462-0418-20 NDC inpatient 1 UN 94.95 61.72 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.19 67.6 999999999 57.49 92.1 percent of total billed charges CAPTOPRIL 12.5 MG TABLET 50698880_1 CDM 0250 RC 60687-0304-21 NDC inpatient 1 UN 5.57 3.62 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.62 65 999999999 3.37 5.4 percent of total billed charges CAPTOPRIL 12.5 MG TABLET 50698880_1 CDM 0250 RC 60687-0304-21 NDC inpatient 1 UN 5.57 3.62 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5.4 97 999999999 3.37 5.4 percent of total billed charges CAPTOPRIL 12.5 MG TABLET 50698880_1 CDM 0250 RC 60687-0304-21 NDC inpatient 1 UN 5.57 3.62 AETNA AETNA 4.4 79 999999999 3.37 5.4 percent of total billed charges CAPTOPRIL 12.5 MG TABLET 50698880_1 CDM 0250 RC 60687-0304-21 NDC inpatient 1 UN 5.57 3.62 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.34 78 999999999 3.37 5.4 percent of total billed charges CAPTOPRIL 12.5 MG TABLET 50698880_1 CDM 0250 RC 60687-0304-21 NDC inpatient 1 UN 5.57 3.62 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.84 69 999999999 3.37 5.4 percent of total billed charges CAPTOPRIL 12.5 MG TABLET 50698880_1 CDM 0250 RC 60687-0304-21 NDC inpatient 1 UN 5.57 3.62 SIHO - ALL PLANS SIHO - ALL PLANS 5.01 90 999999999 3.37 5.4 percent of total billed charges CAPTOPRIL 12.5 MG TABLET 50698880_1 CDM 0250 RC 60687-0304-21 NDC inpatient 1 UN 5.57 3.62 UMR - ALL PLANS UMR - ALL PLANS 3.9 70 999999999 3.37 5.4 percent of total billed charges CAPTOPRIL 12.5 MG TABLET 50698880_1 CDM 0250 RC 60687-0304-21 NDC inpatient 1 UN 5.57 3.62 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.37 60.55 999999999 3.37 5.4 percent of total billed charges CAPTOPRIL 12.5 MG TABLET 50698880_1 CDM 0250 RC 60687-0304-21 NDC inpatient 1 UN 5.57 3.62 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.37 5.4 CAPTOPRIL 12.5 MG TABLET 50698880_1 CDM 0250 RC 60687-0304-21 NDC inpatient 1 UN 5.57 3.62 ANTHEM HMO ANTHEM HMO 999999999 3.37 5.4 CAPTOPRIL 12.5 MG TABLET 50698880_1 CDM 0250 RC 60687-0304-21 NDC inpatient 1 UN 5.57 3.62 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.37 5.4 CAPTOPRIL 12.5 MG TABLET 50698880_1 CDM 0250 RC 60687-0304-21 NDC inpatient 1 UN 5.57 3.62 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.37 5.4 CAPTOPRIL 12.5 MG TABLET 50698880_1 CDM 0250 RC 60687-0304-21 NDC inpatient 1 UN 5.57 3.62 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.37 5.4 CAPTOPRIL 12.5 MG TABLET 50698880_1 CDM 0250 RC 60687-0304-21 NDC inpatient 1 UN 5.57 3.62 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.77 67.6 999999999 3.37 5.4 percent of total billed charges "VINCRISTINE SULFATE, 1 MG" 50698927_1 CDM 0636 RC 61703-0309-26 NDC J9370 HCPCS inpatient 1 UN 48.99 31.84 SELF PAY DISCOUNT SELF PAY DISCOUNT 31.84 65 999999999 29.66 47.52 percent of total billed charges "VINCRISTINE SULFATE, 1 MG" 50698927_1 CDM 0636 RC 61703-0309-26 NDC J9370 HCPCS inpatient 1 UN 48.99 31.84 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 47.52 97 999999999 29.66 47.52 percent of total billed charges "VINCRISTINE SULFATE, 1 MG" 50698927_1 CDM 0636 RC 61703-0309-26 NDC J9370 HCPCS inpatient 1 UN 48.99 31.84 AETNA AETNA 38.7 79 999999999 29.66 47.52 percent of total billed charges "VINCRISTINE SULFATE, 1 MG" 50698927_1 CDM 0636 RC 61703-0309-26 NDC J9370 HCPCS inpatient 1 UN 48.99 31.84 HUMANA - ALL PLANS HUMANA - ALL PLANS 38.21 78 999999999 29.66 47.52 percent of total billed charges "VINCRISTINE SULFATE, 1 MG" 50698927_1 CDM 0636 RC 61703-0309-26 NDC J9370 HCPCS inpatient 1 UN 48.99 31.84 ENCORE - ALL PLANS ENCORE - ALL PLANS 33.8 69 999999999 29.66 47.52 percent of total billed charges "VINCRISTINE SULFATE, 1 MG" 50698927_1 CDM 0636 RC 61703-0309-26 NDC J9370 HCPCS inpatient 1 UN 48.99 31.84 SIHO - ALL PLANS SIHO - ALL PLANS 44.09 90 999999999 29.66 47.52 percent of total billed charges "VINCRISTINE SULFATE, 1 MG" 50698927_1 CDM 0636 RC 61703-0309-26 NDC J9370 HCPCS inpatient 1 UN 48.99 31.84 UMR - ALL PLANS UMR - ALL PLANS 34.29 70 999999999 29.66 47.52 percent of total billed charges "VINCRISTINE SULFATE, 1 MG" 50698927_1 CDM 0636 RC 61703-0309-26 NDC J9370 HCPCS inpatient 1 UN 48.99 31.84 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29.66 60.55 999999999 29.66 47.52 percent of total billed charges "VINCRISTINE SULFATE, 1 MG" 50698927_1 CDM 0636 RC 61703-0309-26 NDC J9370 HCPCS inpatient 1 UN 48.99 31.84 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 29.66 47.52 "VINCRISTINE SULFATE, 1 MG" 50698927_1 CDM 0636 RC 61703-0309-26 NDC J9370 HCPCS inpatient 1 UN 48.99 31.84 ANTHEM HMO ANTHEM HMO 999999999 29.66 47.52 "VINCRISTINE SULFATE, 1 MG" 50698927_1 CDM 0636 RC 61703-0309-26 NDC J9370 HCPCS inpatient 1 UN 48.99 31.84 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 29.66 47.52 "VINCRISTINE SULFATE, 1 MG" 50698927_1 CDM 0636 RC 61703-0309-26 NDC J9370 HCPCS inpatient 1 UN 48.99 31.84 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 29.66 47.52 "VINCRISTINE SULFATE, 1 MG" 50698927_1 CDM 0636 RC 61703-0309-26 NDC J9370 HCPCS inpatient 1 UN 48.99 31.84 UHC - ALL PLANS UHC - ALL PLANS 999999999 29.66 47.52 "VINCRISTINE SULFATE, 1 MG" 50698927_1 CDM 0636 RC 61703-0309-26 NDC J9370 HCPCS inpatient 1 UN 48.99 31.84 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.12 67.6 999999999 29.66 47.52 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699189_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699189_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699189_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699189_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699189_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699189_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699189_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699189_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699189_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699189_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699189_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699189_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699189_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699189_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699190_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699190_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699190_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699190_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699190_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699190_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699190_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699190_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699190_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699190_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699190_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699190_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699190_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699190_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699191_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699191_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699191_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699191_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699191_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699191_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699191_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699191_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699191_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699191_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699191_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699191_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699191_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699191_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699192_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1194.05 65 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699192_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1781.89 97 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699192_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 AETNA AETNA 1451.23 79 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699192_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1432.86 78 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699192_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1267.53 69 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699192_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 SIHO - ALL PLANS SIHO - ALL PLANS 1653.3 90 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699192_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UMR - ALL PLANS UMR - ALL PLANS 1285.9 70 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699192_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1112.3 60.55 999999999 1112.3 1781.89 percent of total billed charges PLATE PATH RED/RAPID BAC TES 50699192_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699192_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM HMO ANTHEM HMO 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699192_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699192_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699192_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1112.3 1781.89 PLATE PATH RED/RAPID BAC TES 50699192_1 CDM 0390 RC P9072 HCPCS inpatient 1837 1194.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1241.81 67.6 999999999 1112.3 1781.89 percent of total billed charges SODIUM BICARBONATE 8.4% VIAL 50704089_1 CDM 0250 RC 51754-5001-05 NDC inpatient 10 UN 38.96 25.32 SELF PAY DISCOUNT SELF PAY DISCOUNT 25.32 65 999999999 23.59 37.79 percent of total billed charges SODIUM BICARBONATE 8.4% VIAL 50704089_1 CDM 0250 RC 51754-5001-05 NDC inpatient 10 UN 38.96 25.32 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37.79 97 999999999 23.59 37.79 percent of total billed charges SODIUM BICARBONATE 8.4% VIAL 50704089_1 CDM 0250 RC 51754-5001-05 NDC inpatient 10 UN 38.96 25.32 AETNA AETNA 30.78 79 999999999 23.59 37.79 percent of total billed charges SODIUM BICARBONATE 8.4% VIAL 50704089_1 CDM 0250 RC 51754-5001-05 NDC inpatient 10 UN 38.96 25.32 HUMANA - ALL PLANS HUMANA - ALL PLANS 30.39 78 999999999 23.59 37.79 percent of total billed charges SODIUM BICARBONATE 8.4% VIAL 50704089_1 CDM 0250 RC 51754-5001-05 NDC inpatient 10 UN 38.96 25.32 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.88 69 999999999 23.59 37.79 percent of total billed charges SODIUM BICARBONATE 8.4% VIAL 50704089_1 CDM 0250 RC 51754-5001-05 NDC inpatient 10 UN 38.96 25.32 SIHO - ALL PLANS SIHO - ALL PLANS 35.06 90 999999999 23.59 37.79 percent of total billed charges SODIUM BICARBONATE 8.4% VIAL 50704089_1 CDM 0250 RC 51754-5001-05 NDC inpatient 10 UN 38.96 25.32 UMR - ALL PLANS UMR - ALL PLANS 27.27 70 999999999 23.59 37.79 percent of total billed charges SODIUM BICARBONATE 8.4% VIAL 50704089_1 CDM 0250 RC 51754-5001-05 NDC inpatient 10 UN 38.96 25.32 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.59 60.55 999999999 23.59 37.79 percent of total billed charges SODIUM BICARBONATE 8.4% VIAL 50704089_1 CDM 0250 RC 51754-5001-05 NDC inpatient 10 UN 38.96 25.32 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.59 37.79 SODIUM BICARBONATE 8.4% VIAL 50704089_1 CDM 0250 RC 51754-5001-05 NDC inpatient 10 UN 38.96 25.32 ANTHEM HMO ANTHEM HMO 999999999 23.59 37.79 SODIUM BICARBONATE 8.4% VIAL 50704089_1 CDM 0250 RC 51754-5001-05 NDC inpatient 10 UN 38.96 25.32 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.59 37.79 SODIUM BICARBONATE 8.4% VIAL 50704089_1 CDM 0250 RC 51754-5001-05 NDC inpatient 10 UN 38.96 25.32 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.59 37.79 SODIUM BICARBONATE 8.4% VIAL 50704089_1 CDM 0250 RC 51754-5001-05 NDC inpatient 10 UN 38.96 25.32 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.59 37.79 SODIUM BICARBONATE 8.4% VIAL 50704089_1 CDM 0250 RC 51754-5001-05 NDC inpatient 10 UN 38.96 25.32 CIGNA - ALL PLANS CIGNA - ALL PLANS 26.34 67.6 999999999 23.59 37.79 percent of total billed charges ADVAIR HFA 230-21 MCG INHALER 50704377_1 CDM 0250 RC 00173-0717-22 NDC inpatient 1 UN 684.03 444.62 SELF PAY DISCOUNT SELF PAY DISCOUNT 444.62 65 999999999 414.18 663.51 percent of total billed charges ADVAIR HFA 230-21 MCG INHALER 50704377_1 CDM 0250 RC 00173-0717-22 NDC inpatient 1 UN 684.03 444.62 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 663.51 97 999999999 414.18 663.51 percent of total billed charges ADVAIR HFA 230-21 MCG INHALER 50704377_1 CDM 0250 RC 00173-0717-22 NDC inpatient 1 UN 684.03 444.62 AETNA AETNA 540.38 79 999999999 414.18 663.51 percent of total billed charges ADVAIR HFA 230-21 MCG INHALER 50704377_1 CDM 0250 RC 00173-0717-22 NDC inpatient 1 UN 684.03 444.62 HUMANA - ALL PLANS HUMANA - ALL PLANS 533.54 78 999999999 414.18 663.51 percent of total billed charges ADVAIR HFA 230-21 MCG INHALER 50704377_1 CDM 0250 RC 00173-0717-22 NDC inpatient 1 UN 684.03 444.62 ENCORE - ALL PLANS ENCORE - ALL PLANS 471.98 69 999999999 414.18 663.51 percent of total billed charges ADVAIR HFA 230-21 MCG INHALER 50704377_1 CDM 0250 RC 00173-0717-22 NDC inpatient 1 UN 684.03 444.62 SIHO - ALL PLANS SIHO - ALL PLANS 615.63 90 999999999 414.18 663.51 percent of total billed charges ADVAIR HFA 230-21 MCG INHALER 50704377_1 CDM 0250 RC 00173-0717-22 NDC inpatient 1 UN 684.03 444.62 UMR - ALL PLANS UMR - ALL PLANS 478.82 70 999999999 414.18 663.51 percent of total billed charges ADVAIR HFA 230-21 MCG INHALER 50704377_1 CDM 0250 RC 00173-0717-22 NDC inpatient 1 UN 684.03 444.62 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 414.18 60.55 999999999 414.18 663.51 percent of total billed charges ADVAIR HFA 230-21 MCG INHALER 50704377_1 CDM 0250 RC 00173-0717-22 NDC inpatient 1 UN 684.03 444.62 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 414.18 663.51 ADVAIR HFA 230-21 MCG INHALER 50704377_1 CDM 0250 RC 00173-0717-22 NDC inpatient 1 UN 684.03 444.62 ANTHEM HMO ANTHEM HMO 999999999 414.18 663.51 ADVAIR HFA 230-21 MCG INHALER 50704377_1 CDM 0250 RC 00173-0717-22 NDC inpatient 1 UN 684.03 444.62 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 414.18 663.51 ADVAIR HFA 230-21 MCG INHALER 50704377_1 CDM 0250 RC 00173-0717-22 NDC inpatient 1 UN 684.03 444.62 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 414.18 663.51 ADVAIR HFA 230-21 MCG INHALER 50704377_1 CDM 0250 RC 00173-0717-22 NDC inpatient 1 UN 684.03 444.62 UHC - ALL PLANS UHC - ALL PLANS 999999999 414.18 663.51 ADVAIR HFA 230-21 MCG INHALER 50704377_1 CDM 0250 RC 00173-0717-22 NDC inpatient 1 UN 684.03 444.62 CIGNA - ALL PLANS CIGNA - ALL PLANS 462.4 67.6 999999999 414.18 663.51 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50707976_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50707976_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50707976_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50707976_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50707976_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50707976_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50707976_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50707976_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50707976_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50707976_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50707976_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50707976_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50707976_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Measurement of antibody for assessment of autoimmune disorder, any method" 50707976_1 CDM 0302 RC 86235 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges FENOFIBRATE 145 MG TABLET 50708081_1 CDM 0250 RC 00378-3066-77 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges FENOFIBRATE 145 MG TABLET 50708081_1 CDM 0250 RC 00378-3066-77 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges FENOFIBRATE 145 MG TABLET 50708081_1 CDM 0250 RC 00378-3066-77 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges FENOFIBRATE 145 MG TABLET 50708081_1 CDM 0250 RC 00378-3066-77 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges FENOFIBRATE 145 MG TABLET 50708081_1 CDM 0250 RC 00378-3066-77 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges FENOFIBRATE 145 MG TABLET 50708081_1 CDM 0250 RC 00378-3066-77 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges FENOFIBRATE 145 MG TABLET 50708081_1 CDM 0250 RC 00378-3066-77 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges FENOFIBRATE 145 MG TABLET 50708081_1 CDM 0250 RC 00378-3066-77 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges FENOFIBRATE 145 MG TABLET 50708081_1 CDM 0250 RC 00378-3066-77 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 FENOFIBRATE 145 MG TABLET 50708081_1 CDM 0250 RC 00378-3066-77 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 FENOFIBRATE 145 MG TABLET 50708081_1 CDM 0250 RC 00378-3066-77 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 FENOFIBRATE 145 MG TABLET 50708081_1 CDM 0250 RC 00378-3066-77 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 FENOFIBRATE 145 MG TABLET 50708081_1 CDM 0250 RC 00378-3066-77 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 FENOFIBRATE 145 MG TABLET 50708081_1 CDM 0250 RC 00378-3066-77 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "Blood test, basic group of blood chemicals (Calcium, total)" 50708298_1 CDM 0301 RC 80048 HCPCS inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges "Blood test, basic group of blood chemicals (Calcium, total)" 50708298_1 CDM 0301 RC 80048 HCPCS inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges "Blood test, basic group of blood chemicals (Calcium, total)" 50708298_1 CDM 0301 RC 80048 HCPCS inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges "Blood test, basic group of blood chemicals (Calcium, total)" 50708298_1 CDM 0301 RC 80048 HCPCS inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges "Blood test, basic group of blood chemicals (Calcium, total)" 50708298_1 CDM 0301 RC 80048 HCPCS inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges "Blood test, basic group of blood chemicals (Calcium, total)" 50708298_1 CDM 0301 RC 80048 HCPCS inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges "Blood test, basic group of blood chemicals (Calcium, total)" 50708298_1 CDM 0301 RC 80048 HCPCS inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges "Blood test, basic group of blood chemicals (Calcium, total)" 50708298_1 CDM 0301 RC 80048 HCPCS inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges "Blood test, basic group of blood chemicals (Calcium, total)" 50708298_1 CDM 0301 RC 80048 HCPCS inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 "Blood test, basic group of blood chemicals (Calcium, total)" 50708298_1 CDM 0301 RC 80048 HCPCS inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 "Blood test, basic group of blood chemicals (Calcium, total)" 50708298_1 CDM 0301 RC 80048 HCPCS inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 "Blood test, basic group of blood chemicals (Calcium, total)" 50708298_1 CDM 0301 RC 80048 HCPCS inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 "Blood test, basic group of blood chemicals (Calcium, total)" 50708298_1 CDM 0301 RC 80048 HCPCS inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 "Blood test, basic group of blood chemicals (Calcium, total)" 50708298_1 CDM 0301 RC 80048 HCPCS inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges "Blood test, comprehensive group of blood chemicals" 50708338_1 CDM 0301 RC 80053 HCPCS inpatient 194 126.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 126.1 65 999999999 117.47 188.18 percent of total billed charges "Blood test, comprehensive group of blood chemicals" 50708338_1 CDM 0301 RC 80053 HCPCS inpatient 194 126.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 188.18 97 999999999 117.47 188.18 percent of total billed charges "Blood test, comprehensive group of blood chemicals" 50708338_1 CDM 0301 RC 80053 HCPCS inpatient 194 126.1 AETNA AETNA 153.26 79 999999999 117.47 188.18 percent of total billed charges "Blood test, comprehensive group of blood chemicals" 50708338_1 CDM 0301 RC 80053 HCPCS inpatient 194 126.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 151.32 78 999999999 117.47 188.18 percent of total billed charges "Blood test, comprehensive group of blood chemicals" 50708338_1 CDM 0301 RC 80053 HCPCS inpatient 194 126.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.86 69 999999999 117.47 188.18 percent of total billed charges "Blood test, comprehensive group of blood chemicals" 50708338_1 CDM 0301 RC 80053 HCPCS inpatient 194 126.1 SIHO - ALL PLANS SIHO - ALL PLANS 174.6 90 999999999 117.47 188.18 percent of total billed charges "Blood test, comprehensive group of blood chemicals" 50708338_1 CDM 0301 RC 80053 HCPCS inpatient 194 126.1 UMR - ALL PLANS UMR - ALL PLANS 135.8 70 999999999 117.47 188.18 percent of total billed charges "Blood test, comprehensive group of blood chemicals" 50708338_1 CDM 0301 RC 80053 HCPCS inpatient 194 126.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 117.47 60.55 999999999 117.47 188.18 percent of total billed charges "Blood test, comprehensive group of blood chemicals" 50708338_1 CDM 0301 RC 80053 HCPCS inpatient 194 126.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 117.47 188.18 "Blood test, comprehensive group of blood chemicals" 50708338_1 CDM 0301 RC 80053 HCPCS inpatient 194 126.1 ANTHEM HMO ANTHEM HMO 999999999 117.47 188.18 "Blood test, comprehensive group of blood chemicals" 50708338_1 CDM 0301 RC 80053 HCPCS inpatient 194 126.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 117.47 188.18 "Blood test, comprehensive group of blood chemicals" 50708338_1 CDM 0301 RC 80053 HCPCS inpatient 194 126.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 117.47 188.18 "Blood test, comprehensive group of blood chemicals" 50708338_1 CDM 0301 RC 80053 HCPCS inpatient 194 126.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 117.47 188.18 "Blood test, comprehensive group of blood chemicals" 50708338_1 CDM 0301 RC 80053 HCPCS inpatient 194 126.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 131.14 67.6 999999999 117.47 188.18 percent of total billed charges Quantitation of therapeutic drug 50708408_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 50708408_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 50708408_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 50708408_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 50708408_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 50708408_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 50708408_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 50708408_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 50708408_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 Quantitation of therapeutic drug 50708408_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 Quantitation of therapeutic drug 50708408_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 Quantitation of therapeutic drug 50708408_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 Quantitation of therapeutic drug 50708408_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 Quantitation of therapeutic drug 50708408_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50708479_1 CDM 0306 RC 87181 HCPCS inpatient 23 14.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.95 65 999999999 13.93 22.31 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50708479_1 CDM 0306 RC 87181 HCPCS inpatient 23 14.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22.31 97 999999999 13.93 22.31 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50708479_1 CDM 0306 RC 87181 HCPCS inpatient 23 14.95 AETNA AETNA 18.17 79 999999999 13.93 22.31 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50708479_1 CDM 0306 RC 87181 HCPCS inpatient 23 14.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.94 78 999999999 13.93 22.31 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50708479_1 CDM 0306 RC 87181 HCPCS inpatient 23 14.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.87 69 999999999 13.93 22.31 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50708479_1 CDM 0306 RC 87181 HCPCS inpatient 23 14.95 SIHO - ALL PLANS SIHO - ALL PLANS 20.7 90 999999999 13.93 22.31 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50708479_1 CDM 0306 RC 87181 HCPCS inpatient 23 14.95 UMR - ALL PLANS UMR - ALL PLANS 16.1 70 999999999 13.93 22.31 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50708479_1 CDM 0306 RC 87181 HCPCS inpatient 23 14.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.93 60.55 999999999 13.93 22.31 percent of total billed charges "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50708479_1 CDM 0306 RC 87181 HCPCS inpatient 23 14.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.93 22.31 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50708479_1 CDM 0306 RC 87181 HCPCS inpatient 23 14.95 ANTHEM HMO ANTHEM HMO 999999999 13.93 22.31 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50708479_1 CDM 0306 RC 87181 HCPCS inpatient 23 14.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.93 22.31 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50708479_1 CDM 0306 RC 87181 HCPCS inpatient 23 14.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.93 22.31 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50708479_1 CDM 0306 RC 87181 HCPCS inpatient 23 14.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.93 22.31 "Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), agar dilution method" 50708479_1 CDM 0306 RC 87181 HCPCS inpatient 23 14.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 15.55 67.6 999999999 13.93 22.31 percent of total billed charges HYDROCHLOROTHIAZIDE 12.5 MG CP 50708674_1 CDM 0250 RC 50228-0146-01 NDC inpatient 1 UN 1.91 1.24 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.24 65 999999999 1.16 1.85 percent of total billed charges HYDROCHLOROTHIAZIDE 12.5 MG CP 50708674_1 CDM 0250 RC 50228-0146-01 NDC inpatient 1 UN 1.91 1.24 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.85 97 999999999 1.16 1.85 percent of total billed charges HYDROCHLOROTHIAZIDE 12.5 MG CP 50708674_1 CDM 0250 RC 50228-0146-01 NDC inpatient 1 UN 1.91 1.24 AETNA AETNA 1.51 79 999999999 1.16 1.85 percent of total billed charges HYDROCHLOROTHIAZIDE 12.5 MG CP 50708674_1 CDM 0250 RC 50228-0146-01 NDC inpatient 1 UN 1.91 1.24 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.49 78 999999999 1.16 1.85 percent of total billed charges HYDROCHLOROTHIAZIDE 12.5 MG CP 50708674_1 CDM 0250 RC 50228-0146-01 NDC inpatient 1 UN 1.91 1.24 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.32 69 999999999 1.16 1.85 percent of total billed charges HYDROCHLOROTHIAZIDE 12.5 MG CP 50708674_1 CDM 0250 RC 50228-0146-01 NDC inpatient 1 UN 1.91 1.24 SIHO - ALL PLANS SIHO - ALL PLANS 1.72 90 999999999 1.16 1.85 percent of total billed charges HYDROCHLOROTHIAZIDE 12.5 MG CP 50708674_1 CDM 0250 RC 50228-0146-01 NDC inpatient 1 UN 1.91 1.24 UMR - ALL PLANS UMR - ALL PLANS 1.34 70 999999999 1.16 1.85 percent of total billed charges HYDROCHLOROTHIAZIDE 12.5 MG CP 50708674_1 CDM 0250 RC 50228-0146-01 NDC inpatient 1 UN 1.91 1.24 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.16 60.55 999999999 1.16 1.85 percent of total billed charges HYDROCHLOROTHIAZIDE 12.5 MG CP 50708674_1 CDM 0250 RC 50228-0146-01 NDC inpatient 1 UN 1.91 1.24 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.16 1.85 HYDROCHLOROTHIAZIDE 12.5 MG CP 50708674_1 CDM 0250 RC 50228-0146-01 NDC inpatient 1 UN 1.91 1.24 ANTHEM HMO ANTHEM HMO 999999999 1.16 1.85 HYDROCHLOROTHIAZIDE 12.5 MG CP 50708674_1 CDM 0250 RC 50228-0146-01 NDC inpatient 1 UN 1.91 1.24 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.16 1.85 HYDROCHLOROTHIAZIDE 12.5 MG CP 50708674_1 CDM 0250 RC 50228-0146-01 NDC inpatient 1 UN 1.91 1.24 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.16 1.85 HYDROCHLOROTHIAZIDE 12.5 MG CP 50708674_1 CDM 0250 RC 50228-0146-01 NDC inpatient 1 UN 1.91 1.24 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.16 1.85 HYDROCHLOROTHIAZIDE 12.5 MG CP 50708674_1 CDM 0250 RC 50228-0146-01 NDC inpatient 1 UN 1.91 1.24 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.29 67.6 999999999 1.16 1.85 percent of total billed charges ENOXAPARIN 30 MG/0.3 ML SYR 50708771_1 CDM 0250 RC 71288-0410-81 NDC inpatient 1 UN 30.12 19.58 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.58 65 999999999 18.24 29.22 percent of total billed charges ENOXAPARIN 30 MG/0.3 ML SYR 50708771_1 CDM 0250 RC 71288-0410-81 NDC inpatient 1 UN 30.12 19.58 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.22 97 999999999 18.24 29.22 percent of total billed charges ENOXAPARIN 30 MG/0.3 ML SYR 50708771_1 CDM 0250 RC 71288-0410-81 NDC inpatient 1 UN 30.12 19.58 AETNA AETNA 23.79 79 999999999 18.24 29.22 percent of total billed charges ENOXAPARIN 30 MG/0.3 ML SYR 50708771_1 CDM 0250 RC 71288-0410-81 NDC inpatient 1 UN 30.12 19.58 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.49 78 999999999 18.24 29.22 percent of total billed charges ENOXAPARIN 30 MG/0.3 ML SYR 50708771_1 CDM 0250 RC 71288-0410-81 NDC inpatient 1 UN 30.12 19.58 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.78 69 999999999 18.24 29.22 percent of total billed charges ENOXAPARIN 30 MG/0.3 ML SYR 50708771_1 CDM 0250 RC 71288-0410-81 NDC inpatient 1 UN 30.12 19.58 SIHO - ALL PLANS SIHO - ALL PLANS 27.11 90 999999999 18.24 29.22 percent of total billed charges ENOXAPARIN 30 MG/0.3 ML SYR 50708771_1 CDM 0250 RC 71288-0410-81 NDC inpatient 1 UN 30.12 19.58 UMR - ALL PLANS UMR - ALL PLANS 21.08 70 999999999 18.24 29.22 percent of total billed charges ENOXAPARIN 30 MG/0.3 ML SYR 50708771_1 CDM 0250 RC 71288-0410-81 NDC inpatient 1 UN 30.12 19.58 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.24 60.55 999999999 18.24 29.22 percent of total billed charges ENOXAPARIN 30 MG/0.3 ML SYR 50708771_1 CDM 0250 RC 71288-0410-81 NDC inpatient 1 UN 30.12 19.58 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.24 29.22 ENOXAPARIN 30 MG/0.3 ML SYR 50708771_1 CDM 0250 RC 71288-0410-81 NDC inpatient 1 UN 30.12 19.58 ANTHEM HMO ANTHEM HMO 999999999 18.24 29.22 ENOXAPARIN 30 MG/0.3 ML SYR 50708771_1 CDM 0250 RC 71288-0410-81 NDC inpatient 1 UN 30.12 19.58 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.24 29.22 ENOXAPARIN 30 MG/0.3 ML SYR 50708771_1 CDM 0250 RC 71288-0410-81 NDC inpatient 1 UN 30.12 19.58 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.24 29.22 ENOXAPARIN 30 MG/0.3 ML SYR 50708771_1 CDM 0250 RC 71288-0410-81 NDC inpatient 1 UN 30.12 19.58 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.24 29.22 ENOXAPARIN 30 MG/0.3 ML SYR 50708771_1 CDM 0250 RC 71288-0410-81 NDC inpatient 1 UN 30.12 19.58 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.36 67.6 999999999 18.24 29.22 percent of total billed charges Analysis for antibody (IgM) to Cytomegalovirus (CMV) 50708772_1 CDM 0302 RC 86645 HCPCS inpatient 157 102.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.05 65 999999999 95.06 152.29 percent of total billed charges Analysis for antibody (IgM) to Cytomegalovirus (CMV) 50708772_1 CDM 0302 RC 86645 HCPCS inpatient 157 102.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 152.29 97 999999999 95.06 152.29 percent of total billed charges Analysis for antibody (IgM) to Cytomegalovirus (CMV) 50708772_1 CDM 0302 RC 86645 HCPCS inpatient 157 102.05 AETNA AETNA 124.03 79 999999999 95.06 152.29 percent of total billed charges Analysis for antibody (IgM) to Cytomegalovirus (CMV) 50708772_1 CDM 0302 RC 86645 HCPCS inpatient 157 102.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 122.46 78 999999999 95.06 152.29 percent of total billed charges Analysis for antibody (IgM) to Cytomegalovirus (CMV) 50708772_1 CDM 0302 RC 86645 HCPCS inpatient 157 102.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 108.33 69 999999999 95.06 152.29 percent of total billed charges Analysis for antibody (IgM) to Cytomegalovirus (CMV) 50708772_1 CDM 0302 RC 86645 HCPCS inpatient 157 102.05 SIHO - ALL PLANS SIHO - ALL PLANS 141.3 90 999999999 95.06 152.29 percent of total billed charges Analysis for antibody (IgM) to Cytomegalovirus (CMV) 50708772_1 CDM 0302 RC 86645 HCPCS inpatient 157 102.05 UMR - ALL PLANS UMR - ALL PLANS 109.9 70 999999999 95.06 152.29 percent of total billed charges Analysis for antibody (IgM) to Cytomegalovirus (CMV) 50708772_1 CDM 0302 RC 86645 HCPCS inpatient 157 102.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.06 60.55 999999999 95.06 152.29 percent of total billed charges Analysis for antibody (IgM) to Cytomegalovirus (CMV) 50708772_1 CDM 0302 RC 86645 HCPCS inpatient 157 102.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.06 152.29 Analysis for antibody (IgM) to Cytomegalovirus (CMV) 50708772_1 CDM 0302 RC 86645 HCPCS inpatient 157 102.05 ANTHEM HMO ANTHEM HMO 999999999 95.06 152.29 Analysis for antibody (IgM) to Cytomegalovirus (CMV) 50708772_1 CDM 0302 RC 86645 HCPCS inpatient 157 102.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.06 152.29 Analysis for antibody (IgM) to Cytomegalovirus (CMV) 50708772_1 CDM 0302 RC 86645 HCPCS inpatient 157 102.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.06 152.29 Analysis for antibody (IgM) to Cytomegalovirus (CMV) 50708772_1 CDM 0302 RC 86645 HCPCS inpatient 157 102.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.06 152.29 Analysis for antibody (IgM) to Cytomegalovirus (CMV) 50708772_1 CDM 0302 RC 86645 HCPCS inpatient 157 102.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.13 67.6 999999999 95.06 152.29 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG" 50708916_1 CDM 0636 RC 68982-0850-03 NDC J1599 HCPCS inpatient 20 UN 1675 1088.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1088.75 65 999999999 1014.21 1624.75 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG" 50708916_1 CDM 0636 RC 68982-0850-03 NDC J1599 HCPCS inpatient 20 UN 1675 1088.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1624.75 97 999999999 1014.21 1624.75 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG" 50708916_1 CDM 0636 RC 68982-0850-03 NDC J1599 HCPCS inpatient 20 UN 1675 1088.75 AETNA AETNA 1323.25 79 999999999 1014.21 1624.75 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG" 50708916_1 CDM 0636 RC 68982-0850-03 NDC J1599 HCPCS inpatient 20 UN 1675 1088.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1306.5 78 999999999 1014.21 1624.75 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG" 50708916_1 CDM 0636 RC 68982-0850-03 NDC J1599 HCPCS inpatient 20 UN 1675 1088.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1155.75 69 999999999 1014.21 1624.75 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG" 50708916_1 CDM 0636 RC 68982-0850-03 NDC J1599 HCPCS inpatient 20 UN 1675 1088.75 SIHO - ALL PLANS SIHO - ALL PLANS 1507.5 90 999999999 1014.21 1624.75 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG" 50708916_1 CDM 0636 RC 68982-0850-03 NDC J1599 HCPCS inpatient 20 UN 1675 1088.75 UMR - ALL PLANS UMR - ALL PLANS 1172.5 70 999999999 1014.21 1624.75 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG" 50708916_1 CDM 0636 RC 68982-0850-03 NDC J1599 HCPCS inpatient 20 UN 1675 1088.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1014.21 60.55 999999999 1014.21 1624.75 percent of total billed charges "INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG" 50708916_1 CDM 0636 RC 68982-0850-03 NDC J1599 HCPCS inpatient 20 UN 1675 1088.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1014.21 1624.75 "INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG" 50708916_1 CDM 0636 RC 68982-0850-03 NDC J1599 HCPCS inpatient 20 UN 1675 1088.75 ANTHEM HMO ANTHEM HMO 999999999 1014.21 1624.75 "INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG" 50708916_1 CDM 0636 RC 68982-0850-03 NDC J1599 HCPCS inpatient 20 UN 1675 1088.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1014.21 1624.75 "INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG" 50708916_1 CDM 0636 RC 68982-0850-03 NDC J1599 HCPCS inpatient 20 UN 1675 1088.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1014.21 1624.75 "INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG" 50708916_1 CDM 0636 RC 68982-0850-03 NDC J1599 HCPCS inpatient 20 UN 1675 1088.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1014.21 1624.75 "INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G., LIQUID), NOT OTHERWISE SPECIFIED, 500 MG" 50708916_1 CDM 0636 RC 68982-0850-03 NDC J1599 HCPCS inpatient 20 UN 1675 1088.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1132.3 67.6 999999999 1014.21 1624.75 percent of total billed charges ALPRAZOLAM 1 MG TABLET 50709058_1 CDM 0250 RC 00228-2031-10 NDC inpatient 1 UN 1.87 1.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.22 65 999999999 1.13 1.81 percent of total billed charges ALPRAZOLAM 1 MG TABLET 50709058_1 CDM 0250 RC 00228-2031-10 NDC inpatient 1 UN 1.87 1.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.81 97 999999999 1.13 1.81 percent of total billed charges ALPRAZOLAM 1 MG TABLET 50709058_1 CDM 0250 RC 00228-2031-10 NDC inpatient 1 UN 1.87 1.22 AETNA AETNA 1.48 79 999999999 1.13 1.81 percent of total billed charges ALPRAZOLAM 1 MG TABLET 50709058_1 CDM 0250 RC 00228-2031-10 NDC inpatient 1 UN 1.87 1.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.46 78 999999999 1.13 1.81 percent of total billed charges ALPRAZOLAM 1 MG TABLET 50709058_1 CDM 0250 RC 00228-2031-10 NDC inpatient 1 UN 1.87 1.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.29 69 999999999 1.13 1.81 percent of total billed charges ALPRAZOLAM 1 MG TABLET 50709058_1 CDM 0250 RC 00228-2031-10 NDC inpatient 1 UN 1.87 1.22 SIHO - ALL PLANS SIHO - ALL PLANS 1.68 90 999999999 1.13 1.81 percent of total billed charges ALPRAZOLAM 1 MG TABLET 50709058_1 CDM 0250 RC 00228-2031-10 NDC inpatient 1 UN 1.87 1.22 UMR - ALL PLANS UMR - ALL PLANS 1.31 70 999999999 1.13 1.81 percent of total billed charges ALPRAZOLAM 1 MG TABLET 50709058_1 CDM 0250 RC 00228-2031-10 NDC inpatient 1 UN 1.87 1.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.13 60.55 999999999 1.13 1.81 percent of total billed charges ALPRAZOLAM 1 MG TABLET 50709058_1 CDM 0250 RC 00228-2031-10 NDC inpatient 1 UN 1.87 1.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.13 1.81 ALPRAZOLAM 1 MG TABLET 50709058_1 CDM 0250 RC 00228-2031-10 NDC inpatient 1 UN 1.87 1.22 ANTHEM HMO ANTHEM HMO 999999999 1.13 1.81 ALPRAZOLAM 1 MG TABLET 50709058_1 CDM 0250 RC 00228-2031-10 NDC inpatient 1 UN 1.87 1.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.13 1.81 ALPRAZOLAM 1 MG TABLET 50709058_1 CDM 0250 RC 00228-2031-10 NDC inpatient 1 UN 1.87 1.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.13 1.81 ALPRAZOLAM 1 MG TABLET 50709058_1 CDM 0250 RC 00228-2031-10 NDC inpatient 1 UN 1.87 1.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.13 1.81 ALPRAZOLAM 1 MG TABLET 50709058_1 CDM 0250 RC 00228-2031-10 NDC inpatient 1 UN 1.87 1.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.26 67.6 999999999 1.13 1.81 percent of total billed charges Injection of anesthetic agent into middle or lower spine sympathetic nerve 50709142_1 CDM 0360 RC 64520 HCPCS inpatient 2821 1833.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1833.65 65 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into middle or lower spine sympathetic nerve 50709142_1 CDM 0360 RC 64520 HCPCS inpatient 2821 1833.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2736.37 97 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into middle or lower spine sympathetic nerve 50709142_1 CDM 0360 RC 64520 HCPCS inpatient 2821 1833.65 AETNA AETNA 2228.59 79 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into middle or lower spine sympathetic nerve 50709142_1 CDM 0360 RC 64520 HCPCS inpatient 2821 1833.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2200.38 78 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into middle or lower spine sympathetic nerve 50709142_1 CDM 0360 RC 64520 HCPCS inpatient 2821 1833.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1946.49 69 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into middle or lower spine sympathetic nerve 50709142_1 CDM 0360 RC 64520 HCPCS inpatient 2821 1833.65 SIHO - ALL PLANS SIHO - ALL PLANS 2538.9 90 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into middle or lower spine sympathetic nerve 50709142_1 CDM 0360 RC 64520 HCPCS inpatient 2821 1833.65 UMR - ALL PLANS UMR - ALL PLANS 1974.7 70 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into middle or lower spine sympathetic nerve 50709142_1 CDM 0360 RC 64520 HCPCS inpatient 2821 1833.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1708.12 60.55 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into middle or lower spine sympathetic nerve 50709142_1 CDM 0360 RC 64520 HCPCS inpatient 2821 1833.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1708.12 2736.37 Injection of anesthetic agent into middle or lower spine sympathetic nerve 50709142_1 CDM 0360 RC 64520 HCPCS inpatient 2821 1833.65 ANTHEM HMO ANTHEM HMO 999999999 1708.12 2736.37 Injection of anesthetic agent into middle or lower spine sympathetic nerve 50709142_1 CDM 0360 RC 64520 HCPCS inpatient 2821 1833.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1708.12 2736.37 Injection of anesthetic agent into middle or lower spine sympathetic nerve 50709142_1 CDM 0360 RC 64520 HCPCS inpatient 2821 1833.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1708.12 2736.37 Injection of anesthetic agent into middle or lower spine sympathetic nerve 50709142_1 CDM 0360 RC 64520 HCPCS inpatient 2821 1833.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1708.12 2736.37 Injection of anesthetic agent into middle or lower spine sympathetic nerve 50709142_1 CDM 0360 RC 64520 HCPCS inpatient 2821 1833.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1907 67.6 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into abdominal sympathetic nerve bundle 50709144_1 CDM 0360 RC 64530 HCPCS inpatient 2821 1833.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1833.65 65 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into abdominal sympathetic nerve bundle 50709144_1 CDM 0360 RC 64530 HCPCS inpatient 2821 1833.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2736.37 97 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into abdominal sympathetic nerve bundle 50709144_1 CDM 0360 RC 64530 HCPCS inpatient 2821 1833.65 AETNA AETNA 2228.59 79 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into abdominal sympathetic nerve bundle 50709144_1 CDM 0360 RC 64530 HCPCS inpatient 2821 1833.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2200.38 78 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into abdominal sympathetic nerve bundle 50709144_1 CDM 0360 RC 64530 HCPCS inpatient 2821 1833.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1946.49 69 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into abdominal sympathetic nerve bundle 50709144_1 CDM 0360 RC 64530 HCPCS inpatient 2821 1833.65 SIHO - ALL PLANS SIHO - ALL PLANS 2538.9 90 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into abdominal sympathetic nerve bundle 50709144_1 CDM 0360 RC 64530 HCPCS inpatient 2821 1833.65 UMR - ALL PLANS UMR - ALL PLANS 1974.7 70 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into abdominal sympathetic nerve bundle 50709144_1 CDM 0360 RC 64530 HCPCS inpatient 2821 1833.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1708.12 60.55 999999999 1708.12 2736.37 percent of total billed charges Injection of anesthetic agent into abdominal sympathetic nerve bundle 50709144_1 CDM 0360 RC 64530 HCPCS inpatient 2821 1833.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1708.12 2736.37 Injection of anesthetic agent into abdominal sympathetic nerve bundle 50709144_1 CDM 0360 RC 64530 HCPCS inpatient 2821 1833.65 ANTHEM HMO ANTHEM HMO 999999999 1708.12 2736.37 Injection of anesthetic agent into abdominal sympathetic nerve bundle 50709144_1 CDM 0360 RC 64530 HCPCS inpatient 2821 1833.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1708.12 2736.37 Injection of anesthetic agent into abdominal sympathetic nerve bundle 50709144_1 CDM 0360 RC 64530 HCPCS inpatient 2821 1833.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1708.12 2736.37 Injection of anesthetic agent into abdominal sympathetic nerve bundle 50709144_1 CDM 0360 RC 64530 HCPCS inpatient 2821 1833.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1708.12 2736.37 Injection of anesthetic agent into abdominal sympathetic nerve bundle 50709144_1 CDM 0360 RC 64530 HCPCS inpatient 2821 1833.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1907 67.6 999999999 1708.12 2736.37 percent of total billed charges Injection of chemical for paralysis of nerve muscles on side of neck excluding voice box 50709149_1 CDM 0360 RC 64616 HCPCS inpatient 720 468 SELF PAY DISCOUNT SELF PAY DISCOUNT 468 65 999999999 435.96 698.4 percent of total billed charges Injection of chemical for paralysis of nerve muscles on side of neck excluding voice box 50709149_1 CDM 0360 RC 64616 HCPCS inpatient 720 468 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 698.4 97 999999999 435.96 698.4 percent of total billed charges Injection of chemical for paralysis of nerve muscles on side of neck excluding voice box 50709149_1 CDM 0360 RC 64616 HCPCS inpatient 720 468 AETNA AETNA 568.8 79 999999999 435.96 698.4 percent of total billed charges Injection of chemical for paralysis of nerve muscles on side of neck excluding voice box 50709149_1 CDM 0360 RC 64616 HCPCS inpatient 720 468 HUMANA - ALL PLANS HUMANA - ALL PLANS 561.6 78 999999999 435.96 698.4 percent of total billed charges Injection of chemical for paralysis of nerve muscles on side of neck excluding voice box 50709149_1 CDM 0360 RC 64616 HCPCS inpatient 720 468 ENCORE - ALL PLANS ENCORE - ALL PLANS 496.8 69 999999999 435.96 698.4 percent of total billed charges Injection of chemical for paralysis of nerve muscles on side of neck excluding voice box 50709149_1 CDM 0360 RC 64616 HCPCS inpatient 720 468 SIHO - ALL PLANS SIHO - ALL PLANS 648 90 999999999 435.96 698.4 percent of total billed charges Injection of chemical for paralysis of nerve muscles on side of neck excluding voice box 50709149_1 CDM 0360 RC 64616 HCPCS inpatient 720 468 UMR - ALL PLANS UMR - ALL PLANS 504 70 999999999 435.96 698.4 percent of total billed charges Injection of chemical for paralysis of nerve muscles on side of neck excluding voice box 50709149_1 CDM 0360 RC 64616 HCPCS inpatient 720 468 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 435.96 60.55 999999999 435.96 698.4 percent of total billed charges Injection of chemical for paralysis of nerve muscles on side of neck excluding voice box 50709149_1 CDM 0360 RC 64616 HCPCS inpatient 720 468 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 435.96 698.4 Injection of chemical for paralysis of nerve muscles on side of neck excluding voice box 50709149_1 CDM 0360 RC 64616 HCPCS inpatient 720 468 ANTHEM HMO ANTHEM HMO 999999999 435.96 698.4 Injection of chemical for paralysis of nerve muscles on side of neck excluding voice box 50709149_1 CDM 0360 RC 64616 HCPCS inpatient 720 468 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 435.96 698.4 Injection of chemical for paralysis of nerve muscles on side of neck excluding voice box 50709149_1 CDM 0360 RC 64616 HCPCS inpatient 720 468 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 435.96 698.4 Injection of chemical for paralysis of nerve muscles on side of neck excluding voice box 50709149_1 CDM 0360 RC 64616 HCPCS inpatient 720 468 UHC - ALL PLANS UHC - ALL PLANS 999999999 435.96 698.4 Injection of chemical for paralysis of nerve muscles on side of neck excluding voice box 50709149_1 CDM 0360 RC 64616 HCPCS inpatient 720 468 CIGNA - ALL PLANS CIGNA - ALL PLANS 486.72 67.6 999999999 435.96 698.4 percent of total billed charges Injection of chemical for paralysis of facial and neck nerve muscles on both sides of face 50709150_1 CDM 0360 RC 64615 HCPCS inpatient 720 468 SELF PAY DISCOUNT SELF PAY DISCOUNT 468 65 999999999 435.96 698.4 percent of total billed charges Injection of chemical for paralysis of facial and neck nerve muscles on both sides of face 50709150_1 CDM 0360 RC 64615 HCPCS inpatient 720 468 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 698.4 97 999999999 435.96 698.4 percent of total billed charges Injection of chemical for paralysis of facial and neck nerve muscles on both sides of face 50709150_1 CDM 0360 RC 64615 HCPCS inpatient 720 468 AETNA AETNA 568.8 79 999999999 435.96 698.4 percent of total billed charges Injection of chemical for paralysis of facial and neck nerve muscles on both sides of face 50709150_1 CDM 0360 RC 64615 HCPCS inpatient 720 468 HUMANA - ALL PLANS HUMANA - ALL PLANS 561.6 78 999999999 435.96 698.4 percent of total billed charges Injection of chemical for paralysis of facial and neck nerve muscles on both sides of face 50709150_1 CDM 0360 RC 64615 HCPCS inpatient 720 468 ENCORE - ALL PLANS ENCORE - ALL PLANS 496.8 69 999999999 435.96 698.4 percent of total billed charges Injection of chemical for paralysis of facial and neck nerve muscles on both sides of face 50709150_1 CDM 0360 RC 64615 HCPCS inpatient 720 468 SIHO - ALL PLANS SIHO - ALL PLANS 648 90 999999999 435.96 698.4 percent of total billed charges Injection of chemical for paralysis of facial and neck nerve muscles on both sides of face 50709150_1 CDM 0360 RC 64615 HCPCS inpatient 720 468 UMR - ALL PLANS UMR - ALL PLANS 504 70 999999999 435.96 698.4 percent of total billed charges Injection of chemical for paralysis of facial and neck nerve muscles on both sides of face 50709150_1 CDM 0360 RC 64615 HCPCS inpatient 720 468 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 435.96 60.55 999999999 435.96 698.4 percent of total billed charges Injection of chemical for paralysis of facial and neck nerve muscles on both sides of face 50709150_1 CDM 0360 RC 64615 HCPCS inpatient 720 468 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 435.96 698.4 Injection of chemical for paralysis of facial and neck nerve muscles on both sides of face 50709150_1 CDM 0360 RC 64615 HCPCS inpatient 720 468 ANTHEM HMO ANTHEM HMO 999999999 435.96 698.4 Injection of chemical for paralysis of facial and neck nerve muscles on both sides of face 50709150_1 CDM 0360 RC 64615 HCPCS inpatient 720 468 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 435.96 698.4 Injection of chemical for paralysis of facial and neck nerve muscles on both sides of face 50709150_1 CDM 0360 RC 64615 HCPCS inpatient 720 468 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 435.96 698.4 Injection of chemical for paralysis of facial and neck nerve muscles on both sides of face 50709150_1 CDM 0360 RC 64615 HCPCS inpatient 720 468 UHC - ALL PLANS UHC - ALL PLANS 999999999 435.96 698.4 Injection of chemical for paralysis of facial and neck nerve muscles on both sides of face 50709150_1 CDM 0360 RC 64615 HCPCS inpatient 720 468 CIGNA - ALL PLANS CIGNA - ALL PLANS 486.72 67.6 999999999 435.96 698.4 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 50709151_1 CDM 0360 RC 64642 HCPCS inpatient 1750 1137.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1137.5 65 999999999 1059.63 1697.5 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 50709151_1 CDM 0360 RC 64642 HCPCS inpatient 1750 1137.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1697.5 97 999999999 1059.63 1697.5 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 50709151_1 CDM 0360 RC 64642 HCPCS inpatient 1750 1137.5 AETNA AETNA 1382.5 79 999999999 1059.63 1697.5 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 50709151_1 CDM 0360 RC 64642 HCPCS inpatient 1750 1137.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1365 78 999999999 1059.63 1697.5 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 50709151_1 CDM 0360 RC 64642 HCPCS inpatient 1750 1137.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1207.5 69 999999999 1059.63 1697.5 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 50709151_1 CDM 0360 RC 64642 HCPCS inpatient 1750 1137.5 SIHO - ALL PLANS SIHO - ALL PLANS 1575 90 999999999 1059.63 1697.5 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 50709151_1 CDM 0360 RC 64642 HCPCS inpatient 1750 1137.5 UMR - ALL PLANS UMR - ALL PLANS 1225 70 999999999 1059.63 1697.5 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 50709151_1 CDM 0360 RC 64642 HCPCS inpatient 1750 1137.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1059.63 60.55 999999999 1059.63 1697.5 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 50709151_1 CDM 0360 RC 64642 HCPCS inpatient 1750 1137.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1059.63 1697.5 "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 50709151_1 CDM 0360 RC 64642 HCPCS inpatient 1750 1137.5 ANTHEM HMO ANTHEM HMO 999999999 1059.63 1697.5 "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 50709151_1 CDM 0360 RC 64642 HCPCS inpatient 1750 1137.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1059.63 1697.5 "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 50709151_1 CDM 0360 RC 64642 HCPCS inpatient 1750 1137.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1059.63 1697.5 "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 50709151_1 CDM 0360 RC 64642 HCPCS inpatient 1750 1137.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1059.63 1697.5 "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 50709151_1 CDM 0360 RC 64642 HCPCS inpatient 1750 1137.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1183 67.6 999999999 1059.63 1697.5 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 50709152_1 CDM 0360 RC 64646 HCPCS inpatient 1750 1137.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1137.5 65 999999999 1059.63 1697.5 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 50709152_1 CDM 0360 RC 64646 HCPCS inpatient 1750 1137.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1697.5 97 999999999 1059.63 1697.5 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 50709152_1 CDM 0360 RC 64646 HCPCS inpatient 1750 1137.5 AETNA AETNA 1382.5 79 999999999 1059.63 1697.5 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 50709152_1 CDM 0360 RC 64646 HCPCS inpatient 1750 1137.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1365 78 999999999 1059.63 1697.5 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 50709152_1 CDM 0360 RC 64646 HCPCS inpatient 1750 1137.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1207.5 69 999999999 1059.63 1697.5 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 50709152_1 CDM 0360 RC 64646 HCPCS inpatient 1750 1137.5 SIHO - ALL PLANS SIHO - ALL PLANS 1575 90 999999999 1059.63 1697.5 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 50709152_1 CDM 0360 RC 64646 HCPCS inpatient 1750 1137.5 UMR - ALL PLANS UMR - ALL PLANS 1225 70 999999999 1059.63 1697.5 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 50709152_1 CDM 0360 RC 64646 HCPCS inpatient 1750 1137.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1059.63 60.55 999999999 1059.63 1697.5 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 50709152_1 CDM 0360 RC 64646 HCPCS inpatient 1750 1137.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1059.63 1697.5 "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 50709152_1 CDM 0360 RC 64646 HCPCS inpatient 1750 1137.5 ANTHEM HMO ANTHEM HMO 999999999 1059.63 1697.5 "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 50709152_1 CDM 0360 RC 64646 HCPCS inpatient 1750 1137.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1059.63 1697.5 "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 50709152_1 CDM 0360 RC 64646 HCPCS inpatient 1750 1137.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1059.63 1697.5 "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 50709152_1 CDM 0360 RC 64646 HCPCS inpatient 1750 1137.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1059.63 1697.5 "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 50709152_1 CDM 0360 RC 64646 HCPCS inpatient 1750 1137.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1183 67.6 999999999 1059.63 1697.5 percent of total billed charges Analysis for antibody to Cytomegalovirus (CMV) 50709178_1 CDM 0302 RC 86644 HCPCS inpatient 165 107.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.25 65 999999999 99.91 160.05 percent of total billed charges Analysis for antibody to Cytomegalovirus (CMV) 50709178_1 CDM 0302 RC 86644 HCPCS inpatient 165 107.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 160.05 97 999999999 99.91 160.05 percent of total billed charges Analysis for antibody to Cytomegalovirus (CMV) 50709178_1 CDM 0302 RC 86644 HCPCS inpatient 165 107.25 AETNA AETNA 130.35 79 999999999 99.91 160.05 percent of total billed charges Analysis for antibody to Cytomegalovirus (CMV) 50709178_1 CDM 0302 RC 86644 HCPCS inpatient 165 107.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.7 78 999999999 99.91 160.05 percent of total billed charges Analysis for antibody to Cytomegalovirus (CMV) 50709178_1 CDM 0302 RC 86644 HCPCS inpatient 165 107.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.85 69 999999999 99.91 160.05 percent of total billed charges Analysis for antibody to Cytomegalovirus (CMV) 50709178_1 CDM 0302 RC 86644 HCPCS inpatient 165 107.25 SIHO - ALL PLANS SIHO - ALL PLANS 148.5 90 999999999 99.91 160.05 percent of total billed charges Analysis for antibody to Cytomegalovirus (CMV) 50709178_1 CDM 0302 RC 86644 HCPCS inpatient 165 107.25 UMR - ALL PLANS UMR - ALL PLANS 115.5 70 999999999 99.91 160.05 percent of total billed charges Analysis for antibody to Cytomegalovirus (CMV) 50709178_1 CDM 0302 RC 86644 HCPCS inpatient 165 107.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.91 60.55 999999999 99.91 160.05 percent of total billed charges Analysis for antibody to Cytomegalovirus (CMV) 50709178_1 CDM 0302 RC 86644 HCPCS inpatient 165 107.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.91 160.05 Analysis for antibody to Cytomegalovirus (CMV) 50709178_1 CDM 0302 RC 86644 HCPCS inpatient 165 107.25 ANTHEM HMO ANTHEM HMO 999999999 99.91 160.05 Analysis for antibody to Cytomegalovirus (CMV) 50709178_1 CDM 0302 RC 86644 HCPCS inpatient 165 107.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.91 160.05 Analysis for antibody to Cytomegalovirus (CMV) 50709178_1 CDM 0302 RC 86644 HCPCS inpatient 165 107.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.91 160.05 Analysis for antibody to Cytomegalovirus (CMV) 50709178_1 CDM 0302 RC 86644 HCPCS inpatient 165 107.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.91 160.05 Analysis for antibody to Cytomegalovirus (CMV) 50709178_1 CDM 0302 RC 86644 HCPCS inpatient 165 107.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.54 67.6 999999999 99.91 160.05 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 50709207_1 CDM 0302 RC 86762 HCPCS inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 50709207_1 CDM 0302 RC 86762 HCPCS inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 50709207_1 CDM 0302 RC 86762 HCPCS inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 50709207_1 CDM 0302 RC 86762 HCPCS inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 50709207_1 CDM 0302 RC 86762 HCPCS inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 50709207_1 CDM 0302 RC 86762 HCPCS inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 50709207_1 CDM 0302 RC 86762 HCPCS inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 50709207_1 CDM 0302 RC 86762 HCPCS inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 50709207_1 CDM 0302 RC 86762 HCPCS inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 Analysis for antibody to Rubella (German measles virus) 50709207_1 CDM 0302 RC 86762 HCPCS inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 Analysis for antibody to Rubella (German measles virus) 50709207_1 CDM 0302 RC 86762 HCPCS inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 Analysis for antibody to Rubella (German measles virus) 50709207_1 CDM 0302 RC 86762 HCPCS inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 Analysis for antibody to Rubella (German measles virus) 50709207_1 CDM 0302 RC 86762 HCPCS inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 Analysis for antibody to Rubella (German measles virus) 50709207_1 CDM 0302 RC 86762 HCPCS inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, second level" 50709223_1 CDM 0360 RC 64494 HCPCS inpatient 635 412.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 412.75 65 999999999 384.49 615.95 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, second level" 50709223_1 CDM 0360 RC 64494 HCPCS inpatient 635 412.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 615.95 97 999999999 384.49 615.95 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, second level" 50709223_1 CDM 0360 RC 64494 HCPCS inpatient 635 412.75 AETNA AETNA 501.65 79 999999999 384.49 615.95 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, second level" 50709223_1 CDM 0360 RC 64494 HCPCS inpatient 635 412.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 495.3 78 999999999 384.49 615.95 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, second level" 50709223_1 CDM 0360 RC 64494 HCPCS inpatient 635 412.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 438.15 69 999999999 384.49 615.95 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, second level" 50709223_1 CDM 0360 RC 64494 HCPCS inpatient 635 412.75 SIHO - ALL PLANS SIHO - ALL PLANS 571.5 90 999999999 384.49 615.95 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, second level" 50709223_1 CDM 0360 RC 64494 HCPCS inpatient 635 412.75 UMR - ALL PLANS UMR - ALL PLANS 444.5 70 999999999 384.49 615.95 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, second level" 50709223_1 CDM 0360 RC 64494 HCPCS inpatient 635 412.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 384.49 60.55 999999999 384.49 615.95 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, second level" 50709223_1 CDM 0360 RC 64494 HCPCS inpatient 635 412.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 384.49 615.95 "Injection of lower or sacral spine facet joint using imaging guidance, second level" 50709223_1 CDM 0360 RC 64494 HCPCS inpatient 635 412.75 ANTHEM HMO ANTHEM HMO 999999999 384.49 615.95 "Injection of lower or sacral spine facet joint using imaging guidance, second level" 50709223_1 CDM 0360 RC 64494 HCPCS inpatient 635 412.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 384.49 615.95 "Injection of lower or sacral spine facet joint using imaging guidance, second level" 50709223_1 CDM 0360 RC 64494 HCPCS inpatient 635 412.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 384.49 615.95 "Injection of lower or sacral spine facet joint using imaging guidance, second level" 50709223_1 CDM 0360 RC 64494 HCPCS inpatient 635 412.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 384.49 615.95 "Injection of lower or sacral spine facet joint using imaging guidance, second level" 50709223_1 CDM 0360 RC 64494 HCPCS inpatient 635 412.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 429.26 67.6 999999999 384.49 615.95 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 50709224_1 CDM 0360 RC 64495 HCPCS inpatient 547 355.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 355.55 65 999999999 331.21 530.59 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 50709224_1 CDM 0360 RC 64495 HCPCS inpatient 547 355.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 530.59 97 999999999 331.21 530.59 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 50709224_1 CDM 0360 RC 64495 HCPCS inpatient 547 355.55 AETNA AETNA 432.13 79 999999999 331.21 530.59 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 50709224_1 CDM 0360 RC 64495 HCPCS inpatient 547 355.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 426.66 78 999999999 331.21 530.59 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 50709224_1 CDM 0360 RC 64495 HCPCS inpatient 547 355.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 377.43 69 999999999 331.21 530.59 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 50709224_1 CDM 0360 RC 64495 HCPCS inpatient 547 355.55 SIHO - ALL PLANS SIHO - ALL PLANS 492.3 90 999999999 331.21 530.59 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 50709224_1 CDM 0360 RC 64495 HCPCS inpatient 547 355.55 UMR - ALL PLANS UMR - ALL PLANS 382.9 70 999999999 331.21 530.59 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 50709224_1 CDM 0360 RC 64495 HCPCS inpatient 547 355.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 331.21 60.55 999999999 331.21 530.59 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 50709224_1 CDM 0360 RC 64495 HCPCS inpatient 547 355.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 331.21 530.59 "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 50709224_1 CDM 0360 RC 64495 HCPCS inpatient 547 355.55 ANTHEM HMO ANTHEM HMO 999999999 331.21 530.59 "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 50709224_1 CDM 0360 RC 64495 HCPCS inpatient 547 355.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 331.21 530.59 "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 50709224_1 CDM 0360 RC 64495 HCPCS inpatient 547 355.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 331.21 530.59 "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 50709224_1 CDM 0360 RC 64495 HCPCS inpatient 547 355.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 331.21 530.59 "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 50709224_1 CDM 0360 RC 64495 HCPCS inpatient 547 355.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 369.77 67.6 999999999 331.21 530.59 percent of total billed charges "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, each additional level" 50709225_1 CDM 0360 RC 64484 HCPCS inpatient 872 566.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 566.8 65 999999999 528 845.84 percent of total billed charges "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, each additional level" 50709225_1 CDM 0360 RC 64484 HCPCS inpatient 872 566.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 845.84 97 999999999 528 845.84 percent of total billed charges "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, each additional level" 50709225_1 CDM 0360 RC 64484 HCPCS inpatient 872 566.8 AETNA AETNA 688.88 79 999999999 528 845.84 percent of total billed charges "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, each additional level" 50709225_1 CDM 0360 RC 64484 HCPCS inpatient 872 566.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 680.16 78 999999999 528 845.84 percent of total billed charges "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, each additional level" 50709225_1 CDM 0360 RC 64484 HCPCS inpatient 872 566.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 601.68 69 999999999 528 845.84 percent of total billed charges "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, each additional level" 50709225_1 CDM 0360 RC 64484 HCPCS inpatient 872 566.8 SIHO - ALL PLANS SIHO - ALL PLANS 784.8 90 999999999 528 845.84 percent of total billed charges "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, each additional level" 50709225_1 CDM 0360 RC 64484 HCPCS inpatient 872 566.8 UMR - ALL PLANS UMR - ALL PLANS 610.4 70 999999999 528 845.84 percent of total billed charges "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, each additional level" 50709225_1 CDM 0360 RC 64484 HCPCS inpatient 872 566.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 528 60.55 999999999 528 845.84 percent of total billed charges "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, each additional level" 50709225_1 CDM 0360 RC 64484 HCPCS inpatient 872 566.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 528 845.84 "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, each additional level" 50709225_1 CDM 0360 RC 64484 HCPCS inpatient 872 566.8 ANTHEM HMO ANTHEM HMO 999999999 528 845.84 "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, each additional level" 50709225_1 CDM 0360 RC 64484 HCPCS inpatient 872 566.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 528 845.84 "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, each additional level" 50709225_1 CDM 0360 RC 64484 HCPCS inpatient 872 566.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 528 845.84 "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, each additional level" 50709225_1 CDM 0360 RC 64484 HCPCS inpatient 872 566.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 528 845.84 "Injection of anesthetic and/or steroid drug into sacral spine nerve root using imaging guidance, each additional level" 50709225_1 CDM 0360 RC 64484 HCPCS inpatient 872 566.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 589.47 67.6 999999999 528 845.84 percent of total billed charges "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, each additional facet joint" 50709226_1 CDM 0360 RC 64636 HCPCS inpatient 2042 1327.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1327.3 65 999999999 1236.43 1980.74 percent of total billed charges "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, each additional facet joint" 50709226_1 CDM 0360 RC 64636 HCPCS inpatient 2042 1327.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1980.74 97 999999999 1236.43 1980.74 percent of total billed charges "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, each additional facet joint" 50709226_1 CDM 0360 RC 64636 HCPCS inpatient 2042 1327.3 AETNA AETNA 1613.18 79 999999999 1236.43 1980.74 percent of total billed charges "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, each additional facet joint" 50709226_1 CDM 0360 RC 64636 HCPCS inpatient 2042 1327.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1592.76 78 999999999 1236.43 1980.74 percent of total billed charges "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, each additional facet joint" 50709226_1 CDM 0360 RC 64636 HCPCS inpatient 2042 1327.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1408.98 69 999999999 1236.43 1980.74 percent of total billed charges "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, each additional facet joint" 50709226_1 CDM 0360 RC 64636 HCPCS inpatient 2042 1327.3 SIHO - ALL PLANS SIHO - ALL PLANS 1837.8 90 999999999 1236.43 1980.74 percent of total billed charges "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, each additional facet joint" 50709226_1 CDM 0360 RC 64636 HCPCS inpatient 2042 1327.3 UMR - ALL PLANS UMR - ALL PLANS 1429.4 70 999999999 1236.43 1980.74 percent of total billed charges "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, each additional facet joint" 50709226_1 CDM 0360 RC 64636 HCPCS inpatient 2042 1327.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1236.43 60.55 999999999 1236.43 1980.74 percent of total billed charges "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, each additional facet joint" 50709226_1 CDM 0360 RC 64636 HCPCS inpatient 2042 1327.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1236.43 1980.74 "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, each additional facet joint" 50709226_1 CDM 0360 RC 64636 HCPCS inpatient 2042 1327.3 ANTHEM HMO ANTHEM HMO 999999999 1236.43 1980.74 "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, each additional facet joint" 50709226_1 CDM 0360 RC 64636 HCPCS inpatient 2042 1327.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1236.43 1980.74 "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, each additional facet joint" 50709226_1 CDM 0360 RC 64636 HCPCS inpatient 2042 1327.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1236.43 1980.74 "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, each additional facet joint" 50709226_1 CDM 0360 RC 64636 HCPCS inpatient 2042 1327.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1236.43 1980.74 "Destruction of lower or sacral spinal facet joint nerves using imaging guidance, each additional facet joint" 50709226_1 CDM 0360 RC 64636 HCPCS inpatient 2042 1327.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1380.39 67.6 999999999 1236.43 1980.74 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 50709965_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 50709965_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 50709965_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 50709965_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 50709965_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 50709965_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 50709965_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 50709965_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 50709965_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Correction of bunion with alignment correction of midfoot bone toward ankle 50709965_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Correction of bunion with alignment correction of midfoot bone toward ankle 50709965_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Correction of bunion with alignment correction of midfoot bone toward ankle 50709965_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Correction of bunion with alignment correction of midfoot bone toward ankle 50709965_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Correction of bunion with alignment correction of midfoot bone toward ankle 50709965_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges LIDOCAINE HCL 2% JELLY 50710317_1 CDM 0250 RC 17478-0711-31 NDC inpatient 10 UN 30.32 19.71 SELF PAY DISCOUNT SELF PAY DISCOUNT 19.71 65 999999999 18.36 29.41 percent of total billed charges LIDOCAINE HCL 2% JELLY 50710317_1 CDM 0250 RC 17478-0711-31 NDC inpatient 10 UN 30.32 19.71 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29.41 97 999999999 18.36 29.41 percent of total billed charges LIDOCAINE HCL 2% JELLY 50710317_1 CDM 0250 RC 17478-0711-31 NDC inpatient 10 UN 30.32 19.71 AETNA AETNA 23.95 79 999999999 18.36 29.41 percent of total billed charges LIDOCAINE HCL 2% JELLY 50710317_1 CDM 0250 RC 17478-0711-31 NDC inpatient 10 UN 30.32 19.71 HUMANA - ALL PLANS HUMANA - ALL PLANS 23.65 78 999999999 18.36 29.41 percent of total billed charges LIDOCAINE HCL 2% JELLY 50710317_1 CDM 0250 RC 17478-0711-31 NDC inpatient 10 UN 30.32 19.71 ENCORE - ALL PLANS ENCORE - ALL PLANS 20.92 69 999999999 18.36 29.41 percent of total billed charges LIDOCAINE HCL 2% JELLY 50710317_1 CDM 0250 RC 17478-0711-31 NDC inpatient 10 UN 30.32 19.71 SIHO - ALL PLANS SIHO - ALL PLANS 27.29 90 999999999 18.36 29.41 percent of total billed charges LIDOCAINE HCL 2% JELLY 50710317_1 CDM 0250 RC 17478-0711-31 NDC inpatient 10 UN 30.32 19.71 UMR - ALL PLANS UMR - ALL PLANS 21.22 70 999999999 18.36 29.41 percent of total billed charges LIDOCAINE HCL 2% JELLY 50710317_1 CDM 0250 RC 17478-0711-31 NDC inpatient 10 UN 30.32 19.71 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18.36 60.55 999999999 18.36 29.41 percent of total billed charges LIDOCAINE HCL 2% JELLY 50710317_1 CDM 0250 RC 17478-0711-31 NDC inpatient 10 UN 30.32 19.71 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 18.36 29.41 LIDOCAINE HCL 2% JELLY 50710317_1 CDM 0250 RC 17478-0711-31 NDC inpatient 10 UN 30.32 19.71 ANTHEM HMO ANTHEM HMO 999999999 18.36 29.41 LIDOCAINE HCL 2% JELLY 50710317_1 CDM 0250 RC 17478-0711-31 NDC inpatient 10 UN 30.32 19.71 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 18.36 29.41 LIDOCAINE HCL 2% JELLY 50710317_1 CDM 0250 RC 17478-0711-31 NDC inpatient 10 UN 30.32 19.71 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 18.36 29.41 LIDOCAINE HCL 2% JELLY 50710317_1 CDM 0250 RC 17478-0711-31 NDC inpatient 10 UN 30.32 19.71 UHC - ALL PLANS UHC - ALL PLANS 999999999 18.36 29.41 LIDOCAINE HCL 2% JELLY 50710317_1 CDM 0250 RC 17478-0711-31 NDC inpatient 10 UN 30.32 19.71 CIGNA - ALL PLANS CIGNA - ALL PLANS 20.5 67.6 999999999 18.36 29.41 percent of total billed charges ***BLANKET PER MEGAN ROTATABLE OVAL 13mm SNARE M00561821 50712744_1 CDM 0272 RC inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges ***BLANKET PER MEGAN ROTATABLE OVAL 13mm SNARE M00561821 50712744_1 CDM 0272 RC inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges ***BLANKET PER MEGAN ROTATABLE OVAL 13mm SNARE M00561821 50712744_1 CDM 0272 RC inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges ***BLANKET PER MEGAN ROTATABLE OVAL 13mm SNARE M00561821 50712744_1 CDM 0272 RC inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges ***BLANKET PER MEGAN ROTATABLE OVAL 13mm SNARE M00561821 50712744_1 CDM 0272 RC inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges ***BLANKET PER MEGAN ROTATABLE OVAL 13mm SNARE M00561821 50712744_1 CDM 0272 RC inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges ***BLANKET PER MEGAN ROTATABLE OVAL 13mm SNARE M00561821 50712744_1 CDM 0272 RC inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges ***BLANKET PER MEGAN ROTATABLE OVAL 13mm SNARE M00561821 50712744_1 CDM 0272 RC inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges ***BLANKET PER MEGAN ROTATABLE OVAL 13mm SNARE M00561821 50712744_1 CDM 0272 RC inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 ***BLANKET PER MEGAN ROTATABLE OVAL 13mm SNARE M00561821 50712744_1 CDM 0272 RC inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 ***BLANKET PER MEGAN ROTATABLE OVAL 13mm SNARE M00561821 50712744_1 CDM 0272 RC inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 ***BLANKET PER MEGAN ROTATABLE OVAL 13mm SNARE M00561821 50712744_1 CDM 0272 RC inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 ***BLANKET PER MEGAN ROTATABLE OVAL 13mm SNARE M00561821 50712744_1 CDM 0272 RC inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 ***BLANKET PER MEGAN ROTATABLE OVAL 13mm SNARE M00561821 50712744_1 CDM 0272 RC inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50713642_1 CDM 0250 RC 76045-0009-11 NDC J1170 HCPCS inpatient 1 UN 28.06 18.24 SELF PAY DISCOUNT SELF PAY DISCOUNT 18.24 65 999999999 16.99 27.22 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50713642_1 CDM 0250 RC 76045-0009-11 NDC J1170 HCPCS inpatient 1 UN 28.06 18.24 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 27.22 97 999999999 16.99 27.22 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50713642_1 CDM 0250 RC 76045-0009-11 NDC J1170 HCPCS inpatient 1 UN 28.06 18.24 AETNA AETNA 22.17 79 999999999 16.99 27.22 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50713642_1 CDM 0250 RC 76045-0009-11 NDC J1170 HCPCS inpatient 1 UN 28.06 18.24 HUMANA - ALL PLANS HUMANA - ALL PLANS 21.89 78 999999999 16.99 27.22 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50713642_1 CDM 0250 RC 76045-0009-11 NDC J1170 HCPCS inpatient 1 UN 28.06 18.24 ENCORE - ALL PLANS ENCORE - ALL PLANS 19.36 69 999999999 16.99 27.22 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50713642_1 CDM 0250 RC 76045-0009-11 NDC J1170 HCPCS inpatient 1 UN 28.06 18.24 SIHO - ALL PLANS SIHO - ALL PLANS 25.25 90 999999999 16.99 27.22 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50713642_1 CDM 0250 RC 76045-0009-11 NDC J1170 HCPCS inpatient 1 UN 28.06 18.24 UMR - ALL PLANS UMR - ALL PLANS 19.64 70 999999999 16.99 27.22 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50713642_1 CDM 0250 RC 76045-0009-11 NDC J1170 HCPCS inpatient 1 UN 28.06 18.24 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.99 60.55 999999999 16.99 27.22 percent of total billed charges "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50713642_1 CDM 0250 RC 76045-0009-11 NDC J1170 HCPCS inpatient 1 UN 28.06 18.24 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.99 27.22 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50713642_1 CDM 0250 RC 76045-0009-11 NDC J1170 HCPCS inpatient 1 UN 28.06 18.24 ANTHEM HMO ANTHEM HMO 999999999 16.99 27.22 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50713642_1 CDM 0250 RC 76045-0009-11 NDC J1170 HCPCS inpatient 1 UN 28.06 18.24 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.99 27.22 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50713642_1 CDM 0250 RC 76045-0009-11 NDC J1170 HCPCS inpatient 1 UN 28.06 18.24 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.99 27.22 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50713642_1 CDM 0250 RC 76045-0009-11 NDC J1170 HCPCS inpatient 1 UN 28.06 18.24 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.99 27.22 "INJECTION, HYDROMORPHONE, UP TO 4 MG" 50713642_1 CDM 0250 RC 76045-0009-11 NDC J1170 HCPCS inpatient 1 UN 28.06 18.24 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.97 67.6 999999999 16.99 27.22 percent of total billed charges "Injection of trigger points, 3 or more muscles" 50713692_1 CDM 0360 RC 20553 HCPCS inpatient 631 410.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 410.15 65 999999999 382.07 612.07 percent of total billed charges "Injection of trigger points, 3 or more muscles" 50713692_1 CDM 0360 RC 20553 HCPCS inpatient 631 410.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 612.07 97 999999999 382.07 612.07 percent of total billed charges "Injection of trigger points, 3 or more muscles" 50713692_1 CDM 0360 RC 20553 HCPCS inpatient 631 410.15 AETNA AETNA 498.49 79 999999999 382.07 612.07 percent of total billed charges "Injection of trigger points, 3 or more muscles" 50713692_1 CDM 0360 RC 20553 HCPCS inpatient 631 410.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 492.18 78 999999999 382.07 612.07 percent of total billed charges "Injection of trigger points, 3 or more muscles" 50713692_1 CDM 0360 RC 20553 HCPCS inpatient 631 410.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 435.39 69 999999999 382.07 612.07 percent of total billed charges "Injection of trigger points, 3 or more muscles" 50713692_1 CDM 0360 RC 20553 HCPCS inpatient 631 410.15 SIHO - ALL PLANS SIHO - ALL PLANS 567.9 90 999999999 382.07 612.07 percent of total billed charges "Injection of trigger points, 3 or more muscles" 50713692_1 CDM 0360 RC 20553 HCPCS inpatient 631 410.15 UMR - ALL PLANS UMR - ALL PLANS 441.7 70 999999999 382.07 612.07 percent of total billed charges "Injection of trigger points, 3 or more muscles" 50713692_1 CDM 0360 RC 20553 HCPCS inpatient 631 410.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 382.07 60.55 999999999 382.07 612.07 percent of total billed charges "Injection of trigger points, 3 or more muscles" 50713692_1 CDM 0360 RC 20553 HCPCS inpatient 631 410.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 382.07 612.07 "Injection of trigger points, 3 or more muscles" 50713692_1 CDM 0360 RC 20553 HCPCS inpatient 631 410.15 ANTHEM HMO ANTHEM HMO 999999999 382.07 612.07 "Injection of trigger points, 3 or more muscles" 50713692_1 CDM 0360 RC 20553 HCPCS inpatient 631 410.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 382.07 612.07 "Injection of trigger points, 3 or more muscles" 50713692_1 CDM 0360 RC 20553 HCPCS inpatient 631 410.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 382.07 612.07 "Injection of trigger points, 3 or more muscles" 50713692_1 CDM 0360 RC 20553 HCPCS inpatient 631 410.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 382.07 612.07 "Injection of trigger points, 3 or more muscles" 50713692_1 CDM 0360 RC 20553 HCPCS inpatient 631 410.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 426.56 67.6 999999999 382.07 612.07 percent of total billed charges Destruction of nerves supplying joint between spine and pelvis using imaging guidance 50713694_1 CDM 0360 RC 64625 HCPCS inpatient 1768 1149.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 1149.2 65 999999999 1070.52 1714.96 percent of total billed charges Destruction of nerves supplying joint between spine and pelvis using imaging guidance 50713694_1 CDM 0360 RC 64625 HCPCS inpatient 1768 1149.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1714.96 97 999999999 1070.52 1714.96 percent of total billed charges Destruction of nerves supplying joint between spine and pelvis using imaging guidance 50713694_1 CDM 0360 RC 64625 HCPCS inpatient 1768 1149.2 AETNA AETNA 1396.72 79 999999999 1070.52 1714.96 percent of total billed charges Destruction of nerves supplying joint between spine and pelvis using imaging guidance 50713694_1 CDM 0360 RC 64625 HCPCS inpatient 1768 1149.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 1379.04 78 999999999 1070.52 1714.96 percent of total billed charges Destruction of nerves supplying joint between spine and pelvis using imaging guidance 50713694_1 CDM 0360 RC 64625 HCPCS inpatient 1768 1149.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 1219.92 69 999999999 1070.52 1714.96 percent of total billed charges Destruction of nerves supplying joint between spine and pelvis using imaging guidance 50713694_1 CDM 0360 RC 64625 HCPCS inpatient 1768 1149.2 SIHO - ALL PLANS SIHO - ALL PLANS 1591.2 90 999999999 1070.52 1714.96 percent of total billed charges Destruction of nerves supplying joint between spine and pelvis using imaging guidance 50713694_1 CDM 0360 RC 64625 HCPCS inpatient 1768 1149.2 UMR - ALL PLANS UMR - ALL PLANS 1237.6 70 999999999 1070.52 1714.96 percent of total billed charges Destruction of nerves supplying joint between spine and pelvis using imaging guidance 50713694_1 CDM 0360 RC 64625 HCPCS inpatient 1768 1149.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1070.52 60.55 999999999 1070.52 1714.96 percent of total billed charges Destruction of nerves supplying joint between spine and pelvis using imaging guidance 50713694_1 CDM 0360 RC 64625 HCPCS inpatient 1768 1149.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1070.52 1714.96 Destruction of nerves supplying joint between spine and pelvis using imaging guidance 50713694_1 CDM 0360 RC 64625 HCPCS inpatient 1768 1149.2 ANTHEM HMO ANTHEM HMO 999999999 1070.52 1714.96 Destruction of nerves supplying joint between spine and pelvis using imaging guidance 50713694_1 CDM 0360 RC 64625 HCPCS inpatient 1768 1149.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1070.52 1714.96 Destruction of nerves supplying joint between spine and pelvis using imaging guidance 50713694_1 CDM 0360 RC 64625 HCPCS inpatient 1768 1149.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1070.52 1714.96 Destruction of nerves supplying joint between spine and pelvis using imaging guidance 50713694_1 CDM 0360 RC 64625 HCPCS inpatient 1768 1149.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1070.52 1714.96 Destruction of nerves supplying joint between spine and pelvis using imaging guidance 50713694_1 CDM 0360 RC 64625 HCPCS inpatient 1768 1149.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 1195.17 67.6 999999999 1070.52 1714.96 percent of total billed charges Destruction of nerve branches of knee using imaging guidance 50713696_1 CDM 0360 RC 64624 HCPCS inpatient 1925 1251.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1251.25 65 999999999 1165.59 1867.25 percent of total billed charges Destruction of nerve branches of knee using imaging guidance 50713696_1 CDM 0360 RC 64624 HCPCS inpatient 1925 1251.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1867.25 97 999999999 1165.59 1867.25 percent of total billed charges Destruction of nerve branches of knee using imaging guidance 50713696_1 CDM 0360 RC 64624 HCPCS inpatient 1925 1251.25 AETNA AETNA 1520.75 79 999999999 1165.59 1867.25 percent of total billed charges Destruction of nerve branches of knee using imaging guidance 50713696_1 CDM 0360 RC 64624 HCPCS inpatient 1925 1251.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1501.5 78 999999999 1165.59 1867.25 percent of total billed charges Destruction of nerve branches of knee using imaging guidance 50713696_1 CDM 0360 RC 64624 HCPCS inpatient 1925 1251.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1328.25 69 999999999 1165.59 1867.25 percent of total billed charges Destruction of nerve branches of knee using imaging guidance 50713696_1 CDM 0360 RC 64624 HCPCS inpatient 1925 1251.25 SIHO - ALL PLANS SIHO - ALL PLANS 1732.5 90 999999999 1165.59 1867.25 percent of total billed charges Destruction of nerve branches of knee using imaging guidance 50713696_1 CDM 0360 RC 64624 HCPCS inpatient 1925 1251.25 UMR - ALL PLANS UMR - ALL PLANS 1347.5 70 999999999 1165.59 1867.25 percent of total billed charges Destruction of nerve branches of knee using imaging guidance 50713696_1 CDM 0360 RC 64624 HCPCS inpatient 1925 1251.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1165.59 60.55 999999999 1165.59 1867.25 percent of total billed charges Destruction of nerve branches of knee using imaging guidance 50713696_1 CDM 0360 RC 64624 HCPCS inpatient 1925 1251.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1165.59 1867.25 Destruction of nerve branches of knee using imaging guidance 50713696_1 CDM 0360 RC 64624 HCPCS inpatient 1925 1251.25 ANTHEM HMO ANTHEM HMO 999999999 1165.59 1867.25 Destruction of nerve branches of knee using imaging guidance 50713696_1 CDM 0360 RC 64624 HCPCS inpatient 1925 1251.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1165.59 1867.25 Destruction of nerve branches of knee using imaging guidance 50713696_1 CDM 0360 RC 64624 HCPCS inpatient 1925 1251.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1165.59 1867.25 Destruction of nerve branches of knee using imaging guidance 50713696_1 CDM 0360 RC 64624 HCPCS inpatient 1925 1251.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1165.59 1867.25 Destruction of nerve branches of knee using imaging guidance 50713696_1 CDM 0360 RC 64624 HCPCS inpatient 1925 1251.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1301.3 67.6 999999999 1165.59 1867.25 percent of total billed charges Albumin (protein) level 50713697_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 50713697_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 50713697_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 50713697_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 50713697_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 50713697_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 50713697_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 50713697_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 50713697_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Albumin (protein) level 50713697_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Albumin (protein) level 50713697_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Albumin (protein) level 50713697_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Albumin (protein) level 50713697_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Albumin (protein) level 50713697_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Gammaglobulin (immune system protein) measurement 50713703_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges Gammaglobulin (immune system protein) measurement 50713703_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges Gammaglobulin (immune system protein) measurement 50713703_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges Gammaglobulin (immune system protein) measurement 50713703_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges Gammaglobulin (immune system protein) measurement 50713703_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges Gammaglobulin (immune system protein) measurement 50713703_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges Gammaglobulin (immune system protein) measurement 50713703_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges Gammaglobulin (immune system protein) measurement 50713703_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges Gammaglobulin (immune system protein) measurement 50713703_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 Gammaglobulin (immune system protein) measurement 50713703_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 Gammaglobulin (immune system protein) measurement 50713703_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 Gammaglobulin (immune system protein) measurement 50713703_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 Gammaglobulin (immune system protein) measurement 50713703_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 Gammaglobulin (immune system protein) measurement 50713703_1 CDM 0301 RC 82784 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges Albumin (protein) level 50713709_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 50713709_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 50713709_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 50713709_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 50713709_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 50713709_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 50713709_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 50713709_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Albumin (protein) level 50713709_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Albumin (protein) level 50713709_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Albumin (protein) level 50713709_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Albumin (protein) level 50713709_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Albumin (protein) level 50713709_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Albumin (protein) level 50713709_1 CDM 0301 RC 82040 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Gammaglobulin (immune system protein) measurement 50713710_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 50713710_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 50713710_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 50713710_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 50713710_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 50713710_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 50713710_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 50713710_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges Gammaglobulin (immune system protein) measurement 50713710_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 50713710_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 50713710_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 50713710_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 50713710_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Gammaglobulin (immune system protein) measurement 50713710_1 CDM 0301 RC 82784 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, second level" 50713749_1 CDM 0360 RC 64491 HCPCS inpatient 644 418.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 418.6 65 999999999 389.94 624.68 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, second level" 50713749_1 CDM 0360 RC 64491 HCPCS inpatient 644 418.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 624.68 97 999999999 389.94 624.68 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, second level" 50713749_1 CDM 0360 RC 64491 HCPCS inpatient 644 418.6 AETNA AETNA 508.76 79 999999999 389.94 624.68 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, second level" 50713749_1 CDM 0360 RC 64491 HCPCS inpatient 644 418.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 502.32 78 999999999 389.94 624.68 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, second level" 50713749_1 CDM 0360 RC 64491 HCPCS inpatient 644 418.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 444.36 69 999999999 389.94 624.68 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, second level" 50713749_1 CDM 0360 RC 64491 HCPCS inpatient 644 418.6 SIHO - ALL PLANS SIHO - ALL PLANS 579.6 90 999999999 389.94 624.68 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, second level" 50713749_1 CDM 0360 RC 64491 HCPCS inpatient 644 418.6 UMR - ALL PLANS UMR - ALL PLANS 450.8 70 999999999 389.94 624.68 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, second level" 50713749_1 CDM 0360 RC 64491 HCPCS inpatient 644 418.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 389.94 60.55 999999999 389.94 624.68 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, second level" 50713749_1 CDM 0360 RC 64491 HCPCS inpatient 644 418.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 389.94 624.68 "Injection of upper or middle spine facet joint using imaging guidance, second level" 50713749_1 CDM 0360 RC 64491 HCPCS inpatient 644 418.6 ANTHEM HMO ANTHEM HMO 999999999 389.94 624.68 "Injection of upper or middle spine facet joint using imaging guidance, second level" 50713749_1 CDM 0360 RC 64491 HCPCS inpatient 644 418.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 389.94 624.68 "Injection of upper or middle spine facet joint using imaging guidance, second level" 50713749_1 CDM 0360 RC 64491 HCPCS inpatient 644 418.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 389.94 624.68 "Injection of upper or middle spine facet joint using imaging guidance, second level" 50713749_1 CDM 0360 RC 64491 HCPCS inpatient 644 418.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 389.94 624.68 "Injection of upper or middle spine facet joint using imaging guidance, second level" 50713749_1 CDM 0360 RC 64491 HCPCS inpatient 644 418.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 435.34 67.6 999999999 389.94 624.68 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 50713750_1 CDM 0360 RC 64492 HCPCS inpatient 585 380.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 380.25 65 999999999 354.22 567.45 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 50713750_1 CDM 0360 RC 64492 HCPCS inpatient 585 380.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 567.45 97 999999999 354.22 567.45 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 50713750_1 CDM 0360 RC 64492 HCPCS inpatient 585 380.25 AETNA AETNA 462.15 79 999999999 354.22 567.45 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 50713750_1 CDM 0360 RC 64492 HCPCS inpatient 585 380.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 456.3 78 999999999 354.22 567.45 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 50713750_1 CDM 0360 RC 64492 HCPCS inpatient 585 380.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 403.65 69 999999999 354.22 567.45 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 50713750_1 CDM 0360 RC 64492 HCPCS inpatient 585 380.25 SIHO - ALL PLANS SIHO - ALL PLANS 526.5 90 999999999 354.22 567.45 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 50713750_1 CDM 0360 RC 64492 HCPCS inpatient 585 380.25 UMR - ALL PLANS UMR - ALL PLANS 409.5 70 999999999 354.22 567.45 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 50713750_1 CDM 0360 RC 64492 HCPCS inpatient 585 380.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 354.22 60.55 999999999 354.22 567.45 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 50713750_1 CDM 0360 RC 64492 HCPCS inpatient 585 380.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 354.22 567.45 "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 50713750_1 CDM 0360 RC 64492 HCPCS inpatient 585 380.25 ANTHEM HMO ANTHEM HMO 999999999 354.22 567.45 "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 50713750_1 CDM 0360 RC 64492 HCPCS inpatient 585 380.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 354.22 567.45 "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 50713750_1 CDM 0360 RC 64492 HCPCS inpatient 585 380.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 354.22 567.45 "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 50713750_1 CDM 0360 RC 64492 HCPCS inpatient 585 380.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 354.22 567.45 "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 50713750_1 CDM 0360 RC 64492 HCPCS inpatient 585 380.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 395.46 67.6 999999999 354.22 567.45 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, each additional facet joint" 50713751_1 CDM 0360 RC 64634 HCPCS inpatient 2101 1365.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1365.65 65 999999999 1272.16 2037.97 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, each additional facet joint" 50713751_1 CDM 0360 RC 64634 HCPCS inpatient 2101 1365.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2037.97 97 999999999 1272.16 2037.97 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, each additional facet joint" 50713751_1 CDM 0360 RC 64634 HCPCS inpatient 2101 1365.65 AETNA AETNA 1659.79 79 999999999 1272.16 2037.97 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, each additional facet joint" 50713751_1 CDM 0360 RC 64634 HCPCS inpatient 2101 1365.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1638.78 78 999999999 1272.16 2037.97 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, each additional facet joint" 50713751_1 CDM 0360 RC 64634 HCPCS inpatient 2101 1365.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1449.69 69 999999999 1272.16 2037.97 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, each additional facet joint" 50713751_1 CDM 0360 RC 64634 HCPCS inpatient 2101 1365.65 SIHO - ALL PLANS SIHO - ALL PLANS 1890.9 90 999999999 1272.16 2037.97 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, each additional facet joint" 50713751_1 CDM 0360 RC 64634 HCPCS inpatient 2101 1365.65 UMR - ALL PLANS UMR - ALL PLANS 1470.7 70 999999999 1272.16 2037.97 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, each additional facet joint" 50713751_1 CDM 0360 RC 64634 HCPCS inpatient 2101 1365.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1272.16 60.55 999999999 1272.16 2037.97 percent of total billed charges "Destruction of upper or middle spinal facet joint nerves using imaging guidance, each additional facet joint" 50713751_1 CDM 0360 RC 64634 HCPCS inpatient 2101 1365.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1272.16 2037.97 "Destruction of upper or middle spinal facet joint nerves using imaging guidance, each additional facet joint" 50713751_1 CDM 0360 RC 64634 HCPCS inpatient 2101 1365.65 ANTHEM HMO ANTHEM HMO 999999999 1272.16 2037.97 "Destruction of upper or middle spinal facet joint nerves using imaging guidance, each additional facet joint" 50713751_1 CDM 0360 RC 64634 HCPCS inpatient 2101 1365.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1272.16 2037.97 "Destruction of upper or middle spinal facet joint nerves using imaging guidance, each additional facet joint" 50713751_1 CDM 0360 RC 64634 HCPCS inpatient 2101 1365.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1272.16 2037.97 "Destruction of upper or middle spinal facet joint nerves using imaging guidance, each additional facet joint" 50713751_1 CDM 0360 RC 64634 HCPCS inpatient 2101 1365.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1272.16 2037.97 "Destruction of upper or middle spinal facet joint nerves using imaging guidance, each additional facet joint" 50713751_1 CDM 0360 RC 64634 HCPCS inpatient 2101 1365.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1420.28 67.6 999999999 1272.16 2037.97 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, each additional level" 50713752_1 CDM 0360 RC 64480 HCPCS inpatient 933 606.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 606.45 65 999999999 564.93 905.01 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, each additional level" 50713752_1 CDM 0360 RC 64480 HCPCS inpatient 933 606.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 905.01 97 999999999 564.93 905.01 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, each additional level" 50713752_1 CDM 0360 RC 64480 HCPCS inpatient 933 606.45 AETNA AETNA 737.07 79 999999999 564.93 905.01 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, each additional level" 50713752_1 CDM 0360 RC 64480 HCPCS inpatient 933 606.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 727.74 78 999999999 564.93 905.01 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, each additional level" 50713752_1 CDM 0360 RC 64480 HCPCS inpatient 933 606.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 643.77 69 999999999 564.93 905.01 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, each additional level" 50713752_1 CDM 0360 RC 64480 HCPCS inpatient 933 606.45 SIHO - ALL PLANS SIHO - ALL PLANS 839.7 90 999999999 564.93 905.01 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, each additional level" 50713752_1 CDM 0360 RC 64480 HCPCS inpatient 933 606.45 UMR - ALL PLANS UMR - ALL PLANS 653.1 70 999999999 564.93 905.01 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, each additional level" 50713752_1 CDM 0360 RC 64480 HCPCS inpatient 933 606.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 564.93 60.55 999999999 564.93 905.01 percent of total billed charges "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, each additional level" 50713752_1 CDM 0360 RC 64480 HCPCS inpatient 933 606.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 564.93 905.01 "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, each additional level" 50713752_1 CDM 0360 RC 64480 HCPCS inpatient 933 606.45 ANTHEM HMO ANTHEM HMO 999999999 564.93 905.01 "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, each additional level" 50713752_1 CDM 0360 RC 64480 HCPCS inpatient 933 606.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 564.93 905.01 "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, each additional level" 50713752_1 CDM 0360 RC 64480 HCPCS inpatient 933 606.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 564.93 905.01 "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, each additional level" 50713752_1 CDM 0360 RC 64480 HCPCS inpatient 933 606.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 564.93 905.01 "Injection of anesthetic and/or steroid drug into upper or middle spine nerve root using imaging guidance, each additional level" 50713752_1 CDM 0360 RC 64480 HCPCS inpatient 933 606.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 630.71 67.6 999999999 564.93 905.01 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 50714883_1 CDM 0305 RC 85025 HCPCS inpatient 130 84.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 84.5 65 999999999 78.72 126.1 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 50714883_1 CDM 0305 RC 85025 HCPCS inpatient 130 84.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 126.1 97 999999999 78.72 126.1 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 50714883_1 CDM 0305 RC 85025 HCPCS inpatient 130 84.5 AETNA AETNA 102.7 79 999999999 78.72 126.1 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 50714883_1 CDM 0305 RC 85025 HCPCS inpatient 130 84.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 101.4 78 999999999 78.72 126.1 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 50714883_1 CDM 0305 RC 85025 HCPCS inpatient 130 84.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.7 69 999999999 78.72 126.1 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 50714883_1 CDM 0305 RC 85025 HCPCS inpatient 130 84.5 SIHO - ALL PLANS SIHO - ALL PLANS 117 90 999999999 78.72 126.1 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 50714883_1 CDM 0305 RC 85025 HCPCS inpatient 130 84.5 UMR - ALL PLANS UMR - ALL PLANS 91 70 999999999 78.72 126.1 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 50714883_1 CDM 0305 RC 85025 HCPCS inpatient 130 84.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.72 60.55 999999999 78.72 126.1 percent of total billed charges "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 50714883_1 CDM 0305 RC 85025 HCPCS inpatient 130 84.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.72 126.1 "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 50714883_1 CDM 0305 RC 85025 HCPCS inpatient 130 84.5 ANTHEM HMO ANTHEM HMO 999999999 78.72 126.1 "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 50714883_1 CDM 0305 RC 85025 HCPCS inpatient 130 84.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.72 126.1 "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 50714883_1 CDM 0305 RC 85025 HCPCS inpatient 130 84.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.72 126.1 "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 50714883_1 CDM 0305 RC 85025 HCPCS inpatient 130 84.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.72 126.1 "Complete blood cell count (red cells, white blood cell, platelets), automated test and automated differential white blood cell count" 50714883_1 CDM 0305 RC 85025 HCPCS inpatient 130 84.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.88 67.6 999999999 78.72 126.1 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50716341_1 CDM 0250 RC 72611-0765-10 NDC J3370 HCPCS inpatient 2 UN 19.61 12.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.75 65 999999999 11.87 19.02 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50716341_1 CDM 0250 RC 72611-0765-10 NDC J3370 HCPCS inpatient 2 UN 19.61 12.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.02 97 999999999 11.87 19.02 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50716341_1 CDM 0250 RC 72611-0765-10 NDC J3370 HCPCS inpatient 2 UN 19.61 12.75 AETNA AETNA 15.49 79 999999999 11.87 19.02 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50716341_1 CDM 0250 RC 72611-0765-10 NDC J3370 HCPCS inpatient 2 UN 19.61 12.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.3 78 999999999 11.87 19.02 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50716341_1 CDM 0250 RC 72611-0765-10 NDC J3370 HCPCS inpatient 2 UN 19.61 12.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.53 69 999999999 11.87 19.02 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50716341_1 CDM 0250 RC 72611-0765-10 NDC J3370 HCPCS inpatient 2 UN 19.61 12.75 SIHO - ALL PLANS SIHO - ALL PLANS 17.65 90 999999999 11.87 19.02 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50716341_1 CDM 0250 RC 72611-0765-10 NDC J3370 HCPCS inpatient 2 UN 19.61 12.75 UMR - ALL PLANS UMR - ALL PLANS 13.73 70 999999999 11.87 19.02 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50716341_1 CDM 0250 RC 72611-0765-10 NDC J3370 HCPCS inpatient 2 UN 19.61 12.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.87 60.55 999999999 11.87 19.02 percent of total billed charges "INJECTION, VANCOMYCIN HCL, 500 MG" 50716341_1 CDM 0250 RC 72611-0765-10 NDC J3370 HCPCS inpatient 2 UN 19.61 12.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.87 19.02 "INJECTION, VANCOMYCIN HCL, 500 MG" 50716341_1 CDM 0250 RC 72611-0765-10 NDC J3370 HCPCS inpatient 2 UN 19.61 12.75 ANTHEM HMO ANTHEM HMO 999999999 11.87 19.02 "INJECTION, VANCOMYCIN HCL, 500 MG" 50716341_1 CDM 0250 RC 72611-0765-10 NDC J3370 HCPCS inpatient 2 UN 19.61 12.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.87 19.02 "INJECTION, VANCOMYCIN HCL, 500 MG" 50716341_1 CDM 0250 RC 72611-0765-10 NDC J3370 HCPCS inpatient 2 UN 19.61 12.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.87 19.02 "INJECTION, VANCOMYCIN HCL, 500 MG" 50716341_1 CDM 0250 RC 72611-0765-10 NDC J3370 HCPCS inpatient 2 UN 19.61 12.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.87 19.02 "INJECTION, VANCOMYCIN HCL, 500 MG" 50716341_1 CDM 0250 RC 72611-0765-10 NDC J3370 HCPCS inpatient 2 UN 19.61 12.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.26 67.6 999999999 11.87 19.02 percent of total billed charges "TRANEXAMIC ACID 1,000 MG/10 ML" 50716342_1 CDM 0250 RC 61990-0611-02 NDC inpatient 1 UN 18.73 12.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 12.17 65 999999999 11.34 18.17 percent of total billed charges "TRANEXAMIC ACID 1,000 MG/10 ML" 50716342_1 CDM 0250 RC 61990-0611-02 NDC inpatient 1 UN 18.73 12.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 18.17 97 999999999 11.34 18.17 percent of total billed charges "TRANEXAMIC ACID 1,000 MG/10 ML" 50716342_1 CDM 0250 RC 61990-0611-02 NDC inpatient 1 UN 18.73 12.17 AETNA AETNA 14.8 79 999999999 11.34 18.17 percent of total billed charges "TRANEXAMIC ACID 1,000 MG/10 ML" 50716342_1 CDM 0250 RC 61990-0611-02 NDC inpatient 1 UN 18.73 12.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 14.61 78 999999999 11.34 18.17 percent of total billed charges "TRANEXAMIC ACID 1,000 MG/10 ML" 50716342_1 CDM 0250 RC 61990-0611-02 NDC inpatient 1 UN 18.73 12.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 12.92 69 999999999 11.34 18.17 percent of total billed charges "TRANEXAMIC ACID 1,000 MG/10 ML" 50716342_1 CDM 0250 RC 61990-0611-02 NDC inpatient 1 UN 18.73 12.17 SIHO - ALL PLANS SIHO - ALL PLANS 16.86 90 999999999 11.34 18.17 percent of total billed charges "TRANEXAMIC ACID 1,000 MG/10 ML" 50716342_1 CDM 0250 RC 61990-0611-02 NDC inpatient 1 UN 18.73 12.17 UMR - ALL PLANS UMR - ALL PLANS 13.11 70 999999999 11.34 18.17 percent of total billed charges "TRANEXAMIC ACID 1,000 MG/10 ML" 50716342_1 CDM 0250 RC 61990-0611-02 NDC inpatient 1 UN 18.73 12.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11.34 60.55 999999999 11.34 18.17 percent of total billed charges "TRANEXAMIC ACID 1,000 MG/10 ML" 50716342_1 CDM 0250 RC 61990-0611-02 NDC inpatient 1 UN 18.73 12.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 11.34 18.17 "TRANEXAMIC ACID 1,000 MG/10 ML" 50716342_1 CDM 0250 RC 61990-0611-02 NDC inpatient 1 UN 18.73 12.17 ANTHEM HMO ANTHEM HMO 999999999 11.34 18.17 "TRANEXAMIC ACID 1,000 MG/10 ML" 50716342_1 CDM 0250 RC 61990-0611-02 NDC inpatient 1 UN 18.73 12.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 11.34 18.17 "TRANEXAMIC ACID 1,000 MG/10 ML" 50716342_1 CDM 0250 RC 61990-0611-02 NDC inpatient 1 UN 18.73 12.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 11.34 18.17 "TRANEXAMIC ACID 1,000 MG/10 ML" 50716342_1 CDM 0250 RC 61990-0611-02 NDC inpatient 1 UN 18.73 12.17 UHC - ALL PLANS UHC - ALL PLANS 999999999 11.34 18.17 "TRANEXAMIC ACID 1,000 MG/10 ML" 50716342_1 CDM 0250 RC 61990-0611-02 NDC inpatient 1 UN 18.73 12.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 12.66 67.6 999999999 11.34 18.17 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50716349_1 CDM 0250 RC 60687-0492-21 NDC J0571 HCPCS inpatient 1 UN 12.47 8.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.11 65 999999999 7.55 12.1 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50716349_1 CDM 0250 RC 60687-0492-21 NDC J0571 HCPCS inpatient 1 UN 12.47 8.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.1 97 999999999 7.55 12.1 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50716349_1 CDM 0250 RC 60687-0492-21 NDC J0571 HCPCS inpatient 1 UN 12.47 8.11 AETNA AETNA 9.85 79 999999999 7.55 12.1 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50716349_1 CDM 0250 RC 60687-0492-21 NDC J0571 HCPCS inpatient 1 UN 12.47 8.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.73 78 999999999 7.55 12.1 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50716349_1 CDM 0250 RC 60687-0492-21 NDC J0571 HCPCS inpatient 1 UN 12.47 8.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.6 69 999999999 7.55 12.1 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50716349_1 CDM 0250 RC 60687-0492-21 NDC J0571 HCPCS inpatient 1 UN 12.47 8.11 SIHO - ALL PLANS SIHO - ALL PLANS 11.22 90 999999999 7.55 12.1 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50716349_1 CDM 0250 RC 60687-0492-21 NDC J0571 HCPCS inpatient 1 UN 12.47 8.11 UMR - ALL PLANS UMR - ALL PLANS 8.73 70 999999999 7.55 12.1 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50716349_1 CDM 0250 RC 60687-0492-21 NDC J0571 HCPCS inpatient 1 UN 12.47 8.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.55 60.55 999999999 7.55 12.1 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50716349_1 CDM 0250 RC 60687-0492-21 NDC J0571 HCPCS inpatient 1 UN 12.47 8.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.55 12.1 "BUPRENORPHINE, ORAL, 1 MG" 50716349_1 CDM 0250 RC 60687-0492-21 NDC J0571 HCPCS inpatient 1 UN 12.47 8.11 ANTHEM HMO ANTHEM HMO 999999999 7.55 12.1 "BUPRENORPHINE, ORAL, 1 MG" 50716349_1 CDM 0250 RC 60687-0492-21 NDC J0571 HCPCS inpatient 1 UN 12.47 8.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.55 12.1 "BUPRENORPHINE, ORAL, 1 MG" 50716349_1 CDM 0250 RC 60687-0492-21 NDC J0571 HCPCS inpatient 1 UN 12.47 8.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.55 12.1 "BUPRENORPHINE, ORAL, 1 MG" 50716349_1 CDM 0250 RC 60687-0492-21 NDC J0571 HCPCS inpatient 1 UN 12.47 8.11 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.55 12.1 "BUPRENORPHINE, ORAL, 1 MG" 50716349_1 CDM 0250 RC 60687-0492-21 NDC J0571 HCPCS inpatient 1 UN 12.47 8.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.43 67.6 999999999 7.55 12.1 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50716706_1 CDM 0636 RC 70121-1238-01 NDC J9070 HCPCS inpatient 5 UN 562.1 365.37 SELF PAY DISCOUNT SELF PAY DISCOUNT 365.37 65 999999999 340.35 545.24 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50716706_1 CDM 0636 RC 70121-1238-01 NDC J9070 HCPCS inpatient 5 UN 562.1 365.37 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 545.24 97 999999999 340.35 545.24 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50716706_1 CDM 0636 RC 70121-1238-01 NDC J9070 HCPCS inpatient 5 UN 562.1 365.37 AETNA AETNA 444.06 79 999999999 340.35 545.24 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50716706_1 CDM 0636 RC 70121-1238-01 NDC J9070 HCPCS inpatient 5 UN 562.1 365.37 HUMANA - ALL PLANS HUMANA - ALL PLANS 438.44 78 999999999 340.35 545.24 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50716706_1 CDM 0636 RC 70121-1238-01 NDC J9070 HCPCS inpatient 5 UN 562.1 365.37 ENCORE - ALL PLANS ENCORE - ALL PLANS 387.85 69 999999999 340.35 545.24 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50716706_1 CDM 0636 RC 70121-1238-01 NDC J9070 HCPCS inpatient 5 UN 562.1 365.37 SIHO - ALL PLANS SIHO - ALL PLANS 505.89 90 999999999 340.35 545.24 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50716706_1 CDM 0636 RC 70121-1238-01 NDC J9070 HCPCS inpatient 5 UN 562.1 365.37 UMR - ALL PLANS UMR - ALL PLANS 393.47 70 999999999 340.35 545.24 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50716706_1 CDM 0636 RC 70121-1238-01 NDC J9070 HCPCS inpatient 5 UN 562.1 365.37 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 340.35 60.55 999999999 340.35 545.24 percent of total billed charges "CYCLOPHOSPHAMIDE, 100 MG" 50716706_1 CDM 0636 RC 70121-1238-01 NDC J9070 HCPCS inpatient 5 UN 562.1 365.37 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 340.35 545.24 "CYCLOPHOSPHAMIDE, 100 MG" 50716706_1 CDM 0636 RC 70121-1238-01 NDC J9070 HCPCS inpatient 5 UN 562.1 365.37 ANTHEM HMO ANTHEM HMO 999999999 340.35 545.24 "CYCLOPHOSPHAMIDE, 100 MG" 50716706_1 CDM 0636 RC 70121-1238-01 NDC J9070 HCPCS inpatient 5 UN 562.1 365.37 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 340.35 545.24 "CYCLOPHOSPHAMIDE, 100 MG" 50716706_1 CDM 0636 RC 70121-1238-01 NDC J9070 HCPCS inpatient 5 UN 562.1 365.37 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 340.35 545.24 "CYCLOPHOSPHAMIDE, 100 MG" 50716706_1 CDM 0636 RC 70121-1238-01 NDC J9070 HCPCS inpatient 5 UN 562.1 365.37 UHC - ALL PLANS UHC - ALL PLANS 999999999 340.35 545.24 "CYCLOPHOSPHAMIDE, 100 MG" 50716706_1 CDM 0636 RC 70121-1238-01 NDC J9070 HCPCS inpatient 5 UN 562.1 365.37 CIGNA - ALL PLANS CIGNA - ALL PLANS 379.98 67.6 999999999 340.35 545.24 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50719509_1 CDM 0250 RC 60687-0481-21 NDC J0571 HCPCS inpatient 1 UN 7.27 4.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.73 65 999999999 4.4 7.05 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50719509_1 CDM 0250 RC 60687-0481-21 NDC J0571 HCPCS inpatient 1 UN 7.27 4.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7.05 97 999999999 4.4 7.05 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50719509_1 CDM 0250 RC 60687-0481-21 NDC J0571 HCPCS inpatient 1 UN 7.27 4.73 AETNA AETNA 5.74 79 999999999 4.4 7.05 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50719509_1 CDM 0250 RC 60687-0481-21 NDC J0571 HCPCS inpatient 1 UN 7.27 4.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 5.67 78 999999999 4.4 7.05 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50719509_1 CDM 0250 RC 60687-0481-21 NDC J0571 HCPCS inpatient 1 UN 7.27 4.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.02 69 999999999 4.4 7.05 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50719509_1 CDM 0250 RC 60687-0481-21 NDC J0571 HCPCS inpatient 1 UN 7.27 4.73 SIHO - ALL PLANS SIHO - ALL PLANS 6.54 90 999999999 4.4 7.05 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50719509_1 CDM 0250 RC 60687-0481-21 NDC J0571 HCPCS inpatient 1 UN 7.27 4.73 UMR - ALL PLANS UMR - ALL PLANS 5.09 70 999999999 4.4 7.05 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50719509_1 CDM 0250 RC 60687-0481-21 NDC J0571 HCPCS inpatient 1 UN 7.27 4.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.4 60.55 999999999 4.4 7.05 percent of total billed charges "BUPRENORPHINE, ORAL, 1 MG" 50719509_1 CDM 0250 RC 60687-0481-21 NDC J0571 HCPCS inpatient 1 UN 7.27 4.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.4 7.05 "BUPRENORPHINE, ORAL, 1 MG" 50719509_1 CDM 0250 RC 60687-0481-21 NDC J0571 HCPCS inpatient 1 UN 7.27 4.73 ANTHEM HMO ANTHEM HMO 999999999 4.4 7.05 "BUPRENORPHINE, ORAL, 1 MG" 50719509_1 CDM 0250 RC 60687-0481-21 NDC J0571 HCPCS inpatient 1 UN 7.27 4.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.4 7.05 "BUPRENORPHINE, ORAL, 1 MG" 50719509_1 CDM 0250 RC 60687-0481-21 NDC J0571 HCPCS inpatient 1 UN 7.27 4.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.4 7.05 "BUPRENORPHINE, ORAL, 1 MG" 50719509_1 CDM 0250 RC 60687-0481-21 NDC J0571 HCPCS inpatient 1 UN 7.27 4.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.4 7.05 "BUPRENORPHINE, ORAL, 1 MG" 50719509_1 CDM 0250 RC 60687-0481-21 NDC J0571 HCPCS inpatient 1 UN 7.27 4.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.91 67.6 999999999 4.4 7.05 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 50719511_1 CDM 0250 RC 25021-0311-02 NDC inpatient 1 UN 23.04 14.98 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.98 65 999999999 13.95 22.35 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 50719511_1 CDM 0250 RC 25021-0311-02 NDC inpatient 1 UN 23.04 14.98 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22.35 97 999999999 13.95 22.35 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 50719511_1 CDM 0250 RC 25021-0311-02 NDC inpatient 1 UN 23.04 14.98 AETNA AETNA 18.2 79 999999999 13.95 22.35 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 50719511_1 CDM 0250 RC 25021-0311-02 NDC inpatient 1 UN 23.04 14.98 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.97 78 999999999 13.95 22.35 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 50719511_1 CDM 0250 RC 25021-0311-02 NDC inpatient 1 UN 23.04 14.98 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.9 69 999999999 13.95 22.35 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 50719511_1 CDM 0250 RC 25021-0311-02 NDC inpatient 1 UN 23.04 14.98 SIHO - ALL PLANS SIHO - ALL PLANS 20.74 90 999999999 13.95 22.35 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 50719511_1 CDM 0250 RC 25021-0311-02 NDC inpatient 1 UN 23.04 14.98 UMR - ALL PLANS UMR - ALL PLANS 16.13 70 999999999 13.95 22.35 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 50719511_1 CDM 0250 RC 25021-0311-02 NDC inpatient 1 UN 23.04 14.98 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.95 60.55 999999999 13.95 22.35 percent of total billed charges FUROSEMIDE 20 MG/2 ML VIAL 50719511_1 CDM 0250 RC 25021-0311-02 NDC inpatient 1 UN 23.04 14.98 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.95 22.35 FUROSEMIDE 20 MG/2 ML VIAL 50719511_1 CDM 0250 RC 25021-0311-02 NDC inpatient 1 UN 23.04 14.98 ANTHEM HMO ANTHEM HMO 999999999 13.95 22.35 FUROSEMIDE 20 MG/2 ML VIAL 50719511_1 CDM 0250 RC 25021-0311-02 NDC inpatient 1 UN 23.04 14.98 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.95 22.35 FUROSEMIDE 20 MG/2 ML VIAL 50719511_1 CDM 0250 RC 25021-0311-02 NDC inpatient 1 UN 23.04 14.98 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.95 22.35 FUROSEMIDE 20 MG/2 ML VIAL 50719511_1 CDM 0250 RC 25021-0311-02 NDC inpatient 1 UN 23.04 14.98 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.95 22.35 FUROSEMIDE 20 MG/2 ML VIAL 50719511_1 CDM 0250 RC 25021-0311-02 NDC inpatient 1 UN 23.04 14.98 CIGNA - ALL PLANS CIGNA - ALL PLANS 15.58 67.6 999999999 13.95 22.35 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50721461_1 CDM 0250 RC 60687-0341-58 NDC inpatient 1 UN 33.69 21.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.9 65 999999999 20.4 32.68 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50721461_1 CDM 0250 RC 60687-0341-58 NDC inpatient 1 UN 33.69 21.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.68 97 999999999 20.4 32.68 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50721461_1 CDM 0250 RC 60687-0341-58 NDC inpatient 1 UN 33.69 21.9 AETNA AETNA 26.62 79 999999999 20.4 32.68 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50721461_1 CDM 0250 RC 60687-0341-58 NDC inpatient 1 UN 33.69 21.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 26.28 78 999999999 20.4 32.68 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50721461_1 CDM 0250 RC 60687-0341-58 NDC inpatient 1 UN 33.69 21.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 23.25 69 999999999 20.4 32.68 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50721461_1 CDM 0250 RC 60687-0341-58 NDC inpatient 1 UN 33.69 21.9 SIHO - ALL PLANS SIHO - ALL PLANS 30.32 90 999999999 20.4 32.68 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50721461_1 CDM 0250 RC 60687-0341-58 NDC inpatient 1 UN 33.69 21.9 UMR - ALL PLANS UMR - ALL PLANS 23.58 70 999999999 20.4 32.68 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50721461_1 CDM 0250 RC 60687-0341-58 NDC inpatient 1 UN 33.69 21.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.4 60.55 999999999 20.4 32.68 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50721461_1 CDM 0250 RC 60687-0341-58 NDC inpatient 1 UN 33.69 21.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.4 32.68 POTASSIUM CL 10% (20 MEQ/15ML) 50721461_1 CDM 0250 RC 60687-0341-58 NDC inpatient 1 UN 33.69 21.9 ANTHEM HMO ANTHEM HMO 999999999 20.4 32.68 POTASSIUM CL 10% (20 MEQ/15ML) 50721461_1 CDM 0250 RC 60687-0341-58 NDC inpatient 1 UN 33.69 21.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.4 32.68 POTASSIUM CL 10% (20 MEQ/15ML) 50721461_1 CDM 0250 RC 60687-0341-58 NDC inpatient 1 UN 33.69 21.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.77 67.6 999999999 20.4 32.68 percent of total billed charges POTASSIUM CL 10% (20 MEQ/15ML) 50721461_1 CDM 0250 RC 60687-0341-58 NDC inpatient 1 UN 33.69 21.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.4 32.68 POTASSIUM CL 10% (20 MEQ/15ML) 50721461_1 CDM 0250 RC 60687-0341-58 NDC inpatient 1 UN 33.69 21.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.4 32.68 Antithrombin III antigen (clotting inhibitor) level 50723641_1 CDM 0305 RC 85301 HCPCS inpatient 130 84.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 84.5 65 999999999 78.72 126.1 percent of total billed charges Antithrombin III antigen (clotting inhibitor) level 50723641_1 CDM 0305 RC 85301 HCPCS inpatient 130 84.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 126.1 97 999999999 78.72 126.1 percent of total billed charges Antithrombin III antigen (clotting inhibitor) level 50723641_1 CDM 0305 RC 85301 HCPCS inpatient 130 84.5 AETNA AETNA 102.7 79 999999999 78.72 126.1 percent of total billed charges Antithrombin III antigen (clotting inhibitor) level 50723641_1 CDM 0305 RC 85301 HCPCS inpatient 130 84.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 101.4 78 999999999 78.72 126.1 percent of total billed charges Antithrombin III antigen (clotting inhibitor) level 50723641_1 CDM 0305 RC 85301 HCPCS inpatient 130 84.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.7 69 999999999 78.72 126.1 percent of total billed charges Antithrombin III antigen (clotting inhibitor) level 50723641_1 CDM 0305 RC 85301 HCPCS inpatient 130 84.5 SIHO - ALL PLANS SIHO - ALL PLANS 117 90 999999999 78.72 126.1 percent of total billed charges Antithrombin III antigen (clotting inhibitor) level 50723641_1 CDM 0305 RC 85301 HCPCS inpatient 130 84.5 UMR - ALL PLANS UMR - ALL PLANS 91 70 999999999 78.72 126.1 percent of total billed charges Antithrombin III antigen (clotting inhibitor) level 50723641_1 CDM 0305 RC 85301 HCPCS inpatient 130 84.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.72 60.55 999999999 78.72 126.1 percent of total billed charges Antithrombin III antigen (clotting inhibitor) level 50723641_1 CDM 0305 RC 85301 HCPCS inpatient 130 84.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.72 126.1 Antithrombin III antigen (clotting inhibitor) level 50723641_1 CDM 0305 RC 85301 HCPCS inpatient 130 84.5 ANTHEM HMO ANTHEM HMO 999999999 78.72 126.1 Antithrombin III antigen (clotting inhibitor) level 50723641_1 CDM 0305 RC 85301 HCPCS inpatient 130 84.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.72 126.1 Antithrombin III antigen (clotting inhibitor) level 50723641_1 CDM 0305 RC 85301 HCPCS inpatient 130 84.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.88 67.6 999999999 78.72 126.1 percent of total billed charges Antithrombin III antigen (clotting inhibitor) level 50723641_1 CDM 0305 RC 85301 HCPCS inpatient 130 84.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.72 126.1 Antithrombin III antigen (clotting inhibitor) level 50723641_1 CDM 0305 RC 85301 HCPCS inpatient 130 84.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.72 126.1 METHOCARBAMOL 500 MG TABLET 50724230_1 CDM 0250 RC 60687-0559-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges METHOCARBAMOL 500 MG TABLET 50724230_1 CDM 0250 RC 60687-0559-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges METHOCARBAMOL 500 MG TABLET 50724230_1 CDM 0250 RC 60687-0559-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges METHOCARBAMOL 500 MG TABLET 50724230_1 CDM 0250 RC 60687-0559-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges METHOCARBAMOL 500 MG TABLET 50724230_1 CDM 0250 RC 60687-0559-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges METHOCARBAMOL 500 MG TABLET 50724230_1 CDM 0250 RC 60687-0559-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges METHOCARBAMOL 500 MG TABLET 50724230_1 CDM 0250 RC 60687-0559-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges METHOCARBAMOL 500 MG TABLET 50724230_1 CDM 0250 RC 60687-0559-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges METHOCARBAMOL 500 MG TABLET 50724230_1 CDM 0250 RC 60687-0559-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 METHOCARBAMOL 500 MG TABLET 50724230_1 CDM 0250 RC 60687-0559-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 METHOCARBAMOL 500 MG TABLET 50724230_1 CDM 0250 RC 60687-0559-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 METHOCARBAMOL 500 MG TABLET 50724230_1 CDM 0250 RC 60687-0559-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges METHOCARBAMOL 500 MG TABLET 50724230_1 CDM 0250 RC 60687-0559-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 METHOCARBAMOL 500 MG TABLET 50724230_1 CDM 0250 RC 60687-0559-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 ROPINIROLE HCL ER 2 MG TABLET 50724232_1 CDM 0250 RC 55111-0659-30 NDC inpatient 1 UN 9.59 6.23 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.23 65 999999999 5.81 9.3 percent of total billed charges ROPINIROLE HCL ER 2 MG TABLET 50724232_1 CDM 0250 RC 55111-0659-30 NDC inpatient 1 UN 9.59 6.23 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.3 97 999999999 5.81 9.3 percent of total billed charges ROPINIROLE HCL ER 2 MG TABLET 50724232_1 CDM 0250 RC 55111-0659-30 NDC inpatient 1 UN 9.59 6.23 AETNA AETNA 7.58 79 999999999 5.81 9.3 percent of total billed charges ROPINIROLE HCL ER 2 MG TABLET 50724232_1 CDM 0250 RC 55111-0659-30 NDC inpatient 1 UN 9.59 6.23 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.48 78 999999999 5.81 9.3 percent of total billed charges ROPINIROLE HCL ER 2 MG TABLET 50724232_1 CDM 0250 RC 55111-0659-30 NDC inpatient 1 UN 9.59 6.23 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.62 69 999999999 5.81 9.3 percent of total billed charges ROPINIROLE HCL ER 2 MG TABLET 50724232_1 CDM 0250 RC 55111-0659-30 NDC inpatient 1 UN 9.59 6.23 SIHO - ALL PLANS SIHO - ALL PLANS 8.63 90 999999999 5.81 9.3 percent of total billed charges ROPINIROLE HCL ER 2 MG TABLET 50724232_1 CDM 0250 RC 55111-0659-30 NDC inpatient 1 UN 9.59 6.23 UMR - ALL PLANS UMR - ALL PLANS 6.71 70 999999999 5.81 9.3 percent of total billed charges ROPINIROLE HCL ER 2 MG TABLET 50724232_1 CDM 0250 RC 55111-0659-30 NDC inpatient 1 UN 9.59 6.23 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.81 60.55 999999999 5.81 9.3 percent of total billed charges ROPINIROLE HCL ER 2 MG TABLET 50724232_1 CDM 0250 RC 55111-0659-30 NDC inpatient 1 UN 9.59 6.23 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.81 9.3 ROPINIROLE HCL ER 2 MG TABLET 50724232_1 CDM 0250 RC 55111-0659-30 NDC inpatient 1 UN 9.59 6.23 ANTHEM HMO ANTHEM HMO 999999999 5.81 9.3 ROPINIROLE HCL ER 2 MG TABLET 50724232_1 CDM 0250 RC 55111-0659-30 NDC inpatient 1 UN 9.59 6.23 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.81 9.3 ROPINIROLE HCL ER 2 MG TABLET 50724232_1 CDM 0250 RC 55111-0659-30 NDC inpatient 1 UN 9.59 6.23 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.48 67.6 999999999 5.81 9.3 percent of total billed charges ROPINIROLE HCL ER 2 MG TABLET 50724232_1 CDM 0250 RC 55111-0659-30 NDC inpatient 1 UN 9.59 6.23 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.81 9.3 ROPINIROLE HCL ER 2 MG TABLET 50724232_1 CDM 0250 RC 55111-0659-30 NDC inpatient 1 UN 9.59 6.23 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.81 9.3 Apolipoprotein level 50724289_1 CDM 0301 RC 82172 HCPCS inpatient 418 271.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 271.7 65 999999999 253.1 405.46 percent of total billed charges Apolipoprotein level 50724289_1 CDM 0301 RC 82172 HCPCS inpatient 418 271.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 405.46 97 999999999 253.1 405.46 percent of total billed charges Apolipoprotein level 50724289_1 CDM 0301 RC 82172 HCPCS inpatient 418 271.7 AETNA AETNA 330.22 79 999999999 253.1 405.46 percent of total billed charges Apolipoprotein level 50724289_1 CDM 0301 RC 82172 HCPCS inpatient 418 271.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 326.04 78 999999999 253.1 405.46 percent of total billed charges Apolipoprotein level 50724289_1 CDM 0301 RC 82172 HCPCS inpatient 418 271.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 288.42 69 999999999 253.1 405.46 percent of total billed charges Apolipoprotein level 50724289_1 CDM 0301 RC 82172 HCPCS inpatient 418 271.7 SIHO - ALL PLANS SIHO - ALL PLANS 376.2 90 999999999 253.1 405.46 percent of total billed charges Apolipoprotein level 50724289_1 CDM 0301 RC 82172 HCPCS inpatient 418 271.7 UMR - ALL PLANS UMR - ALL PLANS 292.6 70 999999999 253.1 405.46 percent of total billed charges Apolipoprotein level 50724289_1 CDM 0301 RC 82172 HCPCS inpatient 418 271.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 253.1 60.55 999999999 253.1 405.46 percent of total billed charges Apolipoprotein level 50724289_1 CDM 0301 RC 82172 HCPCS inpatient 418 271.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 253.1 405.46 Apolipoprotein level 50724289_1 CDM 0301 RC 82172 HCPCS inpatient 418 271.7 ANTHEM HMO ANTHEM HMO 999999999 253.1 405.46 Apolipoprotein level 50724289_1 CDM 0301 RC 82172 HCPCS inpatient 418 271.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 253.1 405.46 Apolipoprotein level 50724289_1 CDM 0301 RC 82172 HCPCS inpatient 418 271.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 282.57 67.6 999999999 253.1 405.46 percent of total billed charges Apolipoprotein level 50724289_1 CDM 0301 RC 82172 HCPCS inpatient 418 271.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 253.1 405.46 Apolipoprotein level 50724289_1 CDM 0301 RC 82172 HCPCS inpatient 418 271.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 253.1 405.46 "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 50724371_1 CDM 0302 RC 86812 HCPCS inpatient 275 178.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.75 65 999999999 166.51 266.75 percent of total billed charges "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 50724371_1 CDM 0302 RC 86812 HCPCS inpatient 275 178.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 266.75 97 999999999 166.51 266.75 percent of total billed charges "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 50724371_1 CDM 0302 RC 86812 HCPCS inpatient 275 178.75 AETNA AETNA 217.25 79 999999999 166.51 266.75 percent of total billed charges "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 50724371_1 CDM 0302 RC 86812 HCPCS inpatient 275 178.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 214.5 78 999999999 166.51 266.75 percent of total billed charges "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 50724371_1 CDM 0302 RC 86812 HCPCS inpatient 275 178.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.75 69 999999999 166.51 266.75 percent of total billed charges "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 50724371_1 CDM 0302 RC 86812 HCPCS inpatient 275 178.75 SIHO - ALL PLANS SIHO - ALL PLANS 247.5 90 999999999 166.51 266.75 percent of total billed charges "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 50724371_1 CDM 0302 RC 86812 HCPCS inpatient 275 178.75 UMR - ALL PLANS UMR - ALL PLANS 192.5 70 999999999 166.51 266.75 percent of total billed charges "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 50724371_1 CDM 0302 RC 86812 HCPCS inpatient 275 178.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 166.51 60.55 999999999 166.51 266.75 percent of total billed charges "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 50724371_1 CDM 0302 RC 86812 HCPCS inpatient 275 178.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 166.51 266.75 "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 50724371_1 CDM 0302 RC 86812 HCPCS inpatient 275 178.75 ANTHEM HMO ANTHEM HMO 999999999 166.51 266.75 "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 50724371_1 CDM 0302 RC 86812 HCPCS inpatient 275 178.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 166.51 266.75 "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 50724371_1 CDM 0302 RC 86812 HCPCS inpatient 275 178.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.9 67.6 999999999 166.51 266.75 percent of total billed charges "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 50724371_1 CDM 0302 RC 86812 HCPCS inpatient 275 178.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 166.51 266.75 "Immunologic analysis for autoimmune disease, A, B, or C, single antigen" 50724371_1 CDM 0302 RC 86812 HCPCS inpatient 275 178.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 166.51 266.75 QUETIAPINE FUMARATE 25 MG TAB 50725301_1 CDM 0250 RC 00904-6638-61 NDC inpatient 1 UN 1.42 0.92 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.92 65 999999999 0.86 1.38 percent of total billed charges QUETIAPINE FUMARATE 25 MG TAB 50725301_1 CDM 0250 RC 00904-6638-61 NDC inpatient 1 UN 1.42 0.92 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.38 97 999999999 0.86 1.38 percent of total billed charges QUETIAPINE FUMARATE 25 MG TAB 50725301_1 CDM 0250 RC 00904-6638-61 NDC inpatient 1 UN 1.42 0.92 AETNA AETNA 1.12 79 999999999 0.86 1.38 percent of total billed charges QUETIAPINE FUMARATE 25 MG TAB 50725301_1 CDM 0250 RC 00904-6638-61 NDC inpatient 1 UN 1.42 0.92 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.11 78 999999999 0.86 1.38 percent of total billed charges QUETIAPINE FUMARATE 25 MG TAB 50725301_1 CDM 0250 RC 00904-6638-61 NDC inpatient 1 UN 1.42 0.92 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.98 69 999999999 0.86 1.38 percent of total billed charges QUETIAPINE FUMARATE 25 MG TAB 50725301_1 CDM 0250 RC 00904-6638-61 NDC inpatient 1 UN 1.42 0.92 SIHO - ALL PLANS SIHO - ALL PLANS 1.28 90 999999999 0.86 1.38 percent of total billed charges QUETIAPINE FUMARATE 25 MG TAB 50725301_1 CDM 0250 RC 00904-6638-61 NDC inpatient 1 UN 1.42 0.92 UMR - ALL PLANS UMR - ALL PLANS 0.99 70 999999999 0.86 1.38 percent of total billed charges QUETIAPINE FUMARATE 25 MG TAB 50725301_1 CDM 0250 RC 00904-6638-61 NDC inpatient 1 UN 1.42 0.92 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.86 60.55 999999999 0.86 1.38 percent of total billed charges QUETIAPINE FUMARATE 25 MG TAB 50725301_1 CDM 0250 RC 00904-6638-61 NDC inpatient 1 UN 1.42 0.92 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.86 1.38 QUETIAPINE FUMARATE 25 MG TAB 50725301_1 CDM 0250 RC 00904-6638-61 NDC inpatient 1 UN 1.42 0.92 ANTHEM HMO ANTHEM HMO 999999999 0.86 1.38 QUETIAPINE FUMARATE 25 MG TAB 50725301_1 CDM 0250 RC 00904-6638-61 NDC inpatient 1 UN 1.42 0.92 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.86 1.38 QUETIAPINE FUMARATE 25 MG TAB 50725301_1 CDM 0250 RC 00904-6638-61 NDC inpatient 1 UN 1.42 0.92 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.96 67.6 999999999 0.86 1.38 percent of total billed charges QUETIAPINE FUMARATE 25 MG TAB 50725301_1 CDM 0250 RC 00904-6638-61 NDC inpatient 1 UN 1.42 0.92 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.86 1.38 QUETIAPINE FUMARATE 25 MG TAB 50725301_1 CDM 0250 RC 00904-6638-61 NDC inpatient 1 UN 1.42 0.92 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.86 1.38 CEPHALEXIN 250 MG/5 ML SUSP 50728003_1 CDM 0250 RC 67877-0545-88 NDC inpatient 1 UN 57.67 37.49 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.49 65 999999999 34.92 55.94 percent of total billed charges CEPHALEXIN 250 MG/5 ML SUSP 50728003_1 CDM 0250 RC 67877-0545-88 NDC inpatient 1 UN 57.67 37.49 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55.94 97 999999999 34.92 55.94 percent of total billed charges CEPHALEXIN 250 MG/5 ML SUSP 50728003_1 CDM 0250 RC 67877-0545-88 NDC inpatient 1 UN 57.67 37.49 AETNA AETNA 45.56 79 999999999 34.92 55.94 percent of total billed charges CEPHALEXIN 250 MG/5 ML SUSP 50728003_1 CDM 0250 RC 67877-0545-88 NDC inpatient 1 UN 57.67 37.49 HUMANA - ALL PLANS HUMANA - ALL PLANS 44.98 78 999999999 34.92 55.94 percent of total billed charges CEPHALEXIN 250 MG/5 ML SUSP 50728003_1 CDM 0250 RC 67877-0545-88 NDC inpatient 1 UN 57.67 37.49 ENCORE - ALL PLANS ENCORE - ALL PLANS 39.79 69 999999999 34.92 55.94 percent of total billed charges CEPHALEXIN 250 MG/5 ML SUSP 50728003_1 CDM 0250 RC 67877-0545-88 NDC inpatient 1 UN 57.67 37.49 SIHO - ALL PLANS SIHO - ALL PLANS 51.9 90 999999999 34.92 55.94 percent of total billed charges CEPHALEXIN 250 MG/5 ML SUSP 50728003_1 CDM 0250 RC 67877-0545-88 NDC inpatient 1 UN 57.67 37.49 UMR - ALL PLANS UMR - ALL PLANS 40.37 70 999999999 34.92 55.94 percent of total billed charges CEPHALEXIN 250 MG/5 ML SUSP 50728003_1 CDM 0250 RC 67877-0545-88 NDC inpatient 1 UN 57.67 37.49 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34.92 60.55 999999999 34.92 55.94 percent of total billed charges CEPHALEXIN 250 MG/5 ML SUSP 50728003_1 CDM 0250 RC 67877-0545-88 NDC inpatient 1 UN 57.67 37.49 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 34.92 55.94 CEPHALEXIN 250 MG/5 ML SUSP 50728003_1 CDM 0250 RC 67877-0545-88 NDC inpatient 1 UN 57.67 37.49 ANTHEM HMO ANTHEM HMO 999999999 34.92 55.94 CEPHALEXIN 250 MG/5 ML SUSP 50728003_1 CDM 0250 RC 67877-0545-88 NDC inpatient 1 UN 57.67 37.49 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 34.92 55.94 CEPHALEXIN 250 MG/5 ML SUSP 50728003_1 CDM 0250 RC 67877-0545-88 NDC inpatient 1 UN 57.67 37.49 CIGNA - ALL PLANS CIGNA - ALL PLANS 38.98 67.6 999999999 34.92 55.94 percent of total billed charges CEPHALEXIN 250 MG/5 ML SUSP 50728003_1 CDM 0250 RC 67877-0545-88 NDC inpatient 1 UN 57.67 37.49 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 34.92 55.94 CEPHALEXIN 250 MG/5 ML SUSP 50728003_1 CDM 0250 RC 67877-0545-88 NDC inpatient 1 UN 57.67 37.49 UHC - ALL PLANS UHC - ALL PLANS 999999999 34.92 55.94 INFANTS' SIMETHICONE DROPS 50728407_1 CDM 0250 RC 00536-1303-75 NDC inpatient 1 UN 7.84 5.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.1 65 999999999 4.75 7.6 percent of total billed charges INFANTS' SIMETHICONE DROPS 50728407_1 CDM 0250 RC 00536-1303-75 NDC inpatient 1 UN 7.84 5.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7.6 97 999999999 4.75 7.6 percent of total billed charges INFANTS' SIMETHICONE DROPS 50728407_1 CDM 0250 RC 00536-1303-75 NDC inpatient 1 UN 7.84 5.1 AETNA AETNA 6.19 79 999999999 4.75 7.6 percent of total billed charges INFANTS' SIMETHICONE DROPS 50728407_1 CDM 0250 RC 00536-1303-75 NDC inpatient 1 UN 7.84 5.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.12 78 999999999 4.75 7.6 percent of total billed charges INFANTS' SIMETHICONE DROPS 50728407_1 CDM 0250 RC 00536-1303-75 NDC inpatient 1 UN 7.84 5.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 5.41 69 999999999 4.75 7.6 percent of total billed charges INFANTS' SIMETHICONE DROPS 50728407_1 CDM 0250 RC 00536-1303-75 NDC inpatient 1 UN 7.84 5.1 SIHO - ALL PLANS SIHO - ALL PLANS 7.06 90 999999999 4.75 7.6 percent of total billed charges INFANTS' SIMETHICONE DROPS 50728407_1 CDM 0250 RC 00536-1303-75 NDC inpatient 1 UN 7.84 5.1 UMR - ALL PLANS UMR - ALL PLANS 5.49 70 999999999 4.75 7.6 percent of total billed charges INFANTS' SIMETHICONE DROPS 50728407_1 CDM 0250 RC 00536-1303-75 NDC inpatient 1 UN 7.84 5.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4.75 60.55 999999999 4.75 7.6 percent of total billed charges INFANTS' SIMETHICONE DROPS 50728407_1 CDM 0250 RC 00536-1303-75 NDC inpatient 1 UN 7.84 5.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4.75 7.6 INFANTS' SIMETHICONE DROPS 50728407_1 CDM 0250 RC 00536-1303-75 NDC inpatient 1 UN 7.84 5.1 ANTHEM HMO ANTHEM HMO 999999999 4.75 7.6 INFANTS' SIMETHICONE DROPS 50728407_1 CDM 0250 RC 00536-1303-75 NDC inpatient 1 UN 7.84 5.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4.75 7.6 INFANTS' SIMETHICONE DROPS 50728407_1 CDM 0250 RC 00536-1303-75 NDC inpatient 1 UN 7.84 5.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.3 67.6 999999999 4.75 7.6 percent of total billed charges INFANTS' SIMETHICONE DROPS 50728407_1 CDM 0250 RC 00536-1303-75 NDC inpatient 1 UN 7.84 5.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4.75 7.6 INFANTS' SIMETHICONE DROPS 50728407_1 CDM 0250 RC 00536-1303-75 NDC inpatient 1 UN 7.84 5.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 4.75 7.6 ROPINIROLE HCL 1 MG TABLET 50728608_1 CDM 0250 RC 00904-6374-61 NDC inpatient 1 UN 2.43 1.58 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.58 65 999999999 1.47 2.36 percent of total billed charges ROPINIROLE HCL 1 MG TABLET 50728608_1 CDM 0250 RC 00904-6374-61 NDC inpatient 1 UN 2.43 1.58 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.36 97 999999999 1.47 2.36 percent of total billed charges ROPINIROLE HCL 1 MG TABLET 50728608_1 CDM 0250 RC 00904-6374-61 NDC inpatient 1 UN 2.43 1.58 AETNA AETNA 1.92 79 999999999 1.47 2.36 percent of total billed charges ROPINIROLE HCL 1 MG TABLET 50728608_1 CDM 0250 RC 00904-6374-61 NDC inpatient 1 UN 2.43 1.58 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.9 78 999999999 1.47 2.36 percent of total billed charges ROPINIROLE HCL 1 MG TABLET 50728608_1 CDM 0250 RC 00904-6374-61 NDC inpatient 1 UN 2.43 1.58 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.68 69 999999999 1.47 2.36 percent of total billed charges ROPINIROLE HCL 1 MG TABLET 50728608_1 CDM 0250 RC 00904-6374-61 NDC inpatient 1 UN 2.43 1.58 SIHO - ALL PLANS SIHO - ALL PLANS 2.19 90 999999999 1.47 2.36 percent of total billed charges ROPINIROLE HCL 1 MG TABLET 50728608_1 CDM 0250 RC 00904-6374-61 NDC inpatient 1 UN 2.43 1.58 UMR - ALL PLANS UMR - ALL PLANS 1.7 70 999999999 1.47 2.36 percent of total billed charges ROPINIROLE HCL 1 MG TABLET 50728608_1 CDM 0250 RC 00904-6374-61 NDC inpatient 1 UN 2.43 1.58 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.47 60.55 999999999 1.47 2.36 percent of total billed charges ROPINIROLE HCL 1 MG TABLET 50728608_1 CDM 0250 RC 00904-6374-61 NDC inpatient 1 UN 2.43 1.58 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.47 2.36 ROPINIROLE HCL 1 MG TABLET 50728608_1 CDM 0250 RC 00904-6374-61 NDC inpatient 1 UN 2.43 1.58 ANTHEM HMO ANTHEM HMO 999999999 1.47 2.36 ROPINIROLE HCL 1 MG TABLET 50728608_1 CDM 0250 RC 00904-6374-61 NDC inpatient 1 UN 2.43 1.58 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.47 2.36 ROPINIROLE HCL 1 MG TABLET 50728608_1 CDM 0250 RC 00904-6374-61 NDC inpatient 1 UN 2.43 1.58 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.64 67.6 999999999 1.47 2.36 percent of total billed charges ROPINIROLE HCL 1 MG TABLET 50728608_1 CDM 0250 RC 00904-6374-61 NDC inpatient 1 UN 2.43 1.58 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.47 2.36 ROPINIROLE HCL 1 MG TABLET 50728608_1 CDM 0250 RC 00904-6374-61 NDC inpatient 1 UN 2.43 1.58 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.47 2.36 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50728617_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 272.35 65 999999999 253.7 406.43 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50728617_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 406.43 97 999999999 253.7 406.43 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50728617_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 AETNA AETNA 331.01 79 999999999 253.7 406.43 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50728617_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 326.82 78 999999999 253.7 406.43 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50728617_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 289.11 69 999999999 253.7 406.43 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50728617_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 SIHO - ALL PLANS SIHO - ALL PLANS 377.1 90 999999999 253.7 406.43 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50728617_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 UMR - ALL PLANS UMR - ALL PLANS 293.3 70 999999999 253.7 406.43 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50728617_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 253.7 60.55 999999999 253.7 406.43 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50728617_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 253.7 406.43 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50728617_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 ANTHEM HMO ANTHEM HMO 999999999 253.7 406.43 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50728617_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 253.7 406.43 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50728617_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 283.24 67.6 999999999 253.7 406.43 percent of total billed charges Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50728617_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 253.7 406.43 Detection test by immunoassay technique for Histoplasma capsulatum (parasite) 50728617_1 CDM 0301 RC 87385 HCPCS inpatient 419 272.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 253.7 406.43 Detection test by immunoassay technique for other organism 50729077_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.3 65 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 50729077_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 176.54 97 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 50729077_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 AETNA AETNA 143.78 79 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 50729077_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.96 78 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 50729077_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 125.58 69 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 50729077_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 SIHO - ALL PLANS SIHO - ALL PLANS 163.8 90 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 50729077_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 UMR - ALL PLANS UMR - ALL PLANS 127.4 70 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 50729077_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.2 60.55 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 50729077_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.2 176.54 Detection test by immunoassay technique for other organism 50729077_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 ANTHEM HMO ANTHEM HMO 999999999 110.2 176.54 Detection test by immunoassay technique for other organism 50729077_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.2 176.54 Detection test by immunoassay technique for other organism 50729077_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.03 67.6 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 50729077_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.2 176.54 Detection test by immunoassay technique for other organism 50729077_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.2 176.54 METOCLOPRAMIDE 5 MG TABLET 50729276_1 CDM 0250 RC 51079-0886-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 5 MG TABLET 50729276_1 CDM 0250 RC 51079-0886-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 5 MG TABLET 50729276_1 CDM 0250 RC 51079-0886-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 5 MG TABLET 50729276_1 CDM 0250 RC 51079-0886-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 5 MG TABLET 50729276_1 CDM 0250 RC 51079-0886-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 5 MG TABLET 50729276_1 CDM 0250 RC 51079-0886-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 5 MG TABLET 50729276_1 CDM 0250 RC 51079-0886-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 5 MG TABLET 50729276_1 CDM 0250 RC 51079-0886-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 5 MG TABLET 50729276_1 CDM 0250 RC 51079-0886-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 METOCLOPRAMIDE 5 MG TABLET 50729276_1 CDM 0250 RC 51079-0886-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 METOCLOPRAMIDE 5 MG TABLET 50729276_1 CDM 0250 RC 51079-0886-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 METOCLOPRAMIDE 5 MG TABLET 50729276_1 CDM 0250 RC 51079-0886-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges METOCLOPRAMIDE 5 MG TABLET 50729276_1 CDM 0250 RC 51079-0886-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 METOCLOPRAMIDE 5 MG TABLET 50729276_1 CDM 0250 RC 51079-0886-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, BUTORPHANOL TARTRATE, 1 MG" 50729463_1 CDM 0250 RC 00409-1626-01 NDC J0595 HCPCS inpatient 2 UN 42.67 27.74 SELF PAY DISCOUNT SELF PAY DISCOUNT 27.74 65 999999999 25.84 41.39 percent of total billed charges "INJECTION, BUTORPHANOL TARTRATE, 1 MG" 50729463_1 CDM 0250 RC 00409-1626-01 NDC J0595 HCPCS inpatient 2 UN 42.67 27.74 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 41.39 97 999999999 25.84 41.39 percent of total billed charges "INJECTION, BUTORPHANOL TARTRATE, 1 MG" 50729463_1 CDM 0250 RC 00409-1626-01 NDC J0595 HCPCS inpatient 2 UN 42.67 27.74 AETNA AETNA 33.71 79 999999999 25.84 41.39 percent of total billed charges "INJECTION, BUTORPHANOL TARTRATE, 1 MG" 50729463_1 CDM 0250 RC 00409-1626-01 NDC J0595 HCPCS inpatient 2 UN 42.67 27.74 HUMANA - ALL PLANS HUMANA - ALL PLANS 33.28 78 999999999 25.84 41.39 percent of total billed charges "INJECTION, BUTORPHANOL TARTRATE, 1 MG" 50729463_1 CDM 0250 RC 00409-1626-01 NDC J0595 HCPCS inpatient 2 UN 42.67 27.74 ENCORE - ALL PLANS ENCORE - ALL PLANS 29.44 69 999999999 25.84 41.39 percent of total billed charges "INJECTION, BUTORPHANOL TARTRATE, 1 MG" 50729463_1 CDM 0250 RC 00409-1626-01 NDC J0595 HCPCS inpatient 2 UN 42.67 27.74 SIHO - ALL PLANS SIHO - ALL PLANS 38.4 90 999999999 25.84 41.39 percent of total billed charges "INJECTION, BUTORPHANOL TARTRATE, 1 MG" 50729463_1 CDM 0250 RC 00409-1626-01 NDC J0595 HCPCS inpatient 2 UN 42.67 27.74 UMR - ALL PLANS UMR - ALL PLANS 29.87 70 999999999 25.84 41.39 percent of total billed charges "INJECTION, BUTORPHANOL TARTRATE, 1 MG" 50729463_1 CDM 0250 RC 00409-1626-01 NDC J0595 HCPCS inpatient 2 UN 42.67 27.74 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 25.84 60.55 999999999 25.84 41.39 percent of total billed charges "INJECTION, BUTORPHANOL TARTRATE, 1 MG" 50729463_1 CDM 0250 RC 00409-1626-01 NDC J0595 HCPCS inpatient 2 UN 42.67 27.74 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 25.84 41.39 "INJECTION, BUTORPHANOL TARTRATE, 1 MG" 50729463_1 CDM 0250 RC 00409-1626-01 NDC J0595 HCPCS inpatient 2 UN 42.67 27.74 ANTHEM HMO ANTHEM HMO 999999999 25.84 41.39 "INJECTION, BUTORPHANOL TARTRATE, 1 MG" 50729463_1 CDM 0250 RC 00409-1626-01 NDC J0595 HCPCS inpatient 2 UN 42.67 27.74 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 25.84 41.39 "INJECTION, BUTORPHANOL TARTRATE, 1 MG" 50729463_1 CDM 0250 RC 00409-1626-01 NDC J0595 HCPCS inpatient 2 UN 42.67 27.74 CIGNA - ALL PLANS CIGNA - ALL PLANS 28.84 67.6 999999999 25.84 41.39 percent of total billed charges "INJECTION, BUTORPHANOL TARTRATE, 1 MG" 50729463_1 CDM 0250 RC 00409-1626-01 NDC J0595 HCPCS inpatient 2 UN 42.67 27.74 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 25.84 41.39 "INJECTION, BUTORPHANOL TARTRATE, 1 MG" 50729463_1 CDM 0250 RC 00409-1626-01 NDC J0595 HCPCS inpatient 2 UN 42.67 27.74 UHC - ALL PLANS UHC - ALL PLANS 999999999 25.84 41.39 Insertion of spinal neurostimulator electrode array through skin 50729498_1 CDM 0360 RC 63650 HCPCS inpatient 16979 11036.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 11036.35 65 999999999 10280.78 16469.63 percent of total billed charges Insertion of spinal neurostimulator electrode array through skin 50729498_1 CDM 0360 RC 63650 HCPCS inpatient 16979 11036.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16469.63 97 999999999 10280.78 16469.63 percent of total billed charges Insertion of spinal neurostimulator electrode array through skin 50729498_1 CDM 0360 RC 63650 HCPCS inpatient 16979 11036.35 AETNA AETNA 13413.41 79 999999999 10280.78 16469.63 percent of total billed charges Insertion of spinal neurostimulator electrode array through skin 50729498_1 CDM 0360 RC 63650 HCPCS inpatient 16979 11036.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 13243.62 78 999999999 10280.78 16469.63 percent of total billed charges Insertion of spinal neurostimulator electrode array through skin 50729498_1 CDM 0360 RC 63650 HCPCS inpatient 16979 11036.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 11715.51 69 999999999 10280.78 16469.63 percent of total billed charges Insertion of spinal neurostimulator electrode array through skin 50729498_1 CDM 0360 RC 63650 HCPCS inpatient 16979 11036.35 SIHO - ALL PLANS SIHO - ALL PLANS 15281.1 90 999999999 10280.78 16469.63 percent of total billed charges Insertion of spinal neurostimulator electrode array through skin 50729498_1 CDM 0360 RC 63650 HCPCS inpatient 16979 11036.35 UMR - ALL PLANS UMR - ALL PLANS 11885.3 70 999999999 10280.78 16469.63 percent of total billed charges Insertion of spinal neurostimulator electrode array through skin 50729498_1 CDM 0360 RC 63650 HCPCS inpatient 16979 11036.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10280.78 60.55 999999999 10280.78 16469.63 percent of total billed charges Insertion of spinal neurostimulator electrode array through skin 50729498_1 CDM 0360 RC 63650 HCPCS inpatient 16979 11036.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10280.78 16469.63 Insertion of spinal neurostimulator electrode array through skin 50729498_1 CDM 0360 RC 63650 HCPCS inpatient 16979 11036.35 ANTHEM HMO ANTHEM HMO 999999999 10280.78 16469.63 Insertion of spinal neurostimulator electrode array through skin 50729498_1 CDM 0360 RC 63650 HCPCS inpatient 16979 11036.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10280.78 16469.63 Insertion of spinal neurostimulator electrode array through skin 50729498_1 CDM 0360 RC 63650 HCPCS inpatient 16979 11036.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 11477.8 67.6 999999999 10280.78 16469.63 percent of total billed charges Insertion of spinal neurostimulator electrode array through skin 50729498_1 CDM 0360 RC 63650 HCPCS inpatient 16979 11036.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10280.78 16469.63 Insertion of spinal neurostimulator electrode array through skin 50729498_1 CDM 0360 RC 63650 HCPCS inpatient 16979 11036.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 10280.78 16469.63 "INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR, (INFLECTRA), 10 MG" 50730094_1 CDM 0636 RC 00069-0809-01 NDC Q5103 HCPCS inpatient 10 UN 2376.61 1544.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1544.8 65 999999999 1439.04 2305.31 percent of total billed charges "INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR, (INFLECTRA), 10 MG" 50730094_1 CDM 0636 RC 00069-0809-01 NDC Q5103 HCPCS inpatient 10 UN 2376.61 1544.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2305.31 97 999999999 1439.04 2305.31 percent of total billed charges "INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR, (INFLECTRA), 10 MG" 50730094_1 CDM 0636 RC 00069-0809-01 NDC Q5103 HCPCS inpatient 10 UN 2376.61 1544.8 AETNA AETNA 1877.52 79 999999999 1439.04 2305.31 percent of total billed charges "INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR, (INFLECTRA), 10 MG" 50730094_1 CDM 0636 RC 00069-0809-01 NDC Q5103 HCPCS inpatient 10 UN 2376.61 1544.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1853.76 78 999999999 1439.04 2305.31 percent of total billed charges "INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR, (INFLECTRA), 10 MG" 50730094_1 CDM 0636 RC 00069-0809-01 NDC Q5103 HCPCS inpatient 10 UN 2376.61 1544.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1639.86 69 999999999 1439.04 2305.31 percent of total billed charges "INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR, (INFLECTRA), 10 MG" 50730094_1 CDM 0636 RC 00069-0809-01 NDC Q5103 HCPCS inpatient 10 UN 2376.61 1544.8 SIHO - ALL PLANS SIHO - ALL PLANS 2138.95 90 999999999 1439.04 2305.31 percent of total billed charges "INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR, (INFLECTRA), 10 MG" 50730094_1 CDM 0636 RC 00069-0809-01 NDC Q5103 HCPCS inpatient 10 UN 2376.61 1544.8 UMR - ALL PLANS UMR - ALL PLANS 1663.63 70 999999999 1439.04 2305.31 percent of total billed charges "INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR, (INFLECTRA), 10 MG" 50730094_1 CDM 0636 RC 00069-0809-01 NDC Q5103 HCPCS inpatient 10 UN 2376.61 1544.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1439.04 60.55 999999999 1439.04 2305.31 percent of total billed charges "INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR, (INFLECTRA), 10 MG" 50730094_1 CDM 0636 RC 00069-0809-01 NDC Q5103 HCPCS inpatient 10 UN 2376.61 1544.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1439.04 2305.31 "INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR, (INFLECTRA), 10 MG" 50730094_1 CDM 0636 RC 00069-0809-01 NDC Q5103 HCPCS inpatient 10 UN 2376.61 1544.8 ANTHEM HMO ANTHEM HMO 999999999 1439.04 2305.31 "INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR, (INFLECTRA), 10 MG" 50730094_1 CDM 0636 RC 00069-0809-01 NDC Q5103 HCPCS inpatient 10 UN 2376.61 1544.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1439.04 2305.31 "INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR, (INFLECTRA), 10 MG" 50730094_1 CDM 0636 RC 00069-0809-01 NDC Q5103 HCPCS inpatient 10 UN 2376.61 1544.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1606.59 67.6 999999999 1439.04 2305.31 percent of total billed charges "INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR, (INFLECTRA), 10 MG" 50730094_1 CDM 0636 RC 00069-0809-01 NDC Q5103 HCPCS inpatient 10 UN 2376.61 1544.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1439.04 2305.31 "INJECTION, INFLIXIMAB-DYYB, BIOSIMILAR, (INFLECTRA), 10 MG" 50730094_1 CDM 0636 RC 00069-0809-01 NDC Q5103 HCPCS inpatient 10 UN 2376.61 1544.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1439.04 2305.31 BUPROPION HCL XL 300 MG TABLET 50730392_1 CDM 0250 RC 63304-0724-30 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges BUPROPION HCL XL 300 MG TABLET 50730392_1 CDM 0250 RC 63304-0724-30 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges BUPROPION HCL XL 300 MG TABLET 50730392_1 CDM 0250 RC 63304-0724-30 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges BUPROPION HCL XL 300 MG TABLET 50730392_1 CDM 0250 RC 63304-0724-30 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges BUPROPION HCL XL 300 MG TABLET 50730392_1 CDM 0250 RC 63304-0724-30 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges BUPROPION HCL XL 300 MG TABLET 50730392_1 CDM 0250 RC 63304-0724-30 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges BUPROPION HCL XL 300 MG TABLET 50730392_1 CDM 0250 RC 63304-0724-30 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges BUPROPION HCL XL 300 MG TABLET 50730392_1 CDM 0250 RC 63304-0724-30 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges BUPROPION HCL XL 300 MG TABLET 50730392_1 CDM 0250 RC 63304-0724-30 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 BUPROPION HCL XL 300 MG TABLET 50730392_1 CDM 0250 RC 63304-0724-30 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 BUPROPION HCL XL 300 MG TABLET 50730392_1 CDM 0250 RC 63304-0724-30 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 BUPROPION HCL XL 300 MG TABLET 50730392_1 CDM 0250 RC 63304-0724-30 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges BUPROPION HCL XL 300 MG TABLET 50730392_1 CDM 0250 RC 63304-0724-30 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 BUPROPION HCL XL 300 MG TABLET 50730392_1 CDM 0250 RC 63304-0724-30 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, AZITHROMYCIN, 500 MG" 50730880_1 CDM 0250 RC 62756-0512-44 NDC J0456 HCPCS inpatient 1 UN 60.88 39.57 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.57 65 999999999 36.86 59.05 percent of total billed charges "INJECTION, AZITHROMYCIN, 500 MG" 50730880_1 CDM 0250 RC 62756-0512-44 NDC J0456 HCPCS inpatient 1 UN 60.88 39.57 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59.05 97 999999999 36.86 59.05 percent of total billed charges "INJECTION, AZITHROMYCIN, 500 MG" 50730880_1 CDM 0250 RC 62756-0512-44 NDC J0456 HCPCS inpatient 1 UN 60.88 39.57 AETNA AETNA 48.1 79 999999999 36.86 59.05 percent of total billed charges "INJECTION, AZITHROMYCIN, 500 MG" 50730880_1 CDM 0250 RC 62756-0512-44 NDC J0456 HCPCS inpatient 1 UN 60.88 39.57 HUMANA - ALL PLANS HUMANA - ALL PLANS 47.49 78 999999999 36.86 59.05 percent of total billed charges "INJECTION, AZITHROMYCIN, 500 MG" 50730880_1 CDM 0250 RC 62756-0512-44 NDC J0456 HCPCS inpatient 1 UN 60.88 39.57 ENCORE - ALL PLANS ENCORE - ALL PLANS 42.01 69 999999999 36.86 59.05 percent of total billed charges "INJECTION, AZITHROMYCIN, 500 MG" 50730880_1 CDM 0250 RC 62756-0512-44 NDC J0456 HCPCS inpatient 1 UN 60.88 39.57 SIHO - ALL PLANS SIHO - ALL PLANS 54.79 90 999999999 36.86 59.05 percent of total billed charges "INJECTION, AZITHROMYCIN, 500 MG" 50730880_1 CDM 0250 RC 62756-0512-44 NDC J0456 HCPCS inpatient 1 UN 60.88 39.57 UMR - ALL PLANS UMR - ALL PLANS 42.62 70 999999999 36.86 59.05 percent of total billed charges "INJECTION, AZITHROMYCIN, 500 MG" 50730880_1 CDM 0250 RC 62756-0512-44 NDC J0456 HCPCS inpatient 1 UN 60.88 39.57 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.86 60.55 999999999 36.86 59.05 percent of total billed charges "INJECTION, AZITHROMYCIN, 500 MG" 50730880_1 CDM 0250 RC 62756-0512-44 NDC J0456 HCPCS inpatient 1 UN 60.88 39.57 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.86 59.05 "INJECTION, AZITHROMYCIN, 500 MG" 50730880_1 CDM 0250 RC 62756-0512-44 NDC J0456 HCPCS inpatient 1 UN 60.88 39.57 ANTHEM HMO ANTHEM HMO 999999999 36.86 59.05 "INJECTION, AZITHROMYCIN, 500 MG" 50730880_1 CDM 0250 RC 62756-0512-44 NDC J0456 HCPCS inpatient 1 UN 60.88 39.57 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.86 59.05 "INJECTION, AZITHROMYCIN, 500 MG" 50730880_1 CDM 0250 RC 62756-0512-44 NDC J0456 HCPCS inpatient 1 UN 60.88 39.57 CIGNA - ALL PLANS CIGNA - ALL PLANS 41.15 67.6 999999999 36.86 59.05 percent of total billed charges "INJECTION, AZITHROMYCIN, 500 MG" 50730880_1 CDM 0250 RC 62756-0512-44 NDC J0456 HCPCS inpatient 1 UN 60.88 39.57 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.86 59.05 "INJECTION, AZITHROMYCIN, 500 MG" 50730880_1 CDM 0250 RC 62756-0512-44 NDC J0456 HCPCS inpatient 1 UN 60.88 39.57 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.86 59.05 LEVOTHYROXINE 137 MCG TABLET 50731399_1 CDM 0250 RC 60687-0563-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 137 MCG TABLET 50731399_1 CDM 0250 RC 60687-0563-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 137 MCG TABLET 50731399_1 CDM 0250 RC 60687-0563-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 137 MCG TABLET 50731399_1 CDM 0250 RC 60687-0563-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 137 MCG TABLET 50731399_1 CDM 0250 RC 60687-0563-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 137 MCG TABLET 50731399_1 CDM 0250 RC 60687-0563-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 137 MCG TABLET 50731399_1 CDM 0250 RC 60687-0563-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 137 MCG TABLET 50731399_1 CDM 0250 RC 60687-0563-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 137 MCG TABLET 50731399_1 CDM 0250 RC 60687-0563-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LEVOTHYROXINE 137 MCG TABLET 50731399_1 CDM 0250 RC 60687-0563-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LEVOTHYROXINE 137 MCG TABLET 50731399_1 CDM 0250 RC 60687-0563-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 137 MCG TABLET 50731399_1 CDM 0250 RC 60687-0563-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 137 MCG TABLET 50731399_1 CDM 0250 RC 60687-0563-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 137 MCG TABLET 50731399_1 CDM 0250 RC 60687-0563-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 Chemistry procedures 50731459_1 CDM 0302 RC 84999 HCPCS inpatient 94 61.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.1 65 999999999 56.92 91.18 percent of total billed charges Chemistry procedures 50731459_1 CDM 0302 RC 84999 HCPCS inpatient 94 61.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.18 97 999999999 56.92 91.18 percent of total billed charges Chemistry procedures 50731459_1 CDM 0302 RC 84999 HCPCS inpatient 94 61.1 AETNA AETNA 74.26 79 999999999 56.92 91.18 percent of total billed charges Chemistry procedures 50731459_1 CDM 0302 RC 84999 HCPCS inpatient 94 61.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.32 78 999999999 56.92 91.18 percent of total billed charges Chemistry procedures 50731459_1 CDM 0302 RC 84999 HCPCS inpatient 94 61.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.86 69 999999999 56.92 91.18 percent of total billed charges Chemistry procedures 50731459_1 CDM 0302 RC 84999 HCPCS inpatient 94 61.1 SIHO - ALL PLANS SIHO - ALL PLANS 84.6 90 999999999 56.92 91.18 percent of total billed charges Chemistry procedures 50731459_1 CDM 0302 RC 84999 HCPCS inpatient 94 61.1 UMR - ALL PLANS UMR - ALL PLANS 65.8 70 999999999 56.92 91.18 percent of total billed charges Chemistry procedures 50731459_1 CDM 0302 RC 84999 HCPCS inpatient 94 61.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.92 60.55 999999999 56.92 91.18 percent of total billed charges Chemistry procedures 50731459_1 CDM 0302 RC 84999 HCPCS inpatient 94 61.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.92 91.18 Chemistry procedures 50731459_1 CDM 0302 RC 84999 HCPCS inpatient 94 61.1 ANTHEM HMO ANTHEM HMO 999999999 56.92 91.18 Chemistry procedures 50731459_1 CDM 0302 RC 84999 HCPCS inpatient 94 61.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.92 91.18 Chemistry procedures 50731459_1 CDM 0302 RC 84999 HCPCS inpatient 94 61.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.54 67.6 999999999 56.92 91.18 percent of total billed charges Chemistry procedures 50731459_1 CDM 0302 RC 84999 HCPCS inpatient 94 61.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.92 91.18 Chemistry procedures 50731459_1 CDM 0302 RC 84999 HCPCS inpatient 94 61.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.92 91.18 Blood typing for Rh (D) antigen 50731460_1 CDM 0302 RC 86901 HCPCS inpatient 85 55.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.25 65 999999999 51.47 82.45 percent of total billed charges Blood typing for Rh (D) antigen 50731460_1 CDM 0302 RC 86901 HCPCS inpatient 85 55.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 82.45 97 999999999 51.47 82.45 percent of total billed charges Blood typing for Rh (D) antigen 50731460_1 CDM 0302 RC 86901 HCPCS inpatient 85 55.25 AETNA AETNA 67.15 79 999999999 51.47 82.45 percent of total billed charges Blood typing for Rh (D) antigen 50731460_1 CDM 0302 RC 86901 HCPCS inpatient 85 55.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 66.3 78 999999999 51.47 82.45 percent of total billed charges Blood typing for Rh (D) antigen 50731460_1 CDM 0302 RC 86901 HCPCS inpatient 85 55.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 58.65 69 999999999 51.47 82.45 percent of total billed charges Blood typing for Rh (D) antigen 50731460_1 CDM 0302 RC 86901 HCPCS inpatient 85 55.25 SIHO - ALL PLANS SIHO - ALL PLANS 76.5 90 999999999 51.47 82.45 percent of total billed charges Blood typing for Rh (D) antigen 50731460_1 CDM 0302 RC 86901 HCPCS inpatient 85 55.25 UMR - ALL PLANS UMR - ALL PLANS 59.5 70 999999999 51.47 82.45 percent of total billed charges Blood typing for Rh (D) antigen 50731460_1 CDM 0302 RC 86901 HCPCS inpatient 85 55.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 51.47 60.55 999999999 51.47 82.45 percent of total billed charges Blood typing for Rh (D) antigen 50731460_1 CDM 0302 RC 86901 HCPCS inpatient 85 55.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 51.47 82.45 Blood typing for Rh (D) antigen 50731460_1 CDM 0302 RC 86901 HCPCS inpatient 85 55.25 ANTHEM HMO ANTHEM HMO 999999999 51.47 82.45 Blood typing for Rh (D) antigen 50731460_1 CDM 0302 RC 86901 HCPCS inpatient 85 55.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 51.47 82.45 Blood typing for Rh (D) antigen 50731460_1 CDM 0302 RC 86901 HCPCS inpatient 85 55.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 57.46 67.6 999999999 51.47 82.45 percent of total billed charges Blood typing for Rh (D) antigen 50731460_1 CDM 0302 RC 86901 HCPCS inpatient 85 55.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 51.47 82.45 Blood typing for Rh (D) antigen 50731460_1 CDM 0302 RC 86901 HCPCS inpatient 85 55.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 51.47 82.45 "Blood unit compatibility test, antiglobulin technique" 50731461_1 CDM 0302 RC 86922 HCPCS inpatient 94 61.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.1 65 999999999 56.92 91.18 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 50731461_1 CDM 0302 RC 86922 HCPCS inpatient 94 61.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.18 97 999999999 56.92 91.18 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 50731461_1 CDM 0302 RC 86922 HCPCS inpatient 94 61.1 AETNA AETNA 74.26 79 999999999 56.92 91.18 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 50731461_1 CDM 0302 RC 86922 HCPCS inpatient 94 61.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.32 78 999999999 56.92 91.18 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 50731461_1 CDM 0302 RC 86922 HCPCS inpatient 94 61.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.86 69 999999999 56.92 91.18 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 50731461_1 CDM 0302 RC 86922 HCPCS inpatient 94 61.1 SIHO - ALL PLANS SIHO - ALL PLANS 84.6 90 999999999 56.92 91.18 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 50731461_1 CDM 0302 RC 86922 HCPCS inpatient 94 61.1 UMR - ALL PLANS UMR - ALL PLANS 65.8 70 999999999 56.92 91.18 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 50731461_1 CDM 0302 RC 86922 HCPCS inpatient 94 61.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.92 60.55 999999999 56.92 91.18 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 50731461_1 CDM 0302 RC 86922 HCPCS inpatient 94 61.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.92 91.18 "Blood unit compatibility test, antiglobulin technique" 50731461_1 CDM 0302 RC 86922 HCPCS inpatient 94 61.1 ANTHEM HMO ANTHEM HMO 999999999 56.92 91.18 "Blood unit compatibility test, antiglobulin technique" 50731461_1 CDM 0302 RC 86922 HCPCS inpatient 94 61.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.92 91.18 "Blood unit compatibility test, antiglobulin technique" 50731461_1 CDM 0302 RC 86922 HCPCS inpatient 94 61.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.54 67.6 999999999 56.92 91.18 percent of total billed charges "Blood unit compatibility test, antiglobulin technique" 50731461_1 CDM 0302 RC 86922 HCPCS inpatient 94 61.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.92 91.18 "Blood unit compatibility test, antiglobulin technique" 50731461_1 CDM 0302 RC 86922 HCPCS inpatient 94 61.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.92 91.18 DICLOFENAC SOD EC 25 MG TAB 50734020_1 CDM 0250 RC 16571-0203-10 NDC inpatient 1 UN 4.74 3.08 SELF PAY DISCOUNT SELF PAY DISCOUNT 3.08 65 999999999 2.87 4.6 percent of total billed charges DICLOFENAC SOD EC 25 MG TAB 50734020_1 CDM 0250 RC 16571-0203-10 NDC inpatient 1 UN 4.74 3.08 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4.6 97 999999999 2.87 4.6 percent of total billed charges DICLOFENAC SOD EC 25 MG TAB 50734020_1 CDM 0250 RC 16571-0203-10 NDC inpatient 1 UN 4.74 3.08 AETNA AETNA 3.74 79 999999999 2.87 4.6 percent of total billed charges DICLOFENAC SOD EC 25 MG TAB 50734020_1 CDM 0250 RC 16571-0203-10 NDC inpatient 1 UN 4.74 3.08 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.7 78 999999999 2.87 4.6 percent of total billed charges DICLOFENAC SOD EC 25 MG TAB 50734020_1 CDM 0250 RC 16571-0203-10 NDC inpatient 1 UN 4.74 3.08 ENCORE - ALL PLANS ENCORE - ALL PLANS 3.27 69 999999999 2.87 4.6 percent of total billed charges DICLOFENAC SOD EC 25 MG TAB 50734020_1 CDM 0250 RC 16571-0203-10 NDC inpatient 1 UN 4.74 3.08 SIHO - ALL PLANS SIHO - ALL PLANS 4.27 90 999999999 2.87 4.6 percent of total billed charges DICLOFENAC SOD EC 25 MG TAB 50734020_1 CDM 0250 RC 16571-0203-10 NDC inpatient 1 UN 4.74 3.08 UMR - ALL PLANS UMR - ALL PLANS 3.32 70 999999999 2.87 4.6 percent of total billed charges DICLOFENAC SOD EC 25 MG TAB 50734020_1 CDM 0250 RC 16571-0203-10 NDC inpatient 1 UN 4.74 3.08 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.87 60.55 999999999 2.87 4.6 percent of total billed charges DICLOFENAC SOD EC 25 MG TAB 50734020_1 CDM 0250 RC 16571-0203-10 NDC inpatient 1 UN 4.74 3.08 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.87 4.6 DICLOFENAC SOD EC 25 MG TAB 50734020_1 CDM 0250 RC 16571-0203-10 NDC inpatient 1 UN 4.74 3.08 ANTHEM HMO ANTHEM HMO 999999999 2.87 4.6 DICLOFENAC SOD EC 25 MG TAB 50734020_1 CDM 0250 RC 16571-0203-10 NDC inpatient 1 UN 4.74 3.08 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.87 4.6 DICLOFENAC SOD EC 25 MG TAB 50734020_1 CDM 0250 RC 16571-0203-10 NDC inpatient 1 UN 4.74 3.08 CIGNA - ALL PLANS CIGNA - ALL PLANS 3.2 67.6 999999999 2.87 4.6 percent of total billed charges DICLOFENAC SOD EC 25 MG TAB 50734020_1 CDM 0250 RC 16571-0203-10 NDC inpatient 1 UN 4.74 3.08 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.87 4.6 DICLOFENAC SOD EC 25 MG TAB 50734020_1 CDM 0250 RC 16571-0203-10 NDC inpatient 1 UN 4.74 3.08 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.87 4.6 "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50734021_1 CDM 0250 RC 60687-0113-01 NDC J0735 HCPCS inpatient 1 UN 1.33 0.86 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.86 65 999999999 0.81 1.29 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50734021_1 CDM 0250 RC 60687-0113-01 NDC J0735 HCPCS inpatient 1 UN 1.33 0.86 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.29 97 999999999 0.81 1.29 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50734021_1 CDM 0250 RC 60687-0113-01 NDC J0735 HCPCS inpatient 1 UN 1.33 0.86 AETNA AETNA 1.05 79 999999999 0.81 1.29 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50734021_1 CDM 0250 RC 60687-0113-01 NDC J0735 HCPCS inpatient 1 UN 1.33 0.86 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.04 78 999999999 0.81 1.29 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50734021_1 CDM 0250 RC 60687-0113-01 NDC J0735 HCPCS inpatient 1 UN 1.33 0.86 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.92 69 999999999 0.81 1.29 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50734021_1 CDM 0250 RC 60687-0113-01 NDC J0735 HCPCS inpatient 1 UN 1.33 0.86 SIHO - ALL PLANS SIHO - ALL PLANS 1.2 90 999999999 0.81 1.29 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50734021_1 CDM 0250 RC 60687-0113-01 NDC J0735 HCPCS inpatient 1 UN 1.33 0.86 UMR - ALL PLANS UMR - ALL PLANS 0.93 70 999999999 0.81 1.29 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50734021_1 CDM 0250 RC 60687-0113-01 NDC J0735 HCPCS inpatient 1 UN 1.33 0.86 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.81 60.55 999999999 0.81 1.29 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50734021_1 CDM 0250 RC 60687-0113-01 NDC J0735 HCPCS inpatient 1 UN 1.33 0.86 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.81 1.29 "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50734021_1 CDM 0250 RC 60687-0113-01 NDC J0735 HCPCS inpatient 1 UN 1.33 0.86 ANTHEM HMO ANTHEM HMO 999999999 0.81 1.29 "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50734021_1 CDM 0250 RC 60687-0113-01 NDC J0735 HCPCS inpatient 1 UN 1.33 0.86 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.81 1.29 "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50734021_1 CDM 0250 RC 60687-0113-01 NDC J0735 HCPCS inpatient 1 UN 1.33 0.86 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.9 67.6 999999999 0.81 1.29 percent of total billed charges "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50734021_1 CDM 0250 RC 60687-0113-01 NDC J0735 HCPCS inpatient 1 UN 1.33 0.86 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.81 1.29 "INJECTION, CLONIDINE HYDROCHLORIDE, 1 MG" 50734021_1 CDM 0250 RC 60687-0113-01 NDC J0735 HCPCS inpatient 1 UN 1.33 0.86 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.81 1.29 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734362_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734362_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734362_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734362_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734362_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734362_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734362_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734362_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734362_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734362_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734362_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734362_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734362_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734362_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734363_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734363_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734363_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734363_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734363_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734363_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734363_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734363_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734363_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734363_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734363_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734363_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734363_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734363_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734364_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734364_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734364_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734364_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734364_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734364_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734364_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734364_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734364_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734364_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734364_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734364_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734364_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50734364_1 CDM 0301 RC 86003 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 "INJECTION, BRENTUXIMAB VEDOTIN, 1 MG" 50734565_1 CDM 0636 RC 51144-0050-01 NDC J9042 HCPCS inpatient 50 UN 42433.38 27581.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 27581.7 65 999999999 25693.41 41160.38 percent of total billed charges "INJECTION, BRENTUXIMAB VEDOTIN, 1 MG" 50734565_1 CDM 0636 RC 51144-0050-01 NDC J9042 HCPCS inpatient 50 UN 42433.38 27581.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 41160.38 97 999999999 25693.41 41160.38 percent of total billed charges "INJECTION, BRENTUXIMAB VEDOTIN, 1 MG" 50734565_1 CDM 0636 RC 51144-0050-01 NDC J9042 HCPCS inpatient 50 UN 42433.38 27581.7 AETNA AETNA 33522.37 79 999999999 25693.41 41160.38 percent of total billed charges "INJECTION, BRENTUXIMAB VEDOTIN, 1 MG" 50734565_1 CDM 0636 RC 51144-0050-01 NDC J9042 HCPCS inpatient 50 UN 42433.38 27581.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 33098.04 78 999999999 25693.41 41160.38 percent of total billed charges "INJECTION, BRENTUXIMAB VEDOTIN, 1 MG" 50734565_1 CDM 0636 RC 51144-0050-01 NDC J9042 HCPCS inpatient 50 UN 42433.38 27581.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 29279.03 69 999999999 25693.41 41160.38 percent of total billed charges "INJECTION, BRENTUXIMAB VEDOTIN, 1 MG" 50734565_1 CDM 0636 RC 51144-0050-01 NDC J9042 HCPCS inpatient 50 UN 42433.38 27581.7 SIHO - ALL PLANS SIHO - ALL PLANS 38190.04 90 999999999 25693.41 41160.38 percent of total billed charges "INJECTION, BRENTUXIMAB VEDOTIN, 1 MG" 50734565_1 CDM 0636 RC 51144-0050-01 NDC J9042 HCPCS inpatient 50 UN 42433.38 27581.7 UMR - ALL PLANS UMR - ALL PLANS 29703.37 70 999999999 25693.41 41160.38 percent of total billed charges "INJECTION, BRENTUXIMAB VEDOTIN, 1 MG" 50734565_1 CDM 0636 RC 51144-0050-01 NDC J9042 HCPCS inpatient 50 UN 42433.38 27581.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 25693.41 60.55 999999999 25693.41 41160.38 percent of total billed charges "INJECTION, BRENTUXIMAB VEDOTIN, 1 MG" 50734565_1 CDM 0636 RC 51144-0050-01 NDC J9042 HCPCS inpatient 50 UN 42433.38 27581.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 25693.41 41160.38 "INJECTION, BRENTUXIMAB VEDOTIN, 1 MG" 50734565_1 CDM 0636 RC 51144-0050-01 NDC J9042 HCPCS inpatient 50 UN 42433.38 27581.7 ANTHEM HMO ANTHEM HMO 999999999 25693.41 41160.38 "INJECTION, BRENTUXIMAB VEDOTIN, 1 MG" 50734565_1 CDM 0636 RC 51144-0050-01 NDC J9042 HCPCS inpatient 50 UN 42433.38 27581.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 25693.41 41160.38 "INJECTION, BRENTUXIMAB VEDOTIN, 1 MG" 50734565_1 CDM 0636 RC 51144-0050-01 NDC J9042 HCPCS inpatient 50 UN 42433.38 27581.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 28684.96 67.6 999999999 25693.41 41160.38 percent of total billed charges "INJECTION, BRENTUXIMAB VEDOTIN, 1 MG" 50734565_1 CDM 0636 RC 51144-0050-01 NDC J9042 HCPCS inpatient 50 UN 42433.38 27581.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 25693.41 41160.38 "INJECTION, BRENTUXIMAB VEDOTIN, 1 MG" 50734565_1 CDM 0636 RC 51144-0050-01 NDC J9042 HCPCS inpatient 50 UN 42433.38 27581.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 25693.41 41160.38 FAMOTIDINE 20 MG TABLET 50734650_1 CDM 0250 RC 60687-0595-01 NDC inpatient 1 UN 1.77 1.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.15 65 999999999 1.07 1.72 percent of total billed charges FAMOTIDINE 20 MG TABLET 50734650_1 CDM 0250 RC 60687-0595-01 NDC inpatient 1 UN 1.77 1.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.72 97 999999999 1.07 1.72 percent of total billed charges FAMOTIDINE 20 MG TABLET 50734650_1 CDM 0250 RC 60687-0595-01 NDC inpatient 1 UN 1.77 1.15 AETNA AETNA 1.4 79 999999999 1.07 1.72 percent of total billed charges FAMOTIDINE 20 MG TABLET 50734650_1 CDM 0250 RC 60687-0595-01 NDC inpatient 1 UN 1.77 1.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.38 78 999999999 1.07 1.72 percent of total billed charges FAMOTIDINE 20 MG TABLET 50734650_1 CDM 0250 RC 60687-0595-01 NDC inpatient 1 UN 1.77 1.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.22 69 999999999 1.07 1.72 percent of total billed charges FAMOTIDINE 20 MG TABLET 50734650_1 CDM 0250 RC 60687-0595-01 NDC inpatient 1 UN 1.77 1.15 SIHO - ALL PLANS SIHO - ALL PLANS 1.59 90 999999999 1.07 1.72 percent of total billed charges FAMOTIDINE 20 MG TABLET 50734650_1 CDM 0250 RC 60687-0595-01 NDC inpatient 1 UN 1.77 1.15 UMR - ALL PLANS UMR - ALL PLANS 1.24 70 999999999 1.07 1.72 percent of total billed charges FAMOTIDINE 20 MG TABLET 50734650_1 CDM 0250 RC 60687-0595-01 NDC inpatient 1 UN 1.77 1.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.07 60.55 999999999 1.07 1.72 percent of total billed charges FAMOTIDINE 20 MG TABLET 50734650_1 CDM 0250 RC 60687-0595-01 NDC inpatient 1 UN 1.77 1.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.07 1.72 FAMOTIDINE 20 MG TABLET 50734650_1 CDM 0250 RC 60687-0595-01 NDC inpatient 1 UN 1.77 1.15 ANTHEM HMO ANTHEM HMO 999999999 1.07 1.72 FAMOTIDINE 20 MG TABLET 50734650_1 CDM 0250 RC 60687-0595-01 NDC inpatient 1 UN 1.77 1.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.07 1.72 FAMOTIDINE 20 MG TABLET 50734650_1 CDM 0250 RC 60687-0595-01 NDC inpatient 1 UN 1.77 1.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.2 67.6 999999999 1.07 1.72 percent of total billed charges FAMOTIDINE 20 MG TABLET 50734650_1 CDM 0250 RC 60687-0595-01 NDC inpatient 1 UN 1.77 1.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.07 1.72 FAMOTIDINE 20 MG TABLET 50734650_1 CDM 0250 RC 60687-0595-01 NDC inpatient 1 UN 1.77 1.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.07 1.72 TERAZOSIN 5 MG CAPSULE 50740050_1 CDM 0250 RC 50268-0766-15 NDC inpatient 1 UN 3.16 2.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.05 65 999999999 1.91 3.07 percent of total billed charges TERAZOSIN 5 MG CAPSULE 50740050_1 CDM 0250 RC 50268-0766-15 NDC inpatient 1 UN 3.16 2.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.07 97 999999999 1.91 3.07 percent of total billed charges TERAZOSIN 5 MG CAPSULE 50740050_1 CDM 0250 RC 50268-0766-15 NDC inpatient 1 UN 3.16 2.05 AETNA AETNA 2.5 79 999999999 1.91 3.07 percent of total billed charges TERAZOSIN 5 MG CAPSULE 50740050_1 CDM 0250 RC 50268-0766-15 NDC inpatient 1 UN 3.16 2.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.46 78 999999999 1.91 3.07 percent of total billed charges TERAZOSIN 5 MG CAPSULE 50740050_1 CDM 0250 RC 50268-0766-15 NDC inpatient 1 UN 3.16 2.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.18 69 999999999 1.91 3.07 percent of total billed charges TERAZOSIN 5 MG CAPSULE 50740050_1 CDM 0250 RC 50268-0766-15 NDC inpatient 1 UN 3.16 2.05 SIHO - ALL PLANS SIHO - ALL PLANS 2.84 90 999999999 1.91 3.07 percent of total billed charges TERAZOSIN 5 MG CAPSULE 50740050_1 CDM 0250 RC 50268-0766-15 NDC inpatient 1 UN 3.16 2.05 UMR - ALL PLANS UMR - ALL PLANS 2.21 70 999999999 1.91 3.07 percent of total billed charges TERAZOSIN 5 MG CAPSULE 50740050_1 CDM 0250 RC 50268-0766-15 NDC inpatient 1 UN 3.16 2.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.91 60.55 999999999 1.91 3.07 percent of total billed charges TERAZOSIN 5 MG CAPSULE 50740050_1 CDM 0250 RC 50268-0766-15 NDC inpatient 1 UN 3.16 2.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.91 3.07 TERAZOSIN 5 MG CAPSULE 50740050_1 CDM 0250 RC 50268-0766-15 NDC inpatient 1 UN 3.16 2.05 ANTHEM HMO ANTHEM HMO 999999999 1.91 3.07 TERAZOSIN 5 MG CAPSULE 50740050_1 CDM 0250 RC 50268-0766-15 NDC inpatient 1 UN 3.16 2.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.91 3.07 TERAZOSIN 5 MG CAPSULE 50740050_1 CDM 0250 RC 50268-0766-15 NDC inpatient 1 UN 3.16 2.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.14 67.6 999999999 1.91 3.07 percent of total billed charges TERAZOSIN 5 MG CAPSULE 50740050_1 CDM 0250 RC 50268-0766-15 NDC inpatient 1 UN 3.16 2.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.91 3.07 TERAZOSIN 5 MG CAPSULE 50740050_1 CDM 0250 RC 50268-0766-15 NDC inpatient 1 UN 3.16 2.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.91 3.07 HYDROCODONE-ACETAMIN 5-325 MG 50740057_1 CDM 0250 RC 00904-6824-61 NDC inpatient 1 UN 1.82 1.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.18 65 999999999 1.1 1.77 percent of total billed charges HYDROCODONE-ACETAMIN 5-325 MG 50740057_1 CDM 0250 RC 00904-6824-61 NDC inpatient 1 UN 1.82 1.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.77 97 999999999 1.1 1.77 percent of total billed charges HYDROCODONE-ACETAMIN 5-325 MG 50740057_1 CDM 0250 RC 00904-6824-61 NDC inpatient 1 UN 1.82 1.18 AETNA AETNA 1.44 79 999999999 1.1 1.77 percent of total billed charges HYDROCODONE-ACETAMIN 5-325 MG 50740057_1 CDM 0250 RC 00904-6824-61 NDC inpatient 1 UN 1.82 1.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.42 78 999999999 1.1 1.77 percent of total billed charges HYDROCODONE-ACETAMIN 5-325 MG 50740057_1 CDM 0250 RC 00904-6824-61 NDC inpatient 1 UN 1.82 1.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.26 69 999999999 1.1 1.77 percent of total billed charges HYDROCODONE-ACETAMIN 5-325 MG 50740057_1 CDM 0250 RC 00904-6824-61 NDC inpatient 1 UN 1.82 1.18 SIHO - ALL PLANS SIHO - ALL PLANS 1.64 90 999999999 1.1 1.77 percent of total billed charges HYDROCODONE-ACETAMIN 5-325 MG 50740057_1 CDM 0250 RC 00904-6824-61 NDC inpatient 1 UN 1.82 1.18 UMR - ALL PLANS UMR - ALL PLANS 1.27 70 999999999 1.1 1.77 percent of total billed charges HYDROCODONE-ACETAMIN 5-325 MG 50740057_1 CDM 0250 RC 00904-6824-61 NDC inpatient 1 UN 1.82 1.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.1 60.55 999999999 1.1 1.77 percent of total billed charges HYDROCODONE-ACETAMIN 5-325 MG 50740057_1 CDM 0250 RC 00904-6824-61 NDC inpatient 1 UN 1.82 1.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.1 1.77 HYDROCODONE-ACETAMIN 5-325 MG 50740057_1 CDM 0250 RC 00904-6824-61 NDC inpatient 1 UN 1.82 1.18 ANTHEM HMO ANTHEM HMO 999999999 1.1 1.77 HYDROCODONE-ACETAMIN 5-325 MG 50740057_1 CDM 0250 RC 00904-6824-61 NDC inpatient 1 UN 1.82 1.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.1 1.77 HYDROCODONE-ACETAMIN 5-325 MG 50740057_1 CDM 0250 RC 00904-6824-61 NDC inpatient 1 UN 1.82 1.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.23 67.6 999999999 1.1 1.77 percent of total billed charges HYDROCODONE-ACETAMIN 5-325 MG 50740057_1 CDM 0250 RC 00904-6824-61 NDC inpatient 1 UN 1.82 1.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.1 1.77 HYDROCODONE-ACETAMIN 5-325 MG 50740057_1 CDM 0250 RC 00904-6824-61 NDC inpatient 1 UN 1.82 1.18 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.1 1.77 BUPIVACAINE 0.5% VIAL 50740236_1 CDM 0250 RC 00409-1162-10 NDC inpatient 1 UN 25.4 16.51 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.51 65 999999999 15.38 24.64 percent of total billed charges BUPIVACAINE 0.5% VIAL 50740236_1 CDM 0250 RC 00409-1162-10 NDC inpatient 1 UN 25.4 16.51 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.64 97 999999999 15.38 24.64 percent of total billed charges BUPIVACAINE 0.5% VIAL 50740236_1 CDM 0250 RC 00409-1162-10 NDC inpatient 1 UN 25.4 16.51 AETNA AETNA 20.07 79 999999999 15.38 24.64 percent of total billed charges BUPIVACAINE 0.5% VIAL 50740236_1 CDM 0250 RC 00409-1162-10 NDC inpatient 1 UN 25.4 16.51 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.81 78 999999999 15.38 24.64 percent of total billed charges BUPIVACAINE 0.5% VIAL 50740236_1 CDM 0250 RC 00409-1162-10 NDC inpatient 1 UN 25.4 16.51 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.53 69 999999999 15.38 24.64 percent of total billed charges BUPIVACAINE 0.5% VIAL 50740236_1 CDM 0250 RC 00409-1162-10 NDC inpatient 1 UN 25.4 16.51 SIHO - ALL PLANS SIHO - ALL PLANS 22.86 90 999999999 15.38 24.64 percent of total billed charges BUPIVACAINE 0.5% VIAL 50740236_1 CDM 0250 RC 00409-1162-10 NDC inpatient 1 UN 25.4 16.51 UMR - ALL PLANS UMR - ALL PLANS 17.78 70 999999999 15.38 24.64 percent of total billed charges BUPIVACAINE 0.5% VIAL 50740236_1 CDM 0250 RC 00409-1162-10 NDC inpatient 1 UN 25.4 16.51 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.38 60.55 999999999 15.38 24.64 percent of total billed charges BUPIVACAINE 0.5% VIAL 50740236_1 CDM 0250 RC 00409-1162-10 NDC inpatient 1 UN 25.4 16.51 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.38 24.64 BUPIVACAINE 0.5% VIAL 50740236_1 CDM 0250 RC 00409-1162-10 NDC inpatient 1 UN 25.4 16.51 ANTHEM HMO ANTHEM HMO 999999999 15.38 24.64 BUPIVACAINE 0.5% VIAL 50740236_1 CDM 0250 RC 00409-1162-10 NDC inpatient 1 UN 25.4 16.51 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.38 24.64 BUPIVACAINE 0.5% VIAL 50740236_1 CDM 0250 RC 00409-1162-10 NDC inpatient 1 UN 25.4 16.51 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.17 67.6 999999999 15.38 24.64 percent of total billed charges BUPIVACAINE 0.5% VIAL 50740236_1 CDM 0250 RC 00409-1162-10 NDC inpatient 1 UN 25.4 16.51 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.38 24.64 BUPIVACAINE 0.5% VIAL 50740236_1 CDM 0250 RC 00409-1162-10 NDC inpatient 1 UN 25.4 16.51 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.38 24.64 CHLORDIAZEPOXIDE 25 MG CAPSULE 50740237_1 CDM 0250 RC 00555-0159-02 NDC inpatient 1 UN 1.95 1.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.27 65 999999999 1.18 1.89 percent of total billed charges CHLORDIAZEPOXIDE 25 MG CAPSULE 50740237_1 CDM 0250 RC 00555-0159-02 NDC inpatient 1 UN 1.95 1.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.89 97 999999999 1.18 1.89 percent of total billed charges CHLORDIAZEPOXIDE 25 MG CAPSULE 50740237_1 CDM 0250 RC 00555-0159-02 NDC inpatient 1 UN 1.95 1.27 AETNA AETNA 1.54 79 999999999 1.18 1.89 percent of total billed charges CHLORDIAZEPOXIDE 25 MG CAPSULE 50740237_1 CDM 0250 RC 00555-0159-02 NDC inpatient 1 UN 1.95 1.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.52 78 999999999 1.18 1.89 percent of total billed charges CHLORDIAZEPOXIDE 25 MG CAPSULE 50740237_1 CDM 0250 RC 00555-0159-02 NDC inpatient 1 UN 1.95 1.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.35 69 999999999 1.18 1.89 percent of total billed charges CHLORDIAZEPOXIDE 25 MG CAPSULE 50740237_1 CDM 0250 RC 00555-0159-02 NDC inpatient 1 UN 1.95 1.27 SIHO - ALL PLANS SIHO - ALL PLANS 1.76 90 999999999 1.18 1.89 percent of total billed charges CHLORDIAZEPOXIDE 25 MG CAPSULE 50740237_1 CDM 0250 RC 00555-0159-02 NDC inpatient 1 UN 1.95 1.27 UMR - ALL PLANS UMR - ALL PLANS 1.37 70 999999999 1.18 1.89 percent of total billed charges CHLORDIAZEPOXIDE 25 MG CAPSULE 50740237_1 CDM 0250 RC 00555-0159-02 NDC inpatient 1 UN 1.95 1.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.18 60.55 999999999 1.18 1.89 percent of total billed charges CHLORDIAZEPOXIDE 25 MG CAPSULE 50740237_1 CDM 0250 RC 00555-0159-02 NDC inpatient 1 UN 1.95 1.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.18 1.89 CHLORDIAZEPOXIDE 25 MG CAPSULE 50740237_1 CDM 0250 RC 00555-0159-02 NDC inpatient 1 UN 1.95 1.27 ANTHEM HMO ANTHEM HMO 999999999 1.18 1.89 CHLORDIAZEPOXIDE 25 MG CAPSULE 50740237_1 CDM 0250 RC 00555-0159-02 NDC inpatient 1 UN 1.95 1.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.18 1.89 CHLORDIAZEPOXIDE 25 MG CAPSULE 50740237_1 CDM 0250 RC 00555-0159-02 NDC inpatient 1 UN 1.95 1.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.32 67.6 999999999 1.18 1.89 percent of total billed charges CHLORDIAZEPOXIDE 25 MG CAPSULE 50740237_1 CDM 0250 RC 00555-0159-02 NDC inpatient 1 UN 1.95 1.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.18 1.89 CHLORDIAZEPOXIDE 25 MG CAPSULE 50740237_1 CDM 0250 RC 00555-0159-02 NDC inpatient 1 UN 1.95 1.27 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.18 1.89 ITRACONAZOLE 100 MG CAPSULE 50740562_1 CDM 0250 RC 60687-0299-25 NDC inpatient 1 UN 12.47 8.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.11 65 999999999 7.55 12.1 percent of total billed charges ITRACONAZOLE 100 MG CAPSULE 50740562_1 CDM 0250 RC 60687-0299-25 NDC inpatient 1 UN 12.47 8.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.1 97 999999999 7.55 12.1 percent of total billed charges ITRACONAZOLE 100 MG CAPSULE 50740562_1 CDM 0250 RC 60687-0299-25 NDC inpatient 1 UN 12.47 8.11 AETNA AETNA 9.85 79 999999999 7.55 12.1 percent of total billed charges ITRACONAZOLE 100 MG CAPSULE 50740562_1 CDM 0250 RC 60687-0299-25 NDC inpatient 1 UN 12.47 8.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.73 78 999999999 7.55 12.1 percent of total billed charges ITRACONAZOLE 100 MG CAPSULE 50740562_1 CDM 0250 RC 60687-0299-25 NDC inpatient 1 UN 12.47 8.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.6 69 999999999 7.55 12.1 percent of total billed charges ITRACONAZOLE 100 MG CAPSULE 50740562_1 CDM 0250 RC 60687-0299-25 NDC inpatient 1 UN 12.47 8.11 SIHO - ALL PLANS SIHO - ALL PLANS 11.22 90 999999999 7.55 12.1 percent of total billed charges ITRACONAZOLE 100 MG CAPSULE 50740562_1 CDM 0250 RC 60687-0299-25 NDC inpatient 1 UN 12.47 8.11 UMR - ALL PLANS UMR - ALL PLANS 8.73 70 999999999 7.55 12.1 percent of total billed charges ITRACONAZOLE 100 MG CAPSULE 50740562_1 CDM 0250 RC 60687-0299-25 NDC inpatient 1 UN 12.47 8.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.55 60.55 999999999 7.55 12.1 percent of total billed charges ITRACONAZOLE 100 MG CAPSULE 50740562_1 CDM 0250 RC 60687-0299-25 NDC inpatient 1 UN 12.47 8.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.55 12.1 ITRACONAZOLE 100 MG CAPSULE 50740562_1 CDM 0250 RC 60687-0299-25 NDC inpatient 1 UN 12.47 8.11 ANTHEM HMO ANTHEM HMO 999999999 7.55 12.1 ITRACONAZOLE 100 MG CAPSULE 50740562_1 CDM 0250 RC 60687-0299-25 NDC inpatient 1 UN 12.47 8.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.55 12.1 ITRACONAZOLE 100 MG CAPSULE 50740562_1 CDM 0250 RC 60687-0299-25 NDC inpatient 1 UN 12.47 8.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.43 67.6 999999999 7.55 12.1 percent of total billed charges ITRACONAZOLE 100 MG CAPSULE 50740562_1 CDM 0250 RC 60687-0299-25 NDC inpatient 1 UN 12.47 8.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.55 12.1 ITRACONAZOLE 100 MG CAPSULE 50740562_1 CDM 0250 RC 60687-0299-25 NDC inpatient 1 UN 12.47 8.11 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.55 12.1 "HYALURONAN OR DERIVATIVE, GELSYN-3, FOR INTRA-ARTICULAR INJECTION, 0.1 MG" 50740863_1 CDM 0250 RC 89130-3111-01 NDC J7328 HCPCS inpatient 17 UN 243 157.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 157.95 65 999999999 147.14 235.71 percent of total billed charges "HYALURONAN OR DERIVATIVE, GELSYN-3, FOR INTRA-ARTICULAR INJECTION, 0.1 MG" 50740863_1 CDM 0250 RC 89130-3111-01 NDC J7328 HCPCS inpatient 17 UN 243 157.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 235.71 97 999999999 147.14 235.71 percent of total billed charges "HYALURONAN OR DERIVATIVE, GELSYN-3, FOR INTRA-ARTICULAR INJECTION, 0.1 MG" 50740863_1 CDM 0250 RC 89130-3111-01 NDC J7328 HCPCS inpatient 17 UN 243 157.95 AETNA AETNA 191.97 79 999999999 147.14 235.71 percent of total billed charges "HYALURONAN OR DERIVATIVE, GELSYN-3, FOR INTRA-ARTICULAR INJECTION, 0.1 MG" 50740863_1 CDM 0250 RC 89130-3111-01 NDC J7328 HCPCS inpatient 17 UN 243 157.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 189.54 78 999999999 147.14 235.71 percent of total billed charges "HYALURONAN OR DERIVATIVE, GELSYN-3, FOR INTRA-ARTICULAR INJECTION, 0.1 MG" 50740863_1 CDM 0250 RC 89130-3111-01 NDC J7328 HCPCS inpatient 17 UN 243 157.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 167.67 69 999999999 147.14 235.71 percent of total billed charges "HYALURONAN OR DERIVATIVE, GELSYN-3, FOR INTRA-ARTICULAR INJECTION, 0.1 MG" 50740863_1 CDM 0250 RC 89130-3111-01 NDC J7328 HCPCS inpatient 17 UN 243 157.95 SIHO - ALL PLANS SIHO - ALL PLANS 218.7 90 999999999 147.14 235.71 percent of total billed charges "HYALURONAN OR DERIVATIVE, GELSYN-3, FOR INTRA-ARTICULAR INJECTION, 0.1 MG" 50740863_1 CDM 0250 RC 89130-3111-01 NDC J7328 HCPCS inpatient 17 UN 243 157.95 UMR - ALL PLANS UMR - ALL PLANS 170.1 70 999999999 147.14 235.71 percent of total billed charges "HYALURONAN OR DERIVATIVE, GELSYN-3, FOR INTRA-ARTICULAR INJECTION, 0.1 MG" 50740863_1 CDM 0250 RC 89130-3111-01 NDC J7328 HCPCS inpatient 17 UN 243 157.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.14 60.55 999999999 147.14 235.71 percent of total billed charges "HYALURONAN OR DERIVATIVE, GELSYN-3, FOR INTRA-ARTICULAR INJECTION, 0.1 MG" 50740863_1 CDM 0250 RC 89130-3111-01 NDC J7328 HCPCS inpatient 17 UN 243 157.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.14 235.71 "HYALURONAN OR DERIVATIVE, GELSYN-3, FOR INTRA-ARTICULAR INJECTION, 0.1 MG" 50740863_1 CDM 0250 RC 89130-3111-01 NDC J7328 HCPCS inpatient 17 UN 243 157.95 ANTHEM HMO ANTHEM HMO 999999999 147.14 235.71 "HYALURONAN OR DERIVATIVE, GELSYN-3, FOR INTRA-ARTICULAR INJECTION, 0.1 MG" 50740863_1 CDM 0250 RC 89130-3111-01 NDC J7328 HCPCS inpatient 17 UN 243 157.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.14 235.71 "HYALURONAN OR DERIVATIVE, GELSYN-3, FOR INTRA-ARTICULAR INJECTION, 0.1 MG" 50740863_1 CDM 0250 RC 89130-3111-01 NDC J7328 HCPCS inpatient 17 UN 243 157.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.27 67.6 999999999 147.14 235.71 percent of total billed charges "HYALURONAN OR DERIVATIVE, GELSYN-3, FOR INTRA-ARTICULAR INJECTION, 0.1 MG" 50740863_1 CDM 0250 RC 89130-3111-01 NDC J7328 HCPCS inpatient 17 UN 243 157.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.14 235.71 "HYALURONAN OR DERIVATIVE, GELSYN-3, FOR INTRA-ARTICULAR INJECTION, 0.1 MG" 50740863_1 CDM 0250 RC 89130-3111-01 NDC J7328 HCPCS inpatient 17 UN 243 157.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.14 235.71 CELECOXIB 200 MG CAPSULE 50741399_1 CDM 0250 RC 60687-0447-01 NDC inpatient 1 UN 3.49 2.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.27 65 999999999 2.11 3.39 percent of total billed charges CELECOXIB 200 MG CAPSULE 50741399_1 CDM 0250 RC 60687-0447-01 NDC inpatient 1 UN 3.49 2.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.39 97 999999999 2.11 3.39 percent of total billed charges CELECOXIB 200 MG CAPSULE 50741399_1 CDM 0250 RC 60687-0447-01 NDC inpatient 1 UN 3.49 2.27 AETNA AETNA 2.76 79 999999999 2.11 3.39 percent of total billed charges CELECOXIB 200 MG CAPSULE 50741399_1 CDM 0250 RC 60687-0447-01 NDC inpatient 1 UN 3.49 2.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 2.72 78 999999999 2.11 3.39 percent of total billed charges CELECOXIB 200 MG CAPSULE 50741399_1 CDM 0250 RC 60687-0447-01 NDC inpatient 1 UN 3.49 2.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.41 69 999999999 2.11 3.39 percent of total billed charges CELECOXIB 200 MG CAPSULE 50741399_1 CDM 0250 RC 60687-0447-01 NDC inpatient 1 UN 3.49 2.27 SIHO - ALL PLANS SIHO - ALL PLANS 3.14 90 999999999 2.11 3.39 percent of total billed charges CELECOXIB 200 MG CAPSULE 50741399_1 CDM 0250 RC 60687-0447-01 NDC inpatient 1 UN 3.49 2.27 UMR - ALL PLANS UMR - ALL PLANS 2.44 70 999999999 2.11 3.39 percent of total billed charges CELECOXIB 200 MG CAPSULE 50741399_1 CDM 0250 RC 60687-0447-01 NDC inpatient 1 UN 3.49 2.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.11 60.55 999999999 2.11 3.39 percent of total billed charges CELECOXIB 200 MG CAPSULE 50741399_1 CDM 0250 RC 60687-0447-01 NDC inpatient 1 UN 3.49 2.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.11 3.39 CELECOXIB 200 MG CAPSULE 50741399_1 CDM 0250 RC 60687-0447-01 NDC inpatient 1 UN 3.49 2.27 ANTHEM HMO ANTHEM HMO 999999999 2.11 3.39 CELECOXIB 200 MG CAPSULE 50741399_1 CDM 0250 RC 60687-0447-01 NDC inpatient 1 UN 3.49 2.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.11 3.39 CELECOXIB 200 MG CAPSULE 50741399_1 CDM 0250 RC 60687-0447-01 NDC inpatient 1 UN 3.49 2.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.36 67.6 999999999 2.11 3.39 percent of total billed charges CELECOXIB 200 MG CAPSULE 50741399_1 CDM 0250 RC 60687-0447-01 NDC inpatient 1 UN 3.49 2.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.11 3.39 CELECOXIB 200 MG CAPSULE 50741399_1 CDM 0250 RC 60687-0447-01 NDC inpatient 1 UN 3.49 2.27 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.11 3.39 Measurement of substance using immunoassay technique 50741400_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.95 65 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 50741400_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.51 97 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 50741400_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 AETNA AETNA 144.57 79 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 50741400_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 142.74 78 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 50741400_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.27 69 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 50741400_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 SIHO - ALL PLANS SIHO - ALL PLANS 164.7 90 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 50741400_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 UMR - ALL PLANS UMR - ALL PLANS 128.1 70 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 50741400_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.81 60.55 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 50741400_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.81 177.51 Measurement of substance using immunoassay technique 50741400_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM HMO ANTHEM HMO 999999999 110.81 177.51 Measurement of substance using immunoassay technique 50741400_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.81 177.51 Measurement of substance using immunoassay technique 50741400_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.71 67.6 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 50741400_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.81 177.51 Measurement of substance using immunoassay technique 50741400_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.81 177.51 Urine porphobilinogen (metabolism substance) level 50741457_1 CDM 0301 RC 84110 HCPCS inpatient 123 79.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.95 65 999999999 74.48 119.31 percent of total billed charges Urine porphobilinogen (metabolism substance) level 50741457_1 CDM 0301 RC 84110 HCPCS inpatient 123 79.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 119.31 97 999999999 74.48 119.31 percent of total billed charges Urine porphobilinogen (metabolism substance) level 50741457_1 CDM 0301 RC 84110 HCPCS inpatient 123 79.95 AETNA AETNA 97.17 79 999999999 74.48 119.31 percent of total billed charges Urine porphobilinogen (metabolism substance) level 50741457_1 CDM 0301 RC 84110 HCPCS inpatient 123 79.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.94 78 999999999 74.48 119.31 percent of total billed charges Urine porphobilinogen (metabolism substance) level 50741457_1 CDM 0301 RC 84110 HCPCS inpatient 123 79.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.87 69 999999999 74.48 119.31 percent of total billed charges Urine porphobilinogen (metabolism substance) level 50741457_1 CDM 0301 RC 84110 HCPCS inpatient 123 79.95 SIHO - ALL PLANS SIHO - ALL PLANS 110.7 90 999999999 74.48 119.31 percent of total billed charges Urine porphobilinogen (metabolism substance) level 50741457_1 CDM 0301 RC 84110 HCPCS inpatient 123 79.95 UMR - ALL PLANS UMR - ALL PLANS 86.1 70 999999999 74.48 119.31 percent of total billed charges Urine porphobilinogen (metabolism substance) level 50741457_1 CDM 0301 RC 84110 HCPCS inpatient 123 79.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 74.48 60.55 999999999 74.48 119.31 percent of total billed charges Urine porphobilinogen (metabolism substance) level 50741457_1 CDM 0301 RC 84110 HCPCS inpatient 123 79.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 74.48 119.31 Urine porphobilinogen (metabolism substance) level 50741457_1 CDM 0301 RC 84110 HCPCS inpatient 123 79.95 ANTHEM HMO ANTHEM HMO 999999999 74.48 119.31 Urine porphobilinogen (metabolism substance) level 50741457_1 CDM 0301 RC 84110 HCPCS inpatient 123 79.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 74.48 119.31 Urine porphobilinogen (metabolism substance) level 50741457_1 CDM 0301 RC 84110 HCPCS inpatient 123 79.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.15 67.6 999999999 74.48 119.31 percent of total billed charges Urine porphobilinogen (metabolism substance) level 50741457_1 CDM 0301 RC 84110 HCPCS inpatient 123 79.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 74.48 119.31 Urine porphobilinogen (metabolism substance) level 50741457_1 CDM 0301 RC 84110 HCPCS inpatient 123 79.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 74.48 119.31 TC ELECTRODE 5CM DISPOSABLE PROBE BX/10 TCD-5-P 50741576_1 CDM 0272 RC inpatient 246 159.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 159.9 65 999999999 148.95 238.62 percent of total billed charges TC ELECTRODE 5CM DISPOSABLE PROBE BX/10 TCD-5-P 50741576_1 CDM 0272 RC inpatient 246 159.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 238.62 97 999999999 148.95 238.62 percent of total billed charges TC ELECTRODE 5CM DISPOSABLE PROBE BX/10 TCD-5-P 50741576_1 CDM 0272 RC inpatient 246 159.9 AETNA AETNA 194.34 79 999999999 148.95 238.62 percent of total billed charges TC ELECTRODE 5CM DISPOSABLE PROBE BX/10 TCD-5-P 50741576_1 CDM 0272 RC inpatient 246 159.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 191.88 78 999999999 148.95 238.62 percent of total billed charges TC ELECTRODE 5CM DISPOSABLE PROBE BX/10 TCD-5-P 50741576_1 CDM 0272 RC inpatient 246 159.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 169.74 69 999999999 148.95 238.62 percent of total billed charges TC ELECTRODE 5CM DISPOSABLE PROBE BX/10 TCD-5-P 50741576_1 CDM 0272 RC inpatient 246 159.9 SIHO - ALL PLANS SIHO - ALL PLANS 221.4 90 999999999 148.95 238.62 percent of total billed charges TC ELECTRODE 5CM DISPOSABLE PROBE BX/10 TCD-5-P 50741576_1 CDM 0272 RC inpatient 246 159.9 UMR - ALL PLANS UMR - ALL PLANS 172.2 70 999999999 148.95 238.62 percent of total billed charges TC ELECTRODE 5CM DISPOSABLE PROBE BX/10 TCD-5-P 50741576_1 CDM 0272 RC inpatient 246 159.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 148.95 60.55 999999999 148.95 238.62 percent of total billed charges TC ELECTRODE 5CM DISPOSABLE PROBE BX/10 TCD-5-P 50741576_1 CDM 0272 RC inpatient 246 159.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 148.95 238.62 TC ELECTRODE 5CM DISPOSABLE PROBE BX/10 TCD-5-P 50741576_1 CDM 0272 RC inpatient 246 159.9 ANTHEM HMO ANTHEM HMO 999999999 148.95 238.62 TC ELECTRODE 5CM DISPOSABLE PROBE BX/10 TCD-5-P 50741576_1 CDM 0272 RC inpatient 246 159.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 148.95 238.62 TC ELECTRODE 5CM DISPOSABLE PROBE BX/10 TCD-5-P 50741576_1 CDM 0272 RC inpatient 246 159.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 166.3 67.6 999999999 148.95 238.62 percent of total billed charges TC ELECTRODE 5CM DISPOSABLE PROBE BX/10 TCD-5-P 50741576_1 CDM 0272 RC inpatient 246 159.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 148.95 238.62 TC ELECTRODE 5CM DISPOSABLE PROBE BX/10 TCD-5-P 50741576_1 CDM 0272 RC inpatient 246 159.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 148.95 238.62 Copper level 50743574_1 CDM 0301 RC 82525 HCPCS inpatient 159 103.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 103.35 65 999999999 96.27 154.23 percent of total billed charges Copper level 50743574_1 CDM 0301 RC 82525 HCPCS inpatient 159 103.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 154.23 97 999999999 96.27 154.23 percent of total billed charges Copper level 50743574_1 CDM 0301 RC 82525 HCPCS inpatient 159 103.35 AETNA AETNA 125.61 79 999999999 96.27 154.23 percent of total billed charges Copper level 50743574_1 CDM 0301 RC 82525 HCPCS inpatient 159 103.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 124.02 78 999999999 96.27 154.23 percent of total billed charges Copper level 50743574_1 CDM 0301 RC 82525 HCPCS inpatient 159 103.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 109.71 69 999999999 96.27 154.23 percent of total billed charges Copper level 50743574_1 CDM 0301 RC 82525 HCPCS inpatient 159 103.35 SIHO - ALL PLANS SIHO - ALL PLANS 143.1 90 999999999 96.27 154.23 percent of total billed charges Copper level 50743574_1 CDM 0301 RC 82525 HCPCS inpatient 159 103.35 UMR - ALL PLANS UMR - ALL PLANS 111.3 70 999999999 96.27 154.23 percent of total billed charges Copper level 50743574_1 CDM 0301 RC 82525 HCPCS inpatient 159 103.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 96.27 60.55 999999999 96.27 154.23 percent of total billed charges Copper level 50743574_1 CDM 0301 RC 82525 HCPCS inpatient 159 103.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 96.27 154.23 Copper level 50743574_1 CDM 0301 RC 82525 HCPCS inpatient 159 103.35 ANTHEM HMO ANTHEM HMO 999999999 96.27 154.23 Copper level 50743574_1 CDM 0301 RC 82525 HCPCS inpatient 159 103.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 96.27 154.23 Copper level 50743574_1 CDM 0301 RC 82525 HCPCS inpatient 159 103.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 107.48 67.6 999999999 96.27 154.23 percent of total billed charges Copper level 50743574_1 CDM 0301 RC 82525 HCPCS inpatient 159 103.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 96.27 154.23 Copper level 50743574_1 CDM 0301 RC 82525 HCPCS inpatient 159 103.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 96.27 154.23 BELBUCA 150 MCG FILM 50743706_1 CDM 0250 RC 59385-0022-60 NDC inpatient 1 UN 26.64 17.32 SELF PAY DISCOUNT SELF PAY DISCOUNT 17.32 65 999999999 16.13 25.84 percent of total billed charges BELBUCA 150 MCG FILM 50743706_1 CDM 0250 RC 59385-0022-60 NDC inpatient 1 UN 26.64 17.32 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.84 97 999999999 16.13 25.84 percent of total billed charges BELBUCA 150 MCG FILM 50743706_1 CDM 0250 RC 59385-0022-60 NDC inpatient 1 UN 26.64 17.32 AETNA AETNA 21.05 79 999999999 16.13 25.84 percent of total billed charges BELBUCA 150 MCG FILM 50743706_1 CDM 0250 RC 59385-0022-60 NDC inpatient 1 UN 26.64 17.32 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.78 78 999999999 16.13 25.84 percent of total billed charges BELBUCA 150 MCG FILM 50743706_1 CDM 0250 RC 59385-0022-60 NDC inpatient 1 UN 26.64 17.32 ENCORE - ALL PLANS ENCORE - ALL PLANS 18.38 69 999999999 16.13 25.84 percent of total billed charges BELBUCA 150 MCG FILM 50743706_1 CDM 0250 RC 59385-0022-60 NDC inpatient 1 UN 26.64 17.32 SIHO - ALL PLANS SIHO - ALL PLANS 23.98 90 999999999 16.13 25.84 percent of total billed charges BELBUCA 150 MCG FILM 50743706_1 CDM 0250 RC 59385-0022-60 NDC inpatient 1 UN 26.64 17.32 UMR - ALL PLANS UMR - ALL PLANS 18.65 70 999999999 16.13 25.84 percent of total billed charges BELBUCA 150 MCG FILM 50743706_1 CDM 0250 RC 59385-0022-60 NDC inpatient 1 UN 26.64 17.32 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16.13 60.55 999999999 16.13 25.84 percent of total billed charges BELBUCA 150 MCG FILM 50743706_1 CDM 0250 RC 59385-0022-60 NDC inpatient 1 UN 26.64 17.32 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16.13 25.84 BELBUCA 150 MCG FILM 50743706_1 CDM 0250 RC 59385-0022-60 NDC inpatient 1 UN 26.64 17.32 ANTHEM HMO ANTHEM HMO 999999999 16.13 25.84 BELBUCA 150 MCG FILM 50743706_1 CDM 0250 RC 59385-0022-60 NDC inpatient 1 UN 26.64 17.32 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16.13 25.84 BELBUCA 150 MCG FILM 50743706_1 CDM 0250 RC 59385-0022-60 NDC inpatient 1 UN 26.64 17.32 CIGNA - ALL PLANS CIGNA - ALL PLANS 18.01 67.6 999999999 16.13 25.84 percent of total billed charges BELBUCA 150 MCG FILM 50743706_1 CDM 0250 RC 59385-0022-60 NDC inpatient 1 UN 26.64 17.32 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16.13 25.84 BELBUCA 150 MCG FILM 50743706_1 CDM 0250 RC 59385-0022-60 NDC inpatient 1 UN 26.64 17.32 UHC - ALL PLANS UHC - ALL PLANS 999999999 16.13 25.84 BELBUCA 300 MCG FILM 50743711_1 CDM 0250 RC 59385-0023-60 NDC inpatient 1 UN 41.83 27.19 SELF PAY DISCOUNT SELF PAY DISCOUNT 27.19 65 999999999 25.33 40.58 percent of total billed charges BELBUCA 300 MCG FILM 50743711_1 CDM 0250 RC 59385-0023-60 NDC inpatient 1 UN 41.83 27.19 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 40.58 97 999999999 25.33 40.58 percent of total billed charges BELBUCA 300 MCG FILM 50743711_1 CDM 0250 RC 59385-0023-60 NDC inpatient 1 UN 41.83 27.19 AETNA AETNA 33.05 79 999999999 25.33 40.58 percent of total billed charges BELBUCA 300 MCG FILM 50743711_1 CDM 0250 RC 59385-0023-60 NDC inpatient 1 UN 41.83 27.19 HUMANA - ALL PLANS HUMANA - ALL PLANS 32.63 78 999999999 25.33 40.58 percent of total billed charges BELBUCA 300 MCG FILM 50743711_1 CDM 0250 RC 59385-0023-60 NDC inpatient 1 UN 41.83 27.19 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.86 69 999999999 25.33 40.58 percent of total billed charges BELBUCA 300 MCG FILM 50743711_1 CDM 0250 RC 59385-0023-60 NDC inpatient 1 UN 41.83 27.19 SIHO - ALL PLANS SIHO - ALL PLANS 37.65 90 999999999 25.33 40.58 percent of total billed charges BELBUCA 300 MCG FILM 50743711_1 CDM 0250 RC 59385-0023-60 NDC inpatient 1 UN 41.83 27.19 UMR - ALL PLANS UMR - ALL PLANS 29.28 70 999999999 25.33 40.58 percent of total billed charges BELBUCA 300 MCG FILM 50743711_1 CDM 0250 RC 59385-0023-60 NDC inpatient 1 UN 41.83 27.19 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 25.33 60.55 999999999 25.33 40.58 percent of total billed charges BELBUCA 300 MCG FILM 50743711_1 CDM 0250 RC 59385-0023-60 NDC inpatient 1 UN 41.83 27.19 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 25.33 40.58 BELBUCA 300 MCG FILM 50743711_1 CDM 0250 RC 59385-0023-60 NDC inpatient 1 UN 41.83 27.19 ANTHEM HMO ANTHEM HMO 999999999 25.33 40.58 BELBUCA 300 MCG FILM 50743711_1 CDM 0250 RC 59385-0023-60 NDC inpatient 1 UN 41.83 27.19 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 25.33 40.58 BELBUCA 300 MCG FILM 50743711_1 CDM 0250 RC 59385-0023-60 NDC inpatient 1 UN 41.83 27.19 CIGNA - ALL PLANS CIGNA - ALL PLANS 28.28 67.6 999999999 25.33 40.58 percent of total billed charges BELBUCA 300 MCG FILM 50743711_1 CDM 0250 RC 59385-0023-60 NDC inpatient 1 UN 41.83 27.19 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 25.33 40.58 BELBUCA 300 MCG FILM 50743711_1 CDM 0250 RC 59385-0023-60 NDC inpatient 1 UN 41.83 27.19 UHC - ALL PLANS UHC - ALL PLANS 999999999 25.33 40.58 CALCITONIN-SALMON 400 UNIT/2ML 50744216_1 CDM 0250 RC 24201-0400-02 NDC inpatient 1 UN 1003.05 651.98 SELF PAY DISCOUNT SELF PAY DISCOUNT 651.98 65 999999999 607.35 972.96 percent of total billed charges CALCITONIN-SALMON 400 UNIT/2ML 50744216_1 CDM 0250 RC 24201-0400-02 NDC inpatient 1 UN 1003.05 651.98 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 972.96 97 999999999 607.35 972.96 percent of total billed charges CALCITONIN-SALMON 400 UNIT/2ML 50744216_1 CDM 0250 RC 24201-0400-02 NDC inpatient 1 UN 1003.05 651.98 AETNA AETNA 792.41 79 999999999 607.35 972.96 percent of total billed charges CALCITONIN-SALMON 400 UNIT/2ML 50744216_1 CDM 0250 RC 24201-0400-02 NDC inpatient 1 UN 1003.05 651.98 HUMANA - ALL PLANS HUMANA - ALL PLANS 782.38 78 999999999 607.35 972.96 percent of total billed charges CALCITONIN-SALMON 400 UNIT/2ML 50744216_1 CDM 0250 RC 24201-0400-02 NDC inpatient 1 UN 1003.05 651.98 ENCORE - ALL PLANS ENCORE - ALL PLANS 692.1 69 999999999 607.35 972.96 percent of total billed charges CALCITONIN-SALMON 400 UNIT/2ML 50744216_1 CDM 0250 RC 24201-0400-02 NDC inpatient 1 UN 1003.05 651.98 SIHO - ALL PLANS SIHO - ALL PLANS 902.75 90 999999999 607.35 972.96 percent of total billed charges CALCITONIN-SALMON 400 UNIT/2ML 50744216_1 CDM 0250 RC 24201-0400-02 NDC inpatient 1 UN 1003.05 651.98 UMR - ALL PLANS UMR - ALL PLANS 702.14 70 999999999 607.35 972.96 percent of total billed charges CALCITONIN-SALMON 400 UNIT/2ML 50744216_1 CDM 0250 RC 24201-0400-02 NDC inpatient 1 UN 1003.05 651.98 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 607.35 60.55 999999999 607.35 972.96 percent of total billed charges CALCITONIN-SALMON 400 UNIT/2ML 50744216_1 CDM 0250 RC 24201-0400-02 NDC inpatient 1 UN 1003.05 651.98 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 607.35 972.96 CALCITONIN-SALMON 400 UNIT/2ML 50744216_1 CDM 0250 RC 24201-0400-02 NDC inpatient 1 UN 1003.05 651.98 ANTHEM HMO ANTHEM HMO 999999999 607.35 972.96 CALCITONIN-SALMON 400 UNIT/2ML 50744216_1 CDM 0250 RC 24201-0400-02 NDC inpatient 1 UN 1003.05 651.98 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 607.35 972.96 CALCITONIN-SALMON 400 UNIT/2ML 50744216_1 CDM 0250 RC 24201-0400-02 NDC inpatient 1 UN 1003.05 651.98 CIGNA - ALL PLANS CIGNA - ALL PLANS 678.06 67.6 999999999 607.35 972.96 percent of total billed charges CALCITONIN-SALMON 400 UNIT/2ML 50744216_1 CDM 0250 RC 24201-0400-02 NDC inpatient 1 UN 1003.05 651.98 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 607.35 972.96 CALCITONIN-SALMON 400 UNIT/2ML 50744216_1 CDM 0250 RC 24201-0400-02 NDC inpatient 1 UN 1003.05 651.98 UHC - ALL PLANS UHC - ALL PLANS 999999999 607.35 972.96 Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 50745130_1 CDM 0510 RC 36476 HCPCS inpatient 8416 5470.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 5470.4 65 999999999 5095.89 8163.52 percent of total billed charges Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 50745130_1 CDM 0510 RC 36476 HCPCS inpatient 8416 5470.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8163.52 97 999999999 5095.89 8163.52 percent of total billed charges Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 50745130_1 CDM 0510 RC 36476 HCPCS inpatient 8416 5470.4 AETNA AETNA 6648.64 79 999999999 5095.89 8163.52 percent of total billed charges Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 50745130_1 CDM 0510 RC 36476 HCPCS inpatient 8416 5470.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 6564.48 78 999999999 5095.89 8163.52 percent of total billed charges Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 50745130_1 CDM 0510 RC 36476 HCPCS inpatient 8416 5470.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 5807.04 69 999999999 5095.89 8163.52 percent of total billed charges Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 50745130_1 CDM 0510 RC 36476 HCPCS inpatient 8416 5470.4 SIHO - ALL PLANS SIHO - ALL PLANS 7574.4 90 999999999 5095.89 8163.52 percent of total billed charges Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 50745130_1 CDM 0510 RC 36476 HCPCS inpatient 8416 5470.4 UMR - ALL PLANS UMR - ALL PLANS 5891.2 70 999999999 5095.89 8163.52 percent of total billed charges Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 50745130_1 CDM 0510 RC 36476 HCPCS inpatient 8416 5470.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5095.89 60.55 999999999 5095.89 8163.52 percent of total billed charges Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 50745130_1 CDM 0510 RC 36476 HCPCS inpatient 8416 5470.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5095.89 8163.52 Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 50745130_1 CDM 0510 RC 36476 HCPCS inpatient 8416 5470.4 ANTHEM HMO ANTHEM HMO 999999999 5095.89 8163.52 Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 50745130_1 CDM 0510 RC 36476 HCPCS inpatient 8416 5470.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5095.89 8163.52 Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 50745130_1 CDM 0510 RC 36476 HCPCS inpatient 8416 5470.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 5689.22 67.6 999999999 5095.89 8163.52 percent of total billed charges Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 50745130_1 CDM 0510 RC 36476 HCPCS inpatient 8416 5470.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5095.89 8163.52 Destruction of subsequent incompetent veins of arm or leg using radiofrequency and imaging guidance 50745130_1 CDM 0510 RC 36476 HCPCS inpatient 8416 5470.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 5095.89 8163.52 Detection test by immunoassay technique for hepatitis B surface antigen 50748100_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 50748100_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 50748100_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 50748100_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 50748100_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 50748100_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 50748100_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 50748100_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 50748100_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 Detection test by immunoassay technique for hepatitis B surface antigen 50748100_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 Detection test by immunoassay technique for hepatitis B surface antigen 50748100_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 Detection test by immunoassay technique for hepatitis B surface antigen 50748100_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 50748100_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 Detection test by immunoassay technique for hepatitis B surface antigen 50748100_1 CDM 0306 RC 87340 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 XARELTO 20 MG TABLET 50748345_1 CDM 0250 RC 50458-0579-10 NDC inpatient 1 UN 54.82 35.63 SELF PAY DISCOUNT SELF PAY DISCOUNT 35.63 65 999999999 33.19 53.18 percent of total billed charges XARELTO 20 MG TABLET 50748345_1 CDM 0250 RC 50458-0579-10 NDC inpatient 1 UN 54.82 35.63 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 53.18 97 999999999 33.19 53.18 percent of total billed charges XARELTO 20 MG TABLET 50748345_1 CDM 0250 RC 50458-0579-10 NDC inpatient 1 UN 54.82 35.63 AETNA AETNA 43.31 79 999999999 33.19 53.18 percent of total billed charges XARELTO 20 MG TABLET 50748345_1 CDM 0250 RC 50458-0579-10 NDC inpatient 1 UN 54.82 35.63 HUMANA - ALL PLANS HUMANA - ALL PLANS 42.76 78 999999999 33.19 53.18 percent of total billed charges XARELTO 20 MG TABLET 50748345_1 CDM 0250 RC 50458-0579-10 NDC inpatient 1 UN 54.82 35.63 ENCORE - ALL PLANS ENCORE - ALL PLANS 37.83 69 999999999 33.19 53.18 percent of total billed charges XARELTO 20 MG TABLET 50748345_1 CDM 0250 RC 50458-0579-10 NDC inpatient 1 UN 54.82 35.63 SIHO - ALL PLANS SIHO - ALL PLANS 49.34 90 999999999 33.19 53.18 percent of total billed charges XARELTO 20 MG TABLET 50748345_1 CDM 0250 RC 50458-0579-10 NDC inpatient 1 UN 54.82 35.63 UMR - ALL PLANS UMR - ALL PLANS 38.37 70 999999999 33.19 53.18 percent of total billed charges XARELTO 20 MG TABLET 50748345_1 CDM 0250 RC 50458-0579-10 NDC inpatient 1 UN 54.82 35.63 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33.19 60.55 999999999 33.19 53.18 percent of total billed charges XARELTO 20 MG TABLET 50748345_1 CDM 0250 RC 50458-0579-10 NDC inpatient 1 UN 54.82 35.63 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 33.19 53.18 XARELTO 20 MG TABLET 50748345_1 CDM 0250 RC 50458-0579-10 NDC inpatient 1 UN 54.82 35.63 ANTHEM HMO ANTHEM HMO 999999999 33.19 53.18 XARELTO 20 MG TABLET 50748345_1 CDM 0250 RC 50458-0579-10 NDC inpatient 1 UN 54.82 35.63 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 33.19 53.18 XARELTO 20 MG TABLET 50748345_1 CDM 0250 RC 50458-0579-10 NDC inpatient 1 UN 54.82 35.63 CIGNA - ALL PLANS CIGNA - ALL PLANS 37.06 67.6 999999999 33.19 53.18 percent of total billed charges XARELTO 20 MG TABLET 50748345_1 CDM 0250 RC 50458-0579-10 NDC inpatient 1 UN 54.82 35.63 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 33.19 53.18 XARELTO 20 MG TABLET 50748345_1 CDM 0250 RC 50458-0579-10 NDC inpatient 1 UN 54.82 35.63 UHC - ALL PLANS UHC - ALL PLANS 999999999 33.19 53.18 DOXYCYCLINE HYCLATE 100 MG VL 50748384_1 CDM 0250 RC 00143-9381-10 NDC inpatient 1 UN 99.71 64.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 64.81 65 999999999 60.37 96.72 percent of total billed charges DOXYCYCLINE HYCLATE 100 MG VL 50748384_1 CDM 0250 RC 00143-9381-10 NDC inpatient 1 UN 99.71 64.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 96.72 97 999999999 60.37 96.72 percent of total billed charges DOXYCYCLINE HYCLATE 100 MG VL 50748384_1 CDM 0250 RC 00143-9381-10 NDC inpatient 1 UN 99.71 64.81 AETNA AETNA 78.77 79 999999999 60.37 96.72 percent of total billed charges DOXYCYCLINE HYCLATE 100 MG VL 50748384_1 CDM 0250 RC 00143-9381-10 NDC inpatient 1 UN 99.71 64.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 77.77 78 999999999 60.37 96.72 percent of total billed charges DOXYCYCLINE HYCLATE 100 MG VL 50748384_1 CDM 0250 RC 00143-9381-10 NDC inpatient 1 UN 99.71 64.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 68.8 69 999999999 60.37 96.72 percent of total billed charges DOXYCYCLINE HYCLATE 100 MG VL 50748384_1 CDM 0250 RC 00143-9381-10 NDC inpatient 1 UN 99.71 64.81 SIHO - ALL PLANS SIHO - ALL PLANS 89.74 90 999999999 60.37 96.72 percent of total billed charges DOXYCYCLINE HYCLATE 100 MG VL 50748384_1 CDM 0250 RC 00143-9381-10 NDC inpatient 1 UN 99.71 64.81 UMR - ALL PLANS UMR - ALL PLANS 69.8 70 999999999 60.37 96.72 percent of total billed charges DOXYCYCLINE HYCLATE 100 MG VL 50748384_1 CDM 0250 RC 00143-9381-10 NDC inpatient 1 UN 99.71 64.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.37 60.55 999999999 60.37 96.72 percent of total billed charges DOXYCYCLINE HYCLATE 100 MG VL 50748384_1 CDM 0250 RC 00143-9381-10 NDC inpatient 1 UN 99.71 64.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.37 96.72 DOXYCYCLINE HYCLATE 100 MG VL 50748384_1 CDM 0250 RC 00143-9381-10 NDC inpatient 1 UN 99.71 64.81 ANTHEM HMO ANTHEM HMO 999999999 60.37 96.72 DOXYCYCLINE HYCLATE 100 MG VL 50748384_1 CDM 0250 RC 00143-9381-10 NDC inpatient 1 UN 99.71 64.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.37 96.72 DOXYCYCLINE HYCLATE 100 MG VL 50748384_1 CDM 0250 RC 00143-9381-10 NDC inpatient 1 UN 99.71 64.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.4 67.6 999999999 60.37 96.72 percent of total billed charges DOXYCYCLINE HYCLATE 100 MG VL 50748384_1 CDM 0250 RC 00143-9381-10 NDC inpatient 1 UN 99.71 64.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.37 96.72 DOXYCYCLINE HYCLATE 100 MG VL 50748384_1 CDM 0250 RC 00143-9381-10 NDC inpatient 1 UN 99.71 64.81 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.37 96.72 CLINDAMYCIN 900 MG/50 ML-D5W 50748631_1 CDM 0250 RC 00781-3290-09 NDC inpatient 1 UN 79.03 51.37 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.37 65 999999999 47.85 76.66 percent of total billed charges CLINDAMYCIN 900 MG/50 ML-D5W 50748631_1 CDM 0250 RC 00781-3290-09 NDC inpatient 1 UN 79.03 51.37 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.66 97 999999999 47.85 76.66 percent of total billed charges CLINDAMYCIN 900 MG/50 ML-D5W 50748631_1 CDM 0250 RC 00781-3290-09 NDC inpatient 1 UN 79.03 51.37 AETNA AETNA 62.43 79 999999999 47.85 76.66 percent of total billed charges CLINDAMYCIN 900 MG/50 ML-D5W 50748631_1 CDM 0250 RC 00781-3290-09 NDC inpatient 1 UN 79.03 51.37 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.64 78 999999999 47.85 76.66 percent of total billed charges CLINDAMYCIN 900 MG/50 ML-D5W 50748631_1 CDM 0250 RC 00781-3290-09 NDC inpatient 1 UN 79.03 51.37 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.53 69 999999999 47.85 76.66 percent of total billed charges CLINDAMYCIN 900 MG/50 ML-D5W 50748631_1 CDM 0250 RC 00781-3290-09 NDC inpatient 1 UN 79.03 51.37 SIHO - ALL PLANS SIHO - ALL PLANS 71.13 90 999999999 47.85 76.66 percent of total billed charges CLINDAMYCIN 900 MG/50 ML-D5W 50748631_1 CDM 0250 RC 00781-3290-09 NDC inpatient 1 UN 79.03 51.37 UMR - ALL PLANS UMR - ALL PLANS 55.32 70 999999999 47.85 76.66 percent of total billed charges CLINDAMYCIN 900 MG/50 ML-D5W 50748631_1 CDM 0250 RC 00781-3290-09 NDC inpatient 1 UN 79.03 51.37 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.85 60.55 999999999 47.85 76.66 percent of total billed charges CLINDAMYCIN 900 MG/50 ML-D5W 50748631_1 CDM 0250 RC 00781-3290-09 NDC inpatient 1 UN 79.03 51.37 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.85 76.66 CLINDAMYCIN 900 MG/50 ML-D5W 50748631_1 CDM 0250 RC 00781-3290-09 NDC inpatient 1 UN 79.03 51.37 ANTHEM HMO ANTHEM HMO 999999999 47.85 76.66 CLINDAMYCIN 900 MG/50 ML-D5W 50748631_1 CDM 0250 RC 00781-3290-09 NDC inpatient 1 UN 79.03 51.37 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.85 76.66 CLINDAMYCIN 900 MG/50 ML-D5W 50748631_1 CDM 0250 RC 00781-3290-09 NDC inpatient 1 UN 79.03 51.37 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.42 67.6 999999999 47.85 76.66 percent of total billed charges CLINDAMYCIN 900 MG/50 ML-D5W 50748631_1 CDM 0250 RC 00781-3290-09 NDC inpatient 1 UN 79.03 51.37 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.85 76.66 CLINDAMYCIN 900 MG/50 ML-D5W 50748631_1 CDM 0250 RC 00781-3290-09 NDC inpatient 1 UN 79.03 51.37 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.85 76.66 08471-0510-01 - Sea Band 1 band Misc 50748909_1 CDM 0250 RC 08471-0510-01 NDC inpatient 1 UN 10.35 6.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.73 65 999999999 6.27 10.04 percent of total billed charges 08471-0510-01 - Sea Band 1 band Misc 50748909_1 CDM 0250 RC 08471-0510-01 NDC inpatient 1 UN 10.35 6.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10.04 97 999999999 6.27 10.04 percent of total billed charges 08471-0510-01 - Sea Band 1 band Misc 50748909_1 CDM 0250 RC 08471-0510-01 NDC inpatient 1 UN 10.35 6.73 AETNA AETNA 8.18 79 999999999 6.27 10.04 percent of total billed charges 08471-0510-01 - Sea Band 1 band Misc 50748909_1 CDM 0250 RC 08471-0510-01 NDC inpatient 1 UN 10.35 6.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 8.07 78 999999999 6.27 10.04 percent of total billed charges 08471-0510-01 - Sea Band 1 band Misc 50748909_1 CDM 0250 RC 08471-0510-01 NDC inpatient 1 UN 10.35 6.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.14 69 999999999 6.27 10.04 percent of total billed charges 08471-0510-01 - Sea Band 1 band Misc 50748909_1 CDM 0250 RC 08471-0510-01 NDC inpatient 1 UN 10.35 6.73 SIHO - ALL PLANS SIHO - ALL PLANS 9.32 90 999999999 6.27 10.04 percent of total billed charges 08471-0510-01 - Sea Band 1 band Misc 50748909_1 CDM 0250 RC 08471-0510-01 NDC inpatient 1 UN 10.35 6.73 UMR - ALL PLANS UMR - ALL PLANS 7.25 70 999999999 6.27 10.04 percent of total billed charges 08471-0510-01 - Sea Band 1 band Misc 50748909_1 CDM 0250 RC 08471-0510-01 NDC inpatient 1 UN 10.35 6.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.27 60.55 999999999 6.27 10.04 percent of total billed charges 08471-0510-01 - Sea Band 1 band Misc 50748909_1 CDM 0250 RC 08471-0510-01 NDC inpatient 1 UN 10.35 6.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.27 10.04 08471-0510-01 - Sea Band 1 band Misc 50748909_1 CDM 0250 RC 08471-0510-01 NDC inpatient 1 UN 10.35 6.73 ANTHEM HMO ANTHEM HMO 999999999 6.27 10.04 08471-0510-01 - Sea Band 1 band Misc 50748909_1 CDM 0250 RC 08471-0510-01 NDC inpatient 1 UN 10.35 6.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.27 10.04 08471-0510-01 - Sea Band 1 band Misc 50748909_1 CDM 0250 RC 08471-0510-01 NDC inpatient 1 UN 10.35 6.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 7 67.6 999999999 6.27 10.04 percent of total billed charges 08471-0510-01 - Sea Band 1 band Misc 50748909_1 CDM 0250 RC 08471-0510-01 NDC inpatient 1 UN 10.35 6.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.27 10.04 08471-0510-01 - Sea Band 1 band Misc 50748909_1 CDM 0250 RC 08471-0510-01 NDC inpatient 1 UN 10.35 6.73 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.27 10.04 MANNITOL 20% (50 GM/250 ML) 50748960_1 CDM 0258 RC 00990-7715-02 NDC inpatient 1 UN 156.88 101.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.97 65 999999999 94.99 152.17 percent of total billed charges MANNITOL 20% (50 GM/250 ML) 50748960_1 CDM 0258 RC 00990-7715-02 NDC inpatient 1 UN 156.88 101.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 152.17 97 999999999 94.99 152.17 percent of total billed charges MANNITOL 20% (50 GM/250 ML) 50748960_1 CDM 0258 RC 00990-7715-02 NDC inpatient 1 UN 156.88 101.97 AETNA AETNA 123.94 79 999999999 94.99 152.17 percent of total billed charges MANNITOL 20% (50 GM/250 ML) 50748960_1 CDM 0258 RC 00990-7715-02 NDC inpatient 1 UN 156.88 101.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 122.37 78 999999999 94.99 152.17 percent of total billed charges MANNITOL 20% (50 GM/250 ML) 50748960_1 CDM 0258 RC 00990-7715-02 NDC inpatient 1 UN 156.88 101.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 108.25 69 999999999 94.99 152.17 percent of total billed charges MANNITOL 20% (50 GM/250 ML) 50748960_1 CDM 0258 RC 00990-7715-02 NDC inpatient 1 UN 156.88 101.97 SIHO - ALL PLANS SIHO - ALL PLANS 141.19 90 999999999 94.99 152.17 percent of total billed charges MANNITOL 20% (50 GM/250 ML) 50748960_1 CDM 0258 RC 00990-7715-02 NDC inpatient 1 UN 156.88 101.97 UMR - ALL PLANS UMR - ALL PLANS 109.82 70 999999999 94.99 152.17 percent of total billed charges MANNITOL 20% (50 GM/250 ML) 50748960_1 CDM 0258 RC 00990-7715-02 NDC inpatient 1 UN 156.88 101.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.99 60.55 999999999 94.99 152.17 percent of total billed charges MANNITOL 20% (50 GM/250 ML) 50748960_1 CDM 0258 RC 00990-7715-02 NDC inpatient 1 UN 156.88 101.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.99 152.17 MANNITOL 20% (50 GM/250 ML) 50748960_1 CDM 0258 RC 00990-7715-02 NDC inpatient 1 UN 156.88 101.97 ANTHEM HMO ANTHEM HMO 999999999 94.99 152.17 MANNITOL 20% (50 GM/250 ML) 50748960_1 CDM 0258 RC 00990-7715-02 NDC inpatient 1 UN 156.88 101.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.99 152.17 MANNITOL 20% (50 GM/250 ML) 50748960_1 CDM 0258 RC 00990-7715-02 NDC inpatient 1 UN 156.88 101.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.05 67.6 999999999 94.99 152.17 percent of total billed charges MANNITOL 20% (50 GM/250 ML) 50748960_1 CDM 0258 RC 00990-7715-02 NDC inpatient 1 UN 156.88 101.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.99 152.17 MANNITOL 20% (50 GM/250 ML) 50748960_1 CDM 0258 RC 00990-7715-02 NDC inpatient 1 UN 156.88 101.97 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.99 152.17 PROPYLTHIOURACIL 50 MG TABLET 50748967_1 CDM 0250 RC 00228-2348-10 NDC inpatient 1 UN 2.31 1.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.5 65 999999999 1.4 2.24 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 50748967_1 CDM 0250 RC 00228-2348-10 NDC inpatient 1 UN 2.31 1.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2.24 97 999999999 1.4 2.24 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 50748967_1 CDM 0250 RC 00228-2348-10 NDC inpatient 1 UN 2.31 1.5 AETNA AETNA 1.82 79 999999999 1.4 2.24 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 50748967_1 CDM 0250 RC 00228-2348-10 NDC inpatient 1 UN 2.31 1.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.8 78 999999999 1.4 2.24 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 50748967_1 CDM 0250 RC 00228-2348-10 NDC inpatient 1 UN 2.31 1.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.59 69 999999999 1.4 2.24 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 50748967_1 CDM 0250 RC 00228-2348-10 NDC inpatient 1 UN 2.31 1.5 SIHO - ALL PLANS SIHO - ALL PLANS 2.08 90 999999999 1.4 2.24 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 50748967_1 CDM 0250 RC 00228-2348-10 NDC inpatient 1 UN 2.31 1.5 UMR - ALL PLANS UMR - ALL PLANS 1.62 70 999999999 1.4 2.24 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 50748967_1 CDM 0250 RC 00228-2348-10 NDC inpatient 1 UN 2.31 1.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.4 60.55 999999999 1.4 2.24 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 50748967_1 CDM 0250 RC 00228-2348-10 NDC inpatient 1 UN 2.31 1.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.4 2.24 PROPYLTHIOURACIL 50 MG TABLET 50748967_1 CDM 0250 RC 00228-2348-10 NDC inpatient 1 UN 2.31 1.5 ANTHEM HMO ANTHEM HMO 999999999 1.4 2.24 PROPYLTHIOURACIL 50 MG TABLET 50748967_1 CDM 0250 RC 00228-2348-10 NDC inpatient 1 UN 2.31 1.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.4 2.24 PROPYLTHIOURACIL 50 MG TABLET 50748967_1 CDM 0250 RC 00228-2348-10 NDC inpatient 1 UN 2.31 1.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.56 67.6 999999999 1.4 2.24 percent of total billed charges PROPYLTHIOURACIL 50 MG TABLET 50748967_1 CDM 0250 RC 00228-2348-10 NDC inpatient 1 UN 2.31 1.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.4 2.24 PROPYLTHIOURACIL 50 MG TABLET 50748967_1 CDM 0250 RC 00228-2348-10 NDC inpatient 1 UN 2.31 1.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.4 2.24 "Detection test by nucleic acid for HIV-1 virus, quantification" 50749208_1 CDM 0306 RC 87536 HCPCS inpatient 309 200.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 200.85 65 999999999 187.1 299.73 percent of total billed charges "Detection test by nucleic acid for HIV-1 virus, quantification" 50749208_1 CDM 0306 RC 87536 HCPCS inpatient 309 200.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 299.73 97 999999999 187.1 299.73 percent of total billed charges "Detection test by nucleic acid for HIV-1 virus, quantification" 50749208_1 CDM 0306 RC 87536 HCPCS inpatient 309 200.85 AETNA AETNA 244.11 79 999999999 187.1 299.73 percent of total billed charges "Detection test by nucleic acid for HIV-1 virus, quantification" 50749208_1 CDM 0306 RC 87536 HCPCS inpatient 309 200.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 241.02 78 999999999 187.1 299.73 percent of total billed charges "Detection test by nucleic acid for HIV-1 virus, quantification" 50749208_1 CDM 0306 RC 87536 HCPCS inpatient 309 200.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 213.21 69 999999999 187.1 299.73 percent of total billed charges "Detection test by nucleic acid for HIV-1 virus, quantification" 50749208_1 CDM 0306 RC 87536 HCPCS inpatient 309 200.85 SIHO - ALL PLANS SIHO - ALL PLANS 278.1 90 999999999 187.1 299.73 percent of total billed charges "Detection test by nucleic acid for HIV-1 virus, quantification" 50749208_1 CDM 0306 RC 87536 HCPCS inpatient 309 200.85 UMR - ALL PLANS UMR - ALL PLANS 216.3 70 999999999 187.1 299.73 percent of total billed charges "Detection test by nucleic acid for HIV-1 virus, quantification" 50749208_1 CDM 0306 RC 87536 HCPCS inpatient 309 200.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 187.1 60.55 999999999 187.1 299.73 percent of total billed charges "Detection test by nucleic acid for HIV-1 virus, quantification" 50749208_1 CDM 0306 RC 87536 HCPCS inpatient 309 200.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 187.1 299.73 "Detection test by nucleic acid for HIV-1 virus, quantification" 50749208_1 CDM 0306 RC 87536 HCPCS inpatient 309 200.85 ANTHEM HMO ANTHEM HMO 999999999 187.1 299.73 "Detection test by nucleic acid for HIV-1 virus, quantification" 50749208_1 CDM 0306 RC 87536 HCPCS inpatient 309 200.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 187.1 299.73 "Detection test by nucleic acid for HIV-1 virus, quantification" 50749208_1 CDM 0306 RC 87536 HCPCS inpatient 309 200.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 208.88 67.6 999999999 187.1 299.73 percent of total billed charges "Detection test by nucleic acid for HIV-1 virus, quantification" 50749208_1 CDM 0306 RC 87536 HCPCS inpatient 309 200.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 187.1 299.73 "Detection test by nucleic acid for HIV-1 virus, quantification" 50749208_1 CDM 0306 RC 87536 HCPCS inpatient 309 200.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 187.1 299.73 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50749264_1 CDM 0636 RC 67457-0794-10 NDC J3489 HCPCS inpatient 5 UN 458.5 298.03 SELF PAY DISCOUNT SELF PAY DISCOUNT 298.03 65 999999999 277.62 444.75 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50749264_1 CDM 0636 RC 67457-0794-10 NDC J3489 HCPCS inpatient 5 UN 458.5 298.03 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 444.75 97 999999999 277.62 444.75 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50749264_1 CDM 0636 RC 67457-0794-10 NDC J3489 HCPCS inpatient 5 UN 458.5 298.03 AETNA AETNA 362.22 79 999999999 277.62 444.75 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50749264_1 CDM 0636 RC 67457-0794-10 NDC J3489 HCPCS inpatient 5 UN 458.5 298.03 HUMANA - ALL PLANS HUMANA - ALL PLANS 357.63 78 999999999 277.62 444.75 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50749264_1 CDM 0636 RC 67457-0794-10 NDC J3489 HCPCS inpatient 5 UN 458.5 298.03 ENCORE - ALL PLANS ENCORE - ALL PLANS 316.37 69 999999999 277.62 444.75 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50749264_1 CDM 0636 RC 67457-0794-10 NDC J3489 HCPCS inpatient 5 UN 458.5 298.03 SIHO - ALL PLANS SIHO - ALL PLANS 412.65 90 999999999 277.62 444.75 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50749264_1 CDM 0636 RC 67457-0794-10 NDC J3489 HCPCS inpatient 5 UN 458.5 298.03 UMR - ALL PLANS UMR - ALL PLANS 320.95 70 999999999 277.62 444.75 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50749264_1 CDM 0636 RC 67457-0794-10 NDC J3489 HCPCS inpatient 5 UN 458.5 298.03 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 277.62 60.55 999999999 277.62 444.75 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50749264_1 CDM 0636 RC 67457-0794-10 NDC J3489 HCPCS inpatient 5 UN 458.5 298.03 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 277.62 444.75 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50749264_1 CDM 0636 RC 67457-0794-10 NDC J3489 HCPCS inpatient 5 UN 458.5 298.03 ANTHEM HMO ANTHEM HMO 999999999 277.62 444.75 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50749264_1 CDM 0636 RC 67457-0794-10 NDC J3489 HCPCS inpatient 5 UN 458.5 298.03 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 277.62 444.75 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50749264_1 CDM 0636 RC 67457-0794-10 NDC J3489 HCPCS inpatient 5 UN 458.5 298.03 CIGNA - ALL PLANS CIGNA - ALL PLANS 309.95 67.6 999999999 277.62 444.75 percent of total billed charges "INJECTION, ZOLEDRONIC ACID, 1 MG" 50749264_1 CDM 0636 RC 67457-0794-10 NDC J3489 HCPCS inpatient 5 UN 458.5 298.03 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 277.62 444.75 "INJECTION, ZOLEDRONIC ACID, 1 MG" 50749264_1 CDM 0636 RC 67457-0794-10 NDC J3489 HCPCS inpatient 5 UN 458.5 298.03 UHC - ALL PLANS UHC - ALL PLANS 999999999 277.62 444.75 "INJECTION, DROPERIDOL, UP TO 5 MG" 50749294_1 CDM 0250 RC 00517-9702-25 NDC J1790 HCPCS inpatient 1 UN 51.75 33.64 SELF PAY DISCOUNT SELF PAY DISCOUNT 33.64 65 999999999 31.33 50.2 percent of total billed charges "INJECTION, DROPERIDOL, UP TO 5 MG" 50749294_1 CDM 0250 RC 00517-9702-25 NDC J1790 HCPCS inpatient 1 UN 51.75 33.64 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 50.2 97 999999999 31.33 50.2 percent of total billed charges "INJECTION, DROPERIDOL, UP TO 5 MG" 50749294_1 CDM 0250 RC 00517-9702-25 NDC J1790 HCPCS inpatient 1 UN 51.75 33.64 AETNA AETNA 40.88 79 999999999 31.33 50.2 percent of total billed charges "INJECTION, DROPERIDOL, UP TO 5 MG" 50749294_1 CDM 0250 RC 00517-9702-25 NDC J1790 HCPCS inpatient 1 UN 51.75 33.64 HUMANA - ALL PLANS HUMANA - ALL PLANS 40.37 78 999999999 31.33 50.2 percent of total billed charges "INJECTION, DROPERIDOL, UP TO 5 MG" 50749294_1 CDM 0250 RC 00517-9702-25 NDC J1790 HCPCS inpatient 1 UN 51.75 33.64 ENCORE - ALL PLANS ENCORE - ALL PLANS 35.71 69 999999999 31.33 50.2 percent of total billed charges "INJECTION, DROPERIDOL, UP TO 5 MG" 50749294_1 CDM 0250 RC 00517-9702-25 NDC J1790 HCPCS inpatient 1 UN 51.75 33.64 SIHO - ALL PLANS SIHO - ALL PLANS 46.58 90 999999999 31.33 50.2 percent of total billed charges "INJECTION, DROPERIDOL, UP TO 5 MG" 50749294_1 CDM 0250 RC 00517-9702-25 NDC J1790 HCPCS inpatient 1 UN 51.75 33.64 UMR - ALL PLANS UMR - ALL PLANS 36.23 70 999999999 31.33 50.2 percent of total billed charges "INJECTION, DROPERIDOL, UP TO 5 MG" 50749294_1 CDM 0250 RC 00517-9702-25 NDC J1790 HCPCS inpatient 1 UN 51.75 33.64 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 31.33 60.55 999999999 31.33 50.2 percent of total billed charges "INJECTION, DROPERIDOL, UP TO 5 MG" 50749294_1 CDM 0250 RC 00517-9702-25 NDC J1790 HCPCS inpatient 1 UN 51.75 33.64 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 31.33 50.2 "INJECTION, DROPERIDOL, UP TO 5 MG" 50749294_1 CDM 0250 RC 00517-9702-25 NDC J1790 HCPCS inpatient 1 UN 51.75 33.64 ANTHEM HMO ANTHEM HMO 999999999 31.33 50.2 "INJECTION, DROPERIDOL, UP TO 5 MG" 50749294_1 CDM 0250 RC 00517-9702-25 NDC J1790 HCPCS inpatient 1 UN 51.75 33.64 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 31.33 50.2 "INJECTION, DROPERIDOL, UP TO 5 MG" 50749294_1 CDM 0250 RC 00517-9702-25 NDC J1790 HCPCS inpatient 1 UN 51.75 33.64 CIGNA - ALL PLANS CIGNA - ALL PLANS 34.98 67.6 999999999 31.33 50.2 percent of total billed charges "INJECTION, DROPERIDOL, UP TO 5 MG" 50749294_1 CDM 0250 RC 00517-9702-25 NDC J1790 HCPCS inpatient 1 UN 51.75 33.64 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 31.33 50.2 "INJECTION, DROPERIDOL, UP TO 5 MG" 50749294_1 CDM 0250 RC 00517-9702-25 NDC J1790 HCPCS inpatient 1 UN 51.75 33.64 UHC - ALL PLANS UHC - ALL PLANS 999999999 31.33 50.2 VITAMIN K-1 1 MG/0.5 ML AMPUL 50749298_1 CDM 0250 RC 00409-9157-01 NDC inpatient 1 UN 38.03 24.72 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.72 65 999999999 23.03 36.89 percent of total billed charges VITAMIN K-1 1 MG/0.5 ML AMPUL 50749298_1 CDM 0250 RC 00409-9157-01 NDC inpatient 1 UN 38.03 24.72 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 36.89 97 999999999 23.03 36.89 percent of total billed charges VITAMIN K-1 1 MG/0.5 ML AMPUL 50749298_1 CDM 0250 RC 00409-9157-01 NDC inpatient 1 UN 38.03 24.72 AETNA AETNA 30.04 79 999999999 23.03 36.89 percent of total billed charges VITAMIN K-1 1 MG/0.5 ML AMPUL 50749298_1 CDM 0250 RC 00409-9157-01 NDC inpatient 1 UN 38.03 24.72 HUMANA - ALL PLANS HUMANA - ALL PLANS 29.66 78 999999999 23.03 36.89 percent of total billed charges VITAMIN K-1 1 MG/0.5 ML AMPUL 50749298_1 CDM 0250 RC 00409-9157-01 NDC inpatient 1 UN 38.03 24.72 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.24 69 999999999 23.03 36.89 percent of total billed charges VITAMIN K-1 1 MG/0.5 ML AMPUL 50749298_1 CDM 0250 RC 00409-9157-01 NDC inpatient 1 UN 38.03 24.72 SIHO - ALL PLANS SIHO - ALL PLANS 34.23 90 999999999 23.03 36.89 percent of total billed charges VITAMIN K-1 1 MG/0.5 ML AMPUL 50749298_1 CDM 0250 RC 00409-9157-01 NDC inpatient 1 UN 38.03 24.72 UMR - ALL PLANS UMR - ALL PLANS 26.62 70 999999999 23.03 36.89 percent of total billed charges VITAMIN K-1 1 MG/0.5 ML AMPUL 50749298_1 CDM 0250 RC 00409-9157-01 NDC inpatient 1 UN 38.03 24.72 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23.03 60.55 999999999 23.03 36.89 percent of total billed charges VITAMIN K-1 1 MG/0.5 ML AMPUL 50749298_1 CDM 0250 RC 00409-9157-01 NDC inpatient 1 UN 38.03 24.72 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23.03 36.89 VITAMIN K-1 1 MG/0.5 ML AMPUL 50749298_1 CDM 0250 RC 00409-9157-01 NDC inpatient 1 UN 38.03 24.72 ANTHEM HMO ANTHEM HMO 999999999 23.03 36.89 VITAMIN K-1 1 MG/0.5 ML AMPUL 50749298_1 CDM 0250 RC 00409-9157-01 NDC inpatient 1 UN 38.03 24.72 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23.03 36.89 VITAMIN K-1 1 MG/0.5 ML AMPUL 50749298_1 CDM 0250 RC 00409-9157-01 NDC inpatient 1 UN 38.03 24.72 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.71 67.6 999999999 23.03 36.89 percent of total billed charges VITAMIN K-1 1 MG/0.5 ML AMPUL 50749298_1 CDM 0250 RC 00409-9157-01 NDC inpatient 1 UN 38.03 24.72 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23.03 36.89 VITAMIN K-1 1 MG/0.5 ML AMPUL 50749298_1 CDM 0250 RC 00409-9157-01 NDC inpatient 1 UN 38.03 24.72 UHC - ALL PLANS UHC - ALL PLANS 999999999 23.03 36.89 Measurement of substance using immunoassay technique 50749468_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 130.65 65 999999999 121.71 194.97 percent of total billed charges Measurement of substance using immunoassay technique 50749468_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 194.97 97 999999999 121.71 194.97 percent of total billed charges Measurement of substance using immunoassay technique 50749468_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 AETNA AETNA 158.79 79 999999999 121.71 194.97 percent of total billed charges Measurement of substance using immunoassay technique 50749468_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 156.78 78 999999999 121.71 194.97 percent of total billed charges Measurement of substance using immunoassay technique 50749468_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 138.69 69 999999999 121.71 194.97 percent of total billed charges Measurement of substance using immunoassay technique 50749468_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 SIHO - ALL PLANS SIHO - ALL PLANS 180.9 90 999999999 121.71 194.97 percent of total billed charges Measurement of substance using immunoassay technique 50749468_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 UMR - ALL PLANS UMR - ALL PLANS 140.7 70 999999999 121.71 194.97 percent of total billed charges Measurement of substance using immunoassay technique 50749468_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 121.71 60.55 999999999 121.71 194.97 percent of total billed charges Measurement of substance using immunoassay technique 50749468_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 121.71 194.97 Measurement of substance using immunoassay technique 50749468_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 ANTHEM HMO ANTHEM HMO 999999999 121.71 194.97 Measurement of substance using immunoassay technique 50749468_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 121.71 194.97 Measurement of substance using immunoassay technique 50749468_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 135.88 67.6 999999999 121.71 194.97 percent of total billed charges Measurement of substance using immunoassay technique 50749468_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 121.71 194.97 Measurement of substance using immunoassay technique 50749468_1 CDM 0301 RC 83520 HCPCS inpatient 201 130.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 121.71 194.97 Measurement of substance using immunoassay technique 50749509_1 CDM 0301 RC 83520 HCPCS inpatient 107 69.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 69.55 65 999999999 64.79 103.79 percent of total billed charges Measurement of substance using immunoassay technique 50749509_1 CDM 0301 RC 83520 HCPCS inpatient 107 69.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 103.79 97 999999999 64.79 103.79 percent of total billed charges Measurement of substance using immunoassay technique 50749509_1 CDM 0301 RC 83520 HCPCS inpatient 107 69.55 AETNA AETNA 84.53 79 999999999 64.79 103.79 percent of total billed charges Measurement of substance using immunoassay technique 50749509_1 CDM 0301 RC 83520 HCPCS inpatient 107 69.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 83.46 78 999999999 64.79 103.79 percent of total billed charges Measurement of substance using immunoassay technique 50749509_1 CDM 0301 RC 83520 HCPCS inpatient 107 69.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.83 69 999999999 64.79 103.79 percent of total billed charges Measurement of substance using immunoassay technique 50749509_1 CDM 0301 RC 83520 HCPCS inpatient 107 69.55 SIHO - ALL PLANS SIHO - ALL PLANS 96.3 90 999999999 64.79 103.79 percent of total billed charges Measurement of substance using immunoassay technique 50749509_1 CDM 0301 RC 83520 HCPCS inpatient 107 69.55 UMR - ALL PLANS UMR - ALL PLANS 74.9 70 999999999 64.79 103.79 percent of total billed charges Measurement of substance using immunoassay technique 50749509_1 CDM 0301 RC 83520 HCPCS inpatient 107 69.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.79 60.55 999999999 64.79 103.79 percent of total billed charges Measurement of substance using immunoassay technique 50749509_1 CDM 0301 RC 83520 HCPCS inpatient 107 69.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.79 103.79 Measurement of substance using immunoassay technique 50749509_1 CDM 0301 RC 83520 HCPCS inpatient 107 69.55 ANTHEM HMO ANTHEM HMO 999999999 64.79 103.79 Measurement of substance using immunoassay technique 50749509_1 CDM 0301 RC 83520 HCPCS inpatient 107 69.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.79 103.79 Measurement of substance using immunoassay technique 50749509_1 CDM 0301 RC 83520 HCPCS inpatient 107 69.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 72.33 67.6 999999999 64.79 103.79 percent of total billed charges Measurement of substance using immunoassay technique 50749509_1 CDM 0301 RC 83520 HCPCS inpatient 107 69.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.79 103.79 Measurement of substance using immunoassay technique 50749509_1 CDM 0301 RC 83520 HCPCS inpatient 107 69.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.79 103.79 LEVOTHYROXINE 125 MCG TABLET 50750694_1 CDM 0250 RC 60687-0519-01 NDC inpatient 1 UN 1.91 1.24 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.24 65 999999999 1.16 1.85 percent of total billed charges LEVOTHYROXINE 125 MCG TABLET 50750694_1 CDM 0250 RC 60687-0519-01 NDC inpatient 1 UN 1.91 1.24 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.85 97 999999999 1.16 1.85 percent of total billed charges LEVOTHYROXINE 125 MCG TABLET 50750694_1 CDM 0250 RC 60687-0519-01 NDC inpatient 1 UN 1.91 1.24 AETNA AETNA 1.51 79 999999999 1.16 1.85 percent of total billed charges LEVOTHYROXINE 125 MCG TABLET 50750694_1 CDM 0250 RC 60687-0519-01 NDC inpatient 1 UN 1.91 1.24 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.49 78 999999999 1.16 1.85 percent of total billed charges LEVOTHYROXINE 125 MCG TABLET 50750694_1 CDM 0250 RC 60687-0519-01 NDC inpatient 1 UN 1.91 1.24 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.32 69 999999999 1.16 1.85 percent of total billed charges LEVOTHYROXINE 125 MCG TABLET 50750694_1 CDM 0250 RC 60687-0519-01 NDC inpatient 1 UN 1.91 1.24 SIHO - ALL PLANS SIHO - ALL PLANS 1.72 90 999999999 1.16 1.85 percent of total billed charges LEVOTHYROXINE 125 MCG TABLET 50750694_1 CDM 0250 RC 60687-0519-01 NDC inpatient 1 UN 1.91 1.24 UMR - ALL PLANS UMR - ALL PLANS 1.34 70 999999999 1.16 1.85 percent of total billed charges LEVOTHYROXINE 125 MCG TABLET 50750694_1 CDM 0250 RC 60687-0519-01 NDC inpatient 1 UN 1.91 1.24 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.16 60.55 999999999 1.16 1.85 percent of total billed charges LEVOTHYROXINE 125 MCG TABLET 50750694_1 CDM 0250 RC 60687-0519-01 NDC inpatient 1 UN 1.91 1.24 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.16 1.85 LEVOTHYROXINE 125 MCG TABLET 50750694_1 CDM 0250 RC 60687-0519-01 NDC inpatient 1 UN 1.91 1.24 ANTHEM HMO ANTHEM HMO 999999999 1.16 1.85 LEVOTHYROXINE 125 MCG TABLET 50750694_1 CDM 0250 RC 60687-0519-01 NDC inpatient 1 UN 1.91 1.24 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.16 1.85 LEVOTHYROXINE 125 MCG TABLET 50750694_1 CDM 0250 RC 60687-0519-01 NDC inpatient 1 UN 1.91 1.24 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.29 67.6 999999999 1.16 1.85 percent of total billed charges LEVOTHYROXINE 125 MCG TABLET 50750694_1 CDM 0250 RC 60687-0519-01 NDC inpatient 1 UN 1.91 1.24 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.16 1.85 LEVOTHYROXINE 125 MCG TABLET 50750694_1 CDM 0250 RC 60687-0519-01 NDC inpatient 1 UN 1.91 1.24 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.16 1.85 "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50750808_1 CDM 0250 RC 67877-0230-22 NDC J7517 HCPCS inpatient 140 UN 1076.1 699.47 SELF PAY DISCOUNT SELF PAY DISCOUNT 699.47 65 999999999 651.58 1043.82 percent of total billed charges "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50750808_1 CDM 0250 RC 67877-0230-22 NDC J7517 HCPCS inpatient 140 UN 1076.1 699.47 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1043.82 97 999999999 651.58 1043.82 percent of total billed charges "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50750808_1 CDM 0250 RC 67877-0230-22 NDC J7517 HCPCS inpatient 140 UN 1076.1 699.47 AETNA AETNA 850.12 79 999999999 651.58 1043.82 percent of total billed charges "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50750808_1 CDM 0250 RC 67877-0230-22 NDC J7517 HCPCS inpatient 140 UN 1076.1 699.47 HUMANA - ALL PLANS HUMANA - ALL PLANS 839.36 78 999999999 651.58 1043.82 percent of total billed charges "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50750808_1 CDM 0250 RC 67877-0230-22 NDC J7517 HCPCS inpatient 140 UN 1076.1 699.47 ENCORE - ALL PLANS ENCORE - ALL PLANS 742.51 69 999999999 651.58 1043.82 percent of total billed charges "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50750808_1 CDM 0250 RC 67877-0230-22 NDC J7517 HCPCS inpatient 140 UN 1076.1 699.47 SIHO - ALL PLANS SIHO - ALL PLANS 968.49 90 999999999 651.58 1043.82 percent of total billed charges "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50750808_1 CDM 0250 RC 67877-0230-22 NDC J7517 HCPCS inpatient 140 UN 1076.1 699.47 UMR - ALL PLANS UMR - ALL PLANS 753.27 70 999999999 651.58 1043.82 percent of total billed charges "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50750808_1 CDM 0250 RC 67877-0230-22 NDC J7517 HCPCS inpatient 140 UN 1076.1 699.47 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 651.58 60.55 999999999 651.58 1043.82 percent of total billed charges "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50750808_1 CDM 0250 RC 67877-0230-22 NDC J7517 HCPCS inpatient 140 UN 1076.1 699.47 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 651.58 1043.82 "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50750808_1 CDM 0250 RC 67877-0230-22 NDC J7517 HCPCS inpatient 140 UN 1076.1 699.47 ANTHEM HMO ANTHEM HMO 999999999 651.58 1043.82 "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50750808_1 CDM 0250 RC 67877-0230-22 NDC J7517 HCPCS inpatient 140 UN 1076.1 699.47 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 651.58 1043.82 "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50750808_1 CDM 0250 RC 67877-0230-22 NDC J7517 HCPCS inpatient 140 UN 1076.1 699.47 CIGNA - ALL PLANS CIGNA - ALL PLANS 727.44 67.6 999999999 651.58 1043.82 percent of total billed charges "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50750808_1 CDM 0250 RC 67877-0230-22 NDC J7517 HCPCS inpatient 140 UN 1076.1 699.47 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 651.58 1043.82 "MYCOPHENOLATE MOFETIL, ORAL, 250 MG" 50750808_1 CDM 0250 RC 67877-0230-22 NDC J7517 HCPCS inpatient 140 UN 1076.1 699.47 UHC - ALL PLANS UHC - ALL PLANS 999999999 651.58 1043.82 CARBAMAZEPINE 100 MG TAB CHEW 50750857_1 CDM 0250 RC 60687-0479-01 NDC inpatient 1 UN 1.74 1.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.13 65 999999999 1.05 1.69 percent of total billed charges CARBAMAZEPINE 100 MG TAB CHEW 50750857_1 CDM 0250 RC 60687-0479-01 NDC inpatient 1 UN 1.74 1.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.69 97 999999999 1.05 1.69 percent of total billed charges CARBAMAZEPINE 100 MG TAB CHEW 50750857_1 CDM 0250 RC 60687-0479-01 NDC inpatient 1 UN 1.74 1.13 AETNA AETNA 1.37 79 999999999 1.05 1.69 percent of total billed charges CARBAMAZEPINE 100 MG TAB CHEW 50750857_1 CDM 0250 RC 60687-0479-01 NDC inpatient 1 UN 1.74 1.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.36 78 999999999 1.05 1.69 percent of total billed charges CARBAMAZEPINE 100 MG TAB CHEW 50750857_1 CDM 0250 RC 60687-0479-01 NDC inpatient 1 UN 1.74 1.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.2 69 999999999 1.05 1.69 percent of total billed charges CARBAMAZEPINE 100 MG TAB CHEW 50750857_1 CDM 0250 RC 60687-0479-01 NDC inpatient 1 UN 1.74 1.13 SIHO - ALL PLANS SIHO - ALL PLANS 1.57 90 999999999 1.05 1.69 percent of total billed charges CARBAMAZEPINE 100 MG TAB CHEW 50750857_1 CDM 0250 RC 60687-0479-01 NDC inpatient 1 UN 1.74 1.13 UMR - ALL PLANS UMR - ALL PLANS 1.22 70 999999999 1.05 1.69 percent of total billed charges CARBAMAZEPINE 100 MG TAB CHEW 50750857_1 CDM 0250 RC 60687-0479-01 NDC inpatient 1 UN 1.74 1.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.05 60.55 999999999 1.05 1.69 percent of total billed charges CARBAMAZEPINE 100 MG TAB CHEW 50750857_1 CDM 0250 RC 60687-0479-01 NDC inpatient 1 UN 1.74 1.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.05 1.69 CARBAMAZEPINE 100 MG TAB CHEW 50750857_1 CDM 0250 RC 60687-0479-01 NDC inpatient 1 UN 1.74 1.13 ANTHEM HMO ANTHEM HMO 999999999 1.05 1.69 CARBAMAZEPINE 100 MG TAB CHEW 50750857_1 CDM 0250 RC 60687-0479-01 NDC inpatient 1 UN 1.74 1.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.05 1.69 CARBAMAZEPINE 100 MG TAB CHEW 50750857_1 CDM 0250 RC 60687-0479-01 NDC inpatient 1 UN 1.74 1.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.18 67.6 999999999 1.05 1.69 percent of total billed charges CARBAMAZEPINE 100 MG TAB CHEW 50750857_1 CDM 0250 RC 60687-0479-01 NDC inpatient 1 UN 1.74 1.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.05 1.69 CARBAMAZEPINE 100 MG TAB CHEW 50750857_1 CDM 0250 RC 60687-0479-01 NDC inpatient 1 UN 1.74 1.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.05 1.69 ATROPINE 8 MG/20 ML VIAL 50750984_1 CDM 0250 RC 16729-0512-43 NDC inpatient 1 UN 109.05 70.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.88 65 999999999 66.03 105.78 percent of total billed charges ATROPINE 8 MG/20 ML VIAL 50750984_1 CDM 0250 RC 16729-0512-43 NDC inpatient 1 UN 109.05 70.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.78 97 999999999 66.03 105.78 percent of total billed charges ATROPINE 8 MG/20 ML VIAL 50750984_1 CDM 0250 RC 16729-0512-43 NDC inpatient 1 UN 109.05 70.88 AETNA AETNA 86.15 79 999999999 66.03 105.78 percent of total billed charges ATROPINE 8 MG/20 ML VIAL 50750984_1 CDM 0250 RC 16729-0512-43 NDC inpatient 1 UN 109.05 70.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.06 78 999999999 66.03 105.78 percent of total billed charges ATROPINE 8 MG/20 ML VIAL 50750984_1 CDM 0250 RC 16729-0512-43 NDC inpatient 1 UN 109.05 70.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.24 69 999999999 66.03 105.78 percent of total billed charges ATROPINE 8 MG/20 ML VIAL 50750984_1 CDM 0250 RC 16729-0512-43 NDC inpatient 1 UN 109.05 70.88 SIHO - ALL PLANS SIHO - ALL PLANS 98.15 90 999999999 66.03 105.78 percent of total billed charges ATROPINE 8 MG/20 ML VIAL 50750984_1 CDM 0250 RC 16729-0512-43 NDC inpatient 1 UN 109.05 70.88 UMR - ALL PLANS UMR - ALL PLANS 76.34 70 999999999 66.03 105.78 percent of total billed charges ATROPINE 8 MG/20 ML VIAL 50750984_1 CDM 0250 RC 16729-0512-43 NDC inpatient 1 UN 109.05 70.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.03 60.55 999999999 66.03 105.78 percent of total billed charges ATROPINE 8 MG/20 ML VIAL 50750984_1 CDM 0250 RC 16729-0512-43 NDC inpatient 1 UN 109.05 70.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.03 105.78 ATROPINE 8 MG/20 ML VIAL 50750984_1 CDM 0250 RC 16729-0512-43 NDC inpatient 1 UN 109.05 70.88 ANTHEM HMO ANTHEM HMO 999999999 66.03 105.78 ATROPINE 8 MG/20 ML VIAL 50750984_1 CDM 0250 RC 16729-0512-43 NDC inpatient 1 UN 109.05 70.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.03 105.78 ATROPINE 8 MG/20 ML VIAL 50750984_1 CDM 0250 RC 16729-0512-43 NDC inpatient 1 UN 109.05 70.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.72 67.6 999999999 66.03 105.78 percent of total billed charges ATROPINE 8 MG/20 ML VIAL 50750984_1 CDM 0250 RC 16729-0512-43 NDC inpatient 1 UN 109.05 70.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.03 105.78 ATROPINE 8 MG/20 ML VIAL 50750984_1 CDM 0250 RC 16729-0512-43 NDC inpatient 1 UN 109.05 70.88 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.03 105.78 DICYCLOMINE 10 MG CAPSULE 50751515_1 CDM 0250 RC 60687-0369-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 10 MG CAPSULE 50751515_1 CDM 0250 RC 60687-0369-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 10 MG CAPSULE 50751515_1 CDM 0250 RC 60687-0369-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 10 MG CAPSULE 50751515_1 CDM 0250 RC 60687-0369-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 10 MG CAPSULE 50751515_1 CDM 0250 RC 60687-0369-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 10 MG CAPSULE 50751515_1 CDM 0250 RC 60687-0369-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 10 MG CAPSULE 50751515_1 CDM 0250 RC 60687-0369-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 10 MG CAPSULE 50751515_1 CDM 0250 RC 60687-0369-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 10 MG CAPSULE 50751515_1 CDM 0250 RC 60687-0369-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 DICYCLOMINE 10 MG CAPSULE 50751515_1 CDM 0250 RC 60687-0369-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 DICYCLOMINE 10 MG CAPSULE 50751515_1 CDM 0250 RC 60687-0369-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 DICYCLOMINE 10 MG CAPSULE 50751515_1 CDM 0250 RC 60687-0369-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges DICYCLOMINE 10 MG CAPSULE 50751515_1 CDM 0250 RC 60687-0369-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 DICYCLOMINE 10 MG CAPSULE 50751515_1 CDM 0250 RC 60687-0369-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 MORPHINE SULFATE 2 MG/ML VIAL 50751516_1 CDM 0250 RC 63323-0452-01 NDC J2275 HCPCS inpatient 1 UN 24.74 16.08 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.08 65 999999999 14.98 24 percent of total billed charges MORPHINE SULFATE 2 MG/ML VIAL 50751516_1 CDM 0250 RC 63323-0452-01 NDC J2275 HCPCS inpatient 1 UN 24.74 16.08 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24 97 999999999 14.98 24 percent of total billed charges MORPHINE SULFATE 2 MG/ML VIAL 50751516_1 CDM 0250 RC 63323-0452-01 NDC J2275 HCPCS inpatient 1 UN 24.74 16.08 AETNA AETNA 19.54 79 999999999 14.98 24 percent of total billed charges MORPHINE SULFATE 2 MG/ML VIAL 50751516_1 CDM 0250 RC 63323-0452-01 NDC J2275 HCPCS inpatient 1 UN 24.74 16.08 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.3 78 999999999 14.98 24 percent of total billed charges MORPHINE SULFATE 2 MG/ML VIAL 50751516_1 CDM 0250 RC 63323-0452-01 NDC J2275 HCPCS inpatient 1 UN 24.74 16.08 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.07 69 999999999 14.98 24 percent of total billed charges MORPHINE SULFATE 2 MG/ML VIAL 50751516_1 CDM 0250 RC 63323-0452-01 NDC J2275 HCPCS inpatient 1 UN 24.74 16.08 SIHO - ALL PLANS SIHO - ALL PLANS 22.27 90 999999999 14.98 24 percent of total billed charges MORPHINE SULFATE 2 MG/ML VIAL 50751516_1 CDM 0250 RC 63323-0452-01 NDC J2275 HCPCS inpatient 1 UN 24.74 16.08 UMR - ALL PLANS UMR - ALL PLANS 17.32 70 999999999 14.98 24 percent of total billed charges MORPHINE SULFATE 2 MG/ML VIAL 50751516_1 CDM 0250 RC 63323-0452-01 NDC J2275 HCPCS inpatient 1 UN 24.74 16.08 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.98 60.55 999999999 14.98 24 percent of total billed charges MORPHINE SULFATE 2 MG/ML VIAL 50751516_1 CDM 0250 RC 63323-0452-01 NDC J2275 HCPCS inpatient 1 UN 24.74 16.08 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.98 24 MORPHINE SULFATE 2 MG/ML VIAL 50751516_1 CDM 0250 RC 63323-0452-01 NDC J2275 HCPCS inpatient 1 UN 24.74 16.08 ANTHEM HMO ANTHEM HMO 999999999 14.98 24 MORPHINE SULFATE 2 MG/ML VIAL 50751516_1 CDM 0250 RC 63323-0452-01 NDC J2275 HCPCS inpatient 1 UN 24.74 16.08 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.98 24 MORPHINE SULFATE 2 MG/ML VIAL 50751516_1 CDM 0250 RC 63323-0452-01 NDC J2275 HCPCS inpatient 1 UN 24.74 16.08 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.72 67.6 999999999 14.98 24 percent of total billed charges MORPHINE SULFATE 2 MG/ML VIAL 50751516_1 CDM 0250 RC 63323-0452-01 NDC J2275 HCPCS inpatient 1 UN 24.74 16.08 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.98 24 MORPHINE SULFATE 2 MG/ML VIAL 50751516_1 CDM 0250 RC 63323-0452-01 NDC J2275 HCPCS inpatient 1 UN 24.74 16.08 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.98 24 HYDROCODONE-ACETAMIN 10-325 MG 50751518_1 CDM 0250 RC 00904-6825-61 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges HYDROCODONE-ACETAMIN 10-325 MG 50751518_1 CDM 0250 RC 00904-6825-61 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges HYDROCODONE-ACETAMIN 10-325 MG 50751518_1 CDM 0250 RC 00904-6825-61 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges HYDROCODONE-ACETAMIN 10-325 MG 50751518_1 CDM 0250 RC 00904-6825-61 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges HYDROCODONE-ACETAMIN 10-325 MG 50751518_1 CDM 0250 RC 00904-6825-61 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges HYDROCODONE-ACETAMIN 10-325 MG 50751518_1 CDM 0250 RC 00904-6825-61 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges HYDROCODONE-ACETAMIN 10-325 MG 50751518_1 CDM 0250 RC 00904-6825-61 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges HYDROCODONE-ACETAMIN 10-325 MG 50751518_1 CDM 0250 RC 00904-6825-61 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges HYDROCODONE-ACETAMIN 10-325 MG 50751518_1 CDM 0250 RC 00904-6825-61 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 HYDROCODONE-ACETAMIN 10-325 MG 50751518_1 CDM 0250 RC 00904-6825-61 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 HYDROCODONE-ACETAMIN 10-325 MG 50751518_1 CDM 0250 RC 00904-6825-61 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 HYDROCODONE-ACETAMIN 10-325 MG 50751518_1 CDM 0250 RC 00904-6825-61 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges HYDROCODONE-ACETAMIN 10-325 MG 50751518_1 CDM 0250 RC 00904-6825-61 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 HYDROCODONE-ACETAMIN 10-325 MG 50751518_1 CDM 0250 RC 00904-6825-61 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 LEVOTHYROXINE 75 MCG TABLET 50751520_1 CDM 0250 RC 60687-0475-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 75 MCG TABLET 50751520_1 CDM 0250 RC 60687-0475-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 75 MCG TABLET 50751520_1 CDM 0250 RC 60687-0475-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 75 MCG TABLET 50751520_1 CDM 0250 RC 60687-0475-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 75 MCG TABLET 50751520_1 CDM 0250 RC 60687-0475-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 75 MCG TABLET 50751520_1 CDM 0250 RC 60687-0475-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 75 MCG TABLET 50751520_1 CDM 0250 RC 60687-0475-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 75 MCG TABLET 50751520_1 CDM 0250 RC 60687-0475-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 75 MCG TABLET 50751520_1 CDM 0250 RC 60687-0475-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 LEVOTHYROXINE 75 MCG TABLET 50751520_1 CDM 0250 RC 60687-0475-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 LEVOTHYROXINE 75 MCG TABLET 50751520_1 CDM 0250 RC 60687-0475-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 75 MCG TABLET 50751520_1 CDM 0250 RC 60687-0475-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges LEVOTHYROXINE 75 MCG TABLET 50751520_1 CDM 0250 RC 60687-0475-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 LEVOTHYROXINE 75 MCG TABLET 50751520_1 CDM 0250 RC 60687-0475-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 50753630_1 CDM 0250 RC 73702-0120-05 NDC J2590 HCPCS inpatient 3 UN 97.21 63.19 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.19 65 999999999 58.86 94.29 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 50753630_1 CDM 0250 RC 73702-0120-05 NDC J2590 HCPCS inpatient 3 UN 97.21 63.19 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 94.29 97 999999999 58.86 94.29 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 50753630_1 CDM 0250 RC 73702-0120-05 NDC J2590 HCPCS inpatient 3 UN 97.21 63.19 AETNA AETNA 76.8 79 999999999 58.86 94.29 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 50753630_1 CDM 0250 RC 73702-0120-05 NDC J2590 HCPCS inpatient 3 UN 97.21 63.19 HUMANA - ALL PLANS HUMANA - ALL PLANS 75.82 78 999999999 58.86 94.29 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 50753630_1 CDM 0250 RC 73702-0120-05 NDC J2590 HCPCS inpatient 3 UN 97.21 63.19 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.07 69 999999999 58.86 94.29 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 50753630_1 CDM 0250 RC 73702-0120-05 NDC J2590 HCPCS inpatient 3 UN 97.21 63.19 SIHO - ALL PLANS SIHO - ALL PLANS 87.49 90 999999999 58.86 94.29 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 50753630_1 CDM 0250 RC 73702-0120-05 NDC J2590 HCPCS inpatient 3 UN 97.21 63.19 UMR - ALL PLANS UMR - ALL PLANS 68.05 70 999999999 58.86 94.29 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 50753630_1 CDM 0250 RC 73702-0120-05 NDC J2590 HCPCS inpatient 3 UN 97.21 63.19 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.86 60.55 999999999 58.86 94.29 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 50753630_1 CDM 0250 RC 73702-0120-05 NDC J2590 HCPCS inpatient 3 UN 97.21 63.19 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.86 94.29 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 50753630_1 CDM 0250 RC 73702-0120-05 NDC J2590 HCPCS inpatient 3 UN 97.21 63.19 ANTHEM HMO ANTHEM HMO 999999999 58.86 94.29 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 50753630_1 CDM 0250 RC 73702-0120-05 NDC J2590 HCPCS inpatient 3 UN 97.21 63.19 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.86 94.29 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 50753630_1 CDM 0250 RC 73702-0120-05 NDC J2590 HCPCS inpatient 3 UN 97.21 63.19 CIGNA - ALL PLANS CIGNA - ALL PLANS 65.71 67.6 999999999 58.86 94.29 percent of total billed charges "INJECTION, OXYTOCIN, UP TO 10 UNITS" 50753630_1 CDM 0250 RC 73702-0120-05 NDC J2590 HCPCS inpatient 3 UN 97.21 63.19 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.86 94.29 "INJECTION, OXYTOCIN, UP TO 10 UNITS" 50753630_1 CDM 0250 RC 73702-0120-05 NDC J2590 HCPCS inpatient 3 UN 97.21 63.19 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.86 94.29 Fetal fibronectin (protein) analysis 50754003_1 CDM 0301 RC 82731 HCPCS inpatient 144 93.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 93.6 65 999999999 87.19 139.68 percent of total billed charges Fetal fibronectin (protein) analysis 50754003_1 CDM 0301 RC 82731 HCPCS inpatient 144 93.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 139.68 97 999999999 87.19 139.68 percent of total billed charges Fetal fibronectin (protein) analysis 50754003_1 CDM 0301 RC 82731 HCPCS inpatient 144 93.6 AETNA AETNA 113.76 79 999999999 87.19 139.68 percent of total billed charges Fetal fibronectin (protein) analysis 50754003_1 CDM 0301 RC 82731 HCPCS inpatient 144 93.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 112.32 78 999999999 87.19 139.68 percent of total billed charges Fetal fibronectin (protein) analysis 50754003_1 CDM 0301 RC 82731 HCPCS inpatient 144 93.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 99.36 69 999999999 87.19 139.68 percent of total billed charges Fetal fibronectin (protein) analysis 50754003_1 CDM 0301 RC 82731 HCPCS inpatient 144 93.6 SIHO - ALL PLANS SIHO - ALL PLANS 129.6 90 999999999 87.19 139.68 percent of total billed charges Fetal fibronectin (protein) analysis 50754003_1 CDM 0301 RC 82731 HCPCS inpatient 144 93.6 UMR - ALL PLANS UMR - ALL PLANS 100.8 70 999999999 87.19 139.68 percent of total billed charges Fetal fibronectin (protein) analysis 50754003_1 CDM 0301 RC 82731 HCPCS inpatient 144 93.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.19 60.55 999999999 87.19 139.68 percent of total billed charges Fetal fibronectin (protein) analysis 50754003_1 CDM 0301 RC 82731 HCPCS inpatient 144 93.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.19 139.68 Fetal fibronectin (protein) analysis 50754003_1 CDM 0301 RC 82731 HCPCS inpatient 144 93.6 ANTHEM HMO ANTHEM HMO 999999999 87.19 139.68 Fetal fibronectin (protein) analysis 50754003_1 CDM 0301 RC 82731 HCPCS inpatient 144 93.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.19 139.68 Fetal fibronectin (protein) analysis 50754003_1 CDM 0301 RC 82731 HCPCS inpatient 144 93.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 97.34 67.6 999999999 87.19 139.68 percent of total billed charges Fetal fibronectin (protein) analysis 50754003_1 CDM 0301 RC 82731 HCPCS inpatient 144 93.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.19 139.68 Fetal fibronectin (protein) analysis 50754003_1 CDM 0301 RC 82731 HCPCS inpatient 144 93.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.19 139.68 "Total protein level, urine" 50754032_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 50754032_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 50754032_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 50754032_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 50754032_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 50754032_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 50754032_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 50754032_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 50754032_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 "Total protein level, urine" 50754032_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 "Total protein level, urine" 50754032_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 "Total protein level, urine" 50754032_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 50754032_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 "Total protein level, urine" 50754032_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 "Immunologic analysis technique on body fluid, other fluids with concentration" 50754033_1 CDM 0302 RC 86335 HCPCS inpatient 116 75.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 75.4 65 999999999 70.24 112.52 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 50754033_1 CDM 0302 RC 86335 HCPCS inpatient 116 75.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 112.52 97 999999999 70.24 112.52 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 50754033_1 CDM 0302 RC 86335 HCPCS inpatient 116 75.4 AETNA AETNA 91.64 79 999999999 70.24 112.52 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 50754033_1 CDM 0302 RC 86335 HCPCS inpatient 116 75.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 90.48 78 999999999 70.24 112.52 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 50754033_1 CDM 0302 RC 86335 HCPCS inpatient 116 75.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.04 69 999999999 70.24 112.52 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 50754033_1 CDM 0302 RC 86335 HCPCS inpatient 116 75.4 SIHO - ALL PLANS SIHO - ALL PLANS 104.4 90 999999999 70.24 112.52 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 50754033_1 CDM 0302 RC 86335 HCPCS inpatient 116 75.4 UMR - ALL PLANS UMR - ALL PLANS 81.2 70 999999999 70.24 112.52 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 50754033_1 CDM 0302 RC 86335 HCPCS inpatient 116 75.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 70.24 60.55 999999999 70.24 112.52 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 50754033_1 CDM 0302 RC 86335 HCPCS inpatient 116 75.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 70.24 112.52 "Immunologic analysis technique on body fluid, other fluids with concentration" 50754033_1 CDM 0302 RC 86335 HCPCS inpatient 116 75.4 ANTHEM HMO ANTHEM HMO 999999999 70.24 112.52 "Immunologic analysis technique on body fluid, other fluids with concentration" 50754033_1 CDM 0302 RC 86335 HCPCS inpatient 116 75.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 70.24 112.52 "Immunologic analysis technique on body fluid, other fluids with concentration" 50754033_1 CDM 0302 RC 86335 HCPCS inpatient 116 75.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 78.42 67.6 999999999 70.24 112.52 percent of total billed charges "Immunologic analysis technique on body fluid, other fluids with concentration" 50754033_1 CDM 0302 RC 86335 HCPCS inpatient 116 75.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 70.24 112.52 "Immunologic analysis technique on body fluid, other fluids with concentration" 50754033_1 CDM 0302 RC 86335 HCPCS inpatient 116 75.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 70.24 112.52 Myoglobin (muscle protein) level 50754945_1 CDM 0301 RC 83874 HCPCS inpatient 301 195.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 195.65 65 999999999 182.26 291.97 percent of total billed charges Myoglobin (muscle protein) level 50754945_1 CDM 0301 RC 83874 HCPCS inpatient 301 195.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291.97 97 999999999 182.26 291.97 percent of total billed charges Myoglobin (muscle protein) level 50754945_1 CDM 0301 RC 83874 HCPCS inpatient 301 195.65 AETNA AETNA 237.79 79 999999999 182.26 291.97 percent of total billed charges Myoglobin (muscle protein) level 50754945_1 CDM 0301 RC 83874 HCPCS inpatient 301 195.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 234.78 78 999999999 182.26 291.97 percent of total billed charges Myoglobin (muscle protein) level 50754945_1 CDM 0301 RC 83874 HCPCS inpatient 301 195.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 207.69 69 999999999 182.26 291.97 percent of total billed charges Myoglobin (muscle protein) level 50754945_1 CDM 0301 RC 83874 HCPCS inpatient 301 195.65 SIHO - ALL PLANS SIHO - ALL PLANS 270.9 90 999999999 182.26 291.97 percent of total billed charges Myoglobin (muscle protein) level 50754945_1 CDM 0301 RC 83874 HCPCS inpatient 301 195.65 UMR - ALL PLANS UMR - ALL PLANS 210.7 70 999999999 182.26 291.97 percent of total billed charges Myoglobin (muscle protein) level 50754945_1 CDM 0301 RC 83874 HCPCS inpatient 301 195.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.26 60.55 999999999 182.26 291.97 percent of total billed charges Myoglobin (muscle protein) level 50754945_1 CDM 0301 RC 83874 HCPCS inpatient 301 195.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.26 291.97 Myoglobin (muscle protein) level 50754945_1 CDM 0301 RC 83874 HCPCS inpatient 301 195.65 ANTHEM HMO ANTHEM HMO 999999999 182.26 291.97 Myoglobin (muscle protein) level 50754945_1 CDM 0301 RC 83874 HCPCS inpatient 301 195.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.26 291.97 Myoglobin (muscle protein) level 50754945_1 CDM 0301 RC 83874 HCPCS inpatient 301 195.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 203.48 67.6 999999999 182.26 291.97 percent of total billed charges Myoglobin (muscle protein) level 50754945_1 CDM 0301 RC 83874 HCPCS inpatient 301 195.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.26 291.97 Myoglobin (muscle protein) level 50754945_1 CDM 0301 RC 83874 HCPCS inpatient 301 195.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.26 291.97 VRAYLAR 1.5 MG CAPSULE 50754959_1 CDM 0250 RC 61874-0115-30 NDC inpatient 10 UN 188.06 122.24 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.24 65 999999999 113.87 182.42 percent of total billed charges VRAYLAR 1.5 MG CAPSULE 50754959_1 CDM 0250 RC 61874-0115-30 NDC inpatient 10 UN 188.06 122.24 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 182.42 97 999999999 113.87 182.42 percent of total billed charges VRAYLAR 1.5 MG CAPSULE 50754959_1 CDM 0250 RC 61874-0115-30 NDC inpatient 10 UN 188.06 122.24 AETNA AETNA 148.57 79 999999999 113.87 182.42 percent of total billed charges VRAYLAR 1.5 MG CAPSULE 50754959_1 CDM 0250 RC 61874-0115-30 NDC inpatient 10 UN 188.06 122.24 HUMANA - ALL PLANS HUMANA - ALL PLANS 146.69 78 999999999 113.87 182.42 percent of total billed charges VRAYLAR 1.5 MG CAPSULE 50754959_1 CDM 0250 RC 61874-0115-30 NDC inpatient 10 UN 188.06 122.24 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.76 69 999999999 113.87 182.42 percent of total billed charges VRAYLAR 1.5 MG CAPSULE 50754959_1 CDM 0250 RC 61874-0115-30 NDC inpatient 10 UN 188.06 122.24 SIHO - ALL PLANS SIHO - ALL PLANS 169.25 90 999999999 113.87 182.42 percent of total billed charges VRAYLAR 1.5 MG CAPSULE 50754959_1 CDM 0250 RC 61874-0115-30 NDC inpatient 10 UN 188.06 122.24 UMR - ALL PLANS UMR - ALL PLANS 131.64 70 999999999 113.87 182.42 percent of total billed charges VRAYLAR 1.5 MG CAPSULE 50754959_1 CDM 0250 RC 61874-0115-30 NDC inpatient 10 UN 188.06 122.24 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.87 60.55 999999999 113.87 182.42 percent of total billed charges VRAYLAR 1.5 MG CAPSULE 50754959_1 CDM 0250 RC 61874-0115-30 NDC inpatient 10 UN 188.06 122.24 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.87 182.42 VRAYLAR 1.5 MG CAPSULE 50754959_1 CDM 0250 RC 61874-0115-30 NDC inpatient 10 UN 188.06 122.24 ANTHEM HMO ANTHEM HMO 999999999 113.87 182.42 VRAYLAR 1.5 MG CAPSULE 50754959_1 CDM 0250 RC 61874-0115-30 NDC inpatient 10 UN 188.06 122.24 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.87 182.42 VRAYLAR 1.5 MG CAPSULE 50754959_1 CDM 0250 RC 61874-0115-30 NDC inpatient 10 UN 188.06 122.24 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.13 67.6 999999999 113.87 182.42 percent of total billed charges VRAYLAR 1.5 MG CAPSULE 50754959_1 CDM 0250 RC 61874-0115-30 NDC inpatient 10 UN 188.06 122.24 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.87 182.42 VRAYLAR 1.5 MG CAPSULE 50754959_1 CDM 0250 RC 61874-0115-30 NDC inpatient 10 UN 188.06 122.24 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.87 182.42 "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50754960_1 CDM 0636 RC 67457-0530-35 NDC J0640 HCPCS inpatient 7 UN 108.52 70.54 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.54 65 999999999 65.71 105.26 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50754960_1 CDM 0636 RC 67457-0530-35 NDC J0640 HCPCS inpatient 7 UN 108.52 70.54 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.26 97 999999999 65.71 105.26 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50754960_1 CDM 0636 RC 67457-0530-35 NDC J0640 HCPCS inpatient 7 UN 108.52 70.54 AETNA AETNA 85.73 79 999999999 65.71 105.26 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50754960_1 CDM 0636 RC 67457-0530-35 NDC J0640 HCPCS inpatient 7 UN 108.52 70.54 HUMANA - ALL PLANS HUMANA - ALL PLANS 84.65 78 999999999 65.71 105.26 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50754960_1 CDM 0636 RC 67457-0530-35 NDC J0640 HCPCS inpatient 7 UN 108.52 70.54 ENCORE - ALL PLANS ENCORE - ALL PLANS 74.88 69 999999999 65.71 105.26 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50754960_1 CDM 0636 RC 67457-0530-35 NDC J0640 HCPCS inpatient 7 UN 108.52 70.54 SIHO - ALL PLANS SIHO - ALL PLANS 97.67 90 999999999 65.71 105.26 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50754960_1 CDM 0636 RC 67457-0530-35 NDC J0640 HCPCS inpatient 7 UN 108.52 70.54 UMR - ALL PLANS UMR - ALL PLANS 75.96 70 999999999 65.71 105.26 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50754960_1 CDM 0636 RC 67457-0530-35 NDC J0640 HCPCS inpatient 7 UN 108.52 70.54 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 65.71 60.55 999999999 65.71 105.26 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50754960_1 CDM 0636 RC 67457-0530-35 NDC J0640 HCPCS inpatient 7 UN 108.52 70.54 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 65.71 105.26 "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50754960_1 CDM 0636 RC 67457-0530-35 NDC J0640 HCPCS inpatient 7 UN 108.52 70.54 ANTHEM HMO ANTHEM HMO 999999999 65.71 105.26 "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50754960_1 CDM 0636 RC 67457-0530-35 NDC J0640 HCPCS inpatient 7 UN 108.52 70.54 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 65.71 105.26 "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50754960_1 CDM 0636 RC 67457-0530-35 NDC J0640 HCPCS inpatient 7 UN 108.52 70.54 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.36 67.6 999999999 65.71 105.26 percent of total billed charges "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50754960_1 CDM 0636 RC 67457-0530-35 NDC J0640 HCPCS inpatient 7 UN 108.52 70.54 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 65.71 105.26 "INJECTION, LEUCOVORIN CALCIUM, PER 50 MG" 50754960_1 CDM 0636 RC 67457-0530-35 NDC J0640 HCPCS inpatient 7 UN 108.52 70.54 UHC - ALL PLANS UHC - ALL PLANS 999999999 65.71 105.26 OLUMIANT 1 MG TABLET 50755264_1 CDM 0250 RC 00002-4732-30 NDC inpatient 1 UN 370.93 241.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 241.1 65 999999999 224.6 359.8 percent of total billed charges OLUMIANT 1 MG TABLET 50755264_1 CDM 0250 RC 00002-4732-30 NDC inpatient 1 UN 370.93 241.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 359.8 97 999999999 224.6 359.8 percent of total billed charges OLUMIANT 1 MG TABLET 50755264_1 CDM 0250 RC 00002-4732-30 NDC inpatient 1 UN 370.93 241.1 AETNA AETNA 293.03 79 999999999 224.6 359.8 percent of total billed charges OLUMIANT 1 MG TABLET 50755264_1 CDM 0250 RC 00002-4732-30 NDC inpatient 1 UN 370.93 241.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 289.33 78 999999999 224.6 359.8 percent of total billed charges OLUMIANT 1 MG TABLET 50755264_1 CDM 0250 RC 00002-4732-30 NDC inpatient 1 UN 370.93 241.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 255.94 69 999999999 224.6 359.8 percent of total billed charges OLUMIANT 1 MG TABLET 50755264_1 CDM 0250 RC 00002-4732-30 NDC inpatient 1 UN 370.93 241.1 SIHO - ALL PLANS SIHO - ALL PLANS 333.84 90 999999999 224.6 359.8 percent of total billed charges OLUMIANT 1 MG TABLET 50755264_1 CDM 0250 RC 00002-4732-30 NDC inpatient 1 UN 370.93 241.1 UMR - ALL PLANS UMR - ALL PLANS 259.65 70 999999999 224.6 359.8 percent of total billed charges OLUMIANT 1 MG TABLET 50755264_1 CDM 0250 RC 00002-4732-30 NDC inpatient 1 UN 370.93 241.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 224.6 60.55 999999999 224.6 359.8 percent of total billed charges OLUMIANT 1 MG TABLET 50755264_1 CDM 0250 RC 00002-4732-30 NDC inpatient 1 UN 370.93 241.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 224.6 359.8 OLUMIANT 1 MG TABLET 50755264_1 CDM 0250 RC 00002-4732-30 NDC inpatient 1 UN 370.93 241.1 ANTHEM HMO ANTHEM HMO 999999999 224.6 359.8 OLUMIANT 1 MG TABLET 50755264_1 CDM 0250 RC 00002-4732-30 NDC inpatient 1 UN 370.93 241.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 224.6 359.8 OLUMIANT 1 MG TABLET 50755264_1 CDM 0250 RC 00002-4732-30 NDC inpatient 1 UN 370.93 241.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 250.75 67.6 999999999 224.6 359.8 percent of total billed charges OLUMIANT 1 MG TABLET 50755264_1 CDM 0250 RC 00002-4732-30 NDC inpatient 1 UN 370.93 241.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 224.6 359.8 OLUMIANT 1 MG TABLET 50755264_1 CDM 0250 RC 00002-4732-30 NDC inpatient 1 UN 370.93 241.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 224.6 359.8 Correction of rigid deformity of first joint of big toe 50755291_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Correction of rigid deformity of first joint of big toe 50755291_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Correction of rigid deformity of first joint of big toe 50755291_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Correction of rigid deformity of first joint of big toe 50755291_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Correction of rigid deformity of first joint of big toe 50755291_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Correction of rigid deformity of first joint of big toe 50755291_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Correction of rigid deformity of first joint of big toe 50755291_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Correction of rigid deformity of first joint of big toe 50755291_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Correction of rigid deformity of first joint of big toe 50755291_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Correction of rigid deformity of first joint of big toe 50755291_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Correction of rigid deformity of first joint of big toe 50755291_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Correction of rigid deformity of first joint of big toe 50755291_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Correction of rigid deformity of first joint of big toe 50755291_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Correction of rigid deformity of first joint of big toe 50755291_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 "Established patient office or other outpatient visit, 10-19 minutes" 50755339_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 208.65 65 999999999 194.37 311.37 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 50755339_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 311.37 97 999999999 194.37 311.37 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 50755339_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 AETNA AETNA 253.59 79 999999999 194.37 311.37 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 50755339_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 250.38 78 999999999 194.37 311.37 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 50755339_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 221.49 69 999999999 194.37 311.37 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 50755339_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 SIHO - ALL PLANS SIHO - ALL PLANS 288.9 90 999999999 194.37 311.37 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 50755339_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 UMR - ALL PLANS UMR - ALL PLANS 224.7 70 999999999 194.37 311.37 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 50755339_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 194.37 60.55 999999999 194.37 311.37 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 50755339_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 194.37 311.37 "Established patient office or other outpatient visit, 10-19 minutes" 50755339_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 ANTHEM HMO ANTHEM HMO 999999999 194.37 311.37 "Established patient office or other outpatient visit, 10-19 minutes" 50755339_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 194.37 311.37 "Established patient office or other outpatient visit, 10-19 minutes" 50755339_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 217 67.6 999999999 194.37 311.37 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 50755339_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 194.37 311.37 "Established patient office or other outpatient visit, 10-19 minutes" 50755339_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 194.37 311.37 "Established patient office or other outpatient visit, 20-29 minutes" 50755340_1 CDM 0510 RC 99213 HCPCS inpatient 363 235.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 235.95 65 999999999 219.8 352.11 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 50755340_1 CDM 0510 RC 99213 HCPCS inpatient 363 235.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 352.11 97 999999999 219.8 352.11 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 50755340_1 CDM 0510 RC 99213 HCPCS inpatient 363 235.95 AETNA AETNA 286.77 79 999999999 219.8 352.11 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 50755340_1 CDM 0510 RC 99213 HCPCS inpatient 363 235.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 283.14 78 999999999 219.8 352.11 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 50755340_1 CDM 0510 RC 99213 HCPCS inpatient 363 235.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 250.47 69 999999999 219.8 352.11 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 50755340_1 CDM 0510 RC 99213 HCPCS inpatient 363 235.95 SIHO - ALL PLANS SIHO - ALL PLANS 326.7 90 999999999 219.8 352.11 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 50755340_1 CDM 0510 RC 99213 HCPCS inpatient 363 235.95 UMR - ALL PLANS UMR - ALL PLANS 254.1 70 999999999 219.8 352.11 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 50755340_1 CDM 0510 RC 99213 HCPCS inpatient 363 235.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 219.8 60.55 999999999 219.8 352.11 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 50755340_1 CDM 0510 RC 99213 HCPCS inpatient 363 235.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 219.8 352.11 "Established patient office or other outpatient visit, 20-29 minutes" 50755340_1 CDM 0510 RC 99213 HCPCS inpatient 363 235.95 ANTHEM HMO ANTHEM HMO 999999999 219.8 352.11 "Established patient office or other outpatient visit, 20-29 minutes" 50755340_1 CDM 0510 RC 99213 HCPCS inpatient 363 235.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 219.8 352.11 "Established patient office or other outpatient visit, 20-29 minutes" 50755340_1 CDM 0510 RC 99213 HCPCS inpatient 363 235.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 245.39 67.6 999999999 219.8 352.11 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 50755340_1 CDM 0510 RC 99213 HCPCS inpatient 363 235.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 219.8 352.11 "Established patient office or other outpatient visit, 20-29 minutes" 50755340_1 CDM 0510 RC 99213 HCPCS inpatient 363 235.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 219.8 352.11 "Established patient office or other outpatient visit, 30-39 minutes" 50755341_1 CDM 0510 RC 99214 HCPCS inpatient 468 304.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 304.2 65 999999999 283.37 453.96 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 50755341_1 CDM 0510 RC 99214 HCPCS inpatient 468 304.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 453.96 97 999999999 283.37 453.96 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 50755341_1 CDM 0510 RC 99214 HCPCS inpatient 468 304.2 AETNA AETNA 369.72 79 999999999 283.37 453.96 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 50755341_1 CDM 0510 RC 99214 HCPCS inpatient 468 304.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 365.04 78 999999999 283.37 453.96 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 50755341_1 CDM 0510 RC 99214 HCPCS inpatient 468 304.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 322.92 69 999999999 283.37 453.96 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 50755341_1 CDM 0510 RC 99214 HCPCS inpatient 468 304.2 SIHO - ALL PLANS SIHO - ALL PLANS 421.2 90 999999999 283.37 453.96 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 50755341_1 CDM 0510 RC 99214 HCPCS inpatient 468 304.2 UMR - ALL PLANS UMR - ALL PLANS 327.6 70 999999999 283.37 453.96 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 50755341_1 CDM 0510 RC 99214 HCPCS inpatient 468 304.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 283.37 60.55 999999999 283.37 453.96 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 50755341_1 CDM 0510 RC 99214 HCPCS inpatient 468 304.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 283.37 453.96 "Established patient office or other outpatient visit, 30-39 minutes" 50755341_1 CDM 0510 RC 99214 HCPCS inpatient 468 304.2 ANTHEM HMO ANTHEM HMO 999999999 283.37 453.96 "Established patient office or other outpatient visit, 30-39 minutes" 50755341_1 CDM 0510 RC 99214 HCPCS inpatient 468 304.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 283.37 453.96 "Established patient office or other outpatient visit, 30-39 minutes" 50755341_1 CDM 0510 RC 99214 HCPCS inpatient 468 304.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 316.37 67.6 999999999 283.37 453.96 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 50755341_1 CDM 0510 RC 99214 HCPCS inpatient 468 304.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 283.37 453.96 "Established patient office or other outpatient visit, 30-39 minutes" 50755341_1 CDM 0510 RC 99214 HCPCS inpatient 468 304.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 283.37 453.96 "Established patient office or other outpatient visit, 40-54 minutes" 50755342_1 CDM 0510 RC 99215 HCPCS inpatient 454 295.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 295.1 65 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 50755342_1 CDM 0510 RC 99215 HCPCS inpatient 454 295.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 440.38 97 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 50755342_1 CDM 0510 RC 99215 HCPCS inpatient 454 295.1 AETNA AETNA 358.66 79 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 50755342_1 CDM 0510 RC 99215 HCPCS inpatient 454 295.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 354.12 78 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 50755342_1 CDM 0510 RC 99215 HCPCS inpatient 454 295.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 313.26 69 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 50755342_1 CDM 0510 RC 99215 HCPCS inpatient 454 295.1 SIHO - ALL PLANS SIHO - ALL PLANS 408.6 90 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 50755342_1 CDM 0510 RC 99215 HCPCS inpatient 454 295.1 UMR - ALL PLANS UMR - ALL PLANS 317.8 70 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 50755342_1 CDM 0510 RC 99215 HCPCS inpatient 454 295.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 274.9 60.55 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 50755342_1 CDM 0510 RC 99215 HCPCS inpatient 454 295.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 274.9 440.38 "Established patient office or other outpatient visit, 40-54 minutes" 50755342_1 CDM 0510 RC 99215 HCPCS inpatient 454 295.1 ANTHEM HMO ANTHEM HMO 999999999 274.9 440.38 "Established patient office or other outpatient visit, 40-54 minutes" 50755342_1 CDM 0510 RC 99215 HCPCS inpatient 454 295.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 274.9 440.38 "Established patient office or other outpatient visit, 40-54 minutes" 50755342_1 CDM 0510 RC 99215 HCPCS inpatient 454 295.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 306.9 67.6 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 50755342_1 CDM 0510 RC 99215 HCPCS inpatient 454 295.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 274.9 440.38 "Established patient office or other outpatient visit, 40-54 minutes" 50755342_1 CDM 0510 RC 99215 HCPCS inpatient 454 295.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 274.9 440.38 "New patient office or other outpatient visit, 15-29 minutes" 50755343_1 CDM 0510 RC 99202 HCPCS inpatient 326 211.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 211.9 65 999999999 197.39 316.22 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 50755343_1 CDM 0510 RC 99202 HCPCS inpatient 326 211.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 316.22 97 999999999 197.39 316.22 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 50755343_1 CDM 0510 RC 99202 HCPCS inpatient 326 211.9 AETNA AETNA 257.54 79 999999999 197.39 316.22 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 50755343_1 CDM 0510 RC 99202 HCPCS inpatient 326 211.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 254.28 78 999999999 197.39 316.22 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 50755343_1 CDM 0510 RC 99202 HCPCS inpatient 326 211.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 224.94 69 999999999 197.39 316.22 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 50755343_1 CDM 0510 RC 99202 HCPCS inpatient 326 211.9 SIHO - ALL PLANS SIHO - ALL PLANS 293.4 90 999999999 197.39 316.22 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 50755343_1 CDM 0510 RC 99202 HCPCS inpatient 326 211.9 UMR - ALL PLANS UMR - ALL PLANS 228.2 70 999999999 197.39 316.22 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 50755343_1 CDM 0510 RC 99202 HCPCS inpatient 326 211.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 197.39 60.55 999999999 197.39 316.22 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 50755343_1 CDM 0510 RC 99202 HCPCS inpatient 326 211.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 197.39 316.22 "New patient office or other outpatient visit, 15-29 minutes" 50755343_1 CDM 0510 RC 99202 HCPCS inpatient 326 211.9 ANTHEM HMO ANTHEM HMO 999999999 197.39 316.22 "New patient office or other outpatient visit, 15-29 minutes" 50755343_1 CDM 0510 RC 99202 HCPCS inpatient 326 211.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 197.39 316.22 "New patient office or other outpatient visit, 15-29 minutes" 50755343_1 CDM 0510 RC 99202 HCPCS inpatient 326 211.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 220.38 67.6 999999999 197.39 316.22 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 50755343_1 CDM 0510 RC 99202 HCPCS inpatient 326 211.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 197.39 316.22 "New patient office or other outpatient visit, 15-29 minutes" 50755343_1 CDM 0510 RC 99202 HCPCS inpatient 326 211.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 197.39 316.22 "New patient office or other outpatient visit, 30-44 minutes" 50755344_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 277.55 65 999999999 258.55 414.19 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 50755344_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 414.19 97 999999999 258.55 414.19 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 50755344_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 AETNA AETNA 337.33 79 999999999 258.55 414.19 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 50755344_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.06 78 999999999 258.55 414.19 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 50755344_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 294.63 69 999999999 258.55 414.19 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 50755344_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 SIHO - ALL PLANS SIHO - ALL PLANS 384.3 90 999999999 258.55 414.19 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 50755344_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 UMR - ALL PLANS UMR - ALL PLANS 298.9 70 999999999 258.55 414.19 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 50755344_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 258.55 60.55 999999999 258.55 414.19 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 50755344_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 258.55 414.19 "New patient office or other outpatient visit, 30-44 minutes" 50755344_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 ANTHEM HMO ANTHEM HMO 999999999 258.55 414.19 "New patient office or other outpatient visit, 30-44 minutes" 50755344_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 258.55 414.19 "New patient office or other outpatient visit, 30-44 minutes" 50755344_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 288.65 67.6 999999999 258.55 414.19 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 50755344_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 258.55 414.19 "New patient office or other outpatient visit, 30-44 minutes" 50755344_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 258.55 414.19 "New patient office or other outpatient visit, 45-59 minutes" 50755345_1 CDM 0510 RC 99204 HCPCS inpatient 535 347.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 347.75 65 999999999 323.94 518.95 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 50755345_1 CDM 0510 RC 99204 HCPCS inpatient 535 347.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 518.95 97 999999999 323.94 518.95 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 50755345_1 CDM 0510 RC 99204 HCPCS inpatient 535 347.75 AETNA AETNA 422.65 79 999999999 323.94 518.95 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 50755345_1 CDM 0510 RC 99204 HCPCS inpatient 535 347.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 417.3 78 999999999 323.94 518.95 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 50755345_1 CDM 0510 RC 99204 HCPCS inpatient 535 347.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 369.15 69 999999999 323.94 518.95 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 50755345_1 CDM 0510 RC 99204 HCPCS inpatient 535 347.75 SIHO - ALL PLANS SIHO - ALL PLANS 481.5 90 999999999 323.94 518.95 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 50755345_1 CDM 0510 RC 99204 HCPCS inpatient 535 347.75 UMR - ALL PLANS UMR - ALL PLANS 374.5 70 999999999 323.94 518.95 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 50755345_1 CDM 0510 RC 99204 HCPCS inpatient 535 347.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 323.94 60.55 999999999 323.94 518.95 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 50755345_1 CDM 0510 RC 99204 HCPCS inpatient 535 347.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 323.94 518.95 "New patient office or other outpatient visit, 45-59 minutes" 50755345_1 CDM 0510 RC 99204 HCPCS inpatient 535 347.75 ANTHEM HMO ANTHEM HMO 999999999 323.94 518.95 "New patient office or other outpatient visit, 45-59 minutes" 50755345_1 CDM 0510 RC 99204 HCPCS inpatient 535 347.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 323.94 518.95 "New patient office or other outpatient visit, 45-59 minutes" 50755345_1 CDM 0510 RC 99204 HCPCS inpatient 535 347.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 361.66 67.6 999999999 323.94 518.95 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 50755345_1 CDM 0510 RC 99204 HCPCS inpatient 535 347.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 323.94 518.95 "New patient office or other outpatient visit, 45-59 minutes" 50755345_1 CDM 0510 RC 99204 HCPCS inpatient 535 347.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 323.94 518.95 "New patient office or other outpatient visit, 60-74 minutes" 50755346_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 354.9 65 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 50755346_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 529.62 97 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 50755346_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 AETNA AETNA 431.34 79 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 50755346_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 425.88 78 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 50755346_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 376.74 69 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 50755346_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 SIHO - ALL PLANS SIHO - ALL PLANS 491.4 90 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 50755346_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 UMR - ALL PLANS UMR - ALL PLANS 382.2 70 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 50755346_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 330.6 60.55 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 50755346_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 330.6 529.62 "New patient office or other outpatient visit, 60-74 minutes" 50755346_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 ANTHEM HMO ANTHEM HMO 999999999 330.6 529.62 "New patient office or other outpatient visit, 60-74 minutes" 50755346_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 330.6 529.62 "New patient office or other outpatient visit, 60-74 minutes" 50755346_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 369.1 67.6 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 50755346_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 330.6 529.62 "New patient office or other outpatient visit, 60-74 minutes" 50755346_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 330.6 529.62 POTASSIUM ACET 100 MEQ/50 ML 50755545_1 CDM 0250 RC 00409-3294-25 NDC inpatient 1 UN 34.49 22.42 SELF PAY DISCOUNT SELF PAY DISCOUNT 22.42 65 999999999 20.88 33.46 percent of total billed charges POTASSIUM ACET 100 MEQ/50 ML 50755545_1 CDM 0250 RC 00409-3294-25 NDC inpatient 1 UN 34.49 22.42 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33.46 97 999999999 20.88 33.46 percent of total billed charges POTASSIUM ACET 100 MEQ/50 ML 50755545_1 CDM 0250 RC 00409-3294-25 NDC inpatient 1 UN 34.49 22.42 AETNA AETNA 27.25 79 999999999 20.88 33.46 percent of total billed charges POTASSIUM ACET 100 MEQ/50 ML 50755545_1 CDM 0250 RC 00409-3294-25 NDC inpatient 1 UN 34.49 22.42 HUMANA - ALL PLANS HUMANA - ALL PLANS 26.9 78 999999999 20.88 33.46 percent of total billed charges POTASSIUM ACET 100 MEQ/50 ML 50755545_1 CDM 0250 RC 00409-3294-25 NDC inpatient 1 UN 34.49 22.42 ENCORE - ALL PLANS ENCORE - ALL PLANS 23.8 69 999999999 20.88 33.46 percent of total billed charges POTASSIUM ACET 100 MEQ/50 ML 50755545_1 CDM 0250 RC 00409-3294-25 NDC inpatient 1 UN 34.49 22.42 SIHO - ALL PLANS SIHO - ALL PLANS 31.04 90 999999999 20.88 33.46 percent of total billed charges POTASSIUM ACET 100 MEQ/50 ML 50755545_1 CDM 0250 RC 00409-3294-25 NDC inpatient 1 UN 34.49 22.42 UMR - ALL PLANS UMR - ALL PLANS 24.14 70 999999999 20.88 33.46 percent of total billed charges POTASSIUM ACET 100 MEQ/50 ML 50755545_1 CDM 0250 RC 00409-3294-25 NDC inpatient 1 UN 34.49 22.42 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.88 60.55 999999999 20.88 33.46 percent of total billed charges POTASSIUM ACET 100 MEQ/50 ML 50755545_1 CDM 0250 RC 00409-3294-25 NDC inpatient 1 UN 34.49 22.42 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.88 33.46 POTASSIUM ACET 100 MEQ/50 ML 50755545_1 CDM 0250 RC 00409-3294-25 NDC inpatient 1 UN 34.49 22.42 ANTHEM HMO ANTHEM HMO 999999999 20.88 33.46 POTASSIUM ACET 100 MEQ/50 ML 50755545_1 CDM 0250 RC 00409-3294-25 NDC inpatient 1 UN 34.49 22.42 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.88 33.46 POTASSIUM ACET 100 MEQ/50 ML 50755545_1 CDM 0250 RC 00409-3294-25 NDC inpatient 1 UN 34.49 22.42 CIGNA - ALL PLANS CIGNA - ALL PLANS 23.32 67.6 999999999 20.88 33.46 percent of total billed charges POTASSIUM ACET 100 MEQ/50 ML 50755545_1 CDM 0250 RC 00409-3294-25 NDC inpatient 1 UN 34.49 22.42 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.88 33.46 POTASSIUM ACET 100 MEQ/50 ML 50755545_1 CDM 0250 RC 00409-3294-25 NDC inpatient 1 UN 34.49 22.42 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.88 33.46 Urine pregnancy test 50755547_1 CDM 0300 RC 81025 HCPCS inpatient 24 15.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 15.6 65 999999999 14.53 23.28 percent of total billed charges Urine pregnancy test 50755547_1 CDM 0300 RC 81025 HCPCS inpatient 24 15.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23.28 97 999999999 14.53 23.28 percent of total billed charges Urine pregnancy test 50755547_1 CDM 0300 RC 81025 HCPCS inpatient 24 15.6 AETNA AETNA 18.96 79 999999999 14.53 23.28 percent of total billed charges Urine pregnancy test 50755547_1 CDM 0300 RC 81025 HCPCS inpatient 24 15.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 18.72 78 999999999 14.53 23.28 percent of total billed charges Urine pregnancy test 50755547_1 CDM 0300 RC 81025 HCPCS inpatient 24 15.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 16.56 69 999999999 14.53 23.28 percent of total billed charges Urine pregnancy test 50755547_1 CDM 0300 RC 81025 HCPCS inpatient 24 15.6 SIHO - ALL PLANS SIHO - ALL PLANS 21.6 90 999999999 14.53 23.28 percent of total billed charges Urine pregnancy test 50755547_1 CDM 0300 RC 81025 HCPCS inpatient 24 15.6 UMR - ALL PLANS UMR - ALL PLANS 16.8 70 999999999 14.53 23.28 percent of total billed charges Urine pregnancy test 50755547_1 CDM 0300 RC 81025 HCPCS inpatient 24 15.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14.53 60.55 999999999 14.53 23.28 percent of total billed charges Urine pregnancy test 50755547_1 CDM 0300 RC 81025 HCPCS inpatient 24 15.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14.53 23.28 Urine pregnancy test 50755547_1 CDM 0300 RC 81025 HCPCS inpatient 24 15.6 ANTHEM HMO ANTHEM HMO 999999999 14.53 23.28 Urine pregnancy test 50755547_1 CDM 0300 RC 81025 HCPCS inpatient 24 15.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14.53 23.28 Urine pregnancy test 50755547_1 CDM 0300 RC 81025 HCPCS inpatient 24 15.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 16.22 67.6 999999999 14.53 23.28 percent of total billed charges Urine pregnancy test 50755547_1 CDM 0300 RC 81025 HCPCS inpatient 24 15.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14.53 23.28 Urine pregnancy test 50755547_1 CDM 0300 RC 81025 HCPCS inpatient 24 15.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 14.53 23.28 ****BLANKET PER MEGAN P. 05/01/2023****SMALL CERVICAL CUP VCARE 32mm 8/CASE 60-6085-200A 50759048_1 CDM 0272 RC inpatient 107 69.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 69.55 65 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****SMALL CERVICAL CUP VCARE 32mm 8/CASE 60-6085-200A 50759048_1 CDM 0272 RC inpatient 107 69.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 103.79 97 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****SMALL CERVICAL CUP VCARE 32mm 8/CASE 60-6085-200A 50759048_1 CDM 0272 RC inpatient 107 69.55 AETNA AETNA 84.53 79 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****SMALL CERVICAL CUP VCARE 32mm 8/CASE 60-6085-200A 50759048_1 CDM 0272 RC inpatient 107 69.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 83.46 78 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****SMALL CERVICAL CUP VCARE 32mm 8/CASE 60-6085-200A 50759048_1 CDM 0272 RC inpatient 107 69.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.83 69 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****SMALL CERVICAL CUP VCARE 32mm 8/CASE 60-6085-200A 50759048_1 CDM 0272 RC inpatient 107 69.55 SIHO - ALL PLANS SIHO - ALL PLANS 96.3 90 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****SMALL CERVICAL CUP VCARE 32mm 8/CASE 60-6085-200A 50759048_1 CDM 0272 RC inpatient 107 69.55 UMR - ALL PLANS UMR - ALL PLANS 74.9 70 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****SMALL CERVICAL CUP VCARE 32mm 8/CASE 60-6085-200A 50759048_1 CDM 0272 RC inpatient 107 69.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.79 60.55 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****SMALL CERVICAL CUP VCARE 32mm 8/CASE 60-6085-200A 50759048_1 CDM 0272 RC inpatient 107 69.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.79 103.79 ****BLANKET PER MEGAN P. 05/01/2023****SMALL CERVICAL CUP VCARE 32mm 8/CASE 60-6085-200A 50759048_1 CDM 0272 RC inpatient 107 69.55 ANTHEM HMO ANTHEM HMO 999999999 64.79 103.79 ****BLANKET PER MEGAN P. 05/01/2023****SMALL CERVICAL CUP VCARE 32mm 8/CASE 60-6085-200A 50759048_1 CDM 0272 RC inpatient 107 69.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.79 103.79 ****BLANKET PER MEGAN P. 05/01/2023****SMALL CERVICAL CUP VCARE 32mm 8/CASE 60-6085-200A 50759048_1 CDM 0272 RC inpatient 107 69.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 72.33 67.6 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****SMALL CERVICAL CUP VCARE 32mm 8/CASE 60-6085-200A 50759048_1 CDM 0272 RC inpatient 107 69.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.79 103.79 ****BLANKET PER MEGAN P. 05/01/2023****SMALL CERVICAL CUP VCARE 32mm 8/CASE 60-6085-200A 50759048_1 CDM 0272 RC inpatient 107 69.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.79 103.79 ****BLANKET PER MEGAN P. 05/01/2023****LARGE CERVICAL CUP VCARE 37mm 8/CASE 60-6085-202A 50759078_1 CDM 0272 RC inpatient 107 69.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 69.55 65 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****LARGE CERVICAL CUP VCARE 37mm 8/CASE 60-6085-202A 50759078_1 CDM 0272 RC inpatient 107 69.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 103.79 97 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****LARGE CERVICAL CUP VCARE 37mm 8/CASE 60-6085-202A 50759078_1 CDM 0272 RC inpatient 107 69.55 AETNA AETNA 84.53 79 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****LARGE CERVICAL CUP VCARE 37mm 8/CASE 60-6085-202A 50759078_1 CDM 0272 RC inpatient 107 69.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 83.46 78 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****LARGE CERVICAL CUP VCARE 37mm 8/CASE 60-6085-202A 50759078_1 CDM 0272 RC inpatient 107 69.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.83 69 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****LARGE CERVICAL CUP VCARE 37mm 8/CASE 60-6085-202A 50759078_1 CDM 0272 RC inpatient 107 69.55 SIHO - ALL PLANS SIHO - ALL PLANS 96.3 90 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****LARGE CERVICAL CUP VCARE 37mm 8/CASE 60-6085-202A 50759078_1 CDM 0272 RC inpatient 107 69.55 UMR - ALL PLANS UMR - ALL PLANS 74.9 70 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****LARGE CERVICAL CUP VCARE 37mm 8/CASE 60-6085-202A 50759078_1 CDM 0272 RC inpatient 107 69.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.79 60.55 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****LARGE CERVICAL CUP VCARE 37mm 8/CASE 60-6085-202A 50759078_1 CDM 0272 RC inpatient 107 69.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.79 103.79 ****BLANKET PER MEGAN P. 05/01/2023****LARGE CERVICAL CUP VCARE 37mm 8/CASE 60-6085-202A 50759078_1 CDM 0272 RC inpatient 107 69.55 ANTHEM HMO ANTHEM HMO 999999999 64.79 103.79 ****BLANKET PER MEGAN P. 05/01/2023****LARGE CERVICAL CUP VCARE 37mm 8/CASE 60-6085-202A 50759078_1 CDM 0272 RC inpatient 107 69.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.79 103.79 ****BLANKET PER MEGAN P. 05/01/2023****LARGE CERVICAL CUP VCARE 37mm 8/CASE 60-6085-202A 50759078_1 CDM 0272 RC inpatient 107 69.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 72.33 67.6 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****LARGE CERVICAL CUP VCARE 37mm 8/CASE 60-6085-202A 50759078_1 CDM 0272 RC inpatient 107 69.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.79 103.79 ****BLANKET PER MEGAN P. 05/01/2023****LARGE CERVICAL CUP VCARE 37mm 8/CASE 60-6085-202A 50759078_1 CDM 0272 RC inpatient 107 69.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.79 103.79 ****BLANKET PER MEGAN P. 05/01/2023****X-LARGE CERVICAL CUP VCARE 40mm 8/CASE 60-6085-203A 50759079_1 CDM 0272 RC inpatient 107 69.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 69.55 65 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****X-LARGE CERVICAL CUP VCARE 40mm 8/CASE 60-6085-203A 50759079_1 CDM 0272 RC inpatient 107 69.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 103.79 97 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****X-LARGE CERVICAL CUP VCARE 40mm 8/CASE 60-6085-203A 50759079_1 CDM 0272 RC inpatient 107 69.55 AETNA AETNA 84.53 79 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****X-LARGE CERVICAL CUP VCARE 40mm 8/CASE 60-6085-203A 50759079_1 CDM 0272 RC inpatient 107 69.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 83.46 78 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****X-LARGE CERVICAL CUP VCARE 40mm 8/CASE 60-6085-203A 50759079_1 CDM 0272 RC inpatient 107 69.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.83 69 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****X-LARGE CERVICAL CUP VCARE 40mm 8/CASE 60-6085-203A 50759079_1 CDM 0272 RC inpatient 107 69.55 SIHO - ALL PLANS SIHO - ALL PLANS 96.3 90 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****X-LARGE CERVICAL CUP VCARE 40mm 8/CASE 60-6085-203A 50759079_1 CDM 0272 RC inpatient 107 69.55 UMR - ALL PLANS UMR - ALL PLANS 74.9 70 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****X-LARGE CERVICAL CUP VCARE 40mm 8/CASE 60-6085-203A 50759079_1 CDM 0272 RC inpatient 107 69.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.79 60.55 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****X-LARGE CERVICAL CUP VCARE 40mm 8/CASE 60-6085-203A 50759079_1 CDM 0272 RC inpatient 107 69.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.79 103.79 ****BLANKET PER MEGAN P. 05/01/2023****X-LARGE CERVICAL CUP VCARE 40mm 8/CASE 60-6085-203A 50759079_1 CDM 0272 RC inpatient 107 69.55 ANTHEM HMO ANTHEM HMO 999999999 64.79 103.79 ****BLANKET PER MEGAN P. 05/01/2023****X-LARGE CERVICAL CUP VCARE 40mm 8/CASE 60-6085-203A 50759079_1 CDM 0272 RC inpatient 107 69.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.79 103.79 ****BLANKET PER MEGAN P. 05/01/2023****X-LARGE CERVICAL CUP VCARE 40mm 8/CASE 60-6085-203A 50759079_1 CDM 0272 RC inpatient 107 69.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 72.33 67.6 999999999 64.79 103.79 percent of total billed charges ****BLANKET PER MEGAN P. 05/01/2023****X-LARGE CERVICAL CUP VCARE 40mm 8/CASE 60-6085-203A 50759079_1 CDM 0272 RC inpatient 107 69.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.79 103.79 ****BLANKET PER MEGAN P. 05/01/2023****X-LARGE CERVICAL CUP VCARE 40mm 8/CASE 60-6085-203A 50759079_1 CDM 0272 RC inpatient 107 69.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.79 103.79 Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760886_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.9 65 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760886_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.02 97 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760886_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 AETNA AETNA 52.14 79 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760886_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.48 78 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760886_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.54 69 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760886_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 SIHO - ALL PLANS SIHO - ALL PLANS 59.4 90 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760886_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 UMR - ALL PLANS UMR - ALL PLANS 46.2 70 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760886_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.96 60.55 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760886_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.96 64.02 Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760886_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 ANTHEM HMO ANTHEM HMO 999999999 39.96 64.02 Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760886_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.96 64.02 Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760886_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.62 67.6 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760886_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.96 64.02 Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760886_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.96 64.02 Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760887_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.9 65 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760887_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.02 97 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760887_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 AETNA AETNA 52.14 79 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760887_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.48 78 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760887_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.54 69 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760887_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 SIHO - ALL PLANS SIHO - ALL PLANS 59.4 90 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760887_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 UMR - ALL PLANS UMR - ALL PLANS 46.2 70 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760887_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.96 60.55 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760887_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.96 64.02 Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760887_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 ANTHEM HMO ANTHEM HMO 999999999 39.96 64.02 Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760887_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.96 64.02 Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760887_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.62 67.6 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760887_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.96 64.02 Analysis for antibody to La crosse (California) virus (encephalitis causing virus) 50760887_1 CDM 0301 RC 86651 HCPCS inpatient 66 42.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.96 64.02 Analysis for antibody to Eastern equine virus (viral encephalitis) 50760888_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.9 65 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Eastern equine virus (viral encephalitis) 50760888_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.02 97 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Eastern equine virus (viral encephalitis) 50760888_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 AETNA AETNA 52.14 79 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Eastern equine virus (viral encephalitis) 50760888_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.48 78 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Eastern equine virus (viral encephalitis) 50760888_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.54 69 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Eastern equine virus (viral encephalitis) 50760888_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 SIHO - ALL PLANS SIHO - ALL PLANS 59.4 90 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Eastern equine virus (viral encephalitis) 50760888_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 UMR - ALL PLANS UMR - ALL PLANS 46.2 70 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Eastern equine virus (viral encephalitis) 50760888_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.96 60.55 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Eastern equine virus (viral encephalitis) 50760888_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.96 64.02 Analysis for antibody to Eastern equine virus (viral encephalitis) 50760888_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 ANTHEM HMO ANTHEM HMO 999999999 39.96 64.02 Analysis for antibody to Eastern equine virus (viral encephalitis) 50760888_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.96 64.02 Analysis for antibody to Eastern equine virus (viral encephalitis) 50760888_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.62 67.6 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Eastern equine virus (viral encephalitis) 50760888_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.96 64.02 Analysis for antibody to Eastern equine virus (viral encephalitis) 50760888_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.96 64.02 Analysis for antibody to Eastern equine virus (viral encephalitis) 50760889_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.9 65 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Eastern equine virus (viral encephalitis) 50760889_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.02 97 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Eastern equine virus (viral encephalitis) 50760889_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 AETNA AETNA 52.14 79 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Eastern equine virus (viral encephalitis) 50760889_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.48 78 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Eastern equine virus (viral encephalitis) 50760889_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.54 69 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Eastern equine virus (viral encephalitis) 50760889_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 SIHO - ALL PLANS SIHO - ALL PLANS 59.4 90 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Eastern equine virus (viral encephalitis) 50760889_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 UMR - ALL PLANS UMR - ALL PLANS 46.2 70 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Eastern equine virus (viral encephalitis) 50760889_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.96 60.55 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Eastern equine virus (viral encephalitis) 50760889_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.96 64.02 Analysis for antibody to Eastern equine virus (viral encephalitis) 50760889_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 ANTHEM HMO ANTHEM HMO 999999999 39.96 64.02 Analysis for antibody to Eastern equine virus (viral encephalitis) 50760889_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.96 64.02 Analysis for antibody to Eastern equine virus (viral encephalitis) 50760889_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.62 67.6 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Eastern equine virus (viral encephalitis) 50760889_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.96 64.02 Analysis for antibody to Eastern equine virus (viral encephalitis) 50760889_1 CDM 0301 RC 86652 HCPCS inpatient 66 42.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.96 64.02 Analysis for antibody to St. Louis virus (viral encephalitis) 50760890_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.9 65 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to St. Louis virus (viral encephalitis) 50760890_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.02 97 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to St. Louis virus (viral encephalitis) 50760890_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 AETNA AETNA 52.14 79 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to St. Louis virus (viral encephalitis) 50760890_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.48 78 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to St. Louis virus (viral encephalitis) 50760890_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.54 69 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to St. Louis virus (viral encephalitis) 50760890_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 SIHO - ALL PLANS SIHO - ALL PLANS 59.4 90 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to St. Louis virus (viral encephalitis) 50760890_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 UMR - ALL PLANS UMR - ALL PLANS 46.2 70 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to St. Louis virus (viral encephalitis) 50760890_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.96 60.55 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to St. Louis virus (viral encephalitis) 50760890_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.96 64.02 Analysis for antibody to St. Louis virus (viral encephalitis) 50760890_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 ANTHEM HMO ANTHEM HMO 999999999 39.96 64.02 Analysis for antibody to St. Louis virus (viral encephalitis) 50760890_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.96 64.02 Analysis for antibody to St. Louis virus (viral encephalitis) 50760890_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.62 67.6 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to St. Louis virus (viral encephalitis) 50760890_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.96 64.02 Analysis for antibody to St. Louis virus (viral encephalitis) 50760890_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.96 64.02 Analysis for antibody to St. Louis virus (viral encephalitis) 50760891_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.9 65 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to St. Louis virus (viral encephalitis) 50760891_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.02 97 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to St. Louis virus (viral encephalitis) 50760891_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 AETNA AETNA 52.14 79 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to St. Louis virus (viral encephalitis) 50760891_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.48 78 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to St. Louis virus (viral encephalitis) 50760891_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.54 69 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to St. Louis virus (viral encephalitis) 50760891_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 SIHO - ALL PLANS SIHO - ALL PLANS 59.4 90 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to St. Louis virus (viral encephalitis) 50760891_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 UMR - ALL PLANS UMR - ALL PLANS 46.2 70 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to St. Louis virus (viral encephalitis) 50760891_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.96 60.55 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to St. Louis virus (viral encephalitis) 50760891_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.96 64.02 Analysis for antibody to St. Louis virus (viral encephalitis) 50760891_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 ANTHEM HMO ANTHEM HMO 999999999 39.96 64.02 Analysis for antibody to St. Louis virus (viral encephalitis) 50760891_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.96 64.02 Analysis for antibody to St. Louis virus (viral encephalitis) 50760891_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.62 67.6 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to St. Louis virus (viral encephalitis) 50760891_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.96 64.02 Analysis for antibody to St. Louis virus (viral encephalitis) 50760891_1 CDM 0301 RC 86653 HCPCS inpatient 66 42.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.96 64.02 Analysis for antibody to West Nile virus 50760892_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.6 65 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 50760892_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.88 97 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 50760892_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 AETNA AETNA 161.16 79 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 50760892_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.12 78 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 50760892_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.76 69 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 50760892_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 SIHO - ALL PLANS SIHO - ALL PLANS 183.6 90 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 50760892_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 UMR - ALL PLANS UMR - ALL PLANS 142.8 70 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 50760892_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.52 60.55 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 50760892_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.52 197.88 Analysis for antibody to West Nile virus 50760892_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 ANTHEM HMO ANTHEM HMO 999999999 123.52 197.88 Analysis for antibody to West Nile virus 50760892_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.52 197.88 Analysis for antibody to West Nile virus 50760892_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.9 67.6 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 50760892_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.52 197.88 Analysis for antibody to West Nile virus 50760892_1 CDM 0301 RC 86789 HCPCS inpatient 204 132.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.52 197.88 Analysis for antibody (IgM) to West Nile virus 50760893_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 134.55 65 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 50760893_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 200.79 97 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 50760893_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 AETNA AETNA 163.53 79 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 50760893_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 161.46 78 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 50760893_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.83 69 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 50760893_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 SIHO - ALL PLANS SIHO - ALL PLANS 186.3 90 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 50760893_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 UMR - ALL PLANS UMR - ALL PLANS 144.9 70 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 50760893_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 125.34 60.55 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 50760893_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 125.34 200.79 Analysis for antibody (IgM) to West Nile virus 50760893_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ANTHEM HMO ANTHEM HMO 999999999 125.34 200.79 Analysis for antibody (IgM) to West Nile virus 50760893_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 125.34 200.79 Analysis for antibody (IgM) to West Nile virus 50760893_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.93 67.6 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 50760893_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 125.34 200.79 Analysis for antibody (IgM) to West Nile virus 50760893_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 125.34 200.79 Analysis for antibody to Western equine virus (viral encephalitis) 50760894_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.9 65 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Western equine virus (viral encephalitis) 50760894_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.02 97 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Western equine virus (viral encephalitis) 50760894_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 AETNA AETNA 52.14 79 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Western equine virus (viral encephalitis) 50760894_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.48 78 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Western equine virus (viral encephalitis) 50760894_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.54 69 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Western equine virus (viral encephalitis) 50760894_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 SIHO - ALL PLANS SIHO - ALL PLANS 59.4 90 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Western equine virus (viral encephalitis) 50760894_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 UMR - ALL PLANS UMR - ALL PLANS 46.2 70 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Western equine virus (viral encephalitis) 50760894_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.96 60.55 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Western equine virus (viral encephalitis) 50760894_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.96 64.02 Analysis for antibody to Western equine virus (viral encephalitis) 50760894_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 ANTHEM HMO ANTHEM HMO 999999999 39.96 64.02 Analysis for antibody to Western equine virus (viral encephalitis) 50760894_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.96 64.02 Analysis for antibody to Western equine virus (viral encephalitis) 50760894_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.62 67.6 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Western equine virus (viral encephalitis) 50760894_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.96 64.02 Analysis for antibody to Western equine virus (viral encephalitis) 50760894_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.96 64.02 Analysis for antibody to Western equine virus (viral encephalitis) 50760895_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.9 65 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Western equine virus (viral encephalitis) 50760895_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 64.02 97 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Western equine virus (viral encephalitis) 50760895_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 AETNA AETNA 52.14 79 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Western equine virus (viral encephalitis) 50760895_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 51.48 78 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Western equine virus (viral encephalitis) 50760895_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 45.54 69 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Western equine virus (viral encephalitis) 50760895_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 SIHO - ALL PLANS SIHO - ALL PLANS 59.4 90 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Western equine virus (viral encephalitis) 50760895_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 UMR - ALL PLANS UMR - ALL PLANS 46.2 70 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Western equine virus (viral encephalitis) 50760895_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.96 60.55 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Western equine virus (viral encephalitis) 50760895_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.96 64.02 Analysis for antibody to Western equine virus (viral encephalitis) 50760895_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 ANTHEM HMO ANTHEM HMO 999999999 39.96 64.02 Analysis for antibody to Western equine virus (viral encephalitis) 50760895_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.96 64.02 Analysis for antibody to Western equine virus (viral encephalitis) 50760895_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 44.62 67.6 999999999 39.96 64.02 percent of total billed charges Analysis for antibody to Western equine virus (viral encephalitis) 50760895_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.96 64.02 Analysis for antibody to Western equine virus (viral encephalitis) 50760895_1 CDM 0301 RC 86654 HCPCS inpatient 66 42.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.96 64.02 FLECAINIDE ACETATE 100 MG TAB 50761834_1 CDM 0250 RC 50268-0321-15 NDC inpatient 1 UN 6.24 4.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 4.06 65 999999999 3.78 6.05 percent of total billed charges FLECAINIDE ACETATE 100 MG TAB 50761834_1 CDM 0250 RC 50268-0321-15 NDC inpatient 1 UN 6.24 4.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6.05 97 999999999 3.78 6.05 percent of total billed charges FLECAINIDE ACETATE 100 MG TAB 50761834_1 CDM 0250 RC 50268-0321-15 NDC inpatient 1 UN 6.24 4.06 AETNA AETNA 4.93 79 999999999 3.78 6.05 percent of total billed charges FLECAINIDE ACETATE 100 MG TAB 50761834_1 CDM 0250 RC 50268-0321-15 NDC inpatient 1 UN 6.24 4.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 4.87 78 999999999 3.78 6.05 percent of total billed charges FLECAINIDE ACETATE 100 MG TAB 50761834_1 CDM 0250 RC 50268-0321-15 NDC inpatient 1 UN 6.24 4.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 4.31 69 999999999 3.78 6.05 percent of total billed charges FLECAINIDE ACETATE 100 MG TAB 50761834_1 CDM 0250 RC 50268-0321-15 NDC inpatient 1 UN 6.24 4.06 SIHO - ALL PLANS SIHO - ALL PLANS 5.62 90 999999999 3.78 6.05 percent of total billed charges FLECAINIDE ACETATE 100 MG TAB 50761834_1 CDM 0250 RC 50268-0321-15 NDC inpatient 1 UN 6.24 4.06 UMR - ALL PLANS UMR - ALL PLANS 4.37 70 999999999 3.78 6.05 percent of total billed charges FLECAINIDE ACETATE 100 MG TAB 50761834_1 CDM 0250 RC 50268-0321-15 NDC inpatient 1 UN 6.24 4.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3.78 60.55 999999999 3.78 6.05 percent of total billed charges FLECAINIDE ACETATE 100 MG TAB 50761834_1 CDM 0250 RC 50268-0321-15 NDC inpatient 1 UN 6.24 4.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3.78 6.05 FLECAINIDE ACETATE 100 MG TAB 50761834_1 CDM 0250 RC 50268-0321-15 NDC inpatient 1 UN 6.24 4.06 ANTHEM HMO ANTHEM HMO 999999999 3.78 6.05 FLECAINIDE ACETATE 100 MG TAB 50761834_1 CDM 0250 RC 50268-0321-15 NDC inpatient 1 UN 6.24 4.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3.78 6.05 FLECAINIDE ACETATE 100 MG TAB 50761834_1 CDM 0250 RC 50268-0321-15 NDC inpatient 1 UN 6.24 4.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 4.22 67.6 999999999 3.78 6.05 percent of total billed charges FLECAINIDE ACETATE 100 MG TAB 50761834_1 CDM 0250 RC 50268-0321-15 NDC inpatient 1 UN 6.24 4.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3.78 6.05 FLECAINIDE ACETATE 100 MG TAB 50761834_1 CDM 0250 RC 50268-0321-15 NDC inpatient 1 UN 6.24 4.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 3.78 6.05 Insertion of tunneled central venous tube for infusion (5 years or older) 50762203_1 CDM 0361 RC 36558 HCPCS inpatient 7891 5129.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 5129.15 65 999999999 4778 7654.27 percent of total billed charges Insertion of tunneled central venous tube for infusion (5 years or older) 50762203_1 CDM 0361 RC 36558 HCPCS inpatient 7891 5129.15 AETNA AETNA 6233.89 79 999999999 4778 7654.27 percent of total billed charges Insertion of tunneled central venous tube for infusion (5 years or older) 50762203_1 CDM 0361 RC 36558 HCPCS inpatient 7891 5129.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7654.27 97 999999999 4778 7654.27 percent of total billed charges Insertion of tunneled central venous tube for infusion (5 years or older) 50762203_1 CDM 0361 RC 36558 HCPCS inpatient 7891 5129.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 6154.98 78 999999999 4778 7654.27 percent of total billed charges Insertion of tunneled central venous tube for infusion (5 years or older) 50762203_1 CDM 0361 RC 36558 HCPCS inpatient 7891 5129.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 5444.79 69 999999999 4778 7654.27 percent of total billed charges Insertion of tunneled central venous tube for infusion (5 years or older) 50762203_1 CDM 0361 RC 36558 HCPCS inpatient 7891 5129.15 SIHO - ALL PLANS SIHO - ALL PLANS 7101.9 90 999999999 4778 7654.27 percent of total billed charges Insertion of tunneled central venous tube for infusion (5 years or older) 50762203_1 CDM 0361 RC 36558 HCPCS inpatient 7891 5129.15 UMR - ALL PLANS UMR - ALL PLANS 5523.7 70 999999999 4778 7654.27 percent of total billed charges Insertion of tunneled central venous tube for infusion (5 years or older) 50762203_1 CDM 0361 RC 36558 HCPCS inpatient 7891 5129.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4778 60.55 999999999 4778 7654.27 percent of total billed charges Insertion of tunneled central venous tube for infusion (5 years or older) 50762203_1 CDM 0361 RC 36558 HCPCS inpatient 7891 5129.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4778 7654.27 Insertion of tunneled central venous tube for infusion (5 years or older) 50762203_1 CDM 0361 RC 36558 HCPCS inpatient 7891 5129.15 ANTHEM HMO ANTHEM HMO 999999999 4778 7654.27 Insertion of tunneled central venous tube for infusion (5 years or older) 50762203_1 CDM 0361 RC 36558 HCPCS inpatient 7891 5129.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4778 7654.27 Insertion of tunneled central venous tube for infusion (5 years or older) 50762203_1 CDM 0361 RC 36558 HCPCS inpatient 7891 5129.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 5334.32 67.6 999999999 4778 7654.27 percent of total billed charges Insertion of tunneled central venous tube for infusion (5 years or older) 50762203_1 CDM 0361 RC 36558 HCPCS inpatient 7891 5129.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4778 7654.27 Insertion of tunneled central venous tube for infusion (5 years or older) 50762203_1 CDM 0361 RC 36558 HCPCS inpatient 7891 5129.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 4778 7654.27 Replacement of tunneled central venous tube 50762204_1 CDM 0361 RC 36581 HCPCS inpatient 7891 5129.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 5129.15 65 999999999 4778 7654.27 percent of total billed charges Replacement of tunneled central venous tube 50762204_1 CDM 0361 RC 36581 HCPCS inpatient 7891 5129.15 AETNA AETNA 6233.89 79 999999999 4778 7654.27 percent of total billed charges Replacement of tunneled central venous tube 50762204_1 CDM 0361 RC 36581 HCPCS inpatient 7891 5129.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7654.27 97 999999999 4778 7654.27 percent of total billed charges Replacement of tunneled central venous tube 50762204_1 CDM 0361 RC 36581 HCPCS inpatient 7891 5129.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 6154.98 78 999999999 4778 7654.27 percent of total billed charges Replacement of tunneled central venous tube 50762204_1 CDM 0361 RC 36581 HCPCS inpatient 7891 5129.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 5444.79 69 999999999 4778 7654.27 percent of total billed charges Replacement of tunneled central venous tube 50762204_1 CDM 0361 RC 36581 HCPCS inpatient 7891 5129.15 SIHO - ALL PLANS SIHO - ALL PLANS 7101.9 90 999999999 4778 7654.27 percent of total billed charges Replacement of tunneled central venous tube 50762204_1 CDM 0361 RC 36581 HCPCS inpatient 7891 5129.15 UMR - ALL PLANS UMR - ALL PLANS 5523.7 70 999999999 4778 7654.27 percent of total billed charges Replacement of tunneled central venous tube 50762204_1 CDM 0361 RC 36581 HCPCS inpatient 7891 5129.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4778 60.55 999999999 4778 7654.27 percent of total billed charges Replacement of tunneled central venous tube 50762204_1 CDM 0361 RC 36581 HCPCS inpatient 7891 5129.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4778 7654.27 Replacement of tunneled central venous tube 50762204_1 CDM 0361 RC 36581 HCPCS inpatient 7891 5129.15 ANTHEM HMO ANTHEM HMO 999999999 4778 7654.27 Replacement of tunneled central venous tube 50762204_1 CDM 0361 RC 36581 HCPCS inpatient 7891 5129.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4778 7654.27 Replacement of tunneled central venous tube 50762204_1 CDM 0361 RC 36581 HCPCS inpatient 7891 5129.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 5334.32 67.6 999999999 4778 7654.27 percent of total billed charges Replacement of tunneled central venous tube 50762204_1 CDM 0361 RC 36581 HCPCS inpatient 7891 5129.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4778 7654.27 Replacement of tunneled central venous tube 50762204_1 CDM 0361 RC 36581 HCPCS inpatient 7891 5129.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 4778 7654.27 Removal of tunneled central venous tube 50762208_1 CDM 0361 RC 36589 HCPCS inpatient 2014 1309.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1309.1 65 999999999 1219.48 1953.58 percent of total billed charges Removal of tunneled central venous tube 50762208_1 CDM 0361 RC 36589 HCPCS inpatient 2014 1309.1 AETNA AETNA 1591.06 79 999999999 1219.48 1953.58 percent of total billed charges Removal of tunneled central venous tube 50762208_1 CDM 0361 RC 36589 HCPCS inpatient 2014 1309.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1953.58 97 999999999 1219.48 1953.58 percent of total billed charges Removal of tunneled central venous tube 50762208_1 CDM 0361 RC 36589 HCPCS inpatient 2014 1309.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1570.92 78 999999999 1219.48 1953.58 percent of total billed charges Removal of tunneled central venous tube 50762208_1 CDM 0361 RC 36589 HCPCS inpatient 2014 1309.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 1389.66 69 999999999 1219.48 1953.58 percent of total billed charges Removal of tunneled central venous tube 50762208_1 CDM 0361 RC 36589 HCPCS inpatient 2014 1309.1 SIHO - ALL PLANS SIHO - ALL PLANS 1812.6 90 999999999 1219.48 1953.58 percent of total billed charges Removal of tunneled central venous tube 50762208_1 CDM 0361 RC 36589 HCPCS inpatient 2014 1309.1 UMR - ALL PLANS UMR - ALL PLANS 1409.8 70 999999999 1219.48 1953.58 percent of total billed charges Removal of tunneled central venous tube 50762208_1 CDM 0361 RC 36589 HCPCS inpatient 2014 1309.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1219.48 60.55 999999999 1219.48 1953.58 percent of total billed charges Removal of tunneled central venous tube 50762208_1 CDM 0361 RC 36589 HCPCS inpatient 2014 1309.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1219.48 1953.58 Removal of tunneled central venous tube 50762208_1 CDM 0361 RC 36589 HCPCS inpatient 2014 1309.1 ANTHEM HMO ANTHEM HMO 999999999 1219.48 1953.58 Removal of tunneled central venous tube 50762208_1 CDM 0361 RC 36589 HCPCS inpatient 2014 1309.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1219.48 1953.58 Removal of tunneled central venous tube 50762208_1 CDM 0361 RC 36589 HCPCS inpatient 2014 1309.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1361.46 67.6 999999999 1219.48 1953.58 percent of total billed charges Removal of tunneled central venous tube 50762208_1 CDM 0361 RC 36589 HCPCS inpatient 2014 1309.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1219.48 1953.58 Removal of tunneled central venous tube 50762208_1 CDM 0361 RC 36589 HCPCS inpatient 2014 1309.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1219.48 1953.58 Relocation of major upper arm vein with connection to arm artery for hemodialysis 50762209_1 CDM 0361 RC 36818 HCPCS inpatient 13148 8546.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 8546.2 65 999999999 7961.11 12753.56 percent of total billed charges Relocation of major upper arm vein with connection to arm artery for hemodialysis 50762209_1 CDM 0361 RC 36818 HCPCS inpatient 13148 8546.2 AETNA AETNA 10386.92 79 999999999 7961.11 12753.56 percent of total billed charges Relocation of major upper arm vein with connection to arm artery for hemodialysis 50762209_1 CDM 0361 RC 36818 HCPCS inpatient 13148 8546.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12753.56 97 999999999 7961.11 12753.56 percent of total billed charges Relocation of major upper arm vein with connection to arm artery for hemodialysis 50762209_1 CDM 0361 RC 36818 HCPCS inpatient 13148 8546.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 10255.44 78 999999999 7961.11 12753.56 percent of total billed charges Relocation of major upper arm vein with connection to arm artery for hemodialysis 50762209_1 CDM 0361 RC 36818 HCPCS inpatient 13148 8546.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 9072.12 69 999999999 7961.11 12753.56 percent of total billed charges Relocation of major upper arm vein with connection to arm artery for hemodialysis 50762209_1 CDM 0361 RC 36818 HCPCS inpatient 13148 8546.2 SIHO - ALL PLANS SIHO - ALL PLANS 11833.2 90 999999999 7961.11 12753.56 percent of total billed charges Relocation of major upper arm vein with connection to arm artery for hemodialysis 50762209_1 CDM 0361 RC 36818 HCPCS inpatient 13148 8546.2 UMR - ALL PLANS UMR - ALL PLANS 9203.6 70 999999999 7961.11 12753.56 percent of total billed charges Relocation of major upper arm vein with connection to arm artery for hemodialysis 50762209_1 CDM 0361 RC 36818 HCPCS inpatient 13148 8546.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7961.11 60.55 999999999 7961.11 12753.56 percent of total billed charges Relocation of major upper arm vein with connection to arm artery for hemodialysis 50762209_1 CDM 0361 RC 36818 HCPCS inpatient 13148 8546.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7961.11 12753.56 Relocation of major upper arm vein with connection to arm artery for hemodialysis 50762209_1 CDM 0361 RC 36818 HCPCS inpatient 13148 8546.2 ANTHEM HMO ANTHEM HMO 999999999 7961.11 12753.56 Relocation of major upper arm vein with connection to arm artery for hemodialysis 50762209_1 CDM 0361 RC 36818 HCPCS inpatient 13148 8546.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7961.11 12753.56 Relocation of major upper arm vein with connection to arm artery for hemodialysis 50762209_1 CDM 0361 RC 36818 HCPCS inpatient 13148 8546.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 8888.05 67.6 999999999 7961.11 12753.56 percent of total billed charges Relocation of major upper arm vein with connection to arm artery for hemodialysis 50762209_1 CDM 0361 RC 36818 HCPCS inpatient 13148 8546.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7961.11 12753.56 Relocation of major upper arm vein with connection to arm artery for hemodialysis 50762209_1 CDM 0361 RC 36818 HCPCS inpatient 13148 8546.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 7961.11 12753.56 Relocation of upper arm surface vein with connection to arm artery for hemodialysis 50762211_1 CDM 0361 RC 36819 HCPCS inpatient 13148 8546.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 8546.2 65 999999999 7961.11 12753.56 percent of total billed charges Relocation of upper arm surface vein with connection to arm artery for hemodialysis 50762211_1 CDM 0361 RC 36819 HCPCS inpatient 13148 8546.2 AETNA AETNA 10386.92 79 999999999 7961.11 12753.56 percent of total billed charges Relocation of upper arm surface vein with connection to arm artery for hemodialysis 50762211_1 CDM 0361 RC 36819 HCPCS inpatient 13148 8546.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12753.56 97 999999999 7961.11 12753.56 percent of total billed charges Relocation of upper arm surface vein with connection to arm artery for hemodialysis 50762211_1 CDM 0361 RC 36819 HCPCS inpatient 13148 8546.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 10255.44 78 999999999 7961.11 12753.56 percent of total billed charges Relocation of upper arm surface vein with connection to arm artery for hemodialysis 50762211_1 CDM 0361 RC 36819 HCPCS inpatient 13148 8546.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 9072.12 69 999999999 7961.11 12753.56 percent of total billed charges Relocation of upper arm surface vein with connection to arm artery for hemodialysis 50762211_1 CDM 0361 RC 36819 HCPCS inpatient 13148 8546.2 SIHO - ALL PLANS SIHO - ALL PLANS 11833.2 90 999999999 7961.11 12753.56 percent of total billed charges Relocation of upper arm surface vein with connection to arm artery for hemodialysis 50762211_1 CDM 0361 RC 36819 HCPCS inpatient 13148 8546.2 UMR - ALL PLANS UMR - ALL PLANS 9203.6 70 999999999 7961.11 12753.56 percent of total billed charges Relocation of upper arm surface vein with connection to arm artery for hemodialysis 50762211_1 CDM 0361 RC 36819 HCPCS inpatient 13148 8546.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7961.11 60.55 999999999 7961.11 12753.56 percent of total billed charges Relocation of upper arm surface vein with connection to arm artery for hemodialysis 50762211_1 CDM 0361 RC 36819 HCPCS inpatient 13148 8546.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7961.11 12753.56 Relocation of upper arm surface vein with connection to arm artery for hemodialysis 50762211_1 CDM 0361 RC 36819 HCPCS inpatient 13148 8546.2 ANTHEM HMO ANTHEM HMO 999999999 7961.11 12753.56 Relocation of upper arm surface vein with connection to arm artery for hemodialysis 50762211_1 CDM 0361 RC 36819 HCPCS inpatient 13148 8546.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7961.11 12753.56 Relocation of upper arm surface vein with connection to arm artery for hemodialysis 50762211_1 CDM 0361 RC 36819 HCPCS inpatient 13148 8546.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 8888.05 67.6 999999999 7961.11 12753.56 percent of total billed charges Relocation of upper arm surface vein with connection to arm artery for hemodialysis 50762211_1 CDM 0361 RC 36819 HCPCS inpatient 13148 8546.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7961.11 12753.56 Relocation of upper arm surface vein with connection to arm artery for hemodialysis 50762211_1 CDM 0361 RC 36819 HCPCS inpatient 13148 8546.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 7961.11 12753.56 Relocation of arm vein with connection to arm artery for hemodialysis 50762212_1 CDM 0361 RC 36821 HCPCS inpatient 7891 5129.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 5129.15 65 999999999 4778 7654.27 percent of total billed charges Relocation of arm vein with connection to arm artery for hemodialysis 50762212_1 CDM 0361 RC 36821 HCPCS inpatient 7891 5129.15 AETNA AETNA 6233.89 79 999999999 4778 7654.27 percent of total billed charges Relocation of arm vein with connection to arm artery for hemodialysis 50762212_1 CDM 0361 RC 36821 HCPCS inpatient 7891 5129.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7654.27 97 999999999 4778 7654.27 percent of total billed charges Relocation of arm vein with connection to arm artery for hemodialysis 50762212_1 CDM 0361 RC 36821 HCPCS inpatient 7891 5129.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 6154.98 78 999999999 4778 7654.27 percent of total billed charges Relocation of arm vein with connection to arm artery for hemodialysis 50762212_1 CDM 0361 RC 36821 HCPCS inpatient 7891 5129.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 5444.79 69 999999999 4778 7654.27 percent of total billed charges Relocation of arm vein with connection to arm artery for hemodialysis 50762212_1 CDM 0361 RC 36821 HCPCS inpatient 7891 5129.15 SIHO - ALL PLANS SIHO - ALL PLANS 7101.9 90 999999999 4778 7654.27 percent of total billed charges Relocation of arm vein with connection to arm artery for hemodialysis 50762212_1 CDM 0361 RC 36821 HCPCS inpatient 7891 5129.15 UMR - ALL PLANS UMR - ALL PLANS 5523.7 70 999999999 4778 7654.27 percent of total billed charges Relocation of arm vein with connection to arm artery for hemodialysis 50762212_1 CDM 0361 RC 36821 HCPCS inpatient 7891 5129.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4778 60.55 999999999 4778 7654.27 percent of total billed charges Relocation of arm vein with connection to arm artery for hemodialysis 50762212_1 CDM 0361 RC 36821 HCPCS inpatient 7891 5129.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4778 7654.27 Relocation of arm vein with connection to arm artery for hemodialysis 50762212_1 CDM 0361 RC 36821 HCPCS inpatient 7891 5129.15 ANTHEM HMO ANTHEM HMO 999999999 4778 7654.27 Relocation of arm vein with connection to arm artery for hemodialysis 50762212_1 CDM 0361 RC 36821 HCPCS inpatient 7891 5129.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4778 7654.27 Relocation of arm vein with connection to arm artery for hemodialysis 50762212_1 CDM 0361 RC 36821 HCPCS inpatient 7891 5129.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 5334.32 67.6 999999999 4778 7654.27 percent of total billed charges Relocation of arm vein with connection to arm artery for hemodialysis 50762212_1 CDM 0361 RC 36821 HCPCS inpatient 7891 5129.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4778 7654.27 Relocation of arm vein with connection to arm artery for hemodialysis 50762212_1 CDM 0361 RC 36821 HCPCS inpatient 7891 5129.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 4778 7654.27 Creation of artery-vein connection using tube graft for hemodialysis 50762213_1 CDM 0361 RC 36830 HCPCS inpatient 13148 8546.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 8546.2 65 999999999 7961.11 12753.56 percent of total billed charges Creation of artery-vein connection using tube graft for hemodialysis 50762213_1 CDM 0361 RC 36830 HCPCS inpatient 13148 8546.2 AETNA AETNA 10386.92 79 999999999 7961.11 12753.56 percent of total billed charges Creation of artery-vein connection using tube graft for hemodialysis 50762213_1 CDM 0361 RC 36830 HCPCS inpatient 13148 8546.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12753.56 97 999999999 7961.11 12753.56 percent of total billed charges Creation of artery-vein connection using tube graft for hemodialysis 50762213_1 CDM 0361 RC 36830 HCPCS inpatient 13148 8546.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 10255.44 78 999999999 7961.11 12753.56 percent of total billed charges Creation of artery-vein connection using tube graft for hemodialysis 50762213_1 CDM 0361 RC 36830 HCPCS inpatient 13148 8546.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 9072.12 69 999999999 7961.11 12753.56 percent of total billed charges Creation of artery-vein connection using tube graft for hemodialysis 50762213_1 CDM 0361 RC 36830 HCPCS inpatient 13148 8546.2 SIHO - ALL PLANS SIHO - ALL PLANS 11833.2 90 999999999 7961.11 12753.56 percent of total billed charges Creation of artery-vein connection using tube graft for hemodialysis 50762213_1 CDM 0361 RC 36830 HCPCS inpatient 13148 8546.2 UMR - ALL PLANS UMR - ALL PLANS 9203.6 70 999999999 7961.11 12753.56 percent of total billed charges Creation of artery-vein connection using tube graft for hemodialysis 50762213_1 CDM 0361 RC 36830 HCPCS inpatient 13148 8546.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7961.11 60.55 999999999 7961.11 12753.56 percent of total billed charges Creation of artery-vein connection using tube graft for hemodialysis 50762213_1 CDM 0361 RC 36830 HCPCS inpatient 13148 8546.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7961.11 12753.56 Creation of artery-vein connection using tube graft for hemodialysis 50762213_1 CDM 0361 RC 36830 HCPCS inpatient 13148 8546.2 ANTHEM HMO ANTHEM HMO 999999999 7961.11 12753.56 Creation of artery-vein connection using tube graft for hemodialysis 50762213_1 CDM 0361 RC 36830 HCPCS inpatient 13148 8546.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7961.11 12753.56 Creation of artery-vein connection using tube graft for hemodialysis 50762213_1 CDM 0361 RC 36830 HCPCS inpatient 13148 8546.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 8888.05 67.6 999999999 7961.11 12753.56 percent of total billed charges Creation of artery-vein connection using tube graft for hemodialysis 50762213_1 CDM 0361 RC 36830 HCPCS inpatient 13148 8546.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7961.11 12753.56 Creation of artery-vein connection using tube graft for hemodialysis 50762213_1 CDM 0361 RC 36830 HCPCS inpatient 13148 8546.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 7961.11 12753.56 Removal of blood clot from hemodialysis graft 50762217_1 CDM 0361 RC 36831 HCPCS inpatient 13148 8546.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 8546.2 65 999999999 7961.11 12753.56 percent of total billed charges Removal of blood clot from hemodialysis graft 50762217_1 CDM 0361 RC 36831 HCPCS inpatient 13148 8546.2 AETNA AETNA 10386.92 79 999999999 7961.11 12753.56 percent of total billed charges Removal of blood clot from hemodialysis graft 50762217_1 CDM 0361 RC 36831 HCPCS inpatient 13148 8546.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12753.56 97 999999999 7961.11 12753.56 percent of total billed charges Removal of blood clot from hemodialysis graft 50762217_1 CDM 0361 RC 36831 HCPCS inpatient 13148 8546.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 10255.44 78 999999999 7961.11 12753.56 percent of total billed charges Removal of blood clot from hemodialysis graft 50762217_1 CDM 0361 RC 36831 HCPCS inpatient 13148 8546.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 9072.12 69 999999999 7961.11 12753.56 percent of total billed charges Removal of blood clot from hemodialysis graft 50762217_1 CDM 0361 RC 36831 HCPCS inpatient 13148 8546.2 SIHO - ALL PLANS SIHO - ALL PLANS 11833.2 90 999999999 7961.11 12753.56 percent of total billed charges Removal of blood clot from hemodialysis graft 50762217_1 CDM 0361 RC 36831 HCPCS inpatient 13148 8546.2 UMR - ALL PLANS UMR - ALL PLANS 9203.6 70 999999999 7961.11 12753.56 percent of total billed charges Removal of blood clot from hemodialysis graft 50762217_1 CDM 0361 RC 36831 HCPCS inpatient 13148 8546.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7961.11 60.55 999999999 7961.11 12753.56 percent of total billed charges Removal of blood clot from hemodialysis graft 50762217_1 CDM 0361 RC 36831 HCPCS inpatient 13148 8546.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7961.11 12753.56 Removal of blood clot from hemodialysis graft 50762217_1 CDM 0361 RC 36831 HCPCS inpatient 13148 8546.2 ANTHEM HMO ANTHEM HMO 999999999 7961.11 12753.56 Removal of blood clot from hemodialysis graft 50762217_1 CDM 0361 RC 36831 HCPCS inpatient 13148 8546.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7961.11 12753.56 Removal of blood clot from hemodialysis graft 50762217_1 CDM 0361 RC 36831 HCPCS inpatient 13148 8546.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 8888.05 67.6 999999999 7961.11 12753.56 percent of total billed charges Removal of blood clot from hemodialysis graft 50762217_1 CDM 0361 RC 36831 HCPCS inpatient 13148 8546.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7961.11 12753.56 Removal of blood clot from hemodialysis graft 50762217_1 CDM 0361 RC 36831 HCPCS inpatient 13148 8546.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 7961.11 12753.56 Revision of hemodialysis graft 50762218_1 CDM 0361 RC 36832 HCPCS inpatient 13148 8546.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 8546.2 65 999999999 7961.11 12753.56 percent of total billed charges Revision of hemodialysis graft 50762218_1 CDM 0361 RC 36832 HCPCS inpatient 13148 8546.2 AETNA AETNA 10386.92 79 999999999 7961.11 12753.56 percent of total billed charges Revision of hemodialysis graft 50762218_1 CDM 0361 RC 36832 HCPCS inpatient 13148 8546.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12753.56 97 999999999 7961.11 12753.56 percent of total billed charges Revision of hemodialysis graft 50762218_1 CDM 0361 RC 36832 HCPCS inpatient 13148 8546.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 10255.44 78 999999999 7961.11 12753.56 percent of total billed charges Revision of hemodialysis graft 50762218_1 CDM 0361 RC 36832 HCPCS inpatient 13148 8546.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 9072.12 69 999999999 7961.11 12753.56 percent of total billed charges Revision of hemodialysis graft 50762218_1 CDM 0361 RC 36832 HCPCS inpatient 13148 8546.2 SIHO - ALL PLANS SIHO - ALL PLANS 11833.2 90 999999999 7961.11 12753.56 percent of total billed charges Revision of hemodialysis graft 50762218_1 CDM 0361 RC 36832 HCPCS inpatient 13148 8546.2 UMR - ALL PLANS UMR - ALL PLANS 9203.6 70 999999999 7961.11 12753.56 percent of total billed charges Revision of hemodialysis graft 50762218_1 CDM 0361 RC 36832 HCPCS inpatient 13148 8546.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7961.11 60.55 999999999 7961.11 12753.56 percent of total billed charges Revision of hemodialysis graft 50762218_1 CDM 0361 RC 36832 HCPCS inpatient 13148 8546.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7961.11 12753.56 Revision of hemodialysis graft 50762218_1 CDM 0361 RC 36832 HCPCS inpatient 13148 8546.2 ANTHEM HMO ANTHEM HMO 999999999 7961.11 12753.56 Revision of hemodialysis graft 50762218_1 CDM 0361 RC 36832 HCPCS inpatient 13148 8546.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7961.11 12753.56 Revision of hemodialysis graft 50762218_1 CDM 0361 RC 36832 HCPCS inpatient 13148 8546.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 8888.05 67.6 999999999 7961.11 12753.56 percent of total billed charges Revision of hemodialysis graft 50762218_1 CDM 0361 RC 36832 HCPCS inpatient 13148 8546.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7961.11 12753.56 Revision of hemodialysis graft 50762218_1 CDM 0361 RC 36832 HCPCS inpatient 13148 8546.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 7961.11 12753.56 Revision of hemodialysis graft with removal of blood clot 50762219_1 CDM 0361 RC 36833 HCPCS inpatient 13148 8546.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 8546.2 65 999999999 7961.11 12753.56 percent of total billed charges Revision of hemodialysis graft with removal of blood clot 50762219_1 CDM 0361 RC 36833 HCPCS inpatient 13148 8546.2 AETNA AETNA 10386.92 79 999999999 7961.11 12753.56 percent of total billed charges Revision of hemodialysis graft with removal of blood clot 50762219_1 CDM 0361 RC 36833 HCPCS inpatient 13148 8546.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12753.56 97 999999999 7961.11 12753.56 percent of total billed charges Revision of hemodialysis graft with removal of blood clot 50762219_1 CDM 0361 RC 36833 HCPCS inpatient 13148 8546.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 10255.44 78 999999999 7961.11 12753.56 percent of total billed charges Revision of hemodialysis graft with removal of blood clot 50762219_1 CDM 0361 RC 36833 HCPCS inpatient 13148 8546.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 9072.12 69 999999999 7961.11 12753.56 percent of total billed charges Revision of hemodialysis graft with removal of blood clot 50762219_1 CDM 0361 RC 36833 HCPCS inpatient 13148 8546.2 SIHO - ALL PLANS SIHO - ALL PLANS 11833.2 90 999999999 7961.11 12753.56 percent of total billed charges Revision of hemodialysis graft with removal of blood clot 50762219_1 CDM 0361 RC 36833 HCPCS inpatient 13148 8546.2 UMR - ALL PLANS UMR - ALL PLANS 9203.6 70 999999999 7961.11 12753.56 percent of total billed charges Revision of hemodialysis graft with removal of blood clot 50762219_1 CDM 0361 RC 36833 HCPCS inpatient 13148 8546.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7961.11 60.55 999999999 7961.11 12753.56 percent of total billed charges Revision of hemodialysis graft with removal of blood clot 50762219_1 CDM 0361 RC 36833 HCPCS inpatient 13148 8546.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7961.11 12753.56 Revision of hemodialysis graft with removal of blood clot 50762219_1 CDM 0361 RC 36833 HCPCS inpatient 13148 8546.2 ANTHEM HMO ANTHEM HMO 999999999 7961.11 12753.56 Revision of hemodialysis graft with removal of blood clot 50762219_1 CDM 0361 RC 36833 HCPCS inpatient 13148 8546.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7961.11 12753.56 Revision of hemodialysis graft with removal of blood clot 50762219_1 CDM 0361 RC 36833 HCPCS inpatient 13148 8546.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 8888.05 67.6 999999999 7961.11 12753.56 percent of total billed charges Revision of hemodialysis graft with removal of blood clot 50762219_1 CDM 0361 RC 36833 HCPCS inpatient 13148 8546.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7961.11 12753.56 Revision of hemodialysis graft with removal of blood clot 50762219_1 CDM 0361 RC 36833 HCPCS inpatient 13148 8546.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 7961.11 12753.56 Insertion of vena cava filter with review by radiologist 50762220_1 CDM 0361 RC 37191 HCPCS inpatient 13148 8546.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 8546.2 65 999999999 7961.11 12753.56 percent of total billed charges Insertion of vena cava filter with review by radiologist 50762220_1 CDM 0361 RC 37191 HCPCS inpatient 13148 8546.2 AETNA AETNA 10386.92 79 999999999 7961.11 12753.56 percent of total billed charges Insertion of vena cava filter with review by radiologist 50762220_1 CDM 0361 RC 37191 HCPCS inpatient 13148 8546.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12753.56 97 999999999 7961.11 12753.56 percent of total billed charges Insertion of vena cava filter with review by radiologist 50762220_1 CDM 0361 RC 37191 HCPCS inpatient 13148 8546.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 10255.44 78 999999999 7961.11 12753.56 percent of total billed charges Insertion of vena cava filter with review by radiologist 50762220_1 CDM 0361 RC 37191 HCPCS inpatient 13148 8546.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 9072.12 69 999999999 7961.11 12753.56 percent of total billed charges Insertion of vena cava filter with review by radiologist 50762220_1 CDM 0361 RC 37191 HCPCS inpatient 13148 8546.2 SIHO - ALL PLANS SIHO - ALL PLANS 11833.2 90 999999999 7961.11 12753.56 percent of total billed charges Insertion of vena cava filter with review by radiologist 50762220_1 CDM 0361 RC 37191 HCPCS inpatient 13148 8546.2 UMR - ALL PLANS UMR - ALL PLANS 9203.6 70 999999999 7961.11 12753.56 percent of total billed charges Insertion of vena cava filter with review by radiologist 50762220_1 CDM 0361 RC 37191 HCPCS inpatient 13148 8546.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7961.11 60.55 999999999 7961.11 12753.56 percent of total billed charges Insertion of vena cava filter with review by radiologist 50762220_1 CDM 0361 RC 37191 HCPCS inpatient 13148 8546.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7961.11 12753.56 Insertion of vena cava filter with review by radiologist 50762220_1 CDM 0361 RC 37191 HCPCS inpatient 13148 8546.2 ANTHEM HMO ANTHEM HMO 999999999 7961.11 12753.56 Insertion of vena cava filter with review by radiologist 50762220_1 CDM 0361 RC 37191 HCPCS inpatient 13148 8546.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7961.11 12753.56 Insertion of vena cava filter with review by radiologist 50762220_1 CDM 0361 RC 37191 HCPCS inpatient 13148 8546.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 8888.05 67.6 999999999 7961.11 12753.56 percent of total billed charges Insertion of vena cava filter with review by radiologist 50762220_1 CDM 0361 RC 37191 HCPCS inpatient 13148 8546.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7961.11 12753.56 Insertion of vena cava filter with review by radiologist 50762220_1 CDM 0361 RC 37191 HCPCS inpatient 13148 8546.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 7961.11 12753.56 "Balloon dilation of groin artery, initial vessel" 50762221_1 CDM 0361 RC 37220 HCPCS inpatient 13664 8881.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 8881.6 65 999999999 8273.55 13254.08 percent of total billed charges "Balloon dilation of groin artery, initial vessel" 50762221_1 CDM 0361 RC 37220 HCPCS inpatient 13664 8881.6 AETNA AETNA 10794.56 79 999999999 8273.55 13254.08 percent of total billed charges "Balloon dilation of groin artery, initial vessel" 50762221_1 CDM 0361 RC 37220 HCPCS inpatient 13664 8881.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13254.08 97 999999999 8273.55 13254.08 percent of total billed charges "Balloon dilation of groin artery, initial vessel" 50762221_1 CDM 0361 RC 37220 HCPCS inpatient 13664 8881.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 10657.92 78 999999999 8273.55 13254.08 percent of total billed charges "Balloon dilation of groin artery, initial vessel" 50762221_1 CDM 0361 RC 37220 HCPCS inpatient 13664 8881.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 9428.16 69 999999999 8273.55 13254.08 percent of total billed charges "Balloon dilation of groin artery, initial vessel" 50762221_1 CDM 0361 RC 37220 HCPCS inpatient 13664 8881.6 SIHO - ALL PLANS SIHO - ALL PLANS 12297.6 90 999999999 8273.55 13254.08 percent of total billed charges "Balloon dilation of groin artery, initial vessel" 50762221_1 CDM 0361 RC 37220 HCPCS inpatient 13664 8881.6 UMR - ALL PLANS UMR - ALL PLANS 9564.8 70 999999999 8273.55 13254.08 percent of total billed charges "Balloon dilation of groin artery, initial vessel" 50762221_1 CDM 0361 RC 37220 HCPCS inpatient 13664 8881.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8273.55 60.55 999999999 8273.55 13254.08 percent of total billed charges "Balloon dilation of groin artery, initial vessel" 50762221_1 CDM 0361 RC 37220 HCPCS inpatient 13664 8881.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8273.55 13254.08 "Balloon dilation of groin artery, initial vessel" 50762221_1 CDM 0361 RC 37220 HCPCS inpatient 13664 8881.6 ANTHEM HMO ANTHEM HMO 999999999 8273.55 13254.08 "Balloon dilation of groin artery, initial vessel" 50762221_1 CDM 0361 RC 37220 HCPCS inpatient 13664 8881.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8273.55 13254.08 "Balloon dilation of groin artery, initial vessel" 50762221_1 CDM 0361 RC 37220 HCPCS inpatient 13664 8881.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 9236.86 67.6 999999999 8273.55 13254.08 percent of total billed charges "Balloon dilation of groin artery, initial vessel" 50762221_1 CDM 0361 RC 37220 HCPCS inpatient 13664 8881.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8273.55 13254.08 "Balloon dilation of groin artery, initial vessel" 50762221_1 CDM 0361 RC 37220 HCPCS inpatient 13664 8881.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 8273.55 13254.08 "Insertion of stent in groin artery, initial vessel" 50762222_1 CDM 0361 RC 37221 HCPCS inpatient 27682 17993.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 17993.3 65 999999999 16761.45 26851.54 percent of total billed charges "Insertion of stent in groin artery, initial vessel" 50762222_1 CDM 0361 RC 37221 HCPCS inpatient 27682 17993.3 AETNA AETNA 21868.78 79 999999999 16761.45 26851.54 percent of total billed charges "Insertion of stent in groin artery, initial vessel" 50762222_1 CDM 0361 RC 37221 HCPCS inpatient 27682 17993.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26851.54 97 999999999 16761.45 26851.54 percent of total billed charges "Insertion of stent in groin artery, initial vessel" 50762222_1 CDM 0361 RC 37221 HCPCS inpatient 27682 17993.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 21591.96 78 999999999 16761.45 26851.54 percent of total billed charges "Insertion of stent in groin artery, initial vessel" 50762222_1 CDM 0361 RC 37221 HCPCS inpatient 27682 17993.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 19100.58 69 999999999 16761.45 26851.54 percent of total billed charges "Insertion of stent in groin artery, initial vessel" 50762222_1 CDM 0361 RC 37221 HCPCS inpatient 27682 17993.3 SIHO - ALL PLANS SIHO - ALL PLANS 24913.8 90 999999999 16761.45 26851.54 percent of total billed charges "Insertion of stent in groin artery, initial vessel" 50762222_1 CDM 0361 RC 37221 HCPCS inpatient 27682 17993.3 UMR - ALL PLANS UMR - ALL PLANS 19377.4 70 999999999 16761.45 26851.54 percent of total billed charges "Insertion of stent in groin artery, initial vessel" 50762222_1 CDM 0361 RC 37221 HCPCS inpatient 27682 17993.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16761.45 60.55 999999999 16761.45 26851.54 percent of total billed charges "Insertion of stent in groin artery, initial vessel" 50762222_1 CDM 0361 RC 37221 HCPCS inpatient 27682 17993.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16761.45 26851.54 "Insertion of stent in groin artery, initial vessel" 50762222_1 CDM 0361 RC 37221 HCPCS inpatient 27682 17993.3 ANTHEM HMO ANTHEM HMO 999999999 16761.45 26851.54 "Insertion of stent in groin artery, initial vessel" 50762222_1 CDM 0361 RC 37221 HCPCS inpatient 27682 17993.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16761.45 26851.54 "Insertion of stent in groin artery, initial vessel" 50762222_1 CDM 0361 RC 37221 HCPCS inpatient 27682 17993.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 18713.03 67.6 999999999 16761.45 26851.54 percent of total billed charges "Insertion of stent in groin artery, initial vessel" 50762222_1 CDM 0361 RC 37221 HCPCS inpatient 27682 17993.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16761.45 26851.54 "Insertion of stent in groin artery, initial vessel" 50762222_1 CDM 0361 RC 37221 HCPCS inpatient 27682 17993.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 16761.45 26851.54 Balloon dilation of artery of leg 50762229_1 CDM 0361 RC 37224 HCPCS inpatient 13664 8881.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 8881.6 65 999999999 8273.55 13254.08 percent of total billed charges Balloon dilation of artery of leg 50762229_1 CDM 0361 RC 37224 HCPCS inpatient 13664 8881.6 AETNA AETNA 10794.56 79 999999999 8273.55 13254.08 percent of total billed charges Balloon dilation of artery of leg 50762229_1 CDM 0361 RC 37224 HCPCS inpatient 13664 8881.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13254.08 97 999999999 8273.55 13254.08 percent of total billed charges Balloon dilation of artery of leg 50762229_1 CDM 0361 RC 37224 HCPCS inpatient 13664 8881.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 10657.92 78 999999999 8273.55 13254.08 percent of total billed charges Balloon dilation of artery of leg 50762229_1 CDM 0361 RC 37224 HCPCS inpatient 13664 8881.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 9428.16 69 999999999 8273.55 13254.08 percent of total billed charges Balloon dilation of artery of leg 50762229_1 CDM 0361 RC 37224 HCPCS inpatient 13664 8881.6 SIHO - ALL PLANS SIHO - ALL PLANS 12297.6 90 999999999 8273.55 13254.08 percent of total billed charges Balloon dilation of artery of leg 50762229_1 CDM 0361 RC 37224 HCPCS inpatient 13664 8881.6 UMR - ALL PLANS UMR - ALL PLANS 9564.8 70 999999999 8273.55 13254.08 percent of total billed charges Balloon dilation of artery of leg 50762229_1 CDM 0361 RC 37224 HCPCS inpatient 13664 8881.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8273.55 60.55 999999999 8273.55 13254.08 percent of total billed charges Balloon dilation of artery of leg 50762229_1 CDM 0361 RC 37224 HCPCS inpatient 13664 8881.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8273.55 13254.08 Balloon dilation of artery of leg 50762229_1 CDM 0361 RC 37224 HCPCS inpatient 13664 8881.6 ANTHEM HMO ANTHEM HMO 999999999 8273.55 13254.08 Balloon dilation of artery of leg 50762229_1 CDM 0361 RC 37224 HCPCS inpatient 13664 8881.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8273.55 13254.08 Balloon dilation of artery of leg 50762229_1 CDM 0361 RC 37224 HCPCS inpatient 13664 8881.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 9236.86 67.6 999999999 8273.55 13254.08 percent of total billed charges Balloon dilation of artery of leg 50762229_1 CDM 0361 RC 37224 HCPCS inpatient 13664 8881.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8273.55 13254.08 Balloon dilation of artery of leg 50762229_1 CDM 0361 RC 37224 HCPCS inpatient 13664 8881.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 8273.55 13254.08 Removal of plaque in arteries of leg 50762230_1 CDM 0361 RC 37225 HCPCS inpatient 27682 17993.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 17993.3 65 999999999 16761.45 26851.54 percent of total billed charges Removal of plaque in arteries of leg 50762230_1 CDM 0361 RC 37225 HCPCS inpatient 27682 17993.3 AETNA AETNA 21868.78 79 999999999 16761.45 26851.54 percent of total billed charges Removal of plaque in arteries of leg 50762230_1 CDM 0361 RC 37225 HCPCS inpatient 27682 17993.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26851.54 97 999999999 16761.45 26851.54 percent of total billed charges Removal of plaque in arteries of leg 50762230_1 CDM 0361 RC 37225 HCPCS inpatient 27682 17993.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 21591.96 78 999999999 16761.45 26851.54 percent of total billed charges Removal of plaque in arteries of leg 50762230_1 CDM 0361 RC 37225 HCPCS inpatient 27682 17993.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 19100.58 69 999999999 16761.45 26851.54 percent of total billed charges Removal of plaque in arteries of leg 50762230_1 CDM 0361 RC 37225 HCPCS inpatient 27682 17993.3 SIHO - ALL PLANS SIHO - ALL PLANS 24913.8 90 999999999 16761.45 26851.54 percent of total billed charges Removal of plaque in arteries of leg 50762230_1 CDM 0361 RC 37225 HCPCS inpatient 27682 17993.3 UMR - ALL PLANS UMR - ALL PLANS 19377.4 70 999999999 16761.45 26851.54 percent of total billed charges Removal of plaque in arteries of leg 50762230_1 CDM 0361 RC 37225 HCPCS inpatient 27682 17993.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16761.45 60.55 999999999 16761.45 26851.54 percent of total billed charges Removal of plaque in arteries of leg 50762230_1 CDM 0361 RC 37225 HCPCS inpatient 27682 17993.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16761.45 26851.54 Removal of plaque in arteries of leg 50762230_1 CDM 0361 RC 37225 HCPCS inpatient 27682 17993.3 ANTHEM HMO ANTHEM HMO 999999999 16761.45 26851.54 Removal of plaque in arteries of leg 50762230_1 CDM 0361 RC 37225 HCPCS inpatient 27682 17993.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16761.45 26851.54 Removal of plaque in arteries of leg 50762230_1 CDM 0361 RC 37225 HCPCS inpatient 27682 17993.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 18713.03 67.6 999999999 16761.45 26851.54 percent of total billed charges Removal of plaque in arteries of leg 50762230_1 CDM 0361 RC 37225 HCPCS inpatient 27682 17993.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16761.45 26851.54 Removal of plaque in arteries of leg 50762230_1 CDM 0361 RC 37225 HCPCS inpatient 27682 17993.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 16761.45 26851.54 Insertion of stent in arteries of leg 50762231_1 CDM 0361 RC 37226 HCPCS inpatient 27682 17993.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 17993.3 65 999999999 16761.45 26851.54 percent of total billed charges Insertion of stent in arteries of leg 50762231_1 CDM 0361 RC 37226 HCPCS inpatient 27682 17993.3 AETNA AETNA 21868.78 79 999999999 16761.45 26851.54 percent of total billed charges Insertion of stent in arteries of leg 50762231_1 CDM 0361 RC 37226 HCPCS inpatient 27682 17993.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26851.54 97 999999999 16761.45 26851.54 percent of total billed charges Insertion of stent in arteries of leg 50762231_1 CDM 0361 RC 37226 HCPCS inpatient 27682 17993.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 21591.96 78 999999999 16761.45 26851.54 percent of total billed charges Insertion of stent in arteries of leg 50762231_1 CDM 0361 RC 37226 HCPCS inpatient 27682 17993.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 19100.58 69 999999999 16761.45 26851.54 percent of total billed charges Insertion of stent in arteries of leg 50762231_1 CDM 0361 RC 37226 HCPCS inpatient 27682 17993.3 SIHO - ALL PLANS SIHO - ALL PLANS 24913.8 90 999999999 16761.45 26851.54 percent of total billed charges Insertion of stent in arteries of leg 50762231_1 CDM 0361 RC 37226 HCPCS inpatient 27682 17993.3 UMR - ALL PLANS UMR - ALL PLANS 19377.4 70 999999999 16761.45 26851.54 percent of total billed charges Insertion of stent in arteries of leg 50762231_1 CDM 0361 RC 37226 HCPCS inpatient 27682 17993.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16761.45 60.55 999999999 16761.45 26851.54 percent of total billed charges Insertion of stent in arteries of leg 50762231_1 CDM 0361 RC 37226 HCPCS inpatient 27682 17993.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16761.45 26851.54 Insertion of stent in arteries of leg 50762231_1 CDM 0361 RC 37226 HCPCS inpatient 27682 17993.3 ANTHEM HMO ANTHEM HMO 999999999 16761.45 26851.54 Insertion of stent in arteries of leg 50762231_1 CDM 0361 RC 37226 HCPCS inpatient 27682 17993.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16761.45 26851.54 Insertion of stent in arteries of leg 50762231_1 CDM 0361 RC 37226 HCPCS inpatient 27682 17993.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 18713.03 67.6 999999999 16761.45 26851.54 percent of total billed charges Insertion of stent in arteries of leg 50762231_1 CDM 0361 RC 37226 HCPCS inpatient 27682 17993.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16761.45 26851.54 Insertion of stent in arteries of leg 50762231_1 CDM 0361 RC 37226 HCPCS inpatient 27682 17993.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 16761.45 26851.54 Removal of plaque and insertion of stents in arteries of leg 50762232_1 CDM 0361 RC 37227 HCPCS inpatient 44277 28780.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 28780.05 65 999999999 26809.72 42948.69 percent of total billed charges Removal of plaque and insertion of stents in arteries of leg 50762232_1 CDM 0361 RC 37227 HCPCS inpatient 44277 28780.05 AETNA AETNA 34978.83 79 999999999 26809.72 42948.69 percent of total billed charges Removal of plaque and insertion of stents in arteries of leg 50762232_1 CDM 0361 RC 37227 HCPCS inpatient 44277 28780.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 42948.69 97 999999999 26809.72 42948.69 percent of total billed charges Removal of plaque and insertion of stents in arteries of leg 50762232_1 CDM 0361 RC 37227 HCPCS inpatient 44277 28780.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 30551.13 69 999999999 26809.72 42948.69 percent of total billed charges Removal of plaque and insertion of stents in arteries of leg 50762232_1 CDM 0361 RC 37227 HCPCS inpatient 44277 28780.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 34536.06 78 999999999 26809.72 42948.69 percent of total billed charges Removal of plaque and insertion of stents in arteries of leg 50762232_1 CDM 0361 RC 37227 HCPCS inpatient 44277 28780.05 SIHO - ALL PLANS SIHO - ALL PLANS 39849.3 90 999999999 26809.72 42948.69 percent of total billed charges Removal of plaque and insertion of stents in arteries of leg 50762232_1 CDM 0361 RC 37227 HCPCS inpatient 44277 28780.05 UMR - ALL PLANS UMR - ALL PLANS 30993.9 70 999999999 26809.72 42948.69 percent of total billed charges Removal of plaque and insertion of stents in arteries of leg 50762232_1 CDM 0361 RC 37227 HCPCS inpatient 44277 28780.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26809.72 60.55 999999999 26809.72 42948.69 percent of total billed charges Removal of plaque and insertion of stents in arteries of leg 50762232_1 CDM 0361 RC 37227 HCPCS inpatient 44277 28780.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26809.72 42948.69 Removal of plaque and insertion of stents in arteries of leg 50762232_1 CDM 0361 RC 37227 HCPCS inpatient 44277 28780.05 ANTHEM HMO ANTHEM HMO 999999999 26809.72 42948.69 Removal of plaque and insertion of stents in arteries of leg 50762232_1 CDM 0361 RC 37227 HCPCS inpatient 44277 28780.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26809.72 42948.69 Removal of plaque and insertion of stents in arteries of leg 50762232_1 CDM 0361 RC 37227 HCPCS inpatient 44277 28780.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 29931.25 67.6 999999999 26809.72 42948.69 percent of total billed charges Removal of plaque and insertion of stents in arteries of leg 50762232_1 CDM 0361 RC 37227 HCPCS inpatient 44277 28780.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26809.72 42948.69 Removal of plaque and insertion of stents in arteries of leg 50762232_1 CDM 0361 RC 37227 HCPCS inpatient 44277 28780.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 26809.72 42948.69 "Balloon dilation of artery of leg, initial vessel" 50762233_1 CDM 0361 RC 37228 HCPCS inpatient 27682 17993.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 17993.3 65 999999999 16761.45 26851.54 percent of total billed charges "Balloon dilation of artery of leg, initial vessel" 50762233_1 CDM 0361 RC 37228 HCPCS inpatient 27682 17993.3 AETNA AETNA 21868.78 79 999999999 16761.45 26851.54 percent of total billed charges "Balloon dilation of artery of leg, initial vessel" 50762233_1 CDM 0361 RC 37228 HCPCS inpatient 27682 17993.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26851.54 97 999999999 16761.45 26851.54 percent of total billed charges "Balloon dilation of artery of leg, initial vessel" 50762233_1 CDM 0361 RC 37228 HCPCS inpatient 27682 17993.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 19100.58 69 999999999 16761.45 26851.54 percent of total billed charges "Balloon dilation of artery of leg, initial vessel" 50762233_1 CDM 0361 RC 37228 HCPCS inpatient 27682 17993.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 21591.96 78 999999999 16761.45 26851.54 percent of total billed charges "Balloon dilation of artery of leg, initial vessel" 50762233_1 CDM 0361 RC 37228 HCPCS inpatient 27682 17993.3 SIHO - ALL PLANS SIHO - ALL PLANS 24913.8 90 999999999 16761.45 26851.54 percent of total billed charges "Balloon dilation of artery of leg, initial vessel" 50762233_1 CDM 0361 RC 37228 HCPCS inpatient 27682 17993.3 UMR - ALL PLANS UMR - ALL PLANS 19377.4 70 999999999 16761.45 26851.54 percent of total billed charges "Balloon dilation of artery of leg, initial vessel" 50762233_1 CDM 0361 RC 37228 HCPCS inpatient 27682 17993.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16761.45 60.55 999999999 16761.45 26851.54 percent of total billed charges "Balloon dilation of artery of leg, initial vessel" 50762233_1 CDM 0361 RC 37228 HCPCS inpatient 27682 17993.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 16761.45 26851.54 "Balloon dilation of artery of leg, initial vessel" 50762233_1 CDM 0361 RC 37228 HCPCS inpatient 27682 17993.3 ANTHEM HMO ANTHEM HMO 999999999 16761.45 26851.54 "Balloon dilation of artery of leg, initial vessel" 50762233_1 CDM 0361 RC 37228 HCPCS inpatient 27682 17993.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 16761.45 26851.54 "Balloon dilation of artery of leg, initial vessel" 50762233_1 CDM 0361 RC 37228 HCPCS inpatient 27682 17993.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 18713.03 67.6 999999999 16761.45 26851.54 percent of total billed charges "Balloon dilation of artery of leg, initial vessel" 50762233_1 CDM 0361 RC 37228 HCPCS inpatient 27682 17993.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 16761.45 26851.54 "Balloon dilation of artery of leg, initial vessel" 50762233_1 CDM 0361 RC 37228 HCPCS inpatient 27682 17993.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 16761.45 26851.54 "Removal of plaque in artery of leg, initial vessel" 50762234_1 CDM 0361 RC 37229 HCPCS inpatient 44277 28780.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 28780.05 65 999999999 26809.72 42948.69 percent of total billed charges "Removal of plaque in artery of leg, initial vessel" 50762234_1 CDM 0361 RC 37229 HCPCS inpatient 44277 28780.05 AETNA AETNA 34978.83 79 999999999 26809.72 42948.69 percent of total billed charges "Removal of plaque in artery of leg, initial vessel" 50762234_1 CDM 0361 RC 37229 HCPCS inpatient 44277 28780.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 42948.69 97 999999999 26809.72 42948.69 percent of total billed charges "Removal of plaque in artery of leg, initial vessel" 50762234_1 CDM 0361 RC 37229 HCPCS inpatient 44277 28780.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 30551.13 69 999999999 26809.72 42948.69 percent of total billed charges "Removal of plaque in artery of leg, initial vessel" 50762234_1 CDM 0361 RC 37229 HCPCS inpatient 44277 28780.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 34536.06 78 999999999 26809.72 42948.69 percent of total billed charges "Removal of plaque in artery of leg, initial vessel" 50762234_1 CDM 0361 RC 37229 HCPCS inpatient 44277 28780.05 SIHO - ALL PLANS SIHO - ALL PLANS 39849.3 90 999999999 26809.72 42948.69 percent of total billed charges "Removal of plaque in artery of leg, initial vessel" 50762234_1 CDM 0361 RC 37229 HCPCS inpatient 44277 28780.05 UMR - ALL PLANS UMR - ALL PLANS 30993.9 70 999999999 26809.72 42948.69 percent of total billed charges "Removal of plaque in artery of leg, initial vessel" 50762234_1 CDM 0361 RC 37229 HCPCS inpatient 44277 28780.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26809.72 60.55 999999999 26809.72 42948.69 percent of total billed charges "Removal of plaque in artery of leg, initial vessel" 50762234_1 CDM 0361 RC 37229 HCPCS inpatient 44277 28780.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26809.72 42948.69 "Removal of plaque in artery of leg, initial vessel" 50762234_1 CDM 0361 RC 37229 HCPCS inpatient 44277 28780.05 ANTHEM HMO ANTHEM HMO 999999999 26809.72 42948.69 "Removal of plaque in artery of leg, initial vessel" 50762234_1 CDM 0361 RC 37229 HCPCS inpatient 44277 28780.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26809.72 42948.69 "Removal of plaque in artery of leg, initial vessel" 50762234_1 CDM 0361 RC 37229 HCPCS inpatient 44277 28780.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 29931.25 67.6 999999999 26809.72 42948.69 percent of total billed charges "Removal of plaque in artery of leg, initial vessel" 50762234_1 CDM 0361 RC 37229 HCPCS inpatient 44277 28780.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26809.72 42948.69 "Removal of plaque in artery of leg, initial vessel" 50762234_1 CDM 0361 RC 37229 HCPCS inpatient 44277 28780.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 26809.72 42948.69 "Insertion of stent in artery of leg, initial vessel" 50762235_1 CDM 0361 RC 37230 HCPCS inpatient 44277 28780.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 28780.05 65 999999999 26809.72 42948.69 percent of total billed charges "Insertion of stent in artery of leg, initial vessel" 50762235_1 CDM 0361 RC 37230 HCPCS inpatient 44277 28780.05 AETNA AETNA 34978.83 79 999999999 26809.72 42948.69 percent of total billed charges "Insertion of stent in artery of leg, initial vessel" 50762235_1 CDM 0361 RC 37230 HCPCS inpatient 44277 28780.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 42948.69 97 999999999 26809.72 42948.69 percent of total billed charges "Insertion of stent in artery of leg, initial vessel" 50762235_1 CDM 0361 RC 37230 HCPCS inpatient 44277 28780.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 30551.13 69 999999999 26809.72 42948.69 percent of total billed charges "Insertion of stent in artery of leg, initial vessel" 50762235_1 CDM 0361 RC 37230 HCPCS inpatient 44277 28780.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 34536.06 78 999999999 26809.72 42948.69 percent of total billed charges "Insertion of stent in artery of leg, initial vessel" 50762235_1 CDM 0361 RC 37230 HCPCS inpatient 44277 28780.05 SIHO - ALL PLANS SIHO - ALL PLANS 39849.3 90 999999999 26809.72 42948.69 percent of total billed charges "Insertion of stent in artery of leg, initial vessel" 50762235_1 CDM 0361 RC 37230 HCPCS inpatient 44277 28780.05 UMR - ALL PLANS UMR - ALL PLANS 30993.9 70 999999999 26809.72 42948.69 percent of total billed charges "Insertion of stent in artery of leg, initial vessel" 50762235_1 CDM 0361 RC 37230 HCPCS inpatient 44277 28780.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26809.72 60.55 999999999 26809.72 42948.69 percent of total billed charges "Insertion of stent in artery of leg, initial vessel" 50762235_1 CDM 0361 RC 37230 HCPCS inpatient 44277 28780.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26809.72 42948.69 "Insertion of stent in artery of leg, initial vessel" 50762235_1 CDM 0361 RC 37230 HCPCS inpatient 44277 28780.05 ANTHEM HMO ANTHEM HMO 999999999 26809.72 42948.69 "Insertion of stent in artery of leg, initial vessel" 50762235_1 CDM 0361 RC 37230 HCPCS inpatient 44277 28780.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26809.72 42948.69 "Insertion of stent in artery of leg, initial vessel" 50762235_1 CDM 0361 RC 37230 HCPCS inpatient 44277 28780.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 29931.25 67.6 999999999 26809.72 42948.69 percent of total billed charges "Insertion of stent in artery of leg, initial vessel" 50762235_1 CDM 0361 RC 37230 HCPCS inpatient 44277 28780.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26809.72 42948.69 "Insertion of stent in artery of leg, initial vessel" 50762235_1 CDM 0361 RC 37230 HCPCS inpatient 44277 28780.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 26809.72 42948.69 "Removal of plaque and insertion of stents in artery of leg, initial vessel" 50762236_1 CDM 0361 RC 37231 HCPCS inpatient 44277 28780.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 28780.05 65 999999999 26809.72 42948.69 percent of total billed charges "Removal of plaque and insertion of stents in artery of leg, initial vessel" 50762236_1 CDM 0361 RC 37231 HCPCS inpatient 44277 28780.05 AETNA AETNA 34978.83 79 999999999 26809.72 42948.69 percent of total billed charges "Removal of plaque and insertion of stents in artery of leg, initial vessel" 50762236_1 CDM 0361 RC 37231 HCPCS inpatient 44277 28780.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 42948.69 97 999999999 26809.72 42948.69 percent of total billed charges "Removal of plaque and insertion of stents in artery of leg, initial vessel" 50762236_1 CDM 0361 RC 37231 HCPCS inpatient 44277 28780.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 30551.13 69 999999999 26809.72 42948.69 percent of total billed charges "Removal of plaque and insertion of stents in artery of leg, initial vessel" 50762236_1 CDM 0361 RC 37231 HCPCS inpatient 44277 28780.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 34536.06 78 999999999 26809.72 42948.69 percent of total billed charges "Removal of plaque and insertion of stents in artery of leg, initial vessel" 50762236_1 CDM 0361 RC 37231 HCPCS inpatient 44277 28780.05 SIHO - ALL PLANS SIHO - ALL PLANS 39849.3 90 999999999 26809.72 42948.69 percent of total billed charges "Removal of plaque and insertion of stents in artery of leg, initial vessel" 50762236_1 CDM 0361 RC 37231 HCPCS inpatient 44277 28780.05 UMR - ALL PLANS UMR - ALL PLANS 30993.9 70 999999999 26809.72 42948.69 percent of total billed charges "Removal of plaque and insertion of stents in artery of leg, initial vessel" 50762236_1 CDM 0361 RC 37231 HCPCS inpatient 44277 28780.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26809.72 60.55 999999999 26809.72 42948.69 percent of total billed charges "Removal of plaque and insertion of stents in artery of leg, initial vessel" 50762236_1 CDM 0361 RC 37231 HCPCS inpatient 44277 28780.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26809.72 42948.69 "Removal of plaque and insertion of stents in artery of leg, initial vessel" 50762236_1 CDM 0361 RC 37231 HCPCS inpatient 44277 28780.05 ANTHEM HMO ANTHEM HMO 999999999 26809.72 42948.69 "Removal of plaque and insertion of stents in artery of leg, initial vessel" 50762236_1 CDM 0361 RC 37231 HCPCS inpatient 44277 28780.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26809.72 42948.69 "Removal of plaque and insertion of stents in artery of leg, initial vessel" 50762236_1 CDM 0361 RC 37231 HCPCS inpatient 44277 28780.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 29931.25 67.6 999999999 26809.72 42948.69 percent of total billed charges "Removal of plaque and insertion of stents in artery of leg, initial vessel" 50762236_1 CDM 0361 RC 37231 HCPCS inpatient 44277 28780.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26809.72 42948.69 "Removal of plaque and insertion of stents in artery of leg, initial vessel" 50762236_1 CDM 0361 RC 37231 HCPCS inpatient 44277 28780.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 26809.72 42948.69 Tying or banding of surgically created artery-vein connection 50762238_1 CDM 0361 RC 37607 HCPCS inpatient 7891 5129.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 5129.15 65 999999999 4778 7654.27 percent of total billed charges Tying or banding of surgically created artery-vein connection 50762238_1 CDM 0361 RC 37607 HCPCS inpatient 7891 5129.15 AETNA AETNA 6233.89 79 999999999 4778 7654.27 percent of total billed charges Tying or banding of surgically created artery-vein connection 50762238_1 CDM 0361 RC 37607 HCPCS inpatient 7891 5129.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7654.27 97 999999999 4778 7654.27 percent of total billed charges Tying or banding of surgically created artery-vein connection 50762238_1 CDM 0361 RC 37607 HCPCS inpatient 7891 5129.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 5444.79 69 999999999 4778 7654.27 percent of total billed charges Tying or banding of surgically created artery-vein connection 50762238_1 CDM 0361 RC 37607 HCPCS inpatient 7891 5129.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 6154.98 78 999999999 4778 7654.27 percent of total billed charges Tying or banding of surgically created artery-vein connection 50762238_1 CDM 0361 RC 37607 HCPCS inpatient 7891 5129.15 SIHO - ALL PLANS SIHO - ALL PLANS 7101.9 90 999999999 4778 7654.27 percent of total billed charges Tying or banding of surgically created artery-vein connection 50762238_1 CDM 0361 RC 37607 HCPCS inpatient 7891 5129.15 UMR - ALL PLANS UMR - ALL PLANS 5523.7 70 999999999 4778 7654.27 percent of total billed charges Tying or banding of surgically created artery-vein connection 50762238_1 CDM 0361 RC 37607 HCPCS inpatient 7891 5129.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4778 60.55 999999999 4778 7654.27 percent of total billed charges Tying or banding of surgically created artery-vein connection 50762238_1 CDM 0361 RC 37607 HCPCS inpatient 7891 5129.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4778 7654.27 Tying or banding of surgically created artery-vein connection 50762238_1 CDM 0361 RC 37607 HCPCS inpatient 7891 5129.15 ANTHEM HMO ANTHEM HMO 999999999 4778 7654.27 Tying or banding of surgically created artery-vein connection 50762238_1 CDM 0361 RC 37607 HCPCS inpatient 7891 5129.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4778 7654.27 Tying or banding of surgically created artery-vein connection 50762238_1 CDM 0361 RC 37607 HCPCS inpatient 7891 5129.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 5334.32 67.6 999999999 4778 7654.27 percent of total billed charges Tying or banding of surgically created artery-vein connection 50762238_1 CDM 0361 RC 37607 HCPCS inpatient 7891 5129.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4778 7654.27 Tying or banding of surgically created artery-vein connection 50762238_1 CDM 0361 RC 37607 HCPCS inpatient 7891 5129.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 4778 7654.27 Tying or biopsy of artery on side of skull 50762239_1 CDM 0361 RC 37609 HCPCS inpatient 3879 2521.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 2521.35 65 999999999 2348.73 3762.63 percent of total billed charges Tying or biopsy of artery on side of skull 50762239_1 CDM 0361 RC 37609 HCPCS inpatient 3879 2521.35 AETNA AETNA 3064.41 79 999999999 2348.73 3762.63 percent of total billed charges Tying or biopsy of artery on side of skull 50762239_1 CDM 0361 RC 37609 HCPCS inpatient 3879 2521.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3762.63 97 999999999 2348.73 3762.63 percent of total billed charges Tying or biopsy of artery on side of skull 50762239_1 CDM 0361 RC 37609 HCPCS inpatient 3879 2521.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 2676.51 69 999999999 2348.73 3762.63 percent of total billed charges Tying or biopsy of artery on side of skull 50762239_1 CDM 0361 RC 37609 HCPCS inpatient 3879 2521.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 3025.62 78 999999999 2348.73 3762.63 percent of total billed charges Tying or biopsy of artery on side of skull 50762239_1 CDM 0361 RC 37609 HCPCS inpatient 3879 2521.35 SIHO - ALL PLANS SIHO - ALL PLANS 3491.1 90 999999999 2348.73 3762.63 percent of total billed charges Tying or biopsy of artery on side of skull 50762239_1 CDM 0361 RC 37609 HCPCS inpatient 3879 2521.35 UMR - ALL PLANS UMR - ALL PLANS 2715.3 70 999999999 2348.73 3762.63 percent of total billed charges Tying or biopsy of artery on side of skull 50762239_1 CDM 0361 RC 37609 HCPCS inpatient 3879 2521.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2348.73 60.55 999999999 2348.73 3762.63 percent of total billed charges Tying or biopsy of artery on side of skull 50762239_1 CDM 0361 RC 37609 HCPCS inpatient 3879 2521.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2348.73 3762.63 Tying or biopsy of artery on side of skull 50762239_1 CDM 0361 RC 37609 HCPCS inpatient 3879 2521.35 ANTHEM HMO ANTHEM HMO 999999999 2348.73 3762.63 Tying or biopsy of artery on side of skull 50762239_1 CDM 0361 RC 37609 HCPCS inpatient 3879 2521.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2348.73 3762.63 Tying or biopsy of artery on side of skull 50762239_1 CDM 0361 RC 37609 HCPCS inpatient 3879 2521.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 2622.2 67.6 999999999 2348.73 3762.63 percent of total billed charges Tying or biopsy of artery on side of skull 50762239_1 CDM 0361 RC 37609 HCPCS inpatient 3879 2521.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2348.73 3762.63 Tying or biopsy of artery on side of skull 50762239_1 CDM 0361 RC 37609 HCPCS inpatient 3879 2521.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 2348.73 3762.63 Tying and division of long leg vein 50762240_1 CDM 0361 RC 37700 HCPCS inpatient 7891 5129.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 5129.15 65 999999999 4778 7654.27 percent of total billed charges Tying and division of long leg vein 50762240_1 CDM 0361 RC 37700 HCPCS inpatient 7891 5129.15 AETNA AETNA 6233.89 79 999999999 4778 7654.27 percent of total billed charges Tying and division of long leg vein 50762240_1 CDM 0361 RC 37700 HCPCS inpatient 7891 5129.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7654.27 97 999999999 4778 7654.27 percent of total billed charges Tying and division of long leg vein 50762240_1 CDM 0361 RC 37700 HCPCS inpatient 7891 5129.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 5444.79 69 999999999 4778 7654.27 percent of total billed charges Tying and division of long leg vein 50762240_1 CDM 0361 RC 37700 HCPCS inpatient 7891 5129.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 6154.98 78 999999999 4778 7654.27 percent of total billed charges Tying and division of long leg vein 50762240_1 CDM 0361 RC 37700 HCPCS inpatient 7891 5129.15 SIHO - ALL PLANS SIHO - ALL PLANS 7101.9 90 999999999 4778 7654.27 percent of total billed charges Tying and division of long leg vein 50762240_1 CDM 0361 RC 37700 HCPCS inpatient 7891 5129.15 UMR - ALL PLANS UMR - ALL PLANS 5523.7 70 999999999 4778 7654.27 percent of total billed charges Tying and division of long leg vein 50762240_1 CDM 0361 RC 37700 HCPCS inpatient 7891 5129.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4778 60.55 999999999 4778 7654.27 percent of total billed charges Tying and division of long leg vein 50762240_1 CDM 0361 RC 37700 HCPCS inpatient 7891 5129.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4778 7654.27 Tying and division of long leg vein 50762240_1 CDM 0361 RC 37700 HCPCS inpatient 7891 5129.15 ANTHEM HMO ANTHEM HMO 999999999 4778 7654.27 Tying and division of long leg vein 50762240_1 CDM 0361 RC 37700 HCPCS inpatient 7891 5129.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4778 7654.27 Tying and division of long leg vein 50762240_1 CDM 0361 RC 37700 HCPCS inpatient 7891 5129.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 5334.32 67.6 999999999 4778 7654.27 percent of total billed charges Tying and division of long leg vein 50762240_1 CDM 0361 RC 37700 HCPCS inpatient 7891 5129.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4778 7654.27 Tying and division of long leg vein 50762240_1 CDM 0361 RC 37700 HCPCS inpatient 7891 5129.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 4778 7654.27 "Tying, incision, and stripping of short leg vein" 50762241_1 CDM 0361 RC 37718 HCPCS inpatient 7891 5129.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 5129.15 65 999999999 4778 7654.27 percent of total billed charges "Tying, incision, and stripping of short leg vein" 50762241_1 CDM 0361 RC 37718 HCPCS inpatient 7891 5129.15 AETNA AETNA 6233.89 79 999999999 4778 7654.27 percent of total billed charges "Tying, incision, and stripping of short leg vein" 50762241_1 CDM 0361 RC 37718 HCPCS inpatient 7891 5129.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7654.27 97 999999999 4778 7654.27 percent of total billed charges "Tying, incision, and stripping of short leg vein" 50762241_1 CDM 0361 RC 37718 HCPCS inpatient 7891 5129.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 5444.79 69 999999999 4778 7654.27 percent of total billed charges "Tying, incision, and stripping of short leg vein" 50762241_1 CDM 0361 RC 37718 HCPCS inpatient 7891 5129.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 6154.98 78 999999999 4778 7654.27 percent of total billed charges "Tying, incision, and stripping of short leg vein" 50762241_1 CDM 0361 RC 37718 HCPCS inpatient 7891 5129.15 SIHO - ALL PLANS SIHO - ALL PLANS 7101.9 90 999999999 4778 7654.27 percent of total billed charges "Tying, incision, and stripping of short leg vein" 50762241_1 CDM 0361 RC 37718 HCPCS inpatient 7891 5129.15 UMR - ALL PLANS UMR - ALL PLANS 5523.7 70 999999999 4778 7654.27 percent of total billed charges "Tying, incision, and stripping of short leg vein" 50762241_1 CDM 0361 RC 37718 HCPCS inpatient 7891 5129.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4778 60.55 999999999 4778 7654.27 percent of total billed charges "Tying, incision, and stripping of short leg vein" 50762241_1 CDM 0361 RC 37718 HCPCS inpatient 7891 5129.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4778 7654.27 "Tying, incision, and stripping of short leg vein" 50762241_1 CDM 0361 RC 37718 HCPCS inpatient 7891 5129.15 ANTHEM HMO ANTHEM HMO 999999999 4778 7654.27 "Tying, incision, and stripping of short leg vein" 50762241_1 CDM 0361 RC 37718 HCPCS inpatient 7891 5129.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4778 7654.27 "Tying, incision, and stripping of short leg vein" 50762241_1 CDM 0361 RC 37718 HCPCS inpatient 7891 5129.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 5334.32 67.6 999999999 4778 7654.27 percent of total billed charges "Tying, incision, and stripping of short leg vein" 50762241_1 CDM 0361 RC 37718 HCPCS inpatient 7891 5129.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4778 7654.27 "Tying, incision, and stripping of short leg vein" 50762241_1 CDM 0361 RC 37718 HCPCS inpatient 7891 5129.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 4778 7654.27 "Tying, incision, and stripping of long leg vein" 50762242_1 CDM 0361 RC 37722 HCPCS inpatient 7891 5129.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 5129.15 65 999999999 4778 7654.27 percent of total billed charges "Tying, incision, and stripping of long leg vein" 50762242_1 CDM 0361 RC 37722 HCPCS inpatient 7891 5129.15 AETNA AETNA 6233.89 79 999999999 4778 7654.27 percent of total billed charges "Tying, incision, and stripping of long leg vein" 50762242_1 CDM 0361 RC 37722 HCPCS inpatient 7891 5129.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7654.27 97 999999999 4778 7654.27 percent of total billed charges "Tying, incision, and stripping of long leg vein" 50762242_1 CDM 0361 RC 37722 HCPCS inpatient 7891 5129.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 5444.79 69 999999999 4778 7654.27 percent of total billed charges "Tying, incision, and stripping of long leg vein" 50762242_1 CDM 0361 RC 37722 HCPCS inpatient 7891 5129.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 6154.98 78 999999999 4778 7654.27 percent of total billed charges "Tying, incision, and stripping of long leg vein" 50762242_1 CDM 0361 RC 37722 HCPCS inpatient 7891 5129.15 SIHO - ALL PLANS SIHO - ALL PLANS 7101.9 90 999999999 4778 7654.27 percent of total billed charges "Tying, incision, and stripping of long leg vein" 50762242_1 CDM 0361 RC 37722 HCPCS inpatient 7891 5129.15 UMR - ALL PLANS UMR - ALL PLANS 5523.7 70 999999999 4778 7654.27 percent of total billed charges "Tying, incision, and stripping of long leg vein" 50762242_1 CDM 0361 RC 37722 HCPCS inpatient 7891 5129.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4778 60.55 999999999 4778 7654.27 percent of total billed charges "Tying, incision, and stripping of long leg vein" 50762242_1 CDM 0361 RC 37722 HCPCS inpatient 7891 5129.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4778 7654.27 "Tying, incision, and stripping of long leg vein" 50762242_1 CDM 0361 RC 37722 HCPCS inpatient 7891 5129.15 ANTHEM HMO ANTHEM HMO 999999999 4778 7654.27 "Tying, incision, and stripping of long leg vein" 50762242_1 CDM 0361 RC 37722 HCPCS inpatient 7891 5129.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4778 7654.27 "Tying, incision, and stripping of long leg vein" 50762242_1 CDM 0361 RC 37722 HCPCS inpatient 7891 5129.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 5334.32 67.6 999999999 4778 7654.27 percent of total billed charges "Tying, incision, and stripping of long leg vein" 50762242_1 CDM 0361 RC 37722 HCPCS inpatient 7891 5129.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4778 7654.27 "Tying, incision, and stripping of long leg vein" 50762242_1 CDM 0361 RC 37722 HCPCS inpatient 7891 5129.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 4778 7654.27 "Removal of varicose veins of arm or leg, 10-20 incisions" 50762243_1 CDM 0361 RC 37765 HCPCS inpatient 8936.91 5808.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 5808.99 65 999999999 5411.3 8668.8 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 50762243_1 CDM 0361 RC 37765 HCPCS inpatient 8936.91 5808.99 AETNA AETNA 7060.16 79 999999999 5411.3 8668.8 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 50762243_1 CDM 0361 RC 37765 HCPCS inpatient 8936.91 5808.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8668.8 97 999999999 5411.3 8668.8 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 50762243_1 CDM 0361 RC 37765 HCPCS inpatient 8936.91 5808.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 6166.47 69 999999999 5411.3 8668.8 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 50762243_1 CDM 0361 RC 37765 HCPCS inpatient 8936.91 5808.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 6970.79 78 999999999 5411.3 8668.8 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 50762243_1 CDM 0361 RC 37765 HCPCS inpatient 8936.91 5808.99 SIHO - ALL PLANS SIHO - ALL PLANS 8043.22 90 999999999 5411.3 8668.8 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 50762243_1 CDM 0361 RC 37765 HCPCS inpatient 8936.91 5808.99 UMR - ALL PLANS UMR - ALL PLANS 6255.84 70 999999999 5411.3 8668.8 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 50762243_1 CDM 0361 RC 37765 HCPCS inpatient 8936.91 5808.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5411.3 60.55 999999999 5411.3 8668.8 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 50762243_1 CDM 0361 RC 37765 HCPCS inpatient 8936.91 5808.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5411.3 8668.8 "Removal of varicose veins of arm or leg, 10-20 incisions" 50762243_1 CDM 0361 RC 37765 HCPCS inpatient 8936.91 5808.99 ANTHEM HMO ANTHEM HMO 999999999 5411.3 8668.8 "Removal of varicose veins of arm or leg, 10-20 incisions" 50762243_1 CDM 0361 RC 37765 HCPCS inpatient 8936.91 5808.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5411.3 8668.8 "Removal of varicose veins of arm or leg, 10-20 incisions" 50762243_1 CDM 0361 RC 37765 HCPCS inpatient 8936.91 5808.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 6041.35 67.6 999999999 5411.3 8668.8 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 50762243_1 CDM 0361 RC 37765 HCPCS inpatient 8936.91 5808.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5411.3 8668.8 "Removal of varicose veins of arm or leg, 10-20 incisions" 50762243_1 CDM 0361 RC 37765 HCPCS inpatient 8936.91 5808.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 5411.3 8668.8 "Removal of varicose veins of arm or leg, more than 20 incisions" 50762244_1 CDM 0361 RC 37766 HCPCS inpatient 8936.91 5808.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 5808.99 65 999999999 5411.3 8668.8 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 50762244_1 CDM 0361 RC 37766 HCPCS inpatient 8936.91 5808.99 AETNA AETNA 7060.16 79 999999999 5411.3 8668.8 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 50762244_1 CDM 0361 RC 37766 HCPCS inpatient 8936.91 5808.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8668.8 97 999999999 5411.3 8668.8 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 50762244_1 CDM 0361 RC 37766 HCPCS inpatient 8936.91 5808.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 6166.47 69 999999999 5411.3 8668.8 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 50762244_1 CDM 0361 RC 37766 HCPCS inpatient 8936.91 5808.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 6970.79 78 999999999 5411.3 8668.8 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 50762244_1 CDM 0361 RC 37766 HCPCS inpatient 8936.91 5808.99 SIHO - ALL PLANS SIHO - ALL PLANS 8043.22 90 999999999 5411.3 8668.8 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 50762244_1 CDM 0361 RC 37766 HCPCS inpatient 8936.91 5808.99 UMR - ALL PLANS UMR - ALL PLANS 6255.84 70 999999999 5411.3 8668.8 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 50762244_1 CDM 0361 RC 37766 HCPCS inpatient 8936.91 5808.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5411.3 60.55 999999999 5411.3 8668.8 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 50762244_1 CDM 0361 RC 37766 HCPCS inpatient 8936.91 5808.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5411.3 8668.8 "Removal of varicose veins of arm or leg, more than 20 incisions" 50762244_1 CDM 0361 RC 37766 HCPCS inpatient 8936.91 5808.99 ANTHEM HMO ANTHEM HMO 999999999 5411.3 8668.8 "Removal of varicose veins of arm or leg, more than 20 incisions" 50762244_1 CDM 0361 RC 37766 HCPCS inpatient 8936.91 5808.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5411.3 8668.8 "Removal of varicose veins of arm or leg, more than 20 incisions" 50762244_1 CDM 0361 RC 37766 HCPCS inpatient 8936.91 5808.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 6041.35 67.6 999999999 5411.3 8668.8 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 50762244_1 CDM 0361 RC 37766 HCPCS inpatient 8936.91 5808.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5411.3 8668.8 "Removal of varicose veins of arm or leg, more than 20 incisions" 50762244_1 CDM 0361 RC 37766 HCPCS inpatient 8936.91 5808.99 UHC - ALL PLANS UHC - ALL PLANS 999999999 5411.3 8668.8 Other procedure on blood vessel 50762245_1 CDM 0361 RC 37799 HCPCS inpatient 1735.5 1128.08 SELF PAY DISCOUNT SELF PAY DISCOUNT 1128.08 65 999999999 1050.85 1683.44 percent of total billed charges Other procedure on blood vessel 50762245_1 CDM 0361 RC 37799 HCPCS inpatient 1735.5 1128.08 AETNA AETNA 1371.05 79 999999999 1050.85 1683.44 percent of total billed charges Other procedure on blood vessel 50762245_1 CDM 0361 RC 37799 HCPCS inpatient 1735.5 1128.08 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1683.44 97 999999999 1050.85 1683.44 percent of total billed charges Other procedure on blood vessel 50762245_1 CDM 0361 RC 37799 HCPCS inpatient 1735.5 1128.08 ENCORE - ALL PLANS ENCORE - ALL PLANS 1197.5 69 999999999 1050.85 1683.44 percent of total billed charges Other procedure on blood vessel 50762245_1 CDM 0361 RC 37799 HCPCS inpatient 1735.5 1128.08 HUMANA - ALL PLANS HUMANA - ALL PLANS 1353.69 78 999999999 1050.85 1683.44 percent of total billed charges Other procedure on blood vessel 50762245_1 CDM 0361 RC 37799 HCPCS inpatient 1735.5 1128.08 SIHO - ALL PLANS SIHO - ALL PLANS 1561.95 90 999999999 1050.85 1683.44 percent of total billed charges Other procedure on blood vessel 50762245_1 CDM 0361 RC 37799 HCPCS inpatient 1735.5 1128.08 UMR - ALL PLANS UMR - ALL PLANS 1214.85 70 999999999 1050.85 1683.44 percent of total billed charges Other procedure on blood vessel 50762245_1 CDM 0361 RC 37799 HCPCS inpatient 1735.5 1128.08 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1050.85 60.55 999999999 1050.85 1683.44 percent of total billed charges Other procedure on blood vessel 50762245_1 CDM 0361 RC 37799 HCPCS inpatient 1735.5 1128.08 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1050.85 1683.44 Other procedure on blood vessel 50762245_1 CDM 0361 RC 37799 HCPCS inpatient 1735.5 1128.08 ANTHEM HMO ANTHEM HMO 999999999 1050.85 1683.44 Other procedure on blood vessel 50762245_1 CDM 0361 RC 37799 HCPCS inpatient 1735.5 1128.08 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1050.85 1683.44 Other procedure on blood vessel 50762245_1 CDM 0361 RC 37799 HCPCS inpatient 1735.5 1128.08 CIGNA - ALL PLANS CIGNA - ALL PLANS 1173.2 67.6 999999999 1050.85 1683.44 percent of total billed charges Other procedure on blood vessel 50762245_1 CDM 0361 RC 37799 HCPCS inpatient 1735.5 1128.08 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1050.85 1683.44 Other procedure on blood vessel 50762245_1 CDM 0361 RC 37799 HCPCS inpatient 1735.5 1128.08 UHC - ALL PLANS UHC - ALL PLANS 999999999 1050.85 1683.44 Insertion of abdominal cavity tube using an endoscope 50762246_1 CDM 0361 RC 49324 HCPCS inpatient 13947 9065.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 9065.55 65 999999999 8444.91 13528.59 percent of total billed charges Insertion of abdominal cavity tube using an endoscope 50762246_1 CDM 0361 RC 49324 HCPCS inpatient 13947 9065.55 AETNA AETNA 11018.13 79 999999999 8444.91 13528.59 percent of total billed charges Insertion of abdominal cavity tube using an endoscope 50762246_1 CDM 0361 RC 49324 HCPCS inpatient 13947 9065.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13528.59 97 999999999 8444.91 13528.59 percent of total billed charges Insertion of abdominal cavity tube using an endoscope 50762246_1 CDM 0361 RC 49324 HCPCS inpatient 13947 9065.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 9623.43 69 999999999 8444.91 13528.59 percent of total billed charges Insertion of abdominal cavity tube using an endoscope 50762246_1 CDM 0361 RC 49324 HCPCS inpatient 13947 9065.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 10878.66 78 999999999 8444.91 13528.59 percent of total billed charges Insertion of abdominal cavity tube using an endoscope 50762246_1 CDM 0361 RC 49324 HCPCS inpatient 13947 9065.55 SIHO - ALL PLANS SIHO - ALL PLANS 12552.3 90 999999999 8444.91 13528.59 percent of total billed charges Insertion of abdominal cavity tube using an endoscope 50762246_1 CDM 0361 RC 49324 HCPCS inpatient 13947 9065.55 UMR - ALL PLANS UMR - ALL PLANS 9762.9 70 999999999 8444.91 13528.59 percent of total billed charges Insertion of abdominal cavity tube using an endoscope 50762246_1 CDM 0361 RC 49324 HCPCS inpatient 13947 9065.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8444.91 60.55 999999999 8444.91 13528.59 percent of total billed charges Insertion of abdominal cavity tube using an endoscope 50762246_1 CDM 0361 RC 49324 HCPCS inpatient 13947 9065.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8444.91 13528.59 Insertion of abdominal cavity tube using an endoscope 50762246_1 CDM 0361 RC 49324 HCPCS inpatient 13947 9065.55 ANTHEM HMO ANTHEM HMO 999999999 8444.91 13528.59 Insertion of abdominal cavity tube using an endoscope 50762246_1 CDM 0361 RC 49324 HCPCS inpatient 13947 9065.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8444.91 13528.59 Insertion of abdominal cavity tube using an endoscope 50762246_1 CDM 0361 RC 49324 HCPCS inpatient 13947 9065.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 9428.17 67.6 999999999 8444.91 13528.59 percent of total billed charges Insertion of abdominal cavity tube using an endoscope 50762246_1 CDM 0361 RC 49324 HCPCS inpatient 13947 9065.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8444.91 13528.59 Insertion of abdominal cavity tube using an endoscope 50762246_1 CDM 0361 RC 49324 HCPCS inpatient 13947 9065.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 8444.91 13528.59 Revision of abdominal cavity tube using an endoscope 50762247_1 CDM 0361 RC 49325 HCPCS inpatient 13947 9065.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 9065.55 65 999999999 8444.91 13528.59 percent of total billed charges Revision of abdominal cavity tube using an endoscope 50762247_1 CDM 0361 RC 49325 HCPCS inpatient 13947 9065.55 AETNA AETNA 11018.13 79 999999999 8444.91 13528.59 percent of total billed charges Revision of abdominal cavity tube using an endoscope 50762247_1 CDM 0361 RC 49325 HCPCS inpatient 13947 9065.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13528.59 97 999999999 8444.91 13528.59 percent of total billed charges Revision of abdominal cavity tube using an endoscope 50762247_1 CDM 0361 RC 49325 HCPCS inpatient 13947 9065.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 9623.43 69 999999999 8444.91 13528.59 percent of total billed charges Revision of abdominal cavity tube using an endoscope 50762247_1 CDM 0361 RC 49325 HCPCS inpatient 13947 9065.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 10878.66 78 999999999 8444.91 13528.59 percent of total billed charges Revision of abdominal cavity tube using an endoscope 50762247_1 CDM 0361 RC 49325 HCPCS inpatient 13947 9065.55 SIHO - ALL PLANS SIHO - ALL PLANS 12552.3 90 999999999 8444.91 13528.59 percent of total billed charges Revision of abdominal cavity tube using an endoscope 50762247_1 CDM 0361 RC 49325 HCPCS inpatient 13947 9065.55 UMR - ALL PLANS UMR - ALL PLANS 9762.9 70 999999999 8444.91 13528.59 percent of total billed charges Revision of abdominal cavity tube using an endoscope 50762247_1 CDM 0361 RC 49325 HCPCS inpatient 13947 9065.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8444.91 60.55 999999999 8444.91 13528.59 percent of total billed charges Revision of abdominal cavity tube using an endoscope 50762247_1 CDM 0361 RC 49325 HCPCS inpatient 13947 9065.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8444.91 13528.59 Revision of abdominal cavity tube using an endoscope 50762247_1 CDM 0361 RC 49325 HCPCS inpatient 13947 9065.55 ANTHEM HMO ANTHEM HMO 999999999 8444.91 13528.59 Revision of abdominal cavity tube using an endoscope 50762247_1 CDM 0361 RC 49325 HCPCS inpatient 13947 9065.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8444.91 13528.59 Revision of abdominal cavity tube using an endoscope 50762247_1 CDM 0361 RC 49325 HCPCS inpatient 13947 9065.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 9428.17 67.6 999999999 8444.91 13528.59 percent of total billed charges Revision of abdominal cavity tube using an endoscope 50762247_1 CDM 0361 RC 49325 HCPCS inpatient 13947 9065.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8444.91 13528.59 Revision of abdominal cavity tube using an endoscope 50762247_1 CDM 0361 RC 49325 HCPCS inpatient 13947 9065.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 8444.91 13528.59 Insertion of abdominal cavity tube for drainage or dialysis 50762248_1 CDM 0361 RC 49421 HCPCS inpatient 8774 5703.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 5703.1 65 999999999 5312.66 8510.78 percent of total billed charges Insertion of abdominal cavity tube for drainage or dialysis 50762248_1 CDM 0361 RC 49421 HCPCS inpatient 8774 5703.1 AETNA AETNA 6931.46 79 999999999 5312.66 8510.78 percent of total billed charges Insertion of abdominal cavity tube for drainage or dialysis 50762248_1 CDM 0361 RC 49421 HCPCS inpatient 8774 5703.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8510.78 97 999999999 5312.66 8510.78 percent of total billed charges Insertion of abdominal cavity tube for drainage or dialysis 50762248_1 CDM 0361 RC 49421 HCPCS inpatient 8774 5703.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 6054.06 69 999999999 5312.66 8510.78 percent of total billed charges Insertion of abdominal cavity tube for drainage or dialysis 50762248_1 CDM 0361 RC 49421 HCPCS inpatient 8774 5703.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 6843.72 78 999999999 5312.66 8510.78 percent of total billed charges Insertion of abdominal cavity tube for drainage or dialysis 50762248_1 CDM 0361 RC 49421 HCPCS inpatient 8774 5703.1 SIHO - ALL PLANS SIHO - ALL PLANS 7896.6 90 999999999 5312.66 8510.78 percent of total billed charges Insertion of abdominal cavity tube for drainage or dialysis 50762248_1 CDM 0361 RC 49421 HCPCS inpatient 8774 5703.1 UMR - ALL PLANS UMR - ALL PLANS 6141.8 70 999999999 5312.66 8510.78 percent of total billed charges Insertion of abdominal cavity tube for drainage or dialysis 50762248_1 CDM 0361 RC 49421 HCPCS inpatient 8774 5703.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5312.66 60.55 999999999 5312.66 8510.78 percent of total billed charges Insertion of abdominal cavity tube for drainage or dialysis 50762248_1 CDM 0361 RC 49421 HCPCS inpatient 8774 5703.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5312.66 8510.78 Insertion of abdominal cavity tube for drainage or dialysis 50762248_1 CDM 0361 RC 49421 HCPCS inpatient 8774 5703.1 ANTHEM HMO ANTHEM HMO 999999999 5312.66 8510.78 Insertion of abdominal cavity tube for drainage or dialysis 50762248_1 CDM 0361 RC 49421 HCPCS inpatient 8774 5703.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5312.66 8510.78 Insertion of abdominal cavity tube for drainage or dialysis 50762248_1 CDM 0361 RC 49421 HCPCS inpatient 8774 5703.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 5931.22 67.6 999999999 5312.66 8510.78 percent of total billed charges Insertion of abdominal cavity tube for drainage or dialysis 50762248_1 CDM 0361 RC 49421 HCPCS inpatient 8774 5703.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5312.66 8510.78 Insertion of abdominal cavity tube for drainage or dialysis 50762248_1 CDM 0361 RC 49421 HCPCS inpatient 8774 5703.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 5312.66 8510.78 Fluoroscopic guidance for insertion or removal of central vein access device 50762250_1 CDM 0320 RC 77001 HCPCS inpatient 413 268.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 268.45 65 999999999 250.07 400.61 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 50762250_1 CDM 0320 RC 77001 HCPCS inpatient 413 268.45 AETNA AETNA 326.27 79 999999999 250.07 400.61 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 50762250_1 CDM 0320 RC 77001 HCPCS inpatient 413 268.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 400.61 97 999999999 250.07 400.61 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 50762250_1 CDM 0320 RC 77001 HCPCS inpatient 413 268.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 284.97 69 999999999 250.07 400.61 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 50762250_1 CDM 0320 RC 77001 HCPCS inpatient 413 268.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 322.14 78 999999999 250.07 400.61 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 50762250_1 CDM 0320 RC 77001 HCPCS inpatient 413 268.45 SIHO - ALL PLANS SIHO - ALL PLANS 371.7 90 999999999 250.07 400.61 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 50762250_1 CDM 0320 RC 77001 HCPCS inpatient 413 268.45 UMR - ALL PLANS UMR - ALL PLANS 289.1 70 999999999 250.07 400.61 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 50762250_1 CDM 0320 RC 77001 HCPCS inpatient 413 268.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 250.07 60.55 999999999 250.07 400.61 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 50762250_1 CDM 0320 RC 77001 HCPCS inpatient 413 268.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 250.07 400.61 Fluoroscopic guidance for insertion or removal of central vein access device 50762250_1 CDM 0320 RC 77001 HCPCS inpatient 413 268.45 ANTHEM HMO ANTHEM HMO 999999999 250.07 400.61 Fluoroscopic guidance for insertion or removal of central vein access device 50762250_1 CDM 0320 RC 77001 HCPCS inpatient 413 268.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 250.07 400.61 Fluoroscopic guidance for insertion or removal of central vein access device 50762250_1 CDM 0320 RC 77001 HCPCS inpatient 413 268.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 279.19 67.6 999999999 250.07 400.61 percent of total billed charges Fluoroscopic guidance for insertion or removal of central vein access device 50762250_1 CDM 0320 RC 77001 HCPCS inpatient 413 268.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 250.07 400.61 Fluoroscopic guidance for insertion or removal of central vein access device 50762250_1 CDM 0320 RC 77001 HCPCS inpatient 413 268.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 250.07 400.61 Removal of abdominal cavity tube 50762255_1 CDM 0361 RC 49422 HCPCS inpatient 7891 5129.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 5129.15 65 999999999 4778 7654.27 percent of total billed charges Removal of abdominal cavity tube 50762255_1 CDM 0361 RC 49422 HCPCS inpatient 7891 5129.15 AETNA AETNA 6233.89 79 999999999 4778 7654.27 percent of total billed charges Removal of abdominal cavity tube 50762255_1 CDM 0361 RC 49422 HCPCS inpatient 7891 5129.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7654.27 97 999999999 4778 7654.27 percent of total billed charges Removal of abdominal cavity tube 50762255_1 CDM 0361 RC 49422 HCPCS inpatient 7891 5129.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 5444.79 69 999999999 4778 7654.27 percent of total billed charges Removal of abdominal cavity tube 50762255_1 CDM 0361 RC 49422 HCPCS inpatient 7891 5129.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 6154.98 78 999999999 4778 7654.27 percent of total billed charges Removal of abdominal cavity tube 50762255_1 CDM 0361 RC 49422 HCPCS inpatient 7891 5129.15 SIHO - ALL PLANS SIHO - ALL PLANS 7101.9 90 999999999 4778 7654.27 percent of total billed charges Removal of abdominal cavity tube 50762255_1 CDM 0361 RC 49422 HCPCS inpatient 7891 5129.15 UMR - ALL PLANS UMR - ALL PLANS 5523.7 70 999999999 4778 7654.27 percent of total billed charges Removal of abdominal cavity tube 50762255_1 CDM 0361 RC 49422 HCPCS inpatient 7891 5129.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4778 60.55 999999999 4778 7654.27 percent of total billed charges Removal of abdominal cavity tube 50762255_1 CDM 0361 RC 49422 HCPCS inpatient 7891 5129.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4778 7654.27 Removal of abdominal cavity tube 50762255_1 CDM 0361 RC 49422 HCPCS inpatient 7891 5129.15 ANTHEM HMO ANTHEM HMO 999999999 4778 7654.27 Removal of abdominal cavity tube 50762255_1 CDM 0361 RC 49422 HCPCS inpatient 7891 5129.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4778 7654.27 Removal of abdominal cavity tube 50762255_1 CDM 0361 RC 49422 HCPCS inpatient 7891 5129.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 5334.32 67.6 999999999 4778 7654.27 percent of total billed charges Removal of abdominal cavity tube 50762255_1 CDM 0361 RC 49422 HCPCS inpatient 7891 5129.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4778 7654.27 Removal of abdominal cavity tube 50762255_1 CDM 0361 RC 49422 HCPCS inpatient 7891 5129.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 4778 7654.27 "Antibody identification test, platelet antibodies" 50762285_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges "Antibody identification test, platelet antibodies" 50762285_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges "Antibody identification test, platelet antibodies" 50762285_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges "Antibody identification test, platelet antibodies" 50762285_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges "Antibody identification test, platelet antibodies" 50762285_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges "Antibody identification test, platelet antibodies" 50762285_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges "Antibody identification test, platelet antibodies" 50762285_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges "Antibody identification test, platelet antibodies" 50762285_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges "Antibody identification test, platelet antibodies" 50762285_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 "Antibody identification test, platelet antibodies" 50762285_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 "Antibody identification test, platelet antibodies" 50762285_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 "Antibody identification test, platelet antibodies" 50762285_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges "Antibody identification test, platelet antibodies" 50762285_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 "Antibody identification test, platelet antibodies" 50762285_1 CDM 0302 RC 86022 HCPCS inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 "DACARBAZINE, 100 MG" 50762612_1 CDM 0636 RC 00143-9245-10 NDC J9130 HCPCS inpatient 2 UN 36.6 23.79 SELF PAY DISCOUNT SELF PAY DISCOUNT 23.79 65 999999999 22.16 35.5 percent of total billed charges "DACARBAZINE, 100 MG" 50762612_1 CDM 0636 RC 00143-9245-10 NDC J9130 HCPCS inpatient 2 UN 36.6 23.79 AETNA AETNA 28.91 79 999999999 22.16 35.5 percent of total billed charges "DACARBAZINE, 100 MG" 50762612_1 CDM 0636 RC 00143-9245-10 NDC J9130 HCPCS inpatient 2 UN 36.6 23.79 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35.5 97 999999999 22.16 35.5 percent of total billed charges "DACARBAZINE, 100 MG" 50762612_1 CDM 0636 RC 00143-9245-10 NDC J9130 HCPCS inpatient 2 UN 36.6 23.79 ENCORE - ALL PLANS ENCORE - ALL PLANS 25.25 69 999999999 22.16 35.5 percent of total billed charges "DACARBAZINE, 100 MG" 50762612_1 CDM 0636 RC 00143-9245-10 NDC J9130 HCPCS inpatient 2 UN 36.6 23.79 HUMANA - ALL PLANS HUMANA - ALL PLANS 28.55 78 999999999 22.16 35.5 percent of total billed charges "DACARBAZINE, 100 MG" 50762612_1 CDM 0636 RC 00143-9245-10 NDC J9130 HCPCS inpatient 2 UN 36.6 23.79 SIHO - ALL PLANS SIHO - ALL PLANS 32.94 90 999999999 22.16 35.5 percent of total billed charges "DACARBAZINE, 100 MG" 50762612_1 CDM 0636 RC 00143-9245-10 NDC J9130 HCPCS inpatient 2 UN 36.6 23.79 UMR - ALL PLANS UMR - ALL PLANS 25.62 70 999999999 22.16 35.5 percent of total billed charges "DACARBAZINE, 100 MG" 50762612_1 CDM 0636 RC 00143-9245-10 NDC J9130 HCPCS inpatient 2 UN 36.6 23.79 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.16 60.55 999999999 22.16 35.5 percent of total billed charges "DACARBAZINE, 100 MG" 50762612_1 CDM 0636 RC 00143-9245-10 NDC J9130 HCPCS inpatient 2 UN 36.6 23.79 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.16 35.5 "DACARBAZINE, 100 MG" 50762612_1 CDM 0636 RC 00143-9245-10 NDC J9130 HCPCS inpatient 2 UN 36.6 23.79 ANTHEM HMO ANTHEM HMO 999999999 22.16 35.5 "DACARBAZINE, 100 MG" 50762612_1 CDM 0636 RC 00143-9245-10 NDC J9130 HCPCS inpatient 2 UN 36.6 23.79 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.16 35.5 "DACARBAZINE, 100 MG" 50762612_1 CDM 0636 RC 00143-9245-10 NDC J9130 HCPCS inpatient 2 UN 36.6 23.79 CIGNA - ALL PLANS CIGNA - ALL PLANS 24.74 67.6 999999999 22.16 35.5 percent of total billed charges "DACARBAZINE, 100 MG" 50762612_1 CDM 0636 RC 00143-9245-10 NDC J9130 HCPCS inpatient 2 UN 36.6 23.79 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.16 35.5 "DACARBAZINE, 100 MG" 50762612_1 CDM 0636 RC 00143-9245-10 NDC J9130 HCPCS inpatient 2 UN 36.6 23.79 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.16 35.5 Quantitation of therapeutic drug 50762702_1 CDM 0301 RC 80299 HCPCS inpatient 301 195.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 195.65 65 999999999 182.26 291.97 percent of total billed charges Quantitation of therapeutic drug 50762702_1 CDM 0301 RC 80299 HCPCS inpatient 301 195.65 AETNA AETNA 237.79 79 999999999 182.26 291.97 percent of total billed charges Quantitation of therapeutic drug 50762702_1 CDM 0301 RC 80299 HCPCS inpatient 301 195.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291.97 97 999999999 182.26 291.97 percent of total billed charges Quantitation of therapeutic drug 50762702_1 CDM 0301 RC 80299 HCPCS inpatient 301 195.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 207.69 69 999999999 182.26 291.97 percent of total billed charges Quantitation of therapeutic drug 50762702_1 CDM 0301 RC 80299 HCPCS inpatient 301 195.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 234.78 78 999999999 182.26 291.97 percent of total billed charges Quantitation of therapeutic drug 50762702_1 CDM 0301 RC 80299 HCPCS inpatient 301 195.65 SIHO - ALL PLANS SIHO - ALL PLANS 270.9 90 999999999 182.26 291.97 percent of total billed charges Quantitation of therapeutic drug 50762702_1 CDM 0301 RC 80299 HCPCS inpatient 301 195.65 UMR - ALL PLANS UMR - ALL PLANS 210.7 70 999999999 182.26 291.97 percent of total billed charges Quantitation of therapeutic drug 50762702_1 CDM 0301 RC 80299 HCPCS inpatient 301 195.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.26 60.55 999999999 182.26 291.97 percent of total billed charges Quantitation of therapeutic drug 50762702_1 CDM 0301 RC 80299 HCPCS inpatient 301 195.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.26 291.97 Quantitation of therapeutic drug 50762702_1 CDM 0301 RC 80299 HCPCS inpatient 301 195.65 ANTHEM HMO ANTHEM HMO 999999999 182.26 291.97 Quantitation of therapeutic drug 50762702_1 CDM 0301 RC 80299 HCPCS inpatient 301 195.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.26 291.97 Quantitation of therapeutic drug 50762702_1 CDM 0301 RC 80299 HCPCS inpatient 301 195.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 203.48 67.6 999999999 182.26 291.97 percent of total billed charges Quantitation of therapeutic drug 50762702_1 CDM 0301 RC 80299 HCPCS inpatient 301 195.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.26 291.97 Quantitation of therapeutic drug 50762702_1 CDM 0301 RC 80299 HCPCS inpatient 301 195.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.26 291.97 Transfer of deep tendon of foot with muscle rerouting 50762706_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Transfer of deep tendon of foot with muscle rerouting 50762706_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Transfer of deep tendon of foot with muscle rerouting 50762706_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Transfer of deep tendon of foot with muscle rerouting 50762706_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Transfer of deep tendon of foot with muscle rerouting 50762706_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Transfer of deep tendon of foot with muscle rerouting 50762706_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Transfer of deep tendon of foot with muscle rerouting 50762706_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Transfer of deep tendon of foot with muscle rerouting 50762706_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Transfer of deep tendon of foot with muscle rerouting 50762706_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Transfer of deep tendon of foot with muscle rerouting 50762706_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Transfer of deep tendon of foot with muscle rerouting 50762706_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Transfer of deep tendon of foot with muscle rerouting 50762706_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Transfer of deep tendon of foot with muscle rerouting 50762706_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Transfer of deep tendon of foot with muscle rerouting 50762706_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Histamine (immune system substance) level 50762754_1 CDM 0301 RC 83088 HCPCS inpatient 238 154.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.7 65 999999999 144.11 230.86 percent of total billed charges Histamine (immune system substance) level 50762754_1 CDM 0301 RC 83088 HCPCS inpatient 238 154.7 AETNA AETNA 188.02 79 999999999 144.11 230.86 percent of total billed charges Histamine (immune system substance) level 50762754_1 CDM 0301 RC 83088 HCPCS inpatient 238 154.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 230.86 97 999999999 144.11 230.86 percent of total billed charges Histamine (immune system substance) level 50762754_1 CDM 0301 RC 83088 HCPCS inpatient 238 154.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.22 69 999999999 144.11 230.86 percent of total billed charges Histamine (immune system substance) level 50762754_1 CDM 0301 RC 83088 HCPCS inpatient 238 154.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 185.64 78 999999999 144.11 230.86 percent of total billed charges Histamine (immune system substance) level 50762754_1 CDM 0301 RC 83088 HCPCS inpatient 238 154.7 SIHO - ALL PLANS SIHO - ALL PLANS 214.2 90 999999999 144.11 230.86 percent of total billed charges Histamine (immune system substance) level 50762754_1 CDM 0301 RC 83088 HCPCS inpatient 238 154.7 UMR - ALL PLANS UMR - ALL PLANS 166.6 70 999999999 144.11 230.86 percent of total billed charges Histamine (immune system substance) level 50762754_1 CDM 0301 RC 83088 HCPCS inpatient 238 154.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.11 60.55 999999999 144.11 230.86 percent of total billed charges Histamine (immune system substance) level 50762754_1 CDM 0301 RC 83088 HCPCS inpatient 238 154.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.11 230.86 Histamine (immune system substance) level 50762754_1 CDM 0301 RC 83088 HCPCS inpatient 238 154.7 ANTHEM HMO ANTHEM HMO 999999999 144.11 230.86 Histamine (immune system substance) level 50762754_1 CDM 0301 RC 83088 HCPCS inpatient 238 154.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.11 230.86 Histamine (immune system substance) level 50762754_1 CDM 0301 RC 83088 HCPCS inpatient 238 154.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.89 67.6 999999999 144.11 230.86 percent of total billed charges Histamine (immune system substance) level 50762754_1 CDM 0301 RC 83088 HCPCS inpatient 238 154.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.11 230.86 Histamine (immune system substance) level 50762754_1 CDM 0301 RC 83088 HCPCS inpatient 238 154.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.11 230.86 Organic acids level 50762767_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 185.9 65 999999999 173.17 277.42 percent of total billed charges Organic acids level 50762767_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 AETNA AETNA 225.94 79 999999999 173.17 277.42 percent of total billed charges Organic acids level 50762767_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 277.42 97 999999999 173.17 277.42 percent of total billed charges Organic acids level 50762767_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 197.34 69 999999999 173.17 277.42 percent of total billed charges Organic acids level 50762767_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 223.08 78 999999999 173.17 277.42 percent of total billed charges Organic acids level 50762767_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 SIHO - ALL PLANS SIHO - ALL PLANS 257.4 90 999999999 173.17 277.42 percent of total billed charges Organic acids level 50762767_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 UMR - ALL PLANS UMR - ALL PLANS 200.2 70 999999999 173.17 277.42 percent of total billed charges Organic acids level 50762767_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 173.17 60.55 999999999 173.17 277.42 percent of total billed charges Organic acids level 50762767_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 173.17 277.42 Organic acids level 50762767_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 ANTHEM HMO ANTHEM HMO 999999999 173.17 277.42 Organic acids level 50762767_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 173.17 277.42 Organic acids level 50762767_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 193.34 67.6 999999999 173.17 277.42 percent of total billed charges Organic acids level 50762767_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 173.17 277.42 Organic acids level 50762767_1 CDM 0301 RC 83918 HCPCS inpatient 286 185.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 173.17 277.42 HCG RAPID PREGNANCY TEST 5000 951311 25/BOX 50764262_1 CDM 0272 RC inpatient 4 2.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 2.6 65 999999999 2.42 3.88 percent of total billed charges HCG RAPID PREGNANCY TEST 5000 951311 25/BOX 50764262_1 CDM 0272 RC inpatient 4 2.6 AETNA AETNA 3.16 79 999999999 2.42 3.88 percent of total billed charges HCG RAPID PREGNANCY TEST 5000 951311 25/BOX 50764262_1 CDM 0272 RC inpatient 4 2.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3.88 97 999999999 2.42 3.88 percent of total billed charges HCG RAPID PREGNANCY TEST 5000 951311 25/BOX 50764262_1 CDM 0272 RC inpatient 4 2.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 2.76 69 999999999 2.42 3.88 percent of total billed charges HCG RAPID PREGNANCY TEST 5000 951311 25/BOX 50764262_1 CDM 0272 RC inpatient 4 2.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 3.12 78 999999999 2.42 3.88 percent of total billed charges HCG RAPID PREGNANCY TEST 5000 951311 25/BOX 50764262_1 CDM 0272 RC inpatient 4 2.6 SIHO - ALL PLANS SIHO - ALL PLANS 3.6 90 999999999 2.42 3.88 percent of total billed charges HCG RAPID PREGNANCY TEST 5000 951311 25/BOX 50764262_1 CDM 0272 RC inpatient 4 2.6 UMR - ALL PLANS UMR - ALL PLANS 2.8 70 999999999 2.42 3.88 percent of total billed charges HCG RAPID PREGNANCY TEST 5000 951311 25/BOX 50764262_1 CDM 0272 RC inpatient 4 2.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2.42 60.55 999999999 2.42 3.88 percent of total billed charges HCG RAPID PREGNANCY TEST 5000 951311 25/BOX 50764262_1 CDM 0272 RC inpatient 4 2.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2.42 3.88 HCG RAPID PREGNANCY TEST 5000 951311 25/BOX 50764262_1 CDM 0272 RC inpatient 4 2.6 ANTHEM HMO ANTHEM HMO 999999999 2.42 3.88 HCG RAPID PREGNANCY TEST 5000 951311 25/BOX 50764262_1 CDM 0272 RC inpatient 4 2.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2.42 3.88 HCG RAPID PREGNANCY TEST 5000 951311 25/BOX 50764262_1 CDM 0272 RC inpatient 4 2.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 2.7 67.6 999999999 2.42 3.88 percent of total billed charges HCG RAPID PREGNANCY TEST 5000 951311 25/BOX 50764262_1 CDM 0272 RC inpatient 4 2.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2.42 3.88 HCG RAPID PREGNANCY TEST 5000 951311 25/BOX 50764262_1 CDM 0272 RC inpatient 4 2.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 2.42 3.88 FEMORAL ARTERIAL CATH KIT ASK-04018-ST 50764267_1 CDM 0272 RC inpatient 348 226.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 226.2 65 999999999 210.71 337.56 percent of total billed charges FEMORAL ARTERIAL CATH KIT ASK-04018-ST 50764267_1 CDM 0272 RC inpatient 348 226.2 AETNA AETNA 274.92 79 999999999 210.71 337.56 percent of total billed charges FEMORAL ARTERIAL CATH KIT ASK-04018-ST 50764267_1 CDM 0272 RC inpatient 348 226.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 337.56 97 999999999 210.71 337.56 percent of total billed charges FEMORAL ARTERIAL CATH KIT ASK-04018-ST 50764267_1 CDM 0272 RC inpatient 348 226.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 240.12 69 999999999 210.71 337.56 percent of total billed charges FEMORAL ARTERIAL CATH KIT ASK-04018-ST 50764267_1 CDM 0272 RC inpatient 348 226.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 271.44 78 999999999 210.71 337.56 percent of total billed charges FEMORAL ARTERIAL CATH KIT ASK-04018-ST 50764267_1 CDM 0272 RC inpatient 348 226.2 SIHO - ALL PLANS SIHO - ALL PLANS 313.2 90 999999999 210.71 337.56 percent of total billed charges FEMORAL ARTERIAL CATH KIT ASK-04018-ST 50764267_1 CDM 0272 RC inpatient 348 226.2 UMR - ALL PLANS UMR - ALL PLANS 243.6 70 999999999 210.71 337.56 percent of total billed charges FEMORAL ARTERIAL CATH KIT ASK-04018-ST 50764267_1 CDM 0272 RC inpatient 348 226.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 210.71 60.55 999999999 210.71 337.56 percent of total billed charges FEMORAL ARTERIAL CATH KIT ASK-04018-ST 50764267_1 CDM 0272 RC inpatient 348 226.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 210.71 337.56 FEMORAL ARTERIAL CATH KIT ASK-04018-ST 50764267_1 CDM 0272 RC inpatient 348 226.2 ANTHEM HMO ANTHEM HMO 999999999 210.71 337.56 FEMORAL ARTERIAL CATH KIT ASK-04018-ST 50764267_1 CDM 0272 RC inpatient 348 226.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 210.71 337.56 FEMORAL ARTERIAL CATH KIT ASK-04018-ST 50764267_1 CDM 0272 RC inpatient 348 226.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 235.25 67.6 999999999 210.71 337.56 percent of total billed charges FEMORAL ARTERIAL CATH KIT ASK-04018-ST 50764267_1 CDM 0272 RC inpatient 348 226.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 210.71 337.56 FEMORAL ARTERIAL CATH KIT ASK-04018-ST 50764267_1 CDM 0272 RC inpatient 348 226.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 210.71 337.56 METAL TROCAR FALLER FT-1100 50764772_1 CDM 0270 RC inpatient 375 243.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 243.75 65 999999999 227.06 363.75 percent of total billed charges METAL TROCAR FALLER FT-1100 50764772_1 CDM 0270 RC inpatient 375 243.75 AETNA AETNA 296.25 79 999999999 227.06 363.75 percent of total billed charges METAL TROCAR FALLER FT-1100 50764772_1 CDM 0270 RC inpatient 375 243.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 363.75 97 999999999 227.06 363.75 percent of total billed charges METAL TROCAR FALLER FT-1100 50764772_1 CDM 0270 RC inpatient 375 243.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 258.75 69 999999999 227.06 363.75 percent of total billed charges METAL TROCAR FALLER FT-1100 50764772_1 CDM 0270 RC inpatient 375 243.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 292.5 78 999999999 227.06 363.75 percent of total billed charges METAL TROCAR FALLER FT-1100 50764772_1 CDM 0270 RC inpatient 375 243.75 SIHO - ALL PLANS SIHO - ALL PLANS 337.5 90 999999999 227.06 363.75 percent of total billed charges METAL TROCAR FALLER FT-1100 50764772_1 CDM 0270 RC inpatient 375 243.75 UMR - ALL PLANS UMR - ALL PLANS 262.5 70 999999999 227.06 363.75 percent of total billed charges METAL TROCAR FALLER FT-1100 50764772_1 CDM 0270 RC inpatient 375 243.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 227.06 60.55 999999999 227.06 363.75 percent of total billed charges METAL TROCAR FALLER FT-1100 50764772_1 CDM 0270 RC inpatient 375 243.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 227.06 363.75 METAL TROCAR FALLER FT-1100 50764772_1 CDM 0270 RC inpatient 375 243.75 ANTHEM HMO ANTHEM HMO 999999999 227.06 363.75 METAL TROCAR FALLER FT-1100 50764772_1 CDM 0270 RC inpatient 375 243.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 227.06 363.75 METAL TROCAR FALLER FT-1100 50764772_1 CDM 0270 RC inpatient 375 243.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 253.5 67.6 999999999 227.06 363.75 percent of total billed charges METAL TROCAR FALLER FT-1100 50764772_1 CDM 0270 RC inpatient 375 243.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 227.06 363.75 METAL TROCAR FALLER FT-1100 50764772_1 CDM 0270 RC inpatient 375 243.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 227.06 363.75 DIALYSIS TITANINM CATHETER CONNECTOR CC-2300 50764773_1 CDM 0270 RC inpatient 679.5 441.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 441.68 65 999999999 411.44 659.12 percent of total billed charges DIALYSIS TITANINM CATHETER CONNECTOR CC-2300 50764773_1 CDM 0270 RC inpatient 679.5 441.68 AETNA AETNA 536.81 79 999999999 411.44 659.12 percent of total billed charges DIALYSIS TITANINM CATHETER CONNECTOR CC-2300 50764773_1 CDM 0270 RC inpatient 679.5 441.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 659.12 97 999999999 411.44 659.12 percent of total billed charges DIALYSIS TITANINM CATHETER CONNECTOR CC-2300 50764773_1 CDM 0270 RC inpatient 679.5 441.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 468.86 69 999999999 411.44 659.12 percent of total billed charges DIALYSIS TITANINM CATHETER CONNECTOR CC-2300 50764773_1 CDM 0270 RC inpatient 679.5 441.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 530.01 78 999999999 411.44 659.12 percent of total billed charges DIALYSIS TITANINM CATHETER CONNECTOR CC-2300 50764773_1 CDM 0270 RC inpatient 679.5 441.68 SIHO - ALL PLANS SIHO - ALL PLANS 611.55 90 999999999 411.44 659.12 percent of total billed charges DIALYSIS TITANINM CATHETER CONNECTOR CC-2300 50764773_1 CDM 0270 RC inpatient 679.5 441.68 UMR - ALL PLANS UMR - ALL PLANS 475.65 70 999999999 411.44 659.12 percent of total billed charges DIALYSIS TITANINM CATHETER CONNECTOR CC-2300 50764773_1 CDM 0270 RC inpatient 679.5 441.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 411.44 60.55 999999999 411.44 659.12 percent of total billed charges DIALYSIS TITANINM CATHETER CONNECTOR CC-2300 50764773_1 CDM 0270 RC inpatient 679.5 441.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 411.44 659.12 DIALYSIS TITANINM CATHETER CONNECTOR CC-2300 50764773_1 CDM 0270 RC inpatient 679.5 441.68 ANTHEM HMO ANTHEM HMO 999999999 411.44 659.12 DIALYSIS TITANINM CATHETER CONNECTOR CC-2300 50764773_1 CDM 0270 RC inpatient 679.5 441.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 411.44 659.12 DIALYSIS TITANINM CATHETER CONNECTOR CC-2300 50764773_1 CDM 0270 RC inpatient 679.5 441.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 459.34 67.6 999999999 411.44 659.12 percent of total billed charges DIALYSIS TITANINM CATHETER CONNECTOR CC-2300 50764773_1 CDM 0270 RC inpatient 679.5 441.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 411.44 659.12 DIALYSIS TITANINM CATHETER CONNECTOR CC-2300 50764773_1 CDM 0270 RC inpatient 679.5 441.68 UHC - ALL PLANS UHC - ALL PLANS 999999999 411.44 659.12 PERITONEAL DIALYSIS FLEXNECK 2 CUFT 62CM CF-5250 50764774_1 CDM 0270 RC inpatient 783 508.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 508.95 65 999999999 474.11 759.51 percent of total billed charges PERITONEAL DIALYSIS FLEXNECK 2 CUFT 62CM CF-5250 50764774_1 CDM 0270 RC inpatient 783 508.95 AETNA AETNA 618.57 79 999999999 474.11 759.51 percent of total billed charges PERITONEAL DIALYSIS FLEXNECK 2 CUFT 62CM CF-5250 50764774_1 CDM 0270 RC inpatient 783 508.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 759.51 97 999999999 474.11 759.51 percent of total billed charges PERITONEAL DIALYSIS FLEXNECK 2 CUFT 62CM CF-5250 50764774_1 CDM 0270 RC inpatient 783 508.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 540.27 69 999999999 474.11 759.51 percent of total billed charges PERITONEAL DIALYSIS FLEXNECK 2 CUFT 62CM CF-5250 50764774_1 CDM 0270 RC inpatient 783 508.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 610.74 78 999999999 474.11 759.51 percent of total billed charges PERITONEAL DIALYSIS FLEXNECK 2 CUFT 62CM CF-5250 50764774_1 CDM 0270 RC inpatient 783 508.95 SIHO - ALL PLANS SIHO - ALL PLANS 704.7 90 999999999 474.11 759.51 percent of total billed charges PERITONEAL DIALYSIS FLEXNECK 2 CUFT 62CM CF-5250 50764774_1 CDM 0270 RC inpatient 783 508.95 UMR - ALL PLANS UMR - ALL PLANS 548.1 70 999999999 474.11 759.51 percent of total billed charges PERITONEAL DIALYSIS FLEXNECK 2 CUFT 62CM CF-5250 50764774_1 CDM 0270 RC inpatient 783 508.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 474.11 60.55 999999999 474.11 759.51 percent of total billed charges PERITONEAL DIALYSIS FLEXNECK 2 CUFT 62CM CF-5250 50764774_1 CDM 0270 RC inpatient 783 508.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 474.11 759.51 PERITONEAL DIALYSIS FLEXNECK 2 CUFT 62CM CF-5250 50764774_1 CDM 0270 RC inpatient 783 508.95 ANTHEM HMO ANTHEM HMO 999999999 474.11 759.51 PERITONEAL DIALYSIS FLEXNECK 2 CUFT 62CM CF-5250 50764774_1 CDM 0270 RC inpatient 783 508.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 474.11 759.51 PERITONEAL DIALYSIS FLEXNECK 2 CUFT 62CM CF-5250 50764774_1 CDM 0270 RC inpatient 783 508.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 529.31 67.6 999999999 474.11 759.51 percent of total billed charges PERITONEAL DIALYSIS FLEXNECK 2 CUFT 62CM CF-5250 50764774_1 CDM 0270 RC inpatient 783 508.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 474.11 759.51 PERITONEAL DIALYSIS FLEXNECK 2 CUFT 62CM CF-5250 50764774_1 CDM 0270 RC inpatient 783 508.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 474.11 759.51 LAPAROSCOPIC DIALYSIS PLACEMENT KIT 50764775_1 CDM 0272 RC inpatient 799.79 519.86 SELF PAY DISCOUNT SELF PAY DISCOUNT 519.86 65 999999999 484.27 775.8 percent of total billed charges LAPAROSCOPIC DIALYSIS PLACEMENT KIT 50764775_1 CDM 0272 RC inpatient 799.79 519.86 AETNA AETNA 631.83 79 999999999 484.27 775.8 percent of total billed charges LAPAROSCOPIC DIALYSIS PLACEMENT KIT 50764775_1 CDM 0272 RC inpatient 799.79 519.86 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 775.8 97 999999999 484.27 775.8 percent of total billed charges LAPAROSCOPIC DIALYSIS PLACEMENT KIT 50764775_1 CDM 0272 RC inpatient 799.79 519.86 ENCORE - ALL PLANS ENCORE - ALL PLANS 551.86 69 999999999 484.27 775.8 percent of total billed charges LAPAROSCOPIC DIALYSIS PLACEMENT KIT 50764775_1 CDM 0272 RC inpatient 799.79 519.86 HUMANA - ALL PLANS HUMANA - ALL PLANS 623.84 78 999999999 484.27 775.8 percent of total billed charges LAPAROSCOPIC DIALYSIS PLACEMENT KIT 50764775_1 CDM 0272 RC inpatient 799.79 519.86 SIHO - ALL PLANS SIHO - ALL PLANS 719.81 90 999999999 484.27 775.8 percent of total billed charges LAPAROSCOPIC DIALYSIS PLACEMENT KIT 50764775_1 CDM 0272 RC inpatient 799.79 519.86 UMR - ALL PLANS UMR - ALL PLANS 559.85 70 999999999 484.27 775.8 percent of total billed charges LAPAROSCOPIC DIALYSIS PLACEMENT KIT 50764775_1 CDM 0272 RC inpatient 799.79 519.86 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 484.27 60.55 999999999 484.27 775.8 percent of total billed charges LAPAROSCOPIC DIALYSIS PLACEMENT KIT 50764775_1 CDM 0272 RC inpatient 799.79 519.86 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 484.27 775.8 LAPAROSCOPIC DIALYSIS PLACEMENT KIT 50764775_1 CDM 0272 RC inpatient 799.79 519.86 ANTHEM HMO ANTHEM HMO 999999999 484.27 775.8 LAPAROSCOPIC DIALYSIS PLACEMENT KIT 50764775_1 CDM 0272 RC inpatient 799.79 519.86 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 484.27 775.8 LAPAROSCOPIC DIALYSIS PLACEMENT KIT 50764775_1 CDM 0272 RC inpatient 799.79 519.86 CIGNA - ALL PLANS CIGNA - ALL PLANS 540.66 67.6 999999999 484.27 775.8 percent of total billed charges LAPAROSCOPIC DIALYSIS PLACEMENT KIT 50764775_1 CDM 0272 RC inpatient 799.79 519.86 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 484.27 775.8 LAPAROSCOPIC DIALYSIS PLACEMENT KIT 50764775_1 CDM 0272 RC inpatient 799.79 519.86 UHC - ALL PLANS UHC - ALL PLANS 999999999 484.27 775.8 TROCAR ENDOPATH XCEL BLADELESS 8mm X 100mm B8LT 50764794_1 CDM 0270 RC inpatient 875.2 568.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 568.88 65 999999999 529.93 848.94 percent of total billed charges TROCAR ENDOPATH XCEL BLADELESS 8mm X 100mm B8LT 50764794_1 CDM 0270 RC inpatient 875.2 568.88 AETNA AETNA 691.41 79 999999999 529.93 848.94 percent of total billed charges TROCAR ENDOPATH XCEL BLADELESS 8mm X 100mm B8LT 50764794_1 CDM 0270 RC inpatient 875.2 568.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 848.94 97 999999999 529.93 848.94 percent of total billed charges TROCAR ENDOPATH XCEL BLADELESS 8mm X 100mm B8LT 50764794_1 CDM 0270 RC inpatient 875.2 568.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 603.89 69 999999999 529.93 848.94 percent of total billed charges TROCAR ENDOPATH XCEL BLADELESS 8mm X 100mm B8LT 50764794_1 CDM 0270 RC inpatient 875.2 568.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 682.66 78 999999999 529.93 848.94 percent of total billed charges TROCAR ENDOPATH XCEL BLADELESS 8mm X 100mm B8LT 50764794_1 CDM 0270 RC inpatient 875.2 568.88 SIHO - ALL PLANS SIHO - ALL PLANS 787.68 90 999999999 529.93 848.94 percent of total billed charges TROCAR ENDOPATH XCEL BLADELESS 8mm X 100mm B8LT 50764794_1 CDM 0270 RC inpatient 875.2 568.88 UMR - ALL PLANS UMR - ALL PLANS 612.64 70 999999999 529.93 848.94 percent of total billed charges TROCAR ENDOPATH XCEL BLADELESS 8mm X 100mm B8LT 50764794_1 CDM 0270 RC inpatient 875.2 568.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 529.93 60.55 999999999 529.93 848.94 percent of total billed charges TROCAR ENDOPATH XCEL BLADELESS 8mm X 100mm B8LT 50764794_1 CDM 0270 RC inpatient 875.2 568.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 529.93 848.94 TROCAR ENDOPATH XCEL BLADELESS 8mm X 100mm B8LT 50764794_1 CDM 0270 RC inpatient 875.2 568.88 ANTHEM HMO ANTHEM HMO 999999999 529.93 848.94 TROCAR ENDOPATH XCEL BLADELESS 8mm X 100mm B8LT 50764794_1 CDM 0270 RC inpatient 875.2 568.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 529.93 848.94 TROCAR ENDOPATH XCEL BLADELESS 8mm X 100mm B8LT 50764794_1 CDM 0270 RC inpatient 875.2 568.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 591.64 67.6 999999999 529.93 848.94 percent of total billed charges TROCAR ENDOPATH XCEL BLADELESS 8mm X 100mm B8LT 50764794_1 CDM 0270 RC inpatient 875.2 568.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 529.93 848.94 TROCAR ENDOPATH XCEL BLADELESS 8mm X 100mm B8LT 50764794_1 CDM 0270 RC inpatient 875.2 568.88 UHC - ALL PLANS UHC - ALL PLANS 999999999 529.93 848.94 "***** BLANKETED ITEM PER MEGAN P - 08/28/2023 *****EDSTAY SAFE EXTENTION SET 12"" 050-95001" 50764795_1 CDM 0270 RC inpatient 148 96.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 96.2 65 999999999 89.61 143.56 percent of total billed charges "***** BLANKETED ITEM PER MEGAN P - 08/28/2023 *****EDSTAY SAFE EXTENTION SET 12"" 050-95001" 50764795_1 CDM 0270 RC inpatient 148 96.2 AETNA AETNA 116.92 79 999999999 89.61 143.56 percent of total billed charges "***** BLANKETED ITEM PER MEGAN P - 08/28/2023 *****EDSTAY SAFE EXTENTION SET 12"" 050-95001" 50764795_1 CDM 0270 RC inpatient 148 96.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 143.56 97 999999999 89.61 143.56 percent of total billed charges "***** BLANKETED ITEM PER MEGAN P - 08/28/2023 *****EDSTAY SAFE EXTENTION SET 12"" 050-95001" 50764795_1 CDM 0270 RC inpatient 148 96.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 102.12 69 999999999 89.61 143.56 percent of total billed charges "***** BLANKETED ITEM PER MEGAN P - 08/28/2023 *****EDSTAY SAFE EXTENTION SET 12"" 050-95001" 50764795_1 CDM 0270 RC inpatient 148 96.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 115.44 78 999999999 89.61 143.56 percent of total billed charges "***** BLANKETED ITEM PER MEGAN P - 08/28/2023 *****EDSTAY SAFE EXTENTION SET 12"" 050-95001" 50764795_1 CDM 0270 RC inpatient 148 96.2 SIHO - ALL PLANS SIHO - ALL PLANS 133.2 90 999999999 89.61 143.56 percent of total billed charges "***** BLANKETED ITEM PER MEGAN P - 08/28/2023 *****EDSTAY SAFE EXTENTION SET 12"" 050-95001" 50764795_1 CDM 0270 RC inpatient 148 96.2 UMR - ALL PLANS UMR - ALL PLANS 103.6 70 999999999 89.61 143.56 percent of total billed charges "***** BLANKETED ITEM PER MEGAN P - 08/28/2023 *****EDSTAY SAFE EXTENTION SET 12"" 050-95001" 50764795_1 CDM 0270 RC inpatient 148 96.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 89.61 60.55 999999999 89.61 143.56 percent of total billed charges "***** BLANKETED ITEM PER MEGAN P - 08/28/2023 *****EDSTAY SAFE EXTENTION SET 12"" 050-95001" 50764795_1 CDM 0270 RC inpatient 148 96.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 89.61 143.56 "***** BLANKETED ITEM PER MEGAN P - 08/28/2023 *****EDSTAY SAFE EXTENTION SET 12"" 050-95001" 50764795_1 CDM 0270 RC inpatient 148 96.2 ANTHEM HMO ANTHEM HMO 999999999 89.61 143.56 "***** BLANKETED ITEM PER MEGAN P - 08/28/2023 *****EDSTAY SAFE EXTENTION SET 12"" 050-95001" 50764795_1 CDM 0270 RC inpatient 148 96.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 89.61 143.56 "***** BLANKETED ITEM PER MEGAN P - 08/28/2023 *****EDSTAY SAFE EXTENTION SET 12"" 050-95001" 50764795_1 CDM 0270 RC inpatient 148 96.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 100.05 67.6 999999999 89.61 143.56 percent of total billed charges "***** BLANKETED ITEM PER MEGAN P - 08/28/2023 *****EDSTAY SAFE EXTENTION SET 12"" 050-95001" 50764795_1 CDM 0270 RC inpatient 148 96.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 89.61 143.56 "***** BLANKETED ITEM PER MEGAN P - 08/28/2023 *****EDSTAY SAFE EXTENTION SET 12"" 050-95001" 50764795_1 CDM 0270 RC inpatient 148 96.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 89.61 143.56 "SUTURE PROLENE 6-0 BV-1 24"" 8805H" 50764798_1 CDM 0272 RC inpatient 127 82.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 82.55 65 999999999 76.9 123.19 percent of total billed charges "SUTURE PROLENE 6-0 BV-1 24"" 8805H" 50764798_1 CDM 0272 RC inpatient 127 82.55 AETNA AETNA 100.33 79 999999999 76.9 123.19 percent of total billed charges "SUTURE PROLENE 6-0 BV-1 24"" 8805H" 50764798_1 CDM 0272 RC inpatient 127 82.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 123.19 97 999999999 76.9 123.19 percent of total billed charges "SUTURE PROLENE 6-0 BV-1 24"" 8805H" 50764798_1 CDM 0272 RC inpatient 127 82.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 87.63 69 999999999 76.9 123.19 percent of total billed charges "SUTURE PROLENE 6-0 BV-1 24"" 8805H" 50764798_1 CDM 0272 RC inpatient 127 82.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 99.06 78 999999999 76.9 123.19 percent of total billed charges "SUTURE PROLENE 6-0 BV-1 24"" 8805H" 50764798_1 CDM 0272 RC inpatient 127 82.55 SIHO - ALL PLANS SIHO - ALL PLANS 114.3 90 999999999 76.9 123.19 percent of total billed charges "SUTURE PROLENE 6-0 BV-1 24"" 8805H" 50764798_1 CDM 0272 RC inpatient 127 82.55 UMR - ALL PLANS UMR - ALL PLANS 88.9 70 999999999 76.9 123.19 percent of total billed charges "SUTURE PROLENE 6-0 BV-1 24"" 8805H" 50764798_1 CDM 0272 RC inpatient 127 82.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 76.9 60.55 999999999 76.9 123.19 percent of total billed charges "SUTURE PROLENE 6-0 BV-1 24"" 8805H" 50764798_1 CDM 0272 RC inpatient 127 82.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 76.9 123.19 "SUTURE PROLENE 6-0 BV-1 24"" 8805H" 50764798_1 CDM 0272 RC inpatient 127 82.55 ANTHEM HMO ANTHEM HMO 999999999 76.9 123.19 "SUTURE PROLENE 6-0 BV-1 24"" 8805H" 50764798_1 CDM 0272 RC inpatient 127 82.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 76.9 123.19 "SUTURE PROLENE 6-0 BV-1 24"" 8805H" 50764798_1 CDM 0272 RC inpatient 127 82.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 85.85 67.6 999999999 76.9 123.19 percent of total billed charges "SUTURE PROLENE 6-0 BV-1 24"" 8805H" 50764798_1 CDM 0272 RC inpatient 127 82.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 76.9 123.19 "SUTURE PROLENE 6-0 BV-1 24"" 8805H" 50764798_1 CDM 0272 RC inpatient 127 82.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 76.9 123.19 "SUTURE PROLENE 7-0, BV-1, 24"" 8702H" 50764799_1 CDM 0272 RC inpatient 132 85.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.8 65 999999999 79.93 128.04 percent of total billed charges "SUTURE PROLENE 7-0, BV-1, 24"" 8702H" 50764799_1 CDM 0272 RC inpatient 132 85.8 AETNA AETNA 104.28 79 999999999 79.93 128.04 percent of total billed charges "SUTURE PROLENE 7-0, BV-1, 24"" 8702H" 50764799_1 CDM 0272 RC inpatient 132 85.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 128.04 97 999999999 79.93 128.04 percent of total billed charges "SUTURE PROLENE 7-0, BV-1, 24"" 8702H" 50764799_1 CDM 0272 RC inpatient 132 85.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.08 69 999999999 79.93 128.04 percent of total billed charges "SUTURE PROLENE 7-0, BV-1, 24"" 8702H" 50764799_1 CDM 0272 RC inpatient 132 85.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.96 78 999999999 79.93 128.04 percent of total billed charges "SUTURE PROLENE 7-0, BV-1, 24"" 8702H" 50764799_1 CDM 0272 RC inpatient 132 85.8 SIHO - ALL PLANS SIHO - ALL PLANS 118.8 90 999999999 79.93 128.04 percent of total billed charges "SUTURE PROLENE 7-0, BV-1, 24"" 8702H" 50764799_1 CDM 0272 RC inpatient 132 85.8 UMR - ALL PLANS UMR - ALL PLANS 92.4 70 999999999 79.93 128.04 percent of total billed charges "SUTURE PROLENE 7-0, BV-1, 24"" 8702H" 50764799_1 CDM 0272 RC inpatient 132 85.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.93 60.55 999999999 79.93 128.04 percent of total billed charges "SUTURE PROLENE 7-0, BV-1, 24"" 8702H" 50764799_1 CDM 0272 RC inpatient 132 85.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.93 128.04 "SUTURE PROLENE 7-0, BV-1, 24"" 8702H" 50764799_1 CDM 0272 RC inpatient 132 85.8 ANTHEM HMO ANTHEM HMO 999999999 79.93 128.04 "SUTURE PROLENE 7-0, BV-1, 24"" 8702H" 50764799_1 CDM 0272 RC inpatient 132 85.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.93 128.04 "SUTURE PROLENE 7-0, BV-1, 24"" 8702H" 50764799_1 CDM 0272 RC inpatient 132 85.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.23 67.6 999999999 79.93 128.04 percent of total billed charges "SUTURE PROLENE 7-0, BV-1, 24"" 8702H" 50764799_1 CDM 0272 RC inpatient 132 85.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.93 128.04 "SUTURE PROLENE 7-0, BV-1, 24"" 8702H" 50764799_1 CDM 0272 RC inpatient 132 85.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.93 128.04 "SUTURE SILK 4-0 BLACK BRAIDED 12-18"" A183H" 50764800_1 CDM 0272 RC inpatient 15 9.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 9.75 65 999999999 9.08 14.55 percent of total billed charges "SUTURE SILK 4-0 BLACK BRAIDED 12-18"" A183H" 50764800_1 CDM 0272 RC inpatient 15 9.75 AETNA AETNA 11.85 79 999999999 9.08 14.55 percent of total billed charges "SUTURE SILK 4-0 BLACK BRAIDED 12-18"" A183H" 50764800_1 CDM 0272 RC inpatient 15 9.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14.55 97 999999999 9.08 14.55 percent of total billed charges "SUTURE SILK 4-0 BLACK BRAIDED 12-18"" A183H" 50764800_1 CDM 0272 RC inpatient 15 9.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 10.35 69 999999999 9.08 14.55 percent of total billed charges "SUTURE SILK 4-0 BLACK BRAIDED 12-18"" A183H" 50764800_1 CDM 0272 RC inpatient 15 9.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 11.7 78 999999999 9.08 14.55 percent of total billed charges "SUTURE SILK 4-0 BLACK BRAIDED 12-18"" A183H" 50764800_1 CDM 0272 RC inpatient 15 9.75 SIHO - ALL PLANS SIHO - ALL PLANS 13.5 90 999999999 9.08 14.55 percent of total billed charges "SUTURE SILK 4-0 BLACK BRAIDED 12-18"" A183H" 50764800_1 CDM 0272 RC inpatient 15 9.75 UMR - ALL PLANS UMR - ALL PLANS 10.5 70 999999999 9.08 14.55 percent of total billed charges "SUTURE SILK 4-0 BLACK BRAIDED 12-18"" A183H" 50764800_1 CDM 0272 RC inpatient 15 9.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9.08 60.55 999999999 9.08 14.55 percent of total billed charges "SUTURE SILK 4-0 BLACK BRAIDED 12-18"" A183H" 50764800_1 CDM 0272 RC inpatient 15 9.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9.08 14.55 "SUTURE SILK 4-0 BLACK BRAIDED 12-18"" A183H" 50764800_1 CDM 0272 RC inpatient 15 9.75 ANTHEM HMO ANTHEM HMO 999999999 9.08 14.55 "SUTURE SILK 4-0 BLACK BRAIDED 12-18"" A183H" 50764800_1 CDM 0272 RC inpatient 15 9.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9.08 14.55 "SUTURE SILK 4-0 BLACK BRAIDED 12-18"" A183H" 50764800_1 CDM 0272 RC inpatient 15 9.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 10.14 67.6 999999999 9.08 14.55 percent of total billed charges "SUTURE SILK 4-0 BLACK BRAIDED 12-18"" A183H" 50764800_1 CDM 0272 RC inpatient 15 9.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9.08 14.55 "SUTURE SILK 4-0 BLACK BRAIDED 12-18"" A183H" 50764800_1 CDM 0272 RC inpatient 15 9.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 9.08 14.55 SUTURE PDS II 5-0 P-3 CLEAR Z493G 50764801_1 CDM 0272 RC inpatient 42 27.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 27.3 65 999999999 25.43 40.74 percent of total billed charges SUTURE PDS II 5-0 P-3 CLEAR Z493G 50764801_1 CDM 0272 RC inpatient 42 27.3 AETNA AETNA 33.18 79 999999999 25.43 40.74 percent of total billed charges SUTURE PDS II 5-0 P-3 CLEAR Z493G 50764801_1 CDM 0272 RC inpatient 42 27.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 40.74 97 999999999 25.43 40.74 percent of total billed charges SUTURE PDS II 5-0 P-3 CLEAR Z493G 50764801_1 CDM 0272 RC inpatient 42 27.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 28.98 69 999999999 25.43 40.74 percent of total billed charges SUTURE PDS II 5-0 P-3 CLEAR Z493G 50764801_1 CDM 0272 RC inpatient 42 27.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 32.76 78 999999999 25.43 40.74 percent of total billed charges SUTURE PDS II 5-0 P-3 CLEAR Z493G 50764801_1 CDM 0272 RC inpatient 42 27.3 SIHO - ALL PLANS SIHO - ALL PLANS 37.8 90 999999999 25.43 40.74 percent of total billed charges SUTURE PDS II 5-0 P-3 CLEAR Z493G 50764801_1 CDM 0272 RC inpatient 42 27.3 UMR - ALL PLANS UMR - ALL PLANS 29.4 70 999999999 25.43 40.74 percent of total billed charges SUTURE PDS II 5-0 P-3 CLEAR Z493G 50764801_1 CDM 0272 RC inpatient 42 27.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 25.43 60.55 999999999 25.43 40.74 percent of total billed charges SUTURE PDS II 5-0 P-3 CLEAR Z493G 50764801_1 CDM 0272 RC inpatient 42 27.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 25.43 40.74 SUTURE PDS II 5-0 P-3 CLEAR Z493G 50764801_1 CDM 0272 RC inpatient 42 27.3 ANTHEM HMO ANTHEM HMO 999999999 25.43 40.74 SUTURE PDS II 5-0 P-3 CLEAR Z493G 50764801_1 CDM 0272 RC inpatient 42 27.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 25.43 40.74 SUTURE PDS II 5-0 P-3 CLEAR Z493G 50764801_1 CDM 0272 RC inpatient 42 27.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 28.39 67.6 999999999 25.43 40.74 percent of total billed charges SUTURE PDS II 5-0 P-3 CLEAR Z493G 50764801_1 CDM 0272 RC inpatient 42 27.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 25.43 40.74 SUTURE PDS II 5-0 P-3 CLEAR Z493G 50764801_1 CDM 0272 RC inpatient 42 27.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 25.43 40.74 YELLOW CLAMP BULLDOG VASCU-STUTT II 1001-533 50764802_1 CDM 0272 RC inpatient 111 72.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.15 65 999999999 67.21 107.67 percent of total billed charges YELLOW CLAMP BULLDOG VASCU-STUTT II 1001-533 50764802_1 CDM 0272 RC inpatient 111 72.15 AETNA AETNA 87.69 79 999999999 67.21 107.67 percent of total billed charges YELLOW CLAMP BULLDOG VASCU-STUTT II 1001-533 50764802_1 CDM 0272 RC inpatient 111 72.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 107.67 97 999999999 67.21 107.67 percent of total billed charges YELLOW CLAMP BULLDOG VASCU-STUTT II 1001-533 50764802_1 CDM 0272 RC inpatient 111 72.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 76.59 69 999999999 67.21 107.67 percent of total billed charges YELLOW CLAMP BULLDOG VASCU-STUTT II 1001-533 50764802_1 CDM 0272 RC inpatient 111 72.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 86.58 78 999999999 67.21 107.67 percent of total billed charges YELLOW CLAMP BULLDOG VASCU-STUTT II 1001-533 50764802_1 CDM 0272 RC inpatient 111 72.15 SIHO - ALL PLANS SIHO - ALL PLANS 99.9 90 999999999 67.21 107.67 percent of total billed charges YELLOW CLAMP BULLDOG VASCU-STUTT II 1001-533 50764802_1 CDM 0272 RC inpatient 111 72.15 UMR - ALL PLANS UMR - ALL PLANS 77.7 70 999999999 67.21 107.67 percent of total billed charges YELLOW CLAMP BULLDOG VASCU-STUTT II 1001-533 50764802_1 CDM 0272 RC inpatient 111 72.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.21 60.55 999999999 67.21 107.67 percent of total billed charges YELLOW CLAMP BULLDOG VASCU-STUTT II 1001-533 50764802_1 CDM 0272 RC inpatient 111 72.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.21 107.67 YELLOW CLAMP BULLDOG VASCU-STUTT II 1001-533 50764802_1 CDM 0272 RC inpatient 111 72.15 ANTHEM HMO ANTHEM HMO 999999999 67.21 107.67 YELLOW CLAMP BULLDOG VASCU-STUTT II 1001-533 50764802_1 CDM 0272 RC inpatient 111 72.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.21 107.67 YELLOW CLAMP BULLDOG VASCU-STUTT II 1001-533 50764802_1 CDM 0272 RC inpatient 111 72.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.04 67.6 999999999 67.21 107.67 percent of total billed charges YELLOW CLAMP BULLDOG VASCU-STUTT II 1001-533 50764802_1 CDM 0272 RC inpatient 111 72.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.21 107.67 YELLOW CLAMP BULLDOG VASCU-STUTT II 1001-533 50764802_1 CDM 0272 RC inpatient 111 72.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.21 107.67 MINI-CAP DISCONNECT W/PROVIDONE-IODINE 5C4466P 50764803_1 CDM 0270 RC inpatient 33.75 21.94 SELF PAY DISCOUNT SELF PAY DISCOUNT 21.94 65 999999999 20.44 32.74 percent of total billed charges MINI-CAP DISCONNECT W/PROVIDONE-IODINE 5C4466P 50764803_1 CDM 0270 RC inpatient 33.75 21.94 AETNA AETNA 26.66 79 999999999 20.44 32.74 percent of total billed charges MINI-CAP DISCONNECT W/PROVIDONE-IODINE 5C4466P 50764803_1 CDM 0270 RC inpatient 33.75 21.94 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32.74 97 999999999 20.44 32.74 percent of total billed charges MINI-CAP DISCONNECT W/PROVIDONE-IODINE 5C4466P 50764803_1 CDM 0270 RC inpatient 33.75 21.94 ENCORE - ALL PLANS ENCORE - ALL PLANS 23.29 69 999999999 20.44 32.74 percent of total billed charges MINI-CAP DISCONNECT W/PROVIDONE-IODINE 5C4466P 50764803_1 CDM 0270 RC inpatient 33.75 21.94 HUMANA - ALL PLANS HUMANA - ALL PLANS 26.33 78 999999999 20.44 32.74 percent of total billed charges MINI-CAP DISCONNECT W/PROVIDONE-IODINE 5C4466P 50764803_1 CDM 0270 RC inpatient 33.75 21.94 SIHO - ALL PLANS SIHO - ALL PLANS 30.38 90 999999999 20.44 32.74 percent of total billed charges MINI-CAP DISCONNECT W/PROVIDONE-IODINE 5C4466P 50764803_1 CDM 0270 RC inpatient 33.75 21.94 UMR - ALL PLANS UMR - ALL PLANS 23.63 70 999999999 20.44 32.74 percent of total billed charges MINI-CAP DISCONNECT W/PROVIDONE-IODINE 5C4466P 50764803_1 CDM 0270 RC inpatient 33.75 21.94 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20.44 60.55 999999999 20.44 32.74 percent of total billed charges MINI-CAP DISCONNECT W/PROVIDONE-IODINE 5C4466P 50764803_1 CDM 0270 RC inpatient 33.75 21.94 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 20.44 32.74 MINI-CAP DISCONNECT W/PROVIDONE-IODINE 5C4466P 50764803_1 CDM 0270 RC inpatient 33.75 21.94 ANTHEM HMO ANTHEM HMO 999999999 20.44 32.74 MINI-CAP DISCONNECT W/PROVIDONE-IODINE 5C4466P 50764803_1 CDM 0270 RC inpatient 33.75 21.94 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 20.44 32.74 MINI-CAP DISCONNECT W/PROVIDONE-IODINE 5C4466P 50764803_1 CDM 0270 RC inpatient 33.75 21.94 CIGNA - ALL PLANS CIGNA - ALL PLANS 22.82 67.6 999999999 20.44 32.74 percent of total billed charges MINI-CAP DISCONNECT W/PROVIDONE-IODINE 5C4466P 50764803_1 CDM 0270 RC inpatient 33.75 21.94 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 20.44 32.74 MINI-CAP DISCONNECT W/PROVIDONE-IODINE 5C4466P 50764803_1 CDM 0270 RC inpatient 33.75 21.94 UHC - ALL PLANS UHC - ALL PLANS 999999999 20.44 32.74 "Gene analysis (calreticulin), common variants" 50765776_1 CDM 0301 RC 81219 HCPCS inpatient 252 163.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.8 65 999999999 152.59 244.44 percent of total billed charges "Gene analysis (calreticulin), common variants" 50765776_1 CDM 0301 RC 81219 HCPCS inpatient 252 163.8 AETNA AETNA 199.08 79 999999999 152.59 244.44 percent of total billed charges "Gene analysis (calreticulin), common variants" 50765776_1 CDM 0301 RC 81219 HCPCS inpatient 252 163.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 244.44 97 999999999 152.59 244.44 percent of total billed charges "Gene analysis (calreticulin), common variants" 50765776_1 CDM 0301 RC 81219 HCPCS inpatient 252 163.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.88 69 999999999 152.59 244.44 percent of total billed charges "Gene analysis (calreticulin), common variants" 50765776_1 CDM 0301 RC 81219 HCPCS inpatient 252 163.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 196.56 78 999999999 152.59 244.44 percent of total billed charges "Gene analysis (calreticulin), common variants" 50765776_1 CDM 0301 RC 81219 HCPCS inpatient 252 163.8 SIHO - ALL PLANS SIHO - ALL PLANS 226.8 90 999999999 152.59 244.44 percent of total billed charges "Gene analysis (calreticulin), common variants" 50765776_1 CDM 0301 RC 81219 HCPCS inpatient 252 163.8 UMR - ALL PLANS UMR - ALL PLANS 176.4 70 999999999 152.59 244.44 percent of total billed charges "Gene analysis (calreticulin), common variants" 50765776_1 CDM 0301 RC 81219 HCPCS inpatient 252 163.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 152.59 60.55 999999999 152.59 244.44 percent of total billed charges "Gene analysis (calreticulin), common variants" 50765776_1 CDM 0301 RC 81219 HCPCS inpatient 252 163.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 152.59 244.44 "Gene analysis (calreticulin), common variants" 50765776_1 CDM 0301 RC 81219 HCPCS inpatient 252 163.8 ANTHEM HMO ANTHEM HMO 999999999 152.59 244.44 "Gene analysis (calreticulin), common variants" 50765776_1 CDM 0301 RC 81219 HCPCS inpatient 252 163.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 152.59 244.44 "Gene analysis (calreticulin), common variants" 50765776_1 CDM 0301 RC 81219 HCPCS inpatient 252 163.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 170.35 67.6 999999999 152.59 244.44 percent of total billed charges "Gene analysis (calreticulin), common variants" 50765776_1 CDM 0301 RC 81219 HCPCS inpatient 252 163.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 152.59 244.44 "Gene analysis (calreticulin), common variants" 50765776_1 CDM 0301 RC 81219 HCPCS inpatient 252 163.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 152.59 244.44 Molecular pathology procedure level 3 50765777_1 CDM 0301 RC 81402 HCPCS inpatient 310 201.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 201.5 65 999999999 187.71 300.7 percent of total billed charges Molecular pathology procedure level 3 50765777_1 CDM 0301 RC 81402 HCPCS inpatient 310 201.5 AETNA AETNA 244.9 79 999999999 187.71 300.7 percent of total billed charges Molecular pathology procedure level 3 50765777_1 CDM 0301 RC 81402 HCPCS inpatient 310 201.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 300.7 97 999999999 187.71 300.7 percent of total billed charges Molecular pathology procedure level 3 50765777_1 CDM 0301 RC 81402 HCPCS inpatient 310 201.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 213.9 69 999999999 187.71 300.7 percent of total billed charges Molecular pathology procedure level 3 50765777_1 CDM 0301 RC 81402 HCPCS inpatient 310 201.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 241.8 78 999999999 187.71 300.7 percent of total billed charges Molecular pathology procedure level 3 50765777_1 CDM 0301 RC 81402 HCPCS inpatient 310 201.5 SIHO - ALL PLANS SIHO - ALL PLANS 279 90 999999999 187.71 300.7 percent of total billed charges Molecular pathology procedure level 3 50765777_1 CDM 0301 RC 81402 HCPCS inpatient 310 201.5 UMR - ALL PLANS UMR - ALL PLANS 217 70 999999999 187.71 300.7 percent of total billed charges Molecular pathology procedure level 3 50765777_1 CDM 0301 RC 81402 HCPCS inpatient 310 201.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 187.71 60.55 999999999 187.71 300.7 percent of total billed charges Molecular pathology procedure level 3 50765777_1 CDM 0301 RC 81402 HCPCS inpatient 310 201.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 187.71 300.7 Molecular pathology procedure level 3 50765777_1 CDM 0301 RC 81402 HCPCS inpatient 310 201.5 ANTHEM HMO ANTHEM HMO 999999999 187.71 300.7 Molecular pathology procedure level 3 50765777_1 CDM 0301 RC 81402 HCPCS inpatient 310 201.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 187.71 300.7 Molecular pathology procedure level 3 50765777_1 CDM 0301 RC 81402 HCPCS inpatient 310 201.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 209.56 67.6 999999999 187.71 300.7 percent of total billed charges Molecular pathology procedure level 3 50765777_1 CDM 0301 RC 81402 HCPCS inpatient 310 201.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 187.71 300.7 Molecular pathology procedure level 3 50765777_1 CDM 0301 RC 81402 HCPCS inpatient 310 201.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 187.71 300.7 Molecular pathology procedure level 4 50765778_1 CDM 0301 RC 81403 HCPCS inpatient 444 288.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 288.6 65 999999999 268.84 430.68 percent of total billed charges Molecular pathology procedure level 4 50765778_1 CDM 0301 RC 81403 HCPCS inpatient 444 288.6 AETNA AETNA 350.76 79 999999999 268.84 430.68 percent of total billed charges Molecular pathology procedure level 4 50765778_1 CDM 0301 RC 81403 HCPCS inpatient 444 288.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 430.68 97 999999999 268.84 430.68 percent of total billed charges Molecular pathology procedure level 4 50765778_1 CDM 0301 RC 81403 HCPCS inpatient 444 288.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 306.36 69 999999999 268.84 430.68 percent of total billed charges Molecular pathology procedure level 4 50765778_1 CDM 0301 RC 81403 HCPCS inpatient 444 288.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 346.32 78 999999999 268.84 430.68 percent of total billed charges Molecular pathology procedure level 4 50765778_1 CDM 0301 RC 81403 HCPCS inpatient 444 288.6 SIHO - ALL PLANS SIHO - ALL PLANS 399.6 90 999999999 268.84 430.68 percent of total billed charges Molecular pathology procedure level 4 50765778_1 CDM 0301 RC 81403 HCPCS inpatient 444 288.6 UMR - ALL PLANS UMR - ALL PLANS 310.8 70 999999999 268.84 430.68 percent of total billed charges Molecular pathology procedure level 4 50765778_1 CDM 0301 RC 81403 HCPCS inpatient 444 288.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 268.84 60.55 999999999 268.84 430.68 percent of total billed charges Molecular pathology procedure level 4 50765778_1 CDM 0301 RC 81403 HCPCS inpatient 444 288.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 268.84 430.68 Molecular pathology procedure level 4 50765778_1 CDM 0301 RC 81403 HCPCS inpatient 444 288.6 ANTHEM HMO ANTHEM HMO 999999999 268.84 430.68 Molecular pathology procedure level 4 50765778_1 CDM 0301 RC 81403 HCPCS inpatient 444 288.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 268.84 430.68 Molecular pathology procedure level 4 50765778_1 CDM 0301 RC 81403 HCPCS inpatient 444 288.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 300.14 67.6 999999999 268.84 430.68 percent of total billed charges Molecular pathology procedure level 4 50765778_1 CDM 0301 RC 81403 HCPCS inpatient 444 288.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 268.84 430.68 Molecular pathology procedure level 4 50765778_1 CDM 0301 RC 81403 HCPCS inpatient 444 288.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 268.84 430.68 Bacterial blood culture 50766643_1 CDM 0306 RC 87040 HCPCS inpatient 357 232.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 232.05 65 999999999 216.16 346.29 percent of total billed charges Bacterial blood culture 50766643_1 CDM 0306 RC 87040 HCPCS inpatient 357 232.05 AETNA AETNA 282.03 79 999999999 216.16 346.29 percent of total billed charges Bacterial blood culture 50766643_1 CDM 0306 RC 87040 HCPCS inpatient 357 232.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 346.29 97 999999999 216.16 346.29 percent of total billed charges Bacterial blood culture 50766643_1 CDM 0306 RC 87040 HCPCS inpatient 357 232.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 246.33 69 999999999 216.16 346.29 percent of total billed charges Bacterial blood culture 50766643_1 CDM 0306 RC 87040 HCPCS inpatient 357 232.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 278.46 78 999999999 216.16 346.29 percent of total billed charges Bacterial blood culture 50766643_1 CDM 0306 RC 87040 HCPCS inpatient 357 232.05 SIHO - ALL PLANS SIHO - ALL PLANS 321.3 90 999999999 216.16 346.29 percent of total billed charges Bacterial blood culture 50766643_1 CDM 0306 RC 87040 HCPCS inpatient 357 232.05 UMR - ALL PLANS UMR - ALL PLANS 249.9 70 999999999 216.16 346.29 percent of total billed charges Bacterial blood culture 50766643_1 CDM 0306 RC 87040 HCPCS inpatient 357 232.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 216.16 60.55 999999999 216.16 346.29 percent of total billed charges Bacterial blood culture 50766643_1 CDM 0306 RC 87040 HCPCS inpatient 357 232.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 216.16 346.29 Bacterial blood culture 50766643_1 CDM 0306 RC 87040 HCPCS inpatient 357 232.05 ANTHEM HMO ANTHEM HMO 999999999 216.16 346.29 Bacterial blood culture 50766643_1 CDM 0306 RC 87040 HCPCS inpatient 357 232.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 216.16 346.29 Bacterial blood culture 50766643_1 CDM 0306 RC 87040 HCPCS inpatient 357 232.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 241.33 67.6 999999999 216.16 346.29 percent of total billed charges Bacterial blood culture 50766643_1 CDM 0306 RC 87040 HCPCS inpatient 357 232.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 216.16 346.29 Bacterial blood culture 50766643_1 CDM 0306 RC 87040 HCPCS inpatient 357 232.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 216.16 346.29 "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50766680_1 CDM 0250 RC 00264-4100-90 NDC J0131 HCPCS inpatient 100 UN 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50766680_1 CDM 0250 RC 00264-4100-90 NDC J0131 HCPCS inpatient 100 UN 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50766680_1 CDM 0250 RC 00264-4100-90 NDC J0131 HCPCS inpatient 100 UN 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50766680_1 CDM 0250 RC 00264-4100-90 NDC J0131 HCPCS inpatient 100 UN 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50766680_1 CDM 0250 RC 00264-4100-90 NDC J0131 HCPCS inpatient 100 UN 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50766680_1 CDM 0250 RC 00264-4100-90 NDC J0131 HCPCS inpatient 100 UN 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50766680_1 CDM 0250 RC 00264-4100-90 NDC J0131 HCPCS inpatient 100 UN 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50766680_1 CDM 0250 RC 00264-4100-90 NDC J0131 HCPCS inpatient 100 UN 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50766680_1 CDM 0250 RC 00264-4100-90 NDC J0131 HCPCS inpatient 100 UN 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50766680_1 CDM 0250 RC 00264-4100-90 NDC J0131 HCPCS inpatient 100 UN 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50766680_1 CDM 0250 RC 00264-4100-90 NDC J0131 HCPCS inpatient 100 UN 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50766680_1 CDM 0250 RC 00264-4100-90 NDC J0131 HCPCS inpatient 100 UN 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50766680_1 CDM 0250 RC 00264-4100-90 NDC J0131 HCPCS inpatient 100 UN 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 "INJECTION, ACETAMINOPHEN, NOT OTHERWISE SPECIFIED,10 MG" 50766680_1 CDM 0250 RC 00264-4100-90 NDC J0131 HCPCS inpatient 100 UN 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50770040_1 CDM 0636 RC 61755-0039-01 NDC Q0243 HCPCS inpatient 1 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50770040_1 CDM 0636 RC 61755-0039-01 NDC Q0243 HCPCS inpatient 1 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50770040_1 CDM 0636 RC 61755-0039-01 NDC Q0243 HCPCS inpatient 1 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50770040_1 CDM 0636 RC 61755-0039-01 NDC Q0243 HCPCS inpatient 1 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50770040_1 CDM 0636 RC 61755-0039-01 NDC Q0243 HCPCS inpatient 1 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50770040_1 CDM 0636 RC 61755-0039-01 NDC Q0243 HCPCS inpatient 1 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50770040_1 CDM 0636 RC 61755-0039-01 NDC Q0243 HCPCS inpatient 1 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50770040_1 CDM 0636 RC 61755-0039-01 NDC Q0243 HCPCS inpatient 1 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50770040_1 CDM 0636 RC 61755-0039-01 NDC Q0243 HCPCS inpatient 1 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50770040_1 CDM 0636 RC 61755-0039-01 NDC Q0243 HCPCS inpatient 1 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50770040_1 CDM 0636 RC 61755-0039-01 NDC Q0243 HCPCS inpatient 1 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50770040_1 CDM 0636 RC 61755-0039-01 NDC Q0243 HCPCS inpatient 1 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50770040_1 CDM 0636 RC 61755-0039-01 NDC Q0243 HCPCS inpatient 1 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 "INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG" 50770040_1 CDM 0636 RC 61755-0039-01 NDC Q0243 HCPCS inpatient 1 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770238_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.15 65 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770238_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 AETNA AETNA 56.09 79 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770238_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 68.87 97 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770238_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.99 69 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770238_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 55.38 78 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770238_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 SIHO - ALL PLANS SIHO - ALL PLANS 63.9 90 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770238_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 UMR - ALL PLANS UMR - ALL PLANS 49.7 70 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770238_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.99 60.55 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770238_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.99 68.87 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770238_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 ANTHEM HMO ANTHEM HMO 999999999 42.99 68.87 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770238_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.99 68.87 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770238_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 48 67.6 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770238_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.99 68.87 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770238_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.99 68.87 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770239_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.15 65 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770239_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 AETNA AETNA 56.09 79 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770239_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 68.87 97 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770239_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.99 69 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770239_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 55.38 78 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770239_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 SIHO - ALL PLANS SIHO - ALL PLANS 63.9 90 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770239_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 UMR - ALL PLANS UMR - ALL PLANS 49.7 70 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770239_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.99 60.55 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770239_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.99 68.87 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770239_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 ANTHEM HMO ANTHEM HMO 999999999 42.99 68.87 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770239_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.99 68.87 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770239_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 48 67.6 999999999 42.99 68.87 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770239_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.99 68.87 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50770239_1 CDM 0301 RC 86003 HCPCS inpatient 71 46.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.99 68.87 "Detection test for candida species (yeast), direct probe technique" 50770336_1 CDM 0306 RC 87480 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50770336_1 CDM 0306 RC 87480 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50770336_1 CDM 0306 RC 87480 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50770336_1 CDM 0306 RC 87480 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50770336_1 CDM 0306 RC 87480 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50770336_1 CDM 0306 RC 87480 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50770336_1 CDM 0306 RC 87480 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50770336_1 CDM 0306 RC 87480 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50770336_1 CDM 0306 RC 87480 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 "Detection test for candida species (yeast), direct probe technique" 50770336_1 CDM 0306 RC 87480 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 "Detection test for candida species (yeast), direct probe technique" 50770336_1 CDM 0306 RC 87480 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 "Detection test for candida species (yeast), direct probe technique" 50770336_1 CDM 0306 RC 87480 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges "Detection test for candida species (yeast), direct probe technique" 50770336_1 CDM 0306 RC 87480 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 "Detection test for candida species (yeast), direct probe technique" 50770336_1 CDM 0306 RC 87480 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50770354_1 CDM 0306 RC 87510 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50770354_1 CDM 0306 RC 87510 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50770354_1 CDM 0306 RC 87510 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50770354_1 CDM 0306 RC 87510 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50770354_1 CDM 0306 RC 87510 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50770354_1 CDM 0306 RC 87510 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50770354_1 CDM 0306 RC 87510 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50770354_1 CDM 0306 RC 87510 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50770354_1 CDM 0306 RC 87510 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50770354_1 CDM 0306 RC 87510 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50770354_1 CDM 0306 RC 87510 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50770354_1 CDM 0306 RC 87510 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50770354_1 CDM 0306 RC 87510 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 "Detection test for gardnerella vaginalis (bacteria), direct probe technique" 50770354_1 CDM 0306 RC 87510 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50770355_1 CDM 0306 RC 87660 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50770355_1 CDM 0306 RC 87660 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50770355_1 CDM 0306 RC 87660 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50770355_1 CDM 0306 RC 87660 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50770355_1 CDM 0306 RC 87660 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50770355_1 CDM 0306 RC 87660 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50770355_1 CDM 0306 RC 87660 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50770355_1 CDM 0306 RC 87660 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50770355_1 CDM 0306 RC 87660 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50770355_1 CDM 0306 RC 87660 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50770355_1 CDM 0306 RC 87660 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50770355_1 CDM 0306 RC 87660 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50770355_1 CDM 0306 RC 87660 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), direct probe technique" 50770355_1 CDM 0306 RC 87660 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 HYDROCODONE-CHLORPHEN ER SUSP 50770433_1 CDM 0250 RC 27808-0086-02 NDC inpatient 1 UN 8.79 5.71 SELF PAY DISCOUNT SELF PAY DISCOUNT 5.71 65 999999999 5.32 8.53 percent of total billed charges HYDROCODONE-CHLORPHEN ER SUSP 50770433_1 CDM 0250 RC 27808-0086-02 NDC inpatient 1 UN 8.79 5.71 AETNA AETNA 6.94 79 999999999 5.32 8.53 percent of total billed charges HYDROCODONE-CHLORPHEN ER SUSP 50770433_1 CDM 0250 RC 27808-0086-02 NDC inpatient 1 UN 8.79 5.71 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8.53 97 999999999 5.32 8.53 percent of total billed charges HYDROCODONE-CHLORPHEN ER SUSP 50770433_1 CDM 0250 RC 27808-0086-02 NDC inpatient 1 UN 8.79 5.71 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.07 69 999999999 5.32 8.53 percent of total billed charges HYDROCODONE-CHLORPHEN ER SUSP 50770433_1 CDM 0250 RC 27808-0086-02 NDC inpatient 1 UN 8.79 5.71 HUMANA - ALL PLANS HUMANA - ALL PLANS 6.86 78 999999999 5.32 8.53 percent of total billed charges HYDROCODONE-CHLORPHEN ER SUSP 50770433_1 CDM 0250 RC 27808-0086-02 NDC inpatient 1 UN 8.79 5.71 SIHO - ALL PLANS SIHO - ALL PLANS 7.91 90 999999999 5.32 8.53 percent of total billed charges HYDROCODONE-CHLORPHEN ER SUSP 50770433_1 CDM 0250 RC 27808-0086-02 NDC inpatient 1 UN 8.79 5.71 UMR - ALL PLANS UMR - ALL PLANS 6.15 70 999999999 5.32 8.53 percent of total billed charges HYDROCODONE-CHLORPHEN ER SUSP 50770433_1 CDM 0250 RC 27808-0086-02 NDC inpatient 1 UN 8.79 5.71 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.32 60.55 999999999 5.32 8.53 percent of total billed charges HYDROCODONE-CHLORPHEN ER SUSP 50770433_1 CDM 0250 RC 27808-0086-02 NDC inpatient 1 UN 8.79 5.71 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.32 8.53 HYDROCODONE-CHLORPHEN ER SUSP 50770433_1 CDM 0250 RC 27808-0086-02 NDC inpatient 1 UN 8.79 5.71 ANTHEM HMO ANTHEM HMO 999999999 5.32 8.53 HYDROCODONE-CHLORPHEN ER SUSP 50770433_1 CDM 0250 RC 27808-0086-02 NDC inpatient 1 UN 8.79 5.71 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.32 8.53 HYDROCODONE-CHLORPHEN ER SUSP 50770433_1 CDM 0250 RC 27808-0086-02 NDC inpatient 1 UN 8.79 5.71 CIGNA - ALL PLANS CIGNA - ALL PLANS 5.94 67.6 999999999 5.32 8.53 percent of total billed charges HYDROCODONE-CHLORPHEN ER SUSP 50770433_1 CDM 0250 RC 27808-0086-02 NDC inpatient 1 UN 8.79 5.71 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.32 8.53 HYDROCODONE-CHLORPHEN ER SUSP 50770433_1 CDM 0250 RC 27808-0086-02 NDC inpatient 1 UN 8.79 5.71 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.32 8.53 "INJ PANTOPRAZOLE SODIUM, VIA" 50771775_1 CDM 0250 RC 00008-0923-51 NDC C9113 HCPCS inpatient 1 UN 31.71 20.61 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.61 65 999999999 19.2 30.76 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 50771775_1 CDM 0250 RC 00008-0923-51 NDC C9113 HCPCS inpatient 1 UN 31.71 20.61 AETNA AETNA 25.05 79 999999999 19.2 30.76 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 50771775_1 CDM 0250 RC 00008-0923-51 NDC C9113 HCPCS inpatient 1 UN 31.71 20.61 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.76 97 999999999 19.2 30.76 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 50771775_1 CDM 0250 RC 00008-0923-51 NDC C9113 HCPCS inpatient 1 UN 31.71 20.61 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.88 69 999999999 19.2 30.76 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 50771775_1 CDM 0250 RC 00008-0923-51 NDC C9113 HCPCS inpatient 1 UN 31.71 20.61 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.73 78 999999999 19.2 30.76 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 50771775_1 CDM 0250 RC 00008-0923-51 NDC C9113 HCPCS inpatient 1 UN 31.71 20.61 SIHO - ALL PLANS SIHO - ALL PLANS 28.54 90 999999999 19.2 30.76 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 50771775_1 CDM 0250 RC 00008-0923-51 NDC C9113 HCPCS inpatient 1 UN 31.71 20.61 UMR - ALL PLANS UMR - ALL PLANS 22.2 70 999999999 19.2 30.76 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 50771775_1 CDM 0250 RC 00008-0923-51 NDC C9113 HCPCS inpatient 1 UN 31.71 20.61 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.2 60.55 999999999 19.2 30.76 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 50771775_1 CDM 0250 RC 00008-0923-51 NDC C9113 HCPCS inpatient 1 UN 31.71 20.61 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.2 30.76 "INJ PANTOPRAZOLE SODIUM, VIA" 50771775_1 CDM 0250 RC 00008-0923-51 NDC C9113 HCPCS inpatient 1 UN 31.71 20.61 ANTHEM HMO ANTHEM HMO 999999999 19.2 30.76 "INJ PANTOPRAZOLE SODIUM, VIA" 50771775_1 CDM 0250 RC 00008-0923-51 NDC C9113 HCPCS inpatient 1 UN 31.71 20.61 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.2 30.76 "INJ PANTOPRAZOLE SODIUM, VIA" 50771775_1 CDM 0250 RC 00008-0923-51 NDC C9113 HCPCS inpatient 1 UN 31.71 20.61 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.44 67.6 999999999 19.2 30.76 percent of total billed charges "INJ PANTOPRAZOLE SODIUM, VIA" 50771775_1 CDM 0250 RC 00008-0923-51 NDC C9113 HCPCS inpatient 1 UN 31.71 20.61 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.2 30.76 "INJ PANTOPRAZOLE SODIUM, VIA" 50771775_1 CDM 0250 RC 00008-0923-51 NDC C9113 HCPCS inpatient 1 UN 31.71 20.61 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.2 30.76 "INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG" 50771916_1 CDM 0250 RC 00006-3516-59 NDC J0743 HCPCS inpatient 2 UN 155.39 101 SELF PAY DISCOUNT SELF PAY DISCOUNT 101 65 999999999 94.09 150.73 percent of total billed charges "INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG" 50771916_1 CDM 0250 RC 00006-3516-59 NDC J0743 HCPCS inpatient 2 UN 155.39 101 AETNA AETNA 122.76 79 999999999 94.09 150.73 percent of total billed charges "INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG" 50771916_1 CDM 0250 RC 00006-3516-59 NDC J0743 HCPCS inpatient 2 UN 155.39 101 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 150.73 97 999999999 94.09 150.73 percent of total billed charges "INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG" 50771916_1 CDM 0250 RC 00006-3516-59 NDC J0743 HCPCS inpatient 2 UN 155.39 101 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.22 69 999999999 94.09 150.73 percent of total billed charges "INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG" 50771916_1 CDM 0250 RC 00006-3516-59 NDC J0743 HCPCS inpatient 2 UN 155.39 101 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.2 78 999999999 94.09 150.73 percent of total billed charges "INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG" 50771916_1 CDM 0250 RC 00006-3516-59 NDC J0743 HCPCS inpatient 2 UN 155.39 101 SIHO - ALL PLANS SIHO - ALL PLANS 139.85 90 999999999 94.09 150.73 percent of total billed charges "INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG" 50771916_1 CDM 0250 RC 00006-3516-59 NDC J0743 HCPCS inpatient 2 UN 155.39 101 UMR - ALL PLANS UMR - ALL PLANS 108.77 70 999999999 94.09 150.73 percent of total billed charges "INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG" 50771916_1 CDM 0250 RC 00006-3516-59 NDC J0743 HCPCS inpatient 2 UN 155.39 101 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.09 60.55 999999999 94.09 150.73 percent of total billed charges "INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG" 50771916_1 CDM 0250 RC 00006-3516-59 NDC J0743 HCPCS inpatient 2 UN 155.39 101 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.09 150.73 "INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG" 50771916_1 CDM 0250 RC 00006-3516-59 NDC J0743 HCPCS inpatient 2 UN 155.39 101 ANTHEM HMO ANTHEM HMO 999999999 94.09 150.73 "INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG" 50771916_1 CDM 0250 RC 00006-3516-59 NDC J0743 HCPCS inpatient 2 UN 155.39 101 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.09 150.73 "INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG" 50771916_1 CDM 0250 RC 00006-3516-59 NDC J0743 HCPCS inpatient 2 UN 155.39 101 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.04 67.6 999999999 94.09 150.73 percent of total billed charges "INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG" 50771916_1 CDM 0250 RC 00006-3516-59 NDC J0743 HCPCS inpatient 2 UN 155.39 101 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.09 150.73 "INJECTION, CILASTATIN SODIUM; IMIPENEM, PER 250 MG" 50771916_1 CDM 0250 RC 00006-3516-59 NDC J0743 HCPCS inpatient 2 UN 155.39 101 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.09 150.73 "Measurement of antibody for assessment of autoimmune disorder, titer" 50772769_1 CDM 0301 RC 86039 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50772769_1 CDM 0301 RC 86039 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50772769_1 CDM 0301 RC 86039 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50772769_1 CDM 0301 RC 86039 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50772769_1 CDM 0301 RC 86039 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50772769_1 CDM 0301 RC 86039 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50772769_1 CDM 0301 RC 86039 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50772769_1 CDM 0301 RC 86039 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50772769_1 CDM 0301 RC 86039 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 "Measurement of antibody for assessment of autoimmune disorder, titer" 50772769_1 CDM 0301 RC 86039 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 "Measurement of antibody for assessment of autoimmune disorder, titer" 50772769_1 CDM 0301 RC 86039 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 "Measurement of antibody for assessment of autoimmune disorder, titer" 50772769_1 CDM 0301 RC 86039 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, titer" 50772769_1 CDM 0301 RC 86039 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 "Measurement of antibody for assessment of autoimmune disorder, titer" 50772769_1 CDM 0301 RC 86039 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 "Measurement of antibody for assessment of autoimmune disorder, any method" 50772792_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50772792_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50772792_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50772792_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50772792_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50772792_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50772792_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50772792_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50772792_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50772792_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50772792_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50772792_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges "Measurement of antibody for assessment of autoimmune disorder, any method" 50772792_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 "Measurement of antibody for assessment of autoimmune disorder, any method" 50772792_1 CDM 0302 RC 86235 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 "Analysis of substance using immunoassay technique, multiple step method" 50772793_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50772793_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50772793_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50772793_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50772793_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50772793_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50772793_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50772793_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50772793_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50772793_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50772793_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50772793_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50772793_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50772793_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50772794_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50772794_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50772794_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50772794_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50772794_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50772794_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50772794_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50772794_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50772794_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50772794_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50772794_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50772794_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50772794_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 50772794_1 CDM 0302 RC 83516 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 BULKAMID KIT 50050 MUST ORDER IN MULTIPLES OF 5 EACH PER ORDER 50775206_1 CDM 0272 RC inpatient 4227 2747.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 2747.55 65 999999999 2559.45 4100.19 percent of total billed charges BULKAMID KIT 50050 MUST ORDER IN MULTIPLES OF 5 EACH PER ORDER 50775206_1 CDM 0272 RC inpatient 4227 2747.55 AETNA AETNA 3339.33 79 999999999 2559.45 4100.19 percent of total billed charges BULKAMID KIT 50050 MUST ORDER IN MULTIPLES OF 5 EACH PER ORDER 50775206_1 CDM 0272 RC inpatient 4227 2747.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4100.19 97 999999999 2559.45 4100.19 percent of total billed charges BULKAMID KIT 50050 MUST ORDER IN MULTIPLES OF 5 EACH PER ORDER 50775206_1 CDM 0272 RC inpatient 4227 2747.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 2916.63 69 999999999 2559.45 4100.19 percent of total billed charges BULKAMID KIT 50050 MUST ORDER IN MULTIPLES OF 5 EACH PER ORDER 50775206_1 CDM 0272 RC inpatient 4227 2747.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 3297.06 78 999999999 2559.45 4100.19 percent of total billed charges BULKAMID KIT 50050 MUST ORDER IN MULTIPLES OF 5 EACH PER ORDER 50775206_1 CDM 0272 RC inpatient 4227 2747.55 SIHO - ALL PLANS SIHO - ALL PLANS 3804.3 90 999999999 2559.45 4100.19 percent of total billed charges BULKAMID KIT 50050 MUST ORDER IN MULTIPLES OF 5 EACH PER ORDER 50775206_1 CDM 0272 RC inpatient 4227 2747.55 UMR - ALL PLANS UMR - ALL PLANS 2958.9 70 999999999 2559.45 4100.19 percent of total billed charges BULKAMID KIT 50050 MUST ORDER IN MULTIPLES OF 5 EACH PER ORDER 50775206_1 CDM 0272 RC inpatient 4227 2747.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2559.45 60.55 999999999 2559.45 4100.19 percent of total billed charges BULKAMID KIT 50050 MUST ORDER IN MULTIPLES OF 5 EACH PER ORDER 50775206_1 CDM 0272 RC inpatient 4227 2747.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2559.45 4100.19 BULKAMID KIT 50050 MUST ORDER IN MULTIPLES OF 5 EACH PER ORDER 50775206_1 CDM 0272 RC inpatient 4227 2747.55 ANTHEM HMO ANTHEM HMO 999999999 2559.45 4100.19 BULKAMID KIT 50050 MUST ORDER IN MULTIPLES OF 5 EACH PER ORDER 50775206_1 CDM 0272 RC inpatient 4227 2747.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2559.45 4100.19 BULKAMID KIT 50050 MUST ORDER IN MULTIPLES OF 5 EACH PER ORDER 50775206_1 CDM 0272 RC inpatient 4227 2747.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 2857.45 67.6 999999999 2559.45 4100.19 percent of total billed charges BULKAMID KIT 50050 MUST ORDER IN MULTIPLES OF 5 EACH PER ORDER 50775206_1 CDM 0272 RC inpatient 4227 2747.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2559.45 4100.19 BULKAMID KIT 50050 MUST ORDER IN MULTIPLES OF 5 EACH PER ORDER 50775206_1 CDM 0272 RC inpatient 4227 2747.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 2559.45 4100.19 "ASCOR 25,000 MG/50 ML BULK VL" 50776672_1 CDM 0250 RC 67157-0101-51 NDC inpatient 1 UN 12.33 8.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.01 65 999999999 7.47 11.96 percent of total billed charges "ASCOR 25,000 MG/50 ML BULK VL" 50776672_1 CDM 0250 RC 67157-0101-51 NDC inpatient 1 UN 12.33 8.01 AETNA AETNA 9.74 79 999999999 7.47 11.96 percent of total billed charges "ASCOR 25,000 MG/50 ML BULK VL" 50776672_1 CDM 0250 RC 67157-0101-51 NDC inpatient 1 UN 12.33 8.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11.96 97 999999999 7.47 11.96 percent of total billed charges "ASCOR 25,000 MG/50 ML BULK VL" 50776672_1 CDM 0250 RC 67157-0101-51 NDC inpatient 1 UN 12.33 8.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.51 69 999999999 7.47 11.96 percent of total billed charges "ASCOR 25,000 MG/50 ML BULK VL" 50776672_1 CDM 0250 RC 67157-0101-51 NDC inpatient 1 UN 12.33 8.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.62 78 999999999 7.47 11.96 percent of total billed charges "ASCOR 25,000 MG/50 ML BULK VL" 50776672_1 CDM 0250 RC 67157-0101-51 NDC inpatient 1 UN 12.33 8.01 SIHO - ALL PLANS SIHO - ALL PLANS 11.1 90 999999999 7.47 11.96 percent of total billed charges "ASCOR 25,000 MG/50 ML BULK VL" 50776672_1 CDM 0250 RC 67157-0101-51 NDC inpatient 1 UN 12.33 8.01 UMR - ALL PLANS UMR - ALL PLANS 8.63 70 999999999 7.47 11.96 percent of total billed charges "ASCOR 25,000 MG/50 ML BULK VL" 50776672_1 CDM 0250 RC 67157-0101-51 NDC inpatient 1 UN 12.33 8.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.47 60.55 999999999 7.47 11.96 percent of total billed charges "ASCOR 25,000 MG/50 ML BULK VL" 50776672_1 CDM 0250 RC 67157-0101-51 NDC inpatient 1 UN 12.33 8.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.47 11.96 "ASCOR 25,000 MG/50 ML BULK VL" 50776672_1 CDM 0250 RC 67157-0101-51 NDC inpatient 1 UN 12.33 8.01 ANTHEM HMO ANTHEM HMO 999999999 7.47 11.96 "ASCOR 25,000 MG/50 ML BULK VL" 50776672_1 CDM 0250 RC 67157-0101-51 NDC inpatient 1 UN 12.33 8.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.47 11.96 "ASCOR 25,000 MG/50 ML BULK VL" 50776672_1 CDM 0250 RC 67157-0101-51 NDC inpatient 1 UN 12.33 8.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.34 67.6 999999999 7.47 11.96 percent of total billed charges "ASCOR 25,000 MG/50 ML BULK VL" 50776672_1 CDM 0250 RC 67157-0101-51 NDC inpatient 1 UN 12.33 8.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.47 11.96 "ASCOR 25,000 MG/50 ML BULK VL" 50776672_1 CDM 0250 RC 67157-0101-51 NDC inpatient 1 UN 12.33 8.01 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.47 11.96 MAGNESIUM CHL 200 MG/ML VIAL 50776678_1 CDM 0250 RC 67457-0134-50 NDC inpatient 1 UN 10.16 6.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.6 65 999999999 6.15 9.86 percent of total billed charges MAGNESIUM CHL 200 MG/ML VIAL 50776678_1 CDM 0250 RC 67457-0134-50 NDC inpatient 1 UN 10.16 6.6 AETNA AETNA 8.03 79 999999999 6.15 9.86 percent of total billed charges MAGNESIUM CHL 200 MG/ML VIAL 50776678_1 CDM 0250 RC 67457-0134-50 NDC inpatient 1 UN 10.16 6.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.86 97 999999999 6.15 9.86 percent of total billed charges MAGNESIUM CHL 200 MG/ML VIAL 50776678_1 CDM 0250 RC 67457-0134-50 NDC inpatient 1 UN 10.16 6.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 7.01 69 999999999 6.15 9.86 percent of total billed charges MAGNESIUM CHL 200 MG/ML VIAL 50776678_1 CDM 0250 RC 67457-0134-50 NDC inpatient 1 UN 10.16 6.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.92 78 999999999 6.15 9.86 percent of total billed charges MAGNESIUM CHL 200 MG/ML VIAL 50776678_1 CDM 0250 RC 67457-0134-50 NDC inpatient 1 UN 10.16 6.6 SIHO - ALL PLANS SIHO - ALL PLANS 9.14 90 999999999 6.15 9.86 percent of total billed charges MAGNESIUM CHL 200 MG/ML VIAL 50776678_1 CDM 0250 RC 67457-0134-50 NDC inpatient 1 UN 10.16 6.6 UMR - ALL PLANS UMR - ALL PLANS 7.11 70 999999999 6.15 9.86 percent of total billed charges MAGNESIUM CHL 200 MG/ML VIAL 50776678_1 CDM 0250 RC 67457-0134-50 NDC inpatient 1 UN 10.16 6.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6.15 60.55 999999999 6.15 9.86 percent of total billed charges MAGNESIUM CHL 200 MG/ML VIAL 50776678_1 CDM 0250 RC 67457-0134-50 NDC inpatient 1 UN 10.16 6.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6.15 9.86 MAGNESIUM CHL 200 MG/ML VIAL 50776678_1 CDM 0250 RC 67457-0134-50 NDC inpatient 1 UN 10.16 6.6 ANTHEM HMO ANTHEM HMO 999999999 6.15 9.86 MAGNESIUM CHL 200 MG/ML VIAL 50776678_1 CDM 0250 RC 67457-0134-50 NDC inpatient 1 UN 10.16 6.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6.15 9.86 MAGNESIUM CHL 200 MG/ML VIAL 50776678_1 CDM 0250 RC 67457-0134-50 NDC inpatient 1 UN 10.16 6.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.87 67.6 999999999 6.15 9.86 percent of total billed charges MAGNESIUM CHL 200 MG/ML VIAL 50776678_1 CDM 0250 RC 67457-0134-50 NDC inpatient 1 UN 10.16 6.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6.15 9.86 MAGNESIUM CHL 200 MG/ML VIAL 50776678_1 CDM 0250 RC 67457-0134-50 NDC inpatient 1 UN 10.16 6.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 6.15 9.86 "INJECTION, TILDRAKIZUMAB, 1 MG" 50777507_1 CDM 0636 RC 47335-0177-95 NDC J3245 HCPCS inpatient 100 UN 69451.06 45143.19 SELF PAY DISCOUNT SELF PAY DISCOUNT 45143.19 65 999999999 42052.62 67367.53 percent of total billed charges "INJECTION, TILDRAKIZUMAB, 1 MG" 50777507_1 CDM 0636 RC 47335-0177-95 NDC J3245 HCPCS inpatient 100 UN 69451.06 45143.19 AETNA AETNA 54866.34 79 999999999 42052.62 67367.53 percent of total billed charges "INJECTION, TILDRAKIZUMAB, 1 MG" 50777507_1 CDM 0636 RC 47335-0177-95 NDC J3245 HCPCS inpatient 100 UN 69451.06 45143.19 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67367.53 97 999999999 42052.62 67367.53 percent of total billed charges "INJECTION, TILDRAKIZUMAB, 1 MG" 50777507_1 CDM 0636 RC 47335-0177-95 NDC J3245 HCPCS inpatient 100 UN 69451.06 45143.19 ENCORE - ALL PLANS ENCORE - ALL PLANS 47921.23 69 999999999 42052.62 67367.53 percent of total billed charges "INJECTION, TILDRAKIZUMAB, 1 MG" 50777507_1 CDM 0636 RC 47335-0177-95 NDC J3245 HCPCS inpatient 100 UN 69451.06 45143.19 HUMANA - ALL PLANS HUMANA - ALL PLANS 54171.83 78 999999999 42052.62 67367.53 percent of total billed charges "INJECTION, TILDRAKIZUMAB, 1 MG" 50777507_1 CDM 0636 RC 47335-0177-95 NDC J3245 HCPCS inpatient 100 UN 69451.06 45143.19 SIHO - ALL PLANS SIHO - ALL PLANS 62505.95 90 999999999 42052.62 67367.53 percent of total billed charges "INJECTION, TILDRAKIZUMAB, 1 MG" 50777507_1 CDM 0636 RC 47335-0177-95 NDC J3245 HCPCS inpatient 100 UN 69451.06 45143.19 UMR - ALL PLANS UMR - ALL PLANS 48615.74 70 999999999 42052.62 67367.53 percent of total billed charges "INJECTION, TILDRAKIZUMAB, 1 MG" 50777507_1 CDM 0636 RC 47335-0177-95 NDC J3245 HCPCS inpatient 100 UN 69451.06 45143.19 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42052.62 60.55 999999999 42052.62 67367.53 percent of total billed charges "INJECTION, TILDRAKIZUMAB, 1 MG" 50777507_1 CDM 0636 RC 47335-0177-95 NDC J3245 HCPCS inpatient 100 UN 69451.06 45143.19 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42052.62 67367.53 "INJECTION, TILDRAKIZUMAB, 1 MG" 50777507_1 CDM 0636 RC 47335-0177-95 NDC J3245 HCPCS inpatient 100 UN 69451.06 45143.19 ANTHEM HMO ANTHEM HMO 999999999 42052.62 67367.53 "INJECTION, TILDRAKIZUMAB, 1 MG" 50777507_1 CDM 0636 RC 47335-0177-95 NDC J3245 HCPCS inpatient 100 UN 69451.06 45143.19 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42052.62 67367.53 "INJECTION, TILDRAKIZUMAB, 1 MG" 50777507_1 CDM 0636 RC 47335-0177-95 NDC J3245 HCPCS inpatient 100 UN 69451.06 45143.19 CIGNA - ALL PLANS CIGNA - ALL PLANS 46948.92 67.6 999999999 42052.62 67367.53 percent of total billed charges "INJECTION, TILDRAKIZUMAB, 1 MG" 50777507_1 CDM 0636 RC 47335-0177-95 NDC J3245 HCPCS inpatient 100 UN 69451.06 45143.19 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42052.62 67367.53 "INJECTION, TILDRAKIZUMAB, 1 MG" 50777507_1 CDM 0636 RC 47335-0177-95 NDC J3245 HCPCS inpatient 100 UN 69451.06 45143.19 UHC - ALL PLANS UHC - ALL PLANS 999999999 42052.62 67367.53 "Influenza vaccine split virus, preservative free" 50777512_1 CDM 0250 RC 58160-0887-52 NDC 90662 HCPCS inpatient 1 UN 25.32 16.46 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.46 65 999999999 15.33 24.56 percent of total billed charges "Influenza vaccine split virus, preservative free" 50777512_1 CDM 0250 RC 58160-0887-52 NDC 90662 HCPCS inpatient 1 UN 25.32 16.46 AETNA AETNA 20 79 999999999 15.33 24.56 percent of total billed charges "Influenza vaccine split virus, preservative free" 50777512_1 CDM 0250 RC 58160-0887-52 NDC 90662 HCPCS inpatient 1 UN 25.32 16.46 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24.56 97 999999999 15.33 24.56 percent of total billed charges "Influenza vaccine split virus, preservative free" 50777512_1 CDM 0250 RC 58160-0887-52 NDC 90662 HCPCS inpatient 1 UN 25.32 16.46 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.47 69 999999999 15.33 24.56 percent of total billed charges "Influenza vaccine split virus, preservative free" 50777512_1 CDM 0250 RC 58160-0887-52 NDC 90662 HCPCS inpatient 1 UN 25.32 16.46 HUMANA - ALL PLANS HUMANA - ALL PLANS 19.75 78 999999999 15.33 24.56 percent of total billed charges "Influenza vaccine split virus, preservative free" 50777512_1 CDM 0250 RC 58160-0887-52 NDC 90662 HCPCS inpatient 1 UN 25.32 16.46 SIHO - ALL PLANS SIHO - ALL PLANS 22.79 90 999999999 15.33 24.56 percent of total billed charges "Influenza vaccine split virus, preservative free" 50777512_1 CDM 0250 RC 58160-0887-52 NDC 90662 HCPCS inpatient 1 UN 25.32 16.46 UMR - ALL PLANS UMR - ALL PLANS 17.72 70 999999999 15.33 24.56 percent of total billed charges "Influenza vaccine split virus, preservative free" 50777512_1 CDM 0250 RC 58160-0887-52 NDC 90662 HCPCS inpatient 1 UN 25.32 16.46 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.33 60.55 999999999 15.33 24.56 percent of total billed charges "Influenza vaccine split virus, preservative free" 50777512_1 CDM 0250 RC 58160-0887-52 NDC 90662 HCPCS inpatient 1 UN 25.32 16.46 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.33 24.56 "Influenza vaccine split virus, preservative free" 50777512_1 CDM 0250 RC 58160-0887-52 NDC 90662 HCPCS inpatient 1 UN 25.32 16.46 ANTHEM HMO ANTHEM HMO 999999999 15.33 24.56 "Influenza vaccine split virus, preservative free" 50777512_1 CDM 0250 RC 58160-0887-52 NDC 90662 HCPCS inpatient 1 UN 25.32 16.46 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.33 24.56 "Influenza vaccine split virus, preservative free" 50777512_1 CDM 0250 RC 58160-0887-52 NDC 90662 HCPCS inpatient 1 UN 25.32 16.46 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.12 67.6 999999999 15.33 24.56 percent of total billed charges "Influenza vaccine split virus, preservative free" 50777512_1 CDM 0250 RC 58160-0887-52 NDC 90662 HCPCS inpatient 1 UN 25.32 16.46 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.33 24.56 "Influenza vaccine split virus, preservative free" 50777512_1 CDM 0250 RC 58160-0887-52 NDC 90662 HCPCS inpatient 1 UN 25.32 16.46 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.33 24.56 "HEPARIN 10,000 UNIT/10 ML VIAL" 50777518_1 CDM 0250 RC 71288-0402-11 NDC inpatient 1 UN 31.98 20.79 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.79 65 999999999 19.36 31.02 percent of total billed charges "HEPARIN 10,000 UNIT/10 ML VIAL" 50777518_1 CDM 0250 RC 71288-0402-11 NDC inpatient 1 UN 31.98 20.79 AETNA AETNA 25.26 79 999999999 19.36 31.02 percent of total billed charges "HEPARIN 10,000 UNIT/10 ML VIAL" 50777518_1 CDM 0250 RC 71288-0402-11 NDC inpatient 1 UN 31.98 20.79 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31.02 97 999999999 19.36 31.02 percent of total billed charges "HEPARIN 10,000 UNIT/10 ML VIAL" 50777518_1 CDM 0250 RC 71288-0402-11 NDC inpatient 1 UN 31.98 20.79 ENCORE - ALL PLANS ENCORE - ALL PLANS 22.07 69 999999999 19.36 31.02 percent of total billed charges "HEPARIN 10,000 UNIT/10 ML VIAL" 50777518_1 CDM 0250 RC 71288-0402-11 NDC inpatient 1 UN 31.98 20.79 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.94 78 999999999 19.36 31.02 percent of total billed charges "HEPARIN 10,000 UNIT/10 ML VIAL" 50777518_1 CDM 0250 RC 71288-0402-11 NDC inpatient 1 UN 31.98 20.79 SIHO - ALL PLANS SIHO - ALL PLANS 28.78 90 999999999 19.36 31.02 percent of total billed charges "HEPARIN 10,000 UNIT/10 ML VIAL" 50777518_1 CDM 0250 RC 71288-0402-11 NDC inpatient 1 UN 31.98 20.79 UMR - ALL PLANS UMR - ALL PLANS 22.39 70 999999999 19.36 31.02 percent of total billed charges "HEPARIN 10,000 UNIT/10 ML VIAL" 50777518_1 CDM 0250 RC 71288-0402-11 NDC inpatient 1 UN 31.98 20.79 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.36 60.55 999999999 19.36 31.02 percent of total billed charges "HEPARIN 10,000 UNIT/10 ML VIAL" 50777518_1 CDM 0250 RC 71288-0402-11 NDC inpatient 1 UN 31.98 20.79 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.36 31.02 "HEPARIN 10,000 UNIT/10 ML VIAL" 50777518_1 CDM 0250 RC 71288-0402-11 NDC inpatient 1 UN 31.98 20.79 ANTHEM HMO ANTHEM HMO 999999999 19.36 31.02 "HEPARIN 10,000 UNIT/10 ML VIAL" 50777518_1 CDM 0250 RC 71288-0402-11 NDC inpatient 1 UN 31.98 20.79 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.36 31.02 "HEPARIN 10,000 UNIT/10 ML VIAL" 50777518_1 CDM 0250 RC 71288-0402-11 NDC inpatient 1 UN 31.98 20.79 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.62 67.6 999999999 19.36 31.02 percent of total billed charges "HEPARIN 10,000 UNIT/10 ML VIAL" 50777518_1 CDM 0250 RC 71288-0402-11 NDC inpatient 1 UN 31.98 20.79 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.36 31.02 "HEPARIN 10,000 UNIT/10 ML VIAL" 50777518_1 CDM 0250 RC 71288-0402-11 NDC inpatient 1 UN 31.98 20.79 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.36 31.02 RALOXIFENE HCL 60 MG TABLET 50777520_1 CDM 0250 RC 50268-0694-15 NDC inpatient 1 UN 9.69 6.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 6.3 65 999999999 5.87 9.4 percent of total billed charges RALOXIFENE HCL 60 MG TABLET 50777520_1 CDM 0250 RC 50268-0694-15 NDC inpatient 1 UN 9.69 6.3 AETNA AETNA 7.66 79 999999999 5.87 9.4 percent of total billed charges RALOXIFENE HCL 60 MG TABLET 50777520_1 CDM 0250 RC 50268-0694-15 NDC inpatient 1 UN 9.69 6.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9.4 97 999999999 5.87 9.4 percent of total billed charges RALOXIFENE HCL 60 MG TABLET 50777520_1 CDM 0250 RC 50268-0694-15 NDC inpatient 1 UN 9.69 6.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 6.69 69 999999999 5.87 9.4 percent of total billed charges RALOXIFENE HCL 60 MG TABLET 50777520_1 CDM 0250 RC 50268-0694-15 NDC inpatient 1 UN 9.69 6.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 7.56 78 999999999 5.87 9.4 percent of total billed charges RALOXIFENE HCL 60 MG TABLET 50777520_1 CDM 0250 RC 50268-0694-15 NDC inpatient 1 UN 9.69 6.3 SIHO - ALL PLANS SIHO - ALL PLANS 8.72 90 999999999 5.87 9.4 percent of total billed charges RALOXIFENE HCL 60 MG TABLET 50777520_1 CDM 0250 RC 50268-0694-15 NDC inpatient 1 UN 9.69 6.3 UMR - ALL PLANS UMR - ALL PLANS 6.78 70 999999999 5.87 9.4 percent of total billed charges RALOXIFENE HCL 60 MG TABLET 50777520_1 CDM 0250 RC 50268-0694-15 NDC inpatient 1 UN 9.69 6.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5.87 60.55 999999999 5.87 9.4 percent of total billed charges RALOXIFENE HCL 60 MG TABLET 50777520_1 CDM 0250 RC 50268-0694-15 NDC inpatient 1 UN 9.69 6.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5.87 9.4 RALOXIFENE HCL 60 MG TABLET 50777520_1 CDM 0250 RC 50268-0694-15 NDC inpatient 1 UN 9.69 6.3 ANTHEM HMO ANTHEM HMO 999999999 5.87 9.4 RALOXIFENE HCL 60 MG TABLET 50777520_1 CDM 0250 RC 50268-0694-15 NDC inpatient 1 UN 9.69 6.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5.87 9.4 RALOXIFENE HCL 60 MG TABLET 50777520_1 CDM 0250 RC 50268-0694-15 NDC inpatient 1 UN 9.69 6.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 6.55 67.6 999999999 5.87 9.4 percent of total billed charges RALOXIFENE HCL 60 MG TABLET 50777520_1 CDM 0250 RC 50268-0694-15 NDC inpatient 1 UN 9.69 6.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5.87 9.4 RALOXIFENE HCL 60 MG TABLET 50777520_1 CDM 0250 RC 50268-0694-15 NDC inpatient 1 UN 9.69 6.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 5.87 9.4 DIAZEPAM 10 MG/2 ML SYRINGE 50777680_1 CDM 0250 RC 69339-0136-34 NDC inpatient 1 UN 98.24 63.86 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.86 65 999999999 59.48 95.29 percent of total billed charges DIAZEPAM 10 MG/2 ML SYRINGE 50777680_1 CDM 0250 RC 69339-0136-34 NDC inpatient 1 UN 98.24 63.86 AETNA AETNA 77.61 79 999999999 59.48 95.29 percent of total billed charges DIAZEPAM 10 MG/2 ML SYRINGE 50777680_1 CDM 0250 RC 69339-0136-34 NDC inpatient 1 UN 98.24 63.86 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.29 97 999999999 59.48 95.29 percent of total billed charges DIAZEPAM 10 MG/2 ML SYRINGE 50777680_1 CDM 0250 RC 69339-0136-34 NDC inpatient 1 UN 98.24 63.86 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.79 69 999999999 59.48 95.29 percent of total billed charges DIAZEPAM 10 MG/2 ML SYRINGE 50777680_1 CDM 0250 RC 69339-0136-34 NDC inpatient 1 UN 98.24 63.86 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.63 78 999999999 59.48 95.29 percent of total billed charges DIAZEPAM 10 MG/2 ML SYRINGE 50777680_1 CDM 0250 RC 69339-0136-34 NDC inpatient 1 UN 98.24 63.86 SIHO - ALL PLANS SIHO - ALL PLANS 88.42 90 999999999 59.48 95.29 percent of total billed charges DIAZEPAM 10 MG/2 ML SYRINGE 50777680_1 CDM 0250 RC 69339-0136-34 NDC inpatient 1 UN 98.24 63.86 UMR - ALL PLANS UMR - ALL PLANS 68.77 70 999999999 59.48 95.29 percent of total billed charges DIAZEPAM 10 MG/2 ML SYRINGE 50777680_1 CDM 0250 RC 69339-0136-34 NDC inpatient 1 UN 98.24 63.86 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.48 60.55 999999999 59.48 95.29 percent of total billed charges DIAZEPAM 10 MG/2 ML SYRINGE 50777680_1 CDM 0250 RC 69339-0136-34 NDC inpatient 1 UN 98.24 63.86 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.48 95.29 DIAZEPAM 10 MG/2 ML SYRINGE 50777680_1 CDM 0250 RC 69339-0136-34 NDC inpatient 1 UN 98.24 63.86 ANTHEM HMO ANTHEM HMO 999999999 59.48 95.29 DIAZEPAM 10 MG/2 ML SYRINGE 50777680_1 CDM 0250 RC 69339-0136-34 NDC inpatient 1 UN 98.24 63.86 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.48 95.29 DIAZEPAM 10 MG/2 ML SYRINGE 50777680_1 CDM 0250 RC 69339-0136-34 NDC inpatient 1 UN 98.24 63.86 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.41 67.6 999999999 59.48 95.29 percent of total billed charges DIAZEPAM 10 MG/2 ML SYRINGE 50777680_1 CDM 0250 RC 69339-0136-34 NDC inpatient 1 UN 98.24 63.86 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.48 95.29 DIAZEPAM 10 MG/2 ML SYRINGE 50777680_1 CDM 0250 RC 69339-0136-34 NDC inpatient 1 UN 98.24 63.86 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.48 95.29 PACERONE 200 MG TABLET 50777989_1 CDM 0250 RC 00245-0147-01 NDC inpatient 10 UN 1.65 1.07 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.07 65 999999999 1 1.6 percent of total billed charges PACERONE 200 MG TABLET 50777989_1 CDM 0250 RC 00245-0147-01 NDC inpatient 10 UN 1.65 1.07 AETNA AETNA 1.3 79 999999999 1 1.6 percent of total billed charges PACERONE 200 MG TABLET 50777989_1 CDM 0250 RC 00245-0147-01 NDC inpatient 10 UN 1.65 1.07 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.6 97 999999999 1 1.6 percent of total billed charges PACERONE 200 MG TABLET 50777989_1 CDM 0250 RC 00245-0147-01 NDC inpatient 10 UN 1.65 1.07 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.14 69 999999999 1 1.6 percent of total billed charges PACERONE 200 MG TABLET 50777989_1 CDM 0250 RC 00245-0147-01 NDC inpatient 10 UN 1.65 1.07 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.29 78 999999999 1 1.6 percent of total billed charges PACERONE 200 MG TABLET 50777989_1 CDM 0250 RC 00245-0147-01 NDC inpatient 10 UN 1.65 1.07 SIHO - ALL PLANS SIHO - ALL PLANS 1.49 90 999999999 1 1.6 percent of total billed charges PACERONE 200 MG TABLET 50777989_1 CDM 0250 RC 00245-0147-01 NDC inpatient 10 UN 1.65 1.07 UMR - ALL PLANS UMR - ALL PLANS 1.16 70 999999999 1 1.6 percent of total billed charges PACERONE 200 MG TABLET 50777989_1 CDM 0250 RC 00245-0147-01 NDC inpatient 10 UN 1.65 1.07 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1 60.55 999999999 1 1.6 percent of total billed charges PACERONE 200 MG TABLET 50777989_1 CDM 0250 RC 00245-0147-01 NDC inpatient 10 UN 1.65 1.07 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1 1.6 PACERONE 200 MG TABLET 50777989_1 CDM 0250 RC 00245-0147-01 NDC inpatient 10 UN 1.65 1.07 ANTHEM HMO ANTHEM HMO 999999999 1 1.6 PACERONE 200 MG TABLET 50777989_1 CDM 0250 RC 00245-0147-01 NDC inpatient 10 UN 1.65 1.07 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1 1.6 PACERONE 200 MG TABLET 50777989_1 CDM 0250 RC 00245-0147-01 NDC inpatient 10 UN 1.65 1.07 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.12 67.6 999999999 1 1.6 percent of total billed charges PACERONE 200 MG TABLET 50777989_1 CDM 0250 RC 00245-0147-01 NDC inpatient 10 UN 1.65 1.07 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1 1.6 PACERONE 200 MG TABLET 50777989_1 CDM 0250 RC 00245-0147-01 NDC inpatient 10 UN 1.65 1.07 UHC - ALL PLANS UHC - ALL PLANS 999999999 1 1.6 FAMOTIDINE 20 MG/2 ML VIAL 50778514_1 CDM 0250 RC 70860-0751-02 NDC inpatient 1 UN 20 13 SELF PAY DISCOUNT SELF PAY DISCOUNT 13 65 999999999 12.11 19.4 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 50778514_1 CDM 0250 RC 70860-0751-02 NDC inpatient 1 UN 20 13 AETNA AETNA 15.8 79 999999999 12.11 19.4 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 50778514_1 CDM 0250 RC 70860-0751-02 NDC inpatient 1 UN 20 13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19.4 97 999999999 12.11 19.4 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 50778514_1 CDM 0250 RC 70860-0751-02 NDC inpatient 1 UN 20 13 ENCORE - ALL PLANS ENCORE - ALL PLANS 13.8 69 999999999 12.11 19.4 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 50778514_1 CDM 0250 RC 70860-0751-02 NDC inpatient 1 UN 20 13 HUMANA - ALL PLANS HUMANA - ALL PLANS 15.6 78 999999999 12.11 19.4 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 50778514_1 CDM 0250 RC 70860-0751-02 NDC inpatient 1 UN 20 13 SIHO - ALL PLANS SIHO - ALL PLANS 18 90 999999999 12.11 19.4 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 50778514_1 CDM 0250 RC 70860-0751-02 NDC inpatient 1 UN 20 13 UMR - ALL PLANS UMR - ALL PLANS 14 70 999999999 12.11 19.4 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 50778514_1 CDM 0250 RC 70860-0751-02 NDC inpatient 1 UN 20 13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.11 60.55 999999999 12.11 19.4 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 50778514_1 CDM 0250 RC 70860-0751-02 NDC inpatient 1 UN 20 13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.11 19.4 FAMOTIDINE 20 MG/2 ML VIAL 50778514_1 CDM 0250 RC 70860-0751-02 NDC inpatient 1 UN 20 13 ANTHEM HMO ANTHEM HMO 999999999 12.11 19.4 FAMOTIDINE 20 MG/2 ML VIAL 50778514_1 CDM 0250 RC 70860-0751-02 NDC inpatient 1 UN 20 13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.11 19.4 FAMOTIDINE 20 MG/2 ML VIAL 50778514_1 CDM 0250 RC 70860-0751-02 NDC inpatient 1 UN 20 13 CIGNA - ALL PLANS CIGNA - ALL PLANS 13.52 67.6 999999999 12.11 19.4 percent of total billed charges FAMOTIDINE 20 MG/2 ML VIAL 50778514_1 CDM 0250 RC 70860-0751-02 NDC inpatient 1 UN 20 13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.11 19.4 FAMOTIDINE 20 MG/2 ML VIAL 50778514_1 CDM 0250 RC 70860-0751-02 NDC inpatient 1 UN 20 13 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.11 19.4 DIPHENOXYLATE-ATROP 2.5-0.025 50779046_1 CDM 0250 RC 60687-0569-01 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges DIPHENOXYLATE-ATROP 2.5-0.025 50779046_1 CDM 0250 RC 60687-0569-01 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges DIPHENOXYLATE-ATROP 2.5-0.025 50779046_1 CDM 0250 RC 60687-0569-01 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges DIPHENOXYLATE-ATROP 2.5-0.025 50779046_1 CDM 0250 RC 60687-0569-01 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges DIPHENOXYLATE-ATROP 2.5-0.025 50779046_1 CDM 0250 RC 60687-0569-01 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges DIPHENOXYLATE-ATROP 2.5-0.025 50779046_1 CDM 0250 RC 60687-0569-01 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges DIPHENOXYLATE-ATROP 2.5-0.025 50779046_1 CDM 0250 RC 60687-0569-01 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges DIPHENOXYLATE-ATROP 2.5-0.025 50779046_1 CDM 0250 RC 60687-0569-01 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges DIPHENOXYLATE-ATROP 2.5-0.025 50779046_1 CDM 0250 RC 60687-0569-01 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 DIPHENOXYLATE-ATROP 2.5-0.025 50779046_1 CDM 0250 RC 60687-0569-01 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 DIPHENOXYLATE-ATROP 2.5-0.025 50779046_1 CDM 0250 RC 60687-0569-01 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 DIPHENOXYLATE-ATROP 2.5-0.025 50779046_1 CDM 0250 RC 60687-0569-01 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges DIPHENOXYLATE-ATROP 2.5-0.025 50779046_1 CDM 0250 RC 60687-0569-01 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 DIPHENOXYLATE-ATROP 2.5-0.025 50779046_1 CDM 0250 RC 60687-0569-01 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 METOPROLOL SUCC ER 25 MG TAB 50779078_1 CDM 0250 RC 51079-0169-20 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 25 MG TAB 50779078_1 CDM 0250 RC 51079-0169-20 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 25 MG TAB 50779078_1 CDM 0250 RC 51079-0169-20 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 25 MG TAB 50779078_1 CDM 0250 RC 51079-0169-20 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 25 MG TAB 50779078_1 CDM 0250 RC 51079-0169-20 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 25 MG TAB 50779078_1 CDM 0250 RC 51079-0169-20 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 25 MG TAB 50779078_1 CDM 0250 RC 51079-0169-20 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 25 MG TAB 50779078_1 CDM 0250 RC 51079-0169-20 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 25 MG TAB 50779078_1 CDM 0250 RC 51079-0169-20 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 METOPROLOL SUCC ER 25 MG TAB 50779078_1 CDM 0250 RC 51079-0169-20 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 METOPROLOL SUCC ER 25 MG TAB 50779078_1 CDM 0250 RC 51079-0169-20 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 METOPROLOL SUCC ER 25 MG TAB 50779078_1 CDM 0250 RC 51079-0169-20 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges METOPROLOL SUCC ER 25 MG TAB 50779078_1 CDM 0250 RC 51079-0169-20 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 METOPROLOL SUCC ER 25 MG TAB 50779078_1 CDM 0250 RC 51079-0169-20 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 EXTRACTOR KATZ FB5000 50781558_1 CDM 0272 RC inpatient 394 256.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 256.1 65 999999999 238.57 382.18 percent of total billed charges EXTRACTOR KATZ FB5000 50781558_1 CDM 0272 RC inpatient 394 256.1 AETNA AETNA 311.26 79 999999999 238.57 382.18 percent of total billed charges EXTRACTOR KATZ FB5000 50781558_1 CDM 0272 RC inpatient 394 256.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 382.18 97 999999999 238.57 382.18 percent of total billed charges EXTRACTOR KATZ FB5000 50781558_1 CDM 0272 RC inpatient 394 256.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 271.86 69 999999999 238.57 382.18 percent of total billed charges EXTRACTOR KATZ FB5000 50781558_1 CDM 0272 RC inpatient 394 256.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 307.32 78 999999999 238.57 382.18 percent of total billed charges EXTRACTOR KATZ FB5000 50781558_1 CDM 0272 RC inpatient 394 256.1 SIHO - ALL PLANS SIHO - ALL PLANS 354.6 90 999999999 238.57 382.18 percent of total billed charges EXTRACTOR KATZ FB5000 50781558_1 CDM 0272 RC inpatient 394 256.1 UMR - ALL PLANS UMR - ALL PLANS 275.8 70 999999999 238.57 382.18 percent of total billed charges EXTRACTOR KATZ FB5000 50781558_1 CDM 0272 RC inpatient 394 256.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 238.57 60.55 999999999 238.57 382.18 percent of total billed charges EXTRACTOR KATZ FB5000 50781558_1 CDM 0272 RC inpatient 394 256.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 238.57 382.18 EXTRACTOR KATZ FB5000 50781558_1 CDM 0272 RC inpatient 394 256.1 ANTHEM HMO ANTHEM HMO 999999999 238.57 382.18 EXTRACTOR KATZ FB5000 50781558_1 CDM 0272 RC inpatient 394 256.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 238.57 382.18 EXTRACTOR KATZ FB5000 50781558_1 CDM 0272 RC inpatient 394 256.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 238.57 382.18 EXTRACTOR KATZ FB5000 50781558_1 CDM 0272 RC inpatient 394 256.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 266.34 67.6 999999999 238.57 382.18 percent of total billed charges EXTRACTOR KATZ FB5000 50781558_1 CDM 0272 RC inpatient 394 256.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 238.57 382.18 THIAMINE 200 MG/2 ML VIAL 50781600_1 CDM 0250 RC 00641-6228-25 NDC inpatient 1 UN 37.81 24.58 SELF PAY DISCOUNT SELF PAY DISCOUNT 24.58 65 999999999 22.89 36.68 percent of total billed charges THIAMINE 200 MG/2 ML VIAL 50781600_1 CDM 0250 RC 00641-6228-25 NDC inpatient 1 UN 37.81 24.58 AETNA AETNA 29.87 79 999999999 22.89 36.68 percent of total billed charges THIAMINE 200 MG/2 ML VIAL 50781600_1 CDM 0250 RC 00641-6228-25 NDC inpatient 1 UN 37.81 24.58 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 36.68 97 999999999 22.89 36.68 percent of total billed charges THIAMINE 200 MG/2 ML VIAL 50781600_1 CDM 0250 RC 00641-6228-25 NDC inpatient 1 UN 37.81 24.58 ENCORE - ALL PLANS ENCORE - ALL PLANS 26.09 69 999999999 22.89 36.68 percent of total billed charges THIAMINE 200 MG/2 ML VIAL 50781600_1 CDM 0250 RC 00641-6228-25 NDC inpatient 1 UN 37.81 24.58 HUMANA - ALL PLANS HUMANA - ALL PLANS 29.49 78 999999999 22.89 36.68 percent of total billed charges THIAMINE 200 MG/2 ML VIAL 50781600_1 CDM 0250 RC 00641-6228-25 NDC inpatient 1 UN 37.81 24.58 SIHO - ALL PLANS SIHO - ALL PLANS 34.03 90 999999999 22.89 36.68 percent of total billed charges THIAMINE 200 MG/2 ML VIAL 50781600_1 CDM 0250 RC 00641-6228-25 NDC inpatient 1 UN 37.81 24.58 UMR - ALL PLANS UMR - ALL PLANS 26.47 70 999999999 22.89 36.68 percent of total billed charges THIAMINE 200 MG/2 ML VIAL 50781600_1 CDM 0250 RC 00641-6228-25 NDC inpatient 1 UN 37.81 24.58 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22.89 60.55 999999999 22.89 36.68 percent of total billed charges THIAMINE 200 MG/2 ML VIAL 50781600_1 CDM 0250 RC 00641-6228-25 NDC inpatient 1 UN 37.81 24.58 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 22.89 36.68 THIAMINE 200 MG/2 ML VIAL 50781600_1 CDM 0250 RC 00641-6228-25 NDC inpatient 1 UN 37.81 24.58 ANTHEM HMO ANTHEM HMO 999999999 22.89 36.68 THIAMINE 200 MG/2 ML VIAL 50781600_1 CDM 0250 RC 00641-6228-25 NDC inpatient 1 UN 37.81 24.58 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 22.89 36.68 THIAMINE 200 MG/2 ML VIAL 50781600_1 CDM 0250 RC 00641-6228-25 NDC inpatient 1 UN 37.81 24.58 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 22.89 36.68 THIAMINE 200 MG/2 ML VIAL 50781600_1 CDM 0250 RC 00641-6228-25 NDC inpatient 1 UN 37.81 24.58 CIGNA - ALL PLANS CIGNA - ALL PLANS 25.56 67.6 999999999 22.89 36.68 percent of total billed charges THIAMINE 200 MG/2 ML VIAL 50781600_1 CDM 0250 RC 00641-6228-25 NDC inpatient 1 UN 37.81 24.58 UHC - ALL PLANS UHC - ALL PLANS 999999999 22.89 36.68 Ultrasound scan of abdominal aorta 50783111_1 CDM 0921 RC 76706 HCPCS inpatient 1085 705.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 705.25 65 999999999 656.97 1052.45 percent of total billed charges Ultrasound scan of abdominal aorta 50783111_1 CDM 0921 RC 76706 HCPCS inpatient 1085 705.25 AETNA AETNA 857.15 79 999999999 656.97 1052.45 percent of total billed charges Ultrasound scan of abdominal aorta 50783111_1 CDM 0921 RC 76706 HCPCS inpatient 1085 705.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1052.45 97 999999999 656.97 1052.45 percent of total billed charges Ultrasound scan of abdominal aorta 50783111_1 CDM 0921 RC 76706 HCPCS inpatient 1085 705.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 748.65 69 999999999 656.97 1052.45 percent of total billed charges Ultrasound scan of abdominal aorta 50783111_1 CDM 0921 RC 76706 HCPCS inpatient 1085 705.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 846.3 78 999999999 656.97 1052.45 percent of total billed charges Ultrasound scan of abdominal aorta 50783111_1 CDM 0921 RC 76706 HCPCS inpatient 1085 705.25 SIHO - ALL PLANS SIHO - ALL PLANS 976.5 90 999999999 656.97 1052.45 percent of total billed charges Ultrasound scan of abdominal aorta 50783111_1 CDM 0921 RC 76706 HCPCS inpatient 1085 705.25 UMR - ALL PLANS UMR - ALL PLANS 759.5 70 999999999 656.97 1052.45 percent of total billed charges Ultrasound scan of abdominal aorta 50783111_1 CDM 0921 RC 76706 HCPCS inpatient 1085 705.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 656.97 60.55 999999999 656.97 1052.45 percent of total billed charges Ultrasound scan of abdominal aorta 50783111_1 CDM 0921 RC 76706 HCPCS inpatient 1085 705.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 656.97 1052.45 Ultrasound scan of abdominal aorta 50783111_1 CDM 0921 RC 76706 HCPCS inpatient 1085 705.25 ANTHEM HMO ANTHEM HMO 999999999 656.97 1052.45 Ultrasound scan of abdominal aorta 50783111_1 CDM 0921 RC 76706 HCPCS inpatient 1085 705.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 656.97 1052.45 Ultrasound scan of abdominal aorta 50783111_1 CDM 0921 RC 76706 HCPCS inpatient 1085 705.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 656.97 1052.45 Ultrasound scan of abdominal aorta 50783111_1 CDM 0921 RC 76706 HCPCS inpatient 1085 705.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 733.46 67.6 999999999 656.97 1052.45 percent of total billed charges Ultrasound scan of abdominal aorta 50783111_1 CDM 0921 RC 76706 HCPCS inpatient 1085 705.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 656.97 1052.45 Ultrasound of leg arteries or artery grafts 50783112_1 CDM 0921 RC 93925 HCPCS inpatient 627 407.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 407.55 65 999999999 379.65 608.19 percent of total billed charges Ultrasound of leg arteries or artery grafts 50783112_1 CDM 0921 RC 93925 HCPCS inpatient 627 407.55 AETNA AETNA 495.33 79 999999999 379.65 608.19 percent of total billed charges Ultrasound of leg arteries or artery grafts 50783112_1 CDM 0921 RC 93925 HCPCS inpatient 627 407.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 608.19 97 999999999 379.65 608.19 percent of total billed charges Ultrasound of leg arteries or artery grafts 50783112_1 CDM 0921 RC 93925 HCPCS inpatient 627 407.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 432.63 69 999999999 379.65 608.19 percent of total billed charges Ultrasound of leg arteries or artery grafts 50783112_1 CDM 0921 RC 93925 HCPCS inpatient 627 407.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 489.06 78 999999999 379.65 608.19 percent of total billed charges Ultrasound of leg arteries or artery grafts 50783112_1 CDM 0921 RC 93925 HCPCS inpatient 627 407.55 SIHO - ALL PLANS SIHO - ALL PLANS 564.3 90 999999999 379.65 608.19 percent of total billed charges Ultrasound of leg arteries or artery grafts 50783112_1 CDM 0921 RC 93925 HCPCS inpatient 627 407.55 UMR - ALL PLANS UMR - ALL PLANS 438.9 70 999999999 379.65 608.19 percent of total billed charges Ultrasound of leg arteries or artery grafts 50783112_1 CDM 0921 RC 93925 HCPCS inpatient 627 407.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 379.65 60.55 999999999 379.65 608.19 percent of total billed charges Ultrasound of leg arteries or artery grafts 50783112_1 CDM 0921 RC 93925 HCPCS inpatient 627 407.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 379.65 608.19 Ultrasound of leg arteries or artery grafts 50783112_1 CDM 0921 RC 93925 HCPCS inpatient 627 407.55 ANTHEM HMO ANTHEM HMO 999999999 379.65 608.19 Ultrasound of leg arteries or artery grafts 50783112_1 CDM 0921 RC 93925 HCPCS inpatient 627 407.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 379.65 608.19 Ultrasound of leg arteries or artery grafts 50783112_1 CDM 0921 RC 93925 HCPCS inpatient 627 407.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 379.65 608.19 Ultrasound of leg arteries or artery grafts 50783112_1 CDM 0921 RC 93925 HCPCS inpatient 627 407.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 423.85 67.6 999999999 379.65 608.19 percent of total billed charges Ultrasound of leg arteries or artery grafts 50783112_1 CDM 0921 RC 93925 HCPCS inpatient 627 407.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 379.65 608.19 Ultrasound of one leg arteries or artery grafts 50783113_1 CDM 0921 RC 93926 HCPCS inpatient 442 287.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 287.3 65 999999999 267.63 428.74 percent of total billed charges Ultrasound of one leg arteries or artery grafts 50783113_1 CDM 0921 RC 93926 HCPCS inpatient 442 287.3 AETNA AETNA 349.18 79 999999999 267.63 428.74 percent of total billed charges Ultrasound of one leg arteries or artery grafts 50783113_1 CDM 0921 RC 93926 HCPCS inpatient 442 287.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 428.74 97 999999999 267.63 428.74 percent of total billed charges Ultrasound of one leg arteries or artery grafts 50783113_1 CDM 0921 RC 93926 HCPCS inpatient 442 287.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 304.98 69 999999999 267.63 428.74 percent of total billed charges Ultrasound of one leg arteries or artery grafts 50783113_1 CDM 0921 RC 93926 HCPCS inpatient 442 287.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 344.76 78 999999999 267.63 428.74 percent of total billed charges Ultrasound of one leg arteries or artery grafts 50783113_1 CDM 0921 RC 93926 HCPCS inpatient 442 287.3 SIHO - ALL PLANS SIHO - ALL PLANS 397.8 90 999999999 267.63 428.74 percent of total billed charges Ultrasound of one leg arteries or artery grafts 50783113_1 CDM 0921 RC 93926 HCPCS inpatient 442 287.3 UMR - ALL PLANS UMR - ALL PLANS 309.4 70 999999999 267.63 428.74 percent of total billed charges Ultrasound of one leg arteries or artery grafts 50783113_1 CDM 0921 RC 93926 HCPCS inpatient 442 287.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 267.63 60.55 999999999 267.63 428.74 percent of total billed charges Ultrasound of one leg arteries or artery grafts 50783113_1 CDM 0921 RC 93926 HCPCS inpatient 442 287.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 267.63 428.74 Ultrasound of one leg arteries or artery grafts 50783113_1 CDM 0921 RC 93926 HCPCS inpatient 442 287.3 ANTHEM HMO ANTHEM HMO 999999999 267.63 428.74 Ultrasound of one leg arteries or artery grafts 50783113_1 CDM 0921 RC 93926 HCPCS inpatient 442 287.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 267.63 428.74 Ultrasound of one leg arteries or artery grafts 50783113_1 CDM 0921 RC 93926 HCPCS inpatient 442 287.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 267.63 428.74 Ultrasound of one leg arteries or artery grafts 50783113_1 CDM 0921 RC 93926 HCPCS inpatient 442 287.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 298.79 67.6 999999999 267.63 428.74 percent of total billed charges Ultrasound of one leg arteries or artery grafts 50783113_1 CDM 0921 RC 93926 HCPCS inpatient 442 287.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 267.63 428.74 Ultrasonic guidance for needle placement 50783114_1 CDM 0921 RC 76942 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 50783114_1 CDM 0921 RC 76942 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 50783114_1 CDM 0921 RC 76942 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 50783114_1 CDM 0921 RC 76942 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 50783114_1 CDM 0921 RC 76942 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 50783114_1 CDM 0921 RC 76942 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 50783114_1 CDM 0921 RC 76942 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 50783114_1 CDM 0921 RC 76942 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 50783114_1 CDM 0921 RC 76942 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 50783114_1 CDM 0921 RC 76942 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Ultrasonic guidance for needle placement 50783114_1 CDM 0921 RC 76942 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 50783114_1 CDM 0921 RC 76942 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 50783114_1 CDM 0921 RC 76942 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 50783114_1 CDM 0921 RC 76942 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Needle biopsy or removal of surface lymph nodes 50783115_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 796.9 65 999999999 742.34 1189.22 percent of total billed charges Needle biopsy or removal of surface lymph nodes 50783115_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 AETNA AETNA 968.54 79 999999999 742.34 1189.22 percent of total billed charges Needle biopsy or removal of surface lymph nodes 50783115_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1189.22 97 999999999 742.34 1189.22 percent of total billed charges Needle biopsy or removal of surface lymph nodes 50783115_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 845.94 69 999999999 742.34 1189.22 percent of total billed charges Needle biopsy or removal of surface lymph nodes 50783115_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 956.28 78 999999999 742.34 1189.22 percent of total billed charges Needle biopsy or removal of surface lymph nodes 50783115_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 SIHO - ALL PLANS SIHO - ALL PLANS 1103.4 90 999999999 742.34 1189.22 percent of total billed charges Needle biopsy or removal of surface lymph nodes 50783115_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 UMR - ALL PLANS UMR - ALL PLANS 858.2 70 999999999 742.34 1189.22 percent of total billed charges Needle biopsy or removal of surface lymph nodes 50783115_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 742.34 60.55 999999999 742.34 1189.22 percent of total billed charges Needle biopsy or removal of surface lymph nodes 50783115_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 742.34 1189.22 Needle biopsy or removal of surface lymph nodes 50783115_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 ANTHEM HMO ANTHEM HMO 999999999 742.34 1189.22 Needle biopsy or removal of surface lymph nodes 50783115_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 742.34 1189.22 Needle biopsy or removal of surface lymph nodes 50783115_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 742.34 1189.22 Needle biopsy or removal of surface lymph nodes 50783115_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 828.78 67.6 999999999 742.34 1189.22 percent of total billed charges Needle biopsy or removal of surface lymph nodes 50783115_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 742.34 1189.22 Ultrasound of both sides of head and neck blood flow 50783116_1 CDM 0921 RC 93880 HCPCS inpatient 1332 865.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 865.8 65 999999999 806.53 1292.04 percent of total billed charges Ultrasound of both sides of head and neck blood flow 50783116_1 CDM 0921 RC 93880 HCPCS inpatient 1332 865.8 AETNA AETNA 1052.28 79 999999999 806.53 1292.04 percent of total billed charges Ultrasound of both sides of head and neck blood flow 50783116_1 CDM 0921 RC 93880 HCPCS inpatient 1332 865.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1292.04 97 999999999 806.53 1292.04 percent of total billed charges Ultrasound of both sides of head and neck blood flow 50783116_1 CDM 0921 RC 93880 HCPCS inpatient 1332 865.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 919.08 69 999999999 806.53 1292.04 percent of total billed charges Ultrasound of both sides of head and neck blood flow 50783116_1 CDM 0921 RC 93880 HCPCS inpatient 1332 865.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 1038.96 78 999999999 806.53 1292.04 percent of total billed charges Ultrasound of both sides of head and neck blood flow 50783116_1 CDM 0921 RC 93880 HCPCS inpatient 1332 865.8 SIHO - ALL PLANS SIHO - ALL PLANS 1198.8 90 999999999 806.53 1292.04 percent of total billed charges Ultrasound of both sides of head and neck blood flow 50783116_1 CDM 0921 RC 93880 HCPCS inpatient 1332 865.8 UMR - ALL PLANS UMR - ALL PLANS 932.4 70 999999999 806.53 1292.04 percent of total billed charges Ultrasound of both sides of head and neck blood flow 50783116_1 CDM 0921 RC 93880 HCPCS inpatient 1332 865.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 806.53 60.55 999999999 806.53 1292.04 percent of total billed charges Ultrasound of both sides of head and neck blood flow 50783116_1 CDM 0921 RC 93880 HCPCS inpatient 1332 865.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 806.53 1292.04 Ultrasound of both sides of head and neck blood flow 50783116_1 CDM 0921 RC 93880 HCPCS inpatient 1332 865.8 ANTHEM HMO ANTHEM HMO 999999999 806.53 1292.04 Ultrasound of both sides of head and neck blood flow 50783116_1 CDM 0921 RC 93880 HCPCS inpatient 1332 865.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 806.53 1292.04 Ultrasound of both sides of head and neck blood flow 50783116_1 CDM 0921 RC 93880 HCPCS inpatient 1332 865.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 806.53 1292.04 Ultrasound of both sides of head and neck blood flow 50783116_1 CDM 0921 RC 93880 HCPCS inpatient 1332 865.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 900.43 67.6 999999999 806.53 1292.04 percent of total billed charges Ultrasound of both sides of head and neck blood flow 50783116_1 CDM 0921 RC 93880 HCPCS inpatient 1332 865.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 806.53 1292.04 Ultrasonic guidance for blood vessel access 50783117_1 CDM 0921 RC 76937 HCPCS inpatient 559 363.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 363.35 65 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 50783117_1 CDM 0921 RC 76937 HCPCS inpatient 559 363.35 AETNA AETNA 441.61 79 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 50783117_1 CDM 0921 RC 76937 HCPCS inpatient 559 363.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 542.23 97 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 50783117_1 CDM 0921 RC 76937 HCPCS inpatient 559 363.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 385.71 69 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 50783117_1 CDM 0921 RC 76937 HCPCS inpatient 559 363.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 436.02 78 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 50783117_1 CDM 0921 RC 76937 HCPCS inpatient 559 363.35 SIHO - ALL PLANS SIHO - ALL PLANS 503.1 90 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 50783117_1 CDM 0921 RC 76937 HCPCS inpatient 559 363.35 UMR - ALL PLANS UMR - ALL PLANS 391.3 70 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 50783117_1 CDM 0921 RC 76937 HCPCS inpatient 559 363.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 338.47 60.55 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 50783117_1 CDM 0921 RC 76937 HCPCS inpatient 559 363.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 338.47 542.23 Ultrasonic guidance for blood vessel access 50783117_1 CDM 0921 RC 76937 HCPCS inpatient 559 363.35 ANTHEM HMO ANTHEM HMO 999999999 338.47 542.23 Ultrasonic guidance for blood vessel access 50783117_1 CDM 0921 RC 76937 HCPCS inpatient 559 363.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 338.47 542.23 Ultrasonic guidance for blood vessel access 50783117_1 CDM 0921 RC 76937 HCPCS inpatient 559 363.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 338.47 542.23 Ultrasonic guidance for blood vessel access 50783117_1 CDM 0921 RC 76937 HCPCS inpatient 559 363.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 377.88 67.6 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 50783117_1 CDM 0921 RC 76937 HCPCS inpatient 559 363.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 338.47 542.23 Ultrasonic guidance during surgery 50783118_1 CDM 0921 RC 76998 HCPCS inpatient 280 182 SELF PAY DISCOUNT SELF PAY DISCOUNT 182 65 999999999 169.54 271.6 percent of total billed charges Ultrasonic guidance during surgery 50783118_1 CDM 0921 RC 76998 HCPCS inpatient 280 182 AETNA AETNA 221.2 79 999999999 169.54 271.6 percent of total billed charges Ultrasonic guidance during surgery 50783118_1 CDM 0921 RC 76998 HCPCS inpatient 280 182 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 271.6 97 999999999 169.54 271.6 percent of total billed charges Ultrasonic guidance during surgery 50783118_1 CDM 0921 RC 76998 HCPCS inpatient 280 182 ENCORE - ALL PLANS ENCORE - ALL PLANS 193.2 69 999999999 169.54 271.6 percent of total billed charges Ultrasonic guidance during surgery 50783118_1 CDM 0921 RC 76998 HCPCS inpatient 280 182 HUMANA - ALL PLANS HUMANA - ALL PLANS 218.4 78 999999999 169.54 271.6 percent of total billed charges Ultrasonic guidance during surgery 50783118_1 CDM 0921 RC 76998 HCPCS inpatient 280 182 SIHO - ALL PLANS SIHO - ALL PLANS 252 90 999999999 169.54 271.6 percent of total billed charges Ultrasonic guidance during surgery 50783118_1 CDM 0921 RC 76998 HCPCS inpatient 280 182 UMR - ALL PLANS UMR - ALL PLANS 196 70 999999999 169.54 271.6 percent of total billed charges Ultrasonic guidance during surgery 50783118_1 CDM 0921 RC 76998 HCPCS inpatient 280 182 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 169.54 60.55 999999999 169.54 271.6 percent of total billed charges Ultrasonic guidance during surgery 50783118_1 CDM 0921 RC 76998 HCPCS inpatient 280 182 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 169.54 271.6 Ultrasonic guidance during surgery 50783118_1 CDM 0921 RC 76998 HCPCS inpatient 280 182 ANTHEM HMO ANTHEM HMO 999999999 169.54 271.6 Ultrasonic guidance during surgery 50783118_1 CDM 0921 RC 76998 HCPCS inpatient 280 182 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 169.54 271.6 Ultrasonic guidance during surgery 50783118_1 CDM 0921 RC 76998 HCPCS inpatient 280 182 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 169.54 271.6 Ultrasonic guidance during surgery 50783118_1 CDM 0921 RC 76998 HCPCS inpatient 280 182 CIGNA - ALL PLANS CIGNA - ALL PLANS 189.28 67.6 999999999 169.54 271.6 percent of total billed charges Ultrasonic guidance during surgery 50783118_1 CDM 0921 RC 76998 HCPCS inpatient 280 182 UHC - ALL PLANS UHC - ALL PLANS 999999999 169.54 271.6 Complete ultrasound of within the brain blood flow 50783119_1 CDM 0921 RC 93886 HCPCS inpatient 635 412.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 412.75 65 999999999 384.49 615.95 percent of total billed charges Complete ultrasound of within the brain blood flow 50783119_1 CDM 0921 RC 93886 HCPCS inpatient 635 412.75 AETNA AETNA 501.65 79 999999999 384.49 615.95 percent of total billed charges Complete ultrasound of within the brain blood flow 50783119_1 CDM 0921 RC 93886 HCPCS inpatient 635 412.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 615.95 97 999999999 384.49 615.95 percent of total billed charges Complete ultrasound of within the brain blood flow 50783119_1 CDM 0921 RC 93886 HCPCS inpatient 635 412.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 438.15 69 999999999 384.49 615.95 percent of total billed charges Complete ultrasound of within the brain blood flow 50783119_1 CDM 0921 RC 93886 HCPCS inpatient 635 412.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 495.3 78 999999999 384.49 615.95 percent of total billed charges Complete ultrasound of within the brain blood flow 50783119_1 CDM 0921 RC 93886 HCPCS inpatient 635 412.75 SIHO - ALL PLANS SIHO - ALL PLANS 571.5 90 999999999 384.49 615.95 percent of total billed charges Complete ultrasound of within the brain blood flow 50783119_1 CDM 0921 RC 93886 HCPCS inpatient 635 412.75 UMR - ALL PLANS UMR - ALL PLANS 444.5 70 999999999 384.49 615.95 percent of total billed charges Complete ultrasound of within the brain blood flow 50783119_1 CDM 0921 RC 93886 HCPCS inpatient 635 412.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 384.49 60.55 999999999 384.49 615.95 percent of total billed charges Complete ultrasound of within the brain blood flow 50783119_1 CDM 0921 RC 93886 HCPCS inpatient 635 412.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 384.49 615.95 Complete ultrasound of within the brain blood flow 50783119_1 CDM 0921 RC 93886 HCPCS inpatient 635 412.75 ANTHEM HMO ANTHEM HMO 999999999 384.49 615.95 Complete ultrasound of within the brain blood flow 50783119_1 CDM 0921 RC 93886 HCPCS inpatient 635 412.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 384.49 615.95 Complete ultrasound of within the brain blood flow 50783119_1 CDM 0921 RC 93886 HCPCS inpatient 635 412.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 384.49 615.95 Complete ultrasound of within the brain blood flow 50783119_1 CDM 0921 RC 93886 HCPCS inpatient 635 412.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 429.26 67.6 999999999 384.49 615.95 percent of total billed charges Complete ultrasound of within the brain blood flow 50783119_1 CDM 0921 RC 93886 HCPCS inpatient 635 412.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 384.49 615.95 Ultrasound of within the brain blood flow 50783120_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 269.1 65 999999999 250.68 401.58 percent of total billed charges Ultrasound of within the brain blood flow 50783120_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 AETNA AETNA 327.06 79 999999999 250.68 401.58 percent of total billed charges Ultrasound of within the brain blood flow 50783120_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 401.58 97 999999999 250.68 401.58 percent of total billed charges Ultrasound of within the brain blood flow 50783120_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 285.66 69 999999999 250.68 401.58 percent of total billed charges Ultrasound of within the brain blood flow 50783120_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 322.92 78 999999999 250.68 401.58 percent of total billed charges Ultrasound of within the brain blood flow 50783120_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 SIHO - ALL PLANS SIHO - ALL PLANS 372.6 90 999999999 250.68 401.58 percent of total billed charges Ultrasound of within the brain blood flow 50783120_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 UMR - ALL PLANS UMR - ALL PLANS 289.8 70 999999999 250.68 401.58 percent of total billed charges Ultrasound of within the brain blood flow 50783120_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 250.68 60.55 999999999 250.68 401.58 percent of total billed charges Ultrasound of within the brain blood flow 50783120_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 250.68 401.58 Ultrasound of within the brain blood flow 50783120_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 ANTHEM HMO ANTHEM HMO 999999999 250.68 401.58 Ultrasound of within the brain blood flow 50783120_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 250.68 401.58 Ultrasound of within the brain blood flow 50783120_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 250.68 401.58 Ultrasound of within the brain blood flow 50783120_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 279.86 67.6 999999999 250.68 401.58 percent of total billed charges Ultrasound of within the brain blood flow 50783120_1 CDM 0921 RC 93888 HCPCS inpatient 414 269.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 250.68 401.58 "Cortisol (hormone) measurement, total" 50785664_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 191.1 65 999999999 178.02 285.18 percent of total billed charges "Cortisol (hormone) measurement, total" 50785664_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 AETNA AETNA 232.26 79 999999999 178.02 285.18 percent of total billed charges "Cortisol (hormone) measurement, total" 50785664_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 285.18 97 999999999 178.02 285.18 percent of total billed charges "Cortisol (hormone) measurement, total" 50785664_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 202.86 69 999999999 178.02 285.18 percent of total billed charges "Cortisol (hormone) measurement, total" 50785664_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 229.32 78 999999999 178.02 285.18 percent of total billed charges "Cortisol (hormone) measurement, total" 50785664_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 SIHO - ALL PLANS SIHO - ALL PLANS 264.6 90 999999999 178.02 285.18 percent of total billed charges "Cortisol (hormone) measurement, total" 50785664_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 UMR - ALL PLANS UMR - ALL PLANS 205.8 70 999999999 178.02 285.18 percent of total billed charges "Cortisol (hormone) measurement, total" 50785664_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 178.02 60.55 999999999 178.02 285.18 percent of total billed charges "Cortisol (hormone) measurement, total" 50785664_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 178.02 285.18 "Cortisol (hormone) measurement, total" 50785664_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 ANTHEM HMO ANTHEM HMO 999999999 178.02 285.18 "Cortisol (hormone) measurement, total" 50785664_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 178.02 285.18 "Cortisol (hormone) measurement, total" 50785664_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 178.02 285.18 "Cortisol (hormone) measurement, total" 50785664_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 198.74 67.6 999999999 178.02 285.18 percent of total billed charges "Cortisol (hormone) measurement, total" 50785664_1 CDM 0301 RC 82533 HCPCS inpatient 294 191.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 178.02 285.18 "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 50785753_1 CDM 0306 RC 87801 HCPCS inpatient 211 137.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 137.15 65 999999999 127.76 204.67 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 50785753_1 CDM 0306 RC 87801 HCPCS inpatient 211 137.15 AETNA AETNA 166.69 79 999999999 127.76 204.67 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 50785753_1 CDM 0306 RC 87801 HCPCS inpatient 211 137.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 204.67 97 999999999 127.76 204.67 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 50785753_1 CDM 0306 RC 87801 HCPCS inpatient 211 137.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 145.59 69 999999999 127.76 204.67 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 50785753_1 CDM 0306 RC 87801 HCPCS inpatient 211 137.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 164.58 78 999999999 127.76 204.67 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 50785753_1 CDM 0306 RC 87801 HCPCS inpatient 211 137.15 SIHO - ALL PLANS SIHO - ALL PLANS 189.9 90 999999999 127.76 204.67 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 50785753_1 CDM 0306 RC 87801 HCPCS inpatient 211 137.15 UMR - ALL PLANS UMR - ALL PLANS 147.7 70 999999999 127.76 204.67 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 50785753_1 CDM 0306 RC 87801 HCPCS inpatient 211 137.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.76 60.55 999999999 127.76 204.67 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 50785753_1 CDM 0306 RC 87801 HCPCS inpatient 211 137.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.76 204.67 "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 50785753_1 CDM 0306 RC 87801 HCPCS inpatient 211 137.15 ANTHEM HMO ANTHEM HMO 999999999 127.76 204.67 "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 50785753_1 CDM 0306 RC 87801 HCPCS inpatient 211 137.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.76 204.67 "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 50785753_1 CDM 0306 RC 87801 HCPCS inpatient 211 137.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.76 204.67 "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 50785753_1 CDM 0306 RC 87801 HCPCS inpatient 211 137.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 142.64 67.6 999999999 127.76 204.67 percent of total billed charges "Detection test by nucleic acid for multiple organisms, amplified probe(s) technique" 50785753_1 CDM 0306 RC 87801 HCPCS inpatient 211 137.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.76 204.67 Cholinesterase (enzyme) level 50785767_1 CDM 0301 RC 82482 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges Cholinesterase (enzyme) level 50785767_1 CDM 0301 RC 82482 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges Cholinesterase (enzyme) level 50785767_1 CDM 0301 RC 82482 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges Cholinesterase (enzyme) level 50785767_1 CDM 0301 RC 82482 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges Cholinesterase (enzyme) level 50785767_1 CDM 0301 RC 82482 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges Cholinesterase (enzyme) level 50785767_1 CDM 0301 RC 82482 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges Cholinesterase (enzyme) level 50785767_1 CDM 0301 RC 82482 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges Cholinesterase (enzyme) level 50785767_1 CDM 0301 RC 82482 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges Cholinesterase (enzyme) level 50785767_1 CDM 0301 RC 82482 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 Cholinesterase (enzyme) level 50785767_1 CDM 0301 RC 82482 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 Cholinesterase (enzyme) level 50785767_1 CDM 0301 RC 82482 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 Cholinesterase (enzyme) level 50785767_1 CDM 0301 RC 82482 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 Cholinesterase (enzyme) level 50785767_1 CDM 0301 RC 82482 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges Cholinesterase (enzyme) level 50785767_1 CDM 0301 RC 82482 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 CT scan of blood vessels of head with contrast 50786408_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1974.05 65 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 50786408_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 AETNA AETNA 2399.23 79 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 50786408_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2945.89 97 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 50786408_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2095.53 69 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 50786408_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 2368.86 78 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 50786408_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 SIHO - ALL PLANS SIHO - ALL PLANS 2733.3 90 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 50786408_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 UMR - ALL PLANS UMR - ALL PLANS 2125.9 70 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 50786408_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1838.9 60.55 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 50786408_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1838.9 2945.89 CT scan of blood vessels of head with contrast 50786408_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 ANTHEM HMO ANTHEM HMO 999999999 1838.9 2945.89 CT scan of blood vessels of head with contrast 50786408_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1838.9 2945.89 CT scan of blood vessels of head with contrast 50786408_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1838.9 2945.89 CT scan of blood vessels of head with contrast 50786408_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2053.01 67.6 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 50786408_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1838.9 2945.89 Screening test for antibody to noninfectious agent 50794463_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 50794463_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 50794463_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 50794463_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 50794463_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 50794463_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 50794463_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 50794463_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 50794463_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 50794463_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 50794463_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 50794463_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 50794463_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 50794463_1 CDM 0301 RC 86255 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 Detection test by immunofluorescent technique for pneumocystis carinii (respiratory parasite) 50798822_1 CDM 0302 RC 87281 HCPCS inpatient 78 50.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.7 65 999999999 47.23 75.66 percent of total billed charges Detection test by immunofluorescent technique for pneumocystis carinii (respiratory parasite) 50798822_1 CDM 0302 RC 87281 HCPCS inpatient 78 50.7 AETNA AETNA 61.62 79 999999999 47.23 75.66 percent of total billed charges Detection test by immunofluorescent technique for pneumocystis carinii (respiratory parasite) 50798822_1 CDM 0302 RC 87281 HCPCS inpatient 78 50.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 75.66 97 999999999 47.23 75.66 percent of total billed charges Detection test by immunofluorescent technique for pneumocystis carinii (respiratory parasite) 50798822_1 CDM 0302 RC 87281 HCPCS inpatient 78 50.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.82 69 999999999 47.23 75.66 percent of total billed charges Detection test by immunofluorescent technique for pneumocystis carinii (respiratory parasite) 50798822_1 CDM 0302 RC 87281 HCPCS inpatient 78 50.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.84 78 999999999 47.23 75.66 percent of total billed charges Detection test by immunofluorescent technique for pneumocystis carinii (respiratory parasite) 50798822_1 CDM 0302 RC 87281 HCPCS inpatient 78 50.7 SIHO - ALL PLANS SIHO - ALL PLANS 70.2 90 999999999 47.23 75.66 percent of total billed charges Detection test by immunofluorescent technique for pneumocystis carinii (respiratory parasite) 50798822_1 CDM 0302 RC 87281 HCPCS inpatient 78 50.7 UMR - ALL PLANS UMR - ALL PLANS 54.6 70 999999999 47.23 75.66 percent of total billed charges Detection test by immunofluorescent technique for pneumocystis carinii (respiratory parasite) 50798822_1 CDM 0302 RC 87281 HCPCS inpatient 78 50.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.23 60.55 999999999 47.23 75.66 percent of total billed charges Detection test by immunofluorescent technique for pneumocystis carinii (respiratory parasite) 50798822_1 CDM 0302 RC 87281 HCPCS inpatient 78 50.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.23 75.66 Detection test by immunofluorescent technique for pneumocystis carinii (respiratory parasite) 50798822_1 CDM 0302 RC 87281 HCPCS inpatient 78 50.7 ANTHEM HMO ANTHEM HMO 999999999 47.23 75.66 Detection test by immunofluorescent technique for pneumocystis carinii (respiratory parasite) 50798822_1 CDM 0302 RC 87281 HCPCS inpatient 78 50.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.23 75.66 Detection test by immunofluorescent technique for pneumocystis carinii (respiratory parasite) 50798822_1 CDM 0302 RC 87281 HCPCS inpatient 78 50.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.23 75.66 Detection test by immunofluorescent technique for pneumocystis carinii (respiratory parasite) 50798822_1 CDM 0302 RC 87281 HCPCS inpatient 78 50.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.73 67.6 999999999 47.23 75.66 percent of total billed charges Detection test by immunofluorescent technique for pneumocystis carinii (respiratory parasite) 50798822_1 CDM 0302 RC 87281 HCPCS inpatient 78 50.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.23 75.66 Quantitation of therapeutic drug 50798830_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 178.1 65 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 50798830_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 AETNA AETNA 216.46 79 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 50798830_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 265.78 97 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 50798830_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 189.06 69 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 50798830_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 213.72 78 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 50798830_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 SIHO - ALL PLANS SIHO - ALL PLANS 246.6 90 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 50798830_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 UMR - ALL PLANS UMR - ALL PLANS 191.8 70 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 50798830_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 165.91 60.55 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 50798830_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 165.91 265.78 Quantitation of therapeutic drug 50798830_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ANTHEM HMO ANTHEM HMO 999999999 165.91 265.78 Quantitation of therapeutic drug 50798830_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 165.91 265.78 Quantitation of therapeutic drug 50798830_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 165.91 265.78 Quantitation of therapeutic drug 50798830_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 185.22 67.6 999999999 165.91 265.78 percent of total billed charges Quantitation of therapeutic drug 50798830_1 CDM 0301 RC 80299 HCPCS inpatient 274 178.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 165.91 265.78 Special stain for inclusion bodies or parasites 50801870_1 CDM 0301 RC 87207 HCPCS inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges Special stain for inclusion bodies or parasites 50801870_1 CDM 0301 RC 87207 HCPCS inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges Special stain for inclusion bodies or parasites 50801870_1 CDM 0301 RC 87207 HCPCS inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges Special stain for inclusion bodies or parasites 50801870_1 CDM 0301 RC 87207 HCPCS inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges Special stain for inclusion bodies or parasites 50801870_1 CDM 0301 RC 87207 HCPCS inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges Special stain for inclusion bodies or parasites 50801870_1 CDM 0301 RC 87207 HCPCS inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges Special stain for inclusion bodies or parasites 50801870_1 CDM 0301 RC 87207 HCPCS inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges Special stain for inclusion bodies or parasites 50801870_1 CDM 0301 RC 87207 HCPCS inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges Special stain for inclusion bodies or parasites 50801870_1 CDM 0301 RC 87207 HCPCS inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 Special stain for inclusion bodies or parasites 50801870_1 CDM 0301 RC 87207 HCPCS inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 Special stain for inclusion bodies or parasites 50801870_1 CDM 0301 RC 87207 HCPCS inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 Special stain for inclusion bodies or parasites 50801870_1 CDM 0301 RC 87207 HCPCS inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 Special stain for inclusion bodies or parasites 50801870_1 CDM 0301 RC 87207 HCPCS inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges Special stain for inclusion bodies or parasites 50801870_1 CDM 0301 RC 87207 HCPCS inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 Measurement of Hepatitis A antibody (IgM) 50801962_1 CDM 0302 RC 86709 HCPCS inpatient 193 125.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 125.45 65 999999999 116.86 187.21 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 50801962_1 CDM 0302 RC 86709 HCPCS inpatient 193 125.45 AETNA AETNA 152.47 79 999999999 116.86 187.21 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 50801962_1 CDM 0302 RC 86709 HCPCS inpatient 193 125.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 187.21 97 999999999 116.86 187.21 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 50801962_1 CDM 0302 RC 86709 HCPCS inpatient 193 125.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.17 69 999999999 116.86 187.21 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 50801962_1 CDM 0302 RC 86709 HCPCS inpatient 193 125.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 150.54 78 999999999 116.86 187.21 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 50801962_1 CDM 0302 RC 86709 HCPCS inpatient 193 125.45 SIHO - ALL PLANS SIHO - ALL PLANS 173.7 90 999999999 116.86 187.21 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 50801962_1 CDM 0302 RC 86709 HCPCS inpatient 193 125.45 UMR - ALL PLANS UMR - ALL PLANS 135.1 70 999999999 116.86 187.21 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 50801962_1 CDM 0302 RC 86709 HCPCS inpatient 193 125.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.86 60.55 999999999 116.86 187.21 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 50801962_1 CDM 0302 RC 86709 HCPCS inpatient 193 125.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.86 187.21 Measurement of Hepatitis A antibody (IgM) 50801962_1 CDM 0302 RC 86709 HCPCS inpatient 193 125.45 ANTHEM HMO ANTHEM HMO 999999999 116.86 187.21 Measurement of Hepatitis A antibody (IgM) 50801962_1 CDM 0302 RC 86709 HCPCS inpatient 193 125.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.86 187.21 Measurement of Hepatitis A antibody (IgM) 50801962_1 CDM 0302 RC 86709 HCPCS inpatient 193 125.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 130.47 67.6 999999999 116.86 187.21 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 50801962_1 CDM 0302 RC 86709 HCPCS inpatient 193 125.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.86 187.21 Measurement of Hepatitis A antibody (IgM) 50801962_1 CDM 0302 RC 86709 HCPCS inpatient 193 125.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.86 187.21 "Detection test by nucleic acid for organism, quantification" 50805206_1 CDM 0306 RC 87799 HCPCS inpatient 596 387.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 387.4 65 999999999 360.88 578.12 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50805206_1 CDM 0306 RC 87799 HCPCS inpatient 596 387.4 AETNA AETNA 470.84 79 999999999 360.88 578.12 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50805206_1 CDM 0306 RC 87799 HCPCS inpatient 596 387.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 578.12 97 999999999 360.88 578.12 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50805206_1 CDM 0306 RC 87799 HCPCS inpatient 596 387.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 411.24 69 999999999 360.88 578.12 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50805206_1 CDM 0306 RC 87799 HCPCS inpatient 596 387.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 464.88 78 999999999 360.88 578.12 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50805206_1 CDM 0306 RC 87799 HCPCS inpatient 596 387.4 SIHO - ALL PLANS SIHO - ALL PLANS 536.4 90 999999999 360.88 578.12 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50805206_1 CDM 0306 RC 87799 HCPCS inpatient 596 387.4 UMR - ALL PLANS UMR - ALL PLANS 417.2 70 999999999 360.88 578.12 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50805206_1 CDM 0306 RC 87799 HCPCS inpatient 596 387.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 360.88 60.55 999999999 360.88 578.12 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50805206_1 CDM 0306 RC 87799 HCPCS inpatient 596 387.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 360.88 578.12 "Detection test by nucleic acid for organism, quantification" 50805206_1 CDM 0306 RC 87799 HCPCS inpatient 596 387.4 ANTHEM HMO ANTHEM HMO 999999999 360.88 578.12 "Detection test by nucleic acid for organism, quantification" 50805206_1 CDM 0306 RC 87799 HCPCS inpatient 596 387.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 360.88 578.12 "Detection test by nucleic acid for organism, quantification" 50805206_1 CDM 0306 RC 87799 HCPCS inpatient 596 387.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 402.9 67.6 999999999 360.88 578.12 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 50805206_1 CDM 0306 RC 87799 HCPCS inpatient 596 387.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 360.88 578.12 "Detection test by nucleic acid for organism, quantification" 50805206_1 CDM 0306 RC 87799 HCPCS inpatient 596 387.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 360.88 578.12 "Detection test by nucleic acid for cytomegalovirus, quantification" 50805282_1 CDM 0306 RC 87497 HCPCS inpatient 240 156 SELF PAY DISCOUNT SELF PAY DISCOUNT 156 65 999999999 145.32 232.8 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 50805282_1 CDM 0306 RC 87497 HCPCS inpatient 240 156 AETNA AETNA 189.6 79 999999999 145.32 232.8 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 50805282_1 CDM 0306 RC 87497 HCPCS inpatient 240 156 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 232.8 97 999999999 145.32 232.8 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 50805282_1 CDM 0306 RC 87497 HCPCS inpatient 240 156 ENCORE - ALL PLANS ENCORE - ALL PLANS 165.6 69 999999999 145.32 232.8 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 50805282_1 CDM 0306 RC 87497 HCPCS inpatient 240 156 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.2 78 999999999 145.32 232.8 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 50805282_1 CDM 0306 RC 87497 HCPCS inpatient 240 156 SIHO - ALL PLANS SIHO - ALL PLANS 216 90 999999999 145.32 232.8 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 50805282_1 CDM 0306 RC 87497 HCPCS inpatient 240 156 UMR - ALL PLANS UMR - ALL PLANS 168 70 999999999 145.32 232.8 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 50805282_1 CDM 0306 RC 87497 HCPCS inpatient 240 156 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.32 60.55 999999999 145.32 232.8 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 50805282_1 CDM 0306 RC 87497 HCPCS inpatient 240 156 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.32 232.8 "Detection test by nucleic acid for cytomegalovirus, quantification" 50805282_1 CDM 0306 RC 87497 HCPCS inpatient 240 156 ANTHEM HMO ANTHEM HMO 999999999 145.32 232.8 "Detection test by nucleic acid for cytomegalovirus, quantification" 50805282_1 CDM 0306 RC 87497 HCPCS inpatient 240 156 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.32 232.8 "Detection test by nucleic acid for cytomegalovirus, quantification" 50805282_1 CDM 0306 RC 87497 HCPCS inpatient 240 156 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.24 67.6 999999999 145.32 232.8 percent of total billed charges "Detection test by nucleic acid for cytomegalovirus, quantification" 50805282_1 CDM 0306 RC 87497 HCPCS inpatient 240 156 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.32 232.8 "Detection test by nucleic acid for cytomegalovirus, quantification" 50805282_1 CDM 0306 RC 87497 HCPCS inpatient 240 156 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.32 232.8 "Detection of infectious agent antibody, quantitative" 50805443_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.1 65 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50805443_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 AETNA AETNA 58.46 79 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50805443_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 71.78 97 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50805443_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.06 69 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50805443_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 57.72 78 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50805443_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 SIHO - ALL PLANS SIHO - ALL PLANS 66.6 90 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50805443_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 UMR - ALL PLANS UMR - ALL PLANS 51.8 70 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50805443_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.81 60.55 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50805443_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 50805443_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 ANTHEM HMO ANTHEM HMO 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 50805443_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 50805443_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.02 67.6 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50805443_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 50805443_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 50805451_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.1 65 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50805451_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 AETNA AETNA 58.46 79 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50805451_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 71.78 97 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50805451_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.06 69 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50805451_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 57.72 78 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50805451_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 SIHO - ALL PLANS SIHO - ALL PLANS 66.6 90 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50805451_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 UMR - ALL PLANS UMR - ALL PLANS 51.8 70 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50805451_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.81 60.55 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50805451_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 50805451_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 ANTHEM HMO ANTHEM HMO 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 50805451_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 50805451_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.02 67.6 999999999 44.81 71.78 percent of total billed charges "Detection of infectious agent antibody, quantitative" 50805451_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.81 71.78 "Detection of infectious agent antibody, quantitative" 50805451_1 CDM 0302 RC 86317 HCPCS inpatient 74 48.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.81 71.78 Vitamin K level 50805459_1 CDM 0301 RC 84597 HCPCS inpatient 263 170.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 170.95 65 999999999 159.25 255.11 percent of total billed charges Vitamin K level 50805459_1 CDM 0301 RC 84597 HCPCS inpatient 263 170.95 AETNA AETNA 207.77 79 999999999 159.25 255.11 percent of total billed charges Vitamin K level 50805459_1 CDM 0301 RC 84597 HCPCS inpatient 263 170.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 255.11 97 999999999 159.25 255.11 percent of total billed charges Vitamin K level 50805459_1 CDM 0301 RC 84597 HCPCS inpatient 263 170.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 181.47 69 999999999 159.25 255.11 percent of total billed charges Vitamin K level 50805459_1 CDM 0301 RC 84597 HCPCS inpatient 263 170.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 205.14 78 999999999 159.25 255.11 percent of total billed charges Vitamin K level 50805459_1 CDM 0301 RC 84597 HCPCS inpatient 263 170.95 SIHO - ALL PLANS SIHO - ALL PLANS 236.7 90 999999999 159.25 255.11 percent of total billed charges Vitamin K level 50805459_1 CDM 0301 RC 84597 HCPCS inpatient 263 170.95 UMR - ALL PLANS UMR - ALL PLANS 184.1 70 999999999 159.25 255.11 percent of total billed charges Vitamin K level 50805459_1 CDM 0301 RC 84597 HCPCS inpatient 263 170.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 159.25 60.55 999999999 159.25 255.11 percent of total billed charges Vitamin K level 50805459_1 CDM 0301 RC 84597 HCPCS inpatient 263 170.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 159.25 255.11 Vitamin K level 50805459_1 CDM 0301 RC 84597 HCPCS inpatient 263 170.95 ANTHEM HMO ANTHEM HMO 999999999 159.25 255.11 Vitamin K level 50805459_1 CDM 0301 RC 84597 HCPCS inpatient 263 170.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 159.25 255.11 Vitamin K level 50805459_1 CDM 0301 RC 84597 HCPCS inpatient 263 170.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 177.79 67.6 999999999 159.25 255.11 percent of total billed charges Vitamin K level 50805459_1 CDM 0301 RC 84597 HCPCS inpatient 263 170.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 159.25 255.11 Vitamin K level 50805459_1 CDM 0301 RC 84597 HCPCS inpatient 263 170.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 159.25 255.11 Analysis for antibody to Rubeola (measles virus) 50805467_1 CDM 0301 RC 86765 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50805467_1 CDM 0301 RC 86765 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50805467_1 CDM 0301 RC 86765 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50805467_1 CDM 0301 RC 86765 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50805467_1 CDM 0301 RC 86765 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50805467_1 CDM 0301 RC 86765 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50805467_1 CDM 0301 RC 86765 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50805467_1 CDM 0301 RC 86765 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50805467_1 CDM 0301 RC 86765 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 Analysis for antibody to Rubeola (measles virus) 50805467_1 CDM 0301 RC 86765 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 Analysis for antibody to Rubeola (measles virus) 50805467_1 CDM 0301 RC 86765 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 Analysis for antibody to Rubeola (measles virus) 50805467_1 CDM 0301 RC 86765 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges Analysis for antibody to Rubeola (measles virus) 50805467_1 CDM 0301 RC 86765 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 Analysis for antibody to Rubeola (measles virus) 50805467_1 CDM 0301 RC 86765 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 "Analysis of substance using immunoassay technique, multiple step method" 50809818_1 CDM 0301 RC 83516 HCPCS inpatient 99 64.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 64.35 65 999999999 59.94 96.03 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50809818_1 CDM 0301 RC 83516 HCPCS inpatient 99 64.35 AETNA AETNA 78.21 79 999999999 59.94 96.03 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50809818_1 CDM 0301 RC 83516 HCPCS inpatient 99 64.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 96.03 97 999999999 59.94 96.03 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50809818_1 CDM 0301 RC 83516 HCPCS inpatient 99 64.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 68.31 69 999999999 59.94 96.03 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50809818_1 CDM 0301 RC 83516 HCPCS inpatient 99 64.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 77.22 78 999999999 59.94 96.03 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50809818_1 CDM 0301 RC 83516 HCPCS inpatient 99 64.35 SIHO - ALL PLANS SIHO - ALL PLANS 89.1 90 999999999 59.94 96.03 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50809818_1 CDM 0301 RC 83516 HCPCS inpatient 99 64.35 UMR - ALL PLANS UMR - ALL PLANS 69.3 70 999999999 59.94 96.03 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50809818_1 CDM 0301 RC 83516 HCPCS inpatient 99 64.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.94 60.55 999999999 59.94 96.03 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50809818_1 CDM 0301 RC 83516 HCPCS inpatient 99 64.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.94 96.03 "Analysis of substance using immunoassay technique, multiple step method" 50809818_1 CDM 0301 RC 83516 HCPCS inpatient 99 64.35 ANTHEM HMO ANTHEM HMO 999999999 59.94 96.03 "Analysis of substance using immunoassay technique, multiple step method" 50809818_1 CDM 0301 RC 83516 HCPCS inpatient 99 64.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.94 96.03 "Analysis of substance using immunoassay technique, multiple step method" 50809818_1 CDM 0301 RC 83516 HCPCS inpatient 99 64.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.92 67.6 999999999 59.94 96.03 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 50809818_1 CDM 0301 RC 83516 HCPCS inpatient 99 64.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.94 96.03 "Analysis of substance using immunoassay technique, multiple step method" 50809818_1 CDM 0301 RC 83516 HCPCS inpatient 99 64.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.94 96.03 "Established patient office or other outpatient visit, 10-19 minutes" 50811425_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 208.65 65 999999999 194.37 311.37 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 50811425_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 AETNA AETNA 253.59 79 999999999 194.37 311.37 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 50811425_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 311.37 97 999999999 194.37 311.37 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 50811425_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 221.49 69 999999999 194.37 311.37 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 50811425_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 250.38 78 999999999 194.37 311.37 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 50811425_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 SIHO - ALL PLANS SIHO - ALL PLANS 288.9 90 999999999 194.37 311.37 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 50811425_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 UMR - ALL PLANS UMR - ALL PLANS 224.7 70 999999999 194.37 311.37 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 50811425_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 194.37 60.55 999999999 194.37 311.37 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 50811425_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 194.37 311.37 "Established patient office or other outpatient visit, 10-19 minutes" 50811425_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 ANTHEM HMO ANTHEM HMO 999999999 194.37 311.37 "Established patient office or other outpatient visit, 10-19 minutes" 50811425_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 194.37 311.37 "Established patient office or other outpatient visit, 10-19 minutes" 50811425_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 217 67.6 999999999 194.37 311.37 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 50811425_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 194.37 311.37 "Established patient office or other outpatient visit, 10-19 minutes" 50811425_1 CDM 0510 RC 99212 HCPCS inpatient 321 208.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 194.37 311.37 "Established patient office or other outpatient visit, 20-29 minutes" 50811426_1 CDM 0510 RC 99213 HCPCS inpatient 421 273.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 273.65 65 999999999 254.92 408.37 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 50811426_1 CDM 0510 RC 99213 HCPCS inpatient 421 273.65 AETNA AETNA 332.59 79 999999999 254.92 408.37 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 50811426_1 CDM 0510 RC 99213 HCPCS inpatient 421 273.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 408.37 97 999999999 254.92 408.37 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 50811426_1 CDM 0510 RC 99213 HCPCS inpatient 421 273.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 290.49 69 999999999 254.92 408.37 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 50811426_1 CDM 0510 RC 99213 HCPCS inpatient 421 273.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 328.38 78 999999999 254.92 408.37 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 50811426_1 CDM 0510 RC 99213 HCPCS inpatient 421 273.65 SIHO - ALL PLANS SIHO - ALL PLANS 378.9 90 999999999 254.92 408.37 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 50811426_1 CDM 0510 RC 99213 HCPCS inpatient 421 273.65 UMR - ALL PLANS UMR - ALL PLANS 294.7 70 999999999 254.92 408.37 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 50811426_1 CDM 0510 RC 99213 HCPCS inpatient 421 273.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 254.92 60.55 999999999 254.92 408.37 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 50811426_1 CDM 0510 RC 99213 HCPCS inpatient 421 273.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 254.92 408.37 "Established patient office or other outpatient visit, 20-29 minutes" 50811426_1 CDM 0510 RC 99213 HCPCS inpatient 421 273.65 ANTHEM HMO ANTHEM HMO 999999999 254.92 408.37 "Established patient office or other outpatient visit, 20-29 minutes" 50811426_1 CDM 0510 RC 99213 HCPCS inpatient 421 273.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 254.92 408.37 "Established patient office or other outpatient visit, 20-29 minutes" 50811426_1 CDM 0510 RC 99213 HCPCS inpatient 421 273.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 284.6 67.6 999999999 254.92 408.37 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 50811426_1 CDM 0510 RC 99213 HCPCS inpatient 421 273.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 254.92 408.37 "Established patient office or other outpatient visit, 20-29 minutes" 50811426_1 CDM 0510 RC 99213 HCPCS inpatient 421 273.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 254.92 408.37 "Established patient office or other outpatient visit, 30-39 minutes" 50811427_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 295.1 65 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 50811427_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 AETNA AETNA 358.66 79 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 50811427_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 440.38 97 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 50811427_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 313.26 69 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 50811427_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 354.12 78 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 50811427_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 SIHO - ALL PLANS SIHO - ALL PLANS 408.6 90 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 50811427_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 UMR - ALL PLANS UMR - ALL PLANS 317.8 70 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 50811427_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 274.9 60.55 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 50811427_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 274.9 440.38 "Established patient office or other outpatient visit, 30-39 minutes" 50811427_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 ANTHEM HMO ANTHEM HMO 999999999 274.9 440.38 "Established patient office or other outpatient visit, 30-39 minutes" 50811427_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 274.9 440.38 "Established patient office or other outpatient visit, 30-39 minutes" 50811427_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 306.9 67.6 999999999 274.9 440.38 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 50811427_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 274.9 440.38 "Established patient office or other outpatient visit, 30-39 minutes" 50811427_1 CDM 0510 RC 99214 HCPCS inpatient 454 295.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 274.9 440.38 "Established patient office or other outpatient visit, 40-54 minutes" 50811428_1 CDM 0510 RC 99215 HCPCS inpatient 486 315.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 315.9 65 999999999 294.27 471.42 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 50811428_1 CDM 0510 RC 99215 HCPCS inpatient 486 315.9 AETNA AETNA 383.94 79 999999999 294.27 471.42 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 50811428_1 CDM 0510 RC 99215 HCPCS inpatient 486 315.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 471.42 97 999999999 294.27 471.42 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 50811428_1 CDM 0510 RC 99215 HCPCS inpatient 486 315.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 335.34 69 999999999 294.27 471.42 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 50811428_1 CDM 0510 RC 99215 HCPCS inpatient 486 315.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 379.08 78 999999999 294.27 471.42 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 50811428_1 CDM 0510 RC 99215 HCPCS inpatient 486 315.9 SIHO - ALL PLANS SIHO - ALL PLANS 437.4 90 999999999 294.27 471.42 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 50811428_1 CDM 0510 RC 99215 HCPCS inpatient 486 315.9 UMR - ALL PLANS UMR - ALL PLANS 340.2 70 999999999 294.27 471.42 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 50811428_1 CDM 0510 RC 99215 HCPCS inpatient 486 315.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 294.27 60.55 999999999 294.27 471.42 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 50811428_1 CDM 0510 RC 99215 HCPCS inpatient 486 315.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 294.27 471.42 "Established patient office or other outpatient visit, 40-54 minutes" 50811428_1 CDM 0510 RC 99215 HCPCS inpatient 486 315.9 ANTHEM HMO ANTHEM HMO 999999999 294.27 471.42 "Established patient office or other outpatient visit, 40-54 minutes" 50811428_1 CDM 0510 RC 99215 HCPCS inpatient 486 315.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 294.27 471.42 "Established patient office or other outpatient visit, 40-54 minutes" 50811428_1 CDM 0510 RC 99215 HCPCS inpatient 486 315.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 328.54 67.6 999999999 294.27 471.42 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 50811428_1 CDM 0510 RC 99215 HCPCS inpatient 486 315.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 294.27 471.42 "Established patient office or other outpatient visit, 40-54 minutes" 50811428_1 CDM 0510 RC 99215 HCPCS inpatient 486 315.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 294.27 471.42 "New patient office or other outpatient visit, 15-29 minutes" 50811429_1 CDM 0510 RC 99202 HCPCS inpatient 277 180.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 180.05 65 999999999 167.72 268.69 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 50811429_1 CDM 0510 RC 99202 HCPCS inpatient 277 180.05 AETNA AETNA 218.83 79 999999999 167.72 268.69 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 50811429_1 CDM 0510 RC 99202 HCPCS inpatient 277 180.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 268.69 97 999999999 167.72 268.69 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 50811429_1 CDM 0510 RC 99202 HCPCS inpatient 277 180.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 191.13 69 999999999 167.72 268.69 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 50811429_1 CDM 0510 RC 99202 HCPCS inpatient 277 180.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 216.06 78 999999999 167.72 268.69 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 50811429_1 CDM 0510 RC 99202 HCPCS inpatient 277 180.05 SIHO - ALL PLANS SIHO - ALL PLANS 249.3 90 999999999 167.72 268.69 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 50811429_1 CDM 0510 RC 99202 HCPCS inpatient 277 180.05 UMR - ALL PLANS UMR - ALL PLANS 193.9 70 999999999 167.72 268.69 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 50811429_1 CDM 0510 RC 99202 HCPCS inpatient 277 180.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 167.72 60.55 999999999 167.72 268.69 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 50811429_1 CDM 0510 RC 99202 HCPCS inpatient 277 180.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 167.72 268.69 "New patient office or other outpatient visit, 15-29 minutes" 50811429_1 CDM 0510 RC 99202 HCPCS inpatient 277 180.05 ANTHEM HMO ANTHEM HMO 999999999 167.72 268.69 "New patient office or other outpatient visit, 15-29 minutes" 50811429_1 CDM 0510 RC 99202 HCPCS inpatient 277 180.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 167.72 268.69 "New patient office or other outpatient visit, 15-29 minutes" 50811429_1 CDM 0510 RC 99202 HCPCS inpatient 277 180.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 187.25 67.6 999999999 167.72 268.69 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 50811429_1 CDM 0510 RC 99202 HCPCS inpatient 277 180.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 167.72 268.69 "New patient office or other outpatient visit, 15-29 minutes" 50811429_1 CDM 0510 RC 99202 HCPCS inpatient 277 180.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 167.72 268.69 "New patient office or other outpatient visit, 30-44 minutes" 50811430_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 277.55 65 999999999 258.55 414.19 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 50811430_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 AETNA AETNA 337.33 79 999999999 258.55 414.19 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 50811430_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 414.19 97 999999999 258.55 414.19 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 50811430_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 294.63 69 999999999 258.55 414.19 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 50811430_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.06 78 999999999 258.55 414.19 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 50811430_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 SIHO - ALL PLANS SIHO - ALL PLANS 384.3 90 999999999 258.55 414.19 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 50811430_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 UMR - ALL PLANS UMR - ALL PLANS 298.9 70 999999999 258.55 414.19 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 50811430_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 258.55 60.55 999999999 258.55 414.19 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 50811430_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 258.55 414.19 "New patient office or other outpatient visit, 30-44 minutes" 50811430_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 ANTHEM HMO ANTHEM HMO 999999999 258.55 414.19 "New patient office or other outpatient visit, 30-44 minutes" 50811430_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 258.55 414.19 "New patient office or other outpatient visit, 30-44 minutes" 50811430_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 288.65 67.6 999999999 258.55 414.19 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 50811430_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 258.55 414.19 "New patient office or other outpatient visit, 30-44 minutes" 50811430_1 CDM 0510 RC 99203 HCPCS inpatient 427 277.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 258.55 414.19 "New patient office or other outpatient visit, 45-59 minutes" 50811431_1 CDM 0510 RC 99204 HCPCS inpatient 527 342.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 342.55 65 999999999 319.1 511.19 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 50811431_1 CDM 0510 RC 99204 HCPCS inpatient 527 342.55 AETNA AETNA 416.33 79 999999999 319.1 511.19 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 50811431_1 CDM 0510 RC 99204 HCPCS inpatient 527 342.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 511.19 97 999999999 319.1 511.19 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 50811431_1 CDM 0510 RC 99204 HCPCS inpatient 527 342.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 363.63 69 999999999 319.1 511.19 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 50811431_1 CDM 0510 RC 99204 HCPCS inpatient 527 342.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 411.06 78 999999999 319.1 511.19 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 50811431_1 CDM 0510 RC 99204 HCPCS inpatient 527 342.55 SIHO - ALL PLANS SIHO - ALL PLANS 474.3 90 999999999 319.1 511.19 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 50811431_1 CDM 0510 RC 99204 HCPCS inpatient 527 342.55 UMR - ALL PLANS UMR - ALL PLANS 368.9 70 999999999 319.1 511.19 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 50811431_1 CDM 0510 RC 99204 HCPCS inpatient 527 342.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 319.1 60.55 999999999 319.1 511.19 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 50811431_1 CDM 0510 RC 99204 HCPCS inpatient 527 342.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 319.1 511.19 "New patient office or other outpatient visit, 45-59 minutes" 50811431_1 CDM 0510 RC 99204 HCPCS inpatient 527 342.55 ANTHEM HMO ANTHEM HMO 999999999 319.1 511.19 "New patient office or other outpatient visit, 45-59 minutes" 50811431_1 CDM 0510 RC 99204 HCPCS inpatient 527 342.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 319.1 511.19 "New patient office or other outpatient visit, 45-59 minutes" 50811431_1 CDM 0510 RC 99204 HCPCS inpatient 527 342.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 356.25 67.6 999999999 319.1 511.19 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 50811431_1 CDM 0510 RC 99204 HCPCS inpatient 527 342.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 319.1 511.19 "New patient office or other outpatient visit, 45-59 minutes" 50811431_1 CDM 0510 RC 99204 HCPCS inpatient 527 342.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 319.1 511.19 "New patient office or other outpatient visit, 60-74 minutes" 50811432_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 354.9 65 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 50811432_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 AETNA AETNA 431.34 79 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 50811432_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 529.62 97 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 50811432_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 376.74 69 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 50811432_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 425.88 78 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 50811432_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 SIHO - ALL PLANS SIHO - ALL PLANS 491.4 90 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 50811432_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 UMR - ALL PLANS UMR - ALL PLANS 382.2 70 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 50811432_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 330.6 60.55 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 50811432_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 330.6 529.62 "New patient office or other outpatient visit, 60-74 minutes" 50811432_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 ANTHEM HMO ANTHEM HMO 999999999 330.6 529.62 "New patient office or other outpatient visit, 60-74 minutes" 50811432_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 330.6 529.62 "New patient office or other outpatient visit, 60-74 minutes" 50811432_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 369.1 67.6 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 50811432_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 330.6 529.62 "New patient office or other outpatient visit, 60-74 minutes" 50811432_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 330.6 529.62 "VINCRISTINE SULFATE, 1 MG" 50814140_1 CDM 0636 RC 61703-0309-06 NDC J9370 HCPCS inpatient 1 UN 78.74 51.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.18 65 999999999 47.68 76.38 percent of total billed charges "VINCRISTINE SULFATE, 1 MG" 50814140_1 CDM 0636 RC 61703-0309-06 NDC J9370 HCPCS inpatient 1 UN 78.74 51.18 AETNA AETNA 62.2 79 999999999 47.68 76.38 percent of total billed charges "VINCRISTINE SULFATE, 1 MG" 50814140_1 CDM 0636 RC 61703-0309-06 NDC J9370 HCPCS inpatient 1 UN 78.74 51.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.38 97 999999999 47.68 76.38 percent of total billed charges "VINCRISTINE SULFATE, 1 MG" 50814140_1 CDM 0636 RC 61703-0309-06 NDC J9370 HCPCS inpatient 1 UN 78.74 51.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.33 69 999999999 47.68 76.38 percent of total billed charges "VINCRISTINE SULFATE, 1 MG" 50814140_1 CDM 0636 RC 61703-0309-06 NDC J9370 HCPCS inpatient 1 UN 78.74 51.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.42 78 999999999 47.68 76.38 percent of total billed charges "VINCRISTINE SULFATE, 1 MG" 50814140_1 CDM 0636 RC 61703-0309-06 NDC J9370 HCPCS inpatient 1 UN 78.74 51.18 SIHO - ALL PLANS SIHO - ALL PLANS 70.87 90 999999999 47.68 76.38 percent of total billed charges "VINCRISTINE SULFATE, 1 MG" 50814140_1 CDM 0636 RC 61703-0309-06 NDC J9370 HCPCS inpatient 1 UN 78.74 51.18 UMR - ALL PLANS UMR - ALL PLANS 55.12 70 999999999 47.68 76.38 percent of total billed charges "VINCRISTINE SULFATE, 1 MG" 50814140_1 CDM 0636 RC 61703-0309-06 NDC J9370 HCPCS inpatient 1 UN 78.74 51.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.68 60.55 999999999 47.68 76.38 percent of total billed charges "VINCRISTINE SULFATE, 1 MG" 50814140_1 CDM 0636 RC 61703-0309-06 NDC J9370 HCPCS inpatient 1 UN 78.74 51.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.68 76.38 "VINCRISTINE SULFATE, 1 MG" 50814140_1 CDM 0636 RC 61703-0309-06 NDC J9370 HCPCS inpatient 1 UN 78.74 51.18 ANTHEM HMO ANTHEM HMO 999999999 47.68 76.38 "VINCRISTINE SULFATE, 1 MG" 50814140_1 CDM 0636 RC 61703-0309-06 NDC J9370 HCPCS inpatient 1 UN 78.74 51.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.68 76.38 "VINCRISTINE SULFATE, 1 MG" 50814140_1 CDM 0636 RC 61703-0309-06 NDC J9370 HCPCS inpatient 1 UN 78.74 51.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.23 67.6 999999999 47.68 76.38 percent of total billed charges "VINCRISTINE SULFATE, 1 MG" 50814140_1 CDM 0636 RC 61703-0309-06 NDC J9370 HCPCS inpatient 1 UN 78.74 51.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.68 76.38 "VINCRISTINE SULFATE, 1 MG" 50814140_1 CDM 0636 RC 61703-0309-06 NDC J9370 HCPCS inpatient 1 UN 78.74 51.18 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.68 76.38 "X-ray of thigh bone, minimum 2 views" 50814646_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 350.35 65 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 50814646_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 AETNA AETNA 425.81 79 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 50814646_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 522.83 97 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 50814646_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 371.91 69 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 50814646_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 420.42 78 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 50814646_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 SIHO - ALL PLANS SIHO - ALL PLANS 485.1 90 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 50814646_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 UMR - ALL PLANS UMR - ALL PLANS 377.3 70 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 50814646_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 326.36 60.55 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 50814646_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 326.36 522.83 "X-ray of thigh bone, minimum 2 views" 50814646_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 ANTHEM HMO ANTHEM HMO 999999999 326.36 522.83 "X-ray of thigh bone, minimum 2 views" 50814646_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 326.36 522.83 "X-ray of thigh bone, minimum 2 views" 50814646_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 364.36 67.6 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 50814646_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 326.36 522.83 "X-ray of thigh bone, minimum 2 views" 50814646_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 326.36 522.83 Thyroglobulin (thyroid protein) antibody measurement 50823672_1 CDM 0301 RC 86800 HCPCS inpatient 158 102.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.7 65 999999999 95.67 153.26 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 50823672_1 CDM 0301 RC 86800 HCPCS inpatient 158 102.7 AETNA AETNA 124.82 79 999999999 95.67 153.26 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 50823672_1 CDM 0301 RC 86800 HCPCS inpatient 158 102.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 153.26 97 999999999 95.67 153.26 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 50823672_1 CDM 0301 RC 86800 HCPCS inpatient 158 102.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 109.02 69 999999999 95.67 153.26 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 50823672_1 CDM 0301 RC 86800 HCPCS inpatient 158 102.7 UMR - ALL PLANS UMR - ALL PLANS 110.6 70 999999999 95.67 153.26 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 50823672_1 CDM 0301 RC 86800 HCPCS inpatient 158 102.7 SIHO - ALL PLANS SIHO - ALL PLANS 142.2 90 999999999 95.67 153.26 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 50823672_1 CDM 0301 RC 86800 HCPCS inpatient 158 102.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 123.24 78 999999999 95.67 153.26 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 50823672_1 CDM 0301 RC 86800 HCPCS inpatient 158 102.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.67 60.55 999999999 95.67 153.26 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 50823672_1 CDM 0301 RC 86800 HCPCS inpatient 158 102.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.67 153.26 Thyroglobulin (thyroid protein) antibody measurement 50823672_1 CDM 0301 RC 86800 HCPCS inpatient 158 102.7 ANTHEM HMO ANTHEM HMO 999999999 95.67 153.26 Thyroglobulin (thyroid protein) antibody measurement 50823672_1 CDM 0301 RC 86800 HCPCS inpatient 158 102.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.67 153.26 Thyroglobulin (thyroid protein) antibody measurement 50823672_1 CDM 0301 RC 86800 HCPCS inpatient 158 102.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.81 67.6 999999999 95.67 153.26 percent of total billed charges Thyroglobulin (thyroid protein) antibody measurement 50823672_1 CDM 0301 RC 86800 HCPCS inpatient 158 102.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.67 153.26 Thyroglobulin (thyroid protein) antibody measurement 50823672_1 CDM 0301 RC 86800 HCPCS inpatient 158 102.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.67 153.26 FENESTRATED GRASPER TIP 3222 50838178_1 CDM 0272 RC inpatient 356 231.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 231.4 65 999999999 215.56 345.32 percent of total billed charges FENESTRATED GRASPER TIP 3222 50838178_1 CDM 0272 RC inpatient 356 231.4 AETNA AETNA 281.24 79 999999999 215.56 345.32 percent of total billed charges FENESTRATED GRASPER TIP 3222 50838178_1 CDM 0272 RC inpatient 356 231.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 345.32 97 999999999 215.56 345.32 percent of total billed charges FENESTRATED GRASPER TIP 3222 50838178_1 CDM 0272 RC inpatient 356 231.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 245.64 69 999999999 215.56 345.32 percent of total billed charges FENESTRATED GRASPER TIP 3222 50838178_1 CDM 0272 RC inpatient 356 231.4 UMR - ALL PLANS UMR - ALL PLANS 249.2 70 999999999 215.56 345.32 percent of total billed charges FENESTRATED GRASPER TIP 3222 50838178_1 CDM 0272 RC inpatient 356 231.4 SIHO - ALL PLANS SIHO - ALL PLANS 320.4 90 999999999 215.56 345.32 percent of total billed charges FENESTRATED GRASPER TIP 3222 50838178_1 CDM 0272 RC inpatient 356 231.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 277.68 78 999999999 215.56 345.32 percent of total billed charges FENESTRATED GRASPER TIP 3222 50838178_1 CDM 0272 RC inpatient 356 231.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 215.56 60.55 999999999 215.56 345.32 percent of total billed charges FENESTRATED GRASPER TIP 3222 50838178_1 CDM 0272 RC inpatient 356 231.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 215.56 345.32 FENESTRATED GRASPER TIP 3222 50838178_1 CDM 0272 RC inpatient 356 231.4 ANTHEM HMO ANTHEM HMO 999999999 215.56 345.32 FENESTRATED GRASPER TIP 3222 50838178_1 CDM 0272 RC inpatient 356 231.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 215.56 345.32 FENESTRATED GRASPER TIP 3222 50838178_1 CDM 0272 RC inpatient 356 231.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 240.66 67.6 999999999 215.56 345.32 percent of total billed charges FENESTRATED GRASPER TIP 3222 50838178_1 CDM 0272 RC inpatient 356 231.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 215.56 345.32 FENESTRATED GRASPER TIP 3222 50838178_1 CDM 0272 RC inpatient 356 231.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 215.56 345.32 Rheumatoid factor level 50840765_1 CDM 0302 RC 86431 HCPCS inpatient 84 54.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 54.6 65 999999999 50.86 81.48 percent of total billed charges Rheumatoid factor level 50840765_1 CDM 0302 RC 86431 HCPCS inpatient 84 54.6 AETNA AETNA 66.36 79 999999999 50.86 81.48 percent of total billed charges Rheumatoid factor level 50840765_1 CDM 0302 RC 86431 HCPCS inpatient 84 54.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 81.48 97 999999999 50.86 81.48 percent of total billed charges Rheumatoid factor level 50840765_1 CDM 0302 RC 86431 HCPCS inpatient 84 54.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.96 69 999999999 50.86 81.48 percent of total billed charges Rheumatoid factor level 50840765_1 CDM 0302 RC 86431 HCPCS inpatient 84 54.6 UMR - ALL PLANS UMR - ALL PLANS 58.8 70 999999999 50.86 81.48 percent of total billed charges Rheumatoid factor level 50840765_1 CDM 0302 RC 86431 HCPCS inpatient 84 54.6 SIHO - ALL PLANS SIHO - ALL PLANS 75.6 90 999999999 50.86 81.48 percent of total billed charges Rheumatoid factor level 50840765_1 CDM 0302 RC 86431 HCPCS inpatient 84 54.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 65.52 78 999999999 50.86 81.48 percent of total billed charges Rheumatoid factor level 50840765_1 CDM 0302 RC 86431 HCPCS inpatient 84 54.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.86 60.55 999999999 50.86 81.48 percent of total billed charges Rheumatoid factor level 50840765_1 CDM 0302 RC 86431 HCPCS inpatient 84 54.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.86 81.48 Rheumatoid factor level 50840765_1 CDM 0302 RC 86431 HCPCS inpatient 84 54.6 ANTHEM HMO ANTHEM HMO 999999999 50.86 81.48 Rheumatoid factor level 50840765_1 CDM 0302 RC 86431 HCPCS inpatient 84 54.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.86 81.48 Rheumatoid factor level 50840765_1 CDM 0302 RC 86431 HCPCS inpatient 84 54.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.78 67.6 999999999 50.86 81.48 percent of total billed charges Rheumatoid factor level 50840765_1 CDM 0302 RC 86431 HCPCS inpatient 84 54.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.86 81.48 Rheumatoid factor level 50840765_1 CDM 0302 RC 86431 HCPCS inpatient 84 54.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.86 81.48 Detection test by immunoassay technique for Aspergillus (fungus) 50842553_1 CDM 0302 RC 87305 HCPCS inpatient 84 54.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 54.6 65 999999999 50.86 81.48 percent of total billed charges Detection test by immunoassay technique for Aspergillus (fungus) 50842553_1 CDM 0302 RC 87305 HCPCS inpatient 84 54.6 AETNA AETNA 66.36 79 999999999 50.86 81.48 percent of total billed charges Detection test by immunoassay technique for Aspergillus (fungus) 50842553_1 CDM 0302 RC 87305 HCPCS inpatient 84 54.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 81.48 97 999999999 50.86 81.48 percent of total billed charges Detection test by immunoassay technique for Aspergillus (fungus) 50842553_1 CDM 0302 RC 87305 HCPCS inpatient 84 54.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.96 69 999999999 50.86 81.48 percent of total billed charges Detection test by immunoassay technique for Aspergillus (fungus) 50842553_1 CDM 0302 RC 87305 HCPCS inpatient 84 54.6 UMR - ALL PLANS UMR - ALL PLANS 58.8 70 999999999 50.86 81.48 percent of total billed charges Detection test by immunoassay technique for Aspergillus (fungus) 50842553_1 CDM 0302 RC 87305 HCPCS inpatient 84 54.6 SIHO - ALL PLANS SIHO - ALL PLANS 75.6 90 999999999 50.86 81.48 percent of total billed charges Detection test by immunoassay technique for Aspergillus (fungus) 50842553_1 CDM 0302 RC 87305 HCPCS inpatient 84 54.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 65.52 78 999999999 50.86 81.48 percent of total billed charges Detection test by immunoassay technique for Aspergillus (fungus) 50842553_1 CDM 0302 RC 87305 HCPCS inpatient 84 54.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.86 60.55 999999999 50.86 81.48 percent of total billed charges Detection test by immunoassay technique for Aspergillus (fungus) 50842553_1 CDM 0302 RC 87305 HCPCS inpatient 84 54.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.86 81.48 Detection test by immunoassay technique for Aspergillus (fungus) 50842553_1 CDM 0302 RC 87305 HCPCS inpatient 84 54.6 ANTHEM HMO ANTHEM HMO 999999999 50.86 81.48 Detection test by immunoassay technique for Aspergillus (fungus) 50842553_1 CDM 0302 RC 87305 HCPCS inpatient 84 54.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.86 81.48 Detection test by immunoassay technique for Aspergillus (fungus) 50842553_1 CDM 0302 RC 87305 HCPCS inpatient 84 54.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.78 67.6 999999999 50.86 81.48 percent of total billed charges Detection test by immunoassay technique for Aspergillus (fungus) 50842553_1 CDM 0302 RC 87305 HCPCS inpatient 84 54.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.86 81.48 Detection test by immunoassay technique for Aspergillus (fungus) 50842553_1 CDM 0302 RC 87305 HCPCS inpatient 84 54.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.86 81.48 TA 60 3.5mm RELOAD 6/BOX 50866732_1 CDM 0272 RC inpatient 814 529.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 529.1 65 999999999 492.88 789.58 percent of total billed charges TA 60 3.5mm RELOAD 6/BOX 50866732_1 CDM 0272 RC inpatient 814 529.1 AETNA AETNA 643.06 79 999999999 492.88 789.58 percent of total billed charges TA 60 3.5mm RELOAD 6/BOX 50866732_1 CDM 0272 RC inpatient 814 529.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 789.58 97 999999999 492.88 789.58 percent of total billed charges TA 60 3.5mm RELOAD 6/BOX 50866732_1 CDM 0272 RC inpatient 814 529.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 561.66 69 999999999 492.88 789.58 percent of total billed charges TA 60 3.5mm RELOAD 6/BOX 50866732_1 CDM 0272 RC inpatient 814 529.1 UMR - ALL PLANS UMR - ALL PLANS 569.8 70 999999999 492.88 789.58 percent of total billed charges TA 60 3.5mm RELOAD 6/BOX 50866732_1 CDM 0272 RC inpatient 814 529.1 SIHO - ALL PLANS SIHO - ALL PLANS 732.6 90 999999999 492.88 789.58 percent of total billed charges TA 60 3.5mm RELOAD 6/BOX 50866732_1 CDM 0272 RC inpatient 814 529.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 634.92 78 999999999 492.88 789.58 percent of total billed charges TA 60 3.5mm RELOAD 6/BOX 50866732_1 CDM 0272 RC inpatient 814 529.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 492.88 60.55 999999999 492.88 789.58 percent of total billed charges TA 60 3.5mm RELOAD 6/BOX 50866732_1 CDM 0272 RC inpatient 814 529.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 492.88 789.58 TA 60 3.5mm RELOAD 6/BOX 50866732_1 CDM 0272 RC inpatient 814 529.1 ANTHEM HMO ANTHEM HMO 999999999 492.88 789.58 TA 60 3.5mm RELOAD 6/BOX 50866732_1 CDM 0272 RC inpatient 814 529.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 492.88 789.58 TA 60 3.5mm RELOAD 6/BOX 50866732_1 CDM 0272 RC inpatient 814 529.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 550.26 67.6 999999999 492.88 789.58 percent of total billed charges TA 60 3.5mm RELOAD 6/BOX 50866732_1 CDM 0272 RC inpatient 814 529.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 492.88 789.58 TA 60 3.5mm RELOAD 6/BOX 50866732_1 CDM 0272 RC inpatient 814 529.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 492.88 789.58 "BIPOLAR PACING CATHETER, SVC INSERTION D97120F5" 50875753_1 CDM 0272 RC inpatient 832 540.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 540.8 65 999999999 503.78 807.04 percent of total billed charges "BIPOLAR PACING CATHETER, SVC INSERTION D97120F5" 50875753_1 CDM 0272 RC inpatient 832 540.8 AETNA AETNA 657.28 79 999999999 503.78 807.04 percent of total billed charges "BIPOLAR PACING CATHETER, SVC INSERTION D97120F5" 50875753_1 CDM 0272 RC inpatient 832 540.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 807.04 97 999999999 503.78 807.04 percent of total billed charges "BIPOLAR PACING CATHETER, SVC INSERTION D97120F5" 50875753_1 CDM 0272 RC inpatient 832 540.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 574.08 69 999999999 503.78 807.04 percent of total billed charges "BIPOLAR PACING CATHETER, SVC INSERTION D97120F5" 50875753_1 CDM 0272 RC inpatient 832 540.8 UMR - ALL PLANS UMR - ALL PLANS 582.4 70 999999999 503.78 807.04 percent of total billed charges "BIPOLAR PACING CATHETER, SVC INSERTION D97120F5" 50875753_1 CDM 0272 RC inpatient 832 540.8 SIHO - ALL PLANS SIHO - ALL PLANS 748.8 90 999999999 503.78 807.04 percent of total billed charges "BIPOLAR PACING CATHETER, SVC INSERTION D97120F5" 50875753_1 CDM 0272 RC inpatient 832 540.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 648.96 78 999999999 503.78 807.04 percent of total billed charges "BIPOLAR PACING CATHETER, SVC INSERTION D97120F5" 50875753_1 CDM 0272 RC inpatient 832 540.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 503.78 60.55 999999999 503.78 807.04 percent of total billed charges "BIPOLAR PACING CATHETER, SVC INSERTION D97120F5" 50875753_1 CDM 0272 RC inpatient 832 540.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 503.78 807.04 "BIPOLAR PACING CATHETER, SVC INSERTION D97120F5" 50875753_1 CDM 0272 RC inpatient 832 540.8 ANTHEM HMO ANTHEM HMO 999999999 503.78 807.04 "BIPOLAR PACING CATHETER, SVC INSERTION D97120F5" 50875753_1 CDM 0272 RC inpatient 832 540.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 503.78 807.04 "BIPOLAR PACING CATHETER, SVC INSERTION D97120F5" 50875753_1 CDM 0272 RC inpatient 832 540.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 562.43 67.6 999999999 503.78 807.04 percent of total billed charges "BIPOLAR PACING CATHETER, SVC INSERTION D97120F5" 50875753_1 CDM 0272 RC inpatient 832 540.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 503.78 807.04 "BIPOLAR PACING CATHETER, SVC INSERTION D97120F5" 50875753_1 CDM 0272 RC inpatient 832 540.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 503.78 807.04 PERCUTANEOUS SHEATH INTRODUCER KIT AK-09601 50875756_1 CDM 0272 RC inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges PERCUTANEOUS SHEATH INTRODUCER KIT AK-09601 50875756_1 CDM 0272 RC inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges PERCUTANEOUS SHEATH INTRODUCER KIT AK-09601 50875756_1 CDM 0272 RC inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges PERCUTANEOUS SHEATH INTRODUCER KIT AK-09601 50875756_1 CDM 0272 RC inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges PERCUTANEOUS SHEATH INTRODUCER KIT AK-09601 50875756_1 CDM 0272 RC inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges PERCUTANEOUS SHEATH INTRODUCER KIT AK-09601 50875756_1 CDM 0272 RC inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges PERCUTANEOUS SHEATH INTRODUCER KIT AK-09601 50875756_1 CDM 0272 RC inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges PERCUTANEOUS SHEATH INTRODUCER KIT AK-09601 50875756_1 CDM 0272 RC inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges PERCUTANEOUS SHEATH INTRODUCER KIT AK-09601 50875756_1 CDM 0272 RC inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 PERCUTANEOUS SHEATH INTRODUCER KIT AK-09601 50875756_1 CDM 0272 RC inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 PERCUTANEOUS SHEATH INTRODUCER KIT AK-09601 50875756_1 CDM 0272 RC inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 PERCUTANEOUS SHEATH INTRODUCER KIT AK-09601 50875756_1 CDM 0272 RC inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges PERCUTANEOUS SHEATH INTRODUCER KIT AK-09601 50875756_1 CDM 0272 RC inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 PERCUTANEOUS SHEATH INTRODUCER KIT AK-09601 50875756_1 CDM 0272 RC inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 50879762_1 CDM 0510 RC 99211 HCPCS inpatient 58 37.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.7 65 999999999 35.12 56.26 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 50879762_1 CDM 0510 RC 99211 HCPCS inpatient 58 37.7 AETNA AETNA 45.82 79 999999999 35.12 56.26 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 50879762_1 CDM 0510 RC 99211 HCPCS inpatient 58 37.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.26 97 999999999 35.12 56.26 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 50879762_1 CDM 0510 RC 99211 HCPCS inpatient 58 37.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.02 69 999999999 35.12 56.26 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 50879762_1 CDM 0510 RC 99211 HCPCS inpatient 58 37.7 UMR - ALL PLANS UMR - ALL PLANS 40.6 70 999999999 35.12 56.26 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 50879762_1 CDM 0510 RC 99211 HCPCS inpatient 58 37.7 SIHO - ALL PLANS SIHO - ALL PLANS 52.2 90 999999999 35.12 56.26 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 50879762_1 CDM 0510 RC 99211 HCPCS inpatient 58 37.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.24 78 999999999 35.12 56.26 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 50879762_1 CDM 0510 RC 99211 HCPCS inpatient 58 37.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.12 60.55 999999999 35.12 56.26 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 50879762_1 CDM 0510 RC 99211 HCPCS inpatient 58 37.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.12 56.26 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 50879762_1 CDM 0510 RC 99211 HCPCS inpatient 58 37.7 ANTHEM HMO ANTHEM HMO 999999999 35.12 56.26 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 50879762_1 CDM 0510 RC 99211 HCPCS inpatient 58 37.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.12 56.26 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 50879762_1 CDM 0510 RC 99211 HCPCS inpatient 58 37.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.21 67.6 999999999 35.12 56.26 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 50879762_1 CDM 0510 RC 99211 HCPCS inpatient 58 37.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.12 56.26 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 50879762_1 CDM 0510 RC 99211 HCPCS inpatient 58 37.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.12 56.26 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50891139_1 CDM 0300 RC 87635 HCPCS inpatient 152 98.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.8 65 999999999 92.04 147.44 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50891139_1 CDM 0300 RC 87635 HCPCS inpatient 152 98.8 AETNA AETNA 120.08 79 999999999 92.04 147.44 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50891139_1 CDM 0300 RC 87635 HCPCS inpatient 152 98.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 147.44 97 999999999 92.04 147.44 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50891139_1 CDM 0300 RC 87635 HCPCS inpatient 152 98.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.88 69 999999999 92.04 147.44 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50891139_1 CDM 0300 RC 87635 HCPCS inpatient 152 98.8 UMR - ALL PLANS UMR - ALL PLANS 106.4 70 999999999 92.04 147.44 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50891139_1 CDM 0300 RC 87635 HCPCS inpatient 152 98.8 SIHO - ALL PLANS SIHO - ALL PLANS 136.8 90 999999999 92.04 147.44 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50891139_1 CDM 0300 RC 87635 HCPCS inpatient 152 98.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 118.56 78 999999999 92.04 147.44 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50891139_1 CDM 0300 RC 87635 HCPCS inpatient 152 98.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.04 60.55 999999999 92.04 147.44 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50891139_1 CDM 0300 RC 87635 HCPCS inpatient 152 98.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.04 147.44 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50891139_1 CDM 0300 RC 87635 HCPCS inpatient 152 98.8 ANTHEM HMO ANTHEM HMO 999999999 92.04 147.44 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50891139_1 CDM 0300 RC 87635 HCPCS inpatient 152 98.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.04 147.44 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50891139_1 CDM 0300 RC 87635 HCPCS inpatient 152 98.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.04 147.44 Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50891139_1 CDM 0300 RC 87635 HCPCS inpatient 152 98.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.75 67.6 999999999 92.04 147.44 percent of total billed charges Amplifed DNA or RNA probe detection of severe acute respiratory syndrome coronavirus 2 (Covid-19) antigen 50891139_1 CDM 0300 RC 87635 HCPCS inpatient 152 98.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.04 147.44 WRIST/THUMB SPICA RT/MED 081235316 50892084_1 CDM 0274 RC inpatient 139 90.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 90.35 65 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/MED 081235316 50892084_1 CDM 0274 RC inpatient 139 90.35 AETNA AETNA 109.81 79 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/MED 081235316 50892084_1 CDM 0274 RC inpatient 139 90.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 134.83 97 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/MED 081235316 50892084_1 CDM 0274 RC inpatient 139 90.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.91 69 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/MED 081235316 50892084_1 CDM 0274 RC inpatient 139 90.35 UMR - ALL PLANS UMR - ALL PLANS 97.3 70 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/MED 081235316 50892084_1 CDM 0274 RC inpatient 139 90.35 SIHO - ALL PLANS SIHO - ALL PLANS 125.1 90 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/MED 081235316 50892084_1 CDM 0274 RC inpatient 139 90.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 108.42 78 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/MED 081235316 50892084_1 CDM 0274 RC inpatient 139 90.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 84.16 60.55 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/MED 081235316 50892084_1 CDM 0274 RC inpatient 139 90.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 84.16 134.83 WRIST/THUMB SPICA RT/MED 081235316 50892084_1 CDM 0274 RC inpatient 139 90.35 ANTHEM HMO ANTHEM HMO 999999999 84.16 134.83 WRIST/THUMB SPICA RT/MED 081235316 50892084_1 CDM 0274 RC inpatient 139 90.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 84.16 134.83 WRIST/THUMB SPICA RT/MED 081235316 50892084_1 CDM 0274 RC inpatient 139 90.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 84.16 134.83 WRIST/THUMB SPICA RT/MED 081235316 50892084_1 CDM 0274 RC inpatient 139 90.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.96 67.6 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/MED 081235316 50892084_1 CDM 0274 RC inpatient 139 90.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 84.16 134.83 WRIST/THUMB SPICA LFT/MED 081235324 50892090_1 CDM 0274 RC inpatient 139 90.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 90.35 65 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/MED 081235324 50892090_1 CDM 0274 RC inpatient 139 90.35 AETNA AETNA 109.81 79 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/MED 081235324 50892090_1 CDM 0274 RC inpatient 139 90.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 134.83 97 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/MED 081235324 50892090_1 CDM 0274 RC inpatient 139 90.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.91 69 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/MED 081235324 50892090_1 CDM 0274 RC inpatient 139 90.35 SIHO - ALL PLANS SIHO - ALL PLANS 125.1 90 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/MED 081235324 50892090_1 CDM 0274 RC inpatient 139 90.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 108.42 78 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/MED 081235324 50892090_1 CDM 0274 RC inpatient 139 90.35 UMR - ALL PLANS UMR - ALL PLANS 97.3 70 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/MED 081235324 50892090_1 CDM 0274 RC inpatient 139 90.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 84.16 60.55 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/MED 081235324 50892090_1 CDM 0274 RC inpatient 139 90.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 84.16 134.83 WRIST/THUMB SPICA LFT/MED 081235324 50892090_1 CDM 0274 RC inpatient 139 90.35 ANTHEM HMO ANTHEM HMO 999999999 84.16 134.83 WRIST/THUMB SPICA LFT/MED 081235324 50892090_1 CDM 0274 RC inpatient 139 90.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 84.16 134.83 WRIST/THUMB SPICA LFT/MED 081235324 50892090_1 CDM 0274 RC inpatient 139 90.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 84.16 134.83 WRIST/THUMB SPICA LFT/MED 081235324 50892090_1 CDM 0274 RC inpatient 139 90.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.96 67.6 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/MED 081235324 50892090_1 CDM 0274 RC inpatient 139 90.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 84.16 134.83 WRIST/THUMB SPICA RT/SM 081235290 50892091_1 CDM 0274 RC inpatient 139 90.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 90.35 65 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/SM 081235290 50892091_1 CDM 0274 RC inpatient 139 90.35 AETNA AETNA 109.81 79 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/SM 081235290 50892091_1 CDM 0274 RC inpatient 139 90.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 134.83 97 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/SM 081235290 50892091_1 CDM 0274 RC inpatient 139 90.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.91 69 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/SM 081235290 50892091_1 CDM 0274 RC inpatient 139 90.35 SIHO - ALL PLANS SIHO - ALL PLANS 125.1 90 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/SM 081235290 50892091_1 CDM 0274 RC inpatient 139 90.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 108.42 78 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/SM 081235290 50892091_1 CDM 0274 RC inpatient 139 90.35 UMR - ALL PLANS UMR - ALL PLANS 97.3 70 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/SM 081235290 50892091_1 CDM 0274 RC inpatient 139 90.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 84.16 60.55 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/SM 081235290 50892091_1 CDM 0274 RC inpatient 139 90.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 84.16 134.83 WRIST/THUMB SPICA RT/SM 081235290 50892091_1 CDM 0274 RC inpatient 139 90.35 ANTHEM HMO ANTHEM HMO 999999999 84.16 134.83 WRIST/THUMB SPICA RT/SM 081235290 50892091_1 CDM 0274 RC inpatient 139 90.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 84.16 134.83 WRIST/THUMB SPICA RT/SM 081235290 50892091_1 CDM 0274 RC inpatient 139 90.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 84.16 134.83 WRIST/THUMB SPICA RT/SM 081235290 50892091_1 CDM 0274 RC inpatient 139 90.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.96 67.6 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/SM 081235290 50892091_1 CDM 0274 RC inpatient 139 90.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 84.16 134.83 WRIST/THUMB SPICA LFT/SM 081235308 50892092_1 CDM 0274 RC inpatient 139 90.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 90.35 65 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/SM 081235308 50892092_1 CDM 0274 RC inpatient 139 90.35 AETNA AETNA 109.81 79 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/SM 081235308 50892092_1 CDM 0274 RC inpatient 139 90.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 134.83 97 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/SM 081235308 50892092_1 CDM 0274 RC inpatient 139 90.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.91 69 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/SM 081235308 50892092_1 CDM 0274 RC inpatient 139 90.35 SIHO - ALL PLANS SIHO - ALL PLANS 125.1 90 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/SM 081235308 50892092_1 CDM 0274 RC inpatient 139 90.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 108.42 78 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/SM 081235308 50892092_1 CDM 0274 RC inpatient 139 90.35 UMR - ALL PLANS UMR - ALL PLANS 97.3 70 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/SM 081235308 50892092_1 CDM 0274 RC inpatient 139 90.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 84.16 60.55 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/SM 081235308 50892092_1 CDM 0274 RC inpatient 139 90.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 84.16 134.83 WRIST/THUMB SPICA LFT/SM 081235308 50892092_1 CDM 0274 RC inpatient 139 90.35 ANTHEM HMO ANTHEM HMO 999999999 84.16 134.83 WRIST/THUMB SPICA LFT/SM 081235308 50892092_1 CDM 0274 RC inpatient 139 90.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 84.16 134.83 WRIST/THUMB SPICA LFT/SM 081235308 50892092_1 CDM 0274 RC inpatient 139 90.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 84.16 134.83 WRIST/THUMB SPICA LFT/SM 081235308 50892092_1 CDM 0274 RC inpatient 139 90.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.96 67.6 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/SM 081235308 50892092_1 CDM 0274 RC inpatient 139 90.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 84.16 134.83 WRIST/THUMB SPICA RT/LG 081235332 50892093_1 CDM 0274 RC inpatient 139 90.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 90.35 65 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/LG 081235332 50892093_1 CDM 0274 RC inpatient 139 90.35 AETNA AETNA 109.81 79 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/LG 081235332 50892093_1 CDM 0274 RC inpatient 139 90.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 134.83 97 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/LG 081235332 50892093_1 CDM 0274 RC inpatient 139 90.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.91 69 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/LG 081235332 50892093_1 CDM 0274 RC inpatient 139 90.35 SIHO - ALL PLANS SIHO - ALL PLANS 125.1 90 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/LG 081235332 50892093_1 CDM 0274 RC inpatient 139 90.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 108.42 78 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/LG 081235332 50892093_1 CDM 0274 RC inpatient 139 90.35 UMR - ALL PLANS UMR - ALL PLANS 97.3 70 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/LG 081235332 50892093_1 CDM 0274 RC inpatient 139 90.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 84.16 60.55 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/LG 081235332 50892093_1 CDM 0274 RC inpatient 139 90.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 84.16 134.83 WRIST/THUMB SPICA RT/LG 081235332 50892093_1 CDM 0274 RC inpatient 139 90.35 ANTHEM HMO ANTHEM HMO 999999999 84.16 134.83 WRIST/THUMB SPICA RT/LG 081235332 50892093_1 CDM 0274 RC inpatient 139 90.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 84.16 134.83 WRIST/THUMB SPICA RT/LG 081235332 50892093_1 CDM 0274 RC inpatient 139 90.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 84.16 134.83 WRIST/THUMB SPICA RT/LG 081235332 50892093_1 CDM 0274 RC inpatient 139 90.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.96 67.6 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA RT/LG 081235332 50892093_1 CDM 0274 RC inpatient 139 90.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 84.16 134.83 WRIST/THUMB SPICA LFT/LG 081235340 50892094_1 CDM 0274 RC inpatient 139 90.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 90.35 65 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/LG 081235340 50892094_1 CDM 0274 RC inpatient 139 90.35 AETNA AETNA 109.81 79 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/LG 081235340 50892094_1 CDM 0274 RC inpatient 139 90.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 134.83 97 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/LG 081235340 50892094_1 CDM 0274 RC inpatient 139 90.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.91 69 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/LG 081235340 50892094_1 CDM 0274 RC inpatient 139 90.35 SIHO - ALL PLANS SIHO - ALL PLANS 125.1 90 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/LG 081235340 50892094_1 CDM 0274 RC inpatient 139 90.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 108.42 78 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/LG 081235340 50892094_1 CDM 0274 RC inpatient 139 90.35 UMR - ALL PLANS UMR - ALL PLANS 97.3 70 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/LG 081235340 50892094_1 CDM 0274 RC inpatient 139 90.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 84.16 60.55 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/LG 081235340 50892094_1 CDM 0274 RC inpatient 139 90.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 84.16 134.83 WRIST/THUMB SPICA LFT/LG 081235340 50892094_1 CDM 0274 RC inpatient 139 90.35 ANTHEM HMO ANTHEM HMO 999999999 84.16 134.83 WRIST/THUMB SPICA LFT/LG 081235340 50892094_1 CDM 0274 RC inpatient 139 90.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 84.16 134.83 WRIST/THUMB SPICA LFT/LG 081235340 50892094_1 CDM 0274 RC inpatient 139 90.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 84.16 134.83 WRIST/THUMB SPICA LFT/LG 081235340 50892094_1 CDM 0274 RC inpatient 139 90.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.96 67.6 999999999 84.16 134.83 percent of total billed charges WRIST/THUMB SPICA LFT/LG 081235340 50892094_1 CDM 0274 RC inpatient 139 90.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 84.16 134.83 Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 50897425_1 CDM 0300 RC 0282U HCPCS inpatient 525 341.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 341.25 65 999999999 317.89 509.25 percent of total billed charges Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 50897425_1 CDM 0300 RC 0282U HCPCS inpatient 525 341.25 AETNA AETNA 414.75 79 999999999 317.89 509.25 percent of total billed charges Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 50897425_1 CDM 0300 RC 0282U HCPCS inpatient 525 341.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 509.25 97 999999999 317.89 509.25 percent of total billed charges Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 50897425_1 CDM 0300 RC 0282U HCPCS inpatient 525 341.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 362.25 69 999999999 317.89 509.25 percent of total billed charges Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 50897425_1 CDM 0300 RC 0282U HCPCS inpatient 525 341.25 SIHO - ALL PLANS SIHO - ALL PLANS 472.5 90 999999999 317.89 509.25 percent of total billed charges Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 50897425_1 CDM 0300 RC 0282U HCPCS inpatient 525 341.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 409.5 78 999999999 317.89 509.25 percent of total billed charges Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 50897425_1 CDM 0300 RC 0282U HCPCS inpatient 525 341.25 UMR - ALL PLANS UMR - ALL PLANS 367.5 70 999999999 317.89 509.25 percent of total billed charges Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 50897425_1 CDM 0300 RC 0282U HCPCS inpatient 525 341.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 317.89 60.55 999999999 317.89 509.25 percent of total billed charges Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 50897425_1 CDM 0300 RC 0282U HCPCS inpatient 525 341.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 317.89 509.25 Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 50897425_1 CDM 0300 RC 0282U HCPCS inpatient 525 341.25 ANTHEM HMO ANTHEM HMO 999999999 317.89 509.25 Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 50897425_1 CDM 0300 RC 0282U HCPCS inpatient 525 341.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 317.89 509.25 Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 50897425_1 CDM 0300 RC 0282U HCPCS inpatient 525 341.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 317.89 509.25 Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 50897425_1 CDM 0300 RC 0282U HCPCS inpatient 525 341.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 354.9 67.6 999999999 317.89 509.25 percent of total billed charges Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 50897425_1 CDM 0300 RC 0282U HCPCS inpatient 525 341.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 317.89 509.25 Lead level 50900253_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.7 65 999999999 144.11 230.86 percent of total billed charges Lead level 50900253_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 AETNA AETNA 188.02 79 999999999 144.11 230.86 percent of total billed charges Lead level 50900253_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 230.86 97 999999999 144.11 230.86 percent of total billed charges Lead level 50900253_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.22 69 999999999 144.11 230.86 percent of total billed charges Lead level 50900253_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 SIHO - ALL PLANS SIHO - ALL PLANS 214.2 90 999999999 144.11 230.86 percent of total billed charges Lead level 50900253_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 185.64 78 999999999 144.11 230.86 percent of total billed charges Lead level 50900253_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 UMR - ALL PLANS UMR - ALL PLANS 166.6 70 999999999 144.11 230.86 percent of total billed charges Lead level 50900253_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.11 60.55 999999999 144.11 230.86 percent of total billed charges Lead level 50900253_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.11 230.86 Lead level 50900253_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 ANTHEM HMO ANTHEM HMO 999999999 144.11 230.86 Lead level 50900253_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.11 230.86 Lead level 50900253_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.11 230.86 Lead level 50900253_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.89 67.6 999999999 144.11 230.86 percent of total billed charges Lead level 50900253_1 CDM 0301 RC 83655 HCPCS inpatient 238 154.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.11 230.86 ADAPTER ELECTRODE TO PHYSIO-CONTROL AED 2110 50907523_1 CDM 0272 RC inpatient 132 85.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.8 65 999999999 79.93 128.04 percent of total billed charges ADAPTER ELECTRODE TO PHYSIO-CONTROL AED 2110 50907523_1 CDM 0272 RC inpatient 132 85.8 AETNA AETNA 104.28 79 999999999 79.93 128.04 percent of total billed charges ADAPTER ELECTRODE TO PHYSIO-CONTROL AED 2110 50907523_1 CDM 0272 RC inpatient 132 85.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 128.04 97 999999999 79.93 128.04 percent of total billed charges ADAPTER ELECTRODE TO PHYSIO-CONTROL AED 2110 50907523_1 CDM 0272 RC inpatient 132 85.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.08 69 999999999 79.93 128.04 percent of total billed charges ADAPTER ELECTRODE TO PHYSIO-CONTROL AED 2110 50907523_1 CDM 0272 RC inpatient 132 85.8 SIHO - ALL PLANS SIHO - ALL PLANS 118.8 90 999999999 79.93 128.04 percent of total billed charges ADAPTER ELECTRODE TO PHYSIO-CONTROL AED 2110 50907523_1 CDM 0272 RC inpatient 132 85.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.96 78 999999999 79.93 128.04 percent of total billed charges ADAPTER ELECTRODE TO PHYSIO-CONTROL AED 2110 50907523_1 CDM 0272 RC inpatient 132 85.8 UMR - ALL PLANS UMR - ALL PLANS 92.4 70 999999999 79.93 128.04 percent of total billed charges ADAPTER ELECTRODE TO PHYSIO-CONTROL AED 2110 50907523_1 CDM 0272 RC inpatient 132 85.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.93 60.55 999999999 79.93 128.04 percent of total billed charges ADAPTER ELECTRODE TO PHYSIO-CONTROL AED 2110 50907523_1 CDM 0272 RC inpatient 132 85.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.93 128.04 ADAPTER ELECTRODE TO PHYSIO-CONTROL AED 2110 50907523_1 CDM 0272 RC inpatient 132 85.8 ANTHEM HMO ANTHEM HMO 999999999 79.93 128.04 ADAPTER ELECTRODE TO PHYSIO-CONTROL AED 2110 50907523_1 CDM 0272 RC inpatient 132 85.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.93 128.04 ADAPTER ELECTRODE TO PHYSIO-CONTROL AED 2110 50907523_1 CDM 0272 RC inpatient 132 85.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.93 128.04 ADAPTER ELECTRODE TO PHYSIO-CONTROL AED 2110 50907523_1 CDM 0272 RC inpatient 132 85.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.23 67.6 999999999 79.93 128.04 percent of total billed charges ADAPTER ELECTRODE TO PHYSIO-CONTROL AED 2110 50907523_1 CDM 0272 RC inpatient 132 85.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.93 128.04 "Blood glucose (sugar) tolerance test, 3 specimens" 50915560_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 50915560_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 50915560_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 50915560_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 50915560_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 50915560_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 50915560_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 50915560_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 50915560_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 "Blood glucose (sugar) tolerance test, 3 specimens" 50915560_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 "Blood glucose (sugar) tolerance test, 3 specimens" 50915560_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 "Blood glucose (sugar) tolerance test, 3 specimens" 50915560_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 "Blood glucose (sugar) tolerance test, 3 specimens" 50915560_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 50915560_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 "Blood glucose (sugar) tolerance test, 3 specimens" 50915561_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 50915561_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 50915561_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 50915561_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 50915561_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 50915561_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 50915561_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 50915561_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 50915561_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 "Blood glucose (sugar) tolerance test, 3 specimens" 50915561_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 "Blood glucose (sugar) tolerance test, 3 specimens" 50915561_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 "Blood glucose (sugar) tolerance test, 3 specimens" 50915561_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 "Blood glucose (sugar) tolerance test, 3 specimens" 50915561_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 50915561_1 CDM 0301 RC 82951 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 "INJECTION, ROMOSOZUMAB-AQQG, 1 MG" 50918494_1 CDM 0636 RC 55513-0880-02 NDC J3111 HCPCS inpatient 105 UN 8718.52 5667.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 5667.04 65 999999999 5279.06 8456.96 percent of total billed charges "INJECTION, ROMOSOZUMAB-AQQG, 1 MG" 50918494_1 CDM 0636 RC 55513-0880-02 NDC J3111 HCPCS inpatient 105 UN 8718.52 5667.04 AETNA AETNA 6887.63 79 999999999 5279.06 8456.96 percent of total billed charges "INJECTION, ROMOSOZUMAB-AQQG, 1 MG" 50918494_1 CDM 0636 RC 55513-0880-02 NDC J3111 HCPCS inpatient 105 UN 8718.52 5667.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8456.96 97 999999999 5279.06 8456.96 percent of total billed charges "INJECTION, ROMOSOZUMAB-AQQG, 1 MG" 50918494_1 CDM 0636 RC 55513-0880-02 NDC J3111 HCPCS inpatient 105 UN 8718.52 5667.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 6015.78 69 999999999 5279.06 8456.96 percent of total billed charges "INJECTION, ROMOSOZUMAB-AQQG, 1 MG" 50918494_1 CDM 0636 RC 55513-0880-02 NDC J3111 HCPCS inpatient 105 UN 8718.52 5667.04 SIHO - ALL PLANS SIHO - ALL PLANS 7846.67 90 999999999 5279.06 8456.96 percent of total billed charges "INJECTION, ROMOSOZUMAB-AQQG, 1 MG" 50918494_1 CDM 0636 RC 55513-0880-02 NDC J3111 HCPCS inpatient 105 UN 8718.52 5667.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 6800.45 78 999999999 5279.06 8456.96 percent of total billed charges "INJECTION, ROMOSOZUMAB-AQQG, 1 MG" 50918494_1 CDM 0636 RC 55513-0880-02 NDC J3111 HCPCS inpatient 105 UN 8718.52 5667.04 UMR - ALL PLANS UMR - ALL PLANS 6102.96 70 999999999 5279.06 8456.96 percent of total billed charges "INJECTION, ROMOSOZUMAB-AQQG, 1 MG" 50918494_1 CDM 0636 RC 55513-0880-02 NDC J3111 HCPCS inpatient 105 UN 8718.52 5667.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5279.06 60.55 999999999 5279.06 8456.96 percent of total billed charges "INJECTION, ROMOSOZUMAB-AQQG, 1 MG" 50918494_1 CDM 0636 RC 55513-0880-02 NDC J3111 HCPCS inpatient 105 UN 8718.52 5667.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5279.06 8456.96 "INJECTION, ROMOSOZUMAB-AQQG, 1 MG" 50918494_1 CDM 0636 RC 55513-0880-02 NDC J3111 HCPCS inpatient 105 UN 8718.52 5667.04 ANTHEM HMO ANTHEM HMO 999999999 5279.06 8456.96 "INJECTION, ROMOSOZUMAB-AQQG, 1 MG" 50918494_1 CDM 0636 RC 55513-0880-02 NDC J3111 HCPCS inpatient 105 UN 8718.52 5667.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5279.06 8456.96 "INJECTION, ROMOSOZUMAB-AQQG, 1 MG" 50918494_1 CDM 0636 RC 55513-0880-02 NDC J3111 HCPCS inpatient 105 UN 8718.52 5667.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5279.06 8456.96 "INJECTION, ROMOSOZUMAB-AQQG, 1 MG" 50918494_1 CDM 0636 RC 55513-0880-02 NDC J3111 HCPCS inpatient 105 UN 8718.52 5667.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 5893.72 67.6 999999999 5279.06 8456.96 percent of total billed charges "INJECTION, ROMOSOZUMAB-AQQG, 1 MG" 50918494_1 CDM 0636 RC 55513-0880-02 NDC J3111 HCPCS inpatient 105 UN 8718.52 5667.04 UHC - ALL PLANS UHC - ALL PLANS 999999999 5279.06 8456.96 Complicated or multiple drainage of skin abscess 50936804_1 CDM 0510 RC 10061 HCPCS inpatient 735 477.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 477.75 65 999999999 445.04 712.95 percent of total billed charges Complicated or multiple drainage of skin abscess 50936804_1 CDM 0510 RC 10061 HCPCS inpatient 735 477.75 AETNA AETNA 580.65 79 999999999 445.04 712.95 percent of total billed charges Complicated or multiple drainage of skin abscess 50936804_1 CDM 0510 RC 10061 HCPCS inpatient 735 477.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 712.95 97 999999999 445.04 712.95 percent of total billed charges Complicated or multiple drainage of skin abscess 50936804_1 CDM 0510 RC 10061 HCPCS inpatient 735 477.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 507.15 69 999999999 445.04 712.95 percent of total billed charges Complicated or multiple drainage of skin abscess 50936804_1 CDM 0510 RC 10061 HCPCS inpatient 735 477.75 SIHO - ALL PLANS SIHO - ALL PLANS 661.5 90 999999999 445.04 712.95 percent of total billed charges Complicated or multiple drainage of skin abscess 50936804_1 CDM 0510 RC 10061 HCPCS inpatient 735 477.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 573.3 78 999999999 445.04 712.95 percent of total billed charges Complicated or multiple drainage of skin abscess 50936804_1 CDM 0510 RC 10061 HCPCS inpatient 735 477.75 UMR - ALL PLANS UMR - ALL PLANS 514.5 70 999999999 445.04 712.95 percent of total billed charges Complicated or multiple drainage of skin abscess 50936804_1 CDM 0510 RC 10061 HCPCS inpatient 735 477.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 445.04 60.55 999999999 445.04 712.95 percent of total billed charges Complicated or multiple drainage of skin abscess 50936804_1 CDM 0510 RC 10061 HCPCS inpatient 735 477.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 445.04 712.95 Complicated or multiple drainage of skin abscess 50936804_1 CDM 0510 RC 10061 HCPCS inpatient 735 477.75 ANTHEM HMO ANTHEM HMO 999999999 445.04 712.95 Complicated or multiple drainage of skin abscess 50936804_1 CDM 0510 RC 10061 HCPCS inpatient 735 477.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 445.04 712.95 Complicated or multiple drainage of skin abscess 50936804_1 CDM 0510 RC 10061 HCPCS inpatient 735 477.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 445.04 712.95 Complicated or multiple drainage of skin abscess 50936804_1 CDM 0510 RC 10061 HCPCS inpatient 735 477.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 496.86 67.6 999999999 445.04 712.95 percent of total billed charges Complicated or multiple drainage of skin abscess 50936804_1 CDM 0510 RC 10061 HCPCS inpatient 735 477.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 445.04 712.95 Removal of tissue from wound gradually 50936805_1 CDM 0510 RC 97602 HCPCS inpatient 521 338.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 338.65 65 999999999 315.47 505.37 percent of total billed charges Removal of tissue from wound gradually 50936805_1 CDM 0510 RC 97602 HCPCS inpatient 521 338.65 AETNA AETNA 411.59 79 999999999 315.47 505.37 percent of total billed charges Removal of tissue from wound gradually 50936805_1 CDM 0510 RC 97602 HCPCS inpatient 521 338.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 505.37 97 999999999 315.47 505.37 percent of total billed charges Removal of tissue from wound gradually 50936805_1 CDM 0510 RC 97602 HCPCS inpatient 521 338.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 359.49 69 999999999 315.47 505.37 percent of total billed charges Removal of tissue from wound gradually 50936805_1 CDM 0510 RC 97602 HCPCS inpatient 521 338.65 SIHO - ALL PLANS SIHO - ALL PLANS 468.9 90 999999999 315.47 505.37 percent of total billed charges Removal of tissue from wound gradually 50936805_1 CDM 0510 RC 97602 HCPCS inpatient 521 338.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 406.38 78 999999999 315.47 505.37 percent of total billed charges Removal of tissue from wound gradually 50936805_1 CDM 0510 RC 97602 HCPCS inpatient 521 338.65 UMR - ALL PLANS UMR - ALL PLANS 364.7 70 999999999 315.47 505.37 percent of total billed charges Removal of tissue from wound gradually 50936805_1 CDM 0510 RC 97602 HCPCS inpatient 521 338.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 315.47 60.55 999999999 315.47 505.37 percent of total billed charges Removal of tissue from wound gradually 50936805_1 CDM 0510 RC 97602 HCPCS inpatient 521 338.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 315.47 505.37 Removal of tissue from wound gradually 50936805_1 CDM 0510 RC 97602 HCPCS inpatient 521 338.65 ANTHEM HMO ANTHEM HMO 999999999 315.47 505.37 Removal of tissue from wound gradually 50936805_1 CDM 0510 RC 97602 HCPCS inpatient 521 338.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 315.47 505.37 Removal of tissue from wound gradually 50936805_1 CDM 0510 RC 97602 HCPCS inpatient 521 338.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 315.47 505.37 Removal of tissue from wound gradually 50936805_1 CDM 0510 RC 97602 HCPCS inpatient 521 338.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 352.2 67.6 999999999 315.47 505.37 percent of total billed charges Removal of tissue from wound gradually 50936805_1 CDM 0510 RC 97602 HCPCS inpatient 521 338.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 315.47 505.37 UNIVERSAL ADAPTER DINAPT 50942175_1 CDM 0272 RC inpatient 163 105.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 105.95 65 999999999 98.7 158.11 percent of total billed charges UNIVERSAL ADAPTER DINAPT 50942175_1 CDM 0272 RC inpatient 163 105.95 AETNA AETNA 128.77 79 999999999 98.7 158.11 percent of total billed charges UNIVERSAL ADAPTER DINAPT 50942175_1 CDM 0272 RC inpatient 163 105.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 158.11 97 999999999 98.7 158.11 percent of total billed charges UNIVERSAL ADAPTER DINAPT 50942175_1 CDM 0272 RC inpatient 163 105.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 112.47 69 999999999 98.7 158.11 percent of total billed charges UNIVERSAL ADAPTER DINAPT 50942175_1 CDM 0272 RC inpatient 163 105.95 SIHO - ALL PLANS SIHO - ALL PLANS 146.7 90 999999999 98.7 158.11 percent of total billed charges UNIVERSAL ADAPTER DINAPT 50942175_1 CDM 0272 RC inpatient 163 105.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.14 78 999999999 98.7 158.11 percent of total billed charges UNIVERSAL ADAPTER DINAPT 50942175_1 CDM 0272 RC inpatient 163 105.95 UMR - ALL PLANS UMR - ALL PLANS 114.1 70 999999999 98.7 158.11 percent of total billed charges UNIVERSAL ADAPTER DINAPT 50942175_1 CDM 0272 RC inpatient 163 105.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 98.7 60.55 999999999 98.7 158.11 percent of total billed charges UNIVERSAL ADAPTER DINAPT 50942175_1 CDM 0272 RC inpatient 163 105.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 98.7 158.11 UNIVERSAL ADAPTER DINAPT 50942175_1 CDM 0272 RC inpatient 163 105.95 ANTHEM HMO ANTHEM HMO 999999999 98.7 158.11 UNIVERSAL ADAPTER DINAPT 50942175_1 CDM 0272 RC inpatient 163 105.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 98.7 158.11 UNIVERSAL ADAPTER DINAPT 50942175_1 CDM 0272 RC inpatient 163 105.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 98.7 158.11 UNIVERSAL ADAPTER DINAPT 50942175_1 CDM 0272 RC inpatient 163 105.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.19 67.6 999999999 98.7 158.11 percent of total billed charges UNIVERSAL ADAPTER DINAPT 50942175_1 CDM 0272 RC inpatient 163 105.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 98.7 158.11 CAPTIVATOR COLD 10mm M00561101 50963952_1 CDM 0272 RC inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges CAPTIVATOR COLD 10mm M00561101 50963952_1 CDM 0272 RC inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges CAPTIVATOR COLD 10mm M00561101 50963952_1 CDM 0272 RC inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges CAPTIVATOR COLD 10mm M00561101 50963952_1 CDM 0272 RC inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges CAPTIVATOR COLD 10mm M00561101 50963952_1 CDM 0272 RC inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges CAPTIVATOR COLD 10mm M00561101 50963952_1 CDM 0272 RC inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges CAPTIVATOR COLD 10mm M00561101 50963952_1 CDM 0272 RC inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges CAPTIVATOR COLD 10mm M00561101 50963952_1 CDM 0272 RC inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges CAPTIVATOR COLD 10mm M00561101 50963952_1 CDM 0272 RC inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 CAPTIVATOR COLD 10mm M00561101 50963952_1 CDM 0272 RC inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 CAPTIVATOR COLD 10mm M00561101 50963952_1 CDM 0272 RC inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 CAPTIVATOR COLD 10mm M00561101 50963952_1 CDM 0272 RC inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 CAPTIVATOR COLD 10mm M00561101 50963952_1 CDM 0272 RC inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges CAPTIVATOR COLD 10mm M00561101 50963952_1 CDM 0272 RC inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 *****BLANKET PER MEGAN P 07/20/2023******* VASCULAR SUPPLEMENT PACK JOVS31A 50964694_1 CDM 0272 RC inpatient 100 65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65 65 999999999 60.55 97 percent of total billed charges *****BLANKET PER MEGAN P 07/20/2023******* VASCULAR SUPPLEMENT PACK JOVS31A 50964694_1 CDM 0272 RC inpatient 100 65 AETNA AETNA 79 79 999999999 60.55 97 percent of total billed charges *****BLANKET PER MEGAN P 07/20/2023******* VASCULAR SUPPLEMENT PACK JOVS31A 50964694_1 CDM 0272 RC inpatient 100 65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97 97 999999999 60.55 97 percent of total billed charges *****BLANKET PER MEGAN P 07/20/2023******* VASCULAR SUPPLEMENT PACK JOVS31A 50964694_1 CDM 0272 RC inpatient 100 65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69 69 999999999 60.55 97 percent of total billed charges *****BLANKET PER MEGAN P 07/20/2023******* VASCULAR SUPPLEMENT PACK JOVS31A 50964694_1 CDM 0272 RC inpatient 100 65 SIHO - ALL PLANS SIHO - ALL PLANS 90 90 999999999 60.55 97 percent of total billed charges *****BLANKET PER MEGAN P 07/20/2023******* VASCULAR SUPPLEMENT PACK JOVS31A 50964694_1 CDM 0272 RC inpatient 100 65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78 78 999999999 60.55 97 percent of total billed charges *****BLANKET PER MEGAN P 07/20/2023******* VASCULAR SUPPLEMENT PACK JOVS31A 50964694_1 CDM 0272 RC inpatient 100 65 UMR - ALL PLANS UMR - ALL PLANS 70 70 999999999 60.55 97 percent of total billed charges *****BLANKET PER MEGAN P 07/20/2023******* VASCULAR SUPPLEMENT PACK JOVS31A 50964694_1 CDM 0272 RC inpatient 100 65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.55 60.55 999999999 60.55 97 percent of total billed charges *****BLANKET PER MEGAN P 07/20/2023******* VASCULAR SUPPLEMENT PACK JOVS31A 50964694_1 CDM 0272 RC inpatient 100 65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.55 97 *****BLANKET PER MEGAN P 07/20/2023******* VASCULAR SUPPLEMENT PACK JOVS31A 50964694_1 CDM 0272 RC inpatient 100 65 ANTHEM HMO ANTHEM HMO 999999999 60.55 97 *****BLANKET PER MEGAN P 07/20/2023******* VASCULAR SUPPLEMENT PACK JOVS31A 50964694_1 CDM 0272 RC inpatient 100 65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.55 97 *****BLANKET PER MEGAN P 07/20/2023******* VASCULAR SUPPLEMENT PACK JOVS31A 50964694_1 CDM 0272 RC inpatient 100 65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.55 97 *****BLANKET PER MEGAN P 07/20/2023******* VASCULAR SUPPLEMENT PACK JOVS31A 50964694_1 CDM 0272 RC inpatient 100 65 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.6 67.6 999999999 60.55 97 percent of total billed charges *****BLANKET PER MEGAN P 07/20/2023******* VASCULAR SUPPLEMENT PACK JOVS31A 50964694_1 CDM 0272 RC inpatient 100 65 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.55 97 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966351_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966351_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966351_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966351_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966351_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966351_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966351_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966351_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966351_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966351_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966351_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966351_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966351_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966351_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966587_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966587_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966587_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966587_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966587_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966587_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966587_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966587_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966587_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966587_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966587_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966587_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966587_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966587_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966590_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966590_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966590_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966590_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966590_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966590_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966590_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966590_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966590_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966590_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966590_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966590_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966590_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966590_1 CDM 0301 RC 86003 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966594_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966594_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966594_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966594_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966594_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966594_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966594_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966594_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966594_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966594_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966594_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966594_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966594_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 50966594_1 CDM 0301 RC 86003 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Carbohydrate analysis, single qualitative" 50967713_1 CDM 0301 RC 84376 HCPCS inpatient 122 79.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.3 65 999999999 73.87 118.34 percent of total billed charges "Carbohydrate analysis, single qualitative" 50967713_1 CDM 0301 RC 84376 HCPCS inpatient 122 79.3 AETNA AETNA 96.38 79 999999999 73.87 118.34 percent of total billed charges "Carbohydrate analysis, single qualitative" 50967713_1 CDM 0301 RC 84376 HCPCS inpatient 122 79.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 118.34 97 999999999 73.87 118.34 percent of total billed charges "Carbohydrate analysis, single qualitative" 50967713_1 CDM 0301 RC 84376 HCPCS inpatient 122 79.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.18 69 999999999 73.87 118.34 percent of total billed charges "Carbohydrate analysis, single qualitative" 50967713_1 CDM 0301 RC 84376 HCPCS inpatient 122 79.3 SIHO - ALL PLANS SIHO - ALL PLANS 109.8 90 999999999 73.87 118.34 percent of total billed charges "Carbohydrate analysis, single qualitative" 50967713_1 CDM 0301 RC 84376 HCPCS inpatient 122 79.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.16 78 999999999 73.87 118.34 percent of total billed charges "Carbohydrate analysis, single qualitative" 50967713_1 CDM 0301 RC 84376 HCPCS inpatient 122 79.3 UMR - ALL PLANS UMR - ALL PLANS 85.4 70 999999999 73.87 118.34 percent of total billed charges "Carbohydrate analysis, single qualitative" 50967713_1 CDM 0301 RC 84376 HCPCS inpatient 122 79.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.87 60.55 999999999 73.87 118.34 percent of total billed charges "Carbohydrate analysis, single qualitative" 50967713_1 CDM 0301 RC 84376 HCPCS inpatient 122 79.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.87 118.34 "Carbohydrate analysis, single qualitative" 50967713_1 CDM 0301 RC 84376 HCPCS inpatient 122 79.3 ANTHEM HMO ANTHEM HMO 999999999 73.87 118.34 "Carbohydrate analysis, single qualitative" 50967713_1 CDM 0301 RC 84376 HCPCS inpatient 122 79.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.87 118.34 "Carbohydrate analysis, single qualitative" 50967713_1 CDM 0301 RC 84376 HCPCS inpatient 122 79.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.87 118.34 "Carbohydrate analysis, single qualitative" 50967713_1 CDM 0301 RC 84376 HCPCS inpatient 122 79.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 82.47 67.6 999999999 73.87 118.34 percent of total billed charges "Carbohydrate analysis, single qualitative" 50967713_1 CDM 0301 RC 84376 HCPCS inpatient 122 79.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.87 118.34 "Detection test by nucleic acid for organism, amplified probe technique" 50967715_1 CDM 0306 RC 87798 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50967715_1 CDM 0306 RC 87798 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50967715_1 CDM 0306 RC 87798 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50967715_1 CDM 0306 RC 87798 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50967715_1 CDM 0306 RC 87798 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50967715_1 CDM 0306 RC 87798 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50967715_1 CDM 0306 RC 87798 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50967715_1 CDM 0306 RC 87798 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50967715_1 CDM 0306 RC 87798 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 "Detection test by nucleic acid for organism, amplified probe technique" 50967715_1 CDM 0306 RC 87798 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 "Detection test by nucleic acid for organism, amplified probe technique" 50967715_1 CDM 0306 RC 87798 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 "Detection test by nucleic acid for organism, amplified probe technique" 50967715_1 CDM 0306 RC 87798 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 "Detection test by nucleic acid for organism, amplified probe technique" 50967715_1 CDM 0306 RC 87798 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50967715_1 CDM 0306 RC 87798 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50967849_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 352.3 65 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50967849_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 AETNA AETNA 428.18 79 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50967849_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 525.74 97 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50967849_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 373.98 69 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50967849_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 SIHO - ALL PLANS SIHO - ALL PLANS 487.8 90 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50967849_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 422.76 78 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50967849_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 UMR - ALL PLANS UMR - ALL PLANS 379.4 70 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50967849_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 328.18 60.55 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50967849_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 328.18 525.74 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50967849_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 ANTHEM HMO ANTHEM HMO 999999999 328.18 525.74 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50967849_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 328.18 525.74 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50967849_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 328.18 525.74 "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50967849_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 366.39 67.6 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for multiple types of respiratory virus, multiple types or subtypes, 12-25 targets" 50967849_1 CDM 0306 RC 87633 HCPCS inpatient 542 352.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 328.18 525.74 "Detection test by nucleic acid for Mycoplasma pneumoniae (bacteria), amplified probe technique" 50967850_1 CDM 0306 RC 87581 HCPCS inpatient 98 63.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.7 65 999999999 59.34 95.06 percent of total billed charges "Detection test by nucleic acid for Mycoplasma pneumoniae (bacteria), amplified probe technique" 50967850_1 CDM 0306 RC 87581 HCPCS inpatient 98 63.7 AETNA AETNA 77.42 79 999999999 59.34 95.06 percent of total billed charges "Detection test by nucleic acid for Mycoplasma pneumoniae (bacteria), amplified probe technique" 50967850_1 CDM 0306 RC 87581 HCPCS inpatient 98 63.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.06 97 999999999 59.34 95.06 percent of total billed charges "Detection test by nucleic acid for Mycoplasma pneumoniae (bacteria), amplified probe technique" 50967850_1 CDM 0306 RC 87581 HCPCS inpatient 98 63.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.62 69 999999999 59.34 95.06 percent of total billed charges "Detection test by nucleic acid for Mycoplasma pneumoniae (bacteria), amplified probe technique" 50967850_1 CDM 0306 RC 87581 HCPCS inpatient 98 63.7 SIHO - ALL PLANS SIHO - ALL PLANS 88.2 90 999999999 59.34 95.06 percent of total billed charges "Detection test by nucleic acid for Mycoplasma pneumoniae (bacteria), amplified probe technique" 50967850_1 CDM 0306 RC 87581 HCPCS inpatient 98 63.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.44 78 999999999 59.34 95.06 percent of total billed charges "Detection test by nucleic acid for Mycoplasma pneumoniae (bacteria), amplified probe technique" 50967850_1 CDM 0306 RC 87581 HCPCS inpatient 98 63.7 UMR - ALL PLANS UMR - ALL PLANS 68.6 70 999999999 59.34 95.06 percent of total billed charges "Detection test by nucleic acid for Mycoplasma pneumoniae (bacteria), amplified probe technique" 50967850_1 CDM 0306 RC 87581 HCPCS inpatient 98 63.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.34 60.55 999999999 59.34 95.06 percent of total billed charges "Detection test by nucleic acid for Mycoplasma pneumoniae (bacteria), amplified probe technique" 50967850_1 CDM 0306 RC 87581 HCPCS inpatient 98 63.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.34 95.06 "Detection test by nucleic acid for Mycoplasma pneumoniae (bacteria), amplified probe technique" 50967850_1 CDM 0306 RC 87581 HCPCS inpatient 98 63.7 ANTHEM HMO ANTHEM HMO 999999999 59.34 95.06 "Detection test by nucleic acid for Mycoplasma pneumoniae (bacteria), amplified probe technique" 50967850_1 CDM 0306 RC 87581 HCPCS inpatient 98 63.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.34 95.06 "Detection test by nucleic acid for Mycoplasma pneumoniae (bacteria), amplified probe technique" 50967850_1 CDM 0306 RC 87581 HCPCS inpatient 98 63.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.34 95.06 "Detection test by nucleic acid for Mycoplasma pneumoniae (bacteria), amplified probe technique" 50967850_1 CDM 0306 RC 87581 HCPCS inpatient 98 63.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.25 67.6 999999999 59.34 95.06 percent of total billed charges "Detection test by nucleic acid for Mycoplasma pneumoniae (bacteria), amplified probe technique" 50967850_1 CDM 0306 RC 87581 HCPCS inpatient 98 63.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.34 95.06 "Detection test by nucleic acid for Chlamydia pneumoniae, amplified probe technique" 50967851_1 CDM 0306 RC 87486 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges "Detection test by nucleic acid for Chlamydia pneumoniae, amplified probe technique" 50967851_1 CDM 0306 RC 87486 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges "Detection test by nucleic acid for Chlamydia pneumoniae, amplified probe technique" 50967851_1 CDM 0306 RC 87486 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges "Detection test by nucleic acid for Chlamydia pneumoniae, amplified probe technique" 50967851_1 CDM 0306 RC 87486 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges "Detection test by nucleic acid for Chlamydia pneumoniae, amplified probe technique" 50967851_1 CDM 0306 RC 87486 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges "Detection test by nucleic acid for Chlamydia pneumoniae, amplified probe technique" 50967851_1 CDM 0306 RC 87486 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges "Detection test by nucleic acid for Chlamydia pneumoniae, amplified probe technique" 50967851_1 CDM 0306 RC 87486 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges "Detection test by nucleic acid for Chlamydia pneumoniae, amplified probe technique" 50967851_1 CDM 0306 RC 87486 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges "Detection test by nucleic acid for Chlamydia pneumoniae, amplified probe technique" 50967851_1 CDM 0306 RC 87486 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 "Detection test by nucleic acid for Chlamydia pneumoniae, amplified probe technique" 50967851_1 CDM 0306 RC 87486 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 "Detection test by nucleic acid for Chlamydia pneumoniae, amplified probe technique" 50967851_1 CDM 0306 RC 87486 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 "Detection test by nucleic acid for Chlamydia pneumoniae, amplified probe technique" 50967851_1 CDM 0306 RC 87486 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 "Detection test by nucleic acid for Chlamydia pneumoniae, amplified probe technique" 50967851_1 CDM 0306 RC 87486 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges "Detection test by nucleic acid for Chlamydia pneumoniae, amplified probe technique" 50967851_1 CDM 0306 RC 87486 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 "Detection test by nucleic acid for organism, amplified probe technique" 50967852_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.2 65 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50967852_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 AETNA AETNA 85.32 79 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50967852_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 104.76 97 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50967852_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 74.52 69 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50967852_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 SIHO - ALL PLANS SIHO - ALL PLANS 97.2 90 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50967852_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 84.24 78 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50967852_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 UMR - ALL PLANS UMR - ALL PLANS 75.6 70 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50967852_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 65.39 60.55 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50967852_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 65.39 104.76 "Detection test by nucleic acid for organism, amplified probe technique" 50967852_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 ANTHEM HMO ANTHEM HMO 999999999 65.39 104.76 "Detection test by nucleic acid for organism, amplified probe technique" 50967852_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 65.39 104.76 "Detection test by nucleic acid for organism, amplified probe technique" 50967852_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 65.39 104.76 "Detection test by nucleic acid for organism, amplified probe technique" 50967852_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.01 67.6 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 50967852_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 65.39 104.76 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50970471_1 CDM 0306 RC 87661 HCPCS inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50970471_1 CDM 0306 RC 87661 HCPCS inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50970471_1 CDM 0306 RC 87661 HCPCS inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50970471_1 CDM 0306 RC 87661 HCPCS inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50970471_1 CDM 0306 RC 87661 HCPCS inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50970471_1 CDM 0306 RC 87661 HCPCS inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50970471_1 CDM 0306 RC 87661 HCPCS inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50970471_1 CDM 0306 RC 87661 HCPCS inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50970471_1 CDM 0306 RC 87661 HCPCS inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50970471_1 CDM 0306 RC 87661 HCPCS inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50970471_1 CDM 0306 RC 87661 HCPCS inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50970471_1 CDM 0306 RC 87661 HCPCS inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50970471_1 CDM 0306 RC 87661 HCPCS inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for Trichomonas vaginalis (genital parasite), amplified probe technique" 50970471_1 CDM 0306 RC 87661 HCPCS inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 50970495_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 93.6 65 999999999 87.19 139.68 percent of total billed charges "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 50970495_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 AETNA AETNA 113.76 79 999999999 87.19 139.68 percent of total billed charges "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 50970495_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 139.68 97 999999999 87.19 139.68 percent of total billed charges "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 50970495_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 99.36 69 999999999 87.19 139.68 percent of total billed charges "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 50970495_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 SIHO - ALL PLANS SIHO - ALL PLANS 129.6 90 999999999 87.19 139.68 percent of total billed charges "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 50970495_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 112.32 78 999999999 87.19 139.68 percent of total billed charges "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 50970495_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 UMR - ALL PLANS UMR - ALL PLANS 100.8 70 999999999 87.19 139.68 percent of total billed charges "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 50970495_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.19 60.55 999999999 87.19 139.68 percent of total billed charges "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 50970495_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.19 139.68 "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 50970495_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 ANTHEM HMO ANTHEM HMO 999999999 87.19 139.68 "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 50970495_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.19 139.68 "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 50970495_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.19 139.68 "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 50970495_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 97.34 67.6 999999999 87.19 139.68 percent of total billed charges "Detection test by nucleic acid for Strep (Streptococcus, group B), amplified probe technique" 50970495_1 CDM 0306 RC 87653 HCPCS inpatient 144 93.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.19 139.68 BRAVO CAPSULES FGS-0635 5/BX 50972413_1 CDM 0270 RC inpatient 1397.7 908.51 SELF PAY DISCOUNT SELF PAY DISCOUNT 908.51 65 999999999 846.31 1355.77 percent of total billed charges BRAVO CAPSULES FGS-0635 5/BX 50972413_1 CDM 0270 RC inpatient 1397.7 908.51 AETNA AETNA 1104.18 79 999999999 846.31 1355.77 percent of total billed charges BRAVO CAPSULES FGS-0635 5/BX 50972413_1 CDM 0270 RC inpatient 1397.7 908.51 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1355.77 97 999999999 846.31 1355.77 percent of total billed charges BRAVO CAPSULES FGS-0635 5/BX 50972413_1 CDM 0270 RC inpatient 1397.7 908.51 ENCORE - ALL PLANS ENCORE - ALL PLANS 964.41 69 999999999 846.31 1355.77 percent of total billed charges BRAVO CAPSULES FGS-0635 5/BX 50972413_1 CDM 0270 RC inpatient 1397.7 908.51 SIHO - ALL PLANS SIHO - ALL PLANS 1257.93 90 999999999 846.31 1355.77 percent of total billed charges BRAVO CAPSULES FGS-0635 5/BX 50972413_1 CDM 0270 RC inpatient 1397.7 908.51 HUMANA - ALL PLANS HUMANA - ALL PLANS 1090.21 78 999999999 846.31 1355.77 percent of total billed charges BRAVO CAPSULES FGS-0635 5/BX 50972413_1 CDM 0270 RC inpatient 1397.7 908.51 UMR - ALL PLANS UMR - ALL PLANS 978.39 70 999999999 846.31 1355.77 percent of total billed charges BRAVO CAPSULES FGS-0635 5/BX 50972413_1 CDM 0270 RC inpatient 1397.7 908.51 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 846.31 60.55 999999999 846.31 1355.77 percent of total billed charges BRAVO CAPSULES FGS-0635 5/BX 50972413_1 CDM 0270 RC inpatient 1397.7 908.51 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 846.31 1355.77 BRAVO CAPSULES FGS-0635 5/BX 50972413_1 CDM 0270 RC inpatient 1397.7 908.51 ANTHEM HMO ANTHEM HMO 999999999 846.31 1355.77 BRAVO CAPSULES FGS-0635 5/BX 50972413_1 CDM 0270 RC inpatient 1397.7 908.51 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 846.31 1355.77 BRAVO CAPSULES FGS-0635 5/BX 50972413_1 CDM 0270 RC inpatient 1397.7 908.51 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 846.31 1355.77 BRAVO CAPSULES FGS-0635 5/BX 50972413_1 CDM 0270 RC inpatient 1397.7 908.51 CIGNA - ALL PLANS CIGNA - ALL PLANS 944.85 67.6 999999999 846.31 1355.77 percent of total billed charges BRAVO CAPSULES FGS-0635 5/BX 50972413_1 CDM 0270 RC inpatient 1397.7 908.51 UHC - ALL PLANS UHC - ALL PLANS 999999999 846.31 1355.77 WORD BALLOON CATH 10FR 5640-00 50985488_1 CDM 0272 RC inpatient 138 89.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.7 65 999999999 83.56 133.86 percent of total billed charges WORD BALLOON CATH 10FR 5640-00 50985488_1 CDM 0272 RC inpatient 138 89.7 AETNA AETNA 109.02 79 999999999 83.56 133.86 percent of total billed charges WORD BALLOON CATH 10FR 5640-00 50985488_1 CDM 0272 RC inpatient 138 89.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 133.86 97 999999999 83.56 133.86 percent of total billed charges WORD BALLOON CATH 10FR 5640-00 50985488_1 CDM 0272 RC inpatient 138 89.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.22 69 999999999 83.56 133.86 percent of total billed charges WORD BALLOON CATH 10FR 5640-00 50985488_1 CDM 0272 RC inpatient 138 89.7 SIHO - ALL PLANS SIHO - ALL PLANS 124.2 90 999999999 83.56 133.86 percent of total billed charges WORD BALLOON CATH 10FR 5640-00 50985488_1 CDM 0272 RC inpatient 138 89.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 107.64 78 999999999 83.56 133.86 percent of total billed charges WORD BALLOON CATH 10FR 5640-00 50985488_1 CDM 0272 RC inpatient 138 89.7 UMR - ALL PLANS UMR - ALL PLANS 96.6 70 999999999 83.56 133.86 percent of total billed charges WORD BALLOON CATH 10FR 5640-00 50985488_1 CDM 0272 RC inpatient 138 89.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 83.56 60.55 999999999 83.56 133.86 percent of total billed charges WORD BALLOON CATH 10FR 5640-00 50985488_1 CDM 0272 RC inpatient 138 89.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 83.56 133.86 WORD BALLOON CATH 10FR 5640-00 50985488_1 CDM 0272 RC inpatient 138 89.7 ANTHEM HMO ANTHEM HMO 999999999 83.56 133.86 WORD BALLOON CATH 10FR 5640-00 50985488_1 CDM 0272 RC inpatient 138 89.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 83.56 133.86 WORD BALLOON CATH 10FR 5640-00 50985488_1 CDM 0272 RC inpatient 138 89.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 83.56 133.86 WORD BALLOON CATH 10FR 5640-00 50985488_1 CDM 0272 RC inpatient 138 89.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.29 67.6 999999999 83.56 133.86 percent of total billed charges WORD BALLOON CATH 10FR 5640-00 50985488_1 CDM 0272 RC inpatient 138 89.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 83.56 133.86 "Clotting factor VII (proconvertin, stable factor)" 50985849_1 CDM 0305 RC 85230 HCPCS inpatient 383 248.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 248.95 65 999999999 231.91 371.51 percent of total billed charges "Clotting factor VII (proconvertin, stable factor)" 50985849_1 CDM 0305 RC 85230 HCPCS inpatient 383 248.95 AETNA AETNA 302.57 79 999999999 231.91 371.51 percent of total billed charges "Clotting factor VII (proconvertin, stable factor)" 50985849_1 CDM 0305 RC 85230 HCPCS inpatient 383 248.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 371.51 97 999999999 231.91 371.51 percent of total billed charges "Clotting factor VII (proconvertin, stable factor)" 50985849_1 CDM 0305 RC 85230 HCPCS inpatient 383 248.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 264.27 69 999999999 231.91 371.51 percent of total billed charges "Clotting factor VII (proconvertin, stable factor)" 50985849_1 CDM 0305 RC 85230 HCPCS inpatient 383 248.95 SIHO - ALL PLANS SIHO - ALL PLANS 344.7 90 999999999 231.91 371.51 percent of total billed charges "Clotting factor VII (proconvertin, stable factor)" 50985849_1 CDM 0305 RC 85230 HCPCS inpatient 383 248.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 298.74 78 999999999 231.91 371.51 percent of total billed charges "Clotting factor VII (proconvertin, stable factor)" 50985849_1 CDM 0305 RC 85230 HCPCS inpatient 383 248.95 UMR - ALL PLANS UMR - ALL PLANS 268.1 70 999999999 231.91 371.51 percent of total billed charges "Clotting factor VII (proconvertin, stable factor)" 50985849_1 CDM 0305 RC 85230 HCPCS inpatient 383 248.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 231.91 60.55 999999999 231.91 371.51 percent of total billed charges "Clotting factor VII (proconvertin, stable factor)" 50985849_1 CDM 0305 RC 85230 HCPCS inpatient 383 248.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 231.91 371.51 "Clotting factor VII (proconvertin, stable factor)" 50985849_1 CDM 0305 RC 85230 HCPCS inpatient 383 248.95 ANTHEM HMO ANTHEM HMO 999999999 231.91 371.51 "Clotting factor VII (proconvertin, stable factor)" 50985849_1 CDM 0305 RC 85230 HCPCS inpatient 383 248.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 231.91 371.51 "Clotting factor VII (proconvertin, stable factor)" 50985849_1 CDM 0305 RC 85230 HCPCS inpatient 383 248.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 231.91 371.51 "Clotting factor VII (proconvertin, stable factor)" 50985849_1 CDM 0305 RC 85230 HCPCS inpatient 383 248.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 258.91 67.6 999999999 231.91 371.51 percent of total billed charges "Clotting factor VII (proconvertin, stable factor)" 50985849_1 CDM 0305 RC 85230 HCPCS inpatient 383 248.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 231.91 371.51 Mercury level 50991935_1 CDM 0301 RC 83825 HCPCS inpatient 260 169 SELF PAY DISCOUNT SELF PAY DISCOUNT 169 65 999999999 157.43 252.2 percent of total billed charges Mercury level 50991935_1 CDM 0301 RC 83825 HCPCS inpatient 260 169 AETNA AETNA 205.4 79 999999999 157.43 252.2 percent of total billed charges Mercury level 50991935_1 CDM 0301 RC 83825 HCPCS inpatient 260 169 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 252.2 97 999999999 157.43 252.2 percent of total billed charges Mercury level 50991935_1 CDM 0301 RC 83825 HCPCS inpatient 260 169 ENCORE - ALL PLANS ENCORE - ALL PLANS 179.4 69 999999999 157.43 252.2 percent of total billed charges Mercury level 50991935_1 CDM 0301 RC 83825 HCPCS inpatient 260 169 SIHO - ALL PLANS SIHO - ALL PLANS 234 90 999999999 157.43 252.2 percent of total billed charges Mercury level 50991935_1 CDM 0301 RC 83825 HCPCS inpatient 260 169 HUMANA - ALL PLANS HUMANA - ALL PLANS 202.8 78 999999999 157.43 252.2 percent of total billed charges Mercury level 50991935_1 CDM 0301 RC 83825 HCPCS inpatient 260 169 UMR - ALL PLANS UMR - ALL PLANS 182 70 999999999 157.43 252.2 percent of total billed charges Mercury level 50991935_1 CDM 0301 RC 83825 HCPCS inpatient 260 169 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 157.43 60.55 999999999 157.43 252.2 percent of total billed charges Mercury level 50991935_1 CDM 0301 RC 83825 HCPCS inpatient 260 169 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 157.43 252.2 Mercury level 50991935_1 CDM 0301 RC 83825 HCPCS inpatient 260 169 ANTHEM HMO ANTHEM HMO 999999999 157.43 252.2 Mercury level 50991935_1 CDM 0301 RC 83825 HCPCS inpatient 260 169 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 157.43 252.2 Mercury level 50991935_1 CDM 0301 RC 83825 HCPCS inpatient 260 169 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 157.43 252.2 Mercury level 50991935_1 CDM 0301 RC 83825 HCPCS inpatient 260 169 CIGNA - ALL PLANS CIGNA - ALL PLANS 175.76 67.6 999999999 157.43 252.2 percent of total billed charges Mercury level 50991935_1 CDM 0301 RC 83825 HCPCS inpatient 260 169 UHC - ALL PLANS UHC - ALL PLANS 999999999 157.43 252.2 Chromium level to test for poisoning or deficiency 50992092_1 CDM 0301 RC 82495 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges Chromium level to test for poisoning or deficiency 50992092_1 CDM 0301 RC 82495 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges Chromium level to test for poisoning or deficiency 50992092_1 CDM 0301 RC 82495 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges Chromium level to test for poisoning or deficiency 50992092_1 CDM 0301 RC 82495 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges Chromium level to test for poisoning or deficiency 50992092_1 CDM 0301 RC 82495 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges Chromium level to test for poisoning or deficiency 50992092_1 CDM 0301 RC 82495 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges Chromium level to test for poisoning or deficiency 50992092_1 CDM 0301 RC 82495 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges Chromium level to test for poisoning or deficiency 50992092_1 CDM 0301 RC 82495 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges Chromium level to test for poisoning or deficiency 50992092_1 CDM 0301 RC 82495 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 Chromium level to test for poisoning or deficiency 50992092_1 CDM 0301 RC 82495 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 Chromium level to test for poisoning or deficiency 50992092_1 CDM 0301 RC 82495 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 Chromium level to test for poisoning or deficiency 50992092_1 CDM 0301 RC 82495 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 Chromium level to test for poisoning or deficiency 50992092_1 CDM 0301 RC 82495 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges Chromium level to test for poisoning or deficiency 50992092_1 CDM 0301 RC 82495 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 Heavy metal level 50992195_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.15 65 999999999 55.1 88.27 percent of total billed charges Heavy metal level 50992195_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 AETNA AETNA 71.89 79 999999999 55.1 88.27 percent of total billed charges Heavy metal level 50992195_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 88.27 97 999999999 55.1 88.27 percent of total billed charges Heavy metal level 50992195_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.79 69 999999999 55.1 88.27 percent of total billed charges Heavy metal level 50992195_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 SIHO - ALL PLANS SIHO - ALL PLANS 81.9 90 999999999 55.1 88.27 percent of total billed charges Heavy metal level 50992195_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.98 78 999999999 55.1 88.27 percent of total billed charges Heavy metal level 50992195_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 UMR - ALL PLANS UMR - ALL PLANS 63.7 70 999999999 55.1 88.27 percent of total billed charges Heavy metal level 50992195_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.1 60.55 999999999 55.1 88.27 percent of total billed charges Heavy metal level 50992195_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.1 88.27 Heavy metal level 50992195_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 ANTHEM HMO ANTHEM HMO 999999999 55.1 88.27 Heavy metal level 50992195_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.1 88.27 Heavy metal level 50992195_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.1 88.27 Heavy metal level 50992195_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 61.52 67.6 999999999 55.1 88.27 percent of total billed charges Heavy metal level 50992195_1 CDM 0301 RC 83018 HCPCS inpatient 91 59.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.1 88.27 Vitamin B-2 (riboflavin) level 50992260_1 CDM 0301 RC 84252 HCPCS inpatient 123 79.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.95 65 999999999 74.48 119.31 percent of total billed charges Vitamin B-2 (riboflavin) level 50992260_1 CDM 0301 RC 84252 HCPCS inpatient 123 79.95 AETNA AETNA 97.17 79 999999999 74.48 119.31 percent of total billed charges Vitamin B-2 (riboflavin) level 50992260_1 CDM 0301 RC 84252 HCPCS inpatient 123 79.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 119.31 97 999999999 74.48 119.31 percent of total billed charges Vitamin B-2 (riboflavin) level 50992260_1 CDM 0301 RC 84252 HCPCS inpatient 123 79.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.87 69 999999999 74.48 119.31 percent of total billed charges Vitamin B-2 (riboflavin) level 50992260_1 CDM 0301 RC 84252 HCPCS inpatient 123 79.95 SIHO - ALL PLANS SIHO - ALL PLANS 110.7 90 999999999 74.48 119.31 percent of total billed charges Vitamin B-2 (riboflavin) level 50992260_1 CDM 0301 RC 84252 HCPCS inpatient 123 79.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.94 78 999999999 74.48 119.31 percent of total billed charges Vitamin B-2 (riboflavin) level 50992260_1 CDM 0301 RC 84252 HCPCS inpatient 123 79.95 UMR - ALL PLANS UMR - ALL PLANS 86.1 70 999999999 74.48 119.31 percent of total billed charges Vitamin B-2 (riboflavin) level 50992260_1 CDM 0301 RC 84252 HCPCS inpatient 123 79.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 74.48 60.55 999999999 74.48 119.31 percent of total billed charges Vitamin B-2 (riboflavin) level 50992260_1 CDM 0301 RC 84252 HCPCS inpatient 123 79.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 74.48 119.31 Vitamin B-2 (riboflavin) level 50992260_1 CDM 0301 RC 84252 HCPCS inpatient 123 79.95 ANTHEM HMO ANTHEM HMO 999999999 74.48 119.31 Vitamin B-2 (riboflavin) level 50992260_1 CDM 0301 RC 84252 HCPCS inpatient 123 79.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 74.48 119.31 Vitamin B-2 (riboflavin) level 50992260_1 CDM 0301 RC 84252 HCPCS inpatient 123 79.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 74.48 119.31 Vitamin B-2 (riboflavin) level 50992260_1 CDM 0301 RC 84252 HCPCS inpatient 123 79.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.15 67.6 999999999 74.48 119.31 percent of total billed charges Vitamin B-2 (riboflavin) level 50992260_1 CDM 0301 RC 84252 HCPCS inpatient 123 79.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 74.48 119.31 "Alpha-1-antitrypsin (protein) blood test, total" 50994075_1 CDM 0301 RC 82103 HCPCS inpatient 145 94.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.25 65 999999999 87.8 140.65 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 50994075_1 CDM 0301 RC 82103 HCPCS inpatient 145 94.25 AETNA AETNA 114.55 79 999999999 87.8 140.65 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 50994075_1 CDM 0301 RC 82103 HCPCS inpatient 145 94.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 140.65 97 999999999 87.8 140.65 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 50994075_1 CDM 0301 RC 82103 HCPCS inpatient 145 94.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.05 69 999999999 87.8 140.65 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 50994075_1 CDM 0301 RC 82103 HCPCS inpatient 145 94.25 SIHO - ALL PLANS SIHO - ALL PLANS 130.5 90 999999999 87.8 140.65 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 50994075_1 CDM 0301 RC 82103 HCPCS inpatient 145 94.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.1 78 999999999 87.8 140.65 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 50994075_1 CDM 0301 RC 82103 HCPCS inpatient 145 94.25 UMR - ALL PLANS UMR - ALL PLANS 101.5 70 999999999 87.8 140.65 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 50994075_1 CDM 0301 RC 82103 HCPCS inpatient 145 94.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 87.8 60.55 999999999 87.8 140.65 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 50994075_1 CDM 0301 RC 82103 HCPCS inpatient 145 94.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 87.8 140.65 "Alpha-1-antitrypsin (protein) blood test, total" 50994075_1 CDM 0301 RC 82103 HCPCS inpatient 145 94.25 ANTHEM HMO ANTHEM HMO 999999999 87.8 140.65 "Alpha-1-antitrypsin (protein) blood test, total" 50994075_1 CDM 0301 RC 82103 HCPCS inpatient 145 94.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 87.8 140.65 "Alpha-1-antitrypsin (protein) blood test, total" 50994075_1 CDM 0301 RC 82103 HCPCS inpatient 145 94.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 87.8 140.65 "Alpha-1-antitrypsin (protein) blood test, total" 50994075_1 CDM 0301 RC 82103 HCPCS inpatient 145 94.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.02 67.6 999999999 87.8 140.65 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, total" 50994075_1 CDM 0301 RC 82103 HCPCS inpatient 145 94.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 87.8 140.65 "Alpha-1-antitrypsin (protein) blood test, phenotype" 50994076_1 CDM 0301 RC 82104 HCPCS inpatient 90 58.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 58.5 65 999999999 54.5 87.3 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, phenotype" 50994076_1 CDM 0301 RC 82104 HCPCS inpatient 90 58.5 AETNA AETNA 71.1 79 999999999 54.5 87.3 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, phenotype" 50994076_1 CDM 0301 RC 82104 HCPCS inpatient 90 58.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 87.3 97 999999999 54.5 87.3 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, phenotype" 50994076_1 CDM 0301 RC 82104 HCPCS inpatient 90 58.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 62.1 69 999999999 54.5 87.3 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, phenotype" 50994076_1 CDM 0301 RC 82104 HCPCS inpatient 90 58.5 SIHO - ALL PLANS SIHO - ALL PLANS 81 90 999999999 54.5 87.3 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, phenotype" 50994076_1 CDM 0301 RC 82104 HCPCS inpatient 90 58.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 70.2 78 999999999 54.5 87.3 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, phenotype" 50994076_1 CDM 0301 RC 82104 HCPCS inpatient 90 58.5 UMR - ALL PLANS UMR - ALL PLANS 63 70 999999999 54.5 87.3 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, phenotype" 50994076_1 CDM 0301 RC 82104 HCPCS inpatient 90 58.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 54.5 60.55 999999999 54.5 87.3 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, phenotype" 50994076_1 CDM 0301 RC 82104 HCPCS inpatient 90 58.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 54.5 87.3 "Alpha-1-antitrypsin (protein) blood test, phenotype" 50994076_1 CDM 0301 RC 82104 HCPCS inpatient 90 58.5 ANTHEM HMO ANTHEM HMO 999999999 54.5 87.3 "Alpha-1-antitrypsin (protein) blood test, phenotype" 50994076_1 CDM 0301 RC 82104 HCPCS inpatient 90 58.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 54.5 87.3 "Alpha-1-antitrypsin (protein) blood test, phenotype" 50994076_1 CDM 0301 RC 82104 HCPCS inpatient 90 58.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 54.5 87.3 "Alpha-1-antitrypsin (protein) blood test, phenotype" 50994076_1 CDM 0301 RC 82104 HCPCS inpatient 90 58.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 60.84 67.6 999999999 54.5 87.3 percent of total billed charges "Alpha-1-antitrypsin (protein) blood test, phenotype" 50994076_1 CDM 0301 RC 82104 HCPCS inpatient 90 58.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 54.5 87.3 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50994927_1 CDM 0301 RC 86008 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50994927_1 CDM 0301 RC 86008 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50994927_1 CDM 0301 RC 86008 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50994927_1 CDM 0301 RC 86008 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50994927_1 CDM 0301 RC 86008 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50994927_1 CDM 0301 RC 86008 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50994927_1 CDM 0301 RC 86008 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50994927_1 CDM 0301 RC 86008 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50994927_1 CDM 0301 RC 86008 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50994927_1 CDM 0301 RC 86008 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50994927_1 CDM 0301 RC 86008 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50994927_1 CDM 0301 RC 86008 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50994927_1 CDM 0301 RC 86008 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, recombinant or purified component, each" 50994927_1 CDM 0301 RC 86008 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 "Measurement of complement (immune system proteins), total hemolytic" 50994938_1 CDM 0302 RC 86162 HCPCS inpatient 401 260.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 260.65 65 999999999 242.81 388.97 percent of total billed charges "Measurement of complement (immune system proteins), total hemolytic" 50994938_1 CDM 0302 RC 86162 HCPCS inpatient 401 260.65 AETNA AETNA 316.79 79 999999999 242.81 388.97 percent of total billed charges "Measurement of complement (immune system proteins), total hemolytic" 50994938_1 CDM 0302 RC 86162 HCPCS inpatient 401 260.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 388.97 97 999999999 242.81 388.97 percent of total billed charges "Measurement of complement (immune system proteins), total hemolytic" 50994938_1 CDM 0302 RC 86162 HCPCS inpatient 401 260.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 276.69 69 999999999 242.81 388.97 percent of total billed charges "Measurement of complement (immune system proteins), total hemolytic" 50994938_1 CDM 0302 RC 86162 HCPCS inpatient 401 260.65 SIHO - ALL PLANS SIHO - ALL PLANS 360.9 90 999999999 242.81 388.97 percent of total billed charges "Measurement of complement (immune system proteins), total hemolytic" 50994938_1 CDM 0302 RC 86162 HCPCS inpatient 401 260.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 312.78 78 999999999 242.81 388.97 percent of total billed charges "Measurement of complement (immune system proteins), total hemolytic" 50994938_1 CDM 0302 RC 86162 HCPCS inpatient 401 260.65 UMR - ALL PLANS UMR - ALL PLANS 280.7 70 999999999 242.81 388.97 percent of total billed charges "Measurement of complement (immune system proteins), total hemolytic" 50994938_1 CDM 0302 RC 86162 HCPCS inpatient 401 260.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 242.81 60.55 999999999 242.81 388.97 percent of total billed charges "Measurement of complement (immune system proteins), total hemolytic" 50994938_1 CDM 0302 RC 86162 HCPCS inpatient 401 260.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 242.81 388.97 "Measurement of complement (immune system proteins), total hemolytic" 50994938_1 CDM 0302 RC 86162 HCPCS inpatient 401 260.65 ANTHEM HMO ANTHEM HMO 999999999 242.81 388.97 "Measurement of complement (immune system proteins), total hemolytic" 50994938_1 CDM 0302 RC 86162 HCPCS inpatient 401 260.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 242.81 388.97 "Measurement of complement (immune system proteins), total hemolytic" 50994938_1 CDM 0302 RC 86162 HCPCS inpatient 401 260.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 242.81 388.97 "Measurement of complement (immune system proteins), total hemolytic" 50994938_1 CDM 0302 RC 86162 HCPCS inpatient 401 260.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 271.08 67.6 999999999 242.81 388.97 percent of total billed charges "Measurement of complement (immune system proteins), total hemolytic" 50994938_1 CDM 0302 RC 86162 HCPCS inpatient 401 260.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 242.81 388.97 Measurement of felbamate 50994991_1 CDM 0301 RC 80167 HCPCS inpatient 244 158.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 158.6 65 999999999 147.74 236.68 percent of total billed charges Measurement of felbamate 50994991_1 CDM 0301 RC 80167 HCPCS inpatient 244 158.6 AETNA AETNA 192.76 79 999999999 147.74 236.68 percent of total billed charges Measurement of felbamate 50994991_1 CDM 0301 RC 80167 HCPCS inpatient 244 158.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 236.68 97 999999999 147.74 236.68 percent of total billed charges Measurement of felbamate 50994991_1 CDM 0301 RC 80167 HCPCS inpatient 244 158.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 168.36 69 999999999 147.74 236.68 percent of total billed charges Measurement of felbamate 50994991_1 CDM 0301 RC 80167 HCPCS inpatient 244 158.6 SIHO - ALL PLANS SIHO - ALL PLANS 219.6 90 999999999 147.74 236.68 percent of total billed charges Measurement of felbamate 50994991_1 CDM 0301 RC 80167 HCPCS inpatient 244 158.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 190.32 78 999999999 147.74 236.68 percent of total billed charges Measurement of felbamate 50994991_1 CDM 0301 RC 80167 HCPCS inpatient 244 158.6 UMR - ALL PLANS UMR - ALL PLANS 170.8 70 999999999 147.74 236.68 percent of total billed charges Measurement of felbamate 50994991_1 CDM 0301 RC 80167 HCPCS inpatient 244 158.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.74 60.55 999999999 147.74 236.68 percent of total billed charges Measurement of felbamate 50994991_1 CDM 0301 RC 80167 HCPCS inpatient 244 158.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.74 236.68 Measurement of felbamate 50994991_1 CDM 0301 RC 80167 HCPCS inpatient 244 158.6 ANTHEM HMO ANTHEM HMO 999999999 147.74 236.68 Measurement of felbamate 50994991_1 CDM 0301 RC 80167 HCPCS inpatient 244 158.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.74 236.68 Measurement of felbamate 50994991_1 CDM 0301 RC 80167 HCPCS inpatient 244 158.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.74 236.68 Measurement of felbamate 50994991_1 CDM 0301 RC 80167 HCPCS inpatient 244 158.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.94 67.6 999999999 147.74 236.68 percent of total billed charges Measurement of felbamate 50994991_1 CDM 0301 RC 80167 HCPCS inpatient 244 158.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.74 236.68 Blood viscosity measurement 50996112_1 CDM 0301 RC 85810 HCPCS inpatient 98 63.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.7 65 999999999 59.34 95.06 percent of total billed charges Blood viscosity measurement 50996112_1 CDM 0301 RC 85810 HCPCS inpatient 98 63.7 AETNA AETNA 77.42 79 999999999 59.34 95.06 percent of total billed charges Blood viscosity measurement 50996112_1 CDM 0301 RC 85810 HCPCS inpatient 98 63.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.06 97 999999999 59.34 95.06 percent of total billed charges Blood viscosity measurement 50996112_1 CDM 0301 RC 85810 HCPCS inpatient 98 63.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.62 69 999999999 59.34 95.06 percent of total billed charges Blood viscosity measurement 50996112_1 CDM 0301 RC 85810 HCPCS inpatient 98 63.7 SIHO - ALL PLANS SIHO - ALL PLANS 88.2 90 999999999 59.34 95.06 percent of total billed charges Blood viscosity measurement 50996112_1 CDM 0301 RC 85810 HCPCS inpatient 98 63.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.44 78 999999999 59.34 95.06 percent of total billed charges Blood viscosity measurement 50996112_1 CDM 0301 RC 85810 HCPCS inpatient 98 63.7 UMR - ALL PLANS UMR - ALL PLANS 68.6 70 999999999 59.34 95.06 percent of total billed charges Blood viscosity measurement 50996112_1 CDM 0301 RC 85810 HCPCS inpatient 98 63.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.34 60.55 999999999 59.34 95.06 percent of total billed charges Blood viscosity measurement 50996112_1 CDM 0301 RC 85810 HCPCS inpatient 98 63.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.34 95.06 Blood viscosity measurement 50996112_1 CDM 0301 RC 85810 HCPCS inpatient 98 63.7 ANTHEM HMO ANTHEM HMO 999999999 59.34 95.06 Blood viscosity measurement 50996112_1 CDM 0301 RC 85810 HCPCS inpatient 98 63.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.34 95.06 Blood viscosity measurement 50996112_1 CDM 0301 RC 85810 HCPCS inpatient 98 63.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.34 95.06 Blood viscosity measurement 50996112_1 CDM 0301 RC 85810 HCPCS inpatient 98 63.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.25 67.6 999999999 59.34 95.06 percent of total billed charges Blood viscosity measurement 50996112_1 CDM 0301 RC 85810 HCPCS inpatient 98 63.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.34 95.06 SQUARE LOOP ELECTRODE 10mm X 10mm DLP-SQ1 51000000_1 CDM 0272 RC inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges SQUARE LOOP ELECTRODE 10mm X 10mm DLP-SQ1 51000000_1 CDM 0272 RC inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges SQUARE LOOP ELECTRODE 10mm X 10mm DLP-SQ1 51000000_1 CDM 0272 RC inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges SQUARE LOOP ELECTRODE 10mm X 10mm DLP-SQ1 51000000_1 CDM 0272 RC inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges SQUARE LOOP ELECTRODE 10mm X 10mm DLP-SQ1 51000000_1 CDM 0272 RC inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges SQUARE LOOP ELECTRODE 10mm X 10mm DLP-SQ1 51000000_1 CDM 0272 RC inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges SQUARE LOOP ELECTRODE 10mm X 10mm DLP-SQ1 51000000_1 CDM 0272 RC inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges SQUARE LOOP ELECTRODE 10mm X 10mm DLP-SQ1 51000000_1 CDM 0272 RC inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges SQUARE LOOP ELECTRODE 10mm X 10mm DLP-SQ1 51000000_1 CDM 0272 RC inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 SQUARE LOOP ELECTRODE 10mm X 10mm DLP-SQ1 51000000_1 CDM 0272 RC inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 SQUARE LOOP ELECTRODE 10mm X 10mm DLP-SQ1 51000000_1 CDM 0272 RC inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 SQUARE LOOP ELECTRODE 10mm X 10mm DLP-SQ1 51000000_1 CDM 0272 RC inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 SQUARE LOOP ELECTRODE 10mm X 10mm DLP-SQ1 51000000_1 CDM 0272 RC inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges SQUARE LOOP ELECTRODE 10mm X 10mm DLP-SQ1 51000000_1 CDM 0272 RC inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 Analysis for antibody to virus 51009303_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 84.5 65 999999999 78.72 126.1 percent of total billed charges Analysis for antibody to virus 51009303_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 AETNA AETNA 102.7 79 999999999 78.72 126.1 percent of total billed charges Analysis for antibody to virus 51009303_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 126.1 97 999999999 78.72 126.1 percent of total billed charges Analysis for antibody to virus 51009303_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.7 69 999999999 78.72 126.1 percent of total billed charges Analysis for antibody to virus 51009303_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 SIHO - ALL PLANS SIHO - ALL PLANS 117 90 999999999 78.72 126.1 percent of total billed charges Analysis for antibody to virus 51009303_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 101.4 78 999999999 78.72 126.1 percent of total billed charges Analysis for antibody to virus 51009303_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 UMR - ALL PLANS UMR - ALL PLANS 91 70 999999999 78.72 126.1 percent of total billed charges Analysis for antibody to virus 51009303_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.72 60.55 999999999 78.72 126.1 percent of total billed charges Analysis for antibody to virus 51009303_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.72 126.1 Analysis for antibody to virus 51009303_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 ANTHEM HMO ANTHEM HMO 999999999 78.72 126.1 Analysis for antibody to virus 51009303_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.72 126.1 Analysis for antibody to virus 51009303_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.72 126.1 Analysis for antibody to virus 51009303_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.88 67.6 999999999 78.72 126.1 percent of total billed charges Analysis for antibody to virus 51009303_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.72 126.1 Analysis for antibody to virus 51009304_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 84.5 65 999999999 78.72 126.1 percent of total billed charges Analysis for antibody to virus 51009304_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 AETNA AETNA 102.7 79 999999999 78.72 126.1 percent of total billed charges Analysis for antibody to virus 51009304_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 126.1 97 999999999 78.72 126.1 percent of total billed charges Analysis for antibody to virus 51009304_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.7 69 999999999 78.72 126.1 percent of total billed charges Analysis for antibody to virus 51009304_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 SIHO - ALL PLANS SIHO - ALL PLANS 117 90 999999999 78.72 126.1 percent of total billed charges Analysis for antibody to virus 51009304_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 101.4 78 999999999 78.72 126.1 percent of total billed charges Analysis for antibody to virus 51009304_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 UMR - ALL PLANS UMR - ALL PLANS 91 70 999999999 78.72 126.1 percent of total billed charges Analysis for antibody to virus 51009304_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.72 60.55 999999999 78.72 126.1 percent of total billed charges Analysis for antibody to virus 51009304_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.72 126.1 Analysis for antibody to virus 51009304_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 ANTHEM HMO ANTHEM HMO 999999999 78.72 126.1 Analysis for antibody to virus 51009304_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.72 126.1 Analysis for antibody to virus 51009304_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.72 126.1 Analysis for antibody to virus 51009304_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.88 67.6 999999999 78.72 126.1 percent of total billed charges Analysis for antibody to virus 51009304_1 CDM 0301 RC 86790 HCPCS inpatient 130 84.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.72 126.1 "Detection test by nucleic acid for Hepatitis B virus, quantification" 51011381_1 CDM 0306 RC 87517 HCPCS inpatient 336 218.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 218.4 65 999999999 203.45 325.92 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 51011381_1 CDM 0306 RC 87517 HCPCS inpatient 336 218.4 AETNA AETNA 265.44 79 999999999 203.45 325.92 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 51011381_1 CDM 0306 RC 87517 HCPCS inpatient 336 218.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 325.92 97 999999999 203.45 325.92 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 51011381_1 CDM 0306 RC 87517 HCPCS inpatient 336 218.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 231.84 69 999999999 203.45 325.92 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 51011381_1 CDM 0306 RC 87517 HCPCS inpatient 336 218.4 SIHO - ALL PLANS SIHO - ALL PLANS 302.4 90 999999999 203.45 325.92 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 51011381_1 CDM 0306 RC 87517 HCPCS inpatient 336 218.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 262.08 78 999999999 203.45 325.92 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 51011381_1 CDM 0306 RC 87517 HCPCS inpatient 336 218.4 UMR - ALL PLANS UMR - ALL PLANS 235.2 70 999999999 203.45 325.92 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 51011381_1 CDM 0306 RC 87517 HCPCS inpatient 336 218.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 203.45 60.55 999999999 203.45 325.92 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 51011381_1 CDM 0306 RC 87517 HCPCS inpatient 336 218.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 203.45 325.92 "Detection test by nucleic acid for Hepatitis B virus, quantification" 51011381_1 CDM 0306 RC 87517 HCPCS inpatient 336 218.4 ANTHEM HMO ANTHEM HMO 999999999 203.45 325.92 "Detection test by nucleic acid for Hepatitis B virus, quantification" 51011381_1 CDM 0306 RC 87517 HCPCS inpatient 336 218.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 203.45 325.92 "Detection test by nucleic acid for Hepatitis B virus, quantification" 51011381_1 CDM 0306 RC 87517 HCPCS inpatient 336 218.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 203.45 325.92 "Detection test by nucleic acid for Hepatitis B virus, quantification" 51011381_1 CDM 0306 RC 87517 HCPCS inpatient 336 218.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 227.14 67.6 999999999 203.45 325.92 percent of total billed charges "Detection test by nucleic acid for Hepatitis B virus, quantification" 51011381_1 CDM 0306 RC 87517 HCPCS inpatient 336 218.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 203.45 325.92 Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 51018632_1 CDM 0300 RC 0282U HCPCS inpatient 720 468 SELF PAY DISCOUNT SELF PAY DISCOUNT 468 65 999999999 435.96 698.4 percent of total billed charges Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 51018632_1 CDM 0300 RC 0282U HCPCS inpatient 720 468 AETNA AETNA 568.8 79 999999999 435.96 698.4 percent of total billed charges Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 51018632_1 CDM 0300 RC 0282U HCPCS inpatient 720 468 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 698.4 97 999999999 435.96 698.4 percent of total billed charges Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 51018632_1 CDM 0300 RC 0282U HCPCS inpatient 720 468 ENCORE - ALL PLANS ENCORE - ALL PLANS 496.8 69 999999999 435.96 698.4 percent of total billed charges Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 51018632_1 CDM 0300 RC 0282U HCPCS inpatient 720 468 SIHO - ALL PLANS SIHO - ALL PLANS 648 90 999999999 435.96 698.4 percent of total billed charges Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 51018632_1 CDM 0300 RC 0282U HCPCS inpatient 720 468 HUMANA - ALL PLANS HUMANA - ALL PLANS 561.6 78 999999999 435.96 698.4 percent of total billed charges Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 51018632_1 CDM 0300 RC 0282U HCPCS inpatient 720 468 UMR - ALL PLANS UMR - ALL PLANS 504 70 999999999 435.96 698.4 percent of total billed charges Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 51018632_1 CDM 0300 RC 0282U HCPCS inpatient 720 468 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 435.96 60.55 999999999 435.96 698.4 percent of total billed charges Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 51018632_1 CDM 0300 RC 0282U HCPCS inpatient 720 468 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 435.96 698.4 Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 51018632_1 CDM 0300 RC 0282U HCPCS inpatient 720 468 ANTHEM HMO ANTHEM HMO 999999999 435.96 698.4 Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 51018632_1 CDM 0300 RC 0282U HCPCS inpatient 720 468 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 435.96 698.4 Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 51018632_1 CDM 0300 RC 0282U HCPCS inpatient 720 468 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 435.96 698.4 Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 51018632_1 CDM 0300 RC 0282U HCPCS inpatient 720 468 CIGNA - ALL PLANS CIGNA - ALL PLANS 486.72 67.6 999999999 435.96 698.4 percent of total billed charges Red blood cell antigen genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes 51018632_1 CDM 0300 RC 0282U HCPCS inpatient 720 468 UHC - ALL PLANS UHC - ALL PLANS 999999999 435.96 698.4 Surgical pathology consultation and report on referred slides prepared elsewhere 51020307_1 CDM 0312 RC 88321 HCPCS inpatient 158 102.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 102.7 65 999999999 95.67 153.26 percent of total billed charges Surgical pathology consultation and report on referred slides prepared elsewhere 51020307_1 CDM 0312 RC 88321 HCPCS inpatient 158 102.7 AETNA AETNA 124.82 79 999999999 95.67 153.26 percent of total billed charges Surgical pathology consultation and report on referred slides prepared elsewhere 51020307_1 CDM 0312 RC 88321 HCPCS inpatient 158 102.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 153.26 97 999999999 95.67 153.26 percent of total billed charges Surgical pathology consultation and report on referred slides prepared elsewhere 51020307_1 CDM 0312 RC 88321 HCPCS inpatient 158 102.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 109.02 69 999999999 95.67 153.26 percent of total billed charges Surgical pathology consultation and report on referred slides prepared elsewhere 51020307_1 CDM 0312 RC 88321 HCPCS inpatient 158 102.7 SIHO - ALL PLANS SIHO - ALL PLANS 142.2 90 999999999 95.67 153.26 percent of total billed charges Surgical pathology consultation and report on referred slides prepared elsewhere 51020307_1 CDM 0312 RC 88321 HCPCS inpatient 158 102.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 123.24 78 999999999 95.67 153.26 percent of total billed charges Surgical pathology consultation and report on referred slides prepared elsewhere 51020307_1 CDM 0312 RC 88321 HCPCS inpatient 158 102.7 UMR - ALL PLANS UMR - ALL PLANS 110.6 70 999999999 95.67 153.26 percent of total billed charges Surgical pathology consultation and report on referred slides prepared elsewhere 51020307_1 CDM 0312 RC 88321 HCPCS inpatient 158 102.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 95.67 60.55 999999999 95.67 153.26 percent of total billed charges Surgical pathology consultation and report on referred slides prepared elsewhere 51020307_1 CDM 0312 RC 88321 HCPCS inpatient 158 102.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 95.67 153.26 Surgical pathology consultation and report on referred slides prepared elsewhere 51020307_1 CDM 0312 RC 88321 HCPCS inpatient 158 102.7 ANTHEM HMO ANTHEM HMO 999999999 95.67 153.26 Surgical pathology consultation and report on referred slides prepared elsewhere 51020307_1 CDM 0312 RC 88321 HCPCS inpatient 158 102.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 95.67 153.26 Surgical pathology consultation and report on referred slides prepared elsewhere 51020307_1 CDM 0312 RC 88321 HCPCS inpatient 158 102.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 95.67 153.26 Surgical pathology consultation and report on referred slides prepared elsewhere 51020307_1 CDM 0312 RC 88321 HCPCS inpatient 158 102.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 106.81 67.6 999999999 95.67 153.26 percent of total billed charges Surgical pathology consultation and report on referred slides prepared elsewhere 51020307_1 CDM 0312 RC 88321 HCPCS inpatient 158 102.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 95.67 153.26 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51020308_1 CDM 0312 RC 88377 HCPCS inpatient 893 580.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 580.45 65 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51020308_1 CDM 0312 RC 88377 HCPCS inpatient 893 580.45 AETNA AETNA 705.47 79 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51020308_1 CDM 0312 RC 88377 HCPCS inpatient 893 580.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 866.21 97 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51020308_1 CDM 0312 RC 88377 HCPCS inpatient 893 580.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 616.17 69 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51020308_1 CDM 0312 RC 88377 HCPCS inpatient 893 580.45 SIHO - ALL PLANS SIHO - ALL PLANS 803.7 90 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51020308_1 CDM 0312 RC 88377 HCPCS inpatient 893 580.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 696.54 78 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51020308_1 CDM 0312 RC 88377 HCPCS inpatient 893 580.45 UMR - ALL PLANS UMR - ALL PLANS 625.1 70 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51020308_1 CDM 0312 RC 88377 HCPCS inpatient 893 580.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 540.71 60.55 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51020308_1 CDM 0312 RC 88377 HCPCS inpatient 893 580.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51020308_1 CDM 0312 RC 88377 HCPCS inpatient 893 580.45 ANTHEM HMO ANTHEM HMO 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51020308_1 CDM 0312 RC 88377 HCPCS inpatient 893 580.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51020308_1 CDM 0312 RC 88377 HCPCS inpatient 893 580.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51020308_1 CDM 0312 RC 88377 HCPCS inpatient 893 580.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 603.67 67.6 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51020308_1 CDM 0312 RC 88377 HCPCS inpatient 893 580.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51020309_1 CDM 0310 RC 88373 HCPCS inpatient 938 609.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 609.7 65 999999999 567.96 909.86 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51020309_1 CDM 0310 RC 88373 HCPCS inpatient 938 609.7 AETNA AETNA 741.02 79 999999999 567.96 909.86 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51020309_1 CDM 0310 RC 88373 HCPCS inpatient 938 609.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 909.86 97 999999999 567.96 909.86 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51020309_1 CDM 0310 RC 88373 HCPCS inpatient 938 609.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 647.22 69 999999999 567.96 909.86 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51020309_1 CDM 0310 RC 88373 HCPCS inpatient 938 609.7 SIHO - ALL PLANS SIHO - ALL PLANS 844.2 90 999999999 567.96 909.86 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51020309_1 CDM 0310 RC 88373 HCPCS inpatient 938 609.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 731.64 78 999999999 567.96 909.86 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51020309_1 CDM 0310 RC 88373 HCPCS inpatient 938 609.7 UMR - ALL PLANS UMR - ALL PLANS 656.6 70 999999999 567.96 909.86 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51020309_1 CDM 0310 RC 88373 HCPCS inpatient 938 609.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 567.96 60.55 999999999 567.96 909.86 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51020309_1 CDM 0310 RC 88373 HCPCS inpatient 938 609.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 567.96 909.86 "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51020309_1 CDM 0310 RC 88373 HCPCS inpatient 938 609.7 ANTHEM HMO ANTHEM HMO 999999999 567.96 909.86 "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51020309_1 CDM 0310 RC 88373 HCPCS inpatient 938 609.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 567.96 909.86 "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51020309_1 CDM 0310 RC 88373 HCPCS inpatient 938 609.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 567.96 909.86 "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51020309_1 CDM 0310 RC 88373 HCPCS inpatient 938 609.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 634.09 67.6 999999999 567.96 909.86 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51020309_1 CDM 0310 RC 88373 HCPCS inpatient 938 609.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 567.96 909.86 Microsatellite instability analysis 51020310_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 843.05 65 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 51020310_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 AETNA AETNA 1024.63 79 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 51020310_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1258.09 97 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 51020310_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 894.93 69 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 51020310_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 SIHO - ALL PLANS SIHO - ALL PLANS 1167.3 90 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 51020310_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1011.66 78 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 51020310_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 UMR - ALL PLANS UMR - ALL PLANS 907.9 70 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 51020310_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 785.33 60.55 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 51020310_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 785.33 1258.09 Microsatellite instability analysis 51020310_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 ANTHEM HMO ANTHEM HMO 999999999 785.33 1258.09 Microsatellite instability analysis 51020310_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 785.33 1258.09 Microsatellite instability analysis 51020310_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 785.33 1258.09 Microsatellite instability analysis 51020310_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 876.77 67.6 999999999 785.33 1258.09 percent of total billed charges Microsatellite instability analysis 51020310_1 CDM 0310 RC 81301 HCPCS inpatient 1297 843.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 785.33 1258.09 Microsatellite instability analysis 51022282_1 CDM 0310 RC 81301 HCPCS inpatient 1296 842.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 842.4 65 999999999 784.73 1257.12 percent of total billed charges Microsatellite instability analysis 51022282_1 CDM 0310 RC 81301 HCPCS inpatient 1296 842.4 AETNA AETNA 1023.84 79 999999999 784.73 1257.12 percent of total billed charges Microsatellite instability analysis 51022282_1 CDM 0310 RC 81301 HCPCS inpatient 1296 842.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1257.12 97 999999999 784.73 1257.12 percent of total billed charges Microsatellite instability analysis 51022282_1 CDM 0310 RC 81301 HCPCS inpatient 1296 842.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 894.24 69 999999999 784.73 1257.12 percent of total billed charges Microsatellite instability analysis 51022282_1 CDM 0310 RC 81301 HCPCS inpatient 1296 842.4 SIHO - ALL PLANS SIHO - ALL PLANS 1166.4 90 999999999 784.73 1257.12 percent of total billed charges Microsatellite instability analysis 51022282_1 CDM 0310 RC 81301 HCPCS inpatient 1296 842.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 1010.88 78 999999999 784.73 1257.12 percent of total billed charges Microsatellite instability analysis 51022282_1 CDM 0310 RC 81301 HCPCS inpatient 1296 842.4 UMR - ALL PLANS UMR - ALL PLANS 907.2 70 999999999 784.73 1257.12 percent of total billed charges Microsatellite instability analysis 51022282_1 CDM 0310 RC 81301 HCPCS inpatient 1296 842.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 784.73 60.55 999999999 784.73 1257.12 percent of total billed charges Microsatellite instability analysis 51022282_1 CDM 0310 RC 81301 HCPCS inpatient 1296 842.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 784.73 1257.12 Microsatellite instability analysis 51022282_1 CDM 0310 RC 81301 HCPCS inpatient 1296 842.4 ANTHEM HMO ANTHEM HMO 999999999 784.73 1257.12 Microsatellite instability analysis 51022282_1 CDM 0310 RC 81301 HCPCS inpatient 1296 842.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 784.73 1257.12 Microsatellite instability analysis 51022282_1 CDM 0310 RC 81301 HCPCS inpatient 1296 842.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 784.73 1257.12 Microsatellite instability analysis 51022282_1 CDM 0310 RC 81301 HCPCS inpatient 1296 842.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 876.1 67.6 999999999 784.73 1257.12 percent of total billed charges Microsatellite instability analysis 51022282_1 CDM 0310 RC 81301 HCPCS inpatient 1296 842.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 784.73 1257.12 INTRAUTERINE COPPER CONTRACEPTIVE 51023645_1 CDM 0250 RC 59365-5128-01 NDC J7300 HCPCS inpatient 1 UN 1125 731.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 731.25 65 999999999 681.19 1091.25 percent of total billed charges INTRAUTERINE COPPER CONTRACEPTIVE 51023645_1 CDM 0250 RC 59365-5128-01 NDC J7300 HCPCS inpatient 1 UN 1125 731.25 AETNA AETNA 888.75 79 999999999 681.19 1091.25 percent of total billed charges INTRAUTERINE COPPER CONTRACEPTIVE 51023645_1 CDM 0250 RC 59365-5128-01 NDC J7300 HCPCS inpatient 1 UN 1125 731.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1091.25 97 999999999 681.19 1091.25 percent of total billed charges INTRAUTERINE COPPER CONTRACEPTIVE 51023645_1 CDM 0250 RC 59365-5128-01 NDC J7300 HCPCS inpatient 1 UN 1125 731.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 776.25 69 999999999 681.19 1091.25 percent of total billed charges INTRAUTERINE COPPER CONTRACEPTIVE 51023645_1 CDM 0250 RC 59365-5128-01 NDC J7300 HCPCS inpatient 1 UN 1125 731.25 SIHO - ALL PLANS SIHO - ALL PLANS 1012.5 90 999999999 681.19 1091.25 percent of total billed charges INTRAUTERINE COPPER CONTRACEPTIVE 51023645_1 CDM 0250 RC 59365-5128-01 NDC J7300 HCPCS inpatient 1 UN 1125 731.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 877.5 78 999999999 681.19 1091.25 percent of total billed charges INTRAUTERINE COPPER CONTRACEPTIVE 51023645_1 CDM 0250 RC 59365-5128-01 NDC J7300 HCPCS inpatient 1 UN 1125 731.25 UMR - ALL PLANS UMR - ALL PLANS 787.5 70 999999999 681.19 1091.25 percent of total billed charges INTRAUTERINE COPPER CONTRACEPTIVE 51023645_1 CDM 0250 RC 59365-5128-01 NDC J7300 HCPCS inpatient 1 UN 1125 731.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 681.19 60.55 999999999 681.19 1091.25 percent of total billed charges INTRAUTERINE COPPER CONTRACEPTIVE 51023645_1 CDM 0250 RC 59365-5128-01 NDC J7300 HCPCS inpatient 1 UN 1125 731.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 681.19 1091.25 INTRAUTERINE COPPER CONTRACEPTIVE 51023645_1 CDM 0250 RC 59365-5128-01 NDC J7300 HCPCS inpatient 1 UN 1125 731.25 ANTHEM HMO ANTHEM HMO 999999999 681.19 1091.25 INTRAUTERINE COPPER CONTRACEPTIVE 51023645_1 CDM 0250 RC 59365-5128-01 NDC J7300 HCPCS inpatient 1 UN 1125 731.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 681.19 1091.25 INTRAUTERINE COPPER CONTRACEPTIVE 51023645_1 CDM 0250 RC 59365-5128-01 NDC J7300 HCPCS inpatient 1 UN 1125 731.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 681.19 1091.25 INTRAUTERINE COPPER CONTRACEPTIVE 51023645_1 CDM 0250 RC 59365-5128-01 NDC J7300 HCPCS inpatient 1 UN 1125 731.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 760.5 67.6 999999999 681.19 1091.25 percent of total billed charges INTRAUTERINE COPPER CONTRACEPTIVE 51023645_1 CDM 0250 RC 59365-5128-01 NDC J7300 HCPCS inpatient 1 UN 1125 731.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 681.19 1091.25 "Detection test by nucleic acid for organism, amplified probe technique" 51025666_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51025666_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51025666_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51025666_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51025666_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51025666_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51025666_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51025666_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51025666_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 51025666_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 51025666_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 51025666_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 51025666_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51025666_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 51025668_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 77.35 65 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51025668_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 AETNA AETNA 94.01 79 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51025668_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 115.43 97 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51025668_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.11 69 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51025668_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 SIHO - ALL PLANS SIHO - ALL PLANS 107.1 90 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51025668_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.82 78 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51025668_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 UMR - ALL PLANS UMR - ALL PLANS 83.3 70 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51025668_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.05 60.55 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51025668_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 51025668_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 ANTHEM HMO ANTHEM HMO 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 51025668_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 51025668_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 80.44 67.6 999999999 72.05 115.43 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51025668_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.05 115.43 "Detection test by nucleic acid for organism, amplified probe technique" 51025668_1 CDM 0301 RC 87798 HCPCS inpatient 119 77.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.05 115.43 Cadmium level 51028959_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Cadmium level 51028959_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Cadmium level 51028959_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Cadmium level 51028959_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Cadmium level 51028959_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Cadmium level 51028959_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Cadmium level 51028959_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Cadmium level 51028959_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Cadmium level 51028959_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Cadmium level 51028959_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Cadmium level 51028959_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Cadmium level 51028959_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Cadmium level 51028959_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Cadmium level 51028959_1 CDM 0301 RC 82300 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Detection test by immunoassay with direct visual observation for other organism 51029214_1 CDM 0301 RC 87899 HCPCS inpatient 125 81.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.25 65 999999999 75.69 121.25 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 51029214_1 CDM 0301 RC 87899 HCPCS inpatient 125 81.25 AETNA AETNA 98.75 79 999999999 75.69 121.25 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 51029214_1 CDM 0301 RC 87899 HCPCS inpatient 125 81.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 121.25 97 999999999 75.69 121.25 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 51029214_1 CDM 0301 RC 87899 HCPCS inpatient 125 81.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.25 69 999999999 75.69 121.25 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 51029214_1 CDM 0301 RC 87899 HCPCS inpatient 125 81.25 SIHO - ALL PLANS SIHO - ALL PLANS 112.5 90 999999999 75.69 121.25 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 51029214_1 CDM 0301 RC 87899 HCPCS inpatient 125 81.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.5 78 999999999 75.69 121.25 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 51029214_1 CDM 0301 RC 87899 HCPCS inpatient 125 81.25 UMR - ALL PLANS UMR - ALL PLANS 87.5 70 999999999 75.69 121.25 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 51029214_1 CDM 0301 RC 87899 HCPCS inpatient 125 81.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.69 60.55 999999999 75.69 121.25 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 51029214_1 CDM 0301 RC 87899 HCPCS inpatient 125 81.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.69 121.25 Detection test by immunoassay with direct visual observation for other organism 51029214_1 CDM 0301 RC 87899 HCPCS inpatient 125 81.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.69 121.25 Detection test by immunoassay with direct visual observation for other organism 51029214_1 CDM 0301 RC 87899 HCPCS inpatient 125 81.25 ANTHEM HMO ANTHEM HMO 999999999 75.69 121.25 Detection test by immunoassay with direct visual observation for other organism 51029214_1 CDM 0301 RC 87899 HCPCS inpatient 125 81.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.5 67.6 999999999 75.69 121.25 percent of total billed charges Detection test by immunoassay with direct visual observation for other organism 51029214_1 CDM 0301 RC 87899 HCPCS inpatient 125 81.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.69 121.25 Detection test by immunoassay with direct visual observation for other organism 51029214_1 CDM 0301 RC 87899 HCPCS inpatient 125 81.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.69 121.25 Translocation analysis (BCR/ABL1) minor breakpoint 51032083_1 CDM 0310 RC 81207 HCPCS inpatient 509 330.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 330.85 65 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 51032083_1 CDM 0310 RC 81207 HCPCS inpatient 509 330.85 AETNA AETNA 402.11 79 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 51032083_1 CDM 0310 RC 81207 HCPCS inpatient 509 330.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 493.73 97 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 51032083_1 CDM 0310 RC 81207 HCPCS inpatient 509 330.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 351.21 69 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 51032083_1 CDM 0310 RC 81207 HCPCS inpatient 509 330.85 SIHO - ALL PLANS SIHO - ALL PLANS 458.1 90 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 51032083_1 CDM 0310 RC 81207 HCPCS inpatient 509 330.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 397.02 78 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 51032083_1 CDM 0310 RC 81207 HCPCS inpatient 509 330.85 UMR - ALL PLANS UMR - ALL PLANS 356.3 70 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 51032083_1 CDM 0310 RC 81207 HCPCS inpatient 509 330.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 308.2 60.55 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 51032083_1 CDM 0310 RC 81207 HCPCS inpatient 509 330.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 308.2 493.73 Translocation analysis (BCR/ABL1) minor breakpoint 51032083_1 CDM 0310 RC 81207 HCPCS inpatient 509 330.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 308.2 493.73 Translocation analysis (BCR/ABL1) minor breakpoint 51032083_1 CDM 0310 RC 81207 HCPCS inpatient 509 330.85 ANTHEM HMO ANTHEM HMO 999999999 308.2 493.73 Translocation analysis (BCR/ABL1) minor breakpoint 51032083_1 CDM 0310 RC 81207 HCPCS inpatient 509 330.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 344.08 67.6 999999999 308.2 493.73 percent of total billed charges Translocation analysis (BCR/ABL1) minor breakpoint 51032083_1 CDM 0310 RC 81207 HCPCS inpatient 509 330.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 308.2 493.73 Translocation analysis (BCR/ABL1) minor breakpoint 51032083_1 CDM 0310 RC 81207 HCPCS inpatient 509 330.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 308.2 493.73 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51032084_1 CDM 0310 RC 88374 HCPCS inpatient 835 542.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 542.75 65 999999999 505.59 809.95 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51032084_1 CDM 0310 RC 88374 HCPCS inpatient 835 542.75 AETNA AETNA 659.65 79 999999999 505.59 809.95 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51032084_1 CDM 0310 RC 88374 HCPCS inpatient 835 542.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 809.95 97 999999999 505.59 809.95 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51032084_1 CDM 0310 RC 88374 HCPCS inpatient 835 542.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 576.15 69 999999999 505.59 809.95 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51032084_1 CDM 0310 RC 88374 HCPCS inpatient 835 542.75 SIHO - ALL PLANS SIHO - ALL PLANS 751.5 90 999999999 505.59 809.95 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51032084_1 CDM 0310 RC 88374 HCPCS inpatient 835 542.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 651.3 78 999999999 505.59 809.95 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51032084_1 CDM 0310 RC 88374 HCPCS inpatient 835 542.75 UMR - ALL PLANS UMR - ALL PLANS 584.5 70 999999999 505.59 809.95 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51032084_1 CDM 0310 RC 88374 HCPCS inpatient 835 542.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 505.59 60.55 999999999 505.59 809.95 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51032084_1 CDM 0310 RC 88374 HCPCS inpatient 835 542.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 505.59 809.95 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51032084_1 CDM 0310 RC 88374 HCPCS inpatient 835 542.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 505.59 809.95 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51032084_1 CDM 0310 RC 88374 HCPCS inpatient 835 542.75 ANTHEM HMO ANTHEM HMO 999999999 505.59 809.95 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51032084_1 CDM 0310 RC 88374 HCPCS inpatient 835 542.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 564.46 67.6 999999999 505.59 809.95 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51032084_1 CDM 0310 RC 88374 HCPCS inpatient 835 542.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 505.59 809.95 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51032084_1 CDM 0310 RC 88374 HCPCS inpatient 835 542.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 505.59 809.95 Antibody identification test for white blood cell antibodies 51034588_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges Antibody identification test for white blood cell antibodies 51034588_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges Antibody identification test for white blood cell antibodies 51034588_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges Antibody identification test for white blood cell antibodies 51034588_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges Antibody identification test for white blood cell antibodies 51034588_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges Antibody identification test for white blood cell antibodies 51034588_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges Antibody identification test for white blood cell antibodies 51034588_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges Antibody identification test for white blood cell antibodies 51034588_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges Antibody identification test for white blood cell antibodies 51034588_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 Antibody identification test for white blood cell antibodies 51034588_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 Antibody identification test for white blood cell antibodies 51034588_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 Antibody identification test for white blood cell antibodies 51034588_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges Antibody identification test for white blood cell antibodies 51034588_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 Antibody identification test for white blood cell antibodies 51034588_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 Antibody identification test for white blood cell antibodies 51034590_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges Antibody identification test for white blood cell antibodies 51034590_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges Antibody identification test for white blood cell antibodies 51034590_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges Antibody identification test for white blood cell antibodies 51034590_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges Antibody identification test for white blood cell antibodies 51034590_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges Antibody identification test for white blood cell antibodies 51034590_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges Antibody identification test for white blood cell antibodies 51034590_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges Antibody identification test for white blood cell antibodies 51034590_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges Antibody identification test for white blood cell antibodies 51034590_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 Antibody identification test for white blood cell antibodies 51034590_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 Antibody identification test for white blood cell antibodies 51034590_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 Antibody identification test for white blood cell antibodies 51034590_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges Antibody identification test for white blood cell antibodies 51034590_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 Antibody identification test for white blood cell antibodies 51034590_1 CDM 0301 RC 86021 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 Clotting factor IX (PTC or Christmas) measurement 51035823_1 CDM 0301 RC 85250 HCPCS inpatient 237 154.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.05 65 999999999 143.5 229.89 percent of total billed charges Clotting factor IX (PTC or Christmas) measurement 51035823_1 CDM 0301 RC 85250 HCPCS inpatient 237 154.05 AETNA AETNA 187.23 79 999999999 143.5 229.89 percent of total billed charges Clotting factor IX (PTC or Christmas) measurement 51035823_1 CDM 0301 RC 85250 HCPCS inpatient 237 154.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 229.89 97 999999999 143.5 229.89 percent of total billed charges Clotting factor IX (PTC or Christmas) measurement 51035823_1 CDM 0301 RC 85250 HCPCS inpatient 237 154.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 163.53 69 999999999 143.5 229.89 percent of total billed charges Clotting factor IX (PTC or Christmas) measurement 51035823_1 CDM 0301 RC 85250 HCPCS inpatient 237 154.05 SIHO - ALL PLANS SIHO - ALL PLANS 213.3 90 999999999 143.5 229.89 percent of total billed charges Clotting factor IX (PTC or Christmas) measurement 51035823_1 CDM 0301 RC 85250 HCPCS inpatient 237 154.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 184.86 78 999999999 143.5 229.89 percent of total billed charges Clotting factor IX (PTC or Christmas) measurement 51035823_1 CDM 0301 RC 85250 HCPCS inpatient 237 154.05 UMR - ALL PLANS UMR - ALL PLANS 165.9 70 999999999 143.5 229.89 percent of total billed charges Clotting factor IX (PTC or Christmas) measurement 51035823_1 CDM 0301 RC 85250 HCPCS inpatient 237 154.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 143.5 60.55 999999999 143.5 229.89 percent of total billed charges Clotting factor IX (PTC or Christmas) measurement 51035823_1 CDM 0301 RC 85250 HCPCS inpatient 237 154.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 143.5 229.89 Clotting factor IX (PTC or Christmas) measurement 51035823_1 CDM 0301 RC 85250 HCPCS inpatient 237 154.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 143.5 229.89 Clotting factor IX (PTC or Christmas) measurement 51035823_1 CDM 0301 RC 85250 HCPCS inpatient 237 154.05 ANTHEM HMO ANTHEM HMO 999999999 143.5 229.89 Clotting factor IX (PTC or Christmas) measurement 51035823_1 CDM 0301 RC 85250 HCPCS inpatient 237 154.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.21 67.6 999999999 143.5 229.89 percent of total billed charges Clotting factor IX (PTC or Christmas) measurement 51035823_1 CDM 0301 RC 85250 HCPCS inpatient 237 154.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 143.5 229.89 Clotting factor IX (PTC or Christmas) measurement 51035823_1 CDM 0301 RC 85250 HCPCS inpatient 237 154.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 143.5 229.89 Clotting factor V (AcG or proaccelerin) measurement 51035824_1 CDM 0301 RC 85220 HCPCS inpatient 237 154.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.05 65 999999999 143.5 229.89 percent of total billed charges Clotting factor V (AcG or proaccelerin) measurement 51035824_1 CDM 0301 RC 85220 HCPCS inpatient 237 154.05 AETNA AETNA 187.23 79 999999999 143.5 229.89 percent of total billed charges Clotting factor V (AcG or proaccelerin) measurement 51035824_1 CDM 0301 RC 85220 HCPCS inpatient 237 154.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 229.89 97 999999999 143.5 229.89 percent of total billed charges Clotting factor V (AcG or proaccelerin) measurement 51035824_1 CDM 0301 RC 85220 HCPCS inpatient 237 154.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 163.53 69 999999999 143.5 229.89 percent of total billed charges Clotting factor V (AcG or proaccelerin) measurement 51035824_1 CDM 0301 RC 85220 HCPCS inpatient 237 154.05 SIHO - ALL PLANS SIHO - ALL PLANS 213.3 90 999999999 143.5 229.89 percent of total billed charges Clotting factor V (AcG or proaccelerin) measurement 51035824_1 CDM 0301 RC 85220 HCPCS inpatient 237 154.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 184.86 78 999999999 143.5 229.89 percent of total billed charges Clotting factor V (AcG or proaccelerin) measurement 51035824_1 CDM 0301 RC 85220 HCPCS inpatient 237 154.05 UMR - ALL PLANS UMR - ALL PLANS 165.9 70 999999999 143.5 229.89 percent of total billed charges Clotting factor V (AcG or proaccelerin) measurement 51035824_1 CDM 0301 RC 85220 HCPCS inpatient 237 154.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 143.5 60.55 999999999 143.5 229.89 percent of total billed charges Clotting factor V (AcG or proaccelerin) measurement 51035824_1 CDM 0301 RC 85220 HCPCS inpatient 237 154.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 143.5 229.89 Clotting factor V (AcG or proaccelerin) measurement 51035824_1 CDM 0301 RC 85220 HCPCS inpatient 237 154.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 143.5 229.89 Clotting factor V (AcG or proaccelerin) measurement 51035824_1 CDM 0301 RC 85220 HCPCS inpatient 237 154.05 ANTHEM HMO ANTHEM HMO 999999999 143.5 229.89 Clotting factor V (AcG or proaccelerin) measurement 51035824_1 CDM 0301 RC 85220 HCPCS inpatient 237 154.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.21 67.6 999999999 143.5 229.89 percent of total billed charges Clotting factor V (AcG or proaccelerin) measurement 51035824_1 CDM 0301 RC 85220 HCPCS inpatient 237 154.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 143.5 229.89 Clotting factor V (AcG or proaccelerin) measurement 51035824_1 CDM 0301 RC 85220 HCPCS inpatient 237 154.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 143.5 229.89 Clotting factor XII (Hageman) measurement 51035826_1 CDM 0301 RC 85280 HCPCS inpatient 237 154.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.05 65 999999999 143.5 229.89 percent of total billed charges Clotting factor XII (Hageman) measurement 51035826_1 CDM 0301 RC 85280 HCPCS inpatient 237 154.05 AETNA AETNA 187.23 79 999999999 143.5 229.89 percent of total billed charges Clotting factor XII (Hageman) measurement 51035826_1 CDM 0301 RC 85280 HCPCS inpatient 237 154.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 229.89 97 999999999 143.5 229.89 percent of total billed charges Clotting factor XII (Hageman) measurement 51035826_1 CDM 0301 RC 85280 HCPCS inpatient 237 154.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 163.53 69 999999999 143.5 229.89 percent of total billed charges Clotting factor XII (Hageman) measurement 51035826_1 CDM 0301 RC 85280 HCPCS inpatient 237 154.05 SIHO - ALL PLANS SIHO - ALL PLANS 213.3 90 999999999 143.5 229.89 percent of total billed charges Clotting factor XII (Hageman) measurement 51035826_1 CDM 0301 RC 85280 HCPCS inpatient 237 154.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 184.86 78 999999999 143.5 229.89 percent of total billed charges Clotting factor XII (Hageman) measurement 51035826_1 CDM 0301 RC 85280 HCPCS inpatient 237 154.05 UMR - ALL PLANS UMR - ALL PLANS 165.9 70 999999999 143.5 229.89 percent of total billed charges Clotting factor XII (Hageman) measurement 51035826_1 CDM 0301 RC 85280 HCPCS inpatient 237 154.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 143.5 60.55 999999999 143.5 229.89 percent of total billed charges Clotting factor XII (Hageman) measurement 51035826_1 CDM 0301 RC 85280 HCPCS inpatient 237 154.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 143.5 229.89 Clotting factor XII (Hageman) measurement 51035826_1 CDM 0301 RC 85280 HCPCS inpatient 237 154.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 143.5 229.89 Clotting factor XII (Hageman) measurement 51035826_1 CDM 0301 RC 85280 HCPCS inpatient 237 154.05 ANTHEM HMO ANTHEM HMO 999999999 143.5 229.89 Clotting factor XII (Hageman) measurement 51035826_1 CDM 0301 RC 85280 HCPCS inpatient 237 154.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.21 67.6 999999999 143.5 229.89 percent of total billed charges Clotting factor XII (Hageman) measurement 51035826_1 CDM 0301 RC 85280 HCPCS inpatient 237 154.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 143.5 229.89 Clotting factor XII (Hageman) measurement 51035826_1 CDM 0301 RC 85280 HCPCS inpatient 237 154.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 143.5 229.89 "Coagulation assessment blood test, plasma or whole blood" 51035870_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 51035870_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 51035870_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 51035870_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 51035870_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 51035870_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 51035870_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 51035870_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 51035870_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 "Coagulation assessment blood test, plasma or whole blood" 51035870_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 "Coagulation assessment blood test, plasma or whole blood" 51035870_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 "Coagulation assessment blood test, plasma or whole blood" 51035870_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges "Coagulation assessment blood test, plasma or whole blood" 51035870_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 "Coagulation assessment blood test, plasma or whole blood" 51035870_1 CDM 0305 RC 85730 HCPCS inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 "Blood test, clotting time" 51035872_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 51035872_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 51035872_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 51035872_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 51035872_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 51035872_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 51035872_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 51035872_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 51035872_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 "Blood test, clotting time" 51035872_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 "Blood test, clotting time" 51035872_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 "Blood test, clotting time" 51035872_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges "Blood test, clotting time" 51035872_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 "Blood test, clotting time" 51035872_1 CDM 0305 RC 85610 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 "Thrombin time, fibrinogen screening test, plasma" 51035875_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges "Thrombin time, fibrinogen screening test, plasma" 51035875_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges "Thrombin time, fibrinogen screening test, plasma" 51035875_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges "Thrombin time, fibrinogen screening test, plasma" 51035875_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges "Thrombin time, fibrinogen screening test, plasma" 51035875_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges "Thrombin time, fibrinogen screening test, plasma" 51035875_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges "Thrombin time, fibrinogen screening test, plasma" 51035875_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges "Thrombin time, fibrinogen screening test, plasma" 51035875_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges "Thrombin time, fibrinogen screening test, plasma" 51035875_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 "Thrombin time, fibrinogen screening test, plasma" 51035875_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 "Thrombin time, fibrinogen screening test, plasma" 51035875_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 "Thrombin time, fibrinogen screening test, plasma" 51035875_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges "Thrombin time, fibrinogen screening test, plasma" 51035875_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 "Thrombin time, fibrinogen screening test, plasma" 51035875_1 CDM 0305 RC 85670 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 Molecular pathology procedure 51036132_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 307.45 65 999999999 286.4 458.81 percent of total billed charges Molecular pathology procedure 51036132_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 AETNA AETNA 373.67 79 999999999 286.4 458.81 percent of total billed charges Molecular pathology procedure 51036132_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 458.81 97 999999999 286.4 458.81 percent of total billed charges Molecular pathology procedure 51036132_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 326.37 69 999999999 286.4 458.81 percent of total billed charges Molecular pathology procedure 51036132_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 SIHO - ALL PLANS SIHO - ALL PLANS 425.7 90 999999999 286.4 458.81 percent of total billed charges Molecular pathology procedure 51036132_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 368.94 78 999999999 286.4 458.81 percent of total billed charges Molecular pathology procedure 51036132_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 UMR - ALL PLANS UMR - ALL PLANS 331.1 70 999999999 286.4 458.81 percent of total billed charges Molecular pathology procedure 51036132_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 286.4 60.55 999999999 286.4 458.81 percent of total billed charges Molecular pathology procedure 51036132_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 286.4 458.81 Molecular pathology procedure 51036132_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 286.4 458.81 Molecular pathology procedure 51036132_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 ANTHEM HMO ANTHEM HMO 999999999 286.4 458.81 Molecular pathology procedure 51036132_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 319.75 67.6 999999999 286.4 458.81 percent of total billed charges Molecular pathology procedure 51036132_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 286.4 458.81 Molecular pathology procedure 51036132_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 286.4 458.81 Molecular pathology procedure 51036170_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 307.45 65 999999999 286.4 458.81 percent of total billed charges Molecular pathology procedure 51036170_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 AETNA AETNA 373.67 79 999999999 286.4 458.81 percent of total billed charges Molecular pathology procedure 51036170_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 458.81 97 999999999 286.4 458.81 percent of total billed charges Molecular pathology procedure 51036170_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 326.37 69 999999999 286.4 458.81 percent of total billed charges Molecular pathology procedure 51036170_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 SIHO - ALL PLANS SIHO - ALL PLANS 425.7 90 999999999 286.4 458.81 percent of total billed charges Molecular pathology procedure 51036170_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 368.94 78 999999999 286.4 458.81 percent of total billed charges Molecular pathology procedure 51036170_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 UMR - ALL PLANS UMR - ALL PLANS 331.1 70 999999999 286.4 458.81 percent of total billed charges Molecular pathology procedure 51036170_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 286.4 60.55 999999999 286.4 458.81 percent of total billed charges Molecular pathology procedure 51036170_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 286.4 458.81 Molecular pathology procedure 51036170_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 286.4 458.81 Molecular pathology procedure 51036170_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 ANTHEM HMO ANTHEM HMO 999999999 286.4 458.81 Molecular pathology procedure 51036170_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 319.75 67.6 999999999 286.4 458.81 percent of total billed charges Molecular pathology procedure 51036170_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 286.4 458.81 Molecular pathology procedure 51036170_1 CDM 0301 RC 81479 HCPCS inpatient 473 307.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 286.4 458.81 "Pretreatment of serum for use in red blood cell antibody analysis and measurement, by differential red cell absorption" 51041638_1 CDM 0302 RC 86978 HCPCS inpatient 270 175.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 175.5 65 999999999 163.49 261.9 percent of total billed charges "Pretreatment of serum for use in red blood cell antibody analysis and measurement, by differential red cell absorption" 51041638_1 CDM 0302 RC 86978 HCPCS inpatient 270 175.5 AETNA AETNA 213.3 79 999999999 163.49 261.9 percent of total billed charges "Pretreatment of serum for use in red blood cell antibody analysis and measurement, by differential red cell absorption" 51041638_1 CDM 0302 RC 86978 HCPCS inpatient 270 175.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 261.9 97 999999999 163.49 261.9 percent of total billed charges "Pretreatment of serum for use in red blood cell antibody analysis and measurement, by differential red cell absorption" 51041638_1 CDM 0302 RC 86978 HCPCS inpatient 270 175.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 186.3 69 999999999 163.49 261.9 percent of total billed charges "Pretreatment of serum for use in red blood cell antibody analysis and measurement, by differential red cell absorption" 51041638_1 CDM 0302 RC 86978 HCPCS inpatient 270 175.5 SIHO - ALL PLANS SIHO - ALL PLANS 243 90 999999999 163.49 261.9 percent of total billed charges "Pretreatment of serum for use in red blood cell antibody analysis and measurement, by differential red cell absorption" 51041638_1 CDM 0302 RC 86978 HCPCS inpatient 270 175.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 210.6 78 999999999 163.49 261.9 percent of total billed charges "Pretreatment of serum for use in red blood cell antibody analysis and measurement, by differential red cell absorption" 51041638_1 CDM 0302 RC 86978 HCPCS inpatient 270 175.5 UMR - ALL PLANS UMR - ALL PLANS 189 70 999999999 163.49 261.9 percent of total billed charges "Pretreatment of serum for use in red blood cell antibody analysis and measurement, by differential red cell absorption" 51041638_1 CDM 0302 RC 86978 HCPCS inpatient 270 175.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 163.49 60.55 999999999 163.49 261.9 percent of total billed charges "Pretreatment of serum for use in red blood cell antibody analysis and measurement, by differential red cell absorption" 51041638_1 CDM 0302 RC 86978 HCPCS inpatient 270 175.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 163.49 261.9 "Pretreatment of serum for use in red blood cell antibody analysis and measurement, by differential red cell absorption" 51041638_1 CDM 0302 RC 86978 HCPCS inpatient 270 175.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 163.49 261.9 "Pretreatment of serum for use in red blood cell antibody analysis and measurement, by differential red cell absorption" 51041638_1 CDM 0302 RC 86978 HCPCS inpatient 270 175.5 ANTHEM HMO ANTHEM HMO 999999999 163.49 261.9 "Pretreatment of serum for use in red blood cell antibody analysis and measurement, by differential red cell absorption" 51041638_1 CDM 0302 RC 86978 HCPCS inpatient 270 175.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 182.52 67.6 999999999 163.49 261.9 percent of total billed charges "Pretreatment of serum for use in red blood cell antibody analysis and measurement, by differential red cell absorption" 51041638_1 CDM 0302 RC 86978 HCPCS inpatient 270 175.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 163.49 261.9 "Pretreatment of serum for use in red blood cell antibody analysis and measurement, by differential red cell absorption" 51041638_1 CDM 0302 RC 86978 HCPCS inpatient 270 175.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 163.49 261.9 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51070573_1 CDM 0311 RC 88189 HCPCS inpatient 818 531.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 531.7 65 999999999 495.3 793.46 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51070573_1 CDM 0311 RC 88189 HCPCS inpatient 818 531.7 AETNA AETNA 646.22 79 999999999 495.3 793.46 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51070573_1 CDM 0311 RC 88189 HCPCS inpatient 818 531.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 793.46 97 999999999 495.3 793.46 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51070573_1 CDM 0311 RC 88189 HCPCS inpatient 818 531.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 564.42 69 999999999 495.3 793.46 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51070573_1 CDM 0311 RC 88189 HCPCS inpatient 818 531.7 SIHO - ALL PLANS SIHO - ALL PLANS 736.2 90 999999999 495.3 793.46 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51070573_1 CDM 0311 RC 88189 HCPCS inpatient 818 531.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 638.04 78 999999999 495.3 793.46 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51070573_1 CDM 0311 RC 88189 HCPCS inpatient 818 531.7 UMR - ALL PLANS UMR - ALL PLANS 572.6 70 999999999 495.3 793.46 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51070573_1 CDM 0311 RC 88189 HCPCS inpatient 818 531.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 495.3 60.55 999999999 495.3 793.46 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51070573_1 CDM 0311 RC 88189 HCPCS inpatient 818 531.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 495.3 793.46 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51070573_1 CDM 0311 RC 88189 HCPCS inpatient 818 531.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 495.3 793.46 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51070573_1 CDM 0311 RC 88189 HCPCS inpatient 818 531.7 ANTHEM HMO ANTHEM HMO 999999999 495.3 793.46 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51070573_1 CDM 0311 RC 88189 HCPCS inpatient 818 531.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 552.97 67.6 999999999 495.3 793.46 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51070573_1 CDM 0311 RC 88189 HCPCS inpatient 818 531.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 495.3 793.46 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51070573_1 CDM 0311 RC 88189 HCPCS inpatient 818 531.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 495.3 793.46 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 51070574_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 330.85 65 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 51070574_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 AETNA AETNA 402.11 79 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 51070574_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 493.73 97 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 51070574_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 351.21 69 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 51070574_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 SIHO - ALL PLANS SIHO - ALL PLANS 458.1 90 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 51070574_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 397.02 78 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 51070574_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 UMR - ALL PLANS UMR - ALL PLANS 356.3 70 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 51070574_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 308.2 60.55 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 51070574_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 308.2 493.73 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 51070574_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 308.2 493.73 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 51070574_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 ANTHEM HMO ANTHEM HMO 999999999 308.2 493.73 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 51070574_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 344.08 67.6 999999999 308.2 493.73 percent of total billed charges Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 51070574_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 308.2 493.73 Gene analysis (v-raf murine sarcoma viral oncogene homolog B1) 51070574_1 CDM 0312 RC 81210 HCPCS inpatient 509 330.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 308.2 493.73 Special stained specimen slides to examine tissue including interpretation and report 51070575_1 CDM 0312 RC 88313 HCPCS inpatient 1145 744.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 744.25 65 999999999 693.3 1110.65 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 51070575_1 CDM 0312 RC 88313 HCPCS inpatient 1145 744.25 AETNA AETNA 904.55 79 999999999 693.3 1110.65 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 51070575_1 CDM 0312 RC 88313 HCPCS inpatient 1145 744.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1110.65 97 999999999 693.3 1110.65 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 51070575_1 CDM 0312 RC 88313 HCPCS inpatient 1145 744.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 790.05 69 999999999 693.3 1110.65 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 51070575_1 CDM 0312 RC 88313 HCPCS inpatient 1145 744.25 SIHO - ALL PLANS SIHO - ALL PLANS 1030.5 90 999999999 693.3 1110.65 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 51070575_1 CDM 0312 RC 88313 HCPCS inpatient 1145 744.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 893.1 78 999999999 693.3 1110.65 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 51070575_1 CDM 0312 RC 88313 HCPCS inpatient 1145 744.25 UMR - ALL PLANS UMR - ALL PLANS 801.5 70 999999999 693.3 1110.65 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 51070575_1 CDM 0312 RC 88313 HCPCS inpatient 1145 744.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 693.3 60.55 999999999 693.3 1110.65 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 51070575_1 CDM 0312 RC 88313 HCPCS inpatient 1145 744.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 693.3 1110.65 Special stained specimen slides to examine tissue including interpretation and report 51070575_1 CDM 0312 RC 88313 HCPCS inpatient 1145 744.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 693.3 1110.65 Special stained specimen slides to examine tissue including interpretation and report 51070575_1 CDM 0312 RC 88313 HCPCS inpatient 1145 744.25 ANTHEM HMO ANTHEM HMO 999999999 693.3 1110.65 Special stained specimen slides to examine tissue including interpretation and report 51070575_1 CDM 0312 RC 88313 HCPCS inpatient 1145 744.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 774.02 67.6 999999999 693.3 1110.65 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 51070575_1 CDM 0312 RC 88313 HCPCS inpatient 1145 744.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 693.3 1110.65 Special stained specimen slides to examine tissue including interpretation and report 51070575_1 CDM 0312 RC 88313 HCPCS inpatient 1145 744.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 693.3 1110.65 "Gene analysis (epidermal growth factor receptor), common variants" 51070578_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 645.45 65 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 51070578_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 AETNA AETNA 784.47 79 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 51070578_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 963.21 97 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 51070578_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 685.17 69 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 51070578_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 SIHO - ALL PLANS SIHO - ALL PLANS 893.7 90 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 51070578_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 774.54 78 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 51070578_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 UMR - ALL PLANS UMR - ALL PLANS 695.1 70 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 51070578_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 601.26 60.55 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 51070578_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 601.26 963.21 "Gene analysis (epidermal growth factor receptor), common variants" 51070578_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 601.26 963.21 "Gene analysis (epidermal growth factor receptor), common variants" 51070578_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 ANTHEM HMO ANTHEM HMO 999999999 601.26 963.21 "Gene analysis (epidermal growth factor receptor), common variants" 51070578_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 671.27 67.6 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 51070578_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 601.26 963.21 "Gene analysis (epidermal growth factor receptor), common variants" 51070578_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 601.26 963.21 "Gene analysis (epidermal growth factor receptor), common variants" 51070579_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 645.45 65 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 51070579_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 AETNA AETNA 784.47 79 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 51070579_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 963.21 97 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 51070579_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 685.17 69 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 51070579_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 SIHO - ALL PLANS SIHO - ALL PLANS 893.7 90 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 51070579_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 774.54 78 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 51070579_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 UMR - ALL PLANS UMR - ALL PLANS 695.1 70 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 51070579_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 601.26 60.55 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 51070579_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 601.26 963.21 "Gene analysis (epidermal growth factor receptor), common variants" 51070579_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 601.26 963.21 "Gene analysis (epidermal growth factor receptor), common variants" 51070579_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 ANTHEM HMO ANTHEM HMO 999999999 601.26 963.21 "Gene analysis (epidermal growth factor receptor), common variants" 51070579_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 671.27 67.6 999999999 601.26 963.21 percent of total billed charges "Gene analysis (epidermal growth factor receptor), common variants" 51070579_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 601.26 963.21 "Gene analysis (epidermal growth factor receptor), common variants" 51070579_1 CDM 0312 RC 81235 HCPCS inpatient 993 645.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 601.26 963.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070580_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 580.45 65 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070580_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 AETNA AETNA 705.47 79 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070580_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 866.21 97 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070580_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 616.17 69 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070580_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 SIHO - ALL PLANS SIHO - ALL PLANS 803.7 90 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070580_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 696.54 78 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070580_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 UMR - ALL PLANS UMR - ALL PLANS 625.1 70 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070580_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 540.71 60.55 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070580_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070580_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070580_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM HMO ANTHEM HMO 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070580_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 603.67 67.6 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070580_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070580_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 540.71 866.21 "Special stained specimen slides to examine tissue, initial procedure" 51070582_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 230.75 65 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51070582_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 AETNA AETNA 280.45 79 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51070582_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 344.35 97 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51070582_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 244.95 69 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51070582_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 SIHO - ALL PLANS SIHO - ALL PLANS 319.5 90 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51070582_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 276.9 78 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51070582_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UMR - ALL PLANS UMR - ALL PLANS 248.5 70 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51070582_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 214.95 60.55 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51070582_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51070582_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51070582_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM HMO ANTHEM HMO 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51070582_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 239.98 67.6 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51070582_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51070582_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 214.95 344.35 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 580.45 65 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 AETNA AETNA 705.47 79 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 866.21 97 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 616.17 69 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 SIHO - ALL PLANS SIHO - ALL PLANS 803.7 90 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 696.54 78 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 UMR - ALL PLANS UMR - ALL PLANS 625.1 70 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 540.71 60.55 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM HMO ANTHEM HMO 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 603.67 67.6 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51070583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 540.71 866.21 "Microscopic genetic analysis of tumor, manual" 51070584_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.75 65 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51070584_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 AETNA AETNA 90.85 79 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51070584_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 111.55 97 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51070584_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 79.35 69 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51070584_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 SIHO - ALL PLANS SIHO - ALL PLANS 103.5 90 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51070584_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 89.7 78 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51070584_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UMR - ALL PLANS UMR - ALL PLANS 80.5 70 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51070584_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.63 60.55 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51070584_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51070584_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51070584_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM HMO ANTHEM HMO 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51070584_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.74 67.6 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51070584_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51070584_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51070585_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.75 65 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51070585_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 AETNA AETNA 90.85 79 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51070585_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 111.55 97 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51070585_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 79.35 69 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51070585_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 SIHO - ALL PLANS SIHO - ALL PLANS 103.5 90 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51070585_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 89.7 78 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51070585_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UMR - ALL PLANS UMR - ALL PLANS 80.5 70 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51070585_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.63 60.55 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51070585_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51070585_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51070585_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM HMO ANTHEM HMO 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51070585_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.74 67.6 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51070585_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51070585_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.63 111.55 "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 51070586_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 676.65 65 999999999 630.33 1009.77 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 51070586_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 AETNA AETNA 822.39 79 999999999 630.33 1009.77 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 51070586_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1009.77 97 999999999 630.33 1009.77 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 51070586_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 718.29 69 999999999 630.33 1009.77 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 51070586_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 SIHO - ALL PLANS SIHO - ALL PLANS 936.9 90 999999999 630.33 1009.77 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 51070586_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 811.98 78 999999999 630.33 1009.77 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 51070586_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 UMR - ALL PLANS UMR - ALL PLANS 728.7 70 999999999 630.33 1009.77 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 51070586_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 630.33 60.55 999999999 630.33 1009.77 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 51070586_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 630.33 1009.77 "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 51070586_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 630.33 1009.77 "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 51070586_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 ANTHEM HMO ANTHEM HMO 999999999 630.33 1009.77 "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 51070586_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 703.72 67.6 999999999 630.33 1009.77 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 51070586_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 630.33 1009.77 "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), targeted sequence" 51070586_1 CDM 0310 RC 81272 HCPCS inpatient 1041 676.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 630.33 1009.77 "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), D816 variants" 51070591_1 CDM 0310 RC 81273 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), D816 variants" 51070591_1 CDM 0310 RC 81273 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), D816 variants" 51070591_1 CDM 0310 RC 81273 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), D816 variants" 51070591_1 CDM 0310 RC 81273 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), D816 variants" 51070591_1 CDM 0310 RC 81273 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), D816 variants" 51070591_1 CDM 0310 RC 81273 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), D816 variants" 51070591_1 CDM 0310 RC 81273 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), D816 variants" 51070591_1 CDM 0310 RC 81273 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), D816 variants" 51070591_1 CDM 0310 RC 81273 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), D816 variants" 51070591_1 CDM 0310 RC 81273 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), D816 variants" 51070591_1 CDM 0310 RC 81273 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), D816 variants" 51070591_1 CDM 0310 RC 81273 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), D816 variants" 51070591_1 CDM 0310 RC 81273 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 "Gene analysis (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog), D816 variants" 51070591_1 CDM 0310 RC 81273 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 "Gene analysis (Kirsten rat sarcoma viral oncogene homolog), additional variants" 51071241_1 CDM 0312 RC 81276 HCPCS inpatient 569 369.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 369.85 65 999999999 344.53 551.93 percent of total billed charges "Gene analysis (Kirsten rat sarcoma viral oncogene homolog), additional variants" 51071241_1 CDM 0312 RC 81276 HCPCS inpatient 569 369.85 AETNA AETNA 449.51 79 999999999 344.53 551.93 percent of total billed charges "Gene analysis (Kirsten rat sarcoma viral oncogene homolog), additional variants" 51071241_1 CDM 0312 RC 81276 HCPCS inpatient 569 369.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 551.93 97 999999999 344.53 551.93 percent of total billed charges "Gene analysis (Kirsten rat sarcoma viral oncogene homolog), additional variants" 51071241_1 CDM 0312 RC 81276 HCPCS inpatient 569 369.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 392.61 69 999999999 344.53 551.93 percent of total billed charges "Gene analysis (Kirsten rat sarcoma viral oncogene homolog), additional variants" 51071241_1 CDM 0312 RC 81276 HCPCS inpatient 569 369.85 SIHO - ALL PLANS SIHO - ALL PLANS 512.1 90 999999999 344.53 551.93 percent of total billed charges "Gene analysis (Kirsten rat sarcoma viral oncogene homolog), additional variants" 51071241_1 CDM 0312 RC 81276 HCPCS inpatient 569 369.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 443.82 78 999999999 344.53 551.93 percent of total billed charges "Gene analysis (Kirsten rat sarcoma viral oncogene homolog), additional variants" 51071241_1 CDM 0312 RC 81276 HCPCS inpatient 569 369.85 UMR - ALL PLANS UMR - ALL PLANS 398.3 70 999999999 344.53 551.93 percent of total billed charges "Gene analysis (Kirsten rat sarcoma viral oncogene homolog), additional variants" 51071241_1 CDM 0312 RC 81276 HCPCS inpatient 569 369.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 344.53 60.55 999999999 344.53 551.93 percent of total billed charges "Gene analysis (Kirsten rat sarcoma viral oncogene homolog), additional variants" 51071241_1 CDM 0312 RC 81276 HCPCS inpatient 569 369.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 344.53 551.93 "Gene analysis (Kirsten rat sarcoma viral oncogene homolog), additional variants" 51071241_1 CDM 0312 RC 81276 HCPCS inpatient 569 369.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 344.53 551.93 "Gene analysis (Kirsten rat sarcoma viral oncogene homolog), additional variants" 51071241_1 CDM 0312 RC 81276 HCPCS inpatient 569 369.85 ANTHEM HMO ANTHEM HMO 999999999 344.53 551.93 "Gene analysis (Kirsten rat sarcoma viral oncogene homolog), additional variants" 51071241_1 CDM 0312 RC 81276 HCPCS inpatient 569 369.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 384.64 67.6 999999999 344.53 551.93 percent of total billed charges "Gene analysis (Kirsten rat sarcoma viral oncogene homolog), additional variants" 51071241_1 CDM 0312 RC 81276 HCPCS inpatient 569 369.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 344.53 551.93 "Gene analysis (Kirsten rat sarcoma viral oncogene homolog), additional variants" 51071241_1 CDM 0312 RC 81276 HCPCS inpatient 569 369.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 344.53 551.93 Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51071580_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 423.15 65 999999999 394.18 631.47 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51071580_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 AETNA AETNA 514.29 79 999999999 394.18 631.47 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51071580_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 631.47 97 999999999 394.18 631.47 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51071580_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 449.19 69 999999999 394.18 631.47 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51071580_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 SIHO - ALL PLANS SIHO - ALL PLANS 585.9 90 999999999 394.18 631.47 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51071580_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 507.78 78 999999999 394.18 631.47 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51071580_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 UMR - ALL PLANS UMR - ALL PLANS 455.7 70 999999999 394.18 631.47 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51071580_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 394.18 60.55 999999999 394.18 631.47 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51071580_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 394.18 631.47 Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51071580_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 394.18 631.47 Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51071580_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 ANTHEM HMO ANTHEM HMO 999999999 394.18 631.47 Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51071580_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 440.08 67.6 999999999 394.18 631.47 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51071580_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 394.18 631.47 Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51071580_1 CDM 0310 RC 81261 HCPCS inpatient 651 423.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 394.18 631.47 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071581_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 553.8 65 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071581_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 AETNA AETNA 673.08 79 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071581_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 826.44 97 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071581_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 587.88 69 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071581_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 SIHO - ALL PLANS SIHO - ALL PLANS 766.8 90 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071581_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 664.56 78 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071581_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 UMR - ALL PLANS UMR - ALL PLANS 596.4 70 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071581_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 515.89 60.55 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071581_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071581_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071581_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM HMO ANTHEM HMO 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071581_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 575.95 67.6 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071581_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071581_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071582_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 553.8 65 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071582_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 AETNA AETNA 673.08 79 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071582_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 826.44 97 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071582_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 587.88 69 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071582_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 SIHO - ALL PLANS SIHO - ALL PLANS 766.8 90 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071582_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 664.56 78 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071582_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 UMR - ALL PLANS UMR - ALL PLANS 596.4 70 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071582_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 515.89 60.55 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071582_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071582_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071582_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM HMO ANTHEM HMO 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071582_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 575.95 67.6 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071582_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51071582_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 580.45 65 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 AETNA AETNA 705.47 79 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 866.21 97 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 616.17 69 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 SIHO - ALL PLANS SIHO - ALL PLANS 803.7 90 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 696.54 78 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 UMR - ALL PLANS UMR - ALL PLANS 625.1 70 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 540.71 60.55 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM HMO ANTHEM HMO 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 603.67 67.6 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1 CDM 0310 RC 88374 HCPCS inpatient 893 580.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1{2} CDM 0310 RC 88374 HCPCS inpatient 893 580.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 580.45 65 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1{2} CDM 0310 RC 88374 HCPCS inpatient 893 580.45 AETNA AETNA 705.47 79 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1{2} CDM 0310 RC 88374 HCPCS inpatient 893 580.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 866.21 97 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1{2} CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 616.17 69 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1{2} CDM 0310 RC 88374 HCPCS inpatient 893 580.45 SIHO - ALL PLANS SIHO - ALL PLANS 803.7 90 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1{2} CDM 0310 RC 88374 HCPCS inpatient 893 580.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 696.54 78 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1{2} CDM 0310 RC 88374 HCPCS inpatient 893 580.45 UMR - ALL PLANS UMR - ALL PLANS 625.1 70 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1{2} CDM 0310 RC 88374 HCPCS inpatient 893 580.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 540.71 60.55 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1{2} CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1{2} CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1{2} CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM HMO ANTHEM HMO 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1{2} CDM 0310 RC 88374 HCPCS inpatient 893 580.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 603.67 67.6 999999999 540.71 866.21 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1{2} CDM 0310 RC 88374 HCPCS inpatient 893 580.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 540.71 866.21 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071583_1{2} CDM 0310 RC 88374 HCPCS inpatient 893 580.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 540.71 866.21 "Special stained specimen slides to examine tissue, initial procedure" 51071584_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 230.75 65 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51071584_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 AETNA AETNA 280.45 79 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51071584_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 344.35 97 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51071584_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 244.95 69 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51071584_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 SIHO - ALL PLANS SIHO - ALL PLANS 319.5 90 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51071584_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 276.9 78 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51071584_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UMR - ALL PLANS UMR - ALL PLANS 248.5 70 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51071584_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 214.95 60.55 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51071584_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51071584_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51071584_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM HMO ANTHEM HMO 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51071584_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 239.98 67.6 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51071584_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51071584_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51071585_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 230.75 65 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51071585_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 AETNA AETNA 280.45 79 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51071585_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 344.35 97 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51071585_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 244.95 69 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51071585_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 SIHO - ALL PLANS SIHO - ALL PLANS 319.5 90 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51071585_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 276.9 78 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51071585_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UMR - ALL PLANS UMR - ALL PLANS 248.5 70 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51071585_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 214.95 60.55 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51071585_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51071585_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51071585_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM HMO ANTHEM HMO 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51071585_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 239.98 67.6 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51071585_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51071585_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 214.95 344.35 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071587_1 CDM 0310 RC 88374 HCPCS inpatient 982 638.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 638.3 65 999999999 594.6 952.54 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071587_1 CDM 0310 RC 88374 HCPCS inpatient 982 638.3 AETNA AETNA 775.78 79 999999999 594.6 952.54 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071587_1 CDM 0310 RC 88374 HCPCS inpatient 982 638.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 952.54 97 999999999 594.6 952.54 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071587_1 CDM 0310 RC 88374 HCPCS inpatient 982 638.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 677.58 69 999999999 594.6 952.54 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071587_1 CDM 0310 RC 88374 HCPCS inpatient 982 638.3 SIHO - ALL PLANS SIHO - ALL PLANS 883.8 90 999999999 594.6 952.54 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071587_1 CDM 0310 RC 88374 HCPCS inpatient 982 638.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 765.96 78 999999999 594.6 952.54 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071587_1 CDM 0310 RC 88374 HCPCS inpatient 982 638.3 UMR - ALL PLANS UMR - ALL PLANS 687.4 70 999999999 594.6 952.54 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071587_1 CDM 0310 RC 88374 HCPCS inpatient 982 638.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 594.6 60.55 999999999 594.6 952.54 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071587_1 CDM 0310 RC 88374 HCPCS inpatient 982 638.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 594.6 952.54 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071587_1 CDM 0310 RC 88374 HCPCS inpatient 982 638.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 594.6 952.54 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071587_1 CDM 0310 RC 88374 HCPCS inpatient 982 638.3 ANTHEM HMO ANTHEM HMO 999999999 594.6 952.54 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071587_1 CDM 0310 RC 88374 HCPCS inpatient 982 638.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 663.83 67.6 999999999 594.6 952.54 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071587_1 CDM 0310 RC 88374 HCPCS inpatient 982 638.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 594.6 952.54 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51071587_1 CDM 0310 RC 88374 HCPCS inpatient 982 638.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 594.6 952.54 Interpretation and report of genetic testing 51071588_1 CDM 0311 RC 88291 HCPCS inpatient 317 206.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 206.05 65 999999999 191.94 307.49 percent of total billed charges Interpretation and report of genetic testing 51071588_1 CDM 0311 RC 88291 HCPCS inpatient 317 206.05 AETNA AETNA 250.43 79 999999999 191.94 307.49 percent of total billed charges Interpretation and report of genetic testing 51071588_1 CDM 0311 RC 88291 HCPCS inpatient 317 206.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 307.49 97 999999999 191.94 307.49 percent of total billed charges Interpretation and report of genetic testing 51071588_1 CDM 0311 RC 88291 HCPCS inpatient 317 206.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 218.73 69 999999999 191.94 307.49 percent of total billed charges Interpretation and report of genetic testing 51071588_1 CDM 0311 RC 88291 HCPCS inpatient 317 206.05 SIHO - ALL PLANS SIHO - ALL PLANS 285.3 90 999999999 191.94 307.49 percent of total billed charges Interpretation and report of genetic testing 51071588_1 CDM 0311 RC 88291 HCPCS inpatient 317 206.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 247.26 78 999999999 191.94 307.49 percent of total billed charges Interpretation and report of genetic testing 51071588_1 CDM 0311 RC 88291 HCPCS inpatient 317 206.05 UMR - ALL PLANS UMR - ALL PLANS 221.9 70 999999999 191.94 307.49 percent of total billed charges Interpretation and report of genetic testing 51071588_1 CDM 0311 RC 88291 HCPCS inpatient 317 206.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 191.94 60.55 999999999 191.94 307.49 percent of total billed charges Interpretation and report of genetic testing 51071588_1 CDM 0311 RC 88291 HCPCS inpatient 317 206.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 191.94 307.49 Interpretation and report of genetic testing 51071588_1 CDM 0311 RC 88291 HCPCS inpatient 317 206.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 191.94 307.49 Interpretation and report of genetic testing 51071588_1 CDM 0311 RC 88291 HCPCS inpatient 317 206.05 ANTHEM HMO ANTHEM HMO 999999999 191.94 307.49 Interpretation and report of genetic testing 51071588_1 CDM 0311 RC 88291 HCPCS inpatient 317 206.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 214.29 67.6 999999999 191.94 307.49 percent of total billed charges Interpretation and report of genetic testing 51071588_1 CDM 0311 RC 88291 HCPCS inpatient 317 206.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 191.94 307.49 Interpretation and report of genetic testing 51071588_1 CDM 0311 RC 88291 HCPCS inpatient 317 206.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 191.94 307.49 "Microscopic genetic analysis of tumor, manual" 51071599_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.75 65 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51071599_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 AETNA AETNA 90.85 79 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51071599_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 111.55 97 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51071599_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 79.35 69 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51071599_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 SIHO - ALL PLANS SIHO - ALL PLANS 103.5 90 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51071599_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 89.7 78 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51071599_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UMR - ALL PLANS UMR - ALL PLANS 80.5 70 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51071599_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.63 60.55 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51071599_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51071599_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51071599_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM HMO ANTHEM HMO 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51071599_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.74 67.6 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51071599_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51071599_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.63 111.55 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51071604_1 CDM 0311 RC 88189 HCPCS inpatient 900 585 SELF PAY DISCOUNT SELF PAY DISCOUNT 585 65 999999999 544.95 873 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51071604_1 CDM 0311 RC 88189 HCPCS inpatient 900 585 AETNA AETNA 711 79 999999999 544.95 873 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51071604_1 CDM 0311 RC 88189 HCPCS inpatient 900 585 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 873 97 999999999 544.95 873 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51071604_1 CDM 0311 RC 88189 HCPCS inpatient 900 585 ENCORE - ALL PLANS ENCORE - ALL PLANS 621 69 999999999 544.95 873 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51071604_1 CDM 0311 RC 88189 HCPCS inpatient 900 585 SIHO - ALL PLANS SIHO - ALL PLANS 810 90 999999999 544.95 873 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51071604_1 CDM 0311 RC 88189 HCPCS inpatient 900 585 HUMANA - ALL PLANS HUMANA - ALL PLANS 702 78 999999999 544.95 873 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51071604_1 CDM 0311 RC 88189 HCPCS inpatient 900 585 UMR - ALL PLANS UMR - ALL PLANS 630 70 999999999 544.95 873 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51071604_1 CDM 0311 RC 88189 HCPCS inpatient 900 585 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 544.95 60.55 999999999 544.95 873 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51071604_1 CDM 0311 RC 88189 HCPCS inpatient 900 585 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 544.95 873 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51071604_1 CDM 0311 RC 88189 HCPCS inpatient 900 585 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 544.95 873 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51071604_1 CDM 0311 RC 88189 HCPCS inpatient 900 585 ANTHEM HMO ANTHEM HMO 999999999 544.95 873 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51071604_1 CDM 0311 RC 88189 HCPCS inpatient 900 585 CIGNA - ALL PLANS CIGNA - ALL PLANS 608.4 67.6 999999999 544.95 873 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51071604_1 CDM 0311 RC 88189 HCPCS inpatient 900 585 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 544.95 873 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51071604_1 CDM 0311 RC 88189 HCPCS inpatient 900 585 UHC - ALL PLANS UHC - ALL PLANS 999999999 544.95 873 SOLO HIGH BACK SLING L 51076664_1 CDM 0271 RC inpatient 228 148.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 148.2 65 999999999 138.05 221.16 percent of total billed charges SOLO HIGH BACK SLING L 51076664_1 CDM 0271 RC inpatient 228 148.2 AETNA AETNA 180.12 79 999999999 138.05 221.16 percent of total billed charges SOLO HIGH BACK SLING L 51076664_1 CDM 0271 RC inpatient 228 148.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 221.16 97 999999999 138.05 221.16 percent of total billed charges SOLO HIGH BACK SLING L 51076664_1 CDM 0271 RC inpatient 228 148.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 157.32 69 999999999 138.05 221.16 percent of total billed charges SOLO HIGH BACK SLING L 51076664_1 CDM 0271 RC inpatient 228 148.2 SIHO - ALL PLANS SIHO - ALL PLANS 205.2 90 999999999 138.05 221.16 percent of total billed charges SOLO HIGH BACK SLING L 51076664_1 CDM 0271 RC inpatient 228 148.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 177.84 78 999999999 138.05 221.16 percent of total billed charges SOLO HIGH BACK SLING L 51076664_1 CDM 0271 RC inpatient 228 148.2 UMR - ALL PLANS UMR - ALL PLANS 159.6 70 999999999 138.05 221.16 percent of total billed charges SOLO HIGH BACK SLING L 51076664_1 CDM 0271 RC inpatient 228 148.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 138.05 60.55 999999999 138.05 221.16 percent of total billed charges SOLO HIGH BACK SLING L 51076664_1 CDM 0271 RC inpatient 228 148.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 138.05 221.16 SOLO HIGH BACK SLING L 51076664_1 CDM 0271 RC inpatient 228 148.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 138.05 221.16 SOLO HIGH BACK SLING L 51076664_1 CDM 0271 RC inpatient 228 148.2 ANTHEM HMO ANTHEM HMO 999999999 138.05 221.16 SOLO HIGH BACK SLING L 51076664_1 CDM 0271 RC inpatient 228 148.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 154.13 67.6 999999999 138.05 221.16 percent of total billed charges SOLO HIGH BACK SLING L 51076664_1 CDM 0271 RC inpatient 228 148.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 138.05 221.16 SOLO HIGH BACK SLING L 51076664_1 CDM 0271 RC inpatient 228 148.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 138.05 221.16 SOLO HIGH BACK SLING XL 51076665_1 CDM 0271 RC inpatient 465 302.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 302.25 65 999999999 281.56 451.05 percent of total billed charges SOLO HIGH BACK SLING XL 51076665_1 CDM 0271 RC inpatient 465 302.25 AETNA AETNA 367.35 79 999999999 281.56 451.05 percent of total billed charges SOLO HIGH BACK SLING XL 51076665_1 CDM 0271 RC inpatient 465 302.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 451.05 97 999999999 281.56 451.05 percent of total billed charges SOLO HIGH BACK SLING XL 51076665_1 CDM 0271 RC inpatient 465 302.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 320.85 69 999999999 281.56 451.05 percent of total billed charges SOLO HIGH BACK SLING XL 51076665_1 CDM 0271 RC inpatient 465 302.25 SIHO - ALL PLANS SIHO - ALL PLANS 418.5 90 999999999 281.56 451.05 percent of total billed charges SOLO HIGH BACK SLING XL 51076665_1 CDM 0271 RC inpatient 465 302.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 362.7 78 999999999 281.56 451.05 percent of total billed charges SOLO HIGH BACK SLING XL 51076665_1 CDM 0271 RC inpatient 465 302.25 UMR - ALL PLANS UMR - ALL PLANS 325.5 70 999999999 281.56 451.05 percent of total billed charges SOLO HIGH BACK SLING XL 51076665_1 CDM 0271 RC inpatient 465 302.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 281.56 60.55 999999999 281.56 451.05 percent of total billed charges SOLO HIGH BACK SLING XL 51076665_1 CDM 0271 RC inpatient 465 302.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 281.56 451.05 SOLO HIGH BACK SLING XL 51076665_1 CDM 0271 RC inpatient 465 302.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 281.56 451.05 SOLO HIGH BACK SLING XL 51076665_1 CDM 0271 RC inpatient 465 302.25 ANTHEM HMO ANTHEM HMO 999999999 281.56 451.05 SOLO HIGH BACK SLING XL 51076665_1 CDM 0271 RC inpatient 465 302.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 314.34 67.6 999999999 281.56 451.05 percent of total billed charges SOLO HIGH BACK SLING XL 51076665_1 CDM 0271 RC inpatient 465 302.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 281.56 451.05 SOLO HIGH BACK SLING XL 51076665_1 CDM 0271 RC inpatient 465 302.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 281.56 451.05 Zinc level 51082656_1 CDM 0301 RC 84630 HCPCS inpatient 196 127.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 127.4 65 999999999 118.68 190.12 percent of total billed charges Zinc level 51082656_1 CDM 0301 RC 84630 HCPCS inpatient 196 127.4 AETNA AETNA 154.84 79 999999999 118.68 190.12 percent of total billed charges Zinc level 51082656_1 CDM 0301 RC 84630 HCPCS inpatient 196 127.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 190.12 97 999999999 118.68 190.12 percent of total billed charges Zinc level 51082656_1 CDM 0301 RC 84630 HCPCS inpatient 196 127.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 135.24 69 999999999 118.68 190.12 percent of total billed charges Zinc level 51082656_1 CDM 0301 RC 84630 HCPCS inpatient 196 127.4 SIHO - ALL PLANS SIHO - ALL PLANS 176.4 90 999999999 118.68 190.12 percent of total billed charges Zinc level 51082656_1 CDM 0301 RC 84630 HCPCS inpatient 196 127.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 152.88 78 999999999 118.68 190.12 percent of total billed charges Zinc level 51082656_1 CDM 0301 RC 84630 HCPCS inpatient 196 127.4 UMR - ALL PLANS UMR - ALL PLANS 137.2 70 999999999 118.68 190.12 percent of total billed charges Zinc level 51082656_1 CDM 0301 RC 84630 HCPCS inpatient 196 127.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 118.68 60.55 999999999 118.68 190.12 percent of total billed charges Zinc level 51082656_1 CDM 0301 RC 84630 HCPCS inpatient 196 127.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 118.68 190.12 Zinc level 51082656_1 CDM 0301 RC 84630 HCPCS inpatient 196 127.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 118.68 190.12 Zinc level 51082656_1 CDM 0301 RC 84630 HCPCS inpatient 196 127.4 ANTHEM HMO ANTHEM HMO 999999999 118.68 190.12 Zinc level 51082656_1 CDM 0301 RC 84630 HCPCS inpatient 196 127.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 132.5 67.6 999999999 118.68 190.12 percent of total billed charges Zinc level 51082656_1 CDM 0301 RC 84630 HCPCS inpatient 196 127.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 118.68 190.12 Zinc level 51082656_1 CDM 0301 RC 84630 HCPCS inpatient 196 127.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 118.68 190.12 Detection test by immunoassay technique for other organism 51082704_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.3 65 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 51082704_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 AETNA AETNA 143.78 79 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 51082704_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 176.54 97 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 51082704_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 125.58 69 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 51082704_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 SIHO - ALL PLANS SIHO - ALL PLANS 163.8 90 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 51082704_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.96 78 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 51082704_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 UMR - ALL PLANS UMR - ALL PLANS 127.4 70 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 51082704_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.2 60.55 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 51082704_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.2 176.54 Detection test by immunoassay technique for other organism 51082704_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.2 176.54 Detection test by immunoassay technique for other organism 51082704_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 ANTHEM HMO ANTHEM HMO 999999999 110.2 176.54 Detection test by immunoassay technique for other organism 51082704_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.03 67.6 999999999 110.2 176.54 percent of total billed charges Detection test by immunoassay technique for other organism 51082704_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.2 176.54 Detection test by immunoassay technique for other organism 51082704_1 CDM 0301 RC 87449 HCPCS inpatient 182 118.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.2 176.54 Detection test by immunoassay technique for Aspergillus (fungus) 51082738_1 CDM 0301 RC 87305 HCPCS inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges Detection test by immunoassay technique for Aspergillus (fungus) 51082738_1 CDM 0301 RC 87305 HCPCS inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges Detection test by immunoassay technique for Aspergillus (fungus) 51082738_1 CDM 0301 RC 87305 HCPCS inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges Detection test by immunoassay technique for Aspergillus (fungus) 51082738_1 CDM 0301 RC 87305 HCPCS inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges Detection test by immunoassay technique for Aspergillus (fungus) 51082738_1 CDM 0301 RC 87305 HCPCS inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges Detection test by immunoassay technique for Aspergillus (fungus) 51082738_1 CDM 0301 RC 87305 HCPCS inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges Detection test by immunoassay technique for Aspergillus (fungus) 51082738_1 CDM 0301 RC 87305 HCPCS inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges Detection test by immunoassay technique for Aspergillus (fungus) 51082738_1 CDM 0301 RC 87305 HCPCS inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges Detection test by immunoassay technique for Aspergillus (fungus) 51082738_1 CDM 0301 RC 87305 HCPCS inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 Detection test by immunoassay technique for Aspergillus (fungus) 51082738_1 CDM 0301 RC 87305 HCPCS inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 Detection test by immunoassay technique for Aspergillus (fungus) 51082738_1 CDM 0301 RC 87305 HCPCS inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 Detection test by immunoassay technique for Aspergillus (fungus) 51082738_1 CDM 0301 RC 87305 HCPCS inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges Detection test by immunoassay technique for Aspergillus (fungus) 51082738_1 CDM 0301 RC 87305 HCPCS inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 Detection test by immunoassay technique for Aspergillus (fungus) 51082738_1 CDM 0301 RC 87305 HCPCS inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 Injection of anesthetic agent and/or steroid into other nerve or branch 51084254_1 CDM 0360 RC 64450 HCPCS inpatient 2000 1300 SELF PAY DISCOUNT SELF PAY DISCOUNT 1300 65 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51084254_1 CDM 0360 RC 64450 HCPCS inpatient 2000 1300 AETNA AETNA 1580 79 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51084254_1 CDM 0360 RC 64450 HCPCS inpatient 2000 1300 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1940 97 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51084254_1 CDM 0360 RC 64450 HCPCS inpatient 2000 1300 ENCORE - ALL PLANS ENCORE - ALL PLANS 1380 69 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51084254_1 CDM 0360 RC 64450 HCPCS inpatient 2000 1300 SIHO - ALL PLANS SIHO - ALL PLANS 1800 90 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51084254_1 CDM 0360 RC 64450 HCPCS inpatient 2000 1300 HUMANA - ALL PLANS HUMANA - ALL PLANS 1560 78 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51084254_1 CDM 0360 RC 64450 HCPCS inpatient 2000 1300 UMR - ALL PLANS UMR - ALL PLANS 1400 70 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51084254_1 CDM 0360 RC 64450 HCPCS inpatient 2000 1300 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1211 60.55 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51084254_1 CDM 0360 RC 64450 HCPCS inpatient 2000 1300 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1211 1940 Injection of anesthetic agent and/or steroid into other nerve or branch 51084254_1 CDM 0360 RC 64450 HCPCS inpatient 2000 1300 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1211 1940 Injection of anesthetic agent and/or steroid into other nerve or branch 51084254_1 CDM 0360 RC 64450 HCPCS inpatient 2000 1300 ANTHEM HMO ANTHEM HMO 999999999 1211 1940 Injection of anesthetic agent and/or steroid into other nerve or branch 51084254_1 CDM 0360 RC 64450 HCPCS inpatient 2000 1300 CIGNA - ALL PLANS CIGNA - ALL PLANS 1352 67.6 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51084254_1 CDM 0360 RC 64450 HCPCS inpatient 2000 1300 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1211 1940 Injection of anesthetic agent and/or steroid into other nerve or branch 51084254_1 CDM 0360 RC 64450 HCPCS inpatient 2000 1300 UHC - ALL PLANS UHC - ALL PLANS 999999999 1211 1940 Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 51084255_1 CDM 0360 RC 64405 HCPCS inpatient 2000 1300 SELF PAY DISCOUNT SELF PAY DISCOUNT 1300 65 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 51084255_1 CDM 0360 RC 64405 HCPCS inpatient 2000 1300 AETNA AETNA 1580 79 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 51084255_1 CDM 0360 RC 64405 HCPCS inpatient 2000 1300 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1940 97 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 51084255_1 CDM 0360 RC 64405 HCPCS inpatient 2000 1300 ENCORE - ALL PLANS ENCORE - ALL PLANS 1380 69 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 51084255_1 CDM 0360 RC 64405 HCPCS inpatient 2000 1300 SIHO - ALL PLANS SIHO - ALL PLANS 1800 90 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 51084255_1 CDM 0360 RC 64405 HCPCS inpatient 2000 1300 HUMANA - ALL PLANS HUMANA - ALL PLANS 1560 78 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 51084255_1 CDM 0360 RC 64405 HCPCS inpatient 2000 1300 UMR - ALL PLANS UMR - ALL PLANS 1400 70 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 51084255_1 CDM 0360 RC 64405 HCPCS inpatient 2000 1300 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1211 60.55 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 51084255_1 CDM 0360 RC 64405 HCPCS inpatient 2000 1300 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1211 1940 Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 51084255_1 CDM 0360 RC 64405 HCPCS inpatient 2000 1300 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1211 1940 Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 51084255_1 CDM 0360 RC 64405 HCPCS inpatient 2000 1300 ANTHEM HMO ANTHEM HMO 999999999 1211 1940 Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 51084255_1 CDM 0360 RC 64405 HCPCS inpatient 2000 1300 CIGNA - ALL PLANS CIGNA - ALL PLANS 1352 67.6 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 51084255_1 CDM 0360 RC 64405 HCPCS inpatient 2000 1300 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1211 1940 Injection of anesthetic agent and/or steroid into upper neck and back of head nerve 51084255_1 CDM 0360 RC 64405 HCPCS inpatient 2000 1300 UHC - ALL PLANS UHC - ALL PLANS 999999999 1211 1940 Insertion of spinal neurostimulator generator or receiver 51084256_1 CDM 0360 RC 63685 HCPCS inpatient 86722 56369.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 56369.3 65 999999999 52510.17 84120.34 percent of total billed charges Insertion of spinal neurostimulator generator or receiver 51084256_1 CDM 0360 RC 63685 HCPCS inpatient 86722 56369.3 AETNA AETNA 68510.38 79 999999999 52510.17 84120.34 percent of total billed charges Insertion of spinal neurostimulator generator or receiver 51084256_1 CDM 0360 RC 63685 HCPCS inpatient 86722 56369.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84120.34 97 999999999 52510.17 84120.34 percent of total billed charges Insertion of spinal neurostimulator generator or receiver 51084256_1 CDM 0360 RC 63685 HCPCS inpatient 86722 56369.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 59838.18 69 999999999 52510.17 84120.34 percent of total billed charges Insertion of spinal neurostimulator generator or receiver 51084256_1 CDM 0360 RC 63685 HCPCS inpatient 86722 56369.3 SIHO - ALL PLANS SIHO - ALL PLANS 78049.8 90 999999999 52510.17 84120.34 percent of total billed charges Insertion of spinal neurostimulator generator or receiver 51084256_1 CDM 0360 RC 63685 HCPCS inpatient 86722 56369.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 67643.16 78 999999999 52510.17 84120.34 percent of total billed charges Insertion of spinal neurostimulator generator or receiver 51084256_1 CDM 0360 RC 63685 HCPCS inpatient 86722 56369.3 UMR - ALL PLANS UMR - ALL PLANS 60705.4 70 999999999 52510.17 84120.34 percent of total billed charges Insertion of spinal neurostimulator generator or receiver 51084256_1 CDM 0360 RC 63685 HCPCS inpatient 86722 56369.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52510.17 60.55 999999999 52510.17 84120.34 percent of total billed charges Insertion of spinal neurostimulator generator or receiver 51084256_1 CDM 0360 RC 63685 HCPCS inpatient 86722 56369.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52510.17 84120.34 Insertion of spinal neurostimulator generator or receiver 51084256_1 CDM 0360 RC 63685 HCPCS inpatient 86722 56369.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52510.17 84120.34 Insertion of spinal neurostimulator generator or receiver 51084256_1 CDM 0360 RC 63685 HCPCS inpatient 86722 56369.3 ANTHEM HMO ANTHEM HMO 999999999 52510.17 84120.34 Insertion of spinal neurostimulator generator or receiver 51084256_1 CDM 0360 RC 63685 HCPCS inpatient 86722 56369.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 58624.07 67.6 999999999 52510.17 84120.34 percent of total billed charges Insertion of spinal neurostimulator generator or receiver 51084256_1 CDM 0360 RC 63685 HCPCS inpatient 86722 56369.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52510.17 84120.34 Insertion of spinal neurostimulator generator or receiver 51084256_1 CDM 0360 RC 63685 HCPCS inpatient 86722 56369.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 52510.17 84120.34 Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 51084257_1 CDM 0360 RC 64415 HCPCS inpatient 2591 1684.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1684.15 65 999999999 1568.85 2513.27 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 51084257_1 CDM 0360 RC 64415 HCPCS inpatient 2591 1684.15 AETNA AETNA 2046.89 79 999999999 1568.85 2513.27 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 51084257_1 CDM 0360 RC 64415 HCPCS inpatient 2591 1684.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2513.27 97 999999999 1568.85 2513.27 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 51084257_1 CDM 0360 RC 64415 HCPCS inpatient 2591 1684.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1787.79 69 999999999 1568.85 2513.27 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 51084257_1 CDM 0360 RC 64415 HCPCS inpatient 2591 1684.15 SIHO - ALL PLANS SIHO - ALL PLANS 2331.9 90 999999999 1568.85 2513.27 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 51084257_1 CDM 0360 RC 64415 HCPCS inpatient 2591 1684.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 2020.98 78 999999999 1568.85 2513.27 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 51084257_1 CDM 0360 RC 64415 HCPCS inpatient 2591 1684.15 UMR - ALL PLANS UMR - ALL PLANS 1813.7 70 999999999 1568.85 2513.27 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 51084257_1 CDM 0360 RC 64415 HCPCS inpatient 2591 1684.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1568.85 60.55 999999999 1568.85 2513.27 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 51084257_1 CDM 0360 RC 64415 HCPCS inpatient 2591 1684.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1568.85 2513.27 Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 51084257_1 CDM 0360 RC 64415 HCPCS inpatient 2591 1684.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1568.85 2513.27 Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 51084257_1 CDM 0360 RC 64415 HCPCS inpatient 2591 1684.15 ANTHEM HMO ANTHEM HMO 999999999 1568.85 2513.27 Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 51084257_1 CDM 0360 RC 64415 HCPCS inpatient 2591 1684.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1751.52 67.6 999999999 1568.85 2513.27 percent of total billed charges Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 51084257_1 CDM 0360 RC 64415 HCPCS inpatient 2591 1684.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1568.85 2513.27 Injection of anesthetic agent and/or steroid into arm nerve bundle (brachial plexus) 51084257_1 CDM 0360 RC 64415 HCPCS inpatient 2591 1684.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1568.85 2513.27 Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51084258_1 CDM 0360 RC 64417 HCPCS inpatient 2591 1684.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1684.15 65 999999999 1568.85 2513.27 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51084258_1 CDM 0360 RC 64417 HCPCS inpatient 2591 1684.15 AETNA AETNA 2046.89 79 999999999 1568.85 2513.27 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51084258_1 CDM 0360 RC 64417 HCPCS inpatient 2591 1684.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2513.27 97 999999999 1568.85 2513.27 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51084258_1 CDM 0360 RC 64417 HCPCS inpatient 2591 1684.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1787.79 69 999999999 1568.85 2513.27 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51084258_1 CDM 0360 RC 64417 HCPCS inpatient 2591 1684.15 SIHO - ALL PLANS SIHO - ALL PLANS 2331.9 90 999999999 1568.85 2513.27 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51084258_1 CDM 0360 RC 64417 HCPCS inpatient 2591 1684.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 2020.98 78 999999999 1568.85 2513.27 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51084258_1 CDM 0360 RC 64417 HCPCS inpatient 2591 1684.15 UMR - ALL PLANS UMR - ALL PLANS 1813.7 70 999999999 1568.85 2513.27 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51084258_1 CDM 0360 RC 64417 HCPCS inpatient 2591 1684.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1568.85 60.55 999999999 1568.85 2513.27 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51084258_1 CDM 0360 RC 64417 HCPCS inpatient 2591 1684.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1568.85 2513.27 Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51084258_1 CDM 0360 RC 64417 HCPCS inpatient 2591 1684.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1568.85 2513.27 Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51084258_1 CDM 0360 RC 64417 HCPCS inpatient 2591 1684.15 ANTHEM HMO ANTHEM HMO 999999999 1568.85 2513.27 Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51084258_1 CDM 0360 RC 64417 HCPCS inpatient 2591 1684.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1751.52 67.6 999999999 1568.85 2513.27 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51084258_1 CDM 0360 RC 64417 HCPCS inpatient 2591 1684.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1568.85 2513.27 Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51084258_1 CDM 0360 RC 64417 HCPCS inpatient 2591 1684.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1568.85 2513.27 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 51084259_1 CDM 0360 RC 66421 HCPCS inpatient 2591 1684.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1684.15 65 999999999 1568.85 2513.27 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 51084259_1 CDM 0360 RC 66421 HCPCS inpatient 2591 1684.15 AETNA AETNA 2046.89 79 999999999 1568.85 2513.27 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 51084259_1 CDM 0360 RC 66421 HCPCS inpatient 2591 1684.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2513.27 97 999999999 1568.85 2513.27 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 51084259_1 CDM 0360 RC 66421 HCPCS inpatient 2591 1684.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1787.79 69 999999999 1568.85 2513.27 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 51084259_1 CDM 0360 RC 66421 HCPCS inpatient 2591 1684.15 SIHO - ALL PLANS SIHO - ALL PLANS 2331.9 90 999999999 1568.85 2513.27 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 51084259_1 CDM 0360 RC 66421 HCPCS inpatient 2591 1684.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 2020.98 78 999999999 1568.85 2513.27 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 51084259_1 CDM 0360 RC 66421 HCPCS inpatient 2591 1684.15 UMR - ALL PLANS UMR - ALL PLANS 1813.7 70 999999999 1568.85 2513.27 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 51084259_1 CDM 0360 RC 66421 HCPCS inpatient 2591 1684.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1568.85 60.55 999999999 1568.85 2513.27 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 51084259_1 CDM 0360 RC 66421 HCPCS inpatient 2591 1684.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1568.85 2513.27 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 51084259_1 CDM 0360 RC 66421 HCPCS inpatient 2591 1684.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1568.85 2513.27 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 51084259_1 CDM 0360 RC 66421 HCPCS inpatient 2591 1684.15 ANTHEM HMO ANTHEM HMO 999999999 1568.85 2513.27 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 51084259_1 CDM 0360 RC 66421 HCPCS inpatient 2591 1684.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1751.52 67.6 999999999 1568.85 2513.27 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 51084259_1 CDM 0360 RC 66421 HCPCS inpatient 2591 1684.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1568.85 2513.27 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 51084259_1 CDM 0360 RC 66421 HCPCS inpatient 2591 1684.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1568.85 2513.27 Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 51084260_1 CDM 0360 RC 64425 HCPCS inpatient 2000 1300 SELF PAY DISCOUNT SELF PAY DISCOUNT 1300 65 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 51084260_1 CDM 0360 RC 64425 HCPCS inpatient 2000 1300 AETNA AETNA 1580 79 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 51084260_1 CDM 0360 RC 64425 HCPCS inpatient 2000 1300 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1940 97 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 51084260_1 CDM 0360 RC 64425 HCPCS inpatient 2000 1300 ENCORE - ALL PLANS ENCORE - ALL PLANS 1380 69 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 51084260_1 CDM 0360 RC 64425 HCPCS inpatient 2000 1300 SIHO - ALL PLANS SIHO - ALL PLANS 1800 90 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 51084260_1 CDM 0360 RC 64425 HCPCS inpatient 2000 1300 HUMANA - ALL PLANS HUMANA - ALL PLANS 1560 78 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 51084260_1 CDM 0360 RC 64425 HCPCS inpatient 2000 1300 UMR - ALL PLANS UMR - ALL PLANS 1400 70 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 51084260_1 CDM 0360 RC 64425 HCPCS inpatient 2000 1300 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1211 60.55 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 51084260_1 CDM 0360 RC 64425 HCPCS inpatient 2000 1300 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1211 1940 Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 51084260_1 CDM 0360 RC 64425 HCPCS inpatient 2000 1300 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1211 1940 Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 51084260_1 CDM 0360 RC 64425 HCPCS inpatient 2000 1300 ANTHEM HMO ANTHEM HMO 999999999 1211 1940 Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 51084260_1 CDM 0360 RC 64425 HCPCS inpatient 2000 1300 CIGNA - ALL PLANS CIGNA - ALL PLANS 1352 67.6 999999999 1211 1940 percent of total billed charges Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 51084260_1 CDM 0360 RC 64425 HCPCS inpatient 2000 1300 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1211 1940 Injection of anesthetic agent and/or steroid into lower abdomen and groin nerve 51084260_1 CDM 0360 RC 64425 HCPCS inpatient 2000 1300 UHC - ALL PLANS UHC - ALL PLANS 999999999 1211 1940 Injection of anesthetic agent and/or steroid into other nerve or branch 51084261_1 CDM 0360 RC 64450 HCPCS inpatient 1870 1215.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1215.5 65 999999999 1132.29 1813.9 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51084261_1 CDM 0360 RC 64450 HCPCS inpatient 1870 1215.5 AETNA AETNA 1477.3 79 999999999 1132.29 1813.9 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51084261_1 CDM 0360 RC 64450 HCPCS inpatient 1870 1215.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1813.9 97 999999999 1132.29 1813.9 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51084261_1 CDM 0360 RC 64450 HCPCS inpatient 1870 1215.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1290.3 69 999999999 1132.29 1813.9 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51084261_1 CDM 0360 RC 64450 HCPCS inpatient 1870 1215.5 SIHO - ALL PLANS SIHO - ALL PLANS 1683 90 999999999 1132.29 1813.9 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51084261_1 CDM 0360 RC 64450 HCPCS inpatient 1870 1215.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1458.6 78 999999999 1132.29 1813.9 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51084261_1 CDM 0360 RC 64450 HCPCS inpatient 1870 1215.5 UMR - ALL PLANS UMR - ALL PLANS 1309 70 999999999 1132.29 1813.9 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51084261_1 CDM 0360 RC 64450 HCPCS inpatient 1870 1215.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1132.29 60.55 999999999 1132.29 1813.9 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51084261_1 CDM 0360 RC 64450 HCPCS inpatient 1870 1215.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1132.29 1813.9 Injection of anesthetic agent and/or steroid into other nerve or branch 51084261_1 CDM 0360 RC 64450 HCPCS inpatient 1870 1215.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1132.29 1813.9 Injection of anesthetic agent and/or steroid into other nerve or branch 51084261_1 CDM 0360 RC 64450 HCPCS inpatient 1870 1215.5 ANTHEM HMO ANTHEM HMO 999999999 1132.29 1813.9 Injection of anesthetic agent and/or steroid into other nerve or branch 51084261_1 CDM 0360 RC 64450 HCPCS inpatient 1870 1215.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1264.12 67.6 999999999 1132.29 1813.9 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51084261_1 CDM 0360 RC 64450 HCPCS inpatient 1870 1215.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1132.29 1813.9 Injection of anesthetic agent and/or steroid into other nerve or branch 51084261_1 CDM 0360 RC 64450 HCPCS inpatient 1870 1215.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1132.29 1813.9 Other procedure on nervous system 51084262_1 CDM 0360 RC 64999 HCPCS inpatient 823 534.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 534.95 65 999999999 498.33 798.31 percent of total billed charges Other procedure on nervous system 51084262_1 CDM 0360 RC 64999 HCPCS inpatient 823 534.95 AETNA AETNA 650.17 79 999999999 498.33 798.31 percent of total billed charges Other procedure on nervous system 51084262_1 CDM 0360 RC 64999 HCPCS inpatient 823 534.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 798.31 97 999999999 498.33 798.31 percent of total billed charges Other procedure on nervous system 51084262_1 CDM 0360 RC 64999 HCPCS inpatient 823 534.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 567.87 69 999999999 498.33 798.31 percent of total billed charges Other procedure on nervous system 51084262_1 CDM 0360 RC 64999 HCPCS inpatient 823 534.95 SIHO - ALL PLANS SIHO - ALL PLANS 740.7 90 999999999 498.33 798.31 percent of total billed charges Other procedure on nervous system 51084262_1 CDM 0360 RC 64999 HCPCS inpatient 823 534.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 641.94 78 999999999 498.33 798.31 percent of total billed charges Other procedure on nervous system 51084262_1 CDM 0360 RC 64999 HCPCS inpatient 823 534.95 UMR - ALL PLANS UMR - ALL PLANS 576.1 70 999999999 498.33 798.31 percent of total billed charges Other procedure on nervous system 51084262_1 CDM 0360 RC 64999 HCPCS inpatient 823 534.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 498.33 60.55 999999999 498.33 798.31 percent of total billed charges Other procedure on nervous system 51084262_1 CDM 0360 RC 64999 HCPCS inpatient 823 534.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 498.33 798.31 Other procedure on nervous system 51084262_1 CDM 0360 RC 64999 HCPCS inpatient 823 534.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 498.33 798.31 Other procedure on nervous system 51084262_1 CDM 0360 RC 64999 HCPCS inpatient 823 534.95 ANTHEM HMO ANTHEM HMO 999999999 498.33 798.31 Other procedure on nervous system 51084262_1 CDM 0360 RC 64999 HCPCS inpatient 823 534.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 556.35 67.6 999999999 498.33 798.31 percent of total billed charges Other procedure on nervous system 51084262_1 CDM 0360 RC 64999 HCPCS inpatient 823 534.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 498.33 798.31 Other procedure on nervous system 51084262_1 CDM 0360 RC 64999 HCPCS inpatient 823 534.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 498.33 798.31 Injection of agent to destroy rib nerve 51084263_1 CDM 0360 RC 64620 HCPCS inpatient 2591 1684.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1684.15 65 999999999 1568.85 2513.27 percent of total billed charges Injection of agent to destroy rib nerve 51084263_1 CDM 0360 RC 64620 HCPCS inpatient 2591 1684.15 AETNA AETNA 2046.89 79 999999999 1568.85 2513.27 percent of total billed charges Injection of agent to destroy rib nerve 51084263_1 CDM 0360 RC 64620 HCPCS inpatient 2591 1684.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2513.27 97 999999999 1568.85 2513.27 percent of total billed charges Injection of agent to destroy rib nerve 51084263_1 CDM 0360 RC 64620 HCPCS inpatient 2591 1684.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1787.79 69 999999999 1568.85 2513.27 percent of total billed charges Injection of agent to destroy rib nerve 51084263_1 CDM 0360 RC 64620 HCPCS inpatient 2591 1684.15 SIHO - ALL PLANS SIHO - ALL PLANS 2331.9 90 999999999 1568.85 2513.27 percent of total billed charges Injection of agent to destroy rib nerve 51084263_1 CDM 0360 RC 64620 HCPCS inpatient 2591 1684.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 2020.98 78 999999999 1568.85 2513.27 percent of total billed charges Injection of agent to destroy rib nerve 51084263_1 CDM 0360 RC 64620 HCPCS inpatient 2591 1684.15 UMR - ALL PLANS UMR - ALL PLANS 1813.7 70 999999999 1568.85 2513.27 percent of total billed charges Injection of agent to destroy rib nerve 51084263_1 CDM 0360 RC 64620 HCPCS inpatient 2591 1684.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1568.85 60.55 999999999 1568.85 2513.27 percent of total billed charges Injection of agent to destroy rib nerve 51084263_1 CDM 0360 RC 64620 HCPCS inpatient 2591 1684.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1568.85 2513.27 Injection of agent to destroy rib nerve 51084263_1 CDM 0360 RC 64620 HCPCS inpatient 2591 1684.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1568.85 2513.27 Injection of agent to destroy rib nerve 51084263_1 CDM 0360 RC 64620 HCPCS inpatient 2591 1684.15 ANTHEM HMO ANTHEM HMO 999999999 1568.85 2513.27 Injection of agent to destroy rib nerve 51084263_1 CDM 0360 RC 64620 HCPCS inpatient 2591 1684.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1751.52 67.6 999999999 1568.85 2513.27 percent of total billed charges Injection of agent to destroy rib nerve 51084263_1 CDM 0360 RC 64620 HCPCS inpatient 2591 1684.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1568.85 2513.27 Injection of agent to destroy rib nerve 51084263_1 CDM 0360 RC 64620 HCPCS inpatient 2591 1684.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1568.85 2513.27 Placement of stabilizing device to lower spine level 51084264_1 CDM 0360 RC 22869 HCPCS inpatient 38792 25214.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 25214.8 65 999999999 23488.56 37628.24 percent of total billed charges Placement of stabilizing device to lower spine level 51084264_1 CDM 0360 RC 22869 HCPCS inpatient 38792 25214.8 AETNA AETNA 30645.68 79 999999999 23488.56 37628.24 percent of total billed charges Placement of stabilizing device to lower spine level 51084264_1 CDM 0360 RC 22869 HCPCS inpatient 38792 25214.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37628.24 97 999999999 23488.56 37628.24 percent of total billed charges Placement of stabilizing device to lower spine level 51084264_1 CDM 0360 RC 22869 HCPCS inpatient 38792 25214.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 26766.48 69 999999999 23488.56 37628.24 percent of total billed charges Placement of stabilizing device to lower spine level 51084264_1 CDM 0360 RC 22869 HCPCS inpatient 38792 25214.8 SIHO - ALL PLANS SIHO - ALL PLANS 34912.8 90 999999999 23488.56 37628.24 percent of total billed charges Placement of stabilizing device to lower spine level 51084264_1 CDM 0360 RC 22869 HCPCS inpatient 38792 25214.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 30257.76 78 999999999 23488.56 37628.24 percent of total billed charges Placement of stabilizing device to lower spine level 51084264_1 CDM 0360 RC 22869 HCPCS inpatient 38792 25214.8 UMR - ALL PLANS UMR - ALL PLANS 27154.4 70 999999999 23488.56 37628.24 percent of total billed charges Placement of stabilizing device to lower spine level 51084264_1 CDM 0360 RC 22869 HCPCS inpatient 38792 25214.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23488.56 60.55 999999999 23488.56 37628.24 percent of total billed charges Placement of stabilizing device to lower spine level 51084264_1 CDM 0360 RC 22869 HCPCS inpatient 38792 25214.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 23488.56 37628.24 Placement of stabilizing device to lower spine level 51084264_1 CDM 0360 RC 22869 HCPCS inpatient 38792 25214.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 23488.56 37628.24 Placement of stabilizing device to lower spine level 51084264_1 CDM 0360 RC 22869 HCPCS inpatient 38792 25214.8 ANTHEM HMO ANTHEM HMO 999999999 23488.56 37628.24 Placement of stabilizing device to lower spine level 51084264_1 CDM 0360 RC 22869 HCPCS inpatient 38792 25214.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 26223.39 67.6 999999999 23488.56 37628.24 percent of total billed charges Placement of stabilizing device to lower spine level 51084264_1 CDM 0360 RC 22869 HCPCS inpatient 38792 25214.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 23488.56 37628.24 Placement of stabilizing device to lower spine level 51084264_1 CDM 0360 RC 22869 HCPCS inpatient 38792 25214.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 23488.56 37628.24 Limited ultrasound scan of joint or other extremity structure except blood vessels 51084365_1 CDM 0921 RC 76882 HCPCS inpatient 360 234 SELF PAY DISCOUNT SELF PAY DISCOUNT 234 65 999999999 217.98 349.2 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 51084365_1 CDM 0921 RC 76882 HCPCS inpatient 360 234 AETNA AETNA 284.4 79 999999999 217.98 349.2 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 51084365_1 CDM 0921 RC 76882 HCPCS inpatient 360 234 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 349.2 97 999999999 217.98 349.2 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 51084365_1 CDM 0921 RC 76882 HCPCS inpatient 360 234 ENCORE - ALL PLANS ENCORE - ALL PLANS 248.4 69 999999999 217.98 349.2 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 51084365_1 CDM 0921 RC 76882 HCPCS inpatient 360 234 SIHO - ALL PLANS SIHO - ALL PLANS 324 90 999999999 217.98 349.2 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 51084365_1 CDM 0921 RC 76882 HCPCS inpatient 360 234 HUMANA - ALL PLANS HUMANA - ALL PLANS 280.8 78 999999999 217.98 349.2 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 51084365_1 CDM 0921 RC 76882 HCPCS inpatient 360 234 UMR - ALL PLANS UMR - ALL PLANS 252 70 999999999 217.98 349.2 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 51084365_1 CDM 0921 RC 76882 HCPCS inpatient 360 234 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 217.98 60.55 999999999 217.98 349.2 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 51084365_1 CDM 0921 RC 76882 HCPCS inpatient 360 234 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 217.98 349.2 Limited ultrasound scan of joint or other extremity structure except blood vessels 51084365_1 CDM 0921 RC 76882 HCPCS inpatient 360 234 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 217.98 349.2 Limited ultrasound scan of joint or other extremity structure except blood vessels 51084365_1 CDM 0921 RC 76882 HCPCS inpatient 360 234 ANTHEM HMO ANTHEM HMO 999999999 217.98 349.2 Limited ultrasound scan of joint or other extremity structure except blood vessels 51084365_1 CDM 0921 RC 76882 HCPCS inpatient 360 234 CIGNA - ALL PLANS CIGNA - ALL PLANS 243.36 67.6 999999999 217.98 349.2 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 51084365_1 CDM 0921 RC 76882 HCPCS inpatient 360 234 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 217.98 349.2 Limited ultrasound scan of joint or other extremity structure except blood vessels 51084365_1 CDM 0921 RC 76882 HCPCS inpatient 360 234 UHC - ALL PLANS UHC - ALL PLANS 999999999 217.98 349.2 FLUENT WASTE BAG 51086352_1 CDM 0271 RC inpatient 315 204.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 204.75 65 999999999 190.73 305.55 percent of total billed charges FLUENT WASTE BAG 51086352_1 CDM 0271 RC inpatient 315 204.75 AETNA AETNA 248.85 79 999999999 190.73 305.55 percent of total billed charges FLUENT WASTE BAG 51086352_1 CDM 0271 RC inpatient 315 204.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 305.55 97 999999999 190.73 305.55 percent of total billed charges FLUENT WASTE BAG 51086352_1 CDM 0271 RC inpatient 315 204.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 217.35 69 999999999 190.73 305.55 percent of total billed charges FLUENT WASTE BAG 51086352_1 CDM 0271 RC inpatient 315 204.75 SIHO - ALL PLANS SIHO - ALL PLANS 283.5 90 999999999 190.73 305.55 percent of total billed charges FLUENT WASTE BAG 51086352_1 CDM 0271 RC inpatient 315 204.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 245.7 78 999999999 190.73 305.55 percent of total billed charges FLUENT WASTE BAG 51086352_1 CDM 0271 RC inpatient 315 204.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 190.73 60.55 999999999 190.73 305.55 percent of total billed charges FLUENT WASTE BAG 51086352_1 CDM 0271 RC inpatient 315 204.75 UMR - ALL PLANS UMR - ALL PLANS 220.5 70 999999999 190.73 305.55 percent of total billed charges FLUENT WASTE BAG 51086352_1 CDM 0271 RC inpatient 315 204.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 190.73 305.55 FLUENT WASTE BAG 51086352_1 CDM 0271 RC inpatient 315 204.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 190.73 305.55 FLUENT WASTE BAG 51086352_1 CDM 0271 RC inpatient 315 204.75 ANTHEM HMO ANTHEM HMO 999999999 190.73 305.55 FLUENT WASTE BAG 51086352_1 CDM 0271 RC inpatient 315 204.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 212.94 67.6 999999999 190.73 305.55 percent of total billed charges FLUENT WASTE BAG 51086352_1 CDM 0271 RC inpatient 315 204.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 190.73 305.55 FLUENT WASTE BAG 51086352_1 CDM 0271 RC inpatient 315 204.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 190.73 305.55 FLUENT TISSUE TRAP 51086353_1 CDM 0271 RC inpatient 53 34.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.45 65 999999999 32.09 51.41 percent of total billed charges FLUENT TISSUE TRAP 51086353_1 CDM 0271 RC inpatient 53 34.45 AETNA AETNA 41.87 79 999999999 32.09 51.41 percent of total billed charges FLUENT TISSUE TRAP 51086353_1 CDM 0271 RC inpatient 53 34.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51.41 97 999999999 32.09 51.41 percent of total billed charges FLUENT TISSUE TRAP 51086353_1 CDM 0271 RC inpatient 53 34.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.57 69 999999999 32.09 51.41 percent of total billed charges FLUENT TISSUE TRAP 51086353_1 CDM 0271 RC inpatient 53 34.45 SIHO - ALL PLANS SIHO - ALL PLANS 47.7 90 999999999 32.09 51.41 percent of total billed charges FLUENT TISSUE TRAP 51086353_1 CDM 0271 RC inpatient 53 34.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 41.34 78 999999999 32.09 51.41 percent of total billed charges FLUENT TISSUE TRAP 51086353_1 CDM 0271 RC inpatient 53 34.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32.09 60.55 999999999 32.09 51.41 percent of total billed charges FLUENT TISSUE TRAP 51086353_1 CDM 0271 RC inpatient 53 34.45 UMR - ALL PLANS UMR - ALL PLANS 37.1 70 999999999 32.09 51.41 percent of total billed charges FLUENT TISSUE TRAP 51086353_1 CDM 0271 RC inpatient 53 34.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 32.09 51.41 FLUENT TISSUE TRAP 51086353_1 CDM 0271 RC inpatient 53 34.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 32.09 51.41 FLUENT TISSUE TRAP 51086353_1 CDM 0271 RC inpatient 53 34.45 ANTHEM HMO ANTHEM HMO 999999999 32.09 51.41 FLUENT TISSUE TRAP 51086353_1 CDM 0271 RC inpatient 53 34.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.83 67.6 999999999 32.09 51.41 percent of total billed charges FLUENT TISSUE TRAP 51086353_1 CDM 0271 RC inpatient 53 34.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 32.09 51.41 FLUENT TISSUE TRAP 51086353_1 CDM 0271 RC inpatient 53 34.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 32.09 51.41 FLUENT PROCEDURE KIT 51086374_1 CDM 0272 RC inpatient 1182 768.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 768.3 65 999999999 715.7 1146.54 percent of total billed charges FLUENT PROCEDURE KIT 51086374_1 CDM 0272 RC inpatient 1182 768.3 AETNA AETNA 933.78 79 999999999 715.7 1146.54 percent of total billed charges FLUENT PROCEDURE KIT 51086374_1 CDM 0272 RC inpatient 1182 768.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1146.54 97 999999999 715.7 1146.54 percent of total billed charges FLUENT PROCEDURE KIT 51086374_1 CDM 0272 RC inpatient 1182 768.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 815.58 69 999999999 715.7 1146.54 percent of total billed charges FLUENT PROCEDURE KIT 51086374_1 CDM 0272 RC inpatient 1182 768.3 SIHO - ALL PLANS SIHO - ALL PLANS 1063.8 90 999999999 715.7 1146.54 percent of total billed charges FLUENT PROCEDURE KIT 51086374_1 CDM 0272 RC inpatient 1182 768.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 921.96 78 999999999 715.7 1146.54 percent of total billed charges FLUENT PROCEDURE KIT 51086374_1 CDM 0272 RC inpatient 1182 768.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 715.7 60.55 999999999 715.7 1146.54 percent of total billed charges FLUENT PROCEDURE KIT 51086374_1 CDM 0272 RC inpatient 1182 768.3 UMR - ALL PLANS UMR - ALL PLANS 827.4 70 999999999 715.7 1146.54 percent of total billed charges FLUENT PROCEDURE KIT 51086374_1 CDM 0272 RC inpatient 1182 768.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 715.7 1146.54 FLUENT PROCEDURE KIT 51086374_1 CDM 0272 RC inpatient 1182 768.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 715.7 1146.54 FLUENT PROCEDURE KIT 51086374_1 CDM 0272 RC inpatient 1182 768.3 ANTHEM HMO ANTHEM HMO 999999999 715.7 1146.54 FLUENT PROCEDURE KIT 51086374_1 CDM 0272 RC inpatient 1182 768.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 799.03 67.6 999999999 715.7 1146.54 percent of total billed charges FLUENT PROCEDURE KIT 51086374_1 CDM 0272 RC inpatient 1182 768.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 715.7 1146.54 FLUENT PROCEDURE KIT 51086374_1 CDM 0272 RC inpatient 1182 768.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 715.7 1146.54 MYOSURE XL - 50-603LX 51086375_1 CDM 0272 RC inpatient 3963 2575.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 2575.95 65 999999999 2399.6 3844.11 percent of total billed charges MYOSURE XL - 50-603LX 51086375_1 CDM 0272 RC inpatient 3963 2575.95 AETNA AETNA 3130.77 79 999999999 2399.6 3844.11 percent of total billed charges MYOSURE XL - 50-603LX 51086375_1 CDM 0272 RC inpatient 3963 2575.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3844.11 97 999999999 2399.6 3844.11 percent of total billed charges MYOSURE XL - 50-603LX 51086375_1 CDM 0272 RC inpatient 3963 2575.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 2734.47 69 999999999 2399.6 3844.11 percent of total billed charges MYOSURE XL - 50-603LX 51086375_1 CDM 0272 RC inpatient 3963 2575.95 SIHO - ALL PLANS SIHO - ALL PLANS 3566.7 90 999999999 2399.6 3844.11 percent of total billed charges MYOSURE XL - 50-603LX 51086375_1 CDM 0272 RC inpatient 3963 2575.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 3091.14 78 999999999 2399.6 3844.11 percent of total billed charges MYOSURE XL - 50-603LX 51086375_1 CDM 0272 RC inpatient 3963 2575.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2399.6 60.55 999999999 2399.6 3844.11 percent of total billed charges MYOSURE XL - 50-603LX 51086375_1 CDM 0272 RC inpatient 3963 2575.95 UMR - ALL PLANS UMR - ALL PLANS 2774.1 70 999999999 2399.6 3844.11 percent of total billed charges MYOSURE XL - 50-603LX 51086375_1 CDM 0272 RC inpatient 3963 2575.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2399.6 3844.11 MYOSURE XL - 50-603LX 51086375_1 CDM 0272 RC inpatient 3963 2575.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2399.6 3844.11 MYOSURE XL - 50-603LX 51086375_1 CDM 0272 RC inpatient 3963 2575.95 ANTHEM HMO ANTHEM HMO 999999999 2399.6 3844.11 MYOSURE XL - 50-603LX 51086375_1 CDM 0272 RC inpatient 3963 2575.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 2678.99 67.6 999999999 2399.6 3844.11 percent of total billed charges MYOSURE XL - 50-603LX 51086375_1 CDM 0272 RC inpatient 3963 2575.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2399.6 3844.11 MYOSURE XL - 50-603LX 51086375_1 CDM 0272 RC inpatient 3963 2575.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 2399.6 3844.11 Magnesium level 51087589_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges Magnesium level 51087589_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges Magnesium level 51087589_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges Magnesium level 51087589_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges Magnesium level 51087589_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges Magnesium level 51087589_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges Magnesium level 51087589_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges Magnesium level 51087589_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges Magnesium level 51087589_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 Magnesium level 51087589_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 Magnesium level 51087589_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 Magnesium level 51087589_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges Magnesium level 51087589_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 Magnesium level 51087589_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 Amylase (enzyme) level 51092187_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 51092187_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 51092187_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 51092187_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 51092187_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 51092187_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 51092187_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 51092187_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 51092187_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 Amylase (enzyme) level 51092187_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 Amylase (enzyme) level 51092187_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 Amylase (enzyme) level 51092187_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 51092187_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 Amylase (enzyme) level 51092187_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 Uric acid level 51092213_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges Uric acid level 51092213_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges Uric acid level 51092213_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges Uric acid level 51092213_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges Uric acid level 51092213_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges Uric acid level 51092213_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges Uric acid level 51092213_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges Uric acid level 51092213_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges Uric acid level 51092213_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 Uric acid level 51092213_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 Uric acid level 51092213_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 Uric acid level 51092213_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges Uric acid level 51092213_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 Uric acid level 51092213_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Glucose (sugar) level on body fluid 51092233_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 51092233_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 51092233_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 51092233_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 51092233_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 51092233_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 51092233_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 51092233_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 51092233_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 Glucose (sugar) level on body fluid 51092233_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 Glucose (sugar) level on body fluid 51092233_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 Glucose (sugar) level on body fluid 51092233_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 51092233_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 Glucose (sugar) level on body fluid 51092233_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 Test for detecting nucleic acid of organism causing infection of central nervous system 51092347_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 406.9 65 999999999 379.04 607.22 percent of total billed charges Test for detecting nucleic acid of organism causing infection of central nervous system 51092347_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 AETNA AETNA 494.54 79 999999999 379.04 607.22 percent of total billed charges Test for detecting nucleic acid of organism causing infection of central nervous system 51092347_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 607.22 97 999999999 379.04 607.22 percent of total billed charges Test for detecting nucleic acid of organism causing infection of central nervous system 51092347_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 431.94 69 999999999 379.04 607.22 percent of total billed charges Test for detecting nucleic acid of organism causing infection of central nervous system 51092347_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 SIHO - ALL PLANS SIHO - ALL PLANS 563.4 90 999999999 379.04 607.22 percent of total billed charges Test for detecting nucleic acid of organism causing infection of central nervous system 51092347_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 488.28 78 999999999 379.04 607.22 percent of total billed charges Test for detecting nucleic acid of organism causing infection of central nervous system 51092347_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 379.04 60.55 999999999 379.04 607.22 percent of total billed charges Test for detecting nucleic acid of organism causing infection of central nervous system 51092347_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 UMR - ALL PLANS UMR - ALL PLANS 438.2 70 999999999 379.04 607.22 percent of total billed charges Test for detecting nucleic acid of organism causing infection of central nervous system 51092347_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 379.04 607.22 Test for detecting nucleic acid of organism causing infection of central nervous system 51092347_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 379.04 607.22 Test for detecting nucleic acid of organism causing infection of central nervous system 51092347_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 ANTHEM HMO ANTHEM HMO 999999999 379.04 607.22 Test for detecting nucleic acid of organism causing infection of central nervous system 51092347_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 423.18 67.6 999999999 379.04 607.22 percent of total billed charges Test for detecting nucleic acid of organism causing infection of central nervous system 51092347_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 379.04 607.22 Test for detecting nucleic acid of organism causing infection of central nervous system 51092347_1 CDM 0300 RC 87483 HCPCS inpatient 626 406.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 379.04 607.22 Urine phosphate level 51092580_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.4 65 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 51092580_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 AETNA AETNA 123.24 79 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 51092580_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 151.32 97 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 51092580_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.64 69 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 51092580_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 SIHO - ALL PLANS SIHO - ALL PLANS 140.4 90 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 51092580_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.68 78 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 51092580_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.46 60.55 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 51092580_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 UMR - ALL PLANS UMR - ALL PLANS 109.2 70 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 51092580_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.46 151.32 Urine phosphate level 51092580_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.46 151.32 Urine phosphate level 51092580_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 ANTHEM HMO ANTHEM HMO 999999999 94.46 151.32 Urine phosphate level 51092580_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.46 67.6 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 51092580_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.46 151.32 Urine phosphate level 51092580_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.46 151.32 Urine calcium level 51093093_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges Urine calcium level 51093093_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges Urine calcium level 51093093_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges Urine calcium level 51093093_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges Urine calcium level 51093093_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges Urine calcium level 51093093_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges Urine calcium level 51093093_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges Urine calcium level 51093093_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges Urine calcium level 51093093_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 Urine calcium level 51093093_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 Urine calcium level 51093093_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 Urine calcium level 51093093_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges Urine calcium level 51093093_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 Urine calcium level 51093093_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 Creatinine level to test for kidney function or muscle injury 51097001_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 51097001_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 51097001_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 51097001_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 51097001_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 51097001_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 51097001_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 51097001_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 51097001_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 Creatinine level to test for kidney function or muscle injury 51097001_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 Creatinine level to test for kidney function or muscle injury 51097001_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 Creatinine level to test for kidney function or muscle injury 51097001_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges Creatinine level to test for kidney function or muscle injury 51097001_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 Creatinine level to test for kidney function or muscle injury 51097001_1 CDM 0301 RC 82570 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 Molecular pathology procedure 51099609_1 CDM 0302 RC 81479 HCPCS inpatient 525 341.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 341.25 65 999999999 317.89 509.25 percent of total billed charges Molecular pathology procedure 51099609_1 CDM 0302 RC 81479 HCPCS inpatient 525 341.25 AETNA AETNA 414.75 79 999999999 317.89 509.25 percent of total billed charges Molecular pathology procedure 51099609_1 CDM 0302 RC 81479 HCPCS inpatient 525 341.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 509.25 97 999999999 317.89 509.25 percent of total billed charges Molecular pathology procedure 51099609_1 CDM 0302 RC 81479 HCPCS inpatient 525 341.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 362.25 69 999999999 317.89 509.25 percent of total billed charges Molecular pathology procedure 51099609_1 CDM 0302 RC 81479 HCPCS inpatient 525 341.25 SIHO - ALL PLANS SIHO - ALL PLANS 472.5 90 999999999 317.89 509.25 percent of total billed charges Molecular pathology procedure 51099609_1 CDM 0302 RC 81479 HCPCS inpatient 525 341.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 409.5 78 999999999 317.89 509.25 percent of total billed charges Molecular pathology procedure 51099609_1 CDM 0302 RC 81479 HCPCS inpatient 525 341.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 317.89 60.55 999999999 317.89 509.25 percent of total billed charges Molecular pathology procedure 51099609_1 CDM 0302 RC 81479 HCPCS inpatient 525 341.25 UMR - ALL PLANS UMR - ALL PLANS 367.5 70 999999999 317.89 509.25 percent of total billed charges Molecular pathology procedure 51099609_1 CDM 0302 RC 81479 HCPCS inpatient 525 341.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 317.89 509.25 Molecular pathology procedure 51099609_1 CDM 0302 RC 81479 HCPCS inpatient 525 341.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 317.89 509.25 Molecular pathology procedure 51099609_1 CDM 0302 RC 81479 HCPCS inpatient 525 341.25 ANTHEM HMO ANTHEM HMO 999999999 317.89 509.25 Molecular pathology procedure 51099609_1 CDM 0302 RC 81479 HCPCS inpatient 525 341.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 354.9 67.6 999999999 317.89 509.25 percent of total billed charges Molecular pathology procedure 51099609_1 CDM 0302 RC 81479 HCPCS inpatient 525 341.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 317.89 509.25 Molecular pathology procedure 51099609_1 CDM 0302 RC 81479 HCPCS inpatient 525 341.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 317.89 509.25 Blood typing for Rh (D) antigen 51099622_1 CDM 0302 RC 86901 HCPCS inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges Blood typing for Rh (D) antigen 51099622_1 CDM 0302 RC 86901 HCPCS inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges Blood typing for Rh (D) antigen 51099622_1 CDM 0302 RC 86901 HCPCS inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges Blood typing for Rh (D) antigen 51099622_1 CDM 0302 RC 86901 HCPCS inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges Blood typing for Rh (D) antigen 51099622_1 CDM 0302 RC 86901 HCPCS inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges Blood typing for Rh (D) antigen 51099622_1 CDM 0302 RC 86901 HCPCS inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges Blood typing for Rh (D) antigen 51099622_1 CDM 0302 RC 86901 HCPCS inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges Blood typing for Rh (D) antigen 51099622_1 CDM 0302 RC 86901 HCPCS inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges Blood typing for Rh (D) antigen 51099622_1 CDM 0302 RC 86901 HCPCS inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 Blood typing for Rh (D) antigen 51099622_1 CDM 0302 RC 86901 HCPCS inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 Blood typing for Rh (D) antigen 51099622_1 CDM 0302 RC 86901 HCPCS inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 Blood typing for Rh (D) antigen 51099622_1 CDM 0302 RC 86901 HCPCS inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges Blood typing for Rh (D) antigen 51099622_1 CDM 0302 RC 86901 HCPCS inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 Blood typing for Rh (D) antigen 51099622_1 CDM 0302 RC 86901 HCPCS inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 "INJECTION, ZIV-AFLIBERCEPT, 1 MG" 51103800_1 CDM 0636 RC 00024-5841-01 NDC J9400 HCPCS inpatient 200 UN 7616.67 4950.84 SELF PAY DISCOUNT SELF PAY DISCOUNT 4950.84 65 999999999 4611.89 7388.17 percent of total billed charges "INJECTION, ZIV-AFLIBERCEPT, 1 MG" 51103800_1 CDM 0636 RC 00024-5841-01 NDC J9400 HCPCS inpatient 200 UN 7616.67 4950.84 AETNA AETNA 6017.17 79 999999999 4611.89 7388.17 percent of total billed charges "INJECTION, ZIV-AFLIBERCEPT, 1 MG" 51103800_1 CDM 0636 RC 00024-5841-01 NDC J9400 HCPCS inpatient 200 UN 7616.67 4950.84 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7388.17 97 999999999 4611.89 7388.17 percent of total billed charges "INJECTION, ZIV-AFLIBERCEPT, 1 MG" 51103800_1 CDM 0636 RC 00024-5841-01 NDC J9400 HCPCS inpatient 200 UN 7616.67 4950.84 ENCORE - ALL PLANS ENCORE - ALL PLANS 5255.5 69 999999999 4611.89 7388.17 percent of total billed charges "INJECTION, ZIV-AFLIBERCEPT, 1 MG" 51103800_1 CDM 0636 RC 00024-5841-01 NDC J9400 HCPCS inpatient 200 UN 7616.67 4950.84 SIHO - ALL PLANS SIHO - ALL PLANS 6855 90 999999999 4611.89 7388.17 percent of total billed charges "INJECTION, ZIV-AFLIBERCEPT, 1 MG" 51103800_1 CDM 0636 RC 00024-5841-01 NDC J9400 HCPCS inpatient 200 UN 7616.67 4950.84 HUMANA - ALL PLANS HUMANA - ALL PLANS 5941 78 999999999 4611.89 7388.17 percent of total billed charges "INJECTION, ZIV-AFLIBERCEPT, 1 MG" 51103800_1 CDM 0636 RC 00024-5841-01 NDC J9400 HCPCS inpatient 200 UN 7616.67 4950.84 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4611.89 60.55 999999999 4611.89 7388.17 percent of total billed charges "INJECTION, ZIV-AFLIBERCEPT, 1 MG" 51103800_1 CDM 0636 RC 00024-5841-01 NDC J9400 HCPCS inpatient 200 UN 7616.67 4950.84 UMR - ALL PLANS UMR - ALL PLANS 5331.67 70 999999999 4611.89 7388.17 percent of total billed charges "INJECTION, ZIV-AFLIBERCEPT, 1 MG" 51103800_1 CDM 0636 RC 00024-5841-01 NDC J9400 HCPCS inpatient 200 UN 7616.67 4950.84 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4611.89 7388.17 "INJECTION, ZIV-AFLIBERCEPT, 1 MG" 51103800_1 CDM 0636 RC 00024-5841-01 NDC J9400 HCPCS inpatient 200 UN 7616.67 4950.84 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4611.89 7388.17 "INJECTION, ZIV-AFLIBERCEPT, 1 MG" 51103800_1 CDM 0636 RC 00024-5841-01 NDC J9400 HCPCS inpatient 200 UN 7616.67 4950.84 ANTHEM HMO ANTHEM HMO 999999999 4611.89 7388.17 "INJECTION, ZIV-AFLIBERCEPT, 1 MG" 51103800_1 CDM 0636 RC 00024-5841-01 NDC J9400 HCPCS inpatient 200 UN 7616.67 4950.84 CIGNA - ALL PLANS CIGNA - ALL PLANS 5148.87 67.6 999999999 4611.89 7388.17 percent of total billed charges "INJECTION, ZIV-AFLIBERCEPT, 1 MG" 51103800_1 CDM 0636 RC 00024-5841-01 NDC J9400 HCPCS inpatient 200 UN 7616.67 4950.84 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4611.89 7388.17 "INJECTION, ZIV-AFLIBERCEPT, 1 MG" 51103800_1 CDM 0636 RC 00024-5841-01 NDC J9400 HCPCS inpatient 200 UN 7616.67 4950.84 UHC - ALL PLANS UHC - ALL PLANS 999999999 4611.89 7388.17 "INJECTION, PEMETREXED (PEMFEXY), 10 MG" 51103808_1 CDM 0636 RC 16729-0244-38 NDC J9304 HCPCS inpatient 100 UN 687.06 446.59 SELF PAY DISCOUNT SELF PAY DISCOUNT 446.59 65 999999999 416.01 666.45 percent of total billed charges "INJECTION, PEMETREXED (PEMFEXY), 10 MG" 51103808_1 CDM 0636 RC 16729-0244-38 NDC J9304 HCPCS inpatient 100 UN 687.06 446.59 AETNA AETNA 542.78 79 999999999 416.01 666.45 percent of total billed charges "INJECTION, PEMETREXED (PEMFEXY), 10 MG" 51103808_1 CDM 0636 RC 16729-0244-38 NDC J9304 HCPCS inpatient 100 UN 687.06 446.59 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 666.45 97 999999999 416.01 666.45 percent of total billed charges "INJECTION, PEMETREXED (PEMFEXY), 10 MG" 51103808_1 CDM 0636 RC 16729-0244-38 NDC J9304 HCPCS inpatient 100 UN 687.06 446.59 ENCORE - ALL PLANS ENCORE - ALL PLANS 474.07 69 999999999 416.01 666.45 percent of total billed charges "INJECTION, PEMETREXED (PEMFEXY), 10 MG" 51103808_1 CDM 0636 RC 16729-0244-38 NDC J9304 HCPCS inpatient 100 UN 687.06 446.59 SIHO - ALL PLANS SIHO - ALL PLANS 618.35 90 999999999 416.01 666.45 percent of total billed charges "INJECTION, PEMETREXED (PEMFEXY), 10 MG" 51103808_1 CDM 0636 RC 16729-0244-38 NDC J9304 HCPCS inpatient 100 UN 687.06 446.59 HUMANA - ALL PLANS HUMANA - ALL PLANS 535.91 78 999999999 416.01 666.45 percent of total billed charges "INJECTION, PEMETREXED (PEMFEXY), 10 MG" 51103808_1 CDM 0636 RC 16729-0244-38 NDC J9304 HCPCS inpatient 100 UN 687.06 446.59 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 416.01 60.55 999999999 416.01 666.45 percent of total billed charges "INJECTION, PEMETREXED (PEMFEXY), 10 MG" 51103808_1 CDM 0636 RC 16729-0244-38 NDC J9304 HCPCS inpatient 100 UN 687.06 446.59 UMR - ALL PLANS UMR - ALL PLANS 480.94 70 999999999 416.01 666.45 percent of total billed charges "INJECTION, PEMETREXED (PEMFEXY), 10 MG" 51103808_1 CDM 0636 RC 16729-0244-38 NDC J9304 HCPCS inpatient 100 UN 687.06 446.59 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 416.01 666.45 "INJECTION, PEMETREXED (PEMFEXY), 10 MG" 51103808_1 CDM 0636 RC 16729-0244-38 NDC J9304 HCPCS inpatient 100 UN 687.06 446.59 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 416.01 666.45 "INJECTION, PEMETREXED (PEMFEXY), 10 MG" 51103808_1 CDM 0636 RC 16729-0244-38 NDC J9304 HCPCS inpatient 100 UN 687.06 446.59 ANTHEM HMO ANTHEM HMO 999999999 416.01 666.45 "INJECTION, PEMETREXED (PEMFEXY), 10 MG" 51103808_1 CDM 0636 RC 16729-0244-38 NDC J9304 HCPCS inpatient 100 UN 687.06 446.59 CIGNA - ALL PLANS CIGNA - ALL PLANS 464.45 67.6 999999999 416.01 666.45 percent of total billed charges "INJECTION, PEMETREXED (PEMFEXY), 10 MG" 51103808_1 CDM 0636 RC 16729-0244-38 NDC J9304 HCPCS inpatient 100 UN 687.06 446.59 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 416.01 666.45 "INJECTION, PEMETREXED (PEMFEXY), 10 MG" 51103808_1 CDM 0636 RC 16729-0244-38 NDC J9304 HCPCS inpatient 100 UN 687.06 446.59 UHC - ALL PLANS UHC - ALL PLANS 999999999 416.01 666.45 "Cerebrospinal fluid, or amniotic fluid albumin (protein) level" 51104580_1 CDM 0301 RC 82042 HCPCS inpatient 103 66.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.95 65 999999999 62.37 99.91 percent of total billed charges "Cerebrospinal fluid, or amniotic fluid albumin (protein) level" 51104580_1 CDM 0301 RC 82042 HCPCS inpatient 103 66.95 AETNA AETNA 81.37 79 999999999 62.37 99.91 percent of total billed charges "Cerebrospinal fluid, or amniotic fluid albumin (protein) level" 51104580_1 CDM 0301 RC 82042 HCPCS inpatient 103 66.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 99.91 97 999999999 62.37 99.91 percent of total billed charges "Cerebrospinal fluid, or amniotic fluid albumin (protein) level" 51104580_1 CDM 0301 RC 82042 HCPCS inpatient 103 66.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.07 69 999999999 62.37 99.91 percent of total billed charges "Cerebrospinal fluid, or amniotic fluid albumin (protein) level" 51104580_1 CDM 0301 RC 82042 HCPCS inpatient 103 66.95 SIHO - ALL PLANS SIHO - ALL PLANS 92.7 90 999999999 62.37 99.91 percent of total billed charges "Cerebrospinal fluid, or amniotic fluid albumin (protein) level" 51104580_1 CDM 0301 RC 82042 HCPCS inpatient 103 66.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 80.34 78 999999999 62.37 99.91 percent of total billed charges "Cerebrospinal fluid, or amniotic fluid albumin (protein) level" 51104580_1 CDM 0301 RC 82042 HCPCS inpatient 103 66.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.37 60.55 999999999 62.37 99.91 percent of total billed charges "Cerebrospinal fluid, or amniotic fluid albumin (protein) level" 51104580_1 CDM 0301 RC 82042 HCPCS inpatient 103 66.95 UMR - ALL PLANS UMR - ALL PLANS 72.1 70 999999999 62.37 99.91 percent of total billed charges "Cerebrospinal fluid, or amniotic fluid albumin (protein) level" 51104580_1 CDM 0301 RC 82042 HCPCS inpatient 103 66.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.37 99.91 "Cerebrospinal fluid, or amniotic fluid albumin (protein) level" 51104580_1 CDM 0301 RC 82042 HCPCS inpatient 103 66.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.37 99.91 "Cerebrospinal fluid, or amniotic fluid albumin (protein) level" 51104580_1 CDM 0301 RC 82042 HCPCS inpatient 103 66.95 ANTHEM HMO ANTHEM HMO 999999999 62.37 99.91 "Cerebrospinal fluid, or amniotic fluid albumin (protein) level" 51104580_1 CDM 0301 RC 82042 HCPCS inpatient 103 66.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 69.63 67.6 999999999 62.37 99.91 percent of total billed charges "Cerebrospinal fluid, or amniotic fluid albumin (protein) level" 51104580_1 CDM 0301 RC 82042 HCPCS inpatient 103 66.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.37 99.91 "Cerebrospinal fluid, or amniotic fluid albumin (protein) level" 51104580_1 CDM 0301 RC 82042 HCPCS inpatient 103 66.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.37 99.91 Creatinine level to test for kidney function or muscle injury 51104581_1 CDM 0301 RC 82570 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges Creatinine level to test for kidney function or muscle injury 51104581_1 CDM 0301 RC 82570 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges Creatinine level to test for kidney function or muscle injury 51104581_1 CDM 0301 RC 82570 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges Creatinine level to test for kidney function or muscle injury 51104581_1 CDM 0301 RC 82570 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges Creatinine level to test for kidney function or muscle injury 51104581_1 CDM 0301 RC 82570 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges Creatinine level to test for kidney function or muscle injury 51104581_1 CDM 0301 RC 82570 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges Creatinine level to test for kidney function or muscle injury 51104581_1 CDM 0301 RC 82570 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges Creatinine level to test for kidney function or muscle injury 51104581_1 CDM 0301 RC 82570 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges Creatinine level to test for kidney function or muscle injury 51104581_1 CDM 0301 RC 82570 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 Creatinine level to test for kidney function or muscle injury 51104581_1 CDM 0301 RC 82570 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 Creatinine level to test for kidney function or muscle injury 51104581_1 CDM 0301 RC 82570 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 Creatinine level to test for kidney function or muscle injury 51104581_1 CDM 0301 RC 82570 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges Creatinine level to test for kidney function or muscle injury 51104581_1 CDM 0301 RC 82570 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 Creatinine level to test for kidney function or muscle injury 51104581_1 CDM 0301 RC 82570 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Microscopic genetic analysis of tumor, manual" 51104813_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.75 65 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104813_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 AETNA AETNA 90.85 79 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104813_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 111.55 97 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104813_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 79.35 69 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104813_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 SIHO - ALL PLANS SIHO - ALL PLANS 103.5 90 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104813_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 89.7 78 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104813_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.63 60.55 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104813_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UMR - ALL PLANS UMR - ALL PLANS 80.5 70 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104813_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104813_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104813_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM HMO ANTHEM HMO 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104813_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.74 67.6 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104813_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104813_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104815_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.75 65 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104815_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 AETNA AETNA 90.85 79 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104815_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 111.55 97 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104815_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 79.35 69 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104815_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 SIHO - ALL PLANS SIHO - ALL PLANS 103.5 90 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104815_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 89.7 78 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104815_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.63 60.55 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104815_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UMR - ALL PLANS UMR - ALL PLANS 80.5 70 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104815_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104815_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104815_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM HMO ANTHEM HMO 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104815_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.74 67.6 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104815_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104815_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104816_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.75 65 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104816_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 AETNA AETNA 90.85 79 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104816_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 111.55 97 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104816_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 79.35 69 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104816_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 SIHO - ALL PLANS SIHO - ALL PLANS 103.5 90 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104816_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 89.7 78 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104816_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.63 60.55 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104816_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UMR - ALL PLANS UMR - ALL PLANS 80.5 70 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104816_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104816_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104816_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM HMO ANTHEM HMO 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104816_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.74 67.6 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104816_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104816_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104817_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.75 65 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104817_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 AETNA AETNA 90.85 79 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104817_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 111.55 97 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104817_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 79.35 69 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104817_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 SIHO - ALL PLANS SIHO - ALL PLANS 103.5 90 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104817_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 89.7 78 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104817_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.63 60.55 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104817_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UMR - ALL PLANS UMR - ALL PLANS 80.5 70 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104817_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104817_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104817_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM HMO ANTHEM HMO 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104817_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.74 67.6 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104817_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104817_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104818_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.75 65 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104818_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 AETNA AETNA 90.85 79 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104818_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 111.55 97 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104818_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 79.35 69 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104818_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 SIHO - ALL PLANS SIHO - ALL PLANS 103.5 90 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104818_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 89.7 78 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104818_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.63 60.55 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104818_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UMR - ALL PLANS UMR - ALL PLANS 80.5 70 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104818_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104818_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104818_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM HMO ANTHEM HMO 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104818_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.74 67.6 999999999 69.63 111.55 percent of total billed charges "Microscopic genetic analysis of tumor, manual" 51104818_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.63 111.55 "Microscopic genetic analysis of tumor, manual" 51104818_1 CDM 0312 RC 88360 HCPCS inpatient 115 74.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.63 111.55 Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 51105025_1 CDM 0310 RC 81445 HCPCS inpatient 1575 1023.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1023.75 65 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 51105025_1 CDM 0310 RC 81445 HCPCS inpatient 1575 1023.75 AETNA AETNA 1244.25 79 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 51105025_1 CDM 0310 RC 81445 HCPCS inpatient 1575 1023.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1527.75 97 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 51105025_1 CDM 0310 RC 81445 HCPCS inpatient 1575 1023.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1086.75 69 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 51105025_1 CDM 0310 RC 81445 HCPCS inpatient 1575 1023.75 SIHO - ALL PLANS SIHO - ALL PLANS 1417.5 90 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 51105025_1 CDM 0310 RC 81445 HCPCS inpatient 1575 1023.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1228.5 78 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 51105025_1 CDM 0310 RC 81445 HCPCS inpatient 1575 1023.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 953.66 60.55 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 51105025_1 CDM 0310 RC 81445 HCPCS inpatient 1575 1023.75 UMR - ALL PLANS UMR - ALL PLANS 1102.5 70 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 51105025_1 CDM 0310 RC 81445 HCPCS inpatient 1575 1023.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 51105025_1 CDM 0310 RC 81445 HCPCS inpatient 1575 1023.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 51105025_1 CDM 0310 RC 81445 HCPCS inpatient 1575 1023.75 ANTHEM HMO ANTHEM HMO 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 51105025_1 CDM 0310 RC 81445 HCPCS inpatient 1575 1023.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1064.7 67.6 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 51105025_1 CDM 0310 RC 81445 HCPCS inpatient 1575 1023.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combined DNA and RNA of 5-50 genes associated with solid organ neoplasm 51105025_1 CDM 0310 RC 81445 HCPCS inpatient 1575 1023.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105028_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1126.45 65 999999999 1049.33 1681.01 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105028_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 AETNA AETNA 1369.07 79 999999999 1049.33 1681.01 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105028_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1681.01 97 999999999 1049.33 1681.01 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105028_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1195.77 69 999999999 1049.33 1681.01 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105028_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 SIHO - ALL PLANS SIHO - ALL PLANS 1559.7 90 999999999 1049.33 1681.01 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105028_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1351.74 78 999999999 1049.33 1681.01 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105028_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1049.33 60.55 999999999 1049.33 1681.01 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105028_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 UMR - ALL PLANS UMR - ALL PLANS 1213.1 70 999999999 1049.33 1681.01 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105028_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1049.33 1681.01 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105028_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1049.33 1681.01 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105028_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 ANTHEM HMO ANTHEM HMO 999999999 1049.33 1681.01 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105028_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1171.51 67.6 999999999 1049.33 1681.01 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105028_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1049.33 1681.01 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105028_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1049.33 1681.01 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105029_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1023.75 65 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105029_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 AETNA AETNA 1244.25 79 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105029_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1527.75 97 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105029_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1086.75 69 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105029_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 SIHO - ALL PLANS SIHO - ALL PLANS 1417.5 90 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105029_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1228.5 78 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105029_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 953.66 60.55 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105029_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UMR - ALL PLANS UMR - ALL PLANS 1102.5 70 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105029_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105029_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105029_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM HMO ANTHEM HMO 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105029_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1064.7 67.6 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105029_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105029_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105030_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1023.75 65 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105030_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 AETNA AETNA 1244.25 79 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105030_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1527.75 97 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105030_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1086.75 69 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105030_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 SIHO - ALL PLANS SIHO - ALL PLANS 1417.5 90 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105030_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1228.5 78 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105030_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 953.66 60.55 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105030_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UMR - ALL PLANS UMR - ALL PLANS 1102.5 70 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105030_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105030_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105030_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM HMO ANTHEM HMO 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105030_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1064.7 67.6 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105030_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105030_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105031_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1023.75 65 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105031_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 AETNA AETNA 1244.25 79 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105031_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1527.75 97 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105031_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1086.75 69 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105031_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 SIHO - ALL PLANS SIHO - ALL PLANS 1417.5 90 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105031_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1228.5 78 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105031_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 953.66 60.55 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105031_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UMR - ALL PLANS UMR - ALL PLANS 1102.5 70 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105031_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105031_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105031_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM HMO ANTHEM HMO 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105031_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1064.7 67.6 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105031_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105031_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 953.66 1527.75 Gene analysis (tumor protein 53) targeted sequence analysis 51105032_1 CDM 0310 RC 81352 HCPCS inpatient 1575 1023.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1023.75 65 999999999 953.66 1527.75 percent of total billed charges Gene analysis (tumor protein 53) targeted sequence analysis 51105032_1 CDM 0310 RC 81352 HCPCS inpatient 1575 1023.75 AETNA AETNA 1244.25 79 999999999 953.66 1527.75 percent of total billed charges Gene analysis (tumor protein 53) targeted sequence analysis 51105032_1 CDM 0310 RC 81352 HCPCS inpatient 1575 1023.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1527.75 97 999999999 953.66 1527.75 percent of total billed charges Gene analysis (tumor protein 53) targeted sequence analysis 51105032_1 CDM 0310 RC 81352 HCPCS inpatient 1575 1023.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1086.75 69 999999999 953.66 1527.75 percent of total billed charges Gene analysis (tumor protein 53) targeted sequence analysis 51105032_1 CDM 0310 RC 81352 HCPCS inpatient 1575 1023.75 SIHO - ALL PLANS SIHO - ALL PLANS 1417.5 90 999999999 953.66 1527.75 percent of total billed charges Gene analysis (tumor protein 53) targeted sequence analysis 51105032_1 CDM 0310 RC 81352 HCPCS inpatient 1575 1023.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1228.5 78 999999999 953.66 1527.75 percent of total billed charges Gene analysis (tumor protein 53) targeted sequence analysis 51105032_1 CDM 0310 RC 81352 HCPCS inpatient 1575 1023.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 953.66 60.55 999999999 953.66 1527.75 percent of total billed charges Gene analysis (tumor protein 53) targeted sequence analysis 51105032_1 CDM 0310 RC 81352 HCPCS inpatient 1575 1023.75 UMR - ALL PLANS UMR - ALL PLANS 1102.5 70 999999999 953.66 1527.75 percent of total billed charges Gene analysis (tumor protein 53) targeted sequence analysis 51105032_1 CDM 0310 RC 81352 HCPCS inpatient 1575 1023.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 953.66 1527.75 Gene analysis (tumor protein 53) targeted sequence analysis 51105032_1 CDM 0310 RC 81352 HCPCS inpatient 1575 1023.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 953.66 1527.75 Gene analysis (tumor protein 53) targeted sequence analysis 51105032_1 CDM 0310 RC 81352 HCPCS inpatient 1575 1023.75 ANTHEM HMO ANTHEM HMO 999999999 953.66 1527.75 Gene analysis (tumor protein 53) targeted sequence analysis 51105032_1 CDM 0310 RC 81352 HCPCS inpatient 1575 1023.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1064.7 67.6 999999999 953.66 1527.75 percent of total billed charges Gene analysis (tumor protein 53) targeted sequence analysis 51105032_1 CDM 0310 RC 81352 HCPCS inpatient 1575 1023.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 953.66 1527.75 Gene analysis (tumor protein 53) targeted sequence analysis 51105032_1 CDM 0310 RC 81352 HCPCS inpatient 1575 1023.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105036_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1023.75 65 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105036_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 AETNA AETNA 1244.25 79 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105036_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1527.75 97 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105036_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1086.75 69 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105036_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 SIHO - ALL PLANS SIHO - ALL PLANS 1417.5 90 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105036_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1228.5 78 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105036_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 953.66 60.55 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105036_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UMR - ALL PLANS UMR - ALL PLANS 1102.5 70 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105036_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105036_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105036_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM HMO ANTHEM HMO 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105036_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1064.7 67.6 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105036_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105036_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105156_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1023.75 65 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105156_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 AETNA AETNA 1244.25 79 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105156_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1527.75 97 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105156_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1086.75 69 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105156_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 SIHO - ALL PLANS SIHO - ALL PLANS 1417.5 90 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105156_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1228.5 78 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105156_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 953.66 60.55 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105156_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UMR - ALL PLANS UMR - ALL PLANS 1102.5 70 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105156_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105156_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105156_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM HMO ANTHEM HMO 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105156_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1064.7 67.6 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105156_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51105156_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 953.66 1527.75 Amylase (enzyme) level 51106029_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Amylase (enzyme) level 51106029_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Amylase (enzyme) level 51106029_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Amylase (enzyme) level 51106029_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Amylase (enzyme) level 51106029_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Amylase (enzyme) level 51106029_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Amylase (enzyme) level 51106029_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Amylase (enzyme) level 51106029_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Amylase (enzyme) level 51106029_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Amylase (enzyme) level 51106029_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Amylase (enzyme) level 51106029_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Amylase (enzyme) level 51106029_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Amylase (enzyme) level 51106029_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Amylase (enzyme) level 51106029_1 CDM 0301 RC 82150 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Glucose (sugar) level on body fluid 51106042_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.95 65 999999999 62.37 99.91 percent of total billed charges Glucose (sugar) level on body fluid 51106042_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 AETNA AETNA 81.37 79 999999999 62.37 99.91 percent of total billed charges Glucose (sugar) level on body fluid 51106042_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 99.91 97 999999999 62.37 99.91 percent of total billed charges Glucose (sugar) level on body fluid 51106042_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.07 69 999999999 62.37 99.91 percent of total billed charges Glucose (sugar) level on body fluid 51106042_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 SIHO - ALL PLANS SIHO - ALL PLANS 92.7 90 999999999 62.37 99.91 percent of total billed charges Glucose (sugar) level on body fluid 51106042_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 80.34 78 999999999 62.37 99.91 percent of total billed charges Glucose (sugar) level on body fluid 51106042_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.37 60.55 999999999 62.37 99.91 percent of total billed charges Glucose (sugar) level on body fluid 51106042_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 UMR - ALL PLANS UMR - ALL PLANS 72.1 70 999999999 62.37 99.91 percent of total billed charges Glucose (sugar) level on body fluid 51106042_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.37 99.91 Glucose (sugar) level on body fluid 51106042_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.37 99.91 Glucose (sugar) level on body fluid 51106042_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 ANTHEM HMO ANTHEM HMO 999999999 62.37 99.91 Glucose (sugar) level on body fluid 51106042_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 69.63 67.6 999999999 62.37 99.91 percent of total billed charges Glucose (sugar) level on body fluid 51106042_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.37 99.91 Glucose (sugar) level on body fluid 51106042_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.37 99.91 Detection of bacteria causing vaginosis and vaginitis by multiplex amplified nucleic acid probe technique 51112861_1 CDM 0306 RC 0352U HCPCS inpatient 350 227.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 227.5 65 999999999 211.93 339.5 percent of total billed charges Detection of bacteria causing vaginosis and vaginitis by multiplex amplified nucleic acid probe technique 51112861_1 CDM 0306 RC 0352U HCPCS inpatient 350 227.5 AETNA AETNA 276.5 79 999999999 211.93 339.5 percent of total billed charges Detection of bacteria causing vaginosis and vaginitis by multiplex amplified nucleic acid probe technique 51112861_1 CDM 0306 RC 0352U HCPCS inpatient 350 227.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 339.5 97 999999999 211.93 339.5 percent of total billed charges Detection of bacteria causing vaginosis and vaginitis by multiplex amplified nucleic acid probe technique 51112861_1 CDM 0306 RC 0352U HCPCS inpatient 350 227.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 241.5 69 999999999 211.93 339.5 percent of total billed charges Detection of bacteria causing vaginosis and vaginitis by multiplex amplified nucleic acid probe technique 51112861_1 CDM 0306 RC 0352U HCPCS inpatient 350 227.5 SIHO - ALL PLANS SIHO - ALL PLANS 315 90 999999999 211.93 339.5 percent of total billed charges Detection of bacteria causing vaginosis and vaginitis by multiplex amplified nucleic acid probe technique 51112861_1 CDM 0306 RC 0352U HCPCS inpatient 350 227.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 273 78 999999999 211.93 339.5 percent of total billed charges Detection of bacteria causing vaginosis and vaginitis by multiplex amplified nucleic acid probe technique 51112861_1 CDM 0306 RC 0352U HCPCS inpatient 350 227.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 211.93 60.55 999999999 211.93 339.5 percent of total billed charges Detection of bacteria causing vaginosis and vaginitis by multiplex amplified nucleic acid probe technique 51112861_1 CDM 0306 RC 0352U HCPCS inpatient 350 227.5 UMR - ALL PLANS UMR - ALL PLANS 245 70 999999999 211.93 339.5 percent of total billed charges Detection of bacteria causing vaginosis and vaginitis by multiplex amplified nucleic acid probe technique 51112861_1 CDM 0306 RC 0352U HCPCS inpatient 350 227.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 211.93 339.5 Detection of bacteria causing vaginosis and vaginitis by multiplex amplified nucleic acid probe technique 51112861_1 CDM 0306 RC 0352U HCPCS inpatient 350 227.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 211.93 339.5 Detection of bacteria causing vaginosis and vaginitis by multiplex amplified nucleic acid probe technique 51112861_1 CDM 0306 RC 0352U HCPCS inpatient 350 227.5 ANTHEM HMO ANTHEM HMO 999999999 211.93 339.5 Detection of bacteria causing vaginosis and vaginitis by multiplex amplified nucleic acid probe technique 51112861_1 CDM 0306 RC 0352U HCPCS inpatient 350 227.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 236.6 67.6 999999999 211.93 339.5 percent of total billed charges Detection of bacteria causing vaginosis and vaginitis by multiplex amplified nucleic acid probe technique 51112861_1 CDM 0306 RC 0352U HCPCS inpatient 350 227.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 211.93 339.5 Detection of bacteria causing vaginosis and vaginitis by multiplex amplified nucleic acid probe technique 51112861_1 CDM 0306 RC 0352U HCPCS inpatient 350 227.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 211.93 339.5 "Thyroxine (thyroid chemical), total" 51116770_1 CDM 0301 RC 84436 HCPCS inpatient 149 96.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 96.85 65 999999999 90.22 144.53 percent of total billed charges "Thyroxine (thyroid chemical), total" 51116770_1 CDM 0301 RC 84436 HCPCS inpatient 149 96.85 AETNA AETNA 117.71 79 999999999 90.22 144.53 percent of total billed charges "Thyroxine (thyroid chemical), total" 51116770_1 CDM 0301 RC 84436 HCPCS inpatient 149 96.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 144.53 97 999999999 90.22 144.53 percent of total billed charges "Thyroxine (thyroid chemical), total" 51116770_1 CDM 0301 RC 84436 HCPCS inpatient 149 96.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 102.81 69 999999999 90.22 144.53 percent of total billed charges "Thyroxine (thyroid chemical), total" 51116770_1 CDM 0301 RC 84436 HCPCS inpatient 149 96.85 SIHO - ALL PLANS SIHO - ALL PLANS 134.1 90 999999999 90.22 144.53 percent of total billed charges "Thyroxine (thyroid chemical), total" 51116770_1 CDM 0301 RC 84436 HCPCS inpatient 149 96.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 116.22 78 999999999 90.22 144.53 percent of total billed charges "Thyroxine (thyroid chemical), total" 51116770_1 CDM 0301 RC 84436 HCPCS inpatient 149 96.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.22 60.55 999999999 90.22 144.53 percent of total billed charges "Thyroxine (thyroid chemical), total" 51116770_1 CDM 0301 RC 84436 HCPCS inpatient 149 96.85 UMR - ALL PLANS UMR - ALL PLANS 104.3 70 999999999 90.22 144.53 percent of total billed charges "Thyroxine (thyroid chemical), total" 51116770_1 CDM 0301 RC 84436 HCPCS inpatient 149 96.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.22 144.53 "Thyroxine (thyroid chemical), total" 51116770_1 CDM 0301 RC 84436 HCPCS inpatient 149 96.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.22 144.53 "Thyroxine (thyroid chemical), total" 51116770_1 CDM 0301 RC 84436 HCPCS inpatient 149 96.85 ANTHEM HMO ANTHEM HMO 999999999 90.22 144.53 "Thyroxine (thyroid chemical), total" 51116770_1 CDM 0301 RC 84436 HCPCS inpatient 149 96.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 100.72 67.6 999999999 90.22 144.53 percent of total billed charges "Thyroxine (thyroid chemical), total" 51116770_1 CDM 0301 RC 84436 HCPCS inpatient 149 96.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.22 144.53 "Thyroxine (thyroid chemical), total" 51116770_1 CDM 0301 RC 84436 HCPCS inpatient 149 96.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.22 144.53 "Total protein level, body fluid" 51116873_1 CDM 0301 RC 84157 HCPCS inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges "Total protein level, body fluid" 51116873_1 CDM 0301 RC 84157 HCPCS inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges "Total protein level, body fluid" 51116873_1 CDM 0301 RC 84157 HCPCS inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges "Total protein level, body fluid" 51116873_1 CDM 0301 RC 84157 HCPCS inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges "Total protein level, body fluid" 51116873_1 CDM 0301 RC 84157 HCPCS inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges "Total protein level, body fluid" 51116873_1 CDM 0301 RC 84157 HCPCS inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges "Total protein level, body fluid" 51116873_1 CDM 0301 RC 84157 HCPCS inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges "Total protein level, body fluid" 51116873_1 CDM 0301 RC 84157 HCPCS inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges "Total protein level, body fluid" 51116873_1 CDM 0301 RC 84157 HCPCS inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 "Total protein level, body fluid" 51116873_1 CDM 0301 RC 84157 HCPCS inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 "Total protein level, body fluid" 51116873_1 CDM 0301 RC 84157 HCPCS inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 "Total protein level, body fluid" 51116873_1 CDM 0301 RC 84157 HCPCS inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges "Total protein level, body fluid" 51116873_1 CDM 0301 RC 84157 HCPCS inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 "Total protein level, body fluid" 51116873_1 CDM 0301 RC 84157 HCPCS inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 Chemical analysis using spectrophotometry (light) 51116975_1 CDM 0301 RC 84311 HCPCS inpatient 177 115.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.05 65 999999999 107.17 171.69 percent of total billed charges Chemical analysis using spectrophotometry (light) 51116975_1 CDM 0301 RC 84311 HCPCS inpatient 177 115.05 AETNA AETNA 139.83 79 999999999 107.17 171.69 percent of total billed charges Chemical analysis using spectrophotometry (light) 51116975_1 CDM 0301 RC 84311 HCPCS inpatient 177 115.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 171.69 97 999999999 107.17 171.69 percent of total billed charges Chemical analysis using spectrophotometry (light) 51116975_1 CDM 0301 RC 84311 HCPCS inpatient 177 115.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.13 69 999999999 107.17 171.69 percent of total billed charges Chemical analysis using spectrophotometry (light) 51116975_1 CDM 0301 RC 84311 HCPCS inpatient 177 115.05 SIHO - ALL PLANS SIHO - ALL PLANS 159.3 90 999999999 107.17 171.69 percent of total billed charges Chemical analysis using spectrophotometry (light) 51116975_1 CDM 0301 RC 84311 HCPCS inpatient 177 115.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.06 78 999999999 107.17 171.69 percent of total billed charges Chemical analysis using spectrophotometry (light) 51116975_1 CDM 0301 RC 84311 HCPCS inpatient 177 115.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.17 60.55 999999999 107.17 171.69 percent of total billed charges Chemical analysis using spectrophotometry (light) 51116975_1 CDM 0301 RC 84311 HCPCS inpatient 177 115.05 UMR - ALL PLANS UMR - ALL PLANS 123.9 70 999999999 107.17 171.69 percent of total billed charges Chemical analysis using spectrophotometry (light) 51116975_1 CDM 0301 RC 84311 HCPCS inpatient 177 115.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.17 171.69 Chemical analysis using spectrophotometry (light) 51116975_1 CDM 0301 RC 84311 HCPCS inpatient 177 115.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.17 171.69 Chemical analysis using spectrophotometry (light) 51116975_1 CDM 0301 RC 84311 HCPCS inpatient 177 115.05 ANTHEM HMO ANTHEM HMO 999999999 107.17 171.69 Chemical analysis using spectrophotometry (light) 51116975_1 CDM 0301 RC 84311 HCPCS inpatient 177 115.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 119.65 67.6 999999999 107.17 171.69 percent of total billed charges Chemical analysis using spectrophotometry (light) 51116975_1 CDM 0301 RC 84311 HCPCS inpatient 177 115.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.17 171.69 Chemical analysis using spectrophotometry (light) 51116975_1 CDM 0301 RC 84311 HCPCS inpatient 177 115.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.17 171.69 Natriuretic peptide (heart and blood vessel protein) level 51117429_1 CDM 0301 RC 83880 HCPCS inpatient 238 154.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 154.7 65 999999999 144.11 230.86 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 51117429_1 CDM 0301 RC 83880 HCPCS inpatient 238 154.7 AETNA AETNA 188.02 79 999999999 144.11 230.86 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 51117429_1 CDM 0301 RC 83880 HCPCS inpatient 238 154.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 230.86 97 999999999 144.11 230.86 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 51117429_1 CDM 0301 RC 83880 HCPCS inpatient 238 154.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.22 69 999999999 144.11 230.86 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 51117429_1 CDM 0301 RC 83880 HCPCS inpatient 238 154.7 SIHO - ALL PLANS SIHO - ALL PLANS 214.2 90 999999999 144.11 230.86 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 51117429_1 CDM 0301 RC 83880 HCPCS inpatient 238 154.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 185.64 78 999999999 144.11 230.86 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 51117429_1 CDM 0301 RC 83880 HCPCS inpatient 238 154.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.11 60.55 999999999 144.11 230.86 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 51117429_1 CDM 0301 RC 83880 HCPCS inpatient 238 154.7 UMR - ALL PLANS UMR - ALL PLANS 166.6 70 999999999 144.11 230.86 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 51117429_1 CDM 0301 RC 83880 HCPCS inpatient 238 154.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.11 230.86 Natriuretic peptide (heart and blood vessel protein) level 51117429_1 CDM 0301 RC 83880 HCPCS inpatient 238 154.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.11 230.86 Natriuretic peptide (heart and blood vessel protein) level 51117429_1 CDM 0301 RC 83880 HCPCS inpatient 238 154.7 ANTHEM HMO ANTHEM HMO 999999999 144.11 230.86 Natriuretic peptide (heart and blood vessel protein) level 51117429_1 CDM 0301 RC 83880 HCPCS inpatient 238 154.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 160.89 67.6 999999999 144.11 230.86 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 51117429_1 CDM 0301 RC 83880 HCPCS inpatient 238 154.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.11 230.86 Natriuretic peptide (heart and blood vessel protein) level 51117429_1 CDM 0301 RC 83880 HCPCS inpatient 238 154.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.11 230.86 Detection of endomysial antibody (EMA) 51117485_1 CDM 0301 RC 86231 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Detection of endomysial antibody (EMA) 51117485_1 CDM 0301 RC 86231 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Detection of endomysial antibody (EMA) 51117485_1 CDM 0301 RC 86231 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Detection of endomysial antibody (EMA) 51117485_1 CDM 0301 RC 86231 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Detection of endomysial antibody (EMA) 51117485_1 CDM 0301 RC 86231 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Detection of endomysial antibody (EMA) 51117485_1 CDM 0301 RC 86231 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Detection of endomysial antibody (EMA) 51117485_1 CDM 0301 RC 86231 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Detection of endomysial antibody (EMA) 51117485_1 CDM 0301 RC 86231 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Detection of endomysial antibody (EMA) 51117485_1 CDM 0301 RC 86231 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Detection of endomysial antibody (EMA) 51117485_1 CDM 0301 RC 86231 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Detection of endomysial antibody (EMA) 51117485_1 CDM 0301 RC 86231 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Detection of endomysial antibody (EMA) 51117485_1 CDM 0301 RC 86231 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Detection of endomysial antibody (EMA) 51117485_1 CDM 0301 RC 86231 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Detection of endomysial antibody (EMA) 51117485_1 CDM 0301 RC 86231 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117498_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117498_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117498_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117498_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117498_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117498_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117498_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117498_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117498_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117498_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117498_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117498_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117498_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117498_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117499_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117499_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117499_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117499_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117499_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117499_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117499_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117499_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117499_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117499_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117499_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117499_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117499_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117499_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117500_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117500_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117500_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117500_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117500_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117500_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117500_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117500_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117500_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117500_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117500_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117500_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117500_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117500_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117501_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117501_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117501_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117501_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117501_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117501_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117501_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117501_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117501_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117501_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117501_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117501_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to Bartonella (bacteria) 51117501_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Analysis for antibody to Bartonella (bacteria) 51117501_1 CDM 0302 RC 86611 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 "Crushing, fragmenting, and removal of bladder stones, less than 2.5 cm" 51118114_1 CDM 0360 RC 52317 HCPCS inpatient 9420.12 6123.08 SELF PAY DISCOUNT SELF PAY DISCOUNT 6123.08 65 999999999 5703.88 9137.52 percent of total billed charges "Crushing, fragmenting, and removal of bladder stones, less than 2.5 cm" 51118114_1 CDM 0360 RC 52317 HCPCS inpatient 9420.12 6123.08 AETNA AETNA 7441.89 79 999999999 5703.88 9137.52 percent of total billed charges "Crushing, fragmenting, and removal of bladder stones, less than 2.5 cm" 51118114_1 CDM 0360 RC 52317 HCPCS inpatient 9420.12 6123.08 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9137.52 97 999999999 5703.88 9137.52 percent of total billed charges "Crushing, fragmenting, and removal of bladder stones, less than 2.5 cm" 51118114_1 CDM 0360 RC 52317 HCPCS inpatient 9420.12 6123.08 ENCORE - ALL PLANS ENCORE - ALL PLANS 6499.88 69 999999999 5703.88 9137.52 percent of total billed charges "Crushing, fragmenting, and removal of bladder stones, less than 2.5 cm" 51118114_1 CDM 0360 RC 52317 HCPCS inpatient 9420.12 6123.08 SIHO - ALL PLANS SIHO - ALL PLANS 8478.11 90 999999999 5703.88 9137.52 percent of total billed charges "Crushing, fragmenting, and removal of bladder stones, less than 2.5 cm" 51118114_1 CDM 0360 RC 52317 HCPCS inpatient 9420.12 6123.08 HUMANA - ALL PLANS HUMANA - ALL PLANS 7347.69 78 999999999 5703.88 9137.52 percent of total billed charges "Crushing, fragmenting, and removal of bladder stones, less than 2.5 cm" 51118114_1 CDM 0360 RC 52317 HCPCS inpatient 9420.12 6123.08 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5703.88 60.55 999999999 5703.88 9137.52 percent of total billed charges "Crushing, fragmenting, and removal of bladder stones, less than 2.5 cm" 51118114_1 CDM 0360 RC 52317 HCPCS inpatient 9420.12 6123.08 UMR - ALL PLANS UMR - ALL PLANS 6594.08 70 999999999 5703.88 9137.52 percent of total billed charges "Crushing, fragmenting, and removal of bladder stones, less than 2.5 cm" 51118114_1 CDM 0360 RC 52317 HCPCS inpatient 9420.12 6123.08 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5703.88 9137.52 "Crushing, fragmenting, and removal of bladder stones, less than 2.5 cm" 51118114_1 CDM 0360 RC 52317 HCPCS inpatient 9420.12 6123.08 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5703.88 9137.52 "Crushing, fragmenting, and removal of bladder stones, less than 2.5 cm" 51118114_1 CDM 0360 RC 52317 HCPCS inpatient 9420.12 6123.08 ANTHEM HMO ANTHEM HMO 999999999 5703.88 9137.52 "Crushing, fragmenting, and removal of bladder stones, less than 2.5 cm" 51118114_1 CDM 0360 RC 52317 HCPCS inpatient 9420.12 6123.08 CIGNA - ALL PLANS CIGNA - ALL PLANS 6368 67.6 999999999 5703.88 9137.52 percent of total billed charges "Crushing, fragmenting, and removal of bladder stones, less than 2.5 cm" 51118114_1 CDM 0360 RC 52317 HCPCS inpatient 9420.12 6123.08 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5703.88 9137.52 "Crushing, fragmenting, and removal of bladder stones, less than 2.5 cm" 51118114_1 CDM 0360 RC 52317 HCPCS inpatient 9420.12 6123.08 UHC - ALL PLANS UHC - ALL PLANS 999999999 5703.88 9137.52 "Crushing, fragmenting, and removal of bladder stones, more than 2.5 cm" 51118115_1 CDM 0360 RC 52318 HCPCS inpatient 9420.12 6123.08 SELF PAY DISCOUNT SELF PAY DISCOUNT 6123.08 65 999999999 5703.88 9137.52 percent of total billed charges "Crushing, fragmenting, and removal of bladder stones, more than 2.5 cm" 51118115_1 CDM 0360 RC 52318 HCPCS inpatient 9420.12 6123.08 AETNA AETNA 7441.89 79 999999999 5703.88 9137.52 percent of total billed charges "Crushing, fragmenting, and removal of bladder stones, more than 2.5 cm" 51118115_1 CDM 0360 RC 52318 HCPCS inpatient 9420.12 6123.08 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9137.52 97 999999999 5703.88 9137.52 percent of total billed charges "Crushing, fragmenting, and removal of bladder stones, more than 2.5 cm" 51118115_1 CDM 0360 RC 52318 HCPCS inpatient 9420.12 6123.08 ENCORE - ALL PLANS ENCORE - ALL PLANS 6499.88 69 999999999 5703.88 9137.52 percent of total billed charges "Crushing, fragmenting, and removal of bladder stones, more than 2.5 cm" 51118115_1 CDM 0360 RC 52318 HCPCS inpatient 9420.12 6123.08 SIHO - ALL PLANS SIHO - ALL PLANS 8478.11 90 999999999 5703.88 9137.52 percent of total billed charges "Crushing, fragmenting, and removal of bladder stones, more than 2.5 cm" 51118115_1 CDM 0360 RC 52318 HCPCS inpatient 9420.12 6123.08 HUMANA - ALL PLANS HUMANA - ALL PLANS 7347.69 78 999999999 5703.88 9137.52 percent of total billed charges "Crushing, fragmenting, and removal of bladder stones, more than 2.5 cm" 51118115_1 CDM 0360 RC 52318 HCPCS inpatient 9420.12 6123.08 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5703.88 60.55 999999999 5703.88 9137.52 percent of total billed charges "Crushing, fragmenting, and removal of bladder stones, more than 2.5 cm" 51118115_1 CDM 0360 RC 52318 HCPCS inpatient 9420.12 6123.08 UMR - ALL PLANS UMR - ALL PLANS 6594.08 70 999999999 5703.88 9137.52 percent of total billed charges "Crushing, fragmenting, and removal of bladder stones, more than 2.5 cm" 51118115_1 CDM 0360 RC 52318 HCPCS inpatient 9420.12 6123.08 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5703.88 9137.52 "Crushing, fragmenting, and removal of bladder stones, more than 2.5 cm" 51118115_1 CDM 0360 RC 52318 HCPCS inpatient 9420.12 6123.08 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5703.88 9137.52 "Crushing, fragmenting, and removal of bladder stones, more than 2.5 cm" 51118115_1 CDM 0360 RC 52318 HCPCS inpatient 9420.12 6123.08 ANTHEM HMO ANTHEM HMO 999999999 5703.88 9137.52 "Crushing, fragmenting, and removal of bladder stones, more than 2.5 cm" 51118115_1 CDM 0360 RC 52318 HCPCS inpatient 9420.12 6123.08 CIGNA - ALL PLANS CIGNA - ALL PLANS 6368 67.6 999999999 5703.88 9137.52 percent of total billed charges "Crushing, fragmenting, and removal of bladder stones, more than 2.5 cm" 51118115_1 CDM 0360 RC 52318 HCPCS inpatient 9420.12 6123.08 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5703.88 9137.52 "Crushing, fragmenting, and removal of bladder stones, more than 2.5 cm" 51118115_1 CDM 0360 RC 52318 HCPCS inpatient 9420.12 6123.08 UHC - ALL PLANS UHC - ALL PLANS 999999999 5703.88 9137.52 Crushing of stone of ureter using an endoscope 51118116_1 CDM 0360 RC 52353 HCPCS inpatient 13517.67 8786.49 SELF PAY DISCOUNT SELF PAY DISCOUNT 8786.49 65 999999999 8184.95 13112.14 percent of total billed charges Crushing of stone of ureter using an endoscope 51118116_1 CDM 0360 RC 52353 HCPCS inpatient 13517.67 8786.49 AETNA AETNA 10678.96 79 999999999 8184.95 13112.14 percent of total billed charges Crushing of stone of ureter using an endoscope 51118116_1 CDM 0360 RC 52353 HCPCS inpatient 13517.67 8786.49 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13112.14 97 999999999 8184.95 13112.14 percent of total billed charges Crushing of stone of ureter using an endoscope 51118116_1 CDM 0360 RC 52353 HCPCS inpatient 13517.67 8786.49 ENCORE - ALL PLANS ENCORE - ALL PLANS 9327.19 69 999999999 8184.95 13112.14 percent of total billed charges Crushing of stone of ureter using an endoscope 51118116_1 CDM 0360 RC 52353 HCPCS inpatient 13517.67 8786.49 SIHO - ALL PLANS SIHO - ALL PLANS 12165.9 90 999999999 8184.95 13112.14 percent of total billed charges Crushing of stone of ureter using an endoscope 51118116_1 CDM 0360 RC 52353 HCPCS inpatient 13517.67 8786.49 HUMANA - ALL PLANS HUMANA - ALL PLANS 10543.78 78 999999999 8184.95 13112.14 percent of total billed charges Crushing of stone of ureter using an endoscope 51118116_1 CDM 0360 RC 52353 HCPCS inpatient 13517.67 8786.49 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8184.95 60.55 999999999 8184.95 13112.14 percent of total billed charges Crushing of stone of ureter using an endoscope 51118116_1 CDM 0360 RC 52353 HCPCS inpatient 13517.67 8786.49 UMR - ALL PLANS UMR - ALL PLANS 9462.37 70 999999999 8184.95 13112.14 percent of total billed charges Crushing of stone of ureter using an endoscope 51118116_1 CDM 0360 RC 52353 HCPCS inpatient 13517.67 8786.49 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8184.95 13112.14 Crushing of stone of ureter using an endoscope 51118116_1 CDM 0360 RC 52353 HCPCS inpatient 13517.67 8786.49 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8184.95 13112.14 Crushing of stone of ureter using an endoscope 51118116_1 CDM 0360 RC 52353 HCPCS inpatient 13517.67 8786.49 ANTHEM HMO ANTHEM HMO 999999999 8184.95 13112.14 Crushing of stone of ureter using an endoscope 51118116_1 CDM 0360 RC 52353 HCPCS inpatient 13517.67 8786.49 CIGNA - ALL PLANS CIGNA - ALL PLANS 9137.94 67.6 999999999 8184.95 13112.14 percent of total billed charges Crushing of stone of ureter using an endoscope 51118116_1 CDM 0360 RC 52353 HCPCS inpatient 13517.67 8786.49 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8184.95 13112.14 Crushing of stone of ureter using an endoscope 51118116_1 CDM 0360 RC 52353 HCPCS inpatient 13517.67 8786.49 UHC - ALL PLANS UHC - ALL PLANS 999999999 8184.95 13112.14 Crushing of stone of ureter with insertion of stent using an endoscope 51118117_1 CDM 0360 RC 52356 HCPCS inpatient 13517.67 8786.49 SELF PAY DISCOUNT SELF PAY DISCOUNT 8786.49 65 999999999 8184.95 13112.14 percent of total billed charges Crushing of stone of ureter with insertion of stent using an endoscope 51118117_1 CDM 0360 RC 52356 HCPCS inpatient 13517.67 8786.49 AETNA AETNA 10678.96 79 999999999 8184.95 13112.14 percent of total billed charges Crushing of stone of ureter with insertion of stent using an endoscope 51118117_1 CDM 0360 RC 52356 HCPCS inpatient 13517.67 8786.49 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13112.14 97 999999999 8184.95 13112.14 percent of total billed charges Crushing of stone of ureter with insertion of stent using an endoscope 51118117_1 CDM 0360 RC 52356 HCPCS inpatient 13517.67 8786.49 ENCORE - ALL PLANS ENCORE - ALL PLANS 9327.19 69 999999999 8184.95 13112.14 percent of total billed charges Crushing of stone of ureter with insertion of stent using an endoscope 51118117_1 CDM 0360 RC 52356 HCPCS inpatient 13517.67 8786.49 SIHO - ALL PLANS SIHO - ALL PLANS 12165.9 90 999999999 8184.95 13112.14 percent of total billed charges Crushing of stone of ureter with insertion of stent using an endoscope 51118117_1 CDM 0360 RC 52356 HCPCS inpatient 13517.67 8786.49 HUMANA - ALL PLANS HUMANA - ALL PLANS 10543.78 78 999999999 8184.95 13112.14 percent of total billed charges Crushing of stone of ureter with insertion of stent using an endoscope 51118117_1 CDM 0360 RC 52356 HCPCS inpatient 13517.67 8786.49 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8184.95 60.55 999999999 8184.95 13112.14 percent of total billed charges Crushing of stone of ureter with insertion of stent using an endoscope 51118117_1 CDM 0360 RC 52356 HCPCS inpatient 13517.67 8786.49 UMR - ALL PLANS UMR - ALL PLANS 9462.37 70 999999999 8184.95 13112.14 percent of total billed charges Crushing of stone of ureter with insertion of stent using an endoscope 51118117_1 CDM 0360 RC 52356 HCPCS inpatient 13517.67 8786.49 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 8184.95 13112.14 Crushing of stone of ureter with insertion of stent using an endoscope 51118117_1 CDM 0360 RC 52356 HCPCS inpatient 13517.67 8786.49 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 8184.95 13112.14 Crushing of stone of ureter with insertion of stent using an endoscope 51118117_1 CDM 0360 RC 52356 HCPCS inpatient 13517.67 8786.49 ANTHEM HMO ANTHEM HMO 999999999 8184.95 13112.14 Crushing of stone of ureter with insertion of stent using an endoscope 51118117_1 CDM 0360 RC 52356 HCPCS inpatient 13517.67 8786.49 CIGNA - ALL PLANS CIGNA - ALL PLANS 9137.94 67.6 999999999 8184.95 13112.14 percent of total billed charges Crushing of stone of ureter with insertion of stent using an endoscope 51118117_1 CDM 0360 RC 52356 HCPCS inpatient 13517.67 8786.49 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 8184.95 13112.14 Crushing of stone of ureter with insertion of stent using an endoscope 51118117_1 CDM 0360 RC 52356 HCPCS inpatient 13517.67 8786.49 UHC - ALL PLANS UHC - ALL PLANS 999999999 8184.95 13112.14 Irrigation of implanted venous access drug delivery device 51120841_1 CDM 0761 RC 96523 HCPCS inpatient 177 115.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.05 65 999999999 107.17 171.69 percent of total billed charges Irrigation of implanted venous access drug delivery device 51120841_1 CDM 0761 RC 96523 HCPCS inpatient 177 115.05 AETNA AETNA 139.83 79 999999999 107.17 171.69 percent of total billed charges Irrigation of implanted venous access drug delivery device 51120841_1 CDM 0761 RC 96523 HCPCS inpatient 177 115.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 171.69 97 999999999 107.17 171.69 percent of total billed charges Irrigation of implanted venous access drug delivery device 51120841_1 CDM 0761 RC 96523 HCPCS inpatient 177 115.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.13 69 999999999 107.17 171.69 percent of total billed charges Irrigation of implanted venous access drug delivery device 51120841_1 CDM 0761 RC 96523 HCPCS inpatient 177 115.05 SIHO - ALL PLANS SIHO - ALL PLANS 159.3 90 999999999 107.17 171.69 percent of total billed charges Irrigation of implanted venous access drug delivery device 51120841_1 CDM 0761 RC 96523 HCPCS inpatient 177 115.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.06 78 999999999 107.17 171.69 percent of total billed charges Irrigation of implanted venous access drug delivery device 51120841_1 CDM 0761 RC 96523 HCPCS inpatient 177 115.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.17 60.55 999999999 107.17 171.69 percent of total billed charges Irrigation of implanted venous access drug delivery device 51120841_1 CDM 0761 RC 96523 HCPCS inpatient 177 115.05 UMR - ALL PLANS UMR - ALL PLANS 123.9 70 999999999 107.17 171.69 percent of total billed charges Irrigation of implanted venous access drug delivery device 51120841_1 CDM 0761 RC 96523 HCPCS inpatient 177 115.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.17 171.69 Irrigation of implanted venous access drug delivery device 51120841_1 CDM 0761 RC 96523 HCPCS inpatient 177 115.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.17 171.69 Irrigation of implanted venous access drug delivery device 51120841_1 CDM 0761 RC 96523 HCPCS inpatient 177 115.05 ANTHEM HMO ANTHEM HMO 999999999 107.17 171.69 Irrigation of implanted venous access drug delivery device 51120841_1 CDM 0761 RC 96523 HCPCS inpatient 177 115.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 119.65 67.6 999999999 107.17 171.69 percent of total billed charges Irrigation of implanted venous access drug delivery device 51120841_1 CDM 0761 RC 96523 HCPCS inpatient 177 115.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.17 171.69 Irrigation of implanted venous access drug delivery device 51120841_1 CDM 0761 RC 96523 HCPCS inpatient 177 115.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.17 171.69 "Analysis of substance using immunoassay technique, multiple step method" 51135048_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.4 65 999999999 58.13 93.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51135048_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 AETNA AETNA 75.84 79 999999999 58.13 93.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51135048_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.12 97 999999999 58.13 93.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51135048_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.24 69 999999999 58.13 93.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51135048_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 SIHO - ALL PLANS SIHO - ALL PLANS 86.4 90 999999999 58.13 93.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51135048_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.88 78 999999999 58.13 93.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51135048_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.13 60.55 999999999 58.13 93.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51135048_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 UMR - ALL PLANS UMR - ALL PLANS 67.2 70 999999999 58.13 93.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51135048_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.13 93.12 "Analysis of substance using immunoassay technique, multiple step method" 51135048_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.13 93.12 "Analysis of substance using immunoassay technique, multiple step method" 51135048_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 ANTHEM HMO ANTHEM HMO 999999999 58.13 93.12 "Analysis of substance using immunoassay technique, multiple step method" 51135048_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.9 67.6 999999999 58.13 93.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51135048_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.13 93.12 "Analysis of substance using immunoassay technique, multiple step method" 51135048_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.13 93.12 "Analysis of substance using immunoassay technique, multiple step method" 51135049_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.4 65 999999999 58.13 93.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51135049_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 AETNA AETNA 75.84 79 999999999 58.13 93.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51135049_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.12 97 999999999 58.13 93.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51135049_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.24 69 999999999 58.13 93.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51135049_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 SIHO - ALL PLANS SIHO - ALL PLANS 86.4 90 999999999 58.13 93.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51135049_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.88 78 999999999 58.13 93.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51135049_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.13 60.55 999999999 58.13 93.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51135049_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 UMR - ALL PLANS UMR - ALL PLANS 67.2 70 999999999 58.13 93.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51135049_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.13 93.12 "Analysis of substance using immunoassay technique, multiple step method" 51135049_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.13 93.12 "Analysis of substance using immunoassay technique, multiple step method" 51135049_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 ANTHEM HMO ANTHEM HMO 999999999 58.13 93.12 "Analysis of substance using immunoassay technique, multiple step method" 51135049_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.9 67.6 999999999 58.13 93.12 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51135049_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.13 93.12 "Analysis of substance using immunoassay technique, multiple step method" 51135049_1 CDM 0301 RC 83516 HCPCS inpatient 96 62.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.13 93.12 Gammaglobulin (immune system protein) measurement 51135159_1 CDM 0301 RC 82784 HCPCS inpatient 139 90.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 90.35 65 999999999 84.16 134.83 percent of total billed charges Gammaglobulin (immune system protein) measurement 51135159_1 CDM 0301 RC 82784 HCPCS inpatient 139 90.35 AETNA AETNA 109.81 79 999999999 84.16 134.83 percent of total billed charges Gammaglobulin (immune system protein) measurement 51135159_1 CDM 0301 RC 82784 HCPCS inpatient 139 90.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 134.83 97 999999999 84.16 134.83 percent of total billed charges Gammaglobulin (immune system protein) measurement 51135159_1 CDM 0301 RC 82784 HCPCS inpatient 139 90.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 95.91 69 999999999 84.16 134.83 percent of total billed charges Gammaglobulin (immune system protein) measurement 51135159_1 CDM 0301 RC 82784 HCPCS inpatient 139 90.35 SIHO - ALL PLANS SIHO - ALL PLANS 125.1 90 999999999 84.16 134.83 percent of total billed charges Gammaglobulin (immune system protein) measurement 51135159_1 CDM 0301 RC 82784 HCPCS inpatient 139 90.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 108.42 78 999999999 84.16 134.83 percent of total billed charges Gammaglobulin (immune system protein) measurement 51135159_1 CDM 0301 RC 82784 HCPCS inpatient 139 90.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 84.16 60.55 999999999 84.16 134.83 percent of total billed charges Gammaglobulin (immune system protein) measurement 51135159_1 CDM 0301 RC 82784 HCPCS inpatient 139 90.35 UMR - ALL PLANS UMR - ALL PLANS 97.3 70 999999999 84.16 134.83 percent of total billed charges Gammaglobulin (immune system protein) measurement 51135159_1 CDM 0301 RC 82784 HCPCS inpatient 139 90.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 84.16 134.83 Gammaglobulin (immune system protein) measurement 51135159_1 CDM 0301 RC 82784 HCPCS inpatient 139 90.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 84.16 134.83 Gammaglobulin (immune system protein) measurement 51135159_1 CDM 0301 RC 82784 HCPCS inpatient 139 90.35 ANTHEM HMO ANTHEM HMO 999999999 84.16 134.83 Gammaglobulin (immune system protein) measurement 51135159_1 CDM 0301 RC 82784 HCPCS inpatient 139 90.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 93.96 67.6 999999999 84.16 134.83 percent of total billed charges Gammaglobulin (immune system protein) measurement 51135159_1 CDM 0301 RC 82784 HCPCS inpatient 139 90.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 84.16 134.83 Gammaglobulin (immune system protein) measurement 51135159_1 CDM 0301 RC 82784 HCPCS inpatient 139 90.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 84.16 134.83 Analysis for antibody to mumps virus 51135180_1 CDM 0301 RC 86735 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to mumps virus 51135180_1 CDM 0301 RC 86735 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to mumps virus 51135180_1 CDM 0301 RC 86735 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to mumps virus 51135180_1 CDM 0301 RC 86735 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to mumps virus 51135180_1 CDM 0301 RC 86735 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to mumps virus 51135180_1 CDM 0301 RC 86735 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to mumps virus 51135180_1 CDM 0301 RC 86735 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to mumps virus 51135180_1 CDM 0301 RC 86735 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to mumps virus 51135180_1 CDM 0301 RC 86735 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Analysis for antibody to mumps virus 51135180_1 CDM 0301 RC 86735 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Analysis for antibody to mumps virus 51135180_1 CDM 0301 RC 86735 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Analysis for antibody to mumps virus 51135180_1 CDM 0301 RC 86735 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges Analysis for antibody to mumps virus 51135180_1 CDM 0301 RC 86735 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Analysis for antibody to mumps virus 51135180_1 CDM 0301 RC 86735 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Quantitation of therapeutic drug 51135244_1 CDM 0301 RC 80299 HCPCS inpatient 71 46.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.15 65 999999999 42.99 68.87 percent of total billed charges Quantitation of therapeutic drug 51135244_1 CDM 0301 RC 80299 HCPCS inpatient 71 46.15 AETNA AETNA 56.09 79 999999999 42.99 68.87 percent of total billed charges Quantitation of therapeutic drug 51135244_1 CDM 0301 RC 80299 HCPCS inpatient 71 46.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 68.87 97 999999999 42.99 68.87 percent of total billed charges Quantitation of therapeutic drug 51135244_1 CDM 0301 RC 80299 HCPCS inpatient 71 46.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.99 69 999999999 42.99 68.87 percent of total billed charges Quantitation of therapeutic drug 51135244_1 CDM 0301 RC 80299 HCPCS inpatient 71 46.15 SIHO - ALL PLANS SIHO - ALL PLANS 63.9 90 999999999 42.99 68.87 percent of total billed charges Quantitation of therapeutic drug 51135244_1 CDM 0301 RC 80299 HCPCS inpatient 71 46.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 55.38 78 999999999 42.99 68.87 percent of total billed charges Quantitation of therapeutic drug 51135244_1 CDM 0301 RC 80299 HCPCS inpatient 71 46.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.99 60.55 999999999 42.99 68.87 percent of total billed charges Quantitation of therapeutic drug 51135244_1 CDM 0301 RC 80299 HCPCS inpatient 71 46.15 UMR - ALL PLANS UMR - ALL PLANS 49.7 70 999999999 42.99 68.87 percent of total billed charges Quantitation of therapeutic drug 51135244_1 CDM 0301 RC 80299 HCPCS inpatient 71 46.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.99 68.87 Quantitation of therapeutic drug 51135244_1 CDM 0301 RC 80299 HCPCS inpatient 71 46.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.99 68.87 Quantitation of therapeutic drug 51135244_1 CDM 0301 RC 80299 HCPCS inpatient 71 46.15 ANTHEM HMO ANTHEM HMO 999999999 42.99 68.87 Quantitation of therapeutic drug 51135244_1 CDM 0301 RC 80299 HCPCS inpatient 71 46.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 48 67.6 999999999 42.99 68.87 percent of total billed charges Quantitation of therapeutic drug 51135244_1 CDM 0301 RC 80299 HCPCS inpatient 71 46.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.99 68.87 Quantitation of therapeutic drug 51135244_1 CDM 0301 RC 80299 HCPCS inpatient 71 46.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.99 68.87 Blood group typing (ABO) 51135910_1 CDM 0301 RC 86900 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges Blood group typing (ABO) 51135910_1 CDM 0301 RC 86900 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges Blood group typing (ABO) 51135910_1 CDM 0301 RC 86900 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges Blood group typing (ABO) 51135910_1 CDM 0301 RC 86900 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges Blood group typing (ABO) 51135910_1 CDM 0301 RC 86900 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges Blood group typing (ABO) 51135910_1 CDM 0301 RC 86900 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges Blood group typing (ABO) 51135910_1 CDM 0301 RC 86900 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges Blood group typing (ABO) 51135910_1 CDM 0301 RC 86900 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges Blood group typing (ABO) 51135910_1 CDM 0301 RC 86900 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 Blood group typing (ABO) 51135910_1 CDM 0301 RC 86900 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 Blood group typing (ABO) 51135910_1 CDM 0301 RC 86900 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 Blood group typing (ABO) 51135910_1 CDM 0301 RC 86900 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges Blood group typing (ABO) 51135910_1 CDM 0301 RC 86900 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 Blood group typing (ABO) 51135910_1 CDM 0301 RC 86900 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 Injection of anesthetic agent and/or steroid into face nerve 51145718_1 CDM 0360 RC 64400 HCPCS inpatient 699 454.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 454.35 65 999999999 423.24 678.03 percent of total billed charges Injection of anesthetic agent and/or steroid into face nerve 51145718_1 CDM 0360 RC 64400 HCPCS inpatient 699 454.35 AETNA AETNA 552.21 79 999999999 423.24 678.03 percent of total billed charges Injection of anesthetic agent and/or steroid into face nerve 51145718_1 CDM 0360 RC 64400 HCPCS inpatient 699 454.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 678.03 97 999999999 423.24 678.03 percent of total billed charges Injection of anesthetic agent and/or steroid into face nerve 51145718_1 CDM 0360 RC 64400 HCPCS inpatient 699 454.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 482.31 69 999999999 423.24 678.03 percent of total billed charges Injection of anesthetic agent and/or steroid into face nerve 51145718_1 CDM 0360 RC 64400 HCPCS inpatient 699 454.35 SIHO - ALL PLANS SIHO - ALL PLANS 629.1 90 999999999 423.24 678.03 percent of total billed charges Injection of anesthetic agent and/or steroid into face nerve 51145718_1 CDM 0360 RC 64400 HCPCS inpatient 699 454.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 545.22 78 999999999 423.24 678.03 percent of total billed charges Injection of anesthetic agent and/or steroid into face nerve 51145718_1 CDM 0360 RC 64400 HCPCS inpatient 699 454.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 423.24 60.55 999999999 423.24 678.03 percent of total billed charges Injection of anesthetic agent and/or steroid into face nerve 51145718_1 CDM 0360 RC 64400 HCPCS inpatient 699 454.35 UMR - ALL PLANS UMR - ALL PLANS 489.3 70 999999999 423.24 678.03 percent of total billed charges Injection of anesthetic agent and/or steroid into face nerve 51145718_1 CDM 0360 RC 64400 HCPCS inpatient 699 454.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 423.24 678.03 Injection of anesthetic agent and/or steroid into face nerve 51145718_1 CDM 0360 RC 64400 HCPCS inpatient 699 454.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 423.24 678.03 Injection of anesthetic agent and/or steroid into face nerve 51145718_1 CDM 0360 RC 64400 HCPCS inpatient 699 454.35 ANTHEM HMO ANTHEM HMO 999999999 423.24 678.03 Injection of anesthetic agent and/or steroid into face nerve 51145718_1 CDM 0360 RC 64400 HCPCS inpatient 699 454.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 472.52 67.6 999999999 423.24 678.03 percent of total billed charges Injection of anesthetic agent and/or steroid into face nerve 51145718_1 CDM 0360 RC 64400 HCPCS inpatient 699 454.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 423.24 678.03 Injection of anesthetic agent and/or steroid into face nerve 51145718_1 CDM 0360 RC 64400 HCPCS inpatient 699 454.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 423.24 678.03 Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 51145719_1 CDM 0360 RC 64421 HCPCS inpatient 1257 817.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 817.05 65 999999999 761.11 1219.29 percent of total billed charges Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 51145719_1 CDM 0360 RC 64421 HCPCS inpatient 1257 817.05 AETNA AETNA 993.03 79 999999999 761.11 1219.29 percent of total billed charges Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 51145719_1 CDM 0360 RC 64421 HCPCS inpatient 1257 817.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1219.29 97 999999999 761.11 1219.29 percent of total billed charges Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 51145719_1 CDM 0360 RC 64421 HCPCS inpatient 1257 817.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 867.33 69 999999999 761.11 1219.29 percent of total billed charges Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 51145719_1 CDM 0360 RC 64421 HCPCS inpatient 1257 817.05 SIHO - ALL PLANS SIHO - ALL PLANS 1131.3 90 999999999 761.11 1219.29 percent of total billed charges Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 51145719_1 CDM 0360 RC 64421 HCPCS inpatient 1257 817.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 980.46 78 999999999 761.11 1219.29 percent of total billed charges Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 51145719_1 CDM 0360 RC 64421 HCPCS inpatient 1257 817.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 761.11 60.55 999999999 761.11 1219.29 percent of total billed charges Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 51145719_1 CDM 0360 RC 64421 HCPCS inpatient 1257 817.05 UMR - ALL PLANS UMR - ALL PLANS 879.9 70 999999999 761.11 1219.29 percent of total billed charges Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 51145719_1 CDM 0360 RC 64421 HCPCS inpatient 1257 817.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 761.11 1219.29 Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 51145719_1 CDM 0360 RC 64421 HCPCS inpatient 1257 817.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 761.11 1219.29 Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 51145719_1 CDM 0360 RC 64421 HCPCS inpatient 1257 817.05 ANTHEM HMO ANTHEM HMO 999999999 761.11 1219.29 Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 51145719_1 CDM 0360 RC 64421 HCPCS inpatient 1257 817.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 849.73 67.6 999999999 761.11 1219.29 percent of total billed charges Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 51145719_1 CDM 0360 RC 64421 HCPCS inpatient 1257 817.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 761.11 1219.29 Injection of anesthetic agent and/or steroid into multiple rib nerves for regional nerve block 51145719_1 CDM 0360 RC 64421 HCPCS inpatient 1257 817.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 761.11 1219.29 Cryofibrinogen (protein) level 51146000_1 CDM 0305 RC 82585 HCPCS inpatient 65 42.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.25 65 999999999 39.36 63.05 percent of total billed charges Cryofibrinogen (protein) level 51146000_1 CDM 0305 RC 82585 HCPCS inpatient 65 42.25 AETNA AETNA 51.35 79 999999999 39.36 63.05 percent of total billed charges Cryofibrinogen (protein) level 51146000_1 CDM 0305 RC 82585 HCPCS inpatient 65 42.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 63.05 97 999999999 39.36 63.05 percent of total billed charges Cryofibrinogen (protein) level 51146000_1 CDM 0305 RC 82585 HCPCS inpatient 65 42.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.85 69 999999999 39.36 63.05 percent of total billed charges Cryofibrinogen (protein) level 51146000_1 CDM 0305 RC 82585 HCPCS inpatient 65 42.25 SIHO - ALL PLANS SIHO - ALL PLANS 58.5 90 999999999 39.36 63.05 percent of total billed charges Cryofibrinogen (protein) level 51146000_1 CDM 0305 RC 82585 HCPCS inpatient 65 42.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 50.7 78 999999999 39.36 63.05 percent of total billed charges Cryofibrinogen (protein) level 51146000_1 CDM 0305 RC 82585 HCPCS inpatient 65 42.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.36 60.55 999999999 39.36 63.05 percent of total billed charges Cryofibrinogen (protein) level 51146000_1 CDM 0305 RC 82585 HCPCS inpatient 65 42.25 UMR - ALL PLANS UMR - ALL PLANS 45.5 70 999999999 39.36 63.05 percent of total billed charges Cryofibrinogen (protein) level 51146000_1 CDM 0305 RC 82585 HCPCS inpatient 65 42.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.36 63.05 Cryofibrinogen (protein) level 51146000_1 CDM 0305 RC 82585 HCPCS inpatient 65 42.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.36 63.05 Cryofibrinogen (protein) level 51146000_1 CDM 0305 RC 82585 HCPCS inpatient 65 42.25 ANTHEM HMO ANTHEM HMO 999999999 39.36 63.05 Cryofibrinogen (protein) level 51146000_1 CDM 0305 RC 82585 HCPCS inpatient 65 42.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.94 67.6 999999999 39.36 63.05 percent of total billed charges Cryofibrinogen (protein) level 51146000_1 CDM 0305 RC 82585 HCPCS inpatient 65 42.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.36 63.05 Cryofibrinogen (protein) level 51146000_1 CDM 0305 RC 82585 HCPCS inpatient 65 42.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.36 63.05 "Injection of upper or middle spine facet joint using imaging guidance, second level" 51146041_1 CDM 0360 RC 64491 HCPCS inpatient 612 397.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 397.8 65 999999999 370.57 593.64 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, second level" 51146041_1 CDM 0360 RC 64491 HCPCS inpatient 612 397.8 AETNA AETNA 483.48 79 999999999 370.57 593.64 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, second level" 51146041_1 CDM 0360 RC 64491 HCPCS inpatient 612 397.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 593.64 97 999999999 370.57 593.64 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, second level" 51146041_1 CDM 0360 RC 64491 HCPCS inpatient 612 397.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 422.28 69 999999999 370.57 593.64 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, second level" 51146041_1 CDM 0360 RC 64491 HCPCS inpatient 612 397.8 SIHO - ALL PLANS SIHO - ALL PLANS 550.8 90 999999999 370.57 593.64 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, second level" 51146041_1 CDM 0360 RC 64491 HCPCS inpatient 612 397.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 477.36 78 999999999 370.57 593.64 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, second level" 51146041_1 CDM 0360 RC 64491 HCPCS inpatient 612 397.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 370.57 60.55 999999999 370.57 593.64 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, second level" 51146041_1 CDM 0360 RC 64491 HCPCS inpatient 612 397.8 UMR - ALL PLANS UMR - ALL PLANS 428.4 70 999999999 370.57 593.64 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, second level" 51146041_1 CDM 0360 RC 64491 HCPCS inpatient 612 397.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 370.57 593.64 "Injection of upper or middle spine facet joint using imaging guidance, second level" 51146041_1 CDM 0360 RC 64491 HCPCS inpatient 612 397.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 370.57 593.64 "Injection of upper or middle spine facet joint using imaging guidance, second level" 51146041_1 CDM 0360 RC 64491 HCPCS inpatient 612 397.8 ANTHEM HMO ANTHEM HMO 999999999 370.57 593.64 "Injection of upper or middle spine facet joint using imaging guidance, second level" 51146041_1 CDM 0360 RC 64491 HCPCS inpatient 612 397.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 413.71 67.6 999999999 370.57 593.64 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, second level" 51146041_1 CDM 0360 RC 64491 HCPCS inpatient 612 397.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 370.57 593.64 "Injection of upper or middle spine facet joint using imaging guidance, second level" 51146041_1 CDM 0360 RC 64491 HCPCS inpatient 612 397.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 370.57 593.64 "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 51146042_1 CDM 0360 RC 64492 HCPCS inpatient 556 361.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 361.4 65 999999999 336.66 539.32 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 51146042_1 CDM 0360 RC 64492 HCPCS inpatient 556 361.4 AETNA AETNA 439.24 79 999999999 336.66 539.32 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 51146042_1 CDM 0360 RC 64492 HCPCS inpatient 556 361.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 539.32 97 999999999 336.66 539.32 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 51146042_1 CDM 0360 RC 64492 HCPCS inpatient 556 361.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 383.64 69 999999999 336.66 539.32 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 51146042_1 CDM 0360 RC 64492 HCPCS inpatient 556 361.4 SIHO - ALL PLANS SIHO - ALL PLANS 500.4 90 999999999 336.66 539.32 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 51146042_1 CDM 0360 RC 64492 HCPCS inpatient 556 361.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 433.68 78 999999999 336.66 539.32 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 51146042_1 CDM 0360 RC 64492 HCPCS inpatient 556 361.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 336.66 60.55 999999999 336.66 539.32 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 51146042_1 CDM 0360 RC 64492 HCPCS inpatient 556 361.4 UMR - ALL PLANS UMR - ALL PLANS 389.2 70 999999999 336.66 539.32 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 51146042_1 CDM 0360 RC 64492 HCPCS inpatient 556 361.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 336.66 539.32 "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 51146042_1 CDM 0360 RC 64492 HCPCS inpatient 556 361.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 336.66 539.32 "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 51146042_1 CDM 0360 RC 64492 HCPCS inpatient 556 361.4 ANTHEM HMO ANTHEM HMO 999999999 336.66 539.32 "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 51146042_1 CDM 0360 RC 64492 HCPCS inpatient 556 361.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 375.86 67.6 999999999 336.66 539.32 percent of total billed charges "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 51146042_1 CDM 0360 RC 64492 HCPCS inpatient 556 361.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 336.66 539.32 "Injection of upper or middle spine facet joint using imaging guidance, third and any additional level" 51146042_1 CDM 0360 RC 64492 HCPCS inpatient 556 361.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 336.66 539.32 Injection of substance into lower spine canal 51146061_1 CDM 0360 RC 62322 HCPCS inpatient 2067 1343.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1343.55 65 999999999 1251.57 2004.99 percent of total billed charges Injection of substance into lower spine canal 51146061_1 CDM 0360 RC 62322 HCPCS inpatient 2067 1343.55 AETNA AETNA 1632.93 79 999999999 1251.57 2004.99 percent of total billed charges Injection of substance into lower spine canal 51146061_1 CDM 0360 RC 62322 HCPCS inpatient 2067 1343.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2004.99 97 999999999 1251.57 2004.99 percent of total billed charges Injection of substance into lower spine canal 51146061_1 CDM 0360 RC 62322 HCPCS inpatient 2067 1343.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1426.23 69 999999999 1251.57 2004.99 percent of total billed charges Injection of substance into lower spine canal 51146061_1 CDM 0360 RC 62322 HCPCS inpatient 2067 1343.55 SIHO - ALL PLANS SIHO - ALL PLANS 1860.3 90 999999999 1251.57 2004.99 percent of total billed charges Injection of substance into lower spine canal 51146061_1 CDM 0360 RC 62322 HCPCS inpatient 2067 1343.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1612.26 78 999999999 1251.57 2004.99 percent of total billed charges Injection of substance into lower spine canal 51146061_1 CDM 0360 RC 62322 HCPCS inpatient 2067 1343.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1251.57 60.55 999999999 1251.57 2004.99 percent of total billed charges Injection of substance into lower spine canal 51146061_1 CDM 0360 RC 62322 HCPCS inpatient 2067 1343.55 UMR - ALL PLANS UMR - ALL PLANS 1446.9 70 999999999 1251.57 2004.99 percent of total billed charges Injection of substance into lower spine canal 51146061_1 CDM 0360 RC 62322 HCPCS inpatient 2067 1343.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1251.57 2004.99 Injection of substance into lower spine canal 51146061_1 CDM 0360 RC 62322 HCPCS inpatient 2067 1343.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1251.57 2004.99 Injection of substance into lower spine canal 51146061_1 CDM 0360 RC 62322 HCPCS inpatient 2067 1343.55 ANTHEM HMO ANTHEM HMO 999999999 1251.57 2004.99 Injection of substance into lower spine canal 51146061_1 CDM 0360 RC 62322 HCPCS inpatient 2067 1343.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1397.29 67.6 999999999 1251.57 2004.99 percent of total billed charges Injection of substance into lower spine canal 51146061_1 CDM 0360 RC 62322 HCPCS inpatient 2067 1343.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1251.57 2004.99 Injection of substance into lower spine canal 51146061_1 CDM 0360 RC 62322 HCPCS inpatient 2067 1343.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1251.57 2004.99 Injection of substance into lower spine canal using imaging guidance 51146064_1 CDM 0360 RC 62323 HCPCS inpatient 2243 1457.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1457.95 65 999999999 1358.14 2175.71 percent of total billed charges Injection of substance into lower spine canal using imaging guidance 51146064_1 CDM 0360 RC 62323 HCPCS inpatient 2243 1457.95 AETNA AETNA 1771.97 79 999999999 1358.14 2175.71 percent of total billed charges Injection of substance into lower spine canal using imaging guidance 51146064_1 CDM 0360 RC 62323 HCPCS inpatient 2243 1457.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2175.71 97 999999999 1358.14 2175.71 percent of total billed charges Injection of substance into lower spine canal using imaging guidance 51146064_1 CDM 0360 RC 62323 HCPCS inpatient 2243 1457.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1547.67 69 999999999 1358.14 2175.71 percent of total billed charges Injection of substance into lower spine canal using imaging guidance 51146064_1 CDM 0360 RC 62323 HCPCS inpatient 2243 1457.95 SIHO - ALL PLANS SIHO - ALL PLANS 2018.7 90 999999999 1358.14 2175.71 percent of total billed charges Injection of substance into lower spine canal using imaging guidance 51146064_1 CDM 0360 RC 62323 HCPCS inpatient 2243 1457.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1749.54 78 999999999 1358.14 2175.71 percent of total billed charges Injection of substance into lower spine canal using imaging guidance 51146064_1 CDM 0360 RC 62323 HCPCS inpatient 2243 1457.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1358.14 60.55 999999999 1358.14 2175.71 percent of total billed charges Injection of substance into lower spine canal using imaging guidance 51146064_1 CDM 0360 RC 62323 HCPCS inpatient 2243 1457.95 UMR - ALL PLANS UMR - ALL PLANS 1570.1 70 999999999 1358.14 2175.71 percent of total billed charges Injection of substance into lower spine canal using imaging guidance 51146064_1 CDM 0360 RC 62323 HCPCS inpatient 2243 1457.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1358.14 2175.71 Injection of substance into lower spine canal using imaging guidance 51146064_1 CDM 0360 RC 62323 HCPCS inpatient 2243 1457.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1358.14 2175.71 Injection of substance into lower spine canal using imaging guidance 51146064_1 CDM 0360 RC 62323 HCPCS inpatient 2243 1457.95 ANTHEM HMO ANTHEM HMO 999999999 1358.14 2175.71 Injection of substance into lower spine canal using imaging guidance 51146064_1 CDM 0360 RC 62323 HCPCS inpatient 2243 1457.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1516.27 67.6 999999999 1358.14 2175.71 percent of total billed charges Injection of substance into lower spine canal using imaging guidance 51146064_1 CDM 0360 RC 62323 HCPCS inpatient 2243 1457.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1358.14 2175.71 Injection of substance into lower spine canal using imaging guidance 51146064_1 CDM 0360 RC 62323 HCPCS inpatient 2243 1457.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1358.14 2175.71 "Injection of lower or sacral spine facet joint using imaging guidance, second level" 51146065_1 CDM 0360 RC 64494 HCPCS inpatient 600 390 SELF PAY DISCOUNT SELF PAY DISCOUNT 390 65 999999999 363.3 582 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, second level" 51146065_1 CDM 0360 RC 64494 HCPCS inpatient 600 390 AETNA AETNA 474 79 999999999 363.3 582 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, second level" 51146065_1 CDM 0360 RC 64494 HCPCS inpatient 600 390 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 582 97 999999999 363.3 582 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, second level" 51146065_1 CDM 0360 RC 64494 HCPCS inpatient 600 390 ENCORE - ALL PLANS ENCORE - ALL PLANS 414 69 999999999 363.3 582 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, second level" 51146065_1 CDM 0360 RC 64494 HCPCS inpatient 600 390 SIHO - ALL PLANS SIHO - ALL PLANS 540 90 999999999 363.3 582 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, second level" 51146065_1 CDM 0360 RC 64494 HCPCS inpatient 600 390 HUMANA - ALL PLANS HUMANA - ALL PLANS 468 78 999999999 363.3 582 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, second level" 51146065_1 CDM 0360 RC 64494 HCPCS inpatient 600 390 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 363.3 60.55 999999999 363.3 582 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, second level" 51146065_1 CDM 0360 RC 64494 HCPCS inpatient 600 390 UMR - ALL PLANS UMR - ALL PLANS 420 70 999999999 363.3 582 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, second level" 51146065_1 CDM 0360 RC 64494 HCPCS inpatient 600 390 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 363.3 582 "Injection of lower or sacral spine facet joint using imaging guidance, second level" 51146065_1 CDM 0360 RC 64494 HCPCS inpatient 600 390 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 363.3 582 "Injection of lower or sacral spine facet joint using imaging guidance, second level" 51146065_1 CDM 0360 RC 64494 HCPCS inpatient 600 390 ANTHEM HMO ANTHEM HMO 999999999 363.3 582 "Injection of lower or sacral spine facet joint using imaging guidance, second level" 51146065_1 CDM 0360 RC 64494 HCPCS inpatient 600 390 CIGNA - ALL PLANS CIGNA - ALL PLANS 405.6 67.6 999999999 363.3 582 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, second level" 51146065_1 CDM 0360 RC 64494 HCPCS inpatient 600 390 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 363.3 582 "Injection of lower or sacral spine facet joint using imaging guidance, second level" 51146065_1 CDM 0360 RC 64494 HCPCS inpatient 600 390 UHC - ALL PLANS UHC - ALL PLANS 999999999 363.3 582 "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 51146066_1 CDM 0360 RC 64495 HCPCS inpatient 556 361.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 361.4 65 999999999 336.66 539.32 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 51146066_1 CDM 0360 RC 64495 HCPCS inpatient 556 361.4 AETNA AETNA 439.24 79 999999999 336.66 539.32 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 51146066_1 CDM 0360 RC 64495 HCPCS inpatient 556 361.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 539.32 97 999999999 336.66 539.32 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 51146066_1 CDM 0360 RC 64495 HCPCS inpatient 556 361.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 383.64 69 999999999 336.66 539.32 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 51146066_1 CDM 0360 RC 64495 HCPCS inpatient 556 361.4 SIHO - ALL PLANS SIHO - ALL PLANS 500.4 90 999999999 336.66 539.32 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 51146066_1 CDM 0360 RC 64495 HCPCS inpatient 556 361.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 433.68 78 999999999 336.66 539.32 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 51146066_1 CDM 0360 RC 64495 HCPCS inpatient 556 361.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 336.66 60.55 999999999 336.66 539.32 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 51146066_1 CDM 0360 RC 64495 HCPCS inpatient 556 361.4 UMR - ALL PLANS UMR - ALL PLANS 389.2 70 999999999 336.66 539.32 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 51146066_1 CDM 0360 RC 64495 HCPCS inpatient 556 361.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 336.66 539.32 "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 51146066_1 CDM 0360 RC 64495 HCPCS inpatient 556 361.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 336.66 539.32 "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 51146066_1 CDM 0360 RC 64495 HCPCS inpatient 556 361.4 ANTHEM HMO ANTHEM HMO 999999999 336.66 539.32 "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 51146066_1 CDM 0360 RC 64495 HCPCS inpatient 556 361.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 375.86 67.6 999999999 336.66 539.32 percent of total billed charges "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 51146066_1 CDM 0360 RC 64495 HCPCS inpatient 556 361.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 336.66 539.32 "Injection of lower or sacral spine facet joint using imaging guidance, third and any additional level" 51146066_1 CDM 0360 RC 64495 HCPCS inpatient 556 361.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 336.66 539.32 Destruction of peripheral nerve or branch 51146070_1 CDM 0360 RC 64640 HCPCS inpatient 1791 1164.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1164.15 65 999999999 1084.45 1737.27 percent of total billed charges Destruction of peripheral nerve or branch 51146070_1 CDM 0360 RC 64640 HCPCS inpatient 1791 1164.15 AETNA AETNA 1414.89 79 999999999 1084.45 1737.27 percent of total billed charges Destruction of peripheral nerve or branch 51146070_1 CDM 0360 RC 64640 HCPCS inpatient 1791 1164.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1737.27 97 999999999 1084.45 1737.27 percent of total billed charges Destruction of peripheral nerve or branch 51146070_1 CDM 0360 RC 64640 HCPCS inpatient 1791 1164.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1235.79 69 999999999 1084.45 1737.27 percent of total billed charges Destruction of peripheral nerve or branch 51146070_1 CDM 0360 RC 64640 HCPCS inpatient 1791 1164.15 SIHO - ALL PLANS SIHO - ALL PLANS 1611.9 90 999999999 1084.45 1737.27 percent of total billed charges Destruction of peripheral nerve or branch 51146070_1 CDM 0360 RC 64640 HCPCS inpatient 1791 1164.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1396.98 78 999999999 1084.45 1737.27 percent of total billed charges Destruction of peripheral nerve or branch 51146070_1 CDM 0360 RC 64640 HCPCS inpatient 1791 1164.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1084.45 60.55 999999999 1084.45 1737.27 percent of total billed charges Destruction of peripheral nerve or branch 51146070_1 CDM 0360 RC 64640 HCPCS inpatient 1791 1164.15 UMR - ALL PLANS UMR - ALL PLANS 1253.7 70 999999999 1084.45 1737.27 percent of total billed charges Destruction of peripheral nerve or branch 51146070_1 CDM 0360 RC 64640 HCPCS inpatient 1791 1164.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1084.45 1737.27 Destruction of peripheral nerve or branch 51146070_1 CDM 0360 RC 64640 HCPCS inpatient 1791 1164.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1084.45 1737.27 Destruction of peripheral nerve or branch 51146070_1 CDM 0360 RC 64640 HCPCS inpatient 1791 1164.15 ANTHEM HMO ANTHEM HMO 999999999 1084.45 1737.27 Destruction of peripheral nerve or branch 51146070_1 CDM 0360 RC 64640 HCPCS inpatient 1791 1164.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1210.72 67.6 999999999 1084.45 1737.27 percent of total billed charges Destruction of peripheral nerve or branch 51146070_1 CDM 0360 RC 64640 HCPCS inpatient 1791 1164.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1084.45 1737.27 Destruction of peripheral nerve or branch 51146070_1 CDM 0360 RC 64640 HCPCS inpatient 1791 1164.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1084.45 1737.27 Insertion of spinal neurostimulator electrode array through skin 51146071_1 CDM 0360 RC 63650 HCPCS inpatient 15119 9827.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 9827.35 65 999999999 9154.55 14665.43 percent of total billed charges Insertion of spinal neurostimulator electrode array through skin 51146071_1 CDM 0360 RC 63650 HCPCS inpatient 15119 9827.35 AETNA AETNA 11944.01 79 999999999 9154.55 14665.43 percent of total billed charges Insertion of spinal neurostimulator electrode array through skin 51146071_1 CDM 0360 RC 63650 HCPCS inpatient 15119 9827.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14665.43 97 999999999 9154.55 14665.43 percent of total billed charges Insertion of spinal neurostimulator electrode array through skin 51146071_1 CDM 0360 RC 63650 HCPCS inpatient 15119 9827.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 10432.11 69 999999999 9154.55 14665.43 percent of total billed charges Insertion of spinal neurostimulator electrode array through skin 51146071_1 CDM 0360 RC 63650 HCPCS inpatient 15119 9827.35 SIHO - ALL PLANS SIHO - ALL PLANS 13607.1 90 999999999 9154.55 14665.43 percent of total billed charges Insertion of spinal neurostimulator electrode array through skin 51146071_1 CDM 0360 RC 63650 HCPCS inpatient 15119 9827.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 11792.82 78 999999999 9154.55 14665.43 percent of total billed charges Insertion of spinal neurostimulator electrode array through skin 51146071_1 CDM 0360 RC 63650 HCPCS inpatient 15119 9827.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9154.55 60.55 999999999 9154.55 14665.43 percent of total billed charges Insertion of spinal neurostimulator electrode array through skin 51146071_1 CDM 0360 RC 63650 HCPCS inpatient 15119 9827.35 UMR - ALL PLANS UMR - ALL PLANS 10583.3 70 999999999 9154.55 14665.43 percent of total billed charges Insertion of spinal neurostimulator electrode array through skin 51146071_1 CDM 0360 RC 63650 HCPCS inpatient 15119 9827.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 9154.55 14665.43 Insertion of spinal neurostimulator electrode array through skin 51146071_1 CDM 0360 RC 63650 HCPCS inpatient 15119 9827.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 9154.55 14665.43 Insertion of spinal neurostimulator electrode array through skin 51146071_1 CDM 0360 RC 63650 HCPCS inpatient 15119 9827.35 ANTHEM HMO ANTHEM HMO 999999999 9154.55 14665.43 Insertion of spinal neurostimulator electrode array through skin 51146071_1 CDM 0360 RC 63650 HCPCS inpatient 15119 9827.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 10220.44 67.6 999999999 9154.55 14665.43 percent of total billed charges Insertion of spinal neurostimulator electrode array through skin 51146071_1 CDM 0360 RC 63650 HCPCS inpatient 15119 9827.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 9154.55 14665.43 Insertion of spinal neurostimulator electrode array through skin 51146071_1 CDM 0360 RC 63650 HCPCS inpatient 15119 9827.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 9154.55 14665.43 Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51146076_1 CDM 0360 RC 64417 HCPCS inpatient 566 367.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 367.9 65 999999999 342.71 549.02 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51146076_1 CDM 0360 RC 64417 HCPCS inpatient 566 367.9 AETNA AETNA 447.14 79 999999999 342.71 549.02 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51146076_1 CDM 0360 RC 64417 HCPCS inpatient 566 367.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 549.02 97 999999999 342.71 549.02 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51146076_1 CDM 0360 RC 64417 HCPCS inpatient 566 367.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 390.54 69 999999999 342.71 549.02 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51146076_1 CDM 0360 RC 64417 HCPCS inpatient 566 367.9 SIHO - ALL PLANS SIHO - ALL PLANS 509.4 90 999999999 342.71 549.02 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51146076_1 CDM 0360 RC 64417 HCPCS inpatient 566 367.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 441.48 78 999999999 342.71 549.02 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51146076_1 CDM 0360 RC 64417 HCPCS inpatient 566 367.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 342.71 60.55 999999999 342.71 549.02 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51146076_1 CDM 0360 RC 64417 HCPCS inpatient 566 367.9 UMR - ALL PLANS UMR - ALL PLANS 396.2 70 999999999 342.71 549.02 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51146076_1 CDM 0360 RC 64417 HCPCS inpatient 566 367.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 342.71 549.02 Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51146076_1 CDM 0360 RC 64417 HCPCS inpatient 566 367.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 342.71 549.02 Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51146076_1 CDM 0360 RC 64417 HCPCS inpatient 566 367.9 ANTHEM HMO ANTHEM HMO 999999999 342.71 549.02 Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51146076_1 CDM 0360 RC 64417 HCPCS inpatient 566 367.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 382.62 67.6 999999999 342.71 549.02 percent of total billed charges Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51146076_1 CDM 0360 RC 64417 HCPCS inpatient 566 367.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 342.71 549.02 Injection of anesthetic agent and/or steroid into upper arm and shoulder nerve (axillary nerve) 51146076_1 CDM 0360 RC 64417 HCPCS inpatient 566 367.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 342.71 549.02 Injection of anesthetic agent into sympathetic nerve bundle 51146077_1 CDM 0360 RC 64510 HCPCS inpatient 2686 1745.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1745.9 65 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into sympathetic nerve bundle 51146077_1 CDM 0360 RC 64510 HCPCS inpatient 2686 1745.9 AETNA AETNA 2121.94 79 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into sympathetic nerve bundle 51146077_1 CDM 0360 RC 64510 HCPCS inpatient 2686 1745.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2605.42 97 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into sympathetic nerve bundle 51146077_1 CDM 0360 RC 64510 HCPCS inpatient 2686 1745.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1853.34 69 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into sympathetic nerve bundle 51146077_1 CDM 0360 RC 64510 HCPCS inpatient 2686 1745.9 SIHO - ALL PLANS SIHO - ALL PLANS 2417.4 90 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into sympathetic nerve bundle 51146077_1 CDM 0360 RC 64510 HCPCS inpatient 2686 1745.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 2095.08 78 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into sympathetic nerve bundle 51146077_1 CDM 0360 RC 64510 HCPCS inpatient 2686 1745.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1626.37 60.55 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into sympathetic nerve bundle 51146077_1 CDM 0360 RC 64510 HCPCS inpatient 2686 1745.9 UMR - ALL PLANS UMR - ALL PLANS 1880.2 70 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into sympathetic nerve bundle 51146077_1 CDM 0360 RC 64510 HCPCS inpatient 2686 1745.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1626.37 2605.42 Injection of anesthetic agent into sympathetic nerve bundle 51146077_1 CDM 0360 RC 64510 HCPCS inpatient 2686 1745.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1626.37 2605.42 Injection of anesthetic agent into sympathetic nerve bundle 51146077_1 CDM 0360 RC 64510 HCPCS inpatient 2686 1745.9 ANTHEM HMO ANTHEM HMO 999999999 1626.37 2605.42 Injection of anesthetic agent into sympathetic nerve bundle 51146077_1 CDM 0360 RC 64510 HCPCS inpatient 2686 1745.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1815.74 67.6 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into sympathetic nerve bundle 51146077_1 CDM 0360 RC 64510 HCPCS inpatient 2686 1745.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1626.37 2605.42 Injection of anesthetic agent into sympathetic nerve bundle 51146077_1 CDM 0360 RC 64510 HCPCS inpatient 2686 1745.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1626.37 2605.42 Injection of anesthetic agent into middle or lower spine sympathetic nerve 51146078_1 CDM 0360 RC 64520 HCPCS inpatient 2686 1745.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1745.9 65 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into middle or lower spine sympathetic nerve 51146078_1 CDM 0360 RC 64520 HCPCS inpatient 2686 1745.9 AETNA AETNA 2121.94 79 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into middle or lower spine sympathetic nerve 51146078_1 CDM 0360 RC 64520 HCPCS inpatient 2686 1745.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2605.42 97 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into middle or lower spine sympathetic nerve 51146078_1 CDM 0360 RC 64520 HCPCS inpatient 2686 1745.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1853.34 69 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into middle or lower spine sympathetic nerve 51146078_1 CDM 0360 RC 64520 HCPCS inpatient 2686 1745.9 SIHO - ALL PLANS SIHO - ALL PLANS 2417.4 90 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into middle or lower spine sympathetic nerve 51146078_1 CDM 0360 RC 64520 HCPCS inpatient 2686 1745.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 2095.08 78 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into middle or lower spine sympathetic nerve 51146078_1 CDM 0360 RC 64520 HCPCS inpatient 2686 1745.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1626.37 60.55 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into middle or lower spine sympathetic nerve 51146078_1 CDM 0360 RC 64520 HCPCS inpatient 2686 1745.9 UMR - ALL PLANS UMR - ALL PLANS 1880.2 70 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into middle or lower spine sympathetic nerve 51146078_1 CDM 0360 RC 64520 HCPCS inpatient 2686 1745.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1626.37 2605.42 Injection of anesthetic agent into middle or lower spine sympathetic nerve 51146078_1 CDM 0360 RC 64520 HCPCS inpatient 2686 1745.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1626.37 2605.42 Injection of anesthetic agent into middle or lower spine sympathetic nerve 51146078_1 CDM 0360 RC 64520 HCPCS inpatient 2686 1745.9 ANTHEM HMO ANTHEM HMO 999999999 1626.37 2605.42 Injection of anesthetic agent into middle or lower spine sympathetic nerve 51146078_1 CDM 0360 RC 64520 HCPCS inpatient 2686 1745.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1815.74 67.6 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into middle or lower spine sympathetic nerve 51146078_1 CDM 0360 RC 64520 HCPCS inpatient 2686 1745.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1626.37 2605.42 Injection of anesthetic agent into middle or lower spine sympathetic nerve 51146078_1 CDM 0360 RC 64520 HCPCS inpatient 2686 1745.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1626.37 2605.42 Injection of anesthetic agent into abdominal sympathetic nerve bundle 51146082_1 CDM 0360 RC 64530 HCPCS inpatient 2686 1745.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1745.9 65 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into abdominal sympathetic nerve bundle 51146082_1 CDM 0360 RC 64530 HCPCS inpatient 2686 1745.9 AETNA AETNA 2121.94 79 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into abdominal sympathetic nerve bundle 51146082_1 CDM 0360 RC 64530 HCPCS inpatient 2686 1745.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2605.42 97 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into abdominal sympathetic nerve bundle 51146082_1 CDM 0360 RC 64530 HCPCS inpatient 2686 1745.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1853.34 69 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into abdominal sympathetic nerve bundle 51146082_1 CDM 0360 RC 64530 HCPCS inpatient 2686 1745.9 SIHO - ALL PLANS SIHO - ALL PLANS 2417.4 90 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into abdominal sympathetic nerve bundle 51146082_1 CDM 0360 RC 64530 HCPCS inpatient 2686 1745.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 2095.08 78 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into abdominal sympathetic nerve bundle 51146082_1 CDM 0360 RC 64530 HCPCS inpatient 2686 1745.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1626.37 60.55 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into abdominal sympathetic nerve bundle 51146082_1 CDM 0360 RC 64530 HCPCS inpatient 2686 1745.9 UMR - ALL PLANS UMR - ALL PLANS 1880.2 70 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into abdominal sympathetic nerve bundle 51146082_1 CDM 0360 RC 64530 HCPCS inpatient 2686 1745.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1626.37 2605.42 Injection of anesthetic agent into abdominal sympathetic nerve bundle 51146082_1 CDM 0360 RC 64530 HCPCS inpatient 2686 1745.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1626.37 2605.42 Injection of anesthetic agent into abdominal sympathetic nerve bundle 51146082_1 CDM 0360 RC 64530 HCPCS inpatient 2686 1745.9 ANTHEM HMO ANTHEM HMO 999999999 1626.37 2605.42 Injection of anesthetic agent into abdominal sympathetic nerve bundle 51146082_1 CDM 0360 RC 64530 HCPCS inpatient 2686 1745.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1815.74 67.6 999999999 1626.37 2605.42 percent of total billed charges Injection of anesthetic agent into abdominal sympathetic nerve bundle 51146082_1 CDM 0360 RC 64530 HCPCS inpatient 2686 1745.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1626.37 2605.42 Injection of anesthetic agent into abdominal sympathetic nerve bundle 51146082_1 CDM 0360 RC 64530 HCPCS inpatient 2686 1745.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1626.37 2605.42 Other procedure on nervous system 51146086_1 CDM 0360 RC 64999 HCPCS inpatient 566 367.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 367.9 65 999999999 342.71 549.02 percent of total billed charges Other procedure on nervous system 51146086_1 CDM 0360 RC 64999 HCPCS inpatient 566 367.9 AETNA AETNA 447.14 79 999999999 342.71 549.02 percent of total billed charges Other procedure on nervous system 51146086_1 CDM 0360 RC 64999 HCPCS inpatient 566 367.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 549.02 97 999999999 342.71 549.02 percent of total billed charges Other procedure on nervous system 51146086_1 CDM 0360 RC 64999 HCPCS inpatient 566 367.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 390.54 69 999999999 342.71 549.02 percent of total billed charges Other procedure on nervous system 51146086_1 CDM 0360 RC 64999 HCPCS inpatient 566 367.9 SIHO - ALL PLANS SIHO - ALL PLANS 509.4 90 999999999 342.71 549.02 percent of total billed charges Other procedure on nervous system 51146086_1 CDM 0360 RC 64999 HCPCS inpatient 566 367.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 441.48 78 999999999 342.71 549.02 percent of total billed charges Other procedure on nervous system 51146086_1 CDM 0360 RC 64999 HCPCS inpatient 566 367.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 342.71 60.55 999999999 342.71 549.02 percent of total billed charges Other procedure on nervous system 51146086_1 CDM 0360 RC 64999 HCPCS inpatient 566 367.9 UMR - ALL PLANS UMR - ALL PLANS 396.2 70 999999999 342.71 549.02 percent of total billed charges Other procedure on nervous system 51146086_1 CDM 0360 RC 64999 HCPCS inpatient 566 367.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 342.71 549.02 Other procedure on nervous system 51146086_1 CDM 0360 RC 64999 HCPCS inpatient 566 367.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 342.71 549.02 Other procedure on nervous system 51146086_1 CDM 0360 RC 64999 HCPCS inpatient 566 367.9 ANTHEM HMO ANTHEM HMO 999999999 342.71 549.02 Other procedure on nervous system 51146086_1 CDM 0360 RC 64999 HCPCS inpatient 566 367.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 382.62 67.6 999999999 342.71 549.02 percent of total billed charges Other procedure on nervous system 51146086_1 CDM 0360 RC 64999 HCPCS inpatient 566 367.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 342.71 549.02 Other procedure on nervous system 51146086_1 CDM 0360 RC 64999 HCPCS inpatient 566 367.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 342.71 549.02 "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 51146087_1 CDM 0360 RC 64642 HCPCS inpatient 1666 1082.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1082.9 65 999999999 1008.76 1616.02 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 51146087_1 CDM 0360 RC 64642 HCPCS inpatient 1666 1082.9 AETNA AETNA 1316.14 79 999999999 1008.76 1616.02 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 51146087_1 CDM 0360 RC 64642 HCPCS inpatient 1666 1082.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1616.02 97 999999999 1008.76 1616.02 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 51146087_1 CDM 0360 RC 64642 HCPCS inpatient 1666 1082.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1149.54 69 999999999 1008.76 1616.02 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 51146087_1 CDM 0360 RC 64642 HCPCS inpatient 1666 1082.9 SIHO - ALL PLANS SIHO - ALL PLANS 1499.4 90 999999999 1008.76 1616.02 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 51146087_1 CDM 0360 RC 64642 HCPCS inpatient 1666 1082.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1299.48 78 999999999 1008.76 1616.02 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 51146087_1 CDM 0360 RC 64642 HCPCS inpatient 1666 1082.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1008.76 60.55 999999999 1008.76 1616.02 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 51146087_1 CDM 0360 RC 64642 HCPCS inpatient 1666 1082.9 UMR - ALL PLANS UMR - ALL PLANS 1166.2 70 999999999 1008.76 1616.02 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 51146087_1 CDM 0360 RC 64642 HCPCS inpatient 1666 1082.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1008.76 1616.02 "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 51146087_1 CDM 0360 RC 64642 HCPCS inpatient 1666 1082.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1008.76 1616.02 "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 51146087_1 CDM 0360 RC 64642 HCPCS inpatient 1666 1082.9 ANTHEM HMO ANTHEM HMO 999999999 1008.76 1616.02 "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 51146087_1 CDM 0360 RC 64642 HCPCS inpatient 1666 1082.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1126.22 67.6 999999999 1008.76 1616.02 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 51146087_1 CDM 0360 RC 64642 HCPCS inpatient 1666 1082.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1008.76 1616.02 "Injection of chemical for paralysis of nerve muscles on arm or leg, 1-4 muscles, first extremity" 51146087_1 CDM 0360 RC 64642 HCPCS inpatient 1666 1082.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1008.76 1616.02 "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 51146088_1 CDM 0360 RC 64646 HCPCS inpatient 1666 1082.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1082.9 65 999999999 1008.76 1616.02 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 51146088_1 CDM 0360 RC 64646 HCPCS inpatient 1666 1082.9 AETNA AETNA 1316.14 79 999999999 1008.76 1616.02 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 51146088_1 CDM 0360 RC 64646 HCPCS inpatient 1666 1082.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1616.02 97 999999999 1008.76 1616.02 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 51146088_1 CDM 0360 RC 64646 HCPCS inpatient 1666 1082.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1149.54 69 999999999 1008.76 1616.02 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 51146088_1 CDM 0360 RC 64646 HCPCS inpatient 1666 1082.9 SIHO - ALL PLANS SIHO - ALL PLANS 1499.4 90 999999999 1008.76 1616.02 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 51146088_1 CDM 0360 RC 64646 HCPCS inpatient 1666 1082.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1299.48 78 999999999 1008.76 1616.02 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 51146088_1 CDM 0360 RC 64646 HCPCS inpatient 1666 1082.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1008.76 60.55 999999999 1008.76 1616.02 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 51146088_1 CDM 0360 RC 64646 HCPCS inpatient 1666 1082.9 UMR - ALL PLANS UMR - ALL PLANS 1166.2 70 999999999 1008.76 1616.02 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 51146088_1 CDM 0360 RC 64646 HCPCS inpatient 1666 1082.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1008.76 1616.02 "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 51146088_1 CDM 0360 RC 64646 HCPCS inpatient 1666 1082.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1008.76 1616.02 "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 51146088_1 CDM 0360 RC 64646 HCPCS inpatient 1666 1082.9 ANTHEM HMO ANTHEM HMO 999999999 1008.76 1616.02 "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 51146088_1 CDM 0360 RC 64646 HCPCS inpatient 1666 1082.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1126.22 67.6 999999999 1008.76 1616.02 percent of total billed charges "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 51146088_1 CDM 0360 RC 64646 HCPCS inpatient 1666 1082.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1008.76 1616.02 "Injection of chemical for paralysis of nerve muscles on trunk, 1-5 muscles" 51146088_1 CDM 0360 RC 64646 HCPCS inpatient 1666 1082.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1008.76 1616.02 Aspiration and/or injection of fluid from small joint using ultrasound guidance 51146099_1 CDM 0360 RC 20604 HCPCS inpatient 642 417.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 417.3 65 999999999 388.73 622.74 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 51146099_1 CDM 0360 RC 20604 HCPCS inpatient 642 417.3 AETNA AETNA 507.18 79 999999999 388.73 622.74 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 51146099_1 CDM 0360 RC 20604 HCPCS inpatient 642 417.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 622.74 97 999999999 388.73 622.74 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 51146099_1 CDM 0360 RC 20604 HCPCS inpatient 642 417.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 442.98 69 999999999 388.73 622.74 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 51146099_1 CDM 0360 RC 20604 HCPCS inpatient 642 417.3 SIHO - ALL PLANS SIHO - ALL PLANS 577.8 90 999999999 388.73 622.74 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 51146099_1 CDM 0360 RC 20604 HCPCS inpatient 642 417.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 500.76 78 999999999 388.73 622.74 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 51146099_1 CDM 0360 RC 20604 HCPCS inpatient 642 417.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 388.73 60.55 999999999 388.73 622.74 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 51146099_1 CDM 0360 RC 20604 HCPCS inpatient 642 417.3 UMR - ALL PLANS UMR - ALL PLANS 449.4 70 999999999 388.73 622.74 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 51146099_1 CDM 0360 RC 20604 HCPCS inpatient 642 417.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 388.73 622.74 Aspiration and/or injection of fluid from small joint using ultrasound guidance 51146099_1 CDM 0360 RC 20604 HCPCS inpatient 642 417.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 388.73 622.74 Aspiration and/or injection of fluid from small joint using ultrasound guidance 51146099_1 CDM 0360 RC 20604 HCPCS inpatient 642 417.3 ANTHEM HMO ANTHEM HMO 999999999 388.73 622.74 Aspiration and/or injection of fluid from small joint using ultrasound guidance 51146099_1 CDM 0360 RC 20604 HCPCS inpatient 642 417.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 433.99 67.6 999999999 388.73 622.74 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 51146099_1 CDM 0360 RC 20604 HCPCS inpatient 642 417.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 388.73 622.74 Aspiration and/or injection of fluid from small joint using ultrasound guidance 51146099_1 CDM 0360 RC 20604 HCPCS inpatient 642 417.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 388.73 622.74 Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51146100_1 CDM 0360 RC 20606 HCPCS inpatient 642 417.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 417.3 65 999999999 388.73 622.74 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51146100_1 CDM 0360 RC 20606 HCPCS inpatient 642 417.3 AETNA AETNA 507.18 79 999999999 388.73 622.74 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51146100_1 CDM 0360 RC 20606 HCPCS inpatient 642 417.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 622.74 97 999999999 388.73 622.74 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51146100_1 CDM 0360 RC 20606 HCPCS inpatient 642 417.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 442.98 69 999999999 388.73 622.74 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51146100_1 CDM 0360 RC 20606 HCPCS inpatient 642 417.3 SIHO - ALL PLANS SIHO - ALL PLANS 577.8 90 999999999 388.73 622.74 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51146100_1 CDM 0360 RC 20606 HCPCS inpatient 642 417.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 500.76 78 999999999 388.73 622.74 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51146100_1 CDM 0360 RC 20606 HCPCS inpatient 642 417.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 388.73 60.55 999999999 388.73 622.74 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51146100_1 CDM 0360 RC 20606 HCPCS inpatient 642 417.3 UMR - ALL PLANS UMR - ALL PLANS 449.4 70 999999999 388.73 622.74 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51146100_1 CDM 0360 RC 20606 HCPCS inpatient 642 417.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 388.73 622.74 Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51146100_1 CDM 0360 RC 20606 HCPCS inpatient 642 417.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 388.73 622.74 Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51146100_1 CDM 0360 RC 20606 HCPCS inpatient 642 417.3 ANTHEM HMO ANTHEM HMO 999999999 388.73 622.74 Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51146100_1 CDM 0360 RC 20606 HCPCS inpatient 642 417.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 433.99 67.6 999999999 388.73 622.74 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51146100_1 CDM 0360 RC 20606 HCPCS inpatient 642 417.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 388.73 622.74 Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51146100_1 CDM 0360 RC 20606 HCPCS inpatient 642 417.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 388.73 622.74 Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 51146104_1 CDM 0360 RC 27096 HCPCS inpatient 1558 1012.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1012.7 65 999999999 943.37 1511.26 percent of total billed charges Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 51146104_1 CDM 0360 RC 27096 HCPCS inpatient 1558 1012.7 AETNA AETNA 1230.82 79 999999999 943.37 1511.26 percent of total billed charges Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 51146104_1 CDM 0360 RC 27096 HCPCS inpatient 1558 1012.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1511.26 97 999999999 943.37 1511.26 percent of total billed charges Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 51146104_1 CDM 0360 RC 27096 HCPCS inpatient 1558 1012.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 1075.02 69 999999999 943.37 1511.26 percent of total billed charges Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 51146104_1 CDM 0360 RC 27096 HCPCS inpatient 1558 1012.7 SIHO - ALL PLANS SIHO - ALL PLANS 1402.2 90 999999999 943.37 1511.26 percent of total billed charges Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 51146104_1 CDM 0360 RC 27096 HCPCS inpatient 1558 1012.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 1215.24 78 999999999 943.37 1511.26 percent of total billed charges Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 51146104_1 CDM 0360 RC 27096 HCPCS inpatient 1558 1012.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 943.37 60.55 999999999 943.37 1511.26 percent of total billed charges Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 51146104_1 CDM 0360 RC 27096 HCPCS inpatient 1558 1012.7 UMR - ALL PLANS UMR - ALL PLANS 1090.6 70 999999999 943.37 1511.26 percent of total billed charges Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 51146104_1 CDM 0360 RC 27096 HCPCS inpatient 1558 1012.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 943.37 1511.26 Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 51146104_1 CDM 0360 RC 27096 HCPCS inpatient 1558 1012.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 943.37 1511.26 Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 51146104_1 CDM 0360 RC 27096 HCPCS inpatient 1558 1012.7 ANTHEM HMO ANTHEM HMO 999999999 943.37 1511.26 Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 51146104_1 CDM 0360 RC 27096 HCPCS inpatient 1558 1012.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 1053.21 67.6 999999999 943.37 1511.26 percent of total billed charges Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 51146104_1 CDM 0360 RC 27096 HCPCS inpatient 1558 1012.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 943.37 1511.26 Injection of anesthetic or steroid into joint between lower spine and hip bone using imaging guidance 51146104_1 CDM 0360 RC 27096 HCPCS inpatient 1558 1012.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 943.37 1511.26 "Use of a drug to induce depression of consciousness by physician performing a procedure, each additional 15 minutes" 51146120_1 CDM 0360 RC 99153 HCPCS inpatient 21 13.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 13.65 65 999999999 12.72 20.37 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure, each additional 15 minutes" 51146120_1 CDM 0360 RC 99153 HCPCS inpatient 21 13.65 AETNA AETNA 16.59 79 999999999 12.72 20.37 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure, each additional 15 minutes" 51146120_1 CDM 0360 RC 99153 HCPCS inpatient 21 13.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20.37 97 999999999 12.72 20.37 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure, each additional 15 minutes" 51146120_1 CDM 0360 RC 99153 HCPCS inpatient 21 13.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 14.49 69 999999999 12.72 20.37 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure, each additional 15 minutes" 51146120_1 CDM 0360 RC 99153 HCPCS inpatient 21 13.65 SIHO - ALL PLANS SIHO - ALL PLANS 18.9 90 999999999 12.72 20.37 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure, each additional 15 minutes" 51146120_1 CDM 0360 RC 99153 HCPCS inpatient 21 13.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 16.38 78 999999999 12.72 20.37 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure, each additional 15 minutes" 51146120_1 CDM 0360 RC 99153 HCPCS inpatient 21 13.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12.72 60.55 999999999 12.72 20.37 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure, each additional 15 minutes" 51146120_1 CDM 0360 RC 99153 HCPCS inpatient 21 13.65 UMR - ALL PLANS UMR - ALL PLANS 14.7 70 999999999 12.72 20.37 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure, each additional 15 minutes" 51146120_1 CDM 0360 RC 99153 HCPCS inpatient 21 13.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 12.72 20.37 "Use of a drug to induce depression of consciousness by physician performing a procedure, each additional 15 minutes" 51146120_1 CDM 0360 RC 99153 HCPCS inpatient 21 13.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 12.72 20.37 "Use of a drug to induce depression of consciousness by physician performing a procedure, each additional 15 minutes" 51146120_1 CDM 0360 RC 99153 HCPCS inpatient 21 13.65 ANTHEM HMO ANTHEM HMO 999999999 12.72 20.37 "Use of a drug to induce depression of consciousness by physician performing a procedure, each additional 15 minutes" 51146120_1 CDM 0360 RC 99153 HCPCS inpatient 21 13.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 12.72 20.37 "Use of a drug to induce depression of consciousness by physician performing a procedure, each additional 15 minutes" 51146120_1 CDM 0360 RC 99153 HCPCS inpatient 21 13.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 14.2 67.6 999999999 12.72 20.37 percent of total billed charges "Use of a drug to induce depression of consciousness by physician performing a procedure, each additional 15 minutes" 51146120_1 CDM 0360 RC 99153 HCPCS inpatient 21 13.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 12.72 20.37 Injection of substance into lower spine canal 51146121_1 CDM 0360 RC 62322 HCPCS inpatient 1923 1249.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1249.95 65 999999999 1164.38 1865.31 percent of total billed charges Injection of substance into lower spine canal 51146121_1 CDM 0360 RC 62322 HCPCS inpatient 1923 1249.95 AETNA AETNA 1519.17 79 999999999 1164.38 1865.31 percent of total billed charges Injection of substance into lower spine canal 51146121_1 CDM 0360 RC 62322 HCPCS inpatient 1923 1249.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1865.31 97 999999999 1164.38 1865.31 percent of total billed charges Injection of substance into lower spine canal 51146121_1 CDM 0360 RC 62322 HCPCS inpatient 1923 1249.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1326.87 69 999999999 1164.38 1865.31 percent of total billed charges Injection of substance into lower spine canal 51146121_1 CDM 0360 RC 62322 HCPCS inpatient 1923 1249.95 SIHO - ALL PLANS SIHO - ALL PLANS 1730.7 90 999999999 1164.38 1865.31 percent of total billed charges Injection of substance into lower spine canal 51146121_1 CDM 0360 RC 62322 HCPCS inpatient 1923 1249.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1499.94 78 999999999 1164.38 1865.31 percent of total billed charges Injection of substance into lower spine canal 51146121_1 CDM 0360 RC 62322 HCPCS inpatient 1923 1249.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1164.38 60.55 999999999 1164.38 1865.31 percent of total billed charges Injection of substance into lower spine canal 51146121_1 CDM 0360 RC 62322 HCPCS inpatient 1923 1249.95 UMR - ALL PLANS UMR - ALL PLANS 1346.1 70 999999999 1164.38 1865.31 percent of total billed charges Injection of substance into lower spine canal 51146121_1 CDM 0360 RC 62322 HCPCS inpatient 1923 1249.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1164.38 1865.31 Injection of substance into lower spine canal 51146121_1 CDM 0360 RC 62322 HCPCS inpatient 1923 1249.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1164.38 1865.31 Injection of substance into lower spine canal 51146121_1 CDM 0360 RC 62322 HCPCS inpatient 1923 1249.95 ANTHEM HMO ANTHEM HMO 999999999 1164.38 1865.31 Injection of substance into lower spine canal 51146121_1 CDM 0360 RC 62322 HCPCS inpatient 1923 1249.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1164.38 1865.31 Injection of substance into lower spine canal 51146121_1 CDM 0360 RC 62322 HCPCS inpatient 1923 1249.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1299.95 67.6 999999999 1164.38 1865.31 percent of total billed charges Injection of substance into lower spine canal 51146121_1 CDM 0360 RC 62322 HCPCS inpatient 1923 1249.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1164.38 1865.31 Injection into tendon at attachment to bone or muscle 51146127_1 CDM 0360 RC 20551 HCPCS inpatient 690 448.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 448.5 65 999999999 417.8 669.3 percent of total billed charges Injection into tendon at attachment to bone or muscle 51146127_1 CDM 0360 RC 20551 HCPCS inpatient 690 448.5 AETNA AETNA 545.1 79 999999999 417.8 669.3 percent of total billed charges Injection into tendon at attachment to bone or muscle 51146127_1 CDM 0360 RC 20551 HCPCS inpatient 690 448.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 669.3 97 999999999 417.8 669.3 percent of total billed charges Injection into tendon at attachment to bone or muscle 51146127_1 CDM 0360 RC 20551 HCPCS inpatient 690 448.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 476.1 69 999999999 417.8 669.3 percent of total billed charges Injection into tendon at attachment to bone or muscle 51146127_1 CDM 0360 RC 20551 HCPCS inpatient 690 448.5 SIHO - ALL PLANS SIHO - ALL PLANS 621 90 999999999 417.8 669.3 percent of total billed charges Injection into tendon at attachment to bone or muscle 51146127_1 CDM 0360 RC 20551 HCPCS inpatient 690 448.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 538.2 78 999999999 417.8 669.3 percent of total billed charges Injection into tendon at attachment to bone or muscle 51146127_1 CDM 0360 RC 20551 HCPCS inpatient 690 448.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 417.8 60.55 999999999 417.8 669.3 percent of total billed charges Injection into tendon at attachment to bone or muscle 51146127_1 CDM 0360 RC 20551 HCPCS inpatient 690 448.5 UMR - ALL PLANS UMR - ALL PLANS 483 70 999999999 417.8 669.3 percent of total billed charges Injection into tendon at attachment to bone or muscle 51146127_1 CDM 0360 RC 20551 HCPCS inpatient 690 448.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 417.8 669.3 Injection into tendon at attachment to bone or muscle 51146127_1 CDM 0360 RC 20551 HCPCS inpatient 690 448.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 417.8 669.3 Injection into tendon at attachment to bone or muscle 51146127_1 CDM 0360 RC 20551 HCPCS inpatient 690 448.5 ANTHEM HMO ANTHEM HMO 999999999 417.8 669.3 Injection into tendon at attachment to bone or muscle 51146127_1 CDM 0360 RC 20551 HCPCS inpatient 690 448.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 417.8 669.3 Injection into tendon at attachment to bone or muscle 51146127_1 CDM 0360 RC 20551 HCPCS inpatient 690 448.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 466.44 67.6 999999999 417.8 669.3 percent of total billed charges Injection into tendon at attachment to bone or muscle 51146127_1 CDM 0360 RC 20551 HCPCS inpatient 690 448.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 417.8 669.3 Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 51146132_1 CDM 0360 RC 95971 HCPCS inpatient 420 273 SELF PAY DISCOUNT SELF PAY DISCOUNT 273 65 999999999 254.31 407.4 percent of total billed charges Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 51146132_1 CDM 0360 RC 95971 HCPCS inpatient 420 273 AETNA AETNA 331.8 79 999999999 254.31 407.4 percent of total billed charges Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 51146132_1 CDM 0360 RC 95971 HCPCS inpatient 420 273 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 407.4 97 999999999 254.31 407.4 percent of total billed charges Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 51146132_1 CDM 0360 RC 95971 HCPCS inpatient 420 273 ENCORE - ALL PLANS ENCORE - ALL PLANS 289.8 69 999999999 254.31 407.4 percent of total billed charges Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 51146132_1 CDM 0360 RC 95971 HCPCS inpatient 420 273 SIHO - ALL PLANS SIHO - ALL PLANS 378 90 999999999 254.31 407.4 percent of total billed charges Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 51146132_1 CDM 0360 RC 95971 HCPCS inpatient 420 273 HUMANA - ALL PLANS HUMANA - ALL PLANS 327.6 78 999999999 254.31 407.4 percent of total billed charges Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 51146132_1 CDM 0360 RC 95971 HCPCS inpatient 420 273 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 254.31 60.55 999999999 254.31 407.4 percent of total billed charges Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 51146132_1 CDM 0360 RC 95971 HCPCS inpatient 420 273 UMR - ALL PLANS UMR - ALL PLANS 294 70 999999999 254.31 407.4 percent of total billed charges Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 51146132_1 CDM 0360 RC 95971 HCPCS inpatient 420 273 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 254.31 407.4 Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 51146132_1 CDM 0360 RC 95971 HCPCS inpatient 420 273 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 254.31 407.4 Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 51146132_1 CDM 0360 RC 95971 HCPCS inpatient 420 273 ANTHEM HMO ANTHEM HMO 999999999 254.31 407.4 Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 51146132_1 CDM 0360 RC 95971 HCPCS inpatient 420 273 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 254.31 407.4 Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 51146132_1 CDM 0360 RC 95971 HCPCS inpatient 420 273 CIGNA - ALL PLANS CIGNA - ALL PLANS 283.92 67.6 999999999 254.31 407.4 percent of total billed charges Electronic analysis of implanted neurostimulator generator with simple spinal cord or peripheral nerve stimulator programming 51146132_1 CDM 0360 RC 95971 HCPCS inpatient 420 273 UHC - ALL PLANS UHC - ALL PLANS 999999999 254.31 407.4 "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 51146235_1 CDM 0306 RC 87476 HCPCS inpatient 465 302.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 302.25 65 999999999 281.56 451.05 percent of total billed charges "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 51146235_1 CDM 0306 RC 87476 HCPCS inpatient 465 302.25 AETNA AETNA 367.35 79 999999999 281.56 451.05 percent of total billed charges "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 51146235_1 CDM 0306 RC 87476 HCPCS inpatient 465 302.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 451.05 97 999999999 281.56 451.05 percent of total billed charges "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 51146235_1 CDM 0306 RC 87476 HCPCS inpatient 465 302.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 320.85 69 999999999 281.56 451.05 percent of total billed charges "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 51146235_1 CDM 0306 RC 87476 HCPCS inpatient 465 302.25 SIHO - ALL PLANS SIHO - ALL PLANS 418.5 90 999999999 281.56 451.05 percent of total billed charges "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 51146235_1 CDM 0306 RC 87476 HCPCS inpatient 465 302.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 362.7 78 999999999 281.56 451.05 percent of total billed charges "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 51146235_1 CDM 0306 RC 87476 HCPCS inpatient 465 302.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 281.56 60.55 999999999 281.56 451.05 percent of total billed charges "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 51146235_1 CDM 0306 RC 87476 HCPCS inpatient 465 302.25 UMR - ALL PLANS UMR - ALL PLANS 325.5 70 999999999 281.56 451.05 percent of total billed charges "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 51146235_1 CDM 0306 RC 87476 HCPCS inpatient 465 302.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 281.56 451.05 "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 51146235_1 CDM 0306 RC 87476 HCPCS inpatient 465 302.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 281.56 451.05 "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 51146235_1 CDM 0306 RC 87476 HCPCS inpatient 465 302.25 ANTHEM HMO ANTHEM HMO 999999999 281.56 451.05 "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 51146235_1 CDM 0306 RC 87476 HCPCS inpatient 465 302.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 281.56 451.05 "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 51146235_1 CDM 0306 RC 87476 HCPCS inpatient 465 302.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 314.34 67.6 999999999 281.56 451.05 percent of total billed charges "Detection by nucleic acid for borrelia burgdorferi (bacteria), amplified probe technique" 51146235_1 CDM 0306 RC 87476 HCPCS inpatient 465 302.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 281.56 451.05 "Detection test by nucleic acid for organism, amplified probe technique" 51146260_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.2 65 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51146260_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 AETNA AETNA 85.32 79 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51146260_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 104.76 97 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51146260_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 74.52 69 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51146260_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 SIHO - ALL PLANS SIHO - ALL PLANS 97.2 90 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51146260_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 84.24 78 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51146260_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 65.39 60.55 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51146260_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 UMR - ALL PLANS UMR - ALL PLANS 75.6 70 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51146260_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 65.39 104.76 "Detection test by nucleic acid for organism, amplified probe technique" 51146260_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 65.39 104.76 "Detection test by nucleic acid for organism, amplified probe technique" 51146260_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 ANTHEM HMO ANTHEM HMO 999999999 65.39 104.76 "Detection test by nucleic acid for organism, amplified probe technique" 51146260_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 65.39 104.76 "Detection test by nucleic acid for organism, amplified probe technique" 51146260_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.01 67.6 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51146260_1 CDM 0306 RC 87798 HCPCS inpatient 108 70.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 65.39 104.76 Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51147934_1 CDM 0310 RC 81261 HCPCS inpatient 400 260 SELF PAY DISCOUNT SELF PAY DISCOUNT 260 65 999999999 242.2 388 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51147934_1 CDM 0310 RC 81261 HCPCS inpatient 400 260 AETNA AETNA 316 79 999999999 242.2 388 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51147934_1 CDM 0310 RC 81261 HCPCS inpatient 400 260 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 388 97 999999999 242.2 388 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51147934_1 CDM 0310 RC 81261 HCPCS inpatient 400 260 ENCORE - ALL PLANS ENCORE - ALL PLANS 276 69 999999999 242.2 388 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51147934_1 CDM 0310 RC 81261 HCPCS inpatient 400 260 SIHO - ALL PLANS SIHO - ALL PLANS 360 90 999999999 242.2 388 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51147934_1 CDM 0310 RC 81261 HCPCS inpatient 400 260 HUMANA - ALL PLANS HUMANA - ALL PLANS 312 78 999999999 242.2 388 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51147934_1 CDM 0310 RC 81261 HCPCS inpatient 400 260 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 242.2 60.55 999999999 242.2 388 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51147934_1 CDM 0310 RC 81261 HCPCS inpatient 400 260 UMR - ALL PLANS UMR - ALL PLANS 280 70 999999999 242.2 388 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51147934_1 CDM 0310 RC 81261 HCPCS inpatient 400 260 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 242.2 388 Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51147934_1 CDM 0310 RC 81261 HCPCS inpatient 400 260 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 242.2 388 Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51147934_1 CDM 0310 RC 81261 HCPCS inpatient 400 260 ANTHEM HMO ANTHEM HMO 999999999 242.2 388 Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51147934_1 CDM 0310 RC 81261 HCPCS inpatient 400 260 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 242.2 388 Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51147934_1 CDM 0310 RC 81261 HCPCS inpatient 400 260 CIGNA - ALL PLANS CIGNA - ALL PLANS 270.4 67.6 999999999 242.2 388 percent of total billed charges Gene rearrangement analysis (immunoglobulin heavy chain locus) to detect abnormal clonal population amplified methodology 51147934_1 CDM 0310 RC 81261 HCPCS inpatient 400 260 UHC - ALL PLANS UHC - ALL PLANS 999999999 242.2 388 Molecular pathology procedure 51147948_1 CDM 0310 RC 81479 HCPCS inpatient 400 260 SELF PAY DISCOUNT SELF PAY DISCOUNT 260 65 999999999 242.2 388 percent of total billed charges Molecular pathology procedure 51147948_1 CDM 0310 RC 81479 HCPCS inpatient 400 260 AETNA AETNA 316 79 999999999 242.2 388 percent of total billed charges Molecular pathology procedure 51147948_1 CDM 0310 RC 81479 HCPCS inpatient 400 260 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 388 97 999999999 242.2 388 percent of total billed charges Molecular pathology procedure 51147948_1 CDM 0310 RC 81479 HCPCS inpatient 400 260 ENCORE - ALL PLANS ENCORE - ALL PLANS 276 69 999999999 242.2 388 percent of total billed charges Molecular pathology procedure 51147948_1 CDM 0310 RC 81479 HCPCS inpatient 400 260 SIHO - ALL PLANS SIHO - ALL PLANS 360 90 999999999 242.2 388 percent of total billed charges Molecular pathology procedure 51147948_1 CDM 0310 RC 81479 HCPCS inpatient 400 260 HUMANA - ALL PLANS HUMANA - ALL PLANS 312 78 999999999 242.2 388 percent of total billed charges Molecular pathology procedure 51147948_1 CDM 0310 RC 81479 HCPCS inpatient 400 260 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 242.2 60.55 999999999 242.2 388 percent of total billed charges Molecular pathology procedure 51147948_1 CDM 0310 RC 81479 HCPCS inpatient 400 260 UMR - ALL PLANS UMR - ALL PLANS 280 70 999999999 242.2 388 percent of total billed charges Molecular pathology procedure 51147948_1 CDM 0310 RC 81479 HCPCS inpatient 400 260 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 242.2 388 Molecular pathology procedure 51147948_1 CDM 0310 RC 81479 HCPCS inpatient 400 260 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 242.2 388 Molecular pathology procedure 51147948_1 CDM 0310 RC 81479 HCPCS inpatient 400 260 ANTHEM HMO ANTHEM HMO 999999999 242.2 388 Molecular pathology procedure 51147948_1 CDM 0310 RC 81479 HCPCS inpatient 400 260 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 242.2 388 Molecular pathology procedure 51147948_1 CDM 0310 RC 81479 HCPCS inpatient 400 260 CIGNA - ALL PLANS CIGNA - ALL PLANS 270.4 67.6 999999999 242.2 388 percent of total billed charges Molecular pathology procedure 51147948_1 CDM 0310 RC 81479 HCPCS inpatient 400 260 UHC - ALL PLANS UHC - ALL PLANS 999999999 242.2 388 "Identification of organisms by genetic analysis, amplified probe technique" 51148908_1 CDM 0306 RC 87150 HCPCS inpatient 96 62.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 62.4 65 999999999 58.13 93.12 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 51148908_1 CDM 0306 RC 87150 HCPCS inpatient 96 62.4 AETNA AETNA 75.84 79 999999999 58.13 93.12 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 51148908_1 CDM 0306 RC 87150 HCPCS inpatient 96 62.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 93.12 97 999999999 58.13 93.12 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 51148908_1 CDM 0306 RC 87150 HCPCS inpatient 96 62.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.24 69 999999999 58.13 93.12 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 51148908_1 CDM 0306 RC 87150 HCPCS inpatient 96 62.4 SIHO - ALL PLANS SIHO - ALL PLANS 86.4 90 999999999 58.13 93.12 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 51148908_1 CDM 0306 RC 87150 HCPCS inpatient 96 62.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 74.88 78 999999999 58.13 93.12 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 51148908_1 CDM 0306 RC 87150 HCPCS inpatient 96 62.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.13 60.55 999999999 58.13 93.12 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 51148908_1 CDM 0306 RC 87150 HCPCS inpatient 96 62.4 UMR - ALL PLANS UMR - ALL PLANS 67.2 70 999999999 58.13 93.12 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 51148908_1 CDM 0306 RC 87150 HCPCS inpatient 96 62.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.13 93.12 "Identification of organisms by genetic analysis, amplified probe technique" 51148908_1 CDM 0306 RC 87150 HCPCS inpatient 96 62.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.13 93.12 "Identification of organisms by genetic analysis, amplified probe technique" 51148908_1 CDM 0306 RC 87150 HCPCS inpatient 96 62.4 ANTHEM HMO ANTHEM HMO 999999999 58.13 93.12 "Identification of organisms by genetic analysis, amplified probe technique" 51148908_1 CDM 0306 RC 87150 HCPCS inpatient 96 62.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.13 93.12 "Identification of organisms by genetic analysis, amplified probe technique" 51148908_1 CDM 0306 RC 87150 HCPCS inpatient 96 62.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 64.9 67.6 999999999 58.13 93.12 percent of total billed charges "Identification of organisms by genetic analysis, amplified probe technique" 51148908_1 CDM 0306 RC 87150 HCPCS inpatient 96 62.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.13 93.12 "LASSO POLYPECTOMY SNARE, OVAL 25mm HOT/COLD, 230cm 1180-03" 51151609_1 CDM 0272 RC inpatient 40 26 SELF PAY DISCOUNT SELF PAY DISCOUNT 26 65 999999999 24.22 38.8 percent of total billed charges "LASSO POLYPECTOMY SNARE, OVAL 25mm HOT/COLD, 230cm 1180-03" 51151609_1 CDM 0272 RC inpatient 40 26 AETNA AETNA 31.6 79 999999999 24.22 38.8 percent of total billed charges "LASSO POLYPECTOMY SNARE, OVAL 25mm HOT/COLD, 230cm 1180-03" 51151609_1 CDM 0272 RC inpatient 40 26 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 38.8 97 999999999 24.22 38.8 percent of total billed charges "LASSO POLYPECTOMY SNARE, OVAL 25mm HOT/COLD, 230cm 1180-03" 51151609_1 CDM 0272 RC inpatient 40 26 ENCORE - ALL PLANS ENCORE - ALL PLANS 27.6 69 999999999 24.22 38.8 percent of total billed charges "LASSO POLYPECTOMY SNARE, OVAL 25mm HOT/COLD, 230cm 1180-03" 51151609_1 CDM 0272 RC inpatient 40 26 SIHO - ALL PLANS SIHO - ALL PLANS 36 90 999999999 24.22 38.8 percent of total billed charges "LASSO POLYPECTOMY SNARE, OVAL 25mm HOT/COLD, 230cm 1180-03" 51151609_1 CDM 0272 RC inpatient 40 26 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.2 78 999999999 24.22 38.8 percent of total billed charges "LASSO POLYPECTOMY SNARE, OVAL 25mm HOT/COLD, 230cm 1180-03" 51151609_1 CDM 0272 RC inpatient 40 26 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.22 60.55 999999999 24.22 38.8 percent of total billed charges "LASSO POLYPECTOMY SNARE, OVAL 25mm HOT/COLD, 230cm 1180-03" 51151609_1 CDM 0272 RC inpatient 40 26 UMR - ALL PLANS UMR - ALL PLANS 28 70 999999999 24.22 38.8 percent of total billed charges "LASSO POLYPECTOMY SNARE, OVAL 25mm HOT/COLD, 230cm 1180-03" 51151609_1 CDM 0272 RC inpatient 40 26 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.22 38.8 "LASSO POLYPECTOMY SNARE, OVAL 25mm HOT/COLD, 230cm 1180-03" 51151609_1 CDM 0272 RC inpatient 40 26 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.22 38.8 "LASSO POLYPECTOMY SNARE, OVAL 25mm HOT/COLD, 230cm 1180-03" 51151609_1 CDM 0272 RC inpatient 40 26 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.22 38.8 "LASSO POLYPECTOMY SNARE, OVAL 25mm HOT/COLD, 230cm 1180-03" 51151609_1 CDM 0272 RC inpatient 40 26 ANTHEM HMO ANTHEM HMO 999999999 24.22 38.8 "LASSO POLYPECTOMY SNARE, OVAL 25mm HOT/COLD, 230cm 1180-03" 51151609_1 CDM 0272 RC inpatient 40 26 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.22 38.8 "LASSO POLYPECTOMY SNARE, OVAL 25mm HOT/COLD, 230cm 1180-03" 51151609_1 CDM 0272 RC inpatient 40 26 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.04 67.6 999999999 24.22 38.8 percent of total billed charges GIJaw BIOPSY FORCEP 1190-02 51152031_1 CDM 0272 RC inpatient 22.5 14.63 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.63 65 999999999 13.62 21.83 percent of total billed charges GIJaw BIOPSY FORCEP 1190-02 51152031_1 CDM 0272 RC inpatient 22.5 14.63 AETNA AETNA 17.78 79 999999999 13.62 21.83 percent of total billed charges GIJaw BIOPSY FORCEP 1190-02 51152031_1 CDM 0272 RC inpatient 22.5 14.63 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21.83 97 999999999 13.62 21.83 percent of total billed charges GIJaw BIOPSY FORCEP 1190-02 51152031_1 CDM 0272 RC inpatient 22.5 14.63 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.53 69 999999999 13.62 21.83 percent of total billed charges GIJaw BIOPSY FORCEP 1190-02 51152031_1 CDM 0272 RC inpatient 22.5 14.63 SIHO - ALL PLANS SIHO - ALL PLANS 20.25 90 999999999 13.62 21.83 percent of total billed charges GIJaw BIOPSY FORCEP 1190-02 51152031_1 CDM 0272 RC inpatient 22.5 14.63 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.55 78 999999999 13.62 21.83 percent of total billed charges GIJaw BIOPSY FORCEP 1190-02 51152031_1 CDM 0272 RC inpatient 22.5 14.63 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.62 60.55 999999999 13.62 21.83 percent of total billed charges GIJaw BIOPSY FORCEP 1190-02 51152031_1 CDM 0272 RC inpatient 22.5 14.63 UMR - ALL PLANS UMR - ALL PLANS 15.75 70 999999999 13.62 21.83 percent of total billed charges GIJaw BIOPSY FORCEP 1190-02 51152031_1 CDM 0272 RC inpatient 22.5 14.63 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.62 21.83 GIJaw BIOPSY FORCEP 1190-02 51152031_1 CDM 0272 RC inpatient 22.5 14.63 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.62 21.83 GIJaw BIOPSY FORCEP 1190-02 51152031_1 CDM 0272 RC inpatient 22.5 14.63 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.62 21.83 GIJaw BIOPSY FORCEP 1190-02 51152031_1 CDM 0272 RC inpatient 22.5 14.63 ANTHEM HMO ANTHEM HMO 999999999 13.62 21.83 GIJaw BIOPSY FORCEP 1190-02 51152031_1 CDM 0272 RC inpatient 22.5 14.63 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.62 21.83 GIJaw BIOPSY FORCEP 1190-02 51152031_1 CDM 0272 RC inpatient 22.5 14.63 CIGNA - ALL PLANS CIGNA - ALL PLANS 15.21 67.6 999999999 13.62 21.83 percent of total billed charges REPLAY HEMOSTASIS CLIPS 1170-02 51152055_1 CDM 0272 RC inpatient 475 308.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 308.75 65 999999999 287.61 460.75 percent of total billed charges REPLAY HEMOSTASIS CLIPS 1170-02 51152055_1 CDM 0272 RC inpatient 475 308.75 AETNA AETNA 375.25 79 999999999 287.61 460.75 percent of total billed charges REPLAY HEMOSTASIS CLIPS 1170-02 51152055_1 CDM 0272 RC inpatient 475 308.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 460.75 97 999999999 287.61 460.75 percent of total billed charges REPLAY HEMOSTASIS CLIPS 1170-02 51152055_1 CDM 0272 RC inpatient 475 308.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 327.75 69 999999999 287.61 460.75 percent of total billed charges REPLAY HEMOSTASIS CLIPS 1170-02 51152055_1 CDM 0272 RC inpatient 475 308.75 SIHO - ALL PLANS SIHO - ALL PLANS 427.5 90 999999999 287.61 460.75 percent of total billed charges REPLAY HEMOSTASIS CLIPS 1170-02 51152055_1 CDM 0272 RC inpatient 475 308.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 370.5 78 999999999 287.61 460.75 percent of total billed charges REPLAY HEMOSTASIS CLIPS 1170-02 51152055_1 CDM 0272 RC inpatient 475 308.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 287.61 60.55 999999999 287.61 460.75 percent of total billed charges REPLAY HEMOSTASIS CLIPS 1170-02 51152055_1 CDM 0272 RC inpatient 475 308.75 UMR - ALL PLANS UMR - ALL PLANS 332.5 70 999999999 287.61 460.75 percent of total billed charges REPLAY HEMOSTASIS CLIPS 1170-02 51152055_1 CDM 0272 RC inpatient 475 308.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 287.61 460.75 REPLAY HEMOSTASIS CLIPS 1170-02 51152055_1 CDM 0272 RC inpatient 475 308.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 287.61 460.75 REPLAY HEMOSTASIS CLIPS 1170-02 51152055_1 CDM 0272 RC inpatient 475 308.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 287.61 460.75 REPLAY HEMOSTASIS CLIPS 1170-02 51152055_1 CDM 0272 RC inpatient 475 308.75 ANTHEM HMO ANTHEM HMO 999999999 287.61 460.75 REPLAY HEMOSTASIS CLIPS 1170-02 51152055_1 CDM 0272 RC inpatient 475 308.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 287.61 460.75 REPLAY HEMOSTASIS CLIPS 1170-02 51152055_1 CDM 0272 RC inpatient 475 308.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 321.1 67.6 999999999 287.61 460.75 percent of total billed charges "LASSO POLYP SNARE, OVAL 10mm 1180-01" 51152056_1 CDM 0272 RC inpatient 40 26 SELF PAY DISCOUNT SELF PAY DISCOUNT 26 65 999999999 24.22 38.8 percent of total billed charges "LASSO POLYP SNARE, OVAL 10mm 1180-01" 51152056_1 CDM 0272 RC inpatient 40 26 AETNA AETNA 31.6 79 999999999 24.22 38.8 percent of total billed charges "LASSO POLYP SNARE, OVAL 10mm 1180-01" 51152056_1 CDM 0272 RC inpatient 40 26 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 38.8 97 999999999 24.22 38.8 percent of total billed charges "LASSO POLYP SNARE, OVAL 10mm 1180-01" 51152056_1 CDM 0272 RC inpatient 40 26 ENCORE - ALL PLANS ENCORE - ALL PLANS 27.6 69 999999999 24.22 38.8 percent of total billed charges "LASSO POLYP SNARE, OVAL 10mm 1180-01" 51152056_1 CDM 0272 RC inpatient 40 26 SIHO - ALL PLANS SIHO - ALL PLANS 36 90 999999999 24.22 38.8 percent of total billed charges "LASSO POLYP SNARE, OVAL 10mm 1180-01" 51152056_1 CDM 0272 RC inpatient 40 26 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.2 78 999999999 24.22 38.8 percent of total billed charges "LASSO POLYP SNARE, OVAL 10mm 1180-01" 51152056_1 CDM 0272 RC inpatient 40 26 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.22 60.55 999999999 24.22 38.8 percent of total billed charges "LASSO POLYP SNARE, OVAL 10mm 1180-01" 51152056_1 CDM 0272 RC inpatient 40 26 UMR - ALL PLANS UMR - ALL PLANS 28 70 999999999 24.22 38.8 percent of total billed charges "LASSO POLYP SNARE, OVAL 10mm 1180-01" 51152056_1 CDM 0272 RC inpatient 40 26 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.22 38.8 "LASSO POLYP SNARE, OVAL 10mm 1180-01" 51152056_1 CDM 0272 RC inpatient 40 26 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.22 38.8 "LASSO POLYP SNARE, OVAL 10mm 1180-01" 51152056_1 CDM 0272 RC inpatient 40 26 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.22 38.8 "LASSO POLYP SNARE, OVAL 10mm 1180-01" 51152056_1 CDM 0272 RC inpatient 40 26 ANTHEM HMO ANTHEM HMO 999999999 24.22 38.8 "LASSO POLYP SNARE, OVAL 10mm 1180-01" 51152056_1 CDM 0272 RC inpatient 40 26 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.22 38.8 "LASSO POLYP SNARE, OVAL 10mm 1180-01" 51152056_1 CDM 0272 RC inpatient 40 26 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.04 67.6 999999999 24.22 38.8 percent of total billed charges "LASSO POLYP SNARE, OVAL 15mm 1180-02" 51152057_1 CDM 0272 RC inpatient 40 26 SELF PAY DISCOUNT SELF PAY DISCOUNT 26 65 999999999 24.22 38.8 percent of total billed charges "LASSO POLYP SNARE, OVAL 15mm 1180-02" 51152057_1 CDM 0272 RC inpatient 40 26 AETNA AETNA 31.6 79 999999999 24.22 38.8 percent of total billed charges "LASSO POLYP SNARE, OVAL 15mm 1180-02" 51152057_1 CDM 0272 RC inpatient 40 26 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 38.8 97 999999999 24.22 38.8 percent of total billed charges "LASSO POLYP SNARE, OVAL 15mm 1180-02" 51152057_1 CDM 0272 RC inpatient 40 26 ENCORE - ALL PLANS ENCORE - ALL PLANS 27.6 69 999999999 24.22 38.8 percent of total billed charges "LASSO POLYP SNARE, OVAL 15mm 1180-02" 51152057_1 CDM 0272 RC inpatient 40 26 SIHO - ALL PLANS SIHO - ALL PLANS 36 90 999999999 24.22 38.8 percent of total billed charges "LASSO POLYP SNARE, OVAL 15mm 1180-02" 51152057_1 CDM 0272 RC inpatient 40 26 HUMANA - ALL PLANS HUMANA - ALL PLANS 31.2 78 999999999 24.22 38.8 percent of total billed charges "LASSO POLYP SNARE, OVAL 15mm 1180-02" 51152057_1 CDM 0272 RC inpatient 40 26 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24.22 60.55 999999999 24.22 38.8 percent of total billed charges "LASSO POLYP SNARE, OVAL 15mm 1180-02" 51152057_1 CDM 0272 RC inpatient 40 26 UMR - ALL PLANS UMR - ALL PLANS 28 70 999999999 24.22 38.8 percent of total billed charges "LASSO POLYP SNARE, OVAL 15mm 1180-02" 51152057_1 CDM 0272 RC inpatient 40 26 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 24.22 38.8 "LASSO POLYP SNARE, OVAL 15mm 1180-02" 51152057_1 CDM 0272 RC inpatient 40 26 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 24.22 38.8 "LASSO POLYP SNARE, OVAL 15mm 1180-02" 51152057_1 CDM 0272 RC inpatient 40 26 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 24.22 38.8 "LASSO POLYP SNARE, OVAL 15mm 1180-02" 51152057_1 CDM 0272 RC inpatient 40 26 ANTHEM HMO ANTHEM HMO 999999999 24.22 38.8 "LASSO POLYP SNARE, OVAL 15mm 1180-02" 51152057_1 CDM 0272 RC inpatient 40 26 UHC - ALL PLANS UHC - ALL PLANS 999999999 24.22 38.8 "LASSO POLYP SNARE, OVAL 15mm 1180-02" 51152057_1 CDM 0272 RC inpatient 40 26 CIGNA - ALL PLANS CIGNA - ALL PLANS 27.04 67.6 999999999 24.22 38.8 percent of total billed charges "INJECTION, MEPOLIZUMAB, 1 MG" 51155899_1 CDM 0636 RC 00173-0892-42 NDC J2182 HCPCS inpatient 100 UN 17061.6 11090.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 11090.04 65 999999999 10330.8 16549.75 percent of total billed charges "INJECTION, MEPOLIZUMAB, 1 MG" 51155899_1 CDM 0636 RC 00173-0892-42 NDC J2182 HCPCS inpatient 100 UN 17061.6 11090.04 AETNA AETNA 13478.66 79 999999999 10330.8 16549.75 percent of total billed charges "INJECTION, MEPOLIZUMAB, 1 MG" 51155899_1 CDM 0636 RC 00173-0892-42 NDC J2182 HCPCS inpatient 100 UN 17061.6 11090.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16549.75 97 999999999 10330.8 16549.75 percent of total billed charges "INJECTION, MEPOLIZUMAB, 1 MG" 51155899_1 CDM 0636 RC 00173-0892-42 NDC J2182 HCPCS inpatient 100 UN 17061.6 11090.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 11772.5 69 999999999 10330.8 16549.75 percent of total billed charges "INJECTION, MEPOLIZUMAB, 1 MG" 51155899_1 CDM 0636 RC 00173-0892-42 NDC J2182 HCPCS inpatient 100 UN 17061.6 11090.04 SIHO - ALL PLANS SIHO - ALL PLANS 15355.44 90 999999999 10330.8 16549.75 percent of total billed charges "INJECTION, MEPOLIZUMAB, 1 MG" 51155899_1 CDM 0636 RC 00173-0892-42 NDC J2182 HCPCS inpatient 100 UN 17061.6 11090.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 13308.05 78 999999999 10330.8 16549.75 percent of total billed charges "INJECTION, MEPOLIZUMAB, 1 MG" 51155899_1 CDM 0636 RC 00173-0892-42 NDC J2182 HCPCS inpatient 100 UN 17061.6 11090.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10330.8 60.55 999999999 10330.8 16549.75 percent of total billed charges "INJECTION, MEPOLIZUMAB, 1 MG" 51155899_1 CDM 0636 RC 00173-0892-42 NDC J2182 HCPCS inpatient 100 UN 17061.6 11090.04 UMR - ALL PLANS UMR - ALL PLANS 11943.12 70 999999999 10330.8 16549.75 percent of total billed charges "INJECTION, MEPOLIZUMAB, 1 MG" 51155899_1 CDM 0636 RC 00173-0892-42 NDC J2182 HCPCS inpatient 100 UN 17061.6 11090.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10330.8 16549.75 "INJECTION, MEPOLIZUMAB, 1 MG" 51155899_1 CDM 0636 RC 00173-0892-42 NDC J2182 HCPCS inpatient 100 UN 17061.6 11090.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10330.8 16549.75 "INJECTION, MEPOLIZUMAB, 1 MG" 51155899_1 CDM 0636 RC 00173-0892-42 NDC J2182 HCPCS inpatient 100 UN 17061.6 11090.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10330.8 16549.75 "INJECTION, MEPOLIZUMAB, 1 MG" 51155899_1 CDM 0636 RC 00173-0892-42 NDC J2182 HCPCS inpatient 100 UN 17061.6 11090.04 ANTHEM HMO ANTHEM HMO 999999999 10330.8 16549.75 "INJECTION, MEPOLIZUMAB, 1 MG" 51155899_1 CDM 0636 RC 00173-0892-42 NDC J2182 HCPCS inpatient 100 UN 17061.6 11090.04 UHC - ALL PLANS UHC - ALL PLANS 999999999 10330.8 16549.75 "INJECTION, MEPOLIZUMAB, 1 MG" 51155899_1 CDM 0636 RC 00173-0892-42 NDC J2182 HCPCS inpatient 100 UN 17061.6 11090.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 11533.64 67.6 999999999 10330.8 16549.75 percent of total billed charges Translocation analysis (PML-RARA regulated adaptor molecule 1) common breakpoint 51157970_1 CDM 0301 RC 81315 HCPCS inpatient 425 276.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 276.25 65 999999999 257.34 412.25 percent of total billed charges Translocation analysis (PML-RARA regulated adaptor molecule 1) common breakpoint 51157970_1 CDM 0301 RC 81315 HCPCS inpatient 425 276.25 AETNA AETNA 335.75 79 999999999 257.34 412.25 percent of total billed charges Translocation analysis (PML-RARA regulated adaptor molecule 1) common breakpoint 51157970_1 CDM 0301 RC 81315 HCPCS inpatient 425 276.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 412.25 97 999999999 257.34 412.25 percent of total billed charges Translocation analysis (PML-RARA regulated adaptor molecule 1) common breakpoint 51157970_1 CDM 0301 RC 81315 HCPCS inpatient 425 276.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 293.25 69 999999999 257.34 412.25 percent of total billed charges Translocation analysis (PML-RARA regulated adaptor molecule 1) common breakpoint 51157970_1 CDM 0301 RC 81315 HCPCS inpatient 425 276.25 SIHO - ALL PLANS SIHO - ALL PLANS 382.5 90 999999999 257.34 412.25 percent of total billed charges Translocation analysis (PML-RARA regulated adaptor molecule 1) common breakpoint 51157970_1 CDM 0301 RC 81315 HCPCS inpatient 425 276.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 331.5 78 999999999 257.34 412.25 percent of total billed charges Translocation analysis (PML-RARA regulated adaptor molecule 1) common breakpoint 51157970_1 CDM 0301 RC 81315 HCPCS inpatient 425 276.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 257.34 60.55 999999999 257.34 412.25 percent of total billed charges Translocation analysis (PML-RARA regulated adaptor molecule 1) common breakpoint 51157970_1 CDM 0301 RC 81315 HCPCS inpatient 425 276.25 UMR - ALL PLANS UMR - ALL PLANS 297.5 70 999999999 257.34 412.25 percent of total billed charges Translocation analysis (PML-RARA regulated adaptor molecule 1) common breakpoint 51157970_1 CDM 0301 RC 81315 HCPCS inpatient 425 276.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 257.34 412.25 Translocation analysis (PML-RARA regulated adaptor molecule 1) common breakpoint 51157970_1 CDM 0301 RC 81315 HCPCS inpatient 425 276.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 257.34 412.25 Translocation analysis (PML-RARA regulated adaptor molecule 1) common breakpoint 51157970_1 CDM 0301 RC 81315 HCPCS inpatient 425 276.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 257.34 412.25 Translocation analysis (PML-RARA regulated adaptor molecule 1) common breakpoint 51157970_1 CDM 0301 RC 81315 HCPCS inpatient 425 276.25 ANTHEM HMO ANTHEM HMO 999999999 257.34 412.25 Translocation analysis (PML-RARA regulated adaptor molecule 1) common breakpoint 51157970_1 CDM 0301 RC 81315 HCPCS inpatient 425 276.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 257.34 412.25 Translocation analysis (PML-RARA regulated adaptor molecule 1) common breakpoint 51157970_1 CDM 0301 RC 81315 HCPCS inpatient 425 276.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 287.3 67.6 999999999 257.34 412.25 percent of total billed charges S-CURVE URETHRAL DIALATOR SET 073701-CD 51158123_1 CDM 0272 RC inpatient 1409.9 916.44 SELF PAY DISCOUNT SELF PAY DISCOUNT 916.44 65 999999999 853.69 1367.6 percent of total billed charges S-CURVE URETHRAL DIALATOR SET 073701-CD 51158123_1 CDM 0272 RC inpatient 1409.9 916.44 AETNA AETNA 1113.82 79 999999999 853.69 1367.6 percent of total billed charges S-CURVE URETHRAL DIALATOR SET 073701-CD 51158123_1 CDM 0272 RC inpatient 1409.9 916.44 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1367.6 97 999999999 853.69 1367.6 percent of total billed charges S-CURVE URETHRAL DIALATOR SET 073701-CD 51158123_1 CDM 0272 RC inpatient 1409.9 916.44 ENCORE - ALL PLANS ENCORE - ALL PLANS 972.83 69 999999999 853.69 1367.6 percent of total billed charges S-CURVE URETHRAL DIALATOR SET 073701-CD 51158123_1 CDM 0272 RC inpatient 1409.9 916.44 SIHO - ALL PLANS SIHO - ALL PLANS 1268.91 90 999999999 853.69 1367.6 percent of total billed charges S-CURVE URETHRAL DIALATOR SET 073701-CD 51158123_1 CDM 0272 RC inpatient 1409.9 916.44 HUMANA - ALL PLANS HUMANA - ALL PLANS 1099.72 78 999999999 853.69 1367.6 percent of total billed charges S-CURVE URETHRAL DIALATOR SET 073701-CD 51158123_1 CDM 0272 RC inpatient 1409.9 916.44 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 853.69 60.55 999999999 853.69 1367.6 percent of total billed charges S-CURVE URETHRAL DIALATOR SET 073701-CD 51158123_1 CDM 0272 RC inpatient 1409.9 916.44 UMR - ALL PLANS UMR - ALL PLANS 986.93 70 999999999 853.69 1367.6 percent of total billed charges S-CURVE URETHRAL DIALATOR SET 073701-CD 51158123_1 CDM 0272 RC inpatient 1409.9 916.44 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 853.69 1367.6 S-CURVE URETHRAL DIALATOR SET 073701-CD 51158123_1 CDM 0272 RC inpatient 1409.9 916.44 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 853.69 1367.6 S-CURVE URETHRAL DIALATOR SET 073701-CD 51158123_1 CDM 0272 RC inpatient 1409.9 916.44 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 853.69 1367.6 S-CURVE URETHRAL DIALATOR SET 073701-CD 51158123_1 CDM 0272 RC inpatient 1409.9 916.44 ANTHEM HMO ANTHEM HMO 999999999 853.69 1367.6 S-CURVE URETHRAL DIALATOR SET 073701-CD 51158123_1 CDM 0272 RC inpatient 1409.9 916.44 UHC - ALL PLANS UHC - ALL PLANS 999999999 853.69 1367.6 S-CURVE URETHRAL DIALATOR SET 073701-CD 51158123_1 CDM 0272 RC inpatient 1409.9 916.44 CIGNA - ALL PLANS CIGNA - ALL PLANS 953.09 67.6 999999999 853.69 1367.6 percent of total billed charges Molecular pathology procedure 51161104_1 CDM 0302 RC 81479 HCPCS inpatient 374 243.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 243.1 65 999999999 226.46 362.78 percent of total billed charges Molecular pathology procedure 51161104_1 CDM 0302 RC 81479 HCPCS inpatient 374 243.1 AETNA AETNA 295.46 79 999999999 226.46 362.78 percent of total billed charges Molecular pathology procedure 51161104_1 CDM 0302 RC 81479 HCPCS inpatient 374 243.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 362.78 97 999999999 226.46 362.78 percent of total billed charges Molecular pathology procedure 51161104_1 CDM 0302 RC 81479 HCPCS inpatient 374 243.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 258.06 69 999999999 226.46 362.78 percent of total billed charges Molecular pathology procedure 51161104_1 CDM 0302 RC 81479 HCPCS inpatient 374 243.1 SIHO - ALL PLANS SIHO - ALL PLANS 336.6 90 999999999 226.46 362.78 percent of total billed charges Molecular pathology procedure 51161104_1 CDM 0302 RC 81479 HCPCS inpatient 374 243.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 291.72 78 999999999 226.46 362.78 percent of total billed charges Molecular pathology procedure 51161104_1 CDM 0302 RC 81479 HCPCS inpatient 374 243.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 226.46 60.55 999999999 226.46 362.78 percent of total billed charges Molecular pathology procedure 51161104_1 CDM 0302 RC 81479 HCPCS inpatient 374 243.1 UMR - ALL PLANS UMR - ALL PLANS 261.8 70 999999999 226.46 362.78 percent of total billed charges Molecular pathology procedure 51161104_1 CDM 0302 RC 81479 HCPCS inpatient 374 243.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 226.46 362.78 Molecular pathology procedure 51161104_1 CDM 0302 RC 81479 HCPCS inpatient 374 243.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 226.46 362.78 Molecular pathology procedure 51161104_1 CDM 0302 RC 81479 HCPCS inpatient 374 243.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 226.46 362.78 Molecular pathology procedure 51161104_1 CDM 0302 RC 81479 HCPCS inpatient 374 243.1 ANTHEM HMO ANTHEM HMO 999999999 226.46 362.78 Molecular pathology procedure 51161104_1 CDM 0302 RC 81479 HCPCS inpatient 374 243.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 226.46 362.78 Molecular pathology procedure 51161104_1 CDM 0302 RC 81479 HCPCS inpatient 374 243.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 252.82 67.6 999999999 226.46 362.78 percent of total billed charges Gene rearrangement analysis detection abnormal clonal population (T cell antigen receptor gamma) 51161308_1 CDM 0310 RC 81342 HCPCS inpatient 410 266.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 266.5 65 999999999 248.26 397.7 percent of total billed charges Gene rearrangement analysis detection abnormal clonal population (T cell antigen receptor gamma) 51161308_1 CDM 0310 RC 81342 HCPCS inpatient 410 266.5 AETNA AETNA 323.9 79 999999999 248.26 397.7 percent of total billed charges Gene rearrangement analysis detection abnormal clonal population (T cell antigen receptor gamma) 51161308_1 CDM 0310 RC 81342 HCPCS inpatient 410 266.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 397.7 97 999999999 248.26 397.7 percent of total billed charges Gene rearrangement analysis detection abnormal clonal population (T cell antigen receptor gamma) 51161308_1 CDM 0310 RC 81342 HCPCS inpatient 410 266.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 282.9 69 999999999 248.26 397.7 percent of total billed charges Gene rearrangement analysis detection abnormal clonal population (T cell antigen receptor gamma) 51161308_1 CDM 0310 RC 81342 HCPCS inpatient 410 266.5 SIHO - ALL PLANS SIHO - ALL PLANS 369 90 999999999 248.26 397.7 percent of total billed charges Gene rearrangement analysis detection abnormal clonal population (T cell antigen receptor gamma) 51161308_1 CDM 0310 RC 81342 HCPCS inpatient 410 266.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 319.8 78 999999999 248.26 397.7 percent of total billed charges Gene rearrangement analysis detection abnormal clonal population (T cell antigen receptor gamma) 51161308_1 CDM 0310 RC 81342 HCPCS inpatient 410 266.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 248.26 60.55 999999999 248.26 397.7 percent of total billed charges Gene rearrangement analysis detection abnormal clonal population (T cell antigen receptor gamma) 51161308_1 CDM 0310 RC 81342 HCPCS inpatient 410 266.5 UMR - ALL PLANS UMR - ALL PLANS 287 70 999999999 248.26 397.7 percent of total billed charges Gene rearrangement analysis detection abnormal clonal population (T cell antigen receptor gamma) 51161308_1 CDM 0310 RC 81342 HCPCS inpatient 410 266.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 248.26 397.7 Gene rearrangement analysis detection abnormal clonal population (T cell antigen receptor gamma) 51161308_1 CDM 0310 RC 81342 HCPCS inpatient 410 266.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 248.26 397.7 Gene rearrangement analysis detection abnormal clonal population (T cell antigen receptor gamma) 51161308_1 CDM 0310 RC 81342 HCPCS inpatient 410 266.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 248.26 397.7 Gene rearrangement analysis detection abnormal clonal population (T cell antigen receptor gamma) 51161308_1 CDM 0310 RC 81342 HCPCS inpatient 410 266.5 ANTHEM HMO ANTHEM HMO 999999999 248.26 397.7 Gene rearrangement analysis detection abnormal clonal population (T cell antigen receptor gamma) 51161308_1 CDM 0310 RC 81342 HCPCS inpatient 410 266.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 248.26 397.7 Gene rearrangement analysis detection abnormal clonal population (T cell antigen receptor gamma) 51161308_1 CDM 0310 RC 81342 HCPCS inpatient 410 266.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 277.16 67.6 999999999 248.26 397.7 percent of total billed charges "INJECTION, POLATUZUMAB VEDOTIN-PIIQ, 1 MG" 51163564_1 CDM 0636 RC 50242-0105-01 NDC J9309 HCPCS inpatient 140 UN 76373 49642.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 49642.45 65 999999999 46243.85 74081.81 percent of total billed charges "INJECTION, POLATUZUMAB VEDOTIN-PIIQ, 1 MG" 51163564_1 CDM 0636 RC 50242-0105-01 NDC J9309 HCPCS inpatient 140 UN 76373 49642.45 AETNA AETNA 60334.67 79 999999999 46243.85 74081.81 percent of total billed charges "INJECTION, POLATUZUMAB VEDOTIN-PIIQ, 1 MG" 51163564_1 CDM 0636 RC 50242-0105-01 NDC J9309 HCPCS inpatient 140 UN 76373 49642.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74081.81 97 999999999 46243.85 74081.81 percent of total billed charges "INJECTION, POLATUZUMAB VEDOTIN-PIIQ, 1 MG" 51163564_1 CDM 0636 RC 50242-0105-01 NDC J9309 HCPCS inpatient 140 UN 76373 49642.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 52697.37 69 999999999 46243.85 74081.81 percent of total billed charges "INJECTION, POLATUZUMAB VEDOTIN-PIIQ, 1 MG" 51163564_1 CDM 0636 RC 50242-0105-01 NDC J9309 HCPCS inpatient 140 UN 76373 49642.45 SIHO - ALL PLANS SIHO - ALL PLANS 68735.7 90 999999999 46243.85 74081.81 percent of total billed charges "INJECTION, POLATUZUMAB VEDOTIN-PIIQ, 1 MG" 51163564_1 CDM 0636 RC 50242-0105-01 NDC J9309 HCPCS inpatient 140 UN 76373 49642.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 59570.94 78 999999999 46243.85 74081.81 percent of total billed charges "INJECTION, POLATUZUMAB VEDOTIN-PIIQ, 1 MG" 51163564_1 CDM 0636 RC 50242-0105-01 NDC J9309 HCPCS inpatient 140 UN 76373 49642.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46243.85 60.55 999999999 46243.85 74081.81 percent of total billed charges "INJECTION, POLATUZUMAB VEDOTIN-PIIQ, 1 MG" 51163564_1 CDM 0636 RC 50242-0105-01 NDC J9309 HCPCS inpatient 140 UN 76373 49642.45 UMR - ALL PLANS UMR - ALL PLANS 53461.1 70 999999999 46243.85 74081.81 percent of total billed charges "INJECTION, POLATUZUMAB VEDOTIN-PIIQ, 1 MG" 51163564_1 CDM 0636 RC 50242-0105-01 NDC J9309 HCPCS inpatient 140 UN 76373 49642.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46243.85 74081.81 "INJECTION, POLATUZUMAB VEDOTIN-PIIQ, 1 MG" 51163564_1 CDM 0636 RC 50242-0105-01 NDC J9309 HCPCS inpatient 140 UN 76373 49642.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46243.85 74081.81 "INJECTION, POLATUZUMAB VEDOTIN-PIIQ, 1 MG" 51163564_1 CDM 0636 RC 50242-0105-01 NDC J9309 HCPCS inpatient 140 UN 76373 49642.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46243.85 74081.81 "INJECTION, POLATUZUMAB VEDOTIN-PIIQ, 1 MG" 51163564_1 CDM 0636 RC 50242-0105-01 NDC J9309 HCPCS inpatient 140 UN 76373 49642.45 ANTHEM HMO ANTHEM HMO 999999999 46243.85 74081.81 "INJECTION, POLATUZUMAB VEDOTIN-PIIQ, 1 MG" 51163564_1 CDM 0636 RC 50242-0105-01 NDC J9309 HCPCS inpatient 140 UN 76373 49642.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 46243.85 74081.81 "INJECTION, POLATUZUMAB VEDOTIN-PIIQ, 1 MG" 51163564_1 CDM 0636 RC 50242-0105-01 NDC J9309 HCPCS inpatient 140 UN 76373 49642.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 51628.15 67.6 999999999 46243.85 74081.81 percent of total billed charges "Gene rearrangement analysis (immunoglobulin heavy chain locus), variable region somatic mutation analysis" 51164838_1 CDM 0310 RC 81263 HCPCS inpatient 600 390 SELF PAY DISCOUNT SELF PAY DISCOUNT 390 65 999999999 363.3 582 percent of total billed charges "Gene rearrangement analysis (immunoglobulin heavy chain locus), variable region somatic mutation analysis" 51164838_1 CDM 0310 RC 81263 HCPCS inpatient 600 390 AETNA AETNA 474 79 999999999 363.3 582 percent of total billed charges "Gene rearrangement analysis (immunoglobulin heavy chain locus), variable region somatic mutation analysis" 51164838_1 CDM 0310 RC 81263 HCPCS inpatient 600 390 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 582 97 999999999 363.3 582 percent of total billed charges "Gene rearrangement analysis (immunoglobulin heavy chain locus), variable region somatic mutation analysis" 51164838_1 CDM 0310 RC 81263 HCPCS inpatient 600 390 ENCORE - ALL PLANS ENCORE - ALL PLANS 414 69 999999999 363.3 582 percent of total billed charges "Gene rearrangement analysis (immunoglobulin heavy chain locus), variable region somatic mutation analysis" 51164838_1 CDM 0310 RC 81263 HCPCS inpatient 600 390 SIHO - ALL PLANS SIHO - ALL PLANS 540 90 999999999 363.3 582 percent of total billed charges "Gene rearrangement analysis (immunoglobulin heavy chain locus), variable region somatic mutation analysis" 51164838_1 CDM 0310 RC 81263 HCPCS inpatient 600 390 HUMANA - ALL PLANS HUMANA - ALL PLANS 468 78 999999999 363.3 582 percent of total billed charges "Gene rearrangement analysis (immunoglobulin heavy chain locus), variable region somatic mutation analysis" 51164838_1 CDM 0310 RC 81263 HCPCS inpatient 600 390 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 363.3 60.55 999999999 363.3 582 percent of total billed charges "Gene rearrangement analysis (immunoglobulin heavy chain locus), variable region somatic mutation analysis" 51164838_1 CDM 0310 RC 81263 HCPCS inpatient 600 390 UMR - ALL PLANS UMR - ALL PLANS 420 70 999999999 363.3 582 percent of total billed charges "Gene rearrangement analysis (immunoglobulin heavy chain locus), variable region somatic mutation analysis" 51164838_1 CDM 0310 RC 81263 HCPCS inpatient 600 390 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 363.3 582 "Gene rearrangement analysis (immunoglobulin heavy chain locus), variable region somatic mutation analysis" 51164838_1 CDM 0310 RC 81263 HCPCS inpatient 600 390 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 363.3 582 "Gene rearrangement analysis (immunoglobulin heavy chain locus), variable region somatic mutation analysis" 51164838_1 CDM 0310 RC 81263 HCPCS inpatient 600 390 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 363.3 582 "Gene rearrangement analysis (immunoglobulin heavy chain locus), variable region somatic mutation analysis" 51164838_1 CDM 0310 RC 81263 HCPCS inpatient 600 390 ANTHEM HMO ANTHEM HMO 999999999 363.3 582 "Gene rearrangement analysis (immunoglobulin heavy chain locus), variable region somatic mutation analysis" 51164838_1 CDM 0310 RC 81263 HCPCS inpatient 600 390 UHC - ALL PLANS UHC - ALL PLANS 999999999 363.3 582 "Gene rearrangement analysis (immunoglobulin heavy chain locus), variable region somatic mutation analysis" 51164838_1 CDM 0310 RC 81263 HCPCS inpatient 600 390 CIGNA - ALL PLANS CIGNA - ALL PLANS 405.6 67.6 999999999 363.3 582 percent of total billed charges Pinworm test 51166165_1 CDM 0306 RC 87172 HCPCS inpatient 94 61.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.1 65 999999999 56.92 91.18 percent of total billed charges Pinworm test 51166165_1 CDM 0306 RC 87172 HCPCS inpatient 94 61.1 AETNA AETNA 74.26 79 999999999 56.92 91.18 percent of total billed charges Pinworm test 51166165_1 CDM 0306 RC 87172 HCPCS inpatient 94 61.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.18 97 999999999 56.92 91.18 percent of total billed charges Pinworm test 51166165_1 CDM 0306 RC 87172 HCPCS inpatient 94 61.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.86 69 999999999 56.92 91.18 percent of total billed charges Pinworm test 51166165_1 CDM 0306 RC 87172 HCPCS inpatient 94 61.1 SIHO - ALL PLANS SIHO - ALL PLANS 84.6 90 999999999 56.92 91.18 percent of total billed charges Pinworm test 51166165_1 CDM 0306 RC 87172 HCPCS inpatient 94 61.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.32 78 999999999 56.92 91.18 percent of total billed charges Pinworm test 51166165_1 CDM 0306 RC 87172 HCPCS inpatient 94 61.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.92 60.55 999999999 56.92 91.18 percent of total billed charges Pinworm test 51166165_1 CDM 0306 RC 87172 HCPCS inpatient 94 61.1 UMR - ALL PLANS UMR - ALL PLANS 65.8 70 999999999 56.92 91.18 percent of total billed charges Pinworm test 51166165_1 CDM 0306 RC 87172 HCPCS inpatient 94 61.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.92 91.18 Pinworm test 51166165_1 CDM 0306 RC 87172 HCPCS inpatient 94 61.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.92 91.18 Pinworm test 51166165_1 CDM 0306 RC 87172 HCPCS inpatient 94 61.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.92 91.18 Pinworm test 51166165_1 CDM 0306 RC 87172 HCPCS inpatient 94 61.1 ANTHEM HMO ANTHEM HMO 999999999 56.92 91.18 Pinworm test 51166165_1 CDM 0306 RC 87172 HCPCS inpatient 94 61.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.92 91.18 Pinworm test 51166165_1 CDM 0306 RC 87172 HCPCS inpatient 94 61.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.54 67.6 999999999 56.92 91.18 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on both sides of body for hemodialysis access 51167659_1 CDM 0510 RC 93985 HCPCS inpatient 690 448.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 448.5 65 999999999 417.8 669.3 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on both sides of body for hemodialysis access 51167659_1 CDM 0510 RC 93985 HCPCS inpatient 690 448.5 AETNA AETNA 545.1 79 999999999 417.8 669.3 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on both sides of body for hemodialysis access 51167659_1 CDM 0510 RC 93985 HCPCS inpatient 690 448.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 669.3 97 999999999 417.8 669.3 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on both sides of body for hemodialysis access 51167659_1 CDM 0510 RC 93985 HCPCS inpatient 690 448.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 476.1 69 999999999 417.8 669.3 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on both sides of body for hemodialysis access 51167659_1 CDM 0510 RC 93985 HCPCS inpatient 690 448.5 SIHO - ALL PLANS SIHO - ALL PLANS 621 90 999999999 417.8 669.3 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on both sides of body for hemodialysis access 51167659_1 CDM 0510 RC 93985 HCPCS inpatient 690 448.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 538.2 78 999999999 417.8 669.3 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on both sides of body for hemodialysis access 51167659_1 CDM 0510 RC 93985 HCPCS inpatient 690 448.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 417.8 60.55 999999999 417.8 669.3 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on both sides of body for hemodialysis access 51167659_1 CDM 0510 RC 93985 HCPCS inpatient 690 448.5 UMR - ALL PLANS UMR - ALL PLANS 483 70 999999999 417.8 669.3 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on both sides of body for hemodialysis access 51167659_1 CDM 0510 RC 93985 HCPCS inpatient 690 448.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 417.8 669.3 Complete ultrasound of artery and vein blood flow pre-op assessment on both sides of body for hemodialysis access 51167659_1 CDM 0510 RC 93985 HCPCS inpatient 690 448.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 417.8 669.3 Complete ultrasound of artery and vein blood flow pre-op assessment on both sides of body for hemodialysis access 51167659_1 CDM 0510 RC 93985 HCPCS inpatient 690 448.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 417.8 669.3 Complete ultrasound of artery and vein blood flow pre-op assessment on both sides of body for hemodialysis access 51167659_1 CDM 0510 RC 93985 HCPCS inpatient 690 448.5 ANTHEM HMO ANTHEM HMO 999999999 417.8 669.3 Complete ultrasound of artery and vein blood flow pre-op assessment on both sides of body for hemodialysis access 51167659_1 CDM 0510 RC 93985 HCPCS inpatient 690 448.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 417.8 669.3 Complete ultrasound of artery and vein blood flow pre-op assessment on both sides of body for hemodialysis access 51167659_1 CDM 0510 RC 93985 HCPCS inpatient 690 448.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 466.44 67.6 999999999 417.8 669.3 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51167662_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 267.15 65 999999999 248.86 398.67 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51167662_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 AETNA AETNA 324.69 79 999999999 248.86 398.67 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51167662_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 398.67 97 999999999 248.86 398.67 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51167662_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 283.59 69 999999999 248.86 398.67 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51167662_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 SIHO - ALL PLANS SIHO - ALL PLANS 369.9 90 999999999 248.86 398.67 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51167662_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 320.58 78 999999999 248.86 398.67 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51167662_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 248.86 60.55 999999999 248.86 398.67 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51167662_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 UMR - ALL PLANS UMR - ALL PLANS 287.7 70 999999999 248.86 398.67 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51167662_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 248.86 398.67 Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51167662_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 248.86 398.67 Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51167662_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 248.86 398.67 Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51167662_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 ANTHEM HMO ANTHEM HMO 999999999 248.86 398.67 Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51167662_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 248.86 398.67 Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51167662_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 277.84 67.6 999999999 248.86 398.67 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51168283_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1023.75 65 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51168283_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 AETNA AETNA 1244.25 79 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51168283_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1527.75 97 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51168283_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1086.75 69 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51168283_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 SIHO - ALL PLANS SIHO - ALL PLANS 1417.5 90 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51168283_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1228.5 78 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51168283_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 953.66 60.55 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51168283_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UMR - ALL PLANS UMR - ALL PLANS 1102.5 70 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51168283_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51168283_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51168283_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51168283_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM HMO ANTHEM HMO 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51168283_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51168283_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1064.7 67.6 999999999 953.66 1527.75 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51172984_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 267.15 65 999999999 248.86 398.67 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51172984_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 AETNA AETNA 324.69 79 999999999 248.86 398.67 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51172984_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 398.67 97 999999999 248.86 398.67 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51172984_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 283.59 69 999999999 248.86 398.67 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51172984_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 320.58 78 999999999 248.86 398.67 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51172984_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 SIHO - ALL PLANS SIHO - ALL PLANS 369.9 90 999999999 248.86 398.67 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51172984_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 248.86 60.55 999999999 248.86 398.67 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51172984_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 UMR - ALL PLANS UMR - ALL PLANS 287.7 70 999999999 248.86 398.67 percent of total billed charges Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51172984_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 248.86 398.67 Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51172984_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 248.86 398.67 Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51172984_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 248.86 398.67 Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51172984_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 ANTHEM HMO ANTHEM HMO 999999999 248.86 398.67 Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51172984_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 248.86 398.67 Complete ultrasound of artery and vein blood flow pre-op assessment on side of body for hemodialysis access 51172984_1 CDM 0510 RC 93986 HCPCS inpatient 411 267.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 277.84 67.6 999999999 248.86 398.67 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51175132_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1126.45 65 999999999 1049.33 1681.01 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51175132_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 AETNA AETNA 1369.07 79 999999999 1049.33 1681.01 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51175132_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1681.01 97 999999999 1049.33 1681.01 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51175132_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1195.77 69 999999999 1049.33 1681.01 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51175132_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1351.74 78 999999999 1049.33 1681.01 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51175132_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 SIHO - ALL PLANS SIHO - ALL PLANS 1559.7 90 999999999 1049.33 1681.01 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51175132_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1049.33 60.55 999999999 1049.33 1681.01 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51175132_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 UMR - ALL PLANS UMR - ALL PLANS 1213.1 70 999999999 1049.33 1681.01 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51175132_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1049.33 1681.01 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51175132_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1049.33 1681.01 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51175132_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1049.33 1681.01 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51175132_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 ANTHEM HMO ANTHEM HMO 999999999 1049.33 1681.01 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51175132_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1049.33 1681.01 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51175132_1 CDM 0310 RC 81450 HCPCS inpatient 1733 1126.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1171.51 67.6 999999999 1049.33 1681.01 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51189332_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1023.75 65 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51189332_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 AETNA AETNA 1244.25 79 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51189332_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1527.75 97 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51189332_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1086.75 69 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51189332_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1228.5 78 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51189332_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 SIHO - ALL PLANS SIHO - ALL PLANS 1417.5 90 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51189332_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 953.66 60.55 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51189332_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UMR - ALL PLANS UMR - ALL PLANS 1102.5 70 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51189332_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51189332_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51189332_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51189332_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM HMO ANTHEM HMO 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51189332_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51189332_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1064.7 67.6 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51191150_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1023.75 65 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51191150_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 AETNA AETNA 1244.25 79 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51191150_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1527.75 97 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51191150_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1086.75 69 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51191150_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1228.5 78 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51191150_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 SIHO - ALL PLANS SIHO - ALL PLANS 1417.5 90 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51191150_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 953.66 60.55 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51191150_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UMR - ALL PLANS UMR - ALL PLANS 1102.5 70 999999999 953.66 1527.75 percent of total billed charges Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51191150_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51191150_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51191150_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51191150_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 ANTHEM HMO ANTHEM HMO 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51191150_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 953.66 1527.75 Targeted genomic sequence analysis panel of DNA or combine DNA and RNA of 5-50 genes associated with blood and lymphatic system disorders 51191150_1 CDM 0310 RC 81450 HCPCS inpatient 1575 1023.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1064.7 67.6 999999999 953.66 1527.75 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 51192942_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 352.3 65 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 51192942_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 AETNA AETNA 428.18 79 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 51192942_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 525.74 97 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 51192942_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 373.98 69 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 51192942_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 422.76 78 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 51192942_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 SIHO - ALL PLANS SIHO - ALL PLANS 487.8 90 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 51192942_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 328.18 60.55 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 51192942_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 UMR - ALL PLANS UMR - ALL PLANS 379.4 70 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 51192942_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 51192942_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 51192942_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 51192942_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ANTHEM HMO ANTHEM HMO 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 51192942_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 51192942_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 366.39 67.6 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 51192943_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 352.3 65 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 51192943_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 AETNA AETNA 428.18 79 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 51192943_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 525.74 97 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 51192943_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 373.98 69 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 51192943_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 422.76 78 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 51192943_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 SIHO - ALL PLANS SIHO - ALL PLANS 487.8 90 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 51192943_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 328.18 60.55 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 51192943_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 UMR - ALL PLANS UMR - ALL PLANS 379.4 70 999999999 328.18 525.74 percent of total billed charges "Detection test by nucleic acid for organism, quantification" 51192943_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 51192943_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 51192943_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 51192943_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 ANTHEM HMO ANTHEM HMO 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 51192943_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 328.18 525.74 "Detection test by nucleic acid for organism, quantification" 51192943_1 CDM 0306 RC 87799 HCPCS inpatient 542 352.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 366.39 67.6 999999999 328.18 525.74 percent of total billed charges Treatment of broken lower jaw bone 51194733_1 CDM 0450 RC 21461 HCPCS inpatient 5150 3347.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 3347.5 65 999999999 3118.33 4995.5 percent of total billed charges Treatment of broken lower jaw bone 51194733_1 CDM 0450 RC 21461 HCPCS inpatient 5150 3347.5 AETNA AETNA 4068.5 79 999999999 3118.33 4995.5 percent of total billed charges Treatment of broken lower jaw bone 51194733_1 CDM 0450 RC 21461 HCPCS inpatient 5150 3347.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4995.5 97 999999999 3118.33 4995.5 percent of total billed charges Treatment of broken lower jaw bone 51194733_1 CDM 0450 RC 21461 HCPCS inpatient 5150 3347.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 3553.5 69 999999999 3118.33 4995.5 percent of total billed charges Treatment of broken lower jaw bone 51194733_1 CDM 0450 RC 21461 HCPCS inpatient 5150 3347.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 4017 78 999999999 3118.33 4995.5 percent of total billed charges Treatment of broken lower jaw bone 51194733_1 CDM 0450 RC 21461 HCPCS inpatient 5150 3347.5 SIHO - ALL PLANS SIHO - ALL PLANS 4635 90 999999999 3118.33 4995.5 percent of total billed charges Treatment of broken lower jaw bone 51194733_1 CDM 0450 RC 21461 HCPCS inpatient 5150 3347.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3118.33 60.55 999999999 3118.33 4995.5 percent of total billed charges Treatment of broken lower jaw bone 51194733_1 CDM 0450 RC 21461 HCPCS inpatient 5150 3347.5 UMR - ALL PLANS UMR - ALL PLANS 3605 70 999999999 3118.33 4995.5 percent of total billed charges Treatment of broken lower jaw bone 51194733_1 CDM 0450 RC 21461 HCPCS inpatient 5150 3347.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3118.33 4995.5 Treatment of broken lower jaw bone 51194733_1 CDM 0450 RC 21461 HCPCS inpatient 5150 3347.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3118.33 4995.5 Treatment of broken lower jaw bone 51194733_1 CDM 0450 RC 21461 HCPCS inpatient 5150 3347.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3118.33 4995.5 Treatment of broken lower jaw bone 51194733_1 CDM 0450 RC 21461 HCPCS inpatient 5150 3347.5 ANTHEM HMO ANTHEM HMO 999999999 3118.33 4995.5 Treatment of broken lower jaw bone 51194733_1 CDM 0450 RC 21461 HCPCS inpatient 5150 3347.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 3118.33 4995.5 Treatment of broken lower jaw bone 51194733_1 CDM 0450 RC 21461 HCPCS inpatient 5150 3347.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 3481.4 67.6 999999999 3118.33 4995.5 percent of total billed charges Closed treatment of dislocated jaw joint 51194888_1 CDM 0450 RC 21480 HCPCS inpatient 611 397.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 397.15 65 999999999 369.96 592.67 percent of total billed charges Closed treatment of dislocated jaw joint 51194888_1 CDM 0450 RC 21480 HCPCS inpatient 611 397.15 AETNA AETNA 482.69 79 999999999 369.96 592.67 percent of total billed charges Closed treatment of dislocated jaw joint 51194888_1 CDM 0450 RC 21480 HCPCS inpatient 611 397.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 592.67 97 999999999 369.96 592.67 percent of total billed charges Closed treatment of dislocated jaw joint 51194888_1 CDM 0450 RC 21480 HCPCS inpatient 611 397.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 421.59 69 999999999 369.96 592.67 percent of total billed charges Closed treatment of dislocated jaw joint 51194888_1 CDM 0450 RC 21480 HCPCS inpatient 611 397.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 476.58 78 999999999 369.96 592.67 percent of total billed charges Closed treatment of dislocated jaw joint 51194888_1 CDM 0450 RC 21480 HCPCS inpatient 611 397.15 SIHO - ALL PLANS SIHO - ALL PLANS 549.9 90 999999999 369.96 592.67 percent of total billed charges Closed treatment of dislocated jaw joint 51194888_1 CDM 0450 RC 21480 HCPCS inpatient 611 397.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 369.96 60.55 999999999 369.96 592.67 percent of total billed charges Closed treatment of dislocated jaw joint 51194888_1 CDM 0450 RC 21480 HCPCS inpatient 611 397.15 UMR - ALL PLANS UMR - ALL PLANS 427.7 70 999999999 369.96 592.67 percent of total billed charges Closed treatment of dislocated jaw joint 51194888_1 CDM 0450 RC 21480 HCPCS inpatient 611 397.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 369.96 592.67 Closed treatment of dislocated jaw joint 51194888_1 CDM 0450 RC 21480 HCPCS inpatient 611 397.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 369.96 592.67 Closed treatment of dislocated jaw joint 51194888_1 CDM 0450 RC 21480 HCPCS inpatient 611 397.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 369.96 592.67 Closed treatment of dislocated jaw joint 51194888_1 CDM 0450 RC 21480 HCPCS inpatient 611 397.15 ANTHEM HMO ANTHEM HMO 999999999 369.96 592.67 Closed treatment of dislocated jaw joint 51194888_1 CDM 0450 RC 21480 HCPCS inpatient 611 397.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 369.96 592.67 Closed treatment of dislocated jaw joint 51194888_1 CDM 0450 RC 21480 HCPCS inpatient 611 397.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 413.04 67.6 999999999 369.96 592.67 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51199355_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51199355_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51199355_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51199355_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51199355_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51199355_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51199355_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51199355_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51199355_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 51199355_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 51199355_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 51199355_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 51199355_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 51199355_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51199356_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51199356_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51199356_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51199356_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51199356_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51199356_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51199356_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51199356_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51199356_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 51199356_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 51199356_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 51199356_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 51199356_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 51199356_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges Screening test for antibody to noninfectious agent 51199357_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 176.8 65 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 51199357_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 AETNA AETNA 214.88 79 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 51199357_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 263.84 97 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 51199357_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 187.68 69 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 51199357_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 212.16 78 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 51199357_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 SIHO - ALL PLANS SIHO - ALL PLANS 244.8 90 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 51199357_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 164.7 60.55 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 51199357_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 UMR - ALL PLANS UMR - ALL PLANS 190.4 70 999999999 164.7 263.84 percent of total billed charges Screening test for antibody to noninfectious agent 51199357_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 51199357_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 51199357_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 51199357_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 ANTHEM HMO ANTHEM HMO 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 51199357_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 164.7 263.84 Screening test for antibody to noninfectious agent 51199357_1 CDM 0301 RC 86255 HCPCS inpatient 272 176.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 183.87 67.6 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 51199363_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 176.8 65 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 51199363_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 AETNA AETNA 214.88 79 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 51199363_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 263.84 97 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 51199363_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 187.68 69 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 51199363_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 212.16 78 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 51199363_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 SIHO - ALL PLANS SIHO - ALL PLANS 244.8 90 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 51199363_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 164.7 60.55 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 51199363_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 UMR - ALL PLANS UMR - ALL PLANS 190.4 70 999999999 164.7 263.84 percent of total billed charges "Measurement of substance using immunoassay technique, by radioimmunoassay" 51199363_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 164.7 263.84 "Measurement of substance using immunoassay technique, by radioimmunoassay" 51199363_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 164.7 263.84 "Measurement of substance using immunoassay technique, by radioimmunoassay" 51199363_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 164.7 263.84 "Measurement of substance using immunoassay technique, by radioimmunoassay" 51199363_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 ANTHEM HMO ANTHEM HMO 999999999 164.7 263.84 "Measurement of substance using immunoassay technique, by radioimmunoassay" 51199363_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 164.7 263.84 "Measurement of substance using immunoassay technique, by radioimmunoassay" 51199363_1 CDM 0301 RC 83519 HCPCS inpatient 272 176.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 183.87 67.6 999999999 164.7 263.84 percent of total billed charges Analysis for antibody to virus 51200576_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.7 65 999999999 35.12 56.26 percent of total billed charges Analysis for antibody to virus 51200576_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 AETNA AETNA 45.82 79 999999999 35.12 56.26 percent of total billed charges Analysis for antibody to virus 51200576_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.26 97 999999999 35.12 56.26 percent of total billed charges Analysis for antibody to virus 51200576_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.02 69 999999999 35.12 56.26 percent of total billed charges Analysis for antibody to virus 51200576_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.24 78 999999999 35.12 56.26 percent of total billed charges Analysis for antibody to virus 51200576_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 SIHO - ALL PLANS SIHO - ALL PLANS 52.2 90 999999999 35.12 56.26 percent of total billed charges Analysis for antibody to virus 51200576_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.12 60.55 999999999 35.12 56.26 percent of total billed charges Analysis for antibody to virus 51200576_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 UMR - ALL PLANS UMR - ALL PLANS 40.6 70 999999999 35.12 56.26 percent of total billed charges Analysis for antibody to virus 51200576_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.12 56.26 Analysis for antibody to virus 51200576_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.12 56.26 Analysis for antibody to virus 51200576_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.12 56.26 Analysis for antibody to virus 51200576_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 ANTHEM HMO ANTHEM HMO 999999999 35.12 56.26 Analysis for antibody to virus 51200576_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.12 56.26 Analysis for antibody to virus 51200576_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.21 67.6 999999999 35.12 56.26 percent of total billed charges VAPOR CLEAN (MH CART) 51206152_1 CDM 0270 RC inpatient 424.38 275.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 275.85 65 999999999 256.96 411.65 percent of total billed charges VAPOR CLEAN (MH CART) 51206152_1 CDM 0270 RC inpatient 424.38 275.85 AETNA AETNA 335.26 79 999999999 256.96 411.65 percent of total billed charges VAPOR CLEAN (MH CART) 51206152_1 CDM 0270 RC inpatient 424.38 275.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 411.65 97 999999999 256.96 411.65 percent of total billed charges VAPOR CLEAN (MH CART) 51206152_1 CDM 0270 RC inpatient 424.38 275.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 292.82 69 999999999 256.96 411.65 percent of total billed charges VAPOR CLEAN (MH CART) 51206152_1 CDM 0270 RC inpatient 424.38 275.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 331.02 78 999999999 256.96 411.65 percent of total billed charges VAPOR CLEAN (MH CART) 51206152_1 CDM 0270 RC inpatient 424.38 275.85 SIHO - ALL PLANS SIHO - ALL PLANS 381.94 90 999999999 256.96 411.65 percent of total billed charges VAPOR CLEAN (MH CART) 51206152_1 CDM 0270 RC inpatient 424.38 275.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 256.96 60.55 999999999 256.96 411.65 percent of total billed charges VAPOR CLEAN (MH CART) 51206152_1 CDM 0270 RC inpatient 424.38 275.85 UMR - ALL PLANS UMR - ALL PLANS 297.07 70 999999999 256.96 411.65 percent of total billed charges VAPOR CLEAN (MH CART) 51206152_1 CDM 0270 RC inpatient 424.38 275.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 256.96 411.65 VAPOR CLEAN (MH CART) 51206152_1 CDM 0270 RC inpatient 424.38 275.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 256.96 411.65 VAPOR CLEAN (MH CART) 51206152_1 CDM 0270 RC inpatient 424.38 275.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 256.96 411.65 VAPOR CLEAN (MH CART) 51206152_1 CDM 0270 RC inpatient 424.38 275.85 ANTHEM HMO ANTHEM HMO 999999999 256.96 411.65 VAPOR CLEAN (MH CART) 51206152_1 CDM 0270 RC inpatient 424.38 275.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 256.96 411.65 VAPOR CLEAN (MH CART) 51206152_1 CDM 0270 RC inpatient 424.38 275.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 286.88 67.6 999999999 256.96 411.65 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51206495_1 CDM 0310 RC 88373 HCPCS inpatient 100 65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65 65 999999999 60.55 97 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51206495_1 CDM 0310 RC 88373 HCPCS inpatient 100 65 AETNA AETNA 79 79 999999999 60.55 97 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51206495_1 CDM 0310 RC 88373 HCPCS inpatient 100 65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97 97 999999999 60.55 97 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51206495_1 CDM 0310 RC 88373 HCPCS inpatient 100 65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69 69 999999999 60.55 97 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51206495_1 CDM 0310 RC 88373 HCPCS inpatient 100 65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78 78 999999999 60.55 97 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51206495_1 CDM 0310 RC 88373 HCPCS inpatient 100 65 SIHO - ALL PLANS SIHO - ALL PLANS 90 90 999999999 60.55 97 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51206495_1 CDM 0310 RC 88373 HCPCS inpatient 100 65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.55 60.55 999999999 60.55 97 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51206495_1 CDM 0310 RC 88373 HCPCS inpatient 100 65 UMR - ALL PLANS UMR - ALL PLANS 70 70 999999999 60.55 97 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51206495_1 CDM 0310 RC 88373 HCPCS inpatient 100 65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.55 97 "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51206495_1 CDM 0310 RC 88373 HCPCS inpatient 100 65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.55 97 "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51206495_1 CDM 0310 RC 88373 HCPCS inpatient 100 65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.55 97 "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51206495_1 CDM 0310 RC 88373 HCPCS inpatient 100 65 ANTHEM HMO ANTHEM HMO 999999999 60.55 97 "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51206495_1 CDM 0310 RC 88373 HCPCS inpatient 100 65 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.55 97 "Microscopic genetic analysis of tissue, computer-assisted technology, each additional procedure" 51206495_1 CDM 0310 RC 88373 HCPCS inpatient 100 65 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.6 67.6 999999999 60.55 97 percent of total billed charges Measurement of substance using immunoassay technique 51208886_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.95 65 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 51208886_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 AETNA AETNA 144.57 79 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 51208886_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.51 97 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 51208886_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.27 69 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 51208886_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 142.74 78 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 51208886_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 SIHO - ALL PLANS SIHO - ALL PLANS 164.7 90 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 51208886_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.81 60.55 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 51208886_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 UMR - ALL PLANS UMR - ALL PLANS 128.1 70 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 51208886_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.81 177.51 Measurement of substance using immunoassay technique 51208886_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.81 177.51 Measurement of substance using immunoassay technique 51208886_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.81 177.51 Measurement of substance using immunoassay technique 51208886_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM HMO ANTHEM HMO 999999999 110.81 177.51 Measurement of substance using immunoassay technique 51208886_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.81 177.51 Measurement of substance using immunoassay technique 51208886_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.71 67.6 999999999 110.81 177.51 percent of total billed charges Everolimus level 51208919_1 CDM 0301 RC 80169 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Everolimus level 51208919_1 CDM 0301 RC 80169 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Everolimus level 51208919_1 CDM 0301 RC 80169 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Everolimus level 51208919_1 CDM 0301 RC 80169 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Everolimus level 51208919_1 CDM 0301 RC 80169 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Everolimus level 51208919_1 CDM 0301 RC 80169 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Everolimus level 51208919_1 CDM 0301 RC 80169 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Everolimus level 51208919_1 CDM 0301 RC 80169 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Everolimus level 51208919_1 CDM 0301 RC 80169 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Everolimus level 51208919_1 CDM 0301 RC 80169 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Everolimus level 51208919_1 CDM 0301 RC 80169 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Everolimus level 51208919_1 CDM 0301 RC 80169 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Everolimus level 51208919_1 CDM 0301 RC 80169 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Everolimus level 51208919_1 CDM 0301 RC 80169 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Triglycerides level 51210760_1 CDM 0301 RC 84478 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges Triglycerides level 51210760_1 CDM 0301 RC 84478 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges Triglycerides level 51210760_1 CDM 0301 RC 84478 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges Triglycerides level 51210760_1 CDM 0301 RC 84478 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges Triglycerides level 51210760_1 CDM 0301 RC 84478 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges Triglycerides level 51210760_1 CDM 0301 RC 84478 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges Triglycerides level 51210760_1 CDM 0301 RC 84478 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges Triglycerides level 51210760_1 CDM 0301 RC 84478 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges Triglycerides level 51210760_1 CDM 0301 RC 84478 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 Triglycerides level 51210760_1 CDM 0301 RC 84478 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 Triglycerides level 51210760_1 CDM 0301 RC 84478 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 Triglycerides level 51210760_1 CDM 0301 RC 84478 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 Triglycerides level 51210760_1 CDM 0301 RC 84478 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 Triglycerides level 51210760_1 CDM 0301 RC 84478 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51210779_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51210779_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51210779_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51210779_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51210779_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51210779_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51210779_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51210779_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51210779_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 51210779_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 51210779_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 51210779_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 51210779_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 "Analysis of substance using immunoassay technique, multiple step method" 51210779_1 CDM 0301 RC 83516 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges Analysis for antibody to Hepatitis D virus 51210788_1 CDM 0301 RC 86692 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Analysis for antibody to Hepatitis D virus 51210788_1 CDM 0301 RC 86692 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Analysis for antibody to Hepatitis D virus 51210788_1 CDM 0301 RC 86692 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Analysis for antibody to Hepatitis D virus 51210788_1 CDM 0301 RC 86692 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Analysis for antibody to Hepatitis D virus 51210788_1 CDM 0301 RC 86692 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Analysis for antibody to Hepatitis D virus 51210788_1 CDM 0301 RC 86692 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Analysis for antibody to Hepatitis D virus 51210788_1 CDM 0301 RC 86692 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Analysis for antibody to Hepatitis D virus 51210788_1 CDM 0301 RC 86692 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Analysis for antibody to Hepatitis D virus 51210788_1 CDM 0301 RC 86692 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Analysis for antibody to Hepatitis D virus 51210788_1 CDM 0301 RC 86692 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Analysis for antibody to Hepatitis D virus 51210788_1 CDM 0301 RC 86692 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Analysis for antibody to Hepatitis D virus 51210788_1 CDM 0301 RC 86692 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Analysis for antibody to Hepatitis D virus 51210788_1 CDM 0301 RC 86692 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Analysis for antibody to Hepatitis D virus 51210788_1 CDM 0301 RC 86692 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51211589_1 CDM 0310 RC 88374 HCPCS inpatient 850 552.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 552.5 65 999999999 514.68 824.5 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51211589_1 CDM 0310 RC 88374 HCPCS inpatient 850 552.5 AETNA AETNA 671.5 79 999999999 514.68 824.5 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51211589_1 CDM 0310 RC 88374 HCPCS inpatient 850 552.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 824.5 97 999999999 514.68 824.5 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51211589_1 CDM 0310 RC 88374 HCPCS inpatient 850 552.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 586.5 69 999999999 514.68 824.5 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51211589_1 CDM 0310 RC 88374 HCPCS inpatient 850 552.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 663 78 999999999 514.68 824.5 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51211589_1 CDM 0310 RC 88374 HCPCS inpatient 850 552.5 SIHO - ALL PLANS SIHO - ALL PLANS 765 90 999999999 514.68 824.5 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51211589_1 CDM 0310 RC 88374 HCPCS inpatient 850 552.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 514.68 60.55 999999999 514.68 824.5 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51211589_1 CDM 0310 RC 88374 HCPCS inpatient 850 552.5 UMR - ALL PLANS UMR - ALL PLANS 595 70 999999999 514.68 824.5 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51211589_1 CDM 0310 RC 88374 HCPCS inpatient 850 552.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 514.68 824.5 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51211589_1 CDM 0310 RC 88374 HCPCS inpatient 850 552.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 514.68 824.5 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51211589_1 CDM 0310 RC 88374 HCPCS inpatient 850 552.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 514.68 824.5 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51211589_1 CDM 0310 RC 88374 HCPCS inpatient 850 552.5 ANTHEM HMO ANTHEM HMO 999999999 514.68 824.5 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51211589_1 CDM 0310 RC 88374 HCPCS inpatient 850 552.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 514.68 824.5 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51211589_1 CDM 0310 RC 88374 HCPCS inpatient 850 552.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 574.6 67.6 999999999 514.68 824.5 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 51211973_1 CDM 0312 RC 88305 HCPCS inpatient 228 148.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 148.2 65 999999999 138.05 221.16 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 51211973_1 CDM 0312 RC 88305 HCPCS inpatient 228 148.2 AETNA AETNA 180.12 79 999999999 138.05 221.16 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 51211973_1 CDM 0312 RC 88305 HCPCS inpatient 228 148.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 221.16 97 999999999 138.05 221.16 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 51211973_1 CDM 0312 RC 88305 HCPCS inpatient 228 148.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 157.32 69 999999999 138.05 221.16 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 51211973_1 CDM 0312 RC 88305 HCPCS inpatient 228 148.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 177.84 78 999999999 138.05 221.16 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 51211973_1 CDM 0312 RC 88305 HCPCS inpatient 228 148.2 SIHO - ALL PLANS SIHO - ALL PLANS 205.2 90 999999999 138.05 221.16 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 51211973_1 CDM 0312 RC 88305 HCPCS inpatient 228 148.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 138.05 60.55 999999999 138.05 221.16 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 51211973_1 CDM 0312 RC 88305 HCPCS inpatient 228 148.2 UMR - ALL PLANS UMR - ALL PLANS 159.6 70 999999999 138.05 221.16 percent of total billed charges "Pathology examination of tissue using a microscope, intermediate complexity" 51211973_1 CDM 0312 RC 88305 HCPCS inpatient 228 148.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 138.05 221.16 "Pathology examination of tissue using a microscope, intermediate complexity" 51211973_1 CDM 0312 RC 88305 HCPCS inpatient 228 148.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 138.05 221.16 "Pathology examination of tissue using a microscope, intermediate complexity" 51211973_1 CDM 0312 RC 88305 HCPCS inpatient 228 148.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 138.05 221.16 "Pathology examination of tissue using a microscope, intermediate complexity" 51211973_1 CDM 0312 RC 88305 HCPCS inpatient 228 148.2 ANTHEM HMO ANTHEM HMO 999999999 138.05 221.16 "Pathology examination of tissue using a microscope, intermediate complexity" 51211973_1 CDM 0312 RC 88305 HCPCS inpatient 228 148.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 138.05 221.16 "Pathology examination of tissue using a microscope, intermediate complexity" 51211973_1 CDM 0312 RC 88305 HCPCS inpatient 228 148.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 154.13 67.6 999999999 138.05 221.16 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 51211974_1 CDM 0312 RC 88313 HCPCS inpatient 116 75.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 75.4 65 999999999 70.24 112.52 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 51211974_1 CDM 0312 RC 88313 HCPCS inpatient 116 75.4 AETNA AETNA 91.64 79 999999999 70.24 112.52 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 51211974_1 CDM 0312 RC 88313 HCPCS inpatient 116 75.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 112.52 97 999999999 70.24 112.52 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 51211974_1 CDM 0312 RC 88313 HCPCS inpatient 116 75.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.04 69 999999999 70.24 112.52 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 51211974_1 CDM 0312 RC 88313 HCPCS inpatient 116 75.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 90.48 78 999999999 70.24 112.52 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 51211974_1 CDM 0312 RC 88313 HCPCS inpatient 116 75.4 SIHO - ALL PLANS SIHO - ALL PLANS 104.4 90 999999999 70.24 112.52 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 51211974_1 CDM 0312 RC 88313 HCPCS inpatient 116 75.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 70.24 60.55 999999999 70.24 112.52 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 51211974_1 CDM 0312 RC 88313 HCPCS inpatient 116 75.4 UMR - ALL PLANS UMR - ALL PLANS 81.2 70 999999999 70.24 112.52 percent of total billed charges Special stained specimen slides to examine tissue including interpretation and report 51211974_1 CDM 0312 RC 88313 HCPCS inpatient 116 75.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 70.24 112.52 Special stained specimen slides to examine tissue including interpretation and report 51211974_1 CDM 0312 RC 88313 HCPCS inpatient 116 75.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 70.24 112.52 Special stained specimen slides to examine tissue including interpretation and report 51211974_1 CDM 0312 RC 88313 HCPCS inpatient 116 75.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 70.24 112.52 Special stained specimen slides to examine tissue including interpretation and report 51211974_1 CDM 0312 RC 88313 HCPCS inpatient 116 75.4 ANTHEM HMO ANTHEM HMO 999999999 70.24 112.52 Special stained specimen slides to examine tissue including interpretation and report 51211974_1 CDM 0312 RC 88313 HCPCS inpatient 116 75.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 70.24 112.52 Special stained specimen slides to examine tissue including interpretation and report 51211974_1 CDM 0312 RC 88313 HCPCS inpatient 116 75.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 78.42 67.6 999999999 70.24 112.52 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 51212003_1 CDM 0311 RC 88185 HCPCS inpatient 60 39 SELF PAY DISCOUNT SELF PAY DISCOUNT 39 65 999999999 36.33 58.2 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 51212003_1 CDM 0311 RC 88185 HCPCS inpatient 60 39 AETNA AETNA 47.4 79 999999999 36.33 58.2 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 51212003_1 CDM 0311 RC 88185 HCPCS inpatient 60 39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.2 97 999999999 36.33 58.2 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 51212003_1 CDM 0311 RC 88185 HCPCS inpatient 60 39 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.4 69 999999999 36.33 58.2 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 51212003_1 CDM 0311 RC 88185 HCPCS inpatient 60 39 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.8 78 999999999 36.33 58.2 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 51212003_1 CDM 0311 RC 88185 HCPCS inpatient 60 39 SIHO - ALL PLANS SIHO - ALL PLANS 54 90 999999999 36.33 58.2 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 51212003_1 CDM 0311 RC 88185 HCPCS inpatient 60 39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.33 60.55 999999999 36.33 58.2 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 51212003_1 CDM 0311 RC 88185 HCPCS inpatient 60 39 UMR - ALL PLANS UMR - ALL PLANS 42 70 999999999 36.33 58.2 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 51212003_1 CDM 0311 RC 88185 HCPCS inpatient 60 39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.33 58.2 "Flow cytometry technique for DNA or cell analysis, each additional marker" 51212003_1 CDM 0311 RC 88185 HCPCS inpatient 60 39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.33 58.2 "Flow cytometry technique for DNA or cell analysis, each additional marker" 51212003_1 CDM 0311 RC 88185 HCPCS inpatient 60 39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.33 58.2 "Flow cytometry technique for DNA or cell analysis, each additional marker" 51212003_1 CDM 0311 RC 88185 HCPCS inpatient 60 39 ANTHEM HMO ANTHEM HMO 999999999 36.33 58.2 "Flow cytometry technique for DNA or cell analysis, each additional marker" 51212003_1 CDM 0311 RC 88185 HCPCS inpatient 60 39 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.33 58.2 "Flow cytometry technique for DNA or cell analysis, each additional marker" 51212003_1 CDM 0311 RC 88185 HCPCS inpatient 60 39 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.56 67.6 999999999 36.33 58.2 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51212004_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.25 65 999999999 75.69 121.25 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51212004_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 AETNA AETNA 98.75 79 999999999 75.69 121.25 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51212004_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 121.25 97 999999999 75.69 121.25 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51212004_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.25 69 999999999 75.69 121.25 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51212004_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.5 78 999999999 75.69 121.25 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51212004_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 SIHO - ALL PLANS SIHO - ALL PLANS 112.5 90 999999999 75.69 121.25 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51212004_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.69 60.55 999999999 75.69 121.25 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51212004_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 UMR - ALL PLANS UMR - ALL PLANS 87.5 70 999999999 75.69 121.25 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51212004_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.69 121.25 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51212004_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.69 121.25 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51212004_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.69 121.25 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51212004_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 ANTHEM HMO ANTHEM HMO 999999999 75.69 121.25 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51212004_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.69 121.25 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51212004_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.5 67.6 999999999 75.69 121.25 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51212847_1 CDM 0300 RC 87798 HCPCS inpatient 108 70.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.2 65 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51212847_1 CDM 0300 RC 87798 HCPCS inpatient 108 70.2 AETNA AETNA 85.32 79 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51212847_1 CDM 0300 RC 87798 HCPCS inpatient 108 70.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 104.76 97 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51212847_1 CDM 0300 RC 87798 HCPCS inpatient 108 70.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 74.52 69 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51212847_1 CDM 0300 RC 87798 HCPCS inpatient 108 70.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 84.24 78 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51212847_1 CDM 0300 RC 87798 HCPCS inpatient 108 70.2 SIHO - ALL PLANS SIHO - ALL PLANS 97.2 90 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51212847_1 CDM 0300 RC 87798 HCPCS inpatient 108 70.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 65.39 60.55 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51212847_1 CDM 0300 RC 87798 HCPCS inpatient 108 70.2 UMR - ALL PLANS UMR - ALL PLANS 75.6 70 999999999 65.39 104.76 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51212847_1 CDM 0300 RC 87798 HCPCS inpatient 108 70.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 65.39 104.76 "Detection test by nucleic acid for organism, amplified probe technique" 51212847_1 CDM 0300 RC 87798 HCPCS inpatient 108 70.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 65.39 104.76 "Detection test by nucleic acid for organism, amplified probe technique" 51212847_1 CDM 0300 RC 87798 HCPCS inpatient 108 70.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 65.39 104.76 "Detection test by nucleic acid for organism, amplified probe technique" 51212847_1 CDM 0300 RC 87798 HCPCS inpatient 108 70.2 ANTHEM HMO ANTHEM HMO 999999999 65.39 104.76 "Detection test by nucleic acid for organism, amplified probe technique" 51212847_1 CDM 0300 RC 87798 HCPCS inpatient 108 70.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 65.39 104.76 "Detection test by nucleic acid for organism, amplified probe technique" 51212847_1 CDM 0300 RC 87798 HCPCS inpatient 108 70.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.01 67.6 999999999 65.39 104.76 percent of total billed charges Preparation of tissue for examination by removing any calcium present 51212980_1 CDM 0312 RC 88311 HCPCS inpatient 51 33.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 33.15 65 999999999 30.88 49.47 percent of total billed charges Preparation of tissue for examination by removing any calcium present 51212980_1 CDM 0312 RC 88311 HCPCS inpatient 51 33.15 AETNA AETNA 40.29 79 999999999 30.88 49.47 percent of total billed charges Preparation of tissue for examination by removing any calcium present 51212980_1 CDM 0312 RC 88311 HCPCS inpatient 51 33.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 49.47 97 999999999 30.88 49.47 percent of total billed charges Preparation of tissue for examination by removing any calcium present 51212980_1 CDM 0312 RC 88311 HCPCS inpatient 51 33.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 35.19 69 999999999 30.88 49.47 percent of total billed charges Preparation of tissue for examination by removing any calcium present 51212980_1 CDM 0312 RC 88311 HCPCS inpatient 51 33.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 39.78 78 999999999 30.88 49.47 percent of total billed charges Preparation of tissue for examination by removing any calcium present 51212980_1 CDM 0312 RC 88311 HCPCS inpatient 51 33.15 SIHO - ALL PLANS SIHO - ALL PLANS 45.9 90 999999999 30.88 49.47 percent of total billed charges Preparation of tissue for examination by removing any calcium present 51212980_1 CDM 0312 RC 88311 HCPCS inpatient 51 33.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.88 60.55 999999999 30.88 49.47 percent of total billed charges Preparation of tissue for examination by removing any calcium present 51212980_1 CDM 0312 RC 88311 HCPCS inpatient 51 33.15 UMR - ALL PLANS UMR - ALL PLANS 35.7 70 999999999 30.88 49.47 percent of total billed charges Preparation of tissue for examination by removing any calcium present 51212980_1 CDM 0312 RC 88311 HCPCS inpatient 51 33.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.88 49.47 Preparation of tissue for examination by removing any calcium present 51212980_1 CDM 0312 RC 88311 HCPCS inpatient 51 33.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.88 49.47 Preparation of tissue for examination by removing any calcium present 51212980_1 CDM 0312 RC 88311 HCPCS inpatient 51 33.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.88 49.47 Preparation of tissue for examination by removing any calcium present 51212980_1 CDM 0312 RC 88311 HCPCS inpatient 51 33.15 ANTHEM HMO ANTHEM HMO 999999999 30.88 49.47 Preparation of tissue for examination by removing any calcium present 51212980_1 CDM 0312 RC 88311 HCPCS inpatient 51 33.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.88 49.47 Preparation of tissue for examination by removing any calcium present 51212980_1 CDM 0312 RC 88311 HCPCS inpatient 51 33.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 34.48 67.6 999999999 30.88 49.47 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51214123_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.25 65 999999999 75.69 121.25 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51214123_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 AETNA AETNA 98.75 79 999999999 75.69 121.25 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51214123_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 121.25 97 999999999 75.69 121.25 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51214123_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.25 69 999999999 75.69 121.25 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51214123_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.5 78 999999999 75.69 121.25 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51214123_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 SIHO - ALL PLANS SIHO - ALL PLANS 112.5 90 999999999 75.69 121.25 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51214123_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.69 60.55 999999999 75.69 121.25 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51214123_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 UMR - ALL PLANS UMR - ALL PLANS 87.5 70 999999999 75.69 121.25 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51214123_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.69 121.25 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51214123_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.69 121.25 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51214123_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.69 121.25 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51214123_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 ANTHEM HMO ANTHEM HMO 999999999 75.69 121.25 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51214123_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.69 121.25 "Flow cytometry technique for DNA or cell analysis, 16 or more markers" 51214123_1 CDM 0311 RC 88189 HCPCS inpatient 125 81.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.5 67.6 999999999 75.69 121.25 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 51214124_1 CDM 0311 RC 88185 HCPCS inpatient 64 41.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 41.6 65 999999999 38.75 62.08 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 51214124_1 CDM 0311 RC 88185 HCPCS inpatient 64 41.6 AETNA AETNA 50.56 79 999999999 38.75 62.08 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 51214124_1 CDM 0311 RC 88185 HCPCS inpatient 64 41.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 62.08 97 999999999 38.75 62.08 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 51214124_1 CDM 0311 RC 88185 HCPCS inpatient 64 41.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.16 69 999999999 38.75 62.08 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 51214124_1 CDM 0311 RC 88185 HCPCS inpatient 64 41.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.92 78 999999999 38.75 62.08 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 51214124_1 CDM 0311 RC 88185 HCPCS inpatient 64 41.6 SIHO - ALL PLANS SIHO - ALL PLANS 57.6 90 999999999 38.75 62.08 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 51214124_1 CDM 0311 RC 88185 HCPCS inpatient 64 41.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.75 60.55 999999999 38.75 62.08 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 51214124_1 CDM 0311 RC 88185 HCPCS inpatient 64 41.6 UMR - ALL PLANS UMR - ALL PLANS 44.8 70 999999999 38.75 62.08 percent of total billed charges "Flow cytometry technique for DNA or cell analysis, each additional marker" 51214124_1 CDM 0311 RC 88185 HCPCS inpatient 64 41.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.75 62.08 "Flow cytometry technique for DNA or cell analysis, each additional marker" 51214124_1 CDM 0311 RC 88185 HCPCS inpatient 64 41.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.75 62.08 "Flow cytometry technique for DNA or cell analysis, each additional marker" 51214124_1 CDM 0311 RC 88185 HCPCS inpatient 64 41.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.75 62.08 "Flow cytometry technique for DNA or cell analysis, each additional marker" 51214124_1 CDM 0311 RC 88185 HCPCS inpatient 64 41.6 ANTHEM HMO ANTHEM HMO 999999999 38.75 62.08 "Flow cytometry technique for DNA or cell analysis, each additional marker" 51214124_1 CDM 0311 RC 88185 HCPCS inpatient 64 41.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.75 62.08 "Flow cytometry technique for DNA or cell analysis, each additional marker" 51214124_1 CDM 0311 RC 88185 HCPCS inpatient 64 41.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.26 67.6 999999999 38.75 62.08 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51214131_1 CDM 0311 RC 88262 HCPCS inpatient 585 380.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 380.25 65 999999999 354.22 567.45 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51214131_1 CDM 0311 RC 88262 HCPCS inpatient 585 380.25 AETNA AETNA 462.15 79 999999999 354.22 567.45 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51214131_1 CDM 0311 RC 88262 HCPCS inpatient 585 380.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 567.45 97 999999999 354.22 567.45 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51214131_1 CDM 0311 RC 88262 HCPCS inpatient 585 380.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 403.65 69 999999999 354.22 567.45 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51214131_1 CDM 0311 RC 88262 HCPCS inpatient 585 380.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 456.3 78 999999999 354.22 567.45 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51214131_1 CDM 0311 RC 88262 HCPCS inpatient 585 380.25 SIHO - ALL PLANS SIHO - ALL PLANS 526.5 90 999999999 354.22 567.45 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51214131_1 CDM 0311 RC 88262 HCPCS inpatient 585 380.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 354.22 60.55 999999999 354.22 567.45 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51214131_1 CDM 0311 RC 88262 HCPCS inpatient 585 380.25 UMR - ALL PLANS UMR - ALL PLANS 409.5 70 999999999 354.22 567.45 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51214131_1 CDM 0311 RC 88262 HCPCS inpatient 585 380.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 354.22 567.45 "Chromosome analysis for genetic defects, count 15-20 cells" 51214131_1 CDM 0311 RC 88262 HCPCS inpatient 585 380.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 354.22 567.45 "Chromosome analysis for genetic defects, count 15-20 cells" 51214131_1 CDM 0311 RC 88262 HCPCS inpatient 585 380.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 354.22 567.45 "Chromosome analysis for genetic defects, count 15-20 cells" 51214131_1 CDM 0311 RC 88262 HCPCS inpatient 585 380.25 ANTHEM HMO ANTHEM HMO 999999999 354.22 567.45 "Chromosome analysis for genetic defects, count 15-20 cells" 51214131_1 CDM 0311 RC 88262 HCPCS inpatient 585 380.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 354.22 567.45 "Chromosome analysis for genetic defects, count 15-20 cells" 51214131_1 CDM 0311 RC 88262 HCPCS inpatient 585 380.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 395.46 67.6 999999999 354.22 567.45 percent of total billed charges COOLSEAL REVEAL CSL-RV105-10 51216611_1 CDM 0272 RC inpatient 2060 1339 SELF PAY DISCOUNT SELF PAY DISCOUNT 1339 65 999999999 1247.33 1998.2 percent of total billed charges COOLSEAL REVEAL CSL-RV105-10 51216611_1 CDM 0272 RC inpatient 2060 1339 AETNA AETNA 1627.4 79 999999999 1247.33 1998.2 percent of total billed charges COOLSEAL REVEAL CSL-RV105-10 51216611_1 CDM 0272 RC inpatient 2060 1339 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1998.2 97 999999999 1247.33 1998.2 percent of total billed charges COOLSEAL REVEAL CSL-RV105-10 51216611_1 CDM 0272 RC inpatient 2060 1339 ENCORE - ALL PLANS ENCORE - ALL PLANS 1421.4 69 999999999 1247.33 1998.2 percent of total billed charges COOLSEAL REVEAL CSL-RV105-10 51216611_1 CDM 0272 RC inpatient 2060 1339 HUMANA - ALL PLANS HUMANA - ALL PLANS 1606.8 78 999999999 1247.33 1998.2 percent of total billed charges COOLSEAL REVEAL CSL-RV105-10 51216611_1 CDM 0272 RC inpatient 2060 1339 SIHO - ALL PLANS SIHO - ALL PLANS 1854 90 999999999 1247.33 1998.2 percent of total billed charges COOLSEAL REVEAL CSL-RV105-10 51216611_1 CDM 0272 RC inpatient 2060 1339 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1247.33 60.55 999999999 1247.33 1998.2 percent of total billed charges COOLSEAL REVEAL CSL-RV105-10 51216611_1 CDM 0272 RC inpatient 2060 1339 UMR - ALL PLANS UMR - ALL PLANS 1442 70 999999999 1247.33 1998.2 percent of total billed charges COOLSEAL REVEAL CSL-RV105-10 51216611_1 CDM 0272 RC inpatient 2060 1339 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1247.33 1998.2 COOLSEAL REVEAL CSL-RV105-10 51216611_1 CDM 0272 RC inpatient 2060 1339 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1247.33 1998.2 COOLSEAL REVEAL CSL-RV105-10 51216611_1 CDM 0272 RC inpatient 2060 1339 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1247.33 1998.2 COOLSEAL REVEAL CSL-RV105-10 51216611_1 CDM 0272 RC inpatient 2060 1339 ANTHEM HMO ANTHEM HMO 999999999 1247.33 1998.2 COOLSEAL REVEAL CSL-RV105-10 51216611_1 CDM 0272 RC inpatient 2060 1339 UHC - ALL PLANS UHC - ALL PLANS 999999999 1247.33 1998.2 COOLSEAL REVEAL CSL-RV105-10 51216611_1 CDM 0272 RC inpatient 2060 1339 CIGNA - ALL PLANS CIGNA - ALL PLANS 1392.56 67.6 999999999 1247.33 1998.2 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51219126_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 45.5 65 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51219126_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 AETNA AETNA 55.3 79 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51219126_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67.9 97 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51219126_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 48.3 69 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51219126_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 54.6 78 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51219126_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 SIHO - ALL PLANS SIHO - ALL PLANS 63 90 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51219126_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42.39 60.55 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51219126_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UMR - ALL PLANS UMR - ALL PLANS 49 70 999999999 42.39 67.9 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51219126_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51219126_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51219126_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51219126_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 ANTHEM HMO ANTHEM HMO 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51219126_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 42.39 67.9 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51219126_1 CDM 0301 RC 86003 HCPCS inpatient 70 45.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 47.32 67.6 999999999 42.39 67.9 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51219717_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 59.8 65 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51219717_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 AETNA AETNA 72.68 79 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51219717_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 89.24 97 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51219717_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 63.48 69 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51219717_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 71.76 78 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51219717_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 SIHO - ALL PLANS SIHO - ALL PLANS 82.8 90 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51219717_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 55.71 60.55 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51219717_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UMR - ALL PLANS UMR - ALL PLANS 64.4 70 999999999 55.71 89.24 percent of total billed charges "Analysis of substance using immunoassay technique, multiple step method" 51219717_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 51219717_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 51219717_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 51219717_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 ANTHEM HMO ANTHEM HMO 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 51219717_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 55.71 89.24 "Analysis of substance using immunoassay technique, multiple step method" 51219717_1 CDM 0301 RC 83516 HCPCS inpatient 92 59.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 62.19 67.6 999999999 55.71 89.24 percent of total billed charges Emergency department visit for problem that may not require health care professional 51219721_1 CDM 0450 RC 99281 HCPCS inpatient 796 517.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 517.4 65 999999999 481.98 772.12 percent of total billed charges Emergency department visit for problem that may not require health care professional 51219721_1 CDM 0450 RC 99281 HCPCS inpatient 796 517.4 AETNA AETNA 628.84 79 999999999 481.98 772.12 percent of total billed charges Emergency department visit for problem that may not require health care professional 51219721_1 CDM 0450 RC 99281 HCPCS inpatient 796 517.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 772.12 97 999999999 481.98 772.12 percent of total billed charges Emergency department visit for problem that may not require health care professional 51219721_1 CDM 0450 RC 99281 HCPCS inpatient 796 517.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 549.24 69 999999999 481.98 772.12 percent of total billed charges Emergency department visit for problem that may not require health care professional 51219721_1 CDM 0450 RC 99281 HCPCS inpatient 796 517.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 620.88 78 999999999 481.98 772.12 percent of total billed charges Emergency department visit for problem that may not require health care professional 51219721_1 CDM 0450 RC 99281 HCPCS inpatient 796 517.4 SIHO - ALL PLANS SIHO - ALL PLANS 716.4 90 999999999 481.98 772.12 percent of total billed charges Emergency department visit for problem that may not require health care professional 51219721_1 CDM 0450 RC 99281 HCPCS inpatient 796 517.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 481.98 60.55 999999999 481.98 772.12 percent of total billed charges Emergency department visit for problem that may not require health care professional 51219721_1 CDM 0450 RC 99281 HCPCS inpatient 796 517.4 UMR - ALL PLANS UMR - ALL PLANS 557.2 70 999999999 481.98 772.12 percent of total billed charges Emergency department visit for problem that may not require health care professional 51219721_1 CDM 0450 RC 99281 HCPCS inpatient 796 517.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 481.98 772.12 Emergency department visit for problem that may not require health care professional 51219721_1 CDM 0450 RC 99281 HCPCS inpatient 796 517.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 481.98 772.12 Emergency department visit for problem that may not require health care professional 51219721_1 CDM 0450 RC 99281 HCPCS inpatient 796 517.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 481.98 772.12 Emergency department visit for problem that may not require health care professional 51219721_1 CDM 0450 RC 99281 HCPCS inpatient 796 517.4 ANTHEM HMO ANTHEM HMO 999999999 481.98 772.12 Emergency department visit for problem that may not require health care professional 51219721_1 CDM 0450 RC 99281 HCPCS inpatient 796 517.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 481.98 772.12 Emergency department visit for problem that may not require health care professional 51219721_1 CDM 0450 RC 99281 HCPCS inpatient 796 517.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 538.1 67.6 999999999 481.98 772.12 percent of total billed charges Emergency department visit with straightforward medical decision making 51219725_1 CDM 0450 RC 99282 HCPCS inpatient 891 579.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 579.15 65 999999999 539.5 864.27 percent of total billed charges Emergency department visit with straightforward medical decision making 51219725_1 CDM 0450 RC 99282 HCPCS inpatient 891 579.15 AETNA AETNA 703.89 79 999999999 539.5 864.27 percent of total billed charges Emergency department visit with straightforward medical decision making 51219725_1 CDM 0450 RC 99282 HCPCS inpatient 891 579.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 864.27 97 999999999 539.5 864.27 percent of total billed charges Emergency department visit with straightforward medical decision making 51219725_1 CDM 0450 RC 99282 HCPCS inpatient 891 579.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 614.79 69 999999999 539.5 864.27 percent of total billed charges Emergency department visit with straightforward medical decision making 51219725_1 CDM 0450 RC 99282 HCPCS inpatient 891 579.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 694.98 78 999999999 539.5 864.27 percent of total billed charges Emergency department visit with straightforward medical decision making 51219725_1 CDM 0450 RC 99282 HCPCS inpatient 891 579.15 SIHO - ALL PLANS SIHO - ALL PLANS 801.9 90 999999999 539.5 864.27 percent of total billed charges Emergency department visit with straightforward medical decision making 51219725_1 CDM 0450 RC 99282 HCPCS inpatient 891 579.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 539.5 60.55 999999999 539.5 864.27 percent of total billed charges Emergency department visit with straightforward medical decision making 51219725_1 CDM 0450 RC 99282 HCPCS inpatient 891 579.15 UMR - ALL PLANS UMR - ALL PLANS 623.7 70 999999999 539.5 864.27 percent of total billed charges Emergency department visit with straightforward medical decision making 51219725_1 CDM 0450 RC 99282 HCPCS inpatient 891 579.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 539.5 864.27 Emergency department visit with straightforward medical decision making 51219725_1 CDM 0450 RC 99282 HCPCS inpatient 891 579.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 539.5 864.27 Emergency department visit with straightforward medical decision making 51219725_1 CDM 0450 RC 99282 HCPCS inpatient 891 579.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 539.5 864.27 Emergency department visit with straightforward medical decision making 51219725_1 CDM 0450 RC 99282 HCPCS inpatient 891 579.15 ANTHEM HMO ANTHEM HMO 999999999 539.5 864.27 Emergency department visit with straightforward medical decision making 51219725_1 CDM 0450 RC 99282 HCPCS inpatient 891 579.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 539.5 864.27 Emergency department visit with straightforward medical decision making 51219725_1 CDM 0450 RC 99282 HCPCS inpatient 891 579.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 602.32 67.6 999999999 539.5 864.27 percent of total billed charges Emergency department visit with low level of medical decision making 51219727_1 CDM 0450 RC 99283 HCPCS inpatient 1158 752.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 752.7 65 999999999 701.17 1123.26 percent of total billed charges Emergency department visit with low level of medical decision making 51219727_1 CDM 0450 RC 99283 HCPCS inpatient 1158 752.7 AETNA AETNA 914.82 79 999999999 701.17 1123.26 percent of total billed charges Emergency department visit with low level of medical decision making 51219727_1 CDM 0450 RC 99283 HCPCS inpatient 1158 752.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1123.26 97 999999999 701.17 1123.26 percent of total billed charges Emergency department visit with low level of medical decision making 51219727_1 CDM 0450 RC 99283 HCPCS inpatient 1158 752.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 799.02 69 999999999 701.17 1123.26 percent of total billed charges Emergency department visit with low level of medical decision making 51219727_1 CDM 0450 RC 99283 HCPCS inpatient 1158 752.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 903.24 78 999999999 701.17 1123.26 percent of total billed charges Emergency department visit with low level of medical decision making 51219727_1 CDM 0450 RC 99283 HCPCS inpatient 1158 752.7 SIHO - ALL PLANS SIHO - ALL PLANS 1042.2 90 999999999 701.17 1123.26 percent of total billed charges Emergency department visit with low level of medical decision making 51219727_1 CDM 0450 RC 99283 HCPCS inpatient 1158 752.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 701.17 60.55 999999999 701.17 1123.26 percent of total billed charges Emergency department visit with low level of medical decision making 51219727_1 CDM 0450 RC 99283 HCPCS inpatient 1158 752.7 UMR - ALL PLANS UMR - ALL PLANS 810.6 70 999999999 701.17 1123.26 percent of total billed charges Emergency department visit with low level of medical decision making 51219727_1 CDM 0450 RC 99283 HCPCS inpatient 1158 752.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 701.17 1123.26 Emergency department visit with low level of medical decision making 51219727_1 CDM 0450 RC 99283 HCPCS inpatient 1158 752.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 701.17 1123.26 Emergency department visit with low level of medical decision making 51219727_1 CDM 0450 RC 99283 HCPCS inpatient 1158 752.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 701.17 1123.26 Emergency department visit with low level of medical decision making 51219727_1 CDM 0450 RC 99283 HCPCS inpatient 1158 752.7 ANTHEM HMO ANTHEM HMO 999999999 701.17 1123.26 Emergency department visit with low level of medical decision making 51219727_1 CDM 0450 RC 99283 HCPCS inpatient 1158 752.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 701.17 1123.26 Emergency department visit with low level of medical decision making 51219727_1 CDM 0450 RC 99283 HCPCS inpatient 1158 752.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 782.81 67.6 999999999 701.17 1123.26 percent of total billed charges Emergency department visit with moderate level of medical decision making 51219728_1 CDM 0450 RC 99284 HCPCS inpatient 1693 1100.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1100.45 65 999999999 1025.11 1642.21 percent of total billed charges Emergency department visit with moderate level of medical decision making 51219728_1 CDM 0450 RC 99284 HCPCS inpatient 1693 1100.45 AETNA AETNA 1337.47 79 999999999 1025.11 1642.21 percent of total billed charges Emergency department visit with moderate level of medical decision making 51219728_1 CDM 0450 RC 99284 HCPCS inpatient 1693 1100.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1642.21 97 999999999 1025.11 1642.21 percent of total billed charges Emergency department visit with moderate level of medical decision making 51219728_1 CDM 0450 RC 99284 HCPCS inpatient 1693 1100.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1168.17 69 999999999 1025.11 1642.21 percent of total billed charges Emergency department visit with moderate level of medical decision making 51219728_1 CDM 0450 RC 99284 HCPCS inpatient 1693 1100.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1320.54 78 999999999 1025.11 1642.21 percent of total billed charges Emergency department visit with moderate level of medical decision making 51219728_1 CDM 0450 RC 99284 HCPCS inpatient 1693 1100.45 SIHO - ALL PLANS SIHO - ALL PLANS 1523.7 90 999999999 1025.11 1642.21 percent of total billed charges Emergency department visit with moderate level of medical decision making 51219728_1 CDM 0450 RC 99284 HCPCS inpatient 1693 1100.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1025.11 60.55 999999999 1025.11 1642.21 percent of total billed charges Emergency department visit with moderate level of medical decision making 51219728_1 CDM 0450 RC 99284 HCPCS inpatient 1693 1100.45 UMR - ALL PLANS UMR - ALL PLANS 1185.1 70 999999999 1025.11 1642.21 percent of total billed charges Emergency department visit with moderate level of medical decision making 51219728_1 CDM 0450 RC 99284 HCPCS inpatient 1693 1100.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1025.11 1642.21 Emergency department visit with moderate level of medical decision making 51219728_1 CDM 0450 RC 99284 HCPCS inpatient 1693 1100.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1025.11 1642.21 Emergency department visit with moderate level of medical decision making 51219728_1 CDM 0450 RC 99284 HCPCS inpatient 1693 1100.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1025.11 1642.21 Emergency department visit with moderate level of medical decision making 51219728_1 CDM 0450 RC 99284 HCPCS inpatient 1693 1100.45 ANTHEM HMO ANTHEM HMO 999999999 1025.11 1642.21 Emergency department visit with moderate level of medical decision making 51219728_1 CDM 0450 RC 99284 HCPCS inpatient 1693 1100.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1025.11 1642.21 Emergency department visit with moderate level of medical decision making 51219728_1 CDM 0450 RC 99284 HCPCS inpatient 1693 1100.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1144.47 67.6 999999999 1025.11 1642.21 percent of total billed charges "Critical care, first 30-74 minutes" 51219733_1 CDM 0450 RC 99291 HCPCS inpatient 3156 2051.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 2051.4 65 999999999 1910.96 3061.32 percent of total billed charges "Critical care, first 30-74 minutes" 51219733_1 CDM 0450 RC 99291 HCPCS inpatient 3156 2051.4 AETNA AETNA 2493.24 79 999999999 1910.96 3061.32 percent of total billed charges "Critical care, first 30-74 minutes" 51219733_1 CDM 0450 RC 99291 HCPCS inpatient 3156 2051.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3061.32 97 999999999 1910.96 3061.32 percent of total billed charges "Critical care, first 30-74 minutes" 51219733_1 CDM 0450 RC 99291 HCPCS inpatient 3156 2051.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 2177.64 69 999999999 1910.96 3061.32 percent of total billed charges "Critical care, first 30-74 minutes" 51219733_1 CDM 0450 RC 99291 HCPCS inpatient 3156 2051.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 2461.68 78 999999999 1910.96 3061.32 percent of total billed charges "Critical care, first 30-74 minutes" 51219733_1 CDM 0450 RC 99291 HCPCS inpatient 3156 2051.4 SIHO - ALL PLANS SIHO - ALL PLANS 2840.4 90 999999999 1910.96 3061.32 percent of total billed charges "Critical care, first 30-74 minutes" 51219733_1 CDM 0450 RC 99291 HCPCS inpatient 3156 2051.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1910.96 60.55 999999999 1910.96 3061.32 percent of total billed charges "Critical care, first 30-74 minutes" 51219733_1 CDM 0450 RC 99291 HCPCS inpatient 3156 2051.4 UMR - ALL PLANS UMR - ALL PLANS 2209.2 70 999999999 1910.96 3061.32 percent of total billed charges "Critical care, first 30-74 minutes" 51219733_1 CDM 0450 RC 99291 HCPCS inpatient 3156 2051.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1910.96 3061.32 "Critical care, first 30-74 minutes" 51219733_1 CDM 0450 RC 99291 HCPCS inpatient 3156 2051.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1910.96 3061.32 "Critical care, first 30-74 minutes" 51219733_1 CDM 0450 RC 99291 HCPCS inpatient 3156 2051.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1910.96 3061.32 "Critical care, first 30-74 minutes" 51219733_1 CDM 0450 RC 99291 HCPCS inpatient 3156 2051.4 ANTHEM HMO ANTHEM HMO 999999999 1910.96 3061.32 "Critical care, first 30-74 minutes" 51219733_1 CDM 0450 RC 99291 HCPCS inpatient 3156 2051.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1910.96 3061.32 "Critical care, first 30-74 minutes" 51219733_1 CDM 0450 RC 99291 HCPCS inpatient 3156 2051.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 2133.46 67.6 999999999 1910.96 3061.32 percent of total billed charges Oncoprotein (cancer related gene) measurement 51220432_1 CDM 0301 RC 83951 HCPCS inpatient 200 130 SELF PAY DISCOUNT SELF PAY DISCOUNT 130 65 999999999 121.1 194 percent of total billed charges Oncoprotein (cancer related gene) measurement 51220432_1 CDM 0301 RC 83951 HCPCS inpatient 200 130 AETNA AETNA 158 79 999999999 121.1 194 percent of total billed charges Oncoprotein (cancer related gene) measurement 51220432_1 CDM 0301 RC 83951 HCPCS inpatient 200 130 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 194 97 999999999 121.1 194 percent of total billed charges Oncoprotein (cancer related gene) measurement 51220432_1 CDM 0301 RC 83951 HCPCS inpatient 200 130 ENCORE - ALL PLANS ENCORE - ALL PLANS 138 69 999999999 121.1 194 percent of total billed charges Oncoprotein (cancer related gene) measurement 51220432_1 CDM 0301 RC 83951 HCPCS inpatient 200 130 HUMANA - ALL PLANS HUMANA - ALL PLANS 156 78 999999999 121.1 194 percent of total billed charges Oncoprotein (cancer related gene) measurement 51220432_1 CDM 0301 RC 83951 HCPCS inpatient 200 130 SIHO - ALL PLANS SIHO - ALL PLANS 180 90 999999999 121.1 194 percent of total billed charges Oncoprotein (cancer related gene) measurement 51220432_1 CDM 0301 RC 83951 HCPCS inpatient 200 130 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 121.1 60.55 999999999 121.1 194 percent of total billed charges Oncoprotein (cancer related gene) measurement 51220432_1 CDM 0301 RC 83951 HCPCS inpatient 200 130 UMR - ALL PLANS UMR - ALL PLANS 140 70 999999999 121.1 194 percent of total billed charges Oncoprotein (cancer related gene) measurement 51220432_1 CDM 0301 RC 83951 HCPCS inpatient 200 130 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 121.1 194 Oncoprotein (cancer related gene) measurement 51220432_1 CDM 0301 RC 83951 HCPCS inpatient 200 130 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 121.1 194 Oncoprotein (cancer related gene) measurement 51220432_1 CDM 0301 RC 83951 HCPCS inpatient 200 130 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 121.1 194 Oncoprotein (cancer related gene) measurement 51220432_1 CDM 0301 RC 83951 HCPCS inpatient 200 130 ANTHEM HMO ANTHEM HMO 999999999 121.1 194 Oncoprotein (cancer related gene) measurement 51220432_1 CDM 0301 RC 83951 HCPCS inpatient 200 130 UHC - ALL PLANS UHC - ALL PLANS 999999999 121.1 194 Oncoprotein (cancer related gene) measurement 51220432_1 CDM 0301 RC 83951 HCPCS inpatient 200 130 CIGNA - ALL PLANS CIGNA - ALL PLANS 135.2 67.6 999999999 121.1 194 percent of total billed charges Emergency department visit with high level of medical decision making 51222762_1 CDM 0450 RC 99285 HCPCS inpatient 2401 1560.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1560.65 65 999999999 1453.81 2328.97 percent of total billed charges Emergency department visit with high level of medical decision making 51222762_1 CDM 0450 RC 99285 HCPCS inpatient 2401 1560.65 AETNA AETNA 1896.79 79 999999999 1453.81 2328.97 percent of total billed charges Emergency department visit with high level of medical decision making 51222762_1 CDM 0450 RC 99285 HCPCS inpatient 2401 1560.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2328.97 97 999999999 1453.81 2328.97 percent of total billed charges Emergency department visit with high level of medical decision making 51222762_1 CDM 0450 RC 99285 HCPCS inpatient 2401 1560.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1656.69 69 999999999 1453.81 2328.97 percent of total billed charges Emergency department visit with high level of medical decision making 51222762_1 CDM 0450 RC 99285 HCPCS inpatient 2401 1560.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1872.78 78 999999999 1453.81 2328.97 percent of total billed charges Emergency department visit with high level of medical decision making 51222762_1 CDM 0450 RC 99285 HCPCS inpatient 2401 1560.65 SIHO - ALL PLANS SIHO - ALL PLANS 2160.9 90 999999999 1453.81 2328.97 percent of total billed charges Emergency department visit with high level of medical decision making 51222762_1 CDM 0450 RC 99285 HCPCS inpatient 2401 1560.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1453.81 60.55 999999999 1453.81 2328.97 percent of total billed charges Emergency department visit with high level of medical decision making 51222762_1 CDM 0450 RC 99285 HCPCS inpatient 2401 1560.65 UMR - ALL PLANS UMR - ALL PLANS 1680.7 70 999999999 1453.81 2328.97 percent of total billed charges Emergency department visit with high level of medical decision making 51222762_1 CDM 0450 RC 99285 HCPCS inpatient 2401 1560.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1453.81 2328.97 Emergency department visit with high level of medical decision making 51222762_1 CDM 0450 RC 99285 HCPCS inpatient 2401 1560.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1453.81 2328.97 Emergency department visit with high level of medical decision making 51222762_1 CDM 0450 RC 99285 HCPCS inpatient 2401 1560.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1453.81 2328.97 Emergency department visit with high level of medical decision making 51222762_1 CDM 0450 RC 99285 HCPCS inpatient 2401 1560.65 ANTHEM HMO ANTHEM HMO 999999999 1453.81 2328.97 Emergency department visit with high level of medical decision making 51222762_1 CDM 0450 RC 99285 HCPCS inpatient 2401 1560.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1453.81 2328.97 Emergency department visit with high level of medical decision making 51222762_1 CDM 0450 RC 99285 HCPCS inpatient 2401 1560.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1623.08 67.6 999999999 1453.81 2328.97 percent of total billed charges "Critical care, each additional 30 minutes" 51222775_1 CDM 0450 RC 99292 HCPCS inpatient 1052 683.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 683.8 65 999999999 636.99 1020.44 percent of total billed charges "Critical care, each additional 30 minutes" 51222775_1 CDM 0450 RC 99292 HCPCS inpatient 1052 683.8 AETNA AETNA 831.08 79 999999999 636.99 1020.44 percent of total billed charges "Critical care, each additional 30 minutes" 51222775_1 CDM 0450 RC 99292 HCPCS inpatient 1052 683.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1020.44 97 999999999 636.99 1020.44 percent of total billed charges "Critical care, each additional 30 minutes" 51222775_1 CDM 0450 RC 99292 HCPCS inpatient 1052 683.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 725.88 69 999999999 636.99 1020.44 percent of total billed charges "Critical care, each additional 30 minutes" 51222775_1 CDM 0450 RC 99292 HCPCS inpatient 1052 683.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 820.56 78 999999999 636.99 1020.44 percent of total billed charges "Critical care, each additional 30 minutes" 51222775_1 CDM 0450 RC 99292 HCPCS inpatient 1052 683.8 SIHO - ALL PLANS SIHO - ALL PLANS 946.8 90 999999999 636.99 1020.44 percent of total billed charges "Critical care, each additional 30 minutes" 51222775_1 CDM 0450 RC 99292 HCPCS inpatient 1052 683.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 636.99 60.55 999999999 636.99 1020.44 percent of total billed charges "Critical care, each additional 30 minutes" 51222775_1 CDM 0450 RC 99292 HCPCS inpatient 1052 683.8 UMR - ALL PLANS UMR - ALL PLANS 736.4 70 999999999 636.99 1020.44 percent of total billed charges "Critical care, each additional 30 minutes" 51222775_1 CDM 0450 RC 99292 HCPCS inpatient 1052 683.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 636.99 1020.44 "Critical care, each additional 30 minutes" 51222775_1 CDM 0450 RC 99292 HCPCS inpatient 1052 683.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 636.99 1020.44 "Critical care, each additional 30 minutes" 51222775_1 CDM 0450 RC 99292 HCPCS inpatient 1052 683.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 636.99 1020.44 "Critical care, each additional 30 minutes" 51222775_1 CDM 0450 RC 99292 HCPCS inpatient 1052 683.8 ANTHEM HMO ANTHEM HMO 999999999 636.99 1020.44 "Critical care, each additional 30 minutes" 51222775_1 CDM 0450 RC 99292 HCPCS inpatient 1052 683.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 636.99 1020.44 "Critical care, each additional 30 minutes" 51222775_1 CDM 0450 RC 99292 HCPCS inpatient 1052 683.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 711.15 67.6 999999999 636.99 1020.44 percent of total billed charges PINK PAD ADVANCED TRENDELENBURG POSITIONING KIT 51222921_1 CDM 0270 RC inpatient 333.33 216.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 216.66 65 999999999 201.83 323.33 percent of total billed charges PINK PAD ADVANCED TRENDELENBURG POSITIONING KIT 51222921_1 CDM 0270 RC inpatient 333.33 216.66 AETNA AETNA 263.33 79 999999999 201.83 323.33 percent of total billed charges PINK PAD ADVANCED TRENDELENBURG POSITIONING KIT 51222921_1 CDM 0270 RC inpatient 333.33 216.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 323.33 97 999999999 201.83 323.33 percent of total billed charges PINK PAD ADVANCED TRENDELENBURG POSITIONING KIT 51222921_1 CDM 0270 RC inpatient 333.33 216.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 230 69 999999999 201.83 323.33 percent of total billed charges PINK PAD ADVANCED TRENDELENBURG POSITIONING KIT 51222921_1 CDM 0270 RC inpatient 333.33 216.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 260 78 999999999 201.83 323.33 percent of total billed charges PINK PAD ADVANCED TRENDELENBURG POSITIONING KIT 51222921_1 CDM 0270 RC inpatient 333.33 216.66 SIHO - ALL PLANS SIHO - ALL PLANS 300 90 999999999 201.83 323.33 percent of total billed charges PINK PAD ADVANCED TRENDELENBURG POSITIONING KIT 51222921_1 CDM 0270 RC inpatient 333.33 216.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 201.83 60.55 999999999 201.83 323.33 percent of total billed charges PINK PAD ADVANCED TRENDELENBURG POSITIONING KIT 51222921_1 CDM 0270 RC inpatient 333.33 216.66 UMR - ALL PLANS UMR - ALL PLANS 233.33 70 999999999 201.83 323.33 percent of total billed charges PINK PAD ADVANCED TRENDELENBURG POSITIONING KIT 51222921_1 CDM 0270 RC inpatient 333.33 216.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 201.83 323.33 PINK PAD ADVANCED TRENDELENBURG POSITIONING KIT 51222921_1 CDM 0270 RC inpatient 333.33 216.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 201.83 323.33 PINK PAD ADVANCED TRENDELENBURG POSITIONING KIT 51222921_1 CDM 0270 RC inpatient 333.33 216.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 201.83 323.33 PINK PAD ADVANCED TRENDELENBURG POSITIONING KIT 51222921_1 CDM 0270 RC inpatient 333.33 216.66 ANTHEM HMO ANTHEM HMO 999999999 201.83 323.33 PINK PAD ADVANCED TRENDELENBURG POSITIONING KIT 51222921_1 CDM 0270 RC inpatient 333.33 216.66 UHC - ALL PLANS UHC - ALL PLANS 999999999 201.83 323.33 PINK PAD ADVANCED TRENDELENBURG POSITIONING KIT 51222921_1 CDM 0270 RC inpatient 333.33 216.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 225.33 67.6 999999999 201.83 323.33 percent of total billed charges Intrinsic factor (stomach protein) antibody measurement 51224897_1 CDM 0302 RC 86340 HCPCS inpatient 149 96.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 96.85 65 999999999 90.22 144.53 percent of total billed charges Intrinsic factor (stomach protein) antibody measurement 51224897_1 CDM 0302 RC 86340 HCPCS inpatient 149 96.85 AETNA AETNA 117.71 79 999999999 90.22 144.53 percent of total billed charges Intrinsic factor (stomach protein) antibody measurement 51224897_1 CDM 0302 RC 86340 HCPCS inpatient 149 96.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 144.53 97 999999999 90.22 144.53 percent of total billed charges Intrinsic factor (stomach protein) antibody measurement 51224897_1 CDM 0302 RC 86340 HCPCS inpatient 149 96.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 102.81 69 999999999 90.22 144.53 percent of total billed charges Intrinsic factor (stomach protein) antibody measurement 51224897_1 CDM 0302 RC 86340 HCPCS inpatient 149 96.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 116.22 78 999999999 90.22 144.53 percent of total billed charges Intrinsic factor (stomach protein) antibody measurement 51224897_1 CDM 0302 RC 86340 HCPCS inpatient 149 96.85 SIHO - ALL PLANS SIHO - ALL PLANS 134.1 90 999999999 90.22 144.53 percent of total billed charges Intrinsic factor (stomach protein) antibody measurement 51224897_1 CDM 0302 RC 86340 HCPCS inpatient 149 96.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.22 60.55 999999999 90.22 144.53 percent of total billed charges Intrinsic factor (stomach protein) antibody measurement 51224897_1 CDM 0302 RC 86340 HCPCS inpatient 149 96.85 UMR - ALL PLANS UMR - ALL PLANS 104.3 70 999999999 90.22 144.53 percent of total billed charges Intrinsic factor (stomach protein) antibody measurement 51224897_1 CDM 0302 RC 86340 HCPCS inpatient 149 96.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.22 144.53 Intrinsic factor (stomach protein) antibody measurement 51224897_1 CDM 0302 RC 86340 HCPCS inpatient 149 96.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.22 144.53 Intrinsic factor (stomach protein) antibody measurement 51224897_1 CDM 0302 RC 86340 HCPCS inpatient 149 96.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.22 144.53 Intrinsic factor (stomach protein) antibody measurement 51224897_1 CDM 0302 RC 86340 HCPCS inpatient 149 96.85 ANTHEM HMO ANTHEM HMO 999999999 90.22 144.53 Intrinsic factor (stomach protein) antibody measurement 51224897_1 CDM 0302 RC 86340 HCPCS inpatient 149 96.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.22 144.53 Intrinsic factor (stomach protein) antibody measurement 51224897_1 CDM 0302 RC 86340 HCPCS inpatient 149 96.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 100.72 67.6 999999999 90.22 144.53 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 51232723_1 CDM 0301 RC 86160 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 51232723_1 CDM 0301 RC 86160 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 51232723_1 CDM 0301 RC 86160 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 51232723_1 CDM 0301 RC 86160 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 51232723_1 CDM 0301 RC 86160 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 51232723_1 CDM 0301 RC 86160 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 51232723_1 CDM 0301 RC 86160 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 51232723_1 CDM 0301 RC 86160 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Measurement of complement (immune system proteins), antigen," 51232723_1 CDM 0301 RC 86160 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 51232723_1 CDM 0301 RC 86160 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 51232723_1 CDM 0301 RC 86160 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 51232723_1 CDM 0301 RC 86160 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 51232723_1 CDM 0301 RC 86160 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 "Measurement of complement (immune system proteins), antigen," 51232723_1 CDM 0301 RC 86160 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges "GI JAW BIOPSY FORCEPS, SERRATED WITH NEEDLE 1190-01" 51263848_1 CDM 0270 RC inpatient 22.5 14.63 SELF PAY DISCOUNT SELF PAY DISCOUNT 14.63 65 999999999 13.62 21.83 percent of total billed charges "GI JAW BIOPSY FORCEPS, SERRATED WITH NEEDLE 1190-01" 51263848_1 CDM 0270 RC inpatient 22.5 14.63 AETNA AETNA 17.78 79 999999999 13.62 21.83 percent of total billed charges "GI JAW BIOPSY FORCEPS, SERRATED WITH NEEDLE 1190-01" 51263848_1 CDM 0270 RC inpatient 22.5 14.63 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21.83 97 999999999 13.62 21.83 percent of total billed charges "GI JAW BIOPSY FORCEPS, SERRATED WITH NEEDLE 1190-01" 51263848_1 CDM 0270 RC inpatient 22.5 14.63 ENCORE - ALL PLANS ENCORE - ALL PLANS 15.53 69 999999999 13.62 21.83 percent of total billed charges "GI JAW BIOPSY FORCEPS, SERRATED WITH NEEDLE 1190-01" 51263848_1 CDM 0270 RC inpatient 22.5 14.63 HUMANA - ALL PLANS HUMANA - ALL PLANS 17.55 78 999999999 13.62 21.83 percent of total billed charges "GI JAW BIOPSY FORCEPS, SERRATED WITH NEEDLE 1190-01" 51263848_1 CDM 0270 RC inpatient 22.5 14.63 SIHO - ALL PLANS SIHO - ALL PLANS 20.25 90 999999999 13.62 21.83 percent of total billed charges "GI JAW BIOPSY FORCEPS, SERRATED WITH NEEDLE 1190-01" 51263848_1 CDM 0270 RC inpatient 22.5 14.63 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13.62 60.55 999999999 13.62 21.83 percent of total billed charges "GI JAW BIOPSY FORCEPS, SERRATED WITH NEEDLE 1190-01" 51263848_1 CDM 0270 RC inpatient 22.5 14.63 UMR - ALL PLANS UMR - ALL PLANS 15.75 70 999999999 13.62 21.83 percent of total billed charges "GI JAW BIOPSY FORCEPS, SERRATED WITH NEEDLE 1190-01" 51263848_1 CDM 0270 RC inpatient 22.5 14.63 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 13.62 21.83 "GI JAW BIOPSY FORCEPS, SERRATED WITH NEEDLE 1190-01" 51263848_1 CDM 0270 RC inpatient 22.5 14.63 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 13.62 21.83 "GI JAW BIOPSY FORCEPS, SERRATED WITH NEEDLE 1190-01" 51263848_1 CDM 0270 RC inpatient 22.5 14.63 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 13.62 21.83 "GI JAW BIOPSY FORCEPS, SERRATED WITH NEEDLE 1190-01" 51263848_1 CDM 0270 RC inpatient 22.5 14.63 ANTHEM HMO ANTHEM HMO 999999999 13.62 21.83 "GI JAW BIOPSY FORCEPS, SERRATED WITH NEEDLE 1190-01" 51263848_1 CDM 0270 RC inpatient 22.5 14.63 UHC - ALL PLANS UHC - ALL PLANS 999999999 13.62 21.83 "GI JAW BIOPSY FORCEPS, SERRATED WITH NEEDLE 1190-01" 51263848_1 CDM 0270 RC inpatient 22.5 14.63 CIGNA - ALL PLANS CIGNA - ALL PLANS 15.21 67.6 999999999 13.62 21.83 percent of total billed charges "INJECTION, RITUXIMAB-ARRX, BIOSIMILAR, (RIABNI), 10 MG" 51263895_1 CDM 0636 RC 55513-0224-01 NDC Q5123 HCPCS inpatient 10 UN 2242.73 1457.77 SELF PAY DISCOUNT SELF PAY DISCOUNT 1457.77 65 999999999 1357.97 2175.45 percent of total billed charges "INJECTION, RITUXIMAB-ARRX, BIOSIMILAR, (RIABNI), 10 MG" 51263895_1 CDM 0636 RC 55513-0224-01 NDC Q5123 HCPCS inpatient 10 UN 2242.73 1457.77 AETNA AETNA 1771.76 79 999999999 1357.97 2175.45 percent of total billed charges "INJECTION, RITUXIMAB-ARRX, BIOSIMILAR, (RIABNI), 10 MG" 51263895_1 CDM 0636 RC 55513-0224-01 NDC Q5123 HCPCS inpatient 10 UN 2242.73 1457.77 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2175.45 97 999999999 1357.97 2175.45 percent of total billed charges "INJECTION, RITUXIMAB-ARRX, BIOSIMILAR, (RIABNI), 10 MG" 51263895_1 CDM 0636 RC 55513-0224-01 NDC Q5123 HCPCS inpatient 10 UN 2242.73 1457.77 ENCORE - ALL PLANS ENCORE - ALL PLANS 1547.48 69 999999999 1357.97 2175.45 percent of total billed charges "INJECTION, RITUXIMAB-ARRX, BIOSIMILAR, (RIABNI), 10 MG" 51263895_1 CDM 0636 RC 55513-0224-01 NDC Q5123 HCPCS inpatient 10 UN 2242.73 1457.77 HUMANA - ALL PLANS HUMANA - ALL PLANS 1749.33 78 999999999 1357.97 2175.45 percent of total billed charges "INJECTION, RITUXIMAB-ARRX, BIOSIMILAR, (RIABNI), 10 MG" 51263895_1 CDM 0636 RC 55513-0224-01 NDC Q5123 HCPCS inpatient 10 UN 2242.73 1457.77 SIHO - ALL PLANS SIHO - ALL PLANS 2018.46 90 999999999 1357.97 2175.45 percent of total billed charges "INJECTION, RITUXIMAB-ARRX, BIOSIMILAR, (RIABNI), 10 MG" 51263895_1 CDM 0636 RC 55513-0224-01 NDC Q5123 HCPCS inpatient 10 UN 2242.73 1457.77 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1357.97 60.55 999999999 1357.97 2175.45 percent of total billed charges "INJECTION, RITUXIMAB-ARRX, BIOSIMILAR, (RIABNI), 10 MG" 51263895_1 CDM 0636 RC 55513-0224-01 NDC Q5123 HCPCS inpatient 10 UN 2242.73 1457.77 UMR - ALL PLANS UMR - ALL PLANS 1569.91 70 999999999 1357.97 2175.45 percent of total billed charges "INJECTION, RITUXIMAB-ARRX, BIOSIMILAR, (RIABNI), 10 MG" 51263895_1 CDM 0636 RC 55513-0224-01 NDC Q5123 HCPCS inpatient 10 UN 2242.73 1457.77 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1357.97 2175.45 "INJECTION, RITUXIMAB-ARRX, BIOSIMILAR, (RIABNI), 10 MG" 51263895_1 CDM 0636 RC 55513-0224-01 NDC Q5123 HCPCS inpatient 10 UN 2242.73 1457.77 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1357.97 2175.45 "INJECTION, RITUXIMAB-ARRX, BIOSIMILAR, (RIABNI), 10 MG" 51263895_1 CDM 0636 RC 55513-0224-01 NDC Q5123 HCPCS inpatient 10 UN 2242.73 1457.77 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1357.97 2175.45 "INJECTION, RITUXIMAB-ARRX, BIOSIMILAR, (RIABNI), 10 MG" 51263895_1 CDM 0636 RC 55513-0224-01 NDC Q5123 HCPCS inpatient 10 UN 2242.73 1457.77 ANTHEM HMO ANTHEM HMO 999999999 1357.97 2175.45 "INJECTION, RITUXIMAB-ARRX, BIOSIMILAR, (RIABNI), 10 MG" 51263895_1 CDM 0636 RC 55513-0224-01 NDC Q5123 HCPCS inpatient 10 UN 2242.73 1457.77 UHC - ALL PLANS UHC - ALL PLANS 999999999 1357.97 2175.45 "INJECTION, RITUXIMAB-ARRX, BIOSIMILAR, (RIABNI), 10 MG" 51263895_1 CDM 0636 RC 55513-0224-01 NDC Q5123 HCPCS inpatient 10 UN 2242.73 1457.77 CIGNA - ALL PLANS CIGNA - ALL PLANS 1516.09 67.6 999999999 1357.97 2175.45 percent of total billed charges Measurement of complement function (immune system proteins) 51264998_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.1 65 999999999 93.25 149.38 percent of total billed charges Measurement of complement function (immune system proteins) 51264998_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 AETNA AETNA 121.66 79 999999999 93.25 149.38 percent of total billed charges Measurement of complement function (immune system proteins) 51264998_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 149.38 97 999999999 93.25 149.38 percent of total billed charges Measurement of complement function (immune system proteins) 51264998_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.26 69 999999999 93.25 149.38 percent of total billed charges Measurement of complement function (immune system proteins) 51264998_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.12 78 999999999 93.25 149.38 percent of total billed charges Measurement of complement function (immune system proteins) 51264998_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 SIHO - ALL PLANS SIHO - ALL PLANS 138.6 90 999999999 93.25 149.38 percent of total billed charges Measurement of complement function (immune system proteins) 51264998_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.25 60.55 999999999 93.25 149.38 percent of total billed charges Measurement of complement function (immune system proteins) 51264998_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 UMR - ALL PLANS UMR - ALL PLANS 107.8 70 999999999 93.25 149.38 percent of total billed charges Measurement of complement function (immune system proteins) 51264998_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.25 149.38 Measurement of complement function (immune system proteins) 51264998_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.25 149.38 Measurement of complement function (immune system proteins) 51264998_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.25 149.38 Measurement of complement function (immune system proteins) 51264998_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 ANTHEM HMO ANTHEM HMO 999999999 93.25 149.38 Measurement of complement function (immune system proteins) 51264998_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.25 149.38 Measurement of complement function (immune system proteins) 51264998_1 CDM 0301 RC 86161 HCPCS inpatient 154 100.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.1 67.6 999999999 93.25 149.38 percent of total billed charges "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51265335_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.14 65 999999999 1.07 1.71 percent of total billed charges "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51265335_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 AETNA AETNA 1.39 79 999999999 1.07 1.71 percent of total billed charges "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51265335_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.71 97 999999999 1.07 1.71 percent of total billed charges "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51265335_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.21 69 999999999 1.07 1.71 percent of total billed charges "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51265335_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.37 78 999999999 1.07 1.71 percent of total billed charges "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51265335_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 SIHO - ALL PLANS SIHO - ALL PLANS 1.58 90 999999999 1.07 1.71 percent of total billed charges "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51265335_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.07 60.55 999999999 1.07 1.71 percent of total billed charges "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51265335_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 UMR - ALL PLANS UMR - ALL PLANS 1.23 70 999999999 1.07 1.71 percent of total billed charges "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51265335_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.07 1.71 "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51265335_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.07 1.71 "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51265335_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.07 1.71 "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51265335_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 ANTHEM HMO ANTHEM HMO 999999999 1.07 1.71 "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51265335_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.07 1.71 "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51265335_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.19 67.6 999999999 1.07 1.71 percent of total billed charges Destruction of foot nerve 51265340_1 CDM 0360 RC 64632 HCPCS inpatient 802 521.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 521.3 65 999999999 485.61 777.94 percent of total billed charges Destruction of foot nerve 51265340_1 CDM 0360 RC 64632 HCPCS inpatient 802 521.3 AETNA AETNA 633.58 79 999999999 485.61 777.94 percent of total billed charges Destruction of foot nerve 51265340_1 CDM 0360 RC 64632 HCPCS inpatient 802 521.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 777.94 97 999999999 485.61 777.94 percent of total billed charges Destruction of foot nerve 51265340_1 CDM 0360 RC 64632 HCPCS inpatient 802 521.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 553.38 69 999999999 485.61 777.94 percent of total billed charges Destruction of foot nerve 51265340_1 CDM 0360 RC 64632 HCPCS inpatient 802 521.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 625.56 78 999999999 485.61 777.94 percent of total billed charges Destruction of foot nerve 51265340_1 CDM 0360 RC 64632 HCPCS inpatient 802 521.3 SIHO - ALL PLANS SIHO - ALL PLANS 721.8 90 999999999 485.61 777.94 percent of total billed charges Destruction of foot nerve 51265340_1 CDM 0360 RC 64632 HCPCS inpatient 802 521.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 485.61 60.55 999999999 485.61 777.94 percent of total billed charges Destruction of foot nerve 51265340_1 CDM 0360 RC 64632 HCPCS inpatient 802 521.3 UMR - ALL PLANS UMR - ALL PLANS 561.4 70 999999999 485.61 777.94 percent of total billed charges Destruction of foot nerve 51265340_1 CDM 0360 RC 64632 HCPCS inpatient 802 521.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 485.61 777.94 Destruction of foot nerve 51265340_1 CDM 0360 RC 64632 HCPCS inpatient 802 521.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 485.61 777.94 Destruction of foot nerve 51265340_1 CDM 0360 RC 64632 HCPCS inpatient 802 521.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 485.61 777.94 Destruction of foot nerve 51265340_1 CDM 0360 RC 64632 HCPCS inpatient 802 521.3 ANTHEM HMO ANTHEM HMO 999999999 485.61 777.94 Destruction of foot nerve 51265340_1 CDM 0360 RC 64632 HCPCS inpatient 802 521.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 485.61 777.94 Destruction of foot nerve 51265340_1 CDM 0360 RC 64632 HCPCS inpatient 802 521.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 542.15 67.6 999999999 485.61 777.94 percent of total billed charges Screening test for pathogenic organisms 51265627_1 CDM 0307 RC 87081 HCPCS inpatient 131 85.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 85.15 65 999999999 79.32 127.07 percent of total billed charges Screening test for pathogenic organisms 51265627_1 CDM 0307 RC 87081 HCPCS inpatient 131 85.15 AETNA AETNA 103.49 79 999999999 79.32 127.07 percent of total billed charges Screening test for pathogenic organisms 51265627_1 CDM 0307 RC 87081 HCPCS inpatient 131 85.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 127.07 97 999999999 79.32 127.07 percent of total billed charges Screening test for pathogenic organisms 51265627_1 CDM 0307 RC 87081 HCPCS inpatient 131 85.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 90.39 69 999999999 79.32 127.07 percent of total billed charges Screening test for pathogenic organisms 51265627_1 CDM 0307 RC 87081 HCPCS inpatient 131 85.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 102.18 78 999999999 79.32 127.07 percent of total billed charges Screening test for pathogenic organisms 51265627_1 CDM 0307 RC 87081 HCPCS inpatient 131 85.15 SIHO - ALL PLANS SIHO - ALL PLANS 117.9 90 999999999 79.32 127.07 percent of total billed charges Screening test for pathogenic organisms 51265627_1 CDM 0307 RC 87081 HCPCS inpatient 131 85.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 79.32 60.55 999999999 79.32 127.07 percent of total billed charges Screening test for pathogenic organisms 51265627_1 CDM 0307 RC 87081 HCPCS inpatient 131 85.15 UMR - ALL PLANS UMR - ALL PLANS 91.7 70 999999999 79.32 127.07 percent of total billed charges Screening test for pathogenic organisms 51265627_1 CDM 0307 RC 87081 HCPCS inpatient 131 85.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 79.32 127.07 Screening test for pathogenic organisms 51265627_1 CDM 0307 RC 87081 HCPCS inpatient 131 85.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 79.32 127.07 Screening test for pathogenic organisms 51265627_1 CDM 0307 RC 87081 HCPCS inpatient 131 85.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 79.32 127.07 Screening test for pathogenic organisms 51265627_1 CDM 0307 RC 87081 HCPCS inpatient 131 85.15 ANTHEM HMO ANTHEM HMO 999999999 79.32 127.07 Screening test for pathogenic organisms 51265627_1 CDM 0307 RC 87081 HCPCS inpatient 131 85.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 79.32 127.07 Screening test for pathogenic organisms 51265627_1 CDM 0307 RC 87081 HCPCS inpatient 131 85.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 88.56 67.6 999999999 79.32 127.07 percent of total billed charges Gene analysis (fragile X mental retardation) abnormal alleles 51269119_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges Gene analysis (fragile X mental retardation) abnormal alleles 51269119_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges Gene analysis (fragile X mental retardation) abnormal alleles 51269119_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges Gene analysis (fragile X mental retardation) abnormal alleles 51269119_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges Gene analysis (fragile X mental retardation) abnormal alleles 51269119_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges Gene analysis (fragile X mental retardation) abnormal alleles 51269119_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges Gene analysis (fragile X mental retardation) abnormal alleles 51269119_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges Gene analysis (fragile X mental retardation) abnormal alleles 51269119_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges Gene analysis (fragile X mental retardation) abnormal alleles 51269119_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 Gene analysis (fragile X mental retardation) abnormal alleles 51269119_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 Gene analysis (fragile X mental retardation) abnormal alleles 51269119_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 Gene analysis (fragile X mental retardation) abnormal alleles 51269119_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 Gene analysis (fragile X mental retardation) abnormal alleles 51269119_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Gene analysis (fragile X mental retardation) abnormal alleles 51269119_1 CDM 0301 RC 81243 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges Analysis for antibody to virus 51273286_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 37.7 65 999999999 35.12 56.26 percent of total billed charges Analysis for antibody to virus 51273286_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 AETNA AETNA 45.82 79 999999999 35.12 56.26 percent of total billed charges Analysis for antibody to virus 51273286_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56.26 97 999999999 35.12 56.26 percent of total billed charges Analysis for antibody to virus 51273286_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 40.02 69 999999999 35.12 56.26 percent of total billed charges Analysis for antibody to virus 51273286_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 45.24 78 999999999 35.12 56.26 percent of total billed charges Analysis for antibody to virus 51273286_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 SIHO - ALL PLANS SIHO - ALL PLANS 52.2 90 999999999 35.12 56.26 percent of total billed charges Analysis for antibody to virus 51273286_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35.12 60.55 999999999 35.12 56.26 percent of total billed charges Analysis for antibody to virus 51273286_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 UMR - ALL PLANS UMR - ALL PLANS 40.6 70 999999999 35.12 56.26 percent of total billed charges Analysis for antibody to virus 51273286_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 35.12 56.26 Analysis for antibody to virus 51273286_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 35.12 56.26 Analysis for antibody to virus 51273286_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 35.12 56.26 Analysis for antibody to virus 51273286_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 ANTHEM HMO ANTHEM HMO 999999999 35.12 56.26 Analysis for antibody to virus 51273286_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 35.12 56.26 Analysis for antibody to virus 51273286_1 CDM 0301 RC 86790 HCPCS inpatient 58 37.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 39.21 67.6 999999999 35.12 56.26 percent of total billed charges Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 51273287_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 169.65 65 999999999 158.04 253.17 percent of total billed charges Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 51273287_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 AETNA AETNA 206.19 79 999999999 158.04 253.17 percent of total billed charges Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 51273287_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 253.17 97 999999999 158.04 253.17 percent of total billed charges Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 51273287_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 180.09 69 999999999 158.04 253.17 percent of total billed charges Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 51273287_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 203.58 78 999999999 158.04 253.17 percent of total billed charges Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 51273287_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 SIHO - ALL PLANS SIHO - ALL PLANS 234.9 90 999999999 158.04 253.17 percent of total billed charges Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 51273287_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 158.04 60.55 999999999 158.04 253.17 percent of total billed charges Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 51273287_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 UMR - ALL PLANS UMR - ALL PLANS 182.7 70 999999999 158.04 253.17 percent of total billed charges Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 51273287_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 158.04 253.17 Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 51273287_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 158.04 253.17 Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 51273287_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 158.04 253.17 Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 51273287_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 ANTHEM HMO ANTHEM HMO 999999999 158.04 253.17 Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 51273287_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 158.04 253.17 Confirmation test for antibody to Human T-cell lymphotropic virus (HTLV) or HIV 51273287_1 CDM 0302 RC 86689 HCPCS inpatient 261 169.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 176.44 67.6 999999999 158.04 253.17 percent of total billed charges Glycated protein level 51276810_1 CDM 0301 RC 82985 HCPCS inpatient 85 55.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.25 65 999999999 51.47 82.45 percent of total billed charges Glycated protein level 51276810_1 CDM 0301 RC 82985 HCPCS inpatient 85 55.25 AETNA AETNA 67.15 79 999999999 51.47 82.45 percent of total billed charges Glycated protein level 51276810_1 CDM 0301 RC 82985 HCPCS inpatient 85 55.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 82.45 97 999999999 51.47 82.45 percent of total billed charges Glycated protein level 51276810_1 CDM 0301 RC 82985 HCPCS inpatient 85 55.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 58.65 69 999999999 51.47 82.45 percent of total billed charges Glycated protein level 51276810_1 CDM 0301 RC 82985 HCPCS inpatient 85 55.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 66.3 78 999999999 51.47 82.45 percent of total billed charges Glycated protein level 51276810_1 CDM 0301 RC 82985 HCPCS inpatient 85 55.25 SIHO - ALL PLANS SIHO - ALL PLANS 76.5 90 999999999 51.47 82.45 percent of total billed charges Glycated protein level 51276810_1 CDM 0301 RC 82985 HCPCS inpatient 85 55.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 51.47 60.55 999999999 51.47 82.45 percent of total billed charges Glycated protein level 51276810_1 CDM 0301 RC 82985 HCPCS inpatient 85 55.25 UMR - ALL PLANS UMR - ALL PLANS 59.5 70 999999999 51.47 82.45 percent of total billed charges Glycated protein level 51276810_1 CDM 0301 RC 82985 HCPCS inpatient 85 55.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 51.47 82.45 Glycated protein level 51276810_1 CDM 0301 RC 82985 HCPCS inpatient 85 55.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 51.47 82.45 Glycated protein level 51276810_1 CDM 0301 RC 82985 HCPCS inpatient 85 55.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 51.47 82.45 Glycated protein level 51276810_1 CDM 0301 RC 82985 HCPCS inpatient 85 55.25 ANTHEM HMO ANTHEM HMO 999999999 51.47 82.45 Glycated protein level 51276810_1 CDM 0301 RC 82985 HCPCS inpatient 85 55.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 51.47 82.45 Glycated protein level 51276810_1 CDM 0301 RC 82985 HCPCS inpatient 85 55.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 57.46 67.6 999999999 51.47 82.45 percent of total billed charges Total cell count for natural killer cells (white blood cell) 51276840_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges Total cell count for natural killer cells (white blood cell) 51276840_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges Total cell count for natural killer cells (white blood cell) 51276840_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges Total cell count for natural killer cells (white blood cell) 51276840_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges Total cell count for natural killer cells (white blood cell) 51276840_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges Total cell count for natural killer cells (white blood cell) 51276840_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges Total cell count for natural killer cells (white blood cell) 51276840_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges Total cell count for natural killer cells (white blood cell) 51276840_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges Total cell count for natural killer cells (white blood cell) 51276840_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 Total cell count for natural killer cells (white blood cell) 51276840_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 Total cell count for natural killer cells (white blood cell) 51276840_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 Total cell count for natural killer cells (white blood cell) 51276840_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 Total cell count for natural killer cells (white blood cell) 51276840_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 Total cell count for natural killer cells (white blood cell) 51276840_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges Total cell count for B cells (white blood cells) 51276841_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges Total cell count for B cells (white blood cells) 51276841_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges Total cell count for B cells (white blood cells) 51276841_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges Total cell count for B cells (white blood cells) 51276841_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges Total cell count for B cells (white blood cells) 51276841_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges Total cell count for B cells (white blood cells) 51276841_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges Total cell count for B cells (white blood cells) 51276841_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges Total cell count for B cells (white blood cells) 51276841_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges Total cell count for B cells (white blood cells) 51276841_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 Total cell count for B cells (white blood cells) 51276841_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 Total cell count for B cells (white blood cells) 51276841_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 Total cell count for B cells (white blood cells) 51276841_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 Total cell count for B cells (white blood cells) 51276841_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 Total cell count for B cells (white blood cells) 51276841_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges "T cells count, total" 51276842_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.75 65 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51276842_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 AETNA AETNA 90.85 79 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51276842_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 111.55 97 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51276842_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 79.35 69 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51276842_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 89.7 78 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51276842_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 SIHO - ALL PLANS SIHO - ALL PLANS 103.5 90 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51276842_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.63 60.55 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51276842_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 UMR - ALL PLANS UMR - ALL PLANS 80.5 70 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51276842_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.63 111.55 "T cells count, total" 51276842_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.63 111.55 "T cells count, total" 51276842_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.63 111.55 "T cells count, total" 51276842_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 ANTHEM HMO ANTHEM HMO 999999999 69.63 111.55 "T cells count, total" 51276842_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.63 111.55 "T cells count, total" 51276842_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.74 67.6 999999999 69.63 111.55 percent of total billed charges "T cell count and ratio, including ratio" 51276843_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.75 65 999999999 69.63 111.55 percent of total billed charges "T cell count and ratio, including ratio" 51276843_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 AETNA AETNA 90.85 79 999999999 69.63 111.55 percent of total billed charges "T cell count and ratio, including ratio" 51276843_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 111.55 97 999999999 69.63 111.55 percent of total billed charges "T cell count and ratio, including ratio" 51276843_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 79.35 69 999999999 69.63 111.55 percent of total billed charges "T cell count and ratio, including ratio" 51276843_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 89.7 78 999999999 69.63 111.55 percent of total billed charges "T cell count and ratio, including ratio" 51276843_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 SIHO - ALL PLANS SIHO - ALL PLANS 103.5 90 999999999 69.63 111.55 percent of total billed charges "T cell count and ratio, including ratio" 51276843_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.63 60.55 999999999 69.63 111.55 percent of total billed charges "T cell count and ratio, including ratio" 51276843_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 UMR - ALL PLANS UMR - ALL PLANS 80.5 70 999999999 69.63 111.55 percent of total billed charges "T cell count and ratio, including ratio" 51276843_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.63 111.55 "T cell count and ratio, including ratio" 51276843_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.63 111.55 "T cell count and ratio, including ratio" 51276843_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.63 111.55 "T cell count and ratio, including ratio" 51276843_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 ANTHEM HMO ANTHEM HMO 999999999 69.63 111.55 "T cell count and ratio, including ratio" 51276843_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.63 111.55 "T cell count and ratio, including ratio" 51276843_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.74 67.6 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51276938_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.75 65 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51276938_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 AETNA AETNA 90.85 79 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51276938_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 111.55 97 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51276938_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 79.35 69 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51276938_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 89.7 78 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51276938_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 SIHO - ALL PLANS SIHO - ALL PLANS 103.5 90 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51276938_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.63 60.55 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51276938_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 UMR - ALL PLANS UMR - ALL PLANS 80.5 70 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51276938_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.63 111.55 "T cells count, total" 51276938_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.63 111.55 "T cells count, total" 51276938_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.63 111.55 "T cells count, total" 51276938_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 ANTHEM HMO ANTHEM HMO 999999999 69.63 111.55 "T cells count, total" 51276938_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.63 111.55 "T cells count, total" 51276938_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.74 67.6 999999999 69.63 111.55 percent of total billed charges "T cell count and ratio, including ratio" 51276940_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.75 65 999999999 69.63 111.55 percent of total billed charges "T cell count and ratio, including ratio" 51276940_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 AETNA AETNA 90.85 79 999999999 69.63 111.55 percent of total billed charges "T cell count and ratio, including ratio" 51276940_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 111.55 97 999999999 69.63 111.55 percent of total billed charges "T cell count and ratio, including ratio" 51276940_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 79.35 69 999999999 69.63 111.55 percent of total billed charges "T cell count and ratio, including ratio" 51276940_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 89.7 78 999999999 69.63 111.55 percent of total billed charges "T cell count and ratio, including ratio" 51276940_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 SIHO - ALL PLANS SIHO - ALL PLANS 103.5 90 999999999 69.63 111.55 percent of total billed charges "T cell count and ratio, including ratio" 51276940_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.63 60.55 999999999 69.63 111.55 percent of total billed charges "T cell count and ratio, including ratio" 51276940_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 UMR - ALL PLANS UMR - ALL PLANS 80.5 70 999999999 69.63 111.55 percent of total billed charges "T cell count and ratio, including ratio" 51276940_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.63 111.55 "T cell count and ratio, including ratio" 51276940_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.63 111.55 "T cell count and ratio, including ratio" 51276940_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.63 111.55 "T cell count and ratio, including ratio" 51276940_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 ANTHEM HMO ANTHEM HMO 999999999 69.63 111.55 "T cell count and ratio, including ratio" 51276940_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.63 111.55 "T cell count and ratio, including ratio" 51276940_1 CDM 0312 RC 86360 HCPCS inpatient 115 74.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.74 67.6 999999999 69.63 111.55 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 51278097_1 CDM 0510 RC 97802 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 51278097_1 CDM 0510 RC 97802 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 51278097_1 CDM 0510 RC 97802 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 51278097_1 CDM 0510 RC 97802 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 51278097_1 CDM 0510 RC 97802 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 51278097_1 CDM 0510 RC 97802 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 51278097_1 CDM 0510 RC 97802 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 51278097_1 CDM 0510 RC 97802 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management, each 15 minutes" 51278097_1 CDM 0510 RC 97802 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 "Therapy procedure for nutrition management, each 15 minutes" 51278097_1 CDM 0510 RC 97802 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 "Therapy procedure for nutrition management, each 15 minutes" 51278097_1 CDM 0510 RC 97802 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 "Therapy procedure for nutrition management, each 15 minutes" 51278097_1 CDM 0510 RC 97802 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 "Therapy procedure for nutrition management, each 15 minutes" 51278097_1 CDM 0510 RC 97802 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 "Therapy procedure for nutrition management, each 15 minutes" 51278097_1 CDM 0510 RC 97802 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges Chemical test for genetic disorder 51278248_1 CDM 0301 RC 82017 HCPCS inpatient 432 280.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 280.8 65 999999999 261.58 419.04 percent of total billed charges Chemical test for genetic disorder 51278248_1 CDM 0301 RC 82017 HCPCS inpatient 432 280.8 AETNA AETNA 341.28 79 999999999 261.58 419.04 percent of total billed charges Chemical test for genetic disorder 51278248_1 CDM 0301 RC 82017 HCPCS inpatient 432 280.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 419.04 97 999999999 261.58 419.04 percent of total billed charges Chemical test for genetic disorder 51278248_1 CDM 0301 RC 82017 HCPCS inpatient 432 280.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 298.08 69 999999999 261.58 419.04 percent of total billed charges Chemical test for genetic disorder 51278248_1 CDM 0301 RC 82017 HCPCS inpatient 432 280.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 336.96 78 999999999 261.58 419.04 percent of total billed charges Chemical test for genetic disorder 51278248_1 CDM 0301 RC 82017 HCPCS inpatient 432 280.8 SIHO - ALL PLANS SIHO - ALL PLANS 388.8 90 999999999 261.58 419.04 percent of total billed charges Chemical test for genetic disorder 51278248_1 CDM 0301 RC 82017 HCPCS inpatient 432 280.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 261.58 60.55 999999999 261.58 419.04 percent of total billed charges Chemical test for genetic disorder 51278248_1 CDM 0301 RC 82017 HCPCS inpatient 432 280.8 UMR - ALL PLANS UMR - ALL PLANS 302.4 70 999999999 261.58 419.04 percent of total billed charges Chemical test for genetic disorder 51278248_1 CDM 0301 RC 82017 HCPCS inpatient 432 280.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 261.58 419.04 Chemical test for genetic disorder 51278248_1 CDM 0301 RC 82017 HCPCS inpatient 432 280.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 261.58 419.04 Chemical test for genetic disorder 51278248_1 CDM 0301 RC 82017 HCPCS inpatient 432 280.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 261.58 419.04 Chemical test for genetic disorder 51278248_1 CDM 0301 RC 82017 HCPCS inpatient 432 280.8 ANTHEM HMO ANTHEM HMO 999999999 261.58 419.04 Chemical test for genetic disorder 51278248_1 CDM 0301 RC 82017 HCPCS inpatient 432 280.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 261.58 419.04 Chemical test for genetic disorder 51278248_1 CDM 0301 RC 82017 HCPCS inpatient 432 280.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 292.03 67.6 999999999 261.58 419.04 percent of total billed charges Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 51278586_1 CDM 0311 RC 81229 HCPCS inpatient 4163 2705.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 2705.95 65 999999999 2520.7 4038.11 percent of total billed charges Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 51278586_1 CDM 0311 RC 81229 HCPCS inpatient 4163 2705.95 AETNA AETNA 3288.77 79 999999999 2520.7 4038.11 percent of total billed charges Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 51278586_1 CDM 0311 RC 81229 HCPCS inpatient 4163 2705.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4038.11 97 999999999 2520.7 4038.11 percent of total billed charges Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 51278586_1 CDM 0311 RC 81229 HCPCS inpatient 4163 2705.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 2872.47 69 999999999 2520.7 4038.11 percent of total billed charges Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 51278586_1 CDM 0311 RC 81229 HCPCS inpatient 4163 2705.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 3247.14 78 999999999 2520.7 4038.11 percent of total billed charges Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 51278586_1 CDM 0311 RC 81229 HCPCS inpatient 4163 2705.95 SIHO - ALL PLANS SIHO - ALL PLANS 3746.7 90 999999999 2520.7 4038.11 percent of total billed charges Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 51278586_1 CDM 0311 RC 81229 HCPCS inpatient 4163 2705.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2520.7 60.55 999999999 2520.7 4038.11 percent of total billed charges Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 51278586_1 CDM 0311 RC 81229 HCPCS inpatient 4163 2705.95 UMR - ALL PLANS UMR - ALL PLANS 2914.1 70 999999999 2520.7 4038.11 percent of total billed charges Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 51278586_1 CDM 0311 RC 81229 HCPCS inpatient 4163 2705.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2520.7 4038.11 Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 51278586_1 CDM 0311 RC 81229 HCPCS inpatient 4163 2705.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2520.7 4038.11 Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 51278586_1 CDM 0311 RC 81229 HCPCS inpatient 4163 2705.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2520.7 4038.11 Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 51278586_1 CDM 0311 RC 81229 HCPCS inpatient 4163 2705.95 ANTHEM HMO ANTHEM HMO 999999999 2520.7 4038.11 Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 51278586_1 CDM 0311 RC 81229 HCPCS inpatient 4163 2705.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 2520.7 4038.11 Genome-wide microarray analysis for copy number and single nucleotide polymorphism (SNP) variants 51278586_1 CDM 0311 RC 81229 HCPCS inpatient 4163 2705.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 2814.19 67.6 999999999 2520.7 4038.11 percent of total billed charges "Therapy procedure reassessment for nutrition management, each 15 minutes" 51289320_1 CDM 0510 RC 97803 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges "Therapy procedure reassessment for nutrition management, each 15 minutes" 51289320_1 CDM 0510 RC 97803 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges "Therapy procedure reassessment for nutrition management, each 15 minutes" 51289320_1 CDM 0510 RC 97803 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges "Therapy procedure reassessment for nutrition management, each 15 minutes" 51289320_1 CDM 0510 RC 97803 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges "Therapy procedure reassessment for nutrition management, each 15 minutes" 51289320_1 CDM 0510 RC 97803 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges "Therapy procedure reassessment for nutrition management, each 15 minutes" 51289320_1 CDM 0510 RC 97803 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges "Therapy procedure reassessment for nutrition management, each 15 minutes" 51289320_1 CDM 0510 RC 97803 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges "Therapy procedure reassessment for nutrition management, each 15 minutes" 51289320_1 CDM 0510 RC 97803 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges "Therapy procedure reassessment for nutrition management, each 15 minutes" 51289320_1 CDM 0510 RC 97803 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 "Therapy procedure reassessment for nutrition management, each 15 minutes" 51289320_1 CDM 0510 RC 97803 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 "Therapy procedure reassessment for nutrition management, each 15 minutes" 51289320_1 CDM 0510 RC 97803 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 "Therapy procedure reassessment for nutrition management, each 15 minutes" 51289320_1 CDM 0510 RC 97803 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 "Therapy procedure reassessment for nutrition management, each 15 minutes" 51289320_1 CDM 0510 RC 97803 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 "Therapy procedure reassessment for nutrition management, each 15 minutes" 51289320_1 CDM 0510 RC 97803 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 51289321_1 CDM 0510 RC 97804 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 51289321_1 CDM 0510 RC 97804 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 51289321_1 CDM 0510 RC 97804 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 51289321_1 CDM 0510 RC 97804 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 51289321_1 CDM 0510 RC 97804 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 51289321_1 CDM 0510 RC 97804 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 51289321_1 CDM 0510 RC 97804 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 51289321_1 CDM 0510 RC 97804 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges "Therapy procedure for nutrition management with group, each 30 minutes" 51289321_1 CDM 0510 RC 97804 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 "Therapy procedure for nutrition management with group, each 30 minutes" 51289321_1 CDM 0510 RC 97804 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 "Therapy procedure for nutrition management with group, each 30 minutes" 51289321_1 CDM 0510 RC 97804 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 "Therapy procedure for nutrition management with group, each 30 minutes" 51289321_1 CDM 0510 RC 97804 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 "Therapy procedure for nutrition management with group, each 30 minutes" 51289321_1 CDM 0510 RC 97804 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 "Therapy procedure for nutrition management with group, each 30 minutes" 51289321_1 CDM 0510 RC 97804 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges "Chromosome analysis for genetic defects, count 5 cells" 51291197_1 CDM 0311 RC 88261 HCPCS inpatient 559 363.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 363.35 65 999999999 338.47 542.23 percent of total billed charges "Chromosome analysis for genetic defects, count 5 cells" 51291197_1 CDM 0311 RC 88261 HCPCS inpatient 559 363.35 AETNA AETNA 441.61 79 999999999 338.47 542.23 percent of total billed charges "Chromosome analysis for genetic defects, count 5 cells" 51291197_1 CDM 0311 RC 88261 HCPCS inpatient 559 363.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 542.23 97 999999999 338.47 542.23 percent of total billed charges "Chromosome analysis for genetic defects, count 5 cells" 51291197_1 CDM 0311 RC 88261 HCPCS inpatient 559 363.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 385.71 69 999999999 338.47 542.23 percent of total billed charges "Chromosome analysis for genetic defects, count 5 cells" 51291197_1 CDM 0311 RC 88261 HCPCS inpatient 559 363.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 436.02 78 999999999 338.47 542.23 percent of total billed charges "Chromosome analysis for genetic defects, count 5 cells" 51291197_1 CDM 0311 RC 88261 HCPCS inpatient 559 363.35 SIHO - ALL PLANS SIHO - ALL PLANS 503.1 90 999999999 338.47 542.23 percent of total billed charges "Chromosome analysis for genetic defects, count 5 cells" 51291197_1 CDM 0311 RC 88261 HCPCS inpatient 559 363.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 338.47 60.55 999999999 338.47 542.23 percent of total billed charges "Chromosome analysis for genetic defects, count 5 cells" 51291197_1 CDM 0311 RC 88261 HCPCS inpatient 559 363.35 UMR - ALL PLANS UMR - ALL PLANS 391.3 70 999999999 338.47 542.23 percent of total billed charges "Chromosome analysis for genetic defects, count 5 cells" 51291197_1 CDM 0311 RC 88261 HCPCS inpatient 559 363.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 338.47 542.23 "Chromosome analysis for genetic defects, count 5 cells" 51291197_1 CDM 0311 RC 88261 HCPCS inpatient 559 363.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 338.47 542.23 "Chromosome analysis for genetic defects, count 5 cells" 51291197_1 CDM 0311 RC 88261 HCPCS inpatient 559 363.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 338.47 542.23 "Chromosome analysis for genetic defects, count 5 cells" 51291197_1 CDM 0311 RC 88261 HCPCS inpatient 559 363.35 ANTHEM HMO ANTHEM HMO 999999999 338.47 542.23 "Chromosome analysis for genetic defects, count 5 cells" 51291197_1 CDM 0311 RC 88261 HCPCS inpatient 559 363.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 338.47 542.23 "Chromosome analysis for genetic defects, count 5 cells" 51291197_1 CDM 0311 RC 88261 HCPCS inpatient 559 363.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 377.88 67.6 999999999 338.47 542.23 percent of total billed charges Tissue culture to identify skin disorders 51292998_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 174.2 65 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 51292998_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 AETNA AETNA 211.72 79 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 51292998_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 259.96 97 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 51292998_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.92 69 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 51292998_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 209.04 78 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 51292998_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 SIHO - ALL PLANS SIHO - ALL PLANS 241.2 90 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 51292998_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 162.27 60.55 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 51292998_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 UMR - ALL PLANS UMR - ALL PLANS 187.6 70 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 51292998_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 162.27 259.96 Tissue culture to identify skin disorders 51292998_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 162.27 259.96 Tissue culture to identify skin disorders 51292998_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 162.27 259.96 Tissue culture to identify skin disorders 51292998_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 ANTHEM HMO ANTHEM HMO 999999999 162.27 259.96 Tissue culture to identify skin disorders 51292998_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 162.27 259.96 Tissue culture to identify skin disorders 51292998_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 181.17 67.6 999999999 162.27 259.96 percent of total billed charges Detection of Mycoplasma genitalium by DNA or RNA probe 51293762_1 CDM 0306 RC 87563 HCPCS inpatient 99 64.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 64.35 65 999999999 59.94 96.03 percent of total billed charges Detection of Mycoplasma genitalium by DNA or RNA probe 51293762_1 CDM 0306 RC 87563 HCPCS inpatient 99 64.35 AETNA AETNA 78.21 79 999999999 59.94 96.03 percent of total billed charges Detection of Mycoplasma genitalium by DNA or RNA probe 51293762_1 CDM 0306 RC 87563 HCPCS inpatient 99 64.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 96.03 97 999999999 59.94 96.03 percent of total billed charges Detection of Mycoplasma genitalium by DNA or RNA probe 51293762_1 CDM 0306 RC 87563 HCPCS inpatient 99 64.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 68.31 69 999999999 59.94 96.03 percent of total billed charges Detection of Mycoplasma genitalium by DNA or RNA probe 51293762_1 CDM 0306 RC 87563 HCPCS inpatient 99 64.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 77.22 78 999999999 59.94 96.03 percent of total billed charges Detection of Mycoplasma genitalium by DNA or RNA probe 51293762_1 CDM 0306 RC 87563 HCPCS inpatient 99 64.35 SIHO - ALL PLANS SIHO - ALL PLANS 89.1 90 999999999 59.94 96.03 percent of total billed charges Detection of Mycoplasma genitalium by DNA or RNA probe 51293762_1 CDM 0306 RC 87563 HCPCS inpatient 99 64.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.94 60.55 999999999 59.94 96.03 percent of total billed charges Detection of Mycoplasma genitalium by DNA or RNA probe 51293762_1 CDM 0306 RC 87563 HCPCS inpatient 99 64.35 UMR - ALL PLANS UMR - ALL PLANS 69.3 70 999999999 59.94 96.03 percent of total billed charges Detection of Mycoplasma genitalium by DNA or RNA probe 51293762_1 CDM 0306 RC 87563 HCPCS inpatient 99 64.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.94 96.03 Detection of Mycoplasma genitalium by DNA or RNA probe 51293762_1 CDM 0306 RC 87563 HCPCS inpatient 99 64.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.94 96.03 Detection of Mycoplasma genitalium by DNA or RNA probe 51293762_1 CDM 0306 RC 87563 HCPCS inpatient 99 64.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.94 96.03 Detection of Mycoplasma genitalium by DNA or RNA probe 51293762_1 CDM 0306 RC 87563 HCPCS inpatient 99 64.35 ANTHEM HMO ANTHEM HMO 999999999 59.94 96.03 Detection of Mycoplasma genitalium by DNA or RNA probe 51293762_1 CDM 0306 RC 87563 HCPCS inpatient 99 64.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.94 96.03 Detection of Mycoplasma genitalium by DNA or RNA probe 51293762_1 CDM 0306 RC 87563 HCPCS inpatient 99 64.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.92 67.6 999999999 59.94 96.03 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293763_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 120.25 65 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293763_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 AETNA AETNA 146.15 79 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293763_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 179.45 97 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293763_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 127.65 69 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293763_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 144.3 78 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293763_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 SIHO - ALL PLANS SIHO - ALL PLANS 166.5 90 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293763_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 112.02 60.55 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293763_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 UMR - ALL PLANS UMR - ALL PLANS 129.5 70 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293763_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 112.02 179.45 "Detection test by nucleic acid for organism, amplified probe technique" 51293763_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 112.02 179.45 "Detection test by nucleic acid for organism, amplified probe technique" 51293763_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 112.02 179.45 "Detection test by nucleic acid for organism, amplified probe technique" 51293763_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 ANTHEM HMO ANTHEM HMO 999999999 112.02 179.45 "Detection test by nucleic acid for organism, amplified probe technique" 51293763_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 112.02 179.45 "Detection test by nucleic acid for organism, amplified probe technique" 51293763_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 125.06 67.6 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293765_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 120.25 65 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293765_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 AETNA AETNA 146.15 79 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293765_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 179.45 97 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293765_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 127.65 69 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293765_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 144.3 78 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293765_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 SIHO - ALL PLANS SIHO - ALL PLANS 166.5 90 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293765_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 112.02 60.55 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293765_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 UMR - ALL PLANS UMR - ALL PLANS 129.5 70 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293765_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 112.02 179.45 "Detection test by nucleic acid for organism, amplified probe technique" 51293765_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 112.02 179.45 "Detection test by nucleic acid for organism, amplified probe technique" 51293765_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 112.02 179.45 "Detection test by nucleic acid for organism, amplified probe technique" 51293765_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 ANTHEM HMO ANTHEM HMO 999999999 112.02 179.45 "Detection test by nucleic acid for organism, amplified probe technique" 51293765_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 112.02 179.45 "Detection test by nucleic acid for organism, amplified probe technique" 51293765_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 125.06 67.6 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293766_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 120.25 65 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293766_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 AETNA AETNA 146.15 79 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293766_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 179.45 97 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293766_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 127.65 69 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293766_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 144.3 78 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293766_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 SIHO - ALL PLANS SIHO - ALL PLANS 166.5 90 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293766_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 112.02 60.55 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293766_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 UMR - ALL PLANS UMR - ALL PLANS 129.5 70 999999999 112.02 179.45 percent of total billed charges "Detection test by nucleic acid for organism, amplified probe technique" 51293766_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 112.02 179.45 "Detection test by nucleic acid for organism, amplified probe technique" 51293766_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 112.02 179.45 "Detection test by nucleic acid for organism, amplified probe technique" 51293766_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 112.02 179.45 "Detection test by nucleic acid for organism, amplified probe technique" 51293766_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 ANTHEM HMO ANTHEM HMO 999999999 112.02 179.45 "Detection test by nucleic acid for organism, amplified probe technique" 51293766_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 112.02 179.45 "Detection test by nucleic acid for organism, amplified probe technique" 51293766_1 CDM 0300 RC 87798 HCPCS inpatient 185 120.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 125.06 67.6 999999999 112.02 179.45 percent of total billed charges POWERGLIDE PRO MIDLINE CATH 8cm X 20g F320088PT 51307700_1 CDM 0272 RC inpatient 563.18 366.07 SELF PAY DISCOUNT SELF PAY DISCOUNT 366.07 65 999999999 341.01 546.28 percent of total billed charges POWERGLIDE PRO MIDLINE CATH 8cm X 20g F320088PT 51307700_1 CDM 0272 RC inpatient 563.18 366.07 AETNA AETNA 444.91 79 999999999 341.01 546.28 percent of total billed charges POWERGLIDE PRO MIDLINE CATH 8cm X 20g F320088PT 51307700_1 CDM 0272 RC inpatient 563.18 366.07 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 546.28 97 999999999 341.01 546.28 percent of total billed charges POWERGLIDE PRO MIDLINE CATH 8cm X 20g F320088PT 51307700_1 CDM 0272 RC inpatient 563.18 366.07 ENCORE - ALL PLANS ENCORE - ALL PLANS 388.59 69 999999999 341.01 546.28 percent of total billed charges POWERGLIDE PRO MIDLINE CATH 8cm X 20g F320088PT 51307700_1 CDM 0272 RC inpatient 563.18 366.07 HUMANA - ALL PLANS HUMANA - ALL PLANS 439.28 78 999999999 341.01 546.28 percent of total billed charges POWERGLIDE PRO MIDLINE CATH 8cm X 20g F320088PT 51307700_1 CDM 0272 RC inpatient 563.18 366.07 SIHO - ALL PLANS SIHO - ALL PLANS 506.86 90 999999999 341.01 546.28 percent of total billed charges POWERGLIDE PRO MIDLINE CATH 8cm X 20g F320088PT 51307700_1 CDM 0272 RC inpatient 563.18 366.07 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 341.01 60.55 999999999 341.01 546.28 percent of total billed charges POWERGLIDE PRO MIDLINE CATH 8cm X 20g F320088PT 51307700_1 CDM 0272 RC inpatient 563.18 366.07 UMR - ALL PLANS UMR - ALL PLANS 394.23 70 999999999 341.01 546.28 percent of total billed charges POWERGLIDE PRO MIDLINE CATH 8cm X 20g F320088PT 51307700_1 CDM 0272 RC inpatient 563.18 366.07 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 341.01 546.28 POWERGLIDE PRO MIDLINE CATH 8cm X 20g F320088PT 51307700_1 CDM 0272 RC inpatient 563.18 366.07 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 341.01 546.28 POWERGLIDE PRO MIDLINE CATH 8cm X 20g F320088PT 51307700_1 CDM 0272 RC inpatient 563.18 366.07 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 341.01 546.28 POWERGLIDE PRO MIDLINE CATH 8cm X 20g F320088PT 51307700_1 CDM 0272 RC inpatient 563.18 366.07 ANTHEM HMO ANTHEM HMO 999999999 341.01 546.28 POWERGLIDE PRO MIDLINE CATH 8cm X 20g F320088PT 51307700_1 CDM 0272 RC inpatient 563.18 366.07 UHC - ALL PLANS UHC - ALL PLANS 999999999 341.01 546.28 POWERGLIDE PRO MIDLINE CATH 8cm X 20g F320088PT 51307700_1 CDM 0272 RC inpatient 563.18 366.07 CIGNA - ALL PLANS CIGNA - ALL PLANS 380.71 67.6 999999999 341.01 546.28 percent of total billed charges SINGLE BD POWERGLIDE 51307713_1 CDM 0272 RC inpatient 373 242.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 242.45 65 999999999 225.85 361.81 percent of total billed charges SINGLE BD POWERGLIDE 51307713_1 CDM 0272 RC inpatient 373 242.45 AETNA AETNA 294.67 79 999999999 225.85 361.81 percent of total billed charges SINGLE BD POWERGLIDE 51307713_1 CDM 0272 RC inpatient 373 242.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 361.81 97 999999999 225.85 361.81 percent of total billed charges SINGLE BD POWERGLIDE 51307713_1 CDM 0272 RC inpatient 373 242.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 257.37 69 999999999 225.85 361.81 percent of total billed charges SINGLE BD POWERGLIDE 51307713_1 CDM 0272 RC inpatient 373 242.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 290.94 78 999999999 225.85 361.81 percent of total billed charges SINGLE BD POWERGLIDE 51307713_1 CDM 0272 RC inpatient 373 242.45 SIHO - ALL PLANS SIHO - ALL PLANS 335.7 90 999999999 225.85 361.81 percent of total billed charges SINGLE BD POWERGLIDE 51307713_1 CDM 0272 RC inpatient 373 242.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 225.85 60.55 999999999 225.85 361.81 percent of total billed charges SINGLE BD POWERGLIDE 51307713_1 CDM 0272 RC inpatient 373 242.45 UMR - ALL PLANS UMR - ALL PLANS 261.1 70 999999999 225.85 361.81 percent of total billed charges SINGLE BD POWERGLIDE 51307713_1 CDM 0272 RC inpatient 373 242.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 225.85 361.81 SINGLE BD POWERGLIDE 51307713_1 CDM 0272 RC inpatient 373 242.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 225.85 361.81 SINGLE BD POWERGLIDE 51307713_1 CDM 0272 RC inpatient 373 242.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 225.85 361.81 SINGLE BD POWERGLIDE 51307713_1 CDM 0272 RC inpatient 373 242.45 ANTHEM HMO ANTHEM HMO 999999999 225.85 361.81 SINGLE BD POWERGLIDE 51307713_1 CDM 0272 RC inpatient 373 242.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 225.85 361.81 SINGLE BD POWERGLIDE 51307713_1 CDM 0272 RC inpatient 373 242.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 252.15 67.6 999999999 225.85 361.81 percent of total billed charges Special stain for parasites 51307749_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 40.95 65 999999999 38.15 61.11 percent of total billed charges Special stain for parasites 51307749_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 AETNA AETNA 49.77 79 999999999 38.15 61.11 percent of total billed charges Special stain for parasites 51307749_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61.11 97 999999999 38.15 61.11 percent of total billed charges Special stain for parasites 51307749_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 43.47 69 999999999 38.15 61.11 percent of total billed charges Special stain for parasites 51307749_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 49.14 78 999999999 38.15 61.11 percent of total billed charges Special stain for parasites 51307749_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 SIHO - ALL PLANS SIHO - ALL PLANS 56.7 90 999999999 38.15 61.11 percent of total billed charges Special stain for parasites 51307749_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38.15 60.55 999999999 38.15 61.11 percent of total billed charges Special stain for parasites 51307749_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 UMR - ALL PLANS UMR - ALL PLANS 44.1 70 999999999 38.15 61.11 percent of total billed charges Special stain for parasites 51307749_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 38.15 61.11 Special stain for parasites 51307749_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 38.15 61.11 Special stain for parasites 51307749_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 38.15 61.11 Special stain for parasites 51307749_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 ANTHEM HMO ANTHEM HMO 999999999 38.15 61.11 Special stain for parasites 51307749_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 38.15 61.11 Special stain for parasites 51307749_1 CDM 0301 RC 87209 HCPCS inpatient 63 40.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 42.59 67.6 999999999 38.15 61.11 percent of total billed charges "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51309505_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.14 65 999999999 1.07 1.71 percent of total billed charges "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51309505_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 AETNA AETNA 1.39 79 999999999 1.07 1.71 percent of total billed charges "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51309505_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.71 97 999999999 1.07 1.71 percent of total billed charges "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51309505_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.21 69 999999999 1.07 1.71 percent of total billed charges "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51309505_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.37 78 999999999 1.07 1.71 percent of total billed charges "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51309505_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 SIHO - ALL PLANS SIHO - ALL PLANS 1.58 90 999999999 1.07 1.71 percent of total billed charges "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51309505_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.07 60.55 999999999 1.07 1.71 percent of total billed charges "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51309505_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 UMR - ALL PLANS UMR - ALL PLANS 1.23 70 999999999 1.07 1.71 percent of total billed charges "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51309505_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.07 1.71 "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51309505_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.07 1.71 "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51309505_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.07 1.71 "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51309505_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 ANTHEM HMO ANTHEM HMO 999999999 1.07 1.71 "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51309505_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.07 1.71 "CAPSAICIN 8% PATCH, PER SQUARE CENTIMETER" 51309505_1 CDM 0250 RC J7336 HCPCS inpatient 1.76 1.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.19 67.6 999999999 1.07 1.71 percent of total billed charges Incision or partial removal of big toe bone with self bone graft to straighten toe 51319678_1 CDM 0510 RC 28307 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone with self bone graft to straighten toe 51319678_1 CDM 0510 RC 28307 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone with self bone graft to straighten toe 51319678_1 CDM 0510 RC 28307 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone with self bone graft to straighten toe 51319678_1 CDM 0510 RC 28307 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone with self bone graft to straighten toe 51319678_1 CDM 0510 RC 28307 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone with self bone graft to straighten toe 51319678_1 CDM 0510 RC 28307 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone with self bone graft to straighten toe 51319678_1 CDM 0510 RC 28307 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone with self bone graft to straighten toe 51319678_1 CDM 0510 RC 28307 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone with self bone graft to straighten toe 51319678_1 CDM 0510 RC 28307 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Incision or partial removal of big toe bone with self bone graft to straighten toe 51319678_1 CDM 0510 RC 28307 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Incision or partial removal of big toe bone with self bone graft to straighten toe 51319678_1 CDM 0510 RC 28307 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Incision or partial removal of big toe bone with self bone graft to straighten toe 51319678_1 CDM 0510 RC 28307 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Incision or partial removal of big toe bone with self bone graft to straighten toe 51319678_1 CDM 0510 RC 28307 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Incision or partial removal of big toe bone with self bone graft to straighten toe 51319678_1 CDM 0510 RC 28307 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone at first toe bone level to straighten toe 51319679_1 CDM 0510 RC 28310 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone at first toe bone level to straighten toe 51319679_1 CDM 0510 RC 28310 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone at first toe bone level to straighten toe 51319679_1 CDM 0510 RC 28310 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone at first toe bone level to straighten toe 51319679_1 CDM 0510 RC 28310 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone at first toe bone level to straighten toe 51319679_1 CDM 0510 RC 28310 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone at first toe bone level to straighten toe 51319679_1 CDM 0510 RC 28310 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone at first toe bone level to straighten toe 51319679_1 CDM 0510 RC 28310 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone at first toe bone level to straighten toe 51319679_1 CDM 0510 RC 28310 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone at first toe bone level to straighten toe 51319679_1 CDM 0510 RC 28310 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Incision or partial removal of big toe bone at first toe bone level to straighten toe 51319679_1 CDM 0510 RC 28310 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Incision or partial removal of big toe bone at first toe bone level to straighten toe 51319679_1 CDM 0510 RC 28310 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Incision or partial removal of big toe bone at first toe bone level to straighten toe 51319679_1 CDM 0510 RC 28310 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Incision or partial removal of big toe bone at first toe bone level to straighten toe 51319679_1 CDM 0510 RC 28310 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Incision or partial removal of big toe bone at first toe bone level to straighten toe 51319679_1 CDM 0510 RC 28310 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Repair of nonhealed broken forefoot bone 51319680_1 CDM 0510 RC 28322 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Repair of nonhealed broken forefoot bone 51319680_1 CDM 0510 RC 28322 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Repair of nonhealed broken forefoot bone 51319680_1 CDM 0510 RC 28322 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Repair of nonhealed broken forefoot bone 51319680_1 CDM 0510 RC 28322 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Repair of nonhealed broken forefoot bone 51319680_1 CDM 0510 RC 28322 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Repair of nonhealed broken forefoot bone 51319680_1 CDM 0510 RC 28322 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Repair of nonhealed broken forefoot bone 51319680_1 CDM 0510 RC 28322 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Repair of nonhealed broken forefoot bone 51319680_1 CDM 0510 RC 28322 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Repair of nonhealed broken forefoot bone 51319680_1 CDM 0510 RC 28322 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Repair of nonhealed broken forefoot bone 51319680_1 CDM 0510 RC 28322 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Repair of nonhealed broken forefoot bone 51319680_1 CDM 0510 RC 28322 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Repair of nonhealed broken forefoot bone 51319680_1 CDM 0510 RC 28322 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Repair of nonhealed broken forefoot bone 51319680_1 CDM 0510 RC 28322 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Repair of nonhealed broken forefoot bone 51319680_1 CDM 0510 RC 28322 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Fusion of all bones of ankle and hindfoot 51319682_1 CDM 0510 RC 28705 HCPCS inpatient 69397 45108.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 45108.05 65 999999999 42019.88 67315.09 percent of total billed charges Fusion of all bones of ankle and hindfoot 51319682_1 CDM 0510 RC 28705 HCPCS inpatient 69397 45108.05 AETNA AETNA 54823.63 79 999999999 42019.88 67315.09 percent of total billed charges Fusion of all bones of ankle and hindfoot 51319682_1 CDM 0510 RC 28705 HCPCS inpatient 69397 45108.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 67315.09 97 999999999 42019.88 67315.09 percent of total billed charges Fusion of all bones of ankle and hindfoot 51319682_1 CDM 0510 RC 28705 HCPCS inpatient 69397 45108.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 47883.93 69 999999999 42019.88 67315.09 percent of total billed charges Fusion of all bones of ankle and hindfoot 51319682_1 CDM 0510 RC 28705 HCPCS inpatient 69397 45108.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 54129.66 78 999999999 42019.88 67315.09 percent of total billed charges Fusion of all bones of ankle and hindfoot 51319682_1 CDM 0510 RC 28705 HCPCS inpatient 69397 45108.05 SIHO - ALL PLANS SIHO - ALL PLANS 62457.3 90 999999999 42019.88 67315.09 percent of total billed charges Fusion of all bones of ankle and hindfoot 51319682_1 CDM 0510 RC 28705 HCPCS inpatient 69397 45108.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42019.88 60.55 999999999 42019.88 67315.09 percent of total billed charges Fusion of all bones of ankle and hindfoot 51319682_1 CDM 0510 RC 28705 HCPCS inpatient 69397 45108.05 UMR - ALL PLANS UMR - ALL PLANS 48577.9 70 999999999 42019.88 67315.09 percent of total billed charges Fusion of all bones of ankle and hindfoot 51319682_1 CDM 0510 RC 28705 HCPCS inpatient 69397 45108.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 42019.88 67315.09 Fusion of all bones of ankle and hindfoot 51319682_1 CDM 0510 RC 28705 HCPCS inpatient 69397 45108.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 42019.88 67315.09 Fusion of all bones of ankle and hindfoot 51319682_1 CDM 0510 RC 28705 HCPCS inpatient 69397 45108.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 42019.88 67315.09 Fusion of all bones of ankle and hindfoot 51319682_1 CDM 0510 RC 28705 HCPCS inpatient 69397 45108.05 ANTHEM HMO ANTHEM HMO 999999999 42019.88 67315.09 Fusion of all bones of ankle and hindfoot 51319682_1 CDM 0510 RC 28705 HCPCS inpatient 69397 45108.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 42019.88 67315.09 Fusion of all bones of ankle and hindfoot 51319682_1 CDM 0510 RC 28705 HCPCS inpatient 69397 45108.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 46912.37 67.6 999999999 42019.88 67315.09 percent of total billed charges Fusion of foot below ankle 51319683_1 CDM 0510 RC 28725 HCPCS inpatient 43291 28139.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 28139.15 65 999999999 26212.7 41992.27 percent of total billed charges Fusion of foot below ankle 51319683_1 CDM 0510 RC 28725 HCPCS inpatient 43291 28139.15 AETNA AETNA 34199.89 79 999999999 26212.7 41992.27 percent of total billed charges Fusion of foot below ankle 51319683_1 CDM 0510 RC 28725 HCPCS inpatient 43291 28139.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 41992.27 97 999999999 26212.7 41992.27 percent of total billed charges Fusion of foot below ankle 51319683_1 CDM 0510 RC 28725 HCPCS inpatient 43291 28139.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 29870.79 69 999999999 26212.7 41992.27 percent of total billed charges Fusion of foot below ankle 51319683_1 CDM 0510 RC 28725 HCPCS inpatient 43291 28139.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 33766.98 78 999999999 26212.7 41992.27 percent of total billed charges Fusion of foot below ankle 51319683_1 CDM 0510 RC 28725 HCPCS inpatient 43291 28139.15 SIHO - ALL PLANS SIHO - ALL PLANS 38961.9 90 999999999 26212.7 41992.27 percent of total billed charges Fusion of foot below ankle 51319683_1 CDM 0510 RC 28725 HCPCS inpatient 43291 28139.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26212.7 60.55 999999999 26212.7 41992.27 percent of total billed charges Fusion of foot below ankle 51319683_1 CDM 0510 RC 28725 HCPCS inpatient 43291 28139.15 UMR - ALL PLANS UMR - ALL PLANS 30303.7 70 999999999 26212.7 41992.27 percent of total billed charges Fusion of foot below ankle 51319683_1 CDM 0510 RC 28725 HCPCS inpatient 43291 28139.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26212.7 41992.27 Fusion of foot below ankle 51319683_1 CDM 0510 RC 28725 HCPCS inpatient 43291 28139.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26212.7 41992.27 Fusion of foot below ankle 51319683_1 CDM 0510 RC 28725 HCPCS inpatient 43291 28139.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26212.7 41992.27 Fusion of foot below ankle 51319683_1 CDM 0510 RC 28725 HCPCS inpatient 43291 28139.15 ANTHEM HMO ANTHEM HMO 999999999 26212.7 41992.27 Fusion of foot below ankle 51319683_1 CDM 0510 RC 28725 HCPCS inpatient 43291 28139.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 26212.7 41992.27 Fusion of foot below ankle 51319683_1 CDM 0510 RC 28725 HCPCS inpatient 43291 28139.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 29264.72 67.6 999999999 26212.7 41992.27 percent of total billed charges Amputation of foot across instep 51319703_1 CDM 0510 RC 28805 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Amputation of foot across instep 51319703_1 CDM 0510 RC 28805 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Amputation of foot across instep 51319703_1 CDM 0510 RC 28805 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Amputation of foot across instep 51319703_1 CDM 0510 RC 28805 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Amputation of foot across instep 51319703_1 CDM 0510 RC 28805 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Amputation of foot across instep 51319703_1 CDM 0510 RC 28805 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Amputation of foot across instep 51319703_1 CDM 0510 RC 28805 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Amputation of foot across instep 51319703_1 CDM 0510 RC 28805 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Amputation of foot across instep 51319703_1 CDM 0510 RC 28805 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Amputation of foot across instep 51319703_1 CDM 0510 RC 28805 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Amputation of foot across instep 51319703_1 CDM 0510 RC 28805 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Amputation of foot across instep 51319703_1 CDM 0510 RC 28805 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Amputation of foot across instep 51319703_1 CDM 0510 RC 28805 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Amputation of foot across instep 51319703_1 CDM 0510 RC 28805 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Complete removal of second to fifth foot bones 51319705_1 CDM 0510 RC 28114 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Complete removal of second to fifth foot bones 51319705_1 CDM 0510 RC 28114 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Complete removal of second to fifth foot bones 51319705_1 CDM 0510 RC 28114 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Complete removal of second to fifth foot bones 51319705_1 CDM 0510 RC 28114 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Complete removal of second to fifth foot bones 51319705_1 CDM 0510 RC 28114 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Complete removal of second to fifth foot bones 51319705_1 CDM 0510 RC 28114 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Complete removal of second to fifth foot bones 51319705_1 CDM 0510 RC 28114 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Complete removal of second to fifth foot bones 51319705_1 CDM 0510 RC 28114 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Complete removal of second to fifth foot bones 51319705_1 CDM 0510 RC 28114 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Complete removal of second to fifth foot bones 51319705_1 CDM 0510 RC 28114 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Complete removal of second to fifth foot bones 51319705_1 CDM 0510 RC 28114 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Complete removal of second to fifth foot bones 51319705_1 CDM 0510 RC 28114 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Complete removal of second to fifth foot bones 51319705_1 CDM 0510 RC 28114 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Complete removal of second to fifth foot bones 51319705_1 CDM 0510 RC 28114 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Release of arm or leg nerve 51319706_1 CDM 0510 RC 64708 HCPCS inpatient 6363.15 4136.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 4136.05 65 999999999 3852.89 6172.26 percent of total billed charges Release of arm or leg nerve 51319706_1 CDM 0510 RC 64708 HCPCS inpatient 6363.15 4136.05 AETNA AETNA 5026.89 79 999999999 3852.89 6172.26 percent of total billed charges Release of arm or leg nerve 51319706_1 CDM 0510 RC 64708 HCPCS inpatient 6363.15 4136.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6172.26 97 999999999 3852.89 6172.26 percent of total billed charges Release of arm or leg nerve 51319706_1 CDM 0510 RC 64708 HCPCS inpatient 6363.15 4136.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 4390.57 69 999999999 3852.89 6172.26 percent of total billed charges Release of arm or leg nerve 51319706_1 CDM 0510 RC 64708 HCPCS inpatient 6363.15 4136.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 4963.26 78 999999999 3852.89 6172.26 percent of total billed charges Release of arm or leg nerve 51319706_1 CDM 0510 RC 64708 HCPCS inpatient 6363.15 4136.05 SIHO - ALL PLANS SIHO - ALL PLANS 5726.84 90 999999999 3852.89 6172.26 percent of total billed charges Release of arm or leg nerve 51319706_1 CDM 0510 RC 64708 HCPCS inpatient 6363.15 4136.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3852.89 60.55 999999999 3852.89 6172.26 percent of total billed charges Release of arm or leg nerve 51319706_1 CDM 0510 RC 64708 HCPCS inpatient 6363.15 4136.05 UMR - ALL PLANS UMR - ALL PLANS 4454.21 70 999999999 3852.89 6172.26 percent of total billed charges Release of arm or leg nerve 51319706_1 CDM 0510 RC 64708 HCPCS inpatient 6363.15 4136.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3852.89 6172.26 Release of arm or leg nerve 51319706_1 CDM 0510 RC 64708 HCPCS inpatient 6363.15 4136.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3852.89 6172.26 Release of arm or leg nerve 51319706_1 CDM 0510 RC 64708 HCPCS inpatient 6363.15 4136.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3852.89 6172.26 Release of arm or leg nerve 51319706_1 CDM 0510 RC 64708 HCPCS inpatient 6363.15 4136.05 ANTHEM HMO ANTHEM HMO 999999999 3852.89 6172.26 Release of arm or leg nerve 51319706_1 CDM 0510 RC 64708 HCPCS inpatient 6363.15 4136.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 3852.89 6172.26 Release of arm or leg nerve 51319706_1 CDM 0510 RC 64708 HCPCS inpatient 6363.15 4136.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 4301.49 67.6 999999999 3852.89 6172.26 percent of total billed charges Drainage of fluid filled sac below connective tissue in foot joint 51319731_1 CDM 0510 RC 28002 HCPCS inpatient 5078 3300.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 3300.7 65 999999999 3074.73 4925.66 percent of total billed charges Drainage of fluid filled sac below connective tissue in foot joint 51319731_1 CDM 0510 RC 28002 HCPCS inpatient 5078 3300.7 AETNA AETNA 4011.62 79 999999999 3074.73 4925.66 percent of total billed charges Drainage of fluid filled sac below connective tissue in foot joint 51319731_1 CDM 0510 RC 28002 HCPCS inpatient 5078 3300.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4925.66 97 999999999 3074.73 4925.66 percent of total billed charges Drainage of fluid filled sac below connective tissue in foot joint 51319731_1 CDM 0510 RC 28002 HCPCS inpatient 5078 3300.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 3503.82 69 999999999 3074.73 4925.66 percent of total billed charges Drainage of fluid filled sac below connective tissue in foot joint 51319731_1 CDM 0510 RC 28002 HCPCS inpatient 5078 3300.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 3960.84 78 999999999 3074.73 4925.66 percent of total billed charges Drainage of fluid filled sac below connective tissue in foot joint 51319731_1 CDM 0510 RC 28002 HCPCS inpatient 5078 3300.7 SIHO - ALL PLANS SIHO - ALL PLANS 4570.2 90 999999999 3074.73 4925.66 percent of total billed charges Drainage of fluid filled sac below connective tissue in foot joint 51319731_1 CDM 0510 RC 28002 HCPCS inpatient 5078 3300.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3074.73 60.55 999999999 3074.73 4925.66 percent of total billed charges Drainage of fluid filled sac below connective tissue in foot joint 51319731_1 CDM 0510 RC 28002 HCPCS inpatient 5078 3300.7 UMR - ALL PLANS UMR - ALL PLANS 3554.6 70 999999999 3074.73 4925.66 percent of total billed charges Drainage of fluid filled sac below connective tissue in foot joint 51319731_1 CDM 0510 RC 28002 HCPCS inpatient 5078 3300.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3074.73 4925.66 Drainage of fluid filled sac below connective tissue in foot joint 51319731_1 CDM 0510 RC 28002 HCPCS inpatient 5078 3300.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3074.73 4925.66 Drainage of fluid filled sac below connective tissue in foot joint 51319731_1 CDM 0510 RC 28002 HCPCS inpatient 5078 3300.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3074.73 4925.66 Drainage of fluid filled sac below connective tissue in foot joint 51319731_1 CDM 0510 RC 28002 HCPCS inpatient 5078 3300.7 ANTHEM HMO ANTHEM HMO 999999999 3074.73 4925.66 Drainage of fluid filled sac below connective tissue in foot joint 51319731_1 CDM 0510 RC 28002 HCPCS inpatient 5078 3300.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 3074.73 4925.66 Drainage of fluid filled sac below connective tissue in foot joint 51319731_1 CDM 0510 RC 28002 HCPCS inpatient 5078 3300.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 3432.73 67.6 999999999 3074.73 4925.66 percent of total billed charges Drainage of fluid filled sacs beneath connective tissue in multiple foot joints 51319732_1 CDM 0510 RC 28003 HCPCS inpatient 10537.26 6849.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.22 65 999999999 6380.31 10221.14 percent of total billed charges Drainage of fluid filled sacs beneath connective tissue in multiple foot joints 51319732_1 CDM 0510 RC 28003 HCPCS inpatient 10537.26 6849.22 AETNA AETNA 8324.44 79 999999999 6380.31 10221.14 percent of total billed charges Drainage of fluid filled sacs beneath connective tissue in multiple foot joints 51319732_1 CDM 0510 RC 28003 HCPCS inpatient 10537.26 6849.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10221.14 97 999999999 6380.31 10221.14 percent of total billed charges Drainage of fluid filled sacs beneath connective tissue in multiple foot joints 51319732_1 CDM 0510 RC 28003 HCPCS inpatient 10537.26 6849.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.71 69 999999999 6380.31 10221.14 percent of total billed charges Drainage of fluid filled sacs beneath connective tissue in multiple foot joints 51319732_1 CDM 0510 RC 28003 HCPCS inpatient 10537.26 6849.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 8219.06 78 999999999 6380.31 10221.14 percent of total billed charges Drainage of fluid filled sacs beneath connective tissue in multiple foot joints 51319732_1 CDM 0510 RC 28003 HCPCS inpatient 10537.26 6849.22 SIHO - ALL PLANS SIHO - ALL PLANS 9483.53 90 999999999 6380.31 10221.14 percent of total billed charges Drainage of fluid filled sacs beneath connective tissue in multiple foot joints 51319732_1 CDM 0510 RC 28003 HCPCS inpatient 10537.26 6849.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.31 60.55 999999999 6380.31 10221.14 percent of total billed charges Drainage of fluid filled sacs beneath connective tissue in multiple foot joints 51319732_1 CDM 0510 RC 28003 HCPCS inpatient 10537.26 6849.22 UMR - ALL PLANS UMR - ALL PLANS 7376.08 70 999999999 6380.31 10221.14 percent of total billed charges Drainage of fluid filled sacs beneath connective tissue in multiple foot joints 51319732_1 CDM 0510 RC 28003 HCPCS inpatient 10537.26 6849.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.31 10221.14 Drainage of fluid filled sacs beneath connective tissue in multiple foot joints 51319732_1 CDM 0510 RC 28003 HCPCS inpatient 10537.26 6849.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.31 10221.14 Drainage of fluid filled sacs beneath connective tissue in multiple foot joints 51319732_1 CDM 0510 RC 28003 HCPCS inpatient 10537.26 6849.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.31 10221.14 Drainage of fluid filled sacs beneath connective tissue in multiple foot joints 51319732_1 CDM 0510 RC 28003 HCPCS inpatient 10537.26 6849.22 ANTHEM HMO ANTHEM HMO 999999999 6380.31 10221.14 Drainage of fluid filled sacs beneath connective tissue in multiple foot joints 51319732_1 CDM 0510 RC 28003 HCPCS inpatient 10537.26 6849.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.31 10221.14 Drainage of fluid filled sacs beneath connective tissue in multiple foot joints 51319732_1 CDM 0510 RC 28003 HCPCS inpatient 10537.26 6849.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.19 67.6 999999999 6380.31 10221.14 percent of total billed charges Total cell count for B cells (white blood cells) 51319784_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges Total cell count for B cells (white blood cells) 51319784_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges Total cell count for B cells (white blood cells) 51319784_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges Total cell count for B cells (white blood cells) 51319784_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges Total cell count for B cells (white blood cells) 51319784_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges Total cell count for B cells (white blood cells) 51319784_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges Total cell count for B cells (white blood cells) 51319784_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges Total cell count for B cells (white blood cells) 51319784_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges Total cell count for B cells (white blood cells) 51319784_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 Total cell count for B cells (white blood cells) 51319784_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 Total cell count for B cells (white blood cells) 51319784_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 Total cell count for B cells (white blood cells) 51319784_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 Total cell count for B cells (white blood cells) 51319784_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 Total cell count for B cells (white blood cells) 51319784_1 CDM 0312 RC 86355 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges "T cells count, total" 51319785_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.75 65 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51319785_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 AETNA AETNA 90.85 79 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51319785_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 111.55 97 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51319785_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 79.35 69 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51319785_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 89.7 78 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51319785_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 SIHO - ALL PLANS SIHO - ALL PLANS 103.5 90 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51319785_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.63 60.55 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51319785_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 UMR - ALL PLANS UMR - ALL PLANS 80.5 70 999999999 69.63 111.55 percent of total billed charges "T cells count, total" 51319785_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.63 111.55 "T cells count, total" 51319785_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.63 111.55 "T cells count, total" 51319785_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.63 111.55 "T cells count, total" 51319785_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 ANTHEM HMO ANTHEM HMO 999999999 69.63 111.55 "T cells count, total" 51319785_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.63 111.55 "T cells count, total" 51319785_1 CDM 0312 RC 86359 HCPCS inpatient 115 74.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.74 67.6 999999999 69.63 111.55 percent of total billed charges Removal of cyst or growth of toe bone 51319991_1 CDM 0510 RC 28108 HCPCS inpatient 5078 3300.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 3300.7 65 999999999 3074.73 4925.66 percent of total billed charges Removal of cyst or growth of toe bone 51319991_1 CDM 0510 RC 28108 HCPCS inpatient 5078 3300.7 AETNA AETNA 4011.62 79 999999999 3074.73 4925.66 percent of total billed charges Removal of cyst or growth of toe bone 51319991_1 CDM 0510 RC 28108 HCPCS inpatient 5078 3300.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4925.66 97 999999999 3074.73 4925.66 percent of total billed charges Removal of cyst or growth of toe bone 51319991_1 CDM 0510 RC 28108 HCPCS inpatient 5078 3300.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 3503.82 69 999999999 3074.73 4925.66 percent of total billed charges Removal of cyst or growth of toe bone 51319991_1 CDM 0510 RC 28108 HCPCS inpatient 5078 3300.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 3960.84 78 999999999 3074.73 4925.66 percent of total billed charges Removal of cyst or growth of toe bone 51319991_1 CDM 0510 RC 28108 HCPCS inpatient 5078 3300.7 SIHO - ALL PLANS SIHO - ALL PLANS 4570.2 90 999999999 3074.73 4925.66 percent of total billed charges Removal of cyst or growth of toe bone 51319991_1 CDM 0510 RC 28108 HCPCS inpatient 5078 3300.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3074.73 60.55 999999999 3074.73 4925.66 percent of total billed charges Removal of cyst or growth of toe bone 51319991_1 CDM 0510 RC 28108 HCPCS inpatient 5078 3300.7 UMR - ALL PLANS UMR - ALL PLANS 3554.6 70 999999999 3074.73 4925.66 percent of total billed charges Removal of cyst or growth of toe bone 51319991_1 CDM 0510 RC 28108 HCPCS inpatient 5078 3300.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3074.73 4925.66 Removal of cyst or growth of toe bone 51319991_1 CDM 0510 RC 28108 HCPCS inpatient 5078 3300.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3074.73 4925.66 Removal of cyst or growth of toe bone 51319991_1 CDM 0510 RC 28108 HCPCS inpatient 5078 3300.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3074.73 4925.66 Removal of cyst or growth of toe bone 51319991_1 CDM 0510 RC 28108 HCPCS inpatient 5078 3300.7 ANTHEM HMO ANTHEM HMO 999999999 3074.73 4925.66 Removal of cyst or growth of toe bone 51319991_1 CDM 0510 RC 28108 HCPCS inpatient 5078 3300.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 3074.73 4925.66 Removal of cyst or growth of toe bone 51319991_1 CDM 0510 RC 28108 HCPCS inpatient 5078 3300.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 3432.73 67.6 999999999 3074.73 4925.66 percent of total billed charges Partial removal of infected foot or heel bone 51319992_1 CDM 0510 RC 28120 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Partial removal of infected foot or heel bone 51319992_1 CDM 0510 RC 28120 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Partial removal of infected foot or heel bone 51319992_1 CDM 0510 RC 28120 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Partial removal of infected foot or heel bone 51319992_1 CDM 0510 RC 28120 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Partial removal of infected foot or heel bone 51319992_1 CDM 0510 RC 28120 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Partial removal of infected foot or heel bone 51319992_1 CDM 0510 RC 28120 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Partial removal of infected foot or heel bone 51319992_1 CDM 0510 RC 28120 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Partial removal of infected foot or heel bone 51319992_1 CDM 0510 RC 28120 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Partial removal of infected foot or heel bone 51319992_1 CDM 0510 RC 28120 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Partial removal of infected foot or heel bone 51319992_1 CDM 0510 RC 28120 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Partial removal of infected foot or heel bone 51319992_1 CDM 0510 RC 28120 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Partial removal of infected foot or heel bone 51319992_1 CDM 0510 RC 28120 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Partial removal of infected foot or heel bone 51319992_1 CDM 0510 RC 28120 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Partial removal of infected foot or heel bone 51319992_1 CDM 0510 RC 28120 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Removal of bunion at fifth toe joint 51319993_1 CDM 0510 RC 28110 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Removal of bunion at fifth toe joint 51319993_1 CDM 0510 RC 28110 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Removal of bunion at fifth toe joint 51319993_1 CDM 0510 RC 28110 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Removal of bunion at fifth toe joint 51319993_1 CDM 0510 RC 28110 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Removal of bunion at fifth toe joint 51319993_1 CDM 0510 RC 28110 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Removal of bunion at fifth toe joint 51319993_1 CDM 0510 RC 28110 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Removal of bunion at fifth toe joint 51319993_1 CDM 0510 RC 28110 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Removal of bunion at fifth toe joint 51319993_1 CDM 0510 RC 28110 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Removal of bunion at fifth toe joint 51319993_1 CDM 0510 RC 28110 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Removal of bunion at fifth toe joint 51319993_1 CDM 0510 RC 28110 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Removal of bunion at fifth toe joint 51319993_1 CDM 0510 RC 28110 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Removal of bunion at fifth toe joint 51319993_1 CDM 0510 RC 28110 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Removal of bunion at fifth toe joint 51319993_1 CDM 0510 RC 28110 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Removal of bunion at fifth toe joint 51319993_1 CDM 0510 RC 28110 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Correction of toe joint deformity 51319995_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Correction of toe joint deformity 51319995_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Correction of toe joint deformity 51319995_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Correction of toe joint deformity 51319995_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Correction of toe joint deformity 51319995_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Correction of toe joint deformity 51319995_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Correction of toe joint deformity 51319995_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Correction of toe joint deformity 51319995_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Correction of toe joint deformity 51319995_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Correction of toe joint deformity 51319995_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Correction of toe joint deformity 51319995_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Correction of toe joint deformity 51319995_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Correction of toe joint deformity 51319995_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Correction of toe joint deformity 51319995_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Incision or partial removal of foot bone (other than big toe) to straighten toe 51323847_1 CDM 0510 RC 28308 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Incision or partial removal of foot bone (other than big toe) to straighten toe 51323847_1 CDM 0510 RC 28308 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Incision or partial removal of foot bone (other than big toe) to straighten toe 51323847_1 CDM 0510 RC 28308 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Incision or partial removal of foot bone (other than big toe) to straighten toe 51323847_1 CDM 0510 RC 28308 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Incision or partial removal of foot bone (other than big toe) to straighten toe 51323847_1 CDM 0510 RC 28308 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Incision or partial removal of foot bone (other than big toe) to straighten toe 51323847_1 CDM 0510 RC 28308 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Incision or partial removal of foot bone (other than big toe) to straighten toe 51323847_1 CDM 0510 RC 28308 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Incision or partial removal of foot bone (other than big toe) to straighten toe 51323847_1 CDM 0510 RC 28308 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Incision or partial removal of foot bone (other than big toe) to straighten toe 51323847_1 CDM 0510 RC 28308 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Incision or partial removal of foot bone (other than big toe) to straighten toe 51323847_1 CDM 0510 RC 28308 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Incision or partial removal of foot bone (other than big toe) to straighten toe 51323847_1 CDM 0510 RC 28308 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Incision or partial removal of foot bone (other than big toe) to straighten toe 51323847_1 CDM 0510 RC 28308 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Incision or partial removal of foot bone (other than big toe) to straighten toe 51323847_1 CDM 0510 RC 28308 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Incision or partial removal of foot bone (other than big toe) to straighten toe 51323847_1 CDM 0510 RC 28308 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Fusion of 3 bones of ankle 51323848_1 CDM 0510 RC 28715 HCPCS inpatient 43291 28139.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 28139.15 65 999999999 26212.7 41992.27 percent of total billed charges Fusion of 3 bones of ankle 51323848_1 CDM 0510 RC 28715 HCPCS inpatient 43291 28139.15 AETNA AETNA 34199.89 79 999999999 26212.7 41992.27 percent of total billed charges Fusion of 3 bones of ankle 51323848_1 CDM 0510 RC 28715 HCPCS inpatient 43291 28139.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 41992.27 97 999999999 26212.7 41992.27 percent of total billed charges Fusion of 3 bones of ankle 51323848_1 CDM 0510 RC 28715 HCPCS inpatient 43291 28139.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 29870.79 69 999999999 26212.7 41992.27 percent of total billed charges Fusion of 3 bones of ankle 51323848_1 CDM 0510 RC 28715 HCPCS inpatient 43291 28139.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 33766.98 78 999999999 26212.7 41992.27 percent of total billed charges Fusion of 3 bones of ankle 51323848_1 CDM 0510 RC 28715 HCPCS inpatient 43291 28139.15 SIHO - ALL PLANS SIHO - ALL PLANS 38961.9 90 999999999 26212.7 41992.27 percent of total billed charges Fusion of 3 bones of ankle 51323848_1 CDM 0510 RC 28715 HCPCS inpatient 43291 28139.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26212.7 60.55 999999999 26212.7 41992.27 percent of total billed charges Fusion of 3 bones of ankle 51323848_1 CDM 0510 RC 28715 HCPCS inpatient 43291 28139.15 UMR - ALL PLANS UMR - ALL PLANS 30303.7 70 999999999 26212.7 41992.27 percent of total billed charges Fusion of 3 bones of ankle 51323848_1 CDM 0510 RC 28715 HCPCS inpatient 43291 28139.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 26212.7 41992.27 Fusion of 3 bones of ankle 51323848_1 CDM 0510 RC 28715 HCPCS inpatient 43291 28139.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 26212.7 41992.27 Fusion of 3 bones of ankle 51323848_1 CDM 0510 RC 28715 HCPCS inpatient 43291 28139.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 26212.7 41992.27 Fusion of 3 bones of ankle 51323848_1 CDM 0510 RC 28715 HCPCS inpatient 43291 28139.15 ANTHEM HMO ANTHEM HMO 999999999 26212.7 41992.27 Fusion of 3 bones of ankle 51323848_1 CDM 0510 RC 28715 HCPCS inpatient 43291 28139.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 26212.7 41992.27 Fusion of 3 bones of ankle 51323848_1 CDM 0510 RC 28715 HCPCS inpatient 43291 28139.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 29264.72 67.6 999999999 26212.7 41992.27 percent of total billed charges Fusion of foot in midfoot region 51323849_1 CDM 0510 RC 28740 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Fusion of foot in midfoot region 51323849_1 CDM 0510 RC 28740 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Fusion of foot in midfoot region 51323849_1 CDM 0510 RC 28740 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Fusion of foot in midfoot region 51323849_1 CDM 0510 RC 28740 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Fusion of foot in midfoot region 51323849_1 CDM 0510 RC 28740 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Fusion of foot in midfoot region 51323849_1 CDM 0510 RC 28740 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Fusion of foot in midfoot region 51323849_1 CDM 0510 RC 28740 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Fusion of foot in midfoot region 51323849_1 CDM 0510 RC 28740 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Fusion of foot in midfoot region 51323849_1 CDM 0510 RC 28740 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Fusion of foot in midfoot region 51323849_1 CDM 0510 RC 28740 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Fusion of foot in midfoot region 51323849_1 CDM 0510 RC 28740 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Fusion of foot in midfoot region 51323849_1 CDM 0510 RC 28740 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Fusion of foot in midfoot region 51323849_1 CDM 0510 RC 28740 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Fusion of foot in midfoot region 51323849_1 CDM 0510 RC 28740 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Complicated removal of foreign body in foot 51323873_1 CDM 0510 RC 28193 HCPCS inpatient 5308 3450.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 3450.2 65 999999999 3213.99 5148.76 percent of total billed charges Complicated removal of foreign body in foot 51323873_1 CDM 0510 RC 28193 HCPCS inpatient 5308 3450.2 AETNA AETNA 4193.32 79 999999999 3213.99 5148.76 percent of total billed charges Complicated removal of foreign body in foot 51323873_1 CDM 0510 RC 28193 HCPCS inpatient 5308 3450.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5148.76 97 999999999 3213.99 5148.76 percent of total billed charges Complicated removal of foreign body in foot 51323873_1 CDM 0510 RC 28193 HCPCS inpatient 5308 3450.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 3662.52 69 999999999 3213.99 5148.76 percent of total billed charges Complicated removal of foreign body in foot 51323873_1 CDM 0510 RC 28193 HCPCS inpatient 5308 3450.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 4140.24 78 999999999 3213.99 5148.76 percent of total billed charges Complicated removal of foreign body in foot 51323873_1 CDM 0510 RC 28193 HCPCS inpatient 5308 3450.2 SIHO - ALL PLANS SIHO - ALL PLANS 4777.2 90 999999999 3213.99 5148.76 percent of total billed charges Complicated removal of foreign body in foot 51323873_1 CDM 0510 RC 28193 HCPCS inpatient 5308 3450.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3213.99 60.55 999999999 3213.99 5148.76 percent of total billed charges Complicated removal of foreign body in foot 51323873_1 CDM 0510 RC 28193 HCPCS inpatient 5308 3450.2 UMR - ALL PLANS UMR - ALL PLANS 3715.6 70 999999999 3213.99 5148.76 percent of total billed charges Complicated removal of foreign body in foot 51323873_1 CDM 0510 RC 28193 HCPCS inpatient 5308 3450.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3213.99 5148.76 Complicated removal of foreign body in foot 51323873_1 CDM 0510 RC 28193 HCPCS inpatient 5308 3450.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3213.99 5148.76 Complicated removal of foreign body in foot 51323873_1 CDM 0510 RC 28193 HCPCS inpatient 5308 3450.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3213.99 5148.76 Complicated removal of foreign body in foot 51323873_1 CDM 0510 RC 28193 HCPCS inpatient 5308 3450.2 ANTHEM HMO ANTHEM HMO 999999999 3213.99 5148.76 Complicated removal of foreign body in foot 51323873_1 CDM 0510 RC 28193 HCPCS inpatient 5308 3450.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 3213.99 5148.76 Complicated removal of foreign body in foot 51323873_1 CDM 0510 RC 28193 HCPCS inpatient 5308 3450.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 3588.21 67.6 999999999 3213.99 5148.76 percent of total billed charges Amputation of toe and midfoot bone 51323901_1 CDM 0510 RC 28810 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Amputation of toe and midfoot bone 51323901_1 CDM 0510 RC 28810 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Amputation of toe and midfoot bone 51323901_1 CDM 0510 RC 28810 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Amputation of toe and midfoot bone 51323901_1 CDM 0510 RC 28810 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Amputation of toe and midfoot bone 51323901_1 CDM 0510 RC 28810 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Amputation of toe and midfoot bone 51323901_1 CDM 0510 RC 28810 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Amputation of toe and midfoot bone 51323901_1 CDM 0510 RC 28810 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Amputation of toe and midfoot bone 51323901_1 CDM 0510 RC 28810 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Amputation of toe and midfoot bone 51323901_1 CDM 0510 RC 28810 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Amputation of toe and midfoot bone 51323901_1 CDM 0510 RC 28810 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Amputation of toe and midfoot bone 51323901_1 CDM 0510 RC 28810 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Amputation of toe and midfoot bone 51323901_1 CDM 0510 RC 28810 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Amputation of toe and midfoot bone 51323901_1 CDM 0510 RC 28810 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Amputation of toe and midfoot bone 51323901_1 CDM 0510 RC 28810 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Total cell count for natural killer cells (white blood cell) 51323943_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges Total cell count for natural killer cells (white blood cell) 51323943_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges Total cell count for natural killer cells (white blood cell) 51323943_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges Total cell count for natural killer cells (white blood cell) 51323943_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges Total cell count for natural killer cells (white blood cell) 51323943_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges Total cell count for natural killer cells (white blood cell) 51323943_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges Total cell count for natural killer cells (white blood cell) 51323943_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges Total cell count for natural killer cells (white blood cell) 51323943_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges Total cell count for natural killer cells (white blood cell) 51323943_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 Total cell count for natural killer cells (white blood cell) 51323943_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 Total cell count for natural killer cells (white blood cell) 51323943_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 Total cell count for natural killer cells (white blood cell) 51323943_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 Total cell count for natural killer cells (white blood cell) 51323943_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 Total cell count for natural killer cells (white blood cell) 51323943_1 CDM 0312 RC 86357 HCPCS inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges Analysis of cell function and analysis for genetic marker 51323950_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 234.65 65 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 51323950_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 AETNA AETNA 285.19 79 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 51323950_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 350.17 97 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 51323950_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 249.09 69 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 51323950_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 281.58 78 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 51323950_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 SIHO - ALL PLANS SIHO - ALL PLANS 324.9 90 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 51323950_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 218.59 60.55 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 51323950_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 UMR - ALL PLANS UMR - ALL PLANS 252.7 70 999999999 218.59 350.17 percent of total billed charges Analysis of cell function and analysis for genetic marker 51323950_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 218.59 350.17 Analysis of cell function and analysis for genetic marker 51323950_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 218.59 350.17 Analysis of cell function and analysis for genetic marker 51323950_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 218.59 350.17 Analysis of cell function and analysis for genetic marker 51323950_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 ANTHEM HMO ANTHEM HMO 999999999 218.59 350.17 Analysis of cell function and analysis for genetic marker 51323950_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 218.59 350.17 Analysis of cell function and analysis for genetic marker 51323950_1 CDM 0301 RC 86352 HCPCS inpatient 361 234.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 244.04 67.6 999999999 218.59 350.17 percent of total billed charges "Removal of foreign body of foot tissue, deep" 51326977_1 CDM 0510 RC 28192 HCPCS inpatient 5308 3450.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 3450.2 65 999999999 3213.99 5148.76 percent of total billed charges "Removal of foreign body of foot tissue, deep" 51326977_1 CDM 0510 RC 28192 HCPCS inpatient 5308 3450.2 AETNA AETNA 4193.32 79 999999999 3213.99 5148.76 percent of total billed charges "Removal of foreign body of foot tissue, deep" 51326977_1 CDM 0510 RC 28192 HCPCS inpatient 5308 3450.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5148.76 97 999999999 3213.99 5148.76 percent of total billed charges "Removal of foreign body of foot tissue, deep" 51326977_1 CDM 0510 RC 28192 HCPCS inpatient 5308 3450.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 3662.52 69 999999999 3213.99 5148.76 percent of total billed charges "Removal of foreign body of foot tissue, deep" 51326977_1 CDM 0510 RC 28192 HCPCS inpatient 5308 3450.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 4140.24 78 999999999 3213.99 5148.76 percent of total billed charges "Removal of foreign body of foot tissue, deep" 51326977_1 CDM 0510 RC 28192 HCPCS inpatient 5308 3450.2 SIHO - ALL PLANS SIHO - ALL PLANS 4777.2 90 999999999 3213.99 5148.76 percent of total billed charges "Removal of foreign body of foot tissue, deep" 51326977_1 CDM 0510 RC 28192 HCPCS inpatient 5308 3450.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3213.99 60.55 999999999 3213.99 5148.76 percent of total billed charges "Removal of foreign body of foot tissue, deep" 51326977_1 CDM 0510 RC 28192 HCPCS inpatient 5308 3450.2 UMR - ALL PLANS UMR - ALL PLANS 3715.6 70 999999999 3213.99 5148.76 percent of total billed charges "Removal of foreign body of foot tissue, deep" 51326977_1 CDM 0510 RC 28192 HCPCS inpatient 5308 3450.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3213.99 5148.76 "Removal of foreign body of foot tissue, deep" 51326977_1 CDM 0510 RC 28192 HCPCS inpatient 5308 3450.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3213.99 5148.76 "Removal of foreign body of foot tissue, deep" 51326977_1 CDM 0510 RC 28192 HCPCS inpatient 5308 3450.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3213.99 5148.76 "Removal of foreign body of foot tissue, deep" 51326977_1 CDM 0510 RC 28192 HCPCS inpatient 5308 3450.2 ANTHEM HMO ANTHEM HMO 999999999 3213.99 5148.76 "Removal of foreign body of foot tissue, deep" 51326977_1 CDM 0510 RC 28192 HCPCS inpatient 5308 3450.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 3213.99 5148.76 "Removal of foreign body of foot tissue, deep" 51326977_1 CDM 0510 RC 28192 HCPCS inpatient 5308 3450.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 3588.21 67.6 999999999 3213.99 5148.76 percent of total billed charges "Removal of toe bone at second, third, or fourth joints" 51326980_1 CDM 0510 RC 28112 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges "Removal of toe bone at second, third, or fourth joints" 51326980_1 CDM 0510 RC 28112 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges "Removal of toe bone at second, third, or fourth joints" 51326980_1 CDM 0510 RC 28112 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges "Removal of toe bone at second, third, or fourth joints" 51326980_1 CDM 0510 RC 28112 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges "Removal of toe bone at second, third, or fourth joints" 51326980_1 CDM 0510 RC 28112 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges "Removal of toe bone at second, third, or fourth joints" 51326980_1 CDM 0510 RC 28112 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges "Removal of toe bone at second, third, or fourth joints" 51326980_1 CDM 0510 RC 28112 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges "Removal of toe bone at second, third, or fourth joints" 51326980_1 CDM 0510 RC 28112 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges "Removal of toe bone at second, third, or fourth joints" 51326980_1 CDM 0510 RC 28112 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 "Removal of toe bone at second, third, or fourth joints" 51326980_1 CDM 0510 RC 28112 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 "Removal of toe bone at second, third, or fourth joints" 51326980_1 CDM 0510 RC 28112 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 "Removal of toe bone at second, third, or fourth joints" 51326980_1 CDM 0510 RC 28112 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 "Removal of toe bone at second, third, or fourth joints" 51326980_1 CDM 0510 RC 28112 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 "Removal of toe bone at second, third, or fourth joints" 51326980_1 CDM 0510 RC 28112 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Release of hand or foot nerve 51326981_1 CDM 0510 RC 64704 HCPCS inpatient 6363 4135.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 4135.95 65 999999999 3852.8 6172.11 percent of total billed charges Release of hand or foot nerve 51326981_1 CDM 0510 RC 64704 HCPCS inpatient 6363 4135.95 AETNA AETNA 5026.77 79 999999999 3852.8 6172.11 percent of total billed charges Release of hand or foot nerve 51326981_1 CDM 0510 RC 64704 HCPCS inpatient 6363 4135.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6172.11 97 999999999 3852.8 6172.11 percent of total billed charges Release of hand or foot nerve 51326981_1 CDM 0510 RC 64704 HCPCS inpatient 6363 4135.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 4390.47 69 999999999 3852.8 6172.11 percent of total billed charges Release of hand or foot nerve 51326981_1 CDM 0510 RC 64704 HCPCS inpatient 6363 4135.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 4963.14 78 999999999 3852.8 6172.11 percent of total billed charges Release of hand or foot nerve 51326981_1 CDM 0510 RC 64704 HCPCS inpatient 6363 4135.95 SIHO - ALL PLANS SIHO - ALL PLANS 5726.7 90 999999999 3852.8 6172.11 percent of total billed charges Release of hand or foot nerve 51326981_1 CDM 0510 RC 64704 HCPCS inpatient 6363 4135.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3852.8 60.55 999999999 3852.8 6172.11 percent of total billed charges Release of hand or foot nerve 51326981_1 CDM 0510 RC 64704 HCPCS inpatient 6363 4135.95 UMR - ALL PLANS UMR - ALL PLANS 4454.1 70 999999999 3852.8 6172.11 percent of total billed charges Release of hand or foot nerve 51326981_1 CDM 0510 RC 64704 HCPCS inpatient 6363 4135.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3852.8 6172.11 Release of hand or foot nerve 51326981_1 CDM 0510 RC 64704 HCPCS inpatient 6363 4135.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3852.8 6172.11 Release of hand or foot nerve 51326981_1 CDM 0510 RC 64704 HCPCS inpatient 6363 4135.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3852.8 6172.11 Release of hand or foot nerve 51326981_1 CDM 0510 RC 64704 HCPCS inpatient 6363 4135.95 ANTHEM HMO ANTHEM HMO 999999999 3852.8 6172.11 Release of hand or foot nerve 51326981_1 CDM 0510 RC 64704 HCPCS inpatient 6363 4135.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 3852.8 6172.11 Release of hand or foot nerve 51326981_1 CDM 0510 RC 64704 HCPCS inpatient 6363 4135.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 4301.39 67.6 999999999 3852.8 6172.11 percent of total billed charges Amputation of toe at toe joint 51327005_1 CDM 0510 RC 28825 HCPCS inpatient 10537.26 6849.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.22 65 999999999 6380.31 10221.14 percent of total billed charges Amputation of toe at toe joint 51327005_1 CDM 0510 RC 28825 HCPCS inpatient 10537.26 6849.22 AETNA AETNA 8324.44 79 999999999 6380.31 10221.14 percent of total billed charges Amputation of toe at toe joint 51327005_1 CDM 0510 RC 28825 HCPCS inpatient 10537.26 6849.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10221.14 97 999999999 6380.31 10221.14 percent of total billed charges Amputation of toe at toe joint 51327005_1 CDM 0510 RC 28825 HCPCS inpatient 10537.26 6849.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.71 69 999999999 6380.31 10221.14 percent of total billed charges Amputation of toe at toe joint 51327005_1 CDM 0510 RC 28825 HCPCS inpatient 10537.26 6849.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 8219.06 78 999999999 6380.31 10221.14 percent of total billed charges Amputation of toe at toe joint 51327005_1 CDM 0510 RC 28825 HCPCS inpatient 10537.26 6849.22 SIHO - ALL PLANS SIHO - ALL PLANS 9483.53 90 999999999 6380.31 10221.14 percent of total billed charges Amputation of toe at toe joint 51327005_1 CDM 0510 RC 28825 HCPCS inpatient 10537.26 6849.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.31 60.55 999999999 6380.31 10221.14 percent of total billed charges Amputation of toe at toe joint 51327005_1 CDM 0510 RC 28825 HCPCS inpatient 10537.26 6849.22 UMR - ALL PLANS UMR - ALL PLANS 7376.08 70 999999999 6380.31 10221.14 percent of total billed charges Amputation of toe at toe joint 51327005_1 CDM 0510 RC 28825 HCPCS inpatient 10537.26 6849.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.31 10221.14 Amputation of toe at toe joint 51327005_1 CDM 0510 RC 28825 HCPCS inpatient 10537.26 6849.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.31 10221.14 Amputation of toe at toe joint 51327005_1 CDM 0510 RC 28825 HCPCS inpatient 10537.26 6849.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.31 10221.14 Amputation of toe at toe joint 51327005_1 CDM 0510 RC 28825 HCPCS inpatient 10537.26 6849.22 ANTHEM HMO ANTHEM HMO 999999999 6380.31 10221.14 Amputation of toe at toe joint 51327005_1 CDM 0510 RC 28825 HCPCS inpatient 10537.26 6849.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.31 10221.14 Amputation of toe at toe joint 51327005_1 CDM 0510 RC 28825 HCPCS inpatient 10537.26 6849.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.19 67.6 999999999 6380.31 10221.14 percent of total billed charges Amputation of toe at joint between forefoot and toes 51327006_1 CDM 0510 RC 28820 HCPCS inpatient 10537.26 6849.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.22 65 999999999 6380.31 10221.14 percent of total billed charges Amputation of toe at joint between forefoot and toes 51327006_1 CDM 0510 RC 28820 HCPCS inpatient 10537.26 6849.22 AETNA AETNA 8324.44 79 999999999 6380.31 10221.14 percent of total billed charges Amputation of toe at joint between forefoot and toes 51327006_1 CDM 0510 RC 28820 HCPCS inpatient 10537.26 6849.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10221.14 97 999999999 6380.31 10221.14 percent of total billed charges Amputation of toe at joint between forefoot and toes 51327006_1 CDM 0510 RC 28820 HCPCS inpatient 10537.26 6849.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.71 69 999999999 6380.31 10221.14 percent of total billed charges Amputation of toe at joint between forefoot and toes 51327006_1 CDM 0510 RC 28820 HCPCS inpatient 10537.26 6849.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 8219.06 78 999999999 6380.31 10221.14 percent of total billed charges Amputation of toe at joint between forefoot and toes 51327006_1 CDM 0510 RC 28820 HCPCS inpatient 10537.26 6849.22 SIHO - ALL PLANS SIHO - ALL PLANS 9483.53 90 999999999 6380.31 10221.14 percent of total billed charges Amputation of toe at joint between forefoot and toes 51327006_1 CDM 0510 RC 28820 HCPCS inpatient 10537.26 6849.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.31 60.55 999999999 6380.31 10221.14 percent of total billed charges Amputation of toe at joint between forefoot and toes 51327006_1 CDM 0510 RC 28820 HCPCS inpatient 10537.26 6849.22 UMR - ALL PLANS UMR - ALL PLANS 7376.08 70 999999999 6380.31 10221.14 percent of total billed charges Amputation of toe at joint between forefoot and toes 51327006_1 CDM 0510 RC 28820 HCPCS inpatient 10537.26 6849.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.31 10221.14 Amputation of toe at joint between forefoot and toes 51327006_1 CDM 0510 RC 28820 HCPCS inpatient 10537.26 6849.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.31 10221.14 Amputation of toe at joint between forefoot and toes 51327006_1 CDM 0510 RC 28820 HCPCS inpatient 10537.26 6849.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.31 10221.14 Amputation of toe at joint between forefoot and toes 51327006_1 CDM 0510 RC 28820 HCPCS inpatient 10537.26 6849.22 ANTHEM HMO ANTHEM HMO 999999999 6380.31 10221.14 Amputation of toe at joint between forefoot and toes 51327006_1 CDM 0510 RC 28820 HCPCS inpatient 10537.26 6849.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.31 10221.14 Amputation of toe at joint between forefoot and toes 51327006_1 CDM 0510 RC 28820 HCPCS inpatient 10537.26 6849.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.19 67.6 999999999 6380.31 10221.14 percent of total billed charges Removal of cyst or growth of foot bone with bone graft 51328991_1 CDM 0510 RC 28107 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of foot bone with bone graft 51328991_1 CDM 0510 RC 28107 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of foot bone with bone graft 51328991_1 CDM 0510 RC 28107 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of foot bone with bone graft 51328991_1 CDM 0510 RC 28107 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of foot bone with bone graft 51328991_1 CDM 0510 RC 28107 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of foot bone with bone graft 51328991_1 CDM 0510 RC 28107 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of foot bone with bone graft 51328991_1 CDM 0510 RC 28107 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of foot bone with bone graft 51328991_1 CDM 0510 RC 28107 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of foot bone with bone graft 51328991_1 CDM 0510 RC 28107 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Removal of cyst or growth of foot bone with bone graft 51328991_1 CDM 0510 RC 28107 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Removal of cyst or growth of foot bone with bone graft 51328991_1 CDM 0510 RC 28107 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Removal of cyst or growth of foot bone with bone graft 51328991_1 CDM 0510 RC 28107 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Removal of cyst or growth of foot bone with bone graft 51328991_1 CDM 0510 RC 28107 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Removal of cyst or growth of foot bone with bone graft 51328991_1 CDM 0510 RC 28107 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Removal of heel bone 51328992_1 CDM 0510 RC 28118 HCPCS inpatient 10537.26 6849.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.22 65 999999999 6380.31 10221.14 percent of total billed charges Removal of heel bone 51328992_1 CDM 0510 RC 28118 HCPCS inpatient 10537.26 6849.22 AETNA AETNA 8324.44 79 999999999 6380.31 10221.14 percent of total billed charges Removal of heel bone 51328992_1 CDM 0510 RC 28118 HCPCS inpatient 10537.26 6849.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10221.14 97 999999999 6380.31 10221.14 percent of total billed charges Removal of heel bone 51328992_1 CDM 0510 RC 28118 HCPCS inpatient 10537.26 6849.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.71 69 999999999 6380.31 10221.14 percent of total billed charges Removal of heel bone 51328992_1 CDM 0510 RC 28118 HCPCS inpatient 10537.26 6849.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 8219.06 78 999999999 6380.31 10221.14 percent of total billed charges Removal of heel bone 51328992_1 CDM 0510 RC 28118 HCPCS inpatient 10537.26 6849.22 SIHO - ALL PLANS SIHO - ALL PLANS 9483.53 90 999999999 6380.31 10221.14 percent of total billed charges Removal of heel bone 51328992_1 CDM 0510 RC 28118 HCPCS inpatient 10537.26 6849.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.31 60.55 999999999 6380.31 10221.14 percent of total billed charges Removal of heel bone 51328992_1 CDM 0510 RC 28118 HCPCS inpatient 10537.26 6849.22 UMR - ALL PLANS UMR - ALL PLANS 7376.08 70 999999999 6380.31 10221.14 percent of total billed charges Removal of heel bone 51328992_1 CDM 0510 RC 28118 HCPCS inpatient 10537.26 6849.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.31 10221.14 Removal of heel bone 51328992_1 CDM 0510 RC 28118 HCPCS inpatient 10537.26 6849.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.31 10221.14 Removal of heel bone 51328992_1 CDM 0510 RC 28118 HCPCS inpatient 10537.26 6849.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.31 10221.14 Removal of heel bone 51328992_1 CDM 0510 RC 28118 HCPCS inpatient 10537.26 6849.22 ANTHEM HMO ANTHEM HMO 999999999 6380.31 10221.14 Removal of heel bone 51328992_1 CDM 0510 RC 28118 HCPCS inpatient 10537.26 6849.22 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.31 10221.14 Removal of heel bone 51328992_1 CDM 0510 RC 28118 HCPCS inpatient 10537.26 6849.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.19 67.6 999999999 6380.31 10221.14 percent of total billed charges Partial removal of foot or heel bone 51328993_1 CDM 0510 RC 28122 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Partial removal of foot or heel bone 51328993_1 CDM 0510 RC 28122 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Partial removal of foot or heel bone 51328993_1 CDM 0510 RC 28122 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Partial removal of foot or heel bone 51328993_1 CDM 0510 RC 28122 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Partial removal of foot or heel bone 51328993_1 CDM 0510 RC 28122 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Partial removal of foot or heel bone 51328993_1 CDM 0510 RC 28122 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Partial removal of foot or heel bone 51328993_1 CDM 0510 RC 28122 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Partial removal of foot or heel bone 51328993_1 CDM 0510 RC 28122 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Partial removal of foot or heel bone 51328993_1 CDM 0510 RC 28122 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Partial removal of foot or heel bone 51328993_1 CDM 0510 RC 28122 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Partial removal of foot or heel bone 51328993_1 CDM 0510 RC 28122 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Partial removal of foot or heel bone 51328993_1 CDM 0510 RC 28122 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Partial removal of foot or heel bone 51328993_1 CDM 0510 RC 28122 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Partial removal of foot or heel bone 51328993_1 CDM 0510 RC 28122 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Partial removal of toe bone 51328997_1 CDM 0510 RC 28124 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Partial removal of toe bone 51328997_1 CDM 0510 RC 28124 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Partial removal of toe bone 51328997_1 CDM 0510 RC 28124 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Partial removal of toe bone 51328997_1 CDM 0510 RC 28124 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Partial removal of toe bone 51328997_1 CDM 0510 RC 28124 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Partial removal of toe bone 51328997_1 CDM 0510 RC 28124 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Partial removal of toe bone 51328997_1 CDM 0510 RC 28124 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Partial removal of toe bone 51328997_1 CDM 0510 RC 28124 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Partial removal of toe bone 51328997_1 CDM 0510 RC 28124 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Partial removal of toe bone 51328997_1 CDM 0510 RC 28124 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Partial removal of toe bone 51328997_1 CDM 0510 RC 28124 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Partial removal of toe bone 51328997_1 CDM 0510 RC 28124 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Partial removal of toe bone 51328997_1 CDM 0510 RC 28124 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Partial removal of toe bone 51328997_1 CDM 0510 RC 28124 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Removal of toe 51328998_1 CDM 0510 RC 28150 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Removal of toe 51328998_1 CDM 0510 RC 28150 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Removal of toe 51328998_1 CDM 0510 RC 28150 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Removal of toe 51328998_1 CDM 0510 RC 28150 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Removal of toe 51328998_1 CDM 0510 RC 28150 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Removal of toe 51328998_1 CDM 0510 RC 28150 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Removal of toe 51328998_1 CDM 0510 RC 28150 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Removal of toe 51328998_1 CDM 0510 RC 28150 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Removal of toe 51328998_1 CDM 0510 RC 28150 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Removal of toe 51328998_1 CDM 0510 RC 28150 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Removal of toe 51328998_1 CDM 0510 RC 28150 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Removal of toe 51328998_1 CDM 0510 RC 28150 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Removal of toe 51328998_1 CDM 0510 RC 28150 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Removal of toe 51328998_1 CDM 0510 RC 28150 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Removal of growth of peripheral nerve 51329607_1 CDM 0510 RC 64784 HCPCS inpatient 6363 4135.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 4135.95 65 999999999 3852.8 6172.11 percent of total billed charges Removal of growth of peripheral nerve 51329607_1 CDM 0510 RC 64784 HCPCS inpatient 6363 4135.95 AETNA AETNA 5026.77 79 999999999 3852.8 6172.11 percent of total billed charges Removal of growth of peripheral nerve 51329607_1 CDM 0510 RC 64784 HCPCS inpatient 6363 4135.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6172.11 97 999999999 3852.8 6172.11 percent of total billed charges Removal of growth of peripheral nerve 51329607_1 CDM 0510 RC 64784 HCPCS inpatient 6363 4135.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 4390.47 69 999999999 3852.8 6172.11 percent of total billed charges Removal of growth of peripheral nerve 51329607_1 CDM 0510 RC 64784 HCPCS inpatient 6363 4135.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 4963.14 78 999999999 3852.8 6172.11 percent of total billed charges Removal of growth of peripheral nerve 51329607_1 CDM 0510 RC 64784 HCPCS inpatient 6363 4135.95 SIHO - ALL PLANS SIHO - ALL PLANS 5726.7 90 999999999 3852.8 6172.11 percent of total billed charges Removal of growth of peripheral nerve 51329607_1 CDM 0510 RC 64784 HCPCS inpatient 6363 4135.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3852.8 60.55 999999999 3852.8 6172.11 percent of total billed charges Removal of growth of peripheral nerve 51329607_1 CDM 0510 RC 64784 HCPCS inpatient 6363 4135.95 UMR - ALL PLANS UMR - ALL PLANS 4454.1 70 999999999 3852.8 6172.11 percent of total billed charges Removal of growth of peripheral nerve 51329607_1 CDM 0510 RC 64784 HCPCS inpatient 6363 4135.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3852.8 6172.11 Removal of growth of peripheral nerve 51329607_1 CDM 0510 RC 64784 HCPCS inpatient 6363 4135.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3852.8 6172.11 Removal of growth of peripheral nerve 51329607_1 CDM 0510 RC 64784 HCPCS inpatient 6363 4135.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3852.8 6172.11 Removal of growth of peripheral nerve 51329607_1 CDM 0510 RC 64784 HCPCS inpatient 6363 4135.95 ANTHEM HMO ANTHEM HMO 999999999 3852.8 6172.11 Removal of growth of peripheral nerve 51329607_1 CDM 0510 RC 64784 HCPCS inpatient 6363 4135.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 3852.8 6172.11 Removal of growth of peripheral nerve 51329607_1 CDM 0510 RC 64784 HCPCS inpatient 6363 4135.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 4301.39 67.6 999999999 3852.8 6172.11 percent of total billed charges Incision to release foot tendon 51329610_1 CDM 0510 RC 28234 HCPCS inpatient 5078 3300.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 3300.7 65 999999999 3074.73 4925.66 percent of total billed charges Incision to release foot tendon 51329610_1 CDM 0510 RC 28234 HCPCS inpatient 5078 3300.7 AETNA AETNA 4011.62 79 999999999 3074.73 4925.66 percent of total billed charges Incision to release foot tendon 51329610_1 CDM 0510 RC 28234 HCPCS inpatient 5078 3300.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4925.66 97 999999999 3074.73 4925.66 percent of total billed charges Incision to release foot tendon 51329610_1 CDM 0510 RC 28234 HCPCS inpatient 5078 3300.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 3503.82 69 999999999 3074.73 4925.66 percent of total billed charges Incision to release foot tendon 51329610_1 CDM 0510 RC 28234 HCPCS inpatient 5078 3300.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 3960.84 78 999999999 3074.73 4925.66 percent of total billed charges Incision to release foot tendon 51329610_1 CDM 0510 RC 28234 HCPCS inpatient 5078 3300.7 SIHO - ALL PLANS SIHO - ALL PLANS 4570.2 90 999999999 3074.73 4925.66 percent of total billed charges Incision to release foot tendon 51329610_1 CDM 0510 RC 28234 HCPCS inpatient 5078 3300.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3074.73 60.55 999999999 3074.73 4925.66 percent of total billed charges Incision to release foot tendon 51329610_1 CDM 0510 RC 28234 HCPCS inpatient 5078 3300.7 UMR - ALL PLANS UMR - ALL PLANS 3554.6 70 999999999 3074.73 4925.66 percent of total billed charges Incision to release foot tendon 51329610_1 CDM 0510 RC 28234 HCPCS inpatient 5078 3300.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3074.73 4925.66 Incision to release foot tendon 51329610_1 CDM 0510 RC 28234 HCPCS inpatient 5078 3300.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3074.73 4925.66 Incision to release foot tendon 51329610_1 CDM 0510 RC 28234 HCPCS inpatient 5078 3300.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3074.73 4925.66 Incision to release foot tendon 51329610_1 CDM 0510 RC 28234 HCPCS inpatient 5078 3300.7 ANTHEM HMO ANTHEM HMO 999999999 3074.73 4925.66 Incision to release foot tendon 51329610_1 CDM 0510 RC 28234 HCPCS inpatient 5078 3300.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 3074.73 4925.66 Incision to release foot tendon 51329610_1 CDM 0510 RC 28234 HCPCS inpatient 5078 3300.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 3432.73 67.6 999999999 3074.73 4925.66 percent of total billed charges Lengthening or shortening of tendon of leg or ankle 51329612_1 CDM 0510 RC 27685 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Lengthening or shortening of tendon of leg or ankle 51329612_1 CDM 0510 RC 27685 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Lengthening or shortening of tendon of leg or ankle 51329612_1 CDM 0510 RC 27685 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Lengthening or shortening of tendon of leg or ankle 51329612_1 CDM 0510 RC 27685 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Lengthening or shortening of tendon of leg or ankle 51329612_1 CDM 0510 RC 27685 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Lengthening or shortening of tendon of leg or ankle 51329612_1 CDM 0510 RC 27685 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Lengthening or shortening of tendon of leg or ankle 51329612_1 CDM 0510 RC 27685 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Lengthening or shortening of tendon of leg or ankle 51329612_1 CDM 0510 RC 27685 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Lengthening or shortening of tendon of leg or ankle 51329612_1 CDM 0510 RC 27685 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Lengthening or shortening of tendon of leg or ankle 51329612_1 CDM 0510 RC 27685 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Lengthening or shortening of tendon of leg or ankle 51329612_1 CDM 0510 RC 27685 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Lengthening or shortening of tendon of leg or ankle 51329612_1 CDM 0510 RC 27685 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Lengthening or shortening of tendon of leg or ankle 51329612_1 CDM 0510 RC 27685 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Lengthening or shortening of tendon of leg or ankle 51329612_1 CDM 0510 RC 27685 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Incision of connective tissue of foot and/or toe 51330174_1 CDM 0510 RC 28008 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Incision of connective tissue of foot and/or toe 51330174_1 CDM 0510 RC 28008 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Incision of connective tissue of foot and/or toe 51330174_1 CDM 0510 RC 28008 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Incision of connective tissue of foot and/or toe 51330174_1 CDM 0510 RC 28008 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Incision of connective tissue of foot and/or toe 51330174_1 CDM 0510 RC 28008 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Incision of connective tissue of foot and/or toe 51330174_1 CDM 0510 RC 28008 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Incision of connective tissue of foot and/or toe 51330174_1 CDM 0510 RC 28008 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Incision of connective tissue of foot and/or toe 51330174_1 CDM 0510 RC 28008 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Incision of connective tissue of foot and/or toe 51330174_1 CDM 0510 RC 28008 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Incision of connective tissue of foot and/or toe 51330174_1 CDM 0510 RC 28008 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Incision of connective tissue of foot and/or toe 51330174_1 CDM 0510 RC 28008 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Incision of connective tissue of foot and/or toe 51330174_1 CDM 0510 RC 28008 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Incision of connective tissue of foot and/or toe 51330174_1 CDM 0510 RC 28008 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Incision of connective tissue of foot and/or toe 51330174_1 CDM 0510 RC 28008 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Creation of webbing between toes 51330313_1 CDM 0510 RC 28280 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Creation of webbing between toes 51330313_1 CDM 0510 RC 28280 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Creation of webbing between toes 51330313_1 CDM 0510 RC 28280 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Creation of webbing between toes 51330313_1 CDM 0510 RC 28280 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Creation of webbing between toes 51330313_1 CDM 0510 RC 28280 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Creation of webbing between toes 51330313_1 CDM 0510 RC 28280 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Creation of webbing between toes 51330313_1 CDM 0510 RC 28280 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Creation of webbing between toes 51330313_1 CDM 0510 RC 28280 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Creation of webbing between toes 51330313_1 CDM 0510 RC 28280 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Creation of webbing between toes 51330313_1 CDM 0510 RC 28280 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Creation of webbing between toes 51330313_1 CDM 0510 RC 28280 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Creation of webbing between toes 51330313_1 CDM 0510 RC 28280 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Creation of webbing between toes 51330313_1 CDM 0510 RC 28280 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Creation of webbing between toes 51330313_1 CDM 0510 RC 28280 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of big toe 51330314_1 CDM 0510 RC 28298 HCPCS inpatient 23415.48 15220.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 15220.06 65 999999999 14178.07 22713.02 percent of total billed charges Correction of bunion with alignment correction of big toe 51330314_1 CDM 0510 RC 28298 HCPCS inpatient 23415.48 15220.06 AETNA AETNA 18498.23 79 999999999 14178.07 22713.02 percent of total billed charges Correction of bunion with alignment correction of big toe 51330314_1 CDM 0510 RC 28298 HCPCS inpatient 23415.48 15220.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22713.02 97 999999999 14178.07 22713.02 percent of total billed charges Correction of bunion with alignment correction of big toe 51330314_1 CDM 0510 RC 28298 HCPCS inpatient 23415.48 15220.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.68 69 999999999 14178.07 22713.02 percent of total billed charges Correction of bunion with alignment correction of big toe 51330314_1 CDM 0510 RC 28298 HCPCS inpatient 23415.48 15220.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 18264.07 78 999999999 14178.07 22713.02 percent of total billed charges Correction of bunion with alignment correction of big toe 51330314_1 CDM 0510 RC 28298 HCPCS inpatient 23415.48 15220.06 SIHO - ALL PLANS SIHO - ALL PLANS 21073.93 90 999999999 14178.07 22713.02 percent of total billed charges Correction of bunion with alignment correction of big toe 51330314_1 CDM 0510 RC 28298 HCPCS inpatient 23415.48 15220.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14178.07 60.55 999999999 14178.07 22713.02 percent of total billed charges Correction of bunion with alignment correction of big toe 51330314_1 CDM 0510 RC 28298 HCPCS inpatient 23415.48 15220.06 UMR - ALL PLANS UMR - ALL PLANS 16390.84 70 999999999 14178.07 22713.02 percent of total billed charges Correction of bunion with alignment correction of big toe 51330314_1 CDM 0510 RC 28298 HCPCS inpatient 23415.48 15220.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14178.07 22713.02 Correction of bunion with alignment correction of big toe 51330314_1 CDM 0510 RC 28298 HCPCS inpatient 23415.48 15220.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14178.07 22713.02 Correction of bunion with alignment correction of big toe 51330314_1 CDM 0510 RC 28298 HCPCS inpatient 23415.48 15220.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14178.07 22713.02 Correction of bunion with alignment correction of big toe 51330314_1 CDM 0510 RC 28298 HCPCS inpatient 23415.48 15220.06 ANTHEM HMO ANTHEM HMO 999999999 14178.07 22713.02 Correction of bunion with alignment correction of big toe 51330314_1 CDM 0510 RC 28298 HCPCS inpatient 23415.48 15220.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 14178.07 22713.02 Correction of bunion with alignment correction of big toe 51330314_1 CDM 0510 RC 28298 HCPCS inpatient 23415.48 15220.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.86 67.6 999999999 14178.07 22713.02 percent of total billed charges Correction of bunion with 2 areas of realignment 51330315_1 CDM 0510 RC 28299 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Correction of bunion with 2 areas of realignment 51330315_1 CDM 0510 RC 28299 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Correction of bunion with 2 areas of realignment 51330315_1 CDM 0510 RC 28299 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Correction of bunion with 2 areas of realignment 51330315_1 CDM 0510 RC 28299 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Correction of bunion with 2 areas of realignment 51330315_1 CDM 0510 RC 28299 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Correction of bunion with 2 areas of realignment 51330315_1 CDM 0510 RC 28299 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Correction of bunion with 2 areas of realignment 51330315_1 CDM 0510 RC 28299 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Correction of bunion with 2 areas of realignment 51330315_1 CDM 0510 RC 28299 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Correction of bunion with 2 areas of realignment 51330315_1 CDM 0510 RC 28299 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Correction of bunion with 2 areas of realignment 51330315_1 CDM 0510 RC 28299 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Correction of bunion with 2 areas of realignment 51330315_1 CDM 0510 RC 28299 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Correction of bunion with 2 areas of realignment 51330315_1 CDM 0510 RC 28299 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Correction of bunion with 2 areas of realignment 51330315_1 CDM 0510 RC 28299 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Correction of bunion with 2 areas of realignment 51330315_1 CDM 0510 RC 28299 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of heel or ankle bone with donor bone graft 51330330_1 CDM 0510 RC 28103 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of heel or ankle bone with donor bone graft 51330330_1 CDM 0510 RC 28103 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of heel or ankle bone with donor bone graft 51330330_1 CDM 0510 RC 28103 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of heel or ankle bone with donor bone graft 51330330_1 CDM 0510 RC 28103 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of heel or ankle bone with donor bone graft 51330330_1 CDM 0510 RC 28103 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of heel or ankle bone with donor bone graft 51330330_1 CDM 0510 RC 28103 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of heel or ankle bone with donor bone graft 51330330_1 CDM 0510 RC 28103 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of heel or ankle bone with donor bone graft 51330330_1 CDM 0510 RC 28103 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of heel or ankle bone with donor bone graft 51330330_1 CDM 0510 RC 28103 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Removal of cyst or growth of heel or ankle bone with donor bone graft 51330330_1 CDM 0510 RC 28103 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Removal of cyst or growth of heel or ankle bone with donor bone graft 51330330_1 CDM 0510 RC 28103 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Removal of cyst or growth of heel or ankle bone with donor bone graft 51330330_1 CDM 0510 RC 28103 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Removal of cyst or growth of heel or ankle bone with donor bone graft 51330330_1 CDM 0510 RC 28103 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Removal of cyst or growth of heel or ankle bone with donor bone graft 51330330_1 CDM 0510 RC 28103 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Transfer of deep tendon of foot with muscle rerouting 51330680_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Transfer of deep tendon of foot with muscle rerouting 51330680_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Transfer of deep tendon of foot with muscle rerouting 51330680_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Transfer of deep tendon of foot with muscle rerouting 51330680_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Transfer of deep tendon of foot with muscle rerouting 51330680_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Transfer of deep tendon of foot with muscle rerouting 51330680_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Transfer of deep tendon of foot with muscle rerouting 51330680_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Transfer of deep tendon of foot with muscle rerouting 51330680_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Transfer of deep tendon of foot with muscle rerouting 51330680_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Transfer of deep tendon of foot with muscle rerouting 51330680_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Transfer of deep tendon of foot with muscle rerouting 51330680_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Transfer of deep tendon of foot with muscle rerouting 51330680_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Transfer of deep tendon of foot with muscle rerouting 51330680_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Transfer of deep tendon of foot with muscle rerouting 51330680_1 CDM 0510 RC 27691 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Repair of tendon on sole of foot 51330681_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 10749.05 65 999999999 10013.15 16040.89 percent of total billed charges Repair of tendon on sole of foot 51330681_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 AETNA AETNA 13064.23 79 999999999 10013.15 16040.89 percent of total billed charges Repair of tendon on sole of foot 51330681_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16040.89 97 999999999 10013.15 16040.89 percent of total billed charges Repair of tendon on sole of foot 51330681_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 12898.86 78 999999999 10013.15 16040.89 percent of total billed charges Repair of tendon on sole of foot 51330681_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 11410.53 69 999999999 10013.15 16040.89 percent of total billed charges Repair of tendon on sole of foot 51330681_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 SIHO - ALL PLANS SIHO - ALL PLANS 14883.3 90 999999999 10013.15 16040.89 percent of total billed charges Repair of tendon on sole of foot 51330681_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10013.15 60.55 999999999 10013.15 16040.89 percent of total billed charges Repair of tendon on sole of foot 51330681_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 UMR - ALL PLANS UMR - ALL PLANS 11575.9 70 999999999 10013.15 16040.89 percent of total billed charges Repair of tendon on sole of foot 51330681_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 10013.15 16040.89 Repair of tendon on sole of foot 51330681_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 10013.15 16040.89 Repair of tendon on sole of foot 51330681_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 10013.15 16040.89 Repair of tendon on sole of foot 51330681_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 ANTHEM HMO ANTHEM HMO 999999999 10013.15 16040.89 Repair of tendon on sole of foot 51330681_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 10013.15 16040.89 Repair of tendon on sole of foot 51330681_1 CDM 0510 RC 28200 HCPCS inpatient 16537 10749.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 11179.01 67.6 999999999 10013.15 16040.89 percent of total billed charges Secondary repair of tendon on sole of foot with graft 51331285_1 CDM 0510 RC 28202 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Secondary repair of tendon on sole of foot with graft 51331285_1 CDM 0510 RC 28202 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Secondary repair of tendon on sole of foot with graft 51331285_1 CDM 0510 RC 28202 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Secondary repair of tendon on sole of foot with graft 51331285_1 CDM 0510 RC 28202 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Secondary repair of tendon on sole of foot with graft 51331285_1 CDM 0510 RC 28202 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Secondary repair of tendon on sole of foot with graft 51331285_1 CDM 0510 RC 28202 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Secondary repair of tendon on sole of foot with graft 51331285_1 CDM 0510 RC 28202 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Secondary repair of tendon on sole of foot with graft 51331285_1 CDM 0510 RC 28202 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Secondary repair of tendon on sole of foot with graft 51331285_1 CDM 0510 RC 28202 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Secondary repair of tendon on sole of foot with graft 51331285_1 CDM 0510 RC 28202 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Secondary repair of tendon on sole of foot with graft 51331285_1 CDM 0510 RC 28202 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Secondary repair of tendon on sole of foot with graft 51331285_1 CDM 0510 RC 28202 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Secondary repair of tendon on sole of foot with graft 51331285_1 CDM 0510 RC 28202 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Secondary repair of tendon on sole of foot with graft 51331285_1 CDM 0510 RC 28202 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Reconstruction of ankle tendon with removal of extra ankle joint bone 51331286_1 CDM 0510 RC 28238 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Reconstruction of ankle tendon with removal of extra ankle joint bone 51331286_1 CDM 0510 RC 28238 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Reconstruction of ankle tendon with removal of extra ankle joint bone 51331286_1 CDM 0510 RC 28238 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Reconstruction of ankle tendon with removal of extra ankle joint bone 51331286_1 CDM 0510 RC 28238 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Reconstruction of ankle tendon with removal of extra ankle joint bone 51331286_1 CDM 0510 RC 28238 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Reconstruction of ankle tendon with removal of extra ankle joint bone 51331286_1 CDM 0510 RC 28238 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Reconstruction of ankle tendon with removal of extra ankle joint bone 51331286_1 CDM 0510 RC 28238 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Reconstruction of ankle tendon with removal of extra ankle joint bone 51331286_1 CDM 0510 RC 28238 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Reconstruction of ankle tendon with removal of extra ankle joint bone 51331286_1 CDM 0510 RC 28238 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Reconstruction of ankle tendon with removal of extra ankle joint bone 51331286_1 CDM 0510 RC 28238 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Reconstruction of ankle tendon with removal of extra ankle joint bone 51331286_1 CDM 0510 RC 28238 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Reconstruction of ankle tendon with removal of extra ankle joint bone 51331286_1 CDM 0510 RC 28238 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Reconstruction of ankle tendon with removal of extra ankle joint bone 51331286_1 CDM 0510 RC 28238 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Reconstruction of ankle tendon with removal of extra ankle joint bone 51331286_1 CDM 0510 RC 28238 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe between toe joints with tendon transfer 51331287_1 CDM 0510 RC 28760 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe between toe joints with tendon transfer 51331287_1 CDM 0510 RC 28760 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe between toe joints with tendon transfer 51331287_1 CDM 0510 RC 28760 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe between toe joints with tendon transfer 51331287_1 CDM 0510 RC 28760 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe between toe joints with tendon transfer 51331287_1 CDM 0510 RC 28760 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe between toe joints with tendon transfer 51331287_1 CDM 0510 RC 28760 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe between toe joints with tendon transfer 51331287_1 CDM 0510 RC 28760 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe between toe joints with tendon transfer 51331287_1 CDM 0510 RC 28760 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe between toe joints with tendon transfer 51331287_1 CDM 0510 RC 28760 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Fusion of big toe between toe joints with tendon transfer 51331287_1 CDM 0510 RC 28760 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Fusion of big toe between toe joints with tendon transfer 51331287_1 CDM 0510 RC 28760 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Fusion of big toe between toe joints with tendon transfer 51331287_1 CDM 0510 RC 28760 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Fusion of big toe between toe joints with tendon transfer 51331287_1 CDM 0510 RC 28760 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Fusion of big toe between toe joints with tendon transfer 51331287_1 CDM 0510 RC 28760 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Analysis for antibody to West Nile virus 51331331_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.6 65 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 51331331_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 AETNA AETNA 161.16 79 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 51331331_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.88 97 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 51331331_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.12 78 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 51331331_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.76 69 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 51331331_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 SIHO - ALL PLANS SIHO - ALL PLANS 183.6 90 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 51331331_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 UMR - ALL PLANS UMR - ALL PLANS 142.8 70 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 51331331_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.52 60.55 999999999 123.52 197.88 percent of total billed charges Analysis for antibody to West Nile virus 51331331_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.52 197.88 Analysis for antibody to West Nile virus 51331331_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.52 197.88 Analysis for antibody to West Nile virus 51331331_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.52 197.88 Analysis for antibody to West Nile virus 51331331_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 ANTHEM HMO ANTHEM HMO 999999999 123.52 197.88 Analysis for antibody to West Nile virus 51331331_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.52 197.88 Analysis for antibody to West Nile virus 51331331_1 CDM 0302 RC 86789 HCPCS inpatient 204 132.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.9 67.6 999999999 123.52 197.88 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 51331332_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 134.55 65 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 51331332_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 AETNA AETNA 163.53 79 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 51331332_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 200.79 97 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 51331332_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 161.46 78 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 51331332_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.83 69 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 51331332_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 SIHO - ALL PLANS SIHO - ALL PLANS 186.3 90 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 51331332_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 UMR - ALL PLANS UMR - ALL PLANS 144.9 70 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 51331332_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 125.34 60.55 999999999 125.34 200.79 percent of total billed charges Analysis for antibody (IgM) to West Nile virus 51331332_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 125.34 200.79 Analysis for antibody (IgM) to West Nile virus 51331332_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 125.34 200.79 Analysis for antibody (IgM) to West Nile virus 51331332_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 125.34 200.79 Analysis for antibody (IgM) to West Nile virus 51331332_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 ANTHEM HMO ANTHEM HMO 999999999 125.34 200.79 Analysis for antibody (IgM) to West Nile virus 51331332_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 125.34 200.79 Analysis for antibody (IgM) to West Nile virus 51331332_1 CDM 0301 RC 86788 HCPCS inpatient 207 134.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.93 67.6 999999999 125.34 200.79 percent of total billed charges "Removal of growth of nerve of hand or foot nerve, first nerve" 51334744_1 CDM 0510 RC 64782 HCPCS inpatient 6363 4135.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 4135.95 65 999999999 3852.8 6172.11 percent of total billed charges "Removal of growth of nerve of hand or foot nerve, first nerve" 51334744_1 CDM 0510 RC 64782 HCPCS inpatient 6363 4135.95 AETNA AETNA 5026.77 79 999999999 3852.8 6172.11 percent of total billed charges "Removal of growth of nerve of hand or foot nerve, first nerve" 51334744_1 CDM 0510 RC 64782 HCPCS inpatient 6363 4135.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6172.11 97 999999999 3852.8 6172.11 percent of total billed charges "Removal of growth of nerve of hand or foot nerve, first nerve" 51334744_1 CDM 0510 RC 64782 HCPCS inpatient 6363 4135.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 4963.14 78 999999999 3852.8 6172.11 percent of total billed charges "Removal of growth of nerve of hand or foot nerve, first nerve" 51334744_1 CDM 0510 RC 64782 HCPCS inpatient 6363 4135.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 4390.47 69 999999999 3852.8 6172.11 percent of total billed charges "Removal of growth of nerve of hand or foot nerve, first nerve" 51334744_1 CDM 0510 RC 64782 HCPCS inpatient 6363 4135.95 SIHO - ALL PLANS SIHO - ALL PLANS 5726.7 90 999999999 3852.8 6172.11 percent of total billed charges "Removal of growth of nerve of hand or foot nerve, first nerve" 51334744_1 CDM 0510 RC 64782 HCPCS inpatient 6363 4135.95 UMR - ALL PLANS UMR - ALL PLANS 4454.1 70 999999999 3852.8 6172.11 percent of total billed charges "Removal of growth of nerve of hand or foot nerve, first nerve" 51334744_1 CDM 0510 RC 64782 HCPCS inpatient 6363 4135.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3852.8 60.55 999999999 3852.8 6172.11 percent of total billed charges "Removal of growth of nerve of hand or foot nerve, first nerve" 51334744_1 CDM 0510 RC 64782 HCPCS inpatient 6363 4135.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3852.8 6172.11 "Removal of growth of nerve of hand or foot nerve, first nerve" 51334744_1 CDM 0510 RC 64782 HCPCS inpatient 6363 4135.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3852.8 6172.11 "Removal of growth of nerve of hand or foot nerve, first nerve" 51334744_1 CDM 0510 RC 64782 HCPCS inpatient 6363 4135.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3852.8 6172.11 "Removal of growth of nerve of hand or foot nerve, first nerve" 51334744_1 CDM 0510 RC 64782 HCPCS inpatient 6363 4135.95 ANTHEM HMO ANTHEM HMO 999999999 3852.8 6172.11 "Removal of growth of nerve of hand or foot nerve, first nerve" 51334744_1 CDM 0510 RC 64782 HCPCS inpatient 6363 4135.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 3852.8 6172.11 "Removal of growth of nerve of hand or foot nerve, first nerve" 51334744_1 CDM 0510 RC 64782 HCPCS inpatient 6363 4135.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 4301.39 67.6 999999999 3852.8 6172.11 percent of total billed charges Incision to lengthen toe tendon 51334746_1 CDM 0510 RC 28232 HCPCS inpatient 5078 3300.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 3300.7 65 999999999 3074.73 4925.66 percent of total billed charges Incision to lengthen toe tendon 51334746_1 CDM 0510 RC 28232 HCPCS inpatient 5078 3300.7 AETNA AETNA 4011.62 79 999999999 3074.73 4925.66 percent of total billed charges Incision to lengthen toe tendon 51334746_1 CDM 0510 RC 28232 HCPCS inpatient 5078 3300.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4925.66 97 999999999 3074.73 4925.66 percent of total billed charges Incision to lengthen toe tendon 51334746_1 CDM 0510 RC 28232 HCPCS inpatient 5078 3300.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 3960.84 78 999999999 3074.73 4925.66 percent of total billed charges Incision to lengthen toe tendon 51334746_1 CDM 0510 RC 28232 HCPCS inpatient 5078 3300.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 3503.82 69 999999999 3074.73 4925.66 percent of total billed charges Incision to lengthen toe tendon 51334746_1 CDM 0510 RC 28232 HCPCS inpatient 5078 3300.7 SIHO - ALL PLANS SIHO - ALL PLANS 4570.2 90 999999999 3074.73 4925.66 percent of total billed charges Incision to lengthen toe tendon 51334746_1 CDM 0510 RC 28232 HCPCS inpatient 5078 3300.7 UMR - ALL PLANS UMR - ALL PLANS 3554.6 70 999999999 3074.73 4925.66 percent of total billed charges Incision to lengthen toe tendon 51334746_1 CDM 0510 RC 28232 HCPCS inpatient 5078 3300.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3074.73 60.55 999999999 3074.73 4925.66 percent of total billed charges Incision to lengthen toe tendon 51334746_1 CDM 0510 RC 28232 HCPCS inpatient 5078 3300.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3074.73 4925.66 Incision to lengthen toe tendon 51334746_1 CDM 0510 RC 28232 HCPCS inpatient 5078 3300.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3074.73 4925.66 Incision to lengthen toe tendon 51334746_1 CDM 0510 RC 28232 HCPCS inpatient 5078 3300.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3074.73 4925.66 Incision to lengthen toe tendon 51334746_1 CDM 0510 RC 28232 HCPCS inpatient 5078 3300.7 ANTHEM HMO ANTHEM HMO 999999999 3074.73 4925.66 Incision to lengthen toe tendon 51334746_1 CDM 0510 RC 28232 HCPCS inpatient 5078 3300.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 3074.73 4925.66 Incision to lengthen toe tendon 51334746_1 CDM 0510 RC 28232 HCPCS inpatient 5078 3300.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 3432.73 67.6 999999999 3074.73 4925.66 percent of total billed charges Release or lengthening of tendon in foot 51334747_1 CDM 0510 RC 28240 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Release or lengthening of tendon in foot 51334747_1 CDM 0510 RC 28240 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Release or lengthening of tendon in foot 51334747_1 CDM 0510 RC 28240 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Release or lengthening of tendon in foot 51334747_1 CDM 0510 RC 28240 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Release or lengthening of tendon in foot 51334747_1 CDM 0510 RC 28240 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Release or lengthening of tendon in foot 51334747_1 CDM 0510 RC 28240 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Release or lengthening of tendon in foot 51334747_1 CDM 0510 RC 28240 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Release or lengthening of tendon in foot 51334747_1 CDM 0510 RC 28240 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Release or lengthening of tendon in foot 51334747_1 CDM 0510 RC 28240 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Release or lengthening of tendon in foot 51334747_1 CDM 0510 RC 28240 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Release or lengthening of tendon in foot 51334747_1 CDM 0510 RC 28240 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Release or lengthening of tendon in foot 51334747_1 CDM 0510 RC 28240 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Release or lengthening of tendon in foot 51334747_1 CDM 0510 RC 28240 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Release or lengthening of tendon in foot 51334747_1 CDM 0510 RC 28240 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with midfoot and hindfoot bone fusion 51337099_1 CDM 0510 RC 28297 HCPCS inpatient 7805 5073.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 5073.25 65 999999999 4725.93 7570.85 percent of total billed charges Correction of bunion with midfoot and hindfoot bone fusion 51337099_1 CDM 0510 RC 28297 HCPCS inpatient 7805 5073.25 AETNA AETNA 6165.95 79 999999999 4725.93 7570.85 percent of total billed charges Correction of bunion with midfoot and hindfoot bone fusion 51337099_1 CDM 0510 RC 28297 HCPCS inpatient 7805 5073.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7570.85 97 999999999 4725.93 7570.85 percent of total billed charges Correction of bunion with midfoot and hindfoot bone fusion 51337099_1 CDM 0510 RC 28297 HCPCS inpatient 7805 5073.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 6087.9 78 999999999 4725.93 7570.85 percent of total billed charges Correction of bunion with midfoot and hindfoot bone fusion 51337099_1 CDM 0510 RC 28297 HCPCS inpatient 7805 5073.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 5385.45 69 999999999 4725.93 7570.85 percent of total billed charges Correction of bunion with midfoot and hindfoot bone fusion 51337099_1 CDM 0510 RC 28297 HCPCS inpatient 7805 5073.25 SIHO - ALL PLANS SIHO - ALL PLANS 7024.5 90 999999999 4725.93 7570.85 percent of total billed charges Correction of bunion with midfoot and hindfoot bone fusion 51337099_1 CDM 0510 RC 28297 HCPCS inpatient 7805 5073.25 UMR - ALL PLANS UMR - ALL PLANS 5463.5 70 999999999 4725.93 7570.85 percent of total billed charges Correction of bunion with midfoot and hindfoot bone fusion 51337099_1 CDM 0510 RC 28297 HCPCS inpatient 7805 5073.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4725.93 60.55 999999999 4725.93 7570.85 percent of total billed charges Correction of bunion with midfoot and hindfoot bone fusion 51337099_1 CDM 0510 RC 28297 HCPCS inpatient 7805 5073.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 4725.93 7570.85 Correction of bunion with midfoot and hindfoot bone fusion 51337099_1 CDM 0510 RC 28297 HCPCS inpatient 7805 5073.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 4725.93 7570.85 Correction of bunion with midfoot and hindfoot bone fusion 51337099_1 CDM 0510 RC 28297 HCPCS inpatient 7805 5073.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 4725.93 7570.85 Correction of bunion with midfoot and hindfoot bone fusion 51337099_1 CDM 0510 RC 28297 HCPCS inpatient 7805 5073.25 ANTHEM HMO ANTHEM HMO 999999999 4725.93 7570.85 Correction of bunion with midfoot and hindfoot bone fusion 51337099_1 CDM 0510 RC 28297 HCPCS inpatient 7805 5073.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 4725.93 7570.85 Correction of bunion with midfoot and hindfoot bone fusion 51337099_1 CDM 0510 RC 28297 HCPCS inpatient 7805 5073.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 5276.18 67.6 999999999 4725.93 7570.85 percent of total billed charges Removal of heel bone spur 51337100_1 CDM 0510 RC 28119 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Removal of heel bone spur 51337100_1 CDM 0510 RC 28119 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Removal of heel bone spur 51337100_1 CDM 0510 RC 28119 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Removal of heel bone spur 51337100_1 CDM 0510 RC 28119 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Removal of heel bone spur 51337100_1 CDM 0510 RC 28119 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Removal of heel bone spur 51337100_1 CDM 0510 RC 28119 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Removal of heel bone spur 51337100_1 CDM 0510 RC 28119 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Removal of heel bone spur 51337100_1 CDM 0510 RC 28119 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Removal of heel bone spur 51337100_1 CDM 0510 RC 28119 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Removal of heel bone spur 51337100_1 CDM 0510 RC 28119 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Removal of heel bone spur 51337100_1 CDM 0510 RC 28119 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Removal of heel bone spur 51337100_1 CDM 0510 RC 28119 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Removal of heel bone spur 51337100_1 CDM 0510 RC 28119 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Removal of heel bone spur 51337100_1 CDM 0510 RC 28119 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Removal of abnormal bones at ankle joint 51337101_1 CDM 0510 RC 28116 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Removal of abnormal bones at ankle joint 51337101_1 CDM 0510 RC 28116 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Removal of abnormal bones at ankle joint 51337101_1 CDM 0510 RC 28116 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Removal of abnormal bones at ankle joint 51337101_1 CDM 0510 RC 28116 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Removal of abnormal bones at ankle joint 51337101_1 CDM 0510 RC 28116 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Removal of abnormal bones at ankle joint 51337101_1 CDM 0510 RC 28116 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Removal of abnormal bones at ankle joint 51337101_1 CDM 0510 RC 28116 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Removal of abnormal bones at ankle joint 51337101_1 CDM 0510 RC 28116 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Removal of abnormal bones at ankle joint 51337101_1 CDM 0510 RC 28116 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Removal of abnormal bones at ankle joint 51337101_1 CDM 0510 RC 28116 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Removal of abnormal bones at ankle joint 51337101_1 CDM 0510 RC 28116 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Removal of abnormal bones at ankle joint 51337101_1 CDM 0510 RC 28116 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Removal of abnormal bones at ankle joint 51337101_1 CDM 0510 RC 28116 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Removal of abnormal bones at ankle joint 51337101_1 CDM 0510 RC 28116 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Incision or partial removal of foot bone with bone graft 51337102_1 CDM 0510 RC 28305 HCPCS inpatient 23415.48 15220.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 15220.06 65 999999999 14178.07 22713.02 percent of total billed charges Incision or partial removal of foot bone with bone graft 51337102_1 CDM 0510 RC 28305 HCPCS inpatient 23415.48 15220.06 AETNA AETNA 18498.23 79 999999999 14178.07 22713.02 percent of total billed charges Incision or partial removal of foot bone with bone graft 51337102_1 CDM 0510 RC 28305 HCPCS inpatient 23415.48 15220.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22713.02 97 999999999 14178.07 22713.02 percent of total billed charges Incision or partial removal of foot bone with bone graft 51337102_1 CDM 0510 RC 28305 HCPCS inpatient 23415.48 15220.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 18264.07 78 999999999 14178.07 22713.02 percent of total billed charges Incision or partial removal of foot bone with bone graft 51337102_1 CDM 0510 RC 28305 HCPCS inpatient 23415.48 15220.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.68 69 999999999 14178.07 22713.02 percent of total billed charges Incision or partial removal of foot bone with bone graft 51337102_1 CDM 0510 RC 28305 HCPCS inpatient 23415.48 15220.06 SIHO - ALL PLANS SIHO - ALL PLANS 21073.93 90 999999999 14178.07 22713.02 percent of total billed charges Incision or partial removal of foot bone with bone graft 51337102_1 CDM 0510 RC 28305 HCPCS inpatient 23415.48 15220.06 UMR - ALL PLANS UMR - ALL PLANS 16390.84 70 999999999 14178.07 22713.02 percent of total billed charges Incision or partial removal of foot bone with bone graft 51337102_1 CDM 0510 RC 28305 HCPCS inpatient 23415.48 15220.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14178.07 60.55 999999999 14178.07 22713.02 percent of total billed charges Incision or partial removal of foot bone with bone graft 51337102_1 CDM 0510 RC 28305 HCPCS inpatient 23415.48 15220.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14178.07 22713.02 Incision or partial removal of foot bone with bone graft 51337102_1 CDM 0510 RC 28305 HCPCS inpatient 23415.48 15220.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14178.07 22713.02 Incision or partial removal of foot bone with bone graft 51337102_1 CDM 0510 RC 28305 HCPCS inpatient 23415.48 15220.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14178.07 22713.02 Incision or partial removal of foot bone with bone graft 51337102_1 CDM 0510 RC 28305 HCPCS inpatient 23415.48 15220.06 ANTHEM HMO ANTHEM HMO 999999999 14178.07 22713.02 Incision or partial removal of foot bone with bone graft 51337102_1 CDM 0510 RC 28305 HCPCS inpatient 23415.48 15220.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 14178.07 22713.02 Incision or partial removal of foot bone with bone graft 51337102_1 CDM 0510 RC 28305 HCPCS inpatient 23415.48 15220.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.86 67.6 999999999 14178.07 22713.02 percent of total billed charges Reconstruction of soft tissue angular deformity of toe 51337245_1 CDM 0510 RC 28313 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Reconstruction of soft tissue angular deformity of toe 51337245_1 CDM 0510 RC 28313 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Reconstruction of soft tissue angular deformity of toe 51337245_1 CDM 0510 RC 28313 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Reconstruction of soft tissue angular deformity of toe 51337245_1 CDM 0510 RC 28313 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Reconstruction of soft tissue angular deformity of toe 51337245_1 CDM 0510 RC 28313 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Reconstruction of soft tissue angular deformity of toe 51337245_1 CDM 0510 RC 28313 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Reconstruction of soft tissue angular deformity of toe 51337245_1 CDM 0510 RC 28313 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Reconstruction of soft tissue angular deformity of toe 51337245_1 CDM 0510 RC 28313 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Reconstruction of soft tissue angular deformity of toe 51337245_1 CDM 0510 RC 28313 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Reconstruction of soft tissue angular deformity of toe 51337245_1 CDM 0510 RC 28313 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Reconstruction of soft tissue angular deformity of toe 51337245_1 CDM 0510 RC 28313 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Reconstruction of soft tissue angular deformity of toe 51337245_1 CDM 0510 RC 28313 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Reconstruction of soft tissue angular deformity of toe 51337245_1 CDM 0510 RC 28313 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Reconstruction of soft tissue angular deformity of toe 51337245_1 CDM 0510 RC 28313 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Removal of small bone underlying long bone of foot at big toe joint 51337246_1 CDM 0510 RC 28315 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Removal of small bone underlying long bone of foot at big toe joint 51337246_1 CDM 0510 RC 28315 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Removal of small bone underlying long bone of foot at big toe joint 51337246_1 CDM 0510 RC 28315 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Removal of small bone underlying long bone of foot at big toe joint 51337246_1 CDM 0510 RC 28315 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Removal of small bone underlying long bone of foot at big toe joint 51337246_1 CDM 0510 RC 28315 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Removal of small bone underlying long bone of foot at big toe joint 51337246_1 CDM 0510 RC 28315 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Removal of small bone underlying long bone of foot at big toe joint 51337246_1 CDM 0510 RC 28315 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Removal of small bone underlying long bone of foot at big toe joint 51337246_1 CDM 0510 RC 28315 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Removal of small bone underlying long bone of foot at big toe joint 51337246_1 CDM 0510 RC 28315 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Removal of small bone underlying long bone of foot at big toe joint 51337246_1 CDM 0510 RC 28315 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Removal of small bone underlying long bone of foot at big toe joint 51337246_1 CDM 0510 RC 28315 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Removal of small bone underlying long bone of foot at big toe joint 51337246_1 CDM 0510 RC 28315 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Removal of small bone underlying long bone of foot at big toe joint 51337246_1 CDM 0510 RC 28315 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Removal of small bone underlying long bone of foot at big toe joint 51337246_1 CDM 0510 RC 28315 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Fusion of big toe between toe joints 51337250_1 CDM 0510 RC 28755 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe between toe joints 51337250_1 CDM 0510 RC 28755 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe between toe joints 51337250_1 CDM 0510 RC 28755 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe between toe joints 51337250_1 CDM 0510 RC 28755 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe between toe joints 51337250_1 CDM 0510 RC 28755 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe between toe joints 51337250_1 CDM 0510 RC 28755 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe between toe joints 51337250_1 CDM 0510 RC 28755 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe between toe joints 51337250_1 CDM 0510 RC 28755 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe between toe joints 51337250_1 CDM 0510 RC 28755 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Fusion of big toe between toe joints 51337250_1 CDM 0510 RC 28755 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Fusion of big toe between toe joints 51337250_1 CDM 0510 RC 28755 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Fusion of big toe between toe joints 51337250_1 CDM 0510 RC 28755 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Fusion of big toe between toe joints 51337250_1 CDM 0510 RC 28755 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Fusion of big toe between toe joints 51337250_1 CDM 0510 RC 28755 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Incision of connective tissue and muscle of sole of foot 51339870_1 CDM 0510 RC 28250 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Incision of connective tissue and muscle of sole of foot 51339870_1 CDM 0510 RC 28250 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Incision of connective tissue and muscle of sole of foot 51339870_1 CDM 0510 RC 28250 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Incision of connective tissue and muscle of sole of foot 51339870_1 CDM 0510 RC 28250 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Incision of connective tissue and muscle of sole of foot 51339870_1 CDM 0510 RC 28250 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Incision of connective tissue and muscle of sole of foot 51339870_1 CDM 0510 RC 28250 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Incision of connective tissue and muscle of sole of foot 51339870_1 CDM 0510 RC 28250 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Incision of connective tissue and muscle of sole of foot 51339870_1 CDM 0510 RC 28250 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Incision of connective tissue and muscle of sole of foot 51339870_1 CDM 0510 RC 28250 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Incision of connective tissue and muscle of sole of foot 51339870_1 CDM 0510 RC 28250 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Incision of connective tissue and muscle of sole of foot 51339870_1 CDM 0510 RC 28250 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Incision of connective tissue and muscle of sole of foot 51339870_1 CDM 0510 RC 28250 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Incision of connective tissue and muscle of sole of foot 51339870_1 CDM 0510 RC 28250 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Incision of connective tissue and muscle of sole of foot 51339870_1 CDM 0510 RC 28250 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Incision or partial removal of heel bone 51339871_1 CDM 0510 RC 28300 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of heel bone 51339871_1 CDM 0510 RC 28300 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of heel bone 51339871_1 CDM 0510 RC 28300 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of heel bone 51339871_1 CDM 0510 RC 28300 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of heel bone 51339871_1 CDM 0510 RC 28300 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of heel bone 51339871_1 CDM 0510 RC 28300 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of heel bone 51339871_1 CDM 0510 RC 28300 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of heel bone 51339871_1 CDM 0510 RC 28300 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of heel bone 51339871_1 CDM 0510 RC 28300 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Incision or partial removal of heel bone 51339871_1 CDM 0510 RC 28300 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Incision or partial removal of heel bone 51339871_1 CDM 0510 RC 28300 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Incision or partial removal of heel bone 51339871_1 CDM 0510 RC 28300 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Incision or partial removal of heel bone 51339871_1 CDM 0510 RC 28300 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Incision or partial removal of heel bone 51339871_1 CDM 0510 RC 28300 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of foot bone 51339872_1 CDM 0510 RC 28304 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of foot bone 51339872_1 CDM 0510 RC 28304 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of foot bone 51339872_1 CDM 0510 RC 28304 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of foot bone 51339872_1 CDM 0510 RC 28304 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of foot bone 51339872_1 CDM 0510 RC 28304 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of foot bone 51339872_1 CDM 0510 RC 28304 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of foot bone 51339872_1 CDM 0510 RC 28304 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of foot bone 51339872_1 CDM 0510 RC 28304 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of foot bone 51339872_1 CDM 0510 RC 28304 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Incision or partial removal of foot bone 51339872_1 CDM 0510 RC 28304 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Incision or partial removal of foot bone 51339872_1 CDM 0510 RC 28304 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Incision or partial removal of foot bone 51339872_1 CDM 0510 RC 28304 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Incision or partial removal of foot bone 51339872_1 CDM 0510 RC 28304 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Incision or partial removal of foot bone 51339872_1 CDM 0510 RC 28304 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Correction of rigid deformity of first joint of big toe using implant 51340016_1 CDM 0510 RC 28291 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Correction of rigid deformity of first joint of big toe using implant 51340016_1 CDM 0510 RC 28291 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Correction of rigid deformity of first joint of big toe using implant 51340016_1 CDM 0510 RC 28291 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Correction of rigid deformity of first joint of big toe using implant 51340016_1 CDM 0510 RC 28291 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Correction of rigid deformity of first joint of big toe using implant 51340016_1 CDM 0510 RC 28291 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Correction of rigid deformity of first joint of big toe using implant 51340016_1 CDM 0510 RC 28291 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Correction of rigid deformity of first joint of big toe using implant 51340016_1 CDM 0510 RC 28291 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Correction of rigid deformity of first joint of big toe using implant 51340016_1 CDM 0510 RC 28291 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Correction of rigid deformity of first joint of big toe using implant 51340016_1 CDM 0510 RC 28291 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Correction of rigid deformity of first joint of big toe using implant 51340016_1 CDM 0510 RC 28291 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Correction of rigid deformity of first joint of big toe using implant 51340016_1 CDM 0510 RC 28291 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Correction of rigid deformity of first joint of big toe using implant 51340016_1 CDM 0510 RC 28291 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Correction of rigid deformity of first joint of big toe using implant 51340016_1 CDM 0510 RC 28291 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Correction of rigid deformity of first joint of big toe using implant 51340016_1 CDM 0510 RC 28291 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe at joint with foot 51340017_1 CDM 0510 RC 28750 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe at joint with foot 51340017_1 CDM 0510 RC 28750 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe at joint with foot 51340017_1 CDM 0510 RC 28750 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe at joint with foot 51340017_1 CDM 0510 RC 28750 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe at joint with foot 51340017_1 CDM 0510 RC 28750 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe at joint with foot 51340017_1 CDM 0510 RC 28750 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe at joint with foot 51340017_1 CDM 0510 RC 28750 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe at joint with foot 51340017_1 CDM 0510 RC 28750 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Fusion of big toe at joint with foot 51340017_1 CDM 0510 RC 28750 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Fusion of big toe at joint with foot 51340017_1 CDM 0510 RC 28750 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Fusion of big toe at joint with foot 51340017_1 CDM 0510 RC 28750 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Fusion of big toe at joint with foot 51340017_1 CDM 0510 RC 28750 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Fusion of big toe at joint with foot 51340017_1 CDM 0510 RC 28750 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Fusion of big toe at joint with foot 51340017_1 CDM 0510 RC 28750 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward toe area 51340018_1 CDM 0510 RC 28296 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward toe area 51340018_1 CDM 0510 RC 28296 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward toe area 51340018_1 CDM 0510 RC 28296 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward toe area 51340018_1 CDM 0510 RC 28296 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward toe area 51340018_1 CDM 0510 RC 28296 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward toe area 51340018_1 CDM 0510 RC 28296 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward toe area 51340018_1 CDM 0510 RC 28296 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward toe area 51340018_1 CDM 0510 RC 28296 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward toe area 51340018_1 CDM 0510 RC 28296 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Correction of bunion with alignment correction of midfoot bone toward toe area 51340018_1 CDM 0510 RC 28296 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Correction of bunion with alignment correction of midfoot bone toward toe area 51340018_1 CDM 0510 RC 28296 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Correction of bunion with alignment correction of midfoot bone toward toe area 51340018_1 CDM 0510 RC 28296 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Correction of bunion with alignment correction of midfoot bone toward toe area 51340018_1 CDM 0510 RC 28296 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Correction of bunion with alignment correction of midfoot bone toward toe area 51340018_1 CDM 0510 RC 28296 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Removal of cyst or growth of heel or ankle bone with self bone graft 51340029_1 CDM 0510 RC 28102 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of heel or ankle bone with self bone graft 51340029_1 CDM 0510 RC 28102 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of heel or ankle bone with self bone graft 51340029_1 CDM 0510 RC 28102 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of heel or ankle bone with self bone graft 51340029_1 CDM 0510 RC 28102 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of heel or ankle bone with self bone graft 51340029_1 CDM 0510 RC 28102 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of heel or ankle bone with self bone graft 51340029_1 CDM 0510 RC 28102 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of heel or ankle bone with self bone graft 51340029_1 CDM 0510 RC 28102 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of heel or ankle bone with self bone graft 51340029_1 CDM 0510 RC 28102 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of heel or ankle bone with self bone graft 51340029_1 CDM 0510 RC 28102 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Removal of cyst or growth of heel or ankle bone with self bone graft 51340029_1 CDM 0510 RC 28102 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Removal of cyst or growth of heel or ankle bone with self bone graft 51340029_1 CDM 0510 RC 28102 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Removal of cyst or growth of heel or ankle bone with self bone graft 51340029_1 CDM 0510 RC 28102 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Removal of cyst or growth of heel or ankle bone with self bone graft 51340029_1 CDM 0510 RC 28102 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Removal of cyst or growth of heel or ankle bone with self bone graft 51340029_1 CDM 0510 RC 28102 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of foot bone with self bone graft 51340030_1 CDM 0510 RC 28106 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of foot bone with self bone graft 51340030_1 CDM 0510 RC 28106 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of foot bone with self bone graft 51340030_1 CDM 0510 RC 28106 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of foot bone with self bone graft 51340030_1 CDM 0510 RC 28106 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of foot bone with self bone graft 51340030_1 CDM 0510 RC 28106 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of foot bone with self bone graft 51340030_1 CDM 0510 RC 28106 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of foot bone with self bone graft 51340030_1 CDM 0510 RC 28106 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of foot bone with self bone graft 51340030_1 CDM 0510 RC 28106 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of foot bone with self bone graft 51340030_1 CDM 0510 RC 28106 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Removal of cyst or growth of foot bone with self bone graft 51340030_1 CDM 0510 RC 28106 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Removal of cyst or growth of foot bone with self bone graft 51340030_1 CDM 0510 RC 28106 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Removal of cyst or growth of foot bone with self bone graft 51340030_1 CDM 0510 RC 28106 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Removal of cyst or growth of foot bone with self bone graft 51340030_1 CDM 0510 RC 28106 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Removal of cyst or growth of foot bone with self bone graft 51340030_1 CDM 0510 RC 28106 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges Removal of cyst or growth of heel or ankle bone 51340031_1 CDM 0510 RC 28100 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Removal of cyst or growth of heel or ankle bone 51340031_1 CDM 0510 RC 28100 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Removal of cyst or growth of heel or ankle bone 51340031_1 CDM 0510 RC 28100 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Removal of cyst or growth of heel or ankle bone 51340031_1 CDM 0510 RC 28100 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Removal of cyst or growth of heel or ankle bone 51340031_1 CDM 0510 RC 28100 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Removal of cyst or growth of heel or ankle bone 51340031_1 CDM 0510 RC 28100 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Removal of cyst or growth of heel or ankle bone 51340031_1 CDM 0510 RC 28100 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Removal of cyst or growth of heel or ankle bone 51340031_1 CDM 0510 RC 28100 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Removal of cyst or growth of heel or ankle bone 51340031_1 CDM 0510 RC 28100 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Removal of cyst or growth of heel or ankle bone 51340031_1 CDM 0510 RC 28100 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Removal of cyst or growth of heel or ankle bone 51340031_1 CDM 0510 RC 28100 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Removal of cyst or growth of heel or ankle bone 51340031_1 CDM 0510 RC 28100 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Removal of cyst or growth of heel or ankle bone 51340031_1 CDM 0510 RC 28100 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Removal of cyst or growth of heel or ankle bone 51340031_1 CDM 0510 RC 28100 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Aspiration of bone marrow sample for diagnosis 51340142_1 CDM 0510 RC 38220 HCPCS inpatient 5308 3450.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 3450.2 65 999999999 3213.99 5148.76 percent of total billed charges Aspiration of bone marrow sample for diagnosis 51340142_1 CDM 0510 RC 38220 HCPCS inpatient 5308 3450.2 AETNA AETNA 4193.32 79 999999999 3213.99 5148.76 percent of total billed charges Aspiration of bone marrow sample for diagnosis 51340142_1 CDM 0510 RC 38220 HCPCS inpatient 5308 3450.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5148.76 97 999999999 3213.99 5148.76 percent of total billed charges Aspiration of bone marrow sample for diagnosis 51340142_1 CDM 0510 RC 38220 HCPCS inpatient 5308 3450.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 4140.24 78 999999999 3213.99 5148.76 percent of total billed charges Aspiration of bone marrow sample for diagnosis 51340142_1 CDM 0510 RC 38220 HCPCS inpatient 5308 3450.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 3662.52 69 999999999 3213.99 5148.76 percent of total billed charges Aspiration of bone marrow sample for diagnosis 51340142_1 CDM 0510 RC 38220 HCPCS inpatient 5308 3450.2 SIHO - ALL PLANS SIHO - ALL PLANS 4777.2 90 999999999 3213.99 5148.76 percent of total billed charges Aspiration of bone marrow sample for diagnosis 51340142_1 CDM 0510 RC 38220 HCPCS inpatient 5308 3450.2 UMR - ALL PLANS UMR - ALL PLANS 3715.6 70 999999999 3213.99 5148.76 percent of total billed charges Aspiration of bone marrow sample for diagnosis 51340142_1 CDM 0510 RC 38220 HCPCS inpatient 5308 3450.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3213.99 60.55 999999999 3213.99 5148.76 percent of total billed charges Aspiration of bone marrow sample for diagnosis 51340142_1 CDM 0510 RC 38220 HCPCS inpatient 5308 3450.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3213.99 5148.76 Aspiration of bone marrow sample for diagnosis 51340142_1 CDM 0510 RC 38220 HCPCS inpatient 5308 3450.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3213.99 5148.76 Aspiration of bone marrow sample for diagnosis 51340142_1 CDM 0510 RC 38220 HCPCS inpatient 5308 3450.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3213.99 5148.76 Aspiration of bone marrow sample for diagnosis 51340142_1 CDM 0510 RC 38220 HCPCS inpatient 5308 3450.2 ANTHEM HMO ANTHEM HMO 999999999 3213.99 5148.76 Aspiration of bone marrow sample for diagnosis 51340142_1 CDM 0510 RC 38220 HCPCS inpatient 5308 3450.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 3213.99 5148.76 Aspiration of bone marrow sample for diagnosis 51340142_1 CDM 0510 RC 38220 HCPCS inpatient 5308 3450.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 3588.21 67.6 999999999 3213.99 5148.76 percent of total billed charges Correction of rigid deformity of first joint of big toe 51340143_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Correction of rigid deformity of first joint of big toe 51340143_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Correction of rigid deformity of first joint of big toe 51340143_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Correction of rigid deformity of first joint of big toe 51340143_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Correction of rigid deformity of first joint of big toe 51340143_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Correction of rigid deformity of first joint of big toe 51340143_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Correction of rigid deformity of first joint of big toe 51340143_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Correction of rigid deformity of first joint of big toe 51340143_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Correction of rigid deformity of first joint of big toe 51340143_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Correction of rigid deformity of first joint of big toe 51340143_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Correction of rigid deformity of first joint of big toe 51340143_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Correction of rigid deformity of first joint of big toe 51340143_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Correction of rigid deformity of first joint of big toe 51340143_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Correction of rigid deformity of first joint of big toe 51340143_1 CDM 0510 RC 28289 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 51340144_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 51340144_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 51340144_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 51340144_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 51340144_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 51340144_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 51340144_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 51340144_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 51340144_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Correction of bunion with alignment correction of midfoot bone toward ankle 51340144_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Correction of bunion with alignment correction of midfoot bone toward ankle 51340144_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Correction of bunion with alignment correction of midfoot bone toward ankle 51340144_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Correction of bunion with alignment correction of midfoot bone toward ankle 51340144_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Correction of bunion with alignment correction of midfoot bone toward ankle 51340144_1 CDM 0510 RC 28295 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Repair of tendon of top side of foot 51340641_1 CDM 0510 RC 28208 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Repair of tendon of top side of foot 51340641_1 CDM 0510 RC 28208 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Repair of tendon of top side of foot 51340641_1 CDM 0510 RC 28208 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Repair of tendon of top side of foot 51340641_1 CDM 0510 RC 28208 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Repair of tendon of top side of foot 51340641_1 CDM 0510 RC 28208 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Repair of tendon of top side of foot 51340641_1 CDM 0510 RC 28208 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Repair of tendon of top side of foot 51340641_1 CDM 0510 RC 28208 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Repair of tendon of top side of foot 51340641_1 CDM 0510 RC 28208 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Repair of tendon of top side of foot 51340641_1 CDM 0510 RC 28208 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Repair of tendon of top side of foot 51340641_1 CDM 0510 RC 28208 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Repair of tendon of top side of foot 51340641_1 CDM 0510 RC 28208 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Repair of tendon of top side of foot 51340641_1 CDM 0510 RC 28208 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Repair of tendon of top side of foot 51340641_1 CDM 0510 RC 28208 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Repair of tendon of top side of foot 51340641_1 CDM 0510 RC 28208 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Application of stress by physician for joint imaging 51341756_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 200.2 65 999999999 186.49 298.76 percent of total billed charges Application of stress by physician for joint imaging 51341756_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 298.76 97 999999999 186.49 298.76 percent of total billed charges Application of stress by physician for joint imaging 51341756_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 AETNA AETNA 243.32 79 999999999 186.49 298.76 percent of total billed charges Application of stress by physician for joint imaging 51341756_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 240.24 78 999999999 186.49 298.76 percent of total billed charges Application of stress by physician for joint imaging 51341756_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 212.52 69 999999999 186.49 298.76 percent of total billed charges Application of stress by physician for joint imaging 51341756_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 SIHO - ALL PLANS SIHO - ALL PLANS 277.2 90 999999999 186.49 298.76 percent of total billed charges Application of stress by physician for joint imaging 51341756_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 UMR - ALL PLANS UMR - ALL PLANS 215.6 70 999999999 186.49 298.76 percent of total billed charges Application of stress by physician for joint imaging 51341756_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 186.49 60.55 999999999 186.49 298.76 percent of total billed charges Application of stress by physician for joint imaging 51341756_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 186.49 298.76 Application of stress by physician for joint imaging 51341756_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 186.49 298.76 Application of stress by physician for joint imaging 51341756_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 186.49 298.76 Application of stress by physician for joint imaging 51341756_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 ANTHEM HMO ANTHEM HMO 999999999 186.49 298.76 Application of stress by physician for joint imaging 51341756_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 186.49 298.76 Application of stress by physician for joint imaging 51341756_1 CDM 0510 RC 77071 HCPCS inpatient 308 200.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 208.21 67.6 999999999 186.49 298.76 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 51342253_1 CDM 0302 RC 86336 HCPCS inpatient 219 142.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 142.35 65 999999999 132.6 212.43 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 51342253_1 CDM 0302 RC 86336 HCPCS inpatient 219 142.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 212.43 97 999999999 132.6 212.43 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 51342253_1 CDM 0302 RC 86336 HCPCS inpatient 219 142.35 AETNA AETNA 173.01 79 999999999 132.6 212.43 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 51342253_1 CDM 0302 RC 86336 HCPCS inpatient 219 142.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.82 78 999999999 132.6 212.43 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 51342253_1 CDM 0302 RC 86336 HCPCS inpatient 219 142.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 151.11 69 999999999 132.6 212.43 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 51342253_1 CDM 0302 RC 86336 HCPCS inpatient 219 142.35 SIHO - ALL PLANS SIHO - ALL PLANS 197.1 90 999999999 132.6 212.43 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 51342253_1 CDM 0302 RC 86336 HCPCS inpatient 219 142.35 UMR - ALL PLANS UMR - ALL PLANS 153.3 70 999999999 132.6 212.43 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 51342253_1 CDM 0302 RC 86336 HCPCS inpatient 219 142.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132.6 60.55 999999999 132.6 212.43 percent of total billed charges Inhibin A (reproductive organ hormone) measurement 51342253_1 CDM 0302 RC 86336 HCPCS inpatient 219 142.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132.6 212.43 Inhibin A (reproductive organ hormone) measurement 51342253_1 CDM 0302 RC 86336 HCPCS inpatient 219 142.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132.6 212.43 Inhibin A (reproductive organ hormone) measurement 51342253_1 CDM 0302 RC 86336 HCPCS inpatient 219 142.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132.6 212.43 Inhibin A (reproductive organ hormone) measurement 51342253_1 CDM 0302 RC 86336 HCPCS inpatient 219 142.35 ANTHEM HMO ANTHEM HMO 999999999 132.6 212.43 Inhibin A (reproductive organ hormone) measurement 51342253_1 CDM 0302 RC 86336 HCPCS inpatient 219 142.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 132.6 212.43 Inhibin A (reproductive organ hormone) measurement 51342253_1 CDM 0302 RC 86336 HCPCS inpatient 219 142.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 148.04 67.6 999999999 132.6 212.43 percent of total billed charges Measurement of substance using immunoassay technique 51342300_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 64.35 65 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 51342300_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 96.03 97 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 51342300_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 AETNA AETNA 78.21 79 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 51342300_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 77.22 78 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 51342300_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 68.31 69 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 51342300_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 SIHO - ALL PLANS SIHO - ALL PLANS 89.1 90 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 51342300_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 UMR - ALL PLANS UMR - ALL PLANS 69.3 70 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 51342300_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.94 60.55 999999999 59.94 96.03 percent of total billed charges Measurement of substance using immunoassay technique 51342300_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.94 96.03 Measurement of substance using immunoassay technique 51342300_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.94 96.03 Measurement of substance using immunoassay technique 51342300_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.94 96.03 Measurement of substance using immunoassay technique 51342300_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 ANTHEM HMO ANTHEM HMO 999999999 59.94 96.03 Measurement of substance using immunoassay technique 51342300_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.94 96.03 Measurement of substance using immunoassay technique 51342300_1 CDM 0301 RC 83520 HCPCS inpatient 99 64.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.92 67.6 999999999 59.94 96.03 percent of total billed charges Estrone (hormone) level 51342301_1 CDM 0301 RC 82679 HCPCS inpatient 100 65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65 65 999999999 60.55 97 percent of total billed charges Estrone (hormone) level 51342301_1 CDM 0301 RC 82679 HCPCS inpatient 100 65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97 97 999999999 60.55 97 percent of total billed charges Estrone (hormone) level 51342301_1 CDM 0301 RC 82679 HCPCS inpatient 100 65 AETNA AETNA 79 79 999999999 60.55 97 percent of total billed charges Estrone (hormone) level 51342301_1 CDM 0301 RC 82679 HCPCS inpatient 100 65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78 78 999999999 60.55 97 percent of total billed charges Estrone (hormone) level 51342301_1 CDM 0301 RC 82679 HCPCS inpatient 100 65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69 69 999999999 60.55 97 percent of total billed charges Estrone (hormone) level 51342301_1 CDM 0301 RC 82679 HCPCS inpatient 100 65 SIHO - ALL PLANS SIHO - ALL PLANS 90 90 999999999 60.55 97 percent of total billed charges Estrone (hormone) level 51342301_1 CDM 0301 RC 82679 HCPCS inpatient 100 65 UMR - ALL PLANS UMR - ALL PLANS 70 70 999999999 60.55 97 percent of total billed charges Estrone (hormone) level 51342301_1 CDM 0301 RC 82679 HCPCS inpatient 100 65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.55 60.55 999999999 60.55 97 percent of total billed charges Estrone (hormone) level 51342301_1 CDM 0301 RC 82679 HCPCS inpatient 100 65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.55 97 Estrone (hormone) level 51342301_1 CDM 0301 RC 82679 HCPCS inpatient 100 65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.55 97 Estrone (hormone) level 51342301_1 CDM 0301 RC 82679 HCPCS inpatient 100 65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.55 97 Estrone (hormone) level 51342301_1 CDM 0301 RC 82679 HCPCS inpatient 100 65 ANTHEM HMO ANTHEM HMO 999999999 60.55 97 Estrone (hormone) level 51342301_1 CDM 0301 RC 82679 HCPCS inpatient 100 65 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.55 97 Estrone (hormone) level 51342301_1 CDM 0301 RC 82679 HCPCS inpatient 100 65 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.6 67.6 999999999 60.55 97 percent of total billed charges "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 12-25 targets" 51342343_1 CDM 0301 RC 87507 HCPCS inpatient 500 325 SELF PAY DISCOUNT SELF PAY DISCOUNT 325 65 999999999 302.75 485 percent of total billed charges "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 12-25 targets" 51342343_1 CDM 0301 RC 87507 HCPCS inpatient 500 325 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 485 97 999999999 302.75 485 percent of total billed charges "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 12-25 targets" 51342343_1 CDM 0301 RC 87507 HCPCS inpatient 500 325 AETNA AETNA 395 79 999999999 302.75 485 percent of total billed charges "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 12-25 targets" 51342343_1 CDM 0301 RC 87507 HCPCS inpatient 500 325 HUMANA - ALL PLANS HUMANA - ALL PLANS 390 78 999999999 302.75 485 percent of total billed charges "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 12-25 targets" 51342343_1 CDM 0301 RC 87507 HCPCS inpatient 500 325 ENCORE - ALL PLANS ENCORE - ALL PLANS 345 69 999999999 302.75 485 percent of total billed charges "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 12-25 targets" 51342343_1 CDM 0301 RC 87507 HCPCS inpatient 500 325 SIHO - ALL PLANS SIHO - ALL PLANS 450 90 999999999 302.75 485 percent of total billed charges "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 12-25 targets" 51342343_1 CDM 0301 RC 87507 HCPCS inpatient 500 325 UMR - ALL PLANS UMR - ALL PLANS 350 70 999999999 302.75 485 percent of total billed charges "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 12-25 targets" 51342343_1 CDM 0301 RC 87507 HCPCS inpatient 500 325 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 302.75 60.55 999999999 302.75 485 percent of total billed charges "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 12-25 targets" 51342343_1 CDM 0301 RC 87507 HCPCS inpatient 500 325 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 302.75 485 "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 12-25 targets" 51342343_1 CDM 0301 RC 87507 HCPCS inpatient 500 325 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 302.75 485 "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 12-25 targets" 51342343_1 CDM 0301 RC 87507 HCPCS inpatient 500 325 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 302.75 485 "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 12-25 targets" 51342343_1 CDM 0301 RC 87507 HCPCS inpatient 500 325 ANTHEM HMO ANTHEM HMO 999999999 302.75 485 "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 12-25 targets" 51342343_1 CDM 0301 RC 87507 HCPCS inpatient 500 325 UHC - ALL PLANS UHC - ALL PLANS 999999999 302.75 485 "Detection test by nucleic acid for digestive tract pathogen, multiple types or subtypes, 12-25 targets" 51342343_1 CDM 0301 RC 87507 HCPCS inpatient 500 325 CIGNA - ALL PLANS CIGNA - ALL PLANS 338 67.6 999999999 302.75 485 percent of total billed charges Screening test for antibody to noninfectious agent 51342465_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 51342465_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 51342465_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 51342465_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 51342465_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 51342465_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 51342465_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 51342465_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Screening test for antibody to noninfectious agent 51342465_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 51342465_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 51342465_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 51342465_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 51342465_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 Screening test for antibody to noninfectious agent 51342465_1 CDM 0302 RC 86255 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges "STAY-SAFE DIALYSIS CATHETER EXTENSION SET WITH LUER LOCK, 12"" 050-95004" 51346763_1 CDM 0272 RC inpatient 192.75 125.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 125.29 65 999999999 116.71 186.97 percent of total billed charges "STAY-SAFE DIALYSIS CATHETER EXTENSION SET WITH LUER LOCK, 12"" 050-95004" 51346763_1 CDM 0272 RC inpatient 192.75 125.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 186.97 97 999999999 116.71 186.97 percent of total billed charges "STAY-SAFE DIALYSIS CATHETER EXTENSION SET WITH LUER LOCK, 12"" 050-95004" 51346763_1 CDM 0272 RC inpatient 192.75 125.29 AETNA AETNA 152.27 79 999999999 116.71 186.97 percent of total billed charges "STAY-SAFE DIALYSIS CATHETER EXTENSION SET WITH LUER LOCK, 12"" 050-95004" 51346763_1 CDM 0272 RC inpatient 192.75 125.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 150.35 78 999999999 116.71 186.97 percent of total billed charges "STAY-SAFE DIALYSIS CATHETER EXTENSION SET WITH LUER LOCK, 12"" 050-95004" 51346763_1 CDM 0272 RC inpatient 192.75 125.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 133 69 999999999 116.71 186.97 percent of total billed charges "STAY-SAFE DIALYSIS CATHETER EXTENSION SET WITH LUER LOCK, 12"" 050-95004" 51346763_1 CDM 0272 RC inpatient 192.75 125.29 SIHO - ALL PLANS SIHO - ALL PLANS 173.48 90 999999999 116.71 186.97 percent of total billed charges "STAY-SAFE DIALYSIS CATHETER EXTENSION SET WITH LUER LOCK, 12"" 050-95004" 51346763_1 CDM 0272 RC inpatient 192.75 125.29 UMR - ALL PLANS UMR - ALL PLANS 134.93 70 999999999 116.71 186.97 percent of total billed charges "STAY-SAFE DIALYSIS CATHETER EXTENSION SET WITH LUER LOCK, 12"" 050-95004" 51346763_1 CDM 0272 RC inpatient 192.75 125.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.71 60.55 999999999 116.71 186.97 percent of total billed charges "STAY-SAFE DIALYSIS CATHETER EXTENSION SET WITH LUER LOCK, 12"" 050-95004" 51346763_1 CDM 0272 RC inpatient 192.75 125.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.71 186.97 "STAY-SAFE DIALYSIS CATHETER EXTENSION SET WITH LUER LOCK, 12"" 050-95004" 51346763_1 CDM 0272 RC inpatient 192.75 125.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.71 186.97 "STAY-SAFE DIALYSIS CATHETER EXTENSION SET WITH LUER LOCK, 12"" 050-95004" 51346763_1 CDM 0272 RC inpatient 192.75 125.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.71 186.97 "STAY-SAFE DIALYSIS CATHETER EXTENSION SET WITH LUER LOCK, 12"" 050-95004" 51346763_1 CDM 0272 RC inpatient 192.75 125.29 ANTHEM HMO ANTHEM HMO 999999999 116.71 186.97 "STAY-SAFE DIALYSIS CATHETER EXTENSION SET WITH LUER LOCK, 12"" 050-95004" 51346763_1 CDM 0272 RC inpatient 192.75 125.29 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.71 186.97 "STAY-SAFE DIALYSIS CATHETER EXTENSION SET WITH LUER LOCK, 12"" 050-95004" 51346763_1 CDM 0272 RC inpatient 192.75 125.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 130.3 67.6 999999999 116.71 186.97 percent of total billed charges Bacterial culture for aerobic isolates 51349190_1 CDM 0306 RC 87077 HCPCS inpatient 98 63.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.7 65 999999999 59.34 95.06 percent of total billed charges Bacterial culture for aerobic isolates 51349190_1 CDM 0306 RC 87077 HCPCS inpatient 98 63.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 95.06 97 999999999 59.34 95.06 percent of total billed charges Bacterial culture for aerobic isolates 51349190_1 CDM 0306 RC 87077 HCPCS inpatient 98 63.7 AETNA AETNA 77.42 79 999999999 59.34 95.06 percent of total billed charges Bacterial culture for aerobic isolates 51349190_1 CDM 0306 RC 87077 HCPCS inpatient 98 63.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 76.44 78 999999999 59.34 95.06 percent of total billed charges Bacterial culture for aerobic isolates 51349190_1 CDM 0306 RC 87077 HCPCS inpatient 98 63.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 67.62 69 999999999 59.34 95.06 percent of total billed charges Bacterial culture for aerobic isolates 51349190_1 CDM 0306 RC 87077 HCPCS inpatient 98 63.7 SIHO - ALL PLANS SIHO - ALL PLANS 88.2 90 999999999 59.34 95.06 percent of total billed charges Bacterial culture for aerobic isolates 51349190_1 CDM 0306 RC 87077 HCPCS inpatient 98 63.7 UMR - ALL PLANS UMR - ALL PLANS 68.6 70 999999999 59.34 95.06 percent of total billed charges Bacterial culture for aerobic isolates 51349190_1 CDM 0306 RC 87077 HCPCS inpatient 98 63.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 59.34 60.55 999999999 59.34 95.06 percent of total billed charges Bacterial culture for aerobic isolates 51349190_1 CDM 0306 RC 87077 HCPCS inpatient 98 63.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 59.34 95.06 Bacterial culture for aerobic isolates 51349190_1 CDM 0306 RC 87077 HCPCS inpatient 98 63.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 59.34 95.06 Bacterial culture for aerobic isolates 51349190_1 CDM 0306 RC 87077 HCPCS inpatient 98 63.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 59.34 95.06 Bacterial culture for aerobic isolates 51349190_1 CDM 0306 RC 87077 HCPCS inpatient 98 63.7 ANTHEM HMO ANTHEM HMO 999999999 59.34 95.06 Bacterial culture for aerobic isolates 51349190_1 CDM 0306 RC 87077 HCPCS inpatient 98 63.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 59.34 95.06 Bacterial culture for aerobic isolates 51349190_1 CDM 0306 RC 87077 HCPCS inpatient 98 63.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 66.25 67.6 999999999 59.34 95.06 percent of total billed charges Collection of blood sample from central venous tube 51349311_1 CDM 0300 RC 36592 HCPCS inpatient 353 229.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 229.45 65 999999999 213.74 342.41 percent of total billed charges Collection of blood sample from central venous tube 51349311_1 CDM 0300 RC 36592 HCPCS inpatient 353 229.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 342.41 97 999999999 213.74 342.41 percent of total billed charges Collection of blood sample from central venous tube 51349311_1 CDM 0300 RC 36592 HCPCS inpatient 353 229.45 AETNA AETNA 278.87 79 999999999 213.74 342.41 percent of total billed charges Collection of blood sample from central venous tube 51349311_1 CDM 0300 RC 36592 HCPCS inpatient 353 229.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 275.34 78 999999999 213.74 342.41 percent of total billed charges Collection of blood sample from central venous tube 51349311_1 CDM 0300 RC 36592 HCPCS inpatient 353 229.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 243.57 69 999999999 213.74 342.41 percent of total billed charges Collection of blood sample from central venous tube 51349311_1 CDM 0300 RC 36592 HCPCS inpatient 353 229.45 SIHO - ALL PLANS SIHO - ALL PLANS 317.7 90 999999999 213.74 342.41 percent of total billed charges Collection of blood sample from central venous tube 51349311_1 CDM 0300 RC 36592 HCPCS inpatient 353 229.45 UMR - ALL PLANS UMR - ALL PLANS 247.1 70 999999999 213.74 342.41 percent of total billed charges Collection of blood sample from central venous tube 51349311_1 CDM 0300 RC 36592 HCPCS inpatient 353 229.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 213.74 60.55 999999999 213.74 342.41 percent of total billed charges Collection of blood sample from central venous tube 51349311_1 CDM 0300 RC 36592 HCPCS inpatient 353 229.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 213.74 342.41 Collection of blood sample from central venous tube 51349311_1 CDM 0300 RC 36592 HCPCS inpatient 353 229.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 213.74 342.41 Collection of blood sample from central venous tube 51349311_1 CDM 0300 RC 36592 HCPCS inpatient 353 229.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 213.74 342.41 Collection of blood sample from central venous tube 51349311_1 CDM 0300 RC 36592 HCPCS inpatient 353 229.45 ANTHEM HMO ANTHEM HMO 999999999 213.74 342.41 Collection of blood sample from central venous tube 51349311_1 CDM 0300 RC 36592 HCPCS inpatient 353 229.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 213.74 342.41 Collection of blood sample from central venous tube 51349311_1 CDM 0300 RC 36592 HCPCS inpatient 353 229.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 238.63 67.6 999999999 213.74 342.41 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP 51350493_1 CDM 0250 RC 60687-0738-56 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP 51350493_1 CDM 0250 RC 60687-0738-56 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP 51350493_1 CDM 0250 RC 60687-0738-56 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP 51350493_1 CDM 0250 RC 60687-0738-56 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP 51350493_1 CDM 0250 RC 60687-0738-56 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP 51350493_1 CDM 0250 RC 60687-0738-56 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP 51350493_1 CDM 0250 RC 60687-0738-56 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP 51350493_1 CDM 0250 RC 60687-0738-56 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges SUCRALFATE 1 GM/10 ML SUSP 51350493_1 CDM 0250 RC 60687-0738-56 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 SUCRALFATE 1 GM/10 ML SUSP 51350493_1 CDM 0250 RC 60687-0738-56 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 SUCRALFATE 1 GM/10 ML SUSP 51350493_1 CDM 0250 RC 60687-0738-56 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 SUCRALFATE 1 GM/10 ML SUSP 51350493_1 CDM 0250 RC 60687-0738-56 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 SUCRALFATE 1 GM/10 ML SUSP 51350493_1 CDM 0250 RC 60687-0738-56 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 SUCRALFATE 1 GM/10 ML SUSP 51350493_1 CDM 0250 RC 60687-0738-56 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350995_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350995_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350995_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350995_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350995_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350995_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350995_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350995_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350995_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350995_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350995_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350995_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350995_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350995_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350996_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350996_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350996_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350996_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350996_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350996_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350996_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350996_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350996_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350996_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350996_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350996_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350996_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350996_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350997_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350997_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350997_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350997_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350997_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350997_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350997_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350997_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350997_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350997_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350997_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350997_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350997_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51350997_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Incision or partial removal of big toe bone to straighten toe 51353855_1 CDM 0510 RC 28306 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone to straighten toe 51353855_1 CDM 0510 RC 28306 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone to straighten toe 51353855_1 CDM 0510 RC 28306 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone to straighten toe 51353855_1 CDM 0510 RC 28306 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone to straighten toe 51353855_1 CDM 0510 RC 28306 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone to straighten toe 51353855_1 CDM 0510 RC 28306 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone to straighten toe 51353855_1 CDM 0510 RC 28306 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone to straighten toe 51353855_1 CDM 0510 RC 28306 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Incision or partial removal of big toe bone to straighten toe 51353855_1 CDM 0510 RC 28306 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Incision or partial removal of big toe bone to straighten toe 51353855_1 CDM 0510 RC 28306 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Incision or partial removal of big toe bone to straighten toe 51353855_1 CDM 0510 RC 28306 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Incision or partial removal of big toe bone to straighten toe 51353855_1 CDM 0510 RC 28306 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Incision or partial removal of big toe bone to straighten toe 51353855_1 CDM 0510 RC 28306 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Incision or partial removal of big toe bone to straighten toe 51353855_1 CDM 0510 RC 28306 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354379_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354380_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354380_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354380_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354380_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354380_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354380_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354380_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354380_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354380_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354380_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354380_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354380_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354380_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354380_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354381_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354381_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354381_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354381_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354381_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354381_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354381_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354381_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354381_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354381_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354381_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354381_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354381_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354381_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354382_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354382_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354382_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354382_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354382_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354382_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354382_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354382_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354382_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354382_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354382_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354382_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354382_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51354382_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355695_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355695_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355695_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355695_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355695_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355695_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355695_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355695_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355695_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355695_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355695_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355695_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355695_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355695_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355696_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355696_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355696_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355696_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355696_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355696_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355696_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355696_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355696_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355696_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355696_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355696_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355696_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51355696_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51357851_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51357851_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51357851_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51357851_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51357851_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51357851_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51357851_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51357851_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51357851_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51357851_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51357851_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51357851_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51357851_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Measurement of antibody (IgE) to allergic substance, crude allergen extract, each" 51357851_1 CDM 0301 RC 86003 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Heart rhythm analysis and report of continous external EKG over more than 48 hours up to 7 days 51358164_1 CDM 0480 RC 93243 HCPCS inpatient 411 267.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 267.15 65 999999999 248.86 398.67 percent of total billed charges Heart rhythm analysis and report of continous external EKG over more than 48 hours up to 7 days 51358164_1 CDM 0480 RC 93243 HCPCS inpatient 411 267.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 398.67 97 999999999 248.86 398.67 percent of total billed charges Heart rhythm analysis and report of continous external EKG over more than 48 hours up to 7 days 51358164_1 CDM 0480 RC 93243 HCPCS inpatient 411 267.15 AETNA AETNA 324.69 79 999999999 248.86 398.67 percent of total billed charges Heart rhythm analysis and report of continous external EKG over more than 48 hours up to 7 days 51358164_1 CDM 0480 RC 93243 HCPCS inpatient 411 267.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 283.59 69 999999999 248.86 398.67 percent of total billed charges Heart rhythm analysis and report of continous external EKG over more than 48 hours up to 7 days 51358164_1 CDM 0480 RC 93243 HCPCS inpatient 411 267.15 SIHO - ALL PLANS SIHO - ALL PLANS 369.9 90 999999999 248.86 398.67 percent of total billed charges Heart rhythm analysis and report of continous external EKG over more than 48 hours up to 7 days 51358164_1 CDM 0480 RC 93243 HCPCS inpatient 411 267.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 320.58 78 999999999 248.86 398.67 percent of total billed charges Heart rhythm analysis and report of continous external EKG over more than 48 hours up to 7 days 51358164_1 CDM 0480 RC 93243 HCPCS inpatient 411 267.15 UMR - ALL PLANS UMR - ALL PLANS 287.7 70 999999999 248.86 398.67 percent of total billed charges Heart rhythm analysis and report of continous external EKG over more than 48 hours up to 7 days 51358164_1 CDM 0480 RC 93243 HCPCS inpatient 411 267.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 248.86 60.55 999999999 248.86 398.67 percent of total billed charges Heart rhythm analysis and report of continous external EKG over more than 48 hours up to 7 days 51358164_1 CDM 0480 RC 93243 HCPCS inpatient 411 267.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 248.86 398.67 Heart rhythm analysis and report of continous external EKG over more than 48 hours up to 7 days 51358164_1 CDM 0480 RC 93243 HCPCS inpatient 411 267.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 248.86 398.67 Heart rhythm analysis and report of continous external EKG over more than 48 hours up to 7 days 51358164_1 CDM 0480 RC 93243 HCPCS inpatient 411 267.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 248.86 398.67 Heart rhythm analysis and report of continous external EKG over more than 48 hours up to 7 days 51358164_1 CDM 0480 RC 93243 HCPCS inpatient 411 267.15 ANTHEM HMO ANTHEM HMO 999999999 248.86 398.67 Heart rhythm analysis and report of continous external EKG over more than 48 hours up to 7 days 51358164_1 CDM 0480 RC 93243 HCPCS inpatient 411 267.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 248.86 398.67 Heart rhythm analysis and report of continous external EKG over more than 48 hours up to 7 days 51358164_1 CDM 0480 RC 93243 HCPCS inpatient 411 267.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 277.84 67.6 999999999 248.86 398.67 percent of total billed charges "BED SENSOR PAD 13"" X 32"" 8283" 51378635_1 CDM 0250 RC inpatient 76.65 49.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.82 65 999999999 46.41 74.35 percent of total billed charges "BED SENSOR PAD 13"" X 32"" 8283" 51378635_1 CDM 0250 RC inpatient 76.65 49.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.35 97 999999999 46.41 74.35 percent of total billed charges "BED SENSOR PAD 13"" X 32"" 8283" 51378635_1 CDM 0250 RC inpatient 76.65 49.82 AETNA AETNA 60.55 79 999999999 46.41 74.35 percent of total billed charges "BED SENSOR PAD 13"" X 32"" 8283" 51378635_1 CDM 0250 RC inpatient 76.65 49.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.89 69 999999999 46.41 74.35 percent of total billed charges "BED SENSOR PAD 13"" X 32"" 8283" 51378635_1 CDM 0250 RC inpatient 76.65 49.82 SIHO - ALL PLANS SIHO - ALL PLANS 68.99 90 999999999 46.41 74.35 percent of total billed charges "BED SENSOR PAD 13"" X 32"" 8283" 51378635_1 CDM 0250 RC inpatient 76.65 49.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.79 78 999999999 46.41 74.35 percent of total billed charges "BED SENSOR PAD 13"" X 32"" 8283" 51378635_1 CDM 0250 RC inpatient 76.65 49.82 UMR - ALL PLANS UMR - ALL PLANS 53.66 70 999999999 46.41 74.35 percent of total billed charges "BED SENSOR PAD 13"" X 32"" 8283" 51378635_1 CDM 0250 RC inpatient 76.65 49.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.41 60.55 999999999 46.41 74.35 percent of total billed charges "BED SENSOR PAD 13"" X 32"" 8283" 51378635_1 CDM 0250 RC inpatient 76.65 49.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.41 74.35 "BED SENSOR PAD 13"" X 32"" 8283" 51378635_1 CDM 0250 RC inpatient 76.65 49.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.41 74.35 "BED SENSOR PAD 13"" X 32"" 8283" 51378635_1 CDM 0250 RC inpatient 76.65 49.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.41 74.35 "BED SENSOR PAD 13"" X 32"" 8283" 51378635_1 CDM 0250 RC inpatient 76.65 49.82 ANTHEM HMO ANTHEM HMO 999999999 46.41 74.35 "BED SENSOR PAD 13"" X 32"" 8283" 51378635_1 CDM 0250 RC inpatient 76.65 49.82 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.41 74.35 "BED SENSOR PAD 13"" X 32"" 8283" 51378635_1 CDM 0250 RC inpatient 76.65 49.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.82 67.6 999999999 46.41 74.35 percent of total billed charges Closed treatment of broken forearm bone on small finger side at elbow with manipulation 51380554_1 CDM 0450 RC 24675 HCPCS inpatient 5078 3300.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 3300.7 65 999999999 3074.73 4925.66 percent of total billed charges Closed treatment of broken forearm bone on small finger side at elbow with manipulation 51380554_1 CDM 0450 RC 24675 HCPCS inpatient 5078 3300.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4925.66 97 999999999 3074.73 4925.66 percent of total billed charges Closed treatment of broken forearm bone on small finger side at elbow with manipulation 51380554_1 CDM 0450 RC 24675 HCPCS inpatient 5078 3300.7 AETNA AETNA 4011.62 79 999999999 3074.73 4925.66 percent of total billed charges Closed treatment of broken forearm bone on small finger side at elbow with manipulation 51380554_1 CDM 0450 RC 24675 HCPCS inpatient 5078 3300.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 3503.82 69 999999999 3074.73 4925.66 percent of total billed charges Closed treatment of broken forearm bone on small finger side at elbow with manipulation 51380554_1 CDM 0450 RC 24675 HCPCS inpatient 5078 3300.7 SIHO - ALL PLANS SIHO - ALL PLANS 4570.2 90 999999999 3074.73 4925.66 percent of total billed charges Closed treatment of broken forearm bone on small finger side at elbow with manipulation 51380554_1 CDM 0450 RC 24675 HCPCS inpatient 5078 3300.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 3960.84 78 999999999 3074.73 4925.66 percent of total billed charges Closed treatment of broken forearm bone on small finger side at elbow with manipulation 51380554_1 CDM 0450 RC 24675 HCPCS inpatient 5078 3300.7 UMR - ALL PLANS UMR - ALL PLANS 3554.6 70 999999999 3074.73 4925.66 percent of total billed charges Closed treatment of broken forearm bone on small finger side at elbow with manipulation 51380554_1 CDM 0450 RC 24675 HCPCS inpatient 5078 3300.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3074.73 60.55 999999999 3074.73 4925.66 percent of total billed charges Closed treatment of broken forearm bone on small finger side at elbow with manipulation 51380554_1 CDM 0450 RC 24675 HCPCS inpatient 5078 3300.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3074.73 4925.66 Closed treatment of broken forearm bone on small finger side at elbow with manipulation 51380554_1 CDM 0450 RC 24675 HCPCS inpatient 5078 3300.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3074.73 4925.66 Closed treatment of broken forearm bone on small finger side at elbow with manipulation 51380554_1 CDM 0450 RC 24675 HCPCS inpatient 5078 3300.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3074.73 4925.66 Closed treatment of broken forearm bone on small finger side at elbow with manipulation 51380554_1 CDM 0450 RC 24675 HCPCS inpatient 5078 3300.7 ANTHEM HMO ANTHEM HMO 999999999 3074.73 4925.66 Closed treatment of broken forearm bone on small finger side at elbow with manipulation 51380554_1 CDM 0450 RC 24675 HCPCS inpatient 5078 3300.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 3074.73 4925.66 Closed treatment of broken forearm bone on small finger side at elbow with manipulation 51380554_1 CDM 0450 RC 24675 HCPCS inpatient 5078 3300.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 3432.73 67.6 999999999 3074.73 4925.66 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 51389076_1 CDM 0483 RC 93351 HCPCS inpatient 4501 2925.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 2925.65 65 999999999 2725.36 4365.97 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 51389076_1 CDM 0483 RC 93351 HCPCS inpatient 4501 2925.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4365.97 97 999999999 2725.36 4365.97 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 51389076_1 CDM 0483 RC 93351 HCPCS inpatient 4501 2925.65 AETNA AETNA 3555.79 79 999999999 2725.36 4365.97 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 51389076_1 CDM 0483 RC 93351 HCPCS inpatient 4501 2925.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 3105.69 69 999999999 2725.36 4365.97 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 51389076_1 CDM 0483 RC 93351 HCPCS inpatient 4501 2925.65 SIHO - ALL PLANS SIHO - ALL PLANS 4050.9 90 999999999 2725.36 4365.97 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 51389076_1 CDM 0483 RC 93351 HCPCS inpatient 4501 2925.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 3510.78 78 999999999 2725.36 4365.97 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 51389076_1 CDM 0483 RC 93351 HCPCS inpatient 4501 2925.65 UMR - ALL PLANS UMR - ALL PLANS 3150.7 70 999999999 2725.36 4365.97 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 51389076_1 CDM 0483 RC 93351 HCPCS inpatient 4501 2925.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2725.36 60.55 999999999 2725.36 4365.97 percent of total billed charges "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 51389076_1 CDM 0483 RC 93351 HCPCS inpatient 4501 2925.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2725.36 4365.97 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 51389076_1 CDM 0483 RC 93351 HCPCS inpatient 4501 2925.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2725.36 4365.97 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 51389076_1 CDM 0483 RC 93351 HCPCS inpatient 4501 2925.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2725.36 4365.97 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 51389076_1 CDM 0483 RC 93351 HCPCS inpatient 4501 2925.65 ANTHEM HMO ANTHEM HMO 999999999 2725.36 4365.97 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 51389076_1 CDM 0483 RC 93351 HCPCS inpatient 4501 2925.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 2725.36 4365.97 "Ultrasound of heart with continuous electrocardiogram (ECG) during rest, exercise and/or drug induced stress with review and report" 51389076_1 CDM 0483 RC 93351 HCPCS inpatient 4501 2925.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 3042.68 67.6 999999999 2725.36 4365.97 percent of total billed charges Other procedure on male genital system 51394044_1 CDM 0450 RC 55899 HCPCS inpatient 760.65 494.42 SELF PAY DISCOUNT SELF PAY DISCOUNT 494.42 65 999999999 460.57 737.83 percent of total billed charges Other procedure on male genital system 51394044_1 CDM 0450 RC 55899 HCPCS inpatient 760.65 494.42 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 737.83 97 999999999 460.57 737.83 percent of total billed charges Other procedure on male genital system 51394044_1 CDM 0450 RC 55899 HCPCS inpatient 760.65 494.42 AETNA AETNA 600.91 79 999999999 460.57 737.83 percent of total billed charges Other procedure on male genital system 51394044_1 CDM 0450 RC 55899 HCPCS inpatient 760.65 494.42 ENCORE - ALL PLANS ENCORE - ALL PLANS 524.85 69 999999999 460.57 737.83 percent of total billed charges Other procedure on male genital system 51394044_1 CDM 0450 RC 55899 HCPCS inpatient 760.65 494.42 SIHO - ALL PLANS SIHO - ALL PLANS 684.59 90 999999999 460.57 737.83 percent of total billed charges Other procedure on male genital system 51394044_1 CDM 0450 RC 55899 HCPCS inpatient 760.65 494.42 HUMANA - ALL PLANS HUMANA - ALL PLANS 593.31 78 999999999 460.57 737.83 percent of total billed charges Other procedure on male genital system 51394044_1 CDM 0450 RC 55899 HCPCS inpatient 760.65 494.42 UMR - ALL PLANS UMR - ALL PLANS 532.46 70 999999999 460.57 737.83 percent of total billed charges Other procedure on male genital system 51394044_1 CDM 0450 RC 55899 HCPCS inpatient 760.65 494.42 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 460.57 60.55 999999999 460.57 737.83 percent of total billed charges Other procedure on male genital system 51394044_1 CDM 0450 RC 55899 HCPCS inpatient 760.65 494.42 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 460.57 737.83 Other procedure on male genital system 51394044_1 CDM 0450 RC 55899 HCPCS inpatient 760.65 494.42 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 460.57 737.83 Other procedure on male genital system 51394044_1 CDM 0450 RC 55899 HCPCS inpatient 760.65 494.42 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 460.57 737.83 Other procedure on male genital system 51394044_1 CDM 0450 RC 55899 HCPCS inpatient 760.65 494.42 ANTHEM HMO ANTHEM HMO 999999999 460.57 737.83 Other procedure on male genital system 51394044_1 CDM 0450 RC 55899 HCPCS inpatient 760.65 494.42 UHC - ALL PLANS UHC - ALL PLANS 999999999 460.57 737.83 Other procedure on male genital system 51394044_1 CDM 0450 RC 55899 HCPCS inpatient 760.65 494.42 CIGNA - ALL PLANS CIGNA - ALL PLANS 514.2 67.6 999999999 460.57 737.83 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 51394160_1 CDM 0510 RC 76882 HCPCS inpatient 378 245.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 245.7 65 999999999 228.88 366.66 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 51394160_1 CDM 0510 RC 76882 HCPCS inpatient 378 245.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 366.66 97 999999999 228.88 366.66 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 51394160_1 CDM 0510 RC 76882 HCPCS inpatient 378 245.7 AETNA AETNA 298.62 79 999999999 228.88 366.66 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 51394160_1 CDM 0510 RC 76882 HCPCS inpatient 378 245.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 260.82 69 999999999 228.88 366.66 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 51394160_1 CDM 0510 RC 76882 HCPCS inpatient 378 245.7 SIHO - ALL PLANS SIHO - ALL PLANS 340.2 90 999999999 228.88 366.66 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 51394160_1 CDM 0510 RC 76882 HCPCS inpatient 378 245.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 294.84 78 999999999 228.88 366.66 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 51394160_1 CDM 0510 RC 76882 HCPCS inpatient 378 245.7 UMR - ALL PLANS UMR - ALL PLANS 264.6 70 999999999 228.88 366.66 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 51394160_1 CDM 0510 RC 76882 HCPCS inpatient 378 245.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 228.88 60.55 999999999 228.88 366.66 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 51394160_1 CDM 0510 RC 76882 HCPCS inpatient 378 245.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 228.88 366.66 Limited ultrasound scan of joint or other extremity structure except blood vessels 51394160_1 CDM 0510 RC 76882 HCPCS inpatient 378 245.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 228.88 366.66 Limited ultrasound scan of joint or other extremity structure except blood vessels 51394160_1 CDM 0510 RC 76882 HCPCS inpatient 378 245.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 228.88 366.66 Limited ultrasound scan of joint or other extremity structure except blood vessels 51394160_1 CDM 0510 RC 76882 HCPCS inpatient 378 245.7 ANTHEM HMO ANTHEM HMO 999999999 228.88 366.66 Limited ultrasound scan of joint or other extremity structure except blood vessels 51394160_1 CDM 0510 RC 76882 HCPCS inpatient 378 245.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 228.88 366.66 Limited ultrasound scan of joint or other extremity structure except blood vessels 51394160_1 CDM 0510 RC 76882 HCPCS inpatient 378 245.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 255.53 67.6 999999999 228.88 366.66 percent of total billed charges Aspiration and/or injection of fluid from small joint 51394163_1 CDM 0510 RC 20600 HCPCS inpatient 962 625.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 625.3 65 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from small joint 51394163_1 CDM 0510 RC 20600 HCPCS inpatient 962 625.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 933.14 97 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from small joint 51394163_1 CDM 0510 RC 20600 HCPCS inpatient 962 625.3 AETNA AETNA 759.98 79 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from small joint 51394163_1 CDM 0510 RC 20600 HCPCS inpatient 962 625.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 663.78 69 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from small joint 51394163_1 CDM 0510 RC 20600 HCPCS inpatient 962 625.3 SIHO - ALL PLANS SIHO - ALL PLANS 865.8 90 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from small joint 51394163_1 CDM 0510 RC 20600 HCPCS inpatient 962 625.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 750.36 78 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from small joint 51394163_1 CDM 0510 RC 20600 HCPCS inpatient 962 625.3 UMR - ALL PLANS UMR - ALL PLANS 673.4 70 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from small joint 51394163_1 CDM 0510 RC 20600 HCPCS inpatient 962 625.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 582.49 60.55 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from small joint 51394163_1 CDM 0510 RC 20600 HCPCS inpatient 962 625.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 582.49 933.14 Aspiration and/or injection of fluid from small joint 51394163_1 CDM 0510 RC 20600 HCPCS inpatient 962 625.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 582.49 933.14 Aspiration and/or injection of fluid from small joint 51394163_1 CDM 0510 RC 20600 HCPCS inpatient 962 625.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 582.49 933.14 Aspiration and/or injection of fluid from small joint 51394163_1 CDM 0510 RC 20600 HCPCS inpatient 962 625.3 ANTHEM HMO ANTHEM HMO 999999999 582.49 933.14 Aspiration and/or injection of fluid from small joint 51394163_1 CDM 0510 RC 20600 HCPCS inpatient 962 625.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 582.49 933.14 Aspiration and/or injection of fluid from small joint 51394163_1 CDM 0510 RC 20600 HCPCS inpatient 962 625.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 650.31 67.6 999999999 582.49 933.14 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.5 cm or less" 51394377_1 CDM 0510 RC 11420 HCPCS inpatient 5308 3450.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 3450.2 65 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.5 cm or less" 51394377_1 CDM 0510 RC 11420 HCPCS inpatient 5308 3450.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5148.76 97 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.5 cm or less" 51394377_1 CDM 0510 RC 11420 HCPCS inpatient 5308 3450.2 AETNA AETNA 4193.32 79 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.5 cm or less" 51394377_1 CDM 0510 RC 11420 HCPCS inpatient 5308 3450.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 3662.52 69 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.5 cm or less" 51394377_1 CDM 0510 RC 11420 HCPCS inpatient 5308 3450.2 SIHO - ALL PLANS SIHO - ALL PLANS 4777.2 90 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.5 cm or less" 51394377_1 CDM 0510 RC 11420 HCPCS inpatient 5308 3450.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 4140.24 78 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.5 cm or less" 51394377_1 CDM 0510 RC 11420 HCPCS inpatient 5308 3450.2 UMR - ALL PLANS UMR - ALL PLANS 3715.6 70 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.5 cm or less" 51394377_1 CDM 0510 RC 11420 HCPCS inpatient 5308 3450.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3213.99 60.55 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.5 cm or less" 51394377_1 CDM 0510 RC 11420 HCPCS inpatient 5308 3450.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.5 cm or less" 51394377_1 CDM 0510 RC 11420 HCPCS inpatient 5308 3450.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.5 cm or less" 51394377_1 CDM 0510 RC 11420 HCPCS inpatient 5308 3450.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.5 cm or less" 51394377_1 CDM 0510 RC 11420 HCPCS inpatient 5308 3450.2 ANTHEM HMO ANTHEM HMO 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.5 cm or less" 51394377_1 CDM 0510 RC 11420 HCPCS inpatient 5308 3450.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.5 cm or less" 51394377_1 CDM 0510 RC 11420 HCPCS inpatient 5308 3450.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 3588.21 67.6 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm" 51394378_1 CDM 0510 RC 11422 HCPCS inpatient 5308 3450.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 3450.2 65 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm" 51394378_1 CDM 0510 RC 11422 HCPCS inpatient 5308 3450.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5148.76 97 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm" 51394378_1 CDM 0510 RC 11422 HCPCS inpatient 5308 3450.2 AETNA AETNA 4193.32 79 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm" 51394378_1 CDM 0510 RC 11422 HCPCS inpatient 5308 3450.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 3662.52 69 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm" 51394378_1 CDM 0510 RC 11422 HCPCS inpatient 5308 3450.2 SIHO - ALL PLANS SIHO - ALL PLANS 4777.2 90 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm" 51394378_1 CDM 0510 RC 11422 HCPCS inpatient 5308 3450.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 4140.24 78 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm" 51394378_1 CDM 0510 RC 11422 HCPCS inpatient 5308 3450.2 UMR - ALL PLANS UMR - ALL PLANS 3715.6 70 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm" 51394378_1 CDM 0510 RC 11422 HCPCS inpatient 5308 3450.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3213.99 60.55 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm" 51394378_1 CDM 0510 RC 11422 HCPCS inpatient 5308 3450.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm" 51394378_1 CDM 0510 RC 11422 HCPCS inpatient 5308 3450.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm" 51394378_1 CDM 0510 RC 11422 HCPCS inpatient 5308 3450.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm" 51394378_1 CDM 0510 RC 11422 HCPCS inpatient 5308 3450.2 ANTHEM HMO ANTHEM HMO 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm" 51394378_1 CDM 0510 RC 11422 HCPCS inpatient 5308 3450.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 1.1-2.0 cm" 51394378_1 CDM 0510 RC 11422 HCPCS inpatient 5308 3450.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 3588.21 67.6 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, more than 4.0 cm" 51394379_1 CDM 0510 RC 11426 HCPCS inpatient 9145 5944.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 5944.25 65 999999999 5537.3 8870.65 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, more than 4.0 cm" 51394379_1 CDM 0510 RC 11426 HCPCS inpatient 9145 5944.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8870.65 97 999999999 5537.3 8870.65 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, more than 4.0 cm" 51394379_1 CDM 0510 RC 11426 HCPCS inpatient 9145 5944.25 AETNA AETNA 7224.55 79 999999999 5537.3 8870.65 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, more than 4.0 cm" 51394379_1 CDM 0510 RC 11426 HCPCS inpatient 9145 5944.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 6310.05 69 999999999 5537.3 8870.65 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, more than 4.0 cm" 51394379_1 CDM 0510 RC 11426 HCPCS inpatient 9145 5944.25 SIHO - ALL PLANS SIHO - ALL PLANS 8230.5 90 999999999 5537.3 8870.65 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, more than 4.0 cm" 51394379_1 CDM 0510 RC 11426 HCPCS inpatient 9145 5944.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 7133.1 78 999999999 5537.3 8870.65 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, more than 4.0 cm" 51394379_1 CDM 0510 RC 11426 HCPCS inpatient 9145 5944.25 UMR - ALL PLANS UMR - ALL PLANS 6401.5 70 999999999 5537.3 8870.65 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, more than 4.0 cm" 51394379_1 CDM 0510 RC 11426 HCPCS inpatient 9145 5944.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5537.3 60.55 999999999 5537.3 8870.65 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, more than 4.0 cm" 51394379_1 CDM 0510 RC 11426 HCPCS inpatient 9145 5944.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5537.3 8870.65 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, more than 4.0 cm" 51394379_1 CDM 0510 RC 11426 HCPCS inpatient 9145 5944.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5537.3 8870.65 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, more than 4.0 cm" 51394379_1 CDM 0510 RC 11426 HCPCS inpatient 9145 5944.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5537.3 8870.65 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, more than 4.0 cm" 51394379_1 CDM 0510 RC 11426 HCPCS inpatient 9145 5944.25 ANTHEM HMO ANTHEM HMO 999999999 5537.3 8870.65 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, more than 4.0 cm" 51394379_1 CDM 0510 RC 11426 HCPCS inpatient 9145 5944.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 5537.3 8870.65 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, more than 4.0 cm" 51394379_1 CDM 0510 RC 11426 HCPCS inpatient 9145 5944.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 6182.02 67.6 999999999 5537.3 8870.65 percent of total billed charges "Removal of fingernails or toenails, 6 or more nails" 51394611_1 CDM 0510 RC 11721 HCPCS inpatient 204 132.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.6 65 999999999 123.52 197.88 percent of total billed charges "Removal of fingernails or toenails, 6 or more nails" 51394611_1 CDM 0510 RC 11721 HCPCS inpatient 204 132.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.88 97 999999999 123.52 197.88 percent of total billed charges "Removal of fingernails or toenails, 6 or more nails" 51394611_1 CDM 0510 RC 11721 HCPCS inpatient 204 132.6 AETNA AETNA 161.16 79 999999999 123.52 197.88 percent of total billed charges "Removal of fingernails or toenails, 6 or more nails" 51394611_1 CDM 0510 RC 11721 HCPCS inpatient 204 132.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.76 69 999999999 123.52 197.88 percent of total billed charges "Removal of fingernails or toenails, 6 or more nails" 51394611_1 CDM 0510 RC 11721 HCPCS inpatient 204 132.6 SIHO - ALL PLANS SIHO - ALL PLANS 183.6 90 999999999 123.52 197.88 percent of total billed charges "Removal of fingernails or toenails, 6 or more nails" 51394611_1 CDM 0510 RC 11721 HCPCS inpatient 204 132.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.12 78 999999999 123.52 197.88 percent of total billed charges "Removal of fingernails or toenails, 6 or more nails" 51394611_1 CDM 0510 RC 11721 HCPCS inpatient 204 132.6 UMR - ALL PLANS UMR - ALL PLANS 142.8 70 999999999 123.52 197.88 percent of total billed charges "Removal of fingernails or toenails, 6 or more nails" 51394611_1 CDM 0510 RC 11721 HCPCS inpatient 204 132.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.52 60.55 999999999 123.52 197.88 percent of total billed charges "Removal of fingernails or toenails, 6 or more nails" 51394611_1 CDM 0510 RC 11721 HCPCS inpatient 204 132.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.52 197.88 "Removal of fingernails or toenails, 6 or more nails" 51394611_1 CDM 0510 RC 11721 HCPCS inpatient 204 132.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.52 197.88 "Removal of fingernails or toenails, 6 or more nails" 51394611_1 CDM 0510 RC 11721 HCPCS inpatient 204 132.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.52 197.88 "Removal of fingernails or toenails, 6 or more nails" 51394611_1 CDM 0510 RC 11721 HCPCS inpatient 204 132.6 ANTHEM HMO ANTHEM HMO 999999999 123.52 197.88 "Removal of fingernails or toenails, 6 or more nails" 51394611_1 CDM 0510 RC 11721 HCPCS inpatient 204 132.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.52 197.88 "Removal of fingernails or toenails, 6 or more nails" 51394611_1 CDM 0510 RC 11721 HCPCS inpatient 204 132.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.9 67.6 999999999 123.52 197.88 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 51394918_1 CDM 0510 RC 99214 HCPCS inpatient 362 235.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 235.3 65 999999999 219.19 351.14 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 51394918_1 CDM 0510 RC 99214 HCPCS inpatient 362 235.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 351.14 97 999999999 219.19 351.14 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 51394918_1 CDM 0510 RC 99214 HCPCS inpatient 362 235.3 AETNA AETNA 285.98 79 999999999 219.19 351.14 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 51394918_1 CDM 0510 RC 99214 HCPCS inpatient 362 235.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 249.78 69 999999999 219.19 351.14 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 51394918_1 CDM 0510 RC 99214 HCPCS inpatient 362 235.3 SIHO - ALL PLANS SIHO - ALL PLANS 325.8 90 999999999 219.19 351.14 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 51394918_1 CDM 0510 RC 99214 HCPCS inpatient 362 235.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 282.36 78 999999999 219.19 351.14 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 51394918_1 CDM 0510 RC 99214 HCPCS inpatient 362 235.3 UMR - ALL PLANS UMR - ALL PLANS 253.4 70 999999999 219.19 351.14 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 51394918_1 CDM 0510 RC 99214 HCPCS inpatient 362 235.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 219.19 60.55 999999999 219.19 351.14 percent of total billed charges "Established patient office or other outpatient visit, 30-39 minutes" 51394918_1 CDM 0510 RC 99214 HCPCS inpatient 362 235.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 219.19 351.14 "Established patient office or other outpatient visit, 30-39 minutes" 51394918_1 CDM 0510 RC 99214 HCPCS inpatient 362 235.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 219.19 351.14 "Established patient office or other outpatient visit, 30-39 minutes" 51394918_1 CDM 0510 RC 99214 HCPCS inpatient 362 235.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 219.19 351.14 "Established patient office or other outpatient visit, 30-39 minutes" 51394918_1 CDM 0510 RC 99214 HCPCS inpatient 362 235.3 ANTHEM HMO ANTHEM HMO 999999999 219.19 351.14 "Established patient office or other outpatient visit, 30-39 minutes" 51394918_1 CDM 0510 RC 99214 HCPCS inpatient 362 235.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 219.19 351.14 "Established patient office or other outpatient visit, 30-39 minutes" 51394918_1 CDM 0510 RC 99214 HCPCS inpatient 362 235.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 244.71 67.6 999999999 219.19 351.14 percent of total billed charges "Outpatient consultation with moderate level of medical decision making, if using time, at least 40 minutes" 51394919_1 CDM 0510 RC 99244 HCPCS inpatient 470 305.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 305.5 65 999999999 284.59 455.9 percent of total billed charges "Outpatient consultation with moderate level of medical decision making, if using time, at least 40 minutes" 51394919_1 CDM 0510 RC 99244 HCPCS inpatient 470 305.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 455.9 97 999999999 284.59 455.9 percent of total billed charges "Outpatient consultation with moderate level of medical decision making, if using time, at least 40 minutes" 51394919_1 CDM 0510 RC 99244 HCPCS inpatient 470 305.5 AETNA AETNA 371.3 79 999999999 284.59 455.9 percent of total billed charges "Outpatient consultation with moderate level of medical decision making, if using time, at least 40 minutes" 51394919_1 CDM 0510 RC 99244 HCPCS inpatient 470 305.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 324.3 69 999999999 284.59 455.9 percent of total billed charges "Outpatient consultation with moderate level of medical decision making, if using time, at least 40 minutes" 51394919_1 CDM 0510 RC 99244 HCPCS inpatient 470 305.5 SIHO - ALL PLANS SIHO - ALL PLANS 423 90 999999999 284.59 455.9 percent of total billed charges "Outpatient consultation with moderate level of medical decision making, if using time, at least 40 minutes" 51394919_1 CDM 0510 RC 99244 HCPCS inpatient 470 305.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 366.6 78 999999999 284.59 455.9 percent of total billed charges "Outpatient consultation with moderate level of medical decision making, if using time, at least 40 minutes" 51394919_1 CDM 0510 RC 99244 HCPCS inpatient 470 305.5 UMR - ALL PLANS UMR - ALL PLANS 329 70 999999999 284.59 455.9 percent of total billed charges "Outpatient consultation with moderate level of medical decision making, if using time, at least 40 minutes" 51394919_1 CDM 0510 RC 99244 HCPCS inpatient 470 305.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 284.59 60.55 999999999 284.59 455.9 percent of total billed charges "Outpatient consultation with moderate level of medical decision making, if using time, at least 40 minutes" 51394919_1 CDM 0510 RC 99244 HCPCS inpatient 470 305.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 284.59 455.9 "Outpatient consultation with moderate level of medical decision making, if using time, at least 40 minutes" 51394919_1 CDM 0510 RC 99244 HCPCS inpatient 470 305.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 284.59 455.9 "Outpatient consultation with moderate level of medical decision making, if using time, at least 40 minutes" 51394919_1 CDM 0510 RC 99244 HCPCS inpatient 470 305.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 284.59 455.9 "Outpatient consultation with moderate level of medical decision making, if using time, at least 40 minutes" 51394919_1 CDM 0510 RC 99244 HCPCS inpatient 470 305.5 ANTHEM HMO ANTHEM HMO 999999999 284.59 455.9 "Outpatient consultation with moderate level of medical decision making, if using time, at least 40 minutes" 51394919_1 CDM 0510 RC 99244 HCPCS inpatient 470 305.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 284.59 455.9 "Outpatient consultation with moderate level of medical decision making, if using time, at least 40 minutes" 51394919_1 CDM 0510 RC 99244 HCPCS inpatient 470 305.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 317.72 67.6 999999999 284.59 455.9 percent of total billed charges "Phenytoin level, free" 51394946_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 140.4 65 999999999 130.79 209.52 percent of total billed charges "Phenytoin level, free" 51394946_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 209.52 97 999999999 130.79 209.52 percent of total billed charges "Phenytoin level, free" 51394946_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 AETNA AETNA 170.64 79 999999999 130.79 209.52 percent of total billed charges "Phenytoin level, free" 51394946_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 149.04 69 999999999 130.79 209.52 percent of total billed charges "Phenytoin level, free" 51394946_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 SIHO - ALL PLANS SIHO - ALL PLANS 194.4 90 999999999 130.79 209.52 percent of total billed charges "Phenytoin level, free" 51394946_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 168.48 78 999999999 130.79 209.52 percent of total billed charges "Phenytoin level, free" 51394946_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 UMR - ALL PLANS UMR - ALL PLANS 151.2 70 999999999 130.79 209.52 percent of total billed charges "Phenytoin level, free" 51394946_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 130.79 60.55 999999999 130.79 209.52 percent of total billed charges "Phenytoin level, free" 51394946_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 130.79 209.52 "Phenytoin level, free" 51394946_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 130.79 209.52 "Phenytoin level, free" 51394946_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 130.79 209.52 "Phenytoin level, free" 51394946_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 ANTHEM HMO ANTHEM HMO 999999999 130.79 209.52 "Phenytoin level, free" 51394946_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 130.79 209.52 "Phenytoin level, free" 51394946_1 CDM 0301 RC 80186 HCPCS inpatient 216 140.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 146.02 67.6 999999999 130.79 209.52 percent of total billed charges Cyanocobalamin (vitamin B-12) level 51396027_1 CDM 0301 RC 82607 HCPCS inpatient 194 126.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 126.1 65 999999999 117.47 188.18 percent of total billed charges Cyanocobalamin (vitamin B-12) level 51396027_1 CDM 0301 RC 82607 HCPCS inpatient 194 126.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 188.18 97 999999999 117.47 188.18 percent of total billed charges Cyanocobalamin (vitamin B-12) level 51396027_1 CDM 0301 RC 82607 HCPCS inpatient 194 126.1 AETNA AETNA 153.26 79 999999999 117.47 188.18 percent of total billed charges Cyanocobalamin (vitamin B-12) level 51396027_1 CDM 0301 RC 82607 HCPCS inpatient 194 126.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.86 69 999999999 117.47 188.18 percent of total billed charges Cyanocobalamin (vitamin B-12) level 51396027_1 CDM 0301 RC 82607 HCPCS inpatient 194 126.1 SIHO - ALL PLANS SIHO - ALL PLANS 174.6 90 999999999 117.47 188.18 percent of total billed charges Cyanocobalamin (vitamin B-12) level 51396027_1 CDM 0301 RC 82607 HCPCS inpatient 194 126.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 151.32 78 999999999 117.47 188.18 percent of total billed charges Cyanocobalamin (vitamin B-12) level 51396027_1 CDM 0301 RC 82607 HCPCS inpatient 194 126.1 UMR - ALL PLANS UMR - ALL PLANS 135.8 70 999999999 117.47 188.18 percent of total billed charges Cyanocobalamin (vitamin B-12) level 51396027_1 CDM 0301 RC 82607 HCPCS inpatient 194 126.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 117.47 60.55 999999999 117.47 188.18 percent of total billed charges Cyanocobalamin (vitamin B-12) level 51396027_1 CDM 0301 RC 82607 HCPCS inpatient 194 126.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 117.47 188.18 Cyanocobalamin (vitamin B-12) level 51396027_1 CDM 0301 RC 82607 HCPCS inpatient 194 126.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 117.47 188.18 Cyanocobalamin (vitamin B-12) level 51396027_1 CDM 0301 RC 82607 HCPCS inpatient 194 126.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 117.47 188.18 Cyanocobalamin (vitamin B-12) level 51396027_1 CDM 0301 RC 82607 HCPCS inpatient 194 126.1 ANTHEM HMO ANTHEM HMO 999999999 117.47 188.18 Cyanocobalamin (vitamin B-12) level 51396027_1 CDM 0301 RC 82607 HCPCS inpatient 194 126.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 117.47 188.18 Cyanocobalamin (vitamin B-12) level 51396027_1 CDM 0301 RC 82607 HCPCS inpatient 194 126.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 131.14 67.6 999999999 117.47 188.18 percent of total billed charges Injection into tendon or ligament 51396132_1 CDM 0510 RC 20550 HCPCS inpatient 962 625.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 625.3 65 999999999 582.49 933.14 percent of total billed charges Injection into tendon or ligament 51396132_1 CDM 0510 RC 20550 HCPCS inpatient 962 625.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 933.14 97 999999999 582.49 933.14 percent of total billed charges Injection into tendon or ligament 51396132_1 CDM 0510 RC 20550 HCPCS inpatient 962 625.3 AETNA AETNA 759.98 79 999999999 582.49 933.14 percent of total billed charges Injection into tendon or ligament 51396132_1 CDM 0510 RC 20550 HCPCS inpatient 962 625.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 663.78 69 999999999 582.49 933.14 percent of total billed charges Injection into tendon or ligament 51396132_1 CDM 0510 RC 20550 HCPCS inpatient 962 625.3 SIHO - ALL PLANS SIHO - ALL PLANS 865.8 90 999999999 582.49 933.14 percent of total billed charges Injection into tendon or ligament 51396132_1 CDM 0510 RC 20550 HCPCS inpatient 962 625.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 750.36 78 999999999 582.49 933.14 percent of total billed charges Injection into tendon or ligament 51396132_1 CDM 0510 RC 20550 HCPCS inpatient 962 625.3 UMR - ALL PLANS UMR - ALL PLANS 673.4 70 999999999 582.49 933.14 percent of total billed charges Injection into tendon or ligament 51396132_1 CDM 0510 RC 20550 HCPCS inpatient 962 625.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 582.49 60.55 999999999 582.49 933.14 percent of total billed charges Injection into tendon or ligament 51396132_1 CDM 0510 RC 20550 HCPCS inpatient 962 625.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 582.49 933.14 Injection into tendon or ligament 51396132_1 CDM 0510 RC 20550 HCPCS inpatient 962 625.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 582.49 933.14 Injection into tendon or ligament 51396132_1 CDM 0510 RC 20550 HCPCS inpatient 962 625.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 582.49 933.14 Injection into tendon or ligament 51396132_1 CDM 0510 RC 20550 HCPCS inpatient 962 625.3 ANTHEM HMO ANTHEM HMO 999999999 582.49 933.14 Injection into tendon or ligament 51396132_1 CDM 0510 RC 20550 HCPCS inpatient 962 625.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 582.49 933.14 Injection into tendon or ligament 51396132_1 CDM 0510 RC 20550 HCPCS inpatient 962 625.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 650.31 67.6 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 51396134_1 CDM 0510 RC 20604 HCPCS inpatient 872 566.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 566.8 65 999999999 528 845.84 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 51396134_1 CDM 0510 RC 20604 HCPCS inpatient 872 566.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 845.84 97 999999999 528 845.84 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 51396134_1 CDM 0510 RC 20604 HCPCS inpatient 872 566.8 AETNA AETNA 688.88 79 999999999 528 845.84 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 51396134_1 CDM 0510 RC 20604 HCPCS inpatient 872 566.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 601.68 69 999999999 528 845.84 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 51396134_1 CDM 0510 RC 20604 HCPCS inpatient 872 566.8 SIHO - ALL PLANS SIHO - ALL PLANS 784.8 90 999999999 528 845.84 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 51396134_1 CDM 0510 RC 20604 HCPCS inpatient 872 566.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 680.16 78 999999999 528 845.84 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 51396134_1 CDM 0510 RC 20604 HCPCS inpatient 872 566.8 UMR - ALL PLANS UMR - ALL PLANS 610.4 70 999999999 528 845.84 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 51396134_1 CDM 0510 RC 20604 HCPCS inpatient 872 566.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 528 60.55 999999999 528 845.84 percent of total billed charges Aspiration and/or injection of fluid from small joint using ultrasound guidance 51396134_1 CDM 0510 RC 20604 HCPCS inpatient 872 566.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 528 845.84 Aspiration and/or injection of fluid from small joint using ultrasound guidance 51396134_1 CDM 0510 RC 20604 HCPCS inpatient 872 566.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 528 845.84 Aspiration and/or injection of fluid from small joint using ultrasound guidance 51396134_1 CDM 0510 RC 20604 HCPCS inpatient 872 566.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 528 845.84 Aspiration and/or injection of fluid from small joint using ultrasound guidance 51396134_1 CDM 0510 RC 20604 HCPCS inpatient 872 566.8 ANTHEM HMO ANTHEM HMO 999999999 528 845.84 Aspiration and/or injection of fluid from small joint using ultrasound guidance 51396134_1 CDM 0510 RC 20604 HCPCS inpatient 872 566.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 528 845.84 Aspiration and/or injection of fluid from small joint using ultrasound guidance 51396134_1 CDM 0510 RC 20604 HCPCS inpatient 872 566.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 589.47 67.6 999999999 528 845.84 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 2.1-3.0 cm" 51396338_1 CDM 0510 RC 11423 HCPCS inpatient 5308 3450.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 3450.2 65 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 2.1-3.0 cm" 51396338_1 CDM 0510 RC 11423 HCPCS inpatient 5308 3450.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5148.76 97 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 2.1-3.0 cm" 51396338_1 CDM 0510 RC 11423 HCPCS inpatient 5308 3450.2 AETNA AETNA 4193.32 79 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 2.1-3.0 cm" 51396338_1 CDM 0510 RC 11423 HCPCS inpatient 5308 3450.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 3662.52 69 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 2.1-3.0 cm" 51396338_1 CDM 0510 RC 11423 HCPCS inpatient 5308 3450.2 SIHO - ALL PLANS SIHO - ALL PLANS 4777.2 90 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 2.1-3.0 cm" 51396338_1 CDM 0510 RC 11423 HCPCS inpatient 5308 3450.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 4140.24 78 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 2.1-3.0 cm" 51396338_1 CDM 0510 RC 11423 HCPCS inpatient 5308 3450.2 UMR - ALL PLANS UMR - ALL PLANS 3715.6 70 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 2.1-3.0 cm" 51396338_1 CDM 0510 RC 11423 HCPCS inpatient 5308 3450.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3213.99 60.55 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 2.1-3.0 cm" 51396338_1 CDM 0510 RC 11423 HCPCS inpatient 5308 3450.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 2.1-3.0 cm" 51396338_1 CDM 0510 RC 11423 HCPCS inpatient 5308 3450.2 ANTHEM HMO ANTHEM HMO 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 2.1-3.0 cm" 51396338_1 CDM 0510 RC 11423 HCPCS inpatient 5308 3450.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 2.1-3.0 cm" 51396338_1 CDM 0510 RC 11423 HCPCS inpatient 5308 3450.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 2.1-3.0 cm" 51396338_1 CDM 0510 RC 11423 HCPCS inpatient 5308 3450.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 2.1-3.0 cm" 51396338_1 CDM 0510 RC 11423 HCPCS inpatient 5308 3450.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 3588.21 67.6 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 3.1-4.0 cm" 51396339_1 CDM 0510 RC 11424 HCPCS inpatient 5308 3450.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 3450.2 65 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 3.1-4.0 cm" 51396339_1 CDM 0510 RC 11424 HCPCS inpatient 5308 3450.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5148.76 97 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 3.1-4.0 cm" 51396339_1 CDM 0510 RC 11424 HCPCS inpatient 5308 3450.2 AETNA AETNA 4193.32 79 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 3.1-4.0 cm" 51396339_1 CDM 0510 RC 11424 HCPCS inpatient 5308 3450.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 3662.52 69 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 3.1-4.0 cm" 51396339_1 CDM 0510 RC 11424 HCPCS inpatient 5308 3450.2 SIHO - ALL PLANS SIHO - ALL PLANS 4777.2 90 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 3.1-4.0 cm" 51396339_1 CDM 0510 RC 11424 HCPCS inpatient 5308 3450.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 4140.24 78 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 3.1-4.0 cm" 51396339_1 CDM 0510 RC 11424 HCPCS inpatient 5308 3450.2 UMR - ALL PLANS UMR - ALL PLANS 3715.6 70 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 3.1-4.0 cm" 51396339_1 CDM 0510 RC 11424 HCPCS inpatient 5308 3450.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3213.99 60.55 999999999 3213.99 5148.76 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 3.1-4.0 cm" 51396339_1 CDM 0510 RC 11424 HCPCS inpatient 5308 3450.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 3.1-4.0 cm" 51396339_1 CDM 0510 RC 11424 HCPCS inpatient 5308 3450.2 ANTHEM HMO ANTHEM HMO 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 3.1-4.0 cm" 51396339_1 CDM 0510 RC 11424 HCPCS inpatient 5308 3450.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 3.1-4.0 cm" 51396339_1 CDM 0510 RC 11424 HCPCS inpatient 5308 3450.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 3.1-4.0 cm" 51396339_1 CDM 0510 RC 11424 HCPCS inpatient 5308 3450.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 3213.99 5148.76 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 3.1-4.0 cm" 51396339_1 CDM 0510 RC 11424 HCPCS inpatient 5308 3450.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 3588.21 67.6 999999999 3213.99 5148.76 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51396399_1 CDM 0510 RC 20606 HCPCS inpatient 2281 1482.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1482.65 65 999999999 1381.15 2212.57 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51396399_1 CDM 0510 RC 20606 HCPCS inpatient 2281 1482.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2212.57 97 999999999 1381.15 2212.57 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51396399_1 CDM 0510 RC 20606 HCPCS inpatient 2281 1482.65 AETNA AETNA 1801.99 79 999999999 1381.15 2212.57 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51396399_1 CDM 0510 RC 20606 HCPCS inpatient 2281 1482.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1573.89 69 999999999 1381.15 2212.57 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51396399_1 CDM 0510 RC 20606 HCPCS inpatient 2281 1482.65 SIHO - ALL PLANS SIHO - ALL PLANS 2052.9 90 999999999 1381.15 2212.57 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51396399_1 CDM 0510 RC 20606 HCPCS inpatient 2281 1482.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1779.18 78 999999999 1381.15 2212.57 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51396399_1 CDM 0510 RC 20606 HCPCS inpatient 2281 1482.65 UMR - ALL PLANS UMR - ALL PLANS 1596.7 70 999999999 1381.15 2212.57 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51396399_1 CDM 0510 RC 20606 HCPCS inpatient 2281 1482.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1381.15 60.55 999999999 1381.15 2212.57 percent of total billed charges Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51396399_1 CDM 0510 RC 20606 HCPCS inpatient 2281 1482.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1381.15 2212.57 Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51396399_1 CDM 0510 RC 20606 HCPCS inpatient 2281 1482.65 ANTHEM HMO ANTHEM HMO 999999999 1381.15 2212.57 Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51396399_1 CDM 0510 RC 20606 HCPCS inpatient 2281 1482.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1381.15 2212.57 Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51396399_1 CDM 0510 RC 20606 HCPCS inpatient 2281 1482.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1381.15 2212.57 Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51396399_1 CDM 0510 RC 20606 HCPCS inpatient 2281 1482.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1381.15 2212.57 Aspiration and/or injection of fluid from medium joint using ultrasound guidance 51396399_1 CDM 0510 RC 20606 HCPCS inpatient 2281 1482.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1541.96 67.6 999999999 1381.15 2212.57 percent of total billed charges Trimming of fingernails or toenails 51396527_1 CDM 0510 RC 11719 HCPCS inpatient 203 131.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 131.95 65 999999999 122.92 196.91 percent of total billed charges Trimming of fingernails or toenails 51396527_1 CDM 0510 RC 11719 HCPCS inpatient 203 131.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 196.91 97 999999999 122.92 196.91 percent of total billed charges Trimming of fingernails or toenails 51396527_1 CDM 0510 RC 11719 HCPCS inpatient 203 131.95 AETNA AETNA 160.37 79 999999999 122.92 196.91 percent of total billed charges Trimming of fingernails or toenails 51396527_1 CDM 0510 RC 11719 HCPCS inpatient 203 131.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.07 69 999999999 122.92 196.91 percent of total billed charges Trimming of fingernails or toenails 51396527_1 CDM 0510 RC 11719 HCPCS inpatient 203 131.95 SIHO - ALL PLANS SIHO - ALL PLANS 182.7 90 999999999 122.92 196.91 percent of total billed charges Trimming of fingernails or toenails 51396527_1 CDM 0510 RC 11719 HCPCS inpatient 203 131.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 158.34 78 999999999 122.92 196.91 percent of total billed charges Trimming of fingernails or toenails 51396527_1 CDM 0510 RC 11719 HCPCS inpatient 203 131.95 UMR - ALL PLANS UMR - ALL PLANS 142.1 70 999999999 122.92 196.91 percent of total billed charges Trimming of fingernails or toenails 51396527_1 CDM 0510 RC 11719 HCPCS inpatient 203 131.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 122.92 60.55 999999999 122.92 196.91 percent of total billed charges Trimming of fingernails or toenails 51396527_1 CDM 0510 RC 11719 HCPCS inpatient 203 131.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 122.92 196.91 Trimming of fingernails or toenails 51396527_1 CDM 0510 RC 11719 HCPCS inpatient 203 131.95 ANTHEM HMO ANTHEM HMO 999999999 122.92 196.91 Trimming of fingernails or toenails 51396527_1 CDM 0510 RC 11719 HCPCS inpatient 203 131.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 122.92 196.91 Trimming of fingernails or toenails 51396527_1 CDM 0510 RC 11719 HCPCS inpatient 203 131.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 122.92 196.91 Trimming of fingernails or toenails 51396527_1 CDM 0510 RC 11719 HCPCS inpatient 203 131.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 122.92 196.91 Trimming of fingernails or toenails 51396527_1 CDM 0510 RC 11719 HCPCS inpatient 203 131.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.23 67.6 999999999 122.92 196.91 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 51396610_1 CDM 0510 RC 11720 HCPCS inpatient 204 132.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.6 65 999999999 123.52 197.88 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 51396610_1 CDM 0510 RC 11720 HCPCS inpatient 204 132.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.88 97 999999999 123.52 197.88 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 51396610_1 CDM 0510 RC 11720 HCPCS inpatient 204 132.6 AETNA AETNA 161.16 79 999999999 123.52 197.88 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 51396610_1 CDM 0510 RC 11720 HCPCS inpatient 204 132.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.76 69 999999999 123.52 197.88 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 51396610_1 CDM 0510 RC 11720 HCPCS inpatient 204 132.6 SIHO - ALL PLANS SIHO - ALL PLANS 183.6 90 999999999 123.52 197.88 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 51396610_1 CDM 0510 RC 11720 HCPCS inpatient 204 132.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.12 78 999999999 123.52 197.88 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 51396610_1 CDM 0510 RC 11720 HCPCS inpatient 204 132.6 UMR - ALL PLANS UMR - ALL PLANS 142.8 70 999999999 123.52 197.88 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 51396610_1 CDM 0510 RC 11720 HCPCS inpatient 204 132.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.52 60.55 999999999 123.52 197.88 percent of total billed charges "Removal of fingernails or toenails, 1-5 nails" 51396610_1 CDM 0510 RC 11720 HCPCS inpatient 204 132.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.52 197.88 "Removal of fingernails or toenails, 1-5 nails" 51396610_1 CDM 0510 RC 11720 HCPCS inpatient 204 132.6 ANTHEM HMO ANTHEM HMO 999999999 123.52 197.88 "Removal of fingernails or toenails, 1-5 nails" 51396610_1 CDM 0510 RC 11720 HCPCS inpatient 204 132.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.52 197.88 "Removal of fingernails or toenails, 1-5 nails" 51396610_1 CDM 0510 RC 11720 HCPCS inpatient 204 132.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.52 197.88 "Removal of fingernails or toenails, 1-5 nails" 51396610_1 CDM 0510 RC 11720 HCPCS inpatient 204 132.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.52 197.88 "Removal of fingernails or toenails, 1-5 nails" 51396610_1 CDM 0510 RC 11720 HCPCS inpatient 204 132.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.9 67.6 999999999 123.52 197.88 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 51396611_1 CDM 0510 RC 11730 HCPCS inpatient 459 298.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 298.35 65 999999999 277.92 445.23 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 51396611_1 CDM 0510 RC 11730 HCPCS inpatient 459 298.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 445.23 97 999999999 277.92 445.23 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 51396611_1 CDM 0510 RC 11730 HCPCS inpatient 459 298.35 AETNA AETNA 362.61 79 999999999 277.92 445.23 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 51396611_1 CDM 0510 RC 11730 HCPCS inpatient 459 298.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 316.71 69 999999999 277.92 445.23 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 51396611_1 CDM 0510 RC 11730 HCPCS inpatient 459 298.35 SIHO - ALL PLANS SIHO - ALL PLANS 413.1 90 999999999 277.92 445.23 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 51396611_1 CDM 0510 RC 11730 HCPCS inpatient 459 298.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 358.02 78 999999999 277.92 445.23 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 51396611_1 CDM 0510 RC 11730 HCPCS inpatient 459 298.35 UMR - ALL PLANS UMR - ALL PLANS 321.3 70 999999999 277.92 445.23 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 51396611_1 CDM 0510 RC 11730 HCPCS inpatient 459 298.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 277.92 60.55 999999999 277.92 445.23 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, first nail" 51396611_1 CDM 0510 RC 11730 HCPCS inpatient 459 298.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 277.92 445.23 "Simple separation of fingernail or toenail from nail bed, first nail" 51396611_1 CDM 0510 RC 11730 HCPCS inpatient 459 298.35 ANTHEM HMO ANTHEM HMO 999999999 277.92 445.23 "Simple separation of fingernail or toenail from nail bed, first nail" 51396611_1 CDM 0510 RC 11730 HCPCS inpatient 459 298.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 277.92 445.23 "Simple separation of fingernail or toenail from nail bed, first nail" 51396611_1 CDM 0510 RC 11730 HCPCS inpatient 459 298.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 277.92 445.23 "Simple separation of fingernail or toenail from nail bed, first nail" 51396611_1 CDM 0510 RC 11730 HCPCS inpatient 459 298.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 277.92 445.23 "Simple separation of fingernail or toenail from nail bed, first nail" 51396611_1 CDM 0510 RC 11730 HCPCS inpatient 459 298.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 310.28 67.6 999999999 277.92 445.23 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, each additional nail" 51396612_1 CDM 0510 RC 11732 HCPCS inpatient 94 61.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.1 65 999999999 56.92 91.18 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, each additional nail" 51396612_1 CDM 0510 RC 11732 HCPCS inpatient 94 61.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.18 97 999999999 56.92 91.18 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, each additional nail" 51396612_1 CDM 0510 RC 11732 HCPCS inpatient 94 61.1 AETNA AETNA 74.26 79 999999999 56.92 91.18 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, each additional nail" 51396612_1 CDM 0510 RC 11732 HCPCS inpatient 94 61.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.86 69 999999999 56.92 91.18 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, each additional nail" 51396612_1 CDM 0510 RC 11732 HCPCS inpatient 94 61.1 SIHO - ALL PLANS SIHO - ALL PLANS 84.6 90 999999999 56.92 91.18 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, each additional nail" 51396612_1 CDM 0510 RC 11732 HCPCS inpatient 94 61.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.32 78 999999999 56.92 91.18 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, each additional nail" 51396612_1 CDM 0510 RC 11732 HCPCS inpatient 94 61.1 UMR - ALL PLANS UMR - ALL PLANS 65.8 70 999999999 56.92 91.18 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, each additional nail" 51396612_1 CDM 0510 RC 11732 HCPCS inpatient 94 61.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.92 60.55 999999999 56.92 91.18 percent of total billed charges "Simple separation of fingernail or toenail from nail bed, each additional nail" 51396612_1 CDM 0510 RC 11732 HCPCS inpatient 94 61.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.92 91.18 "Simple separation of fingernail or toenail from nail bed, each additional nail" 51396612_1 CDM 0510 RC 11732 HCPCS inpatient 94 61.1 ANTHEM HMO ANTHEM HMO 999999999 56.92 91.18 "Simple separation of fingernail or toenail from nail bed, each additional nail" 51396612_1 CDM 0510 RC 11732 HCPCS inpatient 94 61.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.92 91.18 "Simple separation of fingernail or toenail from nail bed, each additional nail" 51396612_1 CDM 0510 RC 11732 HCPCS inpatient 94 61.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.92 91.18 "Simple separation of fingernail or toenail from nail bed, each additional nail" 51396612_1 CDM 0510 RC 11732 HCPCS inpatient 94 61.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.92 91.18 "Simple separation of fingernail or toenail from nail bed, each additional nail" 51396612_1 CDM 0510 RC 11732 HCPCS inpatient 94 61.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.54 67.6 999999999 56.92 91.18 percent of total billed charges Permanent removal fingernail or toenail 51396613_1 CDM 0510 RC 11750 HCPCS inpatient 1321 858.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 858.65 65 999999999 799.87 1281.37 percent of total billed charges Permanent removal fingernail or toenail 51396613_1 CDM 0510 RC 11750 HCPCS inpatient 1321 858.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1281.37 97 999999999 799.87 1281.37 percent of total billed charges Permanent removal fingernail or toenail 51396613_1 CDM 0510 RC 11750 HCPCS inpatient 1321 858.65 AETNA AETNA 1043.59 79 999999999 799.87 1281.37 percent of total billed charges Permanent removal fingernail or toenail 51396613_1 CDM 0510 RC 11750 HCPCS inpatient 1321 858.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 911.49 69 999999999 799.87 1281.37 percent of total billed charges Permanent removal fingernail or toenail 51396613_1 CDM 0510 RC 11750 HCPCS inpatient 1321 858.65 SIHO - ALL PLANS SIHO - ALL PLANS 1188.9 90 999999999 799.87 1281.37 percent of total billed charges Permanent removal fingernail or toenail 51396613_1 CDM 0510 RC 11750 HCPCS inpatient 1321 858.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1030.38 78 999999999 799.87 1281.37 percent of total billed charges Permanent removal fingernail or toenail 51396613_1 CDM 0510 RC 11750 HCPCS inpatient 1321 858.65 UMR - ALL PLANS UMR - ALL PLANS 924.7 70 999999999 799.87 1281.37 percent of total billed charges Permanent removal fingernail or toenail 51396613_1 CDM 0510 RC 11750 HCPCS inpatient 1321 858.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 799.87 60.55 999999999 799.87 1281.37 percent of total billed charges Permanent removal fingernail or toenail 51396613_1 CDM 0510 RC 11750 HCPCS inpatient 1321 858.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 799.87 1281.37 Permanent removal fingernail or toenail 51396613_1 CDM 0510 RC 11750 HCPCS inpatient 1321 858.65 ANTHEM HMO ANTHEM HMO 999999999 799.87 1281.37 Permanent removal fingernail or toenail 51396613_1 CDM 0510 RC 11750 HCPCS inpatient 1321 858.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 799.87 1281.37 Permanent removal fingernail or toenail 51396613_1 CDM 0510 RC 11750 HCPCS inpatient 1321 858.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 799.87 1281.37 Permanent removal fingernail or toenail 51396613_1 CDM 0510 RC 11750 HCPCS inpatient 1321 858.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 799.87 1281.37 Permanent removal fingernail or toenail 51396613_1 CDM 0510 RC 11750 HCPCS inpatient 1321 858.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 893 67.6 999999999 799.87 1281.37 percent of total billed charges Removal of skin of fingernail or toenail 51396614_1 CDM 0510 RC 11765 HCPCS inpatient 1321 858.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 858.65 65 999999999 799.87 1281.37 percent of total billed charges Removal of skin of fingernail or toenail 51396614_1 CDM 0510 RC 11765 HCPCS inpatient 1321 858.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1281.37 97 999999999 799.87 1281.37 percent of total billed charges Removal of skin of fingernail or toenail 51396614_1 CDM 0510 RC 11765 HCPCS inpatient 1321 858.65 AETNA AETNA 1043.59 79 999999999 799.87 1281.37 percent of total billed charges Removal of skin of fingernail or toenail 51396614_1 CDM 0510 RC 11765 HCPCS inpatient 1321 858.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 911.49 69 999999999 799.87 1281.37 percent of total billed charges Removal of skin of fingernail or toenail 51396614_1 CDM 0510 RC 11765 HCPCS inpatient 1321 858.65 SIHO - ALL PLANS SIHO - ALL PLANS 1188.9 90 999999999 799.87 1281.37 percent of total billed charges Removal of skin of fingernail or toenail 51396614_1 CDM 0510 RC 11765 HCPCS inpatient 1321 858.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1030.38 78 999999999 799.87 1281.37 percent of total billed charges Removal of skin of fingernail or toenail 51396614_1 CDM 0510 RC 11765 HCPCS inpatient 1321 858.65 UMR - ALL PLANS UMR - ALL PLANS 924.7 70 999999999 799.87 1281.37 percent of total billed charges Removal of skin of fingernail or toenail 51396614_1 CDM 0510 RC 11765 HCPCS inpatient 1321 858.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 799.87 60.55 999999999 799.87 1281.37 percent of total billed charges Removal of skin of fingernail or toenail 51396614_1 CDM 0510 RC 11765 HCPCS inpatient 1321 858.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 799.87 1281.37 Removal of skin of fingernail or toenail 51396614_1 CDM 0510 RC 11765 HCPCS inpatient 1321 858.65 ANTHEM HMO ANTHEM HMO 999999999 799.87 1281.37 Removal of skin of fingernail or toenail 51396614_1 CDM 0510 RC 11765 HCPCS inpatient 1321 858.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 799.87 1281.37 Removal of skin of fingernail or toenail 51396614_1 CDM 0510 RC 11765 HCPCS inpatient 1321 858.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 799.87 1281.37 Removal of skin of fingernail or toenail 51396614_1 CDM 0510 RC 11765 HCPCS inpatient 1321 858.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 799.87 1281.37 Removal of skin of fingernail or toenail 51396614_1 CDM 0510 RC 11765 HCPCS inpatient 1321 858.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 893 67.6 999999999 799.87 1281.37 percent of total billed charges Injection of anesthetic and/or steroid drug into foot nerve 51396615_1 CDM 0510 RC 64455 HCPCS inpatient 962 625.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 625.3 65 999999999 582.49 933.14 percent of total billed charges Injection of anesthetic and/or steroid drug into foot nerve 51396615_1 CDM 0510 RC 64455 HCPCS inpatient 962 625.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 933.14 97 999999999 582.49 933.14 percent of total billed charges Injection of anesthetic and/or steroid drug into foot nerve 51396615_1 CDM 0510 RC 64455 HCPCS inpatient 962 625.3 AETNA AETNA 759.98 79 999999999 582.49 933.14 percent of total billed charges Injection of anesthetic and/or steroid drug into foot nerve 51396615_1 CDM 0510 RC 64455 HCPCS inpatient 962 625.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 663.78 69 999999999 582.49 933.14 percent of total billed charges Injection of anesthetic and/or steroid drug into foot nerve 51396615_1 CDM 0510 RC 64455 HCPCS inpatient 962 625.3 SIHO - ALL PLANS SIHO - ALL PLANS 865.8 90 999999999 582.49 933.14 percent of total billed charges Injection of anesthetic and/or steroid drug into foot nerve 51396615_1 CDM 0510 RC 64455 HCPCS inpatient 962 625.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 750.36 78 999999999 582.49 933.14 percent of total billed charges Injection of anesthetic and/or steroid drug into foot nerve 51396615_1 CDM 0510 RC 64455 HCPCS inpatient 962 625.3 UMR - ALL PLANS UMR - ALL PLANS 673.4 70 999999999 582.49 933.14 percent of total billed charges Injection of anesthetic and/or steroid drug into foot nerve 51396615_1 CDM 0510 RC 64455 HCPCS inpatient 962 625.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 582.49 60.55 999999999 582.49 933.14 percent of total billed charges Injection of anesthetic and/or steroid drug into foot nerve 51396615_1 CDM 0510 RC 64455 HCPCS inpatient 962 625.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 582.49 933.14 Injection of anesthetic and/or steroid drug into foot nerve 51396615_1 CDM 0510 RC 64455 HCPCS inpatient 962 625.3 ANTHEM HMO ANTHEM HMO 999999999 582.49 933.14 Injection of anesthetic and/or steroid drug into foot nerve 51396615_1 CDM 0510 RC 64455 HCPCS inpatient 962 625.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 582.49 933.14 Injection of anesthetic and/or steroid drug into foot nerve 51396615_1 CDM 0510 RC 64455 HCPCS inpatient 962 625.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 582.49 933.14 Injection of anesthetic and/or steroid drug into foot nerve 51396615_1 CDM 0510 RC 64455 HCPCS inpatient 962 625.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 582.49 933.14 Injection of anesthetic and/or steroid drug into foot nerve 51396615_1 CDM 0510 RC 64455 HCPCS inpatient 962 625.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 650.31 67.6 999999999 582.49 933.14 percent of total billed charges Destruction of foot nerve 51396616_1 CDM 0510 RC 64632 HCPCS inpatient 962 625.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 625.3 65 999999999 582.49 933.14 percent of total billed charges Destruction of foot nerve 51396616_1 CDM 0510 RC 64632 HCPCS inpatient 962 625.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 933.14 97 999999999 582.49 933.14 percent of total billed charges Destruction of foot nerve 51396616_1 CDM 0510 RC 64632 HCPCS inpatient 962 625.3 AETNA AETNA 759.98 79 999999999 582.49 933.14 percent of total billed charges Destruction of foot nerve 51396616_1 CDM 0510 RC 64632 HCPCS inpatient 962 625.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 663.78 69 999999999 582.49 933.14 percent of total billed charges Destruction of foot nerve 51396616_1 CDM 0510 RC 64632 HCPCS inpatient 962 625.3 SIHO - ALL PLANS SIHO - ALL PLANS 865.8 90 999999999 582.49 933.14 percent of total billed charges Destruction of foot nerve 51396616_1 CDM 0510 RC 64632 HCPCS inpatient 962 625.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 750.36 78 999999999 582.49 933.14 percent of total billed charges Destruction of foot nerve 51396616_1 CDM 0510 RC 64632 HCPCS inpatient 962 625.3 UMR - ALL PLANS UMR - ALL PLANS 673.4 70 999999999 582.49 933.14 percent of total billed charges Destruction of foot nerve 51396616_1 CDM 0510 RC 64632 HCPCS inpatient 962 625.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 582.49 60.55 999999999 582.49 933.14 percent of total billed charges Destruction of foot nerve 51396616_1 CDM 0510 RC 64632 HCPCS inpatient 962 625.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 582.49 933.14 Destruction of foot nerve 51396616_1 CDM 0510 RC 64632 HCPCS inpatient 962 625.3 ANTHEM HMO ANTHEM HMO 999999999 582.49 933.14 Destruction of foot nerve 51396616_1 CDM 0510 RC 64632 HCPCS inpatient 962 625.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 582.49 933.14 Destruction of foot nerve 51396616_1 CDM 0510 RC 64632 HCPCS inpatient 962 625.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 582.49 933.14 Destruction of foot nerve 51396616_1 CDM 0510 RC 64632 HCPCS inpatient 962 625.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 582.49 933.14 Destruction of foot nerve 51396616_1 CDM 0510 RC 64632 HCPCS inpatient 962 625.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 650.31 67.6 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from large joint 51396617_1 CDM 0510 RC 20610 HCPCS inpatient 962 625.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 625.3 65 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from large joint 51396617_1 CDM 0510 RC 20610 HCPCS inpatient 962 625.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 933.14 97 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from large joint 51396617_1 CDM 0510 RC 20610 HCPCS inpatient 962 625.3 AETNA AETNA 759.98 79 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from large joint 51396617_1 CDM 0510 RC 20610 HCPCS inpatient 962 625.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 663.78 69 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from large joint 51396617_1 CDM 0510 RC 20610 HCPCS inpatient 962 625.3 SIHO - ALL PLANS SIHO - ALL PLANS 865.8 90 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from large joint 51396617_1 CDM 0510 RC 20610 HCPCS inpatient 962 625.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 750.36 78 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from large joint 51396617_1 CDM 0510 RC 20610 HCPCS inpatient 962 625.3 UMR - ALL PLANS UMR - ALL PLANS 673.4 70 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from large joint 51396617_1 CDM 0510 RC 20610 HCPCS inpatient 962 625.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 582.49 933.14 Aspiration and/or injection of fluid from large joint 51396617_1 CDM 0510 RC 20610 HCPCS inpatient 962 625.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 582.49 60.55 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from large joint 51396617_1 CDM 0510 RC 20610 HCPCS inpatient 962 625.3 ANTHEM HMO ANTHEM HMO 999999999 582.49 933.14 Aspiration and/or injection of fluid from large joint 51396617_1 CDM 0510 RC 20610 HCPCS inpatient 962 625.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 582.49 933.14 Aspiration and/or injection of fluid from large joint 51396617_1 CDM 0510 RC 20610 HCPCS inpatient 962 625.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 582.49 933.14 Aspiration and/or injection of fluid from large joint 51396617_1 CDM 0510 RC 20610 HCPCS inpatient 962 625.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 582.49 933.14 Aspiration and/or injection of fluid from large joint 51396617_1 CDM 0510 RC 20610 HCPCS inpatient 962 625.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 650.31 67.6 999999999 582.49 933.14 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 51396893_1 CDM 0510 RC 99203 HCPCS inpatient 315 204.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 204.75 65 999999999 190.73 305.55 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 51396893_1 CDM 0510 RC 99203 HCPCS inpatient 315 204.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 305.55 97 999999999 190.73 305.55 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 51396893_1 CDM 0510 RC 99203 HCPCS inpatient 315 204.75 AETNA AETNA 248.85 79 999999999 190.73 305.55 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 51396893_1 CDM 0510 RC 99203 HCPCS inpatient 315 204.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 217.35 69 999999999 190.73 305.55 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 51396893_1 CDM 0510 RC 99203 HCPCS inpatient 315 204.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 245.7 78 999999999 190.73 305.55 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 51396893_1 CDM 0510 RC 99203 HCPCS inpatient 315 204.75 SIHO - ALL PLANS SIHO - ALL PLANS 283.5 90 999999999 190.73 305.55 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 51396893_1 CDM 0510 RC 99203 HCPCS inpatient 315 204.75 UMR - ALL PLANS UMR - ALL PLANS 220.5 70 999999999 190.73 305.55 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 51396893_1 CDM 0510 RC 99203 HCPCS inpatient 315 204.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 190.73 305.55 "New patient office or other outpatient visit, 30-44 minutes" 51396893_1 CDM 0510 RC 99203 HCPCS inpatient 315 204.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 190.73 60.55 999999999 190.73 305.55 percent of total billed charges "New patient office or other outpatient visit, 30-44 minutes" 51396893_1 CDM 0510 RC 99203 HCPCS inpatient 315 204.75 ANTHEM HMO ANTHEM HMO 999999999 190.73 305.55 "New patient office or other outpatient visit, 30-44 minutes" 51396893_1 CDM 0510 RC 99203 HCPCS inpatient 315 204.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 190.73 305.55 "New patient office or other outpatient visit, 30-44 minutes" 51396893_1 CDM 0510 RC 99203 HCPCS inpatient 315 204.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 190.73 305.55 "New patient office or other outpatient visit, 30-44 minutes" 51396893_1 CDM 0510 RC 99203 HCPCS inpatient 315 204.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 190.73 305.55 "New patient office or other outpatient visit, 30-44 minutes" 51396893_1 CDM 0510 RC 99203 HCPCS inpatient 315 204.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 212.94 67.6 999999999 190.73 305.55 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 51396894_1 CDM 0510 RC 99204 HCPCS inpatient 470 305.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 305.5 65 999999999 284.59 455.9 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 51396894_1 CDM 0510 RC 99204 HCPCS inpatient 470 305.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 455.9 97 999999999 284.59 455.9 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 51396894_1 CDM 0510 RC 99204 HCPCS inpatient 470 305.5 AETNA AETNA 371.3 79 999999999 284.59 455.9 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 51396894_1 CDM 0510 RC 99204 HCPCS inpatient 470 305.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 324.3 69 999999999 284.59 455.9 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 51396894_1 CDM 0510 RC 99204 HCPCS inpatient 470 305.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 366.6 78 999999999 284.59 455.9 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 51396894_1 CDM 0510 RC 99204 HCPCS inpatient 470 305.5 SIHO - ALL PLANS SIHO - ALL PLANS 423 90 999999999 284.59 455.9 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 51396894_1 CDM 0510 RC 99204 HCPCS inpatient 470 305.5 UMR - ALL PLANS UMR - ALL PLANS 329 70 999999999 284.59 455.9 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 51396894_1 CDM 0510 RC 99204 HCPCS inpatient 470 305.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 284.59 455.9 "New patient office or other outpatient visit, 45-59 minutes" 51396894_1 CDM 0510 RC 99204 HCPCS inpatient 470 305.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 284.59 60.55 999999999 284.59 455.9 percent of total billed charges "New patient office or other outpatient visit, 45-59 minutes" 51396894_1 CDM 0510 RC 99204 HCPCS inpatient 470 305.5 ANTHEM HMO ANTHEM HMO 999999999 284.59 455.9 "New patient office or other outpatient visit, 45-59 minutes" 51396894_1 CDM 0510 RC 99204 HCPCS inpatient 470 305.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 284.59 455.9 "New patient office or other outpatient visit, 45-59 minutes" 51396894_1 CDM 0510 RC 99204 HCPCS inpatient 470 305.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 284.59 455.9 "New patient office or other outpatient visit, 45-59 minutes" 51396894_1 CDM 0510 RC 99204 HCPCS inpatient 470 305.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 284.59 455.9 "New patient office or other outpatient visit, 45-59 minutes" 51396894_1 CDM 0510 RC 99204 HCPCS inpatient 470 305.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 317.72 67.6 999999999 284.59 455.9 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 51396895_1 CDM 0510 RC 99212 HCPCS inpatient 159 103.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 103.35 65 999999999 96.27 154.23 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 51396895_1 CDM 0510 RC 99212 HCPCS inpatient 159 103.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 154.23 97 999999999 96.27 154.23 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 51396895_1 CDM 0510 RC 99212 HCPCS inpatient 159 103.35 AETNA AETNA 125.61 79 999999999 96.27 154.23 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 51396895_1 CDM 0510 RC 99212 HCPCS inpatient 159 103.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 109.71 69 999999999 96.27 154.23 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 51396895_1 CDM 0510 RC 99212 HCPCS inpatient 159 103.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 124.02 78 999999999 96.27 154.23 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 51396895_1 CDM 0510 RC 99212 HCPCS inpatient 159 103.35 SIHO - ALL PLANS SIHO - ALL PLANS 143.1 90 999999999 96.27 154.23 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 51396895_1 CDM 0510 RC 99212 HCPCS inpatient 159 103.35 UMR - ALL PLANS UMR - ALL PLANS 111.3 70 999999999 96.27 154.23 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 51396895_1 CDM 0510 RC 99212 HCPCS inpatient 159 103.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 96.27 154.23 "Established patient office or other outpatient visit, 10-19 minutes" 51396895_1 CDM 0510 RC 99212 HCPCS inpatient 159 103.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 96.27 60.55 999999999 96.27 154.23 percent of total billed charges "Established patient office or other outpatient visit, 10-19 minutes" 51396895_1 CDM 0510 RC 99212 HCPCS inpatient 159 103.35 ANTHEM HMO ANTHEM HMO 999999999 96.27 154.23 "Established patient office or other outpatient visit, 10-19 minutes" 51396895_1 CDM 0510 RC 99212 HCPCS inpatient 159 103.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 96.27 154.23 "Established patient office or other outpatient visit, 10-19 minutes" 51396895_1 CDM 0510 RC 99212 HCPCS inpatient 159 103.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 96.27 154.23 "Established patient office or other outpatient visit, 10-19 minutes" 51396895_1 CDM 0510 RC 99212 HCPCS inpatient 159 103.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 96.27 154.23 "Established patient office or other outpatient visit, 10-19 minutes" 51396895_1 CDM 0510 RC 99212 HCPCS inpatient 159 103.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 107.48 67.6 999999999 96.27 154.23 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 51396896_1 CDM 0510 RC 99213 HCPCS inpatient 256 166.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 166.4 65 999999999 155.01 248.32 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 51396896_1 CDM 0510 RC 99213 HCPCS inpatient 256 166.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 248.32 97 999999999 155.01 248.32 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 51396896_1 CDM 0510 RC 99213 HCPCS inpatient 256 166.4 AETNA AETNA 202.24 79 999999999 155.01 248.32 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 51396896_1 CDM 0510 RC 99213 HCPCS inpatient 256 166.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 176.64 69 999999999 155.01 248.32 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 51396896_1 CDM 0510 RC 99213 HCPCS inpatient 256 166.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 199.68 78 999999999 155.01 248.32 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 51396896_1 CDM 0510 RC 99213 HCPCS inpatient 256 166.4 SIHO - ALL PLANS SIHO - ALL PLANS 230.4 90 999999999 155.01 248.32 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 51396896_1 CDM 0510 RC 99213 HCPCS inpatient 256 166.4 UMR - ALL PLANS UMR - ALL PLANS 179.2 70 999999999 155.01 248.32 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 51396896_1 CDM 0510 RC 99213 HCPCS inpatient 256 166.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 155.01 248.32 "Established patient office or other outpatient visit, 20-29 minutes" 51396896_1 CDM 0510 RC 99213 HCPCS inpatient 256 166.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 155.01 60.55 999999999 155.01 248.32 percent of total billed charges "Established patient office or other outpatient visit, 20-29 minutes" 51396896_1 CDM 0510 RC 99213 HCPCS inpatient 256 166.4 ANTHEM HMO ANTHEM HMO 999999999 155.01 248.32 "Established patient office or other outpatient visit, 20-29 minutes" 51396896_1 CDM 0510 RC 99213 HCPCS inpatient 256 166.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 155.01 248.32 "Established patient office or other outpatient visit, 20-29 minutes" 51396896_1 CDM 0510 RC 99213 HCPCS inpatient 256 166.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 155.01 248.32 "Established patient office or other outpatient visit, 20-29 minutes" 51396896_1 CDM 0510 RC 99213 HCPCS inpatient 256 166.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 155.01 248.32 "Established patient office or other outpatient visit, 20-29 minutes" 51396896_1 CDM 0510 RC 99213 HCPCS inpatient 256 166.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 173.06 67.6 999999999 155.01 248.32 percent of total billed charges "Outpatient consultation with low level of medical decision making, if using time, at least 30 minutes" 51396897_1 CDM 0510 RC 99243 HCPCS inpatient 315 204.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 204.75 65 999999999 190.73 305.55 percent of total billed charges "Outpatient consultation with low level of medical decision making, if using time, at least 30 minutes" 51396897_1 CDM 0510 RC 99243 HCPCS inpatient 315 204.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 305.55 97 999999999 190.73 305.55 percent of total billed charges "Outpatient consultation with low level of medical decision making, if using time, at least 30 minutes" 51396897_1 CDM 0510 RC 99243 HCPCS inpatient 315 204.75 AETNA AETNA 248.85 79 999999999 190.73 305.55 percent of total billed charges "Outpatient consultation with low level of medical decision making, if using time, at least 30 minutes" 51396897_1 CDM 0510 RC 99243 HCPCS inpatient 315 204.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 217.35 69 999999999 190.73 305.55 percent of total billed charges "Outpatient consultation with low level of medical decision making, if using time, at least 30 minutes" 51396897_1 CDM 0510 RC 99243 HCPCS inpatient 315 204.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 245.7 78 999999999 190.73 305.55 percent of total billed charges "Outpatient consultation with low level of medical decision making, if using time, at least 30 minutes" 51396897_1 CDM 0510 RC 99243 HCPCS inpatient 315 204.75 SIHO - ALL PLANS SIHO - ALL PLANS 283.5 90 999999999 190.73 305.55 percent of total billed charges "Outpatient consultation with low level of medical decision making, if using time, at least 30 minutes" 51396897_1 CDM 0510 RC 99243 HCPCS inpatient 315 204.75 UMR - ALL PLANS UMR - ALL PLANS 220.5 70 999999999 190.73 305.55 percent of total billed charges "Outpatient consultation with low level of medical decision making, if using time, at least 30 minutes" 51396897_1 CDM 0510 RC 99243 HCPCS inpatient 315 204.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 190.73 305.55 "Outpatient consultation with low level of medical decision making, if using time, at least 30 minutes" 51396897_1 CDM 0510 RC 99243 HCPCS inpatient 315 204.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 190.73 60.55 999999999 190.73 305.55 percent of total billed charges "Outpatient consultation with low level of medical decision making, if using time, at least 30 minutes" 51396897_1 CDM 0510 RC 99243 HCPCS inpatient 315 204.75 ANTHEM HMO ANTHEM HMO 999999999 190.73 305.55 "Outpatient consultation with low level of medical decision making, if using time, at least 30 minutes" 51396897_1 CDM 0510 RC 99243 HCPCS inpatient 315 204.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 190.73 305.55 "Outpatient consultation with low level of medical decision making, if using time, at least 30 minutes" 51396897_1 CDM 0510 RC 99243 HCPCS inpatient 315 204.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 190.73 305.55 "Outpatient consultation with low level of medical decision making, if using time, at least 30 minutes" 51396897_1 CDM 0510 RC 99243 HCPCS inpatient 315 204.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 190.73 305.55 "Outpatient consultation with low level of medical decision making, if using time, at least 30 minutes" 51396897_1 CDM 0510 RC 99243 HCPCS inpatient 315 204.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 212.94 67.6 999999999 190.73 305.55 percent of total billed charges "Hospital consultation with straightforward medical decision making, if using time, at least 35 minutes" 51396898_1 CDM 0510 RC 99252 HCPCS inpatient 300 195 SELF PAY DISCOUNT SELF PAY DISCOUNT 195 65 999999999 181.65 291 percent of total billed charges "Hospital consultation with straightforward medical decision making, if using time, at least 35 minutes" 51396898_1 CDM 0510 RC 99252 HCPCS inpatient 300 195 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291 97 999999999 181.65 291 percent of total billed charges "Hospital consultation with straightforward medical decision making, if using time, at least 35 minutes" 51396898_1 CDM 0510 RC 99252 HCPCS inpatient 300 195 AETNA AETNA 237 79 999999999 181.65 291 percent of total billed charges "Hospital consultation with straightforward medical decision making, if using time, at least 35 minutes" 51396898_1 CDM 0510 RC 99252 HCPCS inpatient 300 195 ENCORE - ALL PLANS ENCORE - ALL PLANS 207 69 999999999 181.65 291 percent of total billed charges "Hospital consultation with straightforward medical decision making, if using time, at least 35 minutes" 51396898_1 CDM 0510 RC 99252 HCPCS inpatient 300 195 HUMANA - ALL PLANS HUMANA - ALL PLANS 234 78 999999999 181.65 291 percent of total billed charges "Hospital consultation with straightforward medical decision making, if using time, at least 35 minutes" 51396898_1 CDM 0510 RC 99252 HCPCS inpatient 300 195 SIHO - ALL PLANS SIHO - ALL PLANS 270 90 999999999 181.65 291 percent of total billed charges "Hospital consultation with straightforward medical decision making, if using time, at least 35 minutes" 51396898_1 CDM 0510 RC 99252 HCPCS inpatient 300 195 UMR - ALL PLANS UMR - ALL PLANS 210 70 999999999 181.65 291 percent of total billed charges "Hospital consultation with straightforward medical decision making, if using time, at least 35 minutes" 51396898_1 CDM 0510 RC 99252 HCPCS inpatient 300 195 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 181.65 291 "Hospital consultation with straightforward medical decision making, if using time, at least 35 minutes" 51396898_1 CDM 0510 RC 99252 HCPCS inpatient 300 195 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 181.65 60.55 999999999 181.65 291 percent of total billed charges "Hospital consultation with straightforward medical decision making, if using time, at least 35 minutes" 51396898_1 CDM 0510 RC 99252 HCPCS inpatient 300 195 ANTHEM HMO ANTHEM HMO 999999999 181.65 291 "Hospital consultation with straightforward medical decision making, if using time, at least 35 minutes" 51396898_1 CDM 0510 RC 99252 HCPCS inpatient 300 195 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 181.65 291 "Hospital consultation with straightforward medical decision making, if using time, at least 35 minutes" 51396898_1 CDM 0510 RC 99252 HCPCS inpatient 300 195 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 181.65 291 "Hospital consultation with straightforward medical decision making, if using time, at least 35 minutes" 51396898_1 CDM 0510 RC 99252 HCPCS inpatient 300 195 UHC - ALL PLANS UHC - ALL PLANS 999999999 181.65 291 "Hospital consultation with straightforward medical decision making, if using time, at least 35 minutes" 51396898_1 CDM 0510 RC 99252 HCPCS inpatient 300 195 CIGNA - ALL PLANS CIGNA - ALL PLANS 202.8 67.6 999999999 181.65 291 percent of total billed charges "Hospital consultation with low level of medical decision making, if using time, at least 45 minutes" 51396899_1 CDM 0510 RC 99253 HCPCS inpatient 385 250.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 250.25 65 999999999 233.12 373.45 percent of total billed charges "Hospital consultation with low level of medical decision making, if using time, at least 45 minutes" 51396899_1 CDM 0510 RC 99253 HCPCS inpatient 385 250.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 373.45 97 999999999 233.12 373.45 percent of total billed charges "Hospital consultation with low level of medical decision making, if using time, at least 45 minutes" 51396899_1 CDM 0510 RC 99253 HCPCS inpatient 385 250.25 AETNA AETNA 304.15 79 999999999 233.12 373.45 percent of total billed charges "Hospital consultation with low level of medical decision making, if using time, at least 45 minutes" 51396899_1 CDM 0510 RC 99253 HCPCS inpatient 385 250.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 265.65 69 999999999 233.12 373.45 percent of total billed charges "Hospital consultation with low level of medical decision making, if using time, at least 45 minutes" 51396899_1 CDM 0510 RC 99253 HCPCS inpatient 385 250.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 300.3 78 999999999 233.12 373.45 percent of total billed charges "Hospital consultation with low level of medical decision making, if using time, at least 45 minutes" 51396899_1 CDM 0510 RC 99253 HCPCS inpatient 385 250.25 SIHO - ALL PLANS SIHO - ALL PLANS 346.5 90 999999999 233.12 373.45 percent of total billed charges "Hospital consultation with low level of medical decision making, if using time, at least 45 minutes" 51396899_1 CDM 0510 RC 99253 HCPCS inpatient 385 250.25 UMR - ALL PLANS UMR - ALL PLANS 269.5 70 999999999 233.12 373.45 percent of total billed charges "Hospital consultation with low level of medical decision making, if using time, at least 45 minutes" 51396899_1 CDM 0510 RC 99253 HCPCS inpatient 385 250.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 233.12 373.45 "Hospital consultation with low level of medical decision making, if using time, at least 45 minutes" 51396899_1 CDM 0510 RC 99253 HCPCS inpatient 385 250.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 233.12 60.55 999999999 233.12 373.45 percent of total billed charges "Hospital consultation with low level of medical decision making, if using time, at least 45 minutes" 51396899_1 CDM 0510 RC 99253 HCPCS inpatient 385 250.25 ANTHEM HMO ANTHEM HMO 999999999 233.12 373.45 "Hospital consultation with low level of medical decision making, if using time, at least 45 minutes" 51396899_1 CDM 0510 RC 99253 HCPCS inpatient 385 250.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 233.12 373.45 "Hospital consultation with low level of medical decision making, if using time, at least 45 minutes" 51396899_1 CDM 0510 RC 99253 HCPCS inpatient 385 250.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 233.12 373.45 "Hospital consultation with low level of medical decision making, if using time, at least 45 minutes" 51396899_1 CDM 0510 RC 99253 HCPCS inpatient 385 250.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 233.12 373.45 "Hospital consultation with low level of medical decision making, if using time, at least 45 minutes" 51396899_1 CDM 0510 RC 99253 HCPCS inpatient 385 250.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 260.26 67.6 999999999 233.12 373.45 percent of total billed charges "Hospital consultation with moderate level of medical decision making, if using time, at least 45 minutes" 51396900_1 CDM 0510 RC 99254 HCPCS inpatient 425 276.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 276.25 65 999999999 257.34 412.25 percent of total billed charges "Hospital consultation with moderate level of medical decision making, if using time, at least 45 minutes" 51396900_1 CDM 0510 RC 99254 HCPCS inpatient 425 276.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 412.25 97 999999999 257.34 412.25 percent of total billed charges "Hospital consultation with moderate level of medical decision making, if using time, at least 45 minutes" 51396900_1 CDM 0510 RC 99254 HCPCS inpatient 425 276.25 AETNA AETNA 335.75 79 999999999 257.34 412.25 percent of total billed charges "Hospital consultation with moderate level of medical decision making, if using time, at least 45 minutes" 51396900_1 CDM 0510 RC 99254 HCPCS inpatient 425 276.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 293.25 69 999999999 257.34 412.25 percent of total billed charges "Hospital consultation with moderate level of medical decision making, if using time, at least 45 minutes" 51396900_1 CDM 0510 RC 99254 HCPCS inpatient 425 276.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 331.5 78 999999999 257.34 412.25 percent of total billed charges "Hospital consultation with moderate level of medical decision making, if using time, at least 45 minutes" 51396900_1 CDM 0510 RC 99254 HCPCS inpatient 425 276.25 SIHO - ALL PLANS SIHO - ALL PLANS 382.5 90 999999999 257.34 412.25 percent of total billed charges "Hospital consultation with moderate level of medical decision making, if using time, at least 45 minutes" 51396900_1 CDM 0510 RC 99254 HCPCS inpatient 425 276.25 UMR - ALL PLANS UMR - ALL PLANS 297.5 70 999999999 257.34 412.25 percent of total billed charges "Hospital consultation with moderate level of medical decision making, if using time, at least 45 minutes" 51396900_1 CDM 0510 RC 99254 HCPCS inpatient 425 276.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 257.34 412.25 "Hospital consultation with moderate level of medical decision making, if using time, at least 45 minutes" 51396900_1 CDM 0510 RC 99254 HCPCS inpatient 425 276.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 257.34 60.55 999999999 257.34 412.25 percent of total billed charges "Hospital consultation with moderate level of medical decision making, if using time, at least 45 minutes" 51396900_1 CDM 0510 RC 99254 HCPCS inpatient 425 276.25 ANTHEM HMO ANTHEM HMO 999999999 257.34 412.25 "Hospital consultation with moderate level of medical decision making, if using time, at least 45 minutes" 51396900_1 CDM 0510 RC 99254 HCPCS inpatient 425 276.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 257.34 412.25 "Hospital consultation with moderate level of medical decision making, if using time, at least 45 minutes" 51396900_1 CDM 0510 RC 99254 HCPCS inpatient 425 276.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 257.34 412.25 "Hospital consultation with moderate level of medical decision making, if using time, at least 45 minutes" 51396900_1 CDM 0510 RC 99254 HCPCS inpatient 425 276.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 257.34 412.25 "Hospital consultation with moderate level of medical decision making, if using time, at least 45 minutes" 51396900_1 CDM 0510 RC 99254 HCPCS inpatient 425 276.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 287.3 67.6 999999999 257.34 412.25 percent of total billed charges "Hospital consultation with high level of medical decision making, if using time, at least 80 minutes" 51396901_1 CDM 0510 RC 99255 HCPCS inpatient 550 357.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 357.5 65 999999999 333.03 533.5 percent of total billed charges "Hospital consultation with high level of medical decision making, if using time, at least 80 minutes" 51396901_1 CDM 0510 RC 99255 HCPCS inpatient 550 357.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 533.5 97 999999999 333.03 533.5 percent of total billed charges "Hospital consultation with high level of medical decision making, if using time, at least 80 minutes" 51396901_1 CDM 0510 RC 99255 HCPCS inpatient 550 357.5 AETNA AETNA 434.5 79 999999999 333.03 533.5 percent of total billed charges "Hospital consultation with high level of medical decision making, if using time, at least 80 minutes" 51396901_1 CDM 0510 RC 99255 HCPCS inpatient 550 357.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 379.5 69 999999999 333.03 533.5 percent of total billed charges "Hospital consultation with high level of medical decision making, if using time, at least 80 minutes" 51396901_1 CDM 0510 RC 99255 HCPCS inpatient 550 357.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 429 78 999999999 333.03 533.5 percent of total billed charges "Hospital consultation with high level of medical decision making, if using time, at least 80 minutes" 51396901_1 CDM 0510 RC 99255 HCPCS inpatient 550 357.5 SIHO - ALL PLANS SIHO - ALL PLANS 495 90 999999999 333.03 533.5 percent of total billed charges "Hospital consultation with high level of medical decision making, if using time, at least 80 minutes" 51396901_1 CDM 0510 RC 99255 HCPCS inpatient 550 357.5 UMR - ALL PLANS UMR - ALL PLANS 385 70 999999999 333.03 533.5 percent of total billed charges "Hospital consultation with high level of medical decision making, if using time, at least 80 minutes" 51396901_1 CDM 0510 RC 99255 HCPCS inpatient 550 357.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 333.03 533.5 "Hospital consultation with high level of medical decision making, if using time, at least 80 minutes" 51396901_1 CDM 0510 RC 99255 HCPCS inpatient 550 357.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 333.03 60.55 999999999 333.03 533.5 percent of total billed charges "Hospital consultation with high level of medical decision making, if using time, at least 80 minutes" 51396901_1 CDM 0510 RC 99255 HCPCS inpatient 550 357.5 ANTHEM HMO ANTHEM HMO 999999999 333.03 533.5 "Hospital consultation with high level of medical decision making, if using time, at least 80 minutes" 51396901_1 CDM 0510 RC 99255 HCPCS inpatient 550 357.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 333.03 533.5 "Hospital consultation with high level of medical decision making, if using time, at least 80 minutes" 51396901_1 CDM 0510 RC 99255 HCPCS inpatient 550 357.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 333.03 533.5 "Hospital consultation with high level of medical decision making, if using time, at least 80 minutes" 51396901_1 CDM 0510 RC 99255 HCPCS inpatient 550 357.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 333.03 533.5 "Hospital consultation with high level of medical decision making, if using time, at least 80 minutes" 51396901_1 CDM 0510 RC 99255 HCPCS inpatient 550 357.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 371.8 67.6 999999999 333.03 533.5 percent of total billed charges RIVASTIGMINE 3 MG CAPSULE 51399728_1 CDM 0250 RC 62332-0064-60 NDC inpatient 1 UN 2 1.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1.3 65 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 3 MG CAPSULE 51399728_1 CDM 0250 RC 62332-0064-60 NDC inpatient 1 UN 2 1.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.94 97 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 3 MG CAPSULE 51399728_1 CDM 0250 RC 62332-0064-60 NDC inpatient 1 UN 2 1.3 AETNA AETNA 1.58 79 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 3 MG CAPSULE 51399728_1 CDM 0250 RC 62332-0064-60 NDC inpatient 1 UN 2 1.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1.38 69 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 3 MG CAPSULE 51399728_1 CDM 0250 RC 62332-0064-60 NDC inpatient 1 UN 2 1.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.56 78 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 3 MG CAPSULE 51399728_1 CDM 0250 RC 62332-0064-60 NDC inpatient 1 UN 2 1.3 SIHO - ALL PLANS SIHO - ALL PLANS 1.8 90 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 3 MG CAPSULE 51399728_1 CDM 0250 RC 62332-0064-60 NDC inpatient 1 UN 2 1.3 UMR - ALL PLANS UMR - ALL PLANS 1.4 70 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 3 MG CAPSULE 51399728_1 CDM 0250 RC 62332-0064-60 NDC inpatient 1 UN 2 1.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1.21 1.94 RIVASTIGMINE 3 MG CAPSULE 51399728_1 CDM 0250 RC 62332-0064-60 NDC inpatient 1 UN 2 1.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1.21 60.55 999999999 1.21 1.94 percent of total billed charges RIVASTIGMINE 3 MG CAPSULE 51399728_1 CDM 0250 RC 62332-0064-60 NDC inpatient 1 UN 2 1.3 ANTHEM HMO ANTHEM HMO 999999999 1.21 1.94 RIVASTIGMINE 3 MG CAPSULE 51399728_1 CDM 0250 RC 62332-0064-60 NDC inpatient 1 UN 2 1.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1.21 1.94 RIVASTIGMINE 3 MG CAPSULE 51399728_1 CDM 0250 RC 62332-0064-60 NDC inpatient 1 UN 2 1.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1.21 1.94 RIVASTIGMINE 3 MG CAPSULE 51399728_1 CDM 0250 RC 62332-0064-60 NDC inpatient 1 UN 2 1.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1.21 1.94 RIVASTIGMINE 3 MG CAPSULE 51399728_1 CDM 0250 RC 62332-0064-60 NDC inpatient 1 UN 2 1.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1.35 67.6 999999999 1.21 1.94 percent of total billed charges Aspiration and/or injection of fluid from medium joint 51399759_1 CDM 0510 RC 20605 HCPCS inpatient 962 625.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 625.3 65 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from medium joint 51399759_1 CDM 0510 RC 20605 HCPCS inpatient 962 625.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 933.14 97 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from medium joint 51399759_1 CDM 0510 RC 20605 HCPCS inpatient 962 625.3 AETNA AETNA 759.98 79 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from medium joint 51399759_1 CDM 0510 RC 20605 HCPCS inpatient 962 625.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 663.78 69 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from medium joint 51399759_1 CDM 0510 RC 20605 HCPCS inpatient 962 625.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 750.36 78 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from medium joint 51399759_1 CDM 0510 RC 20605 HCPCS inpatient 962 625.3 SIHO - ALL PLANS SIHO - ALL PLANS 865.8 90 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from medium joint 51399759_1 CDM 0510 RC 20605 HCPCS inpatient 962 625.3 UMR - ALL PLANS UMR - ALL PLANS 673.4 70 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from medium joint 51399759_1 CDM 0510 RC 20605 HCPCS inpatient 962 625.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 582.49 933.14 Aspiration and/or injection of fluid from medium joint 51399759_1 CDM 0510 RC 20605 HCPCS inpatient 962 625.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 582.49 60.55 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of fluid from medium joint 51399759_1 CDM 0510 RC 20605 HCPCS inpatient 962 625.3 ANTHEM HMO ANTHEM HMO 999999999 582.49 933.14 Aspiration and/or injection of fluid from medium joint 51399759_1 CDM 0510 RC 20605 HCPCS inpatient 962 625.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 582.49 933.14 Aspiration and/or injection of fluid from medium joint 51399759_1 CDM 0510 RC 20605 HCPCS inpatient 962 625.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 582.49 933.14 Aspiration and/or injection of fluid from medium joint 51399759_1 CDM 0510 RC 20605 HCPCS inpatient 962 625.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 582.49 933.14 Aspiration and/or injection of fluid from medium joint 51399759_1 CDM 0510 RC 20605 HCPCS inpatient 962 625.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 650.31 67.6 999999999 582.49 933.14 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm" 51399847_1 CDM 0510 RC 11421 HCPCS inpatient 2297 1493.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1493.05 65 999999999 1390.83 2228.09 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm" 51399847_1 CDM 0510 RC 11421 HCPCS inpatient 2297 1493.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2228.09 97 999999999 1390.83 2228.09 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm" 51399847_1 CDM 0510 RC 11421 HCPCS inpatient 2297 1493.05 AETNA AETNA 1814.63 79 999999999 1390.83 2228.09 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm" 51399847_1 CDM 0510 RC 11421 HCPCS inpatient 2297 1493.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1584.93 69 999999999 1390.83 2228.09 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm" 51399847_1 CDM 0510 RC 11421 HCPCS inpatient 2297 1493.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1791.66 78 999999999 1390.83 2228.09 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm" 51399847_1 CDM 0510 RC 11421 HCPCS inpatient 2297 1493.05 SIHO - ALL PLANS SIHO - ALL PLANS 2067.3 90 999999999 1390.83 2228.09 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm" 51399847_1 CDM 0510 RC 11421 HCPCS inpatient 2297 1493.05 UMR - ALL PLANS UMR - ALL PLANS 1607.9 70 999999999 1390.83 2228.09 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm" 51399847_1 CDM 0510 RC 11421 HCPCS inpatient 2297 1493.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1390.83 60.55 999999999 1390.83 2228.09 percent of total billed charges "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm" 51399847_1 CDM 0510 RC 11421 HCPCS inpatient 2297 1493.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1390.83 2228.09 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm" 51399847_1 CDM 0510 RC 11421 HCPCS inpatient 2297 1493.05 ANTHEM HMO ANTHEM HMO 999999999 1390.83 2228.09 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm" 51399847_1 CDM 0510 RC 11421 HCPCS inpatient 2297 1493.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1390.83 2228.09 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm" 51399847_1 CDM 0510 RC 11421 HCPCS inpatient 2297 1493.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1390.83 2228.09 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm" 51399847_1 CDM 0510 RC 11421 HCPCS inpatient 2297 1493.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1390.83 2228.09 "Removal of noncancer skin growth of scalp, neck, hands, feet, or genitals, 0.6-1.0 cm" 51399847_1 CDM 0510 RC 11421 HCPCS inpatient 2297 1493.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1552.77 67.6 999999999 1390.83 2228.09 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51400124_1 CDM 0510 RC 64450 HCPCS inpatient 2281 1482.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1482.65 65 999999999 1381.15 2212.57 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51400124_1 CDM 0510 RC 64450 HCPCS inpatient 2281 1482.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2212.57 97 999999999 1381.15 2212.57 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51400124_1 CDM 0510 RC 64450 HCPCS inpatient 2281 1482.65 AETNA AETNA 1801.99 79 999999999 1381.15 2212.57 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51400124_1 CDM 0510 RC 64450 HCPCS inpatient 2281 1482.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1573.89 69 999999999 1381.15 2212.57 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51400124_1 CDM 0510 RC 64450 HCPCS inpatient 2281 1482.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1779.18 78 999999999 1381.15 2212.57 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51400124_1 CDM 0510 RC 64450 HCPCS inpatient 2281 1482.65 SIHO - ALL PLANS SIHO - ALL PLANS 2052.9 90 999999999 1381.15 2212.57 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51400124_1 CDM 0510 RC 64450 HCPCS inpatient 2281 1482.65 UMR - ALL PLANS UMR - ALL PLANS 1596.7 70 999999999 1381.15 2212.57 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51400124_1 CDM 0510 RC 64450 HCPCS inpatient 2281 1482.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1381.15 60.55 999999999 1381.15 2212.57 percent of total billed charges Injection of anesthetic agent and/or steroid into other nerve or branch 51400124_1 CDM 0510 RC 64450 HCPCS inpatient 2281 1482.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1381.15 2212.57 Injection of anesthetic agent and/or steroid into other nerve or branch 51400124_1 CDM 0510 RC 64450 HCPCS inpatient 2281 1482.65 ANTHEM HMO ANTHEM HMO 999999999 1381.15 2212.57 Injection of anesthetic agent and/or steroid into other nerve or branch 51400124_1 CDM 0510 RC 64450 HCPCS inpatient 2281 1482.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1381.15 2212.57 Injection of anesthetic agent and/or steroid into other nerve or branch 51400124_1 CDM 0510 RC 64450 HCPCS inpatient 2281 1482.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1381.15 2212.57 Injection of anesthetic agent and/or steroid into other nerve or branch 51400124_1 CDM 0510 RC 64450 HCPCS inpatient 2281 1482.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1381.15 2212.57 Injection of anesthetic agent and/or steroid into other nerve or branch 51400124_1 CDM 0510 RC 64450 HCPCS inpatient 2281 1482.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1541.96 67.6 999999999 1381.15 2212.57 percent of total billed charges Destruction of peripheral nerve or branch 51400125_1 CDM 0510 RC 64640 HCPCS inpatient 3017 1961.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1961.05 65 999999999 1826.79 2926.49 percent of total billed charges Destruction of peripheral nerve or branch 51400125_1 CDM 0510 RC 64640 HCPCS inpatient 3017 1961.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2926.49 97 999999999 1826.79 2926.49 percent of total billed charges Destruction of peripheral nerve or branch 51400125_1 CDM 0510 RC 64640 HCPCS inpatient 3017 1961.05 AETNA AETNA 2383.43 79 999999999 1826.79 2926.49 percent of total billed charges Destruction of peripheral nerve or branch 51400125_1 CDM 0510 RC 64640 HCPCS inpatient 3017 1961.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2081.73 69 999999999 1826.79 2926.49 percent of total billed charges Destruction of peripheral nerve or branch 51400125_1 CDM 0510 RC 64640 HCPCS inpatient 3017 1961.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 2353.26 78 999999999 1826.79 2926.49 percent of total billed charges Destruction of peripheral nerve or branch 51400125_1 CDM 0510 RC 64640 HCPCS inpatient 3017 1961.05 SIHO - ALL PLANS SIHO - ALL PLANS 2715.3 90 999999999 1826.79 2926.49 percent of total billed charges Destruction of peripheral nerve or branch 51400125_1 CDM 0510 RC 64640 HCPCS inpatient 3017 1961.05 UMR - ALL PLANS UMR - ALL PLANS 2111.9 70 999999999 1826.79 2926.49 percent of total billed charges Destruction of peripheral nerve or branch 51400125_1 CDM 0510 RC 64640 HCPCS inpatient 3017 1961.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1826.79 60.55 999999999 1826.79 2926.49 percent of total billed charges Destruction of peripheral nerve or branch 51400125_1 CDM 0510 RC 64640 HCPCS inpatient 3017 1961.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1826.79 2926.49 Destruction of peripheral nerve or branch 51400125_1 CDM 0510 RC 64640 HCPCS inpatient 3017 1961.05 ANTHEM HMO ANTHEM HMO 999999999 1826.79 2926.49 Destruction of peripheral nerve or branch 51400125_1 CDM 0510 RC 64640 HCPCS inpatient 3017 1961.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1826.79 2926.49 Destruction of peripheral nerve or branch 51400125_1 CDM 0510 RC 64640 HCPCS inpatient 3017 1961.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1826.79 2926.49 Destruction of peripheral nerve or branch 51400125_1 CDM 0510 RC 64640 HCPCS inpatient 3017 1961.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1826.79 2926.49 Destruction of peripheral nerve or branch 51400125_1 CDM 0510 RC 64640 HCPCS inpatient 3017 1961.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2039.49 67.6 999999999 1826.79 2926.49 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 51401807_1 CDM 0510 RC 99202 HCPCS inpatient 204 132.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.6 65 999999999 123.52 197.88 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 51401807_1 CDM 0510 RC 99202 HCPCS inpatient 204 132.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.88 97 999999999 123.52 197.88 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 51401807_1 CDM 0510 RC 99202 HCPCS inpatient 204 132.6 AETNA AETNA 161.16 79 999999999 123.52 197.88 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 51401807_1 CDM 0510 RC 99202 HCPCS inpatient 204 132.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.76 69 999999999 123.52 197.88 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 51401807_1 CDM 0510 RC 99202 HCPCS inpatient 204 132.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.12 78 999999999 123.52 197.88 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 51401807_1 CDM 0510 RC 99202 HCPCS inpatient 204 132.6 SIHO - ALL PLANS SIHO - ALL PLANS 183.6 90 999999999 123.52 197.88 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 51401807_1 CDM 0510 RC 99202 HCPCS inpatient 204 132.6 UMR - ALL PLANS UMR - ALL PLANS 142.8 70 999999999 123.52 197.88 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 51401807_1 CDM 0510 RC 99202 HCPCS inpatient 204 132.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.52 60.55 999999999 123.52 197.88 percent of total billed charges "New patient office or other outpatient visit, 15-29 minutes" 51401807_1 CDM 0510 RC 99202 HCPCS inpatient 204 132.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.52 197.88 "New patient office or other outpatient visit, 15-29 minutes" 51401807_1 CDM 0510 RC 99202 HCPCS inpatient 204 132.6 ANTHEM HMO ANTHEM HMO 999999999 123.52 197.88 "New patient office or other outpatient visit, 15-29 minutes" 51401807_1 CDM 0510 RC 99202 HCPCS inpatient 204 132.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.52 197.88 "New patient office or other outpatient visit, 15-29 minutes" 51401807_1 CDM 0510 RC 99202 HCPCS inpatient 204 132.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.52 197.88 "New patient office or other outpatient visit, 15-29 minutes" 51401807_1 CDM 0510 RC 99202 HCPCS inpatient 204 132.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.52 197.88 "New patient office or other outpatient visit, 15-29 minutes" 51401807_1 CDM 0510 RC 99202 HCPCS inpatient 204 132.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.9 67.6 999999999 123.52 197.88 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 51401808_1 CDM 0510 RC 99215 HCPCS inpatient 508 330.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 330.2 65 999999999 307.59 492.76 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 51401808_1 CDM 0510 RC 99215 HCPCS inpatient 508 330.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 492.76 97 999999999 307.59 492.76 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 51401808_1 CDM 0510 RC 99215 HCPCS inpatient 508 330.2 AETNA AETNA 401.32 79 999999999 307.59 492.76 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 51401808_1 CDM 0510 RC 99215 HCPCS inpatient 508 330.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 350.52 69 999999999 307.59 492.76 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 51401808_1 CDM 0510 RC 99215 HCPCS inpatient 508 330.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 396.24 78 999999999 307.59 492.76 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 51401808_1 CDM 0510 RC 99215 HCPCS inpatient 508 330.2 SIHO - ALL PLANS SIHO - ALL PLANS 457.2 90 999999999 307.59 492.76 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 51401808_1 CDM 0510 RC 99215 HCPCS inpatient 508 330.2 UMR - ALL PLANS UMR - ALL PLANS 355.6 70 999999999 307.59 492.76 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 51401808_1 CDM 0510 RC 99215 HCPCS inpatient 508 330.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 307.59 60.55 999999999 307.59 492.76 percent of total billed charges "Established patient office or other outpatient visit, 40-54 minutes" 51401808_1 CDM 0510 RC 99215 HCPCS inpatient 508 330.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 307.59 492.76 "Established patient office or other outpatient visit, 40-54 minutes" 51401808_1 CDM 0510 RC 99215 HCPCS inpatient 508 330.2 ANTHEM HMO ANTHEM HMO 999999999 307.59 492.76 "Established patient office or other outpatient visit, 40-54 minutes" 51401808_1 CDM 0510 RC 99215 HCPCS inpatient 508 330.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 307.59 492.76 "Established patient office or other outpatient visit, 40-54 minutes" 51401808_1 CDM 0510 RC 99215 HCPCS inpatient 508 330.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 307.59 492.76 "Established patient office or other outpatient visit, 40-54 minutes" 51401808_1 CDM 0510 RC 99215 HCPCS inpatient 508 330.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 307.59 492.76 "Established patient office or other outpatient visit, 40-54 minutes" 51401808_1 CDM 0510 RC 99215 HCPCS inpatient 508 330.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 343.41 67.6 999999999 307.59 492.76 percent of total billed charges "Outpatient consultation with straightforward medical decision making, if using time, at least 20 minutes" 51401809_1 CDM 0510 RC 99242 HCPCS inpatient 204 132.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.6 65 999999999 123.52 197.88 percent of total billed charges "Outpatient consultation with straightforward medical decision making, if using time, at least 20 minutes" 51401809_1 CDM 0510 RC 99242 HCPCS inpatient 204 132.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.88 97 999999999 123.52 197.88 percent of total billed charges "Outpatient consultation with straightforward medical decision making, if using time, at least 20 minutes" 51401809_1 CDM 0510 RC 99242 HCPCS inpatient 204 132.6 AETNA AETNA 161.16 79 999999999 123.52 197.88 percent of total billed charges "Outpatient consultation with straightforward medical decision making, if using time, at least 20 minutes" 51401809_1 CDM 0510 RC 99242 HCPCS inpatient 204 132.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.76 69 999999999 123.52 197.88 percent of total billed charges "Outpatient consultation with straightforward medical decision making, if using time, at least 20 minutes" 51401809_1 CDM 0510 RC 99242 HCPCS inpatient 204 132.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.12 78 999999999 123.52 197.88 percent of total billed charges "Outpatient consultation with straightforward medical decision making, if using time, at least 20 minutes" 51401809_1 CDM 0510 RC 99242 HCPCS inpatient 204 132.6 SIHO - ALL PLANS SIHO - ALL PLANS 183.6 90 999999999 123.52 197.88 percent of total billed charges "Outpatient consultation with straightforward medical decision making, if using time, at least 20 minutes" 51401809_1 CDM 0510 RC 99242 HCPCS inpatient 204 132.6 UMR - ALL PLANS UMR - ALL PLANS 142.8 70 999999999 123.52 197.88 percent of total billed charges "Outpatient consultation with straightforward medical decision making, if using time, at least 20 minutes" 51401809_1 CDM 0510 RC 99242 HCPCS inpatient 204 132.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.52 60.55 999999999 123.52 197.88 percent of total billed charges "Outpatient consultation with straightforward medical decision making, if using time, at least 20 minutes" 51401809_1 CDM 0510 RC 99242 HCPCS inpatient 204 132.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.52 197.88 "Outpatient consultation with straightforward medical decision making, if using time, at least 20 minutes" 51401809_1 CDM 0510 RC 99242 HCPCS inpatient 204 132.6 ANTHEM HMO ANTHEM HMO 999999999 123.52 197.88 "Outpatient consultation with straightforward medical decision making, if using time, at least 20 minutes" 51401809_1 CDM 0510 RC 99242 HCPCS inpatient 204 132.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.52 197.88 "Outpatient consultation with straightforward medical decision making, if using time, at least 20 minutes" 51401809_1 CDM 0510 RC 99242 HCPCS inpatient 204 132.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.52 197.88 "Outpatient consultation with straightforward medical decision making, if using time, at least 20 minutes" 51401809_1 CDM 0510 RC 99242 HCPCS inpatient 204 132.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.52 197.88 "Outpatient consultation with straightforward medical decision making, if using time, at least 20 minutes" 51401809_1 CDM 0510 RC 99242 HCPCS inpatient 204 132.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.9 67.6 999999999 123.52 197.88 percent of total billed charges "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 35 minutes" 51401810_1 CDM 0510 RC 99232 HCPCS inpatient 226 146.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 146.9 65 999999999 136.84 219.22 percent of total billed charges "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 35 minutes" 51401810_1 CDM 0510 RC 99232 HCPCS inpatient 226 146.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 219.22 97 999999999 136.84 219.22 percent of total billed charges "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 35 minutes" 51401810_1 CDM 0510 RC 99232 HCPCS inpatient 226 146.9 AETNA AETNA 178.54 79 999999999 136.84 219.22 percent of total billed charges "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 35 minutes" 51401810_1 CDM 0510 RC 99232 HCPCS inpatient 226 146.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 155.94 69 999999999 136.84 219.22 percent of total billed charges "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 35 minutes" 51401810_1 CDM 0510 RC 99232 HCPCS inpatient 226 146.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 176.28 78 999999999 136.84 219.22 percent of total billed charges "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 35 minutes" 51401810_1 CDM 0510 RC 99232 HCPCS inpatient 226 146.9 SIHO - ALL PLANS SIHO - ALL PLANS 203.4 90 999999999 136.84 219.22 percent of total billed charges "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 35 minutes" 51401810_1 CDM 0510 RC 99232 HCPCS inpatient 226 146.9 UMR - ALL PLANS UMR - ALL PLANS 158.2 70 999999999 136.84 219.22 percent of total billed charges "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 35 minutes" 51401810_1 CDM 0510 RC 99232 HCPCS inpatient 226 146.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 136.84 60.55 999999999 136.84 219.22 percent of total billed charges "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 35 minutes" 51401810_1 CDM 0510 RC 99232 HCPCS inpatient 226 146.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 136.84 219.22 "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 35 minutes" 51401810_1 CDM 0510 RC 99232 HCPCS inpatient 226 146.9 ANTHEM HMO ANTHEM HMO 999999999 136.84 219.22 "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 35 minutes" 51401810_1 CDM 0510 RC 99232 HCPCS inpatient 226 146.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 136.84 219.22 "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 35 minutes" 51401810_1 CDM 0510 RC 99232 HCPCS inpatient 226 146.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 136.84 219.22 "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 35 minutes" 51401810_1 CDM 0510 RC 99232 HCPCS inpatient 226 146.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 136.84 219.22 "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 35 minutes" 51401810_1 CDM 0510 RC 99232 HCPCS inpatient 226 146.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 152.78 67.6 999999999 136.84 219.22 percent of total billed charges "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 50 minutes" 51401811_1 CDM 0510 RC 99233 HCPCS inpatient 340 221 SELF PAY DISCOUNT SELF PAY DISCOUNT 221 65 999999999 205.87 329.8 percent of total billed charges "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 50 minutes" 51401811_1 CDM 0510 RC 99233 HCPCS inpatient 340 221 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 329.8 97 999999999 205.87 329.8 percent of total billed charges "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 50 minutes" 51401811_1 CDM 0510 RC 99233 HCPCS inpatient 340 221 AETNA AETNA 268.6 79 999999999 205.87 329.8 percent of total billed charges "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 50 minutes" 51401811_1 CDM 0510 RC 99233 HCPCS inpatient 340 221 ENCORE - ALL PLANS ENCORE - ALL PLANS 234.6 69 999999999 205.87 329.8 percent of total billed charges "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 50 minutes" 51401811_1 CDM 0510 RC 99233 HCPCS inpatient 340 221 HUMANA - ALL PLANS HUMANA - ALL PLANS 265.2 78 999999999 205.87 329.8 percent of total billed charges "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 50 minutes" 51401811_1 CDM 0510 RC 99233 HCPCS inpatient 340 221 SIHO - ALL PLANS SIHO - ALL PLANS 306 90 999999999 205.87 329.8 percent of total billed charges "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 50 minutes" 51401811_1 CDM 0510 RC 99233 HCPCS inpatient 340 221 UMR - ALL PLANS UMR - ALL PLANS 238 70 999999999 205.87 329.8 percent of total billed charges "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 50 minutes" 51401811_1 CDM 0510 RC 99233 HCPCS inpatient 340 221 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.87 60.55 999999999 205.87 329.8 percent of total billed charges "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 50 minutes" 51401811_1 CDM 0510 RC 99233 HCPCS inpatient 340 221 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.87 329.8 "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 50 minutes" 51401811_1 CDM 0510 RC 99233 HCPCS inpatient 340 221 ANTHEM HMO ANTHEM HMO 999999999 205.87 329.8 "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 50 minutes" 51401811_1 CDM 0510 RC 99233 HCPCS inpatient 340 221 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.87 329.8 "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 50 minutes" 51401811_1 CDM 0510 RC 99233 HCPCS inpatient 340 221 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.87 329.8 "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 50 minutes" 51401811_1 CDM 0510 RC 99233 HCPCS inpatient 340 221 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.87 329.8 "Subsequent hospital care with moderate levelof medical decision making, if using time, at least 50 minutes" 51401811_1 CDM 0510 RC 99233 HCPCS inpatient 340 221 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.84 67.6 999999999 205.87 329.8 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51407274_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 399.75 65 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51407274_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 596.55 97 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51407274_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 AETNA AETNA 485.85 79 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51407274_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 424.35 69 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51407274_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 479.7 78 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51407274_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 UMR - ALL PLANS UMR - ALL PLANS 430.5 70 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51407274_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 SIHO - ALL PLANS SIHO - ALL PLANS 553.5 90 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51407274_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 372.38 60.55 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51407274_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 51407274_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ANTHEM HMO ANTHEM HMO 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 51407274_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 51407274_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 51407274_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 51407274_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 415.74 67.6 999999999 372.38 596.55 percent of total billed charges Tissue culture to identify skin disorders 51407275_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 174.2 65 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 51407275_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 259.96 97 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 51407275_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 AETNA AETNA 211.72 79 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 51407275_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.92 69 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 51407275_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 209.04 78 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 51407275_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 UMR - ALL PLANS UMR - ALL PLANS 187.6 70 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 51407275_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 SIHO - ALL PLANS SIHO - ALL PLANS 241.2 90 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 51407275_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 162.27 60.55 999999999 162.27 259.96 percent of total billed charges Tissue culture to identify skin disorders 51407275_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 162.27 259.96 Tissue culture to identify skin disorders 51407275_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 ANTHEM HMO ANTHEM HMO 999999999 162.27 259.96 Tissue culture to identify skin disorders 51407275_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 162.27 259.96 Tissue culture to identify skin disorders 51407275_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 162.27 259.96 Tissue culture to identify skin disorders 51407275_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 162.27 259.96 Tissue culture to identify skin disorders 51407275_1 CDM 0311 RC 88233 HCPCS inpatient 268 174.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 181.17 67.6 999999999 162.27 259.96 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51409796_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 553.8 65 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51409796_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 826.44 97 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51409796_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 AETNA AETNA 673.08 79 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51409796_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 587.88 69 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51409796_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 664.56 78 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51409796_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 UMR - ALL PLANS UMR - ALL PLANS 596.4 70 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51409796_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 SIHO - ALL PLANS SIHO - ALL PLANS 766.8 90 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51409796_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 515.89 60.55 999999999 515.89 826.44 percent of total billed charges "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51409796_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51409796_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM HMO ANTHEM HMO 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51409796_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51409796_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51409796_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 515.89 826.44 "Microscopic genetic analysis of tissue, manual, each additional multiplex stain procedure" 51409796_1 CDM 0310 RC 88377 HCPCS inpatient 852 553.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 575.95 67.6 999999999 515.89 826.44 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51409810_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 230.75 65 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51409810_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 344.35 97 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51409810_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 AETNA AETNA 280.45 79 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51409810_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 244.95 69 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51409810_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 276.9 78 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51409810_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UMR - ALL PLANS UMR - ALL PLANS 248.5 70 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51409810_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 SIHO - ALL PLANS SIHO - ALL PLANS 319.5 90 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51409810_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 214.95 60.55 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51409810_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51409810_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM HMO ANTHEM HMO 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51409810_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51409810_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51409810_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51409810_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 239.98 67.6 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412693_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 230.75 65 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412693_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 344.35 97 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412693_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 AETNA AETNA 280.45 79 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412693_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 244.95 69 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412693_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 276.9 78 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412693_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UMR - ALL PLANS UMR - ALL PLANS 248.5 70 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412693_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 SIHO - ALL PLANS SIHO - ALL PLANS 319.5 90 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412693_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 214.95 60.55 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412693_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412693_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM HMO ANTHEM HMO 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412693_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412693_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412693_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412693_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 239.98 67.6 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412695_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 230.75 65 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412695_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 344.35 97 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412695_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 AETNA AETNA 280.45 79 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412695_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 244.95 69 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412695_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 276.9 78 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412695_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UMR - ALL PLANS UMR - ALL PLANS 248.5 70 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412695_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 SIHO - ALL PLANS SIHO - ALL PLANS 319.5 90 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412695_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 214.95 60.55 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412695_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412695_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM HMO ANTHEM HMO 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412695_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412695_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412695_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412695_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 239.98 67.6 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412696_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 230.75 65 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412696_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 344.35 97 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412696_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 AETNA AETNA 280.45 79 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412696_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 244.95 69 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412696_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 276.9 78 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412696_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UMR - ALL PLANS UMR - ALL PLANS 248.5 70 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412696_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 SIHO - ALL PLANS SIHO - ALL PLANS 319.5 90 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412696_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 214.95 60.55 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412696_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412696_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM HMO ANTHEM HMO 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412696_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412696_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412696_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412696_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 239.98 67.6 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412698_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 230.75 65 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412698_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 344.35 97 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412698_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 AETNA AETNA 280.45 79 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412698_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 244.95 69 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412698_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 276.9 78 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412698_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UMR - ALL PLANS UMR - ALL PLANS 248.5 70 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412698_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 SIHO - ALL PLANS SIHO - ALL PLANS 319.5 90 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412698_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 214.95 60.55 999999999 214.95 344.35 percent of total billed charges "Special stained specimen slides to examine tissue, initial procedure" 51412698_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412698_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM HMO ANTHEM HMO 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412698_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412698_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412698_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 214.95 344.35 "Special stained specimen slides to examine tissue, initial procedure" 51412698_1 CDM 0310 RC 88342 HCPCS inpatient 355 230.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 239.98 67.6 999999999 214.95 344.35 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 51412862_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 354.9 65 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 51412862_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 529.62 97 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 51412862_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 AETNA AETNA 431.34 79 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 51412862_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 376.74 69 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 51412862_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 425.88 78 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 51412862_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 UMR - ALL PLANS UMR - ALL PLANS 382.2 70 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 51412862_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 SIHO - ALL PLANS SIHO - ALL PLANS 491.4 90 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 51412862_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 330.6 60.55 999999999 330.6 529.62 percent of total billed charges "New patient office or other outpatient visit, 60-74 minutes" 51412862_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 330.6 529.62 "New patient office or other outpatient visit, 60-74 minutes" 51412862_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 ANTHEM HMO ANTHEM HMO 999999999 330.6 529.62 "New patient office or other outpatient visit, 60-74 minutes" 51412862_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 330.6 529.62 "New patient office or other outpatient visit, 60-74 minutes" 51412862_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 330.6 529.62 "New patient office or other outpatient visit, 60-74 minutes" 51412862_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 330.6 529.62 "New patient office or other outpatient visit, 60-74 minutes" 51412862_1 CDM 0510 RC 99205 HCPCS inpatient 546 354.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 369.1 67.6 999999999 330.6 529.62 percent of total billed charges "Electronic analysis of implanted brain, spinal cord, or peripheral neurostimulator generator" 51413816_1 CDM 0360 RC 95970 HCPCS inpatient 411 267.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 267.15 65 999999999 248.86 398.67 percent of total billed charges "Electronic analysis of implanted brain, spinal cord, or peripheral neurostimulator generator" 51413816_1 CDM 0360 RC 95970 HCPCS inpatient 411 267.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 398.67 97 999999999 248.86 398.67 percent of total billed charges "Electronic analysis of implanted brain, spinal cord, or peripheral neurostimulator generator" 51413816_1 CDM 0360 RC 95970 HCPCS inpatient 411 267.15 AETNA AETNA 324.69 79 999999999 248.86 398.67 percent of total billed charges "Electronic analysis of implanted brain, spinal cord, or peripheral neurostimulator generator" 51413816_1 CDM 0360 RC 95970 HCPCS inpatient 411 267.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 283.59 69 999999999 248.86 398.67 percent of total billed charges "Electronic analysis of implanted brain, spinal cord, or peripheral neurostimulator generator" 51413816_1 CDM 0360 RC 95970 HCPCS inpatient 411 267.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 320.58 78 999999999 248.86 398.67 percent of total billed charges "Electronic analysis of implanted brain, spinal cord, or peripheral neurostimulator generator" 51413816_1 CDM 0360 RC 95970 HCPCS inpatient 411 267.15 UMR - ALL PLANS UMR - ALL PLANS 287.7 70 999999999 248.86 398.67 percent of total billed charges "Electronic analysis of implanted brain, spinal cord, or peripheral neurostimulator generator" 51413816_1 CDM 0360 RC 95970 HCPCS inpatient 411 267.15 SIHO - ALL PLANS SIHO - ALL PLANS 369.9 90 999999999 248.86 398.67 percent of total billed charges "Electronic analysis of implanted brain, spinal cord, or peripheral neurostimulator generator" 51413816_1 CDM 0360 RC 95970 HCPCS inpatient 411 267.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 248.86 60.55 999999999 248.86 398.67 percent of total billed charges "Electronic analysis of implanted brain, spinal cord, or peripheral neurostimulator generator" 51413816_1 CDM 0360 RC 95970 HCPCS inpatient 411 267.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 248.86 398.67 "Electronic analysis of implanted brain, spinal cord, or peripheral neurostimulator generator" 51413816_1 CDM 0360 RC 95970 HCPCS inpatient 411 267.15 ANTHEM HMO ANTHEM HMO 999999999 248.86 398.67 "Electronic analysis of implanted brain, spinal cord, or peripheral neurostimulator generator" 51413816_1 CDM 0360 RC 95970 HCPCS inpatient 411 267.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 248.86 398.67 "Electronic analysis of implanted brain, spinal cord, or peripheral neurostimulator generator" 51413816_1 CDM 0360 RC 95970 HCPCS inpatient 411 267.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 248.86 398.67 "Electronic analysis of implanted brain, spinal cord, or peripheral neurostimulator generator" 51413816_1 CDM 0360 RC 95970 HCPCS inpatient 411 267.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 248.86 398.67 "Electronic analysis of implanted brain, spinal cord, or peripheral neurostimulator generator" 51413816_1 CDM 0360 RC 95970 HCPCS inpatient 411 267.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 277.84 67.6 999999999 248.86 398.67 percent of total billed charges Urine calcium level 51419092_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 97.5 65 999999999 90.83 145.5 percent of total billed charges Urine calcium level 51419092_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 145.5 97 999999999 90.83 145.5 percent of total billed charges Urine calcium level 51419092_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 AETNA AETNA 118.5 79 999999999 90.83 145.5 percent of total billed charges Urine calcium level 51419092_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 103.5 69 999999999 90.83 145.5 percent of total billed charges Urine calcium level 51419092_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 117 78 999999999 90.83 145.5 percent of total billed charges Urine calcium level 51419092_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 UMR - ALL PLANS UMR - ALL PLANS 105 70 999999999 90.83 145.5 percent of total billed charges Urine calcium level 51419092_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 SIHO - ALL PLANS SIHO - ALL PLANS 135 90 999999999 90.83 145.5 percent of total billed charges Urine calcium level 51419092_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 90.83 60.55 999999999 90.83 145.5 percent of total billed charges Urine calcium level 51419092_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 90.83 145.5 Urine calcium level 51419092_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 ANTHEM HMO ANTHEM HMO 999999999 90.83 145.5 Urine calcium level 51419092_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 90.83 145.5 Urine calcium level 51419092_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 90.83 145.5 Urine calcium level 51419092_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 90.83 145.5 Urine calcium level 51419092_1 CDM 0301 RC 82340 HCPCS inpatient 150 97.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 101.4 67.6 999999999 90.83 145.5 percent of total billed charges Uric acid level 51429175_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges Uric acid level 51429175_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges Uric acid level 51429175_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges Uric acid level 51429175_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges Uric acid level 51429175_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges Uric acid level 51429175_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges Uric acid level 51429175_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges Uric acid level 51429175_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges Uric acid level 51429175_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 Uric acid level 51429175_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 Uric acid level 51429175_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 Uric acid level 51429175_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 Uric acid level 51429175_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Uric acid level 51429175_1 CDM 0301 RC 84560 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges Magnesium level 51430075_1 CDM 0301 RC 83735 HCPCS inpatient 146 94.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 94.9 65 999999999 88.4 141.62 percent of total billed charges Magnesium level 51430075_1 CDM 0301 RC 83735 HCPCS inpatient 146 94.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 141.62 97 999999999 88.4 141.62 percent of total billed charges Magnesium level 51430075_1 CDM 0301 RC 83735 HCPCS inpatient 146 94.9 AETNA AETNA 115.34 79 999999999 88.4 141.62 percent of total billed charges Magnesium level 51430075_1 CDM 0301 RC 83735 HCPCS inpatient 146 94.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 100.74 69 999999999 88.4 141.62 percent of total billed charges Magnesium level 51430075_1 CDM 0301 RC 83735 HCPCS inpatient 146 94.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 113.88 78 999999999 88.4 141.62 percent of total billed charges Magnesium level 51430075_1 CDM 0301 RC 83735 HCPCS inpatient 146 94.9 SIHO - ALL PLANS SIHO - ALL PLANS 131.4 90 999999999 88.4 141.62 percent of total billed charges Magnesium level 51430075_1 CDM 0301 RC 83735 HCPCS inpatient 146 94.9 UMR - ALL PLANS UMR - ALL PLANS 102.2 70 999999999 88.4 141.62 percent of total billed charges Magnesium level 51430075_1 CDM 0301 RC 83735 HCPCS inpatient 146 94.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 88.4 60.55 999999999 88.4 141.62 percent of total billed charges Magnesium level 51430075_1 CDM 0301 RC 83735 HCPCS inpatient 146 94.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 88.4 141.62 Magnesium level 51430075_1 CDM 0301 RC 83735 HCPCS inpatient 146 94.9 ANTHEM HMO ANTHEM HMO 999999999 88.4 141.62 Magnesium level 51430075_1 CDM 0301 RC 83735 HCPCS inpatient 146 94.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 88.4 141.62 Magnesium level 51430075_1 CDM 0301 RC 83735 HCPCS inpatient 146 94.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 88.4 141.62 Magnesium level 51430075_1 CDM 0301 RC 83735 HCPCS inpatient 146 94.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 88.4 141.62 Magnesium level 51430075_1 CDM 0301 RC 83735 HCPCS inpatient 146 94.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 98.7 67.6 999999999 88.4 141.62 percent of total billed charges Urine phosphate level 51430076_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 101.4 65 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 51430076_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 151.32 97 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 51430076_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 AETNA AETNA 123.24 79 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 51430076_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 107.64 69 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 51430076_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 121.68 78 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 51430076_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 SIHO - ALL PLANS SIHO - ALL PLANS 140.4 90 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 51430076_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 UMR - ALL PLANS UMR - ALL PLANS 109.2 70 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 51430076_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 94.46 60.55 999999999 94.46 151.32 percent of total billed charges Urine phosphate level 51430076_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 94.46 151.32 Urine phosphate level 51430076_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 ANTHEM HMO ANTHEM HMO 999999999 94.46 151.32 Urine phosphate level 51430076_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 94.46 151.32 Urine phosphate level 51430076_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 94.46 151.32 Urine phosphate level 51430076_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 94.46 151.32 Urine phosphate level 51430076_1 CDM 0301 RC 84105 HCPCS inpatient 156 101.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 105.46 67.6 999999999 94.46 151.32 percent of total billed charges "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 51436845_1 CDM 0250 RC J3301 HCPCS inpatient 12.5 8.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 8.13 65 999999999 7.57 12.13 percent of total billed charges "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 51436845_1 CDM 0250 RC J3301 HCPCS inpatient 12.5 8.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12.13 97 999999999 7.57 12.13 percent of total billed charges "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 51436845_1 CDM 0250 RC J3301 HCPCS inpatient 12.5 8.13 AETNA AETNA 9.88 79 999999999 7.57 12.13 percent of total billed charges "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 51436845_1 CDM 0250 RC J3301 HCPCS inpatient 12.5 8.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 8.63 69 999999999 7.57 12.13 percent of total billed charges "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 51436845_1 CDM 0250 RC J3301 HCPCS inpatient 12.5 8.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 9.75 78 999999999 7.57 12.13 percent of total billed charges "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 51436845_1 CDM 0250 RC J3301 HCPCS inpatient 12.5 8.13 SIHO - ALL PLANS SIHO - ALL PLANS 11.25 90 999999999 7.57 12.13 percent of total billed charges "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 51436845_1 CDM 0250 RC J3301 HCPCS inpatient 12.5 8.13 UMR - ALL PLANS UMR - ALL PLANS 8.75 70 999999999 7.57 12.13 percent of total billed charges "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 51436845_1 CDM 0250 RC J3301 HCPCS inpatient 12.5 8.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7.57 60.55 999999999 7.57 12.13 percent of total billed charges "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 51436845_1 CDM 0250 RC J3301 HCPCS inpatient 12.5 8.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7.57 12.13 "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 51436845_1 CDM 0250 RC J3301 HCPCS inpatient 12.5 8.13 ANTHEM HMO ANTHEM HMO 999999999 7.57 12.13 "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 51436845_1 CDM 0250 RC J3301 HCPCS inpatient 12.5 8.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7.57 12.13 "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 51436845_1 CDM 0250 RC J3301 HCPCS inpatient 12.5 8.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7.57 12.13 "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 51436845_1 CDM 0250 RC J3301 HCPCS inpatient 12.5 8.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 7.57 12.13 "INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG" 51436845_1 CDM 0250 RC J3301 HCPCS inpatient 12.5 8.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 8.45 67.6 999999999 7.57 12.13 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 51436980_1 CDM 0510 RC 37766 HCPCS inpatient 10933 7106.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 7106.45 65 999999999 6619.93 10605.01 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 51436980_1 CDM 0510 RC 37766 HCPCS inpatient 10933 7106.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10605.01 97 999999999 6619.93 10605.01 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 51436980_1 CDM 0510 RC 37766 HCPCS inpatient 10933 7106.45 AETNA AETNA 8637.07 79 999999999 6619.93 10605.01 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 51436980_1 CDM 0510 RC 37766 HCPCS inpatient 10933 7106.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 7543.77 69 999999999 6619.93 10605.01 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 51436980_1 CDM 0510 RC 37766 HCPCS inpatient 10933 7106.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 8527.74 78 999999999 6619.93 10605.01 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 51436980_1 CDM 0510 RC 37766 HCPCS inpatient 10933 7106.45 SIHO - ALL PLANS SIHO - ALL PLANS 9839.7 90 999999999 6619.93 10605.01 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 51436980_1 CDM 0510 RC 37766 HCPCS inpatient 10933 7106.45 UMR - ALL PLANS UMR - ALL PLANS 7653.1 70 999999999 6619.93 10605.01 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 51436980_1 CDM 0510 RC 37766 HCPCS inpatient 10933 7106.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6619.93 60.55 999999999 6619.93 10605.01 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 51436980_1 CDM 0510 RC 37766 HCPCS inpatient 10933 7106.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6619.93 10605.01 "Removal of varicose veins of arm or leg, more than 20 incisions" 51436980_1 CDM 0510 RC 37766 HCPCS inpatient 10933 7106.45 ANTHEM HMO ANTHEM HMO 999999999 6619.93 10605.01 "Removal of varicose veins of arm or leg, more than 20 incisions" 51436980_1 CDM 0510 RC 37766 HCPCS inpatient 10933 7106.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6619.93 10605.01 "Removal of varicose veins of arm or leg, more than 20 incisions" 51436980_1 CDM 0510 RC 37766 HCPCS inpatient 10933 7106.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6619.93 10605.01 "Removal of varicose veins of arm or leg, more than 20 incisions" 51436980_1 CDM 0510 RC 37766 HCPCS inpatient 10933 7106.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 6619.93 10605.01 "Removal of varicose veins of arm or leg, more than 20 incisions" 51436980_1 CDM 0510 RC 37766 HCPCS inpatient 10933 7106.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 7390.71 67.6 999999999 6619.93 10605.01 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 51438270_1 CDM 0250 RC J1100 HCPCS inpatient 31.5 20.48 SELF PAY DISCOUNT SELF PAY DISCOUNT 20.48 65 999999999 19.07 30.56 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 51438270_1 CDM 0250 RC J1100 HCPCS inpatient 31.5 20.48 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30.56 97 999999999 19.07 30.56 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 51438270_1 CDM 0250 RC J1100 HCPCS inpatient 31.5 20.48 AETNA AETNA 24.89 79 999999999 19.07 30.56 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 51438270_1 CDM 0250 RC J1100 HCPCS inpatient 31.5 20.48 ENCORE - ALL PLANS ENCORE - ALL PLANS 21.74 69 999999999 19.07 30.56 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 51438270_1 CDM 0250 RC J1100 HCPCS inpatient 31.5 20.48 HUMANA - ALL PLANS HUMANA - ALL PLANS 24.57 78 999999999 19.07 30.56 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 51438270_1 CDM 0250 RC J1100 HCPCS inpatient 31.5 20.48 SIHO - ALL PLANS SIHO - ALL PLANS 28.35 90 999999999 19.07 30.56 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 51438270_1 CDM 0250 RC J1100 HCPCS inpatient 31.5 20.48 UMR - ALL PLANS UMR - ALL PLANS 22.05 70 999999999 19.07 30.56 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 51438270_1 CDM 0250 RC J1100 HCPCS inpatient 31.5 20.48 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19.07 60.55 999999999 19.07 30.56 percent of total billed charges "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 51438270_1 CDM 0250 RC J1100 HCPCS inpatient 31.5 20.48 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 19.07 30.56 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 51438270_1 CDM 0250 RC J1100 HCPCS inpatient 31.5 20.48 ANTHEM HMO ANTHEM HMO 999999999 19.07 30.56 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 51438270_1 CDM 0250 RC J1100 HCPCS inpatient 31.5 20.48 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 19.07 30.56 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 51438270_1 CDM 0250 RC J1100 HCPCS inpatient 31.5 20.48 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 19.07 30.56 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 51438270_1 CDM 0250 RC J1100 HCPCS inpatient 31.5 20.48 UHC - ALL PLANS UHC - ALL PLANS 999999999 19.07 30.56 "INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1 MG" 51438270_1 CDM 0250 RC J1100 HCPCS inpatient 31.5 20.48 CIGNA - ALL PLANS CIGNA - ALL PLANS 21.29 67.6 999999999 19.07 30.56 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 51438525_1 CDM 0510 RC 37765 HCPCS inpatient 10933 7106.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 7106.45 65 999999999 6619.93 10605.01 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 51438525_1 CDM 0510 RC 37765 HCPCS inpatient 10933 7106.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10605.01 97 999999999 6619.93 10605.01 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 51438525_1 CDM 0510 RC 37765 HCPCS inpatient 10933 7106.45 AETNA AETNA 8637.07 79 999999999 6619.93 10605.01 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 51438525_1 CDM 0510 RC 37765 HCPCS inpatient 10933 7106.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 7543.77 69 999999999 6619.93 10605.01 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 51438525_1 CDM 0510 RC 37765 HCPCS inpatient 10933 7106.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 8527.74 78 999999999 6619.93 10605.01 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 51438525_1 CDM 0510 RC 37765 HCPCS inpatient 10933 7106.45 SIHO - ALL PLANS SIHO - ALL PLANS 9839.7 90 999999999 6619.93 10605.01 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 51438525_1 CDM 0510 RC 37765 HCPCS inpatient 10933 7106.45 UMR - ALL PLANS UMR - ALL PLANS 7653.1 70 999999999 6619.93 10605.01 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 51438525_1 CDM 0510 RC 37765 HCPCS inpatient 10933 7106.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6619.93 60.55 999999999 6619.93 10605.01 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 51438525_1 CDM 0510 RC 37765 HCPCS inpatient 10933 7106.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6619.93 10605.01 "Removal of varicose veins of arm or leg, 10-20 incisions" 51438525_1 CDM 0510 RC 37765 HCPCS inpatient 10933 7106.45 ANTHEM HMO ANTHEM HMO 999999999 6619.93 10605.01 "Removal of varicose veins of arm or leg, 10-20 incisions" 51438525_1 CDM 0510 RC 37765 HCPCS inpatient 10933 7106.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6619.93 10605.01 "Removal of varicose veins of arm or leg, 10-20 incisions" 51438525_1 CDM 0510 RC 37765 HCPCS inpatient 10933 7106.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6619.93 10605.01 "Removal of varicose veins of arm or leg, 10-20 incisions" 51438525_1 CDM 0510 RC 37765 HCPCS inpatient 10933 7106.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 6619.93 10605.01 "Removal of varicose veins of arm or leg, 10-20 incisions" 51438525_1 CDM 0510 RC 37765 HCPCS inpatient 10933 7106.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 7390.71 67.6 999999999 6619.93 10605.01 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 51438526_1 CDM 0510 RC 37765 HCPCS inpatient 10933.26 7106.62 SELF PAY DISCOUNT SELF PAY DISCOUNT 7106.62 65 999999999 6620.09 10605.26 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 51438526_1 CDM 0510 RC 37765 HCPCS inpatient 10933.26 7106.62 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10605.26 97 999999999 6620.09 10605.26 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 51438526_1 CDM 0510 RC 37765 HCPCS inpatient 10933.26 7106.62 AETNA AETNA 8637.28 79 999999999 6620.09 10605.26 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 51438526_1 CDM 0510 RC 37765 HCPCS inpatient 10933.26 7106.62 ENCORE - ALL PLANS ENCORE - ALL PLANS 7543.95 69 999999999 6620.09 10605.26 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 51438526_1 CDM 0510 RC 37765 HCPCS inpatient 10933.26 7106.62 HUMANA - ALL PLANS HUMANA - ALL PLANS 8527.94 78 999999999 6620.09 10605.26 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 51438526_1 CDM 0510 RC 37765 HCPCS inpatient 10933.26 7106.62 SIHO - ALL PLANS SIHO - ALL PLANS 9839.93 90 999999999 6620.09 10605.26 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 51438526_1 CDM 0510 RC 37765 HCPCS inpatient 10933.26 7106.62 UMR - ALL PLANS UMR - ALL PLANS 7653.28 70 999999999 6620.09 10605.26 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 51438526_1 CDM 0510 RC 37765 HCPCS inpatient 10933.26 7106.62 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6620.09 60.55 999999999 6620.09 10605.26 percent of total billed charges "Removal of varicose veins of arm or leg, 10-20 incisions" 51438526_1 CDM 0510 RC 37765 HCPCS inpatient 10933.26 7106.62 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6620.09 10605.26 "Removal of varicose veins of arm or leg, 10-20 incisions" 51438526_1 CDM 0510 RC 37765 HCPCS inpatient 10933.26 7106.62 ANTHEM HMO ANTHEM HMO 999999999 6620.09 10605.26 "Removal of varicose veins of arm or leg, 10-20 incisions" 51438526_1 CDM 0510 RC 37765 HCPCS inpatient 10933.26 7106.62 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6620.09 10605.26 "Removal of varicose veins of arm or leg, 10-20 incisions" 51438526_1 CDM 0510 RC 37765 HCPCS inpatient 10933.26 7106.62 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6620.09 10605.26 "Removal of varicose veins of arm or leg, 10-20 incisions" 51438526_1 CDM 0510 RC 37765 HCPCS inpatient 10933.26 7106.62 UHC - ALL PLANS UHC - ALL PLANS 999999999 6620.09 10605.26 "Removal of varicose veins of arm or leg, 10-20 incisions" 51438526_1 CDM 0510 RC 37765 HCPCS inpatient 10933.26 7106.62 CIGNA - ALL PLANS CIGNA - ALL PLANS 7390.88 67.6 999999999 6620.09 10605.26 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 51438529_1 CDM 0510 RC 37766 HCPCS inpatient 10933.26 7106.62 SELF PAY DISCOUNT SELF PAY DISCOUNT 7106.62 65 999999999 6620.09 10605.26 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 51438529_1 CDM 0510 RC 37766 HCPCS inpatient 10933.26 7106.62 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10605.26 97 999999999 6620.09 10605.26 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 51438529_1 CDM 0510 RC 37766 HCPCS inpatient 10933.26 7106.62 AETNA AETNA 8637.28 79 999999999 6620.09 10605.26 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 51438529_1 CDM 0510 RC 37766 HCPCS inpatient 10933.26 7106.62 ENCORE - ALL PLANS ENCORE - ALL PLANS 7543.95 69 999999999 6620.09 10605.26 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 51438529_1 CDM 0510 RC 37766 HCPCS inpatient 10933.26 7106.62 HUMANA - ALL PLANS HUMANA - ALL PLANS 8527.94 78 999999999 6620.09 10605.26 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 51438529_1 CDM 0510 RC 37766 HCPCS inpatient 10933.26 7106.62 SIHO - ALL PLANS SIHO - ALL PLANS 9839.93 90 999999999 6620.09 10605.26 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 51438529_1 CDM 0510 RC 37766 HCPCS inpatient 10933.26 7106.62 UMR - ALL PLANS UMR - ALL PLANS 7653.28 70 999999999 6620.09 10605.26 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 51438529_1 CDM 0510 RC 37766 HCPCS inpatient 10933.26 7106.62 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6620.09 60.55 999999999 6620.09 10605.26 percent of total billed charges "Removal of varicose veins of arm or leg, more than 20 incisions" 51438529_1 CDM 0510 RC 37766 HCPCS inpatient 10933.26 7106.62 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6620.09 10605.26 "Removal of varicose veins of arm or leg, more than 20 incisions" 51438529_1 CDM 0510 RC 37766 HCPCS inpatient 10933.26 7106.62 ANTHEM HMO ANTHEM HMO 999999999 6620.09 10605.26 "Removal of varicose veins of arm or leg, more than 20 incisions" 51438529_1 CDM 0510 RC 37766 HCPCS inpatient 10933.26 7106.62 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6620.09 10605.26 "Removal of varicose veins of arm or leg, more than 20 incisions" 51438529_1 CDM 0510 RC 37766 HCPCS inpatient 10933.26 7106.62 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6620.09 10605.26 "Removal of varicose veins of arm or leg, more than 20 incisions" 51438529_1 CDM 0510 RC 37766 HCPCS inpatient 10933.26 7106.62 UHC - ALL PLANS UHC - ALL PLANS 999999999 6620.09 10605.26 "Removal of varicose veins of arm or leg, more than 20 incisions" 51438529_1 CDM 0510 RC 37766 HCPCS inpatient 10933.26 7106.62 CIGNA - ALL PLANS CIGNA - ALL PLANS 7390.88 67.6 999999999 6620.09 10605.26 percent of total billed charges Detection of orthopoxvirus by amplified nucleic acid probe technique 51440596_1 CDM 0306 RC 87593 HCPCS inpatient 125 81.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 81.25 65 999999999 75.69 121.25 percent of total billed charges Detection of orthopoxvirus by amplified nucleic acid probe technique 51440596_1 CDM 0306 RC 87593 HCPCS inpatient 125 81.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 121.25 97 999999999 75.69 121.25 percent of total billed charges Detection of orthopoxvirus by amplified nucleic acid probe technique 51440596_1 CDM 0306 RC 87593 HCPCS inpatient 125 81.25 AETNA AETNA 98.75 79 999999999 75.69 121.25 percent of total billed charges Detection of orthopoxvirus by amplified nucleic acid probe technique 51440596_1 CDM 0306 RC 87593 HCPCS inpatient 125 81.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 86.25 69 999999999 75.69 121.25 percent of total billed charges Detection of orthopoxvirus by amplified nucleic acid probe technique 51440596_1 CDM 0306 RC 87593 HCPCS inpatient 125 81.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 97.5 78 999999999 75.69 121.25 percent of total billed charges Detection of orthopoxvirus by amplified nucleic acid probe technique 51440596_1 CDM 0306 RC 87593 HCPCS inpatient 125 81.25 SIHO - ALL PLANS SIHO - ALL PLANS 112.5 90 999999999 75.69 121.25 percent of total billed charges Detection of orthopoxvirus by amplified nucleic acid probe technique 51440596_1 CDM 0306 RC 87593 HCPCS inpatient 125 81.25 UMR - ALL PLANS UMR - ALL PLANS 87.5 70 999999999 75.69 121.25 percent of total billed charges Detection of orthopoxvirus by amplified nucleic acid probe technique 51440596_1 CDM 0306 RC 87593 HCPCS inpatient 125 81.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.69 60.55 999999999 75.69 121.25 percent of total billed charges Detection of orthopoxvirus by amplified nucleic acid probe technique 51440596_1 CDM 0306 RC 87593 HCPCS inpatient 125 81.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.69 121.25 Detection of orthopoxvirus by amplified nucleic acid probe technique 51440596_1 CDM 0306 RC 87593 HCPCS inpatient 125 81.25 ANTHEM HMO ANTHEM HMO 999999999 75.69 121.25 Detection of orthopoxvirus by amplified nucleic acid probe technique 51440596_1 CDM 0306 RC 87593 HCPCS inpatient 125 81.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.69 121.25 Detection of orthopoxvirus by amplified nucleic acid probe technique 51440596_1 CDM 0306 RC 87593 HCPCS inpatient 125 81.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.69 121.25 Detection of orthopoxvirus by amplified nucleic acid probe technique 51440596_1 CDM 0306 RC 87593 HCPCS inpatient 125 81.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.69 121.25 Detection of orthopoxvirus by amplified nucleic acid probe technique 51440596_1 CDM 0306 RC 87593 HCPCS inpatient 125 81.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 84.5 67.6 999999999 75.69 121.25 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51440603_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 399.75 65 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51440603_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 596.55 97 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51440603_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 AETNA AETNA 485.85 79 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51440603_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 424.35 69 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51440603_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 479.7 78 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51440603_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 SIHO - ALL PLANS SIHO - ALL PLANS 553.5 90 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51440603_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 UMR - ALL PLANS UMR - ALL PLANS 430.5 70 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51440603_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 372.38 60.55 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51440603_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 51440603_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ANTHEM HMO ANTHEM HMO 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 51440603_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 51440603_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 51440603_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 51440603_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 415.74 67.6 999999999 372.38 596.55 percent of total billed charges Tissue culture to identify white blood cell disorders 51440604_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 150.8 65 999999999 140.48 225.04 percent of total billed charges Tissue culture to identify white blood cell disorders 51440604_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 225.04 97 999999999 140.48 225.04 percent of total billed charges Tissue culture to identify white blood cell disorders 51440604_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 AETNA AETNA 183.28 79 999999999 140.48 225.04 percent of total billed charges Tissue culture to identify white blood cell disorders 51440604_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 160.08 69 999999999 140.48 225.04 percent of total billed charges Tissue culture to identify white blood cell disorders 51440604_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 180.96 78 999999999 140.48 225.04 percent of total billed charges Tissue culture to identify white blood cell disorders 51440604_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 SIHO - ALL PLANS SIHO - ALL PLANS 208.8 90 999999999 140.48 225.04 percent of total billed charges Tissue culture to identify white blood cell disorders 51440604_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 UMR - ALL PLANS UMR - ALL PLANS 162.4 70 999999999 140.48 225.04 percent of total billed charges Tissue culture to identify white blood cell disorders 51440604_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 140.48 60.55 999999999 140.48 225.04 percent of total billed charges Tissue culture to identify white blood cell disorders 51440604_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 140.48 225.04 Tissue culture to identify white blood cell disorders 51440604_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 ANTHEM HMO ANTHEM HMO 999999999 140.48 225.04 Tissue culture to identify white blood cell disorders 51440604_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 140.48 225.04 Tissue culture to identify white blood cell disorders 51440604_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 140.48 225.04 Tissue culture to identify white blood cell disorders 51440604_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 140.48 225.04 Tissue culture to identify white blood cell disorders 51440604_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 156.83 67.6 999999999 140.48 225.04 percent of total billed charges Injection of drug or substance under skin or into muscle 51441188_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 34.13 65 999999999 31.79 50.93 percent of total billed charges Injection of drug or substance under skin or into muscle 51441188_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 50.93 97 999999999 31.79 50.93 percent of total billed charges Injection of drug or substance under skin or into muscle 51441188_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 AETNA AETNA 41.48 79 999999999 31.79 50.93 percent of total billed charges Injection of drug or substance under skin or into muscle 51441188_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 36.23 69 999999999 31.79 50.93 percent of total billed charges Injection of drug or substance under skin or into muscle 51441188_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 40.95 78 999999999 31.79 50.93 percent of total billed charges Injection of drug or substance under skin or into muscle 51441188_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 SIHO - ALL PLANS SIHO - ALL PLANS 47.25 90 999999999 31.79 50.93 percent of total billed charges Injection of drug or substance under skin or into muscle 51441188_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 UMR - ALL PLANS UMR - ALL PLANS 36.75 70 999999999 31.79 50.93 percent of total billed charges Injection of drug or substance under skin or into muscle 51441188_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 31.79 60.55 999999999 31.79 50.93 percent of total billed charges Injection of drug or substance under skin or into muscle 51441188_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 31.79 50.93 Injection of drug or substance under skin or into muscle 51441188_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 ANTHEM HMO ANTHEM HMO 999999999 31.79 50.93 Injection of drug or substance under skin or into muscle 51441188_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 31.79 50.93 Injection of drug or substance under skin or into muscle 51441188_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 31.79 50.93 Injection of drug or substance under skin or into muscle 51441188_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 UHC - ALL PLANS UHC - ALL PLANS 999999999 31.79 50.93 Injection of drug or substance under skin or into muscle 51441188_1 CDM 0510 RC 96372 HCPCS inpatient 52.5 34.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 35.49 67.6 999999999 31.79 50.93 percent of total billed charges Aspiration and/or injection of cyst of tendon 51448333_1 CDM 0510 RC 20612 HCPCS inpatient 962 625.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 625.3 65 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of cyst of tendon 51448333_1 CDM 0510 RC 20612 HCPCS inpatient 962 625.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 933.14 97 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of cyst of tendon 51448333_1 CDM 0510 RC 20612 HCPCS inpatient 962 625.3 AETNA AETNA 759.98 79 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of cyst of tendon 51448333_1 CDM 0510 RC 20612 HCPCS inpatient 962 625.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 663.78 69 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of cyst of tendon 51448333_1 CDM 0510 RC 20612 HCPCS inpatient 962 625.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 750.36 78 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of cyst of tendon 51448333_1 CDM 0510 RC 20612 HCPCS inpatient 962 625.3 SIHO - ALL PLANS SIHO - ALL PLANS 865.8 90 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of cyst of tendon 51448333_1 CDM 0510 RC 20612 HCPCS inpatient 962 625.3 UMR - ALL PLANS UMR - ALL PLANS 673.4 70 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of cyst of tendon 51448333_1 CDM 0510 RC 20612 HCPCS inpatient 962 625.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 582.49 60.55 999999999 582.49 933.14 percent of total billed charges Aspiration and/or injection of cyst of tendon 51448333_1 CDM 0510 RC 20612 HCPCS inpatient 962 625.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 582.49 933.14 Aspiration and/or injection of cyst of tendon 51448333_1 CDM 0510 RC 20612 HCPCS inpatient 962 625.3 ANTHEM HMO ANTHEM HMO 999999999 582.49 933.14 Aspiration and/or injection of cyst of tendon 51448333_1 CDM 0510 RC 20612 HCPCS inpatient 962 625.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 582.49 933.14 Aspiration and/or injection of cyst of tendon 51448333_1 CDM 0510 RC 20612 HCPCS inpatient 962 625.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 582.49 933.14 Aspiration and/or injection of cyst of tendon 51448333_1 CDM 0510 RC 20612 HCPCS inpatient 962 625.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 582.49 933.14 Aspiration and/or injection of cyst of tendon 51448333_1 CDM 0510 RC 20612 HCPCS inpatient 962 625.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 650.31 67.6 999999999 582.49 933.14 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 51448932_1 CDM 0510 RC 76000 HCPCS inpatient 827 537.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 537.55 65 999999999 500.75 802.19 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 51448932_1 CDM 0510 RC 76000 HCPCS inpatient 827 537.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 802.19 97 999999999 500.75 802.19 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 51448932_1 CDM 0510 RC 76000 HCPCS inpatient 827 537.55 AETNA AETNA 653.33 79 999999999 500.75 802.19 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 51448932_1 CDM 0510 RC 76000 HCPCS inpatient 827 537.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 570.63 69 999999999 500.75 802.19 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 51448932_1 CDM 0510 RC 76000 HCPCS inpatient 827 537.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 645.06 78 999999999 500.75 802.19 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 51448932_1 CDM 0510 RC 76000 HCPCS inpatient 827 537.55 SIHO - ALL PLANS SIHO - ALL PLANS 744.3 90 999999999 500.75 802.19 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 51448932_1 CDM 0510 RC 76000 HCPCS inpatient 827 537.55 UMR - ALL PLANS UMR - ALL PLANS 578.9 70 999999999 500.75 802.19 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 51448932_1 CDM 0510 RC 76000 HCPCS inpatient 827 537.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 500.75 60.55 999999999 500.75 802.19 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 51448932_1 CDM 0510 RC 76000 HCPCS inpatient 827 537.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 500.75 802.19 "Imaging guidance for procedure, 60 minutes or less" 51448932_1 CDM 0510 RC 76000 HCPCS inpatient 827 537.55 ANTHEM HMO ANTHEM HMO 999999999 500.75 802.19 "Imaging guidance for procedure, 60 minutes or less" 51448932_1 CDM 0510 RC 76000 HCPCS inpatient 827 537.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 500.75 802.19 "Imaging guidance for procedure, 60 minutes or less" 51448932_1 CDM 0510 RC 76000 HCPCS inpatient 827 537.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 500.75 802.19 "Imaging guidance for procedure, 60 minutes or less" 51448932_1 CDM 0510 RC 76000 HCPCS inpatient 827 537.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 500.75 802.19 "Imaging guidance for procedure, 60 minutes or less" 51448932_1 CDM 0510 RC 76000 HCPCS inpatient 827 537.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 559.05 67.6 999999999 500.75 802.19 percent of total billed charges "Removal of skin and tissue, 20.0 sq cm or less" 51448941_1 CDM 0510 RC 11042 HCPCS inpatient 1321 858.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 858.65 65 999999999 799.87 1281.37 percent of total billed charges "Removal of skin and tissue, 20.0 sq cm or less" 51448941_1 CDM 0510 RC 11042 HCPCS inpatient 1321 858.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1281.37 97 999999999 799.87 1281.37 percent of total billed charges "Removal of skin and tissue, 20.0 sq cm or less" 51448941_1 CDM 0510 RC 11042 HCPCS inpatient 1321 858.65 AETNA AETNA 1043.59 79 999999999 799.87 1281.37 percent of total billed charges "Removal of skin and tissue, 20.0 sq cm or less" 51448941_1 CDM 0510 RC 11042 HCPCS inpatient 1321 858.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 911.49 69 999999999 799.87 1281.37 percent of total billed charges "Removal of skin and tissue, 20.0 sq cm or less" 51448941_1 CDM 0510 RC 11042 HCPCS inpatient 1321 858.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1030.38 78 999999999 799.87 1281.37 percent of total billed charges "Removal of skin and tissue, 20.0 sq cm or less" 51448941_1 CDM 0510 RC 11042 HCPCS inpatient 1321 858.65 SIHO - ALL PLANS SIHO - ALL PLANS 1188.9 90 999999999 799.87 1281.37 percent of total billed charges "Removal of skin and tissue, 20.0 sq cm or less" 51448941_1 CDM 0510 RC 11042 HCPCS inpatient 1321 858.65 UMR - ALL PLANS UMR - ALL PLANS 924.7 70 999999999 799.87 1281.37 percent of total billed charges "Removal of skin and tissue, 20.0 sq cm or less" 51448941_1 CDM 0510 RC 11042 HCPCS inpatient 1321 858.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 799.87 60.55 999999999 799.87 1281.37 percent of total billed charges "Removal of skin and tissue, 20.0 sq cm or less" 51448941_1 CDM 0510 RC 11042 HCPCS inpatient 1321 858.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 799.87 1281.37 "Removal of skin and tissue, 20.0 sq cm or less" 51448941_1 CDM 0510 RC 11042 HCPCS inpatient 1321 858.65 ANTHEM HMO ANTHEM HMO 999999999 799.87 1281.37 "Removal of skin and tissue, 20.0 sq cm or less" 51448941_1 CDM 0510 RC 11042 HCPCS inpatient 1321 858.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 799.87 1281.37 "Removal of skin and tissue, 20.0 sq cm or less" 51448941_1 CDM 0510 RC 11042 HCPCS inpatient 1321 858.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 799.87 1281.37 "Removal of skin and tissue, 20.0 sq cm or less" 51448941_1 CDM 0510 RC 11042 HCPCS inpatient 1321 858.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 799.87 1281.37 "Removal of skin and tissue, 20.0 sq cm or less" 51448941_1 CDM 0510 RC 11042 HCPCS inpatient 1321 858.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 893 67.6 999999999 799.87 1281.37 percent of total billed charges Measurement of substance using immunoassay technique 51448960_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 118.95 65 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 51448960_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 177.51 97 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 51448960_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 AETNA AETNA 144.57 79 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 51448960_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 126.27 69 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 51448960_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 142.74 78 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 51448960_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 SIHO - ALL PLANS SIHO - ALL PLANS 164.7 90 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 51448960_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 UMR - ALL PLANS UMR - ALL PLANS 128.1 70 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 51448960_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 110.81 60.55 999999999 110.81 177.51 percent of total billed charges Measurement of substance using immunoassay technique 51448960_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 110.81 177.51 Measurement of substance using immunoassay technique 51448960_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM HMO ANTHEM HMO 999999999 110.81 177.51 Measurement of substance using immunoassay technique 51448960_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 110.81 177.51 Measurement of substance using immunoassay technique 51448960_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 110.81 177.51 Measurement of substance using immunoassay technique 51448960_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 110.81 177.51 Measurement of substance using immunoassay technique 51448960_1 CDM 0301 RC 83520 HCPCS inpatient 183 118.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 123.71 67.6 999999999 110.81 177.51 percent of total billed charges Simple or single drainage of skin abscess 51452086_1 CDM 0510 RC 10060 HCPCS inpatient 1279 831.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 831.35 65 999999999 774.43 1240.63 percent of total billed charges Simple or single drainage of skin abscess 51452086_1 CDM 0510 RC 10060 HCPCS inpatient 1279 831.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1240.63 97 999999999 774.43 1240.63 percent of total billed charges Simple or single drainage of skin abscess 51452086_1 CDM 0510 RC 10060 HCPCS inpatient 1279 831.35 AETNA AETNA 1010.41 79 999999999 774.43 1240.63 percent of total billed charges Simple or single drainage of skin abscess 51452086_1 CDM 0510 RC 10060 HCPCS inpatient 1279 831.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 882.51 69 999999999 774.43 1240.63 percent of total billed charges Simple or single drainage of skin abscess 51452086_1 CDM 0510 RC 10060 HCPCS inpatient 1279 831.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 997.62 78 999999999 774.43 1240.63 percent of total billed charges Simple or single drainage of skin abscess 51452086_1 CDM 0510 RC 10060 HCPCS inpatient 1279 831.35 SIHO - ALL PLANS SIHO - ALL PLANS 1151.1 90 999999999 774.43 1240.63 percent of total billed charges Simple or single drainage of skin abscess 51452086_1 CDM 0510 RC 10060 HCPCS inpatient 1279 831.35 UMR - ALL PLANS UMR - ALL PLANS 895.3 70 999999999 774.43 1240.63 percent of total billed charges Simple or single drainage of skin abscess 51452086_1 CDM 0510 RC 10060 HCPCS inpatient 1279 831.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 774.43 1240.63 Simple or single drainage of skin abscess 51452086_1 CDM 0510 RC 10060 HCPCS inpatient 1279 831.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 774.43 60.55 999999999 774.43 1240.63 percent of total billed charges Simple or single drainage of skin abscess 51452086_1 CDM 0510 RC 10060 HCPCS inpatient 1279 831.35 ANTHEM HMO ANTHEM HMO 999999999 774.43 1240.63 Simple or single drainage of skin abscess 51452086_1 CDM 0510 RC 10060 HCPCS inpatient 1279 831.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 774.43 1240.63 Simple or single drainage of skin abscess 51452086_1 CDM 0510 RC 10060 HCPCS inpatient 1279 831.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 774.43 1240.63 Simple or single drainage of skin abscess 51452086_1 CDM 0510 RC 10060 HCPCS inpatient 1279 831.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 774.43 1240.63 Simple or single drainage of skin abscess 51452086_1 CDM 0510 RC 10060 HCPCS inpatient 1279 831.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 864.6 67.6 999999999 774.43 1240.63 percent of total billed charges Complicated or multiple drainage of skin abscess 51452087_1 CDM 0510 RC 10061 HCPCS inpatient 1321 858.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 858.65 65 999999999 799.87 1281.37 percent of total billed charges Complicated or multiple drainage of skin abscess 51452087_1 CDM 0510 RC 10061 HCPCS inpatient 1321 858.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1281.37 97 999999999 799.87 1281.37 percent of total billed charges Complicated or multiple drainage of skin abscess 51452087_1 CDM 0510 RC 10061 HCPCS inpatient 1321 858.65 AETNA AETNA 1043.59 79 999999999 799.87 1281.37 percent of total billed charges Complicated or multiple drainage of skin abscess 51452087_1 CDM 0510 RC 10061 HCPCS inpatient 1321 858.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 911.49 69 999999999 799.87 1281.37 percent of total billed charges Complicated or multiple drainage of skin abscess 51452087_1 CDM 0510 RC 10061 HCPCS inpatient 1321 858.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1030.38 78 999999999 799.87 1281.37 percent of total billed charges Complicated or multiple drainage of skin abscess 51452087_1 CDM 0510 RC 10061 HCPCS inpatient 1321 858.65 SIHO - ALL PLANS SIHO - ALL PLANS 1188.9 90 999999999 799.87 1281.37 percent of total billed charges Complicated or multiple drainage of skin abscess 51452087_1 CDM 0510 RC 10061 HCPCS inpatient 1321 858.65 UMR - ALL PLANS UMR - ALL PLANS 924.7 70 999999999 799.87 1281.37 percent of total billed charges Complicated or multiple drainage of skin abscess 51452087_1 CDM 0510 RC 10061 HCPCS inpatient 1321 858.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 799.87 1281.37 Complicated or multiple drainage of skin abscess 51452087_1 CDM 0510 RC 10061 HCPCS inpatient 1321 858.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 799.87 60.55 999999999 799.87 1281.37 percent of total billed charges Complicated or multiple drainage of skin abscess 51452087_1 CDM 0510 RC 10061 HCPCS inpatient 1321 858.65 ANTHEM HMO ANTHEM HMO 999999999 799.87 1281.37 Complicated or multiple drainage of skin abscess 51452087_1 CDM 0510 RC 10061 HCPCS inpatient 1321 858.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 799.87 1281.37 Complicated or multiple drainage of skin abscess 51452087_1 CDM 0510 RC 10061 HCPCS inpatient 1321 858.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 799.87 1281.37 Complicated or multiple drainage of skin abscess 51452087_1 CDM 0510 RC 10061 HCPCS inpatient 1321 858.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 799.87 1281.37 Complicated or multiple drainage of skin abscess 51452087_1 CDM 0510 RC 10061 HCPCS inpatient 1321 858.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 893 67.6 999999999 799.87 1281.37 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 51452088_1 CDM 0510 RC 97597 HCPCS inpatient 639 415.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 415.35 65 999999999 386.91 619.83 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 51452088_1 CDM 0510 RC 97597 HCPCS inpatient 639 415.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 619.83 97 999999999 386.91 619.83 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 51452088_1 CDM 0510 RC 97597 HCPCS inpatient 639 415.35 AETNA AETNA 504.81 79 999999999 386.91 619.83 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 51452088_1 CDM 0510 RC 97597 HCPCS inpatient 639 415.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 440.91 69 999999999 386.91 619.83 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 51452088_1 CDM 0510 RC 97597 HCPCS inpatient 639 415.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 498.42 78 999999999 386.91 619.83 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 51452088_1 CDM 0510 RC 97597 HCPCS inpatient 639 415.35 SIHO - ALL PLANS SIHO - ALL PLANS 575.1 90 999999999 386.91 619.83 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 51452088_1 CDM 0510 RC 97597 HCPCS inpatient 639 415.35 UMR - ALL PLANS UMR - ALL PLANS 447.3 70 999999999 386.91 619.83 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 51452088_1 CDM 0510 RC 97597 HCPCS inpatient 639 415.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 386.91 619.83 "Removal of tissue from wound, 20.0 sq cm or less" 51452088_1 CDM 0510 RC 97597 HCPCS inpatient 639 415.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 386.91 60.55 999999999 386.91 619.83 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 51452088_1 CDM 0510 RC 97597 HCPCS inpatient 639 415.35 ANTHEM HMO ANTHEM HMO 999999999 386.91 619.83 "Removal of tissue from wound, 20.0 sq cm or less" 51452088_1 CDM 0510 RC 97597 HCPCS inpatient 639 415.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 386.91 619.83 "Removal of tissue from wound, 20.0 sq cm or less" 51452088_1 CDM 0510 RC 97597 HCPCS inpatient 639 415.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 386.91 619.83 "Removal of tissue from wound, 20.0 sq cm or less" 51452088_1 CDM 0510 RC 97597 HCPCS inpatient 639 415.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 386.91 619.83 "Removal of tissue from wound, 20.0 sq cm or less" 51452088_1 CDM 0510 RC 97597 HCPCS inpatient 639 415.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 431.96 67.6 999999999 386.91 619.83 percent of total billed charges Treatment of broken midportion of foot 51452548_1 CDM 0510 RC 28485 HCPCS inpatient 23415 15219.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15219.75 65 999999999 14177.78 22712.55 percent of total billed charges Treatment of broken midportion of foot 51452548_1 CDM 0510 RC 28485 HCPCS inpatient 23415 15219.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22712.55 97 999999999 14177.78 22712.55 percent of total billed charges Treatment of broken midportion of foot 51452548_1 CDM 0510 RC 28485 HCPCS inpatient 23415 15219.75 AETNA AETNA 18497.85 79 999999999 14177.78 22712.55 percent of total billed charges Treatment of broken midportion of foot 51452548_1 CDM 0510 RC 28485 HCPCS inpatient 23415 15219.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16156.35 69 999999999 14177.78 22712.55 percent of total billed charges Treatment of broken midportion of foot 51452548_1 CDM 0510 RC 28485 HCPCS inpatient 23415 15219.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18263.7 78 999999999 14177.78 22712.55 percent of total billed charges Treatment of broken midportion of foot 51452548_1 CDM 0510 RC 28485 HCPCS inpatient 23415 15219.75 SIHO - ALL PLANS SIHO - ALL PLANS 21073.5 90 999999999 14177.78 22712.55 percent of total billed charges Treatment of broken midportion of foot 51452548_1 CDM 0510 RC 28485 HCPCS inpatient 23415 15219.75 UMR - ALL PLANS UMR - ALL PLANS 16390.5 70 999999999 14177.78 22712.55 percent of total billed charges Treatment of broken midportion of foot 51452548_1 CDM 0510 RC 28485 HCPCS inpatient 23415 15219.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 14177.78 22712.55 Treatment of broken midportion of foot 51452548_1 CDM 0510 RC 28485 HCPCS inpatient 23415 15219.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14177.78 60.55 999999999 14177.78 22712.55 percent of total billed charges Treatment of broken midportion of foot 51452548_1 CDM 0510 RC 28485 HCPCS inpatient 23415 15219.75 ANTHEM HMO ANTHEM HMO 999999999 14177.78 22712.55 Treatment of broken midportion of foot 51452548_1 CDM 0510 RC 28485 HCPCS inpatient 23415 15219.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 14177.78 22712.55 Treatment of broken midportion of foot 51452548_1 CDM 0510 RC 28485 HCPCS inpatient 23415 15219.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 14177.78 22712.55 Treatment of broken midportion of foot 51452548_1 CDM 0510 RC 28485 HCPCS inpatient 23415 15219.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 14177.78 22712.55 Treatment of broken midportion of foot 51452548_1 CDM 0510 RC 28485 HCPCS inpatient 23415 15219.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 15828.54 67.6 999999999 14177.78 22712.55 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 51453896_1 CDM 0510 RC 10120 HCPCS inpatient 1321 858.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 858.65 65 999999999 799.87 1281.37 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 51453896_1 CDM 0510 RC 10120 HCPCS inpatient 1321 858.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1281.37 97 999999999 799.87 1281.37 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 51453896_1 CDM 0510 RC 10120 HCPCS inpatient 1321 858.65 AETNA AETNA 1043.59 79 999999999 799.87 1281.37 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 51453896_1 CDM 0510 RC 10120 HCPCS inpatient 1321 858.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 911.49 69 999999999 799.87 1281.37 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 51453896_1 CDM 0510 RC 10120 HCPCS inpatient 1321 858.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1030.38 78 999999999 799.87 1281.37 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 51453896_1 CDM 0510 RC 10120 HCPCS inpatient 1321 858.65 SIHO - ALL PLANS SIHO - ALL PLANS 1188.9 90 999999999 799.87 1281.37 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 51453896_1 CDM 0510 RC 10120 HCPCS inpatient 1321 858.65 UMR - ALL PLANS UMR - ALL PLANS 924.7 70 999999999 799.87 1281.37 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 51453896_1 CDM 0510 RC 10120 HCPCS inpatient 1321 858.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 799.87 1281.37 "Removal of foreign body from tissue, accessed beneath the skin, simple" 51453896_1 CDM 0510 RC 10120 HCPCS inpatient 1321 858.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 799.87 60.55 999999999 799.87 1281.37 percent of total billed charges "Removal of foreign body from tissue, accessed beneath the skin, simple" 51453896_1 CDM 0510 RC 10120 HCPCS inpatient 1321 858.65 ANTHEM HMO ANTHEM HMO 999999999 799.87 1281.37 "Removal of foreign body from tissue, accessed beneath the skin, simple" 51453896_1 CDM 0510 RC 10120 HCPCS inpatient 1321 858.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 799.87 1281.37 "Removal of foreign body from tissue, accessed beneath the skin, simple" 51453896_1 CDM 0510 RC 10120 HCPCS inpatient 1321 858.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 799.87 1281.37 "Removal of foreign body from tissue, accessed beneath the skin, simple" 51453896_1 CDM 0510 RC 10120 HCPCS inpatient 1321 858.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 799.87 1281.37 "Removal of foreign body from tissue, accessed beneath the skin, simple" 51453896_1 CDM 0510 RC 10120 HCPCS inpatient 1321 858.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 893 67.6 999999999 799.87 1281.37 percent of total billed charges "Removal of inflamed or infected skin, up to 10% of body surface" 51453897_1 CDM 0510 RC 11000 HCPCS inpatient 2057 1337.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1337.05 65 999999999 1245.51 1995.29 percent of total billed charges "Removal of inflamed or infected skin, up to 10% of body surface" 51453897_1 CDM 0510 RC 11000 HCPCS inpatient 2057 1337.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1995.29 97 999999999 1245.51 1995.29 percent of total billed charges "Removal of inflamed or infected skin, up to 10% of body surface" 51453897_1 CDM 0510 RC 11000 HCPCS inpatient 2057 1337.05 AETNA AETNA 1625.03 79 999999999 1245.51 1995.29 percent of total billed charges "Removal of inflamed or infected skin, up to 10% of body surface" 51453897_1 CDM 0510 RC 11000 HCPCS inpatient 2057 1337.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1419.33 69 999999999 1245.51 1995.29 percent of total billed charges "Removal of inflamed or infected skin, up to 10% of body surface" 51453897_1 CDM 0510 RC 11000 HCPCS inpatient 2057 1337.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1604.46 78 999999999 1245.51 1995.29 percent of total billed charges "Removal of inflamed or infected skin, up to 10% of body surface" 51453897_1 CDM 0510 RC 11000 HCPCS inpatient 2057 1337.05 SIHO - ALL PLANS SIHO - ALL PLANS 1851.3 90 999999999 1245.51 1995.29 percent of total billed charges "Removal of inflamed or infected skin, up to 10% of body surface" 51453897_1 CDM 0510 RC 11000 HCPCS inpatient 2057 1337.05 UMR - ALL PLANS UMR - ALL PLANS 1439.9 70 999999999 1245.51 1995.29 percent of total billed charges "Removal of inflamed or infected skin, up to 10% of body surface" 51453897_1 CDM 0510 RC 11000 HCPCS inpatient 2057 1337.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1245.51 1995.29 "Removal of inflamed or infected skin, up to 10% of body surface" 51453897_1 CDM 0510 RC 11000 HCPCS inpatient 2057 1337.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1245.51 60.55 999999999 1245.51 1995.29 percent of total billed charges "Removal of inflamed or infected skin, up to 10% of body surface" 51453897_1 CDM 0510 RC 11000 HCPCS inpatient 2057 1337.05 ANTHEM HMO ANTHEM HMO 999999999 1245.51 1995.29 "Removal of inflamed or infected skin, up to 10% of body surface" 51453897_1 CDM 0510 RC 11000 HCPCS inpatient 2057 1337.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1245.51 1995.29 "Removal of inflamed or infected skin, up to 10% of body surface" 51453897_1 CDM 0510 RC 11000 HCPCS inpatient 2057 1337.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1245.51 1995.29 "Removal of inflamed or infected skin, up to 10% of body surface" 51453897_1 CDM 0510 RC 11000 HCPCS inpatient 2057 1337.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1245.51 1995.29 "Removal of inflamed or infected skin, up to 10% of body surface" 51453897_1 CDM 0510 RC 11000 HCPCS inpatient 2057 1337.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1390.53 67.6 999999999 1245.51 1995.29 percent of total billed charges "Removal of tissue from wound, each additional 20.0 sq cm" 51453898_1 CDM 0510 RC 97598 HCPCS inpatient 221 143.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 143.65 65 999999999 133.82 214.37 percent of total billed charges "Removal of tissue from wound, each additional 20.0 sq cm" 51453898_1 CDM 0510 RC 97598 HCPCS inpatient 221 143.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 214.37 97 999999999 133.82 214.37 percent of total billed charges "Removal of tissue from wound, each additional 20.0 sq cm" 51453898_1 CDM 0510 RC 97598 HCPCS inpatient 221 143.65 AETNA AETNA 174.59 79 999999999 133.82 214.37 percent of total billed charges "Removal of tissue from wound, each additional 20.0 sq cm" 51453898_1 CDM 0510 RC 97598 HCPCS inpatient 221 143.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 152.49 69 999999999 133.82 214.37 percent of total billed charges "Removal of tissue from wound, each additional 20.0 sq cm" 51453898_1 CDM 0510 RC 97598 HCPCS inpatient 221 143.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 172.38 78 999999999 133.82 214.37 percent of total billed charges "Removal of tissue from wound, each additional 20.0 sq cm" 51453898_1 CDM 0510 RC 97598 HCPCS inpatient 221 143.65 SIHO - ALL PLANS SIHO - ALL PLANS 198.9 90 999999999 133.82 214.37 percent of total billed charges "Removal of tissue from wound, each additional 20.0 sq cm" 51453898_1 CDM 0510 RC 97598 HCPCS inpatient 221 143.65 UMR - ALL PLANS UMR - ALL PLANS 154.7 70 999999999 133.82 214.37 percent of total billed charges "Removal of tissue from wound, each additional 20.0 sq cm" 51453898_1 CDM 0510 RC 97598 HCPCS inpatient 221 143.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 133.82 214.37 "Removal of tissue from wound, each additional 20.0 sq cm" 51453898_1 CDM 0510 RC 97598 HCPCS inpatient 221 143.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 133.82 60.55 999999999 133.82 214.37 percent of total billed charges "Removal of tissue from wound, each additional 20.0 sq cm" 51453898_1 CDM 0510 RC 97598 HCPCS inpatient 221 143.65 ANTHEM HMO ANTHEM HMO 999999999 133.82 214.37 "Removal of tissue from wound, each additional 20.0 sq cm" 51453898_1 CDM 0510 RC 97598 HCPCS inpatient 221 143.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 133.82 214.37 "Removal of tissue from wound, each additional 20.0 sq cm" 51453898_1 CDM 0510 RC 97598 HCPCS inpatient 221 143.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 133.82 214.37 "Removal of tissue from wound, each additional 20.0 sq cm" 51453898_1 CDM 0510 RC 97598 HCPCS inpatient 221 143.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 133.82 214.37 "Removal of tissue from wound, each additional 20.0 sq cm" 51453898_1 CDM 0510 RC 97598 HCPCS inpatient 221 143.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 149.4 67.6 999999999 133.82 214.37 percent of total billed charges "Removal of muscle and/or tissue, 20.0 sq cm or less" 51453899_1 CDM 0510 RC 11043 HCPCS inpatient 2057 1337.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1337.05 65 999999999 1245.51 1995.29 percent of total billed charges "Removal of muscle and/or tissue, 20.0 sq cm or less" 51453899_1 CDM 0510 RC 11043 HCPCS inpatient 2057 1337.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1995.29 97 999999999 1245.51 1995.29 percent of total billed charges "Removal of muscle and/or tissue, 20.0 sq cm or less" 51453899_1 CDM 0510 RC 11043 HCPCS inpatient 2057 1337.05 AETNA AETNA 1625.03 79 999999999 1245.51 1995.29 percent of total billed charges "Removal of muscle and/or tissue, 20.0 sq cm or less" 51453899_1 CDM 0510 RC 11043 HCPCS inpatient 2057 1337.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1419.33 69 999999999 1245.51 1995.29 percent of total billed charges "Removal of muscle and/or tissue, 20.0 sq cm or less" 51453899_1 CDM 0510 RC 11043 HCPCS inpatient 2057 1337.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1604.46 78 999999999 1245.51 1995.29 percent of total billed charges "Removal of muscle and/or tissue, 20.0 sq cm or less" 51453899_1 CDM 0510 RC 11043 HCPCS inpatient 2057 1337.05 SIHO - ALL PLANS SIHO - ALL PLANS 1851.3 90 999999999 1245.51 1995.29 percent of total billed charges "Removal of muscle and/or tissue, 20.0 sq cm or less" 51453899_1 CDM 0510 RC 11043 HCPCS inpatient 2057 1337.05 UMR - ALL PLANS UMR - ALL PLANS 1439.9 70 999999999 1245.51 1995.29 percent of total billed charges "Removal of muscle and/or tissue, 20.0 sq cm or less" 51453899_1 CDM 0510 RC 11043 HCPCS inpatient 2057 1337.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1245.51 1995.29 "Removal of muscle and/or tissue, 20.0 sq cm or less" 51453899_1 CDM 0510 RC 11043 HCPCS inpatient 2057 1337.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1245.51 60.55 999999999 1245.51 1995.29 percent of total billed charges "Removal of muscle and/or tissue, 20.0 sq cm or less" 51453899_1 CDM 0510 RC 11043 HCPCS inpatient 2057 1337.05 ANTHEM HMO ANTHEM HMO 999999999 1245.51 1995.29 "Removal of muscle and/or tissue, 20.0 sq cm or less" 51453899_1 CDM 0510 RC 11043 HCPCS inpatient 2057 1337.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1245.51 1995.29 "Removal of muscle and/or tissue, 20.0 sq cm or less" 51453899_1 CDM 0510 RC 11043 HCPCS inpatient 2057 1337.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1245.51 1995.29 "Removal of muscle and/or tissue, 20.0 sq cm or less" 51453899_1 CDM 0510 RC 11043 HCPCS inpatient 2057 1337.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1245.51 1995.29 "Removal of muscle and/or tissue, 20.0 sq cm or less" 51453899_1 CDM 0510 RC 11043 HCPCS inpatient 2057 1337.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1390.53 67.6 999999999 1245.51 1995.29 percent of total billed charges "Punch biopsy, first skin growth" 51455885_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 858.65 65 999999999 799.87 1281.37 percent of total billed charges "Punch biopsy, first skin growth" 51455885_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1281.37 97 999999999 799.87 1281.37 percent of total billed charges "Punch biopsy, first skin growth" 51455885_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 AETNA AETNA 1043.59 79 999999999 799.87 1281.37 percent of total billed charges "Punch biopsy, first skin growth" 51455885_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 911.49 69 999999999 799.87 1281.37 percent of total billed charges "Punch biopsy, first skin growth" 51455885_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1030.38 78 999999999 799.87 1281.37 percent of total billed charges "Punch biopsy, first skin growth" 51455885_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 SIHO - ALL PLANS SIHO - ALL PLANS 1188.9 90 999999999 799.87 1281.37 percent of total billed charges "Punch biopsy, first skin growth" 51455885_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 UMR - ALL PLANS UMR - ALL PLANS 924.7 70 999999999 799.87 1281.37 percent of total billed charges "Punch biopsy, first skin growth" 51455885_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 799.87 1281.37 "Punch biopsy, first skin growth" 51455885_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 799.87 60.55 999999999 799.87 1281.37 percent of total billed charges "Punch biopsy, first skin growth" 51455885_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 ANTHEM HMO ANTHEM HMO 999999999 799.87 1281.37 "Punch biopsy, first skin growth" 51455885_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 799.87 1281.37 "Punch biopsy, first skin growth" 51455885_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 799.87 1281.37 "Punch biopsy, first skin growth" 51455885_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 799.87 1281.37 "Punch biopsy, first skin growth" 51455885_1 CDM 0510 RC 11104 HCPCS inpatient 1321 858.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 893 67.6 999999999 799.87 1281.37 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 51469015_1 CDM 0510 RC 99211 HCPCS inpatient 65 42.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.25 65 999999999 39.36 63.05 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 51469015_1 CDM 0510 RC 99211 HCPCS inpatient 65 42.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 63.05 97 999999999 39.36 63.05 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 51469015_1 CDM 0510 RC 99211 HCPCS inpatient 65 42.25 AETNA AETNA 51.35 79 999999999 39.36 63.05 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 51469015_1 CDM 0510 RC 99211 HCPCS inpatient 65 42.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.85 69 999999999 39.36 63.05 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 51469015_1 CDM 0510 RC 99211 HCPCS inpatient 65 42.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 50.7 78 999999999 39.36 63.05 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 51469015_1 CDM 0510 RC 99211 HCPCS inpatient 65 42.25 SIHO - ALL PLANS SIHO - ALL PLANS 58.5 90 999999999 39.36 63.05 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 51469015_1 CDM 0510 RC 99211 HCPCS inpatient 65 42.25 UMR - ALL PLANS UMR - ALL PLANS 45.5 70 999999999 39.36 63.05 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 51469015_1 CDM 0510 RC 99211 HCPCS inpatient 65 42.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.36 63.05 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 51469015_1 CDM 0510 RC 99211 HCPCS inpatient 65 42.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.36 60.55 999999999 39.36 63.05 percent of total billed charges Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 51469015_1 CDM 0510 RC 99211 HCPCS inpatient 65 42.25 ANTHEM HMO ANTHEM HMO 999999999 39.36 63.05 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 51469015_1 CDM 0510 RC 99211 HCPCS inpatient 65 42.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.36 63.05 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 51469015_1 CDM 0510 RC 99211 HCPCS inpatient 65 42.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.36 63.05 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 51469015_1 CDM 0510 RC 99211 HCPCS inpatient 65 42.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.36 63.05 Office or other outpatient visit for the evaluation and management of established patient that may not require presence of healthcare professional 51469015_1 CDM 0510 RC 99211 HCPCS inpatient 65 42.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.94 67.6 999999999 39.36 63.05 percent of total billed charges Ultrasonic guidance for blood vessel access 51469865_1 CDM 0272 RC 76937 HCPCS inpatient 559 363.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 363.35 65 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 51469865_1 CDM 0272 RC 76937 HCPCS inpatient 559 363.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 542.23 97 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 51469865_1 CDM 0272 RC 76937 HCPCS inpatient 559 363.35 AETNA AETNA 441.61 79 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 51469865_1 CDM 0272 RC 76937 HCPCS inpatient 559 363.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 385.71 69 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 51469865_1 CDM 0272 RC 76937 HCPCS inpatient 559 363.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 436.02 78 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 51469865_1 CDM 0272 RC 76937 HCPCS inpatient 559 363.35 SIHO - ALL PLANS SIHO - ALL PLANS 503.1 90 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 51469865_1 CDM 0272 RC 76937 HCPCS inpatient 559 363.35 UMR - ALL PLANS UMR - ALL PLANS 391.3 70 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 51469865_1 CDM 0272 RC 76937 HCPCS inpatient 559 363.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 338.47 542.23 Ultrasonic guidance for blood vessel access 51469865_1 CDM 0272 RC 76937 HCPCS inpatient 559 363.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 338.47 60.55 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 51469865_1 CDM 0272 RC 76937 HCPCS inpatient 559 363.35 ANTHEM HMO ANTHEM HMO 999999999 338.47 542.23 Ultrasonic guidance for blood vessel access 51469865_1 CDM 0272 RC 76937 HCPCS inpatient 559 363.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 338.47 542.23 Ultrasonic guidance for blood vessel access 51469865_1 CDM 0272 RC 76937 HCPCS inpatient 559 363.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 338.47 542.23 Ultrasonic guidance for blood vessel access 51469865_1 CDM 0272 RC 76937 HCPCS inpatient 559 363.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 338.47 542.23 Ultrasonic guidance for blood vessel access 51469865_1 CDM 0272 RC 76937 HCPCS inpatient 559 363.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 377.88 67.6 999999999 338.47 542.23 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 51489687_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 73.45 65 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 51489687_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 109.61 97 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 51489687_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 AETNA AETNA 89.27 79 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 51489687_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.97 69 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 51489687_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.14 78 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 51489687_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 SIHO - ALL PLANS SIHO - ALL PLANS 101.7 90 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 51489687_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 UMR - ALL PLANS UMR - ALL PLANS 79.1 70 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 51489687_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 68.42 109.61 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 51489687_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 68.42 60.55 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 51489687_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 ANTHEM HMO ANTHEM HMO 999999999 68.42 109.61 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 51489687_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 68.42 109.61 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 51489687_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 68.42 109.61 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 51489687_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 68.42 109.61 "Detection test by nucleic acid for Neisseria gonorrhoeae (gonorrhoeae bacteria), amplified probe technique" 51489687_1 CDM 0306 RC 87591 HCPCS inpatient 113 73.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 76.39 67.6 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 51489688_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 73.45 65 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 51489688_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 109.61 97 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 51489688_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 AETNA AETNA 89.27 79 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 51489688_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.97 69 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 51489688_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.14 78 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 51489688_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 SIHO - ALL PLANS SIHO - ALL PLANS 101.7 90 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 51489688_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 UMR - ALL PLANS UMR - ALL PLANS 79.1 70 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 51489688_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 68.42 109.61 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 51489688_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 68.42 60.55 999999999 68.42 109.61 percent of total billed charges "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 51489688_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 ANTHEM HMO ANTHEM HMO 999999999 68.42 109.61 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 51489688_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 68.42 109.61 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 51489688_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 68.42 109.61 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 51489688_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 68.42 109.61 "Detection test by nucleic acid for chlamydia trachomatis, amplified probe technique" 51489688_1 CDM 0306 RC 87491 HCPCS inpatient 113 73.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 76.39 67.6 999999999 68.42 109.61 percent of total billed charges Correction of toe joint deformity 51489778_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 6849.05 65 999999999 6380.15 10220.89 percent of total billed charges Correction of toe joint deformity 51489778_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10220.89 97 999999999 6380.15 10220.89 percent of total billed charges Correction of toe joint deformity 51489778_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 AETNA AETNA 8324.23 79 999999999 6380.15 10220.89 percent of total billed charges Correction of toe joint deformity 51489778_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 7270.53 69 999999999 6380.15 10220.89 percent of total billed charges Correction of toe joint deformity 51489778_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 8218.86 78 999999999 6380.15 10220.89 percent of total billed charges Correction of toe joint deformity 51489778_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 SIHO - ALL PLANS SIHO - ALL PLANS 9483.3 90 999999999 6380.15 10220.89 percent of total billed charges Correction of toe joint deformity 51489778_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 UMR - ALL PLANS UMR - ALL PLANS 7375.9 70 999999999 6380.15 10220.89 percent of total billed charges Correction of toe joint deformity 51489778_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6380.15 10220.89 Correction of toe joint deformity 51489778_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6380.15 60.55 999999999 6380.15 10220.89 percent of total billed charges Correction of toe joint deformity 51489778_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 ANTHEM HMO ANTHEM HMO 999999999 6380.15 10220.89 Correction of toe joint deformity 51489778_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6380.15 10220.89 Correction of toe joint deformity 51489778_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6380.15 10220.89 Correction of toe joint deformity 51489778_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 6380.15 10220.89 Correction of toe joint deformity 51489778_1 CDM 0510 RC 28285 HCPCS inpatient 10537 6849.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 7123.01 67.6 999999999 6380.15 10220.89 percent of total billed charges Incision of joint capsule of foot and toe 51490232_1 CDM 0510 RC 28270 HCPCS inpatient 10723 6969.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 6969.95 65 999999999 6492.78 10401.31 percent of total billed charges Incision of joint capsule of foot and toe 51490232_1 CDM 0510 RC 28270 HCPCS inpatient 10723 6969.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10401.31 97 999999999 6492.78 10401.31 percent of total billed charges Incision of joint capsule of foot and toe 51490232_1 CDM 0510 RC 28270 HCPCS inpatient 10723 6969.95 AETNA AETNA 8471.17 79 999999999 6492.78 10401.31 percent of total billed charges Incision of joint capsule of foot and toe 51490232_1 CDM 0510 RC 28270 HCPCS inpatient 10723 6969.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 7398.87 69 999999999 6492.78 10401.31 percent of total billed charges Incision of joint capsule of foot and toe 51490232_1 CDM 0510 RC 28270 HCPCS inpatient 10723 6969.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 8363.94 78 999999999 6492.78 10401.31 percent of total billed charges Incision of joint capsule of foot and toe 51490232_1 CDM 0510 RC 28270 HCPCS inpatient 10723 6969.95 SIHO - ALL PLANS SIHO - ALL PLANS 9650.7 90 999999999 6492.78 10401.31 percent of total billed charges Incision of joint capsule of foot and toe 51490232_1 CDM 0510 RC 28270 HCPCS inpatient 10723 6969.95 UMR - ALL PLANS UMR - ALL PLANS 7506.1 70 999999999 6492.78 10401.31 percent of total billed charges Incision of joint capsule of foot and toe 51490232_1 CDM 0510 RC 28270 HCPCS inpatient 10723 6969.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6492.78 10401.31 Incision of joint capsule of foot and toe 51490232_1 CDM 0510 RC 28270 HCPCS inpatient 10723 6969.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6492.78 60.55 999999999 6492.78 10401.31 percent of total billed charges Incision of joint capsule of foot and toe 51490232_1 CDM 0510 RC 28270 HCPCS inpatient 10723 6969.95 ANTHEM HMO ANTHEM HMO 999999999 6492.78 10401.31 Incision of joint capsule of foot and toe 51490232_1 CDM 0510 RC 28270 HCPCS inpatient 10723 6969.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6492.78 10401.31 Incision of joint capsule of foot and toe 51490232_1 CDM 0510 RC 28270 HCPCS inpatient 10723 6969.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6492.78 10401.31 Incision of joint capsule of foot and toe 51490232_1 CDM 0510 RC 28270 HCPCS inpatient 10723 6969.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 6492.78 10401.31 Incision of joint capsule of foot and toe 51490232_1 CDM 0510 RC 28270 HCPCS inpatient 10723 6969.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 7248.75 67.6 999999999 6492.78 10401.31 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 51497238_1 CDM 0510 RC 28295 HCPCS inpatient 10723 6969.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 6969.95 65 999999999 6492.78 10401.31 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 51497238_1 CDM 0510 RC 28295 HCPCS inpatient 10723 6969.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10401.31 97 999999999 6492.78 10401.31 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 51497238_1 CDM 0510 RC 28295 HCPCS inpatient 10723 6969.95 AETNA AETNA 8471.17 79 999999999 6492.78 10401.31 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 51497238_1 CDM 0510 RC 28295 HCPCS inpatient 10723 6969.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 7398.87 69 999999999 6492.78 10401.31 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 51497238_1 CDM 0510 RC 28295 HCPCS inpatient 10723 6969.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 8363.94 78 999999999 6492.78 10401.31 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 51497238_1 CDM 0510 RC 28295 HCPCS inpatient 10723 6969.95 SIHO - ALL PLANS SIHO - ALL PLANS 9650.7 90 999999999 6492.78 10401.31 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 51497238_1 CDM 0510 RC 28295 HCPCS inpatient 10723 6969.95 UMR - ALL PLANS UMR - ALL PLANS 7506.1 70 999999999 6492.78 10401.31 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 51497238_1 CDM 0510 RC 28295 HCPCS inpatient 10723 6969.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6492.78 10401.31 Correction of bunion with alignment correction of midfoot bone toward ankle 51497238_1 CDM 0510 RC 28295 HCPCS inpatient 10723 6969.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6492.78 60.55 999999999 6492.78 10401.31 percent of total billed charges Correction of bunion with alignment correction of midfoot bone toward ankle 51497238_1 CDM 0510 RC 28295 HCPCS inpatient 10723 6969.95 ANTHEM HMO ANTHEM HMO 999999999 6492.78 10401.31 Correction of bunion with alignment correction of midfoot bone toward ankle 51497238_1 CDM 0510 RC 28295 HCPCS inpatient 10723 6969.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6492.78 10401.31 Correction of bunion with alignment correction of midfoot bone toward ankle 51497238_1 CDM 0510 RC 28295 HCPCS inpatient 10723 6969.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6492.78 10401.31 Correction of bunion with alignment correction of midfoot bone toward ankle 51497238_1 CDM 0510 RC 28295 HCPCS inpatient 10723 6969.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 6492.78 10401.31 Correction of bunion with alignment correction of midfoot bone toward ankle 51497238_1 CDM 0510 RC 28295 HCPCS inpatient 10723 6969.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 7248.75 67.6 999999999 6492.78 10401.31 percent of total billed charges "Removal of noncancer thickened skin growth, 1 growth" 51498032_1 CDM 0510 RC 11055 HCPCS inpatient 663 430.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 430.95 65 999999999 401.45 643.11 percent of total billed charges "Removal of noncancer thickened skin growth, 1 growth" 51498032_1 CDM 0510 RC 11055 HCPCS inpatient 663 430.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 643.11 97 999999999 401.45 643.11 percent of total billed charges "Removal of noncancer thickened skin growth, 1 growth" 51498032_1 CDM 0510 RC 11055 HCPCS inpatient 663 430.95 AETNA AETNA 523.77 79 999999999 401.45 643.11 percent of total billed charges "Removal of noncancer thickened skin growth, 1 growth" 51498032_1 CDM 0510 RC 11055 HCPCS inpatient 663 430.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 457.47 69 999999999 401.45 643.11 percent of total billed charges "Removal of noncancer thickened skin growth, 1 growth" 51498032_1 CDM 0510 RC 11055 HCPCS inpatient 663 430.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 517.14 78 999999999 401.45 643.11 percent of total billed charges "Removal of noncancer thickened skin growth, 1 growth" 51498032_1 CDM 0510 RC 11055 HCPCS inpatient 663 430.95 SIHO - ALL PLANS SIHO - ALL PLANS 596.7 90 999999999 401.45 643.11 percent of total billed charges "Removal of noncancer thickened skin growth, 1 growth" 51498032_1 CDM 0510 RC 11055 HCPCS inpatient 663 430.95 UMR - ALL PLANS UMR - ALL PLANS 464.1 70 999999999 401.45 643.11 percent of total billed charges "Removal of noncancer thickened skin growth, 1 growth" 51498032_1 CDM 0510 RC 11055 HCPCS inpatient 663 430.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 401.45 643.11 "Removal of noncancer thickened skin growth, 1 growth" 51498032_1 CDM 0510 RC 11055 HCPCS inpatient 663 430.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 401.45 60.55 999999999 401.45 643.11 percent of total billed charges "Removal of noncancer thickened skin growth, 1 growth" 51498032_1 CDM 0510 RC 11055 HCPCS inpatient 663 430.95 ANTHEM HMO ANTHEM HMO 999999999 401.45 643.11 "Removal of noncancer thickened skin growth, 1 growth" 51498032_1 CDM 0510 RC 11055 HCPCS inpatient 663 430.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 401.45 643.11 "Removal of noncancer thickened skin growth, 1 growth" 51498032_1 CDM 0510 RC 11055 HCPCS inpatient 663 430.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 401.45 643.11 "Removal of noncancer thickened skin growth, 1 growth" 51498032_1 CDM 0510 RC 11055 HCPCS inpatient 663 430.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 401.45 643.11 "Removal of noncancer thickened skin growth, 1 growth" 51498032_1 CDM 0510 RC 11055 HCPCS inpatient 663 430.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 448.19 67.6 999999999 401.45 643.11 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 51498035_1 CDM 0510 RC 12001 HCPCS inpatient 663 430.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 430.95 65 999999999 401.45 643.11 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 51498035_1 CDM 0510 RC 12001 HCPCS inpatient 663 430.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 643.11 97 999999999 401.45 643.11 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 51498035_1 CDM 0510 RC 12001 HCPCS inpatient 663 430.95 AETNA AETNA 523.77 79 999999999 401.45 643.11 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 51498035_1 CDM 0510 RC 12001 HCPCS inpatient 663 430.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 457.47 69 999999999 401.45 643.11 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 51498035_1 CDM 0510 RC 12001 HCPCS inpatient 663 430.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 517.14 78 999999999 401.45 643.11 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 51498035_1 CDM 0510 RC 12001 HCPCS inpatient 663 430.95 SIHO - ALL PLANS SIHO - ALL PLANS 596.7 90 999999999 401.45 643.11 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 51498035_1 CDM 0510 RC 12001 HCPCS inpatient 663 430.95 UMR - ALL PLANS UMR - ALL PLANS 464.1 70 999999999 401.45 643.11 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 51498035_1 CDM 0510 RC 12001 HCPCS inpatient 663 430.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 401.45 643.11 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 51498035_1 CDM 0510 RC 12001 HCPCS inpatient 663 430.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 401.45 60.55 999999999 401.45 643.11 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 51498035_1 CDM 0510 RC 12001 HCPCS inpatient 663 430.95 ANTHEM HMO ANTHEM HMO 999999999 401.45 643.11 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 51498035_1 CDM 0510 RC 12001 HCPCS inpatient 663 430.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 401.45 643.11 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 51498035_1 CDM 0510 RC 12001 HCPCS inpatient 663 430.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 401.45 643.11 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 51498035_1 CDM 0510 RC 12001 HCPCS inpatient 663 430.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 401.45 643.11 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.5 cm or less" 51498035_1 CDM 0510 RC 12001 HCPCS inpatient 663 430.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 448.19 67.6 999999999 401.45 643.11 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 51498037_1 CDM 0510 RC 12002 HCPCS inpatient 663 430.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 430.95 65 999999999 401.45 643.11 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 51498037_1 CDM 0510 RC 12002 HCPCS inpatient 663 430.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 643.11 97 999999999 401.45 643.11 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 51498037_1 CDM 0510 RC 12002 HCPCS inpatient 663 430.95 AETNA AETNA 523.77 79 999999999 401.45 643.11 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 51498037_1 CDM 0510 RC 12002 HCPCS inpatient 663 430.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 457.47 69 999999999 401.45 643.11 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 51498037_1 CDM 0510 RC 12002 HCPCS inpatient 663 430.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 517.14 78 999999999 401.45 643.11 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 51498037_1 CDM 0510 RC 12002 HCPCS inpatient 663 430.95 SIHO - ALL PLANS SIHO - ALL PLANS 596.7 90 999999999 401.45 643.11 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 51498037_1 CDM 0510 RC 12002 HCPCS inpatient 663 430.95 UMR - ALL PLANS UMR - ALL PLANS 464.1 70 999999999 401.45 643.11 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 51498037_1 CDM 0510 RC 12002 HCPCS inpatient 663 430.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 401.45 643.11 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 51498037_1 CDM 0510 RC 12002 HCPCS inpatient 663 430.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 401.45 60.55 999999999 401.45 643.11 percent of total billed charges "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 51498037_1 CDM 0510 RC 12002 HCPCS inpatient 663 430.95 ANTHEM HMO ANTHEM HMO 999999999 401.45 643.11 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 51498037_1 CDM 0510 RC 12002 HCPCS inpatient 663 430.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 401.45 643.11 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 51498037_1 CDM 0510 RC 12002 HCPCS inpatient 663 430.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 401.45 643.11 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 51498037_1 CDM 0510 RC 12002 HCPCS inpatient 663 430.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 401.45 643.11 "Simple repair of surface wound of scalp, neck, underarms, trunk, arms, or legs, 2.6-7.5 cm" 51498037_1 CDM 0510 RC 12002 HCPCS inpatient 663 430.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 448.19 67.6 999999999 401.45 643.11 percent of total billed charges "Skin graft to tip of finger or toe, 2.0 cm or less" 51498039_1 CDM 0510 RC 15050 HCPCS inpatient 2081 1352.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1352.65 65 999999999 1260.05 2018.57 percent of total billed charges "Skin graft to tip of finger or toe, 2.0 cm or less" 51498039_1 CDM 0510 RC 15050 HCPCS inpatient 2081 1352.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2018.57 97 999999999 1260.05 2018.57 percent of total billed charges "Skin graft to tip of finger or toe, 2.0 cm or less" 51498039_1 CDM 0510 RC 15050 HCPCS inpatient 2081 1352.65 AETNA AETNA 1643.99 79 999999999 1260.05 2018.57 percent of total billed charges "Skin graft to tip of finger or toe, 2.0 cm or less" 51498039_1 CDM 0510 RC 15050 HCPCS inpatient 2081 1352.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1435.89 69 999999999 1260.05 2018.57 percent of total billed charges "Skin graft to tip of finger or toe, 2.0 cm or less" 51498039_1 CDM 0510 RC 15050 HCPCS inpatient 2081 1352.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1623.18 78 999999999 1260.05 2018.57 percent of total billed charges "Skin graft to tip of finger or toe, 2.0 cm or less" 51498039_1 CDM 0510 RC 15050 HCPCS inpatient 2081 1352.65 SIHO - ALL PLANS SIHO - ALL PLANS 1872.9 90 999999999 1260.05 2018.57 percent of total billed charges "Skin graft to tip of finger or toe, 2.0 cm or less" 51498039_1 CDM 0510 RC 15050 HCPCS inpatient 2081 1352.65 UMR - ALL PLANS UMR - ALL PLANS 1456.7 70 999999999 1260.05 2018.57 percent of total billed charges "Skin graft to tip of finger or toe, 2.0 cm or less" 51498039_1 CDM 0510 RC 15050 HCPCS inpatient 2081 1352.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1260.05 2018.57 "Skin graft to tip of finger or toe, 2.0 cm or less" 51498039_1 CDM 0510 RC 15050 HCPCS inpatient 2081 1352.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1260.05 60.55 999999999 1260.05 2018.57 percent of total billed charges "Skin graft to tip of finger or toe, 2.0 cm or less" 51498039_1 CDM 0510 RC 15050 HCPCS inpatient 2081 1352.65 ANTHEM HMO ANTHEM HMO 999999999 1260.05 2018.57 "Skin graft to tip of finger or toe, 2.0 cm or less" 51498039_1 CDM 0510 RC 15050 HCPCS inpatient 2081 1352.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1260.05 2018.57 "Skin graft to tip of finger or toe, 2.0 cm or less" 51498039_1 CDM 0510 RC 15050 HCPCS inpatient 2081 1352.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1260.05 2018.57 "Skin graft to tip of finger or toe, 2.0 cm or less" 51498039_1 CDM 0510 RC 15050 HCPCS inpatient 2081 1352.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1260.05 2018.57 "Skin graft to tip of finger or toe, 2.0 cm or less" 51498039_1 CDM 0510 RC 15050 HCPCS inpatient 2081 1352.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1406.76 67.6 999999999 1260.05 2018.57 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 51498040_1 CDM 0510 RC 15271 HCPCS inpatient 6042 3927.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 3927.3 65 999999999 3658.43 5860.74 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 51498040_1 CDM 0510 RC 15271 HCPCS inpatient 6042 3927.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5860.74 97 999999999 3658.43 5860.74 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 51498040_1 CDM 0510 RC 15271 HCPCS inpatient 6042 3927.3 AETNA AETNA 4773.18 79 999999999 3658.43 5860.74 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 51498040_1 CDM 0510 RC 15271 HCPCS inpatient 6042 3927.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 4168.98 69 999999999 3658.43 5860.74 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 51498040_1 CDM 0510 RC 15271 HCPCS inpatient 6042 3927.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 4712.76 78 999999999 3658.43 5860.74 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 51498040_1 CDM 0510 RC 15271 HCPCS inpatient 6042 3927.3 SIHO - ALL PLANS SIHO - ALL PLANS 5437.8 90 999999999 3658.43 5860.74 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 51498040_1 CDM 0510 RC 15271 HCPCS inpatient 6042 3927.3 UMR - ALL PLANS UMR - ALL PLANS 4229.4 70 999999999 3658.43 5860.74 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 51498040_1 CDM 0510 RC 15271 HCPCS inpatient 6042 3927.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3658.43 5860.74 "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 51498040_1 CDM 0510 RC 15271 HCPCS inpatient 6042 3927.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3658.43 60.55 999999999 3658.43 5860.74 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 51498040_1 CDM 0510 RC 15271 HCPCS inpatient 6042 3927.3 ANTHEM HMO ANTHEM HMO 999999999 3658.43 5860.74 "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 51498040_1 CDM 0510 RC 15271 HCPCS inpatient 6042 3927.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3658.43 5860.74 "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 51498040_1 CDM 0510 RC 15271 HCPCS inpatient 6042 3927.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3658.43 5860.74 "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 51498040_1 CDM 0510 RC 15271 HCPCS inpatient 6042 3927.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 3658.43 5860.74 "Application of skin substitute graft to wound of trunk, arms, or legs, 25.0 sq cm or less of wound 100.0 sq cm or less" 51498040_1 CDM 0510 RC 15271 HCPCS inpatient 6042 3927.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 4084.39 67.6 999999999 3658.43 5860.74 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498041_1 CDM 0510 RC 15272 HCPCS inpatient 1511 982.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 982.15 65 999999999 914.91 1465.67 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498041_1 CDM 0510 RC 15272 HCPCS inpatient 1511 982.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1465.67 97 999999999 914.91 1465.67 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498041_1 CDM 0510 RC 15272 HCPCS inpatient 1511 982.15 AETNA AETNA 1193.69 79 999999999 914.91 1465.67 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498041_1 CDM 0510 RC 15272 HCPCS inpatient 1511 982.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1042.59 69 999999999 914.91 1465.67 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498041_1 CDM 0510 RC 15272 HCPCS inpatient 1511 982.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1178.58 78 999999999 914.91 1465.67 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498041_1 CDM 0510 RC 15272 HCPCS inpatient 1511 982.15 SIHO - ALL PLANS SIHO - ALL PLANS 1359.9 90 999999999 914.91 1465.67 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498041_1 CDM 0510 RC 15272 HCPCS inpatient 1511 982.15 UMR - ALL PLANS UMR - ALL PLANS 1057.7 70 999999999 914.91 1465.67 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498041_1 CDM 0510 RC 15272 HCPCS inpatient 1511 982.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 914.91 1465.67 "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498041_1 CDM 0510 RC 15272 HCPCS inpatient 1511 982.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 914.91 60.55 999999999 914.91 1465.67 percent of total billed charges "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498041_1 CDM 0510 RC 15272 HCPCS inpatient 1511 982.15 ANTHEM HMO ANTHEM HMO 999999999 914.91 1465.67 "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498041_1 CDM 0510 RC 15272 HCPCS inpatient 1511 982.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 914.91 1465.67 "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498041_1 CDM 0510 RC 15272 HCPCS inpatient 1511 982.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 914.91 1465.67 "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498041_1 CDM 0510 RC 15272 HCPCS inpatient 1511 982.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 914.91 1465.67 "Application of skin substitute graft to wound of trunk, arms, or legs, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498041_1 CDM 0510 RC 15272 HCPCS inpatient 1511 982.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1021.44 67.6 999999999 914.91 1465.67 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498042_1 CDM 0510 RC 15276 HCPCS inpatient 1510 981.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 981.5 65 999999999 914.31 1464.7 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498042_1 CDM 0510 RC 15276 HCPCS inpatient 1510 981.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1464.7 97 999999999 914.31 1464.7 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498042_1 CDM 0510 RC 15276 HCPCS inpatient 1510 981.5 AETNA AETNA 1192.9 79 999999999 914.31 1464.7 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498042_1 CDM 0510 RC 15276 HCPCS inpatient 1510 981.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1041.9 69 999999999 914.31 1464.7 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498042_1 CDM 0510 RC 15276 HCPCS inpatient 1510 981.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1177.8 78 999999999 914.31 1464.7 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498042_1 CDM 0510 RC 15276 HCPCS inpatient 1510 981.5 SIHO - ALL PLANS SIHO - ALL PLANS 1359 90 999999999 914.31 1464.7 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498042_1 CDM 0510 RC 15276 HCPCS inpatient 1510 981.5 UMR - ALL PLANS UMR - ALL PLANS 1057 70 999999999 914.31 1464.7 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498042_1 CDM 0510 RC 15276 HCPCS inpatient 1510 981.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 914.31 1464.7 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498042_1 CDM 0510 RC 15276 HCPCS inpatient 1510 981.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 914.31 60.55 999999999 914.31 1464.7 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498042_1 CDM 0510 RC 15276 HCPCS inpatient 1510 981.5 ANTHEM HMO ANTHEM HMO 999999999 914.31 1464.7 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498042_1 CDM 0510 RC 15276 HCPCS inpatient 1510 981.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 914.31 1464.7 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498042_1 CDM 0510 RC 15276 HCPCS inpatient 1510 981.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 914.31 1464.7 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498042_1 CDM 0510 RC 15276 HCPCS inpatient 1510 981.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 914.31 1464.7 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, each additional 25.0 sq cm of wound 100.0 sq cm or less" 51498042_1 CDM 0510 RC 15276 HCPCS inpatient 1510 981.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1020.76 67.6 999999999 914.31 1464.7 percent of total billed charges "Application of walking cast covering foot, ankle, and lower leg" 51498058_1 CDM 0510 RC 29445 HCPCS inpatient 890 578.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 578.5 65 999999999 538.9 863.3 percent of total billed charges "Application of walking cast covering foot, ankle, and lower leg" 51498058_1 CDM 0510 RC 29445 HCPCS inpatient 890 578.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 863.3 97 999999999 538.9 863.3 percent of total billed charges "Application of walking cast covering foot, ankle, and lower leg" 51498058_1 CDM 0510 RC 29445 HCPCS inpatient 890 578.5 AETNA AETNA 703.1 79 999999999 538.9 863.3 percent of total billed charges "Application of walking cast covering foot, ankle, and lower leg" 51498058_1 CDM 0510 RC 29445 HCPCS inpatient 890 578.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 614.1 69 999999999 538.9 863.3 percent of total billed charges "Application of walking cast covering foot, ankle, and lower leg" 51498058_1 CDM 0510 RC 29445 HCPCS inpatient 890 578.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 694.2 78 999999999 538.9 863.3 percent of total billed charges "Application of walking cast covering foot, ankle, and lower leg" 51498058_1 CDM 0510 RC 29445 HCPCS inpatient 890 578.5 SIHO - ALL PLANS SIHO - ALL PLANS 801 90 999999999 538.9 863.3 percent of total billed charges "Application of walking cast covering foot, ankle, and lower leg" 51498058_1 CDM 0510 RC 29445 HCPCS inpatient 890 578.5 UMR - ALL PLANS UMR - ALL PLANS 623 70 999999999 538.9 863.3 percent of total billed charges "Application of walking cast covering foot, ankle, and lower leg" 51498058_1 CDM 0510 RC 29445 HCPCS inpatient 890 578.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 538.9 863.3 "Application of walking cast covering foot, ankle, and lower leg" 51498058_1 CDM 0510 RC 29445 HCPCS inpatient 890 578.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 538.9 60.55 999999999 538.9 863.3 percent of total billed charges "Application of walking cast covering foot, ankle, and lower leg" 51498058_1 CDM 0510 RC 29445 HCPCS inpatient 890 578.5 ANTHEM HMO ANTHEM HMO 999999999 538.9 863.3 "Application of walking cast covering foot, ankle, and lower leg" 51498058_1 CDM 0510 RC 29445 HCPCS inpatient 890 578.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 538.9 863.3 "Application of walking cast covering foot, ankle, and lower leg" 51498058_1 CDM 0510 RC 29445 HCPCS inpatient 890 578.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 538.9 863.3 "Application of walking cast covering foot, ankle, and lower leg" 51498058_1 CDM 0510 RC 29445 HCPCS inpatient 890 578.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 538.9 863.3 "Application of walking cast covering foot, ankle, and lower leg" 51498058_1 CDM 0510 RC 29445 HCPCS inpatient 890 578.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 601.64 67.6 999999999 538.9 863.3 percent of total billed charges Application of short leg splint from calf to foot 51498059_1 CDM 0510 RC 29515 HCPCS inpatient 522 339.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 339.3 65 999999999 316.07 506.34 percent of total billed charges Application of short leg splint from calf to foot 51498059_1 CDM 0510 RC 29515 HCPCS inpatient 522 339.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 506.34 97 999999999 316.07 506.34 percent of total billed charges Application of short leg splint from calf to foot 51498059_1 CDM 0510 RC 29515 HCPCS inpatient 522 339.3 AETNA AETNA 412.38 79 999999999 316.07 506.34 percent of total billed charges Application of short leg splint from calf to foot 51498059_1 CDM 0510 RC 29515 HCPCS inpatient 522 339.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 360.18 69 999999999 316.07 506.34 percent of total billed charges Application of short leg splint from calf to foot 51498059_1 CDM 0510 RC 29515 HCPCS inpatient 522 339.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 407.16 78 999999999 316.07 506.34 percent of total billed charges Application of short leg splint from calf to foot 51498059_1 CDM 0510 RC 29515 HCPCS inpatient 522 339.3 SIHO - ALL PLANS SIHO - ALL PLANS 469.8 90 999999999 316.07 506.34 percent of total billed charges Application of short leg splint from calf to foot 51498059_1 CDM 0510 RC 29515 HCPCS inpatient 522 339.3 UMR - ALL PLANS UMR - ALL PLANS 365.4 70 999999999 316.07 506.34 percent of total billed charges Application of short leg splint from calf to foot 51498059_1 CDM 0510 RC 29515 HCPCS inpatient 522 339.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 316.07 506.34 Application of short leg splint from calf to foot 51498059_1 CDM 0510 RC 29515 HCPCS inpatient 522 339.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 316.07 60.55 999999999 316.07 506.34 percent of total billed charges Application of short leg splint from calf to foot 51498059_1 CDM 0510 RC 29515 HCPCS inpatient 522 339.3 ANTHEM HMO ANTHEM HMO 999999999 316.07 506.34 Application of short leg splint from calf to foot 51498059_1 CDM 0510 RC 29515 HCPCS inpatient 522 339.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 316.07 506.34 Application of short leg splint from calf to foot 51498059_1 CDM 0510 RC 29515 HCPCS inpatient 522 339.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 316.07 506.34 Application of short leg splint from calf to foot 51498059_1 CDM 0510 RC 29515 HCPCS inpatient 522 339.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 316.07 506.34 Application of short leg splint from calf to foot 51498059_1 CDM 0510 RC 29515 HCPCS inpatient 522 339.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 352.87 67.6 999999999 316.07 506.34 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 51498060_1 CDM 0510 RC 29581 HCPCS inpatient 522 339.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 339.3 65 999999999 316.07 506.34 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 51498060_1 CDM 0510 RC 29581 HCPCS inpatient 522 339.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 506.34 97 999999999 316.07 506.34 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 51498060_1 CDM 0510 RC 29581 HCPCS inpatient 522 339.3 AETNA AETNA 412.38 79 999999999 316.07 506.34 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 51498060_1 CDM 0510 RC 29581 HCPCS inpatient 522 339.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 360.18 69 999999999 316.07 506.34 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 51498060_1 CDM 0510 RC 29581 HCPCS inpatient 522 339.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 407.16 78 999999999 316.07 506.34 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 51498060_1 CDM 0510 RC 29581 HCPCS inpatient 522 339.3 SIHO - ALL PLANS SIHO - ALL PLANS 469.8 90 999999999 316.07 506.34 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 51498060_1 CDM 0510 RC 29581 HCPCS inpatient 522 339.3 UMR - ALL PLANS UMR - ALL PLANS 365.4 70 999999999 316.07 506.34 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 51498060_1 CDM 0510 RC 29581 HCPCS inpatient 522 339.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 316.07 506.34 "Application of vein wound compression bandages on lower leg, ankle, and foot" 51498060_1 CDM 0510 RC 29581 HCPCS inpatient 522 339.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 316.07 60.55 999999999 316.07 506.34 percent of total billed charges "Application of vein wound compression bandages on lower leg, ankle, and foot" 51498060_1 CDM 0510 RC 29581 HCPCS inpatient 522 339.3 ANTHEM HMO ANTHEM HMO 999999999 316.07 506.34 "Application of vein wound compression bandages on lower leg, ankle, and foot" 51498060_1 CDM 0510 RC 29581 HCPCS inpatient 522 339.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 316.07 506.34 "Application of vein wound compression bandages on lower leg, ankle, and foot" 51498060_1 CDM 0510 RC 29581 HCPCS inpatient 522 339.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 316.07 506.34 "Application of vein wound compression bandages on lower leg, ankle, and foot" 51498060_1 CDM 0510 RC 29581 HCPCS inpatient 522 339.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 316.07 506.34 "Application of vein wound compression bandages on lower leg, ankle, and foot" 51498060_1 CDM 0510 RC 29581 HCPCS inpatient 522 339.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 352.87 67.6 999999999 316.07 506.34 percent of total billed charges Aldolase (enzyme) level 51498358_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges Aldolase (enzyme) level 51498358_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges Aldolase (enzyme) level 51498358_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges Aldolase (enzyme) level 51498358_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges Aldolase (enzyme) level 51498358_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges Aldolase (enzyme) level 51498358_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges Aldolase (enzyme) level 51498358_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges Aldolase (enzyme) level 51498358_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 Aldolase (enzyme) level 51498358_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges Aldolase (enzyme) level 51498358_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 Aldolase (enzyme) level 51498358_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 Aldolase (enzyme) level 51498358_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 Aldolase (enzyme) level 51498358_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 Aldolase (enzyme) level 51498358_1 CDM 0301 RC 82085 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges Needle biopsy or removal of surface lymph nodes 51499014_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 796.9 65 999999999 742.34 1189.22 percent of total billed charges Needle biopsy or removal of surface lymph nodes 51499014_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1189.22 97 999999999 742.34 1189.22 percent of total billed charges Needle biopsy or removal of surface lymph nodes 51499014_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 AETNA AETNA 968.54 79 999999999 742.34 1189.22 percent of total billed charges Needle biopsy or removal of surface lymph nodes 51499014_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 845.94 69 999999999 742.34 1189.22 percent of total billed charges Needle biopsy or removal of surface lymph nodes 51499014_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 956.28 78 999999999 742.34 1189.22 percent of total billed charges Needle biopsy or removal of surface lymph nodes 51499014_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 SIHO - ALL PLANS SIHO - ALL PLANS 1103.4 90 999999999 742.34 1189.22 percent of total billed charges Needle biopsy or removal of surface lymph nodes 51499014_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 UMR - ALL PLANS UMR - ALL PLANS 858.2 70 999999999 742.34 1189.22 percent of total billed charges Needle biopsy or removal of surface lymph nodes 51499014_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 742.34 1189.22 Needle biopsy or removal of surface lymph nodes 51499014_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 742.34 60.55 999999999 742.34 1189.22 percent of total billed charges Needle biopsy or removal of surface lymph nodes 51499014_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 ANTHEM HMO ANTHEM HMO 999999999 742.34 1189.22 Needle biopsy or removal of surface lymph nodes 51499014_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 742.34 1189.22 Needle biopsy or removal of surface lymph nodes 51499014_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 742.34 1189.22 Needle biopsy or removal of surface lymph nodes 51499014_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 742.34 1189.22 Needle biopsy or removal of surface lymph nodes 51499014_1 CDM 0921 RC 38505 HCPCS inpatient 1226 796.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 828.78 67.6 999999999 742.34 1189.22 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 51500040_1 CDM 0510 RC 15275 HCPCS inpatient 6042 3927.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 3927.3 65 999999999 3658.43 5860.74 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 51500040_1 CDM 0510 RC 15275 HCPCS inpatient 6042 3927.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5860.74 97 999999999 3658.43 5860.74 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 51500040_1 CDM 0510 RC 15275 HCPCS inpatient 6042 3927.3 AETNA AETNA 4773.18 79 999999999 3658.43 5860.74 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 51500040_1 CDM 0510 RC 15275 HCPCS inpatient 6042 3927.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 4168.98 69 999999999 3658.43 5860.74 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 51500040_1 CDM 0510 RC 15275 HCPCS inpatient 6042 3927.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 4712.76 78 999999999 3658.43 5860.74 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 51500040_1 CDM 0510 RC 15275 HCPCS inpatient 6042 3927.3 SIHO - ALL PLANS SIHO - ALL PLANS 5437.8 90 999999999 3658.43 5860.74 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 51500040_1 CDM 0510 RC 15275 HCPCS inpatient 6042 3927.3 UMR - ALL PLANS UMR - ALL PLANS 4229.4 70 999999999 3658.43 5860.74 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 51500040_1 CDM 0510 RC 15275 HCPCS inpatient 6042 3927.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3658.43 5860.74 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 51500040_1 CDM 0510 RC 15275 HCPCS inpatient 6042 3927.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3658.43 60.55 999999999 3658.43 5860.74 percent of total billed charges "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 51500040_1 CDM 0510 RC 15275 HCPCS inpatient 6042 3927.3 ANTHEM HMO ANTHEM HMO 999999999 3658.43 5860.74 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 51500040_1 CDM 0510 RC 15275 HCPCS inpatient 6042 3927.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3658.43 5860.74 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 51500040_1 CDM 0510 RC 15275 HCPCS inpatient 6042 3927.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3658.43 5860.74 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 51500040_1 CDM 0510 RC 15275 HCPCS inpatient 6042 3927.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 3658.43 5860.74 "Application of skin substitute graft to wound of face, scalp, eyelids, mouth, neck, ears, around eyes, genitals, hands, feet, fingers, or toes, 25.0 sq cm or less of wound 100.0 sq cm or less" 51500040_1 CDM 0510 RC 15275 HCPCS inpatient 6042 3927.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 4084.39 67.6 999999999 3658.43 5860.74 percent of total billed charges "Strapping, Unna boot" 51501977_1 CDM 0510 RC 29580 HCPCS inpatient 522 339.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 339.3 65 999999999 316.07 506.34 percent of total billed charges "Strapping, Unna boot" 51501977_1 CDM 0510 RC 29580 HCPCS inpatient 522 339.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 506.34 97 999999999 316.07 506.34 percent of total billed charges "Strapping, Unna boot" 51501977_1 CDM 0510 RC 29580 HCPCS inpatient 522 339.3 AETNA AETNA 412.38 79 999999999 316.07 506.34 percent of total billed charges "Strapping, Unna boot" 51501977_1 CDM 0510 RC 29580 HCPCS inpatient 522 339.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 360.18 69 999999999 316.07 506.34 percent of total billed charges "Strapping, Unna boot" 51501977_1 CDM 0510 RC 29580 HCPCS inpatient 522 339.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 407.16 78 999999999 316.07 506.34 percent of total billed charges "Strapping, Unna boot" 51501977_1 CDM 0510 RC 29580 HCPCS inpatient 522 339.3 SIHO - ALL PLANS SIHO - ALL PLANS 469.8 90 999999999 316.07 506.34 percent of total billed charges "Strapping, Unna boot" 51501977_1 CDM 0510 RC 29580 HCPCS inpatient 522 339.3 UMR - ALL PLANS UMR - ALL PLANS 365.4 70 999999999 316.07 506.34 percent of total billed charges "Strapping, Unna boot" 51501977_1 CDM 0510 RC 29580 HCPCS inpatient 522 339.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 316.07 506.34 "Strapping, Unna boot" 51501977_1 CDM 0510 RC 29580 HCPCS inpatient 522 339.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 316.07 60.55 999999999 316.07 506.34 percent of total billed charges "Strapping, Unna boot" 51501977_1 CDM 0510 RC 29580 HCPCS inpatient 522 339.3 ANTHEM HMO ANTHEM HMO 999999999 316.07 506.34 "Strapping, Unna boot" 51501977_1 CDM 0510 RC 29580 HCPCS inpatient 522 339.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 316.07 506.34 "Strapping, Unna boot" 51501977_1 CDM 0510 RC 29580 HCPCS inpatient 522 339.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 316.07 506.34 "Strapping, Unna boot" 51501977_1 CDM 0510 RC 29580 HCPCS inpatient 522 339.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 316.07 506.34 "Strapping, Unna boot" 51501977_1 CDM 0510 RC 29580 HCPCS inpatient 522 339.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 352.87 67.6 999999999 316.07 506.34 percent of total billed charges Aspiration and/or injection of fluid from medium joint 51504205_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 438.75 65 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from medium joint 51504205_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 654.75 97 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from medium joint 51504205_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 AETNA AETNA 533.25 79 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from medium joint 51504205_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 465.75 69 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from medium joint 51504205_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 526.5 78 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from medium joint 51504205_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 SIHO - ALL PLANS SIHO - ALL PLANS 607.5 90 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from medium joint 51504205_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 UMR - ALL PLANS UMR - ALL PLANS 472.5 70 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from medium joint 51504205_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 408.71 654.75 Aspiration and/or injection of fluid from medium joint 51504205_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 408.71 60.55 999999999 408.71 654.75 percent of total billed charges Aspiration and/or injection of fluid from medium joint 51504205_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 ANTHEM HMO ANTHEM HMO 999999999 408.71 654.75 Aspiration and/or injection of fluid from medium joint 51504205_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 408.71 654.75 Aspiration and/or injection of fluid from medium joint 51504205_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 408.71 654.75 Aspiration and/or injection of fluid from medium joint 51504205_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 408.71 654.75 Aspiration and/or injection of fluid from medium joint 51504205_1 CDM 0360 RC 20605 HCPCS inpatient 675 438.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 456.3 67.6 999999999 408.71 654.75 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51504969_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.6 65 999999999 123.52 197.88 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51504969_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.88 97 999999999 123.52 197.88 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51504969_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 AETNA AETNA 161.16 79 999999999 123.52 197.88 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51504969_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.76 69 999999999 123.52 197.88 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51504969_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.12 78 999999999 123.52 197.88 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51504969_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 SIHO - ALL PLANS SIHO - ALL PLANS 183.6 90 999999999 123.52 197.88 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51504969_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 UMR - ALL PLANS UMR - ALL PLANS 142.8 70 999999999 123.52 197.88 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51504969_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.52 197.88 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51504969_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.52 60.55 999999999 123.52 197.88 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51504969_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 ANTHEM HMO ANTHEM HMO 999999999 123.52 197.88 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51504969_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.52 197.88 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51504969_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.52 197.88 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51504969_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.52 197.88 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51504969_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.9 67.6 999999999 123.52 197.88 percent of total billed charges Detection test by immunoassay technique for Clostridium difficile toxins (stool pathogen) 51504976_1 CDM 0306 RC 87324 HCPCS inpatient 100 65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65 65 999999999 60.55 97 percent of total billed charges Detection test by immunoassay technique for Clostridium difficile toxins (stool pathogen) 51504976_1 CDM 0306 RC 87324 HCPCS inpatient 100 65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97 97 999999999 60.55 97 percent of total billed charges Detection test by immunoassay technique for Clostridium difficile toxins (stool pathogen) 51504976_1 CDM 0306 RC 87324 HCPCS inpatient 100 65 AETNA AETNA 79 79 999999999 60.55 97 percent of total billed charges Detection test by immunoassay technique for Clostridium difficile toxins (stool pathogen) 51504976_1 CDM 0306 RC 87324 HCPCS inpatient 100 65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69 69 999999999 60.55 97 percent of total billed charges Detection test by immunoassay technique for Clostridium difficile toxins (stool pathogen) 51504976_1 CDM 0306 RC 87324 HCPCS inpatient 100 65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78 78 999999999 60.55 97 percent of total billed charges Detection test by immunoassay technique for Clostridium difficile toxins (stool pathogen) 51504976_1 CDM 0306 RC 87324 HCPCS inpatient 100 65 SIHO - ALL PLANS SIHO - ALL PLANS 90 90 999999999 60.55 97 percent of total billed charges Detection test by immunoassay technique for Clostridium difficile toxins (stool pathogen) 51504976_1 CDM 0306 RC 87324 HCPCS inpatient 100 65 UMR - ALL PLANS UMR - ALL PLANS 70 70 999999999 60.55 97 percent of total billed charges Detection test by immunoassay technique for Clostridium difficile toxins (stool pathogen) 51504976_1 CDM 0306 RC 87324 HCPCS inpatient 100 65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.55 97 Detection test by immunoassay technique for Clostridium difficile toxins (stool pathogen) 51504976_1 CDM 0306 RC 87324 HCPCS inpatient 100 65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.55 60.55 999999999 60.55 97 percent of total billed charges Detection test by immunoassay technique for Clostridium difficile toxins (stool pathogen) 51504976_1 CDM 0306 RC 87324 HCPCS inpatient 100 65 ANTHEM HMO ANTHEM HMO 999999999 60.55 97 Detection test by immunoassay technique for Clostridium difficile toxins (stool pathogen) 51504976_1 CDM 0306 RC 87324 HCPCS inpatient 100 65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.55 97 Detection test by immunoassay technique for Clostridium difficile toxins (stool pathogen) 51504976_1 CDM 0306 RC 87324 HCPCS inpatient 100 65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.55 97 Detection test by immunoassay technique for Clostridium difficile toxins (stool pathogen) 51504976_1 CDM 0306 RC 87324 HCPCS inpatient 100 65 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.55 97 Detection test by immunoassay technique for Clostridium difficile toxins (stool pathogen) 51504976_1 CDM 0306 RC 87324 HCPCS inpatient 100 65 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.6 67.6 999999999 60.55 97 percent of total billed charges Detection test by immunoassay technique for other organism 51504977_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 51504977_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 51504977_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 51504977_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 51504977_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 51504977_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 51504977_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 51504977_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 Detection test by immunoassay technique for other organism 51504977_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges Detection test by immunoassay technique for other organism 51504977_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 Detection test by immunoassay technique for other organism 51504977_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 Detection test by immunoassay technique for other organism 51504977_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 Detection test by immunoassay technique for other organism 51504977_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 Detection test by immunoassay technique for other organism 51504977_1 CDM 0306 RC 87449 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51505187_1 CDM 0309 RC 88374 HCPCS inpatient 650 422.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 422.5 65 999999999 393.58 630.5 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51505187_1 CDM 0309 RC 88374 HCPCS inpatient 650 422.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 630.5 97 999999999 393.58 630.5 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51505187_1 CDM 0309 RC 88374 HCPCS inpatient 650 422.5 AETNA AETNA 513.5 79 999999999 393.58 630.5 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51505187_1 CDM 0309 RC 88374 HCPCS inpatient 650 422.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 448.5 69 999999999 393.58 630.5 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51505187_1 CDM 0309 RC 88374 HCPCS inpatient 650 422.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 507 78 999999999 393.58 630.5 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51505187_1 CDM 0309 RC 88374 HCPCS inpatient 650 422.5 SIHO - ALL PLANS SIHO - ALL PLANS 585 90 999999999 393.58 630.5 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51505187_1 CDM 0309 RC 88374 HCPCS inpatient 650 422.5 UMR - ALL PLANS UMR - ALL PLANS 455 70 999999999 393.58 630.5 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51505187_1 CDM 0309 RC 88374 HCPCS inpatient 650 422.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 393.58 630.5 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51505187_1 CDM 0309 RC 88374 HCPCS inpatient 650 422.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 393.58 60.55 999999999 393.58 630.5 percent of total billed charges "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51505187_1 CDM 0309 RC 88374 HCPCS inpatient 650 422.5 ANTHEM HMO ANTHEM HMO 999999999 393.58 630.5 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51505187_1 CDM 0309 RC 88374 HCPCS inpatient 650 422.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 393.58 630.5 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51505187_1 CDM 0309 RC 88374 HCPCS inpatient 650 422.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 393.58 630.5 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51505187_1 CDM 0309 RC 88374 HCPCS inpatient 650 422.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 393.58 630.5 "Microscopic genetic analysis of tissue, computer-assisted technology, initial procedure, each multiplex procedure" 51505187_1 CDM 0309 RC 88374 HCPCS inpatient 650 422.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 439.4 67.6 999999999 393.58 630.5 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 51505194_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 51505194_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 51505194_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 51505194_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 51505194_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 51505194_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 51505194_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 51505194_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 51505194_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 51505194_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 51505194_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 51505194_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 51505194_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 51505194_1 CDM 0301 RC 86141 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges Measurement of adalimumab 51506640_1 CDM 0301 RC 80145 HCPCS inpatient 65 42.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 42.25 65 999999999 39.36 63.05 percent of total billed charges Measurement of adalimumab 51506640_1 CDM 0301 RC 80145 HCPCS inpatient 65 42.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 63.05 97 999999999 39.36 63.05 percent of total billed charges Measurement of adalimumab 51506640_1 CDM 0301 RC 80145 HCPCS inpatient 65 42.25 AETNA AETNA 51.35 79 999999999 39.36 63.05 percent of total billed charges Measurement of adalimumab 51506640_1 CDM 0301 RC 80145 HCPCS inpatient 65 42.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 44.85 69 999999999 39.36 63.05 percent of total billed charges Measurement of adalimumab 51506640_1 CDM 0301 RC 80145 HCPCS inpatient 65 42.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 50.7 78 999999999 39.36 63.05 percent of total billed charges Measurement of adalimumab 51506640_1 CDM 0301 RC 80145 HCPCS inpatient 65 42.25 SIHO - ALL PLANS SIHO - ALL PLANS 58.5 90 999999999 39.36 63.05 percent of total billed charges Measurement of adalimumab 51506640_1 CDM 0301 RC 80145 HCPCS inpatient 65 42.25 UMR - ALL PLANS UMR - ALL PLANS 45.5 70 999999999 39.36 63.05 percent of total billed charges Measurement of adalimumab 51506640_1 CDM 0301 RC 80145 HCPCS inpatient 65 42.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 39.36 63.05 Measurement of adalimumab 51506640_1 CDM 0301 RC 80145 HCPCS inpatient 65 42.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39.36 60.55 999999999 39.36 63.05 percent of total billed charges Measurement of adalimumab 51506640_1 CDM 0301 RC 80145 HCPCS inpatient 65 42.25 ANTHEM HMO ANTHEM HMO 999999999 39.36 63.05 Measurement of adalimumab 51506640_1 CDM 0301 RC 80145 HCPCS inpatient 65 42.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 39.36 63.05 Measurement of adalimumab 51506640_1 CDM 0301 RC 80145 HCPCS inpatient 65 42.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 39.36 63.05 Measurement of adalimumab 51506640_1 CDM 0301 RC 80145 HCPCS inpatient 65 42.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 39.36 63.05 Measurement of adalimumab 51506640_1 CDM 0301 RC 80145 HCPCS inpatient 65 42.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 43.94 67.6 999999999 39.36 63.05 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 51506641_1 CDM 0301 RC 82397 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 51506641_1 CDM 0301 RC 82397 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 51506641_1 CDM 0301 RC 82397 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 51506641_1 CDM 0301 RC 82397 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 51506641_1 CDM 0301 RC 82397 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 51506641_1 CDM 0301 RC 82397 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 51506641_1 CDM 0301 RC 82397 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 51506641_1 CDM 0301 RC 82397 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 Analysis using chemiluminescent technique (light and chemical )reaction 51506641_1 CDM 0301 RC 82397 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges Analysis using chemiluminescent technique (light and chemical )reaction 51506641_1 CDM 0301 RC 82397 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 Analysis using chemiluminescent technique (light and chemical )reaction 51506641_1 CDM 0301 RC 82397 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 Analysis using chemiluminescent technique (light and chemical )reaction 51506641_1 CDM 0301 RC 82397 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 Analysis using chemiluminescent technique (light and chemical )reaction 51506641_1 CDM 0301 RC 82397 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 Analysis using chemiluminescent technique (light and chemical )reaction 51506641_1 CDM 0301 RC 82397 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506853_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 162.5 65 999999999 151.38 242.5 percent of total billed charges "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506853_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 242.5 97 999999999 151.38 242.5 percent of total billed charges "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506853_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 AETNA AETNA 197.5 79 999999999 151.38 242.5 percent of total billed charges "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506853_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 172.5 69 999999999 151.38 242.5 percent of total billed charges "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506853_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 195 78 999999999 151.38 242.5 percent of total billed charges "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506853_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 SIHO - ALL PLANS SIHO - ALL PLANS 225 90 999999999 151.38 242.5 percent of total billed charges "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506853_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 UMR - ALL PLANS UMR - ALL PLANS 175 70 999999999 151.38 242.5 percent of total billed charges "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506853_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.38 242.5 "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506853_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.38 60.55 999999999 151.38 242.5 percent of total billed charges "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506853_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 ANTHEM HMO ANTHEM HMO 999999999 151.38 242.5 "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506853_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.38 242.5 "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506853_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.38 242.5 "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506853_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.38 242.5 "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506853_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 169 67.6 999999999 151.38 242.5 percent of total billed charges "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506854_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 162.5 65 999999999 151.38 242.5 percent of total billed charges "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506854_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 242.5 97 999999999 151.38 242.5 percent of total billed charges "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506854_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 AETNA AETNA 197.5 79 999999999 151.38 242.5 percent of total billed charges "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506854_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 172.5 69 999999999 151.38 242.5 percent of total billed charges "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506854_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 195 78 999999999 151.38 242.5 percent of total billed charges "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506854_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 SIHO - ALL PLANS SIHO - ALL PLANS 225 90 999999999 151.38 242.5 percent of total billed charges "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506854_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 UMR - ALL PLANS UMR - ALL PLANS 175 70 999999999 151.38 242.5 percent of total billed charges "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506854_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.38 242.5 "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506854_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.38 60.55 999999999 151.38 242.5 percent of total billed charges "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506854_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 ANTHEM HMO ANTHEM HMO 999999999 151.38 242.5 "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506854_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.38 242.5 "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506854_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.38 242.5 "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506854_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.38 242.5 "Measurement of bacterial susceptibility to antibiotics, reported as phenotypic minimum inhibitory concentration (MIC) for each organism identified" 51506854_1 CDM 0306 RC 0311U HCPCS inpatient 250 162.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 169 67.6 999999999 151.38 242.5 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51506889_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 132.6 65 999999999 123.52 197.88 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51506889_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 197.88 97 999999999 123.52 197.88 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51506889_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 AETNA AETNA 161.16 79 999999999 123.52 197.88 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51506889_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 140.76 69 999999999 123.52 197.88 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51506889_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.12 78 999999999 123.52 197.88 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51506889_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 SIHO - ALL PLANS SIHO - ALL PLANS 183.6 90 999999999 123.52 197.88 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51506889_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 UMR - ALL PLANS UMR - ALL PLANS 142.8 70 999999999 123.52 197.88 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51506889_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 123.52 197.88 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51506889_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 123.52 60.55 999999999 123.52 197.88 percent of total billed charges "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51506889_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 ANTHEM HMO ANTHEM HMO 999999999 123.52 197.88 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51506889_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 123.52 197.88 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51506889_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 123.52 197.88 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51506889_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 123.52 197.88 "Detection test by nucleic acid for clostridium difficile, amplified probe technique" 51506889_1 CDM 0306 RC 87493 HCPCS inpatient 204 132.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 137.9 67.6 999999999 123.52 197.88 percent of total billed charges "Destruction of skin growth, 1-14 growths" 51511833_1 CDM 0510 RC 17110 HCPCS inpatient 663 430.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 430.95 65 999999999 401.45 643.11 percent of total billed charges "Destruction of skin growth, 1-14 growths" 51511833_1 CDM 0510 RC 17110 HCPCS inpatient 663 430.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 643.11 97 999999999 401.45 643.11 percent of total billed charges "Destruction of skin growth, 1-14 growths" 51511833_1 CDM 0510 RC 17110 HCPCS inpatient 663 430.95 AETNA AETNA 523.77 79 999999999 401.45 643.11 percent of total billed charges "Destruction of skin growth, 1-14 growths" 51511833_1 CDM 0510 RC 17110 HCPCS inpatient 663 430.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 457.47 69 999999999 401.45 643.11 percent of total billed charges "Destruction of skin growth, 1-14 growths" 51511833_1 CDM 0510 RC 17110 HCPCS inpatient 663 430.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 517.14 78 999999999 401.45 643.11 percent of total billed charges "Destruction of skin growth, 1-14 growths" 51511833_1 CDM 0510 RC 17110 HCPCS inpatient 663 430.95 SIHO - ALL PLANS SIHO - ALL PLANS 596.7 90 999999999 401.45 643.11 percent of total billed charges "Destruction of skin growth, 1-14 growths" 51511833_1 CDM 0510 RC 17110 HCPCS inpatient 663 430.95 UMR - ALL PLANS UMR - ALL PLANS 464.1 70 999999999 401.45 643.11 percent of total billed charges "Destruction of skin growth, 1-14 growths" 51511833_1 CDM 0510 RC 17110 HCPCS inpatient 663 430.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 401.45 643.11 "Destruction of skin growth, 1-14 growths" 51511833_1 CDM 0510 RC 17110 HCPCS inpatient 663 430.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 401.45 60.55 999999999 401.45 643.11 percent of total billed charges "Destruction of skin growth, 1-14 growths" 51511833_1 CDM 0510 RC 17110 HCPCS inpatient 663 430.95 ANTHEM HMO ANTHEM HMO 999999999 401.45 643.11 "Destruction of skin growth, 1-14 growths" 51511833_1 CDM 0510 RC 17110 HCPCS inpatient 663 430.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 401.45 643.11 "Destruction of skin growth, 1-14 growths" 51511833_1 CDM 0510 RC 17110 HCPCS inpatient 663 430.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 401.45 643.11 "Destruction of skin growth, 1-14 growths" 51511833_1 CDM 0510 RC 17110 HCPCS inpatient 663 430.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 401.45 643.11 "Destruction of skin growth, 1-14 growths" 51511833_1 CDM 0510 RC 17110 HCPCS inpatient 663 430.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 448.19 67.6 999999999 401.45 643.11 percent of total billed charges "Destruction of skin growth, 15 or more growths" 51512137_1 CDM 0510 RC 17111 HCPCS inpatient 663 430.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 430.95 65 999999999 401.45 643.11 percent of total billed charges "Destruction of skin growth, 15 or more growths" 51512137_1 CDM 0510 RC 17111 HCPCS inpatient 663 430.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 643.11 97 999999999 401.45 643.11 percent of total billed charges "Destruction of skin growth, 15 or more growths" 51512137_1 CDM 0510 RC 17111 HCPCS inpatient 663 430.95 AETNA AETNA 523.77 79 999999999 401.45 643.11 percent of total billed charges "Destruction of skin growth, 15 or more growths" 51512137_1 CDM 0510 RC 17111 HCPCS inpatient 663 430.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 457.47 69 999999999 401.45 643.11 percent of total billed charges "Destruction of skin growth, 15 or more growths" 51512137_1 CDM 0510 RC 17111 HCPCS inpatient 663 430.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 517.14 78 999999999 401.45 643.11 percent of total billed charges "Destruction of skin growth, 15 or more growths" 51512137_1 CDM 0510 RC 17111 HCPCS inpatient 663 430.95 SIHO - ALL PLANS SIHO - ALL PLANS 596.7 90 999999999 401.45 643.11 percent of total billed charges "Destruction of skin growth, 15 or more growths" 51512137_1 CDM 0510 RC 17111 HCPCS inpatient 663 430.95 UMR - ALL PLANS UMR - ALL PLANS 464.1 70 999999999 401.45 643.11 percent of total billed charges "Destruction of skin growth, 15 or more growths" 51512137_1 CDM 0510 RC 17111 HCPCS inpatient 663 430.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 401.45 643.11 "Destruction of skin growth, 15 or more growths" 51512137_1 CDM 0510 RC 17111 HCPCS inpatient 663 430.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 401.45 60.55 999999999 401.45 643.11 percent of total billed charges "Destruction of skin growth, 15 or more growths" 51512137_1 CDM 0510 RC 17111 HCPCS inpatient 663 430.95 ANTHEM HMO ANTHEM HMO 999999999 401.45 643.11 "Destruction of skin growth, 15 or more growths" 51512137_1 CDM 0510 RC 17111 HCPCS inpatient 663 430.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 401.45 643.11 "Destruction of skin growth, 15 or more growths" 51512137_1 CDM 0510 RC 17111 HCPCS inpatient 663 430.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 401.45 643.11 "Destruction of skin growth, 15 or more growths" 51512137_1 CDM 0510 RC 17111 HCPCS inpatient 663 430.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 401.45 643.11 "Destruction of skin growth, 15 or more growths" 51512137_1 CDM 0510 RC 17111 HCPCS inpatient 663 430.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 448.19 67.6 999999999 401.45 643.11 percent of total billed charges Placement of electrical stimulation device for bone healing 51512138_1 CDM 0510 RC 20974 HCPCS inpatient 663 430.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 430.95 65 999999999 401.45 643.11 percent of total billed charges Placement of electrical stimulation device for bone healing 51512138_1 CDM 0510 RC 20974 HCPCS inpatient 663 430.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 643.11 97 999999999 401.45 643.11 percent of total billed charges Placement of electrical stimulation device for bone healing 51512138_1 CDM 0510 RC 20974 HCPCS inpatient 663 430.95 AETNA AETNA 523.77 79 999999999 401.45 643.11 percent of total billed charges Placement of electrical stimulation device for bone healing 51512138_1 CDM 0510 RC 20974 HCPCS inpatient 663 430.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 457.47 69 999999999 401.45 643.11 percent of total billed charges Placement of electrical stimulation device for bone healing 51512138_1 CDM 0510 RC 20974 HCPCS inpatient 663 430.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 517.14 78 999999999 401.45 643.11 percent of total billed charges Placement of electrical stimulation device for bone healing 51512138_1 CDM 0510 RC 20974 HCPCS inpatient 663 430.95 SIHO - ALL PLANS SIHO - ALL PLANS 596.7 90 999999999 401.45 643.11 percent of total billed charges Placement of electrical stimulation device for bone healing 51512138_1 CDM 0510 RC 20974 HCPCS inpatient 663 430.95 UMR - ALL PLANS UMR - ALL PLANS 464.1 70 999999999 401.45 643.11 percent of total billed charges Placement of electrical stimulation device for bone healing 51512138_1 CDM 0510 RC 20974 HCPCS inpatient 663 430.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 401.45 643.11 Placement of electrical stimulation device for bone healing 51512138_1 CDM 0510 RC 20974 HCPCS inpatient 663 430.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 401.45 60.55 999999999 401.45 643.11 percent of total billed charges Placement of electrical stimulation device for bone healing 51512138_1 CDM 0510 RC 20974 HCPCS inpatient 663 430.95 ANTHEM HMO ANTHEM HMO 999999999 401.45 643.11 Placement of electrical stimulation device for bone healing 51512138_1 CDM 0510 RC 20974 HCPCS inpatient 663 430.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 401.45 643.11 Placement of electrical stimulation device for bone healing 51512138_1 CDM 0510 RC 20974 HCPCS inpatient 663 430.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 401.45 643.11 Placement of electrical stimulation device for bone healing 51512138_1 CDM 0510 RC 20974 HCPCS inpatient 663 430.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 401.45 643.11 Placement of electrical stimulation device for bone healing 51512138_1 CDM 0510 RC 20974 HCPCS inpatient 663 430.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 448.19 67.6 999999999 401.45 643.11 percent of total billed charges Tissue culture to identify white blood cell disorders 51516030_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 150.8 65 999999999 140.48 225.04 percent of total billed charges Tissue culture to identify white blood cell disorders 51516030_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 225.04 97 999999999 140.48 225.04 percent of total billed charges Tissue culture to identify white blood cell disorders 51516030_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 AETNA AETNA 183.28 79 999999999 140.48 225.04 percent of total billed charges Tissue culture to identify white blood cell disorders 51516030_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 160.08 69 999999999 140.48 225.04 percent of total billed charges Tissue culture to identify white blood cell disorders 51516030_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 180.96 78 999999999 140.48 225.04 percent of total billed charges Tissue culture to identify white blood cell disorders 51516030_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 SIHO - ALL PLANS SIHO - ALL PLANS 208.8 90 999999999 140.48 225.04 percent of total billed charges Tissue culture to identify white blood cell disorders 51516030_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 UMR - ALL PLANS UMR - ALL PLANS 162.4 70 999999999 140.48 225.04 percent of total billed charges Tissue culture to identify white blood cell disorders 51516030_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 140.48 225.04 Tissue culture to identify white blood cell disorders 51516030_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 140.48 60.55 999999999 140.48 225.04 percent of total billed charges Tissue culture to identify white blood cell disorders 51516030_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 ANTHEM HMO ANTHEM HMO 999999999 140.48 225.04 Tissue culture to identify white blood cell disorders 51516030_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 140.48 225.04 Tissue culture to identify white blood cell disorders 51516030_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 140.48 225.04 Tissue culture to identify white blood cell disorders 51516030_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 140.48 225.04 Tissue culture to identify white blood cell disorders 51516030_1 CDM 0301 RC 88230 HCPCS inpatient 232 150.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 156.83 67.6 999999999 140.48 225.04 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51516076_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 399.75 65 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51516076_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 596.55 97 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51516076_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 AETNA AETNA 485.85 79 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51516076_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 424.35 69 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51516076_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 479.7 78 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51516076_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 SIHO - ALL PLANS SIHO - ALL PLANS 553.5 90 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51516076_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 UMR - ALL PLANS UMR - ALL PLANS 430.5 70 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51516076_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 51516076_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 372.38 60.55 999999999 372.38 596.55 percent of total billed charges "Chromosome analysis for genetic defects, count 15-20 cells" 51516076_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ANTHEM HMO ANTHEM HMO 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 51516076_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 51516076_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 51516076_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 372.38 596.55 "Chromosome analysis for genetic defects, count 15-20 cells" 51516076_1 CDM 0311 RC 88262 HCPCS inpatient 615 399.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 415.74 67.6 999999999 372.38 596.55 percent of total billed charges Ultrasound scan of abdominal aorta 5289002_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 617.5 65 999999999 575.23 921.5 percent of total billed charges Ultrasound scan of abdominal aorta 5289002_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 921.5 97 999999999 575.23 921.5 percent of total billed charges Ultrasound scan of abdominal aorta 5289002_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 AETNA AETNA 750.5 79 999999999 575.23 921.5 percent of total billed charges Ultrasound scan of abdominal aorta 5289002_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 655.5 69 999999999 575.23 921.5 percent of total billed charges Ultrasound scan of abdominal aorta 5289002_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 741 78 999999999 575.23 921.5 percent of total billed charges Ultrasound scan of abdominal aorta 5289002_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 SIHO - ALL PLANS SIHO - ALL PLANS 855 90 999999999 575.23 921.5 percent of total billed charges Ultrasound scan of abdominal aorta 5289002_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 UMR - ALL PLANS UMR - ALL PLANS 665 70 999999999 575.23 921.5 percent of total billed charges Ultrasound scan of abdominal aorta 5289002_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 575.23 921.5 Ultrasound scan of abdominal aorta 5289002_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 575.23 60.55 999999999 575.23 921.5 percent of total billed charges Ultrasound scan of abdominal aorta 5289002_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 ANTHEM HMO ANTHEM HMO 999999999 575.23 921.5 Ultrasound scan of abdominal aorta 5289002_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 575.23 921.5 Ultrasound scan of abdominal aorta 5289002_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 575.23 921.5 Ultrasound scan of abdominal aorta 5289002_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 575.23 921.5 Ultrasound scan of abdominal aorta 5289002_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 642.2 67.6 999999999 575.23 921.5 percent of total billed charges "Digoxin level, total" 5492895_1 CDM 0301 RC 80162 HCPCS inpatient 222 144.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 144.3 65 999999999 134.42 215.34 percent of total billed charges "Digoxin level, total" 5492895_1 CDM 0301 RC 80162 HCPCS inpatient 222 144.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 215.34 97 999999999 134.42 215.34 percent of total billed charges "Digoxin level, total" 5492895_1 CDM 0301 RC 80162 HCPCS inpatient 222 144.3 AETNA AETNA 175.38 79 999999999 134.42 215.34 percent of total billed charges "Digoxin level, total" 5492895_1 CDM 0301 RC 80162 HCPCS inpatient 222 144.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 153.18 69 999999999 134.42 215.34 percent of total billed charges "Digoxin level, total" 5492895_1 CDM 0301 RC 80162 HCPCS inpatient 222 144.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 173.16 78 999999999 134.42 215.34 percent of total billed charges "Digoxin level, total" 5492895_1 CDM 0301 RC 80162 HCPCS inpatient 222 144.3 SIHO - ALL PLANS SIHO - ALL PLANS 199.8 90 999999999 134.42 215.34 percent of total billed charges "Digoxin level, total" 5492895_1 CDM 0301 RC 80162 HCPCS inpatient 222 144.3 UMR - ALL PLANS UMR - ALL PLANS 155.4 70 999999999 134.42 215.34 percent of total billed charges "Digoxin level, total" 5492895_1 CDM 0301 RC 80162 HCPCS inpatient 222 144.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 134.42 215.34 "Digoxin level, total" 5492895_1 CDM 0301 RC 80162 HCPCS inpatient 222 144.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 134.42 60.55 999999999 134.42 215.34 percent of total billed charges "Digoxin level, total" 5492895_1 CDM 0301 RC 80162 HCPCS inpatient 222 144.3 ANTHEM HMO ANTHEM HMO 999999999 134.42 215.34 "Digoxin level, total" 5492895_1 CDM 0301 RC 80162 HCPCS inpatient 222 144.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 134.42 215.34 "Digoxin level, total" 5492895_1 CDM 0301 RC 80162 HCPCS inpatient 222 144.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 134.42 215.34 "Digoxin level, total" 5492895_1 CDM 0301 RC 80162 HCPCS inpatient 222 144.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 134.42 215.34 "Digoxin level, total" 5492895_1 CDM 0301 RC 80162 HCPCS inpatient 222 144.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 150.07 67.6 999999999 134.42 215.34 percent of total billed charges "Valproic acid level, total" 5492898_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 88.4 65 999999999 82.35 131.92 percent of total billed charges "Valproic acid level, total" 5492898_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 131.92 97 999999999 82.35 131.92 percent of total billed charges "Valproic acid level, total" 5492898_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 AETNA AETNA 107.44 79 999999999 82.35 131.92 percent of total billed charges "Valproic acid level, total" 5492898_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 93.84 69 999999999 82.35 131.92 percent of total billed charges "Valproic acid level, total" 5492898_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.08 78 999999999 82.35 131.92 percent of total billed charges "Valproic acid level, total" 5492898_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 SIHO - ALL PLANS SIHO - ALL PLANS 122.4 90 999999999 82.35 131.92 percent of total billed charges "Valproic acid level, total" 5492898_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 UMR - ALL PLANS UMR - ALL PLANS 95.2 70 999999999 82.35 131.92 percent of total billed charges "Valproic acid level, total" 5492898_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.35 131.92 "Valproic acid level, total" 5492898_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.35 60.55 999999999 82.35 131.92 percent of total billed charges "Valproic acid level, total" 5492898_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 ANTHEM HMO ANTHEM HMO 999999999 82.35 131.92 "Valproic acid level, total" 5492898_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.35 131.92 "Valproic acid level, total" 5492898_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.35 131.92 "Valproic acid level, total" 5492898_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.35 131.92 "Valproic acid level, total" 5492898_1 CDM 0301 RC 80164 HCPCS inpatient 136 88.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 91.94 67.6 999999999 82.35 131.92 percent of total billed charges Lithium level 5492899_1 CDM 0301 RC 80178 HCPCS inpatient 151 98.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 98.15 65 999999999 91.43 146.47 percent of total billed charges Lithium level 5492899_1 CDM 0301 RC 80178 HCPCS inpatient 151 98.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 146.47 97 999999999 91.43 146.47 percent of total billed charges Lithium level 5492899_1 CDM 0301 RC 80178 HCPCS inpatient 151 98.15 AETNA AETNA 119.29 79 999999999 91.43 146.47 percent of total billed charges Lithium level 5492899_1 CDM 0301 RC 80178 HCPCS inpatient 151 98.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 104.19 69 999999999 91.43 146.47 percent of total billed charges Lithium level 5492899_1 CDM 0301 RC 80178 HCPCS inpatient 151 98.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 117.78 78 999999999 91.43 146.47 percent of total billed charges Lithium level 5492899_1 CDM 0301 RC 80178 HCPCS inpatient 151 98.15 SIHO - ALL PLANS SIHO - ALL PLANS 135.9 90 999999999 91.43 146.47 percent of total billed charges Lithium level 5492899_1 CDM 0301 RC 80178 HCPCS inpatient 151 98.15 UMR - ALL PLANS UMR - ALL PLANS 105.7 70 999999999 91.43 146.47 percent of total billed charges Lithium level 5492899_1 CDM 0301 RC 80178 HCPCS inpatient 151 98.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 91.43 146.47 Lithium level 5492899_1 CDM 0301 RC 80178 HCPCS inpatient 151 98.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 91.43 60.55 999999999 91.43 146.47 percent of total billed charges Lithium level 5492899_1 CDM 0301 RC 80178 HCPCS inpatient 151 98.15 ANTHEM HMO ANTHEM HMO 999999999 91.43 146.47 Lithium level 5492899_1 CDM 0301 RC 80178 HCPCS inpatient 151 98.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 91.43 146.47 Lithium level 5492899_1 CDM 0301 RC 80178 HCPCS inpatient 151 98.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 91.43 146.47 Lithium level 5492899_1 CDM 0301 RC 80178 HCPCS inpatient 151 98.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 91.43 146.47 Lithium level 5492899_1 CDM 0301 RC 80178 HCPCS inpatient 151 98.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 102.08 67.6 999999999 91.43 146.47 percent of total billed charges Fetal test 5596908_1 CDM 0761 RC 59025 HCPCS inpatient 333 216.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 216.45 65 999999999 201.63 323.01 percent of total billed charges Fetal test 5596908_1 CDM 0761 RC 59025 HCPCS inpatient 333 216.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 323.01 97 999999999 201.63 323.01 percent of total billed charges Fetal test 5596908_1 CDM 0761 RC 59025 HCPCS inpatient 333 216.45 AETNA AETNA 263.07 79 999999999 201.63 323.01 percent of total billed charges Fetal test 5596908_1 CDM 0761 RC 59025 HCPCS inpatient 333 216.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 229.77 69 999999999 201.63 323.01 percent of total billed charges Fetal test 5596908_1 CDM 0761 RC 59025 HCPCS inpatient 333 216.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 259.74 78 999999999 201.63 323.01 percent of total billed charges Fetal test 5596908_1 CDM 0761 RC 59025 HCPCS inpatient 333 216.45 SIHO - ALL PLANS SIHO - ALL PLANS 299.7 90 999999999 201.63 323.01 percent of total billed charges Fetal test 5596908_1 CDM 0761 RC 59025 HCPCS inpatient 333 216.45 UMR - ALL PLANS UMR - ALL PLANS 233.1 70 999999999 201.63 323.01 percent of total billed charges Fetal test 5596908_1 CDM 0761 RC 59025 HCPCS inpatient 333 216.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 201.63 323.01 Fetal test 5596908_1 CDM 0761 RC 59025 HCPCS inpatient 333 216.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 201.63 60.55 999999999 201.63 323.01 percent of total billed charges Fetal test 5596908_1 CDM 0761 RC 59025 HCPCS inpatient 333 216.45 ANTHEM HMO ANTHEM HMO 999999999 201.63 323.01 Fetal test 5596908_1 CDM 0761 RC 59025 HCPCS inpatient 333 216.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 201.63 323.01 Fetal test 5596908_1 CDM 0761 RC 59025 HCPCS inpatient 333 216.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 201.63 323.01 Fetal test 5596908_1 CDM 0761 RC 59025 HCPCS inpatient 333 216.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 201.63 323.01 Fetal test 5596908_1 CDM 0761 RC 59025 HCPCS inpatient 333 216.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 225.11 67.6 999999999 201.63 323.01 percent of total billed charges LABOR ROOM/DELIVERY - CIRCUMCISION 5596920_1 CDM 0723 RC inpatient 419 272.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 272.35 65 999999999 253.7 406.43 percent of total billed charges LABOR ROOM/DELIVERY - CIRCUMCISION 5596920_1 CDM 0723 RC inpatient 419 272.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 406.43 97 999999999 253.7 406.43 percent of total billed charges LABOR ROOM/DELIVERY - CIRCUMCISION 5596920_1 CDM 0723 RC inpatient 419 272.35 AETNA AETNA 331.01 79 999999999 253.7 406.43 percent of total billed charges LABOR ROOM/DELIVERY - CIRCUMCISION 5596920_1 CDM 0723 RC inpatient 419 272.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 289.11 69 999999999 253.7 406.43 percent of total billed charges LABOR ROOM/DELIVERY - CIRCUMCISION 5596920_1 CDM 0723 RC inpatient 419 272.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 326.82 78 999999999 253.7 406.43 percent of total billed charges LABOR ROOM/DELIVERY - CIRCUMCISION 5596920_1 CDM 0723 RC inpatient 419 272.35 SIHO - ALL PLANS SIHO - ALL PLANS 377.1 90 999999999 253.7 406.43 percent of total billed charges LABOR ROOM/DELIVERY - CIRCUMCISION 5596920_1 CDM 0723 RC inpatient 419 272.35 UMR - ALL PLANS UMR - ALL PLANS 293.3 70 999999999 253.7 406.43 percent of total billed charges LABOR ROOM/DELIVERY - CIRCUMCISION 5596920_1 CDM 0723 RC inpatient 419 272.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 253.7 406.43 LABOR ROOM/DELIVERY - CIRCUMCISION 5596920_1 CDM 0723 RC inpatient 419 272.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 253.7 60.55 999999999 253.7 406.43 percent of total billed charges LABOR ROOM/DELIVERY - CIRCUMCISION 5596920_1 CDM 0723 RC inpatient 419 272.35 ANTHEM HMO ANTHEM HMO 999999999 253.7 406.43 LABOR ROOM/DELIVERY - CIRCUMCISION 5596920_1 CDM 0723 RC inpatient 419 272.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 253.7 406.43 LABOR ROOM/DELIVERY - CIRCUMCISION 5596920_1 CDM 0723 RC inpatient 419 272.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 253.7 406.43 LABOR ROOM/DELIVERY - CIRCUMCISION 5596920_1 CDM 0723 RC inpatient 419 272.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 253.7 406.43 LABOR ROOM/DELIVERY - CIRCUMCISION 5596920_1 CDM 0723 RC inpatient 419 272.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 283.24 67.6 999999999 253.7 406.43 percent of total billed charges "Cell examination of specimen, concentration technique" 592809_1 CDM 0311 RC 88108 HCPCS inpatient 193 125.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 125.45 65 999999999 116.86 187.21 percent of total billed charges "Cell examination of specimen, concentration technique" 592809_1 CDM 0311 RC 88108 HCPCS inpatient 193 125.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 187.21 97 999999999 116.86 187.21 percent of total billed charges "Cell examination of specimen, concentration technique" 592809_1 CDM 0311 RC 88108 HCPCS inpatient 193 125.45 AETNA AETNA 152.47 79 999999999 116.86 187.21 percent of total billed charges "Cell examination of specimen, concentration technique" 592809_1 CDM 0311 RC 88108 HCPCS inpatient 193 125.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.17 69 999999999 116.86 187.21 percent of total billed charges "Cell examination of specimen, concentration technique" 592809_1 CDM 0311 RC 88108 HCPCS inpatient 193 125.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 150.54 78 999999999 116.86 187.21 percent of total billed charges "Cell examination of specimen, concentration technique" 592809_1 CDM 0311 RC 88108 HCPCS inpatient 193 125.45 SIHO - ALL PLANS SIHO - ALL PLANS 173.7 90 999999999 116.86 187.21 percent of total billed charges "Cell examination of specimen, concentration technique" 592809_1 CDM 0311 RC 88108 HCPCS inpatient 193 125.45 UMR - ALL PLANS UMR - ALL PLANS 135.1 70 999999999 116.86 187.21 percent of total billed charges "Cell examination of specimen, concentration technique" 592809_1 CDM 0311 RC 88108 HCPCS inpatient 193 125.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.86 187.21 "Cell examination of specimen, concentration technique" 592809_1 CDM 0311 RC 88108 HCPCS inpatient 193 125.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.86 60.55 999999999 116.86 187.21 percent of total billed charges "Cell examination of specimen, concentration technique" 592809_1 CDM 0311 RC 88108 HCPCS inpatient 193 125.45 ANTHEM HMO ANTHEM HMO 999999999 116.86 187.21 "Cell examination of specimen, concentration technique" 592809_1 CDM 0311 RC 88108 HCPCS inpatient 193 125.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.86 187.21 "Cell examination of specimen, concentration technique" 592809_1 CDM 0311 RC 88108 HCPCS inpatient 193 125.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.86 187.21 "Cell examination of specimen, concentration technique" 592809_1 CDM 0311 RC 88108 HCPCS inpatient 193 125.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.86 187.21 "Cell examination of specimen, concentration technique" 592809_1 CDM 0311 RC 88108 HCPCS inpatient 193 125.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 130.47 67.6 999999999 116.86 187.21 percent of total billed charges "Pathology examination of specimen during surgery, each additional tissue block" 592815_1 CDM 0311 RC 88332 HCPCS inpatient 161 104.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 104.65 65 999999999 97.49 156.17 percent of total billed charges "Pathology examination of specimen during surgery, each additional tissue block" 592815_1 CDM 0311 RC 88332 HCPCS inpatient 161 104.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 156.17 97 999999999 97.49 156.17 percent of total billed charges "Pathology examination of specimen during surgery, each additional tissue block" 592815_1 CDM 0311 RC 88332 HCPCS inpatient 161 104.65 AETNA AETNA 127.19 79 999999999 97.49 156.17 percent of total billed charges "Pathology examination of specimen during surgery, each additional tissue block" 592815_1 CDM 0311 RC 88332 HCPCS inpatient 161 104.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 111.09 69 999999999 97.49 156.17 percent of total billed charges "Pathology examination of specimen during surgery, each additional tissue block" 592815_1 CDM 0311 RC 88332 HCPCS inpatient 161 104.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 125.58 78 999999999 97.49 156.17 percent of total billed charges "Pathology examination of specimen during surgery, each additional tissue block" 592815_1 CDM 0311 RC 88332 HCPCS inpatient 161 104.65 SIHO - ALL PLANS SIHO - ALL PLANS 144.9 90 999999999 97.49 156.17 percent of total billed charges "Pathology examination of specimen during surgery, each additional tissue block" 592815_1 CDM 0311 RC 88332 HCPCS inpatient 161 104.65 UMR - ALL PLANS UMR - ALL PLANS 112.7 70 999999999 97.49 156.17 percent of total billed charges "Pathology examination of specimen during surgery, each additional tissue block" 592815_1 CDM 0311 RC 88332 HCPCS inpatient 161 104.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 97.49 156.17 "Pathology examination of specimen during surgery, each additional tissue block" 592815_1 CDM 0311 RC 88332 HCPCS inpatient 161 104.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 97.49 60.55 999999999 97.49 156.17 percent of total billed charges "Pathology examination of specimen during surgery, each additional tissue block" 592815_1 CDM 0311 RC 88332 HCPCS inpatient 161 104.65 ANTHEM HMO ANTHEM HMO 999999999 97.49 156.17 "Pathology examination of specimen during surgery, each additional tissue block" 592815_1 CDM 0311 RC 88332 HCPCS inpatient 161 104.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 97.49 156.17 "Pathology examination of specimen during surgery, each additional tissue block" 592815_1 CDM 0311 RC 88332 HCPCS inpatient 161 104.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 97.49 156.17 "Pathology examination of specimen during surgery, each additional tissue block" 592815_1 CDM 0311 RC 88332 HCPCS inpatient 161 104.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 97.49 156.17 "Pathology examination of specimen during surgery, each additional tissue block" 592815_1 CDM 0311 RC 88332 HCPCS inpatient 161 104.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.84 67.6 999999999 97.49 156.17 percent of total billed charges "Pathology examination of specimen during surgery, first tissue block" 592817_1 CDM 0312 RC 88331 HCPCS inpatient 301 195.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 195.65 65 999999999 182.26 291.97 percent of total billed charges "Pathology examination of specimen during surgery, first tissue block" 592817_1 CDM 0312 RC 88331 HCPCS inpatient 301 195.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291.97 97 999999999 182.26 291.97 percent of total billed charges "Pathology examination of specimen during surgery, first tissue block" 592817_1 CDM 0312 RC 88331 HCPCS inpatient 301 195.65 AETNA AETNA 237.79 79 999999999 182.26 291.97 percent of total billed charges "Pathology examination of specimen during surgery, first tissue block" 592817_1 CDM 0312 RC 88331 HCPCS inpatient 301 195.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 207.69 69 999999999 182.26 291.97 percent of total billed charges "Pathology examination of specimen during surgery, first tissue block" 592817_1 CDM 0312 RC 88331 HCPCS inpatient 301 195.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 234.78 78 999999999 182.26 291.97 percent of total billed charges "Pathology examination of specimen during surgery, first tissue block" 592817_1 CDM 0312 RC 88331 HCPCS inpatient 301 195.65 SIHO - ALL PLANS SIHO - ALL PLANS 270.9 90 999999999 182.26 291.97 percent of total billed charges "Pathology examination of specimen during surgery, first tissue block" 592817_1 CDM 0312 RC 88331 HCPCS inpatient 301 195.65 UMR - ALL PLANS UMR - ALL PLANS 210.7 70 999999999 182.26 291.97 percent of total billed charges "Pathology examination of specimen during surgery, first tissue block" 592817_1 CDM 0312 RC 88331 HCPCS inpatient 301 195.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.26 291.97 "Pathology examination of specimen during surgery, first tissue block" 592817_1 CDM 0312 RC 88331 HCPCS inpatient 301 195.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.26 60.55 999999999 182.26 291.97 percent of total billed charges "Pathology examination of specimen during surgery, first tissue block" 592817_1 CDM 0312 RC 88331 HCPCS inpatient 301 195.65 ANTHEM HMO ANTHEM HMO 999999999 182.26 291.97 "Pathology examination of specimen during surgery, first tissue block" 592817_1 CDM 0312 RC 88331 HCPCS inpatient 301 195.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.26 291.97 "Pathology examination of specimen during surgery, first tissue block" 592817_1 CDM 0312 RC 88331 HCPCS inpatient 301 195.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.26 291.97 "Pathology examination of specimen during surgery, first tissue block" 592817_1 CDM 0312 RC 88331 HCPCS inpatient 301 195.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.26 291.97 "Pathology examination of specimen during surgery, first tissue block" 592817_1 CDM 0312 RC 88331 HCPCS inpatient 301 195.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 203.48 67.6 999999999 182.26 291.97 percent of total billed charges "Surgical pathology consultation and report, comprehensive" 592819_1 CDM 0312 RC 88325 HCPCS inpatient 322 209.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 209.3 65 999999999 194.97 312.34 percent of total billed charges "Surgical pathology consultation and report, comprehensive" 592819_1 CDM 0312 RC 88325 HCPCS inpatient 322 209.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 312.34 97 999999999 194.97 312.34 percent of total billed charges "Surgical pathology consultation and report, comprehensive" 592819_1 CDM 0312 RC 88325 HCPCS inpatient 322 209.3 AETNA AETNA 254.38 79 999999999 194.97 312.34 percent of total billed charges "Surgical pathology consultation and report, comprehensive" 592819_1 CDM 0312 RC 88325 HCPCS inpatient 322 209.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 222.18 69 999999999 194.97 312.34 percent of total billed charges "Surgical pathology consultation and report, comprehensive" 592819_1 CDM 0312 RC 88325 HCPCS inpatient 322 209.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 251.16 78 999999999 194.97 312.34 percent of total billed charges "Surgical pathology consultation and report, comprehensive" 592819_1 CDM 0312 RC 88325 HCPCS inpatient 322 209.3 SIHO - ALL PLANS SIHO - ALL PLANS 289.8 90 999999999 194.97 312.34 percent of total billed charges "Surgical pathology consultation and report, comprehensive" 592819_1 CDM 0312 RC 88325 HCPCS inpatient 322 209.3 UMR - ALL PLANS UMR - ALL PLANS 225.4 70 999999999 194.97 312.34 percent of total billed charges "Surgical pathology consultation and report, comprehensive" 592819_1 CDM 0312 RC 88325 HCPCS inpatient 322 209.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 194.97 312.34 "Surgical pathology consultation and report, comprehensive" 592819_1 CDM 0312 RC 88325 HCPCS inpatient 322 209.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 194.97 60.55 999999999 194.97 312.34 percent of total billed charges "Surgical pathology consultation and report, comprehensive" 592819_1 CDM 0312 RC 88325 HCPCS inpatient 322 209.3 ANTHEM HMO ANTHEM HMO 999999999 194.97 312.34 "Surgical pathology consultation and report, comprehensive" 592819_1 CDM 0312 RC 88325 HCPCS inpatient 322 209.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 194.97 312.34 "Surgical pathology consultation and report, comprehensive" 592819_1 CDM 0312 RC 88325 HCPCS inpatient 322 209.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 194.97 312.34 "Surgical pathology consultation and report, comprehensive" 592819_1 CDM 0312 RC 88325 HCPCS inpatient 322 209.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 194.97 312.34 "Surgical pathology consultation and report, comprehensive" 592819_1 CDM 0312 RC 88325 HCPCS inpatient 322 209.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 217.67 67.6 999999999 194.97 312.34 percent of total billed charges filgrastim 602489_1 CDM 0636 RC inpatient 1071.16 696.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 696.25 65 999999999 648.59 1039.03 percent of total billed charges filgrastim 602489_1 CDM 0636 RC inpatient 1071.16 696.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1039.03 97 999999999 648.59 1039.03 percent of total billed charges filgrastim 602489_1 CDM 0636 RC inpatient 1071.16 696.25 AETNA AETNA 846.22 79 999999999 648.59 1039.03 percent of total billed charges filgrastim 602489_1 CDM 0636 RC inpatient 1071.16 696.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 739.1 69 999999999 648.59 1039.03 percent of total billed charges filgrastim 602489_1 CDM 0636 RC inpatient 1071.16 696.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 835.5 78 999999999 648.59 1039.03 percent of total billed charges filgrastim 602489_1 CDM 0636 RC inpatient 1071.16 696.25 SIHO - ALL PLANS SIHO - ALL PLANS 964.04 90 999999999 648.59 1039.03 percent of total billed charges filgrastim 602489_1 CDM 0636 RC inpatient 1071.16 696.25 UMR - ALL PLANS UMR - ALL PLANS 749.81 70 999999999 648.59 1039.03 percent of total billed charges filgrastim 602489_1 CDM 0636 RC inpatient 1071.16 696.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 648.59 1039.03 filgrastim 602489_1 CDM 0636 RC inpatient 1071.16 696.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 648.59 60.55 999999999 648.59 1039.03 percent of total billed charges filgrastim 602489_1 CDM 0636 RC inpatient 1071.16 696.25 ANTHEM HMO ANTHEM HMO 999999999 648.59 1039.03 filgrastim 602489_1 CDM 0636 RC inpatient 1071.16 696.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 648.59 1039.03 filgrastim 602489_1 CDM 0636 RC inpatient 1071.16 696.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 648.59 1039.03 filgrastim 602489_1 CDM 0636 RC inpatient 1071.16 696.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 648.59 1039.03 filgrastim 602489_1 CDM 0636 RC inpatient 1071.16 696.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 724.1 67.6 999999999 648.59 1039.03 percent of total billed charges Urine pregnancy test 607622_1 CDM 0300 RC 81025 HCPCS inpatient 26 16.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 16.9 65 999999999 15.74 25.22 percent of total billed charges Urine pregnancy test 607622_1 CDM 0300 RC 81025 HCPCS inpatient 26 16.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25.22 97 999999999 15.74 25.22 percent of total billed charges Urine pregnancy test 607622_1 CDM 0300 RC 81025 HCPCS inpatient 26 16.9 AETNA AETNA 20.54 79 999999999 15.74 25.22 percent of total billed charges Urine pregnancy test 607622_1 CDM 0300 RC 81025 HCPCS inpatient 26 16.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 17.94 69 999999999 15.74 25.22 percent of total billed charges Urine pregnancy test 607622_1 CDM 0300 RC 81025 HCPCS inpatient 26 16.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 20.28 78 999999999 15.74 25.22 percent of total billed charges Urine pregnancy test 607622_1 CDM 0300 RC 81025 HCPCS inpatient 26 16.9 SIHO - ALL PLANS SIHO - ALL PLANS 23.4 90 999999999 15.74 25.22 percent of total billed charges Urine pregnancy test 607622_1 CDM 0300 RC 81025 HCPCS inpatient 26 16.9 UMR - ALL PLANS UMR - ALL PLANS 18.2 70 999999999 15.74 25.22 percent of total billed charges Urine pregnancy test 607622_1 CDM 0300 RC 81025 HCPCS inpatient 26 16.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 15.74 25.22 Urine pregnancy test 607622_1 CDM 0300 RC 81025 HCPCS inpatient 26 16.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15.74 60.55 999999999 15.74 25.22 percent of total billed charges Urine pregnancy test 607622_1 CDM 0300 RC 81025 HCPCS inpatient 26 16.9 ANTHEM HMO ANTHEM HMO 999999999 15.74 25.22 Urine pregnancy test 607622_1 CDM 0300 RC 81025 HCPCS inpatient 26 16.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 15.74 25.22 Urine pregnancy test 607622_1 CDM 0300 RC 81025 HCPCS inpatient 26 16.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 15.74 25.22 Urine pregnancy test 607622_1 CDM 0300 RC 81025 HCPCS inpatient 26 16.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 15.74 25.22 Urine pregnancy test 607622_1 CDM 0300 RC 81025 HCPCS inpatient 26 16.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 17.58 67.6 999999999 15.74 25.22 percent of total billed charges Simple insertion of temporary bladder tube 609643_1 CDM 0761 RC 51702 HCPCS inpatient 209 135.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 135.85 65 999999999 126.55 202.73 percent of total billed charges Simple insertion of temporary bladder tube 609643_1 CDM 0761 RC 51702 HCPCS inpatient 209 135.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 202.73 97 999999999 126.55 202.73 percent of total billed charges Simple insertion of temporary bladder tube 609643_1 CDM 0761 RC 51702 HCPCS inpatient 209 135.85 AETNA AETNA 165.11 79 999999999 126.55 202.73 percent of total billed charges Simple insertion of temporary bladder tube 609643_1 CDM 0761 RC 51702 HCPCS inpatient 209 135.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 144.21 69 999999999 126.55 202.73 percent of total billed charges Simple insertion of temporary bladder tube 609643_1 CDM 0761 RC 51702 HCPCS inpatient 209 135.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 163.02 78 999999999 126.55 202.73 percent of total billed charges Simple insertion of temporary bladder tube 609643_1 CDM 0761 RC 51702 HCPCS inpatient 209 135.85 SIHO - ALL PLANS SIHO - ALL PLANS 188.1 90 999999999 126.55 202.73 percent of total billed charges Simple insertion of temporary bladder tube 609643_1 CDM 0761 RC 51702 HCPCS inpatient 209 135.85 UMR - ALL PLANS UMR - ALL PLANS 146.3 70 999999999 126.55 202.73 percent of total billed charges Simple insertion of temporary bladder tube 609643_1 CDM 0761 RC 51702 HCPCS inpatient 209 135.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 126.55 202.73 Simple insertion of temporary bladder tube 609643_1 CDM 0761 RC 51702 HCPCS inpatient 209 135.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 126.55 60.55 999999999 126.55 202.73 percent of total billed charges Simple insertion of temporary bladder tube 609643_1 CDM 0761 RC 51702 HCPCS inpatient 209 135.85 ANTHEM HMO ANTHEM HMO 999999999 126.55 202.73 Simple insertion of temporary bladder tube 609643_1 CDM 0761 RC 51702 HCPCS inpatient 209 135.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 126.55 202.73 Simple insertion of temporary bladder tube 609643_1 CDM 0761 RC 51702 HCPCS inpatient 209 135.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 126.55 202.73 Simple insertion of temporary bladder tube 609643_1 CDM 0761 RC 51702 HCPCS inpatient 209 135.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 126.55 202.73 Simple insertion of temporary bladder tube 609643_1 CDM 0761 RC 51702 HCPCS inpatient 209 135.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 141.28 67.6 999999999 126.55 202.73 percent of total billed charges CT scan of chest without contrast 629704_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1631.5 65 999999999 1519.81 2434.7 percent of total billed charges CT scan of chest without contrast 629704_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2434.7 97 999999999 1519.81 2434.7 percent of total billed charges CT scan of chest without contrast 629704_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 AETNA AETNA 1982.9 79 999999999 1519.81 2434.7 percent of total billed charges CT scan of chest without contrast 629704_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1731.9 69 999999999 1519.81 2434.7 percent of total billed charges CT scan of chest without contrast 629704_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1957.8 78 999999999 1519.81 2434.7 percent of total billed charges CT scan of chest without contrast 629704_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 SIHO - ALL PLANS SIHO - ALL PLANS 2259 90 999999999 1519.81 2434.7 percent of total billed charges CT scan of chest without contrast 629704_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 UMR - ALL PLANS UMR - ALL PLANS 1757 70 999999999 1519.81 2434.7 percent of total billed charges CT scan of chest without contrast 629704_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1519.81 2434.7 CT scan of chest without contrast 629704_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1519.81 60.55 999999999 1519.81 2434.7 percent of total billed charges CT scan of chest without contrast 629704_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 ANTHEM HMO ANTHEM HMO 999999999 1519.81 2434.7 CT scan of chest without contrast 629704_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1519.81 2434.7 CT scan of chest without contrast 629704_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1519.81 2434.7 CT scan of chest without contrast 629704_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1519.81 2434.7 CT scan of chest without contrast 629704_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1696.76 67.6 999999999 1519.81 2434.7 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 630655_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 350.35 65 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 630655_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 522.83 97 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 630655_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 AETNA AETNA 425.81 79 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 630655_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 371.91 69 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 630655_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 420.42 78 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 630655_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 SIHO - ALL PLANS SIHO - ALL PLANS 485.1 90 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 630655_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 UMR - ALL PLANS UMR - ALL PLANS 377.3 70 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 630655_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 326.36 522.83 "X-ray of thigh bone, minimum 2 views" 630655_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 326.36 60.55 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 630655_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 ANTHEM HMO ANTHEM HMO 999999999 326.36 522.83 "X-ray of thigh bone, minimum 2 views" 630655_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 326.36 522.83 "X-ray of thigh bone, minimum 2 views" 630655_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 326.36 522.83 "X-ray of thigh bone, minimum 2 views" 630655_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 326.36 522.83 "X-ray of thigh bone, minimum 2 views" 630655_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 364.36 67.6 999999999 326.36 522.83 percent of total billed charges Amylase (enzyme) level 631567_1 CDM 0301 RC 82150 HCPCS inpatient 87 56.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 56.55 65 999999999 52.68 84.39 percent of total billed charges Amylase (enzyme) level 631567_1 CDM 0301 RC 82150 HCPCS inpatient 87 56.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84.39 97 999999999 52.68 84.39 percent of total billed charges Amylase (enzyme) level 631567_1 CDM 0301 RC 82150 HCPCS inpatient 87 56.55 AETNA AETNA 68.73 79 999999999 52.68 84.39 percent of total billed charges Amylase (enzyme) level 631567_1 CDM 0301 RC 82150 HCPCS inpatient 87 56.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.03 69 999999999 52.68 84.39 percent of total billed charges Amylase (enzyme) level 631567_1 CDM 0301 RC 82150 HCPCS inpatient 87 56.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.86 78 999999999 52.68 84.39 percent of total billed charges Amylase (enzyme) level 631567_1 CDM 0301 RC 82150 HCPCS inpatient 87 56.55 SIHO - ALL PLANS SIHO - ALL PLANS 78.3 90 999999999 52.68 84.39 percent of total billed charges Amylase (enzyme) level 631567_1 CDM 0301 RC 82150 HCPCS inpatient 87 56.55 UMR - ALL PLANS UMR - ALL PLANS 60.9 70 999999999 52.68 84.39 percent of total billed charges Amylase (enzyme) level 631567_1 CDM 0301 RC 82150 HCPCS inpatient 87 56.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.68 84.39 Amylase (enzyme) level 631567_1 CDM 0301 RC 82150 HCPCS inpatient 87 56.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.68 60.55 999999999 52.68 84.39 percent of total billed charges Amylase (enzyme) level 631567_1 CDM 0301 RC 82150 HCPCS inpatient 87 56.55 ANTHEM HMO ANTHEM HMO 999999999 52.68 84.39 Amylase (enzyme) level 631567_1 CDM 0301 RC 82150 HCPCS inpatient 87 56.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.68 84.39 Amylase (enzyme) level 631567_1 CDM 0301 RC 82150 HCPCS inpatient 87 56.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.68 84.39 Amylase (enzyme) level 631567_1 CDM 0301 RC 82150 HCPCS inpatient 87 56.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.68 84.39 Amylase (enzyme) level 631567_1 CDM 0301 RC 82150 HCPCS inpatient 87 56.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.81 67.6 999999999 52.68 84.39 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 633597_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 633597_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 633597_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 633597_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 633597_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 633597_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 633597_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 633597_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 633597_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 633597_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 633597_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 633597_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 633597_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 633597_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 633599_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 106.6 65 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 633599_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 159.08 97 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 633599_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 AETNA AETNA 129.56 79 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 633599_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.16 69 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 633599_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 127.92 78 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 633599_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 SIHO - ALL PLANS SIHO - ALL PLANS 147.6 90 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 633599_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 UMR - ALL PLANS UMR - ALL PLANS 114.8 70 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 633599_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 633599_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.3 60.55 999999999 99.3 159.08 percent of total billed charges "Blood glucose (sugar) tolerance test, 3 specimens" 633599_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM HMO ANTHEM HMO 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 633599_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 633599_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 633599_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.3 159.08 "Blood glucose (sugar) tolerance test, 3 specimens" 633599_1 CDM 0301 RC 82951 HCPCS inpatient 164 106.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 110.86 67.6 999999999 99.3 159.08 percent of total billed charges Glucose (sugar) level on body fluid 633601_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.95 65 999999999 62.37 99.91 percent of total billed charges Glucose (sugar) level on body fluid 633601_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 99.91 97 999999999 62.37 99.91 percent of total billed charges Glucose (sugar) level on body fluid 633601_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 AETNA AETNA 81.37 79 999999999 62.37 99.91 percent of total billed charges Glucose (sugar) level on body fluid 633601_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 71.07 69 999999999 62.37 99.91 percent of total billed charges Glucose (sugar) level on body fluid 633601_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 80.34 78 999999999 62.37 99.91 percent of total billed charges Glucose (sugar) level on body fluid 633601_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 SIHO - ALL PLANS SIHO - ALL PLANS 92.7 90 999999999 62.37 99.91 percent of total billed charges Glucose (sugar) level on body fluid 633601_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 UMR - ALL PLANS UMR - ALL PLANS 72.1 70 999999999 62.37 99.91 percent of total billed charges Glucose (sugar) level on body fluid 633601_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 62.37 99.91 Glucose (sugar) level on body fluid 633601_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62.37 60.55 999999999 62.37 99.91 percent of total billed charges Glucose (sugar) level on body fluid 633601_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 ANTHEM HMO ANTHEM HMO 999999999 62.37 99.91 Glucose (sugar) level on body fluid 633601_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 62.37 99.91 Glucose (sugar) level on body fluid 633601_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 62.37 99.91 Glucose (sugar) level on body fluid 633601_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 62.37 99.91 Glucose (sugar) level on body fluid 633601_1 CDM 0301 RC 82945 HCPCS inpatient 103 66.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 69.63 67.6 999999999 62.37 99.91 percent of total billed charges "Urea nitrogen level to assess kidney function, quantitative" 633605_1 CDM 0301 RC 84520 HCPCS inpatient 86 55.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 55.9 65 999999999 52.07 83.42 percent of total billed charges "Urea nitrogen level to assess kidney function, quantitative" 633605_1 CDM 0301 RC 84520 HCPCS inpatient 86 55.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83.42 97 999999999 52.07 83.42 percent of total billed charges "Urea nitrogen level to assess kidney function, quantitative" 633605_1 CDM 0301 RC 84520 HCPCS inpatient 86 55.9 AETNA AETNA 67.94 79 999999999 52.07 83.42 percent of total billed charges "Urea nitrogen level to assess kidney function, quantitative" 633605_1 CDM 0301 RC 84520 HCPCS inpatient 86 55.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 59.34 69 999999999 52.07 83.42 percent of total billed charges "Urea nitrogen level to assess kidney function, quantitative" 633605_1 CDM 0301 RC 84520 HCPCS inpatient 86 55.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 67.08 78 999999999 52.07 83.42 percent of total billed charges "Urea nitrogen level to assess kidney function, quantitative" 633605_1 CDM 0301 RC 84520 HCPCS inpatient 86 55.9 SIHO - ALL PLANS SIHO - ALL PLANS 77.4 90 999999999 52.07 83.42 percent of total billed charges "Urea nitrogen level to assess kidney function, quantitative" 633605_1 CDM 0301 RC 84520 HCPCS inpatient 86 55.9 UMR - ALL PLANS UMR - ALL PLANS 60.2 70 999999999 52.07 83.42 percent of total billed charges "Urea nitrogen level to assess kidney function, quantitative" 633605_1 CDM 0301 RC 84520 HCPCS inpatient 86 55.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 52.07 83.42 "Urea nitrogen level to assess kidney function, quantitative" 633605_1 CDM 0301 RC 84520 HCPCS inpatient 86 55.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52.07 60.55 999999999 52.07 83.42 percent of total billed charges "Urea nitrogen level to assess kidney function, quantitative" 633605_1 CDM 0301 RC 84520 HCPCS inpatient 86 55.9 ANTHEM HMO ANTHEM HMO 999999999 52.07 83.42 "Urea nitrogen level to assess kidney function, quantitative" 633605_1 CDM 0301 RC 84520 HCPCS inpatient 86 55.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 52.07 83.42 "Urea nitrogen level to assess kidney function, quantitative" 633605_1 CDM 0301 RC 84520 HCPCS inpatient 86 55.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 52.07 83.42 "Urea nitrogen level to assess kidney function, quantitative" 633605_1 CDM 0301 RC 84520 HCPCS inpatient 86 55.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 52.07 83.42 "Urea nitrogen level to assess kidney function, quantitative" 633605_1 CDM 0301 RC 84520 HCPCS inpatient 86 55.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 58.14 67.6 999999999 52.07 83.42 percent of total billed charges Blood creatinine level 633606_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 79.3 65 999999999 73.87 118.34 percent of total billed charges Blood creatinine level 633606_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 118.34 97 999999999 73.87 118.34 percent of total billed charges Blood creatinine level 633606_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 AETNA AETNA 96.38 79 999999999 73.87 118.34 percent of total billed charges Blood creatinine level 633606_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 84.18 69 999999999 73.87 118.34 percent of total billed charges Blood creatinine level 633606_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 95.16 78 999999999 73.87 118.34 percent of total billed charges Blood creatinine level 633606_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 SIHO - ALL PLANS SIHO - ALL PLANS 109.8 90 999999999 73.87 118.34 percent of total billed charges Blood creatinine level 633606_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 UMR - ALL PLANS UMR - ALL PLANS 85.4 70 999999999 73.87 118.34 percent of total billed charges Blood creatinine level 633606_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 73.87 118.34 Blood creatinine level 633606_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 73.87 60.55 999999999 73.87 118.34 percent of total billed charges Blood creatinine level 633606_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 ANTHEM HMO ANTHEM HMO 999999999 73.87 118.34 Blood creatinine level 633606_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 73.87 118.34 Blood creatinine level 633606_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 73.87 118.34 Blood creatinine level 633606_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 73.87 118.34 Blood creatinine level 633606_1 CDM 0301 RC 82565 HCPCS inpatient 122 79.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 82.47 67.6 999999999 73.87 118.34 percent of total billed charges "Analysis of urine, except immunoassays" 633607_1 CDM 0307 RC 81005 HCPCS inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges "Analysis of urine, except immunoassays" 633607_1 CDM 0307 RC 81005 HCPCS inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges "Analysis of urine, except immunoassays" 633607_1 CDM 0307 RC 81005 HCPCS inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges "Analysis of urine, except immunoassays" 633607_1 CDM 0307 RC 81005 HCPCS inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges "Analysis of urine, except immunoassays" 633607_1 CDM 0307 RC 81005 HCPCS inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges "Analysis of urine, except immunoassays" 633607_1 CDM 0307 RC 81005 HCPCS inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges "Analysis of urine, except immunoassays" 633607_1 CDM 0307 RC 81005 HCPCS inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges "Analysis of urine, except immunoassays" 633607_1 CDM 0307 RC 81005 HCPCS inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 "Analysis of urine, except immunoassays" 633607_1 CDM 0307 RC 81005 HCPCS inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges "Analysis of urine, except immunoassays" 633607_1 CDM 0307 RC 81005 HCPCS inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 "Analysis of urine, except immunoassays" 633607_1 CDM 0307 RC 81005 HCPCS inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 "Analysis of urine, except immunoassays" 633607_1 CDM 0307 RC 81005 HCPCS inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 "Analysis of urine, except immunoassays" 633607_1 CDM 0307 RC 81005 HCPCS inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 "Analysis of urine, except immunoassays" 633607_1 CDM 0307 RC 81005 HCPCS inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges Blood sodium level 633611_1 CDM 0301 RC 84295 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Blood sodium level 633611_1 CDM 0301 RC 84295 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Blood sodium level 633611_1 CDM 0301 RC 84295 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Blood sodium level 633611_1 CDM 0301 RC 84295 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Blood sodium level 633611_1 CDM 0301 RC 84295 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Blood sodium level 633611_1 CDM 0301 RC 84295 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Blood sodium level 633611_1 CDM 0301 RC 84295 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Blood sodium level 633611_1 CDM 0301 RC 84295 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Blood sodium level 633611_1 CDM 0301 RC 84295 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Blood sodium level 633611_1 CDM 0301 RC 84295 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Blood sodium level 633611_1 CDM 0301 RC 84295 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Blood sodium level 633611_1 CDM 0301 RC 84295 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Blood sodium level 633611_1 CDM 0301 RC 84295 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Blood sodium level 633611_1 CDM 0301 RC 84295 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Urine sodium level 633612_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges Urine sodium level 633612_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges Urine sodium level 633612_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges Urine sodium level 633612_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges Urine sodium level 633612_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges Urine sodium level 633612_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges Urine sodium level 633612_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges Urine sodium level 633612_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 Urine sodium level 633612_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges Urine sodium level 633612_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 Urine sodium level 633612_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 Urine sodium level 633612_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 Urine sodium level 633612_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 Urine sodium level 633612_1 CDM 0301 RC 84300 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges Blood potassium level 633616_1 CDM 0301 RC 84132 HCPCS inpatient 72 46.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 46.8 65 999999999 43.6 69.84 percent of total billed charges Blood potassium level 633616_1 CDM 0301 RC 84132 HCPCS inpatient 72 46.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69.84 97 999999999 43.6 69.84 percent of total billed charges Blood potassium level 633616_1 CDM 0301 RC 84132 HCPCS inpatient 72 46.8 AETNA AETNA 56.88 79 999999999 43.6 69.84 percent of total billed charges Blood potassium level 633616_1 CDM 0301 RC 84132 HCPCS inpatient 72 46.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 49.68 69 999999999 43.6 69.84 percent of total billed charges Blood potassium level 633616_1 CDM 0301 RC 84132 HCPCS inpatient 72 46.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.16 78 999999999 43.6 69.84 percent of total billed charges Blood potassium level 633616_1 CDM 0301 RC 84132 HCPCS inpatient 72 46.8 SIHO - ALL PLANS SIHO - ALL PLANS 64.8 90 999999999 43.6 69.84 percent of total billed charges Blood potassium level 633616_1 CDM 0301 RC 84132 HCPCS inpatient 72 46.8 UMR - ALL PLANS UMR - ALL PLANS 50.4 70 999999999 43.6 69.84 percent of total billed charges Blood potassium level 633616_1 CDM 0301 RC 84132 HCPCS inpatient 72 46.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 43.6 69.84 Blood potassium level 633616_1 CDM 0301 RC 84132 HCPCS inpatient 72 46.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43.6 60.55 999999999 43.6 69.84 percent of total billed charges Blood potassium level 633616_1 CDM 0301 RC 84132 HCPCS inpatient 72 46.8 ANTHEM HMO ANTHEM HMO 999999999 43.6 69.84 Blood potassium level 633616_1 CDM 0301 RC 84132 HCPCS inpatient 72 46.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 43.6 69.84 Blood potassium level 633616_1 CDM 0301 RC 84132 HCPCS inpatient 72 46.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 43.6 69.84 Blood potassium level 633616_1 CDM 0301 RC 84132 HCPCS inpatient 72 46.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 43.6 69.84 Blood potassium level 633616_1 CDM 0301 RC 84132 HCPCS inpatient 72 46.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 48.67 67.6 999999999 43.6 69.84 percent of total billed charges Urine potassium level 633617_1 CDM 0301 RC 84133 HCPCS inpatient 129 83.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 83.85 65 999999999 78.11 125.13 percent of total billed charges Urine potassium level 633617_1 CDM 0301 RC 84133 HCPCS inpatient 129 83.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 125.13 97 999999999 78.11 125.13 percent of total billed charges Urine potassium level 633617_1 CDM 0301 RC 84133 HCPCS inpatient 129 83.85 AETNA AETNA 101.91 79 999999999 78.11 125.13 percent of total billed charges Urine potassium level 633617_1 CDM 0301 RC 84133 HCPCS inpatient 129 83.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 89.01 69 999999999 78.11 125.13 percent of total billed charges Urine potassium level 633617_1 CDM 0301 RC 84133 HCPCS inpatient 129 83.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 100.62 78 999999999 78.11 125.13 percent of total billed charges Urine potassium level 633617_1 CDM 0301 RC 84133 HCPCS inpatient 129 83.85 SIHO - ALL PLANS SIHO - ALL PLANS 116.1 90 999999999 78.11 125.13 percent of total billed charges Urine potassium level 633617_1 CDM 0301 RC 84133 HCPCS inpatient 129 83.85 UMR - ALL PLANS UMR - ALL PLANS 90.3 70 999999999 78.11 125.13 percent of total billed charges Urine potassium level 633617_1 CDM 0301 RC 84133 HCPCS inpatient 129 83.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 78.11 125.13 Urine potassium level 633617_1 CDM 0301 RC 84133 HCPCS inpatient 129 83.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78.11 60.55 999999999 78.11 125.13 percent of total billed charges Urine potassium level 633617_1 CDM 0301 RC 84133 HCPCS inpatient 129 83.85 ANTHEM HMO ANTHEM HMO 999999999 78.11 125.13 Urine potassium level 633617_1 CDM 0301 RC 84133 HCPCS inpatient 129 83.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 78.11 125.13 Urine potassium level 633617_1 CDM 0301 RC 84133 HCPCS inpatient 129 83.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 78.11 125.13 Urine potassium level 633617_1 CDM 0301 RC 84133 HCPCS inpatient 129 83.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 78.11 125.13 Urine potassium level 633617_1 CDM 0301 RC 84133 HCPCS inpatient 129 83.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 87.2 67.6 999999999 78.11 125.13 percent of total billed charges Blood chloride level 633621_1 CDM 0301 RC 82435 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges Blood chloride level 633621_1 CDM 0301 RC 82435 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges Blood chloride level 633621_1 CDM 0301 RC 82435 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges Blood chloride level 633621_1 CDM 0301 RC 82435 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges Blood chloride level 633621_1 CDM 0301 RC 82435 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges Blood chloride level 633621_1 CDM 0301 RC 82435 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges Blood chloride level 633621_1 CDM 0301 RC 82435 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges Blood chloride level 633621_1 CDM 0301 RC 82435 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 Blood chloride level 633621_1 CDM 0301 RC 82435 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges Blood chloride level 633621_1 CDM 0301 RC 82435 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 Blood chloride level 633621_1 CDM 0301 RC 82435 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 Blood chloride level 633621_1 CDM 0301 RC 82435 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 Blood chloride level 633621_1 CDM 0301 RC 82435 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 Blood chloride level 633621_1 CDM 0301 RC 82435 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges Carbon dioxide (bicarbonate) level 633626_1 CDM 0301 RC 82374 HCPCS inpatient 84 54.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 54.6 65 999999999 50.86 81.48 percent of total billed charges Carbon dioxide (bicarbonate) level 633626_1 CDM 0301 RC 82374 HCPCS inpatient 84 54.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 81.48 97 999999999 50.86 81.48 percent of total billed charges Carbon dioxide (bicarbonate) level 633626_1 CDM 0301 RC 82374 HCPCS inpatient 84 54.6 AETNA AETNA 66.36 79 999999999 50.86 81.48 percent of total billed charges Carbon dioxide (bicarbonate) level 633626_1 CDM 0301 RC 82374 HCPCS inpatient 84 54.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.96 69 999999999 50.86 81.48 percent of total billed charges Carbon dioxide (bicarbonate) level 633626_1 CDM 0301 RC 82374 HCPCS inpatient 84 54.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 65.52 78 999999999 50.86 81.48 percent of total billed charges Carbon dioxide (bicarbonate) level 633626_1 CDM 0301 RC 82374 HCPCS inpatient 84 54.6 SIHO - ALL PLANS SIHO - ALL PLANS 75.6 90 999999999 50.86 81.48 percent of total billed charges Carbon dioxide (bicarbonate) level 633626_1 CDM 0301 RC 82374 HCPCS inpatient 84 54.6 UMR - ALL PLANS UMR - ALL PLANS 58.8 70 999999999 50.86 81.48 percent of total billed charges Carbon dioxide (bicarbonate) level 633626_1 CDM 0301 RC 82374 HCPCS inpatient 84 54.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.86 81.48 Carbon dioxide (bicarbonate) level 633626_1 CDM 0301 RC 82374 HCPCS inpatient 84 54.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.86 60.55 999999999 50.86 81.48 percent of total billed charges Carbon dioxide (bicarbonate) level 633626_1 CDM 0301 RC 82374 HCPCS inpatient 84 54.6 ANTHEM HMO ANTHEM HMO 999999999 50.86 81.48 Carbon dioxide (bicarbonate) level 633626_1 CDM 0301 RC 82374 HCPCS inpatient 84 54.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.86 81.48 Carbon dioxide (bicarbonate) level 633626_1 CDM 0301 RC 82374 HCPCS inpatient 84 54.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.86 81.48 Carbon dioxide (bicarbonate) level 633626_1 CDM 0301 RC 82374 HCPCS inpatient 84 54.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.86 81.48 Carbon dioxide (bicarbonate) level 633626_1 CDM 0301 RC 82374 HCPCS inpatient 84 54.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.78 67.6 999999999 50.86 81.48 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 633629_1 CDM 0301 RC 80307 HCPCS inpatient 239 155.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 155.35 65 999999999 144.71 231.83 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 633629_1 CDM 0301 RC 80307 HCPCS inpatient 239 155.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 231.83 97 999999999 144.71 231.83 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 633629_1 CDM 0301 RC 80307 HCPCS inpatient 239 155.35 AETNA AETNA 188.81 79 999999999 144.71 231.83 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 633629_1 CDM 0301 RC 80307 HCPCS inpatient 239 155.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 164.91 69 999999999 144.71 231.83 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 633629_1 CDM 0301 RC 80307 HCPCS inpatient 239 155.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 186.42 78 999999999 144.71 231.83 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 633629_1 CDM 0301 RC 80307 HCPCS inpatient 239 155.35 SIHO - ALL PLANS SIHO - ALL PLANS 215.1 90 999999999 144.71 231.83 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 633629_1 CDM 0301 RC 80307 HCPCS inpatient 239 155.35 UMR - ALL PLANS UMR - ALL PLANS 167.3 70 999999999 144.71 231.83 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 633629_1 CDM 0301 RC 80307 HCPCS inpatient 239 155.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 144.71 231.83 "Testing for presence of drug, by chemistry analyzers" 633629_1 CDM 0301 RC 80307 HCPCS inpatient 239 155.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 144.71 60.55 999999999 144.71 231.83 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 633629_1 CDM 0301 RC 80307 HCPCS inpatient 239 155.35 ANTHEM HMO ANTHEM HMO 999999999 144.71 231.83 "Testing for presence of drug, by chemistry analyzers" 633629_1 CDM 0301 RC 80307 HCPCS inpatient 239 155.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 144.71 231.83 "Testing for presence of drug, by chemistry analyzers" 633629_1 CDM 0301 RC 80307 HCPCS inpatient 239 155.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 144.71 231.83 "Testing for presence of drug, by chemistry analyzers" 633629_1 CDM 0301 RC 80307 HCPCS inpatient 239 155.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 144.71 231.83 "Testing for presence of drug, by chemistry analyzers" 633629_1 CDM 0301 RC 80307 HCPCS inpatient 239 155.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 161.56 67.6 999999999 144.71 231.83 percent of total billed charges "Liver enzyme (SGPT), level" 633632_1 CDM 0300 RC 84460 HCPCS inpatient 165 107.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.25 65 999999999 99.91 160.05 percent of total billed charges "Liver enzyme (SGPT), level" 633632_1 CDM 0300 RC 84460 HCPCS inpatient 165 107.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 160.05 97 999999999 99.91 160.05 percent of total billed charges "Liver enzyme (SGPT), level" 633632_1 CDM 0300 RC 84460 HCPCS inpatient 165 107.25 AETNA AETNA 130.35 79 999999999 99.91 160.05 percent of total billed charges "Liver enzyme (SGPT), level" 633632_1 CDM 0300 RC 84460 HCPCS inpatient 165 107.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 113.85 69 999999999 99.91 160.05 percent of total billed charges "Liver enzyme (SGPT), level" 633632_1 CDM 0300 RC 84460 HCPCS inpatient 165 107.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 128.7 78 999999999 99.91 160.05 percent of total billed charges "Liver enzyme (SGPT), level" 633632_1 CDM 0300 RC 84460 HCPCS inpatient 165 107.25 SIHO - ALL PLANS SIHO - ALL PLANS 148.5 90 999999999 99.91 160.05 percent of total billed charges "Liver enzyme (SGPT), level" 633632_1 CDM 0300 RC 84460 HCPCS inpatient 165 107.25 UMR - ALL PLANS UMR - ALL PLANS 115.5 70 999999999 99.91 160.05 percent of total billed charges "Liver enzyme (SGPT), level" 633632_1 CDM 0300 RC 84460 HCPCS inpatient 165 107.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 99.91 160.05 "Liver enzyme (SGPT), level" 633632_1 CDM 0300 RC 84460 HCPCS inpatient 165 107.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 99.91 60.55 999999999 99.91 160.05 percent of total billed charges "Liver enzyme (SGPT), level" 633632_1 CDM 0300 RC 84460 HCPCS inpatient 165 107.25 ANTHEM HMO ANTHEM HMO 999999999 99.91 160.05 "Liver enzyme (SGPT), level" 633632_1 CDM 0300 RC 84460 HCPCS inpatient 165 107.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 99.91 160.05 "Liver enzyme (SGPT), level" 633632_1 CDM 0300 RC 84460 HCPCS inpatient 165 107.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 99.91 160.05 "Liver enzyme (SGPT), level" 633632_1 CDM 0300 RC 84460 HCPCS inpatient 165 107.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 99.91 160.05 "Liver enzyme (SGPT), level" 633632_1 CDM 0300 RC 84460 HCPCS inpatient 165 107.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 111.54 67.6 999999999 99.91 160.05 percent of total billed charges "Liver enzyme (SGOT), level" 633633_1 CDM 0300 RC 84450 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges "Liver enzyme (SGOT), level" 633633_1 CDM 0300 RC 84450 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges "Liver enzyme (SGOT), level" 633633_1 CDM 0300 RC 84450 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges "Liver enzyme (SGOT), level" 633633_1 CDM 0300 RC 84450 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges "Liver enzyme (SGOT), level" 633633_1 CDM 0300 RC 84450 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges "Liver enzyme (SGOT), level" 633633_1 CDM 0300 RC 84450 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges "Liver enzyme (SGOT), level" 633633_1 CDM 0300 RC 84450 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges "Liver enzyme (SGOT), level" 633633_1 CDM 0300 RC 84450 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 "Liver enzyme (SGOT), level" 633633_1 CDM 0300 RC 84450 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges "Liver enzyme (SGOT), level" 633633_1 CDM 0300 RC 84450 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 "Liver enzyme (SGOT), level" 633633_1 CDM 0300 RC 84450 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 "Liver enzyme (SGOT), level" 633633_1 CDM 0300 RC 84450 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 "Liver enzyme (SGOT), level" 633633_1 CDM 0300 RC 84450 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 "Liver enzyme (SGOT), level" 633633_1 CDM 0300 RC 84450 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges Albumin (protein) level 633634_1 CDM 0301 RC 82040 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges Albumin (protein) level 633634_1 CDM 0301 RC 82040 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges Albumin (protein) level 633634_1 CDM 0301 RC 82040 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges Albumin (protein) level 633634_1 CDM 0301 RC 82040 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges Albumin (protein) level 633634_1 CDM 0301 RC 82040 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges Albumin (protein) level 633634_1 CDM 0301 RC 82040 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges Albumin (protein) level 633634_1 CDM 0301 RC 82040 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges Albumin (protein) level 633634_1 CDM 0301 RC 82040 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 Albumin (protein) level 633634_1 CDM 0301 RC 82040 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges Albumin (protein) level 633634_1 CDM 0301 RC 82040 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 Albumin (protein) level 633634_1 CDM 0301 RC 82040 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 Albumin (protein) level 633634_1 CDM 0301 RC 82040 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 Albumin (protein) level 633634_1 CDM 0301 RC 82040 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 Albumin (protein) level 633634_1 CDM 0301 RC 82040 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges "Phosphatase (enzyme) level, alkaline" 633642_1 CDM 0301 RC 84075 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges "Phosphatase (enzyme) level, alkaline" 633642_1 CDM 0301 RC 84075 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges "Phosphatase (enzyme) level, alkaline" 633642_1 CDM 0301 RC 84075 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges "Phosphatase (enzyme) level, alkaline" 633642_1 CDM 0301 RC 84075 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges "Phosphatase (enzyme) level, alkaline" 633642_1 CDM 0301 RC 84075 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges "Phosphatase (enzyme) level, alkaline" 633642_1 CDM 0301 RC 84075 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges "Phosphatase (enzyme) level, alkaline" 633642_1 CDM 0301 RC 84075 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges "Phosphatase (enzyme) level, alkaline" 633642_1 CDM 0301 RC 84075 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 "Phosphatase (enzyme) level, alkaline" 633642_1 CDM 0301 RC 84075 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges "Phosphatase (enzyme) level, alkaline" 633642_1 CDM 0301 RC 84075 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 "Phosphatase (enzyme) level, alkaline" 633642_1 CDM 0301 RC 84075 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 "Phosphatase (enzyme) level, alkaline" 633642_1 CDM 0301 RC 84075 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 "Phosphatase (enzyme) level, alkaline" 633642_1 CDM 0301 RC 84075 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 "Phosphatase (enzyme) level, alkaline" 633642_1 CDM 0301 RC 84075 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges Ammonia level 633648_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 165.1 65 999999999 153.8 246.38 percent of total billed charges Ammonia level 633648_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 246.38 97 999999999 153.8 246.38 percent of total billed charges Ammonia level 633648_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 AETNA AETNA 200.66 79 999999999 153.8 246.38 percent of total billed charges Ammonia level 633648_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 175.26 69 999999999 153.8 246.38 percent of total billed charges Ammonia level 633648_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 198.12 78 999999999 153.8 246.38 percent of total billed charges Ammonia level 633648_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 SIHO - ALL PLANS SIHO - ALL PLANS 228.6 90 999999999 153.8 246.38 percent of total billed charges Ammonia level 633648_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 UMR - ALL PLANS UMR - ALL PLANS 177.8 70 999999999 153.8 246.38 percent of total billed charges Ammonia level 633648_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 153.8 246.38 Ammonia level 633648_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 153.8 60.55 999999999 153.8 246.38 percent of total billed charges Ammonia level 633648_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 ANTHEM HMO ANTHEM HMO 999999999 153.8 246.38 Ammonia level 633648_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 153.8 246.38 Ammonia level 633648_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 153.8 246.38 Ammonia level 633648_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 153.8 246.38 Ammonia level 633648_1 CDM 0301 RC 82140 HCPCS inpatient 254 165.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 171.7 67.6 999999999 153.8 246.38 percent of total billed charges "Bilirubin level, direct" 633670_1 CDM 0301 RC 82248 HCPCS inpatient 94 61.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.1 65 999999999 56.92 91.18 percent of total billed charges "Bilirubin level, direct" 633670_1 CDM 0301 RC 82248 HCPCS inpatient 94 61.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.18 97 999999999 56.92 91.18 percent of total billed charges "Bilirubin level, direct" 633670_1 CDM 0301 RC 82248 HCPCS inpatient 94 61.1 AETNA AETNA 74.26 79 999999999 56.92 91.18 percent of total billed charges "Bilirubin level, direct" 633670_1 CDM 0301 RC 82248 HCPCS inpatient 94 61.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.86 69 999999999 56.92 91.18 percent of total billed charges "Bilirubin level, direct" 633670_1 CDM 0301 RC 82248 HCPCS inpatient 94 61.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.32 78 999999999 56.92 91.18 percent of total billed charges "Bilirubin level, direct" 633670_1 CDM 0301 RC 82248 HCPCS inpatient 94 61.1 SIHO - ALL PLANS SIHO - ALL PLANS 84.6 90 999999999 56.92 91.18 percent of total billed charges "Bilirubin level, direct" 633670_1 CDM 0301 RC 82248 HCPCS inpatient 94 61.1 UMR - ALL PLANS UMR - ALL PLANS 65.8 70 999999999 56.92 91.18 percent of total billed charges "Bilirubin level, direct" 633670_1 CDM 0301 RC 82248 HCPCS inpatient 94 61.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.92 91.18 "Bilirubin level, direct" 633670_1 CDM 0301 RC 82248 HCPCS inpatient 94 61.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.92 60.55 999999999 56.92 91.18 percent of total billed charges "Bilirubin level, direct" 633670_1 CDM 0301 RC 82248 HCPCS inpatient 94 61.1 ANTHEM HMO ANTHEM HMO 999999999 56.92 91.18 "Bilirubin level, direct" 633670_1 CDM 0301 RC 82248 HCPCS inpatient 94 61.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.92 91.18 "Bilirubin level, direct" 633670_1 CDM 0301 RC 82248 HCPCS inpatient 94 61.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.92 91.18 "Bilirubin level, direct" 633670_1 CDM 0301 RC 82248 HCPCS inpatient 94 61.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.92 91.18 "Bilirubin level, direct" 633670_1 CDM 0301 RC 82248 HCPCS inpatient 94 61.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.54 67.6 999999999 56.92 91.18 percent of total billed charges "Bilirubin level, total" 633672_1 CDM 0301 RC 82247 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges "Bilirubin level, total" 633672_1 CDM 0301 RC 82247 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges "Bilirubin level, total" 633672_1 CDM 0301 RC 82247 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges "Bilirubin level, total" 633672_1 CDM 0301 RC 82247 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges "Bilirubin level, total" 633672_1 CDM 0301 RC 82247 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges "Bilirubin level, total" 633672_1 CDM 0301 RC 82247 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges "Bilirubin level, total" 633672_1 CDM 0301 RC 82247 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges "Bilirubin level, total" 633672_1 CDM 0301 RC 82247 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 "Bilirubin level, total" 633672_1 CDM 0301 RC 82247 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges "Bilirubin level, total" 633672_1 CDM 0301 RC 82247 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 "Bilirubin level, total" 633672_1 CDM 0301 RC 82247 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 "Bilirubin level, total" 633672_1 CDM 0301 RC 82247 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 "Bilirubin level, total" 633672_1 CDM 0301 RC 82247 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 "Bilirubin level, total" 633672_1 CDM 0301 RC 82247 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges "Calcium level, total" 633690_1 CDM 0300 RC 82310 HCPCS inpatient 162 105.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 105.3 65 999999999 98.09 157.14 percent of total billed charges "Calcium level, total" 633690_1 CDM 0300 RC 82310 HCPCS inpatient 162 105.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 157.14 97 999999999 98.09 157.14 percent of total billed charges "Calcium level, total" 633690_1 CDM 0300 RC 82310 HCPCS inpatient 162 105.3 AETNA AETNA 127.98 79 999999999 98.09 157.14 percent of total billed charges "Calcium level, total" 633690_1 CDM 0300 RC 82310 HCPCS inpatient 162 105.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 111.78 69 999999999 98.09 157.14 percent of total billed charges "Calcium level, total" 633690_1 CDM 0300 RC 82310 HCPCS inpatient 162 105.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 126.36 78 999999999 98.09 157.14 percent of total billed charges "Calcium level, total" 633690_1 CDM 0300 RC 82310 HCPCS inpatient 162 105.3 SIHO - ALL PLANS SIHO - ALL PLANS 145.8 90 999999999 98.09 157.14 percent of total billed charges "Calcium level, total" 633690_1 CDM 0300 RC 82310 HCPCS inpatient 162 105.3 UMR - ALL PLANS UMR - ALL PLANS 113.4 70 999999999 98.09 157.14 percent of total billed charges "Calcium level, total" 633690_1 CDM 0300 RC 82310 HCPCS inpatient 162 105.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 98.09 157.14 "Calcium level, total" 633690_1 CDM 0300 RC 82310 HCPCS inpatient 162 105.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 98.09 60.55 999999999 98.09 157.14 percent of total billed charges "Calcium level, total" 633690_1 CDM 0300 RC 82310 HCPCS inpatient 162 105.3 ANTHEM HMO ANTHEM HMO 999999999 98.09 157.14 "Calcium level, total" 633690_1 CDM 0300 RC 82310 HCPCS inpatient 162 105.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 98.09 157.14 "Calcium level, total" 633690_1 CDM 0300 RC 82310 HCPCS inpatient 162 105.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 98.09 157.14 "Calcium level, total" 633690_1 CDM 0300 RC 82310 HCPCS inpatient 162 105.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 98.09 157.14 "Calcium level, total" 633690_1 CDM 0300 RC 82310 HCPCS inpatient 162 105.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 109.51 67.6 999999999 98.09 157.14 percent of total billed charges Carcinoembryonic antigen (CEA) protein level 633697_1 CDM 0301 RC 82378 HCPCS inpatient 120 78 SELF PAY DISCOUNT SELF PAY DISCOUNT 78 65 999999999 72.66 116.4 percent of total billed charges Carcinoembryonic antigen (CEA) protein level 633697_1 CDM 0301 RC 82378 HCPCS inpatient 120 78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 116.4 97 999999999 72.66 116.4 percent of total billed charges Carcinoembryonic antigen (CEA) protein level 633697_1 CDM 0301 RC 82378 HCPCS inpatient 120 78 AETNA AETNA 94.8 79 999999999 72.66 116.4 percent of total billed charges Carcinoembryonic antigen (CEA) protein level 633697_1 CDM 0301 RC 82378 HCPCS inpatient 120 78 ENCORE - ALL PLANS ENCORE - ALL PLANS 82.8 69 999999999 72.66 116.4 percent of total billed charges Carcinoembryonic antigen (CEA) protein level 633697_1 CDM 0301 RC 82378 HCPCS inpatient 120 78 HUMANA - ALL PLANS HUMANA - ALL PLANS 93.6 78 999999999 72.66 116.4 percent of total billed charges Carcinoembryonic antigen (CEA) protein level 633697_1 CDM 0301 RC 82378 HCPCS inpatient 120 78 SIHO - ALL PLANS SIHO - ALL PLANS 108 90 999999999 72.66 116.4 percent of total billed charges Carcinoembryonic antigen (CEA) protein level 633697_1 CDM 0301 RC 82378 HCPCS inpatient 120 78 UMR - ALL PLANS UMR - ALL PLANS 84 70 999999999 72.66 116.4 percent of total billed charges Carcinoembryonic antigen (CEA) protein level 633697_1 CDM 0301 RC 82378 HCPCS inpatient 120 78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 72.66 116.4 Carcinoembryonic antigen (CEA) protein level 633697_1 CDM 0301 RC 82378 HCPCS inpatient 120 78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 72.66 60.55 999999999 72.66 116.4 percent of total billed charges Carcinoembryonic antigen (CEA) protein level 633697_1 CDM 0301 RC 82378 HCPCS inpatient 120 78 ANTHEM HMO ANTHEM HMO 999999999 72.66 116.4 Carcinoembryonic antigen (CEA) protein level 633697_1 CDM 0301 RC 82378 HCPCS inpatient 120 78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 72.66 116.4 Carcinoembryonic antigen (CEA) protein level 633697_1 CDM 0301 RC 82378 HCPCS inpatient 120 78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 72.66 116.4 Carcinoembryonic antigen (CEA) protein level 633697_1 CDM 0301 RC 82378 HCPCS inpatient 120 78 UHC - ALL PLANS UHC - ALL PLANS 999999999 72.66 116.4 Carcinoembryonic antigen (CEA) protein level 633697_1 CDM 0301 RC 82378 HCPCS inpatient 120 78 CIGNA - ALL PLANS CIGNA - ALL PLANS 81.12 67.6 999999999 72.66 116.4 percent of total billed charges Cholesterol level 633705_1 CDM 0301 RC 82465 HCPCS inpatient 84 54.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 54.6 65 999999999 50.86 81.48 percent of total billed charges Cholesterol level 633705_1 CDM 0301 RC 82465 HCPCS inpatient 84 54.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 81.48 97 999999999 50.86 81.48 percent of total billed charges Cholesterol level 633705_1 CDM 0301 RC 82465 HCPCS inpatient 84 54.6 AETNA AETNA 66.36 79 999999999 50.86 81.48 percent of total billed charges Cholesterol level 633705_1 CDM 0301 RC 82465 HCPCS inpatient 84 54.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.96 69 999999999 50.86 81.48 percent of total billed charges Cholesterol level 633705_1 CDM 0301 RC 82465 HCPCS inpatient 84 54.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 65.52 78 999999999 50.86 81.48 percent of total billed charges Cholesterol level 633705_1 CDM 0301 RC 82465 HCPCS inpatient 84 54.6 SIHO - ALL PLANS SIHO - ALL PLANS 75.6 90 999999999 50.86 81.48 percent of total billed charges Cholesterol level 633705_1 CDM 0301 RC 82465 HCPCS inpatient 84 54.6 UMR - ALL PLANS UMR - ALL PLANS 58.8 70 999999999 50.86 81.48 percent of total billed charges Cholesterol level 633705_1 CDM 0301 RC 82465 HCPCS inpatient 84 54.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.86 81.48 Cholesterol level 633705_1 CDM 0301 RC 82465 HCPCS inpatient 84 54.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.86 60.55 999999999 50.86 81.48 percent of total billed charges Cholesterol level 633705_1 CDM 0301 RC 82465 HCPCS inpatient 84 54.6 ANTHEM HMO ANTHEM HMO 999999999 50.86 81.48 Cholesterol level 633705_1 CDM 0301 RC 82465 HCPCS inpatient 84 54.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.86 81.48 Cholesterol level 633705_1 CDM 0301 RC 82465 HCPCS inpatient 84 54.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.86 81.48 Cholesterol level 633705_1 CDM 0301 RC 82465 HCPCS inpatient 84 54.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.86 81.48 Cholesterol level 633705_1 CDM 0301 RC 82465 HCPCS inpatient 84 54.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.78 67.6 999999999 50.86 81.48 percent of total billed charges "Coagulation function measurement, D-dimer; quantitative" 633718_1 CDM 0305 RC 85379 HCPCS inpatient 154 100.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.1 65 999999999 93.25 149.38 percent of total billed charges "Coagulation function measurement, D-dimer; quantitative" 633718_1 CDM 0305 RC 85379 HCPCS inpatient 154 100.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 149.38 97 999999999 93.25 149.38 percent of total billed charges "Coagulation function measurement, D-dimer; quantitative" 633718_1 CDM 0305 RC 85379 HCPCS inpatient 154 100.1 AETNA AETNA 121.66 79 999999999 93.25 149.38 percent of total billed charges "Coagulation function measurement, D-dimer; quantitative" 633718_1 CDM 0305 RC 85379 HCPCS inpatient 154 100.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.26 69 999999999 93.25 149.38 percent of total billed charges "Coagulation function measurement, D-dimer; quantitative" 633718_1 CDM 0305 RC 85379 HCPCS inpatient 154 100.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.12 78 999999999 93.25 149.38 percent of total billed charges "Coagulation function measurement, D-dimer; quantitative" 633718_1 CDM 0305 RC 85379 HCPCS inpatient 154 100.1 SIHO - ALL PLANS SIHO - ALL PLANS 138.6 90 999999999 93.25 149.38 percent of total billed charges "Coagulation function measurement, D-dimer; quantitative" 633718_1 CDM 0305 RC 85379 HCPCS inpatient 154 100.1 UMR - ALL PLANS UMR - ALL PLANS 107.8 70 999999999 93.25 149.38 percent of total billed charges "Coagulation function measurement, D-dimer; quantitative" 633718_1 CDM 0305 RC 85379 HCPCS inpatient 154 100.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.25 149.38 "Coagulation function measurement, D-dimer; quantitative" 633718_1 CDM 0305 RC 85379 HCPCS inpatient 154 100.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.25 60.55 999999999 93.25 149.38 percent of total billed charges "Coagulation function measurement, D-dimer; quantitative" 633718_1 CDM 0305 RC 85379 HCPCS inpatient 154 100.1 ANTHEM HMO ANTHEM HMO 999999999 93.25 149.38 "Coagulation function measurement, D-dimer; quantitative" 633718_1 CDM 0305 RC 85379 HCPCS inpatient 154 100.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.25 149.38 "Coagulation function measurement, D-dimer; quantitative" 633718_1 CDM 0305 RC 85379 HCPCS inpatient 154 100.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.25 149.38 "Coagulation function measurement, D-dimer; quantitative" 633718_1 CDM 0305 RC 85379 HCPCS inpatient 154 100.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.25 149.38 "Coagulation function measurement, D-dimer; quantitative" 633718_1 CDM 0305 RC 85379 HCPCS inpatient 154 100.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.1 67.6 999999999 93.25 149.38 percent of total billed charges "Digoxin level, total" 633719_1 CDM 0301 RC 80162 HCPCS inpatient 244 158.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 158.6 65 999999999 147.74 236.68 percent of total billed charges "Digoxin level, total" 633719_1 CDM 0301 RC 80162 HCPCS inpatient 244 158.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 236.68 97 999999999 147.74 236.68 percent of total billed charges "Digoxin level, total" 633719_1 CDM 0301 RC 80162 HCPCS inpatient 244 158.6 AETNA AETNA 192.76 79 999999999 147.74 236.68 percent of total billed charges "Digoxin level, total" 633719_1 CDM 0301 RC 80162 HCPCS inpatient 244 158.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 168.36 69 999999999 147.74 236.68 percent of total billed charges "Digoxin level, total" 633719_1 CDM 0301 RC 80162 HCPCS inpatient 244 158.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 190.32 78 999999999 147.74 236.68 percent of total billed charges "Digoxin level, total" 633719_1 CDM 0301 RC 80162 HCPCS inpatient 244 158.6 SIHO - ALL PLANS SIHO - ALL PLANS 219.6 90 999999999 147.74 236.68 percent of total billed charges "Digoxin level, total" 633719_1 CDM 0301 RC 80162 HCPCS inpatient 244 158.6 UMR - ALL PLANS UMR - ALL PLANS 170.8 70 999999999 147.74 236.68 percent of total billed charges "Digoxin level, total" 633719_1 CDM 0301 RC 80162 HCPCS inpatient 244 158.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 147.74 236.68 "Digoxin level, total" 633719_1 CDM 0301 RC 80162 HCPCS inpatient 244 158.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 147.74 60.55 999999999 147.74 236.68 percent of total billed charges "Digoxin level, total" 633719_1 CDM 0301 RC 80162 HCPCS inpatient 244 158.6 ANTHEM HMO ANTHEM HMO 999999999 147.74 236.68 "Digoxin level, total" 633719_1 CDM 0301 RC 80162 HCPCS inpatient 244 158.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 147.74 236.68 "Digoxin level, total" 633719_1 CDM 0301 RC 80162 HCPCS inpatient 244 158.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 147.74 236.68 "Digoxin level, total" 633719_1 CDM 0301 RC 80162 HCPCS inpatient 244 158.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 147.74 236.68 "Digoxin level, total" 633719_1 CDM 0301 RC 80162 HCPCS inpatient 244 158.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 164.94 67.6 999999999 147.74 236.68 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 633725_1 CDM 0301 RC 80307 HCPCS inpatient 191 124.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 124.15 65 999999999 115.65 185.27 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 633725_1 CDM 0301 RC 80307 HCPCS inpatient 191 124.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 185.27 97 999999999 115.65 185.27 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 633725_1 CDM 0301 RC 80307 HCPCS inpatient 191 124.15 AETNA AETNA 150.89 79 999999999 115.65 185.27 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 633725_1 CDM 0301 RC 80307 HCPCS inpatient 191 124.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 131.79 69 999999999 115.65 185.27 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 633725_1 CDM 0301 RC 80307 HCPCS inpatient 191 124.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 148.98 78 999999999 115.65 185.27 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 633725_1 CDM 0301 RC 80307 HCPCS inpatient 191 124.15 SIHO - ALL PLANS SIHO - ALL PLANS 171.9 90 999999999 115.65 185.27 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 633725_1 CDM 0301 RC 80307 HCPCS inpatient 191 124.15 UMR - ALL PLANS UMR - ALL PLANS 133.7 70 999999999 115.65 185.27 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 633725_1 CDM 0301 RC 80307 HCPCS inpatient 191 124.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 115.65 185.27 "Testing for presence of drug, by chemistry analyzers" 633725_1 CDM 0301 RC 80307 HCPCS inpatient 191 124.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 115.65 60.55 999999999 115.65 185.27 percent of total billed charges "Testing for presence of drug, by chemistry analyzers" 633725_1 CDM 0301 RC 80307 HCPCS inpatient 191 124.15 ANTHEM HMO ANTHEM HMO 999999999 115.65 185.27 "Testing for presence of drug, by chemistry analyzers" 633725_1 CDM 0301 RC 80307 HCPCS inpatient 191 124.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 115.65 185.27 "Testing for presence of drug, by chemistry analyzers" 633725_1 CDM 0301 RC 80307 HCPCS inpatient 191 124.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 115.65 185.27 "Testing for presence of drug, by chemistry analyzers" 633725_1 CDM 0301 RC 80307 HCPCS inpatient 191 124.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 115.65 185.27 "Testing for presence of drug, by chemistry analyzers" 633725_1 CDM 0301 RC 80307 HCPCS inpatient 191 124.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 129.12 67.6 999999999 115.65 185.27 percent of total billed charges Glutamyltransferase (liver enzyme) level 633733_1 CDM 0301 RC 82977 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges Glutamyltransferase (liver enzyme) level 633733_1 CDM 0301 RC 82977 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges Glutamyltransferase (liver enzyme) level 633733_1 CDM 0301 RC 82977 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges Glutamyltransferase (liver enzyme) level 633733_1 CDM 0301 RC 82977 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges Glutamyltransferase (liver enzyme) level 633733_1 CDM 0301 RC 82977 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges Glutamyltransferase (liver enzyme) level 633733_1 CDM 0301 RC 82977 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges Glutamyltransferase (liver enzyme) level 633733_1 CDM 0301 RC 82977 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges Glutamyltransferase (liver enzyme) level 633733_1 CDM 0301 RC 82977 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 Glutamyltransferase (liver enzyme) level 633733_1 CDM 0301 RC 82977 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges Glutamyltransferase (liver enzyme) level 633733_1 CDM 0301 RC 82977 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 Glutamyltransferase (liver enzyme) level 633733_1 CDM 0301 RC 82977 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 Glutamyltransferase (liver enzyme) level 633733_1 CDM 0301 RC 82977 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 Glutamyltransferase (liver enzyme) level 633733_1 CDM 0301 RC 82977 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 Glutamyltransferase (liver enzyme) level 633733_1 CDM 0301 RC 82977 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges Gentamicin (antibiotic) level 633735_1 CDM 0301 RC 80170 HCPCS inpatient 356 231.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 231.4 65 999999999 215.56 345.32 percent of total billed charges Gentamicin (antibiotic) level 633735_1 CDM 0301 RC 80170 HCPCS inpatient 356 231.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 345.32 97 999999999 215.56 345.32 percent of total billed charges Gentamicin (antibiotic) level 633735_1 CDM 0301 RC 80170 HCPCS inpatient 356 231.4 AETNA AETNA 281.24 79 999999999 215.56 345.32 percent of total billed charges Gentamicin (antibiotic) level 633735_1 CDM 0301 RC 80170 HCPCS inpatient 356 231.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 245.64 69 999999999 215.56 345.32 percent of total billed charges Gentamicin (antibiotic) level 633735_1 CDM 0301 RC 80170 HCPCS inpatient 356 231.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 277.68 78 999999999 215.56 345.32 percent of total billed charges Gentamicin (antibiotic) level 633735_1 CDM 0301 RC 80170 HCPCS inpatient 356 231.4 SIHO - ALL PLANS SIHO - ALL PLANS 320.4 90 999999999 215.56 345.32 percent of total billed charges Gentamicin (antibiotic) level 633735_1 CDM 0301 RC 80170 HCPCS inpatient 356 231.4 UMR - ALL PLANS UMR - ALL PLANS 249.2 70 999999999 215.56 345.32 percent of total billed charges Gentamicin (antibiotic) level 633735_1 CDM 0301 RC 80170 HCPCS inpatient 356 231.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 215.56 345.32 Gentamicin (antibiotic) level 633735_1 CDM 0301 RC 80170 HCPCS inpatient 356 231.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 215.56 60.55 999999999 215.56 345.32 percent of total billed charges Gentamicin (antibiotic) level 633735_1 CDM 0301 RC 80170 HCPCS inpatient 356 231.4 ANTHEM HMO ANTHEM HMO 999999999 215.56 345.32 Gentamicin (antibiotic) level 633735_1 CDM 0301 RC 80170 HCPCS inpatient 356 231.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 215.56 345.32 Gentamicin (antibiotic) level 633735_1 CDM 0301 RC 80170 HCPCS inpatient 356 231.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 215.56 345.32 Gentamicin (antibiotic) level 633735_1 CDM 0301 RC 80170 HCPCS inpatient 356 231.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 215.56 345.32 Gentamicin (antibiotic) level 633735_1 CDM 0301 RC 80170 HCPCS inpatient 356 231.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 240.66 67.6 999999999 215.56 345.32 percent of total billed charges Gentamicin (antibiotic) level 633737_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 213.2 65 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 633737_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 318.16 97 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 633737_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 AETNA AETNA 259.12 79 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 633737_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 226.32 69 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 633737_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.84 78 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 633737_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 SIHO - ALL PLANS SIHO - ALL PLANS 295.2 90 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 633737_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 UMR - ALL PLANS UMR - ALL PLANS 229.6 70 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 633737_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198.6 318.16 Gentamicin (antibiotic) level 633737_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198.6 60.55 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 633737_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 ANTHEM HMO ANTHEM HMO 999999999 198.6 318.16 Gentamicin (antibiotic) level 633737_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198.6 318.16 Gentamicin (antibiotic) level 633737_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198.6 318.16 Gentamicin (antibiotic) level 633737_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 198.6 318.16 Gentamicin (antibiotic) level 633737_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.73 67.6 999999999 198.6 318.16 percent of total billed charges "Blood count, hemoglobin" 633741_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges "Blood count, hemoglobin" 633741_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges "Blood count, hemoglobin" 633741_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges "Blood count, hemoglobin" 633741_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges "Blood count, hemoglobin" 633741_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges "Blood count, hemoglobin" 633741_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges "Blood count, hemoglobin" 633741_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges "Blood count, hemoglobin" 633741_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 "Blood count, hemoglobin" 633741_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges "Blood count, hemoglobin" 633741_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 "Blood count, hemoglobin" 633741_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 "Blood count, hemoglobin" 633741_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 "Blood count, hemoglobin" 633741_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 "Blood count, hemoglobin" 633741_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges Red blood cell concentration measurement 633742_1 CDM 0305 RC 85014 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges Red blood cell concentration measurement 633742_1 CDM 0305 RC 85014 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges Red blood cell concentration measurement 633742_1 CDM 0305 RC 85014 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges Red blood cell concentration measurement 633742_1 CDM 0305 RC 85014 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges Red blood cell concentration measurement 633742_1 CDM 0305 RC 85014 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges Red blood cell concentration measurement 633742_1 CDM 0305 RC 85014 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges Red blood cell concentration measurement 633742_1 CDM 0305 RC 85014 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges Red blood cell concentration measurement 633742_1 CDM 0305 RC 85014 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 Red blood cell concentration measurement 633742_1 CDM 0305 RC 85014 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges Red blood cell concentration measurement 633742_1 CDM 0305 RC 85014 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 Red blood cell concentration measurement 633742_1 CDM 0305 RC 85014 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 Red blood cell concentration measurement 633742_1 CDM 0305 RC 85014 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 Red blood cell concentration measurement 633742_1 CDM 0305 RC 85014 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 Red blood cell concentration measurement 633742_1 CDM 0305 RC 85014 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges Iron level 633765_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 113.1 65 999999999 105.36 168.78 percent of total billed charges Iron level 633765_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 168.78 97 999999999 105.36 168.78 percent of total billed charges Iron level 633765_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 AETNA AETNA 137.46 79 999999999 105.36 168.78 percent of total billed charges Iron level 633765_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 120.06 69 999999999 105.36 168.78 percent of total billed charges Iron level 633765_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 135.72 78 999999999 105.36 168.78 percent of total billed charges Iron level 633765_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 SIHO - ALL PLANS SIHO - ALL PLANS 156.6 90 999999999 105.36 168.78 percent of total billed charges Iron level 633765_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 UMR - ALL PLANS UMR - ALL PLANS 121.8 70 999999999 105.36 168.78 percent of total billed charges Iron level 633765_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 105.36 168.78 Iron level 633765_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 105.36 60.55 999999999 105.36 168.78 percent of total billed charges Iron level 633765_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 ANTHEM HMO ANTHEM HMO 999999999 105.36 168.78 Iron level 633765_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 105.36 168.78 Iron level 633765_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 105.36 168.78 Iron level 633765_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 105.36 168.78 Iron level 633765_1 CDM 0301 RC 83540 HCPCS inpatient 174 113.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 117.62 67.6 999999999 105.36 168.78 percent of total billed charges Lactate dehydrogenase (enzyme) level 633770_1 CDM 0301 RC 83615 HCPCS inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges Lactate dehydrogenase (enzyme) level 633770_1 CDM 0301 RC 83615 HCPCS inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges Lactate dehydrogenase (enzyme) level 633770_1 CDM 0301 RC 83615 HCPCS inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges Lactate dehydrogenase (enzyme) level 633770_1 CDM 0301 RC 83615 HCPCS inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges Lactate dehydrogenase (enzyme) level 633770_1 CDM 0301 RC 83615 HCPCS inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges Lactate dehydrogenase (enzyme) level 633770_1 CDM 0301 RC 83615 HCPCS inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges Lactate dehydrogenase (enzyme) level 633770_1 CDM 0301 RC 83615 HCPCS inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges Lactate dehydrogenase (enzyme) level 633770_1 CDM 0301 RC 83615 HCPCS inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 Lactate dehydrogenase (enzyme) level 633770_1 CDM 0301 RC 83615 HCPCS inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges Lactate dehydrogenase (enzyme) level 633770_1 CDM 0301 RC 83615 HCPCS inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 Lactate dehydrogenase (enzyme) level 633770_1 CDM 0301 RC 83615 HCPCS inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 Lactate dehydrogenase (enzyme) level 633770_1 CDM 0301 RC 83615 HCPCS inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 Lactate dehydrogenase (enzyme) level 633770_1 CDM 0301 RC 83615 HCPCS inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 Lactate dehydrogenase (enzyme) level 633770_1 CDM 0301 RC 83615 HCPCS inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges Lipase (fat enzyme) level 633776_1 CDM 0301 RC 83690 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges Lipase (fat enzyme) level 633776_1 CDM 0301 RC 83690 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges Lipase (fat enzyme) level 633776_1 CDM 0301 RC 83690 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges Lipase (fat enzyme) level 633776_1 CDM 0301 RC 83690 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges Lipase (fat enzyme) level 633776_1 CDM 0301 RC 83690 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges Lipase (fat enzyme) level 633776_1 CDM 0301 RC 83690 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges Lipase (fat enzyme) level 633776_1 CDM 0301 RC 83690 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges Lipase (fat enzyme) level 633776_1 CDM 0301 RC 83690 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 Lipase (fat enzyme) level 633776_1 CDM 0301 RC 83690 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges Lipase (fat enzyme) level 633776_1 CDM 0301 RC 83690 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 Lipase (fat enzyme) level 633776_1 CDM 0301 RC 83690 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 Lipase (fat enzyme) level 633776_1 CDM 0301 RC 83690 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 Lipase (fat enzyme) level 633776_1 CDM 0301 RC 83690 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 Lipase (fat enzyme) level 633776_1 CDM 0301 RC 83690 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges Lithium level 633778_1 CDM 0301 RC 80178 HCPCS inpatient 161 104.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 104.65 65 999999999 97.49 156.17 percent of total billed charges Lithium level 633778_1 CDM 0301 RC 80178 HCPCS inpatient 161 104.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 156.17 97 999999999 97.49 156.17 percent of total billed charges Lithium level 633778_1 CDM 0301 RC 80178 HCPCS inpatient 161 104.65 AETNA AETNA 127.19 79 999999999 97.49 156.17 percent of total billed charges Lithium level 633778_1 CDM 0301 RC 80178 HCPCS inpatient 161 104.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 111.09 69 999999999 97.49 156.17 percent of total billed charges Lithium level 633778_1 CDM 0301 RC 80178 HCPCS inpatient 161 104.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 125.58 78 999999999 97.49 156.17 percent of total billed charges Lithium level 633778_1 CDM 0301 RC 80178 HCPCS inpatient 161 104.65 SIHO - ALL PLANS SIHO - ALL PLANS 144.9 90 999999999 97.49 156.17 percent of total billed charges Lithium level 633778_1 CDM 0301 RC 80178 HCPCS inpatient 161 104.65 UMR - ALL PLANS UMR - ALL PLANS 112.7 70 999999999 97.49 156.17 percent of total billed charges Lithium level 633778_1 CDM 0301 RC 80178 HCPCS inpatient 161 104.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 97.49 156.17 Lithium level 633778_1 CDM 0301 RC 80178 HCPCS inpatient 161 104.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 97.49 60.55 999999999 97.49 156.17 percent of total billed charges Lithium level 633778_1 CDM 0301 RC 80178 HCPCS inpatient 161 104.65 ANTHEM HMO ANTHEM HMO 999999999 97.49 156.17 Lithium level 633778_1 CDM 0301 RC 80178 HCPCS inpatient 161 104.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 97.49 156.17 Lithium level 633778_1 CDM 0301 RC 80178 HCPCS inpatient 161 104.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 97.49 156.17 Lithium level 633778_1 CDM 0301 RC 80178 HCPCS inpatient 161 104.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 97.49 156.17 Lithium level 633778_1 CDM 0301 RC 80178 HCPCS inpatient 161 104.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 108.84 67.6 999999999 97.49 156.17 percent of total billed charges "Gonadotropin, luteinizing (reproductive hormone) level" 633779_1 CDM 0301 RC 83002 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges "Gonadotropin, luteinizing (reproductive hormone) level" 633779_1 CDM 0301 RC 83002 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges "Gonadotropin, luteinizing (reproductive hormone) level" 633779_1 CDM 0301 RC 83002 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges "Gonadotropin, luteinizing (reproductive hormone) level" 633779_1 CDM 0301 RC 83002 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges "Gonadotropin, luteinizing (reproductive hormone) level" 633779_1 CDM 0301 RC 83002 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges "Gonadotropin, luteinizing (reproductive hormone) level" 633779_1 CDM 0301 RC 83002 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges "Gonadotropin, luteinizing (reproductive hormone) level" 633779_1 CDM 0301 RC 83002 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges "Gonadotropin, luteinizing (reproductive hormone) level" 633779_1 CDM 0301 RC 83002 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 "Gonadotropin, luteinizing (reproductive hormone) level" 633779_1 CDM 0301 RC 83002 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges "Gonadotropin, luteinizing (reproductive hormone) level" 633779_1 CDM 0301 RC 83002 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 "Gonadotropin, luteinizing (reproductive hormone) level" 633779_1 CDM 0301 RC 83002 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 "Gonadotropin, luteinizing (reproductive hormone) level" 633779_1 CDM 0301 RC 83002 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 "Gonadotropin, luteinizing (reproductive hormone) level" 633779_1 CDM 0301 RC 83002 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 "Gonadotropin, luteinizing (reproductive hormone) level" 633779_1 CDM 0301 RC 83002 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges Magnesium level 633781_1 CDM 0301 RC 83735 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges Magnesium level 633781_1 CDM 0301 RC 83735 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges Magnesium level 633781_1 CDM 0301 RC 83735 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges Magnesium level 633781_1 CDM 0301 RC 83735 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges Magnesium level 633781_1 CDM 0301 RC 83735 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges Magnesium level 633781_1 CDM 0301 RC 83735 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges Magnesium level 633781_1 CDM 0301 RC 83735 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges Magnesium level 633781_1 CDM 0301 RC 83735 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 Magnesium level 633781_1 CDM 0301 RC 83735 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges Magnesium level 633781_1 CDM 0301 RC 83735 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 Magnesium level 633781_1 CDM 0301 RC 83735 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 Magnesium level 633781_1 CDM 0301 RC 83735 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 Magnesium level 633781_1 CDM 0301 RC 83735 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 Magnesium level 633781_1 CDM 0301 RC 83735 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges Magnesium level 633783_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges Magnesium level 633783_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges Magnesium level 633783_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges Magnesium level 633783_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges Magnesium level 633783_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges Magnesium level 633783_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges Magnesium level 633783_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges Magnesium level 633783_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 Magnesium level 633783_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges Magnesium level 633783_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 Magnesium level 633783_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 Magnesium level 633783_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 Magnesium level 633783_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 Magnesium level 633783_1 CDM 0301 RC 83735 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges "Blood test, clotting time" 633793_1 CDM 0305 RC 85610 HCPCS inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges "Blood test, clotting time" 633793_1 CDM 0305 RC 85610 HCPCS inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges "Blood test, clotting time" 633793_1 CDM 0305 RC 85610 HCPCS inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges "Blood test, clotting time" 633793_1 CDM 0305 RC 85610 HCPCS inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges "Blood test, clotting time" 633793_1 CDM 0305 RC 85610 HCPCS inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges "Blood test, clotting time" 633793_1 CDM 0305 RC 85610 HCPCS inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges "Blood test, clotting time" 633793_1 CDM 0305 RC 85610 HCPCS inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges "Blood test, clotting time" 633793_1 CDM 0305 RC 85610 HCPCS inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 "Blood test, clotting time" 633793_1 CDM 0305 RC 85610 HCPCS inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges "Blood test, clotting time" 633793_1 CDM 0305 RC 85610 HCPCS inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 "Blood test, clotting time" 633793_1 CDM 0305 RC 85610 HCPCS inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 "Blood test, clotting time" 633793_1 CDM 0305 RC 85610 HCPCS inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 "Blood test, clotting time" 633793_1 CDM 0305 RC 85610 HCPCS inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 "Blood test, clotting time" 633793_1 CDM 0305 RC 85610 HCPCS inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges "Phenytoin level, total" 633801_1 CDM 0301 RC 80185 HCPCS inpatient 251 163.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 163.15 65 999999999 151.98 243.47 percent of total billed charges "Phenytoin level, total" 633801_1 CDM 0301 RC 80185 HCPCS inpatient 251 163.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 243.47 97 999999999 151.98 243.47 percent of total billed charges "Phenytoin level, total" 633801_1 CDM 0301 RC 80185 HCPCS inpatient 251 163.15 AETNA AETNA 198.29 79 999999999 151.98 243.47 percent of total billed charges "Phenytoin level, total" 633801_1 CDM 0301 RC 80185 HCPCS inpatient 251 163.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 173.19 69 999999999 151.98 243.47 percent of total billed charges "Phenytoin level, total" 633801_1 CDM 0301 RC 80185 HCPCS inpatient 251 163.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 195.78 78 999999999 151.98 243.47 percent of total billed charges "Phenytoin level, total" 633801_1 CDM 0301 RC 80185 HCPCS inpatient 251 163.15 SIHO - ALL PLANS SIHO - ALL PLANS 225.9 90 999999999 151.98 243.47 percent of total billed charges "Phenytoin level, total" 633801_1 CDM 0301 RC 80185 HCPCS inpatient 251 163.15 UMR - ALL PLANS UMR - ALL PLANS 175.7 70 999999999 151.98 243.47 percent of total billed charges "Phenytoin level, total" 633801_1 CDM 0301 RC 80185 HCPCS inpatient 251 163.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 151.98 243.47 "Phenytoin level, total" 633801_1 CDM 0301 RC 80185 HCPCS inpatient 251 163.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 151.98 60.55 999999999 151.98 243.47 percent of total billed charges "Phenytoin level, total" 633801_1 CDM 0301 RC 80185 HCPCS inpatient 251 163.15 ANTHEM HMO ANTHEM HMO 999999999 151.98 243.47 "Phenytoin level, total" 633801_1 CDM 0301 RC 80185 HCPCS inpatient 251 163.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 151.98 243.47 "Phenytoin level, total" 633801_1 CDM 0301 RC 80185 HCPCS inpatient 251 163.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 151.98 243.47 "Phenytoin level, total" 633801_1 CDM 0301 RC 80185 HCPCS inpatient 251 163.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 151.98 243.47 "Phenytoin level, total" 633801_1 CDM 0301 RC 80185 HCPCS inpatient 251 163.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 169.68 67.6 999999999 151.98 243.47 percent of total billed charges Phosphate level 633803_1 CDM 0301 RC 84100 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges Phosphate level 633803_1 CDM 0301 RC 84100 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges Phosphate level 633803_1 CDM 0301 RC 84100 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges Phosphate level 633803_1 CDM 0301 RC 84100 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges Phosphate level 633803_1 CDM 0301 RC 84100 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges Phosphate level 633803_1 CDM 0301 RC 84100 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges Phosphate level 633803_1 CDM 0301 RC 84100 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges Phosphate level 633803_1 CDM 0301 RC 84100 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 Phosphate level 633803_1 CDM 0301 RC 84100 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges Phosphate level 633803_1 CDM 0301 RC 84100 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 Phosphate level 633803_1 CDM 0301 RC 84100 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 Phosphate level 633803_1 CDM 0301 RC 84100 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 Phosphate level 633803_1 CDM 0301 RC 84100 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Phosphate level 633803_1 CDM 0301 RC 84100 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Platelet count, automated test" 633807_1 CDM 0305 RC 85049 HCPCS inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges "Platelet count, automated test" 633807_1 CDM 0305 RC 85049 HCPCS inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges "Platelet count, automated test" 633807_1 CDM 0305 RC 85049 HCPCS inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges "Platelet count, automated test" 633807_1 CDM 0305 RC 85049 HCPCS inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges "Platelet count, automated test" 633807_1 CDM 0305 RC 85049 HCPCS inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges "Platelet count, automated test" 633807_1 CDM 0305 RC 85049 HCPCS inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges "Platelet count, automated test" 633807_1 CDM 0305 RC 85049 HCPCS inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges "Platelet count, automated test" 633807_1 CDM 0305 RC 85049 HCPCS inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 "Platelet count, automated test" 633807_1 CDM 0305 RC 85049 HCPCS inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges "Platelet count, automated test" 633807_1 CDM 0305 RC 85049 HCPCS inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 "Platelet count, automated test" 633807_1 CDM 0305 RC 85049 HCPCS inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 "Platelet count, automated test" 633807_1 CDM 0305 RC 85049 HCPCS inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 "Platelet count, automated test" 633807_1 CDM 0305 RC 85049 HCPCS inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 "Platelet count, automated test" 633807_1 CDM 0305 RC 85049 HCPCS inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges Prolactin (milk producing hormone) level 633809_1 CDM 0301 RC 84146 HCPCS inpatient 293 190.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 190.45 65 999999999 177.41 284.21 percent of total billed charges Prolactin (milk producing hormone) level 633809_1 CDM 0301 RC 84146 HCPCS inpatient 293 190.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 284.21 97 999999999 177.41 284.21 percent of total billed charges Prolactin (milk producing hormone) level 633809_1 CDM 0301 RC 84146 HCPCS inpatient 293 190.45 AETNA AETNA 231.47 79 999999999 177.41 284.21 percent of total billed charges Prolactin (milk producing hormone) level 633809_1 CDM 0301 RC 84146 HCPCS inpatient 293 190.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 202.17 69 999999999 177.41 284.21 percent of total billed charges Prolactin (milk producing hormone) level 633809_1 CDM 0301 RC 84146 HCPCS inpatient 293 190.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 228.54 78 999999999 177.41 284.21 percent of total billed charges Prolactin (milk producing hormone) level 633809_1 CDM 0301 RC 84146 HCPCS inpatient 293 190.45 SIHO - ALL PLANS SIHO - ALL PLANS 263.7 90 999999999 177.41 284.21 percent of total billed charges Prolactin (milk producing hormone) level 633809_1 CDM 0301 RC 84146 HCPCS inpatient 293 190.45 UMR - ALL PLANS UMR - ALL PLANS 205.1 70 999999999 177.41 284.21 percent of total billed charges Prolactin (milk producing hormone) level 633809_1 CDM 0301 RC 84146 HCPCS inpatient 293 190.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 177.41 284.21 Prolactin (milk producing hormone) level 633809_1 CDM 0301 RC 84146 HCPCS inpatient 293 190.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 177.41 60.55 999999999 177.41 284.21 percent of total billed charges Prolactin (milk producing hormone) level 633809_1 CDM 0301 RC 84146 HCPCS inpatient 293 190.45 ANTHEM HMO ANTHEM HMO 999999999 177.41 284.21 Prolactin (milk producing hormone) level 633809_1 CDM 0301 RC 84146 HCPCS inpatient 293 190.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 177.41 284.21 Prolactin (milk producing hormone) level 633809_1 CDM 0301 RC 84146 HCPCS inpatient 293 190.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 177.41 284.21 Prolactin (milk producing hormone) level 633809_1 CDM 0301 RC 84146 HCPCS inpatient 293 190.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 177.41 284.21 Prolactin (milk producing hormone) level 633809_1 CDM 0301 RC 84146 HCPCS inpatient 293 190.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 198.07 67.6 999999999 177.41 284.21 percent of total billed charges "Total protein level, body fluid" 633813_1 CDM 0301 RC 84157 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges "Total protein level, body fluid" 633813_1 CDM 0301 RC 84157 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges "Total protein level, body fluid" 633813_1 CDM 0301 RC 84157 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges "Total protein level, body fluid" 633813_1 CDM 0301 RC 84157 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges "Total protein level, body fluid" 633813_1 CDM 0301 RC 84157 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges "Total protein level, body fluid" 633813_1 CDM 0301 RC 84157 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges "Total protein level, body fluid" 633813_1 CDM 0301 RC 84157 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges "Total protein level, body fluid" 633813_1 CDM 0301 RC 84157 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 "Total protein level, body fluid" 633813_1 CDM 0301 RC 84157 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges "Total protein level, body fluid" 633813_1 CDM 0301 RC 84157 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 "Total protein level, body fluid" 633813_1 CDM 0301 RC 84157 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 "Total protein level, body fluid" 633813_1 CDM 0301 RC 84157 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 "Total protein level, body fluid" 633813_1 CDM 0301 RC 84157 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 "Total protein level, body fluid" 633813_1 CDM 0301 RC 84157 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges "Total protein level, urine" 633818_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.3 65 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 633818_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 137.74 97 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 633818_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 AETNA AETNA 112.18 79 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 633818_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 97.98 69 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 633818_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 110.76 78 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 633818_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 SIHO - ALL PLANS SIHO - ALL PLANS 127.8 90 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 633818_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 UMR - ALL PLANS UMR - ALL PLANS 99.4 70 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 633818_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 85.98 137.74 "Total protein level, urine" 633818_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 85.98 60.55 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 633818_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 ANTHEM HMO ANTHEM HMO 999999999 85.98 137.74 "Total protein level, urine" 633818_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 85.98 137.74 "Total protein level, urine" 633818_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 85.98 137.74 "Total protein level, urine" 633818_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 85.98 137.74 "Total protein level, urine" 633818_1 CDM 0301 RC 84156 HCPCS inpatient 142 92.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 95.99 67.6 999999999 85.98 137.74 percent of total billed charges "Total protein level, urine" 633819_1 CDM 0301 RC 84156 HCPCS inpatient 167 108.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 108.55 65 999999999 101.12 161.99 percent of total billed charges "Total protein level, urine" 633819_1 CDM 0301 RC 84156 HCPCS inpatient 167 108.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.99 97 999999999 101.12 161.99 percent of total billed charges "Total protein level, urine" 633819_1 CDM 0301 RC 84156 HCPCS inpatient 167 108.55 AETNA AETNA 131.93 79 999999999 101.12 161.99 percent of total billed charges "Total protein level, urine" 633819_1 CDM 0301 RC 84156 HCPCS inpatient 167 108.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.23 69 999999999 101.12 161.99 percent of total billed charges "Total protein level, urine" 633819_1 CDM 0301 RC 84156 HCPCS inpatient 167 108.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 130.26 78 999999999 101.12 161.99 percent of total billed charges "Total protein level, urine" 633819_1 CDM 0301 RC 84156 HCPCS inpatient 167 108.55 SIHO - ALL PLANS SIHO - ALL PLANS 150.3 90 999999999 101.12 161.99 percent of total billed charges "Total protein level, urine" 633819_1 CDM 0301 RC 84156 HCPCS inpatient 167 108.55 UMR - ALL PLANS UMR - ALL PLANS 116.9 70 999999999 101.12 161.99 percent of total billed charges "Total protein level, urine" 633819_1 CDM 0301 RC 84156 HCPCS inpatient 167 108.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.12 161.99 "Total protein level, urine" 633819_1 CDM 0301 RC 84156 HCPCS inpatient 167 108.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.12 60.55 999999999 101.12 161.99 percent of total billed charges "Total protein level, urine" 633819_1 CDM 0301 RC 84156 HCPCS inpatient 167 108.55 ANTHEM HMO ANTHEM HMO 999999999 101.12 161.99 "Total protein level, urine" 633819_1 CDM 0301 RC 84156 HCPCS inpatient 167 108.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.12 161.99 "Total protein level, urine" 633819_1 CDM 0301 RC 84156 HCPCS inpatient 167 108.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.12 161.99 "Total protein level, urine" 633819_1 CDM 0301 RC 84156 HCPCS inpatient 167 108.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.12 161.99 "Total protein level, urine" 633819_1 CDM 0301 RC 84156 HCPCS inpatient 167 108.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.89 67.6 999999999 101.12 161.99 percent of total billed charges Measurement of salicylate 633829_1 CDM 0301 RC 80179 HCPCS inpatient 213 138.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 138.45 65 999999999 128.97 206.61 percent of total billed charges Measurement of salicylate 633829_1 CDM 0301 RC 80179 HCPCS inpatient 213 138.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 206.61 97 999999999 128.97 206.61 percent of total billed charges Measurement of salicylate 633829_1 CDM 0301 RC 80179 HCPCS inpatient 213 138.45 AETNA AETNA 168.27 79 999999999 128.97 206.61 percent of total billed charges Measurement of salicylate 633829_1 CDM 0301 RC 80179 HCPCS inpatient 213 138.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 146.97 69 999999999 128.97 206.61 percent of total billed charges Measurement of salicylate 633829_1 CDM 0301 RC 80179 HCPCS inpatient 213 138.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 166.14 78 999999999 128.97 206.61 percent of total billed charges Measurement of salicylate 633829_1 CDM 0301 RC 80179 HCPCS inpatient 213 138.45 SIHO - ALL PLANS SIHO - ALL PLANS 191.7 90 999999999 128.97 206.61 percent of total billed charges Measurement of salicylate 633829_1 CDM 0301 RC 80179 HCPCS inpatient 213 138.45 UMR - ALL PLANS UMR - ALL PLANS 149.1 70 999999999 128.97 206.61 percent of total billed charges Measurement of salicylate 633829_1 CDM 0301 RC 80179 HCPCS inpatient 213 138.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 128.97 206.61 Measurement of salicylate 633829_1 CDM 0301 RC 80179 HCPCS inpatient 213 138.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 128.97 60.55 999999999 128.97 206.61 percent of total billed charges Measurement of salicylate 633829_1 CDM 0301 RC 80179 HCPCS inpatient 213 138.45 ANTHEM HMO ANTHEM HMO 999999999 128.97 206.61 Measurement of salicylate 633829_1 CDM 0301 RC 80179 HCPCS inpatient 213 138.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 128.97 206.61 Measurement of salicylate 633829_1 CDM 0301 RC 80179 HCPCS inpatient 213 138.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 128.97 206.61 Measurement of salicylate 633829_1 CDM 0301 RC 80179 HCPCS inpatient 213 138.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 128.97 206.61 Measurement of salicylate 633829_1 CDM 0301 RC 80179 HCPCS inpatient 213 138.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 143.99 67.6 999999999 128.97 206.61 percent of total billed charges "Red blood cell sedimentation rate, to detect inflammation, non-automated" 633830_1 CDM 0300 RC 85651 HCPCS inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges "Red blood cell sedimentation rate, to detect inflammation, non-automated" 633830_1 CDM 0300 RC 85651 HCPCS inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges "Red blood cell sedimentation rate, to detect inflammation, non-automated" 633830_1 CDM 0300 RC 85651 HCPCS inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges "Red blood cell sedimentation rate, to detect inflammation, non-automated" 633830_1 CDM 0300 RC 85651 HCPCS inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges "Red blood cell sedimentation rate, to detect inflammation, non-automated" 633830_1 CDM 0300 RC 85651 HCPCS inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges "Red blood cell sedimentation rate, to detect inflammation, non-automated" 633830_1 CDM 0300 RC 85651 HCPCS inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges "Red blood cell sedimentation rate, to detect inflammation, non-automated" 633830_1 CDM 0300 RC 85651 HCPCS inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges "Red blood cell sedimentation rate, to detect inflammation, non-automated" 633830_1 CDM 0300 RC 85651 HCPCS inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 "Red blood cell sedimentation rate, to detect inflammation, non-automated" 633830_1 CDM 0300 RC 85651 HCPCS inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges "Red blood cell sedimentation rate, to detect inflammation, non-automated" 633830_1 CDM 0300 RC 85651 HCPCS inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 "Red blood cell sedimentation rate, to detect inflammation, non-automated" 633830_1 CDM 0300 RC 85651 HCPCS inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 "Red blood cell sedimentation rate, to detect inflammation, non-automated" 633830_1 CDM 0300 RC 85651 HCPCS inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 "Red blood cell sedimentation rate, to detect inflammation, non-automated" 633830_1 CDM 0300 RC 85651 HCPCS inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 "Red blood cell sedimentation rate, to detect inflammation, non-automated" 633830_1 CDM 0300 RC 85651 HCPCS inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges "Thyroid hormone, T3 measurement, free" 633834_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 183.95 65 999999999 171.36 274.51 percent of total billed charges "Thyroid hormone, T3 measurement, free" 633834_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 274.51 97 999999999 171.36 274.51 percent of total billed charges "Thyroid hormone, T3 measurement, free" 633834_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 AETNA AETNA 223.57 79 999999999 171.36 274.51 percent of total billed charges "Thyroid hormone, T3 measurement, free" 633834_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 195.27 69 999999999 171.36 274.51 percent of total billed charges "Thyroid hormone, T3 measurement, free" 633834_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 220.74 78 999999999 171.36 274.51 percent of total billed charges "Thyroid hormone, T3 measurement, free" 633834_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 SIHO - ALL PLANS SIHO - ALL PLANS 254.7 90 999999999 171.36 274.51 percent of total billed charges "Thyroid hormone, T3 measurement, free" 633834_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 UMR - ALL PLANS UMR - ALL PLANS 198.1 70 999999999 171.36 274.51 percent of total billed charges "Thyroid hormone, T3 measurement, free" 633834_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 171.36 274.51 "Thyroid hormone, T3 measurement, free" 633834_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 171.36 60.55 999999999 171.36 274.51 percent of total billed charges "Thyroid hormone, T3 measurement, free" 633834_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 ANTHEM HMO ANTHEM HMO 999999999 171.36 274.51 "Thyroid hormone, T3 measurement, free" 633834_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 171.36 274.51 "Thyroid hormone, T3 measurement, free" 633834_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 171.36 274.51 "Thyroid hormone, T3 measurement, free" 633834_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 171.36 274.51 "Thyroid hormone, T3 measurement, free" 633834_1 CDM 0301 RC 84481 HCPCS inpatient 283 183.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 191.31 67.6 999999999 171.36 274.51 percent of total billed charges Theophylline level 633839_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 152.1 65 999999999 141.69 226.98 percent of total billed charges Theophylline level 633839_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 226.98 97 999999999 141.69 226.98 percent of total billed charges Theophylline level 633839_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 AETNA AETNA 184.86 79 999999999 141.69 226.98 percent of total billed charges Theophylline level 633839_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 161.46 69 999999999 141.69 226.98 percent of total billed charges Theophylline level 633839_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 182.52 78 999999999 141.69 226.98 percent of total billed charges Theophylline level 633839_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 SIHO - ALL PLANS SIHO - ALL PLANS 210.6 90 999999999 141.69 226.98 percent of total billed charges Theophylline level 633839_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 UMR - ALL PLANS UMR - ALL PLANS 163.8 70 999999999 141.69 226.98 percent of total billed charges Theophylline level 633839_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 141.69 226.98 Theophylline level 633839_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 141.69 60.55 999999999 141.69 226.98 percent of total billed charges Theophylline level 633839_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 ANTHEM HMO ANTHEM HMO 999999999 141.69 226.98 Theophylline level 633839_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 141.69 226.98 Theophylline level 633839_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 141.69 226.98 Theophylline level 633839_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 141.69 226.98 Theophylline level 633839_1 CDM 0301 RC 80198 HCPCS inpatient 234 152.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 158.18 67.6 999999999 141.69 226.98 percent of total billed charges "Blood test, thyroid stimulating hormone (TSH)" 633844_1 CDM 0301 RC 84443 HCPCS inpatient 271 176.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 176.15 65 999999999 164.09 262.87 percent of total billed charges "Blood test, thyroid stimulating hormone (TSH)" 633844_1 CDM 0301 RC 84443 HCPCS inpatient 271 176.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 262.87 97 999999999 164.09 262.87 percent of total billed charges "Blood test, thyroid stimulating hormone (TSH)" 633844_1 CDM 0301 RC 84443 HCPCS inpatient 271 176.15 AETNA AETNA 214.09 79 999999999 164.09 262.87 percent of total billed charges "Blood test, thyroid stimulating hormone (TSH)" 633844_1 CDM 0301 RC 84443 HCPCS inpatient 271 176.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 186.99 69 999999999 164.09 262.87 percent of total billed charges "Blood test, thyroid stimulating hormone (TSH)" 633844_1 CDM 0301 RC 84443 HCPCS inpatient 271 176.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 211.38 78 999999999 164.09 262.87 percent of total billed charges "Blood test, thyroid stimulating hormone (TSH)" 633844_1 CDM 0301 RC 84443 HCPCS inpatient 271 176.15 SIHO - ALL PLANS SIHO - ALL PLANS 243.9 90 999999999 164.09 262.87 percent of total billed charges "Blood test, thyroid stimulating hormone (TSH)" 633844_1 CDM 0301 RC 84443 HCPCS inpatient 271 176.15 UMR - ALL PLANS UMR - ALL PLANS 189.7 70 999999999 164.09 262.87 percent of total billed charges "Blood test, thyroid stimulating hormone (TSH)" 633844_1 CDM 0301 RC 84443 HCPCS inpatient 271 176.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 164.09 262.87 "Blood test, thyroid stimulating hormone (TSH)" 633844_1 CDM 0301 RC 84443 HCPCS inpatient 271 176.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 164.09 60.55 999999999 164.09 262.87 percent of total billed charges "Blood test, thyroid stimulating hormone (TSH)" 633844_1 CDM 0301 RC 84443 HCPCS inpatient 271 176.15 ANTHEM HMO ANTHEM HMO 999999999 164.09 262.87 "Blood test, thyroid stimulating hormone (TSH)" 633844_1 CDM 0301 RC 84443 HCPCS inpatient 271 176.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 164.09 262.87 "Blood test, thyroid stimulating hormone (TSH)" 633844_1 CDM 0301 RC 84443 HCPCS inpatient 271 176.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 164.09 262.87 "Blood test, thyroid stimulating hormone (TSH)" 633844_1 CDM 0301 RC 84443 HCPCS inpatient 271 176.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 164.09 262.87 "Blood test, thyroid stimulating hormone (TSH)" 633844_1 CDM 0301 RC 84443 HCPCS inpatient 271 176.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 183.2 67.6 999999999 164.09 262.87 percent of total billed charges "Thyroxine (thyroid chemical), total" 633845_1 CDM 0301 RC 84436 HCPCS inpatient 155 100.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.75 65 999999999 93.85 150.35 percent of total billed charges "Thyroxine (thyroid chemical), total" 633845_1 CDM 0301 RC 84436 HCPCS inpatient 155 100.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 150.35 97 999999999 93.85 150.35 percent of total billed charges "Thyroxine (thyroid chemical), total" 633845_1 CDM 0301 RC 84436 HCPCS inpatient 155 100.75 AETNA AETNA 122.45 79 999999999 93.85 150.35 percent of total billed charges "Thyroxine (thyroid chemical), total" 633845_1 CDM 0301 RC 84436 HCPCS inpatient 155 100.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.95 69 999999999 93.85 150.35 percent of total billed charges "Thyroxine (thyroid chemical), total" 633845_1 CDM 0301 RC 84436 HCPCS inpatient 155 100.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.9 78 999999999 93.85 150.35 percent of total billed charges "Thyroxine (thyroid chemical), total" 633845_1 CDM 0301 RC 84436 HCPCS inpatient 155 100.75 SIHO - ALL PLANS SIHO - ALL PLANS 139.5 90 999999999 93.85 150.35 percent of total billed charges "Thyroxine (thyroid chemical), total" 633845_1 CDM 0301 RC 84436 HCPCS inpatient 155 100.75 UMR - ALL PLANS UMR - ALL PLANS 108.5 70 999999999 93.85 150.35 percent of total billed charges "Thyroxine (thyroid chemical), total" 633845_1 CDM 0301 RC 84436 HCPCS inpatient 155 100.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.85 150.35 "Thyroxine (thyroid chemical), total" 633845_1 CDM 0301 RC 84436 HCPCS inpatient 155 100.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.85 60.55 999999999 93.85 150.35 percent of total billed charges "Thyroxine (thyroid chemical), total" 633845_1 CDM 0301 RC 84436 HCPCS inpatient 155 100.75 ANTHEM HMO ANTHEM HMO 999999999 93.85 150.35 "Thyroxine (thyroid chemical), total" 633845_1 CDM 0301 RC 84436 HCPCS inpatient 155 100.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.85 150.35 "Thyroxine (thyroid chemical), total" 633845_1 CDM 0301 RC 84436 HCPCS inpatient 155 100.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.85 150.35 "Thyroxine (thyroid chemical), total" 633845_1 CDM 0301 RC 84436 HCPCS inpatient 155 100.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.85 150.35 "Thyroxine (thyroid chemical), total" 633845_1 CDM 0301 RC 84436 HCPCS inpatient 155 100.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.78 67.6 999999999 93.85 150.35 percent of total billed charges "Thyroxine (thyroid chemical), free" 633846_1 CDM 0301 RC 84439 HCPCS inpatient 210 136.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 136.5 65 999999999 127.16 203.7 percent of total billed charges "Thyroxine (thyroid chemical), free" 633846_1 CDM 0301 RC 84439 HCPCS inpatient 210 136.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 203.7 97 999999999 127.16 203.7 percent of total billed charges "Thyroxine (thyroid chemical), free" 633846_1 CDM 0301 RC 84439 HCPCS inpatient 210 136.5 AETNA AETNA 165.9 79 999999999 127.16 203.7 percent of total billed charges "Thyroxine (thyroid chemical), free" 633846_1 CDM 0301 RC 84439 HCPCS inpatient 210 136.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 144.9 69 999999999 127.16 203.7 percent of total billed charges "Thyroxine (thyroid chemical), free" 633846_1 CDM 0301 RC 84439 HCPCS inpatient 210 136.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 163.8 78 999999999 127.16 203.7 percent of total billed charges "Thyroxine (thyroid chemical), free" 633846_1 CDM 0301 RC 84439 HCPCS inpatient 210 136.5 SIHO - ALL PLANS SIHO - ALL PLANS 189 90 999999999 127.16 203.7 percent of total billed charges "Thyroxine (thyroid chemical), free" 633846_1 CDM 0301 RC 84439 HCPCS inpatient 210 136.5 UMR - ALL PLANS UMR - ALL PLANS 147 70 999999999 127.16 203.7 percent of total billed charges "Thyroxine (thyroid chemical), free" 633846_1 CDM 0301 RC 84439 HCPCS inpatient 210 136.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.16 203.7 "Thyroxine (thyroid chemical), free" 633846_1 CDM 0301 RC 84439 HCPCS inpatient 210 136.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.16 60.55 999999999 127.16 203.7 percent of total billed charges "Thyroxine (thyroid chemical), free" 633846_1 CDM 0301 RC 84439 HCPCS inpatient 210 136.5 ANTHEM HMO ANTHEM HMO 999999999 127.16 203.7 "Thyroxine (thyroid chemical), free" 633846_1 CDM 0301 RC 84439 HCPCS inpatient 210 136.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.16 203.7 "Thyroxine (thyroid chemical), free" 633846_1 CDM 0301 RC 84439 HCPCS inpatient 210 136.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.16 203.7 "Thyroxine (thyroid chemical), free" 633846_1 CDM 0301 RC 84439 HCPCS inpatient 210 136.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.16 203.7 "Thyroxine (thyroid chemical), free" 633846_1 CDM 0301 RC 84439 HCPCS inpatient 210 136.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 141.96 67.6 999999999 127.16 203.7 percent of total billed charges Tobramycin (antibiotic) level 633847_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 213.2 65 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633847_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 318.16 97 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633847_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 AETNA AETNA 259.12 79 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633847_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 226.32 69 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633847_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.84 78 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633847_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 SIHO - ALL PLANS SIHO - ALL PLANS 295.2 90 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633847_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 UMR - ALL PLANS UMR - ALL PLANS 229.6 70 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633847_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198.6 318.16 Tobramycin (antibiotic) level 633847_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198.6 60.55 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633847_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM HMO ANTHEM HMO 999999999 198.6 318.16 Tobramycin (antibiotic) level 633847_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198.6 318.16 Tobramycin (antibiotic) level 633847_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198.6 318.16 Tobramycin (antibiotic) level 633847_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 198.6 318.16 Tobramycin (antibiotic) level 633847_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.73 67.6 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633848_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 213.2 65 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633848_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 318.16 97 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633848_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 AETNA AETNA 259.12 79 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633848_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 226.32 69 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633848_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.84 78 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633848_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 SIHO - ALL PLANS SIHO - ALL PLANS 295.2 90 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633848_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 UMR - ALL PLANS UMR - ALL PLANS 229.6 70 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633848_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198.6 318.16 Tobramycin (antibiotic) level 633848_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198.6 60.55 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633848_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM HMO ANTHEM HMO 999999999 198.6 318.16 Tobramycin (antibiotic) level 633848_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198.6 318.16 Tobramycin (antibiotic) level 633848_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198.6 318.16 Tobramycin (antibiotic) level 633848_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 198.6 318.16 Tobramycin (antibiotic) level 633848_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.73 67.6 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633849_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 213.2 65 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633849_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 318.16 97 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633849_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 AETNA AETNA 259.12 79 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633849_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 226.32 69 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633849_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.84 78 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633849_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 SIHO - ALL PLANS SIHO - ALL PLANS 295.2 90 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633849_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 UMR - ALL PLANS UMR - ALL PLANS 229.6 70 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633849_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198.6 318.16 Tobramycin (antibiotic) level 633849_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198.6 60.55 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 633849_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM HMO ANTHEM HMO 999999999 198.6 318.16 Tobramycin (antibiotic) level 633849_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198.6 318.16 Tobramycin (antibiotic) level 633849_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198.6 318.16 Tobramycin (antibiotic) level 633849_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 198.6 318.16 Tobramycin (antibiotic) level 633849_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.73 67.6 999999999 198.6 318.16 percent of total billed charges Transferrin (iron binding protein) level 633851_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 SELF PAY DISCOUNT SELF PAY DISCOUNT 91 65 999999999 84.77 135.8 percent of total billed charges Transferrin (iron binding protein) level 633851_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 135.8 97 999999999 84.77 135.8 percent of total billed charges Transferrin (iron binding protein) level 633851_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 AETNA AETNA 110.6 79 999999999 84.77 135.8 percent of total billed charges Transferrin (iron binding protein) level 633851_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 ENCORE - ALL PLANS ENCORE - ALL PLANS 96.6 69 999999999 84.77 135.8 percent of total billed charges Transferrin (iron binding protein) level 633851_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 HUMANA - ALL PLANS HUMANA - ALL PLANS 109.2 78 999999999 84.77 135.8 percent of total billed charges Transferrin (iron binding protein) level 633851_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 SIHO - ALL PLANS SIHO - ALL PLANS 126 90 999999999 84.77 135.8 percent of total billed charges Transferrin (iron binding protein) level 633851_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 UMR - ALL PLANS UMR - ALL PLANS 98 70 999999999 84.77 135.8 percent of total billed charges Transferrin (iron binding protein) level 633851_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 84.77 135.8 Transferrin (iron binding protein) level 633851_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 84.77 60.55 999999999 84.77 135.8 percent of total billed charges Transferrin (iron binding protein) level 633851_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 ANTHEM HMO ANTHEM HMO 999999999 84.77 135.8 Transferrin (iron binding protein) level 633851_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 84.77 135.8 Transferrin (iron binding protein) level 633851_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 84.77 135.8 Transferrin (iron binding protein) level 633851_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 UHC - ALL PLANS UHC - ALL PLANS 999999999 84.77 135.8 Transferrin (iron binding protein) level 633851_1 CDM 0301 RC 84466 HCPCS inpatient 140 91 CIGNA - ALL PLANS CIGNA - ALL PLANS 94.64 67.6 999999999 84.77 135.8 percent of total billed charges Triglycerides level 633852_1 CDM 0301 RC 84478 HCPCS inpatient 83 53.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.95 65 999999999 50.26 80.51 percent of total billed charges Triglycerides level 633852_1 CDM 0301 RC 84478 HCPCS inpatient 83 53.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 80.51 97 999999999 50.26 80.51 percent of total billed charges Triglycerides level 633852_1 CDM 0301 RC 84478 HCPCS inpatient 83 53.95 AETNA AETNA 65.57 79 999999999 50.26 80.51 percent of total billed charges Triglycerides level 633852_1 CDM 0301 RC 84478 HCPCS inpatient 83 53.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 57.27 69 999999999 50.26 80.51 percent of total billed charges Triglycerides level 633852_1 CDM 0301 RC 84478 HCPCS inpatient 83 53.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 64.74 78 999999999 50.26 80.51 percent of total billed charges Triglycerides level 633852_1 CDM 0301 RC 84478 HCPCS inpatient 83 53.95 SIHO - ALL PLANS SIHO - ALL PLANS 74.7 90 999999999 50.26 80.51 percent of total billed charges Triglycerides level 633852_1 CDM 0301 RC 84478 HCPCS inpatient 83 53.95 UMR - ALL PLANS UMR - ALL PLANS 58.1 70 999999999 50.26 80.51 percent of total billed charges Triglycerides level 633852_1 CDM 0301 RC 84478 HCPCS inpatient 83 53.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 50.26 80.51 Triglycerides level 633852_1 CDM 0301 RC 84478 HCPCS inpatient 83 53.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 50.26 60.55 999999999 50.26 80.51 percent of total billed charges Triglycerides level 633852_1 CDM 0301 RC 84478 HCPCS inpatient 83 53.95 ANTHEM HMO ANTHEM HMO 999999999 50.26 80.51 Triglycerides level 633852_1 CDM 0301 RC 84478 HCPCS inpatient 83 53.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 50.26 80.51 Triglycerides level 633852_1 CDM 0301 RC 84478 HCPCS inpatient 83 53.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 50.26 80.51 Triglycerides level 633852_1 CDM 0301 RC 84478 HCPCS inpatient 83 53.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 50.26 80.51 Triglycerides level 633852_1 CDM 0301 RC 84478 HCPCS inpatient 83 53.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 56.11 67.6 999999999 50.26 80.51 percent of total billed charges "Uric acid level, blood" 633858_1 CDM 0301 RC 84550 HCPCS inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges "Uric acid level, blood" 633858_1 CDM 0301 RC 84550 HCPCS inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges "Uric acid level, blood" 633858_1 CDM 0301 RC 84550 HCPCS inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges "Uric acid level, blood" 633858_1 CDM 0301 RC 84550 HCPCS inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges "Uric acid level, blood" 633858_1 CDM 0301 RC 84550 HCPCS inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges "Uric acid level, blood" 633858_1 CDM 0301 RC 84550 HCPCS inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges "Uric acid level, blood" 633858_1 CDM 0301 RC 84550 HCPCS inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges "Uric acid level, blood" 633858_1 CDM 0301 RC 84550 HCPCS inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 "Uric acid level, blood" 633858_1 CDM 0301 RC 84550 HCPCS inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges "Uric acid level, blood" 633858_1 CDM 0301 RC 84550 HCPCS inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 "Uric acid level, blood" 633858_1 CDM 0301 RC 84550 HCPCS inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 "Uric acid level, blood" 633858_1 CDM 0301 RC 84550 HCPCS inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 "Uric acid level, blood" 633858_1 CDM 0301 RC 84550 HCPCS inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 "Uric acid level, blood" 633858_1 CDM 0301 RC 84550 HCPCS inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges "Valproic acid level, total" 633867_1 CDM 0301 RC 80164 HCPCS inpatient 148 96.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 96.2 65 999999999 89.61 143.56 percent of total billed charges "Valproic acid level, total" 633867_1 CDM 0301 RC 80164 HCPCS inpatient 148 96.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 143.56 97 999999999 89.61 143.56 percent of total billed charges "Valproic acid level, total" 633867_1 CDM 0301 RC 80164 HCPCS inpatient 148 96.2 AETNA AETNA 116.92 79 999999999 89.61 143.56 percent of total billed charges "Valproic acid level, total" 633867_1 CDM 0301 RC 80164 HCPCS inpatient 148 96.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 102.12 69 999999999 89.61 143.56 percent of total billed charges "Valproic acid level, total" 633867_1 CDM 0301 RC 80164 HCPCS inpatient 148 96.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 115.44 78 999999999 89.61 143.56 percent of total billed charges "Valproic acid level, total" 633867_1 CDM 0301 RC 80164 HCPCS inpatient 148 96.2 SIHO - ALL PLANS SIHO - ALL PLANS 133.2 90 999999999 89.61 143.56 percent of total billed charges "Valproic acid level, total" 633867_1 CDM 0301 RC 80164 HCPCS inpatient 148 96.2 UMR - ALL PLANS UMR - ALL PLANS 103.6 70 999999999 89.61 143.56 percent of total billed charges "Valproic acid level, total" 633867_1 CDM 0301 RC 80164 HCPCS inpatient 148 96.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 89.61 143.56 "Valproic acid level, total" 633867_1 CDM 0301 RC 80164 HCPCS inpatient 148 96.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 89.61 60.55 999999999 89.61 143.56 percent of total billed charges "Valproic acid level, total" 633867_1 CDM 0301 RC 80164 HCPCS inpatient 148 96.2 ANTHEM HMO ANTHEM HMO 999999999 89.61 143.56 "Valproic acid level, total" 633867_1 CDM 0301 RC 80164 HCPCS inpatient 148 96.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 89.61 143.56 "Valproic acid level, total" 633867_1 CDM 0301 RC 80164 HCPCS inpatient 148 96.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 89.61 143.56 "Valproic acid level, total" 633867_1 CDM 0301 RC 80164 HCPCS inpatient 148 96.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 89.61 143.56 "Valproic acid level, total" 633867_1 CDM 0301 RC 80164 HCPCS inpatient 148 96.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 100.05 67.6 999999999 89.61 143.56 percent of total billed charges Vancomycin (antibiotic) level 633868_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 131.3 65 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633868_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 195.94 97 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633868_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 AETNA AETNA 159.58 79 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633868_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 139.38 69 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633868_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 157.56 78 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633868_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 SIHO - ALL PLANS SIHO - ALL PLANS 181.8 90 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633868_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 UMR - ALL PLANS UMR - ALL PLANS 141.4 70 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633868_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 122.31 195.94 Vancomycin (antibiotic) level 633868_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 122.31 60.55 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633868_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ANTHEM HMO ANTHEM HMO 999999999 122.31 195.94 Vancomycin (antibiotic) level 633868_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 122.31 195.94 Vancomycin (antibiotic) level 633868_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 122.31 195.94 Vancomycin (antibiotic) level 633868_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 122.31 195.94 Vancomycin (antibiotic) level 633868_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 136.55 67.6 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633869_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 131.3 65 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633869_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 195.94 97 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633869_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 AETNA AETNA 159.58 79 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633869_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 139.38 69 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633869_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 157.56 78 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633869_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 SIHO - ALL PLANS SIHO - ALL PLANS 181.8 90 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633869_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 UMR - ALL PLANS UMR - ALL PLANS 141.4 70 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633869_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 122.31 195.94 Vancomycin (antibiotic) level 633869_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 122.31 60.55 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633869_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ANTHEM HMO ANTHEM HMO 999999999 122.31 195.94 Vancomycin (antibiotic) level 633869_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 122.31 195.94 Vancomycin (antibiotic) level 633869_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 122.31 195.94 Vancomycin (antibiotic) level 633869_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 122.31 195.94 Vancomycin (antibiotic) level 633869_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 136.55 67.6 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633870_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 131.3 65 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633870_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 195.94 97 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633870_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 AETNA AETNA 159.58 79 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633870_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 139.38 69 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633870_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 157.56 78 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633870_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 SIHO - ALL PLANS SIHO - ALL PLANS 181.8 90 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633870_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 UMR - ALL PLANS UMR - ALL PLANS 141.4 70 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633870_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 122.31 195.94 Vancomycin (antibiotic) level 633870_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 122.31 60.55 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 633870_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ANTHEM HMO ANTHEM HMO 999999999 122.31 195.94 Vancomycin (antibiotic) level 633870_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 122.31 195.94 Vancomycin (antibiotic) level 633870_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 122.31 195.94 Vancomycin (antibiotic) level 633870_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 122.31 195.94 Vancomycin (antibiotic) level 633870_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 136.55 67.6 999999999 122.31 195.94 percent of total billed charges Cyanocobalamin (vitamin B-12) level 633871_1 CDM 0301 RC 82607 HCPCS inpatient 210 136.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 136.5 65 999999999 127.16 203.7 percent of total billed charges Cyanocobalamin (vitamin B-12) level 633871_1 CDM 0301 RC 82607 HCPCS inpatient 210 136.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 203.7 97 999999999 127.16 203.7 percent of total billed charges Cyanocobalamin (vitamin B-12) level 633871_1 CDM 0301 RC 82607 HCPCS inpatient 210 136.5 AETNA AETNA 165.9 79 999999999 127.16 203.7 percent of total billed charges Cyanocobalamin (vitamin B-12) level 633871_1 CDM 0301 RC 82607 HCPCS inpatient 210 136.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 144.9 69 999999999 127.16 203.7 percent of total billed charges Cyanocobalamin (vitamin B-12) level 633871_1 CDM 0301 RC 82607 HCPCS inpatient 210 136.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 163.8 78 999999999 127.16 203.7 percent of total billed charges Cyanocobalamin (vitamin B-12) level 633871_1 CDM 0301 RC 82607 HCPCS inpatient 210 136.5 SIHO - ALL PLANS SIHO - ALL PLANS 189 90 999999999 127.16 203.7 percent of total billed charges Cyanocobalamin (vitamin B-12) level 633871_1 CDM 0301 RC 82607 HCPCS inpatient 210 136.5 UMR - ALL PLANS UMR - ALL PLANS 147 70 999999999 127.16 203.7 percent of total billed charges Cyanocobalamin (vitamin B-12) level 633871_1 CDM 0301 RC 82607 HCPCS inpatient 210 136.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 127.16 203.7 Cyanocobalamin (vitamin B-12) level 633871_1 CDM 0301 RC 82607 HCPCS inpatient 210 136.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 127.16 60.55 999999999 127.16 203.7 percent of total billed charges Cyanocobalamin (vitamin B-12) level 633871_1 CDM 0301 RC 82607 HCPCS inpatient 210 136.5 ANTHEM HMO ANTHEM HMO 999999999 127.16 203.7 Cyanocobalamin (vitamin B-12) level 633871_1 CDM 0301 RC 82607 HCPCS inpatient 210 136.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 127.16 203.7 Cyanocobalamin (vitamin B-12) level 633871_1 CDM 0301 RC 82607 HCPCS inpatient 210 136.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 127.16 203.7 Cyanocobalamin (vitamin B-12) level 633871_1 CDM 0301 RC 82607 HCPCS inpatient 210 136.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 127.16 203.7 Cyanocobalamin (vitamin B-12) level 633871_1 CDM 0301 RC 82607 HCPCS inpatient 210 136.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 141.96 67.6 999999999 127.16 203.7 percent of total billed charges Automated white blood cell count 633873_1 CDM 0305 RC 85048 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges Automated white blood cell count 633873_1 CDM 0305 RC 85048 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges Automated white blood cell count 633873_1 CDM 0305 RC 85048 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges Automated white blood cell count 633873_1 CDM 0305 RC 85048 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges Automated white blood cell count 633873_1 CDM 0305 RC 85048 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges Automated white blood cell count 633873_1 CDM 0305 RC 85048 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges Automated white blood cell count 633873_1 CDM 0305 RC 85048 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges Automated white blood cell count 633873_1 CDM 0305 RC 85048 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 Automated white blood cell count 633873_1 CDM 0305 RC 85048 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges Automated white blood cell count 633873_1 CDM 0305 RC 85048 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 Automated white blood cell count 633873_1 CDM 0305 RC 85048 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 Automated white blood cell count 633873_1 CDM 0305 RC 85048 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 Automated white blood cell count 633873_1 CDM 0305 RC 85048 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 Automated white blood cell count 633873_1 CDM 0305 RC 85048 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges "Detection of antimicrobial drug (antibiotic, antifungal, antiviral)" 634025_1 CDM 0306 RC 87185 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges "Detection of antimicrobial drug (antibiotic, antifungal, antiviral)" 634025_1 CDM 0306 RC 87185 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges "Detection of antimicrobial drug (antibiotic, antifungal, antiviral)" 634025_1 CDM 0306 RC 87185 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges "Detection of antimicrobial drug (antibiotic, antifungal, antiviral)" 634025_1 CDM 0306 RC 87185 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges "Detection of antimicrobial drug (antibiotic, antifungal, antiviral)" 634025_1 CDM 0306 RC 87185 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges "Detection of antimicrobial drug (antibiotic, antifungal, antiviral)" 634025_1 CDM 0306 RC 87185 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges "Detection of antimicrobial drug (antibiotic, antifungal, antiviral)" 634025_1 CDM 0306 RC 87185 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges "Detection of antimicrobial drug (antibiotic, antifungal, antiviral)" 634025_1 CDM 0306 RC 87185 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 "Detection of antimicrobial drug (antibiotic, antifungal, antiviral)" 634025_1 CDM 0306 RC 87185 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges "Detection of antimicrobial drug (antibiotic, antifungal, antiviral)" 634025_1 CDM 0306 RC 87185 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 "Detection of antimicrobial drug (antibiotic, antifungal, antiviral)" 634025_1 CDM 0306 RC 87185 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 "Detection of antimicrobial drug (antibiotic, antifungal, antiviral)" 634025_1 CDM 0306 RC 87185 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 "Detection of antimicrobial drug (antibiotic, antifungal, antiviral)" 634025_1 CDM 0306 RC 87185 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 "Detection of antimicrobial drug (antibiotic, antifungal, antiviral)" 634025_1 CDM 0306 RC 87185 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges Bacterial culture for aerobic isolates 634139_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 63.05 65 999999999 58.73 94.09 percent of total billed charges Bacterial culture for aerobic isolates 634139_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 94.09 97 999999999 58.73 94.09 percent of total billed charges Bacterial culture for aerobic isolates 634139_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 AETNA AETNA 76.63 79 999999999 58.73 94.09 percent of total billed charges Bacterial culture for aerobic isolates 634139_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 66.93 69 999999999 58.73 94.09 percent of total billed charges Bacterial culture for aerobic isolates 634139_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 75.66 78 999999999 58.73 94.09 percent of total billed charges Bacterial culture for aerobic isolates 634139_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 SIHO - ALL PLANS SIHO - ALL PLANS 87.3 90 999999999 58.73 94.09 percent of total billed charges Bacterial culture for aerobic isolates 634139_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 UMR - ALL PLANS UMR - ALL PLANS 67.9 70 999999999 58.73 94.09 percent of total billed charges Bacterial culture for aerobic isolates 634139_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 58.73 94.09 Bacterial culture for aerobic isolates 634139_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 58.73 60.55 999999999 58.73 94.09 percent of total billed charges Bacterial culture for aerobic isolates 634139_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 ANTHEM HMO ANTHEM HMO 999999999 58.73 94.09 Bacterial culture for aerobic isolates 634139_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 58.73 94.09 Bacterial culture for aerobic isolates 634139_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 58.73 94.09 Bacterial culture for aerobic isolates 634139_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 58.73 94.09 Bacterial culture for aerobic isolates 634139_1 CDM 0306 RC 87077 HCPCS inpatient 97 63.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 65.57 67.6 999999999 58.73 94.09 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634179_1 CDM 0306 RC 87147 HCPCS inpatient 79 51.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 51.35 65 999999999 47.83 76.63 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634179_1 CDM 0306 RC 87147 HCPCS inpatient 79 51.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76.63 97 999999999 47.83 76.63 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634179_1 CDM 0306 RC 87147 HCPCS inpatient 79 51.35 AETNA AETNA 62.41 79 999999999 47.83 76.63 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634179_1 CDM 0306 RC 87147 HCPCS inpatient 79 51.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 54.51 69 999999999 47.83 76.63 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634179_1 CDM 0306 RC 87147 HCPCS inpatient 79 51.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 61.62 78 999999999 47.83 76.63 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634179_1 CDM 0306 RC 87147 HCPCS inpatient 79 51.35 SIHO - ALL PLANS SIHO - ALL PLANS 71.1 90 999999999 47.83 76.63 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634179_1 CDM 0306 RC 87147 HCPCS inpatient 79 51.35 UMR - ALL PLANS UMR - ALL PLANS 55.3 70 999999999 47.83 76.63 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634179_1 CDM 0306 RC 87147 HCPCS inpatient 79 51.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 47.83 76.63 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634179_1 CDM 0306 RC 87147 HCPCS inpatient 79 51.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47.83 60.55 999999999 47.83 76.63 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634179_1 CDM 0306 RC 87147 HCPCS inpatient 79 51.35 ANTHEM HMO ANTHEM HMO 999999999 47.83 76.63 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634179_1 CDM 0306 RC 87147 HCPCS inpatient 79 51.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 47.83 76.63 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634179_1 CDM 0306 RC 87147 HCPCS inpatient 79 51.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 47.83 76.63 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634179_1 CDM 0306 RC 87147 HCPCS inpatient 79 51.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 47.83 76.63 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634179_1 CDM 0306 RC 87147 HCPCS inpatient 79 51.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 53.4 67.6 999999999 47.83 76.63 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634182_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634182_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634182_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634182_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634182_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634182_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634182_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634182_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634182_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634182_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634182_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634182_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634182_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634182_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634183_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634183_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634183_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634183_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634183_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634183_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634183_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634183_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634183_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634183_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634183_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634183_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634183_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 "Identification of organisms by immunologic analysis, other than immunofluorescence method" 634183_1 CDM 0306 RC 87147 HCPCS inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges Special Gram or Giemsa stain for microorganism 634217_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges Special Gram or Giemsa stain for microorganism 634217_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges Special Gram or Giemsa stain for microorganism 634217_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges Special Gram or Giemsa stain for microorganism 634217_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges Special Gram or Giemsa stain for microorganism 634217_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges Special Gram or Giemsa stain for microorganism 634217_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges Special Gram or Giemsa stain for microorganism 634217_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges Special Gram or Giemsa stain for microorganism 634217_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 Special Gram or Giemsa stain for microorganism 634217_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges Special Gram or Giemsa stain for microorganism 634217_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 Special Gram or Giemsa stain for microorganism 634217_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 Special Gram or Giemsa stain for microorganism 634217_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 Special Gram or Giemsa stain for microorganism 634217_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 Special Gram or Giemsa stain for microorganism 634217_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges "X-ray of chest, 2 views" 689607_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 301.6 65 999999999 280.95 450.08 percent of total billed charges "X-ray of chest, 2 views" 689607_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 450.08 97 999999999 280.95 450.08 percent of total billed charges "X-ray of chest, 2 views" 689607_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 AETNA AETNA 366.56 79 999999999 280.95 450.08 percent of total billed charges "X-ray of chest, 2 views" 689607_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 320.16 69 999999999 280.95 450.08 percent of total billed charges "X-ray of chest, 2 views" 689607_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 361.92 78 999999999 280.95 450.08 percent of total billed charges "X-ray of chest, 2 views" 689607_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 SIHO - ALL PLANS SIHO - ALL PLANS 417.6 90 999999999 280.95 450.08 percent of total billed charges "X-ray of chest, 2 views" 689607_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 UMR - ALL PLANS UMR - ALL PLANS 324.8 70 999999999 280.95 450.08 percent of total billed charges "X-ray of chest, 2 views" 689607_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 280.95 450.08 "X-ray of chest, 2 views" 689607_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 280.95 60.55 999999999 280.95 450.08 percent of total billed charges "X-ray of chest, 2 views" 689607_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 ANTHEM HMO ANTHEM HMO 999999999 280.95 450.08 "X-ray of chest, 2 views" 689607_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 280.95 450.08 "X-ray of chest, 2 views" 689607_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 280.95 450.08 "X-ray of chest, 2 views" 689607_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 280.95 450.08 "X-ray of chest, 2 views" 689607_1 CDM 0324 RC 71046 HCPCS inpatient 464 301.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 313.66 67.6 999999999 280.95 450.08 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 7186970_1 CDM 0402 RC 76882 HCPCS inpatient 603 391.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 391.95 65 999999999 365.12 584.91 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 7186970_1 CDM 0402 RC 76882 HCPCS inpatient 603 391.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 584.91 97 999999999 365.12 584.91 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 7186970_1 CDM 0402 RC 76882 HCPCS inpatient 603 391.95 AETNA AETNA 476.37 79 999999999 365.12 584.91 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 7186970_1 CDM 0402 RC 76882 HCPCS inpatient 603 391.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 416.07 69 999999999 365.12 584.91 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 7186970_1 CDM 0402 RC 76882 HCPCS inpatient 603 391.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 470.34 78 999999999 365.12 584.91 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 7186970_1 CDM 0402 RC 76882 HCPCS inpatient 603 391.95 SIHO - ALL PLANS SIHO - ALL PLANS 542.7 90 999999999 365.12 584.91 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 7186970_1 CDM 0402 RC 76882 HCPCS inpatient 603 391.95 UMR - ALL PLANS UMR - ALL PLANS 422.1 70 999999999 365.12 584.91 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 7186970_1 CDM 0402 RC 76882 HCPCS inpatient 603 391.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 365.12 584.91 Limited ultrasound scan of joint or other extremity structure except blood vessels 7186970_1 CDM 0402 RC 76882 HCPCS inpatient 603 391.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 365.12 60.55 999999999 365.12 584.91 percent of total billed charges Limited ultrasound scan of joint or other extremity structure except blood vessels 7186970_1 CDM 0402 RC 76882 HCPCS inpatient 603 391.95 ANTHEM HMO ANTHEM HMO 999999999 365.12 584.91 Limited ultrasound scan of joint or other extremity structure except blood vessels 7186970_1 CDM 0402 RC 76882 HCPCS inpatient 603 391.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 365.12 584.91 Limited ultrasound scan of joint or other extremity structure except blood vessels 7186970_1 CDM 0402 RC 76882 HCPCS inpatient 603 391.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 365.12 584.91 Limited ultrasound scan of joint or other extremity structure except blood vessels 7186970_1 CDM 0402 RC 76882 HCPCS inpatient 603 391.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 365.12 584.91 Limited ultrasound scan of joint or other extremity structure except blood vessels 7186970_1 CDM 0402 RC 76882 HCPCS inpatient 603 391.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 407.63 67.6 999999999 365.12 584.91 percent of total billed charges Gentamicin (antibiotic) level 7373232_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 213.2 65 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 7373232_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 318.16 97 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 7373232_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 AETNA AETNA 259.12 79 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 7373232_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 226.32 69 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 7373232_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.84 78 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 7373232_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 SIHO - ALL PLANS SIHO - ALL PLANS 295.2 90 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 7373232_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 UMR - ALL PLANS UMR - ALL PLANS 229.6 70 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 7373232_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198.6 318.16 Gentamicin (antibiotic) level 7373232_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198.6 60.55 999999999 198.6 318.16 percent of total billed charges Gentamicin (antibiotic) level 7373232_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 ANTHEM HMO ANTHEM HMO 999999999 198.6 318.16 Gentamicin (antibiotic) level 7373232_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198.6 318.16 Gentamicin (antibiotic) level 7373232_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198.6 318.16 Gentamicin (antibiotic) level 7373232_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 198.6 318.16 Gentamicin (antibiotic) level 7373232_1 CDM 0301 RC 80170 HCPCS inpatient 328 213.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.73 67.6 999999999 198.6 318.16 percent of total billed charges Prealbumin (protein) level 740863_1 CDM 0301 RC 84134 HCPCS inpatient 155 100.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.75 65 999999999 93.85 150.35 percent of total billed charges Prealbumin (protein) level 740863_1 CDM 0301 RC 84134 HCPCS inpatient 155 100.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 150.35 97 999999999 93.85 150.35 percent of total billed charges Prealbumin (protein) level 740863_1 CDM 0301 RC 84134 HCPCS inpatient 155 100.75 AETNA AETNA 122.45 79 999999999 93.85 150.35 percent of total billed charges Prealbumin (protein) level 740863_1 CDM 0301 RC 84134 HCPCS inpatient 155 100.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.95 69 999999999 93.85 150.35 percent of total billed charges Prealbumin (protein) level 740863_1 CDM 0301 RC 84134 HCPCS inpatient 155 100.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.9 78 999999999 93.85 150.35 percent of total billed charges Prealbumin (protein) level 740863_1 CDM 0301 RC 84134 HCPCS inpatient 155 100.75 SIHO - ALL PLANS SIHO - ALL PLANS 139.5 90 999999999 93.85 150.35 percent of total billed charges Prealbumin (protein) level 740863_1 CDM 0301 RC 84134 HCPCS inpatient 155 100.75 UMR - ALL PLANS UMR - ALL PLANS 108.5 70 999999999 93.85 150.35 percent of total billed charges Prealbumin (protein) level 740863_1 CDM 0301 RC 84134 HCPCS inpatient 155 100.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.85 150.35 Prealbumin (protein) level 740863_1 CDM 0301 RC 84134 HCPCS inpatient 155 100.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.85 60.55 999999999 93.85 150.35 percent of total billed charges Prealbumin (protein) level 740863_1 CDM 0301 RC 84134 HCPCS inpatient 155 100.75 ANTHEM HMO ANTHEM HMO 999999999 93.85 150.35 Prealbumin (protein) level 740863_1 CDM 0301 RC 84134 HCPCS inpatient 155 100.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.85 150.35 Prealbumin (protein) level 740863_1 CDM 0301 RC 84134 HCPCS inpatient 155 100.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.85 150.35 Prealbumin (protein) level 740863_1 CDM 0301 RC 84134 HCPCS inpatient 155 100.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.85 150.35 Prealbumin (protein) level 740863_1 CDM 0301 RC 84134 HCPCS inpatient 155 100.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.78 67.6 999999999 93.85 150.35 percent of total billed charges Parathormone (parathyroid hormone) level 740865_1 CDM 0301 RC 83970 HCPCS inpatient 82 53.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 53.3 65 999999999 49.65 79.54 percent of total billed charges Parathormone (parathyroid hormone) level 740865_1 CDM 0301 RC 83970 HCPCS inpatient 82 53.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 79.54 97 999999999 49.65 79.54 percent of total billed charges Parathormone (parathyroid hormone) level 740865_1 CDM 0301 RC 83970 HCPCS inpatient 82 53.3 AETNA AETNA 64.78 79 999999999 49.65 79.54 percent of total billed charges Parathormone (parathyroid hormone) level 740865_1 CDM 0301 RC 83970 HCPCS inpatient 82 53.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 56.58 69 999999999 49.65 79.54 percent of total billed charges Parathormone (parathyroid hormone) level 740865_1 CDM 0301 RC 83970 HCPCS inpatient 82 53.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.96 78 999999999 49.65 79.54 percent of total billed charges Parathormone (parathyroid hormone) level 740865_1 CDM 0301 RC 83970 HCPCS inpatient 82 53.3 SIHO - ALL PLANS SIHO - ALL PLANS 73.8 90 999999999 49.65 79.54 percent of total billed charges Parathormone (parathyroid hormone) level 740865_1 CDM 0301 RC 83970 HCPCS inpatient 82 53.3 UMR - ALL PLANS UMR - ALL PLANS 57.4 70 999999999 49.65 79.54 percent of total billed charges Parathormone (parathyroid hormone) level 740865_1 CDM 0301 RC 83970 HCPCS inpatient 82 53.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.65 79.54 Parathormone (parathyroid hormone) level 740865_1 CDM 0301 RC 83970 HCPCS inpatient 82 53.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.65 60.55 999999999 49.65 79.54 percent of total billed charges Parathormone (parathyroid hormone) level 740865_1 CDM 0301 RC 83970 HCPCS inpatient 82 53.3 ANTHEM HMO ANTHEM HMO 999999999 49.65 79.54 Parathormone (parathyroid hormone) level 740865_1 CDM 0301 RC 83970 HCPCS inpatient 82 53.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.65 79.54 Parathormone (parathyroid hormone) level 740865_1 CDM 0301 RC 83970 HCPCS inpatient 82 53.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.65 79.54 Parathormone (parathyroid hormone) level 740865_1 CDM 0301 RC 83970 HCPCS inpatient 82 53.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.65 79.54 Parathormone (parathyroid hormone) level 740865_1 CDM 0301 RC 83970 HCPCS inpatient 82 53.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 55.43 67.6 999999999 49.65 79.54 percent of total billed charges C-peptide (protein) level 740880_1 CDM 0301 RC 84681 HCPCS inpatient 349 226.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 226.85 65 999999999 211.32 338.53 percent of total billed charges C-peptide (protein) level 740880_1 CDM 0301 RC 84681 HCPCS inpatient 349 226.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 338.53 97 999999999 211.32 338.53 percent of total billed charges C-peptide (protein) level 740880_1 CDM 0301 RC 84681 HCPCS inpatient 349 226.85 AETNA AETNA 275.71 79 999999999 211.32 338.53 percent of total billed charges C-peptide (protein) level 740880_1 CDM 0301 RC 84681 HCPCS inpatient 349 226.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 240.81 69 999999999 211.32 338.53 percent of total billed charges C-peptide (protein) level 740880_1 CDM 0301 RC 84681 HCPCS inpatient 349 226.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 272.22 78 999999999 211.32 338.53 percent of total billed charges C-peptide (protein) level 740880_1 CDM 0301 RC 84681 HCPCS inpatient 349 226.85 SIHO - ALL PLANS SIHO - ALL PLANS 314.1 90 999999999 211.32 338.53 percent of total billed charges C-peptide (protein) level 740880_1 CDM 0301 RC 84681 HCPCS inpatient 349 226.85 UMR - ALL PLANS UMR - ALL PLANS 244.3 70 999999999 211.32 338.53 percent of total billed charges C-peptide (protein) level 740880_1 CDM 0301 RC 84681 HCPCS inpatient 349 226.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 211.32 338.53 C-peptide (protein) level 740880_1 CDM 0301 RC 84681 HCPCS inpatient 349 226.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 211.32 60.55 999999999 211.32 338.53 percent of total billed charges C-peptide (protein) level 740880_1 CDM 0301 RC 84681 HCPCS inpatient 349 226.85 ANTHEM HMO ANTHEM HMO 999999999 211.32 338.53 C-peptide (protein) level 740880_1 CDM 0301 RC 84681 HCPCS inpatient 349 226.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 211.32 338.53 C-peptide (protein) level 740880_1 CDM 0301 RC 84681 HCPCS inpatient 349 226.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 211.32 338.53 C-peptide (protein) level 740880_1 CDM 0301 RC 84681 HCPCS inpatient 349 226.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 211.32 338.53 C-peptide (protein) level 740880_1 CDM 0301 RC 84681 HCPCS inpatient 349 226.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 235.92 67.6 999999999 211.32 338.53 percent of total billed charges Ferritin (blood protein) level 741279_1 CDM 0301 RC 82728 HCPCS inpatient 254 165.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 165.1 65 999999999 153.8 246.38 percent of total billed charges Ferritin (blood protein) level 741279_1 CDM 0301 RC 82728 HCPCS inpatient 254 165.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 246.38 97 999999999 153.8 246.38 percent of total billed charges Ferritin (blood protein) level 741279_1 CDM 0301 RC 82728 HCPCS inpatient 254 165.1 AETNA AETNA 200.66 79 999999999 153.8 246.38 percent of total billed charges Ferritin (blood protein) level 741279_1 CDM 0301 RC 82728 HCPCS inpatient 254 165.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 175.26 69 999999999 153.8 246.38 percent of total billed charges Ferritin (blood protein) level 741279_1 CDM 0301 RC 82728 HCPCS inpatient 254 165.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 198.12 78 999999999 153.8 246.38 percent of total billed charges Ferritin (blood protein) level 741279_1 CDM 0301 RC 82728 HCPCS inpatient 254 165.1 SIHO - ALL PLANS SIHO - ALL PLANS 228.6 90 999999999 153.8 246.38 percent of total billed charges Ferritin (blood protein) level 741279_1 CDM 0301 RC 82728 HCPCS inpatient 254 165.1 UMR - ALL PLANS UMR - ALL PLANS 177.8 70 999999999 153.8 246.38 percent of total billed charges Ferritin (blood protein) level 741279_1 CDM 0301 RC 82728 HCPCS inpatient 254 165.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 153.8 246.38 Ferritin (blood protein) level 741279_1 CDM 0301 RC 82728 HCPCS inpatient 254 165.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 153.8 60.55 999999999 153.8 246.38 percent of total billed charges Ferritin (blood protein) level 741279_1 CDM 0301 RC 82728 HCPCS inpatient 254 165.1 ANTHEM HMO ANTHEM HMO 999999999 153.8 246.38 Ferritin (blood protein) level 741279_1 CDM 0301 RC 82728 HCPCS inpatient 254 165.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 153.8 246.38 Ferritin (blood protein) level 741279_1 CDM 0301 RC 82728 HCPCS inpatient 254 165.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 153.8 246.38 Ferritin (blood protein) level 741279_1 CDM 0301 RC 82728 HCPCS inpatient 254 165.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 153.8 246.38 Ferritin (blood protein) level 741279_1 CDM 0301 RC 82728 HCPCS inpatient 254 165.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 171.7 67.6 999999999 153.8 246.38 percent of total billed charges "Gonadotropin, follicle stimulating (reproductive hormone) level" 741299_1 CDM 0301 RC 83001 HCPCS inpatient 241 156.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 156.65 65 999999999 145.93 233.77 percent of total billed charges "Gonadotropin, follicle stimulating (reproductive hormone) level" 741299_1 CDM 0301 RC 83001 HCPCS inpatient 241 156.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 233.77 97 999999999 145.93 233.77 percent of total billed charges "Gonadotropin, follicle stimulating (reproductive hormone) level" 741299_1 CDM 0301 RC 83001 HCPCS inpatient 241 156.65 AETNA AETNA 190.39 79 999999999 145.93 233.77 percent of total billed charges "Gonadotropin, follicle stimulating (reproductive hormone) level" 741299_1 CDM 0301 RC 83001 HCPCS inpatient 241 156.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 166.29 69 999999999 145.93 233.77 percent of total billed charges "Gonadotropin, follicle stimulating (reproductive hormone) level" 741299_1 CDM 0301 RC 83001 HCPCS inpatient 241 156.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.98 78 999999999 145.93 233.77 percent of total billed charges "Gonadotropin, follicle stimulating (reproductive hormone) level" 741299_1 CDM 0301 RC 83001 HCPCS inpatient 241 156.65 SIHO - ALL PLANS SIHO - ALL PLANS 216.9 90 999999999 145.93 233.77 percent of total billed charges "Gonadotropin, follicle stimulating (reproductive hormone) level" 741299_1 CDM 0301 RC 83001 HCPCS inpatient 241 156.65 UMR - ALL PLANS UMR - ALL PLANS 168.7 70 999999999 145.93 233.77 percent of total billed charges "Gonadotropin, follicle stimulating (reproductive hormone) level" 741299_1 CDM 0301 RC 83001 HCPCS inpatient 241 156.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.93 233.77 "Gonadotropin, follicle stimulating (reproductive hormone) level" 741299_1 CDM 0301 RC 83001 HCPCS inpatient 241 156.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.93 60.55 999999999 145.93 233.77 percent of total billed charges "Gonadotropin, follicle stimulating (reproductive hormone) level" 741299_1 CDM 0301 RC 83001 HCPCS inpatient 241 156.65 ANTHEM HMO ANTHEM HMO 999999999 145.93 233.77 "Gonadotropin, follicle stimulating (reproductive hormone) level" 741299_1 CDM 0301 RC 83001 HCPCS inpatient 241 156.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.93 233.77 "Gonadotropin, follicle stimulating (reproductive hormone) level" 741299_1 CDM 0301 RC 83001 HCPCS inpatient 241 156.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.93 233.77 "Gonadotropin, follicle stimulating (reproductive hormone) level" 741299_1 CDM 0301 RC 83001 HCPCS inpatient 241 156.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.93 233.77 "Gonadotropin, follicle stimulating (reproductive hormone) level" 741299_1 CDM 0301 RC 83001 HCPCS inpatient 241 156.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.92 67.6 999999999 145.93 233.77 percent of total billed charges "Insulin measurement, total" 741408_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 741408_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 741408_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 741408_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 741408_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 741408_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 741408_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 741408_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 "Insulin measurement, total" 741408_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges "Insulin measurement, total" 741408_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 "Insulin measurement, total" 741408_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 "Insulin measurement, total" 741408_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 "Insulin measurement, total" 741408_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 "Insulin measurement, total" 741408_1 CDM 0301 RC 83525 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges Lactic acid level 741412_1 CDM 0301 RC 83605 HCPCS inpatient 223 144.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 144.95 65 999999999 135.03 216.31 percent of total billed charges Lactic acid level 741412_1 CDM 0301 RC 83605 HCPCS inpatient 223 144.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 216.31 97 999999999 135.03 216.31 percent of total billed charges Lactic acid level 741412_1 CDM 0301 RC 83605 HCPCS inpatient 223 144.95 AETNA AETNA 176.17 79 999999999 135.03 216.31 percent of total billed charges Lactic acid level 741412_1 CDM 0301 RC 83605 HCPCS inpatient 223 144.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 153.87 69 999999999 135.03 216.31 percent of total billed charges Lactic acid level 741412_1 CDM 0301 RC 83605 HCPCS inpatient 223 144.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 173.94 78 999999999 135.03 216.31 percent of total billed charges Lactic acid level 741412_1 CDM 0301 RC 83605 HCPCS inpatient 223 144.95 SIHO - ALL PLANS SIHO - ALL PLANS 200.7 90 999999999 135.03 216.31 percent of total billed charges Lactic acid level 741412_1 CDM 0301 RC 83605 HCPCS inpatient 223 144.95 UMR - ALL PLANS UMR - ALL PLANS 156.1 70 999999999 135.03 216.31 percent of total billed charges Lactic acid level 741412_1 CDM 0301 RC 83605 HCPCS inpatient 223 144.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 135.03 216.31 Lactic acid level 741412_1 CDM 0301 RC 83605 HCPCS inpatient 223 144.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 135.03 60.55 999999999 135.03 216.31 percent of total billed charges Lactic acid level 741412_1 CDM 0301 RC 83605 HCPCS inpatient 223 144.95 ANTHEM HMO ANTHEM HMO 999999999 135.03 216.31 Lactic acid level 741412_1 CDM 0301 RC 83605 HCPCS inpatient 223 144.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 135.03 216.31 Lactic acid level 741412_1 CDM 0301 RC 83605 HCPCS inpatient 223 144.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 135.03 216.31 Lactic acid level 741412_1 CDM 0301 RC 83605 HCPCS inpatient 223 144.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 135.03 216.31 Lactic acid level 741412_1 CDM 0301 RC 83605 HCPCS inpatient 223 144.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 150.75 67.6 999999999 135.03 216.31 percent of total billed charges Urine microalbumin (protein) level 741445_1 CDM 0301 RC 82043 HCPCS inpatient 100 65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65 65 999999999 60.55 97 percent of total billed charges Urine microalbumin (protein) level 741445_1 CDM 0301 RC 82043 HCPCS inpatient 100 65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97 97 999999999 60.55 97 percent of total billed charges Urine microalbumin (protein) level 741445_1 CDM 0301 RC 82043 HCPCS inpatient 100 65 AETNA AETNA 79 79 999999999 60.55 97 percent of total billed charges Urine microalbumin (protein) level 741445_1 CDM 0301 RC 82043 HCPCS inpatient 100 65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69 69 999999999 60.55 97 percent of total billed charges Urine microalbumin (protein) level 741445_1 CDM 0301 RC 82043 HCPCS inpatient 100 65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78 78 999999999 60.55 97 percent of total billed charges Urine microalbumin (protein) level 741445_1 CDM 0301 RC 82043 HCPCS inpatient 100 65 SIHO - ALL PLANS SIHO - ALL PLANS 90 90 999999999 60.55 97 percent of total billed charges Urine microalbumin (protein) level 741445_1 CDM 0301 RC 82043 HCPCS inpatient 100 65 UMR - ALL PLANS UMR - ALL PLANS 70 70 999999999 60.55 97 percent of total billed charges Urine microalbumin (protein) level 741445_1 CDM 0301 RC 82043 HCPCS inpatient 100 65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.55 97 Urine microalbumin (protein) level 741445_1 CDM 0301 RC 82043 HCPCS inpatient 100 65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.55 60.55 999999999 60.55 97 percent of total billed charges Urine microalbumin (protein) level 741445_1 CDM 0301 RC 82043 HCPCS inpatient 100 65 ANTHEM HMO ANTHEM HMO 999999999 60.55 97 Urine microalbumin (protein) level 741445_1 CDM 0301 RC 82043 HCPCS inpatient 100 65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.55 97 Urine microalbumin (protein) level 741445_1 CDM 0301 RC 82043 HCPCS inpatient 100 65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.55 97 Urine microalbumin (protein) level 741445_1 CDM 0301 RC 82043 HCPCS inpatient 100 65 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.55 97 Urine microalbumin (protein) level 741445_1 CDM 0301 RC 82043 HCPCS inpatient 100 65 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.6 67.6 999999999 60.55 97 percent of total billed charges Syphilis test 741521_1 CDM 0302 RC 86593 HCPCS inpatient 148 96.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 96.2 65 999999999 89.61 143.56 percent of total billed charges Syphilis test 741521_1 CDM 0302 RC 86593 HCPCS inpatient 148 96.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 143.56 97 999999999 89.61 143.56 percent of total billed charges Syphilis test 741521_1 CDM 0302 RC 86593 HCPCS inpatient 148 96.2 AETNA AETNA 116.92 79 999999999 89.61 143.56 percent of total billed charges Syphilis test 741521_1 CDM 0302 RC 86593 HCPCS inpatient 148 96.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 102.12 69 999999999 89.61 143.56 percent of total billed charges Syphilis test 741521_1 CDM 0302 RC 86593 HCPCS inpatient 148 96.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 115.44 78 999999999 89.61 143.56 percent of total billed charges Syphilis test 741521_1 CDM 0302 RC 86593 HCPCS inpatient 148 96.2 SIHO - ALL PLANS SIHO - ALL PLANS 133.2 90 999999999 89.61 143.56 percent of total billed charges Syphilis test 741521_1 CDM 0302 RC 86593 HCPCS inpatient 148 96.2 UMR - ALL PLANS UMR - ALL PLANS 103.6 70 999999999 89.61 143.56 percent of total billed charges Syphilis test 741521_1 CDM 0302 RC 86593 HCPCS inpatient 148 96.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 89.61 143.56 Syphilis test 741521_1 CDM 0302 RC 86593 HCPCS inpatient 148 96.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 89.61 60.55 999999999 89.61 143.56 percent of total billed charges Syphilis test 741521_1 CDM 0302 RC 86593 HCPCS inpatient 148 96.2 ANTHEM HMO ANTHEM HMO 999999999 89.61 143.56 Syphilis test 741521_1 CDM 0302 RC 86593 HCPCS inpatient 148 96.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 89.61 143.56 Syphilis test 741521_1 CDM 0302 RC 86593 HCPCS inpatient 148 96.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 89.61 143.56 Syphilis test 741521_1 CDM 0302 RC 86593 HCPCS inpatient 148 96.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 89.61 143.56 Syphilis test 741521_1 CDM 0302 RC 86593 HCPCS inpatient 148 96.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 100.05 67.6 999999999 89.61 143.56 percent of total billed charges Detection test by immunoassay with direct visual observation for respiratory syncytial virus 741545_1 CDM 0301 RC 87807 HCPCS inpatient 294 191.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 191.1 65 999999999 178.02 285.18 percent of total billed charges Detection test by immunoassay with direct visual observation for respiratory syncytial virus 741545_1 CDM 0301 RC 87807 HCPCS inpatient 294 191.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 285.18 97 999999999 178.02 285.18 percent of total billed charges Detection test by immunoassay with direct visual observation for respiratory syncytial virus 741545_1 CDM 0301 RC 87807 HCPCS inpatient 294 191.1 AETNA AETNA 232.26 79 999999999 178.02 285.18 percent of total billed charges Detection test by immunoassay with direct visual observation for respiratory syncytial virus 741545_1 CDM 0301 RC 87807 HCPCS inpatient 294 191.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 202.86 69 999999999 178.02 285.18 percent of total billed charges Detection test by immunoassay with direct visual observation for respiratory syncytial virus 741545_1 CDM 0301 RC 87807 HCPCS inpatient 294 191.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 229.32 78 999999999 178.02 285.18 percent of total billed charges Detection test by immunoassay with direct visual observation for respiratory syncytial virus 741545_1 CDM 0301 RC 87807 HCPCS inpatient 294 191.1 SIHO - ALL PLANS SIHO - ALL PLANS 264.6 90 999999999 178.02 285.18 percent of total billed charges Detection test by immunoassay with direct visual observation for respiratory syncytial virus 741545_1 CDM 0301 RC 87807 HCPCS inpatient 294 191.1 UMR - ALL PLANS UMR - ALL PLANS 205.8 70 999999999 178.02 285.18 percent of total billed charges Detection test by immunoassay with direct visual observation for respiratory syncytial virus 741545_1 CDM 0301 RC 87807 HCPCS inpatient 294 191.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 178.02 285.18 Detection test by immunoassay with direct visual observation for respiratory syncytial virus 741545_1 CDM 0301 RC 87807 HCPCS inpatient 294 191.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 178.02 60.55 999999999 178.02 285.18 percent of total billed charges Detection test by immunoassay with direct visual observation for respiratory syncytial virus 741545_1 CDM 0301 RC 87807 HCPCS inpatient 294 191.1 ANTHEM HMO ANTHEM HMO 999999999 178.02 285.18 Detection test by immunoassay with direct visual observation for respiratory syncytial virus 741545_1 CDM 0301 RC 87807 HCPCS inpatient 294 191.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 178.02 285.18 Detection test by immunoassay with direct visual observation for respiratory syncytial virus 741545_1 CDM 0301 RC 87807 HCPCS inpatient 294 191.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 178.02 285.18 Detection test by immunoassay with direct visual observation for respiratory syncytial virus 741545_1 CDM 0301 RC 87807 HCPCS inpatient 294 191.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 178.02 285.18 Detection test by immunoassay with direct visual observation for respiratory syncytial virus 741545_1 CDM 0301 RC 87807 HCPCS inpatient 294 191.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 198.74 67.6 999999999 178.02 285.18 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 751519_1 CDM 0450 RC 94760 HCPCS inpatient 73 47.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 47.45 65 999999999 44.2 70.81 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 751519_1 CDM 0450 RC 94760 HCPCS inpatient 73 47.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70.81 97 999999999 44.2 70.81 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 751519_1 CDM 0450 RC 94760 HCPCS inpatient 73 47.45 AETNA AETNA 57.67 79 999999999 44.2 70.81 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 751519_1 CDM 0450 RC 94760 HCPCS inpatient 73 47.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 50.37 69 999999999 44.2 70.81 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 751519_1 CDM 0450 RC 94760 HCPCS inpatient 73 47.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 56.94 78 999999999 44.2 70.81 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 751519_1 CDM 0450 RC 94760 HCPCS inpatient 73 47.45 SIHO - ALL PLANS SIHO - ALL PLANS 65.7 90 999999999 44.2 70.81 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 751519_1 CDM 0450 RC 94760 HCPCS inpatient 73 47.45 UMR - ALL PLANS UMR - ALL PLANS 51.1 70 999999999 44.2 70.81 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 751519_1 CDM 0450 RC 94760 HCPCS inpatient 73 47.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 44.2 70.81 Test to measure oxygen level in blood using ear or finger device 751519_1 CDM 0450 RC 94760 HCPCS inpatient 73 47.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44.2 60.55 999999999 44.2 70.81 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 751519_1 CDM 0450 RC 94760 HCPCS inpatient 73 47.45 ANTHEM HMO ANTHEM HMO 999999999 44.2 70.81 Test to measure oxygen level in blood using ear or finger device 751519_1 CDM 0450 RC 94760 HCPCS inpatient 73 47.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 44.2 70.81 Test to measure oxygen level in blood using ear or finger device 751519_1 CDM 0450 RC 94760 HCPCS inpatient 73 47.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 44.2 70.81 Test to measure oxygen level in blood using ear or finger device 751519_1 CDM 0450 RC 94760 HCPCS inpatient 73 47.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 44.2 70.81 Test to measure oxygen level in blood using ear or finger device 751519_1 CDM 0450 RC 94760 HCPCS inpatient 73 47.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 49.35 67.6 999999999 44.2 70.81 percent of total billed charges Insertion of tube into airway for aspiration of secretions 751526_1 CDM 0410 RC 31720 HCPCS inpatient 240 156 SELF PAY DISCOUNT SELF PAY DISCOUNT 156 65 999999999 145.32 232.8 percent of total billed charges Insertion of tube into airway for aspiration of secretions 751526_1 CDM 0410 RC 31720 HCPCS inpatient 240 156 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 232.8 97 999999999 145.32 232.8 percent of total billed charges Insertion of tube into airway for aspiration of secretions 751526_1 CDM 0410 RC 31720 HCPCS inpatient 240 156 AETNA AETNA 189.6 79 999999999 145.32 232.8 percent of total billed charges Insertion of tube into airway for aspiration of secretions 751526_1 CDM 0410 RC 31720 HCPCS inpatient 240 156 ENCORE - ALL PLANS ENCORE - ALL PLANS 165.6 69 999999999 145.32 232.8 percent of total billed charges Insertion of tube into airway for aspiration of secretions 751526_1 CDM 0410 RC 31720 HCPCS inpatient 240 156 HUMANA - ALL PLANS HUMANA - ALL PLANS 187.2 78 999999999 145.32 232.8 percent of total billed charges Insertion of tube into airway for aspiration of secretions 751526_1 CDM 0410 RC 31720 HCPCS inpatient 240 156 SIHO - ALL PLANS SIHO - ALL PLANS 216 90 999999999 145.32 232.8 percent of total billed charges Insertion of tube into airway for aspiration of secretions 751526_1 CDM 0410 RC 31720 HCPCS inpatient 240 156 UMR - ALL PLANS UMR - ALL PLANS 168 70 999999999 145.32 232.8 percent of total billed charges Insertion of tube into airway for aspiration of secretions 751526_1 CDM 0410 RC 31720 HCPCS inpatient 240 156 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 145.32 232.8 Insertion of tube into airway for aspiration of secretions 751526_1 CDM 0410 RC 31720 HCPCS inpatient 240 156 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 145.32 60.55 999999999 145.32 232.8 percent of total billed charges Insertion of tube into airway for aspiration of secretions 751526_1 CDM 0410 RC 31720 HCPCS inpatient 240 156 ANTHEM HMO ANTHEM HMO 999999999 145.32 232.8 Insertion of tube into airway for aspiration of secretions 751526_1 CDM 0410 RC 31720 HCPCS inpatient 240 156 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 145.32 232.8 Insertion of tube into airway for aspiration of secretions 751526_1 CDM 0410 RC 31720 HCPCS inpatient 240 156 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 145.32 232.8 Insertion of tube into airway for aspiration of secretions 751526_1 CDM 0410 RC 31720 HCPCS inpatient 240 156 UHC - ALL PLANS UHC - ALL PLANS 999999999 145.32 232.8 Insertion of tube into airway for aspiration of secretions 751526_1 CDM 0410 RC 31720 HCPCS inpatient 240 156 CIGNA - ALL PLANS CIGNA - ALL PLANS 162.24 67.6 999999999 145.32 232.8 percent of total billed charges Complete ultrasound scan of abdomen 752050_1 CDM 0402 RC 76700 HCPCS inpatient 1761 1144.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1144.65 65 999999999 1066.29 1708.17 percent of total billed charges Complete ultrasound scan of abdomen 752050_1 CDM 0402 RC 76700 HCPCS inpatient 1761 1144.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1708.17 97 999999999 1066.29 1708.17 percent of total billed charges Complete ultrasound scan of abdomen 752050_1 CDM 0402 RC 76700 HCPCS inpatient 1761 1144.65 AETNA AETNA 1391.19 79 999999999 1066.29 1708.17 percent of total billed charges Complete ultrasound scan of abdomen 752050_1 CDM 0402 RC 76700 HCPCS inpatient 1761 1144.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1215.09 69 999999999 1066.29 1708.17 percent of total billed charges Complete ultrasound scan of abdomen 752050_1 CDM 0402 RC 76700 HCPCS inpatient 1761 1144.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1373.58 78 999999999 1066.29 1708.17 percent of total billed charges Complete ultrasound scan of abdomen 752050_1 CDM 0402 RC 76700 HCPCS inpatient 1761 1144.65 SIHO - ALL PLANS SIHO - ALL PLANS 1584.9 90 999999999 1066.29 1708.17 percent of total billed charges Complete ultrasound scan of abdomen 752050_1 CDM 0402 RC 76700 HCPCS inpatient 1761 1144.65 UMR - ALL PLANS UMR - ALL PLANS 1232.7 70 999999999 1066.29 1708.17 percent of total billed charges Complete ultrasound scan of abdomen 752050_1 CDM 0402 RC 76700 HCPCS inpatient 1761 1144.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1066.29 1708.17 Complete ultrasound scan of abdomen 752050_1 CDM 0402 RC 76700 HCPCS inpatient 1761 1144.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1066.29 60.55 999999999 1066.29 1708.17 percent of total billed charges Complete ultrasound scan of abdomen 752050_1 CDM 0402 RC 76700 HCPCS inpatient 1761 1144.65 ANTHEM HMO ANTHEM HMO 999999999 1066.29 1708.17 Complete ultrasound scan of abdomen 752050_1 CDM 0402 RC 76700 HCPCS inpatient 1761 1144.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1066.29 1708.17 Complete ultrasound scan of abdomen 752050_1 CDM 0402 RC 76700 HCPCS inpatient 1761 1144.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1066.29 1708.17 Complete ultrasound scan of abdomen 752050_1 CDM 0402 RC 76700 HCPCS inpatient 1761 1144.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1066.29 1708.17 Complete ultrasound scan of abdomen 752050_1 CDM 0402 RC 76700 HCPCS inpatient 1761 1144.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1190.44 67.6 999999999 1066.29 1708.17 percent of total billed charges CT scan of abdomen with contrast 752052_1 CDM 0352 RC 74160 HCPCS inpatient 2177 1415.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1415.05 65 999999999 1318.17 2111.69 percent of total billed charges CT scan of abdomen with contrast 752052_1 CDM 0352 RC 74160 HCPCS inpatient 2177 1415.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2111.69 97 999999999 1318.17 2111.69 percent of total billed charges CT scan of abdomen with contrast 752052_1 CDM 0352 RC 74160 HCPCS inpatient 2177 1415.05 AETNA AETNA 1719.83 79 999999999 1318.17 2111.69 percent of total billed charges CT scan of abdomen with contrast 752052_1 CDM 0352 RC 74160 HCPCS inpatient 2177 1415.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1502.13 69 999999999 1318.17 2111.69 percent of total billed charges CT scan of abdomen with contrast 752052_1 CDM 0352 RC 74160 HCPCS inpatient 2177 1415.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1698.06 78 999999999 1318.17 2111.69 percent of total billed charges CT scan of abdomen with contrast 752052_1 CDM 0352 RC 74160 HCPCS inpatient 2177 1415.05 SIHO - ALL PLANS SIHO - ALL PLANS 1959.3 90 999999999 1318.17 2111.69 percent of total billed charges CT scan of abdomen with contrast 752052_1 CDM 0352 RC 74160 HCPCS inpatient 2177 1415.05 UMR - ALL PLANS UMR - ALL PLANS 1523.9 70 999999999 1318.17 2111.69 percent of total billed charges CT scan of abdomen with contrast 752052_1 CDM 0352 RC 74160 HCPCS inpatient 2177 1415.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1318.17 2111.69 CT scan of abdomen with contrast 752052_1 CDM 0352 RC 74160 HCPCS inpatient 2177 1415.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1318.17 60.55 999999999 1318.17 2111.69 percent of total billed charges CT scan of abdomen with contrast 752052_1 CDM 0352 RC 74160 HCPCS inpatient 2177 1415.05 ANTHEM HMO ANTHEM HMO 999999999 1318.17 2111.69 CT scan of abdomen with contrast 752052_1 CDM 0352 RC 74160 HCPCS inpatient 2177 1415.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1318.17 2111.69 CT scan of abdomen with contrast 752052_1 CDM 0352 RC 74160 HCPCS inpatient 2177 1415.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1318.17 2111.69 CT scan of abdomen with contrast 752052_1 CDM 0352 RC 74160 HCPCS inpatient 2177 1415.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1318.17 2111.69 CT scan of abdomen with contrast 752052_1 CDM 0352 RC 74160 HCPCS inpatient 2177 1415.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1471.65 67.6 999999999 1318.17 2111.69 percent of total billed charges CT scan of abdomen before and after contrast 752978_1 CDM 0352 RC 74170 HCPCS inpatient 2640 1716 SELF PAY DISCOUNT SELF PAY DISCOUNT 1716 65 999999999 1598.52 2560.8 percent of total billed charges CT scan of abdomen before and after contrast 752978_1 CDM 0352 RC 74170 HCPCS inpatient 2640 1716 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2560.8 97 999999999 1598.52 2560.8 percent of total billed charges CT scan of abdomen before and after contrast 752978_1 CDM 0352 RC 74170 HCPCS inpatient 2640 1716 AETNA AETNA 2085.6 79 999999999 1598.52 2560.8 percent of total billed charges CT scan of abdomen before and after contrast 752978_1 CDM 0352 RC 74170 HCPCS inpatient 2640 1716 ENCORE - ALL PLANS ENCORE - ALL PLANS 1821.6 69 999999999 1598.52 2560.8 percent of total billed charges CT scan of abdomen before and after contrast 752978_1 CDM 0352 RC 74170 HCPCS inpatient 2640 1716 HUMANA - ALL PLANS HUMANA - ALL PLANS 2059.2 78 999999999 1598.52 2560.8 percent of total billed charges CT scan of abdomen before and after contrast 752978_1 CDM 0352 RC 74170 HCPCS inpatient 2640 1716 SIHO - ALL PLANS SIHO - ALL PLANS 2376 90 999999999 1598.52 2560.8 percent of total billed charges CT scan of abdomen before and after contrast 752978_1 CDM 0352 RC 74170 HCPCS inpatient 2640 1716 UMR - ALL PLANS UMR - ALL PLANS 1848 70 999999999 1598.52 2560.8 percent of total billed charges CT scan of abdomen before and after contrast 752978_1 CDM 0352 RC 74170 HCPCS inpatient 2640 1716 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1598.52 2560.8 CT scan of abdomen before and after contrast 752978_1 CDM 0352 RC 74170 HCPCS inpatient 2640 1716 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1598.52 60.55 999999999 1598.52 2560.8 percent of total billed charges CT scan of abdomen before and after contrast 752978_1 CDM 0352 RC 74170 HCPCS inpatient 2640 1716 ANTHEM HMO ANTHEM HMO 999999999 1598.52 2560.8 CT scan of abdomen before and after contrast 752978_1 CDM 0352 RC 74170 HCPCS inpatient 2640 1716 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1598.52 2560.8 CT scan of abdomen before and after contrast 752978_1 CDM 0352 RC 74170 HCPCS inpatient 2640 1716 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1598.52 2560.8 CT scan of abdomen before and after contrast 752978_1 CDM 0352 RC 74170 HCPCS inpatient 2640 1716 UHC - ALL PLANS UHC - ALL PLANS 999999999 1598.52 2560.8 CT scan of abdomen before and after contrast 752978_1 CDM 0352 RC 74170 HCPCS inpatient 2640 1716 CIGNA - ALL PLANS CIGNA - ALL PLANS 1784.64 67.6 999999999 1598.52 2560.8 percent of total billed charges CT scan of abdomen without contrast 752980_1 CDM 0352 RC 74150 HCPCS inpatient 2742 1782.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1782.3 65 999999999 1660.28 2659.74 percent of total billed charges CT scan of abdomen without contrast 752980_1 CDM 0352 RC 74150 HCPCS inpatient 2742 1782.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2659.74 97 999999999 1660.28 2659.74 percent of total billed charges CT scan of abdomen without contrast 752980_1 CDM 0352 RC 74150 HCPCS inpatient 2742 1782.3 AETNA AETNA 2166.18 79 999999999 1660.28 2659.74 percent of total billed charges CT scan of abdomen without contrast 752980_1 CDM 0352 RC 74150 HCPCS inpatient 2742 1782.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1891.98 69 999999999 1660.28 2659.74 percent of total billed charges CT scan of abdomen without contrast 752980_1 CDM 0352 RC 74150 HCPCS inpatient 2742 1782.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 2138.76 78 999999999 1660.28 2659.74 percent of total billed charges CT scan of abdomen without contrast 752980_1 CDM 0352 RC 74150 HCPCS inpatient 2742 1782.3 SIHO - ALL PLANS SIHO - ALL PLANS 2467.8 90 999999999 1660.28 2659.74 percent of total billed charges CT scan of abdomen without contrast 752980_1 CDM 0352 RC 74150 HCPCS inpatient 2742 1782.3 UMR - ALL PLANS UMR - ALL PLANS 1919.4 70 999999999 1660.28 2659.74 percent of total billed charges CT scan of abdomen without contrast 752980_1 CDM 0352 RC 74150 HCPCS inpatient 2742 1782.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1660.28 2659.74 CT scan of abdomen without contrast 752980_1 CDM 0352 RC 74150 HCPCS inpatient 2742 1782.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1660.28 60.55 999999999 1660.28 2659.74 percent of total billed charges CT scan of abdomen without contrast 752980_1 CDM 0352 RC 74150 HCPCS inpatient 2742 1782.3 ANTHEM HMO ANTHEM HMO 999999999 1660.28 2659.74 CT scan of abdomen without contrast 752980_1 CDM 0352 RC 74150 HCPCS inpatient 2742 1782.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1660.28 2659.74 CT scan of abdomen without contrast 752980_1 CDM 0352 RC 74150 HCPCS inpatient 2742 1782.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1660.28 2659.74 CT scan of abdomen without contrast 752980_1 CDM 0352 RC 74150 HCPCS inpatient 2742 1782.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1660.28 2659.74 CT scan of abdomen without contrast 752980_1 CDM 0352 RC 74150 HCPCS inpatient 2742 1782.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1853.59 67.6 999999999 1660.28 2659.74 percent of total billed charges CT scan of abdominal aorta and both leg arteries with contrast 752985_1 CDM 0352 RC 75635 HCPCS inpatient 3508 2280.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 2280.2 65 999999999 2124.09 3402.76 percent of total billed charges CT scan of abdominal aorta and both leg arteries with contrast 752985_1 CDM 0352 RC 75635 HCPCS inpatient 3508 2280.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3402.76 97 999999999 2124.09 3402.76 percent of total billed charges CT scan of abdominal aorta and both leg arteries with contrast 752985_1 CDM 0352 RC 75635 HCPCS inpatient 3508 2280.2 AETNA AETNA 2771.32 79 999999999 2124.09 3402.76 percent of total billed charges CT scan of abdominal aorta and both leg arteries with contrast 752985_1 CDM 0352 RC 75635 HCPCS inpatient 3508 2280.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 2420.52 69 999999999 2124.09 3402.76 percent of total billed charges CT scan of abdominal aorta and both leg arteries with contrast 752985_1 CDM 0352 RC 75635 HCPCS inpatient 3508 2280.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 2736.24 78 999999999 2124.09 3402.76 percent of total billed charges CT scan of abdominal aorta and both leg arteries with contrast 752985_1 CDM 0352 RC 75635 HCPCS inpatient 3508 2280.2 SIHO - ALL PLANS SIHO - ALL PLANS 3157.2 90 999999999 2124.09 3402.76 percent of total billed charges CT scan of abdominal aorta and both leg arteries with contrast 752985_1 CDM 0352 RC 75635 HCPCS inpatient 3508 2280.2 UMR - ALL PLANS UMR - ALL PLANS 2455.6 70 999999999 2124.09 3402.76 percent of total billed charges CT scan of abdominal aorta and both leg arteries with contrast 752985_1 CDM 0352 RC 75635 HCPCS inpatient 3508 2280.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2124.09 3402.76 CT scan of abdominal aorta and both leg arteries with contrast 752985_1 CDM 0352 RC 75635 HCPCS inpatient 3508 2280.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2124.09 60.55 999999999 2124.09 3402.76 percent of total billed charges CT scan of abdominal aorta and both leg arteries with contrast 752985_1 CDM 0352 RC 75635 HCPCS inpatient 3508 2280.2 ANTHEM HMO ANTHEM HMO 999999999 2124.09 3402.76 CT scan of abdominal aorta and both leg arteries with contrast 752985_1 CDM 0352 RC 75635 HCPCS inpatient 3508 2280.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2124.09 3402.76 CT scan of abdominal aorta and both leg arteries with contrast 752985_1 CDM 0352 RC 75635 HCPCS inpatient 3508 2280.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2124.09 3402.76 CT scan of abdominal aorta and both leg arteries with contrast 752985_1 CDM 0352 RC 75635 HCPCS inpatient 3508 2280.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 2124.09 3402.76 CT scan of abdominal aorta and both leg arteries with contrast 752985_1 CDM 0352 RC 75635 HCPCS inpatient 3508 2280.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 2371.41 67.6 999999999 2124.09 3402.76 percent of total billed charges CT scan of blood vessels of abdomen with contrast 752987_1 CDM 0352 RC 74175 HCPCS inpatient 3037 1974.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1974.05 65 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of abdomen with contrast 752987_1 CDM 0352 RC 74175 HCPCS inpatient 3037 1974.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2945.89 97 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of abdomen with contrast 752987_1 CDM 0352 RC 74175 HCPCS inpatient 3037 1974.05 AETNA AETNA 2399.23 79 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of abdomen with contrast 752987_1 CDM 0352 RC 74175 HCPCS inpatient 3037 1974.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2095.53 69 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of abdomen with contrast 752987_1 CDM 0352 RC 74175 HCPCS inpatient 3037 1974.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 2368.86 78 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of abdomen with contrast 752987_1 CDM 0352 RC 74175 HCPCS inpatient 3037 1974.05 SIHO - ALL PLANS SIHO - ALL PLANS 2733.3 90 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of abdomen with contrast 752987_1 CDM 0352 RC 74175 HCPCS inpatient 3037 1974.05 UMR - ALL PLANS UMR - ALL PLANS 2125.9 70 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of abdomen with contrast 752987_1 CDM 0352 RC 74175 HCPCS inpatient 3037 1974.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1838.9 2945.89 CT scan of blood vessels of abdomen with contrast 752987_1 CDM 0352 RC 74175 HCPCS inpatient 3037 1974.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1838.9 60.55 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of abdomen with contrast 752987_1 CDM 0352 RC 74175 HCPCS inpatient 3037 1974.05 ANTHEM HMO ANTHEM HMO 999999999 1838.9 2945.89 CT scan of blood vessels of abdomen with contrast 752987_1 CDM 0352 RC 74175 HCPCS inpatient 3037 1974.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1838.9 2945.89 CT scan of blood vessels of abdomen with contrast 752987_1 CDM 0352 RC 74175 HCPCS inpatient 3037 1974.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1838.9 2945.89 CT scan of blood vessels of abdomen with contrast 752987_1 CDM 0352 RC 74175 HCPCS inpatient 3037 1974.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1838.9 2945.89 CT scan of blood vessels of abdomen with contrast 752987_1 CDM 0352 RC 74175 HCPCS inpatient 3037 1974.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2053.01 67.6 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 752989_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1974.05 65 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 752989_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2945.89 97 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 752989_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 AETNA AETNA 2399.23 79 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 752989_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2095.53 69 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 752989_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 2368.86 78 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 752989_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 SIHO - ALL PLANS SIHO - ALL PLANS 2733.3 90 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 752989_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 UMR - ALL PLANS UMR - ALL PLANS 2125.9 70 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 752989_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1838.9 2945.89 CT scan of blood vessels of chest with contrast 752989_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1838.9 60.55 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of chest with contrast 752989_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 ANTHEM HMO ANTHEM HMO 999999999 1838.9 2945.89 CT scan of blood vessels of chest with contrast 752989_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1838.9 2945.89 CT scan of blood vessels of chest with contrast 752989_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1838.9 2945.89 CT scan of blood vessels of chest with contrast 752989_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1838.9 2945.89 CT scan of blood vessels of chest with contrast 752989_1 CDM 0352 RC 71275 HCPCS inpatient 3037 1974.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2053.01 67.6 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 752991_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1974.05 65 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 752991_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2945.89 97 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 752991_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 AETNA AETNA 2399.23 79 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 752991_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2095.53 69 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 752991_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 2368.86 78 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 752991_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 SIHO - ALL PLANS SIHO - ALL PLANS 2733.3 90 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 752991_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 UMR - ALL PLANS UMR - ALL PLANS 2125.9 70 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 752991_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1838.9 2945.89 CT scan of blood vessels of head with contrast 752991_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1838.9 60.55 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of head with contrast 752991_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 ANTHEM HMO ANTHEM HMO 999999999 1838.9 2945.89 CT scan of blood vessels of head with contrast 752991_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1838.9 2945.89 CT scan of blood vessels of head with contrast 752991_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1838.9 2945.89 CT scan of blood vessels of head with contrast 752991_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1838.9 2945.89 CT scan of blood vessels of head with contrast 752991_1 CDM 0351 RC 70496 HCPCS inpatient 3037 1974.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2053.01 67.6 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752993_1 CDM 0350 RC 73706 HCPCS inpatient 4245 2759.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 2759.25 65 999999999 2570.35 4117.65 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752993_1 CDM 0350 RC 73706 HCPCS inpatient 4245 2759.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4117.65 97 999999999 2570.35 4117.65 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752993_1 CDM 0350 RC 73706 HCPCS inpatient 4245 2759.25 AETNA AETNA 3353.55 79 999999999 2570.35 4117.65 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752993_1 CDM 0350 RC 73706 HCPCS inpatient 4245 2759.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 2929.05 69 999999999 2570.35 4117.65 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752993_1 CDM 0350 RC 73706 HCPCS inpatient 4245 2759.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 3311.1 78 999999999 2570.35 4117.65 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752993_1 CDM 0350 RC 73706 HCPCS inpatient 4245 2759.25 SIHO - ALL PLANS SIHO - ALL PLANS 3820.5 90 999999999 2570.35 4117.65 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752993_1 CDM 0350 RC 73706 HCPCS inpatient 4245 2759.25 UMR - ALL PLANS UMR - ALL PLANS 2971.5 70 999999999 2570.35 4117.65 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752993_1 CDM 0350 RC 73706 HCPCS inpatient 4245 2759.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2570.35 4117.65 CT scan of blood vessels of lower leg with contrast 752993_1 CDM 0350 RC 73706 HCPCS inpatient 4245 2759.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2570.35 60.55 999999999 2570.35 4117.65 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752993_1 CDM 0350 RC 73706 HCPCS inpatient 4245 2759.25 ANTHEM HMO ANTHEM HMO 999999999 2570.35 4117.65 CT scan of blood vessels of lower leg with contrast 752993_1 CDM 0350 RC 73706 HCPCS inpatient 4245 2759.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2570.35 4117.65 CT scan of blood vessels of lower leg with contrast 752993_1 CDM 0350 RC 73706 HCPCS inpatient 4245 2759.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2570.35 4117.65 CT scan of blood vessels of lower leg with contrast 752993_1 CDM 0350 RC 73706 HCPCS inpatient 4245 2759.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 2570.35 4117.65 CT scan of blood vessels of lower leg with contrast 752993_1 CDM 0350 RC 73706 HCPCS inpatient 4245 2759.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 2869.62 67.6 999999999 2570.35 4117.65 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752995_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 SELF PAY DISCOUNT SELF PAY DISCOUNT 2951 65 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752995_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4403.8 97 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752995_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 AETNA AETNA 3586.6 79 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752995_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 ENCORE - ALL PLANS ENCORE - ALL PLANS 3132.6 69 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752995_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 HUMANA - ALL PLANS HUMANA - ALL PLANS 3541.2 78 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752995_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 SIHO - ALL PLANS SIHO - ALL PLANS 4086 90 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752995_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 UMR - ALL PLANS UMR - ALL PLANS 3178 70 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752995_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2748.97 4403.8 CT scan of blood vessels of lower leg with contrast 752995_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2748.97 60.55 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752995_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 ANTHEM HMO ANTHEM HMO 999999999 2748.97 4403.8 CT scan of blood vessels of lower leg with contrast 752995_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2748.97 4403.8 CT scan of blood vessels of lower leg with contrast 752995_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2748.97 4403.8 CT scan of blood vessels of lower leg with contrast 752995_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 UHC - ALL PLANS UHC - ALL PLANS 999999999 2748.97 4403.8 CT scan of blood vessels of lower leg with contrast 752995_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 CIGNA - ALL PLANS CIGNA - ALL PLANS 3069.04 67.6 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752997_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 SELF PAY DISCOUNT SELF PAY DISCOUNT 2951 65 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752997_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4403.8 97 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752997_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 AETNA AETNA 3586.6 79 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752997_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 ENCORE - ALL PLANS ENCORE - ALL PLANS 3132.6 69 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752997_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 HUMANA - ALL PLANS HUMANA - ALL PLANS 3541.2 78 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752997_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 SIHO - ALL PLANS SIHO - ALL PLANS 4086 90 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752997_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 UMR - ALL PLANS UMR - ALL PLANS 3178 70 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752997_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2748.97 4403.8 CT scan of blood vessels of lower leg with contrast 752997_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2748.97 60.55 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of lower leg with contrast 752997_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 ANTHEM HMO ANTHEM HMO 999999999 2748.97 4403.8 CT scan of blood vessels of lower leg with contrast 752997_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2748.97 4403.8 CT scan of blood vessels of lower leg with contrast 752997_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2748.97 4403.8 CT scan of blood vessels of lower leg with contrast 752997_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 UHC - ALL PLANS UHC - ALL PLANS 999999999 2748.97 4403.8 CT scan of blood vessels of lower leg with contrast 752997_1 CDM 0350 RC 73706 HCPCS inpatient 4540 2951 CIGNA - ALL PLANS CIGNA - ALL PLANS 3069.04 67.6 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of neck with contrast 752999_1 CDM 0351 RC 70498 HCPCS inpatient 3037 1974.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1974.05 65 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of neck with contrast 752999_1 CDM 0351 RC 70498 HCPCS inpatient 3037 1974.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2945.89 97 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of neck with contrast 752999_1 CDM 0351 RC 70498 HCPCS inpatient 3037 1974.05 AETNA AETNA 2399.23 79 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of neck with contrast 752999_1 CDM 0351 RC 70498 HCPCS inpatient 3037 1974.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2095.53 69 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of neck with contrast 752999_1 CDM 0351 RC 70498 HCPCS inpatient 3037 1974.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 2368.86 78 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of neck with contrast 752999_1 CDM 0351 RC 70498 HCPCS inpatient 3037 1974.05 SIHO - ALL PLANS SIHO - ALL PLANS 2733.3 90 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of neck with contrast 752999_1 CDM 0351 RC 70498 HCPCS inpatient 3037 1974.05 UMR - ALL PLANS UMR - ALL PLANS 2125.9 70 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of neck with contrast 752999_1 CDM 0351 RC 70498 HCPCS inpatient 3037 1974.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1838.9 2945.89 CT scan of blood vessels of neck with contrast 752999_1 CDM 0351 RC 70498 HCPCS inpatient 3037 1974.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1838.9 60.55 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of neck with contrast 752999_1 CDM 0351 RC 70498 HCPCS inpatient 3037 1974.05 ANTHEM HMO ANTHEM HMO 999999999 1838.9 2945.89 CT scan of blood vessels of neck with contrast 752999_1 CDM 0351 RC 70498 HCPCS inpatient 3037 1974.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1838.9 2945.89 CT scan of blood vessels of neck with contrast 752999_1 CDM 0351 RC 70498 HCPCS inpatient 3037 1974.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1838.9 2945.89 CT scan of blood vessels of neck with contrast 752999_1 CDM 0351 RC 70498 HCPCS inpatient 3037 1974.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 1838.9 2945.89 CT scan of blood vessels of neck with contrast 752999_1 CDM 0351 RC 70498 HCPCS inpatient 3037 1974.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2053.01 67.6 999999999 1838.9 2945.89 percent of total billed charges CT scan of blood vessels of pelvis with contrast 753001_1 CDM 0352 RC 72191 HCPCS inpatient 3248 2111.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 2111.2 65 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of pelvis with contrast 753001_1 CDM 0352 RC 72191 HCPCS inpatient 3248 2111.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3150.56 97 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of pelvis with contrast 753001_1 CDM 0352 RC 72191 HCPCS inpatient 3248 2111.2 AETNA AETNA 2565.92 79 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of pelvis with contrast 753001_1 CDM 0352 RC 72191 HCPCS inpatient 3248 2111.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 2241.12 69 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of pelvis with contrast 753001_1 CDM 0352 RC 72191 HCPCS inpatient 3248 2111.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 2533.44 78 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of pelvis with contrast 753001_1 CDM 0352 RC 72191 HCPCS inpatient 3248 2111.2 SIHO - ALL PLANS SIHO - ALL PLANS 2923.2 90 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of pelvis with contrast 753001_1 CDM 0352 RC 72191 HCPCS inpatient 3248 2111.2 UMR - ALL PLANS UMR - ALL PLANS 2273.6 70 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of pelvis with contrast 753001_1 CDM 0352 RC 72191 HCPCS inpatient 3248 2111.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1966.66 3150.56 CT scan of blood vessels of pelvis with contrast 753001_1 CDM 0352 RC 72191 HCPCS inpatient 3248 2111.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1966.66 60.55 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of pelvis with contrast 753001_1 CDM 0352 RC 72191 HCPCS inpatient 3248 2111.2 ANTHEM HMO ANTHEM HMO 999999999 1966.66 3150.56 CT scan of blood vessels of pelvis with contrast 753001_1 CDM 0352 RC 72191 HCPCS inpatient 3248 2111.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1966.66 3150.56 CT scan of blood vessels of pelvis with contrast 753001_1 CDM 0352 RC 72191 HCPCS inpatient 3248 2111.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1966.66 3150.56 CT scan of blood vessels of pelvis with contrast 753001_1 CDM 0352 RC 72191 HCPCS inpatient 3248 2111.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 1966.66 3150.56 CT scan of blood vessels of pelvis with contrast 753001_1 CDM 0352 RC 72191 HCPCS inpatient 3248 2111.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 2195.65 67.6 999999999 1966.66 3150.56 percent of total billed charges CT scan of blood vessels of arm with contrast 753003_1 CDM 0352 RC 73206 HCPCS inpatient 4580 2977 SELF PAY DISCOUNT SELF PAY DISCOUNT 2977 65 999999999 2773.19 4442.6 percent of total billed charges CT scan of blood vessels of arm with contrast 753003_1 CDM 0352 RC 73206 HCPCS inpatient 4580 2977 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4442.6 97 999999999 2773.19 4442.6 percent of total billed charges CT scan of blood vessels of arm with contrast 753003_1 CDM 0352 RC 73206 HCPCS inpatient 4580 2977 AETNA AETNA 3618.2 79 999999999 2773.19 4442.6 percent of total billed charges CT scan of blood vessels of arm with contrast 753003_1 CDM 0352 RC 73206 HCPCS inpatient 4580 2977 ENCORE - ALL PLANS ENCORE - ALL PLANS 3160.2 69 999999999 2773.19 4442.6 percent of total billed charges CT scan of blood vessels of arm with contrast 753003_1 CDM 0352 RC 73206 HCPCS inpatient 4580 2977 HUMANA - ALL PLANS HUMANA - ALL PLANS 3572.4 78 999999999 2773.19 4442.6 percent of total billed charges CT scan of blood vessels of arm with contrast 753003_1 CDM 0352 RC 73206 HCPCS inpatient 4580 2977 SIHO - ALL PLANS SIHO - ALL PLANS 4122 90 999999999 2773.19 4442.6 percent of total billed charges CT scan of blood vessels of arm with contrast 753003_1 CDM 0352 RC 73206 HCPCS inpatient 4580 2977 UMR - ALL PLANS UMR - ALL PLANS 3206 70 999999999 2773.19 4442.6 percent of total billed charges CT scan of blood vessels of arm with contrast 753003_1 CDM 0352 RC 73206 HCPCS inpatient 4580 2977 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2773.19 4442.6 CT scan of blood vessels of arm with contrast 753003_1 CDM 0352 RC 73206 HCPCS inpatient 4580 2977 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2773.19 60.55 999999999 2773.19 4442.6 percent of total billed charges CT scan of blood vessels of arm with contrast 753003_1 CDM 0352 RC 73206 HCPCS inpatient 4580 2977 ANTHEM HMO ANTHEM HMO 999999999 2773.19 4442.6 CT scan of blood vessels of arm with contrast 753003_1 CDM 0352 RC 73206 HCPCS inpatient 4580 2977 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2773.19 4442.6 CT scan of blood vessels of arm with contrast 753003_1 CDM 0352 RC 73206 HCPCS inpatient 4580 2977 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2773.19 4442.6 CT scan of blood vessels of arm with contrast 753003_1 CDM 0352 RC 73206 HCPCS inpatient 4580 2977 UHC - ALL PLANS UHC - ALL PLANS 999999999 2773.19 4442.6 CT scan of blood vessels of arm with contrast 753003_1 CDM 0352 RC 73206 HCPCS inpatient 4580 2977 CIGNA - ALL PLANS CIGNA - ALL PLANS 3096.08 67.6 999999999 2773.19 4442.6 percent of total billed charges CT scan of blood vessels of arm with contrast 753005_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 SELF PAY DISCOUNT SELF PAY DISCOUNT 2951 65 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of arm with contrast 753005_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4403.8 97 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of arm with contrast 753005_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 AETNA AETNA 3586.6 79 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of arm with contrast 753005_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 ENCORE - ALL PLANS ENCORE - ALL PLANS 3132.6 69 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of arm with contrast 753005_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 HUMANA - ALL PLANS HUMANA - ALL PLANS 3541.2 78 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of arm with contrast 753005_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 SIHO - ALL PLANS SIHO - ALL PLANS 4086 90 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of arm with contrast 753005_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 UMR - ALL PLANS UMR - ALL PLANS 3178 70 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of arm with contrast 753005_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2748.97 4403.8 CT scan of blood vessels of arm with contrast 753005_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2748.97 60.55 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of arm with contrast 753005_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 ANTHEM HMO ANTHEM HMO 999999999 2748.97 4403.8 CT scan of blood vessels of arm with contrast 753005_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2748.97 4403.8 CT scan of blood vessels of arm with contrast 753005_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2748.97 4403.8 CT scan of blood vessels of arm with contrast 753005_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 UHC - ALL PLANS UHC - ALL PLANS 999999999 2748.97 4403.8 CT scan of blood vessels of arm with contrast 753005_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 CIGNA - ALL PLANS CIGNA - ALL PLANS 3069.04 67.6 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of arm with contrast 753007_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 SELF PAY DISCOUNT SELF PAY DISCOUNT 2951 65 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of arm with contrast 753007_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4403.8 97 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of arm with contrast 753007_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 AETNA AETNA 3586.6 79 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of arm with contrast 753007_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 ENCORE - ALL PLANS ENCORE - ALL PLANS 3132.6 69 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of arm with contrast 753007_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 HUMANA - ALL PLANS HUMANA - ALL PLANS 3541.2 78 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of arm with contrast 753007_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 SIHO - ALL PLANS SIHO - ALL PLANS 4086 90 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of arm with contrast 753007_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 UMR - ALL PLANS UMR - ALL PLANS 3178 70 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of arm with contrast 753007_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2748.97 4403.8 CT scan of blood vessels of arm with contrast 753007_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2748.97 60.55 999999999 2748.97 4403.8 percent of total billed charges CT scan of blood vessels of arm with contrast 753007_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 ANTHEM HMO ANTHEM HMO 999999999 2748.97 4403.8 CT scan of blood vessels of arm with contrast 753007_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2748.97 4403.8 CT scan of blood vessels of arm with contrast 753007_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2748.97 4403.8 CT scan of blood vessels of arm with contrast 753007_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 UHC - ALL PLANS UHC - ALL PLANS 999999999 2748.97 4403.8 CT scan of blood vessels of arm with contrast 753007_1 CDM 0352 RC 73206 HCPCS inpatient 4540 2951 CIGNA - ALL PLANS CIGNA - ALL PLANS 3069.04 67.6 999999999 2748.97 4403.8 percent of total billed charges CT scan of head or brain before and after contrast 753040_1 CDM 0351 RC 70470 HCPCS inpatient 3223 2094.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 2094.95 65 999999999 1951.53 3126.31 percent of total billed charges CT scan of head or brain before and after contrast 753040_1 CDM 0351 RC 70470 HCPCS inpatient 3223 2094.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3126.31 97 999999999 1951.53 3126.31 percent of total billed charges CT scan of head or brain before and after contrast 753040_1 CDM 0351 RC 70470 HCPCS inpatient 3223 2094.95 AETNA AETNA 2546.17 79 999999999 1951.53 3126.31 percent of total billed charges CT scan of head or brain before and after contrast 753040_1 CDM 0351 RC 70470 HCPCS inpatient 3223 2094.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 2223.87 69 999999999 1951.53 3126.31 percent of total billed charges CT scan of head or brain before and after contrast 753040_1 CDM 0351 RC 70470 HCPCS inpatient 3223 2094.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 2513.94 78 999999999 1951.53 3126.31 percent of total billed charges CT scan of head or brain before and after contrast 753040_1 CDM 0351 RC 70470 HCPCS inpatient 3223 2094.95 SIHO - ALL PLANS SIHO - ALL PLANS 2900.7 90 999999999 1951.53 3126.31 percent of total billed charges CT scan of head or brain before and after contrast 753040_1 CDM 0351 RC 70470 HCPCS inpatient 3223 2094.95 UMR - ALL PLANS UMR - ALL PLANS 2256.1 70 999999999 1951.53 3126.31 percent of total billed charges CT scan of head or brain before and after contrast 753040_1 CDM 0351 RC 70470 HCPCS inpatient 3223 2094.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1951.53 3126.31 CT scan of head or brain before and after contrast 753040_1 CDM 0351 RC 70470 HCPCS inpatient 3223 2094.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1951.53 60.55 999999999 1951.53 3126.31 percent of total billed charges CT scan of head or brain before and after contrast 753040_1 CDM 0351 RC 70470 HCPCS inpatient 3223 2094.95 ANTHEM HMO ANTHEM HMO 999999999 1951.53 3126.31 CT scan of head or brain before and after contrast 753040_1 CDM 0351 RC 70470 HCPCS inpatient 3223 2094.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1951.53 3126.31 CT scan of head or brain before and after contrast 753040_1 CDM 0351 RC 70470 HCPCS inpatient 3223 2094.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1951.53 3126.31 CT scan of head or brain before and after contrast 753040_1 CDM 0351 RC 70470 HCPCS inpatient 3223 2094.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1951.53 3126.31 CT scan of head or brain before and after contrast 753040_1 CDM 0351 RC 70470 HCPCS inpatient 3223 2094.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 2178.75 67.6 999999999 1951.53 3126.31 percent of total billed charges CT scan head or brain with contrast 753042_1 CDM 0352 RC 70460 HCPCS inpatient 1960 1274 SELF PAY DISCOUNT SELF PAY DISCOUNT 1274 65 999999999 1186.78 1901.2 percent of total billed charges CT scan head or brain with contrast 753042_1 CDM 0352 RC 70460 HCPCS inpatient 1960 1274 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1901.2 97 999999999 1186.78 1901.2 percent of total billed charges CT scan head or brain with contrast 753042_1 CDM 0352 RC 70460 HCPCS inpatient 1960 1274 AETNA AETNA 1548.4 79 999999999 1186.78 1901.2 percent of total billed charges CT scan head or brain with contrast 753042_1 CDM 0352 RC 70460 HCPCS inpatient 1960 1274 ENCORE - ALL PLANS ENCORE - ALL PLANS 1352.4 69 999999999 1186.78 1901.2 percent of total billed charges CT scan head or brain with contrast 753042_1 CDM 0352 RC 70460 HCPCS inpatient 1960 1274 HUMANA - ALL PLANS HUMANA - ALL PLANS 1528.8 78 999999999 1186.78 1901.2 percent of total billed charges CT scan head or brain with contrast 753042_1 CDM 0352 RC 70460 HCPCS inpatient 1960 1274 SIHO - ALL PLANS SIHO - ALL PLANS 1764 90 999999999 1186.78 1901.2 percent of total billed charges CT scan head or brain with contrast 753042_1 CDM 0352 RC 70460 HCPCS inpatient 1960 1274 UMR - ALL PLANS UMR - ALL PLANS 1372 70 999999999 1186.78 1901.2 percent of total billed charges CT scan head or brain with contrast 753042_1 CDM 0352 RC 70460 HCPCS inpatient 1960 1274 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1186.78 1901.2 CT scan head or brain with contrast 753042_1 CDM 0352 RC 70460 HCPCS inpatient 1960 1274 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1186.78 60.55 999999999 1186.78 1901.2 percent of total billed charges CT scan head or brain with contrast 753042_1 CDM 0352 RC 70460 HCPCS inpatient 1960 1274 ANTHEM HMO ANTHEM HMO 999999999 1186.78 1901.2 CT scan head or brain with contrast 753042_1 CDM 0352 RC 70460 HCPCS inpatient 1960 1274 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1186.78 1901.2 CT scan head or brain with contrast 753042_1 CDM 0352 RC 70460 HCPCS inpatient 1960 1274 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1186.78 1901.2 CT scan head or brain with contrast 753042_1 CDM 0352 RC 70460 HCPCS inpatient 1960 1274 UHC - ALL PLANS UHC - ALL PLANS 999999999 1186.78 1901.2 CT scan head or brain with contrast 753042_1 CDM 0352 RC 70460 HCPCS inpatient 1960 1274 CIGNA - ALL PLANS CIGNA - ALL PLANS 1324.96 67.6 999999999 1186.78 1901.2 percent of total billed charges CT scan head or brain without contrast 753044_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1364.35 65 999999999 1270.94 2036.03 percent of total billed charges CT scan head or brain without contrast 753044_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2036.03 97 999999999 1270.94 2036.03 percent of total billed charges CT scan head or brain without contrast 753044_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 AETNA AETNA 1658.21 79 999999999 1270.94 2036.03 percent of total billed charges CT scan head or brain without contrast 753044_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1448.31 69 999999999 1270.94 2036.03 percent of total billed charges CT scan head or brain without contrast 753044_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1637.22 78 999999999 1270.94 2036.03 percent of total billed charges CT scan head or brain without contrast 753044_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 SIHO - ALL PLANS SIHO - ALL PLANS 1889.1 90 999999999 1270.94 2036.03 percent of total billed charges CT scan head or brain without contrast 753044_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 UMR - ALL PLANS UMR - ALL PLANS 1469.3 70 999999999 1270.94 2036.03 percent of total billed charges CT scan head or brain without contrast 753044_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1270.94 2036.03 CT scan head or brain without contrast 753044_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1270.94 60.55 999999999 1270.94 2036.03 percent of total billed charges CT scan head or brain without contrast 753044_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 ANTHEM HMO ANTHEM HMO 999999999 1270.94 2036.03 CT scan head or brain without contrast 753044_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1270.94 2036.03 CT scan head or brain without contrast 753044_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1270.94 2036.03 CT scan head or brain without contrast 753044_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1270.94 2036.03 CT scan head or brain without contrast 753044_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1418.92 67.6 999999999 1270.94 2036.03 percent of total billed charges CT scan head or brain without contrast 753045_1 CDM 0351 RC 70450 HCPCS inpatient 2245 1459.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 1459.25 65 999999999 1359.35 2177.65 percent of total billed charges CT scan head or brain without contrast 753045_1 CDM 0351 RC 70450 HCPCS inpatient 2245 1459.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2177.65 97 999999999 1359.35 2177.65 percent of total billed charges CT scan head or brain without contrast 753045_1 CDM 0351 RC 70450 HCPCS inpatient 2245 1459.25 AETNA AETNA 1773.55 79 999999999 1359.35 2177.65 percent of total billed charges CT scan head or brain without contrast 753045_1 CDM 0351 RC 70450 HCPCS inpatient 2245 1459.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 1549.05 69 999999999 1359.35 2177.65 percent of total billed charges CT scan head or brain without contrast 753045_1 CDM 0351 RC 70450 HCPCS inpatient 2245 1459.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 1751.1 78 999999999 1359.35 2177.65 percent of total billed charges CT scan head or brain without contrast 753045_1 CDM 0351 RC 70450 HCPCS inpatient 2245 1459.25 SIHO - ALL PLANS SIHO - ALL PLANS 2020.5 90 999999999 1359.35 2177.65 percent of total billed charges CT scan head or brain without contrast 753045_1 CDM 0351 RC 70450 HCPCS inpatient 2245 1459.25 UMR - ALL PLANS UMR - ALL PLANS 1571.5 70 999999999 1359.35 2177.65 percent of total billed charges CT scan head or brain without contrast 753045_1 CDM 0351 RC 70450 HCPCS inpatient 2245 1459.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1359.35 2177.65 CT scan head or brain without contrast 753045_1 CDM 0351 RC 70450 HCPCS inpatient 2245 1459.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1359.35 60.55 999999999 1359.35 2177.65 percent of total billed charges CT scan head or brain without contrast 753045_1 CDM 0351 RC 70450 HCPCS inpatient 2245 1459.25 ANTHEM HMO ANTHEM HMO 999999999 1359.35 2177.65 CT scan head or brain without contrast 753045_1 CDM 0351 RC 70450 HCPCS inpatient 2245 1459.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1359.35 2177.65 CT scan head or brain without contrast 753045_1 CDM 0351 RC 70450 HCPCS inpatient 2245 1459.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1359.35 2177.65 CT scan head or brain without contrast 753045_1 CDM 0351 RC 70450 HCPCS inpatient 2245 1459.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 1359.35 2177.65 CT scan head or brain without contrast 753045_1 CDM 0351 RC 70450 HCPCS inpatient 2245 1459.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 1517.62 67.6 999999999 1359.35 2177.65 percent of total billed charges CT scan of cranial cavity before and after contrast 753046_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1665.95 65 999999999 1551.9 2486.11 percent of total billed charges CT scan of cranial cavity before and after contrast 753046_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2486.11 97 999999999 1551.9 2486.11 percent of total billed charges CT scan of cranial cavity before and after contrast 753046_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 AETNA AETNA 2024.77 79 999999999 1551.9 2486.11 percent of total billed charges CT scan of cranial cavity before and after contrast 753046_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1768.47 69 999999999 1551.9 2486.11 percent of total billed charges CT scan of cranial cavity before and after contrast 753046_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1999.14 78 999999999 1551.9 2486.11 percent of total billed charges CT scan of cranial cavity before and after contrast 753046_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 SIHO - ALL PLANS SIHO - ALL PLANS 2306.7 90 999999999 1551.9 2486.11 percent of total billed charges CT scan of cranial cavity before and after contrast 753046_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 UMR - ALL PLANS UMR - ALL PLANS 1794.1 70 999999999 1551.9 2486.11 percent of total billed charges CT scan of cranial cavity before and after contrast 753046_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1551.9 2486.11 CT scan of cranial cavity before and after contrast 753046_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1551.9 60.55 999999999 1551.9 2486.11 percent of total billed charges CT scan of cranial cavity before and after contrast 753046_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 ANTHEM HMO ANTHEM HMO 999999999 1551.9 2486.11 CT scan of cranial cavity before and after contrast 753046_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1551.9 2486.11 CT scan of cranial cavity before and after contrast 753046_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1551.9 2486.11 CT scan of cranial cavity before and after contrast 753046_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1551.9 2486.11 CT scan of cranial cavity before and after contrast 753046_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1732.59 67.6 999999999 1551.9 2486.11 percent of total billed charges CT scan of cranial cavity with contrast 753048_1 CDM 0351 RC 70481 HCPCS inpatient 1970 1280.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1280.5 65 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity with contrast 753048_1 CDM 0351 RC 70481 HCPCS inpatient 1970 1280.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1910.9 97 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity with contrast 753048_1 CDM 0351 RC 70481 HCPCS inpatient 1970 1280.5 AETNA AETNA 1556.3 79 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity with contrast 753048_1 CDM 0351 RC 70481 HCPCS inpatient 1970 1280.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1359.3 69 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity with contrast 753048_1 CDM 0351 RC 70481 HCPCS inpatient 1970 1280.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1536.6 78 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity with contrast 753048_1 CDM 0351 RC 70481 HCPCS inpatient 1970 1280.5 SIHO - ALL PLANS SIHO - ALL PLANS 1773 90 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity with contrast 753048_1 CDM 0351 RC 70481 HCPCS inpatient 1970 1280.5 UMR - ALL PLANS UMR - ALL PLANS 1379 70 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity with contrast 753048_1 CDM 0351 RC 70481 HCPCS inpatient 1970 1280.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1192.84 1910.9 CT scan of cranial cavity with contrast 753048_1 CDM 0351 RC 70481 HCPCS inpatient 1970 1280.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1192.84 60.55 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity with contrast 753048_1 CDM 0351 RC 70481 HCPCS inpatient 1970 1280.5 ANTHEM HMO ANTHEM HMO 999999999 1192.84 1910.9 CT scan of cranial cavity with contrast 753048_1 CDM 0351 RC 70481 HCPCS inpatient 1970 1280.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1192.84 1910.9 CT scan of cranial cavity with contrast 753048_1 CDM 0351 RC 70481 HCPCS inpatient 1970 1280.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1192.84 1910.9 CT scan of cranial cavity with contrast 753048_1 CDM 0351 RC 70481 HCPCS inpatient 1970 1280.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1192.84 1910.9 CT scan of cranial cavity with contrast 753048_1 CDM 0351 RC 70481 HCPCS inpatient 1970 1280.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1331.72 67.6 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity without contrast 753050_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1280.5 65 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity without contrast 753050_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1910.9 97 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity without contrast 753050_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 AETNA AETNA 1556.3 79 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity without contrast 753050_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1359.3 69 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity without contrast 753050_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1536.6 78 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity without contrast 753050_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 SIHO - ALL PLANS SIHO - ALL PLANS 1773 90 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity without contrast 753050_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 UMR - ALL PLANS UMR - ALL PLANS 1379 70 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity without contrast 753050_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1192.84 1910.9 CT scan of cranial cavity without contrast 753050_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1192.84 60.55 999999999 1192.84 1910.9 percent of total billed charges CT scan of cranial cavity without contrast 753050_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 ANTHEM HMO ANTHEM HMO 999999999 1192.84 1910.9 CT scan of cranial cavity without contrast 753050_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1192.84 1910.9 CT scan of cranial cavity without contrast 753050_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1192.84 1910.9 CT scan of cranial cavity without contrast 753050_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1192.84 1910.9 CT scan of cranial cavity without contrast 753050_1 CDM 0351 RC 70480 HCPCS inpatient 1970 1280.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1331.72 67.6 999999999 1192.84 1910.9 percent of total billed charges Limited or follow-up CT scan 753061_1 CDM 0350 RC 76380 HCPCS inpatient 1131 735.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 735.15 65 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 753061_1 CDM 0350 RC 76380 HCPCS inpatient 1131 735.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1097.07 97 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 753061_1 CDM 0350 RC 76380 HCPCS inpatient 1131 735.15 AETNA AETNA 893.49 79 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 753061_1 CDM 0350 RC 76380 HCPCS inpatient 1131 735.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 780.39 69 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 753061_1 CDM 0350 RC 76380 HCPCS inpatient 1131 735.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 882.18 78 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 753061_1 CDM 0350 RC 76380 HCPCS inpatient 1131 735.15 SIHO - ALL PLANS SIHO - ALL PLANS 1017.9 90 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 753061_1 CDM 0350 RC 76380 HCPCS inpatient 1131 735.15 UMR - ALL PLANS UMR - ALL PLANS 791.7 70 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 753061_1 CDM 0350 RC 76380 HCPCS inpatient 1131 735.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 684.82 1097.07 Limited or follow-up CT scan 753061_1 CDM 0350 RC 76380 HCPCS inpatient 1131 735.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 684.82 60.55 999999999 684.82 1097.07 percent of total billed charges Limited or follow-up CT scan 753061_1 CDM 0350 RC 76380 HCPCS inpatient 1131 735.15 ANTHEM HMO ANTHEM HMO 999999999 684.82 1097.07 Limited or follow-up CT scan 753061_1 CDM 0350 RC 76380 HCPCS inpatient 1131 735.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 684.82 1097.07 Limited or follow-up CT scan 753061_1 CDM 0350 RC 76380 HCPCS inpatient 1131 735.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 684.82 1097.07 Limited or follow-up CT scan 753061_1 CDM 0350 RC 76380 HCPCS inpatient 1131 735.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 684.82 1097.07 Limited or follow-up CT scan 753061_1 CDM 0350 RC 76380 HCPCS inpatient 1131 735.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 764.56 67.6 999999999 684.82 1097.07 percent of total billed charges CT scan of leg with contrast material 753065_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1549.6 65 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg with contrast material 753065_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2312.48 97 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg with contrast material 753065_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 AETNA AETNA 1883.36 79 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg with contrast material 753065_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1644.96 69 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg with contrast material 753065_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1859.52 78 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg with contrast material 753065_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 SIHO - ALL PLANS SIHO - ALL PLANS 2145.6 90 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg with contrast material 753065_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 UMR - ALL PLANS UMR - ALL PLANS 1668.8 70 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg with contrast material 753065_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1443.51 2312.48 CT scan of leg with contrast material 753065_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1443.51 60.55 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg with contrast material 753065_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 ANTHEM HMO ANTHEM HMO 999999999 1443.51 2312.48 CT scan of leg with contrast material 753065_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1443.51 2312.48 CT scan of leg with contrast material 753065_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1443.51 2312.48 CT scan of leg with contrast material 753065_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1443.51 2312.48 CT scan of leg with contrast material 753065_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1611.58 67.6 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg with contrast material 753067_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1549.6 65 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg with contrast material 753067_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2312.48 97 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg with contrast material 753067_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 AETNA AETNA 1883.36 79 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg with contrast material 753067_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1644.96 69 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg with contrast material 753067_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1859.52 78 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg with contrast material 753067_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 SIHO - ALL PLANS SIHO - ALL PLANS 2145.6 90 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg with contrast material 753067_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 UMR - ALL PLANS UMR - ALL PLANS 1668.8 70 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg with contrast material 753067_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1443.51 2312.48 CT scan of leg with contrast material 753067_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1443.51 60.55 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg with contrast material 753067_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 ANTHEM HMO ANTHEM HMO 999999999 1443.51 2312.48 CT scan of leg with contrast material 753067_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1443.51 2312.48 CT scan of leg with contrast material 753067_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1443.51 2312.48 CT scan of leg with contrast material 753067_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1443.51 2312.48 CT scan of leg with contrast material 753067_1 CDM 0352 RC 73701 HCPCS inpatient 2384 1549.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1611.58 67.6 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg before and after contrast 753071_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 2324.4 65 999999999 2165.27 3468.72 percent of total billed charges CT scan of leg before and after contrast 753071_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3468.72 97 999999999 2165.27 3468.72 percent of total billed charges CT scan of leg before and after contrast 753071_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 AETNA AETNA 2825.04 79 999999999 2165.27 3468.72 percent of total billed charges CT scan of leg before and after contrast 753071_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 2467.44 69 999999999 2165.27 3468.72 percent of total billed charges CT scan of leg before and after contrast 753071_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 2789.28 78 999999999 2165.27 3468.72 percent of total billed charges CT scan of leg before and after contrast 753071_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 SIHO - ALL PLANS SIHO - ALL PLANS 3218.4 90 999999999 2165.27 3468.72 percent of total billed charges CT scan of leg before and after contrast 753071_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 UMR - ALL PLANS UMR - ALL PLANS 2503.2 70 999999999 2165.27 3468.72 percent of total billed charges CT scan of leg before and after contrast 753071_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2165.27 3468.72 CT scan of leg before and after contrast 753071_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2165.27 60.55 999999999 2165.27 3468.72 percent of total billed charges CT scan of leg before and after contrast 753071_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 ANTHEM HMO ANTHEM HMO 999999999 2165.27 3468.72 CT scan of leg before and after contrast 753071_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2165.27 3468.72 CT scan of leg before and after contrast 753071_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2165.27 3468.72 CT scan of leg before and after contrast 753071_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 2165.27 3468.72 CT scan of leg before and after contrast 753071_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 2417.38 67.6 999999999 2165.27 3468.72 percent of total billed charges CT scan of leg before and after contrast 753073_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 2324.4 65 999999999 2165.27 3468.72 percent of total billed charges CT scan of leg before and after contrast 753073_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3468.72 97 999999999 2165.27 3468.72 percent of total billed charges CT scan of leg before and after contrast 753073_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 AETNA AETNA 2825.04 79 999999999 2165.27 3468.72 percent of total billed charges CT scan of leg before and after contrast 753073_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 2467.44 69 999999999 2165.27 3468.72 percent of total billed charges CT scan of leg before and after contrast 753073_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 2789.28 78 999999999 2165.27 3468.72 percent of total billed charges CT scan of leg before and after contrast 753073_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 SIHO - ALL PLANS SIHO - ALL PLANS 3218.4 90 999999999 2165.27 3468.72 percent of total billed charges CT scan of leg before and after contrast 753073_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 UMR - ALL PLANS UMR - ALL PLANS 2503.2 70 999999999 2165.27 3468.72 percent of total billed charges CT scan of leg before and after contrast 753073_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2165.27 3468.72 CT scan of leg before and after contrast 753073_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2165.27 60.55 999999999 2165.27 3468.72 percent of total billed charges CT scan of leg before and after contrast 753073_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 ANTHEM HMO ANTHEM HMO 999999999 2165.27 3468.72 CT scan of leg before and after contrast 753073_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2165.27 3468.72 CT scan of leg before and after contrast 753073_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2165.27 3468.72 CT scan of leg before and after contrast 753073_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 2165.27 3468.72 CT scan of leg before and after contrast 753073_1 CDM 0352 RC 73702 HCPCS inpatient 3576 2324.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 2417.38 67.6 999999999 2165.27 3468.72 percent of total billed charges CT scan of leg without contrast 753077_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1549.6 65 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg without contrast 753077_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2312.48 97 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg without contrast 753077_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 AETNA AETNA 1883.36 79 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg without contrast 753077_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1644.96 69 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg without contrast 753077_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1859.52 78 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg without contrast 753077_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 SIHO - ALL PLANS SIHO - ALL PLANS 2145.6 90 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg without contrast 753077_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 UMR - ALL PLANS UMR - ALL PLANS 1668.8 70 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg without contrast 753077_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1443.51 2312.48 CT scan of leg without contrast 753077_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1443.51 60.55 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg without contrast 753077_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 ANTHEM HMO ANTHEM HMO 999999999 1443.51 2312.48 CT scan of leg without contrast 753077_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1443.51 2312.48 CT scan of leg without contrast 753077_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1443.51 2312.48 CT scan of leg without contrast 753077_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1443.51 2312.48 CT scan of leg without contrast 753077_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1611.58 67.6 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg without contrast 753079_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1549.6 65 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg without contrast 753079_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2312.48 97 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg without contrast 753079_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 AETNA AETNA 1883.36 79 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg without contrast 753079_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1644.96 69 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg without contrast 753079_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1859.52 78 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg without contrast 753079_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 SIHO - ALL PLANS SIHO - ALL PLANS 2145.6 90 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg without contrast 753079_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 UMR - ALL PLANS UMR - ALL PLANS 1668.8 70 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg without contrast 753079_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1443.51 2312.48 CT scan of leg without contrast 753079_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1443.51 60.55 999999999 1443.51 2312.48 percent of total billed charges CT scan of leg without contrast 753079_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 ANTHEM HMO ANTHEM HMO 999999999 1443.51 2312.48 CT scan of leg without contrast 753079_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1443.51 2312.48 CT scan of leg without contrast 753079_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1443.51 2312.48 CT scan of leg without contrast 753079_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1443.51 2312.48 CT scan of leg without contrast 753079_1 CDM 0352 RC 73700 HCPCS inpatient 2384 1549.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1611.58 67.6 999999999 1443.51 2312.48 percent of total billed charges CT scan of face before and after contrast 753081_1 CDM 0351 RC 70488 HCPCS inpatient 1991 1294.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1294.15 65 999999999 1205.55 1931.27 percent of total billed charges CT scan of face before and after contrast 753081_1 CDM 0351 RC 70488 HCPCS inpatient 1991 1294.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1931.27 97 999999999 1205.55 1931.27 percent of total billed charges CT scan of face before and after contrast 753081_1 CDM 0351 RC 70488 HCPCS inpatient 1991 1294.15 AETNA AETNA 1572.89 79 999999999 1205.55 1931.27 percent of total billed charges CT scan of face before and after contrast 753081_1 CDM 0351 RC 70488 HCPCS inpatient 1991 1294.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1373.79 69 999999999 1205.55 1931.27 percent of total billed charges CT scan of face before and after contrast 753081_1 CDM 0351 RC 70488 HCPCS inpatient 1991 1294.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1552.98 78 999999999 1205.55 1931.27 percent of total billed charges CT scan of face before and after contrast 753081_1 CDM 0351 RC 70488 HCPCS inpatient 1991 1294.15 SIHO - ALL PLANS SIHO - ALL PLANS 1791.9 90 999999999 1205.55 1931.27 percent of total billed charges CT scan of face before and after contrast 753081_1 CDM 0351 RC 70488 HCPCS inpatient 1991 1294.15 UMR - ALL PLANS UMR - ALL PLANS 1393.7 70 999999999 1205.55 1931.27 percent of total billed charges CT scan of face before and after contrast 753081_1 CDM 0351 RC 70488 HCPCS inpatient 1991 1294.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1205.55 1931.27 CT scan of face before and after contrast 753081_1 CDM 0351 RC 70488 HCPCS inpatient 1991 1294.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1205.55 60.55 999999999 1205.55 1931.27 percent of total billed charges CT scan of face before and after contrast 753081_1 CDM 0351 RC 70488 HCPCS inpatient 1991 1294.15 ANTHEM HMO ANTHEM HMO 999999999 1205.55 1931.27 CT scan of face before and after contrast 753081_1 CDM 0351 RC 70488 HCPCS inpatient 1991 1294.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1205.55 1931.27 CT scan of face before and after contrast 753081_1 CDM 0351 RC 70488 HCPCS inpatient 1991 1294.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1205.55 1931.27 CT scan of face before and after contrast 753081_1 CDM 0351 RC 70488 HCPCS inpatient 1991 1294.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1205.55 1931.27 CT scan of face before and after contrast 753081_1 CDM 0351 RC 70488 HCPCS inpatient 1991 1294.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1345.92 67.6 999999999 1205.55 1931.27 percent of total billed charges CT scan of face with contrast 753083_1 CDM 0351 RC 70487 HCPCS inpatient 1862 1210.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1210.3 65 999999999 1127.44 1806.14 percent of total billed charges CT scan of face with contrast 753083_1 CDM 0351 RC 70487 HCPCS inpatient 1862 1210.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1806.14 97 999999999 1127.44 1806.14 percent of total billed charges CT scan of face with contrast 753083_1 CDM 0351 RC 70487 HCPCS inpatient 1862 1210.3 AETNA AETNA 1470.98 79 999999999 1127.44 1806.14 percent of total billed charges CT scan of face with contrast 753083_1 CDM 0351 RC 70487 HCPCS inpatient 1862 1210.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1284.78 69 999999999 1127.44 1806.14 percent of total billed charges CT scan of face with contrast 753083_1 CDM 0351 RC 70487 HCPCS inpatient 1862 1210.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1452.36 78 999999999 1127.44 1806.14 percent of total billed charges CT scan of face with contrast 753083_1 CDM 0351 RC 70487 HCPCS inpatient 1862 1210.3 SIHO - ALL PLANS SIHO - ALL PLANS 1675.8 90 999999999 1127.44 1806.14 percent of total billed charges CT scan of face with contrast 753083_1 CDM 0351 RC 70487 HCPCS inpatient 1862 1210.3 UMR - ALL PLANS UMR - ALL PLANS 1303.4 70 999999999 1127.44 1806.14 percent of total billed charges CT scan of face with contrast 753083_1 CDM 0351 RC 70487 HCPCS inpatient 1862 1210.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1127.44 1806.14 CT scan of face with contrast 753083_1 CDM 0351 RC 70487 HCPCS inpatient 1862 1210.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1127.44 60.55 999999999 1127.44 1806.14 percent of total billed charges CT scan of face with contrast 753083_1 CDM 0351 RC 70487 HCPCS inpatient 1862 1210.3 ANTHEM HMO ANTHEM HMO 999999999 1127.44 1806.14 CT scan of face with contrast 753083_1 CDM 0351 RC 70487 HCPCS inpatient 1862 1210.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1127.44 1806.14 CT scan of face with contrast 753083_1 CDM 0351 RC 70487 HCPCS inpatient 1862 1210.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1127.44 1806.14 CT scan of face with contrast 753083_1 CDM 0351 RC 70487 HCPCS inpatient 1862 1210.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1127.44 1806.14 CT scan of face with contrast 753083_1 CDM 0351 RC 70487 HCPCS inpatient 1862 1210.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1258.71 67.6 999999999 1127.44 1806.14 percent of total billed charges CT scan of pelvis before and after contrast 753102_1 CDM 0352 RC 72194 HCPCS inpatient 2640 1716 SELF PAY DISCOUNT SELF PAY DISCOUNT 1716 65 999999999 1598.52 2560.8 percent of total billed charges CT scan of pelvis before and after contrast 753102_1 CDM 0352 RC 72194 HCPCS inpatient 2640 1716 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2560.8 97 999999999 1598.52 2560.8 percent of total billed charges CT scan of pelvis before and after contrast 753102_1 CDM 0352 RC 72194 HCPCS inpatient 2640 1716 AETNA AETNA 2085.6 79 999999999 1598.52 2560.8 percent of total billed charges CT scan of pelvis before and after contrast 753102_1 CDM 0352 RC 72194 HCPCS inpatient 2640 1716 ENCORE - ALL PLANS ENCORE - ALL PLANS 1821.6 69 999999999 1598.52 2560.8 percent of total billed charges CT scan of pelvis before and after contrast 753102_1 CDM 0352 RC 72194 HCPCS inpatient 2640 1716 HUMANA - ALL PLANS HUMANA - ALL PLANS 2059.2 78 999999999 1598.52 2560.8 percent of total billed charges CT scan of pelvis before and after contrast 753102_1 CDM 0352 RC 72194 HCPCS inpatient 2640 1716 SIHO - ALL PLANS SIHO - ALL PLANS 2376 90 999999999 1598.52 2560.8 percent of total billed charges CT scan of pelvis before and after contrast 753102_1 CDM 0352 RC 72194 HCPCS inpatient 2640 1716 UMR - ALL PLANS UMR - ALL PLANS 1848 70 999999999 1598.52 2560.8 percent of total billed charges CT scan of pelvis before and after contrast 753102_1 CDM 0352 RC 72194 HCPCS inpatient 2640 1716 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1598.52 2560.8 CT scan of pelvis before and after contrast 753102_1 CDM 0352 RC 72194 HCPCS inpatient 2640 1716 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1598.52 60.55 999999999 1598.52 2560.8 percent of total billed charges CT scan of pelvis before and after contrast 753102_1 CDM 0352 RC 72194 HCPCS inpatient 2640 1716 ANTHEM HMO ANTHEM HMO 999999999 1598.52 2560.8 CT scan of pelvis before and after contrast 753102_1 CDM 0352 RC 72194 HCPCS inpatient 2640 1716 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1598.52 2560.8 CT scan of pelvis before and after contrast 753102_1 CDM 0352 RC 72194 HCPCS inpatient 2640 1716 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1598.52 2560.8 CT scan of pelvis before and after contrast 753102_1 CDM 0352 RC 72194 HCPCS inpatient 2640 1716 UHC - ALL PLANS UHC - ALL PLANS 999999999 1598.52 2560.8 CT scan of pelvis before and after contrast 753102_1 CDM 0352 RC 72194 HCPCS inpatient 2640 1716 CIGNA - ALL PLANS CIGNA - ALL PLANS 1784.64 67.6 999999999 1598.52 2560.8 percent of total billed charges CT scan of pelvis with contrast 753104_1 CDM 0352 RC 72193 HCPCS inpatient 2331 1515.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1515.15 65 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis with contrast 753104_1 CDM 0352 RC 72193 HCPCS inpatient 2331 1515.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2261.07 97 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis with contrast 753104_1 CDM 0352 RC 72193 HCPCS inpatient 2331 1515.15 AETNA AETNA 1841.49 79 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis with contrast 753104_1 CDM 0352 RC 72193 HCPCS inpatient 2331 1515.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1608.39 69 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis with contrast 753104_1 CDM 0352 RC 72193 HCPCS inpatient 2331 1515.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1818.18 78 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis with contrast 753104_1 CDM 0352 RC 72193 HCPCS inpatient 2331 1515.15 SIHO - ALL PLANS SIHO - ALL PLANS 2097.9 90 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis with contrast 753104_1 CDM 0352 RC 72193 HCPCS inpatient 2331 1515.15 UMR - ALL PLANS UMR - ALL PLANS 1631.7 70 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis with contrast 753104_1 CDM 0352 RC 72193 HCPCS inpatient 2331 1515.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1411.42 2261.07 CT scan of pelvis with contrast 753104_1 CDM 0352 RC 72193 HCPCS inpatient 2331 1515.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1411.42 60.55 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis with contrast 753104_1 CDM 0352 RC 72193 HCPCS inpatient 2331 1515.15 ANTHEM HMO ANTHEM HMO 999999999 1411.42 2261.07 CT scan of pelvis with contrast 753104_1 CDM 0352 RC 72193 HCPCS inpatient 2331 1515.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1411.42 2261.07 CT scan of pelvis with contrast 753104_1 CDM 0352 RC 72193 HCPCS inpatient 2331 1515.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1411.42 2261.07 CT scan of pelvis with contrast 753104_1 CDM 0352 RC 72193 HCPCS inpatient 2331 1515.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1411.42 2261.07 CT scan of pelvis with contrast 753104_1 CDM 0352 RC 72193 HCPCS inpatient 2331 1515.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1575.76 67.6 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis without contrast 753106_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1515.15 65 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis without contrast 753106_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2261.07 97 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis without contrast 753106_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 AETNA AETNA 1841.49 79 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis without contrast 753106_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1608.39 69 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis without contrast 753106_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1818.18 78 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis without contrast 753106_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 SIHO - ALL PLANS SIHO - ALL PLANS 2097.9 90 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis without contrast 753106_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 UMR - ALL PLANS UMR - ALL PLANS 1631.7 70 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis without contrast 753106_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1411.42 2261.07 CT scan of pelvis without contrast 753106_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1411.42 60.55 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis without contrast 753106_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 ANTHEM HMO ANTHEM HMO 999999999 1411.42 2261.07 CT scan of pelvis without contrast 753106_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1411.42 2261.07 CT scan of pelvis without contrast 753106_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1411.42 2261.07 CT scan of pelvis without contrast 753106_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1411.42 2261.07 CT scan of pelvis without contrast 753106_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1575.76 67.6 999999999 1411.42 2261.07 percent of total billed charges CT scan of face without contrast 753121_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1369.55 65 999999999 1275.79 2043.79 percent of total billed charges CT scan of face without contrast 753121_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2043.79 97 999999999 1275.79 2043.79 percent of total billed charges CT scan of face without contrast 753121_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 AETNA AETNA 1664.53 79 999999999 1275.79 2043.79 percent of total billed charges CT scan of face without contrast 753121_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1453.83 69 999999999 1275.79 2043.79 percent of total billed charges CT scan of face without contrast 753121_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1643.46 78 999999999 1275.79 2043.79 percent of total billed charges CT scan of face without contrast 753121_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 SIHO - ALL PLANS SIHO - ALL PLANS 1896.3 90 999999999 1275.79 2043.79 percent of total billed charges CT scan of face without contrast 753121_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 UMR - ALL PLANS UMR - ALL PLANS 1474.9 70 999999999 1275.79 2043.79 percent of total billed charges CT scan of face without contrast 753121_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1275.79 2043.79 CT scan of face without contrast 753121_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1275.79 60.55 999999999 1275.79 2043.79 percent of total billed charges CT scan of face without contrast 753121_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 ANTHEM HMO ANTHEM HMO 999999999 1275.79 2043.79 CT scan of face without contrast 753121_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1275.79 2043.79 CT scan of face without contrast 753121_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1275.79 2043.79 CT scan of face without contrast 753121_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1275.79 2043.79 CT scan of face without contrast 753121_1 CDM 0351 RC 70486 HCPCS inpatient 2107 1369.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1424.33 67.6 999999999 1275.79 2043.79 percent of total billed charges CT scan of soft tissue of neck before and after contrast 753123_1 CDM 0351 RC 70492 HCPCS inpatient 3106 2018.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 2018.9 65 999999999 1880.68 3012.82 percent of total billed charges CT scan of soft tissue of neck before and after contrast 753123_1 CDM 0351 RC 70492 HCPCS inpatient 3106 2018.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3012.82 97 999999999 1880.68 3012.82 percent of total billed charges CT scan of soft tissue of neck before and after contrast 753123_1 CDM 0351 RC 70492 HCPCS inpatient 3106 2018.9 AETNA AETNA 2453.74 79 999999999 1880.68 3012.82 percent of total billed charges CT scan of soft tissue of neck before and after contrast 753123_1 CDM 0351 RC 70492 HCPCS inpatient 3106 2018.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 2143.14 69 999999999 1880.68 3012.82 percent of total billed charges CT scan of soft tissue of neck before and after contrast 753123_1 CDM 0351 RC 70492 HCPCS inpatient 3106 2018.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 2422.68 78 999999999 1880.68 3012.82 percent of total billed charges CT scan of soft tissue of neck before and after contrast 753123_1 CDM 0351 RC 70492 HCPCS inpatient 3106 2018.9 SIHO - ALL PLANS SIHO - ALL PLANS 2795.4 90 999999999 1880.68 3012.82 percent of total billed charges CT scan of soft tissue of neck before and after contrast 753123_1 CDM 0351 RC 70492 HCPCS inpatient 3106 2018.9 UMR - ALL PLANS UMR - ALL PLANS 2174.2 70 999999999 1880.68 3012.82 percent of total billed charges CT scan of soft tissue of neck before and after contrast 753123_1 CDM 0351 RC 70492 HCPCS inpatient 3106 2018.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1880.68 3012.82 CT scan of soft tissue of neck before and after contrast 753123_1 CDM 0351 RC 70492 HCPCS inpatient 3106 2018.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1880.68 60.55 999999999 1880.68 3012.82 percent of total billed charges CT scan of soft tissue of neck before and after contrast 753123_1 CDM 0351 RC 70492 HCPCS inpatient 3106 2018.9 ANTHEM HMO ANTHEM HMO 999999999 1880.68 3012.82 CT scan of soft tissue of neck before and after contrast 753123_1 CDM 0351 RC 70492 HCPCS inpatient 3106 2018.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1880.68 3012.82 CT scan of soft tissue of neck before and after contrast 753123_1 CDM 0351 RC 70492 HCPCS inpatient 3106 2018.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1880.68 3012.82 CT scan of soft tissue of neck before and after contrast 753123_1 CDM 0351 RC 70492 HCPCS inpatient 3106 2018.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1880.68 3012.82 CT scan of soft tissue of neck before and after contrast 753123_1 CDM 0351 RC 70492 HCPCS inpatient 3106 2018.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 2099.66 67.6 999999999 1880.68 3012.82 percent of total billed charges CT scan of soft tissue of neck with contrast 753125_1 CDM 0351 RC 70491 HCPCS inpatient 2380 1547 SELF PAY DISCOUNT SELF PAY DISCOUNT 1547 65 999999999 1441.09 2308.6 percent of total billed charges CT scan of soft tissue of neck with contrast 753125_1 CDM 0351 RC 70491 HCPCS inpatient 2380 1547 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2308.6 97 999999999 1441.09 2308.6 percent of total billed charges CT scan of soft tissue of neck with contrast 753125_1 CDM 0351 RC 70491 HCPCS inpatient 2380 1547 AETNA AETNA 1880.2 79 999999999 1441.09 2308.6 percent of total billed charges CT scan of soft tissue of neck with contrast 753125_1 CDM 0351 RC 70491 HCPCS inpatient 2380 1547 ENCORE - ALL PLANS ENCORE - ALL PLANS 1642.2 69 999999999 1441.09 2308.6 percent of total billed charges CT scan of soft tissue of neck with contrast 753125_1 CDM 0351 RC 70491 HCPCS inpatient 2380 1547 HUMANA - ALL PLANS HUMANA - ALL PLANS 1856.4 78 999999999 1441.09 2308.6 percent of total billed charges CT scan of soft tissue of neck with contrast 753125_1 CDM 0351 RC 70491 HCPCS inpatient 2380 1547 SIHO - ALL PLANS SIHO - ALL PLANS 2142 90 999999999 1441.09 2308.6 percent of total billed charges CT scan of soft tissue of neck with contrast 753125_1 CDM 0351 RC 70491 HCPCS inpatient 2380 1547 UMR - ALL PLANS UMR - ALL PLANS 1666 70 999999999 1441.09 2308.6 percent of total billed charges CT scan of soft tissue of neck with contrast 753125_1 CDM 0351 RC 70491 HCPCS inpatient 2380 1547 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1441.09 2308.6 CT scan of soft tissue of neck with contrast 753125_1 CDM 0351 RC 70491 HCPCS inpatient 2380 1547 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1441.09 60.55 999999999 1441.09 2308.6 percent of total billed charges CT scan of soft tissue of neck with contrast 753125_1 CDM 0351 RC 70491 HCPCS inpatient 2380 1547 ANTHEM HMO ANTHEM HMO 999999999 1441.09 2308.6 CT scan of soft tissue of neck with contrast 753125_1 CDM 0351 RC 70491 HCPCS inpatient 2380 1547 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1441.09 2308.6 CT scan of soft tissue of neck with contrast 753125_1 CDM 0351 RC 70491 HCPCS inpatient 2380 1547 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1441.09 2308.6 CT scan of soft tissue of neck with contrast 753125_1 CDM 0351 RC 70491 HCPCS inpatient 2380 1547 UHC - ALL PLANS UHC - ALL PLANS 999999999 1441.09 2308.6 CT scan of soft tissue of neck with contrast 753125_1 CDM 0351 RC 70491 HCPCS inpatient 2380 1547 CIGNA - ALL PLANS CIGNA - ALL PLANS 1608.88 67.6 999999999 1441.09 2308.6 percent of total billed charges CT scan of soft tissue of neck without contrast 753127_1 CDM 0351 RC 70490 HCPCS inpatient 2749 1786.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1786.85 65 999999999 1664.52 2666.53 percent of total billed charges CT scan of soft tissue of neck without contrast 753127_1 CDM 0351 RC 70490 HCPCS inpatient 2749 1786.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2666.53 97 999999999 1664.52 2666.53 percent of total billed charges CT scan of soft tissue of neck without contrast 753127_1 CDM 0351 RC 70490 HCPCS inpatient 2749 1786.85 AETNA AETNA 2171.71 79 999999999 1664.52 2666.53 percent of total billed charges CT scan of soft tissue of neck without contrast 753127_1 CDM 0351 RC 70490 HCPCS inpatient 2749 1786.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1896.81 69 999999999 1664.52 2666.53 percent of total billed charges CT scan of soft tissue of neck without contrast 753127_1 CDM 0351 RC 70490 HCPCS inpatient 2749 1786.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 2144.22 78 999999999 1664.52 2666.53 percent of total billed charges CT scan of soft tissue of neck without contrast 753127_1 CDM 0351 RC 70490 HCPCS inpatient 2749 1786.85 SIHO - ALL PLANS SIHO - ALL PLANS 2474.1 90 999999999 1664.52 2666.53 percent of total billed charges CT scan of soft tissue of neck without contrast 753127_1 CDM 0351 RC 70490 HCPCS inpatient 2749 1786.85 UMR - ALL PLANS UMR - ALL PLANS 1924.3 70 999999999 1664.52 2666.53 percent of total billed charges CT scan of soft tissue of neck without contrast 753127_1 CDM 0351 RC 70490 HCPCS inpatient 2749 1786.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1664.52 2666.53 CT scan of soft tissue of neck without contrast 753127_1 CDM 0351 RC 70490 HCPCS inpatient 2749 1786.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1664.52 60.55 999999999 1664.52 2666.53 percent of total billed charges CT scan of soft tissue of neck without contrast 753127_1 CDM 0351 RC 70490 HCPCS inpatient 2749 1786.85 ANTHEM HMO ANTHEM HMO 999999999 1664.52 2666.53 CT scan of soft tissue of neck without contrast 753127_1 CDM 0351 RC 70490 HCPCS inpatient 2749 1786.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1664.52 2666.53 CT scan of soft tissue of neck without contrast 753127_1 CDM 0351 RC 70490 HCPCS inpatient 2749 1786.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1664.52 2666.53 CT scan of soft tissue of neck without contrast 753127_1 CDM 0351 RC 70490 HCPCS inpatient 2749 1786.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1664.52 2666.53 CT scan of soft tissue of neck without contrast 753127_1 CDM 0351 RC 70490 HCPCS inpatient 2749 1786.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1858.32 67.6 999999999 1664.52 2666.53 percent of total billed charges CT scan of upper spine without contrast 753133_1 CDM 0352 RC 72125 HCPCS inpatient 3020 1963 SELF PAY DISCOUNT SELF PAY DISCOUNT 1963 65 999999999 1828.61 2929.4 percent of total billed charges CT scan of upper spine without contrast 753133_1 CDM 0352 RC 72125 HCPCS inpatient 3020 1963 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2929.4 97 999999999 1828.61 2929.4 percent of total billed charges CT scan of upper spine without contrast 753133_1 CDM 0352 RC 72125 HCPCS inpatient 3020 1963 AETNA AETNA 2385.8 79 999999999 1828.61 2929.4 percent of total billed charges CT scan of upper spine without contrast 753133_1 CDM 0352 RC 72125 HCPCS inpatient 3020 1963 ENCORE - ALL PLANS ENCORE - ALL PLANS 2083.8 69 999999999 1828.61 2929.4 percent of total billed charges CT scan of upper spine without contrast 753133_1 CDM 0352 RC 72125 HCPCS inpatient 3020 1963 HUMANA - ALL PLANS HUMANA - ALL PLANS 2355.6 78 999999999 1828.61 2929.4 percent of total billed charges CT scan of upper spine without contrast 753133_1 CDM 0352 RC 72125 HCPCS inpatient 3020 1963 SIHO - ALL PLANS SIHO - ALL PLANS 2718 90 999999999 1828.61 2929.4 percent of total billed charges CT scan of upper spine without contrast 753133_1 CDM 0352 RC 72125 HCPCS inpatient 3020 1963 UMR - ALL PLANS UMR - ALL PLANS 2114 70 999999999 1828.61 2929.4 percent of total billed charges CT scan of upper spine without contrast 753133_1 CDM 0352 RC 72125 HCPCS inpatient 3020 1963 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1828.61 2929.4 CT scan of upper spine without contrast 753133_1 CDM 0352 RC 72125 HCPCS inpatient 3020 1963 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1828.61 60.55 999999999 1828.61 2929.4 percent of total billed charges CT scan of upper spine without contrast 753133_1 CDM 0352 RC 72125 HCPCS inpatient 3020 1963 ANTHEM HMO ANTHEM HMO 999999999 1828.61 2929.4 CT scan of upper spine without contrast 753133_1 CDM 0352 RC 72125 HCPCS inpatient 3020 1963 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1828.61 2929.4 CT scan of upper spine without contrast 753133_1 CDM 0352 RC 72125 HCPCS inpatient 3020 1963 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1828.61 2929.4 CT scan of upper spine without contrast 753133_1 CDM 0352 RC 72125 HCPCS inpatient 3020 1963 UHC - ALL PLANS UHC - ALL PLANS 999999999 1828.61 2929.4 CT scan of upper spine without contrast 753133_1 CDM 0352 RC 72125 HCPCS inpatient 3020 1963 CIGNA - ALL PLANS CIGNA - ALL PLANS 2041.52 67.6 999999999 1828.61 2929.4 percent of total billed charges CT scan of lower spine with contrast 753137_1 CDM 0352 RC 72132 HCPCS inpatient 2841 1846.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1846.65 65 999999999 1720.23 2755.77 percent of total billed charges CT scan of lower spine with contrast 753137_1 CDM 0352 RC 72132 HCPCS inpatient 2841 1846.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2755.77 97 999999999 1720.23 2755.77 percent of total billed charges CT scan of lower spine with contrast 753137_1 CDM 0352 RC 72132 HCPCS inpatient 2841 1846.65 AETNA AETNA 2244.39 79 999999999 1720.23 2755.77 percent of total billed charges CT scan of lower spine with contrast 753137_1 CDM 0352 RC 72132 HCPCS inpatient 2841 1846.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1960.29 69 999999999 1720.23 2755.77 percent of total billed charges CT scan of lower spine with contrast 753137_1 CDM 0352 RC 72132 HCPCS inpatient 2841 1846.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2215.98 78 999999999 1720.23 2755.77 percent of total billed charges CT scan of lower spine with contrast 753137_1 CDM 0352 RC 72132 HCPCS inpatient 2841 1846.65 SIHO - ALL PLANS SIHO - ALL PLANS 2556.9 90 999999999 1720.23 2755.77 percent of total billed charges CT scan of lower spine with contrast 753137_1 CDM 0352 RC 72132 HCPCS inpatient 2841 1846.65 UMR - ALL PLANS UMR - ALL PLANS 1988.7 70 999999999 1720.23 2755.77 percent of total billed charges CT scan of lower spine with contrast 753137_1 CDM 0352 RC 72132 HCPCS inpatient 2841 1846.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1720.23 2755.77 CT scan of lower spine with contrast 753137_1 CDM 0352 RC 72132 HCPCS inpatient 2841 1846.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1720.23 60.55 999999999 1720.23 2755.77 percent of total billed charges CT scan of lower spine with contrast 753137_1 CDM 0352 RC 72132 HCPCS inpatient 2841 1846.65 ANTHEM HMO ANTHEM HMO 999999999 1720.23 2755.77 CT scan of lower spine with contrast 753137_1 CDM 0352 RC 72132 HCPCS inpatient 2841 1846.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1720.23 2755.77 CT scan of lower spine with contrast 753137_1 CDM 0352 RC 72132 HCPCS inpatient 2841 1846.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1720.23 2755.77 CT scan of lower spine with contrast 753137_1 CDM 0352 RC 72132 HCPCS inpatient 2841 1846.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1720.23 2755.77 CT scan of lower spine with contrast 753137_1 CDM 0352 RC 72132 HCPCS inpatient 2841 1846.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1920.52 67.6 999999999 1720.23 2755.77 percent of total billed charges CT scan of lower spine without contrast 753139_1 CDM 0352 RC 72131 HCPCS inpatient 2415 1569.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1569.75 65 999999999 1462.28 2342.55 percent of total billed charges CT scan of lower spine without contrast 753139_1 CDM 0352 RC 72131 HCPCS inpatient 2415 1569.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2342.55 97 999999999 1462.28 2342.55 percent of total billed charges CT scan of lower spine without contrast 753139_1 CDM 0352 RC 72131 HCPCS inpatient 2415 1569.75 AETNA AETNA 1907.85 79 999999999 1462.28 2342.55 percent of total billed charges CT scan of lower spine without contrast 753139_1 CDM 0352 RC 72131 HCPCS inpatient 2415 1569.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1666.35 69 999999999 1462.28 2342.55 percent of total billed charges CT scan of lower spine without contrast 753139_1 CDM 0352 RC 72131 HCPCS inpatient 2415 1569.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1883.7 78 999999999 1462.28 2342.55 percent of total billed charges CT scan of lower spine without contrast 753139_1 CDM 0352 RC 72131 HCPCS inpatient 2415 1569.75 SIHO - ALL PLANS SIHO - ALL PLANS 2173.5 90 999999999 1462.28 2342.55 percent of total billed charges CT scan of lower spine without contrast 753139_1 CDM 0352 RC 72131 HCPCS inpatient 2415 1569.75 UMR - ALL PLANS UMR - ALL PLANS 1690.5 70 999999999 1462.28 2342.55 percent of total billed charges CT scan of lower spine without contrast 753139_1 CDM 0352 RC 72131 HCPCS inpatient 2415 1569.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1462.28 2342.55 CT scan of lower spine without contrast 753139_1 CDM 0352 RC 72131 HCPCS inpatient 2415 1569.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1462.28 60.55 999999999 1462.28 2342.55 percent of total billed charges CT scan of lower spine without contrast 753139_1 CDM 0352 RC 72131 HCPCS inpatient 2415 1569.75 ANTHEM HMO ANTHEM HMO 999999999 1462.28 2342.55 CT scan of lower spine without contrast 753139_1 CDM 0352 RC 72131 HCPCS inpatient 2415 1569.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1462.28 2342.55 CT scan of lower spine without contrast 753139_1 CDM 0352 RC 72131 HCPCS inpatient 2415 1569.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1462.28 2342.55 CT scan of lower spine without contrast 753139_1 CDM 0352 RC 72131 HCPCS inpatient 2415 1569.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1462.28 2342.55 CT scan of lower spine without contrast 753139_1 CDM 0352 RC 72131 HCPCS inpatient 2415 1569.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1632.54 67.6 999999999 1462.28 2342.55 percent of total billed charges CT scan of middle spine with contrast 753143_1 CDM 0350 RC 72129 HCPCS inpatient 2766 1797.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1797.9 65 999999999 1674.81 2683.02 percent of total billed charges CT scan of middle spine with contrast 753143_1 CDM 0350 RC 72129 HCPCS inpatient 2766 1797.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2683.02 97 999999999 1674.81 2683.02 percent of total billed charges CT scan of middle spine with contrast 753143_1 CDM 0350 RC 72129 HCPCS inpatient 2766 1797.9 AETNA AETNA 2185.14 79 999999999 1674.81 2683.02 percent of total billed charges CT scan of middle spine with contrast 753143_1 CDM 0350 RC 72129 HCPCS inpatient 2766 1797.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1908.54 69 999999999 1674.81 2683.02 percent of total billed charges CT scan of middle spine with contrast 753143_1 CDM 0350 RC 72129 HCPCS inpatient 2766 1797.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 2157.48 78 999999999 1674.81 2683.02 percent of total billed charges CT scan of middle spine with contrast 753143_1 CDM 0350 RC 72129 HCPCS inpatient 2766 1797.9 SIHO - ALL PLANS SIHO - ALL PLANS 2489.4 90 999999999 1674.81 2683.02 percent of total billed charges CT scan of middle spine with contrast 753143_1 CDM 0350 RC 72129 HCPCS inpatient 2766 1797.9 UMR - ALL PLANS UMR - ALL PLANS 1936.2 70 999999999 1674.81 2683.02 percent of total billed charges CT scan of middle spine with contrast 753143_1 CDM 0350 RC 72129 HCPCS inpatient 2766 1797.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1674.81 2683.02 CT scan of middle spine with contrast 753143_1 CDM 0350 RC 72129 HCPCS inpatient 2766 1797.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1674.81 60.55 999999999 1674.81 2683.02 percent of total billed charges CT scan of middle spine with contrast 753143_1 CDM 0350 RC 72129 HCPCS inpatient 2766 1797.9 ANTHEM HMO ANTHEM HMO 999999999 1674.81 2683.02 CT scan of middle spine with contrast 753143_1 CDM 0350 RC 72129 HCPCS inpatient 2766 1797.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1674.81 2683.02 CT scan of middle spine with contrast 753143_1 CDM 0350 RC 72129 HCPCS inpatient 2766 1797.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1674.81 2683.02 CT scan of middle spine with contrast 753143_1 CDM 0350 RC 72129 HCPCS inpatient 2766 1797.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 1674.81 2683.02 CT scan of middle spine with contrast 753143_1 CDM 0350 RC 72129 HCPCS inpatient 2766 1797.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1869.82 67.6 999999999 1674.81 2683.02 percent of total billed charges CT scan of middle spine without contrast 753145_1 CDM 0350 RC 72128 HCPCS inpatient 3001 1950.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1950.65 65 999999999 1817.11 2910.97 percent of total billed charges CT scan of middle spine without contrast 753145_1 CDM 0350 RC 72128 HCPCS inpatient 3001 1950.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2910.97 97 999999999 1817.11 2910.97 percent of total billed charges CT scan of middle spine without contrast 753145_1 CDM 0350 RC 72128 HCPCS inpatient 3001 1950.65 AETNA AETNA 2370.79 79 999999999 1817.11 2910.97 percent of total billed charges CT scan of middle spine without contrast 753145_1 CDM 0350 RC 72128 HCPCS inpatient 3001 1950.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2070.69 69 999999999 1817.11 2910.97 percent of total billed charges CT scan of middle spine without contrast 753145_1 CDM 0350 RC 72128 HCPCS inpatient 3001 1950.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2340.78 78 999999999 1817.11 2910.97 percent of total billed charges CT scan of middle spine without contrast 753145_1 CDM 0350 RC 72128 HCPCS inpatient 3001 1950.65 SIHO - ALL PLANS SIHO - ALL PLANS 2700.9 90 999999999 1817.11 2910.97 percent of total billed charges CT scan of middle spine without contrast 753145_1 CDM 0350 RC 72128 HCPCS inpatient 3001 1950.65 UMR - ALL PLANS UMR - ALL PLANS 2100.7 70 999999999 1817.11 2910.97 percent of total billed charges CT scan of middle spine without contrast 753145_1 CDM 0350 RC 72128 HCPCS inpatient 3001 1950.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1817.11 2910.97 CT scan of middle spine without contrast 753145_1 CDM 0350 RC 72128 HCPCS inpatient 3001 1950.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1817.11 60.55 999999999 1817.11 2910.97 percent of total billed charges CT scan of middle spine without contrast 753145_1 CDM 0350 RC 72128 HCPCS inpatient 3001 1950.65 ANTHEM HMO ANTHEM HMO 999999999 1817.11 2910.97 CT scan of middle spine without contrast 753145_1 CDM 0350 RC 72128 HCPCS inpatient 3001 1950.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1817.11 2910.97 CT scan of middle spine without contrast 753145_1 CDM 0350 RC 72128 HCPCS inpatient 3001 1950.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1817.11 2910.97 CT scan of middle spine without contrast 753145_1 CDM 0350 RC 72128 HCPCS inpatient 3001 1950.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1817.11 2910.97 CT scan of middle spine without contrast 753145_1 CDM 0350 RC 72128 HCPCS inpatient 3001 1950.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2028.68 67.6 999999999 1817.11 2910.97 percent of total billed charges CT scan of chest before and after contrast 753147_1 CDM 0350 RC 71270 HCPCS inpatient 3846 2499.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 2499.9 65 999999999 2328.75 3730.62 percent of total billed charges CT scan of chest before and after contrast 753147_1 CDM 0350 RC 71270 HCPCS inpatient 3846 2499.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3730.62 97 999999999 2328.75 3730.62 percent of total billed charges CT scan of chest before and after contrast 753147_1 CDM 0350 RC 71270 HCPCS inpatient 3846 2499.9 AETNA AETNA 3038.34 79 999999999 2328.75 3730.62 percent of total billed charges CT scan of chest before and after contrast 753147_1 CDM 0350 RC 71270 HCPCS inpatient 3846 2499.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 2653.74 69 999999999 2328.75 3730.62 percent of total billed charges CT scan of chest before and after contrast 753147_1 CDM 0350 RC 71270 HCPCS inpatient 3846 2499.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 2999.88 78 999999999 2328.75 3730.62 percent of total billed charges CT scan of chest before and after contrast 753147_1 CDM 0350 RC 71270 HCPCS inpatient 3846 2499.9 SIHO - ALL PLANS SIHO - ALL PLANS 3461.4 90 999999999 2328.75 3730.62 percent of total billed charges CT scan of chest before and after contrast 753147_1 CDM 0350 RC 71270 HCPCS inpatient 3846 2499.9 UMR - ALL PLANS UMR - ALL PLANS 2692.2 70 999999999 2328.75 3730.62 percent of total billed charges CT scan of chest before and after contrast 753147_1 CDM 0350 RC 71270 HCPCS inpatient 3846 2499.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2328.75 3730.62 CT scan of chest before and after contrast 753147_1 CDM 0350 RC 71270 HCPCS inpatient 3846 2499.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2328.75 60.55 999999999 2328.75 3730.62 percent of total billed charges CT scan of chest before and after contrast 753147_1 CDM 0350 RC 71270 HCPCS inpatient 3846 2499.9 ANTHEM HMO ANTHEM HMO 999999999 2328.75 3730.62 CT scan of chest before and after contrast 753147_1 CDM 0350 RC 71270 HCPCS inpatient 3846 2499.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2328.75 3730.62 CT scan of chest before and after contrast 753147_1 CDM 0350 RC 71270 HCPCS inpatient 3846 2499.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2328.75 3730.62 CT scan of chest before and after contrast 753147_1 CDM 0350 RC 71270 HCPCS inpatient 3846 2499.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 2328.75 3730.62 CT scan of chest before and after contrast 753147_1 CDM 0350 RC 71270 HCPCS inpatient 3846 2499.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 2599.9 67.6 999999999 2328.75 3730.62 percent of total billed charges CT scan of chest with contrast 753149_1 CDM 0352 RC 71260 HCPCS inpatient 2592 1684.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1684.8 65 999999999 1569.46 2514.24 percent of total billed charges CT scan of chest with contrast 753149_1 CDM 0352 RC 71260 HCPCS inpatient 2592 1684.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2514.24 97 999999999 1569.46 2514.24 percent of total billed charges CT scan of chest with contrast 753149_1 CDM 0352 RC 71260 HCPCS inpatient 2592 1684.8 AETNA AETNA 2047.68 79 999999999 1569.46 2514.24 percent of total billed charges CT scan of chest with contrast 753149_1 CDM 0352 RC 71260 HCPCS inpatient 2592 1684.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1788.48 69 999999999 1569.46 2514.24 percent of total billed charges CT scan of chest with contrast 753149_1 CDM 0352 RC 71260 HCPCS inpatient 2592 1684.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 2021.76 78 999999999 1569.46 2514.24 percent of total billed charges CT scan of chest with contrast 753149_1 CDM 0352 RC 71260 HCPCS inpatient 2592 1684.8 SIHO - ALL PLANS SIHO - ALL PLANS 2332.8 90 999999999 1569.46 2514.24 percent of total billed charges CT scan of chest with contrast 753149_1 CDM 0352 RC 71260 HCPCS inpatient 2592 1684.8 UMR - ALL PLANS UMR - ALL PLANS 1814.4 70 999999999 1569.46 2514.24 percent of total billed charges CT scan of chest with contrast 753149_1 CDM 0352 RC 71260 HCPCS inpatient 2592 1684.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1569.46 2514.24 CT scan of chest with contrast 753149_1 CDM 0352 RC 71260 HCPCS inpatient 2592 1684.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1569.46 60.55 999999999 1569.46 2514.24 percent of total billed charges CT scan of chest with contrast 753149_1 CDM 0352 RC 71260 HCPCS inpatient 2592 1684.8 ANTHEM HMO ANTHEM HMO 999999999 1569.46 2514.24 CT scan of chest with contrast 753149_1 CDM 0352 RC 71260 HCPCS inpatient 2592 1684.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1569.46 2514.24 CT scan of chest with contrast 753149_1 CDM 0352 RC 71260 HCPCS inpatient 2592 1684.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1569.46 2514.24 CT scan of chest with contrast 753149_1 CDM 0352 RC 71260 HCPCS inpatient 2592 1684.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1569.46 2514.24 CT scan of chest with contrast 753149_1 CDM 0352 RC 71260 HCPCS inpatient 2592 1684.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1752.19 67.6 999999999 1569.46 2514.24 percent of total billed charges CT scan of chest without contrast 753151_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1631.5 65 999999999 1519.81 2434.7 percent of total billed charges CT scan of chest without contrast 753151_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2434.7 97 999999999 1519.81 2434.7 percent of total billed charges CT scan of chest without contrast 753151_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 AETNA AETNA 1982.9 79 999999999 1519.81 2434.7 percent of total billed charges CT scan of chest without contrast 753151_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1731.9 69 999999999 1519.81 2434.7 percent of total billed charges CT scan of chest without contrast 753151_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1957.8 78 999999999 1519.81 2434.7 percent of total billed charges CT scan of chest without contrast 753151_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 SIHO - ALL PLANS SIHO - ALL PLANS 2259 90 999999999 1519.81 2434.7 percent of total billed charges CT scan of chest without contrast 753151_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 UMR - ALL PLANS UMR - ALL PLANS 1757 70 999999999 1519.81 2434.7 percent of total billed charges CT scan of chest without contrast 753151_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1519.81 2434.7 CT scan of chest without contrast 753151_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1519.81 60.55 999999999 1519.81 2434.7 percent of total billed charges CT scan of chest without contrast 753151_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 ANTHEM HMO ANTHEM HMO 999999999 1519.81 2434.7 CT scan of chest without contrast 753151_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1519.81 2434.7 CT scan of chest without contrast 753151_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1519.81 2434.7 CT scan of chest without contrast 753151_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 1519.81 2434.7 CT scan of chest without contrast 753151_1 CDM 0352 RC 71250 HCPCS inpatient 2510 1631.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1696.76 67.6 999999999 1519.81 2434.7 percent of total billed charges CT scan of arm with contrast 753155_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1549.6 65 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm with contrast 753155_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2312.48 97 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm with contrast 753155_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 AETNA AETNA 1883.36 79 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm with contrast 753155_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1644.96 69 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm with contrast 753155_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1859.52 78 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm with contrast 753155_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 SIHO - ALL PLANS SIHO - ALL PLANS 2145.6 90 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm with contrast 753155_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 UMR - ALL PLANS UMR - ALL PLANS 1668.8 70 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm with contrast 753155_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1443.51 2312.48 CT scan of arm with contrast 753155_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1443.51 60.55 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm with contrast 753155_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 ANTHEM HMO ANTHEM HMO 999999999 1443.51 2312.48 CT scan of arm with contrast 753155_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1443.51 2312.48 CT scan of arm with contrast 753155_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1443.51 2312.48 CT scan of arm with contrast 753155_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1443.51 2312.48 CT scan of arm with contrast 753155_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1611.58 67.6 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm with contrast 753157_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1549.6 65 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm with contrast 753157_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2312.48 97 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm with contrast 753157_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 AETNA AETNA 1883.36 79 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm with contrast 753157_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1644.96 69 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm with contrast 753157_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1859.52 78 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm with contrast 753157_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 SIHO - ALL PLANS SIHO - ALL PLANS 2145.6 90 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm with contrast 753157_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 UMR - ALL PLANS UMR - ALL PLANS 1668.8 70 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm with contrast 753157_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1443.51 2312.48 CT scan of arm with contrast 753157_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1443.51 60.55 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm with contrast 753157_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 ANTHEM HMO ANTHEM HMO 999999999 1443.51 2312.48 CT scan of arm with contrast 753157_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1443.51 2312.48 CT scan of arm with contrast 753157_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1443.51 2312.48 CT scan of arm with contrast 753157_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1443.51 2312.48 CT scan of arm with contrast 753157_1 CDM 0352 RC 73201 HCPCS inpatient 2384 1549.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1611.58 67.6 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm without contrast 753167_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1549.6 65 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm without contrast 753167_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2312.48 97 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm without contrast 753167_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 AETNA AETNA 1883.36 79 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm without contrast 753167_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1644.96 69 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm without contrast 753167_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1859.52 78 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm without contrast 753167_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 SIHO - ALL PLANS SIHO - ALL PLANS 2145.6 90 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm without contrast 753167_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 UMR - ALL PLANS UMR - ALL PLANS 1668.8 70 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm without contrast 753167_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1443.51 2312.48 CT scan of arm without contrast 753167_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1443.51 60.55 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm without contrast 753167_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 ANTHEM HMO ANTHEM HMO 999999999 1443.51 2312.48 CT scan of arm without contrast 753167_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1443.51 2312.48 CT scan of arm without contrast 753167_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1443.51 2312.48 CT scan of arm without contrast 753167_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1443.51 2312.48 CT scan of arm without contrast 753167_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1611.58 67.6 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm without contrast 753169_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1549.6 65 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm without contrast 753169_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2312.48 97 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm without contrast 753169_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 AETNA AETNA 1883.36 79 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm without contrast 753169_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1644.96 69 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm without contrast 753169_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1859.52 78 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm without contrast 753169_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 SIHO - ALL PLANS SIHO - ALL PLANS 2145.6 90 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm without contrast 753169_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 UMR - ALL PLANS UMR - ALL PLANS 1668.8 70 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm without contrast 753169_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1443.51 2312.48 CT scan of arm without contrast 753169_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1443.51 60.55 999999999 1443.51 2312.48 percent of total billed charges CT scan of arm without contrast 753169_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 ANTHEM HMO ANTHEM HMO 999999999 1443.51 2312.48 CT scan of arm without contrast 753169_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1443.51 2312.48 CT scan of arm without contrast 753169_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1443.51 2312.48 CT scan of arm without contrast 753169_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1443.51 2312.48 CT scan of arm without contrast 753169_1 CDM 0352 RC 73200 HCPCS inpatient 2384 1549.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1611.58 67.6 999999999 1443.51 2312.48 percent of total billed charges Nuclear medicine study of brain with blood flow evaluation 753201_1 CDM 0404 RC 78609 HCPCS inpatient 11182 7268.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 7268.3 65 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study of brain with blood flow evaluation 753201_1 CDM 0404 RC 78609 HCPCS inpatient 11182 7268.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10846.54 97 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study of brain with blood flow evaluation 753201_1 CDM 0404 RC 78609 HCPCS inpatient 11182 7268.3 AETNA AETNA 8833.78 79 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study of brain with blood flow evaluation 753201_1 CDM 0404 RC 78609 HCPCS inpatient 11182 7268.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 7715.58 69 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study of brain with blood flow evaluation 753201_1 CDM 0404 RC 78609 HCPCS inpatient 11182 7268.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 8721.96 78 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study of brain with blood flow evaluation 753201_1 CDM 0404 RC 78609 HCPCS inpatient 11182 7268.3 SIHO - ALL PLANS SIHO - ALL PLANS 10063.8 90 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study of brain with blood flow evaluation 753201_1 CDM 0404 RC 78609 HCPCS inpatient 11182 7268.3 UMR - ALL PLANS UMR - ALL PLANS 7827.4 70 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study of brain with blood flow evaluation 753201_1 CDM 0404 RC 78609 HCPCS inpatient 11182 7268.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6770.7 10846.54 Nuclear medicine study of brain with blood flow evaluation 753201_1 CDM 0404 RC 78609 HCPCS inpatient 11182 7268.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6770.7 60.55 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study of brain with blood flow evaluation 753201_1 CDM 0404 RC 78609 HCPCS inpatient 11182 7268.3 ANTHEM HMO ANTHEM HMO 999999999 6770.7 10846.54 Nuclear medicine study of brain with blood flow evaluation 753201_1 CDM 0404 RC 78609 HCPCS inpatient 11182 7268.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6770.7 10846.54 Nuclear medicine study of brain with blood flow evaluation 753201_1 CDM 0404 RC 78609 HCPCS inpatient 11182 7268.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6770.7 10846.54 Nuclear medicine study of brain with blood flow evaluation 753201_1 CDM 0404 RC 78609 HCPCS inpatient 11182 7268.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 6770.7 10846.54 Nuclear medicine study of brain with blood flow evaluation 753201_1 CDM 0404 RC 78609 HCPCS inpatient 11182 7268.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 7559.03 67.6 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study whole body 753306_1 CDM 0404 RC 78813 HCPCS inpatient 11182 7268.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 7268.3 65 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study whole body 753306_1 CDM 0404 RC 78813 HCPCS inpatient 11182 7268.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10846.54 97 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study whole body 753306_1 CDM 0404 RC 78813 HCPCS inpatient 11182 7268.3 AETNA AETNA 8833.78 79 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study whole body 753306_1 CDM 0404 RC 78813 HCPCS inpatient 11182 7268.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 7715.58 69 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study whole body 753306_1 CDM 0404 RC 78813 HCPCS inpatient 11182 7268.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 8721.96 78 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study whole body 753306_1 CDM 0404 RC 78813 HCPCS inpatient 11182 7268.3 SIHO - ALL PLANS SIHO - ALL PLANS 10063.8 90 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study whole body 753306_1 CDM 0404 RC 78813 HCPCS inpatient 11182 7268.3 UMR - ALL PLANS UMR - ALL PLANS 7827.4 70 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study whole body 753306_1 CDM 0404 RC 78813 HCPCS inpatient 11182 7268.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6770.7 10846.54 Nuclear medicine study whole body 753306_1 CDM 0404 RC 78813 HCPCS inpatient 11182 7268.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6770.7 60.55 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study whole body 753306_1 CDM 0404 RC 78813 HCPCS inpatient 11182 7268.3 ANTHEM HMO ANTHEM HMO 999999999 6770.7 10846.54 Nuclear medicine study whole body 753306_1 CDM 0404 RC 78813 HCPCS inpatient 11182 7268.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6770.7 10846.54 Nuclear medicine study whole body 753306_1 CDM 0404 RC 78813 HCPCS inpatient 11182 7268.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6770.7 10846.54 Nuclear medicine study whole body 753306_1 CDM 0404 RC 78813 HCPCS inpatient 11182 7268.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 6770.7 10846.54 Nuclear medicine study whole body 753306_1 CDM 0404 RC 78813 HCPCS inpatient 11182 7268.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 7559.03 67.6 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study limited area with CT scan 753313_1 CDM 0404 RC 78814 HCPCS inpatient 11182 7268.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 7268.3 65 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study limited area with CT scan 753313_1 CDM 0404 RC 78814 HCPCS inpatient 11182 7268.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10846.54 97 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study limited area with CT scan 753313_1 CDM 0404 RC 78814 HCPCS inpatient 11182 7268.3 AETNA AETNA 8833.78 79 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study limited area with CT scan 753313_1 CDM 0404 RC 78814 HCPCS inpatient 11182 7268.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 7715.58 69 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study limited area with CT scan 753313_1 CDM 0404 RC 78814 HCPCS inpatient 11182 7268.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 8721.96 78 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study limited area with CT scan 753313_1 CDM 0404 RC 78814 HCPCS inpatient 11182 7268.3 SIHO - ALL PLANS SIHO - ALL PLANS 10063.8 90 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study limited area with CT scan 753313_1 CDM 0404 RC 78814 HCPCS inpatient 11182 7268.3 UMR - ALL PLANS UMR - ALL PLANS 7827.4 70 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study limited area with CT scan 753313_1 CDM 0404 RC 78814 HCPCS inpatient 11182 7268.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6770.7 10846.54 Nuclear medicine study limited area with CT scan 753313_1 CDM 0404 RC 78814 HCPCS inpatient 11182 7268.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6770.7 60.55 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study limited area with CT scan 753313_1 CDM 0404 RC 78814 HCPCS inpatient 11182 7268.3 ANTHEM HMO ANTHEM HMO 999999999 6770.7 10846.54 Nuclear medicine study limited area with CT scan 753313_1 CDM 0404 RC 78814 HCPCS inpatient 11182 7268.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6770.7 10846.54 Nuclear medicine study limited area with CT scan 753313_1 CDM 0404 RC 78814 HCPCS inpatient 11182 7268.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6770.7 10846.54 Nuclear medicine study limited area with CT scan 753313_1 CDM 0404 RC 78814 HCPCS inpatient 11182 7268.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 6770.7 10846.54 Nuclear medicine study limited area with CT scan 753313_1 CDM 0404 RC 78814 HCPCS inpatient 11182 7268.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 7559.03 67.6 999999999 6770.7 10846.54 percent of total billed charges Nuclear medicine study from skull base to mid-thigh with CT scan 753315_1 CDM 0404 RC 78815 HCPCS inpatient 10455 6795.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 6795.75 65 999999999 6330.5 10141.35 percent of total billed charges Nuclear medicine study from skull base to mid-thigh with CT scan 753315_1 CDM 0404 RC 78815 HCPCS inpatient 10455 6795.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10141.35 97 999999999 6330.5 10141.35 percent of total billed charges Nuclear medicine study from skull base to mid-thigh with CT scan 753315_1 CDM 0404 RC 78815 HCPCS inpatient 10455 6795.75 AETNA AETNA 8259.45 79 999999999 6330.5 10141.35 percent of total billed charges Nuclear medicine study from skull base to mid-thigh with CT scan 753315_1 CDM 0404 RC 78815 HCPCS inpatient 10455 6795.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 7213.95 69 999999999 6330.5 10141.35 percent of total billed charges Nuclear medicine study from skull base to mid-thigh with CT scan 753315_1 CDM 0404 RC 78815 HCPCS inpatient 10455 6795.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 8154.9 78 999999999 6330.5 10141.35 percent of total billed charges Nuclear medicine study from skull base to mid-thigh with CT scan 753315_1 CDM 0404 RC 78815 HCPCS inpatient 10455 6795.75 SIHO - ALL PLANS SIHO - ALL PLANS 9409.5 90 999999999 6330.5 10141.35 percent of total billed charges Nuclear medicine study from skull base to mid-thigh with CT scan 753315_1 CDM 0404 RC 78815 HCPCS inpatient 10455 6795.75 UMR - ALL PLANS UMR - ALL PLANS 7318.5 70 999999999 6330.5 10141.35 percent of total billed charges Nuclear medicine study from skull base to mid-thigh with CT scan 753315_1 CDM 0404 RC 78815 HCPCS inpatient 10455 6795.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 6330.5 10141.35 Nuclear medicine study from skull base to mid-thigh with CT scan 753315_1 CDM 0404 RC 78815 HCPCS inpatient 10455 6795.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6330.5 60.55 999999999 6330.5 10141.35 percent of total billed charges Nuclear medicine study from skull base to mid-thigh with CT scan 753315_1 CDM 0404 RC 78815 HCPCS inpatient 10455 6795.75 ANTHEM HMO ANTHEM HMO 999999999 6330.5 10141.35 Nuclear medicine study from skull base to mid-thigh with CT scan 753315_1 CDM 0404 RC 78815 HCPCS inpatient 10455 6795.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 6330.5 10141.35 Nuclear medicine study from skull base to mid-thigh with CT scan 753315_1 CDM 0404 RC 78815 HCPCS inpatient 10455 6795.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 6330.5 10141.35 Nuclear medicine study from skull base to mid-thigh with CT scan 753315_1 CDM 0404 RC 78815 HCPCS inpatient 10455 6795.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 6330.5 10141.35 Nuclear medicine study from skull base to mid-thigh with CT scan 753315_1 CDM 0404 RC 78815 HCPCS inpatient 10455 6795.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 7067.58 67.6 999999999 6330.5 10141.35 percent of total billed charges Nuclear medicine study whole body with CT scan 753317_1 CDM 0404 RC 78816 HCPCS inpatient 12300 7995 SELF PAY DISCOUNT SELF PAY DISCOUNT 7995 65 999999999 7447.65 11931 percent of total billed charges Nuclear medicine study whole body with CT scan 753317_1 CDM 0404 RC 78816 HCPCS inpatient 12300 7995 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 11931 97 999999999 7447.65 11931 percent of total billed charges Nuclear medicine study whole body with CT scan 753317_1 CDM 0404 RC 78816 HCPCS inpatient 12300 7995 AETNA AETNA 9717 79 999999999 7447.65 11931 percent of total billed charges Nuclear medicine study whole body with CT scan 753317_1 CDM 0404 RC 78816 HCPCS inpatient 12300 7995 ENCORE - ALL PLANS ENCORE - ALL PLANS 8487 69 999999999 7447.65 11931 percent of total billed charges Nuclear medicine study whole body with CT scan 753317_1 CDM 0404 RC 78816 HCPCS inpatient 12300 7995 HUMANA - ALL PLANS HUMANA - ALL PLANS 9594 78 999999999 7447.65 11931 percent of total billed charges Nuclear medicine study whole body with CT scan 753317_1 CDM 0404 RC 78816 HCPCS inpatient 12300 7995 SIHO - ALL PLANS SIHO - ALL PLANS 11070 90 999999999 7447.65 11931 percent of total billed charges Nuclear medicine study whole body with CT scan 753317_1 CDM 0404 RC 78816 HCPCS inpatient 12300 7995 UMR - ALL PLANS UMR - ALL PLANS 8610 70 999999999 7447.65 11931 percent of total billed charges Nuclear medicine study whole body with CT scan 753317_1 CDM 0404 RC 78816 HCPCS inpatient 12300 7995 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 7447.65 11931 Nuclear medicine study whole body with CT scan 753317_1 CDM 0404 RC 78816 HCPCS inpatient 12300 7995 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7447.65 60.55 999999999 7447.65 11931 percent of total billed charges Nuclear medicine study whole body with CT scan 753317_1 CDM 0404 RC 78816 HCPCS inpatient 12300 7995 ANTHEM HMO ANTHEM HMO 999999999 7447.65 11931 Nuclear medicine study whole body with CT scan 753317_1 CDM 0404 RC 78816 HCPCS inpatient 12300 7995 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 7447.65 11931 Nuclear medicine study whole body with CT scan 753317_1 CDM 0404 RC 78816 HCPCS inpatient 12300 7995 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 7447.65 11931 Nuclear medicine study whole body with CT scan 753317_1 CDM 0404 RC 78816 HCPCS inpatient 12300 7995 UHC - ALL PLANS UHC - ALL PLANS 999999999 7447.65 11931 Nuclear medicine study whole body with CT scan 753317_1 CDM 0404 RC 78816 HCPCS inpatient 12300 7995 CIGNA - ALL PLANS CIGNA - ALL PLANS 8314.8 67.6 999999999 7447.65 11931 percent of total billed charges Limited ultrasound scan of abdomen 753319_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 703.3 65 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753319_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1049.54 97 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753319_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 AETNA AETNA 854.78 79 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753319_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 746.58 69 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753319_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 843.96 78 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753319_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 SIHO - ALL PLANS SIHO - ALL PLANS 973.8 90 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753319_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UMR - ALL PLANS UMR - ALL PLANS 757.4 70 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753319_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753319_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 655.15 60.55 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753319_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM HMO ANTHEM HMO 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753319_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753319_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753319_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753319_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 731.43 67.6 999999999 655.15 1049.54 percent of total billed charges Ultrasound scan of abdominal aorta 753323_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 617.5 65 999999999 575.23 921.5 percent of total billed charges Ultrasound scan of abdominal aorta 753323_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 921.5 97 999999999 575.23 921.5 percent of total billed charges Ultrasound scan of abdominal aorta 753323_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 AETNA AETNA 750.5 79 999999999 575.23 921.5 percent of total billed charges Ultrasound scan of abdominal aorta 753323_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 655.5 69 999999999 575.23 921.5 percent of total billed charges Ultrasound scan of abdominal aorta 753323_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 741 78 999999999 575.23 921.5 percent of total billed charges Ultrasound scan of abdominal aorta 753323_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 SIHO - ALL PLANS SIHO - ALL PLANS 855 90 999999999 575.23 921.5 percent of total billed charges Ultrasound scan of abdominal aorta 753323_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 UMR - ALL PLANS UMR - ALL PLANS 665 70 999999999 575.23 921.5 percent of total billed charges Ultrasound scan of abdominal aorta 753323_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 575.23 921.5 Ultrasound scan of abdominal aorta 753323_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 575.23 60.55 999999999 575.23 921.5 percent of total billed charges Ultrasound scan of abdominal aorta 753323_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 ANTHEM HMO ANTHEM HMO 999999999 575.23 921.5 Ultrasound scan of abdominal aorta 753323_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 575.23 921.5 Ultrasound scan of abdominal aorta 753323_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 575.23 921.5 Ultrasound scan of abdominal aorta 753323_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 575.23 921.5 Ultrasound scan of abdominal aorta 753323_1 CDM 0402 RC 76706 HCPCS inpatient 950 617.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 642.2 67.6 999999999 575.23 921.5 percent of total billed charges Complete ultrasound scan of 1 breast 753331_1 CDM 0402 RC 76641 HCPCS inpatient 1610 1046.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 1046.5 65 999999999 974.86 1561.7 percent of total billed charges Complete ultrasound scan of 1 breast 753331_1 CDM 0402 RC 76641 HCPCS inpatient 1610 1046.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1561.7 97 999999999 974.86 1561.7 percent of total billed charges Complete ultrasound scan of 1 breast 753331_1 CDM 0402 RC 76641 HCPCS inpatient 1610 1046.5 AETNA AETNA 1271.9 79 999999999 974.86 1561.7 percent of total billed charges Complete ultrasound scan of 1 breast 753331_1 CDM 0402 RC 76641 HCPCS inpatient 1610 1046.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 1110.9 69 999999999 974.86 1561.7 percent of total billed charges Complete ultrasound scan of 1 breast 753331_1 CDM 0402 RC 76641 HCPCS inpatient 1610 1046.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1255.8 78 999999999 974.86 1561.7 percent of total billed charges Complete ultrasound scan of 1 breast 753331_1 CDM 0402 RC 76641 HCPCS inpatient 1610 1046.5 SIHO - ALL PLANS SIHO - ALL PLANS 1449 90 999999999 974.86 1561.7 percent of total billed charges Complete ultrasound scan of 1 breast 753331_1 CDM 0402 RC 76641 HCPCS inpatient 1610 1046.5 UMR - ALL PLANS UMR - ALL PLANS 1127 70 999999999 974.86 1561.7 percent of total billed charges Complete ultrasound scan of 1 breast 753331_1 CDM 0402 RC 76641 HCPCS inpatient 1610 1046.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 974.86 1561.7 Complete ultrasound scan of 1 breast 753331_1 CDM 0402 RC 76641 HCPCS inpatient 1610 1046.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 974.86 60.55 999999999 974.86 1561.7 percent of total billed charges Complete ultrasound scan of 1 breast 753331_1 CDM 0402 RC 76641 HCPCS inpatient 1610 1046.5 ANTHEM HMO ANTHEM HMO 999999999 974.86 1561.7 Complete ultrasound scan of 1 breast 753331_1 CDM 0402 RC 76641 HCPCS inpatient 1610 1046.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 974.86 1561.7 Complete ultrasound scan of 1 breast 753331_1 CDM 0402 RC 76641 HCPCS inpatient 1610 1046.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 974.86 1561.7 Complete ultrasound scan of 1 breast 753331_1 CDM 0402 RC 76641 HCPCS inpatient 1610 1046.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 974.86 1561.7 Complete ultrasound scan of 1 breast 753331_1 CDM 0402 RC 76641 HCPCS inpatient 1610 1046.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 1088.36 67.6 999999999 974.86 1561.7 percent of total billed charges Complete ultrasound scan of 1 breast 753333_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 494.65 65 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 753333_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 738.17 97 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 753333_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 AETNA AETNA 601.19 79 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 753333_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 525.09 69 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 753333_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 593.58 78 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 753333_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 SIHO - ALL PLANS SIHO - ALL PLANS 684.9 90 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 753333_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 UMR - ALL PLANS UMR - ALL PLANS 532.7 70 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 753333_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 753333_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 460.79 60.55 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 753333_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ANTHEM HMO ANTHEM HMO 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 753333_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 753333_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 753333_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 753333_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 514.44 67.6 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 753335_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 494.65 65 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 753335_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 738.17 97 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 753335_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 AETNA AETNA 601.19 79 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 753335_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 525.09 69 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 753335_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 593.58 78 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 753335_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 SIHO - ALL PLANS SIHO - ALL PLANS 684.9 90 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 753335_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 UMR - ALL PLANS UMR - ALL PLANS 532.7 70 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 753335_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 753335_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 460.79 60.55 999999999 460.79 738.17 percent of total billed charges Complete ultrasound scan of 1 breast 753335_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ANTHEM HMO ANTHEM HMO 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 753335_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 753335_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 753335_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 460.79 738.17 Complete ultrasound scan of 1 breast 753335_1 CDM 0402 RC 76641 HCPCS inpatient 761 494.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 514.44 67.6 999999999 460.79 738.17 percent of total billed charges Ultrasound scan of chest 753343_1 CDM 0402 RC 76604 HCPCS inpatient 851 553.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 553.15 65 999999999 515.28 825.47 percent of total billed charges Ultrasound scan of chest 753343_1 CDM 0402 RC 76604 HCPCS inpatient 851 553.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 825.47 97 999999999 515.28 825.47 percent of total billed charges Ultrasound scan of chest 753343_1 CDM 0402 RC 76604 HCPCS inpatient 851 553.15 AETNA AETNA 672.29 79 999999999 515.28 825.47 percent of total billed charges Ultrasound scan of chest 753343_1 CDM 0402 RC 76604 HCPCS inpatient 851 553.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 587.19 69 999999999 515.28 825.47 percent of total billed charges Ultrasound scan of chest 753343_1 CDM 0402 RC 76604 HCPCS inpatient 851 553.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 663.78 78 999999999 515.28 825.47 percent of total billed charges Ultrasound scan of chest 753343_1 CDM 0402 RC 76604 HCPCS inpatient 851 553.15 SIHO - ALL PLANS SIHO - ALL PLANS 765.9 90 999999999 515.28 825.47 percent of total billed charges Ultrasound scan of chest 753343_1 CDM 0402 RC 76604 HCPCS inpatient 851 553.15 UMR - ALL PLANS UMR - ALL PLANS 595.7 70 999999999 515.28 825.47 percent of total billed charges Ultrasound scan of chest 753343_1 CDM 0402 RC 76604 HCPCS inpatient 851 553.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 515.28 825.47 Ultrasound scan of chest 753343_1 CDM 0402 RC 76604 HCPCS inpatient 851 553.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 515.28 60.55 999999999 515.28 825.47 percent of total billed charges Ultrasound scan of chest 753343_1 CDM 0402 RC 76604 HCPCS inpatient 851 553.15 ANTHEM HMO ANTHEM HMO 999999999 515.28 825.47 Ultrasound scan of chest 753343_1 CDM 0402 RC 76604 HCPCS inpatient 851 553.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 515.28 825.47 Ultrasound scan of chest 753343_1 CDM 0402 RC 76604 HCPCS inpatient 851 553.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 515.28 825.47 Ultrasound scan of chest 753343_1 CDM 0402 RC 76604 HCPCS inpatient 851 553.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 515.28 825.47 Ultrasound scan of chest 753343_1 CDM 0402 RC 76604 HCPCS inpatient 851 553.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 575.28 67.6 999999999 515.28 825.47 percent of total billed charges Ultrasound of hemodialysis access 753347_1 CDM 0510 RC 93990 HCPCS inpatient 407 264.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 264.55 65 999999999 246.44 394.79 percent of total billed charges Ultrasound of hemodialysis access 753347_1 CDM 0510 RC 93990 HCPCS inpatient 407 264.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 394.79 97 999999999 246.44 394.79 percent of total billed charges Ultrasound of hemodialysis access 753347_1 CDM 0510 RC 93990 HCPCS inpatient 407 264.55 AETNA AETNA 321.53 79 999999999 246.44 394.79 percent of total billed charges Ultrasound of hemodialysis access 753347_1 CDM 0510 RC 93990 HCPCS inpatient 407 264.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 280.83 69 999999999 246.44 394.79 percent of total billed charges Ultrasound of hemodialysis access 753347_1 CDM 0510 RC 93990 HCPCS inpatient 407 264.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 317.46 78 999999999 246.44 394.79 percent of total billed charges Ultrasound of hemodialysis access 753347_1 CDM 0510 RC 93990 HCPCS inpatient 407 264.55 SIHO - ALL PLANS SIHO - ALL PLANS 366.3 90 999999999 246.44 394.79 percent of total billed charges Ultrasound of hemodialysis access 753347_1 CDM 0510 RC 93990 HCPCS inpatient 407 264.55 UMR - ALL PLANS UMR - ALL PLANS 284.9 70 999999999 246.44 394.79 percent of total billed charges Ultrasound of hemodialysis access 753347_1 CDM 0510 RC 93990 HCPCS inpatient 407 264.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 246.44 394.79 Ultrasound of hemodialysis access 753347_1 CDM 0510 RC 93990 HCPCS inpatient 407 264.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 246.44 60.55 999999999 246.44 394.79 percent of total billed charges Ultrasound of hemodialysis access 753347_1 CDM 0510 RC 93990 HCPCS inpatient 407 264.55 ANTHEM HMO ANTHEM HMO 999999999 246.44 394.79 Ultrasound of hemodialysis access 753347_1 CDM 0510 RC 93990 HCPCS inpatient 407 264.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 246.44 394.79 Ultrasound of hemodialysis access 753347_1 CDM 0510 RC 93990 HCPCS inpatient 407 264.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 246.44 394.79 Ultrasound of hemodialysis access 753347_1 CDM 0510 RC 93990 HCPCS inpatient 407 264.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 246.44 394.79 Ultrasound of hemodialysis access 753347_1 CDM 0510 RC 93990 HCPCS inpatient 407 264.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 275.13 67.6 999999999 246.44 394.79 percent of total billed charges Ultrasound scan of brain 753353_1 CDM 0402 RC 76506 HCPCS inpatient 739 480.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 480.35 65 999999999 447.46 716.83 percent of total billed charges Ultrasound scan of brain 753353_1 CDM 0402 RC 76506 HCPCS inpatient 739 480.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 716.83 97 999999999 447.46 716.83 percent of total billed charges Ultrasound scan of brain 753353_1 CDM 0402 RC 76506 HCPCS inpatient 739 480.35 AETNA AETNA 583.81 79 999999999 447.46 716.83 percent of total billed charges Ultrasound scan of brain 753353_1 CDM 0402 RC 76506 HCPCS inpatient 739 480.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 509.91 69 999999999 447.46 716.83 percent of total billed charges Ultrasound scan of brain 753353_1 CDM 0402 RC 76506 HCPCS inpatient 739 480.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 576.42 78 999999999 447.46 716.83 percent of total billed charges Ultrasound scan of brain 753353_1 CDM 0402 RC 76506 HCPCS inpatient 739 480.35 SIHO - ALL PLANS SIHO - ALL PLANS 665.1 90 999999999 447.46 716.83 percent of total billed charges Ultrasound scan of brain 753353_1 CDM 0402 RC 76506 HCPCS inpatient 739 480.35 UMR - ALL PLANS UMR - ALL PLANS 517.3 70 999999999 447.46 716.83 percent of total billed charges Ultrasound scan of brain 753353_1 CDM 0402 RC 76506 HCPCS inpatient 739 480.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 447.46 716.83 Ultrasound scan of brain 753353_1 CDM 0402 RC 76506 HCPCS inpatient 739 480.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 447.46 60.55 999999999 447.46 716.83 percent of total billed charges Ultrasound scan of brain 753353_1 CDM 0402 RC 76506 HCPCS inpatient 739 480.35 ANTHEM HMO ANTHEM HMO 999999999 447.46 716.83 Ultrasound scan of brain 753353_1 CDM 0402 RC 76506 HCPCS inpatient 739 480.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 447.46 716.83 Ultrasound scan of brain 753353_1 CDM 0402 RC 76506 HCPCS inpatient 739 480.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 447.46 716.83 Ultrasound scan of brain 753353_1 CDM 0402 RC 76506 HCPCS inpatient 739 480.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 447.46 716.83 Ultrasound scan of brain 753353_1 CDM 0402 RC 76506 HCPCS inpatient 739 480.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 499.56 67.6 999999999 447.46 716.83 percent of total billed charges Complete ultrasound scan of joint 753355_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1109.55 65 999999999 1033.59 1655.79 percent of total billed charges Complete ultrasound scan of joint 753355_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1655.79 97 999999999 1033.59 1655.79 percent of total billed charges Complete ultrasound scan of joint 753355_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 AETNA AETNA 1348.53 79 999999999 1033.59 1655.79 percent of total billed charges Complete ultrasound scan of joint 753355_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1177.83 69 999999999 1033.59 1655.79 percent of total billed charges Complete ultrasound scan of joint 753355_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1331.46 78 999999999 1033.59 1655.79 percent of total billed charges Complete ultrasound scan of joint 753355_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 SIHO - ALL PLANS SIHO - ALL PLANS 1536.3 90 999999999 1033.59 1655.79 percent of total billed charges Complete ultrasound scan of joint 753355_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 UMR - ALL PLANS UMR - ALL PLANS 1194.9 70 999999999 1033.59 1655.79 percent of total billed charges Complete ultrasound scan of joint 753355_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1033.59 1655.79 Complete ultrasound scan of joint 753355_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1033.59 60.55 999999999 1033.59 1655.79 percent of total billed charges Complete ultrasound scan of joint 753355_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 ANTHEM HMO ANTHEM HMO 999999999 1033.59 1655.79 Complete ultrasound scan of joint 753355_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1033.59 1655.79 Complete ultrasound scan of joint 753355_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1033.59 1655.79 Complete ultrasound scan of joint 753355_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1033.59 1655.79 Complete ultrasound scan of joint 753355_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1153.93 67.6 999999999 1033.59 1655.79 percent of total billed charges Complete ultrasound scan of joint 753357_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1109.55 65 999999999 1033.59 1655.79 percent of total billed charges Complete ultrasound scan of joint 753357_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1655.79 97 999999999 1033.59 1655.79 percent of total billed charges Complete ultrasound scan of joint 753357_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 AETNA AETNA 1348.53 79 999999999 1033.59 1655.79 percent of total billed charges Complete ultrasound scan of joint 753357_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1177.83 69 999999999 1033.59 1655.79 percent of total billed charges Complete ultrasound scan of joint 753357_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1331.46 78 999999999 1033.59 1655.79 percent of total billed charges Complete ultrasound scan of joint 753357_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 SIHO - ALL PLANS SIHO - ALL PLANS 1536.3 90 999999999 1033.59 1655.79 percent of total billed charges Complete ultrasound scan of joint 753357_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 UMR - ALL PLANS UMR - ALL PLANS 1194.9 70 999999999 1033.59 1655.79 percent of total billed charges Complete ultrasound scan of joint 753357_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1033.59 1655.79 Complete ultrasound scan of joint 753357_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1033.59 60.55 999999999 1033.59 1655.79 percent of total billed charges Complete ultrasound scan of joint 753357_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 ANTHEM HMO ANTHEM HMO 999999999 1033.59 1655.79 Complete ultrasound scan of joint 753357_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1033.59 1655.79 Complete ultrasound scan of joint 753357_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1033.59 1655.79 Complete ultrasound scan of joint 753357_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1033.59 1655.79 Complete ultrasound scan of joint 753357_1 CDM 0402 RC 76881 HCPCS inpatient 1707 1109.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1153.93 67.6 999999999 1033.59 1655.79 percent of total billed charges Complete ultrasound scan of joint 753359_1 CDM 0402 RC 76881 HCPCS inpatient 1573 1022.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1022.45 65 999999999 952.45 1525.81 percent of total billed charges Complete ultrasound scan of joint 753359_1 CDM 0402 RC 76881 HCPCS inpatient 1573 1022.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1525.81 97 999999999 952.45 1525.81 percent of total billed charges Complete ultrasound scan of joint 753359_1 CDM 0402 RC 76881 HCPCS inpatient 1573 1022.45 AETNA AETNA 1242.67 79 999999999 952.45 1525.81 percent of total billed charges Complete ultrasound scan of joint 753359_1 CDM 0402 RC 76881 HCPCS inpatient 1573 1022.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1085.37 69 999999999 952.45 1525.81 percent of total billed charges Complete ultrasound scan of joint 753359_1 CDM 0402 RC 76881 HCPCS inpatient 1573 1022.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1226.94 78 999999999 952.45 1525.81 percent of total billed charges Complete ultrasound scan of joint 753359_1 CDM 0402 RC 76881 HCPCS inpatient 1573 1022.45 SIHO - ALL PLANS SIHO - ALL PLANS 1415.7 90 999999999 952.45 1525.81 percent of total billed charges Complete ultrasound scan of joint 753359_1 CDM 0402 RC 76881 HCPCS inpatient 1573 1022.45 UMR - ALL PLANS UMR - ALL PLANS 1101.1 70 999999999 952.45 1525.81 percent of total billed charges Complete ultrasound scan of joint 753359_1 CDM 0402 RC 76881 HCPCS inpatient 1573 1022.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 952.45 1525.81 Complete ultrasound scan of joint 753359_1 CDM 0402 RC 76881 HCPCS inpatient 1573 1022.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 952.45 60.55 999999999 952.45 1525.81 percent of total billed charges Complete ultrasound scan of joint 753359_1 CDM 0402 RC 76881 HCPCS inpatient 1573 1022.45 ANTHEM HMO ANTHEM HMO 999999999 952.45 1525.81 Complete ultrasound scan of joint 753359_1 CDM 0402 RC 76881 HCPCS inpatient 1573 1022.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 952.45 1525.81 Complete ultrasound scan of joint 753359_1 CDM 0402 RC 76881 HCPCS inpatient 1573 1022.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 952.45 1525.81 Complete ultrasound scan of joint 753359_1 CDM 0402 RC 76881 HCPCS inpatient 1573 1022.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 952.45 1525.81 Complete ultrasound scan of joint 753359_1 CDM 0402 RC 76881 HCPCS inpatient 1573 1022.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1063.35 67.6 999999999 952.45 1525.81 percent of total billed charges Ultrasound scan of fetus 753361_1 CDM 0402 RC 76819 HCPCS inpatient 1331 865.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 865.15 65 999999999 805.92 1291.07 percent of total billed charges Ultrasound scan of fetus 753361_1 CDM 0402 RC 76819 HCPCS inpatient 1331 865.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1291.07 97 999999999 805.92 1291.07 percent of total billed charges Ultrasound scan of fetus 753361_1 CDM 0402 RC 76819 HCPCS inpatient 1331 865.15 AETNA AETNA 1051.49 79 999999999 805.92 1291.07 percent of total billed charges Ultrasound scan of fetus 753361_1 CDM 0402 RC 76819 HCPCS inpatient 1331 865.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 918.39 69 999999999 805.92 1291.07 percent of total billed charges Ultrasound scan of fetus 753361_1 CDM 0402 RC 76819 HCPCS inpatient 1331 865.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1038.18 78 999999999 805.92 1291.07 percent of total billed charges Ultrasound scan of fetus 753361_1 CDM 0402 RC 76819 HCPCS inpatient 1331 865.15 SIHO - ALL PLANS SIHO - ALL PLANS 1197.9 90 999999999 805.92 1291.07 percent of total billed charges Ultrasound scan of fetus 753361_1 CDM 0402 RC 76819 HCPCS inpatient 1331 865.15 UMR - ALL PLANS UMR - ALL PLANS 931.7 70 999999999 805.92 1291.07 percent of total billed charges Ultrasound scan of fetus 753361_1 CDM 0402 RC 76819 HCPCS inpatient 1331 865.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 805.92 1291.07 Ultrasound scan of fetus 753361_1 CDM 0402 RC 76819 HCPCS inpatient 1331 865.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 805.92 60.55 999999999 805.92 1291.07 percent of total billed charges Ultrasound scan of fetus 753361_1 CDM 0402 RC 76819 HCPCS inpatient 1331 865.15 ANTHEM HMO ANTHEM HMO 999999999 805.92 1291.07 Ultrasound scan of fetus 753361_1 CDM 0402 RC 76819 HCPCS inpatient 1331 865.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 805.92 1291.07 Ultrasound scan of fetus 753361_1 CDM 0402 RC 76819 HCPCS inpatient 1331 865.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 805.92 1291.07 Ultrasound scan of fetus 753361_1 CDM 0402 RC 76819 HCPCS inpatient 1331 865.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 805.92 1291.07 Ultrasound scan of fetus 753361_1 CDM 0402 RC 76819 HCPCS inpatient 1331 865.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 899.76 67.6 999999999 805.92 1291.07 percent of total billed charges Limited ultrasound scan of abdomen 753381_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 703.3 65 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753381_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1049.54 97 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753381_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 AETNA AETNA 854.78 79 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753381_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 746.58 69 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753381_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 843.96 78 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753381_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 SIHO - ALL PLANS SIHO - ALL PLANS 973.8 90 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753381_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UMR - ALL PLANS UMR - ALL PLANS 757.4 70 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753381_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753381_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 655.15 60.55 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753381_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM HMO ANTHEM HMO 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753381_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753381_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753381_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753381_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 731.43 67.6 999999999 655.15 1049.54 percent of total billed charges Ultrasonic guidance for removal of amniotic fluid 753387_1 CDM 0402 RC 76946 HCPCS inpatient 627 407.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 407.55 65 999999999 379.65 608.19 percent of total billed charges Ultrasonic guidance for removal of amniotic fluid 753387_1 CDM 0402 RC 76946 HCPCS inpatient 627 407.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 608.19 97 999999999 379.65 608.19 percent of total billed charges Ultrasonic guidance for removal of amniotic fluid 753387_1 CDM 0402 RC 76946 HCPCS inpatient 627 407.55 AETNA AETNA 495.33 79 999999999 379.65 608.19 percent of total billed charges Ultrasonic guidance for removal of amniotic fluid 753387_1 CDM 0402 RC 76946 HCPCS inpatient 627 407.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 432.63 69 999999999 379.65 608.19 percent of total billed charges Ultrasonic guidance for removal of amniotic fluid 753387_1 CDM 0402 RC 76946 HCPCS inpatient 627 407.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 489.06 78 999999999 379.65 608.19 percent of total billed charges Ultrasonic guidance for removal of amniotic fluid 753387_1 CDM 0402 RC 76946 HCPCS inpatient 627 407.55 SIHO - ALL PLANS SIHO - ALL PLANS 564.3 90 999999999 379.65 608.19 percent of total billed charges Ultrasonic guidance for removal of amniotic fluid 753387_1 CDM 0402 RC 76946 HCPCS inpatient 627 407.55 UMR - ALL PLANS UMR - ALL PLANS 438.9 70 999999999 379.65 608.19 percent of total billed charges Ultrasonic guidance for removal of amniotic fluid 753387_1 CDM 0402 RC 76946 HCPCS inpatient 627 407.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 379.65 608.19 Ultrasonic guidance for removal of amniotic fluid 753387_1 CDM 0402 RC 76946 HCPCS inpatient 627 407.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 379.65 60.55 999999999 379.65 608.19 percent of total billed charges Ultrasonic guidance for removal of amniotic fluid 753387_1 CDM 0402 RC 76946 HCPCS inpatient 627 407.55 ANTHEM HMO ANTHEM HMO 999999999 379.65 608.19 Ultrasonic guidance for removal of amniotic fluid 753387_1 CDM 0402 RC 76946 HCPCS inpatient 627 407.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 379.65 608.19 Ultrasonic guidance for removal of amniotic fluid 753387_1 CDM 0402 RC 76946 HCPCS inpatient 627 407.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 379.65 608.19 Ultrasonic guidance for removal of amniotic fluid 753387_1 CDM 0402 RC 76946 HCPCS inpatient 627 407.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 379.65 608.19 Ultrasonic guidance for removal of amniotic fluid 753387_1 CDM 0402 RC 76946 HCPCS inpatient 627 407.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 423.85 67.6 999999999 379.65 608.19 percent of total billed charges Ultrasound scan of head and neck soft tissue 753394_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 607.1 65 999999999 565.54 905.98 percent of total billed charges Ultrasound scan of head and neck soft tissue 753394_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 905.98 97 999999999 565.54 905.98 percent of total billed charges Ultrasound scan of head and neck soft tissue 753394_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 AETNA AETNA 737.86 79 999999999 565.54 905.98 percent of total billed charges Ultrasound scan of head and neck soft tissue 753394_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 644.46 69 999999999 565.54 905.98 percent of total billed charges Ultrasound scan of head and neck soft tissue 753394_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 728.52 78 999999999 565.54 905.98 percent of total billed charges Ultrasound scan of head and neck soft tissue 753394_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 SIHO - ALL PLANS SIHO - ALL PLANS 840.6 90 999999999 565.54 905.98 percent of total billed charges Ultrasound scan of head and neck soft tissue 753394_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 UMR - ALL PLANS UMR - ALL PLANS 653.8 70 999999999 565.54 905.98 percent of total billed charges Ultrasound scan of head and neck soft tissue 753394_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 565.54 905.98 Ultrasound scan of head and neck soft tissue 753394_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 565.54 60.55 999999999 565.54 905.98 percent of total billed charges Ultrasound scan of head and neck soft tissue 753394_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 ANTHEM HMO ANTHEM HMO 999999999 565.54 905.98 Ultrasound scan of head and neck soft tissue 753394_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 565.54 905.98 Ultrasound scan of head and neck soft tissue 753394_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 565.54 905.98 Ultrasound scan of head and neck soft tissue 753394_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 565.54 905.98 Ultrasound scan of head and neck soft tissue 753394_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 631.38 67.6 999999999 565.54 905.98 percent of total billed charges "Ultrasound of aorta, vena cava, groin vessels or bypass grafts" 753402_1 CDM 0402 RC 93979 HCPCS inpatient 565 367.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 367.25 65 999999999 342.11 548.05 percent of total billed charges "Ultrasound of aorta, vena cava, groin vessels or bypass grafts" 753402_1 CDM 0402 RC 93979 HCPCS inpatient 565 367.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 548.05 97 999999999 342.11 548.05 percent of total billed charges "Ultrasound of aorta, vena cava, groin vessels or bypass grafts" 753402_1 CDM 0402 RC 93979 HCPCS inpatient 565 367.25 AETNA AETNA 446.35 79 999999999 342.11 548.05 percent of total billed charges "Ultrasound of aorta, vena cava, groin vessels or bypass grafts" 753402_1 CDM 0402 RC 93979 HCPCS inpatient 565 367.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 389.85 69 999999999 342.11 548.05 percent of total billed charges "Ultrasound of aorta, vena cava, groin vessels or bypass grafts" 753402_1 CDM 0402 RC 93979 HCPCS inpatient 565 367.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 440.7 78 999999999 342.11 548.05 percent of total billed charges "Ultrasound of aorta, vena cava, groin vessels or bypass grafts" 753402_1 CDM 0402 RC 93979 HCPCS inpatient 565 367.25 SIHO - ALL PLANS SIHO - ALL PLANS 508.5 90 999999999 342.11 548.05 percent of total billed charges "Ultrasound of aorta, vena cava, groin vessels or bypass grafts" 753402_1 CDM 0402 RC 93979 HCPCS inpatient 565 367.25 UMR - ALL PLANS UMR - ALL PLANS 395.5 70 999999999 342.11 548.05 percent of total billed charges "Ultrasound of aorta, vena cava, groin vessels or bypass grafts" 753402_1 CDM 0402 RC 93979 HCPCS inpatient 565 367.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 342.11 548.05 "Ultrasound of aorta, vena cava, groin vessels or bypass grafts" 753402_1 CDM 0402 RC 93979 HCPCS inpatient 565 367.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 342.11 60.55 999999999 342.11 548.05 percent of total billed charges "Ultrasound of aorta, vena cava, groin vessels or bypass grafts" 753402_1 CDM 0402 RC 93979 HCPCS inpatient 565 367.25 ANTHEM HMO ANTHEM HMO 999999999 342.11 548.05 "Ultrasound of aorta, vena cava, groin vessels or bypass grafts" 753402_1 CDM 0402 RC 93979 HCPCS inpatient 565 367.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 342.11 548.05 "Ultrasound of aorta, vena cava, groin vessels or bypass grafts" 753402_1 CDM 0402 RC 93979 HCPCS inpatient 565 367.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 342.11 548.05 "Ultrasound of aorta, vena cava, groin vessels or bypass grafts" 753402_1 CDM 0402 RC 93979 HCPCS inpatient 565 367.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 342.11 548.05 "Ultrasound of aorta, vena cava, groin vessels or bypass grafts" 753402_1 CDM 0402 RC 93979 HCPCS inpatient 565 367.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 381.94 67.6 999999999 342.11 548.05 percent of total billed charges Complete ultrasound study of arm and leg arteries 753407_1 CDM 0921 RC 93923 HCPCS inpatient 1177 765.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 765.05 65 999999999 712.67 1141.69 percent of total billed charges Complete ultrasound study of arm and leg arteries 753407_1 CDM 0921 RC 93923 HCPCS inpatient 1177 765.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1141.69 97 999999999 712.67 1141.69 percent of total billed charges Complete ultrasound study of arm and leg arteries 753407_1 CDM 0921 RC 93923 HCPCS inpatient 1177 765.05 AETNA AETNA 929.83 79 999999999 712.67 1141.69 percent of total billed charges Complete ultrasound study of arm and leg arteries 753407_1 CDM 0921 RC 93923 HCPCS inpatient 1177 765.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 812.13 69 999999999 712.67 1141.69 percent of total billed charges Complete ultrasound study of arm and leg arteries 753407_1 CDM 0921 RC 93923 HCPCS inpatient 1177 765.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 918.06 78 999999999 712.67 1141.69 percent of total billed charges Complete ultrasound study of arm and leg arteries 753407_1 CDM 0921 RC 93923 HCPCS inpatient 1177 765.05 SIHO - ALL PLANS SIHO - ALL PLANS 1059.3 90 999999999 712.67 1141.69 percent of total billed charges Complete ultrasound study of arm and leg arteries 753407_1 CDM 0921 RC 93923 HCPCS inpatient 1177 765.05 UMR - ALL PLANS UMR - ALL PLANS 823.9 70 999999999 712.67 1141.69 percent of total billed charges Complete ultrasound study of arm and leg arteries 753407_1 CDM 0921 RC 93923 HCPCS inpatient 1177 765.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 712.67 1141.69 Complete ultrasound study of arm and leg arteries 753407_1 CDM 0921 RC 93923 HCPCS inpatient 1177 765.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 712.67 60.55 999999999 712.67 1141.69 percent of total billed charges Complete ultrasound study of arm and leg arteries 753407_1 CDM 0921 RC 93923 HCPCS inpatient 1177 765.05 ANTHEM HMO ANTHEM HMO 999999999 712.67 1141.69 Complete ultrasound study of arm and leg arteries 753407_1 CDM 0921 RC 93923 HCPCS inpatient 1177 765.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 712.67 1141.69 Complete ultrasound study of arm and leg arteries 753407_1 CDM 0921 RC 93923 HCPCS inpatient 1177 765.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 712.67 1141.69 Complete ultrasound study of arm and leg arteries 753407_1 CDM 0921 RC 93923 HCPCS inpatient 1177 765.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 712.67 1141.69 Complete ultrasound study of arm and leg arteries 753407_1 CDM 0921 RC 93923 HCPCS inpatient 1177 765.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 795.65 67.6 999999999 712.67 1141.69 percent of total billed charges Ultrasound study of arm and leg arteries 753409_1 CDM 0402 RC 93922 HCPCS inpatient 627 407.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 407.55 65 999999999 379.65 608.19 percent of total billed charges Ultrasound study of arm and leg arteries 753409_1 CDM 0402 RC 93922 HCPCS inpatient 627 407.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 608.19 97 999999999 379.65 608.19 percent of total billed charges Ultrasound study of arm and leg arteries 753409_1 CDM 0402 RC 93922 HCPCS inpatient 627 407.55 AETNA AETNA 495.33 79 999999999 379.65 608.19 percent of total billed charges Ultrasound study of arm and leg arteries 753409_1 CDM 0402 RC 93922 HCPCS inpatient 627 407.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 432.63 69 999999999 379.65 608.19 percent of total billed charges Ultrasound study of arm and leg arteries 753409_1 CDM 0402 RC 93922 HCPCS inpatient 627 407.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 489.06 78 999999999 379.65 608.19 percent of total billed charges Ultrasound study of arm and leg arteries 753409_1 CDM 0402 RC 93922 HCPCS inpatient 627 407.55 SIHO - ALL PLANS SIHO - ALL PLANS 564.3 90 999999999 379.65 608.19 percent of total billed charges Ultrasound study of arm and leg arteries 753409_1 CDM 0402 RC 93922 HCPCS inpatient 627 407.55 UMR - ALL PLANS UMR - ALL PLANS 438.9 70 999999999 379.65 608.19 percent of total billed charges Ultrasound study of arm and leg arteries 753409_1 CDM 0402 RC 93922 HCPCS inpatient 627 407.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 379.65 608.19 Ultrasound study of arm and leg arteries 753409_1 CDM 0402 RC 93922 HCPCS inpatient 627 407.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 379.65 60.55 999999999 379.65 608.19 percent of total billed charges Ultrasound study of arm and leg arteries 753409_1 CDM 0402 RC 93922 HCPCS inpatient 627 407.55 ANTHEM HMO ANTHEM HMO 999999999 379.65 608.19 Ultrasound study of arm and leg arteries 753409_1 CDM 0402 RC 93922 HCPCS inpatient 627 407.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 379.65 608.19 Ultrasound study of arm and leg arteries 753409_1 CDM 0402 RC 93922 HCPCS inpatient 627 407.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 379.65 608.19 Ultrasound study of arm and leg arteries 753409_1 CDM 0402 RC 93922 HCPCS inpatient 627 407.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 379.65 608.19 Ultrasound study of arm and leg arteries 753409_1 CDM 0402 RC 93922 HCPCS inpatient 627 407.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 423.85 67.6 999999999 379.65 608.19 percent of total billed charges Ultrasound of leg arteries or artery grafts 753411_1 CDM 0921 RC 93925 HCPCS inpatient 677 440.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 440.05 65 999999999 409.92 656.69 percent of total billed charges Ultrasound of leg arteries or artery grafts 753411_1 CDM 0921 RC 93925 HCPCS inpatient 677 440.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 656.69 97 999999999 409.92 656.69 percent of total billed charges Ultrasound of leg arteries or artery grafts 753411_1 CDM 0921 RC 93925 HCPCS inpatient 677 440.05 AETNA AETNA 534.83 79 999999999 409.92 656.69 percent of total billed charges Ultrasound of leg arteries or artery grafts 753411_1 CDM 0921 RC 93925 HCPCS inpatient 677 440.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 467.13 69 999999999 409.92 656.69 percent of total billed charges Ultrasound of leg arteries or artery grafts 753411_1 CDM 0921 RC 93925 HCPCS inpatient 677 440.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 528.06 78 999999999 409.92 656.69 percent of total billed charges Ultrasound of leg arteries or artery grafts 753411_1 CDM 0921 RC 93925 HCPCS inpatient 677 440.05 SIHO - ALL PLANS SIHO - ALL PLANS 609.3 90 999999999 409.92 656.69 percent of total billed charges Ultrasound of leg arteries or artery grafts 753411_1 CDM 0921 RC 93925 HCPCS inpatient 677 440.05 UMR - ALL PLANS UMR - ALL PLANS 473.9 70 999999999 409.92 656.69 percent of total billed charges Ultrasound of leg arteries or artery grafts 753411_1 CDM 0921 RC 93925 HCPCS inpatient 677 440.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 409.92 656.69 Ultrasound of leg arteries or artery grafts 753411_1 CDM 0921 RC 93925 HCPCS inpatient 677 440.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 409.92 60.55 999999999 409.92 656.69 percent of total billed charges Ultrasound of leg arteries or artery grafts 753411_1 CDM 0921 RC 93925 HCPCS inpatient 677 440.05 ANTHEM HMO ANTHEM HMO 999999999 409.92 656.69 Ultrasound of leg arteries or artery grafts 753411_1 CDM 0921 RC 93925 HCPCS inpatient 677 440.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 409.92 656.69 Ultrasound of leg arteries or artery grafts 753411_1 CDM 0921 RC 93925 HCPCS inpatient 677 440.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 409.92 656.69 Ultrasound of leg arteries or artery grafts 753411_1 CDM 0921 RC 93925 HCPCS inpatient 677 440.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 409.92 656.69 Ultrasound of leg arteries or artery grafts 753411_1 CDM 0921 RC 93925 HCPCS inpatient 677 440.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 457.65 67.6 999999999 409.92 656.69 percent of total billed charges Limited ultrasound scan of abdomen 753425_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 703.3 65 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753425_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1049.54 97 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753425_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 AETNA AETNA 854.78 79 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753425_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 746.58 69 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753425_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 843.96 78 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753425_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 SIHO - ALL PLANS SIHO - ALL PLANS 973.8 90 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753425_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UMR - ALL PLANS UMR - ALL PLANS 757.4 70 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753425_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753425_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 655.15 60.55 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753425_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM HMO ANTHEM HMO 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753425_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753425_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753425_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753425_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 731.43 67.6 999999999 655.15 1049.54 percent of total billed charges Complete ultrasound scan of pelvis 753436_1 CDM 0402 RC 76856 HCPCS inpatient 1165 757.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 757.25 65 999999999 705.41 1130.05 percent of total billed charges Complete ultrasound scan of pelvis 753436_1 CDM 0402 RC 76856 HCPCS inpatient 1165 757.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1130.05 97 999999999 705.41 1130.05 percent of total billed charges Complete ultrasound scan of pelvis 753436_1 CDM 0402 RC 76856 HCPCS inpatient 1165 757.25 AETNA AETNA 920.35 79 999999999 705.41 1130.05 percent of total billed charges Complete ultrasound scan of pelvis 753436_1 CDM 0402 RC 76856 HCPCS inpatient 1165 757.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 803.85 69 999999999 705.41 1130.05 percent of total billed charges Complete ultrasound scan of pelvis 753436_1 CDM 0402 RC 76856 HCPCS inpatient 1165 757.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 908.7 78 999999999 705.41 1130.05 percent of total billed charges Complete ultrasound scan of pelvis 753436_1 CDM 0402 RC 76856 HCPCS inpatient 1165 757.25 SIHO - ALL PLANS SIHO - ALL PLANS 1048.5 90 999999999 705.41 1130.05 percent of total billed charges Complete ultrasound scan of pelvis 753436_1 CDM 0402 RC 76856 HCPCS inpatient 1165 757.25 UMR - ALL PLANS UMR - ALL PLANS 815.5 70 999999999 705.41 1130.05 percent of total billed charges Complete ultrasound scan of pelvis 753436_1 CDM 0402 RC 76856 HCPCS inpatient 1165 757.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 705.41 1130.05 Complete ultrasound scan of pelvis 753436_1 CDM 0402 RC 76856 HCPCS inpatient 1165 757.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 705.41 60.55 999999999 705.41 1130.05 percent of total billed charges Complete ultrasound scan of pelvis 753436_1 CDM 0402 RC 76856 HCPCS inpatient 1165 757.25 ANTHEM HMO ANTHEM HMO 999999999 705.41 1130.05 Complete ultrasound scan of pelvis 753436_1 CDM 0402 RC 76856 HCPCS inpatient 1165 757.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 705.41 1130.05 Complete ultrasound scan of pelvis 753436_1 CDM 0402 RC 76856 HCPCS inpatient 1165 757.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 705.41 1130.05 Complete ultrasound scan of pelvis 753436_1 CDM 0402 RC 76856 HCPCS inpatient 1165 757.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 705.41 1130.05 Complete ultrasound scan of pelvis 753436_1 CDM 0402 RC 76856 HCPCS inpatient 1165 757.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 787.54 67.6 999999999 705.41 1130.05 percent of total billed charges Limited ultrasound scan of pelvis 753438_1 CDM 0402 RC 76857 HCPCS inpatient 612 397.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 397.8 65 999999999 370.57 593.64 percent of total billed charges Limited ultrasound scan of pelvis 753438_1 CDM 0402 RC 76857 HCPCS inpatient 612 397.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 593.64 97 999999999 370.57 593.64 percent of total billed charges Limited ultrasound scan of pelvis 753438_1 CDM 0402 RC 76857 HCPCS inpatient 612 397.8 AETNA AETNA 483.48 79 999999999 370.57 593.64 percent of total billed charges Limited ultrasound scan of pelvis 753438_1 CDM 0402 RC 76857 HCPCS inpatient 612 397.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 422.28 69 999999999 370.57 593.64 percent of total billed charges Limited ultrasound scan of pelvis 753438_1 CDM 0402 RC 76857 HCPCS inpatient 612 397.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 477.36 78 999999999 370.57 593.64 percent of total billed charges Limited ultrasound scan of pelvis 753438_1 CDM 0402 RC 76857 HCPCS inpatient 612 397.8 SIHO - ALL PLANS SIHO - ALL PLANS 550.8 90 999999999 370.57 593.64 percent of total billed charges Limited ultrasound scan of pelvis 753438_1 CDM 0402 RC 76857 HCPCS inpatient 612 397.8 UMR - ALL PLANS UMR - ALL PLANS 428.4 70 999999999 370.57 593.64 percent of total billed charges Limited ultrasound scan of pelvis 753438_1 CDM 0402 RC 76857 HCPCS inpatient 612 397.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 370.57 593.64 Limited ultrasound scan of pelvis 753438_1 CDM 0402 RC 76857 HCPCS inpatient 612 397.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 370.57 60.55 999999999 370.57 593.64 percent of total billed charges Limited ultrasound scan of pelvis 753438_1 CDM 0402 RC 76857 HCPCS inpatient 612 397.8 ANTHEM HMO ANTHEM HMO 999999999 370.57 593.64 Limited ultrasound scan of pelvis 753438_1 CDM 0402 RC 76857 HCPCS inpatient 612 397.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 370.57 593.64 Limited ultrasound scan of pelvis 753438_1 CDM 0402 RC 76857 HCPCS inpatient 612 397.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 370.57 593.64 Limited ultrasound scan of pelvis 753438_1 CDM 0402 RC 76857 HCPCS inpatient 612 397.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 370.57 593.64 Limited ultrasound scan of pelvis 753438_1 CDM 0402 RC 76857 HCPCS inpatient 612 397.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 413.71 67.6 999999999 370.57 593.64 percent of total billed charges Vaginal ultrasound of pregnant uterus 753446_1 CDM 0402 RC 76817 HCPCS inpatient 259.5 168.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 168.68 65 999999999 157.13 251.72 percent of total billed charges Vaginal ultrasound of pregnant uterus 753446_1 CDM 0402 RC 76817 HCPCS inpatient 259.5 168.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 251.72 97 999999999 157.13 251.72 percent of total billed charges Vaginal ultrasound of pregnant uterus 753446_1 CDM 0402 RC 76817 HCPCS inpatient 259.5 168.68 AETNA AETNA 205.01 79 999999999 157.13 251.72 percent of total billed charges Vaginal ultrasound of pregnant uterus 753446_1 CDM 0402 RC 76817 HCPCS inpatient 259.5 168.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 179.06 69 999999999 157.13 251.72 percent of total billed charges Vaginal ultrasound of pregnant uterus 753446_1 CDM 0402 RC 76817 HCPCS inpatient 259.5 168.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 202.41 78 999999999 157.13 251.72 percent of total billed charges Vaginal ultrasound of pregnant uterus 753446_1 CDM 0402 RC 76817 HCPCS inpatient 259.5 168.68 SIHO - ALL PLANS SIHO - ALL PLANS 233.55 90 999999999 157.13 251.72 percent of total billed charges Vaginal ultrasound of pregnant uterus 753446_1 CDM 0402 RC 76817 HCPCS inpatient 259.5 168.68 UMR - ALL PLANS UMR - ALL PLANS 181.65 70 999999999 157.13 251.72 percent of total billed charges Vaginal ultrasound of pregnant uterus 753446_1 CDM 0402 RC 76817 HCPCS inpatient 259.5 168.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 157.13 251.72 Vaginal ultrasound of pregnant uterus 753446_1 CDM 0402 RC 76817 HCPCS inpatient 259.5 168.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 157.13 60.55 999999999 157.13 251.72 percent of total billed charges Vaginal ultrasound of pregnant uterus 753446_1 CDM 0402 RC 76817 HCPCS inpatient 259.5 168.68 ANTHEM HMO ANTHEM HMO 999999999 157.13 251.72 Vaginal ultrasound of pregnant uterus 753446_1 CDM 0402 RC 76817 HCPCS inpatient 259.5 168.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 157.13 251.72 Vaginal ultrasound of pregnant uterus 753446_1 CDM 0402 RC 76817 HCPCS inpatient 259.5 168.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 157.13 251.72 Vaginal ultrasound of pregnant uterus 753446_1 CDM 0402 RC 76817 HCPCS inpatient 259.5 168.68 UHC - ALL PLANS UHC - ALL PLANS 999999999 157.13 251.72 Vaginal ultrasound of pregnant uterus 753446_1 CDM 0402 RC 76817 HCPCS inpatient 259.5 168.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 175.42 67.6 999999999 157.13 251.72 percent of total billed charges Ultrasound scan of pelvic region through rectum 753448_1 CDM 0402 RC 76872 HCPCS inpatient 926 601.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 601.9 65 999999999 560.69 898.22 percent of total billed charges Ultrasound scan of pelvic region through rectum 753448_1 CDM 0402 RC 76872 HCPCS inpatient 926 601.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 898.22 97 999999999 560.69 898.22 percent of total billed charges Ultrasound scan of pelvic region through rectum 753448_1 CDM 0402 RC 76872 HCPCS inpatient 926 601.9 AETNA AETNA 731.54 79 999999999 560.69 898.22 percent of total billed charges Ultrasound scan of pelvic region through rectum 753448_1 CDM 0402 RC 76872 HCPCS inpatient 926 601.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 638.94 69 999999999 560.69 898.22 percent of total billed charges Ultrasound scan of pelvic region through rectum 753448_1 CDM 0402 RC 76872 HCPCS inpatient 926 601.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 722.28 78 999999999 560.69 898.22 percent of total billed charges Ultrasound scan of pelvic region through rectum 753448_1 CDM 0402 RC 76872 HCPCS inpatient 926 601.9 SIHO - ALL PLANS SIHO - ALL PLANS 833.4 90 999999999 560.69 898.22 percent of total billed charges Ultrasound scan of pelvic region through rectum 753448_1 CDM 0402 RC 76872 HCPCS inpatient 926 601.9 UMR - ALL PLANS UMR - ALL PLANS 648.2 70 999999999 560.69 898.22 percent of total billed charges Ultrasound scan of pelvic region through rectum 753448_1 CDM 0402 RC 76872 HCPCS inpatient 926 601.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 560.69 898.22 Ultrasound scan of pelvic region through rectum 753448_1 CDM 0402 RC 76872 HCPCS inpatient 926 601.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 560.69 60.55 999999999 560.69 898.22 percent of total billed charges Ultrasound scan of pelvic region through rectum 753448_1 CDM 0402 RC 76872 HCPCS inpatient 926 601.9 ANTHEM HMO ANTHEM HMO 999999999 560.69 898.22 Ultrasound scan of pelvic region through rectum 753448_1 CDM 0402 RC 76872 HCPCS inpatient 926 601.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 560.69 898.22 Ultrasound scan of pelvic region through rectum 753448_1 CDM 0402 RC 76872 HCPCS inpatient 926 601.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 560.69 898.22 Ultrasound scan of pelvic region through rectum 753448_1 CDM 0402 RC 76872 HCPCS inpatient 926 601.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 560.69 898.22 Ultrasound scan of pelvic region through rectum 753448_1 CDM 0402 RC 76872 HCPCS inpatient 926 601.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 625.98 67.6 999999999 560.69 898.22 percent of total billed charges Complete ultrasound scan behind abdominal cavity 753450_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 739.7 65 999999999 689.06 1103.86 percent of total billed charges Complete ultrasound scan behind abdominal cavity 753450_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1103.86 97 999999999 689.06 1103.86 percent of total billed charges Complete ultrasound scan behind abdominal cavity 753450_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 AETNA AETNA 899.02 79 999999999 689.06 1103.86 percent of total billed charges Complete ultrasound scan behind abdominal cavity 753450_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 785.22 69 999999999 689.06 1103.86 percent of total billed charges Complete ultrasound scan behind abdominal cavity 753450_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 887.64 78 999999999 689.06 1103.86 percent of total billed charges Complete ultrasound scan behind abdominal cavity 753450_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 SIHO - ALL PLANS SIHO - ALL PLANS 1024.2 90 999999999 689.06 1103.86 percent of total billed charges Complete ultrasound scan behind abdominal cavity 753450_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 UMR - ALL PLANS UMR - ALL PLANS 796.6 70 999999999 689.06 1103.86 percent of total billed charges Complete ultrasound scan behind abdominal cavity 753450_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 689.06 1103.86 Complete ultrasound scan behind abdominal cavity 753450_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 689.06 60.55 999999999 689.06 1103.86 percent of total billed charges Complete ultrasound scan behind abdominal cavity 753450_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 ANTHEM HMO ANTHEM HMO 999999999 689.06 1103.86 Complete ultrasound scan behind abdominal cavity 753450_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 689.06 1103.86 Complete ultrasound scan behind abdominal cavity 753450_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 689.06 1103.86 Complete ultrasound scan behind abdominal cavity 753450_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 689.06 1103.86 Complete ultrasound scan behind abdominal cavity 753450_1 CDM 0402 RC 76770 HCPCS inpatient 1138 739.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 769.29 67.6 999999999 689.06 1103.86 percent of total billed charges Ultrasound scan of scrotum 753458_1 CDM 0402 RC 76870 HCPCS inpatient 1019 662.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 662.35 65 999999999 617 988.43 percent of total billed charges Ultrasound scan of scrotum 753458_1 CDM 0402 RC 76870 HCPCS inpatient 1019 662.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 988.43 97 999999999 617 988.43 percent of total billed charges Ultrasound scan of scrotum 753458_1 CDM 0402 RC 76870 HCPCS inpatient 1019 662.35 AETNA AETNA 805.01 79 999999999 617 988.43 percent of total billed charges Ultrasound scan of scrotum 753458_1 CDM 0402 RC 76870 HCPCS inpatient 1019 662.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 703.11 69 999999999 617 988.43 percent of total billed charges Ultrasound scan of scrotum 753458_1 CDM 0402 RC 76870 HCPCS inpatient 1019 662.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 794.82 78 999999999 617 988.43 percent of total billed charges Ultrasound scan of scrotum 753458_1 CDM 0402 RC 76870 HCPCS inpatient 1019 662.35 SIHO - ALL PLANS SIHO - ALL PLANS 917.1 90 999999999 617 988.43 percent of total billed charges Ultrasound scan of scrotum 753458_1 CDM 0402 RC 76870 HCPCS inpatient 1019 662.35 UMR - ALL PLANS UMR - ALL PLANS 713.3 70 999999999 617 988.43 percent of total billed charges Ultrasound scan of scrotum 753458_1 CDM 0402 RC 76870 HCPCS inpatient 1019 662.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 617 988.43 Ultrasound scan of scrotum 753458_1 CDM 0402 RC 76870 HCPCS inpatient 1019 662.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 617 60.55 999999999 617 988.43 percent of total billed charges Ultrasound scan of scrotum 753458_1 CDM 0402 RC 76870 HCPCS inpatient 1019 662.35 ANTHEM HMO ANTHEM HMO 999999999 617 988.43 Ultrasound scan of scrotum 753458_1 CDM 0402 RC 76870 HCPCS inpatient 1019 662.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 617 988.43 Ultrasound scan of scrotum 753458_1 CDM 0402 RC 76870 HCPCS inpatient 1019 662.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 617 988.43 Ultrasound scan of scrotum 753458_1 CDM 0402 RC 76870 HCPCS inpatient 1019 662.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 617 988.43 Ultrasound scan of scrotum 753458_1 CDM 0402 RC 76870 HCPCS inpatient 1019 662.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 688.84 67.6 999999999 617 988.43 percent of total billed charges Ultrasound scan of spinal canal 753463_1 CDM 0402 RC 76800 HCPCS inpatient 988 642.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 642.2 65 999999999 598.23 958.36 percent of total billed charges Ultrasound scan of spinal canal 753463_1 CDM 0402 RC 76800 HCPCS inpatient 988 642.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 958.36 97 999999999 598.23 958.36 percent of total billed charges Ultrasound scan of spinal canal 753463_1 CDM 0402 RC 76800 HCPCS inpatient 988 642.2 AETNA AETNA 780.52 79 999999999 598.23 958.36 percent of total billed charges Ultrasound scan of spinal canal 753463_1 CDM 0402 RC 76800 HCPCS inpatient 988 642.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 681.72 69 999999999 598.23 958.36 percent of total billed charges Ultrasound scan of spinal canal 753463_1 CDM 0402 RC 76800 HCPCS inpatient 988 642.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 770.64 78 999999999 598.23 958.36 percent of total billed charges Ultrasound scan of spinal canal 753463_1 CDM 0402 RC 76800 HCPCS inpatient 988 642.2 SIHO - ALL PLANS SIHO - ALL PLANS 889.2 90 999999999 598.23 958.36 percent of total billed charges Ultrasound scan of spinal canal 753463_1 CDM 0402 RC 76800 HCPCS inpatient 988 642.2 UMR - ALL PLANS UMR - ALL PLANS 691.6 70 999999999 598.23 958.36 percent of total billed charges Ultrasound scan of spinal canal 753463_1 CDM 0402 RC 76800 HCPCS inpatient 988 642.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 598.23 958.36 Ultrasound scan of spinal canal 753463_1 CDM 0402 RC 76800 HCPCS inpatient 988 642.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 598.23 60.55 999999999 598.23 958.36 percent of total billed charges Ultrasound scan of spinal canal 753463_1 CDM 0402 RC 76800 HCPCS inpatient 988 642.2 ANTHEM HMO ANTHEM HMO 999999999 598.23 958.36 Ultrasound scan of spinal canal 753463_1 CDM 0402 RC 76800 HCPCS inpatient 988 642.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 598.23 958.36 Ultrasound scan of spinal canal 753463_1 CDM 0402 RC 76800 HCPCS inpatient 988 642.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 598.23 958.36 Ultrasound scan of spinal canal 753463_1 CDM 0402 RC 76800 HCPCS inpatient 988 642.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 598.23 958.36 Ultrasound scan of spinal canal 753463_1 CDM 0402 RC 76800 HCPCS inpatient 988 642.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 667.89 67.6 999999999 598.23 958.36 percent of total billed charges Limited ultrasound scan of abdomen 753465_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 703.3 65 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753465_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1049.54 97 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753465_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 AETNA AETNA 854.78 79 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753465_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 746.58 69 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753465_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 843.96 78 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753465_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 SIHO - ALL PLANS SIHO - ALL PLANS 973.8 90 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753465_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UMR - ALL PLANS UMR - ALL PLANS 757.4 70 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753465_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753465_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 655.15 60.55 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 753465_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM HMO ANTHEM HMO 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753465_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753465_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753465_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 753465_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 731.43 67.6 999999999 655.15 1049.54 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 753471_1 CDM 0402 RC 76830 HCPCS inpatient 585 380.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 380.25 65 999999999 354.22 567.45 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 753471_1 CDM 0402 RC 76830 HCPCS inpatient 585 380.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 567.45 97 999999999 354.22 567.45 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 753471_1 CDM 0402 RC 76830 HCPCS inpatient 585 380.25 AETNA AETNA 462.15 79 999999999 354.22 567.45 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 753471_1 CDM 0402 RC 76830 HCPCS inpatient 585 380.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 403.65 69 999999999 354.22 567.45 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 753471_1 CDM 0402 RC 76830 HCPCS inpatient 585 380.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 456.3 78 999999999 354.22 567.45 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 753471_1 CDM 0402 RC 76830 HCPCS inpatient 585 380.25 SIHO - ALL PLANS SIHO - ALL PLANS 526.5 90 999999999 354.22 567.45 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 753471_1 CDM 0402 RC 76830 HCPCS inpatient 585 380.25 UMR - ALL PLANS UMR - ALL PLANS 409.5 70 999999999 354.22 567.45 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 753471_1 CDM 0402 RC 76830 HCPCS inpatient 585 380.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 354.22 567.45 "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 753471_1 CDM 0402 RC 76830 HCPCS inpatient 585 380.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 354.22 60.55 999999999 354.22 567.45 percent of total billed charges "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 753471_1 CDM 0402 RC 76830 HCPCS inpatient 585 380.25 ANTHEM HMO ANTHEM HMO 999999999 354.22 567.45 "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 753471_1 CDM 0402 RC 76830 HCPCS inpatient 585 380.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 354.22 567.45 "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 753471_1 CDM 0402 RC 76830 HCPCS inpatient 585 380.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 354.22 567.45 "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 753471_1 CDM 0402 RC 76830 HCPCS inpatient 585 380.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 354.22 567.45 "Ultrasound scan of uterus, ovaries, tubes, cervix and pelvic area through vagina" 753471_1 CDM 0402 RC 76830 HCPCS inpatient 585 380.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 395.46 67.6 999999999 354.22 567.45 percent of total billed charges Complete ultrasound study of arm and leg arteries 753473_1 CDM 0402 RC 93923 HCPCS inpatient 2515 1634.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1634.75 65 999999999 1522.83 2439.55 percent of total billed charges Complete ultrasound study of arm and leg arteries 753473_1 CDM 0402 RC 93923 HCPCS inpatient 2515 1634.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2439.55 97 999999999 1522.83 2439.55 percent of total billed charges Complete ultrasound study of arm and leg arteries 753473_1 CDM 0402 RC 93923 HCPCS inpatient 2515 1634.75 AETNA AETNA 1986.85 79 999999999 1522.83 2439.55 percent of total billed charges Complete ultrasound study of arm and leg arteries 753473_1 CDM 0402 RC 93923 HCPCS inpatient 2515 1634.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1735.35 69 999999999 1522.83 2439.55 percent of total billed charges Complete ultrasound study of arm and leg arteries 753473_1 CDM 0402 RC 93923 HCPCS inpatient 2515 1634.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1961.7 78 999999999 1522.83 2439.55 percent of total billed charges Complete ultrasound study of arm and leg arteries 753473_1 CDM 0402 RC 93923 HCPCS inpatient 2515 1634.75 SIHO - ALL PLANS SIHO - ALL PLANS 2263.5 90 999999999 1522.83 2439.55 percent of total billed charges Complete ultrasound study of arm and leg arteries 753473_1 CDM 0402 RC 93923 HCPCS inpatient 2515 1634.75 UMR - ALL PLANS UMR - ALL PLANS 1760.5 70 999999999 1522.83 2439.55 percent of total billed charges Complete ultrasound study of arm and leg arteries 753473_1 CDM 0402 RC 93923 HCPCS inpatient 2515 1634.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1522.83 2439.55 Complete ultrasound study of arm and leg arteries 753473_1 CDM 0402 RC 93923 HCPCS inpatient 2515 1634.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1522.83 60.55 999999999 1522.83 2439.55 percent of total billed charges Complete ultrasound study of arm and leg arteries 753473_1 CDM 0402 RC 93923 HCPCS inpatient 2515 1634.75 ANTHEM HMO ANTHEM HMO 999999999 1522.83 2439.55 Complete ultrasound study of arm and leg arteries 753473_1 CDM 0402 RC 93923 HCPCS inpatient 2515 1634.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1522.83 2439.55 Complete ultrasound study of arm and leg arteries 753473_1 CDM 0402 RC 93923 HCPCS inpatient 2515 1634.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1522.83 2439.55 Complete ultrasound study of arm and leg arteries 753473_1 CDM 0402 RC 93923 HCPCS inpatient 2515 1634.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1522.83 2439.55 Complete ultrasound study of arm and leg arteries 753473_1 CDM 0402 RC 93923 HCPCS inpatient 2515 1634.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1700.14 67.6 999999999 1522.83 2439.55 percent of total billed charges Ultrasound study of arm and leg arteries 753475_1 CDM 0402 RC 93922 HCPCS inpatient 578 375.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 375.7 65 999999999 349.98 560.66 percent of total billed charges Ultrasound study of arm and leg arteries 753475_1 CDM 0402 RC 93922 HCPCS inpatient 578 375.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 560.66 97 999999999 349.98 560.66 percent of total billed charges Ultrasound study of arm and leg arteries 753475_1 CDM 0402 RC 93922 HCPCS inpatient 578 375.7 AETNA AETNA 456.62 79 999999999 349.98 560.66 percent of total billed charges Ultrasound study of arm and leg arteries 753475_1 CDM 0402 RC 93922 HCPCS inpatient 578 375.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 398.82 69 999999999 349.98 560.66 percent of total billed charges Ultrasound study of arm and leg arteries 753475_1 CDM 0402 RC 93922 HCPCS inpatient 578 375.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 450.84 78 999999999 349.98 560.66 percent of total billed charges Ultrasound study of arm and leg arteries 753475_1 CDM 0402 RC 93922 HCPCS inpatient 578 375.7 SIHO - ALL PLANS SIHO - ALL PLANS 520.2 90 999999999 349.98 560.66 percent of total billed charges Ultrasound study of arm and leg arteries 753475_1 CDM 0402 RC 93922 HCPCS inpatient 578 375.7 UMR - ALL PLANS UMR - ALL PLANS 404.6 70 999999999 349.98 560.66 percent of total billed charges Ultrasound study of arm and leg arteries 753475_1 CDM 0402 RC 93922 HCPCS inpatient 578 375.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 349.98 560.66 Ultrasound study of arm and leg arteries 753475_1 CDM 0402 RC 93922 HCPCS inpatient 578 375.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 349.98 60.55 999999999 349.98 560.66 percent of total billed charges Ultrasound study of arm and leg arteries 753475_1 CDM 0402 RC 93922 HCPCS inpatient 578 375.7 ANTHEM HMO ANTHEM HMO 999999999 349.98 560.66 Ultrasound study of arm and leg arteries 753475_1 CDM 0402 RC 93922 HCPCS inpatient 578 375.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 349.98 560.66 Ultrasound study of arm and leg arteries 753475_1 CDM 0402 RC 93922 HCPCS inpatient 578 375.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 349.98 560.66 Ultrasound study of arm and leg arteries 753475_1 CDM 0402 RC 93922 HCPCS inpatient 578 375.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 349.98 560.66 Ultrasound study of arm and leg arteries 753475_1 CDM 0402 RC 93922 HCPCS inpatient 578 375.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 390.73 67.6 999999999 349.98 560.66 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753483_1 CDM 0402 RC 93970 HCPCS inpatient 2809 1825.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1825.85 65 999999999 1700.85 2724.73 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753483_1 CDM 0402 RC 93970 HCPCS inpatient 2809 1825.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2724.73 97 999999999 1700.85 2724.73 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753483_1 CDM 0402 RC 93970 HCPCS inpatient 2809 1825.85 AETNA AETNA 2219.11 79 999999999 1700.85 2724.73 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753483_1 CDM 0402 RC 93970 HCPCS inpatient 2809 1825.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1938.21 69 999999999 1700.85 2724.73 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753483_1 CDM 0402 RC 93970 HCPCS inpatient 2809 1825.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 2191.02 78 999999999 1700.85 2724.73 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753483_1 CDM 0402 RC 93970 HCPCS inpatient 2809 1825.85 SIHO - ALL PLANS SIHO - ALL PLANS 2528.1 90 999999999 1700.85 2724.73 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753483_1 CDM 0402 RC 93970 HCPCS inpatient 2809 1825.85 UMR - ALL PLANS UMR - ALL PLANS 1966.3 70 999999999 1700.85 2724.73 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753483_1 CDM 0402 RC 93970 HCPCS inpatient 2809 1825.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1700.85 2724.73 Ultrasound study of arm or leg veins with compression and maneuvers 753483_1 CDM 0402 RC 93970 HCPCS inpatient 2809 1825.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1700.85 60.55 999999999 1700.85 2724.73 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753483_1 CDM 0402 RC 93970 HCPCS inpatient 2809 1825.85 ANTHEM HMO ANTHEM HMO 999999999 1700.85 2724.73 Ultrasound study of arm or leg veins with compression and maneuvers 753483_1 CDM 0402 RC 93970 HCPCS inpatient 2809 1825.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1700.85 2724.73 Ultrasound study of arm or leg veins with compression and maneuvers 753483_1 CDM 0402 RC 93970 HCPCS inpatient 2809 1825.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1700.85 2724.73 Ultrasound study of arm or leg veins with compression and maneuvers 753483_1 CDM 0402 RC 93970 HCPCS inpatient 2809 1825.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1700.85 2724.73 Ultrasound study of arm or leg veins with compression and maneuvers 753483_1 CDM 0402 RC 93970 HCPCS inpatient 2809 1825.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1898.88 67.6 999999999 1700.85 2724.73 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753485_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1682.85 65 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753485_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2511.33 97 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753485_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 AETNA AETNA 2045.31 79 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753485_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1786.41 69 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753485_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 2019.42 78 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753485_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 SIHO - ALL PLANS SIHO - ALL PLANS 2330.1 90 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753485_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 UMR - ALL PLANS UMR - ALL PLANS 1812.3 70 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753485_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 753485_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1567.64 60.55 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753485_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 ANTHEM HMO ANTHEM HMO 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 753485_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 753485_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 753485_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 753485_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1750.16 67.6 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753487_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1682.85 65 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753487_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2511.33 97 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753487_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 AETNA AETNA 2045.31 79 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753487_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1786.41 69 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753487_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 2019.42 78 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753487_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 SIHO - ALL PLANS SIHO - ALL PLANS 2330.1 90 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753487_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 UMR - ALL PLANS UMR - ALL PLANS 1812.3 70 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753487_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 753487_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1567.64 60.55 999999999 1567.64 2511.33 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 753487_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 ANTHEM HMO ANTHEM HMO 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 753487_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 753487_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 753487_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1567.64 2511.33 Ultrasound study of arm or leg veins with compression and maneuvers 753487_1 CDM 0402 RC 93970 HCPCS inpatient 2589 1682.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1750.16 67.6 999999999 1567.64 2511.33 percent of total billed charges X-ray of both collar bones joints 753491_1 CDM 0320 RC 73050 HCPCS inpatient 403 261.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 261.95 65 999999999 244.02 390.91 percent of total billed charges X-ray of both collar bones joints 753491_1 CDM 0320 RC 73050 HCPCS inpatient 403 261.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 390.91 97 999999999 244.02 390.91 percent of total billed charges X-ray of both collar bones joints 753491_1 CDM 0320 RC 73050 HCPCS inpatient 403 261.95 AETNA AETNA 318.37 79 999999999 244.02 390.91 percent of total billed charges X-ray of both collar bones joints 753491_1 CDM 0320 RC 73050 HCPCS inpatient 403 261.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 278.07 69 999999999 244.02 390.91 percent of total billed charges X-ray of both collar bones joints 753491_1 CDM 0320 RC 73050 HCPCS inpatient 403 261.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 314.34 78 999999999 244.02 390.91 percent of total billed charges X-ray of both collar bones joints 753491_1 CDM 0320 RC 73050 HCPCS inpatient 403 261.95 SIHO - ALL PLANS SIHO - ALL PLANS 362.7 90 999999999 244.02 390.91 percent of total billed charges X-ray of both collar bones joints 753491_1 CDM 0320 RC 73050 HCPCS inpatient 403 261.95 UMR - ALL PLANS UMR - ALL PLANS 282.1 70 999999999 244.02 390.91 percent of total billed charges X-ray of both collar bones joints 753491_1 CDM 0320 RC 73050 HCPCS inpatient 403 261.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 244.02 390.91 X-ray of both collar bones joints 753491_1 CDM 0320 RC 73050 HCPCS inpatient 403 261.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 244.02 60.55 999999999 244.02 390.91 percent of total billed charges X-ray of both collar bones joints 753491_1 CDM 0320 RC 73050 HCPCS inpatient 403 261.95 ANTHEM HMO ANTHEM HMO 999999999 244.02 390.91 X-ray of both collar bones joints 753491_1 CDM 0320 RC 73050 HCPCS inpatient 403 261.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 244.02 390.91 X-ray of both collar bones joints 753491_1 CDM 0320 RC 73050 HCPCS inpatient 403 261.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 244.02 390.91 X-ray of both collar bones joints 753491_1 CDM 0320 RC 73050 HCPCS inpatient 403 261.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 244.02 390.91 X-ray of both collar bones joints 753491_1 CDM 0320 RC 73050 HCPCS inpatient 403 261.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 272.43 67.6 999999999 244.02 390.91 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 753493_1 CDM 0320 RC 74021 HCPCS inpatient 749 486.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 486.85 65 999999999 453.52 726.53 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 753493_1 CDM 0320 RC 74021 HCPCS inpatient 749 486.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 726.53 97 999999999 453.52 726.53 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 753493_1 CDM 0320 RC 74021 HCPCS inpatient 749 486.85 AETNA AETNA 591.71 79 999999999 453.52 726.53 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 753493_1 CDM 0320 RC 74021 HCPCS inpatient 749 486.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 516.81 69 999999999 453.52 726.53 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 753493_1 CDM 0320 RC 74021 HCPCS inpatient 749 486.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 584.22 78 999999999 453.52 726.53 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 753493_1 CDM 0320 RC 74021 HCPCS inpatient 749 486.85 SIHO - ALL PLANS SIHO - ALL PLANS 674.1 90 999999999 453.52 726.53 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 753493_1 CDM 0320 RC 74021 HCPCS inpatient 749 486.85 UMR - ALL PLANS UMR - ALL PLANS 524.3 70 999999999 453.52 726.53 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 753493_1 CDM 0320 RC 74021 HCPCS inpatient 749 486.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 453.52 726.53 "X-ray of abdomen, minimum of 3 views" 753493_1 CDM 0320 RC 74021 HCPCS inpatient 749 486.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 453.52 60.55 999999999 453.52 726.53 percent of total billed charges "X-ray of abdomen, minimum of 3 views" 753493_1 CDM 0320 RC 74021 HCPCS inpatient 749 486.85 ANTHEM HMO ANTHEM HMO 999999999 453.52 726.53 "X-ray of abdomen, minimum of 3 views" 753493_1 CDM 0320 RC 74021 HCPCS inpatient 749 486.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 453.52 726.53 "X-ray of abdomen, minimum of 3 views" 753493_1 CDM 0320 RC 74021 HCPCS inpatient 749 486.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 453.52 726.53 "X-ray of abdomen, minimum of 3 views" 753493_1 CDM 0320 RC 74021 HCPCS inpatient 749 486.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 453.52 726.53 "X-ray of abdomen, minimum of 3 views" 753493_1 CDM 0320 RC 74021 HCPCS inpatient 749 486.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 506.32 67.6 999999999 453.52 726.53 percent of total billed charges "X-ray of ankle, 2 views" 753509_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 233.35 65 999999999 217.37 348.23 percent of total billed charges "X-ray of ankle, 2 views" 753509_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 348.23 97 999999999 217.37 348.23 percent of total billed charges "X-ray of ankle, 2 views" 753509_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 AETNA AETNA 283.61 79 999999999 217.37 348.23 percent of total billed charges "X-ray of ankle, 2 views" 753509_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 247.71 69 999999999 217.37 348.23 percent of total billed charges "X-ray of ankle, 2 views" 753509_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 280.02 78 999999999 217.37 348.23 percent of total billed charges "X-ray of ankle, 2 views" 753509_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 SIHO - ALL PLANS SIHO - ALL PLANS 323.1 90 999999999 217.37 348.23 percent of total billed charges "X-ray of ankle, 2 views" 753509_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 UMR - ALL PLANS UMR - ALL PLANS 251.3 70 999999999 217.37 348.23 percent of total billed charges "X-ray of ankle, 2 views" 753509_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 217.37 348.23 "X-ray of ankle, 2 views" 753509_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 217.37 60.55 999999999 217.37 348.23 percent of total billed charges "X-ray of ankle, 2 views" 753509_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 ANTHEM HMO ANTHEM HMO 999999999 217.37 348.23 "X-ray of ankle, 2 views" 753509_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 217.37 348.23 "X-ray of ankle, 2 views" 753509_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 217.37 348.23 "X-ray of ankle, 2 views" 753509_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 217.37 348.23 "X-ray of ankle, 2 views" 753509_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 242.68 67.6 999999999 217.37 348.23 percent of total billed charges "X-ray of ankle, 2 views" 753511_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 233.35 65 999999999 217.37 348.23 percent of total billed charges "X-ray of ankle, 2 views" 753511_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 348.23 97 999999999 217.37 348.23 percent of total billed charges "X-ray of ankle, 2 views" 753511_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 AETNA AETNA 283.61 79 999999999 217.37 348.23 percent of total billed charges "X-ray of ankle, 2 views" 753511_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 247.71 69 999999999 217.37 348.23 percent of total billed charges "X-ray of ankle, 2 views" 753511_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 280.02 78 999999999 217.37 348.23 percent of total billed charges "X-ray of ankle, 2 views" 753511_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 SIHO - ALL PLANS SIHO - ALL PLANS 323.1 90 999999999 217.37 348.23 percent of total billed charges "X-ray of ankle, 2 views" 753511_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 UMR - ALL PLANS UMR - ALL PLANS 251.3 70 999999999 217.37 348.23 percent of total billed charges "X-ray of ankle, 2 views" 753511_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 217.37 348.23 "X-ray of ankle, 2 views" 753511_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 217.37 60.55 999999999 217.37 348.23 percent of total billed charges "X-ray of ankle, 2 views" 753511_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 ANTHEM HMO ANTHEM HMO 999999999 217.37 348.23 "X-ray of ankle, 2 views" 753511_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 217.37 348.23 "X-ray of ankle, 2 views" 753511_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 217.37 348.23 "X-ray of ankle, 2 views" 753511_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 217.37 348.23 "X-ray of ankle, 2 views" 753511_1 CDM 0320 RC 73600 HCPCS inpatient 359 233.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 242.68 67.6 999999999 217.37 348.23 percent of total billed charges "X-ray of ankle, minimum of 3 views" 753515_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges "X-ray of ankle, minimum of 3 views" 753515_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges "X-ray of ankle, minimum of 3 views" 753515_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges "X-ray of ankle, minimum of 3 views" 753515_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges "X-ray of ankle, minimum of 3 views" 753515_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges "X-ray of ankle, minimum of 3 views" 753515_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges "X-ray of ankle, minimum of 3 views" 753515_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges "X-ray of ankle, minimum of 3 views" 753515_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 "X-ray of ankle, minimum of 3 views" 753515_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges "X-ray of ankle, minimum of 3 views" 753515_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 "X-ray of ankle, minimum of 3 views" 753515_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 "X-ray of ankle, minimum of 3 views" 753515_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 "X-ray of ankle, minimum of 3 views" 753515_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 "X-ray of ankle, minimum of 3 views" 753515_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges "X-ray of ankle, minimum of 3 views" 753517_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges "X-ray of ankle, minimum of 3 views" 753517_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges "X-ray of ankle, minimum of 3 views" 753517_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges "X-ray of ankle, minimum of 3 views" 753517_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges "X-ray of ankle, minimum of 3 views" 753517_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges "X-ray of ankle, minimum of 3 views" 753517_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges "X-ray of ankle, minimum of 3 views" 753517_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges "X-ray of ankle, minimum of 3 views" 753517_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 "X-ray of ankle, minimum of 3 views" 753517_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges "X-ray of ankle, minimum of 3 views" 753517_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 "X-ray of ankle, minimum of 3 views" 753517_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 "X-ray of ankle, minimum of 3 views" 753517_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 "X-ray of ankle, minimum of 3 views" 753517_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 "X-ray of ankle, minimum of 3 views" 753517_1 CDM 0320 RC 73610 HCPCS inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges Review by radiologist of ankle joint image 753521_1 CDM 0322 RC 73615 HCPCS inpatient 1083 703.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 703.95 65 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of ankle joint image 753521_1 CDM 0322 RC 73615 HCPCS inpatient 1083 703.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1050.51 97 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of ankle joint image 753521_1 CDM 0322 RC 73615 HCPCS inpatient 1083 703.95 AETNA AETNA 855.57 79 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of ankle joint image 753521_1 CDM 0322 RC 73615 HCPCS inpatient 1083 703.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 747.27 69 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of ankle joint image 753521_1 CDM 0322 RC 73615 HCPCS inpatient 1083 703.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 844.74 78 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of ankle joint image 753521_1 CDM 0322 RC 73615 HCPCS inpatient 1083 703.95 SIHO - ALL PLANS SIHO - ALL PLANS 974.7 90 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of ankle joint image 753521_1 CDM 0322 RC 73615 HCPCS inpatient 1083 703.95 UMR - ALL PLANS UMR - ALL PLANS 758.1 70 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of ankle joint image 753521_1 CDM 0322 RC 73615 HCPCS inpatient 1083 703.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 655.76 1050.51 Review by radiologist of ankle joint image 753521_1 CDM 0322 RC 73615 HCPCS inpatient 1083 703.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 655.76 60.55 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of ankle joint image 753521_1 CDM 0322 RC 73615 HCPCS inpatient 1083 703.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 655.76 1050.51 Review by radiologist of ankle joint image 753521_1 CDM 0322 RC 73615 HCPCS inpatient 1083 703.95 ANTHEM HMO ANTHEM HMO 999999999 655.76 1050.51 Review by radiologist of ankle joint image 753521_1 CDM 0322 RC 73615 HCPCS inpatient 1083 703.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 655.76 1050.51 Review by radiologist of ankle joint image 753521_1 CDM 0322 RC 73615 HCPCS inpatient 1083 703.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 655.76 1050.51 Review by radiologist of ankle joint image 753521_1 CDM 0322 RC 73615 HCPCS inpatient 1083 703.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 732.11 67.6 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of ankle joint image 753523_1 CDM 0320 RC 73615 HCPCS inpatient 1083 703.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 703.95 65 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of ankle joint image 753523_1 CDM 0320 RC 73615 HCPCS inpatient 1083 703.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1050.51 97 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of ankle joint image 753523_1 CDM 0320 RC 73615 HCPCS inpatient 1083 703.95 AETNA AETNA 855.57 79 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of ankle joint image 753523_1 CDM 0320 RC 73615 HCPCS inpatient 1083 703.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 747.27 69 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of ankle joint image 753523_1 CDM 0320 RC 73615 HCPCS inpatient 1083 703.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 844.74 78 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of ankle joint image 753523_1 CDM 0320 RC 73615 HCPCS inpatient 1083 703.95 SIHO - ALL PLANS SIHO - ALL PLANS 974.7 90 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of ankle joint image 753523_1 CDM 0320 RC 73615 HCPCS inpatient 1083 703.95 UMR - ALL PLANS UMR - ALL PLANS 758.1 70 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of ankle joint image 753523_1 CDM 0320 RC 73615 HCPCS inpatient 1083 703.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 655.76 1050.51 Review by radiologist of ankle joint image 753523_1 CDM 0320 RC 73615 HCPCS inpatient 1083 703.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 655.76 60.55 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of ankle joint image 753523_1 CDM 0320 RC 73615 HCPCS inpatient 1083 703.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 655.76 1050.51 Review by radiologist of ankle joint image 753523_1 CDM 0320 RC 73615 HCPCS inpatient 1083 703.95 ANTHEM HMO ANTHEM HMO 999999999 655.76 1050.51 Review by radiologist of ankle joint image 753523_1 CDM 0320 RC 73615 HCPCS inpatient 1083 703.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 655.76 1050.51 Review by radiologist of ankle joint image 753523_1 CDM 0320 RC 73615 HCPCS inpatient 1083 703.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 655.76 1050.51 Review by radiologist of ankle joint image 753523_1 CDM 0320 RC 73615 HCPCS inpatient 1083 703.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 732.11 67.6 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of elbow image 753525_1 CDM 0320 RC 73085 HCPCS inpatient 2134 1387.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 1387.1 65 999999999 1292.14 2069.98 percent of total billed charges Review by radiologist of elbow image 753525_1 CDM 0320 RC 73085 HCPCS inpatient 2134 1387.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2069.98 97 999999999 1292.14 2069.98 percent of total billed charges Review by radiologist of elbow image 753525_1 CDM 0320 RC 73085 HCPCS inpatient 2134 1387.1 AETNA AETNA 1685.86 79 999999999 1292.14 2069.98 percent of total billed charges Review by radiologist of elbow image 753525_1 CDM 0320 RC 73085 HCPCS inpatient 2134 1387.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 1472.46 69 999999999 1292.14 2069.98 percent of total billed charges Review by radiologist of elbow image 753525_1 CDM 0320 RC 73085 HCPCS inpatient 2134 1387.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1664.52 78 999999999 1292.14 2069.98 percent of total billed charges Review by radiologist of elbow image 753525_1 CDM 0320 RC 73085 HCPCS inpatient 2134 1387.1 SIHO - ALL PLANS SIHO - ALL PLANS 1920.6 90 999999999 1292.14 2069.98 percent of total billed charges Review by radiologist of elbow image 753525_1 CDM 0320 RC 73085 HCPCS inpatient 2134 1387.1 UMR - ALL PLANS UMR - ALL PLANS 1493.8 70 999999999 1292.14 2069.98 percent of total billed charges Review by radiologist of elbow image 753525_1 CDM 0320 RC 73085 HCPCS inpatient 2134 1387.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1292.14 2069.98 Review by radiologist of elbow image 753525_1 CDM 0320 RC 73085 HCPCS inpatient 2134 1387.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1292.14 60.55 999999999 1292.14 2069.98 percent of total billed charges Review by radiologist of elbow image 753525_1 CDM 0320 RC 73085 HCPCS inpatient 2134 1387.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1292.14 2069.98 Review by radiologist of elbow image 753525_1 CDM 0320 RC 73085 HCPCS inpatient 2134 1387.1 ANTHEM HMO ANTHEM HMO 999999999 1292.14 2069.98 Review by radiologist of elbow image 753525_1 CDM 0320 RC 73085 HCPCS inpatient 2134 1387.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1292.14 2069.98 Review by radiologist of elbow image 753525_1 CDM 0320 RC 73085 HCPCS inpatient 2134 1387.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1292.14 2069.98 Review by radiologist of elbow image 753525_1 CDM 0320 RC 73085 HCPCS inpatient 2134 1387.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 1442.58 67.6 999999999 1292.14 2069.98 percent of total billed charges Review by radiologist of elbow image 753527_1 CDM 0322 RC 73085 HCPCS inpatient 1083 703.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 703.95 65 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of elbow image 753527_1 CDM 0322 RC 73085 HCPCS inpatient 1083 703.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1050.51 97 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of elbow image 753527_1 CDM 0322 RC 73085 HCPCS inpatient 1083 703.95 AETNA AETNA 855.57 79 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of elbow image 753527_1 CDM 0322 RC 73085 HCPCS inpatient 1083 703.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 747.27 69 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of elbow image 753527_1 CDM 0322 RC 73085 HCPCS inpatient 1083 703.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 844.74 78 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of elbow image 753527_1 CDM 0322 RC 73085 HCPCS inpatient 1083 703.95 SIHO - ALL PLANS SIHO - ALL PLANS 974.7 90 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of elbow image 753527_1 CDM 0322 RC 73085 HCPCS inpatient 1083 703.95 UMR - ALL PLANS UMR - ALL PLANS 758.1 70 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of elbow image 753527_1 CDM 0322 RC 73085 HCPCS inpatient 1083 703.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 655.76 1050.51 Review by radiologist of elbow image 753527_1 CDM 0322 RC 73085 HCPCS inpatient 1083 703.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 655.76 60.55 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of elbow image 753527_1 CDM 0322 RC 73085 HCPCS inpatient 1083 703.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 655.76 1050.51 Review by radiologist of elbow image 753527_1 CDM 0322 RC 73085 HCPCS inpatient 1083 703.95 ANTHEM HMO ANTHEM HMO 999999999 655.76 1050.51 Review by radiologist of elbow image 753527_1 CDM 0322 RC 73085 HCPCS inpatient 1083 703.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 655.76 1050.51 Review by radiologist of elbow image 753527_1 CDM 0322 RC 73085 HCPCS inpatient 1083 703.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 655.76 1050.51 Review by radiologist of elbow image 753527_1 CDM 0322 RC 73085 HCPCS inpatient 1083 703.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 732.11 67.6 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of elbow image 753529_1 CDM 0320 RC 73085 HCPCS inpatient 1083 703.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 703.95 65 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of elbow image 753529_1 CDM 0320 RC 73085 HCPCS inpatient 1083 703.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1050.51 97 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of elbow image 753529_1 CDM 0320 RC 73085 HCPCS inpatient 1083 703.95 AETNA AETNA 855.57 79 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of elbow image 753529_1 CDM 0320 RC 73085 HCPCS inpatient 1083 703.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 747.27 69 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of elbow image 753529_1 CDM 0320 RC 73085 HCPCS inpatient 1083 703.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 844.74 78 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of elbow image 753529_1 CDM 0320 RC 73085 HCPCS inpatient 1083 703.95 SIHO - ALL PLANS SIHO - ALL PLANS 974.7 90 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of elbow image 753529_1 CDM 0320 RC 73085 HCPCS inpatient 1083 703.95 UMR - ALL PLANS UMR - ALL PLANS 758.1 70 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of elbow image 753529_1 CDM 0320 RC 73085 HCPCS inpatient 1083 703.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 655.76 1050.51 Review by radiologist of elbow image 753529_1 CDM 0320 RC 73085 HCPCS inpatient 1083 703.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 655.76 60.55 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of elbow image 753529_1 CDM 0320 RC 73085 HCPCS inpatient 1083 703.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 655.76 1050.51 Review by radiologist of elbow image 753529_1 CDM 0320 RC 73085 HCPCS inpatient 1083 703.95 ANTHEM HMO ANTHEM HMO 999999999 655.76 1050.51 Review by radiologist of elbow image 753529_1 CDM 0320 RC 73085 HCPCS inpatient 1083 703.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 655.76 1050.51 Review by radiologist of elbow image 753529_1 CDM 0320 RC 73085 HCPCS inpatient 1083 703.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 655.76 1050.51 Review by radiologist of elbow image 753529_1 CDM 0320 RC 73085 HCPCS inpatient 1083 703.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 732.11 67.6 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of hip joint image 753533_1 CDM 0322 RC 73525 HCPCS inpatient 1072 696.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 696.8 65 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 753533_1 CDM 0322 RC 73525 HCPCS inpatient 1072 696.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1039.84 97 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 753533_1 CDM 0322 RC 73525 HCPCS inpatient 1072 696.8 AETNA AETNA 846.88 79 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 753533_1 CDM 0322 RC 73525 HCPCS inpatient 1072 696.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 739.68 69 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 753533_1 CDM 0322 RC 73525 HCPCS inpatient 1072 696.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 836.16 78 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 753533_1 CDM 0322 RC 73525 HCPCS inpatient 1072 696.8 SIHO - ALL PLANS SIHO - ALL PLANS 964.8 90 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 753533_1 CDM 0322 RC 73525 HCPCS inpatient 1072 696.8 UMR - ALL PLANS UMR - ALL PLANS 750.4 70 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 753533_1 CDM 0322 RC 73525 HCPCS inpatient 1072 696.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 649.1 1039.84 Review by radiologist of hip joint image 753533_1 CDM 0322 RC 73525 HCPCS inpatient 1072 696.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 649.1 60.55 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 753533_1 CDM 0322 RC 73525 HCPCS inpatient 1072 696.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 649.1 1039.84 Review by radiologist of hip joint image 753533_1 CDM 0322 RC 73525 HCPCS inpatient 1072 696.8 ANTHEM HMO ANTHEM HMO 999999999 649.1 1039.84 Review by radiologist of hip joint image 753533_1 CDM 0322 RC 73525 HCPCS inpatient 1072 696.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 649.1 1039.84 Review by radiologist of hip joint image 753533_1 CDM 0322 RC 73525 HCPCS inpatient 1072 696.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 649.1 1039.84 Review by radiologist of hip joint image 753533_1 CDM 0322 RC 73525 HCPCS inpatient 1072 696.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 724.67 67.6 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 753535_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 696.8 65 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 753535_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1039.84 97 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 753535_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 AETNA AETNA 846.88 79 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 753535_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 739.68 69 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 753535_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 836.16 78 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 753535_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 SIHO - ALL PLANS SIHO - ALL PLANS 964.8 90 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 753535_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 UMR - ALL PLANS UMR - ALL PLANS 750.4 70 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 753535_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 649.1 1039.84 Review by radiologist of hip joint image 753535_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 649.1 60.55 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of hip joint image 753535_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 649.1 1039.84 Review by radiologist of hip joint image 753535_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 ANTHEM HMO ANTHEM HMO 999999999 649.1 1039.84 Review by radiologist of hip joint image 753535_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 649.1 1039.84 Review by radiologist of hip joint image 753535_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 649.1 1039.84 Review by radiologist of hip joint image 753535_1 CDM 0320 RC 73525 HCPCS inpatient 1072 696.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 724.67 67.6 999999999 649.1 1039.84 percent of total billed charges Review by radiologist of knee joint image 753539_1 CDM 0322 RC 73580 HCPCS inpatient 1013 658.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 658.45 65 999999999 613.37 982.61 percent of total billed charges Review by radiologist of knee joint image 753539_1 CDM 0322 RC 73580 HCPCS inpatient 1013 658.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 982.61 97 999999999 613.37 982.61 percent of total billed charges Review by radiologist of knee joint image 753539_1 CDM 0322 RC 73580 HCPCS inpatient 1013 658.45 AETNA AETNA 800.27 79 999999999 613.37 982.61 percent of total billed charges Review by radiologist of knee joint image 753539_1 CDM 0322 RC 73580 HCPCS inpatient 1013 658.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 698.97 69 999999999 613.37 982.61 percent of total billed charges Review by radiologist of knee joint image 753539_1 CDM 0322 RC 73580 HCPCS inpatient 1013 658.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 790.14 78 999999999 613.37 982.61 percent of total billed charges Review by radiologist of knee joint image 753539_1 CDM 0322 RC 73580 HCPCS inpatient 1013 658.45 SIHO - ALL PLANS SIHO - ALL PLANS 911.7 90 999999999 613.37 982.61 percent of total billed charges Review by radiologist of knee joint image 753539_1 CDM 0322 RC 73580 HCPCS inpatient 1013 658.45 UMR - ALL PLANS UMR - ALL PLANS 709.1 70 999999999 613.37 982.61 percent of total billed charges Review by radiologist of knee joint image 753539_1 CDM 0322 RC 73580 HCPCS inpatient 1013 658.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 613.37 982.61 Review by radiologist of knee joint image 753539_1 CDM 0322 RC 73580 HCPCS inpatient 1013 658.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 613.37 60.55 999999999 613.37 982.61 percent of total billed charges Review by radiologist of knee joint image 753539_1 CDM 0322 RC 73580 HCPCS inpatient 1013 658.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 613.37 982.61 Review by radiologist of knee joint image 753539_1 CDM 0322 RC 73580 HCPCS inpatient 1013 658.45 ANTHEM HMO ANTHEM HMO 999999999 613.37 982.61 Review by radiologist of knee joint image 753539_1 CDM 0322 RC 73580 HCPCS inpatient 1013 658.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 613.37 982.61 Review by radiologist of knee joint image 753539_1 CDM 0322 RC 73580 HCPCS inpatient 1013 658.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 613.37 982.61 Review by radiologist of knee joint image 753539_1 CDM 0322 RC 73580 HCPCS inpatient 1013 658.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 684.79 67.6 999999999 613.37 982.61 percent of total billed charges Review by radiologist of knee joint image 753541_1 CDM 0320 RC 73580 HCPCS inpatient 1083 703.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 703.95 65 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of knee joint image 753541_1 CDM 0320 RC 73580 HCPCS inpatient 1083 703.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1050.51 97 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of knee joint image 753541_1 CDM 0320 RC 73580 HCPCS inpatient 1083 703.95 AETNA AETNA 855.57 79 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of knee joint image 753541_1 CDM 0320 RC 73580 HCPCS inpatient 1083 703.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 747.27 69 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of knee joint image 753541_1 CDM 0320 RC 73580 HCPCS inpatient 1083 703.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 844.74 78 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of knee joint image 753541_1 CDM 0320 RC 73580 HCPCS inpatient 1083 703.95 SIHO - ALL PLANS SIHO - ALL PLANS 974.7 90 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of knee joint image 753541_1 CDM 0320 RC 73580 HCPCS inpatient 1083 703.95 UMR - ALL PLANS UMR - ALL PLANS 758.1 70 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of knee joint image 753541_1 CDM 0320 RC 73580 HCPCS inpatient 1083 703.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 655.76 1050.51 Review by radiologist of knee joint image 753541_1 CDM 0320 RC 73580 HCPCS inpatient 1083 703.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 655.76 60.55 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of knee joint image 753541_1 CDM 0320 RC 73580 HCPCS inpatient 1083 703.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 655.76 1050.51 Review by radiologist of knee joint image 753541_1 CDM 0320 RC 73580 HCPCS inpatient 1083 703.95 ANTHEM HMO ANTHEM HMO 999999999 655.76 1050.51 Review by radiologist of knee joint image 753541_1 CDM 0320 RC 73580 HCPCS inpatient 1083 703.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 655.76 1050.51 Review by radiologist of knee joint image 753541_1 CDM 0320 RC 73580 HCPCS inpatient 1083 703.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 655.76 1050.51 Review by radiologist of knee joint image 753541_1 CDM 0320 RC 73580 HCPCS inpatient 1083 703.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 732.11 67.6 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of shoulder joint image 753547_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1526.85 65 999999999 1422.32 2278.53 percent of total billed charges Review by radiologist of shoulder joint image 753547_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2278.53 97 999999999 1422.32 2278.53 percent of total billed charges Review by radiologist of shoulder joint image 753547_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 AETNA AETNA 1855.71 79 999999999 1422.32 2278.53 percent of total billed charges Review by radiologist of shoulder joint image 753547_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1620.81 69 999999999 1422.32 2278.53 percent of total billed charges Review by radiologist of shoulder joint image 753547_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1832.22 78 999999999 1422.32 2278.53 percent of total billed charges Review by radiologist of shoulder joint image 753547_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 SIHO - ALL PLANS SIHO - ALL PLANS 2114.1 90 999999999 1422.32 2278.53 percent of total billed charges Review by radiologist of shoulder joint image 753547_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 UMR - ALL PLANS UMR - ALL PLANS 1644.3 70 999999999 1422.32 2278.53 percent of total billed charges Review by radiologist of shoulder joint image 753547_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1422.32 2278.53 Review by radiologist of shoulder joint image 753547_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1422.32 60.55 999999999 1422.32 2278.53 percent of total billed charges Review by radiologist of shoulder joint image 753547_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1422.32 2278.53 Review by radiologist of shoulder joint image 753547_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 ANTHEM HMO ANTHEM HMO 999999999 1422.32 2278.53 Review by radiologist of shoulder joint image 753547_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1422.32 2278.53 Review by radiologist of shoulder joint image 753547_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1422.32 2278.53 Review by radiologist of shoulder joint image 753547_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1587.92 67.6 999999999 1422.32 2278.53 percent of total billed charges Review by radiologist of shoulder joint image 753549_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1526.85 65 999999999 1422.32 2278.53 percent of total billed charges Review by radiologist of shoulder joint image 753549_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2278.53 97 999999999 1422.32 2278.53 percent of total billed charges Review by radiologist of shoulder joint image 753549_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 AETNA AETNA 1855.71 79 999999999 1422.32 2278.53 percent of total billed charges Review by radiologist of shoulder joint image 753549_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1620.81 69 999999999 1422.32 2278.53 percent of total billed charges Review by radiologist of shoulder joint image 753549_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1832.22 78 999999999 1422.32 2278.53 percent of total billed charges Review by radiologist of shoulder joint image 753549_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 SIHO - ALL PLANS SIHO - ALL PLANS 2114.1 90 999999999 1422.32 2278.53 percent of total billed charges Review by radiologist of shoulder joint image 753549_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 UMR - ALL PLANS UMR - ALL PLANS 1644.3 70 999999999 1422.32 2278.53 percent of total billed charges Review by radiologist of shoulder joint image 753549_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1422.32 2278.53 Review by radiologist of shoulder joint image 753549_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1422.32 60.55 999999999 1422.32 2278.53 percent of total billed charges Review by radiologist of shoulder joint image 753549_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1422.32 2278.53 Review by radiologist of shoulder joint image 753549_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 ANTHEM HMO ANTHEM HMO 999999999 1422.32 2278.53 Review by radiologist of shoulder joint image 753549_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1422.32 2278.53 Review by radiologist of shoulder joint image 753549_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1422.32 2278.53 Review by radiologist of shoulder joint image 753549_1 CDM 0322 RC 73040 HCPCS inpatient 2349 1526.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1587.92 67.6 999999999 1422.32 2278.53 percent of total billed charges Review by radiologist of wrist joint image 753553_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 703.95 65 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of wrist joint image 753553_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1050.51 97 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of wrist joint image 753553_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 AETNA AETNA 855.57 79 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of wrist joint image 753553_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 747.27 69 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of wrist joint image 753553_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 844.74 78 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of wrist joint image 753553_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 SIHO - ALL PLANS SIHO - ALL PLANS 974.7 90 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of wrist joint image 753553_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 UMR - ALL PLANS UMR - ALL PLANS 758.1 70 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of wrist joint image 753553_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 655.76 1050.51 Review by radiologist of wrist joint image 753553_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 655.76 60.55 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of wrist joint image 753553_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 655.76 1050.51 Review by radiologist of wrist joint image 753553_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 ANTHEM HMO ANTHEM HMO 999999999 655.76 1050.51 Review by radiologist of wrist joint image 753553_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 655.76 1050.51 Review by radiologist of wrist joint image 753553_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 655.76 1050.51 Review by radiologist of wrist joint image 753553_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 732.11 67.6 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of wrist joint image 753555_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 703.95 65 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of wrist joint image 753555_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1050.51 97 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of wrist joint image 753555_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 AETNA AETNA 855.57 79 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of wrist joint image 753555_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 747.27 69 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of wrist joint image 753555_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 844.74 78 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of wrist joint image 753555_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 SIHO - ALL PLANS SIHO - ALL PLANS 974.7 90 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of wrist joint image 753555_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 UMR - ALL PLANS UMR - ALL PLANS 758.1 70 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of wrist joint image 753555_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 655.76 1050.51 Review by radiologist of wrist joint image 753555_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 655.76 60.55 999999999 655.76 1050.51 percent of total billed charges Review by radiologist of wrist joint image 753555_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 655.76 1050.51 Review by radiologist of wrist joint image 753555_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 ANTHEM HMO ANTHEM HMO 999999999 655.76 1050.51 Review by radiologist of wrist joint image 753555_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 655.76 1050.51 Review by radiologist of wrist joint image 753555_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 655.76 1050.51 Review by radiologist of wrist joint image 753555_1 CDM 0322 RC 73115 HCPCS inpatient 1083 703.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 732.11 67.6 999999999 655.76 1050.51 percent of total billed charges Imaging for evaluation of swallowing function 753557_1 CDM 0320 RC 74230 HCPCS inpatient 550 357.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 357.5 65 999999999 333.03 533.5 percent of total billed charges Imaging for evaluation of swallowing function 753557_1 CDM 0320 RC 74230 HCPCS inpatient 550 357.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 533.5 97 999999999 333.03 533.5 percent of total billed charges Imaging for evaluation of swallowing function 753557_1 CDM 0320 RC 74230 HCPCS inpatient 550 357.5 AETNA AETNA 434.5 79 999999999 333.03 533.5 percent of total billed charges Imaging for evaluation of swallowing function 753557_1 CDM 0320 RC 74230 HCPCS inpatient 550 357.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 379.5 69 999999999 333.03 533.5 percent of total billed charges Imaging for evaluation of swallowing function 753557_1 CDM 0320 RC 74230 HCPCS inpatient 550 357.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 429 78 999999999 333.03 533.5 percent of total billed charges Imaging for evaluation of swallowing function 753557_1 CDM 0320 RC 74230 HCPCS inpatient 550 357.5 SIHO - ALL PLANS SIHO - ALL PLANS 495 90 999999999 333.03 533.5 percent of total billed charges Imaging for evaluation of swallowing function 753557_1 CDM 0320 RC 74230 HCPCS inpatient 550 357.5 UMR - ALL PLANS UMR - ALL PLANS 385 70 999999999 333.03 533.5 percent of total billed charges Imaging for evaluation of swallowing function 753557_1 CDM 0320 RC 74230 HCPCS inpatient 550 357.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 333.03 533.5 Imaging for evaluation of swallowing function 753557_1 CDM 0320 RC 74230 HCPCS inpatient 550 357.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 333.03 60.55 999999999 333.03 533.5 percent of total billed charges Imaging for evaluation of swallowing function 753557_1 CDM 0320 RC 74230 HCPCS inpatient 550 357.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 333.03 533.5 Imaging for evaluation of swallowing function 753557_1 CDM 0320 RC 74230 HCPCS inpatient 550 357.5 ANTHEM HMO ANTHEM HMO 999999999 333.03 533.5 Imaging for evaluation of swallowing function 753557_1 CDM 0320 RC 74230 HCPCS inpatient 550 357.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 333.03 533.5 Imaging for evaluation of swallowing function 753557_1 CDM 0320 RC 74230 HCPCS inpatient 550 357.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 333.03 533.5 Imaging for evaluation of swallowing function 753557_1 CDM 0320 RC 74230 HCPCS inpatient 550 357.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 371.8 67.6 999999999 333.03 533.5 percent of total billed charges "COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY, BARIUM ENEMA" 753560_1 CDM 0320 RC G0106 HCPCS inpatient 961 624.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 624.65 65 999999999 581.89 932.17 percent of total billed charges "COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY, BARIUM ENEMA" 753560_1 CDM 0320 RC G0106 HCPCS inpatient 961 624.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 932.17 97 999999999 581.89 932.17 percent of total billed charges "COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY, BARIUM ENEMA" 753560_1 CDM 0320 RC G0106 HCPCS inpatient 961 624.65 AETNA AETNA 759.19 79 999999999 581.89 932.17 percent of total billed charges "COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY, BARIUM ENEMA" 753560_1 CDM 0320 RC G0106 HCPCS inpatient 961 624.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 663.09 69 999999999 581.89 932.17 percent of total billed charges "COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY, BARIUM ENEMA" 753560_1 CDM 0320 RC G0106 HCPCS inpatient 961 624.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 749.58 78 999999999 581.89 932.17 percent of total billed charges "COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY, BARIUM ENEMA" 753560_1 CDM 0320 RC G0106 HCPCS inpatient 961 624.65 SIHO - ALL PLANS SIHO - ALL PLANS 864.9 90 999999999 581.89 932.17 percent of total billed charges "COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY, BARIUM ENEMA" 753560_1 CDM 0320 RC G0106 HCPCS inpatient 961 624.65 UMR - ALL PLANS UMR - ALL PLANS 672.7 70 999999999 581.89 932.17 percent of total billed charges "COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY, BARIUM ENEMA" 753560_1 CDM 0320 RC G0106 HCPCS inpatient 961 624.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 581.89 932.17 "COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY, BARIUM ENEMA" 753560_1 CDM 0320 RC G0106 HCPCS inpatient 961 624.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 581.89 60.55 999999999 581.89 932.17 percent of total billed charges "COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY, BARIUM ENEMA" 753560_1 CDM 0320 RC G0106 HCPCS inpatient 961 624.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 581.89 932.17 "COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY, BARIUM ENEMA" 753560_1 CDM 0320 RC G0106 HCPCS inpatient 961 624.65 ANTHEM HMO ANTHEM HMO 999999999 581.89 932.17 "COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY, BARIUM ENEMA" 753560_1 CDM 0320 RC G0106 HCPCS inpatient 961 624.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 581.89 932.17 "COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY, BARIUM ENEMA" 753560_1 CDM 0320 RC G0106 HCPCS inpatient 961 624.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 581.89 932.17 "COLORECTAL CANCER SCREENING; ALTERNATIVE TO G0104, SCREENING SIGMOIDOSCOPY, BARIUM ENEMA" 753560_1 CDM 0320 RC G0106 HCPCS inpatient 961 624.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 649.64 67.6 999999999 581.89 932.17 percent of total billed charges X-ray for estimating bone age 753568_1 CDM 0320 RC 77072 HCPCS inpatient 469 304.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 304.85 65 999999999 283.98 454.93 percent of total billed charges X-ray for estimating bone age 753568_1 CDM 0320 RC 77072 HCPCS inpatient 469 304.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 454.93 97 999999999 283.98 454.93 percent of total billed charges X-ray for estimating bone age 753568_1 CDM 0320 RC 77072 HCPCS inpatient 469 304.85 AETNA AETNA 370.51 79 999999999 283.98 454.93 percent of total billed charges X-ray for estimating bone age 753568_1 CDM 0320 RC 77072 HCPCS inpatient 469 304.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 323.61 69 999999999 283.98 454.93 percent of total billed charges X-ray for estimating bone age 753568_1 CDM 0320 RC 77072 HCPCS inpatient 469 304.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 365.82 78 999999999 283.98 454.93 percent of total billed charges X-ray for estimating bone age 753568_1 CDM 0320 RC 77072 HCPCS inpatient 469 304.85 SIHO - ALL PLANS SIHO - ALL PLANS 422.1 90 999999999 283.98 454.93 percent of total billed charges X-ray for estimating bone age 753568_1 CDM 0320 RC 77072 HCPCS inpatient 469 304.85 UMR - ALL PLANS UMR - ALL PLANS 328.3 70 999999999 283.98 454.93 percent of total billed charges X-ray for estimating bone age 753568_1 CDM 0320 RC 77072 HCPCS inpatient 469 304.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 283.98 454.93 X-ray for estimating bone age 753568_1 CDM 0320 RC 77072 HCPCS inpatient 469 304.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 283.98 60.55 999999999 283.98 454.93 percent of total billed charges X-ray for estimating bone age 753568_1 CDM 0320 RC 77072 HCPCS inpatient 469 304.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 283.98 454.93 X-ray for estimating bone age 753568_1 CDM 0320 RC 77072 HCPCS inpatient 469 304.85 ANTHEM HMO ANTHEM HMO 999999999 283.98 454.93 X-ray for estimating bone age 753568_1 CDM 0320 RC 77072 HCPCS inpatient 469 304.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 283.98 454.93 X-ray for estimating bone age 753568_1 CDM 0320 RC 77072 HCPCS inpatient 469 304.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 283.98 454.93 X-ray for estimating bone age 753568_1 CDM 0320 RC 77072 HCPCS inpatient 469 304.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 317.04 67.6 999999999 283.98 454.93 percent of total billed charges "X-ray of heel, minimum of 2 views" 753572_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 240.5 65 999999999 224.04 358.9 percent of total billed charges "X-ray of heel, minimum of 2 views" 753572_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 358.9 97 999999999 224.04 358.9 percent of total billed charges "X-ray of heel, minimum of 2 views" 753572_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 AETNA AETNA 292.3 79 999999999 224.04 358.9 percent of total billed charges "X-ray of heel, minimum of 2 views" 753572_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 255.3 69 999999999 224.04 358.9 percent of total billed charges "X-ray of heel, minimum of 2 views" 753572_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 288.6 78 999999999 224.04 358.9 percent of total billed charges "X-ray of heel, minimum of 2 views" 753572_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 SIHO - ALL PLANS SIHO - ALL PLANS 333 90 999999999 224.04 358.9 percent of total billed charges "X-ray of heel, minimum of 2 views" 753572_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 UMR - ALL PLANS UMR - ALL PLANS 259 70 999999999 224.04 358.9 percent of total billed charges "X-ray of heel, minimum of 2 views" 753572_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 224.04 358.9 "X-ray of heel, minimum of 2 views" 753572_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 224.04 60.55 999999999 224.04 358.9 percent of total billed charges "X-ray of heel, minimum of 2 views" 753572_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 224.04 358.9 "X-ray of heel, minimum of 2 views" 753572_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 ANTHEM HMO ANTHEM HMO 999999999 224.04 358.9 "X-ray of heel, minimum of 2 views" 753572_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 224.04 358.9 "X-ray of heel, minimum of 2 views" 753572_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 224.04 358.9 "X-ray of heel, minimum of 2 views" 753572_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 250.12 67.6 999999999 224.04 358.9 percent of total billed charges "X-ray of heel, minimum of 2 views" 753574_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 240.5 65 999999999 224.04 358.9 percent of total billed charges "X-ray of heel, minimum of 2 views" 753574_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 358.9 97 999999999 224.04 358.9 percent of total billed charges "X-ray of heel, minimum of 2 views" 753574_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 AETNA AETNA 292.3 79 999999999 224.04 358.9 percent of total billed charges "X-ray of heel, minimum of 2 views" 753574_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 255.3 69 999999999 224.04 358.9 percent of total billed charges "X-ray of heel, minimum of 2 views" 753574_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 288.6 78 999999999 224.04 358.9 percent of total billed charges "X-ray of heel, minimum of 2 views" 753574_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 SIHO - ALL PLANS SIHO - ALL PLANS 333 90 999999999 224.04 358.9 percent of total billed charges "X-ray of heel, minimum of 2 views" 753574_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 UMR - ALL PLANS UMR - ALL PLANS 259 70 999999999 224.04 358.9 percent of total billed charges "X-ray of heel, minimum of 2 views" 753574_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 224.04 358.9 "X-ray of heel, minimum of 2 views" 753574_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 224.04 60.55 999999999 224.04 358.9 percent of total billed charges "X-ray of heel, minimum of 2 views" 753574_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 224.04 358.9 "X-ray of heel, minimum of 2 views" 753574_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 ANTHEM HMO ANTHEM HMO 999999999 224.04 358.9 "X-ray of heel, minimum of 2 views" 753574_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 224.04 358.9 "X-ray of heel, minimum of 2 views" 753574_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 224.04 358.9 "X-ray of heel, minimum of 2 views" 753574_1 CDM 0320 RC 73650 HCPCS inpatient 370 240.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 250.12 67.6 999999999 224.04 358.9 percent of total billed charges "X-ray of chest, 3 views" 753576_1 CDM 0324 RC 71047 HCPCS inpatient 479 311.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 311.35 65 999999999 290.03 464.63 percent of total billed charges "X-ray of chest, 3 views" 753576_1 CDM 0324 RC 71047 HCPCS inpatient 479 311.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 464.63 97 999999999 290.03 464.63 percent of total billed charges "X-ray of chest, 3 views" 753576_1 CDM 0324 RC 71047 HCPCS inpatient 479 311.35 AETNA AETNA 378.41 79 999999999 290.03 464.63 percent of total billed charges "X-ray of chest, 3 views" 753576_1 CDM 0324 RC 71047 HCPCS inpatient 479 311.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 330.51 69 999999999 290.03 464.63 percent of total billed charges "X-ray of chest, 3 views" 753576_1 CDM 0324 RC 71047 HCPCS inpatient 479 311.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 373.62 78 999999999 290.03 464.63 percent of total billed charges "X-ray of chest, 3 views" 753576_1 CDM 0324 RC 71047 HCPCS inpatient 479 311.35 SIHO - ALL PLANS SIHO - ALL PLANS 431.1 90 999999999 290.03 464.63 percent of total billed charges "X-ray of chest, 3 views" 753576_1 CDM 0324 RC 71047 HCPCS inpatient 479 311.35 UMR - ALL PLANS UMR - ALL PLANS 335.3 70 999999999 290.03 464.63 percent of total billed charges "X-ray of chest, 3 views" 753576_1 CDM 0324 RC 71047 HCPCS inpatient 479 311.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 290.03 464.63 "X-ray of chest, 3 views" 753576_1 CDM 0324 RC 71047 HCPCS inpatient 479 311.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 290.03 60.55 999999999 290.03 464.63 percent of total billed charges "X-ray of chest, 3 views" 753576_1 CDM 0324 RC 71047 HCPCS inpatient 479 311.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 290.03 464.63 "X-ray of chest, 3 views" 753576_1 CDM 0324 RC 71047 HCPCS inpatient 479 311.35 ANTHEM HMO ANTHEM HMO 999999999 290.03 464.63 "X-ray of chest, 3 views" 753576_1 CDM 0324 RC 71047 HCPCS inpatient 479 311.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 290.03 464.63 "X-ray of chest, 3 views" 753576_1 CDM 0324 RC 71047 HCPCS inpatient 479 311.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 290.03 464.63 "X-ray of chest, 3 views" 753576_1 CDM 0324 RC 71047 HCPCS inpatient 479 311.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 323.8 67.6 999999999 290.03 464.63 percent of total billed charges "X-ray of chest, 3 views" 753578_1 CDM 0324 RC 71047 HCPCS inpatient 512 332.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 332.8 65 999999999 310.02 496.64 percent of total billed charges "X-ray of chest, 3 views" 753578_1 CDM 0324 RC 71047 HCPCS inpatient 512 332.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 496.64 97 999999999 310.02 496.64 percent of total billed charges "X-ray of chest, 3 views" 753578_1 CDM 0324 RC 71047 HCPCS inpatient 512 332.8 AETNA AETNA 404.48 79 999999999 310.02 496.64 percent of total billed charges "X-ray of chest, 3 views" 753578_1 CDM 0324 RC 71047 HCPCS inpatient 512 332.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 353.28 69 999999999 310.02 496.64 percent of total billed charges "X-ray of chest, 3 views" 753578_1 CDM 0324 RC 71047 HCPCS inpatient 512 332.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 399.36 78 999999999 310.02 496.64 percent of total billed charges "X-ray of chest, 3 views" 753578_1 CDM 0324 RC 71047 HCPCS inpatient 512 332.8 SIHO - ALL PLANS SIHO - ALL PLANS 460.8 90 999999999 310.02 496.64 percent of total billed charges "X-ray of chest, 3 views" 753578_1 CDM 0324 RC 71047 HCPCS inpatient 512 332.8 UMR - ALL PLANS UMR - ALL PLANS 358.4 70 999999999 310.02 496.64 percent of total billed charges "X-ray of chest, 3 views" 753578_1 CDM 0324 RC 71047 HCPCS inpatient 512 332.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 310.02 496.64 "X-ray of chest, 3 views" 753578_1 CDM 0324 RC 71047 HCPCS inpatient 512 332.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 310.02 60.55 999999999 310.02 496.64 percent of total billed charges "X-ray of chest, 3 views" 753578_1 CDM 0324 RC 71047 HCPCS inpatient 512 332.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 310.02 496.64 "X-ray of chest, 3 views" 753578_1 CDM 0324 RC 71047 HCPCS inpatient 512 332.8 ANTHEM HMO ANTHEM HMO 999999999 310.02 496.64 "X-ray of chest, 3 views" 753578_1 CDM 0324 RC 71047 HCPCS inpatient 512 332.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 310.02 496.64 "X-ray of chest, 3 views" 753578_1 CDM 0324 RC 71047 HCPCS inpatient 512 332.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 310.02 496.64 "X-ray of chest, 3 views" 753578_1 CDM 0324 RC 71047 HCPCS inpatient 512 332.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 346.11 67.6 999999999 310.02 496.64 percent of total billed charges "X-ray of chest, 2 views" 753583_1 CDM 0324 RC 71046 HCPCS inpatient 623 404.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 404.95 65 999999999 377.23 604.31 percent of total billed charges "X-ray of chest, 2 views" 753583_1 CDM 0324 RC 71046 HCPCS inpatient 623 404.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 604.31 97 999999999 377.23 604.31 percent of total billed charges "X-ray of chest, 2 views" 753583_1 CDM 0324 RC 71046 HCPCS inpatient 623 404.95 AETNA AETNA 492.17 79 999999999 377.23 604.31 percent of total billed charges "X-ray of chest, 2 views" 753583_1 CDM 0324 RC 71046 HCPCS inpatient 623 404.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 429.87 69 999999999 377.23 604.31 percent of total billed charges "X-ray of chest, 2 views" 753583_1 CDM 0324 RC 71046 HCPCS inpatient 623 404.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 485.94 78 999999999 377.23 604.31 percent of total billed charges "X-ray of chest, 2 views" 753583_1 CDM 0324 RC 71046 HCPCS inpatient 623 404.95 SIHO - ALL PLANS SIHO - ALL PLANS 560.7 90 999999999 377.23 604.31 percent of total billed charges "X-ray of chest, 2 views" 753583_1 CDM 0324 RC 71046 HCPCS inpatient 623 404.95 UMR - ALL PLANS UMR - ALL PLANS 436.1 70 999999999 377.23 604.31 percent of total billed charges "X-ray of chest, 2 views" 753583_1 CDM 0324 RC 71046 HCPCS inpatient 623 404.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 377.23 604.31 "X-ray of chest, 2 views" 753583_1 CDM 0324 RC 71046 HCPCS inpatient 623 404.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 377.23 60.55 999999999 377.23 604.31 percent of total billed charges "X-ray of chest, 2 views" 753583_1 CDM 0324 RC 71046 HCPCS inpatient 623 404.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 377.23 604.31 "X-ray of chest, 2 views" 753583_1 CDM 0324 RC 71046 HCPCS inpatient 623 404.95 ANTHEM HMO ANTHEM HMO 999999999 377.23 604.31 "X-ray of chest, 2 views" 753583_1 CDM 0324 RC 71046 HCPCS inpatient 623 404.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 377.23 604.31 "X-ray of chest, 2 views" 753583_1 CDM 0324 RC 71046 HCPCS inpatient 623 404.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 377.23 604.31 "X-ray of chest, 2 views" 753583_1 CDM 0324 RC 71046 HCPCS inpatient 623 404.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 421.15 67.6 999999999 377.23 604.31 percent of total billed charges "X-ray of chest, 2 views" 753585_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 432.9 65 999999999 403.26 646.02 percent of total billed charges "X-ray of chest, 2 views" 753585_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 646.02 97 999999999 403.26 646.02 percent of total billed charges "X-ray of chest, 2 views" 753585_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 AETNA AETNA 526.14 79 999999999 403.26 646.02 percent of total billed charges "X-ray of chest, 2 views" 753585_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 459.54 69 999999999 403.26 646.02 percent of total billed charges "X-ray of chest, 2 views" 753585_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 519.48 78 999999999 403.26 646.02 percent of total billed charges "X-ray of chest, 2 views" 753585_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 SIHO - ALL PLANS SIHO - ALL PLANS 599.4 90 999999999 403.26 646.02 percent of total billed charges "X-ray of chest, 2 views" 753585_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 UMR - ALL PLANS UMR - ALL PLANS 466.2 70 999999999 403.26 646.02 percent of total billed charges "X-ray of chest, 2 views" 753585_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 403.26 646.02 "X-ray of chest, 2 views" 753585_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 403.26 60.55 999999999 403.26 646.02 percent of total billed charges "X-ray of chest, 2 views" 753585_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 403.26 646.02 "X-ray of chest, 2 views" 753585_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 ANTHEM HMO ANTHEM HMO 999999999 403.26 646.02 "X-ray of chest, 2 views" 753585_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 403.26 646.02 "X-ray of chest, 2 views" 753585_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 403.26 646.02 "X-ray of chest, 2 views" 753585_1 CDM 0324 RC 71046 HCPCS inpatient 666 432.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 450.22 67.6 999999999 403.26 646.02 percent of total billed charges Simple radiation therapy planning for delivery of external radiation 753591_1 CDM 0321 RC 77306 HCPCS inpatient 471 306.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 306.15 65 999999999 285.19 456.87 percent of total billed charges Simple radiation therapy planning for delivery of external radiation 753591_1 CDM 0321 RC 77306 HCPCS inpatient 471 306.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 456.87 97 999999999 285.19 456.87 percent of total billed charges Simple radiation therapy planning for delivery of external radiation 753591_1 CDM 0321 RC 77306 HCPCS inpatient 471 306.15 AETNA AETNA 372.09 79 999999999 285.19 456.87 percent of total billed charges Simple radiation therapy planning for delivery of external radiation 753591_1 CDM 0321 RC 77306 HCPCS inpatient 471 306.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 324.99 69 999999999 285.19 456.87 percent of total billed charges Simple radiation therapy planning for delivery of external radiation 753591_1 CDM 0321 RC 77306 HCPCS inpatient 471 306.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 367.38 78 999999999 285.19 456.87 percent of total billed charges Simple radiation therapy planning for delivery of external radiation 753591_1 CDM 0321 RC 77306 HCPCS inpatient 471 306.15 SIHO - ALL PLANS SIHO - ALL PLANS 423.9 90 999999999 285.19 456.87 percent of total billed charges Simple radiation therapy planning for delivery of external radiation 753591_1 CDM 0321 RC 77306 HCPCS inpatient 471 306.15 UMR - ALL PLANS UMR - ALL PLANS 329.7 70 999999999 285.19 456.87 percent of total billed charges Simple radiation therapy planning for delivery of external radiation 753591_1 CDM 0321 RC 77306 HCPCS inpatient 471 306.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 285.19 456.87 Simple radiation therapy planning for delivery of external radiation 753591_1 CDM 0321 RC 77306 HCPCS inpatient 471 306.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 285.19 60.55 999999999 285.19 456.87 percent of total billed charges Simple radiation therapy planning for delivery of external radiation 753591_1 CDM 0321 RC 77306 HCPCS inpatient 471 306.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 285.19 456.87 Simple radiation therapy planning for delivery of external radiation 753591_1 CDM 0321 RC 77306 HCPCS inpatient 471 306.15 ANTHEM HMO ANTHEM HMO 999999999 285.19 456.87 Simple radiation therapy planning for delivery of external radiation 753591_1 CDM 0321 RC 77306 HCPCS inpatient 471 306.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 285.19 456.87 Simple radiation therapy planning for delivery of external radiation 753591_1 CDM 0321 RC 77306 HCPCS inpatient 471 306.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 285.19 456.87 Simple radiation therapy planning for delivery of external radiation 753591_1 CDM 0321 RC 77306 HCPCS inpatient 471 306.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 318.4 67.6 999999999 285.19 456.87 percent of total billed charges X-ray of collar bone 753599_1 CDM 0320 RC 73000 HCPCS inpatient 696 452.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 452.4 65 999999999 421.43 675.12 percent of total billed charges X-ray of collar bone 753599_1 CDM 0320 RC 73000 HCPCS inpatient 696 452.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 675.12 97 999999999 421.43 675.12 percent of total billed charges X-ray of collar bone 753599_1 CDM 0320 RC 73000 HCPCS inpatient 696 452.4 AETNA AETNA 549.84 79 999999999 421.43 675.12 percent of total billed charges X-ray of collar bone 753599_1 CDM 0320 RC 73000 HCPCS inpatient 696 452.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 480.24 69 999999999 421.43 675.12 percent of total billed charges X-ray of collar bone 753599_1 CDM 0320 RC 73000 HCPCS inpatient 696 452.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 542.88 78 999999999 421.43 675.12 percent of total billed charges X-ray of collar bone 753599_1 CDM 0320 RC 73000 HCPCS inpatient 696 452.4 SIHO - ALL PLANS SIHO - ALL PLANS 626.4 90 999999999 421.43 675.12 percent of total billed charges X-ray of collar bone 753599_1 CDM 0320 RC 73000 HCPCS inpatient 696 452.4 UMR - ALL PLANS UMR - ALL PLANS 487.2 70 999999999 421.43 675.12 percent of total billed charges X-ray of collar bone 753599_1 CDM 0320 RC 73000 HCPCS inpatient 696 452.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 421.43 675.12 X-ray of collar bone 753599_1 CDM 0320 RC 73000 HCPCS inpatient 696 452.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 421.43 60.55 999999999 421.43 675.12 percent of total billed charges X-ray of collar bone 753599_1 CDM 0320 RC 73000 HCPCS inpatient 696 452.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 421.43 675.12 X-ray of collar bone 753599_1 CDM 0320 RC 73000 HCPCS inpatient 696 452.4 ANTHEM HMO ANTHEM HMO 999999999 421.43 675.12 X-ray of collar bone 753599_1 CDM 0320 RC 73000 HCPCS inpatient 696 452.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 421.43 675.12 X-ray of collar bone 753599_1 CDM 0320 RC 73000 HCPCS inpatient 696 452.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 421.43 675.12 X-ray of collar bone 753599_1 CDM 0320 RC 73000 HCPCS inpatient 696 452.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 470.5 67.6 999999999 421.43 675.12 percent of total billed charges X-ray of collar bone 753601_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 254.8 65 999999999 237.36 380.24 percent of total billed charges X-ray of collar bone 753601_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 380.24 97 999999999 237.36 380.24 percent of total billed charges X-ray of collar bone 753601_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 AETNA AETNA 309.68 79 999999999 237.36 380.24 percent of total billed charges X-ray of collar bone 753601_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 270.48 69 999999999 237.36 380.24 percent of total billed charges X-ray of collar bone 753601_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 305.76 78 999999999 237.36 380.24 percent of total billed charges X-ray of collar bone 753601_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 SIHO - ALL PLANS SIHO - ALL PLANS 352.8 90 999999999 237.36 380.24 percent of total billed charges X-ray of collar bone 753601_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 UMR - ALL PLANS UMR - ALL PLANS 274.4 70 999999999 237.36 380.24 percent of total billed charges X-ray of collar bone 753601_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 237.36 380.24 X-ray of collar bone 753601_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 237.36 60.55 999999999 237.36 380.24 percent of total billed charges X-ray of collar bone 753601_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 237.36 380.24 X-ray of collar bone 753601_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 ANTHEM HMO ANTHEM HMO 999999999 237.36 380.24 X-ray of collar bone 753601_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 237.36 380.24 X-ray of collar bone 753601_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 237.36 380.24 X-ray of collar bone 753601_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 264.99 67.6 999999999 237.36 380.24 percent of total billed charges X-ray of collar bone 753603_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 254.8 65 999999999 237.36 380.24 percent of total billed charges X-ray of collar bone 753603_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 380.24 97 999999999 237.36 380.24 percent of total billed charges X-ray of collar bone 753603_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 AETNA AETNA 309.68 79 999999999 237.36 380.24 percent of total billed charges X-ray of collar bone 753603_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 270.48 69 999999999 237.36 380.24 percent of total billed charges X-ray of collar bone 753603_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 305.76 78 999999999 237.36 380.24 percent of total billed charges X-ray of collar bone 753603_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 SIHO - ALL PLANS SIHO - ALL PLANS 352.8 90 999999999 237.36 380.24 percent of total billed charges X-ray of collar bone 753603_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 UMR - ALL PLANS UMR - ALL PLANS 274.4 70 999999999 237.36 380.24 percent of total billed charges X-ray of collar bone 753603_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 237.36 60.55 999999999 237.36 380.24 percent of total billed charges X-ray of collar bone 753603_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 237.36 380.24 X-ray of collar bone 753603_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 237.36 380.24 X-ray of collar bone 753603_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 ANTHEM HMO ANTHEM HMO 999999999 237.36 380.24 X-ray of collar bone 753603_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 237.36 380.24 X-ray of collar bone 753603_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 237.36 380.24 X-ray of collar bone 753603_1 CDM 0320 RC 73000 HCPCS inpatient 392 254.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 264.99 67.6 999999999 237.36 380.24 percent of total billed charges Review by radiologist of urinary bladder image 753605_1 CDM 0320 RC 74430 HCPCS inpatient 479 311.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 311.35 65 999999999 290.03 464.63 percent of total billed charges Review by radiologist of urinary bladder image 753605_1 CDM 0320 RC 74430 HCPCS inpatient 479 311.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 464.63 97 999999999 290.03 464.63 percent of total billed charges Review by radiologist of urinary bladder image 753605_1 CDM 0320 RC 74430 HCPCS inpatient 479 311.35 AETNA AETNA 378.41 79 999999999 290.03 464.63 percent of total billed charges Review by radiologist of urinary bladder image 753605_1 CDM 0320 RC 74430 HCPCS inpatient 479 311.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 330.51 69 999999999 290.03 464.63 percent of total billed charges Review by radiologist of urinary bladder image 753605_1 CDM 0320 RC 74430 HCPCS inpatient 479 311.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 373.62 78 999999999 290.03 464.63 percent of total billed charges Review by radiologist of urinary bladder image 753605_1 CDM 0320 RC 74430 HCPCS inpatient 479 311.35 SIHO - ALL PLANS SIHO - ALL PLANS 431.1 90 999999999 290.03 464.63 percent of total billed charges Review by radiologist of urinary bladder image 753605_1 CDM 0320 RC 74430 HCPCS inpatient 479 311.35 UMR - ALL PLANS UMR - ALL PLANS 335.3 70 999999999 290.03 464.63 percent of total billed charges Review by radiologist of urinary bladder image 753605_1 CDM 0320 RC 74430 HCPCS inpatient 479 311.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 290.03 60.55 999999999 290.03 464.63 percent of total billed charges Review by radiologist of urinary bladder image 753605_1 CDM 0320 RC 74430 HCPCS inpatient 479 311.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 290.03 464.63 Review by radiologist of urinary bladder image 753605_1 CDM 0320 RC 74430 HCPCS inpatient 479 311.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 290.03 464.63 Review by radiologist of urinary bladder image 753605_1 CDM 0320 RC 74430 HCPCS inpatient 479 311.35 ANTHEM HMO ANTHEM HMO 999999999 290.03 464.63 Review by radiologist of urinary bladder image 753605_1 CDM 0320 RC 74430 HCPCS inpatient 479 311.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 290.03 464.63 Review by radiologist of urinary bladder image 753605_1 CDM 0320 RC 74430 HCPCS inpatient 479 311.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 290.03 464.63 Review by radiologist of urinary bladder image 753605_1 CDM 0320 RC 74430 HCPCS inpatient 479 311.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 323.8 67.6 999999999 290.03 464.63 percent of total billed charges "X-ray of face bones, minimum of 3 views" 753640_1 CDM 0320 RC 70150 HCPCS inpatient 765 497.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 497.25 65 999999999 463.21 742.05 percent of total billed charges "X-ray of face bones, minimum of 3 views" 753640_1 CDM 0320 RC 70150 HCPCS inpatient 765 497.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 742.05 97 999999999 463.21 742.05 percent of total billed charges "X-ray of face bones, minimum of 3 views" 753640_1 CDM 0320 RC 70150 HCPCS inpatient 765 497.25 AETNA AETNA 604.35 79 999999999 463.21 742.05 percent of total billed charges "X-ray of face bones, minimum of 3 views" 753640_1 CDM 0320 RC 70150 HCPCS inpatient 765 497.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 527.85 69 999999999 463.21 742.05 percent of total billed charges "X-ray of face bones, minimum of 3 views" 753640_1 CDM 0320 RC 70150 HCPCS inpatient 765 497.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 596.7 78 999999999 463.21 742.05 percent of total billed charges "X-ray of face bones, minimum of 3 views" 753640_1 CDM 0320 RC 70150 HCPCS inpatient 765 497.25 SIHO - ALL PLANS SIHO - ALL PLANS 688.5 90 999999999 463.21 742.05 percent of total billed charges "X-ray of face bones, minimum of 3 views" 753640_1 CDM 0320 RC 70150 HCPCS inpatient 765 497.25 UMR - ALL PLANS UMR - ALL PLANS 535.5 70 999999999 463.21 742.05 percent of total billed charges "X-ray of face bones, minimum of 3 views" 753640_1 CDM 0320 RC 70150 HCPCS inpatient 765 497.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 463.21 60.55 999999999 463.21 742.05 percent of total billed charges "X-ray of face bones, minimum of 3 views" 753640_1 CDM 0320 RC 70150 HCPCS inpatient 765 497.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 463.21 742.05 "X-ray of face bones, minimum of 3 views" 753640_1 CDM 0320 RC 70150 HCPCS inpatient 765 497.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 463.21 742.05 "X-ray of face bones, minimum of 3 views" 753640_1 CDM 0320 RC 70150 HCPCS inpatient 765 497.25 ANTHEM HMO ANTHEM HMO 999999999 463.21 742.05 "X-ray of face bones, minimum of 3 views" 753640_1 CDM 0320 RC 70150 HCPCS inpatient 765 497.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 463.21 742.05 "X-ray of face bones, minimum of 3 views" 753640_1 CDM 0320 RC 70150 HCPCS inpatient 765 497.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 463.21 742.05 "X-ray of face bones, minimum of 3 views" 753640_1 CDM 0320 RC 70150 HCPCS inpatient 765 497.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 517.14 67.6 999999999 463.21 742.05 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753642_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 327.6 65 999999999 305.17 488.88 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753642_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 488.88 97 999999999 305.17 488.88 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753642_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 AETNA AETNA 398.16 79 999999999 305.17 488.88 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753642_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 347.76 69 999999999 305.17 488.88 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753642_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 393.12 78 999999999 305.17 488.88 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753642_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 SIHO - ALL PLANS SIHO - ALL PLANS 453.6 90 999999999 305.17 488.88 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753642_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 UMR - ALL PLANS UMR - ALL PLANS 352.8 70 999999999 305.17 488.88 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753642_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 305.17 60.55 999999999 305.17 488.88 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753642_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 305.17 488.88 "X-ray of thigh bone, minimum 2 views" 753642_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 305.17 488.88 "X-ray of thigh bone, minimum 2 views" 753642_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 ANTHEM HMO ANTHEM HMO 999999999 305.17 488.88 "X-ray of thigh bone, minimum 2 views" 753642_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 305.17 488.88 "X-ray of thigh bone, minimum 2 views" 753642_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 305.17 488.88 "X-ray of thigh bone, minimum 2 views" 753642_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 340.7 67.6 999999999 305.17 488.88 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753644_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 350.35 65 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753644_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 522.83 97 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753644_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 AETNA AETNA 425.81 79 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753644_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 371.91 69 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753644_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 420.42 78 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753644_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 SIHO - ALL PLANS SIHO - ALL PLANS 485.1 90 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753644_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 UMR - ALL PLANS UMR - ALL PLANS 377.3 70 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753644_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 326.36 60.55 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753644_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 326.36 522.83 "X-ray of thigh bone, minimum 2 views" 753644_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 326.36 522.83 "X-ray of thigh bone, minimum 2 views" 753644_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 ANTHEM HMO ANTHEM HMO 999999999 326.36 522.83 "X-ray of thigh bone, minimum 2 views" 753644_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 326.36 522.83 "X-ray of thigh bone, minimum 2 views" 753644_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 326.36 522.83 "X-ray of thigh bone, minimum 2 views" 753644_1 CDM 0320 RC 73552 HCPCS inpatient 539 350.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 364.36 67.6 999999999 326.36 522.83 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753646_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 327.6 65 999999999 305.17 488.88 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753646_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 488.88 97 999999999 305.17 488.88 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753646_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 AETNA AETNA 398.16 79 999999999 305.17 488.88 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753646_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 347.76 69 999999999 305.17 488.88 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753646_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 393.12 78 999999999 305.17 488.88 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753646_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 SIHO - ALL PLANS SIHO - ALL PLANS 453.6 90 999999999 305.17 488.88 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753646_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 UMR - ALL PLANS UMR - ALL PLANS 352.8 70 999999999 305.17 488.88 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753646_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 305.17 60.55 999999999 305.17 488.88 percent of total billed charges "X-ray of thigh bone, minimum 2 views" 753646_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 305.17 488.88 "X-ray of thigh bone, minimum 2 views" 753646_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 ANTHEM HMO ANTHEM HMO 999999999 305.17 488.88 "X-ray of thigh bone, minimum 2 views" 753646_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 305.17 488.88 "X-ray of thigh bone, minimum 2 views" 753646_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 305.17 488.88 "X-ray of thigh bone, minimum 2 views" 753646_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 305.17 488.88 "X-ray of thigh bone, minimum 2 views" 753646_1 CDM 0320 RC 73552 HCPCS inpatient 504 327.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 340.7 67.6 999999999 305.17 488.88 percent of total billed charges "X-ray of finger, minimum of 2 views" 753648_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 245.7 65 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753648_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 366.66 97 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753648_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 AETNA AETNA 298.62 79 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753648_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 260.82 69 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753648_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 294.84 78 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753648_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SIHO - ALL PLANS SIHO - ALL PLANS 340.2 90 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753648_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UMR - ALL PLANS UMR - ALL PLANS 264.6 70 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753648_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 228.88 60.55 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753648_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753648_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM HMO ANTHEM HMO 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753648_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753648_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753648_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753648_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 255.53 67.6 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753650_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 245.7 65 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753650_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 366.66 97 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753650_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 AETNA AETNA 298.62 79 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753650_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 260.82 69 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753650_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 294.84 78 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753650_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SIHO - ALL PLANS SIHO - ALL PLANS 340.2 90 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753650_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UMR - ALL PLANS UMR - ALL PLANS 264.6 70 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753650_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 228.88 60.55 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753650_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753650_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM HMO ANTHEM HMO 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753650_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753650_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753650_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753650_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 255.53 67.6 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753652_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 245.7 65 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753652_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 366.66 97 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753652_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 AETNA AETNA 298.62 79 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753652_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 260.82 69 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753652_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 294.84 78 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753652_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SIHO - ALL PLANS SIHO - ALL PLANS 340.2 90 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753652_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UMR - ALL PLANS UMR - ALL PLANS 264.6 70 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753652_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 228.88 60.55 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753652_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753652_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM HMO ANTHEM HMO 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753652_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753652_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753652_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753652_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 255.53 67.6 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753654_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 245.7 65 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753654_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 366.66 97 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753654_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 AETNA AETNA 298.62 79 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753654_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 260.82 69 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753654_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 294.84 78 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753654_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SIHO - ALL PLANS SIHO - ALL PLANS 340.2 90 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753654_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UMR - ALL PLANS UMR - ALL PLANS 264.6 70 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753654_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 228.88 60.55 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753654_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753654_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM HMO ANTHEM HMO 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753654_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753654_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753654_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753654_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 255.53 67.6 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753656_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 245.7 65 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753656_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 366.66 97 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753656_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 AETNA AETNA 298.62 79 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753656_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 260.82 69 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753656_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 294.84 78 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753656_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SIHO - ALL PLANS SIHO - ALL PLANS 340.2 90 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753656_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UMR - ALL PLANS UMR - ALL PLANS 264.6 70 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753656_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 228.88 60.55 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753656_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753656_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM HMO ANTHEM HMO 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753656_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753656_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753656_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753656_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 255.53 67.6 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753658_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 245.7 65 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753658_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 366.66 97 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753658_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 AETNA AETNA 298.62 79 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753658_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 260.82 69 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753658_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 294.84 78 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753658_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SIHO - ALL PLANS SIHO - ALL PLANS 340.2 90 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753658_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UMR - ALL PLANS UMR - ALL PLANS 264.6 70 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753658_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 228.88 60.55 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753658_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753658_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM HMO ANTHEM HMO 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753658_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753658_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753658_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753658_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 255.53 67.6 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753660_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 245.7 65 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753660_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 366.66 97 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753660_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 AETNA AETNA 298.62 79 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753660_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 260.82 69 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753660_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 294.84 78 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753660_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SIHO - ALL PLANS SIHO - ALL PLANS 340.2 90 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753660_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UMR - ALL PLANS UMR - ALL PLANS 264.6 70 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753660_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 228.88 60.55 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753660_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753660_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM HMO ANTHEM HMO 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753660_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753660_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753660_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753660_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 255.53 67.6 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753662_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 245.7 65 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753662_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 366.66 97 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753662_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 AETNA AETNA 298.62 79 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753662_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 260.82 69 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753662_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 294.84 78 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753662_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 SIHO - ALL PLANS SIHO - ALL PLANS 340.2 90 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753662_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UMR - ALL PLANS UMR - ALL PLANS 264.6 70 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753662_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 228.88 60.55 999999999 228.88 366.66 percent of total billed charges "X-ray of finger, minimum of 2 views" 753662_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753662_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM HMO ANTHEM HMO 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753662_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753662_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753662_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 228.88 366.66 "X-ray of finger, minimum of 2 views" 753662_1 CDM 0320 RC 73140 HCPCS inpatient 378 245.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 255.53 67.6 999999999 228.88 366.66 percent of total billed charges FLUOROSCOPE EXAM EXTENSIVE 753680_1 CDM 0320 RC 76001 HCPCS inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges FLUOROSCOPE EXAM EXTENSIVE 753680_1 CDM 0320 RC 76001 HCPCS inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges FLUOROSCOPE EXAM EXTENSIVE 753680_1 CDM 0320 RC 76001 HCPCS inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges FLUOROSCOPE EXAM EXTENSIVE 753680_1 CDM 0320 RC 76001 HCPCS inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges FLUOROSCOPE EXAM EXTENSIVE 753680_1 CDM 0320 RC 76001 HCPCS inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges FLUOROSCOPE EXAM EXTENSIVE 753680_1 CDM 0320 RC 76001 HCPCS inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges FLUOROSCOPE EXAM EXTENSIVE 753680_1 CDM 0320 RC 76001 HCPCS inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges FLUOROSCOPE EXAM EXTENSIVE 753680_1 CDM 0320 RC 76001 HCPCS inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges FLUOROSCOPE EXAM EXTENSIVE 753680_1 CDM 0320 RC 76001 HCPCS inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 FLUOROSCOPE EXAM EXTENSIVE 753680_1 CDM 0320 RC 76001 HCPCS inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 FLUOROSCOPE EXAM EXTENSIVE 753680_1 CDM 0320 RC 76001 HCPCS inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 FLUOROSCOPE EXAM EXTENSIVE 753680_1 CDM 0320 RC 76001 HCPCS inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 FLUOROSCOPE EXAM EXTENSIVE 753680_1 CDM 0320 RC 76001 HCPCS inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 FLUOROSCOPE EXAM EXTENSIVE 753680_1 CDM 0320 RC 76001 HCPCS inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges "X-ray of foot, minimum of 3 views" 753693_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges "X-ray of foot, minimum of 3 views" 753693_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges "X-ray of foot, minimum of 3 views" 753693_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges "X-ray of foot, minimum of 3 views" 753693_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges "X-ray of foot, minimum of 3 views" 753693_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges "X-ray of foot, minimum of 3 views" 753693_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges "X-ray of foot, minimum of 3 views" 753693_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges "X-ray of foot, minimum of 3 views" 753693_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges "X-ray of foot, minimum of 3 views" 753693_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 "X-ray of foot, minimum of 3 views" 753693_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 "X-ray of foot, minimum of 3 views" 753693_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 "X-ray of foot, minimum of 3 views" 753693_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 "X-ray of foot, minimum of 3 views" 753693_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 "X-ray of foot, minimum of 3 views" 753693_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges "X-ray of foot, minimum of 3 views" 753695_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges "X-ray of foot, minimum of 3 views" 753695_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges "X-ray of foot, minimum of 3 views" 753695_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges "X-ray of foot, minimum of 3 views" 753695_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges "X-ray of foot, minimum of 3 views" 753695_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges "X-ray of foot, minimum of 3 views" 753695_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges "X-ray of foot, minimum of 3 views" 753695_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges "X-ray of foot, minimum of 3 views" 753695_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges "X-ray of foot, minimum of 3 views" 753695_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 "X-ray of foot, minimum of 3 views" 753695_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 "X-ray of foot, minimum of 3 views" 753695_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 "X-ray of foot, minimum of 3 views" 753695_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 "X-ray of foot, minimum of 3 views" 753695_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 "X-ray of foot, minimum of 3 views" 753695_1 CDM 0320 RC 73630 HCPCS inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges "X-ray of forearm, 2 views" 753699_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 298.35 65 999999999 277.92 445.23 percent of total billed charges "X-ray of forearm, 2 views" 753699_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 445.23 97 999999999 277.92 445.23 percent of total billed charges "X-ray of forearm, 2 views" 753699_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 AETNA AETNA 362.61 79 999999999 277.92 445.23 percent of total billed charges "X-ray of forearm, 2 views" 753699_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 316.71 69 999999999 277.92 445.23 percent of total billed charges "X-ray of forearm, 2 views" 753699_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 358.02 78 999999999 277.92 445.23 percent of total billed charges "X-ray of forearm, 2 views" 753699_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 SIHO - ALL PLANS SIHO - ALL PLANS 413.1 90 999999999 277.92 445.23 percent of total billed charges "X-ray of forearm, 2 views" 753699_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 UMR - ALL PLANS UMR - ALL PLANS 321.3 70 999999999 277.92 445.23 percent of total billed charges "X-ray of forearm, 2 views" 753699_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 277.92 60.55 999999999 277.92 445.23 percent of total billed charges "X-ray of forearm, 2 views" 753699_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 277.92 445.23 "X-ray of forearm, 2 views" 753699_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 ANTHEM HMO ANTHEM HMO 999999999 277.92 445.23 "X-ray of forearm, 2 views" 753699_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 277.92 445.23 "X-ray of forearm, 2 views" 753699_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 277.92 445.23 "X-ray of forearm, 2 views" 753699_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 277.92 445.23 "X-ray of forearm, 2 views" 753699_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 310.28 67.6 999999999 277.92 445.23 percent of total billed charges "X-ray of forearm, 2 views" 753701_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 298.35 65 999999999 277.92 445.23 percent of total billed charges "X-ray of forearm, 2 views" 753701_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 445.23 97 999999999 277.92 445.23 percent of total billed charges "X-ray of forearm, 2 views" 753701_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 AETNA AETNA 362.61 79 999999999 277.92 445.23 percent of total billed charges "X-ray of forearm, 2 views" 753701_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 316.71 69 999999999 277.92 445.23 percent of total billed charges "X-ray of forearm, 2 views" 753701_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 358.02 78 999999999 277.92 445.23 percent of total billed charges "X-ray of forearm, 2 views" 753701_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 SIHO - ALL PLANS SIHO - ALL PLANS 413.1 90 999999999 277.92 445.23 percent of total billed charges "X-ray of forearm, 2 views" 753701_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 UMR - ALL PLANS UMR - ALL PLANS 321.3 70 999999999 277.92 445.23 percent of total billed charges "X-ray of forearm, 2 views" 753701_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 277.92 60.55 999999999 277.92 445.23 percent of total billed charges "X-ray of forearm, 2 views" 753701_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 277.92 445.23 "X-ray of forearm, 2 views" 753701_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 ANTHEM HMO ANTHEM HMO 999999999 277.92 445.23 "X-ray of forearm, 2 views" 753701_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 277.92 445.23 "X-ray of forearm, 2 views" 753701_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 277.92 445.23 "X-ray of forearm, 2 views" 753701_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 277.92 445.23 "X-ray of forearm, 2 views" 753701_1 CDM 0320 RC 73090 HCPCS inpatient 459 298.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 310.28 67.6 999999999 277.92 445.23 percent of total billed charges "X-ray of hand, 2 views" 753709_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 213.2 65 999999999 198.6 318.16 percent of total billed charges "X-ray of hand, 2 views" 753709_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 318.16 97 999999999 198.6 318.16 percent of total billed charges "X-ray of hand, 2 views" 753709_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 AETNA AETNA 259.12 79 999999999 198.6 318.16 percent of total billed charges "X-ray of hand, 2 views" 753709_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 226.32 69 999999999 198.6 318.16 percent of total billed charges "X-ray of hand, 2 views" 753709_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.84 78 999999999 198.6 318.16 percent of total billed charges "X-ray of hand, 2 views" 753709_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 SIHO - ALL PLANS SIHO - ALL PLANS 295.2 90 999999999 198.6 318.16 percent of total billed charges "X-ray of hand, 2 views" 753709_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 UMR - ALL PLANS UMR - ALL PLANS 229.6 70 999999999 198.6 318.16 percent of total billed charges "X-ray of hand, 2 views" 753709_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198.6 60.55 999999999 198.6 318.16 percent of total billed charges "X-ray of hand, 2 views" 753709_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198.6 318.16 "X-ray of hand, 2 views" 753709_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 ANTHEM HMO ANTHEM HMO 999999999 198.6 318.16 "X-ray of hand, 2 views" 753709_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198.6 318.16 "X-ray of hand, 2 views" 753709_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198.6 318.16 "X-ray of hand, 2 views" 753709_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 198.6 318.16 "X-ray of hand, 2 views" 753709_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.73 67.6 999999999 198.6 318.16 percent of total billed charges "X-ray of hand, 2 views" 753711_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 213.2 65 999999999 198.6 318.16 percent of total billed charges "X-ray of hand, 2 views" 753711_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 318.16 97 999999999 198.6 318.16 percent of total billed charges "X-ray of hand, 2 views" 753711_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 AETNA AETNA 259.12 79 999999999 198.6 318.16 percent of total billed charges "X-ray of hand, 2 views" 753711_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 226.32 69 999999999 198.6 318.16 percent of total billed charges "X-ray of hand, 2 views" 753711_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.84 78 999999999 198.6 318.16 percent of total billed charges "X-ray of hand, 2 views" 753711_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 SIHO - ALL PLANS SIHO - ALL PLANS 295.2 90 999999999 198.6 318.16 percent of total billed charges "X-ray of hand, 2 views" 753711_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 UMR - ALL PLANS UMR - ALL PLANS 229.6 70 999999999 198.6 318.16 percent of total billed charges "X-ray of hand, 2 views" 753711_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198.6 60.55 999999999 198.6 318.16 percent of total billed charges "X-ray of hand, 2 views" 753711_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198.6 318.16 "X-ray of hand, 2 views" 753711_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 ANTHEM HMO ANTHEM HMO 999999999 198.6 318.16 "X-ray of hand, 2 views" 753711_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198.6 318.16 "X-ray of hand, 2 views" 753711_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198.6 318.16 "X-ray of hand, 2 views" 753711_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 198.6 318.16 "X-ray of hand, 2 views" 753711_1 CDM 0320 RC 73120 HCPCS inpatient 328 213.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.73 67.6 999999999 198.6 318.16 percent of total billed charges "X-ray of hand, minimum of 3 views" 753715_1 CDM 0320 RC 73130 HCPCS inpatient 430 279.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 279.5 65 999999999 260.37 417.1 percent of total billed charges "X-ray of hand, minimum of 3 views" 753715_1 CDM 0320 RC 73130 HCPCS inpatient 430 279.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 417.1 97 999999999 260.37 417.1 percent of total billed charges "X-ray of hand, minimum of 3 views" 753715_1 CDM 0320 RC 73130 HCPCS inpatient 430 279.5 AETNA AETNA 339.7 79 999999999 260.37 417.1 percent of total billed charges "X-ray of hand, minimum of 3 views" 753715_1 CDM 0320 RC 73130 HCPCS inpatient 430 279.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 296.7 69 999999999 260.37 417.1 percent of total billed charges "X-ray of hand, minimum of 3 views" 753715_1 CDM 0320 RC 73130 HCPCS inpatient 430 279.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 335.4 78 999999999 260.37 417.1 percent of total billed charges "X-ray of hand, minimum of 3 views" 753715_1 CDM 0320 RC 73130 HCPCS inpatient 430 279.5 SIHO - ALL PLANS SIHO - ALL PLANS 387 90 999999999 260.37 417.1 percent of total billed charges "X-ray of hand, minimum of 3 views" 753715_1 CDM 0320 RC 73130 HCPCS inpatient 430 279.5 UMR - ALL PLANS UMR - ALL PLANS 301 70 999999999 260.37 417.1 percent of total billed charges "X-ray of hand, minimum of 3 views" 753715_1 CDM 0320 RC 73130 HCPCS inpatient 430 279.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 260.37 60.55 999999999 260.37 417.1 percent of total billed charges "X-ray of hand, minimum of 3 views" 753715_1 CDM 0320 RC 73130 HCPCS inpatient 430 279.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 260.37 417.1 "X-ray of hand, minimum of 3 views" 753715_1 CDM 0320 RC 73130 HCPCS inpatient 430 279.5 ANTHEM HMO ANTHEM HMO 999999999 260.37 417.1 "X-ray of hand, minimum of 3 views" 753715_1 CDM 0320 RC 73130 HCPCS inpatient 430 279.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 260.37 417.1 "X-ray of hand, minimum of 3 views" 753715_1 CDM 0320 RC 73130 HCPCS inpatient 430 279.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 260.37 417.1 "X-ray of hand, minimum of 3 views" 753715_1 CDM 0320 RC 73130 HCPCS inpatient 430 279.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 260.37 417.1 "X-ray of hand, minimum of 3 views" 753715_1 CDM 0320 RC 73130 HCPCS inpatient 430 279.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 290.68 67.6 999999999 260.37 417.1 percent of total billed charges "X-ray of hand, minimum of 3 views" 753717_1 CDM 0320 RC 73130 HCPCS inpatient 428 278.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 278.2 65 999999999 259.15 415.16 percent of total billed charges "X-ray of hand, minimum of 3 views" 753717_1 CDM 0320 RC 73130 HCPCS inpatient 428 278.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 415.16 97 999999999 259.15 415.16 percent of total billed charges "X-ray of hand, minimum of 3 views" 753717_1 CDM 0320 RC 73130 HCPCS inpatient 428 278.2 AETNA AETNA 338.12 79 999999999 259.15 415.16 percent of total billed charges "X-ray of hand, minimum of 3 views" 753717_1 CDM 0320 RC 73130 HCPCS inpatient 428 278.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 295.32 69 999999999 259.15 415.16 percent of total billed charges "X-ray of hand, minimum of 3 views" 753717_1 CDM 0320 RC 73130 HCPCS inpatient 428 278.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 333.84 78 999999999 259.15 415.16 percent of total billed charges "X-ray of hand, minimum of 3 views" 753717_1 CDM 0320 RC 73130 HCPCS inpatient 428 278.2 SIHO - ALL PLANS SIHO - ALL PLANS 385.2 90 999999999 259.15 415.16 percent of total billed charges "X-ray of hand, minimum of 3 views" 753717_1 CDM 0320 RC 73130 HCPCS inpatient 428 278.2 UMR - ALL PLANS UMR - ALL PLANS 299.6 70 999999999 259.15 415.16 percent of total billed charges "X-ray of hand, minimum of 3 views" 753717_1 CDM 0320 RC 73130 HCPCS inpatient 428 278.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 259.15 60.55 999999999 259.15 415.16 percent of total billed charges "X-ray of hand, minimum of 3 views" 753717_1 CDM 0320 RC 73130 HCPCS inpatient 428 278.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 259.15 415.16 "X-ray of hand, minimum of 3 views" 753717_1 CDM 0320 RC 73130 HCPCS inpatient 428 278.2 ANTHEM HMO ANTHEM HMO 999999999 259.15 415.16 "X-ray of hand, minimum of 3 views" 753717_1 CDM 0320 RC 73130 HCPCS inpatient 428 278.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 259.15 415.16 "X-ray of hand, minimum of 3 views" 753717_1 CDM 0320 RC 73130 HCPCS inpatient 428 278.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 259.15 415.16 "X-ray of hand, minimum of 3 views" 753717_1 CDM 0320 RC 73130 HCPCS inpatient 428 278.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 259.15 415.16 "X-ray of hand, minimum of 3 views" 753717_1 CDM 0320 RC 73130 HCPCS inpatient 428 278.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 289.33 67.6 999999999 259.15 415.16 percent of total billed charges "X-ray of upper arm, minimum of 2 views" 753734_1 CDM 0320 RC 73060 HCPCS inpatient 457 297.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 297.05 65 999999999 276.71 443.29 percent of total billed charges "X-ray of upper arm, minimum of 2 views" 753734_1 CDM 0320 RC 73060 HCPCS inpatient 457 297.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 443.29 97 999999999 276.71 443.29 percent of total billed charges "X-ray of upper arm, minimum of 2 views" 753734_1 CDM 0320 RC 73060 HCPCS inpatient 457 297.05 AETNA AETNA 361.03 79 999999999 276.71 443.29 percent of total billed charges "X-ray of upper arm, minimum of 2 views" 753734_1 CDM 0320 RC 73060 HCPCS inpatient 457 297.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 315.33 69 999999999 276.71 443.29 percent of total billed charges "X-ray of upper arm, minimum of 2 views" 753734_1 CDM 0320 RC 73060 HCPCS inpatient 457 297.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 356.46 78 999999999 276.71 443.29 percent of total billed charges "X-ray of upper arm, minimum of 2 views" 753734_1 CDM 0320 RC 73060 HCPCS inpatient 457 297.05 SIHO - ALL PLANS SIHO - ALL PLANS 411.3 90 999999999 276.71 443.29 percent of total billed charges "X-ray of upper arm, minimum of 2 views" 753734_1 CDM 0320 RC 73060 HCPCS inpatient 457 297.05 UMR - ALL PLANS UMR - ALL PLANS 319.9 70 999999999 276.71 443.29 percent of total billed charges "X-ray of upper arm, minimum of 2 views" 753734_1 CDM 0320 RC 73060 HCPCS inpatient 457 297.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 276.71 60.55 999999999 276.71 443.29 percent of total billed charges "X-ray of upper arm, minimum of 2 views" 753734_1 CDM 0320 RC 73060 HCPCS inpatient 457 297.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 276.71 443.29 "X-ray of upper arm, minimum of 2 views" 753734_1 CDM 0320 RC 73060 HCPCS inpatient 457 297.05 ANTHEM HMO ANTHEM HMO 999999999 276.71 443.29 "X-ray of upper arm, minimum of 2 views" 753734_1 CDM 0320 RC 73060 HCPCS inpatient 457 297.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 276.71 443.29 "X-ray of upper arm, minimum of 2 views" 753734_1 CDM 0320 RC 73060 HCPCS inpatient 457 297.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 276.71 443.29 "X-ray of upper arm, minimum of 2 views" 753734_1 CDM 0320 RC 73060 HCPCS inpatient 457 297.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 276.71 443.29 "X-ray of upper arm, minimum of 2 views" 753734_1 CDM 0320 RC 73060 HCPCS inpatient 457 297.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 308.93 67.6 999999999 276.71 443.29 percent of total billed charges "X-ray of upper arm, minimum of 2 views" 753736_1 CDM 0320 RC 73060 HCPCS inpatient 423 274.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 274.95 65 999999999 256.13 410.31 percent of total billed charges "X-ray of upper arm, minimum of 2 views" 753736_1 CDM 0320 RC 73060 HCPCS inpatient 423 274.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 410.31 97 999999999 256.13 410.31 percent of total billed charges "X-ray of upper arm, minimum of 2 views" 753736_1 CDM 0320 RC 73060 HCPCS inpatient 423 274.95 AETNA AETNA 334.17 79 999999999 256.13 410.31 percent of total billed charges "X-ray of upper arm, minimum of 2 views" 753736_1 CDM 0320 RC 73060 HCPCS inpatient 423 274.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 291.87 69 999999999 256.13 410.31 percent of total billed charges "X-ray of upper arm, minimum of 2 views" 753736_1 CDM 0320 RC 73060 HCPCS inpatient 423 274.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 329.94 78 999999999 256.13 410.31 percent of total billed charges "X-ray of upper arm, minimum of 2 views" 753736_1 CDM 0320 RC 73060 HCPCS inpatient 423 274.95 SIHO - ALL PLANS SIHO - ALL PLANS 380.7 90 999999999 256.13 410.31 percent of total billed charges "X-ray of upper arm, minimum of 2 views" 753736_1 CDM 0320 RC 73060 HCPCS inpatient 423 274.95 UMR - ALL PLANS UMR - ALL PLANS 296.1 70 999999999 256.13 410.31 percent of total billed charges "X-ray of upper arm, minimum of 2 views" 753736_1 CDM 0320 RC 73060 HCPCS inpatient 423 274.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 256.13 60.55 999999999 256.13 410.31 percent of total billed charges "X-ray of upper arm, minimum of 2 views" 753736_1 CDM 0320 RC 73060 HCPCS inpatient 423 274.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 256.13 410.31 "X-ray of upper arm, minimum of 2 views" 753736_1 CDM 0320 RC 73060 HCPCS inpatient 423 274.95 ANTHEM HMO ANTHEM HMO 999999999 256.13 410.31 "X-ray of upper arm, minimum of 2 views" 753736_1 CDM 0320 RC 73060 HCPCS inpatient 423 274.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 256.13 410.31 "X-ray of upper arm, minimum of 2 views" 753736_1 CDM 0320 RC 73060 HCPCS inpatient 423 274.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 256.13 410.31 "X-ray of upper arm, minimum of 2 views" 753736_1 CDM 0320 RC 73060 HCPCS inpatient 423 274.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 256.13 410.31 "X-ray of upper arm, minimum of 2 views" 753736_1 CDM 0320 RC 73060 HCPCS inpatient 423 274.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 285.95 67.6 999999999 256.13 410.31 percent of total billed charges Review by radiologist of uterine tube and ovary image 753738_1 CDM 0320 RC 74740 HCPCS inpatient 563 365.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 365.95 65 999999999 340.9 546.11 percent of total billed charges Review by radiologist of uterine tube and ovary image 753738_1 CDM 0320 RC 74740 HCPCS inpatient 563 365.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 546.11 97 999999999 340.9 546.11 percent of total billed charges Review by radiologist of uterine tube and ovary image 753738_1 CDM 0320 RC 74740 HCPCS inpatient 563 365.95 AETNA AETNA 444.77 79 999999999 340.9 546.11 percent of total billed charges Review by radiologist of uterine tube and ovary image 753738_1 CDM 0320 RC 74740 HCPCS inpatient 563 365.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 388.47 69 999999999 340.9 546.11 percent of total billed charges Review by radiologist of uterine tube and ovary image 753738_1 CDM 0320 RC 74740 HCPCS inpatient 563 365.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 439.14 78 999999999 340.9 546.11 percent of total billed charges Review by radiologist of uterine tube and ovary image 753738_1 CDM 0320 RC 74740 HCPCS inpatient 563 365.95 SIHO - ALL PLANS SIHO - ALL PLANS 506.7 90 999999999 340.9 546.11 percent of total billed charges Review by radiologist of uterine tube and ovary image 753738_1 CDM 0320 RC 74740 HCPCS inpatient 563 365.95 UMR - ALL PLANS UMR - ALL PLANS 394.1 70 999999999 340.9 546.11 percent of total billed charges Review by radiologist of uterine tube and ovary image 753738_1 CDM 0320 RC 74740 HCPCS inpatient 563 365.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 340.9 60.55 999999999 340.9 546.11 percent of total billed charges Review by radiologist of uterine tube and ovary image 753738_1 CDM 0320 RC 74740 HCPCS inpatient 563 365.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 340.9 546.11 Review by radiologist of uterine tube and ovary image 753738_1 CDM 0320 RC 74740 HCPCS inpatient 563 365.95 ANTHEM HMO ANTHEM HMO 999999999 340.9 546.11 Review by radiologist of uterine tube and ovary image 753738_1 CDM 0320 RC 74740 HCPCS inpatient 563 365.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 340.9 546.11 Review by radiologist of uterine tube and ovary image 753738_1 CDM 0320 RC 74740 HCPCS inpatient 563 365.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 340.9 546.11 Review by radiologist of uterine tube and ovary image 753738_1 CDM 0320 RC 74740 HCPCS inpatient 563 365.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 340.9 546.11 Review by radiologist of uterine tube and ovary image 753738_1 CDM 0320 RC 74740 HCPCS inpatient 563 365.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 380.59 67.6 999999999 340.9 546.11 percent of total billed charges "X-ray of knee, 1-2 views" 753747_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 283.4 65 999999999 264 422.92 percent of total billed charges "X-ray of knee, 1-2 views" 753747_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 422.92 97 999999999 264 422.92 percent of total billed charges "X-ray of knee, 1-2 views" 753747_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 AETNA AETNA 344.44 79 999999999 264 422.92 percent of total billed charges "X-ray of knee, 1-2 views" 753747_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 300.84 69 999999999 264 422.92 percent of total billed charges "X-ray of knee, 1-2 views" 753747_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 340.08 78 999999999 264 422.92 percent of total billed charges "X-ray of knee, 1-2 views" 753747_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 SIHO - ALL PLANS SIHO - ALL PLANS 392.4 90 999999999 264 422.92 percent of total billed charges "X-ray of knee, 1-2 views" 753747_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 UMR - ALL PLANS UMR - ALL PLANS 305.2 70 999999999 264 422.92 percent of total billed charges "X-ray of knee, 1-2 views" 753747_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 264 60.55 999999999 264 422.92 percent of total billed charges "X-ray of knee, 1-2 views" 753747_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 264 422.92 "X-ray of knee, 1-2 views" 753747_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 ANTHEM HMO ANTHEM HMO 999999999 264 422.92 "X-ray of knee, 1-2 views" 753747_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 264 422.92 "X-ray of knee, 1-2 views" 753747_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 264 422.92 "X-ray of knee, 1-2 views" 753747_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 264 422.92 "X-ray of knee, 1-2 views" 753747_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 294.74 67.6 999999999 264 422.92 percent of total billed charges "X-ray of knee, 1-2 views" 753749_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 283.4 65 999999999 264 422.92 percent of total billed charges "X-ray of knee, 1-2 views" 753749_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 422.92 97 999999999 264 422.92 percent of total billed charges "X-ray of knee, 1-2 views" 753749_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 AETNA AETNA 344.44 79 999999999 264 422.92 percent of total billed charges "X-ray of knee, 1-2 views" 753749_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 300.84 69 999999999 264 422.92 percent of total billed charges "X-ray of knee, 1-2 views" 753749_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 340.08 78 999999999 264 422.92 percent of total billed charges "X-ray of knee, 1-2 views" 753749_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 SIHO - ALL PLANS SIHO - ALL PLANS 392.4 90 999999999 264 422.92 percent of total billed charges "X-ray of knee, 1-2 views" 753749_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 UMR - ALL PLANS UMR - ALL PLANS 305.2 70 999999999 264 422.92 percent of total billed charges "X-ray of knee, 1-2 views" 753749_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 264 60.55 999999999 264 422.92 percent of total billed charges "X-ray of knee, 1-2 views" 753749_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 264 422.92 "X-ray of knee, 1-2 views" 753749_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 ANTHEM HMO ANTHEM HMO 999999999 264 422.92 "X-ray of knee, 1-2 views" 753749_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 264 422.92 "X-ray of knee, 1-2 views" 753749_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 264 422.92 "X-ray of knee, 1-2 views" 753749_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 264 422.92 "X-ray of knee, 1-2 views" 753749_1 CDM 0320 RC 73560 HCPCS inpatient 436 283.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 294.74 67.6 999999999 264 422.92 percent of total billed charges "X-ray of knee, 3 views" 753756_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 317.85 65 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 753756_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 474.33 97 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 753756_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 AETNA AETNA 386.31 79 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 753756_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 337.41 69 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 753756_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 381.42 78 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 753756_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 SIHO - ALL PLANS SIHO - ALL PLANS 440.1 90 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 753756_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 UMR - ALL PLANS UMR - ALL PLANS 342.3 70 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 753756_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 296.09 60.55 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 753756_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 296.09 474.33 "X-ray of knee, 3 views" 753756_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ANTHEM HMO ANTHEM HMO 999999999 296.09 474.33 "X-ray of knee, 3 views" 753756_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 296.09 474.33 "X-ray of knee, 3 views" 753756_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 296.09 474.33 "X-ray of knee, 3 views" 753756_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 296.09 474.33 "X-ray of knee, 3 views" 753756_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 330.56 67.6 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 4 or more views" 753759_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 361.4 65 999999999 336.66 539.32 percent of total billed charges "X-ray of knee, 4 or more views" 753759_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 539.32 97 999999999 336.66 539.32 percent of total billed charges "X-ray of knee, 4 or more views" 753759_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 AETNA AETNA 439.24 79 999999999 336.66 539.32 percent of total billed charges "X-ray of knee, 4 or more views" 753759_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 383.64 69 999999999 336.66 539.32 percent of total billed charges "X-ray of knee, 4 or more views" 753759_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 433.68 78 999999999 336.66 539.32 percent of total billed charges "X-ray of knee, 4 or more views" 753759_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 SIHO - ALL PLANS SIHO - ALL PLANS 500.4 90 999999999 336.66 539.32 percent of total billed charges "X-ray of knee, 4 or more views" 753759_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 UMR - ALL PLANS UMR - ALL PLANS 389.2 70 999999999 336.66 539.32 percent of total billed charges "X-ray of knee, 4 or more views" 753759_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 336.66 60.55 999999999 336.66 539.32 percent of total billed charges "X-ray of knee, 4 or more views" 753759_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 336.66 539.32 "X-ray of knee, 4 or more views" 753759_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 ANTHEM HMO ANTHEM HMO 999999999 336.66 539.32 "X-ray of knee, 4 or more views" 753759_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 336.66 539.32 "X-ray of knee, 4 or more views" 753759_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 336.66 539.32 "X-ray of knee, 4 or more views" 753759_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 336.66 539.32 "X-ray of knee, 4 or more views" 753759_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 375.86 67.6 999999999 336.66 539.32 percent of total billed charges "X-ray of knee, 4 or more views" 753761_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 361.4 65 999999999 336.66 539.32 percent of total billed charges "X-ray of knee, 4 or more views" 753761_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 539.32 97 999999999 336.66 539.32 percent of total billed charges "X-ray of knee, 4 or more views" 753761_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 AETNA AETNA 439.24 79 999999999 336.66 539.32 percent of total billed charges "X-ray of knee, 4 or more views" 753761_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 383.64 69 999999999 336.66 539.32 percent of total billed charges "X-ray of knee, 4 or more views" 753761_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 433.68 78 999999999 336.66 539.32 percent of total billed charges "X-ray of knee, 4 or more views" 753761_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 SIHO - ALL PLANS SIHO - ALL PLANS 500.4 90 999999999 336.66 539.32 percent of total billed charges "X-ray of knee, 4 or more views" 753761_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 UMR - ALL PLANS UMR - ALL PLANS 389.2 70 999999999 336.66 539.32 percent of total billed charges "X-ray of knee, 4 or more views" 753761_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 336.66 60.55 999999999 336.66 539.32 percent of total billed charges "X-ray of knee, 4 or more views" 753761_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 336.66 539.32 "X-ray of knee, 4 or more views" 753761_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 ANTHEM HMO ANTHEM HMO 999999999 336.66 539.32 "X-ray of knee, 4 or more views" 753761_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 336.66 539.32 "X-ray of knee, 4 or more views" 753761_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 336.66 539.32 "X-ray of knee, 4 or more views" 753761_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 336.66 539.32 "X-ray of knee, 4 or more views" 753761_1 CDM 0320 RC 73564 HCPCS inpatient 556 361.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 375.86 67.6 999999999 336.66 539.32 percent of total billed charges Review by radiologist of upper urinary tract image 753763_1 CDM 0320 RC 74425 HCPCS inpatient 957 622.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 622.05 65 999999999 579.46 928.29 percent of total billed charges Review by radiologist of upper urinary tract image 753763_1 CDM 0320 RC 74425 HCPCS inpatient 957 622.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 928.29 97 999999999 579.46 928.29 percent of total billed charges Review by radiologist of upper urinary tract image 753763_1 CDM 0320 RC 74425 HCPCS inpatient 957 622.05 AETNA AETNA 756.03 79 999999999 579.46 928.29 percent of total billed charges Review by radiologist of upper urinary tract image 753763_1 CDM 0320 RC 74425 HCPCS inpatient 957 622.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 660.33 69 999999999 579.46 928.29 percent of total billed charges Review by radiologist of upper urinary tract image 753763_1 CDM 0320 RC 74425 HCPCS inpatient 957 622.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 746.46 78 999999999 579.46 928.29 percent of total billed charges Review by radiologist of upper urinary tract image 753763_1 CDM 0320 RC 74425 HCPCS inpatient 957 622.05 SIHO - ALL PLANS SIHO - ALL PLANS 861.3 90 999999999 579.46 928.29 percent of total billed charges Review by radiologist of upper urinary tract image 753763_1 CDM 0320 RC 74425 HCPCS inpatient 957 622.05 UMR - ALL PLANS UMR - ALL PLANS 669.9 70 999999999 579.46 928.29 percent of total billed charges Review by radiologist of upper urinary tract image 753763_1 CDM 0320 RC 74425 HCPCS inpatient 957 622.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 579.46 60.55 999999999 579.46 928.29 percent of total billed charges Review by radiologist of upper urinary tract image 753763_1 CDM 0320 RC 74425 HCPCS inpatient 957 622.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 579.46 928.29 Review by radiologist of upper urinary tract image 753763_1 CDM 0320 RC 74425 HCPCS inpatient 957 622.05 ANTHEM HMO ANTHEM HMO 999999999 579.46 928.29 Review by radiologist of upper urinary tract image 753763_1 CDM 0320 RC 74425 HCPCS inpatient 957 622.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 579.46 928.29 Review by radiologist of upper urinary tract image 753763_1 CDM 0320 RC 74425 HCPCS inpatient 957 622.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 579.46 928.29 Review by radiologist of upper urinary tract image 753763_1 CDM 0320 RC 74425 HCPCS inpatient 957 622.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 579.46 928.29 Review by radiologist of upper urinary tract image 753763_1 CDM 0320 RC 74425 HCPCS inpatient 957 622.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 646.93 67.6 999999999 579.46 928.29 percent of total billed charges "X-ray of infant leg, minimum of 2 views" 753768_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 257.4 65 999999999 239.78 384.12 percent of total billed charges "X-ray of infant leg, minimum of 2 views" 753768_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 384.12 97 999999999 239.78 384.12 percent of total billed charges "X-ray of infant leg, minimum of 2 views" 753768_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 AETNA AETNA 312.84 79 999999999 239.78 384.12 percent of total billed charges "X-ray of infant leg, minimum of 2 views" 753768_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 273.24 69 999999999 239.78 384.12 percent of total billed charges "X-ray of infant leg, minimum of 2 views" 753768_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 308.88 78 999999999 239.78 384.12 percent of total billed charges "X-ray of infant leg, minimum of 2 views" 753768_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 SIHO - ALL PLANS SIHO - ALL PLANS 356.4 90 999999999 239.78 384.12 percent of total billed charges "X-ray of infant leg, minimum of 2 views" 753768_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 UMR - ALL PLANS UMR - ALL PLANS 277.2 70 999999999 239.78 384.12 percent of total billed charges "X-ray of infant leg, minimum of 2 views" 753768_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 239.78 60.55 999999999 239.78 384.12 percent of total billed charges "X-ray of infant leg, minimum of 2 views" 753768_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 239.78 384.12 "X-ray of infant leg, minimum of 2 views" 753768_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 ANTHEM HMO ANTHEM HMO 999999999 239.78 384.12 "X-ray of infant leg, minimum of 2 views" 753768_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 239.78 384.12 "X-ray of infant leg, minimum of 2 views" 753768_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 239.78 384.12 "X-ray of infant leg, minimum of 2 views" 753768_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 239.78 384.12 "X-ray of infant leg, minimum of 2 views" 753768_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 267.7 67.6 999999999 239.78 384.12 percent of total billed charges "X-ray of infant leg, minimum of 2 views" 753770_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 257.4 65 999999999 239.78 384.12 percent of total billed charges "X-ray of infant leg, minimum of 2 views" 753770_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 384.12 97 999999999 239.78 384.12 percent of total billed charges "X-ray of infant leg, minimum of 2 views" 753770_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 AETNA AETNA 312.84 79 999999999 239.78 384.12 percent of total billed charges "X-ray of infant leg, minimum of 2 views" 753770_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 273.24 69 999999999 239.78 384.12 percent of total billed charges "X-ray of infant leg, minimum of 2 views" 753770_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 308.88 78 999999999 239.78 384.12 percent of total billed charges "X-ray of infant leg, minimum of 2 views" 753770_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 SIHO - ALL PLANS SIHO - ALL PLANS 356.4 90 999999999 239.78 384.12 percent of total billed charges "X-ray of infant leg, minimum of 2 views" 753770_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 UMR - ALL PLANS UMR - ALL PLANS 277.2 70 999999999 239.78 384.12 percent of total billed charges "X-ray of infant leg, minimum of 2 views" 753770_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 239.78 60.55 999999999 239.78 384.12 percent of total billed charges "X-ray of infant leg, minimum of 2 views" 753770_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 239.78 384.12 "X-ray of infant leg, minimum of 2 views" 753770_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 ANTHEM HMO ANTHEM HMO 999999999 239.78 384.12 "X-ray of infant leg, minimum of 2 views" 753770_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 239.78 384.12 "X-ray of infant leg, minimum of 2 views" 753770_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 239.78 384.12 "X-ray of infant leg, minimum of 2 views" 753770_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 239.78 384.12 "X-ray of infant leg, minimum of 2 views" 753770_1 CDM 0320 RC 73592 HCPCS inpatient 396 257.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 267.7 67.6 999999999 239.78 384.12 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 753772_1 CDM 0320 RC 62270 HCPCS inpatient 807 524.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 524.55 65 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 753772_1 CDM 0320 RC 62270 HCPCS inpatient 807 524.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 782.79 97 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 753772_1 CDM 0320 RC 62270 HCPCS inpatient 807 524.55 AETNA AETNA 637.53 79 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 753772_1 CDM 0320 RC 62270 HCPCS inpatient 807 524.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 556.83 69 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 753772_1 CDM 0320 RC 62270 HCPCS inpatient 807 524.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 629.46 78 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 753772_1 CDM 0320 RC 62270 HCPCS inpatient 807 524.55 SIHO - ALL PLANS SIHO - ALL PLANS 726.3 90 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 753772_1 CDM 0320 RC 62270 HCPCS inpatient 807 524.55 UMR - ALL PLANS UMR - ALL PLANS 564.9 70 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 753772_1 CDM 0320 RC 62270 HCPCS inpatient 807 524.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 488.64 60.55 999999999 488.64 782.79 percent of total billed charges Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 753772_1 CDM 0320 RC 62270 HCPCS inpatient 807 524.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 488.64 782.79 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 753772_1 CDM 0320 RC 62270 HCPCS inpatient 807 524.55 ANTHEM HMO ANTHEM HMO 999999999 488.64 782.79 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 753772_1 CDM 0320 RC 62270 HCPCS inpatient 807 524.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 488.64 782.79 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 753772_1 CDM 0320 RC 62270 HCPCS inpatient 807 524.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 488.64 782.79 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 753772_1 CDM 0320 RC 62270 HCPCS inpatient 807 524.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 488.64 782.79 Removal of cerebrospinal fluid with lower back spinal tap for diagnostic test 753772_1 CDM 0320 RC 62270 HCPCS inpatient 807 524.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 545.53 67.6 999999999 488.64 782.79 percent of total billed charges "X-ray of part of lower jaw, 1-4 views" 753777_1 CDM 0320 RC 70100 HCPCS inpatient 517 336.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 336.05 65 999999999 313.04 501.49 percent of total billed charges "X-ray of part of lower jaw, 1-4 views" 753777_1 CDM 0320 RC 70100 HCPCS inpatient 517 336.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 501.49 97 999999999 313.04 501.49 percent of total billed charges "X-ray of part of lower jaw, 1-4 views" 753777_1 CDM 0320 RC 70100 HCPCS inpatient 517 336.05 AETNA AETNA 408.43 79 999999999 313.04 501.49 percent of total billed charges "X-ray of part of lower jaw, 1-4 views" 753777_1 CDM 0320 RC 70100 HCPCS inpatient 517 336.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 356.73 69 999999999 313.04 501.49 percent of total billed charges "X-ray of part of lower jaw, 1-4 views" 753777_1 CDM 0320 RC 70100 HCPCS inpatient 517 336.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 403.26 78 999999999 313.04 501.49 percent of total billed charges "X-ray of part of lower jaw, 1-4 views" 753777_1 CDM 0320 RC 70100 HCPCS inpatient 517 336.05 SIHO - ALL PLANS SIHO - ALL PLANS 465.3 90 999999999 313.04 501.49 percent of total billed charges "X-ray of part of lower jaw, 1-4 views" 753777_1 CDM 0320 RC 70100 HCPCS inpatient 517 336.05 UMR - ALL PLANS UMR - ALL PLANS 361.9 70 999999999 313.04 501.49 percent of total billed charges "X-ray of part of lower jaw, 1-4 views" 753777_1 CDM 0320 RC 70100 HCPCS inpatient 517 336.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 313.04 60.55 999999999 313.04 501.49 percent of total billed charges "X-ray of part of lower jaw, 1-4 views" 753777_1 CDM 0320 RC 70100 HCPCS inpatient 517 336.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 313.04 501.49 "X-ray of part of lower jaw, 1-4 views" 753777_1 CDM 0320 RC 70100 HCPCS inpatient 517 336.05 ANTHEM HMO ANTHEM HMO 999999999 313.04 501.49 "X-ray of part of lower jaw, 1-4 views" 753777_1 CDM 0320 RC 70100 HCPCS inpatient 517 336.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 313.04 501.49 "X-ray of part of lower jaw, 1-4 views" 753777_1 CDM 0320 RC 70100 HCPCS inpatient 517 336.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 313.04 501.49 "X-ray of part of lower jaw, 1-4 views" 753777_1 CDM 0320 RC 70100 HCPCS inpatient 517 336.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 313.04 501.49 "X-ray of part of lower jaw, 1-4 views" 753777_1 CDM 0320 RC 70100 HCPCS inpatient 517 336.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 349.49 67.6 999999999 313.04 501.49 percent of total billed charges "X-ray of bone behind the ear, minimum of 3 views per side" 753783_1 CDM 0320 RC 70130 HCPCS inpatient 600 390 SELF PAY DISCOUNT SELF PAY DISCOUNT 390 65 999999999 363.3 582 percent of total billed charges "X-ray of bone behind the ear, minimum of 3 views per side" 753783_1 CDM 0320 RC 70130 HCPCS inpatient 600 390 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 582 97 999999999 363.3 582 percent of total billed charges "X-ray of bone behind the ear, minimum of 3 views per side" 753783_1 CDM 0320 RC 70130 HCPCS inpatient 600 390 AETNA AETNA 474 79 999999999 363.3 582 percent of total billed charges "X-ray of bone behind the ear, minimum of 3 views per side" 753783_1 CDM 0320 RC 70130 HCPCS inpatient 600 390 ENCORE - ALL PLANS ENCORE - ALL PLANS 414 69 999999999 363.3 582 percent of total billed charges "X-ray of bone behind the ear, minimum of 3 views per side" 753783_1 CDM 0320 RC 70130 HCPCS inpatient 600 390 HUMANA - ALL PLANS HUMANA - ALL PLANS 468 78 999999999 363.3 582 percent of total billed charges "X-ray of bone behind the ear, minimum of 3 views per side" 753783_1 CDM 0320 RC 70130 HCPCS inpatient 600 390 SIHO - ALL PLANS SIHO - ALL PLANS 540 90 999999999 363.3 582 percent of total billed charges "X-ray of bone behind the ear, minimum of 3 views per side" 753783_1 CDM 0320 RC 70130 HCPCS inpatient 600 390 UMR - ALL PLANS UMR - ALL PLANS 420 70 999999999 363.3 582 percent of total billed charges "X-ray of bone behind the ear, minimum of 3 views per side" 753783_1 CDM 0320 RC 70130 HCPCS inpatient 600 390 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 363.3 60.55 999999999 363.3 582 percent of total billed charges "X-ray of bone behind the ear, minimum of 3 views per side" 753783_1 CDM 0320 RC 70130 HCPCS inpatient 600 390 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 363.3 582 "X-ray of bone behind the ear, minimum of 3 views per side" 753783_1 CDM 0320 RC 70130 HCPCS inpatient 600 390 ANTHEM HMO ANTHEM HMO 999999999 363.3 582 "X-ray of bone behind the ear, minimum of 3 views per side" 753783_1 CDM 0320 RC 70130 HCPCS inpatient 600 390 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 363.3 582 "X-ray of bone behind the ear, minimum of 3 views per side" 753783_1 CDM 0320 RC 70130 HCPCS inpatient 600 390 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 363.3 582 "X-ray of bone behind the ear, minimum of 3 views per side" 753783_1 CDM 0320 RC 70130 HCPCS inpatient 600 390 UHC - ALL PLANS UHC - ALL PLANS 999999999 363.3 582 "X-ray of bone behind the ear, minimum of 3 views per side" 753783_1 CDM 0320 RC 70130 HCPCS inpatient 600 390 CIGNA - ALL PLANS CIGNA - ALL PLANS 405.6 67.6 999999999 363.3 582 percent of total billed charges Review by radiologist of upper spinal canal image 753785_1 CDM 0320 RC 72240 HCPCS inpatient 1537 999.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 999.05 65 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of upper spinal canal image 753785_1 CDM 0320 RC 72240 HCPCS inpatient 1537 999.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1490.89 97 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of upper spinal canal image 753785_1 CDM 0320 RC 72240 HCPCS inpatient 1537 999.05 AETNA AETNA 1214.23 79 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of upper spinal canal image 753785_1 CDM 0320 RC 72240 HCPCS inpatient 1537 999.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1060.53 69 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of upper spinal canal image 753785_1 CDM 0320 RC 72240 HCPCS inpatient 1537 999.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1198.86 78 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of upper spinal canal image 753785_1 CDM 0320 RC 72240 HCPCS inpatient 1537 999.05 SIHO - ALL PLANS SIHO - ALL PLANS 1383.3 90 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of upper spinal canal image 753785_1 CDM 0320 RC 72240 HCPCS inpatient 1537 999.05 UMR - ALL PLANS UMR - ALL PLANS 1075.9 70 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of upper spinal canal image 753785_1 CDM 0320 RC 72240 HCPCS inpatient 1537 999.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 930.65 60.55 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of upper spinal canal image 753785_1 CDM 0320 RC 72240 HCPCS inpatient 1537 999.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 930.65 1490.89 Review by radiologist of upper spinal canal image 753785_1 CDM 0320 RC 72240 HCPCS inpatient 1537 999.05 ANTHEM HMO ANTHEM HMO 999999999 930.65 1490.89 Review by radiologist of upper spinal canal image 753785_1 CDM 0320 RC 72240 HCPCS inpatient 1537 999.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 930.65 1490.89 Review by radiologist of upper spinal canal image 753785_1 CDM 0320 RC 72240 HCPCS inpatient 1537 999.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 930.65 1490.89 Review by radiologist of upper spinal canal image 753785_1 CDM 0320 RC 72240 HCPCS inpatient 1537 999.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 930.65 1490.89 Review by radiologist of upper spinal canal image 753785_1 CDM 0320 RC 72240 HCPCS inpatient 1537 999.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1039.01 67.6 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of lower spinal canal image 753790_1 CDM 0320 RC 72265 HCPCS inpatient 1537 999.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 999.05 65 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of lower spinal canal image 753790_1 CDM 0320 RC 72265 HCPCS inpatient 1537 999.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1490.89 97 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of lower spinal canal image 753790_1 CDM 0320 RC 72265 HCPCS inpatient 1537 999.05 AETNA AETNA 1214.23 79 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of lower spinal canal image 753790_1 CDM 0320 RC 72265 HCPCS inpatient 1537 999.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1060.53 69 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of lower spinal canal image 753790_1 CDM 0320 RC 72265 HCPCS inpatient 1537 999.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1198.86 78 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of lower spinal canal image 753790_1 CDM 0320 RC 72265 HCPCS inpatient 1537 999.05 SIHO - ALL PLANS SIHO - ALL PLANS 1383.3 90 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of lower spinal canal image 753790_1 CDM 0320 RC 72265 HCPCS inpatient 1537 999.05 UMR - ALL PLANS UMR - ALL PLANS 1075.9 70 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of lower spinal canal image 753790_1 CDM 0320 RC 72265 HCPCS inpatient 1537 999.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 930.65 60.55 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of lower spinal canal image 753790_1 CDM 0320 RC 72265 HCPCS inpatient 1537 999.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 930.65 1490.89 Review by radiologist of lower spinal canal image 753790_1 CDM 0320 RC 72265 HCPCS inpatient 1537 999.05 ANTHEM HMO ANTHEM HMO 999999999 930.65 1490.89 Review by radiologist of lower spinal canal image 753790_1 CDM 0320 RC 72265 HCPCS inpatient 1537 999.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 930.65 1490.89 Review by radiologist of lower spinal canal image 753790_1 CDM 0320 RC 72265 HCPCS inpatient 1537 999.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 930.65 1490.89 Review by radiologist of lower spinal canal image 753790_1 CDM 0320 RC 72265 HCPCS inpatient 1537 999.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 930.65 1490.89 Review by radiologist of lower spinal canal image 753790_1 CDM 0320 RC 72265 HCPCS inpatient 1537 999.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1039.01 67.6 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of middle spinal canal image 753800_1 CDM 0320 RC 72255 HCPCS inpatient 1537 999.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 999.05 65 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of middle spinal canal image 753800_1 CDM 0320 RC 72255 HCPCS inpatient 1537 999.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1490.89 97 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of middle spinal canal image 753800_1 CDM 0320 RC 72255 HCPCS inpatient 1537 999.05 AETNA AETNA 1214.23 79 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of middle spinal canal image 753800_1 CDM 0320 RC 72255 HCPCS inpatient 1537 999.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1198.86 78 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of middle spinal canal image 753800_1 CDM 0320 RC 72255 HCPCS inpatient 1537 999.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1060.53 69 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of middle spinal canal image 753800_1 CDM 0320 RC 72255 HCPCS inpatient 1537 999.05 SIHO - ALL PLANS SIHO - ALL PLANS 1383.3 90 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of middle spinal canal image 753800_1 CDM 0320 RC 72255 HCPCS inpatient 1537 999.05 UMR - ALL PLANS UMR - ALL PLANS 1075.9 70 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of middle spinal canal image 753800_1 CDM 0320 RC 72255 HCPCS inpatient 1537 999.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 930.65 60.55 999999999 930.65 1490.89 percent of total billed charges Review by radiologist of middle spinal canal image 753800_1 CDM 0320 RC 72255 HCPCS inpatient 1537 999.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 930.65 1490.89 Review by radiologist of middle spinal canal image 753800_1 CDM 0320 RC 72255 HCPCS inpatient 1537 999.05 ANTHEM HMO ANTHEM HMO 999999999 930.65 1490.89 Review by radiologist of middle spinal canal image 753800_1 CDM 0320 RC 72255 HCPCS inpatient 1537 999.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 930.65 1490.89 Review by radiologist of middle spinal canal image 753800_1 CDM 0320 RC 72255 HCPCS inpatient 1537 999.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 930.65 1490.89 Review by radiologist of middle spinal canal image 753800_1 CDM 0320 RC 72255 HCPCS inpatient 1537 999.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 930.65 1490.89 Review by radiologist of middle spinal canal image 753800_1 CDM 0320 RC 72255 HCPCS inpatient 1537 999.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1039.01 67.6 999999999 930.65 1490.89 percent of total billed charges "X-ray of nose bones, minimum of 3 views" 753805_1 CDM 0320 RC 70160 HCPCS inpatient 585 380.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 380.25 65 999999999 354.22 567.45 percent of total billed charges "X-ray of nose bones, minimum of 3 views" 753805_1 CDM 0320 RC 70160 HCPCS inpatient 585 380.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 567.45 97 999999999 354.22 567.45 percent of total billed charges "X-ray of nose bones, minimum of 3 views" 753805_1 CDM 0320 RC 70160 HCPCS inpatient 585 380.25 AETNA AETNA 462.15 79 999999999 354.22 567.45 percent of total billed charges "X-ray of nose bones, minimum of 3 views" 753805_1 CDM 0320 RC 70160 HCPCS inpatient 585 380.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 456.3 78 999999999 354.22 567.45 percent of total billed charges "X-ray of nose bones, minimum of 3 views" 753805_1 CDM 0320 RC 70160 HCPCS inpatient 585 380.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 403.65 69 999999999 354.22 567.45 percent of total billed charges "X-ray of nose bones, minimum of 3 views" 753805_1 CDM 0320 RC 70160 HCPCS inpatient 585 380.25 SIHO - ALL PLANS SIHO - ALL PLANS 526.5 90 999999999 354.22 567.45 percent of total billed charges "X-ray of nose bones, minimum of 3 views" 753805_1 CDM 0320 RC 70160 HCPCS inpatient 585 380.25 UMR - ALL PLANS UMR - ALL PLANS 409.5 70 999999999 354.22 567.45 percent of total billed charges "X-ray of nose bones, minimum of 3 views" 753805_1 CDM 0320 RC 70160 HCPCS inpatient 585 380.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 354.22 60.55 999999999 354.22 567.45 percent of total billed charges "X-ray of nose bones, minimum of 3 views" 753805_1 CDM 0320 RC 70160 HCPCS inpatient 585 380.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 354.22 567.45 "X-ray of nose bones, minimum of 3 views" 753805_1 CDM 0320 RC 70160 HCPCS inpatient 585 380.25 ANTHEM HMO ANTHEM HMO 999999999 354.22 567.45 "X-ray of nose bones, minimum of 3 views" 753805_1 CDM 0320 RC 70160 HCPCS inpatient 585 380.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 354.22 567.45 "X-ray of nose bones, minimum of 3 views" 753805_1 CDM 0320 RC 70160 HCPCS inpatient 585 380.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 354.22 567.45 "X-ray of nose bones, minimum of 3 views" 753805_1 CDM 0320 RC 70160 HCPCS inpatient 585 380.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 354.22 567.45 "X-ray of nose bones, minimum of 3 views" 753805_1 CDM 0320 RC 70160 HCPCS inpatient 585 380.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 395.46 67.6 999999999 354.22 567.45 percent of total billed charges X-ray of soft tissue of neck 753807_1 CDM 0320 RC 70360 HCPCS inpatient 396 257.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 257.4 65 999999999 239.78 384.12 percent of total billed charges X-ray of soft tissue of neck 753807_1 CDM 0320 RC 70360 HCPCS inpatient 396 257.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 384.12 97 999999999 239.78 384.12 percent of total billed charges X-ray of soft tissue of neck 753807_1 CDM 0320 RC 70360 HCPCS inpatient 396 257.4 AETNA AETNA 312.84 79 999999999 239.78 384.12 percent of total billed charges X-ray of soft tissue of neck 753807_1 CDM 0320 RC 70360 HCPCS inpatient 396 257.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 308.88 78 999999999 239.78 384.12 percent of total billed charges X-ray of soft tissue of neck 753807_1 CDM 0320 RC 70360 HCPCS inpatient 396 257.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 273.24 69 999999999 239.78 384.12 percent of total billed charges X-ray of soft tissue of neck 753807_1 CDM 0320 RC 70360 HCPCS inpatient 396 257.4 SIHO - ALL PLANS SIHO - ALL PLANS 356.4 90 999999999 239.78 384.12 percent of total billed charges X-ray of soft tissue of neck 753807_1 CDM 0320 RC 70360 HCPCS inpatient 396 257.4 UMR - ALL PLANS UMR - ALL PLANS 277.2 70 999999999 239.78 384.12 percent of total billed charges X-ray of soft tissue of neck 753807_1 CDM 0320 RC 70360 HCPCS inpatient 396 257.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 239.78 60.55 999999999 239.78 384.12 percent of total billed charges X-ray of soft tissue of neck 753807_1 CDM 0320 RC 70360 HCPCS inpatient 396 257.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 239.78 384.12 X-ray of soft tissue of neck 753807_1 CDM 0320 RC 70360 HCPCS inpatient 396 257.4 ANTHEM HMO ANTHEM HMO 999999999 239.78 384.12 X-ray of soft tissue of neck 753807_1 CDM 0320 RC 70360 HCPCS inpatient 396 257.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 239.78 384.12 X-ray of soft tissue of neck 753807_1 CDM 0320 RC 70360 HCPCS inpatient 396 257.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 239.78 384.12 X-ray of soft tissue of neck 753807_1 CDM 0320 RC 70360 HCPCS inpatient 396 257.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 239.78 384.12 X-ray of soft tissue of neck 753807_1 CDM 0320 RC 70360 HCPCS inpatient 396 257.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 267.7 67.6 999999999 239.78 384.12 percent of total billed charges X-ray of eye for detection of foreign body 753809_1 CDM 0320 RC 70030 HCPCS inpatient 420 273 SELF PAY DISCOUNT SELF PAY DISCOUNT 273 65 999999999 254.31 407.4 percent of total billed charges X-ray of eye for detection of foreign body 753809_1 CDM 0320 RC 70030 HCPCS inpatient 420 273 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 407.4 97 999999999 254.31 407.4 percent of total billed charges X-ray of eye for detection of foreign body 753809_1 CDM 0320 RC 70030 HCPCS inpatient 420 273 AETNA AETNA 331.8 79 999999999 254.31 407.4 percent of total billed charges X-ray of eye for detection of foreign body 753809_1 CDM 0320 RC 70030 HCPCS inpatient 420 273 HUMANA - ALL PLANS HUMANA - ALL PLANS 327.6 78 999999999 254.31 407.4 percent of total billed charges X-ray of eye for detection of foreign body 753809_1 CDM 0320 RC 70030 HCPCS inpatient 420 273 ENCORE - ALL PLANS ENCORE - ALL PLANS 289.8 69 999999999 254.31 407.4 percent of total billed charges X-ray of eye for detection of foreign body 753809_1 CDM 0320 RC 70030 HCPCS inpatient 420 273 SIHO - ALL PLANS SIHO - ALL PLANS 378 90 999999999 254.31 407.4 percent of total billed charges X-ray of eye for detection of foreign body 753809_1 CDM 0320 RC 70030 HCPCS inpatient 420 273 UMR - ALL PLANS UMR - ALL PLANS 294 70 999999999 254.31 407.4 percent of total billed charges X-ray of eye for detection of foreign body 753809_1 CDM 0320 RC 70030 HCPCS inpatient 420 273 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 254.31 60.55 999999999 254.31 407.4 percent of total billed charges X-ray of eye for detection of foreign body 753809_1 CDM 0320 RC 70030 HCPCS inpatient 420 273 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 254.31 407.4 X-ray of eye for detection of foreign body 753809_1 CDM 0320 RC 70030 HCPCS inpatient 420 273 ANTHEM HMO ANTHEM HMO 999999999 254.31 407.4 X-ray of eye for detection of foreign body 753809_1 CDM 0320 RC 70030 HCPCS inpatient 420 273 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 254.31 407.4 X-ray of eye for detection of foreign body 753809_1 CDM 0320 RC 70030 HCPCS inpatient 420 273 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 254.31 407.4 X-ray of eye for detection of foreign body 753809_1 CDM 0320 RC 70030 HCPCS inpatient 420 273 UHC - ALL PLANS UHC - ALL PLANS 999999999 254.31 407.4 X-ray of eye for detection of foreign body 753809_1 CDM 0320 RC 70030 HCPCS inpatient 420 273 CIGNA - ALL PLANS CIGNA - ALL PLANS 283.92 67.6 999999999 254.31 407.4 percent of total billed charges "X-ray of hip, 2-3 views" 753817_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 302.25 65 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 753817_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 451.05 97 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 753817_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 AETNA AETNA 367.35 79 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 753817_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 362.7 78 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 753817_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 320.85 69 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 753817_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 SIHO - ALL PLANS SIHO - ALL PLANS 418.5 90 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 753817_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 UMR - ALL PLANS UMR - ALL PLANS 325.5 70 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 753817_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 281.56 60.55 999999999 281.56 451.05 percent of total billed charges "X-ray of hip, 2-3 views" 753817_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 281.56 451.05 "X-ray of hip, 2-3 views" 753817_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 ANTHEM HMO ANTHEM HMO 999999999 281.56 451.05 "X-ray of hip, 2-3 views" 753817_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 281.56 451.05 "X-ray of hip, 2-3 views" 753817_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 281.56 451.05 "X-ray of hip, 2-3 views" 753817_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 281.56 451.05 "X-ray of hip, 2-3 views" 753817_1 CDM 0320 RC 73502 HCPCS inpatient 465 302.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 314.34 67.6 999999999 281.56 451.05 percent of total billed charges "X-ray of pelvis, 1-2 views" 753819_1 CDM 0320 RC 72170 HCPCS inpatient 546 354.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 354.9 65 999999999 330.6 529.62 percent of total billed charges "X-ray of pelvis, 1-2 views" 753819_1 CDM 0320 RC 72170 HCPCS inpatient 546 354.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 529.62 97 999999999 330.6 529.62 percent of total billed charges "X-ray of pelvis, 1-2 views" 753819_1 CDM 0320 RC 72170 HCPCS inpatient 546 354.9 AETNA AETNA 431.34 79 999999999 330.6 529.62 percent of total billed charges "X-ray of pelvis, 1-2 views" 753819_1 CDM 0320 RC 72170 HCPCS inpatient 546 354.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 425.88 78 999999999 330.6 529.62 percent of total billed charges "X-ray of pelvis, 1-2 views" 753819_1 CDM 0320 RC 72170 HCPCS inpatient 546 354.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 376.74 69 999999999 330.6 529.62 percent of total billed charges "X-ray of pelvis, 1-2 views" 753819_1 CDM 0320 RC 72170 HCPCS inpatient 546 354.9 SIHO - ALL PLANS SIHO - ALL PLANS 491.4 90 999999999 330.6 529.62 percent of total billed charges "X-ray of pelvis, 1-2 views" 753819_1 CDM 0320 RC 72170 HCPCS inpatient 546 354.9 UMR - ALL PLANS UMR - ALL PLANS 382.2 70 999999999 330.6 529.62 percent of total billed charges "X-ray of pelvis, 1-2 views" 753819_1 CDM 0320 RC 72170 HCPCS inpatient 546 354.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 330.6 60.55 999999999 330.6 529.62 percent of total billed charges "X-ray of pelvis, 1-2 views" 753819_1 CDM 0320 RC 72170 HCPCS inpatient 546 354.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 330.6 529.62 "X-ray of pelvis, 1-2 views" 753819_1 CDM 0320 RC 72170 HCPCS inpatient 546 354.9 ANTHEM HMO ANTHEM HMO 999999999 330.6 529.62 "X-ray of pelvis, 1-2 views" 753819_1 CDM 0320 RC 72170 HCPCS inpatient 546 354.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 330.6 529.62 "X-ray of pelvis, 1-2 views" 753819_1 CDM 0320 RC 72170 HCPCS inpatient 546 354.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 330.6 529.62 "X-ray of pelvis, 1-2 views" 753819_1 CDM 0320 RC 72170 HCPCS inpatient 546 354.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 330.6 529.62 "X-ray of pelvis, 1-2 views" 753819_1 CDM 0320 RC 72170 HCPCS inpatient 546 354.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 369.1 67.6 999999999 330.6 529.62 percent of total billed charges "X-ray of joint between lower spine and hip bone, 3 or more views" 753833_1 CDM 0320 RC 72202 HCPCS inpatient 474 308.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 308.1 65 999999999 287.01 459.78 percent of total billed charges "X-ray of joint between lower spine and hip bone, 3 or more views" 753833_1 CDM 0320 RC 72202 HCPCS inpatient 474 308.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 459.78 97 999999999 287.01 459.78 percent of total billed charges "X-ray of joint between lower spine and hip bone, 3 or more views" 753833_1 CDM 0320 RC 72202 HCPCS inpatient 474 308.1 AETNA AETNA 374.46 79 999999999 287.01 459.78 percent of total billed charges "X-ray of joint between lower spine and hip bone, 3 or more views" 753833_1 CDM 0320 RC 72202 HCPCS inpatient 474 308.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 369.72 78 999999999 287.01 459.78 percent of total billed charges "X-ray of joint between lower spine and hip bone, 3 or more views" 753833_1 CDM 0320 RC 72202 HCPCS inpatient 474 308.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 327.06 69 999999999 287.01 459.78 percent of total billed charges "X-ray of joint between lower spine and hip bone, 3 or more views" 753833_1 CDM 0320 RC 72202 HCPCS inpatient 474 308.1 SIHO - ALL PLANS SIHO - ALL PLANS 426.6 90 999999999 287.01 459.78 percent of total billed charges "X-ray of joint between lower spine and hip bone, 3 or more views" 753833_1 CDM 0320 RC 72202 HCPCS inpatient 474 308.1 UMR - ALL PLANS UMR - ALL PLANS 331.8 70 999999999 287.01 459.78 percent of total billed charges "X-ray of joint between lower spine and hip bone, 3 or more views" 753833_1 CDM 0320 RC 72202 HCPCS inpatient 474 308.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 287.01 60.55 999999999 287.01 459.78 percent of total billed charges "X-ray of joint between lower spine and hip bone, 3 or more views" 753833_1 CDM 0320 RC 72202 HCPCS inpatient 474 308.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 287.01 459.78 "X-ray of joint between lower spine and hip bone, 3 or more views" 753833_1 CDM 0320 RC 72202 HCPCS inpatient 474 308.1 ANTHEM HMO ANTHEM HMO 999999999 287.01 459.78 "X-ray of joint between lower spine and hip bone, 3 or more views" 753833_1 CDM 0320 RC 72202 HCPCS inpatient 474 308.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 287.01 459.78 "X-ray of joint between lower spine and hip bone, 3 or more views" 753833_1 CDM 0320 RC 72202 HCPCS inpatient 474 308.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 287.01 459.78 "X-ray of joint between lower spine and hip bone, 3 or more views" 753833_1 CDM 0320 RC 72202 HCPCS inpatient 474 308.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 287.01 459.78 "X-ray of joint between lower spine and hip bone, 3 or more views" 753833_1 CDM 0320 RC 72202 HCPCS inpatient 474 308.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 320.42 67.6 999999999 287.01 459.78 percent of total billed charges "X-ray of sacrum and tailbone, minimum of 2 views" 753835_1 CDM 0320 RC 72220 HCPCS inpatient 439 285.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 285.35 65 999999999 265.81 425.83 percent of total billed charges "X-ray of sacrum and tailbone, minimum of 2 views" 753835_1 CDM 0320 RC 72220 HCPCS inpatient 439 285.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 425.83 97 999999999 265.81 425.83 percent of total billed charges "X-ray of sacrum and tailbone, minimum of 2 views" 753835_1 CDM 0320 RC 72220 HCPCS inpatient 439 285.35 AETNA AETNA 346.81 79 999999999 265.81 425.83 percent of total billed charges "X-ray of sacrum and tailbone, minimum of 2 views" 753835_1 CDM 0320 RC 72220 HCPCS inpatient 439 285.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 342.42 78 999999999 265.81 425.83 percent of total billed charges "X-ray of sacrum and tailbone, minimum of 2 views" 753835_1 CDM 0320 RC 72220 HCPCS inpatient 439 285.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 302.91 69 999999999 265.81 425.83 percent of total billed charges "X-ray of sacrum and tailbone, minimum of 2 views" 753835_1 CDM 0320 RC 72220 HCPCS inpatient 439 285.35 SIHO - ALL PLANS SIHO - ALL PLANS 395.1 90 999999999 265.81 425.83 percent of total billed charges "X-ray of sacrum and tailbone, minimum of 2 views" 753835_1 CDM 0320 RC 72220 HCPCS inpatient 439 285.35 UMR - ALL PLANS UMR - ALL PLANS 307.3 70 999999999 265.81 425.83 percent of total billed charges "X-ray of sacrum and tailbone, minimum of 2 views" 753835_1 CDM 0320 RC 72220 HCPCS inpatient 439 285.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 265.81 60.55 999999999 265.81 425.83 percent of total billed charges "X-ray of sacrum and tailbone, minimum of 2 views" 753835_1 CDM 0320 RC 72220 HCPCS inpatient 439 285.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 265.81 425.83 "X-ray of sacrum and tailbone, minimum of 2 views" 753835_1 CDM 0320 RC 72220 HCPCS inpatient 439 285.35 ANTHEM HMO ANTHEM HMO 999999999 265.81 425.83 "X-ray of sacrum and tailbone, minimum of 2 views" 753835_1 CDM 0320 RC 72220 HCPCS inpatient 439 285.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 265.81 425.83 "X-ray of sacrum and tailbone, minimum of 2 views" 753835_1 CDM 0320 RC 72220 HCPCS inpatient 439 285.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 265.81 425.83 "X-ray of sacrum and tailbone, minimum of 2 views" 753835_1 CDM 0320 RC 72220 HCPCS inpatient 439 285.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 265.81 425.83 "X-ray of sacrum and tailbone, minimum of 2 views" 753835_1 CDM 0320 RC 72220 HCPCS inpatient 439 285.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 296.76 67.6 999999999 265.81 425.83 percent of total billed charges X-ray of shoulder blade 753839_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 SELF PAY DISCOUNT SELF PAY DISCOUNT 312 65 999999999 290.64 465.6 percent of total billed charges X-ray of shoulder blade 753839_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 465.6 97 999999999 290.64 465.6 percent of total billed charges X-ray of shoulder blade 753839_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 AETNA AETNA 379.2 79 999999999 290.64 465.6 percent of total billed charges X-ray of shoulder blade 753839_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 HUMANA - ALL PLANS HUMANA - ALL PLANS 374.4 78 999999999 290.64 465.6 percent of total billed charges X-ray of shoulder blade 753839_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 ENCORE - ALL PLANS ENCORE - ALL PLANS 331.2 69 999999999 290.64 465.6 percent of total billed charges X-ray of shoulder blade 753839_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 SIHO - ALL PLANS SIHO - ALL PLANS 432 90 999999999 290.64 465.6 percent of total billed charges X-ray of shoulder blade 753839_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 UMR - ALL PLANS UMR - ALL PLANS 336 70 999999999 290.64 465.6 percent of total billed charges X-ray of shoulder blade 753839_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 290.64 60.55 999999999 290.64 465.6 percent of total billed charges X-ray of shoulder blade 753839_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 290.64 465.6 X-ray of shoulder blade 753839_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 ANTHEM HMO ANTHEM HMO 999999999 290.64 465.6 X-ray of shoulder blade 753839_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 290.64 465.6 X-ray of shoulder blade 753839_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 290.64 465.6 X-ray of shoulder blade 753839_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 UHC - ALL PLANS UHC - ALL PLANS 999999999 290.64 465.6 X-ray of shoulder blade 753839_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 CIGNA - ALL PLANS CIGNA - ALL PLANS 324.48 67.6 999999999 290.64 465.6 percent of total billed charges X-ray of shoulder blade 753841_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 SELF PAY DISCOUNT SELF PAY DISCOUNT 312 65 999999999 290.64 465.6 percent of total billed charges X-ray of shoulder blade 753841_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 465.6 97 999999999 290.64 465.6 percent of total billed charges X-ray of shoulder blade 753841_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 AETNA AETNA 379.2 79 999999999 290.64 465.6 percent of total billed charges X-ray of shoulder blade 753841_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 HUMANA - ALL PLANS HUMANA - ALL PLANS 374.4 78 999999999 290.64 465.6 percent of total billed charges X-ray of shoulder blade 753841_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 ENCORE - ALL PLANS ENCORE - ALL PLANS 331.2 69 999999999 290.64 465.6 percent of total billed charges X-ray of shoulder blade 753841_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 SIHO - ALL PLANS SIHO - ALL PLANS 432 90 999999999 290.64 465.6 percent of total billed charges X-ray of shoulder blade 753841_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 UMR - ALL PLANS UMR - ALL PLANS 336 70 999999999 290.64 465.6 percent of total billed charges X-ray of shoulder blade 753841_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 290.64 60.55 999999999 290.64 465.6 percent of total billed charges X-ray of shoulder blade 753841_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 290.64 465.6 X-ray of shoulder blade 753841_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 ANTHEM HMO ANTHEM HMO 999999999 290.64 465.6 X-ray of shoulder blade 753841_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 290.64 465.6 X-ray of shoulder blade 753841_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 290.64 465.6 X-ray of shoulder blade 753841_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 UHC - ALL PLANS UHC - ALL PLANS 999999999 290.64 465.6 X-ray of shoulder blade 753841_1 CDM 0320 RC 73010 HCPCS inpatient 480 312 CIGNA - ALL PLANS CIGNA - ALL PLANS 324.48 67.6 999999999 290.64 465.6 percent of total billed charges Review by radiologist of salivary structure image 753857_1 CDM 0320 RC 70390 HCPCS inpatient 763 495.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 495.95 65 999999999 462 740.11 percent of total billed charges Review by radiologist of salivary structure image 753857_1 CDM 0320 RC 70390 HCPCS inpatient 763 495.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 740.11 97 999999999 462 740.11 percent of total billed charges Review by radiologist of salivary structure image 753857_1 CDM 0320 RC 70390 HCPCS inpatient 763 495.95 AETNA AETNA 602.77 79 999999999 462 740.11 percent of total billed charges Review by radiologist of salivary structure image 753857_1 CDM 0320 RC 70390 HCPCS inpatient 763 495.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 595.14 78 999999999 462 740.11 percent of total billed charges Review by radiologist of salivary structure image 753857_1 CDM 0320 RC 70390 HCPCS inpatient 763 495.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 526.47 69 999999999 462 740.11 percent of total billed charges Review by radiologist of salivary structure image 753857_1 CDM 0320 RC 70390 HCPCS inpatient 763 495.95 SIHO - ALL PLANS SIHO - ALL PLANS 686.7 90 999999999 462 740.11 percent of total billed charges Review by radiologist of salivary structure image 753857_1 CDM 0320 RC 70390 HCPCS inpatient 763 495.95 UMR - ALL PLANS UMR - ALL PLANS 534.1 70 999999999 462 740.11 percent of total billed charges Review by radiologist of salivary structure image 753857_1 CDM 0320 RC 70390 HCPCS inpatient 763 495.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 462 60.55 999999999 462 740.11 percent of total billed charges Review by radiologist of salivary structure image 753857_1 CDM 0320 RC 70390 HCPCS inpatient 763 495.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 462 740.11 Review by radiologist of salivary structure image 753857_1 CDM 0320 RC 70390 HCPCS inpatient 763 495.95 ANTHEM HMO ANTHEM HMO 999999999 462 740.11 Review by radiologist of salivary structure image 753857_1 CDM 0320 RC 70390 HCPCS inpatient 763 495.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 462 740.11 Review by radiologist of salivary structure image 753857_1 CDM 0320 RC 70390 HCPCS inpatient 763 495.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 462 740.11 Review by radiologist of salivary structure image 753857_1 CDM 0320 RC 70390 HCPCS inpatient 763 495.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 462 740.11 Review by radiologist of salivary structure image 753857_1 CDM 0320 RC 70390 HCPCS inpatient 763 495.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 515.79 67.6 999999999 462 740.11 percent of total billed charges "X-ray of paranasal sinus, minimum of 3 views" 753863_1 CDM 0320 RC 70220 HCPCS inpatient 479 311.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 311.35 65 999999999 290.03 464.63 percent of total billed charges "X-ray of paranasal sinus, minimum of 3 views" 753863_1 CDM 0320 RC 70220 HCPCS inpatient 479 311.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 464.63 97 999999999 290.03 464.63 percent of total billed charges "X-ray of paranasal sinus, minimum of 3 views" 753863_1 CDM 0320 RC 70220 HCPCS inpatient 479 311.35 AETNA AETNA 378.41 79 999999999 290.03 464.63 percent of total billed charges "X-ray of paranasal sinus, minimum of 3 views" 753863_1 CDM 0320 RC 70220 HCPCS inpatient 479 311.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 373.62 78 999999999 290.03 464.63 percent of total billed charges "X-ray of paranasal sinus, minimum of 3 views" 753863_1 CDM 0320 RC 70220 HCPCS inpatient 479 311.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 330.51 69 999999999 290.03 464.63 percent of total billed charges "X-ray of paranasal sinus, minimum of 3 views" 753863_1 CDM 0320 RC 70220 HCPCS inpatient 479 311.35 SIHO - ALL PLANS SIHO - ALL PLANS 431.1 90 999999999 290.03 464.63 percent of total billed charges "X-ray of paranasal sinus, minimum of 3 views" 753863_1 CDM 0320 RC 70220 HCPCS inpatient 479 311.35 UMR - ALL PLANS UMR - ALL PLANS 335.3 70 999999999 290.03 464.63 percent of total billed charges "X-ray of paranasal sinus, minimum of 3 views" 753863_1 CDM 0320 RC 70220 HCPCS inpatient 479 311.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 290.03 60.55 999999999 290.03 464.63 percent of total billed charges "X-ray of paranasal sinus, minimum of 3 views" 753863_1 CDM 0320 RC 70220 HCPCS inpatient 479 311.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 290.03 464.63 "X-ray of paranasal sinus, minimum of 3 views" 753863_1 CDM 0320 RC 70220 HCPCS inpatient 479 311.35 ANTHEM HMO ANTHEM HMO 999999999 290.03 464.63 "X-ray of paranasal sinus, minimum of 3 views" 753863_1 CDM 0320 RC 70220 HCPCS inpatient 479 311.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 290.03 464.63 "X-ray of paranasal sinus, minimum of 3 views" 753863_1 CDM 0320 RC 70220 HCPCS inpatient 479 311.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 290.03 464.63 "X-ray of paranasal sinus, minimum of 3 views" 753863_1 CDM 0320 RC 70220 HCPCS inpatient 479 311.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 290.03 464.63 "X-ray of paranasal sinus, minimum of 3 views" 753863_1 CDM 0320 RC 70220 HCPCS inpatient 479 311.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 323.8 67.6 999999999 290.03 464.63 percent of total billed charges Single contrast X-ray of small intestine 753869_1 CDM 0320 RC 74250 HCPCS inpatient 654 425.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 425.1 65 999999999 396 634.38 percent of total billed charges Single contrast X-ray of small intestine 753869_1 CDM 0320 RC 74250 HCPCS inpatient 654 425.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 634.38 97 999999999 396 634.38 percent of total billed charges Single contrast X-ray of small intestine 753869_1 CDM 0320 RC 74250 HCPCS inpatient 654 425.1 AETNA AETNA 516.66 79 999999999 396 634.38 percent of total billed charges Single contrast X-ray of small intestine 753869_1 CDM 0320 RC 74250 HCPCS inpatient 654 425.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 510.12 78 999999999 396 634.38 percent of total billed charges Single contrast X-ray of small intestine 753869_1 CDM 0320 RC 74250 HCPCS inpatient 654 425.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 451.26 69 999999999 396 634.38 percent of total billed charges Single contrast X-ray of small intestine 753869_1 CDM 0320 RC 74250 HCPCS inpatient 654 425.1 SIHO - ALL PLANS SIHO - ALL PLANS 588.6 90 999999999 396 634.38 percent of total billed charges Single contrast X-ray of small intestine 753869_1 CDM 0320 RC 74250 HCPCS inpatient 654 425.1 UMR - ALL PLANS UMR - ALL PLANS 457.8 70 999999999 396 634.38 percent of total billed charges Single contrast X-ray of small intestine 753869_1 CDM 0320 RC 74250 HCPCS inpatient 654 425.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 396 60.55 999999999 396 634.38 percent of total billed charges Single contrast X-ray of small intestine 753869_1 CDM 0320 RC 74250 HCPCS inpatient 654 425.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 396 634.38 Single contrast X-ray of small intestine 753869_1 CDM 0320 RC 74250 HCPCS inpatient 654 425.1 ANTHEM HMO ANTHEM HMO 999999999 396 634.38 Single contrast X-ray of small intestine 753869_1 CDM 0320 RC 74250 HCPCS inpatient 654 425.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 396 634.38 Single contrast X-ray of small intestine 753869_1 CDM 0320 RC 74250 HCPCS inpatient 654 425.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 396 634.38 Single contrast X-ray of small intestine 753869_1 CDM 0320 RC 74250 HCPCS inpatient 654 425.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 396 634.38 Single contrast X-ray of small intestine 753869_1 CDM 0320 RC 74250 HCPCS inpatient 654 425.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 442.1 67.6 999999999 396 634.38 percent of total billed charges "X-ray of spine, 1 view" 753877_1 CDM 0320 RC 72020 HCPCS inpatient 355 230.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 230.75 65 999999999 214.95 344.35 percent of total billed charges "X-ray of spine, 1 view" 753877_1 CDM 0320 RC 72020 HCPCS inpatient 355 230.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 344.35 97 999999999 214.95 344.35 percent of total billed charges "X-ray of spine, 1 view" 753877_1 CDM 0320 RC 72020 HCPCS inpatient 355 230.75 AETNA AETNA 280.45 79 999999999 214.95 344.35 percent of total billed charges "X-ray of spine, 1 view" 753877_1 CDM 0320 RC 72020 HCPCS inpatient 355 230.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 276.9 78 999999999 214.95 344.35 percent of total billed charges "X-ray of spine, 1 view" 753877_1 CDM 0320 RC 72020 HCPCS inpatient 355 230.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 244.95 69 999999999 214.95 344.35 percent of total billed charges "X-ray of spine, 1 view" 753877_1 CDM 0320 RC 72020 HCPCS inpatient 355 230.75 SIHO - ALL PLANS SIHO - ALL PLANS 319.5 90 999999999 214.95 344.35 percent of total billed charges "X-ray of spine, 1 view" 753877_1 CDM 0320 RC 72020 HCPCS inpatient 355 230.75 UMR - ALL PLANS UMR - ALL PLANS 248.5 70 999999999 214.95 344.35 percent of total billed charges "X-ray of spine, 1 view" 753877_1 CDM 0320 RC 72020 HCPCS inpatient 355 230.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 214.95 60.55 999999999 214.95 344.35 percent of total billed charges "X-ray of spine, 1 view" 753877_1 CDM 0320 RC 72020 HCPCS inpatient 355 230.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 214.95 344.35 "X-ray of spine, 1 view" 753877_1 CDM 0320 RC 72020 HCPCS inpatient 355 230.75 ANTHEM HMO ANTHEM HMO 999999999 214.95 344.35 "X-ray of spine, 1 view" 753877_1 CDM 0320 RC 72020 HCPCS inpatient 355 230.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 214.95 344.35 "X-ray of spine, 1 view" 753877_1 CDM 0320 RC 72020 HCPCS inpatient 355 230.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 214.95 344.35 "X-ray of spine, 1 view" 753877_1 CDM 0320 RC 72020 HCPCS inpatient 355 230.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 214.95 344.35 "X-ray of spine, 1 view" 753877_1 CDM 0320 RC 72020 HCPCS inpatient 355 230.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 239.98 67.6 999999999 214.95 344.35 percent of total billed charges "X-ray of upper spine, 2-3 views" 753883_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 687.05 65 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 753883_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1025.29 97 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 753883_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 AETNA AETNA 835.03 79 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 753883_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 824.46 78 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 753883_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 729.33 69 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 753883_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 SIHO - ALL PLANS SIHO - ALL PLANS 951.3 90 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 753883_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 UMR - ALL PLANS UMR - ALL PLANS 739.9 70 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 753883_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 640.01 60.55 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 753883_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 640.01 1025.29 "X-ray of upper spine, 2-3 views" 753883_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 ANTHEM HMO ANTHEM HMO 999999999 640.01 1025.29 "X-ray of upper spine, 2-3 views" 753883_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 640.01 1025.29 "X-ray of upper spine, 2-3 views" 753883_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 640.01 1025.29 "X-ray of upper spine, 2-3 views" 753883_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 640.01 1025.29 "X-ray of upper spine, 2-3 views" 753883_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 714.53 67.6 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 753885_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 687.05 65 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 753885_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1025.29 97 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 753885_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 AETNA AETNA 835.03 79 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 753885_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 824.46 78 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 753885_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 729.33 69 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 753885_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 SIHO - ALL PLANS SIHO - ALL PLANS 951.3 90 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 753885_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 UMR - ALL PLANS UMR - ALL PLANS 739.9 70 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 753885_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 640.01 60.55 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 753885_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 640.01 1025.29 "X-ray of upper spine, 2-3 views" 753885_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 ANTHEM HMO ANTHEM HMO 999999999 640.01 1025.29 "X-ray of upper spine, 2-3 views" 753885_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 640.01 1025.29 "X-ray of upper spine, 2-3 views" 753885_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 640.01 1025.29 "X-ray of upper spine, 2-3 views" 753885_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 640.01 1025.29 "X-ray of upper spine, 2-3 views" 753885_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 714.53 67.6 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 6 or more views" 753887_1 CDM 0320 RC 72052 HCPCS inpatient 1108 720.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 720.2 65 999999999 670.89 1074.76 percent of total billed charges "X-ray of upper spine, 6 or more views" 753887_1 CDM 0320 RC 72052 HCPCS inpatient 1108 720.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1074.76 97 999999999 670.89 1074.76 percent of total billed charges "X-ray of upper spine, 6 or more views" 753887_1 CDM 0320 RC 72052 HCPCS inpatient 1108 720.2 AETNA AETNA 875.32 79 999999999 670.89 1074.76 percent of total billed charges "X-ray of upper spine, 6 or more views" 753887_1 CDM 0320 RC 72052 HCPCS inpatient 1108 720.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 864.24 78 999999999 670.89 1074.76 percent of total billed charges "X-ray of upper spine, 6 or more views" 753887_1 CDM 0320 RC 72052 HCPCS inpatient 1108 720.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 764.52 69 999999999 670.89 1074.76 percent of total billed charges "X-ray of upper spine, 6 or more views" 753887_1 CDM 0320 RC 72052 HCPCS inpatient 1108 720.2 SIHO - ALL PLANS SIHO - ALL PLANS 997.2 90 999999999 670.89 1074.76 percent of total billed charges "X-ray of upper spine, 6 or more views" 753887_1 CDM 0320 RC 72052 HCPCS inpatient 1108 720.2 UMR - ALL PLANS UMR - ALL PLANS 775.6 70 999999999 670.89 1074.76 percent of total billed charges "X-ray of upper spine, 6 or more views" 753887_1 CDM 0320 RC 72052 HCPCS inpatient 1108 720.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 670.89 60.55 999999999 670.89 1074.76 percent of total billed charges "X-ray of upper spine, 6 or more views" 753887_1 CDM 0320 RC 72052 HCPCS inpatient 1108 720.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 670.89 1074.76 "X-ray of upper spine, 6 or more views" 753887_1 CDM 0320 RC 72052 HCPCS inpatient 1108 720.2 ANTHEM HMO ANTHEM HMO 999999999 670.89 1074.76 "X-ray of upper spine, 6 or more views" 753887_1 CDM 0320 RC 72052 HCPCS inpatient 1108 720.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 670.89 1074.76 "X-ray of upper spine, 6 or more views" 753887_1 CDM 0320 RC 72052 HCPCS inpatient 1108 720.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 670.89 1074.76 "X-ray of upper spine, 6 or more views" 753887_1 CDM 0320 RC 72052 HCPCS inpatient 1108 720.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 670.89 1074.76 "X-ray of upper spine, 6 or more views" 753887_1 CDM 0320 RC 72052 HCPCS inpatient 1108 720.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 749.01 67.6 999999999 670.89 1074.76 percent of total billed charges "X-ray of lower and sacral spine, 2-3 views" 753889_1 CDM 0320 RC 72100 HCPCS inpatient 558 362.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 362.7 65 999999999 337.87 541.26 percent of total billed charges "X-ray of lower and sacral spine, 2-3 views" 753889_1 CDM 0320 RC 72100 HCPCS inpatient 558 362.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 541.26 97 999999999 337.87 541.26 percent of total billed charges "X-ray of lower and sacral spine, 2-3 views" 753889_1 CDM 0320 RC 72100 HCPCS inpatient 558 362.7 AETNA AETNA 440.82 79 999999999 337.87 541.26 percent of total billed charges "X-ray of lower and sacral spine, 2-3 views" 753889_1 CDM 0320 RC 72100 HCPCS inpatient 558 362.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 435.24 78 999999999 337.87 541.26 percent of total billed charges "X-ray of lower and sacral spine, 2-3 views" 753889_1 CDM 0320 RC 72100 HCPCS inpatient 558 362.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 385.02 69 999999999 337.87 541.26 percent of total billed charges "X-ray of lower and sacral spine, 2-3 views" 753889_1 CDM 0320 RC 72100 HCPCS inpatient 558 362.7 SIHO - ALL PLANS SIHO - ALL PLANS 502.2 90 999999999 337.87 541.26 percent of total billed charges "X-ray of lower and sacral spine, 2-3 views" 753889_1 CDM 0320 RC 72100 HCPCS inpatient 558 362.7 UMR - ALL PLANS UMR - ALL PLANS 390.6 70 999999999 337.87 541.26 percent of total billed charges "X-ray of lower and sacral spine, 2-3 views" 753889_1 CDM 0320 RC 72100 HCPCS inpatient 558 362.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 337.87 60.55 999999999 337.87 541.26 percent of total billed charges "X-ray of lower and sacral spine, 2-3 views" 753889_1 CDM 0320 RC 72100 HCPCS inpatient 558 362.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 337.87 541.26 "X-ray of lower and sacral spine, 2-3 views" 753889_1 CDM 0320 RC 72100 HCPCS inpatient 558 362.7 ANTHEM HMO ANTHEM HMO 999999999 337.87 541.26 "X-ray of lower and sacral spine, 2-3 views" 753889_1 CDM 0320 RC 72100 HCPCS inpatient 558 362.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 337.87 541.26 "X-ray of lower and sacral spine, 2-3 views" 753889_1 CDM 0320 RC 72100 HCPCS inpatient 558 362.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 337.87 541.26 "X-ray of lower and sacral spine, 2-3 views" 753889_1 CDM 0320 RC 72100 HCPCS inpatient 558 362.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 337.87 541.26 "X-ray of lower and sacral spine, 2-3 views" 753889_1 CDM 0320 RC 72100 HCPCS inpatient 558 362.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 377.21 67.6 999999999 337.87 541.26 percent of total billed charges "X-ray lower and sacral spine, minimum of 6 views" 753891_1 CDM 0320 RC 72114 HCPCS inpatient 1192 774.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 774.8 65 999999999 721.76 1156.24 percent of total billed charges "X-ray lower and sacral spine, minimum of 6 views" 753891_1 CDM 0320 RC 72114 HCPCS inpatient 1192 774.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1156.24 97 999999999 721.76 1156.24 percent of total billed charges "X-ray lower and sacral spine, minimum of 6 views" 753891_1 CDM 0320 RC 72114 HCPCS inpatient 1192 774.8 AETNA AETNA 941.68 79 999999999 721.76 1156.24 percent of total billed charges "X-ray lower and sacral spine, minimum of 6 views" 753891_1 CDM 0320 RC 72114 HCPCS inpatient 1192 774.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 929.76 78 999999999 721.76 1156.24 percent of total billed charges "X-ray lower and sacral spine, minimum of 6 views" 753891_1 CDM 0320 RC 72114 HCPCS inpatient 1192 774.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 822.48 69 999999999 721.76 1156.24 percent of total billed charges "X-ray lower and sacral spine, minimum of 6 views" 753891_1 CDM 0320 RC 72114 HCPCS inpatient 1192 774.8 SIHO - ALL PLANS SIHO - ALL PLANS 1072.8 90 999999999 721.76 1156.24 percent of total billed charges "X-ray lower and sacral spine, minimum of 6 views" 753891_1 CDM 0320 RC 72114 HCPCS inpatient 1192 774.8 UMR - ALL PLANS UMR - ALL PLANS 834.4 70 999999999 721.76 1156.24 percent of total billed charges "X-ray lower and sacral spine, minimum of 6 views" 753891_1 CDM 0320 RC 72114 HCPCS inpatient 1192 774.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 721.76 60.55 999999999 721.76 1156.24 percent of total billed charges "X-ray lower and sacral spine, minimum of 6 views" 753891_1 CDM 0320 RC 72114 HCPCS inpatient 1192 774.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 721.76 1156.24 "X-ray lower and sacral spine, minimum of 6 views" 753891_1 CDM 0320 RC 72114 HCPCS inpatient 1192 774.8 ANTHEM HMO ANTHEM HMO 999999999 721.76 1156.24 "X-ray lower and sacral spine, minimum of 6 views" 753891_1 CDM 0320 RC 72114 HCPCS inpatient 1192 774.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 721.76 1156.24 "X-ray lower and sacral spine, minimum of 6 views" 753891_1 CDM 0320 RC 72114 HCPCS inpatient 1192 774.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 721.76 1156.24 "X-ray lower and sacral spine, minimum of 6 views" 753891_1 CDM 0320 RC 72114 HCPCS inpatient 1192 774.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 721.76 1156.24 "X-ray lower and sacral spine, minimum of 6 views" 753891_1 CDM 0320 RC 72114 HCPCS inpatient 1192 774.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 805.79 67.6 999999999 721.76 1156.24 percent of total billed charges "X-ray of lower and sacral spine, minimum of 4 views" 753893_1 CDM 0320 RC 72110 HCPCS inpatient 631 410.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 410.15 65 999999999 382.07 612.07 percent of total billed charges "X-ray of lower and sacral spine, minimum of 4 views" 753893_1 CDM 0320 RC 72110 HCPCS inpatient 631 410.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 612.07 97 999999999 382.07 612.07 percent of total billed charges "X-ray of lower and sacral spine, minimum of 4 views" 753893_1 CDM 0320 RC 72110 HCPCS inpatient 631 410.15 AETNA AETNA 498.49 79 999999999 382.07 612.07 percent of total billed charges "X-ray of lower and sacral spine, minimum of 4 views" 753893_1 CDM 0320 RC 72110 HCPCS inpatient 631 410.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 492.18 78 999999999 382.07 612.07 percent of total billed charges "X-ray of lower and sacral spine, minimum of 4 views" 753893_1 CDM 0320 RC 72110 HCPCS inpatient 631 410.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 435.39 69 999999999 382.07 612.07 percent of total billed charges "X-ray of lower and sacral spine, minimum of 4 views" 753893_1 CDM 0320 RC 72110 HCPCS inpatient 631 410.15 SIHO - ALL PLANS SIHO - ALL PLANS 567.9 90 999999999 382.07 612.07 percent of total billed charges "X-ray of lower and sacral spine, minimum of 4 views" 753893_1 CDM 0320 RC 72110 HCPCS inpatient 631 410.15 UMR - ALL PLANS UMR - ALL PLANS 441.7 70 999999999 382.07 612.07 percent of total billed charges "X-ray of lower and sacral spine, minimum of 4 views" 753893_1 CDM 0320 RC 72110 HCPCS inpatient 631 410.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 382.07 60.55 999999999 382.07 612.07 percent of total billed charges "X-ray of lower and sacral spine, minimum of 4 views" 753893_1 CDM 0320 RC 72110 HCPCS inpatient 631 410.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 382.07 612.07 "X-ray of lower and sacral spine, minimum of 4 views" 753893_1 CDM 0320 RC 72110 HCPCS inpatient 631 410.15 ANTHEM HMO ANTHEM HMO 999999999 382.07 612.07 "X-ray of lower and sacral spine, minimum of 4 views" 753893_1 CDM 0320 RC 72110 HCPCS inpatient 631 410.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 382.07 612.07 "X-ray of lower and sacral spine, minimum of 4 views" 753893_1 CDM 0320 RC 72110 HCPCS inpatient 631 410.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 382.07 612.07 "X-ray of lower and sacral spine, minimum of 4 views" 753893_1 CDM 0320 RC 72110 HCPCS inpatient 631 410.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 382.07 612.07 "X-ray of lower and sacral spine, minimum of 4 views" 753893_1 CDM 0320 RC 72110 HCPCS inpatient 631 410.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 426.56 67.6 999999999 382.07 612.07 percent of total billed charges "X-ray of joint between breast and collar bones, minimum of 2 views" 753901_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 253.5 65 999999999 236.15 378.3 percent of total billed charges "X-ray of joint between breast and collar bones, minimum of 2 views" 753901_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 378.3 97 999999999 236.15 378.3 percent of total billed charges "X-ray of joint between breast and collar bones, minimum of 2 views" 753901_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 AETNA AETNA 308.1 79 999999999 236.15 378.3 percent of total billed charges "X-ray of joint between breast and collar bones, minimum of 2 views" 753901_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 304.2 78 999999999 236.15 378.3 percent of total billed charges "X-ray of joint between breast and collar bones, minimum of 2 views" 753901_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 269.1 69 999999999 236.15 378.3 percent of total billed charges "X-ray of joint between breast and collar bones, minimum of 2 views" 753901_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 SIHO - ALL PLANS SIHO - ALL PLANS 351 90 999999999 236.15 378.3 percent of total billed charges "X-ray of joint between breast and collar bones, minimum of 2 views" 753901_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 UMR - ALL PLANS UMR - ALL PLANS 273 70 999999999 236.15 378.3 percent of total billed charges "X-ray of joint between breast and collar bones, minimum of 2 views" 753901_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 236.15 60.55 999999999 236.15 378.3 percent of total billed charges "X-ray of joint between breast and collar bones, minimum of 2 views" 753901_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 236.15 378.3 "X-ray of joint between breast and collar bones, minimum of 2 views" 753901_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 ANTHEM HMO ANTHEM HMO 999999999 236.15 378.3 "X-ray of joint between breast and collar bones, minimum of 2 views" 753901_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 236.15 378.3 "X-ray of joint between breast and collar bones, minimum of 2 views" 753901_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 236.15 378.3 "X-ray of joint between breast and collar bones, minimum of 2 views" 753901_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 236.15 378.3 "X-ray of joint between breast and collar bones, minimum of 2 views" 753901_1 CDM 0320 RC 71130 HCPCS inpatient 390 253.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 263.64 67.6 999999999 236.15 378.3 percent of total billed charges "X-ray of chest bone, minimum of 2 views" 753903_1 CDM 0320 RC 71120 HCPCS inpatient 414 269.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 269.1 65 999999999 250.68 401.58 percent of total billed charges "X-ray of chest bone, minimum of 2 views" 753903_1 CDM 0320 RC 71120 HCPCS inpatient 414 269.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 401.58 97 999999999 250.68 401.58 percent of total billed charges "X-ray of chest bone, minimum of 2 views" 753903_1 CDM 0320 RC 71120 HCPCS inpatient 414 269.1 AETNA AETNA 327.06 79 999999999 250.68 401.58 percent of total billed charges "X-ray of chest bone, minimum of 2 views" 753903_1 CDM 0320 RC 71120 HCPCS inpatient 414 269.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 322.92 78 999999999 250.68 401.58 percent of total billed charges "X-ray of chest bone, minimum of 2 views" 753903_1 CDM 0320 RC 71120 HCPCS inpatient 414 269.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 285.66 69 999999999 250.68 401.58 percent of total billed charges "X-ray of chest bone, minimum of 2 views" 753903_1 CDM 0320 RC 71120 HCPCS inpatient 414 269.1 SIHO - ALL PLANS SIHO - ALL PLANS 372.6 90 999999999 250.68 401.58 percent of total billed charges "X-ray of chest bone, minimum of 2 views" 753903_1 CDM 0320 RC 71120 HCPCS inpatient 414 269.1 UMR - ALL PLANS UMR - ALL PLANS 289.8 70 999999999 250.68 401.58 percent of total billed charges "X-ray of chest bone, minimum of 2 views" 753903_1 CDM 0320 RC 71120 HCPCS inpatient 414 269.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 250.68 60.55 999999999 250.68 401.58 percent of total billed charges "X-ray of chest bone, minimum of 2 views" 753903_1 CDM 0320 RC 71120 HCPCS inpatient 414 269.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 250.68 401.58 "X-ray of chest bone, minimum of 2 views" 753903_1 CDM 0320 RC 71120 HCPCS inpatient 414 269.1 ANTHEM HMO ANTHEM HMO 999999999 250.68 401.58 "X-ray of chest bone, minimum of 2 views" 753903_1 CDM 0320 RC 71120 HCPCS inpatient 414 269.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 250.68 401.58 "X-ray of chest bone, minimum of 2 views" 753903_1 CDM 0320 RC 71120 HCPCS inpatient 414 269.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 250.68 401.58 "X-ray of chest bone, minimum of 2 views" 753903_1 CDM 0320 RC 71120 HCPCS inpatient 414 269.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 250.68 401.58 "X-ray of chest bone, minimum of 2 views" 753903_1 CDM 0320 RC 71120 HCPCS inpatient 414 269.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 279.86 67.6 999999999 250.68 401.58 percent of total billed charges X-ray of jaw joints on both sides of mouth 753907_1 CDM 0320 RC 70330 HCPCS inpatient 547 355.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 355.55 65 999999999 331.21 530.59 percent of total billed charges X-ray of jaw joints on both sides of mouth 753907_1 CDM 0320 RC 70330 HCPCS inpatient 547 355.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 530.59 97 999999999 331.21 530.59 percent of total billed charges X-ray of jaw joints on both sides of mouth 753907_1 CDM 0320 RC 70330 HCPCS inpatient 547 355.55 AETNA AETNA 432.13 79 999999999 331.21 530.59 percent of total billed charges X-ray of jaw joints on both sides of mouth 753907_1 CDM 0320 RC 70330 HCPCS inpatient 547 355.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 426.66 78 999999999 331.21 530.59 percent of total billed charges X-ray of jaw joints on both sides of mouth 753907_1 CDM 0320 RC 70330 HCPCS inpatient 547 355.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 377.43 69 999999999 331.21 530.59 percent of total billed charges X-ray of jaw joints on both sides of mouth 753907_1 CDM 0320 RC 70330 HCPCS inpatient 547 355.55 SIHO - ALL PLANS SIHO - ALL PLANS 492.3 90 999999999 331.21 530.59 percent of total billed charges X-ray of jaw joints on both sides of mouth 753907_1 CDM 0320 RC 70330 HCPCS inpatient 547 355.55 UMR - ALL PLANS UMR - ALL PLANS 382.9 70 999999999 331.21 530.59 percent of total billed charges X-ray of jaw joints on both sides of mouth 753907_1 CDM 0320 RC 70330 HCPCS inpatient 547 355.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 331.21 60.55 999999999 331.21 530.59 percent of total billed charges X-ray of jaw joints on both sides of mouth 753907_1 CDM 0320 RC 70330 HCPCS inpatient 547 355.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 331.21 530.59 X-ray of jaw joints on both sides of mouth 753907_1 CDM 0320 RC 70330 HCPCS inpatient 547 355.55 ANTHEM HMO ANTHEM HMO 999999999 331.21 530.59 X-ray of jaw joints on both sides of mouth 753907_1 CDM 0320 RC 70330 HCPCS inpatient 547 355.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 331.21 530.59 X-ray of jaw joints on both sides of mouth 753907_1 CDM 0320 RC 70330 HCPCS inpatient 547 355.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 331.21 530.59 X-ray of jaw joints on both sides of mouth 753907_1 CDM 0320 RC 70330 HCPCS inpatient 547 355.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 331.21 530.59 X-ray of jaw joints on both sides of mouth 753907_1 CDM 0320 RC 70330 HCPCS inpatient 547 355.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 369.77 67.6 999999999 331.21 530.59 percent of total billed charges "X-ray of lower leg, 2 views" 753918_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 298.35 65 999999999 277.92 445.23 percent of total billed charges "X-ray of lower leg, 2 views" 753918_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 445.23 97 999999999 277.92 445.23 percent of total billed charges "X-ray of lower leg, 2 views" 753918_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 AETNA AETNA 362.61 79 999999999 277.92 445.23 percent of total billed charges "X-ray of lower leg, 2 views" 753918_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 358.02 78 999999999 277.92 445.23 percent of total billed charges "X-ray of lower leg, 2 views" 753918_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 316.71 69 999999999 277.92 445.23 percent of total billed charges "X-ray of lower leg, 2 views" 753918_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 SIHO - ALL PLANS SIHO - ALL PLANS 413.1 90 999999999 277.92 445.23 percent of total billed charges "X-ray of lower leg, 2 views" 753918_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 UMR - ALL PLANS UMR - ALL PLANS 321.3 70 999999999 277.92 445.23 percent of total billed charges "X-ray of lower leg, 2 views" 753918_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 277.92 60.55 999999999 277.92 445.23 percent of total billed charges "X-ray of lower leg, 2 views" 753918_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 277.92 445.23 "X-ray of lower leg, 2 views" 753918_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 ANTHEM HMO ANTHEM HMO 999999999 277.92 445.23 "X-ray of lower leg, 2 views" 753918_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 277.92 445.23 "X-ray of lower leg, 2 views" 753918_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 277.92 445.23 "X-ray of lower leg, 2 views" 753918_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 277.92 445.23 "X-ray of lower leg, 2 views" 753918_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 310.28 67.6 999999999 277.92 445.23 percent of total billed charges "X-ray of lower leg, 2 views" 753920_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 298.35 65 999999999 277.92 445.23 percent of total billed charges "X-ray of lower leg, 2 views" 753920_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 445.23 97 999999999 277.92 445.23 percent of total billed charges "X-ray of lower leg, 2 views" 753920_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 AETNA AETNA 362.61 79 999999999 277.92 445.23 percent of total billed charges "X-ray of lower leg, 2 views" 753920_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 358.02 78 999999999 277.92 445.23 percent of total billed charges "X-ray of lower leg, 2 views" 753920_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 316.71 69 999999999 277.92 445.23 percent of total billed charges "X-ray of lower leg, 2 views" 753920_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 SIHO - ALL PLANS SIHO - ALL PLANS 413.1 90 999999999 277.92 445.23 percent of total billed charges "X-ray of lower leg, 2 views" 753920_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 UMR - ALL PLANS UMR - ALL PLANS 321.3 70 999999999 277.92 445.23 percent of total billed charges "X-ray of lower leg, 2 views" 753920_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 277.92 60.55 999999999 277.92 445.23 percent of total billed charges "X-ray of lower leg, 2 views" 753920_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 277.92 445.23 "X-ray of lower leg, 2 views" 753920_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 ANTHEM HMO ANTHEM HMO 999999999 277.92 445.23 "X-ray of lower leg, 2 views" 753920_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 277.92 445.23 "X-ray of lower leg, 2 views" 753920_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 277.92 445.23 "X-ray of lower leg, 2 views" 753920_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 277.92 445.23 "X-ray of lower leg, 2 views" 753920_1 CDM 0320 RC 73590 HCPCS inpatient 459 298.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 310.28 67.6 999999999 277.92 445.23 percent of total billed charges "X-ray of toe, minimum of 2 views" 753922_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 SELF PAY DISCOUNT SELF PAY DISCOUNT 221 65 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753922_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 329.8 97 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753922_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 AETNA AETNA 268.6 79 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753922_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 HUMANA - ALL PLANS HUMANA - ALL PLANS 265.2 78 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753922_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ENCORE - ALL PLANS ENCORE - ALL PLANS 234.6 69 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753922_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 SIHO - ALL PLANS SIHO - ALL PLANS 306 90 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753922_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UMR - ALL PLANS UMR - ALL PLANS 238 70 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753922_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.87 60.55 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753922_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753922_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM HMO ANTHEM HMO 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753922_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753922_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753922_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753922_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.84 67.6 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753924_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 SELF PAY DISCOUNT SELF PAY DISCOUNT 221 65 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753924_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 329.8 97 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753924_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 AETNA AETNA 268.6 79 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753924_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 HUMANA - ALL PLANS HUMANA - ALL PLANS 265.2 78 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753924_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ENCORE - ALL PLANS ENCORE - ALL PLANS 234.6 69 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753924_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 SIHO - ALL PLANS SIHO - ALL PLANS 306 90 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753924_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UMR - ALL PLANS UMR - ALL PLANS 238 70 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753924_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.87 60.55 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753924_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753924_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM HMO ANTHEM HMO 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753924_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753924_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753924_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753924_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.84 67.6 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753926_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 SELF PAY DISCOUNT SELF PAY DISCOUNT 221 65 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753926_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 329.8 97 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753926_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 AETNA AETNA 268.6 79 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753926_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 HUMANA - ALL PLANS HUMANA - ALL PLANS 265.2 78 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753926_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ENCORE - ALL PLANS ENCORE - ALL PLANS 234.6 69 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753926_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 SIHO - ALL PLANS SIHO - ALL PLANS 306 90 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753926_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UMR - ALL PLANS UMR - ALL PLANS 238 70 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753926_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.87 60.55 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753926_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753926_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM HMO ANTHEM HMO 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753926_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753926_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753926_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753926_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.84 67.6 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753928_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 SELF PAY DISCOUNT SELF PAY DISCOUNT 221 65 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753928_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 329.8 97 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753928_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 AETNA AETNA 268.6 79 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753928_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 HUMANA - ALL PLANS HUMANA - ALL PLANS 265.2 78 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753928_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ENCORE - ALL PLANS ENCORE - ALL PLANS 234.6 69 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753928_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 SIHO - ALL PLANS SIHO - ALL PLANS 306 90 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753928_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UMR - ALL PLANS UMR - ALL PLANS 238 70 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753928_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.87 60.55 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753928_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753928_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM HMO ANTHEM HMO 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753928_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753928_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753928_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753928_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.84 67.6 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753930_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 SELF PAY DISCOUNT SELF PAY DISCOUNT 221 65 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753930_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 329.8 97 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753930_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 AETNA AETNA 268.6 79 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753930_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 HUMANA - ALL PLANS HUMANA - ALL PLANS 265.2 78 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753930_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ENCORE - ALL PLANS ENCORE - ALL PLANS 234.6 69 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753930_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 SIHO - ALL PLANS SIHO - ALL PLANS 306 90 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753930_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UMR - ALL PLANS UMR - ALL PLANS 238 70 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753930_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.87 60.55 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753930_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753930_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM HMO ANTHEM HMO 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753930_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753930_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753930_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753930_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.84 67.6 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753932_1 CDM 0320 RC 73660 HCPCS inpatient 364 236.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 236.6 65 999999999 220.4 353.08 percent of total billed charges "X-ray of toe, minimum of 2 views" 753932_1 CDM 0320 RC 73660 HCPCS inpatient 364 236.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 353.08 97 999999999 220.4 353.08 percent of total billed charges "X-ray of toe, minimum of 2 views" 753932_1 CDM 0320 RC 73660 HCPCS inpatient 364 236.6 AETNA AETNA 287.56 79 999999999 220.4 353.08 percent of total billed charges "X-ray of toe, minimum of 2 views" 753932_1 CDM 0320 RC 73660 HCPCS inpatient 364 236.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 283.92 78 999999999 220.4 353.08 percent of total billed charges "X-ray of toe, minimum of 2 views" 753932_1 CDM 0320 RC 73660 HCPCS inpatient 364 236.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 251.16 69 999999999 220.4 353.08 percent of total billed charges "X-ray of toe, minimum of 2 views" 753932_1 CDM 0320 RC 73660 HCPCS inpatient 364 236.6 SIHO - ALL PLANS SIHO - ALL PLANS 327.6 90 999999999 220.4 353.08 percent of total billed charges "X-ray of toe, minimum of 2 views" 753932_1 CDM 0320 RC 73660 HCPCS inpatient 364 236.6 UMR - ALL PLANS UMR - ALL PLANS 254.8 70 999999999 220.4 353.08 percent of total billed charges "X-ray of toe, minimum of 2 views" 753932_1 CDM 0320 RC 73660 HCPCS inpatient 364 236.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 220.4 60.55 999999999 220.4 353.08 percent of total billed charges "X-ray of toe, minimum of 2 views" 753932_1 CDM 0320 RC 73660 HCPCS inpatient 364 236.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 220.4 353.08 "X-ray of toe, minimum of 2 views" 753932_1 CDM 0320 RC 73660 HCPCS inpatient 364 236.6 ANTHEM HMO ANTHEM HMO 999999999 220.4 353.08 "X-ray of toe, minimum of 2 views" 753932_1 CDM 0320 RC 73660 HCPCS inpatient 364 236.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 220.4 353.08 "X-ray of toe, minimum of 2 views" 753932_1 CDM 0320 RC 73660 HCPCS inpatient 364 236.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 220.4 353.08 "X-ray of toe, minimum of 2 views" 753932_1 CDM 0320 RC 73660 HCPCS inpatient 364 236.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 220.4 353.08 "X-ray of toe, minimum of 2 views" 753932_1 CDM 0320 RC 73660 HCPCS inpatient 364 236.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 246.06 67.6 999999999 220.4 353.08 percent of total billed charges "X-ray of toe, minimum of 2 views" 753934_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 SELF PAY DISCOUNT SELF PAY DISCOUNT 221 65 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753934_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 329.8 97 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753934_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 AETNA AETNA 268.6 79 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753934_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 HUMANA - ALL PLANS HUMANA - ALL PLANS 265.2 78 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753934_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ENCORE - ALL PLANS ENCORE - ALL PLANS 234.6 69 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753934_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 SIHO - ALL PLANS SIHO - ALL PLANS 306 90 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753934_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UMR - ALL PLANS UMR - ALL PLANS 238 70 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753934_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.87 60.55 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753934_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753934_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM HMO ANTHEM HMO 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753934_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753934_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753934_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753934_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.84 67.6 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753936_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 SELF PAY DISCOUNT SELF PAY DISCOUNT 221 65 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753936_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 329.8 97 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753936_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 AETNA AETNA 268.6 79 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753936_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 HUMANA - ALL PLANS HUMANA - ALL PLANS 265.2 78 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753936_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ENCORE - ALL PLANS ENCORE - ALL PLANS 234.6 69 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753936_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 SIHO - ALL PLANS SIHO - ALL PLANS 306 90 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753936_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UMR - ALL PLANS UMR - ALL PLANS 238 70 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753936_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 205.87 60.55 999999999 205.87 329.8 percent of total billed charges "X-ray of toe, minimum of 2 views" 753936_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753936_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM HMO ANTHEM HMO 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753936_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753936_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753936_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 UHC - ALL PLANS UHC - ALL PLANS 999999999 205.87 329.8 "X-ray of toe, minimum of 2 views" 753936_1 CDM 0320 RC 73660 HCPCS inpatient 340 221 CIGNA - ALL PLANS CIGNA - ALL PLANS 229.84 67.6 999999999 205.87 329.8 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 753944_1 CDM 0761 RC inpatient 267 173.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 173.55 65 999999999 161.67 258.99 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 753944_1 CDM 0761 RC inpatient 267 173.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 258.99 97 999999999 161.67 258.99 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 753944_1 CDM 0761 RC inpatient 267 173.55 AETNA AETNA 210.93 79 999999999 161.67 258.99 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 753944_1 CDM 0761 RC inpatient 267 173.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 208.26 78 999999999 161.67 258.99 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 753944_1 CDM 0761 RC inpatient 267 173.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 184.23 69 999999999 161.67 258.99 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 753944_1 CDM 0761 RC inpatient 267 173.55 SIHO - ALL PLANS SIHO - ALL PLANS 240.3 90 999999999 161.67 258.99 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 753944_1 CDM 0761 RC inpatient 267 173.55 UMR - ALL PLANS UMR - ALL PLANS 186.9 70 999999999 161.67 258.99 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 753944_1 CDM 0761 RC inpatient 267 173.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 161.67 60.55 999999999 161.67 258.99 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 753944_1 CDM 0761 RC inpatient 267 173.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 161.67 258.99 SPECIALTY SERVICES - TREATMENT ROOM 753944_1 CDM 0761 RC inpatient 267 173.55 ANTHEM HMO ANTHEM HMO 999999999 161.67 258.99 SPECIALTY SERVICES - TREATMENT ROOM 753944_1 CDM 0761 RC inpatient 267 173.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 161.67 258.99 SPECIALTY SERVICES - TREATMENT ROOM 753944_1 CDM 0761 RC inpatient 267 173.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 161.67 258.99 SPECIALTY SERVICES - TREATMENT ROOM 753944_1 CDM 0761 RC inpatient 267 173.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 161.67 258.99 SPECIALTY SERVICES - TREATMENT ROOM 753944_1 CDM 0761 RC inpatient 267 173.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 180.49 67.6 999999999 161.67 258.99 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753946_1 CDM 0320 RC 73092 HCPCS inpatient 724 470.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 470.6 65 999999999 438.38 702.28 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753946_1 CDM 0320 RC 73092 HCPCS inpatient 724 470.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 702.28 97 999999999 438.38 702.28 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753946_1 CDM 0320 RC 73092 HCPCS inpatient 724 470.6 AETNA AETNA 571.96 79 999999999 438.38 702.28 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753946_1 CDM 0320 RC 73092 HCPCS inpatient 724 470.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 564.72 78 999999999 438.38 702.28 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753946_1 CDM 0320 RC 73092 HCPCS inpatient 724 470.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 499.56 69 999999999 438.38 702.28 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753946_1 CDM 0320 RC 73092 HCPCS inpatient 724 470.6 SIHO - ALL PLANS SIHO - ALL PLANS 651.6 90 999999999 438.38 702.28 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753946_1 CDM 0320 RC 73092 HCPCS inpatient 724 470.6 UMR - ALL PLANS UMR - ALL PLANS 506.8 70 999999999 438.38 702.28 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753946_1 CDM 0320 RC 73092 HCPCS inpatient 724 470.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 438.38 60.55 999999999 438.38 702.28 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753946_1 CDM 0320 RC 73092 HCPCS inpatient 724 470.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 438.38 702.28 "X-ray of infant arm, minimum of 2 views" 753946_1 CDM 0320 RC 73092 HCPCS inpatient 724 470.6 ANTHEM HMO ANTHEM HMO 999999999 438.38 702.28 "X-ray of infant arm, minimum of 2 views" 753946_1 CDM 0320 RC 73092 HCPCS inpatient 724 470.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 438.38 702.28 "X-ray of infant arm, minimum of 2 views" 753946_1 CDM 0320 RC 73092 HCPCS inpatient 724 470.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 438.38 702.28 "X-ray of infant arm, minimum of 2 views" 753946_1 CDM 0320 RC 73092 HCPCS inpatient 724 470.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 438.38 702.28 "X-ray of infant arm, minimum of 2 views" 753946_1 CDM 0320 RC 73092 HCPCS inpatient 724 470.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 489.42 67.6 999999999 438.38 702.28 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753948_1 CDM 0320 RC 73092 HCPCS inpatient 365 237.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 237.25 65 999999999 221.01 354.05 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753948_1 CDM 0320 RC 73092 HCPCS inpatient 365 237.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 354.05 97 999999999 221.01 354.05 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753948_1 CDM 0320 RC 73092 HCPCS inpatient 365 237.25 AETNA AETNA 288.35 79 999999999 221.01 354.05 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753948_1 CDM 0320 RC 73092 HCPCS inpatient 365 237.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 284.7 78 999999999 221.01 354.05 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753948_1 CDM 0320 RC 73092 HCPCS inpatient 365 237.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 251.85 69 999999999 221.01 354.05 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753948_1 CDM 0320 RC 73092 HCPCS inpatient 365 237.25 SIHO - ALL PLANS SIHO - ALL PLANS 328.5 90 999999999 221.01 354.05 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753948_1 CDM 0320 RC 73092 HCPCS inpatient 365 237.25 UMR - ALL PLANS UMR - ALL PLANS 255.5 70 999999999 221.01 354.05 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753948_1 CDM 0320 RC 73092 HCPCS inpatient 365 237.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 221.01 60.55 999999999 221.01 354.05 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753948_1 CDM 0320 RC 73092 HCPCS inpatient 365 237.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 221.01 354.05 "X-ray of infant arm, minimum of 2 views" 753948_1 CDM 0320 RC 73092 HCPCS inpatient 365 237.25 ANTHEM HMO ANTHEM HMO 999999999 221.01 354.05 "X-ray of infant arm, minimum of 2 views" 753948_1 CDM 0320 RC 73092 HCPCS inpatient 365 237.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 221.01 354.05 "X-ray of infant arm, minimum of 2 views" 753948_1 CDM 0320 RC 73092 HCPCS inpatient 365 237.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 221.01 354.05 "X-ray of infant arm, minimum of 2 views" 753948_1 CDM 0320 RC 73092 HCPCS inpatient 365 237.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 221.01 354.05 "X-ray of infant arm, minimum of 2 views" 753948_1 CDM 0320 RC 73092 HCPCS inpatient 365 237.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 246.74 67.6 999999999 221.01 354.05 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753950_1 CDM 0320 RC 73092 HCPCS inpatient 402 261.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 261.3 65 999999999 243.41 389.94 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753950_1 CDM 0320 RC 73092 HCPCS inpatient 402 261.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 389.94 97 999999999 243.41 389.94 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753950_1 CDM 0320 RC 73092 HCPCS inpatient 402 261.3 AETNA AETNA 317.58 79 999999999 243.41 389.94 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753950_1 CDM 0320 RC 73092 HCPCS inpatient 402 261.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 313.56 78 999999999 243.41 389.94 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753950_1 CDM 0320 RC 73092 HCPCS inpatient 402 261.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 277.38 69 999999999 243.41 389.94 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753950_1 CDM 0320 RC 73092 HCPCS inpatient 402 261.3 SIHO - ALL PLANS SIHO - ALL PLANS 361.8 90 999999999 243.41 389.94 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753950_1 CDM 0320 RC 73092 HCPCS inpatient 402 261.3 UMR - ALL PLANS UMR - ALL PLANS 281.4 70 999999999 243.41 389.94 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753950_1 CDM 0320 RC 73092 HCPCS inpatient 402 261.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 243.41 60.55 999999999 243.41 389.94 percent of total billed charges "X-ray of infant arm, minimum of 2 views" 753950_1 CDM 0320 RC 73092 HCPCS inpatient 402 261.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 243.41 389.94 "X-ray of infant arm, minimum of 2 views" 753950_1 CDM 0320 RC 73092 HCPCS inpatient 402 261.3 ANTHEM HMO ANTHEM HMO 999999999 243.41 389.94 "X-ray of infant arm, minimum of 2 views" 753950_1 CDM 0320 RC 73092 HCPCS inpatient 402 261.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 243.41 389.94 "X-ray of infant arm, minimum of 2 views" 753950_1 CDM 0320 RC 73092 HCPCS inpatient 402 261.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 243.41 389.94 "X-ray of infant arm, minimum of 2 views" 753950_1 CDM 0320 RC 73092 HCPCS inpatient 402 261.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 243.41 389.94 "X-ray of infant arm, minimum of 2 views" 753950_1 CDM 0320 RC 73092 HCPCS inpatient 402 261.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 271.75 67.6 999999999 243.41 389.94 percent of total billed charges Double contrast X-ray of upper digestive tract 753954_1 CDM 0320 RC 74246 HCPCS inpatient 943 612.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 612.95 65 999999999 570.99 914.71 percent of total billed charges Double contrast X-ray of upper digestive tract 753954_1 CDM 0320 RC 74246 HCPCS inpatient 943 612.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 914.71 97 999999999 570.99 914.71 percent of total billed charges Double contrast X-ray of upper digestive tract 753954_1 CDM 0320 RC 74246 HCPCS inpatient 943 612.95 AETNA AETNA 744.97 79 999999999 570.99 914.71 percent of total billed charges Double contrast X-ray of upper digestive tract 753954_1 CDM 0320 RC 74246 HCPCS inpatient 943 612.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 735.54 78 999999999 570.99 914.71 percent of total billed charges Double contrast X-ray of upper digestive tract 753954_1 CDM 0320 RC 74246 HCPCS inpatient 943 612.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 650.67 69 999999999 570.99 914.71 percent of total billed charges Double contrast X-ray of upper digestive tract 753954_1 CDM 0320 RC 74246 HCPCS inpatient 943 612.95 SIHO - ALL PLANS SIHO - ALL PLANS 848.7 90 999999999 570.99 914.71 percent of total billed charges Double contrast X-ray of upper digestive tract 753954_1 CDM 0320 RC 74246 HCPCS inpatient 943 612.95 UMR - ALL PLANS UMR - ALL PLANS 660.1 70 999999999 570.99 914.71 percent of total billed charges Double contrast X-ray of upper digestive tract 753954_1 CDM 0320 RC 74246 HCPCS inpatient 943 612.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 570.99 60.55 999999999 570.99 914.71 percent of total billed charges Double contrast X-ray of upper digestive tract 753954_1 CDM 0320 RC 74246 HCPCS inpatient 943 612.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 570.99 914.71 Double contrast X-ray of upper digestive tract 753954_1 CDM 0320 RC 74246 HCPCS inpatient 943 612.95 ANTHEM HMO ANTHEM HMO 999999999 570.99 914.71 Double contrast X-ray of upper digestive tract 753954_1 CDM 0320 RC 74246 HCPCS inpatient 943 612.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 570.99 914.71 Double contrast X-ray of upper digestive tract 753954_1 CDM 0320 RC 74246 HCPCS inpatient 943 612.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 570.99 914.71 Double contrast X-ray of upper digestive tract 753954_1 CDM 0320 RC 74246 HCPCS inpatient 943 612.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 570.99 914.71 Double contrast X-ray of upper digestive tract 753954_1 CDM 0320 RC 74246 HCPCS inpatient 943 612.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 637.47 67.6 999999999 570.99 914.71 percent of total billed charges Review by radiologist of urinary bladder and urethra images with contrast and after passing urine 753967_1 CDM 0320 RC 74455 HCPCS inpatient 512 332.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 332.8 65 999999999 310.02 496.64 percent of total billed charges Review by radiologist of urinary bladder and urethra images with contrast and after passing urine 753967_1 CDM 0320 RC 74455 HCPCS inpatient 512 332.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 496.64 97 999999999 310.02 496.64 percent of total billed charges Review by radiologist of urinary bladder and urethra images with contrast and after passing urine 753967_1 CDM 0320 RC 74455 HCPCS inpatient 512 332.8 AETNA AETNA 404.48 79 999999999 310.02 496.64 percent of total billed charges Review by radiologist of urinary bladder and urethra images with contrast and after passing urine 753967_1 CDM 0320 RC 74455 HCPCS inpatient 512 332.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 399.36 78 999999999 310.02 496.64 percent of total billed charges Review by radiologist of urinary bladder and urethra images with contrast and after passing urine 753967_1 CDM 0320 RC 74455 HCPCS inpatient 512 332.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 353.28 69 999999999 310.02 496.64 percent of total billed charges Review by radiologist of urinary bladder and urethra images with contrast and after passing urine 753967_1 CDM 0320 RC 74455 HCPCS inpatient 512 332.8 SIHO - ALL PLANS SIHO - ALL PLANS 460.8 90 999999999 310.02 496.64 percent of total billed charges Review by radiologist of urinary bladder and urethra images with contrast and after passing urine 753967_1 CDM 0320 RC 74455 HCPCS inpatient 512 332.8 UMR - ALL PLANS UMR - ALL PLANS 358.4 70 999999999 310.02 496.64 percent of total billed charges Review by radiologist of urinary bladder and urethra images with contrast and after passing urine 753967_1 CDM 0320 RC 74455 HCPCS inpatient 512 332.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 310.02 60.55 999999999 310.02 496.64 percent of total billed charges Review by radiologist of urinary bladder and urethra images with contrast and after passing urine 753967_1 CDM 0320 RC 74455 HCPCS inpatient 512 332.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 310.02 496.64 Review by radiologist of urinary bladder and urethra images with contrast and after passing urine 753967_1 CDM 0320 RC 74455 HCPCS inpatient 512 332.8 ANTHEM HMO ANTHEM HMO 999999999 310.02 496.64 Review by radiologist of urinary bladder and urethra images with contrast and after passing urine 753967_1 CDM 0320 RC 74455 HCPCS inpatient 512 332.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 310.02 496.64 Review by radiologist of urinary bladder and urethra images with contrast and after passing urine 753967_1 CDM 0320 RC 74455 HCPCS inpatient 512 332.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 310.02 496.64 Review by radiologist of urinary bladder and urethra images with contrast and after passing urine 753967_1 CDM 0320 RC 74455 HCPCS inpatient 512 332.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 310.02 496.64 Review by radiologist of urinary bladder and urethra images with contrast and after passing urine 753967_1 CDM 0320 RC 74455 HCPCS inpatient 512 332.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 346.11 67.6 999999999 310.02 496.64 percent of total billed charges Review by radiologist of urinary bladder and urethra images with contrast 753972_1 CDM 0320 RC 74450 HCPCS inpatient 714 464.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 464.1 65 999999999 432.33 692.58 percent of total billed charges Review by radiologist of urinary bladder and urethra images with contrast 753972_1 CDM 0320 RC 74450 HCPCS inpatient 714 464.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 692.58 97 999999999 432.33 692.58 percent of total billed charges Review by radiologist of urinary bladder and urethra images with contrast 753972_1 CDM 0320 RC 74450 HCPCS inpatient 714 464.1 AETNA AETNA 564.06 79 999999999 432.33 692.58 percent of total billed charges Review by radiologist of urinary bladder and urethra images with contrast 753972_1 CDM 0320 RC 74450 HCPCS inpatient 714 464.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 556.92 78 999999999 432.33 692.58 percent of total billed charges Review by radiologist of urinary bladder and urethra images with contrast 753972_1 CDM 0320 RC 74450 HCPCS inpatient 714 464.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 492.66 69 999999999 432.33 692.58 percent of total billed charges Review by radiologist of urinary bladder and urethra images with contrast 753972_1 CDM 0320 RC 74450 HCPCS inpatient 714 464.1 SIHO - ALL PLANS SIHO - ALL PLANS 642.6 90 999999999 432.33 692.58 percent of total billed charges Review by radiologist of urinary bladder and urethra images with contrast 753972_1 CDM 0320 RC 74450 HCPCS inpatient 714 464.1 UMR - ALL PLANS UMR - ALL PLANS 499.8 70 999999999 432.33 692.58 percent of total billed charges Review by radiologist of urinary bladder and urethra images with contrast 753972_1 CDM 0320 RC 74450 HCPCS inpatient 714 464.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 432.33 60.55 999999999 432.33 692.58 percent of total billed charges Review by radiologist of urinary bladder and urethra images with contrast 753972_1 CDM 0320 RC 74450 HCPCS inpatient 714 464.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 432.33 692.58 Review by radiologist of urinary bladder and urethra images with contrast 753972_1 CDM 0320 RC 74450 HCPCS inpatient 714 464.1 ANTHEM HMO ANTHEM HMO 999999999 432.33 692.58 Review by radiologist of urinary bladder and urethra images with contrast 753972_1 CDM 0320 RC 74450 HCPCS inpatient 714 464.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 432.33 692.58 Review by radiologist of urinary bladder and urethra images with contrast 753972_1 CDM 0320 RC 74450 HCPCS inpatient 714 464.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 432.33 692.58 Review by radiologist of urinary bladder and urethra images with contrast 753972_1 CDM 0320 RC 74450 HCPCS inpatient 714 464.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 432.33 692.58 Review by radiologist of urinary bladder and urethra images with contrast 753972_1 CDM 0320 RC 74450 HCPCS inpatient 714 464.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 482.66 67.6 999999999 432.33 692.58 percent of total billed charges Imaging of urinary tract following injection of a contrast agent 753978_1 CDM 0320 RC 74420 HCPCS inpatient 742 482.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 482.3 65 999999999 449.28 719.74 percent of total billed charges Imaging of urinary tract following injection of a contrast agent 753978_1 CDM 0320 RC 74420 HCPCS inpatient 742 482.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 719.74 97 999999999 449.28 719.74 percent of total billed charges Imaging of urinary tract following injection of a contrast agent 753978_1 CDM 0320 RC 74420 HCPCS inpatient 742 482.3 AETNA AETNA 586.18 79 999999999 449.28 719.74 percent of total billed charges Imaging of urinary tract following injection of a contrast agent 753978_1 CDM 0320 RC 74420 HCPCS inpatient 742 482.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 578.76 78 999999999 449.28 719.74 percent of total billed charges Imaging of urinary tract following injection of a contrast agent 753978_1 CDM 0320 RC 74420 HCPCS inpatient 742 482.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 511.98 69 999999999 449.28 719.74 percent of total billed charges Imaging of urinary tract following injection of a contrast agent 753978_1 CDM 0320 RC 74420 HCPCS inpatient 742 482.3 SIHO - ALL PLANS SIHO - ALL PLANS 667.8 90 999999999 449.28 719.74 percent of total billed charges Imaging of urinary tract following injection of a contrast agent 753978_1 CDM 0320 RC 74420 HCPCS inpatient 742 482.3 UMR - ALL PLANS UMR - ALL PLANS 519.4 70 999999999 449.28 719.74 percent of total billed charges Imaging of urinary tract following injection of a contrast agent 753978_1 CDM 0320 RC 74420 HCPCS inpatient 742 482.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 449.28 60.55 999999999 449.28 719.74 percent of total billed charges Imaging of urinary tract following injection of a contrast agent 753978_1 CDM 0320 RC 74420 HCPCS inpatient 742 482.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 449.28 719.74 Imaging of urinary tract following injection of a contrast agent 753978_1 CDM 0320 RC 74420 HCPCS inpatient 742 482.3 ANTHEM HMO ANTHEM HMO 999999999 449.28 719.74 Imaging of urinary tract following injection of a contrast agent 753978_1 CDM 0320 RC 74420 HCPCS inpatient 742 482.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 449.28 719.74 Imaging of urinary tract following injection of a contrast agent 753978_1 CDM 0320 RC 74420 HCPCS inpatient 742 482.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 449.28 719.74 Imaging of urinary tract following injection of a contrast agent 753978_1 CDM 0320 RC 74420 HCPCS inpatient 742 482.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 449.28 719.74 Imaging of urinary tract following injection of a contrast agent 753978_1 CDM 0320 RC 74420 HCPCS inpatient 742 482.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 501.59 67.6 999999999 449.28 719.74 percent of total billed charges "X-ray of wrist, 2 views" 754005_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 217.1 65 999999999 202.24 323.98 percent of total billed charges "X-ray of wrist, 2 views" 754005_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 323.98 97 999999999 202.24 323.98 percent of total billed charges "X-ray of wrist, 2 views" 754005_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 AETNA AETNA 263.86 79 999999999 202.24 323.98 percent of total billed charges "X-ray of wrist, 2 views" 754005_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 260.52 78 999999999 202.24 323.98 percent of total billed charges "X-ray of wrist, 2 views" 754005_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 230.46 69 999999999 202.24 323.98 percent of total billed charges "X-ray of wrist, 2 views" 754005_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 SIHO - ALL PLANS SIHO - ALL PLANS 300.6 90 999999999 202.24 323.98 percent of total billed charges "X-ray of wrist, 2 views" 754005_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 UMR - ALL PLANS UMR - ALL PLANS 233.8 70 999999999 202.24 323.98 percent of total billed charges "X-ray of wrist, 2 views" 754005_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 202.24 60.55 999999999 202.24 323.98 percent of total billed charges "X-ray of wrist, 2 views" 754005_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 202.24 323.98 "X-ray of wrist, 2 views" 754005_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 ANTHEM HMO ANTHEM HMO 999999999 202.24 323.98 "X-ray of wrist, 2 views" 754005_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 202.24 323.98 "X-ray of wrist, 2 views" 754005_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 202.24 323.98 "X-ray of wrist, 2 views" 754005_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 202.24 323.98 "X-ray of wrist, 2 views" 754005_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 225.78 67.6 999999999 202.24 323.98 percent of total billed charges "X-ray of wrist, 2 views" 754007_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 217.1 65 999999999 202.24 323.98 percent of total billed charges "X-ray of wrist, 2 views" 754007_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 323.98 97 999999999 202.24 323.98 percent of total billed charges "X-ray of wrist, 2 views" 754007_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 AETNA AETNA 263.86 79 999999999 202.24 323.98 percent of total billed charges "X-ray of wrist, 2 views" 754007_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 260.52 78 999999999 202.24 323.98 percent of total billed charges "X-ray of wrist, 2 views" 754007_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 230.46 69 999999999 202.24 323.98 percent of total billed charges "X-ray of wrist, 2 views" 754007_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 SIHO - ALL PLANS SIHO - ALL PLANS 300.6 90 999999999 202.24 323.98 percent of total billed charges "X-ray of wrist, 2 views" 754007_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 UMR - ALL PLANS UMR - ALL PLANS 233.8 70 999999999 202.24 323.98 percent of total billed charges "X-ray of wrist, 2 views" 754007_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 202.24 60.55 999999999 202.24 323.98 percent of total billed charges "X-ray of wrist, 2 views" 754007_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 202.24 323.98 "X-ray of wrist, 2 views" 754007_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 ANTHEM HMO ANTHEM HMO 999999999 202.24 323.98 "X-ray of wrist, 2 views" 754007_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 202.24 323.98 "X-ray of wrist, 2 views" 754007_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 202.24 323.98 "X-ray of wrist, 2 views" 754007_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 202.24 323.98 "X-ray of wrist, 2 views" 754007_1 CDM 0320 RC 73100 HCPCS inpatient 334 217.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 225.78 67.6 999999999 202.24 323.98 percent of total billed charges "X-ray of wrist, minimum of 3 views" 754011_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 279.5 65 999999999 260.37 417.1 percent of total billed charges "X-ray of wrist, minimum of 3 views" 754011_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 417.1 97 999999999 260.37 417.1 percent of total billed charges "X-ray of wrist, minimum of 3 views" 754011_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 AETNA AETNA 339.7 79 999999999 260.37 417.1 percent of total billed charges "X-ray of wrist, minimum of 3 views" 754011_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 335.4 78 999999999 260.37 417.1 percent of total billed charges "X-ray of wrist, minimum of 3 views" 754011_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 296.7 69 999999999 260.37 417.1 percent of total billed charges "X-ray of wrist, minimum of 3 views" 754011_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 SIHO - ALL PLANS SIHO - ALL PLANS 387 90 999999999 260.37 417.1 percent of total billed charges "X-ray of wrist, minimum of 3 views" 754011_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 UMR - ALL PLANS UMR - ALL PLANS 301 70 999999999 260.37 417.1 percent of total billed charges "X-ray of wrist, minimum of 3 views" 754011_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 260.37 60.55 999999999 260.37 417.1 percent of total billed charges "X-ray of wrist, minimum of 3 views" 754011_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 260.37 417.1 "X-ray of wrist, minimum of 3 views" 754011_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 ANTHEM HMO ANTHEM HMO 999999999 260.37 417.1 "X-ray of wrist, minimum of 3 views" 754011_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 260.37 417.1 "X-ray of wrist, minimum of 3 views" 754011_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 260.37 417.1 "X-ray of wrist, minimum of 3 views" 754011_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 260.37 417.1 "X-ray of wrist, minimum of 3 views" 754011_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 290.68 67.6 999999999 260.37 417.1 percent of total billed charges "X-ray of wrist, minimum of 3 views" 754013_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 279.5 65 999999999 260.37 417.1 percent of total billed charges "X-ray of wrist, minimum of 3 views" 754013_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 417.1 97 999999999 260.37 417.1 percent of total billed charges "X-ray of wrist, minimum of 3 views" 754013_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 AETNA AETNA 339.7 79 999999999 260.37 417.1 percent of total billed charges "X-ray of wrist, minimum of 3 views" 754013_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 335.4 78 999999999 260.37 417.1 percent of total billed charges "X-ray of wrist, minimum of 3 views" 754013_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 296.7 69 999999999 260.37 417.1 percent of total billed charges "X-ray of wrist, minimum of 3 views" 754013_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 SIHO - ALL PLANS SIHO - ALL PLANS 387 90 999999999 260.37 417.1 percent of total billed charges "X-ray of wrist, minimum of 3 views" 754013_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 UMR - ALL PLANS UMR - ALL PLANS 301 70 999999999 260.37 417.1 percent of total billed charges "X-ray of wrist, minimum of 3 views" 754013_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 260.37 60.55 999999999 260.37 417.1 percent of total billed charges "X-ray of wrist, minimum of 3 views" 754013_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 260.37 417.1 "X-ray of wrist, minimum of 3 views" 754013_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 ANTHEM HMO ANTHEM HMO 999999999 260.37 417.1 "X-ray of wrist, minimum of 3 views" 754013_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 260.37 417.1 "X-ray of wrist, minimum of 3 views" 754013_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 260.37 417.1 "X-ray of wrist, minimum of 3 views" 754013_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 260.37 417.1 "X-ray of wrist, minimum of 3 views" 754013_1 CDM 0320 RC 73110 HCPCS inpatient 430 279.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 290.68 67.6 999999999 260.37 417.1 percent of total billed charges Body fluid cell count with cell identification 754348_1 CDM 0309 RC 89051 HCPCS inpatient 283 183.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 183.95 65 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 754348_1 CDM 0309 RC 89051 HCPCS inpatient 283 183.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 274.51 97 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 754348_1 CDM 0309 RC 89051 HCPCS inpatient 283 183.95 AETNA AETNA 223.57 79 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 754348_1 CDM 0309 RC 89051 HCPCS inpatient 283 183.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 220.74 78 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 754348_1 CDM 0309 RC 89051 HCPCS inpatient 283 183.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 195.27 69 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 754348_1 CDM 0309 RC 89051 HCPCS inpatient 283 183.95 SIHO - ALL PLANS SIHO - ALL PLANS 254.7 90 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 754348_1 CDM 0309 RC 89051 HCPCS inpatient 283 183.95 UMR - ALL PLANS UMR - ALL PLANS 198.1 70 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 754348_1 CDM 0309 RC 89051 HCPCS inpatient 283 183.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 171.36 60.55 999999999 171.36 274.51 percent of total billed charges Body fluid cell count with cell identification 754348_1 CDM 0309 RC 89051 HCPCS inpatient 283 183.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 171.36 274.51 Body fluid cell count with cell identification 754348_1 CDM 0309 RC 89051 HCPCS inpatient 283 183.95 ANTHEM HMO ANTHEM HMO 999999999 171.36 274.51 Body fluid cell count with cell identification 754348_1 CDM 0309 RC 89051 HCPCS inpatient 283 183.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 171.36 274.51 Body fluid cell count with cell identification 754348_1 CDM 0309 RC 89051 HCPCS inpatient 283 183.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 171.36 274.51 Body fluid cell count with cell identification 754348_1 CDM 0309 RC 89051 HCPCS inpatient 283 183.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 171.36 274.51 Body fluid cell count with cell identification 754348_1 CDM 0309 RC 89051 HCPCS inpatient 283 183.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 191.31 67.6 999999999 171.36 274.51 percent of total billed charges Hepatitis B surface antibody measurement 755198_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 755198_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 755198_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 755198_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 755198_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 755198_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 755198_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 755198_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 755198_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 Hepatitis B surface antibody measurement 755198_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 Hepatitis B surface antibody measurement 755198_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 Hepatitis B surface antibody measurement 755198_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 Hepatitis B surface antibody measurement 755198_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 Hepatitis B surface antibody measurement 755198_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 755200_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 89.05 65 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 755200_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 132.89 97 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 755200_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 AETNA AETNA 108.23 79 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 755200_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 106.86 78 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 755200_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 94.53 69 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 755200_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 SIHO - ALL PLANS SIHO - ALL PLANS 123.3 90 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 755200_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 UMR - ALL PLANS UMR - ALL PLANS 95.9 70 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 755200_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 82.95 60.55 999999999 82.95 132.89 percent of total billed charges Hepatitis B surface antibody measurement 755200_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 82.95 132.89 Hepatitis B surface antibody measurement 755200_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 ANTHEM HMO ANTHEM HMO 999999999 82.95 132.89 Hepatitis B surface antibody measurement 755200_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 82.95 132.89 Hepatitis B surface antibody measurement 755200_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 82.95 132.89 Hepatitis B surface antibody measurement 755200_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 82.95 132.89 Hepatitis B surface antibody measurement 755200_1 CDM 0301 RC 86706 HCPCS inpatient 137 89.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 92.61 67.6 999999999 82.95 132.89 percent of total billed charges Manual attempt to restore blood circulation and breathing 755917_1 CDM 0410 RC 92950 HCPCS inpatient 353 229.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 229.45 65 999999999 213.74 342.41 percent of total billed charges Manual attempt to restore blood circulation and breathing 755917_1 CDM 0410 RC 92950 HCPCS inpatient 353 229.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 342.41 97 999999999 213.74 342.41 percent of total billed charges Manual attempt to restore blood circulation and breathing 755917_1 CDM 0410 RC 92950 HCPCS inpatient 353 229.45 AETNA AETNA 278.87 79 999999999 213.74 342.41 percent of total billed charges Manual attempt to restore blood circulation and breathing 755917_1 CDM 0410 RC 92950 HCPCS inpatient 353 229.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 275.34 78 999999999 213.74 342.41 percent of total billed charges Manual attempt to restore blood circulation and breathing 755917_1 CDM 0410 RC 92950 HCPCS inpatient 353 229.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 243.57 69 999999999 213.74 342.41 percent of total billed charges Manual attempt to restore blood circulation and breathing 755917_1 CDM 0410 RC 92950 HCPCS inpatient 353 229.45 SIHO - ALL PLANS SIHO - ALL PLANS 317.7 90 999999999 213.74 342.41 percent of total billed charges Manual attempt to restore blood circulation and breathing 755917_1 CDM 0410 RC 92950 HCPCS inpatient 353 229.45 UMR - ALL PLANS UMR - ALL PLANS 247.1 70 999999999 213.74 342.41 percent of total billed charges Manual attempt to restore blood circulation and breathing 755917_1 CDM 0410 RC 92950 HCPCS inpatient 353 229.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 213.74 60.55 999999999 213.74 342.41 percent of total billed charges Manual attempt to restore blood circulation and breathing 755917_1 CDM 0410 RC 92950 HCPCS inpatient 353 229.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 213.74 342.41 Manual attempt to restore blood circulation and breathing 755917_1 CDM 0410 RC 92950 HCPCS inpatient 353 229.45 ANTHEM HMO ANTHEM HMO 999999999 213.74 342.41 Manual attempt to restore blood circulation and breathing 755917_1 CDM 0410 RC 92950 HCPCS inpatient 353 229.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 213.74 342.41 Manual attempt to restore blood circulation and breathing 755917_1 CDM 0410 RC 92950 HCPCS inpatient 353 229.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 213.74 342.41 Manual attempt to restore blood circulation and breathing 755917_1 CDM 0410 RC 92950 HCPCS inpatient 353 229.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 213.74 342.41 Manual attempt to restore blood circulation and breathing 755917_1 CDM 0410 RC 92950 HCPCS inpatient 353 229.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 238.63 67.6 999999999 213.74 342.41 percent of total billed charges Emergent insertion of breathing tube into windpipe using an endoscope 755928_1 CDM 0410 RC 31500 HCPCS inpatient 656 426.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 426.4 65 999999999 397.21 636.32 percent of total billed charges Emergent insertion of breathing tube into windpipe using an endoscope 755928_1 CDM 0410 RC 31500 HCPCS inpatient 656 426.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 636.32 97 999999999 397.21 636.32 percent of total billed charges Emergent insertion of breathing tube into windpipe using an endoscope 755928_1 CDM 0410 RC 31500 HCPCS inpatient 656 426.4 AETNA AETNA 518.24 79 999999999 397.21 636.32 percent of total billed charges Emergent insertion of breathing tube into windpipe using an endoscope 755928_1 CDM 0410 RC 31500 HCPCS inpatient 656 426.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 511.68 78 999999999 397.21 636.32 percent of total billed charges Emergent insertion of breathing tube into windpipe using an endoscope 755928_1 CDM 0410 RC 31500 HCPCS inpatient 656 426.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 452.64 69 999999999 397.21 636.32 percent of total billed charges Emergent insertion of breathing tube into windpipe using an endoscope 755928_1 CDM 0410 RC 31500 HCPCS inpatient 656 426.4 SIHO - ALL PLANS SIHO - ALL PLANS 590.4 90 999999999 397.21 636.32 percent of total billed charges Emergent insertion of breathing tube into windpipe using an endoscope 755928_1 CDM 0410 RC 31500 HCPCS inpatient 656 426.4 UMR - ALL PLANS UMR - ALL PLANS 459.2 70 999999999 397.21 636.32 percent of total billed charges Emergent insertion of breathing tube into windpipe using an endoscope 755928_1 CDM 0410 RC 31500 HCPCS inpatient 656 426.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 397.21 60.55 999999999 397.21 636.32 percent of total billed charges Emergent insertion of breathing tube into windpipe using an endoscope 755928_1 CDM 0410 RC 31500 HCPCS inpatient 656 426.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 397.21 636.32 Emergent insertion of breathing tube into windpipe using an endoscope 755928_1 CDM 0410 RC 31500 HCPCS inpatient 656 426.4 ANTHEM HMO ANTHEM HMO 999999999 397.21 636.32 Emergent insertion of breathing tube into windpipe using an endoscope 755928_1 CDM 0410 RC 31500 HCPCS inpatient 656 426.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 397.21 636.32 Emergent insertion of breathing tube into windpipe using an endoscope 755928_1 CDM 0410 RC 31500 HCPCS inpatient 656 426.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 397.21 636.32 Emergent insertion of breathing tube into windpipe using an endoscope 755928_1 CDM 0410 RC 31500 HCPCS inpatient 656 426.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 397.21 636.32 Emergent insertion of breathing tube into windpipe using an endoscope 755928_1 CDM 0410 RC 31500 HCPCS inpatient 656 426.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 443.46 67.6 999999999 397.21 636.32 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755936_1 CDM 0760 RC 94762 HCPCS inpatient 452 293.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 293.8 65 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755936_1 CDM 0760 RC 94762 HCPCS inpatient 452 293.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 438.44 97 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755936_1 CDM 0760 RC 94762 HCPCS inpatient 452 293.8 AETNA AETNA 357.08 79 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755936_1 CDM 0760 RC 94762 HCPCS inpatient 452 293.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 352.56 78 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755936_1 CDM 0760 RC 94762 HCPCS inpatient 452 293.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 311.88 69 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755936_1 CDM 0760 RC 94762 HCPCS inpatient 452 293.8 SIHO - ALL PLANS SIHO - ALL PLANS 406.8 90 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755936_1 CDM 0760 RC 94762 HCPCS inpatient 452 293.8 UMR - ALL PLANS UMR - ALL PLANS 316.4 70 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755936_1 CDM 0760 RC 94762 HCPCS inpatient 452 293.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 273.69 60.55 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755936_1 CDM 0760 RC 94762 HCPCS inpatient 452 293.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 273.69 438.44 Test to measure oxygen level in blood using ear or finger device continuously overnight 755936_1 CDM 0760 RC 94762 HCPCS inpatient 452 293.8 ANTHEM HMO ANTHEM HMO 999999999 273.69 438.44 Test to measure oxygen level in blood using ear or finger device continuously overnight 755936_1 CDM 0760 RC 94762 HCPCS inpatient 452 293.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 273.69 438.44 Test to measure oxygen level in blood using ear or finger device continuously overnight 755936_1 CDM 0760 RC 94762 HCPCS inpatient 452 293.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 273.69 438.44 Test to measure oxygen level in blood using ear or finger device continuously overnight 755936_1 CDM 0760 RC 94762 HCPCS inpatient 452 293.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 273.69 438.44 Test to measure oxygen level in blood using ear or finger device continuously overnight 755936_1 CDM 0760 RC 94762 HCPCS inpatient 452 293.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 305.55 67.6 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755937_1 CDM 0483 RC 94762 HCPCS inpatient 452 293.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 293.8 65 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755937_1 CDM 0483 RC 94762 HCPCS inpatient 452 293.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 438.44 97 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755937_1 CDM 0483 RC 94762 HCPCS inpatient 452 293.8 AETNA AETNA 357.08 79 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755937_1 CDM 0483 RC 94762 HCPCS inpatient 452 293.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 352.56 78 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755937_1 CDM 0483 RC 94762 HCPCS inpatient 452 293.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 311.88 69 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755937_1 CDM 0483 RC 94762 HCPCS inpatient 452 293.8 SIHO - ALL PLANS SIHO - ALL PLANS 406.8 90 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755937_1 CDM 0483 RC 94762 HCPCS inpatient 452 293.8 UMR - ALL PLANS UMR - ALL PLANS 316.4 70 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755937_1 CDM 0483 RC 94762 HCPCS inpatient 452 293.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 273.69 60.55 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755937_1 CDM 0483 RC 94762 HCPCS inpatient 452 293.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 273.69 438.44 Test to measure oxygen level in blood using ear or finger device continuously overnight 755937_1 CDM 0483 RC 94762 HCPCS inpatient 452 293.8 ANTHEM HMO ANTHEM HMO 999999999 273.69 438.44 Test to measure oxygen level in blood using ear or finger device continuously overnight 755937_1 CDM 0483 RC 94762 HCPCS inpatient 452 293.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 273.69 438.44 Test to measure oxygen level in blood using ear or finger device continuously overnight 755937_1 CDM 0483 RC 94762 HCPCS inpatient 452 293.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 273.69 438.44 Test to measure oxygen level in blood using ear or finger device continuously overnight 755937_1 CDM 0483 RC 94762 HCPCS inpatient 452 293.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 273.69 438.44 Test to measure oxygen level in blood using ear or finger device continuously overnight 755937_1 CDM 0483 RC 94762 HCPCS inpatient 452 293.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 305.55 67.6 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device multiple times 755938_1 CDM 0460 RC 94761 HCPCS inpatient 190 123.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 123.5 65 999999999 115.05 184.3 percent of total billed charges Test to measure oxygen level in blood using ear or finger device multiple times 755938_1 CDM 0460 RC 94761 HCPCS inpatient 190 123.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 184.3 97 999999999 115.05 184.3 percent of total billed charges Test to measure oxygen level in blood using ear or finger device multiple times 755938_1 CDM 0460 RC 94761 HCPCS inpatient 190 123.5 AETNA AETNA 150.1 79 999999999 115.05 184.3 percent of total billed charges Test to measure oxygen level in blood using ear or finger device multiple times 755938_1 CDM 0460 RC 94761 HCPCS inpatient 190 123.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 148.2 78 999999999 115.05 184.3 percent of total billed charges Test to measure oxygen level in blood using ear or finger device multiple times 755938_1 CDM 0460 RC 94761 HCPCS inpatient 190 123.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 131.1 69 999999999 115.05 184.3 percent of total billed charges Test to measure oxygen level in blood using ear or finger device multiple times 755938_1 CDM 0460 RC 94761 HCPCS inpatient 190 123.5 SIHO - ALL PLANS SIHO - ALL PLANS 171 90 999999999 115.05 184.3 percent of total billed charges Test to measure oxygen level in blood using ear or finger device multiple times 755938_1 CDM 0460 RC 94761 HCPCS inpatient 190 123.5 UMR - ALL PLANS UMR - ALL PLANS 133 70 999999999 115.05 184.3 percent of total billed charges Test to measure oxygen level in blood using ear or finger device multiple times 755938_1 CDM 0460 RC 94761 HCPCS inpatient 190 123.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 115.05 60.55 999999999 115.05 184.3 percent of total billed charges Test to measure oxygen level in blood using ear or finger device multiple times 755938_1 CDM 0460 RC 94761 HCPCS inpatient 190 123.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 115.05 184.3 Test to measure oxygen level in blood using ear or finger device multiple times 755938_1 CDM 0460 RC 94761 HCPCS inpatient 190 123.5 ANTHEM HMO ANTHEM HMO 999999999 115.05 184.3 Test to measure oxygen level in blood using ear or finger device multiple times 755938_1 CDM 0460 RC 94761 HCPCS inpatient 190 123.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 115.05 184.3 Test to measure oxygen level in blood using ear or finger device multiple times 755938_1 CDM 0460 RC 94761 HCPCS inpatient 190 123.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 115.05 184.3 Test to measure oxygen level in blood using ear or finger device multiple times 755938_1 CDM 0460 RC 94761 HCPCS inpatient 190 123.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 115.05 184.3 Test to measure oxygen level in blood using ear or finger device multiple times 755938_1 CDM 0460 RC 94761 HCPCS inpatient 190 123.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 128.44 67.6 999999999 115.05 184.3 percent of total billed charges Initial therapy service to facilitate lung function 755941_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 146.25 65 999999999 136.24 218.25 percent of total billed charges Initial therapy service to facilitate lung function 755941_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 218.25 97 999999999 136.24 218.25 percent of total billed charges Initial therapy service to facilitate lung function 755941_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 AETNA AETNA 177.75 79 999999999 136.24 218.25 percent of total billed charges Initial therapy service to facilitate lung function 755941_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 175.5 78 999999999 136.24 218.25 percent of total billed charges Initial therapy service to facilitate lung function 755941_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 155.25 69 999999999 136.24 218.25 percent of total billed charges Initial therapy service to facilitate lung function 755941_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 SIHO - ALL PLANS SIHO - ALL PLANS 202.5 90 999999999 136.24 218.25 percent of total billed charges Initial therapy service to facilitate lung function 755941_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 UMR - ALL PLANS UMR - ALL PLANS 157.5 70 999999999 136.24 218.25 percent of total billed charges Initial therapy service to facilitate lung function 755941_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 136.24 60.55 999999999 136.24 218.25 percent of total billed charges Initial therapy service to facilitate lung function 755941_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 136.24 218.25 Initial therapy service to facilitate lung function 755941_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 ANTHEM HMO ANTHEM HMO 999999999 136.24 218.25 Initial therapy service to facilitate lung function 755941_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 136.24 218.25 Initial therapy service to facilitate lung function 755941_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 136.24 218.25 Initial therapy service to facilitate lung function 755941_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 136.24 218.25 Initial therapy service to facilitate lung function 755941_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 152.1 67.6 999999999 136.24 218.25 percent of total billed charges Follow-up therapy service to facilitate lung function 755942_1 CDM 0410 RC 94668 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges Follow-up therapy service to facilitate lung function 755942_1 CDM 0410 RC 94668 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges Follow-up therapy service to facilitate lung function 755942_1 CDM 0410 RC 94668 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges Follow-up therapy service to facilitate lung function 755942_1 CDM 0410 RC 94668 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges Follow-up therapy service to facilitate lung function 755942_1 CDM 0410 RC 94668 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges Follow-up therapy service to facilitate lung function 755942_1 CDM 0410 RC 94668 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges Follow-up therapy service to facilitate lung function 755942_1 CDM 0410 RC 94668 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges Follow-up therapy service to facilitate lung function 755942_1 CDM 0410 RC 94668 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges Follow-up therapy service to facilitate lung function 755942_1 CDM 0410 RC 94668 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 Follow-up therapy service to facilitate lung function 755942_1 CDM 0410 RC 94668 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 Follow-up therapy service to facilitate lung function 755942_1 CDM 0410 RC 94668 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 Follow-up therapy service to facilitate lung function 755942_1 CDM 0410 RC 94668 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 Follow-up therapy service to facilitate lung function 755942_1 CDM 0410 RC 94668 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 Follow-up therapy service to facilitate lung function 755942_1 CDM 0410 RC 94668 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755946_1 CDM 0460 RC 94762 HCPCS inpatient 483 313.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 313.95 65 999999999 292.46 468.51 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755946_1 CDM 0460 RC 94762 HCPCS inpatient 483 313.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 468.51 97 999999999 292.46 468.51 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755946_1 CDM 0460 RC 94762 HCPCS inpatient 483 313.95 AETNA AETNA 381.57 79 999999999 292.46 468.51 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755946_1 CDM 0460 RC 94762 HCPCS inpatient 483 313.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 376.74 78 999999999 292.46 468.51 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755946_1 CDM 0460 RC 94762 HCPCS inpatient 483 313.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 333.27 69 999999999 292.46 468.51 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755946_1 CDM 0460 RC 94762 HCPCS inpatient 483 313.95 SIHO - ALL PLANS SIHO - ALL PLANS 434.7 90 999999999 292.46 468.51 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755946_1 CDM 0460 RC 94762 HCPCS inpatient 483 313.95 UMR - ALL PLANS UMR - ALL PLANS 338.1 70 999999999 292.46 468.51 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755946_1 CDM 0460 RC 94762 HCPCS inpatient 483 313.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 292.46 60.55 999999999 292.46 468.51 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 755946_1 CDM 0460 RC 94762 HCPCS inpatient 483 313.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 292.46 468.51 Test to measure oxygen level in blood using ear or finger device continuously overnight 755946_1 CDM 0460 RC 94762 HCPCS inpatient 483 313.95 ANTHEM HMO ANTHEM HMO 999999999 292.46 468.51 Test to measure oxygen level in blood using ear or finger device continuously overnight 755946_1 CDM 0460 RC 94762 HCPCS inpatient 483 313.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 292.46 468.51 Test to measure oxygen level in blood using ear or finger device continuously overnight 755946_1 CDM 0460 RC 94762 HCPCS inpatient 483 313.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 292.46 468.51 Test to measure oxygen level in blood using ear or finger device continuously overnight 755946_1 CDM 0460 RC 94762 HCPCS inpatient 483 313.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 292.46 468.51 Test to measure oxygen level in blood using ear or finger device continuously overnight 755946_1 CDM 0460 RC 94762 HCPCS inpatient 483 313.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 326.51 67.6 999999999 292.46 468.51 percent of total billed charges Follow-up inpatient or observation ventilation assistance and management 755957_1 CDM 0410 RC 94003 HCPCS inpatient 1014 659.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 659.1 65 999999999 613.98 983.58 percent of total billed charges Follow-up inpatient or observation ventilation assistance and management 755957_1 CDM 0410 RC 94003 HCPCS inpatient 1014 659.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 983.58 97 999999999 613.98 983.58 percent of total billed charges Follow-up inpatient or observation ventilation assistance and management 755957_1 CDM 0410 RC 94003 HCPCS inpatient 1014 659.1 AETNA AETNA 801.06 79 999999999 613.98 983.58 percent of total billed charges Follow-up inpatient or observation ventilation assistance and management 755957_1 CDM 0410 RC 94003 HCPCS inpatient 1014 659.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 790.92 78 999999999 613.98 983.58 percent of total billed charges Follow-up inpatient or observation ventilation assistance and management 755957_1 CDM 0410 RC 94003 HCPCS inpatient 1014 659.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 699.66 69 999999999 613.98 983.58 percent of total billed charges Follow-up inpatient or observation ventilation assistance and management 755957_1 CDM 0410 RC 94003 HCPCS inpatient 1014 659.1 SIHO - ALL PLANS SIHO - ALL PLANS 912.6 90 999999999 613.98 983.58 percent of total billed charges Follow-up inpatient or observation ventilation assistance and management 755957_1 CDM 0410 RC 94003 HCPCS inpatient 1014 659.1 UMR - ALL PLANS UMR - ALL PLANS 709.8 70 999999999 613.98 983.58 percent of total billed charges Follow-up inpatient or observation ventilation assistance and management 755957_1 CDM 0410 RC 94003 HCPCS inpatient 1014 659.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 613.98 60.55 999999999 613.98 983.58 percent of total billed charges Follow-up inpatient or observation ventilation assistance and management 755957_1 CDM 0410 RC 94003 HCPCS inpatient 1014 659.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 613.98 983.58 Follow-up inpatient or observation ventilation assistance and management 755957_1 CDM 0410 RC 94003 HCPCS inpatient 1014 659.1 ANTHEM HMO ANTHEM HMO 999999999 613.98 983.58 Follow-up inpatient or observation ventilation assistance and management 755957_1 CDM 0410 RC 94003 HCPCS inpatient 1014 659.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 613.98 983.58 Follow-up inpatient or observation ventilation assistance and management 755957_1 CDM 0410 RC 94003 HCPCS inpatient 1014 659.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 613.98 983.58 Follow-up inpatient or observation ventilation assistance and management 755957_1 CDM 0410 RC 94003 HCPCS inpatient 1014 659.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 613.98 983.58 Follow-up inpatient or observation ventilation assistance and management 755957_1 CDM 0410 RC 94003 HCPCS inpatient 1014 659.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 685.46 67.6 999999999 613.98 983.58 percent of total billed charges Test to measure the total volume of air that can be exhaled after inhaling 755958_1 CDM 0410 RC 94150 HCPCS inpatient 299 194.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 194.35 65 999999999 181.04 290.03 percent of total billed charges Test to measure the total volume of air that can be exhaled after inhaling 755958_1 CDM 0410 RC 94150 HCPCS inpatient 299 194.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 290.03 97 999999999 181.04 290.03 percent of total billed charges Test to measure the total volume of air that can be exhaled after inhaling 755958_1 CDM 0410 RC 94150 HCPCS inpatient 299 194.35 AETNA AETNA 236.21 79 999999999 181.04 290.03 percent of total billed charges Test to measure the total volume of air that can be exhaled after inhaling 755958_1 CDM 0410 RC 94150 HCPCS inpatient 299 194.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 233.22 78 999999999 181.04 290.03 percent of total billed charges Test to measure the total volume of air that can be exhaled after inhaling 755958_1 CDM 0410 RC 94150 HCPCS inpatient 299 194.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 206.31 69 999999999 181.04 290.03 percent of total billed charges Test to measure the total volume of air that can be exhaled after inhaling 755958_1 CDM 0410 RC 94150 HCPCS inpatient 299 194.35 SIHO - ALL PLANS SIHO - ALL PLANS 269.1 90 999999999 181.04 290.03 percent of total billed charges Test to measure the total volume of air that can be exhaled after inhaling 755958_1 CDM 0410 RC 94150 HCPCS inpatient 299 194.35 UMR - ALL PLANS UMR - ALL PLANS 209.3 70 999999999 181.04 290.03 percent of total billed charges Test to measure the total volume of air that can be exhaled after inhaling 755958_1 CDM 0410 RC 94150 HCPCS inpatient 299 194.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 181.04 60.55 999999999 181.04 290.03 percent of total billed charges Test to measure the total volume of air that can be exhaled after inhaling 755958_1 CDM 0410 RC 94150 HCPCS inpatient 299 194.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 181.04 290.03 Test to measure the total volume of air that can be exhaled after inhaling 755958_1 CDM 0410 RC 94150 HCPCS inpatient 299 194.35 ANTHEM HMO ANTHEM HMO 999999999 181.04 290.03 Test to measure the total volume of air that can be exhaled after inhaling 755958_1 CDM 0410 RC 94150 HCPCS inpatient 299 194.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 181.04 290.03 Test to measure the total volume of air that can be exhaled after inhaling 755958_1 CDM 0410 RC 94150 HCPCS inpatient 299 194.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 181.04 290.03 Test to measure the total volume of air that can be exhaled after inhaling 755958_1 CDM 0410 RC 94150 HCPCS inpatient 299 194.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 181.04 290.03 Test to measure the total volume of air that can be exhaled after inhaling 755958_1 CDM 0410 RC 94150 HCPCS inpatient 299 194.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 202.12 67.6 999999999 181.04 290.03 percent of total billed charges Nuclear medicine study of liver and spleen 756078_1 CDM 0341 RC 78215 HCPCS inpatient 1721 1118.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1118.65 65 999999999 1042.07 1669.37 percent of total billed charges Nuclear medicine study of liver and spleen 756078_1 CDM 0341 RC 78215 HCPCS inpatient 1721 1118.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1669.37 97 999999999 1042.07 1669.37 percent of total billed charges Nuclear medicine study of liver and spleen 756078_1 CDM 0341 RC 78215 HCPCS inpatient 1721 1118.65 AETNA AETNA 1359.59 79 999999999 1042.07 1669.37 percent of total billed charges Nuclear medicine study of liver and spleen 756078_1 CDM 0341 RC 78215 HCPCS inpatient 1721 1118.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1342.38 78 999999999 1042.07 1669.37 percent of total billed charges Nuclear medicine study of liver and spleen 756078_1 CDM 0341 RC 78215 HCPCS inpatient 1721 1118.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1187.49 69 999999999 1042.07 1669.37 percent of total billed charges Nuclear medicine study of liver and spleen 756078_1 CDM 0341 RC 78215 HCPCS inpatient 1721 1118.65 SIHO - ALL PLANS SIHO - ALL PLANS 1548.9 90 999999999 1042.07 1669.37 percent of total billed charges Nuclear medicine study of liver and spleen 756078_1 CDM 0341 RC 78215 HCPCS inpatient 1721 1118.65 UMR - ALL PLANS UMR - ALL PLANS 1204.7 70 999999999 1042.07 1669.37 percent of total billed charges Nuclear medicine study of liver and spleen 756078_1 CDM 0341 RC 78215 HCPCS inpatient 1721 1118.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1042.07 60.55 999999999 1042.07 1669.37 percent of total billed charges Nuclear medicine study of liver and spleen 756078_1 CDM 0341 RC 78215 HCPCS inpatient 1721 1118.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1042.07 1669.37 Nuclear medicine study of liver and spleen 756078_1 CDM 0341 RC 78215 HCPCS inpatient 1721 1118.65 ANTHEM HMO ANTHEM HMO 999999999 1042.07 1669.37 Nuclear medicine study of liver and spleen 756078_1 CDM 0341 RC 78215 HCPCS inpatient 1721 1118.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1042.07 1669.37 Nuclear medicine study of liver and spleen 756078_1 CDM 0341 RC 78215 HCPCS inpatient 1721 1118.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1042.07 1669.37 Nuclear medicine study of liver and spleen 756078_1 CDM 0341 RC 78215 HCPCS inpatient 1721 1118.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1042.07 1669.37 Nuclear medicine study of liver and spleen 756078_1 CDM 0341 RC 78215 HCPCS inpatient 1721 1118.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1163.4 67.6 999999999 1042.07 1669.37 percent of total billed charges Nuclear medicine study of lung circulation 756084_1 CDM 0341 RC 78580 HCPCS inpatient 1415 919.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 919.75 65 999999999 856.78 1372.55 percent of total billed charges Nuclear medicine study of lung circulation 756084_1 CDM 0341 RC 78580 HCPCS inpatient 1415 919.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1372.55 97 999999999 856.78 1372.55 percent of total billed charges Nuclear medicine study of lung circulation 756084_1 CDM 0341 RC 78580 HCPCS inpatient 1415 919.75 AETNA AETNA 1117.85 79 999999999 856.78 1372.55 percent of total billed charges Nuclear medicine study of lung circulation 756084_1 CDM 0341 RC 78580 HCPCS inpatient 1415 919.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1103.7 78 999999999 856.78 1372.55 percent of total billed charges Nuclear medicine study of lung circulation 756084_1 CDM 0341 RC 78580 HCPCS inpatient 1415 919.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 976.35 69 999999999 856.78 1372.55 percent of total billed charges Nuclear medicine study of lung circulation 756084_1 CDM 0341 RC 78580 HCPCS inpatient 1415 919.75 SIHO - ALL PLANS SIHO - ALL PLANS 1273.5 90 999999999 856.78 1372.55 percent of total billed charges Nuclear medicine study of lung circulation 756084_1 CDM 0341 RC 78580 HCPCS inpatient 1415 919.75 UMR - ALL PLANS UMR - ALL PLANS 990.5 70 999999999 856.78 1372.55 percent of total billed charges Nuclear medicine study of lung circulation 756084_1 CDM 0341 RC 78580 HCPCS inpatient 1415 919.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 856.78 60.55 999999999 856.78 1372.55 percent of total billed charges Nuclear medicine study of lung circulation 756084_1 CDM 0341 RC 78580 HCPCS inpatient 1415 919.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 856.78 1372.55 Nuclear medicine study of lung circulation 756084_1 CDM 0341 RC 78580 HCPCS inpatient 1415 919.75 ANTHEM HMO ANTHEM HMO 999999999 856.78 1372.55 Nuclear medicine study of lung circulation 756084_1 CDM 0341 RC 78580 HCPCS inpatient 1415 919.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 856.78 1372.55 Nuclear medicine study of lung circulation 756084_1 CDM 0341 RC 78580 HCPCS inpatient 1415 919.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 856.78 1372.55 Nuclear medicine study of lung circulation 756084_1 CDM 0341 RC 78580 HCPCS inpatient 1415 919.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 856.78 1372.55 Nuclear medicine study of lung circulation 756084_1 CDM 0341 RC 78580 HCPCS inpatient 1415 919.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 956.54 67.6 999999999 856.78 1372.55 percent of total billed charges Nuclear medicine study of lung ventilation and circulation 756088_1 CDM 0341 RC 78582 HCPCS inpatient 3274 2128.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 2128.1 65 999999999 1982.41 3175.78 percent of total billed charges Nuclear medicine study of lung ventilation and circulation 756088_1 CDM 0341 RC 78582 HCPCS inpatient 3274 2128.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3175.78 97 999999999 1982.41 3175.78 percent of total billed charges Nuclear medicine study of lung ventilation and circulation 756088_1 CDM 0341 RC 78582 HCPCS inpatient 3274 2128.1 AETNA AETNA 2586.46 79 999999999 1982.41 3175.78 percent of total billed charges Nuclear medicine study of lung ventilation and circulation 756088_1 CDM 0341 RC 78582 HCPCS inpatient 3274 2128.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 2553.72 78 999999999 1982.41 3175.78 percent of total billed charges Nuclear medicine study of lung ventilation and circulation 756088_1 CDM 0341 RC 78582 HCPCS inpatient 3274 2128.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 2259.06 69 999999999 1982.41 3175.78 percent of total billed charges Nuclear medicine study of lung ventilation and circulation 756088_1 CDM 0341 RC 78582 HCPCS inpatient 3274 2128.1 SIHO - ALL PLANS SIHO - ALL PLANS 2946.6 90 999999999 1982.41 3175.78 percent of total billed charges Nuclear medicine study of lung ventilation and circulation 756088_1 CDM 0341 RC 78582 HCPCS inpatient 3274 2128.1 UMR - ALL PLANS UMR - ALL PLANS 2291.8 70 999999999 1982.41 3175.78 percent of total billed charges Nuclear medicine study of lung ventilation and circulation 756088_1 CDM 0341 RC 78582 HCPCS inpatient 3274 2128.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1982.41 60.55 999999999 1982.41 3175.78 percent of total billed charges Nuclear medicine study of lung ventilation and circulation 756088_1 CDM 0341 RC 78582 HCPCS inpatient 3274 2128.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1982.41 3175.78 Nuclear medicine study of lung ventilation and circulation 756088_1 CDM 0341 RC 78582 HCPCS inpatient 3274 2128.1 ANTHEM HMO ANTHEM HMO 999999999 1982.41 3175.78 Nuclear medicine study of lung ventilation and circulation 756088_1 CDM 0341 RC 78582 HCPCS inpatient 3274 2128.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1982.41 3175.78 Nuclear medicine study of lung ventilation and circulation 756088_1 CDM 0341 RC 78582 HCPCS inpatient 3274 2128.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1982.41 3175.78 Nuclear medicine study of lung ventilation and circulation 756088_1 CDM 0341 RC 78582 HCPCS inpatient 3274 2128.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 1982.41 3175.78 Nuclear medicine study of lung ventilation and circulation 756088_1 CDM 0341 RC 78582 HCPCS inpatient 3274 2128.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 2213.22 67.6 999999999 1982.41 3175.78 percent of total billed charges Nuclear medicine study of testicle and blood flow 756102_1 CDM 0341 RC 78761 HCPCS inpatient 1824 1185.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1185.6 65 999999999 1104.43 1769.28 percent of total billed charges Nuclear medicine study of testicle and blood flow 756102_1 CDM 0341 RC 78761 HCPCS inpatient 1824 1185.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1769.28 97 999999999 1104.43 1769.28 percent of total billed charges Nuclear medicine study of testicle and blood flow 756102_1 CDM 0341 RC 78761 HCPCS inpatient 1824 1185.6 AETNA AETNA 1440.96 79 999999999 1104.43 1769.28 percent of total billed charges Nuclear medicine study of testicle and blood flow 756102_1 CDM 0341 RC 78761 HCPCS inpatient 1824 1185.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1422.72 78 999999999 1104.43 1769.28 percent of total billed charges Nuclear medicine study of testicle and blood flow 756102_1 CDM 0341 RC 78761 HCPCS inpatient 1824 1185.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1258.56 69 999999999 1104.43 1769.28 percent of total billed charges Nuclear medicine study of testicle and blood flow 756102_1 CDM 0341 RC 78761 HCPCS inpatient 1824 1185.6 SIHO - ALL PLANS SIHO - ALL PLANS 1641.6 90 999999999 1104.43 1769.28 percent of total billed charges Nuclear medicine study of testicle and blood flow 756102_1 CDM 0341 RC 78761 HCPCS inpatient 1824 1185.6 UMR - ALL PLANS UMR - ALL PLANS 1276.8 70 999999999 1104.43 1769.28 percent of total billed charges Nuclear medicine study of testicle and blood flow 756102_1 CDM 0341 RC 78761 HCPCS inpatient 1824 1185.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1104.43 60.55 999999999 1104.43 1769.28 percent of total billed charges Nuclear medicine study of testicle and blood flow 756102_1 CDM 0341 RC 78761 HCPCS inpatient 1824 1185.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1104.43 1769.28 Nuclear medicine study of testicle and blood flow 756102_1 CDM 0341 RC 78761 HCPCS inpatient 1824 1185.6 ANTHEM HMO ANTHEM HMO 999999999 1104.43 1769.28 Nuclear medicine study of testicle and blood flow 756102_1 CDM 0341 RC 78761 HCPCS inpatient 1824 1185.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1104.43 1769.28 Nuclear medicine study of testicle and blood flow 756102_1 CDM 0341 RC 78761 HCPCS inpatient 1824 1185.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1104.43 1769.28 Nuclear medicine study of testicle and blood flow 756102_1 CDM 0341 RC 78761 HCPCS inpatient 1824 1185.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1104.43 1769.28 Nuclear medicine study of testicle and blood flow 756102_1 CDM 0341 RC 78761 HCPCS inpatient 1824 1185.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1233.02 67.6 999999999 1104.43 1769.28 percent of total billed charges Nuclear medicine study of bone marrow limited area 756124_1 CDM 0320 RC 78102 HCPCS inpatient 1447 940.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 940.55 65 999999999 876.16 1403.59 percent of total billed charges Nuclear medicine study of bone marrow limited area 756124_1 CDM 0320 RC 78102 HCPCS inpatient 1447 940.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1403.59 97 999999999 876.16 1403.59 percent of total billed charges Nuclear medicine study of bone marrow limited area 756124_1 CDM 0320 RC 78102 HCPCS inpatient 1447 940.55 AETNA AETNA 1143.13 79 999999999 876.16 1403.59 percent of total billed charges Nuclear medicine study of bone marrow limited area 756124_1 CDM 0320 RC 78102 HCPCS inpatient 1447 940.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1128.66 78 999999999 876.16 1403.59 percent of total billed charges Nuclear medicine study of bone marrow limited area 756124_1 CDM 0320 RC 78102 HCPCS inpatient 1447 940.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 998.43 69 999999999 876.16 1403.59 percent of total billed charges Nuclear medicine study of bone marrow limited area 756124_1 CDM 0320 RC 78102 HCPCS inpatient 1447 940.55 SIHO - ALL PLANS SIHO - ALL PLANS 1302.3 90 999999999 876.16 1403.59 percent of total billed charges Nuclear medicine study of bone marrow limited area 756124_1 CDM 0320 RC 78102 HCPCS inpatient 1447 940.55 UMR - ALL PLANS UMR - ALL PLANS 1012.9 70 999999999 876.16 1403.59 percent of total billed charges Nuclear medicine study of bone marrow limited area 756124_1 CDM 0320 RC 78102 HCPCS inpatient 1447 940.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 876.16 60.55 999999999 876.16 1403.59 percent of total billed charges Nuclear medicine study of bone marrow limited area 756124_1 CDM 0320 RC 78102 HCPCS inpatient 1447 940.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 876.16 1403.59 Nuclear medicine study of bone marrow limited area 756124_1 CDM 0320 RC 78102 HCPCS inpatient 1447 940.55 ANTHEM HMO ANTHEM HMO 999999999 876.16 1403.59 Nuclear medicine study of bone marrow limited area 756124_1 CDM 0320 RC 78102 HCPCS inpatient 1447 940.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 876.16 1403.59 Nuclear medicine study of bone marrow limited area 756124_1 CDM 0320 RC 78102 HCPCS inpatient 1447 940.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 876.16 1403.59 Nuclear medicine study of bone marrow limited area 756124_1 CDM 0320 RC 78102 HCPCS inpatient 1447 940.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 876.16 1403.59 Nuclear medicine study of bone marrow limited area 756124_1 CDM 0320 RC 78102 HCPCS inpatient 1447 940.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 978.17 67.6 999999999 876.16 1403.59 percent of total billed charges Nuclear medicine study of stomach to assess emptying 756132_1 CDM 0341 RC 78264 HCPCS inpatient 2342 1522.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1522.3 65 999999999 1418.08 2271.74 percent of total billed charges Nuclear medicine study of stomach to assess emptying 756132_1 CDM 0341 RC 78264 HCPCS inpatient 2342 1522.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2271.74 97 999999999 1418.08 2271.74 percent of total billed charges Nuclear medicine study of stomach to assess emptying 756132_1 CDM 0341 RC 78264 HCPCS inpatient 2342 1522.3 AETNA AETNA 1850.18 79 999999999 1418.08 2271.74 percent of total billed charges Nuclear medicine study of stomach to assess emptying 756132_1 CDM 0341 RC 78264 HCPCS inpatient 2342 1522.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 1826.76 78 999999999 1418.08 2271.74 percent of total billed charges Nuclear medicine study of stomach to assess emptying 756132_1 CDM 0341 RC 78264 HCPCS inpatient 2342 1522.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1615.98 69 999999999 1418.08 2271.74 percent of total billed charges Nuclear medicine study of stomach to assess emptying 756132_1 CDM 0341 RC 78264 HCPCS inpatient 2342 1522.3 SIHO - ALL PLANS SIHO - ALL PLANS 2107.8 90 999999999 1418.08 2271.74 percent of total billed charges Nuclear medicine study of stomach to assess emptying 756132_1 CDM 0341 RC 78264 HCPCS inpatient 2342 1522.3 UMR - ALL PLANS UMR - ALL PLANS 1639.4 70 999999999 1418.08 2271.74 percent of total billed charges Nuclear medicine study of stomach to assess emptying 756132_1 CDM 0341 RC 78264 HCPCS inpatient 2342 1522.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1418.08 60.55 999999999 1418.08 2271.74 percent of total billed charges Nuclear medicine study of stomach to assess emptying 756132_1 CDM 0341 RC 78264 HCPCS inpatient 2342 1522.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1418.08 2271.74 Nuclear medicine study of stomach to assess emptying 756132_1 CDM 0341 RC 78264 HCPCS inpatient 2342 1522.3 ANTHEM HMO ANTHEM HMO 999999999 1418.08 2271.74 Nuclear medicine study of stomach to assess emptying 756132_1 CDM 0341 RC 78264 HCPCS inpatient 2342 1522.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1418.08 2271.74 Nuclear medicine study of stomach to assess emptying 756132_1 CDM 0341 RC 78264 HCPCS inpatient 2342 1522.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1418.08 2271.74 Nuclear medicine study of stomach to assess emptying 756132_1 CDM 0341 RC 78264 HCPCS inpatient 2342 1522.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1418.08 2271.74 Nuclear medicine study of stomach to assess emptying 756132_1 CDM 0341 RC 78264 HCPCS inpatient 2342 1522.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1583.19 67.6 999999999 1418.08 2271.74 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 756167_1 CDM 0341 RC 78803 HCPCS inpatient 2004 1302.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1302.6 65 999999999 1213.42 1943.88 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 756167_1 CDM 0341 RC 78803 HCPCS inpatient 2004 1302.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1943.88 97 999999999 1213.42 1943.88 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 756167_1 CDM 0341 RC 78803 HCPCS inpatient 2004 1302.6 AETNA AETNA 1583.16 79 999999999 1213.42 1943.88 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 756167_1 CDM 0341 RC 78803 HCPCS inpatient 2004 1302.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1563.12 78 999999999 1213.42 1943.88 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 756167_1 CDM 0341 RC 78803 HCPCS inpatient 2004 1302.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1382.76 69 999999999 1213.42 1943.88 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 756167_1 CDM 0341 RC 78803 HCPCS inpatient 2004 1302.6 SIHO - ALL PLANS SIHO - ALL PLANS 1803.6 90 999999999 1213.42 1943.88 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 756167_1 CDM 0341 RC 78803 HCPCS inpatient 2004 1302.6 UMR - ALL PLANS UMR - ALL PLANS 1402.8 70 999999999 1213.42 1943.88 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 756167_1 CDM 0341 RC 78803 HCPCS inpatient 2004 1302.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1213.42 60.55 999999999 1213.42 1943.88 percent of total billed charges "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 756167_1 CDM 0341 RC 78803 HCPCS inpatient 2004 1302.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1213.42 1943.88 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 756167_1 CDM 0341 RC 78803 HCPCS inpatient 2004 1302.6 ANTHEM HMO ANTHEM HMO 999999999 1213.42 1943.88 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 756167_1 CDM 0341 RC 78803 HCPCS inpatient 2004 1302.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1213.42 1943.88 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 756167_1 CDM 0341 RC 78803 HCPCS inpatient 2004 1302.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1213.42 1943.88 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 756167_1 CDM 0341 RC 78803 HCPCS inpatient 2004 1302.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1213.42 1943.88 "Nuclear medicine study, SPECT imaging, 1 area or single acquisition, single day imaging" 756167_1 CDM 0341 RC 78803 HCPCS inpatient 2004 1302.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1354.7 67.6 999999999 1213.42 1943.88 percent of total billed charges Nuclear medicine study of lymphatic system 756177_1 CDM 0341 RC 78195 HCPCS inpatient 1394 906.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 906.1 65 999999999 844.07 1352.18 percent of total billed charges Nuclear medicine study of lymphatic system 756177_1 CDM 0341 RC 78195 HCPCS inpatient 1394 906.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1352.18 97 999999999 844.07 1352.18 percent of total billed charges Nuclear medicine study of lymphatic system 756177_1 CDM 0341 RC 78195 HCPCS inpatient 1394 906.1 AETNA AETNA 1101.26 79 999999999 844.07 1352.18 percent of total billed charges Nuclear medicine study of lymphatic system 756177_1 CDM 0341 RC 78195 HCPCS inpatient 1394 906.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 1087.32 78 999999999 844.07 1352.18 percent of total billed charges Nuclear medicine study of lymphatic system 756177_1 CDM 0341 RC 78195 HCPCS inpatient 1394 906.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 961.86 69 999999999 844.07 1352.18 percent of total billed charges Nuclear medicine study of lymphatic system 756177_1 CDM 0341 RC 78195 HCPCS inpatient 1394 906.1 SIHO - ALL PLANS SIHO - ALL PLANS 1254.6 90 999999999 844.07 1352.18 percent of total billed charges Nuclear medicine study of lymphatic system 756177_1 CDM 0341 RC 78195 HCPCS inpatient 1394 906.1 UMR - ALL PLANS UMR - ALL PLANS 975.8 70 999999999 844.07 1352.18 percent of total billed charges Nuclear medicine study of lymphatic system 756177_1 CDM 0341 RC 78195 HCPCS inpatient 1394 906.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 844.07 60.55 999999999 844.07 1352.18 percent of total billed charges Nuclear medicine study of lymphatic system 756177_1 CDM 0341 RC 78195 HCPCS inpatient 1394 906.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 844.07 1352.18 Nuclear medicine study of lymphatic system 756177_1 CDM 0341 RC 78195 HCPCS inpatient 1394 906.1 ANTHEM HMO ANTHEM HMO 999999999 844.07 1352.18 Nuclear medicine study of lymphatic system 756177_1 CDM 0341 RC 78195 HCPCS inpatient 1394 906.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 844.07 1352.18 Nuclear medicine study of lymphatic system 756177_1 CDM 0341 RC 78195 HCPCS inpatient 1394 906.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 844.07 1352.18 Nuclear medicine study of lymphatic system 756177_1 CDM 0341 RC 78195 HCPCS inpatient 1394 906.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 844.07 1352.18 Nuclear medicine study of lymphatic system 756177_1 CDM 0341 RC 78195 HCPCS inpatient 1394 906.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 942.34 67.6 999999999 844.07 1352.18 percent of total billed charges Nuclear medicine study of parathyroid with SPECT 756179_1 CDM 0341 RC 78071 HCPCS inpatient 1969 1279.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1279.85 65 999999999 1192.23 1909.93 percent of total billed charges Nuclear medicine study of parathyroid with SPECT 756179_1 CDM 0341 RC 78071 HCPCS inpatient 1969 1279.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1909.93 97 999999999 1192.23 1909.93 percent of total billed charges Nuclear medicine study of parathyroid with SPECT 756179_1 CDM 0341 RC 78071 HCPCS inpatient 1969 1279.85 AETNA AETNA 1555.51 79 999999999 1192.23 1909.93 percent of total billed charges Nuclear medicine study of parathyroid with SPECT 756179_1 CDM 0341 RC 78071 HCPCS inpatient 1969 1279.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 1535.82 78 999999999 1192.23 1909.93 percent of total billed charges Nuclear medicine study of parathyroid with SPECT 756179_1 CDM 0341 RC 78071 HCPCS inpatient 1969 1279.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1358.61 69 999999999 1192.23 1909.93 percent of total billed charges Nuclear medicine study of parathyroid with SPECT 756179_1 CDM 0341 RC 78071 HCPCS inpatient 1969 1279.85 SIHO - ALL PLANS SIHO - ALL PLANS 1772.1 90 999999999 1192.23 1909.93 percent of total billed charges Nuclear medicine study of parathyroid with SPECT 756179_1 CDM 0341 RC 78071 HCPCS inpatient 1969 1279.85 UMR - ALL PLANS UMR - ALL PLANS 1378.3 70 999999999 1192.23 1909.93 percent of total billed charges Nuclear medicine study of parathyroid with SPECT 756179_1 CDM 0341 RC 78071 HCPCS inpatient 1969 1279.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1192.23 60.55 999999999 1192.23 1909.93 percent of total billed charges Nuclear medicine study of parathyroid with SPECT 756179_1 CDM 0341 RC 78071 HCPCS inpatient 1969 1279.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1192.23 1909.93 Nuclear medicine study of parathyroid with SPECT 756179_1 CDM 0341 RC 78071 HCPCS inpatient 1969 1279.85 ANTHEM HMO ANTHEM HMO 999999999 1192.23 1909.93 Nuclear medicine study of parathyroid with SPECT 756179_1 CDM 0341 RC 78071 HCPCS inpatient 1969 1279.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1192.23 1909.93 Nuclear medicine study of parathyroid with SPECT 756179_1 CDM 0341 RC 78071 HCPCS inpatient 1969 1279.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1192.23 1909.93 Nuclear medicine study of parathyroid with SPECT 756179_1 CDM 0341 RC 78071 HCPCS inpatient 1969 1279.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1192.23 1909.93 Nuclear medicine study of parathyroid with SPECT 756179_1 CDM 0341 RC 78071 HCPCS inpatient 1969 1279.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1331.04 67.6 999999999 1192.23 1909.93 percent of total billed charges Nuclear medicine study of whole body for thyroid cancer 756195_1 CDM 0341 RC 78018 HCPCS inpatient 1583 1028.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1028.95 65 999999999 958.51 1535.51 percent of total billed charges Nuclear medicine study of whole body for thyroid cancer 756195_1 CDM 0341 RC 78018 HCPCS inpatient 1583 1028.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1535.51 97 999999999 958.51 1535.51 percent of total billed charges Nuclear medicine study of whole body for thyroid cancer 756195_1 CDM 0341 RC 78018 HCPCS inpatient 1583 1028.95 AETNA AETNA 1250.57 79 999999999 958.51 1535.51 percent of total billed charges Nuclear medicine study of whole body for thyroid cancer 756195_1 CDM 0341 RC 78018 HCPCS inpatient 1583 1028.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1234.74 78 999999999 958.51 1535.51 percent of total billed charges Nuclear medicine study of whole body for thyroid cancer 756195_1 CDM 0341 RC 78018 HCPCS inpatient 1583 1028.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1092.27 69 999999999 958.51 1535.51 percent of total billed charges Nuclear medicine study of whole body for thyroid cancer 756195_1 CDM 0341 RC 78018 HCPCS inpatient 1583 1028.95 SIHO - ALL PLANS SIHO - ALL PLANS 1424.7 90 999999999 958.51 1535.51 percent of total billed charges Nuclear medicine study of whole body for thyroid cancer 756195_1 CDM 0341 RC 78018 HCPCS inpatient 1583 1028.95 UMR - ALL PLANS UMR - ALL PLANS 1108.1 70 999999999 958.51 1535.51 percent of total billed charges Nuclear medicine study of whole body for thyroid cancer 756195_1 CDM 0341 RC 78018 HCPCS inpatient 1583 1028.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 958.51 60.55 999999999 958.51 1535.51 percent of total billed charges Nuclear medicine study of whole body for thyroid cancer 756195_1 CDM 0341 RC 78018 HCPCS inpatient 1583 1028.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 958.51 1535.51 Nuclear medicine study of whole body for thyroid cancer 756195_1 CDM 0341 RC 78018 HCPCS inpatient 1583 1028.95 ANTHEM HMO ANTHEM HMO 999999999 958.51 1535.51 Nuclear medicine study of whole body for thyroid cancer 756195_1 CDM 0341 RC 78018 HCPCS inpatient 1583 1028.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 958.51 1535.51 Nuclear medicine study of whole body for thyroid cancer 756195_1 CDM 0341 RC 78018 HCPCS inpatient 1583 1028.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 958.51 1535.51 Nuclear medicine study of whole body for thyroid cancer 756195_1 CDM 0341 RC 78018 HCPCS inpatient 1583 1028.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 958.51 1535.51 Nuclear medicine study of whole body for thyroid cancer 756195_1 CDM 0341 RC 78018 HCPCS inpatient 1583 1028.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1070.11 67.6 999999999 958.51 1535.51 percent of total billed charges Ultrasonic guidance for blood vessel access 756369_1 CDM 0402 RC 76937 HCPCS inpatient 559 363.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 363.35 65 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 756369_1 CDM 0402 RC 76937 HCPCS inpatient 559 363.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 542.23 97 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 756369_1 CDM 0402 RC 76937 HCPCS inpatient 559 363.35 AETNA AETNA 441.61 79 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 756369_1 CDM 0402 RC 76937 HCPCS inpatient 559 363.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 436.02 78 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 756369_1 CDM 0402 RC 76937 HCPCS inpatient 559 363.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 385.71 69 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 756369_1 CDM 0402 RC 76937 HCPCS inpatient 559 363.35 SIHO - ALL PLANS SIHO - ALL PLANS 503.1 90 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 756369_1 CDM 0402 RC 76937 HCPCS inpatient 559 363.35 UMR - ALL PLANS UMR - ALL PLANS 391.3 70 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 756369_1 CDM 0402 RC 76937 HCPCS inpatient 559 363.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 338.47 60.55 999999999 338.47 542.23 percent of total billed charges Ultrasonic guidance for blood vessel access 756369_1 CDM 0402 RC 76937 HCPCS inpatient 559 363.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 338.47 542.23 Ultrasonic guidance for blood vessel access 756369_1 CDM 0402 RC 76937 HCPCS inpatient 559 363.35 ANTHEM HMO ANTHEM HMO 999999999 338.47 542.23 Ultrasonic guidance for blood vessel access 756369_1 CDM 0402 RC 76937 HCPCS inpatient 559 363.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 338.47 542.23 Ultrasonic guidance for blood vessel access 756369_1 CDM 0402 RC 76937 HCPCS inpatient 559 363.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 338.47 542.23 Ultrasonic guidance for blood vessel access 756369_1 CDM 0402 RC 76937 HCPCS inpatient 559 363.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 338.47 542.23 Ultrasonic guidance for blood vessel access 756369_1 CDM 0402 RC 76937 HCPCS inpatient 559 363.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 377.88 67.6 999999999 338.47 542.23 percent of total billed charges Bier Block 758742_1 CDM 0370 RC inpatient 374.5 243.43 SELF PAY DISCOUNT SELF PAY DISCOUNT 243.43 65 999999999 226.76 363.27 percent of total billed charges Bier Block 758742_1 CDM 0370 RC inpatient 374.5 243.43 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 363.27 97 999999999 226.76 363.27 percent of total billed charges Bier Block 758742_1 CDM 0370 RC inpatient 374.5 243.43 AETNA AETNA 295.86 79 999999999 226.76 363.27 percent of total billed charges Bier Block 758742_1 CDM 0370 RC inpatient 374.5 243.43 HUMANA - ALL PLANS HUMANA - ALL PLANS 292.11 78 999999999 226.76 363.27 percent of total billed charges Bier Block 758742_1 CDM 0370 RC inpatient 374.5 243.43 ENCORE - ALL PLANS ENCORE - ALL PLANS 258.41 69 999999999 226.76 363.27 percent of total billed charges Bier Block 758742_1 CDM 0370 RC inpatient 374.5 243.43 SIHO - ALL PLANS SIHO - ALL PLANS 337.05 90 999999999 226.76 363.27 percent of total billed charges Bier Block 758742_1 CDM 0370 RC inpatient 374.5 243.43 UMR - ALL PLANS UMR - ALL PLANS 262.15 70 999999999 226.76 363.27 percent of total billed charges Bier Block 758742_1 CDM 0370 RC inpatient 374.5 243.43 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 226.76 60.55 999999999 226.76 363.27 percent of total billed charges Bier Block 758742_1 CDM 0370 RC inpatient 374.5 243.43 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 226.76 363.27 Bier Block 758742_1 CDM 0370 RC inpatient 374.5 243.43 ANTHEM HMO ANTHEM HMO 999999999 226.76 363.27 Bier Block 758742_1 CDM 0370 RC inpatient 374.5 243.43 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 226.76 363.27 Bier Block 758742_1 CDM 0370 RC inpatient 374.5 243.43 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 226.76 363.27 Bier Block 758742_1 CDM 0370 RC inpatient 374.5 243.43 UHC - ALL PLANS UHC - ALL PLANS 999999999 226.76 363.27 Bier Block 758742_1 CDM 0370 RC inpatient 374.5 243.43 CIGNA - ALL PLANS CIGNA - ALL PLANS 253.16 67.6 999999999 226.76 363.27 percent of total billed charges Epidural 758745_1 CDM 0370 RC inpatient 342.4 222.56 SELF PAY DISCOUNT SELF PAY DISCOUNT 222.56 65 999999999 207.32 332.13 percent of total billed charges Epidural 758745_1 CDM 0370 RC inpatient 342.4 222.56 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 332.13 97 999999999 207.32 332.13 percent of total billed charges Epidural 758745_1 CDM 0370 RC inpatient 342.4 222.56 AETNA AETNA 270.5 79 999999999 207.32 332.13 percent of total billed charges Epidural 758745_1 CDM 0370 RC inpatient 342.4 222.56 HUMANA - ALL PLANS HUMANA - ALL PLANS 267.07 78 999999999 207.32 332.13 percent of total billed charges Epidural 758745_1 CDM 0370 RC inpatient 342.4 222.56 ENCORE - ALL PLANS ENCORE - ALL PLANS 236.26 69 999999999 207.32 332.13 percent of total billed charges Epidural 758745_1 CDM 0370 RC inpatient 342.4 222.56 SIHO - ALL PLANS SIHO - ALL PLANS 308.16 90 999999999 207.32 332.13 percent of total billed charges Epidural 758745_1 CDM 0370 RC inpatient 342.4 222.56 UMR - ALL PLANS UMR - ALL PLANS 239.68 70 999999999 207.32 332.13 percent of total billed charges Epidural 758745_1 CDM 0370 RC inpatient 342.4 222.56 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 207.32 60.55 999999999 207.32 332.13 percent of total billed charges Epidural 758745_1 CDM 0370 RC inpatient 342.4 222.56 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 207.32 332.13 Epidural 758745_1 CDM 0370 RC inpatient 342.4 222.56 ANTHEM HMO ANTHEM HMO 999999999 207.32 332.13 Epidural 758745_1 CDM 0370 RC inpatient 342.4 222.56 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 207.32 332.13 Epidural 758745_1 CDM 0370 RC inpatient 342.4 222.56 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 207.32 332.13 Epidural 758745_1 CDM 0370 RC inpatient 342.4 222.56 UHC - ALL PLANS UHC - ALL PLANS 999999999 207.32 332.13 Epidural 758745_1 CDM 0370 RC inpatient 342.4 222.56 CIGNA - ALL PLANS CIGNA - ALL PLANS 231.46 67.6 999999999 207.32 332.13 percent of total billed charges Regional Block 758750_1 CDM 0370 RC inpatient 414.63 269.51 SELF PAY DISCOUNT SELF PAY DISCOUNT 269.51 65 999999999 251.06 402.19 percent of total billed charges Regional Block 758750_1 CDM 0370 RC inpatient 414.63 269.51 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 402.19 97 999999999 251.06 402.19 percent of total billed charges Regional Block 758750_1 CDM 0370 RC inpatient 414.63 269.51 AETNA AETNA 327.56 79 999999999 251.06 402.19 percent of total billed charges Regional Block 758750_1 CDM 0370 RC inpatient 414.63 269.51 HUMANA - ALL PLANS HUMANA - ALL PLANS 323.41 78 999999999 251.06 402.19 percent of total billed charges Regional Block 758750_1 CDM 0370 RC inpatient 414.63 269.51 ENCORE - ALL PLANS ENCORE - ALL PLANS 286.09 69 999999999 251.06 402.19 percent of total billed charges Regional Block 758750_1 CDM 0370 RC inpatient 414.63 269.51 SIHO - ALL PLANS SIHO - ALL PLANS 373.17 90 999999999 251.06 402.19 percent of total billed charges Regional Block 758750_1 CDM 0370 RC inpatient 414.63 269.51 UMR - ALL PLANS UMR - ALL PLANS 290.24 70 999999999 251.06 402.19 percent of total billed charges Regional Block 758750_1 CDM 0370 RC inpatient 414.63 269.51 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 251.06 60.55 999999999 251.06 402.19 percent of total billed charges Regional Block 758750_1 CDM 0370 RC inpatient 414.63 269.51 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 251.06 402.19 Regional Block 758750_1 CDM 0370 RC inpatient 414.63 269.51 ANTHEM HMO ANTHEM HMO 999999999 251.06 402.19 Regional Block 758750_1 CDM 0370 RC inpatient 414.63 269.51 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 251.06 402.19 Regional Block 758750_1 CDM 0370 RC inpatient 414.63 269.51 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 251.06 402.19 Regional Block 758750_1 CDM 0370 RC inpatient 414.63 269.51 UHC - ALL PLANS UHC - ALL PLANS 999999999 251.06 402.19 Regional Block 758750_1 CDM 0370 RC inpatient 414.63 269.51 CIGNA - ALL PLANS CIGNA - ALL PLANS 280.29 67.6 999999999 251.06 402.19 percent of total billed charges Spinal 758752_1 CDM 0370 RC inpatient 296.04 192.43 SELF PAY DISCOUNT SELF PAY DISCOUNT 192.43 65 999999999 179.25 287.16 percent of total billed charges Spinal 758752_1 CDM 0370 RC inpatient 296.04 192.43 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 287.16 97 999999999 179.25 287.16 percent of total billed charges Spinal 758752_1 CDM 0370 RC inpatient 296.04 192.43 AETNA AETNA 233.87 79 999999999 179.25 287.16 percent of total billed charges Spinal 758752_1 CDM 0370 RC inpatient 296.04 192.43 HUMANA - ALL PLANS HUMANA - ALL PLANS 230.91 78 999999999 179.25 287.16 percent of total billed charges Spinal 758752_1 CDM 0370 RC inpatient 296.04 192.43 ENCORE - ALL PLANS ENCORE - ALL PLANS 204.27 69 999999999 179.25 287.16 percent of total billed charges Spinal 758752_1 CDM 0370 RC inpatient 296.04 192.43 SIHO - ALL PLANS SIHO - ALL PLANS 266.44 90 999999999 179.25 287.16 percent of total billed charges Spinal 758752_1 CDM 0370 RC inpatient 296.04 192.43 UMR - ALL PLANS UMR - ALL PLANS 207.23 70 999999999 179.25 287.16 percent of total billed charges Spinal 758752_1 CDM 0370 RC inpatient 296.04 192.43 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 179.25 60.55 999999999 179.25 287.16 percent of total billed charges Spinal 758752_1 CDM 0370 RC inpatient 296.04 192.43 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 179.25 287.16 Spinal 758752_1 CDM 0370 RC inpatient 296.04 192.43 ANTHEM HMO ANTHEM HMO 999999999 179.25 287.16 Spinal 758752_1 CDM 0370 RC inpatient 296.04 192.43 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 179.25 287.16 Spinal 758752_1 CDM 0370 RC inpatient 296.04 192.43 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 179.25 287.16 Spinal 758752_1 CDM 0370 RC inpatient 296.04 192.43 UHC - ALL PLANS UHC - ALL PLANS 999999999 179.25 287.16 Spinal 758752_1 CDM 0370 RC inpatient 296.04 192.43 CIGNA - ALL PLANS CIGNA - ALL PLANS 200.12 67.6 999999999 179.25 287.16 percent of total billed charges General 758754_1 CDM 0370 RC inpatient 462 300.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 300.3 65 999999999 279.74 448.14 percent of total billed charges General 758754_1 CDM 0370 RC inpatient 462 300.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 448.14 97 999999999 279.74 448.14 percent of total billed charges General 758754_1 CDM 0370 RC inpatient 462 300.3 AETNA AETNA 364.98 79 999999999 279.74 448.14 percent of total billed charges General 758754_1 CDM 0370 RC inpatient 462 300.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 360.36 78 999999999 279.74 448.14 percent of total billed charges General 758754_1 CDM 0370 RC inpatient 462 300.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 318.78 69 999999999 279.74 448.14 percent of total billed charges General 758754_1 CDM 0370 RC inpatient 462 300.3 SIHO - ALL PLANS SIHO - ALL PLANS 415.8 90 999999999 279.74 448.14 percent of total billed charges General 758754_1 CDM 0370 RC inpatient 462 300.3 UMR - ALL PLANS UMR - ALL PLANS 323.4 70 999999999 279.74 448.14 percent of total billed charges General 758754_1 CDM 0370 RC inpatient 462 300.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 279.74 60.55 999999999 279.74 448.14 percent of total billed charges General 758754_1 CDM 0370 RC inpatient 462 300.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 279.74 448.14 General 758754_1 CDM 0370 RC inpatient 462 300.3 ANTHEM HMO ANTHEM HMO 999999999 279.74 448.14 General 758754_1 CDM 0370 RC inpatient 462 300.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 279.74 448.14 General 758754_1 CDM 0370 RC inpatient 462 300.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 279.74 448.14 General 758754_1 CDM 0370 RC inpatient 462 300.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 279.74 448.14 General 758754_1 CDM 0370 RC inpatient 462 300.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 312.31 67.6 999999999 279.74 448.14 percent of total billed charges MAC 758755_1 CDM 0370 RC inpatient 432.54 281.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 281.15 65 999999999 261.9 419.56 percent of total billed charges MAC 758755_1 CDM 0370 RC inpatient 432.54 281.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 419.56 97 999999999 261.9 419.56 percent of total billed charges MAC 758755_1 CDM 0370 RC inpatient 432.54 281.15 AETNA AETNA 341.71 79 999999999 261.9 419.56 percent of total billed charges MAC 758755_1 CDM 0370 RC inpatient 432.54 281.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 337.38 78 999999999 261.9 419.56 percent of total billed charges MAC 758755_1 CDM 0370 RC inpatient 432.54 281.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 298.45 69 999999999 261.9 419.56 percent of total billed charges MAC 758755_1 CDM 0370 RC inpatient 432.54 281.15 SIHO - ALL PLANS SIHO - ALL PLANS 389.29 90 999999999 261.9 419.56 percent of total billed charges MAC 758755_1 CDM 0370 RC inpatient 432.54 281.15 UMR - ALL PLANS UMR - ALL PLANS 302.78 70 999999999 261.9 419.56 percent of total billed charges MAC 758755_1 CDM 0370 RC inpatient 432.54 281.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 261.9 60.55 999999999 261.9 419.56 percent of total billed charges MAC 758755_1 CDM 0370 RC inpatient 432.54 281.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 261.9 419.56 MAC 758755_1 CDM 0370 RC inpatient 432.54 281.15 ANTHEM HMO ANTHEM HMO 999999999 261.9 419.56 MAC 758755_1 CDM 0370 RC inpatient 432.54 281.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 261.9 419.56 MAC 758755_1 CDM 0370 RC inpatient 432.54 281.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 261.9 419.56 MAC 758755_1 CDM 0370 RC inpatient 432.54 281.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 261.9 419.56 MAC 758755_1 CDM 0370 RC inpatient 432.54 281.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 292.4 67.6 999999999 261.9 419.56 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 758756_1 CDM 0360 RC inpatient 2595.57 1687.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 1687.12 65 999999999 1571.62 2517.7 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 758756_1 CDM 0360 RC inpatient 2595.57 1687.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2517.7 97 999999999 1571.62 2517.7 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 758756_1 CDM 0360 RC inpatient 2595.57 1687.12 AETNA AETNA 2050.5 79 999999999 1571.62 2517.7 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 758756_1 CDM 0360 RC inpatient 2595.57 1687.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 2024.54 78 999999999 1571.62 2517.7 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 758756_1 CDM 0360 RC inpatient 2595.57 1687.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 1790.94 69 999999999 1571.62 2517.7 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 758756_1 CDM 0360 RC inpatient 2595.57 1687.12 SIHO - ALL PLANS SIHO - ALL PLANS 2336.01 90 999999999 1571.62 2517.7 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 758756_1 CDM 0360 RC inpatient 2595.57 1687.12 UMR - ALL PLANS UMR - ALL PLANS 1816.9 70 999999999 1571.62 2517.7 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 758756_1 CDM 0360 RC inpatient 2595.57 1687.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1571.62 60.55 999999999 1571.62 2517.7 percent of total billed charges OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 758756_1 CDM 0360 RC inpatient 2595.57 1687.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1571.62 2517.7 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 758756_1 CDM 0360 RC inpatient 2595.57 1687.12 ANTHEM HMO ANTHEM HMO 999999999 1571.62 2517.7 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 758756_1 CDM 0360 RC inpatient 2595.57 1687.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1571.62 2517.7 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 758756_1 CDM 0360 RC inpatient 2595.57 1687.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1571.62 2517.7 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 758756_1 CDM 0360 RC inpatient 2595.57 1687.12 UHC - ALL PLANS UHC - ALL PLANS 999999999 1571.62 2517.7 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 758756_1 CDM 0360 RC inpatient 2595.57 1687.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 1754.61 67.6 999999999 1571.62 2517.7 percent of total billed charges "Training for community or work reintegration, each 15 minutes" 768490_1 CDM 0430 RC 97537 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges "Training for community or work reintegration, each 15 minutes" 768490_1 CDM 0430 RC 97537 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges "Training for community or work reintegration, each 15 minutes" 768490_1 CDM 0430 RC 97537 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges "Training for community or work reintegration, each 15 minutes" 768490_1 CDM 0430 RC 97537 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges "Training for community or work reintegration, each 15 minutes" 768490_1 CDM 0430 RC 97537 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges "Training for community or work reintegration, each 15 minutes" 768490_1 CDM 0430 RC 97537 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges "Training for community or work reintegration, each 15 minutes" 768490_1 CDM 0430 RC 97537 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges "Training for community or work reintegration, each 15 minutes" 768490_1 CDM 0430 RC 97537 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges "Training for community or work reintegration, each 15 minutes" 768490_1 CDM 0430 RC 97537 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 "Training for community or work reintegration, each 15 minutes" 768490_1 CDM 0430 RC 97537 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 "Training for community or work reintegration, each 15 minutes" 768490_1 CDM 0430 RC 97537 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 "Training for community or work reintegration, each 15 minutes" 768490_1 CDM 0430 RC 97537 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 "Training for community or work reintegration, each 15 minutes" 768490_1 CDM 0430 RC 97537 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 "Training for community or work reintegration, each 15 minutes" 768490_1 CDM 0430 RC 97537 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 768492_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 113.75 65 999999999 105.96 169.75 percent of total billed charges "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 768492_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 169.75 97 999999999 105.96 169.75 percent of total billed charges "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 768492_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 AETNA AETNA 138.25 79 999999999 105.96 169.75 percent of total billed charges "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 768492_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 136.5 78 999999999 105.96 169.75 percent of total billed charges "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 768492_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 120.75 69 999999999 105.96 169.75 percent of total billed charges "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 768492_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 SIHO - ALL PLANS SIHO - ALL PLANS 157.5 90 999999999 105.96 169.75 percent of total billed charges "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 768492_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 UMR - ALL PLANS UMR - ALL PLANS 122.5 70 999999999 105.96 169.75 percent of total billed charges "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 768492_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 105.96 60.55 999999999 105.96 169.75 percent of total billed charges "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 768492_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 105.96 169.75 "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 768492_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 ANTHEM HMO ANTHEM HMO 999999999 105.96 169.75 "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 768492_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 105.96 169.75 "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 768492_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 105.96 169.75 "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 768492_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 105.96 169.75 "DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT, EACH 15 MINUTES" 768492_1 CDM 0430 RC 97532 HCPCS inpatient 175 113.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 118.3 67.6 999999999 105.96 169.75 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 768508_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 99.45 65 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 768508_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 148.41 97 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 768508_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 AETNA AETNA 120.87 79 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 768508_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 119.34 78 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 768508_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 105.57 69 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 768508_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 SIHO - ALL PLANS SIHO - ALL PLANS 137.7 90 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 768508_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 UMR - ALL PLANS UMR - ALL PLANS 107.1 70 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 768508_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 92.64 60.55 999999999 92.64 148.41 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 768508_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 92.64 148.41 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 768508_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 ANTHEM HMO ANTHEM HMO 999999999 92.64 148.41 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 768508_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 92.64 148.41 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 768508_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 92.64 148.41 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 768508_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 92.64 148.41 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 768508_1 CDM 0430 RC 97110 HCPCS inpatient 153 99.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 103.43 67.6 999999999 92.64 148.41 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 768518_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 117.65 65 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 768518_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 175.57 97 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 768518_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 AETNA AETNA 142.99 79 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 768518_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 141.18 78 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 768518_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.89 69 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 768518_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 SIHO - ALL PLANS SIHO - ALL PLANS 162.9 90 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 768518_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 UMR - ALL PLANS UMR - ALL PLANS 126.7 70 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 768518_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 109.6 60.55 999999999 109.6 175.57 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 768518_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 768518_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 ANTHEM HMO ANTHEM HMO 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 768518_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 768518_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 768518_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 109.6 175.57 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 768518_1 CDM 0430 RC 97112 HCPCS inpatient 181 117.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 122.36 67.6 999999999 109.6 175.57 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 768521_1 CDM 0430 RC 97140 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 768521_1 CDM 0430 RC 97140 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 768521_1 CDM 0430 RC 97140 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 768521_1 CDM 0430 RC 97140 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 768521_1 CDM 0430 RC 97140 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 768521_1 CDM 0430 RC 97140 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 768521_1 CDM 0430 RC 97140 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 768521_1 CDM 0430 RC 97140 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 768521_1 CDM 0430 RC 97140 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 "Therapy procedure using manual technique, each 15 minutes" 768521_1 CDM 0430 RC 97140 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 "Therapy procedure using manual technique, each 15 minutes" 768521_1 CDM 0430 RC 97140 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 "Therapy procedure using manual technique, each 15 minutes" 768521_1 CDM 0430 RC 97140 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 "Therapy procedure using manual technique, each 15 minutes" 768521_1 CDM 0430 RC 97140 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 "Therapy procedure using manual technique, each 15 minutes" 768521_1 CDM 0430 RC 97140 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 769583_1 CDM 0420 RC 97110 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 769583_1 CDM 0420 RC 97110 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 769583_1 CDM 0420 RC 97110 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 769583_1 CDM 0420 RC 97110 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 769583_1 CDM 0420 RC 97110 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 769583_1 CDM 0420 RC 97110 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 769583_1 CDM 0420 RC 97110 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 769583_1 CDM 0420 RC 97110 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 769583_1 CDM 0420 RC 97110 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 769583_1 CDM 0420 RC 97110 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 769583_1 CDM 0420 RC 97110 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 769583_1 CDM 0420 RC 97110 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 769583_1 CDM 0420 RC 97110 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 "Therapy procedure using exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes" 769583_1 CDM 0420 RC 97110 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges "Application of ultrasound, each 15 minutes" 769603_1 CDM 0420 RC 97035 HCPCS inpatient 166 107.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 107.9 65 999999999 100.51 161.02 percent of total billed charges "Application of ultrasound, each 15 minutes" 769603_1 CDM 0420 RC 97035 HCPCS inpatient 166 107.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 161.02 97 999999999 100.51 161.02 percent of total billed charges "Application of ultrasound, each 15 minutes" 769603_1 CDM 0420 RC 97035 HCPCS inpatient 166 107.9 AETNA AETNA 131.14 79 999999999 100.51 161.02 percent of total billed charges "Application of ultrasound, each 15 minutes" 769603_1 CDM 0420 RC 97035 HCPCS inpatient 166 107.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 129.48 78 999999999 100.51 161.02 percent of total billed charges "Application of ultrasound, each 15 minutes" 769603_1 CDM 0420 RC 97035 HCPCS inpatient 166 107.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 114.54 69 999999999 100.51 161.02 percent of total billed charges "Application of ultrasound, each 15 minutes" 769603_1 CDM 0420 RC 97035 HCPCS inpatient 166 107.9 SIHO - ALL PLANS SIHO - ALL PLANS 149.4 90 999999999 100.51 161.02 percent of total billed charges "Application of ultrasound, each 15 minutes" 769603_1 CDM 0420 RC 97035 HCPCS inpatient 166 107.9 UMR - ALL PLANS UMR - ALL PLANS 116.2 70 999999999 100.51 161.02 percent of total billed charges "Application of ultrasound, each 15 minutes" 769603_1 CDM 0420 RC 97035 HCPCS inpatient 166 107.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 100.51 60.55 999999999 100.51 161.02 percent of total billed charges "Application of ultrasound, each 15 minutes" 769603_1 CDM 0420 RC 97035 HCPCS inpatient 166 107.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 100.51 161.02 "Application of ultrasound, each 15 minutes" 769603_1 CDM 0420 RC 97035 HCPCS inpatient 166 107.9 ANTHEM HMO ANTHEM HMO 999999999 100.51 161.02 "Application of ultrasound, each 15 minutes" 769603_1 CDM 0420 RC 97035 HCPCS inpatient 166 107.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 100.51 161.02 "Application of ultrasound, each 15 minutes" 769603_1 CDM 0420 RC 97035 HCPCS inpatient 166 107.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 100.51 161.02 "Application of ultrasound, each 15 minutes" 769603_1 CDM 0420 RC 97035 HCPCS inpatient 166 107.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 100.51 161.02 "Application of ultrasound, each 15 minutes" 769603_1 CDM 0420 RC 97035 HCPCS inpatient 166 107.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 112.22 67.6 999999999 100.51 161.02 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 769604_1 CDM 0420 RC 97112 HCPCS inpatient 199 129.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 129.35 65 999999999 120.49 193.03 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 769604_1 CDM 0420 RC 97112 HCPCS inpatient 199 129.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 193.03 97 999999999 120.49 193.03 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 769604_1 CDM 0420 RC 97112 HCPCS inpatient 199 129.35 AETNA AETNA 157.21 79 999999999 120.49 193.03 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 769604_1 CDM 0420 RC 97112 HCPCS inpatient 199 129.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 155.22 78 999999999 120.49 193.03 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 769604_1 CDM 0420 RC 97112 HCPCS inpatient 199 129.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 137.31 69 999999999 120.49 193.03 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 769604_1 CDM 0420 RC 97112 HCPCS inpatient 199 129.35 SIHO - ALL PLANS SIHO - ALL PLANS 179.1 90 999999999 120.49 193.03 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 769604_1 CDM 0420 RC 97112 HCPCS inpatient 199 129.35 UMR - ALL PLANS UMR - ALL PLANS 139.3 70 999999999 120.49 193.03 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 769604_1 CDM 0420 RC 97112 HCPCS inpatient 199 129.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 120.49 60.55 999999999 120.49 193.03 percent of total billed charges "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 769604_1 CDM 0420 RC 97112 HCPCS inpatient 199 129.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 120.49 193.03 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 769604_1 CDM 0420 RC 97112 HCPCS inpatient 199 129.35 ANTHEM HMO ANTHEM HMO 999999999 120.49 193.03 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 769604_1 CDM 0420 RC 97112 HCPCS inpatient 199 129.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 120.49 193.03 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 769604_1 CDM 0420 RC 97112 HCPCS inpatient 199 129.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 120.49 193.03 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 769604_1 CDM 0420 RC 97112 HCPCS inpatient 199 129.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 120.49 193.03 "Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes" 769604_1 CDM 0420 RC 97112 HCPCS inpatient 199 129.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 134.52 67.6 999999999 120.49 193.03 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 769606_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.2 65 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 769606_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 162.96 97 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 769606_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 AETNA AETNA 132.72 79 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 769606_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.04 78 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 769606_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 115.92 69 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 769606_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 SIHO - ALL PLANS SIHO - ALL PLANS 151.2 90 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 769606_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 UMR - ALL PLANS UMR - ALL PLANS 117.6 70 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 769606_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 101.72 60.55 999999999 101.72 162.96 percent of total billed charges "Evaluation for wheelchair, each 15 minutes" 769606_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 769606_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 ANTHEM HMO ANTHEM HMO 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 769606_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 769606_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 769606_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 101.72 162.96 "Evaluation for wheelchair, each 15 minutes" 769606_1 CDM 0420 RC 97542 HCPCS inpatient 168 109.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 113.57 67.6 999999999 101.72 162.96 percent of total billed charges Therapy procedure using functional activities 769611_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 109.85 65 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 769611_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 163.93 97 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 769611_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 AETNA AETNA 133.51 79 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 769611_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 131.82 78 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 769611_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 116.61 69 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 769611_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 SIHO - ALL PLANS SIHO - ALL PLANS 152.1 90 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 769611_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 UMR - ALL PLANS UMR - ALL PLANS 118.3 70 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 769611_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 102.33 60.55 999999999 102.33 163.93 percent of total billed charges Therapy procedure using functional activities 769611_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 102.33 163.93 Therapy procedure using functional activities 769611_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 ANTHEM HMO ANTHEM HMO 999999999 102.33 163.93 Therapy procedure using functional activities 769611_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 102.33 163.93 Therapy procedure using functional activities 769611_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 102.33 163.93 Therapy procedure using functional activities 769611_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 102.33 163.93 Therapy procedure using functional activities 769611_1 CDM 0420 RC 97530 HCPCS inpatient 169 109.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 114.24 67.6 999999999 102.33 163.93 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 769613_1 CDM 0430 RC 97116 HCPCS inpatient 180 117 SELF PAY DISCOUNT SELF PAY DISCOUNT 117 65 999999999 108.99 174.6 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 769613_1 CDM 0430 RC 97116 HCPCS inpatient 180 117 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 174.6 97 999999999 108.99 174.6 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 769613_1 CDM 0430 RC 97116 HCPCS inpatient 180 117 AETNA AETNA 142.2 79 999999999 108.99 174.6 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 769613_1 CDM 0430 RC 97116 HCPCS inpatient 180 117 HUMANA - ALL PLANS HUMANA - ALL PLANS 140.4 78 999999999 108.99 174.6 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 769613_1 CDM 0430 RC 97116 HCPCS inpatient 180 117 ENCORE - ALL PLANS ENCORE - ALL PLANS 124.2 69 999999999 108.99 174.6 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 769613_1 CDM 0430 RC 97116 HCPCS inpatient 180 117 SIHO - ALL PLANS SIHO - ALL PLANS 162 90 999999999 108.99 174.6 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 769613_1 CDM 0430 RC 97116 HCPCS inpatient 180 117 UMR - ALL PLANS UMR - ALL PLANS 126 70 999999999 108.99 174.6 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 769613_1 CDM 0430 RC 97116 HCPCS inpatient 180 117 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 108.99 60.55 999999999 108.99 174.6 percent of total billed charges "Therapy procedure for walking training, each 15 minutes" 769613_1 CDM 0430 RC 97116 HCPCS inpatient 180 117 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 108.99 174.6 "Therapy procedure for walking training, each 15 minutes" 769613_1 CDM 0430 RC 97116 HCPCS inpatient 180 117 ANTHEM HMO ANTHEM HMO 999999999 108.99 174.6 "Therapy procedure for walking training, each 15 minutes" 769613_1 CDM 0430 RC 97116 HCPCS inpatient 180 117 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 108.99 174.6 "Therapy procedure for walking training, each 15 minutes" 769613_1 CDM 0430 RC 97116 HCPCS inpatient 180 117 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 108.99 174.6 "Therapy procedure for walking training, each 15 minutes" 769613_1 CDM 0430 RC 97116 HCPCS inpatient 180 117 UHC - ALL PLANS UHC - ALL PLANS 999999999 108.99 174.6 "Therapy procedure for walking training, each 15 minutes" 769613_1 CDM 0430 RC 97116 HCPCS inpatient 180 117 CIGNA - ALL PLANS CIGNA - ALL PLANS 121.68 67.6 999999999 108.99 174.6 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 769618_1 CDM 0420 RC 97140 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 769618_1 CDM 0420 RC 97140 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 769618_1 CDM 0420 RC 97140 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 769618_1 CDM 0420 RC 97140 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 769618_1 CDM 0420 RC 97140 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 769618_1 CDM 0420 RC 97140 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 769618_1 CDM 0420 RC 97140 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 769618_1 CDM 0420 RC 97140 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges "Therapy procedure using manual technique, each 15 minutes" 769618_1 CDM 0420 RC 97140 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 "Therapy procedure using manual technique, each 15 minutes" 769618_1 CDM 0420 RC 97140 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 "Therapy procedure using manual technique, each 15 minutes" 769618_1 CDM 0420 RC 97140 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 "Therapy procedure using manual technique, each 15 minutes" 769618_1 CDM 0420 RC 97140 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 "Therapy procedure using manual technique, each 15 minutes" 769618_1 CDM 0420 RC 97140 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 "Therapy procedure using manual technique, each 15 minutes" 769618_1 CDM 0420 RC 97140 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 769624_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 140.4 65 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 769624_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 209.52 97 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 769624_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 AETNA AETNA 170.64 79 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 769624_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 168.48 78 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 769624_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 149.04 69 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 769624_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 SIHO - ALL PLANS SIHO - ALL PLANS 194.4 90 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 769624_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 UMR - ALL PLANS UMR - ALL PLANS 151.2 70 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 769624_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 130.79 60.55 999999999 130.79 209.52 percent of total billed charges "Application of medication using electrical current, each 15 minutes" 769624_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 769624_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 ANTHEM HMO ANTHEM HMO 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 769624_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 769624_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 769624_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 130.79 209.52 "Application of medication using electrical current, each 15 minutes" 769624_1 CDM 0420 RC 97033 HCPCS inpatient 216 140.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 146.02 67.6 999999999 130.79 209.52 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 769625_1 CDM 0420 RC 97032 HCPCS inpatient 201 130.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 130.65 65 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 769625_1 CDM 0420 RC 97032 HCPCS inpatient 201 130.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 194.97 97 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 769625_1 CDM 0420 RC 97032 HCPCS inpatient 201 130.65 AETNA AETNA 158.79 79 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 769625_1 CDM 0420 RC 97032 HCPCS inpatient 201 130.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 156.78 78 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 769625_1 CDM 0420 RC 97032 HCPCS inpatient 201 130.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 138.69 69 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 769625_1 CDM 0420 RC 97032 HCPCS inpatient 201 130.65 SIHO - ALL PLANS SIHO - ALL PLANS 180.9 90 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 769625_1 CDM 0420 RC 97032 HCPCS inpatient 201 130.65 UMR - ALL PLANS UMR - ALL PLANS 140.7 70 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 769625_1 CDM 0420 RC 97032 HCPCS inpatient 201 130.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 121.71 60.55 999999999 121.71 194.97 percent of total billed charges "Application of electrical stimulation with therapist present, each 15 minutes" 769625_1 CDM 0420 RC 97032 HCPCS inpatient 201 130.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 121.71 194.97 "Application of electrical stimulation with therapist present, each 15 minutes" 769625_1 CDM 0420 RC 97032 HCPCS inpatient 201 130.65 ANTHEM HMO ANTHEM HMO 999999999 121.71 194.97 "Application of electrical stimulation with therapist present, each 15 minutes" 769625_1 CDM 0420 RC 97032 HCPCS inpatient 201 130.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 121.71 194.97 "Application of electrical stimulation with therapist present, each 15 minutes" 769625_1 CDM 0420 RC 97032 HCPCS inpatient 201 130.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 121.71 194.97 "Application of electrical stimulation with therapist present, each 15 minutes" 769625_1 CDM 0420 RC 97032 HCPCS inpatient 201 130.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 121.71 194.97 "Application of electrical stimulation with therapist present, each 15 minutes" 769625_1 CDM 0420 RC 97032 HCPCS inpatient 201 130.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 135.88 67.6 999999999 121.71 194.97 percent of total billed charges REV - PHYSICAL THERAPY 769626_1 CDM 0420 RC inpatient 124 80.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 80.6 65 999999999 75.08 120.28 percent of total billed charges REV - PHYSICAL THERAPY 769626_1 CDM 0420 RC inpatient 124 80.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 120.28 97 999999999 75.08 120.28 percent of total billed charges REV - PHYSICAL THERAPY 769626_1 CDM 0420 RC inpatient 124 80.6 AETNA AETNA 97.96 79 999999999 75.08 120.28 percent of total billed charges REV - PHYSICAL THERAPY 769626_1 CDM 0420 RC inpatient 124 80.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 96.72 78 999999999 75.08 120.28 percent of total billed charges REV - PHYSICAL THERAPY 769626_1 CDM 0420 RC inpatient 124 80.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 85.56 69 999999999 75.08 120.28 percent of total billed charges REV - PHYSICAL THERAPY 769626_1 CDM 0420 RC inpatient 124 80.6 SIHO - ALL PLANS SIHO - ALL PLANS 111.6 90 999999999 75.08 120.28 percent of total billed charges REV - PHYSICAL THERAPY 769626_1 CDM 0420 RC inpatient 124 80.6 UMR - ALL PLANS UMR - ALL PLANS 86.8 70 999999999 75.08 120.28 percent of total billed charges REV - PHYSICAL THERAPY 769626_1 CDM 0420 RC inpatient 124 80.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 75.08 60.55 999999999 75.08 120.28 percent of total billed charges REV - PHYSICAL THERAPY 769626_1 CDM 0420 RC inpatient 124 80.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 75.08 120.28 REV - PHYSICAL THERAPY 769626_1 CDM 0420 RC inpatient 124 80.6 ANTHEM HMO ANTHEM HMO 999999999 75.08 120.28 REV - PHYSICAL THERAPY 769626_1 CDM 0420 RC inpatient 124 80.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 75.08 120.28 REV - PHYSICAL THERAPY 769626_1 CDM 0420 RC inpatient 124 80.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 75.08 120.28 REV - PHYSICAL THERAPY 769626_1 CDM 0420 RC inpatient 124 80.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 75.08 120.28 REV - PHYSICAL THERAPY 769626_1 CDM 0420 RC inpatient 124 80.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 83.82 67.6 999999999 75.08 120.28 percent of total billed charges Therapy procedure in a group setting 769639_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 769639_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 769639_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 769639_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 769639_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 769639_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 769639_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 769639_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges Therapy procedure in a group setting 769639_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 Therapy procedure in a group setting 769639_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 Therapy procedure in a group setting 769639_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 Therapy procedure in a group setting 769639_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 Therapy procedure in a group setting 769639_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 Therapy procedure in a group setting 769639_1 CDM 0420 RC 97150 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges REV - PHYSICAL THERAPY 770118_1 CDM 0420 RC inpatient 458 297.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 297.7 65 999999999 277.32 444.26 percent of total billed charges REV - PHYSICAL THERAPY 770118_1 CDM 0420 RC inpatient 458 297.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 444.26 97 999999999 277.32 444.26 percent of total billed charges REV - PHYSICAL THERAPY 770118_1 CDM 0420 RC inpatient 458 297.7 AETNA AETNA 361.82 79 999999999 277.32 444.26 percent of total billed charges REV - PHYSICAL THERAPY 770118_1 CDM 0420 RC inpatient 458 297.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 357.24 78 999999999 277.32 444.26 percent of total billed charges REV - PHYSICAL THERAPY 770118_1 CDM 0420 RC inpatient 458 297.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 316.02 69 999999999 277.32 444.26 percent of total billed charges REV - PHYSICAL THERAPY 770118_1 CDM 0420 RC inpatient 458 297.7 SIHO - ALL PLANS SIHO - ALL PLANS 412.2 90 999999999 277.32 444.26 percent of total billed charges REV - PHYSICAL THERAPY 770118_1 CDM 0420 RC inpatient 458 297.7 UMR - ALL PLANS UMR - ALL PLANS 320.6 70 999999999 277.32 444.26 percent of total billed charges REV - PHYSICAL THERAPY 770118_1 CDM 0420 RC inpatient 458 297.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 277.32 60.55 999999999 277.32 444.26 percent of total billed charges REV - PHYSICAL THERAPY 770118_1 CDM 0420 RC inpatient 458 297.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 277.32 444.26 REV - PHYSICAL THERAPY 770118_1 CDM 0420 RC inpatient 458 297.7 ANTHEM HMO ANTHEM HMO 999999999 277.32 444.26 REV - PHYSICAL THERAPY 770118_1 CDM 0420 RC inpatient 458 297.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 277.32 444.26 REV - PHYSICAL THERAPY 770118_1 CDM 0420 RC inpatient 458 297.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 277.32 444.26 REV - PHYSICAL THERAPY 770118_1 CDM 0420 RC inpatient 458 297.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 277.32 444.26 REV - PHYSICAL THERAPY 770118_1 CDM 0420 RC inpatient 458 297.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 309.61 67.6 999999999 277.32 444.26 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 770557_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 129.35 65 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 770557_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 193.03 97 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 770557_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 AETNA AETNA 157.21 79 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 770557_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 155.22 78 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 770557_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 137.31 69 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 770557_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 SIHO - ALL PLANS SIHO - ALL PLANS 179.1 90 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 770557_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 UMR - ALL PLANS UMR - ALL PLANS 139.3 70 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 770557_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 120.49 60.55 999999999 120.49 193.03 percent of total billed charges "Re-evaluation for physical therapy, typically 20 minutes" 770557_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 120.49 193.03 "Re-evaluation for physical therapy, typically 20 minutes" 770557_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 ANTHEM HMO ANTHEM HMO 999999999 120.49 193.03 "Re-evaluation for physical therapy, typically 20 minutes" 770557_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 120.49 193.03 "Re-evaluation for physical therapy, typically 20 minutes" 770557_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 120.49 193.03 "Re-evaluation for physical therapy, typically 20 minutes" 770557_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 120.49 193.03 "Re-evaluation for physical therapy, typically 20 minutes" 770557_1 CDM 0424 RC 97164 HCPCS inpatient 199 129.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 134.52 67.6 999999999 120.49 193.03 percent of total billed charges Evaluation of swallowing function 777339_1 CDM 0444 RC 92610 HCPCS inpatient 673 437.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 437.45 65 999999999 407.5 652.81 percent of total billed charges Evaluation of swallowing function 777339_1 CDM 0444 RC 92610 HCPCS inpatient 673 437.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 652.81 97 999999999 407.5 652.81 percent of total billed charges Evaluation of swallowing function 777339_1 CDM 0444 RC 92610 HCPCS inpatient 673 437.45 AETNA AETNA 531.67 79 999999999 407.5 652.81 percent of total billed charges Evaluation of swallowing function 777339_1 CDM 0444 RC 92610 HCPCS inpatient 673 437.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 524.94 78 999999999 407.5 652.81 percent of total billed charges Evaluation of swallowing function 777339_1 CDM 0444 RC 92610 HCPCS inpatient 673 437.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 464.37 69 999999999 407.5 652.81 percent of total billed charges Evaluation of swallowing function 777339_1 CDM 0444 RC 92610 HCPCS inpatient 673 437.45 SIHO - ALL PLANS SIHO - ALL PLANS 605.7 90 999999999 407.5 652.81 percent of total billed charges Evaluation of swallowing function 777339_1 CDM 0444 RC 92610 HCPCS inpatient 673 437.45 UMR - ALL PLANS UMR - ALL PLANS 471.1 70 999999999 407.5 652.81 percent of total billed charges Evaluation of swallowing function 777339_1 CDM 0444 RC 92610 HCPCS inpatient 673 437.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 407.5 60.55 999999999 407.5 652.81 percent of total billed charges Evaluation of swallowing function 777339_1 CDM 0444 RC 92610 HCPCS inpatient 673 437.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 407.5 652.81 Evaluation of swallowing function 777339_1 CDM 0444 RC 92610 HCPCS inpatient 673 437.45 ANTHEM HMO ANTHEM HMO 999999999 407.5 652.81 Evaluation of swallowing function 777339_1 CDM 0444 RC 92610 HCPCS inpatient 673 437.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 407.5 652.81 Evaluation of swallowing function 777339_1 CDM 0444 RC 92610 HCPCS inpatient 673 437.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 407.5 652.81 Evaluation of swallowing function 777339_1 CDM 0444 RC 92610 HCPCS inpatient 673 437.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 407.5 652.81 Evaluation of swallowing function 777339_1 CDM 0444 RC 92610 HCPCS inpatient 673 437.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 454.95 67.6 999999999 407.5 652.81 percent of total billed charges Treatment of swallowing and feeding disorder 777599_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 227.5 65 999999999 211.93 339.5 percent of total billed charges Treatment of swallowing and feeding disorder 777599_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 339.5 97 999999999 211.93 339.5 percent of total billed charges Treatment of swallowing and feeding disorder 777599_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 AETNA AETNA 276.5 79 999999999 211.93 339.5 percent of total billed charges Treatment of swallowing and feeding disorder 777599_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 273 78 999999999 211.93 339.5 percent of total billed charges Treatment of swallowing and feeding disorder 777599_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 241.5 69 999999999 211.93 339.5 percent of total billed charges Treatment of swallowing and feeding disorder 777599_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 SIHO - ALL PLANS SIHO - ALL PLANS 315 90 999999999 211.93 339.5 percent of total billed charges Treatment of swallowing and feeding disorder 777599_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 UMR - ALL PLANS UMR - ALL PLANS 245 70 999999999 211.93 339.5 percent of total billed charges Treatment of swallowing and feeding disorder 777599_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 211.93 60.55 999999999 211.93 339.5 percent of total billed charges Treatment of swallowing and feeding disorder 777599_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 211.93 339.5 Treatment of swallowing and feeding disorder 777599_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 ANTHEM HMO ANTHEM HMO 999999999 211.93 339.5 Treatment of swallowing and feeding disorder 777599_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 211.93 339.5 Treatment of swallowing and feeding disorder 777599_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 211.93 339.5 Treatment of swallowing and feeding disorder 777599_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 211.93 339.5 Treatment of swallowing and feeding disorder 777599_1 CDM 0440 RC 92526 HCPCS inpatient 350 227.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 236.6 67.6 999999999 211.93 339.5 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 778039_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 227.5 65 999999999 211.93 339.5 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 778039_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 339.5 97 999999999 211.93 339.5 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 778039_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 AETNA AETNA 276.5 79 999999999 211.93 339.5 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 778039_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 273 78 999999999 211.93 339.5 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 778039_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 241.5 69 999999999 211.93 339.5 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 778039_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 SIHO - ALL PLANS SIHO - ALL PLANS 315 90 999999999 211.93 339.5 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 778039_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 UMR - ALL PLANS UMR - ALL PLANS 245 70 999999999 211.93 339.5 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 778039_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 211.93 60.55 999999999 211.93 339.5 percent of total billed charges "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 778039_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 211.93 339.5 "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 778039_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 ANTHEM HMO ANTHEM HMO 999999999 211.93 339.5 "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 778039_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 211.93 339.5 "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 778039_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 211.93 339.5 "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 778039_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 211.93 339.5 "Treatment of speech, language, voice, communication, and/or hearing processing disorder" 778039_1 CDM 0440 RC 92507 HCPCS inpatient 350 227.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 236.6 67.6 999999999 211.93 339.5 percent of total billed charges Measurement of substance using immunoassay technique 7796995_1 CDM 0301 RC 83520 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges Measurement of substance using immunoassay technique 7796995_1 CDM 0301 RC 83520 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges Measurement of substance using immunoassay technique 7796995_1 CDM 0301 RC 83520 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges Measurement of substance using immunoassay technique 7796995_1 CDM 0301 RC 83520 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges Measurement of substance using immunoassay technique 7796995_1 CDM 0301 RC 83520 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges Measurement of substance using immunoassay technique 7796995_1 CDM 0301 RC 83520 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges Measurement of substance using immunoassay technique 7796995_1 CDM 0301 RC 83520 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges Measurement of substance using immunoassay technique 7796995_1 CDM 0301 RC 83520 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges Measurement of substance using immunoassay technique 7796995_1 CDM 0301 RC 83520 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 Measurement of substance using immunoassay technique 7796995_1 CDM 0301 RC 83520 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 Measurement of substance using immunoassay technique 7796995_1 CDM 0301 RC 83520 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 Measurement of substance using immunoassay technique 7796995_1 CDM 0301 RC 83520 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 Measurement of substance using immunoassay technique 7796995_1 CDM 0301 RC 83520 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 Measurement of substance using immunoassay technique 7796995_1 CDM 0301 RC 83520 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges "Carbamazepine level, total" 788585_1 CDM 0301 RC 80156 HCPCS inpatient 205 133.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.25 65 999999999 124.13 198.85 percent of total billed charges "Carbamazepine level, total" 788585_1 CDM 0301 RC 80156 HCPCS inpatient 205 133.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 198.85 97 999999999 124.13 198.85 percent of total billed charges "Carbamazepine level, total" 788585_1 CDM 0301 RC 80156 HCPCS inpatient 205 133.25 AETNA AETNA 161.95 79 999999999 124.13 198.85 percent of total billed charges "Carbamazepine level, total" 788585_1 CDM 0301 RC 80156 HCPCS inpatient 205 133.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 159.9 78 999999999 124.13 198.85 percent of total billed charges "Carbamazepine level, total" 788585_1 CDM 0301 RC 80156 HCPCS inpatient 205 133.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 141.45 69 999999999 124.13 198.85 percent of total billed charges "Carbamazepine level, total" 788585_1 CDM 0301 RC 80156 HCPCS inpatient 205 133.25 SIHO - ALL PLANS SIHO - ALL PLANS 184.5 90 999999999 124.13 198.85 percent of total billed charges "Carbamazepine level, total" 788585_1 CDM 0301 RC 80156 HCPCS inpatient 205 133.25 UMR - ALL PLANS UMR - ALL PLANS 143.5 70 999999999 124.13 198.85 percent of total billed charges "Carbamazepine level, total" 788585_1 CDM 0301 RC 80156 HCPCS inpatient 205 133.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.13 60.55 999999999 124.13 198.85 percent of total billed charges "Carbamazepine level, total" 788585_1 CDM 0301 RC 80156 HCPCS inpatient 205 133.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.13 198.85 "Carbamazepine level, total" 788585_1 CDM 0301 RC 80156 HCPCS inpatient 205 133.25 ANTHEM HMO ANTHEM HMO 999999999 124.13 198.85 "Carbamazepine level, total" 788585_1 CDM 0301 RC 80156 HCPCS inpatient 205 133.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.13 198.85 "Carbamazepine level, total" 788585_1 CDM 0301 RC 80156 HCPCS inpatient 205 133.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.13 198.85 "Carbamazepine level, total" 788585_1 CDM 0301 RC 80156 HCPCS inpatient 205 133.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.13 198.85 "Carbamazepine level, total" 788585_1 CDM 0301 RC 80156 HCPCS inpatient 205 133.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 138.58 67.6 999999999 124.13 198.85 percent of total billed charges Blood group typing (ABO) 7960969_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges Blood group typing (ABO) 7960969_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges Blood group typing (ABO) 7960969_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges Blood group typing (ABO) 7960969_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges Blood group typing (ABO) 7960969_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges Blood group typing (ABO) 7960969_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges Blood group typing (ABO) 7960969_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges Blood group typing (ABO) 7960969_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges Blood group typing (ABO) 7960969_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 Blood group typing (ABO) 7960969_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 Blood group typing (ABO) 7960969_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 Blood group typing (ABO) 7960969_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 Blood group typing (ABO) 7960969_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 Blood group typing (ABO) 7960969_1 CDM 0301 RC 86900 HCPCS inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges TNF 797120_1 CDM 0259 RC inpatient 1.4 0.91 SELF PAY DISCOUNT SELF PAY DISCOUNT 0.91 65 999999999 0.85 1.36 percent of total billed charges TNF 797120_1 CDM 0259 RC inpatient 1.4 0.91 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1.36 97 999999999 0.85 1.36 percent of total billed charges TNF 797120_1 CDM 0259 RC inpatient 1.4 0.91 AETNA AETNA 1.11 79 999999999 0.85 1.36 percent of total billed charges TNF 797120_1 CDM 0259 RC inpatient 1.4 0.91 HUMANA - ALL PLANS HUMANA - ALL PLANS 1.09 78 999999999 0.85 1.36 percent of total billed charges TNF 797120_1 CDM 0259 RC inpatient 1.4 0.91 ENCORE - ALL PLANS ENCORE - ALL PLANS 0.97 69 999999999 0.85 1.36 percent of total billed charges TNF 797120_1 CDM 0259 RC inpatient 1.4 0.91 SIHO - ALL PLANS SIHO - ALL PLANS 1.26 90 999999999 0.85 1.36 percent of total billed charges TNF 797120_1 CDM 0259 RC inpatient 1.4 0.91 UMR - ALL PLANS UMR - ALL PLANS 0.98 70 999999999 0.85 1.36 percent of total billed charges TNF 797120_1 CDM 0259 RC inpatient 1.4 0.91 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 0.85 60.55 999999999 0.85 1.36 percent of total billed charges TNF 797120_1 CDM 0259 RC inpatient 1.4 0.91 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 0.85 1.36 TNF 797120_1 CDM 0259 RC inpatient 1.4 0.91 ANTHEM HMO ANTHEM HMO 999999999 0.85 1.36 TNF 797120_1 CDM 0259 RC inpatient 1.4 0.91 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 0.85 1.36 TNF 797120_1 CDM 0259 RC inpatient 1.4 0.91 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 0.85 1.36 TNF 797120_1 CDM 0259 RC inpatient 1.4 0.91 UHC - ALL PLANS UHC - ALL PLANS 999999999 0.85 1.36 TNF 797120_1 CDM 0259 RC inpatient 1.4 0.91 CIGNA - ALL PLANS CIGNA - ALL PLANS 0.95 67.6 999999999 0.85 1.36 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 797587_1 CDM 0761 RC inpatient 465 302.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 302.25 65 999999999 281.56 451.05 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 797587_1 CDM 0761 RC inpatient 465 302.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 451.05 97 999999999 281.56 451.05 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 797587_1 CDM 0761 RC inpatient 465 302.25 AETNA AETNA 367.35 79 999999999 281.56 451.05 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 797587_1 CDM 0761 RC inpatient 465 302.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 362.7 78 999999999 281.56 451.05 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 797587_1 CDM 0761 RC inpatient 465 302.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 320.85 69 999999999 281.56 451.05 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 797587_1 CDM 0761 RC inpatient 465 302.25 SIHO - ALL PLANS SIHO - ALL PLANS 418.5 90 999999999 281.56 451.05 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 797587_1 CDM 0761 RC inpatient 465 302.25 UMR - ALL PLANS UMR - ALL PLANS 325.5 70 999999999 281.56 451.05 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 797587_1 CDM 0761 RC inpatient 465 302.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 281.56 60.55 999999999 281.56 451.05 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 797587_1 CDM 0761 RC inpatient 465 302.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 281.56 451.05 SPECIALTY SERVICES - TREATMENT ROOM 797587_1 CDM 0761 RC inpatient 465 302.25 ANTHEM HMO ANTHEM HMO 999999999 281.56 451.05 SPECIALTY SERVICES - TREATMENT ROOM 797587_1 CDM 0761 RC inpatient 465 302.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 281.56 451.05 SPECIALTY SERVICES - TREATMENT ROOM 797587_1 CDM 0761 RC inpatient 465 302.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 281.56 451.05 SPECIALTY SERVICES - TREATMENT ROOM 797587_1 CDM 0761 RC inpatient 465 302.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 281.56 451.05 SPECIALTY SERVICES - TREATMENT ROOM 797587_1 CDM 0761 RC inpatient 465 302.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 314.34 67.6 999999999 281.56 451.05 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 797595_1 CDM 0761 RC inpatient 497 323.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 323.05 65 999999999 300.93 482.09 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 797595_1 CDM 0761 RC inpatient 497 323.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 482.09 97 999999999 300.93 482.09 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 797595_1 CDM 0761 RC inpatient 497 323.05 AETNA AETNA 392.63 79 999999999 300.93 482.09 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 797595_1 CDM 0761 RC inpatient 497 323.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 387.66 78 999999999 300.93 482.09 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 797595_1 CDM 0761 RC inpatient 497 323.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 342.93 69 999999999 300.93 482.09 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 797595_1 CDM 0761 RC inpatient 497 323.05 SIHO - ALL PLANS SIHO - ALL PLANS 447.3 90 999999999 300.93 482.09 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 797595_1 CDM 0761 RC inpatient 497 323.05 UMR - ALL PLANS UMR - ALL PLANS 347.9 70 999999999 300.93 482.09 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 797595_1 CDM 0761 RC inpatient 497 323.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 300.93 60.55 999999999 300.93 482.09 percent of total billed charges SPECIALTY SERVICES - TREATMENT ROOM 797595_1 CDM 0761 RC inpatient 497 323.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 300.93 482.09 SPECIALTY SERVICES - TREATMENT ROOM 797595_1 CDM 0761 RC inpatient 497 323.05 ANTHEM HMO ANTHEM HMO 999999999 300.93 482.09 SPECIALTY SERVICES - TREATMENT ROOM 797595_1 CDM 0761 RC inpatient 497 323.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 300.93 482.09 SPECIALTY SERVICES - TREATMENT ROOM 797595_1 CDM 0761 RC inpatient 497 323.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 300.93 482.09 SPECIALTY SERVICES - TREATMENT ROOM 797595_1 CDM 0761 RC inpatient 497 323.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 300.93 482.09 SPECIALTY SERVICES - TREATMENT ROOM 797595_1 CDM 0761 RC inpatient 497 323.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 335.97 67.6 999999999 300.93 482.09 percent of total billed charges Activity 8025202_1 CDM 0450 RC inpatient 60.09 39.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 39.06 65 999999999 36.38 58.29 percent of total billed charges Activity 8025202_1 CDM 0450 RC inpatient 60.09 39.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58.29 97 999999999 36.38 58.29 percent of total billed charges Activity 8025202_1 CDM 0450 RC inpatient 60.09 39.06 AETNA AETNA 47.47 79 999999999 36.38 58.29 percent of total billed charges Activity 8025202_1 CDM 0450 RC inpatient 60.09 39.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 46.87 78 999999999 36.38 58.29 percent of total billed charges Activity 8025202_1 CDM 0450 RC inpatient 60.09 39.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 41.46 69 999999999 36.38 58.29 percent of total billed charges Activity 8025202_1 CDM 0450 RC inpatient 60.09 39.06 SIHO - ALL PLANS SIHO - ALL PLANS 54.08 90 999999999 36.38 58.29 percent of total billed charges Activity 8025202_1 CDM 0450 RC inpatient 60.09 39.06 UMR - ALL PLANS UMR - ALL PLANS 42.06 70 999999999 36.38 58.29 percent of total billed charges Activity 8025202_1 CDM 0450 RC inpatient 60.09 39.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36.38 60.55 999999999 36.38 58.29 percent of total billed charges Activity 8025202_1 CDM 0450 RC inpatient 60.09 39.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 36.38 58.29 Activity 8025202_1 CDM 0450 RC inpatient 60.09 39.06 ANTHEM HMO ANTHEM HMO 999999999 36.38 58.29 Activity 8025202_1 CDM 0450 RC inpatient 60.09 39.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 36.38 58.29 Activity 8025202_1 CDM 0450 RC inpatient 60.09 39.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 36.38 58.29 Activity 8025202_1 CDM 0450 RC inpatient 60.09 39.06 UHC - ALL PLANS UHC - ALL PLANS 999999999 36.38 58.29 Activity 8025202_1 CDM 0450 RC inpatient 60.09 39.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 40.62 67.6 999999999 36.38 58.29 percent of total billed charges Application of whirlpool therapy 8025316_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 92.95 65 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 8025316_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 138.71 97 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 8025316_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 AETNA AETNA 112.97 79 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 8025316_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 111.54 78 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 8025316_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 98.67 69 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 8025316_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 SIHO - ALL PLANS SIHO - ALL PLANS 128.7 90 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 8025316_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 UMR - ALL PLANS UMR - ALL PLANS 100.1 70 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 8025316_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 86.59 60.55 999999999 86.59 138.71 percent of total billed charges Application of whirlpool therapy 8025316_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 86.59 138.71 Application of whirlpool therapy 8025316_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 ANTHEM HMO ANTHEM HMO 999999999 86.59 138.71 Application of whirlpool therapy 8025316_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 86.59 138.71 Application of whirlpool therapy 8025316_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 86.59 138.71 Application of whirlpool therapy 8025316_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 86.59 138.71 Application of whirlpool therapy 8025316_1 CDM 0430 RC 97022 HCPCS inpatient 143 92.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 96.67 67.6 999999999 86.59 138.71 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 8025351_1 CDM 0430 RC 97597 HCPCS inpatient 456 296.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 296.4 65 999999999 276.11 442.32 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 8025351_1 CDM 0430 RC 97597 HCPCS inpatient 456 296.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 442.32 97 999999999 276.11 442.32 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 8025351_1 CDM 0430 RC 97597 HCPCS inpatient 456 296.4 AETNA AETNA 360.24 79 999999999 276.11 442.32 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 8025351_1 CDM 0430 RC 97597 HCPCS inpatient 456 296.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 355.68 78 999999999 276.11 442.32 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 8025351_1 CDM 0430 RC 97597 HCPCS inpatient 456 296.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 314.64 69 999999999 276.11 442.32 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 8025351_1 CDM 0430 RC 97597 HCPCS inpatient 456 296.4 SIHO - ALL PLANS SIHO - ALL PLANS 410.4 90 999999999 276.11 442.32 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 8025351_1 CDM 0430 RC 97597 HCPCS inpatient 456 296.4 UMR - ALL PLANS UMR - ALL PLANS 319.2 70 999999999 276.11 442.32 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 8025351_1 CDM 0430 RC 97597 HCPCS inpatient 456 296.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 276.11 60.55 999999999 276.11 442.32 percent of total billed charges "Removal of tissue from wound, 20.0 sq cm or less" 8025351_1 CDM 0430 RC 97597 HCPCS inpatient 456 296.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 276.11 442.32 "Removal of tissue from wound, 20.0 sq cm or less" 8025351_1 CDM 0430 RC 97597 HCPCS inpatient 456 296.4 ANTHEM HMO ANTHEM HMO 999999999 276.11 442.32 "Removal of tissue from wound, 20.0 sq cm or less" 8025351_1 CDM 0430 RC 97597 HCPCS inpatient 456 296.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 276.11 442.32 "Removal of tissue from wound, 20.0 sq cm or less" 8025351_1 CDM 0430 RC 97597 HCPCS inpatient 456 296.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 276.11 442.32 "Removal of tissue from wound, 20.0 sq cm or less" 8025351_1 CDM 0430 RC 97597 HCPCS inpatient 456 296.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 276.11 442.32 "Removal of tissue from wound, 20.0 sq cm or less" 8025351_1 CDM 0430 RC 97597 HCPCS inpatient 456 296.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 308.26 67.6 999999999 276.11 442.32 percent of total billed charges Treatment of swallowing and feeding disorder 816008_1 CDM 0440 RC 92526 HCPCS inpatient 374 243.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 243.1 65 999999999 226.46 362.78 percent of total billed charges Treatment of swallowing and feeding disorder 816008_1 CDM 0440 RC 92526 HCPCS inpatient 374 243.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 362.78 97 999999999 226.46 362.78 percent of total billed charges Treatment of swallowing and feeding disorder 816008_1 CDM 0440 RC 92526 HCPCS inpatient 374 243.1 AETNA AETNA 295.46 79 999999999 226.46 362.78 percent of total billed charges Treatment of swallowing and feeding disorder 816008_1 CDM 0440 RC 92526 HCPCS inpatient 374 243.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 291.72 78 999999999 226.46 362.78 percent of total billed charges Treatment of swallowing and feeding disorder 816008_1 CDM 0440 RC 92526 HCPCS inpatient 374 243.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 258.06 69 999999999 226.46 362.78 percent of total billed charges Treatment of swallowing and feeding disorder 816008_1 CDM 0440 RC 92526 HCPCS inpatient 374 243.1 SIHO - ALL PLANS SIHO - ALL PLANS 336.6 90 999999999 226.46 362.78 percent of total billed charges Treatment of swallowing and feeding disorder 816008_1 CDM 0440 RC 92526 HCPCS inpatient 374 243.1 UMR - ALL PLANS UMR - ALL PLANS 261.8 70 999999999 226.46 362.78 percent of total billed charges Treatment of swallowing and feeding disorder 816008_1 CDM 0440 RC 92526 HCPCS inpatient 374 243.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 226.46 60.55 999999999 226.46 362.78 percent of total billed charges Treatment of swallowing and feeding disorder 816008_1 CDM 0440 RC 92526 HCPCS inpatient 374 243.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 226.46 362.78 Treatment of swallowing and feeding disorder 816008_1 CDM 0440 RC 92526 HCPCS inpatient 374 243.1 ANTHEM HMO ANTHEM HMO 999999999 226.46 362.78 Treatment of swallowing and feeding disorder 816008_1 CDM 0440 RC 92526 HCPCS inpatient 374 243.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 226.46 362.78 Treatment of swallowing and feeding disorder 816008_1 CDM 0440 RC 92526 HCPCS inpatient 374 243.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 226.46 362.78 Treatment of swallowing and feeding disorder 816008_1 CDM 0440 RC 92526 HCPCS inpatient 374 243.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 226.46 362.78 Treatment of swallowing and feeding disorder 816008_1 CDM 0440 RC 92526 HCPCS inpatient 374 243.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 252.82 67.6 999999999 226.46 362.78 percent of total billed charges Evaluation of swallowing function image 816014_1 CDM 0444 RC 92611 HCPCS inpatient 720 468 SELF PAY DISCOUNT SELF PAY DISCOUNT 468 65 999999999 435.96 698.4 percent of total billed charges Evaluation of swallowing function image 816014_1 CDM 0444 RC 92611 HCPCS inpatient 720 468 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 698.4 97 999999999 435.96 698.4 percent of total billed charges Evaluation of swallowing function image 816014_1 CDM 0444 RC 92611 HCPCS inpatient 720 468 AETNA AETNA 568.8 79 999999999 435.96 698.4 percent of total billed charges Evaluation of swallowing function image 816014_1 CDM 0444 RC 92611 HCPCS inpatient 720 468 HUMANA - ALL PLANS HUMANA - ALL PLANS 561.6 78 999999999 435.96 698.4 percent of total billed charges Evaluation of swallowing function image 816014_1 CDM 0444 RC 92611 HCPCS inpatient 720 468 ENCORE - ALL PLANS ENCORE - ALL PLANS 496.8 69 999999999 435.96 698.4 percent of total billed charges Evaluation of swallowing function image 816014_1 CDM 0444 RC 92611 HCPCS inpatient 720 468 SIHO - ALL PLANS SIHO - ALL PLANS 648 90 999999999 435.96 698.4 percent of total billed charges Evaluation of swallowing function image 816014_1 CDM 0444 RC 92611 HCPCS inpatient 720 468 UMR - ALL PLANS UMR - ALL PLANS 504 70 999999999 435.96 698.4 percent of total billed charges Evaluation of swallowing function image 816014_1 CDM 0444 RC 92611 HCPCS inpatient 720 468 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 435.96 60.55 999999999 435.96 698.4 percent of total billed charges Evaluation of swallowing function image 816014_1 CDM 0444 RC 92611 HCPCS inpatient 720 468 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 435.96 698.4 Evaluation of swallowing function image 816014_1 CDM 0444 RC 92611 HCPCS inpatient 720 468 ANTHEM HMO ANTHEM HMO 999999999 435.96 698.4 Evaluation of swallowing function image 816014_1 CDM 0444 RC 92611 HCPCS inpatient 720 468 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 435.96 698.4 Evaluation of swallowing function image 816014_1 CDM 0444 RC 92611 HCPCS inpatient 720 468 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 435.96 698.4 Evaluation of swallowing function image 816014_1 CDM 0444 RC 92611 HCPCS inpatient 720 468 UHC - ALL PLANS UHC - ALL PLANS 999999999 435.96 698.4 Evaluation of swallowing function image 816014_1 CDM 0444 RC 92611 HCPCS inpatient 720 468 CIGNA - ALL PLANS CIGNA - ALL PLANS 486.72 67.6 999999999 435.96 698.4 percent of total billed charges Artery puncture collection of blood sample 816045_1 CDM 0410 RC 36600 HCPCS inpatient 114 74.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 74.1 65 999999999 69.03 110.58 percent of total billed charges Artery puncture collection of blood sample 816045_1 CDM 0410 RC 36600 HCPCS inpatient 114 74.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110.58 97 999999999 69.03 110.58 percent of total billed charges Artery puncture collection of blood sample 816045_1 CDM 0410 RC 36600 HCPCS inpatient 114 74.1 AETNA AETNA 90.06 79 999999999 69.03 110.58 percent of total billed charges Artery puncture collection of blood sample 816045_1 CDM 0410 RC 36600 HCPCS inpatient 114 74.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 88.92 78 999999999 69.03 110.58 percent of total billed charges Artery puncture collection of blood sample 816045_1 CDM 0410 RC 36600 HCPCS inpatient 114 74.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 78.66 69 999999999 69.03 110.58 percent of total billed charges Artery puncture collection of blood sample 816045_1 CDM 0410 RC 36600 HCPCS inpatient 114 74.1 SIHO - ALL PLANS SIHO - ALL PLANS 102.6 90 999999999 69.03 110.58 percent of total billed charges Artery puncture collection of blood sample 816045_1 CDM 0410 RC 36600 HCPCS inpatient 114 74.1 UMR - ALL PLANS UMR - ALL PLANS 79.8 70 999999999 69.03 110.58 percent of total billed charges Artery puncture collection of blood sample 816045_1 CDM 0410 RC 36600 HCPCS inpatient 114 74.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69.03 60.55 999999999 69.03 110.58 percent of total billed charges Artery puncture collection of blood sample 816045_1 CDM 0410 RC 36600 HCPCS inpatient 114 74.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 69.03 110.58 Artery puncture collection of blood sample 816045_1 CDM 0410 RC 36600 HCPCS inpatient 114 74.1 ANTHEM HMO ANTHEM HMO 999999999 69.03 110.58 Artery puncture collection of blood sample 816045_1 CDM 0410 RC 36600 HCPCS inpatient 114 74.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 69.03 110.58 Artery puncture collection of blood sample 816045_1 CDM 0410 RC 36600 HCPCS inpatient 114 74.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 69.03 110.58 Artery puncture collection of blood sample 816045_1 CDM 0410 RC 36600 HCPCS inpatient 114 74.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 69.03 110.58 Artery puncture collection of blood sample 816045_1 CDM 0410 RC 36600 HCPCS inpatient 114 74.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 77.06 67.6 999999999 69.03 110.58 percent of total billed charges Insertion of needle into vein for collection of blood sample 816049_1 CDM 0300 RC 36415 HCPCS inpatient 50 32.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 32.5 65 999999999 30.28 48.5 percent of total billed charges Insertion of needle into vein for collection of blood sample 816049_1 CDM 0300 RC 36415 HCPCS inpatient 50 32.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48.5 97 999999999 30.28 48.5 percent of total billed charges Insertion of needle into vein for collection of blood sample 816049_1 CDM 0300 RC 36415 HCPCS inpatient 50 32.5 AETNA AETNA 39.5 79 999999999 30.28 48.5 percent of total billed charges Insertion of needle into vein for collection of blood sample 816049_1 CDM 0300 RC 36415 HCPCS inpatient 50 32.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 39 78 999999999 30.28 48.5 percent of total billed charges Insertion of needle into vein for collection of blood sample 816049_1 CDM 0300 RC 36415 HCPCS inpatient 50 32.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 34.5 69 999999999 30.28 48.5 percent of total billed charges Insertion of needle into vein for collection of blood sample 816049_1 CDM 0300 RC 36415 HCPCS inpatient 50 32.5 SIHO - ALL PLANS SIHO - ALL PLANS 45 90 999999999 30.28 48.5 percent of total billed charges Insertion of needle into vein for collection of blood sample 816049_1 CDM 0300 RC 36415 HCPCS inpatient 50 32.5 UMR - ALL PLANS UMR - ALL PLANS 35 70 999999999 30.28 48.5 percent of total billed charges Insertion of needle into vein for collection of blood sample 816049_1 CDM 0300 RC 36415 HCPCS inpatient 50 32.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30.28 60.55 999999999 30.28 48.5 percent of total billed charges Insertion of needle into vein for collection of blood sample 816049_1 CDM 0300 RC 36415 HCPCS inpatient 50 32.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 30.28 48.5 Insertion of needle into vein for collection of blood sample 816049_1 CDM 0300 RC 36415 HCPCS inpatient 50 32.5 ANTHEM HMO ANTHEM HMO 999999999 30.28 48.5 Insertion of needle into vein for collection of blood sample 816049_1 CDM 0300 RC 36415 HCPCS inpatient 50 32.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 30.28 48.5 Insertion of needle into vein for collection of blood sample 816049_1 CDM 0300 RC 36415 HCPCS inpatient 50 32.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 30.28 48.5 Insertion of needle into vein for collection of blood sample 816049_1 CDM 0300 RC 36415 HCPCS inpatient 50 32.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 30.28 48.5 Insertion of needle into vein for collection of blood sample 816049_1 CDM 0300 RC 36415 HCPCS inpatient 50 32.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 33.8 67.6 999999999 30.28 48.5 percent of total billed charges Blood glucose (sugar) test performed by hand-held instrument 818591_1 CDM 0301 RC 82962 HCPCS inpatient 128 83.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 83.2 65 999999999 77.5 124.16 percent of total billed charges Blood glucose (sugar) test performed by hand-held instrument 818591_1 CDM 0301 RC 82962 HCPCS inpatient 128 83.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 124.16 97 999999999 77.5 124.16 percent of total billed charges Blood glucose (sugar) test performed by hand-held instrument 818591_1 CDM 0301 RC 82962 HCPCS inpatient 128 83.2 AETNA AETNA 101.12 79 999999999 77.5 124.16 percent of total billed charges Blood glucose (sugar) test performed by hand-held instrument 818591_1 CDM 0301 RC 82962 HCPCS inpatient 128 83.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 99.84 78 999999999 77.5 124.16 percent of total billed charges Blood glucose (sugar) test performed by hand-held instrument 818591_1 CDM 0301 RC 82962 HCPCS inpatient 128 83.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 88.32 69 999999999 77.5 124.16 percent of total billed charges Blood glucose (sugar) test performed by hand-held instrument 818591_1 CDM 0301 RC 82962 HCPCS inpatient 128 83.2 SIHO - ALL PLANS SIHO - ALL PLANS 115.2 90 999999999 77.5 124.16 percent of total billed charges Blood glucose (sugar) test performed by hand-held instrument 818591_1 CDM 0301 RC 82962 HCPCS inpatient 128 83.2 UMR - ALL PLANS UMR - ALL PLANS 89.6 70 999999999 77.5 124.16 percent of total billed charges Blood glucose (sugar) test performed by hand-held instrument 818591_1 CDM 0301 RC 82962 HCPCS inpatient 128 83.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 77.5 60.55 999999999 77.5 124.16 percent of total billed charges Blood glucose (sugar) test performed by hand-held instrument 818591_1 CDM 0301 RC 82962 HCPCS inpatient 128 83.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 77.5 124.16 Blood glucose (sugar) test performed by hand-held instrument 818591_1 CDM 0301 RC 82962 HCPCS inpatient 128 83.2 ANTHEM HMO ANTHEM HMO 999999999 77.5 124.16 Blood glucose (sugar) test performed by hand-held instrument 818591_1 CDM 0301 RC 82962 HCPCS inpatient 128 83.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 77.5 124.16 Blood glucose (sugar) test performed by hand-held instrument 818591_1 CDM 0301 RC 82962 HCPCS inpatient 128 83.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 77.5 124.16 Blood glucose (sugar) test performed by hand-held instrument 818591_1 CDM 0301 RC 82962 HCPCS inpatient 128 83.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 77.5 124.16 Blood glucose (sugar) test performed by hand-held instrument 818591_1 CDM 0301 RC 82962 HCPCS inpatient 128 83.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 86.53 67.6 999999999 77.5 124.16 percent of total billed charges Initial hospital inpatient or observation ventilation assistance and management 818953_1 CDM 0410 RC 94002 HCPCS inpatient 1262 820.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 820.3 65 999999999 764.14 1224.14 percent of total billed charges Initial hospital inpatient or observation ventilation assistance and management 818953_1 CDM 0410 RC 94002 HCPCS inpatient 1262 820.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1224.14 97 999999999 764.14 1224.14 percent of total billed charges Initial hospital inpatient or observation ventilation assistance and management 818953_1 CDM 0410 RC 94002 HCPCS inpatient 1262 820.3 AETNA AETNA 996.98 79 999999999 764.14 1224.14 percent of total billed charges Initial hospital inpatient or observation ventilation assistance and management 818953_1 CDM 0410 RC 94002 HCPCS inpatient 1262 820.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 984.36 78 999999999 764.14 1224.14 percent of total billed charges Initial hospital inpatient or observation ventilation assistance and management 818953_1 CDM 0410 RC 94002 HCPCS inpatient 1262 820.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 870.78 69 999999999 764.14 1224.14 percent of total billed charges Initial hospital inpatient or observation ventilation assistance and management 818953_1 CDM 0410 RC 94002 HCPCS inpatient 1262 820.3 SIHO - ALL PLANS SIHO - ALL PLANS 1135.8 90 999999999 764.14 1224.14 percent of total billed charges Initial hospital inpatient or observation ventilation assistance and management 818953_1 CDM 0410 RC 94002 HCPCS inpatient 1262 820.3 UMR - ALL PLANS UMR - ALL PLANS 883.4 70 999999999 764.14 1224.14 percent of total billed charges Initial hospital inpatient or observation ventilation assistance and management 818953_1 CDM 0410 RC 94002 HCPCS inpatient 1262 820.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 764.14 60.55 999999999 764.14 1224.14 percent of total billed charges Initial hospital inpatient or observation ventilation assistance and management 818953_1 CDM 0410 RC 94002 HCPCS inpatient 1262 820.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 764.14 1224.14 Initial hospital inpatient or observation ventilation assistance and management 818953_1 CDM 0410 RC 94002 HCPCS inpatient 1262 820.3 ANTHEM HMO ANTHEM HMO 999999999 764.14 1224.14 Initial hospital inpatient or observation ventilation assistance and management 818953_1 CDM 0410 RC 94002 HCPCS inpatient 1262 820.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 764.14 1224.14 Initial hospital inpatient or observation ventilation assistance and management 818953_1 CDM 0410 RC 94002 HCPCS inpatient 1262 820.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 764.14 1224.14 Initial hospital inpatient or observation ventilation assistance and management 818953_1 CDM 0410 RC 94002 HCPCS inpatient 1262 820.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 764.14 1224.14 Initial hospital inpatient or observation ventilation assistance and management 818953_1 CDM 0410 RC 94002 HCPCS inpatient 1262 820.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 853.11 67.6 999999999 764.14 1224.14 percent of total billed charges Therapy procedure using a positive pressure ventilator 818955_1 CDM 0410 RC 94660 HCPCS inpatient 747 485.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 485.55 65 999999999 452.31 724.59 percent of total billed charges Therapy procedure using a positive pressure ventilator 818955_1 CDM 0410 RC 94660 HCPCS inpatient 747 485.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 724.59 97 999999999 452.31 724.59 percent of total billed charges Therapy procedure using a positive pressure ventilator 818955_1 CDM 0410 RC 94660 HCPCS inpatient 747 485.55 AETNA AETNA 590.13 79 999999999 452.31 724.59 percent of total billed charges Therapy procedure using a positive pressure ventilator 818955_1 CDM 0410 RC 94660 HCPCS inpatient 747 485.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 582.66 78 999999999 452.31 724.59 percent of total billed charges Therapy procedure using a positive pressure ventilator 818955_1 CDM 0410 RC 94660 HCPCS inpatient 747 485.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 515.43 69 999999999 452.31 724.59 percent of total billed charges Therapy procedure using a positive pressure ventilator 818955_1 CDM 0410 RC 94660 HCPCS inpatient 747 485.55 SIHO - ALL PLANS SIHO - ALL PLANS 672.3 90 999999999 452.31 724.59 percent of total billed charges Therapy procedure using a positive pressure ventilator 818955_1 CDM 0410 RC 94660 HCPCS inpatient 747 485.55 UMR - ALL PLANS UMR - ALL PLANS 522.9 70 999999999 452.31 724.59 percent of total billed charges Therapy procedure using a positive pressure ventilator 818955_1 CDM 0410 RC 94660 HCPCS inpatient 747 485.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 452.31 60.55 999999999 452.31 724.59 percent of total billed charges Therapy procedure using a positive pressure ventilator 818955_1 CDM 0410 RC 94660 HCPCS inpatient 747 485.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 452.31 724.59 Therapy procedure using a positive pressure ventilator 818955_1 CDM 0410 RC 94660 HCPCS inpatient 747 485.55 ANTHEM HMO ANTHEM HMO 999999999 452.31 724.59 Therapy procedure using a positive pressure ventilator 818955_1 CDM 0410 RC 94660 HCPCS inpatient 747 485.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 452.31 724.59 Therapy procedure using a positive pressure ventilator 818955_1 CDM 0410 RC 94660 HCPCS inpatient 747 485.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 452.31 724.59 Therapy procedure using a positive pressure ventilator 818955_1 CDM 0410 RC 94660 HCPCS inpatient 747 485.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 452.31 724.59 Therapy procedure using a positive pressure ventilator 818955_1 CDM 0410 RC 94660 HCPCS inpatient 747 485.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 504.97 67.6 999999999 452.31 724.59 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 818959_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 205.4 65 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 818959_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 306.52 97 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 818959_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 AETNA AETNA 249.64 79 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 818959_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 246.48 78 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 818959_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 218.04 69 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 818959_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 SIHO - ALL PLANS SIHO - ALL PLANS 284.4 90 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 818959_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 UMR - ALL PLANS UMR - ALL PLANS 221.2 70 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 818959_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 191.34 60.55 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 818959_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 818959_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 ANTHEM HMO ANTHEM HMO 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 818959_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 818959_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 818959_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 818959_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 213.62 67.6 999999999 191.34 306.52 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819006_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 150.15 65 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819006_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 224.07 97 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819006_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 AETNA AETNA 182.49 79 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819006_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 180.18 78 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819006_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 159.39 69 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819006_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 SIHO - ALL PLANS SIHO - ALL PLANS 207.9 90 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819006_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 UMR - ALL PLANS UMR - ALL PLANS 161.7 70 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819006_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 139.87 60.55 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819006_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 819006_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM HMO ANTHEM HMO 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 819006_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 819006_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 819006_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 819006_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 156.16 67.6 999999999 139.87 224.07 percent of total billed charges Test to measure largest amount of air breathed in an out 819007_1 CDM 0410 RC 94200 HCPCS inpatient 102 66.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 66.3 65 999999999 61.76 98.94 percent of total billed charges Test to measure largest amount of air breathed in an out 819007_1 CDM 0410 RC 94200 HCPCS inpatient 102 66.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 98.94 97 999999999 61.76 98.94 percent of total billed charges Test to measure largest amount of air breathed in an out 819007_1 CDM 0410 RC 94200 HCPCS inpatient 102 66.3 AETNA AETNA 80.58 79 999999999 61.76 98.94 percent of total billed charges Test to measure largest amount of air breathed in an out 819007_1 CDM 0410 RC 94200 HCPCS inpatient 102 66.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 79.56 78 999999999 61.76 98.94 percent of total billed charges Test to measure largest amount of air breathed in an out 819007_1 CDM 0410 RC 94200 HCPCS inpatient 102 66.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 70.38 69 999999999 61.76 98.94 percent of total billed charges Test to measure largest amount of air breathed in an out 819007_1 CDM 0410 RC 94200 HCPCS inpatient 102 66.3 SIHO - ALL PLANS SIHO - ALL PLANS 91.8 90 999999999 61.76 98.94 percent of total billed charges Test to measure largest amount of air breathed in an out 819007_1 CDM 0410 RC 94200 HCPCS inpatient 102 66.3 UMR - ALL PLANS UMR - ALL PLANS 71.4 70 999999999 61.76 98.94 percent of total billed charges Test to measure largest amount of air breathed in an out 819007_1 CDM 0410 RC 94200 HCPCS inpatient 102 66.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.76 60.55 999999999 61.76 98.94 percent of total billed charges Test to measure largest amount of air breathed in an out 819007_1 CDM 0410 RC 94200 HCPCS inpatient 102 66.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.76 98.94 Test to measure largest amount of air breathed in an out 819007_1 CDM 0410 RC 94200 HCPCS inpatient 102 66.3 ANTHEM HMO ANTHEM HMO 999999999 61.76 98.94 Test to measure largest amount of air breathed in an out 819007_1 CDM 0410 RC 94200 HCPCS inpatient 102 66.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.76 98.94 Test to measure largest amount of air breathed in an out 819007_1 CDM 0410 RC 94200 HCPCS inpatient 102 66.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.76 98.94 Test to measure largest amount of air breathed in an out 819007_1 CDM 0410 RC 94200 HCPCS inpatient 102 66.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.76 98.94 Test to measure largest amount of air breathed in an out 819007_1 CDM 0410 RC 94200 HCPCS inpatient 102 66.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.95 67.6 999999999 61.76 98.94 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819008_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 150.15 65 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819008_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 224.07 97 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819008_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 AETNA AETNA 182.49 79 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819008_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 180.18 78 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819008_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 159.39 69 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819008_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 SIHO - ALL PLANS SIHO - ALL PLANS 207.9 90 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819008_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 UMR - ALL PLANS UMR - ALL PLANS 161.7 70 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819008_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 139.87 60.55 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819008_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 819008_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM HMO ANTHEM HMO 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 819008_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 819008_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 819008_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 819008_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 156.16 67.6 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819009_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 150.15 65 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819009_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 224.07 97 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819009_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 AETNA AETNA 182.49 79 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819009_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 180.18 78 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819009_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 159.39 69 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819009_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 SIHO - ALL PLANS SIHO - ALL PLANS 207.9 90 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819009_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 UMR - ALL PLANS UMR - ALL PLANS 161.7 70 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819009_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 139.87 60.55 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819009_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 819009_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM HMO ANTHEM HMO 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 819009_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 819009_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 819009_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 139.87 224.07 Inhalation treatment for airway obstruction or sputum production 819009_1 CDM 0410 RC 94640 HCPCS inpatient 231 150.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 156.16 67.6 999999999 139.87 224.07 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819011_1 CDM 0410 RC 94640 HCPCS inpatient 247 160.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 160.55 65 999999999 149.56 239.59 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819011_1 CDM 0410 RC 94640 HCPCS inpatient 247 160.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 239.59 97 999999999 149.56 239.59 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819011_1 CDM 0410 RC 94640 HCPCS inpatient 247 160.55 AETNA AETNA 195.13 79 999999999 149.56 239.59 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819011_1 CDM 0410 RC 94640 HCPCS inpatient 247 160.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 192.66 78 999999999 149.56 239.59 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819011_1 CDM 0410 RC 94640 HCPCS inpatient 247 160.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 170.43 69 999999999 149.56 239.59 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819011_1 CDM 0410 RC 94640 HCPCS inpatient 247 160.55 SIHO - ALL PLANS SIHO - ALL PLANS 222.3 90 999999999 149.56 239.59 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819011_1 CDM 0410 RC 94640 HCPCS inpatient 247 160.55 UMR - ALL PLANS UMR - ALL PLANS 172.9 70 999999999 149.56 239.59 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819011_1 CDM 0410 RC 94640 HCPCS inpatient 247 160.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 149.56 60.55 999999999 149.56 239.59 percent of total billed charges Inhalation treatment for airway obstruction or sputum production 819011_1 CDM 0410 RC 94640 HCPCS inpatient 247 160.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 149.56 239.59 Inhalation treatment for airway obstruction or sputum production 819011_1 CDM 0410 RC 94640 HCPCS inpatient 247 160.55 ANTHEM HMO ANTHEM HMO 999999999 149.56 239.59 Inhalation treatment for airway obstruction or sputum production 819011_1 CDM 0410 RC 94640 HCPCS inpatient 247 160.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 149.56 239.59 Inhalation treatment for airway obstruction or sputum production 819011_1 CDM 0410 RC 94640 HCPCS inpatient 247 160.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 149.56 239.59 Inhalation treatment for airway obstruction or sputum production 819011_1 CDM 0410 RC 94640 HCPCS inpatient 247 160.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 149.56 239.59 Inhalation treatment for airway obstruction or sputum production 819011_1 CDM 0410 RC 94640 HCPCS inpatient 247 160.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 166.97 67.6 999999999 149.56 239.59 percent of total billed charges Initial therapy service to facilitate lung function 819012_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 146.25 65 999999999 136.24 218.25 percent of total billed charges Initial therapy service to facilitate lung function 819012_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 218.25 97 999999999 136.24 218.25 percent of total billed charges Initial therapy service to facilitate lung function 819012_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 AETNA AETNA 177.75 79 999999999 136.24 218.25 percent of total billed charges Initial therapy service to facilitate lung function 819012_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 175.5 78 999999999 136.24 218.25 percent of total billed charges Initial therapy service to facilitate lung function 819012_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 155.25 69 999999999 136.24 218.25 percent of total billed charges Initial therapy service to facilitate lung function 819012_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 SIHO - ALL PLANS SIHO - ALL PLANS 202.5 90 999999999 136.24 218.25 percent of total billed charges Initial therapy service to facilitate lung function 819012_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 UMR - ALL PLANS UMR - ALL PLANS 157.5 70 999999999 136.24 218.25 percent of total billed charges Initial therapy service to facilitate lung function 819012_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 136.24 60.55 999999999 136.24 218.25 percent of total billed charges Initial therapy service to facilitate lung function 819012_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 136.24 218.25 Initial therapy service to facilitate lung function 819012_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 ANTHEM HMO ANTHEM HMO 999999999 136.24 218.25 Initial therapy service to facilitate lung function 819012_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 136.24 218.25 Initial therapy service to facilitate lung function 819012_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 136.24 218.25 Initial therapy service to facilitate lung function 819012_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 136.24 218.25 Initial therapy service to facilitate lung function 819012_1 CDM 0410 RC 94667 HCPCS inpatient 225 146.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 152.1 67.6 999999999 136.24 218.25 percent of total billed charges Follow-up therapy service to facilitate lung function 819013_1 CDM 0460 RC 94668 HCPCS inpatient 193 125.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 125.45 65 999999999 116.86 187.21 percent of total billed charges Follow-up therapy service to facilitate lung function 819013_1 CDM 0460 RC 94668 HCPCS inpatient 193 125.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 187.21 97 999999999 116.86 187.21 percent of total billed charges Follow-up therapy service to facilitate lung function 819013_1 CDM 0460 RC 94668 HCPCS inpatient 193 125.45 AETNA AETNA 152.47 79 999999999 116.86 187.21 percent of total billed charges Follow-up therapy service to facilitate lung function 819013_1 CDM 0460 RC 94668 HCPCS inpatient 193 125.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 150.54 78 999999999 116.86 187.21 percent of total billed charges Follow-up therapy service to facilitate lung function 819013_1 CDM 0460 RC 94668 HCPCS inpatient 193 125.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 133.17 69 999999999 116.86 187.21 percent of total billed charges Follow-up therapy service to facilitate lung function 819013_1 CDM 0460 RC 94668 HCPCS inpatient 193 125.45 SIHO - ALL PLANS SIHO - ALL PLANS 173.7 90 999999999 116.86 187.21 percent of total billed charges Follow-up therapy service to facilitate lung function 819013_1 CDM 0460 RC 94668 HCPCS inpatient 193 125.45 UMR - ALL PLANS UMR - ALL PLANS 135.1 70 999999999 116.86 187.21 percent of total billed charges Follow-up therapy service to facilitate lung function 819013_1 CDM 0460 RC 94668 HCPCS inpatient 193 125.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.86 60.55 999999999 116.86 187.21 percent of total billed charges Follow-up therapy service to facilitate lung function 819013_1 CDM 0460 RC 94668 HCPCS inpatient 193 125.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.86 187.21 Follow-up therapy service to facilitate lung function 819013_1 CDM 0460 RC 94668 HCPCS inpatient 193 125.45 ANTHEM HMO ANTHEM HMO 999999999 116.86 187.21 Follow-up therapy service to facilitate lung function 819013_1 CDM 0460 RC 94668 HCPCS inpatient 193 125.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.86 187.21 Follow-up therapy service to facilitate lung function 819013_1 CDM 0460 RC 94668 HCPCS inpatient 193 125.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.86 187.21 Follow-up therapy service to facilitate lung function 819013_1 CDM 0460 RC 94668 HCPCS inpatient 193 125.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.86 187.21 Follow-up therapy service to facilitate lung function 819013_1 CDM 0460 RC 94668 HCPCS inpatient 193 125.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 130.47 67.6 999999999 116.86 187.21 percent of total billed charges CT scan of cranial cavity before and after contrast 8196951_1 CDM 0351 RC 70482 HCPCS inpatient 2782 1808.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 1808.3 65 999999999 1684.5 2698.54 percent of total billed charges CT scan of cranial cavity before and after contrast 8196951_1 CDM 0351 RC 70482 HCPCS inpatient 2782 1808.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2698.54 97 999999999 1684.5 2698.54 percent of total billed charges CT scan of cranial cavity before and after contrast 8196951_1 CDM 0351 RC 70482 HCPCS inpatient 2782 1808.3 AETNA AETNA 2197.78 79 999999999 1684.5 2698.54 percent of total billed charges CT scan of cranial cavity before and after contrast 8196951_1 CDM 0351 RC 70482 HCPCS inpatient 2782 1808.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 2169.96 78 999999999 1684.5 2698.54 percent of total billed charges CT scan of cranial cavity before and after contrast 8196951_1 CDM 0351 RC 70482 HCPCS inpatient 2782 1808.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 1919.58 69 999999999 1684.5 2698.54 percent of total billed charges CT scan of cranial cavity before and after contrast 8196951_1 CDM 0351 RC 70482 HCPCS inpatient 2782 1808.3 SIHO - ALL PLANS SIHO - ALL PLANS 2503.8 90 999999999 1684.5 2698.54 percent of total billed charges CT scan of cranial cavity before and after contrast 8196951_1 CDM 0351 RC 70482 HCPCS inpatient 2782 1808.3 UMR - ALL PLANS UMR - ALL PLANS 1947.4 70 999999999 1684.5 2698.54 percent of total billed charges CT scan of cranial cavity before and after contrast 8196951_1 CDM 0351 RC 70482 HCPCS inpatient 2782 1808.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1684.5 60.55 999999999 1684.5 2698.54 percent of total billed charges CT scan of cranial cavity before and after contrast 8196951_1 CDM 0351 RC 70482 HCPCS inpatient 2782 1808.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1684.5 2698.54 CT scan of cranial cavity before and after contrast 8196951_1 CDM 0351 RC 70482 HCPCS inpatient 2782 1808.3 ANTHEM HMO ANTHEM HMO 999999999 1684.5 2698.54 CT scan of cranial cavity before and after contrast 8196951_1 CDM 0351 RC 70482 HCPCS inpatient 2782 1808.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1684.5 2698.54 CT scan of cranial cavity before and after contrast 8196951_1 CDM 0351 RC 70482 HCPCS inpatient 2782 1808.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1684.5 2698.54 CT scan of cranial cavity before and after contrast 8196951_1 CDM 0351 RC 70482 HCPCS inpatient 2782 1808.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 1684.5 2698.54 CT scan of cranial cavity before and after contrast 8196951_1 CDM 0351 RC 70482 HCPCS inpatient 2782 1808.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 1880.63 67.6 999999999 1684.5 2698.54 percent of total billed charges MRI scan of heart before and after contrast 8196986_1 CDM 0610 RC 75561 HCPCS inpatient 4964 3226.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 3226.6 65 999999999 3005.7 4815.08 percent of total billed charges MRI scan of heart before and after contrast 8196986_1 CDM 0610 RC 75561 HCPCS inpatient 4964 3226.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4815.08 97 999999999 3005.7 4815.08 percent of total billed charges MRI scan of heart before and after contrast 8196986_1 CDM 0610 RC 75561 HCPCS inpatient 4964 3226.6 AETNA AETNA 3921.56 79 999999999 3005.7 4815.08 percent of total billed charges MRI scan of heart before and after contrast 8196986_1 CDM 0610 RC 75561 HCPCS inpatient 4964 3226.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 3871.92 78 999999999 3005.7 4815.08 percent of total billed charges MRI scan of heart before and after contrast 8196986_1 CDM 0610 RC 75561 HCPCS inpatient 4964 3226.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 3425.16 69 999999999 3005.7 4815.08 percent of total billed charges MRI scan of heart before and after contrast 8196986_1 CDM 0610 RC 75561 HCPCS inpatient 4964 3226.6 SIHO - ALL PLANS SIHO - ALL PLANS 4467.6 90 999999999 3005.7 4815.08 percent of total billed charges MRI scan of heart before and after contrast 8196986_1 CDM 0610 RC 75561 HCPCS inpatient 4964 3226.6 UMR - ALL PLANS UMR - ALL PLANS 3474.8 70 999999999 3005.7 4815.08 percent of total billed charges MRI scan of heart before and after contrast 8196986_1 CDM 0610 RC 75561 HCPCS inpatient 4964 3226.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3005.7 60.55 999999999 3005.7 4815.08 percent of total billed charges MRI scan of heart before and after contrast 8196986_1 CDM 0610 RC 75561 HCPCS inpatient 4964 3226.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3005.7 4815.08 MRI scan of heart before and after contrast 8196986_1 CDM 0610 RC 75561 HCPCS inpatient 4964 3226.6 ANTHEM HMO ANTHEM HMO 999999999 3005.7 4815.08 MRI scan of heart before and after contrast 8196986_1 CDM 0610 RC 75561 HCPCS inpatient 4964 3226.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3005.7 4815.08 MRI scan of heart before and after contrast 8196986_1 CDM 0610 RC 75561 HCPCS inpatient 4964 3226.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3005.7 4815.08 MRI scan of heart before and after contrast 8196986_1 CDM 0610 RC 75561 HCPCS inpatient 4964 3226.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 3005.7 4815.08 MRI scan of heart before and after contrast 8196986_1 CDM 0610 RC 75561 HCPCS inpatient 4964 3226.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 3355.66 67.6 999999999 3005.7 4815.08 percent of total billed charges Ultrasonic guidance for needle placement 8196991_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196991_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196991_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196991_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196991_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196991_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196991_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196991_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196991_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 8196991_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Ultrasonic guidance for needle placement 8196991_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 8196991_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 8196991_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 8196991_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196993_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196993_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196993_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196993_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196993_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196993_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196993_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196993_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196993_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 8196993_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Ultrasonic guidance for needle placement 8196993_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 8196993_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 8196993_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 8196993_1 CDM 0402 RC 76942 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196995_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196995_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196995_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196995_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196995_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196995_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196995_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196995_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 8196995_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 8196995_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Ultrasonic guidance for needle placement 8196995_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 8196995_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 8196995_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 8196995_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 820923_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 205.4 65 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 820923_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 306.52 97 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 820923_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 AETNA AETNA 249.64 79 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 820923_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 246.48 78 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 820923_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 218.04 69 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 820923_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 SIHO - ALL PLANS SIHO - ALL PLANS 284.4 90 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 820923_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 UMR - ALL PLANS UMR - ALL PLANS 221.2 70 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 820923_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 191.34 60.55 999999999 191.34 306.52 percent of total billed charges Routine electrocardiogram (ECG) using at least 12 leads with tracing 820923_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 820923_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 ANTHEM HMO ANTHEM HMO 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 820923_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 820923_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 820923_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 191.34 306.52 Routine electrocardiogram (ECG) using at least 12 leads with tracing 820923_1 CDM 0730 RC 93005 HCPCS inpatient 316 205.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 213.62 67.6 999999999 191.34 306.52 percent of total billed charges CT scan of blood vessels of abdomen and pelvis with contrast 8284945_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 2959.45 65 999999999 2756.84 4416.41 percent of total billed charges CT scan of blood vessels of abdomen and pelvis with contrast 8284945_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4416.41 97 999999999 2756.84 4416.41 percent of total billed charges CT scan of blood vessels of abdomen and pelvis with contrast 8284945_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 AETNA AETNA 3596.87 79 999999999 2756.84 4416.41 percent of total billed charges CT scan of blood vessels of abdomen and pelvis with contrast 8284945_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 3551.34 78 999999999 2756.84 4416.41 percent of total billed charges CT scan of blood vessels of abdomen and pelvis with contrast 8284945_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 3141.57 69 999999999 2756.84 4416.41 percent of total billed charges CT scan of blood vessels of abdomen and pelvis with contrast 8284945_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 SIHO - ALL PLANS SIHO - ALL PLANS 4097.7 90 999999999 2756.84 4416.41 percent of total billed charges CT scan of blood vessels of abdomen and pelvis with contrast 8284945_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 UMR - ALL PLANS UMR - ALL PLANS 3187.1 70 999999999 2756.84 4416.41 percent of total billed charges CT scan of blood vessels of abdomen and pelvis with contrast 8284945_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2756.84 60.55 999999999 2756.84 4416.41 percent of total billed charges CT scan of blood vessels of abdomen and pelvis with contrast 8284945_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2756.84 4416.41 CT scan of blood vessels of abdomen and pelvis with contrast 8284945_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 ANTHEM HMO ANTHEM HMO 999999999 2756.84 4416.41 CT scan of blood vessels of abdomen and pelvis with contrast 8284945_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2756.84 4416.41 CT scan of blood vessels of abdomen and pelvis with contrast 8284945_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2756.84 4416.41 CT scan of blood vessels of abdomen and pelvis with contrast 8284945_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 2756.84 4416.41 CT scan of blood vessels of abdomen and pelvis with contrast 8284945_1 CDM 0352 RC 74174 HCPCS inpatient 4553 2959.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 3077.83 67.6 999999999 2756.84 4416.41 percent of total billed charges "Ketone bodies analysis, qualitative" 832624_1 CDM 0301 RC 82009 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Ketone bodies analysis, qualitative" 832624_1 CDM 0301 RC 82009 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Ketone bodies analysis, qualitative" 832624_1 CDM 0301 RC 82009 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Ketone bodies analysis, qualitative" 832624_1 CDM 0301 RC 82009 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Ketone bodies analysis, qualitative" 832624_1 CDM 0301 RC 82009 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Ketone bodies analysis, qualitative" 832624_1 CDM 0301 RC 82009 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Ketone bodies analysis, qualitative" 832624_1 CDM 0301 RC 82009 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Ketone bodies analysis, qualitative" 832624_1 CDM 0301 RC 82009 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Ketone bodies analysis, qualitative" 832624_1 CDM 0301 RC 82009 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Ketone bodies analysis, qualitative" 832624_1 CDM 0301 RC 82009 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Ketone bodies analysis, qualitative" 832624_1 CDM 0301 RC 82009 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Ketone bodies analysis, qualitative" 832624_1 CDM 0301 RC 82009 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Ketone bodies analysis, qualitative" 832624_1 CDM 0301 RC 82009 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 "Ketone bodies analysis, qualitative" 832624_1 CDM 0301 RC 82009 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 844593_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 141.7 65 999999999 132 211.46 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 844593_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 211.46 97 999999999 132 211.46 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 844593_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 AETNA AETNA 172.22 79 999999999 132 211.46 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 844593_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.04 78 999999999 132 211.46 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 844593_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 150.42 69 999999999 132 211.46 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 844593_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 SIHO - ALL PLANS SIHO - ALL PLANS 196.2 90 999999999 132 211.46 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 844593_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 UMR - ALL PLANS UMR - ALL PLANS 152.6 70 999999999 132 211.46 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 844593_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132 60.55 999999999 132 211.46 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 844593_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132 211.46 Detection test by nucleic acid for multiple types influenza virus 844593_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 ANTHEM HMO ANTHEM HMO 999999999 132 211.46 Detection test by nucleic acid for multiple types influenza virus 844593_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132 211.46 Detection test by nucleic acid for multiple types influenza virus 844593_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132 211.46 Detection test by nucleic acid for multiple types influenza virus 844593_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 132 211.46 Detection test by nucleic acid for multiple types influenza virus 844593_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 147.37 67.6 999999999 132 211.46 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 844595_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 141.7 65 999999999 132 211.46 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 844595_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 211.46 97 999999999 132 211.46 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 844595_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 AETNA AETNA 172.22 79 999999999 132 211.46 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 844595_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 170.04 78 999999999 132 211.46 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 844595_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 150.42 69 999999999 132 211.46 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 844595_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 SIHO - ALL PLANS SIHO - ALL PLANS 196.2 90 999999999 132 211.46 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 844595_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 UMR - ALL PLANS UMR - ALL PLANS 152.6 70 999999999 132 211.46 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 844595_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 132 60.55 999999999 132 211.46 percent of total billed charges Detection test by nucleic acid for multiple types influenza virus 844595_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 132 211.46 Detection test by nucleic acid for multiple types influenza virus 844595_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 ANTHEM HMO ANTHEM HMO 999999999 132 211.46 Detection test by nucleic acid for multiple types influenza virus 844595_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 132 211.46 Detection test by nucleic acid for multiple types influenza virus 844595_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 132 211.46 Detection test by nucleic acid for multiple types influenza virus 844595_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 132 211.46 Detection test by nucleic acid for multiple types influenza virus 844595_1 CDM 0306 RC 87502 HCPCS inpatient 218 141.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 147.37 67.6 999999999 132 211.46 percent of total billed charges Bacterial blood culture 8463198_1 CDM 0306 RC 87040 HCPCS inpatient 334 217.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 217.1 65 999999999 202.24 323.98 percent of total billed charges Bacterial blood culture 8463198_1 CDM 0306 RC 87040 HCPCS inpatient 334 217.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 323.98 97 999999999 202.24 323.98 percent of total billed charges Bacterial blood culture 8463198_1 CDM 0306 RC 87040 HCPCS inpatient 334 217.1 AETNA AETNA 263.86 79 999999999 202.24 323.98 percent of total billed charges Bacterial blood culture 8463198_1 CDM 0306 RC 87040 HCPCS inpatient 334 217.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 260.52 78 999999999 202.24 323.98 percent of total billed charges Bacterial blood culture 8463198_1 CDM 0306 RC 87040 HCPCS inpatient 334 217.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 230.46 69 999999999 202.24 323.98 percent of total billed charges Bacterial blood culture 8463198_1 CDM 0306 RC 87040 HCPCS inpatient 334 217.1 SIHO - ALL PLANS SIHO - ALL PLANS 300.6 90 999999999 202.24 323.98 percent of total billed charges Bacterial blood culture 8463198_1 CDM 0306 RC 87040 HCPCS inpatient 334 217.1 UMR - ALL PLANS UMR - ALL PLANS 233.8 70 999999999 202.24 323.98 percent of total billed charges Bacterial blood culture 8463198_1 CDM 0306 RC 87040 HCPCS inpatient 334 217.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 202.24 60.55 999999999 202.24 323.98 percent of total billed charges Bacterial blood culture 8463198_1 CDM 0306 RC 87040 HCPCS inpatient 334 217.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 202.24 323.98 Bacterial blood culture 8463198_1 CDM 0306 RC 87040 HCPCS inpatient 334 217.1 ANTHEM HMO ANTHEM HMO 999999999 202.24 323.98 Bacterial blood culture 8463198_1 CDM 0306 RC 87040 HCPCS inpatient 334 217.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 202.24 323.98 Bacterial blood culture 8463198_1 CDM 0306 RC 87040 HCPCS inpatient 334 217.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 202.24 323.98 Bacterial blood culture 8463198_1 CDM 0306 RC 87040 HCPCS inpatient 334 217.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 202.24 323.98 Bacterial blood culture 8463198_1 CDM 0306 RC 87040 HCPCS inpatient 334 217.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 225.78 67.6 999999999 202.24 323.98 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463199_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 75.4 65 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463199_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 112.52 97 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463199_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 AETNA AETNA 91.64 79 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463199_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 90.48 78 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463199_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.04 69 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463199_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 SIHO - ALL PLANS SIHO - ALL PLANS 104.4 90 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463199_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 UMR - ALL PLANS UMR - ALL PLANS 81.2 70 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463199_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 70.24 60.55 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463199_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 70.24 112.52 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463199_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 ANTHEM HMO ANTHEM HMO 999999999 70.24 112.52 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463199_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 70.24 112.52 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463199_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 70.24 112.52 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463199_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 70.24 112.52 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463199_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 78.42 67.6 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463200_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 69.55 65 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463200_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 103.79 97 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463200_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 AETNA AETNA 84.53 79 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463200_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 83.46 78 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463200_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.83 69 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463200_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 SIHO - ALL PLANS SIHO - ALL PLANS 96.3 90 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463200_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 UMR - ALL PLANS UMR - ALL PLANS 74.9 70 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463200_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.79 60.55 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463200_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463200_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM HMO ANTHEM HMO 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463200_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463200_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463200_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463200_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 72.33 67.6 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463202_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65 65 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463202_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97 97 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463202_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 AETNA AETNA 79 79 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463202_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78 78 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463202_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69 69 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463202_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 SIHO - ALL PLANS SIHO - ALL PLANS 90 90 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463202_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 UMR - ALL PLANS UMR - ALL PLANS 70 70 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463202_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.55 60.55 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463202_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.55 97 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463202_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ANTHEM HMO ANTHEM HMO 999999999 60.55 97 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463202_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.55 97 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463202_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.55 97 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463202_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.55 97 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463202_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.6 67.6 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463203_1 CDM 0306 RC 87070 HCPCS inpatient 118 76.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 76.7 65 999999999 71.45 114.46 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463203_1 CDM 0306 RC 87070 HCPCS inpatient 118 76.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 114.46 97 999999999 71.45 114.46 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463203_1 CDM 0306 RC 87070 HCPCS inpatient 118 76.7 AETNA AETNA 93.22 79 999999999 71.45 114.46 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463203_1 CDM 0306 RC 87070 HCPCS inpatient 118 76.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.04 78 999999999 71.45 114.46 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463203_1 CDM 0306 RC 87070 HCPCS inpatient 118 76.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 81.42 69 999999999 71.45 114.46 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463203_1 CDM 0306 RC 87070 HCPCS inpatient 118 76.7 SIHO - ALL PLANS SIHO - ALL PLANS 106.2 90 999999999 71.45 114.46 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463203_1 CDM 0306 RC 87070 HCPCS inpatient 118 76.7 UMR - ALL PLANS UMR - ALL PLANS 82.6 70 999999999 71.45 114.46 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463203_1 CDM 0306 RC 87070 HCPCS inpatient 118 76.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 71.45 60.55 999999999 71.45 114.46 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463203_1 CDM 0306 RC 87070 HCPCS inpatient 118 76.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 71.45 114.46 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463203_1 CDM 0306 RC 87070 HCPCS inpatient 118 76.7 ANTHEM HMO ANTHEM HMO 999999999 71.45 114.46 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463203_1 CDM 0306 RC 87070 HCPCS inpatient 118 76.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 71.45 114.46 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463203_1 CDM 0306 RC 87070 HCPCS inpatient 118 76.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 71.45 114.46 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463203_1 CDM 0306 RC 87070 HCPCS inpatient 118 76.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 71.45 114.46 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463203_1 CDM 0306 RC 87070 HCPCS inpatient 118 76.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 79.77 67.6 999999999 71.45 114.46 percent of total billed charges Stool culture 8463205_1 CDM 0306 RC 87045 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges Stool culture 8463205_1 CDM 0306 RC 87045 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges Stool culture 8463205_1 CDM 0306 RC 87045 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges Stool culture 8463205_1 CDM 0306 RC 87045 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges Stool culture 8463205_1 CDM 0306 RC 87045 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges Stool culture 8463205_1 CDM 0306 RC 87045 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges Stool culture 8463205_1 CDM 0306 RC 87045 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges Stool culture 8463205_1 CDM 0306 RC 87045 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges Stool culture 8463205_1 CDM 0306 RC 87045 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 Stool culture 8463205_1 CDM 0306 RC 87045 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 Stool culture 8463205_1 CDM 0306 RC 87045 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 Stool culture 8463205_1 CDM 0306 RC 87045 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 Stool culture 8463205_1 CDM 0306 RC 87045 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 Stool culture 8463205_1 CDM 0306 RC 87045 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463207_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 69.55 65 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463207_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 103.79 97 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463207_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 AETNA AETNA 84.53 79 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463207_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 83.46 78 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463207_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.83 69 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463207_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 SIHO - ALL PLANS SIHO - ALL PLANS 96.3 90 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463207_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 UMR - ALL PLANS UMR - ALL PLANS 74.9 70 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463207_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.79 60.55 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463207_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463207_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM HMO ANTHEM HMO 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463207_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463207_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463207_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463207_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 72.33 67.6 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463212_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 75.4 65 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463212_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 112.52 97 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463212_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 AETNA AETNA 91.64 79 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463212_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 90.48 78 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463212_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.04 69 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463212_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 SIHO - ALL PLANS SIHO - ALL PLANS 104.4 90 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463212_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 UMR - ALL PLANS UMR - ALL PLANS 81.2 70 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463212_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 70.24 60.55 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463212_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 70.24 112.52 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463212_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 ANTHEM HMO ANTHEM HMO 999999999 70.24 112.52 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463212_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 70.24 112.52 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463212_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 70.24 112.52 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463212_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 70.24 112.52 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463212_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 78.42 67.6 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463213_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 75.4 65 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463213_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 112.52 97 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463213_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 AETNA AETNA 91.64 79 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463213_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 90.48 78 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463213_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 80.04 69 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463213_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 SIHO - ALL PLANS SIHO - ALL PLANS 104.4 90 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463213_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 UMR - ALL PLANS UMR - ALL PLANS 81.2 70 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463213_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 70.24 60.55 999999999 70.24 112.52 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463213_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 70.24 112.52 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463213_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 ANTHEM HMO ANTHEM HMO 999999999 70.24 112.52 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463213_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 70.24 112.52 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463213_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 70.24 112.52 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463213_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 70.24 112.52 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463213_1 CDM 0306 RC 87070 HCPCS inpatient 116 75.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 78.42 67.6 999999999 70.24 112.52 percent of total billed charges "Bacterial colony count, urine" 8463221_1 CDM 0306 RC 87086 HCPCS inpatient 118 76.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 76.7 65 999999999 71.45 114.46 percent of total billed charges "Bacterial colony count, urine" 8463221_1 CDM 0306 RC 87086 HCPCS inpatient 118 76.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 114.46 97 999999999 71.45 114.46 percent of total billed charges "Bacterial colony count, urine" 8463221_1 CDM 0306 RC 87086 HCPCS inpatient 118 76.7 AETNA AETNA 93.22 79 999999999 71.45 114.46 percent of total billed charges "Bacterial colony count, urine" 8463221_1 CDM 0306 RC 87086 HCPCS inpatient 118 76.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 92.04 78 999999999 71.45 114.46 percent of total billed charges "Bacterial colony count, urine" 8463221_1 CDM 0306 RC 87086 HCPCS inpatient 118 76.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 81.42 69 999999999 71.45 114.46 percent of total billed charges "Bacterial colony count, urine" 8463221_1 CDM 0306 RC 87086 HCPCS inpatient 118 76.7 SIHO - ALL PLANS SIHO - ALL PLANS 106.2 90 999999999 71.45 114.46 percent of total billed charges "Bacterial colony count, urine" 8463221_1 CDM 0306 RC 87086 HCPCS inpatient 118 76.7 UMR - ALL PLANS UMR - ALL PLANS 82.6 70 999999999 71.45 114.46 percent of total billed charges "Bacterial colony count, urine" 8463221_1 CDM 0306 RC 87086 HCPCS inpatient 118 76.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 71.45 60.55 999999999 71.45 114.46 percent of total billed charges "Bacterial colony count, urine" 8463221_1 CDM 0306 RC 87086 HCPCS inpatient 118 76.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 71.45 114.46 "Bacterial colony count, urine" 8463221_1 CDM 0306 RC 87086 HCPCS inpatient 118 76.7 ANTHEM HMO ANTHEM HMO 999999999 71.45 114.46 "Bacterial colony count, urine" 8463221_1 CDM 0306 RC 87086 HCPCS inpatient 118 76.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 71.45 114.46 "Bacterial colony count, urine" 8463221_1 CDM 0306 RC 87086 HCPCS inpatient 118 76.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 71.45 114.46 "Bacterial colony count, urine" 8463221_1 CDM 0306 RC 87086 HCPCS inpatient 118 76.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 71.45 114.46 "Bacterial colony count, urine" 8463221_1 CDM 0306 RC 87086 HCPCS inpatient 118 76.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 79.77 67.6 999999999 71.45 114.46 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463223_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65 65 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463223_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97 97 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463223_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 AETNA AETNA 79 79 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463223_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78 78 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463223_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69 69 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463223_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 SIHO - ALL PLANS SIHO - ALL PLANS 90 90 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463223_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 UMR - ALL PLANS UMR - ALL PLANS 70 70 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463223_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.55 60.55 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463223_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.55 97 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463223_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ANTHEM HMO ANTHEM HMO 999999999 60.55 97 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463223_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.55 97 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463223_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.55 97 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463223_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.55 97 "Bacterial culture, any other source except urine, blood or stool, aerobic" 8463223_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.6 67.6 999999999 60.55 97 percent of total billed charges Special Gram or Giemsa stain for microorganism 8463226_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65.65 65 999999999 61.16 97.97 percent of total billed charges Special Gram or Giemsa stain for microorganism 8463226_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97.97 97 999999999 61.16 97.97 percent of total billed charges Special Gram or Giemsa stain for microorganism 8463226_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 AETNA AETNA 79.79 79 999999999 61.16 97.97 percent of total billed charges Special Gram or Giemsa stain for microorganism 8463226_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78.78 78 999999999 61.16 97.97 percent of total billed charges Special Gram or Giemsa stain for microorganism 8463226_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69.69 69 999999999 61.16 97.97 percent of total billed charges Special Gram or Giemsa stain for microorganism 8463226_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 SIHO - ALL PLANS SIHO - ALL PLANS 90.9 90 999999999 61.16 97.97 percent of total billed charges Special Gram or Giemsa stain for microorganism 8463226_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 UMR - ALL PLANS UMR - ALL PLANS 70.7 70 999999999 61.16 97.97 percent of total billed charges Special Gram or Giemsa stain for microorganism 8463226_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 61.16 60.55 999999999 61.16 97.97 percent of total billed charges Special Gram or Giemsa stain for microorganism 8463226_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 61.16 97.97 Special Gram or Giemsa stain for microorganism 8463226_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 ANTHEM HMO ANTHEM HMO 999999999 61.16 97.97 Special Gram or Giemsa stain for microorganism 8463226_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 61.16 97.97 Special Gram or Giemsa stain for microorganism 8463226_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 61.16 97.97 Special Gram or Giemsa stain for microorganism 8463226_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 61.16 97.97 Special Gram or Giemsa stain for microorganism 8463226_1 CDM 0306 RC 87205 HCPCS inpatient 101 65.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 68.28 67.6 999999999 61.16 97.97 percent of total billed charges Phenobarbital level 8475011_1 CDM 0301 RC 80184 HCPCS inpatient 216 140.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 140.4 65 999999999 130.79 209.52 percent of total billed charges Phenobarbital level 8475011_1 CDM 0301 RC 80184 HCPCS inpatient 216 140.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 209.52 97 999999999 130.79 209.52 percent of total billed charges Phenobarbital level 8475011_1 CDM 0301 RC 80184 HCPCS inpatient 216 140.4 AETNA AETNA 170.64 79 999999999 130.79 209.52 percent of total billed charges Phenobarbital level 8475011_1 CDM 0301 RC 80184 HCPCS inpatient 216 140.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 168.48 78 999999999 130.79 209.52 percent of total billed charges Phenobarbital level 8475011_1 CDM 0301 RC 80184 HCPCS inpatient 216 140.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 149.04 69 999999999 130.79 209.52 percent of total billed charges Phenobarbital level 8475011_1 CDM 0301 RC 80184 HCPCS inpatient 216 140.4 SIHO - ALL PLANS SIHO - ALL PLANS 194.4 90 999999999 130.79 209.52 percent of total billed charges Phenobarbital level 8475011_1 CDM 0301 RC 80184 HCPCS inpatient 216 140.4 UMR - ALL PLANS UMR - ALL PLANS 151.2 70 999999999 130.79 209.52 percent of total billed charges Phenobarbital level 8475011_1 CDM 0301 RC 80184 HCPCS inpatient 216 140.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 130.79 60.55 999999999 130.79 209.52 percent of total billed charges Phenobarbital level 8475011_1 CDM 0301 RC 80184 HCPCS inpatient 216 140.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 130.79 209.52 Phenobarbital level 8475011_1 CDM 0301 RC 80184 HCPCS inpatient 216 140.4 ANTHEM HMO ANTHEM HMO 999999999 130.79 209.52 Phenobarbital level 8475011_1 CDM 0301 RC 80184 HCPCS inpatient 216 140.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 130.79 209.52 Phenobarbital level 8475011_1 CDM 0301 RC 80184 HCPCS inpatient 216 140.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 130.79 209.52 Phenobarbital level 8475011_1 CDM 0301 RC 80184 HCPCS inpatient 216 140.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 130.79 209.52 Phenobarbital level 8475011_1 CDM 0301 RC 80184 HCPCS inpatient 216 140.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 146.02 67.6 999999999 130.79 209.52 percent of total billed charges Red blood cell hemoglobin concentration 8475352_1 CDM 0305 RC 85013 HCPCS inpatient 94 61.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 61.1 65 999999999 56.92 91.18 percent of total billed charges Red blood cell hemoglobin concentration 8475352_1 CDM 0305 RC 85013 HCPCS inpatient 94 61.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 91.18 97 999999999 56.92 91.18 percent of total billed charges Red blood cell hemoglobin concentration 8475352_1 CDM 0305 RC 85013 HCPCS inpatient 94 61.1 AETNA AETNA 74.26 79 999999999 56.92 91.18 percent of total billed charges Red blood cell hemoglobin concentration 8475352_1 CDM 0305 RC 85013 HCPCS inpatient 94 61.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 73.32 78 999999999 56.92 91.18 percent of total billed charges Red blood cell hemoglobin concentration 8475352_1 CDM 0305 RC 85013 HCPCS inpatient 94 61.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 64.86 69 999999999 56.92 91.18 percent of total billed charges Red blood cell hemoglobin concentration 8475352_1 CDM 0305 RC 85013 HCPCS inpatient 94 61.1 SIHO - ALL PLANS SIHO - ALL PLANS 84.6 90 999999999 56.92 91.18 percent of total billed charges Red blood cell hemoglobin concentration 8475352_1 CDM 0305 RC 85013 HCPCS inpatient 94 61.1 UMR - ALL PLANS UMR - ALL PLANS 65.8 70 999999999 56.92 91.18 percent of total billed charges Red blood cell hemoglobin concentration 8475352_1 CDM 0305 RC 85013 HCPCS inpatient 94 61.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56.92 60.55 999999999 56.92 91.18 percent of total billed charges Red blood cell hemoglobin concentration 8475352_1 CDM 0305 RC 85013 HCPCS inpatient 94 61.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 56.92 91.18 Red blood cell hemoglobin concentration 8475352_1 CDM 0305 RC 85013 HCPCS inpatient 94 61.1 ANTHEM HMO ANTHEM HMO 999999999 56.92 91.18 Red blood cell hemoglobin concentration 8475352_1 CDM 0305 RC 85013 HCPCS inpatient 94 61.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 56.92 91.18 Red blood cell hemoglobin concentration 8475352_1 CDM 0305 RC 85013 HCPCS inpatient 94 61.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 56.92 91.18 Red blood cell hemoglobin concentration 8475352_1 CDM 0305 RC 85013 HCPCS inpatient 94 61.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 56.92 91.18 Red blood cell hemoglobin concentration 8475352_1 CDM 0305 RC 85013 HCPCS inpatient 94 61.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 63.54 67.6 999999999 56.92 91.18 percent of total billed charges Evaluation of use of breathing device 8511292_1 CDM 0948 RC 94664 HCPCS inpatient 188 122.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 122.2 65 999999999 113.83 182.36 percent of total billed charges Evaluation of use of breathing device 8511292_1 CDM 0948 RC 94664 HCPCS inpatient 188 122.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 182.36 97 999999999 113.83 182.36 percent of total billed charges Evaluation of use of breathing device 8511292_1 CDM 0948 RC 94664 HCPCS inpatient 188 122.2 AETNA AETNA 148.52 79 999999999 113.83 182.36 percent of total billed charges Evaluation of use of breathing device 8511292_1 CDM 0948 RC 94664 HCPCS inpatient 188 122.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 146.64 78 999999999 113.83 182.36 percent of total billed charges Evaluation of use of breathing device 8511292_1 CDM 0948 RC 94664 HCPCS inpatient 188 122.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 129.72 69 999999999 113.83 182.36 percent of total billed charges Evaluation of use of breathing device 8511292_1 CDM 0948 RC 94664 HCPCS inpatient 188 122.2 SIHO - ALL PLANS SIHO - ALL PLANS 169.2 90 999999999 113.83 182.36 percent of total billed charges Evaluation of use of breathing device 8511292_1 CDM 0948 RC 94664 HCPCS inpatient 188 122.2 UMR - ALL PLANS UMR - ALL PLANS 131.6 70 999999999 113.83 182.36 percent of total billed charges Evaluation of use of breathing device 8511292_1 CDM 0948 RC 94664 HCPCS inpatient 188 122.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 113.83 60.55 999999999 113.83 182.36 percent of total billed charges Evaluation of use of breathing device 8511292_1 CDM 0948 RC 94664 HCPCS inpatient 188 122.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 113.83 182.36 Evaluation of use of breathing device 8511292_1 CDM 0948 RC 94664 HCPCS inpatient 188 122.2 ANTHEM HMO ANTHEM HMO 999999999 113.83 182.36 Evaluation of use of breathing device 8511292_1 CDM 0948 RC 94664 HCPCS inpatient 188 122.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 113.83 182.36 Evaluation of use of breathing device 8511292_1 CDM 0948 RC 94664 HCPCS inpatient 188 122.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 113.83 182.36 Evaluation of use of breathing device 8511292_1 CDM 0948 RC 94664 HCPCS inpatient 188 122.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 113.83 182.36 Evaluation of use of breathing device 8511292_1 CDM 0948 RC 94664 HCPCS inpatient 188 122.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 127.09 67.6 999999999 113.83 182.36 percent of total billed charges Limited ultrasound scan behind abdominal cavity 8592955_1 CDM 0402 RC 76775 HCPCS inpatient 799 519.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 519.35 65 999999999 483.79 775.03 percent of total billed charges Limited ultrasound scan behind abdominal cavity 8592955_1 CDM 0402 RC 76775 HCPCS inpatient 799 519.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 775.03 97 999999999 483.79 775.03 percent of total billed charges Limited ultrasound scan behind abdominal cavity 8592955_1 CDM 0402 RC 76775 HCPCS inpatient 799 519.35 AETNA AETNA 631.21 79 999999999 483.79 775.03 percent of total billed charges Limited ultrasound scan behind abdominal cavity 8592955_1 CDM 0402 RC 76775 HCPCS inpatient 799 519.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 623.22 78 999999999 483.79 775.03 percent of total billed charges Limited ultrasound scan behind abdominal cavity 8592955_1 CDM 0402 RC 76775 HCPCS inpatient 799 519.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 551.31 69 999999999 483.79 775.03 percent of total billed charges Limited ultrasound scan behind abdominal cavity 8592955_1 CDM 0402 RC 76775 HCPCS inpatient 799 519.35 SIHO - ALL PLANS SIHO - ALL PLANS 719.1 90 999999999 483.79 775.03 percent of total billed charges Limited ultrasound scan behind abdominal cavity 8592955_1 CDM 0402 RC 76775 HCPCS inpatient 799 519.35 UMR - ALL PLANS UMR - ALL PLANS 559.3 70 999999999 483.79 775.03 percent of total billed charges Limited ultrasound scan behind abdominal cavity 8592955_1 CDM 0402 RC 76775 HCPCS inpatient 799 519.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 483.79 60.55 999999999 483.79 775.03 percent of total billed charges Limited ultrasound scan behind abdominal cavity 8592955_1 CDM 0402 RC 76775 HCPCS inpatient 799 519.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 483.79 775.03 Limited ultrasound scan behind abdominal cavity 8592955_1 CDM 0402 RC 76775 HCPCS inpatient 799 519.35 ANTHEM HMO ANTHEM HMO 999999999 483.79 775.03 Limited ultrasound scan behind abdominal cavity 8592955_1 CDM 0402 RC 76775 HCPCS inpatient 799 519.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 483.79 775.03 Limited ultrasound scan behind abdominal cavity 8592955_1 CDM 0402 RC 76775 HCPCS inpatient 799 519.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 483.79 775.03 Limited ultrasound scan behind abdominal cavity 8592955_1 CDM 0402 RC 76775 HCPCS inpatient 799 519.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 483.79 775.03 Limited ultrasound scan behind abdominal cavity 8592955_1 CDM 0402 RC 76775 HCPCS inpatient 799 519.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 540.12 67.6 999999999 483.79 775.03 percent of total billed charges "Ketone bodies analysis, quantitative" 871805_1 CDM 0301 RC 82010 HCPCS inpatient 75 48.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 48.75 65 999999999 45.41 72.75 percent of total billed charges "Ketone bodies analysis, quantitative" 871805_1 CDM 0301 RC 82010 HCPCS inpatient 75 48.75 AETNA AETNA 59.25 79 999999999 45.41 72.75 percent of total billed charges "Ketone bodies analysis, quantitative" 871805_1 CDM 0301 RC 82010 HCPCS inpatient 75 48.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72.75 97 999999999 45.41 72.75 percent of total billed charges "Ketone bodies analysis, quantitative" 871805_1 CDM 0301 RC 82010 HCPCS inpatient 75 48.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 58.5 78 999999999 45.41 72.75 percent of total billed charges "Ketone bodies analysis, quantitative" 871805_1 CDM 0301 RC 82010 HCPCS inpatient 75 48.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 51.75 69 999999999 45.41 72.75 percent of total billed charges "Ketone bodies analysis, quantitative" 871805_1 CDM 0301 RC 82010 HCPCS inpatient 75 48.75 SIHO - ALL PLANS SIHO - ALL PLANS 67.5 90 999999999 45.41 72.75 percent of total billed charges "Ketone bodies analysis, quantitative" 871805_1 CDM 0301 RC 82010 HCPCS inpatient 75 48.75 UMR - ALL PLANS UMR - ALL PLANS 52.5 70 999999999 45.41 72.75 percent of total billed charges "Ketone bodies analysis, quantitative" 871805_1 CDM 0301 RC 82010 HCPCS inpatient 75 48.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45.41 60.55 999999999 45.41 72.75 percent of total billed charges "Ketone bodies analysis, quantitative" 871805_1 CDM 0301 RC 82010 HCPCS inpatient 75 48.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 45.41 72.75 "Ketone bodies analysis, quantitative" 871805_1 CDM 0301 RC 82010 HCPCS inpatient 75 48.75 ANTHEM HMO ANTHEM HMO 999999999 45.41 72.75 "Ketone bodies analysis, quantitative" 871805_1 CDM 0301 RC 82010 HCPCS inpatient 75 48.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 45.41 72.75 "Ketone bodies analysis, quantitative" 871805_1 CDM 0301 RC 82010 HCPCS inpatient 75 48.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 45.41 72.75 "Ketone bodies analysis, quantitative" 871805_1 CDM 0301 RC 82010 HCPCS inpatient 75 48.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 50.7 67.6 999999999 45.41 72.75 percent of total billed charges "Ketone bodies analysis, quantitative" 871805_1 CDM 0301 RC 82010 HCPCS inpatient 75 48.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 45.41 72.75 Amylase (enzyme) level 871821_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 871821_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 871821_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 871821_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 871821_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 871821_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 871821_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 871821_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 871821_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 Amylase (enzyme) level 871821_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 Amylase (enzyme) level 871821_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 Amylase (enzyme) level 871821_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 Amylase (enzyme) level 871821_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges Amylase (enzyme) level 871821_1 CDM 0301 RC 82150 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 Natriuretic peptide (heart and blood vessel protein) level 872048_1 CDM 0301 RC 83880 HCPCS inpatient 249 161.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 161.85 65 999999999 150.77 241.53 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 872048_1 CDM 0301 RC 83880 HCPCS inpatient 249 161.85 AETNA AETNA 196.71 79 999999999 150.77 241.53 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 872048_1 CDM 0301 RC 83880 HCPCS inpatient 249 161.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 241.53 97 999999999 150.77 241.53 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 872048_1 CDM 0301 RC 83880 HCPCS inpatient 249 161.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 194.22 78 999999999 150.77 241.53 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 872048_1 CDM 0301 RC 83880 HCPCS inpatient 249 161.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 171.81 69 999999999 150.77 241.53 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 872048_1 CDM 0301 RC 83880 HCPCS inpatient 249 161.85 SIHO - ALL PLANS SIHO - ALL PLANS 224.1 90 999999999 150.77 241.53 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 872048_1 CDM 0301 RC 83880 HCPCS inpatient 249 161.85 UMR - ALL PLANS UMR - ALL PLANS 174.3 70 999999999 150.77 241.53 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 872048_1 CDM 0301 RC 83880 HCPCS inpatient 249 161.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 150.77 60.55 999999999 150.77 241.53 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 872048_1 CDM 0301 RC 83880 HCPCS inpatient 249 161.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 150.77 241.53 Natriuretic peptide (heart and blood vessel protein) level 872048_1 CDM 0301 RC 83880 HCPCS inpatient 249 161.85 ANTHEM HMO ANTHEM HMO 999999999 150.77 241.53 Natriuretic peptide (heart and blood vessel protein) level 872048_1 CDM 0301 RC 83880 HCPCS inpatient 249 161.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 150.77 241.53 Natriuretic peptide (heart and blood vessel protein) level 872048_1 CDM 0301 RC 83880 HCPCS inpatient 249 161.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 150.77 241.53 Natriuretic peptide (heart and blood vessel protein) level 872048_1 CDM 0301 RC 83880 HCPCS inpatient 249 161.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 168.32 67.6 999999999 150.77 241.53 percent of total billed charges Natriuretic peptide (heart and blood vessel protein) level 872048_1 CDM 0301 RC 83880 HCPCS inpatient 249 161.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 150.77 241.53 Glucose (sugar) level on body fluid 872519_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 71.5 65 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 872519_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 AETNA AETNA 86.9 79 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 872519_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 106.7 97 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 872519_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.8 78 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 872519_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.9 69 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 872519_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 SIHO - ALL PLANS SIHO - ALL PLANS 99 90 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 872519_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 UMR - ALL PLANS UMR - ALL PLANS 77 70 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 872519_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66.61 60.55 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 872519_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66.61 106.7 Glucose (sugar) level on body fluid 872519_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM HMO ANTHEM HMO 999999999 66.61 106.7 Glucose (sugar) level on body fluid 872519_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66.61 106.7 Glucose (sugar) level on body fluid 872519_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66.61 106.7 Glucose (sugar) level on body fluid 872519_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 74.36 67.6 999999999 66.61 106.7 percent of total billed charges Glucose (sugar) level on body fluid 872519_1 CDM 0301 RC 82945 HCPCS inpatient 110 71.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 66.61 106.7 "Test for detection of infectious agent antibody, qualitative or semiquantitative" 872520_1 CDM 0302 RC 86318 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges "Test for detection of infectious agent antibody, qualitative or semiquantitative" 872520_1 CDM 0302 RC 86318 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges "Test for detection of infectious agent antibody, qualitative or semiquantitative" 872520_1 CDM 0302 RC 86318 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges "Test for detection of infectious agent antibody, qualitative or semiquantitative" 872520_1 CDM 0302 RC 86318 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges "Test for detection of infectious agent antibody, qualitative or semiquantitative" 872520_1 CDM 0302 RC 86318 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges "Test for detection of infectious agent antibody, qualitative or semiquantitative" 872520_1 CDM 0302 RC 86318 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges "Test for detection of infectious agent antibody, qualitative or semiquantitative" 872520_1 CDM 0302 RC 86318 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges "Test for detection of infectious agent antibody, qualitative or semiquantitative" 872520_1 CDM 0302 RC 86318 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges "Test for detection of infectious agent antibody, qualitative or semiquantitative" 872520_1 CDM 0302 RC 86318 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 "Test for detection of infectious agent antibody, qualitative or semiquantitative" 872520_1 CDM 0302 RC 86318 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 "Test for detection of infectious agent antibody, qualitative or semiquantitative" 872520_1 CDM 0302 RC 86318 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 "Test for detection of infectious agent antibody, qualitative or semiquantitative" 872520_1 CDM 0302 RC 86318 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 "Test for detection of infectious agent antibody, qualitative or semiquantitative" 872520_1 CDM 0302 RC 86318 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges "Test for detection of infectious agent antibody, qualitative or semiquantitative" 872520_1 CDM 0302 RC 86318 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 Measurement of Hepatitis A antibody (IgM) 872525_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 133.9 65 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 872525_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 AETNA AETNA 162.74 79 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 872525_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 199.82 97 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 872525_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 160.68 78 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 872525_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 142.14 69 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 872525_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 SIHO - ALL PLANS SIHO - ALL PLANS 185.4 90 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 872525_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 UMR - ALL PLANS UMR - ALL PLANS 144.2 70 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 872525_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 124.73 60.55 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 872525_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 124.73 199.82 Measurement of Hepatitis A antibody (IgM) 872525_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 ANTHEM HMO ANTHEM HMO 999999999 124.73 199.82 Measurement of Hepatitis A antibody (IgM) 872525_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 124.73 199.82 Measurement of Hepatitis A antibody (IgM) 872525_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 124.73 199.82 Measurement of Hepatitis A antibody (IgM) 872525_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 139.26 67.6 999999999 124.73 199.82 percent of total billed charges Measurement of Hepatitis A antibody (IgM) 872525_1 CDM 0301 RC 86709 HCPCS inpatient 206 133.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 124.73 199.82 Detection test by immunoassay technique for hepatitis B surface antigen 872526_1 CDM 0301 RC 87340 HCPCS inpatient 80 52 SELF PAY DISCOUNT SELF PAY DISCOUNT 52 65 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 872526_1 CDM 0301 RC 87340 HCPCS inpatient 80 52 AETNA AETNA 63.2 79 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 872526_1 CDM 0301 RC 87340 HCPCS inpatient 80 52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77.6 97 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 872526_1 CDM 0301 RC 87340 HCPCS inpatient 80 52 HUMANA - ALL PLANS HUMANA - ALL PLANS 62.4 78 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 872526_1 CDM 0301 RC 87340 HCPCS inpatient 80 52 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.2 69 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 872526_1 CDM 0301 RC 87340 HCPCS inpatient 80 52 SIHO - ALL PLANS SIHO - ALL PLANS 72 90 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 872526_1 CDM 0301 RC 87340 HCPCS inpatient 80 52 UMR - ALL PLANS UMR - ALL PLANS 56 70 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 872526_1 CDM 0301 RC 87340 HCPCS inpatient 80 52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48.44 60.55 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 872526_1 CDM 0301 RC 87340 HCPCS inpatient 80 52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 48.44 77.6 Detection test by immunoassay technique for hepatitis B surface antigen 872526_1 CDM 0301 RC 87340 HCPCS inpatient 80 52 ANTHEM HMO ANTHEM HMO 999999999 48.44 77.6 Detection test by immunoassay technique for hepatitis B surface antigen 872526_1 CDM 0301 RC 87340 HCPCS inpatient 80 52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 48.44 77.6 Detection test by immunoassay technique for hepatitis B surface antigen 872526_1 CDM 0301 RC 87340 HCPCS inpatient 80 52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 48.44 77.6 Detection test by immunoassay technique for hepatitis B surface antigen 872526_1 CDM 0301 RC 87340 HCPCS inpatient 80 52 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.08 67.6 999999999 48.44 77.6 percent of total billed charges Detection test by immunoassay technique for hepatitis B surface antigen 872526_1 CDM 0301 RC 87340 HCPCS inpatient 80 52 UHC - ALL PLANS UHC - ALL PLANS 999999999 48.44 77.6 Hepatitis C antibody measurement 872527_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 68.25 65 999999999 63.58 101.85 percent of total billed charges Hepatitis C antibody measurement 872527_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 AETNA AETNA 82.95 79 999999999 63.58 101.85 percent of total billed charges Hepatitis C antibody measurement 872527_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 101.85 97 999999999 63.58 101.85 percent of total billed charges Hepatitis C antibody measurement 872527_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 81.9 78 999999999 63.58 101.85 percent of total billed charges Hepatitis C antibody measurement 872527_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 72.45 69 999999999 63.58 101.85 percent of total billed charges Hepatitis C antibody measurement 872527_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 SIHO - ALL PLANS SIHO - ALL PLANS 94.5 90 999999999 63.58 101.85 percent of total billed charges Hepatitis C antibody measurement 872527_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 UMR - ALL PLANS UMR - ALL PLANS 73.5 70 999999999 63.58 101.85 percent of total billed charges Hepatitis C antibody measurement 872527_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 63.58 60.55 999999999 63.58 101.85 percent of total billed charges Hepatitis C antibody measurement 872527_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 63.58 101.85 Hepatitis C antibody measurement 872527_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 ANTHEM HMO ANTHEM HMO 999999999 63.58 101.85 Hepatitis C antibody measurement 872527_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 63.58 101.85 Hepatitis C antibody measurement 872527_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 63.58 101.85 Hepatitis C antibody measurement 872527_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 70.98 67.6 999999999 63.58 101.85 percent of total billed charges Hepatitis C antibody measurement 872527_1 CDM 0301 RC 86803 HCPCS inpatient 105 68.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 63.58 101.85 "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 872536_1 CDM 0302 RC 86141 HCPCS inpatient 192 124.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 124.8 65 999999999 116.26 186.24 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 872536_1 CDM 0302 RC 86141 HCPCS inpatient 192 124.8 AETNA AETNA 151.68 79 999999999 116.26 186.24 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 872536_1 CDM 0302 RC 86141 HCPCS inpatient 192 124.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 186.24 97 999999999 116.26 186.24 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 872536_1 CDM 0302 RC 86141 HCPCS inpatient 192 124.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 149.76 78 999999999 116.26 186.24 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 872536_1 CDM 0302 RC 86141 HCPCS inpatient 192 124.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 132.48 69 999999999 116.26 186.24 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 872536_1 CDM 0302 RC 86141 HCPCS inpatient 192 124.8 SIHO - ALL PLANS SIHO - ALL PLANS 172.8 90 999999999 116.26 186.24 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 872536_1 CDM 0302 RC 86141 HCPCS inpatient 192 124.8 UMR - ALL PLANS UMR - ALL PLANS 134.4 70 999999999 116.26 186.24 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 872536_1 CDM 0302 RC 86141 HCPCS inpatient 192 124.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 116.26 60.55 999999999 116.26 186.24 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 872536_1 CDM 0302 RC 86141 HCPCS inpatient 192 124.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 116.26 186.24 "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 872536_1 CDM 0302 RC 86141 HCPCS inpatient 192 124.8 ANTHEM HMO ANTHEM HMO 999999999 116.26 186.24 "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 872536_1 CDM 0302 RC 86141 HCPCS inpatient 192 124.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 116.26 186.24 "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 872536_1 CDM 0302 RC 86141 HCPCS inpatient 192 124.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 116.26 186.24 "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 872536_1 CDM 0302 RC 86141 HCPCS inpatient 192 124.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 129.79 67.6 999999999 116.26 186.24 percent of total billed charges "Measurement C-reactive protein for detection of infection or inflammation, high sensitivity" 872536_1 CDM 0302 RC 86141 HCPCS inpatient 192 124.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 116.26 186.24 Analysis for antibody to HIV-1 and HIV-2 virus 872538_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.1 65 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 872538_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 AETNA AETNA 121.66 79 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 872538_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 149.38 97 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 872538_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.12 78 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 872538_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.26 69 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 872538_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 SIHO - ALL PLANS SIHO - ALL PLANS 138.6 90 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 872538_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 UMR - ALL PLANS UMR - ALL PLANS 107.8 70 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 872538_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.25 60.55 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 872538_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.25 149.38 Analysis for antibody to HIV-1 and HIV-2 virus 872538_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 ANTHEM HMO ANTHEM HMO 999999999 93.25 149.38 Analysis for antibody to HIV-1 and HIV-2 virus 872538_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.25 149.38 Analysis for antibody to HIV-1 and HIV-2 virus 872538_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.25 149.38 Analysis for antibody to HIV-1 and HIV-2 virus 872538_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.1 67.6 999999999 93.25 149.38 percent of total billed charges Analysis for antibody to HIV-1 and HIV-2 virus 872538_1 CDM 0302 RC 86703 HCPCS inpatient 154 100.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.25 149.38 Body fluid pH level 872568_1 CDM 0301 RC 83986 HCPCS inpatient 77 50.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 50.05 65 999999999 46.62 74.69 percent of total billed charges Body fluid pH level 872568_1 CDM 0301 RC 83986 HCPCS inpatient 77 50.05 AETNA AETNA 60.83 79 999999999 46.62 74.69 percent of total billed charges Body fluid pH level 872568_1 CDM 0301 RC 83986 HCPCS inpatient 77 50.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 74.69 97 999999999 46.62 74.69 percent of total billed charges Body fluid pH level 872568_1 CDM 0301 RC 83986 HCPCS inpatient 77 50.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 60.06 78 999999999 46.62 74.69 percent of total billed charges Body fluid pH level 872568_1 CDM 0301 RC 83986 HCPCS inpatient 77 50.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 53.13 69 999999999 46.62 74.69 percent of total billed charges Body fluid pH level 872568_1 CDM 0301 RC 83986 HCPCS inpatient 77 50.05 SIHO - ALL PLANS SIHO - ALL PLANS 69.3 90 999999999 46.62 74.69 percent of total billed charges Body fluid pH level 872568_1 CDM 0301 RC 83986 HCPCS inpatient 77 50.05 UMR - ALL PLANS UMR - ALL PLANS 53.9 70 999999999 46.62 74.69 percent of total billed charges Body fluid pH level 872568_1 CDM 0301 RC 83986 HCPCS inpatient 77 50.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.62 60.55 999999999 46.62 74.69 percent of total billed charges Body fluid pH level 872568_1 CDM 0301 RC 83986 HCPCS inpatient 77 50.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.62 74.69 Body fluid pH level 872568_1 CDM 0301 RC 83986 HCPCS inpatient 77 50.05 ANTHEM HMO ANTHEM HMO 999999999 46.62 74.69 Body fluid pH level 872568_1 CDM 0301 RC 83986 HCPCS inpatient 77 50.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.62 74.69 Body fluid pH level 872568_1 CDM 0301 RC 83986 HCPCS inpatient 77 50.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.62 74.69 Body fluid pH level 872568_1 CDM 0301 RC 83986 HCPCS inpatient 77 50.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 52.05 67.6 999999999 46.62 74.69 percent of total billed charges Body fluid pH level 872568_1 CDM 0301 RC 83986 HCPCS inpatient 77 50.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.62 74.69 Measurement C-reactive protein for detection of infection or inflammation 8727051_1 CDM 0302 RC 86140 HCPCS inpatient 155 100.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.75 65 999999999 93.85 150.35 percent of total billed charges Measurement C-reactive protein for detection of infection or inflammation 8727051_1 CDM 0302 RC 86140 HCPCS inpatient 155 100.75 AETNA AETNA 122.45 79 999999999 93.85 150.35 percent of total billed charges Measurement C-reactive protein for detection of infection or inflammation 8727051_1 CDM 0302 RC 86140 HCPCS inpatient 155 100.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 150.35 97 999999999 93.85 150.35 percent of total billed charges Measurement C-reactive protein for detection of infection or inflammation 8727051_1 CDM 0302 RC 86140 HCPCS inpatient 155 100.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.9 78 999999999 93.85 150.35 percent of total billed charges Measurement C-reactive protein for detection of infection or inflammation 8727051_1 CDM 0302 RC 86140 HCPCS inpatient 155 100.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.95 69 999999999 93.85 150.35 percent of total billed charges Measurement C-reactive protein for detection of infection or inflammation 8727051_1 CDM 0302 RC 86140 HCPCS inpatient 155 100.75 SIHO - ALL PLANS SIHO - ALL PLANS 139.5 90 999999999 93.85 150.35 percent of total billed charges Measurement C-reactive protein for detection of infection or inflammation 8727051_1 CDM 0302 RC 86140 HCPCS inpatient 155 100.75 UMR - ALL PLANS UMR - ALL PLANS 108.5 70 999999999 93.85 150.35 percent of total billed charges Measurement C-reactive protein for detection of infection or inflammation 8727051_1 CDM 0302 RC 86140 HCPCS inpatient 155 100.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.85 60.55 999999999 93.85 150.35 percent of total billed charges Measurement C-reactive protein for detection of infection or inflammation 8727051_1 CDM 0302 RC 86140 HCPCS inpatient 155 100.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.85 150.35 Measurement C-reactive protein for detection of infection or inflammation 8727051_1 CDM 0302 RC 86140 HCPCS inpatient 155 100.75 ANTHEM HMO ANTHEM HMO 999999999 93.85 150.35 Measurement C-reactive protein for detection of infection or inflammation 8727051_1 CDM 0302 RC 86140 HCPCS inpatient 155 100.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.85 150.35 Measurement C-reactive protein for detection of infection or inflammation 8727051_1 CDM 0302 RC 86140 HCPCS inpatient 155 100.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.85 150.35 Measurement C-reactive protein for detection of infection or inflammation 8727051_1 CDM 0302 RC 86140 HCPCS inpatient 155 100.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.78 67.6 999999999 93.85 150.35 percent of total billed charges Measurement C-reactive protein for detection of infection or inflammation 8727051_1 CDM 0302 RC 86140 HCPCS inpatient 155 100.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.85 150.35 "Blood count, hemoglobin" 873001_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 52.65 65 999999999 49.05 78.57 percent of total billed charges "Blood count, hemoglobin" 873001_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 AETNA AETNA 63.99 79 999999999 49.05 78.57 percent of total billed charges "Blood count, hemoglobin" 873001_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78.57 97 999999999 49.05 78.57 percent of total billed charges "Blood count, hemoglobin" 873001_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 63.18 78 999999999 49.05 78.57 percent of total billed charges "Blood count, hemoglobin" 873001_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 55.89 69 999999999 49.05 78.57 percent of total billed charges "Blood count, hemoglobin" 873001_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 SIHO - ALL PLANS SIHO - ALL PLANS 72.9 90 999999999 49.05 78.57 percent of total billed charges "Blood count, hemoglobin" 873001_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 UMR - ALL PLANS UMR - ALL PLANS 56.7 70 999999999 49.05 78.57 percent of total billed charges "Blood count, hemoglobin" 873001_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 49.05 60.55 999999999 49.05 78.57 percent of total billed charges "Blood count, hemoglobin" 873001_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 49.05 78.57 "Blood count, hemoglobin" 873001_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 ANTHEM HMO ANTHEM HMO 999999999 49.05 78.57 "Blood count, hemoglobin" 873001_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 49.05 78.57 "Blood count, hemoglobin" 873001_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 49.05 78.57 "Blood count, hemoglobin" 873001_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 54.76 67.6 999999999 49.05 78.57 percent of total billed charges "Blood count, hemoglobin" 873001_1 CDM 0305 RC 85018 HCPCS inpatient 81 52.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 49.05 78.57 Red blood cell concentration measurement 873002_1 CDM 0305 RC 85014 HCPCS inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges Red blood cell concentration measurement 873002_1 CDM 0305 RC 85014 HCPCS inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges Red blood cell concentration measurement 873002_1 CDM 0305 RC 85014 HCPCS inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges Red blood cell concentration measurement 873002_1 CDM 0305 RC 85014 HCPCS inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges Red blood cell concentration measurement 873002_1 CDM 0305 RC 85014 HCPCS inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges Red blood cell concentration measurement 873002_1 CDM 0305 RC 85014 HCPCS inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges Red blood cell concentration measurement 873002_1 CDM 0305 RC 85014 HCPCS inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges Red blood cell concentration measurement 873002_1 CDM 0305 RC 85014 HCPCS inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges Red blood cell concentration measurement 873002_1 CDM 0305 RC 85014 HCPCS inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 Red blood cell concentration measurement 873002_1 CDM 0305 RC 85014 HCPCS inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 Red blood cell concentration measurement 873002_1 CDM 0305 RC 85014 HCPCS inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 Red blood cell concentration measurement 873002_1 CDM 0305 RC 85014 HCPCS inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 Red blood cell concentration measurement 873002_1 CDM 0305 RC 85014 HCPCS inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges Red blood cell concentration measurement 873002_1 CDM 0305 RC 85014 HCPCS inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA) 8766947_1 CDM 0300 RC G0103 HCPCS inpatient 311 202.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 202.15 65 999999999 188.31 301.67 percent of total billed charges PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA) 8766947_1 CDM 0300 RC G0103 HCPCS inpatient 311 202.15 AETNA AETNA 245.69 79 999999999 188.31 301.67 percent of total billed charges PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA) 8766947_1 CDM 0300 RC G0103 HCPCS inpatient 311 202.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 301.67 97 999999999 188.31 301.67 percent of total billed charges PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA) 8766947_1 CDM 0300 RC G0103 HCPCS inpatient 311 202.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 242.58 78 999999999 188.31 301.67 percent of total billed charges PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA) 8766947_1 CDM 0300 RC G0103 HCPCS inpatient 311 202.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 214.59 69 999999999 188.31 301.67 percent of total billed charges PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA) 8766947_1 CDM 0300 RC G0103 HCPCS inpatient 311 202.15 SIHO - ALL PLANS SIHO - ALL PLANS 279.9 90 999999999 188.31 301.67 percent of total billed charges PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA) 8766947_1 CDM 0300 RC G0103 HCPCS inpatient 311 202.15 UMR - ALL PLANS UMR - ALL PLANS 217.7 70 999999999 188.31 301.67 percent of total billed charges PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA) 8766947_1 CDM 0300 RC G0103 HCPCS inpatient 311 202.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 188.31 60.55 999999999 188.31 301.67 percent of total billed charges PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA) 8766947_1 CDM 0300 RC G0103 HCPCS inpatient 311 202.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 188.31 301.67 PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA) 8766947_1 CDM 0300 RC G0103 HCPCS inpatient 311 202.15 ANTHEM HMO ANTHEM HMO 999999999 188.31 301.67 PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA) 8766947_1 CDM 0300 RC G0103 HCPCS inpatient 311 202.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 188.31 301.67 PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA) 8766947_1 CDM 0300 RC G0103 HCPCS inpatient 311 202.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 188.31 301.67 PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA) 8766947_1 CDM 0300 RC G0103 HCPCS inpatient 311 202.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 210.24 67.6 999999999 188.31 301.67 percent of total billed charges PROSTATE CANCER SCREENING; PROSTATE SPECIFIC ANTIGEN TEST (PSA) 8766947_1 CDM 0300 RC G0103 HCPCS inpatient 311 202.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 188.31 301.67 Analysis for antibody to Rubella (German measles virus) 8766948_1 CDM 0302 RC 86762 HCPCS inpatient 109 70.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 70.85 65 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 8766948_1 CDM 0302 RC 86762 HCPCS inpatient 109 70.85 AETNA AETNA 86.11 79 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 8766948_1 CDM 0302 RC 86762 HCPCS inpatient 109 70.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 105.73 97 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 8766948_1 CDM 0302 RC 86762 HCPCS inpatient 109 70.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 85.02 78 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 8766948_1 CDM 0302 RC 86762 HCPCS inpatient 109 70.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 75.21 69 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 8766948_1 CDM 0302 RC 86762 HCPCS inpatient 109 70.85 SIHO - ALL PLANS SIHO - ALL PLANS 98.1 90 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 8766948_1 CDM 0302 RC 86762 HCPCS inpatient 109 70.85 UMR - ALL PLANS UMR - ALL PLANS 76.3 70 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 8766948_1 CDM 0302 RC 86762 HCPCS inpatient 109 70.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 66 60.55 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 8766948_1 CDM 0302 RC 86762 HCPCS inpatient 109 70.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 66 105.73 Analysis for antibody to Rubella (German measles virus) 8766948_1 CDM 0302 RC 86762 HCPCS inpatient 109 70.85 ANTHEM HMO ANTHEM HMO 999999999 66 105.73 Analysis for antibody to Rubella (German measles virus) 8766948_1 CDM 0302 RC 86762 HCPCS inpatient 109 70.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 66 105.73 Analysis for antibody to Rubella (German measles virus) 8766948_1 CDM 0302 RC 86762 HCPCS inpatient 109 70.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 66 105.73 Analysis for antibody to Rubella (German measles virus) 8766948_1 CDM 0302 RC 86762 HCPCS inpatient 109 70.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 73.68 67.6 999999999 66 105.73 percent of total billed charges Analysis for antibody to Rubella (German measles virus) 8766948_1 CDM 0302 RC 86762 HCPCS inpatient 109 70.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 66 105.73 Moderate Sedation 884755_1 CDM 0370 RC inpatient 477 310.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 310.05 65 999999999 288.82 462.69 percent of total billed charges Moderate Sedation 884755_1 CDM 0370 RC inpatient 477 310.05 AETNA AETNA 376.83 79 999999999 288.82 462.69 percent of total billed charges Moderate Sedation 884755_1 CDM 0370 RC inpatient 477 310.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 462.69 97 999999999 288.82 462.69 percent of total billed charges Moderate Sedation 884755_1 CDM 0370 RC inpatient 477 310.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 329.13 69 999999999 288.82 462.69 percent of total billed charges Moderate Sedation 884755_1 CDM 0370 RC inpatient 477 310.05 SIHO - ALL PLANS SIHO - ALL PLANS 429.3 90 999999999 288.82 462.69 percent of total billed charges Moderate Sedation 884755_1 CDM 0370 RC inpatient 477 310.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 372.06 78 999999999 288.82 462.69 percent of total billed charges Moderate Sedation 884755_1 CDM 0370 RC inpatient 477 310.05 UMR - ALL PLANS UMR - ALL PLANS 333.9 70 999999999 288.82 462.69 percent of total billed charges Moderate Sedation 884755_1 CDM 0370 RC inpatient 477 310.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 288.82 60.55 999999999 288.82 462.69 percent of total billed charges Moderate Sedation 884755_1 CDM 0370 RC inpatient 477 310.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 288.82 462.69 Moderate Sedation 884755_1 CDM 0370 RC inpatient 477 310.05 ANTHEM HMO ANTHEM HMO 999999999 288.82 462.69 Moderate Sedation 884755_1 CDM 0370 RC inpatient 477 310.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 288.82 462.69 Moderate Sedation 884755_1 CDM 0370 RC inpatient 477 310.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 288.82 462.69 Moderate Sedation 884755_1 CDM 0370 RC inpatient 477 310.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 322.45 67.6 999999999 288.82 462.69 percent of total billed charges Moderate Sedation 884755_1 CDM 0370 RC inpatient 477 310.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 288.82 462.69 Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 8856230_1 CDM 0450 RC 64447 HCPCS inpatient 795 516.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 516.75 65 999999999 481.37 771.15 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 8856230_1 CDM 0450 RC 64447 HCPCS inpatient 795 516.75 AETNA AETNA 628.05 79 999999999 481.37 771.15 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 8856230_1 CDM 0450 RC 64447 HCPCS inpatient 795 516.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 771.15 97 999999999 481.37 771.15 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 8856230_1 CDM 0450 RC 64447 HCPCS inpatient 795 516.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 548.55 69 999999999 481.37 771.15 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 8856230_1 CDM 0450 RC 64447 HCPCS inpatient 795 516.75 SIHO - ALL PLANS SIHO - ALL PLANS 715.5 90 999999999 481.37 771.15 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 8856230_1 CDM 0450 RC 64447 HCPCS inpatient 795 516.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 620.1 78 999999999 481.37 771.15 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 8856230_1 CDM 0450 RC 64447 HCPCS inpatient 795 516.75 UMR - ALL PLANS UMR - ALL PLANS 556.5 70 999999999 481.37 771.15 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 8856230_1 CDM 0450 RC 64447 HCPCS inpatient 795 516.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 481.37 60.55 999999999 481.37 771.15 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 8856230_1 CDM 0450 RC 64447 HCPCS inpatient 795 516.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 481.37 771.15 Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 8856230_1 CDM 0450 RC 64447 HCPCS inpatient 795 516.75 ANTHEM HMO ANTHEM HMO 999999999 481.37 771.15 Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 8856230_1 CDM 0450 RC 64447 HCPCS inpatient 795 516.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 481.37 771.15 Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 8856230_1 CDM 0450 RC 64447 HCPCS inpatient 795 516.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 481.37 771.15 Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 8856230_1 CDM 0450 RC 64447 HCPCS inpatient 795 516.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 537.42 67.6 999999999 481.37 771.15 percent of total billed charges Injection of anesthetic agent and/or steroid into thigh nerve (femoral nerve) 8856230_1 CDM 0450 RC 64447 HCPCS inpatient 795 516.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 481.37 771.15 Vancomycin (antibiotic) level 8869253_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 131.3 65 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 8869253_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 AETNA AETNA 159.58 79 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 8869253_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 195.94 97 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 8869253_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 139.38 69 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 8869253_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 SIHO - ALL PLANS SIHO - ALL PLANS 181.8 90 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 8869253_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 157.56 78 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 8869253_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 UMR - ALL PLANS UMR - ALL PLANS 141.4 70 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 8869253_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 122.31 60.55 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 8869253_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 122.31 195.94 Vancomycin (antibiotic) level 8869253_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ANTHEM HMO ANTHEM HMO 999999999 122.31 195.94 Vancomycin (antibiotic) level 8869253_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 122.31 195.94 Vancomycin (antibiotic) level 8869253_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 122.31 195.94 Vancomycin (antibiotic) level 8869253_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 136.55 67.6 999999999 122.31 195.94 percent of total billed charges Vancomycin (antibiotic) level 8869253_1 CDM 0301 RC 80202 HCPCS inpatient 202 131.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 122.31 195.94 Tobramycin (antibiotic) level 8869256_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 213.2 65 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 8869256_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 AETNA AETNA 259.12 79 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 8869256_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 318.16 97 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 8869256_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 226.32 69 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 8869256_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 SIHO - ALL PLANS SIHO - ALL PLANS 295.2 90 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 8869256_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 255.84 78 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 8869256_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 UMR - ALL PLANS UMR - ALL PLANS 229.6 70 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 8869256_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 198.6 60.55 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 8869256_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 198.6 318.16 Tobramycin (antibiotic) level 8869256_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM HMO ANTHEM HMO 999999999 198.6 318.16 Tobramycin (antibiotic) level 8869256_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 198.6 318.16 Tobramycin (antibiotic) level 8869256_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 198.6 318.16 Tobramycin (antibiotic) level 8869256_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 221.73 67.6 999999999 198.6 318.16 percent of total billed charges Tobramycin (antibiotic) level 8869256_1 CDM 0301 RC 80200 HCPCS inpatient 328 213.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 198.6 318.16 LABOR ROOM/DELIVERY - CIRCUMCISION 8973572_1 CDM 0723 RC inpatient 448 291.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 291.2 65 999999999 271.26 434.56 percent of total billed charges LABOR ROOM/DELIVERY - CIRCUMCISION 8973572_1 CDM 0723 RC inpatient 448 291.2 AETNA AETNA 353.92 79 999999999 271.26 434.56 percent of total billed charges LABOR ROOM/DELIVERY - CIRCUMCISION 8973572_1 CDM 0723 RC inpatient 448 291.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 434.56 97 999999999 271.26 434.56 percent of total billed charges LABOR ROOM/DELIVERY - CIRCUMCISION 8973572_1 CDM 0723 RC inpatient 448 291.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 309.12 69 999999999 271.26 434.56 percent of total billed charges LABOR ROOM/DELIVERY - CIRCUMCISION 8973572_1 CDM 0723 RC inpatient 448 291.2 SIHO - ALL PLANS SIHO - ALL PLANS 403.2 90 999999999 271.26 434.56 percent of total billed charges LABOR ROOM/DELIVERY - CIRCUMCISION 8973572_1 CDM 0723 RC inpatient 448 291.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 349.44 78 999999999 271.26 434.56 percent of total billed charges LABOR ROOM/DELIVERY - CIRCUMCISION 8973572_1 CDM 0723 RC inpatient 448 291.2 UMR - ALL PLANS UMR - ALL PLANS 313.6 70 999999999 271.26 434.56 percent of total billed charges LABOR ROOM/DELIVERY - CIRCUMCISION 8973572_1 CDM 0723 RC inpatient 448 291.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 271.26 60.55 999999999 271.26 434.56 percent of total billed charges LABOR ROOM/DELIVERY - CIRCUMCISION 8973572_1 CDM 0723 RC inpatient 448 291.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 271.26 434.56 LABOR ROOM/DELIVERY - CIRCUMCISION 8973572_1 CDM 0723 RC inpatient 448 291.2 ANTHEM HMO ANTHEM HMO 999999999 271.26 434.56 LABOR ROOM/DELIVERY - CIRCUMCISION 8973572_1 CDM 0723 RC inpatient 448 291.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 271.26 434.56 LABOR ROOM/DELIVERY - CIRCUMCISION 8973572_1 CDM 0723 RC inpatient 448 291.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 271.26 434.56 LABOR ROOM/DELIVERY - CIRCUMCISION 8973572_1 CDM 0723 RC inpatient 448 291.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 302.85 67.6 999999999 271.26 434.56 percent of total billed charges LABOR ROOM/DELIVERY - CIRCUMCISION 8973572_1 CDM 0723 RC inpatient 448 291.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 271.26 434.56 "Test or measurement for functional capacity, each 15 minutes" 8985354_1 CDM 0420 RC 97750 HCPCS inpatient 1504 977.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 977.6 65 999999999 910.67 1458.88 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 8985354_1 CDM 0420 RC 97750 HCPCS inpatient 1504 977.6 AETNA AETNA 1188.16 79 999999999 910.67 1458.88 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 8985354_1 CDM 0420 RC 97750 HCPCS inpatient 1504 977.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1458.88 97 999999999 910.67 1458.88 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 8985354_1 CDM 0420 RC 97750 HCPCS inpatient 1504 977.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1037.76 69 999999999 910.67 1458.88 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 8985354_1 CDM 0420 RC 97750 HCPCS inpatient 1504 977.6 SIHO - ALL PLANS SIHO - ALL PLANS 1353.6 90 999999999 910.67 1458.88 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 8985354_1 CDM 0420 RC 97750 HCPCS inpatient 1504 977.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1173.12 78 999999999 910.67 1458.88 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 8985354_1 CDM 0420 RC 97750 HCPCS inpatient 1504 977.6 UMR - ALL PLANS UMR - ALL PLANS 1052.8 70 999999999 910.67 1458.88 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 8985354_1 CDM 0420 RC 97750 HCPCS inpatient 1504 977.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 910.67 60.55 999999999 910.67 1458.88 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 8985354_1 CDM 0420 RC 97750 HCPCS inpatient 1504 977.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 910.67 1458.88 "Test or measurement for functional capacity, each 15 minutes" 8985354_1 CDM 0420 RC 97750 HCPCS inpatient 1504 977.6 ANTHEM HMO ANTHEM HMO 999999999 910.67 1458.88 "Test or measurement for functional capacity, each 15 minutes" 8985354_1 CDM 0420 RC 97750 HCPCS inpatient 1504 977.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 910.67 1458.88 "Test or measurement for functional capacity, each 15 minutes" 8985354_1 CDM 0420 RC 97750 HCPCS inpatient 1504 977.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 910.67 1458.88 "Test or measurement for functional capacity, each 15 minutes" 8985354_1 CDM 0420 RC 97750 HCPCS inpatient 1504 977.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1016.7 67.6 999999999 910.67 1458.88 percent of total billed charges "Test or measurement for functional capacity, each 15 minutes" 8985354_1 CDM 0420 RC 97750 HCPCS inpatient 1504 977.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 910.67 1458.88 Test to assess the ability to complete specific functional tasks applicable to environment 8985366_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 243.1 65 999999999 226.46 362.78 percent of total billed charges Test to assess the ability to complete specific functional tasks applicable to environment 8985366_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 AETNA AETNA 295.46 79 999999999 226.46 362.78 percent of total billed charges Test to assess the ability to complete specific functional tasks applicable to environment 8985366_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 362.78 97 999999999 226.46 362.78 percent of total billed charges Test to assess the ability to complete specific functional tasks applicable to environment 8985366_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 258.06 69 999999999 226.46 362.78 percent of total billed charges Test to assess the ability to complete specific functional tasks applicable to environment 8985366_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 SIHO - ALL PLANS SIHO - ALL PLANS 336.6 90 999999999 226.46 362.78 percent of total billed charges Test to assess the ability to complete specific functional tasks applicable to environment 8985366_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 291.72 78 999999999 226.46 362.78 percent of total billed charges Test to assess the ability to complete specific functional tasks applicable to environment 8985366_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 UMR - ALL PLANS UMR - ALL PLANS 261.8 70 999999999 226.46 362.78 percent of total billed charges Test to assess the ability to complete specific functional tasks applicable to environment 8985366_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 226.46 60.55 999999999 226.46 362.78 percent of total billed charges Test to assess the ability to complete specific functional tasks applicable to environment 8985366_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 226.46 362.78 Test to assess the ability to complete specific functional tasks applicable to environment 8985366_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 ANTHEM HMO ANTHEM HMO 999999999 226.46 362.78 Test to assess the ability to complete specific functional tasks applicable to environment 8985366_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 226.46 362.78 Test to assess the ability to complete specific functional tasks applicable to environment 8985366_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 226.46 362.78 Test to assess the ability to complete specific functional tasks applicable to environment 8985366_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 252.82 67.6 999999999 226.46 362.78 percent of total billed charges Test to assess the ability to complete specific functional tasks applicable to environment 8985366_1 CDM 0440 RC 96125 HCPCS inpatient 374 243.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 226.46 362.78 Test to measure oxygen level in blood using ear or finger device continuously overnight 8985367_1 CDM 0460 RC 94762 HCPCS inpatient 452 293.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 293.8 65 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 8985367_1 CDM 0460 RC 94762 HCPCS inpatient 452 293.8 AETNA AETNA 357.08 79 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 8985367_1 CDM 0460 RC 94762 HCPCS inpatient 452 293.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 438.44 97 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 8985367_1 CDM 0460 RC 94762 HCPCS inpatient 452 293.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 311.88 69 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 8985367_1 CDM 0460 RC 94762 HCPCS inpatient 452 293.8 SIHO - ALL PLANS SIHO - ALL PLANS 406.8 90 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 8985367_1 CDM 0460 RC 94762 HCPCS inpatient 452 293.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 352.56 78 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 8985367_1 CDM 0460 RC 94762 HCPCS inpatient 452 293.8 UMR - ALL PLANS UMR - ALL PLANS 316.4 70 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 8985367_1 CDM 0460 RC 94762 HCPCS inpatient 452 293.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 273.69 60.55 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 8985367_1 CDM 0460 RC 94762 HCPCS inpatient 452 293.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 273.69 438.44 Test to measure oxygen level in blood using ear or finger device continuously overnight 8985367_1 CDM 0460 RC 94762 HCPCS inpatient 452 293.8 ANTHEM HMO ANTHEM HMO 999999999 273.69 438.44 Test to measure oxygen level in blood using ear or finger device continuously overnight 8985367_1 CDM 0460 RC 94762 HCPCS inpatient 452 293.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 273.69 438.44 Test to measure oxygen level in blood using ear or finger device continuously overnight 8985367_1 CDM 0460 RC 94762 HCPCS inpatient 452 293.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 273.69 438.44 Test to measure oxygen level in blood using ear or finger device continuously overnight 8985367_1 CDM 0460 RC 94762 HCPCS inpatient 452 293.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 305.55 67.6 999999999 273.69 438.44 percent of total billed charges Test to measure oxygen level in blood using ear or finger device continuously overnight 8985367_1 CDM 0460 RC 94762 HCPCS inpatient 452 293.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 273.69 438.44 Test to measure oxygen level in blood using ear or finger device 8985368_1 CDM 0460 RC 94760 HCPCS inpatient 68 44.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 44.2 65 999999999 41.17 65.96 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 8985368_1 CDM 0460 RC 94760 HCPCS inpatient 68 44.2 AETNA AETNA 53.72 79 999999999 41.17 65.96 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 8985368_1 CDM 0460 RC 94760 HCPCS inpatient 68 44.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 65.96 97 999999999 41.17 65.96 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 8985368_1 CDM 0460 RC 94760 HCPCS inpatient 68 44.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 46.92 69 999999999 41.17 65.96 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 8985368_1 CDM 0460 RC 94760 HCPCS inpatient 68 44.2 SIHO - ALL PLANS SIHO - ALL PLANS 61.2 90 999999999 41.17 65.96 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 8985368_1 CDM 0460 RC 94760 HCPCS inpatient 68 44.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 53.04 78 999999999 41.17 65.96 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 8985368_1 CDM 0460 RC 94760 HCPCS inpatient 68 44.2 UMR - ALL PLANS UMR - ALL PLANS 47.6 70 999999999 41.17 65.96 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 8985368_1 CDM 0460 RC 94760 HCPCS inpatient 68 44.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41.17 60.55 999999999 41.17 65.96 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 8985368_1 CDM 0460 RC 94760 HCPCS inpatient 68 44.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 41.17 65.96 Test to measure oxygen level in blood using ear or finger device 8985368_1 CDM 0460 RC 94760 HCPCS inpatient 68 44.2 ANTHEM HMO ANTHEM HMO 999999999 41.17 65.96 Test to measure oxygen level in blood using ear or finger device 8985368_1 CDM 0460 RC 94760 HCPCS inpatient 68 44.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 41.17 65.96 Test to measure oxygen level in blood using ear or finger device 8985368_1 CDM 0460 RC 94760 HCPCS inpatient 68 44.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 41.17 65.96 Test to measure oxygen level in blood using ear or finger device 8985368_1 CDM 0460 RC 94760 HCPCS inpatient 68 44.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 45.97 67.6 999999999 41.17 65.96 percent of total billed charges Test to measure oxygen level in blood using ear or finger device 8985368_1 CDM 0460 RC 94760 HCPCS inpatient 68 44.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 41.17 65.96 "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006953_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 69.55 65 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006953_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 AETNA AETNA 84.53 79 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006953_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 103.79 97 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006953_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 73.83 69 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006953_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 SIHO - ALL PLANS SIHO - ALL PLANS 96.3 90 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006953_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 83.46 78 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006953_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 UMR - ALL PLANS UMR - ALL PLANS 74.9 70 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006953_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 64.79 60.55 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006953_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006953_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM HMO ANTHEM HMO 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006953_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006953_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006953_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 72.33 67.6 999999999 64.79 103.79 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006953_1 CDM 0306 RC 87070 HCPCS inpatient 107 69.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 64.79 103.79 "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006954_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 SELF PAY DISCOUNT SELF PAY DISCOUNT 65 65 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006954_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 AETNA AETNA 79 79 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006954_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97 97 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006954_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ENCORE - ALL PLANS ENCORE - ALL PLANS 69 69 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006954_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 SIHO - ALL PLANS SIHO - ALL PLANS 90 90 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006954_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 HUMANA - ALL PLANS HUMANA - ALL PLANS 78 78 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006954_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 UMR - ALL PLANS UMR - ALL PLANS 70 70 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006954_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60.55 60.55 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006954_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 60.55 97 "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006954_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ANTHEM HMO ANTHEM HMO 999999999 60.55 97 "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006954_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 60.55 97 "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006954_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 60.55 97 "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006954_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 CIGNA - ALL PLANS CIGNA - ALL PLANS 67.6 67.6 999999999 60.55 97 percent of total billed charges "Bacterial culture, any other source except urine, blood or stool, aerobic" 9006954_1 CDM 0306 RC 87070 HCPCS inpatient 100 65 UHC - ALL PLANS UHC - ALL PLANS 999999999 60.55 97 Blood glucose (sugar) level 904677_1 CDM 0301 RC 82947 HCPCS inpatient 88 57.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 57.2 65 999999999 53.28 85.36 percent of total billed charges Blood glucose (sugar) level 904677_1 CDM 0301 RC 82947 HCPCS inpatient 88 57.2 AETNA AETNA 69.52 79 999999999 53.28 85.36 percent of total billed charges Blood glucose (sugar) level 904677_1 CDM 0301 RC 82947 HCPCS inpatient 88 57.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 85.36 97 999999999 53.28 85.36 percent of total billed charges Blood glucose (sugar) level 904677_1 CDM 0301 RC 82947 HCPCS inpatient 88 57.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 60.72 69 999999999 53.28 85.36 percent of total billed charges Blood glucose (sugar) level 904677_1 CDM 0301 RC 82947 HCPCS inpatient 88 57.2 SIHO - ALL PLANS SIHO - ALL PLANS 79.2 90 999999999 53.28 85.36 percent of total billed charges Blood glucose (sugar) level 904677_1 CDM 0301 RC 82947 HCPCS inpatient 88 57.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 68.64 78 999999999 53.28 85.36 percent of total billed charges Blood glucose (sugar) level 904677_1 CDM 0301 RC 82947 HCPCS inpatient 88 57.2 UMR - ALL PLANS UMR - ALL PLANS 61.6 70 999999999 53.28 85.36 percent of total billed charges Blood glucose (sugar) level 904677_1 CDM 0301 RC 82947 HCPCS inpatient 88 57.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53.28 60.55 999999999 53.28 85.36 percent of total billed charges Blood glucose (sugar) level 904677_1 CDM 0301 RC 82947 HCPCS inpatient 88 57.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 53.28 85.36 Blood glucose (sugar) level 904677_1 CDM 0301 RC 82947 HCPCS inpatient 88 57.2 ANTHEM HMO ANTHEM HMO 999999999 53.28 85.36 Blood glucose (sugar) level 904677_1 CDM 0301 RC 82947 HCPCS inpatient 88 57.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 53.28 85.36 Blood glucose (sugar) level 904677_1 CDM 0301 RC 82947 HCPCS inpatient 88 57.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 53.28 85.36 Blood glucose (sugar) level 904677_1 CDM 0301 RC 82947 HCPCS inpatient 88 57.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 59.49 67.6 999999999 53.28 85.36 percent of total billed charges Blood glucose (sugar) level 904677_1 CDM 0301 RC 82947 HCPCS inpatient 88 57.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 53.28 85.36 Semen analysis for sperm presence 914892_1 CDM 0309 RC 89321 HCPCS inpatient 133 86.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 86.45 65 999999999 80.53 129.01 percent of total billed charges Semen analysis for sperm presence 914892_1 CDM 0309 RC 89321 HCPCS inpatient 133 86.45 AETNA AETNA 105.07 79 999999999 80.53 129.01 percent of total billed charges Semen analysis for sperm presence 914892_1 CDM 0309 RC 89321 HCPCS inpatient 133 86.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 129.01 97 999999999 80.53 129.01 percent of total billed charges Semen analysis for sperm presence 914892_1 CDM 0309 RC 89321 HCPCS inpatient 133 86.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 91.77 69 999999999 80.53 129.01 percent of total billed charges Semen analysis for sperm presence 914892_1 CDM 0309 RC 89321 HCPCS inpatient 133 86.45 SIHO - ALL PLANS SIHO - ALL PLANS 119.7 90 999999999 80.53 129.01 percent of total billed charges Semen analysis for sperm presence 914892_1 CDM 0309 RC 89321 HCPCS inpatient 133 86.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 103.74 78 999999999 80.53 129.01 percent of total billed charges Semen analysis for sperm presence 914892_1 CDM 0309 RC 89321 HCPCS inpatient 133 86.45 UMR - ALL PLANS UMR - ALL PLANS 93.1 70 999999999 80.53 129.01 percent of total billed charges Semen analysis for sperm presence 914892_1 CDM 0309 RC 89321 HCPCS inpatient 133 86.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 80.53 60.55 999999999 80.53 129.01 percent of total billed charges Semen analysis for sperm presence 914892_1 CDM 0309 RC 89321 HCPCS inpatient 133 86.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 80.53 129.01 Semen analysis for sperm presence 914892_1 CDM 0309 RC 89321 HCPCS inpatient 133 86.45 ANTHEM HMO ANTHEM HMO 999999999 80.53 129.01 Semen analysis for sperm presence 914892_1 CDM 0309 RC 89321 HCPCS inpatient 133 86.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 80.53 129.01 Semen analysis for sperm presence 914892_1 CDM 0309 RC 89321 HCPCS inpatient 133 86.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 80.53 129.01 Semen analysis for sperm presence 914892_1 CDM 0309 RC 89321 HCPCS inpatient 133 86.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 89.91 67.6 999999999 80.53 129.01 percent of total billed charges Semen analysis for sperm presence 914892_1 CDM 0309 RC 89321 HCPCS inpatient 133 86.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 80.53 129.01 CT scan head or brain without contrast 9189794_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 1364.35 65 999999999 1270.94 2036.03 percent of total billed charges CT scan head or brain without contrast 9189794_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 AETNA AETNA 1658.21 79 999999999 1270.94 2036.03 percent of total billed charges CT scan head or brain without contrast 9189794_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2036.03 97 999999999 1270.94 2036.03 percent of total billed charges CT scan head or brain without contrast 9189794_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 1448.31 69 999999999 1270.94 2036.03 percent of total billed charges CT scan head or brain without contrast 9189794_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 SIHO - ALL PLANS SIHO - ALL PLANS 1889.1 90 999999999 1270.94 2036.03 percent of total billed charges CT scan head or brain without contrast 9189794_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 1637.22 78 999999999 1270.94 2036.03 percent of total billed charges CT scan head or brain without contrast 9189794_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 UMR - ALL PLANS UMR - ALL PLANS 1469.3 70 999999999 1270.94 2036.03 percent of total billed charges CT scan head or brain without contrast 9189794_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1270.94 60.55 999999999 1270.94 2036.03 percent of total billed charges CT scan head or brain without contrast 9189794_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1270.94 2036.03 CT scan head or brain without contrast 9189794_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 ANTHEM HMO ANTHEM HMO 999999999 1270.94 2036.03 CT scan head or brain without contrast 9189794_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1270.94 2036.03 CT scan head or brain without contrast 9189794_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1270.94 2036.03 CT scan head or brain without contrast 9189794_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 1418.92 67.6 999999999 1270.94 2036.03 percent of total billed charges CT scan head or brain without contrast 9189794_1 CDM 0351 RC 70450 HCPCS inpatient 2099 1364.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 1270.94 2036.03 CT scan of abdomen and pelvis with contrast 9189812_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 SELF PAY DISCOUNT SELF PAY DISCOUNT 2626 65 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 9189812_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 AETNA AETNA 3191.6 79 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 9189812_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3918.8 97 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 9189812_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 ENCORE - ALL PLANS ENCORE - ALL PLANS 2787.6 69 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 9189812_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 SIHO - ALL PLANS SIHO - ALL PLANS 3636 90 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 9189812_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 HUMANA - ALL PLANS HUMANA - ALL PLANS 3151.2 78 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 9189812_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 UMR - ALL PLANS UMR - ALL PLANS 2828 70 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 9189812_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2446.22 60.55 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 9189812_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2446.22 3918.8 CT scan of abdomen and pelvis with contrast 9189812_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 ANTHEM HMO ANTHEM HMO 999999999 2446.22 3918.8 CT scan of abdomen and pelvis with contrast 9189812_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2446.22 3918.8 CT scan of abdomen and pelvis with contrast 9189812_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2446.22 3918.8 CT scan of abdomen and pelvis with contrast 9189812_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 CIGNA - ALL PLANS CIGNA - ALL PLANS 2731.04 67.6 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 9189812_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 UHC - ALL PLANS UHC - ALL PLANS 999999999 2446.22 3918.8 CT scan of cranial cavity before and after contrast 9189836_1 CDM 0351 RC 70482 HCPCS inpatient 2564 1666.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1666.6 65 999999999 1552.5 2487.08 percent of total billed charges CT scan of cranial cavity before and after contrast 9189836_1 CDM 0351 RC 70482 HCPCS inpatient 2564 1666.6 AETNA AETNA 2025.56 79 999999999 1552.5 2487.08 percent of total billed charges CT scan of cranial cavity before and after contrast 9189836_1 CDM 0351 RC 70482 HCPCS inpatient 2564 1666.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2487.08 97 999999999 1552.5 2487.08 percent of total billed charges CT scan of cranial cavity before and after contrast 9189836_1 CDM 0351 RC 70482 HCPCS inpatient 2564 1666.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1769.16 69 999999999 1552.5 2487.08 percent of total billed charges CT scan of cranial cavity before and after contrast 9189836_1 CDM 0351 RC 70482 HCPCS inpatient 2564 1666.6 SIHO - ALL PLANS SIHO - ALL PLANS 2307.6 90 999999999 1552.5 2487.08 percent of total billed charges CT scan of cranial cavity before and after contrast 9189836_1 CDM 0351 RC 70482 HCPCS inpatient 2564 1666.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 1999.92 78 999999999 1552.5 2487.08 percent of total billed charges CT scan of cranial cavity before and after contrast 9189836_1 CDM 0351 RC 70482 HCPCS inpatient 2564 1666.6 UMR - ALL PLANS UMR - ALL PLANS 1794.8 70 999999999 1552.5 2487.08 percent of total billed charges CT scan of cranial cavity before and after contrast 9189836_1 CDM 0351 RC 70482 HCPCS inpatient 2564 1666.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1552.5 60.55 999999999 1552.5 2487.08 percent of total billed charges CT scan of cranial cavity before and after contrast 9189836_1 CDM 0351 RC 70482 HCPCS inpatient 2564 1666.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1552.5 2487.08 CT scan of cranial cavity before and after contrast 9189836_1 CDM 0351 RC 70482 HCPCS inpatient 2564 1666.6 ANTHEM HMO ANTHEM HMO 999999999 1552.5 2487.08 CT scan of cranial cavity before and after contrast 9189836_1 CDM 0351 RC 70482 HCPCS inpatient 2564 1666.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1552.5 2487.08 CT scan of cranial cavity before and after contrast 9189836_1 CDM 0351 RC 70482 HCPCS inpatient 2564 1666.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1552.5 2487.08 CT scan of cranial cavity before and after contrast 9189836_1 CDM 0351 RC 70482 HCPCS inpatient 2564 1666.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1733.26 67.6 999999999 1552.5 2487.08 percent of total billed charges CT scan of cranial cavity before and after contrast 9189836_1 CDM 0351 RC 70482 HCPCS inpatient 2564 1666.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1552.5 2487.08 CT scan of cranial cavity before and after contrast 9189848_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1665.95 65 999999999 1551.9 2486.11 percent of total billed charges CT scan of cranial cavity before and after contrast 9189848_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 AETNA AETNA 2024.77 79 999999999 1551.9 2486.11 percent of total billed charges CT scan of cranial cavity before and after contrast 9189848_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2486.11 97 999999999 1551.9 2486.11 percent of total billed charges CT scan of cranial cavity before and after contrast 9189848_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1768.47 69 999999999 1551.9 2486.11 percent of total billed charges CT scan of cranial cavity before and after contrast 9189848_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 SIHO - ALL PLANS SIHO - ALL PLANS 2306.7 90 999999999 1551.9 2486.11 percent of total billed charges CT scan of cranial cavity before and after contrast 9189848_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1999.14 78 999999999 1551.9 2486.11 percent of total billed charges CT scan of cranial cavity before and after contrast 9189848_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 UMR - ALL PLANS UMR - ALL PLANS 1794.1 70 999999999 1551.9 2486.11 percent of total billed charges CT scan of cranial cavity before and after contrast 9189848_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1551.9 60.55 999999999 1551.9 2486.11 percent of total billed charges CT scan of cranial cavity before and after contrast 9189848_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1551.9 2486.11 CT scan of cranial cavity before and after contrast 9189848_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 ANTHEM HMO ANTHEM HMO 999999999 1551.9 2486.11 CT scan of cranial cavity before and after contrast 9189848_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1551.9 2486.11 CT scan of cranial cavity before and after contrast 9189848_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1551.9 2486.11 CT scan of cranial cavity before and after contrast 9189848_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1732.59 67.6 999999999 1551.9 2486.11 percent of total billed charges CT scan of cranial cavity before and after contrast 9189848_1 CDM 0351 RC 70482 HCPCS inpatient 2563 1665.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1551.9 2486.11 CT scan of cranial cavity without contrast 9189854_1 CDM 0351 RC 70480 HCPCS inpatient 2107 1369.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 1369.55 65 999999999 1275.79 2043.79 percent of total billed charges CT scan of cranial cavity without contrast 9189854_1 CDM 0351 RC 70480 HCPCS inpatient 2107 1369.55 AETNA AETNA 1664.53 79 999999999 1275.79 2043.79 percent of total billed charges CT scan of cranial cavity without contrast 9189854_1 CDM 0351 RC 70480 HCPCS inpatient 2107 1369.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2043.79 97 999999999 1275.79 2043.79 percent of total billed charges CT scan of cranial cavity without contrast 9189854_1 CDM 0351 RC 70480 HCPCS inpatient 2107 1369.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 1453.83 69 999999999 1275.79 2043.79 percent of total billed charges CT scan of cranial cavity without contrast 9189854_1 CDM 0351 RC 70480 HCPCS inpatient 2107 1369.55 SIHO - ALL PLANS SIHO - ALL PLANS 1896.3 90 999999999 1275.79 2043.79 percent of total billed charges CT scan of cranial cavity without contrast 9189854_1 CDM 0351 RC 70480 HCPCS inpatient 2107 1369.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 1643.46 78 999999999 1275.79 2043.79 percent of total billed charges CT scan of cranial cavity without contrast 9189854_1 CDM 0351 RC 70480 HCPCS inpatient 2107 1369.55 UMR - ALL PLANS UMR - ALL PLANS 1474.9 70 999999999 1275.79 2043.79 percent of total billed charges CT scan of cranial cavity without contrast 9189854_1 CDM 0351 RC 70480 HCPCS inpatient 2107 1369.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1275.79 60.55 999999999 1275.79 2043.79 percent of total billed charges CT scan of cranial cavity without contrast 9189854_1 CDM 0351 RC 70480 HCPCS inpatient 2107 1369.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1275.79 2043.79 CT scan of cranial cavity without contrast 9189854_1 CDM 0351 RC 70480 HCPCS inpatient 2107 1369.55 ANTHEM HMO ANTHEM HMO 999999999 1275.79 2043.79 CT scan of cranial cavity without contrast 9189854_1 CDM 0351 RC 70480 HCPCS inpatient 2107 1369.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1275.79 2043.79 CT scan of cranial cavity without contrast 9189854_1 CDM 0351 RC 70480 HCPCS inpatient 2107 1369.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1275.79 2043.79 CT scan of cranial cavity without contrast 9189854_1 CDM 0351 RC 70480 HCPCS inpatient 2107 1369.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 1424.33 67.6 999999999 1275.79 2043.79 percent of total billed charges CT scan of cranial cavity without contrast 9189854_1 CDM 0351 RC 70480 HCPCS inpatient 2107 1369.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 1275.79 2043.79 MRI scan of arm joint before and after contrast 9190107_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 5971.55 65 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 9190107_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 AETNA AETNA 7257.73 79 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 9190107_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8911.39 97 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 9190107_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 6339.03 69 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 9190107_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 SIHO - ALL PLANS SIHO - ALL PLANS 8268.3 90 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 9190107_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 7165.86 78 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 9190107_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 UMR - ALL PLANS UMR - ALL PLANS 6430.9 70 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 9190107_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5562.73 60.55 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 9190107_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5562.73 8911.39 MRI scan of arm joint before and after contrast 9190107_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 ANTHEM HMO ANTHEM HMO 999999999 5562.73 8911.39 MRI scan of arm joint before and after contrast 9190107_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5562.73 8911.39 MRI scan of arm joint before and after contrast 9190107_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5562.73 8911.39 MRI scan of arm joint before and after contrast 9190107_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 6210.41 67.6 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 9190107_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 5562.73 8911.39 MRI scan of arm joint before and after contrast 9190110_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 5971.55 65 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 9190110_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 AETNA AETNA 7257.73 79 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 9190110_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8911.39 97 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 9190110_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 6339.03 69 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 9190110_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 SIHO - ALL PLANS SIHO - ALL PLANS 8268.3 90 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 9190110_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 7165.86 78 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 9190110_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 UMR - ALL PLANS UMR - ALL PLANS 6430.9 70 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 9190110_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5562.73 60.55 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 9190110_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5562.73 8911.39 MRI scan of arm joint before and after contrast 9190110_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 ANTHEM HMO ANTHEM HMO 999999999 5562.73 8911.39 MRI scan of arm joint before and after contrast 9190110_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5562.73 8911.39 MRI scan of arm joint before and after contrast 9190110_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5562.73 8911.39 MRI scan of arm joint before and after contrast 9190110_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 6210.41 67.6 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 9190110_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 5562.73 8911.39 MRI scan of arm joint without contrast 9190119_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 2686.45 65 999999999 2502.53 4009.01 percent of total billed charges MRI scan of arm joint without contrast 9190119_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 AETNA AETNA 3265.07 79 999999999 2502.53 4009.01 percent of total billed charges MRI scan of arm joint without contrast 9190119_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4009.01 97 999999999 2502.53 4009.01 percent of total billed charges MRI scan of arm joint without contrast 9190119_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 2851.77 69 999999999 2502.53 4009.01 percent of total billed charges MRI scan of arm joint without contrast 9190119_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 SIHO - ALL PLANS SIHO - ALL PLANS 3719.7 90 999999999 2502.53 4009.01 percent of total billed charges MRI scan of arm joint without contrast 9190119_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 3223.74 78 999999999 2502.53 4009.01 percent of total billed charges MRI scan of arm joint without contrast 9190119_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 UMR - ALL PLANS UMR - ALL PLANS 2893.1 70 999999999 2502.53 4009.01 percent of total billed charges MRI scan of arm joint without contrast 9190119_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2502.53 60.55 999999999 2502.53 4009.01 percent of total billed charges MRI scan of arm joint without contrast 9190119_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2502.53 4009.01 MRI scan of arm joint without contrast 9190119_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 ANTHEM HMO ANTHEM HMO 999999999 2502.53 4009.01 MRI scan of arm joint without contrast 9190119_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2502.53 4009.01 MRI scan of arm joint without contrast 9190119_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2502.53 4009.01 MRI scan of arm joint without contrast 9190119_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 2793.91 67.6 999999999 2502.53 4009.01 percent of total billed charges MRI scan of arm joint without contrast 9190119_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 2502.53 4009.01 MRI scan of arm joint without contrast 9190122_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 2686.45 65 999999999 2502.53 4009.01 percent of total billed charges MRI scan of arm joint without contrast 9190122_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 AETNA AETNA 3265.07 79 999999999 2502.53 4009.01 percent of total billed charges MRI scan of arm joint without contrast 9190122_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4009.01 97 999999999 2502.53 4009.01 percent of total billed charges MRI scan of arm joint without contrast 9190122_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 2851.77 69 999999999 2502.53 4009.01 percent of total billed charges MRI scan of arm joint without contrast 9190122_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 SIHO - ALL PLANS SIHO - ALL PLANS 3719.7 90 999999999 2502.53 4009.01 percent of total billed charges MRI scan of arm joint without contrast 9190122_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 3223.74 78 999999999 2502.53 4009.01 percent of total billed charges MRI scan of arm joint without contrast 9190122_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 UMR - ALL PLANS UMR - ALL PLANS 2893.1 70 999999999 2502.53 4009.01 percent of total billed charges MRI scan of arm joint without contrast 9190122_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2502.53 60.55 999999999 2502.53 4009.01 percent of total billed charges MRI scan of arm joint without contrast 9190122_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2502.53 4009.01 MRI scan of arm joint without contrast 9190122_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 ANTHEM HMO ANTHEM HMO 999999999 2502.53 4009.01 MRI scan of arm joint without contrast 9190122_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2502.53 4009.01 MRI scan of arm joint without contrast 9190122_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2502.53 4009.01 MRI scan of arm joint without contrast 9190122_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 2793.91 67.6 999999999 2502.53 4009.01 percent of total billed charges MRI scan of arm joint without contrast 9190122_1 CDM 0610 RC 73221 HCPCS inpatient 4133 2686.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 2502.53 4009.01 Limited ultrasound scan of abdomen 9190218_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 703.3 65 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 9190218_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 AETNA AETNA 854.78 79 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 9190218_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1049.54 97 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 9190218_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 746.58 69 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 9190218_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 SIHO - ALL PLANS SIHO - ALL PLANS 973.8 90 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 9190218_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 843.96 78 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 9190218_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UMR - ALL PLANS UMR - ALL PLANS 757.4 70 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 9190218_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 655.15 60.55 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 9190218_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 9190218_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM HMO ANTHEM HMO 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 9190218_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 9190218_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 9190218_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 731.43 67.6 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 9190218_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 9190224_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 703.3 65 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 9190224_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 AETNA AETNA 854.78 79 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 9190224_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1049.54 97 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 9190224_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 746.58 69 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 9190224_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 SIHO - ALL PLANS SIHO - ALL PLANS 973.8 90 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 9190224_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 843.96 78 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 9190224_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UMR - ALL PLANS UMR - ALL PLANS 757.4 70 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 9190224_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 655.15 60.55 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 9190224_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 9190224_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM HMO ANTHEM HMO 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 9190224_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 9190224_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 9190224_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 731.43 67.6 999999999 655.15 1049.54 percent of total billed charges Limited ultrasound scan of abdomen 9190224_1 CDM 0402 RC 76705 HCPCS inpatient 1082 703.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 655.15 1049.54 Limited ultrasound scan of abdomen 9190227_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 651.3 65 999999999 606.71 971.94 percent of total billed charges Limited ultrasound scan of abdomen 9190227_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 AETNA AETNA 791.58 79 999999999 606.71 971.94 percent of total billed charges Limited ultrasound scan of abdomen 9190227_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 971.94 97 999999999 606.71 971.94 percent of total billed charges Limited ultrasound scan of abdomen 9190227_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 691.38 69 999999999 606.71 971.94 percent of total billed charges Limited ultrasound scan of abdomen 9190227_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 SIHO - ALL PLANS SIHO - ALL PLANS 901.8 90 999999999 606.71 971.94 percent of total billed charges Limited ultrasound scan of abdomen 9190227_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 781.56 78 999999999 606.71 971.94 percent of total billed charges Limited ultrasound scan of abdomen 9190227_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 UMR - ALL PLANS UMR - ALL PLANS 701.4 70 999999999 606.71 971.94 percent of total billed charges Limited ultrasound scan of abdomen 9190227_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 606.71 971.94 Limited ultrasound scan of abdomen 9190227_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 606.71 60.55 999999999 606.71 971.94 percent of total billed charges Limited ultrasound scan of abdomen 9190227_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 ANTHEM HMO ANTHEM HMO 999999999 606.71 971.94 Limited ultrasound scan of abdomen 9190227_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 606.71 971.94 Limited ultrasound scan of abdomen 9190227_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 606.71 971.94 Limited ultrasound scan of abdomen 9190227_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 677.35 67.6 999999999 606.71 971.94 percent of total billed charges Limited ultrasound scan of abdomen 9190227_1 CDM 0402 RC 76705 HCPCS inpatient 1002 651.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 606.71 971.94 Ultrasonic guidance for needle placement 9190230_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 627.25 65 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190230_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 AETNA AETNA 762.35 79 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190230_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 936.05 97 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190230_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 665.85 69 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190230_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SIHO - ALL PLANS SIHO - ALL PLANS 868.5 90 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190230_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 752.7 78 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190230_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UMR - ALL PLANS UMR - ALL PLANS 675.5 70 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190230_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9190230_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 584.31 60.55 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190230_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM HMO ANTHEM HMO 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9190230_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9190230_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9190230_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 652.34 67.6 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190230_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9190245_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 570.05 65 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 9190245_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 AETNA AETNA 692.83 79 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 9190245_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 850.69 97 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 9190245_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 605.13 69 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 9190245_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 SIHO - ALL PLANS SIHO - ALL PLANS 789.3 90 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 9190245_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 684.06 78 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 9190245_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 UMR - ALL PLANS UMR - ALL PLANS 613.9 70 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 9190245_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 9190245_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 531.02 60.55 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 9190245_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 ANTHEM HMO ANTHEM HMO 999999999 531.02 850.69 Ultrasonic guidance for needle placement 9190245_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 9190245_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 531.02 850.69 Ultrasonic guidance for needle placement 9190245_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 592.85 67.6 999999999 531.02 850.69 percent of total billed charges Ultrasonic guidance for needle placement 9190245_1 CDM 0320 RC 76942 HCPCS inpatient 877 570.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 531.02 850.69 Ultrasonic guidance for needle placement 9190248_1 CDM 0320 RC 76942 HCPCS inpatient 819 532.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 532.35 65 999999999 495.9 794.43 percent of total billed charges Ultrasonic guidance for needle placement 9190248_1 CDM 0320 RC 76942 HCPCS inpatient 819 532.35 AETNA AETNA 647.01 79 999999999 495.9 794.43 percent of total billed charges Ultrasonic guidance for needle placement 9190248_1 CDM 0320 RC 76942 HCPCS inpatient 819 532.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 794.43 97 999999999 495.9 794.43 percent of total billed charges Ultrasonic guidance for needle placement 9190248_1 CDM 0320 RC 76942 HCPCS inpatient 819 532.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 565.11 69 999999999 495.9 794.43 percent of total billed charges Ultrasonic guidance for needle placement 9190248_1 CDM 0320 RC 76942 HCPCS inpatient 819 532.35 SIHO - ALL PLANS SIHO - ALL PLANS 737.1 90 999999999 495.9 794.43 percent of total billed charges Ultrasonic guidance for needle placement 9190248_1 CDM 0320 RC 76942 HCPCS inpatient 819 532.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 638.82 78 999999999 495.9 794.43 percent of total billed charges Ultrasonic guidance for needle placement 9190248_1 CDM 0320 RC 76942 HCPCS inpatient 819 532.35 UMR - ALL PLANS UMR - ALL PLANS 573.3 70 999999999 495.9 794.43 percent of total billed charges Ultrasonic guidance for needle placement 9190248_1 CDM 0320 RC 76942 HCPCS inpatient 819 532.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 495.9 794.43 Ultrasonic guidance for needle placement 9190248_1 CDM 0320 RC 76942 HCPCS inpatient 819 532.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 495.9 60.55 999999999 495.9 794.43 percent of total billed charges Ultrasonic guidance for needle placement 9190248_1 CDM 0320 RC 76942 HCPCS inpatient 819 532.35 ANTHEM HMO ANTHEM HMO 999999999 495.9 794.43 Ultrasonic guidance for needle placement 9190248_1 CDM 0320 RC 76942 HCPCS inpatient 819 532.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 495.9 794.43 Ultrasonic guidance for needle placement 9190248_1 CDM 0320 RC 76942 HCPCS inpatient 819 532.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 495.9 794.43 Ultrasonic guidance for needle placement 9190248_1 CDM 0320 RC 76942 HCPCS inpatient 819 532.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 553.64 67.6 999999999 495.9 794.43 percent of total billed charges Ultrasonic guidance for needle placement 9190248_1 CDM 0320 RC 76942 HCPCS inpatient 819 532.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 495.9 794.43 "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190299_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 976.95 65 999999999 910.07 1457.91 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190299_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 AETNA AETNA 1187.37 79 999999999 910.07 1457.91 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190299_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1457.91 97 999999999 910.07 1457.91 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190299_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1037.07 69 999999999 910.07 1457.91 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190299_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 SIHO - ALL PLANS SIHO - ALL PLANS 1352.7 90 999999999 910.07 1457.91 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190299_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1172.34 78 999999999 910.07 1457.91 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190299_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 UMR - ALL PLANS UMR - ALL PLANS 1052.1 70 999999999 910.07 1457.91 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190299_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 910.07 1457.91 "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190299_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 910.07 60.55 999999999 910.07 1457.91 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190299_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 ANTHEM HMO ANTHEM HMO 999999999 910.07 1457.91 "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190299_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 910.07 1457.91 "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190299_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 910.07 1457.91 "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190299_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1016.03 67.6 999999999 910.07 1457.91 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190299_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 910.07 1457.91 "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190302_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 976.95 65 999999999 910.07 1457.91 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190302_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 AETNA AETNA 1187.37 79 999999999 910.07 1457.91 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190302_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1457.91 97 999999999 910.07 1457.91 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190302_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1037.07 69 999999999 910.07 1457.91 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190302_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 SIHO - ALL PLANS SIHO - ALL PLANS 1352.7 90 999999999 910.07 1457.91 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190302_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1172.34 78 999999999 910.07 1457.91 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190302_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 UMR - ALL PLANS UMR - ALL PLANS 1052.1 70 999999999 910.07 1457.91 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190302_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 910.07 1457.91 "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190302_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 910.07 60.55 999999999 910.07 1457.91 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190302_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 ANTHEM HMO ANTHEM HMO 999999999 910.07 1457.91 "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190302_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 910.07 1457.91 "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190302_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 910.07 1457.91 "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190302_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1016.03 67.6 999999999 910.07 1457.91 percent of total billed charges "Biopsy of breast and placement of locating device using ultrasound, first growth" 9190302_1 CDM 0320 RC 19083 HCPCS inpatient 1503 976.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 910.07 1457.91 Complete ultrasound of abdomen and pelvis artery and vein blood flow 9190320_1 CDM 0921 RC 93975 HCPCS inpatient 864 561.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 561.6 65 999999999 523.15 838.08 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 9190320_1 CDM 0921 RC 93975 HCPCS inpatient 864 561.6 AETNA AETNA 682.56 79 999999999 523.15 838.08 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 9190320_1 CDM 0921 RC 93975 HCPCS inpatient 864 561.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 838.08 97 999999999 523.15 838.08 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 9190320_1 CDM 0921 RC 93975 HCPCS inpatient 864 561.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 596.16 69 999999999 523.15 838.08 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 9190320_1 CDM 0921 RC 93975 HCPCS inpatient 864 561.6 SIHO - ALL PLANS SIHO - ALL PLANS 777.6 90 999999999 523.15 838.08 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 9190320_1 CDM 0921 RC 93975 HCPCS inpatient 864 561.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 673.92 78 999999999 523.15 838.08 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 9190320_1 CDM 0921 RC 93975 HCPCS inpatient 864 561.6 UMR - ALL PLANS UMR - ALL PLANS 604.8 70 999999999 523.15 838.08 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 9190320_1 CDM 0921 RC 93975 HCPCS inpatient 864 561.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 523.15 838.08 Complete ultrasound of abdomen and pelvis artery and vein blood flow 9190320_1 CDM 0921 RC 93975 HCPCS inpatient 864 561.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 523.15 60.55 999999999 523.15 838.08 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 9190320_1 CDM 0921 RC 93975 HCPCS inpatient 864 561.6 ANTHEM HMO ANTHEM HMO 999999999 523.15 838.08 Complete ultrasound of abdomen and pelvis artery and vein blood flow 9190320_1 CDM 0921 RC 93975 HCPCS inpatient 864 561.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 523.15 838.08 Complete ultrasound of abdomen and pelvis artery and vein blood flow 9190320_1 CDM 0921 RC 93975 HCPCS inpatient 864 561.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 523.15 838.08 Complete ultrasound of abdomen and pelvis artery and vein blood flow 9190320_1 CDM 0921 RC 93975 HCPCS inpatient 864 561.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 584.06 67.6 999999999 523.15 838.08 percent of total billed charges Complete ultrasound of abdomen and pelvis artery and vein blood flow 9190320_1 CDM 0921 RC 93975 HCPCS inpatient 864 561.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 523.15 838.08 Ultrasound of abdomen and pelvis artery and vein blood flow 9190323_1 CDM 0921 RC 93976 HCPCS inpatient 301 195.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 195.65 65 999999999 182.26 291.97 percent of total billed charges Ultrasound of abdomen and pelvis artery and vein blood flow 9190323_1 CDM 0921 RC 93976 HCPCS inpatient 301 195.65 AETNA AETNA 237.79 79 999999999 182.26 291.97 percent of total billed charges Ultrasound of abdomen and pelvis artery and vein blood flow 9190323_1 CDM 0921 RC 93976 HCPCS inpatient 301 195.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 291.97 97 999999999 182.26 291.97 percent of total billed charges Ultrasound of abdomen and pelvis artery and vein blood flow 9190323_1 CDM 0921 RC 93976 HCPCS inpatient 301 195.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 207.69 69 999999999 182.26 291.97 percent of total billed charges Ultrasound of abdomen and pelvis artery and vein blood flow 9190323_1 CDM 0921 RC 93976 HCPCS inpatient 301 195.65 SIHO - ALL PLANS SIHO - ALL PLANS 270.9 90 999999999 182.26 291.97 percent of total billed charges Ultrasound of abdomen and pelvis artery and vein blood flow 9190323_1 CDM 0921 RC 93976 HCPCS inpatient 301 195.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 234.78 78 999999999 182.26 291.97 percent of total billed charges Ultrasound of abdomen and pelvis artery and vein blood flow 9190323_1 CDM 0921 RC 93976 HCPCS inpatient 301 195.65 UMR - ALL PLANS UMR - ALL PLANS 210.7 70 999999999 182.26 291.97 percent of total billed charges Ultrasound of abdomen and pelvis artery and vein blood flow 9190323_1 CDM 0921 RC 93976 HCPCS inpatient 301 195.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 182.26 291.97 Ultrasound of abdomen and pelvis artery and vein blood flow 9190323_1 CDM 0921 RC 93976 HCPCS inpatient 301 195.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 182.26 60.55 999999999 182.26 291.97 percent of total billed charges Ultrasound of abdomen and pelvis artery and vein blood flow 9190323_1 CDM 0921 RC 93976 HCPCS inpatient 301 195.65 ANTHEM HMO ANTHEM HMO 999999999 182.26 291.97 Ultrasound of abdomen and pelvis artery and vein blood flow 9190323_1 CDM 0921 RC 93976 HCPCS inpatient 301 195.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 182.26 291.97 Ultrasound of abdomen and pelvis artery and vein blood flow 9190323_1 CDM 0921 RC 93976 HCPCS inpatient 301 195.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 182.26 291.97 Ultrasound of abdomen and pelvis artery and vein blood flow 9190323_1 CDM 0921 RC 93976 HCPCS inpatient 301 195.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 203.48 67.6 999999999 182.26 291.97 percent of total billed charges Ultrasound of abdomen and pelvis artery and vein blood flow 9190323_1 CDM 0921 RC 93976 HCPCS inpatient 301 195.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 182.26 291.97 Ultrasound of one leg arteries or artery grafts 9190371_1 CDM 0402 RC 93926 HCPCS inpatient 486 315.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 315.9 65 999999999 294.27 471.42 percent of total billed charges Ultrasound of one leg arteries or artery grafts 9190371_1 CDM 0402 RC 93926 HCPCS inpatient 486 315.9 AETNA AETNA 383.94 79 999999999 294.27 471.42 percent of total billed charges Ultrasound of one leg arteries or artery grafts 9190371_1 CDM 0402 RC 93926 HCPCS inpatient 486 315.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 471.42 97 999999999 294.27 471.42 percent of total billed charges Ultrasound of one leg arteries or artery grafts 9190371_1 CDM 0402 RC 93926 HCPCS inpatient 486 315.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 335.34 69 999999999 294.27 471.42 percent of total billed charges Ultrasound of one leg arteries or artery grafts 9190371_1 CDM 0402 RC 93926 HCPCS inpatient 486 315.9 SIHO - ALL PLANS SIHO - ALL PLANS 437.4 90 999999999 294.27 471.42 percent of total billed charges Ultrasound of one leg arteries or artery grafts 9190371_1 CDM 0402 RC 93926 HCPCS inpatient 486 315.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 379.08 78 999999999 294.27 471.42 percent of total billed charges Ultrasound of one leg arteries or artery grafts 9190371_1 CDM 0402 RC 93926 HCPCS inpatient 486 315.9 UMR - ALL PLANS UMR - ALL PLANS 340.2 70 999999999 294.27 471.42 percent of total billed charges Ultrasound of one leg arteries or artery grafts 9190371_1 CDM 0402 RC 93926 HCPCS inpatient 486 315.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 294.27 471.42 Ultrasound of one leg arteries or artery grafts 9190371_1 CDM 0402 RC 93926 HCPCS inpatient 486 315.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 294.27 60.55 999999999 294.27 471.42 percent of total billed charges Ultrasound of one leg arteries or artery grafts 9190371_1 CDM 0402 RC 93926 HCPCS inpatient 486 315.9 ANTHEM HMO ANTHEM HMO 999999999 294.27 471.42 Ultrasound of one leg arteries or artery grafts 9190371_1 CDM 0402 RC 93926 HCPCS inpatient 486 315.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 294.27 471.42 Ultrasound of one leg arteries or artery grafts 9190371_1 CDM 0402 RC 93926 HCPCS inpatient 486 315.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 294.27 471.42 Ultrasound of one leg arteries or artery grafts 9190371_1 CDM 0402 RC 93926 HCPCS inpatient 486 315.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 328.54 67.6 999999999 294.27 471.42 percent of total billed charges Ultrasound of one leg arteries or artery grafts 9190371_1 CDM 0402 RC 93926 HCPCS inpatient 486 315.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 294.27 471.42 Ultrasound of one leg arteries or artery grafts 9190374_1 CDM 0402 RC 93926 HCPCS inpatient 442 287.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 287.3 65 999999999 267.63 428.74 percent of total billed charges Ultrasound of one leg arteries or artery grafts 9190374_1 CDM 0402 RC 93926 HCPCS inpatient 442 287.3 AETNA AETNA 349.18 79 999999999 267.63 428.74 percent of total billed charges Ultrasound of one leg arteries or artery grafts 9190374_1 CDM 0402 RC 93926 HCPCS inpatient 442 287.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 428.74 97 999999999 267.63 428.74 percent of total billed charges Ultrasound of one leg arteries or artery grafts 9190374_1 CDM 0402 RC 93926 HCPCS inpatient 442 287.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 304.98 69 999999999 267.63 428.74 percent of total billed charges Ultrasound of one leg arteries or artery grafts 9190374_1 CDM 0402 RC 93926 HCPCS inpatient 442 287.3 SIHO - ALL PLANS SIHO - ALL PLANS 397.8 90 999999999 267.63 428.74 percent of total billed charges Ultrasound of one leg arteries or artery grafts 9190374_1 CDM 0402 RC 93926 HCPCS inpatient 442 287.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 344.76 78 999999999 267.63 428.74 percent of total billed charges Ultrasound of one leg arteries or artery grafts 9190374_1 CDM 0402 RC 93926 HCPCS inpatient 442 287.3 UMR - ALL PLANS UMR - ALL PLANS 309.4 70 999999999 267.63 428.74 percent of total billed charges Ultrasound of one leg arteries or artery grafts 9190374_1 CDM 0402 RC 93926 HCPCS inpatient 442 287.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 267.63 428.74 Ultrasound of one leg arteries or artery grafts 9190374_1 CDM 0402 RC 93926 HCPCS inpatient 442 287.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 267.63 60.55 999999999 267.63 428.74 percent of total billed charges Ultrasound of one leg arteries or artery grafts 9190374_1 CDM 0402 RC 93926 HCPCS inpatient 442 287.3 ANTHEM HMO ANTHEM HMO 999999999 267.63 428.74 Ultrasound of one leg arteries or artery grafts 9190374_1 CDM 0402 RC 93926 HCPCS inpatient 442 287.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 267.63 428.74 Ultrasound of one leg arteries or artery grafts 9190374_1 CDM 0402 RC 93926 HCPCS inpatient 442 287.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 267.63 428.74 Ultrasound of one leg arteries or artery grafts 9190374_1 CDM 0402 RC 93926 HCPCS inpatient 442 287.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 298.79 67.6 999999999 267.63 428.74 percent of total billed charges Ultrasound of one leg arteries or artery grafts 9190374_1 CDM 0402 RC 93926 HCPCS inpatient 442 287.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 267.63 428.74 Ultrasound study of arm or leg veins with compression and maneuvers 9190404_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1817.4 65 999999999 1692.98 2712.12 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 9190404_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 AETNA AETNA 2208.84 79 999999999 1692.98 2712.12 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 9190404_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2712.12 97 999999999 1692.98 2712.12 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 9190404_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 1929.24 69 999999999 1692.98 2712.12 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 9190404_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 SIHO - ALL PLANS SIHO - ALL PLANS 2516.4 90 999999999 1692.98 2712.12 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 9190404_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 2180.88 78 999999999 1692.98 2712.12 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 9190404_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 UMR - ALL PLANS UMR - ALL PLANS 1957.2 70 999999999 1692.98 2712.12 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 9190404_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1692.98 2712.12 Ultrasound study of arm or leg veins with compression and maneuvers 9190404_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1692.98 60.55 999999999 1692.98 2712.12 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 9190404_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 ANTHEM HMO ANTHEM HMO 999999999 1692.98 2712.12 Ultrasound study of arm or leg veins with compression and maneuvers 9190404_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1692.98 2712.12 Ultrasound study of arm or leg veins with compression and maneuvers 9190404_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1692.98 2712.12 Ultrasound study of arm or leg veins with compression and maneuvers 9190404_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 1890.1 67.6 999999999 1692.98 2712.12 percent of total billed charges Ultrasound study of arm or leg veins with compression and maneuvers 9190404_1 CDM 0921 RC 93970 HCPCS inpatient 2796 1817.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1692.98 2712.12 Ultrasound study of one arm or leg veins with compression and maneuvers 9190407_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 929.5 65 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 9190407_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 AETNA AETNA 1129.7 79 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 9190407_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1387.1 97 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 9190407_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 986.7 69 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 9190407_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 SIHO - ALL PLANS SIHO - ALL PLANS 1287 90 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 9190407_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 1115.4 78 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 9190407_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 UMR - ALL PLANS UMR - ALL PLANS 1001 70 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 9190407_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 865.87 1387.1 Ultrasound study of one arm or leg veins with compression and maneuvers 9190407_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 865.87 60.55 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 9190407_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 ANTHEM HMO ANTHEM HMO 999999999 865.87 1387.1 Ultrasound study of one arm or leg veins with compression and maneuvers 9190407_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 865.87 1387.1 Ultrasound study of one arm or leg veins with compression and maneuvers 9190407_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 865.87 1387.1 Ultrasound study of one arm or leg veins with compression and maneuvers 9190407_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 966.68 67.6 999999999 865.87 1387.1 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 9190407_1 CDM 0402 RC 93971 HCPCS inpatient 1430 929.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 865.87 1387.1 Ultrasound study of one arm or leg veins with compression and maneuvers 9190410_1 CDM 0921 RC 93971 HCPCS inpatient 1411 917.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 917.15 65 999999999 854.36 1368.67 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 9190410_1 CDM 0921 RC 93971 HCPCS inpatient 1411 917.15 AETNA AETNA 1114.69 79 999999999 854.36 1368.67 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 9190410_1 CDM 0921 RC 93971 HCPCS inpatient 1411 917.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1368.67 97 999999999 854.36 1368.67 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 9190410_1 CDM 0921 RC 93971 HCPCS inpatient 1411 917.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 973.59 69 999999999 854.36 1368.67 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 9190410_1 CDM 0921 RC 93971 HCPCS inpatient 1411 917.15 SIHO - ALL PLANS SIHO - ALL PLANS 1269.9 90 999999999 854.36 1368.67 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 9190410_1 CDM 0921 RC 93971 HCPCS inpatient 1411 917.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1100.58 78 999999999 854.36 1368.67 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 9190410_1 CDM 0921 RC 93971 HCPCS inpatient 1411 917.15 UMR - ALL PLANS UMR - ALL PLANS 987.7 70 999999999 854.36 1368.67 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 9190410_1 CDM 0921 RC 93971 HCPCS inpatient 1411 917.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 854.36 1368.67 Ultrasound study of one arm or leg veins with compression and maneuvers 9190410_1 CDM 0921 RC 93971 HCPCS inpatient 1411 917.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 854.36 60.55 999999999 854.36 1368.67 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 9190410_1 CDM 0921 RC 93971 HCPCS inpatient 1411 917.15 ANTHEM HMO ANTHEM HMO 999999999 854.36 1368.67 Ultrasound study of one arm or leg veins with compression and maneuvers 9190410_1 CDM 0921 RC 93971 HCPCS inpatient 1411 917.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 854.36 1368.67 Ultrasound study of one arm or leg veins with compression and maneuvers 9190410_1 CDM 0921 RC 93971 HCPCS inpatient 1411 917.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 854.36 1368.67 Ultrasound study of one arm or leg veins with compression and maneuvers 9190410_1 CDM 0921 RC 93971 HCPCS inpatient 1411 917.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 953.84 67.6 999999999 854.36 1368.67 percent of total billed charges Ultrasound study of one arm or leg veins with compression and maneuvers 9190410_1 CDM 0921 RC 93971 HCPCS inpatient 1411 917.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 854.36 1368.67 Ultrasonic guidance for needle placement 9190479_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 627.25 65 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190479_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 AETNA AETNA 762.35 79 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190479_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 936.05 97 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190479_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 665.85 69 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190479_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SIHO - ALL PLANS SIHO - ALL PLANS 868.5 90 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190479_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 752.7 78 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190479_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UMR - ALL PLANS UMR - ALL PLANS 675.5 70 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190479_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9190479_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 584.31 60.55 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190479_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM HMO ANTHEM HMO 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9190479_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9190479_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9190479_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 652.34 67.6 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190479_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9190482_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 627.25 65 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190482_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 AETNA AETNA 762.35 79 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190482_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 936.05 97 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190482_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 665.85 69 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190482_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SIHO - ALL PLANS SIHO - ALL PLANS 868.5 90 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190482_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 752.7 78 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190482_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UMR - ALL PLANS UMR - ALL PLANS 675.5 70 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190482_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9190482_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 584.31 60.55 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190482_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM HMO ANTHEM HMO 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9190482_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9190482_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9190482_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 652.34 67.6 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9190482_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 584.31 936.05 Ultrasound of one arm arteries or artery grafts 9190485_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 230.75 65 999999999 214.95 344.35 percent of total billed charges Ultrasound of one arm arteries or artery grafts 9190485_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 AETNA AETNA 280.45 79 999999999 214.95 344.35 percent of total billed charges Ultrasound of one arm arteries or artery grafts 9190485_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 344.35 97 999999999 214.95 344.35 percent of total billed charges Ultrasound of one arm arteries or artery grafts 9190485_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 244.95 69 999999999 214.95 344.35 percent of total billed charges Ultrasound of one arm arteries or artery grafts 9190485_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 SIHO - ALL PLANS SIHO - ALL PLANS 319.5 90 999999999 214.95 344.35 percent of total billed charges Ultrasound of one arm arteries or artery grafts 9190485_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 276.9 78 999999999 214.95 344.35 percent of total billed charges Ultrasound of one arm arteries or artery grafts 9190485_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 UMR - ALL PLANS UMR - ALL PLANS 248.5 70 999999999 214.95 344.35 percent of total billed charges Ultrasound of one arm arteries or artery grafts 9190485_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 214.95 344.35 Ultrasound of one arm arteries or artery grafts 9190485_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 214.95 60.55 999999999 214.95 344.35 percent of total billed charges Ultrasound of one arm arteries or artery grafts 9190485_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 ANTHEM HMO ANTHEM HMO 999999999 214.95 344.35 Ultrasound of one arm arteries or artery grafts 9190485_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 214.95 344.35 Ultrasound of one arm arteries or artery grafts 9190485_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 214.95 344.35 Ultrasound of one arm arteries or artery grafts 9190485_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 239.98 67.6 999999999 214.95 344.35 percent of total billed charges Ultrasound of one arm arteries or artery grafts 9190485_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 214.95 344.35 Ultrasound of one arm arteries or artery grafts 9190488_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 230.75 65 999999999 214.95 344.35 percent of total billed charges Ultrasound of one arm arteries or artery grafts 9190488_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 AETNA AETNA 280.45 79 999999999 214.95 344.35 percent of total billed charges Ultrasound of one arm arteries or artery grafts 9190488_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 344.35 97 999999999 214.95 344.35 percent of total billed charges Ultrasound of one arm arteries or artery grafts 9190488_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 244.95 69 999999999 214.95 344.35 percent of total billed charges Ultrasound of one arm arteries or artery grafts 9190488_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 SIHO - ALL PLANS SIHO - ALL PLANS 319.5 90 999999999 214.95 344.35 percent of total billed charges Ultrasound of one arm arteries or artery grafts 9190488_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 276.9 78 999999999 214.95 344.35 percent of total billed charges Ultrasound of one arm arteries or artery grafts 9190488_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 UMR - ALL PLANS UMR - ALL PLANS 248.5 70 999999999 214.95 344.35 percent of total billed charges Ultrasound of one arm arteries or artery grafts 9190488_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 214.95 344.35 Ultrasound of one arm arteries or artery grafts 9190488_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 214.95 60.55 999999999 214.95 344.35 percent of total billed charges Ultrasound of one arm arteries or artery grafts 9190488_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 ANTHEM HMO ANTHEM HMO 999999999 214.95 344.35 Ultrasound of one arm arteries or artery grafts 9190488_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 214.95 344.35 Ultrasound of one arm arteries or artery grafts 9190488_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 214.95 344.35 Ultrasound of one arm arteries or artery grafts 9190488_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 239.98 67.6 999999999 214.95 344.35 percent of total billed charges Ultrasound of one arm arteries or artery grafts 9190488_1 CDM 0402 RC 93931 HCPCS inpatient 355 230.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 214.95 344.35 Double contrast X-ray of large intestine 9190545_1 CDM 0320 RC 74280 HCPCS inpatient 1263 820.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 820.95 65 999999999 764.75 1225.11 percent of total billed charges Double contrast X-ray of large intestine 9190545_1 CDM 0320 RC 74280 HCPCS inpatient 1263 820.95 AETNA AETNA 997.77 79 999999999 764.75 1225.11 percent of total billed charges Double contrast X-ray of large intestine 9190545_1 CDM 0320 RC 74280 HCPCS inpatient 1263 820.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1225.11 97 999999999 764.75 1225.11 percent of total billed charges Double contrast X-ray of large intestine 9190545_1 CDM 0320 RC 74280 HCPCS inpatient 1263 820.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 871.47 69 999999999 764.75 1225.11 percent of total billed charges Double contrast X-ray of large intestine 9190545_1 CDM 0320 RC 74280 HCPCS inpatient 1263 820.95 SIHO - ALL PLANS SIHO - ALL PLANS 1136.7 90 999999999 764.75 1225.11 percent of total billed charges Double contrast X-ray of large intestine 9190545_1 CDM 0320 RC 74280 HCPCS inpatient 1263 820.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 985.14 78 999999999 764.75 1225.11 percent of total billed charges Double contrast X-ray of large intestine 9190545_1 CDM 0320 RC 74280 HCPCS inpatient 1263 820.95 UMR - ALL PLANS UMR - ALL PLANS 884.1 70 999999999 764.75 1225.11 percent of total billed charges Double contrast X-ray of large intestine 9190545_1 CDM 0320 RC 74280 HCPCS inpatient 1263 820.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 764.75 1225.11 Double contrast X-ray of large intestine 9190545_1 CDM 0320 RC 74280 HCPCS inpatient 1263 820.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 764.75 60.55 999999999 764.75 1225.11 percent of total billed charges Double contrast X-ray of large intestine 9190545_1 CDM 0320 RC 74280 HCPCS inpatient 1263 820.95 ANTHEM HMO ANTHEM HMO 999999999 764.75 1225.11 Double contrast X-ray of large intestine 9190545_1 CDM 0320 RC 74280 HCPCS inpatient 1263 820.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 764.75 1225.11 Double contrast X-ray of large intestine 9190545_1 CDM 0320 RC 74280 HCPCS inpatient 1263 820.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 764.75 1225.11 Double contrast X-ray of large intestine 9190545_1 CDM 0320 RC 74280 HCPCS inpatient 1263 820.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 853.79 67.6 999999999 764.75 1225.11 percent of total billed charges Double contrast X-ray of large intestine 9190545_1 CDM 0320 RC 74280 HCPCS inpatient 1263 820.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 764.75 1225.11 "X-ray of chest, 1 view" 9190560_1 CDM 0324 RC 71045 HCPCS inpatient 370 240.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 240.5 65 999999999 224.04 358.9 percent of total billed charges "X-ray of chest, 1 view" 9190560_1 CDM 0324 RC 71045 HCPCS inpatient 370 240.5 AETNA AETNA 292.3 79 999999999 224.04 358.9 percent of total billed charges "X-ray of chest, 1 view" 9190560_1 CDM 0324 RC 71045 HCPCS inpatient 370 240.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 358.9 97 999999999 224.04 358.9 percent of total billed charges "X-ray of chest, 1 view" 9190560_1 CDM 0324 RC 71045 HCPCS inpatient 370 240.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 255.3 69 999999999 224.04 358.9 percent of total billed charges "X-ray of chest, 1 view" 9190560_1 CDM 0324 RC 71045 HCPCS inpatient 370 240.5 SIHO - ALL PLANS SIHO - ALL PLANS 333 90 999999999 224.04 358.9 percent of total billed charges "X-ray of chest, 1 view" 9190560_1 CDM 0324 RC 71045 HCPCS inpatient 370 240.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 288.6 78 999999999 224.04 358.9 percent of total billed charges "X-ray of chest, 1 view" 9190560_1 CDM 0324 RC 71045 HCPCS inpatient 370 240.5 UMR - ALL PLANS UMR - ALL PLANS 259 70 999999999 224.04 358.9 percent of total billed charges "X-ray of chest, 1 view" 9190560_1 CDM 0324 RC 71045 HCPCS inpatient 370 240.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 224.04 358.9 "X-ray of chest, 1 view" 9190560_1 CDM 0324 RC 71045 HCPCS inpatient 370 240.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 224.04 60.55 999999999 224.04 358.9 percent of total billed charges "X-ray of chest, 1 view" 9190560_1 CDM 0324 RC 71045 HCPCS inpatient 370 240.5 ANTHEM HMO ANTHEM HMO 999999999 224.04 358.9 "X-ray of chest, 1 view" 9190560_1 CDM 0324 RC 71045 HCPCS inpatient 370 240.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 224.04 358.9 "X-ray of chest, 1 view" 9190560_1 CDM 0324 RC 71045 HCPCS inpatient 370 240.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 224.04 358.9 "X-ray of chest, 1 view" 9190560_1 CDM 0324 RC 71045 HCPCS inpatient 370 240.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 250.12 67.6 999999999 224.04 358.9 percent of total billed charges "X-ray of chest, 1 view" 9190560_1 CDM 0324 RC 71045 HCPCS inpatient 370 240.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 224.04 358.9 Single contrast X-ray of large intestine 9190587_1 CDM 0320 RC 74270 HCPCS inpatient 961 624.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 624.65 65 999999999 581.89 932.17 percent of total billed charges Single contrast X-ray of large intestine 9190587_1 CDM 0320 RC 74270 HCPCS inpatient 961 624.65 AETNA AETNA 759.19 79 999999999 581.89 932.17 percent of total billed charges Single contrast X-ray of large intestine 9190587_1 CDM 0320 RC 74270 HCPCS inpatient 961 624.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 932.17 97 999999999 581.89 932.17 percent of total billed charges Single contrast X-ray of large intestine 9190587_1 CDM 0320 RC 74270 HCPCS inpatient 961 624.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 663.09 69 999999999 581.89 932.17 percent of total billed charges Single contrast X-ray of large intestine 9190587_1 CDM 0320 RC 74270 HCPCS inpatient 961 624.65 SIHO - ALL PLANS SIHO - ALL PLANS 864.9 90 999999999 581.89 932.17 percent of total billed charges Single contrast X-ray of large intestine 9190587_1 CDM 0320 RC 74270 HCPCS inpatient 961 624.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 749.58 78 999999999 581.89 932.17 percent of total billed charges Single contrast X-ray of large intestine 9190587_1 CDM 0320 RC 74270 HCPCS inpatient 961 624.65 UMR - ALL PLANS UMR - ALL PLANS 672.7 70 999999999 581.89 932.17 percent of total billed charges Single contrast X-ray of large intestine 9190587_1 CDM 0320 RC 74270 HCPCS inpatient 961 624.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 581.89 932.17 Single contrast X-ray of large intestine 9190587_1 CDM 0320 RC 74270 HCPCS inpatient 961 624.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 581.89 60.55 999999999 581.89 932.17 percent of total billed charges Single contrast X-ray of large intestine 9190587_1 CDM 0320 RC 74270 HCPCS inpatient 961 624.65 ANTHEM HMO ANTHEM HMO 999999999 581.89 932.17 Single contrast X-ray of large intestine 9190587_1 CDM 0320 RC 74270 HCPCS inpatient 961 624.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 581.89 932.17 Single contrast X-ray of large intestine 9190587_1 CDM 0320 RC 74270 HCPCS inpatient 961 624.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 581.89 932.17 Single contrast X-ray of large intestine 9190587_1 CDM 0320 RC 74270 HCPCS inpatient 961 624.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 649.64 67.6 999999999 581.89 932.17 percent of total billed charges Single contrast X-ray of large intestine 9190587_1 CDM 0320 RC 74270 HCPCS inpatient 961 624.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 581.89 932.17 "X-ray of joints, multiple" 9190680_1 CDM 0320 RC 77077 HCPCS inpatient 479 311.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 311.35 65 999999999 290.03 464.63 percent of total billed charges "X-ray of joints, multiple" 9190680_1 CDM 0320 RC 77077 HCPCS inpatient 479 311.35 AETNA AETNA 378.41 79 999999999 290.03 464.63 percent of total billed charges "X-ray of joints, multiple" 9190680_1 CDM 0320 RC 77077 HCPCS inpatient 479 311.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 464.63 97 999999999 290.03 464.63 percent of total billed charges "X-ray of joints, multiple" 9190680_1 CDM 0320 RC 77077 HCPCS inpatient 479 311.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 330.51 69 999999999 290.03 464.63 percent of total billed charges "X-ray of joints, multiple" 9190680_1 CDM 0320 RC 77077 HCPCS inpatient 479 311.35 SIHO - ALL PLANS SIHO - ALL PLANS 431.1 90 999999999 290.03 464.63 percent of total billed charges "X-ray of joints, multiple" 9190680_1 CDM 0320 RC 77077 HCPCS inpatient 479 311.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 373.62 78 999999999 290.03 464.63 percent of total billed charges "X-ray of joints, multiple" 9190680_1 CDM 0320 RC 77077 HCPCS inpatient 479 311.35 UMR - ALL PLANS UMR - ALL PLANS 335.3 70 999999999 290.03 464.63 percent of total billed charges "X-ray of joints, multiple" 9190680_1 CDM 0320 RC 77077 HCPCS inpatient 479 311.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 290.03 464.63 "X-ray of joints, multiple" 9190680_1 CDM 0320 RC 77077 HCPCS inpatient 479 311.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 290.03 60.55 999999999 290.03 464.63 percent of total billed charges "X-ray of joints, multiple" 9190680_1 CDM 0320 RC 77077 HCPCS inpatient 479 311.35 ANTHEM HMO ANTHEM HMO 999999999 290.03 464.63 "X-ray of joints, multiple" 9190680_1 CDM 0320 RC 77077 HCPCS inpatient 479 311.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 290.03 464.63 "X-ray of joints, multiple" 9190680_1 CDM 0320 RC 77077 HCPCS inpatient 479 311.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 290.03 464.63 "X-ray of joints, multiple" 9190680_1 CDM 0320 RC 77077 HCPCS inpatient 479 311.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 323.8 67.6 999999999 290.03 464.63 percent of total billed charges "X-ray of joints, multiple" 9190680_1 CDM 0320 RC 77077 HCPCS inpatient 479 311.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 290.03 464.63 Review by radiologist of multiple spinal canals image 9190710_1 CDM 0320 RC 72270 HCPCS inpatient 1971 1281.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1281.15 65 999999999 1193.44 1911.87 percent of total billed charges Review by radiologist of multiple spinal canals image 9190710_1 CDM 0320 RC 72270 HCPCS inpatient 1971 1281.15 AETNA AETNA 1557.09 79 999999999 1193.44 1911.87 percent of total billed charges Review by radiologist of multiple spinal canals image 9190710_1 CDM 0320 RC 72270 HCPCS inpatient 1971 1281.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1911.87 97 999999999 1193.44 1911.87 percent of total billed charges Review by radiologist of multiple spinal canals image 9190710_1 CDM 0320 RC 72270 HCPCS inpatient 1971 1281.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1359.99 69 999999999 1193.44 1911.87 percent of total billed charges Review by radiologist of multiple spinal canals image 9190710_1 CDM 0320 RC 72270 HCPCS inpatient 1971 1281.15 SIHO - ALL PLANS SIHO - ALL PLANS 1773.9 90 999999999 1193.44 1911.87 percent of total billed charges Review by radiologist of multiple spinal canals image 9190710_1 CDM 0320 RC 72270 HCPCS inpatient 1971 1281.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1537.38 78 999999999 1193.44 1911.87 percent of total billed charges Review by radiologist of multiple spinal canals image 9190710_1 CDM 0320 RC 72270 HCPCS inpatient 1971 1281.15 UMR - ALL PLANS UMR - ALL PLANS 1379.7 70 999999999 1193.44 1911.87 percent of total billed charges Review by radiologist of multiple spinal canals image 9190710_1 CDM 0320 RC 72270 HCPCS inpatient 1971 1281.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1193.44 1911.87 Review by radiologist of multiple spinal canals image 9190710_1 CDM 0320 RC 72270 HCPCS inpatient 1971 1281.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1193.44 60.55 999999999 1193.44 1911.87 percent of total billed charges Review by radiologist of multiple spinal canals image 9190710_1 CDM 0320 RC 72270 HCPCS inpatient 1971 1281.15 ANTHEM HMO ANTHEM HMO 999999999 1193.44 1911.87 Review by radiologist of multiple spinal canals image 9190710_1 CDM 0320 RC 72270 HCPCS inpatient 1971 1281.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1193.44 1911.87 Review by radiologist of multiple spinal canals image 9190710_1 CDM 0320 RC 72270 HCPCS inpatient 1971 1281.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1193.44 1911.87 Review by radiologist of multiple spinal canals image 9190710_1 CDM 0320 RC 72270 HCPCS inpatient 1971 1281.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1332.4 67.6 999999999 1193.44 1911.87 percent of total billed charges Review by radiologist of multiple spinal canals image 9190710_1 CDM 0320 RC 72270 HCPCS inpatient 1971 1281.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1193.44 1911.87 X-ray of surgical specimen 9190734_1 CDM 0320 RC 76098 HCPCS inpatient 1113 723.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 723.45 65 999999999 673.92 1079.61 percent of total billed charges X-ray of surgical specimen 9190734_1 CDM 0320 RC 76098 HCPCS inpatient 1113 723.45 AETNA AETNA 879.27 79 999999999 673.92 1079.61 percent of total billed charges X-ray of surgical specimen 9190734_1 CDM 0320 RC 76098 HCPCS inpatient 1113 723.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1079.61 97 999999999 673.92 1079.61 percent of total billed charges X-ray of surgical specimen 9190734_1 CDM 0320 RC 76098 HCPCS inpatient 1113 723.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 767.97 69 999999999 673.92 1079.61 percent of total billed charges X-ray of surgical specimen 9190734_1 CDM 0320 RC 76098 HCPCS inpatient 1113 723.45 SIHO - ALL PLANS SIHO - ALL PLANS 1001.7 90 999999999 673.92 1079.61 percent of total billed charges X-ray of surgical specimen 9190734_1 CDM 0320 RC 76098 HCPCS inpatient 1113 723.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 868.14 78 999999999 673.92 1079.61 percent of total billed charges X-ray of surgical specimen 9190734_1 CDM 0320 RC 76098 HCPCS inpatient 1113 723.45 UMR - ALL PLANS UMR - ALL PLANS 779.1 70 999999999 673.92 1079.61 percent of total billed charges X-ray of surgical specimen 9190734_1 CDM 0320 RC 76098 HCPCS inpatient 1113 723.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 673.92 1079.61 X-ray of surgical specimen 9190734_1 CDM 0320 RC 76098 HCPCS inpatient 1113 723.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 673.92 60.55 999999999 673.92 1079.61 percent of total billed charges X-ray of surgical specimen 9190734_1 CDM 0320 RC 76098 HCPCS inpatient 1113 723.45 ANTHEM HMO ANTHEM HMO 999999999 673.92 1079.61 X-ray of surgical specimen 9190734_1 CDM 0320 RC 76098 HCPCS inpatient 1113 723.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 673.92 1079.61 X-ray of surgical specimen 9190734_1 CDM 0320 RC 76098 HCPCS inpatient 1113 723.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 673.92 1079.61 X-ray of surgical specimen 9190734_1 CDM 0320 RC 76098 HCPCS inpatient 1113 723.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 752.39 67.6 999999999 673.92 1079.61 percent of total billed charges X-ray of surgical specimen 9190734_1 CDM 0320 RC 76098 HCPCS inpatient 1113 723.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 673.92 1079.61 "DXA bone density measurement of hip, pelvis, spine" 922818_1 CDM 0320 RC 77080 HCPCS inpatient 668 434.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 434.2 65 999999999 404.47 647.96 percent of total billed charges "DXA bone density measurement of hip, pelvis, spine" 922818_1 CDM 0320 RC 77080 HCPCS inpatient 668 434.2 AETNA AETNA 527.72 79 999999999 404.47 647.96 percent of total billed charges "DXA bone density measurement of hip, pelvis, spine" 922818_1 CDM 0320 RC 77080 HCPCS inpatient 668 434.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 647.96 97 999999999 404.47 647.96 percent of total billed charges "DXA bone density measurement of hip, pelvis, spine" 922818_1 CDM 0320 RC 77080 HCPCS inpatient 668 434.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 460.92 69 999999999 404.47 647.96 percent of total billed charges "DXA bone density measurement of hip, pelvis, spine" 922818_1 CDM 0320 RC 77080 HCPCS inpatient 668 434.2 SIHO - ALL PLANS SIHO - ALL PLANS 601.2 90 999999999 404.47 647.96 percent of total billed charges "DXA bone density measurement of hip, pelvis, spine" 922818_1 CDM 0320 RC 77080 HCPCS inpatient 668 434.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 521.04 78 999999999 404.47 647.96 percent of total billed charges "DXA bone density measurement of hip, pelvis, spine" 922818_1 CDM 0320 RC 77080 HCPCS inpatient 668 434.2 UMR - ALL PLANS UMR - ALL PLANS 467.6 70 999999999 404.47 647.96 percent of total billed charges "DXA bone density measurement of hip, pelvis, spine" 922818_1 CDM 0320 RC 77080 HCPCS inpatient 668 434.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 404.47 647.96 "DXA bone density measurement of hip, pelvis, spine" 922818_1 CDM 0320 RC 77080 HCPCS inpatient 668 434.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 404.47 60.55 999999999 404.47 647.96 percent of total billed charges "DXA bone density measurement of hip, pelvis, spine" 922818_1 CDM 0320 RC 77080 HCPCS inpatient 668 434.2 ANTHEM HMO ANTHEM HMO 999999999 404.47 647.96 "DXA bone density measurement of hip, pelvis, spine" 922818_1 CDM 0320 RC 77080 HCPCS inpatient 668 434.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 404.47 647.96 "DXA bone density measurement of hip, pelvis, spine" 922818_1 CDM 0320 RC 77080 HCPCS inpatient 668 434.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 404.47 647.96 "DXA bone density measurement of hip, pelvis, spine" 922818_1 CDM 0320 RC 77080 HCPCS inpatient 668 434.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 451.57 67.6 999999999 404.47 647.96 percent of total billed charges "DXA bone density measurement of hip, pelvis, spine" 922818_1 CDM 0320 RC 77080 HCPCS inpatient 668 434.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 404.47 647.96 CT scan of abdomen and pelvis before and after contrast 922827_1 CDM 0352 RC 74178 HCPCS inpatient 2103 1366.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1366.95 65 999999999 1273.37 2039.91 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 922827_1 CDM 0352 RC 74178 HCPCS inpatient 2103 1366.95 AETNA AETNA 1661.37 79 999999999 1273.37 2039.91 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 922827_1 CDM 0352 RC 74178 HCPCS inpatient 2103 1366.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2039.91 97 999999999 1273.37 2039.91 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 922827_1 CDM 0352 RC 74178 HCPCS inpatient 2103 1366.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1451.07 69 999999999 1273.37 2039.91 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 922827_1 CDM 0352 RC 74178 HCPCS inpatient 2103 1366.95 SIHO - ALL PLANS SIHO - ALL PLANS 1892.7 90 999999999 1273.37 2039.91 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 922827_1 CDM 0352 RC 74178 HCPCS inpatient 2103 1366.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1640.34 78 999999999 1273.37 2039.91 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 922827_1 CDM 0352 RC 74178 HCPCS inpatient 2103 1366.95 UMR - ALL PLANS UMR - ALL PLANS 1472.1 70 999999999 1273.37 2039.91 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 922827_1 CDM 0352 RC 74178 HCPCS inpatient 2103 1366.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1273.37 2039.91 CT scan of abdomen and pelvis before and after contrast 922827_1 CDM 0352 RC 74178 HCPCS inpatient 2103 1366.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1273.37 60.55 999999999 1273.37 2039.91 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 922827_1 CDM 0352 RC 74178 HCPCS inpatient 2103 1366.95 ANTHEM HMO ANTHEM HMO 999999999 1273.37 2039.91 CT scan of abdomen and pelvis before and after contrast 922827_1 CDM 0352 RC 74178 HCPCS inpatient 2103 1366.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1273.37 2039.91 CT scan of abdomen and pelvis before and after contrast 922827_1 CDM 0352 RC 74178 HCPCS inpatient 2103 1366.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1273.37 2039.91 CT scan of abdomen and pelvis before and after contrast 922827_1 CDM 0352 RC 74178 HCPCS inpatient 2103 1366.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1421.63 67.6 999999999 1273.37 2039.91 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 922827_1 CDM 0352 RC 74178 HCPCS inpatient 2103 1366.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1273.37 2039.91 Nuclear medicine study of heart pumping function by labeling red blood cells with measurement of internal blood volume ejected with every beat over multiple cycles 922836_1 CDM 0341 RC 78472 HCPCS inpatient 2869 1864.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 1864.85 65 999999999 1737.18 2782.93 percent of total billed charges Nuclear medicine study of heart pumping function by labeling red blood cells with measurement of internal blood volume ejected with every beat over multiple cycles 922836_1 CDM 0341 RC 78472 HCPCS inpatient 2869 1864.85 AETNA AETNA 2266.51 79 999999999 1737.18 2782.93 percent of total billed charges Nuclear medicine study of heart pumping function by labeling red blood cells with measurement of internal blood volume ejected with every beat over multiple cycles 922836_1 CDM 0341 RC 78472 HCPCS inpatient 2869 1864.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2782.93 97 999999999 1737.18 2782.93 percent of total billed charges Nuclear medicine study of heart pumping function by labeling red blood cells with measurement of internal blood volume ejected with every beat over multiple cycles 922836_1 CDM 0341 RC 78472 HCPCS inpatient 2869 1864.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 1979.61 69 999999999 1737.18 2782.93 percent of total billed charges Nuclear medicine study of heart pumping function by labeling red blood cells with measurement of internal blood volume ejected with every beat over multiple cycles 922836_1 CDM 0341 RC 78472 HCPCS inpatient 2869 1864.85 SIHO - ALL PLANS SIHO - ALL PLANS 2582.1 90 999999999 1737.18 2782.93 percent of total billed charges Nuclear medicine study of heart pumping function by labeling red blood cells with measurement of internal blood volume ejected with every beat over multiple cycles 922836_1 CDM 0341 RC 78472 HCPCS inpatient 2869 1864.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 2237.82 78 999999999 1737.18 2782.93 percent of total billed charges Nuclear medicine study of heart pumping function by labeling red blood cells with measurement of internal blood volume ejected with every beat over multiple cycles 922836_1 CDM 0341 RC 78472 HCPCS inpatient 2869 1864.85 UMR - ALL PLANS UMR - ALL PLANS 2008.3 70 999999999 1737.18 2782.93 percent of total billed charges Nuclear medicine study of heart pumping function by labeling red blood cells with measurement of internal blood volume ejected with every beat over multiple cycles 922836_1 CDM 0341 RC 78472 HCPCS inpatient 2869 1864.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1737.18 2782.93 Nuclear medicine study of heart pumping function by labeling red blood cells with measurement of internal blood volume ejected with every beat over multiple cycles 922836_1 CDM 0341 RC 78472 HCPCS inpatient 2869 1864.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1737.18 60.55 999999999 1737.18 2782.93 percent of total billed charges Nuclear medicine study of heart pumping function by labeling red blood cells with measurement of internal blood volume ejected with every beat over multiple cycles 922836_1 CDM 0341 RC 78472 HCPCS inpatient 2869 1864.85 ANTHEM HMO ANTHEM HMO 999999999 1737.18 2782.93 Nuclear medicine study of heart pumping function by labeling red blood cells with measurement of internal blood volume ejected with every beat over multiple cycles 922836_1 CDM 0341 RC 78472 HCPCS inpatient 2869 1864.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1737.18 2782.93 Nuclear medicine study of heart pumping function by labeling red blood cells with measurement of internal blood volume ejected with every beat over multiple cycles 922836_1 CDM 0341 RC 78472 HCPCS inpatient 2869 1864.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1737.18 2782.93 Nuclear medicine study of heart pumping function by labeling red blood cells with measurement of internal blood volume ejected with every beat over multiple cycles 922836_1 CDM 0341 RC 78472 HCPCS inpatient 2869 1864.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 1939.44 67.6 999999999 1737.18 2782.93 percent of total billed charges Nuclear medicine study of heart pumping function by labeling red blood cells with measurement of internal blood volume ejected with every beat over multiple cycles 922836_1 CDM 0341 RC 78472 HCPCS inpatient 2869 1864.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 1737.18 2782.93 Nuclear medicine study to assess blood loss 922839_1 CDM 0341 RC 78278 HCPCS inpatient 1841 1196.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1196.65 65 999999999 1114.73 1785.77 percent of total billed charges Nuclear medicine study to assess blood loss 922839_1 CDM 0341 RC 78278 HCPCS inpatient 1841 1196.65 AETNA AETNA 1454.39 79 999999999 1114.73 1785.77 percent of total billed charges Nuclear medicine study to assess blood loss 922839_1 CDM 0341 RC 78278 HCPCS inpatient 1841 1196.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1785.77 97 999999999 1114.73 1785.77 percent of total billed charges Nuclear medicine study to assess blood loss 922839_1 CDM 0341 RC 78278 HCPCS inpatient 1841 1196.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 1270.29 69 999999999 1114.73 1785.77 percent of total billed charges Nuclear medicine study to assess blood loss 922839_1 CDM 0341 RC 78278 HCPCS inpatient 1841 1196.65 SIHO - ALL PLANS SIHO - ALL PLANS 1656.9 90 999999999 1114.73 1785.77 percent of total billed charges Nuclear medicine study to assess blood loss 922839_1 CDM 0341 RC 78278 HCPCS inpatient 1841 1196.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 1435.98 78 999999999 1114.73 1785.77 percent of total billed charges Nuclear medicine study to assess blood loss 922839_1 CDM 0341 RC 78278 HCPCS inpatient 1841 1196.65 UMR - ALL PLANS UMR - ALL PLANS 1288.7 70 999999999 1114.73 1785.77 percent of total billed charges Nuclear medicine study to assess blood loss 922839_1 CDM 0341 RC 78278 HCPCS inpatient 1841 1196.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1114.73 1785.77 Nuclear medicine study to assess blood loss 922839_1 CDM 0341 RC 78278 HCPCS inpatient 1841 1196.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1114.73 60.55 999999999 1114.73 1785.77 percent of total billed charges Nuclear medicine study to assess blood loss 922839_1 CDM 0341 RC 78278 HCPCS inpatient 1841 1196.65 ANTHEM HMO ANTHEM HMO 999999999 1114.73 1785.77 Nuclear medicine study to assess blood loss 922839_1 CDM 0341 RC 78278 HCPCS inpatient 1841 1196.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1114.73 1785.77 Nuclear medicine study to assess blood loss 922839_1 CDM 0341 RC 78278 HCPCS inpatient 1841 1196.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1114.73 1785.77 Nuclear medicine study to assess blood loss 922839_1 CDM 0341 RC 78278 HCPCS inpatient 1841 1196.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 1244.52 67.6 999999999 1114.73 1785.77 percent of total billed charges Nuclear medicine study to assess blood loss 922839_1 CDM 0341 RC 78278 HCPCS inpatient 1841 1196.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1114.73 1785.77 Nuclear medicine study of intestine 922845_1 CDM 0341 RC 78290 HCPCS inpatient 1095 711.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 711.75 65 999999999 663.02 1062.15 percent of total billed charges Nuclear medicine study of intestine 922845_1 CDM 0341 RC 78290 HCPCS inpatient 1095 711.75 AETNA AETNA 865.05 79 999999999 663.02 1062.15 percent of total billed charges Nuclear medicine study of intestine 922845_1 CDM 0341 RC 78290 HCPCS inpatient 1095 711.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1062.15 97 999999999 663.02 1062.15 percent of total billed charges Nuclear medicine study of intestine 922845_1 CDM 0341 RC 78290 HCPCS inpatient 1095 711.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 755.55 69 999999999 663.02 1062.15 percent of total billed charges Nuclear medicine study of intestine 922845_1 CDM 0341 RC 78290 HCPCS inpatient 1095 711.75 SIHO - ALL PLANS SIHO - ALL PLANS 985.5 90 999999999 663.02 1062.15 percent of total billed charges Nuclear medicine study of intestine 922845_1 CDM 0341 RC 78290 HCPCS inpatient 1095 711.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 854.1 78 999999999 663.02 1062.15 percent of total billed charges Nuclear medicine study of intestine 922845_1 CDM 0341 RC 78290 HCPCS inpatient 1095 711.75 UMR - ALL PLANS UMR - ALL PLANS 766.5 70 999999999 663.02 1062.15 percent of total billed charges Nuclear medicine study of intestine 922845_1 CDM 0341 RC 78290 HCPCS inpatient 1095 711.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 663.02 1062.15 Nuclear medicine study of intestine 922845_1 CDM 0341 RC 78290 HCPCS inpatient 1095 711.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 663.02 60.55 999999999 663.02 1062.15 percent of total billed charges Nuclear medicine study of intestine 922845_1 CDM 0341 RC 78290 HCPCS inpatient 1095 711.75 ANTHEM HMO ANTHEM HMO 999999999 663.02 1062.15 Nuclear medicine study of intestine 922845_1 CDM 0341 RC 78290 HCPCS inpatient 1095 711.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 663.02 1062.15 Nuclear medicine study of intestine 922845_1 CDM 0341 RC 78290 HCPCS inpatient 1095 711.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 663.02 1062.15 Nuclear medicine study of intestine 922845_1 CDM 0341 RC 78290 HCPCS inpatient 1095 711.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 740.22 67.6 999999999 663.02 1062.15 percent of total billed charges Nuclear medicine study of intestine 922845_1 CDM 0341 RC 78290 HCPCS inpatient 1095 711.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 663.02 1062.15 Nuclear medicine study of heart muscle at rest and with stress and SPECT 922848_1 CDM 0341 RC 78451 HCPCS inpatient 4255 2765.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 2765.75 65 999999999 2576.4 4127.35 percent of total billed charges Nuclear medicine study of heart muscle at rest and with stress and SPECT 922848_1 CDM 0341 RC 78451 HCPCS inpatient 4255 2765.75 AETNA AETNA 3361.45 79 999999999 2576.4 4127.35 percent of total billed charges Nuclear medicine study of heart muscle at rest and with stress and SPECT 922848_1 CDM 0341 RC 78451 HCPCS inpatient 4255 2765.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4127.35 97 999999999 2576.4 4127.35 percent of total billed charges Nuclear medicine study of heart muscle at rest and with stress and SPECT 922848_1 CDM 0341 RC 78451 HCPCS inpatient 4255 2765.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 2935.95 69 999999999 2576.4 4127.35 percent of total billed charges Nuclear medicine study of heart muscle at rest and with stress and SPECT 922848_1 CDM 0341 RC 78451 HCPCS inpatient 4255 2765.75 SIHO - ALL PLANS SIHO - ALL PLANS 3829.5 90 999999999 2576.4 4127.35 percent of total billed charges Nuclear medicine study of heart muscle at rest and with stress and SPECT 922848_1 CDM 0341 RC 78451 HCPCS inpatient 4255 2765.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 3318.9 78 999999999 2576.4 4127.35 percent of total billed charges Nuclear medicine study of heart muscle at rest and with stress and SPECT 922848_1 CDM 0341 RC 78451 HCPCS inpatient 4255 2765.75 UMR - ALL PLANS UMR - ALL PLANS 2978.5 70 999999999 2576.4 4127.35 percent of total billed charges Nuclear medicine study of heart muscle at rest and with stress and SPECT 922848_1 CDM 0341 RC 78451 HCPCS inpatient 4255 2765.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2576.4 4127.35 Nuclear medicine study of heart muscle at rest and with stress and SPECT 922848_1 CDM 0341 RC 78451 HCPCS inpatient 4255 2765.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2576.4 60.55 999999999 2576.4 4127.35 percent of total billed charges Nuclear medicine study of heart muscle at rest and with stress and SPECT 922848_1 CDM 0341 RC 78451 HCPCS inpatient 4255 2765.75 ANTHEM HMO ANTHEM HMO 999999999 2576.4 4127.35 Nuclear medicine study of heart muscle at rest and with stress and SPECT 922848_1 CDM 0341 RC 78451 HCPCS inpatient 4255 2765.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2576.4 4127.35 Nuclear medicine study of heart muscle at rest and with stress and SPECT 922848_1 CDM 0341 RC 78451 HCPCS inpatient 4255 2765.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2576.4 4127.35 Nuclear medicine study of heart muscle at rest and with stress and SPECT 922848_1 CDM 0341 RC 78451 HCPCS inpatient 4255 2765.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 2876.38 67.6 999999999 2576.4 4127.35 percent of total billed charges Nuclear medicine study of heart muscle at rest and with stress and SPECT 922848_1 CDM 0341 RC 78451 HCPCS inpatient 4255 2765.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 2576.4 4127.35 "Nuclear medicine study of kidney, blood, flow, and function with drug administration" 922863_1 CDM 0341 RC 78708 HCPCS inpatient 2103 1366.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 1366.95 65 999999999 1273.37 2039.91 percent of total billed charges "Nuclear medicine study of kidney, blood, flow, and function with drug administration" 922863_1 CDM 0341 RC 78708 HCPCS inpatient 2103 1366.95 AETNA AETNA 1661.37 79 999999999 1273.37 2039.91 percent of total billed charges "Nuclear medicine study of kidney, blood, flow, and function with drug administration" 922863_1 CDM 0341 RC 78708 HCPCS inpatient 2103 1366.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2039.91 97 999999999 1273.37 2039.91 percent of total billed charges "Nuclear medicine study of kidney, blood, flow, and function with drug administration" 922863_1 CDM 0341 RC 78708 HCPCS inpatient 2103 1366.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 1451.07 69 999999999 1273.37 2039.91 percent of total billed charges "Nuclear medicine study of kidney, blood, flow, and function with drug administration" 922863_1 CDM 0341 RC 78708 HCPCS inpatient 2103 1366.95 SIHO - ALL PLANS SIHO - ALL PLANS 1892.7 90 999999999 1273.37 2039.91 percent of total billed charges "Nuclear medicine study of kidney, blood, flow, and function with drug administration" 922863_1 CDM 0341 RC 78708 HCPCS inpatient 2103 1366.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 1640.34 78 999999999 1273.37 2039.91 percent of total billed charges "Nuclear medicine study of kidney, blood, flow, and function with drug administration" 922863_1 CDM 0341 RC 78708 HCPCS inpatient 2103 1366.95 UMR - ALL PLANS UMR - ALL PLANS 1472.1 70 999999999 1273.37 2039.91 percent of total billed charges "Nuclear medicine study of kidney, blood, flow, and function with drug administration" 922863_1 CDM 0341 RC 78708 HCPCS inpatient 2103 1366.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1273.37 2039.91 "Nuclear medicine study of kidney, blood, flow, and function with drug administration" 922863_1 CDM 0341 RC 78708 HCPCS inpatient 2103 1366.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1273.37 60.55 999999999 1273.37 2039.91 percent of total billed charges "Nuclear medicine study of kidney, blood, flow, and function with drug administration" 922863_1 CDM 0341 RC 78708 HCPCS inpatient 2103 1366.95 ANTHEM HMO ANTHEM HMO 999999999 1273.37 2039.91 "Nuclear medicine study of kidney, blood, flow, and function with drug administration" 922863_1 CDM 0341 RC 78708 HCPCS inpatient 2103 1366.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1273.37 2039.91 "Nuclear medicine study of kidney, blood, flow, and function with drug administration" 922863_1 CDM 0341 RC 78708 HCPCS inpatient 2103 1366.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1273.37 2039.91 "Nuclear medicine study of kidney, blood, flow, and function with drug administration" 922863_1 CDM 0341 RC 78708 HCPCS inpatient 2103 1366.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 1421.63 67.6 999999999 1273.37 2039.91 percent of total billed charges "Nuclear medicine study of kidney, blood, flow, and function with drug administration" 922863_1 CDM 0341 RC 78708 HCPCS inpatient 2103 1366.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1273.37 2039.91 "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 922920_1 CDM 0402 RC 76805 HCPCS inpatient 1148 746.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 746.2 65 999999999 695.11 1113.56 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 922920_1 CDM 0402 RC 76805 HCPCS inpatient 1148 746.2 AETNA AETNA 906.92 79 999999999 695.11 1113.56 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 922920_1 CDM 0402 RC 76805 HCPCS inpatient 1148 746.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1113.56 97 999999999 695.11 1113.56 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 922920_1 CDM 0402 RC 76805 HCPCS inpatient 1148 746.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 792.12 69 999999999 695.11 1113.56 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 922920_1 CDM 0402 RC 76805 HCPCS inpatient 1148 746.2 SIHO - ALL PLANS SIHO - ALL PLANS 1033.2 90 999999999 695.11 1113.56 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 922920_1 CDM 0402 RC 76805 HCPCS inpatient 1148 746.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 895.44 78 999999999 695.11 1113.56 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 922920_1 CDM 0402 RC 76805 HCPCS inpatient 1148 746.2 UMR - ALL PLANS UMR - ALL PLANS 803.6 70 999999999 695.11 1113.56 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 922920_1 CDM 0402 RC 76805 HCPCS inpatient 1148 746.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 695.11 1113.56 "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 922920_1 CDM 0402 RC 76805 HCPCS inpatient 1148 746.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 695.11 60.55 999999999 695.11 1113.56 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 922920_1 CDM 0402 RC 76805 HCPCS inpatient 1148 746.2 ANTHEM HMO ANTHEM HMO 999999999 695.11 1113.56 "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 922920_1 CDM 0402 RC 76805 HCPCS inpatient 1148 746.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 695.11 1113.56 "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 922920_1 CDM 0402 RC 76805 HCPCS inpatient 1148 746.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 695.11 1113.56 "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 922920_1 CDM 0402 RC 76805 HCPCS inpatient 1148 746.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 776.05 67.6 999999999 695.11 1113.56 percent of total billed charges "Ultrasound scan of pregnant uterus (14 weeks or more), single or first fetus" 922920_1 CDM 0402 RC 76805 HCPCS inpatient 1148 746.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 695.11 1113.56 Limited ultrasound of pregnant uterus 922923_1 CDM 0402 RC 76815 HCPCS inpatient 867 563.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 563.55 65 999999999 524.97 840.99 percent of total billed charges Limited ultrasound of pregnant uterus 922923_1 CDM 0402 RC 76815 HCPCS inpatient 867 563.55 AETNA AETNA 684.93 79 999999999 524.97 840.99 percent of total billed charges Limited ultrasound of pregnant uterus 922923_1 CDM 0402 RC 76815 HCPCS inpatient 867 563.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 840.99 97 999999999 524.97 840.99 percent of total billed charges Limited ultrasound of pregnant uterus 922923_1 CDM 0402 RC 76815 HCPCS inpatient 867 563.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 598.23 69 999999999 524.97 840.99 percent of total billed charges Limited ultrasound of pregnant uterus 922923_1 CDM 0402 RC 76815 HCPCS inpatient 867 563.55 SIHO - ALL PLANS SIHO - ALL PLANS 780.3 90 999999999 524.97 840.99 percent of total billed charges Limited ultrasound of pregnant uterus 922923_1 CDM 0402 RC 76815 HCPCS inpatient 867 563.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 676.26 78 999999999 524.97 840.99 percent of total billed charges Limited ultrasound of pregnant uterus 922923_1 CDM 0402 RC 76815 HCPCS inpatient 867 563.55 UMR - ALL PLANS UMR - ALL PLANS 606.9 70 999999999 524.97 840.99 percent of total billed charges Limited ultrasound of pregnant uterus 922923_1 CDM 0402 RC 76815 HCPCS inpatient 867 563.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 524.97 840.99 Limited ultrasound of pregnant uterus 922923_1 CDM 0402 RC 76815 HCPCS inpatient 867 563.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 524.97 60.55 999999999 524.97 840.99 percent of total billed charges Limited ultrasound of pregnant uterus 922923_1 CDM 0402 RC 76815 HCPCS inpatient 867 563.55 ANTHEM HMO ANTHEM HMO 999999999 524.97 840.99 Limited ultrasound of pregnant uterus 922923_1 CDM 0402 RC 76815 HCPCS inpatient 867 563.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 524.97 840.99 Limited ultrasound of pregnant uterus 922923_1 CDM 0402 RC 76815 HCPCS inpatient 867 563.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 524.97 840.99 Limited ultrasound of pregnant uterus 922923_1 CDM 0402 RC 76815 HCPCS inpatient 867 563.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 586.09 67.6 999999999 524.97 840.99 percent of total billed charges Limited ultrasound of pregnant uterus 922923_1 CDM 0402 RC 76815 HCPCS inpatient 867 563.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 524.97 840.99 "X-ray of abdomen, 1 view" 922935_1 CDM 0320 RC 74018 HCPCS inpatient 630 409.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 409.5 65 999999999 381.47 611.1 percent of total billed charges "X-ray of abdomen, 1 view" 922935_1 CDM 0320 RC 74018 HCPCS inpatient 630 409.5 AETNA AETNA 497.7 79 999999999 381.47 611.1 percent of total billed charges "X-ray of abdomen, 1 view" 922935_1 CDM 0320 RC 74018 HCPCS inpatient 630 409.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 611.1 97 999999999 381.47 611.1 percent of total billed charges "X-ray of abdomen, 1 view" 922935_1 CDM 0320 RC 74018 HCPCS inpatient 630 409.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 434.7 69 999999999 381.47 611.1 percent of total billed charges "X-ray of abdomen, 1 view" 922935_1 CDM 0320 RC 74018 HCPCS inpatient 630 409.5 SIHO - ALL PLANS SIHO - ALL PLANS 567 90 999999999 381.47 611.1 percent of total billed charges "X-ray of abdomen, 1 view" 922935_1 CDM 0320 RC 74018 HCPCS inpatient 630 409.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 491.4 78 999999999 381.47 611.1 percent of total billed charges "X-ray of abdomen, 1 view" 922935_1 CDM 0320 RC 74018 HCPCS inpatient 630 409.5 UMR - ALL PLANS UMR - ALL PLANS 441 70 999999999 381.47 611.1 percent of total billed charges "X-ray of abdomen, 1 view" 922935_1 CDM 0320 RC 74018 HCPCS inpatient 630 409.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 381.47 611.1 "X-ray of abdomen, 1 view" 922935_1 CDM 0320 RC 74018 HCPCS inpatient 630 409.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 381.47 60.55 999999999 381.47 611.1 percent of total billed charges "X-ray of abdomen, 1 view" 922935_1 CDM 0320 RC 74018 HCPCS inpatient 630 409.5 ANTHEM HMO ANTHEM HMO 999999999 381.47 611.1 "X-ray of abdomen, 1 view" 922935_1 CDM 0320 RC 74018 HCPCS inpatient 630 409.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 381.47 611.1 "X-ray of abdomen, 1 view" 922935_1 CDM 0320 RC 74018 HCPCS inpatient 630 409.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 381.47 611.1 "X-ray of abdomen, 1 view" 922935_1 CDM 0320 RC 74018 HCPCS inpatient 630 409.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 425.88 67.6 999999999 381.47 611.1 percent of total billed charges "X-ray of abdomen, 1 view" 922935_1 CDM 0320 RC 74018 HCPCS inpatient 630 409.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 381.47 611.1 "X-ray of shoulder, minimum of 2 views" 922947_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 331.5 65 999999999 308.81 494.7 percent of total billed charges "X-ray of shoulder, minimum of 2 views" 922947_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 AETNA AETNA 402.9 79 999999999 308.81 494.7 percent of total billed charges "X-ray of shoulder, minimum of 2 views" 922947_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 494.7 97 999999999 308.81 494.7 percent of total billed charges "X-ray of shoulder, minimum of 2 views" 922947_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 351.9 69 999999999 308.81 494.7 percent of total billed charges "X-ray of shoulder, minimum of 2 views" 922947_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 SIHO - ALL PLANS SIHO - ALL PLANS 459 90 999999999 308.81 494.7 percent of total billed charges "X-ray of shoulder, minimum of 2 views" 922947_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 397.8 78 999999999 308.81 494.7 percent of total billed charges "X-ray of shoulder, minimum of 2 views" 922947_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 UMR - ALL PLANS UMR - ALL PLANS 357 70 999999999 308.81 494.7 percent of total billed charges "X-ray of shoulder, minimum of 2 views" 922947_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 308.81 494.7 "X-ray of shoulder, minimum of 2 views" 922947_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 308.81 60.55 999999999 308.81 494.7 percent of total billed charges "X-ray of shoulder, minimum of 2 views" 922947_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 ANTHEM HMO ANTHEM HMO 999999999 308.81 494.7 "X-ray of shoulder, minimum of 2 views" 922947_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 308.81 494.7 "X-ray of shoulder, minimum of 2 views" 922947_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 308.81 494.7 "X-ray of shoulder, minimum of 2 views" 922947_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 344.76 67.6 999999999 308.81 494.7 percent of total billed charges "X-ray of shoulder, minimum of 2 views" 922947_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 308.81 494.7 "X-ray of shoulder, minimum of 2 views" 922950_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 331.5 65 999999999 308.81 494.7 percent of total billed charges "X-ray of shoulder, minimum of 2 views" 922950_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 AETNA AETNA 402.9 79 999999999 308.81 494.7 percent of total billed charges "X-ray of shoulder, minimum of 2 views" 922950_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 494.7 97 999999999 308.81 494.7 percent of total billed charges "X-ray of shoulder, minimum of 2 views" 922950_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 351.9 69 999999999 308.81 494.7 percent of total billed charges "X-ray of shoulder, minimum of 2 views" 922950_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 SIHO - ALL PLANS SIHO - ALL PLANS 459 90 999999999 308.81 494.7 percent of total billed charges "X-ray of shoulder, minimum of 2 views" 922950_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 397.8 78 999999999 308.81 494.7 percent of total billed charges "X-ray of shoulder, minimum of 2 views" 922950_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 UMR - ALL PLANS UMR - ALL PLANS 357 70 999999999 308.81 494.7 percent of total billed charges "X-ray of shoulder, minimum of 2 views" 922950_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 308.81 494.7 "X-ray of shoulder, minimum of 2 views" 922950_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 308.81 60.55 999999999 308.81 494.7 percent of total billed charges "X-ray of shoulder, minimum of 2 views" 922950_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 ANTHEM HMO ANTHEM HMO 999999999 308.81 494.7 "X-ray of shoulder, minimum of 2 views" 922950_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 308.81 494.7 "X-ray of shoulder, minimum of 2 views" 922950_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 308.81 494.7 "X-ray of shoulder, minimum of 2 views" 922950_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 344.76 67.6 999999999 308.81 494.7 percent of total billed charges "X-ray of shoulder, minimum of 2 views" 922950_1 CDM 0320 RC 73030 HCPCS inpatient 510 331.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 308.81 494.7 "Red blood count automated, with additional calculations" 9253050_1 CDM 0305 RC 85046 HCPCS inpatient 154 100.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 100.1 65 999999999 93.25 149.38 percent of total billed charges "Red blood count automated, with additional calculations" 9253050_1 CDM 0305 RC 85046 HCPCS inpatient 154 100.1 AETNA AETNA 121.66 79 999999999 93.25 149.38 percent of total billed charges "Red blood count automated, with additional calculations" 9253050_1 CDM 0305 RC 85046 HCPCS inpatient 154 100.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 149.38 97 999999999 93.25 149.38 percent of total billed charges "Red blood count automated, with additional calculations" 9253050_1 CDM 0305 RC 85046 HCPCS inpatient 154 100.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 106.26 69 999999999 93.25 149.38 percent of total billed charges "Red blood count automated, with additional calculations" 9253050_1 CDM 0305 RC 85046 HCPCS inpatient 154 100.1 SIHO - ALL PLANS SIHO - ALL PLANS 138.6 90 999999999 93.25 149.38 percent of total billed charges "Red blood count automated, with additional calculations" 9253050_1 CDM 0305 RC 85046 HCPCS inpatient 154 100.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 120.12 78 999999999 93.25 149.38 percent of total billed charges "Red blood count automated, with additional calculations" 9253050_1 CDM 0305 RC 85046 HCPCS inpatient 154 100.1 UMR - ALL PLANS UMR - ALL PLANS 107.8 70 999999999 93.25 149.38 percent of total billed charges "Red blood count automated, with additional calculations" 9253050_1 CDM 0305 RC 85046 HCPCS inpatient 154 100.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 93.25 149.38 "Red blood count automated, with additional calculations" 9253050_1 CDM 0305 RC 85046 HCPCS inpatient 154 100.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 93.25 60.55 999999999 93.25 149.38 percent of total billed charges "Red blood count automated, with additional calculations" 9253050_1 CDM 0305 RC 85046 HCPCS inpatient 154 100.1 ANTHEM HMO ANTHEM HMO 999999999 93.25 149.38 "Red blood count automated, with additional calculations" 9253050_1 CDM 0305 RC 85046 HCPCS inpatient 154 100.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 93.25 149.38 "Red blood count automated, with additional calculations" 9253050_1 CDM 0305 RC 85046 HCPCS inpatient 154 100.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 93.25 149.38 "Red blood count automated, with additional calculations" 9253050_1 CDM 0305 RC 85046 HCPCS inpatient 154 100.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 104.1 67.6 999999999 93.25 149.38 percent of total billed charges "Red blood count automated, with additional calculations" 9253050_1 CDM 0305 RC 85046 HCPCS inpatient 154 100.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 93.25 149.38 Screening mammography 926904_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 315.9 65 999999999 294.27 471.42 percent of total billed charges Screening mammography 926904_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 AETNA AETNA 383.94 79 999999999 294.27 471.42 percent of total billed charges Screening mammography 926904_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 471.42 97 999999999 294.27 471.42 percent of total billed charges Screening mammography 926904_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 335.34 69 999999999 294.27 471.42 percent of total billed charges Screening mammography 926904_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 SIHO - ALL PLANS SIHO - ALL PLANS 437.4 90 999999999 294.27 471.42 percent of total billed charges Screening mammography 926904_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 379.08 78 999999999 294.27 471.42 percent of total billed charges Screening mammography 926904_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 UMR - ALL PLANS UMR - ALL PLANS 340.2 70 999999999 294.27 471.42 percent of total billed charges Screening mammography 926904_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 294.27 471.42 Screening mammography 926904_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 294.27 60.55 999999999 294.27 471.42 percent of total billed charges Screening mammography 926904_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 ANTHEM HMO ANTHEM HMO 999999999 294.27 471.42 Screening mammography 926904_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 294.27 471.42 Screening mammography 926904_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 294.27 471.42 Screening mammography 926904_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 328.54 67.6 999999999 294.27 471.42 percent of total billed charges Screening mammography 926904_1 CDM 0403 RC 77067 HCPCS inpatient 486 315.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 294.27 471.42 MRI scan of blood vessels of head before and after contrast 926916_1 CDM 0615 RC 70546 HCPCS inpatient 3183 2068.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 2068.95 65 999999999 1927.31 3087.51 percent of total billed charges MRI scan of blood vessels of head before and after contrast 926916_1 CDM 0615 RC 70546 HCPCS inpatient 3183 2068.95 AETNA AETNA 2514.57 79 999999999 1927.31 3087.51 percent of total billed charges MRI scan of blood vessels of head before and after contrast 926916_1 CDM 0615 RC 70546 HCPCS inpatient 3183 2068.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3087.51 97 999999999 1927.31 3087.51 percent of total billed charges MRI scan of blood vessels of head before and after contrast 926916_1 CDM 0615 RC 70546 HCPCS inpatient 3183 2068.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 2196.27 69 999999999 1927.31 3087.51 percent of total billed charges MRI scan of blood vessels of head before and after contrast 926916_1 CDM 0615 RC 70546 HCPCS inpatient 3183 2068.95 SIHO - ALL PLANS SIHO - ALL PLANS 2864.7 90 999999999 1927.31 3087.51 percent of total billed charges MRI scan of blood vessels of head before and after contrast 926916_1 CDM 0615 RC 70546 HCPCS inpatient 3183 2068.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 2482.74 78 999999999 1927.31 3087.51 percent of total billed charges MRI scan of blood vessels of head before and after contrast 926916_1 CDM 0615 RC 70546 HCPCS inpatient 3183 2068.95 UMR - ALL PLANS UMR - ALL PLANS 2228.1 70 999999999 1927.31 3087.51 percent of total billed charges MRI scan of blood vessels of head before and after contrast 926916_1 CDM 0615 RC 70546 HCPCS inpatient 3183 2068.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1927.31 3087.51 MRI scan of blood vessels of head before and after contrast 926916_1 CDM 0615 RC 70546 HCPCS inpatient 3183 2068.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1927.31 60.55 999999999 1927.31 3087.51 percent of total billed charges MRI scan of blood vessels of head before and after contrast 926916_1 CDM 0615 RC 70546 HCPCS inpatient 3183 2068.95 ANTHEM HMO ANTHEM HMO 999999999 1927.31 3087.51 MRI scan of blood vessels of head before and after contrast 926916_1 CDM 0615 RC 70546 HCPCS inpatient 3183 2068.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1927.31 3087.51 MRI scan of blood vessels of head before and after contrast 926916_1 CDM 0615 RC 70546 HCPCS inpatient 3183 2068.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1927.31 3087.51 MRI scan of blood vessels of head before and after contrast 926916_1 CDM 0615 RC 70546 HCPCS inpatient 3183 2068.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 2151.71 67.6 999999999 1927.31 3087.51 percent of total billed charges MRI scan of blood vessels of head before and after contrast 926916_1 CDM 0615 RC 70546 HCPCS inpatient 3183 2068.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 1927.31 3087.51 MRI scan of blood vessels of head with contrast 926918_1 CDM 0615 RC 70545 HCPCS inpatient 3004 1952.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1952.6 65 999999999 1818.92 2913.88 percent of total billed charges MRI scan of blood vessels of head with contrast 926918_1 CDM 0615 RC 70545 HCPCS inpatient 3004 1952.6 AETNA AETNA 2373.16 79 999999999 1818.92 2913.88 percent of total billed charges MRI scan of blood vessels of head with contrast 926918_1 CDM 0615 RC 70545 HCPCS inpatient 3004 1952.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2913.88 97 999999999 1818.92 2913.88 percent of total billed charges MRI scan of blood vessels of head with contrast 926918_1 CDM 0615 RC 70545 HCPCS inpatient 3004 1952.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 2072.76 69 999999999 1818.92 2913.88 percent of total billed charges MRI scan of blood vessels of head with contrast 926918_1 CDM 0615 RC 70545 HCPCS inpatient 3004 1952.6 SIHO - ALL PLANS SIHO - ALL PLANS 2703.6 90 999999999 1818.92 2913.88 percent of total billed charges MRI scan of blood vessels of head with contrast 926918_1 CDM 0615 RC 70545 HCPCS inpatient 3004 1952.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 2343.12 78 999999999 1818.92 2913.88 percent of total billed charges MRI scan of blood vessels of head with contrast 926918_1 CDM 0615 RC 70545 HCPCS inpatient 3004 1952.6 UMR - ALL PLANS UMR - ALL PLANS 2102.8 70 999999999 1818.92 2913.88 percent of total billed charges MRI scan of blood vessels of head with contrast 926918_1 CDM 0615 RC 70545 HCPCS inpatient 3004 1952.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1818.92 2913.88 MRI scan of blood vessels of head with contrast 926918_1 CDM 0615 RC 70545 HCPCS inpatient 3004 1952.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1818.92 60.55 999999999 1818.92 2913.88 percent of total billed charges MRI scan of blood vessels of head with contrast 926918_1 CDM 0615 RC 70545 HCPCS inpatient 3004 1952.6 ANTHEM HMO ANTHEM HMO 999999999 1818.92 2913.88 MRI scan of blood vessels of head with contrast 926918_1 CDM 0615 RC 70545 HCPCS inpatient 3004 1952.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1818.92 2913.88 MRI scan of blood vessels of head with contrast 926918_1 CDM 0615 RC 70545 HCPCS inpatient 3004 1952.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1818.92 2913.88 MRI scan of blood vessels of head with contrast 926918_1 CDM 0615 RC 70545 HCPCS inpatient 3004 1952.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 2030.7 67.6 999999999 1818.92 2913.88 percent of total billed charges MRI scan of blood vessels of head with contrast 926918_1 CDM 0615 RC 70545 HCPCS inpatient 3004 1952.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1818.92 2913.88 MRI scan of blood vessels of head without contrast 926920_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1934.4 65 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of head without contrast 926920_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 AETNA AETNA 2351.04 79 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of head without contrast 926920_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2886.72 97 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of head without contrast 926920_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 2053.44 69 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of head without contrast 926920_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 SIHO - ALL PLANS SIHO - ALL PLANS 2678.4 90 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of head without contrast 926920_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 2321.28 78 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of head without contrast 926920_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 UMR - ALL PLANS UMR - ALL PLANS 2083.2 70 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of head without contrast 926920_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1801.97 2886.72 MRI scan of blood vessels of head without contrast 926920_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1801.97 60.55 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of head without contrast 926920_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 ANTHEM HMO ANTHEM HMO 999999999 1801.97 2886.72 MRI scan of blood vessels of head without contrast 926920_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1801.97 2886.72 MRI scan of blood vessels of head without contrast 926920_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1801.97 2886.72 MRI scan of blood vessels of head without contrast 926920_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 2011.78 67.6 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of head without contrast 926920_1 CDM 0615 RC 70544 HCPCS inpatient 2976 1934.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1801.97 2886.72 MRI scan of blood vessels of neck before and after contrast 926928_1 CDM 0615 RC 70549 HCPCS inpatient 3456 2246.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 2246.4 65 999999999 2092.61 3352.32 percent of total billed charges MRI scan of blood vessels of neck before and after contrast 926928_1 CDM 0615 RC 70549 HCPCS inpatient 3456 2246.4 AETNA AETNA 2730.24 79 999999999 2092.61 3352.32 percent of total billed charges MRI scan of blood vessels of neck before and after contrast 926928_1 CDM 0615 RC 70549 HCPCS inpatient 3456 2246.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3352.32 97 999999999 2092.61 3352.32 percent of total billed charges MRI scan of blood vessels of neck before and after contrast 926928_1 CDM 0615 RC 70549 HCPCS inpatient 3456 2246.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 2384.64 69 999999999 2092.61 3352.32 percent of total billed charges MRI scan of blood vessels of neck before and after contrast 926928_1 CDM 0615 RC 70549 HCPCS inpatient 3456 2246.4 SIHO - ALL PLANS SIHO - ALL PLANS 3110.4 90 999999999 2092.61 3352.32 percent of total billed charges MRI scan of blood vessels of neck before and after contrast 926928_1 CDM 0615 RC 70549 HCPCS inpatient 3456 2246.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 2695.68 78 999999999 2092.61 3352.32 percent of total billed charges MRI scan of blood vessels of neck before and after contrast 926928_1 CDM 0615 RC 70549 HCPCS inpatient 3456 2246.4 UMR - ALL PLANS UMR - ALL PLANS 2419.2 70 999999999 2092.61 3352.32 percent of total billed charges MRI scan of blood vessels of neck before and after contrast 926928_1 CDM 0615 RC 70549 HCPCS inpatient 3456 2246.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2092.61 3352.32 MRI scan of blood vessels of neck before and after contrast 926928_1 CDM 0615 RC 70549 HCPCS inpatient 3456 2246.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2092.61 60.55 999999999 2092.61 3352.32 percent of total billed charges MRI scan of blood vessels of neck before and after contrast 926928_1 CDM 0615 RC 70549 HCPCS inpatient 3456 2246.4 ANTHEM HMO ANTHEM HMO 999999999 2092.61 3352.32 MRI scan of blood vessels of neck before and after contrast 926928_1 CDM 0615 RC 70549 HCPCS inpatient 3456 2246.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2092.61 3352.32 MRI scan of blood vessels of neck before and after contrast 926928_1 CDM 0615 RC 70549 HCPCS inpatient 3456 2246.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2092.61 3352.32 MRI scan of blood vessels of neck before and after contrast 926928_1 CDM 0615 RC 70549 HCPCS inpatient 3456 2246.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 2336.26 67.6 999999999 2092.61 3352.32 percent of total billed charges MRI scan of blood vessels of neck before and after contrast 926928_1 CDM 0615 RC 70549 HCPCS inpatient 3456 2246.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 2092.61 3352.32 MRI scan of blood vessels of neck with contrast 926930_1 CDM 0615 RC 70548 HCPCS inpatient 2978 1935.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 1935.7 65 999999999 1803.18 2888.66 percent of total billed charges MRI scan of blood vessels of neck with contrast 926930_1 CDM 0615 RC 70548 HCPCS inpatient 2978 1935.7 AETNA AETNA 2352.62 79 999999999 1803.18 2888.66 percent of total billed charges MRI scan of blood vessels of neck with contrast 926930_1 CDM 0615 RC 70548 HCPCS inpatient 2978 1935.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2888.66 97 999999999 1803.18 2888.66 percent of total billed charges MRI scan of blood vessels of neck with contrast 926930_1 CDM 0615 RC 70548 HCPCS inpatient 2978 1935.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 2054.82 69 999999999 1803.18 2888.66 percent of total billed charges MRI scan of blood vessels of neck with contrast 926930_1 CDM 0615 RC 70548 HCPCS inpatient 2978 1935.7 SIHO - ALL PLANS SIHO - ALL PLANS 2680.2 90 999999999 1803.18 2888.66 percent of total billed charges MRI scan of blood vessels of neck with contrast 926930_1 CDM 0615 RC 70548 HCPCS inpatient 2978 1935.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 2322.84 78 999999999 1803.18 2888.66 percent of total billed charges MRI scan of blood vessels of neck with contrast 926930_1 CDM 0615 RC 70548 HCPCS inpatient 2978 1935.7 UMR - ALL PLANS UMR - ALL PLANS 2084.6 70 999999999 1803.18 2888.66 percent of total billed charges MRI scan of blood vessels of neck with contrast 926930_1 CDM 0615 RC 70548 HCPCS inpatient 2978 1935.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1803.18 2888.66 MRI scan of blood vessels of neck with contrast 926930_1 CDM 0615 RC 70548 HCPCS inpatient 2978 1935.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1803.18 60.55 999999999 1803.18 2888.66 percent of total billed charges MRI scan of blood vessels of neck with contrast 926930_1 CDM 0615 RC 70548 HCPCS inpatient 2978 1935.7 ANTHEM HMO ANTHEM HMO 999999999 1803.18 2888.66 MRI scan of blood vessels of neck with contrast 926930_1 CDM 0615 RC 70548 HCPCS inpatient 2978 1935.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1803.18 2888.66 MRI scan of blood vessels of neck with contrast 926930_1 CDM 0615 RC 70548 HCPCS inpatient 2978 1935.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1803.18 2888.66 MRI scan of blood vessels of neck with contrast 926930_1 CDM 0615 RC 70548 HCPCS inpatient 2978 1935.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 2013.13 67.6 999999999 1803.18 2888.66 percent of total billed charges MRI scan of blood vessels of neck with contrast 926930_1 CDM 0615 RC 70548 HCPCS inpatient 2978 1935.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 1803.18 2888.66 MRI scan of blood vessels of neck without contrast 926932_1 CDM 0615 RC 70547 HCPCS inpatient 2976 1934.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 1934.4 65 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of neck without contrast 926932_1 CDM 0615 RC 70547 HCPCS inpatient 2976 1934.4 AETNA AETNA 2351.04 79 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of neck without contrast 926932_1 CDM 0615 RC 70547 HCPCS inpatient 2976 1934.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2886.72 97 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of neck without contrast 926932_1 CDM 0615 RC 70547 HCPCS inpatient 2976 1934.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 2053.44 69 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of neck without contrast 926932_1 CDM 0615 RC 70547 HCPCS inpatient 2976 1934.4 SIHO - ALL PLANS SIHO - ALL PLANS 2678.4 90 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of neck without contrast 926932_1 CDM 0615 RC 70547 HCPCS inpatient 2976 1934.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 2321.28 78 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of neck without contrast 926932_1 CDM 0615 RC 70547 HCPCS inpatient 2976 1934.4 UMR - ALL PLANS UMR - ALL PLANS 2083.2 70 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of neck without contrast 926932_1 CDM 0615 RC 70547 HCPCS inpatient 2976 1934.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1801.97 2886.72 MRI scan of blood vessels of neck without contrast 926932_1 CDM 0615 RC 70547 HCPCS inpatient 2976 1934.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1801.97 60.55 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of neck without contrast 926932_1 CDM 0615 RC 70547 HCPCS inpatient 2976 1934.4 ANTHEM HMO ANTHEM HMO 999999999 1801.97 2886.72 MRI scan of blood vessels of neck without contrast 926932_1 CDM 0615 RC 70547 HCPCS inpatient 2976 1934.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1801.97 2886.72 MRI scan of blood vessels of neck without contrast 926932_1 CDM 0615 RC 70547 HCPCS inpatient 2976 1934.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1801.97 2886.72 MRI scan of blood vessels of neck without contrast 926932_1 CDM 0615 RC 70547 HCPCS inpatient 2976 1934.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 2011.78 67.6 999999999 1801.97 2886.72 percent of total billed charges MRI scan of blood vessels of neck without contrast 926932_1 CDM 0615 RC 70547 HCPCS inpatient 2976 1934.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 1801.97 2886.72 MRI scan of abdomen before and after contrast 926936_1 CDM 0610 RC 74183 HCPCS inpatient 4337 2819.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 2819.05 65 999999999 2626.05 4206.89 percent of total billed charges MRI scan of abdomen before and after contrast 926936_1 CDM 0610 RC 74183 HCPCS inpatient 4337 2819.05 AETNA AETNA 3426.23 79 999999999 2626.05 4206.89 percent of total billed charges MRI scan of abdomen before and after contrast 926936_1 CDM 0610 RC 74183 HCPCS inpatient 4337 2819.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4206.89 97 999999999 2626.05 4206.89 percent of total billed charges MRI scan of abdomen before and after contrast 926936_1 CDM 0610 RC 74183 HCPCS inpatient 4337 2819.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2992.53 69 999999999 2626.05 4206.89 percent of total billed charges MRI scan of abdomen before and after contrast 926936_1 CDM 0610 RC 74183 HCPCS inpatient 4337 2819.05 SIHO - ALL PLANS SIHO - ALL PLANS 3903.3 90 999999999 2626.05 4206.89 percent of total billed charges MRI scan of abdomen before and after contrast 926936_1 CDM 0610 RC 74183 HCPCS inpatient 4337 2819.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 3382.86 78 999999999 2626.05 4206.89 percent of total billed charges MRI scan of abdomen before and after contrast 926936_1 CDM 0610 RC 74183 HCPCS inpatient 4337 2819.05 UMR - ALL PLANS UMR - ALL PLANS 3035.9 70 999999999 2626.05 4206.89 percent of total billed charges MRI scan of abdomen before and after contrast 926936_1 CDM 0610 RC 74183 HCPCS inpatient 4337 2819.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2626.05 4206.89 MRI scan of abdomen before and after contrast 926936_1 CDM 0610 RC 74183 HCPCS inpatient 4337 2819.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2626.05 60.55 999999999 2626.05 4206.89 percent of total billed charges MRI scan of abdomen before and after contrast 926936_1 CDM 0610 RC 74183 HCPCS inpatient 4337 2819.05 ANTHEM HMO ANTHEM HMO 999999999 2626.05 4206.89 MRI scan of abdomen before and after contrast 926936_1 CDM 0610 RC 74183 HCPCS inpatient 4337 2819.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2626.05 4206.89 MRI scan of abdomen before and after contrast 926936_1 CDM 0610 RC 74183 HCPCS inpatient 4337 2819.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2626.05 4206.89 MRI scan of abdomen before and after contrast 926936_1 CDM 0610 RC 74183 HCPCS inpatient 4337 2819.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2931.81 67.6 999999999 2626.05 4206.89 percent of total billed charges MRI scan of abdomen before and after contrast 926936_1 CDM 0610 RC 74183 HCPCS inpatient 4337 2819.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 2626.05 4206.89 MRI scan of abdomen with contrast 926938_1 CDM 0610 RC 74182 HCPCS inpatient 4594 2986.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 2986.1 65 999999999 2781.67 4456.18 percent of total billed charges MRI scan of abdomen with contrast 926938_1 CDM 0610 RC 74182 HCPCS inpatient 4594 2986.1 AETNA AETNA 3629.26 79 999999999 2781.67 4456.18 percent of total billed charges MRI scan of abdomen with contrast 926938_1 CDM 0610 RC 74182 HCPCS inpatient 4594 2986.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4456.18 97 999999999 2781.67 4456.18 percent of total billed charges MRI scan of abdomen with contrast 926938_1 CDM 0610 RC 74182 HCPCS inpatient 4594 2986.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 3169.86 69 999999999 2781.67 4456.18 percent of total billed charges MRI scan of abdomen with contrast 926938_1 CDM 0610 RC 74182 HCPCS inpatient 4594 2986.1 SIHO - ALL PLANS SIHO - ALL PLANS 4134.6 90 999999999 2781.67 4456.18 percent of total billed charges MRI scan of abdomen with contrast 926938_1 CDM 0610 RC 74182 HCPCS inpatient 4594 2986.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 3583.32 78 999999999 2781.67 4456.18 percent of total billed charges MRI scan of abdomen with contrast 926938_1 CDM 0610 RC 74182 HCPCS inpatient 4594 2986.1 UMR - ALL PLANS UMR - ALL PLANS 3215.8 70 999999999 2781.67 4456.18 percent of total billed charges MRI scan of abdomen with contrast 926938_1 CDM 0610 RC 74182 HCPCS inpatient 4594 2986.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2781.67 4456.18 MRI scan of abdomen with contrast 926938_1 CDM 0610 RC 74182 HCPCS inpatient 4594 2986.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2781.67 60.55 999999999 2781.67 4456.18 percent of total billed charges MRI scan of abdomen with contrast 926938_1 CDM 0610 RC 74182 HCPCS inpatient 4594 2986.1 ANTHEM HMO ANTHEM HMO 999999999 2781.67 4456.18 MRI scan of abdomen with contrast 926938_1 CDM 0610 RC 74182 HCPCS inpatient 4594 2986.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2781.67 4456.18 MRI scan of abdomen with contrast 926938_1 CDM 0610 RC 74182 HCPCS inpatient 4594 2986.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2781.67 4456.18 MRI scan of abdomen with contrast 926938_1 CDM 0610 RC 74182 HCPCS inpatient 4594 2986.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 3105.54 67.6 999999999 2781.67 4456.18 percent of total billed charges MRI scan of abdomen with contrast 926938_1 CDM 0610 RC 74182 HCPCS inpatient 4594 2986.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 2781.67 4456.18 MRI scan of abdomen without contrast 926940_1 CDM 0610 RC 74181 HCPCS inpatient 4959 3223.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 3223.35 65 999999999 3002.67 4810.23 percent of total billed charges MRI scan of abdomen without contrast 926940_1 CDM 0610 RC 74181 HCPCS inpatient 4959 3223.35 AETNA AETNA 3917.61 79 999999999 3002.67 4810.23 percent of total billed charges MRI scan of abdomen without contrast 926940_1 CDM 0610 RC 74181 HCPCS inpatient 4959 3223.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4810.23 97 999999999 3002.67 4810.23 percent of total billed charges MRI scan of abdomen without contrast 926940_1 CDM 0610 RC 74181 HCPCS inpatient 4959 3223.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 3421.71 69 999999999 3002.67 4810.23 percent of total billed charges MRI scan of abdomen without contrast 926940_1 CDM 0610 RC 74181 HCPCS inpatient 4959 3223.35 SIHO - ALL PLANS SIHO - ALL PLANS 4463.1 90 999999999 3002.67 4810.23 percent of total billed charges MRI scan of abdomen without contrast 926940_1 CDM 0610 RC 74181 HCPCS inpatient 4959 3223.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 3868.02 78 999999999 3002.67 4810.23 percent of total billed charges MRI scan of abdomen without contrast 926940_1 CDM 0610 RC 74181 HCPCS inpatient 4959 3223.35 UMR - ALL PLANS UMR - ALL PLANS 3471.3 70 999999999 3002.67 4810.23 percent of total billed charges MRI scan of abdomen without contrast 926940_1 CDM 0610 RC 74181 HCPCS inpatient 4959 3223.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3002.67 4810.23 MRI scan of abdomen without contrast 926940_1 CDM 0610 RC 74181 HCPCS inpatient 4959 3223.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3002.67 60.55 999999999 3002.67 4810.23 percent of total billed charges MRI scan of abdomen without contrast 926940_1 CDM 0610 RC 74181 HCPCS inpatient 4959 3223.35 ANTHEM HMO ANTHEM HMO 999999999 3002.67 4810.23 MRI scan of abdomen without contrast 926940_1 CDM 0610 RC 74181 HCPCS inpatient 4959 3223.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3002.67 4810.23 MRI scan of abdomen without contrast 926940_1 CDM 0610 RC 74181 HCPCS inpatient 4959 3223.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3002.67 4810.23 MRI scan of abdomen without contrast 926940_1 CDM 0610 RC 74181 HCPCS inpatient 4959 3223.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 3352.28 67.6 999999999 3002.67 4810.23 percent of total billed charges MRI scan of abdomen without contrast 926940_1 CDM 0610 RC 74181 HCPCS inpatient 4959 3223.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 3002.67 4810.23 MRI scan of brain before and after contrast 926942_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 2968.55 65 999999999 2765.32 4429.99 percent of total billed charges MRI scan of brain before and after contrast 926942_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 AETNA AETNA 3607.93 79 999999999 2765.32 4429.99 percent of total billed charges MRI scan of brain before and after contrast 926942_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4429.99 97 999999999 2765.32 4429.99 percent of total billed charges MRI scan of brain before and after contrast 926942_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 3151.23 69 999999999 2765.32 4429.99 percent of total billed charges MRI scan of brain before and after contrast 926942_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 SIHO - ALL PLANS SIHO - ALL PLANS 4110.3 90 999999999 2765.32 4429.99 percent of total billed charges MRI scan of brain before and after contrast 926942_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 3562.26 78 999999999 2765.32 4429.99 percent of total billed charges MRI scan of brain before and after contrast 926942_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 UMR - ALL PLANS UMR - ALL PLANS 3196.9 70 999999999 2765.32 4429.99 percent of total billed charges MRI scan of brain before and after contrast 926942_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2765.32 4429.99 MRI scan of brain before and after contrast 926942_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2765.32 60.55 999999999 2765.32 4429.99 percent of total billed charges MRI scan of brain before and after contrast 926942_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 ANTHEM HMO ANTHEM HMO 999999999 2765.32 4429.99 MRI scan of brain before and after contrast 926942_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2765.32 4429.99 MRI scan of brain before and after contrast 926942_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2765.32 4429.99 MRI scan of brain before and after contrast 926942_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 3087.29 67.6 999999999 2765.32 4429.99 percent of total billed charges MRI scan of brain before and after contrast 926942_1 CDM 0611 RC 70553 HCPCS inpatient 4567 2968.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 2765.32 4429.99 MRI scan of brain with contrast 926944_1 CDM 0611 RC 70552 HCPCS inpatient 4137 2689.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 2689.05 65 999999999 2504.95 4012.89 percent of total billed charges MRI scan of brain with contrast 926944_1 CDM 0611 RC 70552 HCPCS inpatient 4137 2689.05 AETNA AETNA 3268.23 79 999999999 2504.95 4012.89 percent of total billed charges MRI scan of brain with contrast 926944_1 CDM 0611 RC 70552 HCPCS inpatient 4137 2689.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4012.89 97 999999999 2504.95 4012.89 percent of total billed charges MRI scan of brain with contrast 926944_1 CDM 0611 RC 70552 HCPCS inpatient 4137 2689.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2854.53 69 999999999 2504.95 4012.89 percent of total billed charges MRI scan of brain with contrast 926944_1 CDM 0611 RC 70552 HCPCS inpatient 4137 2689.05 SIHO - ALL PLANS SIHO - ALL PLANS 3723.3 90 999999999 2504.95 4012.89 percent of total billed charges MRI scan of brain with contrast 926944_1 CDM 0611 RC 70552 HCPCS inpatient 4137 2689.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 3226.86 78 999999999 2504.95 4012.89 percent of total billed charges MRI scan of brain with contrast 926944_1 CDM 0611 RC 70552 HCPCS inpatient 4137 2689.05 UMR - ALL PLANS UMR - ALL PLANS 2895.9 70 999999999 2504.95 4012.89 percent of total billed charges MRI scan of brain with contrast 926944_1 CDM 0611 RC 70552 HCPCS inpatient 4137 2689.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2504.95 4012.89 MRI scan of brain with contrast 926944_1 CDM 0611 RC 70552 HCPCS inpatient 4137 2689.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2504.95 60.55 999999999 2504.95 4012.89 percent of total billed charges MRI scan of brain with contrast 926944_1 CDM 0611 RC 70552 HCPCS inpatient 4137 2689.05 ANTHEM HMO ANTHEM HMO 999999999 2504.95 4012.89 MRI scan of brain with contrast 926944_1 CDM 0611 RC 70552 HCPCS inpatient 4137 2689.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2504.95 4012.89 MRI scan of brain with contrast 926944_1 CDM 0611 RC 70552 HCPCS inpatient 4137 2689.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2504.95 4012.89 MRI scan of brain with contrast 926944_1 CDM 0611 RC 70552 HCPCS inpatient 4137 2689.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2796.61 67.6 999999999 2504.95 4012.89 percent of total billed charges MRI scan of brain with contrast 926944_1 CDM 0611 RC 70552 HCPCS inpatient 4137 2689.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 2504.95 4012.89 MRI scan of brain without contrast 926946_1 CDM 0611 RC 70551 HCPCS inpatient 4137 2689.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 2689.05 65 999999999 2504.95 4012.89 percent of total billed charges MRI scan of brain without contrast 926946_1 CDM 0611 RC 70551 HCPCS inpatient 4137 2689.05 AETNA AETNA 3268.23 79 999999999 2504.95 4012.89 percent of total billed charges MRI scan of brain without contrast 926946_1 CDM 0611 RC 70551 HCPCS inpatient 4137 2689.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4012.89 97 999999999 2504.95 4012.89 percent of total billed charges MRI scan of brain without contrast 926946_1 CDM 0611 RC 70551 HCPCS inpatient 4137 2689.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2854.53 69 999999999 2504.95 4012.89 percent of total billed charges MRI scan of brain without contrast 926946_1 CDM 0611 RC 70551 HCPCS inpatient 4137 2689.05 SIHO - ALL PLANS SIHO - ALL PLANS 3723.3 90 999999999 2504.95 4012.89 percent of total billed charges MRI scan of brain without contrast 926946_1 CDM 0611 RC 70551 HCPCS inpatient 4137 2689.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 3226.86 78 999999999 2504.95 4012.89 percent of total billed charges MRI scan of brain without contrast 926946_1 CDM 0611 RC 70551 HCPCS inpatient 4137 2689.05 UMR - ALL PLANS UMR - ALL PLANS 2895.9 70 999999999 2504.95 4012.89 percent of total billed charges MRI scan of brain without contrast 926946_1 CDM 0611 RC 70551 HCPCS inpatient 4137 2689.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2504.95 4012.89 MRI scan of brain without contrast 926946_1 CDM 0611 RC 70551 HCPCS inpatient 4137 2689.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2504.95 60.55 999999999 2504.95 4012.89 percent of total billed charges MRI scan of brain without contrast 926946_1 CDM 0611 RC 70551 HCPCS inpatient 4137 2689.05 ANTHEM HMO ANTHEM HMO 999999999 2504.95 4012.89 MRI scan of brain without contrast 926946_1 CDM 0611 RC 70551 HCPCS inpatient 4137 2689.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2504.95 4012.89 MRI scan of brain without contrast 926946_1 CDM 0611 RC 70551 HCPCS inpatient 4137 2689.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2504.95 4012.89 MRI scan of brain without contrast 926946_1 CDM 0611 RC 70551 HCPCS inpatient 4137 2689.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2796.61 67.6 999999999 2504.95 4012.89 percent of total billed charges MRI scan of brain without contrast 926946_1 CDM 0611 RC 70551 HCPCS inpatient 4137 2689.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 2504.95 4012.89 MRI scan of chest before and after contrast 926948_1 CDM 0610 RC 71552 HCPCS inpatient 4592 2984.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 2984.8 65 999999999 2780.46 4454.24 percent of total billed charges MRI scan of chest before and after contrast 926948_1 CDM 0610 RC 71552 HCPCS inpatient 4592 2984.8 AETNA AETNA 3627.68 79 999999999 2780.46 4454.24 percent of total billed charges MRI scan of chest before and after contrast 926948_1 CDM 0610 RC 71552 HCPCS inpatient 4592 2984.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4454.24 97 999999999 2780.46 4454.24 percent of total billed charges MRI scan of chest before and after contrast 926948_1 CDM 0610 RC 71552 HCPCS inpatient 4592 2984.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 3168.48 69 999999999 2780.46 4454.24 percent of total billed charges MRI scan of chest before and after contrast 926948_1 CDM 0610 RC 71552 HCPCS inpatient 4592 2984.8 SIHO - ALL PLANS SIHO - ALL PLANS 4132.8 90 999999999 2780.46 4454.24 percent of total billed charges MRI scan of chest before and after contrast 926948_1 CDM 0610 RC 71552 HCPCS inpatient 4592 2984.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 3581.76 78 999999999 2780.46 4454.24 percent of total billed charges MRI scan of chest before and after contrast 926948_1 CDM 0610 RC 71552 HCPCS inpatient 4592 2984.8 UMR - ALL PLANS UMR - ALL PLANS 3214.4 70 999999999 2780.46 4454.24 percent of total billed charges MRI scan of chest before and after contrast 926948_1 CDM 0610 RC 71552 HCPCS inpatient 4592 2984.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2780.46 4454.24 MRI scan of chest before and after contrast 926948_1 CDM 0610 RC 71552 HCPCS inpatient 4592 2984.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2780.46 60.55 999999999 2780.46 4454.24 percent of total billed charges MRI scan of chest before and after contrast 926948_1 CDM 0610 RC 71552 HCPCS inpatient 4592 2984.8 ANTHEM HMO ANTHEM HMO 999999999 2780.46 4454.24 MRI scan of chest before and after contrast 926948_1 CDM 0610 RC 71552 HCPCS inpatient 4592 2984.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2780.46 4454.24 MRI scan of chest before and after contrast 926948_1 CDM 0610 RC 71552 HCPCS inpatient 4592 2984.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2780.46 4454.24 MRI scan of chest before and after contrast 926948_1 CDM 0610 RC 71552 HCPCS inpatient 4592 2984.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 3104.19 67.6 999999999 2780.46 4454.24 percent of total billed charges MRI scan of chest before and after contrast 926948_1 CDM 0610 RC 71552 HCPCS inpatient 4592 2984.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 2780.46 4454.24 MRI scan of chest with contrast 926950_1 CDM 0610 RC 71551 HCPCS inpatient 4067 2643.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 2643.55 65 999999999 2462.57 3944.99 percent of total billed charges MRI scan of chest with contrast 926950_1 CDM 0610 RC 71551 HCPCS inpatient 4067 2643.55 AETNA AETNA 3212.93 79 999999999 2462.57 3944.99 percent of total billed charges MRI scan of chest with contrast 926950_1 CDM 0610 RC 71551 HCPCS inpatient 4067 2643.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3944.99 97 999999999 2462.57 3944.99 percent of total billed charges MRI scan of chest with contrast 926950_1 CDM 0610 RC 71551 HCPCS inpatient 4067 2643.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 2806.23 69 999999999 2462.57 3944.99 percent of total billed charges MRI scan of chest with contrast 926950_1 CDM 0610 RC 71551 HCPCS inpatient 4067 2643.55 SIHO - ALL PLANS SIHO - ALL PLANS 3660.3 90 999999999 2462.57 3944.99 percent of total billed charges MRI scan of chest with contrast 926950_1 CDM 0610 RC 71551 HCPCS inpatient 4067 2643.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 3172.26 78 999999999 2462.57 3944.99 percent of total billed charges MRI scan of chest with contrast 926950_1 CDM 0610 RC 71551 HCPCS inpatient 4067 2643.55 UMR - ALL PLANS UMR - ALL PLANS 2846.9 70 999999999 2462.57 3944.99 percent of total billed charges MRI scan of chest with contrast 926950_1 CDM 0610 RC 71551 HCPCS inpatient 4067 2643.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2462.57 3944.99 MRI scan of chest with contrast 926950_1 CDM 0610 RC 71551 HCPCS inpatient 4067 2643.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2462.57 60.55 999999999 2462.57 3944.99 percent of total billed charges MRI scan of chest with contrast 926950_1 CDM 0610 RC 71551 HCPCS inpatient 4067 2643.55 ANTHEM HMO ANTHEM HMO 999999999 2462.57 3944.99 MRI scan of chest with contrast 926950_1 CDM 0610 RC 71551 HCPCS inpatient 4067 2643.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2462.57 3944.99 MRI scan of chest with contrast 926950_1 CDM 0610 RC 71551 HCPCS inpatient 4067 2643.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2462.57 3944.99 MRI scan of chest with contrast 926950_1 CDM 0610 RC 71551 HCPCS inpatient 4067 2643.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 2749.29 67.6 999999999 2462.57 3944.99 percent of total billed charges MRI scan of chest with contrast 926950_1 CDM 0610 RC 71551 HCPCS inpatient 4067 2643.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 2462.57 3944.99 MRI scan of chest without contrast 926952_1 CDM 0610 RC 71550 HCPCS inpatient 3801 2470.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 2470.65 65 999999999 2301.51 3686.97 percent of total billed charges MRI scan of chest without contrast 926952_1 CDM 0610 RC 71550 HCPCS inpatient 3801 2470.65 AETNA AETNA 3002.79 79 999999999 2301.51 3686.97 percent of total billed charges MRI scan of chest without contrast 926952_1 CDM 0610 RC 71550 HCPCS inpatient 3801 2470.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3686.97 97 999999999 2301.51 3686.97 percent of total billed charges MRI scan of chest without contrast 926952_1 CDM 0610 RC 71550 HCPCS inpatient 3801 2470.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2622.69 69 999999999 2301.51 3686.97 percent of total billed charges MRI scan of chest without contrast 926952_1 CDM 0610 RC 71550 HCPCS inpatient 3801 2470.65 SIHO - ALL PLANS SIHO - ALL PLANS 3420.9 90 999999999 2301.51 3686.97 percent of total billed charges MRI scan of chest without contrast 926952_1 CDM 0610 RC 71550 HCPCS inpatient 3801 2470.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2964.78 78 999999999 2301.51 3686.97 percent of total billed charges MRI scan of chest without contrast 926952_1 CDM 0610 RC 71550 HCPCS inpatient 3801 2470.65 UMR - ALL PLANS UMR - ALL PLANS 2660.7 70 999999999 2301.51 3686.97 percent of total billed charges MRI scan of chest without contrast 926952_1 CDM 0610 RC 71550 HCPCS inpatient 3801 2470.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2301.51 3686.97 MRI scan of chest without contrast 926952_1 CDM 0610 RC 71550 HCPCS inpatient 3801 2470.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2301.51 60.55 999999999 2301.51 3686.97 percent of total billed charges MRI scan of chest without contrast 926952_1 CDM 0610 RC 71550 HCPCS inpatient 3801 2470.65 ANTHEM HMO ANTHEM HMO 999999999 2301.51 3686.97 MRI scan of chest without contrast 926952_1 CDM 0610 RC 71550 HCPCS inpatient 3801 2470.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2301.51 3686.97 MRI scan of chest without contrast 926952_1 CDM 0610 RC 71550 HCPCS inpatient 3801 2470.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2301.51 3686.97 MRI scan of chest without contrast 926952_1 CDM 0610 RC 71550 HCPCS inpatient 3801 2470.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2569.48 67.6 999999999 2301.51 3686.97 percent of total billed charges MRI scan of chest without contrast 926952_1 CDM 0610 RC 71550 HCPCS inpatient 3801 2470.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 2301.51 3686.97 MRI scan of leg joint before and after contrast 926956_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 3065.4 65 999999999 2855.54 4574.52 percent of total billed charges MRI scan of leg joint before and after contrast 926956_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 AETNA AETNA 3725.64 79 999999999 2855.54 4574.52 percent of total billed charges MRI scan of leg joint before and after contrast 926956_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4574.52 97 999999999 2855.54 4574.52 percent of total billed charges MRI scan of leg joint before and after contrast 926956_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 3254.04 69 999999999 2855.54 4574.52 percent of total billed charges MRI scan of leg joint before and after contrast 926956_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 SIHO - ALL PLANS SIHO - ALL PLANS 4244.4 90 999999999 2855.54 4574.52 percent of total billed charges MRI scan of leg joint before and after contrast 926956_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 3678.48 78 999999999 2855.54 4574.52 percent of total billed charges MRI scan of leg joint before and after contrast 926956_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 UMR - ALL PLANS UMR - ALL PLANS 3301.2 70 999999999 2855.54 4574.52 percent of total billed charges MRI scan of leg joint before and after contrast 926956_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2855.54 4574.52 MRI scan of leg joint before and after contrast 926956_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2855.54 60.55 999999999 2855.54 4574.52 percent of total billed charges MRI scan of leg joint before and after contrast 926956_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 ANTHEM HMO ANTHEM HMO 999999999 2855.54 4574.52 MRI scan of leg joint before and after contrast 926956_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2855.54 4574.52 MRI scan of leg joint before and after contrast 926956_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2855.54 4574.52 MRI scan of leg joint before and after contrast 926956_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 3188.02 67.6 999999999 2855.54 4574.52 percent of total billed charges MRI scan of leg joint before and after contrast 926956_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 2855.54 4574.52 MRI scan of leg joint before and after contrast 926958_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 3065.4 65 999999999 2855.54 4574.52 percent of total billed charges MRI scan of leg joint before and after contrast 926958_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 AETNA AETNA 3725.64 79 999999999 2855.54 4574.52 percent of total billed charges MRI scan of leg joint before and after contrast 926958_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4574.52 97 999999999 2855.54 4574.52 percent of total billed charges MRI scan of leg joint before and after contrast 926958_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 3254.04 69 999999999 2855.54 4574.52 percent of total billed charges MRI scan of leg joint before and after contrast 926958_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 SIHO - ALL PLANS SIHO - ALL PLANS 4244.4 90 999999999 2855.54 4574.52 percent of total billed charges MRI scan of leg joint before and after contrast 926958_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 3678.48 78 999999999 2855.54 4574.52 percent of total billed charges MRI scan of leg joint before and after contrast 926958_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 UMR - ALL PLANS UMR - ALL PLANS 3301.2 70 999999999 2855.54 4574.52 percent of total billed charges MRI scan of leg joint before and after contrast 926958_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2855.54 4574.52 MRI scan of leg joint before and after contrast 926958_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2855.54 60.55 999999999 2855.54 4574.52 percent of total billed charges MRI scan of leg joint before and after contrast 926958_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 ANTHEM HMO ANTHEM HMO 999999999 2855.54 4574.52 MRI scan of leg joint before and after contrast 926958_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2855.54 4574.52 MRI scan of leg joint before and after contrast 926958_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2855.54 4574.52 MRI scan of leg joint before and after contrast 926958_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 3188.02 67.6 999999999 2855.54 4574.52 percent of total billed charges MRI scan of leg joint before and after contrast 926958_1 CDM 0610 RC 73723 HCPCS inpatient 4716 3065.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 2855.54 4574.52 MRI scan of leg joint with contrast 926962_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 2993.25 65 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg joint with contrast 926962_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 AETNA AETNA 3637.95 79 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg joint with contrast 926962_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4466.85 97 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg joint with contrast 926962_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 3177.45 69 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg joint with contrast 926962_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 SIHO - ALL PLANS SIHO - ALL PLANS 4144.5 90 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg joint with contrast 926962_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 3591.9 78 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg joint with contrast 926962_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 UMR - ALL PLANS UMR - ALL PLANS 3223.5 70 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg joint with contrast 926962_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2788.33 4466.85 MRI scan of leg joint with contrast 926962_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2788.33 60.55 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg joint with contrast 926962_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 ANTHEM HMO ANTHEM HMO 999999999 2788.33 4466.85 MRI scan of leg joint with contrast 926962_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2788.33 4466.85 MRI scan of leg joint with contrast 926962_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2788.33 4466.85 MRI scan of leg joint with contrast 926962_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 3112.98 67.6 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg joint with contrast 926962_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 2788.33 4466.85 MRI scan of leg joint with contrast 926964_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 2993.25 65 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg joint with contrast 926964_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 AETNA AETNA 3637.95 79 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg joint with contrast 926964_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4466.85 97 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg joint with contrast 926964_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 3177.45 69 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg joint with contrast 926964_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 SIHO - ALL PLANS SIHO - ALL PLANS 4144.5 90 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg joint with contrast 926964_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 3591.9 78 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg joint with contrast 926964_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 UMR - ALL PLANS UMR - ALL PLANS 3223.5 70 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg joint with contrast 926964_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2788.33 4466.85 MRI scan of leg joint with contrast 926964_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2788.33 60.55 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg joint with contrast 926964_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 ANTHEM HMO ANTHEM HMO 999999999 2788.33 4466.85 MRI scan of leg joint with contrast 926964_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2788.33 4466.85 MRI scan of leg joint with contrast 926964_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2788.33 4466.85 MRI scan of leg joint with contrast 926964_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 3112.98 67.6 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg joint with contrast 926964_1 CDM 0610 RC 73722 HCPCS inpatient 4605 2993.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 2788.33 4466.85 MRI scan of leg joint without contrast 926968_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 2511.6 65 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg joint without contrast 926968_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 AETNA AETNA 3052.56 79 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg joint without contrast 926968_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3748.08 97 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg joint without contrast 926968_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 2666.16 69 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg joint without contrast 926968_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 SIHO - ALL PLANS SIHO - ALL PLANS 3477.6 90 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg joint without contrast 926968_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 3013.92 78 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg joint without contrast 926968_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 UMR - ALL PLANS UMR - ALL PLANS 2704.8 70 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg joint without contrast 926968_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2339.65 3748.08 MRI scan of leg joint without contrast 926968_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2339.65 60.55 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg joint without contrast 926968_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 ANTHEM HMO ANTHEM HMO 999999999 2339.65 3748.08 MRI scan of leg joint without contrast 926968_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2339.65 3748.08 MRI scan of leg joint without contrast 926968_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2339.65 3748.08 MRI scan of leg joint without contrast 926968_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 2612.06 67.6 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg joint without contrast 926968_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 2339.65 3748.08 MRI scan of leg joint without contrast 926970_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 2511.6 65 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg joint without contrast 926970_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 AETNA AETNA 3052.56 79 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg joint without contrast 926970_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3748.08 97 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg joint without contrast 926970_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 2666.16 69 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg joint without contrast 926970_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 SIHO - ALL PLANS SIHO - ALL PLANS 3477.6 90 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg joint without contrast 926970_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 3013.92 78 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg joint without contrast 926970_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 UMR - ALL PLANS UMR - ALL PLANS 2704.8 70 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg joint without contrast 926970_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2339.65 3748.08 MRI scan of leg joint without contrast 926970_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2339.65 60.55 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg joint without contrast 926970_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 ANTHEM HMO ANTHEM HMO 999999999 2339.65 3748.08 MRI scan of leg joint without contrast 926970_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2339.65 3748.08 MRI scan of leg joint without contrast 926970_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2339.65 3748.08 MRI scan of leg joint without contrast 926970_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 2612.06 67.6 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg joint without contrast 926970_1 CDM 0610 RC 73721 HCPCS inpatient 3864 2511.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 2339.65 3748.08 MRI scan of leg before and after contrast 926974_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 2511.6 65 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg before and after contrast 926974_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 AETNA AETNA 3052.56 79 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg before and after contrast 926974_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3748.08 97 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg before and after contrast 926974_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 2666.16 69 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg before and after contrast 926974_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 SIHO - ALL PLANS SIHO - ALL PLANS 3477.6 90 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg before and after contrast 926974_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 3013.92 78 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg before and after contrast 926974_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 UMR - ALL PLANS UMR - ALL PLANS 2704.8 70 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg before and after contrast 926974_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2339.65 3748.08 MRI scan of leg before and after contrast 926974_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2339.65 60.55 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg before and after contrast 926974_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 ANTHEM HMO ANTHEM HMO 999999999 2339.65 3748.08 MRI scan of leg before and after contrast 926974_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2339.65 3748.08 MRI scan of leg before and after contrast 926974_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2339.65 3748.08 MRI scan of leg before and after contrast 926974_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 2612.06 67.6 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg before and after contrast 926974_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 2339.65 3748.08 MRI scan of leg before and after contrast 926976_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 2511.6 65 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg before and after contrast 926976_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 AETNA AETNA 3052.56 79 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg before and after contrast 926976_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3748.08 97 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg before and after contrast 926976_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 2666.16 69 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg before and after contrast 926976_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 SIHO - ALL PLANS SIHO - ALL PLANS 3477.6 90 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg before and after contrast 926976_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 3013.92 78 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg before and after contrast 926976_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 UMR - ALL PLANS UMR - ALL PLANS 2704.8 70 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg before and after contrast 926976_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2339.65 3748.08 MRI scan of leg before and after contrast 926976_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2339.65 60.55 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg before and after contrast 926976_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 ANTHEM HMO ANTHEM HMO 999999999 2339.65 3748.08 MRI scan of leg before and after contrast 926976_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2339.65 3748.08 MRI scan of leg before and after contrast 926976_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2339.65 3748.08 MRI scan of leg before and after contrast 926976_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 2612.06 67.6 999999999 2339.65 3748.08 percent of total billed charges MRI scan of leg before and after contrast 926976_1 CDM 0610 RC 73720 HCPCS inpatient 3864 2511.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 2339.65 3748.08 MRI scan of leg with contrast 926980_1 CDM 0610 RC 73719 HCPCS inpatient 4303 2796.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 2796.95 65 999999999 2605.47 4173.91 percent of total billed charges MRI scan of leg with contrast 926980_1 CDM 0610 RC 73719 HCPCS inpatient 4303 2796.95 AETNA AETNA 3399.37 79 999999999 2605.47 4173.91 percent of total billed charges MRI scan of leg with contrast 926980_1 CDM 0610 RC 73719 HCPCS inpatient 4303 2796.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4173.91 97 999999999 2605.47 4173.91 percent of total billed charges MRI scan of leg with contrast 926980_1 CDM 0610 RC 73719 HCPCS inpatient 4303 2796.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 2969.07 69 999999999 2605.47 4173.91 percent of total billed charges MRI scan of leg with contrast 926980_1 CDM 0610 RC 73719 HCPCS inpatient 4303 2796.95 SIHO - ALL PLANS SIHO - ALL PLANS 3872.7 90 999999999 2605.47 4173.91 percent of total billed charges MRI scan of leg with contrast 926980_1 CDM 0610 RC 73719 HCPCS inpatient 4303 2796.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 3356.34 78 999999999 2605.47 4173.91 percent of total billed charges MRI scan of leg with contrast 926980_1 CDM 0610 RC 73719 HCPCS inpatient 4303 2796.95 UMR - ALL PLANS UMR - ALL PLANS 3012.1 70 999999999 2605.47 4173.91 percent of total billed charges MRI scan of leg with contrast 926980_1 CDM 0610 RC 73719 HCPCS inpatient 4303 2796.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2605.47 4173.91 MRI scan of leg with contrast 926980_1 CDM 0610 RC 73719 HCPCS inpatient 4303 2796.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2605.47 60.55 999999999 2605.47 4173.91 percent of total billed charges MRI scan of leg with contrast 926980_1 CDM 0610 RC 73719 HCPCS inpatient 4303 2796.95 ANTHEM HMO ANTHEM HMO 999999999 2605.47 4173.91 MRI scan of leg with contrast 926980_1 CDM 0610 RC 73719 HCPCS inpatient 4303 2796.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2605.47 4173.91 MRI scan of leg with contrast 926980_1 CDM 0610 RC 73719 HCPCS inpatient 4303 2796.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2605.47 4173.91 MRI scan of leg with contrast 926980_1 CDM 0610 RC 73719 HCPCS inpatient 4303 2796.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 2908.83 67.6 999999999 2605.47 4173.91 percent of total billed charges MRI scan of leg with contrast 926980_1 CDM 0610 RC 73719 HCPCS inpatient 4303 2796.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 2605.47 4173.91 MRI scan of leg with contrast 926982_1 CDM 0610 RC 73719 HCPCS inpatient 4605 2993.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 2993.25 65 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg with contrast 926982_1 CDM 0610 RC 73719 HCPCS inpatient 4605 2993.25 AETNA AETNA 3637.95 79 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg with contrast 926982_1 CDM 0610 RC 73719 HCPCS inpatient 4605 2993.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4466.85 97 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg with contrast 926982_1 CDM 0610 RC 73719 HCPCS inpatient 4605 2993.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 3177.45 69 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg with contrast 926982_1 CDM 0610 RC 73719 HCPCS inpatient 4605 2993.25 SIHO - ALL PLANS SIHO - ALL PLANS 4144.5 90 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg with contrast 926982_1 CDM 0610 RC 73719 HCPCS inpatient 4605 2993.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 3591.9 78 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg with contrast 926982_1 CDM 0610 RC 73719 HCPCS inpatient 4605 2993.25 UMR - ALL PLANS UMR - ALL PLANS 3223.5 70 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg with contrast 926982_1 CDM 0610 RC 73719 HCPCS inpatient 4605 2993.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2788.33 4466.85 MRI scan of leg with contrast 926982_1 CDM 0610 RC 73719 HCPCS inpatient 4605 2993.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2788.33 60.55 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg with contrast 926982_1 CDM 0610 RC 73719 HCPCS inpatient 4605 2993.25 ANTHEM HMO ANTHEM HMO 999999999 2788.33 4466.85 MRI scan of leg with contrast 926982_1 CDM 0610 RC 73719 HCPCS inpatient 4605 2993.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2788.33 4466.85 MRI scan of leg with contrast 926982_1 CDM 0610 RC 73719 HCPCS inpatient 4605 2993.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2788.33 4466.85 MRI scan of leg with contrast 926982_1 CDM 0610 RC 73719 HCPCS inpatient 4605 2993.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 3112.98 67.6 999999999 2788.33 4466.85 percent of total billed charges MRI scan of leg with contrast 926982_1 CDM 0610 RC 73719 HCPCS inpatient 4605 2993.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 2788.33 4466.85 MRI scan of leg without contrast 926986_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 3020.55 65 999999999 2813.76 4507.59 percent of total billed charges MRI scan of leg without contrast 926986_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 AETNA AETNA 3671.13 79 999999999 2813.76 4507.59 percent of total billed charges MRI scan of leg without contrast 926986_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4507.59 97 999999999 2813.76 4507.59 percent of total billed charges MRI scan of leg without contrast 926986_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 3206.43 69 999999999 2813.76 4507.59 percent of total billed charges MRI scan of leg without contrast 926986_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 SIHO - ALL PLANS SIHO - ALL PLANS 4182.3 90 999999999 2813.76 4507.59 percent of total billed charges MRI scan of leg without contrast 926986_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 3624.66 78 999999999 2813.76 4507.59 percent of total billed charges MRI scan of leg without contrast 926986_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 UMR - ALL PLANS UMR - ALL PLANS 3252.9 70 999999999 2813.76 4507.59 percent of total billed charges MRI scan of leg without contrast 926986_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2813.76 4507.59 MRI scan of leg without contrast 926986_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2813.76 60.55 999999999 2813.76 4507.59 percent of total billed charges MRI scan of leg without contrast 926986_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 ANTHEM HMO ANTHEM HMO 999999999 2813.76 4507.59 MRI scan of leg without contrast 926986_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2813.76 4507.59 MRI scan of leg without contrast 926986_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2813.76 4507.59 MRI scan of leg without contrast 926986_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 3141.37 67.6 999999999 2813.76 4507.59 percent of total billed charges MRI scan of leg without contrast 926986_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 2813.76 4507.59 MRI scan of leg without contrast 926988_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 3020.55 65 999999999 2813.76 4507.59 percent of total billed charges MRI scan of leg without contrast 926988_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 AETNA AETNA 3671.13 79 999999999 2813.76 4507.59 percent of total billed charges MRI scan of leg without contrast 926988_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4507.59 97 999999999 2813.76 4507.59 percent of total billed charges MRI scan of leg without contrast 926988_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 3206.43 69 999999999 2813.76 4507.59 percent of total billed charges MRI scan of leg without contrast 926988_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 SIHO - ALL PLANS SIHO - ALL PLANS 4182.3 90 999999999 2813.76 4507.59 percent of total billed charges MRI scan of leg without contrast 926988_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 3624.66 78 999999999 2813.76 4507.59 percent of total billed charges MRI scan of leg without contrast 926988_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 UMR - ALL PLANS UMR - ALL PLANS 3252.9 70 999999999 2813.76 4507.59 percent of total billed charges MRI scan of leg without contrast 926988_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2813.76 4507.59 MRI scan of leg without contrast 926988_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2813.76 60.55 999999999 2813.76 4507.59 percent of total billed charges MRI scan of leg without contrast 926988_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 ANTHEM HMO ANTHEM HMO 999999999 2813.76 4507.59 MRI scan of leg without contrast 926988_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2813.76 4507.59 MRI scan of leg without contrast 926988_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2813.76 4507.59 MRI scan of leg without contrast 926988_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 3141.37 67.6 999999999 2813.76 4507.59 percent of total billed charges MRI scan of leg without contrast 926988_1 CDM 0610 RC 73718 HCPCS inpatient 4647 3020.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 2813.76 4507.59 MRI scan of pelvis before and after contrast 926990_1 CDM 0610 RC 72197 HCPCS inpatient 5046 3279.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 3279.9 65 999999999 3055.35 4894.62 percent of total billed charges MRI scan of pelvis before and after contrast 926990_1 CDM 0610 RC 72197 HCPCS inpatient 5046 3279.9 AETNA AETNA 3986.34 79 999999999 3055.35 4894.62 percent of total billed charges MRI scan of pelvis before and after contrast 926990_1 CDM 0610 RC 72197 HCPCS inpatient 5046 3279.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4894.62 97 999999999 3055.35 4894.62 percent of total billed charges MRI scan of pelvis before and after contrast 926990_1 CDM 0610 RC 72197 HCPCS inpatient 5046 3279.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 3481.74 69 999999999 3055.35 4894.62 percent of total billed charges MRI scan of pelvis before and after contrast 926990_1 CDM 0610 RC 72197 HCPCS inpatient 5046 3279.9 SIHO - ALL PLANS SIHO - ALL PLANS 4541.4 90 999999999 3055.35 4894.62 percent of total billed charges MRI scan of pelvis before and after contrast 926990_1 CDM 0610 RC 72197 HCPCS inpatient 5046 3279.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 3935.88 78 999999999 3055.35 4894.62 percent of total billed charges MRI scan of pelvis before and after contrast 926990_1 CDM 0610 RC 72197 HCPCS inpatient 5046 3279.9 UMR - ALL PLANS UMR - ALL PLANS 3532.2 70 999999999 3055.35 4894.62 percent of total billed charges MRI scan of pelvis before and after contrast 926990_1 CDM 0610 RC 72197 HCPCS inpatient 5046 3279.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3055.35 4894.62 MRI scan of pelvis before and after contrast 926990_1 CDM 0610 RC 72197 HCPCS inpatient 5046 3279.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3055.35 60.55 999999999 3055.35 4894.62 percent of total billed charges MRI scan of pelvis before and after contrast 926990_1 CDM 0610 RC 72197 HCPCS inpatient 5046 3279.9 ANTHEM HMO ANTHEM HMO 999999999 3055.35 4894.62 MRI scan of pelvis before and after contrast 926990_1 CDM 0610 RC 72197 HCPCS inpatient 5046 3279.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3055.35 4894.62 MRI scan of pelvis before and after contrast 926990_1 CDM 0610 RC 72197 HCPCS inpatient 5046 3279.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3055.35 4894.62 MRI scan of pelvis before and after contrast 926990_1 CDM 0610 RC 72197 HCPCS inpatient 5046 3279.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 3411.1 67.6 999999999 3055.35 4894.62 percent of total billed charges MRI scan of pelvis before and after contrast 926990_1 CDM 0610 RC 72197 HCPCS inpatient 5046 3279.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 3055.35 4894.62 MRI scan of pelvis with contrast 926992_1 CDM 0610 RC 72196 HCPCS inpatient 4738 3079.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 3079.7 65 999999999 2868.86 4595.86 percent of total billed charges MRI scan of pelvis with contrast 926992_1 CDM 0610 RC 72196 HCPCS inpatient 4738 3079.7 AETNA AETNA 3743.02 79 999999999 2868.86 4595.86 percent of total billed charges MRI scan of pelvis with contrast 926992_1 CDM 0610 RC 72196 HCPCS inpatient 4738 3079.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4595.86 97 999999999 2868.86 4595.86 percent of total billed charges MRI scan of pelvis with contrast 926992_1 CDM 0610 RC 72196 HCPCS inpatient 4738 3079.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 3269.22 69 999999999 2868.86 4595.86 percent of total billed charges MRI scan of pelvis with contrast 926992_1 CDM 0610 RC 72196 HCPCS inpatient 4738 3079.7 SIHO - ALL PLANS SIHO - ALL PLANS 4264.2 90 999999999 2868.86 4595.86 percent of total billed charges MRI scan of pelvis with contrast 926992_1 CDM 0610 RC 72196 HCPCS inpatient 4738 3079.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 3695.64 78 999999999 2868.86 4595.86 percent of total billed charges MRI scan of pelvis with contrast 926992_1 CDM 0610 RC 72196 HCPCS inpatient 4738 3079.7 UMR - ALL PLANS UMR - ALL PLANS 3316.6 70 999999999 2868.86 4595.86 percent of total billed charges MRI scan of pelvis with contrast 926992_1 CDM 0610 RC 72196 HCPCS inpatient 4738 3079.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2868.86 4595.86 MRI scan of pelvis with contrast 926992_1 CDM 0610 RC 72196 HCPCS inpatient 4738 3079.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2868.86 60.55 999999999 2868.86 4595.86 percent of total billed charges MRI scan of pelvis with contrast 926992_1 CDM 0610 RC 72196 HCPCS inpatient 4738 3079.7 ANTHEM HMO ANTHEM HMO 999999999 2868.86 4595.86 MRI scan of pelvis with contrast 926992_1 CDM 0610 RC 72196 HCPCS inpatient 4738 3079.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2868.86 4595.86 MRI scan of pelvis with contrast 926992_1 CDM 0610 RC 72196 HCPCS inpatient 4738 3079.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2868.86 4595.86 MRI scan of pelvis with contrast 926992_1 CDM 0610 RC 72196 HCPCS inpatient 4738 3079.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 3202.89 67.6 999999999 2868.86 4595.86 percent of total billed charges MRI scan of pelvis with contrast 926992_1 CDM 0610 RC 72196 HCPCS inpatient 4738 3079.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 2868.86 4595.86 MRI scan of pelvis without contrast 926994_1 CDM 0610 RC 72195 HCPCS inpatient 4779 3106.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 3106.35 65 999999999 2893.68 4635.63 percent of total billed charges MRI scan of pelvis without contrast 926994_1 CDM 0610 RC 72195 HCPCS inpatient 4779 3106.35 AETNA AETNA 3775.41 79 999999999 2893.68 4635.63 percent of total billed charges MRI scan of pelvis without contrast 926994_1 CDM 0610 RC 72195 HCPCS inpatient 4779 3106.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4635.63 97 999999999 2893.68 4635.63 percent of total billed charges MRI scan of pelvis without contrast 926994_1 CDM 0610 RC 72195 HCPCS inpatient 4779 3106.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 3297.51 69 999999999 2893.68 4635.63 percent of total billed charges MRI scan of pelvis without contrast 926994_1 CDM 0610 RC 72195 HCPCS inpatient 4779 3106.35 SIHO - ALL PLANS SIHO - ALL PLANS 4301.1 90 999999999 2893.68 4635.63 percent of total billed charges MRI scan of pelvis without contrast 926994_1 CDM 0610 RC 72195 HCPCS inpatient 4779 3106.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 3727.62 78 999999999 2893.68 4635.63 percent of total billed charges MRI scan of pelvis without contrast 926994_1 CDM 0610 RC 72195 HCPCS inpatient 4779 3106.35 UMR - ALL PLANS UMR - ALL PLANS 3345.3 70 999999999 2893.68 4635.63 percent of total billed charges MRI scan of pelvis without contrast 926994_1 CDM 0610 RC 72195 HCPCS inpatient 4779 3106.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2893.68 4635.63 MRI scan of pelvis without contrast 926994_1 CDM 0610 RC 72195 HCPCS inpatient 4779 3106.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2893.68 60.55 999999999 2893.68 4635.63 percent of total billed charges MRI scan of pelvis without contrast 926994_1 CDM 0610 RC 72195 HCPCS inpatient 4779 3106.35 ANTHEM HMO ANTHEM HMO 999999999 2893.68 4635.63 MRI scan of pelvis without contrast 926994_1 CDM 0610 RC 72195 HCPCS inpatient 4779 3106.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2893.68 4635.63 MRI scan of pelvis without contrast 926994_1 CDM 0610 RC 72195 HCPCS inpatient 4779 3106.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2893.68 4635.63 MRI scan of pelvis without contrast 926994_1 CDM 0610 RC 72195 HCPCS inpatient 4779 3106.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 3230.6 67.6 999999999 2893.68 4635.63 percent of total billed charges MRI scan of pelvis without contrast 926994_1 CDM 0610 RC 72195 HCPCS inpatient 4779 3106.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 2893.68 4635.63 MRI scan of upper spinal canal before and after contrast 926996_1 CDM 0612 RC 72156 HCPCS inpatient 5276 3429.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 3429.4 65 999999999 3194.62 5117.72 percent of total billed charges MRI scan of upper spinal canal before and after contrast 926996_1 CDM 0612 RC 72156 HCPCS inpatient 5276 3429.4 AETNA AETNA 4168.04 79 999999999 3194.62 5117.72 percent of total billed charges MRI scan of upper spinal canal before and after contrast 926996_1 CDM 0612 RC 72156 HCPCS inpatient 5276 3429.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5117.72 97 999999999 3194.62 5117.72 percent of total billed charges MRI scan of upper spinal canal before and after contrast 926996_1 CDM 0612 RC 72156 HCPCS inpatient 5276 3429.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 3640.44 69 999999999 3194.62 5117.72 percent of total billed charges MRI scan of upper spinal canal before and after contrast 926996_1 CDM 0612 RC 72156 HCPCS inpatient 5276 3429.4 SIHO - ALL PLANS SIHO - ALL PLANS 4748.4 90 999999999 3194.62 5117.72 percent of total billed charges MRI scan of upper spinal canal before and after contrast 926996_1 CDM 0612 RC 72156 HCPCS inpatient 5276 3429.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 4115.28 78 999999999 3194.62 5117.72 percent of total billed charges MRI scan of upper spinal canal before and after contrast 926996_1 CDM 0612 RC 72156 HCPCS inpatient 5276 3429.4 UMR - ALL PLANS UMR - ALL PLANS 3693.2 70 999999999 3194.62 5117.72 percent of total billed charges MRI scan of upper spinal canal before and after contrast 926996_1 CDM 0612 RC 72156 HCPCS inpatient 5276 3429.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3194.62 5117.72 MRI scan of upper spinal canal before and after contrast 926996_1 CDM 0612 RC 72156 HCPCS inpatient 5276 3429.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3194.62 60.55 999999999 3194.62 5117.72 percent of total billed charges MRI scan of upper spinal canal before and after contrast 926996_1 CDM 0612 RC 72156 HCPCS inpatient 5276 3429.4 ANTHEM HMO ANTHEM HMO 999999999 3194.62 5117.72 MRI scan of upper spinal canal before and after contrast 926996_1 CDM 0612 RC 72156 HCPCS inpatient 5276 3429.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3194.62 5117.72 MRI scan of upper spinal canal before and after contrast 926996_1 CDM 0612 RC 72156 HCPCS inpatient 5276 3429.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3194.62 5117.72 MRI scan of upper spinal canal before and after contrast 926996_1 CDM 0612 RC 72156 HCPCS inpatient 5276 3429.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 3566.58 67.6 999999999 3194.62 5117.72 percent of total billed charges MRI scan of upper spinal canal before and after contrast 926996_1 CDM 0612 RC 72156 HCPCS inpatient 5276 3429.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 3194.62 5117.72 MRI scan of upper spinal canal with contrast 926998_1 CDM 0612 RC 72142 HCPCS inpatient 4868 3164.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 3164.2 65 999999999 2947.57 4721.96 percent of total billed charges MRI scan of upper spinal canal with contrast 926998_1 CDM 0612 RC 72142 HCPCS inpatient 4868 3164.2 AETNA AETNA 3845.72 79 999999999 2947.57 4721.96 percent of total billed charges MRI scan of upper spinal canal with contrast 926998_1 CDM 0612 RC 72142 HCPCS inpatient 4868 3164.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4721.96 97 999999999 2947.57 4721.96 percent of total billed charges MRI scan of upper spinal canal with contrast 926998_1 CDM 0612 RC 72142 HCPCS inpatient 4868 3164.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 3358.92 69 999999999 2947.57 4721.96 percent of total billed charges MRI scan of upper spinal canal with contrast 926998_1 CDM 0612 RC 72142 HCPCS inpatient 4868 3164.2 SIHO - ALL PLANS SIHO - ALL PLANS 4381.2 90 999999999 2947.57 4721.96 percent of total billed charges MRI scan of upper spinal canal with contrast 926998_1 CDM 0612 RC 72142 HCPCS inpatient 4868 3164.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 3797.04 78 999999999 2947.57 4721.96 percent of total billed charges MRI scan of upper spinal canal with contrast 926998_1 CDM 0612 RC 72142 HCPCS inpatient 4868 3164.2 UMR - ALL PLANS UMR - ALL PLANS 3407.6 70 999999999 2947.57 4721.96 percent of total billed charges MRI scan of upper spinal canal with contrast 926998_1 CDM 0612 RC 72142 HCPCS inpatient 4868 3164.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2947.57 4721.96 MRI scan of upper spinal canal with contrast 926998_1 CDM 0612 RC 72142 HCPCS inpatient 4868 3164.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2947.57 60.55 999999999 2947.57 4721.96 percent of total billed charges MRI scan of upper spinal canal with contrast 926998_1 CDM 0612 RC 72142 HCPCS inpatient 4868 3164.2 ANTHEM HMO ANTHEM HMO 999999999 2947.57 4721.96 MRI scan of upper spinal canal with contrast 926998_1 CDM 0612 RC 72142 HCPCS inpatient 4868 3164.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2947.57 4721.96 MRI scan of upper spinal canal with contrast 926998_1 CDM 0612 RC 72142 HCPCS inpatient 4868 3164.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2947.57 4721.96 MRI scan of upper spinal canal with contrast 926998_1 CDM 0612 RC 72142 HCPCS inpatient 4868 3164.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 3290.77 67.6 999999999 2947.57 4721.96 percent of total billed charges MRI scan of upper spinal canal with contrast 926998_1 CDM 0612 RC 72142 HCPCS inpatient 4868 3164.2 UHC - ALL PLANS UHC - ALL PLANS 999999999 2947.57 4721.96 MRI scan of upper spinal canal without contrast 927000_1 CDM 0612 RC 72141 HCPCS inpatient 4801 3120.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 3120.65 65 999999999 2907.01 4656.97 percent of total billed charges MRI scan of upper spinal canal without contrast 927000_1 CDM 0612 RC 72141 HCPCS inpatient 4801 3120.65 AETNA AETNA 3792.79 79 999999999 2907.01 4656.97 percent of total billed charges MRI scan of upper spinal canal without contrast 927000_1 CDM 0612 RC 72141 HCPCS inpatient 4801 3120.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4656.97 97 999999999 2907.01 4656.97 percent of total billed charges MRI scan of upper spinal canal without contrast 927000_1 CDM 0612 RC 72141 HCPCS inpatient 4801 3120.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 3312.69 69 999999999 2907.01 4656.97 percent of total billed charges MRI scan of upper spinal canal without contrast 927000_1 CDM 0612 RC 72141 HCPCS inpatient 4801 3120.65 SIHO - ALL PLANS SIHO - ALL PLANS 4320.9 90 999999999 2907.01 4656.97 percent of total billed charges MRI scan of upper spinal canal without contrast 927000_1 CDM 0612 RC 72141 HCPCS inpatient 4801 3120.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 3744.78 78 999999999 2907.01 4656.97 percent of total billed charges MRI scan of upper spinal canal without contrast 927000_1 CDM 0612 RC 72141 HCPCS inpatient 4801 3120.65 UMR - ALL PLANS UMR - ALL PLANS 3360.7 70 999999999 2907.01 4656.97 percent of total billed charges MRI scan of upper spinal canal without contrast 927000_1 CDM 0612 RC 72141 HCPCS inpatient 4801 3120.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2907.01 4656.97 MRI scan of upper spinal canal without contrast 927000_1 CDM 0612 RC 72141 HCPCS inpatient 4801 3120.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2907.01 60.55 999999999 2907.01 4656.97 percent of total billed charges MRI scan of upper spinal canal without contrast 927000_1 CDM 0612 RC 72141 HCPCS inpatient 4801 3120.65 ANTHEM HMO ANTHEM HMO 999999999 2907.01 4656.97 MRI scan of upper spinal canal without contrast 927000_1 CDM 0612 RC 72141 HCPCS inpatient 4801 3120.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2907.01 4656.97 MRI scan of upper spinal canal without contrast 927000_1 CDM 0612 RC 72141 HCPCS inpatient 4801 3120.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2907.01 4656.97 MRI scan of upper spinal canal without contrast 927000_1 CDM 0612 RC 72141 HCPCS inpatient 4801 3120.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 3245.48 67.6 999999999 2907.01 4656.97 percent of total billed charges MRI scan of upper spinal canal without contrast 927000_1 CDM 0612 RC 72141 HCPCS inpatient 4801 3120.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 2907.01 4656.97 MRI scan of lower spinal canal before and after contrast 927002_1 CDM 0612 RC 72158 HCPCS inpatient 5300 3445 SELF PAY DISCOUNT SELF PAY DISCOUNT 3445 65 999999999 3209.15 5141 percent of total billed charges MRI scan of lower spinal canal before and after contrast 927002_1 CDM 0612 RC 72158 HCPCS inpatient 5300 3445 AETNA AETNA 4187 79 999999999 3209.15 5141 percent of total billed charges MRI scan of lower spinal canal before and after contrast 927002_1 CDM 0612 RC 72158 HCPCS inpatient 5300 3445 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5141 97 999999999 3209.15 5141 percent of total billed charges MRI scan of lower spinal canal before and after contrast 927002_1 CDM 0612 RC 72158 HCPCS inpatient 5300 3445 ENCORE - ALL PLANS ENCORE - ALL PLANS 3657 69 999999999 3209.15 5141 percent of total billed charges MRI scan of lower spinal canal before and after contrast 927002_1 CDM 0612 RC 72158 HCPCS inpatient 5300 3445 SIHO - ALL PLANS SIHO - ALL PLANS 4770 90 999999999 3209.15 5141 percent of total billed charges MRI scan of lower spinal canal before and after contrast 927002_1 CDM 0612 RC 72158 HCPCS inpatient 5300 3445 HUMANA - ALL PLANS HUMANA - ALL PLANS 4134 78 999999999 3209.15 5141 percent of total billed charges MRI scan of lower spinal canal before and after contrast 927002_1 CDM 0612 RC 72158 HCPCS inpatient 5300 3445 UMR - ALL PLANS UMR - ALL PLANS 3710 70 999999999 3209.15 5141 percent of total billed charges MRI scan of lower spinal canal before and after contrast 927002_1 CDM 0612 RC 72158 HCPCS inpatient 5300 3445 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3209.15 5141 MRI scan of lower spinal canal before and after contrast 927002_1 CDM 0612 RC 72158 HCPCS inpatient 5300 3445 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3209.15 60.55 999999999 3209.15 5141 percent of total billed charges MRI scan of lower spinal canal before and after contrast 927002_1 CDM 0612 RC 72158 HCPCS inpatient 5300 3445 ANTHEM HMO ANTHEM HMO 999999999 3209.15 5141 MRI scan of lower spinal canal before and after contrast 927002_1 CDM 0612 RC 72158 HCPCS inpatient 5300 3445 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3209.15 5141 MRI scan of lower spinal canal before and after contrast 927002_1 CDM 0612 RC 72158 HCPCS inpatient 5300 3445 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3209.15 5141 MRI scan of lower spinal canal before and after contrast 927002_1 CDM 0612 RC 72158 HCPCS inpatient 5300 3445 CIGNA - ALL PLANS CIGNA - ALL PLANS 3582.8 67.6 999999999 3209.15 5141 percent of total billed charges MRI scan of lower spinal canal before and after contrast 927002_1 CDM 0612 RC 72158 HCPCS inpatient 5300 3445 UHC - ALL PLANS UHC - ALL PLANS 999999999 3209.15 5141 MRI scan of lower spinal canal with contrast 927004_1 CDM 0612 RC 72149 HCPCS inpatient 4425 2876.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 2876.25 65 999999999 2679.34 4292.25 percent of total billed charges MRI scan of lower spinal canal with contrast 927004_1 CDM 0612 RC 72149 HCPCS inpatient 4425 2876.25 AETNA AETNA 3495.75 79 999999999 2679.34 4292.25 percent of total billed charges MRI scan of lower spinal canal with contrast 927004_1 CDM 0612 RC 72149 HCPCS inpatient 4425 2876.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4292.25 97 999999999 2679.34 4292.25 percent of total billed charges MRI scan of lower spinal canal with contrast 927004_1 CDM 0612 RC 72149 HCPCS inpatient 4425 2876.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 3053.25 69 999999999 2679.34 4292.25 percent of total billed charges MRI scan of lower spinal canal with contrast 927004_1 CDM 0612 RC 72149 HCPCS inpatient 4425 2876.25 SIHO - ALL PLANS SIHO - ALL PLANS 3982.5 90 999999999 2679.34 4292.25 percent of total billed charges MRI scan of lower spinal canal with contrast 927004_1 CDM 0612 RC 72149 HCPCS inpatient 4425 2876.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 3451.5 78 999999999 2679.34 4292.25 percent of total billed charges MRI scan of lower spinal canal with contrast 927004_1 CDM 0612 RC 72149 HCPCS inpatient 4425 2876.25 UMR - ALL PLANS UMR - ALL PLANS 3097.5 70 999999999 2679.34 4292.25 percent of total billed charges MRI scan of lower spinal canal with contrast 927004_1 CDM 0612 RC 72149 HCPCS inpatient 4425 2876.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2679.34 4292.25 MRI scan of lower spinal canal with contrast 927004_1 CDM 0612 RC 72149 HCPCS inpatient 4425 2876.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2679.34 60.55 999999999 2679.34 4292.25 percent of total billed charges MRI scan of lower spinal canal with contrast 927004_1 CDM 0612 RC 72149 HCPCS inpatient 4425 2876.25 ANTHEM HMO ANTHEM HMO 999999999 2679.34 4292.25 MRI scan of lower spinal canal with contrast 927004_1 CDM 0612 RC 72149 HCPCS inpatient 4425 2876.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2679.34 4292.25 MRI scan of lower spinal canal with contrast 927004_1 CDM 0612 RC 72149 HCPCS inpatient 4425 2876.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2679.34 4292.25 MRI scan of lower spinal canal with contrast 927004_1 CDM 0612 RC 72149 HCPCS inpatient 4425 2876.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 2991.3 67.6 999999999 2679.34 4292.25 percent of total billed charges MRI scan of lower spinal canal with contrast 927004_1 CDM 0612 RC 72149 HCPCS inpatient 4425 2876.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 2679.34 4292.25 MRI scan of lower spinal canal without contrast 927006_1 CDM 0612 RC 72148 HCPCS inpatient 4137 2689.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 2689.05 65 999999999 2504.95 4012.89 percent of total billed charges MRI scan of lower spinal canal without contrast 927006_1 CDM 0612 RC 72148 HCPCS inpatient 4137 2689.05 AETNA AETNA 3268.23 79 999999999 2504.95 4012.89 percent of total billed charges MRI scan of lower spinal canal without contrast 927006_1 CDM 0612 RC 72148 HCPCS inpatient 4137 2689.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4012.89 97 999999999 2504.95 4012.89 percent of total billed charges MRI scan of lower spinal canal without contrast 927006_1 CDM 0612 RC 72148 HCPCS inpatient 4137 2689.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 2854.53 69 999999999 2504.95 4012.89 percent of total billed charges MRI scan of lower spinal canal without contrast 927006_1 CDM 0612 RC 72148 HCPCS inpatient 4137 2689.05 SIHO - ALL PLANS SIHO - ALL PLANS 3723.3 90 999999999 2504.95 4012.89 percent of total billed charges MRI scan of lower spinal canal without contrast 927006_1 CDM 0612 RC 72148 HCPCS inpatient 4137 2689.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 3226.86 78 999999999 2504.95 4012.89 percent of total billed charges MRI scan of lower spinal canal without contrast 927006_1 CDM 0612 RC 72148 HCPCS inpatient 4137 2689.05 UMR - ALL PLANS UMR - ALL PLANS 2895.9 70 999999999 2504.95 4012.89 percent of total billed charges MRI scan of lower spinal canal without contrast 927006_1 CDM 0612 RC 72148 HCPCS inpatient 4137 2689.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2504.95 4012.89 MRI scan of lower spinal canal without contrast 927006_1 CDM 0612 RC 72148 HCPCS inpatient 4137 2689.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2504.95 60.55 999999999 2504.95 4012.89 percent of total billed charges MRI scan of lower spinal canal without contrast 927006_1 CDM 0612 RC 72148 HCPCS inpatient 4137 2689.05 ANTHEM HMO ANTHEM HMO 999999999 2504.95 4012.89 MRI scan of lower spinal canal without contrast 927006_1 CDM 0612 RC 72148 HCPCS inpatient 4137 2689.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2504.95 4012.89 MRI scan of lower spinal canal without contrast 927006_1 CDM 0612 RC 72148 HCPCS inpatient 4137 2689.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2504.95 4012.89 MRI scan of lower spinal canal without contrast 927006_1 CDM 0612 RC 72148 HCPCS inpatient 4137 2689.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 2796.61 67.6 999999999 2504.95 4012.89 percent of total billed charges MRI scan of lower spinal canal without contrast 927006_1 CDM 0612 RC 72148 HCPCS inpatient 4137 2689.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 2504.95 4012.89 MRI scan of middle spinal canal before and after contrast 927008_1 CDM 0612 RC 72157 HCPCS inpatient 4567 2968.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 2968.55 65 999999999 2765.32 4429.99 percent of total billed charges MRI scan of middle spinal canal before and after contrast 927008_1 CDM 0612 RC 72157 HCPCS inpatient 4567 2968.55 AETNA AETNA 3607.93 79 999999999 2765.32 4429.99 percent of total billed charges MRI scan of middle spinal canal before and after contrast 927008_1 CDM 0612 RC 72157 HCPCS inpatient 4567 2968.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4429.99 97 999999999 2765.32 4429.99 percent of total billed charges MRI scan of middle spinal canal before and after contrast 927008_1 CDM 0612 RC 72157 HCPCS inpatient 4567 2968.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 3151.23 69 999999999 2765.32 4429.99 percent of total billed charges MRI scan of middle spinal canal before and after contrast 927008_1 CDM 0612 RC 72157 HCPCS inpatient 4567 2968.55 SIHO - ALL PLANS SIHO - ALL PLANS 4110.3 90 999999999 2765.32 4429.99 percent of total billed charges MRI scan of middle spinal canal before and after contrast 927008_1 CDM 0612 RC 72157 HCPCS inpatient 4567 2968.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 3562.26 78 999999999 2765.32 4429.99 percent of total billed charges MRI scan of middle spinal canal before and after contrast 927008_1 CDM 0612 RC 72157 HCPCS inpatient 4567 2968.55 UMR - ALL PLANS UMR - ALL PLANS 3196.9 70 999999999 2765.32 4429.99 percent of total billed charges MRI scan of middle spinal canal before and after contrast 927008_1 CDM 0612 RC 72157 HCPCS inpatient 4567 2968.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2765.32 4429.99 MRI scan of middle spinal canal before and after contrast 927008_1 CDM 0612 RC 72157 HCPCS inpatient 4567 2968.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2765.32 60.55 999999999 2765.32 4429.99 percent of total billed charges MRI scan of middle spinal canal before and after contrast 927008_1 CDM 0612 RC 72157 HCPCS inpatient 4567 2968.55 ANTHEM HMO ANTHEM HMO 999999999 2765.32 4429.99 MRI scan of middle spinal canal before and after contrast 927008_1 CDM 0612 RC 72157 HCPCS inpatient 4567 2968.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2765.32 4429.99 MRI scan of middle spinal canal before and after contrast 927008_1 CDM 0612 RC 72157 HCPCS inpatient 4567 2968.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2765.32 4429.99 MRI scan of middle spinal canal before and after contrast 927008_1 CDM 0612 RC 72157 HCPCS inpatient 4567 2968.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 3087.29 67.6 999999999 2765.32 4429.99 percent of total billed charges MRI scan of middle spinal canal before and after contrast 927008_1 CDM 0612 RC 72157 HCPCS inpatient 4567 2968.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 2765.32 4429.99 MRI scan of middle spinal canal with contrast 927010_1 CDM 0612 RC 72147 HCPCS inpatient 4425 2876.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 2876.25 65 999999999 2679.34 4292.25 percent of total billed charges MRI scan of middle spinal canal with contrast 927010_1 CDM 0612 RC 72147 HCPCS inpatient 4425 2876.25 AETNA AETNA 3495.75 79 999999999 2679.34 4292.25 percent of total billed charges MRI scan of middle spinal canal with contrast 927010_1 CDM 0612 RC 72147 HCPCS inpatient 4425 2876.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4292.25 97 999999999 2679.34 4292.25 percent of total billed charges MRI scan of middle spinal canal with contrast 927010_1 CDM 0612 RC 72147 HCPCS inpatient 4425 2876.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 3053.25 69 999999999 2679.34 4292.25 percent of total billed charges MRI scan of middle spinal canal with contrast 927010_1 CDM 0612 RC 72147 HCPCS inpatient 4425 2876.25 SIHO - ALL PLANS SIHO - ALL PLANS 3982.5 90 999999999 2679.34 4292.25 percent of total billed charges MRI scan of middle spinal canal with contrast 927010_1 CDM 0612 RC 72147 HCPCS inpatient 4425 2876.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 3451.5 78 999999999 2679.34 4292.25 percent of total billed charges MRI scan of middle spinal canal with contrast 927010_1 CDM 0612 RC 72147 HCPCS inpatient 4425 2876.25 UMR - ALL PLANS UMR - ALL PLANS 3097.5 70 999999999 2679.34 4292.25 percent of total billed charges MRI scan of middle spinal canal with contrast 927010_1 CDM 0612 RC 72147 HCPCS inpatient 4425 2876.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2679.34 4292.25 MRI scan of middle spinal canal with contrast 927010_1 CDM 0612 RC 72147 HCPCS inpatient 4425 2876.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2679.34 60.55 999999999 2679.34 4292.25 percent of total billed charges MRI scan of middle spinal canal with contrast 927010_1 CDM 0612 RC 72147 HCPCS inpatient 4425 2876.25 ANTHEM HMO ANTHEM HMO 999999999 2679.34 4292.25 MRI scan of middle spinal canal with contrast 927010_1 CDM 0612 RC 72147 HCPCS inpatient 4425 2876.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2679.34 4292.25 MRI scan of middle spinal canal with contrast 927010_1 CDM 0612 RC 72147 HCPCS inpatient 4425 2876.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2679.34 4292.25 MRI scan of middle spinal canal with contrast 927010_1 CDM 0612 RC 72147 HCPCS inpatient 4425 2876.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 2991.3 67.6 999999999 2679.34 4292.25 percent of total billed charges MRI scan of middle spinal canal with contrast 927010_1 CDM 0612 RC 72147 HCPCS inpatient 4425 2876.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 2679.34 4292.25 MRI scan of middle spinal canal without contrast 927012_1 CDM 0612 RC 72146 HCPCS inpatient 4779 3106.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 3106.35 65 999999999 2893.68 4635.63 percent of total billed charges MRI scan of middle spinal canal without contrast 927012_1 CDM 0612 RC 72146 HCPCS inpatient 4779 3106.35 AETNA AETNA 3775.41 79 999999999 2893.68 4635.63 percent of total billed charges MRI scan of middle spinal canal without contrast 927012_1 CDM 0612 RC 72146 HCPCS inpatient 4779 3106.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4635.63 97 999999999 2893.68 4635.63 percent of total billed charges MRI scan of middle spinal canal without contrast 927012_1 CDM 0612 RC 72146 HCPCS inpatient 4779 3106.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 3297.51 69 999999999 2893.68 4635.63 percent of total billed charges MRI scan of middle spinal canal without contrast 927012_1 CDM 0612 RC 72146 HCPCS inpatient 4779 3106.35 SIHO - ALL PLANS SIHO - ALL PLANS 4301.1 90 999999999 2893.68 4635.63 percent of total billed charges MRI scan of middle spinal canal without contrast 927012_1 CDM 0612 RC 72146 HCPCS inpatient 4779 3106.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 3727.62 78 999999999 2893.68 4635.63 percent of total billed charges MRI scan of middle spinal canal without contrast 927012_1 CDM 0612 RC 72146 HCPCS inpatient 4779 3106.35 UMR - ALL PLANS UMR - ALL PLANS 3345.3 70 999999999 2893.68 4635.63 percent of total billed charges MRI scan of middle spinal canal without contrast 927012_1 CDM 0612 RC 72146 HCPCS inpatient 4779 3106.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2893.68 4635.63 MRI scan of middle spinal canal without contrast 927012_1 CDM 0612 RC 72146 HCPCS inpatient 4779 3106.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2893.68 60.55 999999999 2893.68 4635.63 percent of total billed charges MRI scan of middle spinal canal without contrast 927012_1 CDM 0612 RC 72146 HCPCS inpatient 4779 3106.35 ANTHEM HMO ANTHEM HMO 999999999 2893.68 4635.63 MRI scan of middle spinal canal without contrast 927012_1 CDM 0612 RC 72146 HCPCS inpatient 4779 3106.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2893.68 4635.63 MRI scan of middle spinal canal without contrast 927012_1 CDM 0612 RC 72146 HCPCS inpatient 4779 3106.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2893.68 4635.63 MRI scan of middle spinal canal without contrast 927012_1 CDM 0612 RC 72146 HCPCS inpatient 4779 3106.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 3230.6 67.6 999999999 2893.68 4635.63 percent of total billed charges MRI scan of middle spinal canal without contrast 927012_1 CDM 0612 RC 72146 HCPCS inpatient 4779 3106.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 2893.68 4635.63 MRI scan of jaw joint 927014_1 CDM 0610 RC 70336 HCPCS inpatient 4424 2875.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 2875.6 65 999999999 2678.73 4291.28 percent of total billed charges MRI scan of jaw joint 927014_1 CDM 0610 RC 70336 HCPCS inpatient 4424 2875.6 AETNA AETNA 3494.96 79 999999999 2678.73 4291.28 percent of total billed charges MRI scan of jaw joint 927014_1 CDM 0610 RC 70336 HCPCS inpatient 4424 2875.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4291.28 97 999999999 2678.73 4291.28 percent of total billed charges MRI scan of jaw joint 927014_1 CDM 0610 RC 70336 HCPCS inpatient 4424 2875.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 3052.56 69 999999999 2678.73 4291.28 percent of total billed charges MRI scan of jaw joint 927014_1 CDM 0610 RC 70336 HCPCS inpatient 4424 2875.6 SIHO - ALL PLANS SIHO - ALL PLANS 3981.6 90 999999999 2678.73 4291.28 percent of total billed charges MRI scan of jaw joint 927014_1 CDM 0610 RC 70336 HCPCS inpatient 4424 2875.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 3450.72 78 999999999 2678.73 4291.28 percent of total billed charges MRI scan of jaw joint 927014_1 CDM 0610 RC 70336 HCPCS inpatient 4424 2875.6 UMR - ALL PLANS UMR - ALL PLANS 3096.8 70 999999999 2678.73 4291.28 percent of total billed charges MRI scan of jaw joint 927014_1 CDM 0610 RC 70336 HCPCS inpatient 4424 2875.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2678.73 4291.28 MRI scan of jaw joint 927014_1 CDM 0610 RC 70336 HCPCS inpatient 4424 2875.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2678.73 60.55 999999999 2678.73 4291.28 percent of total billed charges MRI scan of jaw joint 927014_1 CDM 0610 RC 70336 HCPCS inpatient 4424 2875.6 ANTHEM HMO ANTHEM HMO 999999999 2678.73 4291.28 MRI scan of jaw joint 927014_1 CDM 0610 RC 70336 HCPCS inpatient 4424 2875.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2678.73 4291.28 MRI scan of jaw joint 927014_1 CDM 0610 RC 70336 HCPCS inpatient 4424 2875.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2678.73 4291.28 MRI scan of jaw joint 927014_1 CDM 0610 RC 70336 HCPCS inpatient 4424 2875.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 2990.62 67.6 999999999 2678.73 4291.28 percent of total billed charges MRI scan of jaw joint 927014_1 CDM 0610 RC 70336 HCPCS inpatient 4424 2875.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 2678.73 4291.28 MRI scan of arm joint before and after contrast 927016_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 5971.55 65 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 927016_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 AETNA AETNA 7257.73 79 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 927016_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8911.39 97 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 927016_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 6339.03 69 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 927016_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 SIHO - ALL PLANS SIHO - ALL PLANS 8268.3 90 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 927016_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 7165.86 78 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 927016_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 UMR - ALL PLANS UMR - ALL PLANS 6430.9 70 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 927016_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5562.73 8911.39 MRI scan of arm joint before and after contrast 927016_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5562.73 60.55 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 927016_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 ANTHEM HMO ANTHEM HMO 999999999 5562.73 8911.39 MRI scan of arm joint before and after contrast 927016_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5562.73 8911.39 MRI scan of arm joint before and after contrast 927016_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5562.73 8911.39 MRI scan of arm joint before and after contrast 927016_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 6210.41 67.6 999999999 5562.73 8911.39 percent of total billed charges MRI scan of arm joint before and after contrast 927016_1 CDM 0610 RC 73223 HCPCS inpatient 9187 5971.55 UHC - ALL PLANS UHC - ALL PLANS 999999999 5562.73 8911.39 MRI scan of arm joint before and after contrast 927018_1 CDM 0610 RC 73223 HCPCS inpatient 4090 2658.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 2658.5 65 999999999 2476.5 3967.3 percent of total billed charges MRI scan of arm joint before and after contrast 927018_1 CDM 0610 RC 73223 HCPCS inpatient 4090 2658.5 AETNA AETNA 3231.1 79 999999999 2476.5 3967.3 percent of total billed charges MRI scan of arm joint before and after contrast 927018_1 CDM 0610 RC 73223 HCPCS inpatient 4090 2658.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3967.3 97 999999999 2476.5 3967.3 percent of total billed charges MRI scan of arm joint before and after contrast 927018_1 CDM 0610 RC 73223 HCPCS inpatient 4090 2658.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 2822.1 69 999999999 2476.5 3967.3 percent of total billed charges MRI scan of arm joint before and after contrast 927018_1 CDM 0610 RC 73223 HCPCS inpatient 4090 2658.5 SIHO - ALL PLANS SIHO - ALL PLANS 3681 90 999999999 2476.5 3967.3 percent of total billed charges MRI scan of arm joint before and after contrast 927018_1 CDM 0610 RC 73223 HCPCS inpatient 4090 2658.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 3190.2 78 999999999 2476.5 3967.3 percent of total billed charges MRI scan of arm joint before and after contrast 927018_1 CDM 0610 RC 73223 HCPCS inpatient 4090 2658.5 UMR - ALL PLANS UMR - ALL PLANS 2863 70 999999999 2476.5 3967.3 percent of total billed charges MRI scan of arm joint before and after contrast 927018_1 CDM 0610 RC 73223 HCPCS inpatient 4090 2658.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2476.5 3967.3 MRI scan of arm joint before and after contrast 927018_1 CDM 0610 RC 73223 HCPCS inpatient 4090 2658.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2476.5 60.55 999999999 2476.5 3967.3 percent of total billed charges MRI scan of arm joint before and after contrast 927018_1 CDM 0610 RC 73223 HCPCS inpatient 4090 2658.5 ANTHEM HMO ANTHEM HMO 999999999 2476.5 3967.3 MRI scan of arm joint before and after contrast 927018_1 CDM 0610 RC 73223 HCPCS inpatient 4090 2658.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2476.5 3967.3 MRI scan of arm joint before and after contrast 927018_1 CDM 0610 RC 73223 HCPCS inpatient 4090 2658.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2476.5 3967.3 MRI scan of arm joint before and after contrast 927018_1 CDM 0610 RC 73223 HCPCS inpatient 4090 2658.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 2764.84 67.6 999999999 2476.5 3967.3 percent of total billed charges MRI scan of arm joint before and after contrast 927018_1 CDM 0610 RC 73223 HCPCS inpatient 4090 2658.5 UHC - ALL PLANS UHC - ALL PLANS 999999999 2476.5 3967.3 MRI scan of arm joint before and after contrast 927020_1 CDM 0610 RC 73223 HCPCS inpatient 4374 2843.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 2843.1 65 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm joint before and after contrast 927020_1 CDM 0610 RC 73223 HCPCS inpatient 4374 2843.1 AETNA AETNA 3455.46 79 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm joint before and after contrast 927020_1 CDM 0610 RC 73223 HCPCS inpatient 4374 2843.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4242.78 97 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm joint before and after contrast 927020_1 CDM 0610 RC 73223 HCPCS inpatient 4374 2843.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 3018.06 69 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm joint before and after contrast 927020_1 CDM 0610 RC 73223 HCPCS inpatient 4374 2843.1 SIHO - ALL PLANS SIHO - ALL PLANS 3936.6 90 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm joint before and after contrast 927020_1 CDM 0610 RC 73223 HCPCS inpatient 4374 2843.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 3411.72 78 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm joint before and after contrast 927020_1 CDM 0610 RC 73223 HCPCS inpatient 4374 2843.1 UMR - ALL PLANS UMR - ALL PLANS 3061.8 70 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm joint before and after contrast 927020_1 CDM 0610 RC 73223 HCPCS inpatient 4374 2843.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2648.46 4242.78 MRI scan of arm joint before and after contrast 927020_1 CDM 0610 RC 73223 HCPCS inpatient 4374 2843.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2648.46 60.55 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm joint before and after contrast 927020_1 CDM 0610 RC 73223 HCPCS inpatient 4374 2843.1 ANTHEM HMO ANTHEM HMO 999999999 2648.46 4242.78 MRI scan of arm joint before and after contrast 927020_1 CDM 0610 RC 73223 HCPCS inpatient 4374 2843.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2648.46 4242.78 MRI scan of arm joint before and after contrast 927020_1 CDM 0610 RC 73223 HCPCS inpatient 4374 2843.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2648.46 4242.78 MRI scan of arm joint before and after contrast 927020_1 CDM 0610 RC 73223 HCPCS inpatient 4374 2843.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 2956.82 67.6 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm joint before and after contrast 927020_1 CDM 0610 RC 73223 HCPCS inpatient 4374 2843.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 2648.46 4242.78 MRI scan of arm joint with contrast 927022_1 CDM 0610 RC 73222 HCPCS inpatient 9011 5857.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 5857.15 65 999999999 5456.16 8740.67 percent of total billed charges MRI scan of arm joint with contrast 927022_1 CDM 0610 RC 73222 HCPCS inpatient 9011 5857.15 AETNA AETNA 7118.69 79 999999999 5456.16 8740.67 percent of total billed charges MRI scan of arm joint with contrast 927022_1 CDM 0610 RC 73222 HCPCS inpatient 9011 5857.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8740.67 97 999999999 5456.16 8740.67 percent of total billed charges MRI scan of arm joint with contrast 927022_1 CDM 0610 RC 73222 HCPCS inpatient 9011 5857.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 6217.59 69 999999999 5456.16 8740.67 percent of total billed charges MRI scan of arm joint with contrast 927022_1 CDM 0610 RC 73222 HCPCS inpatient 9011 5857.15 SIHO - ALL PLANS SIHO - ALL PLANS 8109.9 90 999999999 5456.16 8740.67 percent of total billed charges MRI scan of arm joint with contrast 927022_1 CDM 0610 RC 73222 HCPCS inpatient 9011 5857.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 7028.58 78 999999999 5456.16 8740.67 percent of total billed charges MRI scan of arm joint with contrast 927022_1 CDM 0610 RC 73222 HCPCS inpatient 9011 5857.15 UMR - ALL PLANS UMR - ALL PLANS 6307.7 70 999999999 5456.16 8740.67 percent of total billed charges MRI scan of arm joint with contrast 927022_1 CDM 0610 RC 73222 HCPCS inpatient 9011 5857.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5456.16 8740.67 MRI scan of arm joint with contrast 927022_1 CDM 0610 RC 73222 HCPCS inpatient 9011 5857.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5456.16 60.55 999999999 5456.16 8740.67 percent of total billed charges MRI scan of arm joint with contrast 927022_1 CDM 0610 RC 73222 HCPCS inpatient 9011 5857.15 ANTHEM HMO ANTHEM HMO 999999999 5456.16 8740.67 MRI scan of arm joint with contrast 927022_1 CDM 0610 RC 73222 HCPCS inpatient 9011 5857.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5456.16 8740.67 MRI scan of arm joint with contrast 927022_1 CDM 0610 RC 73222 HCPCS inpatient 9011 5857.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5456.16 8740.67 MRI scan of arm joint with contrast 927022_1 CDM 0610 RC 73222 HCPCS inpatient 9011 5857.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 6091.44 67.6 999999999 5456.16 8740.67 percent of total billed charges MRI scan of arm joint with contrast 927022_1 CDM 0610 RC 73222 HCPCS inpatient 9011 5857.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 5456.16 8740.67 MRI scan of arm joint with contrast 927024_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 SELF PAY DISCOUNT SELF PAY DISCOUNT 2847 65 999999999 2652.09 4248.6 percent of total billed charges MRI scan of arm joint with contrast 927024_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 AETNA AETNA 3460.2 79 999999999 2652.09 4248.6 percent of total billed charges MRI scan of arm joint with contrast 927024_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4248.6 97 999999999 2652.09 4248.6 percent of total billed charges MRI scan of arm joint with contrast 927024_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 ENCORE - ALL PLANS ENCORE - ALL PLANS 3022.2 69 999999999 2652.09 4248.6 percent of total billed charges MRI scan of arm joint with contrast 927024_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 SIHO - ALL PLANS SIHO - ALL PLANS 3942 90 999999999 2652.09 4248.6 percent of total billed charges MRI scan of arm joint with contrast 927024_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 HUMANA - ALL PLANS HUMANA - ALL PLANS 3416.4 78 999999999 2652.09 4248.6 percent of total billed charges MRI scan of arm joint with contrast 927024_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 UMR - ALL PLANS UMR - ALL PLANS 3066 70 999999999 2652.09 4248.6 percent of total billed charges MRI scan of arm joint with contrast 927024_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2652.09 4248.6 MRI scan of arm joint with contrast 927024_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2652.09 60.55 999999999 2652.09 4248.6 percent of total billed charges MRI scan of arm joint with contrast 927024_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 ANTHEM HMO ANTHEM HMO 999999999 2652.09 4248.6 MRI scan of arm joint with contrast 927024_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2652.09 4248.6 MRI scan of arm joint with contrast 927024_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2652.09 4248.6 MRI scan of arm joint with contrast 927024_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 CIGNA - ALL PLANS CIGNA - ALL PLANS 2960.88 67.6 999999999 2652.09 4248.6 percent of total billed charges MRI scan of arm joint with contrast 927024_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 UHC - ALL PLANS UHC - ALL PLANS 999999999 2652.09 4248.6 MRI scan of arm joint with contrast 927026_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 SELF PAY DISCOUNT SELF PAY DISCOUNT 2847 65 999999999 2652.09 4248.6 percent of total billed charges MRI scan of arm joint with contrast 927026_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 AETNA AETNA 3460.2 79 999999999 2652.09 4248.6 percent of total billed charges MRI scan of arm joint with contrast 927026_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4248.6 97 999999999 2652.09 4248.6 percent of total billed charges MRI scan of arm joint with contrast 927026_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 ENCORE - ALL PLANS ENCORE - ALL PLANS 3022.2 69 999999999 2652.09 4248.6 percent of total billed charges MRI scan of arm joint with contrast 927026_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 SIHO - ALL PLANS SIHO - ALL PLANS 3942 90 999999999 2652.09 4248.6 percent of total billed charges MRI scan of arm joint with contrast 927026_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 HUMANA - ALL PLANS HUMANA - ALL PLANS 3416.4 78 999999999 2652.09 4248.6 percent of total billed charges MRI scan of arm joint with contrast 927026_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 UMR - ALL PLANS UMR - ALL PLANS 3066 70 999999999 2652.09 4248.6 percent of total billed charges MRI scan of arm joint with contrast 927026_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2652.09 4248.6 MRI scan of arm joint with contrast 927026_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2652.09 60.55 999999999 2652.09 4248.6 percent of total billed charges MRI scan of arm joint with contrast 927026_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 ANTHEM HMO ANTHEM HMO 999999999 2652.09 4248.6 MRI scan of arm joint with contrast 927026_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2652.09 4248.6 MRI scan of arm joint with contrast 927026_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2652.09 4248.6 MRI scan of arm joint with contrast 927026_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 CIGNA - ALL PLANS CIGNA - ALL PLANS 2960.88 67.6 999999999 2652.09 4248.6 percent of total billed charges MRI scan of arm joint with contrast 927026_1 CDM 0610 RC 73222 HCPCS inpatient 4380 2847 UHC - ALL PLANS UHC - ALL PLANS 999999999 2652.09 4248.6 MRI scan of arm joint without contrast 927028_1 CDM 0610 RC 73221 HCPCS inpatient 8842 5747.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 5747.3 65 999999999 5353.83 8576.74 percent of total billed charges MRI scan of arm joint without contrast 927028_1 CDM 0610 RC 73221 HCPCS inpatient 8842 5747.3 AETNA AETNA 6985.18 79 999999999 5353.83 8576.74 percent of total billed charges MRI scan of arm joint without contrast 927028_1 CDM 0610 RC 73221 HCPCS inpatient 8842 5747.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8576.74 97 999999999 5353.83 8576.74 percent of total billed charges MRI scan of arm joint without contrast 927028_1 CDM 0610 RC 73221 HCPCS inpatient 8842 5747.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 6100.98 69 999999999 5353.83 8576.74 percent of total billed charges MRI scan of arm joint without contrast 927028_1 CDM 0610 RC 73221 HCPCS inpatient 8842 5747.3 SIHO - ALL PLANS SIHO - ALL PLANS 7957.8 90 999999999 5353.83 8576.74 percent of total billed charges MRI scan of arm joint without contrast 927028_1 CDM 0610 RC 73221 HCPCS inpatient 8842 5747.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 6896.76 78 999999999 5353.83 8576.74 percent of total billed charges MRI scan of arm joint without contrast 927028_1 CDM 0610 RC 73221 HCPCS inpatient 8842 5747.3 UMR - ALL PLANS UMR - ALL PLANS 6189.4 70 999999999 5353.83 8576.74 percent of total billed charges MRI scan of arm joint without contrast 927028_1 CDM 0610 RC 73221 HCPCS inpatient 8842 5747.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5353.83 8576.74 MRI scan of arm joint without contrast 927028_1 CDM 0610 RC 73221 HCPCS inpatient 8842 5747.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5353.83 60.55 999999999 5353.83 8576.74 percent of total billed charges MRI scan of arm joint without contrast 927028_1 CDM 0610 RC 73221 HCPCS inpatient 8842 5747.3 ANTHEM HMO ANTHEM HMO 999999999 5353.83 8576.74 MRI scan of arm joint without contrast 927028_1 CDM 0610 RC 73221 HCPCS inpatient 8842 5747.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5353.83 8576.74 MRI scan of arm joint without contrast 927028_1 CDM 0610 RC 73221 HCPCS inpatient 8842 5747.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5353.83 8576.74 MRI scan of arm joint without contrast 927028_1 CDM 0610 RC 73221 HCPCS inpatient 8842 5747.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 5977.19 67.6 999999999 5353.83 8576.74 percent of total billed charges MRI scan of arm joint without contrast 927028_1 CDM 0610 RC 73221 HCPCS inpatient 8842 5747.3 UHC - ALL PLANS UHC - ALL PLANS 999999999 5353.83 8576.74 MRI scan of arm joint without contrast 927030_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 2901.6 65 999999999 2702.95 4330.08 percent of total billed charges MRI scan of arm joint without contrast 927030_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 AETNA AETNA 3526.56 79 999999999 2702.95 4330.08 percent of total billed charges MRI scan of arm joint without contrast 927030_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4330.08 97 999999999 2702.95 4330.08 percent of total billed charges MRI scan of arm joint without contrast 927030_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 3080.16 69 999999999 2702.95 4330.08 percent of total billed charges MRI scan of arm joint without contrast 927030_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 SIHO - ALL PLANS SIHO - ALL PLANS 4017.6 90 999999999 2702.95 4330.08 percent of total billed charges MRI scan of arm joint without contrast 927030_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 3481.92 78 999999999 2702.95 4330.08 percent of total billed charges MRI scan of arm joint without contrast 927030_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 UMR - ALL PLANS UMR - ALL PLANS 3124.8 70 999999999 2702.95 4330.08 percent of total billed charges MRI scan of arm joint without contrast 927030_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2702.95 4330.08 MRI scan of arm joint without contrast 927030_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2702.95 60.55 999999999 2702.95 4330.08 percent of total billed charges MRI scan of arm joint without contrast 927030_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 ANTHEM HMO ANTHEM HMO 999999999 2702.95 4330.08 MRI scan of arm joint without contrast 927030_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2702.95 4330.08 MRI scan of arm joint without contrast 927030_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2702.95 4330.08 MRI scan of arm joint without contrast 927030_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 3017.66 67.6 999999999 2702.95 4330.08 percent of total billed charges MRI scan of arm joint without contrast 927030_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 2702.95 4330.08 MRI scan of arm joint without contrast 927032_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 2901.6 65 999999999 2702.95 4330.08 percent of total billed charges MRI scan of arm joint without contrast 927032_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 AETNA AETNA 3526.56 79 999999999 2702.95 4330.08 percent of total billed charges MRI scan of arm joint without contrast 927032_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4330.08 97 999999999 2702.95 4330.08 percent of total billed charges MRI scan of arm joint without contrast 927032_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 3080.16 69 999999999 2702.95 4330.08 percent of total billed charges MRI scan of arm joint without contrast 927032_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 SIHO - ALL PLANS SIHO - ALL PLANS 4017.6 90 999999999 2702.95 4330.08 percent of total billed charges MRI scan of arm joint without contrast 927032_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 3481.92 78 999999999 2702.95 4330.08 percent of total billed charges MRI scan of arm joint without contrast 927032_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 UMR - ALL PLANS UMR - ALL PLANS 3124.8 70 999999999 2702.95 4330.08 percent of total billed charges MRI scan of arm joint without contrast 927032_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2702.95 4330.08 MRI scan of arm joint without contrast 927032_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2702.95 60.55 999999999 2702.95 4330.08 percent of total billed charges MRI scan of arm joint without contrast 927032_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 ANTHEM HMO ANTHEM HMO 999999999 2702.95 4330.08 MRI scan of arm joint without contrast 927032_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2702.95 4330.08 MRI scan of arm joint without contrast 927032_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2702.95 4330.08 MRI scan of arm joint without contrast 927032_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 3017.66 67.6 999999999 2702.95 4330.08 percent of total billed charges MRI scan of arm joint without contrast 927032_1 CDM 0610 RC 73221 HCPCS inpatient 4464 2901.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 2702.95 4330.08 MRI scan of arm before and after contrast 927034_1 CDM 0610 RC 73220 HCPCS inpatient 9006 5853.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 5853.9 65 999999999 5453.13 8735.82 percent of total billed charges MRI scan of arm before and after contrast 927034_1 CDM 0610 RC 73220 HCPCS inpatient 9006 5853.9 AETNA AETNA 7114.74 79 999999999 5453.13 8735.82 percent of total billed charges MRI scan of arm before and after contrast 927034_1 CDM 0610 RC 73220 HCPCS inpatient 9006 5853.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 8735.82 97 999999999 5453.13 8735.82 percent of total billed charges MRI scan of arm before and after contrast 927034_1 CDM 0610 RC 73220 HCPCS inpatient 9006 5853.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 6214.14 69 999999999 5453.13 8735.82 percent of total billed charges MRI scan of arm before and after contrast 927034_1 CDM 0610 RC 73220 HCPCS inpatient 9006 5853.9 SIHO - ALL PLANS SIHO - ALL PLANS 8105.4 90 999999999 5453.13 8735.82 percent of total billed charges MRI scan of arm before and after contrast 927034_1 CDM 0610 RC 73220 HCPCS inpatient 9006 5853.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 7024.68 78 999999999 5453.13 8735.82 percent of total billed charges MRI scan of arm before and after contrast 927034_1 CDM 0610 RC 73220 HCPCS inpatient 9006 5853.9 UMR - ALL PLANS UMR - ALL PLANS 6304.2 70 999999999 5453.13 8735.82 percent of total billed charges MRI scan of arm before and after contrast 927034_1 CDM 0610 RC 73220 HCPCS inpatient 9006 5853.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 5453.13 8735.82 MRI scan of arm before and after contrast 927034_1 CDM 0610 RC 73220 HCPCS inpatient 9006 5853.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 5453.13 60.55 999999999 5453.13 8735.82 percent of total billed charges MRI scan of arm before and after contrast 927034_1 CDM 0610 RC 73220 HCPCS inpatient 9006 5853.9 ANTHEM HMO ANTHEM HMO 999999999 5453.13 8735.82 MRI scan of arm before and after contrast 927034_1 CDM 0610 RC 73220 HCPCS inpatient 9006 5853.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 5453.13 8735.82 MRI scan of arm before and after contrast 927034_1 CDM 0610 RC 73220 HCPCS inpatient 9006 5853.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 5453.13 8735.82 MRI scan of arm before and after contrast 927034_1 CDM 0610 RC 73220 HCPCS inpatient 9006 5853.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 6088.06 67.6 999999999 5453.13 8735.82 percent of total billed charges MRI scan of arm before and after contrast 927034_1 CDM 0610 RC 73220 HCPCS inpatient 9006 5853.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 5453.13 8735.82 MRI scan of arm before and after contrast 927036_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 2843.1 65 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm before and after contrast 927036_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 AETNA AETNA 3455.46 79 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm before and after contrast 927036_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4242.78 97 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm before and after contrast 927036_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 3018.06 69 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm before and after contrast 927036_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 SIHO - ALL PLANS SIHO - ALL PLANS 3936.6 90 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm before and after contrast 927036_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 3411.72 78 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm before and after contrast 927036_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 UMR - ALL PLANS UMR - ALL PLANS 3061.8 70 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm before and after contrast 927036_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2648.46 4242.78 MRI scan of arm before and after contrast 927036_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2648.46 60.55 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm before and after contrast 927036_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 ANTHEM HMO ANTHEM HMO 999999999 2648.46 4242.78 MRI scan of arm before and after contrast 927036_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2648.46 4242.78 MRI scan of arm before and after contrast 927036_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2648.46 4242.78 MRI scan of arm before and after contrast 927036_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 2956.82 67.6 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm before and after contrast 927036_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 2648.46 4242.78 MRI scan of arm before and after contrast 927038_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 2843.1 65 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm before and after contrast 927038_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 AETNA AETNA 3455.46 79 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm before and after contrast 927038_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4242.78 97 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm before and after contrast 927038_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 3018.06 69 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm before and after contrast 927038_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 SIHO - ALL PLANS SIHO - ALL PLANS 3936.6 90 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm before and after contrast 927038_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 3411.72 78 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm before and after contrast 927038_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 UMR - ALL PLANS UMR - ALL PLANS 3061.8 70 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm before and after contrast 927038_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2648.46 4242.78 MRI scan of arm before and after contrast 927038_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2648.46 60.55 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm before and after contrast 927038_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 ANTHEM HMO ANTHEM HMO 999999999 2648.46 4242.78 MRI scan of arm before and after contrast 927038_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2648.46 4242.78 MRI scan of arm before and after contrast 927038_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2648.46 4242.78 MRI scan of arm before and after contrast 927038_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 2956.82 67.6 999999999 2648.46 4242.78 percent of total billed charges MRI scan of arm before and after contrast 927038_1 CDM 0610 RC 73220 HCPCS inpatient 4374 2843.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 2648.46 4242.78 MRI scan of arm with contrast 927042_1 CDM 0610 RC 73219 HCPCS inpatient 4679 3041.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 3041.35 65 999999999 2833.13 4538.63 percent of total billed charges MRI scan of arm with contrast 927042_1 CDM 0610 RC 73219 HCPCS inpatient 4679 3041.35 AETNA AETNA 3696.41 79 999999999 2833.13 4538.63 percent of total billed charges MRI scan of arm with contrast 927042_1 CDM 0610 RC 73219 HCPCS inpatient 4679 3041.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4538.63 97 999999999 2833.13 4538.63 percent of total billed charges MRI scan of arm with contrast 927042_1 CDM 0610 RC 73219 HCPCS inpatient 4679 3041.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 3228.51 69 999999999 2833.13 4538.63 percent of total billed charges MRI scan of arm with contrast 927042_1 CDM 0610 RC 73219 HCPCS inpatient 4679 3041.35 SIHO - ALL PLANS SIHO - ALL PLANS 4211.1 90 999999999 2833.13 4538.63 percent of total billed charges MRI scan of arm with contrast 927042_1 CDM 0610 RC 73219 HCPCS inpatient 4679 3041.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 3649.62 78 999999999 2833.13 4538.63 percent of total billed charges MRI scan of arm with contrast 927042_1 CDM 0610 RC 73219 HCPCS inpatient 4679 3041.35 UMR - ALL PLANS UMR - ALL PLANS 3275.3 70 999999999 2833.13 4538.63 percent of total billed charges MRI scan of arm with contrast 927042_1 CDM 0610 RC 73219 HCPCS inpatient 4679 3041.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2833.13 4538.63 MRI scan of arm with contrast 927042_1 CDM 0610 RC 73219 HCPCS inpatient 4679 3041.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2833.13 60.55 999999999 2833.13 4538.63 percent of total billed charges MRI scan of arm with contrast 927042_1 CDM 0610 RC 73219 HCPCS inpatient 4679 3041.35 ANTHEM HMO ANTHEM HMO 999999999 2833.13 4538.63 MRI scan of arm with contrast 927042_1 CDM 0610 RC 73219 HCPCS inpatient 4679 3041.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2833.13 4538.63 MRI scan of arm with contrast 927042_1 CDM 0610 RC 73219 HCPCS inpatient 4679 3041.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2833.13 4538.63 MRI scan of arm with contrast 927042_1 CDM 0610 RC 73219 HCPCS inpatient 4679 3041.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 3163 67.6 999999999 2833.13 4538.63 percent of total billed charges MRI scan of arm with contrast 927042_1 CDM 0610 RC 73219 HCPCS inpatient 4679 3041.35 UHC - ALL PLANS UHC - ALL PLANS 999999999 2833.13 4538.63 MRI scan of arm with contrast 927044_1 CDM 0610 RC 73219 HCPCS inpatient 4452 2893.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 2893.8 65 999999999 2695.69 4318.44 percent of total billed charges MRI scan of arm with contrast 927044_1 CDM 0610 RC 73219 HCPCS inpatient 4452 2893.8 AETNA AETNA 3517.08 79 999999999 2695.69 4318.44 percent of total billed charges MRI scan of arm with contrast 927044_1 CDM 0610 RC 73219 HCPCS inpatient 4452 2893.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4318.44 97 999999999 2695.69 4318.44 percent of total billed charges MRI scan of arm with contrast 927044_1 CDM 0610 RC 73219 HCPCS inpatient 4452 2893.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 3071.88 69 999999999 2695.69 4318.44 percent of total billed charges MRI scan of arm with contrast 927044_1 CDM 0610 RC 73219 HCPCS inpatient 4452 2893.8 SIHO - ALL PLANS SIHO - ALL PLANS 4006.8 90 999999999 2695.69 4318.44 percent of total billed charges MRI scan of arm with contrast 927044_1 CDM 0610 RC 73219 HCPCS inpatient 4452 2893.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 3472.56 78 999999999 2695.69 4318.44 percent of total billed charges MRI scan of arm with contrast 927044_1 CDM 0610 RC 73219 HCPCS inpatient 4452 2893.8 UMR - ALL PLANS UMR - ALL PLANS 3116.4 70 999999999 2695.69 4318.44 percent of total billed charges MRI scan of arm with contrast 927044_1 CDM 0610 RC 73219 HCPCS inpatient 4452 2893.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2695.69 4318.44 MRI scan of arm with contrast 927044_1 CDM 0610 RC 73219 HCPCS inpatient 4452 2893.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2695.69 60.55 999999999 2695.69 4318.44 percent of total billed charges MRI scan of arm with contrast 927044_1 CDM 0610 RC 73219 HCPCS inpatient 4452 2893.8 ANTHEM HMO ANTHEM HMO 999999999 2695.69 4318.44 MRI scan of arm with contrast 927044_1 CDM 0610 RC 73219 HCPCS inpatient 4452 2893.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2695.69 4318.44 MRI scan of arm with contrast 927044_1 CDM 0610 RC 73219 HCPCS inpatient 4452 2893.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2695.69 4318.44 MRI scan of arm with contrast 927044_1 CDM 0610 RC 73219 HCPCS inpatient 4452 2893.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 3009.55 67.6 999999999 2695.69 4318.44 percent of total billed charges MRI scan of arm with contrast 927044_1 CDM 0610 RC 73219 HCPCS inpatient 4452 2893.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 2695.69 4318.44 MRI scan of arm without contrast 927048_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 2921.1 65 999999999 2721.12 4359.18 percent of total billed charges MRI scan of arm without contrast 927048_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 AETNA AETNA 3550.26 79 999999999 2721.12 4359.18 percent of total billed charges MRI scan of arm without contrast 927048_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4359.18 97 999999999 2721.12 4359.18 percent of total billed charges MRI scan of arm without contrast 927048_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 3100.86 69 999999999 2721.12 4359.18 percent of total billed charges MRI scan of arm without contrast 927048_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 SIHO - ALL PLANS SIHO - ALL PLANS 4044.6 90 999999999 2721.12 4359.18 percent of total billed charges MRI scan of arm without contrast 927048_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 3505.32 78 999999999 2721.12 4359.18 percent of total billed charges MRI scan of arm without contrast 927048_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 UMR - ALL PLANS UMR - ALL PLANS 3145.8 70 999999999 2721.12 4359.18 percent of total billed charges MRI scan of arm without contrast 927048_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2721.12 4359.18 MRI scan of arm without contrast 927048_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2721.12 60.55 999999999 2721.12 4359.18 percent of total billed charges MRI scan of arm without contrast 927048_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 ANTHEM HMO ANTHEM HMO 999999999 2721.12 4359.18 MRI scan of arm without contrast 927048_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2721.12 4359.18 MRI scan of arm without contrast 927048_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2721.12 4359.18 MRI scan of arm without contrast 927048_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 3037.94 67.6 999999999 2721.12 4359.18 percent of total billed charges MRI scan of arm without contrast 927048_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 2721.12 4359.18 MRI scan of arm without contrast 927050_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 2921.1 65 999999999 2721.12 4359.18 percent of total billed charges MRI scan of arm without contrast 927050_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 AETNA AETNA 3550.26 79 999999999 2721.12 4359.18 percent of total billed charges MRI scan of arm without contrast 927050_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4359.18 97 999999999 2721.12 4359.18 percent of total billed charges MRI scan of arm without contrast 927050_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 3100.86 69 999999999 2721.12 4359.18 percent of total billed charges MRI scan of arm without contrast 927050_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 SIHO - ALL PLANS SIHO - ALL PLANS 4044.6 90 999999999 2721.12 4359.18 percent of total billed charges MRI scan of arm without contrast 927050_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 3505.32 78 999999999 2721.12 4359.18 percent of total billed charges MRI scan of arm without contrast 927050_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 UMR - ALL PLANS UMR - ALL PLANS 3145.8 70 999999999 2721.12 4359.18 percent of total billed charges MRI scan of arm without contrast 927050_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2721.12 4359.18 MRI scan of arm without contrast 927050_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2721.12 60.55 999999999 2721.12 4359.18 percent of total billed charges MRI scan of arm without contrast 927050_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 ANTHEM HMO ANTHEM HMO 999999999 2721.12 4359.18 MRI scan of arm without contrast 927050_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2721.12 4359.18 MRI scan of arm without contrast 927050_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2721.12 4359.18 MRI scan of arm without contrast 927050_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 3037.94 67.6 999999999 2721.12 4359.18 percent of total billed charges MRI scan of arm without contrast 927050_1 CDM 0610 RC 73218 HCPCS inpatient 4494 2921.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 2721.12 4359.18 Ultrasound scan of head and neck soft tissue 927052_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 607.1 65 999999999 565.54 905.98 percent of total billed charges Ultrasound scan of head and neck soft tissue 927052_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 AETNA AETNA 737.86 79 999999999 565.54 905.98 percent of total billed charges Ultrasound scan of head and neck soft tissue 927052_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 905.98 97 999999999 565.54 905.98 percent of total billed charges Ultrasound scan of head and neck soft tissue 927052_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 644.46 69 999999999 565.54 905.98 percent of total billed charges Ultrasound scan of head and neck soft tissue 927052_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 SIHO - ALL PLANS SIHO - ALL PLANS 840.6 90 999999999 565.54 905.98 percent of total billed charges Ultrasound scan of head and neck soft tissue 927052_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 728.52 78 999999999 565.54 905.98 percent of total billed charges Ultrasound scan of head and neck soft tissue 927052_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 UMR - ALL PLANS UMR - ALL PLANS 653.8 70 999999999 565.54 905.98 percent of total billed charges Ultrasound scan of head and neck soft tissue 927052_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 565.54 905.98 Ultrasound scan of head and neck soft tissue 927052_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 565.54 60.55 999999999 565.54 905.98 percent of total billed charges Ultrasound scan of head and neck soft tissue 927052_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 ANTHEM HMO ANTHEM HMO 999999999 565.54 905.98 Ultrasound scan of head and neck soft tissue 927052_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 565.54 905.98 Ultrasound scan of head and neck soft tissue 927052_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 565.54 905.98 Ultrasound scan of head and neck soft tissue 927052_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 631.38 67.6 999999999 565.54 905.98 percent of total billed charges Ultrasound scan of head and neck soft tissue 927052_1 CDM 0402 RC 76536 HCPCS inpatient 934 607.1 UHC - ALL PLANS UHC - ALL PLANS 999999999 565.54 905.98 Complete X-ray of body bones 927433_1 CDM 0320 RC 77075 HCPCS inpatient 1032 670.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 670.8 65 999999999 624.88 1001.04 percent of total billed charges Complete X-ray of body bones 927433_1 CDM 0320 RC 77075 HCPCS inpatient 1032 670.8 AETNA AETNA 815.28 79 999999999 624.88 1001.04 percent of total billed charges Complete X-ray of body bones 927433_1 CDM 0320 RC 77075 HCPCS inpatient 1032 670.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1001.04 97 999999999 624.88 1001.04 percent of total billed charges Complete X-ray of body bones 927433_1 CDM 0320 RC 77075 HCPCS inpatient 1032 670.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 712.08 69 999999999 624.88 1001.04 percent of total billed charges Complete X-ray of body bones 927433_1 CDM 0320 RC 77075 HCPCS inpatient 1032 670.8 SIHO - ALL PLANS SIHO - ALL PLANS 928.8 90 999999999 624.88 1001.04 percent of total billed charges Complete X-ray of body bones 927433_1 CDM 0320 RC 77075 HCPCS inpatient 1032 670.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 804.96 78 999999999 624.88 1001.04 percent of total billed charges Complete X-ray of body bones 927433_1 CDM 0320 RC 77075 HCPCS inpatient 1032 670.8 UMR - ALL PLANS UMR - ALL PLANS 722.4 70 999999999 624.88 1001.04 percent of total billed charges Complete X-ray of body bones 927433_1 CDM 0320 RC 77075 HCPCS inpatient 1032 670.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 624.88 1001.04 Complete X-ray of body bones 927433_1 CDM 0320 RC 77075 HCPCS inpatient 1032 670.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 624.88 60.55 999999999 624.88 1001.04 percent of total billed charges Complete X-ray of body bones 927433_1 CDM 0320 RC 77075 HCPCS inpatient 1032 670.8 ANTHEM HMO ANTHEM HMO 999999999 624.88 1001.04 Complete X-ray of body bones 927433_1 CDM 0320 RC 77075 HCPCS inpatient 1032 670.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 624.88 1001.04 Complete X-ray of body bones 927433_1 CDM 0320 RC 77075 HCPCS inpatient 1032 670.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 624.88 1001.04 Complete X-ray of body bones 927433_1 CDM 0320 RC 77075 HCPCS inpatient 1032 670.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 697.63 67.6 999999999 624.88 1001.04 percent of total billed charges Complete X-ray of body bones 927433_1 CDM 0320 RC 77075 HCPCS inpatient 1032 670.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 624.88 1001.04 "X-ray of knee, 3 views" 928597_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 317.85 65 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 928597_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 AETNA AETNA 386.31 79 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 928597_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 474.33 97 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 928597_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 337.41 69 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 928597_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 SIHO - ALL PLANS SIHO - ALL PLANS 440.1 90 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 928597_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 381.42 78 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 928597_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 UMR - ALL PLANS UMR - ALL PLANS 342.3 70 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 928597_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 296.09 474.33 "X-ray of knee, 3 views" 928597_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 296.09 60.55 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 928597_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ANTHEM HMO ANTHEM HMO 999999999 296.09 474.33 "X-ray of knee, 3 views" 928597_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 296.09 474.33 "X-ray of knee, 3 views" 928597_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 296.09 474.33 "X-ray of knee, 3 views" 928597_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 330.56 67.6 999999999 296.09 474.33 percent of total billed charges "X-ray of knee, 3 views" 928597_1 CDM 0320 RC 73562 HCPCS inpatient 489 317.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 296.09 474.33 CT scan of abdomen and pelvis before and after contrast 931310_1 CDM 0352 RC 74178 HCPCS inpatient 5229 3398.85 SELF PAY DISCOUNT SELF PAY DISCOUNT 3398.85 65 999999999 3166.16 5072.13 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 931310_1 CDM 0352 RC 74178 HCPCS inpatient 5229 3398.85 AETNA AETNA 4130.91 79 999999999 3166.16 5072.13 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 931310_1 CDM 0352 RC 74178 HCPCS inpatient 5229 3398.85 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5072.13 97 999999999 3166.16 5072.13 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 931310_1 CDM 0352 RC 74178 HCPCS inpatient 5229 3398.85 ENCORE - ALL PLANS ENCORE - ALL PLANS 3608.01 69 999999999 3166.16 5072.13 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 931310_1 CDM 0352 RC 74178 HCPCS inpatient 5229 3398.85 SIHO - ALL PLANS SIHO - ALL PLANS 4706.1 90 999999999 3166.16 5072.13 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 931310_1 CDM 0352 RC 74178 HCPCS inpatient 5229 3398.85 HUMANA - ALL PLANS HUMANA - ALL PLANS 4078.62 78 999999999 3166.16 5072.13 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 931310_1 CDM 0352 RC 74178 HCPCS inpatient 5229 3398.85 UMR - ALL PLANS UMR - ALL PLANS 3660.3 70 999999999 3166.16 5072.13 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 931310_1 CDM 0352 RC 74178 HCPCS inpatient 5229 3398.85 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 3166.16 5072.13 CT scan of abdomen and pelvis before and after contrast 931310_1 CDM 0352 RC 74178 HCPCS inpatient 5229 3398.85 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3166.16 60.55 999999999 3166.16 5072.13 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 931310_1 CDM 0352 RC 74178 HCPCS inpatient 5229 3398.85 ANTHEM HMO ANTHEM HMO 999999999 3166.16 5072.13 CT scan of abdomen and pelvis before and after contrast 931310_1 CDM 0352 RC 74178 HCPCS inpatient 5229 3398.85 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 3166.16 5072.13 CT scan of abdomen and pelvis before and after contrast 931310_1 CDM 0352 RC 74178 HCPCS inpatient 5229 3398.85 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 3166.16 5072.13 CT scan of abdomen and pelvis before and after contrast 931310_1 CDM 0352 RC 74178 HCPCS inpatient 5229 3398.85 CIGNA - ALL PLANS CIGNA - ALL PLANS 3534.8 67.6 999999999 3166.16 5072.13 percent of total billed charges CT scan of abdomen and pelvis before and after contrast 931310_1 CDM 0352 RC 74178 HCPCS inpatient 5229 3398.85 UHC - ALL PLANS UHC - ALL PLANS 999999999 3166.16 5072.13 CT scan of abdomen and pelvis with contrast 931313_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 SELF PAY DISCOUNT SELF PAY DISCOUNT 2626 65 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 931313_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 AETNA AETNA 3191.6 79 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 931313_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3918.8 97 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 931313_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 ENCORE - ALL PLANS ENCORE - ALL PLANS 2787.6 69 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 931313_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 SIHO - ALL PLANS SIHO - ALL PLANS 3636 90 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 931313_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 HUMANA - ALL PLANS HUMANA - ALL PLANS 3151.2 78 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 931313_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 UMR - ALL PLANS UMR - ALL PLANS 2828 70 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 931313_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2446.22 3918.8 CT scan of abdomen and pelvis with contrast 931313_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2446.22 60.55 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 931313_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 ANTHEM HMO ANTHEM HMO 999999999 2446.22 3918.8 CT scan of abdomen and pelvis with contrast 931313_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2446.22 3918.8 CT scan of abdomen and pelvis with contrast 931313_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2446.22 3918.8 CT scan of abdomen and pelvis with contrast 931313_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 CIGNA - ALL PLANS CIGNA - ALL PLANS 2731.04 67.6 999999999 2446.22 3918.8 percent of total billed charges CT scan of abdomen and pelvis with contrast 931313_1 CDM 0352 RC 74177 HCPCS inpatient 4040 2626 UHC - ALL PLANS UHC - ALL PLANS 999999999 2446.22 3918.8 CT scan of abdomen and pelvis without contrast 931316_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 SELF PAY DISCOUNT SELF PAY DISCOUNT 3003 65 999999999 2797.41 4481.4 percent of total billed charges CT scan of abdomen and pelvis without contrast 931316_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 AETNA AETNA 3649.8 79 999999999 2797.41 4481.4 percent of total billed charges CT scan of abdomen and pelvis without contrast 931316_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4481.4 97 999999999 2797.41 4481.4 percent of total billed charges CT scan of abdomen and pelvis without contrast 931316_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 ENCORE - ALL PLANS ENCORE - ALL PLANS 3187.8 69 999999999 2797.41 4481.4 percent of total billed charges CT scan of abdomen and pelvis without contrast 931316_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 SIHO - ALL PLANS SIHO - ALL PLANS 4158 90 999999999 2797.41 4481.4 percent of total billed charges CT scan of abdomen and pelvis without contrast 931316_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 HUMANA - ALL PLANS HUMANA - ALL PLANS 3603.6 78 999999999 2797.41 4481.4 percent of total billed charges CT scan of abdomen and pelvis without contrast 931316_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 UMR - ALL PLANS UMR - ALL PLANS 3234 70 999999999 2797.41 4481.4 percent of total billed charges CT scan of abdomen and pelvis without contrast 931316_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2797.41 4481.4 CT scan of abdomen and pelvis without contrast 931316_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2797.41 60.55 999999999 2797.41 4481.4 percent of total billed charges CT scan of abdomen and pelvis without contrast 931316_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 ANTHEM HMO ANTHEM HMO 999999999 2797.41 4481.4 CT scan of abdomen and pelvis without contrast 931316_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2797.41 4481.4 CT scan of abdomen and pelvis without contrast 931316_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2797.41 4481.4 CT scan of abdomen and pelvis without contrast 931316_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 CIGNA - ALL PLANS CIGNA - ALL PLANS 3123.12 67.6 999999999 2797.41 4481.4 percent of total billed charges CT scan of abdomen and pelvis without contrast 931316_1 CDM 0352 RC 74176 HCPCS inpatient 4620 3003 UHC - ALL PLANS UHC - ALL PLANS 999999999 2797.41 4481.4 CT scan of pelvis without contrast 931331_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 1515.15 65 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis without contrast 931331_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 AETNA AETNA 1841.49 79 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis without contrast 931331_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2261.07 97 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis without contrast 931331_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 1608.39 69 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis without contrast 931331_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 SIHO - ALL PLANS SIHO - ALL PLANS 2097.9 90 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis without contrast 931331_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 1818.18 78 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis without contrast 931331_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 UMR - ALL PLANS UMR - ALL PLANS 1631.7 70 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis without contrast 931331_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1411.42 2261.07 CT scan of pelvis without contrast 931331_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1411.42 60.55 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis without contrast 931331_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 ANTHEM HMO ANTHEM HMO 999999999 1411.42 2261.07 CT scan of pelvis without contrast 931331_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1411.42 2261.07 CT scan of pelvis without contrast 931331_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1411.42 2261.07 CT scan of pelvis without contrast 931331_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 1575.76 67.6 999999999 1411.42 2261.07 percent of total billed charges CT scan of pelvis without contrast 931331_1 CDM 0352 RC 72192 HCPCS inpatient 2331 1515.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 1411.42 2261.07 CT scan of chest with contrast 931334_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 1801.8 65 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 931334_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 AETNA AETNA 2189.88 79 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 931334_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2688.84 97 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 931334_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 1912.68 69 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 931334_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 SIHO - ALL PLANS SIHO - ALL PLANS 2494.8 90 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 931334_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 2162.16 78 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 931334_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 UMR - ALL PLANS UMR - ALL PLANS 1940.4 70 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 931334_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1678.45 2688.84 CT scan of chest with contrast 931334_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1678.45 60.55 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 931334_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 ANTHEM HMO ANTHEM HMO 999999999 1678.45 2688.84 CT scan of chest with contrast 931334_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1678.45 2688.84 CT scan of chest with contrast 931334_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1678.45 2688.84 CT scan of chest with contrast 931334_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 1873.87 67.6 999999999 1678.45 2688.84 percent of total billed charges CT scan of chest with contrast 931334_1 CDM 0352 RC 71260 HCPCS inpatient 2772 1801.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 1678.45 2688.84 CT scan of chest without contrast 931337_1 CDM 0352 RC 71250 HCPCS inpatient 2684 1744.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 1744.6 65 999999999 1625.16 2603.48 percent of total billed charges CT scan of chest without contrast 931337_1 CDM 0352 RC 71250 HCPCS inpatient 2684 1744.6 AETNA AETNA 2120.36 79 999999999 1625.16 2603.48 percent of total billed charges CT scan of chest without contrast 931337_1 CDM 0352 RC 71250 HCPCS inpatient 2684 1744.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2603.48 97 999999999 1625.16 2603.48 percent of total billed charges CT scan of chest without contrast 931337_1 CDM 0352 RC 71250 HCPCS inpatient 2684 1744.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 1851.96 69 999999999 1625.16 2603.48 percent of total billed charges CT scan of chest without contrast 931337_1 CDM 0352 RC 71250 HCPCS inpatient 2684 1744.6 SIHO - ALL PLANS SIHO - ALL PLANS 2415.6 90 999999999 1625.16 2603.48 percent of total billed charges CT scan of chest without contrast 931337_1 CDM 0352 RC 71250 HCPCS inpatient 2684 1744.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 2093.52 78 999999999 1625.16 2603.48 percent of total billed charges CT scan of chest without contrast 931337_1 CDM 0352 RC 71250 HCPCS inpatient 2684 1744.6 UMR - ALL PLANS UMR - ALL PLANS 1878.8 70 999999999 1625.16 2603.48 percent of total billed charges CT scan of chest without contrast 931337_1 CDM 0352 RC 71250 HCPCS inpatient 2684 1744.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1625.16 2603.48 CT scan of chest without contrast 931337_1 CDM 0352 RC 71250 HCPCS inpatient 2684 1744.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1625.16 60.55 999999999 1625.16 2603.48 percent of total billed charges CT scan of chest without contrast 931337_1 CDM 0352 RC 71250 HCPCS inpatient 2684 1744.6 ANTHEM HMO ANTHEM HMO 999999999 1625.16 2603.48 CT scan of chest without contrast 931337_1 CDM 0352 RC 71250 HCPCS inpatient 2684 1744.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1625.16 2603.48 CT scan of chest without contrast 931337_1 CDM 0352 RC 71250 HCPCS inpatient 2684 1744.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1625.16 2603.48 CT scan of chest without contrast 931337_1 CDM 0352 RC 71250 HCPCS inpatient 2684 1744.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 1814.38 67.6 999999999 1625.16 2603.48 percent of total billed charges CT scan of chest without contrast 931337_1 CDM 0352 RC 71250 HCPCS inpatient 2684 1744.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 1625.16 2603.48 MRI scan of blood vessels of chest 931508_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 1950.65 65 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 931508_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 AETNA AETNA 2370.79 79 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 931508_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2910.97 97 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 931508_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 2070.69 69 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 931508_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 SIHO - ALL PLANS SIHO - ALL PLANS 2700.9 90 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 931508_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 2340.78 78 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 931508_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 UMR - ALL PLANS UMR - ALL PLANS 2100.7 70 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 931508_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1817.11 2910.97 MRI scan of blood vessels of chest 931508_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1817.11 60.55 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 931508_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 ANTHEM HMO ANTHEM HMO 999999999 1817.11 2910.97 MRI scan of blood vessels of chest 931508_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1817.11 2910.97 MRI scan of blood vessels of chest 931508_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1817.11 2910.97 MRI scan of blood vessels of chest 931508_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 2028.68 67.6 999999999 1817.11 2910.97 percent of total billed charges MRI scan of blood vessels of chest 931508_1 CDM 0618 RC 71555 HCPCS inpatient 3001 1950.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 1817.11 2910.97 MRI BOTH BREASTS 931571_1 CDM 0610 RC 77059 HCPCS inpatient 4741 3081.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 3081.65 65 999999999 2870.68 4598.77 percent of total billed charges MRI BOTH BREASTS 931571_1 CDM 0610 RC 77059 HCPCS inpatient 4741 3081.65 AETNA AETNA 3745.39 79 999999999 2870.68 4598.77 percent of total billed charges MRI BOTH BREASTS 931571_1 CDM 0610 RC 77059 HCPCS inpatient 4741 3081.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4598.77 97 999999999 2870.68 4598.77 percent of total billed charges MRI BOTH BREASTS 931571_1 CDM 0610 RC 77059 HCPCS inpatient 4741 3081.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 3271.29 69 999999999 2870.68 4598.77 percent of total billed charges MRI BOTH BREASTS 931571_1 CDM 0610 RC 77059 HCPCS inpatient 4741 3081.65 SIHO - ALL PLANS SIHO - ALL PLANS 4266.9 90 999999999 2870.68 4598.77 percent of total billed charges MRI BOTH BREASTS 931571_1 CDM 0610 RC 77059 HCPCS inpatient 4741 3081.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 3697.98 78 999999999 2870.68 4598.77 percent of total billed charges MRI BOTH BREASTS 931571_1 CDM 0610 RC 77059 HCPCS inpatient 4741 3081.65 UMR - ALL PLANS UMR - ALL PLANS 3318.7 70 999999999 2870.68 4598.77 percent of total billed charges MRI BOTH BREASTS 931571_1 CDM 0610 RC 77059 HCPCS inpatient 4741 3081.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2870.68 4598.77 MRI BOTH BREASTS 931571_1 CDM 0610 RC 77059 HCPCS inpatient 4741 3081.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2870.68 60.55 999999999 2870.68 4598.77 percent of total billed charges MRI BOTH BREASTS 931571_1 CDM 0610 RC 77059 HCPCS inpatient 4741 3081.65 ANTHEM HMO ANTHEM HMO 999999999 2870.68 4598.77 MRI BOTH BREASTS 931571_1 CDM 0610 RC 77059 HCPCS inpatient 4741 3081.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2870.68 4598.77 MRI BOTH BREASTS 931571_1 CDM 0610 RC 77059 HCPCS inpatient 4741 3081.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2870.68 4598.77 MRI BOTH BREASTS 931571_1 CDM 0610 RC 77059 HCPCS inpatient 4741 3081.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 3204.92 67.6 999999999 2870.68 4598.77 percent of total billed charges MRI BOTH BREASTS 931571_1 CDM 0610 RC 77059 HCPCS inpatient 4741 3081.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 2870.68 4598.77 MRI ONE BREAST 931573_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 3081.65 65 999999999 2870.68 4598.77 percent of total billed charges MRI ONE BREAST 931573_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 AETNA AETNA 3745.39 79 999999999 2870.68 4598.77 percent of total billed charges MRI ONE BREAST 931573_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4598.77 97 999999999 2870.68 4598.77 percent of total billed charges MRI ONE BREAST 931573_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 3271.29 69 999999999 2870.68 4598.77 percent of total billed charges MRI ONE BREAST 931573_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 SIHO - ALL PLANS SIHO - ALL PLANS 4266.9 90 999999999 2870.68 4598.77 percent of total billed charges MRI ONE BREAST 931573_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 3697.98 78 999999999 2870.68 4598.77 percent of total billed charges MRI ONE BREAST 931573_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 UMR - ALL PLANS UMR - ALL PLANS 3318.7 70 999999999 2870.68 4598.77 percent of total billed charges MRI ONE BREAST 931573_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2870.68 4598.77 MRI ONE BREAST 931573_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2870.68 60.55 999999999 2870.68 4598.77 percent of total billed charges MRI ONE BREAST 931573_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 ANTHEM HMO ANTHEM HMO 999999999 2870.68 4598.77 MRI ONE BREAST 931573_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2870.68 4598.77 MRI ONE BREAST 931573_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2870.68 4598.77 MRI ONE BREAST 931573_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 3204.92 67.6 999999999 2870.68 4598.77 percent of total billed charges MRI ONE BREAST 931573_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 2870.68 4598.77 MRI ONE BREAST 931575_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 3081.65 65 999999999 2870.68 4598.77 percent of total billed charges MRI ONE BREAST 931575_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 AETNA AETNA 3745.39 79 999999999 2870.68 4598.77 percent of total billed charges MRI ONE BREAST 931575_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4598.77 97 999999999 2870.68 4598.77 percent of total billed charges MRI ONE BREAST 931575_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 3271.29 69 999999999 2870.68 4598.77 percent of total billed charges MRI ONE BREAST 931575_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 SIHO - ALL PLANS SIHO - ALL PLANS 4266.9 90 999999999 2870.68 4598.77 percent of total billed charges MRI ONE BREAST 931575_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 3697.98 78 999999999 2870.68 4598.77 percent of total billed charges MRI ONE BREAST 931575_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 UMR - ALL PLANS UMR - ALL PLANS 3318.7 70 999999999 2870.68 4598.77 percent of total billed charges MRI ONE BREAST 931575_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2870.68 4598.77 MRI ONE BREAST 931575_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2870.68 60.55 999999999 2870.68 4598.77 percent of total billed charges MRI ONE BREAST 931575_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 ANTHEM HMO ANTHEM HMO 999999999 2870.68 4598.77 MRI ONE BREAST 931575_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2870.68 4598.77 MRI ONE BREAST 931575_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2870.68 4598.77 MRI ONE BREAST 931575_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 3204.92 67.6 999999999 2870.68 4598.77 percent of total billed charges MRI ONE BREAST 931575_1 CDM 0610 RC 77058 HCPCS inpatient 4741 3081.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 2870.68 4598.77 MRI scan of heart without contrast 931595_1 CDM 0610 RC 75557 HCPCS inpatient 4741 3081.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 3081.65 65 999999999 2870.68 4598.77 percent of total billed charges MRI scan of heart without contrast 931595_1 CDM 0610 RC 75557 HCPCS inpatient 4741 3081.65 AETNA AETNA 3745.39 79 999999999 2870.68 4598.77 percent of total billed charges MRI scan of heart without contrast 931595_1 CDM 0610 RC 75557 HCPCS inpatient 4741 3081.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4598.77 97 999999999 2870.68 4598.77 percent of total billed charges MRI scan of heart without contrast 931595_1 CDM 0610 RC 75557 HCPCS inpatient 4741 3081.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 3271.29 69 999999999 2870.68 4598.77 percent of total billed charges MRI scan of heart without contrast 931595_1 CDM 0610 RC 75557 HCPCS inpatient 4741 3081.65 SIHO - ALL PLANS SIHO - ALL PLANS 4266.9 90 999999999 2870.68 4598.77 percent of total billed charges MRI scan of heart without contrast 931595_1 CDM 0610 RC 75557 HCPCS inpatient 4741 3081.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 3697.98 78 999999999 2870.68 4598.77 percent of total billed charges MRI scan of heart without contrast 931595_1 CDM 0610 RC 75557 HCPCS inpatient 4741 3081.65 UMR - ALL PLANS UMR - ALL PLANS 3318.7 70 999999999 2870.68 4598.77 percent of total billed charges MRI scan of heart without contrast 931595_1 CDM 0610 RC 75557 HCPCS inpatient 4741 3081.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2870.68 4598.77 MRI scan of heart without contrast 931595_1 CDM 0610 RC 75557 HCPCS inpatient 4741 3081.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2870.68 60.55 999999999 2870.68 4598.77 percent of total billed charges MRI scan of heart without contrast 931595_1 CDM 0610 RC 75557 HCPCS inpatient 4741 3081.65 ANTHEM HMO ANTHEM HMO 999999999 2870.68 4598.77 MRI scan of heart without contrast 931595_1 CDM 0610 RC 75557 HCPCS inpatient 4741 3081.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2870.68 4598.77 MRI scan of heart without contrast 931595_1 CDM 0610 RC 75557 HCPCS inpatient 4741 3081.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2870.68 4598.77 MRI scan of heart without contrast 931595_1 CDM 0610 RC 75557 HCPCS inpatient 4741 3081.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 3204.92 67.6 999999999 2870.68 4598.77 percent of total billed charges MRI scan of heart without contrast 931595_1 CDM 0610 RC 75557 HCPCS inpatient 4741 3081.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 2870.68 4598.77 "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 931623_1 CDM 0611 RC 70543 HCPCS inpatient 4286 2785.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 2785.9 65 999999999 2595.17 4157.42 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 931623_1 CDM 0611 RC 70543 HCPCS inpatient 4286 2785.9 AETNA AETNA 3385.94 79 999999999 2595.17 4157.42 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 931623_1 CDM 0611 RC 70543 HCPCS inpatient 4286 2785.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4157.42 97 999999999 2595.17 4157.42 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 931623_1 CDM 0611 RC 70543 HCPCS inpatient 4286 2785.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 2957.34 69 999999999 2595.17 4157.42 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 931623_1 CDM 0611 RC 70543 HCPCS inpatient 4286 2785.9 SIHO - ALL PLANS SIHO - ALL PLANS 3857.4 90 999999999 2595.17 4157.42 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 931623_1 CDM 0611 RC 70543 HCPCS inpatient 4286 2785.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 3343.08 78 999999999 2595.17 4157.42 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 931623_1 CDM 0611 RC 70543 HCPCS inpatient 4286 2785.9 UMR - ALL PLANS UMR - ALL PLANS 3000.2 70 999999999 2595.17 4157.42 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 931623_1 CDM 0611 RC 70543 HCPCS inpatient 4286 2785.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2595.17 4157.42 "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 931623_1 CDM 0611 RC 70543 HCPCS inpatient 4286 2785.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2595.17 60.55 999999999 2595.17 4157.42 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 931623_1 CDM 0611 RC 70543 HCPCS inpatient 4286 2785.9 ANTHEM HMO ANTHEM HMO 999999999 2595.17 4157.42 "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 931623_1 CDM 0611 RC 70543 HCPCS inpatient 4286 2785.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2595.17 4157.42 "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 931623_1 CDM 0611 RC 70543 HCPCS inpatient 4286 2785.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2595.17 4157.42 "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 931623_1 CDM 0611 RC 70543 HCPCS inpatient 4286 2785.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 2897.34 67.6 999999999 2595.17 4157.42 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck before and after contrast" 931623_1 CDM 0611 RC 70543 HCPCS inpatient 4286 2785.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 2595.17 4157.42 "MRI scan of bone of eye socket, face, and/or neck with contrast" 931625_1 CDM 0611 RC 70542 HCPCS inpatient 4913 3193.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 3193.45 65 999999999 2974.82 4765.61 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck with contrast" 931625_1 CDM 0611 RC 70542 HCPCS inpatient 4913 3193.45 AETNA AETNA 3881.27 79 999999999 2974.82 4765.61 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck with contrast" 931625_1 CDM 0611 RC 70542 HCPCS inpatient 4913 3193.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4765.61 97 999999999 2974.82 4765.61 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck with contrast" 931625_1 CDM 0611 RC 70542 HCPCS inpatient 4913 3193.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 3389.97 69 999999999 2974.82 4765.61 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck with contrast" 931625_1 CDM 0611 RC 70542 HCPCS inpatient 4913 3193.45 SIHO - ALL PLANS SIHO - ALL PLANS 4421.7 90 999999999 2974.82 4765.61 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck with contrast" 931625_1 CDM 0611 RC 70542 HCPCS inpatient 4913 3193.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 3832.14 78 999999999 2974.82 4765.61 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck with contrast" 931625_1 CDM 0611 RC 70542 HCPCS inpatient 4913 3193.45 UMR - ALL PLANS UMR - ALL PLANS 3439.1 70 999999999 2974.82 4765.61 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck with contrast" 931625_1 CDM 0611 RC 70542 HCPCS inpatient 4913 3193.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2974.82 4765.61 "MRI scan of bone of eye socket, face, and/or neck with contrast" 931625_1 CDM 0611 RC 70542 HCPCS inpatient 4913 3193.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2974.82 60.55 999999999 2974.82 4765.61 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck with contrast" 931625_1 CDM 0611 RC 70542 HCPCS inpatient 4913 3193.45 ANTHEM HMO ANTHEM HMO 999999999 2974.82 4765.61 "MRI scan of bone of eye socket, face, and/or neck with contrast" 931625_1 CDM 0611 RC 70542 HCPCS inpatient 4913 3193.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2974.82 4765.61 "MRI scan of bone of eye socket, face, and/or neck with contrast" 931625_1 CDM 0611 RC 70542 HCPCS inpatient 4913 3193.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2974.82 4765.61 "MRI scan of bone of eye socket, face, and/or neck with contrast" 931625_1 CDM 0611 RC 70542 HCPCS inpatient 4913 3193.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 3321.19 67.6 999999999 2974.82 4765.61 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck with contrast" 931625_1 CDM 0611 RC 70542 HCPCS inpatient 4913 3193.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 2974.82 4765.61 "MRI scan of bone of eye socket, face, and/or neck without contrast" 931627_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 3107.65 65 999999999 2894.9 4637.57 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck without contrast" 931627_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 AETNA AETNA 3776.99 79 999999999 2894.9 4637.57 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck without contrast" 931627_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4637.57 97 999999999 2894.9 4637.57 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck without contrast" 931627_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 3298.89 69 999999999 2894.9 4637.57 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck without contrast" 931627_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 SIHO - ALL PLANS SIHO - ALL PLANS 4302.9 90 999999999 2894.9 4637.57 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck without contrast" 931627_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 3729.18 78 999999999 2894.9 4637.57 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck without contrast" 931627_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 UMR - ALL PLANS UMR - ALL PLANS 3346.7 70 999999999 2894.9 4637.57 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck without contrast" 931627_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 2894.9 4637.57 "MRI scan of bone of eye socket, face, and/or neck without contrast" 931627_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2894.9 60.55 999999999 2894.9 4637.57 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck without contrast" 931627_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 ANTHEM HMO ANTHEM HMO 999999999 2894.9 4637.57 "MRI scan of bone of eye socket, face, and/or neck without contrast" 931627_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 2894.9 4637.57 "MRI scan of bone of eye socket, face, and/or neck without contrast" 931627_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 2894.9 4637.57 "MRI scan of bone of eye socket, face, and/or neck without contrast" 931627_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 3231.96 67.6 999999999 2894.9 4637.57 percent of total billed charges "MRI scan of bone of eye socket, face, and/or neck without contrast" 931627_1 CDM 0611 RC 70540 HCPCS inpatient 4781 3107.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 2894.9 4637.57 Ultrasound of both sides of head and neck blood flow 931827_1 CDM 0921 RC 93880 HCPCS inpatient 1546 1004.9 SELF PAY DISCOUNT SELF PAY DISCOUNT 1004.9 65 999999999 936.1 1499.62 percent of total billed charges Ultrasound of both sides of head and neck blood flow 931827_1 CDM 0921 RC 93880 HCPCS inpatient 1546 1004.9 AETNA AETNA 1221.34 79 999999999 936.1 1499.62 percent of total billed charges Ultrasound of both sides of head and neck blood flow 931827_1 CDM 0921 RC 93880 HCPCS inpatient 1546 1004.9 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1499.62 97 999999999 936.1 1499.62 percent of total billed charges Ultrasound of both sides of head and neck blood flow 931827_1 CDM 0921 RC 93880 HCPCS inpatient 1546 1004.9 ENCORE - ALL PLANS ENCORE - ALL PLANS 1066.74 69 999999999 936.1 1499.62 percent of total billed charges Ultrasound of both sides of head and neck blood flow 931827_1 CDM 0921 RC 93880 HCPCS inpatient 1546 1004.9 SIHO - ALL PLANS SIHO - ALL PLANS 1391.4 90 999999999 936.1 1499.62 percent of total billed charges Ultrasound of both sides of head and neck blood flow 931827_1 CDM 0921 RC 93880 HCPCS inpatient 1546 1004.9 HUMANA - ALL PLANS HUMANA - ALL PLANS 1205.88 78 999999999 936.1 1499.62 percent of total billed charges Ultrasound of both sides of head and neck blood flow 931827_1 CDM 0921 RC 93880 HCPCS inpatient 1546 1004.9 UMR - ALL PLANS UMR - ALL PLANS 1082.2 70 999999999 936.1 1499.62 percent of total billed charges Ultrasound of both sides of head and neck blood flow 931827_1 CDM 0921 RC 93880 HCPCS inpatient 1546 1004.9 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 936.1 1499.62 Ultrasound of both sides of head and neck blood flow 931827_1 CDM 0921 RC 93880 HCPCS inpatient 1546 1004.9 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 936.1 60.55 999999999 936.1 1499.62 percent of total billed charges Ultrasound of both sides of head and neck blood flow 931827_1 CDM 0921 RC 93880 HCPCS inpatient 1546 1004.9 ANTHEM HMO ANTHEM HMO 999999999 936.1 1499.62 Ultrasound of both sides of head and neck blood flow 931827_1 CDM 0921 RC 93880 HCPCS inpatient 1546 1004.9 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 936.1 1499.62 Ultrasound of both sides of head and neck blood flow 931827_1 CDM 0921 RC 93880 HCPCS inpatient 1546 1004.9 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 936.1 1499.62 Ultrasound of both sides of head and neck blood flow 931827_1 CDM 0921 RC 93880 HCPCS inpatient 1546 1004.9 CIGNA - ALL PLANS CIGNA - ALL PLANS 1045.1 67.6 999999999 936.1 1499.62 percent of total billed charges Ultrasound of both sides of head and neck blood flow 931827_1 CDM 0921 RC 93880 HCPCS inpatient 1546 1004.9 UHC - ALL PLANS UHC - ALL PLANS 999999999 936.1 1499.62 X-ray of infant body bones 931859_1 CDM 0320 RC 77076 HCPCS inpatient 444 288.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 288.6 65 999999999 268.84 430.68 percent of total billed charges X-ray of infant body bones 931859_1 CDM 0320 RC 77076 HCPCS inpatient 444 288.6 AETNA AETNA 350.76 79 999999999 268.84 430.68 percent of total billed charges X-ray of infant body bones 931859_1 CDM 0320 RC 77076 HCPCS inpatient 444 288.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 430.68 97 999999999 268.84 430.68 percent of total billed charges X-ray of infant body bones 931859_1 CDM 0320 RC 77076 HCPCS inpatient 444 288.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 306.36 69 999999999 268.84 430.68 percent of total billed charges X-ray of infant body bones 931859_1 CDM 0320 RC 77076 HCPCS inpatient 444 288.6 SIHO - ALL PLANS SIHO - ALL PLANS 399.6 90 999999999 268.84 430.68 percent of total billed charges X-ray of infant body bones 931859_1 CDM 0320 RC 77076 HCPCS inpatient 444 288.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 346.32 78 999999999 268.84 430.68 percent of total billed charges X-ray of infant body bones 931859_1 CDM 0320 RC 77076 HCPCS inpatient 444 288.6 UMR - ALL PLANS UMR - ALL PLANS 310.8 70 999999999 268.84 430.68 percent of total billed charges X-ray of infant body bones 931859_1 CDM 0320 RC 77076 HCPCS inpatient 444 288.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 268.84 430.68 X-ray of infant body bones 931859_1 CDM 0320 RC 77076 HCPCS inpatient 444 288.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 268.84 60.55 999999999 268.84 430.68 percent of total billed charges X-ray of infant body bones 931859_1 CDM 0320 RC 77076 HCPCS inpatient 444 288.6 ANTHEM HMO ANTHEM HMO 999999999 268.84 430.68 X-ray of infant body bones 931859_1 CDM 0320 RC 77076 HCPCS inpatient 444 288.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 268.84 430.68 X-ray of infant body bones 931859_1 CDM 0320 RC 77076 HCPCS inpatient 444 288.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 268.84 430.68 X-ray of infant body bones 931859_1 CDM 0320 RC 77076 HCPCS inpatient 444 288.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 300.14 67.6 999999999 268.84 430.68 percent of total billed charges X-ray of infant body bones 931859_1 CDM 0320 RC 77076 HCPCS inpatient 444 288.6 UHC - ALL PLANS UHC - ALL PLANS 999999999 268.84 430.68 X-ray of both knees while standing 931878_1 CDM 0320 RC 73565 HCPCS inpatient 471 306.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 306.15 65 999999999 285.19 456.87 percent of total billed charges X-ray of both knees while standing 931878_1 CDM 0320 RC 73565 HCPCS inpatient 471 306.15 AETNA AETNA 372.09 79 999999999 285.19 456.87 percent of total billed charges X-ray of both knees while standing 931878_1 CDM 0320 RC 73565 HCPCS inpatient 471 306.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 456.87 97 999999999 285.19 456.87 percent of total billed charges X-ray of both knees while standing 931878_1 CDM 0320 RC 73565 HCPCS inpatient 471 306.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 324.99 69 999999999 285.19 456.87 percent of total billed charges X-ray of both knees while standing 931878_1 CDM 0320 RC 73565 HCPCS inpatient 471 306.15 SIHO - ALL PLANS SIHO - ALL PLANS 423.9 90 999999999 285.19 456.87 percent of total billed charges X-ray of both knees while standing 931878_1 CDM 0320 RC 73565 HCPCS inpatient 471 306.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 367.38 78 999999999 285.19 456.87 percent of total billed charges X-ray of both knees while standing 931878_1 CDM 0320 RC 73565 HCPCS inpatient 471 306.15 UMR - ALL PLANS UMR - ALL PLANS 329.7 70 999999999 285.19 456.87 percent of total billed charges X-ray of both knees while standing 931878_1 CDM 0320 RC 73565 HCPCS inpatient 471 306.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 285.19 456.87 X-ray of both knees while standing 931878_1 CDM 0320 RC 73565 HCPCS inpatient 471 306.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 285.19 60.55 999999999 285.19 456.87 percent of total billed charges X-ray of both knees while standing 931878_1 CDM 0320 RC 73565 HCPCS inpatient 471 306.15 ANTHEM HMO ANTHEM HMO 999999999 285.19 456.87 X-ray of both knees while standing 931878_1 CDM 0320 RC 73565 HCPCS inpatient 471 306.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 285.19 456.87 X-ray of both knees while standing 931878_1 CDM 0320 RC 73565 HCPCS inpatient 471 306.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 285.19 456.87 X-ray of both knees while standing 931878_1 CDM 0320 RC 73565 HCPCS inpatient 471 306.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 318.4 67.6 999999999 285.19 456.87 percent of total billed charges X-ray of both knees while standing 931878_1 CDM 0320 RC 73565 HCPCS inpatient 471 306.15 UHC - ALL PLANS UHC - ALL PLANS 999999999 285.19 456.87 "X-ray of upper spine, 2-3 views" 931917_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 687.05 65 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 931917_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 AETNA AETNA 835.03 79 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 931917_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1025.29 97 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 931917_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 729.33 69 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 931917_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 SIHO - ALL PLANS SIHO - ALL PLANS 951.3 90 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 931917_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 824.46 78 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 931917_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 UMR - ALL PLANS UMR - ALL PLANS 739.9 70 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 931917_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 640.01 1025.29 "X-ray of upper spine, 2-3 views" 931917_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 640.01 60.55 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 931917_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 ANTHEM HMO ANTHEM HMO 999999999 640.01 1025.29 "X-ray of upper spine, 2-3 views" 931917_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 640.01 1025.29 "X-ray of upper spine, 2-3 views" 931917_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 640.01 1025.29 "X-ray of upper spine, 2-3 views" 931917_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 714.53 67.6 999999999 640.01 1025.29 percent of total billed charges "X-ray of upper spine, 2-3 views" 931917_1 CDM 0320 RC 72040 HCPCS inpatient 1057 687.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 640.01 1025.29 "X-ray lower and sacral spine, 2-3 views bending views" 931920_1 CDM 0320 RC 72120 HCPCS inpatient 640 416 SELF PAY DISCOUNT SELF PAY DISCOUNT 416 65 999999999 387.52 620.8 percent of total billed charges "X-ray lower and sacral spine, 2-3 views bending views" 931920_1 CDM 0320 RC 72120 HCPCS inpatient 640 416 AETNA AETNA 505.6 79 999999999 387.52 620.8 percent of total billed charges "X-ray lower and sacral spine, 2-3 views bending views" 931920_1 CDM 0320 RC 72120 HCPCS inpatient 640 416 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 620.8 97 999999999 387.52 620.8 percent of total billed charges "X-ray lower and sacral spine, 2-3 views bending views" 931920_1 CDM 0320 RC 72120 HCPCS inpatient 640 416 ENCORE - ALL PLANS ENCORE - ALL PLANS 441.6 69 999999999 387.52 620.8 percent of total billed charges "X-ray lower and sacral spine, 2-3 views bending views" 931920_1 CDM 0320 RC 72120 HCPCS inpatient 640 416 SIHO - ALL PLANS SIHO - ALL PLANS 576 90 999999999 387.52 620.8 percent of total billed charges "X-ray lower and sacral spine, 2-3 views bending views" 931920_1 CDM 0320 RC 72120 HCPCS inpatient 640 416 HUMANA - ALL PLANS HUMANA - ALL PLANS 499.2 78 999999999 387.52 620.8 percent of total billed charges "X-ray lower and sacral spine, 2-3 views bending views" 931920_1 CDM 0320 RC 72120 HCPCS inpatient 640 416 UMR - ALL PLANS UMR - ALL PLANS 448 70 999999999 387.52 620.8 percent of total billed charges "X-ray lower and sacral spine, 2-3 views bending views" 931920_1 CDM 0320 RC 72120 HCPCS inpatient 640 416 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 387.52 620.8 "X-ray lower and sacral spine, 2-3 views bending views" 931920_1 CDM 0320 RC 72120 HCPCS inpatient 640 416 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 387.52 60.55 999999999 387.52 620.8 percent of total billed charges "X-ray lower and sacral spine, 2-3 views bending views" 931920_1 CDM 0320 RC 72120 HCPCS inpatient 640 416 ANTHEM HMO ANTHEM HMO 999999999 387.52 620.8 "X-ray lower and sacral spine, 2-3 views bending views" 931920_1 CDM 0320 RC 72120 HCPCS inpatient 640 416 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 387.52 620.8 "X-ray lower and sacral spine, 2-3 views bending views" 931920_1 CDM 0320 RC 72120 HCPCS inpatient 640 416 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 387.52 620.8 "X-ray lower and sacral spine, 2-3 views bending views" 931920_1 CDM 0320 RC 72120 HCPCS inpatient 640 416 CIGNA - ALL PLANS CIGNA - ALL PLANS 432.64 67.6 999999999 387.52 620.8 percent of total billed charges "X-ray lower and sacral spine, 2-3 views bending views" 931920_1 CDM 0320 RC 72120 HCPCS inpatient 640 416 UHC - ALL PLANS UHC - ALL PLANS 999999999 387.52 620.8 "X-ray of entire middle and lower spine, 2-3 views" 931923_1 CDM 0320 RC 72082 HCPCS inpatient 478 310.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 310.7 65 999999999 289.43 463.66 percent of total billed charges "X-ray of entire middle and lower spine, 2-3 views" 931923_1 CDM 0320 RC 72082 HCPCS inpatient 478 310.7 AETNA AETNA 377.62 79 999999999 289.43 463.66 percent of total billed charges "X-ray of entire middle and lower spine, 2-3 views" 931923_1 CDM 0320 RC 72082 HCPCS inpatient 478 310.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 463.66 97 999999999 289.43 463.66 percent of total billed charges "X-ray of entire middle and lower spine, 2-3 views" 931923_1 CDM 0320 RC 72082 HCPCS inpatient 478 310.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 329.82 69 999999999 289.43 463.66 percent of total billed charges "X-ray of entire middle and lower spine, 2-3 views" 931923_1 CDM 0320 RC 72082 HCPCS inpatient 478 310.7 SIHO - ALL PLANS SIHO - ALL PLANS 430.2 90 999999999 289.43 463.66 percent of total billed charges "X-ray of entire middle and lower spine, 2-3 views" 931923_1 CDM 0320 RC 72082 HCPCS inpatient 478 310.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 372.84 78 999999999 289.43 463.66 percent of total billed charges "X-ray of entire middle and lower spine, 2-3 views" 931923_1 CDM 0320 RC 72082 HCPCS inpatient 478 310.7 UMR - ALL PLANS UMR - ALL PLANS 334.6 70 999999999 289.43 463.66 percent of total billed charges "X-ray of entire middle and lower spine, 2-3 views" 931923_1 CDM 0320 RC 72082 HCPCS inpatient 478 310.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 289.43 60.55 999999999 289.43 463.66 percent of total billed charges "X-ray of entire middle and lower spine, 2-3 views" 931923_1 CDM 0320 RC 72082 HCPCS inpatient 478 310.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 289.43 463.66 "X-ray of entire middle and lower spine, 2-3 views" 931923_1 CDM 0320 RC 72082 HCPCS inpatient 478 310.7 ANTHEM HMO ANTHEM HMO 999999999 289.43 463.66 "X-ray of entire middle and lower spine, 2-3 views" 931923_1 CDM 0320 RC 72082 HCPCS inpatient 478 310.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 289.43 463.66 "X-ray of entire middle and lower spine, 2-3 views" 931923_1 CDM 0320 RC 72082 HCPCS inpatient 478 310.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 289.43 463.66 "X-ray of entire middle and lower spine, 2-3 views" 931923_1 CDM 0320 RC 72082 HCPCS inpatient 478 310.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 323.13 67.6 999999999 289.43 463.66 percent of total billed charges "X-ray of entire middle and lower spine, 2-3 views" 931923_1 CDM 0320 RC 72082 HCPCS inpatient 478 310.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 289.43 463.66 Follow-through X-ray of small intestines 931925_1 CDM 0320 RC 74248 HCPCS inpatient 1201 780.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 780.65 65 999999999 727.21 1164.97 percent of total billed charges Follow-through X-ray of small intestines 931925_1 CDM 0320 RC 74248 HCPCS inpatient 1201 780.65 AETNA AETNA 948.79 79 999999999 727.21 1164.97 percent of total billed charges Follow-through X-ray of small intestines 931925_1 CDM 0320 RC 74248 HCPCS inpatient 1201 780.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1164.97 97 999999999 727.21 1164.97 percent of total billed charges Follow-through X-ray of small intestines 931925_1 CDM 0320 RC 74248 HCPCS inpatient 1201 780.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 828.69 69 999999999 727.21 1164.97 percent of total billed charges Follow-through X-ray of small intestines 931925_1 CDM 0320 RC 74248 HCPCS inpatient 1201 780.65 SIHO - ALL PLANS SIHO - ALL PLANS 1080.9 90 999999999 727.21 1164.97 percent of total billed charges Follow-through X-ray of small intestines 931925_1 CDM 0320 RC 74248 HCPCS inpatient 1201 780.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 936.78 78 999999999 727.21 1164.97 percent of total billed charges Follow-through X-ray of small intestines 931925_1 CDM 0320 RC 74248 HCPCS inpatient 1201 780.65 UMR - ALL PLANS UMR - ALL PLANS 840.7 70 999999999 727.21 1164.97 percent of total billed charges Follow-through X-ray of small intestines 931925_1 CDM 0320 RC 74248 HCPCS inpatient 1201 780.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 727.21 60.55 999999999 727.21 1164.97 percent of total billed charges Follow-through X-ray of small intestines 931925_1 CDM 0320 RC 74248 HCPCS inpatient 1201 780.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 727.21 1164.97 Follow-through X-ray of small intestines 931925_1 CDM 0320 RC 74248 HCPCS inpatient 1201 780.65 ANTHEM HMO ANTHEM HMO 999999999 727.21 1164.97 Follow-through X-ray of small intestines 931925_1 CDM 0320 RC 74248 HCPCS inpatient 1201 780.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 727.21 1164.97 Follow-through X-ray of small intestines 931925_1 CDM 0320 RC 74248 HCPCS inpatient 1201 780.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 727.21 1164.97 Follow-through X-ray of small intestines 931925_1 CDM 0320 RC 74248 HCPCS inpatient 1201 780.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 811.88 67.6 999999999 727.21 1164.97 percent of total billed charges Follow-through X-ray of small intestines 931925_1 CDM 0320 RC 74248 HCPCS inpatient 1201 780.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 727.21 1164.97 "Troponin (protein) analysis, quantitative" 940718_1 CDM 0301 RC 84484 HCPCS inpatient 363 235.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 235.95 65 999999999 219.8 352.11 percent of total billed charges "Troponin (protein) analysis, quantitative" 940718_1 CDM 0301 RC 84484 HCPCS inpatient 363 235.95 AETNA AETNA 286.77 79 999999999 219.8 352.11 percent of total billed charges "Troponin (protein) analysis, quantitative" 940718_1 CDM 0301 RC 84484 HCPCS inpatient 363 235.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 352.11 97 999999999 219.8 352.11 percent of total billed charges "Troponin (protein) analysis, quantitative" 940718_1 CDM 0301 RC 84484 HCPCS inpatient 363 235.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 250.47 69 999999999 219.8 352.11 percent of total billed charges "Troponin (protein) analysis, quantitative" 940718_1 CDM 0301 RC 84484 HCPCS inpatient 363 235.95 SIHO - ALL PLANS SIHO - ALL PLANS 326.7 90 999999999 219.8 352.11 percent of total billed charges "Troponin (protein) analysis, quantitative" 940718_1 CDM 0301 RC 84484 HCPCS inpatient 363 235.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 283.14 78 999999999 219.8 352.11 percent of total billed charges "Troponin (protein) analysis, quantitative" 940718_1 CDM 0301 RC 84484 HCPCS inpatient 363 235.95 UMR - ALL PLANS UMR - ALL PLANS 254.1 70 999999999 219.8 352.11 percent of total billed charges "Troponin (protein) analysis, quantitative" 940718_1 CDM 0301 RC 84484 HCPCS inpatient 363 235.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 219.8 60.55 999999999 219.8 352.11 percent of total billed charges "Troponin (protein) analysis, quantitative" 940718_1 CDM 0301 RC 84484 HCPCS inpatient 363 235.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 219.8 352.11 "Troponin (protein) analysis, quantitative" 940718_1 CDM 0301 RC 84484 HCPCS inpatient 363 235.95 ANTHEM HMO ANTHEM HMO 999999999 219.8 352.11 "Troponin (protein) analysis, quantitative" 940718_1 CDM 0301 RC 84484 HCPCS inpatient 363 235.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 219.8 352.11 "Troponin (protein) analysis, quantitative" 940718_1 CDM 0301 RC 84484 HCPCS inpatient 363 235.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 219.8 352.11 "Troponin (protein) analysis, quantitative" 940718_1 CDM 0301 RC 84484 HCPCS inpatient 363 235.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 245.39 67.6 999999999 219.8 352.11 percent of total billed charges "Troponin (protein) analysis, quantitative" 940718_1 CDM 0301 RC 84484 HCPCS inpatient 363 235.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 219.8 352.11 "Creatine kinase (cardiac enzyme) level, MB fraction only" 948721_1 CDM 0301 RC 82553 HCPCS inpatient 112 72.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 72.8 65 999999999 67.82 108.64 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 948721_1 CDM 0301 RC 82553 HCPCS inpatient 112 72.8 AETNA AETNA 88.48 79 999999999 67.82 108.64 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 948721_1 CDM 0301 RC 82553 HCPCS inpatient 112 72.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 108.64 97 999999999 67.82 108.64 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 948721_1 CDM 0301 RC 82553 HCPCS inpatient 112 72.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 77.28 69 999999999 67.82 108.64 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 948721_1 CDM 0301 RC 82553 HCPCS inpatient 112 72.8 SIHO - ALL PLANS SIHO - ALL PLANS 100.8 90 999999999 67.82 108.64 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 948721_1 CDM 0301 RC 82553 HCPCS inpatient 112 72.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 87.36 78 999999999 67.82 108.64 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 948721_1 CDM 0301 RC 82553 HCPCS inpatient 112 72.8 UMR - ALL PLANS UMR - ALL PLANS 78.4 70 999999999 67.82 108.64 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 948721_1 CDM 0301 RC 82553 HCPCS inpatient 112 72.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 67.82 60.55 999999999 67.82 108.64 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 948721_1 CDM 0301 RC 82553 HCPCS inpatient 112 72.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 67.82 108.64 "Creatine kinase (cardiac enzyme) level, MB fraction only" 948721_1 CDM 0301 RC 82553 HCPCS inpatient 112 72.8 ANTHEM HMO ANTHEM HMO 999999999 67.82 108.64 "Creatine kinase (cardiac enzyme) level, MB fraction only" 948721_1 CDM 0301 RC 82553 HCPCS inpatient 112 72.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 67.82 108.64 "Creatine kinase (cardiac enzyme) level, MB fraction only" 948721_1 CDM 0301 RC 82553 HCPCS inpatient 112 72.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 67.82 108.64 "Creatine kinase (cardiac enzyme) level, MB fraction only" 948721_1 CDM 0301 RC 82553 HCPCS inpatient 112 72.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 75.71 67.6 999999999 67.82 108.64 percent of total billed charges "Creatine kinase (cardiac enzyme) level, MB fraction only" 948721_1 CDM 0301 RC 82553 HCPCS inpatient 112 72.8 UHC - ALL PLANS UHC - ALL PLANS 999999999 67.82 108.64 Ultrasonic guidance for needle placement 9731109_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 627.25 65 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9731109_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 AETNA AETNA 762.35 79 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9731109_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 936.05 97 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9731109_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 665.85 69 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9731109_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SIHO - ALL PLANS SIHO - ALL PLANS 868.5 90 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9731109_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 752.7 78 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9731109_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UMR - ALL PLANS UMR - ALL PLANS 675.5 70 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9731109_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 584.31 60.55 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9731109_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9731109_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM HMO ANTHEM HMO 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9731109_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9731109_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9731109_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 652.34 67.6 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9731109_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9731112_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 627.25 65 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9731112_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 AETNA AETNA 762.35 79 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9731112_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 936.05 97 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9731112_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 665.85 69 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9731112_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 SIHO - ALL PLANS SIHO - ALL PLANS 868.5 90 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9731112_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 752.7 78 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9731112_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UMR - ALL PLANS UMR - ALL PLANS 675.5 70 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9731112_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 584.31 60.55 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9731112_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9731112_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM HMO ANTHEM HMO 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9731112_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9731112_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 584.31 936.05 Ultrasonic guidance for needle placement 9731112_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 652.34 67.6 999999999 584.31 936.05 percent of total billed charges Ultrasonic guidance for needle placement 9731112_1 CDM 0402 RC 76942 HCPCS inpatient 965 627.25 UHC - ALL PLANS UHC - ALL PLANS 999999999 584.31 936.05 Imaging of urinary tract with injection of contrast into a vein 9731121_1 CDM 0320 RC 74400 HCPCS inpatient 841 546.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 546.65 65 999999999 509.23 815.77 percent of total billed charges Imaging of urinary tract with injection of contrast into a vein 9731121_1 CDM 0320 RC 74400 HCPCS inpatient 841 546.65 AETNA AETNA 664.39 79 999999999 509.23 815.77 percent of total billed charges Imaging of urinary tract with injection of contrast into a vein 9731121_1 CDM 0320 RC 74400 HCPCS inpatient 841 546.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 815.77 97 999999999 509.23 815.77 percent of total billed charges Imaging of urinary tract with injection of contrast into a vein 9731121_1 CDM 0320 RC 74400 HCPCS inpatient 841 546.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 580.29 69 999999999 509.23 815.77 percent of total billed charges Imaging of urinary tract with injection of contrast into a vein 9731121_1 CDM 0320 RC 74400 HCPCS inpatient 841 546.65 SIHO - ALL PLANS SIHO - ALL PLANS 756.9 90 999999999 509.23 815.77 percent of total billed charges Imaging of urinary tract with injection of contrast into a vein 9731121_1 CDM 0320 RC 74400 HCPCS inpatient 841 546.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 655.98 78 999999999 509.23 815.77 percent of total billed charges Imaging of urinary tract with injection of contrast into a vein 9731121_1 CDM 0320 RC 74400 HCPCS inpatient 841 546.65 UMR - ALL PLANS UMR - ALL PLANS 588.7 70 999999999 509.23 815.77 percent of total billed charges Imaging of urinary tract with injection of contrast into a vein 9731121_1 CDM 0320 RC 74400 HCPCS inpatient 841 546.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 509.23 60.55 999999999 509.23 815.77 percent of total billed charges Imaging of urinary tract with injection of contrast into a vein 9731121_1 CDM 0320 RC 74400 HCPCS inpatient 841 546.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 509.23 815.77 Imaging of urinary tract with injection of contrast into a vein 9731121_1 CDM 0320 RC 74400 HCPCS inpatient 841 546.65 ANTHEM HMO ANTHEM HMO 999999999 509.23 815.77 Imaging of urinary tract with injection of contrast into a vein 9731121_1 CDM 0320 RC 74400 HCPCS inpatient 841 546.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 509.23 815.77 Imaging of urinary tract with injection of contrast into a vein 9731121_1 CDM 0320 RC 74400 HCPCS inpatient 841 546.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 509.23 815.77 Imaging of urinary tract with injection of contrast into a vein 9731121_1 CDM 0320 RC 74400 HCPCS inpatient 841 546.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 568.52 67.6 999999999 509.23 815.77 percent of total billed charges Imaging of urinary tract with injection of contrast into a vein 9731121_1 CDM 0320 RC 74400 HCPCS inpatient 841 546.65 UHC - ALL PLANS UHC - ALL PLANS 999999999 509.23 815.77 Complete ultrasound scan of pelvis 982633_1 CDM 0402 RC 76856 HCPCS inpatient 363 235.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 235.95 65 999999999 219.8 352.11 percent of total billed charges Complete ultrasound scan of pelvis 982633_1 CDM 0402 RC 76856 HCPCS inpatient 363 235.95 AETNA AETNA 286.77 79 999999999 219.8 352.11 percent of total billed charges Complete ultrasound scan of pelvis 982633_1 CDM 0402 RC 76856 HCPCS inpatient 363 235.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 352.11 97 999999999 219.8 352.11 percent of total billed charges Complete ultrasound scan of pelvis 982633_1 CDM 0402 RC 76856 HCPCS inpatient 363 235.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 250.47 69 999999999 219.8 352.11 percent of total billed charges Complete ultrasound scan of pelvis 982633_1 CDM 0402 RC 76856 HCPCS inpatient 363 235.95 SIHO - ALL PLANS SIHO - ALL PLANS 326.7 90 999999999 219.8 352.11 percent of total billed charges Complete ultrasound scan of pelvis 982633_1 CDM 0402 RC 76856 HCPCS inpatient 363 235.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 283.14 78 999999999 219.8 352.11 percent of total billed charges Complete ultrasound scan of pelvis 982633_1 CDM 0402 RC 76856 HCPCS inpatient 363 235.95 UMR - ALL PLANS UMR - ALL PLANS 254.1 70 999999999 219.8 352.11 percent of total billed charges Complete ultrasound scan of pelvis 982633_1 CDM 0402 RC 76856 HCPCS inpatient 363 235.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 219.8 60.55 999999999 219.8 352.11 percent of total billed charges Complete ultrasound scan of pelvis 982633_1 CDM 0402 RC 76856 HCPCS inpatient 363 235.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 219.8 352.11 Complete ultrasound scan of pelvis 982633_1 CDM 0402 RC 76856 HCPCS inpatient 363 235.95 ANTHEM HMO ANTHEM HMO 999999999 219.8 352.11 Complete ultrasound scan of pelvis 982633_1 CDM 0402 RC 76856 HCPCS inpatient 363 235.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 219.8 352.11 Complete ultrasound scan of pelvis 982633_1 CDM 0402 RC 76856 HCPCS inpatient 363 235.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 219.8 352.11 Complete ultrasound scan of pelvis 982633_1 CDM 0402 RC 76856 HCPCS inpatient 363 235.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 245.39 67.6 999999999 219.8 352.11 percent of total billed charges Complete ultrasound scan of pelvis 982633_1 CDM 0402 RC 76856 HCPCS inpatient 363 235.95 UHC - ALL PLANS UHC - ALL PLANS 999999999 219.8 352.11 ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990674_1 CDM 0110 RC inpatient 1617 1051.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1051.05 65 999999999 979.09 1568.49 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990674_1 CDM 0110 RC inpatient 1617 1051.05 AETNA AETNA 1277.43 79 999999999 979.09 1568.49 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990674_1 CDM 0110 RC inpatient 1617 1051.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1568.49 97 999999999 979.09 1568.49 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990674_1 CDM 0110 RC inpatient 1617 1051.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1115.73 69 999999999 979.09 1568.49 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990674_1 CDM 0110 RC inpatient 1617 1051.05 SIHO - ALL PLANS SIHO - ALL PLANS 1455.3 90 999999999 979.09 1568.49 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990674_1 CDM 0110 RC inpatient 1617 1051.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1261.26 78 999999999 979.09 1568.49 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990674_1 CDM 0110 RC inpatient 1617 1051.05 UMR - ALL PLANS UMR - ALL PLANS 1131.9 70 999999999 979.09 1568.49 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990674_1 CDM 0110 RC inpatient 1617 1051.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 979.09 60.55 999999999 979.09 1568.49 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990674_1 CDM 0110 RC inpatient 1617 1051.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 979.09 1568.49 ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990674_1 CDM 0110 RC inpatient 1617 1051.05 ANTHEM HMO ANTHEM HMO 999999999 979.09 1568.49 ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990674_1 CDM 0110 RC inpatient 1617 1051.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 979.09 1568.49 ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990674_1 CDM 0110 RC inpatient 1617 1051.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 979.09 1568.49 ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990674_1 CDM 0110 RC inpatient 1617 1051.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1093.09 67.6 999999999 979.09 1568.49 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990674_1 CDM 0110 RC inpatient 1617 1051.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 979.09 1568.49 ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - GENERAL CLASSIFICATION 990675_1 CDM 0120 RC inpatient 1617 1051.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 1051.05 65 999999999 979.09 1568.49 percent of total billed charges ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - GENERAL CLASSIFICATION 990675_1 CDM 0120 RC inpatient 1617 1051.05 AETNA AETNA 1277.43 79 999999999 979.09 1568.49 percent of total billed charges ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - GENERAL CLASSIFICATION 990675_1 CDM 0120 RC inpatient 1617 1051.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1568.49 97 999999999 979.09 1568.49 percent of total billed charges ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - GENERAL CLASSIFICATION 990675_1 CDM 0120 RC inpatient 1617 1051.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 1115.73 69 999999999 979.09 1568.49 percent of total billed charges ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - GENERAL CLASSIFICATION 990675_1 CDM 0120 RC inpatient 1617 1051.05 SIHO - ALL PLANS SIHO - ALL PLANS 1455.3 90 999999999 979.09 1568.49 percent of total billed charges ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - GENERAL CLASSIFICATION 990675_1 CDM 0120 RC inpatient 1617 1051.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 1261.26 78 999999999 979.09 1568.49 percent of total billed charges ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - GENERAL CLASSIFICATION 990675_1 CDM 0120 RC inpatient 1617 1051.05 UMR - ALL PLANS UMR - ALL PLANS 1131.9 70 999999999 979.09 1568.49 percent of total billed charges ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - GENERAL CLASSIFICATION 990675_1 CDM 0120 RC inpatient 1617 1051.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 979.09 60.55 999999999 979.09 1568.49 percent of total billed charges ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - GENERAL CLASSIFICATION 990675_1 CDM 0120 RC inpatient 1617 1051.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 979.09 1568.49 ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - GENERAL CLASSIFICATION 990675_1 CDM 0120 RC inpatient 1617 1051.05 ANTHEM HMO ANTHEM HMO 999999999 979.09 1568.49 ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - GENERAL CLASSIFICATION 990675_1 CDM 0120 RC inpatient 1617 1051.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 979.09 1568.49 ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - GENERAL CLASSIFICATION 990675_1 CDM 0120 RC inpatient 1617 1051.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 979.09 1568.49 ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - GENERAL CLASSIFICATION 990675_1 CDM 0120 RC inpatient 1617 1051.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 1093.09 67.6 999999999 979.09 1568.49 percent of total billed charges ROOM & BOARD - SEMI-PRIVATE (TWO BEDS) - GENERAL CLASSIFICATION 990675_1 CDM 0120 RC inpatient 1617 1051.05 UHC - ALL PLANS UHC - ALL PLANS 999999999 979.09 1568.49 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 990676_1 CDM 0762 RC G0378 HCPCS inpatient 140 91 SELF PAY DISCOUNT SELF PAY DISCOUNT 91 65 999999999 84.77 135.8 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 990676_1 CDM 0762 RC G0378 HCPCS inpatient 140 91 AETNA AETNA 110.6 79 999999999 84.77 135.8 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 990676_1 CDM 0762 RC G0378 HCPCS inpatient 140 91 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 135.8 97 999999999 84.77 135.8 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 990676_1 CDM 0762 RC G0378 HCPCS inpatient 140 91 ENCORE - ALL PLANS ENCORE - ALL PLANS 96.6 69 999999999 84.77 135.8 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 990676_1 CDM 0762 RC G0378 HCPCS inpatient 140 91 SIHO - ALL PLANS SIHO - ALL PLANS 126 90 999999999 84.77 135.8 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 990676_1 CDM 0762 RC G0378 HCPCS inpatient 140 91 HUMANA - ALL PLANS HUMANA - ALL PLANS 109.2 78 999999999 84.77 135.8 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 990676_1 CDM 0762 RC G0378 HCPCS inpatient 140 91 UMR - ALL PLANS UMR - ALL PLANS 98 70 999999999 84.77 135.8 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 990676_1 CDM 0762 RC G0378 HCPCS inpatient 140 91 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 84.77 60.55 999999999 84.77 135.8 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 990676_1 CDM 0762 RC G0378 HCPCS inpatient 140 91 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 84.77 135.8 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 990676_1 CDM 0762 RC G0378 HCPCS inpatient 140 91 ANTHEM HMO ANTHEM HMO 999999999 84.77 135.8 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 990676_1 CDM 0762 RC G0378 HCPCS inpatient 140 91 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 84.77 135.8 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 990676_1 CDM 0762 RC G0378 HCPCS inpatient 140 91 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 84.77 135.8 "HOSPITAL OBSERVATION SERVICE, PER HOUR" 990676_1 CDM 0762 RC G0378 HCPCS inpatient 140 91 CIGNA - ALL PLANS CIGNA - ALL PLANS 94.64 67.6 999999999 84.77 135.8 percent of total billed charges "HOSPITAL OBSERVATION SERVICE, PER HOUR" 990676_1 CDM 0762 RC G0378 HCPCS inpatient 140 91 UHC - ALL PLANS UHC - ALL PLANS 999999999 84.77 135.8 ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990677_1 CDM 0110 RC inpatient 2075 1348.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 1348.75 65 999999999 1256.41 2012.75 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990677_1 CDM 0110 RC inpatient 2075 1348.75 AETNA AETNA 1639.25 79 999999999 1256.41 2012.75 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990677_1 CDM 0110 RC inpatient 2075 1348.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2012.75 97 999999999 1256.41 2012.75 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990677_1 CDM 0110 RC inpatient 2075 1348.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 1431.75 69 999999999 1256.41 2012.75 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990677_1 CDM 0110 RC inpatient 2075 1348.75 SIHO - ALL PLANS SIHO - ALL PLANS 1867.5 90 999999999 1256.41 2012.75 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990677_1 CDM 0110 RC inpatient 2075 1348.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 1618.5 78 999999999 1256.41 2012.75 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990677_1 CDM 0110 RC inpatient 2075 1348.75 UMR - ALL PLANS UMR - ALL PLANS 1452.5 70 999999999 1256.41 2012.75 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990677_1 CDM 0110 RC inpatient 2075 1348.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1256.41 60.55 999999999 1256.41 2012.75 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990677_1 CDM 0110 RC inpatient 2075 1348.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1256.41 2012.75 ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990677_1 CDM 0110 RC inpatient 2075 1348.75 ANTHEM HMO ANTHEM HMO 999999999 1256.41 2012.75 ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990677_1 CDM 0110 RC inpatient 2075 1348.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1256.41 2012.75 ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990677_1 CDM 0110 RC inpatient 2075 1348.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1256.41 2012.75 ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990677_1 CDM 0110 RC inpatient 2075 1348.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 1402.7 67.6 999999999 1256.41 2012.75 percent of total billed charges ROOM & BOARD - PRIVATE (ONE BED) - GENERAL CLASSIFICATION 990677_1 CDM 0110 RC inpatient 2075 1348.75 UHC - ALL PLANS UHC - ALL PLANS 999999999 1256.41 2012.75 Hemoglobin A1C level 9938966_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 115.7 65 999999999 107.78 172.66 percent of total billed charges Hemoglobin A1C level 9938966_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 AETNA AETNA 140.62 79 999999999 107.78 172.66 percent of total billed charges Hemoglobin A1C level 9938966_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 172.66 97 999999999 107.78 172.66 percent of total billed charges Hemoglobin A1C level 9938966_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 122.82 69 999999999 107.78 172.66 percent of total billed charges Hemoglobin A1C level 9938966_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 SIHO - ALL PLANS SIHO - ALL PLANS 160.2 90 999999999 107.78 172.66 percent of total billed charges Hemoglobin A1C level 9938966_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 138.84 78 999999999 107.78 172.66 percent of total billed charges Hemoglobin A1C level 9938966_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 UMR - ALL PLANS UMR - ALL PLANS 124.6 70 999999999 107.78 172.66 percent of total billed charges Hemoglobin A1C level 9938966_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 107.78 60.55 999999999 107.78 172.66 percent of total billed charges Hemoglobin A1C level 9938966_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 107.78 172.66 Hemoglobin A1C level 9938966_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 ANTHEM HMO ANTHEM HMO 999999999 107.78 172.66 Hemoglobin A1C level 9938966_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 107.78 172.66 Hemoglobin A1C level 9938966_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 107.78 172.66 Hemoglobin A1C level 9938966_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 120.33 67.6 999999999 107.78 172.66 percent of total billed charges Hemoglobin A1C level 9938966_1 CDM 0301 RC 83036 HCPCS inpatient 178 115.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 107.78 172.66 Complete ultrasound scan of pelvis 9940993_1 CDM 0402 RC 76856 HCPCS inpatient 378 245.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 245.7 65 999999999 228.88 366.66 percent of total billed charges Complete ultrasound scan of pelvis 9940993_1 CDM 0402 RC 76856 HCPCS inpatient 378 245.7 AETNA AETNA 298.62 79 999999999 228.88 366.66 percent of total billed charges Complete ultrasound scan of pelvis 9940993_1 CDM 0402 RC 76856 HCPCS inpatient 378 245.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 366.66 97 999999999 228.88 366.66 percent of total billed charges Complete ultrasound scan of pelvis 9940993_1 CDM 0402 RC 76856 HCPCS inpatient 378 245.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 260.82 69 999999999 228.88 366.66 percent of total billed charges Complete ultrasound scan of pelvis 9940993_1 CDM 0402 RC 76856 HCPCS inpatient 378 245.7 SIHO - ALL PLANS SIHO - ALL PLANS 340.2 90 999999999 228.88 366.66 percent of total billed charges Complete ultrasound scan of pelvis 9940993_1 CDM 0402 RC 76856 HCPCS inpatient 378 245.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 294.84 78 999999999 228.88 366.66 percent of total billed charges Complete ultrasound scan of pelvis 9940993_1 CDM 0402 RC 76856 HCPCS inpatient 378 245.7 UMR - ALL PLANS UMR - ALL PLANS 264.6 70 999999999 228.88 366.66 percent of total billed charges Complete ultrasound scan of pelvis 9940993_1 CDM 0402 RC 76856 HCPCS inpatient 378 245.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 228.88 60.55 999999999 228.88 366.66 percent of total billed charges Complete ultrasound scan of pelvis 9940993_1 CDM 0402 RC 76856 HCPCS inpatient 378 245.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 228.88 366.66 Complete ultrasound scan of pelvis 9940993_1 CDM 0402 RC 76856 HCPCS inpatient 378 245.7 ANTHEM HMO ANTHEM HMO 999999999 228.88 366.66 Complete ultrasound scan of pelvis 9940993_1 CDM 0402 RC 76856 HCPCS inpatient 378 245.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 228.88 366.66 Complete ultrasound scan of pelvis 9940993_1 CDM 0402 RC 76856 HCPCS inpatient 378 245.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 228.88 366.66 Complete ultrasound scan of pelvis 9940993_1 CDM 0402 RC 76856 HCPCS inpatient 378 245.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 255.53 67.6 999999999 228.88 366.66 percent of total billed charges Complete ultrasound scan of pelvis 9940993_1 CDM 0402 RC 76856 HCPCS inpatient 378 245.7 UHC - ALL PLANS UHC - ALL PLANS 999999999 228.88 366.66 "Imaging guidance for procedure, 60 minutes or less" 9941002_1 CDM 0320 RC 76000 HCPCS inpatient 1733 1126.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 1126.45 65 999999999 1049.33 1681.01 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 9941002_1 CDM 0320 RC 76000 HCPCS inpatient 1733 1126.45 AETNA AETNA 1369.07 79 999999999 1049.33 1681.01 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 9941002_1 CDM 0320 RC 76000 HCPCS inpatient 1733 1126.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 1681.01 97 999999999 1049.33 1681.01 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 9941002_1 CDM 0320 RC 76000 HCPCS inpatient 1733 1126.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 1195.77 69 999999999 1049.33 1681.01 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 9941002_1 CDM 0320 RC 76000 HCPCS inpatient 1733 1126.45 SIHO - ALL PLANS SIHO - ALL PLANS 1559.7 90 999999999 1049.33 1681.01 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 9941002_1 CDM 0320 RC 76000 HCPCS inpatient 1733 1126.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 1351.74 78 999999999 1049.33 1681.01 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 9941002_1 CDM 0320 RC 76000 HCPCS inpatient 1733 1126.45 UMR - ALL PLANS UMR - ALL PLANS 1213.1 70 999999999 1049.33 1681.01 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 9941002_1 CDM 0320 RC 76000 HCPCS inpatient 1733 1126.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1049.33 60.55 999999999 1049.33 1681.01 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 9941002_1 CDM 0320 RC 76000 HCPCS inpatient 1733 1126.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 1049.33 1681.01 "Imaging guidance for procedure, 60 minutes or less" 9941002_1 CDM 0320 RC 76000 HCPCS inpatient 1733 1126.45 ANTHEM HMO ANTHEM HMO 999999999 1049.33 1681.01 "Imaging guidance for procedure, 60 minutes or less" 9941002_1 CDM 0320 RC 76000 HCPCS inpatient 1733 1126.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 1049.33 1681.01 "Imaging guidance for procedure, 60 minutes or less" 9941002_1 CDM 0320 RC 76000 HCPCS inpatient 1733 1126.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 1049.33 1681.01 "Imaging guidance for procedure, 60 minutes or less" 9941002_1 CDM 0320 RC 76000 HCPCS inpatient 1733 1126.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 1171.51 67.6 999999999 1049.33 1681.01 percent of total billed charges "Imaging guidance for procedure, 60 minutes or less" 9941002_1 CDM 0320 RC 76000 HCPCS inpatient 1733 1126.45 UHC - ALL PLANS UHC - ALL PLANS 999999999 1049.33 1681.01 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 9943244_1 CDM 0301 RC 82274 HCPCS inpatient 76 49.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 49.4 65 999999999 46.02 73.72 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 9943244_1 CDM 0301 RC 82274 HCPCS inpatient 76 49.4 AETNA AETNA 60.04 79 999999999 46.02 73.72 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 9943244_1 CDM 0301 RC 82274 HCPCS inpatient 76 49.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73.72 97 999999999 46.02 73.72 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 9943244_1 CDM 0301 RC 82274 HCPCS inpatient 76 49.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 52.44 69 999999999 46.02 73.72 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 9943244_1 CDM 0301 RC 82274 HCPCS inpatient 76 49.4 SIHO - ALL PLANS SIHO - ALL PLANS 68.4 90 999999999 46.02 73.72 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 9943244_1 CDM 0301 RC 82274 HCPCS inpatient 76 49.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 59.28 78 999999999 46.02 73.72 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 9943244_1 CDM 0301 RC 82274 HCPCS inpatient 76 49.4 UMR - ALL PLANS UMR - ALL PLANS 53.2 70 999999999 46.02 73.72 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 9943244_1 CDM 0301 RC 82274 HCPCS inpatient 76 49.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46.02 60.55 999999999 46.02 73.72 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 9943244_1 CDM 0301 RC 82274 HCPCS inpatient 76 49.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 999999999 46.02 73.72 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 9943244_1 CDM 0301 RC 82274 HCPCS inpatient 76 49.4 ANTHEM HMO ANTHEM HMO 999999999 46.02 73.72 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 9943244_1 CDM 0301 RC 82274 HCPCS inpatient 76 49.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 999999999 46.02 73.72 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 9943244_1 CDM 0301 RC 82274 HCPCS inpatient 76 49.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 999999999 46.02 73.72 "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 9943244_1 CDM 0301 RC 82274 HCPCS inpatient 76 49.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 51.38 67.6 999999999 46.02 73.72 percent of total billed charges "Stool analysis for blood, by fecal hemoglobin determination by immunoassay" 9943244_1 CDM 0301 RC 82274 HCPCS inpatient 76 49.4 UHC - ALL PLANS UHC - ALL PLANS 999999999 46.02 73.72 SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 029 MS-DRG inpatient 1 UN 128443.02 83487.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 83487.96 65 999999999 29139.7 124589.73 percent of total billed charges SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 029 MS-DRG inpatient 1 UN 128443.02 83487.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 124589.73 97 999999999 29139.7 124589.73 percent of total billed charges SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 029 MS-DRG inpatient 1 UN 128443.02 83487.96 UMR - ALL PLANS UMR - ALL PLANS 89910.11 70 999999999 29139.7 124589.73 percent of total billed charges SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 029 MS-DRG inpatient 1 UN 128443.02 83487.96 SIHO - ALL PLANS SIHO - ALL PLANS 115598.72 90 999999999 29139.7 124589.73 percent of total billed charges SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 029 MS-DRG inpatient 1 UN 128443.02 83487.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 55029.47 999999999 29139.7 124589.73 case rate SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 029 MS-DRG inpatient 1 UN 128443.02 83487.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 51971.51 999999999 29139.7 124589.73 case rate SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 029 MS-DRG inpatient 1 UN 128443.02 83487.96 ANTHEM HMO ANTHEM HMO 48910.13 999999999 29139.7 124589.73 case rate SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 029 MS-DRG inpatient 1 UN 128443.02 83487.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 46774.36 999999999 29139.7 124589.73 case rate SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 029 MS-DRG inpatient 1 UN 128443.02 83487.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 86827.48 67.6 999999999 29139.7 124589.73 percent of total billed charges SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 029 MS-DRG inpatient 1 UN 128443.02 83487.96 AETNA AETNA 101469.99 79 999999999 29139.7 124589.73 percent of total billed charges SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 029 MS-DRG inpatient 1 UN 128443.02 83487.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 100185.56 78 999999999 29139.7 124589.73 percent of total billed charges SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 029 MS-DRG inpatient 1 UN 128443.02 83487.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 88625.68 69 999999999 29139.7 124589.73 percent of total billed charges SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 029 MS-DRG inpatient 1 UN 128443.02 83487.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 77772.25 60.55 999999999 29139.7 124589.73 percent of total billed charges SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS 029 MS-DRG inpatient 1 UN 128443.02 83487.96 UHC - ALL PLANS UHC - ALL PLANS 29139.7 999999999 29139.7 124589.73 case rate DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC 057 MS-DRG inpatient 1 UN 34513.77 22433.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 26920.74 78 999999999 11587.2 33478.36 percent of total billed charges DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC 057 MS-DRG inpatient 1 UN 34513.77 22433.95 SIHO - ALL PLANS SIHO - ALL PLANS 31062.39 90 999999999 11587.2 33478.36 percent of total billed charges DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC 057 MS-DRG inpatient 1 UN 34513.77 22433.95 ANTHEM HMO ANTHEM HMO 19448.77 999999999 11587.2 33478.36 case rate DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC 057 MS-DRG inpatient 1 UN 34513.77 22433.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 18599.5 999999999 11587.2 33478.36 case rate DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC 057 MS-DRG inpatient 1 UN 34513.77 22433.95 UHC - ALL PLANS UHC - ALL PLANS 11587.2 999999999 11587.2 33478.36 case rate DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC 057 MS-DRG inpatient 1 UN 34513.77 22433.95 UMR - ALL PLANS UMR - ALL PLANS 24159.64 70 999999999 11587.2 33478.36 percent of total billed charges DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC 057 MS-DRG inpatient 1 UN 34513.77 22433.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33478.36 97 999999999 11587.2 33478.36 percent of total billed charges DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC 057 MS-DRG inpatient 1 UN 34513.77 22433.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20898.09 60.55 999999999 11587.2 33478.36 percent of total billed charges DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC 057 MS-DRG inpatient 1 UN 34513.77 22433.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 23814.5 69 999999999 11587.2 33478.36 percent of total billed charges DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC 057 MS-DRG inpatient 1 UN 34513.77 22433.95 AETNA AETNA 27265.88 79 999999999 11587.2 33478.36 percent of total billed charges DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC 057 MS-DRG inpatient 1 UN 34513.77 22433.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 22433.95 65 999999999 11587.2 33478.36 percent of total billed charges DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC 057 MS-DRG inpatient 1 UN 34513.77 22433.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 23331.31 67.6 999999999 11587.2 33478.36 percent of total billed charges DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC 057 MS-DRG inpatient 1 UN 34513.77 22433.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 21882.09 999999999 11587.2 33478.36 case rate DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC 057 MS-DRG inpatient 1 UN 34513.77 22433.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 20666.11 999999999 11587.2 33478.36 case rate INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC 064 MS-DRG inpatient 1 UN 49088.49 31907.52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 30365.48 999999999 17025.5 47615.83 case rate INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC 064 MS-DRG inpatient 1 UN 49088.49 31907.52 ANTHEM HMO ANTHEM HMO 28576.8 999999999 17025.5 47615.83 case rate INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC 064 MS-DRG inpatient 1 UN 49088.49 31907.52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 32152.16 999999999 17025.5 47615.83 case rate INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC 064 MS-DRG inpatient 1 UN 49088.49 31907.52 CIGNA - ALL PLANS CIGNA - ALL PLANS 33183.82 67.6 999999999 17025.5 47615.83 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC 064 MS-DRG inpatient 1 UN 49088.49 31907.52 SELF PAY DISCOUNT SELF PAY DISCOUNT 31907.52 65 999999999 17025.5 47615.83 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC 064 MS-DRG inpatient 1 UN 49088.49 31907.52 AETNA AETNA 38779.91 79 999999999 17025.5 47615.83 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC 064 MS-DRG inpatient 1 UN 49088.49 31907.52 ENCORE - ALL PLANS ENCORE - ALL PLANS 33871.06 69 999999999 17025.5 47615.83 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC 064 MS-DRG inpatient 1 UN 49088.49 31907.52 HUMANA - ALL PLANS HUMANA - ALL PLANS 38289.02 78 999999999 17025.5 47615.83 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC 064 MS-DRG inpatient 1 UN 49088.49 31907.52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29723.08 60.55 999999999 17025.5 47615.83 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC 064 MS-DRG inpatient 1 UN 49088.49 31907.52 UMR - ALL PLANS UMR - ALL PLANS 34361.94 70 999999999 17025.5 47615.83 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC 064 MS-DRG inpatient 1 UN 49088.49 31907.52 UHC - ALL PLANS UHC - ALL PLANS 17025.5 999999999 17025.5 47615.83 case rate INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC 064 MS-DRG inpatient 1 UN 49088.49 31907.52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 27328.93 999999999 17025.5 47615.83 case rate INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC 064 MS-DRG inpatient 1 UN 49088.49 31907.52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 47615.83 97 999999999 17025.5 47615.83 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC 064 MS-DRG inpatient 1 UN 49088.49 31907.52 SIHO - ALL PLANS SIHO - ALL PLANS 44179.64 90 999999999 17025.5 47615.83 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS 065 MS-DRG inpatient 1 UN 38247.39 24860.8 SIHO - ALL PLANS SIHO - ALL PLANS 34422.65 90 999999999 8639.4 37099.97 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS 065 MS-DRG inpatient 1 UN 38247.39 24860.8 UMR - ALL PLANS UMR - ALL PLANS 26773.17 70 999999999 8639.4 37099.97 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS 065 MS-DRG inpatient 1 UN 38247.39 24860.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37099.97 97 999999999 8639.4 37099.97 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS 065 MS-DRG inpatient 1 UN 38247.39 24860.8 AETNA AETNA 30215.44 79 999999999 8639.4 37099.97 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS 065 MS-DRG inpatient 1 UN 38247.39 24860.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23158.79 60.55 999999999 8639.4 37099.97 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS 065 MS-DRG inpatient 1 UN 38247.39 24860.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 26390.7 69 999999999 8639.4 37099.97 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS 065 MS-DRG inpatient 1 UN 38247.39 24860.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 29832.96 78 999999999 8639.4 37099.97 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS 065 MS-DRG inpatient 1 UN 38247.39 24860.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 24860.8 65 999999999 8639.4 37099.97 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS 065 MS-DRG inpatient 1 UN 38247.39 24860.8 UHC - ALL PLANS UHC - ALL PLANS 8639.4 999999999 8639.4 37099.97 case rate INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS 065 MS-DRG inpatient 1 UN 38247.39 24860.8 ANTHEM HMO ANTHEM HMO 14500.98 999999999 8639.4 37099.97 case rate INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS 065 MS-DRG inpatient 1 UN 38247.39 24860.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 13867.76 999999999 8639.4 37099.97 case rate INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS 065 MS-DRG inpatient 1 UN 38247.39 24860.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 25855.23 67.6 999999999 8639.4 37099.97 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS 065 MS-DRG inpatient 1 UN 38247.39 24860.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 16315.25 999999999 8639.4 37099.97 case rate INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS 065 MS-DRG inpatient 1 UN 38247.39 24860.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 15408.62 999999999 8639.4 37099.97 case rate INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC 066 MS-DRG inpatient 1 UN 27733.06 18026.49 CIGNA - ALL PLANS CIGNA - ALL PLANS 18747.55 67.6 999999999 5843.75 26901.07 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC 066 MS-DRG inpatient 1 UN 27733.06 18026.49 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 11035.75 999999999 5843.75 26901.07 case rate INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC 066 MS-DRG inpatient 1 UN 27733.06 18026.49 SELF PAY DISCOUNT SELF PAY DISCOUNT 18026.49 65 999999999 5843.75 26901.07 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC 066 MS-DRG inpatient 1 UN 27733.06 18026.49 AETNA AETNA 21909.12 79 999999999 5843.75 26901.07 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC 066 MS-DRG inpatient 1 UN 27733.06 18026.49 ENCORE - ALL PLANS ENCORE - ALL PLANS 19135.81 69 999999999 5843.75 26901.07 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC 066 MS-DRG inpatient 1 UN 27733.06 18026.49 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16792.37 60.55 999999999 5843.75 26901.07 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC 066 MS-DRG inpatient 1 UN 27733.06 18026.49 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26901.07 97 999999999 5843.75 26901.07 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC 066 MS-DRG inpatient 1 UN 27733.06 18026.49 UMR - ALL PLANS UMR - ALL PLANS 19413.14 70 999999999 5843.75 26901.07 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC 066 MS-DRG inpatient 1 UN 27733.06 18026.49 ANTHEM HMO ANTHEM HMO 9808.56 999999999 5843.75 26901.07 case rate INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC 066 MS-DRG inpatient 1 UN 27733.06 18026.49 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 10422.5 999999999 5843.75 26901.07 case rate INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC 066 MS-DRG inpatient 1 UN 27733.06 18026.49 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 9380.25 999999999 5843.75 26901.07 case rate INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC 066 MS-DRG inpatient 1 UN 27733.06 18026.49 SIHO - ALL PLANS SIHO - ALL PLANS 24959.75 90 999999999 5843.75 26901.07 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC 066 MS-DRG inpatient 1 UN 27733.06 18026.49 HUMANA - ALL PLANS HUMANA - ALL PLANS 21631.79 78 999999999 5843.75 26901.07 percent of total billed charges INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC 066 MS-DRG inpatient 1 UN 27733.06 18026.49 UHC - ALL PLANS UHC - ALL PLANS 5843.75 999999999 5843.75 26901.07 case rate NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC 068 MS-DRG inpatient 1 UN 23245.25 15109.41 UMR - ALL PLANS UMR - ALL PLANS 16271.68 70 999999999 7403.5 22547.89 percent of total billed charges NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC 068 MS-DRG inpatient 1 UN 23245.25 15109.41 AETNA AETNA 18363.75 79 999999999 7403.5 22547.89 percent of total billed charges NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC 068 MS-DRG inpatient 1 UN 23245.25 15109.41 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22547.89 97 999999999 7403.5 22547.89 percent of total billed charges NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC 068 MS-DRG inpatient 1 UN 23245.25 15109.41 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14075 60.55 999999999 7403.5 22547.89 percent of total billed charges NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC 068 MS-DRG inpatient 1 UN 23245.25 15109.41 HUMANA - ALL PLANS HUMANA - ALL PLANS 18131.3 78 999999999 7403.5 22547.89 percent of total billed charges NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC 068 MS-DRG inpatient 1 UN 23245.25 15109.41 ENCORE - ALL PLANS ENCORE - ALL PLANS 16039.22 69 999999999 7403.5 22547.89 percent of total billed charges NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC 068 MS-DRG inpatient 1 UN 23245.25 15109.41 SIHO - ALL PLANS SIHO - ALL PLANS 20920.73 90 999999999 7403.5 22547.89 percent of total billed charges NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC 068 MS-DRG inpatient 1 UN 23245.25 15109.41 SELF PAY DISCOUNT SELF PAY DISCOUNT 15109.41 65 999999999 7403.5 22547.89 percent of total billed charges NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC 068 MS-DRG inpatient 1 UN 23245.25 15109.41 UHC - ALL PLANS UHC - ALL PLANS 7403.5 999999999 7403.5 22547.89 case rate NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC 068 MS-DRG inpatient 1 UN 23245.25 15109.41 CIGNA - ALL PLANS CIGNA - ALL PLANS 15713.79 67.6 999999999 7403.5 22547.89 percent of total billed charges NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC 068 MS-DRG inpatient 1 UN 23245.25 15109.41 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 11883.92 999999999 7403.5 22547.89 case rate NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC 068 MS-DRG inpatient 1 UN 23245.25 15109.41 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13204.36 999999999 7403.5 22547.89 case rate NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC 068 MS-DRG inpatient 1 UN 23245.25 15109.41 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 13981.29 999999999 7403.5 22547.89 case rate NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC 068 MS-DRG inpatient 1 UN 23245.25 15109.41 ANTHEM HMO ANTHEM HMO 12426.56 999999999 7403.5 22547.89 case rate TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC 069 MS-DRG inpatient 1 UN 28854.12 18755.17 ANTHEM HMO ANTHEM HMO 11395.05 999999999 6788.95 27988.49 case rate TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC 069 MS-DRG inpatient 1 UN 28854.12 18755.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10897.46 999999999 6788.95 27988.49 case rate TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC 069 MS-DRG inpatient 1 UN 28854.12 18755.17 UHC - ALL PLANS UHC - ALL PLANS 6788.95 999999999 6788.95 27988.49 case rate TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC 069 MS-DRG inpatient 1 UN 28854.12 18755.17 SIHO - ALL PLANS SIHO - ALL PLANS 25968.7 90 999999999 6788.95 27988.49 percent of total billed charges TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC 069 MS-DRG inpatient 1 UN 28854.12 18755.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 22506.21 78 999999999 6788.95 27988.49 percent of total billed charges TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC 069 MS-DRG inpatient 1 UN 28854.12 18755.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 19505.38 67.6 999999999 6788.95 27988.49 percent of total billed charges TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC 069 MS-DRG inpatient 1 UN 28854.12 18755.17 AETNA AETNA 22794.75 79 999999999 6788.95 27988.49 percent of total billed charges TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC 069 MS-DRG inpatient 1 UN 28854.12 18755.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 18755.18 65 999999999 6788.95 27988.49 percent of total billed charges TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC 069 MS-DRG inpatient 1 UN 28854.12 18755.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 19909.34 69 999999999 6788.95 27988.49 percent of total billed charges TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC 069 MS-DRG inpatient 1 UN 28854.12 18755.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 12108.29 999999999 6788.95 27988.49 case rate TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC 069 MS-DRG inpatient 1 UN 28854.12 18755.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12820.73 999999999 6788.95 27988.49 case rate TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC 069 MS-DRG inpatient 1 UN 28854.12 18755.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17471.17 60.55 999999999 6788.95 27988.49 percent of total billed charges TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC 069 MS-DRG inpatient 1 UN 28854.12 18755.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 27988.49 97 999999999 6788.95 27988.49 percent of total billed charges TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC 069 MS-DRG inpatient 1 UN 28854.12 18755.17 UMR - ALL PLANS UMR - ALL PLANS 20197.88 70 999999999 6788.95 27988.49 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC 070 MS-DRG inpatient 1 UN 33365.08 21687.3 UMR - ALL PLANS UMR - ALL PLANS 23355.55 70 999999999 15210.75 32364.12 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC 070 MS-DRG inpatient 1 UN 33365.08 21687.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32364.12 97 999999999 15210.75 32364.12 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC 070 MS-DRG inpatient 1 UN 33365.08 21687.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20202.55 60.55 999999999 15210.75 32364.12 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC 070 MS-DRG inpatient 1 UN 33365.08 21687.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 28725.05 999999999 15210.75 32364.12 case rate NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC 070 MS-DRG inpatient 1 UN 33365.08 21687.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 27128.82 999999999 15210.75 32364.12 case rate NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC 070 MS-DRG inpatient 1 UN 33365.08 21687.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 23021.9 69 999999999 15210.75 32364.12 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC 070 MS-DRG inpatient 1 UN 33365.08 21687.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 21687.3 65 999999999 15210.75 32364.12 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC 070 MS-DRG inpatient 1 UN 33365.08 21687.3 AETNA AETNA 26358.41 79 999999999 15210.75 32364.12 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC 070 MS-DRG inpatient 1 UN 33365.08 21687.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 22554.79 67.6 999999999 15210.75 32364.12 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC 070 MS-DRG inpatient 1 UN 33365.08 21687.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 26024.76 78 999999999 15210.75 32364.12 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC 070 MS-DRG inpatient 1 UN 33365.08 21687.3 SIHO - ALL PLANS SIHO - ALL PLANS 30028.57 90 999999999 15210.75 32364.12 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC 070 MS-DRG inpatient 1 UN 33365.08 21687.3 UHC - ALL PLANS UHC - ALL PLANS 15210.75 999999999 15210.75 32364.12 case rate NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC 070 MS-DRG inpatient 1 UN 33365.08 21687.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 24415.94 999999999 15210.75 32364.12 case rate NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC 070 MS-DRG inpatient 1 UN 33365.08 21687.3 ANTHEM HMO ANTHEM HMO 25530.8 999999999 15210.75 32364.12 case rate NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC 071 MS-DRG inpatient 1 UN 23490.92 15269.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 17044.01 999999999 9025.3 22786.19 case rate NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC 071 MS-DRG inpatient 1 UN 23490.92 15269.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 15879.86 67.6 999999999 9025.3 22786.19 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC 071 MS-DRG inpatient 1 UN 23490.92 15269.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 16096.89 999999999 9025.3 22786.19 case rate NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC 071 MS-DRG inpatient 1 UN 23490.92 15269.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14223.75 60.55 999999999 9025.3 22786.19 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC 071 MS-DRG inpatient 1 UN 23490.92 15269.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 16208.73 69 999999999 9025.3 22786.19 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC 071 MS-DRG inpatient 1 UN 23490.92 15269.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 15269.1 65 999999999 9025.3 22786.19 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC 071 MS-DRG inpatient 1 UN 23490.92 15269.1 AETNA AETNA 18557.83 79 999999999 9025.3 22786.19 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC 071 MS-DRG inpatient 1 UN 23490.92 15269.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22786.19 97 999999999 9025.3 22786.19 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC 071 MS-DRG inpatient 1 UN 23490.92 15269.1 UMR - ALL PLANS UMR - ALL PLANS 16443.64 70 999999999 9025.3 22786.19 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC 071 MS-DRG inpatient 1 UN 23490.92 15269.1 UHC - ALL PLANS UHC - ALL PLANS 9025.3 999999999 9025.3 22786.19 case rate NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC 071 MS-DRG inpatient 1 UN 23490.92 15269.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 14487.2 999999999 9025.3 22786.19 case rate NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC 071 MS-DRG inpatient 1 UN 23490.92 15269.1 ANTHEM HMO ANTHEM HMO 15148.7 999999999 9025.3 22786.19 case rate NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC 071 MS-DRG inpatient 1 UN 23490.92 15269.1 SIHO - ALL PLANS SIHO - ALL PLANS 21141.83 90 999999999 9025.3 22786.19 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC 071 MS-DRG inpatient 1 UN 23490.92 15269.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 18322.92 78 999999999 9025.3 22786.19 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC 072 MS-DRG inpatient 1 UN 33294.32 21641.31 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32295.49 97 999999999 6655.5 32295.49 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC 072 MS-DRG inpatient 1 UN 33294.32 21641.31 UMR - ALL PLANS UMR - ALL PLANS 23306.02 70 999999999 6655.5 32295.49 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC 072 MS-DRG inpatient 1 UN 33294.32 21641.31 AETNA AETNA 26302.51 79 999999999 6655.5 32295.49 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC 072 MS-DRG inpatient 1 UN 33294.32 21641.31 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12568.72 999999999 6655.5 32295.49 case rate NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC 072 MS-DRG inpatient 1 UN 33294.32 21641.31 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20159.71 60.55 999999999 6655.5 32295.49 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC 072 MS-DRG inpatient 1 UN 33294.32 21641.31 HUMANA - ALL PLANS HUMANA - ALL PLANS 25969.57 78 999999999 6655.5 32295.49 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC 072 MS-DRG inpatient 1 UN 33294.32 21641.31 ENCORE - ALL PLANS ENCORE - ALL PLANS 22973.08 69 999999999 6655.5 32295.49 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC 072 MS-DRG inpatient 1 UN 33294.32 21641.31 SELF PAY DISCOUNT SELF PAY DISCOUNT 21641.31 65 999999999 6655.5 32295.49 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC 072 MS-DRG inpatient 1 UN 33294.32 21641.31 UHC - ALL PLANS UHC - ALL PLANS 6655.5 999999999 6655.5 32295.49 case rate NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC 072 MS-DRG inpatient 1 UN 33294.32 21641.31 SIHO - ALL PLANS SIHO - ALL PLANS 29964.89 90 999999999 6655.5 32295.49 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC 072 MS-DRG inpatient 1 UN 33294.32 21641.31 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10683.25 999999999 6655.5 32295.49 case rate NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC 072 MS-DRG inpatient 1 UN 33294.32 21641.31 CIGNA - ALL PLANS CIGNA - ALL PLANS 22506.96 67.6 999999999 6655.5 32295.49 percent of total billed charges NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC 072 MS-DRG inpatient 1 UN 33294.32 21641.31 ANTHEM HMO ANTHEM HMO 11171.06 999999999 6655.5 32295.49 case rate NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC 072 MS-DRG inpatient 1 UN 33294.32 21641.31 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 11870.28 999999999 6655.5 32295.49 case rate CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC 074 MS-DRG inpatient 1 UN 21918.09 14246.76 SELF PAY DISCOUNT SELF PAY DISCOUNT 14246.76 65 999999999 8722.7 21260.54 percent of total billed charges CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC 074 MS-DRG inpatient 1 UN 21918.09 14246.76 UMR - ALL PLANS UMR - ALL PLANS 15342.66 70 999999999 8722.7 21260.54 percent of total billed charges CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC 074 MS-DRG inpatient 1 UN 21918.09 14246.76 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21260.54 97 999999999 8722.7 21260.54 percent of total billed charges CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC 074 MS-DRG inpatient 1 UN 21918.09 14246.76 SIHO - ALL PLANS SIHO - ALL PLANS 19726.28 90 999999999 8722.7 21260.54 percent of total billed charges CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC 074 MS-DRG inpatient 1 UN 21918.09 14246.76 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 16472.56 999999999 8722.7 21260.54 case rate CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC 074 MS-DRG inpatient 1 UN 21918.09 14246.76 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 15557.19 999999999 8722.7 21260.54 case rate CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC 074 MS-DRG inpatient 1 UN 21918.09 14246.76 ANTHEM HMO ANTHEM HMO 14640.8 999999999 8722.7 21260.54 case rate CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC 074 MS-DRG inpatient 1 UN 21918.09 14246.76 CIGNA - ALL PLANS CIGNA - ALL PLANS 14816.63 67.6 999999999 8722.7 21260.54 percent of total billed charges CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC 074 MS-DRG inpatient 1 UN 21918.09 14246.76 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 14001.47 999999999 8722.7 21260.54 case rate CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC 074 MS-DRG inpatient 1 UN 21918.09 14246.76 AETNA AETNA 17315.29 79 999999999 8722.7 21260.54 percent of total billed charges CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC 074 MS-DRG inpatient 1 UN 21918.09 14246.76 HUMANA - ALL PLANS HUMANA - ALL PLANS 17096.11 78 999999999 8722.7 21260.54 percent of total billed charges CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC 074 MS-DRG inpatient 1 UN 21918.09 14246.76 ENCORE - ALL PLANS ENCORE - ALL PLANS 15123.48 69 999999999 8722.7 21260.54 percent of total billed charges CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC 074 MS-DRG inpatient 1 UN 21918.09 14246.76 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13271.4 60.55 999999999 8722.7 21260.54 percent of total billed charges CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC 074 MS-DRG inpatient 1 UN 21918.09 14246.76 UHC - ALL PLANS UHC - ALL PLANS 8722.7 999999999 8722.7 21260.54 case rate HYPERTENSIVE ENCEPHALOPATHY WITH MCC 077 MS-DRG inpatient 1 UN 52849.57 34352.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32000.41 60.55 999999999 12842.65 51264.08 percent of total billed charges HYPERTENSIVE ENCEPHALOPATHY WITH MCC 077 MS-DRG inpatient 1 UN 52849.57 34352.22 UMR - ALL PLANS UMR - ALL PLANS 36994.7 70 999999999 12842.65 51264.08 percent of total billed charges HYPERTENSIVE ENCEPHALOPATHY WITH MCC 077 MS-DRG inpatient 1 UN 52849.57 34352.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 41222.66 78 999999999 12842.65 51264.08 percent of total billed charges HYPERTENSIVE ENCEPHALOPATHY WITH MCC 077 MS-DRG inpatient 1 UN 52849.57 34352.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 36466.2 69 999999999 12842.65 51264.08 percent of total billed charges HYPERTENSIVE ENCEPHALOPATHY WITH MCC 077 MS-DRG inpatient 1 UN 52849.57 34352.22 AETNA AETNA 41751.16 79 999999999 12842.65 51264.08 percent of total billed charges HYPERTENSIVE ENCEPHALOPATHY WITH MCC 077 MS-DRG inpatient 1 UN 52849.57 34352.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 22905.24 999999999 12842.65 51264.08 case rate HYPERTENSIVE ENCEPHALOPATHY WITH MCC 077 MS-DRG inpatient 1 UN 52849.57 34352.22 ANTHEM HMO ANTHEM HMO 21556.01 999999999 12842.65 51264.08 case rate HYPERTENSIVE ENCEPHALOPATHY WITH MCC 077 MS-DRG inpatient 1 UN 52849.57 34352.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 24252.97 999999999 12842.65 51264.08 case rate HYPERTENSIVE ENCEPHALOPATHY WITH MCC 077 MS-DRG inpatient 1 UN 52849.57 34352.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 35726.31 67.6 999999999 12842.65 51264.08 percent of total billed charges HYPERTENSIVE ENCEPHALOPATHY WITH MCC 077 MS-DRG inpatient 1 UN 52849.57 34352.22 SIHO - ALL PLANS SIHO - ALL PLANS 47564.61 90 999999999 12842.65 51264.08 percent of total billed charges HYPERTENSIVE ENCEPHALOPATHY WITH MCC 077 MS-DRG inpatient 1 UN 52849.57 34352.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51264.08 97 999999999 12842.65 51264.08 percent of total billed charges HYPERTENSIVE ENCEPHALOPATHY WITH MCC 077 MS-DRG inpatient 1 UN 52849.57 34352.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 34352.22 65 999999999 12842.65 51264.08 percent of total billed charges HYPERTENSIVE ENCEPHALOPATHY WITH MCC 077 MS-DRG inpatient 1 UN 52849.57 34352.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 20614.72 999999999 12842.65 51264.08 case rate HYPERTENSIVE ENCEPHALOPATHY WITH MCC 077 MS-DRG inpatient 1 UN 52849.57 34352.22 UHC - ALL PLANS UHC - ALL PLANS 12842.65 999999999 12842.65 51264.08 case rate NONTRAUMATIC STUPOR AND COMA WITHOUT MCC 081 MS-DRG inpatient 1 UN 40394.55 26256.46 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 14599.29 999999999 7730.75 39182.71 case rate NONTRAUMATIC STUPOR AND COMA WITHOUT MCC 081 MS-DRG inpatient 1 UN 40394.55 26256.46 CIGNA - ALL PLANS CIGNA - ALL PLANS 27306.72 67.6 999999999 7730.75 39182.71 percent of total billed charges NONTRAUMATIC STUPOR AND COMA WITHOUT MCC 081 MS-DRG inpatient 1 UN 40394.55 26256.46 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13788.02 999999999 7730.75 39182.71 case rate NONTRAUMATIC STUPOR AND COMA WITHOUT MCC 081 MS-DRG inpatient 1 UN 40394.55 26256.46 AETNA AETNA 31911.69 79 999999999 7730.75 39182.71 percent of total billed charges NONTRAUMATIC STUPOR AND COMA WITHOUT MCC 081 MS-DRG inpatient 1 UN 40394.55 26256.46 SELF PAY DISCOUNT SELF PAY DISCOUNT 26256.46 65 999999999 7730.75 39182.71 percent of total billed charges NONTRAUMATIC STUPOR AND COMA WITHOUT MCC 081 MS-DRG inpatient 1 UN 40394.55 26256.46 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24458.9 60.55 999999999 7730.75 39182.71 percent of total billed charges NONTRAUMATIC STUPOR AND COMA WITHOUT MCC 081 MS-DRG inpatient 1 UN 40394.55 26256.46 ENCORE - ALL PLANS ENCORE - ALL PLANS 27872.24 69 999999999 7730.75 39182.71 percent of total billed charges NONTRAUMATIC STUPOR AND COMA WITHOUT MCC 081 MS-DRG inpatient 1 UN 40394.55 26256.46 UMR - ALL PLANS UMR - ALL PLANS 28276.19 70 999999999 7730.75 39182.71 percent of total billed charges NONTRAUMATIC STUPOR AND COMA WITHOUT MCC 081 MS-DRG inpatient 1 UN 40394.55 26256.46 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39182.71 97 999999999 7730.75 39182.71 percent of total billed charges NONTRAUMATIC STUPOR AND COMA WITHOUT MCC 081 MS-DRG inpatient 1 UN 40394.55 26256.46 UHC - ALL PLANS UHC - ALL PLANS 7730.75 999999999 7730.75 39182.71 case rate NONTRAUMATIC STUPOR AND COMA WITHOUT MCC 081 MS-DRG inpatient 1 UN 40394.55 26256.46 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 12409.22 999999999 7730.75 39182.71 case rate NONTRAUMATIC STUPOR AND COMA WITHOUT MCC 081 MS-DRG inpatient 1 UN 40394.55 26256.46 ANTHEM HMO ANTHEM HMO 12975.84 999999999 7730.75 39182.71 case rate NONTRAUMATIC STUPOR AND COMA WITHOUT MCC 081 MS-DRG inpatient 1 UN 40394.55 26256.46 SIHO - ALL PLANS SIHO - ALL PLANS 36355.1 90 999999999 7730.75 39182.71 percent of total billed charges NONTRAUMATIC STUPOR AND COMA WITHOUT MCC 081 MS-DRG inpatient 1 UN 40394.55 26256.46 HUMANA - ALL PLANS HUMANA - ALL PLANS 31507.75 78 999999999 7730.75 39182.71 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC 091 MS-DRG inpatient 1 UN 47635.26 30962.92 SIHO - ALL PLANS SIHO - ALL PLANS 42871.73 90 999999999 15208.2 46206.2 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC 091 MS-DRG inpatient 1 UN 47635.26 30962.92 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 24411.84 999999999 15208.2 46206.2 case rate OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC 091 MS-DRG inpatient 1 UN 47635.26 30962.92 UHC - ALL PLANS UHC - ALL PLANS 15208.2 999999999 15208.2 46206.2 case rate OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC 091 MS-DRG inpatient 1 UN 47635.26 30962.92 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 46206.2 97 999999999 15208.2 46206.2 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC 091 MS-DRG inpatient 1 UN 47635.26 30962.92 UMR - ALL PLANS UMR - ALL PLANS 33344.68 70 999999999 15208.2 46206.2 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC 091 MS-DRG inpatient 1 UN 47635.26 30962.92 ENCORE - ALL PLANS ENCORE - ALL PLANS 32868.33 69 999999999 15208.2 46206.2 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC 091 MS-DRG inpatient 1 UN 47635.26 30962.92 HUMANA - ALL PLANS HUMANA - ALL PLANS 37155.5 78 999999999 15208.2 46206.2 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC 091 MS-DRG inpatient 1 UN 47635.26 30962.92 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 28843.15 60.55 999999999 15208.2 46206.2 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC 091 MS-DRG inpatient 1 UN 47635.26 30962.92 SELF PAY DISCOUNT SELF PAY DISCOUNT 30962.92 65 999999999 15208.2 46206.2 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC 091 MS-DRG inpatient 1 UN 47635.26 30962.92 AETNA AETNA 37631.85 79 999999999 15208.2 46206.2 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC 091 MS-DRG inpatient 1 UN 47635.26 30962.92 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 27124.27 999999999 15208.2 46206.2 case rate OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC 091 MS-DRG inpatient 1 UN 47635.26 30962.92 ANTHEM HMO ANTHEM HMO 25526.52 999999999 15208.2 46206.2 case rate OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC 091 MS-DRG inpatient 1 UN 47635.26 30962.92 CIGNA - ALL PLANS CIGNA - ALL PLANS 32201.43 67.6 999999999 15208.2 46206.2 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC 091 MS-DRG inpatient 1 UN 47635.26 30962.92 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 28720.24 999999999 15208.2 46206.2 case rate OTHER DISORDERS OF NERVOUS SYSTEM WITH CC 092 MS-DRG inpatient 1 UN 21972.35 14282.03 CIGNA - ALL PLANS CIGNA - ALL PLANS 14853.31 67.6 999999999 8721.85 21313.18 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITH CC 092 MS-DRG inpatient 1 UN 21972.35 14282.03 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 14000.11 999999999 8721.85 21313.18 case rate OTHER DISORDERS OF NERVOUS SYSTEM WITH CC 092 MS-DRG inpatient 1 UN 21972.35 14282.03 ANTHEM HMO ANTHEM HMO 14639.37 999999999 8721.85 21313.18 case rate OTHER DISORDERS OF NERVOUS SYSTEM WITH CC 092 MS-DRG inpatient 1 UN 21972.35 14282.03 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 15555.68 999999999 8721.85 21313.18 case rate OTHER DISORDERS OF NERVOUS SYSTEM WITH CC 092 MS-DRG inpatient 1 UN 21972.35 14282.03 UHC - ALL PLANS UHC - ALL PLANS 8721.85 999999999 8721.85 21313.18 case rate OTHER DISORDERS OF NERVOUS SYSTEM WITH CC 092 MS-DRG inpatient 1 UN 21972.35 14282.03 SIHO - ALL PLANS SIHO - ALL PLANS 19775.12 90 999999999 8721.85 21313.18 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITH CC 092 MS-DRG inpatient 1 UN 21972.35 14282.03 HUMANA - ALL PLANS HUMANA - ALL PLANS 17138.43 78 999999999 8721.85 21313.18 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITH CC 092 MS-DRG inpatient 1 UN 21972.35 14282.03 ENCORE - ALL PLANS ENCORE - ALL PLANS 15160.92 69 999999999 8721.85 21313.18 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITH CC 092 MS-DRG inpatient 1 UN 21972.35 14282.03 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13304.26 60.55 999999999 8721.85 21313.18 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITH CC 092 MS-DRG inpatient 1 UN 21972.35 14282.03 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 16470.96 999999999 8721.85 21313.18 case rate OTHER DISORDERS OF NERVOUS SYSTEM WITH CC 092 MS-DRG inpatient 1 UN 21972.35 14282.03 AETNA AETNA 17358.16 79 999999999 8721.85 21313.18 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITH CC 092 MS-DRG inpatient 1 UN 21972.35 14282.03 SELF PAY DISCOUNT SELF PAY DISCOUNT 14282.03 65 999999999 8721.85 21313.18 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITH CC 092 MS-DRG inpatient 1 UN 21972.35 14282.03 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21313.18 97 999999999 8721.85 21313.18 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITH CC 092 MS-DRG inpatient 1 UN 21972.35 14282.03 UMR - ALL PLANS UMR - ALL PLANS 15380.65 70 999999999 8721.85 21313.18 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 093 MS-DRG inpatient 1 UN 32930.97 21405.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 22722.37 69 999999999 6582.4 31943.04 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 093 MS-DRG inpatient 1 UN 32930.97 21405.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19939.7 60.55 999999999 6582.4 31943.04 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 093 MS-DRG inpatient 1 UN 32930.97 21405.13 AETNA AETNA 26015.47 79 999999999 6582.4 31943.04 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 093 MS-DRG inpatient 1 UN 32930.97 21405.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 25686.16 78 999999999 6582.4 31943.04 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 093 MS-DRG inpatient 1 UN 32930.97 21405.13 ANTHEM HMO ANTHEM HMO 11048.36 999999999 6582.4 31943.04 case rate OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 093 MS-DRG inpatient 1 UN 32930.97 21405.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 11739.9 999999999 6582.4 31943.04 case rate OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 093 MS-DRG inpatient 1 UN 32930.97 21405.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 22261.34 67.6 999999999 6582.4 31943.04 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 093 MS-DRG inpatient 1 UN 32930.97 21405.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10565.91 999999999 6582.4 31943.04 case rate OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 093 MS-DRG inpatient 1 UN 32930.97 21405.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12430.67 999999999 6582.4 31943.04 case rate OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 093 MS-DRG inpatient 1 UN 32930.97 21405.13 SIHO - ALL PLANS SIHO - ALL PLANS 29637.87 90 999999999 6582.4 31943.04 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 093 MS-DRG inpatient 1 UN 32930.97 21405.13 UMR - ALL PLANS UMR - ALL PLANS 23051.68 70 999999999 6582.4 31943.04 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 093 MS-DRG inpatient 1 UN 32930.97 21405.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31943.04 97 999999999 6582.4 31943.04 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 093 MS-DRG inpatient 1 UN 32930.97 21405.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 21405.13 65 999999999 6582.4 31943.04 percent of total billed charges OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC 093 MS-DRG inpatient 1 UN 32930.97 21405.13 UHC - ALL PLANS UHC - ALL PLANS 6582.4 999999999 6582.4 31943.04 case rate BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC 096 MS-DRG inpatient 1 UN 61477.64 39960.47 UHC - ALL PLANS UHC - ALL PLANS 18527.45 999999999 18527.45 59633.31 case rate BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC 096 MS-DRG inpatient 1 UN 61477.64 39960.47 SELF PAY DISCOUNT SELF PAY DISCOUNT 39960.47 65 999999999 18527.45 59633.31 percent of total billed charges BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC 096 MS-DRG inpatient 1 UN 61477.64 39960.47 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 29739.83 999999999 18527.45 59633.31 case rate BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC 096 MS-DRG inpatient 1 UN 61477.64 39960.47 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59633.31 97 999999999 18527.45 59633.31 percent of total billed charges BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC 096 MS-DRG inpatient 1 UN 61477.64 39960.47 SIHO - ALL PLANS SIHO - ALL PLANS 55329.88 90 999999999 18527.45 59633.31 percent of total billed charges BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC 096 MS-DRG inpatient 1 UN 61477.64 39960.47 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 34988.54 999999999 18527.45 59633.31 case rate BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC 096 MS-DRG inpatient 1 UN 61477.64 39960.47 CIGNA - ALL PLANS CIGNA - ALL PLANS 41558.88 67.6 999999999 18527.45 59633.31 percent of total billed charges BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC 096 MS-DRG inpatient 1 UN 61477.64 39960.47 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 33044.25 999999999 18527.45 59633.31 case rate BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC 096 MS-DRG inpatient 1 UN 61477.64 39960.47 ANTHEM HMO ANTHEM HMO 31097.78 999999999 18527.45 59633.31 case rate BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC 096 MS-DRG inpatient 1 UN 61477.64 39960.47 HUMANA - ALL PLANS HUMANA - ALL PLANS 47952.56 78 999999999 18527.45 59633.31 percent of total billed charges BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC 096 MS-DRG inpatient 1 UN 61477.64 39960.47 ENCORE - ALL PLANS ENCORE - ALL PLANS 42419.57 69 999999999 18527.45 59633.31 percent of total billed charges BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC 096 MS-DRG inpatient 1 UN 61477.64 39960.47 AETNA AETNA 48567.34 79 999999999 18527.45 59633.31 percent of total billed charges BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC 096 MS-DRG inpatient 1 UN 61477.64 39960.47 UMR - ALL PLANS UMR - ALL PLANS 43034.35 70 999999999 18527.45 59633.31 percent of total billed charges BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC 096 MS-DRG inpatient 1 UN 61477.64 39960.47 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 37224.71 60.55 999999999 18527.45 59633.31 percent of total billed charges NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC 097 MS-DRG inpatient 1 UN 43250.71 28112.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 33735.55 78 999999999 26188.3 43250.71 percent of total billed charges NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC 097 MS-DRG inpatient 1 UN 43250.71 28112.96 UHC - ALL PLANS UHC - ALL PLANS 30913.65 999999999 26188.3 43250.71 case rate NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC 097 MS-DRG inpatient 1 UN 43250.71 28112.96 SIHO - ALL PLANS SIHO - ALL PLANS 38925.64 90 999999999 26188.3 43250.71 percent of total billed charges NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC 097 MS-DRG inpatient 1 UN 43250.71 28112.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 43250.71 999999999 26188.3 43250.71 case rate NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC 097 MS-DRG inpatient 1 UN 43250.71 28112.96 ANTHEM HMO ANTHEM HMO 43250.71 999999999 26188.3 43250.71 case rate NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC 097 MS-DRG inpatient 1 UN 43250.71 28112.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 43250.71 999999999 26188.3 43250.71 case rate NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC 097 MS-DRG inpatient 1 UN 43250.71 28112.96 UMR - ALL PLANS UMR - ALL PLANS 30275.5 70 999999999 26188.3 43250.71 percent of total billed charges NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC 097 MS-DRG inpatient 1 UN 43250.71 28112.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 41953.19 97 999999999 26188.3 43250.71 percent of total billed charges NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC 097 MS-DRG inpatient 1 UN 43250.71 28112.96 AETNA AETNA 34168.06 79 999999999 26188.3 43250.71 percent of total billed charges NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC 097 MS-DRG inpatient 1 UN 43250.71 28112.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 28112.96 65 999999999 26188.3 43250.71 percent of total billed charges NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC 097 MS-DRG inpatient 1 UN 43250.71 28112.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26188.3 60.55 999999999 26188.3 43250.71 percent of total billed charges NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC 097 MS-DRG inpatient 1 UN 43250.71 28112.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 29842.99 69 999999999 26188.3 43250.71 percent of total billed charges NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC 097 MS-DRG inpatient 1 UN 43250.71 28112.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 43250.71 999999999 26188.3 43250.71 case rate NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC 097 MS-DRG inpatient 1 UN 43250.71 28112.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 29237.48 67.6 999999999 26188.3 43250.71 percent of total billed charges SEIZURES WITH MCC 100 MS-DRG inpatient 1 UN 36332.78 23616.31 CIGNA - ALL PLANS CIGNA - ALL PLANS 24560.96 67.6 999999999 16851.25 35242.8 percent of total billed charges SEIZURES WITH MCC 100 MS-DRG inpatient 1 UN 36332.78 23616.31 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 31823.09 999999999 16851.25 35242.8 case rate SEIZURES WITH MCC 100 MS-DRG inpatient 1 UN 36332.78 23616.31 ENCORE - ALL PLANS ENCORE - ALL PLANS 25069.62 69 999999999 16851.25 35242.8 percent of total billed charges SEIZURES WITH MCC 100 MS-DRG inpatient 1 UN 36332.78 23616.31 HUMANA - ALL PLANS HUMANA - ALL PLANS 28339.57 78 999999999 16851.25 35242.8 percent of total billed charges SEIZURES WITH MCC 100 MS-DRG inpatient 1 UN 36332.78 23616.31 SELF PAY DISCOUNT SELF PAY DISCOUNT 23616.31 65 999999999 16851.25 35242.8 percent of total billed charges SEIZURES WITH MCC 100 MS-DRG inpatient 1 UN 36332.78 23616.31 SIHO - ALL PLANS SIHO - ALL PLANS 32699.5 90 999999999 16851.25 35242.8 percent of total billed charges SEIZURES WITH MCC 100 MS-DRG inpatient 1 UN 36332.78 23616.31 UHC - ALL PLANS UHC - ALL PLANS 16851.25 999999999 16851.25 35242.8 case rate SEIZURES WITH MCC 100 MS-DRG inpatient 1 UN 36332.78 23616.31 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 27049.23 999999999 16851.25 35242.8 case rate SEIZURES WITH MCC 100 MS-DRG inpatient 1 UN 36332.78 23616.31 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 30054.7 999999999 16851.25 35242.8 case rate SEIZURES WITH MCC 100 MS-DRG inpatient 1 UN 36332.78 23616.31 ANTHEM HMO ANTHEM HMO 28284.33 999999999 16851.25 35242.8 case rate SEIZURES WITH MCC 100 MS-DRG inpatient 1 UN 36332.78 23616.31 AETNA AETNA 28702.9 79 999999999 16851.25 35242.8 percent of total billed charges SEIZURES WITH MCC 100 MS-DRG inpatient 1 UN 36332.78 23616.31 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35242.8 97 999999999 16851.25 35242.8 percent of total billed charges SEIZURES WITH MCC 100 MS-DRG inpatient 1 UN 36332.78 23616.31 UMR - ALL PLANS UMR - ALL PLANS 25432.95 70 999999999 16851.25 35242.8 percent of total billed charges SEIZURES WITH MCC 100 MS-DRG inpatient 1 UN 36332.78 23616.31 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21999.5 60.55 999999999 16851.25 35242.8 percent of total billed charges SEIZURES WITHOUT MCC 101 MS-DRG inpatient 1 UN 19839.08 12895.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12012.56 60.55 999999999 7731.6 19243.91 percent of total billed charges SEIZURES WITHOUT MCC 101 MS-DRG inpatient 1 UN 19839.08 12895.4 UHC - ALL PLANS UHC - ALL PLANS 7731.6 999999999 7731.6 19243.91 case rate SEIZURES WITHOUT MCC 101 MS-DRG inpatient 1 UN 19839.08 12895.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 13688.97 69 999999999 7731.6 19243.91 percent of total billed charges SEIZURES WITHOUT MCC 101 MS-DRG inpatient 1 UN 19839.08 12895.4 UMR - ALL PLANS UMR - ALL PLANS 13887.36 70 999999999 7731.6 19243.91 percent of total billed charges SEIZURES WITHOUT MCC 101 MS-DRG inpatient 1 UN 19839.08 12895.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19243.91 97 999999999 7731.6 19243.91 percent of total billed charges SEIZURES WITHOUT MCC 101 MS-DRG inpatient 1 UN 19839.08 12895.4 AETNA AETNA 15672.88 79 999999999 7731.6 19243.91 percent of total billed charges SEIZURES WITHOUT MCC 101 MS-DRG inpatient 1 UN 19839.08 12895.4 ANTHEM HMO ANTHEM HMO 12977.26 999999999 7731.6 19243.91 case rate SEIZURES WITHOUT MCC 101 MS-DRG inpatient 1 UN 19839.08 12895.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 13411.22 67.6 999999999 7731.6 19243.91 percent of total billed charges SEIZURES WITHOUT MCC 101 MS-DRG inpatient 1 UN 19839.08 12895.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 12410.58 999999999 7731.6 19243.91 case rate SEIZURES WITHOUT MCC 101 MS-DRG inpatient 1 UN 19839.08 12895.4 SIHO - ALL PLANS SIHO - ALL PLANS 17855.17 90 999999999 7731.6 19243.91 percent of total billed charges SEIZURES WITHOUT MCC 101 MS-DRG inpatient 1 UN 19839.08 12895.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 12895.4 65 999999999 7731.6 19243.91 percent of total billed charges SEIZURES WITHOUT MCC 101 MS-DRG inpatient 1 UN 19839.08 12895.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 15474.48 78 999999999 7731.6 19243.91 percent of total billed charges SEIZURES WITHOUT MCC 101 MS-DRG inpatient 1 UN 19839.08 12895.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 14600.9 999999999 7731.6 19243.91 case rate SEIZURES WITHOUT MCC 101 MS-DRG inpatient 1 UN 19839.08 12895.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13789.54 999999999 7731.6 19243.91 case rate HEADACHES WITHOUT MCC 103 MS-DRG inpatient 1 UN 42131.56 27385.51 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 13522.2 999999999 7160.4 40867.61 case rate HEADACHES WITHOUT MCC 103 MS-DRG inpatient 1 UN 42131.56 27385.51 CIGNA - ALL PLANS CIGNA - ALL PLANS 28480.93 67.6 999999999 7160.4 40867.61 percent of total billed charges HEADACHES WITHOUT MCC 103 MS-DRG inpatient 1 UN 42131.56 27385.51 HUMANA - ALL PLANS HUMANA - ALL PLANS 32862.62 78 999999999 7160.4 40867.61 percent of total billed charges HEADACHES WITHOUT MCC 103 MS-DRG inpatient 1 UN 42131.56 27385.51 ENCORE - ALL PLANS ENCORE - ALL PLANS 29070.78 69 999999999 7160.4 40867.61 percent of total billed charges HEADACHES WITHOUT MCC 103 MS-DRG inpatient 1 UN 42131.56 27385.51 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 25510.66 60.55 999999999 7160.4 40867.61 percent of total billed charges HEADACHES WITHOUT MCC 103 MS-DRG inpatient 1 UN 42131.56 27385.51 AETNA AETNA 33283.93 79 999999999 7160.4 40867.61 percent of total billed charges HEADACHES WITHOUT MCC 103 MS-DRG inpatient 1 UN 42131.56 27385.51 SIHO - ALL PLANS SIHO - ALL PLANS 37918.4 90 999999999 7160.4 40867.61 percent of total billed charges HEADACHES WITHOUT MCC 103 MS-DRG inpatient 1 UN 42131.56 27385.51 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 11493.71 999999999 7160.4 40867.61 case rate HEADACHES WITHOUT MCC 103 MS-DRG inpatient 1 UN 42131.56 27385.51 UHC - ALL PLANS UHC - ALL PLANS 7160.4 999999999 7160.4 40867.61 case rate HEADACHES WITHOUT MCC 103 MS-DRG inpatient 1 UN 42131.56 27385.51 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 12770.78 999999999 7160.4 40867.61 case rate HEADACHES WITHOUT MCC 103 MS-DRG inpatient 1 UN 42131.56 27385.51 ANTHEM HMO ANTHEM HMO 12018.52 999999999 7160.4 40867.61 case rate HEADACHES WITHOUT MCC 103 MS-DRG inpatient 1 UN 42131.56 27385.51 SELF PAY DISCOUNT SELF PAY DISCOUNT 27385.51 65 999999999 7160.4 40867.61 percent of total billed charges HEADACHES WITHOUT MCC 103 MS-DRG inpatient 1 UN 42131.56 27385.51 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 40867.61 97 999999999 7160.4 40867.61 percent of total billed charges HEADACHES WITHOUT MCC 103 MS-DRG inpatient 1 UN 42131.56 27385.51 UMR - ALL PLANS UMR - ALL PLANS 29492.09 70 999999999 7160.4 40867.61 percent of total billed charges OTHER DISORDERS OF THE EYE WITHOUT MCC 125 MS-DRG inpatient 1 UN 26842 17447.3 SIHO - ALL PLANS SIHO - ALL PLANS 24157.8 90 999999999 6778.75 26036.74 percent of total billed charges OTHER DISORDERS OF THE EYE WITHOUT MCC 125 MS-DRG inpatient 1 UN 26842 17447.3 HUMANA - ALL PLANS HUMANA - ALL PLANS 20936.76 78 999999999 6778.75 26036.74 percent of total billed charges OTHER DISORDERS OF THE EYE WITHOUT MCC 125 MS-DRG inpatient 1 UN 26842 17447.3 UHC - ALL PLANS UHC - ALL PLANS 6778.75 999999999 6778.75 26036.74 case rate OTHER DISORDERS OF THE EYE WITHOUT MCC 125 MS-DRG inpatient 1 UN 26842 17447.3 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10881.09 999999999 6778.75 26036.74 case rate OTHER DISORDERS OF THE EYE WITHOUT MCC 125 MS-DRG inpatient 1 UN 26842 17447.3 ANTHEM HMO ANTHEM HMO 11377.93 999999999 6778.75 26036.74 case rate OTHER DISORDERS OF THE EYE WITHOUT MCC 125 MS-DRG inpatient 1 UN 26842 17447.3 UMR - ALL PLANS UMR - ALL PLANS 18789.4 70 999999999 6778.75 26036.74 percent of total billed charges OTHER DISORDERS OF THE EYE WITHOUT MCC 125 MS-DRG inpatient 1 UN 26842 17447.3 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26036.74 97 999999999 6778.75 26036.74 percent of total billed charges OTHER DISORDERS OF THE EYE WITHOUT MCC 125 MS-DRG inpatient 1 UN 26842 17447.3 AETNA AETNA 21205.18 79 999999999 6778.75 26036.74 percent of total billed charges OTHER DISORDERS OF THE EYE WITHOUT MCC 125 MS-DRG inpatient 1 UN 26842 17447.3 SELF PAY DISCOUNT SELF PAY DISCOUNT 17447.3 65 999999999 6778.75 26036.74 percent of total billed charges OTHER DISORDERS OF THE EYE WITHOUT MCC 125 MS-DRG inpatient 1 UN 26842 17447.3 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16252.83 60.55 999999999 6778.75 26036.74 percent of total billed charges OTHER DISORDERS OF THE EYE WITHOUT MCC 125 MS-DRG inpatient 1 UN 26842 17447.3 ENCORE - ALL PLANS ENCORE - ALL PLANS 18520.98 69 999999999 6778.75 26036.74 percent of total billed charges OTHER DISORDERS OF THE EYE WITHOUT MCC 125 MS-DRG inpatient 1 UN 26842 17447.3 CIGNA - ALL PLANS CIGNA - ALL PLANS 18145.19 67.6 999999999 6778.75 26036.74 percent of total billed charges OTHER DISORDERS OF THE EYE WITHOUT MCC 125 MS-DRG inpatient 1 UN 26842 17447.3 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12801.47 999999999 6778.75 26036.74 case rate OTHER DISORDERS OF THE EYE WITHOUT MCC 125 MS-DRG inpatient 1 UN 26842 17447.3 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 12090.1 999999999 6778.75 26036.74 case rate "OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC" 144 MS-DRG inpatient 1 UN 36045.87 23429.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 23429.82 65 999999999 14709.25 34964.49 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC" 144 MS-DRG inpatient 1 UN 36045.87 23429.82 UMR - ALL PLANS UMR - ALL PLANS 25232.11 70 999999999 14709.25 34964.49 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC" 144 MS-DRG inpatient 1 UN 36045.87 23429.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34964.49 97 999999999 14709.25 34964.49 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC" 144 MS-DRG inpatient 1 UN 36045.87 23429.82 SIHO - ALL PLANS SIHO - ALL PLANS 32441.28 90 999999999 14709.25 34964.49 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC" 144 MS-DRG inpatient 1 UN 36045.87 23429.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 26234.38 999999999 14709.25 34964.49 case rate "OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC" 144 MS-DRG inpatient 1 UN 36045.87 23429.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 27777.99 999999999 14709.25 34964.49 case rate "OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC" 144 MS-DRG inpatient 1 UN 36045.87 23429.82 AETNA AETNA 28476.24 79 999999999 14709.25 34964.49 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC" 144 MS-DRG inpatient 1 UN 36045.87 23429.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 28115.78 78 999999999 14709.25 34964.49 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC" 144 MS-DRG inpatient 1 UN 36045.87 23429.82 ANTHEM HMO ANTHEM HMO 24689.04 999999999 14709.25 34964.49 case rate "OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC" 144 MS-DRG inpatient 1 UN 36045.87 23429.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 24367.01 67.6 999999999 14709.25 34964.49 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC" 144 MS-DRG inpatient 1 UN 36045.87 23429.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 23610.94 999999999 14709.25 34964.49 case rate "OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC" 144 MS-DRG inpatient 1 UN 36045.87 23429.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 24871.65 69 999999999 14709.25 34964.49 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC" 144 MS-DRG inpatient 1 UN 36045.87 23429.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21825.77 60.55 999999999 14709.25 34964.49 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC" 144 MS-DRG inpatient 1 UN 36045.87 23429.82 UHC - ALL PLANS UHC - ALL PLANS 14709.25 999999999 14709.25 34964.49 case rate DYSEQUILIBRIUM 149 MS-DRG inpatient 1 UN 32978.18 21435.81 UHC - ALL PLANS UHC - ALL PLANS 6329.95 999999999 6329.95 31988.83 case rate DYSEQUILIBRIUM 149 MS-DRG inpatient 1 UN 32978.18 21435.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19968.29 60.55 999999999 6329.95 31988.83 percent of total billed charges DYSEQUILIBRIUM 149 MS-DRG inpatient 1 UN 32978.18 21435.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 22754.94 69 999999999 6329.95 31988.83 percent of total billed charges DYSEQUILIBRIUM 149 MS-DRG inpatient 1 UN 32978.18 21435.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 25722.98 78 999999999 6329.95 31988.83 percent of total billed charges DYSEQUILIBRIUM 149 MS-DRG inpatient 1 UN 32978.18 21435.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10160.69 999999999 6329.95 31988.83 case rate DYSEQUILIBRIUM 149 MS-DRG inpatient 1 UN 32978.18 21435.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 22293.25 67.6 999999999 6329.95 31988.83 percent of total billed charges DYSEQUILIBRIUM 149 MS-DRG inpatient 1 UN 32978.18 21435.81 SIHO - ALL PLANS SIHO - ALL PLANS 29680.36 90 999999999 6329.95 31988.83 percent of total billed charges DYSEQUILIBRIUM 149 MS-DRG inpatient 1 UN 32978.18 21435.81 AETNA AETNA 26052.76 79 999999999 6329.95 31988.83 percent of total billed charges DYSEQUILIBRIUM 149 MS-DRG inpatient 1 UN 32978.18 21435.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 11289.65 999999999 6329.95 31988.83 case rate DYSEQUILIBRIUM 149 MS-DRG inpatient 1 UN 32978.18 21435.81 ANTHEM HMO ANTHEM HMO 10624.63 999999999 6329.95 31988.83 case rate DYSEQUILIBRIUM 149 MS-DRG inpatient 1 UN 32978.18 21435.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31988.83 97 999999999 6329.95 31988.83 percent of total billed charges DYSEQUILIBRIUM 149 MS-DRG inpatient 1 UN 32978.18 21435.81 UMR - ALL PLANS UMR - ALL PLANS 23084.72 70 999999999 6329.95 31988.83 percent of total billed charges DYSEQUILIBRIUM 149 MS-DRG inpatient 1 UN 32978.18 21435.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 21435.81 65 999999999 6329.95 31988.83 percent of total billed charges DYSEQUILIBRIUM 149 MS-DRG inpatient 1 UN 32978.18 21435.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 11953.92 999999999 6329.95 31988.83 case rate EPISTAXIS WITHOUT MCC 151 MS-DRG inpatient 1 UN 27044.92 17579.2 UHC - ALL PLANS UHC - ALL PLANS 6550.95 999999999 6550.95 26233.57 case rate EPISTAXIS WITHOUT MCC 151 MS-DRG inpatient 1 UN 27044.92 17579.2 SELF PAY DISCOUNT SELF PAY DISCOUNT 17579.2 65 999999999 6550.95 26233.57 percent of total billed charges EPISTAXIS WITHOUT MCC 151 MS-DRG inpatient 1 UN 27044.92 17579.2 UMR - ALL PLANS UMR - ALL PLANS 18931.44 70 999999999 6550.95 26233.57 percent of total billed charges EPISTAXIS WITHOUT MCC 151 MS-DRG inpatient 1 UN 27044.92 17579.2 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26233.57 97 999999999 6550.95 26233.57 percent of total billed charges EPISTAXIS WITHOUT MCC 151 MS-DRG inpatient 1 UN 27044.92 17579.2 SIHO - ALL PLANS SIHO - ALL PLANS 24340.43 90 999999999 6550.95 26233.57 percent of total billed charges EPISTAXIS WITHOUT MCC 151 MS-DRG inpatient 1 UN 27044.92 17579.2 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12371.28 999999999 6550.95 26233.57 case rate EPISTAXIS WITHOUT MCC 151 MS-DRG inpatient 1 UN 27044.92 17579.2 HUMANA - ALL PLANS HUMANA - ALL PLANS 21095.04 78 999999999 6550.95 26233.57 percent of total billed charges EPISTAXIS WITHOUT MCC 151 MS-DRG inpatient 1 UN 27044.92 17579.2 AETNA AETNA 21365.49 79 999999999 6550.95 26233.57 percent of total billed charges EPISTAXIS WITHOUT MCC 151 MS-DRG inpatient 1 UN 27044.92 17579.2 CIGNA - ALL PLANS CIGNA - ALL PLANS 18282.37 67.6 999999999 6550.95 26233.57 percent of total billed charges EPISTAXIS WITHOUT MCC 151 MS-DRG inpatient 1 UN 27044.92 17579.2 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 11683.81 999999999 6550.95 26233.57 case rate EPISTAXIS WITHOUT MCC 151 MS-DRG inpatient 1 UN 27044.92 17579.2 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10515.43 999999999 6550.95 26233.57 case rate EPISTAXIS WITHOUT MCC 151 MS-DRG inpatient 1 UN 27044.92 17579.2 ANTHEM HMO ANTHEM HMO 10995.58 999999999 6550.95 26233.57 case rate EPISTAXIS WITHOUT MCC 151 MS-DRG inpatient 1 UN 27044.92 17579.2 ENCORE - ALL PLANS ENCORE - ALL PLANS 18660.99 69 999999999 6550.95 26233.57 percent of total billed charges EPISTAXIS WITHOUT MCC 151 MS-DRG inpatient 1 UN 27044.92 17579.2 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16375.7 60.55 999999999 6550.95 26233.57 percent of total billed charges OTITIS MEDIA AND URI WITHOUT MCC 153 MS-DRG inpatient 1 UN 20444.84 13289.14 SIHO - ALL PLANS SIHO - ALL PLANS 18400.35 90 999999999 6245.8 19831.49 percent of total billed charges OTITIS MEDIA AND URI WITHOUT MCC 153 MS-DRG inpatient 1 UN 20444.84 13289.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 15946.97 78 999999999 6245.8 19831.49 percent of total billed charges OTITIS MEDIA AND URI WITHOUT MCC 153 MS-DRG inpatient 1 UN 20444.84 13289.14 AETNA AETNA 16151.42 79 999999999 6245.8 19831.49 percent of total billed charges OTITIS MEDIA AND URI WITHOUT MCC 153 MS-DRG inpatient 1 UN 20444.84 13289.14 ANTHEM HMO ANTHEM HMO 10483.39 999999999 6245.8 19831.49 case rate OTITIS MEDIA AND URI WITHOUT MCC 153 MS-DRG inpatient 1 UN 20444.84 13289.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10025.61 999999999 6245.8 19831.49 case rate OTITIS MEDIA AND URI WITHOUT MCC 153 MS-DRG inpatient 1 UN 20444.84 13289.14 UHC - ALL PLANS UHC - ALL PLANS 6245.8 999999999 6245.8 19831.49 case rate OTITIS MEDIA AND URI WITHOUT MCC 153 MS-DRG inpatient 1 UN 20444.84 13289.14 UMR - ALL PLANS UMR - ALL PLANS 14311.38 70 999999999 6245.8 19831.49 percent of total billed charges OTITIS MEDIA AND URI WITHOUT MCC 153 MS-DRG inpatient 1 UN 20444.84 13289.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19831.49 97 999999999 6245.8 19831.49 percent of total billed charges OTITIS MEDIA AND URI WITHOUT MCC 153 MS-DRG inpatient 1 UN 20444.84 13289.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 13289.14 65 999999999 6245.8 19831.49 percent of total billed charges OTITIS MEDIA AND URI WITHOUT MCC 153 MS-DRG inpatient 1 UN 20444.84 13289.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12379.35 60.55 999999999 6245.8 19831.49 percent of total billed charges OTITIS MEDIA AND URI WITHOUT MCC 153 MS-DRG inpatient 1 UN 20444.84 13289.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 14106.94 69 999999999 6245.8 19831.49 percent of total billed charges OTITIS MEDIA AND URI WITHOUT MCC 153 MS-DRG inpatient 1 UN 20444.84 13289.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 11795.01 999999999 6245.8 19831.49 case rate OTITIS MEDIA AND URI WITHOUT MCC 153 MS-DRG inpatient 1 UN 20444.84 13289.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 13820.71 67.6 999999999 6245.8 19831.49 percent of total billed charges OTITIS MEDIA AND URI WITHOUT MCC 153 MS-DRG inpatient 1 UN 20444.84 13289.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 11139.57 999999999 6245.8 19831.49 case rate "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC" 155 MS-DRG inpatient 1 UN 35480.91 23062.59 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 12915.41 999999999 8046.1 34416.48 case rate "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC" 155 MS-DRG inpatient 1 UN 35480.91 23062.59 ANTHEM HMO ANTHEM HMO 13505.14 999999999 8046.1 34416.48 case rate "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC" 155 MS-DRG inpatient 1 UN 35480.91 23062.59 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 14350.46 999999999 8046.1 34416.48 case rate "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC" 155 MS-DRG inpatient 1 UN 35480.91 23062.59 SIHO - ALL PLANS SIHO - ALL PLANS 31932.82 90 999999999 8046.1 34416.48 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC" 155 MS-DRG inpatient 1 UN 35480.91 23062.59 UHC - ALL PLANS UHC - ALL PLANS 8046.1 999999999 8046.1 34416.48 case rate "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC" 155 MS-DRG inpatient 1 UN 35480.91 23062.59 HUMANA - ALL PLANS HUMANA - ALL PLANS 27675.11 78 999999999 8046.1 34416.48 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC" 155 MS-DRG inpatient 1 UN 35480.91 23062.59 ENCORE - ALL PLANS ENCORE - ALL PLANS 24481.83 69 999999999 8046.1 34416.48 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC" 155 MS-DRG inpatient 1 UN 35480.91 23062.59 CIGNA - ALL PLANS CIGNA - ALL PLANS 23985.1 67.6 999999999 8046.1 34416.48 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC" 155 MS-DRG inpatient 1 UN 35480.91 23062.59 AETNA AETNA 28029.92 79 999999999 8046.1 34416.48 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC" 155 MS-DRG inpatient 1 UN 35480.91 23062.59 SELF PAY DISCOUNT SELF PAY DISCOUNT 23062.59 65 999999999 8046.1 34416.48 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC" 155 MS-DRG inpatient 1 UN 35480.91 23062.59 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 15194.82 999999999 8046.1 34416.48 case rate "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC" 155 MS-DRG inpatient 1 UN 35480.91 23062.59 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34416.48 97 999999999 8046.1 34416.48 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC" 155 MS-DRG inpatient 1 UN 35480.91 23062.59 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21483.69 60.55 999999999 8046.1 34416.48 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC" 155 MS-DRG inpatient 1 UN 35480.91 23062.59 UMR - ALL PLANS UMR - ALL PLANS 24836.64 70 999999999 8046.1 34416.48 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC" 156 MS-DRG inpatient 1 UN 18450.64 11992.91 SIHO - ALL PLANS SIHO - ALL PLANS 16605.57 90 999999999 5571.75 17897.12 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC" 156 MS-DRG inpatient 1 UN 18450.64 11992.91 AETNA AETNA 14576 79 999999999 5571.75 17897.12 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC" 156 MS-DRG inpatient 1 UN 18450.64 11992.91 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17897.12 97 999999999 5571.75 17897.12 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC" 156 MS-DRG inpatient 1 UN 18450.64 11992.91 UHC - ALL PLANS UHC - ALL PLANS 5571.75 999999999 5571.75 17897.12 case rate "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC" 156 MS-DRG inpatient 1 UN 18450.64 11992.91 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 8943.64 999999999 5571.75 17897.12 case rate "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC" 156 MS-DRG inpatient 1 UN 18450.64 11992.91 UMR - ALL PLANS UMR - ALL PLANS 12915.44 70 999999999 5571.75 17897.12 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC" 156 MS-DRG inpatient 1 UN 18450.64 11992.91 SELF PAY DISCOUNT SELF PAY DISCOUNT 11992.91 65 999999999 5571.75 17897.12 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC" 156 MS-DRG inpatient 1 UN 18450.64 11992.91 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11171.86 60.55 999999999 5571.75 17897.12 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC" 156 MS-DRG inpatient 1 UN 18450.64 11992.91 ENCORE - ALL PLANS ENCORE - ALL PLANS 12730.94 69 999999999 5571.75 17897.12 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC" 156 MS-DRG inpatient 1 UN 18450.64 11992.91 HUMANA - ALL PLANS HUMANA - ALL PLANS 14391.5 78 999999999 5571.75 17897.12 percent of total billed charges "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC" 156 MS-DRG inpatient 1 UN 18450.64 11992.91 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 10522.09 999999999 5571.75 17897.12 case rate "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC" 156 MS-DRG inpatient 1 UN 18450.64 11992.91 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 9937.38 999999999 5571.75 17897.12 case rate "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC" 156 MS-DRG inpatient 1 UN 18450.64 11992.91 ANTHEM HMO ANTHEM HMO 9352.02 999999999 5571.75 17897.12 case rate "OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC" 156 MS-DRG inpatient 1 UN 18450.64 11992.91 CIGNA - ALL PLANS CIGNA - ALL PLANS 12472.63 67.6 999999999 5571.75 17897.12 percent of total billed charges OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC 166 MS-DRG inpatient 1 UN 37473.31 24357.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 24357.65 65 999999999 22690.09 37473.31 percent of total billed charges OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC 166 MS-DRG inpatient 1 UN 37473.31 24357.65 AETNA AETNA 29603.91 79 999999999 22690.09 37473.31 percent of total billed charges OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC 166 MS-DRG inpatient 1 UN 37473.31 24357.65 UMR - ALL PLANS UMR - ALL PLANS 26231.32 70 999999999 22690.09 37473.31 percent of total billed charges OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC 166 MS-DRG inpatient 1 UN 37473.31 24357.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 36349.11 97 999999999 22690.09 37473.31 percent of total billed charges OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC 166 MS-DRG inpatient 1 UN 37473.31 24357.65 SIHO - ALL PLANS SIHO - ALL PLANS 33725.98 90 999999999 22690.09 37473.31 percent of total billed charges OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC 166 MS-DRG inpatient 1 UN 37473.31 24357.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 37473.31 999999999 22690.09 37473.31 case rate OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC 166 MS-DRG inpatient 1 UN 37473.31 24357.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 37473.31 999999999 22690.09 37473.31 case rate OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC 166 MS-DRG inpatient 1 UN 37473.31 24357.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 29229.18 78 999999999 22690.09 37473.31 percent of total billed charges OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC 166 MS-DRG inpatient 1 UN 37473.31 24357.65 ANTHEM HMO ANTHEM HMO 37473.31 999999999 22690.09 37473.31 case rate OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC 166 MS-DRG inpatient 1 UN 37473.31 24357.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 37473.31 999999999 22690.09 37473.31 case rate OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC 166 MS-DRG inpatient 1 UN 37473.31 24357.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 25331.96 67.6 999999999 22690.09 37473.31 percent of total billed charges OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC 166 MS-DRG inpatient 1 UN 37473.31 24357.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22690.09 60.55 999999999 22690.09 37473.31 percent of total billed charges OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC 166 MS-DRG inpatient 1 UN 37473.31 24357.65 UHC - ALL PLANS UHC - ALL PLANS 34491.3 999999999 22690.09 37473.31 case rate OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC 166 MS-DRG inpatient 1 UN 37473.31 24357.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 25856.58 69 999999999 22690.09 37473.31 percent of total billed charges PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE 175 MS-DRG inpatient 1 UN 36209.03 23535.87 SIHO - ALL PLANS SIHO - ALL PLANS 32588.13 90 999999999 11925.5 35122.76 percent of total billed charges PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE 175 MS-DRG inpatient 1 UN 36209.03 23535.87 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35122.76 97 999999999 11925.5 35122.76 percent of total billed charges PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE 175 MS-DRG inpatient 1 UN 36209.03 23535.87 AETNA AETNA 28605.13 79 999999999 11925.5 35122.76 percent of total billed charges PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE 175 MS-DRG inpatient 1 UN 36209.03 23535.87 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 19142.53 999999999 11925.5 35122.76 case rate PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE 175 MS-DRG inpatient 1 UN 36209.03 23535.87 UHC - ALL PLANS UHC - ALL PLANS 11925.5 999999999 11925.5 35122.76 case rate PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE 175 MS-DRG inpatient 1 UN 36209.03 23535.87 UMR - ALL PLANS UMR - ALL PLANS 25346.32 70 999999999 11925.5 35122.76 percent of total billed charges PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE 175 MS-DRG inpatient 1 UN 36209.03 23535.87 SELF PAY DISCOUNT SELF PAY DISCOUNT 23535.87 65 999999999 11925.5 35122.76 percent of total billed charges PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE 175 MS-DRG inpatient 1 UN 36209.03 23535.87 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21924.57 60.55 999999999 11925.5 35122.76 percent of total billed charges PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE 175 MS-DRG inpatient 1 UN 36209.03 23535.87 HUMANA - ALL PLANS HUMANA - ALL PLANS 28243.04 78 999999999 11925.5 35122.76 percent of total billed charges PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE 175 MS-DRG inpatient 1 UN 36209.03 23535.87 ENCORE - ALL PLANS ENCORE - ALL PLANS 24984.23 69 999999999 11925.5 35122.76 percent of total billed charges PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE 175 MS-DRG inpatient 1 UN 36209.03 23535.87 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 22520.96 999999999 11925.5 35122.76 case rate PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE 175 MS-DRG inpatient 1 UN 36209.03 23535.87 CIGNA - ALL PLANS CIGNA - ALL PLANS 24477.3 67.6 999999999 11925.5 35122.76 percent of total billed charges PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE 175 MS-DRG inpatient 1 UN 36209.03 23535.87 ANTHEM HMO ANTHEM HMO 20016.6 999999999 11925.5 35122.76 case rate PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE 175 MS-DRG inpatient 1 UN 36209.03 23535.87 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 21269.48 999999999 11925.5 35122.76 case rate PULMONARY EMBOLISM WITHOUT MCC 176 MS-DRG inpatient 1 UN 27592.51 17935.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 17935.13 65 999999999 6932.6 26764.73 percent of total billed charges PULMONARY EMBOLISM WITHOUT MCC 176 MS-DRG inpatient 1 UN 27592.51 17935.13 AETNA AETNA 21798.08 79 999999999 6932.6 26764.73 percent of total billed charges PULMONARY EMBOLISM WITHOUT MCC 176 MS-DRG inpatient 1 UN 27592.51 17935.13 UMR - ALL PLANS UMR - ALL PLANS 19314.75 70 999999999 6932.6 26764.73 percent of total billed charges PULMONARY EMBOLISM WITHOUT MCC 176 MS-DRG inpatient 1 UN 27592.51 17935.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26764.73 97 999999999 6932.6 26764.73 percent of total billed charges PULMONARY EMBOLISM WITHOUT MCC 176 MS-DRG inpatient 1 UN 27592.51 17935.13 SIHO - ALL PLANS SIHO - ALL PLANS 24833.26 90 999999999 6932.6 26764.73 percent of total billed charges PULMONARY EMBOLISM WITHOUT MCC 176 MS-DRG inpatient 1 UN 27592.51 17935.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 13092.01 999999999 6932.6 26764.73 case rate PULMONARY EMBOLISM WITHOUT MCC 176 MS-DRG inpatient 1 UN 27592.51 17935.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 12364.5 999999999 6932.6 26764.73 case rate PULMONARY EMBOLISM WITHOUT MCC 176 MS-DRG inpatient 1 UN 27592.51 17935.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 21522.15 78 999999999 6932.6 26764.73 percent of total billed charges PULMONARY EMBOLISM WITHOUT MCC 176 MS-DRG inpatient 1 UN 27592.51 17935.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 18652.53 67.6 999999999 6932.6 26764.73 percent of total billed charges PULMONARY EMBOLISM WITHOUT MCC 176 MS-DRG inpatient 1 UN 27592.51 17935.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 11128.05 999999999 6932.6 26764.73 case rate PULMONARY EMBOLISM WITHOUT MCC 176 MS-DRG inpatient 1 UN 27592.51 17935.13 ANTHEM HMO ANTHEM HMO 11636.17 999999999 6932.6 26764.73 case rate PULMONARY EMBOLISM WITHOUT MCC 176 MS-DRG inpatient 1 UN 27592.51 17935.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16707.26 60.55 999999999 6932.6 26764.73 percent of total billed charges PULMONARY EMBOLISM WITHOUT MCC 176 MS-DRG inpatient 1 UN 27592.51 17935.13 UHC - ALL PLANS UHC - ALL PLANS 6932.6 999999999 6932.6 26764.73 case rate PULMONARY EMBOLISM WITHOUT MCC 176 MS-DRG inpatient 1 UN 27592.51 17935.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 19038.83 69 999999999 6932.6 26764.73 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC 177 MS-DRG inpatient 1 UN 45072.91 29297.39 ENCORE - ALL PLANS ENCORE - ALL PLANS 31100.31 69 999999999 14419.4 43720.72 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC 177 MS-DRG inpatient 1 UN 45072.91 29297.39 UHC - ALL PLANS UHC - ALL PLANS 14419.4 999999999 14419.4 43720.72 case rate RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC 177 MS-DRG inpatient 1 UN 45072.91 29297.39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27291.64 60.55 999999999 14419.4 43720.72 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC 177 MS-DRG inpatient 1 UN 45072.91 29297.39 ANTHEM HMO ANTHEM HMO 24202.54 999999999 14419.4 43720.72 case rate RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC 177 MS-DRG inpatient 1 UN 45072.91 29297.39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 23145.68 999999999 14419.4 43720.72 case rate RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC 177 MS-DRG inpatient 1 UN 45072.91 29297.39 CIGNA - ALL PLANS CIGNA - ALL PLANS 30469.28 67.6 999999999 14419.4 43720.72 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC 177 MS-DRG inpatient 1 UN 45072.91 29297.39 HUMANA - ALL PLANS HUMANA - ALL PLANS 35156.87 78 999999999 14419.4 43720.72 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC 177 MS-DRG inpatient 1 UN 45072.91 29297.39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 25717.42 999999999 14419.4 43720.72 case rate RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC 177 MS-DRG inpatient 1 UN 45072.91 29297.39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 27230.61 999999999 14419.4 43720.72 case rate RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC 177 MS-DRG inpatient 1 UN 45072.91 29297.39 SIHO - ALL PLANS SIHO - ALL PLANS 40565.62 90 999999999 14419.4 43720.72 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC 177 MS-DRG inpatient 1 UN 45072.91 29297.39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 43720.72 97 999999999 14419.4 43720.72 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC 177 MS-DRG inpatient 1 UN 45072.91 29297.39 UMR - ALL PLANS UMR - ALL PLANS 31551.03 70 999999999 14419.4 43720.72 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC 177 MS-DRG inpatient 1 UN 45072.91 29297.39 AETNA AETNA 35607.6 79 999999999 14419.4 43720.72 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC 177 MS-DRG inpatient 1 UN 45072.91 29297.39 SELF PAY DISCOUNT SELF PAY DISCOUNT 29297.39 65 999999999 14419.4 43720.72 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC 178 MS-DRG inpatient 1 UN 28411.15 18467.25 ANTHEM HMO ANTHEM HMO 14077.25 999999999 8386.95 27558.82 case rate RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC 178 MS-DRG inpatient 1 UN 28411.15 18467.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 14958.37 999999999 8386.95 27558.82 case rate RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC 178 MS-DRG inpatient 1 UN 28411.15 18467.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 13462.53 999999999 8386.95 27558.82 case rate RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC 178 MS-DRG inpatient 1 UN 28411.15 18467.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 19205.94 67.6 999999999 8386.95 27558.82 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC 178 MS-DRG inpatient 1 UN 28411.15 18467.25 SIHO - ALL PLANS SIHO - ALL PLANS 25570.04 90 999999999 8386.95 27558.82 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC 178 MS-DRG inpatient 1 UN 28411.15 18467.25 UHC - ALL PLANS UHC - ALL PLANS 8386.95 999999999 8386.95 27558.82 case rate RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC 178 MS-DRG inpatient 1 UN 28411.15 18467.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 19603.7 69 999999999 8386.95 27558.82 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC 178 MS-DRG inpatient 1 UN 28411.15 18467.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 22160.7 78 999999999 8386.95 27558.82 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC 178 MS-DRG inpatient 1 UN 28411.15 18467.25 AETNA AETNA 22444.81 79 999999999 8386.95 27558.82 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC 178 MS-DRG inpatient 1 UN 28411.15 18467.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 18467.25 65 999999999 8386.95 27558.82 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC 178 MS-DRG inpatient 1 UN 28411.15 18467.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 15838.51 999999999 8386.95 27558.82 case rate RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC 178 MS-DRG inpatient 1 UN 28411.15 18467.25 UMR - ALL PLANS UMR - ALL PLANS 19887.81 70 999999999 8386.95 27558.82 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC 178 MS-DRG inpatient 1 UN 28411.15 18467.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 27558.82 97 999999999 8386.95 27558.82 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC 178 MS-DRG inpatient 1 UN 28411.15 18467.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17202.95 60.55 999999999 8386.95 27558.82 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC 179 MS-DRG inpatient 1 UN 27627.32 17957.76 UMR - ALL PLANS UMR - ALL PLANS 19339.13 70 999999999 6488.05 26798.5 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC 179 MS-DRG inpatient 1 UN 27627.32 17957.76 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26798.5 97 999999999 6488.05 26798.5 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC 179 MS-DRG inpatient 1 UN 27627.32 17957.76 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12252.49 999999999 6488.05 26798.5 case rate RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC 179 MS-DRG inpatient 1 UN 27627.32 17957.76 SELF PAY DISCOUNT SELF PAY DISCOUNT 17957.76 65 999999999 6488.05 26798.5 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC 179 MS-DRG inpatient 1 UN 27627.32 17957.76 AETNA AETNA 21825.59 79 999999999 6488.05 26798.5 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC 179 MS-DRG inpatient 1 UN 27627.32 17957.76 HUMANA - ALL PLANS HUMANA - ALL PLANS 21549.31 78 999999999 6488.05 26798.5 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC 179 MS-DRG inpatient 1 UN 27627.32 17957.76 ENCORE - ALL PLANS ENCORE - ALL PLANS 19062.85 69 999999999 6488.05 26798.5 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC 179 MS-DRG inpatient 1 UN 27627.32 17957.76 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16728.35 60.55 999999999 6488.05 26798.5 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC 179 MS-DRG inpatient 1 UN 27627.32 17957.76 UHC - ALL PLANS UHC - ALL PLANS 6488.05 999999999 6488.05 26798.5 case rate RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC 179 MS-DRG inpatient 1 UN 27627.32 17957.76 SIHO - ALL PLANS SIHO - ALL PLANS 24864.59 90 999999999 6488.05 26798.5 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC 179 MS-DRG inpatient 1 UN 27627.32 17957.76 CIGNA - ALL PLANS CIGNA - ALL PLANS 18676.07 67.6 999999999 6488.05 26798.5 percent of total billed charges RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC 179 MS-DRG inpatient 1 UN 27627.32 17957.76 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10414.47 999999999 6488.05 26798.5 case rate RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC 179 MS-DRG inpatient 1 UN 27627.32 17957.76 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 11571.63 999999999 6488.05 26798.5 case rate RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC 179 MS-DRG inpatient 1 UN 27627.32 17957.76 ANTHEM HMO ANTHEM HMO 10890 999999999 6488.05 26798.5 case rate RESPIRATORY NEOPLASMS WITH MCC 180 MS-DRG inpatient 1 UN 80746.31 52485.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 54584.51 67.6 999999999 14774.7 78323.92 percent of total billed charges RESPIRATORY NEOPLASMS WITH MCC 180 MS-DRG inpatient 1 UN 80746.31 52485.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 27901.59 999999999 14774.7 78323.92 case rate RESPIRATORY NEOPLASMS WITH MCC 180 MS-DRG inpatient 1 UN 80746.31 52485.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48891.89 60.55 999999999 14774.7 78323.92 percent of total billed charges RESPIRATORY NEOPLASMS WITH MCC 180 MS-DRG inpatient 1 UN 80746.31 52485.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 55714.95 69 999999999 14774.7 78323.92 percent of total billed charges RESPIRATORY NEOPLASMS WITH MCC 180 MS-DRG inpatient 1 UN 80746.31 52485.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 52485.1 65 999999999 14774.7 78323.92 percent of total billed charges RESPIRATORY NEOPLASMS WITH MCC 180 MS-DRG inpatient 1 UN 80746.31 52485.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 26351.11 999999999 14774.7 78323.92 case rate RESPIRATORY NEOPLASMS WITH MCC 180 MS-DRG inpatient 1 UN 80746.31 52485.1 ANTHEM HMO ANTHEM HMO 24798.9 999999999 14774.7 78323.92 case rate RESPIRATORY NEOPLASMS WITH MCC 180 MS-DRG inpatient 1 UN 80746.31 52485.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 23716 999999999 14774.7 78323.92 case rate RESPIRATORY NEOPLASMS WITH MCC 180 MS-DRG inpatient 1 UN 80746.31 52485.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 78323.92 97 999999999 14774.7 78323.92 percent of total billed charges RESPIRATORY NEOPLASMS WITH MCC 180 MS-DRG inpatient 1 UN 80746.31 52485.1 UMR - ALL PLANS UMR - ALL PLANS 56522.42 70 999999999 14774.7 78323.92 percent of total billed charges RESPIRATORY NEOPLASMS WITH MCC 180 MS-DRG inpatient 1 UN 80746.31 52485.1 SIHO - ALL PLANS SIHO - ALL PLANS 72671.68 90 999999999 14774.7 78323.92 percent of total billed charges RESPIRATORY NEOPLASMS WITH MCC 180 MS-DRG inpatient 1 UN 80746.31 52485.1 AETNA AETNA 63789.59 79 999999999 14774.7 78323.92 percent of total billed charges RESPIRATORY NEOPLASMS WITH MCC 180 MS-DRG inpatient 1 UN 80746.31 52485.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 62982.12 78 999999999 14774.7 78323.92 percent of total billed charges RESPIRATORY NEOPLASMS WITH MCC 180 MS-DRG inpatient 1 UN 80746.31 52485.1 UHC - ALL PLANS UHC - ALL PLANS 14774.7 999999999 14774.7 78323.92 case rate RESPIRATORY NEOPLASMS WITH CC 181 MS-DRG inpatient 1 UN 15432.69 10031.25 UMR - ALL PLANS UMR - ALL PLANS 10802.88 70 999999999 9344.49 15432.69 percent of total billed charges RESPIRATORY NEOPLASMS WITH CC 181 MS-DRG inpatient 1 UN 15432.69 10031.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14969.71 97 999999999 9344.49 15432.69 percent of total billed charges RESPIRATORY NEOPLASMS WITH CC 181 MS-DRG inpatient 1 UN 15432.69 10031.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9344.49 60.55 999999999 9344.49 15432.69 percent of total billed charges RESPIRATORY NEOPLASMS WITH CC 181 MS-DRG inpatient 1 UN 15432.69 10031.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 10648.56 69 999999999 9344.49 15432.69 percent of total billed charges RESPIRATORY NEOPLASMS WITH CC 181 MS-DRG inpatient 1 UN 15432.69 10031.25 AETNA AETNA 12191.83 79 999999999 9344.49 15432.69 percent of total billed charges RESPIRATORY NEOPLASMS WITH CC 181 MS-DRG inpatient 1 UN 15432.69 10031.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 10031.25 65 999999999 9344.49 15432.69 percent of total billed charges RESPIRATORY NEOPLASMS WITH CC 181 MS-DRG inpatient 1 UN 15432.69 10031.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 15432.69 999999999 9344.49 15432.69 case rate RESPIRATORY NEOPLASMS WITH CC 181 MS-DRG inpatient 1 UN 15432.69 10031.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 15432.69 999999999 9344.49 15432.69 case rate RESPIRATORY NEOPLASMS WITH CC 181 MS-DRG inpatient 1 UN 15432.69 10031.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 12037.5 78 999999999 9344.49 15432.69 percent of total billed charges RESPIRATORY NEOPLASMS WITH CC 181 MS-DRG inpatient 1 UN 15432.69 10031.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 10432.5 67.6 999999999 9344.49 15432.69 percent of total billed charges RESPIRATORY NEOPLASMS WITH CC 181 MS-DRG inpatient 1 UN 15432.69 10031.25 SIHO - ALL PLANS SIHO - ALL PLANS 13889.42 90 999999999 9344.49 15432.69 percent of total billed charges RESPIRATORY NEOPLASMS WITH CC 181 MS-DRG inpatient 1 UN 15432.69 10031.25 UHC - ALL PLANS UHC - ALL PLANS 9359.35 999999999 9344.49 15432.69 case rate RESPIRATORY NEOPLASMS WITH CC 181 MS-DRG inpatient 1 UN 15432.69 10031.25 ANTHEM HMO ANTHEM HMO 15432.69 999999999 9344.49 15432.69 case rate RESPIRATORY NEOPLASMS WITH CC 181 MS-DRG inpatient 1 UN 15432.69 10031.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 15023.41 999999999 9344.49 15432.69 case rate MAJOR CHEST TRAUMA WITH CC 184 MS-DRG inpatient 1 UN 40670.26 26435.67 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 16885.1 999999999 8941.15 39450.15 case rate MAJOR CHEST TRAUMA WITH CC 184 MS-DRG inpatient 1 UN 40670.26 26435.67 CIGNA - ALL PLANS CIGNA - ALL PLANS 27493.09 67.6 999999999 8941.15 39450.15 percent of total billed charges MAJOR CHEST TRAUMA WITH CC 184 MS-DRG inpatient 1 UN 40670.26 26435.67 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 15946.8 999999999 8941.15 39450.15 case rate MAJOR CHEST TRAUMA WITH CC 184 MS-DRG inpatient 1 UN 40670.26 26435.67 ANTHEM HMO ANTHEM HMO 15007.46 999999999 8941.15 39450.15 case rate MAJOR CHEST TRAUMA WITH CC 184 MS-DRG inpatient 1 UN 40670.26 26435.67 HUMANA - ALL PLANS HUMANA - ALL PLANS 31722.8 78 999999999 8941.15 39450.15 percent of total billed charges MAJOR CHEST TRAUMA WITH CC 184 MS-DRG inpatient 1 UN 40670.26 26435.67 SELF PAY DISCOUNT SELF PAY DISCOUNT 26435.67 65 999999999 8941.15 39450.15 percent of total billed charges MAJOR CHEST TRAUMA WITH CC 184 MS-DRG inpatient 1 UN 40670.26 26435.67 UHC - ALL PLANS UHC - ALL PLANS 8941.15 999999999 8941.15 39450.15 case rate MAJOR CHEST TRAUMA WITH CC 184 MS-DRG inpatient 1 UN 40670.26 26435.67 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 14352.12 999999999 8941.15 39450.15 case rate MAJOR CHEST TRAUMA WITH CC 184 MS-DRG inpatient 1 UN 40670.26 26435.67 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24625.84 60.55 999999999 8941.15 39450.15 percent of total billed charges MAJOR CHEST TRAUMA WITH CC 184 MS-DRG inpatient 1 UN 40670.26 26435.67 ENCORE - ALL PLANS ENCORE - ALL PLANS 28062.48 69 999999999 8941.15 39450.15 percent of total billed charges MAJOR CHEST TRAUMA WITH CC 184 MS-DRG inpatient 1 UN 40670.26 26435.67 AETNA AETNA 32129.5 79 999999999 8941.15 39450.15 percent of total billed charges MAJOR CHEST TRAUMA WITH CC 184 MS-DRG inpatient 1 UN 40670.26 26435.67 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39450.15 97 999999999 8941.15 39450.15 percent of total billed charges MAJOR CHEST TRAUMA WITH CC 184 MS-DRG inpatient 1 UN 40670.26 26435.67 UMR - ALL PLANS UMR - ALL PLANS 28469.18 70 999999999 8941.15 39450.15 percent of total billed charges MAJOR CHEST TRAUMA WITH CC 184 MS-DRG inpatient 1 UN 40670.26 26435.67 SIHO - ALL PLANS SIHO - ALL PLANS 36603.23 90 999999999 8941.15 39450.15 percent of total billed charges MAJOR CHEST TRAUMA WITHOUT CC/MCC 185 MS-DRG inpatient 1 UN 30030.87 19520.07 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18183.69 60.55 999999999 6423.45 29129.94 percent of total billed charges MAJOR CHEST TRAUMA WITHOUT CC/MCC 185 MS-DRG inpatient 1 UN 30030.87 19520.07 UHC - ALL PLANS UHC - ALL PLANS 6423.45 999999999 6423.45 29129.94 case rate MAJOR CHEST TRAUMA WITHOUT CC/MCC 185 MS-DRG inpatient 1 UN 30030.87 19520.07 ENCORE - ALL PLANS ENCORE - ALL PLANS 20721.3 69 999999999 6423.45 29129.94 percent of total billed charges MAJOR CHEST TRAUMA WITHOUT CC/MCC 185 MS-DRG inpatient 1 UN 30030.87 19520.07 HUMANA - ALL PLANS HUMANA - ALL PLANS 23424.08 78 999999999 6423.45 29129.94 percent of total billed charges MAJOR CHEST TRAUMA WITHOUT CC/MCC 185 MS-DRG inpatient 1 UN 30030.87 19520.07 CIGNA - ALL PLANS CIGNA - ALL PLANS 20300.87 67.6 999999999 6423.45 29129.94 percent of total billed charges MAJOR CHEST TRAUMA WITHOUT CC/MCC 185 MS-DRG inpatient 1 UN 30030.87 19520.07 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10310.77 999999999 6423.45 29129.94 case rate MAJOR CHEST TRAUMA WITHOUT CC/MCC 185 MS-DRG inpatient 1 UN 30030.87 19520.07 ANTHEM HMO ANTHEM HMO 10781.57 999999999 6423.45 29129.94 case rate MAJOR CHEST TRAUMA WITHOUT CC/MCC 185 MS-DRG inpatient 1 UN 30030.87 19520.07 SIHO - ALL PLANS SIHO - ALL PLANS 27027.78 90 999999999 6423.45 29129.94 percent of total billed charges MAJOR CHEST TRAUMA WITHOUT CC/MCC 185 MS-DRG inpatient 1 UN 30030.87 19520.07 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12130.5 999999999 6423.45 29129.94 case rate MAJOR CHEST TRAUMA WITHOUT CC/MCC 185 MS-DRG inpatient 1 UN 30030.87 19520.07 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 11456.41 999999999 6423.45 29129.94 case rate MAJOR CHEST TRAUMA WITHOUT CC/MCC 185 MS-DRG inpatient 1 UN 30030.87 19520.07 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29129.94 97 999999999 6423.45 29129.94 percent of total billed charges MAJOR CHEST TRAUMA WITHOUT CC/MCC 185 MS-DRG inpatient 1 UN 30030.87 19520.07 UMR - ALL PLANS UMR - ALL PLANS 21021.61 70 999999999 6423.45 29129.94 percent of total billed charges MAJOR CHEST TRAUMA WITHOUT CC/MCC 185 MS-DRG inpatient 1 UN 30030.87 19520.07 AETNA AETNA 23724.39 79 999999999 6423.45 29129.94 percent of total billed charges MAJOR CHEST TRAUMA WITHOUT CC/MCC 185 MS-DRG inpatient 1 UN 30030.87 19520.07 SELF PAY DISCOUNT SELF PAY DISCOUNT 19520.07 65 999999999 6423.45 29129.94 percent of total billed charges PLEURAL EFFUSION WITH MCC 186 MS-DRG inpatient 1 UN 45546.95 29605.52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 23529.84 999999999 13192.85 44180.54 case rate PLEURAL EFFUSION WITH MCC 186 MS-DRG inpatient 1 UN 45546.95 29605.52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 24914.31 999999999 13192.85 44180.54 case rate PLEURAL EFFUSION WITH MCC 186 MS-DRG inpatient 1 UN 45546.95 29605.52 CIGNA - ALL PLANS CIGNA - ALL PLANS 30789.74 67.6 999999999 13192.85 44180.54 percent of total billed charges PLEURAL EFFUSION WITH MCC 186 MS-DRG inpatient 1 UN 45546.95 29605.52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27578.68 60.55 999999999 13192.85 44180.54 percent of total billed charges PLEURAL EFFUSION WITH MCC 186 MS-DRG inpatient 1 UN 45546.95 29605.52 HUMANA - ALL PLANS HUMANA - ALL PLANS 35526.62 78 999999999 13192.85 44180.54 percent of total billed charges PLEURAL EFFUSION WITH MCC 186 MS-DRG inpatient 1 UN 45546.95 29605.52 ENCORE - ALL PLANS ENCORE - ALL PLANS 31427.4 69 999999999 13192.85 44180.54 percent of total billed charges PLEURAL EFFUSION WITH MCC 186 MS-DRG inpatient 1 UN 45546.95 29605.52 SELF PAY DISCOUNT SELF PAY DISCOUNT 29605.52 65 999999999 13192.85 44180.54 percent of total billed charges PLEURAL EFFUSION WITH MCC 186 MS-DRG inpatient 1 UN 45546.95 29605.52 ANTHEM HMO ANTHEM HMO 22143.81 999999999 13192.85 44180.54 case rate PLEURAL EFFUSION WITH MCC 186 MS-DRG inpatient 1 UN 45546.95 29605.52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 21176.85 999999999 13192.85 44180.54 case rate PLEURAL EFFUSION WITH MCC 186 MS-DRG inpatient 1 UN 45546.95 29605.52 UHC - ALL PLANS UHC - ALL PLANS 13192.85 999999999 13192.85 44180.54 case rate PLEURAL EFFUSION WITH MCC 186 MS-DRG inpatient 1 UN 45546.95 29605.52 UMR - ALL PLANS UMR - ALL PLANS 31882.87 70 999999999 13192.85 44180.54 percent of total billed charges PLEURAL EFFUSION WITH MCC 186 MS-DRG inpatient 1 UN 45546.95 29605.52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 44180.54 97 999999999 13192.85 44180.54 percent of total billed charges PLEURAL EFFUSION WITH MCC 186 MS-DRG inpatient 1 UN 45546.95 29605.52 AETNA AETNA 35982.09 79 999999999 13192.85 44180.54 percent of total billed charges PLEURAL EFFUSION WITH MCC 186 MS-DRG inpatient 1 UN 45546.95 29605.52 SIHO - ALL PLANS SIHO - ALL PLANS 40992.26 90 999999999 13192.85 44180.54 percent of total billed charges PULMONARY EDEMA AND RESPIRATORY FAILURE 189 MS-DRG inpatient 1 UN 29090.29 18908.69 HUMANA - ALL PLANS HUMANA - ALL PLANS 22690.43 78 999999999 10472 28217.58 percent of total billed charges PULMONARY EDEMA AND RESPIRATORY FAILURE 189 MS-DRG inpatient 1 UN 29090.29 18908.69 AETNA AETNA 22981.33 79 999999999 10472 28217.58 percent of total billed charges PULMONARY EDEMA AND RESPIRATORY FAILURE 189 MS-DRG inpatient 1 UN 29090.29 18908.69 SIHO - ALL PLANS SIHO - ALL PLANS 26181.26 90 999999999 10472 28217.58 percent of total billed charges PULMONARY EDEMA AND RESPIRATORY FAILURE 189 MS-DRG inpatient 1 UN 29090.29 18908.69 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 28217.58 97 999999999 10472 28217.58 percent of total billed charges PULMONARY EDEMA AND RESPIRATORY FAILURE 189 MS-DRG inpatient 1 UN 29090.29 18908.69 UMR - ALL PLANS UMR - ALL PLANS 20363.2 70 999999999 10472 28217.58 percent of total billed charges PULMONARY EDEMA AND RESPIRATORY FAILURE 189 MS-DRG inpatient 1 UN 29090.29 18908.69 UHC - ALL PLANS UHC - ALL PLANS 10472 999999999 10472 28217.58 case rate PULMONARY EDEMA AND RESPIRATORY FAILURE 189 MS-DRG inpatient 1 UN 29090.29 18908.69 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 16809.41 999999999 10472 28217.58 case rate PULMONARY EDEMA AND RESPIRATORY FAILURE 189 MS-DRG inpatient 1 UN 29090.29 18908.69 ANTHEM HMO ANTHEM HMO 17576.94 999999999 10472 28217.58 case rate PULMONARY EDEMA AND RESPIRATORY FAILURE 189 MS-DRG inpatient 1 UN 29090.29 18908.69 SELF PAY DISCOUNT SELF PAY DISCOUNT 18908.69 65 999999999 10472 28217.58 percent of total billed charges PULMONARY EDEMA AND RESPIRATORY FAILURE 189 MS-DRG inpatient 1 UN 29090.29 18908.69 ENCORE - ALL PLANS ENCORE - ALL PLANS 20072.3 69 999999999 10472 28217.58 percent of total billed charges PULMONARY EDEMA AND RESPIRATORY FAILURE 189 MS-DRG inpatient 1 UN 29090.29 18908.69 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17614.17 60.55 999999999 10472 28217.58 percent of total billed charges PULMONARY EDEMA AND RESPIRATORY FAILURE 189 MS-DRG inpatient 1 UN 29090.29 18908.69 CIGNA - ALL PLANS CIGNA - ALL PLANS 19665.04 67.6 999999999 10472 28217.58 percent of total billed charges PULMONARY EDEMA AND RESPIRATORY FAILURE 189 MS-DRG inpatient 1 UN 29090.29 18908.69 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 19776.06 999999999 10472 28217.58 case rate PULMONARY EDEMA AND RESPIRATORY FAILURE 189 MS-DRG inpatient 1 UN 29090.29 18908.69 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 18677.12 999999999 10472 28217.58 case rate CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC 190 MS-DRG inpatient 1 UN 27821.05 18083.68 ANTHEM HMO ANTHEM HMO 15722.23 999999999 9367 26986.42 case rate CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC 190 MS-DRG inpatient 1 UN 27821.05 18083.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 18807.03 67.6 999999999 9367 26986.42 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC 190 MS-DRG inpatient 1 UN 27821.05 18083.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 15035.69 999999999 9367 26986.42 case rate CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC 190 MS-DRG inpatient 1 UN 27821.05 18083.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 17689.3 999999999 9367 26986.42 case rate CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC 190 MS-DRG inpatient 1 UN 27821.05 18083.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 16706.32 999999999 9367 26986.42 case rate CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC 190 MS-DRG inpatient 1 UN 27821.05 18083.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 21700.42 78 999999999 9367 26986.42 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC 190 MS-DRG inpatient 1 UN 27821.05 18083.68 UHC - ALL PLANS UHC - ALL PLANS 9367 999999999 9367 26986.42 case rate CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC 190 MS-DRG inpatient 1 UN 27821.05 18083.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 18083.68 65 999999999 9367 26986.42 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC 190 MS-DRG inpatient 1 UN 27821.05 18083.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16845.64 60.55 999999999 9367 26986.42 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC 190 MS-DRG inpatient 1 UN 27821.05 18083.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 19196.52 69 999999999 9367 26986.42 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC 190 MS-DRG inpatient 1 UN 27821.05 18083.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26986.42 97 999999999 9367 26986.42 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC 190 MS-DRG inpatient 1 UN 27821.05 18083.68 AETNA AETNA 21978.63 79 999999999 9367 26986.42 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC 190 MS-DRG inpatient 1 UN 27821.05 18083.68 UMR - ALL PLANS UMR - ALL PLANS 19474.73 70 999999999 9367 26986.42 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC 190 MS-DRG inpatient 1 UN 27821.05 18083.68 SIHO - ALL PLANS SIHO - ALL PLANS 25038.94 90 999999999 9367 26986.42 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC 191 MS-DRG inpatient 1 UN 24167.02 15708.56 UMR - ALL PLANS UMR - ALL PLANS 16916.92 70 999999999 7216.5 23442.01 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC 191 MS-DRG inpatient 1 UN 24167.02 15708.56 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14633.13 60.55 999999999 7216.5 23442.01 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC 191 MS-DRG inpatient 1 UN 24167.02 15708.56 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23442.01 97 999999999 7216.5 23442.01 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC 191 MS-DRG inpatient 1 UN 24167.02 15708.56 AETNA AETNA 19091.95 79 999999999 7216.5 23442.01 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC 191 MS-DRG inpatient 1 UN 24167.02 15708.56 SELF PAY DISCOUNT SELF PAY DISCOUNT 15708.56 65 999999999 7216.5 23442.01 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC 191 MS-DRG inpatient 1 UN 24167.02 15708.56 ENCORE - ALL PLANS ENCORE - ALL PLANS 16675.25 69 999999999 7216.5 23442.01 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC 191 MS-DRG inpatient 1 UN 24167.02 15708.56 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 13628.15 999999999 7216.5 23442.01 case rate CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC 191 MS-DRG inpatient 1 UN 24167.02 15708.56 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 12870.84 999999999 7216.5 23442.01 case rate CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC 191 MS-DRG inpatient 1 UN 24167.02 15708.56 HUMANA - ALL PLANS HUMANA - ALL PLANS 18850.28 78 999999999 7216.5 23442.01 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC 191 MS-DRG inpatient 1 UN 24167.02 15708.56 CIGNA - ALL PLANS CIGNA - ALL PLANS 16336.91 67.6 999999999 7216.5 23442.01 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC 191 MS-DRG inpatient 1 UN 24167.02 15708.56 SIHO - ALL PLANS SIHO - ALL PLANS 21750.32 90 999999999 7216.5 23442.01 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC 191 MS-DRG inpatient 1 UN 24167.02 15708.56 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 11583.76 999999999 7216.5 23442.01 case rate CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC 191 MS-DRG inpatient 1 UN 24167.02 15708.56 ANTHEM HMO ANTHEM HMO 12112.68 999999999 7216.5 23442.01 case rate CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC 191 MS-DRG inpatient 1 UN 24167.02 15708.56 UHC - ALL PLANS UHC - ALL PLANS 7216.5 999999999 7216.5 23442.01 case rate CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC 192 MS-DRG inpatient 1 UN 22545.78 14654.76 CIGNA - ALL PLANS CIGNA - ALL PLANS 15240.95 67.6 999999999 5455.3 21869.41 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC 192 MS-DRG inpatient 1 UN 22545.78 14654.76 ANTHEM HMO ANTHEM HMO 9156.56 999999999 5455.3 21869.41 case rate CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC 192 MS-DRG inpatient 1 UN 22545.78 14654.76 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 9729.69 999999999 5455.3 21869.41 case rate CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC 192 MS-DRG inpatient 1 UN 22545.78 14654.76 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 10302.17 999999999 5455.3 21869.41 case rate CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC 192 MS-DRG inpatient 1 UN 22545.78 14654.76 HUMANA - ALL PLANS HUMANA - ALL PLANS 17585.71 78 999999999 5455.3 21869.41 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC 192 MS-DRG inpatient 1 UN 22545.78 14654.76 ENCORE - ALL PLANS ENCORE - ALL PLANS 15556.59 69 999999999 5455.3 21869.41 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC 192 MS-DRG inpatient 1 UN 22545.78 14654.76 SELF PAY DISCOUNT SELF PAY DISCOUNT 14654.76 65 999999999 5455.3 21869.41 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC 192 MS-DRG inpatient 1 UN 22545.78 14654.76 UHC - ALL PLANS UHC - ALL PLANS 5455.3 999999999 5455.3 21869.41 case rate CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC 192 MS-DRG inpatient 1 UN 22545.78 14654.76 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 8756.72 999999999 5455.3 21869.41 case rate CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC 192 MS-DRG inpatient 1 UN 22545.78 14654.76 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13651.47 60.55 999999999 5455.3 21869.41 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC 192 MS-DRG inpatient 1 UN 22545.78 14654.76 AETNA AETNA 17811.17 79 999999999 5455.3 21869.41 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC 192 MS-DRG inpatient 1 UN 22545.78 14654.76 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21869.41 97 999999999 5455.3 21869.41 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC 192 MS-DRG inpatient 1 UN 22545.78 14654.76 UMR - ALL PLANS UMR - ALL PLANS 15782.05 70 999999999 5455.3 21869.41 percent of total billed charges CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC 192 MS-DRG inpatient 1 UN 22545.78 14654.76 SIHO - ALL PLANS SIHO - ALL PLANS 20291.2 90 999999999 5455.3 21869.41 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITH MCC 193 MS-DRG inpatient 1 UN 30794.12 20016.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18645.84 60.55 999999999 11276.1 29870.3 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITH MCC 193 MS-DRG inpatient 1 UN 30794.12 20016.18 UHC - ALL PLANS UHC - ALL PLANS 11276.1 999999999 11276.1 29870.3 case rate SIMPLE PNEUMONIA AND PLEURISY WITH MCC 193 MS-DRG inpatient 1 UN 30794.12 20016.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 24019.41 78 999999999 11276.1 29870.3 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITH MCC 193 MS-DRG inpatient 1 UN 30794.12 20016.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 21247.94 69 999999999 11276.1 29870.3 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITH MCC 193 MS-DRG inpatient 1 UN 30794.12 20016.18 AETNA AETNA 24327.36 79 999999999 11276.1 29870.3 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITH MCC 193 MS-DRG inpatient 1 UN 30794.12 20016.18 SIHO - ALL PLANS SIHO - ALL PLANS 27714.71 90 999999999 11276.1 29870.3 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITH MCC 193 MS-DRG inpatient 1 UN 30794.12 20016.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 20816.83 67.6 999999999 11276.1 29870.3 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITH MCC 193 MS-DRG inpatient 1 UN 30794.12 20016.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 18100.13 999999999 11276.1 29870.3 case rate SIMPLE PNEUMONIA AND PLEURISY WITH MCC 193 MS-DRG inpatient 1 UN 30794.12 20016.18 ANTHEM HMO ANTHEM HMO 18926.6 999999999 11276.1 29870.3 case rate SIMPLE PNEUMONIA AND PLEURISY WITH MCC 193 MS-DRG inpatient 1 UN 30794.12 20016.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 20111.26 999999999 11276.1 29870.3 case rate SIMPLE PNEUMONIA AND PLEURISY WITH MCC 193 MS-DRG inpatient 1 UN 30794.12 20016.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29870.3 97 999999999 11276.1 29870.3 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITH MCC 193 MS-DRG inpatient 1 UN 30794.12 20016.18 UMR - ALL PLANS UMR - ALL PLANS 21555.88 70 999999999 11276.1 29870.3 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITH MCC 193 MS-DRG inpatient 1 UN 30794.12 20016.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 20016.18 65 999999999 11276.1 29870.3 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITH MCC 193 MS-DRG inpatient 1 UN 30794.12 20016.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 21294.58 999999999 11276.1 29870.3 case rate SIMPLE PNEUMONIA AND PLEURISY WITH CC 194 MS-DRG inpatient 1 UN 22262.47 14470.61 UHC - ALL PLANS UHC - ALL PLANS 6988.7 999999999 6988.7 21594.6 case rate SIMPLE PNEUMONIA AND PLEURISY WITH CC 194 MS-DRG inpatient 1 UN 22262.47 14470.61 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 11218.1 999999999 6988.7 21594.6 case rate SIMPLE PNEUMONIA AND PLEURISY WITH CC 194 MS-DRG inpatient 1 UN 22262.47 14470.61 ANTHEM HMO ANTHEM HMO 11730.33 999999999 6988.7 21594.6 case rate SIMPLE PNEUMONIA AND PLEURISY WITH CC 194 MS-DRG inpatient 1 UN 22262.47 14470.61 SIHO - ALL PLANS SIHO - ALL PLANS 20036.22 90 999999999 6988.7 21594.6 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITH CC 194 MS-DRG inpatient 1 UN 22262.47 14470.61 HUMANA - ALL PLANS HUMANA - ALL PLANS 17364.73 78 999999999 6988.7 21594.6 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITH CC 194 MS-DRG inpatient 1 UN 22262.47 14470.61 CIGNA - ALL PLANS CIGNA - ALL PLANS 15049.43 67.6 999999999 6988.7 21594.6 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITH CC 194 MS-DRG inpatient 1 UN 22262.47 14470.61 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 12464.55 999999999 6988.7 21594.6 case rate SIMPLE PNEUMONIA AND PLEURISY WITH CC 194 MS-DRG inpatient 1 UN 22262.47 14470.61 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 13197.95 999999999 6988.7 21594.6 case rate SIMPLE PNEUMONIA AND PLEURISY WITH CC 194 MS-DRG inpatient 1 UN 22262.47 14470.61 ENCORE - ALL PLANS ENCORE - ALL PLANS 15361.1 69 999999999 6988.7 21594.6 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITH CC 194 MS-DRG inpatient 1 UN 22262.47 14470.61 AETNA AETNA 17587.35 79 999999999 6988.7 21594.6 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITH CC 194 MS-DRG inpatient 1 UN 22262.47 14470.61 SELF PAY DISCOUNT SELF PAY DISCOUNT 14470.61 65 999999999 6988.7 21594.6 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITH CC 194 MS-DRG inpatient 1 UN 22262.47 14470.61 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21594.6 97 999999999 6988.7 21594.6 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITH CC 194 MS-DRG inpatient 1 UN 22262.47 14470.61 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13479.93 60.55 999999999 6988.7 21594.6 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITH CC 194 MS-DRG inpatient 1 UN 22262.47 14470.61 UMR - ALL PLANS UMR - ALL PLANS 15583.73 70 999999999 6988.7 21594.6 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC 195 MS-DRG inpatient 1 UN 18959.07 12323.39 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11479.72 60.55 999999999 5317.6 18390.3 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC 195 MS-DRG inpatient 1 UN 18959.07 12323.39 UHC - ALL PLANS UHC - ALL PLANS 5317.6 999999999 5317.6 18390.3 case rate SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC 195 MS-DRG inpatient 1 UN 18959.07 12323.39 ENCORE - ALL PLANS ENCORE - ALL PLANS 13081.76 69 999999999 5317.6 18390.3 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC 195 MS-DRG inpatient 1 UN 18959.07 12323.39 HUMANA - ALL PLANS HUMANA - ALL PLANS 14788.07 78 999999999 5317.6 18390.3 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC 195 MS-DRG inpatient 1 UN 18959.07 12323.39 ANTHEM HMO ANTHEM HMO 8925.44 999999999 5317.6 18390.3 case rate SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC 195 MS-DRG inpatient 1 UN 18959.07 12323.39 CIGNA - ALL PLANS CIGNA - ALL PLANS 12816.33 67.6 999999999 5317.6 18390.3 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC 195 MS-DRG inpatient 1 UN 18959.07 12323.39 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 8535.69 999999999 5317.6 18390.3 case rate SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC 195 MS-DRG inpatient 1 UN 18959.07 12323.39 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 9484.1 999999999 5317.6 18390.3 case rate SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC 195 MS-DRG inpatient 1 UN 18959.07 12323.39 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 10042.13 999999999 5317.6 18390.3 case rate SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC 195 MS-DRG inpatient 1 UN 18959.07 12323.39 SIHO - ALL PLANS SIHO - ALL PLANS 17063.16 90 999999999 5317.6 18390.3 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC 195 MS-DRG inpatient 1 UN 18959.07 12323.39 UMR - ALL PLANS UMR - ALL PLANS 13271.35 70 999999999 5317.6 18390.3 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC 195 MS-DRG inpatient 1 UN 18959.07 12323.39 AETNA AETNA 14977.66 79 999999999 5317.6 18390.3 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC 195 MS-DRG inpatient 1 UN 18959.07 12323.39 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 18390.3 97 999999999 5317.6 18390.3 percent of total billed charges SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC 195 MS-DRG inpatient 1 UN 18959.07 12323.39 SELF PAY DISCOUNT SELF PAY DISCOUNT 12323.39 65 999999999 5317.6 18390.3 percent of total billed charges INTERSTITIAL LUNG DISEASE WITH MCC 196 MS-DRG inpatient 1 UN 41218.52 26792.04 ANTHEM HMO ANTHEM HMO 27041.67 999999999 16110.9 39981.96 case rate INTERSTITIAL LUNG DISEASE WITH MCC 196 MS-DRG inpatient 1 UN 41218.52 26792.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 28734.26 999999999 16110.9 39981.96 case rate INTERSTITIAL LUNG DISEASE WITH MCC 196 MS-DRG inpatient 1 UN 41218.52 26792.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 25860.84 999999999 16110.9 39981.96 case rate INTERSTITIAL LUNG DISEASE WITH MCC 196 MS-DRG inpatient 1 UN 41218.52 26792.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 27863.72 67.6 999999999 16110.9 39981.96 percent of total billed charges INTERSTITIAL LUNG DISEASE WITH MCC 196 MS-DRG inpatient 1 UN 41218.52 26792.04 UHC - ALL PLANS UHC - ALL PLANS 16110.9 999999999 16110.9 39981.96 case rate INTERSTITIAL LUNG DISEASE WITH MCC 196 MS-DRG inpatient 1 UN 41218.52 26792.04 SIHO - ALL PLANS SIHO - ALL PLANS 37096.67 90 999999999 16110.9 39981.96 percent of total billed charges INTERSTITIAL LUNG DISEASE WITH MCC 196 MS-DRG inpatient 1 UN 41218.52 26792.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 32150.45 78 999999999 16110.9 39981.96 percent of total billed charges INTERSTITIAL LUNG DISEASE WITH MCC 196 MS-DRG inpatient 1 UN 41218.52 26792.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 28440.78 69 999999999 16110.9 39981.96 percent of total billed charges INTERSTITIAL LUNG DISEASE WITH MCC 196 MS-DRG inpatient 1 UN 41218.52 26792.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 30424.96 999999999 16110.9 39981.96 case rate INTERSTITIAL LUNG DISEASE WITH MCC 196 MS-DRG inpatient 1 UN 41218.52 26792.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 26792.04 65 999999999 16110.9 39981.96 percent of total billed charges INTERSTITIAL LUNG DISEASE WITH MCC 196 MS-DRG inpatient 1 UN 41218.52 26792.04 AETNA AETNA 32562.63 79 999999999 16110.9 39981.96 percent of total billed charges INTERSTITIAL LUNG DISEASE WITH MCC 196 MS-DRG inpatient 1 UN 41218.52 26792.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39981.96 97 999999999 16110.9 39981.96 percent of total billed charges INTERSTITIAL LUNG DISEASE WITH MCC 196 MS-DRG inpatient 1 UN 41218.52 26792.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24957.81 60.55 999999999 16110.9 39981.96 percent of total billed charges INTERSTITIAL LUNG DISEASE WITH MCC 196 MS-DRG inpatient 1 UN 41218.52 26792.04 UMR - ALL PLANS UMR - ALL PLANS 28852.96 70 999999999 16110.9 39981.96 percent of total billed charges PNEUMOTHORAX WITH MCC 199 MS-DRG inpatient 1 UN 45251.76 29413.64 HUMANA - ALL PLANS HUMANA - ALL PLANS 35296.37 78 999999999 15079.85 43894.21 percent of total billed charges PNEUMOTHORAX WITH MCC 199 MS-DRG inpatient 1 UN 45251.76 29413.64 SIHO - ALL PLANS SIHO - ALL PLANS 40726.58 90 999999999 15079.85 43894.21 percent of total billed charges PNEUMOTHORAX WITH MCC 199 MS-DRG inpatient 1 UN 45251.76 29413.64 AETNA AETNA 35748.89 79 999999999 15079.85 43894.21 percent of total billed charges PNEUMOTHORAX WITH MCC 199 MS-DRG inpatient 1 UN 45251.76 29413.64 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 43894.21 97 999999999 15079.85 43894.21 percent of total billed charges PNEUMOTHORAX WITH MCC 199 MS-DRG inpatient 1 UN 45251.76 29413.64 UMR - ALL PLANS UMR - ALL PLANS 31676.23 70 999999999 15079.85 43894.21 percent of total billed charges PNEUMOTHORAX WITH MCC 199 MS-DRG inpatient 1 UN 45251.76 29413.64 ANTHEM HMO ANTHEM HMO 25311.08 999999999 15079.85 43894.21 case rate PNEUMOTHORAX WITH MCC 199 MS-DRG inpatient 1 UN 45251.76 29413.64 UHC - ALL PLANS UHC - ALL PLANS 15079.85 999999999 15079.85 43894.21 case rate PNEUMOTHORAX WITH MCC 199 MS-DRG inpatient 1 UN 45251.76 29413.64 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 24205.82 999999999 15079.85 43894.21 case rate PNEUMOTHORAX WITH MCC 199 MS-DRG inpatient 1 UN 45251.76 29413.64 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27399.94 60.55 999999999 15079.85 43894.21 percent of total billed charges PNEUMOTHORAX WITH MCC 199 MS-DRG inpatient 1 UN 45251.76 29413.64 ENCORE - ALL PLANS ENCORE - ALL PLANS 31223.71 69 999999999 15079.85 43894.21 percent of total billed charges PNEUMOTHORAX WITH MCC 199 MS-DRG inpatient 1 UN 45251.76 29413.64 SELF PAY DISCOUNT SELF PAY DISCOUNT 29413.64 65 999999999 15079.85 43894.21 percent of total billed charges PNEUMOTHORAX WITH MCC 199 MS-DRG inpatient 1 UN 45251.76 29413.64 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 26895.36 999999999 15079.85 43894.21 case rate PNEUMOTHORAX WITH MCC 199 MS-DRG inpatient 1 UN 45251.76 29413.64 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 28477.85 999999999 15079.85 43894.21 case rate PNEUMOTHORAX WITH MCC 199 MS-DRG inpatient 1 UN 45251.76 29413.64 CIGNA - ALL PLANS CIGNA - ALL PLANS 30590.19 67.6 999999999 15079.85 43894.21 percent of total billed charges PNEUMOTHORAX WITH CC 200 MS-DRG inpatient 1 UN 21343.35 13873.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 14428.1 67.6 999999999 9154.5 20703.05 percent of total billed charges PNEUMOTHORAX WITH CC 200 MS-DRG inpatient 1 UN 21343.35 13873.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 14694.59 999999999 9154.5 20703.05 case rate PNEUMOTHORAX WITH CC 200 MS-DRG inpatient 1 UN 21343.35 13873.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 16327.32 999999999 9154.5 20703.05 case rate PNEUMOTHORAX WITH CC 200 MS-DRG inpatient 1 UN 21343.35 13873.18 ANTHEM HMO ANTHEM HMO 15365.56 999999999 9154.5 20703.05 case rate PNEUMOTHORAX WITH CC 200 MS-DRG inpatient 1 UN 21343.35 13873.18 UHC - ALL PLANS UHC - ALL PLANS 9154.5 999999999 9154.5 20703.05 case rate PNEUMOTHORAX WITH CC 200 MS-DRG inpatient 1 UN 21343.35 13873.18 SIHO - ALL PLANS SIHO - ALL PLANS 19209.02 90 999999999 9154.5 20703.05 percent of total billed charges PNEUMOTHORAX WITH CC 200 MS-DRG inpatient 1 UN 21343.35 13873.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12923.4 60.55 999999999 9154.5 20703.05 percent of total billed charges PNEUMOTHORAX WITH CC 200 MS-DRG inpatient 1 UN 21343.35 13873.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 16647.81 78 999999999 9154.5 20703.05 percent of total billed charges PNEUMOTHORAX WITH CC 200 MS-DRG inpatient 1 UN 21343.35 13873.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 14726.91 69 999999999 9154.5 20703.05 percent of total billed charges PNEUMOTHORAX WITH CC 200 MS-DRG inpatient 1 UN 21343.35 13873.18 AETNA AETNA 16861.25 79 999999999 9154.5 20703.05 percent of total billed charges PNEUMOTHORAX WITH CC 200 MS-DRG inpatient 1 UN 21343.35 13873.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 13873.18 65 999999999 9154.5 20703.05 percent of total billed charges PNEUMOTHORAX WITH CC 200 MS-DRG inpatient 1 UN 21343.35 13873.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 17288 999999999 9154.5 20703.05 case rate PNEUMOTHORAX WITH CC 200 MS-DRG inpatient 1 UN 21343.35 13873.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20703.05 97 999999999 9154.5 20703.05 percent of total billed charges PNEUMOTHORAX WITH CC 200 MS-DRG inpatient 1 UN 21343.35 13873.18 UMR - ALL PLANS UMR - ALL PLANS 14940.35 70 999999999 9154.5 20703.05 percent of total billed charges BRONCHITIS AND ASTHMA WITH CC/MCC 202 MS-DRG inpatient 1 UN 15445 10039.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 10657.05 69 999999999 8138.75 15369.79 percent of total billed charges BRONCHITIS AND ASTHMA WITH CC/MCC 202 MS-DRG inpatient 1 UN 15445 10039.25 UHC - ALL PLANS UHC - ALL PLANS 8138.75 999999999 8138.75 15369.79 case rate BRONCHITIS AND ASTHMA WITH CC/MCC 202 MS-DRG inpatient 1 UN 15445 10039.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9351.95 60.55 999999999 8138.75 15369.79 percent of total billed charges BRONCHITIS AND ASTHMA WITH CC/MCC 202 MS-DRG inpatient 1 UN 15445 10039.25 ANTHEM HMO ANTHEM HMO 13660.65 999999999 8138.75 15369.79 case rate BRONCHITIS AND ASTHMA WITH CC/MCC 202 MS-DRG inpatient 1 UN 15445 10039.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 13064.13 999999999 8138.75 15369.79 case rate BRONCHITIS AND ASTHMA WITH CC/MCC 202 MS-DRG inpatient 1 UN 15445 10039.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 10440.82 67.6 999999999 8138.75 15369.79 percent of total billed charges BRONCHITIS AND ASTHMA WITH CC/MCC 202 MS-DRG inpatient 1 UN 15445 10039.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 12047.1 78 999999999 8138.75 15369.79 percent of total billed charges BRONCHITIS AND ASTHMA WITH CC/MCC 202 MS-DRG inpatient 1 UN 15445 10039.25 SIHO - ALL PLANS SIHO - ALL PLANS 13900.5 90 999999999 8138.75 15369.79 percent of total billed charges BRONCHITIS AND ASTHMA WITH CC/MCC 202 MS-DRG inpatient 1 UN 15445 10039.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 15369.79 999999999 8138.75 15369.79 case rate BRONCHITIS AND ASTHMA WITH CC/MCC 202 MS-DRG inpatient 1 UN 15445 10039.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 14515.7 999999999 8138.75 15369.79 case rate BRONCHITIS AND ASTHMA WITH CC/MCC 202 MS-DRG inpatient 1 UN 15445 10039.25 UMR - ALL PLANS UMR - ALL PLANS 10811.5 70 999999999 8138.75 15369.79 percent of total billed charges BRONCHITIS AND ASTHMA WITH CC/MCC 202 MS-DRG inpatient 1 UN 15445 10039.25 AETNA AETNA 12201.55 79 999999999 8138.75 15369.79 percent of total billed charges BRONCHITIS AND ASTHMA WITH CC/MCC 202 MS-DRG inpatient 1 UN 15445 10039.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14981.65 97 999999999 8138.75 15369.79 percent of total billed charges BRONCHITIS AND ASTHMA WITH CC/MCC 202 MS-DRG inpatient 1 UN 15445 10039.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 10039.25 65 999999999 8138.75 15369.79 percent of total billed charges BRONCHITIS AND ASTHMA WITHOUT CC/MCC 203 MS-DRG inpatient 1 UN 26499.4 17224.61 CIGNA - ALL PLANS CIGNA - ALL PLANS 17913.59 67.6 999999999 5906.65 25704.42 percent of total billed charges BRONCHITIS AND ASTHMA WITHOUT CC/MCC 203 MS-DRG inpatient 1 UN 26499.4 17224.61 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 11154.53 999999999 5906.65 25704.42 case rate BRONCHITIS AND ASTHMA WITHOUT CC/MCC 203 MS-DRG inpatient 1 UN 26499.4 17224.61 SELF PAY DISCOUNT SELF PAY DISCOUNT 17224.61 65 999999999 5906.65 25704.42 percent of total billed charges BRONCHITIS AND ASTHMA WITHOUT CC/MCC 203 MS-DRG inpatient 1 UN 26499.4 17224.61 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16045.39 60.55 999999999 5906.65 25704.42 percent of total billed charges BRONCHITIS AND ASTHMA WITHOUT CC/MCC 203 MS-DRG inpatient 1 UN 26499.4 17224.61 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 10534.68 999999999 5906.65 25704.42 case rate BRONCHITIS AND ASTHMA WITHOUT CC/MCC 203 MS-DRG inpatient 1 UN 26499.4 17224.61 ANTHEM HMO ANTHEM HMO 9914.14 999999999 5906.65 25704.42 case rate BRONCHITIS AND ASTHMA WITHOUT CC/MCC 203 MS-DRG inpatient 1 UN 26499.4 17224.61 UMR - ALL PLANS UMR - ALL PLANS 18549.58 70 999999999 5906.65 25704.42 percent of total billed charges BRONCHITIS AND ASTHMA WITHOUT CC/MCC 203 MS-DRG inpatient 1 UN 26499.4 17224.61 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25704.42 97 999999999 5906.65 25704.42 percent of total billed charges BRONCHITIS AND ASTHMA WITHOUT CC/MCC 203 MS-DRG inpatient 1 UN 26499.4 17224.61 SIHO - ALL PLANS SIHO - ALL PLANS 23849.46 90 999999999 5906.65 25704.42 percent of total billed charges BRONCHITIS AND ASTHMA WITHOUT CC/MCC 203 MS-DRG inpatient 1 UN 26499.4 17224.61 AETNA AETNA 20934.53 79 999999999 5906.65 25704.42 percent of total billed charges BRONCHITIS AND ASTHMA WITHOUT CC/MCC 203 MS-DRG inpatient 1 UN 26499.4 17224.61 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 9481.22 999999999 5906.65 25704.42 case rate BRONCHITIS AND ASTHMA WITHOUT CC/MCC 203 MS-DRG inpatient 1 UN 26499.4 17224.61 UHC - ALL PLANS UHC - ALL PLANS 5906.65 999999999 5906.65 25704.42 case rate BRONCHITIS AND ASTHMA WITHOUT CC/MCC 203 MS-DRG inpatient 1 UN 26499.4 17224.61 ENCORE - ALL PLANS ENCORE - ALL PLANS 18284.59 69 999999999 5906.65 25704.42 percent of total billed charges BRONCHITIS AND ASTHMA WITHOUT CC/MCC 203 MS-DRG inpatient 1 UN 26499.4 17224.61 HUMANA - ALL PLANS HUMANA - ALL PLANS 20669.53 78 999999999 5906.65 25704.42 percent of total billed charges RESPIRATORY SIGNS AND SYMPTOMS 204 MS-DRG inpatient 1 UN 20909.03 13590.87 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12660.42 60.55 999999999 6994.65 20281.76 percent of total billed charges RESPIRATORY SIGNS AND SYMPTOMS 204 MS-DRG inpatient 1 UN 20909.03 13590.87 UMR - ALL PLANS UMR - ALL PLANS 14636.32 70 999999999 6994.65 20281.76 percent of total billed charges RESPIRATORY SIGNS AND SYMPTOMS 204 MS-DRG inpatient 1 UN 20909.03 13590.87 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 12475.16 999999999 6994.65 20281.76 case rate RESPIRATORY SIGNS AND SYMPTOMS 204 MS-DRG inpatient 1 UN 20909.03 13590.87 ANTHEM HMO ANTHEM HMO 11740.31 999999999 6994.65 20281.76 case rate RESPIRATORY SIGNS AND SYMPTOMS 204 MS-DRG inpatient 1 UN 20909.03 13590.87 ENCORE - ALL PLANS ENCORE - ALL PLANS 14427.23 69 999999999 6994.65 20281.76 percent of total billed charges RESPIRATORY SIGNS AND SYMPTOMS 204 MS-DRG inpatient 1 UN 20909.03 13590.87 HUMANA - ALL PLANS HUMANA - ALL PLANS 16309.04 78 999999999 6994.65 20281.76 percent of total billed charges RESPIRATORY SIGNS AND SYMPTOMS 204 MS-DRG inpatient 1 UN 20909.03 13590.87 SIHO - ALL PLANS SIHO - ALL PLANS 18818.13 90 999999999 6994.65 20281.76 percent of total billed charges RESPIRATORY SIGNS AND SYMPTOMS 204 MS-DRG inpatient 1 UN 20909.03 13590.87 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 13209.19 999999999 6994.65 20281.76 case rate RESPIRATORY SIGNS AND SYMPTOMS 204 MS-DRG inpatient 1 UN 20909.03 13590.87 CIGNA - ALL PLANS CIGNA - ALL PLANS 14134.5 67.6 999999999 6994.65 20281.76 percent of total billed charges RESPIRATORY SIGNS AND SYMPTOMS 204 MS-DRG inpatient 1 UN 20909.03 13590.87 AETNA AETNA 16518.13 79 999999999 6994.65 20281.76 percent of total billed charges RESPIRATORY SIGNS AND SYMPTOMS 204 MS-DRG inpatient 1 UN 20909.03 13590.87 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20281.76 97 999999999 6994.65 20281.76 percent of total billed charges RESPIRATORY SIGNS AND SYMPTOMS 204 MS-DRG inpatient 1 UN 20909.03 13590.87 UHC - ALL PLANS UHC - ALL PLANS 6994.65 999999999 6994.65 20281.76 case rate RESPIRATORY SIGNS AND SYMPTOMS 204 MS-DRG inpatient 1 UN 20909.03 13590.87 SELF PAY DISCOUNT SELF PAY DISCOUNT 13590.87 65 999999999 6994.65 20281.76 percent of total billed charges RESPIRATORY SIGNS AND SYMPTOMS 204 MS-DRG inpatient 1 UN 20909.03 13590.87 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 11227.65 999999999 6994.65 20281.76 case rate OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC 205 MS-DRG inpatient 1 UN 31442.09 20437.36 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 27444.15 999999999 15387.55 30498.83 case rate OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC 205 MS-DRG inpatient 1 UN 31442.09 20437.36 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 29058.94 999999999 15387.55 30498.83 case rate OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC 205 MS-DRG inpatient 1 UN 31442.09 20437.36 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 24699.73 999999999 15387.55 30498.83 case rate OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC 205 MS-DRG inpatient 1 UN 31442.09 20437.36 CIGNA - ALL PLANS CIGNA - ALL PLANS 21254.85 67.6 999999999 15387.55 30498.83 percent of total billed charges OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC 205 MS-DRG inpatient 1 UN 31442.09 20437.36 ANTHEM HMO ANTHEM HMO 25827.55 999999999 15387.55 30498.83 case rate OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC 205 MS-DRG inpatient 1 UN 31442.09 20437.36 SELF PAY DISCOUNT SELF PAY DISCOUNT 20437.36 65 999999999 15387.55 30498.83 percent of total billed charges OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC 205 MS-DRG inpatient 1 UN 31442.09 20437.36 UHC - ALL PLANS UHC - ALL PLANS 15387.55 999999999 15387.55 30498.83 case rate OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC 205 MS-DRG inpatient 1 UN 31442.09 20437.36 SIHO - ALL PLANS SIHO - ALL PLANS 28297.88 90 999999999 15387.55 30498.83 percent of total billed charges OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC 205 MS-DRG inpatient 1 UN 31442.09 20437.36 HUMANA - ALL PLANS HUMANA - ALL PLANS 24524.83 78 999999999 15387.55 30498.83 percent of total billed charges OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC 205 MS-DRG inpatient 1 UN 31442.09 20437.36 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19038.19 60.55 999999999 15387.55 30498.83 percent of total billed charges OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC 205 MS-DRG inpatient 1 UN 31442.09 20437.36 ENCORE - ALL PLANS ENCORE - ALL PLANS 21695.04 69 999999999 15387.55 30498.83 percent of total billed charges OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC 205 MS-DRG inpatient 1 UN 31442.09 20437.36 AETNA AETNA 24839.25 79 999999999 15387.55 30498.83 percent of total billed charges OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC 205 MS-DRG inpatient 1 UN 31442.09 20437.36 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30498.83 97 999999999 15387.55 30498.83 percent of total billed charges OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC 205 MS-DRG inpatient 1 UN 31442.09 20437.36 UMR - ALL PLANS UMR - ALL PLANS 22009.46 70 999999999 15387.55 30498.83 percent of total billed charges OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC 206 MS-DRG inpatient 1 UN 27631.9 17960.74 HUMANA - ALL PLANS HUMANA - ALL PLANS 21552.88 78 999999999 7764.75 26802.94 percent of total billed charges OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC 206 MS-DRG inpatient 1 UN 27631.9 17960.74 SIHO - ALL PLANS SIHO - ALL PLANS 24868.71 90 999999999 7764.75 26802.94 percent of total billed charges OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC 206 MS-DRG inpatient 1 UN 27631.9 17960.74 AETNA AETNA 21829.2 79 999999999 7764.75 26802.94 percent of total billed charges OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC 206 MS-DRG inpatient 1 UN 27631.9 17960.74 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26802.94 97 999999999 7764.75 26802.94 percent of total billed charges OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC 206 MS-DRG inpatient 1 UN 27631.9 17960.74 UMR - ALL PLANS UMR - ALL PLANS 19342.33 70 999999999 7764.75 26802.94 percent of total billed charges OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC 206 MS-DRG inpatient 1 UN 27631.9 17960.74 ANTHEM HMO ANTHEM HMO 13032.9 999999999 7764.75 26802.94 case rate OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC 206 MS-DRG inpatient 1 UN 27631.9 17960.74 UHC - ALL PLANS UHC - ALL PLANS 7764.75 999999999 7764.75 26802.94 case rate OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC 206 MS-DRG inpatient 1 UN 27631.9 17960.74 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 12463.79 999999999 7764.75 26802.94 case rate OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC 206 MS-DRG inpatient 1 UN 27631.9 17960.74 ENCORE - ALL PLANS ENCORE - ALL PLANS 19066.01 69 999999999 7764.75 26802.94 percent of total billed charges OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC 206 MS-DRG inpatient 1 UN 27631.9 17960.74 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16731.12 60.55 999999999 7764.75 26802.94 percent of total billed charges OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC 206 MS-DRG inpatient 1 UN 27631.9 17960.74 SELF PAY DISCOUNT SELF PAY DISCOUNT 17960.74 65 999999999 7764.75 26802.94 percent of total billed charges OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC 206 MS-DRG inpatient 1 UN 27631.9 17960.74 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13848.66 999999999 7764.75 26802.94 case rate OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC 206 MS-DRG inpatient 1 UN 27631.9 17960.74 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 14663.5 999999999 7764.75 26802.94 case rate OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC 206 MS-DRG inpatient 1 UN 27631.9 17960.74 CIGNA - ALL PLANS CIGNA - ALL PLANS 18679.16 67.6 999999999 7764.75 26802.94 percent of total billed charges RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS 207 MS-DRG inpatient 1 UN 190943.85 124113.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 129078.04 67.6 999999999 58718 185215.53 percent of total billed charges RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS 207 MS-DRG inpatient 1 UN 190943.85 124113.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 110887.22 999999999 58718 185215.53 case rate RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS 207 MS-DRG inpatient 1 UN 190943.85 124113.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 104725.28 999999999 58718 185215.53 case rate RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS 207 MS-DRG inpatient 1 UN 190943.85 124113.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 124113.5 65 999999999 58718 185215.53 percent of total billed charges RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS 207 MS-DRG inpatient 1 UN 190943.85 124113.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 115616.5 60.55 999999999 58718 185215.53 percent of total billed charges RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS 207 MS-DRG inpatient 1 UN 190943.85 124113.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 131751.26 69 999999999 58718 185215.53 percent of total billed charges RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS 207 MS-DRG inpatient 1 UN 190943.85 124113.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 148936.2 78 999999999 58718 185215.53 percent of total billed charges RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS 207 MS-DRG inpatient 1 UN 190943.85 124113.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 94252.75 999999999 58718 185215.53 case rate RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS 207 MS-DRG inpatient 1 UN 190943.85 124113.5 UHC - ALL PLANS UHC - ALL PLANS 58718 999999999 58718 185215.53 case rate RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS 207 MS-DRG inpatient 1 UN 190943.85 124113.5 ANTHEM HMO ANTHEM HMO 98556.44 999999999 58718 185215.53 case rate RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS 207 MS-DRG inpatient 1 UN 190943.85 124113.5 UMR - ALL PLANS UMR - ALL PLANS 133660.69 70 999999999 58718 185215.53 percent of total billed charges RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS 207 MS-DRG inpatient 1 UN 190943.85 124113.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 185215.53 97 999999999 58718 185215.53 percent of total billed charges RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS 207 MS-DRG inpatient 1 UN 190943.85 124113.5 AETNA AETNA 150845.64 79 999999999 58718 185215.53 percent of total billed charges RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS 207 MS-DRG inpatient 1 UN 190943.85 124113.5 SIHO - ALL PLANS SIHO - ALL PLANS 171849.47 90 999999999 58718 185215.53 percent of total billed charges RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS 208 MS-DRG inpatient 1 UN 63905.72 41538.72 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 38694.91 60.55 999999999 22982.3 61988.55 percent of total billed charges RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS 208 MS-DRG inpatient 1 UN 63905.72 41538.72 UHC - ALL PLANS UHC - ALL PLANS 22982.3 999999999 22982.3 61988.55 case rate RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS 208 MS-DRG inpatient 1 UN 63905.72 41538.72 ENCORE - ALL PLANS ENCORE - ALL PLANS 44094.95 69 999999999 22982.3 61988.55 percent of total billed charges RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS 208 MS-DRG inpatient 1 UN 63905.72 41538.72 HUMANA - ALL PLANS HUMANA - ALL PLANS 49846.46 78 999999999 22982.3 61988.55 percent of total billed charges RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS 208 MS-DRG inpatient 1 UN 63905.72 41538.72 ANTHEM HMO ANTHEM HMO 38575.11 999999999 22982.3 61988.55 case rate RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS 208 MS-DRG inpatient 1 UN 63905.72 41538.72 CIGNA - ALL PLANS CIGNA - ALL PLANS 43200.27 67.6 999999999 22982.3 61988.55 percent of total billed charges RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS 208 MS-DRG inpatient 1 UN 63905.72 41538.72 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 36890.65 999999999 22982.3 61988.55 case rate RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS 208 MS-DRG inpatient 1 UN 63905.72 41538.72 SIHO - ALL PLANS SIHO - ALL PLANS 57515.15 90 999999999 22982.3 61988.55 percent of total billed charges RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS 208 MS-DRG inpatient 1 UN 63905.72 41538.72 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 40989.61 999999999 22982.3 61988.55 case rate RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS 208 MS-DRG inpatient 1 UN 63905.72 41538.72 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 43401.4 999999999 22982.3 61988.55 case rate RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS 208 MS-DRG inpatient 1 UN 63905.72 41538.72 AETNA AETNA 50485.52 79 999999999 22982.3 61988.55 percent of total billed charges RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS 208 MS-DRG inpatient 1 UN 63905.72 41538.72 UMR - ALL PLANS UMR - ALL PLANS 44734 70 999999999 22982.3 61988.55 percent of total billed charges RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS 208 MS-DRG inpatient 1 UN 63905.72 41538.72 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 61988.55 97 999999999 22982.3 61988.55 percent of total billed charges RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS 208 MS-DRG inpatient 1 UN 63905.72 41538.72 SELF PAY DISCOUNT SELF PAY DISCOUNT 41538.72 65 999999999 22982.3 61988.55 percent of total billed charges OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 264 MS-DRG inpatient 1 UN 23671.29 15386.34 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 23671.29 999999999 14332.96 27761 case rate OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 264 MS-DRG inpatient 1 UN 23671.29 15386.34 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 23671.29 999999999 14332.96 27761 case rate OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 264 MS-DRG inpatient 1 UN 23671.29 15386.34 ANTHEM HMO ANTHEM HMO 23671.29 999999999 14332.96 27761 case rate OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 264 MS-DRG inpatient 1 UN 23671.29 15386.34 CIGNA - ALL PLANS CIGNA - ALL PLANS 16001.79 67.6 999999999 14332.96 27761 percent of total billed charges OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 264 MS-DRG inpatient 1 UN 23671.29 15386.34 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 23671.29 999999999 14332.96 27761 case rate OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 264 MS-DRG inpatient 1 UN 23671.29 15386.34 SELF PAY DISCOUNT SELF PAY DISCOUNT 15386.34 65 999999999 14332.96 27761 percent of total billed charges OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 264 MS-DRG inpatient 1 UN 23671.29 15386.34 UHC - ALL PLANS UHC - ALL PLANS 27761 999999999 14332.96 27761 case rate OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 264 MS-DRG inpatient 1 UN 23671.29 15386.34 HUMANA - ALL PLANS HUMANA - ALL PLANS 18463.6 78 999999999 14332.96 27761 percent of total billed charges OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 264 MS-DRG inpatient 1 UN 23671.29 15386.34 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14332.96 60.55 999999999 14332.96 27761 percent of total billed charges OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 264 MS-DRG inpatient 1 UN 23671.29 15386.34 ENCORE - ALL PLANS ENCORE - ALL PLANS 16333.19 69 999999999 14332.96 27761 percent of total billed charges OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 264 MS-DRG inpatient 1 UN 23671.29 15386.34 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22961.15 97 999999999 14332.96 27761 percent of total billed charges OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 264 MS-DRG inpatient 1 UN 23671.29 15386.34 AETNA AETNA 18700.32 79 999999999 14332.96 27761 percent of total billed charges OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 264 MS-DRG inpatient 1 UN 23671.29 15386.34 UMR - ALL PLANS UMR - ALL PLANS 16569.9 70 999999999 14332.96 27761 percent of total billed charges OTHER CIRCULATORY SYSTEM O.R. PROCEDURES 264 MS-DRG inpatient 1 UN 23671.29 15386.34 SIHO - ALL PLANS SIHO - ALL PLANS 21304.16 90 999999999 14332.96 27761 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC" 280 MS-DRG inpatient 1 UN 24915.11 16194.82 UMR - ALL PLANS UMR - ALL PLANS 17440.57 70 999999999 13485.25 24915.11 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC" 280 MS-DRG inpatient 1 UN 24915.11 16194.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24167.65 97 999999999 13485.25 24915.11 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC" 280 MS-DRG inpatient 1 UN 24915.11 16194.82 AETNA AETNA 19682.94 79 999999999 13485.25 24915.11 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC" 280 MS-DRG inpatient 1 UN 24915.11 16194.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 24915.11 999999999 13485.25 24915.11 case rate "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC" 280 MS-DRG inpatient 1 UN 24915.11 16194.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 17191.42 69 999999999 13485.25 24915.11 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC" 280 MS-DRG inpatient 1 UN 24915.11 16194.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 19433.78 78 999999999 13485.25 24915.11 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC" 280 MS-DRG inpatient 1 UN 24915.11 16194.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15086.1 60.55 999999999 13485.25 24915.11 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC" 280 MS-DRG inpatient 1 UN 24915.11 16194.82 SIHO - ALL PLANS SIHO - ALL PLANS 22423.6 90 999999999 13485.25 24915.11 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC" 280 MS-DRG inpatient 1 UN 24915.11 16194.82 UHC - ALL PLANS UHC - ALL PLANS 13485.25 999999999 13485.25 24915.11 case rate "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC" 280 MS-DRG inpatient 1 UN 24915.11 16194.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 16194.82 65 999999999 13485.25 24915.11 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC" 280 MS-DRG inpatient 1 UN 24915.11 16194.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 21646.21 999999999 13485.25 24915.11 case rate "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC" 280 MS-DRG inpatient 1 UN 24915.11 16194.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 16842.61 67.6 999999999 13485.25 24915.11 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC" 280 MS-DRG inpatient 1 UN 24915.11 16194.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 24051.34 999999999 13485.25 24915.11 case rate "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC" 280 MS-DRG inpatient 1 UN 24915.11 16194.82 ANTHEM HMO ANTHEM HMO 22634.6 999999999 13485.25 24915.11 case rate "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC" 281 MS-DRG inpatient 1 UN 17928.23 11653.35 ANTHEM HMO ANTHEM HMO 13025.77 999999999 7760.5 17390.38 case rate "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC" 281 MS-DRG inpatient 1 UN 17928.23 11653.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 12456.97 999999999 7760.5 17390.38 case rate "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC" 281 MS-DRG inpatient 1 UN 17928.23 11653.35 UHC - ALL PLANS UHC - ALL PLANS 7760.5 999999999 7760.5 17390.38 case rate "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC" 281 MS-DRG inpatient 1 UN 17928.23 11653.35 AETNA AETNA 14163.3 79 999999999 7760.5 17390.38 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC" 281 MS-DRG inpatient 1 UN 17928.23 11653.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 12119.48 67.6 999999999 7760.5 17390.38 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC" 281 MS-DRG inpatient 1 UN 17928.23 11653.35 SIHO - ALL PLANS SIHO - ALL PLANS 16135.4 90 999999999 7760.5 17390.38 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC" 281 MS-DRG inpatient 1 UN 17928.23 11653.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 14655.48 999999999 7760.5 17390.38 case rate "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC" 281 MS-DRG inpatient 1 UN 17928.23 11653.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13841.08 999999999 7760.5 17390.38 case rate "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC" 281 MS-DRG inpatient 1 UN 17928.23 11653.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 11653.35 65 999999999 7760.5 17390.38 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC" 281 MS-DRG inpatient 1 UN 17928.23 11653.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 13984.02 78 999999999 7760.5 17390.38 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC" 281 MS-DRG inpatient 1 UN 17928.23 11653.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 12370.48 69 999999999 7760.5 17390.38 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC" 281 MS-DRG inpatient 1 UN 17928.23 11653.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17390.38 97 999999999 7760.5 17390.38 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC" 281 MS-DRG inpatient 1 UN 17928.23 11653.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10855.54 60.55 999999999 7760.5 17390.38 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC" 281 MS-DRG inpatient 1 UN 17928.23 11653.35 UMR - ALL PLANS UMR - ALL PLANS 12549.76 70 999999999 7760.5 17390.38 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC" 282 MS-DRG inpatient 1 UN 23472.55 15257.15 SIHO - ALL PLANS SIHO - ALL PLANS 21125.29 90 999999999 6103.85 22768.37 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC" 282 MS-DRG inpatient 1 UN 23472.55 15257.15 UMR - ALL PLANS UMR - ALL PLANS 16430.78 70 999999999 6103.85 22768.37 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC" 282 MS-DRG inpatient 1 UN 23472.55 15257.15 AETNA AETNA 18543.31 79 999999999 6103.85 22768.37 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC" 282 MS-DRG inpatient 1 UN 23472.55 15257.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22768.37 97 999999999 6103.85 22768.37 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC" 282 MS-DRG inpatient 1 UN 23472.55 15257.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 16196.06 69 999999999 6103.85 22768.37 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC" 282 MS-DRG inpatient 1 UN 23472.55 15257.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14212.63 60.55 999999999 6103.85 22768.37 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC" 282 MS-DRG inpatient 1 UN 23472.55 15257.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 15257.15 65 999999999 6103.85 22768.37 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC" 282 MS-DRG inpatient 1 UN 23472.55 15257.15 UHC - ALL PLANS UHC - ALL PLANS 6103.85 999999999 6103.85 22768.37 case rate "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC" 282 MS-DRG inpatient 1 UN 23472.55 15257.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 18308.59 78 999999999 6103.85 22768.37 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC" 282 MS-DRG inpatient 1 UN 23472.55 15257.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 15867.44 67.6 999999999 6103.85 22768.37 percent of total billed charges "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC" 282 MS-DRG inpatient 1 UN 23472.55 15257.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 9797.76 999999999 6103.85 22768.37 case rate "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC" 282 MS-DRG inpatient 1 UN 23472.55 15257.15 ANTHEM HMO ANTHEM HMO 10245.13 999999999 6103.85 22768.37 case rate "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC" 282 MS-DRG inpatient 1 UN 23472.55 15257.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 10886.4 999999999 6103.85 22768.37 case rate "ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC" 282 MS-DRG inpatient 1 UN 23472.55 15257.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 11526.94 999999999 6103.85 22768.37 case rate HEART FAILURE AND SHOCK WITH MCC 291 MS-DRG inpatient 1 UN 35718.4 23216.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 20609.16 999999999 10913.15 34646.85 case rate HEART FAILURE AND SHOCK WITH MCC 291 MS-DRG inpatient 1 UN 35718.4 23216.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 24145.64 67.6 999999999 10913.15 34646.85 percent of total billed charges HEART FAILURE AND SHOCK WITH MCC 291 MS-DRG inpatient 1 UN 35718.4 23216.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21627.49 60.55 999999999 10913.15 34646.85 percent of total billed charges HEART FAILURE AND SHOCK WITH MCC 291 MS-DRG inpatient 1 UN 35718.4 23216.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 23216.96 65 999999999 10913.15 34646.85 percent of total billed charges HEART FAILURE AND SHOCK WITH MCC 291 MS-DRG inpatient 1 UN 35718.4 23216.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 19463.92 999999999 10913.15 34646.85 case rate HEART FAILURE AND SHOCK WITH MCC 291 MS-DRG inpatient 1 UN 35718.4 23216.96 ANTHEM HMO ANTHEM HMO 18317.4 999999999 10913.15 34646.85 case rate HEART FAILURE AND SHOCK WITH MCC 291 MS-DRG inpatient 1 UN 35718.4 23216.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34646.85 97 999999999 10913.15 34646.85 percent of total billed charges HEART FAILURE AND SHOCK WITH MCC 291 MS-DRG inpatient 1 UN 35718.4 23216.96 UMR - ALL PLANS UMR - ALL PLANS 25002.88 70 999999999 10913.15 34646.85 percent of total billed charges HEART FAILURE AND SHOCK WITH MCC 291 MS-DRG inpatient 1 UN 35718.4 23216.96 AETNA AETNA 28217.54 79 999999999 10913.15 34646.85 percent of total billed charges HEART FAILURE AND SHOCK WITH MCC 291 MS-DRG inpatient 1 UN 35718.4 23216.96 SIHO - ALL PLANS SIHO - ALL PLANS 32146.56 90 999999999 10913.15 34646.85 percent of total billed charges HEART FAILURE AND SHOCK WITH MCC 291 MS-DRG inpatient 1 UN 35718.4 23216.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 17517.53 999999999 10913.15 34646.85 case rate HEART FAILURE AND SHOCK WITH MCC 291 MS-DRG inpatient 1 UN 35718.4 23216.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 27860.35 78 999999999 10913.15 34646.85 percent of total billed charges HEART FAILURE AND SHOCK WITH MCC 291 MS-DRG inpatient 1 UN 35718.4 23216.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 24645.7 69 999999999 10913.15 34646.85 percent of total billed charges HEART FAILURE AND SHOCK WITH MCC 291 MS-DRG inpatient 1 UN 35718.4 23216.96 UHC - ALL PLANS UHC - ALL PLANS 10913.15 999999999 10913.15 34646.85 case rate HEART FAILURE AND SHOCK WITH CC 292 MS-DRG inpatient 1 UN 24353.46 15829.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23622.85 97 999999999 7280.25 23622.85 percent of total billed charges HEART FAILURE AND SHOCK WITH CC 292 MS-DRG inpatient 1 UN 24353.46 15829.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 16803.89 69 999999999 7280.25 23622.85 percent of total billed charges HEART FAILURE AND SHOCK WITH CC 292 MS-DRG inpatient 1 UN 24353.46 15829.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14746.02 60.55 999999999 7280.25 23622.85 percent of total billed charges HEART FAILURE AND SHOCK WITH CC 292 MS-DRG inpatient 1 UN 24353.46 15829.75 UHC - ALL PLANS UHC - ALL PLANS 7280.25 999999999 7280.25 23622.85 case rate HEART FAILURE AND SHOCK WITH CC 292 MS-DRG inpatient 1 UN 24353.46 15829.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 15829.75 65 999999999 7280.25 23622.85 percent of total billed charges HEART FAILURE AND SHOCK WITH CC 292 MS-DRG inpatient 1 UN 24353.46 15829.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 18995.7 78 999999999 7280.25 23622.85 percent of total billed charges HEART FAILURE AND SHOCK WITH CC 292 MS-DRG inpatient 1 UN 24353.46 15829.75 ANTHEM HMO ANTHEM HMO 12219.69 999999999 7280.25 23622.85 case rate HEART FAILURE AND SHOCK WITH CC 292 MS-DRG inpatient 1 UN 24353.46 15829.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 11686.09 999999999 7280.25 23622.85 case rate HEART FAILURE AND SHOCK WITH CC 292 MS-DRG inpatient 1 UN 24353.46 15829.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 16462.94 67.6 999999999 7280.25 23622.85 percent of total billed charges HEART FAILURE AND SHOCK WITH CC 292 MS-DRG inpatient 1 UN 24353.46 15829.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 13748.54 999999999 7280.25 23622.85 case rate HEART FAILURE AND SHOCK WITH CC 292 MS-DRG inpatient 1 UN 24353.46 15829.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 12984.54 999999999 7280.25 23622.85 case rate HEART FAILURE AND SHOCK WITH CC 292 MS-DRG inpatient 1 UN 24353.46 15829.75 SIHO - ALL PLANS SIHO - ALL PLANS 21918.11 90 999999999 7280.25 23622.85 percent of total billed charges HEART FAILURE AND SHOCK WITH CC 292 MS-DRG inpatient 1 UN 24353.46 15829.75 UMR - ALL PLANS UMR - ALL PLANS 17047.42 70 999999999 7280.25 23622.85 percent of total billed charges HEART FAILURE AND SHOCK WITH CC 292 MS-DRG inpatient 1 UN 24353.46 15829.75 AETNA AETNA 19239.23 79 999999999 7280.25 23622.85 percent of total billed charges HEART FAILURE AND SHOCK WITHOUT CC/MCC 293 MS-DRG inpatient 1 UN 15737.4 10229.31 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 8512.34 999999999 4772.75 15265.28 case rate HEART FAILURE AND SHOCK WITHOUT CC/MCC 293 MS-DRG inpatient 1 UN 15737.4 10229.31 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 9013.2 999999999 4772.75 15265.28 case rate HEART FAILURE AND SHOCK WITHOUT CC/MCC 293 MS-DRG inpatient 1 UN 15737.4 10229.31 CIGNA - ALL PLANS CIGNA - ALL PLANS 10638.48 67.6 999999999 4772.75 15265.28 percent of total billed charges HEART FAILURE AND SHOCK WITHOUT CC/MCC 293 MS-DRG inpatient 1 UN 15737.4 10229.31 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 7661.11 999999999 4772.75 15265.28 case rate HEART FAILURE AND SHOCK WITHOUT CC/MCC 293 MS-DRG inpatient 1 UN 15737.4 10229.31 ANTHEM HMO ANTHEM HMO 8010.92 999999999 4772.75 15265.28 case rate HEART FAILURE AND SHOCK WITHOUT CC/MCC 293 MS-DRG inpatient 1 UN 15737.4 10229.31 SIHO - ALL PLANS SIHO - ALL PLANS 14163.66 90 999999999 4772.75 15265.28 percent of total billed charges HEART FAILURE AND SHOCK WITHOUT CC/MCC 293 MS-DRG inpatient 1 UN 15737.4 10229.31 SELF PAY DISCOUNT SELF PAY DISCOUNT 10229.31 65 999999999 4772.75 15265.28 percent of total billed charges HEART FAILURE AND SHOCK WITHOUT CC/MCC 293 MS-DRG inpatient 1 UN 15737.4 10229.31 UHC - ALL PLANS UHC - ALL PLANS 4772.75 999999999 4772.75 15265.28 case rate HEART FAILURE AND SHOCK WITHOUT CC/MCC 293 MS-DRG inpatient 1 UN 15737.4 10229.31 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9529 60.55 999999999 4772.75 15265.28 percent of total billed charges HEART FAILURE AND SHOCK WITHOUT CC/MCC 293 MS-DRG inpatient 1 UN 15737.4 10229.31 ENCORE - ALL PLANS ENCORE - ALL PLANS 10858.81 69 999999999 4772.75 15265.28 percent of total billed charges HEART FAILURE AND SHOCK WITHOUT CC/MCC 293 MS-DRG inpatient 1 UN 15737.4 10229.31 HUMANA - ALL PLANS HUMANA - ALL PLANS 12275.17 78 999999999 4772.75 15265.28 percent of total billed charges HEART FAILURE AND SHOCK WITHOUT CC/MCC 293 MS-DRG inpatient 1 UN 15737.4 10229.31 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15265.28 97 999999999 4772.75 15265.28 percent of total billed charges HEART FAILURE AND SHOCK WITHOUT CC/MCC 293 MS-DRG inpatient 1 UN 15737.4 10229.31 AETNA AETNA 12432.55 79 999999999 4772.75 15265.28 percent of total billed charges HEART FAILURE AND SHOCK WITHOUT CC/MCC 293 MS-DRG inpatient 1 UN 15737.4 10229.31 UMR - ALL PLANS UMR - ALL PLANS 11016.18 70 999999999 4772.75 15265.28 percent of total billed charges PERIPHERAL VASCULAR DISORDERS WITH MCC 299 MS-DRG inpatient 1 UN 35687.84 23197.09 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21608.98 60.55 999999999 13397.7 34617.2 percent of total billed charges PERIPHERAL VASCULAR DISORDERS WITH MCC 299 MS-DRG inpatient 1 UN 35687.84 23197.09 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34617.2 97 999999999 13397.7 34617.2 percent of total billed charges PERIPHERAL VASCULAR DISORDERS WITH MCC 299 MS-DRG inpatient 1 UN 35687.84 23197.09 UMR - ALL PLANS UMR - ALL PLANS 24981.48 70 999999999 13397.7 34617.2 percent of total billed charges PERIPHERAL VASCULAR DISORDERS WITH MCC 299 MS-DRG inpatient 1 UN 35687.84 23197.09 SELF PAY DISCOUNT SELF PAY DISCOUNT 23197.09 65 999999999 13397.7 34617.2 percent of total billed charges PERIPHERAL VASCULAR DISORDERS WITH MCC 299 MS-DRG inpatient 1 UN 35687.84 23197.09 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 25301.16 999999999 13397.7 34617.2 case rate PERIPHERAL VASCULAR DISORDERS WITH MCC 299 MS-DRG inpatient 1 UN 35687.84 23197.09 HUMANA - ALL PLANS HUMANA - ALL PLANS 27836.51 78 999999999 13397.7 34617.2 percent of total billed charges PERIPHERAL VASCULAR DISORDERS WITH MCC 299 MS-DRG inpatient 1 UN 35687.84 23197.09 ENCORE - ALL PLANS ENCORE - ALL PLANS 24624.61 69 999999999 13397.7 34617.2 percent of total billed charges PERIPHERAL VASCULAR DISORDERS WITH MCC 299 MS-DRG inpatient 1 UN 35687.84 23197.09 CIGNA - ALL PLANS CIGNA - ALL PLANS 24124.98 67.6 999999999 13397.7 34617.2 percent of total billed charges PERIPHERAL VASCULAR DISORDERS WITH MCC 299 MS-DRG inpatient 1 UN 35687.84 23197.09 UHC - ALL PLANS UHC - ALL PLANS 13397.7 999999999 13397.7 34617.2 case rate PERIPHERAL VASCULAR DISORDERS WITH MCC 299 MS-DRG inpatient 1 UN 35687.84 23197.09 AETNA AETNA 28193.39 79 999999999 13397.7 34617.2 percent of total billed charges PERIPHERAL VASCULAR DISORDERS WITH MCC 299 MS-DRG inpatient 1 UN 35687.84 23197.09 SIHO - ALL PLANS SIHO - ALL PLANS 32119.05 90 999999999 13397.7 34617.2 percent of total billed charges PERIPHERAL VASCULAR DISORDERS WITH MCC 299 MS-DRG inpatient 1 UN 35687.84 23197.09 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 21505.67 999999999 13397.7 34617.2 case rate PERIPHERAL VASCULAR DISORDERS WITH MCC 299 MS-DRG inpatient 1 UN 35687.84 23197.09 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 23895.19 999999999 13397.7 34617.2 case rate PERIPHERAL VASCULAR DISORDERS WITH MCC 299 MS-DRG inpatient 1 UN 35687.84 23197.09 ANTHEM HMO ANTHEM HMO 22487.65 999999999 13397.7 34617.2 case rate PERIPHERAL VASCULAR DISORDERS WITH CC 300 MS-DRG inpatient 1 UN 22388.83 14552.74 ANTHEM HMO ANTHEM HMO 15222.89 999999999 9069.5 21717.17 case rate PERIPHERAL VASCULAR DISORDERS WITH CC 300 MS-DRG inpatient 1 UN 22388.83 14552.74 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 16175.72 999999999 9069.5 21717.17 case rate PERIPHERAL VASCULAR DISORDERS WITH CC 300 MS-DRG inpatient 1 UN 22388.83 14552.74 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 14558.15 999999999 9069.5 21717.17 case rate PERIPHERAL VASCULAR DISORDERS WITH CC 300 MS-DRG inpatient 1 UN 22388.83 14552.74 CIGNA - ALL PLANS CIGNA - ALL PLANS 15134.85 67.6 999999999 9069.5 21717.17 percent of total billed charges PERIPHERAL VASCULAR DISORDERS WITH CC 300 MS-DRG inpatient 1 UN 22388.83 14552.74 SIHO - ALL PLANS SIHO - ALL PLANS 20149.95 90 999999999 9069.5 21717.17 percent of total billed charges PERIPHERAL VASCULAR DISORDERS WITH CC 300 MS-DRG inpatient 1 UN 22388.83 14552.74 AETNA AETNA 17687.18 79 999999999 9069.5 21717.17 percent of total billed charges PERIPHERAL VASCULAR DISORDERS WITH CC 300 MS-DRG inpatient 1 UN 22388.83 14552.74 SELF PAY DISCOUNT SELF PAY DISCOUNT 14552.74 65 999999999 9069.5 21717.17 percent of total billed charges PERIPHERAL VASCULAR DISORDERS WITH CC 300 MS-DRG inpatient 1 UN 22388.83 14552.74 UHC - ALL PLANS UHC - ALL PLANS 9069.5 999999999 9069.5 21717.17 case rate PERIPHERAL VASCULAR DISORDERS WITH CC 300 MS-DRG inpatient 1 UN 22388.83 14552.74 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13556.44 60.55 999999999 9069.5 21717.17 percent of total billed charges PERIPHERAL VASCULAR DISORDERS WITH CC 300 MS-DRG inpatient 1 UN 22388.83 14552.74 ENCORE - ALL PLANS ENCORE - ALL PLANS 15448.29 69 999999999 9069.5 21717.17 percent of total billed charges PERIPHERAL VASCULAR DISORDERS WITH CC 300 MS-DRG inpatient 1 UN 22388.83 14552.74 HUMANA - ALL PLANS HUMANA - ALL PLANS 17463.29 78 999999999 9069.5 21717.17 percent of total billed charges PERIPHERAL VASCULAR DISORDERS WITH CC 300 MS-DRG inpatient 1 UN 22388.83 14552.74 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 17127.48 999999999 9069.5 21717.17 case rate PERIPHERAL VASCULAR DISORDERS WITH CC 300 MS-DRG inpatient 1 UN 22388.83 14552.74 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21717.17 97 999999999 9069.5 21717.17 percent of total billed charges PERIPHERAL VASCULAR DISORDERS WITH CC 300 MS-DRG inpatient 1 UN 22388.83 14552.74 UMR - ALL PLANS UMR - ALL PLANS 15672.18 70 999999999 9069.5 21717.17 percent of total billed charges HYPERTENSION WITH MCC 304 MS-DRG inpatient 1 UN 15216.23 9890.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9213.43 60.55 999999999 9213.43 15216.23 percent of total billed charges HYPERTENSION WITH MCC 304 MS-DRG inpatient 1 UN 15216.23 9890.55 UMR - ALL PLANS UMR - ALL PLANS 10651.36 70 999999999 9213.43 15216.23 percent of total billed charges HYPERTENSION WITH MCC 304 MS-DRG inpatient 1 UN 15216.23 9890.55 ANTHEM HMO ANTHEM HMO 15216.23 999999999 9213.43 15216.23 case rate HYPERTENSION WITH MCC 304 MS-DRG inpatient 1 UN 15216.23 9890.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 15216.23 999999999 9213.43 15216.23 case rate HYPERTENSION WITH MCC 304 MS-DRG inpatient 1 UN 15216.23 9890.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 9890.55 65 999999999 9213.43 15216.23 percent of total billed charges HYPERTENSION WITH MCC 304 MS-DRG inpatient 1 UN 15216.23 9890.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 11868.66 78 999999999 9213.43 15216.23 percent of total billed charges HYPERTENSION WITH MCC 304 MS-DRG inpatient 1 UN 15216.23 9890.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 10499.2 69 999999999 9213.43 15216.23 percent of total billed charges HYPERTENSION WITH MCC 304 MS-DRG inpatient 1 UN 15216.23 9890.55 SIHO - ALL PLANS SIHO - ALL PLANS 13694.61 90 999999999 9213.43 15216.23 percent of total billed charges HYPERTENSION WITH MCC 304 MS-DRG inpatient 1 UN 15216.23 9890.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 15216.23 999999999 9213.43 15216.23 case rate HYPERTENSION WITH MCC 304 MS-DRG inpatient 1 UN 15216.23 9890.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 10286.17 67.6 999999999 9213.43 15216.23 percent of total billed charges HYPERTENSION WITH MCC 304 MS-DRG inpatient 1 UN 15216.23 9890.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14759.74 97 999999999 9213.43 15216.23 percent of total billed charges HYPERTENSION WITH MCC 304 MS-DRG inpatient 1 UN 15216.23 9890.55 AETNA AETNA 12020.82 79 999999999 9213.43 15216.23 percent of total billed charges HYPERTENSION WITH MCC 304 MS-DRG inpatient 1 UN 15216.23 9890.55 UHC - ALL PLANS UHC - ALL PLANS 9766.5 999999999 9213.43 15216.23 case rate HYPERTENSION WITH MCC 304 MS-DRG inpatient 1 UN 15216.23 9890.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 15216.23 999999999 9213.43 15216.23 case rate HYPERTENSION WITHOUT MCC 305 MS-DRG inpatient 1 UN 27013.38 17558.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 11423.06 999999999 6404.75 26202.98 case rate HYPERTENSION WITHOUT MCC 305 MS-DRG inpatient 1 UN 27013.38 17558.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12095.18 999999999 6404.75 26202.98 case rate HYPERTENSION WITHOUT MCC 305 MS-DRG inpatient 1 UN 27013.38 17558.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 18261.05 67.6 999999999 6404.75 26202.98 percent of total billed charges HYPERTENSION WITHOUT MCC 305 MS-DRG inpatient 1 UN 27013.38 17558.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10280.75 999999999 6404.75 26202.98 case rate HYPERTENSION WITHOUT MCC 305 MS-DRG inpatient 1 UN 27013.38 17558.7 ANTHEM HMO ANTHEM HMO 10750.18 999999999 6404.75 26202.98 case rate HYPERTENSION WITHOUT MCC 305 MS-DRG inpatient 1 UN 27013.38 17558.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 21070.44 78 999999999 6404.75 26202.98 percent of total billed charges HYPERTENSION WITHOUT MCC 305 MS-DRG inpatient 1 UN 27013.38 17558.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 17558.7 65 999999999 6404.75 26202.98 percent of total billed charges HYPERTENSION WITHOUT MCC 305 MS-DRG inpatient 1 UN 27013.38 17558.7 UHC - ALL PLANS UHC - ALL PLANS 6404.75 999999999 6404.75 26202.98 case rate HYPERTENSION WITHOUT MCC 305 MS-DRG inpatient 1 UN 27013.38 17558.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16356.6 60.55 999999999 6404.75 26202.98 percent of total billed charges HYPERTENSION WITHOUT MCC 305 MS-DRG inpatient 1 UN 27013.38 17558.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 18639.24 69 999999999 6404.75 26202.98 percent of total billed charges HYPERTENSION WITHOUT MCC 305 MS-DRG inpatient 1 UN 27013.38 17558.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26202.98 97 999999999 6404.75 26202.98 percent of total billed charges HYPERTENSION WITHOUT MCC 305 MS-DRG inpatient 1 UN 27013.38 17558.7 SIHO - ALL PLANS SIHO - ALL PLANS 24312.05 90 999999999 6404.75 26202.98 percent of total billed charges HYPERTENSION WITHOUT MCC 305 MS-DRG inpatient 1 UN 27013.38 17558.7 AETNA AETNA 21340.57 79 999999999 6404.75 26202.98 percent of total billed charges HYPERTENSION WITHOUT MCC 305 MS-DRG inpatient 1 UN 27013.38 17558.7 UMR - ALL PLANS UMR - ALL PLANS 18909.37 70 999999999 6404.75 26202.98 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC 308 MS-DRG inpatient 1 UN 40824.62 26536 HUMANA - ALL PLANS HUMANA - ALL PLANS 31843.2 78 999999999 10218.7 39599.88 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC 308 MS-DRG inpatient 1 UN 40824.62 26536 ENCORE - ALL PLANS ENCORE - ALL PLANS 28168.99 69 999999999 10218.7 39599.88 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC 308 MS-DRG inpatient 1 UN 40824.62 26536 UHC - ALL PLANS UHC - ALL PLANS 10218.7 999999999 10218.7 39599.88 case rate CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC 308 MS-DRG inpatient 1 UN 40824.62 26536 AETNA AETNA 32251.45 79 999999999 10218.7 39599.88 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC 308 MS-DRG inpatient 1 UN 40824.62 26536 SIHO - ALL PLANS SIHO - ALL PLANS 36742.16 90 999999999 10218.7 39599.88 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC 308 MS-DRG inpatient 1 UN 40824.62 26536 CIGNA - ALL PLANS CIGNA - ALL PLANS 27597.44 67.6 999999999 10218.7 39599.88 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC 308 MS-DRG inpatient 1 UN 40824.62 26536 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 16402.82 999999999 10218.7 39599.88 case rate CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC 308 MS-DRG inpatient 1 UN 40824.62 26536 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39599.88 97 999999999 10218.7 39599.88 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC 308 MS-DRG inpatient 1 UN 40824.62 26536 ANTHEM HMO ANTHEM HMO 17151.79 999999999 10218.7 39599.88 case rate CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC 308 MS-DRG inpatient 1 UN 40824.62 26536 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 18225.35 999999999 10218.7 39599.88 case rate CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC 308 MS-DRG inpatient 1 UN 40824.62 26536 SELF PAY DISCOUNT SELF PAY DISCOUNT 26536 65 999999999 10218.7 39599.88 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC 308 MS-DRG inpatient 1 UN 40824.62 26536 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24719.31 60.55 999999999 10218.7 39599.88 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC 308 MS-DRG inpatient 1 UN 40824.62 26536 UMR - ALL PLANS UMR - ALL PLANS 28577.23 70 999999999 10218.7 39599.88 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC 308 MS-DRG inpatient 1 UN 40824.62 26536 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 19297.71 999999999 10218.7 39599.88 case rate CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC 309 MS-DRG inpatient 1 UN 26701.47 17355.96 UHC - ALL PLANS UHC - ALL PLANS 6329.95 999999999 6329.95 25900.43 case rate CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC 309 MS-DRG inpatient 1 UN 26701.47 17355.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10160.69 999999999 6329.95 25900.43 case rate CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC 309 MS-DRG inpatient 1 UN 26701.47 17355.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25900.43 97 999999999 6329.95 25900.43 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC 309 MS-DRG inpatient 1 UN 26701.47 17355.96 AETNA AETNA 21094.16 79 999999999 6329.95 25900.43 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC 309 MS-DRG inpatient 1 UN 26701.47 17355.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 11953.92 999999999 6329.95 25900.43 case rate CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC 309 MS-DRG inpatient 1 UN 26701.47 17355.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 18050.2 67.6 999999999 6329.95 25900.43 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC 309 MS-DRG inpatient 1 UN 26701.47 17355.96 SIHO - ALL PLANS SIHO - ALL PLANS 24031.32 90 999999999 6329.95 25900.43 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC 309 MS-DRG inpatient 1 UN 26701.47 17355.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 11289.65 999999999 6329.95 25900.43 case rate CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC 309 MS-DRG inpatient 1 UN 26701.47 17355.96 ANTHEM HMO ANTHEM HMO 10624.63 999999999 6329.95 25900.43 case rate CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC 309 MS-DRG inpatient 1 UN 26701.47 17355.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 20827.15 78 999999999 6329.95 25900.43 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC 309 MS-DRG inpatient 1 UN 26701.47 17355.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 18424.02 69 999999999 6329.95 25900.43 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC 309 MS-DRG inpatient 1 UN 26701.47 17355.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 17355.96 65 999999999 6329.95 25900.43 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC 309 MS-DRG inpatient 1 UN 26701.47 17355.96 UMR - ALL PLANS UMR - ALL PLANS 18691.03 70 999999999 6329.95 25900.43 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC 309 MS-DRG inpatient 1 UN 26701.47 17355.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16167.74 60.55 999999999 6329.95 25900.43 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC 310 MS-DRG inpatient 1 UN 18126.8 11782.42 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17582.99 97 999999999 4700.5 17582.99 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC 310 MS-DRG inpatient 1 UN 18126.8 11782.42 SELF PAY DISCOUNT SELF PAY DISCOUNT 11782.42 65 999999999 4700.5 17582.99 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC 310 MS-DRG inpatient 1 UN 18126.8 11782.42 AETNA AETNA 14320.17 79 999999999 4700.5 17582.99 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC 310 MS-DRG inpatient 1 UN 18126.8 11782.42 SIHO - ALL PLANS SIHO - ALL PLANS 16314.12 90 999999999 4700.5 17582.99 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC 310 MS-DRG inpatient 1 UN 18126.8 11782.42 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 8876.76 999999999 4700.5 17582.99 case rate CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC 310 MS-DRG inpatient 1 UN 18126.8 11782.42 HUMANA - ALL PLANS HUMANA - ALL PLANS 14138.9 78 999999999 4700.5 17582.99 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC 310 MS-DRG inpatient 1 UN 18126.8 11782.42 ENCORE - ALL PLANS ENCORE - ALL PLANS 12507.49 69 999999999 4700.5 17582.99 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC 310 MS-DRG inpatient 1 UN 18126.8 11782.42 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10975.78 60.55 999999999 4700.5 17582.99 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC 310 MS-DRG inpatient 1 UN 18126.8 11782.42 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 8383.48 999999999 4700.5 17582.99 case rate CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC 310 MS-DRG inpatient 1 UN 18126.8 11782.42 ANTHEM HMO ANTHEM HMO 7889.65 999999999 4700.5 17582.99 case rate CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC 310 MS-DRG inpatient 1 UN 18126.8 11782.42 UHC - ALL PLANS UHC - ALL PLANS 4700.5 999999999 4700.5 17582.99 case rate CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC 310 MS-DRG inpatient 1 UN 18126.8 11782.42 UMR - ALL PLANS UMR - ALL PLANS 12688.76 70 999999999 4700.5 17582.99 percent of total billed charges CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC 310 MS-DRG inpatient 1 UN 18126.8 11782.42 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 7545.13 999999999 4700.5 17582.99 case rate CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC 310 MS-DRG inpatient 1 UN 18126.8 11782.42 CIGNA - ALL PLANS CIGNA - ALL PLANS 12253.71 67.6 999999999 4700.5 17582.99 percent of total billed charges SYNCOPE AND COLLAPSE 312 MS-DRG inpatient 1 UN 23030.88 14970.07 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13090.66 999999999 7339.75 22339.96 case rate SYNCOPE AND COLLAPSE 312 MS-DRG inpatient 1 UN 23030.88 14970.07 UHC - ALL PLANS UHC - ALL PLANS 7339.75 999999999 7339.75 22339.96 case rate SYNCOPE AND COLLAPSE 312 MS-DRG inpatient 1 UN 23030.88 14970.07 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 13860.9 999999999 7339.75 22339.96 case rate SYNCOPE AND COLLAPSE 312 MS-DRG inpatient 1 UN 23030.88 14970.07 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 11781.59 999999999 7339.75 22339.96 case rate SYNCOPE AND COLLAPSE 312 MS-DRG inpatient 1 UN 23030.88 14970.07 ANTHEM HMO ANTHEM HMO 12319.55 999999999 7339.75 22339.96 case rate SYNCOPE AND COLLAPSE 312 MS-DRG inpatient 1 UN 23030.88 14970.07 SIHO - ALL PLANS SIHO - ALL PLANS 20727.79 90 999999999 7339.75 22339.96 percent of total billed charges SYNCOPE AND COLLAPSE 312 MS-DRG inpatient 1 UN 23030.88 14970.07 SELF PAY DISCOUNT SELF PAY DISCOUNT 14970.07 65 999999999 7339.75 22339.96 percent of total billed charges SYNCOPE AND COLLAPSE 312 MS-DRG inpatient 1 UN 23030.88 14970.07 AETNA AETNA 18194.4 79 999999999 7339.75 22339.96 percent of total billed charges SYNCOPE AND COLLAPSE 312 MS-DRG inpatient 1 UN 23030.88 14970.07 CIGNA - ALL PLANS CIGNA - ALL PLANS 15568.88 67.6 999999999 7339.75 22339.96 percent of total billed charges SYNCOPE AND COLLAPSE 312 MS-DRG inpatient 1 UN 23030.88 14970.07 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22339.96 97 999999999 7339.75 22339.96 percent of total billed charges SYNCOPE AND COLLAPSE 312 MS-DRG inpatient 1 UN 23030.88 14970.07 UMR - ALL PLANS UMR - ALL PLANS 16121.62 70 999999999 7339.75 22339.96 percent of total billed charges SYNCOPE AND COLLAPSE 312 MS-DRG inpatient 1 UN 23030.88 14970.07 ENCORE - ALL PLANS ENCORE - ALL PLANS 15891.31 69 999999999 7339.75 22339.96 percent of total billed charges SYNCOPE AND COLLAPSE 312 MS-DRG inpatient 1 UN 23030.88 14970.07 HUMANA - ALL PLANS HUMANA - ALL PLANS 17964.09 78 999999999 7339.75 22339.96 percent of total billed charges SYNCOPE AND COLLAPSE 312 MS-DRG inpatient 1 UN 23030.88 14970.07 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13945.2 60.55 999999999 7339.75 22339.96 percent of total billed charges CHEST PAIN 313 MS-DRG inpatient 1 UN 21805.99 14173.89 AETNA AETNA 17226.73 79 999999999 6150.6 21151.81 percent of total billed charges CHEST PAIN 313 MS-DRG inpatient 1 UN 21805.99 14173.89 SIHO - ALL PLANS SIHO - ALL PLANS 19625.39 90 999999999 6150.6 21151.81 percent of total billed charges CHEST PAIN 313 MS-DRG inpatient 1 UN 21805.99 14173.89 HUMANA - ALL PLANS HUMANA - ALL PLANS 17008.67 78 999999999 6150.6 21151.81 percent of total billed charges CHEST PAIN 313 MS-DRG inpatient 1 UN 21805.99 14173.89 ENCORE - ALL PLANS ENCORE - ALL PLANS 15046.13 69 999999999 6150.6 21151.81 percent of total billed charges CHEST PAIN 313 MS-DRG inpatient 1 UN 21805.99 14173.89 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 10969.78 999999999 6150.6 21151.81 case rate CHEST PAIN 313 MS-DRG inpatient 1 UN 21805.99 14173.89 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13203.53 60.55 999999999 6150.6 21151.81 percent of total billed charges CHEST PAIN 313 MS-DRG inpatient 1 UN 21805.99 14173.89 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 11615.23 999999999 6150.6 21151.81 case rate CHEST PAIN 313 MS-DRG inpatient 1 UN 21805.99 14173.89 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21151.81 97 999999999 6150.6 21151.81 percent of total billed charges CHEST PAIN 313 MS-DRG inpatient 1 UN 21805.99 14173.89 UHC - ALL PLANS UHC - ALL PLANS 6150.6 999999999 6150.6 21151.81 case rate CHEST PAIN 313 MS-DRG inpatient 1 UN 21805.99 14173.89 UMR - ALL PLANS UMR - ALL PLANS 15264.19 70 999999999 6150.6 21151.81 percent of total billed charges CHEST PAIN 313 MS-DRG inpatient 1 UN 21805.99 14173.89 SELF PAY DISCOUNT SELF PAY DISCOUNT 14173.89 65 999999999 6150.6 21151.81 percent of total billed charges CHEST PAIN 313 MS-DRG inpatient 1 UN 21805.99 14173.89 ANTHEM HMO ANTHEM HMO 10323.6 999999999 6150.6 21151.81 case rate CHEST PAIN 313 MS-DRG inpatient 1 UN 21805.99 14173.89 CIGNA - ALL PLANS CIGNA - ALL PLANS 14740.85 67.6 999999999 6150.6 21151.81 percent of total billed charges CHEST PAIN 313 MS-DRG inpatient 1 UN 21805.99 14173.89 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 9872.8 999999999 6150.6 21151.81 case rate OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC 314 MS-DRG inpatient 1 UN 25908.02 16840.21 CIGNA - ALL PLANS CIGNA - ALL PLANS 17513.82 67.6 999999999 15687.31 25908.02 percent of total billed charges OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC 314 MS-DRG inpatient 1 UN 25908.02 16840.21 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 25908.02 999999999 15687.31 25908.02 case rate OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC 314 MS-DRG inpatient 1 UN 25908.02 16840.21 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15687.31 60.55 999999999 15687.31 25908.02 percent of total billed charges OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC 314 MS-DRG inpatient 1 UN 25908.02 16840.21 AETNA AETNA 20467.34 79 999999999 15687.31 25908.02 percent of total billed charges OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC 314 MS-DRG inpatient 1 UN 25908.02 16840.21 HUMANA - ALL PLANS HUMANA - ALL PLANS 20208.26 78 999999999 15687.31 25908.02 percent of total billed charges OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC 314 MS-DRG inpatient 1 UN 25908.02 16840.21 ENCORE - ALL PLANS ENCORE - ALL PLANS 17876.53 69 999999999 15687.31 25908.02 percent of total billed charges OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC 314 MS-DRG inpatient 1 UN 25908.02 16840.21 SELF PAY DISCOUNT SELF PAY DISCOUNT 16840.21 65 999999999 15687.31 25908.02 percent of total billed charges OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC 314 MS-DRG inpatient 1 UN 25908.02 16840.21 UHC - ALL PLANS UHC - ALL PLANS 17794.75 999999999 15687.31 25908.02 case rate OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC 314 MS-DRG inpatient 1 UN 25908.02 16840.21 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 25908.02 999999999 15687.31 25908.02 case rate OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC 314 MS-DRG inpatient 1 UN 25908.02 16840.21 SIHO - ALL PLANS SIHO - ALL PLANS 23317.22 90 999999999 15687.31 25908.02 percent of total billed charges OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC 314 MS-DRG inpatient 1 UN 25908.02 16840.21 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25130.78 97 999999999 15687.31 25908.02 percent of total billed charges OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC 314 MS-DRG inpatient 1 UN 25908.02 16840.21 ANTHEM HMO ANTHEM HMO 25908.02 999999999 15687.31 25908.02 case rate OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC 314 MS-DRG inpatient 1 UN 25908.02 16840.21 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 25908.02 999999999 15687.31 25908.02 case rate OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC 314 MS-DRG inpatient 1 UN 25908.02 16840.21 UMR - ALL PLANS UMR - ALL PLANS 18135.61 70 999999999 15687.31 25908.02 percent of total billed charges OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC 315 MS-DRG inpatient 1 UN 24833.14 16141.54 UHC - ALL PLANS UHC - ALL PLANS 8222.05 999999999 8222.05 24088.14 case rate OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC 315 MS-DRG inpatient 1 UN 24833.14 16141.54 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15036.46 60.55 999999999 8222.05 24088.14 percent of total billed charges OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC 315 MS-DRG inpatient 1 UN 24833.14 16141.54 HUMANA - ALL PLANS HUMANA - ALL PLANS 19369.85 78 999999999 8222.05 24088.14 percent of total billed charges OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC 315 MS-DRG inpatient 1 UN 24833.14 16141.54 ENCORE - ALL PLANS ENCORE - ALL PLANS 17134.86 69 999999999 8222.05 24088.14 percent of total billed charges OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC 315 MS-DRG inpatient 1 UN 24833.14 16141.54 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 13197.84 999999999 8222.05 24088.14 case rate OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC 315 MS-DRG inpatient 1 UN 24833.14 16141.54 UMR - ALL PLANS UMR - ALL PLANS 17383.19 70 999999999 8222.05 24088.14 percent of total billed charges OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC 315 MS-DRG inpatient 1 UN 24833.14 16141.54 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24088.14 97 999999999 8222.05 24088.14 percent of total billed charges OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC 315 MS-DRG inpatient 1 UN 24833.14 16141.54 CIGNA - ALL PLANS CIGNA - ALL PLANS 16787.2 67.6 999999999 8222.05 24088.14 percent of total billed charges OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC 315 MS-DRG inpatient 1 UN 24833.14 16141.54 AETNA AETNA 19618.18 79 999999999 8222.05 24088.14 percent of total billed charges OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC 315 MS-DRG inpatient 1 UN 24833.14 16141.54 SELF PAY DISCOUNT SELF PAY DISCOUNT 16141.54 65 999999999 8222.05 24088.14 percent of total billed charges OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC 315 MS-DRG inpatient 1 UN 24833.14 16141.54 SIHO - ALL PLANS SIHO - ALL PLANS 22349.82 90 999999999 8222.05 24088.14 percent of total billed charges OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC 315 MS-DRG inpatient 1 UN 24833.14 16141.54 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 14664.27 999999999 8222.05 24088.14 case rate OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC 315 MS-DRG inpatient 1 UN 24833.14 16141.54 ANTHEM HMO ANTHEM HMO 13800.47 999999999 8222.05 24088.14 case rate OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC 315 MS-DRG inpatient 1 UN 24833.14 16141.54 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 15527.1 999999999 8222.05 24088.14 case rate "STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC" 328 MS-DRG inpatient 1 UN 70914.2 46094.23 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 25639.86 999999999 13577.05 68786.77 case rate "STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC" 328 MS-DRG inpatient 1 UN 70914.2 46094.23 CIGNA - ALL PLANS CIGNA - ALL PLANS 47938 67.6 999999999 13577.05 68786.77 percent of total billed charges "STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC" 328 MS-DRG inpatient 1 UN 70914.2 46094.23 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42938.55 60.55 999999999 13577.05 68786.77 percent of total billed charges "STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC" 328 MS-DRG inpatient 1 UN 70914.2 46094.23 SELF PAY DISCOUNT SELF PAY DISCOUNT 46094.23 65 999999999 13577.05 68786.77 percent of total billed charges "STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC" 328 MS-DRG inpatient 1 UN 70914.2 46094.23 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 24215.07 999999999 13577.05 68786.77 case rate "STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC" 328 MS-DRG inpatient 1 UN 70914.2 46094.23 ANTHEM HMO ANTHEM HMO 22788.68 999999999 13577.05 68786.77 case rate "STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC" 328 MS-DRG inpatient 1 UN 70914.2 46094.23 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 68786.77 97 999999999 13577.05 68786.77 percent of total billed charges "STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC" 328 MS-DRG inpatient 1 UN 70914.2 46094.23 UMR - ALL PLANS UMR - ALL PLANS 49639.94 70 999999999 13577.05 68786.77 percent of total billed charges "STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC" 328 MS-DRG inpatient 1 UN 70914.2 46094.23 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 21793.56 999999999 13577.05 68786.77 case rate "STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC" 328 MS-DRG inpatient 1 UN 70914.2 46094.23 SIHO - ALL PLANS SIHO - ALL PLANS 63822.78 90 999999999 13577.05 68786.77 percent of total billed charges "STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC" 328 MS-DRG inpatient 1 UN 70914.2 46094.23 AETNA AETNA 56022.22 79 999999999 13577.05 68786.77 percent of total billed charges "STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC" 328 MS-DRG inpatient 1 UN 70914.2 46094.23 ENCORE - ALL PLANS ENCORE - ALL PLANS 48930.8 69 999999999 13577.05 68786.77 percent of total billed charges "STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC" 328 MS-DRG inpatient 1 UN 70914.2 46094.23 HUMANA - ALL PLANS HUMANA - ALL PLANS 55313.08 78 999999999 13577.05 68786.77 percent of total billed charges "STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC" 328 MS-DRG inpatient 1 UN 70914.2 46094.23 UHC - ALL PLANS UHC - ALL PLANS 13577.05 999999999 13577.05 68786.77 case rate MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 329 MS-DRG inpatient 1 UN 113776.06 73954.44 UHC - ALL PLANS UHC - ALL PLANS 38392.8 999999999 38392.8 110362.78 case rate MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 329 MS-DRG inpatient 1 UN 113776.06 73954.44 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 68891.41 60.55 999999999 38392.8 110362.78 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 329 MS-DRG inpatient 1 UN 113776.06 73954.44 HUMANA - ALL PLANS HUMANA - ALL PLANS 88745.33 78 999999999 38392.8 110362.78 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 329 MS-DRG inpatient 1 UN 113776.06 73954.44 ENCORE - ALL PLANS ENCORE - ALL PLANS 78505.48 69 999999999 38392.8 110362.78 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 329 MS-DRG inpatient 1 UN 113776.06 73954.44 AETNA AETNA 89883.09 79 999999999 38392.8 110362.78 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 329 MS-DRG inpatient 1 UN 113776.06 73954.44 SIHO - ALL PLANS SIHO - ALL PLANS 102398.46 90 999999999 38392.8 110362.78 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 329 MS-DRG inpatient 1 UN 113776.06 73954.44 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 61627.22 999999999 38392.8 110362.78 case rate MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 329 MS-DRG inpatient 1 UN 113776.06 73954.44 CIGNA - ALL PLANS CIGNA - ALL PLANS 76912.62 67.6 999999999 38392.8 110362.78 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 329 MS-DRG inpatient 1 UN 113776.06 73954.44 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 110362.78 97 999999999 38392.8 110362.78 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 329 MS-DRG inpatient 1 UN 113776.06 73954.44 ANTHEM HMO ANTHEM HMO 64441.19 999999999 38392.8 110362.78 case rate MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 329 MS-DRG inpatient 1 UN 113776.06 73954.44 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 68474.69 999999999 38392.8 110362.78 case rate MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 329 MS-DRG inpatient 1 UN 113776.06 73954.44 SELF PAY DISCOUNT SELF PAY DISCOUNT 73954.44 65 999999999 38392.8 110362.78 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 329 MS-DRG inpatient 1 UN 113776.06 73954.44 UMR - ALL PLANS UMR - ALL PLANS 79643.24 70 999999999 38392.8 110362.78 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 329 MS-DRG inpatient 1 UN 113776.06 73954.44 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 72503.67 999999999 38392.8 110362.78 case rate MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 330 MS-DRG inpatient 1 UN 60727.15 39472.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 39472.65 65 999999999 20162.85 58905.33 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 330 MS-DRG inpatient 1 UN 60727.15 39472.65 UMR - ALL PLANS UMR - ALL PLANS 42509 70 999999999 20162.85 58905.33 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 330 MS-DRG inpatient 1 UN 60727.15 39472.65 AETNA AETNA 47974.45 79 999999999 20162.85 58905.33 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 330 MS-DRG inpatient 1 UN 60727.15 39472.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58905.33 97 999999999 20162.85 58905.33 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 330 MS-DRG inpatient 1 UN 60727.15 39472.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 35961.04 999999999 20162.85 58905.33 case rate MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 330 MS-DRG inpatient 1 UN 60727.15 39472.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 38076.95 999999999 20162.85 58905.33 case rate MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 330 MS-DRG inpatient 1 UN 60727.15 39472.65 SIHO - ALL PLANS SIHO - ALL PLANS 54654.43 90 999999999 20162.85 58905.33 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 330 MS-DRG inpatient 1 UN 60727.15 39472.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 41051.55 67.6 999999999 20162.85 58905.33 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 330 MS-DRG inpatient 1 UN 60727.15 39472.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 32364.93 999999999 20162.85 58905.33 case rate MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 330 MS-DRG inpatient 1 UN 60727.15 39472.65 ANTHEM HMO ANTHEM HMO 33842.75 999999999 20162.85 58905.33 case rate MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 330 MS-DRG inpatient 1 UN 60727.15 39472.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 47367.18 78 999999999 20162.85 58905.33 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 330 MS-DRG inpatient 1 UN 60727.15 39472.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 41901.73 69 999999999 20162.85 58905.33 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 330 MS-DRG inpatient 1 UN 60727.15 39472.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36770.29 60.55 999999999 20162.85 58905.33 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 330 MS-DRG inpatient 1 UN 60727.15 39472.65 UHC - ALL PLANS UHC - ALL PLANS 20162.85 999999999 20162.85 58905.33 case rate MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 331 MS-DRG inpatient 1 UN 60918.4 39596.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 47516.35 78 999999999 14212 59090.85 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 331 MS-DRG inpatient 1 UN 60918.4 39596.96 SIHO - ALL PLANS SIHO - ALL PLANS 54826.56 90 999999999 14212 59090.85 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 331 MS-DRG inpatient 1 UN 60918.4 39596.96 AETNA AETNA 48125.54 79 999999999 14212 59090.85 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 331 MS-DRG inpatient 1 UN 60918.4 39596.96 UMR - ALL PLANS UMR - ALL PLANS 42642.88 70 999999999 14212 59090.85 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 331 MS-DRG inpatient 1 UN 60918.4 39596.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59090.85 97 999999999 14212 59090.85 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 331 MS-DRG inpatient 1 UN 60918.4 39596.96 ANTHEM HMO ANTHEM HMO 23854.42 999999999 14212 59090.85 case rate MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 331 MS-DRG inpatient 1 UN 60918.4 39596.96 UHC - ALL PLANS UHC - ALL PLANS 14212 999999999 14212 59090.85 case rate MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 331 MS-DRG inpatient 1 UN 60918.4 39596.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 22812.77 999999999 14212 59090.85 case rate MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 331 MS-DRG inpatient 1 UN 60918.4 39596.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 39596.96 65 999999999 14212 59090.85 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 331 MS-DRG inpatient 1 UN 60918.4 39596.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36886.09 60.55 999999999 14212 59090.85 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 331 MS-DRG inpatient 1 UN 60918.4 39596.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 42033.7 69 999999999 14212 59090.85 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 331 MS-DRG inpatient 1 UN 60918.4 39596.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 26838.94 999999999 14212 59090.85 case rate MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 331 MS-DRG inpatient 1 UN 60918.4 39596.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 41180.84 67.6 999999999 14212 59090.85 percent of total billed charges MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 331 MS-DRG inpatient 1 UN 60918.4 39596.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 25347.52 999999999 14212 59090.85 case rate PERITONEAL ADHESIOLYSIS WITH MCC 335 MS-DRG inpatient 1 UN 129001.71 83851.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 83851.11 65 999999999 30387.5 125131.66 percent of total billed charges PERITONEAL ADHESIOLYSIS WITH MCC 335 MS-DRG inpatient 1 UN 129001.71 83851.11 AETNA AETNA 101911.35 79 999999999 30387.5 125131.66 percent of total billed charges PERITONEAL ADHESIOLYSIS WITH MCC 335 MS-DRG inpatient 1 UN 129001.71 83851.11 UMR - ALL PLANS UMR - ALL PLANS 90301.2 70 999999999 30387.5 125131.66 percent of total billed charges PERITONEAL ADHESIOLYSIS WITH MCC 335 MS-DRG inpatient 1 UN 129001.71 83851.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 125131.66 97 999999999 30387.5 125131.66 percent of total billed charges PERITONEAL ADHESIOLYSIS WITH MCC 335 MS-DRG inpatient 1 UN 129001.71 83851.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 54197 999999999 30387.5 125131.66 case rate PERITONEAL ADHESIOLYSIS WITH MCC 335 MS-DRG inpatient 1 UN 129001.71 83851.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 57385.9 999999999 30387.5 125131.66 case rate PERITONEAL ADHESIOLYSIS WITH MCC 335 MS-DRG inpatient 1 UN 129001.71 83851.11 SIHO - ALL PLANS SIHO - ALL PLANS 116101.54 90 999999999 30387.5 125131.66 percent of total billed charges PERITONEAL ADHESIOLYSIS WITH MCC 335 MS-DRG inpatient 1 UN 129001.71 83851.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 100621.33 78 999999999 30387.5 125131.66 percent of total billed charges PERITONEAL ADHESIOLYSIS WITH MCC 335 MS-DRG inpatient 1 UN 129001.71 83851.11 ANTHEM HMO ANTHEM HMO 51004.53 999999999 30387.5 125131.66 case rate PERITONEAL ADHESIOLYSIS WITH MCC 335 MS-DRG inpatient 1 UN 129001.71 83851.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 48777.3 999999999 30387.5 125131.66 case rate PERITONEAL ADHESIOLYSIS WITH MCC 335 MS-DRG inpatient 1 UN 129001.71 83851.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 87205.16 67.6 999999999 30387.5 125131.66 percent of total billed charges PERITONEAL ADHESIOLYSIS WITH MCC 335 MS-DRG inpatient 1 UN 129001.71 83851.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 89011.18 69 999999999 30387.5 125131.66 percent of total billed charges PERITONEAL ADHESIOLYSIS WITH MCC 335 MS-DRG inpatient 1 UN 129001.71 83851.11 UHC - ALL PLANS UHC - ALL PLANS 30387.5 999999999 30387.5 125131.66 case rate PERITONEAL ADHESIOLYSIS WITH MCC 335 MS-DRG inpatient 1 UN 129001.71 83851.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 78110.54 60.55 999999999 30387.5 125131.66 percent of total billed charges PERITONEAL ADHESIOLYSIS WITH CC 336 MS-DRG inpatient 1 UN 49125.26 31931.42 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29745.34 60.55 999999999 17895.05 47651.5 percent of total billed charges PERITONEAL ADHESIOLYSIS WITH CC 336 MS-DRG inpatient 1 UN 49125.26 31931.42 UHC - ALL PLANS UHC - ALL PLANS 17895.05 999999999 17895.05 47651.5 case rate PERITONEAL ADHESIOLYSIS WITH CC 336 MS-DRG inpatient 1 UN 49125.26 31931.42 ENCORE - ALL PLANS ENCORE - ALL PLANS 33896.43 69 999999999 17895.05 47651.5 percent of total billed charges PERITONEAL ADHESIOLYSIS WITH CC 336 MS-DRG inpatient 1 UN 49125.26 31931.42 HUMANA - ALL PLANS HUMANA - ALL PLANS 38317.7 78 999999999 17895.05 47651.5 percent of total billed charges PERITONEAL ADHESIOLYSIS WITH CC 336 MS-DRG inpatient 1 UN 49125.26 31931.42 CIGNA - ALL PLANS CIGNA - ALL PLANS 33208.67 67.6 999999999 17895.05 47651.5 percent of total billed charges PERITONEAL ADHESIOLYSIS WITH CC 336 MS-DRG inpatient 1 UN 49125.26 31931.42 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 28724.71 999999999 17895.05 47651.5 case rate PERITONEAL ADHESIOLYSIS WITH CC 336 MS-DRG inpatient 1 UN 49125.26 31931.42 SIHO - ALL PLANS SIHO - ALL PLANS 44212.73 90 999999999 17895.05 47651.5 percent of total billed charges PERITONEAL ADHESIOLYSIS WITH CC 336 MS-DRG inpatient 1 UN 49125.26 31931.42 AETNA AETNA 38808.95 79 999999999 17895.05 47651.5 percent of total billed charges PERITONEAL ADHESIOLYSIS WITH CC 336 MS-DRG inpatient 1 UN 49125.26 31931.42 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 47651.5 97 999999999 17895.05 47651.5 percent of total billed charges PERITONEAL ADHESIOLYSIS WITH CC 336 MS-DRG inpatient 1 UN 49125.26 31931.42 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 31916.35 999999999 17895.05 47651.5 case rate PERITONEAL ADHESIOLYSIS WITH CC 336 MS-DRG inpatient 1 UN 49125.26 31931.42 ANTHEM HMO ANTHEM HMO 30036.32 999999999 17895.05 47651.5 case rate PERITONEAL ADHESIOLYSIS WITH CC 336 MS-DRG inpatient 1 UN 49125.26 31931.42 SELF PAY DISCOUNT SELF PAY DISCOUNT 31931.42 65 999999999 17895.05 47651.5 percent of total billed charges PERITONEAL ADHESIOLYSIS WITH CC 336 MS-DRG inpatient 1 UN 49125.26 31931.42 UMR - ALL PLANS UMR - ALL PLANS 34387.68 70 999999999 17895.05 47651.5 percent of total billed charges PERITONEAL ADHESIOLYSIS WITH CC 336 MS-DRG inpatient 1 UN 49125.26 31931.42 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 33794.28 999999999 17895.05 47651.5 case rate PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC 337 MS-DRG inpatient 1 UN 44551.61 28958.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 22685.42 999999999 12719.4 43215.06 case rate PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC 337 MS-DRG inpatient 1 UN 44551.61 28958.55 ANTHEM HMO ANTHEM HMO 21349.14 999999999 12719.4 43215.06 case rate PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC 337 MS-DRG inpatient 1 UN 44551.61 28958.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 30116.89 67.6 999999999 12719.4 43215.06 percent of total billed charges PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC 337 MS-DRG inpatient 1 UN 44551.61 28958.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 24020.21 999999999 12719.4 43215.06 case rate PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC 337 MS-DRG inpatient 1 UN 44551.61 28958.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 30740.61 69 999999999 12719.4 43215.06 percent of total billed charges PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC 337 MS-DRG inpatient 1 UN 44551.61 28958.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 34750.26 78 999999999 12719.4 43215.06 percent of total billed charges PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC 337 MS-DRG inpatient 1 UN 44551.61 28958.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 28958.55 65 999999999 12719.4 43215.06 percent of total billed charges PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC 337 MS-DRG inpatient 1 UN 44551.61 28958.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26976 60.55 999999999 12719.4 43215.06 percent of total billed charges PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC 337 MS-DRG inpatient 1 UN 44551.61 28958.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 20416.88 999999999 12719.4 43215.06 case rate PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC 337 MS-DRG inpatient 1 UN 44551.61 28958.55 UHC - ALL PLANS UHC - ALL PLANS 12719.4 999999999 12719.4 43215.06 case rate PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC 337 MS-DRG inpatient 1 UN 44551.61 28958.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 43215.06 97 999999999 12719.4 43215.06 percent of total billed charges PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC 337 MS-DRG inpatient 1 UN 44551.61 28958.55 AETNA AETNA 35195.77 79 999999999 12719.4 43215.06 percent of total billed charges PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC 337 MS-DRG inpatient 1 UN 44551.61 28958.55 UMR - ALL PLANS UMR - ALL PLANS 31186.13 70 999999999 12719.4 43215.06 percent of total billed charges PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC 337 MS-DRG inpatient 1 UN 44551.61 28958.55 SIHO - ALL PLANS SIHO - ALL PLANS 40096.45 90 999999999 12719.4 43215.06 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 338 MS-DRG inpatient 1 UN 70747.7 45986.01 SIHO - ALL PLANS SIHO - ALL PLANS 63672.93 90 999999999 22580.25 68625.27 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 338 MS-DRG inpatient 1 UN 70747.7 45986.01 AETNA AETNA 55890.68 79 999999999 22580.25 68625.27 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 338 MS-DRG inpatient 1 UN 70747.7 45986.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 68625.27 97 999999999 22580.25 68625.27 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 338 MS-DRG inpatient 1 UN 70747.7 45986.01 UHC - ALL PLANS UHC - ALL PLANS 22580.25 999999999 22580.25 68625.27 case rate APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 338 MS-DRG inpatient 1 UN 70747.7 45986.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 36245.29 999999999 22580.25 68625.27 case rate APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 338 MS-DRG inpatient 1 UN 70747.7 45986.01 UMR - ALL PLANS UMR - ALL PLANS 49523.39 70 999999999 22580.25 68625.27 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 338 MS-DRG inpatient 1 UN 70747.7 45986.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 45986.01 65 999999999 22580.25 68625.27 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 338 MS-DRG inpatient 1 UN 70747.7 45986.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 55183.21 78 999999999 22580.25 68625.27 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 338 MS-DRG inpatient 1 UN 70747.7 45986.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 48815.91 69 999999999 22580.25 68625.27 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 338 MS-DRG inpatient 1 UN 70747.7 45986.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 42837.73 60.55 999999999 22580.25 68625.27 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 338 MS-DRG inpatient 1 UN 70747.7 45986.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 42642.14 999999999 22580.25 68625.27 case rate APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 338 MS-DRG inpatient 1 UN 70747.7 45986.01 ANTHEM HMO ANTHEM HMO 37900.29 999999999 22580.25 68625.27 case rate APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 338 MS-DRG inpatient 1 UN 70747.7 45986.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 40272.54 999999999 22580.25 68625.27 case rate APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 338 MS-DRG inpatient 1 UN 70747.7 45986.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 47825.45 67.6 999999999 22580.25 68625.27 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC 339 MS-DRG inpatient 1 UN 53714.39 34914.35 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 22217.89 999999999 13841.4 52102.96 case rate APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC 339 MS-DRG inpatient 1 UN 53714.39 34914.35 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 24686.54 999999999 13841.4 52102.96 case rate APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC 339 MS-DRG inpatient 1 UN 53714.39 34914.35 ANTHEM HMO ANTHEM HMO 23232.38 999999999 13841.4 52102.96 case rate APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC 339 MS-DRG inpatient 1 UN 53714.39 34914.35 SIHO - ALL PLANS SIHO - ALL PLANS 48342.95 90 999999999 13841.4 52102.96 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC 339 MS-DRG inpatient 1 UN 53714.39 34914.35 AETNA AETNA 42434.37 79 999999999 13841.4 52102.96 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC 339 MS-DRG inpatient 1 UN 53714.39 34914.35 UHC - ALL PLANS UHC - ALL PLANS 13841.4 999999999 13841.4 52102.96 case rate APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC 339 MS-DRG inpatient 1 UN 53714.39 34914.35 HUMANA - ALL PLANS HUMANA - ALL PLANS 41897.22 78 999999999 13841.4 52102.96 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC 339 MS-DRG inpatient 1 UN 53714.39 34914.35 ENCORE - ALL PLANS ENCORE - ALL PLANS 37062.93 69 999999999 13841.4 52102.96 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC 339 MS-DRG inpatient 1 UN 53714.39 34914.35 CIGNA - ALL PLANS CIGNA - ALL PLANS 36310.93 67.6 999999999 13841.4 52102.96 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC 339 MS-DRG inpatient 1 UN 53714.39 34914.35 SELF PAY DISCOUNT SELF PAY DISCOUNT 34914.35 65 999999999 13841.4 52102.96 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC 339 MS-DRG inpatient 1 UN 53714.39 34914.35 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 26139.08 999999999 13841.4 52102.96 case rate APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC 339 MS-DRG inpatient 1 UN 53714.39 34914.35 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32524.06 60.55 999999999 13841.4 52102.96 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC 339 MS-DRG inpatient 1 UN 53714.39 34914.35 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 52102.96 97 999999999 13841.4 52102.96 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC 339 MS-DRG inpatient 1 UN 53714.39 34914.35 UMR - ALL PLANS UMR - ALL PLANS 37600.07 70 999999999 13841.4 52102.96 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 340 MS-DRG inpatient 1 UN 49876.83 32419.94 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48380.52 97 999999999 10199.15 48380.52 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 340 MS-DRG inpatient 1 UN 49876.83 32419.94 UMR - ALL PLANS UMR - ALL PLANS 34913.78 70 999999999 10199.15 48380.52 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 340 MS-DRG inpatient 1 UN 49876.83 32419.94 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 19260.79 999999999 10199.15 48380.52 case rate APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 340 MS-DRG inpatient 1 UN 49876.83 32419.94 SELF PAY DISCOUNT SELF PAY DISCOUNT 32419.94 65 999999999 10199.15 48380.52 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 340 MS-DRG inpatient 1 UN 49876.83 32419.94 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30200.42 60.55 999999999 10199.15 48380.52 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 340 MS-DRG inpatient 1 UN 49876.83 32419.94 ENCORE - ALL PLANS ENCORE - ALL PLANS 34415.01 69 999999999 10199.15 48380.52 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 340 MS-DRG inpatient 1 UN 49876.83 32419.94 HUMANA - ALL PLANS HUMANA - ALL PLANS 38903.93 78 999999999 10199.15 48380.52 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 340 MS-DRG inpatient 1 UN 49876.83 32419.94 UHC - ALL PLANS UHC - ALL PLANS 10199.15 999999999 10199.15 48380.52 case rate APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 340 MS-DRG inpatient 1 UN 49876.83 32419.94 AETNA AETNA 39402.69 79 999999999 10199.15 48380.52 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 340 MS-DRG inpatient 1 UN 49876.83 32419.94 SIHO - ALL PLANS SIHO - ALL PLANS 44889.15 90 999999999 10199.15 48380.52 percent of total billed charges APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 340 MS-DRG inpatient 1 UN 49876.83 32419.94 ANTHEM HMO ANTHEM HMO 17118.97 999999999 10199.15 48380.52 case rate APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 340 MS-DRG inpatient 1 UN 49876.83 32419.94 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 18190.48 999999999 10199.15 48380.52 case rate APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 340 MS-DRG inpatient 1 UN 49876.83 32419.94 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 16371.44 999999999 10199.15 48380.52 case rate APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 340 MS-DRG inpatient 1 UN 49876.83 32419.94 CIGNA - ALL PLANS CIGNA - ALL PLANS 33716.74 67.6 999999999 10199.15 48380.52 percent of total billed charges APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 341 MS-DRG inpatient 1 UN 61834.86 40192.66 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 34246.44 999999999 19201.5 59979.81 case rate APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 341 MS-DRG inpatient 1 UN 61834.86 40192.66 CIGNA - ALL PLANS CIGNA - ALL PLANS 41800.37 67.6 999999999 19201.5 59979.81 percent of total billed charges APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 341 MS-DRG inpatient 1 UN 61834.86 40192.66 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 36261.47 999999999 19201.5 59979.81 case rate APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 341 MS-DRG inpatient 1 UN 61834.86 40192.66 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 37441.01 60.55 999999999 19201.5 59979.81 percent of total billed charges APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 341 MS-DRG inpatient 1 UN 61834.86 40192.66 ENCORE - ALL PLANS ENCORE - ALL PLANS 42666.05 69 999999999 19201.5 59979.81 percent of total billed charges APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 341 MS-DRG inpatient 1 UN 61834.86 40192.66 HUMANA - ALL PLANS HUMANA - ALL PLANS 48231.19 78 999999999 19201.5 59979.81 percent of total billed charges APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 341 MS-DRG inpatient 1 UN 61834.86 40192.66 SELF PAY DISCOUNT SELF PAY DISCOUNT 40192.66 65 999999999 19201.5 59979.81 percent of total billed charges APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 341 MS-DRG inpatient 1 UN 61834.86 40192.66 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59979.81 97 999999999 19201.5 59979.81 percent of total billed charges APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 341 MS-DRG inpatient 1 UN 61834.86 40192.66 UMR - ALL PLANS UMR - ALL PLANS 43284.4 70 999999999 19201.5 59979.81 percent of total billed charges APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 341 MS-DRG inpatient 1 UN 61834.86 40192.66 ANTHEM HMO ANTHEM HMO 32229.15 999999999 19201.5 59979.81 case rate APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 341 MS-DRG inpatient 1 UN 61834.86 40192.66 UHC - ALL PLANS UHC - ALL PLANS 19201.5 999999999 19201.5 59979.81 case rate APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 341 MS-DRG inpatient 1 UN 61834.86 40192.66 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 30821.8 999999999 19201.5 59979.81 case rate APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 341 MS-DRG inpatient 1 UN 61834.86 40192.66 AETNA AETNA 48849.54 79 999999999 19201.5 59979.81 percent of total billed charges APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC 341 MS-DRG inpatient 1 UN 61834.86 40192.66 SIHO - ALL PLANS SIHO - ALL PLANS 55651.37 90 999999999 19201.5 59979.81 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 344 MS-DRG inpatient 1 UN 95469.49 62055.17 SIHO - ALL PLANS SIHO - ALL PLANS 85922.54 90 999999999 23293.4 92605.41 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 344 MS-DRG inpatient 1 UN 95469.49 62055.17 AETNA AETNA 75420.9 79 999999999 23293.4 92605.41 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 344 MS-DRG inpatient 1 UN 95469.49 62055.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 92605.41 97 999999999 23293.4 92605.41 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 344 MS-DRG inpatient 1 UN 95469.49 62055.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 37390.02 999999999 23293.4 92605.41 case rate MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 344 MS-DRG inpatient 1 UN 95469.49 62055.17 UHC - ALL PLANS UHC - ALL PLANS 23293.4 999999999 23293.4 92605.41 case rate MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 344 MS-DRG inpatient 1 UN 95469.49 62055.17 UMR - ALL PLANS UMR - ALL PLANS 66828.64 70 999999999 23293.4 92605.41 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 344 MS-DRG inpatient 1 UN 95469.49 62055.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 62055.17 65 999999999 23293.4 92605.41 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 344 MS-DRG inpatient 1 UN 95469.49 62055.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 74466.2 78 999999999 23293.4 92605.41 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 344 MS-DRG inpatient 1 UN 95469.49 62055.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 65873.95 69 999999999 23293.4 92605.41 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 344 MS-DRG inpatient 1 UN 95469.49 62055.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 57806.78 60.55 999999999 23293.4 92605.41 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 344 MS-DRG inpatient 1 UN 95469.49 62055.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 64537.38 67.6 999999999 23293.4 92605.41 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 344 MS-DRG inpatient 1 UN 95469.49 62055.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 41544.46 999999999 23293.4 92605.41 case rate MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 344 MS-DRG inpatient 1 UN 95469.49 62055.17 ANTHEM HMO ANTHEM HMO 39097.29 999999999 23293.4 92605.41 case rate MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC 344 MS-DRG inpatient 1 UN 95469.49 62055.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 43988.9 999999999 23293.4 92605.41 case rate MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 345 MS-DRG inpatient 1 UN 25351.35 16478.38 SELF PAY DISCOUNT SELF PAY DISCOUNT 16478.38 65 999999999 13095.1 24729.71 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 345 MS-DRG inpatient 1 UN 25351.35 16478.38 AETNA AETNA 20027.57 79 999999999 13095.1 24729.71 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 345 MS-DRG inpatient 1 UN 25351.35 16478.38 UMR - ALL PLANS UMR - ALL PLANS 17745.95 70 999999999 13095.1 24729.71 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 345 MS-DRG inpatient 1 UN 25351.35 16478.38 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24590.81 97 999999999 13095.1 24729.71 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 345 MS-DRG inpatient 1 UN 25351.35 16478.38 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 23355.5 999999999 13095.1 24729.71 case rate MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 345 MS-DRG inpatient 1 UN 25351.35 16478.38 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 24729.71 999999999 13095.1 24729.71 case rate MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 345 MS-DRG inpatient 1 UN 25351.35 16478.38 SIHO - ALL PLANS SIHO - ALL PLANS 22816.22 90 999999999 13095.1 24729.71 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 345 MS-DRG inpatient 1 UN 25351.35 16478.38 ANTHEM HMO ANTHEM HMO 21979.74 999999999 13095.1 24729.71 case rate MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 345 MS-DRG inpatient 1 UN 25351.35 16478.38 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 21019.95 999999999 13095.1 24729.71 case rate MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 345 MS-DRG inpatient 1 UN 25351.35 16478.38 CIGNA - ALL PLANS CIGNA - ALL PLANS 17137.51 67.6 999999999 13095.1 24729.71 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 345 MS-DRG inpatient 1 UN 25351.35 16478.38 HUMANA - ALL PLANS HUMANA - ALL PLANS 19774.05 78 999999999 13095.1 24729.71 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 345 MS-DRG inpatient 1 UN 25351.35 16478.38 ENCORE - ALL PLANS ENCORE - ALL PLANS 17492.43 69 999999999 13095.1 24729.71 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 345 MS-DRG inpatient 1 UN 25351.35 16478.38 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15350.24 60.55 999999999 13095.1 24729.71 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC 345 MS-DRG inpatient 1 UN 25351.35 16478.38 UHC - ALL PLANS UHC - ALL PLANS 13095.1 999999999 13095.1 24729.71 case rate MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 346 MS-DRG inpatient 1 UN 40546.25 26355.06 UMR - ALL PLANS UMR - ALL PLANS 28382.37 70 999999999 10946.3 39329.86 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 346 MS-DRG inpatient 1 UN 40546.25 26355.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39329.86 97 999999999 10946.3 39329.86 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 346 MS-DRG inpatient 1 UN 40546.25 26355.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24550.75 60.55 999999999 10946.3 39329.86 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 346 MS-DRG inpatient 1 UN 40546.25 26355.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 19523.05 999999999 10946.3 39329.86 case rate MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 346 MS-DRG inpatient 1 UN 40546.25 26355.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 20671.77 999999999 10946.3 39329.86 case rate MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 346 MS-DRG inpatient 1 UN 40546.25 26355.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 27976.91 69 999999999 10946.3 39329.86 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 346 MS-DRG inpatient 1 UN 40546.25 26355.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 26355.06 65 999999999 10946.3 39329.86 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 346 MS-DRG inpatient 1 UN 40546.25 26355.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 27409.26 67.6 999999999 10946.3 39329.86 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 346 MS-DRG inpatient 1 UN 40546.25 26355.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 31626.07 78 999999999 10946.3 39329.86 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 346 MS-DRG inpatient 1 UN 40546.25 26355.06 AETNA AETNA 32031.53 79 999999999 10946.3 39329.86 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 346 MS-DRG inpatient 1 UN 40546.25 26355.06 SIHO - ALL PLANS SIHO - ALL PLANS 36491.62 90 999999999 10946.3 39329.86 percent of total billed charges MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 346 MS-DRG inpatient 1 UN 40546.25 26355.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 17570.74 999999999 10946.3 39329.86 case rate MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 346 MS-DRG inpatient 1 UN 40546.25 26355.06 ANTHEM HMO ANTHEM HMO 18373.04 999999999 10946.3 39329.86 case rate MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC 346 MS-DRG inpatient 1 UN 40546.25 26355.06 UHC - ALL PLANS UHC - ALL PLANS 10946.3 999999999 10946.3 39329.86 case rate ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC 349 MS-DRG inpatient 1 UN 31942.75 20762.79 UHC - ALL PLANS UHC - ALL PLANS 8294.3 999999999 8294.3 30984.47 case rate ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC 349 MS-DRG inpatient 1 UN 31942.75 20762.79 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 13313.82 999999999 8294.3 30984.47 case rate ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC 349 MS-DRG inpatient 1 UN 31942.75 20762.79 SELF PAY DISCOUNT SELF PAY DISCOUNT 20762.79 65 999999999 8294.3 30984.47 percent of total billed charges ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC 349 MS-DRG inpatient 1 UN 31942.75 20762.79 AETNA AETNA 25234.77 79 999999999 8294.3 30984.47 percent of total billed charges ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC 349 MS-DRG inpatient 1 UN 31942.75 20762.79 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30984.47 97 999999999 8294.3 30984.47 percent of total billed charges ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC 349 MS-DRG inpatient 1 UN 31942.75 20762.79 SIHO - ALL PLANS SIHO - ALL PLANS 28748.48 90 999999999 8294.3 30984.47 percent of total billed charges ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC 349 MS-DRG inpatient 1 UN 31942.75 20762.79 CIGNA - ALL PLANS CIGNA - ALL PLANS 21593.3 67.6 999999999 8294.3 30984.47 percent of total billed charges ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC 349 MS-DRG inpatient 1 UN 31942.75 20762.79 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 15663.54 999999999 8294.3 30984.47 case rate ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC 349 MS-DRG inpatient 1 UN 31942.75 20762.79 ENCORE - ALL PLANS ENCORE - ALL PLANS 22040.5 69 999999999 8294.3 30984.47 percent of total billed charges ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC 349 MS-DRG inpatient 1 UN 31942.75 20762.79 HUMANA - ALL PLANS HUMANA - ALL PLANS 24915.35 78 999999999 8294.3 30984.47 percent of total billed charges ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC 349 MS-DRG inpatient 1 UN 31942.75 20762.79 ANTHEM HMO ANTHEM HMO 13921.74 999999999 8294.3 30984.47 case rate ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC 349 MS-DRG inpatient 1 UN 31942.75 20762.79 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 14793.13 999999999 8294.3 30984.47 case rate ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC 349 MS-DRG inpatient 1 UN 31942.75 20762.79 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19341.34 60.55 999999999 8294.3 30984.47 percent of total billed charges ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC 349 MS-DRG inpatient 1 UN 31942.75 20762.79 UMR - ALL PLANS UMR - ALL PLANS 22359.93 70 999999999 8294.3 30984.47 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC 354 MS-DRG inpatient 1 UN 48883.34 31774.17 UMR - ALL PLANS UMR - ALL PLANS 34218.34 70 999999999 14601.3 47416.84 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC 354 MS-DRG inpatient 1 UN 48883.34 31774.17 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29598.86 60.55 999999999 14601.3 47416.84 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC 354 MS-DRG inpatient 1 UN 48883.34 31774.17 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 47416.84 97 999999999 14601.3 47416.84 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC 354 MS-DRG inpatient 1 UN 48883.34 31774.17 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 26041.85 999999999 14601.3 47416.84 case rate HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC 354 MS-DRG inpatient 1 UN 48883.34 31774.17 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 27574.13 999999999 14601.3 47416.84 case rate HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC 354 MS-DRG inpatient 1 UN 48883.34 31774.17 ENCORE - ALL PLANS ENCORE - ALL PLANS 33729.5 69 999999999 14601.3 47416.84 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC 354 MS-DRG inpatient 1 UN 48883.34 31774.17 SELF PAY DISCOUNT SELF PAY DISCOUNT 31774.17 65 999999999 14601.3 47416.84 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC 354 MS-DRG inpatient 1 UN 48883.34 31774.17 CIGNA - ALL PLANS CIGNA - ALL PLANS 33045.14 67.6 999999999 14601.3 47416.84 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC 354 MS-DRG inpatient 1 UN 48883.34 31774.17 HUMANA - ALL PLANS HUMANA - ALL PLANS 38129.01 78 999999999 14601.3 47416.84 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC 354 MS-DRG inpatient 1 UN 48883.34 31774.17 AETNA AETNA 38617.84 79 999999999 14601.3 47416.84 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC 354 MS-DRG inpatient 1 UN 48883.34 31774.17 SIHO - ALL PLANS SIHO - ALL PLANS 43995.01 90 999999999 14601.3 47416.84 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC 354 MS-DRG inpatient 1 UN 48883.34 31774.17 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 23437.66 999999999 14601.3 47416.84 case rate HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC 354 MS-DRG inpatient 1 UN 48883.34 31774.17 ANTHEM HMO ANTHEM HMO 24507.85 999999999 14601.3 47416.84 case rate HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC 354 MS-DRG inpatient 1 UN 48883.34 31774.17 UHC - ALL PLANS UHC - ALL PLANS 14601.3 999999999 14601.3 47416.84 case rate HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC 355 MS-DRG inpatient 1 UN 50026.05 32516.93 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 21872.46 999999999 11582.1 48525.27 case rate HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC 355 MS-DRG inpatient 1 UN 50026.05 32516.93 SELF PAY DISCOUNT SELF PAY DISCOUNT 32516.93 65 999999999 11582.1 48525.27 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC 355 MS-DRG inpatient 1 UN 50026.05 32516.93 UMR - ALL PLANS UMR - ALL PLANS 35018.24 70 999999999 11582.1 48525.27 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC 355 MS-DRG inpatient 1 UN 50026.05 32516.93 AETNA AETNA 39520.58 79 999999999 11582.1 48525.27 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC 355 MS-DRG inpatient 1 UN 50026.05 32516.93 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 48525.27 97 999999999 11582.1 48525.27 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC 355 MS-DRG inpatient 1 UN 50026.05 32516.93 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 20657.02 999999999 11582.1 48525.27 case rate HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC 355 MS-DRG inpatient 1 UN 50026.05 32516.93 ANTHEM HMO ANTHEM HMO 19440.21 999999999 11582.1 48525.27 case rate HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC 355 MS-DRG inpatient 1 UN 50026.05 32516.93 SIHO - ALL PLANS SIHO - ALL PLANS 45023.45 90 999999999 11582.1 48525.27 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC 355 MS-DRG inpatient 1 UN 50026.05 32516.93 CIGNA - ALL PLANS CIGNA - ALL PLANS 33817.61 67.6 999999999 11582.1 48525.27 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC 355 MS-DRG inpatient 1 UN 50026.05 32516.93 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 18591.31 999999999 11582.1 48525.27 case rate HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC 355 MS-DRG inpatient 1 UN 50026.05 32516.93 HUMANA - ALL PLANS HUMANA - ALL PLANS 39020.32 78 999999999 11582.1 48525.27 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC 355 MS-DRG inpatient 1 UN 50026.05 32516.93 ENCORE - ALL PLANS ENCORE - ALL PLANS 34517.97 69 999999999 11582.1 48525.27 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC 355 MS-DRG inpatient 1 UN 50026.05 32516.93 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30290.77 60.55 999999999 11582.1 48525.27 percent of total billed charges HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC 355 MS-DRG inpatient 1 UN 50026.05 32516.93 UHC - ALL PLANS UHC - ALL PLANS 11582.1 999999999 11582.1 48525.27 case rate OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC 356 MS-DRG inpatient 1 UN 2954.36 1920.33 SIHO - ALL PLANS SIHO - ALL PLANS 2658.92 90 999999999 1788.87 36368.95 percent of total billed charges OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC 356 MS-DRG inpatient 1 UN 2954.36 1920.33 AETNA AETNA 2333.94 79 999999999 1788.87 36368.95 percent of total billed charges OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC 356 MS-DRG inpatient 1 UN 2954.36 1920.33 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 1788.87 60.55 999999999 1788.87 36368.95 percent of total billed charges OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC 356 MS-DRG inpatient 1 UN 2954.36 1920.33 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 2865.73 97 999999999 1788.87 36368.95 percent of total billed charges OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC 356 MS-DRG inpatient 1 UN 2954.36 1920.33 UHC - ALL PLANS UHC - ALL PLANS 36368.95 999999999 1788.87 36368.95 case rate OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC 356 MS-DRG inpatient 1 UN 2954.36 1920.33 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 2954.36 999999999 1788.87 36368.95 case rate OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC 356 MS-DRG inpatient 1 UN 2954.36 1920.33 UMR - ALL PLANS UMR - ALL PLANS 2068.05 70 999999999 1788.87 36368.95 percent of total billed charges OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC 356 MS-DRG inpatient 1 UN 2954.36 1920.33 ENCORE - ALL PLANS ENCORE - ALL PLANS 2038.51 69 999999999 1788.87 36368.95 percent of total billed charges OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC 356 MS-DRG inpatient 1 UN 2954.36 1920.33 HUMANA - ALL PLANS HUMANA - ALL PLANS 2304.4 78 999999999 1788.87 36368.95 percent of total billed charges OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC 356 MS-DRG inpatient 1 UN 2954.36 1920.33 SELF PAY DISCOUNT SELF PAY DISCOUNT 1920.33 65 999999999 1788.87 36368.95 percent of total billed charges OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC 356 MS-DRG inpatient 1 UN 2954.36 1920.33 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 2954.36 999999999 1788.87 36368.95 case rate OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC 356 MS-DRG inpatient 1 UN 2954.36 1920.33 CIGNA - ALL PLANS CIGNA - ALL PLANS 1997.15 67.6 999999999 1788.87 36368.95 percent of total billed charges OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC 356 MS-DRG inpatient 1 UN 2954.36 1920.33 ANTHEM HMO ANTHEM HMO 2954.36 999999999 1788.87 36368.95 case rate OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC 356 MS-DRG inpatient 1 UN 2954.36 1920.33 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 2954.36 999999999 1788.87 36368.95 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC 371 MS-DRG inpatient 1 UN 28111.01 18272.16 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 26495.13 999999999 5086 28054.08 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC 371 MS-DRG inpatient 1 UN 28111.01 18272.16 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 28054.08 999999999 5086 28054.08 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC 371 MS-DRG inpatient 1 UN 28111.01 18272.16 UHC - ALL PLANS UHC - ALL PLANS 14855.45 999999999 5086 28054.08 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC 371 MS-DRG inpatient 1 UN 28111.01 18272.16 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 23845.62 999999999 5086 28054.08 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC 371 MS-DRG inpatient 1 UN 28111.01 18272.16 ANTHEM HMO ANTHEM HMO 24934.44 999999999 5086 28054.08 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC 371 MS-DRG inpatient 1 UN 28111.01 18272.16 AETNA AETNA 22207.7 79 999999999 5086 28054.08 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC 371 MS-DRG inpatient 1 UN 28111.01 18272.16 SELF PAY DISCOUNT SELF PAY DISCOUNT 18272.16 65 999999999 5086 28054.08 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC 371 MS-DRG inpatient 1 UN 28111.01 18272.16 UMR - ALL PLANS UMR - ALL PLANS 19677.71 70 999999999 5086 28054.08 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC 371 MS-DRG inpatient 1 UN 28111.01 18272.16 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 27267.68 97 999999999 5086 28054.08 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC 371 MS-DRG inpatient 1 UN 28111.01 18272.16 CIGNA - ALL PLANS CIGNA - ALL PLANS 5086 999999999 5086 28054.08 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC 371 MS-DRG inpatient 1 UN 28111.01 18272.16 HUMANA - ALL PLANS HUMANA - ALL PLANS 21926.59 78 999999999 5086 28054.08 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC 371 MS-DRG inpatient 1 UN 28111.01 18272.16 ENCORE - ALL PLANS ENCORE - ALL PLANS 19396.6 69 999999999 5086 28054.08 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC 371 MS-DRG inpatient 1 UN 28111.01 18272.16 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17021.22 60.55 999999999 5086 28054.08 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC 371 MS-DRG inpatient 1 UN 28111.01 18272.16 SIHO - ALL PLANS SIHO - ALL PLANS 25299.91 90 999999999 5086 28054.08 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC 372 MS-DRG inpatient 1 UN 26349.11 17126.92 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25558.64 97 999999999 3881 25558.64 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC 372 MS-DRG inpatient 1 UN 26349.11 17126.92 AETNA AETNA 20815.8 79 999999999 3881 25558.64 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC 372 MS-DRG inpatient 1 UN 26349.11 17126.92 SIHO - ALL PLANS SIHO - ALL PLANS 23714.2 90 999999999 3881 25558.64 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC 372 MS-DRG inpatient 1 UN 26349.11 17126.92 SELF PAY DISCOUNT SELF PAY DISCOUNT 17126.92 65 999999999 3881 25558.64 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC 372 MS-DRG inpatient 1 UN 26349.11 17126.92 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15954.39 60.55 999999999 3881 25558.64 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC 372 MS-DRG inpatient 1 UN 26349.11 17126.92 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 16731 999999999 3881 25558.64 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC 372 MS-DRG inpatient 1 UN 26349.11 17126.92 ANTHEM HMO ANTHEM HMO 14870.49 999999999 3881 25558.64 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC 372 MS-DRG inpatient 1 UN 26349.11 17126.92 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 15801.27 999999999 3881 25558.64 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC 372 MS-DRG inpatient 1 UN 26349.11 17126.92 HUMANA - ALL PLANS HUMANA - ALL PLANS 20552.31 78 999999999 3881 25558.64 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC 372 MS-DRG inpatient 1 UN 26349.11 17126.92 ENCORE - ALL PLANS ENCORE - ALL PLANS 18180.89 69 999999999 3881 25558.64 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC 372 MS-DRG inpatient 1 UN 26349.11 17126.92 UHC - ALL PLANS UHC - ALL PLANS 8859.55 999999999 3881 25558.64 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC 372 MS-DRG inpatient 1 UN 26349.11 17126.92 UMR - ALL PLANS UMR - ALL PLANS 18444.38 70 999999999 3881 25558.64 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC 372 MS-DRG inpatient 1 UN 26349.11 17126.92 CIGNA - ALL PLANS CIGNA - ALL PLANS 3881 999999999 3881 25558.64 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC 372 MS-DRG inpatient 1 UN 26349.11 17126.92 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 14221.14 999999999 3881 25558.64 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC 373 MS-DRG inpatient 1 UN 24870.73 16165.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 3881 999999999 3881 24124.61 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC 373 MS-DRG inpatient 1 UN 24870.73 16165.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15059.23 60.55 999999999 3881 24124.61 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC 373 MS-DRG inpatient 1 UN 24870.73 16165.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 17160.8 69 999999999 3881 24124.61 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC 373 MS-DRG inpatient 1 UN 24870.73 16165.97 UHC - ALL PLANS UHC - ALL PLANS 6090.25 999999999 3881 24124.61 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC 373 MS-DRG inpatient 1 UN 24870.73 16165.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 19399.17 78 999999999 3881 24124.61 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC 373 MS-DRG inpatient 1 UN 24870.73 16165.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 10862.14 999999999 3881 24124.61 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC 373 MS-DRG inpatient 1 UN 24870.73 16165.97 ANTHEM HMO ANTHEM HMO 10222.31 999999999 3881 24124.61 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC 373 MS-DRG inpatient 1 UN 24870.73 16165.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 9775.93 999999999 3881 24124.61 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC 373 MS-DRG inpatient 1 UN 24870.73 16165.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 11501.26 999999999 3881 24124.61 case rate MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC 373 MS-DRG inpatient 1 UN 24870.73 16165.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 16165.97 65 999999999 3881 24124.61 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC 373 MS-DRG inpatient 1 UN 24870.73 16165.97 SIHO - ALL PLANS SIHO - ALL PLANS 22383.66 90 999999999 3881 24124.61 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC 373 MS-DRG inpatient 1 UN 24870.73 16165.97 AETNA AETNA 19647.88 79 999999999 3881 24124.61 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC 373 MS-DRG inpatient 1 UN 24870.73 16165.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24124.61 97 999999999 3881 24124.61 percent of total billed charges MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC 373 MS-DRG inpatient 1 UN 24870.73 16165.97 UMR - ALL PLANS UMR - ALL PLANS 17409.51 70 999999999 3881 24124.61 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITH MCC 377 MS-DRG inpatient 1 UN 45625.96 29656.88 UMR - ALL PLANS UMR - ALL PLANS 31938.17 70 999999999 15217.55 44257.19 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITH MCC 377 MS-DRG inpatient 1 UN 45625.96 29656.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 29656.88 65 999999999 15217.55 44257.19 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITH MCC 377 MS-DRG inpatient 1 UN 45625.96 29656.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 44257.19 97 999999999 15217.55 44257.19 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITH MCC 377 MS-DRG inpatient 1 UN 45625.96 29656.88 ANTHEM HMO ANTHEM HMO 25542.21 999999999 15217.55 44257.19 case rate GASTROINTESTINAL HEMORRHAGE WITH MCC 377 MS-DRG inpatient 1 UN 45625.96 29656.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 27140.95 999999999 15217.55 44257.19 case rate GASTROINTESTINAL HEMORRHAGE WITH MCC 377 MS-DRG inpatient 1 UN 45625.96 29656.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 24426.85 999999999 15217.55 44257.19 case rate GASTROINTESTINAL HEMORRHAGE WITH MCC 377 MS-DRG inpatient 1 UN 45625.96 29656.88 UHC - ALL PLANS UHC - ALL PLANS 15217.55 999999999 15217.55 44257.19 case rate GASTROINTESTINAL HEMORRHAGE WITH MCC 377 MS-DRG inpatient 1 UN 45625.96 29656.88 SIHO - ALL PLANS SIHO - ALL PLANS 41063.37 90 999999999 15217.55 44257.19 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITH MCC 377 MS-DRG inpatient 1 UN 45625.96 29656.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 31481.92 69 999999999 15217.55 44257.19 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITH MCC 377 MS-DRG inpatient 1 UN 45625.96 29656.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 35588.25 78 999999999 15217.55 44257.19 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITH MCC 377 MS-DRG inpatient 1 UN 45625.96 29656.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27626.52 60.55 999999999 15217.55 44257.19 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITH MCC 377 MS-DRG inpatient 1 UN 45625.96 29656.88 AETNA AETNA 36044.51 79 999999999 15217.55 44257.19 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITH MCC 377 MS-DRG inpatient 1 UN 45625.96 29656.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 30843.15 67.6 999999999 15217.55 44257.19 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITH MCC 377 MS-DRG inpatient 1 UN 45625.96 29656.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 28737.9 999999999 15217.55 44257.19 case rate GASTROINTESTINAL HEMORRHAGE WITH CC 378 MS-DRG inpatient 1 UN 35410.4 23016.76 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 14914.41 999999999 8362.3 34348.08 case rate GASTROINTESTINAL HEMORRHAGE WITH CC 378 MS-DRG inpatient 1 UN 35410.4 23016.76 ANTHEM HMO ANTHEM HMO 14035.87 999999999 8362.3 34348.08 case rate GASTROINTESTINAL HEMORRHAGE WITH CC 378 MS-DRG inpatient 1 UN 35410.4 23016.76 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 15791.96 999999999 8362.3 34348.08 case rate GASTROINTESTINAL HEMORRHAGE WITH CC 378 MS-DRG inpatient 1 UN 35410.4 23016.76 SIHO - ALL PLANS SIHO - ALL PLANS 31869.36 90 999999999 8362.3 34348.08 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITH CC 378 MS-DRG inpatient 1 UN 35410.4 23016.76 SELF PAY DISCOUNT SELF PAY DISCOUNT 23016.76 65 999999999 8362.3 34348.08 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITH CC 378 MS-DRG inpatient 1 UN 35410.4 23016.76 AETNA AETNA 27974.21 79 999999999 8362.3 34348.08 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITH CC 378 MS-DRG inpatient 1 UN 35410.4 23016.76 UMR - ALL PLANS UMR - ALL PLANS 24787.28 70 999999999 8362.3 34348.08 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITH CC 378 MS-DRG inpatient 1 UN 35410.4 23016.76 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34348.08 97 999999999 8362.3 34348.08 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITH CC 378 MS-DRG inpatient 1 UN 35410.4 23016.76 CIGNA - ALL PLANS CIGNA - ALL PLANS 23937.43 67.6 999999999 8362.3 34348.08 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITH CC 378 MS-DRG inpatient 1 UN 35410.4 23016.76 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 13422.97 999999999 8362.3 34348.08 case rate GASTROINTESTINAL HEMORRHAGE WITH CC 378 MS-DRG inpatient 1 UN 35410.4 23016.76 UHC - ALL PLANS UHC - ALL PLANS 8362.3 999999999 8362.3 34348.08 case rate GASTROINTESTINAL HEMORRHAGE WITH CC 378 MS-DRG inpatient 1 UN 35410.4 23016.76 HUMANA - ALL PLANS HUMANA - ALL PLANS 27620.11 78 999999999 8362.3 34348.08 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITH CC 378 MS-DRG inpatient 1 UN 35410.4 23016.76 ENCORE - ALL PLANS ENCORE - ALL PLANS 24433.17 69 999999999 8362.3 34348.08 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITH CC 378 MS-DRG inpatient 1 UN 35410.4 23016.76 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21440.99 60.55 999999999 8362.3 34348.08 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC 379 MS-DRG inpatient 1 UN 59413.77 38618.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 57631.36 97 999999999 5382.2 57631.36 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC 379 MS-DRG inpatient 1 UN 59413.77 38618.95 UMR - ALL PLANS UMR - ALL PLANS 41589.64 70 999999999 5382.2 57631.36 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC 379 MS-DRG inpatient 1 UN 59413.77 38618.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 9599.31 999999999 5382.2 57631.36 case rate GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC 379 MS-DRG inpatient 1 UN 59413.77 38618.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 10164.13 999999999 5382.2 57631.36 case rate GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC 379 MS-DRG inpatient 1 UN 59413.77 38618.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 38618.95 65 999999999 5382.2 57631.36 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC 379 MS-DRG inpatient 1 UN 59413.77 38618.95 AETNA AETNA 46936.88 79 999999999 5382.2 57631.36 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC 379 MS-DRG inpatient 1 UN 59413.77 38618.95 SIHO - ALL PLANS SIHO - ALL PLANS 53472.39 90 999999999 5382.2 57631.36 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC 379 MS-DRG inpatient 1 UN 59413.77 38618.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 46342.74 78 999999999 5382.2 57631.36 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC 379 MS-DRG inpatient 1 UN 59413.77 38618.95 UHC - ALL PLANS UHC - ALL PLANS 5382.2 999999999 5382.2 57631.36 case rate GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC 379 MS-DRG inpatient 1 UN 59413.77 38618.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 8639.38 999999999 5382.2 57631.36 case rate GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC 379 MS-DRG inpatient 1 UN 59413.77 38618.95 ANTHEM HMO ANTHEM HMO 9033.86 999999999 5382.2 57631.36 case rate GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC 379 MS-DRG inpatient 1 UN 59413.77 38618.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35975.04 60.55 999999999 5382.2 57631.36 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC 379 MS-DRG inpatient 1 UN 59413.77 38618.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 40995.5 69 999999999 5382.2 57631.36 percent of total billed charges GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC 379 MS-DRG inpatient 1 UN 59413.77 38618.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 40163.71 67.6 999999999 5382.2 57631.36 percent of total billed charges COMPLICATED PEPTIC ULCER WITH MCC 380 MS-DRG inpatient 1 UN 34578.55 22476.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 31277.32 999999999 16562.25 33541.19 case rate COMPLICATED PEPTIC ULCER WITH MCC 380 MS-DRG inpatient 1 UN 34578.55 22476.06 UHC - ALL PLANS UHC - ALL PLANS 16562.25 999999999 16562.25 33541.19 case rate COMPLICATED PEPTIC ULCER WITH MCC 380 MS-DRG inpatient 1 UN 34578.55 22476.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 29539.26 999999999 16562.25 33541.19 case rate COMPLICATED PEPTIC ULCER WITH MCC 380 MS-DRG inpatient 1 UN 34578.55 22476.06 ANTHEM HMO ANTHEM HMO 27799.25 999999999 16562.25 33541.19 case rate COMPLICATED PEPTIC ULCER WITH MCC 380 MS-DRG inpatient 1 UN 34578.55 22476.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 26585.33 999999999 16562.25 33541.19 case rate COMPLICATED PEPTIC ULCER WITH MCC 380 MS-DRG inpatient 1 UN 34578.55 22476.06 SIHO - ALL PLANS SIHO - ALL PLANS 31120.7 90 999999999 16562.25 33541.19 percent of total billed charges COMPLICATED PEPTIC ULCER WITH MCC 380 MS-DRG inpatient 1 UN 34578.55 22476.06 AETNA AETNA 27317.05 79 999999999 16562.25 33541.19 percent of total billed charges COMPLICATED PEPTIC ULCER WITH MCC 380 MS-DRG inpatient 1 UN 34578.55 22476.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 22476.06 65 999999999 16562.25 33541.19 percent of total billed charges COMPLICATED PEPTIC ULCER WITH MCC 380 MS-DRG inpatient 1 UN 34578.55 22476.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 23375.1 67.6 999999999 16562.25 33541.19 percent of total billed charges COMPLICATED PEPTIC ULCER WITH MCC 380 MS-DRG inpatient 1 UN 34578.55 22476.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33541.19 97 999999999 16562.25 33541.19 percent of total billed charges COMPLICATED PEPTIC ULCER WITH MCC 380 MS-DRG inpatient 1 UN 34578.55 22476.06 UMR - ALL PLANS UMR - ALL PLANS 24204.99 70 999999999 16562.25 33541.19 percent of total billed charges COMPLICATED PEPTIC ULCER WITH MCC 380 MS-DRG inpatient 1 UN 34578.55 22476.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 23859.2 69 999999999 16562.25 33541.19 percent of total billed charges COMPLICATED PEPTIC ULCER WITH MCC 380 MS-DRG inpatient 1 UN 34578.55 22476.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 26971.27 78 999999999 16562.25 33541.19 percent of total billed charges COMPLICATED PEPTIC ULCER WITH MCC 380 MS-DRG inpatient 1 UN 34578.55 22476.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20937.31 60.55 999999999 16562.25 33541.19 percent of total billed charges COMPLICATED PEPTIC ULCER WITHOUT CC/MCC 382 MS-DRG inpatient 1 UN 45934.71 29857.56 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27813.47 60.55 999999999 6435.35 44556.67 percent of total billed charges COMPLICATED PEPTIC ULCER WITHOUT CC/MCC 382 MS-DRG inpatient 1 UN 45934.71 29857.56 HUMANA - ALL PLANS HUMANA - ALL PLANS 35829.07 78 999999999 6435.35 44556.67 percent of total billed charges COMPLICATED PEPTIC ULCER WITHOUT CC/MCC 382 MS-DRG inpatient 1 UN 45934.71 29857.56 ENCORE - ALL PLANS ENCORE - ALL PLANS 31694.95 69 999999999 6435.35 44556.67 percent of total billed charges COMPLICATED PEPTIC ULCER WITHOUT CC/MCC 382 MS-DRG inpatient 1 UN 45934.71 29857.56 UHC - ALL PLANS UHC - ALL PLANS 6435.35 999999999 6435.35 44556.67 case rate COMPLICATED PEPTIC ULCER WITHOUT CC/MCC 382 MS-DRG inpatient 1 UN 45934.71 29857.56 CIGNA - ALL PLANS CIGNA - ALL PLANS 31051.86 67.6 999999999 6435.35 44556.67 percent of total billed charges COMPLICATED PEPTIC ULCER WITHOUT CC/MCC 382 MS-DRG inpatient 1 UN 45934.71 29857.56 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10329.87 999999999 6435.35 44556.67 case rate COMPLICATED PEPTIC ULCER WITHOUT CC/MCC 382 MS-DRG inpatient 1 UN 45934.71 29857.56 UMR - ALL PLANS UMR - ALL PLANS 32154.3 70 999999999 6435.35 44556.67 percent of total billed charges COMPLICATED PEPTIC ULCER WITHOUT CC/MCC 382 MS-DRG inpatient 1 UN 45934.71 29857.56 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 44556.67 97 999999999 6435.35 44556.67 percent of total billed charges COMPLICATED PEPTIC ULCER WITHOUT CC/MCC 382 MS-DRG inpatient 1 UN 45934.71 29857.56 SELF PAY DISCOUNT SELF PAY DISCOUNT 29857.56 65 999999999 6435.35 44556.67 percent of total billed charges COMPLICATED PEPTIC ULCER WITHOUT CC/MCC 382 MS-DRG inpatient 1 UN 45934.71 29857.56 AETNA AETNA 36288.42 79 999999999 6435.35 44556.67 percent of total billed charges COMPLICATED PEPTIC ULCER WITHOUT CC/MCC 382 MS-DRG inpatient 1 UN 45934.71 29857.56 SIHO - ALL PLANS SIHO - ALL PLANS 41341.24 90 999999999 6435.35 44556.67 percent of total billed charges COMPLICATED PEPTIC ULCER WITHOUT CC/MCC 382 MS-DRG inpatient 1 UN 45934.71 29857.56 ANTHEM HMO ANTHEM HMO 10801.55 999999999 6435.35 44556.67 case rate COMPLICATED PEPTIC ULCER WITHOUT CC/MCC 382 MS-DRG inpatient 1 UN 45934.71 29857.56 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 11477.64 999999999 6435.35 44556.67 case rate COMPLICATED PEPTIC ULCER WITHOUT CC/MCC 382 MS-DRG inpatient 1 UN 45934.71 29857.56 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12152.97 999999999 6435.35 44556.67 case rate INFLAMMATORY BOWEL DISEASE WITH CC 386 MS-DRG inpatient 1 UN 16536.67 10748.83 ANTHEM HMO ANTHEM HMO 13861.82 999999999 8258.6 16040.56 case rate INFLAMMATORY BOWEL DISEASE WITH CC 386 MS-DRG inpatient 1 UN 16536.67 10748.83 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 13256.51 999999999 8258.6 16040.56 case rate INFLAMMATORY BOWEL DISEASE WITH CC 386 MS-DRG inpatient 1 UN 16536.67 10748.83 CIGNA - ALL PLANS CIGNA - ALL PLANS 11178.79 67.6 999999999 8258.6 16040.56 percent of total billed charges INFLAMMATORY BOWEL DISEASE WITH CC 386 MS-DRG inpatient 1 UN 16536.67 10748.83 SELF PAY DISCOUNT SELF PAY DISCOUNT 10748.83 65 999999999 8258.6 16040.56 percent of total billed charges INFLAMMATORY BOWEL DISEASE WITH CC 386 MS-DRG inpatient 1 UN 16536.67 10748.83 UMR - ALL PLANS UMR - ALL PLANS 11575.67 70 999999999 8258.6 16040.56 percent of total billed charges INFLAMMATORY BOWEL DISEASE WITH CC 386 MS-DRG inpatient 1 UN 16536.67 10748.83 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16040.56 97 999999999 8258.6 16040.56 percent of total billed charges INFLAMMATORY BOWEL DISEASE WITH CC 386 MS-DRG inpatient 1 UN 16536.67 10748.83 UHC - ALL PLANS UHC - ALL PLANS 8258.6 999999999 8258.6 16040.56 case rate INFLAMMATORY BOWEL DISEASE WITH CC 386 MS-DRG inpatient 1 UN 16536.67 10748.83 ENCORE - ALL PLANS ENCORE - ALL PLANS 11410.3 69 999999999 8258.6 16040.56 percent of total billed charges INFLAMMATORY BOWEL DISEASE WITH CC 386 MS-DRG inpatient 1 UN 16536.67 10748.83 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 14729.46 999999999 8258.6 16040.56 case rate INFLAMMATORY BOWEL DISEASE WITH CC 386 MS-DRG inpatient 1 UN 16536.67 10748.83 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 15596.12 999999999 8258.6 16040.56 case rate INFLAMMATORY BOWEL DISEASE WITH CC 386 MS-DRG inpatient 1 UN 16536.67 10748.83 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10012.95 60.55 999999999 8258.6 16040.56 percent of total billed charges INFLAMMATORY BOWEL DISEASE WITH CC 386 MS-DRG inpatient 1 UN 16536.67 10748.83 HUMANA - ALL PLANS HUMANA - ALL PLANS 12898.6 78 999999999 8258.6 16040.56 percent of total billed charges INFLAMMATORY BOWEL DISEASE WITH CC 386 MS-DRG inpatient 1 UN 16536.67 10748.83 SIHO - ALL PLANS SIHO - ALL PLANS 14883 90 999999999 8258.6 16040.56 percent of total billed charges INFLAMMATORY BOWEL DISEASE WITH CC 386 MS-DRG inpatient 1 UN 16536.67 10748.83 AETNA AETNA 13063.97 79 999999999 8258.6 16040.56 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITH MCC 388 MS-DRG inpatient 1 UN 57465.01 37352.25 UMR - ALL PLANS UMR - ALL PLANS 40225.5 70 999999999 12354.75 55741.05 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITH MCC 388 MS-DRG inpatient 1 UN 57465.01 37352.25 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55741.05 97 999999999 12354.75 55741.05 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITH MCC 388 MS-DRG inpatient 1 UN 57465.01 37352.25 ANTHEM HMO ANTHEM HMO 20737.08 999999999 12354.75 55741.05 case rate GASTROINTESTINAL OBSTRUCTION WITH MCC 388 MS-DRG inpatient 1 UN 57465.01 37352.25 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 22035.06 999999999 12354.75 55741.05 case rate GASTROINTESTINAL OBSTRUCTION WITH MCC 388 MS-DRG inpatient 1 UN 57465.01 37352.25 UHC - ALL PLANS UHC - ALL PLANS 12354.75 999999999 12354.75 55741.05 case rate GASTROINTESTINAL OBSTRUCTION WITH MCC 388 MS-DRG inpatient 1 UN 57465.01 37352.25 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 19831.55 999999999 12354.75 55741.05 case rate GASTROINTESTINAL OBSTRUCTION WITH MCC 388 MS-DRG inpatient 1 UN 57465.01 37352.25 SIHO - ALL PLANS SIHO - ALL PLANS 51718.5 90 999999999 12354.75 55741.05 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITH MCC 388 MS-DRG inpatient 1 UN 57465.01 37352.25 SELF PAY DISCOUNT SELF PAY DISCOUNT 37352.25 65 999999999 12354.75 55741.05 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITH MCC 388 MS-DRG inpatient 1 UN 57465.01 37352.25 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34795.06 60.55 999999999 12354.75 55741.05 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITH MCC 388 MS-DRG inpatient 1 UN 57465.01 37352.25 AETNA AETNA 45397.35 79 999999999 12354.75 55741.05 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITH MCC 388 MS-DRG inpatient 1 UN 57465.01 37352.25 ENCORE - ALL PLANS ENCORE - ALL PLANS 39650.85 69 999999999 12354.75 55741.05 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITH MCC 388 MS-DRG inpatient 1 UN 57465.01 37352.25 HUMANA - ALL PLANS HUMANA - ALL PLANS 44822.7 78 999999999 12354.75 55741.05 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITH MCC 388 MS-DRG inpatient 1 UN 57465.01 37352.25 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 23331.58 999999999 12354.75 55741.05 case rate GASTROINTESTINAL OBSTRUCTION WITH MCC 388 MS-DRG inpatient 1 UN 57465.01 37352.25 CIGNA - ALL PLANS CIGNA - ALL PLANS 38846.34 67.6 999999999 12354.75 55741.05 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITH CC 389 MS-DRG inpatient 1 UN 33837.11 21994.12 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12783.81 999999999 6769.4 32822 case rate GASTROINTESTINAL OBSTRUCTION WITH CC 389 MS-DRG inpatient 1 UN 33837.11 21994.12 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 12073.42 999999999 6769.4 32822 case rate GASTROINTESTINAL OBSTRUCTION WITH CC 389 MS-DRG inpatient 1 UN 33837.11 21994.12 HUMANA - ALL PLANS HUMANA - ALL PLANS 26392.95 78 999999999 6769.4 32822 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITH CC 389 MS-DRG inpatient 1 UN 33837.11 21994.12 AETNA AETNA 26731.32 79 999999999 6769.4 32822 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITH CC 389 MS-DRG inpatient 1 UN 33837.11 21994.12 SELF PAY DISCOUNT SELF PAY DISCOUNT 21994.12 65 999999999 6769.4 32822 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITH CC 389 MS-DRG inpatient 1 UN 33837.11 21994.12 SIHO - ALL PLANS SIHO - ALL PLANS 30453.4 90 999999999 6769.4 32822 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITH CC 389 MS-DRG inpatient 1 UN 33837.11 21994.12 CIGNA - ALL PLANS CIGNA - ALL PLANS 22873.89 67.6 999999999 6769.4 32822 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITH CC 389 MS-DRG inpatient 1 UN 33837.11 21994.12 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10866.08 999999999 6769.4 32822 case rate GASTROINTESTINAL OBSTRUCTION WITH CC 389 MS-DRG inpatient 1 UN 33837.11 21994.12 ANTHEM HMO ANTHEM HMO 11362.24 999999999 6769.4 32822 case rate GASTROINTESTINAL OBSTRUCTION WITH CC 389 MS-DRG inpatient 1 UN 33837.11 21994.12 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32822 97 999999999 6769.4 32822 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITH CC 389 MS-DRG inpatient 1 UN 33837.11 21994.12 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20488.37 60.55 999999999 6769.4 32822 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITH CC 389 MS-DRG inpatient 1 UN 33837.11 21994.12 UHC - ALL PLANS UHC - ALL PLANS 6769.4 999999999 6769.4 32822 case rate GASTROINTESTINAL OBSTRUCTION WITH CC 389 MS-DRG inpatient 1 UN 33837.11 21994.12 UMR - ALL PLANS UMR - ALL PLANS 23685.98 70 999999999 6769.4 32822 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITH CC 389 MS-DRG inpatient 1 UN 33837.11 21994.12 ENCORE - ALL PLANS ENCORE - ALL PLANS 23347.61 69 999999999 6769.4 32822 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC 390 MS-DRG inpatient 1 UN 17080.41 11102.26 ENCORE - ALL PLANS ENCORE - ALL PLANS 11785.48 69 999999999 4751.5 16567.99 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC 390 MS-DRG inpatient 1 UN 17080.41 11102.26 UMR - ALL PLANS UMR - ALL PLANS 11956.28 70 999999999 4751.5 16567.99 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC 390 MS-DRG inpatient 1 UN 17080.41 11102.26 UHC - ALL PLANS UHC - ALL PLANS 4751.5 999999999 4751.5 16567.99 case rate GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC 390 MS-DRG inpatient 1 UN 17080.41 11102.26 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10342.19 60.55 999999999 4751.5 16567.99 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC 390 MS-DRG inpatient 1 UN 17080.41 11102.26 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16567.99 97 999999999 4751.5 16567.99 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC 390 MS-DRG inpatient 1 UN 17080.41 11102.26 ANTHEM HMO ANTHEM HMO 7975.25 999999999 4751.5 16567.99 case rate GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC 390 MS-DRG inpatient 1 UN 17080.41 11102.26 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 7627 999999999 4751.5 16567.99 case rate GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC 390 MS-DRG inpatient 1 UN 17080.41 11102.26 CIGNA - ALL PLANS CIGNA - ALL PLANS 11546.35 67.6 999999999 4751.5 16567.99 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC 390 MS-DRG inpatient 1 UN 17080.41 11102.26 SIHO - ALL PLANS SIHO - ALL PLANS 15372.37 90 999999999 4751.5 16567.99 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC 390 MS-DRG inpatient 1 UN 17080.41 11102.26 SELF PAY DISCOUNT SELF PAY DISCOUNT 11102.26 65 999999999 4751.5 16567.99 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC 390 MS-DRG inpatient 1 UN 17080.41 11102.26 AETNA AETNA 13493.52 79 999999999 4751.5 16567.99 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC 390 MS-DRG inpatient 1 UN 17080.41 11102.26 HUMANA - ALL PLANS HUMANA - ALL PLANS 13322.72 78 999999999 4751.5 16567.99 percent of total billed charges GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC 390 MS-DRG inpatient 1 UN 17080.41 11102.26 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 8474.44 999999999 4751.5 16567.99 case rate GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC 390 MS-DRG inpatient 1 UN 17080.41 11102.26 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 8973.07 999999999 4751.5 16567.99 case rate "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC" 391 MS-DRG inpatient 1 UN 34910.41 22691.77 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 17405.65 999999999 10843.45 33863.1 case rate "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC" 391 MS-DRG inpatient 1 UN 34910.41 22691.77 UHC - ALL PLANS UHC - ALL PLANS 10843.45 999999999 10843.45 33863.1 case rate "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC" 391 MS-DRG inpatient 1 UN 34910.41 22691.77 ANTHEM HMO ANTHEM HMO 18200.41 999999999 10843.45 33863.1 case rate "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC" 391 MS-DRG inpatient 1 UN 34910.41 22691.77 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 19339.61 999999999 10843.45 33863.1 case rate "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC" 391 MS-DRG inpatient 1 UN 34910.41 22691.77 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33863.1 97 999999999 10843.45 33863.1 percent of total billed charges "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC" 391 MS-DRG inpatient 1 UN 34910.41 22691.77 SELF PAY DISCOUNT SELF PAY DISCOUNT 22691.77 65 999999999 10843.45 33863.1 percent of total billed charges "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC" 391 MS-DRG inpatient 1 UN 34910.41 22691.77 UMR - ALL PLANS UMR - ALL PLANS 24437.29 70 999999999 10843.45 33863.1 percent of total billed charges "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC" 391 MS-DRG inpatient 1 UN 34910.41 22691.77 CIGNA - ALL PLANS CIGNA - ALL PLANS 23599.44 67.6 999999999 10843.45 33863.1 percent of total billed charges "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC" 391 MS-DRG inpatient 1 UN 34910.41 22691.77 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 20477.54 999999999 10843.45 33863.1 case rate "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC" 391 MS-DRG inpatient 1 UN 34910.41 22691.77 HUMANA - ALL PLANS HUMANA - ALL PLANS 27230.12 78 999999999 10843.45 33863.1 percent of total billed charges "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC" 391 MS-DRG inpatient 1 UN 34910.41 22691.77 ENCORE - ALL PLANS ENCORE - ALL PLANS 24088.18 69 999999999 10843.45 33863.1 percent of total billed charges "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC" 391 MS-DRG inpatient 1 UN 34910.41 22691.77 SIHO - ALL PLANS SIHO - ALL PLANS 31419.37 90 999999999 10843.45 33863.1 percent of total billed charges "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC" 391 MS-DRG inpatient 1 UN 34910.41 22691.77 AETNA AETNA 27579.23 79 999999999 10843.45 33863.1 percent of total billed charges "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC" 391 MS-DRG inpatient 1 UN 34910.41 22691.77 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21138.25 60.55 999999999 10843.45 33863.1 percent of total billed charges "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC" 392 MS-DRG inpatient 1 UN 23673.2 15387.58 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22963 97 999999999 6677.6 22963 percent of total billed charges "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC" 392 MS-DRG inpatient 1 UN 23673.2 15387.58 UMR - ALL PLANS UMR - ALL PLANS 16571.24 70 999999999 6677.6 22963 percent of total billed charges "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC" 392 MS-DRG inpatient 1 UN 23673.2 15387.58 AETNA AETNA 18701.83 79 999999999 6677.6 22963 percent of total billed charges "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC" 392 MS-DRG inpatient 1 UN 23673.2 15387.58 SIHO - ALL PLANS SIHO - ALL PLANS 21305.88 90 999999999 6677.6 22963 percent of total billed charges "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC" 392 MS-DRG inpatient 1 UN 23673.2 15387.58 SELF PAY DISCOUNT SELF PAY DISCOUNT 15387.58 65 999999999 6677.6 22963 percent of total billed charges "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC" 392 MS-DRG inpatient 1 UN 23673.2 15387.58 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12610.45 999999999 6677.6 22963 case rate "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC" 392 MS-DRG inpatient 1 UN 23673.2 15387.58 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 11909.7 999999999 6677.6 22963 case rate "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC" 392 MS-DRG inpatient 1 UN 23673.2 15387.58 ANTHEM HMO ANTHEM HMO 11208.16 999999999 6677.6 22963 case rate "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC" 392 MS-DRG inpatient 1 UN 23673.2 15387.58 ENCORE - ALL PLANS ENCORE - ALL PLANS 16334.51 69 999999999 6677.6 22963 percent of total billed charges "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC" 392 MS-DRG inpatient 1 UN 23673.2 15387.58 HUMANA - ALL PLANS HUMANA - ALL PLANS 18465.1 78 999999999 6677.6 22963 percent of total billed charges "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC" 392 MS-DRG inpatient 1 UN 23673.2 15387.58 UHC - ALL PLANS UHC - ALL PLANS 6677.6 999999999 6677.6 22963 case rate "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC" 392 MS-DRG inpatient 1 UN 23673.2 15387.58 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14334.12 60.55 999999999 6677.6 22963 percent of total billed charges "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC" 392 MS-DRG inpatient 1 UN 23673.2 15387.58 CIGNA - ALL PLANS CIGNA - ALL PLANS 16003.08 67.6 999999999 6677.6 22963 percent of total billed charges "ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC" 392 MS-DRG inpatient 1 UN 23673.2 15387.58 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10718.73 999999999 6677.6 22963 case rate OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC 393 MS-DRG inpatient 1 UN 55751.21 36238.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 25997.82 999999999 13766.6 54078.67 case rate OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC 393 MS-DRG inpatient 1 UN 55751.21 36238.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 24553.14 999999999 13766.6 54078.67 case rate OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC 393 MS-DRG inpatient 1 UN 55751.21 36238.29 AETNA AETNA 44043.46 79 999999999 13766.6 54078.67 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC 393 MS-DRG inpatient 1 UN 55751.21 36238.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 43485.94 78 999999999 13766.6 54078.67 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC 393 MS-DRG inpatient 1 UN 55751.21 36238.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 36238.29 65 999999999 13766.6 54078.67 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC 393 MS-DRG inpatient 1 UN 55751.21 36238.29 SIHO - ALL PLANS SIHO - ALL PLANS 50176.09 90 999999999 13766.6 54078.67 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC 393 MS-DRG inpatient 1 UN 55751.21 36238.29 ANTHEM HMO ANTHEM HMO 23106.83 999999999 13766.6 54078.67 case rate OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC 393 MS-DRG inpatient 1 UN 55751.21 36238.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 37687.82 67.6 999999999 13766.6 54078.67 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC 393 MS-DRG inpatient 1 UN 55751.21 36238.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 22097.82 999999999 13766.6 54078.67 case rate OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC 393 MS-DRG inpatient 1 UN 55751.21 36238.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 54078.67 97 999999999 13766.6 54078.67 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC 393 MS-DRG inpatient 1 UN 55751.21 36238.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33757.36 60.55 999999999 13766.6 54078.67 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC 393 MS-DRG inpatient 1 UN 55751.21 36238.29 UHC - ALL PLANS UHC - ALL PLANS 13766.6 999999999 13766.6 54078.67 case rate OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC 393 MS-DRG inpatient 1 UN 55751.21 36238.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 38468.33 69 999999999 13766.6 54078.67 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC 393 MS-DRG inpatient 1 UN 55751.21 36238.29 UMR - ALL PLANS UMR - ALL PLANS 39025.85 70 999999999 13766.6 54078.67 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC 394 MS-DRG inpatient 1 UN 16540.03 10751.02 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10014.99 60.55 999999999 7963.65 16043.83 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC 394 MS-DRG inpatient 1 UN 16540.03 10751.02 HUMANA - ALL PLANS HUMANA - ALL PLANS 12901.22 78 999999999 7963.65 16043.83 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC 394 MS-DRG inpatient 1 UN 16540.03 10751.02 ENCORE - ALL PLANS ENCORE - ALL PLANS 11412.62 69 999999999 7963.65 16043.83 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC 394 MS-DRG inpatient 1 UN 16540.03 10751.02 UMR - ALL PLANS UMR - ALL PLANS 11578.02 70 999999999 7963.65 16043.83 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC 394 MS-DRG inpatient 1 UN 16540.03 10751.02 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16043.83 97 999999999 7963.65 16043.83 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC 394 MS-DRG inpatient 1 UN 16540.03 10751.02 CIGNA - ALL PLANS CIGNA - ALL PLANS 11181.06 67.6 999999999 7963.65 16043.83 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC 394 MS-DRG inpatient 1 UN 16540.03 10751.02 AETNA AETNA 13066.62 79 999999999 7963.65 16043.83 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC 394 MS-DRG inpatient 1 UN 16540.03 10751.02 SELF PAY DISCOUNT SELF PAY DISCOUNT 10751.02 65 999999999 7963.65 16043.83 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC 394 MS-DRG inpatient 1 UN 16540.03 10751.02 SIHO - ALL PLANS SIHO - ALL PLANS 14886.03 90 999999999 7963.65 16043.83 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC 394 MS-DRG inpatient 1 UN 16540.03 10751.02 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 12783.06 999999999 7963.65 16043.83 case rate OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC 394 MS-DRG inpatient 1 UN 16540.03 10751.02 ANTHEM HMO ANTHEM HMO 13366.75 999999999 7963.65 16043.83 case rate OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC 394 MS-DRG inpatient 1 UN 16540.03 10751.02 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 14203.4 999999999 7963.65 16043.83 case rate OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC 394 MS-DRG inpatient 1 UN 16540.03 10751.02 UHC - ALL PLANS UHC - ALL PLANS 7963.65 999999999 7963.65 16043.83 case rate OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC 394 MS-DRG inpatient 1 UN 16540.03 10751.02 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 15039.12 999999999 7963.65 16043.83 case rate OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC 395 MS-DRG inpatient 1 UN 14628.76 9508.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 9889.04 67.6 999999999 5503.75 14189.9 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC 395 MS-DRG inpatient 1 UN 14628.76 9508.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 10393.67 999999999 5503.75 14189.9 case rate OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC 395 MS-DRG inpatient 1 UN 14628.76 9508.7 AETNA AETNA 11556.72 79 999999999 5503.75 14189.9 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC 395 MS-DRG inpatient 1 UN 14628.76 9508.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8857.72 60.55 999999999 5503.75 14189.9 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC 395 MS-DRG inpatient 1 UN 14628.76 9508.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 11410.44 78 999999999 5503.75 14189.9 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC 395 MS-DRG inpatient 1 UN 14628.76 9508.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 10093.85 69 999999999 5503.75 14189.9 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC 395 MS-DRG inpatient 1 UN 14628.76 9508.7 UHC - ALL PLANS UHC - ALL PLANS 5503.75 999999999 5503.75 14189.9 case rate OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC 395 MS-DRG inpatient 1 UN 14628.76 9508.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 8834.49 999999999 5503.75 14189.9 case rate OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC 395 MS-DRG inpatient 1 UN 14628.76 9508.7 SIHO - ALL PLANS SIHO - ALL PLANS 13165.89 90 999999999 5503.75 14189.9 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC 395 MS-DRG inpatient 1 UN 14628.76 9508.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14189.9 97 999999999 5503.75 14189.9 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC 395 MS-DRG inpatient 1 UN 14628.76 9508.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 9508.7 65 999999999 5503.75 14189.9 percent of total billed charges OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC 395 MS-DRG inpatient 1 UN 14628.76 9508.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 9816.1 999999999 5503.75 14189.9 case rate OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC 395 MS-DRG inpatient 1 UN 14628.76 9508.7 ANTHEM HMO ANTHEM HMO 9237.88 999999999 5503.75 14189.9 case rate OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC 395 MS-DRG inpatient 1 UN 14628.76 9508.7 UMR - ALL PLANS UMR - ALL PLANS 10240.13 70 999999999 5503.75 14189.9 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC 417 MS-DRG inpatient 1 UN 64753.75 42089.94 SIHO - ALL PLANS SIHO - ALL PLANS 58278.38 90 999999999 19701.3 62811.14 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC 417 MS-DRG inpatient 1 UN 64753.75 42089.94 AETNA AETNA 51155.46 79 999999999 19701.3 62811.14 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC 417 MS-DRG inpatient 1 UN 64753.75 42089.94 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39208.4 60.55 999999999 19701.3 62811.14 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC 417 MS-DRG inpatient 1 UN 64753.75 42089.94 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 62811.14 97 999999999 19701.3 62811.14 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC 417 MS-DRG inpatient 1 UN 64753.75 42089.94 UMR - ALL PLANS UMR - ALL PLANS 45327.63 70 999999999 19701.3 62811.14 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC 417 MS-DRG inpatient 1 UN 64753.75 42089.94 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 31624.06 999999999 19701.3 62811.14 case rate LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC 417 MS-DRG inpatient 1 UN 64753.75 42089.94 UHC - ALL PLANS UHC - ALL PLANS 19701.3 999999999 19701.3 62811.14 case rate LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC 417 MS-DRG inpatient 1 UN 64753.75 42089.94 ENCORE - ALL PLANS ENCORE - ALL PLANS 44680.09 69 999999999 19701.3 62811.14 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC 417 MS-DRG inpatient 1 UN 64753.75 42089.94 HUMANA - ALL PLANS HUMANA - ALL PLANS 50507.93 78 999999999 19701.3 62811.14 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC 417 MS-DRG inpatient 1 UN 64753.75 42089.94 SELF PAY DISCOUNT SELF PAY DISCOUNT 42089.94 65 999999999 19701.3 62811.14 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC 417 MS-DRG inpatient 1 UN 64753.75 42089.94 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 37205.33 999999999 19701.3 62811.14 case rate LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC 417 MS-DRG inpatient 1 UN 64753.75 42089.94 CIGNA - ALL PLANS CIGNA - ALL PLANS 43773.54 67.6 999999999 19701.3 62811.14 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC 417 MS-DRG inpatient 1 UN 64753.75 42089.94 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 35137.85 999999999 19701.3 62811.14 case rate LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC 417 MS-DRG inpatient 1 UN 64753.75 42089.94 ANTHEM HMO ANTHEM HMO 33068.05 999999999 19701.3 62811.14 case rate LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC 418 MS-DRG inpatient 1 UN 41045.13 26679.34 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 26240.2 999999999 13894.95 39813.78 case rate LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC 418 MS-DRG inpatient 1 UN 41045.13 26679.34 SELF PAY DISCOUNT SELF PAY DISCOUNT 26679.34 65 999999999 13894.95 39813.78 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC 418 MS-DRG inpatient 1 UN 41045.13 26679.34 AETNA AETNA 32425.66 79 999999999 13894.95 39813.78 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC 418 MS-DRG inpatient 1 UN 41045.13 26679.34 UMR - ALL PLANS UMR - ALL PLANS 28731.59 70 999999999 13894.95 39813.78 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC 418 MS-DRG inpatient 1 UN 41045.13 26679.34 ANTHEM HMO ANTHEM HMO 23322.26 999999999 13894.95 39813.78 case rate LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC 418 MS-DRG inpatient 1 UN 41045.13 26679.34 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 24782.05 999999999 13894.95 39813.78 case rate LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC 418 MS-DRG inpatient 1 UN 41045.13 26679.34 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39813.78 97 999999999 13894.95 39813.78 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC 418 MS-DRG inpatient 1 UN 41045.13 26679.34 SIHO - ALL PLANS SIHO - ALL PLANS 36940.62 90 999999999 13894.95 39813.78 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC 418 MS-DRG inpatient 1 UN 41045.13 26679.34 CIGNA - ALL PLANS CIGNA - ALL PLANS 27746.51 67.6 999999999 13894.95 39813.78 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC 418 MS-DRG inpatient 1 UN 41045.13 26679.34 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 22303.85 999999999 13894.95 39813.78 case rate LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC 418 MS-DRG inpatient 1 UN 41045.13 26679.34 HUMANA - ALL PLANS HUMANA - ALL PLANS 32015.2 78 999999999 13894.95 39813.78 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC 418 MS-DRG inpatient 1 UN 41045.13 26679.34 ENCORE - ALL PLANS ENCORE - ALL PLANS 28321.14 69 999999999 13894.95 39813.78 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC 418 MS-DRG inpatient 1 UN 41045.13 26679.34 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24852.83 60.55 999999999 13894.95 39813.78 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC 418 MS-DRG inpatient 1 UN 41045.13 26679.34 UHC - ALL PLANS UHC - ALL PLANS 13894.95 999999999 13894.95 39813.78 case rate LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC 419 MS-DRG inpatient 1 UN 56648.06 36821.24 UHC - ALL PLANS UHC - ALL PLANS 11162.2 999999999 11162.2 54948.62 case rate LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC 419 MS-DRG inpatient 1 UN 56648.06 36821.24 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34300.4 60.55 999999999 11162.2 54948.62 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC 419 MS-DRG inpatient 1 UN 56648.06 36821.24 ENCORE - ALL PLANS ENCORE - ALL PLANS 39087.16 69 999999999 11162.2 54948.62 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC 419 MS-DRG inpatient 1 UN 56648.06 36821.24 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 17917.3 999999999 11162.2 54948.62 case rate LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC 419 MS-DRG inpatient 1 UN 56648.06 36821.24 CIGNA - ALL PLANS CIGNA - ALL PLANS 38294.09 67.6 999999999 11162.2 54948.62 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC 419 MS-DRG inpatient 1 UN 56648.06 36821.24 ANTHEM HMO ANTHEM HMO 18735.42 999999999 11162.2 54948.62 case rate LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC 419 MS-DRG inpatient 1 UN 56648.06 36821.24 HUMANA - ALL PLANS HUMANA - ALL PLANS 44185.49 78 999999999 11162.2 54948.62 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC 419 MS-DRG inpatient 1 UN 56648.06 36821.24 SIHO - ALL PLANS SIHO - ALL PLANS 50983.25 90 999999999 11162.2 54948.62 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC 419 MS-DRG inpatient 1 UN 56648.06 36821.24 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 19908.11 999999999 11162.2 54948.62 case rate LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC 419 MS-DRG inpatient 1 UN 56648.06 36821.24 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 21079.49 999999999 11162.2 54948.62 case rate LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC 419 MS-DRG inpatient 1 UN 56648.06 36821.24 UMR - ALL PLANS UMR - ALL PLANS 39653.64 70 999999999 11162.2 54948.62 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC 419 MS-DRG inpatient 1 UN 56648.06 36821.24 AETNA AETNA 44751.97 79 999999999 11162.2 54948.62 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC 419 MS-DRG inpatient 1 UN 56648.06 36821.24 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 54948.62 97 999999999 11162.2 54948.62 percent of total billed charges LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC 419 MS-DRG inpatient 1 UN 56648.06 36821.24 SELF PAY DISCOUNT SELF PAY DISCOUNT 36821.24 65 999999999 11162.2 54948.62 percent of total billed charges CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC 433 MS-DRG inpatient 1 UN 31515.03 20484.77 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 16549.61 999999999 8763.5 30569.58 case rate CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC 433 MS-DRG inpatient 1 UN 31515.03 20484.77 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 15629.96 999999999 8763.5 30569.58 case rate CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC 433 MS-DRG inpatient 1 UN 31515.03 20484.77 ANTHEM HMO ANTHEM HMO 14709.28 999999999 8763.5 30569.58 case rate CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC 433 MS-DRG inpatient 1 UN 31515.03 20484.77 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 14066.96 999999999 8763.5 30569.58 case rate CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC 433 MS-DRG inpatient 1 UN 31515.03 20484.77 CIGNA - ALL PLANS CIGNA - ALL PLANS 21304.16 67.6 999999999 8763.5 30569.58 percent of total billed charges CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC 433 MS-DRG inpatient 1 UN 31515.03 20484.77 SELF PAY DISCOUNT SELF PAY DISCOUNT 20484.77 65 999999999 8763.5 30569.58 percent of total billed charges CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC 433 MS-DRG inpatient 1 UN 31515.03 20484.77 UHC - ALL PLANS UHC - ALL PLANS 8763.5 999999999 8763.5 30569.58 case rate CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC 433 MS-DRG inpatient 1 UN 31515.03 20484.77 HUMANA - ALL PLANS HUMANA - ALL PLANS 24581.73 78 999999999 8763.5 30569.58 percent of total billed charges CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC 433 MS-DRG inpatient 1 UN 31515.03 20484.77 ENCORE - ALL PLANS ENCORE - ALL PLANS 21745.37 69 999999999 8763.5 30569.58 percent of total billed charges CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC 433 MS-DRG inpatient 1 UN 31515.03 20484.77 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30569.58 97 999999999 8763.5 30569.58 percent of total billed charges CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC 433 MS-DRG inpatient 1 UN 31515.03 20484.77 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19082.35 60.55 999999999 8763.5 30569.58 percent of total billed charges CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC 433 MS-DRG inpatient 1 UN 31515.03 20484.77 AETNA AETNA 24896.88 79 999999999 8763.5 30569.58 percent of total billed charges CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC 433 MS-DRG inpatient 1 UN 31515.03 20484.77 UMR - ALL PLANS UMR - ALL PLANS 22060.52 70 999999999 8763.5 30569.58 percent of total billed charges CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC 433 MS-DRG inpatient 1 UN 31515.03 20484.77 SIHO - ALL PLANS SIHO - ALL PLANS 28363.53 90 999999999 8763.5 30569.58 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC 438 MS-DRG inpatient 1 UN 37908.38 24640.45 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22953.52 60.55 999999999 14184.8 36771.13 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC 438 MS-DRG inpatient 1 UN 37908.38 24640.45 ENCORE - ALL PLANS ENCORE - ALL PLANS 26156.78 69 999999999 14184.8 36771.13 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC 438 MS-DRG inpatient 1 UN 37908.38 24640.45 ANTHEM HMO ANTHEM HMO 23808.77 999999999 14184.8 36771.13 case rate DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC 438 MS-DRG inpatient 1 UN 37908.38 24640.45 CIGNA - ALL PLANS CIGNA - ALL PLANS 25626.06 67.6 999999999 14184.8 36771.13 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC 438 MS-DRG inpatient 1 UN 37908.38 24640.45 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 22769.11 999999999 14184.8 36771.13 case rate DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC 438 MS-DRG inpatient 1 UN 37908.38 24640.45 HUMANA - ALL PLANS HUMANA - ALL PLANS 29568.54 78 999999999 14184.8 36771.13 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC 438 MS-DRG inpatient 1 UN 37908.38 24640.45 SIHO - ALL PLANS SIHO - ALL PLANS 34117.54 90 999999999 14184.8 36771.13 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC 438 MS-DRG inpatient 1 UN 37908.38 24640.45 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 26787.58 999999999 14184.8 36771.13 case rate DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC 438 MS-DRG inpatient 1 UN 37908.38 24640.45 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 25299.01 999999999 14184.8 36771.13 case rate DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC 438 MS-DRG inpatient 1 UN 37908.38 24640.45 AETNA AETNA 29947.62 79 999999999 14184.8 36771.13 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC 438 MS-DRG inpatient 1 UN 37908.38 24640.45 UMR - ALL PLANS UMR - ALL PLANS 26535.87 70 999999999 14184.8 36771.13 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC 438 MS-DRG inpatient 1 UN 37908.38 24640.45 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 36771.13 97 999999999 14184.8 36771.13 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC 438 MS-DRG inpatient 1 UN 37908.38 24640.45 UHC - ALL PLANS UHC - ALL PLANS 14184.8 999999999 14184.8 36771.13 case rate DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC 438 MS-DRG inpatient 1 UN 37908.38 24640.45 SELF PAY DISCOUNT SELF PAY DISCOUNT 24640.45 65 999999999 14184.8 36771.13 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC 439 MS-DRG inpatient 1 UN 23367.49 15188.87 ANTHEM HMO ANTHEM HMO 12201.14 999999999 7269.2 22666.47 case rate DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC 439 MS-DRG inpatient 1 UN 23367.49 15188.87 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 12964.83 999999999 7269.2 22666.47 case rate DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC 439 MS-DRG inpatient 1 UN 23367.49 15188.87 CIGNA - ALL PLANS CIGNA - ALL PLANS 15796.43 67.6 999999999 7269.2 22666.47 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC 439 MS-DRG inpatient 1 UN 23367.49 15188.87 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 11668.35 999999999 7269.2 22666.47 case rate DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC 439 MS-DRG inpatient 1 UN 23367.49 15188.87 AETNA AETNA 18460.32 79 999999999 7269.2 22666.47 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC 439 MS-DRG inpatient 1 UN 23367.49 15188.87 UHC - ALL PLANS UHC - ALL PLANS 7269.2 999999999 7269.2 22666.47 case rate DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC 439 MS-DRG inpatient 1 UN 23367.49 15188.87 SIHO - ALL PLANS SIHO - ALL PLANS 21030.74 90 999999999 7269.2 22666.47 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC 439 MS-DRG inpatient 1 UN 23367.49 15188.87 ENCORE - ALL PLANS ENCORE - ALL PLANS 16123.57 69 999999999 7269.2 22666.47 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC 439 MS-DRG inpatient 1 UN 23367.49 15188.87 HUMANA - ALL PLANS HUMANA - ALL PLANS 18226.65 78 999999999 7269.2 22666.47 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC 439 MS-DRG inpatient 1 UN 23367.49 15188.87 SELF PAY DISCOUNT SELF PAY DISCOUNT 15188.87 65 999999999 7269.2 22666.47 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC 439 MS-DRG inpatient 1 UN 23367.49 15188.87 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14149.02 60.55 999999999 7269.2 22666.47 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC 439 MS-DRG inpatient 1 UN 23367.49 15188.87 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 13727.67 999999999 7269.2 22666.47 case rate DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC 439 MS-DRG inpatient 1 UN 23367.49 15188.87 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22666.47 97 999999999 7269.2 22666.47 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC 439 MS-DRG inpatient 1 UN 23367.49 15188.87 UMR - ALL PLANS UMR - ALL PLANS 16357.25 70 999999999 7269.2 22666.47 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC 440 MS-DRG inpatient 1 UN 19205.35 12483.48 UMR - ALL PLANS UMR - ALL PLANS 13443.74 70 999999999 5232.6 18629.19 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC 440 MS-DRG inpatient 1 UN 19205.35 12483.48 AETNA AETNA 15172.23 79 999999999 5232.6 18629.19 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC 440 MS-DRG inpatient 1 UN 19205.35 12483.48 SIHO - ALL PLANS SIHO - ALL PLANS 17284.81 90 999999999 5232.6 18629.19 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC 440 MS-DRG inpatient 1 UN 19205.35 12483.48 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11628.84 60.55 999999999 5232.6 18629.19 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC 440 MS-DRG inpatient 1 UN 19205.35 12483.48 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 18629.19 97 999999999 5232.6 18629.19 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC 440 MS-DRG inpatient 1 UN 19205.35 12483.48 ENCORE - ALL PLANS ENCORE - ALL PLANS 13251.69 69 999999999 5232.6 18629.19 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC 440 MS-DRG inpatient 1 UN 19205.35 12483.48 HUMANA - ALL PLANS HUMANA - ALL PLANS 14980.17 78 999999999 5232.6 18629.19 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC 440 MS-DRG inpatient 1 UN 19205.35 12483.48 UHC - ALL PLANS UHC - ALL PLANS 5232.6 999999999 5232.6 18629.19 case rate DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC 440 MS-DRG inpatient 1 UN 19205.35 12483.48 SELF PAY DISCOUNT SELF PAY DISCOUNT 12483.48 65 999999999 5232.6 18629.19 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC 440 MS-DRG inpatient 1 UN 19205.35 12483.48 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 8399.25 999999999 5232.6 18629.19 case rate DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC 440 MS-DRG inpatient 1 UN 19205.35 12483.48 CIGNA - ALL PLANS CIGNA - ALL PLANS 12982.82 67.6 999999999 5232.6 18629.19 percent of total billed charges DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC 440 MS-DRG inpatient 1 UN 19205.35 12483.48 ANTHEM HMO ANTHEM HMO 8782.77 999999999 5232.6 18629.19 case rate DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC 440 MS-DRG inpatient 1 UN 19205.35 12483.48 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 9332.5 999999999 5232.6 18629.19 case rate DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC 440 MS-DRG inpatient 1 UN 19205.35 12483.48 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 9881.61 999999999 5232.6 18629.19 case rate "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC" 441 MS-DRG inpatient 1 UN 53039.73 34475.82 ANTHEM HMO ANTHEM HMO 26082.93 999999999 15539.7 51448.54 case rate "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC" 441 MS-DRG inpatient 1 UN 53039.73 34475.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 24943.96 999999999 15539.7 51448.54 case rate "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC" 441 MS-DRG inpatient 1 UN 53039.73 34475.82 UHC - ALL PLANS UHC - ALL PLANS 15539.7 999999999 15539.7 51448.54 case rate "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC" 441 MS-DRG inpatient 1 UN 53039.73 34475.82 AETNA AETNA 41901.39 79 999999999 15539.7 51448.54 percent of total billed charges "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC" 441 MS-DRG inpatient 1 UN 53039.73 34475.82 SIHO - ALL PLANS SIHO - ALL PLANS 47735.76 90 999999999 15539.7 51448.54 percent of total billed charges "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC" 441 MS-DRG inpatient 1 UN 53039.73 34475.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 41370.99 78 999999999 15539.7 51448.54 percent of total billed charges "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC" 441 MS-DRG inpatient 1 UN 53039.73 34475.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 35854.86 67.6 999999999 15539.7 51448.54 percent of total billed charges "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC" 441 MS-DRG inpatient 1 UN 53039.73 34475.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 34475.82 65 999999999 15539.7 51448.54 percent of total billed charges "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC" 441 MS-DRG inpatient 1 UN 53039.73 34475.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 36597.41 69 999999999 15539.7 51448.54 percent of total billed charges "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC" 441 MS-DRG inpatient 1 UN 53039.73 34475.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 29346.27 999999999 15539.7 51448.54 case rate "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC" 441 MS-DRG inpatient 1 UN 53039.73 34475.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 27715.51 999999999 15539.7 51448.54 case rate "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC" 441 MS-DRG inpatient 1 UN 53039.73 34475.82 UMR - ALL PLANS UMR - ALL PLANS 37127.81 70 999999999 15539.7 51448.54 percent of total billed charges "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC" 441 MS-DRG inpatient 1 UN 53039.73 34475.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32115.56 60.55 999999999 15539.7 51448.54 percent of total billed charges "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC" 441 MS-DRG inpatient 1 UN 53039.73 34475.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51448.54 97 999999999 15539.7 51448.54 percent of total billed charges "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC" 442 MS-DRG inpatient 1 UN 24358.17 15832.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14748.87 60.55 999999999 8087.75 23627.43 percent of total billed charges "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC" 442 MS-DRG inpatient 1 UN 24358.17 15832.81 UMR - ALL PLANS UMR - ALL PLANS 17050.72 70 999999999 8087.75 23627.43 percent of total billed charges "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC" 442 MS-DRG inpatient 1 UN 24358.17 15832.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 14424.74 999999999 8087.75 23627.43 case rate "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC" 442 MS-DRG inpatient 1 UN 24358.17 15832.81 ANTHEM HMO ANTHEM HMO 13575.05 999999999 8087.75 23627.43 case rate "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC" 442 MS-DRG inpatient 1 UN 24358.17 15832.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 16807.14 69 999999999 8087.75 23627.43 percent of total billed charges "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC" 442 MS-DRG inpatient 1 UN 24358.17 15832.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 18999.38 78 999999999 8087.75 23627.43 percent of total billed charges "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC" 442 MS-DRG inpatient 1 UN 24358.17 15832.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 15832.81 65 999999999 8087.75 23627.43 percent of total billed charges "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC" 442 MS-DRG inpatient 1 UN 24358.17 15832.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 16466.13 67.6 999999999 8087.75 23627.43 percent of total billed charges "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC" 442 MS-DRG inpatient 1 UN 24358.17 15832.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 15273.48 999999999 8087.75 23627.43 case rate "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC" 442 MS-DRG inpatient 1 UN 24358.17 15832.81 SIHO - ALL PLANS SIHO - ALL PLANS 21922.36 90 999999999 8087.75 23627.43 percent of total billed charges "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC" 442 MS-DRG inpatient 1 UN 24358.17 15832.81 AETNA AETNA 19242.96 79 999999999 8087.75 23627.43 percent of total billed charges "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC" 442 MS-DRG inpatient 1 UN 24358.17 15832.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23627.43 97 999999999 8087.75 23627.43 percent of total billed charges "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC" 442 MS-DRG inpatient 1 UN 24358.17 15832.81 UHC - ALL PLANS UHC - ALL PLANS 8087.75 999999999 8087.75 23627.43 case rate "DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC" 442 MS-DRG inpatient 1 UN 24358.17 15832.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 12982.27 999999999 8087.75 23627.43 case rate DISORDERS OF THE BILIARY TRACT WITH MCC 444 MS-DRG inpatient 1 UN 23903.09 15537.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 23903.09 999999999 13882.2 23903.09 case rate DISORDERS OF THE BILIARY TRACT WITH MCC 444 MS-DRG inpatient 1 UN 23903.09 15537.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 16158.49 67.6 999999999 13882.2 23903.09 percent of total billed charges DISORDERS OF THE BILIARY TRACT WITH MCC 444 MS-DRG inpatient 1 UN 23903.09 15537.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 23903.09 999999999 13882.2 23903.09 case rate DISORDERS OF THE BILIARY TRACT WITH MCC 444 MS-DRG inpatient 1 UN 23903.09 15537.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 15537.01 65 999999999 13882.2 23903.09 percent of total billed charges DISORDERS OF THE BILIARY TRACT WITH MCC 444 MS-DRG inpatient 1 UN 23903.09 15537.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14473.32 60.55 999999999 13882.2 23903.09 percent of total billed charges DISORDERS OF THE BILIARY TRACT WITH MCC 444 MS-DRG inpatient 1 UN 23903.09 15537.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 16493.13 69 999999999 13882.2 23903.09 percent of total billed charges DISORDERS OF THE BILIARY TRACT WITH MCC 444 MS-DRG inpatient 1 UN 23903.09 15537.01 UMR - ALL PLANS UMR - ALL PLANS 16732.16 70 999999999 13882.2 23903.09 percent of total billed charges DISORDERS OF THE BILIARY TRACT WITH MCC 444 MS-DRG inpatient 1 UN 23903.09 15537.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23186 97 999999999 13882.2 23903.09 percent of total billed charges DISORDERS OF THE BILIARY TRACT WITH MCC 444 MS-DRG inpatient 1 UN 23903.09 15537.01 ANTHEM HMO ANTHEM HMO 23300.86 999999999 13882.2 23903.09 case rate DISORDERS OF THE BILIARY TRACT WITH MCC 444 MS-DRG inpatient 1 UN 23903.09 15537.01 UHC - ALL PLANS UHC - ALL PLANS 13882.2 999999999 13882.2 23903.09 case rate DISORDERS OF THE BILIARY TRACT WITH MCC 444 MS-DRG inpatient 1 UN 23903.09 15537.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 22283.38 999999999 13882.2 23903.09 case rate DISORDERS OF THE BILIARY TRACT WITH MCC 444 MS-DRG inpatient 1 UN 23903.09 15537.01 SIHO - ALL PLANS SIHO - ALL PLANS 21512.78 90 999999999 13882.2 23903.09 percent of total billed charges DISORDERS OF THE BILIARY TRACT WITH MCC 444 MS-DRG inpatient 1 UN 23903.09 15537.01 AETNA AETNA 18883.44 79 999999999 13882.2 23903.09 percent of total billed charges DISORDERS OF THE BILIARY TRACT WITH MCC 444 MS-DRG inpatient 1 UN 23903.09 15537.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 18644.41 78 999999999 13882.2 23903.09 percent of total billed charges DISORDERS OF THE BILIARY TRACT WITH CC 445 MS-DRG inpatient 1 UN 26728.37 17373.44 AETNA AETNA 21115.41 79 999999999 9237.8 25926.51 percent of total billed charges DISORDERS OF THE BILIARY TRACT WITH CC 445 MS-DRG inpatient 1 UN 26728.37 17373.44 UMR - ALL PLANS UMR - ALL PLANS 18709.86 70 999999999 9237.8 25926.51 percent of total billed charges DISORDERS OF THE BILIARY TRACT WITH CC 445 MS-DRG inpatient 1 UN 26728.37 17373.44 SIHO - ALL PLANS SIHO - ALL PLANS 24055.53 90 999999999 9237.8 25926.51 percent of total billed charges DISORDERS OF THE BILIARY TRACT WITH CC 445 MS-DRG inpatient 1 UN 26728.37 17373.44 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25926.51 97 999999999 9237.8 25926.51 percent of total billed charges DISORDERS OF THE BILIARY TRACT WITH CC 445 MS-DRG inpatient 1 UN 26728.37 17373.44 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16184.02 60.55 999999999 9237.8 25926.51 percent of total billed charges DISORDERS OF THE BILIARY TRACT WITH CC 445 MS-DRG inpatient 1 UN 26728.37 17373.44 ENCORE - ALL PLANS ENCORE - ALL PLANS 18442.57 69 999999999 9237.8 25926.51 percent of total billed charges DISORDERS OF THE BILIARY TRACT WITH CC 445 MS-DRG inpatient 1 UN 26728.37 17373.44 HUMANA - ALL PLANS HUMANA - ALL PLANS 20848.12 78 999999999 9237.8 25926.51 percent of total billed charges DISORDERS OF THE BILIARY TRACT WITH CC 445 MS-DRG inpatient 1 UN 26728.37 17373.44 UHC - ALL PLANS UHC - ALL PLANS 9237.8 999999999 9237.8 25926.51 case rate DISORDERS OF THE BILIARY TRACT WITH CC 445 MS-DRG inpatient 1 UN 26728.37 17373.44 SELF PAY DISCOUNT SELF PAY DISCOUNT 17373.44 65 999999999 9237.8 25926.51 percent of total billed charges DISORDERS OF THE BILIARY TRACT WITH CC 445 MS-DRG inpatient 1 UN 26728.37 17373.44 ANTHEM HMO ANTHEM HMO 15505.38 999999999 9237.8 25926.51 case rate DISORDERS OF THE BILIARY TRACT WITH CC 445 MS-DRG inpatient 1 UN 26728.37 17373.44 CIGNA - ALL PLANS CIGNA - ALL PLANS 18068.37 67.6 999999999 9237.8 25926.51 percent of total billed charges DISORDERS OF THE BILIARY TRACT WITH CC 445 MS-DRG inpatient 1 UN 26728.37 17373.44 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 14828.3 999999999 9237.8 25926.51 case rate DISORDERS OF THE BILIARY TRACT WITH CC 445 MS-DRG inpatient 1 UN 26728.37 17373.44 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 17445.31 999999999 9237.8 25926.51 case rate DISORDERS OF THE BILIARY TRACT WITH CC 445 MS-DRG inpatient 1 UN 26728.37 17373.44 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 16475.89 999999999 9237.8 25926.51 case rate WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC 464 MS-DRG inpatient 1 UN 38320.2 24908.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 38320.2 999999999 23202.88 38320.2 case rate WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC 464 MS-DRG inpatient 1 UN 38320.2 24908.13 ANTHEM HMO ANTHEM HMO 38320.2 999999999 23202.88 38320.2 case rate WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC 464 MS-DRG inpatient 1 UN 38320.2 24908.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 38320.2 999999999 23202.88 38320.2 case rate WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC 464 MS-DRG inpatient 1 UN 38320.2 24908.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 25904.46 67.6 999999999 23202.88 38320.2 percent of total billed charges WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC 464 MS-DRG inpatient 1 UN 38320.2 24908.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 24908.13 65 999999999 23202.88 38320.2 percent of total billed charges WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC 464 MS-DRG inpatient 1 UN 38320.2 24908.13 UHC - ALL PLANS UHC - ALL PLANS 25511.9 999999999 23202.88 38320.2 case rate WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC 464 MS-DRG inpatient 1 UN 38320.2 24908.13 SIHO - ALL PLANS SIHO - ALL PLANS 34488.18 90 999999999 23202.88 38320.2 percent of total billed charges WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC 464 MS-DRG inpatient 1 UN 38320.2 24908.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 26440.94 69 999999999 23202.88 38320.2 percent of total billed charges WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC 464 MS-DRG inpatient 1 UN 38320.2 24908.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 29889.76 78 999999999 23202.88 38320.2 percent of total billed charges WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC 464 MS-DRG inpatient 1 UN 38320.2 24908.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23202.88 60.55 999999999 23202.88 38320.2 percent of total billed charges WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC 464 MS-DRG inpatient 1 UN 38320.2 24908.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 38320.2 999999999 23202.88 38320.2 case rate WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC 464 MS-DRG inpatient 1 UN 38320.2 24908.13 UMR - ALL PLANS UMR - ALL PLANS 26824.14 70 999999999 23202.88 38320.2 percent of total billed charges WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC 464 MS-DRG inpatient 1 UN 38320.2 24908.13 AETNA AETNA 30272.96 79 999999999 23202.88 38320.2 percent of total billed charges WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC 464 MS-DRG inpatient 1 UN 38320.2 24908.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37170.59 97 999999999 23202.88 38320.2 percent of total billed charges MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC 470 MS-DRG inpatient 1 UN 80039.69 52025.8 AETNA AETNA 63231.36 79 999999999 15994.45 77638.5 percent of total billed charges MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC 470 MS-DRG inpatient 1 UN 80039.69 52025.8 SIHO - ALL PLANS SIHO - ALL PLANS 72035.72 90 999999999 15994.45 77638.5 percent of total billed charges MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC 470 MS-DRG inpatient 1 UN 80039.69 52025.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 48464.03 60.55 999999999 15994.45 77638.5 percent of total billed charges MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC 470 MS-DRG inpatient 1 UN 80039.69 52025.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 62430.96 78 999999999 15994.45 77638.5 percent of total billed charges MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC 470 MS-DRG inpatient 1 UN 80039.69 52025.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 55227.39 69 999999999 15994.45 77638.5 percent of total billed charges MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC 470 MS-DRG inpatient 1 UN 80039.69 52025.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 28526.57 999999999 15994.45 77638.5 case rate MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC 470 MS-DRG inpatient 1 UN 80039.69 52025.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 30205.05 999999999 15994.45 77638.5 case rate MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC 470 MS-DRG inpatient 1 UN 80039.69 52025.8 UMR - ALL PLANS UMR - ALL PLANS 56027.78 70 999999999 15994.45 77638.5 percent of total billed charges MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC 470 MS-DRG inpatient 1 UN 80039.69 52025.8 UHC - ALL PLANS UHC - ALL PLANS 15994.45 999999999 15994.45 77638.5 case rate MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC 470 MS-DRG inpatient 1 UN 80039.69 52025.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 77638.5 97 999999999 15994.45 77638.5 percent of total billed charges MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC 470 MS-DRG inpatient 1 UN 80039.69 52025.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 54106.83 67.6 999999999 15994.45 77638.5 percent of total billed charges MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC 470 MS-DRG inpatient 1 UN 80039.69 52025.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 25673.91 999999999 15994.45 77638.5 case rate MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC 470 MS-DRG inpatient 1 UN 80039.69 52025.8 ANTHEM HMO ANTHEM HMO 26846.21 999999999 15994.45 77638.5 case rate MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC 470 MS-DRG inpatient 1 UN 80039.69 52025.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 52025.8 65 999999999 15994.45 77638.5 percent of total billed charges AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC 474 MS-DRG inpatient 1 UN 86253.91 56065.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 58307.64 67.6 999999999 36573.8 83666.29 percent of total billed charges AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC 474 MS-DRG inpatient 1 UN 86253.91 56065.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52226.74 60.55 999999999 36573.8 83666.29 percent of total billed charges AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC 474 MS-DRG inpatient 1 UN 86253.91 56065.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 59515.2 69 999999999 36573.8 83666.29 percent of total billed charges AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC 474 MS-DRG inpatient 1 UN 86253.91 56065.04 ANTHEM HMO ANTHEM HMO 61388.05 999999999 36573.8 83666.29 case rate AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC 474 MS-DRG inpatient 1 UN 86253.91 56065.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 58707.4 999999999 36573.8 83666.29 case rate AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC 474 MS-DRG inpatient 1 UN 86253.91 56065.04 UHC - ALL PLANS UHC - ALL PLANS 36573.8 999999999 36573.8 83666.29 case rate AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC 474 MS-DRG inpatient 1 UN 86253.91 56065.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 67278.05 78 999999999 36573.8 83666.29 percent of total billed charges AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC 474 MS-DRG inpatient 1 UN 86253.91 56065.04 SIHO - ALL PLANS SIHO - ALL PLANS 77628.52 90 999999999 36573.8 83666.29 percent of total billed charges AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC 474 MS-DRG inpatient 1 UN 86253.91 56065.04 AETNA AETNA 68140.59 79 999999999 36573.8 83666.29 percent of total billed charges AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC 474 MS-DRG inpatient 1 UN 86253.91 56065.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 56065.04 65 999999999 36573.8 83666.29 percent of total billed charges AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC 474 MS-DRG inpatient 1 UN 86253.91 56065.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 69068.55 999999999 36573.8 83666.29 case rate AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC 474 MS-DRG inpatient 1 UN 86253.91 56065.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 65230.45 999999999 36573.8 83666.29 case rate AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC 474 MS-DRG inpatient 1 UN 86253.91 56065.04 UMR - ALL PLANS UMR - ALL PLANS 60377.74 70 999999999 36573.8 83666.29 percent of total billed charges AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC 474 MS-DRG inpatient 1 UN 86253.91 56065.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83666.29 97 999999999 36573.8 83666.29 percent of total billed charges BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC 478 MS-DRG inpatient 1 UN 103548.11 67306.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 71448.2 69 999999999 20261.45 100441.67 percent of total billed charges BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC 478 MS-DRG inpatient 1 UN 103548.11 67306.27 UMR - ALL PLANS UMR - ALL PLANS 72483.68 70 999999999 20261.45 100441.67 percent of total billed charges BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC 478 MS-DRG inpatient 1 UN 103548.11 67306.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62698.38 60.55 999999999 20261.45 100441.67 percent of total billed charges BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC 478 MS-DRG inpatient 1 UN 103548.11 67306.27 UHC - ALL PLANS UHC - ALL PLANS 20261.45 999999999 20261.45 100441.67 case rate BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC 478 MS-DRG inpatient 1 UN 103548.11 67306.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 69998.52 67.6 999999999 20261.45 100441.67 percent of total billed charges BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC 478 MS-DRG inpatient 1 UN 103548.11 67306.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 32523.2 999999999 20261.45 100441.67 case rate BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC 478 MS-DRG inpatient 1 UN 103548.11 67306.27 ANTHEM HMO ANTHEM HMO 34008.25 999999999 20261.45 100441.67 case rate BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC 478 MS-DRG inpatient 1 UN 103548.11 67306.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 100441.67 97 999999999 20261.45 100441.67 percent of total billed charges BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC 478 MS-DRG inpatient 1 UN 103548.11 67306.27 SIHO - ALL PLANS SIHO - ALL PLANS 93193.3 90 999999999 20261.45 100441.67 percent of total billed charges BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC 478 MS-DRG inpatient 1 UN 103548.11 67306.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 80767.53 78 999999999 20261.45 100441.67 percent of total billed charges BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC 478 MS-DRG inpatient 1 UN 103548.11 67306.27 AETNA AETNA 81803.01 79 999999999 20261.45 100441.67 percent of total billed charges BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC 478 MS-DRG inpatient 1 UN 103548.11 67306.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 67306.27 65 999999999 20261.45 100441.67 percent of total billed charges BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC 478 MS-DRG inpatient 1 UN 103548.11 67306.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 36136.89 999999999 20261.45 100441.67 case rate BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC 478 MS-DRG inpatient 1 UN 103548.11 67306.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 38263.15 999999999 20261.45 100441.67 case rate HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC 480 MS-DRG inpatient 1 UN 103739.14 67430.44 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 44705.32 999999999 25065.65 100626.97 case rate HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC 480 MS-DRG inpatient 1 UN 103739.14 67430.44 ANTHEM HMO ANTHEM HMO 42071.96 999999999 25065.65 100626.97 case rate HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC 480 MS-DRG inpatient 1 UN 103739.14 67430.44 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 47335.74 999999999 25065.65 100626.97 case rate HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC 480 MS-DRG inpatient 1 UN 103739.14 67430.44 AETNA AETNA 81953.92 79 999999999 25065.65 100626.97 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC 480 MS-DRG inpatient 1 UN 103739.14 67430.44 SELF PAY DISCOUNT SELF PAY DISCOUNT 67430.44 65 999999999 25065.65 100626.97 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC 480 MS-DRG inpatient 1 UN 103739.14 67430.44 SIHO - ALL PLANS SIHO - ALL PLANS 93365.23 90 999999999 25065.65 100626.97 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC 480 MS-DRG inpatient 1 UN 103739.14 67430.44 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 100626.97 97 999999999 25065.65 100626.97 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC 480 MS-DRG inpatient 1 UN 103739.14 67430.44 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 40234.79 999999999 25065.65 100626.97 case rate HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC 480 MS-DRG inpatient 1 UN 103739.14 67430.44 CIGNA - ALL PLANS CIGNA - ALL PLANS 70127.66 67.6 999999999 25065.65 100626.97 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC 480 MS-DRG inpatient 1 UN 103739.14 67430.44 UHC - ALL PLANS UHC - ALL PLANS 25065.65 999999999 25065.65 100626.97 case rate HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC 480 MS-DRG inpatient 1 UN 103739.14 67430.44 UMR - ALL PLANS UMR - ALL PLANS 72617.4 70 999999999 25065.65 100626.97 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC 480 MS-DRG inpatient 1 UN 103739.14 67430.44 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 62814.05 60.55 999999999 25065.65 100626.97 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC 480 MS-DRG inpatient 1 UN 103739.14 67430.44 ENCORE - ALL PLANS ENCORE - ALL PLANS 71580.01 69 999999999 25065.65 100626.97 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC 480 MS-DRG inpatient 1 UN 103739.14 67430.44 HUMANA - ALL PLANS HUMANA - ALL PLANS 80916.53 78 999999999 25065.65 100626.97 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC 481 MS-DRG inpatient 1 UN 86142.1 55992.36 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 83557.84 97 999999999 17636.65 83557.84 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC 481 MS-DRG inpatient 1 UN 86142.1 55992.36 UMR - ALL PLANS UMR - ALL PLANS 60299.47 70 999999999 17636.65 83557.84 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC 481 MS-DRG inpatient 1 UN 86142.1 55992.36 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 31455.48 999999999 17636.65 83557.84 case rate HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC 481 MS-DRG inpatient 1 UN 86142.1 55992.36 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 33306.29 999999999 17636.65 83557.84 case rate HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC 481 MS-DRG inpatient 1 UN 86142.1 55992.36 SELF PAY DISCOUNT SELF PAY DISCOUNT 55992.37 65 999999999 17636.65 83557.84 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC 481 MS-DRG inpatient 1 UN 86142.1 55992.36 AETNA AETNA 68052.26 79 999999999 17636.65 83557.84 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC 481 MS-DRG inpatient 1 UN 86142.1 55992.36 SIHO - ALL PLANS SIHO - ALL PLANS 77527.89 90 999999999 17636.65 83557.84 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC 481 MS-DRG inpatient 1 UN 86142.1 55992.36 HUMANA - ALL PLANS HUMANA - ALL PLANS 67190.84 78 999999999 17636.65 83557.84 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC 481 MS-DRG inpatient 1 UN 86142.1 55992.36 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 28309.94 999999999 17636.65 83557.84 case rate HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC 481 MS-DRG inpatient 1 UN 86142.1 55992.36 ANTHEM HMO ANTHEM HMO 29602.6 999999999 17636.65 83557.84 case rate HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC 481 MS-DRG inpatient 1 UN 86142.1 55992.36 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52159.04 60.55 999999999 17636.65 83557.84 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC 481 MS-DRG inpatient 1 UN 86142.1 55992.36 ENCORE - ALL PLANS ENCORE - ALL PLANS 59438.05 69 999999999 17636.65 83557.84 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC 481 MS-DRG inpatient 1 UN 86142.1 55992.36 UHC - ALL PLANS UHC - ALL PLANS 17636.65 999999999 17636.65 83557.84 case rate HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC 481 MS-DRG inpatient 1 UN 86142.1 55992.36 CIGNA - ALL PLANS CIGNA - ALL PLANS 58232.06 67.6 999999999 17636.65 83557.84 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC 482 MS-DRG inpatient 1 UN 58373.12 37942.53 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 24080.14 999999999 13501.4 56621.93 case rate HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC 482 MS-DRG inpatient 1 UN 58373.12 37942.53 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 25497 999999999 13501.4 56621.93 case rate HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC 482 MS-DRG inpatient 1 UN 58373.12 37942.53 SELF PAY DISCOUNT SELF PAY DISCOUNT 37942.53 65 999999999 13501.4 56621.93 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC 482 MS-DRG inpatient 1 UN 58373.12 37942.53 HUMANA - ALL PLANS HUMANA - ALL PLANS 45531.03 78 999999999 13501.4 56621.93 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC 482 MS-DRG inpatient 1 UN 58373.12 37942.53 AETNA AETNA 46114.77 79 999999999 13501.4 56621.93 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC 482 MS-DRG inpatient 1 UN 58373.12 37942.53 SIHO - ALL PLANS SIHO - ALL PLANS 52535.81 90 999999999 13501.4 56621.93 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC 482 MS-DRG inpatient 1 UN 58373.12 37942.53 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 56621.93 97 999999999 13501.4 56621.93 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC 482 MS-DRG inpatient 1 UN 58373.12 37942.53 ANTHEM HMO ANTHEM HMO 22661.7 999999999 13501.4 56621.93 case rate HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC 482 MS-DRG inpatient 1 UN 58373.12 37942.53 CIGNA - ALL PLANS CIGNA - ALL PLANS 39460.23 67.6 999999999 13501.4 56621.93 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC 482 MS-DRG inpatient 1 UN 58373.12 37942.53 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 21672.13 999999999 13501.4 56621.93 case rate HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC 482 MS-DRG inpatient 1 UN 58373.12 37942.53 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 35344.92 60.55 999999999 13501.4 56621.93 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC 482 MS-DRG inpatient 1 UN 58373.12 37942.53 UHC - ALL PLANS UHC - ALL PLANS 13501.4 999999999 13501.4 56621.93 case rate HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC 482 MS-DRG inpatient 1 UN 58373.12 37942.53 ENCORE - ALL PLANS ENCORE - ALL PLANS 40277.45 69 999999999 13501.4 56621.93 percent of total billed charges HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC 482 MS-DRG inpatient 1 UN 58373.12 37942.53 UMR - ALL PLANS UMR - ALL PLANS 40861.18 70 999999999 13501.4 56621.93 percent of total billed charges MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES 483 MS-DRG inpatient 1 UN 100592.02 65384.81 UMR - ALL PLANS UMR - ALL PLANS 70414.41 70 999999999 21115.7 97574.26 percent of total billed charges MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES 483 MS-DRG inpatient 1 UN 100592.02 65384.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 69408.49 69 999999999 21115.7 97574.26 percent of total billed charges MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES 483 MS-DRG inpatient 1 UN 100592.02 65384.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 78461.78 78 999999999 21115.7 97574.26 percent of total billed charges MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES 483 MS-DRG inpatient 1 UN 100592.02 65384.81 UHC - ALL PLANS UHC - ALL PLANS 21115.7 999999999 21115.7 97574.26 case rate MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES 483 MS-DRG inpatient 1 UN 100592.02 65384.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 60908.47 60.55 999999999 21115.7 97574.26 percent of total billed charges MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES 483 MS-DRG inpatient 1 UN 100592.02 65384.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 33894.42 999999999 21115.7 97574.26 case rate MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES 483 MS-DRG inpatient 1 UN 100592.02 65384.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 68000.21 67.6 999999999 21115.7 97574.26 percent of total billed charges MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES 483 MS-DRG inpatient 1 UN 100592.02 65384.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 97574.26 97 999999999 21115.7 97574.26 percent of total billed charges MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES 483 MS-DRG inpatient 1 UN 100592.02 65384.81 AETNA AETNA 79467.7 79 999999999 21115.7 97574.26 percent of total billed charges MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES 483 MS-DRG inpatient 1 UN 100592.02 65384.81 SIHO - ALL PLANS SIHO - ALL PLANS 90532.82 90 999999999 21115.7 97574.26 percent of total billed charges MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES 483 MS-DRG inpatient 1 UN 100592.02 65384.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 65384.81 65 999999999 21115.7 97574.26 percent of total billed charges MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES 483 MS-DRG inpatient 1 UN 100592.02 65384.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 39876.38 999999999 21115.7 97574.26 case rate MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES 483 MS-DRG inpatient 1 UN 100592.02 65384.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 37660.47 999999999 21115.7 97574.26 case rate MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES 483 MS-DRG inpatient 1 UN 100592.02 65384.81 ANTHEM HMO ANTHEM HMO 35442.08 999999999 21115.7 97574.26 case rate KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 489 MS-DRG inpatient 1 UN 62378.32 40545.91 ANTHEM HMO ANTHEM HMO 17658.27 999999999 10520.45 60506.97 case rate KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 489 MS-DRG inpatient 1 UN 62378.32 40545.91 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 16887.18 999999999 10520.45 60506.97 case rate KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 489 MS-DRG inpatient 1 UN 62378.32 40545.91 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 18763.53 999999999 10520.45 60506.97 case rate KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 489 MS-DRG inpatient 1 UN 62378.32 40545.91 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 19867.56 999999999 10520.45 60506.97 case rate KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 489 MS-DRG inpatient 1 UN 62378.32 40545.91 AETNA AETNA 49278.87 79 999999999 10520.45 60506.97 percent of total billed charges KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 489 MS-DRG inpatient 1 UN 62378.32 40545.91 SELF PAY DISCOUNT SELF PAY DISCOUNT 40545.91 65 999999999 10520.45 60506.97 percent of total billed charges KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 489 MS-DRG inpatient 1 UN 62378.32 40545.91 SIHO - ALL PLANS SIHO - ALL PLANS 56140.49 90 999999999 10520.45 60506.97 percent of total billed charges KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 489 MS-DRG inpatient 1 UN 62378.32 40545.91 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 60506.97 97 999999999 10520.45 60506.97 percent of total billed charges KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 489 MS-DRG inpatient 1 UN 62378.32 40545.91 UMR - ALL PLANS UMR - ALL PLANS 43664.82 70 999999999 10520.45 60506.97 percent of total billed charges KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 489 MS-DRG inpatient 1 UN 62378.32 40545.91 CIGNA - ALL PLANS CIGNA - ALL PLANS 42167.74 67.6 999999999 10520.45 60506.97 percent of total billed charges KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 489 MS-DRG inpatient 1 UN 62378.32 40545.91 ENCORE - ALL PLANS ENCORE - ALL PLANS 43041.04 69 999999999 10520.45 60506.97 percent of total billed charges KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 489 MS-DRG inpatient 1 UN 62378.32 40545.91 UHC - ALL PLANS UHC - ALL PLANS 10520.45 999999999 10520.45 60506.97 case rate KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 489 MS-DRG inpatient 1 UN 62378.32 40545.91 HUMANA - ALL PLANS HUMANA - ALL PLANS 48655.09 78 999999999 10520.45 60506.97 percent of total billed charges KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC 489 MS-DRG inpatient 1 UN 62378.32 40545.91 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 37770.07 60.55 999999999 10520.45 60506.97 percent of total billed charges "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC" 493 MS-DRG inpatient 1 UN 114839.14 74645.44 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 69535.1 60.55 999999999 20414.45 111393.97 percent of total billed charges "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC" 493 MS-DRG inpatient 1 UN 114839.14 74645.44 AETNA AETNA 90722.92 79 999999999 20414.45 111393.97 percent of total billed charges "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC" 493 MS-DRG inpatient 1 UN 114839.14 74645.44 SIHO - ALL PLANS SIHO - ALL PLANS 103355.23 90 999999999 20414.45 111393.97 percent of total billed charges "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC" 493 MS-DRG inpatient 1 UN 114839.14 74645.44 ENCORE - ALL PLANS ENCORE - ALL PLANS 79239.01 69 999999999 20414.45 111393.97 percent of total billed charges "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC" 493 MS-DRG inpatient 1 UN 114839.14 74645.44 HUMANA - ALL PLANS HUMANA - ALL PLANS 89574.53 78 999999999 20414.45 111393.97 percent of total billed charges "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC" 493 MS-DRG inpatient 1 UN 114839.14 74645.44 CIGNA - ALL PLANS CIGNA - ALL PLANS 77631.26 67.6 999999999 20414.45 111393.97 percent of total billed charges "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC" 493 MS-DRG inpatient 1 UN 114839.14 74645.44 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 38552.09 999999999 20414.45 111393.97 case rate "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC" 493 MS-DRG inpatient 1 UN 114839.14 74645.44 UMR - ALL PLANS UMR - ALL PLANS 80387.4 70 999999999 20414.45 111393.97 percent of total billed charges "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC" 493 MS-DRG inpatient 1 UN 114839.14 74645.44 SELF PAY DISCOUNT SELF PAY DISCOUNT 74645.44 65 999999999 20414.45 111393.97 percent of total billed charges "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC" 493 MS-DRG inpatient 1 UN 114839.14 74645.44 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 111393.97 97 999999999 20414.45 111393.97 percent of total billed charges "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC" 493 MS-DRG inpatient 1 UN 114839.14 74645.44 UHC - ALL PLANS UHC - ALL PLANS 20414.45 999999999 20414.45 111393.97 case rate "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC" 493 MS-DRG inpatient 1 UN 114839.14 74645.44 ANTHEM HMO ANTHEM HMO 34265.05 999999999 20414.45 111393.97 case rate "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC" 493 MS-DRG inpatient 1 UN 114839.14 74645.44 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 36409.77 999999999 20414.45 111393.97 case rate "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC" 493 MS-DRG inpatient 1 UN 114839.14 74645.44 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 32768.79 999999999 20414.45 111393.97 case rate "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC" 494 MS-DRG inpatient 1 UN 52793.21 34315.58 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 28337.07 999999999 15888.2 51209.41 case rate "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC" 494 MS-DRG inpatient 1 UN 52793.21 34315.58 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 30004.4 999999999 15888.2 51209.41 case rate "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC" 494 MS-DRG inpatient 1 UN 52793.21 34315.58 SELF PAY DISCOUNT SELF PAY DISCOUNT 34315.58 65 999999999 15888.2 51209.41 percent of total billed charges "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC" 494 MS-DRG inpatient 1 UN 52793.21 34315.58 AETNA AETNA 41706.63 79 999999999 15888.2 51209.41 percent of total billed charges "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC" 494 MS-DRG inpatient 1 UN 52793.21 34315.58 HUMANA - ALL PLANS HUMANA - ALL PLANS 41178.7 78 999999999 15888.2 51209.41 percent of total billed charges "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC" 494 MS-DRG inpatient 1 UN 52793.21 34315.58 SIHO - ALL PLANS SIHO - ALL PLANS 47513.88 90 999999999 15888.2 51209.41 percent of total billed charges "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC" 494 MS-DRG inpatient 1 UN 52793.21 34315.58 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 51209.41 97 999999999 15888.2 51209.41 percent of total billed charges "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC" 494 MS-DRG inpatient 1 UN 52793.21 34315.58 CIGNA - ALL PLANS CIGNA - ALL PLANS 35688.21 67.6 999999999 15888.2 51209.41 percent of total billed charges "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC" 494 MS-DRG inpatient 1 UN 52793.21 34315.58 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 25503.36 999999999 15888.2 51209.41 case rate "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC" 494 MS-DRG inpatient 1 UN 52793.21 34315.58 ANTHEM HMO ANTHEM HMO 26667.88 999999999 15888.2 51209.41 case rate "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC" 494 MS-DRG inpatient 1 UN 52793.21 34315.58 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 31966.29 60.55 999999999 15888.2 51209.41 percent of total billed charges "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC" 494 MS-DRG inpatient 1 UN 52793.21 34315.58 UHC - ALL PLANS UHC - ALL PLANS 15888.2 999999999 15888.2 51209.41 case rate "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC" 494 MS-DRG inpatient 1 UN 52793.21 34315.58 UMR - ALL PLANS UMR - ALL PLANS 36955.24 70 999999999 15888.2 51209.41 percent of total billed charges "LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC" 494 MS-DRG inpatient 1 UN 52793.21 34315.58 ENCORE - ALL PLANS ENCORE - ALL PLANS 36427.31 69 999999999 15888.2 51209.41 percent of total billed charges SOFT TISSUE PROCEDURES WITH MCC 500 MS-DRG inpatient 1 UN 123666.49 80383.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 74880.06 60.55 999999999 27563.8 119956.5 percent of total billed charges SOFT TISSUE PROCEDURES WITH MCC 500 MS-DRG inpatient 1 UN 123666.49 80383.22 ANTHEM HMO ANTHEM HMO 46265.03 999999999 27563.8 119956.5 case rate SOFT TISSUE PROCEDURES WITH MCC 500 MS-DRG inpatient 1 UN 123666.49 80383.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 49160.85 999999999 27563.8 119956.5 case rate SOFT TISSUE PROCEDURES WITH MCC 500 MS-DRG inpatient 1 UN 123666.49 80383.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 96459.86 78 999999999 27563.8 119956.5 percent of total billed charges SOFT TISSUE PROCEDURES WITH MCC 500 MS-DRG inpatient 1 UN 123666.49 80383.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 85329.88 69 999999999 27563.8 119956.5 percent of total billed charges SOFT TISSUE PROCEDURES WITH MCC 500 MS-DRG inpatient 1 UN 123666.49 80383.22 SIHO - ALL PLANS SIHO - ALL PLANS 111299.84 90 999999999 27563.8 119956.5 percent of total billed charges SOFT TISSUE PROCEDURES WITH MCC 500 MS-DRG inpatient 1 UN 123666.49 80383.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 52053.43 999999999 27563.8 119956.5 case rate SOFT TISSUE PROCEDURES WITH MCC 500 MS-DRG inpatient 1 UN 123666.49 80383.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 83598.55 67.6 999999999 27563.8 119956.5 percent of total billed charges SOFT TISSUE PROCEDURES WITH MCC 500 MS-DRG inpatient 1 UN 123666.49 80383.22 AETNA AETNA 97696.53 79 999999999 27563.8 119956.5 percent of total billed charges SOFT TISSUE PROCEDURES WITH MCC 500 MS-DRG inpatient 1 UN 123666.49 80383.22 UMR - ALL PLANS UMR - ALL PLANS 86566.54 70 999999999 27563.8 119956.5 percent of total billed charges SOFT TISSUE PROCEDURES WITH MCC 500 MS-DRG inpatient 1 UN 123666.49 80383.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 119956.5 97 999999999 27563.8 119956.5 percent of total billed charges SOFT TISSUE PROCEDURES WITH MCC 500 MS-DRG inpatient 1 UN 123666.49 80383.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 44244.76 999999999 27563.8 119956.5 case rate SOFT TISSUE PROCEDURES WITH MCC 500 MS-DRG inpatient 1 UN 123666.49 80383.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 80383.22 65 999999999 27563.8 119956.5 percent of total billed charges SOFT TISSUE PROCEDURES WITH MCC 500 MS-DRG inpatient 1 UN 123666.49 80383.22 UHC - ALL PLANS UHC - ALL PLANS 27563.8 999999999 27563.8 119956.5 case rate SOFT TISSUE PROCEDURES WITH CC 501 MS-DRG inpatient 1 UN 51646.8 33570.42 UHC - ALL PLANS UHC - ALL PLANS 14753.45 999999999 14753.45 50097.4 case rate SOFT TISSUE PROCEDURES WITH CC 501 MS-DRG inpatient 1 UN 51646.8 33570.42 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 23681.89 999999999 14753.45 50097.4 case rate SOFT TISSUE PROCEDURES WITH CC 501 MS-DRG inpatient 1 UN 51646.8 33570.42 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 50097.4 97 999999999 14753.45 50097.4 percent of total billed charges SOFT TISSUE PROCEDURES WITH CC 501 MS-DRG inpatient 1 UN 51646.8 33570.42 AETNA AETNA 40800.97 79 999999999 14753.45 50097.4 percent of total billed charges SOFT TISSUE PROCEDURES WITH CC 501 MS-DRG inpatient 1 UN 51646.8 33570.42 CIGNA - ALL PLANS CIGNA - ALL PLANS 34913.24 67.6 999999999 14753.45 50097.4 percent of total billed charges SOFT TISSUE PROCEDURES WITH CC 501 MS-DRG inpatient 1 UN 51646.8 33570.42 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 27861.46 999999999 14753.45 50097.4 case rate SOFT TISSUE PROCEDURES WITH CC 501 MS-DRG inpatient 1 UN 51646.8 33570.42 SIHO - ALL PLANS SIHO - ALL PLANS 46482.12 90 999999999 14753.45 50097.4 percent of total billed charges SOFT TISSUE PROCEDURES WITH CC 501 MS-DRG inpatient 1 UN 51646.8 33570.42 ENCORE - ALL PLANS ENCORE - ALL PLANS 35636.29 69 999999999 14753.45 50097.4 percent of total billed charges SOFT TISSUE PROCEDURES WITH CC 501 MS-DRG inpatient 1 UN 51646.8 33570.42 HUMANA - ALL PLANS HUMANA - ALL PLANS 40284.51 78 999999999 14753.45 50097.4 percent of total billed charges SOFT TISSUE PROCEDURES WITH CC 501 MS-DRG inpatient 1 UN 51646.8 33570.42 SELF PAY DISCOUNT SELF PAY DISCOUNT 33570.42 65 999999999 14753.45 50097.4 percent of total billed charges SOFT TISSUE PROCEDURES WITH CC 501 MS-DRG inpatient 1 UN 51646.8 33570.42 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 26313.21 999999999 14753.45 50097.4 case rate SOFT TISSUE PROCEDURES WITH CC 501 MS-DRG inpatient 1 UN 51646.8 33570.42 ANTHEM HMO ANTHEM HMO 24763.23 999999999 14753.45 50097.4 case rate SOFT TISSUE PROCEDURES WITH CC 501 MS-DRG inpatient 1 UN 51646.8 33570.42 UMR - ALL PLANS UMR - ALL PLANS 36152.76 70 999999999 14753.45 50097.4 percent of total billed charges SOFT TISSUE PROCEDURES WITH CC 501 MS-DRG inpatient 1 UN 51646.8 33570.42 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 31272.14 60.55 999999999 14753.45 50097.4 percent of total billed charges SOFT TISSUE PROCEDURES WITHOUT CC/MCC 502 MS-DRG inpatient 1 UN 30463.01 19800.96 AETNA AETNA 24065.78 79 999999999 11752.95 29549.12 percent of total billed charges SOFT TISSUE PROCEDURES WITHOUT CC/MCC 502 MS-DRG inpatient 1 UN 30463.01 19800.96 UMR - ALL PLANS UMR - ALL PLANS 21324.11 70 999999999 11752.95 29549.12 percent of total billed charges SOFT TISSUE PROCEDURES WITHOUT CC/MCC 502 MS-DRG inpatient 1 UN 30463.01 19800.96 SIHO - ALL PLANS SIHO - ALL PLANS 27416.71 90 999999999 11752.95 29549.12 percent of total billed charges SOFT TISSUE PROCEDURES WITHOUT CC/MCC 502 MS-DRG inpatient 1 UN 30463.01 19800.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18445.35 60.55 999999999 11752.95 29549.12 percent of total billed charges SOFT TISSUE PROCEDURES WITHOUT CC/MCC 502 MS-DRG inpatient 1 UN 30463.01 19800.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29549.12 97 999999999 11752.95 29549.12 percent of total billed charges SOFT TISSUE PROCEDURES WITHOUT CC/MCC 502 MS-DRG inpatient 1 UN 30463.01 19800.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 21019.48 69 999999999 11752.95 29549.12 percent of total billed charges SOFT TISSUE PROCEDURES WITHOUT CC/MCC 502 MS-DRG inpatient 1 UN 30463.01 19800.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 23761.15 78 999999999 11752.95 29549.12 percent of total billed charges SOFT TISSUE PROCEDURES WITHOUT CC/MCC 502 MS-DRG inpatient 1 UN 30463.01 19800.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 19800.96 65 999999999 11752.95 29549.12 percent of total billed charges SOFT TISSUE PROCEDURES WITHOUT CC/MCC 502 MS-DRG inpatient 1 UN 30463.01 19800.96 UHC - ALL PLANS UHC - ALL PLANS 11752.95 999999999 11752.95 29549.12 case rate SOFT TISSUE PROCEDURES WITHOUT CC/MCC 502 MS-DRG inpatient 1 UN 30463.01 19800.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 22195.1 999999999 11752.95 29549.12 case rate SOFT TISSUE PROCEDURES WITHOUT CC/MCC 502 MS-DRG inpatient 1 UN 30463.01 19800.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 20961.73 999999999 11752.95 29549.12 case rate SOFT TISSUE PROCEDURES WITHOUT CC/MCC 502 MS-DRG inpatient 1 UN 30463.01 19800.96 ANTHEM HMO ANTHEM HMO 19726.98 999999999 11752.95 29549.12 case rate SOFT TISSUE PROCEDURES WITHOUT CC/MCC 502 MS-DRG inpatient 1 UN 30463.01 19800.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 18865.56 999999999 11752.95 29549.12 case rate SOFT TISSUE PROCEDURES WITHOUT CC/MCC 502 MS-DRG inpatient 1 UN 30463.01 19800.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 20592.99 67.6 999999999 11752.95 29549.12 percent of total billed charges FOOT PROCEDURES WITH CC 504 MS-DRG inpatient 1 UN 73807.08 47974.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 27723.41 999999999 14680.35 71592.86 case rate FOOT PROCEDURES WITH CC 504 MS-DRG inpatient 1 UN 73807.08 47974.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 47974.6 65 999999999 14680.35 71592.86 percent of total billed charges FOOT PROCEDURES WITH CC 504 MS-DRG inpatient 1 UN 73807.08 47974.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 44690.18 60.55 999999999 14680.35 71592.86 percent of total billed charges FOOT PROCEDURES WITH CC 504 MS-DRG inpatient 1 UN 73807.08 47974.6 UMR - ALL PLANS UMR - ALL PLANS 51664.95 70 999999999 14680.35 71592.86 percent of total billed charges FOOT PROCEDURES WITH CC 504 MS-DRG inpatient 1 UN 73807.08 47974.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 71592.86 97 999999999 14680.35 71592.86 percent of total billed charges FOOT PROCEDURES WITH CC 504 MS-DRG inpatient 1 UN 73807.08 47974.6 ANTHEM HMO ANTHEM HMO 24640.54 999999999 14680.35 71592.86 case rate FOOT PROCEDURES WITH CC 504 MS-DRG inpatient 1 UN 73807.08 47974.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 26182.84 999999999 14680.35 71592.86 case rate FOOT PROCEDURES WITH CC 504 MS-DRG inpatient 1 UN 73807.08 47974.6 SIHO - ALL PLANS SIHO - ALL PLANS 66426.37 90 999999999 14680.35 71592.86 percent of total billed charges FOOT PROCEDURES WITH CC 504 MS-DRG inpatient 1 UN 73807.08 47974.6 AETNA AETNA 58307.59 79 999999999 14680.35 71592.86 percent of total billed charges FOOT PROCEDURES WITH CC 504 MS-DRG inpatient 1 UN 73807.08 47974.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 49893.58 67.6 999999999 14680.35 71592.86 percent of total billed charges FOOT PROCEDURES WITH CC 504 MS-DRG inpatient 1 UN 73807.08 47974.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 23564.55 999999999 14680.35 71592.86 case rate FOOT PROCEDURES WITH CC 504 MS-DRG inpatient 1 UN 73807.08 47974.6 UHC - ALL PLANS UHC - ALL PLANS 14680.35 999999999 14680.35 71592.86 case rate FOOT PROCEDURES WITH CC 504 MS-DRG inpatient 1 UN 73807.08 47974.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 50926.88 69 999999999 14680.35 71592.86 percent of total billed charges FOOT PROCEDURES WITH CC 504 MS-DRG inpatient 1 UN 73807.08 47974.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 57569.52 78 999999999 14680.35 71592.86 percent of total billed charges FOOT PROCEDURES WITHOUT CC/MCC 505 MS-DRG inpatient 1 UN 33422.66 21724.73 HUMANA - ALL PLANS HUMANA - ALL PLANS 26069.67 78 999999999 14498.45 32419.98 percent of total billed charges FOOT PROCEDURES WITHOUT CC/MCC 505 MS-DRG inpatient 1 UN 33422.66 21724.73 ENCORE - ALL PLANS ENCORE - ALL PLANS 23061.64 69 999999999 14498.45 32419.98 percent of total billed charges FOOT PROCEDURES WITHOUT CC/MCC 505 MS-DRG inpatient 1 UN 33422.66 21724.73 UHC - ALL PLANS UHC - ALL PLANS 14498.45 999999999 14498.45 32419.98 case rate FOOT PROCEDURES WITHOUT CC/MCC 505 MS-DRG inpatient 1 UN 33422.66 21724.73 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20237.42 60.55 999999999 14498.45 32419.98 percent of total billed charges FOOT PROCEDURES WITHOUT CC/MCC 505 MS-DRG inpatient 1 UN 33422.66 21724.73 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 23272.57 999999999 14498.45 32419.98 case rate FOOT PROCEDURES WITHOUT CC/MCC 505 MS-DRG inpatient 1 UN 33422.66 21724.73 CIGNA - ALL PLANS CIGNA - ALL PLANS 22593.72 67.6 999999999 14498.45 32419.98 percent of total billed charges FOOT PROCEDURES WITHOUT CC/MCC 505 MS-DRG inpatient 1 UN 33422.66 21724.73 SIHO - ALL PLANS SIHO - ALL PLANS 30080.39 90 999999999 14498.45 32419.98 percent of total billed charges FOOT PROCEDURES WITHOUT CC/MCC 505 MS-DRG inpatient 1 UN 33422.66 21724.73 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 25858.41 999999999 14498.45 32419.98 case rate FOOT PROCEDURES WITHOUT CC/MCC 505 MS-DRG inpatient 1 UN 33422.66 21724.73 ANTHEM HMO ANTHEM HMO 24335.22 999999999 14498.45 32419.98 case rate FOOT PROCEDURES WITHOUT CC/MCC 505 MS-DRG inpatient 1 UN 33422.66 21724.73 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32419.98 97 999999999 14498.45 32419.98 percent of total billed charges FOOT PROCEDURES WITHOUT CC/MCC 505 MS-DRG inpatient 1 UN 33422.66 21724.73 UMR - ALL PLANS UMR - ALL PLANS 23395.86 70 999999999 14498.45 32419.98 percent of total billed charges FOOT PROCEDURES WITHOUT CC/MCC 505 MS-DRG inpatient 1 UN 33422.66 21724.73 AETNA AETNA 26403.9 79 999999999 14498.45 32419.98 percent of total billed charges FOOT PROCEDURES WITHOUT CC/MCC 505 MS-DRG inpatient 1 UN 33422.66 21724.73 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 27379.9 999999999 14498.45 32419.98 case rate FOOT PROCEDURES WITHOUT CC/MCC 505 MS-DRG inpatient 1 UN 33422.66 21724.73 SELF PAY DISCOUNT SELF PAY DISCOUNT 21724.73 65 999999999 14498.45 32419.98 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC 521 MS-DRG inpatient 1 UN 93286.27 60636.08 ANTHEM HMO ANTHEM HMO 42718.25 999999999 25450.7 90487.68 case rate HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC 521 MS-DRG inpatient 1 UN 93286.27 60636.08 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 45392.07 999999999 25450.7 90487.68 case rate HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC 521 MS-DRG inpatient 1 UN 93286.27 60636.08 CIGNA - ALL PLANS CIGNA - ALL PLANS 63061.52 67.6 999999999 25450.7 90487.68 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC 521 MS-DRG inpatient 1 UN 93286.27 60636.08 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 40852.86 999999999 25450.7 90487.68 case rate HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC 521 MS-DRG inpatient 1 UN 93286.27 60636.08 SIHO - ALL PLANS SIHO - ALL PLANS 83957.64 90 999999999 25450.7 90487.68 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC 521 MS-DRG inpatient 1 UN 93286.27 60636.08 UHC - ALL PLANS UHC - ALL PLANS 25450.7 999999999 25450.7 90487.68 case rate HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC 521 MS-DRG inpatient 1 UN 93286.27 60636.08 AETNA AETNA 73696.15 79 999999999 25450.7 90487.68 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC 521 MS-DRG inpatient 1 UN 93286.27 60636.08 HUMANA - ALL PLANS HUMANA - ALL PLANS 72763.29 78 999999999 25450.7 90487.68 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC 521 MS-DRG inpatient 1 UN 93286.27 60636.08 ENCORE - ALL PLANS ENCORE - ALL PLANS 64367.53 69 999999999 25450.7 90487.68 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC 521 MS-DRG inpatient 1 UN 93286.27 60636.08 SELF PAY DISCOUNT SELF PAY DISCOUNT 60636.08 65 999999999 25450.7 90487.68 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC 521 MS-DRG inpatient 1 UN 93286.27 60636.08 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 48062.9 999999999 25450.7 90487.68 case rate HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC 521 MS-DRG inpatient 1 UN 93286.27 60636.08 UMR - ALL PLANS UMR - ALL PLANS 65300.39 70 999999999 25450.7 90487.68 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC 521 MS-DRG inpatient 1 UN 93286.27 60636.08 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 90487.68 97 999999999 25450.7 90487.68 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC 521 MS-DRG inpatient 1 UN 93286.27 60636.08 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 56484.84 60.55 999999999 25450.7 90487.68 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 522 MS-DRG inpatient 1 UN 71737.34 46629.27 AETNA AETNA 56672.5 79 999999999 17953.7 69585.22 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 522 MS-DRG inpatient 1 UN 71737.34 46629.27 SIHO - ALL PLANS SIHO - ALL PLANS 64563.61 90 999999999 17953.7 69585.22 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 522 MS-DRG inpatient 1 UN 71737.34 46629.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 69585.22 97 999999999 17953.7 69585.22 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 522 MS-DRG inpatient 1 UN 71737.34 46629.27 UMR - ALL PLANS UMR - ALL PLANS 50216.14 70 999999999 17953.7 69585.22 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 522 MS-DRG inpatient 1 UN 71737.34 46629.27 UHC - ALL PLANS UHC - ALL PLANS 17953.7 999999999 17953.7 69585.22 case rate HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 522 MS-DRG inpatient 1 UN 71737.34 46629.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 28818.86 999999999 17953.7 69585.22 case rate HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 522 MS-DRG inpatient 1 UN 71737.34 46629.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 46629.27 65 999999999 17953.7 69585.22 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 522 MS-DRG inpatient 1 UN 71737.34 46629.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43436.96 60.55 999999999 17953.7 69585.22 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 522 MS-DRG inpatient 1 UN 71737.34 46629.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 55955.13 78 999999999 17953.7 69585.22 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 522 MS-DRG inpatient 1 UN 71737.34 46629.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 49498.77 69 999999999 17953.7 69585.22 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 522 MS-DRG inpatient 1 UN 71737.34 46629.27 ANTHEM HMO ANTHEM HMO 30134.76 999999999 17953.7 69585.22 case rate HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 522 MS-DRG inpatient 1 UN 71737.34 46629.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 32020.95 999999999 17953.7 69585.22 case rate HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 522 MS-DRG inpatient 1 UN 71737.34 46629.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 48494.44 67.6 999999999 17953.7 69585.22 percent of total billed charges HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC 522 MS-DRG inpatient 1 UN 71737.34 46629.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 33905.03 999999999 17953.7 69585.22 case rate FRACTURES OF HIP AND PELVIS WITH MCC 535 MS-DRG inpatient 1 UN 36909.32 23991.05 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 19657.97 999999999 11021.95 35802.04 case rate FRACTURES OF HIP AND PELVIS WITH MCC 535 MS-DRG inpatient 1 UN 36909.32 23991.05 ANTHEM HMO ANTHEM HMO 18500.02 999999999 11021.95 35802.04 case rate FRACTURES OF HIP AND PELVIS WITH MCC 535 MS-DRG inpatient 1 UN 36909.32 23991.05 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 17692.17 999999999 11021.95 35802.04 case rate FRACTURES OF HIP AND PELVIS WITH MCC 535 MS-DRG inpatient 1 UN 36909.32 23991.05 CIGNA - ALL PLANS CIGNA - ALL PLANS 24950.7 67.6 999999999 11021.95 35802.04 percent of total billed charges FRACTURES OF HIP AND PELVIS WITH MCC 535 MS-DRG inpatient 1 UN 36909.32 23991.05 SIHO - ALL PLANS SIHO - ALL PLANS 33218.38 90 999999999 11021.95 35802.04 percent of total billed charges FRACTURES OF HIP AND PELVIS WITH MCC 535 MS-DRG inpatient 1 UN 36909.32 23991.05 UHC - ALL PLANS UHC - ALL PLANS 11021.95 999999999 11021.95 35802.04 case rate FRACTURES OF HIP AND PELVIS WITH MCC 535 MS-DRG inpatient 1 UN 36909.32 23991.05 AETNA AETNA 29158.36 79 999999999 11021.95 35802.04 percent of total billed charges FRACTURES OF HIP AND PELVIS WITH MCC 535 MS-DRG inpatient 1 UN 36909.32 23991.05 ENCORE - ALL PLANS ENCORE - ALL PLANS 25467.43 69 999999999 11021.95 35802.04 percent of total billed charges FRACTURES OF HIP AND PELVIS WITH MCC 535 MS-DRG inpatient 1 UN 36909.32 23991.05 HUMANA - ALL PLANS HUMANA - ALL PLANS 28789.27 78 999999999 11021.95 35802.04 percent of total billed charges FRACTURES OF HIP AND PELVIS WITH MCC 535 MS-DRG inpatient 1 UN 36909.32 23991.05 SELF PAY DISCOUNT SELF PAY DISCOUNT 23991.06 65 999999999 11021.95 35802.04 percent of total billed charges FRACTURES OF HIP AND PELVIS WITH MCC 535 MS-DRG inpatient 1 UN 36909.32 23991.05 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 20814.63 999999999 11021.95 35802.04 case rate FRACTURES OF HIP AND PELVIS WITH MCC 535 MS-DRG inpatient 1 UN 36909.32 23991.05 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22348.59 60.55 999999999 11021.95 35802.04 percent of total billed charges FRACTURES OF HIP AND PELVIS WITH MCC 535 MS-DRG inpatient 1 UN 36909.32 23991.05 UMR - ALL PLANS UMR - ALL PLANS 25836.52 70 999999999 11021.95 35802.04 percent of total billed charges FRACTURES OF HIP AND PELVIS WITH MCC 535 MS-DRG inpatient 1 UN 36909.32 23991.05 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 35802.04 97 999999999 11021.95 35802.04 percent of total billed charges FRACTURES OF HIP AND PELVIS WITHOUT MCC 536 MS-DRG inpatient 1 UN 20198.55 13129.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12230.22 60.55 999999999 6690.35 19592.59 percent of total billed charges FRACTURES OF HIP AND PELVIS WITHOUT MCC 536 MS-DRG inpatient 1 UN 20198.55 13129.06 ANTHEM HMO ANTHEM HMO 11229.56 999999999 6690.35 19592.59 case rate FRACTURES OF HIP AND PELVIS WITHOUT MCC 536 MS-DRG inpatient 1 UN 20198.55 13129.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 13654.22 67.6 999999999 6690.35 19592.59 percent of total billed charges FRACTURES OF HIP AND PELVIS WITHOUT MCC 536 MS-DRG inpatient 1 UN 20198.55 13129.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 11932.44 999999999 6690.35 19592.59 case rate FRACTURES OF HIP AND PELVIS WITHOUT MCC 536 MS-DRG inpatient 1 UN 20198.55 13129.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 15754.87 78 999999999 6690.35 19592.59 percent of total billed charges FRACTURES OF HIP AND PELVIS WITHOUT MCC 536 MS-DRG inpatient 1 UN 20198.55 13129.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 13937 69 999999999 6690.35 19592.59 percent of total billed charges FRACTURES OF HIP AND PELVIS WITHOUT MCC 536 MS-DRG inpatient 1 UN 20198.55 13129.06 SIHO - ALL PLANS SIHO - ALL PLANS 18178.7 90 999999999 6690.35 19592.59 percent of total billed charges FRACTURES OF HIP AND PELVIS WITHOUT MCC 536 MS-DRG inpatient 1 UN 20198.55 13129.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12634.53 999999999 6690.35 19592.59 case rate FRACTURES OF HIP AND PELVIS WITHOUT MCC 536 MS-DRG inpatient 1 UN 20198.55 13129.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19592.59 97 999999999 6690.35 19592.59 percent of total billed charges FRACTURES OF HIP AND PELVIS WITHOUT MCC 536 MS-DRG inpatient 1 UN 20198.55 13129.06 UMR - ALL PLANS UMR - ALL PLANS 14138.99 70 999999999 6690.35 19592.59 percent of total billed charges FRACTURES OF HIP AND PELVIS WITHOUT MCC 536 MS-DRG inpatient 1 UN 20198.55 13129.06 AETNA AETNA 15956.85 79 999999999 6690.35 19592.59 percent of total billed charges FRACTURES OF HIP AND PELVIS WITHOUT MCC 536 MS-DRG inpatient 1 UN 20198.55 13129.06 UHC - ALL PLANS UHC - ALL PLANS 6690.35 999999999 6690.35 19592.59 case rate FRACTURES OF HIP AND PELVIS WITHOUT MCC 536 MS-DRG inpatient 1 UN 20198.55 13129.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 13129.06 65 999999999 6690.35 19592.59 percent of total billed charges FRACTURES OF HIP AND PELVIS WITHOUT MCC 536 MS-DRG inpatient 1 UN 20198.55 13129.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10739.19 999999999 6690.35 19592.59 case rate "SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC" 538 MS-DRG inpatient 1 UN 40079.98 26051.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 26051.99 65 999999999 6027.35 38877.58 percent of total billed charges "SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC" 538 MS-DRG inpatient 1 UN 40079.98 26051.99 AETNA AETNA 31663.18 79 999999999 6027.35 38877.58 percent of total billed charges "SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC" 538 MS-DRG inpatient 1 UN 40079.98 26051.99 UMR - ALL PLANS UMR - ALL PLANS 28055.99 70 999999999 6027.35 38877.58 percent of total billed charges "SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC" 538 MS-DRG inpatient 1 UN 40079.98 26051.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 38877.58 97 999999999 6027.35 38877.58 percent of total billed charges "SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC" 538 MS-DRG inpatient 1 UN 40079.98 26051.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 11382.47 999999999 6027.35 38877.58 case rate "SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC" 538 MS-DRG inpatient 1 UN 40079.98 26051.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 10749.96 999999999 6027.35 38877.58 case rate "SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC" 538 MS-DRG inpatient 1 UN 40079.98 26051.99 SIHO - ALL PLANS SIHO - ALL PLANS 36071.98 90 999999999 6027.35 38877.58 percent of total billed charges "SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC" 538 MS-DRG inpatient 1 UN 40079.98 26051.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 31262.38 78 999999999 6027.35 38877.58 percent of total billed charges "SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC" 538 MS-DRG inpatient 1 UN 40079.98 26051.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 27094.07 67.6 999999999 6027.35 38877.58 percent of total billed charges "SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC" 538 MS-DRG inpatient 1 UN 40079.98 26051.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 9674.96 999999999 6027.35 38877.58 case rate "SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC" 538 MS-DRG inpatient 1 UN 40079.98 26051.99 ANTHEM HMO ANTHEM HMO 10116.73 999999999 6027.35 38877.58 case rate "SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC" 538 MS-DRG inpatient 1 UN 40079.98 26051.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24268.43 60.55 999999999 6027.35 38877.58 percent of total billed charges "SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC" 538 MS-DRG inpatient 1 UN 40079.98 26051.99 UHC - ALL PLANS UHC - ALL PLANS 6027.35 999999999 6027.35 38877.58 case rate "SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC" 538 MS-DRG inpatient 1 UN 40079.98 26051.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 27655.19 69 999999999 6027.35 38877.58 percent of total billed charges OSTEOMYELITIS WITH CC 540 MS-DRG inpatient 1 UN 17820.89 11583.58 HUMANA - ALL PLANS HUMANA - ALL PLANS 13900.29 78 999999999 10790.55 17820.89 percent of total billed charges OSTEOMYELITIS WITH CC 540 MS-DRG inpatient 1 UN 17820.89 11583.58 UHC - ALL PLANS UHC - ALL PLANS 11034.7 999999999 10790.55 17820.89 case rate OSTEOMYELITIS WITH CC 540 MS-DRG inpatient 1 UN 17820.89 11583.58 SIHO - ALL PLANS SIHO - ALL PLANS 16038.8 90 999999999 10790.55 17820.89 percent of total billed charges OSTEOMYELITIS WITH CC 540 MS-DRG inpatient 1 UN 17820.89 11583.58 AETNA AETNA 14078.5 79 999999999 10790.55 17820.89 percent of total billed charges OSTEOMYELITIS WITH CC 540 MS-DRG inpatient 1 UN 17820.89 11583.58 UMR - ALL PLANS UMR - ALL PLANS 12474.62 70 999999999 10790.55 17820.89 percent of total billed charges OSTEOMYELITIS WITH CC 540 MS-DRG inpatient 1 UN 17820.89 11583.58 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17286.26 97 999999999 10790.55 17820.89 percent of total billed charges OSTEOMYELITIS WITH CC 540 MS-DRG inpatient 1 UN 17820.89 11583.58 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 17820.89 999999999 10790.55 17820.89 case rate OSTEOMYELITIS WITH CC 540 MS-DRG inpatient 1 UN 17820.89 11583.58 ANTHEM HMO ANTHEM HMO 17820.89 999999999 10790.55 17820.89 case rate OSTEOMYELITIS WITH CC 540 MS-DRG inpatient 1 UN 17820.89 11583.58 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 17712.64 999999999 10790.55 17820.89 case rate OSTEOMYELITIS WITH CC 540 MS-DRG inpatient 1 UN 17820.89 11583.58 SELF PAY DISCOUNT SELF PAY DISCOUNT 11583.58 65 999999999 10790.55 17820.89 percent of total billed charges OSTEOMYELITIS WITH CC 540 MS-DRG inpatient 1 UN 17820.89 11583.58 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10790.55 60.55 999999999 10790.55 17820.89 percent of total billed charges OSTEOMYELITIS WITH CC 540 MS-DRG inpatient 1 UN 17820.89 11583.58 ENCORE - ALL PLANS ENCORE - ALL PLANS 12296.41 69 999999999 10790.55 17820.89 percent of total billed charges OSTEOMYELITIS WITH CC 540 MS-DRG inpatient 1 UN 17820.89 11583.58 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 17820.89 999999999 10790.55 17820.89 case rate OSTEOMYELITIS WITH CC 540 MS-DRG inpatient 1 UN 17820.89 11583.58 CIGNA - ALL PLANS CIGNA - ALL PLANS 12046.92 67.6 999999999 10790.55 17820.89 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC 542 MS-DRG inpatient 1 UN 35250.17 22912.61 UHC - ALL PLANS UHC - ALL PLANS 15501.45 999999999 15501.45 34192.66 case rate PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC 542 MS-DRG inpatient 1 UN 35250.17 22912.61 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 24882.56 999999999 15501.45 34192.66 case rate PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC 542 MS-DRG inpatient 1 UN 35250.17 22912.61 ANTHEM HMO ANTHEM HMO 26018.73 999999999 15501.45 34192.66 case rate PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC 542 MS-DRG inpatient 1 UN 35250.17 22912.61 AETNA AETNA 27847.63 79 999999999 15501.45 34192.66 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC 542 MS-DRG inpatient 1 UN 35250.17 22912.61 CIGNA - ALL PLANS CIGNA - ALL PLANS 23829.11 67.6 999999999 15501.45 34192.66 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC 542 MS-DRG inpatient 1 UN 35250.17 22912.61 SIHO - ALL PLANS SIHO - ALL PLANS 31725.15 90 999999999 15501.45 34192.66 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC 542 MS-DRG inpatient 1 UN 35250.17 22912.61 ENCORE - ALL PLANS ENCORE - ALL PLANS 24322.62 69 999999999 15501.45 34192.66 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC 542 MS-DRG inpatient 1 UN 35250.17 22912.61 HUMANA - ALL PLANS HUMANA - ALL PLANS 27495.13 78 999999999 15501.45 34192.66 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC 542 MS-DRG inpatient 1 UN 35250.17 22912.61 SELF PAY DISCOUNT SELF PAY DISCOUNT 22912.61 65 999999999 15501.45 34192.66 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC 542 MS-DRG inpatient 1 UN 35250.17 22912.61 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 29274.03 999999999 15501.45 34192.66 case rate PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC 542 MS-DRG inpatient 1 UN 35250.17 22912.61 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 27647.29 999999999 15501.45 34192.66 case rate PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC 542 MS-DRG inpatient 1 UN 35250.17 22912.61 UMR - ALL PLANS UMR - ALL PLANS 24675.12 70 999999999 15501.45 34192.66 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC 542 MS-DRG inpatient 1 UN 35250.17 22912.61 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34192.66 97 999999999 15501.45 34192.66 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC 542 MS-DRG inpatient 1 UN 35250.17 22912.61 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21343.98 60.55 999999999 15501.45 34192.66 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC 543 MS-DRG inpatient 1 UN 26837.26 17444.22 AETNA AETNA 21201.44 79 999999999 9270.95 26032.14 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC 543 MS-DRG inpatient 1 UN 26837.26 17444.22 UMR - ALL PLANS UMR - ALL PLANS 18786.08 70 999999999 9270.95 26032.14 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC 543 MS-DRG inpatient 1 UN 26837.26 17444.22 SIHO - ALL PLANS SIHO - ALL PLANS 24153.53 90 999999999 9270.95 26032.14 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC 543 MS-DRG inpatient 1 UN 26837.26 17444.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16249.96 60.55 999999999 9270.95 26032.14 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC 543 MS-DRG inpatient 1 UN 26837.26 17444.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26032.14 97 999999999 9270.95 26032.14 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC 543 MS-DRG inpatient 1 UN 26837.26 17444.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 18517.71 69 999999999 9270.95 26032.14 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC 543 MS-DRG inpatient 1 UN 26837.26 17444.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 17444.22 65 999999999 9270.95 26032.14 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC 543 MS-DRG inpatient 1 UN 26837.26 17444.22 UHC - ALL PLANS UHC - ALL PLANS 9270.95 999999999 9270.95 26032.14 case rate PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC 543 MS-DRG inpatient 1 UN 26837.26 17444.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 20933.06 78 999999999 9270.95 26032.14 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC 543 MS-DRG inpatient 1 UN 26837.26 17444.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 16535.01 999999999 9270.95 26032.14 case rate PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC 543 MS-DRG inpatient 1 UN 26837.26 17444.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 17507.92 999999999 9270.95 26032.14 case rate PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC 543 MS-DRG inpatient 1 UN 26837.26 17444.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 18141.99 67.6 999999999 9270.95 26032.14 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC 543 MS-DRG inpatient 1 UN 26837.26 17444.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 14881.51 999999999 9270.95 26032.14 case rate PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC 543 MS-DRG inpatient 1 UN 26837.26 17444.22 ANTHEM HMO ANTHEM HMO 15561.02 999999999 9270.95 26032.14 case rate PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC 544 MS-DRG inpatient 1 UN 26709.8 17361.37 UHC - ALL PLANS UHC - ALL PLANS 6523.75 999999999 6523.75 25908.51 case rate PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC 544 MS-DRG inpatient 1 UN 26709.8 17361.37 SELF PAY DISCOUNT SELF PAY DISCOUNT 17361.37 65 999999999 6523.75 25908.51 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC 544 MS-DRG inpatient 1 UN 26709.8 17361.37 AETNA AETNA 21100.74 79 999999999 6523.75 25908.51 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC 544 MS-DRG inpatient 1 UN 26709.8 17361.37 UMR - ALL PLANS UMR - ALL PLANS 18696.86 70 999999999 6523.75 25908.51 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC 544 MS-DRG inpatient 1 UN 26709.8 17361.37 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25908.51 97 999999999 6523.75 25908.51 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC 544 MS-DRG inpatient 1 UN 26709.8 17361.37 SIHO - ALL PLANS SIHO - ALL PLANS 24038.82 90 999999999 6523.75 25908.51 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC 544 MS-DRG inpatient 1 UN 26709.8 17361.37 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12319.91 999999999 6523.75 25908.51 case rate PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC 544 MS-DRG inpatient 1 UN 26709.8 17361.37 HUMANA - ALL PLANS HUMANA - ALL PLANS 20833.64 78 999999999 6523.75 25908.51 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC 544 MS-DRG inpatient 1 UN 26709.8 17361.37 ANTHEM HMO ANTHEM HMO 10949.92 999999999 6523.75 25908.51 case rate PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC 544 MS-DRG inpatient 1 UN 26709.8 17361.37 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 11635.3 999999999 6523.75 25908.51 case rate PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC 544 MS-DRG inpatient 1 UN 26709.8 17361.37 CIGNA - ALL PLANS CIGNA - ALL PLANS 18055.82 67.6 999999999 6523.75 25908.51 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC 544 MS-DRG inpatient 1 UN 26709.8 17361.37 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10471.77 999999999 6523.75 25908.51 case rate PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC 544 MS-DRG inpatient 1 UN 26709.8 17361.37 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16172.78 60.55 999999999 6523.75 25908.51 percent of total billed charges PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC 544 MS-DRG inpatient 1 UN 26709.8 17361.37 ENCORE - ALL PLANS ENCORE - ALL PLANS 18429.76 69 999999999 6523.75 25908.51 percent of total billed charges CONNECTIVE TISSUE DISORDERS WITH CC 546 MS-DRG inpatient 1 UN 10959.29 7123.54 UMR - ALL PLANS UMR - ALL PLANS 7671.5 70 999999999 6635.85 10959.29 percent of total billed charges CONNECTIVE TISSUE DISORDERS WITH CC 546 MS-DRG inpatient 1 UN 10959.29 7123.54 AETNA AETNA 8657.84 79 999999999 6635.85 10959.29 percent of total billed charges CONNECTIVE TISSUE DISORDERS WITH CC 546 MS-DRG inpatient 1 UN 10959.29 7123.54 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6635.85 60.55 999999999 6635.85 10959.29 percent of total billed charges CONNECTIVE TISSUE DISORDERS WITH CC 546 MS-DRG inpatient 1 UN 10959.29 7123.54 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 10630.51 97 999999999 6635.85 10959.29 percent of total billed charges CONNECTIVE TISSUE DISORDERS WITH CC 546 MS-DRG inpatient 1 UN 10959.29 7123.54 ENCORE - ALL PLANS ENCORE - ALL PLANS 7561.91 69 999999999 6635.85 10959.29 percent of total billed charges CONNECTIVE TISSUE DISORDERS WITH CC 546 MS-DRG inpatient 1 UN 10959.29 7123.54 HUMANA - ALL PLANS HUMANA - ALL PLANS 8548.25 78 999999999 6635.85 10959.29 percent of total billed charges CONNECTIVE TISSUE DISORDERS WITH CC 546 MS-DRG inpatient 1 UN 10959.29 7123.54 SELF PAY DISCOUNT SELF PAY DISCOUNT 7123.54 65 999999999 6635.85 10959.29 percent of total billed charges CONNECTIVE TISSUE DISORDERS WITH CC 546 MS-DRG inpatient 1 UN 10959.29 7123.54 UHC - ALL PLANS UHC - ALL PLANS 10194.05 999999999 6635.85 10959.29 case rate CONNECTIVE TISSUE DISORDERS WITH CC 546 MS-DRG inpatient 1 UN 10959.29 7123.54 SIHO - ALL PLANS SIHO - ALL PLANS 9863.36 90 999999999 6635.85 10959.29 percent of total billed charges CONNECTIVE TISSUE DISORDERS WITH CC 546 MS-DRG inpatient 1 UN 10959.29 7123.54 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 10959.29 999999999 6635.85 10959.29 case rate CONNECTIVE TISSUE DISORDERS WITH CC 546 MS-DRG inpatient 1 UN 10959.29 7123.54 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 10959.29 999999999 6635.85 10959.29 case rate CONNECTIVE TISSUE DISORDERS WITH CC 546 MS-DRG inpatient 1 UN 10959.29 7123.54 ANTHEM HMO ANTHEM HMO 10959.29 999999999 6635.85 10959.29 case rate CONNECTIVE TISSUE DISORDERS WITH CC 546 MS-DRG inpatient 1 UN 10959.29 7123.54 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10959.29 999999999 6635.85 10959.29 case rate CONNECTIVE TISSUE DISORDERS WITH CC 546 MS-DRG inpatient 1 UN 10959.29 7123.54 CIGNA - ALL PLANS CIGNA - ALL PLANS 7408.48 67.6 999999999 6635.85 10959.29 percent of total billed charges SEPTIC ARTHRITIS WITHOUT CC/MCC 550 MS-DRG inpatient 1 UN 22460.13 14599.08 UHC - ALL PLANS UHC - ALL PLANS 7826.8 999999999 7826.8 21786.33 case rate SEPTIC ARTHRITIS WITHOUT CC/MCC 550 MS-DRG inpatient 1 UN 22460.13 14599.08 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 12563.4 999999999 7826.8 21786.33 case rate SEPTIC ARTHRITIS WITHOUT CC/MCC 550 MS-DRG inpatient 1 UN 22460.13 14599.08 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21786.33 97 999999999 7826.8 21786.33 percent of total billed charges SEPTIC ARTHRITIS WITHOUT CC/MCC 550 MS-DRG inpatient 1 UN 22460.13 14599.08 AETNA AETNA 17743.5 79 999999999 7826.8 21786.33 percent of total billed charges SEPTIC ARTHRITIS WITHOUT CC/MCC 550 MS-DRG inpatient 1 UN 22460.13 14599.08 SIHO - ALL PLANS SIHO - ALL PLANS 20214.12 90 999999999 7826.8 21786.33 percent of total billed charges SEPTIC ARTHRITIS WITHOUT CC/MCC 550 MS-DRG inpatient 1 UN 22460.13 14599.08 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 14780.68 999999999 7826.8 21786.33 case rate SEPTIC ARTHRITIS WITHOUT CC/MCC 550 MS-DRG inpatient 1 UN 22460.13 14599.08 CIGNA - ALL PLANS CIGNA - ALL PLANS 15183.05 67.6 999999999 7826.8 21786.33 percent of total billed charges SEPTIC ARTHRITIS WITHOUT CC/MCC 550 MS-DRG inpatient 1 UN 22460.13 14599.08 SELF PAY DISCOUNT SELF PAY DISCOUNT 14599.08 65 999999999 7826.8 21786.33 percent of total billed charges SEPTIC ARTHRITIS WITHOUT CC/MCC 550 MS-DRG inpatient 1 UN 22460.13 14599.08 HUMANA - ALL PLANS HUMANA - ALL PLANS 17518.9 78 999999999 7826.8 21786.33 percent of total billed charges SEPTIC ARTHRITIS WITHOUT CC/MCC 550 MS-DRG inpatient 1 UN 22460.13 14599.08 ENCORE - ALL PLANS ENCORE - ALL PLANS 15497.49 69 999999999 7826.8 21786.33 percent of total billed charges SEPTIC ARTHRITIS WITHOUT CC/MCC 550 MS-DRG inpatient 1 UN 22460.13 14599.08 ANTHEM HMO ANTHEM HMO 13137.05 999999999 7826.8 21786.33 case rate SEPTIC ARTHRITIS WITHOUT CC/MCC 550 MS-DRG inpatient 1 UN 22460.13 14599.08 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13959.33 999999999 7826.8 21786.33 case rate SEPTIC ARTHRITIS WITHOUT CC/MCC 550 MS-DRG inpatient 1 UN 22460.13 14599.08 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13599.61 60.55 999999999 7826.8 21786.33 percent of total billed charges SEPTIC ARTHRITIS WITHOUT CC/MCC 550 MS-DRG inpatient 1 UN 22460.13 14599.08 UMR - ALL PLANS UMR - ALL PLANS 15722.09 70 999999999 7826.8 21786.33 percent of total billed charges MEDICAL BACK PROBLEMS WITHOUT MCC 552 MS-DRG inpatient 1 UN 18325.36 11911.49 HUMANA - ALL PLANS HUMANA - ALL PLANS 14293.78 78 999999999 8213.55 17775.6 percent of total billed charges MEDICAL BACK PROBLEMS WITHOUT MCC 552 MS-DRG inpatient 1 UN 18325.36 11911.49 AETNA AETNA 14477.04 79 999999999 8213.55 17775.6 percent of total billed charges MEDICAL BACK PROBLEMS WITHOUT MCC 552 MS-DRG inpatient 1 UN 18325.36 11911.49 SIHO - ALL PLANS SIHO - ALL PLANS 16492.83 90 999999999 8213.55 17775.6 percent of total billed charges MEDICAL BACK PROBLEMS WITHOUT MCC 552 MS-DRG inpatient 1 UN 18325.36 11911.49 UHC - ALL PLANS UHC - ALL PLANS 8213.55 999999999 8213.55 17775.6 case rate MEDICAL BACK PROBLEMS WITHOUT MCC 552 MS-DRG inpatient 1 UN 18325.36 11911.49 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 13184.2 999999999 8213.55 17775.6 case rate MEDICAL BACK PROBLEMS WITHOUT MCC 552 MS-DRG inpatient 1 UN 18325.36 11911.49 ANTHEM HMO ANTHEM HMO 13786.2 999999999 8213.55 17775.6 case rate MEDICAL BACK PROBLEMS WITHOUT MCC 552 MS-DRG inpatient 1 UN 18325.36 11911.49 UMR - ALL PLANS UMR - ALL PLANS 12827.75 70 999999999 8213.55 17775.6 percent of total billed charges MEDICAL BACK PROBLEMS WITHOUT MCC 552 MS-DRG inpatient 1 UN 18325.36 11911.49 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 17775.6 97 999999999 8213.55 17775.6 percent of total billed charges MEDICAL BACK PROBLEMS WITHOUT MCC 552 MS-DRG inpatient 1 UN 18325.36 11911.49 SELF PAY DISCOUNT SELF PAY DISCOUNT 11911.49 65 999999999 8213.55 17775.6 percent of total billed charges MEDICAL BACK PROBLEMS WITHOUT MCC 552 MS-DRG inpatient 1 UN 18325.36 11911.49 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 11096.01 60.55 999999999 8213.55 17775.6 percent of total billed charges MEDICAL BACK PROBLEMS WITHOUT MCC 552 MS-DRG inpatient 1 UN 18325.36 11911.49 ENCORE - ALL PLANS ENCORE - ALL PLANS 12644.5 69 999999999 8213.55 17775.6 percent of total billed charges MEDICAL BACK PROBLEMS WITHOUT MCC 552 MS-DRG inpatient 1 UN 18325.36 11911.49 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 15511.05 999999999 8213.55 17775.6 case rate MEDICAL BACK PROBLEMS WITHOUT MCC 552 MS-DRG inpatient 1 UN 18325.36 11911.49 CIGNA - ALL PLANS CIGNA - ALL PLANS 12387.94 67.6 999999999 8213.55 17775.6 percent of total billed charges MEDICAL BACK PROBLEMS WITHOUT MCC 552 MS-DRG inpatient 1 UN 18325.36 11911.49 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 14649.11 999999999 8213.55 17775.6 case rate SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC 556 MS-DRG inpatient 1 UN 34417.34 22371.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 22371.27 65 999999999 7007.4 33384.81 percent of total billed charges SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC 556 MS-DRG inpatient 1 UN 34417.34 22371.27 AETNA AETNA 27189.69 79 999999999 7007.4 33384.81 percent of total billed charges SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC 556 MS-DRG inpatient 1 UN 34417.34 22371.27 UMR - ALL PLANS UMR - ALL PLANS 24092.13 70 999999999 7007.4 33384.81 percent of total billed charges SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC 556 MS-DRG inpatient 1 UN 34417.34 22371.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33384.81 97 999999999 7007.4 33384.81 percent of total billed charges SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC 556 MS-DRG inpatient 1 UN 34417.34 22371.27 SIHO - ALL PLANS SIHO - ALL PLANS 30975.6 90 999999999 7007.4 33384.81 percent of total billed charges SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC 556 MS-DRG inpatient 1 UN 34417.34 22371.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 12497.9 999999999 7007.4 33384.81 case rate SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC 556 MS-DRG inpatient 1 UN 34417.34 22371.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 13233.27 999999999 7007.4 33384.81 case rate SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC 556 MS-DRG inpatient 1 UN 34417.34 22371.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 26845.52 78 999999999 7007.4 33384.81 percent of total billed charges SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC 556 MS-DRG inpatient 1 UN 34417.34 22371.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 23266.12 67.6 999999999 7007.4 33384.81 percent of total billed charges SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC 556 MS-DRG inpatient 1 UN 34417.34 22371.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 11248.11 999999999 7007.4 33384.81 case rate SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC 556 MS-DRG inpatient 1 UN 34417.34 22371.27 ANTHEM HMO ANTHEM HMO 11761.71 999999999 7007.4 33384.81 case rate SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC 556 MS-DRG inpatient 1 UN 34417.34 22371.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 23747.96 69 999999999 7007.4 33384.81 percent of total billed charges SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC 556 MS-DRG inpatient 1 UN 34417.34 22371.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20839.7 60.55 999999999 7007.4 33384.81 percent of total billed charges SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC 556 MS-DRG inpatient 1 UN 34417.34 22371.27 UHC - ALL PLANS UHC - ALL PLANS 7007.4 999999999 7007.4 33384.81 case rate "TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC" 558 MS-DRG inpatient 1 UN 23990.22 15593.64 SIHO - ALL PLANS SIHO - ALL PLANS 21591.2 90 999999999 7466.4 23270.51 percent of total billed charges "TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC" 558 MS-DRG inpatient 1 UN 23990.22 15593.64 HUMANA - ALL PLANS HUMANA - ALL PLANS 18712.37 78 999999999 7466.4 23270.51 percent of total billed charges "TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC" 558 MS-DRG inpatient 1 UN 23990.22 15593.64 AETNA AETNA 18952.27 79 999999999 7466.4 23270.51 percent of total billed charges "TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC" 558 MS-DRG inpatient 1 UN 23990.22 15593.64 ANTHEM HMO ANTHEM HMO 12532.13 999999999 7466.4 23270.51 case rate "TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC" 558 MS-DRG inpatient 1 UN 23990.22 15593.64 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 11984.89 999999999 7466.4 23270.51 case rate "TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC" 558 MS-DRG inpatient 1 UN 23990.22 15593.64 UHC - ALL PLANS UHC - ALL PLANS 7466.4 999999999 7466.4 23270.51 case rate "TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC" 558 MS-DRG inpatient 1 UN 23990.22 15593.64 UMR - ALL PLANS UMR - ALL PLANS 16793.15 70 999999999 7466.4 23270.51 percent of total billed charges "TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC" 558 MS-DRG inpatient 1 UN 23990.22 15593.64 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23270.51 97 999999999 7466.4 23270.51 percent of total billed charges "TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC" 558 MS-DRG inpatient 1 UN 23990.22 15593.64 SELF PAY DISCOUNT SELF PAY DISCOUNT 15593.64 65 999999999 7466.4 23270.51 percent of total billed charges "TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC" 558 MS-DRG inpatient 1 UN 23990.22 15593.64 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14526.08 60.55 999999999 7466.4 23270.51 percent of total billed charges "TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC" 558 MS-DRG inpatient 1 UN 23990.22 15593.64 ENCORE - ALL PLANS ENCORE - ALL PLANS 16553.25 69 999999999 7466.4 23270.51 percent of total billed charges "TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC" 558 MS-DRG inpatient 1 UN 23990.22 15593.64 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13316.54 999999999 7466.4 23270.51 case rate "TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC" 558 MS-DRG inpatient 1 UN 23990.22 15593.64 CIGNA - ALL PLANS CIGNA - ALL PLANS 16217.39 67.6 999999999 7466.4 23270.51 percent of total billed charges "TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC" 558 MS-DRG inpatient 1 UN 23990.22 15593.64 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 14100.08 999999999 7466.4 23270.51 case rate "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC" 560 MS-DRG inpatient 1 UN 25926.19 16852.02 ANTHEM HMO ANTHEM HMO 16151.67 999999999 9622.85 25148.4 case rate "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC" 560 MS-DRG inpatient 1 UN 25926.19 16852.02 CIGNA - ALL PLANS CIGNA - ALL PLANS 17526.1 67.6 999999999 9622.85 25148.4 percent of total billed charges "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC" 560 MS-DRG inpatient 1 UN 25926.19 16852.02 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 15446.37 999999999 9622.85 25148.4 case rate "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC" 560 MS-DRG inpatient 1 UN 25926.19 16852.02 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 17162.64 999999999 9622.85 25148.4 case rate "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC" 560 MS-DRG inpatient 1 UN 25926.19 16852.02 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 18172.47 999999999 9622.85 25148.4 case rate "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC" 560 MS-DRG inpatient 1 UN 25926.19 16852.02 HUMANA - ALL PLANS HUMANA - ALL PLANS 20222.43 78 999999999 9622.85 25148.4 percent of total billed charges "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC" 560 MS-DRG inpatient 1 UN 25926.19 16852.02 UHC - ALL PLANS UHC - ALL PLANS 9622.85 999999999 9622.85 25148.4 case rate "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC" 560 MS-DRG inpatient 1 UN 25926.19 16852.02 SELF PAY DISCOUNT SELF PAY DISCOUNT 16852.02 65 999999999 9622.85 25148.4 percent of total billed charges "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC" 560 MS-DRG inpatient 1 UN 25926.19 16852.02 ENCORE - ALL PLANS ENCORE - ALL PLANS 17889.07 69 999999999 9622.85 25148.4 percent of total billed charges "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC" 560 MS-DRG inpatient 1 UN 25926.19 16852.02 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25148.4 97 999999999 9622.85 25148.4 percent of total billed charges "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC" 560 MS-DRG inpatient 1 UN 25926.19 16852.02 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15698.31 60.55 999999999 9622.85 25148.4 percent of total billed charges "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC" 560 MS-DRG inpatient 1 UN 25926.19 16852.02 AETNA AETNA 20481.69 79 999999999 9622.85 25148.4 percent of total billed charges "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC" 560 MS-DRG inpatient 1 UN 25926.19 16852.02 UMR - ALL PLANS UMR - ALL PLANS 18148.33 70 999999999 9622.85 25148.4 percent of total billed charges "AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC" 560 MS-DRG inpatient 1 UN 25926.19 16852.02 SIHO - ALL PLANS SIHO - ALL PLANS 23333.57 90 999999999 9622.85 25148.4 percent of total billed charges "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC" 562 MS-DRG inpatient 1 UN 41226.25 26797.06 UMR - ALL PLANS UMR - ALL PLANS 28858.37 70 999999999 12925.95 39989.46 percent of total billed charges "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC" 562 MS-DRG inpatient 1 UN 41226.25 26797.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24962.49 60.55 999999999 12925.95 39989.46 percent of total billed charges "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC" 562 MS-DRG inpatient 1 UN 41226.25 26797.06 ANTHEM HMO ANTHEM HMO 21695.83 999999999 12925.95 39989.46 case rate "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC" 562 MS-DRG inpatient 1 UN 41226.25 26797.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 23053.81 999999999 12925.95 39989.46 case rate "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC" 562 MS-DRG inpatient 1 UN 41226.25 26797.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 28446.11 69 999999999 12925.95 39989.46 percent of total billed charges "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC" 562 MS-DRG inpatient 1 UN 41226.25 26797.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 32156.47 78 999999999 12925.95 39989.46 percent of total billed charges "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC" 562 MS-DRG inpatient 1 UN 41226.25 26797.06 SIHO - ALL PLANS SIHO - ALL PLANS 37103.62 90 999999999 12925.95 39989.46 percent of total billed charges "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC" 562 MS-DRG inpatient 1 UN 41226.25 26797.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 27868.94 67.6 999999999 12925.95 39989.46 percent of total billed charges "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC" 562 MS-DRG inpatient 1 UN 41226.25 26797.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 24410.28 999999999 12925.95 39989.46 case rate "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC" 562 MS-DRG inpatient 1 UN 41226.25 26797.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39989.46 97 999999999 12925.95 39989.46 percent of total billed charges "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC" 562 MS-DRG inpatient 1 UN 41226.25 26797.06 AETNA AETNA 32568.73 79 999999999 12925.95 39989.46 percent of total billed charges "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC" 562 MS-DRG inpatient 1 UN 41226.25 26797.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 26797.06 65 999999999 12925.95 39989.46 percent of total billed charges "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC" 562 MS-DRG inpatient 1 UN 41226.25 26797.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 20748.43 999999999 12925.95 39989.46 case rate "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC" 562 MS-DRG inpatient 1 UN 41226.25 26797.06 UHC - ALL PLANS UHC - ALL PLANS 12925.95 999999999 12925.95 39989.46 case rate "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC" 563 MS-DRG inpatient 1 UN 23862.44 15510.58 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 12219.57 999999999 7612.6 23146.56 case rate "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC" 563 MS-DRG inpatient 1 UN 23862.44 15510.58 CIGNA - ALL PLANS CIGNA - ALL PLANS 16131.01 67.6 999999999 7612.6 23146.56 percent of total billed charges "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC" 563 MS-DRG inpatient 1 UN 23862.44 15510.58 ANTHEM HMO ANTHEM HMO 12777.53 999999999 7612.6 23146.56 case rate "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC" 563 MS-DRG inpatient 1 UN 23862.44 15510.58 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 14376.17 999999999 7612.6 23146.56 case rate "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC" 563 MS-DRG inpatient 1 UN 23862.44 15510.58 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13577.3 999999999 7612.6 23146.56 case rate "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC" 563 MS-DRG inpatient 1 UN 23862.44 15510.58 SIHO - ALL PLANS SIHO - ALL PLANS 21476.19 90 999999999 7612.6 23146.56 percent of total billed charges "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC" 563 MS-DRG inpatient 1 UN 23862.44 15510.58 SELF PAY DISCOUNT SELF PAY DISCOUNT 15510.58 65 999999999 7612.6 23146.56 percent of total billed charges "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC" 563 MS-DRG inpatient 1 UN 23862.44 15510.58 UHC - ALL PLANS UHC - ALL PLANS 7612.6 999999999 7612.6 23146.56 case rate "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC" 563 MS-DRG inpatient 1 UN 23862.44 15510.58 ENCORE - ALL PLANS ENCORE - ALL PLANS 16465.08 69 999999999 7612.6 23146.56 percent of total billed charges "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC" 563 MS-DRG inpatient 1 UN 23862.44 15510.58 HUMANA - ALL PLANS HUMANA - ALL PLANS 18612.7 78 999999999 7612.6 23146.56 percent of total billed charges "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC" 563 MS-DRG inpatient 1 UN 23862.44 15510.58 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23146.56 97 999999999 7612.6 23146.56 percent of total billed charges "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC" 563 MS-DRG inpatient 1 UN 23862.44 15510.58 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14448.7 60.55 999999999 7612.6 23146.56 percent of total billed charges "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC" 563 MS-DRG inpatient 1 UN 23862.44 15510.58 AETNA AETNA 18851.32 79 999999999 7612.6 23146.56 percent of total billed charges "FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC" 563 MS-DRG inpatient 1 UN 23862.44 15510.58 UMR - ALL PLANS UMR - ALL PLANS 16703.7 70 999999999 7612.6 23146.56 percent of total billed charges SKIN DEBRIDEMENT WITH MCC 570 MS-DRG inpatient 1 UN 46101.07 29965.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 44718.04 97 999999999 24838.7 46101.07 percent of total billed charges SKIN DEBRIDEMENT WITH MCC 570 MS-DRG inpatient 1 UN 46101.07 29965.7 UMR - ALL PLANS UMR - ALL PLANS 32270.75 70 999999999 24838.7 46101.07 percent of total billed charges SKIN DEBRIDEMENT WITH MCC 570 MS-DRG inpatient 1 UN 46101.07 29965.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 46101.07 999999999 24838.7 46101.07 case rate SKIN DEBRIDEMENT WITH MCC 570 MS-DRG inpatient 1 UN 46101.07 29965.7 ANTHEM HMO ANTHEM HMO 41691.03 999999999 24838.7 46101.07 case rate SKIN DEBRIDEMENT WITH MCC 570 MS-DRG inpatient 1 UN 46101.07 29965.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 44300.55 999999999 24838.7 46101.07 case rate SKIN DEBRIDEMENT WITH MCC 570 MS-DRG inpatient 1 UN 46101.07 29965.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 29965.7 65 999999999 24838.7 46101.07 percent of total billed charges SKIN DEBRIDEMENT WITH MCC 570 MS-DRG inpatient 1 UN 46101.07 29965.7 AETNA AETNA 36419.85 79 999999999 24838.7 46101.07 percent of total billed charges SKIN DEBRIDEMENT WITH MCC 570 MS-DRG inpatient 1 UN 46101.07 29965.7 SIHO - ALL PLANS SIHO - ALL PLANS 41490.97 90 999999999 24838.7 46101.07 percent of total billed charges SKIN DEBRIDEMENT WITH MCC 570 MS-DRG inpatient 1 UN 46101.07 29965.7 UHC - ALL PLANS UHC - ALL PLANS 24838.7 999999999 24838.7 46101.07 case rate SKIN DEBRIDEMENT WITH MCC 570 MS-DRG inpatient 1 UN 46101.07 29965.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 39870.5 999999999 24838.7 46101.07 case rate SKIN DEBRIDEMENT WITH MCC 570 MS-DRG inpatient 1 UN 46101.07 29965.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27914.2 60.55 999999999 24838.7 46101.07 percent of total billed charges SKIN DEBRIDEMENT WITH MCC 570 MS-DRG inpatient 1 UN 46101.07 29965.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 35958.84 78 999999999 24838.7 46101.07 percent of total billed charges SKIN DEBRIDEMENT WITH MCC 570 MS-DRG inpatient 1 UN 46101.07 29965.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 31809.74 69 999999999 24838.7 46101.07 percent of total billed charges SKIN DEBRIDEMENT WITH MCC 570 MS-DRG inpatient 1 UN 46101.07 29965.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 31164.32 67.6 999999999 24838.7 46101.07 percent of total billed charges SKIN DEBRIDEMENT WITH CC 571 MS-DRG inpatient 1 UN 25093.56 16310.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 25093.56 999999999 14381.15 25093.56 case rate SKIN DEBRIDEMENT WITH CC 571 MS-DRG inpatient 1 UN 25093.56 16310.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 25093.56 999999999 14381.15 25093.56 case rate SKIN DEBRIDEMENT WITH CC 571 MS-DRG inpatient 1 UN 25093.56 16310.81 ANTHEM HMO ANTHEM HMO 24138.34 999999999 14381.15 25093.56 case rate SKIN DEBRIDEMENT WITH CC 571 MS-DRG inpatient 1 UN 25093.56 16310.81 SIHO - ALL PLANS SIHO - ALL PLANS 22584.2 90 999999999 14381.15 25093.56 percent of total billed charges SKIN DEBRIDEMENT WITH CC 571 MS-DRG inpatient 1 UN 25093.56 16310.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 16310.81 65 999999999 14381.15 25093.56 percent of total billed charges SKIN DEBRIDEMENT WITH CC 571 MS-DRG inpatient 1 UN 25093.56 16310.81 AETNA AETNA 19823.91 79 999999999 14381.15 25093.56 percent of total billed charges SKIN DEBRIDEMENT WITH CC 571 MS-DRG inpatient 1 UN 25093.56 16310.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24340.75 97 999999999 14381.15 25093.56 percent of total billed charges SKIN DEBRIDEMENT WITH CC 571 MS-DRG inpatient 1 UN 25093.56 16310.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 16963.25 67.6 999999999 14381.15 25093.56 percent of total billed charges SKIN DEBRIDEMENT WITH CC 571 MS-DRG inpatient 1 UN 25093.56 16310.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 23084.28 999999999 14381.15 25093.56 case rate SKIN DEBRIDEMENT WITH CC 571 MS-DRG inpatient 1 UN 25093.56 16310.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15194.15 60.55 999999999 14381.15 25093.56 percent of total billed charges SKIN DEBRIDEMENT WITH CC 571 MS-DRG inpatient 1 UN 25093.56 16310.81 UHC - ALL PLANS UHC - ALL PLANS 14381.15 999999999 14381.15 25093.56 case rate SKIN DEBRIDEMENT WITH CC 571 MS-DRG inpatient 1 UN 25093.56 16310.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 19572.98 78 999999999 14381.15 25093.56 percent of total billed charges SKIN DEBRIDEMENT WITH CC 571 MS-DRG inpatient 1 UN 25093.56 16310.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 17314.56 69 999999999 14381.15 25093.56 percent of total billed charges SKIN DEBRIDEMENT WITH CC 571 MS-DRG inpatient 1 UN 25093.56 16310.81 UMR - ALL PLANS UMR - ALL PLANS 17565.49 70 999999999 14381.15 25093.56 percent of total billed charges SKIN DEBRIDEMENT WITHOUT CC/MCC 572 MS-DRG inpatient 1 UN 61012.94 39658.41 AETNA AETNA 48200.22 79 999999999 9686.6 59182.55 percent of total billed charges SKIN DEBRIDEMENT WITHOUT CC/MCC 572 MS-DRG inpatient 1 UN 61012.94 39658.41 SIHO - ALL PLANS SIHO - ALL PLANS 54911.65 90 999999999 9686.6 59182.55 percent of total billed charges SKIN DEBRIDEMENT WITHOUT CC/MCC 572 MS-DRG inpatient 1 UN 61012.94 39658.41 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36943.34 60.55 999999999 9686.6 59182.55 percent of total billed charges SKIN DEBRIDEMENT WITHOUT CC/MCC 572 MS-DRG inpatient 1 UN 61012.94 39658.41 HUMANA - ALL PLANS HUMANA - ALL PLANS 47590.09 78 999999999 9686.6 59182.55 percent of total billed charges SKIN DEBRIDEMENT WITHOUT CC/MCC 572 MS-DRG inpatient 1 UN 61012.94 39658.41 ENCORE - ALL PLANS ENCORE - ALL PLANS 42098.93 69 999999999 9686.6 59182.55 percent of total billed charges SKIN DEBRIDEMENT WITHOUT CC/MCC 572 MS-DRG inpatient 1 UN 61012.94 39658.41 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 18292.86 999999999 9686.6 59182.55 case rate SKIN DEBRIDEMENT WITHOUT CC/MCC 572 MS-DRG inpatient 1 UN 61012.94 39658.41 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 59182.55 97 999999999 9686.6 59182.55 percent of total billed charges SKIN DEBRIDEMENT WITHOUT CC/MCC 572 MS-DRG inpatient 1 UN 61012.94 39658.41 UMR - ALL PLANS UMR - ALL PLANS 42709.06 70 999999999 9686.6 59182.55 percent of total billed charges SKIN DEBRIDEMENT WITHOUT CC/MCC 572 MS-DRG inpatient 1 UN 61012.94 39658.41 SELF PAY DISCOUNT SELF PAY DISCOUNT 39658.41 65 999999999 9686.6 59182.55 percent of total billed charges SKIN DEBRIDEMENT WITHOUT CC/MCC 572 MS-DRG inpatient 1 UN 61012.94 39658.41 UHC - ALL PLANS UHC - ALL PLANS 9686.6 999999999 9686.6 59182.55 case rate SKIN DEBRIDEMENT WITHOUT CC/MCC 572 MS-DRG inpatient 1 UN 61012.94 39658.41 ANTHEM HMO ANTHEM HMO 16258.67 999999999 9686.6 59182.55 case rate SKIN DEBRIDEMENT WITHOUT CC/MCC 572 MS-DRG inpatient 1 UN 61012.94 39658.41 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 17276.34 999999999 9686.6 59182.55 case rate SKIN DEBRIDEMENT WITHOUT CC/MCC 572 MS-DRG inpatient 1 UN 61012.94 39658.41 CIGNA - ALL PLANS CIGNA - ALL PLANS 41244.75 67.6 999999999 9686.6 59182.55 percent of total billed charges SKIN DEBRIDEMENT WITHOUT CC/MCC 572 MS-DRG inpatient 1 UN 61012.94 39658.41 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 15548.7 999999999 9686.6 59182.55 case rate SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC 573 MS-DRG inpatient 1 UN 78933.78 51306.96 CIGNA - ALL PLANS CIGNA - ALL PLANS 53359.24 67.6 999999999 47794.4 78933.78 percent of total billed charges SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC 573 MS-DRG inpatient 1 UN 78933.78 51306.96 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47794.4 60.55 999999999 47794.4 78933.78 percent of total billed charges SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC 573 MS-DRG inpatient 1 UN 78933.78 51306.96 ENCORE - ALL PLANS ENCORE - ALL PLANS 54464.31 69 999999999 47794.4 78933.78 percent of total billed charges SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC 573 MS-DRG inpatient 1 UN 78933.78 51306.96 ANTHEM HMO ANTHEM HMO 78933.78 999999999 47794.4 78933.78 case rate SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC 573 MS-DRG inpatient 1 UN 78933.78 51306.96 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 78933.78 999999999 47794.4 78933.78 case rate SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC 573 MS-DRG inpatient 1 UN 78933.78 51306.96 UHC - ALL PLANS UHC - ALL PLANS 52853.85 999999999 47794.4 78933.78 case rate SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC 573 MS-DRG inpatient 1 UN 78933.78 51306.96 HUMANA - ALL PLANS HUMANA - ALL PLANS 61568.35 78 999999999 47794.4 78933.78 percent of total billed charges SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC 573 MS-DRG inpatient 1 UN 78933.78 51306.96 SIHO - ALL PLANS SIHO - ALL PLANS 71040.4 90 999999999 47794.4 78933.78 percent of total billed charges SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC 573 MS-DRG inpatient 1 UN 78933.78 51306.96 AETNA AETNA 62357.69 79 999999999 47794.4 78933.78 percent of total billed charges SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC 573 MS-DRG inpatient 1 UN 78933.78 51306.96 SELF PAY DISCOUNT SELF PAY DISCOUNT 51306.96 65 999999999 47794.4 78933.78 percent of total billed charges SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC 573 MS-DRG inpatient 1 UN 78933.78 51306.96 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 78933.78 999999999 47794.4 78933.78 case rate SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC 573 MS-DRG inpatient 1 UN 78933.78 51306.96 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 78933.78 999999999 47794.4 78933.78 case rate SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC 573 MS-DRG inpatient 1 UN 78933.78 51306.96 UMR - ALL PLANS UMR - ALL PLANS 55253.65 70 999999999 47794.4 78933.78 percent of total billed charges SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC 573 MS-DRG inpatient 1 UN 78933.78 51306.96 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76565.77 97 999999999 47794.4 78933.78 percent of total billed charges SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC 574 MS-DRG inpatient 1 UN 47131.92 30635.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 36762.9 78 999999999 28538.38 47131.92 percent of total billed charges SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC 574 MS-DRG inpatient 1 UN 47131.92 30635.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 32521.02 69 999999999 28538.38 47131.92 percent of total billed charges SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC 574 MS-DRG inpatient 1 UN 47131.92 30635.75 UMR - ALL PLANS UMR - ALL PLANS 32992.34 70 999999999 28538.38 47131.92 percent of total billed charges SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC 574 MS-DRG inpatient 1 UN 47131.92 30635.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 28538.38 60.55 999999999 28538.38 47131.92 percent of total billed charges SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC 574 MS-DRG inpatient 1 UN 47131.92 30635.75 UHC - ALL PLANS UHC - ALL PLANS 28949.3 999999999 28538.38 47131.92 case rate SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC 574 MS-DRG inpatient 1 UN 47131.92 30635.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 31861.18 67.6 999999999 28538.38 47131.92 percent of total billed charges SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC 574 MS-DRG inpatient 1 UN 47131.92 30635.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 46468.74 999999999 28538.38 47131.92 case rate SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC 574 MS-DRG inpatient 1 UN 47131.92 30635.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 45717.96 97 999999999 28538.38 47131.92 percent of total billed charges SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC 574 MS-DRG inpatient 1 UN 47131.92 30635.75 AETNA AETNA 37234.22 79 999999999 28538.38 47131.92 percent of total billed charges SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC 574 MS-DRG inpatient 1 UN 47131.92 30635.75 SIHO - ALL PLANS SIHO - ALL PLANS 42418.73 90 999999999 28538.38 47131.92 percent of total billed charges SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC 574 MS-DRG inpatient 1 UN 47131.92 30635.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 30635.75 65 999999999 28538.38 47131.92 percent of total billed charges SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC 574 MS-DRG inpatient 1 UN 47131.92 30635.75 ANTHEM HMO ANTHEM HMO 47131.92 999999999 28538.38 47131.92 case rate SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC 574 MS-DRG inpatient 1 UN 47131.92 30635.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 47131.92 999999999 28538.38 47131.92 case rate SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC 574 MS-DRG inpatient 1 UN 47131.92 30635.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 47131.92 999999999 28538.38 47131.92 case rate SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC 577 MS-DRG inpatient 1 UN 34315.73 22305.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 34315.73 999999999 20778.17 34315.73 case rate SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC 577 MS-DRG inpatient 1 UN 34315.73 22305.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 34315.73 999999999 20778.17 34315.73 case rate SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC 577 MS-DRG inpatient 1 UN 34315.73 22305.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 22305.22 65 999999999 20778.17 34315.73 percent of total billed charges SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC 577 MS-DRG inpatient 1 UN 34315.73 22305.22 AETNA AETNA 27109.43 79 999999999 20778.17 34315.73 percent of total billed charges SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC 577 MS-DRG inpatient 1 UN 34315.73 22305.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 26766.27 78 999999999 20778.17 34315.73 percent of total billed charges SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC 577 MS-DRG inpatient 1 UN 34315.73 22305.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33286.26 97 999999999 20778.17 34315.73 percent of total billed charges SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC 577 MS-DRG inpatient 1 UN 34315.73 22305.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 34315.73 999999999 20778.17 34315.73 case rate SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC 577 MS-DRG inpatient 1 UN 34315.73 22305.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 23197.43 67.6 999999999 20778.17 34315.73 percent of total billed charges SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC 577 MS-DRG inpatient 1 UN 34315.73 22305.22 ANTHEM HMO ANTHEM HMO 34315.73 999999999 20778.17 34315.73 case rate SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC 577 MS-DRG inpatient 1 UN 34315.73 22305.22 SIHO - ALL PLANS SIHO - ALL PLANS 30884.16 90 999999999 20778.17 34315.73 percent of total billed charges SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC 577 MS-DRG inpatient 1 UN 34315.73 22305.22 UHC - ALL PLANS UHC - ALL PLANS 22517.35 999999999 20778.17 34315.73 case rate SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC 577 MS-DRG inpatient 1 UN 34315.73 22305.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20778.17 60.55 999999999 20778.17 34315.73 percent of total billed charges SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC 577 MS-DRG inpatient 1 UN 34315.73 22305.22 UMR - ALL PLANS UMR - ALL PLANS 24021.01 70 999999999 20778.17 34315.73 percent of total billed charges SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC 577 MS-DRG inpatient 1 UN 34315.73 22305.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 23677.85 69 999999999 20778.17 34315.73 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC" 579 MS-DRG inpatient 1 UN 76016.53 49410.74 CIGNA - ALL PLANS CIGNA - ALL PLANS 51387.17 67.6 999999999 28408.7 73736.03 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC" 579 MS-DRG inpatient 1 UN 76016.53 49410.74 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 73736.03 97 999999999 28408.7 73736.03 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC" 579 MS-DRG inpatient 1 UN 76016.53 49410.74 HUMANA - ALL PLANS HUMANA - ALL PLANS 59292.89 78 999999999 28408.7 73736.03 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC" 579 MS-DRG inpatient 1 UN 76016.53 49410.74 ENCORE - ALL PLANS ENCORE - ALL PLANS 52451.41 69 999999999 28408.7 73736.03 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC" 579 MS-DRG inpatient 1 UN 76016.53 49410.74 ANTHEM HMO ANTHEM HMO 47683.17 999999999 28408.7 73736.03 case rate "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC" 579 MS-DRG inpatient 1 UN 76016.53 49410.74 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 50667.75 999999999 28408.7 73736.03 case rate "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC" 579 MS-DRG inpatient 1 UN 76016.53 49410.74 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 53648.99 999999999 28408.7 73736.03 case rate "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC" 579 MS-DRG inpatient 1 UN 76016.53 49410.74 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 46028.01 60.55 999999999 28408.7 73736.03 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC" 579 MS-DRG inpatient 1 UN 76016.53 49410.74 SELF PAY DISCOUNT SELF PAY DISCOUNT 49410.74 65 999999999 28408.7 73736.03 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC" 579 MS-DRG inpatient 1 UN 76016.53 49410.74 AETNA AETNA 60053.06 79 999999999 28408.7 73736.03 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC" 579 MS-DRG inpatient 1 UN 76016.53 49410.74 SIHO - ALL PLANS SIHO - ALL PLANS 68414.88 90 999999999 28408.7 73736.03 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC" 579 MS-DRG inpatient 1 UN 76016.53 49410.74 UMR - ALL PLANS UMR - ALL PLANS 53211.57 70 999999999 28408.7 73736.03 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC" 579 MS-DRG inpatient 1 UN 76016.53 49410.74 UHC - ALL PLANS UHC - ALL PLANS 28408.7 999999999 28408.7 73736.03 case rate "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC" 579 MS-DRG inpatient 1 UN 76016.53 49410.74 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 45600.98 999999999 28408.7 73736.03 case rate "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC" 580 MS-DRG inpatient 1 UN 44729.99 29074.49 CIGNA - ALL PLANS CIGNA - ALL PLANS 30237.47 67.6 999999999 14846.1 43388.09 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC" 580 MS-DRG inpatient 1 UN 44729.99 29074.49 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 28036.42 999999999 14846.1 43388.09 case rate "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC" 580 MS-DRG inpatient 1 UN 44729.99 29074.49 AETNA AETNA 35336.69 79 999999999 14846.1 43388.09 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC" 580 MS-DRG inpatient 1 UN 44729.99 29074.49 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 27084.01 60.55 999999999 14846.1 43388.09 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC" 580 MS-DRG inpatient 1 UN 44729.99 29074.49 HUMANA - ALL PLANS HUMANA - ALL PLANS 34889.39 78 999999999 14846.1 43388.09 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC" 580 MS-DRG inpatient 1 UN 44729.99 29074.49 ENCORE - ALL PLANS ENCORE - ALL PLANS 30863.69 69 999999999 14846.1 43388.09 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC" 580 MS-DRG inpatient 1 UN 44729.99 29074.49 SELF PAY DISCOUNT SELF PAY DISCOUNT 29074.49 65 999999999 14846.1 43388.09 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC" 580 MS-DRG inpatient 1 UN 44729.99 29074.49 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 43388.09 97 999999999 14846.1 43388.09 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC" 580 MS-DRG inpatient 1 UN 44729.99 29074.49 ANTHEM HMO ANTHEM HMO 24918.74 999999999 14846.1 43388.09 case rate "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC" 580 MS-DRG inpatient 1 UN 44729.99 29074.49 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 26478.46 999999999 14846.1 43388.09 case rate "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC" 580 MS-DRG inpatient 1 UN 44729.99 29074.49 UHC - ALL PLANS UHC - ALL PLANS 14846.1 999999999 14846.1 43388.09 case rate "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC" 580 MS-DRG inpatient 1 UN 44729.99 29074.49 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 23830.61 999999999 14846.1 43388.09 case rate "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC" 580 MS-DRG inpatient 1 UN 44729.99 29074.49 SIHO - ALL PLANS SIHO - ALL PLANS 40256.99 90 999999999 14846.1 43388.09 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC" 580 MS-DRG inpatient 1 UN 44729.99 29074.49 UMR - ALL PLANS UMR - ALL PLANS 31310.99 70 999999999 14846.1 43388.09 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC" 581 MS-DRG inpatient 1 UN 37991.84 24694.7 UMR - ALL PLANS UMR - ALL PLANS 26594.29 70 999999999 11446.95 36852.08 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC" 581 MS-DRG inpatient 1 UN 37991.84 24694.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 36852.08 97 999999999 11446.95 36852.08 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC" 581 MS-DRG inpatient 1 UN 37991.84 24694.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 29633.64 78 999999999 11446.95 36852.08 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC" 581 MS-DRG inpatient 1 UN 37991.84 24694.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 18374.37 999999999 11446.95 36852.08 case rate "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC" 581 MS-DRG inpatient 1 UN 37991.84 24694.7 UHC - ALL PLANS UHC - ALL PLANS 11446.95 999999999 11446.95 36852.08 case rate "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC" 581 MS-DRG inpatient 1 UN 37991.84 24694.7 ANTHEM HMO ANTHEM HMO 19213.37 999999999 11446.95 36852.08 case rate "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC" 581 MS-DRG inpatient 1 UN 37991.84 24694.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 20415.97 999999999 11446.95 36852.08 case rate "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC" 581 MS-DRG inpatient 1 UN 37991.84 24694.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 21617.23 999999999 11446.95 36852.08 case rate "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC" 581 MS-DRG inpatient 1 UN 37991.84 24694.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 24694.7 65 999999999 11446.95 36852.08 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC" 581 MS-DRG inpatient 1 UN 37991.84 24694.7 SIHO - ALL PLANS SIHO - ALL PLANS 34192.66 90 999999999 11446.95 36852.08 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC" 581 MS-DRG inpatient 1 UN 37991.84 24694.7 AETNA AETNA 30013.55 79 999999999 11446.95 36852.08 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC" 581 MS-DRG inpatient 1 UN 37991.84 24694.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 26214.37 69 999999999 11446.95 36852.08 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC" 581 MS-DRG inpatient 1 UN 37991.84 24694.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23004.06 60.55 999999999 11446.95 36852.08 percent of total billed charges "OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC" 581 MS-DRG inpatient 1 UN 37991.84 24694.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 25682.48 67.6 999999999 11446.95 36852.08 percent of total billed charges "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC" 585 MS-DRG inpatient 1 UN 16961.27 11024.83 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 16961.27 999999999 10270.05 16961.27 case rate "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC" 585 MS-DRG inpatient 1 UN 16961.27 11024.83 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 16961.27 999999999 10270.05 16961.27 case rate "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC" 585 MS-DRG inpatient 1 UN 16961.27 11024.83 AETNA AETNA 13399.4 79 999999999 10270.05 16961.27 percent of total billed charges "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC" 585 MS-DRG inpatient 1 UN 16961.27 11024.83 HUMANA - ALL PLANS HUMANA - ALL PLANS 13229.79 78 999999999 10270.05 16961.27 percent of total billed charges "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC" 585 MS-DRG inpatient 1 UN 16961.27 11024.83 SELF PAY DISCOUNT SELF PAY DISCOUNT 11024.83 65 999999999 10270.05 16961.27 percent of total billed charges "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC" 585 MS-DRG inpatient 1 UN 16961.27 11024.83 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16452.43 97 999999999 10270.05 16961.27 percent of total billed charges "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC" 585 MS-DRG inpatient 1 UN 16961.27 11024.83 ANTHEM HMO ANTHEM HMO 16961.27 999999999 10270.05 16961.27 case rate "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC" 585 MS-DRG inpatient 1 UN 16961.27 11024.83 CIGNA - ALL PLANS CIGNA - ALL PLANS 11465.82 67.6 999999999 10270.05 16961.27 percent of total billed charges "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC" 585 MS-DRG inpatient 1 UN 16961.27 11024.83 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 16961.27 999999999 10270.05 16961.27 case rate "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC" 585 MS-DRG inpatient 1 UN 16961.27 11024.83 SIHO - ALL PLANS SIHO - ALL PLANS 15265.14 90 999999999 10270.05 16961.27 percent of total billed charges "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC" 585 MS-DRG inpatient 1 UN 16961.27 11024.83 ENCORE - ALL PLANS ENCORE - ALL PLANS 11703.28 69 999999999 10270.05 16961.27 percent of total billed charges "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC" 585 MS-DRG inpatient 1 UN 16961.27 11024.83 UMR - ALL PLANS UMR - ALL PLANS 11872.89 70 999999999 10270.05 16961.27 percent of total billed charges "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC" 585 MS-DRG inpatient 1 UN 16961.27 11024.83 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10270.05 60.55 999999999 10270.05 16961.27 percent of total billed charges "BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC" 585 MS-DRG inpatient 1 UN 16961.27 11024.83 UHC - ALL PLANS UHC - ALL PLANS 14314 999999999 10270.05 16961.27 case rate SKIN ULCERS WITH MCC 592 MS-DRG inpatient 1 UN 24361.75 15835.14 UMR - ALL PLANS UMR - ALL PLANS 17053.23 70 999999999 14751.04 24361.75 percent of total billed charges SKIN ULCERS WITH MCC 592 MS-DRG inpatient 1 UN 24361.75 15835.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23630.9 97 999999999 14751.04 24361.75 percent of total billed charges SKIN ULCERS WITH MCC 592 MS-DRG inpatient 1 UN 24361.75 15835.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 19002.17 78 999999999 14751.04 24361.75 percent of total billed charges SKIN ULCERS WITH MCC 592 MS-DRG inpatient 1 UN 24361.75 15835.14 ANTHEM HMO ANTHEM HMO 24361.75 999999999 14751.04 24361.75 case rate SKIN ULCERS WITH MCC 592 MS-DRG inpatient 1 UN 24361.75 15835.14 UHC - ALL PLANS UHC - ALL PLANS 17765.85 999999999 14751.04 24361.75 case rate SKIN ULCERS WITH MCC 592 MS-DRG inpatient 1 UN 24361.75 15835.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 24361.75 999999999 14751.04 24361.75 case rate SKIN ULCERS WITH MCC 592 MS-DRG inpatient 1 UN 24361.75 15835.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 24361.75 999999999 14751.04 24361.75 case rate SKIN ULCERS WITH MCC 592 MS-DRG inpatient 1 UN 24361.75 15835.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 24361.75 999999999 14751.04 24361.75 case rate SKIN ULCERS WITH MCC 592 MS-DRG inpatient 1 UN 24361.75 15835.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 15835.14 65 999999999 14751.04 24361.75 percent of total billed charges SKIN ULCERS WITH MCC 592 MS-DRG inpatient 1 UN 24361.75 15835.14 AETNA AETNA 19245.78 79 999999999 14751.04 24361.75 percent of total billed charges SKIN ULCERS WITH MCC 592 MS-DRG inpatient 1 UN 24361.75 15835.14 SIHO - ALL PLANS SIHO - ALL PLANS 21925.58 90 999999999 14751.04 24361.75 percent of total billed charges SKIN ULCERS WITH MCC 592 MS-DRG inpatient 1 UN 24361.75 15835.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 16809.61 69 999999999 14751.04 24361.75 percent of total billed charges SKIN ULCERS WITH MCC 592 MS-DRG inpatient 1 UN 24361.75 15835.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14751.04 60.55 999999999 14751.04 24361.75 percent of total billed charges SKIN ULCERS WITH MCC 592 MS-DRG inpatient 1 UN 24361.75 15835.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 16468.54 67.6 999999999 14751.04 24361.75 percent of total billed charges SKIN ULCERS WITH CC 593 MS-DRG inpatient 1 UN 23109.81 15021.38 CIGNA - ALL PLANS CIGNA - ALL PLANS 15622.23 67.6 999999999 10284.15 22416.52 percent of total billed charges SKIN ULCERS WITH CC 593 MS-DRG inpatient 1 UN 23109.81 15021.38 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13992.99 60.55 999999999 10284.15 22416.52 percent of total billed charges SKIN ULCERS WITH CC 593 MS-DRG inpatient 1 UN 23109.81 15021.38 ENCORE - ALL PLANS ENCORE - ALL PLANS 15945.77 69 999999999 10284.15 22416.52 percent of total billed charges SKIN ULCERS WITH CC 593 MS-DRG inpatient 1 UN 23109.81 15021.38 AETNA AETNA 18256.75 79 999999999 10284.15 22416.52 percent of total billed charges SKIN ULCERS WITH CC 593 MS-DRG inpatient 1 UN 23109.81 15021.38 SELF PAY DISCOUNT SELF PAY DISCOUNT 15021.38 65 999999999 10284.15 22416.52 percent of total billed charges SKIN ULCERS WITH CC 593 MS-DRG inpatient 1 UN 23109.81 15021.38 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 19421.31 999999999 10284.15 22416.52 case rate SKIN ULCERS WITH CC 593 MS-DRG inpatient 1 UN 23109.81 15021.38 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 18342.08 999999999 10284.15 22416.52 case rate SKIN ULCERS WITH CC 593 MS-DRG inpatient 1 UN 23109.81 15021.38 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 16507.88 999999999 10284.15 22416.52 case rate SKIN ULCERS WITH CC 593 MS-DRG inpatient 1 UN 23109.81 15021.38 UHC - ALL PLANS UHC - ALL PLANS 10284.15 999999999 10284.15 22416.52 case rate SKIN ULCERS WITH CC 593 MS-DRG inpatient 1 UN 23109.81 15021.38 ANTHEM HMO ANTHEM HMO 17261.64 999999999 10284.15 22416.52 case rate SKIN ULCERS WITH CC 593 MS-DRG inpatient 1 UN 23109.81 15021.38 HUMANA - ALL PLANS HUMANA - ALL PLANS 18025.65 78 999999999 10284.15 22416.52 percent of total billed charges SKIN ULCERS WITH CC 593 MS-DRG inpatient 1 UN 23109.81 15021.38 SIHO - ALL PLANS SIHO - ALL PLANS 20798.83 90 999999999 10284.15 22416.52 percent of total billed charges SKIN ULCERS WITH CC 593 MS-DRG inpatient 1 UN 23109.81 15021.38 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22416.52 97 999999999 10284.15 22416.52 percent of total billed charges SKIN ULCERS WITH CC 593 MS-DRG inpatient 1 UN 23109.81 15021.38 UMR - ALL PLANS UMR - ALL PLANS 16176.87 70 999999999 10284.15 22416.52 percent of total billed charges SKIN ULCERS WITHOUT CC/MCC 594 MS-DRG inpatient 1 UN 21342.52 13872.64 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12922.9 60.55 999999999 6692.9 20702.24 percent of total billed charges SKIN ULCERS WITHOUT CC/MCC 594 MS-DRG inpatient 1 UN 21342.52 13872.64 UHC - ALL PLANS UHC - ALL PLANS 6692.9 999999999 6692.9 20702.24 case rate SKIN ULCERS WITHOUT CC/MCC 594 MS-DRG inpatient 1 UN 21342.52 13872.64 HUMANA - ALL PLANS HUMANA - ALL PLANS 16647.17 78 999999999 6692.9 20702.24 percent of total billed charges SKIN ULCERS WITHOUT CC/MCC 594 MS-DRG inpatient 1 UN 21342.52 13872.64 ENCORE - ALL PLANS ENCORE - ALL PLANS 14726.34 69 999999999 6692.9 20702.24 percent of total billed charges SKIN ULCERS WITHOUT CC/MCC 594 MS-DRG inpatient 1 UN 21342.52 13872.64 UMR - ALL PLANS UMR - ALL PLANS 14939.76 70 999999999 6692.9 20702.24 percent of total billed charges SKIN ULCERS WITHOUT CC/MCC 594 MS-DRG inpatient 1 UN 21342.52 13872.64 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20702.24 97 999999999 6692.9 20702.24 percent of total billed charges SKIN ULCERS WITHOUT CC/MCC 594 MS-DRG inpatient 1 UN 21342.52 13872.64 CIGNA - ALL PLANS CIGNA - ALL PLANS 14427.54 67.6 999999999 6692.9 20702.24 percent of total billed charges SKIN ULCERS WITHOUT CC/MCC 594 MS-DRG inpatient 1 UN 21342.52 13872.64 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10743.29 999999999 6692.9 20702.24 case rate SKIN ULCERS WITHOUT CC/MCC 594 MS-DRG inpatient 1 UN 21342.52 13872.64 SIHO - ALL PLANS SIHO - ALL PLANS 19208.27 90 999999999 6692.9 20702.24 percent of total billed charges SKIN ULCERS WITHOUT CC/MCC 594 MS-DRG inpatient 1 UN 21342.52 13872.64 AETNA AETNA 16860.59 79 999999999 6692.9 20702.24 percent of total billed charges SKIN ULCERS WITHOUT CC/MCC 594 MS-DRG inpatient 1 UN 21342.52 13872.64 SELF PAY DISCOUNT SELF PAY DISCOUNT 13872.64 65 999999999 6692.9 20702.24 percent of total billed charges SKIN ULCERS WITHOUT CC/MCC 594 MS-DRG inpatient 1 UN 21342.52 13872.64 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12639.34 999999999 6692.9 20702.24 case rate SKIN ULCERS WITHOUT CC/MCC 594 MS-DRG inpatient 1 UN 21342.52 13872.64 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 11936.98 999999999 6692.9 20702.24 case rate SKIN ULCERS WITHOUT CC/MCC 594 MS-DRG inpatient 1 UN 21342.52 13872.64 ANTHEM HMO ANTHEM HMO 11233.84 999999999 6692.9 20702.24 case rate MALIGNANT BREAST DISORDERS WITH CC 598 MS-DRG inpatient 1 UN 29044.67 18879.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 16356.43 999999999 10189.8 28173.33 case rate MALIGNANT BREAST DISORDERS WITH CC 598 MS-DRG inpatient 1 UN 29044.67 18879.04 UHC - ALL PLANS UHC - ALL PLANS 10189.8 999999999 10189.8 28173.33 case rate MALIGNANT BREAST DISORDERS WITH CC 598 MS-DRG inpatient 1 UN 29044.67 18879.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 18173.81 999999999 10189.8 28173.33 case rate MALIGNANT BREAST DISORDERS WITH CC 598 MS-DRG inpatient 1 UN 29044.67 18879.04 ANTHEM HMO ANTHEM HMO 17103.28 999999999 10189.8 28173.33 case rate MALIGNANT BREAST DISORDERS WITH CC 598 MS-DRG inpatient 1 UN 29044.67 18879.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 18879.04 65 999999999 10189.8 28173.33 percent of total billed charges MALIGNANT BREAST DISORDERS WITH CC 598 MS-DRG inpatient 1 UN 29044.67 18879.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 28173.33 97 999999999 10189.8 28173.33 percent of total billed charges MALIGNANT BREAST DISORDERS WITH CC 598 MS-DRG inpatient 1 UN 29044.67 18879.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 20040.82 69 999999999 10189.8 28173.33 percent of total billed charges MALIGNANT BREAST DISORDERS WITH CC 598 MS-DRG inpatient 1 UN 29044.67 18879.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 22654.84 78 999999999 10189.8 28173.33 percent of total billed charges MALIGNANT BREAST DISORDERS WITH CC 598 MS-DRG inpatient 1 UN 29044.67 18879.04 UMR - ALL PLANS UMR - ALL PLANS 20331.27 70 999999999 10189.8 28173.33 percent of total billed charges MALIGNANT BREAST DISORDERS WITH CC 598 MS-DRG inpatient 1 UN 29044.67 18879.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 19243.14 999999999 10189.8 28173.33 case rate MALIGNANT BREAST DISORDERS WITH CC 598 MS-DRG inpatient 1 UN 29044.67 18879.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 19634.2 67.6 999999999 10189.8 28173.33 percent of total billed charges MALIGNANT BREAST DISORDERS WITH CC 598 MS-DRG inpatient 1 UN 29044.67 18879.04 AETNA AETNA 22945.29 79 999999999 10189.8 28173.33 percent of total billed charges MALIGNANT BREAST DISORDERS WITH CC 598 MS-DRG inpatient 1 UN 29044.67 18879.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17586.55 60.55 999999999 10189.8 28173.33 percent of total billed charges MALIGNANT BREAST DISORDERS WITH CC 598 MS-DRG inpatient 1 UN 29044.67 18879.04 SIHO - ALL PLANS SIHO - ALL PLANS 26140.2 90 999999999 10189.8 28173.33 percent of total billed charges CELLULITIS WITH MCC 602 MS-DRG inpatient 1 UN 30461.99 19800.29 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18444.73 60.55 999999999 12643.75 29548.13 percent of total billed charges CELLULITIS WITH MCC 602 MS-DRG inpatient 1 UN 30461.99 19800.29 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 23877.35 999999999 12643.75 29548.13 case rate CELLULITIS WITH MCC 602 MS-DRG inpatient 1 UN 30461.99 19800.29 SIHO - ALL PLANS SIHO - ALL PLANS 27415.79 90 999999999 12643.75 29548.13 percent of total billed charges CELLULITIS WITH MCC 602 MS-DRG inpatient 1 UN 30461.99 19800.29 HUMANA - ALL PLANS HUMANA - ALL PLANS 23760.35 78 999999999 12643.75 29548.13 percent of total billed charges CELLULITIS WITH MCC 602 MS-DRG inpatient 1 UN 30461.99 19800.29 ENCORE - ALL PLANS ENCORE - ALL PLANS 21018.77 69 999999999 12643.75 29548.13 percent of total billed charges CELLULITIS WITH MCC 602 MS-DRG inpatient 1 UN 30461.99 19800.29 CIGNA - ALL PLANS CIGNA - ALL PLANS 20592.31 67.6 999999999 12643.75 29548.13 percent of total billed charges CELLULITIS WITH MCC 602 MS-DRG inpatient 1 UN 30461.99 19800.29 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 22550.5 999999999 12643.75 29548.13 case rate CELLULITIS WITH MCC 602 MS-DRG inpatient 1 UN 30461.99 19800.29 ANTHEM HMO ANTHEM HMO 21222.16 999999999 12643.75 29548.13 case rate CELLULITIS WITH MCC 602 MS-DRG inpatient 1 UN 30461.99 19800.29 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29548.13 97 999999999 12643.75 29548.13 percent of total billed charges CELLULITIS WITH MCC 602 MS-DRG inpatient 1 UN 30461.99 19800.29 UMR - ALL PLANS UMR - ALL PLANS 21323.39 70 999999999 12643.75 29548.13 percent of total billed charges CELLULITIS WITH MCC 602 MS-DRG inpatient 1 UN 30461.99 19800.29 AETNA AETNA 24064.97 79 999999999 12643.75 29548.13 percent of total billed charges CELLULITIS WITH MCC 602 MS-DRG inpatient 1 UN 30461.99 19800.29 UHC - ALL PLANS UHC - ALL PLANS 12643.75 999999999 12643.75 29548.13 case rate CELLULITIS WITH MCC 602 MS-DRG inpatient 1 UN 30461.99 19800.29 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 20295.45 999999999 12643.75 29548.13 case rate CELLULITIS WITH MCC 602 MS-DRG inpatient 1 UN 30461.99 19800.29 SELF PAY DISCOUNT SELF PAY DISCOUNT 19800.29 65 999999999 12643.75 29548.13 percent of total billed charges CELLULITIS WITHOUT MCC 603 MS-DRG inpatient 1 UN 25008.49 16255.52 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 14201.2 999999999 7519.95 24258.23 case rate CELLULITIS WITHOUT MCC 603 MS-DRG inpatient 1 UN 25008.49 16255.52 CIGNA - ALL PLANS CIGNA - ALL PLANS 16905.74 67.6 999999999 7519.95 24258.23 percent of total billed charges CELLULITIS WITHOUT MCC 603 MS-DRG inpatient 1 UN 25008.49 16255.52 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13412.05 999999999 7519.95 24258.23 case rate CELLULITIS WITHOUT MCC 603 MS-DRG inpatient 1 UN 25008.49 16255.52 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15142.64 60.55 999999999 7519.95 24258.23 percent of total billed charges CELLULITIS WITHOUT MCC 603 MS-DRG inpatient 1 UN 25008.49 16255.52 ENCORE - ALL PLANS ENCORE - ALL PLANS 17255.86 69 999999999 7519.95 24258.23 percent of total billed charges CELLULITIS WITHOUT MCC 603 MS-DRG inpatient 1 UN 25008.49 16255.52 SELF PAY DISCOUNT SELF PAY DISCOUNT 16255.52 65 999999999 7519.95 24258.23 percent of total billed charges CELLULITIS WITHOUT MCC 603 MS-DRG inpatient 1 UN 25008.49 16255.52 AETNA AETNA 19756.7 79 999999999 7519.95 24258.23 percent of total billed charges CELLULITIS WITHOUT MCC 603 MS-DRG inpatient 1 UN 25008.49 16255.52 SIHO - ALL PLANS SIHO - ALL PLANS 22507.64 90 999999999 7519.95 24258.23 percent of total billed charges CELLULITIS WITHOUT MCC 603 MS-DRG inpatient 1 UN 25008.49 16255.52 UMR - ALL PLANS UMR - ALL PLANS 17505.94 70 999999999 7519.95 24258.23 percent of total billed charges CELLULITIS WITHOUT MCC 603 MS-DRG inpatient 1 UN 25008.49 16255.52 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24258.23 97 999999999 7519.95 24258.23 percent of total billed charges CELLULITIS WITHOUT MCC 603 MS-DRG inpatient 1 UN 25008.49 16255.52 ANTHEM HMO ANTHEM HMO 12622.01 999999999 7519.95 24258.23 case rate CELLULITIS WITHOUT MCC 603 MS-DRG inpatient 1 UN 25008.49 16255.52 UHC - ALL PLANS UHC - ALL PLANS 7519.95 999999999 7519.95 24258.23 case rate CELLULITIS WITHOUT MCC 603 MS-DRG inpatient 1 UN 25008.49 16255.52 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 12070.85 999999999 7519.95 24258.23 case rate CELLULITIS WITHOUT MCC 603 MS-DRG inpatient 1 UN 25008.49 16255.52 HUMANA - ALL PLANS HUMANA - ALL PLANS 19506.62 78 999999999 7519.95 24258.23 percent of total billed charges "TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC" 605 MS-DRG inpatient 1 UN 28385.35 18450.48 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17187.33 60.55 999999999 7724.8 27533.79 percent of total billed charges "TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC" 605 MS-DRG inpatient 1 UN 28385.35 18450.48 UMR - ALL PLANS UMR - ALL PLANS 19869.75 70 999999999 7724.8 27533.79 percent of total billed charges "TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC" 605 MS-DRG inpatient 1 UN 28385.35 18450.48 CIGNA - ALL PLANS CIGNA - ALL PLANS 19188.5 67.6 999999999 7724.8 27533.79 percent of total billed charges "TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC" 605 MS-DRG inpatient 1 UN 28385.35 18450.48 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 14588.06 999999999 7724.8 27533.79 case rate "TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC" 605 MS-DRG inpatient 1 UN 28385.35 18450.48 SIHO - ALL PLANS SIHO - ALL PLANS 25546.82 90 999999999 7724.8 27533.79 percent of total billed charges "TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC" 605 MS-DRG inpatient 1 UN 28385.35 18450.48 HUMANA - ALL PLANS HUMANA - ALL PLANS 22140.57 78 999999999 7724.8 27533.79 percent of total billed charges "TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC" 605 MS-DRG inpatient 1 UN 28385.35 18450.48 ENCORE - ALL PLANS ENCORE - ALL PLANS 19585.89 69 999999999 7724.8 27533.79 percent of total billed charges "TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC" 605 MS-DRG inpatient 1 UN 28385.35 18450.48 SELF PAY DISCOUNT SELF PAY DISCOUNT 18450.48 65 999999999 7724.8 27533.79 percent of total billed charges "TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC" 605 MS-DRG inpatient 1 UN 28385.35 18450.48 ANTHEM HMO ANTHEM HMO 12965.85 999999999 7724.8 27533.79 case rate "TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC" 605 MS-DRG inpatient 1 UN 28385.35 18450.48 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13777.41 999999999 7724.8 27533.79 case rate "TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC" 605 MS-DRG inpatient 1 UN 28385.35 18450.48 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 27533.79 97 999999999 7724.8 27533.79 percent of total billed charges "TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC" 605 MS-DRG inpatient 1 UN 28385.35 18450.48 AETNA AETNA 22424.43 79 999999999 7724.8 27533.79 percent of total billed charges "TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC" 605 MS-DRG inpatient 1 UN 28385.35 18450.48 UHC - ALL PLANS UHC - ALL PLANS 7724.8 999999999 7724.8 27533.79 case rate "TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC" 605 MS-DRG inpatient 1 UN 28385.35 18450.48 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 12399.67 999999999 7724.8 27533.79 case rate MINOR SKIN DISORDERS WITHOUT MCC 607 MS-DRG inpatient 1 UN 16147.35 10495.78 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13545.46 999999999 7594.75 15662.93 case rate MINOR SKIN DISORDERS WITHOUT MCC 607 MS-DRG inpatient 1 UN 16147.35 10495.78 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 14342.46 999999999 7594.75 15662.93 case rate MINOR SKIN DISORDERS WITHOUT MCC 607 MS-DRG inpatient 1 UN 16147.35 10495.78 ANTHEM HMO ANTHEM HMO 12747.56 999999999 7594.75 15662.93 case rate MINOR SKIN DISORDERS WITHOUT MCC 607 MS-DRG inpatient 1 UN 16147.35 10495.78 CIGNA - ALL PLANS CIGNA - ALL PLANS 10915.61 67.6 999999999 7594.75 15662.93 percent of total billed charges MINOR SKIN DISORDERS WITHOUT MCC 607 MS-DRG inpatient 1 UN 16147.35 10495.78 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 12190.91 999999999 7594.75 15662.93 case rate MINOR SKIN DISORDERS WITHOUT MCC 607 MS-DRG inpatient 1 UN 16147.35 10495.78 HUMANA - ALL PLANS HUMANA - ALL PLANS 12594.93 78 999999999 7594.75 15662.93 percent of total billed charges MINOR SKIN DISORDERS WITHOUT MCC 607 MS-DRG inpatient 1 UN 16147.35 10495.78 SELF PAY DISCOUNT SELF PAY DISCOUNT 10495.78 65 999999999 7594.75 15662.93 percent of total billed charges MINOR SKIN DISORDERS WITHOUT MCC 607 MS-DRG inpatient 1 UN 16147.35 10495.78 UHC - ALL PLANS UHC - ALL PLANS 7594.75 999999999 7594.75 15662.93 case rate MINOR SKIN DISORDERS WITHOUT MCC 607 MS-DRG inpatient 1 UN 16147.35 10495.78 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9777.22 60.55 999999999 7594.75 15662.93 percent of total billed charges MINOR SKIN DISORDERS WITHOUT MCC 607 MS-DRG inpatient 1 UN 16147.35 10495.78 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15662.93 97 999999999 7594.75 15662.93 percent of total billed charges MINOR SKIN DISORDERS WITHOUT MCC 607 MS-DRG inpatient 1 UN 16147.35 10495.78 ENCORE - ALL PLANS ENCORE - ALL PLANS 11141.67 69 999999999 7594.75 15662.93 percent of total billed charges MINOR SKIN DISORDERS WITHOUT MCC 607 MS-DRG inpatient 1 UN 16147.35 10495.78 SIHO - ALL PLANS SIHO - ALL PLANS 14532.62 90 999999999 7594.75 15662.93 percent of total billed charges MINOR SKIN DISORDERS WITHOUT MCC 607 MS-DRG inpatient 1 UN 16147.35 10495.78 AETNA AETNA 12756.41 79 999999999 7594.75 15662.93 percent of total billed charges MINOR SKIN DISORDERS WITHOUT MCC 607 MS-DRG inpatient 1 UN 16147.35 10495.78 UMR - ALL PLANS UMR - ALL PLANS 11303.15 70 999999999 7594.75 15662.93 percent of total billed charges "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC" 616 MS-DRG inpatient 1 UN 37590.98 24434.14 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 22761.34 60.55 999999999 22761.34 37590.98 percent of total billed charges "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC" 616 MS-DRG inpatient 1 UN 37590.98 24434.14 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 36463.25 97 999999999 22761.34 37590.98 percent of total billed charges "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC" 616 MS-DRG inpatient 1 UN 37590.98 24434.14 UMR - ALL PLANS UMR - ALL PLANS 26313.69 70 999999999 22761.34 37590.98 percent of total billed charges "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC" 616 MS-DRG inpatient 1 UN 37590.98 24434.14 SIHO - ALL PLANS SIHO - ALL PLANS 33831.88 90 999999999 22761.34 37590.98 percent of total billed charges "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC" 616 MS-DRG inpatient 1 UN 37590.98 24434.14 CIGNA - ALL PLANS CIGNA - ALL PLANS 25411.5 67.6 999999999 22761.34 37590.98 percent of total billed charges "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC" 616 MS-DRG inpatient 1 UN 37590.98 24434.14 SELF PAY DISCOUNT SELF PAY DISCOUNT 24434.14 65 999999999 22761.34 37590.98 percent of total billed charges "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC" 616 MS-DRG inpatient 1 UN 37590.98 24434.14 ENCORE - ALL PLANS ENCORE - ALL PLANS 25937.78 69 999999999 22761.34 37590.98 percent of total billed charges "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC" 616 MS-DRG inpatient 1 UN 37590.98 24434.14 HUMANA - ALL PLANS HUMANA - ALL PLANS 29320.96 78 999999999 22761.34 37590.98 percent of total billed charges "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC" 616 MS-DRG inpatient 1 UN 37590.98 24434.14 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 37590.98 999999999 22761.34 37590.98 case rate "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC" 616 MS-DRG inpatient 1 UN 37590.98 24434.14 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 37590.98 999999999 22761.34 37590.98 case rate "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC" 616 MS-DRG inpatient 1 UN 37590.98 24434.14 AETNA AETNA 29696.87 79 999999999 22761.34 37590.98 percent of total billed charges "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC" 616 MS-DRG inpatient 1 UN 37590.98 24434.14 UHC - ALL PLANS UHC - ALL PLANS 33640.45 999999999 22761.34 37590.98 case rate "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC" 616 MS-DRG inpatient 1 UN 37590.98 24434.14 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 37590.98 999999999 22761.34 37590.98 case rate "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC" 616 MS-DRG inpatient 1 UN 37590.98 24434.14 ANTHEM HMO ANTHEM HMO 37590.98 999999999 22761.34 37590.98 case rate "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 617 MS-DRG inpatient 1 UN 31411.67 20417.59 SELF PAY DISCOUNT SELF PAY DISCOUNT 20417.59 65 999999999 16868.25 31411.67 percent of total billed charges "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 617 MS-DRG inpatient 1 UN 31411.67 20417.59 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30469.32 97 999999999 16868.25 31411.67 percent of total billed charges "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 617 MS-DRG inpatient 1 UN 31411.67 20417.59 AETNA AETNA 24815.22 79 999999999 16868.25 31411.67 percent of total billed charges "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 617 MS-DRG inpatient 1 UN 31411.67 20417.59 UMR - ALL PLANS UMR - ALL PLANS 21988.17 70 999999999 16868.25 31411.67 percent of total billed charges "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 617 MS-DRG inpatient 1 UN 31411.67 20417.59 CIGNA - ALL PLANS CIGNA - ALL PLANS 21234.29 67.6 999999999 16868.25 31411.67 percent of total billed charges "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 617 MS-DRG inpatient 1 UN 31411.67 20417.59 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 27076.52 999999999 16868.25 31411.67 case rate "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 617 MS-DRG inpatient 1 UN 31411.67 20417.59 ANTHEM HMO ANTHEM HMO 28312.86 999999999 16868.25 31411.67 case rate "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 617 MS-DRG inpatient 1 UN 31411.67 20417.59 HUMANA - ALL PLANS HUMANA - ALL PLANS 24501.1 78 999999999 16868.25 31411.67 percent of total billed charges "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 617 MS-DRG inpatient 1 UN 31411.67 20417.59 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 31411.67 999999999 16868.25 31411.67 case rate "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 617 MS-DRG inpatient 1 UN 31411.67 20417.59 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 30085.02 999999999 16868.25 31411.67 case rate "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 617 MS-DRG inpatient 1 UN 31411.67 20417.59 SIHO - ALL PLANS SIHO - ALL PLANS 28270.5 90 999999999 16868.25 31411.67 percent of total billed charges "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 617 MS-DRG inpatient 1 UN 31411.67 20417.59 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19019.77 60.55 999999999 16868.25 31411.67 percent of total billed charges "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 617 MS-DRG inpatient 1 UN 31411.67 20417.59 UHC - ALL PLANS UHC - ALL PLANS 16868.25 999999999 16868.25 31411.67 case rate "AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 617 MS-DRG inpatient 1 UN 31411.67 20417.59 ENCORE - ALL PLANS ENCORE - ALL PLANS 21674.05 69 999999999 16868.25 31411.67 percent of total billed charges O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC 621 MS-DRG inpatient 1 UN 107807.4 70074.81 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 65277.38 60.55 999999999 12897.05 104573.18 percent of total billed charges O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC 621 MS-DRG inpatient 1 UN 107807.4 70074.81 UMR - ALL PLANS UMR - ALL PLANS 75465.18 70 999999999 12897.05 104573.18 percent of total billed charges O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC 621 MS-DRG inpatient 1 UN 107807.4 70074.81 SIHO - ALL PLANS SIHO - ALL PLANS 97026.66 90 999999999 12897.05 104573.18 percent of total billed charges O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC 621 MS-DRG inpatient 1 UN 107807.4 70074.81 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 24355.7 999999999 12897.05 104573.18 case rate O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC 621 MS-DRG inpatient 1 UN 107807.4 70074.81 CIGNA - ALL PLANS CIGNA - ALL PLANS 72877.8 67.6 999999999 12897.05 104573.18 percent of total billed charges O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC 621 MS-DRG inpatient 1 UN 107807.4 70074.81 HUMANA - ALL PLANS HUMANA - ALL PLANS 84089.77 78 999999999 12897.05 104573.18 percent of total billed charges O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC 621 MS-DRG inpatient 1 UN 107807.4 70074.81 ENCORE - ALL PLANS ENCORE - ALL PLANS 74387.11 69 999999999 12897.05 104573.18 percent of total billed charges O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC 621 MS-DRG inpatient 1 UN 107807.4 70074.81 ANTHEM HMO ANTHEM HMO 21647.32 999999999 12897.05 104573.18 case rate O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC 621 MS-DRG inpatient 1 UN 107807.4 70074.81 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 23002.27 999999999 12897.05 104573.18 case rate O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC 621 MS-DRG inpatient 1 UN 107807.4 70074.81 AETNA AETNA 85167.85 79 999999999 12897.05 104573.18 percent of total billed charges O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC 621 MS-DRG inpatient 1 UN 107807.4 70074.81 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 104573.18 97 999999999 12897.05 104573.18 percent of total billed charges O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC 621 MS-DRG inpatient 1 UN 107807.4 70074.81 SELF PAY DISCOUNT SELF PAY DISCOUNT 70074.81 65 999999999 12897.05 104573.18 percent of total billed charges O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC 621 MS-DRG inpatient 1 UN 107807.4 70074.81 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 20702.04 999999999 12897.05 104573.18 case rate O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC 621 MS-DRG inpatient 1 UN 107807.4 70074.81 UHC - ALL PLANS UHC - ALL PLANS 12897.05 999999999 12897.05 104573.18 case rate "SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 623 MS-DRG inpatient 1 UN 88890.72 57778.97 UHC - ALL PLANS UHC - ALL PLANS 15821.9 999999999 15821.9 86224 case rate "SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 623 MS-DRG inpatient 1 UN 88890.72 57778.97 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 25396.94 999999999 15821.9 86224 case rate "SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 623 MS-DRG inpatient 1 UN 88890.72 57778.97 ANTHEM HMO ANTHEM HMO 26556.59 999999999 15821.9 86224 case rate "SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 623 MS-DRG inpatient 1 UN 88890.72 57778.97 AETNA AETNA 70223.67 79 999999999 15821.9 86224 percent of total billed charges "SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 623 MS-DRG inpatient 1 UN 88890.72 57778.97 SIHO - ALL PLANS SIHO - ALL PLANS 80001.65 90 999999999 15821.9 86224 percent of total billed charges "SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 623 MS-DRG inpatient 1 UN 88890.72 57778.97 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 28218.82 999999999 15821.9 86224 case rate "SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 623 MS-DRG inpatient 1 UN 88890.72 57778.97 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 29879.19 999999999 15821.9 86224 case rate "SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 623 MS-DRG inpatient 1 UN 88890.72 57778.97 ENCORE - ALL PLANS ENCORE - ALL PLANS 61334.6 69 999999999 15821.9 86224 percent of total billed charges "SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 623 MS-DRG inpatient 1 UN 88890.72 57778.97 SELF PAY DISCOUNT SELF PAY DISCOUNT 57778.97 65 999999999 15821.9 86224 percent of total billed charges "SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 623 MS-DRG inpatient 1 UN 88890.72 57778.97 CIGNA - ALL PLANS CIGNA - ALL PLANS 60090.13 67.6 999999999 15821.9 86224 percent of total billed charges "SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 623 MS-DRG inpatient 1 UN 88890.72 57778.97 HUMANA - ALL PLANS HUMANA - ALL PLANS 69334.76 78 999999999 15821.9 86224 percent of total billed charges "SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 623 MS-DRG inpatient 1 UN 88890.72 57778.97 UMR - ALL PLANS UMR - ALL PLANS 62223.5 70 999999999 15821.9 86224 percent of total billed charges "SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 623 MS-DRG inpatient 1 UN 88890.72 57778.97 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 86224 97 999999999 15821.9 86224 percent of total billed charges "SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC" 623 MS-DRG inpatient 1 UN 88890.72 57778.97 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 53823.33 60.55 999999999 15821.9 86224 percent of total billed charges "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC" 628 MS-DRG inpatient 1 UN 74500.11 48425.07 AETNA AETNA 58855.09 79 999999999 34123.25 72265.11 percent of total billed charges "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC" 628 MS-DRG inpatient 1 UN 74500.11 48425.07 SIHO - ALL PLANS SIHO - ALL PLANS 67050.1 90 999999999 34123.25 72265.11 percent of total billed charges "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC" 628 MS-DRG inpatient 1 UN 74500.11 48425.07 UMR - ALL PLANS UMR - ALL PLANS 52150.08 70 999999999 34123.25 72265.11 percent of total billed charges "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC" 628 MS-DRG inpatient 1 UN 74500.11 48425.07 UHC - ALL PLANS UHC - ALL PLANS 34123.25 999999999 34123.25 72265.11 case rate "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC" 628 MS-DRG inpatient 1 UN 74500.11 48425.07 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 54773.84 999999999 34123.25 72265.11 case rate "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC" 628 MS-DRG inpatient 1 UN 74500.11 48425.07 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 72265.11 97 999999999 34123.25 72265.11 percent of total billed charges "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC" 628 MS-DRG inpatient 1 UN 74500.11 48425.07 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 45109.82 60.55 999999999 34123.25 72265.11 percent of total billed charges "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC" 628 MS-DRG inpatient 1 UN 74500.11 48425.07 HUMANA - ALL PLANS HUMANA - ALL PLANS 58110.09 78 999999999 34123.25 72265.11 percent of total billed charges "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC" 628 MS-DRG inpatient 1 UN 74500.11 48425.07 ENCORE - ALL PLANS ENCORE - ALL PLANS 51405.08 69 999999999 34123.25 72265.11 percent of total billed charges "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC" 628 MS-DRG inpatient 1 UN 74500.11 48425.07 SELF PAY DISCOUNT SELF PAY DISCOUNT 48425.07 65 999999999 34123.25 72265.11 percent of total billed charges "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC" 628 MS-DRG inpatient 1 UN 74500.11 48425.07 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 64440.75 999999999 34123.25 72265.11 case rate "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC" 628 MS-DRG inpatient 1 UN 74500.11 48425.07 CIGNA - ALL PLANS CIGNA - ALL PLANS 50362.07 67.6 999999999 34123.25 72265.11 percent of total billed charges "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC" 628 MS-DRG inpatient 1 UN 74500.11 48425.07 ANTHEM HMO ANTHEM HMO 57274.87 999999999 34123.25 72265.11 case rate "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC" 628 MS-DRG inpatient 1 UN 74500.11 48425.07 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 60859.82 999999999 34123.25 72265.11 case rate "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC" 629 MS-DRG inpatient 1 UN 35009.64 22756.26 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 34304.05 999999999 19233.8 35009.64 case rate "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC" 629 MS-DRG inpatient 1 UN 35009.64 22756.26 ANTHEM HMO ANTHEM HMO 32283.37 999999999 19233.8 35009.64 case rate "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC" 629 MS-DRG inpatient 1 UN 35009.64 22756.26 CIGNA - ALL PLANS CIGNA - ALL PLANS 23666.51 67.6 999999999 19233.8 35009.64 percent of total billed charges "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC" 629 MS-DRG inpatient 1 UN 35009.64 22756.26 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 35009.64 999999999 19233.8 35009.64 case rate "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC" 629 MS-DRG inpatient 1 UN 35009.64 22756.26 SELF PAY DISCOUNT SELF PAY DISCOUNT 22756.26 65 999999999 19233.8 35009.64 percent of total billed charges "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC" 629 MS-DRG inpatient 1 UN 35009.64 22756.26 ENCORE - ALL PLANS ENCORE - ALL PLANS 24156.65 69 999999999 19233.8 35009.64 percent of total billed charges "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC" 629 MS-DRG inpatient 1 UN 35009.64 22756.26 HUMANA - ALL PLANS HUMANA - ALL PLANS 27307.52 78 999999999 19233.8 35009.64 percent of total billed charges "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC" 629 MS-DRG inpatient 1 UN 35009.64 22756.26 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33959.35 97 999999999 19233.8 35009.64 percent of total billed charges "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC" 629 MS-DRG inpatient 1 UN 35009.64 22756.26 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21198.33 60.55 999999999 19233.8 35009.64 percent of total billed charges "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC" 629 MS-DRG inpatient 1 UN 35009.64 22756.26 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 30873.64 999999999 19233.8 35009.64 case rate "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC" 629 MS-DRG inpatient 1 UN 35009.64 22756.26 UHC - ALL PLANS UHC - ALL PLANS 19233.8 999999999 19233.8 35009.64 case rate "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC" 629 MS-DRG inpatient 1 UN 35009.64 22756.26 SIHO - ALL PLANS SIHO - ALL PLANS 31508.67 90 999999999 19233.8 35009.64 percent of total billed charges "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC" 629 MS-DRG inpatient 1 UN 35009.64 22756.26 AETNA AETNA 27657.61 79 999999999 19233.8 35009.64 percent of total billed charges "OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC" 629 MS-DRG inpatient 1 UN 35009.64 22756.26 UMR - ALL PLANS UMR - ALL PLANS 24506.74 70 999999999 19233.8 35009.64 percent of total billed charges DIABETES WITH MCC 637 MS-DRG inpatient 1 UN 25298.27 16443.87 UMR - ALL PLANS UMR - ALL PLANS 17708.79 70 999999999 12319.05 24539.32 percent of total billed charges DIABETES WITH MCC 637 MS-DRG inpatient 1 UN 25298.27 16443.87 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24539.32 97 999999999 12319.05 24539.32 percent of total billed charges DIABETES WITH MCC 637 MS-DRG inpatient 1 UN 25298.27 16443.87 HUMANA - ALL PLANS HUMANA - ALL PLANS 19732.65 78 999999999 12319.05 24539.32 percent of total billed charges DIABETES WITH MCC 637 MS-DRG inpatient 1 UN 25298.27 16443.87 ENCORE - ALL PLANS ENCORE - ALL PLANS 17455.8 69 999999999 12319.05 24539.32 percent of total billed charges DIABETES WITH MCC 637 MS-DRG inpatient 1 UN 25298.27 16443.87 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15318.1 60.55 999999999 12319.05 24539.32 percent of total billed charges DIABETES WITH MCC 637 MS-DRG inpatient 1 UN 25298.27 16443.87 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 23264.16 999999999 12319.05 24539.32 case rate DIABETES WITH MCC 637 MS-DRG inpatient 1 UN 25298.27 16443.87 SELF PAY DISCOUNT SELF PAY DISCOUNT 16443.87 65 999999999 12319.05 24539.32 percent of total billed charges DIABETES WITH MCC 637 MS-DRG inpatient 1 UN 25298.27 16443.87 SIHO - ALL PLANS SIHO - ALL PLANS 22768.44 90 999999999 12319.05 24539.32 percent of total billed charges DIABETES WITH MCC 637 MS-DRG inpatient 1 UN 25298.27 16443.87 AETNA AETNA 19985.63 79 999999999 12319.05 24539.32 percent of total billed charges DIABETES WITH MCC 637 MS-DRG inpatient 1 UN 25298.27 16443.87 UHC - ALL PLANS UHC - ALL PLANS 12319.05 999999999 12319.05 24539.32 case rate DIABETES WITH MCC 637 MS-DRG inpatient 1 UN 25298.27 16443.87 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 21971.39 999999999 12319.05 24539.32 case rate DIABETES WITH MCC 637 MS-DRG inpatient 1 UN 25298.27 16443.87 ANTHEM HMO ANTHEM HMO 20677.16 999999999 12319.05 24539.32 case rate DIABETES WITH MCC 637 MS-DRG inpatient 1 UN 25298.27 16443.87 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 19774.25 999999999 12319.05 24539.32 case rate DIABETES WITH MCC 637 MS-DRG inpatient 1 UN 25298.27 16443.87 CIGNA - ALL PLANS CIGNA - ALL PLANS 17101.63 67.6 999999999 12319.05 24539.32 percent of total billed charges DIABETES WITH CC 638 MS-DRG inpatient 1 UN 23010.93 14957.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 14957.11 65 999999999 7644.9 22320.61 percent of total billed charges DIABETES WITH CC 638 MS-DRG inpatient 1 UN 23010.93 14957.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22320.61 97 999999999 7644.9 22320.61 percent of total billed charges DIABETES WITH CC 638 MS-DRG inpatient 1 UN 23010.93 14957.11 UMR - ALL PLANS UMR - ALL PLANS 16107.65 70 999999999 7644.9 22320.61 percent of total billed charges DIABETES WITH CC 638 MS-DRG inpatient 1 UN 23010.93 14957.11 AETNA AETNA 18178.64 79 999999999 7644.9 22320.61 percent of total billed charges DIABETES WITH CC 638 MS-DRG inpatient 1 UN 23010.93 14957.11 SIHO - ALL PLANS SIHO - ALL PLANS 20709.84 90 999999999 7644.9 22320.61 percent of total billed charges DIABETES WITH CC 638 MS-DRG inpatient 1 UN 23010.93 14957.11 ANTHEM HMO ANTHEM HMO 12831.74 999999999 7644.9 22320.61 case rate DIABETES WITH CC 638 MS-DRG inpatient 1 UN 23010.93 14957.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 15555.39 67.6 999999999 7644.9 22320.61 percent of total billed charges DIABETES WITH CC 638 MS-DRG inpatient 1 UN 23010.93 14957.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 12271.41 999999999 7644.9 22320.61 case rate DIABETES WITH CC 638 MS-DRG inpatient 1 UN 23010.93 14957.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 14437.17 999999999 7644.9 22320.61 case rate DIABETES WITH CC 638 MS-DRG inpatient 1 UN 23010.93 14957.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13634.9 999999999 7644.9 22320.61 case rate DIABETES WITH CC 638 MS-DRG inpatient 1 UN 23010.93 14957.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 17948.53 78 999999999 7644.9 22320.61 percent of total billed charges DIABETES WITH CC 638 MS-DRG inpatient 1 UN 23010.93 14957.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 15877.54 69 999999999 7644.9 22320.61 percent of total billed charges DIABETES WITH CC 638 MS-DRG inpatient 1 UN 23010.93 14957.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13933.12 60.55 999999999 7644.9 22320.61 percent of total billed charges DIABETES WITH CC 638 MS-DRG inpatient 1 UN 23010.93 14957.11 UHC - ALL PLANS UHC - ALL PLANS 7644.9 999999999 7644.9 22320.61 case rate DIABETES WITHOUT CC/MCC 639 MS-DRG inpatient 1 UN 13078.69 8501.15 UMR - ALL PLANS UMR - ALL PLANS 9155.08 70 999999999 5291.25 12686.32 percent of total billed charges DIABETES WITHOUT CC/MCC 639 MS-DRG inpatient 1 UN 13078.69 8501.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 12686.32 97 999999999 5291.25 12686.32 percent of total billed charges DIABETES WITHOUT CC/MCC 639 MS-DRG inpatient 1 UN 13078.69 8501.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 7919.14 60.55 999999999 5291.25 12686.32 percent of total billed charges DIABETES WITHOUT CC/MCC 639 MS-DRG inpatient 1 UN 13078.69 8501.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 8841.19 67.6 999999999 5291.25 12686.32 percent of total billed charges DIABETES WITHOUT CC/MCC 639 MS-DRG inpatient 1 UN 13078.69 8501.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 10201.37 78 999999999 5291.25 12686.32 percent of total billed charges DIABETES WITHOUT CC/MCC 639 MS-DRG inpatient 1 UN 13078.69 8501.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 9437.1 999999999 5291.25 12686.32 case rate DIABETES WITHOUT CC/MCC 639 MS-DRG inpatient 1 UN 13078.69 8501.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 9992.37 999999999 5291.25 12686.32 case rate DIABETES WITHOUT CC/MCC 639 MS-DRG inpatient 1 UN 13078.69 8501.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 9024.29 69 999999999 5291.25 12686.32 percent of total billed charges DIABETES WITHOUT CC/MCC 639 MS-DRG inpatient 1 UN 13078.69 8501.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 8501.15 65 999999999 5291.25 12686.32 percent of total billed charges DIABETES WITHOUT CC/MCC 639 MS-DRG inpatient 1 UN 13078.69 8501.15 SIHO - ALL PLANS SIHO - ALL PLANS 11770.82 90 999999999 5291.25 12686.32 percent of total billed charges DIABETES WITHOUT CC/MCC 639 MS-DRG inpatient 1 UN 13078.69 8501.15 AETNA AETNA 10332.16 79 999999999 5291.25 12686.32 percent of total billed charges DIABETES WITHOUT CC/MCC 639 MS-DRG inpatient 1 UN 13078.69 8501.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 8493.39 999999999 5291.25 12686.32 case rate DIABETES WITHOUT CC/MCC 639 MS-DRG inpatient 1 UN 13078.69 8501.15 ANTHEM HMO ANTHEM HMO 8881.21 999999999 5291.25 12686.32 case rate DIABETES WITHOUT CC/MCC 639 MS-DRG inpatient 1 UN 13078.69 8501.15 UHC - ALL PLANS UHC - ALL PLANS 5291.25 999999999 5291.25 12686.32 case rate "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC" 640 MS-DRG inpatient 1 UN 30697.75 19953.54 CIGNA - ALL PLANS CIGNA - ALL PLANS 20751.68 67.6 999999999 11179.2 29776.82 percent of total billed charges "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC" 640 MS-DRG inpatient 1 UN 30697.75 19953.54 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 17944.59 999999999 11179.2 29776.82 case rate "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC" 640 MS-DRG inpatient 1 UN 30697.75 19953.54 ANTHEM HMO ANTHEM HMO 18763.96 999999999 11179.2 29776.82 case rate "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC" 640 MS-DRG inpatient 1 UN 30697.75 19953.54 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 19938.43 999999999 11179.2 29776.82 case rate "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC" 640 MS-DRG inpatient 1 UN 30697.75 19953.54 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 21111.59 999999999 11179.2 29776.82 case rate "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC" 640 MS-DRG inpatient 1 UN 30697.75 19953.54 SELF PAY DISCOUNT SELF PAY DISCOUNT 19953.54 65 999999999 11179.2 29776.82 percent of total billed charges "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC" 640 MS-DRG inpatient 1 UN 30697.75 19953.54 UHC - ALL PLANS UHC - ALL PLANS 11179.2 999999999 11179.2 29776.82 case rate "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC" 640 MS-DRG inpatient 1 UN 30697.75 19953.54 SIHO - ALL PLANS SIHO - ALL PLANS 27627.98 90 999999999 11179.2 29776.82 percent of total billed charges "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC" 640 MS-DRG inpatient 1 UN 30697.75 19953.54 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29776.82 97 999999999 11179.2 29776.82 percent of total billed charges "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC" 640 MS-DRG inpatient 1 UN 30697.75 19953.54 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18587.49 60.55 999999999 11179.2 29776.82 percent of total billed charges "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC" 640 MS-DRG inpatient 1 UN 30697.75 19953.54 HUMANA - ALL PLANS HUMANA - ALL PLANS 23944.25 78 999999999 11179.2 29776.82 percent of total billed charges "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC" 640 MS-DRG inpatient 1 UN 30697.75 19953.54 ENCORE - ALL PLANS ENCORE - ALL PLANS 21181.45 69 999999999 11179.2 29776.82 percent of total billed charges "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC" 640 MS-DRG inpatient 1 UN 30697.75 19953.54 AETNA AETNA 24251.23 79 999999999 11179.2 29776.82 percent of total billed charges "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC" 640 MS-DRG inpatient 1 UN 30697.75 19953.54 UMR - ALL PLANS UMR - ALL PLANS 21488.43 70 999999999 11179.2 29776.82 percent of total billed charges "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC" 641 MS-DRG inpatient 1 UN 20978.19 13635.82 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12702.29 60.55 999999999 6641.9 20348.84 percent of total billed charges "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC" 641 MS-DRG inpatient 1 UN 20978.19 13635.82 UMR - ALL PLANS UMR - ALL PLANS 14684.73 70 999999999 6641.9 20348.84 percent of total billed charges "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC" 641 MS-DRG inpatient 1 UN 20978.19 13635.82 SIHO - ALL PLANS SIHO - ALL PLANS 18880.37 90 999999999 6641.9 20348.84 percent of total billed charges "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC" 641 MS-DRG inpatient 1 UN 20978.19 13635.82 CIGNA - ALL PLANS CIGNA - ALL PLANS 14181.26 67.6 999999999 6641.9 20348.84 percent of total billed charges "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC" 641 MS-DRG inpatient 1 UN 20978.19 13635.82 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12543.03 999999999 6641.9 20348.84 case rate "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC" 641 MS-DRG inpatient 1 UN 20978.19 13635.82 ANTHEM HMO ANTHEM HMO 11148.23 999999999 6641.9 20348.84 case rate "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC" 641 MS-DRG inpatient 1 UN 20978.19 13635.82 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 11846.02 999999999 6641.9 20348.84 case rate "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC" 641 MS-DRG inpatient 1 UN 20978.19 13635.82 ENCORE - ALL PLANS ENCORE - ALL PLANS 14474.95 69 999999999 6641.9 20348.84 percent of total billed charges "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC" 641 MS-DRG inpatient 1 UN 20978.19 13635.82 HUMANA - ALL PLANS HUMANA - ALL PLANS 16362.99 78 999999999 6641.9 20348.84 percent of total billed charges "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC" 641 MS-DRG inpatient 1 UN 20978.19 13635.82 AETNA AETNA 16572.77 79 999999999 6641.9 20348.84 percent of total billed charges "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC" 641 MS-DRG inpatient 1 UN 20978.19 13635.82 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20348.84 97 999999999 6641.9 20348.84 percent of total billed charges "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC" 641 MS-DRG inpatient 1 UN 20978.19 13635.82 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10661.42 999999999 6641.9 20348.84 case rate "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC" 641 MS-DRG inpatient 1 UN 20978.19 13635.82 SELF PAY DISCOUNT SELF PAY DISCOUNT 13635.82 65 999999999 6641.9 20348.84 percent of total billed charges "MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC" 641 MS-DRG inpatient 1 UN 20978.19 13635.82 UHC - ALL PLANS UHC - ALL PLANS 6641.9 999999999 6641.9 20348.84 case rate ENDOCRINE DISORDERS WITH MCC 643 MS-DRG inpatient 1 UN 17064.94 11092.21 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 17064.94 999999999 10332.82 17064.94 case rate ENDOCRINE DISORDERS WITH MCC 643 MS-DRG inpatient 1 UN 17064.94 11092.21 CIGNA - ALL PLANS CIGNA - ALL PLANS 11535.9 67.6 999999999 10332.82 17064.94 percent of total billed charges ENDOCRINE DISORDERS WITH MCC 643 MS-DRG inpatient 1 UN 17064.94 11092.21 ANTHEM HMO ANTHEM HMO 17064.94 999999999 10332.82 17064.94 case rate ENDOCRINE DISORDERS WITH MCC 643 MS-DRG inpatient 1 UN 17064.94 11092.21 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 17064.94 999999999 10332.82 17064.94 case rate ENDOCRINE DISORDERS WITH MCC 643 MS-DRG inpatient 1 UN 17064.94 11092.21 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 17064.94 999999999 10332.82 17064.94 case rate ENDOCRINE DISORDERS WITH MCC 643 MS-DRG inpatient 1 UN 17064.94 11092.21 SELF PAY DISCOUNT SELF PAY DISCOUNT 11092.21 65 999999999 10332.82 17064.94 percent of total billed charges ENDOCRINE DISORDERS WITH MCC 643 MS-DRG inpatient 1 UN 17064.94 11092.21 UHC - ALL PLANS UHC - ALL PLANS 13983.35 999999999 10332.82 17064.94 case rate ENDOCRINE DISORDERS WITH MCC 643 MS-DRG inpatient 1 UN 17064.94 11092.21 HUMANA - ALL PLANS HUMANA - ALL PLANS 13310.65 78 999999999 10332.82 17064.94 percent of total billed charges ENDOCRINE DISORDERS WITH MCC 643 MS-DRG inpatient 1 UN 17064.94 11092.21 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16552.99 97 999999999 10332.82 17064.94 percent of total billed charges ENDOCRINE DISORDERS WITH MCC 643 MS-DRG inpatient 1 UN 17064.94 11092.21 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10332.82 60.55 999999999 10332.82 17064.94 percent of total billed charges ENDOCRINE DISORDERS WITH MCC 643 MS-DRG inpatient 1 UN 17064.94 11092.21 ENCORE - ALL PLANS ENCORE - ALL PLANS 11774.81 69 999999999 10332.82 17064.94 percent of total billed charges ENDOCRINE DISORDERS WITH MCC 643 MS-DRG inpatient 1 UN 17064.94 11092.21 SIHO - ALL PLANS SIHO - ALL PLANS 15358.45 90 999999999 10332.82 17064.94 percent of total billed charges ENDOCRINE DISORDERS WITH MCC 643 MS-DRG inpatient 1 UN 17064.94 11092.21 AETNA AETNA 13481.3 79 999999999 10332.82 17064.94 percent of total billed charges ENDOCRINE DISORDERS WITH MCC 643 MS-DRG inpatient 1 UN 17064.94 11092.21 UMR - ALL PLANS UMR - ALL PLANS 11945.46 70 999999999 10332.82 17064.94 percent of total billed charges ENDOCRINE DISORDERS WITH CC 644 MS-DRG inpatient 1 UN 13608.93 8845.8 SIHO - ALL PLANS SIHO - ALL PLANS 12248.03 90 999999999 8240.2 13608.93 percent of total billed charges ENDOCRINE DISORDERS WITH CC 644 MS-DRG inpatient 1 UN 13608.93 8845.8 UMR - ALL PLANS UMR - ALL PLANS 9526.25 70 999999999 8240.2 13608.93 percent of total billed charges ENDOCRINE DISORDERS WITH CC 644 MS-DRG inpatient 1 UN 13608.93 8845.8 UHC - ALL PLANS UHC - ALL PLANS 9024.45 999999999 8240.2 13608.93 case rate ENDOCRINE DISORDERS WITH CC 644 MS-DRG inpatient 1 UN 13608.93 8845.8 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 13608.93 999999999 8240.2 13608.93 case rate ENDOCRINE DISORDERS WITH CC 644 MS-DRG inpatient 1 UN 13608.93 8845.8 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13200.66 97 999999999 8240.2 13608.93 percent of total billed charges ENDOCRINE DISORDERS WITH CC 644 MS-DRG inpatient 1 UN 13608.93 8845.8 AETNA AETNA 10751.05 79 999999999 8240.2 13608.93 percent of total billed charges ENDOCRINE DISORDERS WITH CC 644 MS-DRG inpatient 1 UN 13608.93 8845.8 HUMANA - ALL PLANS HUMANA - ALL PLANS 10614.96 78 999999999 8240.2 13608.93 percent of total billed charges ENDOCRINE DISORDERS WITH CC 644 MS-DRG inpatient 1 UN 13608.93 8845.8 ENCORE - ALL PLANS ENCORE - ALL PLANS 9390.16 69 999999999 8240.2 13608.93 percent of total billed charges ENDOCRINE DISORDERS WITH CC 644 MS-DRG inpatient 1 UN 13608.93 8845.8 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8240.2 60.55 999999999 8240.2 13608.93 percent of total billed charges ENDOCRINE DISORDERS WITH CC 644 MS-DRG inpatient 1 UN 13608.93 8845.8 SELF PAY DISCOUNT SELF PAY DISCOUNT 8845.8 65 999999999 8240.2 13608.93 percent of total billed charges ENDOCRINE DISORDERS WITH CC 644 MS-DRG inpatient 1 UN 13608.93 8845.8 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 13608.93 999999999 8240.2 13608.93 case rate ENDOCRINE DISORDERS WITH CC 644 MS-DRG inpatient 1 UN 13608.93 8845.8 ANTHEM HMO ANTHEM HMO 13608.93 999999999 8240.2 13608.93 case rate ENDOCRINE DISORDERS WITH CC 644 MS-DRG inpatient 1 UN 13608.93 8845.8 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13608.93 999999999 8240.2 13608.93 case rate ENDOCRINE DISORDERS WITH CC 644 MS-DRG inpatient 1 UN 13608.93 8845.8 CIGNA - ALL PLANS CIGNA - ALL PLANS 9199.63 67.6 999999999 8240.2 13608.93 percent of total billed charges ENDOCRINE DISORDERS WITHOUT CC/MCC 645 MS-DRG inpatient 1 UN 34896.96 22683.02 CIGNA - ALL PLANS CIGNA - ALL PLANS 23590.35 67.6 999999999 6467.65 33850.05 percent of total billed charges ENDOCRINE DISORDERS WITHOUT CC/MCC 645 MS-DRG inpatient 1 UN 34896.96 22683.02 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10381.72 999999999 6467.65 33850.05 case rate ENDOCRINE DISORDERS WITHOUT CC/MCC 645 MS-DRG inpatient 1 UN 34896.96 22683.02 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 11535.24 999999999 6467.65 33850.05 case rate ENDOCRINE DISORDERS WITHOUT CC/MCC 645 MS-DRG inpatient 1 UN 34896.96 22683.02 ANTHEM HMO ANTHEM HMO 10855.76 999999999 6467.65 33850.05 case rate ENDOCRINE DISORDERS WITHOUT CC/MCC 645 MS-DRG inpatient 1 UN 34896.96 22683.02 UHC - ALL PLANS UHC - ALL PLANS 6467.65 999999999 6467.65 33850.05 case rate ENDOCRINE DISORDERS WITHOUT CC/MCC 645 MS-DRG inpatient 1 UN 34896.96 22683.02 AETNA AETNA 27568.6 79 999999999 6467.65 33850.05 percent of total billed charges ENDOCRINE DISORDERS WITHOUT CC/MCC 645 MS-DRG inpatient 1 UN 34896.96 22683.02 SIHO - ALL PLANS SIHO - ALL PLANS 31407.26 90 999999999 6467.65 33850.05 percent of total billed charges ENDOCRINE DISORDERS WITHOUT CC/MCC 645 MS-DRG inpatient 1 UN 34896.96 22683.02 SELF PAY DISCOUNT SELF PAY DISCOUNT 22683.02 65 999999999 6467.65 33850.05 percent of total billed charges ENDOCRINE DISORDERS WITHOUT CC/MCC 645 MS-DRG inpatient 1 UN 34896.96 22683.02 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21130.11 60.55 999999999 6467.65 33850.05 percent of total billed charges ENDOCRINE DISORDERS WITHOUT CC/MCC 645 MS-DRG inpatient 1 UN 34896.96 22683.02 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12213.97 999999999 6467.65 33850.05 case rate ENDOCRINE DISORDERS WITHOUT CC/MCC 645 MS-DRG inpatient 1 UN 34896.96 22683.02 ENCORE - ALL PLANS ENCORE - ALL PLANS 24078.9 69 999999999 6467.65 33850.05 percent of total billed charges ENDOCRINE DISORDERS WITHOUT CC/MCC 645 MS-DRG inpatient 1 UN 34896.96 22683.02 HUMANA - ALL PLANS HUMANA - ALL PLANS 27219.63 78 999999999 6467.65 33850.05 percent of total billed charges ENDOCRINE DISORDERS WITHOUT CC/MCC 645 MS-DRG inpatient 1 UN 34896.96 22683.02 UMR - ALL PLANS UMR - ALL PLANS 24427.87 70 999999999 6467.65 33850.05 percent of total billed charges ENDOCRINE DISORDERS WITHOUT CC/MCC 645 MS-DRG inpatient 1 UN 34896.96 22683.02 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 33850.05 97 999999999 6467.65 33850.05 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC 659 MS-DRG inpatient 1 UN 40411.17 26267.26 ENCORE - ALL PLANS ENCORE - ALL PLANS 27883.71 69 999999999 22005.65 40411.17 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC 659 MS-DRG inpatient 1 UN 40411.17 26267.26 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24468.96 60.55 999999999 22005.65 40411.17 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC 659 MS-DRG inpatient 1 UN 40411.17 26267.26 UHC - ALL PLANS UHC - ALL PLANS 22005.65 999999999 22005.65 40411.17 case rate KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC 659 MS-DRG inpatient 1 UN 40411.17 26267.26 SIHO - ALL PLANS SIHO - ALL PLANS 36370.05 90 999999999 22005.65 40411.17 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC 659 MS-DRG inpatient 1 UN 40411.17 26267.26 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 40411.17 999999999 22005.65 40411.17 case rate KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC 659 MS-DRG inpatient 1 UN 40411.17 26267.26 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 39247.72 999999999 22005.65 40411.17 case rate KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC 659 MS-DRG inpatient 1 UN 40411.17 26267.26 ANTHEM HMO ANTHEM HMO 36935.84 999999999 22005.65 40411.17 case rate KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC 659 MS-DRG inpatient 1 UN 40411.17 26267.26 CIGNA - ALL PLANS CIGNA - ALL PLANS 27317.95 67.6 999999999 22005.65 40411.17 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC 659 MS-DRG inpatient 1 UN 40411.17 26267.26 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 35322.95 999999999 22005.65 40411.17 case rate KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC 659 MS-DRG inpatient 1 UN 40411.17 26267.26 HUMANA - ALL PLANS HUMANA - ALL PLANS 31520.71 78 999999999 22005.65 40411.17 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC 659 MS-DRG inpatient 1 UN 40411.17 26267.26 UMR - ALL PLANS UMR - ALL PLANS 28287.82 70 999999999 22005.65 40411.17 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC 659 MS-DRG inpatient 1 UN 40411.17 26267.26 AETNA AETNA 31924.82 79 999999999 22005.65 40411.17 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC 659 MS-DRG inpatient 1 UN 40411.17 26267.26 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 39198.83 97 999999999 22005.65 40411.17 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC 659 MS-DRG inpatient 1 UN 40411.17 26267.26 SELF PAY DISCOUNT SELF PAY DISCOUNT 26267.26 65 999999999 22005.65 40411.17 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC 660 MS-DRG inpatient 1 UN 60547.61 39355.95 SELF PAY DISCOUNT SELF PAY DISCOUNT 39355.95 65 999999999 11440.15 58731.18 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC 660 MS-DRG inpatient 1 UN 60547.61 39355.95 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 18363.46 999999999 11440.15 58731.18 case rate KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC 660 MS-DRG inpatient 1 UN 60547.61 39355.95 UHC - ALL PLANS UHC - ALL PLANS 11440.15 999999999 11440.15 58731.18 case rate KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC 660 MS-DRG inpatient 1 UN 60547.61 39355.95 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 58731.18 97 999999999 11440.15 58731.18 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC 660 MS-DRG inpatient 1 UN 60547.61 39355.95 AETNA AETNA 47832.61 79 999999999 11440.15 58731.18 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC 660 MS-DRG inpatient 1 UN 60547.61 39355.95 HUMANA - ALL PLANS HUMANA - ALL PLANS 47227.13 78 999999999 11440.15 58731.18 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC 660 MS-DRG inpatient 1 UN 60547.61 39355.95 ENCORE - ALL PLANS ENCORE - ALL PLANS 41777.85 69 999999999 11440.15 58731.18 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC 660 MS-DRG inpatient 1 UN 60547.61 39355.95 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 20403.84 999999999 11440.15 58731.18 case rate KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC 660 MS-DRG inpatient 1 UN 60547.61 39355.95 ANTHEM HMO ANTHEM HMO 19201.96 999999999 11440.15 58731.18 case rate KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC 660 MS-DRG inpatient 1 UN 60547.61 39355.95 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 21604.39 999999999 11440.15 58731.18 case rate KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC 660 MS-DRG inpatient 1 UN 60547.61 39355.95 CIGNA - ALL PLANS CIGNA - ALL PLANS 40930.18 67.6 999999999 11440.15 58731.18 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC 660 MS-DRG inpatient 1 UN 60547.61 39355.95 SIHO - ALL PLANS SIHO - ALL PLANS 54492.85 90 999999999 11440.15 58731.18 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC 660 MS-DRG inpatient 1 UN 60547.61 39355.95 UMR - ALL PLANS UMR - ALL PLANS 42383.33 70 999999999 11440.15 58731.18 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC 660 MS-DRG inpatient 1 UN 60547.61 39355.95 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 36661.58 60.55 999999999 11440.15 58731.18 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC 661 MS-DRG inpatient 1 UN 33241.05 21606.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 22936.32 69 999999999 8911.4 32243.82 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC 661 MS-DRG inpatient 1 UN 33241.05 21606.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 25928.02 78 999999999 8911.4 32243.82 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC 661 MS-DRG inpatient 1 UN 33241.05 21606.68 UHC - ALL PLANS UHC - ALL PLANS 8911.4 999999999 8911.4 32243.82 case rate KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC 661 MS-DRG inpatient 1 UN 33241.05 21606.68 UMR - ALL PLANS UMR - ALL PLANS 23268.74 70 999999999 8911.4 32243.82 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC 661 MS-DRG inpatient 1 UN 33241.05 21606.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 32243.82 97 999999999 8911.4 32243.82 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC 661 MS-DRG inpatient 1 UN 33241.05 21606.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 15893.74 999999999 8911.4 32243.82 case rate KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC 661 MS-DRG inpatient 1 UN 33241.05 21606.68 ANTHEM HMO ANTHEM HMO 14957.52 999999999 8911.4 32243.82 case rate KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC 661 MS-DRG inpatient 1 UN 33241.05 21606.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 14304.37 999999999 8911.4 32243.82 case rate KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC 661 MS-DRG inpatient 1 UN 33241.05 21606.68 AETNA AETNA 26260.43 79 999999999 8911.4 32243.82 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC 661 MS-DRG inpatient 1 UN 33241.05 21606.68 SIHO - ALL PLANS SIHO - ALL PLANS 29916.95 90 999999999 8911.4 32243.82 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC 661 MS-DRG inpatient 1 UN 33241.05 21606.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 20127.46 60.55 999999999 8911.4 32243.82 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC 661 MS-DRG inpatient 1 UN 33241.05 21606.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 21606.68 65 999999999 8911.4 32243.82 percent of total billed charges KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC 661 MS-DRG inpatient 1 UN 33241.05 21606.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 16828.92 999999999 8911.4 32243.82 case rate KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC 661 MS-DRG inpatient 1 UN 33241.05 21606.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 22470.95 67.6 999999999 8911.4 32243.82 percent of total billed charges RENAL FAILURE WITH MCC 682 MS-DRG inpatient 1 UN 27360.93 17784.6 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 24090.84 999999999 12756.8 26540.1 case rate RENAL FAILURE WITH MCC 682 MS-DRG inpatient 1 UN 27360.93 17784.6 ANTHEM HMO ANTHEM HMO 21411.91 999999999 12756.8 26540.1 case rate RENAL FAILURE WITH MCC 682 MS-DRG inpatient 1 UN 27360.93 17784.6 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 22752.13 999999999 12756.8 26540.1 case rate RENAL FAILURE WITH MCC 682 MS-DRG inpatient 1 UN 27360.93 17784.6 SELF PAY DISCOUNT SELF PAY DISCOUNT 17784.61 65 999999999 12756.8 26540.1 percent of total billed charges RENAL FAILURE WITH MCC 682 MS-DRG inpatient 1 UN 27360.93 17784.6 AETNA AETNA 21615.13 79 999999999 12756.8 26540.1 percent of total billed charges RENAL FAILURE WITH MCC 682 MS-DRG inpatient 1 UN 27360.93 17784.6 SIHO - ALL PLANS SIHO - ALL PLANS 24624.84 90 999999999 12756.8 26540.1 percent of total billed charges RENAL FAILURE WITH MCC 682 MS-DRG inpatient 1 UN 27360.93 17784.6 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 20476.92 999999999 12756.8 26540.1 case rate RENAL FAILURE WITH MCC 682 MS-DRG inpatient 1 UN 27360.93 17784.6 CIGNA - ALL PLANS CIGNA - ALL PLANS 18495.99 67.6 999999999 12756.8 26540.1 percent of total billed charges RENAL FAILURE WITH MCC 682 MS-DRG inpatient 1 UN 27360.93 17784.6 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26540.1 97 999999999 12756.8 26540.1 percent of total billed charges RENAL FAILURE WITH MCC 682 MS-DRG inpatient 1 UN 27360.93 17784.6 UHC - ALL PLANS UHC - ALL PLANS 12756.8 999999999 12756.8 26540.1 case rate RENAL FAILURE WITH MCC 682 MS-DRG inpatient 1 UN 27360.93 17784.6 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16567.04 60.55 999999999 12756.8 26540.1 percent of total billed charges RENAL FAILURE WITH MCC 682 MS-DRG inpatient 1 UN 27360.93 17784.6 HUMANA - ALL PLANS HUMANA - ALL PLANS 21341.53 78 999999999 12756.8 26540.1 percent of total billed charges RENAL FAILURE WITH MCC 682 MS-DRG inpatient 1 UN 27360.93 17784.6 ENCORE - ALL PLANS ENCORE - ALL PLANS 18879.04 69 999999999 12756.8 26540.1 percent of total billed charges RENAL FAILURE WITH MCC 682 MS-DRG inpatient 1 UN 27360.93 17784.6 UMR - ALL PLANS UMR - ALL PLANS 19152.65 70 999999999 12756.8 26540.1 percent of total billed charges RENAL FAILURE WITH CC 683 MS-DRG inpatient 1 UN 32034.32 20822.31 AETNA AETNA 25307.11 79 999999999 7656.8 31073.29 percent of total billed charges RENAL FAILURE WITH CC 683 MS-DRG inpatient 1 UN 32034.32 20822.31 SIHO - ALL PLANS SIHO - ALL PLANS 28830.89 90 999999999 7656.8 31073.29 percent of total billed charges RENAL FAILURE WITH CC 683 MS-DRG inpatient 1 UN 32034.32 20822.31 ENCORE - ALL PLANS ENCORE - ALL PLANS 22103.68 69 999999999 7656.8 31073.29 percent of total billed charges RENAL FAILURE WITH CC 683 MS-DRG inpatient 1 UN 32034.32 20822.31 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 14459.64 999999999 7656.8 31073.29 case rate RENAL FAILURE WITH CC 683 MS-DRG inpatient 1 UN 32034.32 20822.31 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19396.78 60.55 999999999 7656.8 31073.29 percent of total billed charges RENAL FAILURE WITH CC 683 MS-DRG inpatient 1 UN 32034.32 20822.31 HUMANA - ALL PLANS HUMANA - ALL PLANS 24986.77 78 999999999 7656.8 31073.29 percent of total billed charges RENAL FAILURE WITH CC 683 MS-DRG inpatient 1 UN 32034.32 20822.31 UMR - ALL PLANS UMR - ALL PLANS 22424.02 70 999999999 7656.8 31073.29 percent of total billed charges RENAL FAILURE WITH CC 683 MS-DRG inpatient 1 UN 32034.32 20822.31 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31073.29 97 999999999 7656.8 31073.29 percent of total billed charges RENAL FAILURE WITH CC 683 MS-DRG inpatient 1 UN 32034.32 20822.31 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 12290.52 999999999 7656.8 31073.29 case rate RENAL FAILURE WITH CC 683 MS-DRG inpatient 1 UN 32034.32 20822.31 SELF PAY DISCOUNT SELF PAY DISCOUNT 20822.31 65 999999999 7656.8 31073.29 percent of total billed charges RENAL FAILURE WITH CC 683 MS-DRG inpatient 1 UN 32034.32 20822.31 UHC - ALL PLANS UHC - ALL PLANS 7656.8 999999999 7656.8 31073.29 case rate RENAL FAILURE WITH CC 683 MS-DRG inpatient 1 UN 32034.32 20822.31 CIGNA - ALL PLANS CIGNA - ALL PLANS 21655.2 67.6 999999999 7656.8 31073.29 percent of total billed charges RENAL FAILURE WITH CC 683 MS-DRG inpatient 1 UN 32034.32 20822.31 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13656.13 999999999 7656.8 31073.29 case rate RENAL FAILURE WITH CC 683 MS-DRG inpatient 1 UN 32034.32 20822.31 ANTHEM HMO ANTHEM HMO 12851.71 999999999 7656.8 31073.29 case rate RENAL FAILURE WITHOUT CC/MCC 684 MS-DRG inpatient 1 UN 20294.49 13191.42 CIGNA - ALL PLANS CIGNA - ALL PLANS 13719.07 67.6 999999999 5172.25 19685.65 percent of total billed charges RENAL FAILURE WITHOUT CC/MCC 684 MS-DRG inpatient 1 UN 20294.49 13191.42 ENCORE - ALL PLANS ENCORE - ALL PLANS 14003.2 69 999999999 5172.25 19685.65 percent of total billed charges RENAL FAILURE WITHOUT CC/MCC 684 MS-DRG inpatient 1 UN 20294.49 13191.42 SIHO - ALL PLANS SIHO - ALL PLANS 18265.04 90 999999999 5172.25 19685.65 percent of total billed charges RENAL FAILURE WITHOUT CC/MCC 684 MS-DRG inpatient 1 UN 20294.49 13191.42 AETNA AETNA 16032.64 79 999999999 5172.25 19685.65 percent of total billed charges RENAL FAILURE WITHOUT CC/MCC 684 MS-DRG inpatient 1 UN 20294.49 13191.42 SELF PAY DISCOUNT SELF PAY DISCOUNT 13191.42 65 999999999 5172.25 19685.65 percent of total billed charges RENAL FAILURE WITHOUT CC/MCC 684 MS-DRG inpatient 1 UN 20294.49 13191.42 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 9767.64 999999999 5172.25 19685.65 case rate RENAL FAILURE WITHOUT CC/MCC 684 MS-DRG inpatient 1 UN 20294.49 13191.42 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 9224.86 999999999 5172.25 19685.65 case rate RENAL FAILURE WITHOUT CC/MCC 684 MS-DRG inpatient 1 UN 20294.49 13191.42 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12288.31 60.55 999999999 5172.25 19685.65 percent of total billed charges RENAL FAILURE WITHOUT CC/MCC 684 MS-DRG inpatient 1 UN 20294.49 13191.42 ANTHEM HMO ANTHEM HMO 8681.47 999999999 5172.25 19685.65 case rate RENAL FAILURE WITHOUT CC/MCC 684 MS-DRG inpatient 1 UN 20294.49 13191.42 UHC - ALL PLANS UHC - ALL PLANS 5172.25 999999999 5172.25 19685.65 case rate RENAL FAILURE WITHOUT CC/MCC 684 MS-DRG inpatient 1 UN 20294.49 13191.42 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 8302.37 999999999 5172.25 19685.65 case rate RENAL FAILURE WITHOUT CC/MCC 684 MS-DRG inpatient 1 UN 20294.49 13191.42 HUMANA - ALL PLANS HUMANA - ALL PLANS 15829.7 78 999999999 5172.25 19685.65 percent of total billed charges RENAL FAILURE WITHOUT CC/MCC 684 MS-DRG inpatient 1 UN 20294.49 13191.42 UMR - ALL PLANS UMR - ALL PLANS 14206.14 70 999999999 5172.25 19685.65 percent of total billed charges RENAL FAILURE WITHOUT CC/MCC 684 MS-DRG inpatient 1 UN 20294.49 13191.42 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 19685.65 97 999999999 5172.25 19685.65 percent of total billed charges KIDNEY AND URINARY TRACT INFECTIONS WITH MCC 689 MS-DRG inpatient 1 UN 26172.12 17011.88 HUMANA - ALL PLANS HUMANA - ALL PLANS 20414.26 78 999999999 9982.4 25386.96 percent of total billed charges KIDNEY AND URINARY TRACT INFECTIONS WITH MCC 689 MS-DRG inpatient 1 UN 26172.12 17011.88 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15847.22 60.55 999999999 9982.4 25386.96 percent of total billed charges KIDNEY AND URINARY TRACT INFECTIONS WITH MCC 689 MS-DRG inpatient 1 UN 26172.12 17011.88 SIHO - ALL PLANS SIHO - ALL PLANS 23554.91 90 999999999 9982.4 25386.96 percent of total billed charges KIDNEY AND URINARY TRACT INFECTIONS WITH MCC 689 MS-DRG inpatient 1 UN 26172.12 17011.88 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25386.96 97 999999999 9982.4 25386.96 percent of total billed charges KIDNEY AND URINARY TRACT INFECTIONS WITH MCC 689 MS-DRG inpatient 1 UN 26172.12 17011.88 UMR - ALL PLANS UMR - ALL PLANS 18320.49 70 999999999 9982.4 25386.96 percent of total billed charges KIDNEY AND URINARY TRACT INFECTIONS WITH MCC 689 MS-DRG inpatient 1 UN 26172.12 17011.88 CIGNA - ALL PLANS CIGNA - ALL PLANS 17692.36 67.6 999999999 9982.4 25386.96 percent of total billed charges KIDNEY AND URINARY TRACT INFECTIONS WITH MCC 689 MS-DRG inpatient 1 UN 26172.12 17011.88 UHC - ALL PLANS UHC - ALL PLANS 9982.4 999999999 9982.4 25386.96 case rate KIDNEY AND URINARY TRACT INFECTIONS WITH MCC 689 MS-DRG inpatient 1 UN 26172.12 17011.88 ENCORE - ALL PLANS ENCORE - ALL PLANS 18058.77 69 999999999 9982.4 25386.96 percent of total billed charges KIDNEY AND URINARY TRACT INFECTIONS WITH MCC 689 MS-DRG inpatient 1 UN 26172.12 17011.88 AETNA AETNA 20675.98 79 999999999 9982.4 25386.96 percent of total billed charges KIDNEY AND URINARY TRACT INFECTIONS WITH MCC 689 MS-DRG inpatient 1 UN 26172.12 17011.88 SELF PAY DISCOUNT SELF PAY DISCOUNT 17011.88 65 999999999 9982.4 25386.96 percent of total billed charges KIDNEY AND URINARY TRACT INFECTIONS WITH MCC 689 MS-DRG inpatient 1 UN 26172.12 17011.88 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 18851.47 999999999 9982.4 25386.96 case rate KIDNEY AND URINARY TRACT INFECTIONS WITH MCC 689 MS-DRG inpatient 1 UN 26172.12 17011.88 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 17803.9 999999999 9982.4 25386.96 case rate KIDNEY AND URINARY TRACT INFECTIONS WITH MCC 689 MS-DRG inpatient 1 UN 26172.12 17011.88 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 16023.51 999999999 9982.4 25386.96 case rate KIDNEY AND URINARY TRACT INFECTIONS WITH MCC 689 MS-DRG inpatient 1 UN 26172.12 17011.88 ANTHEM HMO ANTHEM HMO 16755.16 999999999 9982.4 25386.96 case rate KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC 690 MS-DRG inpatient 1 UN 23839.88 15495.92 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12952.36 999999999 6858.65 23124.68 case rate KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC 690 MS-DRG inpatient 1 UN 23839.88 15495.92 CIGNA - ALL PLANS CIGNA - ALL PLANS 16115.76 67.6 999999999 6858.65 23124.68 percent of total billed charges KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC 690 MS-DRG inpatient 1 UN 23839.88 15495.92 SELF PAY DISCOUNT SELF PAY DISCOUNT 15495.92 65 999999999 6858.65 23124.68 percent of total billed charges KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC 690 MS-DRG inpatient 1 UN 23839.88 15495.92 ENCORE - ALL PLANS ENCORE - ALL PLANS 16449.52 69 999999999 6858.65 23124.68 percent of total billed charges KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC 690 MS-DRG inpatient 1 UN 23839.88 15495.92 HUMANA - ALL PLANS HUMANA - ALL PLANS 18595.11 78 999999999 6858.65 23124.68 percent of total billed charges KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC 690 MS-DRG inpatient 1 UN 23839.88 15495.92 AETNA AETNA 18833.51 79 999999999 6858.65 23124.68 percent of total billed charges KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC 690 MS-DRG inpatient 1 UN 23839.88 15495.92 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 23124.68 97 999999999 6858.65 23124.68 percent of total billed charges KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC 690 MS-DRG inpatient 1 UN 23839.88 15495.92 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 12232.6 999999999 6858.65 23124.68 case rate KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC 690 MS-DRG inpatient 1 UN 23839.88 15495.92 ANTHEM HMO ANTHEM HMO 11512.04 999999999 6858.65 23124.68 case rate KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC 690 MS-DRG inpatient 1 UN 23839.88 15495.92 UHC - ALL PLANS UHC - ALL PLANS 6858.65 999999999 6858.65 23124.68 case rate KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC 690 MS-DRG inpatient 1 UN 23839.88 15495.92 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 11009.34 999999999 6858.65 23124.68 case rate KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC 690 MS-DRG inpatient 1 UN 23839.88 15495.92 SIHO - ALL PLANS SIHO - ALL PLANS 21455.89 90 999999999 6858.65 23124.68 percent of total billed charges KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC 690 MS-DRG inpatient 1 UN 23839.88 15495.92 UMR - ALL PLANS UMR - ALL PLANS 16687.92 70 999999999 6858.65 23124.68 percent of total billed charges KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC 690 MS-DRG inpatient 1 UN 23839.88 15495.92 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14435.05 60.55 999999999 6858.65 23124.68 percent of total billed charges URINARY STONES WITHOUT MCC 694 MS-DRG inpatient 1 UN 15325.5 9961.58 UHC - ALL PLANS UHC - ALL PLANS 6652.95 999999999 6652.95 14865.74 case rate URINARY STONES WITHOUT MCC 694 MS-DRG inpatient 1 UN 15325.5 9961.58 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9279.59 60.55 999999999 6652.95 14865.74 percent of total billed charges URINARY STONES WITHOUT MCC 694 MS-DRG inpatient 1 UN 15325.5 9961.58 UMR - ALL PLANS UMR - ALL PLANS 10727.85 70 999999999 6652.95 14865.74 percent of total billed charges URINARY STONES WITHOUT MCC 694 MS-DRG inpatient 1 UN 15325.5 9961.58 HUMANA - ALL PLANS HUMANA - ALL PLANS 11953.89 78 999999999 6652.95 14865.74 percent of total billed charges URINARY STONES WITHOUT MCC 694 MS-DRG inpatient 1 UN 15325.5 9961.58 ENCORE - ALL PLANS ENCORE - ALL PLANS 10574.6 69 999999999 6652.95 14865.74 percent of total billed charges URINARY STONES WITHOUT MCC 694 MS-DRG inpatient 1 UN 15325.5 9961.58 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14865.74 97 999999999 6652.95 14865.74 percent of total billed charges URINARY STONES WITHOUT MCC 694 MS-DRG inpatient 1 UN 15325.5 9961.58 CIGNA - ALL PLANS CIGNA - ALL PLANS 10360.04 67.6 999999999 6652.95 14865.74 percent of total billed charges URINARY STONES WITHOUT MCC 694 MS-DRG inpatient 1 UN 15325.5 9961.58 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10679.16 999999999 6652.95 14865.74 case rate URINARY STONES WITHOUT MCC 694 MS-DRG inpatient 1 UN 15325.5 9961.58 SIHO - ALL PLANS SIHO - ALL PLANS 13792.95 90 999999999 6652.95 14865.74 percent of total billed charges URINARY STONES WITHOUT MCC 694 MS-DRG inpatient 1 UN 15325.5 9961.58 AETNA AETNA 12107.15 79 999999999 6652.95 14865.74 percent of total billed charges URINARY STONES WITHOUT MCC 694 MS-DRG inpatient 1 UN 15325.5 9961.58 SELF PAY DISCOUNT SELF PAY DISCOUNT 9961.58 65 999999999 6652.95 14865.74 percent of total billed charges URINARY STONES WITHOUT MCC 694 MS-DRG inpatient 1 UN 15325.5 9961.58 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12563.9 999999999 6652.95 14865.74 case rate URINARY STONES WITHOUT MCC 694 MS-DRG inpatient 1 UN 15325.5 9961.58 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 11865.73 999999999 6652.95 14865.74 case rate URINARY STONES WITHOUT MCC 694 MS-DRG inpatient 1 UN 15325.5 9961.58 ANTHEM HMO ANTHEM HMO 11166.78 999999999 6652.95 14865.74 case rate OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC 698 MS-DRG inpatient 1 UN 21996.36 14297.64 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 21996.36 999999999 13318.8 21996.36 case rate OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC 698 MS-DRG inpatient 1 UN 21996.36 14297.64 SELF PAY DISCOUNT SELF PAY DISCOUNT 14297.64 65 999999999 13318.8 21996.36 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC 698 MS-DRG inpatient 1 UN 21996.36 14297.64 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 21996.36 999999999 13318.8 21996.36 case rate OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC 698 MS-DRG inpatient 1 UN 21996.36 14297.64 ANTHEM HMO ANTHEM HMO 21996.36 999999999 13318.8 21996.36 case rate OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC 698 MS-DRG inpatient 1 UN 21996.36 14297.64 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21336.47 97 999999999 13318.8 21996.36 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC 698 MS-DRG inpatient 1 UN 21996.36 14297.64 UHC - ALL PLANS UHC - ALL PLANS 14062.4 999999999 13318.8 21996.36 case rate OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC 698 MS-DRG inpatient 1 UN 21996.36 14297.64 ENCORE - ALL PLANS ENCORE - ALL PLANS 15177.49 69 999999999 13318.8 21996.36 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC 698 MS-DRG inpatient 1 UN 21996.36 14297.64 HUMANA - ALL PLANS HUMANA - ALL PLANS 17157.16 78 999999999 13318.8 21996.36 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC 698 MS-DRG inpatient 1 UN 21996.36 14297.64 UMR - ALL PLANS UMR - ALL PLANS 15397.45 70 999999999 13318.8 21996.36 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC 698 MS-DRG inpatient 1 UN 21996.36 14297.64 CIGNA - ALL PLANS CIGNA - ALL PLANS 14869.54 67.6 999999999 13318.8 21996.36 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC 698 MS-DRG inpatient 1 UN 21996.36 14297.64 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 21996.36 999999999 13318.8 21996.36 case rate OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC 698 MS-DRG inpatient 1 UN 21996.36 14297.64 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13318.8 60.55 999999999 13318.8 21996.36 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC 698 MS-DRG inpatient 1 UN 21996.36 14297.64 AETNA AETNA 17377.13 79 999999999 13318.8 21996.36 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC 698 MS-DRG inpatient 1 UN 21996.36 14297.64 SIHO - ALL PLANS SIHO - ALL PLANS 19796.73 90 999999999 13318.8 21996.36 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC 699 MS-DRG inpatient 1 UN 15034.07 9772.15 AETNA AETNA 11876.92 79 999999999 8676.8 15034.07 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC 699 MS-DRG inpatient 1 UN 15034.07 9772.15 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 15034.07 999999999 8676.8 15034.07 case rate OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC 699 MS-DRG inpatient 1 UN 15034.07 9772.15 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 15034.07 999999999 8676.8 15034.07 case rate OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC 699 MS-DRG inpatient 1 UN 15034.07 9772.15 HUMANA - ALL PLANS HUMANA - ALL PLANS 11726.57 78 999999999 8676.8 15034.07 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC 699 MS-DRG inpatient 1 UN 15034.07 9772.15 ENCORE - ALL PLANS ENCORE - ALL PLANS 10373.51 69 999999999 8676.8 15034.07 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC 699 MS-DRG inpatient 1 UN 15034.07 9772.15 SIHO - ALL PLANS SIHO - ALL PLANS 13530.66 90 999999999 8676.8 15034.07 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC 699 MS-DRG inpatient 1 UN 15034.07 9772.15 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9103.13 60.55 999999999 8676.8 15034.07 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC 699 MS-DRG inpatient 1 UN 15034.07 9772.15 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14583.05 97 999999999 8676.8 15034.07 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC 699 MS-DRG inpatient 1 UN 15034.07 9772.15 UHC - ALL PLANS UHC - ALL PLANS 8676.8 999999999 8676.8 15034.07 case rate OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC 699 MS-DRG inpatient 1 UN 15034.07 9772.15 UMR - ALL PLANS UMR - ALL PLANS 10523.85 70 999999999 8676.8 15034.07 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC 699 MS-DRG inpatient 1 UN 15034.07 9772.15 ANTHEM HMO ANTHEM HMO 14563.75 999999999 8676.8 15034.07 case rate OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC 699 MS-DRG inpatient 1 UN 15034.07 9772.15 CIGNA - ALL PLANS CIGNA - ALL PLANS 10163.03 67.6 999999999 8676.8 15034.07 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC 699 MS-DRG inpatient 1 UN 15034.07 9772.15 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 13927.8 999999999 8676.8 15034.07 case rate OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC 699 MS-DRG inpatient 1 UN 15034.07 9772.15 SELF PAY DISCOUNT SELF PAY DISCOUNT 9772.15 65 999999999 8676.8 15034.07 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC 700 MS-DRG inpatient 1 UN 21355.9 13881.34 ANTHEM HMO ANTHEM HMO 10105.32 999999999 6020.55 20715.22 case rate OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC 700 MS-DRG inpatient 1 UN 21355.9 13881.34 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 10737.83 999999999 6020.55 20715.22 case rate OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC 700 MS-DRG inpatient 1 UN 21355.9 13881.34 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 9664.05 999999999 6020.55 20715.22 case rate OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC 700 MS-DRG inpatient 1 UN 21355.9 13881.34 CIGNA - ALL PLANS CIGNA - ALL PLANS 14436.59 67.6 999999999 6020.55 20715.22 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC 700 MS-DRG inpatient 1 UN 21355.9 13881.34 SIHO - ALL PLANS SIHO - ALL PLANS 19220.31 90 999999999 6020.55 20715.22 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC 700 MS-DRG inpatient 1 UN 21355.9 13881.34 UHC - ALL PLANS UHC - ALL PLANS 6020.55 999999999 6020.55 20715.22 case rate OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC 700 MS-DRG inpatient 1 UN 21355.9 13881.34 AETNA AETNA 16871.16 79 999999999 6020.55 20715.22 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC 700 MS-DRG inpatient 1 UN 21355.9 13881.34 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 11369.63 999999999 6020.55 20715.22 case rate OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC 700 MS-DRG inpatient 1 UN 21355.9 13881.34 SELF PAY DISCOUNT SELF PAY DISCOUNT 13881.34 65 999999999 6020.55 20715.22 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC 700 MS-DRG inpatient 1 UN 21355.9 13881.34 ENCORE - ALL PLANS ENCORE - ALL PLANS 14735.57 69 999999999 6020.55 20715.22 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC 700 MS-DRG inpatient 1 UN 21355.9 13881.34 HUMANA - ALL PLANS HUMANA - ALL PLANS 16657.6 78 999999999 6020.55 20715.22 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC 700 MS-DRG inpatient 1 UN 21355.9 13881.34 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 12931 60.55 999999999 6020.55 20715.22 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC 700 MS-DRG inpatient 1 UN 21355.9 13881.34 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 20715.22 97 999999999 6020.55 20715.22 percent of total billed charges OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC 700 MS-DRG inpatient 1 UN 21355.9 13881.34 UMR - ALL PLANS UMR - ALL PLANS 14949.13 70 999999999 6020.55 20715.22 percent of total billed charges BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC 726 MS-DRG inpatient 1 UN 32106.5 20869.23 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19440.49 60.55 999999999 6212.65 31143.31 percent of total billed charges BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC 726 MS-DRG inpatient 1 UN 32106.5 20869.23 UHC - ALL PLANS UHC - ALL PLANS 6212.65 999999999 6212.65 31143.31 case rate BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC 726 MS-DRG inpatient 1 UN 32106.5 20869.23 HUMANA - ALL PLANS HUMANA - ALL PLANS 25043.07 78 999999999 6212.65 31143.31 percent of total billed charges BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC 726 MS-DRG inpatient 1 UN 32106.5 20869.23 ENCORE - ALL PLANS ENCORE - ALL PLANS 22153.49 69 999999999 6212.65 31143.31 percent of total billed charges BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC 726 MS-DRG inpatient 1 UN 32106.5 20869.23 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 31143.31 97 999999999 6212.65 31143.31 percent of total billed charges BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC 726 MS-DRG inpatient 1 UN 32106.5 20869.23 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 11080.44 999999999 6212.65 31143.31 case rate BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC 726 MS-DRG inpatient 1 UN 32106.5 20869.23 ANTHEM HMO ANTHEM HMO 10427.75 999999999 6212.65 31143.31 case rate BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC 726 MS-DRG inpatient 1 UN 32106.5 20869.23 SIHO - ALL PLANS SIHO - ALL PLANS 28895.85 90 999999999 6212.65 31143.31 percent of total billed charges BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC 726 MS-DRG inpatient 1 UN 32106.5 20869.23 AETNA AETNA 25364.14 79 999999999 6212.65 31143.31 percent of total billed charges BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC 726 MS-DRG inpatient 1 UN 32106.5 20869.23 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 9972.4 999999999 6212.65 31143.31 case rate BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC 726 MS-DRG inpatient 1 UN 32106.5 20869.23 CIGNA - ALL PLANS CIGNA - ALL PLANS 21703.99 67.6 999999999 6212.65 31143.31 percent of total billed charges BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC 726 MS-DRG inpatient 1 UN 32106.5 20869.23 SELF PAY DISCOUNT SELF PAY DISCOUNT 20869.23 65 999999999 6212.65 31143.31 percent of total billed charges BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC 726 MS-DRG inpatient 1 UN 32106.5 20869.23 UMR - ALL PLANS UMR - ALL PLANS 22474.55 70 999999999 6212.65 31143.31 percent of total billed charges BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC 726 MS-DRG inpatient 1 UN 32106.5 20869.23 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 11732.41 999999999 6212.65 31143.31 case rate INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC 727 MS-DRG inpatient 1 UN 48314.19 31404.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 32660.39 67.6 999999999 13778.5 46864.76 percent of total billed charges INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC 727 MS-DRG inpatient 1 UN 48314.19 31404.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 22116.92 999999999 13778.5 46864.76 case rate INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC 727 MS-DRG inpatient 1 UN 48314.19 31404.22 ANTHEM HMO ANTHEM HMO 23126.81 999999999 13778.5 46864.76 case rate INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC 727 MS-DRG inpatient 1 UN 48314.19 31404.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 24574.36 999999999 13778.5 46864.76 case rate INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC 727 MS-DRG inpatient 1 UN 48314.19 31404.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 26020.29 999999999 13778.5 46864.76 case rate INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC 727 MS-DRG inpatient 1 UN 48314.19 31404.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 37685.07 78 999999999 13778.5 46864.76 percent of total billed charges INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC 727 MS-DRG inpatient 1 UN 48314.19 31404.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 31404.22 65 999999999 13778.5 46864.76 percent of total billed charges INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC 727 MS-DRG inpatient 1 UN 48314.19 31404.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29254.24 60.55 999999999 13778.5 46864.76 percent of total billed charges INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC 727 MS-DRG inpatient 1 UN 48314.19 31404.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 46864.76 97 999999999 13778.5 46864.76 percent of total billed charges INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC 727 MS-DRG inpatient 1 UN 48314.19 31404.22 UHC - ALL PLANS UHC - ALL PLANS 13778.5 999999999 13778.5 46864.76 case rate INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC 727 MS-DRG inpatient 1 UN 48314.19 31404.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 33336.79 69 999999999 13778.5 46864.76 percent of total billed charges INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC 727 MS-DRG inpatient 1 UN 48314.19 31404.22 AETNA AETNA 38168.21 79 999999999 13778.5 46864.76 percent of total billed charges INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC 727 MS-DRG inpatient 1 UN 48314.19 31404.22 UMR - ALL PLANS UMR - ALL PLANS 33819.93 70 999999999 13778.5 46864.76 percent of total billed charges INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC 727 MS-DRG inpatient 1 UN 48314.19 31404.22 SIHO - ALL PLANS SIHO - ALL PLANS 43482.77 90 999999999 13778.5 46864.76 percent of total billed charges INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC 728 MS-DRG inpatient 1 UN 35546.92 23105.5 SIHO - ALL PLANS SIHO - ALL PLANS 31992.23 90 999999999 6800.85 34480.51 percent of total billed charges INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC 728 MS-DRG inpatient 1 UN 35546.92 23105.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34480.51 97 999999999 6800.85 34480.51 percent of total billed charges INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC 728 MS-DRG inpatient 1 UN 35546.92 23105.5 UMR - ALL PLANS UMR - ALL PLANS 24882.84 70 999999999 6800.85 34480.51 percent of total billed charges INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC 728 MS-DRG inpatient 1 UN 35546.92 23105.5 UHC - ALL PLANS UHC - ALL PLANS 6800.85 999999999 6800.85 34480.51 case rate INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC 728 MS-DRG inpatient 1 UN 35546.92 23105.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10916.56 999999999 6800.85 34480.51 case rate INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC 728 MS-DRG inpatient 1 UN 35546.92 23105.5 ANTHEM HMO ANTHEM HMO 11415.03 999999999 6800.85 34480.51 case rate INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC 728 MS-DRG inpatient 1 UN 35546.92 23105.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21523.66 60.55 999999999 6800.85 34480.51 percent of total billed charges INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC 728 MS-DRG inpatient 1 UN 35546.92 23105.5 AETNA AETNA 28082.07 79 999999999 6800.85 34480.51 percent of total billed charges INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC 728 MS-DRG inpatient 1 UN 35546.92 23105.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 23105.5 65 999999999 6800.85 34480.51 percent of total billed charges INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC 728 MS-DRG inpatient 1 UN 35546.92 23105.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 27726.6 78 999999999 6800.85 34480.51 percent of total billed charges INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC 728 MS-DRG inpatient 1 UN 35546.92 23105.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 24527.37 69 999999999 6800.85 34480.51 percent of total billed charges INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC 728 MS-DRG inpatient 1 UN 35546.92 23105.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 12129.52 999999999 6800.85 34480.51 case rate INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC 728 MS-DRG inpatient 1 UN 35546.92 23105.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12843.21 999999999 6800.85 34480.51 case rate INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC 728 MS-DRG inpatient 1 UN 35546.92 23105.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 24029.72 67.6 999999999 6800.85 34480.51 percent of total billed charges UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC 742 MS-DRG inpatient 1 UN 87461.04 56849.68 ANTHEM HMO ANTHEM HMO 25422.37 999999999 15146.15 84837.21 case rate UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC 742 MS-DRG inpatient 1 UN 87461.04 56849.68 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 24312.24 999999999 15146.15 84837.21 case rate UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC 742 MS-DRG inpatient 1 UN 87461.04 56849.68 CIGNA - ALL PLANS CIGNA - ALL PLANS 59123.66 67.6 999999999 15146.15 84837.21 percent of total billed charges UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC 742 MS-DRG inpatient 1 UN 87461.04 56849.68 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 28603.06 999999999 15146.15 84837.21 case rate UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC 742 MS-DRG inpatient 1 UN 87461.04 56849.68 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 27013.6 999999999 15146.15 84837.21 case rate UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC 742 MS-DRG inpatient 1 UN 87461.04 56849.68 HUMANA - ALL PLANS HUMANA - ALL PLANS 68219.61 78 999999999 15146.15 84837.21 percent of total billed charges UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC 742 MS-DRG inpatient 1 UN 87461.04 56849.68 UHC - ALL PLANS UHC - ALL PLANS 15146.15 999999999 15146.15 84837.21 case rate UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC 742 MS-DRG inpatient 1 UN 87461.04 56849.68 SELF PAY DISCOUNT SELF PAY DISCOUNT 56849.68 65 999999999 15146.15 84837.21 percent of total billed charges UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC 742 MS-DRG inpatient 1 UN 87461.04 56849.68 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 84837.21 97 999999999 15146.15 84837.21 percent of total billed charges UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC 742 MS-DRG inpatient 1 UN 87461.04 56849.68 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 52957.66 60.55 999999999 15146.15 84837.21 percent of total billed charges UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC 742 MS-DRG inpatient 1 UN 87461.04 56849.68 ENCORE - ALL PLANS ENCORE - ALL PLANS 60348.12 69 999999999 15146.15 84837.21 percent of total billed charges UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC 742 MS-DRG inpatient 1 UN 87461.04 56849.68 SIHO - ALL PLANS SIHO - ALL PLANS 78714.94 90 999999999 15146.15 84837.21 percent of total billed charges UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC 742 MS-DRG inpatient 1 UN 87461.04 56849.68 UMR - ALL PLANS UMR - ALL PLANS 61222.73 70 999999999 15146.15 84837.21 percent of total billed charges UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC 742 MS-DRG inpatient 1 UN 87461.04 56849.68 AETNA AETNA 69094.22 79 999999999 15146.15 84837.21 percent of total billed charges UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC 743 MS-DRG inpatient 1 UN 39981.82 25988.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 27587.45 69 999999999 9877 38782.36 percent of total billed charges UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC 743 MS-DRG inpatient 1 UN 39981.82 25988.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 24208.99 60.55 999999999 9877 38782.36 percent of total billed charges UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC 743 MS-DRG inpatient 1 UN 39981.82 25988.18 UHC - ALL PLANS UHC - ALL PLANS 9877 999999999 9877 38782.36 case rate UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC 743 MS-DRG inpatient 1 UN 39981.82 25988.18 SIHO - ALL PLANS SIHO - ALL PLANS 35983.63 90 999999999 9877 38782.36 percent of total billed charges UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC 743 MS-DRG inpatient 1 UN 39981.82 25988.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 18652.42 999999999 9877 38782.36 case rate UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC 743 MS-DRG inpatient 1 UN 39981.82 25988.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 17615.92 999999999 9877 38782.36 case rate UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC 743 MS-DRG inpatient 1 UN 39981.82 25988.18 ANTHEM HMO ANTHEM HMO 16578.25 999999999 9877 38782.36 case rate UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC 743 MS-DRG inpatient 1 UN 39981.82 25988.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 27027.71 67.6 999999999 9877 38782.36 percent of total billed charges UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC 743 MS-DRG inpatient 1 UN 39981.82 25988.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 15854.33 999999999 9877 38782.36 case rate UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC 743 MS-DRG inpatient 1 UN 39981.82 25988.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 31185.82 78 999999999 9877 38782.36 percent of total billed charges UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC 743 MS-DRG inpatient 1 UN 39981.82 25988.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 38782.36 97 999999999 9877 38782.36 percent of total billed charges UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC 743 MS-DRG inpatient 1 UN 39981.82 25988.18 UMR - ALL PLANS UMR - ALL PLANS 27987.27 70 999999999 9877 38782.36 percent of total billed charges UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC 743 MS-DRG inpatient 1 UN 39981.82 25988.18 AETNA AETNA 31585.63 79 999999999 9877 38782.36 percent of total billed charges UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC 743 MS-DRG inpatient 1 UN 39981.82 25988.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 25988.18 65 999999999 9877 38782.36 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC" 757 MS-DRG inpatient 1 UN 31699.23 20604.5 SELF PAY DISCOUNT SELF PAY DISCOUNT 20604.5 65 999999999 12678.6 30748.25 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC" 757 MS-DRG inpatient 1 UN 31699.23 20604.5 AETNA AETNA 25042.39 79 999999999 12678.6 30748.25 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC" 757 MS-DRG inpatient 1 UN 31699.23 20604.5 UMR - ALL PLANS UMR - ALL PLANS 22189.46 70 999999999 12678.6 30748.25 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC" 757 MS-DRG inpatient 1 UN 31699.23 20604.5 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30748.25 97 999999999 12678.6 30748.25 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC" 757 MS-DRG inpatient 1 UN 31699.23 20604.5 HUMANA - ALL PLANS HUMANA - ALL PLANS 24725.4 78 999999999 12678.6 30748.25 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC" 757 MS-DRG inpatient 1 UN 31699.23 20604.5 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 20351.39 999999999 12678.6 30748.25 case rate "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC" 757 MS-DRG inpatient 1 UN 31699.23 20604.5 CIGNA - ALL PLANS CIGNA - ALL PLANS 21428.68 67.6 999999999 12678.6 30748.25 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC" 757 MS-DRG inpatient 1 UN 31699.23 20604.5 ANTHEM HMO ANTHEM HMO 21280.66 999999999 12678.6 30748.25 case rate "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC" 757 MS-DRG inpatient 1 UN 31699.23 20604.5 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 22612.66 999999999 12678.6 30748.25 case rate "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC" 757 MS-DRG inpatient 1 UN 31699.23 20604.5 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 23943.16 999999999 12678.6 30748.25 case rate "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC" 757 MS-DRG inpatient 1 UN 31699.23 20604.5 SIHO - ALL PLANS SIHO - ALL PLANS 28529.31 90 999999999 12678.6 30748.25 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC" 757 MS-DRG inpatient 1 UN 31699.23 20604.5 UHC - ALL PLANS UHC - ALL PLANS 12678.6 999999999 12678.6 30748.25 case rate "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC" 757 MS-DRG inpatient 1 UN 31699.23 20604.5 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 19193.88 60.55 999999999 12678.6 30748.25 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC" 757 MS-DRG inpatient 1 UN 31699.23 20604.5 ENCORE - ALL PLANS ENCORE - ALL PLANS 21872.47 69 999999999 12678.6 30748.25 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC" 758 MS-DRG inpatient 1 UN 29092.33 18910.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 28219.56 97 999999999 8437.1 28219.56 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC" 758 MS-DRG inpatient 1 UN 29092.33 18910.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17615.41 60.55 999999999 8437.1 28219.56 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC" 758 MS-DRG inpatient 1 UN 29092.33 18910.01 UMR - ALL PLANS UMR - ALL PLANS 20364.63 70 999999999 8437.1 28219.56 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC" 758 MS-DRG inpatient 1 UN 29092.33 18910.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 20073.71 69 999999999 8437.1 28219.56 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC" 758 MS-DRG inpatient 1 UN 29092.33 18910.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 22692.02 78 999999999 8437.1 28219.56 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC" 758 MS-DRG inpatient 1 UN 29092.33 18910.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 19666.42 67.6 999999999 8437.1 28219.56 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC" 758 MS-DRG inpatient 1 UN 29092.33 18910.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 15933.22 999999999 8437.1 28219.56 case rate "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC" 758 MS-DRG inpatient 1 UN 29092.33 18910.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 18910.01 65 999999999 8437.1 28219.56 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC" 758 MS-DRG inpatient 1 UN 29092.33 18910.01 AETNA AETNA 22982.94 79 999999999 8437.1 28219.56 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC" 758 MS-DRG inpatient 1 UN 29092.33 18910.01 UHC - ALL PLANS UHC - ALL PLANS 8437.1 999999999 8437.1 28219.56 case rate "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC" 758 MS-DRG inpatient 1 UN 29092.33 18910.01 SIHO - ALL PLANS SIHO - ALL PLANS 26183.1 90 999999999 8437.1 28219.56 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC" 758 MS-DRG inpatient 1 UN 29092.33 18910.01 ANTHEM HMO ANTHEM HMO 14161.42 999999999 8437.1 28219.56 case rate "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC" 758 MS-DRG inpatient 1 UN 29092.33 18910.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 15047.82 999999999 8437.1 28219.56 case rate "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC" 758 MS-DRG inpatient 1 UN 29092.33 18910.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 13543.03 999999999 8437.1 28219.56 case rate "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC" 759 MS-DRG inpatient 1 UN 35238.45 22904.99 ANTHEM HMO ANTHEM HMO 9219.34 999999999 5492.7 34181.3 case rate "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC" 759 MS-DRG inpatient 1 UN 35238.45 22904.99 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 9796.39 999999999 5492.7 34181.3 case rate "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC" 759 MS-DRG inpatient 1 UN 35238.45 22904.99 CIGNA - ALL PLANS CIGNA - ALL PLANS 23821.19 67.6 999999999 5492.7 34181.3 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC" 759 MS-DRG inpatient 1 UN 35238.45 22904.99 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 10372.8 999999999 5492.7 34181.3 case rate "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC" 759 MS-DRG inpatient 1 UN 35238.45 22904.99 HUMANA - ALL PLANS HUMANA - ALL PLANS 27485.99 78 999999999 5492.7 34181.3 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC" 759 MS-DRG inpatient 1 UN 35238.45 22904.99 ENCORE - ALL PLANS ENCORE - ALL PLANS 24314.53 69 999999999 5492.7 34181.3 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC" 759 MS-DRG inpatient 1 UN 35238.45 22904.99 SELF PAY DISCOUNT SELF PAY DISCOUNT 22904.99 65 999999999 5492.7 34181.3 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC" 759 MS-DRG inpatient 1 UN 35238.45 22904.99 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34181.3 97 999999999 5492.7 34181.3 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC" 759 MS-DRG inpatient 1 UN 35238.45 22904.99 UHC - ALL PLANS UHC - ALL PLANS 5492.7 999999999 5492.7 34181.3 case rate "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC" 759 MS-DRG inpatient 1 UN 35238.45 22904.99 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 8816.75 999999999 5492.7 34181.3 case rate "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC" 759 MS-DRG inpatient 1 UN 35238.45 22904.99 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21336.88 60.55 999999999 5492.7 34181.3 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC" 759 MS-DRG inpatient 1 UN 35238.45 22904.99 UMR - ALL PLANS UMR - ALL PLANS 24666.92 70 999999999 5492.7 34181.3 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC" 759 MS-DRG inpatient 1 UN 35238.45 22904.99 SIHO - ALL PLANS SIHO - ALL PLANS 31714.61 90 999999999 5492.7 34181.3 percent of total billed charges "INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC" 759 MS-DRG inpatient 1 UN 35238.45 22904.99 AETNA AETNA 27838.38 79 999999999 5492.7 34181.3 percent of total billed charges POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES 776 MS-DRG inpatient 1 UN 22430.07 14579.55 UMR - ALL PLANS UMR - ALL PLANS 15701.05 70 999999999 6091.95 21757.17 percent of total billed charges POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES 776 MS-DRG inpatient 1 UN 22430.07 14579.55 ENCORE - ALL PLANS ENCORE - ALL PLANS 15476.75 69 999999999 6091.95 21757.17 percent of total billed charges POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES 776 MS-DRG inpatient 1 UN 22430.07 14579.55 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13581.41 60.55 999999999 6091.95 21757.17 percent of total billed charges POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES 776 MS-DRG inpatient 1 UN 22430.07 14579.55 SIHO - ALL PLANS SIHO - ALL PLANS 20187.07 90 999999999 6091.95 21757.17 percent of total billed charges POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES 776 MS-DRG inpatient 1 UN 22430.07 14579.55 UHC - ALL PLANS UHC - ALL PLANS 6091.95 999999999 6091.95 21757.17 case rate POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES 776 MS-DRG inpatient 1 UN 22430.07 14579.55 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21757.17 97 999999999 6091.95 21757.17 percent of total billed charges POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES 776 MS-DRG inpatient 1 UN 22430.07 14579.55 ANTHEM HMO ANTHEM HMO 10225.16 999999999 6091.95 21757.17 case rate POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES 776 MS-DRG inpatient 1 UN 22430.07 14579.55 CIGNA - ALL PLANS CIGNA - ALL PLANS 15162.73 67.6 999999999 6091.95 21757.17 percent of total billed charges POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES 776 MS-DRG inpatient 1 UN 22430.07 14579.55 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 10865.17 999999999 6091.95 21757.17 case rate POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES 776 MS-DRG inpatient 1 UN 22430.07 14579.55 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 9778.65 999999999 6091.95 21757.17 case rate POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES 776 MS-DRG inpatient 1 UN 22430.07 14579.55 SELF PAY DISCOUNT SELF PAY DISCOUNT 14579.55 65 999999999 6091.95 21757.17 percent of total billed charges POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES 776 MS-DRG inpatient 1 UN 22430.07 14579.55 HUMANA - ALL PLANS HUMANA - ALL PLANS 17495.46 78 999999999 6091.95 21757.17 percent of total billed charges POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES 776 MS-DRG inpatient 1 UN 22430.07 14579.55 AETNA AETNA 17719.76 79 999999999 6091.95 21757.17 percent of total billed charges POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES 776 MS-DRG inpatient 1 UN 22430.07 14579.55 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 11504.47 999999999 6091.95 21757.17 case rate CESAREAN SECTION WITHOUT STERILIZATION WITH MCC 786 MS-DRG inpatient 1 UN 78403.09 50962.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 26522.42 999999999 14870.75 76051 case rate CESAREAN SECTION WITHOUT STERILIZATION WITH MCC 786 MS-DRG inpatient 1 UN 78403.09 50962.01 ANTHEM HMO ANTHEM HMO 24960.12 999999999 14870.75 76051 case rate CESAREAN SECTION WITHOUT STERILIZATION WITH MCC 786 MS-DRG inpatient 1 UN 78403.09 50962.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 28082.97 999999999 14870.75 76051 case rate CESAREAN SECTION WITHOUT STERILIZATION WITH MCC 786 MS-DRG inpatient 1 UN 78403.09 50962.01 SIHO - ALL PLANS SIHO - ALL PLANS 70562.78 90 999999999 14870.75 76051 percent of total billed charges CESAREAN SECTION WITHOUT STERILIZATION WITH MCC 786 MS-DRG inpatient 1 UN 78403.09 50962.01 AETNA AETNA 61938.44 79 999999999 14870.75 76051 percent of total billed charges CESAREAN SECTION WITHOUT STERILIZATION WITH MCC 786 MS-DRG inpatient 1 UN 78403.09 50962.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 50962.01 65 999999999 14870.75 76051 percent of total billed charges CESAREAN SECTION WITHOUT STERILIZATION WITH MCC 786 MS-DRG inpatient 1 UN 78403.09 50962.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 23870.18 999999999 14870.75 76051 case rate CESAREAN SECTION WITHOUT STERILIZATION WITH MCC 786 MS-DRG inpatient 1 UN 78403.09 50962.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 53000.49 67.6 999999999 14870.75 76051 percent of total billed charges CESAREAN SECTION WITHOUT STERILIZATION WITH MCC 786 MS-DRG inpatient 1 UN 78403.09 50962.01 UMR - ALL PLANS UMR - ALL PLANS 54882.16 70 999999999 14870.75 76051 percent of total billed charges CESAREAN SECTION WITHOUT STERILIZATION WITH MCC 786 MS-DRG inpatient 1 UN 78403.09 50962.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 76051 97 999999999 14870.75 76051 percent of total billed charges CESAREAN SECTION WITHOUT STERILIZATION WITH MCC 786 MS-DRG inpatient 1 UN 78403.09 50962.01 UHC - ALL PLANS UHC - ALL PLANS 14870.75 999999999 14870.75 76051 case rate CESAREAN SECTION WITHOUT STERILIZATION WITH MCC 786 MS-DRG inpatient 1 UN 78403.09 50962.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 54098.13 69 999999999 14870.75 76051 percent of total billed charges CESAREAN SECTION WITHOUT STERILIZATION WITH MCC 786 MS-DRG inpatient 1 UN 78403.09 50962.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 61154.41 78 999999999 14870.75 76051 percent of total billed charges CESAREAN SECTION WITHOUT STERILIZATION WITH MCC 786 MS-DRG inpatient 1 UN 78403.09 50962.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 47473.07 60.55 999999999 14870.75 76051 percent of total billed charges "NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY" 789 MS-DRG inpatient 1 UN 3955.82 2571.28 UMR - ALL PLANS UMR - ALL PLANS 2769.07 70 999999999 2395.25 15464.9 percent of total billed charges "NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY" 789 MS-DRG inpatient 1 UN 3955.82 2571.28 SIHO - ALL PLANS SIHO - ALL PLANS 3560.24 90 999999999 2395.25 15464.9 percent of total billed charges "NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY" 789 MS-DRG inpatient 1 UN 3955.82 2571.28 UHC - ALL PLANS UHC - ALL PLANS 15464.9 999999999 2395.25 15464.9 case rate "NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY" 789 MS-DRG inpatient 1 UN 3955.82 2571.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 3955.82 999999999 2395.25 15464.9 case rate "NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY" 789 MS-DRG inpatient 1 UN 3955.82 2571.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2395.25 60.55 999999999 2395.25 15464.9 percent of total billed charges "NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY" 789 MS-DRG inpatient 1 UN 3955.82 2571.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 3955.82 999999999 2395.25 15464.9 case rate "NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY" 789 MS-DRG inpatient 1 UN 3955.82 2571.28 ANTHEM HMO ANTHEM HMO 3955.82 999999999 2395.25 15464.9 case rate "NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY" 789 MS-DRG inpatient 1 UN 3955.82 2571.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3837.14 97 999999999 2395.25 15464.9 percent of total billed charges "NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY" 789 MS-DRG inpatient 1 UN 3955.82 2571.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 2571.28 65 999999999 2395.25 15464.9 percent of total billed charges "NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY" 789 MS-DRG inpatient 1 UN 3955.82 2571.28 AETNA AETNA 3125.1 79 999999999 2395.25 15464.9 percent of total billed charges "NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY" 789 MS-DRG inpatient 1 UN 3955.82 2571.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 3085.54 78 999999999 2395.25 15464.9 percent of total billed charges "NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY" 789 MS-DRG inpatient 1 UN 3955.82 2571.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 2729.51 69 999999999 2395.25 15464.9 percent of total billed charges "NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY" 789 MS-DRG inpatient 1 UN 3955.82 2571.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 2674.13 67.6 999999999 2395.25 15464.9 percent of total billed charges "NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY" 789 MS-DRG inpatient 1 UN 3955.82 2571.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 3955.82 999999999 2395.25 15464.9 case rate PREMATURITY WITHOUT MAJOR PROBLEMS 792 MS-DRG inpatient 1 UN 6149.07 3996.89 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 6149.07 999999999 3723.26 21016.25 case rate PREMATURITY WITHOUT MAJOR PROBLEMS 792 MS-DRG inpatient 1 UN 6149.07 3996.89 ANTHEM HMO ANTHEM HMO 6149.07 999999999 3723.26 21016.25 case rate PREMATURITY WITHOUT MAJOR PROBLEMS 792 MS-DRG inpatient 1 UN 6149.07 3996.89 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 6149.07 999999999 3723.26 21016.25 case rate PREMATURITY WITHOUT MAJOR PROBLEMS 792 MS-DRG inpatient 1 UN 6149.07 3996.89 SIHO - ALL PLANS SIHO - ALL PLANS 5534.16 90 999999999 3723.26 21016.25 percent of total billed charges PREMATURITY WITHOUT MAJOR PROBLEMS 792 MS-DRG inpatient 1 UN 6149.07 3996.89 AETNA AETNA 4857.76 79 999999999 3723.26 21016.25 percent of total billed charges PREMATURITY WITHOUT MAJOR PROBLEMS 792 MS-DRG inpatient 1 UN 6149.07 3996.89 SELF PAY DISCOUNT SELF PAY DISCOUNT 3996.89 65 999999999 3723.26 21016.25 percent of total billed charges PREMATURITY WITHOUT MAJOR PROBLEMS 792 MS-DRG inpatient 1 UN 6149.07 3996.89 CIGNA - ALL PLANS CIGNA - ALL PLANS 4156.77 67.6 999999999 3723.26 21016.25 percent of total billed charges PREMATURITY WITHOUT MAJOR PROBLEMS 792 MS-DRG inpatient 1 UN 6149.07 3996.89 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 6149.07 999999999 3723.26 21016.25 case rate PREMATURITY WITHOUT MAJOR PROBLEMS 792 MS-DRG inpatient 1 UN 6149.07 3996.89 UMR - ALL PLANS UMR - ALL PLANS 4304.35 70 999999999 3723.26 21016.25 percent of total billed charges PREMATURITY WITHOUT MAJOR PROBLEMS 792 MS-DRG inpatient 1 UN 6149.07 3996.89 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5964.6 97 999999999 3723.26 21016.25 percent of total billed charges PREMATURITY WITHOUT MAJOR PROBLEMS 792 MS-DRG inpatient 1 UN 6149.07 3996.89 UHC - ALL PLANS UHC - ALL PLANS 21016.25 999999999 3723.26 21016.25 case rate PREMATURITY WITHOUT MAJOR PROBLEMS 792 MS-DRG inpatient 1 UN 6149.07 3996.89 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3723.26 60.55 999999999 3723.26 21016.25 percent of total billed charges PREMATURITY WITHOUT MAJOR PROBLEMS 792 MS-DRG inpatient 1 UN 6149.07 3996.89 HUMANA - ALL PLANS HUMANA - ALL PLANS 4796.27 78 999999999 3723.26 21016.25 percent of total billed charges PREMATURITY WITHOUT MAJOR PROBLEMS 792 MS-DRG inpatient 1 UN 6149.07 3996.89 ENCORE - ALL PLANS ENCORE - ALL PLANS 4242.86 69 999999999 3723.26 21016.25 percent of total billed charges FULL TERM NEONATE WITH MAJOR PROBLEMS 793 MS-DRG inpatient 1 UN 6707.32 4359.75 UMR - ALL PLANS UMR - ALL PLANS 4695.12 70 999999999 4061.28 35779.05 percent of total billed charges FULL TERM NEONATE WITH MAJOR PROBLEMS 793 MS-DRG inpatient 1 UN 6707.32 4359.75 SIHO - ALL PLANS SIHO - ALL PLANS 6036.58 90 999999999 4061.28 35779.05 percent of total billed charges FULL TERM NEONATE WITH MAJOR PROBLEMS 793 MS-DRG inpatient 1 UN 6707.32 4359.75 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4061.28 60.55 999999999 4061.28 35779.05 percent of total billed charges FULL TERM NEONATE WITH MAJOR PROBLEMS 793 MS-DRG inpatient 1 UN 6707.32 4359.75 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 6707.32 999999999 4061.28 35779.05 case rate FULL TERM NEONATE WITH MAJOR PROBLEMS 793 MS-DRG inpatient 1 UN 6707.32 4359.75 UHC - ALL PLANS UHC - ALL PLANS 35779.05 999999999 4061.28 35779.05 case rate FULL TERM NEONATE WITH MAJOR PROBLEMS 793 MS-DRG inpatient 1 UN 6707.32 4359.75 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 6707.32 999999999 4061.28 35779.05 case rate FULL TERM NEONATE WITH MAJOR PROBLEMS 793 MS-DRG inpatient 1 UN 6707.32 4359.75 ANTHEM HMO ANTHEM HMO 6707.32 999999999 4061.28 35779.05 case rate FULL TERM NEONATE WITH MAJOR PROBLEMS 793 MS-DRG inpatient 1 UN 6707.32 4359.75 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 6506.1 97 999999999 4061.28 35779.05 percent of total billed charges FULL TERM NEONATE WITH MAJOR PROBLEMS 793 MS-DRG inpatient 1 UN 6707.32 4359.75 SELF PAY DISCOUNT SELF PAY DISCOUNT 4359.76 65 999999999 4061.28 35779.05 percent of total billed charges FULL TERM NEONATE WITH MAJOR PROBLEMS 793 MS-DRG inpatient 1 UN 6707.32 4359.75 AETNA AETNA 5298.78 79 999999999 4061.28 35779.05 percent of total billed charges FULL TERM NEONATE WITH MAJOR PROBLEMS 793 MS-DRG inpatient 1 UN 6707.32 4359.75 ENCORE - ALL PLANS ENCORE - ALL PLANS 4628.05 69 999999999 4061.28 35779.05 percent of total billed charges FULL TERM NEONATE WITH MAJOR PROBLEMS 793 MS-DRG inpatient 1 UN 6707.32 4359.75 HUMANA - ALL PLANS HUMANA - ALL PLANS 5231.71 78 999999999 4061.28 35779.05 percent of total billed charges FULL TERM NEONATE WITH MAJOR PROBLEMS 793 MS-DRG inpatient 1 UN 6707.32 4359.75 CIGNA - ALL PLANS CIGNA - ALL PLANS 4534.14 67.6 999999999 4061.28 35779.05 percent of total billed charges FULL TERM NEONATE WITH MAJOR PROBLEMS 793 MS-DRG inpatient 1 UN 6707.32 4359.75 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 6707.32 999999999 4061.28 35779.05 case rate NEONATE WITH OTHER SIGNIFICANT PROBLEMS 794 MS-DRG inpatient 1 UN 4657.78 3027.56 SELF PAY DISCOUNT SELF PAY DISCOUNT 3027.56 65 999999999 2820.28 12664.15 percent of total billed charges NEONATE WITH OTHER SIGNIFICANT PROBLEMS 794 MS-DRG inpatient 1 UN 4657.78 3027.56 ANTHEM HMO ANTHEM HMO 4657.78 999999999 2820.28 12664.15 case rate NEONATE WITH OTHER SIGNIFICANT PROBLEMS 794 MS-DRG inpatient 1 UN 4657.78 3027.56 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 4657.78 999999999 2820.28 12664.15 case rate NEONATE WITH OTHER SIGNIFICANT PROBLEMS 794 MS-DRG inpatient 1 UN 4657.78 3027.56 CIGNA - ALL PLANS CIGNA - ALL PLANS 3148.66 67.6 999999999 2820.28 12664.15 percent of total billed charges NEONATE WITH OTHER SIGNIFICANT PROBLEMS 794 MS-DRG inpatient 1 UN 4657.78 3027.56 UMR - ALL PLANS UMR - ALL PLANS 3260.45 70 999999999 2820.28 12664.15 percent of total billed charges NEONATE WITH OTHER SIGNIFICANT PROBLEMS 794 MS-DRG inpatient 1 UN 4657.78 3027.56 UHC - ALL PLANS UHC - ALL PLANS 12664.15 999999999 2820.28 12664.15 case rate NEONATE WITH OTHER SIGNIFICANT PROBLEMS 794 MS-DRG inpatient 1 UN 4657.78 3027.56 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 4518.05 97 999999999 2820.28 12664.15 percent of total billed charges NEONATE WITH OTHER SIGNIFICANT PROBLEMS 794 MS-DRG inpatient 1 UN 4657.78 3027.56 HUMANA - ALL PLANS HUMANA - ALL PLANS 3633.07 78 999999999 2820.28 12664.15 percent of total billed charges NEONATE WITH OTHER SIGNIFICANT PROBLEMS 794 MS-DRG inpatient 1 UN 4657.78 3027.56 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2820.28 60.55 999999999 2820.28 12664.15 percent of total billed charges NEONATE WITH OTHER SIGNIFICANT PROBLEMS 794 MS-DRG inpatient 1 UN 4657.78 3027.56 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 4657.78 999999999 2820.28 12664.15 case rate NEONATE WITH OTHER SIGNIFICANT PROBLEMS 794 MS-DRG inpatient 1 UN 4657.78 3027.56 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 4657.78 999999999 2820.28 12664.15 case rate NEONATE WITH OTHER SIGNIFICANT PROBLEMS 794 MS-DRG inpatient 1 UN 4657.78 3027.56 ENCORE - ALL PLANS ENCORE - ALL PLANS 3213.87 69 999999999 2820.28 12664.15 percent of total billed charges NEONATE WITH OTHER SIGNIFICANT PROBLEMS 794 MS-DRG inpatient 1 UN 4657.78 3027.56 SIHO - ALL PLANS SIHO - ALL PLANS 4192 90 999999999 2820.28 12664.15 percent of total billed charges NEONATE WITH OTHER SIGNIFICANT PROBLEMS 794 MS-DRG inpatient 1 UN 4657.78 3027.56 AETNA AETNA 3679.65 79 999999999 2820.28 12664.15 percent of total billed charges NORMAL NEWBORN 795 MS-DRG inpatient 1 UN 3777.34 2455.27 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 2287.18 60.55 999999999 1714.45 3664.02 percent of total billed charges NORMAL NEWBORN 795 MS-DRG inpatient 1 UN 3777.34 2455.27 HUMANA - ALL PLANS HUMANA - ALL PLANS 2946.32 78 999999999 1714.45 3664.02 percent of total billed charges NORMAL NEWBORN 795 MS-DRG inpatient 1 UN 3777.34 2455.27 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 3664.02 97 999999999 1714.45 3664.02 percent of total billed charges NORMAL NEWBORN 795 MS-DRG inpatient 1 UN 3777.34 2455.27 UMR - ALL PLANS UMR - ALL PLANS 2644.14 70 999999999 1714.45 3664.02 percent of total billed charges NORMAL NEWBORN 795 MS-DRG inpatient 1 UN 3777.34 2455.27 CIGNA - ALL PLANS CIGNA - ALL PLANS 2553.48 67.6 999999999 1714.45 3664.02 percent of total billed charges NORMAL NEWBORN 795 MS-DRG inpatient 1 UN 3777.34 2455.27 ENCORE - ALL PLANS ENCORE - ALL PLANS 2606.36 69 999999999 1714.45 3664.02 percent of total billed charges NORMAL NEWBORN 795 MS-DRG inpatient 1 UN 3777.34 2455.27 UHC - ALL PLANS UHC - ALL PLANS 1714.45 999999999 1714.45 3664.02 case rate NORMAL NEWBORN 795 MS-DRG inpatient 1 UN 3777.34 2455.27 AETNA AETNA 2984.1 79 999999999 1714.45 3664.02 percent of total billed charges NORMAL NEWBORN 795 MS-DRG inpatient 1 UN 3777.34 2455.27 SELF PAY DISCOUNT SELF PAY DISCOUNT 2455.27 65 999999999 1714.45 3664.02 percent of total billed charges NORMAL NEWBORN 795 MS-DRG inpatient 1 UN 3777.34 2455.27 SIHO - ALL PLANS SIHO - ALL PLANS 3399.6 90 999999999 1714.45 3664.02 percent of total billed charges NORMAL NEWBORN 795 MS-DRG inpatient 1 UN 3777.34 2455.27 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 3057.77 999999999 1714.45 3664.02 case rate NORMAL NEWBORN 795 MS-DRG inpatient 1 UN 3777.34 2455.27 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 3237.69 999999999 1714.45 3664.02 case rate NORMAL NEWBORN 795 MS-DRG inpatient 1 UN 3777.34 2455.27 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 2751.99 999999999 1714.45 3664.02 case rate NORMAL NEWBORN 795 MS-DRG inpatient 1 UN 3777.34 2455.27 ANTHEM HMO ANTHEM HMO 2877.65 999999999 1714.45 3664.02 case rate MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC 810 MS-DRG inpatient 1 UN 27544.71 17904.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 16124.23 999999999 8538.25 26718.37 case rate MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC 810 MS-DRG inpatient 1 UN 27544.71 17904.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 18620.22 67.6 999999999 8538.25 26718.37 percent of total billed charges MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC 810 MS-DRG inpatient 1 UN 27544.71 17904.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 15228.22 999999999 8538.25 26718.37 case rate MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC 810 MS-DRG inpatient 1 UN 27544.71 17904.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 19005.85 69 999999999 8538.25 26718.37 percent of total billed charges MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC 810 MS-DRG inpatient 1 UN 27544.71 17904.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 17904.06 65 999999999 8538.25 26718.37 percent of total billed charges MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC 810 MS-DRG inpatient 1 UN 27544.71 17904.06 AETNA AETNA 21760.32 79 999999999 8538.25 26718.37 percent of total billed charges MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC 810 MS-DRG inpatient 1 UN 27544.71 17904.06 SIHO - ALL PLANS SIHO - ALL PLANS 24790.24 90 999999999 8538.25 26718.37 percent of total billed charges MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC 810 MS-DRG inpatient 1 UN 27544.71 17904.06 UHC - ALL PLANS UHC - ALL PLANS 8538.25 999999999 8538.25 26718.37 case rate MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC 810 MS-DRG inpatient 1 UN 27544.71 17904.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 13705.4 999999999 8538.25 26718.37 case rate MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC 810 MS-DRG inpatient 1 UN 27544.71 17904.06 ANTHEM HMO ANTHEM HMO 14331.2 999999999 8538.25 26718.37 case rate MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC 810 MS-DRG inpatient 1 UN 27544.71 17904.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 16678.32 60.55 999999999 8538.25 26718.37 percent of total billed charges MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC 810 MS-DRG inpatient 1 UN 27544.71 17904.06 UMR - ALL PLANS UMR - ALL PLANS 19281.3 70 999999999 8538.25 26718.37 percent of total billed charges MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC 810 MS-DRG inpatient 1 UN 27544.71 17904.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 26718.37 97 999999999 8538.25 26718.37 percent of total billed charges MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC 810 MS-DRG inpatient 1 UN 27544.71 17904.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 21484.87 78 999999999 8538.25 26718.37 percent of total billed charges RED BLOOD CELL DISORDERS WITH MCC 811 MS-DRG inpatient 1 UN 38154.36 24800.33 AETNA AETNA 30141.94 79 999999999 11930.6 37009.73 percent of total billed charges RED BLOOD CELL DISORDERS WITH MCC 811 MS-DRG inpatient 1 UN 38154.36 24800.33 UMR - ALL PLANS UMR - ALL PLANS 26708.05 70 999999999 11930.6 37009.73 percent of total billed charges RED BLOOD CELL DISORDERS WITH MCC 811 MS-DRG inpatient 1 UN 38154.36 24800.33 SIHO - ALL PLANS SIHO - ALL PLANS 34338.92 90 999999999 11930.6 37009.73 percent of total billed charges RED BLOOD CELL DISORDERS WITH MCC 811 MS-DRG inpatient 1 UN 38154.36 24800.33 ENCORE - ALL PLANS ENCORE - ALL PLANS 26326.51 69 999999999 11930.6 37009.73 percent of total billed charges RED BLOOD CELL DISORDERS WITH MCC 811 MS-DRG inpatient 1 UN 38154.36 24800.33 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 37009.73 97 999999999 11930.6 37009.73 percent of total billed charges RED BLOOD CELL DISORDERS WITH MCC 811 MS-DRG inpatient 1 UN 38154.36 24800.33 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 23102.46 60.55 999999999 11930.6 37009.73 percent of total billed charges RED BLOOD CELL DISORDERS WITH MCC 811 MS-DRG inpatient 1 UN 38154.36 24800.33 UHC - ALL PLANS UHC - ALL PLANS 11930.6 999999999 11930.6 37009.73 case rate RED BLOOD CELL DISORDERS WITH MCC 811 MS-DRG inpatient 1 UN 38154.36 24800.33 SELF PAY DISCOUNT SELF PAY DISCOUNT 24800.33 65 999999999 11930.6 37009.73 percent of total billed charges RED BLOOD CELL DISORDERS WITH MCC 811 MS-DRG inpatient 1 UN 38154.36 24800.33 HUMANA - ALL PLANS HUMANA - ALL PLANS 29760.4 78 999999999 11930.6 37009.73 percent of total billed charges RED BLOOD CELL DISORDERS WITH MCC 811 MS-DRG inpatient 1 UN 38154.36 24800.33 ANTHEM HMO ANTHEM HMO 20025.16 999999999 11930.6 37009.73 case rate RED BLOOD CELL DISORDERS WITH MCC 811 MS-DRG inpatient 1 UN 38154.36 24800.33 CIGNA - ALL PLANS CIGNA - ALL PLANS 25792.35 67.6 999999999 11930.6 37009.73 percent of total billed charges RED BLOOD CELL DISORDERS WITH MCC 811 MS-DRG inpatient 1 UN 38154.36 24800.33 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 19150.72 999999999 11930.6 37009.73 case rate RED BLOOD CELL DISORDERS WITH MCC 811 MS-DRG inpatient 1 UN 38154.36 24800.33 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 22530.59 999999999 11930.6 37009.73 case rate RED BLOOD CELL DISORDERS WITH MCC 811 MS-DRG inpatient 1 UN 38154.36 24800.33 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 21278.58 999999999 11930.6 37009.73 case rate RED BLOOD CELL DISORDERS WITHOUT MCC 812 MS-DRG inpatient 1 UN 29662.16 19280.4 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13654.61 999999999 7655.95 28772.3 case rate RED BLOOD CELL DISORDERS WITHOUT MCC 812 MS-DRG inpatient 1 UN 29662.16 19280.4 ANTHEM HMO ANTHEM HMO 12850.29 999999999 7655.95 28772.3 case rate RED BLOOD CELL DISORDERS WITHOUT MCC 812 MS-DRG inpatient 1 UN 29662.16 19280.4 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 12289.15 999999999 7655.95 28772.3 case rate RED BLOOD CELL DISORDERS WITHOUT MCC 812 MS-DRG inpatient 1 UN 29662.16 19280.4 CIGNA - ALL PLANS CIGNA - ALL PLANS 20051.62 67.6 999999999 7655.95 28772.3 percent of total billed charges RED BLOOD CELL DISORDERS WITHOUT MCC 812 MS-DRG inpatient 1 UN 29662.16 19280.4 SIHO - ALL PLANS SIHO - ALL PLANS 26695.94 90 999999999 7655.95 28772.3 percent of total billed charges RED BLOOD CELL DISORDERS WITHOUT MCC 812 MS-DRG inpatient 1 UN 29662.16 19280.4 AETNA AETNA 23433.11 79 999999999 7655.95 28772.3 percent of total billed charges RED BLOOD CELL DISORDERS WITHOUT MCC 812 MS-DRG inpatient 1 UN 29662.16 19280.4 UHC - ALL PLANS UHC - ALL PLANS 7655.95 999999999 7655.95 28772.3 case rate RED BLOOD CELL DISORDERS WITHOUT MCC 812 MS-DRG inpatient 1 UN 29662.16 19280.4 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17960.44 60.55 999999999 7655.95 28772.3 percent of total billed charges RED BLOOD CELL DISORDERS WITHOUT MCC 812 MS-DRG inpatient 1 UN 29662.16 19280.4 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 14458.04 999999999 7655.95 28772.3 case rate RED BLOOD CELL DISORDERS WITHOUT MCC 812 MS-DRG inpatient 1 UN 29662.16 19280.4 SELF PAY DISCOUNT SELF PAY DISCOUNT 19280.4 65 999999999 7655.95 28772.3 percent of total billed charges RED BLOOD CELL DISORDERS WITHOUT MCC 812 MS-DRG inpatient 1 UN 29662.16 19280.4 ENCORE - ALL PLANS ENCORE - ALL PLANS 20466.89 69 999999999 7655.95 28772.3 percent of total billed charges RED BLOOD CELL DISORDERS WITHOUT MCC 812 MS-DRG inpatient 1 UN 29662.16 19280.4 HUMANA - ALL PLANS HUMANA - ALL PLANS 23136.48 78 999999999 7655.95 28772.3 percent of total billed charges RED BLOOD CELL DISORDERS WITHOUT MCC 812 MS-DRG inpatient 1 UN 29662.16 19280.4 UMR - ALL PLANS UMR - ALL PLANS 20763.51 70 999999999 7655.95 28772.3 percent of total billed charges RED BLOOD CELL DISORDERS WITHOUT MCC 812 MS-DRG inpatient 1 UN 29662.16 19280.4 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 28772.3 97 999999999 7655.95 28772.3 percent of total billed charges COAGULATION DISORDERS 813 MS-DRG inpatient 1 UN 29409.82 19116.38 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 17807.65 60.55 999999999 13260 28527.53 percent of total billed charges COAGULATION DISORDERS 813 MS-DRG inpatient 1 UN 29409.82 19116.38 SIHO - ALL PLANS SIHO - ALL PLANS 26468.84 90 999999999 13260 28527.53 percent of total billed charges COAGULATION DISORDERS 813 MS-DRG inpatient 1 UN 29409.82 19116.38 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 25041.12 999999999 13260 28527.53 case rate COAGULATION DISORDERS 813 MS-DRG inpatient 1 UN 29409.82 19116.38 UHC - ALL PLANS UHC - ALL PLANS 13260 999999999 13260 28527.53 case rate COAGULATION DISORDERS 813 MS-DRG inpatient 1 UN 29409.82 19116.38 HUMANA - ALL PLANS HUMANA - ALL PLANS 22939.66 78 999999999 13260 28527.53 percent of total billed charges COAGULATION DISORDERS 813 MS-DRG inpatient 1 UN 29409.82 19116.38 ENCORE - ALL PLANS ENCORE - ALL PLANS 20292.78 69 999999999 13260 28527.53 percent of total billed charges COAGULATION DISORDERS 813 MS-DRG inpatient 1 UN 29409.82 19116.38 ANTHEM HMO ANTHEM HMO 22256.52 999999999 13260 28527.53 case rate COAGULATION DISORDERS 813 MS-DRG inpatient 1 UN 29409.82 19116.38 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 23649.6 999999999 13260 28527.53 case rate COAGULATION DISORDERS 813 MS-DRG inpatient 1 UN 29409.82 19116.38 CIGNA - ALL PLANS CIGNA - ALL PLANS 19881.04 67.6 999999999 13260 28527.53 percent of total billed charges COAGULATION DISORDERS 813 MS-DRG inpatient 1 UN 29409.82 19116.38 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 28527.53 97 999999999 13260 28527.53 percent of total billed charges COAGULATION DISORDERS 813 MS-DRG inpatient 1 UN 29409.82 19116.38 UMR - ALL PLANS UMR - ALL PLANS 20586.87 70 999999999 13260 28527.53 percent of total billed charges COAGULATION DISORDERS 813 MS-DRG inpatient 1 UN 29409.82 19116.38 AETNA AETNA 23233.76 79 999999999 13260 28527.53 percent of total billed charges COAGULATION DISORDERS 813 MS-DRG inpatient 1 UN 29409.82 19116.38 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 21284.64 999999999 13260 28527.53 case rate COAGULATION DISORDERS 813 MS-DRG inpatient 1 UN 29409.82 19116.38 SELF PAY DISCOUNT SELF PAY DISCOUNT 19116.38 65 999999999 13260 28527.53 percent of total billed charges OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC 833 MS-DRG inpatient 1 UN 5393.71 3505.91 SELF PAY DISCOUNT SELF PAY DISCOUNT 3505.91 65 999999999 3265.89 5393.71 percent of total billed charges OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC 833 MS-DRG inpatient 1 UN 5393.71 3505.91 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 5393.71 999999999 3265.89 5393.71 case rate OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC 833 MS-DRG inpatient 1 UN 5393.71 3505.91 AETNA AETNA 4261.03 79 999999999 3265.89 5393.71 percent of total billed charges OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC 833 MS-DRG inpatient 1 UN 5393.71 3505.91 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5231.89 97 999999999 3265.89 5393.71 percent of total billed charges OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC 833 MS-DRG inpatient 1 UN 5393.71 3505.91 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 5393.71 999999999 3265.89 5393.71 case rate OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC 833 MS-DRG inpatient 1 UN 5393.71 3505.91 ANTHEM HMO ANTHEM HMO 5393.71 999999999 3265.89 5393.71 case rate OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC 833 MS-DRG inpatient 1 UN 5393.71 3505.91 ENCORE - ALL PLANS ENCORE - ALL PLANS 3721.66 69 999999999 3265.89 5393.71 percent of total billed charges OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC 833 MS-DRG inpatient 1 UN 5393.71 3505.91 HUMANA - ALL PLANS HUMANA - ALL PLANS 4207.09 78 999999999 3265.89 5393.71 percent of total billed charges OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC 833 MS-DRG inpatient 1 UN 5393.71 3505.91 UHC - ALL PLANS UHC - ALL PLANS 4350.3 999999999 3265.89 5393.71 case rate OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC 833 MS-DRG inpatient 1 UN 5393.71 3505.91 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 5393.71 999999999 3265.89 5393.71 case rate OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC 833 MS-DRG inpatient 1 UN 5393.71 3505.91 CIGNA - ALL PLANS CIGNA - ALL PLANS 3646.14 67.6 999999999 3265.89 5393.71 percent of total billed charges OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC 833 MS-DRG inpatient 1 UN 5393.71 3505.91 SIHO - ALL PLANS SIHO - ALL PLANS 4854.33 90 999999999 3265.89 5393.71 percent of total billed charges OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC 833 MS-DRG inpatient 1 UN 5393.71 3505.91 UMR - ALL PLANS UMR - ALL PLANS 3775.59 70 999999999 3265.89 5393.71 percent of total billed charges OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC 833 MS-DRG inpatient 1 UN 5393.71 3505.91 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3265.89 60.55 999999999 3265.89 5393.71 percent of total billed charges OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC 844 MS-DRG inpatient 1 UN 48416.25 31470.56 UMR - ALL PLANS UMR - ALL PLANS 33891.38 70 999999999 9836.2 46963.76 percent of total billed charges OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC 844 MS-DRG inpatient 1 UN 48416.25 31470.56 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 29316.04 60.55 999999999 9836.2 46963.76 percent of total billed charges OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC 844 MS-DRG inpatient 1 UN 48416.25 31470.56 SIHO - ALL PLANS SIHO - ALL PLANS 43574.63 90 999999999 9836.2 46963.76 percent of total billed charges OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC 844 MS-DRG inpatient 1 UN 48416.25 31470.56 CIGNA - ALL PLANS CIGNA - ALL PLANS 32729.39 67.6 999999999 9836.2 46963.76 percent of total billed charges OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC 844 MS-DRG inpatient 1 UN 48416.25 31470.56 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 18575.37 999999999 9836.2 46963.76 case rate OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC 844 MS-DRG inpatient 1 UN 48416.25 31470.56 UHC - ALL PLANS UHC - ALL PLANS 9836.2 999999999 9836.2 46963.76 case rate OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC 844 MS-DRG inpatient 1 UN 48416.25 31470.56 HUMANA - ALL PLANS HUMANA - ALL PLANS 37764.68 78 999999999 9836.2 46963.76 percent of total billed charges OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC 844 MS-DRG inpatient 1 UN 48416.25 31470.56 ENCORE - ALL PLANS ENCORE - ALL PLANS 33407.21 69 999999999 9836.2 46963.76 percent of total billed charges OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC 844 MS-DRG inpatient 1 UN 48416.25 31470.56 ANTHEM HMO ANTHEM HMO 16509.77 999999999 9836.2 46963.76 case rate OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC 844 MS-DRG inpatient 1 UN 48416.25 31470.56 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 17543.15 999999999 9836.2 46963.76 case rate OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC 844 MS-DRG inpatient 1 UN 48416.25 31470.56 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 46963.76 97 999999999 9836.2 46963.76 percent of total billed charges OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC 844 MS-DRG inpatient 1 UN 48416.25 31470.56 AETNA AETNA 38248.84 79 999999999 9836.2 46963.76 percent of total billed charges OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC 844 MS-DRG inpatient 1 UN 48416.25 31470.56 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 15788.84 999999999 9836.2 46963.76 case rate OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC 844 MS-DRG inpatient 1 UN 48416.25 31470.56 SELF PAY DISCOUNT SELF PAY DISCOUNT 31470.56 65 999999999 9836.2 46963.76 percent of total billed charges INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC 853 MS-DRG inpatient 1 UN 56917.05 36996.08 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 56917.05 999999999 34463.27 56917.05 case rate INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC 853 MS-DRG inpatient 1 UN 56917.05 36996.08 CIGNA - ALL PLANS CIGNA - ALL PLANS 38475.93 67.6 999999999 34463.27 56917.05 percent of total billed charges INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC 853 MS-DRG inpatient 1 UN 56917.05 36996.08 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 56917.05 999999999 34463.27 56917.05 case rate INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC 853 MS-DRG inpatient 1 UN 56917.05 36996.08 ENCORE - ALL PLANS ENCORE - ALL PLANS 39272.76 69 999999999 34463.27 56917.05 percent of total billed charges INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC 853 MS-DRG inpatient 1 UN 56917.05 36996.08 SELF PAY DISCOUNT SELF PAY DISCOUNT 36996.08 65 999999999 34463.27 56917.05 percent of total billed charges INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC 853 MS-DRG inpatient 1 UN 56917.05 36996.08 AETNA AETNA 44964.47 79 999999999 34463.27 56917.05 percent of total billed charges INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC 853 MS-DRG inpatient 1 UN 56917.05 36996.08 SIHO - ALL PLANS SIHO - ALL PLANS 51225.35 90 999999999 34463.27 56917.05 percent of total billed charges INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC 853 MS-DRG inpatient 1 UN 56917.05 36996.08 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34463.27 60.55 999999999 34463.27 56917.05 percent of total billed charges INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC 853 MS-DRG inpatient 1 UN 56917.05 36996.08 ANTHEM HMO ANTHEM HMO 56917.05 999999999 34463.27 56917.05 case rate INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC 853 MS-DRG inpatient 1 UN 56917.05 36996.08 UHC - ALL PLANS UHC - ALL PLANS 42494.05 999999999 34463.27 56917.05 case rate INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC 853 MS-DRG inpatient 1 UN 56917.05 36996.08 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 56917.05 999999999 34463.27 56917.05 case rate INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC 853 MS-DRG inpatient 1 UN 56917.05 36996.08 UMR - ALL PLANS UMR - ALL PLANS 39841.94 70 999999999 34463.27 56917.05 percent of total billed charges INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC 853 MS-DRG inpatient 1 UN 56917.05 36996.08 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 55209.54 97 999999999 34463.27 56917.05 percent of total billed charges INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC 853 MS-DRG inpatient 1 UN 56917.05 36996.08 HUMANA - ALL PLANS HUMANA - ALL PLANS 44395.3 78 999999999 34463.27 56917.05 percent of total billed charges INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC 854 MS-DRG inpatient 1 UN 56576.37 36774.64 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 27809.2 999999999 17324.7 54879.08 case rate INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC 854 MS-DRG inpatient 1 UN 56576.37 36774.64 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 30899.11 999999999 17324.7 54879.08 case rate INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC 854 MS-DRG inpatient 1 UN 56576.37 36774.64 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 32717.19 999999999 17324.7 54879.08 case rate INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC 854 MS-DRG inpatient 1 UN 56576.37 36774.64 AETNA AETNA 44695.33 79 999999999 17324.7 54879.08 percent of total billed charges INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC 854 MS-DRG inpatient 1 UN 56576.37 36774.64 UMR - ALL PLANS UMR - ALL PLANS 39603.46 70 999999999 17324.7 54879.08 percent of total billed charges INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC 854 MS-DRG inpatient 1 UN 56576.37 36774.64 ENCORE - ALL PLANS ENCORE - ALL PLANS 39037.7 69 999999999 17324.7 54879.08 percent of total billed charges INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC 854 MS-DRG inpatient 1 UN 56576.37 36774.64 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 54879.08 97 999999999 17324.7 54879.08 percent of total billed charges INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC 854 MS-DRG inpatient 1 UN 56576.37 36774.64 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 34256.99 60.55 999999999 17324.7 54879.08 percent of total billed charges INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC 854 MS-DRG inpatient 1 UN 56576.37 36774.64 UHC - ALL PLANS UHC - ALL PLANS 17324.7 999999999 17324.7 54879.08 case rate INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC 854 MS-DRG inpatient 1 UN 56576.37 36774.64 SELF PAY DISCOUNT SELF PAY DISCOUNT 36774.64 65 999999999 17324.7 54879.08 percent of total billed charges INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC 854 MS-DRG inpatient 1 UN 56576.37 36774.64 HUMANA - ALL PLANS HUMANA - ALL PLANS 44129.57 78 999999999 17324.7 54879.08 percent of total billed charges INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC 854 MS-DRG inpatient 1 UN 56576.37 36774.64 SIHO - ALL PLANS SIHO - ALL PLANS 50918.74 90 999999999 17324.7 54879.08 percent of total billed charges INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC 854 MS-DRG inpatient 1 UN 56576.37 36774.64 ANTHEM HMO ANTHEM HMO 29079 999999999 17324.7 54879.08 case rate INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC 854 MS-DRG inpatient 1 UN 56576.37 36774.64 CIGNA - ALL PLANS CIGNA - ALL PLANS 38245.63 67.6 999999999 17324.7 54879.08 percent of total billed charges POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC 857 MS-DRG inpatient 1 UN 42335.55 27518.1 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 34282.26 999999999 18153.45 41065.48 case rate POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC 857 MS-DRG inpatient 1 UN 42335.55 27518.1 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 32377.21 999999999 18153.45 41065.48 case rate POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC 857 MS-DRG inpatient 1 UN 42335.55 27518.1 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 29139.49 999999999 18153.45 41065.48 case rate POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC 857 MS-DRG inpatient 1 UN 42335.55 27518.1 CIGNA - ALL PLANS CIGNA - ALL PLANS 28618.83 67.6 999999999 18153.45 41065.48 percent of total billed charges POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC 857 MS-DRG inpatient 1 UN 42335.55 27518.1 ANTHEM HMO ANTHEM HMO 30470.03 999999999 18153.45 41065.48 case rate POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC 857 MS-DRG inpatient 1 UN 42335.55 27518.1 HUMANA - ALL PLANS HUMANA - ALL PLANS 33021.73 78 999999999 18153.45 41065.48 percent of total billed charges POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC 857 MS-DRG inpatient 1 UN 42335.55 27518.1 SELF PAY DISCOUNT SELF PAY DISCOUNT 27518.1 65 999999999 18153.45 41065.48 percent of total billed charges POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC 857 MS-DRG inpatient 1 UN 42335.55 27518.1 UHC - ALL PLANS UHC - ALL PLANS 18153.45 999999999 18153.45 41065.48 case rate POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC 857 MS-DRG inpatient 1 UN 42335.55 27518.1 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 25634.17 60.55 999999999 18153.45 41065.48 percent of total billed charges POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC 857 MS-DRG inpatient 1 UN 42335.55 27518.1 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 41065.48 97 999999999 18153.45 41065.48 percent of total billed charges POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC 857 MS-DRG inpatient 1 UN 42335.55 27518.1 ENCORE - ALL PLANS ENCORE - ALL PLANS 29211.53 69 999999999 18153.45 41065.48 percent of total billed charges POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC 857 MS-DRG inpatient 1 UN 42335.55 27518.1 UMR - ALL PLANS UMR - ALL PLANS 29634.88 70 999999999 18153.45 41065.48 percent of total billed charges POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC 857 MS-DRG inpatient 1 UN 42335.55 27518.1 AETNA AETNA 33445.08 79 999999999 18153.45 41065.48 percent of total billed charges POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC 857 MS-DRG inpatient 1 UN 42335.55 27518.1 SIHO - ALL PLANS SIHO - ALL PLANS 38101.99 90 999999999 18153.45 41065.48 percent of total billed charges POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 863 MS-DRG inpatient 1 UN 51799.46 33669.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 31364.57 60.55 999999999 8546.75 50245.48 percent of total billed charges POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 863 MS-DRG inpatient 1 UN 51799.46 33669.65 UHC - ALL PLANS UHC - ALL PLANS 8546.75 999999999 8546.75 50245.48 case rate POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 863 MS-DRG inpatient 1 UN 51799.46 33669.65 UMR - ALL PLANS UMR - ALL PLANS 36259.62 70 999999999 8546.75 50245.48 percent of total billed charges POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 863 MS-DRG inpatient 1 UN 51799.46 33669.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 35741.63 69 999999999 8546.75 50245.48 percent of total billed charges POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 863 MS-DRG inpatient 1 UN 51799.46 33669.65 SIHO - ALL PLANS SIHO - ALL PLANS 46619.51 90 999999999 8546.75 50245.48 percent of total billed charges POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 863 MS-DRG inpatient 1 UN 51799.46 33669.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 50245.48 97 999999999 8546.75 50245.48 percent of total billed charges POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 863 MS-DRG inpatient 1 UN 51799.46 33669.65 ANTHEM HMO ANTHEM HMO 14345.47 999999999 8546.75 50245.48 case rate POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 863 MS-DRG inpatient 1 UN 51799.46 33669.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 35016.44 67.6 999999999 8546.75 50245.48 percent of total billed charges POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 863 MS-DRG inpatient 1 UN 51799.46 33669.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 13719.04 999999999 8546.75 50245.48 case rate POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 863 MS-DRG inpatient 1 UN 51799.46 33669.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 33669.65 65 999999999 8546.75 50245.48 percent of total billed charges POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 863 MS-DRG inpatient 1 UN 51799.46 33669.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 40403.58 78 999999999 8546.75 50245.48 percent of total billed charges POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 863 MS-DRG inpatient 1 UN 51799.46 33669.65 AETNA AETNA 40921.57 79 999999999 8546.75 50245.48 percent of total billed charges POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 863 MS-DRG inpatient 1 UN 51799.46 33669.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 15243.38 999999999 8546.75 50245.48 case rate POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC 863 MS-DRG inpatient 1 UN 51799.46 33669.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 16140.29 999999999 8546.75 50245.48 case rate FEVER AND INFLAMMATORY CONDITIONS 864 MS-DRG inpatient 1 UN 30748.43 19986.48 CIGNA - ALL PLANS CIGNA - ALL PLANS 20785.94 67.6 999999999 7503.8 29825.98 percent of total billed charges FEVER AND INFLAMMATORY CONDITIONS 864 MS-DRG inpatient 1 UN 30748.43 19986.48 ENCORE - ALL PLANS ENCORE - ALL PLANS 21216.42 69 999999999 7503.8 29825.98 percent of total billed charges FEVER AND INFLAMMATORY CONDITIONS 864 MS-DRG inpatient 1 UN 30748.43 19986.48 UHC - ALL PLANS UHC - ALL PLANS 7503.8 999999999 7503.8 29825.98 case rate FEVER AND INFLAMMATORY CONDITIONS 864 MS-DRG inpatient 1 UN 30748.43 19986.48 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 14170.71 999999999 7503.8 29825.98 case rate FEVER AND INFLAMMATORY CONDITIONS 864 MS-DRG inpatient 1 UN 30748.43 19986.48 SELF PAY DISCOUNT SELF PAY DISCOUNT 19986.48 65 999999999 7503.8 29825.98 percent of total billed charges FEVER AND INFLAMMATORY CONDITIONS 864 MS-DRG inpatient 1 UN 30748.43 19986.48 SIHO - ALL PLANS SIHO - ALL PLANS 27673.59 90 999999999 7503.8 29825.98 percent of total billed charges FEVER AND INFLAMMATORY CONDITIONS 864 MS-DRG inpatient 1 UN 30748.43 19986.48 AETNA AETNA 24291.26 79 999999999 7503.8 29825.98 percent of total billed charges FEVER AND INFLAMMATORY CONDITIONS 864 MS-DRG inpatient 1 UN 30748.43 19986.48 HUMANA - ALL PLANS HUMANA - ALL PLANS 23983.78 78 999999999 7503.8 29825.98 percent of total billed charges FEVER AND INFLAMMATORY CONDITIONS 864 MS-DRG inpatient 1 UN 30748.43 19986.48 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 12044.92 999999999 7503.8 29825.98 case rate FEVER AND INFLAMMATORY CONDITIONS 864 MS-DRG inpatient 1 UN 30748.43 19986.48 ANTHEM HMO ANTHEM HMO 12594.91 999999999 7503.8 29825.98 case rate FEVER AND INFLAMMATORY CONDITIONS 864 MS-DRG inpatient 1 UN 30748.43 19986.48 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13383.25 999999999 7503.8 29825.98 case rate FEVER AND INFLAMMATORY CONDITIONS 864 MS-DRG inpatient 1 UN 30748.43 19986.48 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18618.18 60.55 999999999 7503.8 29825.98 percent of total billed charges FEVER AND INFLAMMATORY CONDITIONS 864 MS-DRG inpatient 1 UN 30748.43 19986.48 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 29825.98 97 999999999 7503.8 29825.98 percent of total billed charges FEVER AND INFLAMMATORY CONDITIONS 864 MS-DRG inpatient 1 UN 30748.43 19986.48 UMR - ALL PLANS UMR - ALL PLANS 21523.9 70 999999999 7503.8 29825.98 percent of total billed charges VIRAL ILLNESS WITH MCC 865 MS-DRG inpatient 1 UN 10266.24 6673.06 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 9958.25 97 999999999 6216.21 13939.15 percent of total billed charges VIRAL ILLNESS WITH MCC 865 MS-DRG inpatient 1 UN 10266.24 6673.06 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 10266.24 999999999 6216.21 13939.15 case rate VIRAL ILLNESS WITH MCC 865 MS-DRG inpatient 1 UN 10266.24 6673.06 ANTHEM HMO ANTHEM HMO 10266.24 999999999 6216.21 13939.15 case rate VIRAL ILLNESS WITH MCC 865 MS-DRG inpatient 1 UN 10266.24 6673.06 HUMANA - ALL PLANS HUMANA - ALL PLANS 8007.67 78 999999999 6216.21 13939.15 percent of total billed charges VIRAL ILLNESS WITH MCC 865 MS-DRG inpatient 1 UN 10266.24 6673.06 ENCORE - ALL PLANS ENCORE - ALL PLANS 7083.71 69 999999999 6216.21 13939.15 percent of total billed charges VIRAL ILLNESS WITH MCC 865 MS-DRG inpatient 1 UN 10266.24 6673.06 AETNA AETNA 8110.33 79 999999999 6216.21 13939.15 percent of total billed charges VIRAL ILLNESS WITH MCC 865 MS-DRG inpatient 1 UN 10266.24 6673.06 SIHO - ALL PLANS SIHO - ALL PLANS 9239.62 90 999999999 6216.21 13939.15 percent of total billed charges VIRAL ILLNESS WITH MCC 865 MS-DRG inpatient 1 UN 10266.24 6673.06 SELF PAY DISCOUNT SELF PAY DISCOUNT 6673.06 65 999999999 6216.21 13939.15 percent of total billed charges VIRAL ILLNESS WITH MCC 865 MS-DRG inpatient 1 UN 10266.24 6673.06 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 10266.24 999999999 6216.21 13939.15 case rate VIRAL ILLNESS WITH MCC 865 MS-DRG inpatient 1 UN 10266.24 6673.06 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 6216.21 60.55 999999999 6216.21 13939.15 percent of total billed charges VIRAL ILLNESS WITH MCC 865 MS-DRG inpatient 1 UN 10266.24 6673.06 UHC - ALL PLANS UHC - ALL PLANS 13939.15 999999999 6216.21 13939.15 case rate VIRAL ILLNESS WITH MCC 865 MS-DRG inpatient 1 UN 10266.24 6673.06 UMR - ALL PLANS UMR - ALL PLANS 7186.37 70 999999999 6216.21 13939.15 percent of total billed charges VIRAL ILLNESS WITH MCC 865 MS-DRG inpatient 1 UN 10266.24 6673.06 CIGNA - ALL PLANS CIGNA - ALL PLANS 6939.98 67.6 999999999 6216.21 13939.15 percent of total billed charges VIRAL ILLNESS WITH MCC 865 MS-DRG inpatient 1 UN 10266.24 6673.06 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10266.24 999999999 6216.21 13939.15 case rate SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS 870 MS-DRG inpatient 1 UN 138356.94 89932.01 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 111800.57 999999999 59201.65 134206.23 case rate SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS 870 MS-DRG inpatient 1 UN 138356.94 89932.01 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 105587.88 999999999 59201.65 134206.23 case rate SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS 870 MS-DRG inpatient 1 UN 138356.94 89932.01 ANTHEM HMO ANTHEM HMO 99368.23 999999999 59201.65 134206.23 case rate SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS 870 MS-DRG inpatient 1 UN 138356.94 89932.01 SIHO - ALL PLANS SIHO - ALL PLANS 124521.25 90 999999999 59201.65 134206.23 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS 870 MS-DRG inpatient 1 UN 138356.94 89932.01 SELF PAY DISCOUNT SELF PAY DISCOUNT 89932.01 65 999999999 59201.65 134206.23 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS 870 MS-DRG inpatient 1 UN 138356.94 89932.01 AETNA AETNA 109301.98 79 999999999 59201.65 134206.23 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS 870 MS-DRG inpatient 1 UN 138356.94 89932.01 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 95029.1 999999999 59201.65 134206.23 case rate SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS 870 MS-DRG inpatient 1 UN 138356.94 89932.01 CIGNA - ALL PLANS CIGNA - ALL PLANS 93529.29 67.6 999999999 59201.65 134206.23 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS 870 MS-DRG inpatient 1 UN 138356.94 89932.01 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 134206.23 97 999999999 59201.65 134206.23 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS 870 MS-DRG inpatient 1 UN 138356.94 89932.01 HUMANA - ALL PLANS HUMANA - ALL PLANS 107918.41 78 999999999 59201.65 134206.23 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS 870 MS-DRG inpatient 1 UN 138356.94 89932.01 ENCORE - ALL PLANS ENCORE - ALL PLANS 95466.29 69 999999999 59201.65 134206.23 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS 870 MS-DRG inpatient 1 UN 138356.94 89932.01 UMR - ALL PLANS UMR - ALL PLANS 96849.86 70 999999999 59201.65 134206.23 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS 870 MS-DRG inpatient 1 UN 138356.94 89932.01 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 83775.13 60.55 999999999 59201.65 134206.23 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS 870 MS-DRG inpatient 1 UN 138356.94 89932.01 UHC - ALL PLANS UHC - ALL PLANS 59201.65 999999999 59201.65 134206.23 case rate SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC 871 MS-DRG inpatient 1 UN 43245.12 28109.33 SIHO - ALL PLANS SIHO - ALL PLANS 38920.61 90 999999999 16852.1 41947.77 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC 871 MS-DRG inpatient 1 UN 43245.12 28109.33 AETNA AETNA 34163.65 79 999999999 16852.1 41947.77 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC 871 MS-DRG inpatient 1 UN 43245.12 28109.33 UMR - ALL PLANS UMR - ALL PLANS 30271.59 70 999999999 16852.1 41947.77 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC 871 MS-DRG inpatient 1 UN 43245.12 28109.33 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 31824.7 999999999 16852.1 41947.77 case rate SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC 871 MS-DRG inpatient 1 UN 43245.12 28109.33 CIGNA - ALL PLANS CIGNA - ALL PLANS 29233.7 67.6 999999999 16852.1 41947.77 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC 871 MS-DRG inpatient 1 UN 43245.12 28109.33 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 26184.92 60.55 999999999 16852.1 41947.77 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC 871 MS-DRG inpatient 1 UN 43245.12 28109.33 UHC - ALL PLANS UHC - ALL PLANS 16852.1 999999999 16852.1 41947.77 case rate SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC 871 MS-DRG inpatient 1 UN 43245.12 28109.33 HUMANA - ALL PLANS HUMANA - ALL PLANS 33731.2 78 999999999 16852.1 41947.77 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC 871 MS-DRG inpatient 1 UN 43245.12 28109.33 ENCORE - ALL PLANS ENCORE - ALL PLANS 29839.13 69 999999999 16852.1 41947.77 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC 871 MS-DRG inpatient 1 UN 43245.12 28109.33 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 41947.77 97 999999999 16852.1 41947.77 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC 871 MS-DRG inpatient 1 UN 43245.12 28109.33 SELF PAY DISCOUNT SELF PAY DISCOUNT 28109.33 65 999999999 16852.1 41947.77 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC 871 MS-DRG inpatient 1 UN 43245.12 28109.33 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 27050.59 999999999 16852.1 41947.77 case rate SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC 871 MS-DRG inpatient 1 UN 43245.12 28109.33 ANTHEM HMO ANTHEM HMO 28285.75 999999999 16852.1 41947.77 case rate SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC 871 MS-DRG inpatient 1 UN 43245.12 28109.33 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 30056.22 999999999 16852.1 41947.77 case rate SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC 872 MS-DRG inpatient 1 UN 25459.54 16548.7 CIGNA - ALL PLANS CIGNA - ALL PLANS 17210.65 67.6 999999999 8754.15 24695.75 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC 872 MS-DRG inpatient 1 UN 25459.54 16548.7 ENCORE - ALL PLANS ENCORE - ALL PLANS 17567.08 69 999999999 8754.15 24695.75 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC 872 MS-DRG inpatient 1 UN 25459.54 16548.7 AETNA AETNA 20113.04 79 999999999 8754.15 24695.75 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC 872 MS-DRG inpatient 1 UN 25459.54 16548.7 SIHO - ALL PLANS SIHO - ALL PLANS 22913.59 90 999999999 8754.15 24695.75 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC 872 MS-DRG inpatient 1 UN 25459.54 16548.7 SELF PAY DISCOUNT SELF PAY DISCOUNT 16548.7 65 999999999 8754.15 24695.75 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC 872 MS-DRG inpatient 1 UN 25459.54 16548.7 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 16531.95 999999999 8754.15 24695.75 case rate SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC 872 MS-DRG inpatient 1 UN 25459.54 16548.7 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 15613.28 999999999 8754.15 24695.75 case rate SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC 872 MS-DRG inpatient 1 UN 25459.54 16548.7 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 14051.96 999999999 8754.15 24695.75 case rate SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC 872 MS-DRG inpatient 1 UN 25459.54 16548.7 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15415.75 60.55 999999999 8754.15 24695.75 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC 872 MS-DRG inpatient 1 UN 25459.54 16548.7 ANTHEM HMO ANTHEM HMO 14693.58 999999999 8754.15 24695.75 case rate SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC 872 MS-DRG inpatient 1 UN 25459.54 16548.7 HUMANA - ALL PLANS HUMANA - ALL PLANS 19858.44 78 999999999 8754.15 24695.75 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC 872 MS-DRG inpatient 1 UN 25459.54 16548.7 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 24695.75 97 999999999 8754.15 24695.75 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC 872 MS-DRG inpatient 1 UN 25459.54 16548.7 UMR - ALL PLANS UMR - ALL PLANS 17821.68 70 999999999 8754.15 24695.75 percent of total billed charges SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC 872 MS-DRG inpatient 1 UN 25459.54 16548.7 UHC - ALL PLANS UHC - ALL PLANS 8754.15 999999999 8754.15 24695.75 case rate ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY 884 MS-DRG inpatient 1 UN 50714.13 32964.18 UHC - ALL PLANS UHC - ALL PLANS 14933.65 999999999 14933.65 49192.71 case rate ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY 884 MS-DRG inpatient 1 UN 50714.13 32964.18 UMR - ALL PLANS UMR - ALL PLANS 35499.89 70 999999999 14933.65 49192.71 percent of total billed charges ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY 884 MS-DRG inpatient 1 UN 50714.13 32964.18 SIHO - ALL PLANS SIHO - ALL PLANS 45642.72 90 999999999 14933.65 49192.71 percent of total billed charges ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY 884 MS-DRG inpatient 1 UN 50714.13 32964.18 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 23971.14 999999999 14933.65 49192.71 case rate ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY 884 MS-DRG inpatient 1 UN 50714.13 32964.18 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 26634.6 999999999 14933.65 49192.71 case rate ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY 884 MS-DRG inpatient 1 UN 50714.13 32964.18 CIGNA - ALL PLANS CIGNA - ALL PLANS 34282.75 67.6 999999999 14933.65 49192.71 percent of total billed charges ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY 884 MS-DRG inpatient 1 UN 50714.13 32964.18 ANTHEM HMO ANTHEM HMO 25065.69 999999999 14933.65 49192.71 case rate ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY 884 MS-DRG inpatient 1 UN 50714.13 32964.18 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 49192.71 97 999999999 14933.65 49192.71 percent of total billed charges ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY 884 MS-DRG inpatient 1 UN 50714.13 32964.18 ENCORE - ALL PLANS ENCORE - ALL PLANS 34992.75 69 999999999 14933.65 49192.71 percent of total billed charges ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY 884 MS-DRG inpatient 1 UN 50714.13 32964.18 HUMANA - ALL PLANS HUMANA - ALL PLANS 39557.02 78 999999999 14933.65 49192.71 percent of total billed charges ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY 884 MS-DRG inpatient 1 UN 50714.13 32964.18 AETNA AETNA 40064.16 79 999999999 14933.65 49192.71 percent of total billed charges ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY 884 MS-DRG inpatient 1 UN 50714.13 32964.18 SELF PAY DISCOUNT SELF PAY DISCOUNT 32964.18 65 999999999 14933.65 49192.71 percent of total billed charges ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY 884 MS-DRG inpatient 1 UN 50714.13 32964.18 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30707.41 60.55 999999999 14933.65 49192.71 percent of total billed charges ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY 884 MS-DRG inpatient 1 UN 50714.13 32964.18 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 28201.76 999999999 14933.65 49192.71 case rate "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA" 894 MS-DRG inpatient 1 UN 13928.88 9053.77 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 9221.87 999999999 4883.25 13511.01 case rate "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA" 894 MS-DRG inpatient 1 UN 13928.88 9053.77 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8433.94 60.55 999999999 4883.25 13511.01 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA" 894 MS-DRG inpatient 1 UN 13928.88 9053.77 SELF PAY DISCOUNT SELF PAY DISCOUNT 9053.77 65 999999999 4883.25 13511.01 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA" 894 MS-DRG inpatient 1 UN 13928.88 9053.77 AETNA AETNA 11003.81 79 999999999 4883.25 13511.01 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA" 894 MS-DRG inpatient 1 UN 13928.88 9053.77 HUMANA - ALL PLANS HUMANA - ALL PLANS 10864.53 78 999999999 4883.25 13511.01 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA" 894 MS-DRG inpatient 1 UN 13928.88 9053.77 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 13511.01 97 999999999 4883.25 13511.01 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA" 894 MS-DRG inpatient 1 UN 13928.88 9053.77 ANTHEM HMO ANTHEM HMO 8196.39 999999999 4883.25 13511.01 case rate "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA" 894 MS-DRG inpatient 1 UN 13928.88 9053.77 CIGNA - ALL PLANS CIGNA - ALL PLANS 9415.92 67.6 999999999 4883.25 13511.01 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA" 894 MS-DRG inpatient 1 UN 13928.88 9053.77 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 8709.42 999999999 4883.25 13511.01 case rate "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA" 894 MS-DRG inpatient 1 UN 13928.88 9053.77 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 7838.48 999999999 4883.25 13511.01 case rate "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA" 894 MS-DRG inpatient 1 UN 13928.88 9053.77 SIHO - ALL PLANS SIHO - ALL PLANS 12535.99 90 999999999 4883.25 13511.01 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA" 894 MS-DRG inpatient 1 UN 13928.88 9053.77 UMR - ALL PLANS UMR - ALL PLANS 9750.22 70 999999999 4883.25 13511.01 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA" 894 MS-DRG inpatient 1 UN 13928.88 9053.77 ENCORE - ALL PLANS ENCORE - ALL PLANS 9610.93 69 999999999 4883.25 13511.01 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA" 894 MS-DRG inpatient 1 UN 13928.88 9053.77 UHC - ALL PLANS UHC - ALL PLANS 4883.25 999999999 4883.25 13511.01 case rate "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC" 896 MS-DRG inpatient 1 UN 7269.82 4725.38 SIHO - ALL PLANS SIHO - ALL PLANS 6542.84 90 999999999 4401.88 15113.85 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC" 896 MS-DRG inpatient 1 UN 7269.82 4725.38 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 4401.88 60.55 999999999 4401.88 15113.85 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC" 896 MS-DRG inpatient 1 UN 7269.82 4725.38 UMR - ALL PLANS UMR - ALL PLANS 5088.87 70 999999999 4401.88 15113.85 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC" 896 MS-DRG inpatient 1 UN 7269.82 4725.38 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 7051.73 97 999999999 4401.88 15113.85 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC" 896 MS-DRG inpatient 1 UN 7269.82 4725.38 CIGNA - ALL PLANS CIGNA - ALL PLANS 4914.4 67.6 999999999 4401.88 15113.85 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC" 896 MS-DRG inpatient 1 UN 7269.82 4725.38 UHC - ALL PLANS UHC - ALL PLANS 15113.85 999999999 4401.88 15113.85 case rate "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC" 896 MS-DRG inpatient 1 UN 7269.82 4725.38 HUMANA - ALL PLANS HUMANA - ALL PLANS 5670.46 78 999999999 4401.88 15113.85 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC" 896 MS-DRG inpatient 1 UN 7269.82 4725.38 ENCORE - ALL PLANS ENCORE - ALL PLANS 5016.18 69 999999999 4401.88 15113.85 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC" 896 MS-DRG inpatient 1 UN 7269.82 4725.38 AETNA AETNA 5743.16 79 999999999 4401.88 15113.85 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC" 896 MS-DRG inpatient 1 UN 7269.82 4725.38 SELF PAY DISCOUNT SELF PAY DISCOUNT 4725.38 65 999999999 4401.88 15113.85 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC" 896 MS-DRG inpatient 1 UN 7269.82 4725.38 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 7269.82 999999999 4401.88 15113.85 case rate "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC" 896 MS-DRG inpatient 1 UN 7269.82 4725.38 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 7269.82 999999999 4401.88 15113.85 case rate "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC" 896 MS-DRG inpatient 1 UN 7269.82 4725.38 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 7269.82 999999999 4401.88 15113.85 case rate "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC" 896 MS-DRG inpatient 1 UN 7269.82 4725.38 ANTHEM HMO ANTHEM HMO 7269.82 999999999 4401.88 15113.85 case rate "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC" 897 MS-DRG inpatient 1 UN 23131.73 15035.63 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 11673.81 999999999 7272.6 22437.78 case rate "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC" 897 MS-DRG inpatient 1 UN 23131.73 15035.63 CIGNA - ALL PLANS CIGNA - ALL PLANS 15637.05 67.6 999999999 7272.6 22437.78 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC" 897 MS-DRG inpatient 1 UN 23131.73 15035.63 UHC - ALL PLANS UHC - ALL PLANS 7272.6 999999999 7272.6 22437.78 case rate "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC" 897 MS-DRG inpatient 1 UN 23131.73 15035.63 UMR - ALL PLANS UMR - ALL PLANS 16192.21 70 999999999 7272.6 22437.78 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC" 897 MS-DRG inpatient 1 UN 23131.73 15035.63 AETNA AETNA 18274.07 79 999999999 7272.6 22437.78 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC" 897 MS-DRG inpatient 1 UN 23131.73 15035.63 SIHO - ALL PLANS SIHO - ALL PLANS 20818.56 90 999999999 7272.6 22437.78 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC" 897 MS-DRG inpatient 1 UN 23131.73 15035.63 SELF PAY DISCOUNT SELF PAY DISCOUNT 15035.63 65 999999999 7272.6 22437.78 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC" 897 MS-DRG inpatient 1 UN 23131.73 15035.63 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 13734.09 999999999 7272.6 22437.78 case rate "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC" 897 MS-DRG inpatient 1 UN 23131.73 15035.63 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 14006.27 60.55 999999999 7272.6 22437.78 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC" 897 MS-DRG inpatient 1 UN 23131.73 15035.63 ANTHEM HMO ANTHEM HMO 12206.85 999999999 7272.6 22437.78 case rate "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC" 897 MS-DRG inpatient 1 UN 23131.73 15035.63 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 12970.9 999999999 7272.6 22437.78 case rate "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC" 897 MS-DRG inpatient 1 UN 23131.73 15035.63 HUMANA - ALL PLANS HUMANA - ALL PLANS 18042.75 78 999999999 7272.6 22437.78 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC" 897 MS-DRG inpatient 1 UN 23131.73 15035.63 ENCORE - ALL PLANS ENCORE - ALL PLANS 15960.9 69 999999999 7272.6 22437.78 percent of total billed charges "ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC" 897 MS-DRG inpatient 1 UN 23131.73 15035.63 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 22437.78 97 999999999 7272.6 22437.78 percent of total billed charges OTHER O.R. PROCEDURES FOR INJURIES WITH CC 908 MS-DRG inpatient 1 UN 55075.55 35799.11 AETNA AETNA 43509.68 79 999999999 17034.85 53423.28 percent of total billed charges OTHER O.R. PROCEDURES FOR INJURIES WITH CC 908 MS-DRG inpatient 1 UN 55075.55 35799.11 SIHO - ALL PLANS SIHO - ALL PLANS 49568 90 999999999 17034.85 53423.28 percent of total billed charges OTHER O.R. PROCEDURES FOR INJURIES WITH CC 908 MS-DRG inpatient 1 UN 55075.55 35799.11 UHC - ALL PLANS UHC - ALL PLANS 17034.85 999999999 17034.85 53423.28 case rate OTHER O.R. PROCEDURES FOR INJURIES WITH CC 908 MS-DRG inpatient 1 UN 55075.55 35799.11 UMR - ALL PLANS UMR - ALL PLANS 38552.89 70 999999999 17034.85 53423.28 percent of total billed charges OTHER O.R. PROCEDURES FOR INJURIES WITH CC 908 MS-DRG inpatient 1 UN 55075.55 35799.11 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 33348.25 60.55 999999999 17034.85 53423.28 percent of total billed charges OTHER O.R. PROCEDURES FOR INJURIES WITH CC 908 MS-DRG inpatient 1 UN 55075.55 35799.11 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 27343.94 999999999 17034.85 53423.28 case rate OTHER O.R. PROCEDURES FOR INJURIES WITH CC 908 MS-DRG inpatient 1 UN 55075.55 35799.11 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 53423.28 97 999999999 17034.85 53423.28 percent of total billed charges OTHER O.R. PROCEDURES FOR INJURIES WITH CC 908 MS-DRG inpatient 1 UN 55075.55 35799.11 HUMANA - ALL PLANS HUMANA - ALL PLANS 42958.93 78 999999999 17034.85 53423.28 percent of total billed charges OTHER O.R. PROCEDURES FOR INJURIES WITH CC 908 MS-DRG inpatient 1 UN 55075.55 35799.11 ENCORE - ALL PLANS ENCORE - ALL PLANS 38002.13 69 999999999 17034.85 53423.28 percent of total billed charges OTHER O.R. PROCEDURES FOR INJURIES WITH CC 908 MS-DRG inpatient 1 UN 55075.55 35799.11 SELF PAY DISCOUNT SELF PAY DISCOUNT 35799.11 65 999999999 17034.85 53423.28 percent of total billed charges OTHER O.R. PROCEDURES FOR INJURIES WITH CC 908 MS-DRG inpatient 1 UN 55075.55 35799.11 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 30382.16 999999999 17034.85 53423.28 case rate OTHER O.R. PROCEDURES FOR INJURIES WITH CC 908 MS-DRG inpatient 1 UN 55075.55 35799.11 ANTHEM HMO ANTHEM HMO 28592.49 999999999 17034.85 53423.28 case rate OTHER O.R. PROCEDURES FOR INJURIES WITH CC 908 MS-DRG inpatient 1 UN 55075.55 35799.11 CIGNA - ALL PLANS CIGNA - ALL PLANS 37231.07 67.6 999999999 17034.85 53423.28 percent of total billed charges OTHER O.R. PROCEDURES FOR INJURIES WITH CC 908 MS-DRG inpatient 1 UN 55075.55 35799.11 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 32169.81 999999999 17034.85 53423.28 case rate TRAUMATIC INJURY WITHOUT MCC 914 MS-DRG inpatient 1 UN 16772.65 10902.22 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13760.73 999999999 7715.45 16269.47 case rate TRAUMATIC INJURY WITHOUT MCC 914 MS-DRG inpatient 1 UN 16772.65 10902.22 ANTHEM HMO ANTHEM HMO 12950.16 999999999 7715.45 16269.47 case rate TRAUMATIC INJURY WITHOUT MCC 914 MS-DRG inpatient 1 UN 16772.65 10902.22 CIGNA - ALL PLANS CIGNA - ALL PLANS 11338.31 67.6 999999999 7715.45 16269.47 percent of total billed charges TRAUMATIC INJURY WITHOUT MCC 914 MS-DRG inpatient 1 UN 16772.65 10902.22 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 12384.66 999999999 7715.45 16269.47 case rate TRAUMATIC INJURY WITHOUT MCC 914 MS-DRG inpatient 1 UN 16772.65 10902.22 SELF PAY DISCOUNT SELF PAY DISCOUNT 10902.22 65 999999999 7715.45 16269.47 percent of total billed charges TRAUMATIC INJURY WITHOUT MCC 914 MS-DRG inpatient 1 UN 16772.65 10902.22 AETNA AETNA 13250.39 79 999999999 7715.45 16269.47 percent of total billed charges TRAUMATIC INJURY WITHOUT MCC 914 MS-DRG inpatient 1 UN 16772.65 10902.22 UHC - ALL PLANS UHC - ALL PLANS 7715.45 999999999 7715.45 16269.47 case rate TRAUMATIC INJURY WITHOUT MCC 914 MS-DRG inpatient 1 UN 16772.65 10902.22 SIHO - ALL PLANS SIHO - ALL PLANS 15095.39 90 999999999 7715.45 16269.47 percent of total billed charges TRAUMATIC INJURY WITHOUT MCC 914 MS-DRG inpatient 1 UN 16772.65 10902.22 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10155.84 60.55 999999999 7715.45 16269.47 percent of total billed charges TRAUMATIC INJURY WITHOUT MCC 914 MS-DRG inpatient 1 UN 16772.65 10902.22 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 14570.4 999999999 7715.45 16269.47 case rate TRAUMATIC INJURY WITHOUT MCC 914 MS-DRG inpatient 1 UN 16772.65 10902.22 ENCORE - ALL PLANS ENCORE - ALL PLANS 11573.13 69 999999999 7715.45 16269.47 percent of total billed charges TRAUMATIC INJURY WITHOUT MCC 914 MS-DRG inpatient 1 UN 16772.65 10902.22 HUMANA - ALL PLANS HUMANA - ALL PLANS 13082.67 78 999999999 7715.45 16269.47 percent of total billed charges TRAUMATIC INJURY WITHOUT MCC 914 MS-DRG inpatient 1 UN 16772.65 10902.22 UMR - ALL PLANS UMR - ALL PLANS 11740.86 70 999999999 7715.45 16269.47 percent of total billed charges TRAUMATIC INJURY WITHOUT MCC 914 MS-DRG inpatient 1 UN 16772.65 10902.22 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16269.47 97 999999999 7715.45 16269.47 percent of total billed charges ALLERGIC REACTIONS WITHOUT MCC 916 MS-DRG inpatient 1 UN 25781 16757.65 HUMANA - ALL PLANS HUMANA - ALL PLANS 20109.18 78 999999999 5599.8 25007.57 percent of total billed charges ALLERGIC REACTIONS WITHOUT MCC 916 MS-DRG inpatient 1 UN 25781 16757.65 UHC - ALL PLANS UHC - ALL PLANS 5599.8 999999999 5599.8 25007.57 case rate ALLERGIC REACTIONS WITHOUT MCC 916 MS-DRG inpatient 1 UN 25781 16757.65 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 25007.57 97 999999999 5599.8 25007.57 percent of total billed charges ALLERGIC REACTIONS WITHOUT MCC 916 MS-DRG inpatient 1 UN 25781 16757.65 UMR - ALL PLANS UMR - ALL PLANS 18046.7 70 999999999 5599.8 25007.57 percent of total billed charges ALLERGIC REACTIONS WITHOUT MCC 916 MS-DRG inpatient 1 UN 25781 16757.65 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 8988.67 999999999 5599.8 25007.57 case rate ALLERGIC REACTIONS WITHOUT MCC 916 MS-DRG inpatient 1 UN 25781 16757.65 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 15610.39 60.55 999999999 5599.8 25007.57 percent of total billed charges ALLERGIC REACTIONS WITHOUT MCC 916 MS-DRG inpatient 1 UN 25781 16757.65 ANTHEM HMO ANTHEM HMO 9399.1 999999999 5599.8 25007.57 case rate ALLERGIC REACTIONS WITHOUT MCC 916 MS-DRG inpatient 1 UN 25781 16757.65 SIHO - ALL PLANS SIHO - ALL PLANS 23202.9 90 999999999 5599.8 25007.57 percent of total billed charges ALLERGIC REACTIONS WITHOUT MCC 916 MS-DRG inpatient 1 UN 25781 16757.65 AETNA AETNA 20366.99 79 999999999 5599.8 25007.57 percent of total billed charges ALLERGIC REACTIONS WITHOUT MCC 916 MS-DRG inpatient 1 UN 25781 16757.65 ENCORE - ALL PLANS ENCORE - ALL PLANS 17788.89 69 999999999 5599.8 25007.57 percent of total billed charges ALLERGIC REACTIONS WITHOUT MCC 916 MS-DRG inpatient 1 UN 25781 16757.65 SELF PAY DISCOUNT SELF PAY DISCOUNT 16757.65 65 999999999 5599.8 25007.57 percent of total billed charges ALLERGIC REACTIONS WITHOUT MCC 916 MS-DRG inpatient 1 UN 25781 16757.65 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 9987.41 999999999 5599.8 25007.57 case rate ALLERGIC REACTIONS WITHOUT MCC 916 MS-DRG inpatient 1 UN 25781 16757.65 CIGNA - ALL PLANS CIGNA - ALL PLANS 17427.95 67.6 999999999 5599.8 25007.57 percent of total billed charges ALLERGIC REACTIONS WITHOUT MCC 916 MS-DRG inpatient 1 UN 25781 16757.65 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 10575.06 999999999 5599.8 25007.57 case rate POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC 917 MS-DRG inpatient 1 UN 35098.66 22814.13 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 21252.24 60.55 999999999 13565.15 34045.7 percent of total billed charges POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC 917 MS-DRG inpatient 1 UN 35098.66 22814.13 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 21774.46 999999999 13565.15 34045.7 case rate POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC 917 MS-DRG inpatient 1 UN 35098.66 22814.13 SELF PAY DISCOUNT SELF PAY DISCOUNT 22814.13 65 999999999 13565.15 34045.7 percent of total billed charges POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC 917 MS-DRG inpatient 1 UN 35098.66 22814.13 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 34045.7 97 999999999 13565.15 34045.7 percent of total billed charges POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC 917 MS-DRG inpatient 1 UN 35098.66 22814.13 UMR - ALL PLANS UMR - ALL PLANS 24569.06 70 999999999 13565.15 34045.7 percent of total billed charges POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC 917 MS-DRG inpatient 1 UN 35098.66 22814.13 AETNA AETNA 27727.94 79 999999999 13565.15 34045.7 percent of total billed charges POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC 917 MS-DRG inpatient 1 UN 35098.66 22814.13 ENCORE - ALL PLANS ENCORE - ALL PLANS 24218.08 69 999999999 13565.15 34045.7 percent of total billed charges POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC 917 MS-DRG inpatient 1 UN 35098.66 22814.13 HUMANA - ALL PLANS HUMANA - ALL PLANS 27376.95 78 999999999 13565.15 34045.7 percent of total billed charges POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC 917 MS-DRG inpatient 1 UN 35098.66 22814.13 UHC - ALL PLANS UHC - ALL PLANS 13565.15 999999999 13565.15 34045.7 case rate POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC 917 MS-DRG inpatient 1 UN 35098.66 22814.13 ANTHEM HMO ANTHEM HMO 22768.71 999999999 13565.15 34045.7 case rate POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC 917 MS-DRG inpatient 1 UN 35098.66 22814.13 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 24193.84 999999999 13565.15 34045.7 case rate POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC 917 MS-DRG inpatient 1 UN 35098.66 22814.13 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 25617.39 999999999 13565.15 34045.7 case rate POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC 917 MS-DRG inpatient 1 UN 35098.66 22814.13 CIGNA - ALL PLANS CIGNA - ALL PLANS 23726.69 67.6 999999999 13565.15 34045.7 percent of total billed charges POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC 917 MS-DRG inpatient 1 UN 35098.66 22814.13 SIHO - ALL PLANS SIHO - ALL PLANS 31588.79 90 999999999 13565.15 34045.7 percent of total billed charges POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC 918 MS-DRG inpatient 1 UN 14669.11 9534.92 UMR - ALL PLANS UMR - ALL PLANS 10268.38 70 999999999 7317.65 14229.04 percent of total billed charges POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC 918 MS-DRG inpatient 1 UN 14669.11 9534.92 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 14229.04 97 999999999 7317.65 14229.04 percent of total billed charges POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC 918 MS-DRG inpatient 1 UN 14669.11 9534.92 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 11746.12 999999999 7317.65 14229.04 case rate POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC 918 MS-DRG inpatient 1 UN 14669.11 9534.92 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 8882.15 60.55 999999999 7317.65 14229.04 percent of total billed charges POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC 918 MS-DRG inpatient 1 UN 14669.11 9534.92 ANTHEM HMO ANTHEM HMO 12282.46 999999999 7317.65 14229.04 case rate POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC 918 MS-DRG inpatient 1 UN 14669.11 9534.92 AETNA AETNA 11588.6 79 999999999 7317.65 14229.04 percent of total billed charges POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC 918 MS-DRG inpatient 1 UN 14669.11 9534.92 ENCORE - ALL PLANS ENCORE - ALL PLANS 10121.69 69 999999999 7317.65 14229.04 percent of total billed charges POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC 918 MS-DRG inpatient 1 UN 14669.11 9534.92 HUMANA - ALL PLANS HUMANA - ALL PLANS 11441.91 78 999999999 7317.65 14229.04 percent of total billed charges POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC 918 MS-DRG inpatient 1 UN 14669.11 9534.92 SELF PAY DISCOUNT SELF PAY DISCOUNT 9534.92 65 999999999 7317.65 14229.04 percent of total billed charges POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC 918 MS-DRG inpatient 1 UN 14669.11 9534.92 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 13819.17 999999999 7317.65 14229.04 case rate POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC 918 MS-DRG inpatient 1 UN 14669.11 9534.92 CIGNA - ALL PLANS CIGNA - ALL PLANS 9916.32 67.6 999999999 7317.65 14229.04 percent of total billed charges POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC 918 MS-DRG inpatient 1 UN 14669.11 9534.92 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 13051.24 999999999 7317.65 14229.04 case rate POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC 918 MS-DRG inpatient 1 UN 14669.11 9534.92 UHC - ALL PLANS UHC - ALL PLANS 7317.65 999999999 7317.65 14229.04 case rate POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC 918 MS-DRG inpatient 1 UN 14669.11 9534.92 SIHO - ALL PLANS SIHO - ALL PLANS 13202.2 90 999999999 7317.65 14229.04 percent of total billed charges COMPLICATIONS OF TREATMENT WITH MCC 919 MS-DRG inpatient 1 UN 17024.18 11065.72 UHC - ALL PLANS UHC - ALL PLANS 15509.95 999999999 10308.14 17024.18 case rate COMPLICATIONS OF TREATMENT WITH MCC 919 MS-DRG inpatient 1 UN 17024.18 11065.72 ENCORE - ALL PLANS ENCORE - ALL PLANS 11746.68 69 999999999 10308.14 17024.18 percent of total billed charges COMPLICATIONS OF TREATMENT WITH MCC 919 MS-DRG inpatient 1 UN 17024.18 11065.72 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 10308.14 60.55 999999999 10308.14 17024.18 percent of total billed charges COMPLICATIONS OF TREATMENT WITH MCC 919 MS-DRG inpatient 1 UN 17024.18 11065.72 SELF PAY DISCOUNT SELF PAY DISCOUNT 11065.72 65 999999999 10308.14 17024.18 percent of total billed charges COMPLICATIONS OF TREATMENT WITH MCC 919 MS-DRG inpatient 1 UN 17024.18 11065.72 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 16513.45 97 999999999 10308.14 17024.18 percent of total billed charges COMPLICATIONS OF TREATMENT WITH MCC 919 MS-DRG inpatient 1 UN 17024.18 11065.72 AETNA AETNA 13449.1 79 999999999 10308.14 17024.18 percent of total billed charges COMPLICATIONS OF TREATMENT WITH MCC 919 MS-DRG inpatient 1 UN 17024.18 11065.72 UMR - ALL PLANS UMR - ALL PLANS 11916.93 70 999999999 10308.14 17024.18 percent of total billed charges COMPLICATIONS OF TREATMENT WITH MCC 919 MS-DRG inpatient 1 UN 17024.18 11065.72 HUMANA - ALL PLANS HUMANA - ALL PLANS 13278.86 78 999999999 10308.14 17024.18 percent of total billed charges COMPLICATIONS OF TREATMENT WITH MCC 919 MS-DRG inpatient 1 UN 17024.18 11065.72 CIGNA - ALL PLANS CIGNA - ALL PLANS 11508.35 67.6 999999999 10308.14 17024.18 percent of total billed charges COMPLICATIONS OF TREATMENT WITH MCC 919 MS-DRG inpatient 1 UN 17024.18 11065.72 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 17024.18 999999999 10308.14 17024.18 case rate COMPLICATIONS OF TREATMENT WITH MCC 919 MS-DRG inpatient 1 UN 17024.18 11065.72 ANTHEM HMO ANTHEM HMO 17024.18 999999999 10308.14 17024.18 case rate COMPLICATIONS OF TREATMENT WITH MCC 919 MS-DRG inpatient 1 UN 17024.18 11065.72 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 17024.18 999999999 10308.14 17024.18 case rate COMPLICATIONS OF TREATMENT WITH MCC 919 MS-DRG inpatient 1 UN 17024.18 11065.72 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 17024.18 999999999 10308.14 17024.18 case rate COMPLICATIONS OF TREATMENT WITH MCC 919 MS-DRG inpatient 1 UN 17024.18 11065.72 SIHO - ALL PLANS SIHO - ALL PLANS 15321.76 90 999999999 10308.14 17024.18 percent of total billed charges COMPLICATIONS OF TREATMENT WITHOUT CC/MCC 921 MS-DRG inpatient 1 UN 30960.06 20124.04 HUMANA - ALL PLANS HUMANA - ALL PLANS 24148.85 78 999999999 5931.3 30031.26 percent of total billed charges COMPLICATIONS OF TREATMENT WITHOUT CC/MCC 921 MS-DRG inpatient 1 UN 30960.06 20124.04 CIGNA - ALL PLANS CIGNA - ALL PLANS 20929 67.6 999999999 5931.3 30031.26 percent of total billed charges COMPLICATIONS OF TREATMENT WITHOUT CC/MCC 921 MS-DRG inpatient 1 UN 30960.06 20124.04 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 11201.09 999999999 5931.3 30031.26 case rate COMPLICATIONS OF TREATMENT WITHOUT CC/MCC 921 MS-DRG inpatient 1 UN 30960.06 20124.04 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 10578.65 999999999 5931.3 30031.26 case rate COMPLICATIONS OF TREATMENT WITHOUT CC/MCC 921 MS-DRG inpatient 1 UN 30960.06 20124.04 ENCORE - ALL PLANS ENCORE - ALL PLANS 21362.44 69 999999999 5931.3 30031.26 percent of total billed charges COMPLICATIONS OF TREATMENT WITHOUT CC/MCC 921 MS-DRG inpatient 1 UN 30960.06 20124.04 UHC - ALL PLANS UHC - ALL PLANS 5931.3 999999999 5931.3 30031.26 case rate COMPLICATIONS OF TREATMENT WITHOUT CC/MCC 921 MS-DRG inpatient 1 UN 30960.06 20124.04 SELF PAY DISCOUNT SELF PAY DISCOUNT 20124.04 65 999999999 5931.3 30031.26 percent of total billed charges COMPLICATIONS OF TREATMENT WITHOUT CC/MCC 921 MS-DRG inpatient 1 UN 30960.06 20124.04 SIHO - ALL PLANS SIHO - ALL PLANS 27864.05 90 999999999 5931.3 30031.26 percent of total billed charges COMPLICATIONS OF TREATMENT WITHOUT CC/MCC 921 MS-DRG inpatient 1 UN 30960.06 20124.04 AETNA AETNA 24458.45 79 999999999 5931.3 30031.26 percent of total billed charges COMPLICATIONS OF TREATMENT WITHOUT CC/MCC 921 MS-DRG inpatient 1 UN 30960.06 20124.04 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 9520.78 999999999 5931.3 30031.26 case rate COMPLICATIONS OF TREATMENT WITHOUT CC/MCC 921 MS-DRG inpatient 1 UN 30960.06 20124.04 ANTHEM HMO ANTHEM HMO 9955.51 999999999 5931.3 30031.26 case rate COMPLICATIONS OF TREATMENT WITHOUT CC/MCC 921 MS-DRG inpatient 1 UN 30960.06 20124.04 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 30031.26 97 999999999 5931.3 30031.26 percent of total billed charges COMPLICATIONS OF TREATMENT WITHOUT CC/MCC 921 MS-DRG inpatient 1 UN 30960.06 20124.04 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 18746.32 60.55 999999999 5931.3 30031.26 percent of total billed charges COMPLICATIONS OF TREATMENT WITHOUT CC/MCC 921 MS-DRG inpatient 1 UN 30960.06 20124.04 UMR - ALL PLANS UMR - ALL PLANS 21672.04 70 999999999 5931.3 30031.26 percent of total billed charges "OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC" 923 MS-DRG inpatient 1 UN 15707.13 10209.63 UHC - ALL PLANS UHC - ALL PLANS 8596.9 999999999 8596.9 15707.13 case rate "OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC" 923 MS-DRG inpatient 1 UN 15707.13 10209.63 HUMANA - ALL PLANS HUMANA - ALL PLANS 12251.56 78 999999999 8596.9 15707.13 percent of total billed charges "OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC" 923 MS-DRG inpatient 1 UN 15707.13 10209.63 ENCORE - ALL PLANS ENCORE - ALL PLANS 10837.92 69 999999999 8596.9 15707.13 percent of total billed charges "OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC" 923 MS-DRG inpatient 1 UN 15707.13 10209.63 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 15707.13 999999999 8596.9 15707.13 case rate "OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC" 923 MS-DRG inpatient 1 UN 15707.13 10209.63 CIGNA - ALL PLANS CIGNA - ALL PLANS 10618.02 67.6 999999999 8596.9 15707.13 percent of total billed charges "OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC" 923 MS-DRG inpatient 1 UN 15707.13 10209.63 SELF PAY DISCOUNT SELF PAY DISCOUNT 10209.63 65 999999999 8596.9 15707.13 percent of total billed charges "OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC" 923 MS-DRG inpatient 1 UN 15707.13 10209.63 AETNA AETNA 12408.63 79 999999999 8596.9 15707.13 percent of total billed charges "OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC" 923 MS-DRG inpatient 1 UN 15707.13 10209.63 SIHO - ALL PLANS SIHO - ALL PLANS 14136.42 90 999999999 8596.9 15707.13 percent of total billed charges "OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC" 923 MS-DRG inpatient 1 UN 15707.13 10209.63 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 13799.54 999999999 8596.9 15707.13 case rate "OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC" 923 MS-DRG inpatient 1 UN 15707.13 10209.63 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 9510.67 60.55 999999999 8596.9 15707.13 percent of total billed charges "OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC" 923 MS-DRG inpatient 1 UN 15707.13 10209.63 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 15332.82 999999999 8596.9 15707.13 case rate "OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC" 923 MS-DRG inpatient 1 UN 15707.13 10209.63 ANTHEM HMO ANTHEM HMO 14429.64 999999999 8596.9 15707.13 case rate "OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC" 923 MS-DRG inpatient 1 UN 15707.13 10209.63 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 15235.92 97 999999999 8596.9 15707.13 percent of total billed charges "OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC" 923 MS-DRG inpatient 1 UN 15707.13 10209.63 UMR - ALL PLANS UMR - ALL PLANS 10994.99 70 999999999 8596.9 15707.13 percent of total billed charges NON-EXTENSIVE BURNS 935 MS-DRG inpatient 1 UN 5557.36 3612.28 SIHO - ALL PLANS SIHO - ALL PLANS 5001.62 90 999999999 3364.98 17349.35 percent of total billed charges NON-EXTENSIVE BURNS 935 MS-DRG inpatient 1 UN 5557.36 3612.28 CIGNA - ALL PLANS CIGNA - ALL PLANS 3756.78 67.6 999999999 3364.98 17349.35 percent of total billed charges NON-EXTENSIVE BURNS 935 MS-DRG inpatient 1 UN 5557.36 3612.28 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 5557.36 999999999 3364.98 17349.35 case rate NON-EXTENSIVE BURNS 935 MS-DRG inpatient 1 UN 5557.36 3612.28 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 5557.36 999999999 3364.98 17349.35 case rate NON-EXTENSIVE BURNS 935 MS-DRG inpatient 1 UN 5557.36 3612.28 HUMANA - ALL PLANS HUMANA - ALL PLANS 4334.74 78 999999999 3364.98 17349.35 percent of total billed charges NON-EXTENSIVE BURNS 935 MS-DRG inpatient 1 UN 5557.36 3612.28 ENCORE - ALL PLANS ENCORE - ALL PLANS 3834.58 69 999999999 3364.98 17349.35 percent of total billed charges NON-EXTENSIVE BURNS 935 MS-DRG inpatient 1 UN 5557.36 3612.28 SELF PAY DISCOUNT SELF PAY DISCOUNT 3612.28 65 999999999 3364.98 17349.35 percent of total billed charges NON-EXTENSIVE BURNS 935 MS-DRG inpatient 1 UN 5557.36 3612.28 UHC - ALL PLANS UHC - ALL PLANS 17349.35 999999999 3364.98 17349.35 case rate NON-EXTENSIVE BURNS 935 MS-DRG inpatient 1 UN 5557.36 3612.28 AETNA AETNA 4390.31 79 999999999 3364.98 17349.35 percent of total billed charges NON-EXTENSIVE BURNS 935 MS-DRG inpatient 1 UN 5557.36 3612.28 ANTHEM HMO ANTHEM HMO 5557.36 999999999 3364.98 17349.35 case rate NON-EXTENSIVE BURNS 935 MS-DRG inpatient 1 UN 5557.36 3612.28 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 5557.36 999999999 3364.98 17349.35 case rate NON-EXTENSIVE BURNS 935 MS-DRG inpatient 1 UN 5557.36 3612.28 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 5390.64 97 999999999 3364.98 17349.35 percent of total billed charges NON-EXTENSIVE BURNS 935 MS-DRG inpatient 1 UN 5557.36 3612.28 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 3364.98 60.55 999999999 3364.98 17349.35 percent of total billed charges NON-EXTENSIVE BURNS 935 MS-DRG inpatient 1 UN 5557.36 3612.28 UMR - ALL PLANS UMR - ALL PLANS 3890.15 70 999999999 3364.98 17349.35 percent of total billed charges SIGNS AND SYMPTOMS WITH MCC 947 MS-DRG inpatient 1 UN 53702.42 34906.57 SIHO - ALL PLANS SIHO - ALL PLANS 48332.18 90 999999999 10638.6 52091.35 percent of total billed charges SIGNS AND SYMPTOMS WITH MCC 947 MS-DRG inpatient 1 UN 53702.42 34906.57 AETNA AETNA 42424.91 79 999999999 10638.6 52091.35 percent of total billed charges SIGNS AND SYMPTOMS WITH MCC 947 MS-DRG inpatient 1 UN 53702.42 34906.57 UMR - ALL PLANS UMR - ALL PLANS 37591.69 70 999999999 10638.6 52091.35 percent of total billed charges SIGNS AND SYMPTOMS WITH MCC 947 MS-DRG inpatient 1 UN 53702.42 34906.57 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 18974.26 999999999 10638.6 52091.35 case rate SIGNS AND SYMPTOMS WITH MCC 947 MS-DRG inpatient 1 UN 53702.42 34906.57 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 20090.68 999999999 10638.6 52091.35 case rate SIGNS AND SYMPTOMS WITH MCC 947 MS-DRG inpatient 1 UN 53702.42 34906.57 ANTHEM HMO ANTHEM HMO 17856.58 999999999 10638.6 52091.35 case rate SIGNS AND SYMPTOMS WITH MCC 947 MS-DRG inpatient 1 UN 53702.42 34906.57 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 17076.83 999999999 10638.6 52091.35 case rate SIGNS AND SYMPTOMS WITH MCC 947 MS-DRG inpatient 1 UN 53702.42 34906.57 CIGNA - ALL PLANS CIGNA - ALL PLANS 36302.84 67.6 999999999 10638.6 52091.35 percent of total billed charges SIGNS AND SYMPTOMS WITH MCC 947 MS-DRG inpatient 1 UN 53702.42 34906.57 SELF PAY DISCOUNT SELF PAY DISCOUNT 34906.57 65 999999999 10638.6 52091.35 percent of total billed charges SIGNS AND SYMPTOMS WITH MCC 947 MS-DRG inpatient 1 UN 53702.42 34906.57 UHC - ALL PLANS UHC - ALL PLANS 10638.6 999999999 10638.6 52091.35 case rate SIGNS AND SYMPTOMS WITH MCC 947 MS-DRG inpatient 1 UN 53702.42 34906.57 HUMANA - ALL PLANS HUMANA - ALL PLANS 41887.89 78 999999999 10638.6 52091.35 percent of total billed charges SIGNS AND SYMPTOMS WITH MCC 947 MS-DRG inpatient 1 UN 53702.42 34906.57 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 52091.35 97 999999999 10638.6 52091.35 percent of total billed charges SIGNS AND SYMPTOMS WITH MCC 947 MS-DRG inpatient 1 UN 53702.42 34906.57 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 32516.81 60.55 999999999 10638.6 52091.35 percent of total billed charges SIGNS AND SYMPTOMS WITH MCC 947 MS-DRG inpatient 1 UN 53702.42 34906.57 ENCORE - ALL PLANS ENCORE - ALL PLANS 37054.67 69 999999999 10638.6 52091.35 percent of total billed charges SIGNS AND SYMPTOMS WITHOUT MCC 948 MS-DRG inpatient 1 UN 22194.83 14426.64 HUMANA - ALL PLANS HUMANA - ALL PLANS 17311.97 78 999999999 6808.5 21528.99 percent of total billed charges SIGNS AND SYMPTOMS WITHOUT MCC 948 MS-DRG inpatient 1 UN 22194.83 14426.64 CIGNA - ALL PLANS CIGNA - ALL PLANS 15003.71 67.6 999999999 6808.5 21528.99 percent of total billed charges SIGNS AND SYMPTOMS WITHOUT MCC 948 MS-DRG inpatient 1 UN 22194.83 14426.64 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 12857.65 999999999 6808.5 21528.99 case rate SIGNS AND SYMPTOMS WITHOUT MCC 948 MS-DRG inpatient 1 UN 22194.83 14426.64 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 12143.16 999999999 6808.5 21528.99 case rate SIGNS AND SYMPTOMS WITHOUT MCC 948 MS-DRG inpatient 1 UN 22194.83 14426.64 UHC - ALL PLANS UHC - ALL PLANS 6808.5 999999999 6808.5 21528.99 case rate SIGNS AND SYMPTOMS WITHOUT MCC 948 MS-DRG inpatient 1 UN 22194.83 14426.64 SELF PAY DISCOUNT SELF PAY DISCOUNT 14426.64 65 999999999 6808.5 21528.99 percent of total billed charges SIGNS AND SYMPTOMS WITHOUT MCC 948 MS-DRG inpatient 1 UN 22194.83 14426.64 ENCORE - ALL PLANS ENCORE - ALL PLANS 15314.43 69 999999999 6808.5 21528.99 percent of total billed charges SIGNS AND SYMPTOMS WITHOUT MCC 948 MS-DRG inpatient 1 UN 22194.83 14426.64 SIHO - ALL PLANS SIHO - ALL PLANS 19975.35 90 999999999 6808.5 21528.99 percent of total billed charges SIGNS AND SYMPTOMS WITHOUT MCC 948 MS-DRG inpatient 1 UN 22194.83 14426.64 AETNA AETNA 17533.92 79 999999999 6808.5 21528.99 percent of total billed charges SIGNS AND SYMPTOMS WITHOUT MCC 948 MS-DRG inpatient 1 UN 22194.83 14426.64 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 10928.84 999999999 6808.5 21528.99 case rate SIGNS AND SYMPTOMS WITHOUT MCC 948 MS-DRG inpatient 1 UN 22194.83 14426.64 ANTHEM HMO ANTHEM HMO 11427.87 999999999 6808.5 21528.99 case rate SIGNS AND SYMPTOMS WITHOUT MCC 948 MS-DRG inpatient 1 UN 22194.83 14426.64 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 13438.97 60.55 999999999 6808.5 21528.99 percent of total billed charges SIGNS AND SYMPTOMS WITHOUT MCC 948 MS-DRG inpatient 1 UN 22194.83 14426.64 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 21528.99 97 999999999 6808.5 21528.99 percent of total billed charges SIGNS AND SYMPTOMS WITHOUT MCC 948 MS-DRG inpatient 1 UN 22194.83 14426.64 UMR - ALL PLANS UMR - ALL PLANS 15536.38 70 999999999 6808.5 21528.99 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 981 MS-DRG inpatient 1 UN 72192.6 46925.19 UMR - ALL PLANS UMR - ALL PLANS 50534.82 70 999999999 40293.4 72192.6 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 981 MS-DRG inpatient 1 UN 72192.6 46925.19 CIGNA - ALL PLANS CIGNA - ALL PLANS 48802.2 67.6 999999999 40293.4 72192.6 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 981 MS-DRG inpatient 1 UN 72192.6 46925.19 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 72192.6 999999999 40293.4 72192.6 case rate EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 981 MS-DRG inpatient 1 UN 72192.6 46925.19 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 43712.62 60.55 999999999 40293.4 72192.6 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 981 MS-DRG inpatient 1 UN 72192.6 46925.19 ENCORE - ALL PLANS ENCORE - ALL PLANS 49812.89 69 999999999 40293.4 72192.6 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 981 MS-DRG inpatient 1 UN 72192.6 46925.19 HUMANA - ALL PLANS HUMANA - ALL PLANS 56310.23 78 999999999 40293.4 72192.6 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 981 MS-DRG inpatient 1 UN 72192.6 46925.19 UHC - ALL PLANS UHC - ALL PLANS 40293.4 999999999 40293.4 72192.6 case rate EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 981 MS-DRG inpatient 1 UN 72192.6 46925.19 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 70026.82 97 999999999 40293.4 72192.6 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 981 MS-DRG inpatient 1 UN 72192.6 46925.19 ANTHEM HMO ANTHEM HMO 67631.29 999999999 40293.4 72192.6 case rate EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 981 MS-DRG inpatient 1 UN 72192.6 46925.19 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 71864.46 999999999 40293.4 72192.6 case rate EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 981 MS-DRG inpatient 1 UN 72192.6 46925.19 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 64678.02 999999999 40293.4 72192.6 case rate EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 981 MS-DRG inpatient 1 UN 72192.6 46925.19 SELF PAY DISCOUNT SELF PAY DISCOUNT 46925.19 65 999999999 40293.4 72192.6 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 981 MS-DRG inpatient 1 UN 72192.6 46925.19 AETNA AETNA 57032.15 79 999999999 40293.4 72192.6 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 981 MS-DRG inpatient 1 UN 72192.6 46925.19 SIHO - ALL PLANS SIHO - ALL PLANS 64973.34 90 999999999 40293.4 72192.6 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 982 MS-DRG inpatient 1 UN 64502.27 41926.48 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 39056.12 60.55 999999999 21131 62567.2 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 982 MS-DRG inpatient 1 UN 64502.27 41926.48 HUMANA - ALL PLANS HUMANA - ALL PLANS 50311.77 78 999999999 21131 62567.2 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 982 MS-DRG inpatient 1 UN 64502.27 41926.48 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 33918.98 999999999 21131 62567.2 case rate EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 982 MS-DRG inpatient 1 UN 64502.27 41926.48 ANTHEM HMO ANTHEM HMO 35467.76 999999999 21131 62567.2 case rate EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 982 MS-DRG inpatient 1 UN 64502.27 41926.48 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 37687.76 999999999 21131 62567.2 case rate EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 982 MS-DRG inpatient 1 UN 64502.27 41926.48 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 39905.27 999999999 21131 62567.2 case rate EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 982 MS-DRG inpatient 1 UN 64502.27 41926.48 AETNA AETNA 50956.79 79 999999999 21131 62567.2 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 982 MS-DRG inpatient 1 UN 64502.27 41926.48 SELF PAY DISCOUNT SELF PAY DISCOUNT 41926.48 65 999999999 21131 62567.2 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 982 MS-DRG inpatient 1 UN 64502.27 41926.48 SIHO - ALL PLANS SIHO - ALL PLANS 58052.04 90 999999999 21131 62567.2 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 982 MS-DRG inpatient 1 UN 64502.27 41926.48 UHC - ALL PLANS UHC - ALL PLANS 21131 999999999 21131 62567.2 case rate EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 982 MS-DRG inpatient 1 UN 64502.27 41926.48 ENCORE - ALL PLANS ENCORE - ALL PLANS 44506.57 69 999999999 21131 62567.2 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 982 MS-DRG inpatient 1 UN 64502.27 41926.48 CIGNA - ALL PLANS CIGNA - ALL PLANS 43603.53 67.6 999999999 21131 62567.2 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 982 MS-DRG inpatient 1 UN 64502.27 41926.48 UMR - ALL PLANS UMR - ALL PLANS 45151.59 70 999999999 21131 62567.2 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 982 MS-DRG inpatient 1 UN 64502.27 41926.48 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 62567.2 97 999999999 21131 62567.2 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 983 MS-DRG inpatient 1 UN 47048.17 30581.31 ENCORE - ALL PLANS ENCORE - ALL PLANS 32463.24 69 999999999 13899.2 45636.72 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 983 MS-DRG inpatient 1 UN 47048.17 30581.31 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 26248.23 999999999 13899.2 45636.72 case rate EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 983 MS-DRG inpatient 1 UN 47048.17 30581.31 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 24789.63 999999999 13899.2 45636.72 case rate EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 983 MS-DRG inpatient 1 UN 47048.17 30581.31 HUMANA - ALL PLANS HUMANA - ALL PLANS 36697.57 78 999999999 13899.2 45636.72 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 983 MS-DRG inpatient 1 UN 47048.17 30581.31 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 28487.67 60.55 999999999 13899.2 45636.72 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 983 MS-DRG inpatient 1 UN 47048.17 30581.31 UMR - ALL PLANS UMR - ALL PLANS 32933.72 70 999999999 13899.2 45636.72 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 983 MS-DRG inpatient 1 UN 47048.17 30581.31 UHC - ALL PLANS UHC - ALL PLANS 13899.2 999999999 13899.2 45636.72 case rate EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 983 MS-DRG inpatient 1 UN 47048.17 30581.31 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 45636.72 97 999999999 13899.2 45636.72 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 983 MS-DRG inpatient 1 UN 47048.17 30581.31 ANTHEM HMO ANTHEM HMO 23329.4 999999999 13899.2 45636.72 case rate EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 983 MS-DRG inpatient 1 UN 47048.17 30581.31 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 22310.67 999999999 13899.2 45636.72 case rate EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 983 MS-DRG inpatient 1 UN 47048.17 30581.31 CIGNA - ALL PLANS CIGNA - ALL PLANS 31804.56 67.6 999999999 13899.2 45636.72 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 983 MS-DRG inpatient 1 UN 47048.17 30581.31 SELF PAY DISCOUNT SELF PAY DISCOUNT 30581.31 65 999999999 13899.2 45636.72 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 983 MS-DRG inpatient 1 UN 47048.17 30581.31 AETNA AETNA 37168.05 79 999999999 13899.2 45636.72 percent of total billed charges EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC 983 MS-DRG inpatient 1 UN 47048.17 30581.31 SIHO - ALL PLANS SIHO - ALL PLANS 42343.35 90 999999999 13899.2 45636.72 percent of total billed charges NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 987 MS-DRG inpatient 1 UN 68776.22 44704.54 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 41644 60.55 999999999 28701.95 66712.93 percent of total billed charges NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 987 MS-DRG inpatient 1 UN 68776.22 44704.54 HUMANA - ALL PLANS HUMANA - ALL PLANS 53645.45 78 999999999 28701.95 66712.93 percent of total billed charges NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 987 MS-DRG inpatient 1 UN 68776.22 44704.54 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 46071.69 999999999 28701.95 66712.93 case rate NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 987 MS-DRG inpatient 1 UN 68776.22 44704.54 ANTHEM HMO ANTHEM HMO 48175.38 999999999 28701.95 66712.93 case rate NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 987 MS-DRG inpatient 1 UN 68776.22 44704.54 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 51190.77 999999999 28701.95 66712.93 case rate NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 987 MS-DRG inpatient 1 UN 68776.22 44704.54 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 54202.79 999999999 28701.95 66712.93 case rate NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 987 MS-DRG inpatient 1 UN 68776.22 44704.54 AETNA AETNA 54333.21 79 999999999 28701.95 66712.93 percent of total billed charges NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 987 MS-DRG inpatient 1 UN 68776.22 44704.54 SELF PAY DISCOUNT SELF PAY DISCOUNT 44704.54 65 999999999 28701.95 66712.93 percent of total billed charges NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 987 MS-DRG inpatient 1 UN 68776.22 44704.54 SIHO - ALL PLANS SIHO - ALL PLANS 61898.6 90 999999999 28701.95 66712.93 percent of total billed charges NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 987 MS-DRG inpatient 1 UN 68776.22 44704.54 ENCORE - ALL PLANS ENCORE - ALL PLANS 47455.59 69 999999999 28701.95 66712.93 percent of total billed charges NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 987 MS-DRG inpatient 1 UN 68776.22 44704.54 UHC - ALL PLANS UHC - ALL PLANS 28701.95 999999999 28701.95 66712.93 case rate NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 987 MS-DRG inpatient 1 UN 68776.22 44704.54 CIGNA - ALL PLANS CIGNA - ALL PLANS 46492.72 67.6 999999999 28701.95 66712.93 percent of total billed charges NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 987 MS-DRG inpatient 1 UN 68776.22 44704.54 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 66712.93 97 999999999 28701.95 66712.93 percent of total billed charges NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC 987 MS-DRG inpatient 1 UN 68776.22 44704.54 UMR - ALL PLANS UMR - ALL PLANS 48143.35 70 999999999 28701.95 66712.93 percent of total billed charges NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 988 MS-DRG inpatient 1 UN 50594.82 32886.63 HUMANA - ALL PLANS HUMANA - ALL PLANS 39463.96 78 999999999 14424.5 49076.97 percent of total billed charges NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 988 MS-DRG inpatient 1 UN 50594.82 32886.63 ENCORE - ALL PLANS ENCORE - ALL PLANS 34910.42 69 999999999 14424.5 49076.97 percent of total billed charges NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 988 MS-DRG inpatient 1 UN 50594.82 32886.63 ANTHEM PPO/OFF EXCHANGE ANTHEM PPO/OFF EXCHANGE 25726.52 999999999 14424.5 49076.97 case rate NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 988 MS-DRG inpatient 1 UN 50594.82 32886.63 ANTHEM HMO ANTHEM HMO 24211.1 999999999 14424.5 49076.97 case rate NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 988 MS-DRG inpatient 1 UN 50594.82 32886.63 ANTHEM TRADITIONAL - ALL OTHER PLANS ANTHEM TRADITIONAL - ALL OTHER PLANS 27240.24 999999999 14424.5 49076.97 case rate NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 988 MS-DRG inpatient 1 UN 50594.82 32886.63 SIHO - ALL PLANS SIHO - ALL PLANS 45535.33 90 999999999 14424.5 49076.97 percent of total billed charges NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 988 MS-DRG inpatient 1 UN 50594.82 32886.63 UNIFIED GROUP - ALL PLANS UNIFIED GROUP - ALL PLANS 30635.16 60.55 999999999 14424.5 49076.97 percent of total billed charges NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 988 MS-DRG inpatient 1 UN 50594.82 32886.63 UMR - ALL PLANS UMR - ALL PLANS 35416.37 70 999999999 14424.5 49076.97 percent of total billed charges NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 988 MS-DRG inpatient 1 UN 50594.82 32886.63 UHC - ALL PLANS UHC - ALL PLANS 14424.5 999999999 14424.5 49076.97 case rate NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 988 MS-DRG inpatient 1 UN 50594.82 32886.63 MULTIPLAN - ALL PLANS MULTIPLAN - ALL PLANS 49076.97 97 999999999 14424.5 49076.97 percent of total billed charges NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 988 MS-DRG inpatient 1 UN 50594.82 32886.63 CIGNA - ALL PLANS CIGNA - ALL PLANS 34202.1 67.6 999999999 14424.5 49076.97 percent of total billed charges NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 988 MS-DRG inpatient 1 UN 50594.82 32886.63 ANTHEM ON EXCHANGE ANTHEM ON EXCHANGE 23153.87 999999999 14424.5 49076.97 case rate NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 988 MS-DRG inpatient 1 UN 50594.82 32886.63 SELF PAY DISCOUNT SELF PAY DISCOUNT 32886.63 65 999999999 14424.5 49076.97 percent of total billed charges NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC 988 MS-DRG inpatient 1 UN 50594.82 32886.63 AETNA AETNA 39969.9 79 999999999 14424.5 49076.97 percent of total billed charges